title: Simple noninvasive systems predict long-term outcomes of patients with nonalcoholic fatty liver disease.
abstract: OBJECTIVE
  Some patients with nonalcoholic fatty liver disease (NAFLD) develop liver-related complications and have higher mortality than other patients with NAFLD. We determined the accuracy of simple, noninvasive scoring systems in identification of patients at increased risk for liver-related complications or death.
  
  
  METHODS
  We performed a retrospective, international, multicenter cohort study of 320 patients diagnosed with NAFLD, based on liver biopsy analysis through 2002 and followed through 2011. Patients were assigned to mild-, intermediate-, or high-risk groups based on cutoff values for 2 of the following: NAFLD fibrosis score, aspartate aminotransferase/platelet ratio index, FIB-4 score, and BARD score. Outcomes included liver-related complications and death or liver transplantation. We used multivariate Cox proportional hazard regression analysis to adjust for relevant variables and calculate adjusted hazard ratios (aHRs).
  
  
  RESULTS
  During a median follow-up period of 104.8 months (range, 3-317 months), 14% of patients developed liver-related events and 13% died or underwent liver transplantation. The aHRs for liver-related events in the intermediate-risk and high-risk groups, compared with the low-risk group, were 7.7 (95% confidence interval [CI]: 1.4-42.7) and 34.2 (95% CI: 6.5-180.1), respectively, based on NAFLD fibrosis score; 8.8 (95% CI: 1.1-67.3) and 20.9 (95% CI: 2.6-165.3) based on the aspartate aminotransferase/platelet ratio index; and 6.2 (95% CI: 1.4-27.2) and 6.6 (95% CI: 1.4-31.1) based on the BARD score. The aHRs for death or liver transplantation in the intermediate-risk and high-risk groups compared with the low-risk group were 4.2 (95% CI: 1.3-13.8) and 9.8 (95% CI: 2.7-35.3), respectively, based on the NAFLD fibrosis scores. Based on aspartate aminotransferase/platelet ratio index and FIB-4 score, only the high-risk group had a greater risk of death or liver transplantation (aHR = 3.1; 95% CI: 1.1-8.4 and aHR = 6.6; 95% CI: 2.3-20.4, respectively).
  
  
  CONCLUSIONS
  Simple noninvasive scoring systems help identify patients with NAFLD who are at increased risk for liver-related complications or death. NAFLD fibrosis score appears to be the best indicator of patients at risk, based on HRs. The results of this study require external validation.
authors.affiliation: Division of Digestive Diseases and Nutrition, University of Kentucky Medical Center, Lexington, Kentucky. Electronic address: paul.angulo@uky.edu.
authors.forename: Paul
authors.initials: P
authors.lastname: Angulo
authors.forename: Elisabetta
authors.initials: E
authors.lastname: Bugianesi
authors.forename: Einar S
authors.initials: ES
authors.lastname: Bjornsson
authors.forename: Phunchai
authors.initials: P
authors.lastname: Charatcharoenwitthaya
authors.forename: Peter R
authors.initials: PR
authors.lastname: Mills
authors.forename: Francisco
authors.initials: F
authors.lastname: Barrera
authors.forename: Svanhildur
authors.initials: S
authors.lastname: Haflidadottir
authors.forename: Christopher P
authors.initials: CP
authors.lastname: Day
authors.forename: Jacob
authors.initials: J
authors.lastname: George
mesh_terms: D000328:Adult; D015331:Cohort Studies; D005234:Fatty Liver / Q000150:complications* / Q000401:mortality; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D053208:Kaplan-Meier Estimate; D008297:Male; D008875:Middle Aged; D065626:Non-alcoholic Fatty Liver Disease; D012189:Retrospective Studies
keywords: ALT; APRI; AST; AST/platelet ratio index; BMI; HCC; NAFLD; NAFLD fibrosis score; NAFLD-FS; NASH; ROC; aHR; adjusted hazard ratio; alanine aminotransferase; aspartate aminotransferase; body mass index; hepatocellular carcinoma; nonalcoholic fatty liver disease; nonalcoholic steatohepatitis; receiver operating characteristic