title: ELF score ≥9.8 indicates advanced hepatic fibrosis and is influenced by age, steatosis and histological activity.
abstract: OBJECTIVE
  There is increasing need to identify individuals with advanced liver fibrosis, who are at risk of complications such as hepatocellular carcinoma. The commercially available enhanced liver fibrosis (ELF) test provides a non-invasive assessment of fibrosis severity. This study was designed to determine the diagnostic accuracy of the manufacturer's cut-off value (≥9.8) in identifying advanced fibrosis.
  
  
  METHODS
  The relationship between ELF score and fibrosis was examined using serum collected at time of liver biopsy for investigation of liver disease, particularly viral hepatitis. Fibrosis was staged using a modified METAVIR score. If available, liver tissue was recut and stained with Sirius red to determine collagen proportional area (CPA) and subsinusoidal fibrosis (SSF).
  
  
  RESULTS
  Enhanced liver fibrosis score ≥9.8 had a sensitivity of 74.4% and specificity 92.4% for detecting advanced fibrosis. In the whole cohort (n = 329), ELF score was more likely to incorrectly classify individuals if age was ≥45 years and METAVIR inflammatory grade was 2 or 3 (adjusted OR, odds ratio 3.71 and 2.62 respectively). In contrast, ELF score was less likely to misclassify individuals in the presence of steatosis (OR 0.37). Neither SSF nor CPA explained the discordance in ELF score for patients with or without advanced fibrosis.
  
  
  CONCLUSIONS
  Although ELF score ≥9.8 reliably identifies advanced fibrosis in patients with chronic liver disease, both age and inflammatory activity need to be considered when interpreting the result. Importantly, ELF score performed well in the presence of steatosis and could thus be helpful in the assessment of fatty liver disease.
authors.affiliation: Department of Gastroenterology and Hepatology, Princess Alexandra Hospital, Brisbane, Qld, Australia.|Centre for Liver Disease Research, School of Medicine, The University of Queensland, Brisbane, Qld, Australia.
authors.forename: Kevin J
authors.initials: KJ
authors.lastname: Fagan
authors.affiliation: School of Medicine, The University of Queensland, Brisbane, Qld, Australia.|Department of Chemical Pathology, Pathology Queensland, Brisbane, Qld, Australia.
authors.forename: Carel J
authors.initials: CJ
authors.lastname: Pretorius
authors.affiliation: Department of Gastroenterology and Hepatology, Princess Alexandra Hospital, Brisbane, Qld, Australia.|Centre for Liver Disease Research, School of Medicine, The University of Queensland, Brisbane, Qld, Australia.
authors.forename: Leigh U
authors.initials: LU
authors.lastname: Horsfall
authors.affiliation: Centre for Liver Disease Research, School of Medicine, The University of Queensland, Brisbane, Qld, Australia.
authors.forename: Katharine M
authors.initials: KM
authors.lastname: Irvine
authors.affiliation: School of Medicine, The University of Queensland, Brisbane, Qld, Australia.|Department of Chemical Pathology, Pathology Queensland, Brisbane, Qld, Australia.
authors.forename: Urs
authors.initials: U
authors.lastname: Wilgen
authors.affiliation: Centre for Liver Disease Research, School of Medicine, The University of Queensland, Brisbane, Qld, Australia.
authors.forename: Kihoon
authors.initials: K
authors.lastname: Choi
authors.affiliation: Department of Gastroenterology and Hepatology, Princess Alexandra Hospital, Brisbane, Qld, Australia.|School of Medicine, The University of Queensland, Brisbane, Qld, Australia.
authors.forename: Linda M
authors.initials: LM
authors.lastname: Fletcher
authors.affiliation: Department of Chemical Pathology, Pathology Queensland, Brisbane, Qld, Australia.
authors.forename: Jill
authors.initials: J
authors.lastname: Tate
authors.affiliation: Centre for Liver Disease Research, School of Medicine, The University of Queensland, Brisbane, Qld, Australia.
authors.forename: Michelle
authors.initials: M
authors.lastname: Melino
authors.affiliation: Centre for Liver Disease Research, School of Medicine, The University of Queensland, Brisbane, Qld, Australia.
authors.forename: Sharmin
authors.initials: S
authors.lastname: Nusrat
authors.affiliation: Centre for Liver Disease Research, School of Medicine, The University of Queensland, Brisbane, Qld, Australia.
authors.forename: Gregory C
authors.initials: GC
authors.lastname: Miller
authors.affiliation: Centre for Liver Disease Research, School of Medicine, The University of Queensland, Brisbane, Qld, Australia.
authors.forename: Andrew D
authors.initials: AD
authors.lastname: Clouston
authors.affiliation: Statistics Unit, QIMR Berghofer Medical Research Institute, Brisbane, Qld, Australia.
authors.forename: Emma
authors.initials: E
authors.lastname: Ballard
authors.affiliation: Statistics Unit, QIMR Berghofer Medical Research Institute, Brisbane, Qld, Australia.
authors.forename: Peter
authors.initials: P
authors.lastname: O'Rourke
authors.affiliation: Pathology Queensland, Princess Alexandra Hospital, Brisbane, Qld, Australia.
authors.forename: Guy
authors.initials: G
authors.lastname: Lampe
authors.affiliation: Department of Chemical Pathology, Pathology Queensland, Brisbane, Qld, Australia.
authors.forename: Jacobus P J
authors.initials: JP
authors.lastname: Ungerer
authors.affiliation: Department of Gastroenterology and Hepatology, Princess Alexandra Hospital, Brisbane, Qld, Australia.|Centre for Liver Disease Research, School of Medicine, The University of Queensland, Brisbane, Qld, Australia.
authors.forename: Elizabeth E
authors.initials: EE
authors.lastname: Powell
mesh_terms: D000367:Age Factors; D015415:Biomarkers / Q000097:blood*; D001706:Biopsy; D003094:Collagen; D005260:Female; D006801:Humans; D008099:Liver / Q000473:pathology*; D008103:Liver Cirrhosis / Q000097:blood / Q000175:diagnosis*; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D065626:Non-alcoholic Fatty Liver Disease / Q000473:pathology*; D009765:Obesity / Q000150:complications; D018570:Risk Assessment; D012680:Sensitivity and Specificity; D012720:Severity of Illness Index
chemical_list: D015415:Biomarkers; D003094:Collagen
keywords: biomarker; cirrhosis; collagen proportional area; liver; non-alcoholic fatty liver disease