title: A novel 2-step approach combining the NAFLD fibrosis score and liver stiffness measurement for predicting advanced fibrosis.
abstract: BACKGROUND
  The non-alcoholic fatty liver disease (NAFLD) fibrosis score (NFS) is indeterminate in a proportion of NAFLD patients. Combining the NFS with liver stiffness measurement (LSM) may improve prediction of advanced fibrosis. We aim to evaluate the NFS and LSM in predicting advanced fibrosis in NAFLD patients.
  
  
  METHODS
  The NFS was calculated and LSM obtained for consecutive adult NAFLD patients scheduled for liver biopsy. The accuracy of predicting advanced fibrosis using either modality and in combination were assessed. An algorithm combining the NFS and LSM was developed from a training cohort and subsequently tested in a validation cohort.
  
  
  RESULTS
  There were 101 and 46 patients in the training and validation cohort, respectively. In the training cohort, the percentages of misclassifications using the NFS alone, LSM alone, LSM alone (with grey zone), both tests for all patients and a 2-step approach using LSM only for patients with indeterminate and high NFS were 5.0, 28.7, 2.0, 2.0 and 4.0 %, respectively. The percentages of patients requiring liver biopsy were 30.7, 0, 36.6, 36.6 and 18.8 %, respectively. In the validation cohort, the percentages of misclassifications were 8.7, 28.3, 2.2, 2.2 and 8.7 %, respectively. The percentages of patients requiring liver biopsy were 28.3, 0, 41.3, 43.5 and 19.6 %, respectively.
  
  
  CONCLUSIONS
  The novel 2-step approach further reduced the number of patients requiring a liver biopsy whilst maintaining the accuracy to predict advanced fibrosis. The combination of NFS and LSM for all patients provided no apparent advantage over using either of the tests alone.
authors: Gastroenterology and Hepatology Unit, Gastrointestinal Endoscopy Unit, Department of Medicine, Faculty of Medicine, University of Malaya, 50603, Kuala Lumpur, Malaysia. wahkheong2003@hotmail.com.
authors: Wah-Kheong
authors: WK
authors: Chan
authors: Department of Pathology, Hospital Alor Setar, Alor Setar, Malaysia.
authors: Nik Raihan
authors: NR
authors: Nik Mustapha
authors: Gastroenterology and Hepatology Unit, Gastrointestinal Endoscopy Unit, Department of Medicine, Faculty of Medicine, University of Malaya, 50603, Kuala Lumpur, Malaysia.
authors: Sanjiv
authors: S
authors: Mahadeva
mesh_terms: D000465:Algorithms; D001706:Biopsy; D018450:Disease Progression; D004548:Elasticity; D054459:Elasticity Imaging Techniques; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008099:Liver / Q000000981:diagnostic imaging / Q000473:pathology / Q000503:physiopathology*; D008103:Liver Cirrhosis / Q000000981:diagnostic imaging* / Q000209:etiology / Q000503:physiopathology; D008297:Male; D008875:Middle Aged; D065626:Non-alcoholic Fatty Liver Disease / Q000150:complications / Q000000981:diagnostic imaging* / Q000503:physiopathology; D011237:Predictive Value of Tests; D011379:Prognosis; D011446:Prospective Studies; D012720:Severity of Illness Index
keywords: Fibroscan; Liver fibrosis; Liver stiffness measurement; NAFLD fibrosis score; Non-alcoholic fatty liver disease (NAFLD); Non-invasive test