FibroTest-ActiTest as a non-invasive marker of liver...

FibroTest-ActiTest as a non-invasive marker of liver brosis

FibroTest-ActiTest : marqueur non-invasif de la brose hépatique

Corresponding author: Département de Virologie, Laboratoire Alphabio, Marseille. Maladies Infectieuses, Hôpital Ambroise Paré, Marseille. 23 Rue de Friedland 13006 Marseille, France E-mail address: [email protected]

© 2008 Elsevier Masson SAS. Tous droits réservés.

Gastrœntérol Clin Bio (2008) 32, 22-39

KEYWORDSFibrotest-Actitest; Non-invasive marker of liver brosis; Hepatite C; CHB; ALD; NAFLD

Philippe Halfona,*, Mona Munteanub, Thierry Poynardc

a Laboratoire Alphabio, Maladies Infectieuses, Hôpital Ambroise Paré Marseille, France b BioPredictive Paris, France c Hepato-Gastroenterology, Groupe Hospitalier Pitié Salpêtrière, University Paris 5 and 6 Paris, France.

Summary

FibroTest (FT) is a biomarker of liver brosis initially validated in patients with chronic hepatitis C (CHC) and subsequently assessed in other frequent liver diseases, including chronic hepatitis B (CHB), alcoholic liver disease (ALD) and non-alcoholic fatty liver disease (NAFLD). The primary aim of the present study was to update a previous meta-analysis of FT diagnostic value, and to summarize its advantages and limitations. The secondary aim was to provide an overview of the prognostic value of FT in CHC, CHB and ALD. For diagnostic value, the main endpoint was the FT area under the ROC curves (AUROCs) for the diagnosis of bridging brosis (F2/F3/F4 vs F0/F1), standardized for the spectrum of brosis. Sensitivity analysis integrated the non-standardized observed AUROCs, the independency of authors, size (length) of biopsy, prospective design, correctness of procedures, co-morbidities, and timelag between biopsy and serum sampling. For prognostic value, the main endpoint was the FT AUROC for the prognostic value of liver complications or death related to liver disease. A total of 38 diagnostic studies were included, which pooled 7985 subjects who had undergone both FT and biopsy (4600 HCV, 1580 HBV, 267 NAFLD, 524 ALD and 1014 mixed). The mean standardized AUROC was 0.84 (95% CI, 0.83–0.86), with no differences in terms of causes of liver disease: HCV 0.84 (0.82–0.87); HBV 0.81 (0.78–0.83); NAFLD 0.84 (0.76–0.92); ALD 0.87 (0.82–0.92); and mixed 0.85 (0.81–0.89). Three prognostic studies were also included. FT was found to have higher or similar prognostic value compared with biopsy in patients with CHC, CHB or ALD. FibroTest is an effective alternative to biopsy in patients with chronic hepatitis C or B, ALD or NAFLD. Indeed, the prognostic performance of FibroTest was at least as accurate as that of biopsy in patients with chronic hepatitis C or B, or ALD. © 2008 Elsevier Masson SAS. All rights reserved.

FibroTest-ActiTest as a non-invasive marker of liver brosis 23

Abbreviations

ALT: Alanine aminotransferases

AST: Aspartate aminotransferases

AUROC: Area under the ROC curves

AT: ActiTest

ALD: Alcoholic liver disease

CHB: Chronic hepatitis B

CHC: Chronic hepatitis C

FT: FibroTest

HCV: Hepatitis C virus

HIV: Human immunodeciency virus

NAFLD: Non-alcoholic fatty liver disease

Résumé

Le FibroTest (FT) est un marqueur biologique de fibrose hépatique initialement validé au cours de l’hépatite C puis au cours de l’hépatite B, de la maladie alcoolique du foie et de la stéatopathie métabolique. L’objectif principal de cet article était de présenter une méta-analyse récente sur la valeur diagnostique du FT et de résumer les avantages et les limites du FT. L’autre objectif était de présenter la valeur pronostique du FT au cours de l’hépatite C, de l’hépatite B et de la maladie alcoolique du foie. Pour le diagnostic, l’objectif principal était d’évaluer l’aire sous la courbe ROC (AUROC) du FT pour le diagnostic de la brose signicative (F2F3F4 vs. F0F1), standardisée selon les stades de brose. L’analyse a intégrée les AUROC observées non standardisées, l’indépendance des auteurs, la longueur de la biopsie, le caractère prospectif de l’étude, le respect des procédures, les comorbidités et la durée entre la biopsie et el prélèvement sanguin. Pour le pronostic, l’objectif principal était d’évaluer les AUROC du FT pour la survenue des complications hépatiques et du décès par maladie hépatique. Un total de 38 études diagnostiques ont été évaluées permettant l’inclusion de 7985 sujets avec à la fois FT et biopsie (4600 hépatites C, 1580 hépatites B, 267 stéatopathies métaboliques, 524 maladies alcooliques du foie, et 1014 étiologies multiples). L’AUROC moyenne standardisée était de 0,84 (intervalle de conance à 95%, 0,83-0,86), sans différence entre les différentes étiologies: hépatite C 0,84 (0,82-0,87), hépatite B 0,81 (0,78-0,83), stéatopathie métabolique 0,84 (0,76-0,92), maladie alcoolique du foie 0,87 (0,82-0,92), étiologies multiples 0,85 (0,81-0,89). Trois études pronostiques ont été incluses. Le FT avait une valeur pronostique meilleure ou identique à celle de la biopsie chez les malades avec hépatite C, hépatite B et maladie alcoolique du foie. Le FT est une excellente alternative à la biopsie chez les malades avec hépatite C, hépatite B et maladie alcoolique du foie. La valeur pronostique du FT est au moins identique à celle de la biopsie chez les malades avec hépatite C, hépatite B et maladie alcoolique du foie. © 2008 Elsevier Masson SAS. Tous droits réservés.

Introduction

The development of FibroTest (FT)-ActiTest (AT) (BioPredictive, Paris, France) in 2001 and its widespread use by clinicians has changed the management of patients with chronic liver disease [1]. Evaluating liver brosis and necroinammatory activity through a simple blood test without performing a liver biopsy was not thought to be realistic 20 years ago.

The ‘gold standard’reference for determining hepatic histology used to be liver biopsy (LB). However, LB is an invasive procedure that has been associated with a risk of morbidity between 0.3% and 0.6%, and a risk of mortality of 0.05% [2]. Moreover, assessment of brosis by LB is limited by the variability of the distribution of brosis in the liver, and by inter- and intrapathologist variability, reported to be around 20% [3]. The FT-AT non-invasive alternatives to LB in patients infected with HCV (hepatitis C virus) include two combinations of simple serum biochemical markers: FT

MOTS CLÉSFibrotest-Actitest ; Marqueur non-invasif de la brose hépatique ; Hépatite chronique B ; Maladie alcoolique du foie ; Stéaose hépatique

24 Ph. Halfon et al.

for the assessment of brosis; and AT for the assessment of necroinammatory activity [4–11]. With biopsy as the standard reference, the diagnostic value of FT for a diagnosis of advanced brosis (bridging brosis), as estimated by the standardized area under the ROC curve (AUROC), is 0.84 (95% CI, 0.83–0.86) [4–11].

Many studies have been performed to evaluate the use of readily available laboratory tests to predict signicant brosis or cirrhosis in patients with HCV, and to substantially reduce the number of biopsies performed in the management of HCV infection. The primary objective of this review is to update the last published meta-analysis on the clinical vali-dation of FT-AT in the management of patients with chronic hepatitis C (CHC), chronic hepatitis B (CHB) and patients with alcoholic (ALD) or non-alcoholic fatty liver disease (NAFLD). The secondary aim was to offer an overview of the prognostic value of FT in CHC, CHB and ALD.

Description and initial area of application of FT-AT

Poynard et al., in 2001, proposed a scoring algorithm using a panel of ve biochemical markers—!2-macroglobulin; apoli-poprotein A1, haptoglobin, "-glutamyl-transpeptidase (GGT) and total bilirubin for liver brosis measurement (FT)—plus alanine aminotransferase (ALT) for liver activity (ActiTest), adjusted by age and gender [1]. These non-invasive tests are able to discriminate, with great accuracy, between the absence of signicant brosis (F0/F1 on METAVIR scoring) and clinically signicant brosis (F2/F3/F4), and minor (A0/A1) vs relevant necroinammatory (A2/A3) activity, in patients with chronic HCV.

Analytical validation and recommendations

Pre-analytical recommendation

Biochemical assays are usually performed with fresh serum. Serum can be decanted and stored for a maximum of 72 h at +2–8 °C, under no-light conditions. Assays of the specic proteins (!2-macroglobulin, haptoglobin and apolipoprotein A1) can be carried out on serum stored at +2–8 °C for up to 5 days. For deferred protein assays beyond 5 days, fresh serum must be frozen at –80 °C, although freezing and thawing can only be done once. Fasting is not mandatory for FT-AT.

Analytical recommendations

The dosage methods for each of the FT-AT parameters have been veried and tested under standardized conditions, as listed in the technical recommendations (www.biopredic-tive.com). Following the analytical recommendations is mandatory and ensures the quality of the results.

For specic protein dosages, two analytical methods—nephelometry and turbidimetry—have been validated using a large panel of analyzers, and permit the routine use of FT-AT

in any laboratory. For ALT, the method using pyridoxal phos-phate and the calibration approved by the IFCC will improve the results and transferability between different analytical systems. Moreover, using calibrations according to the IFCC for all biochemical parameters will improve transferability between different analytical systems [13, 14].

Updated FT meta-analysis in patients with chronic HCV infection and in patients with CHB, ALD or NAFLD

The primary outcome was the differentiation of mild and moderate brosis (F0– F1 vs F2– F4). This endpoint was selected because it is typically considered an indication for antiviral therapy, and most clinicians perceive this to be the role of the currently available brosis markers, at least in the short term until more precise tools are developed.

Methods

Design

To select published studies, we used the Standards for Reporting of Diagnostic Accuracy (STARD) criteria and the Cochrane Database of Systematic Reviews (CDSR) methods [15]. Key STARD criteria include factors such as whether: 1) the study population is relevant to the clinical question being addressed; 2) there is an clear description of the population from which the patients were drawn, as well as actual inclusions and exclu-sions; 3) recruitment and the mode of sampling are adequately described; 4) researchers interpreting the non-invasive test are blinded to the reference test result; and 5) sufcient data are provided to complete a 2×2 table of true and false positive and negative diagnoses. Studies with only a published abstract offered insufcient data and were excluded [16].

Search strategy

We searched MEDLINE with the key word ‘FibroTest’, and hand-searched key journals (Gastroenterology, Hepatology, Journal of Hepatology, Gut, Journal of Viral Hepatitis and American Journal of Gastroenterology) from February 2001 to June 2008 to validate the search, as well as abstract books of the American and European Associations for the Study of Liver Disease annual meetings.

Inclusion and exclusion criteria

We excluded all studies except those that included: patients with chronic liver disease; stated that all patients had under-gone FT and liver biopsy; provided data for true positives and negatives, false positives and negatives, and AUROCs for advanced brosis; stated that the FT had been assessed blind to the biopsy; and stated the method used for dening the degree of brosis. We were careful to avoid including data from duplicate publications.


Data extraction

To allow comparisons between causes of liver disease in the studies, we categorized patients into ve classes: CHC; CHB; NAFLD; ALD; and mixed.

We extracted the following, whenever possible, from the published studies and from the integrated database for sensitivity analyses: study design (prospective or retrospective); analytical procedures (fresh serum and compliance with the recommended procedures or not); spectrum of disease (patients with elevated or normal transaminases); co-morbidity (several concomitant diseases, including HCV, HBV, alcohol consumption, HIV co-infection and presence/absence of renal disease); and whether or not the study was performed by the FT inventor group (as ‘yes’, ‘no’and ‘mixed groups including inventor’); and simultaneous biopsy (less than one week or not). Patient inclusion was never dependent on the result of the non-invasive test under investigation.

Results

Databases

A total of 39 studies (one population = one study) published between 2001 and 2008 were identied (Table 1) [4–11, 17–39]; however, in one study, the AUROC was unknown [20] and so was not included, resulting in 38 included studies (Figure 1). This gave a total of 7985 patients with both FT and biopsy (4600 HCV, 1580 HBV, 267 NAFLD, 524 ALD and 1014 mixed). One study of 208 patients with ALD focused on the diagnostic value of the AshTest for the diagnosis of alcoholic hepatitis [25], and details of the FT AUROCs for the diagnosis of brosis, previously not given in the original publication, have now been included in the present overview (Table 1). One study involved 258 patients with different biomarkers and biopsy, and FT details have been passed on to the present authors for inclusion in the present study.

ALDNaveauThabutCales 2AveHBVPoynard 5Poynard 6Poynard 4Myers 2ZhaoSebastianiAveHCVCacoubVaraudSebastiani 4Sebastiani 1ValletPoynard 2WilsonPoynard 3GigorescuSebastiani 3HalfonHalfon-ToursSebastiani 2SeneImbert 1LeroyCasteraMoraliMyers 1Cales 2Imbert 2AveMixedAdlerCales 1CallewaertCocoAveNAFLDRatziu 2Ratziu 1Ave Total

Aut

hor

Mean Di!erence0.0 0.1 0.2 0.2 0.3 0.4 0.5 0.5 0.6

Observed AUROCs Combined ALD HBV HCV Mixed NAFLD

Fibro Test AUROCs vs Random (0.50) Updated Meta-analysis

Figure 1 Meta-analysis of the observed area under the ROC curves (AUROC) assessed in published studies of FibroTest diagnostic value. AUROCs were all statistically signicant for FibroTest (P < 0.001, upper panel). There was no signicant difference among the different liver diseases. ALD: alcoholic liver disease; HBV: hepatitis B virus; HCV: hepatitis C virus; NAFLD: non-alcoholic fatty liver disease. Méta-analyse de l’aire sous la courbe ROC observée (AUROC) estimée selon les études publiées sur la valeur diagnostique du FibroTest. Les AUROC sont toutes signicativement plus élevées pour leFibroTest que la valeur du hasard 0,50 (panel supérieur) (p < 0,001). Il n’y avait pas de différence signicative entre les différentes étiologies de maladies hépatiques. ALD : maladie alcoolique du foie, HBV : hépatite B ; HCV : hépatite C ; NAFLD : stéatopathie métabolique.


Table 1 Characteristics of FibroTest diagnostic studies for staging hepatic brosis in patients with chronic liver disease. Caractéristiques des études du Fibrotest pour le diagnostic de la brose hépatique chez les malades avec maladie hépatique chronique.

First author {ref}

Patients (n)

Methodology

Age

AURO

C SE

DAN

A

Size (mm

)

Independent

Guidelines and

fresh serum

Simultaneous

biopsy and FT (< 1 w

eek)

High-risk prole

$ (%)

HCV n = 23

Imbert 1, 2001 (1)

189 Prospective

Single-center

Training cohort

47 0.84

0.03

2.03 16 No Yes Yes NA

Imbert 2, 2001 (1)

134 Prospective

Single-center

Validation cohort

48 0.87

0.03

2.16 16 No Yes Yes NA

Poynard 1, 2002 (36)

299 Retrospective

Randomized

Multicenter

41 0.74

0.03

1.42 NA Mixed Yes No NA

Poynard 2, 2003 (37)

352 Retrospective

Randomized

Multicenter

Before treatment

45 0.73

0.03

1.71 17 Mixed No No 0

(0)

Poynard 3, 2003 (37)

352 Retrospective

Randomized trial

Multicenter

After treatment

47 0.77

0.03

1.73 17 Mixed No No 0

(0)

Rossi, 2003 (17)

125 Prospective

Multicenter

40 0.74

0.05

1.95 NA Yes No Yes 0

(0)

Myers 1, 2003 (18)

130 Retrospective

Single-center

HCV-HIV

co-infection

38 0.86

0.04

2.15 NA No Yes No NA

Castera, 2005 (19)

183 Prospective

Single-center

51 0.84

0.03

1.95 17 Yes Yes Yes NA

Cales 2, 2005 (26)

120 Prospective

Single-center

Validation cohort

44 0.86

0.06

2.09 21 Yes No Yes NA


Table 1 (suite) Characteristics of FibroTest diagnostic studies for staging hepatic brosis in patients with chronic liver disease. Caractéristiques des études du Fibrotest pour le diagnostic de la brose hépatique chez les malades avec maladie hépatique chronique.

First author {ref}

Patients (n)

Methodology

Age

AURO

C SE

DAN

A

Size (mm

)

Independent

Guidelines and

fresh serum

Simultaneous


eek)

High-risk prole

$ (%)

Varaut 1, 2005 (21)

50 Retrospective

Single-center

Dialysis patients

48 0.53

0.04

1.61 19 Yes No No 2

(4)

Varaut 2, 2005 (25)

60 Retrospective

Single-center

Kidney recipients

44 0.71

0.04

1.84 19 Yes No No 2

(3.3)

Halfon, 2002 (38)

504 Prospective

Multicenter

45 0.79

0.02

1.87 15 Yes Yes Yes 15

(3)

Sebastiani 1, 2006 (22)

65 Prospective

PNALT

45 0.71

0.04

2.21 18 Yes Yes Yes Excluded


125 Prospective

EALT

50 0.81

0.03

1.83 18 Yes Yes Yes Excluded

Wilson, 2006 * (23)

115 Retrospective

Multicenter

30% HIV

42 0.74

0.05

1.87 11 Yes No Yes NA

Sene, 2006 (39)

138 Prospective

Single-center

Cryoglobulinemia Vasculitis

58 0.83

0.03

3.05 18 No Yes No 11

(8)

Halfon 2, 2007 (27)

158 Prospective

Single-center

41 0.79

0.03


Leroy, 2007 (28)

180 Prospective

Single-center

44 0.84

0.03


Grigorescu, 2007 (29)

206 Single-center 47 0.78

0.02

1.80 NA Yes Yes No? Excluded

Vallet-Pichard, 2007** (30)

258 Retrospective Single-center

? 0.73 0.03

1.65 ? Yes ? No ?

Morali, 2007 (31)

325 Prospective Multicenter

? 0.85 0.02

2.53 ? Yes ? ? ?

Cacoub, 2008 (48)

272 Retrospective, Multicenter

? 0.64 0.02

1.60 ? Yes ? No ?


Table 1 (suite) Characteristics of FibroTest diagnostic studies for staging hepatic brosis in patients with chronic liver disease. Caractéristiques des études du Fibrotest pour le diagnostic de la brose hépatique chez les malades avec maladie hépatique chronique.

First author {ref}

Patients (n)

Methodology

Age

AURO

C SE

DAN

A

Size (mm

)

Independent

Guidelines and

fresh serum

Simultaneous


eek)

High-risk prole

$ (%)

HBV (n = 5)

Myers 2 (6)

209 Prospective (42) Retrospective (167)

39 0.78

0.04

2.31 18 No Yes 1 NA

Poynard 4, 2005 (5)

214 Prospective 40 0.77

0.03

2.17 NA Mixed Yes 150 7

(3.2)



0.04

2.19 17 Yes Yes 0 Excluded

Poynard 5, 2008 (11)

924 Retrospective 39 0.76

0.02

1.77 13 Mixed Yes 90 80 excluded

(8)

Zhao, 2007 (24)

123 Prospective, Single-center

? 0.81 0.04

2.20 ? Yes Yes ? ?

ALD (n = 2)

Naveau, 2005 (8)

221 Prospective

Single-center

47 0.84

003

2.34 15 Mixed Yes 9 4

(1.8)

Thabut, 2006 (25)

208 Prospective

Two centers

51 0.91

0.02

2.98 12 Mixed Yes 0 15

(7.2)

NAFLD (n = 2)

Ratziu 1, 2006 (9)


0.03

2.30 20 No Yes 0 5

(2.9)

Ratziu 2, 2006 (9)


0.04

2.04 18 Yes Yes 0 2

(2)

Mixed (n = 4)

Cales 1, 2005 (26)

478 Prospective, Single-center HCV, HBV, ALD

45 0.82

0.03

2.08 18 Yes No < 7 NA

Callewaert, 2004 (34)

106 Prospective

HCV and ALD

NA 0.89

0.04

2.73 NA Yes Yes NA NA

Coco, 2007 (35)

164 Prospective

HCV and HBV

50 0.89

0.05

3.15 25 Yes Yes 90 NA

Adler, 2008 (33)

290 HCV, HBV, ALD, NAFLD

0.80 0.02

NA ? Yes ? ? ?

*Details for stages given out of 119, not 115; **half of Knodell F3 has been counted as METAVIR F2 NA: not available; PNALT: persistently normal ALT; EALT: elevated ALT $High-risk prole dened as hemolysis, Gilbert’s syndrome or acute inammation; mean 143/3495 (4.1%)


Prospective analysis of the prognostic value of biomarkers (FT) in patients with chronic hepatitis C and in patients with CHB, ALD or NAFLD

Statistical analysis

Comparison of FT diagnostic values for different chronic liver diseases

The main endpoint was the FT value for the diagnosis of advanced brosis (bridging brosis, or stages F2– F4 of the METAVIR scoring system) [3, 40, 41], as assessed by the area under the receiver operating characteristic curve (AUROC).

Statistical methods

A signicance level of 5% was used as the alpha risk. Each estimate was given with its 95% condence interval (95% CI). Comparisons of the odds ratios and percentages between strata were performed using the 95% CI. The primary analysis was per patient. In two studies, patients were included twice, as they had had FT and biopsy both before and after treatment; a sensitivity analysis was performed including and excluding these studies.

We used a random-effects model for the primary meta-analysis to obtain a summary estimate for the AUROCs with a 95% CI of FT compared with liver biopsy.

The AUROC was used as a measure of discrimination, estimated by the empirical (non-parametric) method of DeLong et al. [42], and compared using the paired method of Zhou et al. [43]. All analyses were performed on NCSS

ALDNaveauThabutCales 2AveHBVPoynard 5Myers 2Poynard 4Poynard 6ZhaoSebastianiAve

HCVCacoubSebastiani 1VaraudSeneSebastiani 4RossiWilsonPoynard 2ValletMoraliPoynard 3Poynard 1GigorescuHalfonSebastiani 3Sebastiani 2Imbert 1LeroyMyers 1Cales 2Imbert 2Halfon-ToursCasteraAveMixedCocoCales 1CallewaertAve

NAFLDRatziu 2Ratziu 1Ave Total

Aut

hor

Mean Di!erence

0.0 0.1 0.2 0.2 0.3 0.4 0.5 0.5 0.6

Adjusted AUROCs Combined ALD HBV HCV Mixed NAFLD

Fibro Test AUROCs vs Random (0.50) Updated Meta-analysis

Figure 2 Meta-analysis of the standardized area under the ROC curves (AUROC) assessed in published studies of FibroTest diagnostic value. There was no signicant difference among the different liver diseases. ALD: alcoholic liver disease; HBV: hepatitis B virus. Méta-analyse des aires sous la courbe ROC standardisées estimées selon les études publiées sur la valeur diagnostique du FibroTest. Il n’y avait pas de différence signicative entre les différentes maladies hépatiques. ALD : maladie alcoolique du foie, HBV : hépatite B


software (Kaysville, Utah, USA). Sensitivity analyses compared standardized AUROCs for prespecified items.

Meta-analysis was performed twice—once according to the absolute value of the observed AUROCs (ObAUROC), and once according to the AUROCs standardized for the spectrum of fibrosis stages (AdAUROC). We have previ-ously demonstrated that AUROCs are strongly related to the difference between the mean fibrosis stages in

advanced and non-advanced fibrosis groups (DANA); the AdAUROC is the AUROC adjusted for the difference in the observed DANA vs a standardized DANA of 2.5 fibrosis METAVIR units (DANA = 2.5 if there is a uniform prevalence of 0.20 in each of the five fibrosis stages); all AUROCs were adjusted to a DANA of 2.5 according to the formula: AdAUROC = ObAUROC + (0.1056) (2.5-ObDANA) [44, 45].

Table 2 Sensitivity analyses of FibroTest diagnostic values according to published studies. Analyses de sensibilité de la valeur diagnostique du Fibrotest selon les études publiées

Observed AUROC Standardized AUROCs

Characteristic (number of studies)

All (30) 0.80 (0.78–0.82) 0.84 (0.83–0.86)

Disease

HCV (19) 0.79 (0.76–0.82) 0.85 (0.82–0.87)

HBV (4) 0.77 (0.74–0.81) 0.80 (0.77–0.84)

ALD (2) 0.88 (0.81–0.84) 0.86 (0.80–0.92)

NAFLD (2) 0.81 (0.70–0.91) 0.84 (0.76–0.92)

Mixed (3) 0.86 (0.81–0.91) 0.85 (0.80–0.93)

Design

Prospective (19) 0.83 (0.81–0.85)* 0.86 (0.84–0.88)

Retrospective (11) 0.76 (0.73–0.78) 0.82 (0.80–0.84)

Authors

Independent (16) 0.80 (0.77–0.83) 0.85 (0.82–0.88)

Mixed (5) 0.76 (0.73–0.80) 0.83 (0.81–0.86)

Inventor (9) 0.83 (0.79–0.87) 0.84 (0.81–0.88)

Guidelines/fresh serum

No (7) 0.77 (0.72–0.79) 0.83 (0.80–0.86)

Yes (23) 0.82 (0.79–0.84)** 0.84 (0.83–0.86)

Length of biopsy

< 18 mm (6) 0.81 (0.76–0.86) 0.84 (0.80–0.87)

! 18 mm (18) 0.81 (0.78–0.84) 0.85 (0.83–0.87)

Timelag between serum and biopsy

! 7 days (8) 0.79 (0.74–0.84) 0.81 (0.78–0.84)

< 7 days (15) 0.80 (0.78–0.83) 0.85 (0.83–0.87)

Co-morbidity

No (21) 0.79 (0.77–0.81) 0.85 (0.83–0.87)

Yes (8) 0.83 (0.78–0.88) 0.83 (0.80–0.87)

*P = 0.001; **P = 0.05


Comparison of FT diagnostic values for different chronic liver diseases

The mean of the observed AUROCs was 0.80 (95% CI, 0.78–0.82) (Figure 1), and the mean of the standardized AUROCs was 0.84 (95% CI, 0.83–0.86) (Figure 2). There was signicant heterogeneity between studies for the ObAUROCs (Cochran Q = 56; P = 0.001), but not for the AdAUROCS (Cochran Q = 26; P = 0.19). Furthermore, there was no signicant difference between the ObAUROCs (Figure 1) or AdAUROCs (Figure 2) in HCV patients compared with other liver diseases (Table 2).

Sensitivity analyses according to study characteristics are detailed in Table 2. There were no signicant differ-ences in terms of liver disease, baseline transaminases, authors’independency, mean size (length) of biopsy, timelag between FT and biopsy, and co-morbidity. Prospective studies and those that followed guidelines were associated with higher ObAUROCs, but these differences were no longer signicant with the AdAUROCs.

FT prognostic value in HCV

The primary aim of the prospective study of Ngo et al. [46] was to assess the prognostic value of FT for 5-year HCV-related mortality and morbidity compared with the prog-nostic value of histological features found on liver biopsy, the current standard reference. A secondary endpoint was to validate whether or not the classication of HCV patients into three classes of severity by FT values is truly associated with mortality and morbidity.

The study included a prospective hospital-based cohort of 537 CHC patients with LB and FT analyzed on the same day. Complications related to liver disease were dened as liver-related death, liver transplantation or one of the following: decompensation; variceal bleeding; or hepatocellular carci-noma (HCC). The observed survival was compared with the survival expected in the general French population matched for age, gender, follow-up period and conditional probability of death based on ofcially published census tables.

Panel (A) Panel (B)

Without HCV complications

Number of patients

baseline 30months

60months

FT < 0.32 243 191 122 FT 0.32 –0.58 137 115 60 FT > 0.58 157 117 61

Without HCV -related death

Number of patients

baseline

30months

60months

FT < 0.32 243 191 122

FT 0.32 –0.58 137 115 61

FT > 0.58 157 133 75

0.00

0.25

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0 10 20 30 40 50 60 70

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Figure 3 Five-year survival curves predicted by FibroTest (FT) severity groups at baseline. Survival without complications [Panel (A)] and without death [Panel (B)] related to HCV were higher in patients with minimal (green line) or moderate (orange line) FibroTest values in comparison to severe values (red line) (all log-rank tests, P < 0.001); there was no signicant difference between minimal and moderate groups except for overall survival (P = 0.02) (data not shown). Courbes de survie à 5 ans selon la gravité du FibroTest (FT) initial. La survie sans complications (Panel A) et sans décès (panel B) lié au virus de l’hépatite C était plus élevée chez les patients avec valeurs de FT minimes (ligne verte) ou modérée (ligne orange) par rapport aux valeurs sévères (ligne rouge) (test de log rank, p<0,001) ; pas de différence évidente entre les groupes minimes et modérés sauf pour la survie globale (p=0 ;002) (données non montrées).


In this study, FT classied 157 patients as having severe brosis (FT score > 0.58), 137 as moderate brosis (0.32–0.58) and 243 as no or minimal brosis (< 0.32). Baseline biopsy found 45% F2/F3/F4. Only 26% of patients had received treatment, mostly with peg-interferon and ribavirin, and those with severe brosis had been treated more frequently than those without. Only 50% of the treated patients achieved a sustained virological response.

At 5 years, the global survival rate without HCV-related complications was 93% (95% CI = 91–96%), and the survival rate without HCV-related death was 98% (95% CI = 96–99%; nine deaths) (Figure 3). The overall survival was 95% (95% CI = 93–97%; 20 deaths), which was lower than the 97% (95% CI = 97–98%) in paired controls (P = 0.06).

In patients with severe brosis (FT score > 0.59), survival without HCV complications was 78.5% (95% CI = 71.2–85.9%; 28 complications), and survival without HCV-related death was 92.7% (95% CI = 88.0–97.3%; 9 HCV-related deaths). In patients with moderate brosis (FT score 0.32–0.58), survival without HCV complications was 98.8% (95% CI = 96.6–100%; one complication; P < 0.001) and survival without HCV-related death was 100% (no HCV deaths; P < 0.001). In patients with minimal brosis (FT score < 0.32), the rates of survival were both 100% (no complications, P < 0.001; and no HCV deaths, P < 0.001) (Table 3).

FT was a better predictor than LB histological stag-ing for HCV complications, with AUROCs (95% CI) = 0.96 (0.93–0.97) vs 0.91 (0.85–0.94) (P = 0.01) for LB, and for HCV-related deaths, with AUROCs = 0.96 (0.93–0.98) vs 0.87 (0.70–0.94) (P = 0.046) for LB. The prognostic value of FT was signicantly higher than brosis staging by LB multivariate regression analyses (P < 0.01), taking into account treatment response and known prognostic factors (HIV co-infection, alcohol consumption).

Ngo et al. concluded that FT had a 5-year prognostic value that, at least, was similar to that of LB as it is a true surrogate marker of hepatitis C severity, with validation in the three classes of brosis previously dened as ‘minimal’ (green zone), ‘moderate’ (orange zone) and ‘severe’ (red zone) (Figure 4).

FT prognostic value in HBV

The combination of transaminases (ALT), biopsy, hepatitis Be antibody (HBeAb) and viral load classically denes the status of ‘inactive carrier’in patients with chronic hepatitis B (CHB).

Table 3 Survival according to baseline FibroTest class of brosis: no or minimal, moderate and severe. Survie selon la valeur initiale de brose selon le Fibrotest : absente ou minime, modérée et sévère.

Survival accord-ing to baseline FibroTest

n HCVcom-plica-tions

Survival without HCV complications

Death related to HCV

Survival without HCV death

Death Global survival Survival in matched controls

0.00–0.31

No/minimal brosis

243 0 100 0 100 2 98.9 (97.3–1.00)

98.7 (98.6–98.9)

0.32–0.58

Moderate brosis

137 1 98.8 (96.6–1.00)

0 100 6 93.4 (88.1–98.7)

97.4 (96.9–97.9)

0.59–1.00

Severe brosis 157 28 78.5* (71.2–85.9)

9 92.7* (88.0–97.3)

12 90.5* (85.3–95.7)

95.1* (92.3–96.0)

Never treated 64 13 72.5 (58.7–86.2)

7 84.5 (73.2–95.7)

10 78.5 (66.2–90.9)

94.2 (92.5–96.1)

Non-responders 54 12 74.0 (61.0–87.1)

2 95.1 (88.45–1.00)

2 95.1 (88.5–1.00)

95.8 (94.8–96.7)

SVR 39 2 92.3 (83.9–1.00)

0 100 0 100 95.6 (94.6–96.7)

All 537 29 93.2 (90.7–95.7)

9 97.8 (96.3–99.3)

20 95.0 (92.8–97.2)

97.3 (97.1–97.6)

*Signicantly higher in SVR (sustained viral response) vs both non-responders and non-treated; **Cirrhosis reversal observed in 8/13 patients in SVR as assessed by FibroTest vs 1/19 in non-responders and 0/8 in non-treated patients


The primary aim of the Ngo et al. study was to compare the 4-year prognostic value of FT-AT with viral load and biopsy (in a subpopulation with simultaneous biopsy). The secondary aim was to compare the 4-year prognostic value of combining FT-AT and viral load for a better denition of inactive HBV carrier status [47].

The main endpoint was the absence of liver-related com-plications, dened as death, liver transplantation or any of the following: decompensation (ascites, hepatic encephalopathy

or jaundice, with total bilirubin > 51 #mol/L); variceal bleeding; or hepatocellular carcinoma (HCC). The adjust-ment factors were age, gender, HBeAg, ethnic origin, alcohol consumption, HIV-hepatitis D virus (HDV)-HCV co-infections and treatment.

A total of 1074 patients (mean age 41 years, 69% male, 47% African, 27% Asian, 20% Caucasian and 15.5% co-infected) with baseline FT-AT and viral load were included, and followed-up for a mean of 7.7 years (2.5 years prospective

Panel (A)

Panel (B)

Panel (C)

AUROCs of survival without HCV complications

FT Biopsy Pugh APRI Forns

0.96 0.91 0.80 0.82 0.86

P value 0.01 0.006 0.03 0.04

AUROCs of survival without HCV death

FT Bio psy Pugh APRI Forns

0.96 0.87 0.89 0.82 0.87

P value 0.04 NS 0.02 0.04

AUROCs of overall survival

FT Biopsy Pugh APRI Forns

0.76 0.66 0.71 0.67 0.73

P value 0.04 NS 0.02 0.04 0.00

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Figure 4 Comparison of the AUROCs for survival endpoints between FibroTest (FT) and histology. Panel (A): AUROCs of survival without HCV complications; Panel (B): AUROCs of survival without HCV-related death; Panel (C): AUROCs of overall survival. NS: not signicant. Comparaison des AUROC pour la survie entre le FibroTest (FT) et l’histologie. Panel A : AUROC pour la survie sans complication liée au virus de l’hépatite C ; Panel B : AUROC pour la survie sans décès liés au virus de l’hépatite C ; Panel C : AUROCs pour la survie globale. NS : non signicatif.


Table 4 Four-year prognostic value of FibroTest compared with ALT and viral load for survival without prediction of HBV-related complications. Valeur pronostique à 4 ans du FibroTest par rapport à l’ALT et la charge virale sur la survie sans complications liées au virus de l’hépatite B.

Method AUROC (95% CI) Regression coefcient in multivariate Cox model

FibroTest 0.89 (0.84–0.93)* 5.2 (3.5–6.8; P < 0.0001)

Viral load 0.63 (0.53–0.70) 0.52 (0.14–0.89; P = 0.008)

ALT 0.53 (0.46–0.60) -0.001(-0.02–0.0001; P = 0.04)

* P < 0.0001 vs all others

ALT: alanine aminotransferase; HBV: hepatitis B virus

Table 5 Ten-year survival in patients with alcoholic liver disease according to baseline FibroTest. Survie à 10 ans des malades avec maladie alcoolique du foie selon la valeur initiale du FibroTest.

Baseline values n Liver- related death

Survival or non-liver-related death

Death Overallsurvival

Overall survival in matched controlsb

FibroTest value

0.00–0.31

No or minimal brosis 81 5 92.0 (84.9–99.0) 21 71.4 (60.7–82.2) 97.7 (97.0–98.4)

0.32–0.58

Moderate brosis 43 4 87.5 (75.5–99.5) 12 69.8 (55.2–84.4) 97.8 (97.1–98.5)

0.59–1.00

Severe brosisa 94 32 62.6 (52.2–73.1) 50 42.4 (31.1–53.6) 96.4 (95.5–97.3)

All 218 41 78.5 (72.4–84.6) 83 58.8 (51.7–65.9) 97.2 (96.7–97.6)

aSurvival signicantly lower than in the other two groups (P < 0.0001) bOverall survival of patients with alcoholic liver disease was signicantly lower than that in matched controls, patients with no or minimal brosis, moderate brosis and severe brosis (all P < 0.0001)

Table 6 Prognostic value of the clinical performance of the tests is based on three published studies, involving a total of 1873 patients. La valeur pronostique de la performance clinique est basée sur 3 étude publiées incluant au total 1873 patients.

Liver disease Number of patients

Mean duration of follow-up

No death and no liver complications AUROC (95% CI)

No liver-related death

No death (overall survival)

Chronic hepatitis C 537 5 years 0.96 (0.75–0.79) 0.96 (0.75–0.79) 0.76 (0.81–0.85)

Chronic hepatitis B 1074 4 years 0.89 (0.84–0.93) 0.95 (0.91–0.97) 0.94 (0.89–0.96)

Alcoholic liver disease 262 10 years Not performed 0.79 (0.68–0.86) 0.69 (0.61–0.76)

All AUROCS were statistically signicant (P < 0.0001) (no prognostic value)


and 5.2 years retrospective). Manufacturers’denitions were used: normal FT (" 0.27); normal AT (" 0.29). The prevalences according to three classes of viral load in IU/mL (low = < log-3, intermediate = log-3 to log-5 and high = > log-5) were 55%, 28% and 17%, respectively. The accuracy [AUROC (95% CI)] of FT in 97 patients with simultaneous liver biopsy in the diagnosis of advanced brosis was similar to previous validations [AUROC = 0.83 (0.71–0.91)], and higher than ALT [0.60 (0.47–0.71)] and viral load [0.53 (0.39–0.63)] (all P < 0.0001), but not statistically signicantly different from LB.

At the 4-year follow-up, 50 complications were reported (survival without complications was 93.4%) and 36 had died (survival 95.0%), including 27 deaths related to HBV (survival 96.1%). The prognostic value of FT was higher than that of viral load or ALT, when compared using AUROC curves (all P < 0.0001), survival curves and multivariate Cox models (Table 4). Among the 336 patients without co-infection with either HCV, HDV or HIV, but who fullled the classical denition of inactive carriers, 74 (22%) had advanced brosis according to FT, and three had died or had complications 4 years later. A new denition of inactive carriers was pro-posed with an algorithm combining ‘zero’scores with FT-AT (F0 and A0) and viral-load classes. This algorithm provided a 100% negative predictive value (NPV) for the prediction of liver-related complications or death at 4 years.

In conclusion, the results showed an overall survival of patients with non-severe brosis at baseline that was similar to that of matched controls in the general popula-tion. In patients with severe brosis, overall survival was 17% lower than that of the controls. The combination of FT with baseline viral load proved to be the best combination for predicting HBV survival without complications at the 4-year follow-up, regardless of treatment and other risk factors.

FT prognostic value in ALD

In the study by Naveau et al., the diagnostic and prognostic values of FT was assessed at 10 years [8, 11] (Table 5).

A total of 218 consecutive patients with ALD and available LB examinations and biomarkers were included. LB and FT were performed less than one month apart, and FT was assessed according to analytical recommendations. For inclusion, patients had to have consumed at least 50 g/d of alcohol during the previous year. Exclusion criteria included the presence of concomitant liver disease, HCV, HBV, HIV antibodies and immu-nosuppression, severe associated disease, non-available serum and non-available biopsy. Biomarkers were compared using univariate [area under the diagnostic and prognostic (10-year) ROC curves (AUROCs)] and multivariate analyses (logistic regression and Cox). Overall survivals were compared with those of national reference populations, matched according to year, age and gender. The median follow-up was 8.2 years; 78% were male, 31% had cirrhosis and 21% were abstaining from alcohol at the time of follow-up.

Altogether, 85 patients died, including 42 deaths related to liver complications. The diagnostic FT values (AUROC ± SE) for advanced brosis (F2/F3/F4) were 0.83 ± 0.03, and 0.94 ± 0.02 for cirrhosis. The prognostic FT values for liver disease-related deaths (AUROC = 0.79 ± 0.04) did not differ from those of biopsy brosis staging (0.77 ± 0.04). As for hepatitis

C and B, the three classes of brosis severity according to FT score were able to predict a low-risk group (FT " 0.31: 92% survival without complications), an intermediate-risk group (FT 0.31–0.58: 87.5%) and a severe-risk group (FT 0.59–1: 62.6%). The overall survivals (whatever the cause of death) in the three classes were all lower (P < 0.0001) than those in the matched general population: 71% vs 98%, 70% vs 98% and 42% vs 96%, respectively. In the multivariate analyses adjusted for alcohol abstinence, the most signicant predictors were FT (P = 0.002) and biopsy (P = 0.05).

In conclusion, in patients with ALD, FT and LB had simi-lar prognostic values, as observed in patients with chronic hepatitis C or B. As biomarkers and biopsy similarly predicted survival or non-liver-related death, biomarkers appear to have the same rate of error as LB for baseline diagnosis (Table 6).

Usefulness of FT-AT in specic HCV populations

Patients with HCV-HIV co-infection

Two studies were performed, involving 130 and 274 patients with HCV-HIV co-infection, using baseline serum sample assessment and liver biopsy evaluation [23, 48]. The study was by Cacoub et al. independently of the Poynard team, and compared other biomarkers of brosis. In the Cacoub et al. and Myers et al. studies, FT staged liver brosis in all patients with AUROCs of 0.78 and 0.86, respectively, with a diagnosis of ! F2.

In conclusion, FT, instead of LB, should be recommended for HIV-HCV co-infected patients for diagnosis of signicant brosis.

Hemophiliac patients

Hemophiliacs belong to a distinct group in whom the prevalence of HCV is highest, ranging from 70% to 90%. Not unexpectedly, there is a reluctance to perform LB in patients with coagulation disorders, given the concerns over the safety of the procedure in such a population. Maor et al. looked at the distribution of brosis stage estimated by FT in 132 HCV-infected hemophilia patients (124 male), and found scores compatible with F0– F1 and F2– F4 in 65% and 35%, respectively of the patients. In clinically dened sub-groups, the FT score estimated advanced brosis (F3– F4) in all patients with clinically suspected advanced liver disease whereas, in all HCV RNA-negative patients, the scores cor-related with minimal brosis (F0– F1) [49].

In conclusion, a practical combination of tests (FT, FibroMeters and FibroScan) has the potential to avoid the need for liver biopsy in the majority of hemophilia patients.

Patients with chronic inammation and mixed cryoglobulinemia vasculitis

Two important serum parameters included in the FT-AT—haptoglobin and !2-macroglobulin—may be inuenced by


the presence of serum inammation markers. Of 138 HCV-infected patients with LB and FT performed on the same day, 36 (26%) had systemic vasculitis and 37 (27%) had serum inammation. The diagnostic value of FT (F2/F3/F4 vs F0/F1) had an AUROC of 0.83, with no differences between patients with and without systemic vasculitis (0.81 vs 0.84; P = 0.7), or between patients with and without serum inammation (0.91 vs 0.79; P = 0.2).

In conclusion, the accuracy of other non-invasive biomarker indices was not inuenced by the presence of serum inammation or systemic vasculitis [50]. Also, serum levels of !2-macroglobulin were not inuenced by the pres-ence of serum inammation, which accords well with recent studies demonstrating that, in humans, !2-macroglobulin is not an inammatory acute-phase protein [51]. However, severe acute serum inammation, such as induced by an acute bacterial infection, may increase serum levels of haptoglobin and, consequently, decrease the reliability of FT-AT.

Patients with renal failure

The diagnostic accuracy of FT was assessed in 110 patients with biopsy-proven HCV, including 60 renal-transplant recipients, and 50 hemodialysis/renal-transplant patients, with chronic HCV infection [25]. The authors concluded that, as the FT has similar diagnostic value as seen in other populations with CHC, this initial study should be extended to include patients with renal failure to obtain a denitive recommendation.

Patients with normal ALT

Several studies were performed using biomarkers in HCV carriers with normal or persistently normal ALT (PNALT) [24, 52, 53]. Indirect comparisons between non-invasive markers have to be standardized according to the prevalence of stages dening advanced and non-advanced brosis to avoid spectrum bias. This is particularly true in patients with normal ALT, in whom F2 is usually the most frequently diagnosed stage among the advanced stages that lead to spectrum bias $44%. After correction for spectrum bias, FT was found to be as effective in patients with baseline normal transaminases (NALT) as it is in patients with elevated transaminases, and may be an alternative to liver biopsy [54].

Patients with diabetes

Jacqueminet et al. examined prospectively the efcacy of a screening strategy with FT in 1131 consecutive patients with no history of liver disease in patients with diabetes [55]. The biomarker data were obtained, and patients with presumed advanced brosis were reinvestigated by a hepatologist, using elastography and, if necessary, ultrasonography, endoscopy or LB. The biomarker predicted advanced brosis in 63 (5.6%) of the 1131 patients. A total of 45 patients were reinvestigated, and advanced brosis was conrmed in 32, resulting in a 2.8%

(32/1131) prevalence of conrmed advanced brosis, along with ve cases of cirrhosis and four cases of hepatocellular carcinoma. In the population with type 2 diabetes who were 45 years or older, the prevalence of conrmed advanced brosis was 4.3% (30/696), and hepatocellular carcinoma was 5.7% (4/696).

In conclusion, FT may be useful in the detection of advanced brosis in patients with type 2 diabetes.

Patients with allograft liver transplants

A recent study aimed to assess, in patients retrospectively, immediately and during the rst year after transplanta-tion for HCV cirrhosis, the value of FT-AT as non-invasive markers of brosis and other disease activity. The results demonstrated that an absence of normalization of FT-AT after liver transplantation was predictive of complications or HCV relapse [56]. The dynamic of serum proteins included in FT-AT showed that their prole before transplantation persisted one week after transplantation and then declined gradually, to be replaced by graft serum proteins after one month. Long-term studies are needed to assess the role of FT-AT for HCV re-treatment in those who relapse.

FT in elderly patients and in children

Given the sparse data available on CHC in elderly patients, Thabut et al. determined the usefulness of FT-AT in a cohort of 6865 patients aged 65 years or older [57]. They used FT to compare the features and severity of CHC, and the efcacy and safety of antiviral therapy, in patients aged " 65 years and those > 80 years.

In one prospective study, de Lédinghen et al. assessed the feasibility of liver stiffness measurement, and compared FibroScan, FT and the aspartate transaminase/platelet ratio index (APRI) with LB for the diagnosis of cirrhosis in 116 chil-dren with chronic liver disease [58]. For the diagnosis of cirrhosis, the AUROC was 0.88, 0.73 and 0.73 for FibroScan, FT and APRI, respectively. However, only 33 liver biopsies were performed in this cohort. Further studies comparing non-invasive methods with liver biopsy may prove helpful for the management of chronic liver diseases in children.

Limitations of FT-AT and system expert recommendations

The overall applicability, prevalence of patients who are not at high risk of false positives or false negatives (HR-FP, HR-FN) after exclusion of the more frequent causes of FT failure (suspected Gilbert’s syndrome, hemolysis and acute inam-mation) was 95%. The most frequent abnormal value observed during post-marketing follow-up was haptoglobin < 0.08 g/L in 1.87% of patients. Among the patients with low haptoglobin, 0.51% of HR-FP cases had no other components supportive of a diagnosis of advanced brosis. Patients with extremely low haptoglobin may have had hemolysis, especially when the rest of the tests were minimally altered. HR-FP possibly due to


Gilbert’s syndrome was observed in 1.36%, whereas the most frequent cause of abnormally elevated values for bilirubin was Gilbert’s syndrome.

A quality-control study was carried out in a population in 954 apparently healthy blood donors. Validation algorithms detected 29 (3%) HR-FP proles, including nine Gilbert’s syndrome (0.9%) and four HR-FP cases with a hemolysis prole (0.4%). No blood donors had advanced brosis (F2/F3/F4), and 909 (98.3%) had either no or insignicant brosis (F0/F1; FT < 0.32).

Conclusion

FibroTest may be an alternative to liver biopsy in the four more common chronic liver diseases—namely, HCV, HBV, NAFLD and ALD. However, neither biomarkers nor biopsy alone are sufcient to allow denitive decisions to be made for a given patient, and all clinical and biological data must be taken into account.

However, due to the dramatically poor risk– benet ratio of liver biopsy (coefcient variation 40%, 0.3% severe adverse events and 3/10,000 mortality), it is surprising that so many opinion leaders and professional associations in the eld of hepatology continue to recommend it as the rst-line investigation for millions of people exposed to the risk of brosis. The present review reinforces our previous conclusion that, based on the current evidence, a wise recommendation would be a moratorium on liver biopsy as a rst-line procedure while awaiting studies that demonstrate its cost– benet prole compared with that of biomarkers [59]. Biopsy as a second-line estimate of liver injury should still be indicated for complex disorders or clinicobiological discordance.

The eld is evolving rapidly and, in France alone, a nationwide survey recently found that, of 546 hepatologists, 81% used non-invasive biomarkers (FT-AT) and 32% used elastography, with a dramatic decrease in the use of liver biopsy in more than 50% of patients with chronic hepatitis C, and a subsequent increase in the number of patients treated [60]. FT is available in more than 50 countries and the cost varies from 100–300 euros, depending on the country, and the cost of the ve components and algorithms. In France, the component cost has been covered by social security since 2002, while reimbursement of the algorithms has been approved since December 2006.

An overview by French health authorities has ofcially approved the non-invasive biomarkers FibroTest and elastography (FibroScan) as rst-line estimates of brosis in patients with chronic hepatitis C, with recommended reimbursement from the government, and approved liver biopsy only as second-line estimate in cases of discordance or non-interpretability of the non-invasive markers [61]. An updated overview for other chronic liver diseases is expected at the end of 2008. Guidance for deciding on the method of brosis assessment should take into considera-tion the patients’risk factors for erroneous results (such as hemolysis, Gilbert’s syndrome and acute inammation for FT, and obesity for FibroScan). In future, it is highly likely that there will be a place for patented algorithms, provided

that their risk– benet ratios are as well accepted as those for approved drugs 11 .

Conict of interest:

Competing interests T.P. is a consultant with a nancial interest in BioPredictive, the company marketing FibroTest, although the patents belong to Assistance Publique Hôpitaux de Paris, and M.M. is a full-time employee of BioPredictive. P.H. has neither a nancial interest in BioPredictive, nor is he a consultant for that company. As the corresponding author, P.H. had full access to all the data in the present study, and was responsible for the decision to submit this manuscipt for publication.

Authors’contributions P.H., T.P. and M.M. all contributed to the manuscript. T.P. designed the study, performed the statistical analyses, par-ticipated in coordinating all aspects of the study and data monitoring, and drafted the manuscript. All of the authors have read and approved the nal manuscript.

AcknowledgmentsThe authors are grateful to the Association pour la Recherche sur les Maladies Hépatiques et Virales for its support in the collection of data for this review.

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