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Compensated Advanced Chronic Liver Disease in Nonalcoholic Fatty Liver Disease: Two-Step Strategy is Better than Baveno Criteria

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Abstract

Background

Advanced fibrosis and cirrhosis (compensated advanced chronic liver disease [cACLD]) are clinically indistinguishable and increase risk of developing clinically significant portal hypertension. Baveno VII recommends using elastography to rule out and diagnose cACLD with liver stiffness measurement (LSM) cut-offs of 10/15 kPa.

Methods

In a retrospective analysis of 330 nonalcoholic fatty liver disease (NAFLD) patients, performance of the Baveno VII cut-offs for diagnosing cACLD was compared with newly suggested lower cut-offs (8/12 kPa). A model for detecting cACLD among those with LSM between 8 and 12 kPa was developed and compared with recently published models.

Results

Seventy (21.2%) of the 330 NAFLD patients had biopsy-proven cACLD. The Baveno VII cut-offs (10/15 kPa) had a lower sensitivity of 72.8% (60.9–82.8%) and a specificity of 93.4% (89.7–96.1%). Sensitivity and specificity of lower cut-offs (8/12 kPa) were 91.4% (82.3–96.8%) and 88.5% (83.9–92.1%), respectively. Modeling based on the presence of diabetes (odds ratio [OR] 3.625[1.161–11.320], p = 0.027) and serum aspartate aminotransferase (AST) levels (OR 1.636[1.098–2.436], p = 0.015) correctly identified 75.7% of patients with LSM between 8 and 12 kPa. Our model performed best with an area under receiver operator curve (AUROC) of 0.725 (95%CI 0.609–0.822), compared to Papatheodoridi (AUROC 0.626, CI 0.506–.736) and Zhou (AUROC 0.523, CI 0.403–0.640) models. A two-step strategy comprising application of lower LSM cut-offs followed by the predictive model correctly identified the presence of cACLD in 83% of the patients as compared to 75% by the Baveno VII cut-offs.

Conclusion

A two-step strategy employing lower LSM cut-offs and modeling based on diabetes and AST levels outperforms Baveno VII cut-offs for identifying cACLD in NAFLD patients.

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Abbreviations

cACLD:

Compensated advanced chronic liver disease

LSM:

Liver stiffness measurement

TE:

Transient elastography

NAFLD:

Nonalcoholic fatty liver disease

BMI:

Body mass index

DM:

Diabetes mellitus

AST:

Aspartate aminotransferase

ALT:

Alanine aminotransferase

Alk P:

Alkaline phosphatase

HBsAg:

Hepatitis B surface antigen

FIB-4:

Fibrosis-4 index

APRI:

AST-to-platelet ratio index

CAP:

Controlled attenuation parameter

IQR:

Interquartile range

PPLB:

Percutaneous plugged liver biopsy

NASH:

Nonalcoholic steatohepatitis

CRN:

Clinical research network

NAS:

NAFLD activity score

PPV:

Positive predictive value

NPV:

Negative predictive value

PLR:

Positive likelihood ratio

NLR:

Negative likelihood ratio

DA:

Diagnostic accuracy

AUROC:

Area under receiver operator curve

OR:

Odds ratio

CSPH:

Clinically significant portal hypertension

CPA:

Collagen proportionate area

HVPG:

Hepatic venous pressure gradient

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Authors and Affiliations

  1. Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi, India

    Anshuman Elhence, Abhinav Anand, Sagnik Biswas, Manas Vaishnav &  Shalimar

  2. Department of Pathology, All India Institute of Medical Sciences, New Delhi, India

    Rajni Yadav & Prasenjit Das

  3. Department of Gastrointestinal Surgery and Liver Transplant, All India Institute of Medical Sciences, New Delhi, India

    Rajesh Panwar

  4. Department of Surgical Disciplines, All India Institute of Medical Sciences, New Delhi, India

    Sandeep Agarwal

  5. Department of Radiodiagnosis, All India Institute of Medical Sciences, New Delhi, India

    Shivanand Gamanagatti

  6. Department of Gastroenterology, All India Institute of Medical Sciences, Patna, India

    Ramesh Kumar

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  1. Anshuman Elhence
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Contributions

All authors contributed to the study conception and design. Material preparation, data collection, and analysis were performed by Shalimar, Anshuman Elhence and Abhinav Anand. The first draft of the manuscript was written by Shalimar, and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.

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Correspondence to Shalimar.

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Elhence, A., Anand, A., Biswas, S. et al. Compensated Advanced Chronic Liver Disease in Nonalcoholic Fatty Liver Disease: Two-Step Strategy is Better than Baveno Criteria. Dig Dis Sci 68, 1016–1025 (2023). https://doi.org/10.1007/s10620-022-07579-5

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