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      Impact of Implementing a “FIB‐4 First” Strategy on a Pathway for Patients With NAFLD Referred From Primary Care

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          Abstract

          Detection of advanced fibrosis in nonalcoholic fatty liver disease (NAFLD) is essential for stratifying patients according to the risk of liver‐related morbidity. Noninvasive methods such as vibration‐controlled transient elastography (VCTE) and Fibrosis‐4 index (FIB‐4) have been recommended to identify patients for further assessment. The aim of this study was to assess the potential impact of implementing a “FIB‐4 First” strategy to triage patients entering a NAFLD assessment pathway. The pathway for patients with suspected NAFLD was piloted at a tertiary liver center. Referral criteria were 16‐65 years old, elevated alanine aminotransferase and/or steatosis on imaging, and absence of a previous liver diagnosis. A registered nurse risk‐stratified all patients based on VCTE and FIB‐4 was calculated. Potential alternative diagnoses were excluded with bloodwork. A total of 565 patients underwent risk stratification with VCTE with a 97% success rate. Ten percent had VCTE of at least 8 kPa; 560 patients had FIB‐4 available for analysis and 87% had values less than 1.3. Of those with a FIB‐4 of at least 1.3, 69% had a VCTE less than 8 kPa. Further modeling showed that the presence of diabetes, age, and body mass index had only a moderate impact on the association between FIB‐4 and elastography values if using a FIB‐4 threshold of 1.3. Conclusion: A FIB‐4 threshold of 1.3 was acceptable for excluding the presence of advanced fibrosis (assessed by VCTE). A staged risk‐stratification model using FIB‐4 and VCTE could save up to 87% of further assessments. This model could improve accessibility by moving the initial fibrosis evaluation to the medical home and helping to prioritize patients for further specialized care.

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          Magnetic Resonance Elastography vs Transient Elastography in Detection of Fibrosis and Noninvasive Measurement of Steatosis in Patients With Biopsy-Proven Nonalcoholic Fatty Liver Disease.

          Magnetic resonance imaging (MRI) techniques and ultrasound-based transient elastography (TE) can be used in noninvasive diagnosis of fibrosis and steatosis in patients with nonalcoholic fatty liver disease (NAFLD). We performed a prospective study to compare the performance of magnetic resonance elastography (MRE) vs TE for diagnosis of fibrosis, and MRI-based proton density fat fraction (MRI-PDFF) analysis vs TE-based controlled attenuation parameter (CAP) for diagnosis of steatosis in patients undergoing biopsy to assess NAFLD.
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            Clinical patterns of hepatocellular carcinoma in nonalcoholic fatty liver disease: A multicenter prospective study.

            Nonalcoholic fatty liver disease (NAFLD) represents the hepatic manifestation of metabolic syndrome and may evolve into hepatocellular carcinoma (HCC). Only scanty clinical information is available on HCC in NAFLD. The aim of this multicenter observational prospective study was to assess the clinical features of patients with NAFLD-related HCC (NAFLD-HCC) and to compare them to those of hepatitis C virus (HCV)-related HCC. A total of 756 patients with either NAFLD (145) or HCV-related chronic liver disease (611) were enrolled in secondary care Italian centers. Survival was modeled according to clinical parameters, lead-time bias, and propensity analysis. Compared to HCV, HCC in NAFLD patients had a larger volume, showed more often an infiltrative pattern, and was detected outside specific surveillance. Cirrhosis was present in only about 50% of NAFLD-HCC patients, in contrast to the near totality of HCV-HCC. Regardless of tumor stage, survival was significantly shorter (P = 0.017) in patients with NAFLD-HCC, 25.5 months (95% confidence interval 21.9-29.1), than in those with HCV-HCC, 33.7 months (95% confidence interval 31.9-35.4). To eliminate possible confounders, a propensity score analysis was performed, which showed no more significant difference between the two groups. Additionally, analysis of patients within Milan criteria submitted to curative treatments did not show any difference in survival between NAFLD-HCC and HCV-HCC (respectively, 38.6 versus 41.0 months, P = nonsignificant)
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              Determination of reliability criteria for liver stiffness evaluation by transient elastography.

              Liver stiffness evaluation (LSE) is usually considered as reliable when it fulfills all the following criteria: ≥10 valid measurements, ≥60% success rate, and interquartile range / median ratio (IQR/M) ≤0.30. However, such reliable LSE have never been shown to be more accurate than unreliable LSE. Thus, we aimed to evaluate the relevance of the usual definition for LSE reliability, and to improve reliability by using diagnostic accuracy as a primary outcome in a large population. 1,165 patients with chronic liver disease from 19 French centers were included. All patients had liver biopsy and LSE. 75.7% of LSE were reliable according to the usual definition. However, these reliable LSE were not significantly more accurate than unreliable LSE with, respectively: 85.8% versus 81.5% well-classified patients for the diagnosis of cirrhosis (P = 0.082). In multivariate analyses with different diagnostic targets, LSE median and IQR/M were independent predictors of fibrosis staging, with no significant influence of ≥10 valid measurements or LSE success rate. These two reliability criteria determined three LSE groups: "very reliable" (IQR/M ≤0.10), "reliable" (0.10 0.30 with LSE median 0.30 with LSE median ≥7.1 kPa). The rates of well-classified patients for the diagnosis of cirrhosis were, respectively: 90.4%, 85.8%, and 69.5% (P < 10(-3) ). According to these new reliability criteria, 9.1% of LSE were poorly reliable (versus 24.3% unreliable LSE with the usual definition, P < 10(-3) ), 74.3% were reliable, and 16.6% were very reliable. The usual definition for LSE reliability is not relevant. LSE reliability depends on IQR/M according to liver stiffness median level, defining thus three reliability categories: very reliable, reliable, and poorly reliable LSE. (HEPATOLOGY 2013). Copyright © 2012 American Association for the Study of Liver Diseases.
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                Author and article information

                Contributors
                juan.g.abraldes@ualberta.ca
                mang.ma@ualberta.ca
                Journal
                Hepatol Commun
                Hepatol Commun
                10.1002/(ISSN)2471-254X
                HEP4
                Hepatology Communications
                John Wiley and Sons Inc. (Hoboken )
                2471-254X
                29 July 2019
                October 2019
                : 3
                : 10 ( doiID: 10.1002/hep4.v3.10 )
                : 1322-1333
                Affiliations
                [ 1 ] LiverSafe Clinic, Division of Gastroenterology (Liver Unit) University of Alberta, CEGIIR Edmonton Canada
                [ 2 ] Alberta Health Services Edmonton Canada
                Author notes
                [*] [* ] Address Correspondence and Reprint Requests to:

                Juan G. Abraldes, M.D., M.M.Sc.

                Division of Gastroenterology, University of Alberta

                1‐38 Zeidler Ledcor Centre

                8540 112th Street NW

                Edmonton, AB T6G 2X8, Canada

                E‐mail: juan.g.abraldes@ 123456ualberta.ca

                Tel.: +1‐780‐492‐0796

                or

                Mang M. Ma, M.D.

                Division of Gastroenterology, University of Alberta

                1‐24A Zeidler Ledcor Centre

                8540 112th Street NW

                Edmonton, AB T6G 2X8, Canada

                E‐mail: mang.ma@ 123456ualberta.ca

                Tel.: +1‐780‐492‐8146

                [†]

                These authors contributed equally to this work.

                Author information
                https://orcid.org/0000-0001-6022-7715
                https://orcid.org/0000-0003-0486-0174
                https://orcid.org/0000-0003-3421-937X
                https://orcid.org/0000-0003-2587-1788
                Article
                HEP41411
                10.1002/hep4.1411
                6771169
                31592044
                f0cfe6db-61b8-4d52-aba4-77c54f1d0c26
                © 2019 The Authors. Hepatology Communications published by Wiley Periodicals, Inc., on behalf of the American Association for the Study of Liver Diseases.

                This is an open access article under the terms of the http://creativecommons.org/licenses/by-nc-nd/4.0/ License, which permits use and distribution in any medium, provided the original work is properly cited, the use is non‐commercial and no modifications or adaptations are made.

                History
                : 04 March 2019
                : 07 July 2019
                Page count
                Figures: 6, Tables: 2, Pages: 12, Words: 11351
                Funding
                Funded by: Institute of Health Economics
                Award ID: 15‐080‐355‐01
                Categories
                Original Article
                Original Articles
                Custom metadata
                2.0
                hep41411
                October 2019
                Converter:WILEY_ML3GV2_TO_NLMPMC version:5.6.9 mode:remove_FC converted:01.10.2019

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