Fibroscan unreliable?

[desrt]

A Sagir, A Erhardt, M Schmitt, and others. Transient elastography is unreliable for detection of cirrhosis in patients with acute liver damage. Hepatology 47(2): 592-595. February 2008

[desrt]

Actually, looking back on the title of the original paper I posted, acute would seem to have a third meaning.

[desrt]

My typo - there should have been three esses in disss


http://www.cdc.gov/ncphi/disss/nndss/casedef/hepatitisacutecurrent.htm

Some day I'll get my daughter to show me how to do that cut and paste thing.


From the CDC:

Clinical case defenition

"An acute illness with a discrete onset of any sign or symptom consistent with acute viral hepatitis (e.g., anorexia, abdominal discomfort, nausea, vomiting), and either a) jaundice or b) serum alanine aminotransferase (ALT) levels >400IU/L."

Having had "a discrete onset" of symptoms for three types of hep (yelow eyes, dark urine, feeling lke I'd been kicked in the stomach, etc) this definition has always made the most sense to me. I see many places, including Wikipedia, use acute as synonymous with newly infected, so only time will tell if common usage wins out over the medical definition.

Have a great day :-)

[sfbaygirl]

I got on the study#2 Jim posted. It says what I was saying.  " The study was conducted in Germany with 20 patients with acute hepatitis (Hepatitis is when acute infection happened recently. After six months of hepatitis infection becomes infection called "chronic")"

This tends to support my claim of "acute" as being newly infected.

[sfbaygirl]

BTW I couldn't open that page. It said not available at this time. Perhaps, I can try in the morning.  

[sfbaygirl]

BTW I couldn't open that page. It said not available at this time. Perhaps, I can try in the morning.  

[sfbaygirl]

Thanks!  I was under the impression that acute meant newly infected!  

Linda

[desrt]

Although many on this forum use 'acute' to mean 'newly infected', this is not correct.

http://www.cdc.gov/ncphi/diss/nndss/casedef/hepatitisacutecurrent.htm

[sfbaygirl]

I had at least ten, last time 13 scans/photos. My ribs are so tight he had a hard time getting through and had to go under the left side this time. This is where I had more damage. left side. He didn't do this last time, so we have no base. Protocol, doesn't call for this in a fibroscan. They want the probe to go into the same place the bx needle would go. I would ask him to go to never never land again!  So what if it isn't the protocol of how the FDA is going to approve it? I would think it would be just as accurate. I know you are going, Ask. Check it out.  Send me a PM if you can afterwards. I would love to hear your takes on it all.  It is sooooo worth it. Just to talk to him. I learn so much!  

Still confused by 'acute', as that means newly infected. Why does this study say this? I think it could be because those newly infected have a stiff liver....Perhaps, these new wounds are more inflamed. I remember my lft's were so high and I was so sick...makes me wonder.

[willing]

there's a more clinical, and no doubt more accurate, explanation in that quote above "the reasons ..could be related to hepatocyte swelling.."etc. but one analogy is that, with eyes closed, the stiffness of an old, heavily scarred wound, might feel similar to the stiffness of a new, unscarred but inflamed wound. The machine bounces sound waves and can't tell an old stiff from a new stiff (sorry).

BTW, do you remember how many "snapshots" hr took?  There seems to be some disagreement on that with some arguing  as few as three are adequate, others favoring as many as ten.

[Ginger12521]

http://www.hivandhepatitis.com/recent/2006/020306_c.html

[sfbaygirl]

I wonder why that is? How is it different that chronic hep. Is the stiffness different in fibrosis for acute than chronic?  

[willing]

yes - that was my read of it as well. There seems to be  something about acute-stage liver infection, wherether viral or chemical, that makes for an unsually stiff liver. In garden-variety chronic  infection on the other hand, stiffness is a good proxy for fibrosis.

[sfbaygirl]

What caught my eye was the word "acute" . Most of us have chronic Hep C...wonder it that makes a difference.  

[willing]

agreed -  for all those for whom tx/re-tx is  a long way off, that 95% negative predictive value  seems very valuable. At least you can have  good confidence that if your FS score falls under 14-15 you are not choosing to delay in the presence of cirrhosis.  BTW, there was an editorial that accompanied the recent article desrt posted titled

"Transient elastography in acute hepatitis: All that's stiff is not fibrosis."

http://www.ncbi.nlm.nih.gov/pubmed/18220278

I thought this was something goof might have had a hand in, but was disappointed:

"The conclusions of these two papers merit reiteration: 1. LSM(liver stiffness measurement ) in the cirrhotic range does not predict advanced fibrosis and cirrhosis in those with acute hepatitis. 2. A high LSM in the context of chronic liver disease may be due to an acute (aminotransferase) flare. 3. Necroinflammatory activity should be considered in studies of the performance of transient elastography."

sounds like accompanying a FS with a liver panel may be good practice.

[Forseegood]

that I don't have time now, but I read a really favorable study on the fibroscan, a few months ago that was fairly recent....try to find it when I have more time unless someone has it on hand...that methodology that was suggested, that you look at all the tests, then run it through experts and find a mean...I think you can apply that too studies too:)

[sfbaygirl]

Interesting!  A threshold of 14.6kPa is not as high as I have heard from a fibroscan. Perhaps that is the level of cirrhosis. As I said before, I plan on using the anti fibrotics to lower my fibrosis, as I am not tx'ing again. One guy HR did a fibroscan for was a 15 and went down to an 8 with the anti fibrotics! This is good enough news for me!  Of course HR is not sure which one is the one that does it, so the whole diet needs to be taken....

Linda

[Mikkimoe]

Here is one I got from my favorite research site (litle older but positive) The site is
http://www3.interscience.wiley.com/cgi-bin/abstract/113489566/ABSTRACT
If you sign up you can view all the abstrats free. Let me know if this is the same procedure

article:
Liver Failure and Liver Disease
Accuracy of liver stiffness measurement for the diagnosis of cirrhosis in patients with chronic liver diseases

Abstract
A proper diagnosis of cirrhosis is essential for the management of patients with chronic liver diseases. We assessed the accuracy of liver stiffness measurement by Fibroscan for the diagnosis of cirrhosis in 1,257 patients with chronic liver diseases of various causes enrolled in a prospective multicenter study as well as clarified causes of discrepancies between liver histology and Fibroscan. One hundred thirty-two patients had unsuitable biopsy specimens, and 118 had unreliable liver stiffness measurements. Because 232 patients overlapped with a previous study, analysis was performed in the 775 new patients then derived in the whole population (1,007; 165 cirrhosis). Diagnostic accuracy was assessed by receiver operator curve (ROC) analysis. Liver samples were re-analyzed in case of discrepancies. The area under the ROC (AUROC) was 0.95 (95% CI, 0.93-0.96) for the diagnosis of cirrhosis in either 775 or 1,007 patients. The cutoff value with optimal diagnosis accuracy was 14.6 kPa in 1,007 patients (positive and negative predictive values, 74% and 96%) with discrepancies among the etiological groups. Eighty patients were misclassified: (1) among 45 patients without cirrhosis with liver stiffness 14.6 kPa or greater, 27 (60%) had extensive fibrosis and 10 (22%) significant perisinusoidal fibrosis; and (2) among 35 patients with cirrhosis and liver stiffness less than 14.6 kPa, 10 (29%) had a macronodular pattern and 25 (71%) either none or mild activity. In conclusion, Fibroscan is a reliable method for the diagnosis of cirrhosis in patients with chronic liver diseases, better at excluding than at predicting cirrhosis using a threshold of 14.6 kPa. False-negatives are mainly attributable to inactive or macronodular cirrhosis. (HEPATOLOGY 2006;44:1511-1517.)



--------------------------------------------------------------------------------
Received: 16 December 2005; Accepted: 20 August 2006

[willing]

dsert : many thanks for posting - you find quite a bit of interesting stuff!

all: I believe the key word here is acute. The 20 patients scanned showed up with acute liver damage caused by a variety of drugs:

"Toxic hepatitis was due to intake of nitrofurantoin, efavirenz, amphetamine, prophylthiouracil, sirolimus, flumatid, lamictal, and opipramol.".

Among them, the FS scores did in fact overstate the likelihood of cirrhosis:

"Fifteen patients (75%) showed during the acute phase of the liver damage liver stiffness values above 12.5 kPa, that is, values suggestive of liver cirrhosis. Liver biopsy was performed in 11 (73%) of these 15 patients (that is, patients 1, 10-16, and 18-20). None of these patients showed a higher stage of fibrosis than F2 in the liver biopsy. "

(12.5 -13 seems to be the FS score accepted as indicative of cirrhosis in chronic patients. )

The authors don't seem to believe their results in any way detract from the value of FS for evaluation of chronic hep:

"A  good correlation between the grade of liver fibrosis and liver stiffness measured by FS has been demonstrated for patients with chronic hepatitis of different etiologies (hepatitis C virus, hepatitis B virus, alcohol, and human immunodeficiency virus/hepatitis C virus coinfection).[11][15] A cutoff value of 12.5 kPa has been described for discrimination of liver cirrhosis from liver fibrosis in patients with chronic hepatitis C.[10] In our own study group comprising 147 patients with chronic hepatitis of various etiologies, a similar cutoff value of 13 kPa was determined.[9]"

rather, there  seems to be something, not yet understood, that makes for unusually stiff liver during acute infection

"The data in the present study show that liver stiffness measurements by FS in patients with acute liver damage overestimate the real stage of fibrosis and may erroneously suggest the presence of liver cirrhosis. The reasons underlying the high stiffness in acute toxic liver damage are unknown but could be related to hepatocyte swelling, cholestasis, or infiltrates of inflammatory cells in the acutely inflamed liver. A significant difference in the initial bilirubin level was observed between patients with an initial liver stiffness below and above 12.5 kPa. This may indicate that the intrahepatic cholestasis may influence the initial measured liver stiffness. "

since I keep procrastinating on getting a FS with HR I was quite interested in this. However I didn't see anything that changed my mind. In fact most of the related articles seem to provide endorsements for the diagnostic value of the technique.

[copyman]

Agree with jim here. get all 3 tests if possible. Biopsy, fibroscan and fibrosure. let the doctor use all three to determine the amount of damage.  i would rate the biopsy as the all around  most realible not only for damage but other liver histology. Second would be the fibroscan and third the blood test marker i.e. fibrosure. There has to be a reason why the fibroscan has not got FDA approval yet. My feeling is that it can not accurately determine stages and only good for telling you if you have cirrhosis or not. Last year I emailed the French company that makes the fibroscan and they said it "should" get FDA approval the beginning of 2008. we will see what all the trial data says, hopefully soon.

[sfbaygirl]

Are you saying that I may have LESS fibrosis than the fibroscan says I do, or is this only for acutes?  I will check out your link. Now that I am in college again, I do have access to lots of data in the library. Wow, I was going to do a research paper (love them) and when last I did one, only ERIC was available. I was so overwhelmed, I chose option # 2, watch a video and read some manuals.  I need to figure this out!  I will look for Hepatology. It is $1800. a year to subscribe! I think I can get to it, if I figure out how to get to all the articles and stuff online with my password!  

I agree, more knowledge and more tests are good. I don't like the fibrosure. How can they say I have bridging fibrosis with a blood test?  The palpation of the liver by a good Hepatologist seems as good a test as the others!  

Linda

[jmjm530]

See study #2 for re-translated version: http://tinyurl.com/2636td

According to study, Fibroscan apparently overestimates liver damage at least in those with acute liver damage mistaking inflammation for fibrosis. As has been stated by others here before -- including HR -- always best to join as many points as possible -- biopsy, scan, blood markers, physical exam, etc -- and then run it all through a knowledgeable liver specialist who can help make the best possible diagnosis.

-- Jim

[sfbaygirl]

I tend to disagree. Can't get to that article! Subscribing cost a fortune! The premise is that it is unreliable. I would say the bx is unreliable. A bx can only look at one spot on the liver. As we know if you can look at many places, we could see different fibrosis in different spots. A person who doesn't know they have cirrhosis could very well have it with the "gold standard biopsy". So what do they suggest?  I have had two and they were similar, except in the places not tested before. Yes, the fibroscan is not FDA approved yet, but I found it reliable enough to find similar results, perhaps going down in spots since tx. I do know that there has to be those that check for results that are not going to help the fibroscan. I wish some of those would check out the Biopsy too.

Linda

[joachim2007]

well according to the abstract it seems to be too sensitive in those cases. I.e., it tells you that you have cirrhosis even if you do not have it.

-> i am glad that it's not the other way round, to be honest.

btw, my own fibroscan last year was done by exactly the team that wrote this article. Hmm, and when i'm up there next time, i will ask for the current consensus regarding fibroscan.