Early diagnosis of advanced liver fibrosis in the compensated stage enables better treatment outcomes, leading to fibrosis regression and lower mortality rates from cirrhosis related complications such as HCC and portal hypertension.
For years, the use of either NAFLD Score or FIB-4, in combination with SWE predicts the severity of liver fibrosis, thereby assisting the decision whether a patient should undergo a biopsy or clinical follow-up/further investigation of liver cirrhosis and complications.
In our study, a community based clinic was chosen arbitrarily, containing 658 patients at the age of 45-65, without known liver disease. 55% of them were women and 19% with diabetes. For each of the patients, the NAFLD and FIb-4 Scores were calculated. Using agreeable threshold levels of NAFLD (> 0.675) and FIB-4 (>2.67), determined those patients sent to further SWE. Participants with advanced fibrosis according to SWE (stage F3-F4), were further placed to follow-up and medical treatment in order to delay/prevent further progression of the disease.
- Out of 26 patients that were identified above threshold by NAFLD score, only 16/26 (61.5%) agreed to undergo further SWE that demonstrated significant fibrosis in 7/16 (43%).
- Out of 13 patients that were identified above threshold by FIB-4 score, 10/13 (76.9%) agreed to undergo further SWE that demonstrated significant fibrosis in 7/10 (70%).
- Only 3 patients were identified above threshold by both scores and SWE demonstrated significant fibrosis in all 3.
In total, 14/26 patients were identified having significant fibrosis by SWE, tended to be male, older, obese, diabetic with higher liver enzymes, and lower platelet counts. All these parameters are statistically significant.
A significant false negative (F.N) rate (4/11 ~ 36%) was identified when using only a single score test (NAFLD or FIB-4).
The positive predictive value for significant liver fibrosis on SWE was higher when using the FIB-4 score (7/10 = 70%) compared to using the NAFLD score (7/17= 43%), and corresponds to the published literature.
In light of our findings, we believe that the use of both scores (NAFLD and Fib-4) or the development of a new score method is needed, in order to lower the F.N rate.
The main limitation of our study is the relatively small sample size of patients in a single community based clinic. Further studies containing a larger sample size of patients in several community based clinics to confirm our findings is mandatory, prior to commencing a general screening program for liver cirrhosis in the general population without known liver disease.
