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MRE in NAFLD: Promising but Further Validation is Required
John D. Ryan, Emmanuel A. Tsochatzis
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e.tsochatzis@ucl.ac.uk

Correspondence and reprint request:
UCL Institute for Liver and Digestive Health and Sheila Sherlock Liver Unit, Royal Free Hospital and UCL, London, UK
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="p0010" class="elsevierStylePara elsevierViewall">Non-alcoholic fatty liver disease &#40;NAFLD&#41; is a hugely prevalent condition affecting up to 30&#37; of adults in the developed world&#46; The diagnosis is associated with an increased risk of liver-related morbidity and mortality&#46; The best determinant of major outcomes &#40;liver-related events&#44; need for liver transplant or death&#41; is the presence of fibro-sis on a liver biopsy&#46; In a recent retrospective study of 619 NAFLD patients followed for a median of 12&#46;6 years&#44; An-gulo&#44; <span class="elsevierStyleItalic">et al&#46;</span> highlighted the independent association of any stage of liver fibrosis on biopsy &#40;present in &#62; 50&#37; of the study patients&#41; and these outcomes&#46; For instance&#44; hazard ratios for factors associated with death or liver transplant included fibrosis stage 1 &#40;HR&#44; 1&#46;88&#59; 95&#37; confidence interval &#91;CI&#93;&#44; 1&#46;28-2&#46;77&#41;&#44; stage 2 &#40;HR&#44; 2&#46;89&#59; 95&#37; CI&#44; 1&#46;93-4&#46;33&#41;&#44; stage 3 &#40;HR&#44; 3&#46;76&#59; 95&#37; CI&#44; 2&#46;40-5&#46;89&#41;&#44; and stage 4 &#40;HR&#44; 10&#46;9&#59; 95&#37; CI&#44; 6&#46;06-19&#46;62&#41; compared with stage 0&#46; Conversely&#44; the presence or severity of steatosis or steatohepa-titis&#44; a diagnostic feature of NAFLD and NASH&#44; was not associated with outcomes&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">1</span></a> This valuable study underlined the importance of liver fibrosis detection in NAFLD patients to guide management and monitoring&#44; but also the urgent need to identify robust non-invasive fibrosis markers in order to avert the need for an invasive liver biopsy with the associated risks&#44; cost&#44; and impracticalities when considering such a significant patient population&#46;</p><p id="p0015" class="elsevierStylePara elsevierViewall">Thankfully&#44; a burgeoning market of non-invasive tests for liver fibrosis has developed over the past decade&#46; These tests are either blood or imaging-based&#44; with the former often utilized as cheaper screening tools with high negative predictive values allowing the reliable exclusion of advanced fibrosis &#40;F3-F4&#41;&#59; while the latter techniques are performed in specialist centres&#44; and offer the advantage of a targeted assessment for liver fibrosis along with simultaneous detection of steatosis in NAFLD&#46; Despite very good diagnostic performance for advanced fibrosis detection in NAFLD&#44; both non-invasive techniques tend to lack diagnostic accuracy for delineating earlier fibrosis stages&#44; an important factor when deciding on the need for aggressive therapy and follow up&#46; Moreover&#44; knowing that the presence of any fibrosis on biopsy has implications for disease outcomes means that a diagnostic test with high diagnostic accuracy across all fibrosis stages would be of significant value&#46;</p><p id="p0020" class="elsevierStylePara elsevierViewall">In a recent prospective cross-sectional study by Park&#44; <span class="elsevierStyleItalic">et al&#46;</span> from California&#44; USA&#44; two of the most studied imag-ing-based techniques for the non-invasive assessment of liver fibrosis&#44; ultrasound transient elastography &#40;TE&#41; or Fibroscan&#174;&#44; and magnetic resonance elastography &#40;MRE&#41; were compared&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">3</span></a> Elastography measures liver stiffness&#44; a surrogate of liver fibrosis&#44; by analyzing the speed at which mechanical waves can propagate through the liver&#46; Both TE and MRE can also estimate liver steatosis simultaneously&#44; using the controlled attenuation parameter &#40;CAP&#41; or MRI-based proton density fat fraction &#40;MRI-PDFF&#41; methods&#44; respectively&#46; One short-coming of TE is high failure rates in obese patients&#44; which has been reduced by the advent of an XL-probe&#46; Indeed&#44; another recent Japanese study by Imajo&#44; <span class="elsevierStyleItalic">et al&#46;</span> also compared MRE with TE in NAFLD patients&#44; but reported a 10&#37; failure rate for TE in part due to a lack of the XL-probe&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">4</span></a> In the Park study both the standard &#8216;M&#8217; and XL probes were available for use&#44; potentially allowing a more meaningful assessment of the performance of MRE <span class="elsevierStyleItalic">vs&#46;</span> TE in fibrosis detection in NAFLD&#46; The authors also felt that the US-based cohort would yield more generalizable results to Western NAFLD populations than that described in the Imajo paper&#46; The Park study involved 104 consecutive NAFLD patients who had undergone a liver biopsy&#44; MRE and TE assessment&#46; The patient cohort was 56&#46;7&#37; female&#44; with a mean &#40;&#177; SD&#41; age of 50&#46;8 &#40;&#177; 14&#46;6&#41; years&#44; BMI of 30&#46;4 &#40;&#177; 5&#46;2&#41; kg&#47;m<span class="elsevierStyleSup">2</span> and diabetes prevalence of 27&#46;9&#37;&#46; The XL probe was used in approximately 50&#37; of cases&#44; although a failure rate of 6&#46;7&#37; was reported&#46; At first glance&#44; the study results were impressive&#59; MRE significantly outperformed TE in the detection of any stage of fibrosis &#40;stage 1 and above&#41;&#44; with an area under the receiver operating characteristic curve &#40;AUROC&#41; of 0&#46;82 &#40;95&#37; confidence interval &#91;CI&#93;&#44; 0&#46;74-0&#46;91&#41;&#44; for MRE compared with an AUROC of 0&#46;67 &#40;95&#37; CI&#44; 0&#46;56-0&#46;78&#41; for TE &#40;p &#61; 0&#46;0116&#41;&#46; MRI-PDFF detected any steatosis with an AUROC of 0&#46;99 &#40;95&#37; CI&#44; 0&#46;98-1&#46;00&#41;&#44; significantly higher than that of CAP &#40;AUROC&#44; 0&#46;85&#59; 95&#37; CI&#44; 0&#46;75-0&#46;96&#41;&#44; p &#61; 0&#46;0091&#44; and MRE was also significantly better at distinguishing grades of steatosis than CAP&#46;</p><p id="p0025" class="elsevierStylePara elsevierViewall">Despite these positive findings&#44; several issues limit the interpretation and application of the study results&#46; Although MRE performed well in the primary study objectives&#44; TE seemed to grossly underperform compared to other published studies&#46; Indeed&#44; the study cohort suffered from a clear &#8216;spectrum bias&#8217;&#44; where stages of fibrosis were unevenly distributed amongst the group making meaningful comparisons difficult&#46; The vast majority of patients had no or mild fibrosis &#40;45&#46;6&#37; F0&#59; 23&#46;3&#37; F1&#59; 10&#46;7&#37; F2&#59; 12&#46;6&#37; F3&#59; 7&#46;8&#37; F4&#41;&#46; This meant that that cut-offs used to determine the diagnostic accuracy for TE were atypical&#59; for instance a value of 6&#46;9kPa was the threshold for distinguishing F4 from F0-3 stages&#44; compared to a minimum of 11&#46;7kPa in other&#44; larger series&#46; Unlike the Imajo study&#44; no comparison was made with the efficacy of cheaper&#44; more readily available&#44; blood-based fibrosis scores such as the NAFLD fibrosis score &#40;NFS&#41; or the FIB-4 index&#46; Indeed&#44; the NFS performed as well as MRE in detecting any fibrosis&#44; advanced fibrosis or cirrhosis in the larger group of 127 NAFLD patients from the Imajo study&#46; Moreover&#44; the MR facility used in the Park study was a 3&#46;0T MR scanner&#44; whose use would be typically confined to research facilities and associated with a significant cost&#46; Finally&#44; although the detection of steatosis is useful to aid the diagnosis of NAFLD due to false negatives with standard ultrasound&#44; the grading of steatosis does not appear to have implications for disease severity and long-term out-comes&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">1</span></a> Nevertheless&#44; hepatic steatosis seems to closely reflect adipose insulin resistance specifically&#44; and highly sensitive techniques such as MRI-PDFF may yet prove useful in determining treatment choice and response for this multi-system disease in the future&#46;</p><p id="p0030" class="elsevierStylePara elsevierViewall">In conclusion&#44; although MRE is a useful addition to the available non-invasive fibrosis tests&#44; it requires further validation in larger cohorts of patients with more even distribution of fibrosis&#46; Ultimately&#44; what is required is a non-invasive fibrosis test that can be used sequentially and accurately reflect the progression or regression of fibrosis&#44; and therefore be used as a surrogate marker in clinical trials&#46; It remains to be determined if MRE is such a test&#46;</p></span>"
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        "resumen" => "<span id="abs0010" class="elsevierStyleSection elsevierViewall"><p id="sp0010" class="elsevierStyleSimplePara elsevierViewall">MR elastography is a novel method for non-invasive fibrosis assessment&#44; not yet sufficiently validated&#46; In a recent study in 104 patients Park&#44; <span class="elsevierStyleItalic">Gastroenterology</span> 2017&#59; 152&#58; 598-602&#41;&#44; MRE was compared to transient elastography for the diagnosis of fibrosis is nonalcoholic fatty liver disease&#46; The current viewpoint critically appraises this study&#46;</p></span>"
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                      "titulo" => "Liver Fibrosis but No Other Histologic Features&#44; Is Associated With Long-term Outcomes of Patients With Nonalcoholic Fatty Liver Disease"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:7 [
                            0 => "Angulo P&#46;"
                            1 => "Kleiner D&#46;E&#46;"
                            2 => "Dam-Larsen S&#46;"
                            3 => "Adams L&#46;A&#46;"
                            4 => "Bjornsson E&#46;S&#46;"
                            5 => "Charatcharoenwitthaya P&#46;"
                            6 => "Mills P&#46;R&#46;"
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                      "doi" => "10.1053/j.gastro.2015.04.043"
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                        "fecha" => "2015"
                        "volumen" => "149"
                        "paginaInicial" => "389"
                        "paginaFinal" => "397"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/25935633"
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                          ]
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                          "etal" => false
                          "autores" => array:4 [
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                            2 => "Moolla A&#46;"
                            3 => "Ryan J&#46;D&#46;"
                          ]
                        ]
                      ]
                    ]
                  ]
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                      "doi" => "10.3389/fphar.2016.00323"
                      "Revista" => array:4 [
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                        "fecha" => "2016"
                        "volumen" => "7"
                        "link" => array:1 [
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                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/27708582"
                            "web" => "Medline"
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                      "autores" => array:1 [
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                          "autores" => array:7 [
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                            1 => "Nguyen P&#46;"
                            2 => "Hernandez C&#46;"
                            3 => "Bettencourt R&#46;"
                            4 => "Ramirez K&#46;"
                            5 => "Fortney L&#46;"
                            6 => "Hooker J&#46;"
                          ]
                        ]
                      ]
                    ]
                  ]
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                      "doi" => "10.1053/j.gastro.2016.10.026"
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                        "tituloSerie" => "Gastroenterology"
                        "fecha" => "2017"
                        "volumen" => "152"
                        "paginaInicial" => "598"
                        "paginaFinal" => "607"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/27911262"
                            "web" => "Medline"
                          ]
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                      ]
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                  ]
                ]
              ]
            ]
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              "referencia" => array:1 [
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                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Magnetic Resonance Imaging More Accurately Classifies Steatosis and Fibrosis in Patients With Nonalcoholic Fatty Liver Disease Than Transient Elastogra-phy"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:7 [
                            0 => "Imajo K&#46;"
                            1 => "Kessoku T&#46;"
                            2 => "Honda Y&#46;"
                            3 => "Tomeno W&#46;"
                            4 => "Ogawa Y&#46;"
                            5 => "Mawa-tari H&#46;"
                            6 => "Fujita K&#46;"
                          ]
                        ]
                      ]
                    ]
                  ]
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                    0 => array:2 [
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                        "fecha" => "2016"
                        "volumen" => "150"
                        "paginaInicial" => "626"
                        "paginaFinal" => "637"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/26677985"
                            "web" => "Medline"
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                      "titulo" => "Elastography for the diagnosis of severity of fibrosis in chronic liver disease&#58; a meta-analy-sis of diagnostic accuracy"
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                          "autores" => array:6 [
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                            1 => "Gurusamy K&#46;S&#46;"
                            2 => "Ntaoula S&#46;"
                            3 => "Cholongitas E&#46;"
                            4 => "Davidson B&#46;R&#46;"
                            5 => "Burroughs A&#46;K&#46;"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
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                        "paginaFinal" => "659"
                      ]
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Article information
ISSN: 16652681
Original language: English
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es en pt

¿Es usted profesional sanitario apto para prescribir o dispensar medicamentos?

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Você é um profissional de saúde habilitado a prescrever ou dispensar medicamentos