Prognostic Value of Non-Invasive Detection in Patients with NAFLD

 

Interview with Professor Michael Pavlides of Radcliffe School of Medicine, Oxford University, UK

Editor's note: Progressive liver fibrosis is an important diagnostic goal of nonalcoholic fatty liver disease (NAFLD), which can help identify patients with poor prognosis. Some studies have shown that the combined evaluation of different fibrosis detection can significantly improve the accuracy of liver fibrosis diagnosis in patients with chronic hepatitis C. So, what is the prognostic value of non-invasive detection in patients with NAFLD? Are more and more combination strategies applicable to the diagnosis of progressive fibrosis in NAFLD? From November 4 to 8, 2022, the 2022 American Association for the Study of Liver (AASLD) Annual Conference, an annual academic event in the field of hepatology, was held at the Convention and Exhibition Center in Washington, D.C. This magazine specially invited the experts - Professor Michael Pavlides of Radcliffe School of Medicine, Oxford University, UK, to conduct an in-depth interview on the prognostic value of non-invasive testing for NAFLD patients.

 

iHepatology：Current noninvasive assessment scores for the staging of liver fibrosis usually include aminotransferase levels and exclude γ-glutamyl transferase (GGT) levels. However, the elevation of GGT levels is commonly seen in patients with NAFLD. How to evaluate the prognostic value of GGT in these patients?

Dr Pavlides: As far as I am aware, there is no prognostic information from GGT. Even though this information on inflammation in the liver is important, it doesn’t seem to have prognostic value.

 

iHepatology：This study showed that fibrosis biomarkers have prognostic performance similar to histology and supported the adoption of non-invasive tests as “likely-accepted” surrogate endpoints in clinical trials. When it comes to routine practice, are there still patients who should be considered for liver biopsy?

Dr Pavlides: I think that is a very good question. I think, yes, there would be patients who should be considered for biopsy. That depends on your view of who should have surveillance for hepatocellular carcinoma. Currently, it is only happening for cirrhosis, so there is a role for biopsy in patients who have slightly elevated non-invasive tests but are not obviously cirrhotic. In those patients, I think biopsy will still have value.

 

iHepatology：What are the factors that may affect the performance of noninvasive tests for assessing the prognosis of patients with NAFLD in routine clinical practice and clinical trials? Would diagnostic performance be improved if multiple noninvasive tests were used in combination?

Dr Pavlides: Again, a very good question. We have looked at this before - the factors that can affect diagnostic performance. Obesity comes out as a strong factor, diabetes also, often related with obesity. So there are some factors that we have to be careful with. With regard to combination tests, it is a tricky one. It is well described that you can use simple biomarkers with a more advanced biomarker in a sequence, FIB-4 and liver stiffness, for example, or FIB-4 and ELF. But when you come to looking at combinations in parallel, then it becomes a little more difficult, because you don’t know what it means when they disagree. So, sequential combinations of simple biomarkers first and more advanced ones second helps you save money, because you can start simply first and then use the more expensive biomarkers as required. If you put biomarkers together, I think you would have to use a lot of them, and if four of the six, for example, show advanced fibrosis, then there is likely advanced fibrosis. If you have two or three and they disagree, then you don’t know which one to believe.

 

iHepatology：Among the ongoing clinical trials of new drugs for NASH, are there any clinical trials using non-invasive tests as the study endpoint?

Dr Pavlides: I am not aware of any using them as a primary endpoint. A lot of the trials have histological changes as an endpoint, but they assess non-invasive tests alongside that. But I am not aware of any studies that use it as a primary endpoint.