Liver stiffness is associated with risk of decompensation, liver cancer, and death in patients with chronic liver diseases: a systematic review and meta-analysis

Abstract

Background & aims: Liver stiffness measurement (LSM), using elastography, can independently predict outcomes of patients with chronic liver diseases (CLDs). However, there is much variation in reporting and consistency of findings. We performed a systematic review and meta-analysis to evaluate the association between LSM and outcomes of patients with CLDs.

Methods: We performed a systematic review of the literature, through February 2013, for studies that followed up patients with CLDs prospectively for at least 6 months and reported the association between baseline LSM and subsequent development of decompensated cirrhosis or hepatocellular carcinoma (HCC), as well as mortality. Summary relative risk (RR) estimates per unit of LSM and 95% confidence intervals (CIs) were estimated using the random effects model.

Results: Our final analysis included 17 studies, reporting on 7058 patients with CLDs. Baseline LSM was associated significantly with risk of hepatic decompensation (6 studies; RR, 1.07; 95% CI, 1.03-1.11), HCC (9 studies; RR, 1.11; 95% CI, 1.05-1.18), death (5 studies; RR, 1.22; 95% CI, 1.05-1.43), or a composite of these outcomes (7 studies; RR, 1.32; 95% CI, 1.16-1.51). We observed considerable heterogeneity among studies-primarily in the magnitude of effect, rather than the direction of effect. This heterogeneity could not be explained by variations in study locations, etiologies and stages of CLD, techniques to measure liver stiffness, adjustment for covariates, or method of imputing relationship in the meta-analysis.

Conclusions: Based on a meta-analysis of cohort studies, the degree of liver stiffness is associated with risk of decompensated cirrhosis, HCC, and death in patients with CLDs. LSM therefore might be used in risk stratification.

Keywords: CI; CLD; Cancer; Cirrhosis; Elastography; HCC; HCV; HR; HVPG; LSM; LT; MELD; MRE; Outcomes; Prognosis; RR; TE; chronic liver disease; confidence interval; hazard ratio; hepatic venous pressure gradient; hepatitis C virus; hepatocellular carcinoma; liver stiffness measurement; liver transplantation; magnetic resonance elastography; model for end-stage liver disease; relative risk; transient elastography.

Figure 1

Flowchart showing the study identification and selection process. EV, esophageal varices; ICU, intensive care unit; PHTN, portal hypertension.

Figure 2

Quality assessment of included studies using the Quality In Prognosis Studies tool. All studies were scored as low, moderate, or high risk of bias across 6 domains: study participation, study attrition, prognostic factor measurement (ie, elastographic technique), outcome assessment, confounding factors, and statistical analysis and reporting.

Figure 3

Association between baseline LSM and subsequent risk of (A) hepatic decompensation, (B) HCC, (C) mortality, and (D) composite outcome of liver-related events in patients with CLD. Pooled estimate represents increase in risk of liver-related event per unit of LSM.