Acoustic radiation force impulse elastography, FibroScan®, Forns' index and their combination in the assessment of liver fibrosis in patients with chronic hepatitis B, and the impact of inflammatory activity and steatosis on these diagnostic methods

Abstract

The aim of the present study was to investigate the combination of certain serological markers (Forns' index; FI), FibroScan® and acoustic radiation force impulse elastography (ARFI) in the assessment of liver fibrosis in patients with hepatitis B, and to explore the impact of inflammatory activity and steatosis on the accuracy of these diagnostic methods. Eighty‑one patients who had been diagnosed with hepatitis B were recruited and the stage of fibrosis was determined by biopsy. The diagnostic accuracy of FI, FibroScan and ARFI, as well as that of the combination of these methods, was evaluated based on the conformity of the results from these tests with those of biopsies. The effect of concomitant inflammation on diagnostic accuracy was also investigated by dividing the patients into two groups based on the grade of inflammation (G<2 and G≥2). The overall univariate correlation between steatosis and the diagnostic value of the three methods was also evaluated. There was a significant association between the stage of fibrosis and the results obtained using ARFI and FibroScan (Kruskal‑Wallis; P<0.001 for all patients), and FI (t-test, P<0.001 for all patients). The combination of FI with ARFI/FibroScan increased the predictive accuracy with a fibrosis stage of S≥2 or cirrhosis. There was a significant correlation between the grade of inflammation and the results obtained using ARFI and FibroScan (Kruskal‑Wallis, P<0.001 for all patients), and FI (t-test; P<0.001 for all patients). No significant correlation was detected between the measurements obtained using ARFI, FibroScan and FI, and steatosis (r=‑0.100, P=0.407; r=0.170, P=0.163; and r=0.154, P=0.216, respectively). ARFI was shown to be as effective in the diagnosis of liver fibrosis as FibroScan or FI, and the combination of ARFI or FibroScan with FI may improve the accuracy of diagnosis. The presence of inflammatory activity, but not that of steatosis, may affect the diagnostic accuracy of these methods.

Figure 1

Flow diagram depicting patient assessments in the present study. ARFI, acoustic radiation force impulse elastography.

Figure 2

Median ARFI and liver stiffness values in patients with different stages of liver fibrosis. (A) Median ARFI values in patients with S0, S1, S2, S3 and S4 were 1.28, 1.33, 1.43, 2.07 and 1.98 m/s, respectively. (B) Median liver stiffness values in patients with S0, S1, S2, S3 and S4 were 4.8, 6.69, 9.87, 14.8 and 24.2 kPa, respectively. Upper horizontal line, maximum value beside outlier; lower horizontal line, the minimum value; middle horizontal line, median; box, ¼–3/4 of values; star/circle/dot, outliers. ARFI, acoustic radiation force impulse elastography; Fib, FibroScan.

Figure 3

Diagnostic performance of ARFI, FibroScan and FI for the different histological stages of fibrosis. (A) ROC of ARFI, FibroScan and FI for the diagnosis of histological stages ≥S1; (B) ROC of ARFI, FibroScan and FI for the diagnosis of histological stages ≥S2; (C) ROC of ARFI, FibroScan and FI for the diagnosis of histological stages ≥S3; (D) ROC of ARFI, FibroScan and FI for the diagnosis of histological stage S4. ARFI, acoustic radiation force impulse elastography; Fib, FibroScan; FI, Forns’ index; ROC, receiver operator curve.

Figure 4

Flowchart of the synchronous application of FI with either ARFI or FibroScan^® for the diagnosis of S≥2. ARFI, acoustic radiation force impulse elastography; FI, Forns’ index; NPV, negative predictive value; PPV, positive predictive value.