Diagnostic accuracy of controlled attenuation parameter (CAP) as a non-invasive test for steatosis in suspected non-alcoholic fatty liver disease: a systematic review and meta-analysis

doi:10.1186/s12876-019-0961-9

Meta-Analysis

. 2019 Apr 8;19(1):51.

doi: 10.1186/s12876-019-0961-9.

Diagnostic accuracy of controlled attenuation parameter (CAP) as a non-invasive test for steatosis in suspected non-alcoholic fatty liver disease: a systematic review and meta-analysis

Ke Pu^{1

2}, Yuping Wang^{1

2}, Suyang Bai^{1

2}, Hui Wei^{1

2}, Yongning Zhou^{1

2}, Jiangao Fan³, Liang Qiao^{4

5

6}

Affiliations

¹ Department of Gastroenterology, The First Hospital of Lanzhou University, Lanzhou, China.
² Key Laboratory for Gastrointestinal Diseases of Gansu Province, Lanzhou University, Lanzhou, China.
³ Storr Liver Centre, Westmead Institute for Medical Research, University of Sydney at Westmead Clinical School, Westmead, Australia.
⁴ Department of Gastroenterology, The First Hospital of Lanzhou University, Lanzhou, China. liang.qiao@sydney.edu.au.
⁵ Key Laboratory for Gastrointestinal Diseases of Gansu Province, Lanzhou University, Lanzhou, China. liang.qiao@sydney.edu.au.
⁶ Storr Liver Centre, Westmead Institute for Medical Research, University of Sydney at Westmead Clinical School, Westmead, Australia. liang.qiao@sydney.edu.au.

PMID: 30961539
PMCID: PMC6454693
DOI: 10.1186/s12876-019-0961-9

Meta-Analysis

Diagnostic accuracy of controlled attenuation parameter (CAP) as a non-invasive test for steatosis in suspected non-alcoholic fatty liver disease: a systematic review and meta-analysis

Ke Pu et al. BMC Gastroenterol. 2019.

. 2019 Apr 8;19(1):51.

doi: 10.1186/s12876-019-0961-9.

Authors

Ke Pu^{1

2}, Yuping Wang^{1

2}, Suyang Bai^{1

2}, Hui Wei^{1

2}, Yongning Zhou^{1

2}, Jiangao Fan³, Liang Qiao^{4

5

6}

Affiliations

¹ Department of Gastroenterology, The First Hospital of Lanzhou University, Lanzhou, China.
² Key Laboratory for Gastrointestinal Diseases of Gansu Province, Lanzhou University, Lanzhou, China.
³ Storr Liver Centre, Westmead Institute for Medical Research, University of Sydney at Westmead Clinical School, Westmead, Australia.
⁴ Department of Gastroenterology, The First Hospital of Lanzhou University, Lanzhou, China. liang.qiao@sydney.edu.au.
⁵ Key Laboratory for Gastrointestinal Diseases of Gansu Province, Lanzhou University, Lanzhou, China. liang.qiao@sydney.edu.au.
⁶ Storr Liver Centre, Westmead Institute for Medical Research, University of Sydney at Westmead Clinical School, Westmead, Australia. liang.qiao@sydney.edu.au.

PMID: 30961539
PMCID: PMC6454693
DOI: 10.1186/s12876-019-0961-9

Abstract

Background: Controlled attenuation parameter (CAP) is a non-invasive method for diagnosing hepatic steatosis. Despite good diagnostic performance, clinical application of CAP is limited due to the influences of covariates. Here, a systematic review on the performance of CAP in the diagnosis and staging of hepatic steatosis in NAFLD patients was performed.

Methods: The sensitivity, specificity, diagnostic odds ratio (DOR) and area under receiver operating characteristics (AUROC) curves of the pooled data for CAP in diagnosing and staging the mild (Stage 1), moderate (Stage 2) and severe (Stage 3) steatosis in NAFLD patients were assessed. The clinical utility of CAP was evaluated by Fagan plot. Heterogeneity was explored using subgroup analysis.

Results: Nine studies involving 1297 patients with liver biopsy-proven NAFLD were analyzed. The pooled sensitivity of CAP in detecting mild hepatic steatosis was 87% with a specificity of 91% and a DOR of 84.35. The pooled sensitivity of CAP in detecting moderate hepatic steatosis was 85% with a specificity of 74% and a DOR of 21.28. For severe steatosis, the pooled sensitivity was 76% with a specificity of 58% and a DOR of 4.70. The mean AUROC value for CAP in the diagnosis of mild, moderate, and severe steatosis was 0.96, 0.82 and 0.70, respectively. A subgroup analysis indicated that variation in the geographic regions, cutoffs, age and body mass index (BMI) could be the potential sources of heterogeneity in the diagnosis of moderate to severe steatosis.

Conclusions: CAP should be cautiously considered as a non-invasive substitute for liver biopsy in clinical practice.

Keywords: Controlled attenuation parameter (CAP); Hepatic steatosis, diagnostic accuracy; Non-alcoholic fatty liver disease (NAFLD); Transient elastography.

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Figures

**Fig. 2**
Quality assessment of the included studies by methodological quality graph (a) and Cochrane Handbook (b)

**Fig. 3**
Forest plots and meta-analyses of studies showing pooled sensitivity (a) and specificity (b) of CAP for detection of ≥S1 steatosis (Stage 0 vs Stage 1–3) in NAFLD patients. c Summary of AUROC of CAP for the diagnosis of ≥S1 steatosis (Stage 0 vs Stage 1–3) in NAFLD patients

**Fig. 4**
Forest plots and meta-analyses of studies showing pooled sensitivity (a) and specificity (b) of CAP for detection of ≥S2 steatosis (Stage 0–1 vs Stage 2–3) in NAFLD patients. c Summary of AUROC of CAP for the diagnosis of ≥S2 steatosis (Stage 0–1 vs Stage 2–3) in NAFLD patients

**Fig. 5**
Forest plots and meta-analyses of studies showing pooled sensitivity (a) and specificity (b) of CAP for detection of ≥S3 steatosis (Stage 0–2 vs Stage 3) in NAFLD patients. c Summary of AUROC of CAP for the diagnosis of ≥S3 steatosis (Stage 0–2 vs Stage 3) in NAFLD patients

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References

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1. Hu X, Huang Y, Bao Z, Wang Y, Shi D, Liu F, et al. Prevalence and factors associated with nonalcoholic fatty liver disease in Shanghai work-units. BMC Gastroenterol. 2012;12:123. doi: 10.1186/1471-230X-12-123. - DOI - PMC - PubMed
1. FanJG ZJ, Li XJ, Chen L, Li L, Dai F, et al. Prevalence of and risk factors for fatty liver in a general population of Shanghai, China. J Hepatol. 2005;43:508–514. doi: 10.1016/j.jhep.2005.02.042. - DOI - PubMed
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[1] Starley BQ, Calcagno CJ, Harrison SA. Nonalcoholic fatty liver disease and hepatocellular carcinoma: a weighty connection. Hepatology. 2010;51:1820–1832. doi: 10.1002/hep.23594. - DOI - PubMed

[2] Starley BQ, Calcagno CJ, Harrison SA. Nonalcoholic fatty liver disease and hepatocellular carcinoma: a weighty connection. Hepatology. 2010;51:1820–1832. doi: 10.1002/hep.23594. - DOI - PubMed

[3] Younossi ZM, Koenig AB, Abdelatif D, Fazel Y, Henry L, Wymer M. Global epidemiology of nonalcoholic fatty liver disease-meta-analytic assessment of prevalence, incidence, and outcomes. Hepatology. 2016;64:73–84. doi: 10.1002/hep.28431. - DOI - PubMed

[4] Younossi ZM, Koenig AB, Abdelatif D, Fazel Y, Henry L, Wymer M. Global epidemiology of nonalcoholic fatty liver disease-meta-analytic assessment of prevalence, incidence, and outcomes. Hepatology. 2016;64:73–84. doi: 10.1002/hep.28431. - DOI - PubMed

[5] Hu X, Huang Y, Bao Z, Wang Y, Shi D, Liu F, et al. Prevalence and factors associated with nonalcoholic fatty liver disease in Shanghai work-units. BMC Gastroenterol. 2012;12:123. doi: 10.1186/1471-230X-12-123. - DOI - PMC - PubMed

[6] Hu X, Huang Y, Bao Z, Wang Y, Shi D, Liu F, et al. Prevalence and factors associated with nonalcoholic fatty liver disease in Shanghai work-units. BMC Gastroenterol. 2012;12:123. doi: 10.1186/1471-230X-12-123. - DOI - PMC - PubMed

[7] FanJG ZJ, Li XJ, Chen L, Li L, Dai F, et al. Prevalence of and risk factors for fatty liver in a general population of Shanghai, China. J Hepatol. 2005;43:508–514. doi: 10.1016/j.jhep.2005.02.042. - DOI - PubMed

[8] FanJG ZJ, Li XJ, Chen L, Li L, Dai F, et al. Prevalence of and risk factors for fatty liver in a general population of Shanghai, China. J Hepatol. 2005;43:508–514. doi: 10.1016/j.jhep.2005.02.042. - DOI - PubMed

[9] ZhouYJ LYY, Nie YQ, Ma JX, Lu LG, Shi SL, et al. Prevalence of fatty liver disease and its risk factors in the population of South China. World J Gastroenterol. 2007;13:6419–6424. doi: 10.3748/wjg.v13.i47.6419. - DOI - PMC - PubMed

[10] ZhouYJ LYY, Nie YQ, Ma JX, Lu LG, Shi SL, et al. Prevalence of fatty liver disease and its risk factors in the population of South China. World J Gastroenterol. 2007;13:6419–6424. doi: 10.3748/wjg.v13.i47.6419. - DOI - PMC - PubMed

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