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Transient elastography for the detection of hepatic fibrosis in HIV-monoinfected adults with elevated aminotransferases on antiretroviral therapy
Published by Anton POZNAK

Updated: 1 February, 2016

Morse CG et al. AIDS. 2015 Nov;29(17):2297-302.

Vibration-controlled transient elastography (VCTE) is increasingly used to assess liver fibrosis in viral hepatitis and fatty liver disease populations. The accuracy of VCTE in HIV-monoinfected populations has not been established. This study evaluated its performance in assessing liver fibrosis in a cohort of HIV-monoinfected adults undergoing liver biopsy.

Design : Observational cross-sectional study. HIV-infected adults with aspartate aminotransferase (AST) or alanine aminotransferase (ALT) elevations greater than the upper limit of normal (AST >34U/l or ALT> 41U/l) on at least three occasions over at least 6 months while receiving combination ART for at least 1 year were eligible if they had no evidence of active viral hepatitis, hereditary or autoimmune liver disease, or hemochromatosis, no ongoing alcohol abuse, and no contraindication to liver biopsy. The AST/platelet ratio index (APRI), fibrosis-4 (FIB-4), and non-alcoholic fatty liver disease fibrosis score (NAFLD-FS) indices were calculated as noninvasive markers of fibrosis, using laboratory and clinical parameters at the time of study enrollment. Liver stiffness was determined using VCTE. Percutaneous liver biopsy was performed under ultrasound guidance using an 18-gauge needle. Fibrosis and inflammatory activity were scored according to the modified histology activity index (Ishak) scoring system.

Sixty-six patients were evaluated by VCTE and liver biopsy. The cohort was in the majority male (92%), with a median age of 50 years (range 17–68). Biopsy identified bridging fibrosis in 14 (21%) and nonalcoholic steatohepatitis (NASH) in 38 (58%) participants. VCTE was unsuccessful in three participants with obesity (all with NASH) and unreliable in an additional four participants (two with NASH, two with nonspecific changes on biopsy) – a failure rate of 11%. In the 59 participants with reliable results, median liver stiffness measurement (LSM) was 5.9 kPa (range 3.3– 29.2 kPa); 25 participants (42%) had a LSM above 7.1 kPa, a value consistent with increased liver stiffness in other populations. VCTE had good sensitivity and specificity with an area under the receiver-operating characteristic curve (AUROC) of 93% for detection of moderate fibrosis (Ishak F ≥ 2; 95% confidence interval 86–99%). The NPV to exclude F ≥ 2 was 97%. The performance of VCTE, APRI, FIB-4, and NAFLDFS for the detection of significant fibrosis (F ≥ 2) is presented in Table.

Conclusion : In HIV-monoinfected adults with biopsy-proven liver disease, LSM by VCTE was the best noninvasive predictor of fibrosis. These findings support the continued use of VCTE for fibrosis screening in HIV-monoinfected patients with elevated aminotransferases.

AUROC (%, 95% CI) 93 (86-99) 61 (46-77) 64 (49-79) 70 (55-85)
Cut-off (kPa) ≥7.1 >1.5 >2.67 >0.676
Sensitivity (%) 93 21 21 14
Specificity (%) 73 82 89 96
Positive predictive value (%) 52 27 38 50
Negative predictive value (%) 97 77 78 78