Thank you for the opportunity to reply to the letter
by our colleagues, in which an important point is
addressed regarding the interpretation of liver stiffness
measurements (LSMs), performed by transient elastography,
in population-based studies. The letter is in
reference to our article published in HEPATOLOGY in
January 2016, in which we described our observations
among 3,041 presumed healthy individuals who had
undergone hepatic ultrasonography and transient elastography
measurements. In this population, we
found a median LSM of 4.7 kPa (interquartile range
3.8-5.8), and in 5.6% LSM was ≥8.0 kPa. At this 8.0
kPa cutoff, in most studies as well as in clinical practice,
liver fibrosis is diagnosed or, at least, suspected.
Thiele et al. rightfully state that liver stiffness does not
automatically equate with liver fibrosis, especially in
populations with low prevalence of chronic liver disease.
We fully agree. However, the true prevalence of
liver fibrosis in the general population is unknown.
This is because liver biopsy, which is the gold standard
of liver fibrosis assessment, is not appropriate for use in
the general population, considering its invasive nature.
This leaves noninvasive tests, such as transient elastography,
as the only usable screening options, albeit with
limitations.
The real question is how healthy this presumedhealthy
population truly is, given the fact that 24% had
abnormal liver enzymes (in which 11.3% had LSM
≥8.0 kPa versus 3.7% in those with normal liver
enzymes) and 32.8% had ultrasonographic evidence of
nonalcoholic fatty liver disease (NAFLD) (in which
8.4% had LSM ≥8.0 kPa versus 3.5% in those without
NAFLD). Furthermore, in the only other populationbased
study in Caucasians, by Roulot et al., measuring
liver stiffness in 1,190 adults attending a medical
checkup, 7.5% were found to have LSM ≥8.0 kPa. It
is noteworthy that in all cases an underlying liver disease
was found, most of them NAFLD. Given the current
NAFLD epidemic, maybe the general population
is no longer a low-prevalence population for chronic
liver diseases.
We therefore agree with Thiele et al. that early detection
of chronic liver disease in the general population is
of utmost importance and deserves appropriate attention.
In fact, this has become the goal of a recently
established research network of European centers for
investigation of early detection of chronic liver diseases
in the general population. This effort is led by Dr.
Gines from the Barcelona group and includes several
European investigators, including the group by Thiele
et al. and the undersigned. Hopefully, in the near
future, we will learn from this effort and develop better
tools for screening. Until then, the existing noninvasive
tools, including transient elastography and serological
markers, are likely going to be the only screening tools
at our disposal in the general population. Interpretation
of these findings should always be balanced against the
background prevalence, diagnostic performance, and
possible confounders.
Additional Metadata | |
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doi.org/10.1002/hep.28789, hdl.handle.net/1765/93933 | |
Hepatology | |
Organisation | Erasmus MC: University Medical Center Rotterdam |
Darwish Murad, S., Koehler, E., Plompen, E., & Janssen, H. (2017). Reply. Hepatology, 65(2), 749–750. doi:10.1002/hep.28789 |