World Congress at ACG2017

Simultaneous Plenary Session 1A: Liver

13 - Validity of Non-Invasive Fibrosis Scores to Detect Advanced Fibrosis in Patients With Type 2 Diabetes With Suspected Non-Alcoholic Fatty Liver Disease

Monday, October 16
4:50 PM - 5:00 PM
Location: Valencia Ballroom A (Level 4)



Award: 2017 ACG Governors Award for Excellence in Clinical Research

Category: Liver       

Amandeep Singh, MD1, Rocio Lopez, MS, MPH 1, Eric Lawitz, MD2, Fred Poordad, MD 2, Naim Alkhouri, MD1
1Cleveland Clinic Foundation, Cleveland, OH; 2Texas Liver Institute, San Antonio, TX
Introduction: Recent guidelines from the European Association for the Study of the Liver recommended screening for nonalcoholic fatty liver (NAFLD) and case finding of advanced disease with fibrosis in patients with type 2 diabetes (T2D). Due to the high prevalence of NAFLD in diabetics, inexpensive noninvasive scores are needed to replace costly imaging tests and liver biopsy. The aim of this study was to assess the accuracy of commonly used noninvasive scores to predict the presence of advanced fibrosis (stage 3-4) in a large cohort of diabetics in the real life settings.

Methods: Using ICD-9 codes, all patients with the diagnosis of T2D who had a liver biopsy were reviewed and a retrospective chart analysis was done. Patients with secondary causes of hepatic steatosis (excessive alcohol consumption, hepatitis C etc.) or with incomplete data were excluded. Liver biopsy results were noted and evaluated for any fibrosis. AST/ ALT ratio, AST to platelet ration index (APRI), FIB-4 index, and NAFLD fibrosis score (NFS) were calculated to predict advanced disease. Sensitivity, specificity, and area under the ROC curve (AUC) were calculated to predict the overall accuracy of each score.

Results: A total of 1157 subjects met the inclusion criteria of having T2D and liver biopsy for suspected NAFLD. Overall, 85% of the population was overweight or obese (BMI > 25 kg/m2). 94 % with advanced fibrosis were Caucasian (p= < 0.01), 60.8% had hyperlipidemia (p= < 0.01), and 22.1% had chronic kidney disease (p= < 0.01). 42.2 % were on insulin therapy (p=0.001) and 48% on antilipid agents (p=0.010). Liver biopsy showed 68.7% with no or early fibrosis (Metavir score 0-2) and 31.7% with advanced fibrosis (Metavir score 3-4). In comparison to liver biopsy, for the diagnosis of advanced disease (NASH with fibrosis), AST/ALT ratio, APRI, FIB-4 and NFS had reasonable specificities of 84.2%, 97.4%, 69.9%, 93% but poor sensitivities of 27.4 %, 16.5%, 6.7% and 44.1% respectively (Figure 1 and Table 1).

Discussion: In this large cohort of adult patients with T2D and NAFLD, commonly used fibrosis scores had poor sensitivity for predicting advanced disease defined as the presence of NASH with advanced fibrosis. Development of reliable biomarkers for NAFLD/ NASH in diabetics is urgently needed.

Supported by Industry Grant: No


Table 1. Validity of Fibrosis Scores Cutpoints in Subjects with Diabetes Type II and NAFLD






































Test Sensitivity Specificity PPV NPV
AST/ALT > 1.4 27.4 (22.8, 32.0) 84.2 (81.6, 86.8) 44.6 (38.1, 51.1) 71.5 (68.5, 74.4)
APRI > 1.5 16.5 (12.6, 20.3) 97.4 (96.3, 98.5) 74.7 (65.1, 84.3) 71.7 (68.9, 74.4)
NFS > 0.676 63.7 (58.5, 68.8) 69.9 (66.6, 73.3) 49.7 (44.9, 54.4) 80.5 (77.4, 83.6)
FIB-4 > 2.67 44.1 (39.0, 49.3) 93.0 (91.3, 94.8) 74.5 (68.7, 80.4) 78.3 (75.6, 81.0)

PPV: positive predictive value; NPV: negative predictive value
Gold standard used: Advanced fibrosis on biopsy
Wald 95% confidence intervals reported

Citation: . VALIDITY OF NON-INVASIVE FIBROSIS SCORES TO DETECT ADVANCED FIBROSIS IN PATIENTS WITH TYPE 2 DIABETES WITH SUSPECTED NON-ALCOHOLIC FATTY LIVER DISEASE. Program No. 13. World Congress of Gastroenterology at ACG2017 Meeting Abstracts. Orlando, FL: American College of Gastroenterology.

Amandeep Singh

Cleveland Clinic Foundation
Cleveland, Ohio

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