Reply to: “Non-invasive prediction of fibrosis in nonalcoholic fatty liver disease”
Authors: Eduardo Fassio, Gabriela Ruffillo
Journal: Journal of Hepatology (2011)

Non-invasive prediction of fibrosis in non-alcoholic fatty liver diseaseJournal of HepatologyVol. 55Issue 2PreviewNon-alcoholic fatty liver disease (NAFLD) is one of the most common causes of liver disease worldwide. It includes a wide spectrum of liver diseases, ranging from pure steatosis to nonalcoholic steatohepatitis (NASH), and eventually to liver cirrhosis with its complications. Full-Text PDF Open Access We would like to address the concerns presented by Dr. Dogru et al. in their letter to the Editor. The first issue commented on pertains to one of the six variables included in the formula of the NAFLD fibrosis score: impaired fasting glucose/diabetes. For that variable, we took the same definition from the original paper by Angulo et al. [[1]Angulo P. Hui J.M. Marchesini G. Bugianesi E. George J. Farrell G.C. et al.The NAFLD fibrosis score: a noninvasive system that identifies liver fibrosis in patients with NAFLD.Hepatology. 2007; 45: 846-854Crossref PubMed Scopus (2048) Google Scholar]. Diabetes was defined as a fasting glucose level ⩾126 mg/dl or a patient who was already under treatment with anti-diabetic drugs; and impaired fasting glucose, as a fasting glucose level ⩾110 mg/dl. We did not perform any glucose tolerance test in our patients. As stated in our paper [[3]Ruffillo G. Fassio E. Alvarez E. Landeira G. Longo C. Domínguez N. et al.Comparison of NAFLD fibrosis score and BARD score in predicting fibrosis in nonalcoholic fatty liver disease.J Hepatol. 2011; 54: 160-163Abstract Full Text Full Text PDF PubMed Scopus (67) Google Scholar], we just retrospectively analyzed data of consecutive patients with biopsy proven NAFLD that had been prospectively collected. One advantage of both, the NAFLD fibrosis score and the BARD score [[2]Harrison S.A. Oliver D. Arnold H.L. Gogia S. Neuschwander-Tetri B.A. Development and validation of a simple NAFLD clinical scoring system for identifying patients without advanced disease.Gut. 2008; 57: 1441-1447Crossref PubMed Scopus (585) Google Scholar], is that they include 6 and 3, respectively, easily available variables. Being a group that is especially interested in research on NAFLD, we had all of these variables available in our database. In fact, at present if we wanted to repeat the analysis of comparison between both scoring systems, data on 182 biopsy proven NAFLD patients would be available (instead of 138 in our published paper). The second concern raises the point about the lack of information on medications that patients could be receiving. We agree that some drugs may influence the serum levels of aspartate aminotransferase (AST) and alanine aminotransferase (ALT) and we do not have the complete information about medications taken by our patients. Some of them were receiving antihypertensive drugs such as enalapril, or antihyperlipidemic drugs such as statins. However, the pattern of liver enzymes in our NAFLD patients conformed to those commonly found; with a mild to moderate elevation and an ALT predominance. Median ALT was 69 IU/L, interquartile range 50–96.5 IU/L and, in only 4 out of 138 patients (2.9%), levels above 200 IU/L (that is, five times above upper limit of normal) were found (maximal value, 294). AST/ALT ratios in these 4 patients were 0.61, 0.52, 0.78 and 0.55, similar to the whole group of patients. Thus, we might suggest that most of the patients were not showing a drug-induced liver injury able to modify AST or ALT levels. The AST/ALT ratio is a very important variable, strongly associated with the presence of advanced fibrosis in the univariate analysis (with higher odds ratio than other variables) and therefore, is included in both scoring systems, the NAFLD fibrosis score and the BARD score. Furthermore, in the BARD score, an AST/ALT ratio ⩾0.8 sums 2 points while the other two variables, presence of diabetes or body mass index ⩾28, sum only 1 point. However, the information on the list of medications taken by the patients is also lacking in the two original studies [1Angulo P. Hui J.M. Marchesini G. Bugianesi E. George J. Farrell G.C. et al.The NAFLD fibrosis score: a noninvasive system that identifies liver fibrosis in patients with NAFLD.Hepatology. 2007; 45: 846-854Crossref PubMed Scopus (2048) Google Scholar, 2Harrison S.A. Oliver D. Arnold H.L. Gogia S. Neuschwander-Tetri B.A. Development and validation of a simple NAFLD clinical scoring system for identifying patients without advanced disease.Gut. 2008; 57: 1441-1447Crossref PubMed Scopus (585) Google Scholar]. The authors declared that they do not have anything to disclose regarding funding or conflict of interest with respect to this manuscript.