Interpreting liver stiffness in the cirrhotic range: What are we measuring?
Authors: Laurent Castéra, Xavier Forns, Alfredo Alberti
Journal: Journal of Hepatology (2008)

We thank Dr. Bioulac-Sage and colleagues for their interest in our review. The case of cardiac hepatopathy they report emphasizes the fact that interpretation of the results of transient elastography (TE) and other non-invasive tests should always be done by expert clinicians according to the clinical context. Indeed, although the clinical and biological features of this patient could be consistent with the diagnosis of cirrhosis related to NASH, the patient had a past history of severe cardiac disease (myocardial infarction, triple coronary bypasses, and an implantable cardioverter–defibrillator). No information regarding physical examination or ultrasonography is provided by the authors. The presence of enlarged liver and/or hepato-jugular reflux on physical examination together with dilated hepatic veins and inferior vena cava, suggestive of chronic heart failure, would have helped to anticipate the findings of liver biopsy. Although we believe that combining TE with serum non-invasive markers such as Fibrotest increases diagnostic accuracy, we emphasize that so far, it has only been studied in patients with hepatitis C [[1]Castera L. Vergniol J. Foucher J. Le Bail B. Chanteloup E. Haaser M. et al.Prospective comparison of transient elastography, Fibrotest, APRI, and liver biopsy for the assessment of fibrosis in chronic hepatitis C.Gastroenterology. 2005; 128: 343-350Abstract Full Text Full Text PDF PubMed Scopus (2009) Google Scholar]. The discrepancy between the two TE results is surprising within such a short period of time (2 months): “quality criteria” (interquartile range (IQR) and success rate) for interpretation of TE results are not provided by the authors but measurements are said to be satisfactory. Although TE has been shown to be a reproducible technique, longitudinal data are still lacking. Preliminary results regarding liver stiffness dynamics in a control group of untreated patients with chronic hepatitis C suggest that liver stiffness values are stable over time [[2]Hézode C. Castéra L. Rosa I. Roulot D. Leroy V. Bouvier-Alias M. et al.Dynamics of liver stiffness during peginterferon alpha-ribavirin treatment in patients with chronic hepatitis C (abstract).J Hepatol. 2008; 48: S296Abstract Full Text PDF Google Scholar]. Thus, this discrepancy remains difficult to explain. As stressed by the authors, it is likely that perisinuosidal fibrosis contributed to the increased liver stiffness values. As suggested by morphometric studies [[3]Wong G.L. Wong V.W. Choi P.C. Chan A.W. Chum R.H. Chan H.K. et al.Assessment of fibrosis by transient elastography compared with liver biopsy and morphometry in chronic liver diseases.Clin Gastroenterol Hepatol. 2008; 6: 1027-1035Abstract Full Text Full Text PDF PubMed Scopus (126) Google Scholar], liver stiffness seems to accurately reflect the amount of liver fibrosis whatever its location and influence on liver architecture. Consistent with this finding, marked perisinusoidal fibrosis was reported in 10 out of 45 patients without cirrhosis but with increased liver stiffness values suggestive of cirrhosis (>14.6 kPa) [[4]Ganne-Carrie N. Ziol M. de Ledinghen V. Douvin C. Marcellin P. Castera L. et al.Accuracy of liver stiffness measurement for the diagnosis of cirrhosis in patients with chronic liver diseases.Hepatology. 2006; 44: 1511-1517Crossref PubMed Scopus (424) Google Scholar]. Also, a good correlation between liver stiffness values and the degree of perisinusoidal fibrosis has been shown in a recent study in alcoholic patients in whom perisinusoidal fibrosis is common [[5]Nguyen-Khac E. Chatelain D. Tramier B. Decrombecque C. Robert B. Joly J.P. et al.Assessment of asymptomatic liver fibrosis in alcoholic patients using fibroscan: prospective comparison with 7 non-invasive laboratory tests.Aliment Pharmacol Ther. 2008; 28: 1188-1198Crossref PubMed Scopus (160) Google Scholar]. However, in multivariate analysis, liver stiffness values were only correlated with Metavir Fibrosis score. Apart from fibrosis, other parameters such as necro-inflammatory activity may also influence liver stiffness measurements [[6]Arena U. Vizzutti F. Abraldes J. Corti G. Stasi C. Moscarella S. et al.Reliability of transient elastography for the diagnosis of advanced fibrosis in chronic hepatitis C.Gut. 2008; 57: 1288-1293Crossref PubMed Scopus (227) Google Scholar], but the reported patient had normal transaminase levels and no inflammation on liver biopsy. Finally, the influence of architectural disturbances such as sinusoidal dilatation on liver stiffness measurements remains unknown. More data are awaited on that specific issue in patients with sinusoidal and vascular diseases.