Noninvasive imaging biomarker assessment of liver fibrosis by elastography in NAFLD

Key Points

  • NAFLD is the most common form of chronic liver disease, and patient-centred risk-assessment strategies are therefore needed for cost-effective care

  • Liver elastography — or liver stiffness measurement — is an alternative to liver biopsy to evaluate patients with NAFLD for the presence of advanced fibrosis or cirrhosis

  • Of the available elastographic modalities, vibration-controlled transient elastography is the most studied and magnetic resonance elastography is the most accurate; ultrasound-based elastography is promising but lacks defined examination quality criteria

  • Future research is needed to establish the optimal sequence of modalities for use in the clinic and the definition of clinically meaningful changes in liver stiffness

Abstract

NAFLD is a global epidemic. The prevalence of NAFLD is 20–30% in North America, northern Europe, Australia, Japan, India and China. It is crucial that patients with NAFLD receive an assessment for their risk of advanced fibrosis, which increases the risk of hepatocellular carcinoma and other complications of cirrhosis. Risk stratification that is efficient, cost-effective, patient-centred and evidence-based is one of the most important issues facing clinicians who care for those with liver disease. Given patients' preference to avoid liver biopsy, noninvasive alternatives to assess liver fibrosis are in high demand. The most accurate noninvasive methods are based on liver elastography. Research on these techniques — which include vibration-controlled transient elastography (VCTE), magnetic resonance elastography (MRE), shear-wave elastography and acoustic radiation force impulse — has proliferated. Unfortunately, the literature has not kept pace with clinical practice. There is limited guidance for how clinicians should anticipate and manage the pitfalls of these tests. Furthermore, guidance is unavailable for clinicians regarding the optimal incorporation of VCTE, MRE or the emerging elastographic techniques into their clinical strategy, particularly for patients with NAFLD. In this Review, we summarize the available evidence, highlight gaps to address in further research and explore optimization of these techniques in clinical practice.

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Figure 1: Example images from elastographic techniques.
Figure 2: A suggested strategy for risk stratification of patients with NAFLD using multiple elastographic methods.

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Acknowledgements

R.L. is supported in part by the grant R01-DK106419-03. Research reported in this publication was supported in part by the US National Institute of Environmental Health Sciences of the US National Institutes of Health under award number P42ES010337. The content is solely the responsibility of the authors and does not necessarily represent the official views of the US NIH.

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Correspondence to Rohit Loomba.

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R.L. has received research funding support from General Electric and Siemens.

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Tapper, E., Loomba, R. Noninvasive imaging biomarker assessment of liver fibrosis by elastography in NAFLD. Nat Rev Gastroenterol Hepatol 15, 274–282 (2018). https://doi.org/10.1038/nrgastro.2018.10

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