Performance of Transient Elastography for the Staging of Liver Fibrosis: A Meta-Analysis

Background & Aims: Transient elastography has been studied in a multitude of liver diseases for the staging of liver fibrosis with variable results. A meta-analysis was performed to assess the overall performance of transient elastography for the diagnosis of liver fibrosis and to analyze factors influencing the diagnostic accuracy. Methods: Literature databases and international conference abstracts were searched. Inclusion criteria were as follows: evaluation of transient elastography, liver biopsy as reference, and assessment of the area under the receiver operating characteristic curve (AUROC). The meta-analysis was performed using the random-effects model for the AUROC, summary receiver operating curve techniques, as well as meta-regression approaches. Results: Fifty studies were included in the analysis. The mean AUROC for the diagnosis of significant fibrosis, severe fibrosis, and cirrhosis were 0.84 (95% confidence interval [CI], 0.82–0.86), 0.89 (95% CI, 0.88–0.91), and 0.94 (95% CI, 0.93–0.95), respectively. For the diagnosis of significant fibrosis a significant reduction of heterogeneity of the AUROC was found when differentiating between the underlying liver diseases (P < .001). Other factors influencing the AUROC were the scoring system used and the country in which the study was performed. Age, body mass index, and biopsy quality did not have a significant effect on the AUROC. Conclusions: Transient elastography can be performed with excellent diagnostic accuracy and independent of the underlying liver disease for the diagnosis of cirrhosis. However, for the diagnosis of significant fibrosis, a high variation of the AUROC was found that is dependent on the underlying liver disease. Background & Aims: Transient elastography has been studied in a multitude of liver diseases for the staging of liver fibrosis with variable results. A meta-analysis was performed to assess the overall performance of transient elastography for the diagnosis of liver fibrosis and to analyze factors influencing the diagnostic accuracy. Methods: Literature databases and international conference abstracts were searched. Inclusion criteria were as follows: evaluation of transient elastography, liver biopsy as reference, and assessment of the area under the receiver operating characteristic curve (AUROC). The meta-analysis was performed using the random-effects model for the AUROC, summary receiver operating curve techniques, as well as meta-regression approaches. Results: Fifty studies were included in the analysis. The mean AUROC for the diagnosis of significant fibrosis, severe fibrosis, and cirrhosis were 0.84 (95% confidence interval [CI], 0.82–0.86), 0.89 (95% CI, 0.88–0.91), and 0.94 (95% CI, 0.93–0.95), respectively. For the diagnosis of significant fibrosis a significant reduction of heterogeneity of the AUROC was found when differentiating between the underlying liver diseases (P < .001). Other factors influencing the AUROC were the scoring system used and the country in which the study was performed. Age, body mass index, and biopsy quality did not have a significant effect on the AUROC. Conclusions: Transient elastography can be performed with excellent diagnostic accuracy and independent of the underlying liver disease for the diagnosis of cirrhosis. However, for the diagnosis of significant fibrosis, a high variation of the AUROC was found that is dependent on the underlying liver disease. CME exam on page 1238. CME exam on page 1238. Liver fibrosis is a common pathway for a multitude of liver injuries. Viral, autoimmune, hereditary, metabolic, and toxin-mediated liver disease can result in hepatocellular dysfunction, expansion of extracellular matrix with distortion of hepatic architecture, portal hypertension, and, finally, cirrhosis.1Lauer G.M. Walker B.D. Hepatitis C virus infection.N Engl J Med. 2001; 345: 41-52Crossref PubMed Scopus (2535) Google Scholar A precise estimation of the degree of liver fibrosis is important for estimation of prognosis, surveillance, and treatment decisions in patients with chronic liver disease.2Strader D.B. Wright T. Thomas D.L. et al.American Association for the Study of Liver Diseases Diagnosis, management, and treatment of hepatitis C.Hepatology. 2004; 39: 1147-1171Crossref PubMed Scopus (1603) Google Scholar, 3Lok A.S. McMahon B.J. Chronic hepatitis B.Hepatology. 2007; 45: 507-539Crossref PubMed Scopus (2187) Google Scholar At present, liver biopsy still most commonly is used as the reference standard for the assessment of liver fibrosis. However, it is an invasive method that is associated with patient discomfort and in rare cases with serious complications.4Bravo A.A. Sheth S.G. Chopra S. Liver biopsy.N Engl J Med. 2001; 344: 495-500Crossref PubMed Scopus (1950) Google Scholar In addition, the accuracy of liver biopsy is limited as a result of intraobserver and interobserver variability and sampling errors.5Bedossa P. Dargere D. Paradise V. Sampling variability of liver fibrosis in chronic hepatitis C.Hepatology. 2003; 38: 1449-1457Crossref PubMed Scopus (2054) Google Scholar Therefore, a lot of research has been focused on the evaluation of noninvasive methods for the assessment of liver fibrosis. The different approaches include routine hematologic and biochemical tests; serum surrogate fibrosis markers and panels; extracellular matrix markers and panels; and specialized tests for liver function, glycomics, proteomics, radiologic imaging, and transient elastography (FibroScan; Echosens, Paris, France). In the past few years an increasing number of studies have evaluated transient elastography for the diagnosis of liver fibrosis in a multitude of liver diseases. We performed a meta-analysis to assess the overall performance of transient elastography for the diagnosis of liver fibrosis and to analyze the heterogeneity between the available studies. Transient elastography is a novel method. The first clinical data from transient elastography were published in 2002. Transient elastography is performed with an ultrasound transducer probe mounted on the axis of a vibrator. A vibration transmitted from the vibrator toward the tissue induces an elastic shear wave that propagates through the tissue. These propagations are followed by pulse-echo ultrasound acquisitions and their velocity is measured, which is related directly to tissue stiffness. The harder the tissue, the faster the shear wave propagates.6Sandrin L. Fourquet B. Hasquenoph J.M. et al.Transient elastography: a new non-invasive method for assessment of hepatic fibrosis.Ultrasound Med Biol. 2003; 29: 1705-1713Abstract Full Text Full Text PDF PubMed Scopus (2265) Google Scholar Up to 10 successful acquisitions are performed routinely on each patient and the examination lasts about 5–10 minutes. The success rate is calculated automatically by the machine as the ratio of the number of successful acquisitions over the total number of acquisitions. According to the manufacturer’s recommendations, only transient elastography results obtained with 10 valid measurements and with a success rate of at least 60% are considered reliable. However, recent publications have suggested that 3 valid measurements could be performed with the same results as 10 valid measurements for cirrhosis diagnosis, but the minimum number for significant and advanced fibrosis is unknown.7Kettaneh A. Marcellin P. Douvin C. et al.Features associated with success rate and performance of Fibroscan measurements for the diagnosis of cirrhosis in HCV patients: a prospective study of 935 patients.J Hepatol. 2007; 46: 628-634Abstract Full Text Full Text PDF PubMed Scopus (223) Google Scholar The quality assessment using the success rates varied between studies, with a range from 30% to 65%. Ten valid measurements and a success rate of at least 60% can be achieved in 90%–96% of examinations. Transient elastography can be learned easily and has a high intraobserver (96%–98%) and interobserver (89%–98%) agreement.8Fraquelli M. Rigamonti C. Casazza G. et al.Reproducibility of transient elastography in the evaluation of liver fibrosis in patients with chronic liver disease.Gut. 2007; 56: 968-973Crossref PubMed Scopus (423) Google Scholar A systematic literature search was performed to evaluate the performance of transient elastography for the diagnosis of liver fibrosis in chronic liver disease. Sources searched included the following.•Electronic databases from 2002 to April 2007: Pub Med, EMBASE, and CENTRAL on The Cochrane Library using a search strategy derived from literature.9Deeks J.J. Systematic reviews of evaluation of diagnostic and screening tests.BMJ. 2001; 323: 157-162Crossref PubMed Scopus (84) Google Scholar, 10Haynes R.B. Wilczynski N.L. Optimal search strategies for retrieving scientifically strong studies of diagnosis from Medline: analytical survey.BMJ. 2004; 328: 1040Crossref PubMed Google Scholar Terms used were “FibroScan,” “transient elastography,” “elastography and liver,” “liver stiffness,” “liver fibrosis.”•Citation database Web of Science from 2002 to April 2007 (Institute of Scientific Information) was searched using the same terms shown earlier.•Relevant websites and conference abstract books: American Association for the Study of the Liver, European Association for the Study of the Liver, Digestive Disease Week, Liver Transplantation, Asian Pacific Association for the Study of the Liver, Conference on Retroviral and Opportunistic Infections, Interscience Conference on Antimicrobial Agents and Chemotherapy, and International Symposium on Ultrasonic Imaging and Tissue Characterization were searched for conference proceedings and abstracts (2002–April 2007).•Authors of full-length articles and authors who presented their studies at the earlier-mentioned conferences were contacted via e-mail to obtain relevant data that were missing.•Reference lists from relevant articles. Studies were included if they met the following criteria: they evaluated transient elastography; they used liver biopsy as a reference standard; they used a comparable liver biopsy staging system: METAVIR, Ishak, Brunt, Ludwig’s, Knodell, Desmet, and Scheuer; they assessed the diagnostic accuracy (area under the receiver operating characteristic curve [AUROC]) for fibrosis stage F ≥ 2, F ≥ 3, or F = 4 according to METAVIR or a comparable staging system; and/or they assessed sensitivity, specificity, positive predictive value, or negative predictive value for the diagnosis of a fibrosis stage based on some cut-off point for liver stiffness. Studies were excluded if they met the following criteria: they did not evaluate transient elastography; they did not use liver biopsy as a reference test; they used a fibrosis staging system not comparable with METAVIR; they did not report data on diagnostic accuracy (AUROC), sensitivity, or specificity for any fibrosis stage; they were reviews, corresponding letters, or editorials not reporting own results; they were abstracts with data that have been published as full-length articles in the meantime; or they were abstracts that obviously presented data of the same study at different meetings (same study group, same patient population, identical study design, same number of patients, or increased number of patients). In this case the most recent abstract was included in this analysis. Data extraction was undertaken by one reviewer (M.F.R.) and checked by a second reviewer (M.F.O.). Disagreements were resolved by discussion and analysis of the data. Data and results of the included studies are presented in Table 1, Table 2, Table 3.Table 1Characteristics of Studies Evaluating the Performance of Transient Elastography for the Diagnosis of Liver FibrosisStudyTypeCountryNo.No. for analysisaNumber of patients suitable for analysis, excluding patient with failed transient elastography measurement or liver biopsy.Exclusion failure, %Mean age, y% MaleFS(reason)LB(reason)Sandrin et al6Sandrin L. Fourquet B. Hasquenoph J.M. et al.Transient elastography: a new non-invasive method for assessment of hepatic fibrosis.Ultrasound Med Biol. 2003; 29: 1705-1713Abstract Full Text Full Text PDF PubMed Scopus (2265) Google ScholarOriginalFrance9167521 (<10 pt)4861Ziol et al, 200526Ziol M. Handra-Luca A. Kettaneh A. et al.Noninvasive assessment of liver fibrosis by measurement of stiffness in patients with chronic hepatitis C.Hepatology. 2005; 41: 48-54Crossref PubMed Scopus (1292) Google ScholarOriginalFrance3272517 (SR < 60%, VM < 10)16 (<10 pt)4861Castera et al, 200517Castera L. Vergniol J. Foucher J. 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 (2137) Google ScholarOriginalFrance1931835.5 (SR < 60%, VM < 10)N/R5157Foucher et al, 200527Foucher J. Chanteloup E. Vergniol J. et al.Diagnosis of cirrhosis by transient elastography (FibroScan): a prospective study.Gut. 2006; 55: 403-408Crossref PubMed Scopus (1073) Google ScholarOriginalFrance758354N/R (SR < 60%, VM < 5)N/R (<10 pt)5058Coletta et al, 200518Colletta C. Smirne C. Fabris C. et al.Value of two noninvasive methods to detect progression of fibrosis among HCV carriers with normal aminotransferases.Hepatology. 2005; 42: 838-845Crossref PubMed Scopus (179) Google ScholarOriginalItaly4040N/RN/R4455de Ledinghen et al, 200620De Ledinghen V. Douvin C. Kettaneh A. et al.Diagnosis of hepatic fibrosis and cirrhosis by transient elastography in HIV/hepatitis C virus-coinfected patients.J Acquir Immune Defic Syndr. 2006; 41: 175-179Crossref PubMed Scopus (343) Google ScholarOriginalFrance7772N/R (SR < 30%, VM < 5)6.5 (<10 pt, <7 mm length)4272Corpechot et al, 200619Corpechot C. El Naggar A. Poujol-Robert A. et al.Assessment of biliary fibrosis by transient elastography in patients with PBC and PSC.Hepatology. 2006; 43: 1118-1124Crossref PubMed Scopus (391) Google ScholarOriginalFrance101952 (SR < 60%, VM < 10)45726Carrion et al, 200616Carrion J.A. Navasa M. Bosch J. et al.Transient elastography for diagnosis of advanced fibrosis and portal hypertension in patients with hepatitis C recurrence after liver transplantation.Liver Transpl. 2006; 12: 1791-1798Crossref PubMed Scopus (372) Google ScholarOriginalSpain135124 (169bThere were 167 biopsies performed at different time points together with FS in 124 patients.)1 (SR < 60%)16066Gomez-Dominguez et al, 200623Gomez-Dominguez E. Mendoza J. Rubio S. et al.Transient elastography: a valid alternative to biopsy in patients with chronic liver disease.Aliment Pharmacol Ther. 2006; 24: 513-518Crossref PubMed Scopus (97) Google ScholarOriginalSpain103945 (SR < 60%, VM < 10)44957Ganne-Carrie et al, 200622Ganne-Carrie N. Ziol M. de Ledinghen V. 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 (444) Google ScholarOriginalFrance12577759 (SR < 50%, VM < 8)10 (<10 mm length)4965Erhardt et al, 200621Erhardt A. Lorke J. Vogt C. et al.Transient elastography for diagnosing liver cirrhosis.Dtsch Med Wochenschr. 2006; 131: 2765-2769Crossref PubMed Scopus (33) Google ScholarOriginalGermany1471358 (SR < 60%, VM < 6)05263Nahon et al, 200624Nahon P. Thabut G. Ziol M. et al.Liver stiffness measurement versus clinicians’ prediction or both for the assessment of liver fibrosis in patients with chronic hepatitis C.Am J Gastroenterol. 2006; 101: 2744-2751Crossref PubMed Scopus (32) Google ScholarOriginalFrance142142N/R (SR < 60%, VM < 10)N/R4661Takeda et al, 200628Takeda T. Yasuda T. Nakayama Y. et al.Usefulness of noninvasive transient elastography for assessment of liver fibrosis stage in chronic hepatitis C.World J Gastroenterol. 2006; 12: 7768-7773PubMed Google ScholarOriginalJapan287287N/RN/R5843Posthouwer et al, 200725Posthouwer D. Mauser-Bunschoten E.P. Fischer K. et al.Significant liver damage in patients with bleeding disorders and chronic hepatitis C: non-invasive assessment of liver fibrosis using transient elastography.J Thromb Haemost. 2007; 5: 25-30Crossref PubMed Scopus (23) Google ScholarOriginalThe Netherlands63/12463N/R (SR < 40%, VM < 10)N/R44N/RKettaneh et al, 20077Kettaneh A. Marcellin P. Douvin C. et al.Features associated with success rate and performance of Fibroscan measurements for the diagnosis of cirrhosis in HCV patients: a prospective study of 935 patients.J Hepatol. 2007; 46: 628-634Abstract Full Text Full Text PDF PubMed Scopus (223) Google ScholarOriginalFrance9355608.537 (15 mm length)4862Marin et al, 200752Marin J.C. De la Cruz J. Fernandez I. et al.Prospective comparison between transient elastography (FibroScan), APRI and Forns test for assessing liver fibrosis in patients with histological features of NAFLD.J Hepatol. 2007; 46: S275AAbstract Full Text PDF Google ScholarAbstractSpain11047N/RN/RN/RN/RBlanc et al, 200731Blanc P.L. Gabbuti A. Marino N. et al.Liver stiffness in chronic hepatitis C: will it modify the assessment of patients?.J Hepatol. 2007; 46: S201AAbstract Full Text PDF Google ScholarAbstractItaly5081367 (SR < 65%)N/RN/RN/RGaia et al, 200743Gaia S. Carenzi S. Brunello F. et al.Is liver stiffness measurement different in patients with NASH or with viral hepatitis?.J Hepatol. 2007; 46: S268AAbstract Full Text PDF Google ScholarAbstractItaly12478N/RN/RN/RN/R46Nahon et al, 200754Nahon P. Ziol M. De Ledinghen V. et al.Assessment of liver fibrosis using liver stiffness measurement (LSM) in patients with alcoholic liver disease.J Hepatol. 2007; 46: S278AAbstract Full Text PDF Google ScholarAbstractFrance12610511 (VM < 8)6 (<10 mm length)5475Nguyen-Khac et al, 200755Nguyen-Khac E. Robert B. Brevet M. et al.Assessment of asymptomatic liver fibrosis in alcohol abuser patients by transient elastography (FibroScan).J Hepatol. 2007; 46: S280AGoogle ScholarAbstractFrance6161N/RN/R5175Miailhes et al, 200753Miailhes P, Perrot G, Bailly F, et al. Prospective comparison of transient elastography and liver biopsy for the assessment of fibrosis in patients with HIV/HBV co-infection. 14th Conference on Retroviruses and Opportunistic Infections 2007.Google ScholarAbstractFrance3131N/R (SR < 60%, IQR < 30%)N/R4377Vergara et al, 200762Vergara S, Macías J, Rivero A, et al. Failure of transient elatometry (FibroScan) to differentiate mild from significant liver fibrosis in HIV/HCV-co-infected patients. 14th Conference on Retroviruses and Opportunistic Infections 2007.Google ScholarAbstractSpain101101N/RN/RN/RN/RChang et al, 200734Chang J, Tan HH, Yew BS, et al. Transient elastography (FibroScan®) to assess hepatic fibrosis in Chinese with chronic hepatitis B. 17th Asian Pacific Association for the Study of Liver Conference 2007.Google ScholarAbstractSingapore35336043N/RServin-Abad et al, 200661Servin-Abad L.A. Jeffers L.J. Bejarano P. et al.Correlation between liver histology, laparoscopic gross appearance and elasticity measured with the shear elasticity probe (FibroScan) in patients with chronic liver disease.Hepatology. 2006; 44: 578AGoogle ScholarAbstractUnited States3939N/RN/R5244Gomez-Dominguez et al, 200645Gomez-Dominguez E. Jimenez-Ridruejo J.M. Monteagudo J.A.M. et al.Efficiency of liver stiffness measurement (FibroScan®) for the follow up of patients with primary biliary cirrhosis.Hepatology. 2006; 44: 633APubMed Google ScholarAbstractSpain6454N/RN/R568Baldaia et al, 200629Baldaia C. Serejo F. Marinho R. et al.Transient elastography in chronic hepatitis C—comparison between different noninvasive methods for liver fibrosis assessment.Hepatology. 2006; 44: 276AGoogle ScholarAbstractPortugal105105N/RN/R (<10 mm length)4474Serejo et al, 200660Serejo F. Marinho R. Costa A. et al.Transient elastography (FibroScan®) in chronic hepatitis C Will it modify the assessment and the follow-up of treated patients?.Hepatology. 2006; 44: 322A-323AGoogle ScholarAbstractPortugal15860N/RN/RN/RN/RBeaugrand et al, 200663Beaugrand M. Ziol M. Sandrin L. et al.Liver elasticity measurement by ultrasonic transient elastography: a new non-invasive method for assessment of liver fibrosis in chronic viral hepatitis.Hepatology. 2003; 38: 438A-439ACrossref Google ScholarAbstractFrance6394949 (VM < 8)13 (<10 pt, <10 mm length)4965Rigamonti et al, 200659Rigamonti C. Donato F. Fraquelli M. et al.Transient elastography (TE, FibroScan®) in the evaluation of recurrent disease after liver transplantation (LT).Hepatology. 2006; 44: 195APubMed Google ScholarAbstractItaly78735 (SR < 65%, VM < 10)N/R5377Lewin et al, 200650Lewin M. Poujol-Robert A. Boelle P.Y. et al.Diffusion-weighted MR imaging for the diagnosis of liver fibrosis in patients with chronic hepatitis C.Hepatology. 2006; 44: 280A-281APubMed Google ScholarAbstractFrance5454N/RN/RN/RN/RFraquelli et al, 200642Fraquelli M. Rigamonti C. Conte D. et al.Reproducibility of transient elastography (TE) in assessing hepatic fibrosis.Hepatology. 2006; 44: 444AGoogle ScholarAbstractItaly2001962 (VM < 10)N/RN/R59Corradi et al, 200638Corradi F. Piscaglia F. Tame R. et al.Staging of hepatic fibrosis by liver elastometry (FibroScan) in recurrent HCV infection in liver transplant recipients.J Hepatol. 2006; 44: S59AAbstract Full Text PDF Google ScholarAbstractItaly3636N/RN/RN/RN/RKim et al, 200648Kim K.M. Park S.H. Yu E.S. et al.Diagnosis of hepatic steatosis and fibrosis by transient elastography in asymptomatic healthy people: a prospective study in potential living related liver donors.J Hepatol. 2006; 44: S91AGoogle ScholarAbstractKorea4747N/RN/R4623Coco et al, 200637Coco B. Oliveri F. Colombatto B. et al.Liver stiffness measured by transient elastography: the influence of biochemical activity.J Hepatol. 2006; 44: S196AAbstract Full Text PDF Google ScholarAbstractItaly256181N/RN/RN/RN/Rde Ledinghen et al, 200640De Ledinghen V. Beaugrand M. Kelleher T.B. et al.Prediction of liver fibrosis in non-alcoholic steatohepatitis (NASH): risk factors and diagnostic potential of liver elasticity using FibroScan.J Hepatol. 2006; 44: S39AAbstract Full Text PDF Google ScholarAbstractFrance/United States129129N/RN/R54N/RLaharie et al, 200649Laharie D. Foucher J. Bernard P.H. et al.Assessment of cirrhosis and its severity by FibroScan and biochemical markers in alcoholic patients.DDW. 2006; (Abstract ID: M1026)Google ScholarAbstractFrance292608N/R5469Jeon et al, 200646Jeon S.W. Cho C.M. Park Y.D. et al.Correlation between liver elasticity measured by Fibroscan® and liver fibrosis assessed by histology; preliminary study in Korea.DDW. 2006; (Abstract ID: S1610)Google ScholarAbstractKorea4747N/RN/RN/R64Castera et al, 200633Castera L. Foucher J. Le Bail B. et al.Prospective and independent validation of the Lok index for prediction of cirrhosis in patients with chronic hepatitis C: comparison with FibroScan, FibroTest and APRI.DDW. 2006; (Abstract-ID: 552)Google ScholarAbstractFrance4122524.5N/R5256Rigamonti et al, 200658Rigamonti C. Donato M.F. Fraquelli M. et al.Evaluation of liver graft fibrosis by transient elastography (TE).Liver Transpl. 2006; 12: C60AGoogle ScholarAbstractItaly423111 (SR < 50%, VM < 10)N/R5374Khokhar et al, 200547Khohkar A. Farnan R. MacFarlane C. et al.Liver stiffness and biomarkers: correlation with cirrhosis, portal hypertension and hepatic synthetic function.Hepatology. 2005; 42: 433AGoogle ScholarAbstractUnited States175175N/RN/RN/RN/RCoco et al, 200536Coco B. Oliveri F. Colombatto P. et al.Monitoring liver stiffness: a new tool to measure liver fibrosis during therapy.Hepatology. 2005; 42: 435AGoogle ScholarAbstractItaly24122823N/RN/RCastera et al, 200532Castera L. Van hecke A. Trimoulet P. et al.Independent validation and comparison with FibroScan, FibroTest and liver biopsy of clinical glycomics for the non invasive assessment of liver fibrosis in chronic hepatitis C.Hepatology. 2005; 42: 436AGoogle ScholarAbstractFrance and Belgium111111N/RN/R5351Pares et al, 200557Pares A. Caballeria L. Lazaro E. et al.Transient elastography: a new and useful non-invasive method for assessing liver damage progression in primary biliary cirrhosis.Hepatology. 2005; 42: 464AGoogle ScholarAbstractSpain150150N/RN/R608Ganne-Carrie et al, 200544Ganne-Carrie N. De Ledinghen V. Douvin C. et al.Accuracy of liver stiffness measurement (LSM) for the diagnosis of cirrhosis in patients with chronic liver diseases (CLD): a study in 1345 patients.Hepatology. 2005; 42: 338AGoogle ScholarAbstractFrance134589116 (SR < 50%, VM < 10)18 (<10 mm length)4763De Ledinghen et al, 200539De Ledinghen V. Le Bail B. Rebouissoux L. et al.FibroScan® is a new non-invasive method for the diagnosis of liver fibrosis in children: a prospective comparison with FibroSure®, and liver biopsy.Hepatology. 2005; 42: 472AGoogle ScholarAbstractFrance10425N/RN/R1147Barrault et al, 200530Barrault C. Medkour F. Atanaiu C. et al.Non invasive assessment of liver graft fibrosis by transient elastography after liver transplantation.Hepatology. 2005; 42: 485A-486AGoogle ScholarAbstractFrance3030N/RN/R5683Marcellin et al, 200551Marcellin P. De Ledinghen V. Dhumeaux D. et al.Non-invasive assessment of liver fibrosis in chronic hepatitis B using FibroScan®.Hepatology. 2005; 42: 715A-716AGoogle ScholarAbstractFrance2201705 (VM < 8)17 (<10 pt)N/RN/RFoucher et al, 200541Foucher J. Vergniol J. Castera L. et al.Fibrosis evaluation in chronic liver diseases: comparison of FibroScan® with liver biopsy, FibroTest®, Forns score, APRI, hyaluronan, prothrombin time, and AST/ALT ratio.J Hepatol. 2005; 42: 78AGoogle ScholarAbstractFrance363363N/RN/R5160Chanteloup et al, 200435Chanteloup E. Foucher J. Castera L. et al.FibroScan® is a new non invasive method for the detection of cirrhosis and its complications in patients with chronic liver diseases. Results of a prospective study in 456 patients.Hepatology. 2004; 40: 515AGoogle ScholarAbstractFrance456456N/RN/R5356Palau et al, 200356Palau R. Mal F. Christidis C. et al.Transient elastography a new non invasive method for assessment of liver fibrosis: results in patients with HCV chronic hepatitis.J Hepatol. 2003; 38: 126AAbstract Full Text PDF Google ScholarAbstractFrance12096416N/RN/RAIH, autoimmune hepatitis; FS, FibroScan; HBV, hepatitis B virus infection; IQR, interquartile; LB, liver biopsy; NAFLD, nonalcoholic fatty liver disease; PBC, primary biliary cirrhosis; post-Tx, posttransplantation; PSC, primary sclerosing cholangitis; pt, portal tracts; SR, success rate; VM, valid FibroScan measurements.a Number of patients suitable for analysis, excluding patient with failed transient elastography measurement or liver biopsy.b There were 167 biopsies performed at different time points together with FS in 124 patients. Open table in a new tab Table 2Histology Distribution and Quality of Studies Evaluating the Performance of Transient ElastographyDiagnosisMean BMIMETAVIR and other scoring systems, %Mean or median length of LB (fragmentation)F = 0F = 0–1F = 2F = 3F = 4HCVN/R740252114N/RHCV, HCV/HIV, HCV/HBV240.43535111918HCV2502629202517 (2)HCV, HBV, HCV/HIV, NASH, ASH, PBC, other25N/R3128142716.5HCV217.56522.512.5020HCV/HIV22N/R393172320PBC, PSCN/RN/R4023211617 (2)HCV post-Tx2524582499N/RHCV, PBC, AIH, ASHN/R018442117N/RHCV, HBV, HCV/HIV, NASH, ASH, PBC, otherN/RN/RN/RN/RN/R1517HCV, HBV, NASH, ASH, PBC, other261631221433N/RHCVN/R03132102715.8HCVN/R17.45724613N/RHCVN/R6542413933HCV25N/R5026141021NAFLD263676116.56.5N/RHCVN/RN/RN/RN/RN/RN/RN/RHCV, HBVN/R54722427N/RNASHN/R335022199N/RASH2708182648N/RASHN/R153425251612HBV/HIV22N/R3632(F3–F4: 32%)18HCV/HIVN/RN/RN/RN/RN/R37N/RHBV262066(F2–F3: 14%)20N/RHCV, HBV, ASH, otherN/R2.6133625.525.5N/RPBCN/RN/RN/RN/RN/RN/RN/RHCV, HBVN/RN/R1951121819HCVN/RN/R(F0–F2: 70%)(F3–F4: 30%)N/RHCV25645311014N/RHCV, HBV, PBC, PSC, otherN/RN/R5314N/RN/R35HCVN/R25715919N/RDifferent causesN/RN/RN/RN/RN/RN/RN/RHCV post-TxN/R0672283N/RHCV, HBV, HCV/HBV, NAFLD, PBC, other2401936331224HCV, HBVN/RN/RN/RN/RN/RN/RN/RNASH30N/R5021920N/RASH25N/RN/RN/RN/RN/RN/RHCV, HBVN/R823323015N/RHCVN/RN/R2436202019post-Tx with HCV, HBV, other24N/R71(F2–F4: 29%)N/RHCV, HBV, ASH, NASHN/RN/R(F0–F2: 39%)1149N/RHCV, HBVN/RN/RN/RN/RN/RN/RN/RHCVN/RN/R25272325N/RPBCN/R05625.313.35.3N/RHCV, HBV, ASH, hemochromatosis, other24N/RN/RN/RN/RN/RN/RHCV, HBV, cystic fibrosis and others, children onlyN/RN/R32162428N/RHCV, ASH, otherN/RN/RN/RN/RN/RN/RN/RHBVN/R642301414N/RHCV, HBV, ASH, otherN/RN/R31281427N/RHCV, HBV, NASH, ASH, hemochromatosis, otherN/RN/RN/RN/RN/R21N/RHCVN/RN/RN/RN/RN/RN/RN/R Open table in a new tab Table 3Results of Studies Evaluating the Performance of Transient Elastography for the Diagnosis of Liver FibrosisStudyMETAVIR and other scoring systems F ≥ 2METAVIR and other scoring systems F ≥ 3METAVIR and other scoring systems F = 4AUROCCut-off value, kPaSensitivity, %Specificity, %AUROCCut-off value, kPaSensitivity, %Specificity, %AUROCCut-off value, kPaSensitivity, %Specificity, %Sandrin et al, 20030.880.910.99Ziol et al, 20050.798.856910.919.686850.9714.68696Castera et al, 20050.837.167890.909.573910.9512.58791Foucher et al, 20060.807.264850.9012.565950.9617.67797Coletta et al, 20051.008.741001009.6de Ledinghen et al, 20060.724.593180.910.9711.810093Corpechot et al, 20060.927.384870.959.891900.9617.39395Carrion et al, 20060.908.5090810.930.9812.5010087Gomez-Dominguez et al, 20060.745.0094330.721158890.9416.008996Ganne-Carrie et al, 20060.9511.79187Erhardt et al, 20060.910.9413.09082Nahon et al, 20060.680.780.89Takeda et al, 20060.810.880.88Posthouwer et al, 20070.877.172850.899.57190Kettaneh et al, 20070.790.890.91Marin et al, 20070.830.880.97Blanc et al, 20070.800.910.95Gaia et al, 20070.840.84—0.740.900.98Nahon et al, 20070.960.90Nguyen-Khac et al, 20070.94199081Miailhes et al, 20070.790.73Vergara et al, 20070.887.20.9514.6Chang et al, 200711.8907814.58692Servin-Abad et al,