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Stepwise Combination of Simple Noninvasive Fibrosis Scoring Systems Increases Diagnostic Accuracy in Nonalcoholic Fatty Liver Disease

Demir, Münevver MD*; Lang, Sonja MD*; Nierhoff, Dirk MD*; Drebber, Uta MD; Hardt, Aline MD; Wedemeyer, Inga MD; Schulte, Sigrid MD*; Quasdorff, Maria MD, PhD*; Goeser, Tobias MD*; Töx, Ulrich MD*; Steffen, Hans-Michael MD*

Journal of Clinical Gastroenterology: September 2013 - Volume 47 - Issue 8 - p 719–726
doi: 10.1097/MCG.0b013e3182819a89

Objective: Nonalcoholic fatty liver disease (NAFLD) is a common chronic liver disease ranging from simple fatty liver to steatohepatitis, fibrosis, and cirrhosis. We aimed to analyze the diagnostic performance and clinical utility of simple noninvasive tests alone or in combination for the detection of advanced fibrosis in patients with NAFLD.

Design and Subjects: Data from 323 patients with biopsy-proven NAFLD/NASH who presented to the Clinic for Gastroenterology and Hepatology, University Hospital of Cologne between July 1998 and November 2009, were analyzed retrospectively. Sensitivity, specificity, positive predictive values, and negative predictive values were determined along with the area under receiver operating characteristic curves (AUROC) using published formulas for NAFLD, FIB-4, and BARD fibrosis scores.

Results: The area under receiver operating characteristic curves were as follows: NAFLD fibrosis score 0.96 [95% confidence interval (CI), 0.92-0.99], FIB-4 0.95 (95% CI, 0.91-1.00), BARD 0.82 (95% CI, 0.71-0.92) with negative predictive values for advanced fibrosis of 96%, 98%, and 96%, respectively. When applying the NAFLD, FIB-4, or BARD scoring systems 25%, 15%, or 26% of cases with advanced fibrosis would have been missed. Combining FIB-4 and BARD in a stepwise fashion, patients would have been correctly classified without biopsy in 67% of cases without missing a single case of advanced fibrosis.

Conclusions: The FIB-4 and NAFLD fibrosis scores perform better than the BARD scoring system. Liver biopsy can securely be replaced only with a stepwise combination of simple noninvasive tests, otherwise the assessment of risk due to advanced fibrosis may be misleading in a clinically meaningful proportion of patients.

*Clinic for Gastroenterology and Hepatology

Institute for Pathology, University Hospital of Cologne, Cologne, Germany

M.D. and S.L. contributed equally.

The authors declare that they have nothing to disclose.

Reprints: Münevver Demir, MD, Clinic for Gastroenterology and Hepatology, University Hospital of Cologne, D-50924 Cologne, Germany (e-mail:

Received April 20, 2012

Accepted December 5, 2012

© 2013 by Lippincott Williams & Wilkins