Author information
1Epidemiology and Data Science, Amsterdam Public Health, University of Amsterdam, Amsterdam, Netherlands.
2Laboratoire Hémodynamique, Interaction Fibrose et Invasivité Tumorales Hépatiques, University Paris Research, Structure Fédérative de Recherche, Interactions Cellulaires et Applications Thérapeutiques 4208, University of Angers, Angers, France; Department of Hepato-Gastroenterology and Digestive Oncology, University Hospital of Angers, Angers, France.
3Section of Gastroenterology and Hepatology, Promozione della Salute, Materno-Infantile, di Medicina Interna e Specialistica di Eccellenza, Department, University of Palermo, Palermo, Italy.
4Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK.
5Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK; Department of Pathology, Aretaieion Hospital, National and Kapodistrian University of Athens, Athens, Greece.
6Division of Hepatology, Department of Medicine II, Wurzburg University Hospital, Wurzburg, Germany.
7Department of Gastroenterology Hepatology, Antwerp University Hospital, Laboratory of Experimental Medicine and Paediatrics, University of Antwerp, Antwerp, Belgium.
8Liver Unit, Department of Medicine, Cambridge National Institute for Health and Care Research Biomedical Research Centre, Cambridge University National Health Service Foundation Trust, Cambridge, UK.
9Gastroenterology Department, National and Kapodistrian University of Athens, Athens, Greece.
10University Clinic of Gastroenterology, Faculty of Medicine, University of Lisbon, Lisbon, Portugal.
11Public Assistance Hospital of Paris, Pitié Salpêtrière Hospital, Institute of Cardiometabolism and Nutrition, Sorbonne University, Paris, France.
12Hepatology, Department of Biomedical Research, University of Bern, Bern, Switzerland.
13Nordic Bioscience, Herlev, Denmark.
14The Radcliffe Department of Medicine, University of Oxford, Oxford, UK.
15Lilly Research Laboratories, Eli Lilly, Indianapolis, IN, USA.
16Department of Gastroenterology and Hepatology, Oxford National Institute for Health and Care Research Biomedical Research Centre, Oxford University Hospitals, Oxford, UK.
17Department of Medicine, Oxford National Institute for Health and Care Research Biomedical Research Centre, Oxford, UK.
18Department of Internal and Vascular Medicine, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, Netherlands.
19Department of Medicine, Helsinki University Hospital, University of Helsinki, Helsinki, Finland; Minerva Foundation Institute for Medical Research, Helsinki, Finland.
20Gastroenterology and Hepatology Department, Valdecilla Health Research Institute, Marqués de Valdecilla University Hospital, Santander, Spain.
21SomaLogic, Boulder, CO, USA.
22Cardiovascular, Renal or Metabolism Regulatory Affairs, AstraZeneca, Mölndal, Sweden.
23Clinical Development and Operations, Pfizer, Lake Mary, FL, USA.
24Novartis Pharmaceuticals, East Hanover, NJ, USA.
25Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden.
26Nottingham Digestive Diseases Centre, School of Medicine, National Institute for Health and Care Research Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust, The University of Nottingham, Nottingham, UK.
27Metabolic Liver Research Program, Department of Medicine, University Medical Center Mainz, Mainz, Germany.
28Department of Medical Sciences, Division of Gastro-Hepatology, City of Health and Science of Turin, University of Turin, Turin, Italy.
29Digestive Diseases, Virgen of Rocio University Hospital, Institute of Biomedicine of Seville, Department of Medicine, University of Seville, Seville, Spain.
30Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK; Newcastle National Institute for Health and Care Research Biomedical Research Centre, Newcastle upon Tyne Hospitals National Health Service Trust, Newcastle upon Tyne, UK. Electronic address: quentin.anstee@newcastle.ac
Abstract
Background: The reference standard for detecting non-alcoholic steatohepatitis (NASH) and staging fibrosis-liver biopsy-is invasive and resource intensive. Non-invasive biomarkers are urgently needed, but few studies have compared these biomarkers in a single cohort. As part of the Liver Investigation: Testing Marker Utility in Steatohepatitis (LITMUS) project, we aimed to evaluate the diagnostic accuracy of 17 biomarkers and multimarker scores in detecting NASH and clinically significant fibrosis in patients with non-alcoholic fatty liver disease (NAFLD) and identify their optimal cutoffs as screening tests in clinical trial recruitment.
Methods: This was a comparative diagnostic accuracy study in people with biopsy-confirmed NAFLD from 13 countries across Europe, recruited between Jan 6, 2010, and Dec 29, 2017, from the LITMUS metacohort of the prospective European NAFLD Registry. Adults (aged ≥18 years) with paired liver biopsy and serum samples were eligible; those with excessive alcohol consumption or evidence of other chronic liver diseases were excluded. The diagnostic accuracy of the biomarkers was expressed as the area under the receiver operating characteristic curve (AUC) with liver histology as the reference standard and compared with the Fibrosis-4 index for liver fibrosis (FIB-4) in the same subgroup. Target conditions were the presence of NASH with clinically significant fibrosis (ie, at-risk NASH; NAFLD Activity Score ≥4 and F≥2) or the presence of advanced fibrosis (F≥3), analysed in all participants with complete data. We identified thres holds for each biomarker for reducing the number of biopsy-based screen failures when recruiting people with both NASH and clinically significant fibrosis for future trials.
Findings: Of 1430 participants with NAFLD in the LITMUS metacohort with serum samples, 966 (403 women and 563 men) were included after all exclusion criteria had been applied. 335 (35%) of 966 participants had biopsy-confirmed NASH and clinically significant fibrosis and 271 (28%) had advanced fibrosis. For people with NASH and clinically significant fibrosis, no single biomarker or multimarker score significantly reached the predefined AUC 0·80 acceptability threshold (AUCs ranging from 0·61 [95% CI 0·54-0·67] for FibroScan controlled attenuation parameter to 0·81 [0·75-0·86] for SomaSignal), with accuracy mostly similar to FIB-4. Regarding detection of advanced fibrosis, SomaSignal (AUC 0·90 [95% CI 0·86-0·94]), ADAPT (0·85 [0·81-0·89]), and FibroScan liver stiffness measurement (0·83 [0·80-0·86]) reached acceptable accuracy. With 11 of 17 markers, histological screen failure rates could be reduced to 33% in trials if only people who were marker positive had a biopsy for evaluating eligibility. The best screening performance for NASH and clinically significant fibrosis was observed for SomaSignal (number needed to test [NNT] to find one true positive was four [95% CI 4-5]), then ADAPT (six [5-7]), MACK-3 (seven [6-8]), and PRO-C3 (nine [7-11]).
Interpretation: None of the single markers or multimarker scores achieved the predefined acceptable AUC for replacing biopsy in detecting people with both NASH and clinically significant fibrosis. However, several biomarkers could be applied in a prescreening strategy in clinical trial recruitment. The performance of promising markers will be further evaluated in the ongoing prospective LITMUS study cohort.
Funding: The Innovative Medicines Initiative 2 Joint Undertaking.