The Value Evaluation Of Fibroscan In The Diagnosis Of Liver Fibrosis In Chronic Hepatitis B Patients With Low Alanine Aminotransferase In Combination With Hepatic Steatosis

Objectives: Liver stiffness measurement(LSM)and controlled attenuation parameter(CAP)were measured by Fibroscan,and to analyze the influences on LSM.In addition,the impact and severity of hepatic steatosis on liver fibrosis diagnosis by LSM as well as the diagnostic effectiveness of LSM based on hepatic steatosis were explored.To develop a diagnostic flowchart for the degree of fibrosis in patients including hepatic steatosis.To assist the decision-making of antiviral therapy in chronic hepatitis B(CHB)patients with low alanine aminotransferase levels and hepatic steatosis.Methods: A total of 218 CHB patients who were admitted to the Department of Hepatology of the Third People’s Hospital of Kunming from January 2021 to September 2022 and completed liver biopsy and Fibroscan within one week were selected.The patients’ liver biopsy results,LSM and CAP values from Fibroscan were collected,and the general demographic data,general cytological analysis,liver and kidney function,coagulation indicators,and virological indicators of the enrolled patients were collected.According to the CAP results,the patients were divided into groups with and without non-alcoholic fatty liver disease.The general data of the two groups were compared,and the factors affecting the LSM values were analyzed by univariate and multivariate linear regression analysis.Liver biopsy results were divided into S0-S4 stage according to Metavir scoring system.Mann-Whitney U test was used to analyze the differences of LSM values between S0-S4 stage patients with and without hepatic steatosis.The patients in the hepatic steatosis group were further stratified into mild,moderate and severe fatty liver,and the Kruskal-Walli’s rank sum test was used to analyze the effect of S0-S4 with different degrees of steatosis on LSM values.Logistic regression analysis was used to analyze the factors related to the accuracy of Fibroscan in the diagnosis of fibrosis.The ROC curve,area under the receiver operating characteristic curve(AUROC),and Cut-off value were used to describe the diagnostic efficacy of LSM for liver fibrosis stage.The Kappa consistency test was used to compare the agreement between our study results and reference values in the diagnosis of significant fibrosis and liver biopsy results,and according to the Cut-off value,the diagnostic flow chart of liver fibrosis degree considering hepatic steatosis was developed.Results1.Among the 218 patients included in the study,80(36.7%)patients were complicated with hepatic steatosis,of which 47(21.6%)patients were complicated with moderate to severe hepatic steatosis.Liver biopsy showed that 177 patients(81.2%)had fibrosis stage S0-S1,and 41 patients(18.8%)had fibrosis stage ≥S2.The median values of LSM for S0,S1,S2,S3 and S4 were 5.5k Pa,5.8k Pa,6.3k Pa,9.2k Pa and 17.4k Pa,respectively.Liver fibrosis stage was significantly correlated with LSM value,β=2.174,P<0.001.2.The age,BMI,ALT,GGT,CAP and LSM levels of patients with hepatic steatosis were higher than those of patients without hepatic steatosis,while the positive rate of HBe Ag and INR were lower than those of CHB patients without hepatic steatosis,and the differences were statistically significant(P<0.05).ALT,AFP,liver fibrosis stage and hepatic steatosis degree were independently positively correlated with LSM values(P<0.05).3.The LSM values of CHB patients with hepatic steatosis in stage S0-S1 were significantly higher than those without hepatic steatosis.Further stratified by the degree of steatosis,it was found that moderate to severe steatosis increased the LSM value of patients without obvious fibrosis(S0-S1).Among the 60 patients with hepatic steatosis confirmed by liver biopsy as stage S0-S1,Fibroscan misdiagnosed21 patients(35%)as significant fibrosis,significant fibrosis,or cirrhosis.After Logistic regression analysis,CAP(OR=1.03,P<0.05)was an independent risk factor for misdiagnosis.When the Cut-off value was 273 d B/m,the AUROC was 0.772,the sensitivity was 0.762,and the specificity was 0.795.4.For patients with CAP=238-273 d B/m,when the Cut-off values were 8.3k Pa and9.5k Pa,the AUROC of Fibroscan for the diagnosis of significant fibrosis and significant fibrosis were 0.880 and 0.973,respectively,and the sensitivity were 0.786 and 0.833,respectively.The specificity was 0.944 and 0.886,respectively.For patients with CAP≥273d B/m,when the Cut-off values were 9.6k Pa and 10.8k Pa,the AUROC of Fibroscan for the diagnosis of significant fibrosis and significant fibrosis were 0.771 and 0.988,respectively,and the sensitivity were 0.667 and 0.998,respectively.The specificity was 0.875 and 0.963,respectively.The positive likelihood ratios of all results were greater than 5,and the negative likelihood ratios were less than 0.4,all with statistical significance(P<0.001).5.Kappa consistency test was used to evaluate the consistency of Fibroscan in the diagnosis of significant fibrosis and liver biopsy.In patients with CAP value of238-273 d B/m,the diagnostic results were significantly consistent with the biopsy results when the cut-off value was 7.3k Pa(Kappa value 0.702,P<0.001).However,in patients with CAP≥273d B/m,a cutoff value of 7.3k Pa could not diagnose significant fibrosis(P<0.05).According to the results of our study,when the cut-off values were8.3k Pa and 9.6k Pa in patients with CAP values of 238-273 d B/m and CAP≥273d B/m,respectively,the diagnosis of significant fibrosis in patients was significantly consistent with the results of liver biopsy(Kappa values both>0.5,P<0.05).Conclusions1.Hepatic steatosis in CHB patients may affect the diagnostic accuracy of Fibroscan for fibrosis.Especially in patients without obvious fibrosis,the presence of moderate to severe steatosis will increase the LSM value.A large proportion of patients with hepatic steatosis without obvious fibrosis will be misdiagnosed as obvious fibrosis,significant fibrosis or even cirrhosis to varying degrees,resulting in overtreatment of such patients.2.The CAP-based flow chart of Fibroscan for the diagnosis of obvious fibrosis and significant fibrosis in patients with CHB has good clinical application value.It can be used as a reference for assessing the degree of liver fibrosis in CHB patients with low ALT levels and steatosis,providing a basis for antiviral decision-making in such patients and avoiding unnecessary liver biopsy.