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We are impressed by the interesting article by Sebastiani et al.1 The authors are congratulated for conducting a multicentre, large-scale validation study of three algorithms to predict liver fibrosis in chronic hepatitis C patients. We would like to address a few issues.

The three algorithms under investigation, sequential algorithm for fibrosis evaluation (SAFE biopsy), Fibropaca algorithm and Leroy algorithm, are based on either sequential or synchronous combination of FibroTest, Forns’ index and aspartate aminotransferase-to-platelet ratio index. Such complicated algorithms may be difficult to apply in the busy clinic setting. In contrast, physical measurements such as transient elastography are more user-friendly.2–4 In a multicentre prospective study, transient elastography was superior to several biomarkers of liver fibrosis in predicting liver cirrhosis.5

One limitation of transient elastography is the increase in liver stiffness measurement with higher ALT levels independent of fibrosis staging.3, 6 Owing to the different mechanisms of serum formulae and transient elastography, there is increasing enthusiasm to combine these two modalities to increase the accuracy. For example, the addition of Forns’ index increased the accuracy of transient elastography in chronic hepatitis B patients.7 Another limitation of transient elastography is the lower success rate in obese patients,8, 9 whereas serum markers can be performed essentially in all patients. On the other hand, decrease in absolute liver stiffness value was found to be unreliable to indicate regression of liver fibrosis,10 whereas serum markers have not been well-studied as an on-treatment monitoring of liver fibrosis.

We believe that transient elastography and serum markers do have a supplementary role to each other.

Finally, we must not forget that the reference standard, liver biopsy, is imperfect. Fibrosis is also a surrogate marker and not the final target. More studies are needed to validate the non-invasive tests in predicting important clinical outcomes.

Acknowledgements

  1. Top of page
  2. Acknowledgements
  3. References

Declaration of personal interests: Vincent Wong has served in the advisory boards of Novartis, Roche, Gilead and Otsuka. He is also a speaker for Abbott Diagnostics, Novartis, Roche, Bristol-Myers Squibb and Echosens. Grace Wong has served as a speaker for Echosens. Declaration of funding interests: None.

References

  1. Top of page
  2. Acknowledgements
  3. References