Importance of the selected lower FIB-4 cutoff point

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I read with great interest the recent article titled ‘Fibrosis-4 (FIB-4) and imaging for measuring fibrosis in hepatitis C virus’ by Turner et al. 1. In their research, the authors aimed to compare the diagnostic performance of FIB-4 alone or performed in conjunction with imaging to identify likely fibrosis. Ultimately, they concluded that, among patients with newly diagnosed chronic hepatitis C virus (HCV) infection, identification of patients with fibrosis depends on the noninvasive measure used. I appreciate the hard work of the authors in the study. However, a few concerns in terms of this study should be stated from the point of view of the diagnostic performance of different FIB-4 cutoffs.
The FIB-4 index was initially established in HIV/HCV coinfected patients with a lower cutoff point of 1.45 2. Since then, different lower cutoff points have been evaluated 3. In the recently published article by Turner and colleagues 56.8% of patients had likely fibrosis on the basis of FIB-4 alone, whereas 42.6% of patients had likely fibrosis by FIB-4 plus imaging. In my opinion, the 14.2% difference may be due to the improper use of the lower FIB-4 cutoff point of 1.45, as in a recently published article by Kayadibi et al. 4 it was evidenced that use of the lower FIB-4 cutoff point of 1.62 had higher diagnostic accuracy than 1.45. If the authors had used a cutoff point greater than 1.45 for FIB-4, they may have obtained similar results as in FIB-4 plus imaging. This is because, when you increase the cutoff point for the diagnosis of likely fibrosis, the percentage of the disease of interest will decrease, and the positive predictive value will increase as false-positive results will reduce.
In conclusion, proper use of the lower FIB-4 cutoff point may decrease the need for additional diagnostic techniques like imaging or others for the prediction of patients with likely fibrosis.
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