Simple noninvasive tests for the detection of advanced liver fibrosis in patients with chronic hepatitis B

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We read with great interest the article by Lang et al.1 in which they analyzed the diagnostic performance of simple noninvasive tests (NITs) including the fibrosis index based on the four factors (FIB-4), aspartate aminotransferase–alanine aminotransferase ratio index, aspartate aminotransferase-to-platelet ratio index (APRI), and age–platelet index for the detection of advanced fibrosis (F3–F4) in 239 chronic hepatitis B (CHB) patients. They could not confirm a reliable clinical utility for these NITs for prediction of advanced fibrosis in CHB patients with a predominantly Caucasian population 1. The study is very interesting. However, the results should be interpreted with cautions.
First, platelet count is an important component in most of the NITs in the study 1. The platelets are easily affected by many factors such as infections, chronic inflammatory diseases, some hematological disorders, and drug use 2–4. However, the authors only excluded the patients with coexisting viral infection and alcohol abuse 1. The patients were not evaluated for the existence of comorbidities such as chronic inflammatory diseases and hematological disorders, which might have affected the results.
Second, in the study by Lang et al.1, CHB patients were divided into two groups according to the stage of fibrosis by liver biopsy: mild fibrosis (F0–F2) and advanced fibrosis (F3–F4). The authors used 0.5 (low cutoff values) and 1.5 (high cutoff values) to distinguish F0–F2 and F3–F4 for APRI, 1.45 (low cutoff values) and 3.25 (high cutoff values) to distinguish F0–F2 and F3–F4 for FIB-4 1. However, the above thresholds of APRI and FIB-4 are recommended for diagnosing significant fibrosis (≥F2) rather than advanced fibrosis (F3–F4) in the WHO guidelines for CHB 5. Thus, the results might be biased if the authors used these thresholds for diagnosing advanced fibrosis (F3–F4).
Therefore, large-scale studies with well-defined inclusion and exclusion criteria are required to validate the diagnostic accuracy of NITs and establish optimal thresholds for the detection of different fibrosis stages in CHB patients.

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