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The development of non-invasive methods, particularly serum markers and transient elastography, for the evaluation of fibrosis progression and their validation for use in clinical practice certainly represents a relevant advancement in hepatology. Although non-invasive methods were designed to predict the fibrotic stage of chronic liver diseases (CLDs) and, ultimately, replace liver biopsy in clinical practice, there is now a large consensus on the use of these methods as cross-sectional discriminators of three major stages: absence or very limited fibrosis, advanced fibrosis/cirrhosis and the stage in between these two extremes, often referred to as the ‘gray area’. Overall, the application of these methods, alone or in combination, reduces the number of liver biopsies by at least 50%.1
Serum markers for the prediction of the stage of liver fibrosis are grouped in two categories: (a) ‘direct markers’ reflecting the shedding into the systemic circulation of peptides involved in the accumulation of fibrillar extracellular matrix (fibrogenesis); involved in its degradation (fibrolysis); or involved, more generally, in tissue inflammation, and (b) ‘indirect markers’ a mixture of common biochemical abnormalities found in CLDs and clinical parameters. The predictive ability of several possible combinations of these markers is enhanced by their inclusion in a mathematic algorithm. At present, most of the information on serum markers is associated with their diagnostic accuracy for a given fibrotic stage. As shown in figure 1, each individual marker included in the algorithms proposed so far coincides with a specific phase of disease progression. Accordingly, what …