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Validating non-invasive markers of fibrosis: the need for a new histological reference standard
  1. Emmanuel A Tsochatzis1,
  2. Pinelopi Manousou1,
  3. Giuseppe Fede1,
  4. Amar P Dhillon2,
  5. Andrew K Burroughs1
  1. 1The Royal Free Sheila Sherlock Liver Centre and University Department of Surgery, London, UK
  2. 2Royal Free Hospital and Department of Cellular Pathology, UCL Medical School, London, UK
  1. Correspondence to Professor Andrew K Burroughs, The Royal Free Sheila Sherlock Liver Centre and University Department of Surgery, UCL and Royal Free Hospital, Pond Street, Hampstead, London NW3 2QG, UK; andrew.burroughs{at}

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We read with interest the article by Parkes et al in Gut1 and fully agree with the authors' aims in evaluating the performance of a non-invasive marker of fibrosis, the enhanced liver fibrosis (ELF) test, with respect to clinically meaningful end points of liver-related complications and mortality. However, we believe that the methodology used is inappropriate and has led to potentially misleading conclusions.

The authors have previously shown that ‘severe fibrosis’, i.e. stage 3 (‘bridging fibrosis’) and 4 (cirrhosis) in patients with non-alcoholic steatohepatitis is better predicted by an ELF panel score of 9.9–10.35.2 They also showed that ELF scores are not significantly different between different liver disease aetiologies. In this paper,1 they …

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  • Funding EAT has received an educational grant from the Hellenic Foundation of Gastroenterology and Nutrition.

  • Competing interests None.

  • Provenance and peer review Not commissioned; not externally peer reviewed.

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    Julie Parkes