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Non-invasive tests and advanced chronic liver disease in NAFLD: two steps forward and one step back?
  1. Avik Majumdar1,
  2. Emmanuel A Tsochatzis2,3
  1. 1 AW Morrow Gastroenterology and Liver Centre, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia
  2. 2 UCL Institute for Liver and Digestive Health, London, UK
  3. 3 Royal Free Hospital Sheila Sherlock Liver Centre, London, UK
  1. Correspondence to Professor Emmanuel A Tsochatzis, UCL Institute for Liver and Digestive Health, London NW3 2QG, UK; e.tsochatzis{at}

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We read with great interest the study by Mózes et al on non-invasive tests (NITs) in non-alcoholic fatty liver disease (NAFLD)1 and commend the authors on their comprehensive individual patient data meta-analysis. The authors have confirmed that a two-step algorithm of fibrosis-4 index (FIB-4) and liver stiffness measurement with vibration controlled transient elastography (LSM-VCTE) has superior diagnostic performance for ruling in and ruling out advanced fibrosis and/or cirrhosis. Indeed, this concept has been demonstrated previously, including in our own work.2–4 However, we would like to highlight a few points for clarification.

First, the authors suggest a reduction in liver biopsies from 33% to as low as 19% when using the proposed rule-in cut-offs for cirrhosis, as summarised in Sankey diagrams. In our opinion, this comparative reduction in biopsies is not justified as the first diagnostic algorithm …

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  • Contributors AM: manuscript preparation, study concept. EAT: manuscript preparation and critical review, study concept

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.

  • Provenance and peer review Not commissioned; internally peer reviewed.

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