Title: FIB-4, APRI, and AST/ALT ratio compared to FibroScan for the assessment of hepatic
fibrosis in patients with non-alcoholic fatty liver disease in Bandar Abbas, Iran
Version: 1 Date: 14 Jun 2021
Reviewer's report:
Non-alcoholic fatty liver disease (NAFLD) is the leading global cause of chronic liver disease,
estimated to affect approximately 25% of the world’s population. It is not only important to
diagnose MAFLD, but also to distinguish between simple steatosis that can be managed at
primary healthcare level and those with advanced fibrosis (F#2) who need to be referred to
secondary or tertiary levels of care.
Simple point-of-care non-invasive tests (NITs) should be utilized to identify individuals with
advanced fibrosis. APRI (AST-to-platelet) ratio, FIB 4 index and the non-alcoholic fatty liver
disease fibrosis score (NFS) have excellent negative predictive values for advanced fibrosis/
cirrhosis. FIB-4 index is the usual recommended NIT in the absence of a Fibroscan.
Amernia and colleagues compared the FIB-4 index, AST/ALT ratio, and the APRI score with
FibroScan results for the diagnosis of hepatic fibrosis in patients with NAFLD. The APRI score
and FIB-4 were the better indices than the AST/ALT ratio to assess liver fibrosis in NAFLD
patients.
Sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of
APRI at the 0.702 cut-off for the differentiation of F3 and F4 from F2 and F1 were 84.1, 88.2,
66.1, 95.3, and 87.3%, FIB-4 at the 1.19 cut-off were 97.7, 72.7, 49.4, 99.2 and 78%, and AST/
ALT at the 0.94 cut-off were 61.4, 77, 42.2, 87.9, and 73.7% respectively.
In contrast to other published NIT recommendations, the APRI score performed better than
the FIB-4 index with an AUROC curve of 0.923 (95% CI 0.876-0.970) compared to 0.913
(0.868-0.958)
The authors postulate that the difference in the diagnostic performance of NITs (FIB-4 vs
APRI ratio) between previous studies and theirs, is that previous studies used the liver biopsy
as the reference instead of the FibroScan results.  Using the liver biopsy as a reference
has limitations including small sample size, sample not being representative and variable
histological interpretation by histopathologists.
Amernia and colleagues confirm that the non-invasive tests of APRI and FIB-4 had excellent
negative predictive values advanced fibrosis/cirrhosis and these individuals can be managed at
primary care level.
Title: FIB-4, APRI, and AST/ALT ratio compared to FibroScan for the assessment of hepatic
fibrosis in patients with non-alcoholic fatty liver disease in Bandar Abbas, Iran
Version: 1 Date: 14 Jun 2021
Reviewer's report:
Non-alcoholic fatty liver disease (NAFLD) is the leading global cause of chronic liver disease,
estimated to affect approximately 25% of the world’s population. It is not only important to
diagnose MAFLD, but also to distinguish between simple steatosis that can be managed at
primary healthcare level and those with advanced fibrosis (F#2) who need to be referred to
secondary or tertiary levels of care.
Simple point-of-care non-invasive tests (NITs) should be utilized to identify individuals with
advanced fibrosis. APRI (AST-to-platelet) ratio, FIB 4 index and the non-alcoholic fatty liver
disease fibrosis score (NFS) have excellent negative predictive values for advanced fibrosis/
cirrhosis. FIB-4 index is the usual recommended NIT in the absence of a Fibroscan.
Amernia and colleagues compared the FIB-4 index, AST/ALT ratio, and the APRI score with
FibroScan results for the diagnosis of hepatic fibrosis in patients with NAFLD. The APRI score
and FIB-4 were the better indices than the AST/ALT ratio to assess liver fibrosis in NAFLD
patients.
Sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of
APRI at the 0.702 cut-off for the differentiation of F3 and F4 from F2 and F1 were 84.1, 88.2,
66.1, 95.3, and 87.3%, FIB-4 at the 1.19 cut-off were 97.7, 72.7, 49.4, 99.2 and 78%, and AST/
ALT at the 0.94 cut-off were 61.4, 77, 42.2, 87.9, and 73.7% respectively.
In contrast to other published NIT recommendations, the APRI score performed better than
the FIB-4 index with an AUROC curve of 0.923 (95% CI 0.876-0.970) compared to 0.913
(0.868-0.958)
The authors postulate that the difference in the diagnostic performance of NITs (FIB-4 vs
APRI ratio) between previous studies and theirs, is that previous studies used the liver biopsy
as the reference instead of the FibroScan results.  Using the liver biopsy as a reference
has limitations including small sample size, sample not being representative and variable
histological interpretation by histopathologists.
Amernia and colleagues confirm that the non-invasive tests of APRI and FIB-4 had excellent
negative predictive values advanced fibrosis/cirrhosis and these individuals can be managed at
primary care level.
Please review this paper.
user
Title: FIB-4, APRI, and AST/ALT ratio compared to FibroScan for the assessment of hepatic
fibrosis in patients with non-alcoholic fatty liver disease in Bandar Abbas, Iran
Version: 1 Date: 14 Jun 2021
Reviewer's report:
Non-alcoholic fatty liver disease (NAFLD) is the leading global cause of chronic liver disease,
estimated to affect approximately 25% of the world’s population. It is not only important to
diagnose MAFLD, but also to distinguish between simple steatosis that can be managed at
primary healthcare level and those with advanced fibrosis (F#2) who need to be referred to
secondary or tertiary levels of care.
Simple point-of-care non-invasive tests (NITs) should be utilized to identify individuals with
advanced fibrosis. APRI (AST-to-platelet) ratio, FIB 4 index and the non-alcoholic fatty liver
disease fibrosis score (NFS) have excellent negative predictive values for advanced fibrosis/
cirrhosis. FIB-4 index is the usual recommended NIT in the absence of a Fibroscan.
Amernia and colleagues compared the FIB-4 index, AST/ALT ratio, and the APRI score with
FibroScan results for the diagnosis of hepatic fibrosis in patients with NAFLD. The APRI score
and FIB-4 were the better indices than the AST/ALT ratio to assess liver fibrosis in NAFLD
patients.
Sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of
APRI at the 0.702 cut-off for the differentiation of F3 and F4 from F2 and F1 were 84.1, 88.2,
66.1, 95.3, and 87.3%, FIB-4 at the 1.19 cut-off were 97.7, 72.7, 49.4, 99.2 and 78%, and AST/
ALT at the 0.94 cut-off were 61.4, 77, 42.2, 87.9, and 73.7% respectively.
In contrast to other published NIT recommendations, the APRI score performed better than
the FIB-4 index with an AUROC curve of 0.923 (95% CI 0.876-0.970) compared to 0.913
(0.868-0.958)
The authors postulate that the difference in the diagnostic performance of NITs (FIB-4 vs
APRI ratio) between previous studies and theirs, is that previous studies used the liver biopsy
as the reference instead of the FibroScan results.  Using the liver biopsy as a reference
has limitations including small sample size, sample not being representative and variable
histological interpretation by histopathologists.
Amernia and colleagues confirm that the non-invasive tests of APRI and FIB-4 had excellent
negative predictive values advanced fibrosis/cirrhosis and these individuals can be managed at
primary care level.
assistant