Relevant clinical details, including gender, age, weight, and height, were obtained at the time of biopsy. The body mass index was calculated by the formula: weight (kg)/height (m)2. Patients were identified as having diabetes if they had been diagnosed with diabetes according to the 2004 American Diabetes Association criteria or if they were taking an oral hypoglycemic drug or insulin (23 (link)).
Percutaneous liver biopsies were performed as per unit protocol at the sites and were assessed by an experienced local hepatopathologist. Patients with liver biopsies specimens <15 mm in length were excluded. Histological scoring was performed according to the non-alcoholic steatohepatitis (NASH) Clinical Research Network criteria (24 (link)). The NAFLD activity score was graded from 0 to 8, including scores for steatosis (0–3), lobular inflammation (0–3), and hepatocellular ballooning (0–2). NASH was defined as steatosis with hepatocyte ballooning and inflammation ± fibrosis (25 (link)). Fibrosis was staged from F0 to F4 (24 (link)). Patients with stage F3 or F4 fibrosis were considered to have advanced fibrosis.
The AST/ALT ratio, FIB-4, and NFS were calculated from blood tests taken at the time of liver biopsy as previously described (16 (link), 26 (link), 27 (link)). Details of the formulas and cutoffs for the tests under investigation are shown in
To validate new cutoffs for the NFS and FIB-4 score optimized for use in older patients (aged ≥65 years) that were derived in the initial ascertainment cohort, anonymized biochemical, histological, and anthropometric data were collected from a separate group of histologically characterized patients from the EPoS/EASL European NAFLD Registry. The “European NAFLD Registry” was established during the EU FP7 FLIP project (2010-) and is now maintained by the EU H2020 EPoS (Elucidating Pathways of Steatohepatitis) consortium to facilitate collaborative research into NAFLD. It is the largest multi-national registry of patients with histologically characterized NAFLD. These patients had data collected according to the same methodology as the main cohort.
All statistical analyses were performed using the SPSS software version 22.0 (SPSS, Chicago, IL). Continuous normally distributed variables were represented as mean ± s.d. Categorical and non-normal variables were summarized as median and range. Chi squared tests were used to determine the distribution of categorical variables between groups. To compare the means of normally distributed variables between groups, the Student's t-test or analysis of variance test was performed. To determine differences between groups for continuous non-normally distributed variables, medians were compared using the Mann–Whitney U-test. The diagnostic performance of the non-invasive tests was assessed by receiver operating characteristic (ROC) curve analysis. The area under the ROC (AUROC) was used as an index to compare the accuracy of tests. The sensitivity, specificity, positive predictive values (PPVs), negative predictive values (NPVs), positive likelihood ratios (LR +ve), and negative likelihood ratios (LR −ve) for relevant cutoffs were also displayed. In order to assess changes in sensitivity and specificity of the tests with age, plots of sensitivity and specificity in different age groups were displayed graphically. New cutoffs for the FIB-4 and NFS were derived for ≥65-year-old patients by taking the point on the ROC where the combined value of sensitivity and specificity was the highest. As the prevalence of advanced fibrosis can vary in different populations, the PPVs and NPVs for the new cutoffs were displayed at advanced fibrosis prevalence rates of 5, 10, 20, 30, and 40%. A P value of <0.05 was considered significant.