Transient elastography scores accurately predict liver-related events in MASLD

Vibration-controlled transient elastography (VCTE)–based Agile scores, developed for diagnosis of advanced fibrosis (Agile 3+ score) and cirrhosis (Agile 4 score) in patients with metabolic dysfunction–associated steatotic liver disease (MASLD), are highly accurate in predicting liver-related events (LREs) and may be suitable alternatives to liver biopsy in routine clinical practice and in phase IIb/III clinical trials for steatohepatitis, researchers from the VCTE-Prognosis Study Group have reported.

In the multicentre cohort study, VCTE-based Agile scores outperformed commonly used simple fibrosis scores in predicting LREs in patients with MASLD. In addition, changes in Agile scores over time demonstrated a positive nonlinear association with changes in LRE risk, providing insights that may affect clinical management of MASLD patients. [JAMA 2024;doi:10.1001/jama.2024.1447]

By combining liver stiffness measurement (LSM) and simple clinical parameters (ie, platelet count, aminotransferases, diabetes, age, and sex), Agile scores are shown to improve accuracy and reduce indeterminate zone in diagnosing advanced fibrosis and cirrhosis among MASLD patients. [J Hepatol 2023;78:247-259]

The current study included 16,603 adult patients (mean age, 52.5 years; male, 57.8 percent) with MASLD who underwent VCTE examination at baseline at 16 tertiary referral centres in the US, Europe and Asia between February 2004 and January 2023. Prospective data collection was carried out at 14 centres. Among these patients, 13,573 (81.8 percent) were from Asia, including 4,037 from Hong Kong.

VCTE was used for controlled attenuation parameter assessment and LSM. From these evaluations, VCTE-based Agile 3+, Agile 4, and FibroScan-aspartate aminotransferase (FAST) scores were calculated. Simple fibrosis scores, including Fibrosis-4 index (FIB-4), nonalcoholic fatty liver disease (NAFLD) fibrosis score (NFS), aspartate aminotransferase (AST) to platelet ratio index (APRI), BARD (BMI, AST to alanine aminotransferase [ALT] ratio, and diabetes) score, and AST to ALT ratio, were also calculated for comparison.

At a median follow-up of 51.7 months, the primary outcome of LREs (defined as hepatocellular carcinoma or hepatic decompensation [ie, ascites, variceal haemorrhage, hepatic encephalopathy, or hepatorenal syndrome], liver transplant, and liver-related deaths) occurred in 1.9 percent (n=316) of patients.

“Both the Agile 3+ and Agile 4 scores demonstrated the highest discriminatory power in predicting LREs [integrated area under the time-dependent receiver-operating characteristic curve, 0.89]. They classified fewer patients [10.2 percent for Agile 3+ and 8.7 percent for Agile 4] in the intermediate-risk group than the other fibrosis scores,” the researchers reported.

Among 10,920 patients (65.8 percent) who underwent repeated VCTE examination at a median interval of 15 months, serial analysis showed that most patients had stable Agile 3+ (81.9 percent [n=7,208 of 8,810]) and Agile 4 (92.6 percent [n=8,163 of 8,810]) scores, indicating same risk categories at both assessments. In patients with persistently low and persistently high Agile 3+ scores, the incidence of LREs was 0.6 and 30.1 per 1,000 person-years, respectively.

“In those with high Agile 3+ score at baseline, a ≥20 decrease in the score was associated with a substantial reduction in LRE risk. A similar trend was observed for the Agile 4 score, although it missed more LREs in the low-risk group,” the researchers noted.

“Regardless of baseline Agile scores and LSM, a ≥10 percent relative decrease in the test results was associated with a lower risk of LREs, whereas an increase in the test results was associated with an increased risk of events,” they continued. “The greater the change observed in Agile scores or LSM, the greater the change in incidence of LREs.”