Chronic hepatitis C and liver fibrosis

Table 2 Comparison of the main characteristics of liver biopsy, serum biomarkers and transient elastography

	Liver biopsy	Serum biomarkers	Transient elastography
Advantages	Direct assessment of liver fibrosis	Immediate result	Immediate result
	Stage by stage fibrosis classification	Fast (one time blood sample)	Duration of examination 5 min
	Evaluation of coexisting disorders (inflammation, steatosis, iron overload)	Patient friendly	Operator and patient friendly
Limitations	Complications (pain, bleeding)	Cost (unitary cost per patient for patented tests)	Cost (one time per machine)
	Sampling error, intra-observer and inter-observer variability	High rates of unclassified patients (APRI, Fib-4, Forns’ index, Lok index)	Failure in 5% of cases (25% in obese patients)
	Hospitalization (day hospital) often required		Unreliable results in 15% of cases (obesity, ascites, limited operator experience)
	Cost	Lower performance for diagnosis of significant fibrosis	Lower performance for diagnosis of significant fibrosis
	Delayed result (2-4 wk)	Unable to discriminate between intermediate stages of fibrosis	Unable to discriminate between intermediate stages of fibrosis
Contraindications	Absolute: uncooperative patient, severe coagulopathy, extrahepatic biliary obstruction	None	Pacemaker, pregnancy
	Relative: ascites, morbid obesity, possible vascular lesions, amyloidosis
Risk factors for error	Biopsy sample < 2 cm in length, containing < 10 complete portal tracts; inexperienced pathologist	Autoimmune thrombocytopenia (APRI); Gilbert’s sydrome, extrahepatic cholestasis, hemolytic anemia (Fibrotest)	Transaminases flares; acute viral hepatitis; non-fasting patient; vascular hepatic congestion; extrahepatic cholestasis; IQR ≥ 30%

APRI: Aspartate aminotransferase to platelet ratio index; IQR: Interquartile range.