Retrospective Study
Copyright ©The Author(s) 2019. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Gastroenterol. Sep 7, 2019; 25(33): 4959-4969
Published online Sep 7, 2019. doi: 10.3748/wjg.v25.i33.4959
Value of controlled attenuation parameter in fibrosis prediction in nonalcoholic steatohepatitis
Jung Il Lee, Hyun Woong Lee, Kwan Sik Lee
Jung Il Lee, Hyun Woong Lee, Kwan Sik Lee, Department of Internal Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul 06273, South Korea
Author contributions: All authors helped to perform research; Lee JI and Lee KS drafted the concept, design the study; Lee HW collected the data and wrote the manuscript; Lee JI and Lee HW analyzed the data.
Supported by Basic Science Research Program through the National Research Foundation of Korea (NRF) funded by the Ministry of Science, ICT and Future Planning (NRF-2016R1A2B4015192).
Institutional review board statement: This study was reviewed and approved by the Institutional review board of Gangnam Severance Hospital (Permit No: 3-2019-0010).
Informed consent statement: Written informed consent of the patients was exempted by the institutional review board since the researchers only accessed the database for the analysis purposes and the personal information was blinded by coding.
Conflict-of-interest statement: Jung Il Lee has served as a speaker for Echosens; the other authors have nothing to disclose.
Data sharing statement: No additional data are available.
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See:
Corresponding author: Jung Il Lee, MD, PhD, Associate Professor, Department of Internal Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, 211 Eonju-ro, Gangnam-gu, Seoul 06273, South Korea.
Telephone: +82-2-20194365 Fax: +82-2-34633882
Received: April 24, 2019
Peer-review started: April 24, 2019
First decision: July 22, 2019
Revised: July 29, 2019
Accepted: August 7, 2019
Article in press: August 7, 2019
Published online: September 7, 2019

Liver stiffness measurement (LSM) tends to overestimate fibrosis stage in nonalcoholic fatty liver disease (NAFLD). Controlled attenuation parameter (CAP), provided by LSM device, has been introduced for noninvasive quantification of hepatic steatosis.


To determine the role of CAP values in predicting liver fibrosis stage by LSM in nonalcoholic steatohepatitis (NASH).


One hundred eighty-four patients with biopsy proven NASH had LSM and CAP evaluated at baseline. Among them, 130 patients had 1-year follow up LSM and analyzed for the changes of LSM after pioglitazone or ursodeoxycholic acid (UDCA) treatment.


In Kleiner fibrosis stage F0-1, LSM values increased at higher CAP tertile (P = 0.001), and in F2, at middle and higher tertiles (P = 0.027). No difference across CAP tertiles was noticed in F3-4 (P = 0.752). Receiver operating characteristic curve for LSM cutoff in diagnosis of F ≥ 2 identified 8.05 kPa for lower CAP tertile, 9.35 kPa for middle, and 10.55 kPa for high tertile. When changes in proportion of significant fibrosis (F ≥ 2) were assessed among pioglitazone and UDCA treated patients considering CAP values, pioglitazone treated patients demonstrated decrease in proportion of high LSM.


In patient with NAFLD, interpretation of LSM in association with CAP scores may provide helpful information sparing unnecessary liver biopsy.

Keywords: Fibroscan, Controlled attenuation parameter, Liver stiffness, Nonalcoholic steatohepatitis, Liver fibrosis

Core tip: Liver stiffness measurement (LSM) is said to be exaggerated in nonalcoholic fatty liver disease (NAFLD). We investigated the role of controlled attenuation parameter (CAP), a means of measuring steatosis noninvasively, in predicting liver fibrosis by LSM in 184 biopsy proven nonalcoholic steatohepatitis patients. The optimum LSM cutoff for Kleiner fibrosis stage (F) ≥ 2 reflecting CAP values showed higher cutoff with increased CAP tertile (LSM, 8.05 kPa for lower CAP tertile, 9.35 kPa for middle, 10.45 kPa for high CAP tertile). Therefore, we suggest that interpretation of LSM in patients with NAFLD should take CAP scores into account in order to avoid unnecessary liver biopsy.