Cale `s1,2 and multicentric groups from SNIFF 32, VINDIAG 7, and ANRS/HC/EP23 FIBROSTAR studies
The sequential algorithm for fibrosis evaluation (SAFE) and the Bordeaux algorithm (BA), which cross-check FibroTest with the aspartate aminotransferase-to-platelet ratio index (APRI) or FibroScan, are very accurate but provide only a binary diagnosis of significant fibrosis (SAFE or BA for Metavir F ! 2) or cirrhosis (SAFE or BA for F4). Therefore, in clinical practice, physicians have to apply the algorithm for F ! 2, and then, when needed, the algorithm for F4 (''successive algorithms''). We aimed to evaluate successive SAFE, successive BA, and a new, noninvasive, detailed classification of fibrosis. The study included 1785 patients with chronic hepatitis C, liver biopsy, blood fibrosis tests, and FibroScan (the latter in 729 patients). The most accurate synchronous combination of FibroScan with a blood test (FibroMeter) provided a new detailed (six classes) classification (FM1FS). Successive SAFE had a significantly (P < 10 23 ) lower diagnostic accuracy (87.3%) than individual SAFE for F ! 2 (94.6%) or SAFE for F4 (89.5%), and required significantly more biopsies (70.8% versus 64.0% or 6.4%, respectively, P < 10 23 ). Similarly, successive BA had significantly (P 10 23 ) lower diagnostic accuracy (84.7%) than individual BA for F ! 2 (88.3%) or BA for F4 (94.2%), and required significantly more biopsies (49.8% versus 34.6% or 24.6%, respectively, P < 10 23 ). The diagnostic accuracy of the FM1FS classification (86.7%) was not significantly different from those of successive SAFE or BA. However, this new classification required no biopsy. Conclusion: SAFE and BA for significant fibrosis or cirrhosis are very accurate. However, their successive use induces a significant decrease in diagnostic accuracy and a significant increase in required liver biopsy. A new fibrosis classification that synchronously combines two fibrosis tests was as accurate as successive SAFE or BA, while providing an entirely noninvasive (0% liver biopsy) and more precise (six versus two or three fibrosis classes) fibrosis diagnosis. (HEPATOLOGY 2012;55:58-67) S everal fibrosis algorithms combining different fibrosis tests have been proposed to improve the accuracy of the noninvasive diagnosis of liver fibrosis in chronic hepatitis C. [1][2][3][4][5] These decision-making algorithms were developed to provide an accurate diagnosis of liver fibrosis and limit liver biopsy to indeterminate cases. They use either two blood tests in a sequential procedure, as in the sequential algorithm for fibrosis evaluation (SAFE), 6 or are based on agreement between a blood test and FibroScan (Echosens, Paris, France) results, as in the Bordeaux algorithm (BA). 1 Although the accuracy of SAFE and BA has been shown to be excellent for the diagnosis of significant fibrosis or cirrhosis, 1,2,6-8 they have some limitations in clinical practice. First, SAFE uses the aspartate aminotransferase-to-platelet ratio index (APRI) as a first-line Abbreviations:: BA, Bordeaux algorithm; SAFE, sequential algorithm for fibrosis evaluation.