肝损伤的诊断评估是治疗慢性肝病(CLD)患者的重要步骤。虽然肝活检是评估坏死性炎症和纤维化的参考标准,侵入性手术的固有局限性,并且需要重复采样,已经导致了几种非侵入性测试(NIT)作为肝活检的替代品的发展。这种非侵入性方法主要包括生物(血清生物标记算法)或物理(组织硬度的成像评估)评估。然而,目前可用的NIT有几个限制,比如可变性,准确性不足和错误的风险因素,而新一代纤维化生物标志物的开发可能受到参考标准固有的抽样误差的限制。许多目前的NIT最初被开发用于诊断慢性丙型肝炎的显著纤维化,随后用于诊断非酒精性脂肪性肝病患者的晚期纤维化,并进一步适用于CLD的预测。一个重要的考虑因素是,尽管它们在临床实践中的使用越来越多,这些NIT不是为了反映纤维发生的动态过程,区分相邻的疾病阶段,诊断非酒精性脂肪性肝炎,或遵循由自然史或治疗干预引起的纤维化或疾病活动的纵向变化。了解这些NIT的优势和局限性将允许在临床背景下进行更明智的解释,其中NIT应被视为补充,而不是替代,肝活检。
The diagnostic assessment of liver injury is an important step in the management of patients with chronic liver disease (CLD). Although liver biopsy is the reference standard for the assessment of necroinflammation and fibrosis, the inherent limitations of an invasive procedure, and need for repeat sampling, have led to the development of several non-invasive tests (NITs) as alternatives to liver biopsy. Such non-invasive approaches mostly include biological (serum biomarker algorithms) or physical (imaging assessment of tissue stiffness) assessments. However, currently available NITs have several limitations, such as variability, inadequate accuracy and risk factors for error, while the development of a newer generation of biomarkers for fibrosis may be limited by the sampling error inherent to the reference standard. Many of the current NITs were initially developed to diagnose significant fibrosis in chronic hepatitis C, subsequently refined for the diagnosis of advanced fibrosis in patients with non-alcoholic fatty liver disease, and further adapted for prognostication in CLD. An important consideration is that despite their increased use in clinical practice, these NITs were not designed to reflect the dynamic process of fibrogenesis, differentiate between adjacent disease stages, diagnose non-alcoholic steatohepatitis, or follow longitudinal changes in fibrosis or disease activity caused by natural history or therapeutic intervention. Understanding the strengths and limitations of these NITs will allow for more judicious interpretation in the clinical context, where NITs should be viewed as complementary to, rather than as a replacement for, liver biopsy.