Naim Alkhouri, MD: Benefit of Agile Scores for Noninvasive Fibrosis, Cirrhosis Testing

Liver biopsy serves as a valuable prognostic tool across multiple hepatic diseases, including metabolic dysfunction-associated steatotic liver disease (MASLD). However, its applicability in clinical practice is limited by high cost, sampling error, the potential for complications, and the overall invasive nature of the procedure.

Several noninvasive tests (NITs) have emerged as potential alternatives to liver biopsy for determining the prevalence of MASLD-related fibrosis and cirrhosis without the aforementioned drawbacks, but many of these tests come with their own set of limitations, including overall accuracy and positive predictive value.

In an interview with HCPLive, Naim Alkhouri, MD, chief medical officer, chief of transplant hepatology, and director of the Fatty Liver Program at Arizona Liver Health, explained the “urgent need” for reliable NITs capable of doing 3 things: determining baseline disease severity, assessing response to intervention, and providing prognostication.

“One of the issues we have with noninvasive tests is the relatively lower positive predictive value,” he said. “Sometimes in the initial scientific publication, you can see a specificity of 90% and a positive predictive value of 80%. However, when you take it to the general population, now your positive predictive value can drop to 40% or 50%.”

Alkhouri described the good negative predictive values seen in clinic with vibration-controlled transient elastography (VCTE), typically conducted with FibroScan, that allow clinicians to rule out significant or advanced fibrosis based on a lower score. However, he also acknowledged shortcomings of the positive predictive value due to the lower prevalence of advanced fibrosis among patients seen in clinic, something he said the Agile scoring system was designed to help address.

“The idea here was that we added some serologic and clinical characteristics into the scores, so serologic biomarkers include AST and ALT ratio, your platelet count, and then we also added age, diabetes, gender, things that are associated with more advanced disease,” he explained. “We put all these factors in a calculator, and then you get a score between 0 to 1, and typically a value more than 0.57 indicates a high likelihood of having cirrhosis. We can do the same with the Agile 3 +, but this is to predict the presence of F3 and F4.”

Alkhouri went on to describe its use in practice, saying “In my clinic, if I have a patient with a liver stiffness of 16 or 17 and their Agile 4 is at 0.7, I tell them with confidence that, yes, you probably do have cirrhosis. If I have a patient in my clinic with a stiffness of 16 and the Agile 4 is 0.05, I tell them the test is probably overestimating, and then maybe I need to do another noninvasive test.”

Reference

^{Brooks, A. Study Estimates MASLD-Related Fibrosis, Cirrhosis Prevalence Using AGILE Scoring. HCPLive. July 26, 2024. Accessed August 19, 2024. https://www.hcplive.com/view/study-estimates-masld-fibrosis-cirrhosis-prevalence-agile-scoring}