Diagnostic value of transient elastography in assessing the degree of liver fibrosis in chronic hepatitis B patients with low alanine aminotransferase levels and concomitant hepatic steatosis

Background: Assessment of liver fibrosis is crucial for antiviral decision-making in chronic hepatitis B virus (HBV)-infected patients with low alanine aminotransferase (ALT) levels, but accurate assessment data of Transient elastography (TE) are lacking in individuals with steatosis. We aimed to evaluate the accuracy of TE in determining liver fibrosis in individuals with hepatic steatosis and associated factors. Methods: A total of 218 patients with chronic HBV infection from China were included in the study. Logistic regression analysis was conducted to identify factors influencing liver stiffness measurement (LSM). Significant fibrosis cut-off values were calculated by receiver operating characteristic (ROC) curve based on controlled attenuation parameter (CAP) stratification, and a TE diagnostic flowchart was thus developed. Results: Among 218 patients, the prevalence of steatosis was 36.7%. In individuals without significant fibrosis (S0-S1), moderate-to-severe steatosis increases LSM values. Of 60 patients with histological stage S0-S1 combined with steatosis, 21 (35%) were misdiagnosed as significant fibrosis or above. Multivariate logistic analysis revealed that CAP was an independent risk factor for misdiagnosis (OR = 1.03, P < 0.05). ROC curve analysis showed that 273 dB/m was the optimal cut-off value for misdiagnosis. For patients with CAP = 238–273 dB/m and CAP ≥273 dB/m, the AUROC of TE in diagnosing significant fibrosis was 0.880 and 0.771, respectively, using cut-off values of 8.3 kPa and 9.6 kPa. The results are consistent with histological diagnosis (all Kappa values >0.5, P < 0.05). Conclusion: In chronic HBV-infected patients without significant fibrosis but with moderate-to-severe hepatic steatosis, the degree of liver fibrosis may be overestimated. A TE diagnostic flowchart based on the CAP stratification may enhance the accuracy of liver fibrosis diagnosis.