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Original article

Vol. 149 No. 1718 (2019)

Controlled attenuation parameter for the assessment of liver steatosis in comparison with liver histology: a single-centre real life experience

  • Stephan Baumeler
  • Wolfram Jochum
  • Jörg Neuweiler
  • Irina Bergamin
  • David Semela
Cite this as:
Swiss Med Wkly. 2019;149:w20077



Accurate diagnosis and staging of non-alcoholic fatty liver disease are essential for the management of this disorder. Controlled attenuation parameter (CAP) has been suggested as a new noninvasive measurement made during transient elastography to assess liver steatosis. The aim of this study was to evaluate CAP as a diagnostic tool for identifying the presence and degree of hepatic steatosis in consecutive patients in an outpatient liver unit of a tertiary centre.


Between March 2015 and August 2016, all patients who underwent liver biopsy underwent liver stiffness measurement with simultaneous CAP determination using the FibroScan® M or XL probe. Steatosis, inflammatory activity and fibrosis were assessed using the histological SAF scoring system. In addition, fibrosis was scored according to the METAVIR system, and body mass index (BMI) and the underlying liver disease were also recorded.


224 patients were included in the analysis; 146 (65.2%) were male. Steatosis grades were distributed as follows: S0 n = 85 (37.9%), S1 n = 82 (36.6%), S2 n = 33 (14.7%), S3 n = 24 (10.7%). Mean BMI was 26.8 kg/m2, for the S0 group 24.9 kg/m2, S1 26.5 kg/m2, S2 27.3 kg/m2 and S3 32.5 kg/m2. The CAP differed significantly between steatosis groups S0 to S3. The area under receiver operating characteristics curve for S0 vs S1–S3 was 0.78, for S0/1 vs S2/3 0.83 and for S0–2 vs S3 0.82. Calculated cut-off values were 258.5 dB/m for S0 vs S1–3, 282.5 dB/m for S0/1 vs S2/3 and 307.5 dB/m for S0–2 vs S3.


CAP values are strongly associated with the degree of steatosis irrespective of the underlying liver disease. Integrating CAP measurements in the standard work-up may identify patients with NAFLD.


  1. Angulo P. Nonalcoholic fatty liver disease. N Engl J Med. 2002;346(16):1221–31. doi:.
  2. Bellentani S. The epidemiology of non-alcoholic fatty liver disease. Liver Int. 2017;37(Suppl 1):81–4. doi:.
  3. Bedogni G, Miglioli L, Masutti F, Castiglione A, Crocè LS, Tiribelli C, et al. Incidence and natural course of fatty liver in the general population: the Dionysos study. Hepatology. 2007;46(5):1387–91. doi:.
  4. Diehl AM, Day C. Nonalcoholic Steatohepatitis. N Engl J Med. 2018;378(8):781.
  5. Targher G, Day CP, Bonora E. Risk of cardiovascular disease in patients with nonalcoholic fatty liver disease. N Engl J Med. 2010;363(14):1341–50. doi:.
  6. Afendy A, Kallman JB, Stepanova M, Younoszai Z, Aquino RD, Bianchi G, et al. Predictors of health-related quality of life in patients with chronic liver disease. Aliment Pharmacol Ther. 2009;30(5):469–76. doi:.
  7. Younossi ZM, Blissett D, Blissett R, Henry L, Stepanova M, Younossi Y, et al. The economic and clinical burden of nonalcoholic fatty liver disease in the United States and Europe. Hepatology. 2016;64(5):1577–86. doi:.
  8. Younossi ZM, Stepanova M, Afendy M, Fang Y, Younossi Y, Mir H, et al. Changes in the prevalence of the most common causes of chronic liver diseases in the United States from 1988 to 2008. Clin Gastroenterol Hepatol. 2011;9(6):524–530.e1, quiz e60. doi:.
  9. Brunt EM, Ramrakhiani S, Cordes BG, Neuschwander-Tetri BA, Janney CG, Bacon BR, et al. Concurrence of histologic features of steatohepatitis with other forms of chronic liver disease. Mod Pathol. 2003;16(1):49–56. doi:.
  10. Chan AW, Wong GL, Chan HY, Tong JH, Yu YH, Choi PC, et al. Concurrent fatty liver increases risk of hepatocellular carcinoma among patients with chronic hepatitis B. J Gastroenterol Hepatol. 2017;32(3):667–76. doi:.
  11. Pekow JR, Bhan AK, Zheng H, Chung RT. Hepatic steatosis is associated with increased frequency of hepatocellular carcinoma in patients with hepatitis C-related cirrhosis. Cancer. 2007;109(12):2490–6. doi:.
  12. Persico M, Iolascon A. Steatosis as a co-factor in chronic liver diseases. World J Gastroenterol. 2010;16(10):1171–6. doi:.
  13. Ratziu V, Charlotte F, Heurtier A, Gombert S, Giral P, Bruckert E, et al.; LIDO Study Group. Sampling variability of liver biopsy in nonalcoholic fatty liver disease. Gastroenterology. 2005;128(7):1898–906. doi:.
  14. Merriman RB, Ferrell LD, Patti MG, Weston SR, Pabst MS, Aouizerat BE, et al. Correlation of paired liver biopsies in morbidly obese patients with suspected nonalcoholic fatty liver disease. Hepatology. 2006;44(4):874–80. doi:.
  15. European Association for the Study of the Liver (EASL), European Association for the Study of Diabetes (EASD), European Association for the Study of Obesity (EASO). EASL-EASD-EASO Clinical Practice Guidelines for the management of non-alcoholic fatty liver disease. J Hepatol. 2016;64(6):1388–402. doi:.
  16. Imajo K, Kessoku T, Honda Y, Tomeno W, Ogawa Y, Mawatari H, et al. Magnetic Resonance Imaging More Accurately Classifies Steatosis and Fibrosis in Patients With Nonalcoholic Fatty Liver Disease Than Transient Elastography. Gastroenterology. 2016;150(3):626–637.e7. doi:.
  17. Johnson NA, Walton DW, Sachinwalla T, Thompson CH, Smith K, Ruell PA, et al. Noninvasive assessment of hepatic lipid composition: Advancing understanding and management of fatty liver disorders. Hepatology. 2008;47(5):1513–23. doi:.
  18. Fransen van de Putte D, Blom R, van Soest H, Mundt M, Verveer C, Arends J, et al. Impact of Fibroscan on management of chronic viral hepatitis in clinical practice. Ann Hepatol. 2011;10(4):469–76.
  19. Garg H, Aggarwal S, Shalimar, Yadav R, Datta Gupta S, Agarwal L, et al. Utility of transient elastography (fibroscan) and impact of bariatric surgery on nonalcoholic fatty liver disease (NAFLD) in morbidly obese patients. Surg Obes Relat Dis. 2018;14(1):81–91. doi:.
  20. Ferraioli G, Tinelli C, De Silvestri A, Lissandrin R, Above E, Dellafiore C, et al. The clinical value of controlled attenuation parameter for the noninvasive assessment of liver steatosis. Liver Int. 2016;36(12):1860–6. doi:.
  21. de Lédinghen V, Vergniol J, Capdepont M, Chermak F, Hiriart JB, Cassinotto C, et al. Controlled attenuation parameter (CAP) for the diagnosis of steatosis: a prospective study of 5323 examinations. J Hepatol. 2014;60(5):1026–31. doi:.
  22. Sasso M, Miette V, Sandrin L, Beaugrand M. The controlled attenuation parameter (CAP): a novel tool for the non-invasive evaluation of steatosis using Fibroscan. Clin Res Hepatol Gastroenterol. 2012;36(1):13–20. doi:.
  23. Cardoso AC, Beaugrand M, de Ledinghen V, Douvin C, Poupon R, Trinchet JC, et al. Diagnostic performance of controlled attenuation parameter for predicting steatosis grade in chronic hepatitis B. Ann Hepatol. 2015;14(6):826–36. doi:.
  24. Chan WK, Nik Mustapha NR, Mahadeva S. Controlled attenuation parameter for the detection and quantification of hepatic steatosis in nonalcoholic fatty liver disease. J Gastroenterol Hepatol. 2014;29(7):1470–6. doi:.
  25. Chen J, Wu D, Wang M, Chen E, Bai L, Liu C, et al. Controlled attenuation parameter for the detection of hepatic steatosis in patients with chronic hepatitis B. Infect Dis (Lond). 2016;48(9):670–5. doi:.
  26. de Lédinghen V, Wong GL, Vergniol J, Chan HL, Hiriart JB, Chan AW, et al. Controlled attenuation parameter for the diagnosis of steatosis in non-alcoholic fatty liver disease. J Gastroenterol Hepatol. 2016;31(4):848–55. doi:.
  27. Shen F, Zheng RD, Mi YQ, Wang XY, Pan Q, Chen GY, et al. Controlled attenuation parameter for non-invasive assessment of hepatic steatosis in Chinese patients. World J Gastroenterol. 2014;20(16):4702–11. doi:.
  28. Gaia S, Carenzi S, Barilli AL, Bugianesi E, Smedile A, Brunello F, et al. Reliability of transient elastography for the detection of fibrosis in non-alcoholic fatty liver disease and chronic viral hepatitis. J Hepatol. 2011;54(1):64–71. doi:.
  29. Sasso M, Beaugrand M, de Ledinghen V, Douvin C, Marcellin P, Poupon R, et al. Controlled attenuation parameter (CAP): a novel VCTE™ guided ultrasonic attenuation measurement for the evaluation of hepatic steatosis: preliminary study and validation in a cohort of patients with chronic liver disease from various causes. Ultrasound Med Biol. 2010;36(11):1825–35. doi:.
  30. Castéra L, Foucher J, Bernard PH, Carvalho F, Allaix D, Merrouche W, et al. Pitfalls of liver stiffness measurement: a 5-year prospective study of 13,369 examinations. Hepatology. 2010;51(3):828–35. doi:.
  31. Bedossa P, Poitou C, Veyrie N, Bouillot JL, Basdevant A, Paradis V, et al. Histopathological algorithm and scoring system for evaluation of liver lesions in morbidly obese patients. Hepatology. 2012;56(5):1751–9. doi:.
  32. Bedossa P. Pathology of non-alcoholic fatty liver disease. Liver Int. 2017;37(Suppl 1):85–9. doi:.
  33. Bedossa P, Poynard T ; The METAVIR Cooperative Study Group. An algorithm for the grading of activity in chronic hepatitis C. Hepatology. 1996;24(2):289–93. doi:.
  34. Robin X, Turck N, Hainard A, Tiberti N, Lisacek F, Sanchez JC, et al. pROC: an open-source package for R and S+ to analyze and compare ROC curves. BMC Bioinformatics. 2011;12(1):77. doi:.
  35. TEAM RC. R: A Language and Environment for Statistical Computing. R Foundation for Statistical Computing. Vienna, Austria, 2017.
  36. Sasso M, Tengher-Barna I, Ziol M, Miette V, Fournier C, Sandrin L, et al. Novel controlled attenuation parameter for noninvasive assessment of steatosis using Fibroscan(®): validation in chronic hepatitis C. J Viral Hepat. 2012;19(4):244–53. doi:.
  37. Chon YE, Jung KS, Kim KJ, Joo DJ, Kim BK, Park JY, et al. Normal controlled attenuation parameter values: a prospective study of healthy subjects undergoing health checkups and liver donors in Korea. Dig Dis Sci. 2015;60(1):234–42. doi:.
  38. Karlas T, Petroff D, Sasso M, Fan JG, Mi YQ, de Lédinghen V, et al. Individual patient data meta-analysis of controlled attenuation parameter (CAP) technology for assessing steatosis. J Hepatol. 2017;66(5):1022–30. doi:.
  39. Younossi ZM, Stepanova M, Rafiq N, Makhlouf H, Younoszai Z, Agrawal R, et al. Pathologic criteria for nonalcoholic steatohepatitis: interprotocol agreement and ability to predict liver-related mortality. Hepatology. 2011;53(6):1874–82. doi:.
  40. Argo CK, Northup PG, Al-Osaimi AM, Caldwell SH. Systematic review of risk factors for fibrosis progression in non-alcoholic steatohepatitis. J Hepatol. 2009;51(2):371–9. doi:.
  41. Negro F. Steatosis and insulin resistance in response to treatment of chronic hepatitis C. J Viral Hepat. 2012;19(Suppl 1):42–7. doi:.
  42. Negro F. Facts and fictions of HCV and comorbidities: steatosis, diabetes mellitus, and cardiovascular diseases. J Hepatol. 2014;61(1, Suppl):S69–78. doi:.
  43. Leandro G, Mangia A, Hui J, Fabris P, Rubbia-Brandt L, Colloredo G, et al.; HCV Meta-Analysis (on) Individual Patients’ Data Study Group. Relationship between steatosis, inflammation, and fibrosis in chronic hepatitis C: a meta-analysis of individual patient data. Gastroenterology. 2006;130(6):1636–42. doi:.
  44. Adinolfi LE, Rinaldi L, Guerrera B, Restivo L, Marrone A, Giordano M, et al. NAFLD and NASH in HCV Infection: Prevalence and Significance in Hepatic and Extrahepatic Manifestations. Int J Mol Sci. 2016;17(6):803. doi:.
  45. Mirandola S, Osterreicher CH, Marcolongo M, Datz C, Aigner E, Schlabrakowski A, et al. Microsomal triglyceride transfer protein polymorphism (-493G/T) is associated with hepatic steatosis in patients with chronic hepatitis C. Liver Int. 2009;29(4):557–65. doi:.
  46. Lonardo A, Adinolfi LE, Restivo L, Ballestri S, Romagnoli D, Baldelli E, et al. Pathogenesis and significance of hepatitis C virus steatosis: an update on survival strategy of a successful pathogen. World J Gastroenterol. 2014;20(23):7089–103. doi:.
  47. Stevenson HL, Utay NS. Hepatic steatosis in HCV-infected persons in the direct-acting antiviral era. Trop Dis Travel Med Vaccines. 2016;2(1):21. doi:.
  48. Jung KS, Kim BK, Kim SU, Chon YE, Chun KH, Kim SB, et al. Factors affecting the accuracy of controlled attenuation parameter (CAP) in assessing hepatic steatosis in patients with chronic liver disease. PLoS One. 2014;9(6):e98689. doi:.
  49. Myers RP, Pomier-Layrargues G, Kirsch R, Pollett A, Duarte-Rojo A, Wong D, et al. Feasibility and diagnostic performance of the FibroScan XL probe for liver stiffness measurement in overweight and obese patients. Hepatology. 2012;55(1):199–208. doi:.
  50. Sasso M, Audière S, Kemgang A, Gaouar F, Corpechot C, Chazouillères O, et al. Liver Steatosis Assessed by Controlled Attenuation Parameter (CAP) Measured with the XL Probe of the FibroScan: A Pilot Study Assessing Diagnostic Accuracy. Ultrasound Med Biol. 2016;42(1):92–103. doi:.
  51. de Lédinghen V, Hiriart JB, Vergniol J, Merrouche W, Bedossa P, Paradis V. Controlled Attenuation Parameter (CAP) with the XL Probe of the Fibroscan®: A Comparative Study with the M Probe and Liver Biopsy. Dig Dis Sci. 2017;62(9):2569–77. doi:.
  52. Xiao G, Zhu S, Xiao X, Yan L, Yang J, Wu G. Comparison of laboratory tests, ultrasound, or magnetic resonance elastography to detect fibrosis in patients with nonalcoholic fatty liver disease: A meta-analysis. Hepatology. 2017;66(5):1486–501. doi:.
  53. Park CC, Nguyen P, Hernandez C, Bettencourt R, Ramirez K, Fortney L, et al. Magnetic Resonance Elastography vs Transient Elastography in Detection of Fibrosis and Noninvasive Measurement of Steatosis in Patients With Biopsy-Proven Nonalcoholic Fatty Liver Disease. Gastroenterology. 2017;152(3):598–607.e2. doi:.

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