Individual patient data meta-analysis of controlled attenuation parameter (CAP) technology for assessing steatosis
Open accessAbstract
Background & aims The prevalence of fatty liver underscores the need for non-invasive characterization of steatosis, such as the ultrasound based controlled attenuation parameter (CAP). Despite good diagnostic accuracy, clinical use of CAP is limited due to uncertainty regarding optimal cut-offs and the influence of covariates. We therefore conducted an individual patient data meta-analysis.Methods A review of the literature identified studies containing histology verified CAP data (M probe, vibration controlled transient elastography with FibroScan®) for grading of steatosis (S0-S3). Receiver operating characteristic analysis after correcting for center effects was used as well as mixed models to test the impact of covariates on CAP. The primary outcome was establishing CAP cut-offs for distinguishing steatosis grades.Results Data from 19/21 eligible papers were provided, comprising 3830/3968 (97%) of patients. Considering data overlap and exclusion criteria, 2735 patients were included in the final analysis (37% hepatitis B, 36% hepatitis C, 20% NAFLD/NASH, 7% other). Steatosis distribution was 51%/27%/16%/6% for S0/S1/S2/S3. CAP values in dB/m (95% CI) were influenced by several covariates with an estimated shift of 10 (4.5-17) for NAFLD/NASH patients, 10 (3.5-16) for diabetics and 4.4 (3.8-5.0) per BMI unit. Areas under the curves were 0.823 (0.809-0.837) and 0.865 (0.850-0.880) respectively. Optimal cut-offs were 248 (237-261) and 268 (257-284) for those above S0 and S1 respectively.Conclusions CAP provides a standardized non-invasive measure of hepatic steatosis. Prevalence, etiology, diabetes, and BMI deserve consideration when interpreting CAP. Longitudinal data are needed to demonstrate how CAP relates to clinical outcomes.Lay summary There is an increase in fatty liver for patients with chronic liver disease, linked to the epidemic of the obesity. Invasive liver biopsies are considered the best means of diagnosing fatty liver. The ultrasound based controlled attenuation parameter (CAP) can be used instead, but factors such as the underlying disease, BMI and diabetes must be taken into account. Registration: Prospero CRD42015027238.
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The discordance between CAP and MRI-PDFF outcomes may be due to CAP being more susceptible to operator dependence, probe selection, technical variability, and influenced by BMI and degree of hepatic steatosis, whereas MRI-PDFF is less affected by these factors and maintains higher precision.
“CAP quantifies ultrasound attenuation and is more susceptible to operator dependence, probe selection, and technical variability, and its performance may be influenced by patient characteristics such as body mass index (BMI) and the degree of hepatic steatosis (30).”
From Intermittent fasting versus continuous energy restriction in MASLD: a systematic review and meta-analysis (2026) · cites this paper as [31]
Ultrasound-based CAP values provide a good estimate of the liver steatosis grade.
“Ultrasound-based CAP values provide a good estimate of the liver steatosis grade.”
From EASL-EASD-EASO Clinical Practice Guidelines on the management of metabolic dysfunction-associated steatotic liver disease (MASLD). (2024) · cites this paper as [166]
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- Authors
- Karlas, T., Petroff, D., Sasso, M., Fan, J.-G., Mi, Y.-Q., de Lédinghen, V., Kumar, M., Lupsor-Platon, M., Han, K.-H., Cardoso, A. C., Ferraioli, G., Chan, W.-K., Wong, V. W.-S., Myers, R. P., Chayama, K., Friedrich-Rust, M., Beaugrand, M., Shen, F., Hiriart, J.-B., Sarin, S. K., Badea, R., Jung, K. S., Marcellin, P., Filice, C., Mahadeva, S., Wong, G. L.-H., Crotty, P., Masaki, K., Bojunga, J., Bedossa, P., Keim, V., & Wiegand, J.
- Affiliations
- University Hospital Leipzig (DE)
- IFB Adiposity Diseases (DE)
- Echosens (France) (FR)
- Shanghai Jiao Tong University (CN)
- Institute of Liver and Biliary Sciences (IN)
- Yonsei University (KR)
- Inserm (FR)
- University of Pavia (IT)
- University of Malaya (MY)
- Chinese University of Hong Kong (HK)
- University of Calgary (CA)
- Hiroshima University Hospital (JP)
- Hôpital Jean-Verdier (FR)
- Centre Hospitalier Universitaire de Bordeaux (FR)
- Iuliu Hațieganu University of Medicine and Pharmacy (RO)
- University Hospital Frankfurt (DE)
- Corresponding author
- Wiegand, Johannes
- ORCID
- Karlas, Thomas
- Petroff, David
- Sasso, Magali
- Fan, Jian-Gao
- Kumar, Manoj
- Han, Kwang-Hyub
- Cardoso, Ana C.
- Ferraioli, Giovanna
- Chan, Wah-Kheong
- Wong, Vincent Wai-Sun
- Chayama, Kazuaki
- Shen, Feng
- Hiriart, Jean-Baptiste
- Sarin, Shiv K.
- Badea, Radu
- Marcellin, Patrick
- Mahadeva, Sanjiv
- Wong, Grace Lai-Hung
- Crotty, Pam
- Bojunga, Joerg
- Wiegand, Johannes
- Venue
- Journal of Hepatology
- Publisher
- Elsevier BV
- Published
- 2017-05
- Volume
- 66
- Issue
- 5
- Pages
- 1022-1030
- ISSN
- 0168-8278 (ISSN-L)
- OpenAlex
- W2564467149
- Cited by
- 1,275
- References
- 65
- Citations by year
- 2026: 164 · 2025: 185 · 2024: 180 · 2023: 139 · 2022: 161 · 2021: 150 · 2020: 117 · 2019: 77 · 2018: 67 · 2017: 31 · 2016: 2 · 2015: 1
- FWCI
- 7.94
- Type
- journal article
- Language
- en
- Open access
- Licence
- cc-by-nc-nd
- www.elsevier.com/tdm/userlicense/1.0/ (tdm)
- Locations
- Journal of Hepatology (publishedVersion)
- PubMed (publishedVersion)
- YUHSpace (Yonsei University Medical Library) (submittedVersion, cc-by-nc-nd)
- Topics
- Health Sciences › Medicine › Epidemiology › Liver Disease Diagnosis and Treatment
- Health Sciences › Medicine › Radiology, Nuclear Medicine and Imaging › Ultrasound Imaging and Elastography
- Health Sciences › Medicine › Critical Care and Intensive Care Medicine › Ultrasound in Clinical Applications
- Keywords
- controlled attenuation parameter, hepatic steatosis, vibration-controlled transient elastography, FibroScan, chronic liver disease, diabetes mellitus, body mass index, liver ultrasound, receiver operating characteristic
- MeSH terms
- Adult, Fatty Liver, Female, Humans, Male, Middle Aged, ROC Curve, Ultrasonography, Meta-Analysis as Topic, Body Mass Index, Hepatocytes
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