Background: There is substantial variation in how histologic definitions and scoring systems of non-alcoholic fatty liver disease (NAFLD) are operationalised. Aim: To develop a consensus-based framework for standardising histologic assessment of liver biopsies in clinical trials of NAFLD. Methods: An expert panel of 14 liver pathologists and three hepatologists was assembled. Using modified RAND/University of California Los Angeles appropriateness methodology, 130 items derived from literature review and expert opinion were rated by each panel member on a 1-9 scale. Disagreement was defined as ≥5 ratings in the lowest (1-3) and highest (7-9) categories. Items were classified as inappropriate (median 1-3.5 without disagreement), uncertain (median 3.5-6.5 or any median with disagreement) or appropriate (median 6.5-9 without disagreement). Survey results were discussed as a group before voting. Results: Current measures of disease activity and fibrosis may not fully capture important features of non-alcoholic steatohepatitis (NASH). Alternative methods to evaluate ballooning degeneration are needed. Panellists were uncertain whether portal inflammation, degree of steatosis and Mallory-Denk bodies are important measures of disease activity. Furthermore, it was felt that current staging systems do not capture the full spectrum of fibrosis in NASH. A consensus definition and sub-stages for bridging fibrosis are needed. The severity of perisinusoidal fibrosis should be captured at all stages. Lastly, a method to evaluate features of fibrosis regression should be developed. Conclusion: The operating properties of the modifications proposed should be evaluated prospectively to determine reliability and responsiveness.
Bibliographical noteFunding Information:
Funding information This study was supported in part by the Intramural Research Program of the NIH, National Cancer Institute. We thank Leonardo Guizzetti (Robarts Clinical Trials, Inc) for helping prepare the survey results. Declaration of personal interests: RL has received funding support from NIEHS (5P42ES010337), NCATS (5UL1TR001442) and NIDDK (R01DK106419); RKP has received consulting income from Genentech, Eli Lilly, and Robarts Clinical Trials Inc; DEK has no relevant conflict of interest to disclose; JH has no relevant conflict of interest to disclose; OAA has no relevant conflict of interest to disclose; ADC has no relevant conflict of interest to disclose; CAB has received consulting fees from ICON and Covance through Pacific Rim Pathology Group; DJ has no relevant conflict of interest to disclose; SK has no relevant conflict of interest to disclose; MB has received speaker fees from Merck; LB has no relevant conflict of interest to disclose; KPB has no relevant conflict of interest to disclose; MAV has no relevant conflict of interest to disclose; MST has no relevant conflict of interest to disclose; MG has no relevant conflict of interest to disclose; HLW has no relevant conflict of interest to disclose; VA has no relevant conflict of interest to disclose; LAA has no relevant conflict of interest to disclose; CEP is an employee of Robarts Clinical Trials, Inc; BGF has received grant/research support from AbbVie Inc, Amgen Inc, AstraZeneca/MedImmune Ltd., Atlantic Pharmaceuticals Ltd., Boehringer-Ingelheim, Celgene Corporation, Celltech, Genentech Inc/Hoffmann-La Roche Ltd., Gilead Sciences Inc, GlaxoSmithKline (GSK), Janssen Research & Development LLC., Pfizer Inc, Receptos Inc/Celgene International, Sanofi, Santarus Inc, Takeda Development Center Americas Inc, Tillotts Pharma AG and UCB; consulting fees from Abbott/AbbVie, Akebia Therapeutics, Allergan, Amgen, Applied Molecular Transport Inc, Aptevo Therapeutics, Astra Zeneca, Atlantic Pharma, Avir Pharma, Biogen Idec, BioMx Israel, Boehringer-Ingelheim, Bristol-Myers Squibb, Calypso Biotech, Celgene, Elan/Biogen, EnGene, Ferring Pharma, Roche/Genentech, Galapagos, GiCare Pharma, Gilead, Gossamer Pharma, GSK, Inception IBD Inc, JnJ/Janssen, Kyowa Kakko Kirin Co Ltd., Lexicon, Lilly, Lycera BioTech, Merck, Mesoblast Pharma, Millennium, Nestle, Nextbiotix, Novonordisk, Pfizer, Prometheus Therapeutics and Diagnostics, Progenity, Protagonist, Receptos, Salix Pharma, Shire, Sienna Biologics, Sigmoid Pharma, Sterna Biologicals, Synergy Pharma Inc, Takeda, Teva Pharma, TiGenix, Tillotts, UCB Pharma, Vertex Pharma, Vivelix Pharma, VHsquared Ltd. and Zyngenia; speakers bureau fees from Abbott/AbbVie, JnJ/Janssen, Lilly, Takeda, Tillotts and UCB Pharma; is a scientific advisory board member for Abbott/AbbVie, Allergan, Amgen, Astra Zeneca, Atlantic Pharma, Avaxia Biologics Inc, Boehringer-Ingelheim, Bristol-Myers Squibb, Celgene, Centocor Inc, Elan/Biogen, Galapagos, Genentech/Roche, JnJ/Janssen, Merck, Nestle, Novartis, Novonordisk, Pfizer, Prometheus Laboratories, Protagonist, Salix Pharma, Sterna Biologicals, Takeda, Teva, TiGenix, Tillotts Pharma AG and UCB Pharma; and is the Senior Scientific Officer of Robarts Clinical Trials Inc; RL serves as a consultant or advisory board member for Arrowhead Pharmaceuticals, AstraZeneca, Bird Rock Bio, Boehringer Ingelheim, Bristol-Myer Squibb, Celgene, Cirius, CohBar, Conatus, Eli Lilly, Galmed, Gemphire, Gilead, Glympse bio, GNI, GRI Bio, Intercept, Ionis, Janssen Inc, Merck, Metacrine, Inc, NGM Biopharmaceuticals, Novartis, Novo Nordisk, Pfizer, Prometheus, Sanofi, Siemens, and Viking Therapeutics. In addition, his institution has received grant support from Allergan, Boehringer-Ingelheim, Bristol-Myers Squibb, Cirius, Eli Lilly and Company, Galectin Therapeutics, Galmed Pharmaceuticals, GE, Genfit, Gilead, Intercept, Janssen, Madrigal Pharmaceuticals, Merck, NGM Biopharmaceuticals, NuSirt, Pfizer, Prometheus, and Siemens. He is also co-founder of Liponexus, Inc; VJ has received consulting fees from AbbVie, Takeda, Eli Lilly, Pfizer, Janssen, Ferring, Shire, Merck, GSK, Celltrion, and Robarts Clinical Trials Inc; serves as an advisory board member for AbbVie, Takeda, Janssen, Arena, GSK, Eli Lilly and Ferring; and has received speakers' bureau fees from Takeda, AbbVie, Janssen, Pfizer, Shire and Ferring.
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