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Do we need a histological score to diagnose non‐alcoholic steatohepatitis?

SIRS, We read the article by Hjelkrem et al. with interest. The authors reviewed histological slides of 386 adults with non-alcoholic fatty liver disease (NAFLD) and tested the accuracy of the NAFLD activity score in diagnosing non-alcoholic steatohepatitis (NASH). Overall, NAFLD activity score had moderate agreement with the diagnosis of NASH based on global histological assessment. An NAFLD activity score cut-off of 4 points had better accuracy in diagnosing NASH than the original proposed cut-off of 5 points. Do we need NAFLD activity score to diagnose NASH? Unlike various noninvasive tests, NAFLD activity score is a histological score. 3 Liver biopsies cannot be spared. If NAFLD activity score is to be used for diagnosing NASH, it should be either more reproducible or more accurate in predicting liver-related complications than global histological assessment. In this study, the same pathologist was responsible for both diagnosing NASH and recording NAFLD activity score. It is not surprising that the degree of agreement between NAFLD activity score and global histological assessment was higher than that reported by the NASH Clinical Research Network (CRN), where the biopsies were reviewed by nine pathologists. For example, discrepant diagnosis of NASH may arise when ballooning is identified by one pathologist but not the other. Nevertheless, a structured scoring system may reduce inter-observer variability in the diagnosis of NASH. The possibility should be further explored using large histological series. A more fundamental question, however, is the importance of detecting NASH in clinical practice. In a recent longitudinal study, liver fibrosis but not the other histological parameters was independently associated with liver-related mortality in patients with NAFLD. The detection of ballooning and inflammation suffers from substantial intra-observer, inter-observer and sampling variability. When liver biopsy is repeated over time, changes in disease activity are not uncommon. Before these questions can be answered, NAFLD activity score should stay as a monitoring tool of treatment effects in clinical studies.