The consensus conference statements recommend liver biopsy in the management of almost all patients with the most frequent chronic liver diseases: chronic hepatitis C (HCV) and B (HBV), non-alcoholic fatty liver disease (NAFLD), with its risk of non alcoholic steato-hepatitis (NASH), and alcoholic fatty liver disease (AFLD) with its risk of non alcoholic steatohepatitis (ASH), but also underline the necessity of developing reliable non-invasive tests. Numerousstudies strongly suggest that due to the limitations and risks of biopsy, as well as the improvement of the diagnostic accuracy of biochemical markers, liver biopsy should no longer be considered mandatory.

Non - invasive Alternatives
Among the non-invasive alternatives to liver biopsy, several studies have demonstrated the predictive value of two combinations of simple serum biochemical markers: FibroTest™ (or HCV-FibroSURE™ in the US) for the quantitative assessment of fibrosis and ActiTest™ (or HCV-FibroSURE in the US) for the qu ntitative assessment of necroinflammation, Similar results have not been obtained with other diagnostic tests. Since September 2002 FibroSURE-FibroTest-ActiTests (FTAT) have been used in several countries as an alternative to liver biopsy. Several systematic reviews and independent prospective studies have validated these panels of tests.

The diagnostic values of FT were similar for the four most frequent fibrotic liver diseases. The diagnostic values were similar between intermediate or extreme stages as assessed by area under the receiver operator characteristic (AUROC) between all stage combinations. It has been also demonstrated that biomarkers may provide a more accurate picture of fibrogenic and necrotic events occurring within the liver than a low-quality liver biopsy. A prospective study observed that 18% of discordances were attributable to biopsy failure (mostly due to small length) and 2% to the failure of the tests. The prospective follow-up of these patients during five years has also dem nstrated that the prognostic value of FibroSURE was greater than that of biopsy for predicting mortality and morbidity.

Since June 2006 three new combinations of biomarkers have completed the spectrum of non invasive liver biomarkers: SteatoTest™, for the diagnosis of steatosis (fatty liver), NashTest™ for the diagnosis of NASH, and AshTest™ for the diagnosis of Ash. In the US, Nash- FibroSURE™ included FibroTest-SteatoTest and NashTest; Ash-FibroSURE™ included FibroTest- SteatoTest and AshTest.