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Am Fam Physician. 2021;103(8):453

Original Article: Nonalcoholic Fatty Liver Disease: Common Questions and Answers on Diagnosis and Management

Issue Date: November 15, 2020

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To the Editor: Overall, the article by Dr. Westfall and colleagues was well written; however, we have concerns about the 1.6% death rate the authors quoted for liver biopsy. This statistic was obtained from a 1999 article that provided the complication and fatality rates based on 484 cases from a single hospital in Thailand from 1987 to 1996.1

A 2010 article provides more contemporary and accurate data on liver biopsy procedures.2 The study included 61,187 patients in the United Kingdom National Health Service from 1998 to 2005 and found that all-cause mortality rates from liver biopsy were closer to 0.2%, with the biopsy itself implicated as the direct cause of death in about one in 10,000 procedures.

Physicians reading Dr. Westfall 's article might overestimate the risks of liver biopsy and be reluctant to refer their patients for an indicated test or not accurately counsel their patients regarding the risks and benefits of this procedure.

In Reply: We thank Drs. Stott and Dang for their letter and are grateful for their commitment to ensuring the accuracy and clarity of our article. There are significant variations in the reported morbidity and mortality rates associated with liver biopsies because of the retrospective nature of most studies, variations in indications for biopsy, patient characteristics, biopsy technique, and inconsistency in the definitions of complications (i.e., some studies do not distinguish between death as a consequence of biopsy and death from other causes). The 2020 guidelines on the use of liver biopsy in clinical practice from the British Society of Gastroenterology, the Royal College of Radiologists, and the Royal College of Pathologists address the lack of established complication figures by strongly recommending that clinicians “use local data where available, tailored to the patient's individual situation.”1

We agree that clinicians must cautiously interpret the data about complications of liver biopsy and not overestimate the risks, which could deter referral for the procedure when necessary. Our article has been updated to reflect this.

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This series is coordinated by Kenny Lin, MD, MPH, deputy editor.

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