No abstract

Advanced liver fibrosis is associated with an increased risk of cirrhosis, hepatocellular carcinoma and liver-related mortality in patients with chronic liver diseases. [1][2][3][4][5][6][7] Efforts to improve the non-invasive detection of advanced fibrosis have included the use of the Fibrosis-4 index (FIB-4), a serological advanced fibrosis risk assessment tool that relies upon readily available blood tests (aminotransferases and platelet count) stored within the electronic health record (EHR). [8][9][10][11] FIB-4 has provided accurate fibrosis risk assessment in

Aims The fibrosis‐4 index (FIB‐4) and NAFLD fibrosis score (NFS) are noninvasive and accessible methods for assessing advanced liver fibrosis risk in primary care. We evaluated the distribution of FIB‐4 and NFS scores in primary care patients with clinical signals for nonalcoholic fatty liver disease (NAFLD). Materials and Methods This retrospective cohort study of electronic record data between 2007 and 2018 included adults with at least one abnormal aminotransferase and no known (non‐NAFLD) liver disease. We calculated patient‐level FIB‐4 and NFS scores, the proportion of patients with mean values exceeding advanced fibrosis thresholds (indeterminate risk: FIB‐4 > 1.3, NFS > −1.455; high‐risk: FIB‐4 > 2.67, NFS > 0.676), and the proportion of patients with a NAFLD International Classification of Diseases‐9/10 code. Logistic regression models evaluated the associations of metabolic syndrome (MetS) components with elevated FIB‐4 and NFS scores. Results The cohort included 6506 patients with a median of 6 (interquartile range: 3–13) FIB‐4 and NFS scores per patient. Of these patients, 81% had at least two components of MetS, 29% had mean FIB‐4 and NFS scores for indeterminate fibrosis risk, and 11% had either mean FIB‐4 or NFS scores exceeding the high advanced fibrosis risk thresholds. Regression models identified associations of low high‐density lipoprotein, hyperglycemia, Black race and male gender with high‐risk FIB‐4 and NFS values. Only 5% of patients had existing diagnoses for NAFLD identified. Conclusions Many primary care patients have FIB‐4 and NFS scores concerning for advanced fibrosis, but rarely a diagnosis of NAFLD. Elevated FIB‐4 and NFS scores may provide signals for further clinical evaluation of liver disease in primary care settings.

Autoimmune hepatitis is a common cause of acute liver failure. Treatment includes steroids for acute liver injury and liver transplantation in those who fail to respond or develop acute liver failure. The aim of this study is to further characterize acute liver failure secondary to autoimmune hepatitis and identify variables that predict 21-day transplant-free survival. This study included adults hospitalized with acute liver failure enrolled in the Acute Liver Failure Study Group Registry between 1998 and 2019 from 32 centers within the US. The etiology of all cases was reviewed by the Adjudication Committee, and all cases identified as autoimmune hepatitis were included. Acute liver injury was defined as an INR ≥2.0 without encephalopathy and acute liver failure as INR ≥ 1.5 with encephalopathy. Laboratory and clinical data were reviewed. Variables significantly associated with 21-day transplant-free survival were used to develop a multivariable logistic regression model.  A total of 193 cases of acute liver failure secondary to autoimmune hepatitis were identified and reviewed. There were 161 patients (83.4%) diagnosed with acute liver failure on enrollment, and 32 (16.6%) developed acute liver failure during hospitalization. At 21 days, 115 (59.6%) underwent liver transplantation, 28 (14.5%) had transplant-free survival, and 46 (23.8%) died before liver transplantation. Higher admission values of bilirubin, INR, and coma grade were associated with worse outcomes. A prognostic index incorporating bilirubin, INR, coma grade, and platelet count had a concordance statistic of 0.84. Acute liver failure secondary to autoimmune hepatitis is associated with a high short-term mortality. We developed a model specifically for autoimmune hepatitis that may be helpful in predicting 21-day transplant-free survival and early identification of patients in need of expedited liver transplant evaluation.

Goals and Background: Using natural language processing to create a nonalcoholic fatty liver disease (NAFLD) cohort in primary care, we assessed advanced fibrosis risk with the Fibrosis-4 Index (FIB-4) and NAFLD Fibrosis Score (NFS) and evaluated risk score agreement. Materials and Methods:In this retrospective study of adults with radiographic evidence of hepatic steatosis, we calculated patientlevel FIB-4 and NFS scores and categorized them by fibrosis risk. Risk category and risk score agreement was analyzed using weighted κ, Pearson correlation, and Bland-Altman analysis. A multinomial logistic regression model evaluated associations between clinical variables and discrepant FIB-4 and NFS results.Results: Of the 767 patient cohorts, 71% had a FIB-4 or NFS score in the indeterminate-risk or high-risk category for fibrosis. Risk categories disagreed in 43%, and scores would have resulted in different clinical decisions in 30% of the sample. The weighted κ statistic for risk category agreement was 0.41 [95% confidence interval (CI): 0.36-0.46] and the Pearson correlation coefficient for log FIB-4 and NFS was 0.66 (95% CI: 0.62-0.70). The multinomial logistic regression analysis identified black race (odds ratio = 2.64, 95% CI: 1.84-3.78) and hemoglobin A1c (odds ratio = 1.37, 95% CI: 1.23-1.52) with higher odds of having an NFS risk category exceeding FIB-4. Conclusions:In a primary care NAFLD cohort, many patients had elevated FIB-4 and NFS risk scores and these risk categories were often in disagreement. The choice between FIB-4 and NFS for fibrosis risk assessment can impact clinical decision-making and may contribute to disparities of care.