Embedding assessment of liver fibrosis into routine diabetic review in primary care

Abstract

Background & Aims: Individuals with type 2 diabetes (T2DM) are at high risk of developing non-alcoholic fatty liver disease (NAFLD) and advanced fibrosis/cirrhosis. Screening patients with T2DM and normal liver enzymes for NAFLD in primary care remains contentious. Our aim was to develop and assess a primary care pathway integrating two-tier (Fib-4 then transient elastography [TE]) liver fibrosis assessment, irrespective of aetiology, into routine annual review of all patients with T2DM. Methods: All patients aged >35 years with T2DM attending annual review at 2 primary care practices in North East England between April 2018 and September 2019 (n = 467) had Fib-4 requested via the electronic patient record. Those with a Fib-4 score above the 'high-sensitivity' threshold (>1.3 for < − 65 years and >2.0 for >65 years) underwent TE and were reviewed in secondary care if the liver stiffness measurement (LSM) was >8 kPa. The number of patients identified with advanced disease, service uptake, and predictors of advanced disease were assessed. Results: A total of 85/467 (18.5%) patients had raised Fib-4; 27/467(5.8%) were excluded as a result of frailty or known cirrhosis. A total of 58/467 (12.2%) were referred for TE. Twenty-five of 58 (43.1%) had an LSM of >8 kPa and 13/58 (22.4%) had an LSM >15 kPa; 4/58 (6.7%) did not attend and 5/58 (9.3%) had an invalid reading. Twenty of 440 (4.5%) patients were found to have advanced liver disease following specialist review, compared to 3 patients previously identified through standard care (odds ratio [OR] 6.

Impact of non-invasive biomarkers on hepatology practice: Past, present and future

“…Another strategy, recommended by EASL guidelines 77 (FIB-4 followed by VCTE in patients with FIB-4 >1.3), has been assessed in 440 patients with T2DM seen in primary care. 140 Twenty (4.5%) patients were found to have advanced liver disease following specialist review, compared to 3 patients previously identified through standard care (odds ratio [OR] 6.71; 2.0-22.7; p = 0.002). Such sequential approaches have been suggested to be cost-effective in healthcare systems in the UK and US, [141][142][143] but further studies in other countries are needed.…”

Malaysian Society of Gastroenterology and Hepatology consensus statement on metabolic dysfunction‐associated fatty liver disease

“…2). 33,49,53 In a study on all patients age > 35 years with T2DM attending annual review at two primary care practices, the use of two‐tier assessment of liver fibrosis, that is, FIB‐4 followed by liver stiffness measurement in those with elevated FIB‐4, significantly improved identification of advanced liver fibrosis 54 . In another study to evaluate the performance of FIB‐4‐based screening strategy for the diagnosis of advanced liver fibrosis in patients with diabetes or prediabetes, the presence of cirrhosis and HCC was found to be significantly higher among patients with high FIB‐4 than among patients with intermediate or low FIB‐4 55 .…”

Low Screening Rates Despite a High Prevalence of Significant Liver Fibrosis in People with Diabetes from Primary and Secondary Care

“…Fibrosis prevalence levels with TE were similar to that estimated using the FIB-4 and APRI panels, and both modalities correlated well with biopsy findings. A similar analysis from the UK identified that 18.5% of people with T2D attending primary care clinics (n = 467) had a FIB-4 >1.3 for ≤65 years and >2.0 for >65 years, of which nearly two thirds had a TE >8 kPa [35].…”