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

Dina Mansour; Allison Grapes; Marc Herscovitz; Paul Cassidy; Jonathan Vernazza; Andrea Broad; Quentin M Anstee; Stuart McPherson

doi:10.1016/j.jhepr.2021.100293

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

JHEP Rep. 2021 Apr 22;3(4):100293. doi: 10.1016/j.jhepr.2021.100293. eCollection 2021 Aug.

Authors

Dina Mansour^{1

2}, Allison Grapes¹, Marc Herscovitz³, Paul Cassidy⁴, Jonathan Vernazza¹, Andrea Broad⁵, Quentin M Anstee^{2

6}, Stuart McPherson^{2

6}

Affiliations

¹ Queen Elizabeth Hospital, Gateshead, UK.
² Translational & Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK.
³ Bewick Road Surgery, Gateshead, UK.
⁴ Teams Medical Centre, Gateshead, UK.
⁵ Raigmore Hospital, Inverness, UK.
⁶ Liver Unit, Newcastle Upon Tyne Hospitals NHS Trust, Freeman Hospital, Newcastle upon Tyne, UK.

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] 6.71 [2.0-22.7] p = 0.0022). Alcohol (OR 1.05 [1.02-1.08] p = 0.001) and BMI (OR 1.09 [1.01-1.17] p = 0.021) were predictors of advanced disease, particularly drinking >14/21 units/week (p <0.0001).

Conclusions: Incorporating 2-tier assessment of liver fibrosis into routine annual diabetes review in primary care significantly improves identification of advanced liver disease in patients with T2DM.

Lay summary: People with type 2 diabetes are at increased risk of developing non-alcoholic fatty liver disease and developing more significant complications. This study looks at introducing screening for advanced liver disease into the annual diabetes reviews performed routinely in primary care; we found that significantly more people were identified as having significant liver disease through this pathway than with current standard care.

Keywords: ALP, alkaline phosphatase; ALT, alanine aminotransferase; AST, aspartate aminotransferase; EASL, European Association for the Study of the Liver; ELF, enhanced liver fibrosis test; Fibrosis; GGT, gamma-glutamyl transferase; HCC, hepatocellular carcinoma; HbA1c, glycated haemoglobin; LFTs, liver function tests; LSM, liver stiffness measurement; Liver stiffness; NAFLD, non-alcoholic fatty liver disease; NASH, non-alcoholic steatohepatitis; Non-alcoholic fatty liver disease; Non-invasive; OR, odds ratio; Serum biomarkers; T2DM, type 2 diabetes; TE, transient elastography; Transient elastography; Type 2 diabetes mellitus.