Direct targeting of risk factors significantly increases the detection of liver cirrhosis in primary care: a cross-sectional diagnostic study utilising transient elastography.
OBJECTIVE
To assess the feasibility of a novel diagnostic algorithm targeting patients with risk factors for chronic liver disease in a community setting.


METHODS
Prospective cross-sectional study.


METHODS
Two primary care practices (adult patient population 10,479) in Nottingham, UK.


METHODS
Adult patients (aged 18 years or over) fulfilling one or more selected risk factors for developing chronic liver disease: (1) hazardous alcohol use, (2) type 2 diabetes or (3) persistently elevated alanine aminotransferase (ALT) liver function enzyme with negative serology.


METHODS
A serial biomarker algorithm, using a simple blood-based marker (aspartate aminotransferase:ALT ratio for hazardous alcohol users, BARD score for other risk groups) and subsequently liver stiffness measurement using transient elastography (TE).


METHODS
Diagnosis of clinically significant liver disease (defined as liver stiffness ≥8 kPa); definitive diagnosis of liver cirrhosis.


RESULTS
We identified 920 patients with the defined risk factors of whom 504 patients agreed to undergo investigation. A normal blood biomarker was found in 62 patients (12.3%) who required no further investigation. Subsequently, 378 patients agreed to undergo TE, of whom 98 (26.8% of valid scans) had elevated liver stiffness. Importantly, 71/98 (72.4%) patients with elevated liver stiffness had normal liver enzymes and would be missed by traditional investigation algorithms. We identified 11 new patients with definite cirrhosis, representing a 140% increase in the number of diagnosed cases in this population.


CONCLUSIONS
A non-invasive liver investigation algorithm based in a community setting is feasible to implement. Targeting risk factors using a non-invasive biomarker approach identified a substantial number of patients with previously undetected cirrhosis.


BACKGROUND
The diagnostic algorithm utilised for this study can be found on clinicaltrials.gov (NCT02037867), and is part of a continuing longitudinal cohort study.
National Institute for Health Research Nottingham Digestive Diseases Biomedical Research Unit (NDDBRU), Nottingham University Hospitals NHS Trust and University of Nottingham, Nottingham, UK.
David J
DJ
Harman
National Institute for Health Research Nottingham Digestive Diseases Biomedical Research Unit (NDDBRU), Nottingham University Hospitals NHS Trust and University of Nottingham, Nottingham, UK.
Stephen D
SD
Ryder
National Institute for Health Research Nottingham Digestive Diseases Biomedical Research Unit (NDDBRU), Nottingham University Hospitals NHS Trust and University of Nottingham, Nottingham, UK.
Martin W
MW
James
NHS Rushcliffe Clinical Commissioning Group, Nottingham, UK.
Matthew
M
Jelpke
NHS Rushcliffe Clinical Commissioning Group, Nottingham, UK.
Dominic S
DS
Ottey
National Institute for Health Research Nottingham Digestive Diseases Biomedical Research Unit (NDDBRU), Nottingham University Hospitals NHS Trust and University of Nottingham, Nottingham, UK.
Emilie A
EA
Wilkes
National Institute for Health Research Nottingham Digestive Diseases Biomedical Research Unit (NDDBRU), Nottingham University Hospitals NHS Trust and University of Nottingham, Nottingham, UK Division of Epidemiology and Public Health, University of Nottingham, Nottingham, UK.
Timothy R
TR
Card
National Institute for Health Research Nottingham Digestive Diseases Biomedical Research Unit (NDDBRU), Nottingham University Hospitals NHS Trust and University of Nottingham, Nottingham, UK.
Guruprasad P
GP
Aithal
National Institute for Health Research Nottingham Digestive Diseases Biomedical Research Unit (NDDBRU), Nottingham University Hospitals NHS Trust and University of Nottingham, Nottingham, UK.
Indra Neil
IN
Guha
D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000410:Alanine Transaminase / Q000097:blood; D000437:Alcoholism / Q000150:complications; D000465:Algorithms; D003430:Cross-Sectional Studies; D003924:Diabetes Mellitus, Type 2 / Q000150:complications; D054459:Elasticity Imaging Techniques / Q000379:methods*; D005240:Feasibility Studies; D005260:Female; D006801:Humans; D008099:Liver / Q000000981:diagnostic imaging; D008103:Liver Cirrhosis / Q000175:diagnosis* / Q000000981:diagnostic imaging; D008297:Male; D008875:Middle Aged; D011446:Prospective Studies; D012372:ROC Curve; D012307:Risk Factors; D006113:United Kingdom; D055815:Young Adult
D000410:Alanine Transaminase
GENERAL MEDICINE (see Internal Medicine)