title: The Enhanced liver fibrosis score is associated with clinical outcomes and disease progression in patients with chronic liver disease.
abstract: OBJECTIVE
  Current tools for risk stratification of chronic liver disease subjects are limited. We aimed to determine whether the serum-based ELF (Enhanced Liver Fibrosis) test predicted liver-related clinical outcomes, or progression to advanced liver disease, and to compare the performance of ELF to liver biopsy and non-invasive algorithms.
  
  
  METHODS
  Three hundred patients with ELF scores assayed at the time of liver biopsy were followed up (median 6.1 years) for liver-related clinical outcomes (n = 16) and clear evidence of progression to advanced fibrosis (n = 18), by review of medical records and clinical data.
  
  
  RESULTS
  Fourteen of 73 (19.2%) patients with ELF score indicative of advanced fibrosis (≥9.8, the manufacturer's cut-off) had a liver-related clinical outcome, compared to only two of 227 (<1%) patients with ELF score <9.8. In contrast, the simple scores APRI and FIB-4 would only have predicted subsequent decompensation in six and four patients respectively. A unit increase in ELF score was associated with a 2.53-fold increased risk of a liver-related event (adjusted for age and stage of fibrosis). In patients without advanced fibrosis on biopsy at recruitment, 55% (10/18) with an ELF score ≥9.8 showed clear evidence of progression to advanced fibrosis (after an average 6 years), whereas only 3.5% of those with an ELF score <9.8 (8/207) progressed (average 14 years). In these subjects, a unit increase in ELF score was associated with a 4.34-fold increased risk of progression.
  
  
  CONCLUSIONS
  The ELF score is a valuable tool for risk stratification of patients with chronic liver disease.
authors.affiliation: Centre for Liver Disease Research, School of Medicine, The University of Queensland, Brisbane, QLD, Australia.
authors.forename: Katharine M
authors.initials: KM
authors.lastname: Irvine
authors.affiliation: Statistics Unit, QIMR Berghofer Medical Research Institute, Brisbane, QLD, Australia.
authors.forename: Leesa F
authors.identifier: http://orcid.org/0000-0002-8921-9265
authors.initials: LF
authors.lastname: Wockner
authors.affiliation: Centre for Liver Disease Research, School of Medicine, The University of Queensland, Brisbane, QLD, Australia.
authors.forename: Mihir
authors.initials: M
authors.lastname: Shanker
authors.affiliation: Centre for Liver Disease Research, School of Medicine, The University of Queensland, Brisbane, QLD, Australia.|Department of Gastroenterology and Hepatology, Princess Alexandra Hospital, Brisbane, QLD, Australia.
authors.forename: Kevin J
authors.initials: KJ
authors.lastname: Fagan
authors.affiliation: Centre for Liver Disease Research, School of Medicine, The University of Queensland, Brisbane, QLD, Australia.|Department of Gastroenterology and Hepatology, Princess Alexandra Hospital, Brisbane, QLD, Australia.
authors.forename: Leigh U
authors.initials: LU
authors.lastname: Horsfall
authors.affiliation: Department of Gastroenterology and Hepatology, Princess Alexandra Hospital, Brisbane, QLD, Australia.
authors.forename: Linda M
authors.initials: LM
authors.lastname: Fletcher
authors.affiliation: Department of Chemical Pathology, Pathology Queensland, Brisbane, QLD, Australia.
authors.forename: Jacobus P J
authors.initials: JP
authors.lastname: Ungerer
authors.affiliation: Department of Chemical Pathology, Pathology Queensland, Brisbane, QLD, Australia.
authors.forename: Carel J
authors.initials: CJ
authors.lastname: Pretorius
authors.affiliation: Centre for Liver Disease Research, School of Medicine, The University of Queensland, Brisbane, QLD, Australia.
authors.forename: Gregory C
authors.initials: GC
authors.lastname: Miller
authors.affiliation: Centre for Liver Disease Research, School of Medicine, The University of Queensland, Brisbane, QLD, Australia.
authors.forename: Andrew D
authors.initials: AD
authors.lastname: Clouston
authors.affiliation: Pathology Queensland, Princess Alexandra Hospital, Brisbane, QLD, Australia.
authors.forename: Guy
authors.initials: G
authors.lastname: Lampe
authors.affiliation: Centre for Liver Disease Research, School of Medicine, The University of Queensland, Brisbane, QLD, Australia.|Department of Gastroenterology and Hepatology, Princess Alexandra Hospital, Brisbane, QLD, Australia.
authors.forename: Elizabeth E
authors.initials: EE
authors.lastname: Powell
mesh_terms: D000328:Adult; D000465:Algorithms; D015415:Biomarkers / Q000097:blood; D001706:Biopsy; D002908:Chronic Disease; D003661:Decision Support Techniques; D018450:Disease Progression; D005260:Female; D006801:Humans; D006820:Hyaluronic Acid / Q000097:blood*; D008099:Liver / Q000378:metabolism* / Q000473:pathology; D008103:Liver Cirrhosis / Q000097:blood / Q000175:diagnosis* / Q000209:etiology / Q000473:pathology; D008107:Liver Diseases / Q000150:complications* / Q000175:diagnosis; D008297:Male; D008875:Middle Aged; D010446:Peptide Fragments / Q000097:blood*; D011237:Predictive Value of Tests; D011347:Procollagen / Q000097:blood*; D015203:Reproducibility of Results; D012189:Retrospective Studies; D012307:Risk Factors; D012720:Severity of Illness Index; D013997:Time Factors; D019715:Tissue Inhibitor of Metalloproteinase-1 / Q000097:blood*
chemical_list: D015415:Biomarkers; D010446:Peptide Fragments; D011347:Procollagen; C560822:TIMP1 protein, human; D019715:Tissue Inhibitor of Metalloproteinase-1; C041876:procollagen Type III-N-terminal peptide; D006820:Hyaluronic Acid
keywords: decompensation; liver cancer; liver cirrhosis; non-invasive biomarkers; prediction of clinical outcomes