Liver fibrosis in routine care for diabetes could uncover advanced liver disease patients

28 August 2020: Routinely assessing liver fibrosis in people with type 2 diabetes mellitus (T2DM) has the potential to identify large numbers of previously undiscovered cases of advanced liver disease, according to a pilot study conducted in two primary care practices in North East England. The study, reported at The Digital International Liver Congress 2020, tested a two-tier liver fibrosis assessment as part of routine diabetic reviews and discovered that 4.8% of their patients with diabetes also had advanced fibrosis or cirrhosis of the liver, putting them at elevated risk of liver cancer or liver transplant.

Non-alcoholic fatty liver disease (NAFLD) is considered to be the liver manifestation of metabolic syndrome and affects up to 25% of adults worldwide. It is a progressive condition characterized by deposition of fat in the liver that, eventually, leads to inflammation and scarring (known as fibrosis). This more advanced condition is known as non-alcoholic steatohepatitis (NASH). T2DM is an important risk factor for NAFLD, with prevalence as high as 50% in this population, and may also accelerate progression to NASH and liver cirrhosis,. Despite some guidelines recommending screening for NASH or advanced fibrosis in at-risk populations, it is not universally implemented and remains controversial.

In this pilot study, a two-tier fibrosis assessment was incorporated into routine diabetic review for 477 successive patients with T2DM (between April 2018 and September 2019). All patients over 35 years of age had their FIB-4 score (a measure of potential liver fibrosis based on blood biomarkers and age) calculated. A total of 84 patients had a FIB-4 score above the age-related cut-off, of whom 56 were suitable for assessment of their fibrosis by transient elastography (FibroScan ). Patients with a liver stiffness measurement (LSM) of less than or equal to 8 kPa remained in primary care and were advised to repeat staging in 3 years. However, 24 patients had an LSM of >8 kPa, indicating significant fibrosis, and were referred to secondary care. Patients thought to have advanced fibrosis/cirrhosis on specialist assessment were enrolled into surveillance programs. The overall rate of advanced fibrosis/cirrhosis was 4.8%, representing a 7-fold increase in the diagnosis of advanced liver disease/cirrhosis over what had been previously experienced in patients with diabetes at this center. In addition, the study found that over 50% of patients who were diagnosed with significant fibrosis or advanced liver disease presented with normal alanine aminotransferase (ALT) levels. Two asymptomatic patients were also diagnosed with hepatocellular carcinoma.

‘We identified a significant number of patients with advanced liver disease, over half of whom had normal ALT, who would have been missed if only national guidelines had been followed’, said Dr Dina Mansour, Consultant Gastroenterologist at the Queen Elizabeth Hospital in Gateshead, UK. ‘To our knowledge, this is the first pathway incorporating two-tier liver fibrosis assessment into routine diabetic reviews in primary care’.

‘NAFLD is very prevalent and is rapidly becoming the main indication for liver transplantation. It is therefore important to diagnose severe liver disease when patients are still in the asymptomatic phase so that further disease progression can be prevented’, said Professor Emmanuel Tsochatzis of the Royal Free Hospital and University College London, UK, and an EASL Governing Board member. ‘We cannot rely on clinical judgment or abnormal liver tests for this and we do need staging pathways with non-invasive fibrosis assessment in primary care or diabetic clinics. This study provides the proof of concept that such pathways are feasible and highly effective’.

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This annual congress is EASL’s flagship event, attracting scientific and medical experts from around the world to learn about the latest in liver research and exchange clinical experience. Attending specialists present, share, debate and conclude on the latest science and research in hepatology, working to enhance the treatment and management of liver disease in clinical practice. This year, the congress is being held entirely digitally due to the global health situation. The Digital International Liver Congress™ 2020 will take place from 27-29 August 2020. For more information on attendance and registration, please visit

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About The European Association for the Study of the Liver (EASL)

Since its foundation in 1966, this not-for-profit organization has grown to over 4,500 members from all over the world, including many of the leading hepatologists in Europe and beyond. EASL is the leading liver association in Europe, having evolved into a major European association with international influence, and with an impressive track record in promoting research in liver disease, supporting wider education, and promoting changes in European liver policy.

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Session details

Session title: Assessing the burden of liver disease

Date and time of session: Friday 28 August 2020, 11.45-12.00

Presenter: Dina Mansour, UK

Abstract: Incorporating assessment of liver fibrosis into routine diabetic review in primary care: a pilot

Author disclosures

Dina Mansour has no relevant disclosures.

References

1. Wainwright P, Byrne CD. Bidirectional relationships and disconnects between NAFLD and features of the metabolic syndrome. Int J Mol Sci. 2016;17(3):367.

2. Younossi ZM, et al. Global epidemiology of non-alcoholic fatty liver disease – Meta-analytic assessment of prevalence, incidence, and outcomes. Hepatology. 2016;64(1):73-84.

3. Younossi ZM, et al. The global epidemiology of NAFLD and NASH in patients with type 2 diabetes: A systematic review and meta-analysis. J Hepatol. 2019;71:793-801.

4. Bertot LC, Adams LA. The natural course of non-alcoholic fatty liver disease. Int J Mol Sci. 2016;17(5):774.

5. EASL-EASD-EASO Clinical Practice Guidelines for the management of non-alcoholic fatty liver disease. J Hepatol. 2016;64:1388-402.