Moving forward with the detection of chronic liver disease

The recent article by Abeysekera et al provides valuable insights into the evolving attitude towards non-invasive fibrosis testing (NIT) in the UK.¹ By comparing two surveys conducted among gastroenterology and hepatology specialists in 2014–2015 and 2021, the authors shed light on the changing landscape in this field. The results of the study are encouraging and point towards progress.

One notable finding is that almost all the clinicians surveyed now routinely perform fibrosis assessment, indicating a widespread acceptance of non-invasive testing methods. This marks a positive shift away from the traditional reliance on liver biopsies for fibrosis staging, which has been associated with limitations and risks. Transient elastography has remained the favoured NIT among specialists and is being used frequently as a reliable alternative to biopsy. There has been a rise in the use of indirect fibrosis biomarkers, such as FIB-4 and the non-alcoholic fatty liver disease (NAFLD) fibrosis score, which are routinely available and can reliably exclude advanced fibrosis. Use of these tests can help rationalise the use of transient elastography, which remains a limited resource in many areas. This work has also shown that most gastroenterologists and hepatologists now view NITs as suitable alternatives for both staging liver fibrosis and assessing prognosis. Liver biopsy is now primarily being reserved for cases of diagnostic uncertainty, suspected autoimmune hepatitis or situations where there is discordance between NITs and the clinical presentation. Overall, this trend indicates that clinicians are embracing less invasive approaches for fibrosis assessment.

Given the progress in the adoption of NITs to stage liver disease in secondary care, this paves the way for the development of pathways to proactively detect liver disease in the community. The article by Abeysekera et al highlights many of the barriers that hinder the implementation of liver fibrosis staging pathways in secondary care. These barriers are important to consider as the liver community seeks to expand the pathways from the current ‘reactive’ approach to finding liver disease (eg, investigation of abnormal liver blood tests) to a more proactive approach in which individuals with risk factors for liver disease have a liver fibrosis assessment using NITs in the community setting. It should be noted that the surveys conducted by Abeysekera et al were completed by a selected group of gastroenterologists and hepatologists, and as such, knowledge about NITs and access to pathways may be different in primary care and in parts of the country not represented in the surveys. These differences must be considered when developing services aimed at implementing proactive liver disease detection in the community.

Evolution of pathways to detect liver disease

Quality standards from the British Association for the Study of the Liver (BASL) and British Society of Gastroenterology (BSG) recommend that all services have an agreed local clinical pathway for the investigation of suspected liver disease, which should include an assessment for liver fibrosis using available NITs.² Whilst it is encouraging that the surveys by Abeysekera et al have shown an increase in the existence of fibrosis assessment pathways in secondary care, there is still significant variability in the availability and use of NIT pathways across the UK.

The recent BASL/BSG national audit on the care of patients with NAFLD reported that, of the 34 participating sites, 85% had established pathways in place. However, only 28% of patients with suspected NAFLD had documented non-invasive fibrosis assessment at the point of referral to secondary care, indicating that adherence to these pathways is likely to be suboptimal.³ Moreover, research carried out in primary care settings suggests that more than half of clinical commissioning groups and health boards lack pathways to assess liver disease in primary care.⁴ Clearly, further work is needed to develop and implement liver disease assessment pathways in all regions of the UK. Achieving this will require close collaboration between primary and secondary care. The UK Liver Alliance has recognised this as a priority as it seeks to improve outcomes for patients with liver disease in the UK.

Currently, many liver disease assessment pathways rely on abnormal liver blood tests as the primary criterion for entry. However, it is well known that serum alanine aminotransferase levels can be normal in patients with advanced liver fibrosis, and as such these pathways can miss individuals with significant liver disease. To increase the diagnosis of people with advanced fibrosis more proactive strategies are needed, which involve screening or case finding using NITs in high-risk individuals, such as those with type 2 diabetes or excessive alcohol consumption. Ongoing studies are exploring the impact of this approach, aiming to determine the most efficient and cost-effective combination of NITs. Pathways incorporating the sequential use of least two NITs are recommended by guidelines to stage liver fibrosis, with simple risk scores, such as FIB-4 or NAFLD fibrosis score as the first-line tests in primary care, followed by more expensive tests such as transient elastography or the enhanced liver fibrosis test for indeterminate cases, conducted in primary or secondary case depending on availability.² Lack of access to second line NITs has been identified as the most significant barrier to implementation of assessment pathways.¹ Recently published guidelines from the National Institute of Health and Care Excellence recommend transient elastography as an option for staging liver fibrosis outside secondary care settings. Hopefully, this recommendation combined with plans for transient elastography to be available in the new Community Diagnostic Centres in England may improve access to this crucial diagnostic tool.

Surveys have indicated a lack confidence among general practitioners in identifying and managing liver disease, as well as interpreting liver investigations, including NIT results.⁵ One way of simplifying the investigation of suspected liver disease in primary care is to expand the use of the automated iLFT system developed in Tayside, Scotland.⁶ This system allows clinicians to input a few simple clinical variables, and the iLFT system initiates reflex testing for a liver aetiology screen and NITs when appropriate. It then generates a report with a suggested diagnosis and management advice. The iLFT system has significantly increased the diagnosis of liver disease and has proven cost-effective. Although this approach is being expanded in Scotland and other parts of the UK, its expansion has been limited by inadequate IT infrastructure in some areas.

The absence of Quality and Outcomes Frameworks (QoF) for liver disease is another significant obstacle in implementing a comprehensive approach for liver disease in primary care.⁴ With the substantial rise in the prevalence of liver disease, there is an urgent need for a dedicated liver disease QoF that provides healthcare professionals with a clear framework for monitoring and assessing the quality of care for this patient group.

Overall, there has been significant progress in the evolution of pathways for liver disease in the UK, and it is promising to see evidence of increased utilisation of NITs. However, there is still significant variability in approaches and a lack of access to NITs in some regions. Collaborative efforts between primary and secondary care are currently underway to address these challenges and expand access to NITs, while also striving to establish more efficient pathways for liver disease assessment.

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