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Liver stiffness measurement in the primary care setting detects high rates of advanced fibrosis and predicts liver-related events in hepatitis C

  • Stephen Bloom
    Correspondence
    Corresponding author. Address: Department of Gastroenterology, Eastern Health, 8 Arnold Street, Box Hill, Vic 3162, Australia.
    Affiliations
    Department of Gastroenterology, Eastern Health, Box Hill, Victoria, Australia

    Department of Gastroenterology, Alfred Health, and Monash University, Melbourne, Victoria, Australia

    Eastern Health Clinical School, Monash University, Melbourne, Australia

    CATCH Study Group (Community Approach Targeting Cirrhosis and Hepatocellular Carcinoma), Australia
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  • William Kemp
    Affiliations
    Department of Gastroenterology, Alfred Health, and Monash University, Melbourne, Victoria, Australia

    CATCH Study Group (Community Approach Targeting Cirrhosis and Hepatocellular Carcinoma), Australia
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  • Amanda Nicoll
    Affiliations
    Department of Gastroenterology, Eastern Health, Box Hill, Victoria, Australia

    Department of Gastroenterology and Hepatology, Royal Melbourne Hospital, Parkville, Victoria, Australia

    Eastern Health Clinical School, Monash University, Melbourne, Australia

    CATCH Study Group (Community Approach Targeting Cirrhosis and Hepatocellular Carcinoma), Australia
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  • Stuart K. Roberts
    Affiliations
    Department of Gastroenterology, Alfred Health, and Monash University, Melbourne, Victoria, Australia

    CATCH Study Group (Community Approach Targeting Cirrhosis and Hepatocellular Carcinoma), Australia
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  • Paul Gow
    Affiliations
    Department of Gastroenterology, Austin Health, Heidelberg, Victoria, Australia

    CATCH Study Group (Community Approach Targeting Cirrhosis and Hepatocellular Carcinoma), Australia
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  • Anouk Dev
    Affiliations
    Department of Gastroenterology, Monash Health, Clayton, Victoria, Australia

    CATCH Study Group (Community Approach Targeting Cirrhosis and Hepatocellular Carcinoma), Australia
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  • Sally Bell
    Affiliations
    Department of Gastroenterology, St Vincent’s Hospital, Fitzroy, Victoria, Australia

    CATCH Study Group (Community Approach Targeting Cirrhosis and Hepatocellular Carcinoma), Australia
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  • Siddharth Sood
    Affiliations
    Department of Gastroenterology and Hepatology, Royal Melbourne Hospital, Parkville, Victoria, Australia

    CATCH Study Group (Community Approach Targeting Cirrhosis and Hepatocellular Carcinoma), Australia
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  • Ian Kronborg
    Affiliations
    Department of Gastroenterology, Western Health, Footscray, Victoria, Australia

    CATCH Study Group (Community Approach Targeting Cirrhosis and Hepatocellular Carcinoma), Australia
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  • Virginia Knight
    Affiliations
    Department of Gastroenterology, Monash Health, Clayton, Victoria, Australia

    CATCH Study Group (Community Approach Targeting Cirrhosis and Hepatocellular Carcinoma), Australia
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  • Diana Lewis
    Affiliations
    Department of Gastroenterology, Eastern Health, Box Hill, Victoria, Australia

    Eastern Health Clinical School, Monash University, Melbourne, Australia

    CATCH Study Group (Community Approach Targeting Cirrhosis and Hepatocellular Carcinoma), Australia
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  • John Lubel
    Affiliations
    Department of Gastroenterology, Eastern Health, Box Hill, Victoria, Australia

    Eastern Health Clinical School, Monash University, Melbourne, Australia

    CATCH Study Group (Community Approach Targeting Cirrhosis and Hepatocellular Carcinoma), Australia
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Published:April 27, 2018DOI:https://doi.org/10.1016/j.jhep.2018.04.013

      Highlights

      • The rate of advanced fibrosis in community hepatitis C is significant at 16.5%.
      • No laboratory features of active disease were seen in 8.5% at risk of cirrhosis.
      • Rates of advanced fibrosis were comparable between a hospital and community groups.
      • Older age, high BMI, ALT and alcohol use were linked to elevated liver stiffness.
      • A liver stiffness greater than 24 kPa predicted liver related events in this cohort.

      Background & Aims

      As many as 70% of individuals with chronic hepatitis C (CHC) are managed solely in primary care. The aims of this study were to determine the prevalence of elevated liver stiffness measurement (LSM) in a cohort of community managed patients with CHC and to evaluate predictors of advanced liver disease and liver-related events.

      Methods

      A prospective cohort of adult patients with CHC were recruited from 21 primary care practices throughout Victoria, Australia. Inclusion criteria included the presence of CHC for >6 months, no recent (<18 months) specialist input and no history of hepatocellular carcinoma. Clinical assessment, LSM and phlebotomy were carried out in primary care. A hospital cohort was recruited for comparison. Participants were followed longitudinally and monitored for liver-related events.

      Results

      Over 26 months, 780 community patients were recruited and included in the analysis. The median LSM was 6.9 kPa in the community, with 16.5% of patients at risk of advanced fibrosis (LSM ≥12.5 kPa); of these 8.5% had no laboratory features of advanced liver disease. The proportion at risk of cirrhosis was no different between the community and hospital cohorts (p = 0.169). At-risk alcohol consumption, advancing age, elevated body mass index and alanine aminotransferase were independent predictors of elevated LSM. Over a median follow-up of 15.2 months, liver-related events occurred in 9.3% of those with an LSM ≥12.5 kPa. An LSM of 24 kPa had the highest predictive power for liver-related events (hazard ratio 152; p <0.001).

      Conclusion

      The prevalence of advanced fibrosis, as determined by LSM, in primary care managed CHC is significant and comparable to a hospital cohort. Furthermore, this study supports the use of LSM as a community screening tool in a CHC population and indicates a possible role in predicting liver-related events.

      Lay summary

      The prevalence of advanced liver disease in primary care managed hepatitis C is unknown. Our data suggests that rates of advanced fibrosis in the community are significant (16.5%), often underdiagnosed and comparable to rates seen in specialist referral centres. Liver stiffness measurement is a feasible community screening tool prior to hepatitis C therapy and can predict liver-related adverse events.

      Graphical abstract

      Keywords

      Linked Article

      • Screening is caring: Community-based non-invasive diagnosis and treatment strategies for hepatitis C to reduce liver disease burden
        Journal of HepatologyVol. 69Issue 3
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          For several chronic liver diseases, effective treatment is available. This includes hereditary hemochromatosis and other inborn errors of metabolism, primary biliary cholangitis and autoimmune hepatitis as well as chronic viral hepatitis. However, many patients are not identified by current strategies for the prevention, screening and diagnosis of liver disease.1,2 Since the implementation of the highly successful therapy with direct acting antivirals (DAA) against the hepatitis C virus (HCV), the eradication of HCV infection as a major public health threat has come into reach.
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