The Lancet Commissions: Screening at risk liver patients

Back in December a conversation in the comments between myself and Lori happened after this post.  I said that I would write a post where I go into greater detail about liver blood tests for her and share it here for anyone else who is interested.  These recommendations detailed below are taken from The Lancet Commission that was discussed in this post and focuses predominantly on primary care screening for at risk liver patients.

Panel 11: Recommendations for engagement of primary care

1 Liver disease should be positioned in primary care within the so-called Big Five chronic, preventable lifestyle-related diseases that share common lifestyle risk factors with cardiovascular disease, diabetes, chronic lung disease, and renal disease to maximise the effects from generic lifestyle interventions and to coordinate chronic disease management with the introduction of an appropriate funding mechanism.  The shared lifestyle risk factors provide an opportunity to expand the breadth of existing disease monitoring, but without a substantial increase in workload (eg, annual cardiovascular, renal, or diabetic checks that already commonly include liver blood tests)

2 Liver function tests should include measurement of the aspartate aminotransferase (AST) value to allow the calculation of the AST to alanine aminotransferase (ALT) ratio in all samples with an increased ALT and in the proposed diagnostic pathway, with serum γ-glutamyl transpeptidase concentrations and incorporation of liver elastography as a confirmatory test for hepatic fibrosis would distinguish between patients who are most likely to develop progressive liver disease from those who are not, thereby establishing appropriate referral for secondary care.

Key to our proposed diagnostic pathway is the routine inclusion of AST and GGT into the standard panel of tests for liver function when liver disease is clinically suspected. The AST value will enable calculation of the AST/ALT ratio (panel 9), and a score in the non-invasive
algorithm APRI and others in patients with non-alcoholic fatty liver disease. GGT concentration is a marker for alcohol intake and had the highest predictive value in terms of subsequent liver disease and mortality in a large community study. Abnormalities in this enzyme can also be used to motivate positive changes in behavioural in people who drink to excess because GGT concentrations rapidly decrease with abstinence from alcohol

Furthermore, the addition of liver elastography to the screening process is very cheap. When a practice nurse uses a portable machine, the cost of elastography is about £20 per scan, less than a tenth of the cost for outpatient referral to a specialist and targeted programmes of screening in the community have been successful (panels 9 and 10).

Use of liver elastography in the diagnostic pathway

Transient liver elastography is the gold standard in the assessment for liver fibrosis. Transient liver elastography directly measures liver stiffness by use of a fibroscan or a modified ultrasound machine and is predictive of liver-related events and death. In a meta-analysis of 7000 patients in more than 50 studies shows the area under the curve analyses (AUROC) for cirrhosis (0·94),severe fibrosis (0·89), or early fibrosis (0·84).

At present, most GPs do not have access to the machines to do liver elastography. However, most new ultrasound machines can be adapted to do liver elastography. This form of assessment should, in our opinion, be included as part of the standard operating procedure for all liver examinations by use of ultrasound requested from primary care. Additional time to include liver elastography per examination is low at possibly 5 min, and extra training needed for the workforce will be small. Furthermore, rapid access assessments by nurses for liver elastography could be organised in the same way that rapid access endoscopy is made available to GPs. Elastography will need to be promoted to the radiological and ultrasound community by the Royal College of Radiologists and British Medical Ultrasound Society. Additionally, portable elastography could be used in the community as reported in the Southampton and Nottingham studies (panel 10). This approach formed part of the very successful Love your Liver workshops organised around the UK by the British Liver Trust successfully raised awareness.

At present the capacity to substantially expand the engagement of GPs in such programmes is restricted, and funding issues will need to be addressed. The Quality and Outcomes Framework (an annual reward and incentive programme detailing GP practice achievement introduced in 2004) is being scaled back rather than expanded and the introduction of a new clinical domain is deemed unlikely. Additionally, valuable lifestyle advice indicators were removed in the governments’ budget of April, 2014, including the targets of giving people with hypertension advice about smoking cessation, safe quantities of alcohol consumption, and a healthy diet.

Development of clear protocols and schedules for investigation, clarification of referral criteria, and additional training programmes will improve the confidence of primary care workers in the management of liver disease. Identification of liver disease in patients at high risk in communities at an early stage will enable effective behavioural interventions
and treatments and will prevent the inexorable progression of liver disease in many cases. Furthermore, by using simple algorithms of existing blood tests to exclude severe liver disease in non-alcoholic fatty liver disease and using portable elastography services led by
nurses to identify severe liver disease in primary care, expensive referrals to specialist secondary care clinics can be used more efficiently (panel 11).

You can read the full report here where the panels mentioned and references are detailed in full:

Lancet commissions addressing liver disease in the uk 2014

These recommendations are very straight forward, do not involve a huge amount of additional cost or work, apart from staff training costs which I’m sure could be off-set if liver screening was included into QOF funding clinical domain schedules.  Alas what is actually happening in primary care is the opposite – these are being reduced not increased and alcohol IBA funding is also being removed so there is no financial incentive for GP’s to be engaging in alcohol induced liver health issues.

So to summarise (in non-medical speak!) you need to make sure that your blood test includes AST levels, and ideally GGT levels.  In the UK LFT’s (liver function tests) usually routinely include ALT levels, alkaline phosphatase, bilirubin, total protein and albumin levels.  Also when the blood results are received by the surgery ask for a copy of them!  These are your health records and you are quite within your rights to have a copy of your own blood test results.

And if I could go down to my GP surgery and ask for anything to reassure me about my liver health it would be a liver fibroscan.  I’ll be looking out for the next British Liver Trust ‘Love Your Liver’ UK roadshow and will be stalking them to get this non-invasive diagnostic test done as the likelihood of this being available at my GP surgery anytime soon has two hopes, Bob Hope and no hope ……..



9 thoughts on “The Lancet Commissions: Screening at risk liver patients

  1. Really interesting Lucy! Thank you the screening test on love your liver is a good one too.

    I’ll be looking out for those roadshows, given how little screening costs, its crazy you can’t get one easily.

    A piece on Radio Scotland yesterday highlighted a new report out about Edinburgh’s drinking and the cost to employers of £85 million annually. Its about to be published but it created quite a discussion on the radio yesterday. Can’t find any links to it sorry.

      1. Yup that’s it funny I couldn’t find it! 🙂 And looking forward to future posts, as always!

      2. Fab lovely – I’ve expanded it into a full post next month as there was some good stuff in that news piece so thank you!! 🙂 xx

  2. Thanks for this Lucy. When I decided I had to stop drinking in May 2014 I told my GP who straightaway ordered blood tests. I drank in a similar fashion to lots of people – too much on the weekends and not at all during the week because of work, although this had been happening for many many years. The liver functioning tests came back abnormal, now I’ve had 3 blood tests, some scores improved, some haven’t, an ultrasound where liver looked ok and she’s just referred me for a CT scan. Hopefully things will be ok but I would encourage anyone to talk to their GP and have the blood tests just in case.

    1. Good for you Manda! 🙂 Hope the CT scan goes okay and your liver blood test results improve with time.

  3. Thanks for the follow-up 🙂 I have to admit, I’m not always good about asking for copies of my results, but I know my cholesterol, triglycerides and liver enzymes are much better since I’ve stopped–imagine that! Of course I wasn’t honest with my GP about my drinking habits in the past, but now I realize how important it is. Bob Hope and no hope…sad but true. xx

    1. You’re welcome Lori! Happy to hear your bloods have improved too 🙂 xx

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