TWO-TIERED LIVER FIBROSIS ASSESSMENT IN PRIMARY CARE ANNUAL DIABETIC SCREENING - 3 YEAR FOLLOW UP

ABSTRACT

Introduction We previously presented the outcome of a pathway incorporating 2-tiered fibrosis assessment into annual diabetic reviews in primary care. This 3 year follow up study looks at 1. Outcomes in patients referred into secondary care with moderate-advanced fibrosis Ongoing service delivery requirements after the first year of case finding Effectiveness of the pathway in detecting patients with advanced disease, by looking at the number of patients missed in the pathway presenting with advanced disease. Methods All patients aged >35 years with Type 2 Diabetes Mellitus (T2DM) attending annual review at two primary care practices in North East England between April 2018 and September 2019 (n=467) had a Fib-4 requested, followed by transient elastography (TE) if the Fib-4 was above the high sensitivity threshold. Those with a liver stiffness measurement (LSM) >8kPa were reviewed in secondary care. This pathway was continued in both practices after the end of the initial study period. We reviewed the outcomes of all patients referred to secondary care;the number of patients referred in the subsequent years with ongoing case-finding;and any patients missed from initial screening presenting with decompensated/ symptomatic disease. Results From the 467 patients in the initial study, 58 were referred for TE, 25 had a LSM>8kPa and 20 had advanced disease (on imaging/biopsy/endoscopy). 6/20 (30%) patients with advanced disease have died- 2/20 liver related deaths (hepatocellular carcinoma (HCC) and decompensated cirrhosis);1 patient diagnosed with HCC was treated with curative transarterial chemoembolisation;3 patients had varices on OGD (2 started on carvedilol for primary prophylaxis);12 remain under follow up. In all patients with LSM >8kPa (n=25) 8/25 (32%) died (3/8 from COVID-19);24% (6) LSM improved, 8% (2) LSM deteriorated;32% (8/25) lost weight. No patients missed by the pathway presented with decompensated disease. Serial FIB- 4 at annual screening 2019-2021 4 patients new raised Fib-4 scores - 1 DNA, 1 TE is awaited, 1 LSM <8kPa (discharged), 1 advanced disease (LSM 17.1kPa). Conclusion Incorporation of a two-tiered liver fibrosis assessment into primary care annual diabetic screening significantly improves identification of advanced liver disease and no patients have presented with advanced disease out-with the pathway. It allows for early detection and interventions against the complications associated with advanced liver disease. Mortality in patients with advanced liver disease remains high. Referrals for TE and into secondary care dramatically reduce after the initial year of case finding.