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

Abstract

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 CHC patients and to evaluate predictors of advanced liver disease and liver related events. A prospective cohort of adult CHC patients were recruited from 21 primary care practises throughout Victoria, Australia. Inclusion criteria included the presence of CHC for >6months, no recent (<18months) specialist input and no history of hepatocellular carcinoma. Clinical assessment, LSM and phlebotomy occurred in primary care. A hospital cohort was recruited for comparison. Participants were followed longitudinally and monitored for liver related events. Over 26 months, 780 community patients were recruited and included in the analysis. The median LSM was 6.9kPa in the community, with 16.5% at risk of advanced fibrosis (LSM≥12.5kPa); 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 BMI and ALT 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≥12.5kPa. An LSM of 24 kPa had the highest predictive power for liver related events (HR 152 p<0.001). 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. 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 is 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 able to predict liver related adverse events.