Performance of the Enhanced Liver Fibrosis Score,Comparison with Vibration-controlled Transient Elastography Data,and Development of a Simple Algorithm to Predict Significant Liver Fibrosis in a Community-based Liver Service:A Retrospective Evaluation

Background and Aims:Liver fibrosis is a key risk factor for cirrhosis,hepatocellular carcinoma and end stage liver failure.The National Institute for Health and Care Excellence guidelines for assessment for advanced(≥F3)liver fibrosis in people with nonalcoholic fatty liver disease recommend the use of enhanced liver fibrosis(ELF)test,followed by vibration-controlled transient elastography(VCTE).Performance of ELF at predicting significant(≥F2)fibrosis in real-world practice is uncertain.To assess the accuracy of ELF using VCTE;investigate the optimum ELF cutoff value to identify≥F2and≥F3;and develop a simple algorithm,with and without ELF score,for detecting≥F2.Methods:Retrospective evaluation of patients referred to a Community Liver Service for VCTE,Jan-Dec 2020.Assessment included:body mass index(BMI),diabetes status,alanine aminotransferase(ALT)levels,ELF score and biopsy-validated fibrosis stages according to VCTE.Results:Data from 273 patients were available.n=110 patients had diabetes.ELF showed fair performance for≥F2 and≥F3,area under the curve(AUC)=0.70,95%confidence interval(CI)0.64-0.76 and AUC=0.72,95%CI:0.65-0.79 respectively.For≥F2 Youden's index for ELF=9.85 and for≥F3,ELF=9.95.Combining ALT,BMI,and HbA1c(ALBA algorithm)to predict≥F2 showed good performance(AUC=0.80,95%CI:0.69-0.92),adding ALBA to ELF improved performance(AUC=0.82,95%CI:0.77-0.88).Results were independently validated.Conclusions:Optimal ELF cutoff for≥F2 is 9.85 and 9.95 for≥F3.ALT,BMI,and HbA1c(ALBA algorithm)can stratify patients at risk of≥F2.ELFperformance is improved by adding ALBA.

Diabetes is associated with increased risk of hepatocellular carcinoma in non-alcoholic steatohepatitis with cirrhosis-implications for surveillance and future pharmacotherapy

Hepatocellular carcinoma(HCC)is the most common liver-related complication seen in patients with non-alcoholic fatty liver disease(NAFLD)and non-alcoholic steatohepatitis(NASH)(1).NASH is strongly associated with type 2 diabetes mellitus(T2DM)but it has also been apparent for a number of years that T2DM is associated with an increased risk of HCC independent of the presence of NASH(2).A 2006 meta-analysis of retrospective cohort studies and case-control studies demonstrated an association between T2DM and an increased risk of HCC(3).International guidelines advocate surveillance for HCC in patients with NASH who have progressed to cirrhosis(4).An important clinical question is whether T2DM confers an increased risk of HCC once patients with NASH have progressed to cirrhosis.In a recent study by Yang and colleagues(5),the authors reported strong evidence that T2DM is an independent risk factor for HCC in patients with NASH-related cirrhosis.Yang and colleagues performed a retrospective analysis of a prospectively registered research dataset of patients with NASH-related cirrhosis.