The Scarred Liver Project : the Community Stratification of Chronic Liver Disease using Fibrosis Biomarkers
Deaths due to liver disease continue to rise in the United Kingdom, with liver disease is now the 3rd leading cause of premature death. There are two main reasons for this. Firstly, a rise in lifestyle-related risk factors for liver disease in the general population, in particular alcohol consumption, obesity due to poor diet and exercise, and related type 2 diabetes. Secondly, the standard liver blood tests performed both in the community and in hospitals (liver function tests) are very poor at detecting any liver scarring (liver fibrosis), or even advanced liver scarring (liver cirrhosis). As a result, we still do not detect half of liver cirrhosis cases in the UK until patients present to hospital with symptoms and signs of liver failure.
More recently, new tests have become available which more accurately detect live scarring before patients have symptoms. One such test is Transient Elastography (Fibroscan; Echosens, France) which is an imaging test based upon ultrasound which measures liver stiffness. Transient Elastography is now commonly used in clinical practice in the hospital setting, however few studies have assessed its use in a community setting to detect previously undiscovered cases of liver scarring and cirrhosis.
In the Nottingham Community Study, we are working with several local General Practices, to assess the feasibility of using a risk focussed approach. Moreover, we are testing whether better diagnostic tests for liver scarring can be implemented within a community setting. We anticipate that this novel approach will detect more cases of significant liver disease and importantly, at a stage where the scarring can reverse. Participants are invited to have tests performed in their local GP practice, if they have risk factors for liver disease risk including hazardous alcohol, obesity and type 2 diabetes.. Participants are given lifestyle advice following the scan, irrespective of the result, and patients with a scan above a liver stiffness threshold of 8 kilopascals are invited to a community-based clinic appointment with a Consultant Hepatologist. All participants are also asked to donate a blood sample, and provide consent to allow long term follow up of future hospitalisations and relevant health episodes.
To date, we have completed two initial pilot studies in Rushcliffe, Nottingham (2012-2013) and Inner City Nottingham (2013-2014). In total, more than 1,000 adults with a liver disease risk factor have been screened for liver disease, from a total adult practice population of 20,000. Over 200 new cases of clinically significant liver scarring have been detected, with a more than 2-fold increase in liver cirrhosis diagnosis in the studied populations. The study was awarded the NHS Innovations Challenge prize for Improving Diagnostic Innovation in 2013. We are now collaborating with the East Midlands Academic Health Sciences Network to implement the pathway at different sites in the region. The Leicester phase began in April 2015.