Toggle Main Menu Toggle Search

Open Access padlockePrints

Embedding assessment of liver fibrosis into routine diabetic review in primary care

Lookup NU author(s): Dr Dina Mansour, Professor Quentin AnsteeORCiD, Professor Stuart McPhersonORCiD



This work is licensed under a Creative Commons Attribution 4.0 International License (CC BY 4.0).


© 2021 The Author(s)Background & Aims: Individuals with type 2 diabetes (T2DM) are at high risk of developing non-alcoholic fatty liver disease (NAFLD) and advanced fibrosis/cirrhosis. Screening patients with T2DM and normal liver enzymes for NAFLD in primary care remains contentious. Our aim was to develop and assess a primary care pathway integrating two-tier (Fib-4 then transient elastography [TE]) liver fibrosis assessment, irrespective of aetiology, into routine annual review of all patients with T2DM. Methods: All patients aged >35 years with T2DM attending annual review at 2 primary care practices in North East England between April 2018 and September 2019 (n = 467) had Fib-4 requested via the electronic patient record. Those with a Fib-4 score above the ‘high-sensitivity’ threshold (>1.3 for ≤65 years and >2.0 for >65 years) underwent TE and were reviewed in secondary care if the liver stiffness measurement (LSM) was >8 kPa. The number of patients identified with advanced disease, service uptake, and predictors of advanced disease were assessed. Results: A total of 85/467 (18.5%) patients had raised Fib-4; 27/467(5.8%) were excluded as a result of frailty or known cirrhosis. A total of 58/467 (12.2%) were referred for TE. Twenty-five of 58 (43.1%) had an LSM of >8 kPa and 13/58 (22.4%) had an LSM >15 kPa; 4/58 (6.7%) did not attend and 5/58 (9.3%) had an invalid reading. Twenty of 440 (4.5%) patients were found to have advanced liver disease following specialist review, compared to 3 patients previously identified through standard care (odds ratio [OR] 6.71 [2.0–22.7] p = 0.0022). Alcohol (OR 1.05 [1.02–1.08] p = 0.001) and BMI (OR 1.09 [1.01–1.17] p = 0.021) were predictors of advanced disease, particularly drinking >14/21 units/week (p <0.0001) Conclusions: Incorporating 2-tier assessment of liver fibrosis into routine annual diabetes review in primary care significantly improves identification of advanced liver disease in patients with T2DM. Lay summary: People with type 2 diabetes are at increased risk of developing non-alcoholic fatty liver disease and developing more significant complications. This study looks at introducing screening for advanced liver disease into the annual diabetes reviews performed routinely in primary care; we found that significantly more people were identified as having significant liver disease through this pathway than with current standard care.

Publication metadata

Author(s): Mansour D, Grapes A, Herscovitz M, Cassidy P, Vernazza J, Broad A, Anstee QM, McPherson S

Publication type: Article

Publication status: Published

Journal: JHEP Reports

Year: 2021

Volume: 3

Issue: 4

Online publication date: 22/04/2021

Acceptance date: 13/04/2021

Date deposited: 24/06/2021

ISSN (print): 2589-5559

Publisher: Elsevier B.V.


DOI: 10.1016/j.jhepr.2021.100293


Altmetrics provided by Altmetric