Shanahan William, Bagwe Isha, Brassill Mary Jane, O'Regan Paud
Department of Gastroenterology, Tipperary University Hospital, Clonmel, Co Tipperary, Ireland.
Department of Endocrinology, Tipperary University Hospital, Clonmel, Co Tipperary, Ireland.
Ir J Med Sci. 2023 Apr;192(2):649-654. doi: 10.1007/s11845-022-03019-5. Epub 2022 Apr 29.
Fatty liver disease and fibrosis are common in patients with type 2 diabetes mellitus (T2DM). Recently published European Association for the Study of the Liver guidelines have suggested screening such patients using liver stiffness measurement (LSM) or fibrosis-4 index (FIB-4) to exclude advanced fibrosis.
We initiated a screening programme at the diabetes out-patient clinic to assess the reliability of the suggested approaches and resulting referrals.
In this prospective study, consecutive patients attending for T2DM review at an Irish level 3 (district general) hospital between September and November 2021 were screened for liver fibrosis using LSM and had their FIB-4 calculated. The first 100 patients with valid LSM measurements were included in the analysis.
Referral rates to the hepatology clinic varied by modality used. If FIB-4 ≥ 1.3 criterion was used, the referral rate to the hepatology clinic was 45%; using LSM < 8 kPa to rule out advanced fibrosis resulted in 34% referral rate; using LSM ≥ 10 kPa to suggest probable compensated advanced chronic liver disease reduced referral rates to 15%. Combining FIB-4 with LSM in a two-step algorithm led to missed potentially significant liver disease in large numbers. 47% patients with LSM ≥ 8 kPa and 33% with LSM ≥ 10 kPa had FIB-4 < 1.3.
Screening of patients with T2DM using LSM alone rather than FIB-4 leads to reduced numbers of, and more appropriate, referrals to the hepatology clinic. Shifting from an exclusion (LSM < 8 kPa) to an inclusion based (LSM ≥ 10 kPa) approach may lessen the potential of screening to overwhelm hepatology services.
脂肪肝疾病和肝纤维化在2型糖尿病（T2DM）患者中很常见。最近发布的欧洲肝脏研究协会指南建议对这类患者进行肝硬度测量（LSM）或纤维化-4指数（FIB-4）筛查，以排除晚期纤维化。
我们在糖尿病门诊启动了一项筛查计划，以评估所建议方法及后续转诊的可靠性。
在这项前瞻性研究中，于2021年9月至11月期间在爱尔兰一家三级（地区综合）医院就诊进行T2DM复查的连续患者，使用LSM进行肝纤维化筛查并计算其FIB-4。分析纳入了前100例有有效LSM测量值的患者。
转诊至肝病门诊的比例因使用的筛查方式而异。若采用FIB-4≥1.3的标准，转诊至肝病门诊的比例为45%；使用LSM<8 kPa来排除晚期纤维化，转诊率为34%；使用LSM≥10 kPa提示可能为代偿性晚期慢性肝病，转诊率降至15%。在两步算法中结合使用FIB-4和LSM会导致大量潜在的严重肝病被漏诊。47%的LSM≥8 kPa患者和33%的LSM≥10 kPa患者FIB-4<1.3。
仅使用LSM而非FIB-4对T2DM患者进行筛查，可减少转诊至肝病门诊的人数，并使转诊更合理。从排除性（LSM<8 kPa）方法转变为纳入性（LSM≥10 kPa）方法，可能会降低筛查给肝病服务带来的压力。
