A192 CHARACTERISTICS AND OUTCOMES OF PATIENTS REFERRED TO THE HEPATOLOGY TRIAGE CLINIC: A QUALITY IMPROVEMENT INITIATIVE TO ASSESS AND OPTIMIZE SCREENING PROTOCOLS AND RESOURCE ALLOCATION STRATEGIES FOR MANAGEMENT OF PATIENTS WITH NON-ALCOHOLIC FATTY LIVER DISEASE

Abstract

Background

Non-alcoholic fatty liver disease (NAFLD) is the most common liver disease in adults. Remarkably, its natural history and course is highly variable and poorly understood. It is anticipated that the number of referrals for assessment and management of suspected NAFLD will overwhelm the current installed capacity of the health care system. Therefore, strategies for screening and management of these patients are in demand.

Aims

To describe a cohort of subjects referred to the Hepatology Triage Clinic (HepTriC) for assessment of abnormal liver function tests and the outcomes of a pilot program for initial screening and management of these patients.

Methods

Descriptive cross-sectional examination and description of relevant clinical outcomes + cohort assembly. Criteria for referrals to the HepTriC include: Age 16 to 50 y, abnormal ALT (>50 IU/mL), no history of existing chronic liver disease other than NAFLD, no evidence of cirrhosis or acute liver ilnes.

Referred patients underwent an Initial assessment that included extended labwork and a transient elastography (Fibroscan) plus controlled attenuation parameter (CAP) performed by a registered nurse. Depending on the results of this assessment, patients were booked for further evaluation by an hepatologist +/- liver biopsy or to be followed in 1 or 2 years (Fig 1a).

Results

From Nov-16 to Jun-17, 156 referrals were seen at the HepTriC (mean waiting time= 21d). Cohort baseline characteristics included: 74% Male, 42 ± 10 yrs., BMI 31 ± 6 m/Kg², diabetes 20.5%, dyslipidemia 30.7%, hypertension 29.5%, AST 40 ± 22 IU/L, ALT 66 ± 34 IU/L, Bilirubin 13 ± 7mM Albumin 44 ± 2 g/L, FIB₄ 0.99 ± 0.79, APRI 0.46 ± 0.11, NFS -2.3 ± 1.23.

Transient elastography assessment was accomplished in 150 (96%) subjects 43% of those required the XL probe. Mean stiffness 7.1 ± 4.5 kPa, (range 3.2 to 36.3 kPa). Mean CAP 318 ± 48 dB/m (range 204 to 400 dB/m). Significant Alcohol use was documented in 28 (18%) patients, from those, 9 (32%) had advance liver fibrosis. NAFLD transient elastography results). Liver stiffness assessed by internal acoustic radiation force (ARFI) was available in 23 patients. The correlation between Fibroscan and ARFI was very poor 5.9%, p=0.8.

In total 14 Liver biopsies were performed in patient in whom there was diagnostic uncertainty. Fibroscan but not CAP results have a proportional correlation with the pathology fibrosis scoring. (Fig1b)

Conclusions

NAFLD is the most common cause of otherwise unexplained abnormal LFTs. However, alcohol intake and uncommon metabolic conditions need to be explore in this population. Fibroscan seems to have strong correlation with liver pathology results. Fibroscan and ARFI elastography have very poor correlation.

Funding Agencies

Public Health Agency or Canada (PHAC), Digestive Health Strategic Clinical Network (DH-SCN)