Redefining risk of liver disease in the general population: analysis of the Health Survey for England 2016

Abstract

Background and aims: the health, financial and societal arguments for public health action to prevent lifestyle related liver disease are clear. Primary care has frequently been suggested as a key location for prevention strategies. Evidence on the most appropriate cut-offs for liver biochemistry and indirect fibrosis markers, which may be used for screening before more definitive assessment, has predominantly been gathered in patients with existing liver disease. These thresholds may not be suitable in community settings. For the first time liver function tests, from a sample representative of the general population in England, are available. We explored the distribution of risk factors for liver disease, liver function test results and liver fibrosis scores in the Health Survey for England (HSE) 2016.
Method: cross-sectional survey with interview, examination and blood tests. Multi-stage, stratified, random probability sample designed to be representative of the population living in private households in England. Participants: 7,826 adults aged 18 years and over, of whom 3,791 had a blood test. Exposures and markers: Risk factors were alcohol consumption >14 units/wk, body mass index ≥25 and diabetes. Liver function tests were Alanine aminotransferase (ALT) and Aspartate Aminotransferase (AST). Liver fibrosis scores calculated were FIB-4 score (high>2.67), APRI score (high≥1.0), AST:ALT ratio (high>0.8), BARD score (high≥2).Results: 85.5% (84.4 to 86.7%,n=5670) of the population representative sample have at least one risk factor for liver disease. 25.9% (24.4 to 27.5%,n=4685) have two or more risk factors. 2.5% (2.0 to 3.1%,n=3388) had a high FIB-4; 11.5% (10.3 to 12.8%,n=3607) had a raised ALT; 86.0% (84.5 to 87.3%,n=3424) had a high AST:ALT ratio. Only 5.1% (4.3 to 6.0%,n=4031) of those with at least one risk factor and 7.9% (6.1 to 10.1%,n=3749) of those with two or more risk factors had been told by a health professional that they were at risk of liver disease. 12.9% (11.8 to 14.1%, n=4722) of the sample and 17.7% (10.9 to 27.3%, n=85) of those with a high FIB-4 score report ever being tested for liver disease.
Conclusion: this is the first analysis of liver biochemistry and indirect fibrosis markers in a sample representative of the general population of England. Modifiable lifestyle risk factors for liver disease are present in more than 85% of participants. Multiple risk factors are common and may be synergistic. Commonly used liver function tests and fibrosis scores showed large variation in positivity. Awareness of risk and testing for liver disease was low, even in those with multiple risk factors. The best approach to achieve detection of liver disease in primary care remains unclear.

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Identifiers

ORCID for Julie Parkes: orcid.org/0000-0002-6490-395X

ORCID for Paul Roderick: orcid.org/0000-0001-9475-6850

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