Reduced and more appropriate referrals of patients with type 2 diabetes using liver stiffness measurement compared to FIB-4

Background 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. Aims We initiated a screening programme at the diabetes out-patient clinic to assess the reliability of the suggested approaches and resulting referrals. Methods 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. Results 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. Conclusions 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.