[Viva] Fwd: CATIE News - Canadian physicians reveal their choices for assessing liver fibrosis

Wed Jan 29 10:08:01 PST 2014

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From: CATIE <mailer at catie.ca>
Date: Tue, Jan 28, 2014 at 9:54 AM
Subject: CATIE News - Canadian physicians reveal their choices for
assessing liver fibrosis
To: dbecker106 at gmail.com

     CATIE News - Bite-sized HIV and hepatitis C news bulletins
       CATIE News - Canadian physicians reveal their choices for assessing
liver fibrosis

According to researchers, the main causes of persistent liver disease
include:

   - chronic hepatitis B virus (HBV) infection
   - chronic hepatitis C virus (HCV) infection
   - alcoholic liver disease (ALD)
   - non-alcoholic fatty liver disease (NAFLD)
   - autoimmune liver disease

 Regardless of the instigator of chronic liver disease, liver damage
usually proceeds along a common route, causing chronic inflammation, the
death of formerly healthy liver tissue and its replacement by scar tissue.
This process is called fibrosis. If the underlying cause of chronic liver
disease is left untreated, the scarring eventually spreads throughout the
liver and this vital organ becomes increasingly dysfunctional. This can
lead to serious health complications, including in some cases, liver cancer.

Assessing fibrosis is important so that doctors and their patients can keep
abreast of changes to this organ and determine if interventions to improve
the health of the liver are having an effect. In the case of ALD and NAFLD,
such interventions are behavioural, including cutting back on alcohol and
incorporating exercise into daily routines. In the cases of viral
infections--HBV and HCV--interventions include treatment with antiviral
medicines.
 Fibrosis assessment

Historically, the most highly regarded way of assessing liver fibrosis has
been a liver biopsy--a procedure that involves removing a tiny piece of the
liver for laboratory analysis. This procedure can be done relatively
quickly. However, liver biopsies can have drawbacks:

   - They are invasive.
   - They can be painful and costly, particularly if complications occur.
   - As the biopsy involves removing only a tiny piece of the liver, damage
   in other parts of this organ can potentially be missed.

 Blood tests

There are several non-invasive means of assessing the degree of fibrosis in
the liver, which are largely dependent on blood tests. These include:

   - Fibrotest - this involves measuring levels of several proteins in the
   blood--the liver enzyme GGT, the amount of the waste product bilirubin,
   alpha-2-macroglobulin, apolipoprotein A1 and haptoglobin. In addition to
   these levels, a person's age and gender are taken into account.
   - APRI - this method involves dividing a person's level of the liver
   enzyme AST by the number of platelets (used for clotting) in their blood.

 Tests that evaluate the physical state of the liver, or stiffness of the
liver, can also assess injury. These include:

   - Fibroscan - a specialized form of ultrasound (also called transient
   elastography)
   - Magnetic resonance elastography - similar to an MRI (magnetic
   resonance imaging) scan of the liver.

 No liver assessment technique or technology is perfect; each one has
advantages and disadvantages. However, care and treatment guidelines across
high-income regions in North America and Western Europe increasingly call
for the use of non-invasive means for assessing liver health. As a result,
researchers at McGill University and the University of Calgary were
interested in determining how non-invasive technologies were being used to
assess damage to the liver. The researchers developed an internet-based
survey, which was disseminated with the help of scientific societies such
as the Canadian Association of Gastroenterologists (CAG) and the CIHR
Canadian HIV Trials Network (CTN). The survey asked doctors who cared for
patients with chronic liver disease detailed questions about what they used
to assess liver injury in patients.

The researchers found that the use of liver biopsy was still relatively
common--nearly 46% of participants reported using it. However, researchers
stated that "non-invasive methods, particularly Fibroscan, have
significantly reduced the need for liver biopsy in Canada." Further
findings from the survey appear later in this *CATIE News* bulletin.
 Results--Focus on who responded

A total of 237 doctors were invited to participate in the survey. Of those,
104 doctors (44%) chose to do so. The responding doctors had the following
organizational affiliations:

   - CAG members - 80%
   - CTN members - 20%

 Respondents consisted of 80% men and 20% women.

Other features of the responding doctors were as follows:

Speciality

   - Gastroenterology - 64%
   - Hepatology (liver specialty) - 16%
   - Infectious diseases - 10%
   - Other specialties (family medicine, internal medicine) - 10%

 Clinic location

   - University-based hospital - 51%
   - Community hospital or clinic - 28%
   - Private practice - 21%

 Distribution of respondents by province:

   - Ontario - 40%
   - Quebec - 37%
   - British Columbia - 10%
   - Alberta - 7%
   - Rest of Canada - 7%

 Types of chronic liver disease treated by the surveyed doctors:

   - NAFLD - 84%
   - Autoimmune liver disease - 81%
   - ALD - 80%
   - HCV infection - 79%
   - HBV infection - 67%
   - HIV and HCV and/or HBV co-infection - 32%

 The proportion of physicians who routinely assessed the liver fibrosis of
patients by condition was as follows:

   - HCV - 77%
   - Autoimmune liver disease - 60%
   - HBV - 53%
   - NAFLD - 44%
   - ALD - 40%
   - HIV co-infection - 32%

 Choice of tools

The tool most commonly used to assess liver fibrosis was liver biopsy, used
by 46% of physicians. This was followed by Fibroscan, used by 39% and
Fibrotest, used by 8% of doctors.

The researchers found that overall, the use of non-invasive methods of
assessing liver injury reduced the need for liver biopsy by 43%.

Older physicians, hepatologists and infectious disease specialists were
more likely to use non-invasive methods than younger doctors. Also,
physicians who worked out of a university-based hospital or private
practice were more likely to use non-invasive methods.
 Physician satisfaction

The survey asked doctors whether non-invasive methods provided an "accurate
assessment" of liver fibrosis. Most doctors (83%) agreed that they did
while 9% disagreed and 9% neither agreed nor disagreed. Overall, doctors
rated Fibroscan as the "best non-invasive method for [assessing the degree
of liver fibrosis]."
 Barriers

Nearly 60% of survey respondents did not have a Fibroscan in their clinics.
Furthermore, 61% of these doctors disclosed that they did not have
"convenient access" to a Fibroscan elsewhere. All doctors who disclosed
that they did not have a Fibroscan or convenient access to one stated that
should their clinic acquire a Fibroscan or should they otherwise acquire
convenient access to one, they would increase their use of it for
non-invasive assessment of the liver.

Some doctors surveyed also underscored the need for the development of
guidelines to help them use and interpret Fibroscan results.

A U.S. study has found that the cost of a liver biopsy is about $US 1,000
and rises to nearly $US 3,000 when complications occur.

In Canada, according to the researchers, "the [average] cost of a
complicated liver biopsy requiring hospitalization [approaches $US 4,000]."

The cost of Fibroscan was a major concern for nearly 15% of doctors
surveyed. Fibroscan was developed in France and approved in 2007 for use in
that country, where the cost of Fibroscan machines and tests are paid for
by the state. Fibroscans have subsequently become widely used throughout
Western Europe. Not surprisingly, since that time, the use of liver biopsy
as the initial means of assessing liver fibrosis has declined dramatically
according to a survey of physicians in France. Fibroscan is approved for
use in Canada, but so far, only in Quebec does the healthcare system
subsidize its use.

The Canadian survey is useful because it shows that non-invasive means of
assessing liver fibrosis are increasingly used and would be used by more
doctors should access to Fibroscan become available in their province.

 *--Sean R. Hosein*

*Resource*

hepcinfo.ca <http://www.hepcinfo.ca/> - CATIE's hepatitis C website

REFERENCES:

   1. Sebastiani G, Ghali P, Wong P, et al. Physicians' practices for
   diagnosing liver fibrosis in chronic liver diseases: A nationwide, Canadian
   survey. *Canadian Journal of Gastroenterology*. 2014 Jan;28(1):23-30.
   2. Castera L, Denis J, Babany G, et al. Evolving practices of
   non-invasive markers of liver fibrosis in patients with chronic hepatitis C
   in France: time for new guidelines? *Journal of Hepatology*. 2007
   Mar;46(3):528-9.

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