The Enhanced Liver Fibrosis (ELF) score predicts hepatic decompensation and mortality

Background & Aims In community pathways for detection of liver disease the most common reason for referral is fibrosis assessment. We investigated the impact of adding the Enhanced Liver Fibrosis (ELF) score as a second-line test (after indeterminate or high fibrosis-4 index (FIB-4) and/or non-alcoholic fatty liver disease fibrosis score) to guide referral and prognostication in our multi-aetiology pathway. Methods Patients with ELF results from the intelligent Liver Function Testing (iLFT) pathway were recruited. Case note review was undertaken to compare ELF with end points of cirrhosis, hepatic decompensation, and mortality (liver-related and all-cause). Results 1,327 individuals were included with median follow-up 859 days and median ELF score 10.2. Overall sensitivity for cirrhosis at the 9.8 threshold was 94% (100% for metabolic-associated steatotic liver disease, 89% for alcohol-related liver disease). Use of ELF as a second-line test reduced referral by 34%. ELF predicted hepatic outcomes; each unit change was associated with increased decompensation (adjusted Hazard Ratio (aHR) 2.215, 95% CI 1.934 – 2.537) and liver-related mortality (aHR 2.024, 95% CI 1.674 - 2.446). ELF outperformed FIB-4 for risk of liver-related mortality, particularly in the short-term (area under the curve (AUC) 94.3% vs 82.8% at six months). Where FIB-4 was indeterminate, ELF had higher AUC for all outcomes within at least two years. ELF ≥13 is associated with particularly high rates of decompensation (26% within 90 days) and all-cause mortality (38% at one year). Conclusions The addition of ELF has safely reduced the number of individuals referred for fibrosis assessment from the iLFT pathway and provides useful prognostic information. Individuals with ELF ≥13 are at high risk of negative outcomes and warrant urgent clinic assessment. Impact and implications Primary care pathways for suspected liver disease are increasingly common and often lead to increased specialist hepatology referrals for fibrosis assessment. This study – using clinical follow-up for liver-related outcomes – adds to the evidence that ELF can safely reduce referrals in a two-step approach with other simple fibrosis markers. Additionally, ELF predicts liver-related morbidity and mortality, with ELF ≥13 an indicator of particularly high risk. This study may help inform the implementation of diagnostic pathways for early detection of liver disease and indicates the need for urgent review of individuals with very high ELF scores.