• David J Harman, Stephen D Ryder, Martin W James, Matthew Jelpke, Dominic S Ottey, Emilie A Wilkes, Timothy R Card, Guruprasad P Aithal, and Indra Neil Guha.
• National Institute for Health Research Nottingham Digestive Diseases Biomedical Research Unit (NDDBRU), Nottingham University Hospitals NHS Trust and University of Nottingham, Nottingham, UK.
• BMJ Open. 2015 Jan 1;5(4):e007516.

ObjectivesTo assess the feasibility of a novel diagnostic algorithm targeting patients with risk factors for chronic liver disease in a community setting.DesignProspective cross-sectional study.SettingTwo primary care practices (adult patient population 10,479) in Nottingham, UK.ParticipantsAdult patients (aged 18 years or over) fulfilling one or more selected risk factors for developing chronic liver disease: (1) hazardous alcohol use, (2) type 2 diabetes or (3) persistently elevated alanine aminotransferase (ALT) liver function enzyme with negative serology.InterventionsA serial biomarker algorithm, using a simple blood-based marker (aspartate aminotransferase:ALT ratio for hazardous alcohol users, BARD score for other risk groups) and subsequently liver stiffness measurement using transient elastography (TE).Main Outcome MeasuresDiagnosis of clinically significant liver disease (defined as liver stiffness ≥8 kPa); definitive diagnosis of liver cirrhosis.ResultsWe identified 920 patients with the defined risk factors of whom 504 patients agreed to undergo investigation. A normal blood biomarker was found in 62 patients (12.3%) who required no further investigation. Subsequently, 378 patients agreed to undergo TE, of whom 98 (26.8% of valid scans) had elevated liver stiffness. Importantly, 71/98 (72.4%) patients with elevated liver stiffness had normal liver enzymes and would be missed by traditional investigation algorithms. We identified 11 new patients with definite cirrhosis, representing a 140% increase in the number of diagnosed cases in this population.ConclusionsA non-invasive liver investigation algorithm based in a community setting is feasible to implement. Targeting risk factors using a non-invasive biomarker approach identified a substantial number of patients with previously undetected cirrhosis.Trial Registration NumberThe diagnostic algorithm utilised for this study can be found on clinicaltrials.gov (NCT02037867), and is part of a continuing longitudinal cohort study.Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.

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