Birmingham and Lambeth Liver Evaluation Testing Strategies (BALLETS): a prospective cohort study
Objective: To evaluate mildly abnormal liver function test (LFT) results in general practice among patients who do not have known liver disease. Design: Prospective cohort study of people with abnormal LFT results identified in primary care. Participants were intensively investigated using a common...
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| Format: | Article |
| Language: | English |
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NIHR Journals Library
2013-07-01
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| Series: | Health Technology Assessment |
| Subjects: | |
| Online Access: | https://doi.org/10.3310/hta17280 |
| _version_ | 1818478290019549184 |
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| author | RJ Lilford L Bentham A Girling I Litchfield R Lancashire D Armstrong R Jones T Marteau J Neuberger P Gill R Cramb S Olliff D Arnold K Khan MJ Armstrong DD Houlihan PN Newsome PJ Chilton K Moons D Altman |
| author_facet | RJ Lilford L Bentham A Girling I Litchfield R Lancashire D Armstrong R Jones T Marteau J Neuberger P Gill R Cramb S Olliff D Arnold K Khan MJ Armstrong DD Houlihan PN Newsome PJ Chilton K Moons D Altman |
| author_sort | RJ Lilford |
| collection | DOAJ |
| description | Objective: To evaluate mildly abnormal liver function test (LFT) results in general practice among patients who do not have known liver disease. Design: Prospective cohort study of people with abnormal LFT results identified in primary care. Participants were intensively investigated using a common protocol and followed up for 2 years. Substudies investigated the psychological sequelae of abnormal test results, clinicians' reasons for testing, decision options when LFT results were abnormal and early detection of liver fibrosis. Setting: Eleven primary-care practices: eight in Birmingham and three in Lambeth. Participants: Adults with abnormal LFT results who did not have pre-existing or obvious liver disease. Eight analytes were included in the panel of LFTs. Main outcome measures: Statistical tests were used to identify the interactions between clinical features, the initial pattern of abnormal LFT results and (1) specific viral, genetic and autoimmune diseases, such as viral hepatitis, haemochromatosis and primary biliary cirrhosis; (2) a range of other serious diseases, such as metastatic cancer and hypothyroidism; (3) ‘fatty liver’ not associated with the above; and (4) the absence of detectable disease. Results: Fewer than 5% of people with abnormal LFT results had a specific disease of the liver, and many of these were unlikely to need treatment. The diagnostic potential of the LFT panel is largely subsumed into just two analytes: alanine aminotransferase (ALT) and alkaline phosphatase (ALP). Gamma-glutamyltransferase (GGT) offers a small increase in sensitivity at the margin at the cost of a large loss of specificity. Eighty-four per cent of abnormal LFT results remain abnormal on retesting 1 month later. In many cases, carrying out a definitive or specific test will be more efficient than repeating LFTs, with a view to specific testing only if the test remains abnormal. An ultrasound diagnosis of ‘fatty liver’ was present in nearly 40% of patients with abnormal LFTs and a small amount of weight loss over 2 years was associated with a reduced incidence of liver fat. There was a J-shaped relationship between alcohol intake and fatty liver in men. An abnormal LFT result causes temporary anxiety, which does not appear to promote sustained behaviour change. Conclusions: Liver disease is rare among people with abnormal LFT results in primary care. Only two analytes (ALT and ALP) are helpful in identifying the majority of liver disease. GGT adds little information in return for a high false-positive rate but it is sensitive to alcohol intake. LFT results seldom revert from abnormal to normal over a 1-month period, and modelling shows that repeating an abnormal LFT panel, as recommended in the current guidelines, is inefficient. LFTs are often undertaken to meet perceived patient need for a blood test, but as they are neither specific nor indicative of any particular disease they are among the least suitable tests for this purpose. Obesity and raised ALT provide strong evidence for a presumptive diagnosis of ‘fatty’ liver. Abnormal LFTs and ‘fatty’ liver provoke only short-term anxiety and neither is associated with sustained weight loss. Even a small amount of weight loss reduces liver fat. Future work recommendations: (1) the cases of ‘fatty liver’ and controls should be followed up in the long term to identify features that predict development of hepatosteatosis and then cirrhosis; (2) the acceptability of replacing the traditional six- to eight-analyte LFT panel with a drop down menu including the ALT/ALP combination should be evaluated. Funding: The National Institute for Health Research Health Technology Assessment programme. |
| first_indexed | 2024-12-10T09:46:09Z |
| format | Article |
| id | doaj.art-5efd4c0b369345159f616aa3acc70408 |
| institution | Directory Open Access Journal |
| issn | 1366-5278 2046-4924 |
| language | English |
| last_indexed | 2024-12-10T09:46:09Z |
| publishDate | 2013-07-01 |
| publisher | NIHR Journals Library |
| record_format | Article |
| series | Health Technology Assessment |
| spelling | doaj.art-5efd4c0b369345159f616aa3acc704082022-12-22T01:53:50ZengNIHR Journals LibraryHealth Technology Assessment1366-52782046-49242013-07-01172810.3310/hta1728003/38/01Birmingham and Lambeth Liver Evaluation Testing Strategies (BALLETS): a prospective cohort studyRJ Lilford0L Bentham1A Girling2I Litchfield3R Lancashire4D Armstrong5R Jones6T Marteau7J Neuberger8P Gill9R Cramb10S Olliff11D Arnold12K Khan13MJ Armstrong14DD Houlihan15PN Newsome16PJ Chilton17K Moons18D Altman19School of Health and Population Sciences, University of Birmingham, Edgbaston, UKSchool of Health and Population Sciences, University of Birmingham, Edgbaston, UKSchool of Health and Population Sciences, University of Birmingham, Edgbaston, UKSchool of Health and Population Sciences, University of Birmingham, Edgbaston, UKSchool of Health and Population Sciences, University of Birmingham, Edgbaston, UKDepartment of Primary Care and Public Health Sciences, Kings College London, London, UKDepartment of Primary Care and Public Health Sciences, Kings College London, London, UKHealth Psychology Section, Kings College London, London, UKSchool of Health and Population Sciences, University of Birmingham, Edgbaston, UKSchool of Health and Population Sciences, University of Birmingham, Edgbaston, UKQueen Elizabeth Hospital Birmingham, Birmingham, UKQueen Elizabeth Hospital Birmingham, Birmingham, UKSchool of Medicine, Cardiff University, Cardiff, UKQueen Elizabeth Hospital Birmingham, Birmingham, UKNational Institute for Health Research Biomedical Research Unit, Birmingham, UKNational Institute for Health Research Biomedical Research Unit, Birmingham, UKNational Institute for Health Research Biomedical Research Unit, Birmingham, UKSchool of Health and Population Sciences, University of Birmingham, Edgbaston, UKUniversitair Medisch Centrum Utrecht, Utrecht, the NetherlandsCentre for Statistics in Medicine, University of Oxford, Oxford, UKObjective: To evaluate mildly abnormal liver function test (LFT) results in general practice among patients who do not have known liver disease. Design: Prospective cohort study of people with abnormal LFT results identified in primary care. Participants were intensively investigated using a common protocol and followed up for 2 years. Substudies investigated the psychological sequelae of abnormal test results, clinicians' reasons for testing, decision options when LFT results were abnormal and early detection of liver fibrosis. Setting: Eleven primary-care practices: eight in Birmingham and three in Lambeth. Participants: Adults with abnormal LFT results who did not have pre-existing or obvious liver disease. Eight analytes were included in the panel of LFTs. Main outcome measures: Statistical tests were used to identify the interactions between clinical features, the initial pattern of abnormal LFT results and (1) specific viral, genetic and autoimmune diseases, such as viral hepatitis, haemochromatosis and primary biliary cirrhosis; (2) a range of other serious diseases, such as metastatic cancer and hypothyroidism; (3) ‘fatty liver’ not associated with the above; and (4) the absence of detectable disease. Results: Fewer than 5% of people with abnormal LFT results had a specific disease of the liver, and many of these were unlikely to need treatment. The diagnostic potential of the LFT panel is largely subsumed into just two analytes: alanine aminotransferase (ALT) and alkaline phosphatase (ALP). Gamma-glutamyltransferase (GGT) offers a small increase in sensitivity at the margin at the cost of a large loss of specificity. Eighty-four per cent of abnormal LFT results remain abnormal on retesting 1 month later. In many cases, carrying out a definitive or specific test will be more efficient than repeating LFTs, with a view to specific testing only if the test remains abnormal. An ultrasound diagnosis of ‘fatty liver’ was present in nearly 40% of patients with abnormal LFTs and a small amount of weight loss over 2 years was associated with a reduced incidence of liver fat. There was a J-shaped relationship between alcohol intake and fatty liver in men. An abnormal LFT result causes temporary anxiety, which does not appear to promote sustained behaviour change. Conclusions: Liver disease is rare among people with abnormal LFT results in primary care. Only two analytes (ALT and ALP) are helpful in identifying the majority of liver disease. GGT adds little information in return for a high false-positive rate but it is sensitive to alcohol intake. LFT results seldom revert from abnormal to normal over a 1-month period, and modelling shows that repeating an abnormal LFT panel, as recommended in the current guidelines, is inefficient. LFTs are often undertaken to meet perceived patient need for a blood test, but as they are neither specific nor indicative of any particular disease they are among the least suitable tests for this purpose. Obesity and raised ALT provide strong evidence for a presumptive diagnosis of ‘fatty’ liver. Abnormal LFTs and ‘fatty’ liver provoke only short-term anxiety and neither is associated with sustained weight loss. Even a small amount of weight loss reduces liver fat. Future work recommendations: (1) the cases of ‘fatty liver’ and controls should be followed up in the long term to identify features that predict development of hepatosteatosis and then cirrhosis; (2) the acceptability of replacing the traditional six- to eight-analyte LFT panel with a drop down menu including the ALT/ALP combination should be evaluated. Funding: The National Institute for Health Research Health Technology Assessment programme.https://doi.org/10.3310/hta17280liver function testliver diseaseviral hepatitishaemochromatosisprimary biliary cirrhosisanalytealkaline phosphatasealanine aminotransferasefatty livercohort study |
| spellingShingle | RJ Lilford L Bentham A Girling I Litchfield R Lancashire D Armstrong R Jones T Marteau J Neuberger P Gill R Cramb S Olliff D Arnold K Khan MJ Armstrong DD Houlihan PN Newsome PJ Chilton K Moons D Altman Birmingham and Lambeth Liver Evaluation Testing Strategies (BALLETS): a prospective cohort study Health Technology Assessment liver function test liver disease viral hepatitis haemochromatosis primary biliary cirrhosis analyte alkaline phosphatase alanine aminotransferase fatty liver cohort study |
| title | Birmingham and Lambeth Liver Evaluation Testing Strategies (BALLETS): a prospective cohort study |
| title_full | Birmingham and Lambeth Liver Evaluation Testing Strategies (BALLETS): a prospective cohort study |
| title_fullStr | Birmingham and Lambeth Liver Evaluation Testing Strategies (BALLETS): a prospective cohort study |
| title_full_unstemmed | Birmingham and Lambeth Liver Evaluation Testing Strategies (BALLETS): a prospective cohort study |
| title_short | Birmingham and Lambeth Liver Evaluation Testing Strategies (BALLETS): a prospective cohort study |
| title_sort | birmingham and lambeth liver evaluation testing strategies ballets a prospective cohort study |
| topic | liver function test liver disease viral hepatitis haemochromatosis primary biliary cirrhosis analyte alkaline phosphatase alanine aminotransferase fatty liver cohort study |
| url | https://doi.org/10.3310/hta17280 |
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