Birmingham and Lambeth Liver Evaluation Testing Strategies (BALETS): a prospective cohort study
Birmingham and Lambeth Liver Evaluation Testing Strategies (BALETS): a prospective cohort study
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DOI：
10.3310/hta17280
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发表时间：
2013-07-01
影响因子：
3.6
通讯作者：
Altman, D.
中科院分区：
文献类型：
--
作者：
Lilford, R. J.;Bentham, L.;Altman, D.
目的：评价肝功能轻度异常(LFT)在非肝病患者中的全科检查结果。设计：对在初级保健中发现LFT异常的人群进行前瞻性队列研究。参与者使用共同的方案进行了密集的调查，并进行了2年的跟踪调查。子研究调查了检查结果异常的心理后遗症、临床医生进行测试的原因、LFT结果异常时的决策选择以及肝纤维化的早期检测。地点：11家初级保健机构：8家在伯明翰，3家在兰贝斯。参与者：LFT结果异常的成年人，没有既往或明显的肝病。主要观察指标：使用统计学检验确定临床特征、LFT结果异常的初始模式与(1)特定的病毒、遗传和自身免疫性疾病之间的相互作用，如病毒性肝炎、血色沉着和原发性胆汁性肝硬变；(2)一系列其他严重疾病，如转移性癌症和甲状腺功能减退症；(3)与上述疾病无关的‘脂肪肝’；以及(4)没有可检测到的疾病。结果：LFT结果异常的人中，只有不到5%的人患有特定的肝脏疾病，其中许多不太可能需要治疗。LFT小组的诊断潜力主要归结为两种分析：丙氨酸氨基转移酶(ALT)和碱性磷酸酶(ALP)。γ-谷氨酰基转移酶(GGT)在边缘提供了少量的敏感性增加，但代价是大量的特异性损失。在1个月后的复测中，84%的异常LFT结果仍然异常。在许多情况下，进行确定的或特定的测试将比重复LFT更有效率，以便只有在测试仍然不正常的情况下才进行特定的测试。在LFTs异常的患者中，有近40%的人被超声诊断为“脂肪肝”，两年内体重小幅下降与肝脏脂肪发生率的降低有关。男性饮酒与脂肪肝之间存在J型关系。LFT结果异常会引起暂时的焦虑，这似乎不会促进持续的行为改变。结论：在初级保健中LFT结果异常的人中，肝脏疾病很少见。只有两种分析方法(丙氨酸氨基转移酶和碱性磷酸酶)有助于识别大多数肝病。GGT增加的信息很少，但假阳性率很高，但它对酒精摄入量很敏感。LFT结果很少在一个月的时间内从异常恢复到正常，建模表明重复当前指南中建议的异常LFT面板是低效的。进行LFT通常是为了满足患者对血液测试的预期需求，但由于它们既不是特定的，也不是任何特定疾病的迹象，因此它们是最不适合用于这一目的的测试之一。肥胖和ALT升高为“脂肪肝”的推定诊断提供了强有力的证据。异常的LFT和“肥胖”的肝脏只会引起短期的焦虑，而这两者都与持续的减肥无关。未来的工作建议：(1)应长期跟踪“脂肪肝”和对照组的病例，以确定预测肝脏骨质疏松症和肝硬变发展的特征；(2)应评估用包括ALT/ALP组合的下拉菜单取代传统的六到八种分析的LFT仪表板的可接受性。
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.