Diagnostic accuracy of routine liver function tests to identify patients with significant and advanced alcohol-related liver fibrosis

Aims: Alcohol is the leading cause of cirrhosis, but most patients go undetected until decompensation occurs despite frequent contacts with the healthcare system. We aimed to evaluate the diagnostic accuracy of routine liver function tests compared with indirect and direct fibrosis markers and to assess doctors’ abilities to diagnose significant and advanced alcohol-related liver fibrosis. Methods: This study was a retrospective evaluation of liver function tests for diagnosing alcohol-related liver disease compared to indirect fibrosis tests, the ELF test, and transient elastography. We also surveyed nine doctors who were presented with 225 patient cases from a cross-sectional, biopsy-controlled, single-centre study that evaluated diagnostic tools for alcohol-related liver fibrosis. The doctors assessed each case for significant (≥F2) or advanced (≥F3) fibrosis. We assessed inter-rater variability with Fleiss’ kappa. Results: Routine liver function tests had poor diagnostic accuracy (highest area under the ROC curve for platelet count = 0.752) and poor sensitivities (10%–67%) when using the upper or lower normal limits as cut-offs. Indirect fibrosis indices performed significantly better but were still inferior to the ELF test and transient elastography. The nine doctors disagreed substantially in their predictions, with Fleiss’ kappa of 0.24 (95% CI0.22–0.26) and 0.51 (0.44–0.55) for significant and advanced fibrosis. All nine doctors exhibited poor case-finding abilities with sensitivities of 22–93%. Conclusions: When using routine liver function tests, doctors may fail to diagnose more than half of all alcohol-overusing patients with advanced fibrosis, probably because they rely on upper and lower normal limits of routine liver function tests.