Supplementary Table 1. Non-invasive serum markers for assessing liver fibrosis stage currently available in Australia

Method

Formula

Key threshold for excluding cirrhosis*

APRI

APRI = (AST [IU/L] ÷ AST ULN [IU/L] × 100) ÷ platelet count ( × 10⁹/L)

Online calculator

APRI < 1.0

     FIB-4

FIB-4 = (age [years] × AST [U/L])
÷ (platelet count [× 10⁹/L] × √ALT [U/L])

Online calculator

Hepascore

Patented formula combining bilirubin, GGT, hyaluronate, α-2-macroglobulin, age and sex

Hepascore < 0.80

  ELF test

Patented formula combining age, hyaluronate, MMP-3 and TIMP-1

ELF < 9.8

APRI = AST to platelet ratio index; AST = aspartate aminotransferase; ELF = Enhanced Liver Fibrosis; GGT = gamma-glutamyl transferase; HIV = human immunodeficiency virus; MMP-3 = matrix metalloproteinase-3; TIMP-1 = tissue inhibitor of metalloproteinase-1; ULN = upper limit of normal.

* These thresholds have good performance characteristics for excluding the presence of cirrhosis. Patients in whom results exceed these thresholds should be referred for further assessment for the presence of cirrhosis by a specialist with experience in assessing liver disease severity and managing patients with advanced liver disease. These thresholds alone should not be used to diagnose cirrhosis.

† FIB-4 score < 1.45 has a negative predictive value of 90% for advanced liver fibrosis.

Note that the performance of Hepascore and APRI for predicting the presence of cirrhosis may be less accurate in people with HIV coinfection than in people with HCV mono-infection (be aware of false positive results due to HIV-induced thrombocytopaenia with APRI, or antiretroviral treatment-related hyperbilirubinaemia with Hepascore).

References:

• EASL-ALEH clinical practice guidelines: non-invasive tests for evaluation of liver disease severity and prognosis.
  J Hepatol 2015; 63: 237-264.
• World Health Organization. Guidelines for the screening, care and treatment of persons with hepatitis C infection. April 2014 (http://apps.who.int/iris/bitstream/10665/111747/1/9789241548755_eng.pdf?ua=1).
• Lin ZH, Xin YN, Dong QJ, et al. Performance of the aspartate aminotransferase-to-platelet ratio index for the staging of hepatitis C-related fibrosis: an updated meta-analysis. Hepatology 2011; 53: 726-736.
• Adams LA, Bulsara M, Rossi E, et al. Hepascore: an accurate validated predictor of liver fibrosis in chronic hepatitis C infection. Clin Chem 2005; 51: 1867-1873.
• Parkes J, Guha IN, Roderick P, et al. Enhanced Liver Fibrosis (ELF) test accurately identifies liver fibrosis in patients with chronic hepatitis C. J Viral Hepat 2011; 18: 23-31.

Supplementary Table 2. Child–Pugh and Model for End-Stage Liver Disease (MELD) scoring systems for predicting prognosis in people with decompensated liver disease

A. Child–Pugh score

Points

Clinical measure

1

2

3

Albumin (g/L)

> 35

28–35

< 28

Bilirubin (mmol/L)

< 34

34–51

> 51

INR

< 1.7

1.7–2.3

> 2.3

Ascites

Nil

Slight

Moderate

Encephalopathy

Nil

Grade 1–2

Grade 3-4

Interpretation

Classification

1-year mortality

Consider transplant centre referral

Class A (5–6 points)

0

No

Class B (7–9 points)

20%

Yes*

Class C (10+ points)

55%

B. MELD score

MELD = 10 × ((0.957 × Log_e (creatinine/88.4)) + (0.378 × Log_e (bilirubin/17.1)) + (1.12 × Log_e (INR))) + 6.43

Online calculators are available.

Classification

3-month mortality

Consider transplant centre referral

MELD < 10

1.9%

No

MELD 10–19

6.0%

Yes if MELD ≥ 13*

MELD 20–29

19.6%

MELD 30–39

52.6%

MELD 40+

71.3%

INR = international normalised ratio.

* Indications for assessment by a liver transplant centre include Child–Pugh score ≥ B7, MELD score ≥ 13 or one of the following clinical events: refractory ascites, spontaneous bacterial peritonitis, hepatorenal syndrome, recurrent or chronic hepatic encephalopathy, small hepatocellular carcinoma or severe malnutrition.