Announcer:
Welcome to CME on ReachMD. This episode is part of our MinuteCE curriculum.

Prior to beginning the activity, please be sure to review the faculty and commercial support disclosure statements as well as the learning objectives. 

Dr. Kowdley:
This is CME on Reach MD, and I’m Dr. Kris Kowdley. Here with me today is Dr. Atoosa Rabiee.

Let’s take a look at some important issues in PBC by reviewing a patient case. Dr. Rabiee, do you want to present a case for us?

Dr. Rabiee:
When we first evaluate patient, as an example a 65-year-old gentleman with newly diagnosed biopsy-proven PBC, when we bring him into clinic to discuss, sort of, the progression of the disease and how the upcoming years would be for them, one of the most important things that is being asked is the possibility of decompensation and also disease stage.

Now it used to be that we always relied on biopsy. However, more and more we are moving towards noninvasive assessment of stages of disease. And knowing that, I want to highlight 2 important parts of the information that we can use to assess stage of disease, whether it is liver stiffness, as is measured by transient elastography that is widely available – sometimes it’s used as point of care – as well as ELF, which is enhanced liver fibrosis test – it’s a blood test – and after being approved by FDA, now is widely available.

Now, for liver stiffness, there are different cutoffs that can be used. One of the important cutoffs that I use for risk stratification is presence or absence of advanced fibrosis, which is a single most important factor in a patient’s journey of developing decompensation. So we know that for patients with PBC, usually liver stiffness below 6.5 kPa can discriminate between presence or absence of advanced fibrosis, and on the other end of the spectrum, liver stiffness of above 11 kPa, again, can be a good discriminating factor.

We usually, once I evaluate the patient with liver stiffness, after 1 year of therapy with UDCA, I reevaluate them. And it’s important to know that the longitudinal assessment of liver stiffness will give you much more information than just a one-time of measurement of liver stiffness. It also gives you a good risk stratification as far as being associated with poor clinical outcomes.

As an example, we know that when liver stiffness is somewhere between 8 to 15, there is 20% to 50% risk of poor clinical outcomes over a 10-year period. When liver stiffness rises above 15, you’re thinking about 50% to 90% risk of poor clinical outcomes over 10 years.

ELF also, both at baseline as well as prospectively, correlates with disease severity and risk of long-term outcomes. It basically measures 3 proteomic markers of fibrosis. And we know that as time goes by and with every point, increase in ELF can be associated with 3-fold increase in future complications.

Dr. Kowdley:
So the key takeaway, I think, for this segment is liver biopsy is no longer required to make the diagnosis of PBC. We now have the availability of elastography and, as you very nicely summarized, in a case where the stiffness is less than 8 kPa, we can reassure the patient they have an excellent prognosis; they have low stage. Whereas, if they have more than 10 kPa, then that would suggest increased risk of moderate to advanced fibrosis, and we might want to be a little bit more aggressive about making assessments regarding second-line therapy, how closely we monitor the patient, et cetera.

Thanks for tuning in.

Announcer:
You have been listening to CME on ReachMD.  This activity is provided by Prova Education.

To receive your free CME credit, or to download this activity, go to ReachMD.com/Prova. Thank you for listening.