CORE blimey! A promising new tool for identifying risk of significant liver disease

Liver disease is a rising health concern, with the latest data showing that the rate of premature deaths from liver disease increased by almost 40% in England in the 20 years up to 2022. Further, the hospital admission rates from liver disease continue to rise year on year.  

Early detection of those at high risk could facilitate targeting of preventative measures, such as management of underlying metabolic risk factors for MASLD, alcohol reduction support and prompt referral to secondary care where needed. However, in practice it can be incredibly difficult to predict future development of cirrhosis. Tools such as the FIB-4 score are helpful in identifying current fibrosis, but less effective at detecting future risk. 

Enter a promising new risk assessment tool ‘CORE’ (aka Cirrhosis Outcome Risk Estimator), developed with primary care data and designed for implementation in a primary care setting. The CORE risk score uses tests and parameters generally available in primary care, namely age, sex, AST, ALT and gGT. The output is a 10-year risk composite risk of MALO (Major Adverse Liver Outcomes; including cirrhosis, oesophageal varices, hepatic ascites, hepatocellular carcinoma, and liver transplantation). 

The CORE risk model was originally developed from primary are data collected from Swedish patients (n=480,651, aged 18-80), with no known history of liver disease at baseline. It was evaluated in a population-based cohort study recently published in the BMJ, benchmarked against the widely used FIB-4 score. The study included external validation in UK and Finish cohorts (using data from the UK Biobank, FINRISK and Health2000). The median follow-up time was 28 years, with 7168 MALO events observed in that time. The incidence of MALO at 10 years was 0.27% in the Swedish cohort, and 0.4% in the UK cohort (slightly older population). 

How did it perform? CORE achieved better discrimination for MALO within 10 yrs than FIB-4 (with good correlation between predicted and observed risk). 

What are the implications for practice? 

Before we get too excited about this new tool, we have to look at how it fits with existing guidance. BSG guidelines for suspected NALFD incorporate FIB4 in determining the need for further investigation and specialist referral, and NICE advises use of the enhanced liver fibrosis score (ELF). This new paper does not compare CORE against ELF and there is no current consensus on what threshold of CORE risk score should trigger specialist referral. At this stage further analysis is needed to understand how CORE could be used in practice.

A strength of CORE is that is gives a defined risk estimation of developing serious liver complications over the next 10 years, rather than a figure which is largely meaningless to patients. Using absolute risk to explain the issue to our patients is much simpler to understand and could be the starting point for engagement with disease modifying management.

Overall, the main learning points from this paper include a reminder that liver disease is a growing but frequently silent threat to health, with 1 in 250 of our patients at risk of developing a significant liver complication over the next 10 years, and it is increasingly possible to identify patients most at risk. In a new age where treatments such as SGLT2 inhibitors and GLP1 receptor agonists have been shown to reduce liver fibrosis due to metabolic dysfunction-associated steatotic liver disease there has never been a stronger rationale for finding them.

If you are interested in exploring the tool you can access the CORE calculator here.