From the Guidelines
The Enhanced Liver Fibrosis (ELF) test is a valuable tool in managing primary sclerosing cholangitis (PSC), as it can predict transplant-free survival and retains predictive value longitudinally despite dynamic fluctuations in the course of PSC. The ELF test measures three serum markers of extracellular matrix turnover: hyaluronic acid, tissue inhibitor of metalloproteinase-1, and procollagen III amino terminal peptide. In PSC management, the ELF test helps clinicians monitor disease progression without requiring liver biopsies, which are invasive and carry risks. According to the 2022 EASL clinical practice guidelines on sclerosing cholangitis 1, the ELF test can predict transplant-free survival in PSC and retains predictive value longitudinally.
The ELF test is particularly useful for risk stratification, allowing physicians to identify high-risk patients who may need more aggressive monitoring or earlier consideration for transplantation. As recommended by the 2021 EASL clinical practice guidelines on non-invasive tests for evaluation of liver disease severity and prognosis 1, both the ELF score and liver stiffness measurement (LSM) by transient elastography (TE) should be used for risk stratification in PSC patients, both at baseline and during follow-up.
Some key points to consider when using the ELF test in PSC management include:
- The ELF test can predict adverse outcomes such as liver transplantation or death
- ELF scores above 9.8 generally indicate advanced fibrosis, while scores above 10.5 suggest cirrhosis in PSC patients
- Serial ELF measurements can track fibrosis progression over time, helping to assess response to therapy and inform treatment decisions
- The ELF test should be interpreted alongside other clinical parameters, imaging studies, and biochemical markers for comprehensive PSC management, as stated in the guidelines 1.
From the Research
Role of Enhanced Liver Fibrosis (ELF) Test in Primary Sclerosing Cholangitis (PSC)
The ELF test is a biomarker that has been studied for its potential role in managing PSC. The key findings from the studies are:
- The ELF test can predict transplant-free survival in PSC patients 2, 3
- The ELF score is associated with the severity of fibrosis and clinical outcomes in PSC patients 2, 3
- The ELF test can distinguish between mild and severe disease defined by clinical outcome (transplantation or death) with an area under the curve of 0.81 2
- The ELF test is a potent prognostic marker in PSC, independent of the Mayo risk score 2
Comparison with Other Biomarkers
The ELF test has been compared with other biomarkers, including:
- Liver stiffness measurement (LSM) using vibration-controlled transient elastography (VCTE) 4
- Alkaline phosphatase (ALP) and bilirubin 5
- The ELF test has been shown to have superior reliability for risk stratification compared with LSM in PSC 5
Association with Cholangiocarcinoma
The ELF test has also been studied in relation to cholangiocarcinoma (CCA) in PSC patients:
- CCA is associated with a raised ELF score independent of PSC 6
- The ELF score may be used to risk stratify for CCA in PSC 6
Longitudinal Changes
The longitudinal changes in ELF test and LSM have been studied: