{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,8,4]],"date-time":"2026-08-04T00:01:50Z","timestamp":1785801710246,"version":"3.56.0"},"reference-count":53,"publisher":"BMJ","issue":"3","license":[{"start":{"date-parts":[[2020,3,31]],"date-time":"2020-03-31T00:00:00Z","timestamp":1585612800000},"content-version":"unspecified","delay-in-days":30,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"funder":[{"DOI":"10.13039\/501100000278","name":"Department for International Development","doi-asserted-by":"publisher","id":[{"id":"10.13039\/501100000278","id-type":"DOI","asserted-by":"publisher"}]},{"DOI":"10.13039\/501100000272","name":"National Institute for Health Research","doi-asserted-by":"publisher","id":[{"id":"10.13039\/501100000272","id-type":"DOI","asserted-by":"publisher"}]},{"DOI":"10.13039\/100004440","name":"Wellcome Trust","doi-asserted-by":"publisher","award":["110110"],"award-info":[{"award-number":["110110"]}],"id":[{"id":"10.13039\/100004440","id-type":"DOI","asserted-by":"publisher"}]},{"DOI":"10.13039\/501100000275","name":"Leverhulme Trust","doi-asserted-by":"publisher","id":[{"id":"10.13039\/501100000275","id-type":"DOI","asserted-by":"publisher"}]},{"DOI":"10.13039\/501100000265","name":"Medical Research Council","doi-asserted-by":"publisher","id":[{"id":"10.13039\/501100000265","id-type":"DOI","asserted-by":"publisher"}]}],"content-domain":{"domain":["bmj.com"],"crossmark-restriction":true},"short-container-title":["BMJ Open"],"accepted":{"date-parts":[[2020,2,17]]},"published-print":{"date-parts":[[2020,3]]},"abstract":"<jats:sec>\n                    <jats:title>Objectives<\/jats:title>\n                    <jats:p>Liver disease is a major cause of morbidity and mortality in sub-Saharan Africa, but its prevalence, distribution and aetiology have not been well characterised. We therefore set out to examine liver function tests (LFTs) and liver fibrosis scores in a rural African population.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Design<\/jats:title>\n                    <jats:p>We undertook a cross-sectional survey of LFTs. We classified abnormal LFTs based on reference ranges set in America and in Africa. We derived fibrosis scores (aspartate aminotransferase (AST) to Platelet Ratio Index (APRI), fibrosis-4, gamma-glutamyl transferase (GGT) to platelet ratio (GPR), red cell distribution width to platelet ratio and S-index). We collected information about alcohol intake, and infection with HIV, hepatitis B virus (HBV) and hepatitis C virus (HCV).<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Setting<\/jats:title>\n                    <jats:p>We studied a population cohort in South-Western Uganda.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Participants<\/jats:title>\n                    <jats:p>Data were available for 8099 adults (median age 30 years; 56% female).<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>The prevalence of HBV, HCV and HIV infection was 3%, 0.2% and 8%, respectively. The prevalence of abnormal LFTs was higher based on the American reference range compared with the African reference range (eg, for AST 13% vs 3%, respectively). Elevated AST\/ALT ratio was significantly associated with self-reported alcohol consumption (p&lt;0.001), and the overall prevalence of AST\/ALT ratio &gt;2 was 11% (suggesting alcoholic hepatitis). The highest prevalence of fibrosis was predicted by the GPR score, with 24% of the population falling above the threshold for fibrosis. There was an association between the presence of HIV or HBV and raised GPR (p=0.005) and S-index (p&lt;0.001). By multivariate analysis, elevated LFTs and fibrosis scores were most consistently associated with older age, male sex, being under-weight, HIV or HBV infection and alcohol consumption.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusions<\/jats:title>\n                    <jats:p>Further work is required to determine normal reference ranges for LFTs in this setting, to evaluate the specificity and sensitivity of fibrosis scores and to determine the aetiology of liver disease.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1136\/bmjopen-2019-032890","type":"journal-article","created":{"date-parts":[[2020,3,31]],"date-time":"2020-03-31T15:39:27Z","timestamp":1585669167000},"page":"e032890","update-policy":"https:\/\/doi.org\/10.1136\/crossmarkpolicy","source":"Crossref","is-referenced-by-count":27,"title":["Liver function tests and fibrosis scores in a rural population in Africa: a cross-sectional study to estimate the burden of disease and associated risk factors"],"prefix":"10.1136","volume":"10","author":[{"given":"Geraldine","family":"O'Hara","sequence":"first","affiliation":[{"name":"Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jolynne","family":"Mokaya","sequence":"additional","affiliation":[{"name":"Nuffied Department of Medicine, University of Oxford, Oxford, UK"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-3656-6538","authenticated-orcid":false,"given":"Jeffrey P","family":"Hau","sequence":"additional","affiliation":[{"name":"Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK"},{"name":"Medical Research Council\/Uganda Virus Research Institute, Entebbe, Uganda"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Louise O","family":"Downs","sequence":"additional","affiliation":[{"name":"Nuffied Department of Medicine, University of Oxford, Oxford, UK"},{"name":"Department of Microbiology and Infectious Diseases, Oxford University Hospitals NHS Foundation Trust, Oxford, UK"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Anna L","family":"McNaughton","sequence":"additional","affiliation":[{"name":"Nuffied Department of Medicine, University of Oxford, Oxford, UK"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Alex","family":"Karabarinde","sequence":"additional","affiliation":[{"name":"Medical Research Council\/Uganda Virus Research Institute, Entebbe, Uganda"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Gershim","family":"Asiki","sequence":"additional","affiliation":[{"name":"Medical Research Council\/Uganda Virus Research Institute, Entebbe, Uganda"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Janet","family":"Seeley","sequence":"additional","affiliation":[{"name":"Medical Research Council\/Uganda Virus Research Institute, Entebbe, Uganda"},{"name":"Department of Global Health & Development, London School of Hygiene and Tropical Medicine, London, UK"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-4036-4269","authenticated-orcid":false,"given":"Philippa C","family":"Matthews","sequence":"additional","affiliation":[{"name":"Nuffied Department of Medicine, University of Oxford, Oxford, UK"},{"name":"Department of Microbiology and Infectious Diseases, Oxford University Hospitals NHS Foundation Trust, Oxford, UK"},{"name":"NIHR BRC, John Radcliffe Hospital, Oxford, UK"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Robert","family":"Newton","sequence":"additional","affiliation":[{"name":"Medical Research Council\/Uganda Virus Research Institute, Entebbe, Uganda"},{"name":"Department of Health Sciences, University of York, York, UK"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"239","published-online":{"date-parts":[[2020,3,31]]},"reference":[{"key":"2025121512424249000_10.3.e032890.1","doi-asserted-by":"publisher","DOI":"10.1111\/liv.12884"},{"key":"2025121512424249000_10.3.e032890.2","doi-asserted-by":"crossref","first-page":"e1060","DOI":"10.1016\/S2214-109X(18)30344-9","article-title":"Liver cirrhosis in sub-Saharan Africa: neglected, yet important","volume":"6","author":"Vento","year":"2018","journal-title":"Lancet Glob Health"},{"key":"2025121512424249000_10.3.e032890.3","doi-asserted-by":"publisher","DOI":"10.1016\/j.cgh.2010.08.024"},{"key":"2025121512424249000_10.3.e032890.4","doi-asserted-by":"crossref","DOI":"10.1371\/journal.pntd.0000412","article-title":"Neglected tropical diseases in sub-Saharan Africa: review of their prevalence, distribution, and disease burden","volume":"3","author":"Hotez","year":"2009","journal-title":"PLoS Negl Trop Dis"},{"key":"2025121512424249000_10.3.e032890.5","unstructured":"O\u2019Hara G , Mokaya J , Hau J , et al . Liver function tests and fibrosis scores in a rural population in Africa. figshare. dataset, 2019. https:\/\/doi.org\/10.6084\/m9.figshare.8292194"},{"key":"2025121512424249000_10.3.e032890.6","first-page":"39","article-title":"The pathophysiology of thrombocytopenia in chronic liver disease","volume":"8","author":"Mitchell","year":"2016","journal-title":"Hepat Med"},{"key":"2025121512424249000_10.3.e032890.7","doi-asserted-by":"crossref","first-page":"1","DOI":"10.1097\/MEG.0000000000000233","article-title":"A systematic review of the prevalence of mildly abnormal liver function tests and associated health outcomes","volume":"27","author":"Radcke","year":"2015","journal-title":"Eur J Gastroenterol Hepatol"},{"key":"2025121512424249000_10.3.e032890.8","first-page":"117","article-title":"The de ritis ratio: the test of time","volume":"34","author":"Botros","year":"2013","journal-title":"Clin Biochem Rev"},{"key":"2025121512424249000_10.3.e032890.9","doi-asserted-by":"publisher","DOI":"10.1136\/pmj.79.932.307"},{"key":"2025121512424249000_10.3.e032890.10","doi-asserted-by":"crossref","first-page":"1738","DOI":"10.1111\/liv.13410","article-title":"Non-Invasive fibrosis markers for chronic hepatitis B in sub-Saharan Africa","volume":"37","author":"Huang","year":"2017","journal-title":"Liver Int"},{"key":"2025121512424249000_10.3.e032890.11","doi-asserted-by":"crossref","first-page":"215","DOI":"10.7196\/SAMJ.8791","article-title":"Prevalence and causes of thrombocytopenia in an academic state-sector laboratory in Soweto, Johannesburg, South Africa","volume":"105","author":"Vaughan","year":"2015","journal-title":"S Afr Med J"},{"key":"2025121512424249000_10.3.e032890.12","first-page":"103","article-title":"Noninvasive assessment of liver fibrosis with the aspartate transaminase to platelet ratio index (APRI): usefulness in patients with chronic liver disease: apri in chronic liver disease","volume":"11","author":"Yilmaz","year":"2011","journal-title":"Hepat Mon"},{"key":"2025121512424249000_10.3.e032890.13","doi-asserted-by":"publisher","DOI":"10.1136\/gutjnl-2015-309260"},{"key":"2025121512424249000_10.3.e032890.14","doi-asserted-by":"crossref","DOI":"10.1097\/MD.0000000000009781","article-title":"Assessment of liver fibrosis in Egyptian chronic hepatitis B patients","volume":"97","author":"Tag-Adeen","year":"2018","journal-title":"Medicine"},{"key":"2025121512424249000_10.3.e032890.15","doi-asserted-by":"crossref","first-page":"1461","DOI":"10.1111\/liv.13393","article-title":"Are non-invasive fibrosis markers for chronic hepatitis B reliable in sub-Saharan Africa?","volume":"37","author":"Desalegn","year":"2017","journal-title":"Liver Int"},{"key":"2025121512424249000_10.3.e032890.16","article-title":"Prospective comparison of transient elastography, point shear wave elastography, apri, and FIB\u20104 for staging liver fibrosis in chronic viral hepatitis","volume":"jvh","author":"Udompap","year":"2019","journal-title":"J Viral Hepat"},{"key":"2025121512424249000_10.3.e032890.17","doi-asserted-by":"crossref","DOI":"10.1371\/journal.pone.0072916","article-title":"First definition of reference intervals of liver function tests in China: a large-population-based multi-center study about healthy adults","volume":"8","author":"Mu","year":"2013","journal-title":"PLoS One"},{"key":"2025121512424249000_10.3.e032890.18","doi-asserted-by":"crossref","DOI":"10.1371\/journal.pone.0004401","article-title":"CLSI-derived hematology and biochemistry reference intervals for healthy adults in eastern and southern Africa","volume":"4","author":"Karita","year":"2009","journal-title":"PLoS One"},{"key":"2025121512424249000_10.3.e032890.19","doi-asserted-by":"crossref","DOI":"10.1186\/1756-0500-5-493","article-title":"Robust reference intervals for liver function test (LFT) analytes in newborns and infants","volume":"5","author":"Melkie","year":"2012","journal-title":"BMC Res Notes"},{"key":"2025121512424249000_10.3.e032890.20","doi-asserted-by":"publisher","DOI":"10.1080\/00365510410006324"},{"key":"2025121512424249000_10.3.e032890.21","doi-asserted-by":"publisher","DOI":"10.1001\/archinternmed.2007.131"},{"key":"2025121512424249000_10.3.e032890.22","doi-asserted-by":"crossref","DOI":"10.1371\/journal.pone.0002043","article-title":"Baseline morbidity in 2,990 adult African volunteers recruited to characterize laboratory reference intervals for future HIV vaccine clinical trials","volume":"3","author":"Stevens","year":"2008","journal-title":"PLoS One"},{"key":"2025121512424249000_10.3.e032890.23","doi-asserted-by":"crossref","DOI":"10.1371\/journal.pone.0126166","article-title":"Prevalence of dyslipidaemia and associated risk factors in a rural population in south-western Uganda: a community based survey","volume":"10","author":"Asiki","year":"2015","journal-title":"PLoS One"},{"key":"2025121512424249000_10.3.e032890.24","doi-asserted-by":"publisher","DOI":"10.1093\/ije\/dyt184"},{"key":"2025121512424249000_10.3.e032890.25","doi-asserted-by":"crossref","first-page":"882.2","DOI":"10.1136\/gutjnl-2015-311133","article-title":"The gamma-glutamyl transpeptidase to platelet ratio (GPR) shows poor correlation with transient elastography measurements of liver fibrosis in HIV-positive patients with chronic hepatitis B in West Africa. Response to: 'The gamma-glutamyl transpeptidase to platelet ratio (GPR) predicts significant liver fibrosis and cirrhosis in patients with chronic HBV infection in West Africa' by Lemoine et al","volume":"65","author":"Stockdale","year":"2016","journal-title":"Gut"},{"key":"2025121512424249000_10.3.e032890.26","doi-asserted-by":"publisher","DOI":"10.1002\/hep.24105"},{"key":"2025121512424249000_10.3.e032890.27","doi-asserted-by":"publisher","DOI":"10.1002\/hep.21178"},{"key":"2025121512424249000_10.3.e032890.28","doi-asserted-by":"crossref","DOI":"10.1371\/journal.pone.0068780","article-title":"RDW to platelet ratio: a novel noninvasive index for predicting hepatic fibrosis and cirrhosis in chronic hepatitis B","volume":"8","author":"Chen","year":"2013","journal-title":"PLoS One"},{"key":"2025121512424249000_10.3.e032890.29","doi-asserted-by":"crossref","DOI":"10.1097\/MD.0000000000009781","article-title":"Assessment of liver fibrosis in Egyptian chronic hepatitis B patients: a comparative study including 5 noninvasive indexes","volume":"97","author":"Tag-Adeen","year":"2018","journal-title":"Medicine"},{"key":"2025121512424249000_10.3.e032890.30","doi-asserted-by":"crossref","DOI":"10.1186\/s12879-018-3367-3","article-title":"Hepatitis virus (HCV) diagnosis and access to treatment in a UK cohort","volume":"18","author":"Adland","year":"2018","journal-title":"BMC Infect Dis"},{"key":"2025121512424249000_10.3.e032890.31","doi-asserted-by":"crossref","unstructured":"Population Attributable Risk (PAR) . Encyclopedia of public health. Netherlands: Springer, 2008: 1117\u20138.","DOI":"10.1007\/978-1-4020-5614-7_2685"},{"key":"2025121512424249000_10.3.e032890.32","doi-asserted-by":"crossref","unstructured":"Yap CY , Choon Aw T . Liver function tests (LFTs). vol. 19. Proceedings of Singapore Healthcare, 2010.","DOI":"10.1177\/201010581001900113"},{"key":"2025121512424249000_10.3.e032890.33","unstructured":"World health Organisation . Guidelines for the care and treatment of persons diagnosed with chronic hepatitis C virus infection, 2018. Available: http:\/\/apps.who.int\/iris\/bitstream\/handle\/10665\/273174\/9789241550345-eng.pdf?ua=1"},{"key":"2025121512424249000_10.3.e032890.34","unstructured":"World health Organisation . Guidelines for the prevention, care and treatment of persons with chronic hepatitis B infection, 2015. Available: http:\/\/apps.who.int\/iris\/bitstream\/handle\/10665\/154590\/9789241549059_eng.pdf?sequence=1"},{"key":"2025121512424249000_10.3.e032890.35","doi-asserted-by":"crossref","DOI":"10.1371\/journal.pntd.0005842","article-title":"Hepatitis B virus infection as a neglected tropical disease","volume":"11","author":"O'Hara","year":"2017","journal-title":"PLoS Negl Trop Dis"},{"key":"2025121512424249000_10.3.e032890.36","doi-asserted-by":"crossref","first-page":"e559","DOI":"10.1016\/S2214-109X(16)30130-9","article-title":"Acceptability and feasibility of a screen-and-treat programme for hepatitis B virus infection in the Gambia: the prevention of liver fibrosis and cancer in Africa (prolifica) study","volume":"4","author":"Lemoine","year":"2016","journal-title":"Lancet Glob Health"},{"key":"2025121512424249000_10.3.e032890.37","first-page":"30","article-title":"What is the real function of the liver 'function' tests?","volume":"81","author":"Hall","year":"2012","journal-title":"Ulster Med J"},{"key":"2025121512424249000_10.3.e032890.38","doi-asserted-by":"crossref","first-page":"23","DOI":"10.11604\/pamj.2013.15.23.2040","article-title":"Diagnosis of alcohol misuse and alcoholic liver disease among patients in the medical emergency admission service of a large urban hospital in sub-Saharan Africa; a cross sectional study","volume":"15","author":"Opio","year":"2013","journal-title":"Pan Afr Med J"},{"key":"2025121512424249000_10.3.e032890.39","doi-asserted-by":"crossref","DOI":"10.3402\/gha.v9.31302","article-title":"Alcohol use among adults in Uganda: findings from the countrywide non-communicable diseases risk factor cross-sectional survey","volume":"9","author":"Kabwama","year":"2016","journal-title":"Glob Health Action"},{"key":"2025121512424249000_10.3.e032890.40","doi-asserted-by":"crossref","first-page":"1683","DOI":"10.1001\/jamaoncol.2017.3055","article-title":"The burden of primary liver cancer and underlying etiologies from 1990 to 2015 at the global, regional, and national level: results from the global burden of disease study 2015","volume":"3","author":"Akinyemiju","year":"2017","journal-title":"JAMA Oncol"},{"key":"2025121512424249000_10.3.e032890.41","doi-asserted-by":"publisher","DOI":"10.1007\/s10620-007-9999-6"},{"key":"2025121512424249000_10.3.e032890.42","doi-asserted-by":"crossref","DOI":"10.1371\/journal.pone.0134449","article-title":"Hepatic enzyme alterations in HIV patients on antiretroviral therapy: a case-control study in a hospital setting in Ghana","volume":"10","author":"Osakunor","year":"2015","journal-title":"PLoS One"},{"key":"2025121512424249000_10.3.e032890.43","doi-asserted-by":"crossref","DOI":"10.4254\/wjh.v4.i3.91","article-title":"Human immunodeficiency virus infection and the liver","volume":"4","author":"Crane","year":"2012","journal-title":"World J Hepatol"},{"key":"2025121512424249000_10.3.e032890.44","doi-asserted-by":"publisher","DOI":"10.1186\/1743-422X-6-4"},{"key":"2025121512424249000_10.3.e032890.45","doi-asserted-by":"crossref","DOI":"10.1186\/s12876-018-0755-5","article-title":"Unexplained chronic liver disease in Ethiopia: a cross-sectional study","volume":"18","author":"Orlien","year":"2018","journal-title":"BMC Gastroenterol"},{"key":"2025121512424249000_10.3.e032890.46","doi-asserted-by":"crossref","first-page":"1553","DOI":"10.1289\/ehp.11661","article-title":"Aflatoxin exposure and viral hepatitis in the etiology of liver cirrhosis in the Gambia, West Africa","volume":"116","author":"Kuniholm","year":"2008","journal-title":"Environ Health Perspect"},{"key":"2025121512424249000_10.3.e032890.47","doi-asserted-by":"crossref","first-page":"1322","DOI":"10.1080\/19440049.2015.1048749","article-title":"Longitudinal evaluation of aflatoxin exposure in two cohorts in south-western Uganda","volume":"32","author":"Kang","year":"2015","journal-title":"Food Addit Contam Part A Chem Anal Control Expo Risk Assess"},{"key":"2025121512424249000_10.3.e032890.48","doi-asserted-by":"publisher","DOI":"10.1289\/ehp.0901388"},{"key":"2025121512424249000_10.3.e032890.49","doi-asserted-by":"crossref","first-page":"12","DOI":"10.1016\/j.ajg.2014.01.008","article-title":"Non alcoholic fatty liver disease (NAFLD) in a Sudanese population: what is the prevalence and risk factors?","volume":"15","author":"Almobarak","year":"2014","journal-title":"Arab J Gastroenterol"},{"key":"2025121512424249000_10.3.e032890.50","doi-asserted-by":"publisher","DOI":"10.1136\/flgastro-2013-100403"},{"key":"2025121512424249000_10.3.e032890.51","doi-asserted-by":"crossref","first-page":"119","DOI":"10.1016\/S1665-2681(19)31559-5","article-title":"Non-Alcoholic fatty liver disease and the metabolic syndrome in an urban Hospital serving an African community","volume":"10","author":"Onyekwere","year":"2011","journal-title":"Ann Hepatol"},{"key":"2025121512424249000_10.3.e032890.52","doi-asserted-by":"publisher","DOI":"10.1016\/j.cld.2009.07.005"},{"key":"2025121512424249000_10.3.e032890.53","doi-asserted-by":"publisher","DOI":"10.1053\/j.gastro.2010.09.038"}],"container-title":["BMJ Open"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/syndication.highwire.org\/content\/doi\/10.1136\/bmjopen-2019-032890","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,12,15]],"date-time":"2025-12-15T20:42:51Z","timestamp":1765831371000},"score":1,"resource":{"primary":{"URL":"https:\/\/bmjopen.bmj.com\/lookup\/doi\/10.1136\/bmjopen-2019-032890"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2020,3]]},"references-count":53,"journal-issue":{"issue":"3","published-online":{"date-parts":[[2020,3,31]]},"published-print":{"date-parts":[[2020,3]]}},"alternative-id":["10.1136\/bmjopen-2019-032890"],"URL":"https:\/\/doi.org\/10.1136\/bmjopen-2019-032890","relation":{"has-preprint":[{"id-type":"doi","id":"10.1101\/19000968","asserted-by":"object"}]},"ISSN":["2044-6055","2044-6055"],"issn-type":[{"value":"2044-6055","type":"print"},{"value":"2044-6055","type":"electronic"}],"subject":[],"published":{"date-parts":[[2020,3]]}}}