Assessing strategies to target screening for advanced liver fibrosis among overweight and obese patients

Abstract

Aim: The optimal screening strategy for advanced liver fibrosis in overweight and obese patients is unknown. The aim of this study is to compare the performance of different strategies to select patients at high risk of advanced liver fibrosis for screening using non-invasive tools. Methods: All patients underwent: liver 1H-MRS and percutaneous liver biopsy (in those with nonalcoholic fatty liver disease [NAFLD]). Unique selection strategies were compared to determine the best screening algorithm: (A) A "metabolic approach": selecting patients based on HOMA-IR ≥ 3; (B) A "diabetes approach": selecting only patients with type 2 diabetes; (C) An "imaging approach": selecting patients with hepatic steatosis based on 1H-MRS; (D) A "liver biochemistry approach": selecting patients with elevated ALT (i.e., ≥ 30 IU/L for males and ≥ 19 IU/L for females); and (E) Universal screening of overweight and obese patients. FIB-4 index, NAFLD fibrosis score, and APRI were applied as screening strategies. Results: A total of 275 patients were included in the study. Patients with advanced fibrosis (n = 29) were matched for age, gender, ethnicity, and BMI. Selecting patients by ALT elevation provided the most effective strategy, limiting the false positive rate while maintaining the sensitivity compared to universal screening. Selecting patients by any other strategy did not contribute to increasing the sensitivity of the approach and resulted in more false positive results. Conclusion: Universal screening of overweight/obese patients for advanced fibrosis with non-invasive tools is unwarranted, as selection strategies based on elevated ALT levels lead to the same sensitivity with a lower false positive rate (i.e., fewer patients that would require a liver biopsy or referral to hepatology).

Noninvasive tests to identify liver fibrosis in metabolic dysfunction‐associated steatotic liver disease are affected by race

“…Overall, the performance of NITs compared with VCTE was poor, with a significantly low agreement between the two approaches. Despite wide promotion of the FIB‐4 index in recent guidelines, there remain several questions regarding the best screening strategy [31]. Moreover, several studies have shown the limitations of this tool to identify patients with advanced fibrosis in large samples [22, 32].…”

“…Despite wide promotion of the FIB-4 index in recent guidelines, there remain several questions regarding the best screening strategy [31].…”

Screening for advanced liver fibrosis in overweight and obese patients with NAFLD

“…While most of the blood-based markers and clinical scores of fibrosis are widely available and, in most cases, relatively cheap, the imaging-based markers of fibrosis are quite expensive. Kanwal and colleagues' call to action [23] , and the associated clinical care pathway [24] , suggested a global guiding strategy to promote the early diagnosis of NAFLD and NASH, starting in the primary care clinic. Three high-risk groups of people were identified by the task force: people with diabetes, those with metabolic syndrome, and people with steatosis or increased concentrations of plasma aminotransferases (ALT and/or AST), or both [24] .…”

“…Kanwal and colleagues' call to action [23] , and the associated clinical care pathway [24] , suggested a global guiding strategy to promote the early diagnosis of NAFLD and NASH, starting in the primary care clinic. Three high-risk groups of people were identified by the task force: people with diabetes, those with metabolic syndrome, and people with steatosis or increased concentrations of plasma aminotransferases (ALT and/or AST), or both [24] . Furthermore, the Fibrosis-4 (FIB-4) index was selected as the initial screening tool.…”

“…Targeting screening of patients with elevated ALT levels using FIB-4 or APRI provides the most costeffective first-line approach [Figure 1]. Still, because in most patients plasma aminotransferases are not elevated [26][27][28] , current guidelines [24,29] recommend FIB-4 (over APRI or NFS) to identify advanced fibrosis in high-risk patients given the superior screening and long-term outcomes predictive value of FIB-4 [29][30][31] . Future research is warranted to better stratify subjects with suspected NAFLD regarding duration of diabetes, quality of blood glucose control and body fat distribution.…”