Identification of Patients with Advanced Fibrosis Due to Nonalcoholic Fatty Liver Disease: Considerations for Best Practice

Abstract

Nonalcoholic fatty liver disease (NAFLD) and nonalcoholic steatohepatitis (NASH) prevalence has increased in the past two decades, resulting in a significant but under-recognised public health burden. This impacts the prevalence of advanced fibrosis, end-stage liver disease and associated extrahepatic manifestations. To understand the challenges in recognising patients with advanced fibrosis due to NASH and develop a standardised approach to screen these patients, the authors of this document provided their opinions and expertise from practice and published evidence to identify key challenges and current approaches for diagnosing NASH. The severity of liver fibrosis due to NASH is the main indicator of associated morbidity and mortality outcomes. Therefore, identifying patients with, or at risk of, advanced fibrosis due to NASH and linking them to appropriate care is critical. This can be challenging due to a lack of awareness of NASH among healthcare professionals and a lack of standardised protocols for identifying patients. Simple noninvasive tests may provide an opportunity to facilitate early identification of these patients. This article proposes a simple, universally applicable diagnostic algorithm for use in clinical practice, that includes sequential use of noninvasive tests, ideally a biological marker and an imaging technique, which may help to facilitate early diagnosis of these patients. In the opinion of the authors, early detection of advanced fibrosis is fundamental in the efforts to halt the progression of NASH and diagnostic algorithms may facilitate pre-emptive interventions to curtail the disease.

American Association of Clinical Endocrinology Clinical Practice Guideline for the Diagnosis and Management of Nonalcoholic Fatty Liver Disease in Primary Care and Endocrinology Clinical Settings

“…Fibrosis stage is an important predictor of long-term outcomes. 43,148,195 Again, the initial steps of risk stratification using the algorithms outlined in Algorithm Figures 1 and 2 should be performed by endocrinologists and in the primary care setting. 194,[196][197][198] For persons with evidence of advanced liver disease (eg, ascites, hepatic encephalopathy, esophageal varices, hypersplenism/low platelet count, or evidence of hepatic synthetic dysfunction as characterized by a low albumin level and/or evidence of prolonged prothrombin time/international normalized ratio), assessment and management by a gastroenterologist or hepatologist may be necessary.…”

Defining comprehensive models of care for NAFLD

“…49,50 However, there is growing evidence that combinations of NITs used in sequential algorithms can help to detect advanced fibrosis. [51][52][53][54][55] All of the care pathways we identified that utilize NITs for the risk stratification of patients follow a sequential approach that relies on the high negative predictive value of the tests to rule out the presence of advanced fibrosis. The optimal choice of NIT and the corresponding cut-offs are being explored in a number of prospective studies to determine an acceptable balance between healthcare spending and favourable clinical outcome.…”

Mechanisms of Non-Alcoholic Fatty Liver Disease in the Metabolic Syndrome. A Narrative Review

“…Hence, liver ultrasound (US) and the quantification of fat and fibrosis with transient elastography (Fibroscan) and Control Attenuation Parameter (CAP) software currently represent the non-invasive and inexpensive tools to diagnose NAFLD in the clinical practice [ 194 ]. Beyond these, also the evaluation of genetic polymorphisms (PNPLA3, TM6SF3, MBOTT) and scores (e.g., NAFDL fibrosis score, FIB4, APRI score) may support the identification of subjects at higher risk of disease progression [ 195 ]. The histological evaluation of liver tissue by US-guided biopsy is an invasive method which allows for an effective assessment of the degree of progression of fibrosis and inflammation.…”