Letter to the Editor: More questions than answers—Response to the POP-NEXT project

Abstract

To the editor, Ratziu et al's [1] fascinating survey of clinical variability in the diagnosis and management of NAFLD emphasizes the uncertain place that it occupies in the field of hepatology. Is it a liver condition or one manifestation of a metabolic disorder? Is the hepatogastroenterologist responsible for "managing the liver" or the whole person? Does NAFLD's extremely high prevalence present an insurmountable challenge for public health systems, thus explaining the tendency in some countries for patients to be referred back to primary care? Are continuing attempts to find effective therapies targeted at inflammation and fibrosis just ignoring what appears to be the proximate cause in the majority of cases, obesity? [2,3] The authors should be congratulated for avoiding a judgmental tone in the narrative; however, implicit in their paper is the expectation that specialists should conduct a multisystem assessment (sleep apnea, kidney disease, and cardiovascular risk), and extend their responsibilities to prescribing statins when appropriate. In reality, the number of patients presenting to clinics means that such comprehensive assessment is not possible, and it is reasonable to request that primary physicians lead on these aspects. It is interesting to note that decisions and interventions that sit comfortably within the skill sets and influence of specialists (such as hepatoma screening, liver biopsy, and longterm follow-up of mild disease) were done more frequently-perhaps to an inappropriate degree-than interventions likely to be a greater overall benefit in terms of survival, for example, cardiovascular risk assessment. [4] This survey of hepatogastroenterologists affords, inevitably, a narrow perspective. Respondents (a self-selected 4% of the total invited number) were likely to be more interested in the pathogenesis of NAFLD, and their clinical behaviors may not be representative. As the authors concede, it is essential now to investigate both awareness and the degree of understanding among community physicians, for it is there that rational screening with noninvasive tests and holistic approaches to lifestyle and risk factors must occur if economically viable models of care are to be sustained. [5] CONFLICTS OF INTERESTThe authors have no conflicts to report.