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Intersection of NAFLD, Cirrhosis Brings Complexities to Patient Care
Cirrhosis is evolving and much of what we see in this evolution is an increase in the number of patients arriving with cirrhosis due to nonalcoholic steatohepatitis. This burgeoning epidemic of nonalcoholic fatty liver disease leading to NASH requires us to understand a lot more about the comprehensive internal medicine aspects of a patient in the liver clinic compared with what the liver clinic patient used to look like.
This month’s cover story breaks down identification and treatment of cirrhosis, pointing toward NAFLD and NASH as the growing drivers of irreversible liver damage. This begs for a larger discussion of how we manage the patient with NAFLD or NASH.
The Challenge of Comorbidities
In the past, the hepatologist never acted as a primary care practitioner because most of the patient’s medical needs (from our perspective) focused around the liver. This was especially true with viral hepatitis. Even in those with advanced disease, the focus was on screening for complications such as hepatocellular carcinoma and management that centered on controlling the virus. But as a hepatologist you didn’t worry about cardiovascular disease and lipid management. Transplant would have been the exception where, as a hepatologist, we had a more active role in primary care. Still, this generally was co-management with an internist who needed assistance to integrate therapy with immune modulation or where our patient had unique needs.
But when we look at the patient with NAFLD, it is not so simple. NAFLD is not just a liver disease. If you look at the leading causes of death for patients with fatty liver disease, they are cardiovascular complications, malignancies and then liver-related death.
As a hepatologist, you can’t ignore the other two drivers of mortality in your patient and concentrate just on the liver. Either you must have a coordinated management strategy with other disciplines that cover these comorbidities or you must be aware of the management of these conditions yourself.
This is a challenge that we have not previously embraced.
Most of us focus our training in GI and hepatology and, in doing so, we distance ourselves from most aspects of primary care such as dyslipidemia, diabetes management and USPSTF recommendations outside of colorectal cancer screening. Even our board certification is allowing us to maintain certification only in our subspecialty, disincentivising us further to remain up to date on aspects of medicine we consider outside of our field. This is definitely an educational complexity that will need to be addressed.
Multidisciplinary Approach
We at Rush have a multidisciplinary obesity clinic that includes endocrinology, cardiology and hepatology. We may not cover all aspects of the metabolic syndrome, but together we cover as much as we can.
Most large centers like ours also have an obesity center that includes surgical options as well as lifestyle courses because these patients need to make behavioral changes for their health. Unfortunately, implementing these changes long-term are often just as difficult as getting someone who has alcohol dependence to stop drinking. The risk for relapse is incredibly high if you define relapse as someone who goes off their diet and regains their weight.
There are studies looking at gastric procedures at the time of transplant, but there is still a lot of mystery in managing this. There is a lot of mystery in management of obesity overall.
Obesity is still quite stigmatized and the conversation is still difficult to have. There’s a hard balance to increase one’s recognition for one’s health and give them strategies to improve their health and be sensitive to the psychosocial aspects of behavioral change.
We don’t yet have the magical formula for taking care of a fatty liver disease patient. It’s a hard place to be for a complex problem that doesn’t have an easy answer.
Transplantation in NASH
When you transition this patient with metabolic syndrome to a patient with end stage liver disease that’s being evaluated for transplant, there’s more that needs to be considered than our historical patients. In addition to surgical risk and their psychosocial health, we now have to anticipate the lifestyle aspects that will result in recurrent NASH or the co-morbid conditions that increase mortality driven by obesity.
Weight restrictions for transplant are center-specific. Some centers have BMI cut-offs, but it is often looked at on a case-by-case basis. When you look at outcomes, patients with obesity have higher short-term risks such as longer hospitalization, etc. But it’s another animal to consider long-term risks.
Programs are systematically evaluated by 1- and 3-year post-transplant outcomes, however many of us are concerned that the morbidly obese are at higher risk for cardiovascular complications and malignancies post-transplant or experience lower quality of life.
Now you’re worrying if you transplant, will this patient in 3 years have a stroke? A heart attack? Will she die of breast cancer or another malignancy seen at a higher rate in a person with obesity? How do we balance out recurrent NAFLD?
In most of these patients who get transplanted, you’ve done nothing about the driver of this disease. You’ve given them a new organ for one facet of a multifaceted systemic disease. How do you prevent the new liver from becoming injured in a patient where you didn’t necessarily make changes that result in disease regression?
Call to Action
With this epidemic entering our hepatology realm with some force, I would like to remind PCPs and gastroenterologists that cirrhosis development isn’t always symptomatic. A lot of NAFLD patients present to hepatology with advanced fibrosis because by the time they demonstrate a symptom that increases awareness of their disease or pushes their PCP to triggers a liver or a GI consult, they often are beyond a point where we could ideally help them.
We need better algorithms for early recognition — one developed by primary care to better prepare their practitioners or perhaps one developed with the hepatology community so we can enter the equation sooner. Either way, cirrhosis is not the time to identify your patient.
How are you working together to identify NAFLD earlier? What steps should we take as a medical community to prevent NAFLD progressing to NASH and progressing to cirrhosis? Give us your thoughts and join the conversation with @HealioGastro.
Disclosure: Reau reports receiving research support from AbbVie and serving on medical advisory boards for AbbVie, Gilead and Merck in the last 12 months.