Patients at risk for NASH are under-recognized in primary care

SAN DIEGO – Patients at risk for non-alcoholic steatohepatitis may be “considerably under-recognized” in primary care, but the NAFLD Fibrosis Score is an effective tool for identifying these patients, according to findings presented at Digestive Disease Week.

“Non-alcoholic fatty liver disease affects 80 million Americans and is associated with metabolic syndrome,” Namphuong Tran, MD, of California Pacific Medical Center, San Francisco, and colleagues wrote. “Patients with NAFLD and NASH can be clinically asymptomatic as they progress to cirrhosis; early identification is essential for preventing disease progression.”

The researchers performed a retrospective review of medical records among adults aged 50 years and older who had been diagnosed with diabetes and were seen between 2013 and 2016.

The initial review conducted by the researchers identified 847 patients at greater risk for NASH with fibrosis. Patients were considered to be at high risk for NASH with advanced fibrosis (F3-F4) if their NAFLD Fibrosis Score was less than 0.655. Patients were classified as indeterminate risk if their NAFLD Fibrosis Score was between -1.455 and 0.655 and low risk if their scores were lower than -1.455. Ultrasound features considered indicative of advanced fibrosis included portal vein size of greater than 10 mm, splenomegaly and the presence of hepatic parenchymal heterogeneity.

Eligible patients had alanine aminotransferase levels above the upper limit of normal (40 U/L). Patients were excluded if they had ALT levels higher than 400 IU/L and chronic hepatitis B or C infection. Women were excluded if they reported consuming more than 14 standard drinks per week; men were excluded if they reported consuming more than 21 drinks per week.

Following exclusions, the cohort consisted of 110 patients, including 56 men and 54 women.

Mean age of patients was 69 years (+/- 1.7 years) and average BMI was 27.31 kg/m²(+/- 3.5 kg/m²). Average alanine aminotransferase was 70.1 U/L (+/- 28.6 U/L).

More than half of the patients (59%; n = 65) had an indeterminate risk for advanced fibrosis, while approximately a quarter of patients (26.3%; n = 29) were considered low risk. Only 14.5% of the cohort (n = 16) were determined to be at high risk for advanced fibrosis.

Abdominal ultrasounds were available for 13.7% (n = 4) of the low-risk patients, 27.5% (n = 8) of the indeterminate-risk patients and 58.6% (n = 17) of the high-risk patients. Features indicative of advanced fibrosis were most common in the high-risk group, with 75.9% of patients (n = 22) demonstrating such features. These features were less common in the low-risk (n = 0) and indeterminate-risk (24.1%; n = 7) groups. Nine patients – including four in the low-risk group, two in the indeterminate-risk group and three in the high-risk group – were referred to a hepatologist.

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While patients at risk for NASH may not be readily identified in the primary care setting, the NAFLD Fibrosis Score “is a simple, validated clinical equation” that can help identify these patients, according to the researchers.

“Higher-risk patients who undergo abdominal ultrasound may have correlating radiographic features of otherwise asymptomatic advanced fibrosis, further demonstrating the importance of diligent recognition of risk,” they wrote. “Efforts to identify these patients at highest risk in primary care could lead to earlier identification and treatment of patients and ultimately reduce the growing complications of advanced disease.” - by Julia Ernst, MS

Reference:

Tran N, et al. Abstract Sa1643. Presented at: Digestive Disease Week; May 18-21, 2019; San Diego.

Disclosures: Tran reports no relevant financial disclosures. Please see the abstract for a list of all other authors’ relevant financial disclosures.