Spotting NASH Starts With Simple Calculations
Approximately 30% of Americans have fatty liver, but only a small proportion have progressed to nonalcoholic steatohepatitis. One of the complications that we face in finding these patients is that our current treatment guidelines for nonalcoholic fatty liver disease do not recommend routine screening. Additionally, it is not feasible to send every patient with potential risk factors for an invasive procedure like liver biopsy. What we have at our disposal, however, are some very simple noninvasive biomarkers and tools to help stratify which patients should be followed for fatty liver and its progression.
Many primary care physicians can struggle with knowing when to evaluate a patient for liver disease and these patients may not see a hepatologist until they have developed severe liver complications. We know that in patients with fatty liver disease the number one cause of death is still cardiovascular disease followed by malignancy. Liver disease is actually the third cause of death in this patient population. This leaves us with a problem of considering resources and cost-effectiveness in identifying patients who could benefit from liver-related evaluations.
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The NAFLD fibrosis score and the Fibrosis-4 index are both easy to calculate, but not many physicians are aware that these tools are available in routine clinical practice. The NAFLD fibrosis score is a validated tool that uses routinely measured laboratory data including platelet count, albumin, alanine aminotransferase and aspartate aminotransferase along with patient characteristics such as age, BMI and impaired fasting glucose/diabetes status. Similarly, the Fibrosis-4 index or FIB-4 tool calculates a patient’s risk using their age, platelet count and AST and AL. Another option is to use transient elastography such as the FibroScan device from Echosens. FibroScan has continued to show significant accuracy in non-invasively evaluating amount of hepatic steatosis and fibrosis.
Obviously, each test has its limitations, and depending on the individual patient one may be more accurate than another. A particular challenge stems from concerns about cost-effectiveness and health care resource utilization. In current clinical practice we try and make use of multiple easily accessible non-invasive tests that can help avoid liver biopsy or missing a patient with advanced liver disease. This can be particularly helpful when an individual test result returns with an “indeterminant” staging result.
As physicians, our thought process and recommendations for how we should approach screening and risk stratification will be dynamic over the next few years. There is no recommendation for screening right now, even in patients at high risk of having NAFLD, but this will likely change in the not-too-distant future.
Future guidelines will likely recommend evaluating patients with metabolic syndrome and patients with type 2 diabetes for potential underlying liver disease because those are the patients that are more likely to have NASH and significant fibrosis. For now, it’s important to raise awareness about routinely available non-invasive scoring systems based on labs that can help risk stratify patients and identify individuals who are in most need of further evaluation.
Disclosures: Tincopa reports no relevant financial disclosures.