MASLD requires multidisciplinary care to ‘improve global metabolic, liver health’
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Finding adequate providers with the expertise to treat the growing population of patients with chronic liver diseases, including metabolic dysfunction-associated steatotic liver disease, is a challenging but important endeavor.
In 2017, a study published in Hepatology provided an updated assessment of the hepatology workforce. At the time of publication, the focus of most hepatologists was treating the large number of hepatitis C virus-infected patients, but there was already recognition of a growing population of patients with MASLD. The study predicted there would be a paucity of dedicated hepatology providers available to treat this expanding burden of liver disease.
A follow-up study in 2020 formally modeled the predicted shortages of hepatology providers by reconciling economic demand and socioeconomic needs with the number of available hepatology providers. They estimated a 10% shortage of adult hepatology providers in 2023, which would increase to 35% in 2033.
Clinical Burden of MASH ‘Already Being Felt’
As predicted, MASLD prevalence has grown exponentially over the past decade, affecting 35% of the North American population. Of these patients, 30% will have the more dangerous and progressive form of MASLD called metabolic dysfunction-associated steatohepatitis.
The clinical burden of MASH is already being felt, as it is the most rapidly growing indication for liver transplantation and represents the No. 1 underlying liver disease in women, patients older than 65 years and those with hepatocellular carcinoma awaiting LT.
Given the paucity of available dedicated hepatology providers, it will be critical to engage gastroenterologists and others with expertise in treating metabolic disease — primary care providers, endocrinologists, cardiologists, obesity medicine providers, dieticians — to help identify patients with high-risk MASH and link them to appropriate evaluation and treatment resources. As such, these providers will need to be knowledgeable of the fundamental aspects of liver disease evaluation and management.
Primary, Metabolic Care Providers Must Help Screen
The AASLD, AGA, the American Association of Clinical Endocrinology and other gastrointestinal and liver societies have recently released various care pathways that seek to risk-stratify patients with MASLD to limit the population of patients who need to be referred to only those with a high risk for advanced liver disease. However, the majority of patients with even low-risk MASLD will have elevated liver-related blood tests.
A critical component of evaluating patients with MASLD is screening for alternative causes for elevated liver blood tests, a task usually managed by GI and hepatology providers. Given the anticipated size of the patient population requiring this evaluation, primary or other metabolic care providers will also need to be able to perform this task. This will limit GI and hepatology referrals to only those patients with abnormal or inconclusive screening tests or those at risk for advanced MASH.
It will therefore be important for GI and hepatology societies to engage and train other providers to provide this screening evaluation.
Understanding Disease Nuances Can Help Providers ‘Tailor Their Treatments’
MASLD is a new nomenclature that was recently instituted to better clarify the disease as a metabolic syndrome-related disorder. Like other metabolic syndrome disorders, such as diabetes, cardiovascular disease and obesity, requires multidisciplinary care. It is the duty of the MASLD provider to ensure they are giving or arranging comprehensive metabolic care.
Despite this, it is clear that some, if not most, obesity and metabolic care for patients will need to be performed by other specialties such as endocrinology, cardiology, obesity medicine, psychology/psychiatry, dietetics and sleep medicine. The management decisions made by these providers can have signifi cant impact on MASH and liver-related health.
Understanding the nuances of liver disease that are affected by the management of the diseases they treat can help these providers tailor their treatments to improve global metabolic health, including liver health.
Providers Should Be ‘Well-Versed’ in Advanced Liver Disease
Another reason why non-hepatology providers need a fundamental knowledge of hepatology care is because of the burden of MASH-related advanced liver disease expected to flood the health care system.
As more patients with advanced MASH present with liver decompensation, there will be inadequate numbers of hepatology-dedicated providers available to care for them. GI and non-GI providers, including hospitalists and metabolic providers, must be ready to not only identify advanced liver disease but also aid in the management of these patients including evaluation of etiology, referral for treatment, screening for and identifying risk for complications, and patient counseling.
Importantly, providers who are well-versed in the above will also be more able to identify when patients are either too sick or too complex to remain under their care and seek the assistance of more advanced liver disease specialists.
To this point, it is not uncommon for a patient to be referred to a liver transplant (LT) center when their disease has progressed to the point that their life can no longer be saved by a LT. A better understanding of advanced liver disease can help avoid this tragic situation.
Collaborative Care Benefits Disease Progression, Complications
MASLD is a complex, highly prevalent disease that is poised to impart a significant clinical burden on the health care system. There are inadequate hepatology-trained providers to provide appropriate care to this large patient population. Adequate screening, staging, treatment and management of these patients will require the assistance of not only gastroenterology providers but also primary care and metabolic disease specialists.
A collaborative approach to MASH and liver disease care has the potential to positively affect MASH progression and the deleterious complications it can impart to patients and their families.
- References:
- Jinjuvadia R, et al. J Clin Gastroenterol. 2017;doi:10.1097/MCG.0000000000000666.
- Koh JH, et al. Clin Gastroenterol Hepatol. 2024;doi:10.1016/j.cgh.2023.05.019.
- Le MH, et al. Clin Gastroenterol Hepatol. 2022;doi:10.1016/j.cgh.2021.12.002.
- Rinella ME, et al. Hepatology. 2023;doi:10.1097/HEP.0000000000000323.
- Rinella ME, et al. J Hepatol. 2023;doi:10.1016/j.jhep.2023.06.003.
- Repking S, et al. Gastroenterol Nurs. 2023 doi: 10.1097/SGA.0000000000000740.
- Russo MW, et al. Hepatology. 2017;doi:10.1002/hep.28810.
- Russo MW, et al. Hepatology. 2020;doi:10.1002/hep.31425.
- US census quick facts. https://www.census.gov/quickfacts/. Accessed Jan. 20, 2024.
- For more information:
- Sujit V. Janardhan, MD, PhD, Dipl ABOM, is medical director of liver transplant, director of the Weight Intervention in Liver Disease clinical program and assistant professor at Rush University Medical Center. He can be reached at sujit_janardhan@rush.edu.
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