Fatty Liver A Primary Care Approach

Описание: Neil Skolnik reviews the latest guidelines for a condition that PCPs see a lot of but may be failing to notice.
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-- TRANSCRIPT --
I'm Dr Neil Skolnik. Today, we are going to talk about two guidelines: the American Association for the Study of Liver Diseases (AASLD) clinical assessment and management of nonalcoholic fatty liver disease (NAFLD) and the American Association of Clinical Endocrinology Clinical Practice Guideline for the Diagnosis and Management of Nonalcoholic Fatty Liver Disease in Primary Care and Endocrinology Clinical Settings, co-sponsored by AASLD.

Very few things do we see more and notice less than NAFLD.

NAFLD is present in over one quarter of the population in general and in over half of individuals with type 2 diabetes, and it doesn't exist in isolation. The relation between NAFLD and metabolic syndrome, including obesity and diabetes, is bidirectional: Each makes the other worse.

Let's clarify terminology. NAFLD refers to all grades of fatty liver disease, defined as more than 5% of hepatocytes having microvesicular steatosis when no other cause is identified. What really concerns us is when fatty infiltration of the liver leads to inflammation of the liver. Then it is called nonalcoholic steatohepatitis (NASH). This occurs in about one out of six people with NAFLD, with a higher proportion in people with type 2 diabetes. When NASH progresses to high-grade fibrosis, defined as stage 2 or higher fibrosis, rate and risk for progression to cirrhosis and liver failure are increased.

The algorithm for the evaluation of NAFLD is essentially constructed to identify those patients who are unlikely to have clinically significant fibrosis so that those people can be confidently given lifestyle interventions and follow-up without a need for further referral. Individuals who are at higher risk can then receive further evaluation.

NAFLD is usually found incidentally on ultrasound that is done for some other reason, as part of the evaluation of abnormal liver function tests, or as a part of targeted screening. Targeted screening can be considered for people at increased risk for NAFLD, such as those with type 2 diabetes or obesity with metabolic complications. Screening is best done using a validated NAFLD risk calculator, such as the FIB-4, which I'll discuss shortly.

So how should we approach NAFLD? First, other etiologies of liver disease need to be reasonably ruled out. The extent of the evaluation that is needed is a matter of clinical judgement and is not directly addressed in the guidelines. Here's my opinion. Ask about alcohol use and check hepatitis serologies as well as a ferritin level and a celiac disease panel. Additional testing such as antinuclear antibody, anti–smooth muscle antibody, alpha-1 antitrypsin, ceruloplasmin, microsomal antibody, and protein electrophoresis may or may not be indicated.

Patients who are at high risk for NAFLD based on metabolic risk factors or when fatty infiltration of the liver is incidentally identified by imaging should undergo primary risk assessment with a validated NAFLD risk calculator. The best validated and most frequently used risk calculator is the FIB-4. The FIB-4 score is calculated using a simple algorithm where you input the patient's age, alanine transaminase and aspartate transaminase levels, and platelet count.

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