Associate Professor Leon Adams
The forecasted scale of the problem of metabolic (dysfunction) associated fatty liver disease (MAFLD) – its global prevalence now at 37% and rising – will create challenges in its management.
Associate Professor Leon Adams, from the Sir Charles Gairdner Hospital and the University of Western Australia, told AGW 2023 that GPs and specialists would have to work effectively together to manage the spectrum of disease.
“We know from our clinics that there is an under-awareness of MAFLD out in the community amongst our GPs and that patients are being referred late with advanced disease and yet patients who don’t need the services of a hepatologist are being referred for a specialist assessment,” he said.
However new GESA recommendations for the assessment, diagnosis and monitoring of MAFLD in primary care will assist, he said.
Associate Professor Adams presented 21 evidence-based recommendations after a robust process including a systematic review of the literature, three Delphi rounds and consensus building.
The panel included hepatologists, GPs, endocrinologists, other metabolic experts and stakeholder groups.
“The target audience is GPs but we are the ones who will educating and disseminating it to our primary care colleagues.”
He said the guidance will hopefully improve awareness and recognition of MAFLD, increase the detection of advanced disease in the community, facilitate appropriate referrals and ultimately improve patient care.
Many of the recommendations address the assessment and monitoring of MAFLD comorbidities including obesity, type 2 diabetes, cardiovascular disease, obstructive sleep apnoea and chronic kidney disease.
“We did not want to reinvent the wheel regarding management of these comorbidities so we have referenced the existing guidelines. This includes the assessment of obesity according to the Australian Obesity Management Algorithm [link here] and screening for underlying type 2 diabetes recognising that the prevalence in MAFLD is higher than in the general population.”
Associate Professor Adams said liver ultrasound should be the first line test to diagnose hepatitis steatosis in people at high risk of MAFLD.
There was also a recommendation to assess for other common causes of fatty liver disease including screening for harmful alcohol use, medications and viral hepatitis.
“As part of this, people with MAFLD and elevated serum aminotransferase levels should undergo baseline evaluation for hepatitis B and C infection, nopting that the prevalence in Australia is between 0.5 and 1%,” he said.
Patients with elevated LFTs are should also undergo evaluation for iron overload.
Liver fibrosis
Associate Professor Adams told the meeting that non-invasive testing should be offered to people with MAFLD to assess their risk of liver fibrosis.
The FIB-4 was recommended as the first line test to “rule out” advanced liver disease with second line testing including liver elastography or a direct liver fibrosis test.
“We’ve deliberately been a little bit vague about the definition of direct liver fibrosis tests acknowledging that there are new tests which will become available in the future.”
He said patients with evidence of cirrhosis should be referred for liver specialist review.
Patients with initially low and indeterminate FIB-4s should undergo repeat testing at a 3-year time interval.
Associate Professor Adams said there was no absolute chronological age cut-off for monitoring for fibrosis progression.
However from about 75 years, depending on physiological age and comorbidities, the benefit of assessing for fibrosis in a slowly progressive disease was undermined by the competing risks of other conditions.
The recommendations include 6-monthly surveillance for HCC in patients with cirrhosis.
“We felt this was an important recommendation to start to introduce into the primary care space because we foresee that the burden of cirrhosis related to fatty liver disease will overwhelm our speciality clinics,” he said.
Associate Professor Adams told the limbic that FIB-4 was not perfect and there was a need for access to good specific biomarkers.
“So what that will do is reduce the amount of inappropriate referrals and it’ll actually pick up more patients with occult disease that may be missed by FIB-4 just by virtue of being more accurate. The downside there is the cost so I think it’s heavily reliant on cost effective analyses, and we’re doing some work to try to look into that to help those decisions.”
The GESA recommendations are going through the process of endorsement and will be ready for dissemination in 2024.