Screening test combo suggested for NAFLD fibrosis

Prof Elizabeth Powell

GPs and all specialists managing patients with metabolic risk factors could be screening for clinically significant fibrosis associated with non-alcoholic fatty liver disease (NAFLD), Queensland researchers say.

A study of patients with NAFLD and attending either a type 2 diabetes clinic at a major Brisbane hospital or an integrated primary-secondary care diabetes service identified clinically significant fibrosis in about 28% of the group.

For more than 90% of these patients with clinically significant fibrosis, this was a new diagnosis leading to a change in management and a recommendation of ongoing review in a liver clinic including surveillance for liver cancer.

The study found simple scoring tools such as the FIB-4 test and NAFLD fibrosis score often lacked accuracy, and further assessment with liver stiffness measurements via FibroScan and/or the Enhanced Liver Fibrosis (ELF) test was required to appropriately stratify patients according to fibrosis risk.

“Overall, 77.6% of patients had indeterminate or high scores in at least one test (FIB-4 test and NAFLD fibrosis score),” the study authors said.

Furthermore, FibroScan measurements may be confounded by severe obesity, and age could impact the ELF test. However a combination of the two tests may enhance accuracy and confidence in identifying clinically significant fibrosis, they added.

Professor Elizabeth Powell, from the Department of Gastroenterology and Hepatology at the Princess Alexandra Hospital, told the limbic the rates of NAFLD were ‘very sobering and concerning’.

She said there was recognition in Europe that liver disease would shortly overtake ischemic heart disease as the leading cause of years of working life lost.

And the situation was complicated by low awareness of NAFLD, the asymptomatic nature of early liver disease, and the difficulty accessing non-invasive tests like FibroScan and the ELF test.

“NAFLD is really important and we are trying to raise awareness in the general community and also among GPs to start thinking about fatty liver disease because it is very, very common in their patient group.”

“GPs see a lot of patients with metabolic risk factors, with type 2 diabetes, hypertension, cardiovascular disease and those are the patient groups where NAFLD is very common.”

“About 70-80% of people with central obesity have a fatty liver on imaging; about 80% of people with T2D.”

Professor Powell said their research was aimed at developing pragmatic strategies to help identify people at risk of progressive liver scarring.

“Noninvasive serum biomarkers are a very good way to start and we suggest using these simple scores in the community. They are pretty good at ruling out advanced liver scarring but a proportion of people will have either high scores or indeterminate scores and they need a second line test.”

She said it was unfortunate that neither FibroScan nor ELF tests were publicly funded in Australia.

“The next piece of work we are going to do is to try and move these second line tests back into the community so that GPs can start to use them as well, so we can streamline the process of risk stratification a bit better.”

“It’s very important that the step of assessing liver scarring is undertaken so people with clinically significant liver disease aren’t missed.”

“At the moment there are no Australian recommendations to screen for fatty liver in the community, but most guidelines would suggest that NAFLD with advanced fibrosis should be identified in people at risk (age >50 years, type 2 diabetes or metabolic syndrome), because of its prognostic implications.”

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