A 2-step fibrosis assessment pathway can streamline hepatology referrals for NAFLD and may facilitate a more cost-effective and targeted use of specialist hepatology resources, Australian research shows.
The Towards Collaborative Management of NAFLD (TCM-NAFLD) pathway comprised an overall risk stratification by GPs using online calculators for the NAFLD Fibrosis Score (NFS) and FIB-4 scores.
Patients with two low scores were classified as low risk for advanced fibrosis and remained with their GP for ongoing monitoring and management of cardiometabolic risk factors.
Patients who returned at least one high score were classified as high risk for advanced fibrosis and referred to a hepatology management clinic at a nearby hospital for further assessment.
Indeterminate risk patients – if one or both scores were indeterminate and neither score was high – required a community-based Fibroscan to further assess fibrosis severity. Patients with liver stiffness measurements <8.0 KPa were followed up in primary care while those with a higher measurement were referred to the hepatology management clinic.
The feasibility study, published in the Internal Medicine Journal, by clinicians from the Department of Gastroenterology and Hepatology, Princess Alexandra Hospital, Brisbane, comprised 162 patient assessments.
“The overall prevalence of clinically significant fibrosis (≥F2) was 9.2%,” they noted
The study found that most patients without clinically significant fibrosis (87.8%) avoided referral to secondary care, and almost half of patients evaluated in secondary care (45.2%) had at least clinically significant fibrosis.
Two patients designated low risk on the basis of their NFS and FIB-4 scores were referred to hospital due to clinical concerns – one due to splenomegaly on imaging and one on methotrexate therapy.
The study noted that five patients scored low on the FIB-4 and may not have received further evaluation if composite scoring had not been used in step-1 of the TCM-NAFLD pathway.
“In our unselected primary care cohort of patients with NAFLD, we found fibrosis assessment was attainable and streamlined referrals to local hepatology clinics.”
“Although it’s not yet known whether community-based NAFLD fibrosis assessment pathways reduce future adverse liver outcomes, modelling in the UK suggests the approach is cost efficient and improves resource utilisation,’ the study said.
A strategy for streamlining referrals from general practice sits within the context of NAFLD reaching “epidemic proportions” in the community.
An historical narrative on NAFLD published in JHEP Reports traces it from first descriptions in the early-mid 19th Century, its association with diabetes in the early-mid 20th Century, to a new name (MAFLD) and better understanding of the heterogeneous disease in the 21st Century.
“Rising population-level trends in obesity, diabetes and other metabolic risk factors provide a prescient warning of a potential cascade of NAFLD, MAFLD, NASH, cirrhosis and HCC cases, as a silent but predictable epidemic,” its author WA gastroenterologist Dr Oyekoya Ayonrinde wrote.