Identifying Patients With NAFLD, NASH in the Clinic

With no approved medications for the treatment of nonalcoholic fatty liver disease (NAFLD) or nonalcoholic steatohepatitis (NASH), health care providers must emphasize lifestyle changes, treatment of comorbidities, and careful staging and monitoring of disease, according to the speaker at the session about Clinical Management of NASH at the American Association for the Study of Liver Diseases (AASLD) annual meeting.

Mazen Noureddin, MD, MHSc, who is the director of the of the Fatty Liver Program at Cedars-Sinai Medical Center in Los Angeles, California, addressed the issue of identifying which patients with NAFLD or NASH are at the highest risk of progression to more severe disease, including increasing levels of fibrosis and on to cirrhosis.

“Staging is often done by biopsy, which has its own issues,” Dr Noureddin said, including its invasive nature and the practicality and costs of conducting biopsies when NAFLD and NASH are becoming more prevalent.” However, he said, staging is important in the overall management of these conditions, because patients with stage 2 fibrosis or higher “are at higher risk of ascites, hepatic encephalopathy, variceal bleeds, and overall mortality.”       

Several methods of noninvasive testing that are accurate in staging liver disease are now available. Dr Noureddin reviewed numerous studies of both serologic markers and imaging studies, including Fibrosis-4 (FIB-4), NAFLD Fibrosis Score (NFS), cholyl-lysyl-fluorescein (CLF), and propeptide of type III collagen (Pro-C3), and enhanced liver fibrosis (ELF) have demonstrated accuracy in assessing fibrosis and histological features of liver disease, he explained. By conducting several noninvasive tests in sequence, clinicians can better identify patients who requires intervention and those who are low risk of disease progression.

Imaging tests can refine the identification of patients even further, Dr Noureddin explained. Vibration-controlled transient elastography (VCTE) and magnetic resonance elastrography (MRE) provide accurate measures of tissue stiffness, a marker of fibrosis. These tests are among those recommended by AASLD and other professional societies for staging and monitoring patients with NAFLD and NASH.

Several scoring systems that combine results from marker and imaging tests have been developed to lend even greater precision to staging of liver disease, helping to determine therapeutic interventions and monitoring patients during their care.

However, Dr Noureddin noted, “With these menus, we also have to use clinical judgement, as medicine is an art as much as a science.”

—Rebecca Mashaw

Reference:

Noureddin M. How do I identify patients with NASH who are at greatest risk of disease progression? Talk presented at: American Association for the Study of Liver Diseases annual meeting; November 13, 2020. Virtual.