What are AASLD/ACG/AGA guidelines for the workup of nonalcoholic fatty liver disease (NAFLD)?

Updated: Apr 12, 2018
  • Author: Emily Tommolino, MD; Chief Editor: BS Anand, MD  more...
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Recommendations from a 2018 practice guideline from the American Association for the Study of Liver Diseases (AASLD), the American College of Gastroenterology (ACG), and the American Gastroenterological Association (AGA) regarding the workup of nonalcoholic fatty liver disease (NAFLD) are below [24] , with the updated 2018 AASLD recommendations incorporated. [89]

  • Clinicians should look for metabolic risk factors and alternate etiologies for hepatic steatosis in patients who have other types of chronic liver disease and who also have steatosis and steatohepatitis.

  • Patients with nonalcoholic steatohepatitis (NASH) cirrhosis should be screened for gastroesophageal varices and should be considered for hepatocellular carcinoma screening.

  • Screening for NAFLD is not advised in adults attending primary care clinics or high-risk groups attending diabetes or obesity clinics because of uncertainties surrounding diagnostic tests, treatment options, long-term benefits, and cost-effectiveness.

  • Clinicians should have a high index of suspicion for NASH and NAFLD in patients with type 2 diabetes; decision aids such as the NAFLD Fibrosis Score (NFS), vibration-controlled transient elastography (VCTE), or the Fibrosis-4 Index (FIB-4) can be used to determine those individuals who are at risk for advanced fibrosis.

  • Systematic screening of family members of patients with NAFLD is currently not recommended.

  • Competing etiologies for steatosis and coexisting common chronic liver disease must be excluded in patients with suspected NAFLD.

  • Liver biopsy should be considered in patients with suspected NAFLD in whom competing etiologies for hepatic steatosis and coexisting chronic liver diseases cannot be otherwise excluded.
  • Persistently high serum ferritin levels and increased iron saturation may warrant a liver biopsy, especially in patients with homozygous or heterozygous C282Y HFE (hemochromatosis) gene mutations.

  • Patients with high serum titers of autoantibodies and other features suggesting autoimmune liver disease (eg, very high aminotransferases or high globulin levels) should undergo a more thorough workup for autoimmune liver disease.

  • Patients with suspected NAFLD should be considered for evaluation of commonly associated comorbidities, such as dyslipidemia, obesity, insulin resistance or diabetes, hypothyroidism, polycystic ovary syndrome, and sleep apnea.
  • Metabolic syndrome predicts the presence of steatohepatitis in patients with NAFLD and can therefore be used to target patients for a liver biopsy.

  • The NFS or FIB-4 helps to identify patients with NAFLD who have a higher likelihood of having bridging fibrosis or cirrhosis.

  • VCTE or magnetic resonance elastography (MRE) are clinically useful tools for identifying advanced fibrosis in patients with NAFLD.

  • Metabolic syndrome, NFS, or FIB-4, or liver stiffness measured by VCTE or MRE, may be used to identify patients at risk for advanced fibrosis or steatohepatitis.

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