New System Detects Cirrhosis in Fatty Liver Disease

Damian McNamara

April 26, 2017

AMSTERDAM — A two-step risk-stratification process for patients in primary care with nonalcoholic fatty liver disease (NAFLD) can identify advanced fibrosis and cirrhosis, according to a 2-year analysis.

"NAFLD is a major healthcare problem confronting primary care physicians, with a prevalence of 25% to 40% in the European and US populations," said Ankur Srivastava, MD, from the University College London Institute for Liver and Digestive Health.

"The challenge is identifying patients with liver fibrosis, a major determinant of morbidity and mortality," he told Medscape Medical News.

Dr Srivastava presented results from a 2-year assessment of an NAFLD pathway designed for primary care here at the International Liver Congress 2017. The first step in the process was to assess risk for advanced fibrosis or cirrhosis using the Fibrosis-4 Index.

Assessing Risk

Patients with a Fibrosis-4 score below 1.30 were considered to be at low risk. Aggressive primary care management of any metabolic disorder or weight issue was recommended, along with annual follow-up. Patients with a Fibrosis-4 score above 3.5 were considered to be at high risk, and were referred to a hepatologist for further workup and treatment.

For the remaining patients, Fibrosis-4 sensitivity and specificity neither confirmed nor disproved the presence of liver fibrosis. These patients were considered to be at indeterminate risk, and underwent subsequent Enhanced Liver Fibrosis testing.

A liver fibrosis score below 9.5 indicated low risk and a score above 9.5 triggered a specialty referral.

Detection of advanced fibrosis or cirrhosis was 7.4 times higher with this strategy than with the previous standard of care, in which the physician assessed need for referral.

"Overall, 81.1% were stratified as low risk and recommended for management in primary care," Dr Srivastava reported. For the other 18.9% of patients, referral to a specialist was recommended.

The number needed to refer to identify one patient with advanced fibrosis or cirrhosis was much lower with the stratification pathway than without (3.4 vs 13.1). "This means there was a 3.9-fold decrease in 'inappropriate' referrals," Dr Srivastava explained.

Table. Risk Stratification of Primary Care Patients (n = 1452)

Level of Risk Fibrosis-4 Test, % Enhanced Liver Fibrosis Test, %
Low 71.3 40.0
Indeterminate 25.0
High 3.7 60.0


Reducing the referral of milder cases "could improve efficiency and use of healthcare resources," Dr Srivastava pointed out.

"Strategies to improve earlier cirrhosis detection are developed to improve liver-related outcomes for patients with NAFLD," he said, and "these real-life data provide proof-of-concept evidence" that they work.

"The study was well conducted, and the results are intriguing," said Fabio Piscaglia, MD, from the University of Bologna in Italy.

This pathway will help optimize resources "and leave more time for doctors to see advanced cases at tertiary care centers," he told Medscape Medical News. It is also a way to deliver better healthcare at the primary care level, because it presents an opportunity to counsel all patients, regardless of risk, he pointed out.

It's important that patient management does not stop with the test.

"If the primary care physician finds that a patient does not have advanced fibrosis and is fine, the patient often continues to live the same lifestyle," Dr Piscaglia explained. But these patients could go on to develop fibrosis, "so it's important that patient management does not stop with the test."

Session comoderator Vincent Wong, MD, from the Chinese University of Hong Kong in Sha Tin, asked how the pathway was received by primary care doctors.

"We have two cohorts," Dr Srivastava explained. There are the enthusiastic GPs who see this as a real problem, and then there are the GPs that "needed to be motivated to use the pathway."

He said he and his team hold educational events to promote its use, "but ultimately, the management of the patient comes down to the GP."

Dr Srivastava is on the speakers bureau for Siemens Healthcare. Dr Piscaglia is on the advisory board for Bayer and Eisai, is a researcher for Esaote, and is on the speakers bureau for Bayer, Bracco, and Meda Pharma.

International Liver Congress (ILC) 2017: Abstract PS-121. Presented April 22, 2017.

Follow Medscape Gastroenterology on Twitter @MedscapeGastro and Damian McNamara @MedReporter


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