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Karhiaho IP, Kurki SH, Parviainen HI, Kullamaa L, Färkkilä MA, Matikainen N, Tuomi T. The hidden epidemic: Uncovering incidental fatty liver disease and its metabolic comorbidities by datamining in a hospital data lake - A real-world cohort study. Diabetes Res Clin Pract 2024; 210:111609. [PMID: 38479446 DOI: 10.1016/j.diabres.2024.111609] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2023] [Revised: 02/20/2024] [Accepted: 03/10/2024] [Indexed: 03/18/2024]
Abstract
AIMS To identify individuals with incidental fatty liver disease (FLD), and to evaluate its prevalence, metabolic co-morbidities and impact on follow-up. METHODS We leveraged the data-lake of Helsinki Uusimaa Hospital district (Finland) with a population of 1.7 million (specialist and primary care). A phrase recognition script on abdominal imaging reports (2008-2020) identified/excluded FLD or cirrhosis; we extracted ICD-codes, laboratory and BMI data. RESULTS Excluding those with other liver diseases, the prevalence of FLD was 29% (steatosis yes/no, N=61,271/155,521; cirrhosis, N=3502). The false positive and negative rates were 5-6%. Only 1.6% of the FLD cases had the ICD code recorded and 32% had undergone full clinical evaluation for associated co-morbidities. Of the 35-65-year-old individuals with FLD, 20% had diabetes, 42% prediabetes and 28% a high liver fibrosis index. FLD was independently predicted by diabetes (OR 1.56, CI 1.46-1.66, p = 2.3 * 10^-41), BMI (1.46, 1.42-1.50, p = 1.7 * 10^-154) and plasma triglyceride level (1.5, 1.43-1.57, p = 3.5 * 10^-68). Alanine aminotransferase level mildly increased (1.12, 1.08-1.16, p = 2.2 * 10^-9) and high age decreased the risk (0.92, 0.89-0.94, p = 4.65*10^-09). Half of the cases had normal ALT. CONCLUSIONS The incidental radiological finding of FLD is reliable and associated with metabolic risks but largely ignored, although it should lead to metabolic and hepatic follow-up.
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Affiliation(s)
- Iiro P Karhiaho
- Endocrinology, Abdominal Center, Helsinki University Hospital, Helsinki, Finland
| | - Samu H Kurki
- Endocrinology, Abdominal Center, Helsinki University Hospital, Helsinki, Finland; Institute for Molecular Medicine Finland, University of Helsinki, Helsinki, Finland
| | - Helka I Parviainen
- Medical Imaging Center, Department of Radiology, Helsinki University Hospital and University of Helsinki and Department of Radiology, Vaasa Central Hospital, Wellbeing Services County of Ostrobothnia, Finland
| | - Liisa Kullamaa
- Endocrinology, Abdominal Center, Helsinki University Hospital, Helsinki, Finland
| | - Martti A Färkkilä
- Gastroenterology, Abdominal Center, Helsinki University Hospital, Helsinki, Finland
| | - Niina Matikainen
- Endocrinology, Abdominal Center, Helsinki University Hospital, Helsinki, Finland; Research Program of Clinical and Molecular Metabolism, University of Helsinki, Helsinki, Finland
| | - Tiinamaija Tuomi
- Endocrinology, Abdominal Center, Helsinki University Hospital, Helsinki, Finland; Institute for Molecular Medicine Finland, University of Helsinki, Helsinki, Finland; Research Program of Clinical and Molecular Metabolism, University of Helsinki, Helsinki, Finland; Folkhälsan Research Centre, Helsinki, Finland; Lund University, Diabetes Centre, Malmo, Sweden.
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Chhatwal J, Hajjar A, Mueller PP, Nemutlu G, Kulkarni N, Peters MLB, Kanwal F. Hepatocellular Carcinoma Incidence Threshold for Surveillance in Virologically Cured Hepatitis C Individuals. Clin Gastroenterol Hepatol 2024; 22:91-101.e6. [PMID: 37302445 PMCID: PMC10709527 DOI: 10.1016/j.cgh.2023.05.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Revised: 05/13/2023] [Accepted: 05/20/2023] [Indexed: 06/13/2023]
Abstract
BACKGROUND & AIMS Guidelines recommend biannual surveillance for hepatocellular carcinoma (HCC) in hepatitis C individuals with cirrhosis if the HCC incidence rate is above 1.5 per 100 person-years (PY). However, the incidence threshold for surveillance in individuals who achieve a virologic cure is unknown. We estimated the HCC incidence rate above which routine HCC surveillance is cost-effective in this growing population of virologically cured hepatitis C individuals with cirrhosis or advanced fibrosis. METHODS We developed a Markov-based microsimulation model of the natural history of HCC in individuals with hepatitis C who achieved virologic cure with oral direct-acting antivirals. We used published data on the natural history of hepatitis C, competing risk post virologic cure, HCC tumor progression, real-world HCC surveillance adherence, contemporary HCC treatment options and associated costs, and utilities of different health states. We estimated the HCC incidence above which biannual HCC surveillance using ultrasound and alpha-fetoprotein would be cost-effective. RESULTS In virologically cured hepatitis C individuals with cirrhosis or advanced fibrosis, HCC surveillance is cost-effective if HCC incidence exceeds 0.7 per 100 PY using $100,000 per quality-adjusted life year willingness-to-pay. At this HCC incidence, routine HCC surveillance would result in 2650 and 5700 additional life years per 100,000 cirrhosis and advanced fibrosis persons, respectively, compared with no surveillance. At $150,000 willingness-to-pay, surveillance is cost-effective if HCC incidence exceeds 0.4 per 100 PY. Sensitivity analysis showed that the threshold mostly remained below 1.5 per 100 PY. CONCLUSIONS The contemporary HCC incidence threshold is much lower than the previous 1.5% incidence value used to guide HCC surveillance decisions. Updating clinical guidelines could improve the early diagnosis of HCC.
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Affiliation(s)
- Jagpreet Chhatwal
- Institute for Technology Assessment, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts; Dana Farber/Harvard Cancer Center, Boston, Massachusetts; Liver Center and Gastrointestinal Division, Massachusetts General Hospital, Boston, Massachusetts.
| | - Ali Hajjar
- Institute for Technology Assessment, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts; Prince Mohammed Bin Salman College of Business & Entrepreneurship, King Abdullah Economic City, Saudi Arabia
| | - Peter P Mueller
- Institute for Technology Assessment, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Gizem Nemutlu
- Institute for Technology Assessment, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts; Brandeis International Business School, Brandeis University, Boston, Massachusetts
| | - Neeti Kulkarni
- Institute for Technology Assessment, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Mary Linton B Peters
- Institute for Technology Assessment, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts; Division of Medical Oncology, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Fasiha Kanwal
- Department of Medicine, Baylor College of Medicine, Houston, Texas; Houston Veterans Affairs Health Services Research and Development Center of Excellence, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas
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Anand A, Shalimar, Arora U, Asadullah M, Shivashankar R, Biswas S, Vaishnav M, Aggarwal A, Kandasamy D, Kondal D, Rautela G, Peerzada A, Grover B, Amarchand R, Nayak B, Sharma R, Ramakrishnan L, Prabhakaran D, Krishnan A, Tandon N. ABDA Score: A Non-invasive Model to Identify Subjects with Fibrotic Non-alcoholic Steatohepatitis in the Community. J Clin Exp Hepatol 2023; 13:742-752. [PMID: 37693275 PMCID: PMC10482999 DOI: 10.1016/j.jceh.2023.03.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Accepted: 03/22/2023] [Indexed: 09/12/2023] Open
Abstract
Background Non-alcoholic fatty liver disease and non-alcoholic steatohepatitis (NASH) are prevalent in the community, especially among those with metabolic syndrome. Patients with fibrotic NASH are at increased risk of liver-related-events. Currently available non-invasive tests have not been utilized for screening for fibrotic NASH among the community. We aimed to develop a screening tool for fibrotic NASH among community members. Methods We included two large cohorts aimed at assessing cardiovascular disease among community members. Fibrotic NASH was defined using the FibroScan-aspartate aminotransferase score of ≥0.67 that identifies ≥F2 fibrosis and a non-alcoholic fatty liver disease activity score ≥4 with a specificity of 90%. Metabolic parameters, biochemical tests and anthropometry were used to develop a multivariate model. Results The derivation cohort (n = 1660) included a population with a median age 45 years, 42.5% males, metabolic syndrome in 66% and 2.7% (n = 45) with fibrotic NASH. Multivariate analysis identified the four significant variables (Age, body mass index , Diabetes and alanine aminotransferas levels) used to derive an ABDA score. The score had high diagnostic accuracy (the area under receiver-operating characteristic curve, 0.952) with adequate internal validity. An ABDA score ≥-3.52 identified fibrotic NASH in the derivation cohort with a sensitivity and specificity of 88.9% and 88.3%. The score was validated in a second cohort (n = 357) that included 21 patients (5.9%) with fibrotic NASH, where it demonstrated a high area under receiver-operating characteristic curve (0.948), sensitivity (81%) and specificity (89.3%). Conclusions ABDA score utilizes four easily available parameters to identify fibrotic NASH with high accuracy in the community.
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Affiliation(s)
- Abhinav Anand
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, New Delhi, India
| | - Shalimar
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, New Delhi, India
| | - Umang Arora
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, New Delhi, India
| | - Md Asadullah
- Centre for Community Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Roopa Shivashankar
- Division of Non-communicable Diseases, Indian Council of Medical Research, New Delhi, India
| | - Sagnik Biswas
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, New Delhi, India
| | - Manas Vaishnav
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, New Delhi, India
| | - Arnav Aggarwal
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, New Delhi, India
| | | | - Dimple Kondal
- Public Health Foundation of India, Gurgaon, Haryana, India
| | | | - Ariba Peerzada
- Department of Endocrinology and Metabolism, All India Institute of Medical Sciences, New Delhi, India
| | - Bhanvi Grover
- Department of Endocrinology and Metabolism, All India Institute of Medical Sciences, New Delhi, India
| | - Ritvik Amarchand
- Centre for Community Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Baibaswata Nayak
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, New Delhi, India
| | - Raju Sharma
- Department of Radiodiagnosis, All India Institute of Medical Sciences, New Delhi, India
| | - Lakshmy Ramakrishnan
- Department of Cardiac Biochemistry, All India Institute of Medical Sciences, New Delhi, India
| | | | - Anand Krishnan
- Centre for Community Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Nikhil Tandon
- Department of Endocrinology and Metabolism, All India Institute of Medical Sciences, New Delhi, India
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Urias E, Chen VL. Screening for At-Risk Nonalcoholic Fatty Liver Disease in the Primary Care Setting. Semin Liver Dis 2023; 43:133-141. [PMID: 37105224 PMCID: PMC10668862 DOI: 10.1055/a-2082-5203] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/29/2023]
Abstract
While nonalcoholic fatty liver disease is a leading cause of end-stage liver disease, most patients with nonalcoholic fatty liver disease do not develop cirrhosis and its complications. Therefore, risk stratification using inexpensive, noninvasive screening modalities is critical to avoid overdiagnosis and overtreatment of a large proportion of the population. In this review, we discuss the data supporting screening and current professional society recommendations on this topic. Screening for at-risk nonalcoholic fatty liver disease is recommended in patients with risk factors including diabetes, the metabolic syndrome, hepatic steatosis, and elevated aminotransferases. Screening typically consists of noninvasive testing using serum biomarkers followed by elastography using specialized imaging modalities. This sequential screening approach accurately identifies both high- and low-risk patients and is cost-effective when applied to at-risk populations. In conclusion, screening for advanced nonalcoholic fatty liver disease in the primary care setting is a crucial part of identifying high-risk patients who may benefit from aggressive intervention while avoiding overtreatment of patients at low risk of liver-related complications.
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Affiliation(s)
- Esteban Urias
- Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan
| | - Vincent L Chen
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan
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Sangha K, Chang ST, Cheung R, Deshpande VS. Cost-effectiveness of MRE versus VCTE in staging fibrosis for nonalcoholic fatty liver disease (NAFLD) patients with advanced fibrosis. Hepatology 2023; 77:1702-1711. [PMID: 37018145 DOI: 10.1097/hep.0000000000000262] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Accepted: 11/14/2022] [Indexed: 04/06/2023]
Abstract
INTRODUCTION NAFLD is a common cause of liver disease. To determine the optimal testing strategy for NAFLD patients with advanced fibrosis, several factors such as diagnostic accuracy, failure rates, costs of examinations, and potential treatment options need to be considered. The purpose of this study was to determine the cost-effectiveness of combination testing involving vibration-controlled transient elastography (VCTE) versus magnetic resonance elastography (MRE) as a frontline imaging strategy for NAFLD patients with advanced fibrosis. METHODS A Markov model was developed from the US perspective. The base-case scenario in this model included patients aged 50 years with a Fibrosis-4 score of ≥2.67 and suspected advanced fibrosis. The model included a decision tree and a Markov state-transition model including 5 health states: fibrosis stage 1-2, advanced fibrosis, compensated cirrhosis, decompensated cirrhosis, and death. Both deterministic and probabilistic sensitivity analyses were performed. RESULTS Staging fibrosis with MRE cost $8388 more than VCTE but led to an additional 1.19 Quality-adjusted life years (QALYs) with the incremental cost-effectiveness ratio of $7048/QALY. The cost-effectiveness analysis of the 5 strategies revealed that MRE+biopsy and VCTE+MRE+biopsy were the most cost-effective with the incremental cost-effectiveness ratios of $8054/QALY and $8241/QALY, respectively. Furthermore, sensitivity analyses indicated that MRE remained cost-effective with a sensitivity of ≥0.77, whereas VCTE became cost-effective with a sensitivity of ≥0.82. CONCLUSIONS MRE was not only cost-effective than VCTE as the frontline modality for staging NAFLD patients with Fibrosis-4 ≥2.67 with incremental cost-effectiveness ratio of $7048/QALY but also remained cost-effective when used as a follow-up in instances of VCTE failure to diagnose.
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Affiliation(s)
| | - Stephanie T Chang
- Department of Radiology, VA Palo Alto Healthcare System California, USA
- Department of Medicine, VA Palo Alto Healthcare System, California, USA
| | - Ramsey Cheung
- Stanford University, Palo Alto, California, USA
- Department of Medicine, VA Palo Alto Healthcare System, California, USA
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Pickhardt PJ, Correale L, Hassan C. AI-based opportunistic CT screening of incidental cardiovascular disease, osteoporosis, and sarcopenia: cost-effectiveness analysis. Abdom Radiol (NY) 2023; 48:1181-1198. [PMID: 36670245 DOI: 10.1007/s00261-023-03800-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Revised: 01/02/2023] [Accepted: 01/04/2023] [Indexed: 01/22/2023]
Abstract
PURPOSE To assess the cost-effectiveness and clinical efficacy of AI-assisted abdominal CT-based opportunistic screening for atherosclerotic cardiovascular (CV) disease, osteoporosis, and sarcopenia using artificial intelligence (AI) body composition algorithms. METHODS Markov models were constructed and 10-year simulations were performed on hypothetical age- and sex-specific cohorts of 10,000 U.S. adults (base case: 55 year olds) undergoing abdominal CT. Using expected disease prevalence, transition probabilities between health states, associated healthcare costs, and treatment effectiveness related to relevant conditions (CV disease/osteoporosis/sarcopenia) were modified by three mutually exclusive screening models: (1) usual care ("treat none"; no intervention regardless of opportunistic CT findings), (2) universal statin therapy ("treat all" for CV prevention; again, no consideration of CT findings), and (3) AI-assisted abdominal CT-based opportunistic screening for CV disease, osteoporosis, and sarcopenia using automated quantitative algorithms for abdominal aortic calcification, bone mineral density, and skeletal muscle, respectively. Model validity was assessed against published clinical cohorts. RESULTS For the base-case scenarios of 55-year-old men and women modeled over 10 years, AI-assisted CT-based opportunistic screening was a cost-saving and more effective clinical strategy, unlike the "treat none" and "treat all" strategies that ignored incidental CT body composition data. Over a wide range of input assumptions beyond the base case, the CT-based opportunistic strategy was dominant over the other two scenarios, as it was both more clinically efficacious and more cost-effective. Cost savings and clinical improvement for opportunistic CT remained for AI tool costs up to $227/patient in men ($65 in women) from the $10/patient base-case scenario. CONCLUSION AI-assisted CT-based opportunistic screening appears to be a highly cost-effective and clinically efficacious strategy across a broad array of input assumptions, and was cost saving in most scenarios.
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Affiliation(s)
- Perry J Pickhardt
- Department of Radiology, University of Wisconsin School of Medicine & Public Heatlh, 600 Highland Ave, Madison, WI, 53792, USA.
| | - Loredana Correale
- Department of Gastroenterology, IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089, Rozzano, Milan, Italy
| | - Cesare Hassan
- Department of Gastroenterology, IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089, Rozzano, Milan, Italy
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, 20072, Pieve Emanuele, Milan, Italy
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Gruneau L, Ekstedt M, Kechagias S, Henriksson M. Disease Progression Modeling for Economic Evaluation in Nonalcoholic Fatty Liver Disease-A Systematic Review. Clin Gastroenterol Hepatol 2023; 21:283-298. [PMID: 34757199 DOI: 10.1016/j.cgh.2021.10.040] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Revised: 09/10/2021] [Accepted: 10/24/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Globally, 25% of people have nonalcoholic fatty liver disease (NAFLD), and, currently, there are no approved pharmacologic treatments for NAFLD. With a slow disease progression, long-term impact of pharmacologic treatments can be assessed only by complementing emerging clinical trial evidence with data from other sources in disease progression modeling. Although this modeling is crucial for economic evaluation studies assessing the clinical and economic consequences of new treatments, the approach to modeling the natural history of NAFLD differs in contemporary research. This systematic literature review investigated modeling of the natural history of NAFLD. METHODS A systematic literature review was conducted searching PubMed, Scopus, Cochrane, and the National Health Service Economic Evaluation Database to identify articles focusing on modeling of the natural history of NAFLD. Model structure and transition probabilities were extracted from included studies. RESULTS Of the 28 articles identified, differences were seen in model structure and data input. Clear definitions of nonalcoholic steatohepatitis and NAFLD often were lacking; differences in the granularity of modeling fibrosis progression, the approach to disease regression, and modeling of advanced liver disease varied across studies. Observed transition probabilities for F0 to F1, F1 to F2, F2 to F3, and F3 to compensated cirrhosis varied between 0.059 to 0.095, 0.023 to 0.140, 0.018 to 0.070, and 0.040 to 0.118, respectively. CONCLUSIONS The difference in disease progression modeling for seemingly similar models warrants further inquiry regarding how to model the natural course of NAFLD. Such differences may have a large impact when assessing the value of emerging pharmacologic treatments.
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Affiliation(s)
- Lina Gruneau
- Center for Medical Technology Assessment, Linköping, Sweden.
| | - Mattias Ekstedt
- Division of Diagnostics and Specialist Medicine, Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
| | - Stergios Kechagias
- Division of Diagnostics and Specialist Medicine, Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
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Zhang S, Mak LY, Yuen MF, Seto WK. Screening strategy for non-alcoholic fatty liver disease. Clin Mol Hepatol 2023; 29:S103-S122. [PMID: 36447420 PMCID: PMC10029948 DOI: 10.3350/cmh.2022.0336] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2022] [Accepted: 11/16/2022] [Indexed: 12/02/2022] Open
Abstract
Non-alcoholic fatty liver disease (NAFLD) is the most common chronic liver disease, affecting approximately 25% of the general population worldwide, and is forecasted to increase global health burden in the 21st century. With the advancement of non-invasive tests for assessing and monitoring of steatosis and fibrosis, NAFLD screening is now feasible, and is increasingly highlighted in international guidelines related to hepatology, endocrinology, and pediatrics. Identifying high-risk populations (e.g., diabetes mellitus, obesity, metabolic syndrome) based on risk factors and metabolic characteristics for non-invasive screening is crucial and may aid in designing screening strategies to be more precise and effective. Many screening modalities are currently available, from serum-based methods to ultrasonography, transient elastography, and magnetic resonance imaging, although the diagnostic performance, cost, and accessibility of different methods may impact the actual implementation. A two-step assessment with serum-based fibrosis-4 index followed by imaging test vibration-controlled transient elastography can be an option to stratify the risk of liverrelated complications in NAFLD. There is a need for fibrosis surveillance, as well as investigating the cost-effectiveness of different screening algorithms and engaging primary care for first-stage triage screening.
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Affiliation(s)
- Saisai Zhang
- Department of Medicine, School of Clinical Medicine, The University of Hong Kong, Hong Kong
| | - Lung-Yi Mak
- Department of Medicine, School of Clinical Medicine, The University of Hong Kong, Hong Kong
- State Key Laboratory of Liver Research, The University of Hong Kong, Hong Kong
| | - Man-Fung Yuen
- Department of Medicine, School of Clinical Medicine, The University of Hong Kong, Hong Kong
- State Key Laboratory of Liver Research, The University of Hong Kong, Hong Kong
| | - Wai-Kay Seto
- Department of Medicine, School of Clinical Medicine, The University of Hong Kong, Hong Kong
- State Key Laboratory of Liver Research, The University of Hong Kong, Hong Kong
- Department of Medicine, The University of Hong Kong-Shenzhen Hospital, Shenzhen, China
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Cordero A, Escribano D, Quintanilla MA, López-Ayala JM, Masiá MD, Cazorla D, Martínez Rey-Rañal E, Moreno-Arribas J, Zuazola P. Prognostic value of liver fibrosis assessed by the FIB-4 index in patients with acute coronary syndrome. REVISTA ESPANOLA DE CARDIOLOGIA (ENGLISH ED.) 2023:S1885-5857(23)00028-2. [PMID: 36669734 DOI: 10.1016/j.rec.2022.12.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/19/2022] [Accepted: 12/19/2022] [Indexed: 01/19/2023]
Abstract
INTRODUCTION AND OBJECTIVES Liver fibrosis is present in nonalcoholic liver disease (NAFLD) and both precede liver failure. Subclinical forms of liver fibrosis might increase the risk of cardiovascular events. The objective of this study was to describe the prognostic value of the FIB-4 index on in-hospital mortality and postdischarge outcomes in patients with acute coronary syndrome (ACS). METHODS Retrospective study including all consecutive patients admitted for ACS between 2009 and 2019. According to the FIB-4 index, patients were categorized as <1.30, 1.30-2.67 or> 2.67. Heart failure (HF) and major bleeding (MB) were assessed taking all-cause mortality as a competing event and subhazard ratios (sHR) are presented. Recurrent events were evaluated by the incidence rate ratio (IRR). RESULTS We included 3106 patients and 6.66% had a FIB-4 index ≥ 1.3. A multivariate analysis verified a higher risk of in-hospital mortality associated with the FIB-4 index (OR, 1.24; P=.016). Patients with a FIB-4 index> 2.67 had a 2-fold higher in-hospital mortality risk (OR, 2.35; P=.038). After discharge (median follow-up 1112 days), the FIB-4 index had no prognostic value for mortality. In contrast, patients with FIB-4 index ≥ 1.3 had a higher risk of first (sHR, 1.61; P=.04) or recurrent (IRR, 1.70; P=.001) HF readmission. Similarly, FIB-4 index ≥ 1.30 was associated with a higher MB risk (sHR, 1.62; P=.030). CONCLUSIONS The assessment of liver fibrosis by the FIB-4 index identifies ACS patients not only at higher risk of in-hospital mortality but also at higher risk of HF and MB after discharge.
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Affiliation(s)
- Alberto Cordero
- Departamento de Cardiología, Hospital Universitario de San Juan, San Juan, Alicante, Spain; Unidad de Investigación de Cardiología, Fundación para el Fomento de la Investigación Sanitaria y Biomédica de la Comunitat Valenciana (FISABIO), Spain; Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Spain.
| | - David Escribano
- Departamento de Cardiología, Hospital Universitario de San Juan, San Juan, Alicante, Spain; Unidad de Investigación de Cardiología, Fundación para el Fomento de la Investigación Sanitaria y Biomédica de la Comunitat Valenciana (FISABIO), Spain
| | | | - José M López-Ayala
- Departamento de Cardiología, Hospital Universitario de San Juan, San Juan, Alicante, Spain
| | - María D Masiá
- Departamento de Cardiología, Hospital Universitario de San Juan, San Juan, Alicante, Spain
| | - Diego Cazorla
- Departamento de Cardiología, Hospital Universitario de San Juan, San Juan, Alicante, Spain
| | | | - José Moreno-Arribas
- Departamento de Cardiología, Hospital Universitario de San Juan, San Juan, Alicante, Spain; Unidad de Investigación de Cardiología, Fundación para el Fomento de la Investigación Sanitaria y Biomédica de la Comunitat Valenciana (FISABIO), Spain
| | - Pilar Zuazola
- Departamento de Cardiología, Hospital Universitario de San Juan, San Juan, Alicante, Spain
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Rojano A, Sena E, Manzano-Nuñez R, Pericàs JM, Ciudin A. NAFLD as the metabolic hallmark of obesity. Intern Emerg Med 2023; 18:31-41. [PMID: 36357606 DOI: 10.1007/s11739-022-03139-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2022] [Accepted: 10/17/2022] [Indexed: 11/12/2022]
Abstract
Non-alcoholic fatty liver disease (NAFLD) has become the most common chronic liver disease worldwide, associated with a high risk of progression to NASH, liver cirrhosis and hepatocarcinoma. Its prevalence is closely related to obesity (understood as adipose-based disease and insulin resistance), which makes that at present NAFLD can be considered a metabolic dysfunction hallmark, regardless of the body mass index. Despite being such a prevalent condition, with such severe consequences, at present there are no reliable biomarkers for its diagnosis or specific treatment. Significant and sustained weight loss, as well as some antidiabetic treatments, has shown promising results for NAFLD but data needs confirmation in larger clinical trials and longer follow-up. Efforts should be made for a better and more accurate baseline diagnosis (including large-scale genetics), identification of patients at higher risk for progression to NASH as well as adequate treatment, to allow us to offer a personalized approach in NAFLD in the context of precision medicine.
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Affiliation(s)
- Alba Rojano
- Endocrinology and Nutrition Department, Vall d'HebronInstitut de Recerca (VHIR), Hospital Universitari Vall d'Hebron, Vall d'Hebron Barcelona Campus Hospitalari, Barcelona, Spain
| | - Elena Sena
- Liver Unit, Internal Medicine Department, Vall d'HebronInstitut de Recerca (VHIR), Hospital Universitari Vall d'Hebron, Vall d'Hebron Barcelona Campus Hospitalari, Barcelona, Spain
| | - Ramiro Manzano-Nuñez
- Liver Unit, Internal Medicine Department, Vall d'HebronInstitut de Recerca (VHIR), Hospital Universitari Vall d'Hebron, Vall d'Hebron Barcelona Campus Hospitalari, Barcelona, Spain
| | - Juan M Pericàs
- Liver Unit, Internal Medicine Department, Vall d'HebronInstitut de Recerca (VHIR), Hospital Universitari Vall d'Hebron, Vall d'Hebron Barcelona Campus Hospitalari, Barcelona, Spain.
- Centro de Investigación Biomédica en Red de Enfermedades Digestivas Y Hepáticas (CIBERehd), Instituto de Salud Carlos III, Madrid, Spain.
| | - Andreea Ciudin
- Endocrinology and Nutrition Department, Vall d'HebronInstitut de Recerca (VHIR), Hospital Universitari Vall d'Hebron, Vall d'Hebron Barcelona Campus Hospitalari, Barcelona, Spain.
- CIBER de Diabetes Y Enfermedades Metabólicas Asociadas (CIBERDem), Instituto de Salud Carlos III, Madrid, Spain.
- Department of Cellular Biology, Physiology and Immunology, Universitat Autònoma de Barcelona, Barcelona, Spain.
- Pathology Department, Hospital Universitari Vall d'Hebron, Vall d'Hebron Barcelona Campus Hospitalari, Barcelona, Spain.
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11
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Zhou XD, Cai J, Targher G, Byrne CD, Shapiro MD, Sung KC, Somers VK, Chahal CAA, George J, Chen LL, Zhou Y, Zheng MH. Metabolic dysfunction-associated fatty liver disease and implications for cardiovascular risk and disease prevention. Cardiovasc Diabetol 2022; 21:270. [PMID: 36463192 PMCID: PMC9719631 DOI: 10.1186/s12933-022-01697-0] [Citation(s) in RCA: 26] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Accepted: 11/14/2022] [Indexed: 12/07/2022] Open
Abstract
The newly proposed term "metabolic dysfunction-associated fatty liver disease" (MAFLD) is replacing the old term "non-alcoholic fatty liver disease" (NAFLD) in many global regions, because it better reflects the pathophysiology and cardiometabolic implications of this common liver disease. The proposed change in terminology from NAFLD to MAFLD is not simply a single-letter change in an acronym, since MAFLD is defined by a set of specific and positive diagnostic criteria. In particular, the MAFLD definition specifically incorporates within the classification recognized cardiovascular risk factors. Although convincing evidence supports a significant association between both NAFLD and MAFLD, with increased risk of CVD morbidity and mortality, neither NAFLD nor MAFLD have received sufficient attention from the Cardiology community. In fact, there is a paucity of scientific guidelines focusing on this common and burdensome liver disease from cardiovascular professional societies. This Perspective article discusses the rationale and clinical relevance for Cardiologists of the newly proposed MAFLD definition.
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Affiliation(s)
- Xiao-Dong Zhou
- grid.414906.e0000 0004 1808 0918Department of Cardiovascular Medicine, the Heart Center, the First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Jingjing Cai
- grid.216417.70000 0001 0379 7164Department of Cardiology, the Third Xiangya Hospital, Central South University, Changsha, China
| | - Giovanni Targher
- grid.5611.30000 0004 1763 1124Department of Medicine, Section of Endocrinology, Diabetes, and Metabolism, University of Verona, Verona, Italy
| | - Christopher D. Byrne
- grid.123047.30000000103590315Southampton National Institute for Health and Care Research Biomedical Research Centre, University Hospital Southampton, Southampton General Hospital, Southampton, UK
| | - Michael D. Shapiro
- grid.241167.70000 0001 2185 3318Center for Prevention of Cardiovascular Disease, Section On Cardiovascular Medicine, Wake Forest University School of Medicine, Winston-Salem, NC USA
| | - Ki-Chul Sung
- grid.264381.a0000 0001 2181 989XDepartment of Internal Medicine, Division of Cardiology, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Virend K. Somers
- grid.66875.3a0000 0004 0459 167XDepartment of Cardiovascular Medicine, Mayo Clinic College of Medicine, Rochester, USA
| | - C. Anwar A. Chahal
- grid.411115.10000 0004 0435 0884Division of Cardiovascular Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA USA
| | - Jacob George
- grid.1013.30000 0004 1936 834XStorr Liver Centre, Westmead Institute for Medical Research, Westmead Hospital and University of Sydney, Sydney, NSW Australia
| | - Li-Li Chen
- grid.414906.e0000 0004 1808 0918MAFLD Research Center, Department of Hepatology, the First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Yong Zhou
- grid.16821.3c0000 0004 0368 8293Clinical Research Institute, Shanghai General Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Ming-Hua Zheng
- grid.414906.e0000 0004 1808 0918MAFLD Research Center, Department of Hepatology, the First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China ,grid.268099.c0000 0001 0348 3990Institute of Hepatology, Wenzhou Medical University, Wenzhou, China ,Key Laboratory of Diagnosis and Treatment for the Development of Chronic Liver Disease in Zhejiang Province, Wenzhou, China
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12
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Herring WL, Gould IG, Wittrup-Jensen V, Ertle J, Kuti E, Wolowacz S. Evaluation of emerging NASH therapies: the impact of treatment efficacy profiles on long-term health outcomes. J Comp Eff Res 2022; 11:1349-1363. [PMID: 36317935 DOI: 10.2217/cer-2021-0194] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Aim: Evaluations of nonalcoholic steatohepatitis (NASH) treatments require predicting lifetime outcomes from short-term clinical trials. Materials & methods: A Markov model with NASH fibrosis stages F0-F3, NASH resolution, compensated cirrhosis (F4/CC), and liver-related complication (LRC) states was developed using literature-based standard of care (SoC) data. Hypothetical efficacy profiles were defined affecting resolution (100%-increase), fibrosis improvement (100% increase), or fibrosis worsening (50% decrease). Results: For the SoC, 10-year LRC rates increased with baseline fibrosis stage (F1: 3.0%; F2: 9.8%; F3: 27.2%; F4/CC: 64.9%). The fibrosis worsening profile reduced predicted 10-year LRC rates (F1: 1.9%; F2: 6.5%; F3: 19.1%; F4/CC: 55.0%) more than the resolution and fibrosis improvement profiles (F1: 2.6%/2.6%; F2: 8.5%/8.3%; F3: 23.3%/23.0%; F4/CC: NA/59.0%). Scenario analyses considered alternative SoC progression, treatment efficacy and treatment-stopping rules. Conclusion: Potential NASH efficacy profiles have differing impacts on predicted long-term outcomes, providing insights for future stakeholders.
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Affiliation(s)
- William L Herring
- RTI Health Solutions, 3040 East Cornwallis Road, Research Triangle Park, NC 27709, USA
| | - Ian Gopal Gould
- RTI Health Solutions, 3040 East Cornwallis Road, Research Triangle Park, NC 27709, USA
| | - Villum Wittrup-Jensen
- Boehringer Ingelheim International GmbH, Binger Strasse 17, Ingelheim am Rhein, 55216, Germany
| | - Judith Ertle
- Boehringer Ingelheim International GmbH, Binger Strasse 17, Ingelheim am Rhein, 55216, Germany
| | - Effie Kuti
- Boehringer Ingelheim Pharmaceuticals, Inc., 900 Ridgebury Road, Ridgefield, CT 06877, USA
| | - Sorrel Wolowacz
- RTI Health Solutions, Towers Business Park, Wilmslow Road, Manchester, M20 2RY, UK
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13
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Josloff K, Beiriger J, Khan A, Gawel RJ, Kirby RS, Kendrick AD, Rao AK, Wang RX, Schafer MM, Pearce ME, Chauhan K, Shah YB, Marhefka GD, Halegoua-DeMarzio D. Comprehensive Review of Cardiovascular Disease Risk in Nonalcoholic Fatty Liver Disease. J Cardiovasc Dev Dis 2022; 9:419. [PMID: 36547416 PMCID: PMC9786069 DOI: 10.3390/jcdd9120419] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2022] [Revised: 11/16/2022] [Accepted: 11/23/2022] [Indexed: 11/29/2022] Open
Abstract
Nonalcoholic Fatty Liver Disease (NAFLD) is a growing global phenomenon, and its damaging effects in terms of cardiovascular disease (CVD) risk are becoming more apparent. NAFLD is estimated to affect around one quarter of the world population and is often comorbid with other metabolic disorders including diabetes mellitus, hypertension, coronary artery disease, and metabolic syndrome. In this review, we examine the current evidence describing the many ways that NAFLD itself increases CVD risk. We also discuss the emerging and complex biochemical relationship between NAFLD and its common comorbid conditions, and how they coalesce to increase CVD risk. With NAFLD's rising prevalence and deleterious effects on the cardiovascular system, a complete understanding of the disease must be undertaken, as well as effective strategies to prevent and treat its common comorbid conditions.
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Affiliation(s)
- Kevan Josloff
- Sidney Kimmel Medical College, Thomas Jefferson University Hospital, Philadelphia, PA 19107, USA
| | - Jacob Beiriger
- Sidney Kimmel Medical College, Thomas Jefferson University Hospital, Philadelphia, PA 19107, USA
| | - Adnan Khan
- Department of Internal Medicine, Thomas Jefferson University Hospital, Philadelphia, PA 19107, USA
| | - Richard J. Gawel
- Sidney Kimmel Medical College, Thomas Jefferson University Hospital, Philadelphia, PA 19107, USA
| | - Richard S. Kirby
- Sidney Kimmel Medical College, Thomas Jefferson University Hospital, Philadelphia, PA 19107, USA
| | - Aaron D. Kendrick
- Sidney Kimmel Medical College, Thomas Jefferson University Hospital, Philadelphia, PA 19107, USA
| | - Abhinav K. Rao
- Sidney Kimmel Medical College, Thomas Jefferson University Hospital, Philadelphia, PA 19107, USA
| | - Roy X. Wang
- Sidney Kimmel Medical College, Thomas Jefferson University Hospital, Philadelphia, PA 19107, USA
| | - Michelle M. Schafer
- Sidney Kimmel Medical College, Thomas Jefferson University Hospital, Philadelphia, PA 19107, USA
| | - Margaret E. Pearce
- Sidney Kimmel Medical College, Thomas Jefferson University Hospital, Philadelphia, PA 19107, USA
| | - Kashyap Chauhan
- Department of Internal Medicine, Thomas Jefferson University Hospital, Philadelphia, PA 19107, USA
| | - Yash B. Shah
- Sidney Kimmel Medical College, Thomas Jefferson University Hospital, Philadelphia, PA 19107, USA
| | - Gregary D. Marhefka
- Department of Internal Medicine, Division of Cardiology, Thomas Jefferson University Hospital, Philadelphia, PA 19107, USA
| | - Dina Halegoua-DeMarzio
- Department of Internal Medicine, Division of Gastroenterology & Hepatology, Thomas Jefferson University Hospital, Philadelphia, PA 19107, USA
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14
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Accuracy of Non-invasive Indices for Diagnosing Hepatic Steatosis Compared to Imaging in a Real-World Cohort. Dig Dis Sci 2022; 67:5300-5308. [PMID: 35166966 DOI: 10.1007/s10620-022-07415-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Accepted: 01/23/2022] [Indexed: 01/05/2023]
Abstract
BACKGROUND & AIMS Nonalcoholic fatty liver disease is common and under-diagnosed. This study evaluated the accuracy of several previously reported indices, including hepatic steatosis index, alanine aminotransferase (ALT) method, Framingham steatosis index, and Dallas steatosis index, to diagnose hepatic steatosis in a real-world cohort. METHODS This study included 701 randomly selected adult patients seen in our integrated healthcare system between 2015 and 2020 with appropriate abdominal imaging and routine outpatient laboratory studies. Information on demographics, comorbidities and existing liver disease, anthropometrics, laboratory studies, and abdominal imaging was collected. The sensitivity, specificity, and C-statistic of each method in detecting hepatic steatosis based on abdominal imaging were determined. RESULTS 202/701 patients (28.8%) had hepatic steatosis on abdominal imaging. These patients were more likely to have metabolic syndrome components and higher body mass index. All indices performed similarly with moderate accuracy in detecting hepatic steatosis based on the C-statistic (95% confidence interval): Hepatic steatosis index 0.76 (0.72-0.79), Framingham steatosis index 0.78 (0.74-0.82), and Dallas steatosis index 0.80 (0.76-0.83). ALT method had sensitivity 44.7% (36.9-52.7%) and specificity 88.6% (85.0-91.7%). Several sensitivity analyses were performed, which did not significantly alter the performance of any index. CONCLUSION The findings support both the clinical utility of these indices in diagnosing hepatic steatosis in the absence of imaging in real-world settings and the research utility of these indices in generating reliable electronic medical record-based nonalcoholic fatty liver disease cohorts.
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15
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Long MT, Noureddin M, Lim JK. AGA Clinical Practice Update: Diagnosis and Management of Nonalcoholic Fatty Liver Disease in Lean Individuals: Expert Review. Gastroenterology 2022; 163:764-774.e1. [PMID: 35842345 PMCID: PMC9398982 DOI: 10.1053/j.gastro.2022.06.023] [Citation(s) in RCA: 79] [Impact Index Per Article: 39.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Revised: 05/31/2022] [Accepted: 06/02/2022] [Indexed: 02/07/2023]
Abstract
DESCRIPTION Nonalcoholic fatty liver disease (NAFLD) is well recognized as a leading etiology for chronic liver disease, affecting >25% of the US and global populations. Up to 1 in 4 individuals with NAFLD have nonalcoholic steatohepatitis, which is associated with significant morbidity and mortality due to complications of liver cirrhosis, hepatic decompensation, and hepatocellular carcinoma. Although NAFLD is observed predominantly in persons with obesity and/or type 2 diabetes mellitus, an estimated 7%-20% of individuals with NAFLD have lean body habitus. Limited guidance is available to clinicians on appropriate clinical evaluation in lean individuals with NAFLD, such as for inherited/genetic disorders, lipodystrophy, drug-induced NAFLD, and inflammatory disorders. Emerging data now provide more robust evidence to define the epidemiology, natural history, prognosis, and mortality of lean individuals with NAFLD. Multiple studies have found that NAFLD among lean individuals is associated with increased cardiovascular, liver, and all-cause mortality relative to those without NAFLD. This American Gastroenterological Association Clinical Practice Update provides Best Practice Advice to assist clinicians in evidence-based approaches to the diagnosis, staging, and management of NAFLD in lean individuals. METHODS This expert review was commissioned and approved by the American Gastroenterological Association (AGA) Institute Clinical Practice Updates Committee and the AGA Governing Board to provide timely guidance on a topic of high clinical importance to the AGA membership and underwent internal peer review by the Clinical Practice Updates Committee and external peer review through standard procedures of Gastroenterology. Best Practice Advice Statements BEST PRACTICE ADVICE 1: Lean NAFLD should be diagnosed in individuals with NAFLD and body mass index <25 kg/m2 (non-Asian race) or body mass index <23 kg/m2 (Asian race). BEST PRACTICE ADVICE 2: Lean individuals with NAFLD should be evaluated routinely for comorbid conditions, such as type 2 diabetes mellitus, dyslipidemia, and hypertension. BEST PRACTICE ADVICE 3: Lean individuals with NAFLD should be risk stratified for hepatic fibrosis to identify those with advanced fibrosis or cirrhosis. BEST PRACTICE ADVICE 4: Lean individuals in the general population should not undergo routine screening for NAFLD; however, screening should be considered for individuals older than 40 years with type 2 diabetes mellitus. BEST PRACTICE ADVICE 5: NAFLD should be considered in lean individuals with metabolic diseases (such as type 2 diabetes mellitus, dyslipidemia, and hypertension), elevated liver biochemical tests, or incidentally noted hepatic steatosis. BEST PRACTICE ADVICE 6: Clinicians should query patients routinely regarding alcohol consumption patterns in all patients with lean NAFLD. BEST PRACTICE ADVICE 7: In patients with lean NAFLD, other causes of liver disease should be ruled out, including other causes of fatty liver, such as HIV, lipodystrophy, lysosomal acid lipase deficiency, familial hypobetalipoproteinemia, and medication-induced hepatic steatosis (methotrexate, amiodarone, tamoxifen, and steroids). BEST PRACTICE ADVICE 8: Current evidence is inadequate to support routine testing for genetic variants in patients with lean NAFLD. BEST PRACTICE ADVICE 9: Liver biopsy, as the reference standard, should be considered if there is uncertainty regarding contributing causes of liver injury and/or the stage of liver fibrosis. BEST PRACTICE ADVICE 10: Serum indices (NAFLD fibrosis score and Fibrosis-4 score) and imaging techniques (transient elastography and magnetic resonance elastography) may be used as alternatives to liver biopsy for fibrosis staging and patient follow-up. These tests can be performed at the time of diagnosis and repeated at intervals of 6 months to 2 years, depending on fibrosis stage and the patient's response to intervention. BEST PRACTICE ADVICE 11: If noninvasive tests (eg, Fibrosis-4 and NAFLD fibrosis score) are indeterminate, a second noninvasive test (eg, transient elastography or magnetic resonance elastography) should be performed to confirm the stage and prognosis of NAFLD. BEST PRACTICE ADVICE 12: In lean patients with NAFLD, lifestyle intervention, including exercise, diet modification, and avoidance of fructose- and sugar-sweetened drinks, to target a modest weight loss of 3%-5% is suggested. BEST PRACTICE ADVICE 13: Administration of vitamin E may be considered in lean persons with biopsy-confirmed nonalcoholic steatohepatitis, but without type 2 diabetes mellitus or cirrhosis. Oral pioglitazone 30 mg daily may be considered in lean persons with biopsy-confirmed nonalcoholic steatohepatitis without cirrhosis. BEST PRACTICE ADVICE 14: The therapeutic role of glucagon-like peptide-1 agonists and sodium-glucose cotransporter-2 inhibitors in the management of lean NAFLD is not fully defined and requires further investigation. BEST PRACTICE ADVICE 15: Hepatocellular carcinoma surveillance with abdominal ultrasound with or without serum α-fetoprotein twice per year is suggested in patients with lean NAFLD and clinical markers compatible with liver cirrhosis.
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Affiliation(s)
- Michelle T Long
- Section of Gastroenterology, Boston Medical Center, Boston University School of Medicine, Boston, Massachusetts.
| | - Mazen Noureddin
- Fatty Liver Program, Karsh Division of Gastroenterology and Hepatology, Cedars Sinai Medical Center, Los Angeles, California
| | - Joseph K Lim
- Section of Digestive Diseases and Yale Liver Center, Yale University School of Medicine, New Haven, Connecticut
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16
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Dunn W, Song X, Koestler D, Grdinovac K, Al‐hihi E, Chen J, Taylor R, Wilson J, Weinman SA. Patients with type 2 diabetes and elevated fibrosis-4 are under-referred to hepatology and have unrecognized hepatic decompensation. J Gastroenterol Hepatol 2022; 37:1815-1821. [PMID: 35613944 PMCID: PMC9543724 DOI: 10.1111/jgh.15900] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2022] [Revised: 05/05/2022] [Accepted: 05/22/2022] [Indexed: 12/09/2022]
Abstract
BACKGROUND AND AIM The American Association for the Study of Liver Diseases recommends a high index of suspicion for nonalcoholic steatohepatitis and advanced fibrosis in patients with type 2 diabetes (T2D) and an elevated fibrosis-4 index (FIB-4). We investigated the referral pattern of patients with T2D and FIB4 > 3.25 to the hepatology clinic and evaluated the clinical benefits to the patient. METHODS We included patients aged 18-80 years with T2D and a FIB4 score >3.25 who had visited the internal medicine, family medicine, endocrinology clinic from 01/01/2014-5/31/2019. The first time point of high-risk FIB-4 was identified as the baseline for time-to-event analysis. The patients were classified based on whether they had visited the hepatology clinic (referred vs not referred). RESULTS Of the 2174 patients, 290 (13.3%) were referred to the hepatology clinic, and 1884 (86.7%) were not referred. In multivariate analyses, the referred patients had a lower overall mortality risk (Hazard Ratio: 0.57; 95% CI: 0.38-87). Notably, the referred patients had the same rate of biochemical decompensation, as measured by progression to MELD ≥ 14, but a substantially higher rate of diagnosis in cirrhosis (27, 19-38) and cirrhosis complications, including ascites (2.9, 2.0-4.1), hepatic encephalopathy (99, 13-742), and liver cancer (14, 5-38). CONCLUSIONS We found that patients with T2D and high-risk FIB4 are associated with better overall survival after referral to a hepatology clinic. We speculate that the survival difference is due to the increased recognition of cirrhosis and cirrhosis complications in the referred populations.
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Affiliation(s)
- Winston Dunn
- Department of Internal MedicineUniversity of Kansas Medical CenterKansas CityKansasUSA
| | - Xing Song
- Center for Medical Informatics and Enterprise AnalyticsUniversity of Kansas Medical CenterKansas CityKansasUSA
| | - Devin Koestler
- Department of Biostatistics and Data ScienceUniversity of Kansas Medical CenterKansas CityKansasUSA
| | - Kristine Grdinovac
- Department of Internal MedicineUniversity of Kansas Medical CenterKansas CityKansasUSA
| | - Eyad Al‐hihi
- Department of Internal MedicineUniversity of Kansas Medical CenterKansas CityKansasUSA
| | - John Chen
- Center for Medical Informatics and Enterprise AnalyticsUniversity of Kansas Medical CenterKansas CityKansasUSA
| | - Ryan Taylor
- Department of Internal MedicineUniversity of Kansas Medical CenterKansas CityKansasUSA
| | - Jessica Wilson
- Department of Internal MedicineUniversity of Kansas Medical CenterKansas CityKansasUSA
| | - Steven A. Weinman
- Department of Internal MedicineUniversity of Kansas Medical CenterKansas CityKansasUSA
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17
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Garg T, Chu LC, Zimmerman SL, Weiss CR, FCIRSE MDFSIR, Fishman EK, Azadi JR. Prevalence of Hepatic Steatosis in Adults Presenting to the Emergency Department Identified by Unenhanced Chest CT. Curr Probl Diagn Radiol 2022; 52:35-40. [DOI: 10.1067/j.cpradiol.2022.07.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2022] [Accepted: 07/27/2022] [Indexed: 11/22/2022]
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18
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Rojano-Toimil A, Rivera-Esteban J, Manzano-Nuñez R, Bañares J, Martinez Selva D, Gabriel-Medina P, Ferrer R, Pericàs JM, Ciudin A. When Sugar Reaches the Liver: Phenotypes of Patients with Diabetes and NAFLD. J Clin Med 2022; 11:jcm11123286. [PMID: 35743358 PMCID: PMC9225139 DOI: 10.3390/jcm11123286] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Revised: 06/03/2022] [Accepted: 06/06/2022] [Indexed: 01/27/2023] Open
Abstract
Type 2 diabetes mellitus (T2DM) and non-alcoholic fatty liver disease (NAFLD) have been traditionally linked to one another. Recent studies suggest that NAFLD may be increasingly common in other types of diabetes such as type 1 diabetes (T1DM) and less frequently ketone-prone and Maturity-onset Diabetes of the Young (MODY) diabetes. In this review, we address the relationship between hyperglycemia and insulin resistance and the onset and progression of NAFLD. In addition, despite the high rate of patients with T2DM and other diabetes phenotypes that can alter liver metabolism and consequently develop steatosis, fibrosis, and cirrhosis, NALFD screening is not still implemented in the daily care routine. Incorporating a clinical algorithm created around a simple, non-invasive, cost-effective model would identify high-risk patients. The principle behind managing these patients is to improve insulin resistance and hyperglycemia states with lifestyle changes, weight loss, and new drug therapies.
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Affiliation(s)
- Alba Rojano-Toimil
- Endocrinology Department, Vall d’Hebron University Hospital, 08035 Barcelona, Spain;
- Vall d’Hebron Institut de Recerca (VHIR), 08035 Barcelona, Spain; (J.R.-E.); (R.M.-N.); (J.B.); (D.M.S.)
| | - Jesús Rivera-Esteban
- Vall d’Hebron Institut de Recerca (VHIR), 08035 Barcelona, Spain; (J.R.-E.); (R.M.-N.); (J.B.); (D.M.S.)
- Medicine Department Bellaterra, Universitat Autònoma de Barcelona, 08193 Barcelona, Spain
- Liver Unit, Vall d’Hebron University Hospital, 08035 Barcelona, Spain
| | - Ramiro Manzano-Nuñez
- Vall d’Hebron Institut de Recerca (VHIR), 08035 Barcelona, Spain; (J.R.-E.); (R.M.-N.); (J.B.); (D.M.S.)
- Liver Unit, Vall d’Hebron University Hospital, 08035 Barcelona, Spain
| | - Juan Bañares
- Vall d’Hebron Institut de Recerca (VHIR), 08035 Barcelona, Spain; (J.R.-E.); (R.M.-N.); (J.B.); (D.M.S.)
- Liver Unit, Vall d’Hebron University Hospital, 08035 Barcelona, Spain
| | - David Martinez Selva
- Vall d’Hebron Institut de Recerca (VHIR), 08035 Barcelona, Spain; (J.R.-E.); (R.M.-N.); (J.B.); (D.M.S.)
- Spanish Network of Biomedical Research Centers, Diabetes and Metabolic Associated Disorders (CIBERdem), 28029 Madrid, Spain
| | - Pablo Gabriel-Medina
- Biochemistry Department, Vall d’Hebron University Hospital, 08035 Barcelona, Spain; (P.G.-M.); (R.F.)
- Biochemistry and Molecular Biology Department, Universitat Autònoma de Barcelona (UAB), Bellaterra, 08193 Barcelona, Spain
| | - Roser Ferrer
- Biochemistry Department, Vall d’Hebron University Hospital, 08035 Barcelona, Spain; (P.G.-M.); (R.F.)
| | - Juan M Pericàs
- Vall d’Hebron Institut de Recerca (VHIR), 08035 Barcelona, Spain; (J.R.-E.); (R.M.-N.); (J.B.); (D.M.S.)
- Liver Unit, Vall d’Hebron University Hospital, 08035 Barcelona, Spain
- Spanish Network of Biomedical Research Centers, Liver and Digestive Diseases (CIBERehd), 28801 Madrid, Spain
- Correspondence: (J.M.P.); (A.C.)
| | - Andreea Ciudin
- Endocrinology Department, Vall d’Hebron University Hospital, 08035 Barcelona, Spain;
- Vall d’Hebron Institut de Recerca (VHIR), 08035 Barcelona, Spain; (J.R.-E.); (R.M.-N.); (J.B.); (D.M.S.)
- Medicine Department Bellaterra, Universitat Autònoma de Barcelona, 08193 Barcelona, Spain
- Spanish Network of Biomedical Research Centers, Diabetes and Metabolic Associated Disorders (CIBERdem), 28029 Madrid, Spain
- Correspondence: (J.M.P.); (A.C.)
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19
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Mitrovic B, Gluvic ZM, Obradovic M, Radunovic M, Rizzo M, Banach M, Isenovic ER. Non-alcoholic fatty liver disease, metabolic syndrome, and type 2 diabetes mellitus: where do we stand today? Arch Med Sci 2022; 19:884-894. [PMID: 37560721 PMCID: PMC10408022 DOI: 10.5114/aoms/150639] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2022] [Accepted: 06/02/2022] [Indexed: 08/11/2023] Open
Abstract
Non-alcoholic fatty liver disease (NAFLD), metabolic syndrome (MetS), and type 2 diabetes (T2DM) are metabolic disorders that belong to a highly prevalent disease cluster with a significant impact on public health worldwide. MetS is a complex condition characterized by metabolism perturbations that include glucose intolerance, insulin resistance, dyslipidaemia, associated pro-inflammatory state, and arterial hypertension. Because the components of MetS commonly co-occur, the management of these disorders cannot be considered separate issues. Thus NAFLD, recognized as a hepatic manifestation of MetS, is frequently associated with T2DM. This review analyses the underlying connections between these diseases and the risks associated with their co-occurrence. The effective management of NAFLD associated with MetS and T2DM involves an early diagnosis and optimal treatment of each condition leading to improvement in glycaemic and lipid regulation, liver steatosis, and arterial hypertension. The net effect of such treatment is the prevention of atherosclerotic cardiovascular diseases and liver fibrosis.
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Affiliation(s)
- Bojan Mitrovic
- University Clinical-Hospital Centre Zemun-Belgrade, Clinic of Internal medicine, School of Medicine, University of Belgrade, Belgrade, Serbia
| | - Zoran M. Gluvic
- University Clinical-Hospital Centre Zemun-Belgrade, Clinic of Internal medicine, School of Medicine, University of Belgrade, Belgrade, Serbia
| | - Milan Obradovic
- Department of Radiobiology and Molecular Genetics, “VINČA” Institute of Nuclear Sciences – National Institute of the Republic of Serbia, University of Belgrade, Belgrade, Serbia
| | - Maja Radunovic
- Faculty of Stomatology, Pancevo, University Business Academy, Novi Sad, Serbia
| | - Manfredi Rizzo
- Department of Internal Medicine and Medical Specialties, University of Palermo, Palermo, Italy
| | - Maciej Banach
- Department of Hypertension, Medical University of Lodz, Lodz, Poland
| | - Esma R. Isenovic
- Department of Radiobiology and Molecular Genetics, “VINČA” Institute of Nuclear Sciences – National Institute of the Republic of Serbia, University of Belgrade, Belgrade, Serbia
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Gracen L, Hayward KL, Aikebuse M, Williams S, Russell A, O'Beirne J, Powell EE, Valery PC. An exploration of barriers and facilitators to implementing a nonalcoholic fatty liver disease pathway for people with type 2 diabetes in primary care. Diabet Med 2022; 39:e14799. [PMID: 35100462 PMCID: PMC9303899 DOI: 10.1111/dme.14799] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Accepted: 01/28/2022] [Indexed: 11/30/2022]
Abstract
AIMS We explored barriers and facilitators to the implementation of nonalcoholic fatty liver disease (NAFLD) pathway for people with diabetes to identify determinants of behaviour surrounding the diagnosis, assessment and management of NAFLD. METHODS Health practitioners (n = 24) recruited from multidisciplinary diabetes clinics in primary care (n = 3) and hospital (n = 1) settings participated in four focus group discussions, and common themes were identified using thematic analysis. RESULTS Lack of knowledge and access to resources were key factors that underpinned an inconsistent approach by clinicians to NAFLD diagnosis and risk stratification and impacted their confidence to discuss the diagnosis with patients. Participants often prioritised other medical issues above NAFLD due to lack of concern about liver-related consequences, reluctance to overburden patients with information, lack of time and perceived absence of accessible fibrosis tests. All participants agreed that implementation of a NAFLD pathway would improve patient care and the general practitioners proposed that screening for NAFLD could be incorporated into routine review cycles for type 2 diabetes. A consistent message from participants was that educating patients about their liver disease needs to be implemented in an integrated care pathway. CONCLUSIONS From the perspectives of health practitioners, there is a gap in clinical practice for the implementation of clear, evidence-based guidelines for NAFLD in people with T2D. By focusing on comorbidity prevention and integrating NAFLD as a diabetes complication to be addressed during established cycles of care, many barriers to implementing a NAFLD pathway in primary care could be overcome.
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Affiliation(s)
- Lucy Gracen
- Centre for Liver Disease ResearchFaculty of MedicineTranslational Research InstituteThe University of QueenslandBrisbaneQueenslandAustralia
- Department of Gastroenterology and HepatologyPrincess Alexandra HospitalBrisbaneQueenslandAustralia
| | - Kelly L. Hayward
- Centre for Liver Disease ResearchFaculty of MedicineTranslational Research InstituteThe University of QueenslandBrisbaneQueenslandAustralia
- Department of Gastroenterology and HepatologyPrincess Alexandra HospitalBrisbaneQueenslandAustralia
| | - Melanie Aikebuse
- Centre for Liver Disease ResearchFaculty of MedicineTranslational Research InstituteThe University of QueenslandBrisbaneQueenslandAustralia
- Department of Gastroenterology and HepatologyPrincess Alexandra HospitalBrisbaneQueenslandAustralia
| | | | - Anthony Russell
- Centre for Health Services ResearchFaculty of MedicineThe University of QueenslandWoolloongabbaQueenslandAustralia
- Department of EndocrinologyPrincess Alexandra HospitalBrisbaneQueenslandAustralia
| | - James O'Beirne
- Department of Gastroenterology and HepatologySunshine Coast University HospitalBirtinyaAustralia
| | - Elizabeth E. Powell
- Centre for Liver Disease ResearchFaculty of MedicineTranslational Research InstituteThe University of QueenslandBrisbaneQueenslandAustralia
- Department of Gastroenterology and HepatologyPrincess Alexandra HospitalBrisbaneQueenslandAustralia
| | - Patricia C. Valery
- Centre for Liver Disease ResearchFaculty of MedicineTranslational Research InstituteThe University of QueenslandBrisbaneQueenslandAustralia
- QIMR Berghofer Medical Research InstituteRoyal Brisbane HospitalBrisbaneQueenslandAustralia
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21
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Lake JE, Overton T, Naggie S, Sulkowski M, Loomba R, Kleiner DE, Price JC, Chew KW, Chung RT, Corey KE. Expert Panel Review on Nonalcoholic Fatty Liver Disease in Persons With Human Immunodeficiency Virus. Clin Gastroenterol Hepatol 2022; 20:256-268. [PMID: 33069882 PMCID: PMC9069630 DOI: 10.1016/j.cgh.2020.10.018] [Citation(s) in RCA: 31] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2020] [Revised: 10/07/2020] [Accepted: 10/12/2020] [Indexed: 02/07/2023]
Abstract
Nonalcoholic fatty liver disease (NAFLD) affects 25% of adults in the general population and is a disease spectrum ranging from steatosis to nonalcoholic steatohepatitis (NASH) to end-stage liver disease. NAFLD is an independent risk factor for cardiovascular disease, diabetes mellitus, and all-cause mortality, and NASH cirrhosis is a frequent indication for liver transplantation. In persons with human immunodeficiency virus (PWH), chronic liver disease is the second leading cause of non-human immunodeficiency virus-related mortality. Between 20% and 63% of PWH have NASH, and 14% to 63% have NASH with fibrosis. However, little is known about the optimal diagnostic strategies, risk factors for, and treatment of NAFLD in PWH. Here, we review current data on and identify knowledge gaps in the epidemiology, pathophysiology, diagnosis, and management of NAFLD in PWH and highlight priorities for research.
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Affiliation(s)
- Jordan E Lake
- Division of Infectious Disease, University of Texas Health Sciences Center at Houston, Houston, Texas.
| | - Turner Overton
- Division of Infectious Disease, University of Alabama School of Medicine, Birmingham, Alabama
| | - Susanna Naggie
- Division of Infections Disease, Duke University School of Medicine, Durham, North Carolina
| | - Mark Sulkowski
- Division of Infectious Disease, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Rohit Loomba
- Division of Gastroenterology, University of California San Diego School of Medicine, San Diego, California
| | - David E Kleiner
- Center for Cancer Research, National Cancer Institute, Bethesda, Maryland
| | - Jennifer C Price
- Division of Gastroenterology, University of California San Francisco School of Medicine, San Francisco, California
| | - Kara W Chew
- Division of Infectious Diseases, University of California Los Angeles School of Medicine, Los Angeles, California
| | - Raymond T Chung
- Division of Gastroenterology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Kathleen E Corey
- Division of Gastroenterology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
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22
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Anand A, Singh AA, Elhence A, Vaishnav M, Biswas S, Gunjan D, Gamanagatti SR, Nayak B, Kumar R, Shalimar. Prevalence and Predictors of Nonalcoholic Fatty Liver Disease in Family Members of Patients With Nonalcoholic Fatty Liver Disease. J Clin Exp Hepatol 2022; 12:362-371. [PMID: 35535086 PMCID: PMC9077183 DOI: 10.1016/j.jceh.2021.07.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Accepted: 07/25/2021] [Indexed: 12/12/2022] Open
Abstract
Background and aims Nonalcoholic fatty liver disease (NAFLD) is the commonest cause of chronic liver disease worldwide. Despite the high prevalence, no screening recommendations yet exist. We designed a prospective observational study to estimate the prevalence of NAFLD in the family of patients with NAFLD and develop a predictive model for identifying it. Methodology The prevalence of NAFLD in patients' family members was estimated using ultrasonography, and univariate and multivariate odds were calculated for its predictors. A model was created using the significant parameters on multivariate odds, and its performance was tested using the area under the receiver operating characteristic (AUROC). Results Among 447 family members of 191 patients with NAFLD, the prevalence of NAFLD was 55.9%. Family members with NAFLD were younger and had lower serum levels of aspartate aminotransferase, alanine aminotransferase (ALT), triglycerides. The liver stiffness measurement and controlled attenuation parameter values were also lesser in family members compared to the index cases. Age, body mass index (BMI), and ALT were independent predictors of NAFLD in the family members. A model combining age and BMI had an AUROC of 0.838 [95% confidence interval (CI) 0.800-0.876, P < 0.001]. Age ≥30 years and BMI ≥25 kg/m2 had an odds ratio of 33.5 (95% CI 17.0-66.0, P < 0.001) for prediction of NAFLD, in comparison to BMI <25 kg/m2 and age <30 years. Conclusion Family members of patients with NAFLD are at increased risk of NAFLD. Screening strategies using BMI and age ensure early identification and could be beneficial in clinical practice.
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Key Words
- ALT, Alanine aminotransferase
- APRI, AST to platelet ratio index
- AST, Aspartate aminotransferase
- AUROC, Area under ROC
- BMI
- BMI, Body mass index
- CAP, Controlled attenuation parameter
- CI, Confidence interval
- EASL, European Association for the Study of the Liver
- FAST, FibroScan-AST
- FDRs, First-degree relatives
- FIB-4, Fibrosis-4
- HDL-C, High-density lipoprotein-cholesterol
- HbA1C, Glycosylated hemoglobin
- LSM, Liver stiffness measure
- MetS, Metabolic syndrome
- NAFLD, Non-alcoholic fatty liver disease
- NASH, Non-alcoholic steatohepatitis
- NCEP-ATP, National Cholesterol Education Program- Adult Treatment Panel
- NFS, NAFLD fibrosis score
- OR, Odds ratio
- ROC, Receiver operating curve
- family members
- nonalcoholic fatty liver disease
- predictors
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Affiliation(s)
- Abhinav Anand
- Department of Gastroenterology and Human Nutrition Unit, All India Institute of Medical Sciences, New Delhi, India
| | - Amit A. Singh
- Department of Gastroenterology and Human Nutrition Unit, All India Institute of Medical Sciences, New Delhi, India
| | - Anshuman Elhence
- Department of Gastroenterology and Human Nutrition Unit, All India Institute of Medical Sciences, New Delhi, India
| | - Manas Vaishnav
- Department of Gastroenterology and Human Nutrition Unit, All India Institute of Medical Sciences, New Delhi, India
| | - Sagnik Biswas
- Department of Gastroenterology and Human Nutrition Unit, All India Institute of Medical Sciences, New Delhi, India
| | - Deepak Gunjan
- Department of Gastroenterology and Human Nutrition Unit, All India Institute of Medical Sciences, New Delhi, India
| | | | - Baibaswata Nayak
- Department of Gastroenterology and Human Nutrition Unit, All India Institute of Medical Sciences, New Delhi, India
| | - Ramesh Kumar
- Department of Gastroenterology, All India Institute of Medical Sciences, Patna, Bihar, India
| | - Shalimar
- Department of Gastroenterology and Human Nutrition Unit, All India Institute of Medical Sciences, New Delhi, India,Address for correspondence: Dr Shalimar, Additional Professor, Department of Gastroenterology and Human Nutrition Unit, All India Institute of Medical Sciences, New Delhi, 110029, India. Tel.: +91 9968405815; Fax: +91 11 26588663, +91 11 26588641.
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Gluvic Z, Tomasevic R, Bojovic K, Obradovic M, Isenovic ER. Non-alcoholic fatty liver disease: a multidisciplinary clinical practice approach—the institutional adaptation to existing Clinical Practice Guidelines. EMERGENCY AND CRITICAL CARE MEDICINE 2021; 2:12-22. [DOI: 10.1097/ec9.0000000000000016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/13/2023]
Abstract
Abstract
Non-alcoholic fatty liver disease (NAFLD) is among the most frequently encountered chronic liver diseases in everyday clinical practice. It is considered the hepatic manifestation of metabolic syndrome. Today, liver biopsy is still the gold standard for NAFLD confirmation and assessing NAFLD's possible progression to non-alcoholic steatohepatitis, fibrosis, cirrhosis, and hepatocellular carcinoma. Because of the high prevalence of NAFLD and potential associated risks of invasive diagnostic procedures, it is of great interest to recruit the patients for liver biopsy. However, as the presence of liver fibrosis determines the further clinical course, liver biopsy is expectedly reserved for those with increased fibrosis risk. The quality of liver biopsy recruitment and patient monitoring could be significantly improved by using non-invasive tools to assess liver fibrosis presence and interactive collaboration between general practitioners, gastroenterologists, and endocrinologists. As a result, the quality of liver biopsy recruitment and patients monitoring could be significantly improved. Here, we proposed clinical practice guidelines that could be implemented for everyday clinical practice in NAFLD patients.
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Affiliation(s)
- Zoran Gluvic
- University Clinical-Hospital Centre Zemun-Belgrade, Clinic of Internal Medicine, School of Medicine, University of Belgrade, Belgrade, Serbia
| | - Ratko Tomasevic
- University Clinical-Hospital Centre Zemun-Belgrade, Clinic of Internal Medicine, School of Medicine, University of Belgrade, Belgrade, Serbia
| | - Ksenija Bojovic
- Clinical Centre of Serbia, Clinic of Infectious and Tropical Diseases, School of Medicine, University of Belgrade, Belgrade, Serbia
| | - Milan Obradovic
- Department of Radiobiology and Molecular Genetics, “VINČA” Institute of Nuclear Sciences – National Institute of thе Republic of Serbia, University of Belgrade, Belgrade, Serbia
| | - Esma R. Isenovic
- Department of Radiobiology and Molecular Genetics, “VINČA” Institute of Nuclear Sciences – National Institute of thе Republic of Serbia, University of Belgrade, Belgrade, Serbia
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24
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Wong RJ, Kachru N, Martinez DJ, Moynihan M, Ozbay AB, Gordon SC. Real-world Comorbidity Burden, Health Care Utilization, and Costs of Nonalcoholic Steatohepatitis Patients With Advanced Liver Diseases. J Clin Gastroenterol 2021; 55:891-902. [PMID: 32815873 PMCID: PMC8500367 DOI: 10.1097/mcg.0000000000001409] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Accepted: 07/15/2020] [Indexed: 12/13/2022]
Abstract
GOALS This study evaluates the real-world comorbidity burden, health care resource utilization (HRU), and costs among nonalcoholic fatty liver disease/nonalcoholic steatohepatitis (NAFLD/NASH) patients with advanced liver diseases [compensated cirrhosis (CC), decompensated cirrhosis (DCC), liver transplantation (LT), hepatocellular carcinoma (HCC)]. BACKGROUND NAFLD/NASH is a leading cause of liver diseases. MATERIALS AND METHODS Adult NAFLD/NASH patients were identified retrospectively from MarketScan Commercial claims (2006-2016). Following initial NAFLD/NASH diagnosis, advanced liver diseases were identified using the first diagnosis as their index date. Mean annual all-cause HRU and costs (2016 USD) were reported. Adjusted costs were estimated through generalized linear models. Cumulative costs were illustrated for patient subsets with variable follow-up for each stage. RESULTS Within the database, 485,774 NAFLD/NASH patients met eligibility criteria. Of these, 93.4% (453,564) were NAFLD/NASH patients without advanced liver diseases, 1.6% (7665) with CC, 3.3% (15,833) with DCC, 0.1% (696) with LT, and 0.1% (428) with HCC. Comorbidity burden was high and increased as patients progressed through liver disease severity stages. Compared with NAFLD/NASH without advanced liver diseases (adjusted costs: $23,860), the annual cost of CC, DCC, LT, and HCC were 1.22, 5.64, 8.27, and 4.09 times higher [adjusted costs: $29,078, $134,448, $197,392, and $97,563 (P<0.0001)]. Inpatient admissions significantly drove increasing HRU. CONCLUSION Study findings suggest the need for early identification and effective management of NAFLD/NASH patients to minimize comorbidity burden, HRU, and costs in the privately insured US population.
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Affiliation(s)
- Robert J. Wong
- Division of Gastroenterology and Hepatology, Alameda Health System, Highland Hospital, Oakland
| | - Nandita Kachru
- Gilead Sciences Inc., Health Economics Outcomes Research, Foster City, CA
| | | | | | - A. Burak Ozbay
- Gilead Sciences Inc., Health Economics Outcomes Research, Foster City, CA
| | - Stuart C. Gordon
- Department of Gastroenterology and Hepatology, Henry Ford Hospital, Wayne State University School of Medicine, Detroit, MI
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25
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Dietrich CG, Rau M, Geier A. Screening for nonalcoholic fatty liver disease-when, who and how? World J Gastroenterol 2021; 27:5803-5821. [PMID: 34629804 PMCID: PMC8475001 DOI: 10.3748/wjg.v27.i35.5803] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Revised: 05/13/2021] [Accepted: 08/30/2021] [Indexed: 02/06/2023] Open
Abstract
Nonalcoholic fatty liver disease (NAFLD) is becoming a frequent liver disease, especially in patients with metabolic syndrome and especially in Western countries. Complications of NAFLD comprise progressive fibrosis, cirrhosis and hepatocellular carcinoma. NAFLD also represents an independent risk factor for cardiovascular disease, extrahepatic neoplasia and other organ damage, such as renal insufficiency. Given the epidemiological importance of the disease, new developments in specific treatment of the disease and the wide availability of noninvasive techniques in estimating steatosis and fibrosis, NAFLD should be subject to screening programs, at least in countries with a high prevalence of the disease. The review discusses prerequisites for screening, cost-effectiveness, current guideline recommendations, suitability of techniques for screening and propositions for the following questions: Who should be screened? Who should perform screening? How should screening be performed? It is time for a screening program in patients at risk for NAFLD.
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Affiliation(s)
- Christoph G Dietrich
- Department of Internal Medicine, Bethlehem Health Center, Stolberg 52222, Germany
| | - Monika Rau
- Department of Internal Medicine II, University Hospital Würzburg, Würzburg 97080, Germany
| | - Andreas Geier
- Department of Medicine II, University Hospital Würzburg, Würzburg 97080, Germany
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26
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Saeed N, Glass LM, Habbal H, Mahmood A, Sengstock D, Saini SD, Tincopa MA. Primary care and referring physician perspectives on non-alcoholic fatty liver disease management: a nationwide survey. Therap Adv Gastroenterol 2021; 14:17562848211042200. [PMID: 34567270 PMCID: PMC8460969 DOI: 10.1177/17562848211042200] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Accepted: 07/12/2021] [Indexed: 02/04/2023] Open
Abstract
INTRODUCTION The optimal approach to screening and risk stratification for non-alcoholic fatty liver disease is challenging given disease burden and variable progression. The aim of this study was to assess primary care physician and referring physician practice patterns regarding non-alcoholic fatty liver disease. METHODS An anonymous nationwide survey was administered to primary care physicians, endocrinologists, and cardiologists in a: (1) tertiary academic hospital, (2) community hospital, and (3) the American College of Physicians Insider Panel. Survey domains assessed non-alcoholic fatty liver disease knowledge, recommendations for screening, risk stratification, treatment, and referral patterns. RESULTS A total of 440 providers completed the survey (35.2% completion rate; N = 82 academic hospital, N = 21 community hospital, N = 337 American College of Physicians). Half were male (51.7%), 78% from internal medicine, with 5% subspecialists. Providers were knowledgeable regarding prevalence and risk factors for non-alcoholic fatty liver disease. 58% would support screening for non-alcoholic fatty liver disease and used liver enzymes to do so. Only 22.5% used serum biomarkers and 23% used transient elastography for risk stratification. Primary reason for referral was advanced fibrosis/cirrhosis. 80% reported barriers to treating non-alcoholic fatty liver disease. There was no consistent diet recommended. CONCLUSION In this nationwide survey, we demonstrated that while overall disease knowledge was good, there was an important disconnect between current guidelines and real-world clinical practice. There is also significant heterogeneity in practice patterns for first-line therapy of non-alcoholic fatty liver disease and the majority of provider's report barriers to treating non-alcoholic fatty liver disease. These findings highlight the potential role for reevaluating screening and risk stratification recommendations in primary care to better align with needs in that setting.
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Affiliation(s)
- Naba Saeed
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, University of Kentucky, Lexington, KY, USA,Division of Gastroenterology and Hepatology, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Lisa M. Glass
- Department of Internal Medicine, John D. Dingell VA Medical Center, Detroit, MI, USA,Department of Internal Medicine, Wayne State University, Detroit, MI, USA
| | - Heba Habbal
- Department of Internal Medicine, Beaumont Health, Dearborn, MI, USA
| | - Asad Mahmood
- Department of Internal Medicine, John D. Dingell VA Medical Center, Detroit, MI, USA,Department of Internal Medicine, Wayne State University, Detroit, MI, USA
| | - David Sengstock
- Department of Internal Medicine, Beaumont Health, Dearborn, MI, USA
| | - Sameer D. Saini
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA,VA Ann Arbor Center for Clinical Management Research, Ann Arbor, MI, USA
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Determining the Target Population That Would Most Benefit from Screening for Hepatic Fibrosis in a Primary Care Setting. Diagnostics (Basel) 2021; 11:diagnostics11091605. [PMID: 34573947 PMCID: PMC8470742 DOI: 10.3390/diagnostics11091605] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2021] [Revised: 08/27/2021] [Accepted: 08/31/2021] [Indexed: 12/15/2022] Open
Abstract
Due to its high prevalence, screening for hepatic fibrosis in the low-risk population is called for action in the primary care clinic. However, current guidelines provide conflicting recommendations on populations to be screened. We aimed to identify the target populations that would most benefit from screening for hepatic fibrosis in clinical practice. This study examined 1288 subjects who underwent magnetic resonance elastography. The diagnostic performance of the Fibrosis-4 (FIB-4) index and NAFLD fibrosis score was compared in the following groups: (1) ultrasonography (USG)-diagnosed NAFLD, (2) elevated liver enzyme, (3) metabolic syndrome, (4) impaired fasting glucose, and (5) type 2 diabetes regardless of fatty liver. Decision curve analysis was performed to express the net benefit of groups over a range of probability thresholds (Pts). The diabetes group showed a better area under the receiver operating characteristic curve (AUROC: 0.69) compared with subjects in the USG-diagnosed NAFLD (AUROC: 0.57) and elevated liver enzyme (AUROC: 0.55) groups based on the FIB-4 index. In decision curve analysis, the diabetes group showed the highest net benefit for the detection of significant fibrosis across a wide range of Pts. Patients with diabetes, even in the absence of fatty liver, would be preferable for hepatic fibrosis screening in low-risk populations.
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Alhinai A, Patel K, Fonseca VA, Sebastiani G. Non-invasive diagnosis of nonalcoholic fatty liver disease in patients with type 2 diabetes. J Diabetes Complications 2021; 35:107978. [PMID: 34183247 DOI: 10.1016/j.jdiacomp.2021.107978] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2021] [Revised: 05/19/2021] [Accepted: 06/12/2021] [Indexed: 02/07/2023]
Abstract
Liver disease has emerged as a significant cause of death in people with type 2 diabetes (T2D). Due to a common underlying pathogenic mechanism, namely insulin resistance, T2D represents the main risk factor for nonalcoholic fatty liver disease (NAFLD), characterized by a buildup of fat in the liver. Globally, NAFLD is the most common liver disease, affecting a quarter of the general adult population. The development of nonalcoholic steatohepatitis (NASH) signifies an increased risk of liver fibrosis progression that can result in cirrhosis, hepatocellular carcinoma (HCC), and death. Liver fibrosis progression and development of cirrhosis is mostly asymptomatic until complications from decompensated end-stage liver disease arise. Traditionally, liver biopsy is used to diagnose NASH and stage fibrosis, however, it is invasive and costly. Non-invasive diagnostic alternatives include serum biomarkers and imaging techniques. Early identification of advanced liver fibrosis is pivotal to prompt initiation of targeted surveillance, including screening for HCC, as well as providing options for current and investigational therapeutic interventions to reduce fibrosis progression. This review gives an update on non-invasive diagnostic tools for NAFLD and liver fibrosis in the specific context of T2D, providing clinicians a pragmatic diagnostic approach to this frequent comorbidity in diabetes medicine.
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Affiliation(s)
- Alshaima Alhinai
- Division of Experimental Medicine, McGill University, Montreal, QC, Canada
| | - Keyur Patel
- Division of Gastroenterology and Hepatology, University Health Network Toronto, Toronto General Hospital, Toronto, ON, Canada
| | - Vivian A Fonseca
- Department of Medicine, Division of Endocrinology and Metabolism, School of Medicine, Tulane University Health Sciences Center, New Orleans, LA, USA
| | - Giada Sebastiani
- Division of Experimental Medicine, McGill University, Montreal, QC, Canada; Division of Gastroenterology and Hepatology, McGill University Health Centre, Montreal, QC, Canada.
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Canbay A, Kachru N, Haas JS, Meise D, Ozbay AB, Sowa JP. Healthcare resource utilization and costs among nonalcoholic fatty liver disease patients in Germany. ANNALS OF TRANSLATIONAL MEDICINE 2021; 9:615. [PMID: 33987313 PMCID: PMC8106103 DOI: 10.21037/atm-20-7179] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Background Patients with nonalcoholic fatty liver disease (NAFLD) and nonalcoholic steatohepatitis (NASH) are associated with progression to advanced liver diseases that include compensated cirrhosis, decompensated cirrhosis, liver transplantation, and hepatocellular carcinoma (HCC). This study characterized comorbidities, healthcare resource utilization (HRU), and associated costs among NAFLD patients in Germany. Methods German healthcare claims data between 2011 and 2016 were analyzed retrospectively. Adult patients diagnosed with NAFLD and/or NASH were categorized as NAFLD, NAFLD non-progressors, compensated cirrhosis, decompensated cirrhosis, liver transplant, or HCC. Within each stage, annual all-cause HRU and costs were measured during the pre- and post-index periods. Results Among 4,580,434 patients in the database, proportion of NAFLD was 4.7% (n=215,655). Of them, 36.8% were non-progressors, 0.2% compensated cirrhosis, 9.6% decompensated cirrhosis, 0.0005% liver transplant, and 0.2% HCC. Comorbidity rates were significantly higher in compensated cirrhosis, decompensated cirrhosis, and HCC compared with non-progressors (52.07%, 56.46%, 57.58% vs. 27.49% for cardiovascular disease; 77.13%, 76.61%, 83.47% vs. 54.89% for hypertension; 47.20%, 53.81%, 52.89% vs. 35.21% for hyperlipidemia; 49.88%, 36.67%, 48.21% vs. 20.38% for type 2 diabetes mellitus). The mean annual numbers of post-index outpatient visits and inpatient hospitalizations were significantly higher in patients with advanced liver diseases versus non-progressors. Mean annual costs were significantly higher among patients with advanced liver diseases (compensated cirrhosis, €10,291; decompensated cirrhosis, €22,561; liver transplant, €34,089; HCC, €35,910) than non-progressors (€3,818, P<0.001, except liver transplant cohort). This trend remained consistent after adjusting for baseline demographics and comorbidities. Conclusions NAFLD patients in Germany are grossly underdiagnosed and exert substantial healthcare resource use and economic burden, particularly those with advanced liver diseases. Optimal strategies for early identification and management are needed to prevent disease progression and limit the rising costs.
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Affiliation(s)
- Ali Canbay
- Department of Internal Medicine, Ruhr-University Bochum, Bochum, Germany
| | - Nandita Kachru
- Gilead Sciences, Inc., Health Economics Outcomes Research, Foster City, CA, USA
| | | | | | - A Burak Ozbay
- Gilead Sciences, Inc., Health Economics Outcomes Research, Foster City, CA, USA
| | - Jan-Peter Sowa
- Department of Internal Medicine, Ruhr-University Bochum, Bochum, Germany
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30
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Readiness for the epidemic: The adult nonalcoholic fatty liver disease toolkit for primary care nurse practitioners. J Am Assoc Nurse Pract 2020; 32:323-331. [PMID: 31274677 DOI: 10.1097/jxx.0000000000000223] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND PURPOSE Nonalcoholic fatty liver disease (NAFLD) prevalence has reached epidemic proportions, and the severe form, nonalcoholic steatohepatitis, can result in cirrhosis and liver failure. The growing prevalence requires primary care (PC) providers to be adept at recognition and management; however, they experience significant knowledge gaps that can result in delayed access to interventions that could improve outcomes. This study's aim was to develop and evaluate a toolkit to improve knowledge gaps and support evidence-based practice (EBP) among PC nurse practitioners caring for patients with NAFLD in a midwestern state. METHODS AND INTERVENTION The Adult NAFLD Toolkit was designed using the Knowledge to Action framework and guidelines from the Agency for Healthcare Research and Quality. The success of the toolkit was evaluated by administering the NAFLD survey for general practitioners in a pre-post evaluation design. RESULTS Pre-post survey scores (N = 11) were compared for statistically significant change using the Wilcoxon signed rank test for matched pairs and showed improvement in overall knowledge (p = .011), perceived preparedness to care for NAFLD (p = .007), intention to recommend weight loss for management (p = .008), and intention to use the NAFLD fibrosis score for patient monitoring (p = .008). CONCLUSIONS The results of this pilot study demonstrate successful implementation and positive outcomes of an EBP toolkit and support its expanded use. Continued evaluation on a larger scale is needed. Health care providers can use the process described in this article to develop and implement toolkits to support EBP of other PC issues.
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Noureddin M, Jones C, Alkhouri N, Gomez EV, Dieterich DT, Rinella ME. Screening for Nonalcoholic Fatty Liver Disease in Persons with Type 2 Diabetes in the United States Is Cost-effective: A Comprehensive Cost-Utility Analysis. Gastroenterology 2020; 159:1985-1987.e4. [PMID: 32763241 DOI: 10.1053/j.gastro.2020.07.050] [Citation(s) in RCA: 73] [Impact Index Per Article: 18.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2020] [Revised: 07/24/2020] [Accepted: 07/30/2020] [Indexed: 02/08/2023]
Affiliation(s)
- Mazen Noureddin
- Division of Digestive and Liver Diseases, Comprehensive Transplant Center, Cedars Sinai Medical Center, Los Angeles, California.
| | - Calum Jones
- Health Economics, McCann Health, Glasgow, United Kingdom
| | - Naim Alkhouri
- Texas Liver Institute, University of Texas Health San Antonio, San Antonio, Texas
| | - Eduardo Vilar Gomez
- Division of Gastroenterology/Hepatology, Indiana University, Indianapolis, Indiana
| | - Douglas T Dieterich
- Division of Liver Disease, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Mary E Rinella
- Feinberg School of Medicine, Northwestern University, Chicago, Illinois
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Rosato V, Masarone M, Aglitti A, Persico M. The diagnostic conundrum in non-alcoholic fatty liver disease. EXPLORATION OF MEDICINE 2020. [DOI: 10.37349/emed.2020.00018] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Non-alcoholic fatty liver disease (NAFLD) has become the most common liver alteration worldwide. It encompasses a spectrum of disorders that range from simple steatosis to a progressive form, defined non-alcoholic steatohepatitis (NASH), that can lead to advanced fibrosis and eventually cirrhosis and hepatocellular carcinoma. On liver histology, NASH is characterized by the concomitant presence of significant fat accumulation and inflammatory reaction with hepatocellular injury. Until now, liver biopsy is still required to differentiate simple steatosis from NASH and evaluate the degree of liver fibrosis. Unfortunately, this technique has well-known limitations, including invasiveness and expensiveness. Moreover, it may be biased by sampling error and intra- or inter-observed variability. Furthermore, due to the increasing prevalence of NAFLD worldwide, to program a systematic screening with liver biopsy is not imaginable. In recent years, different techniques were developed and validated with the aim of non-invasively identifying NASH and assess liver fibrosis degrees. The non-invasive tests range from simple blood-tests analyses to composite scores and complex imaging techniques. Nevertheless, even if they could represent cost-effective strategies for diagnosing NASH, advanced fibrosis and cirrhosis, their accuracy and consequent usefulness are to be discussed. With this aim, in this review the authors summarize the current state of non-invasive assessment of NAFLD. In particular, in addition to the well-established tests, the authors describe the future perspectives in this field, reporting the latest tests based on OMICS, gut-miocrobioma and micro-RNAs. Finally, the authors provide an accurate assessment of how these non-invasive tools perform in clinical practice depending on the clinical context, with the aim of giving the clinicians a useful tool to try to resolve the diagnostic conundrum of NAFLD.
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Affiliation(s)
- Valerio Rosato
- Internal Medicine and Hepatology Unit, Department of Medicine, Surgery and Odontostomatology “Scuola Medica Salernitana”- University of Salerno, Street Salvador Allende, 43, Fisciano, 84084 Campania, Italy
| | - Mario Masarone
- Internal Medicine and Hepatology Unit, Department of Medicine, Surgery and Odontostomatology “Scuola Medica Salernitana”- University of Salerno, Street Salvador Allende, 43, Fisciano, 84084 Campania, Italy
| | - Andrea Aglitti
- Internal Medicine and Hepatology Unit, Department of Medicine, Surgery and Odontostomatology “Scuola Medica Salernitana”- University of Salerno, Street Salvador Allende, 43, Fisciano, 84084 Campania, Italy
| | - Marcello Persico
- Internal Medicine and Hepatology Unit, Department of Medicine, Surgery and Odontostomatology “Scuola Medica Salernitana”- University of Salerno, Street Salvador Allende, 43, Fisciano, 84084 Campania, Italy
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Younossi ZM, Corey KE, Alkhouri N, Noureddin M, Jacobson I, Lam B, Clement S, Basu R, Gordon SC, Ravendhra N, Puri P, Rinella M, Scudera P, Singal AK, Henry L. Clinical assessment for high-risk patients with non-alcoholic fatty liver disease in primary care and diabetology practices. Aliment Pharmacol Ther 2020; 52:513-526. [PMID: 32598051 DOI: 10.1111/apt.15830] [Citation(s) in RCA: 56] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Revised: 04/21/2020] [Accepted: 05/12/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND Primary care practitioners (PCPs) and diabetologists are at the frontline of potentially encountering patients with NASH. Identification of those at high risk for adverse outcomes is important. AIM To provide practical guidance to providers on how to identify these patients and link them to specialty care. METHODS US members of the Global Council on NASH evaluated the evidence about NASH and non-invasive tests and developed a simple algorithm to identify high-risk NASH patients for diabetologists and primary care providers. These tools can assist frontline providers in decision-making and referral to gastroenterology/hepatology practices for additional assessments. RESULTS The presence of NASH-related advanced fibrosis is an independent predictor of adverse outcomes. These patients with NASH are considered high risk and referral to specialists is warranted. Given that staging of fibrosis requires a liver biopsy, non-invasive tests for fibrosis would be preferred. Consensus recommendation from the group is to risk-stratify patients based on metabolic risk factors using the FIB-4 as the initial non-invasive test due to its simplicity and ease of use. A FIB-4 score ≥1.3 can be used for further assessment and linkage to specialty care where additional technology to assess liver stiffness or serum fibrosis test will be available. CONCLUSION Due to the growing burden of NAFLD and NASH, PCPs and diabetologists are faced with increased patient encounters in their clinical practices necessitating referral decisions. To assist in identifying high-risk NASH patients requiring specialty care, we provide a simple and easy to use algorithm.
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Petta S, Ting J, Saragoni S, Degli Esposti L, Shreay S, Petroni ML, Marchesini G. Healthcare resource utilization and costs of nonalcoholic steatohepatitis patients with advanced liver disease in Italy. Nutr Metab Cardiovasc Dis 2020; 30:1014-1022. [PMID: 32423665 DOI: 10.1016/j.numecd.2020.02.016] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2019] [Revised: 02/21/2020] [Accepted: 02/24/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND AND AIMS Nonalcoholic steatohepatitis (NASH) may progress to advanced liver disease (AdvLD). This study characterized comorbidities, healthcare resource utilization (HCRU) and associated costs among hospitalized patients with AdvLD due to NASH in Italy. METHODS AND RESULTS Adult nonalcoholic fatty liver disease (NAFLD)/NASH patients from 2011 to 2017 were identified from administrative databases of Italian local health units using ICD-9-CM codes. Development of compensated cirrhosis (CC), decompensated cirrhosis (DCC), hepatocellular carcinoma (HCC), or liver transplant (LT) was identified using first diagnosis date for each severity cohort (index-date). Patients progressing to multiple disease stages were included in >1 cohort. Patients were followed from index-date until the earliest of disease progression, end of coverage, death, or end of study. Within each cohort, per member per month values were annualized to calculate all-cause HCRU or costs(€) in 2017. Of the 9,729 hospitalized NAFLD/NASH patients identified, 97% were without AdvLD, 1.3% had CC, 3.1% DCC, 0.8% HCC, 0.1% LT. Comorbidity burden was high across all cohorts. Mean annual number of inpatient services was greater in patients with AdvLD than without AdvLD. Similar trends were observed in outpatient visits and pharmacy fills. Mean total annual costs increased with disease severity, driven primarily by inpatient services costs. CONCLUSION NAFLD/NASH patients in Italy have high comorbidity burden. AdvLD patients had significantly higher costs. The higher prevalence of DCC compared to CC in this population may suggest challenges of effectively screening and identifying NAFLD/NASH patients. Early identification and effective management are needed to reduce risk of disease progression and subsequent HCRU and costs.
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Affiliation(s)
- Salvatore Petta
- Section of Gastroenterology and Hepatology, PROMISE, University of Palermo, Palermo, Italy.
| | - Jie Ting
- Gilead Sciences, Inc., Health Economics & Outcomes Research, Foster City, CA, USA
| | | | | | - Sanatan Shreay
- Gilead Sciences, Inc., Health Economics & Outcomes Research, Foster City, CA, USA
| | - Maria Letizia Petroni
- Department of Medical and Surgical Sciences, "Alma Mater" University, Bologna, Italy
| | - Giulio Marchesini
- Department of Medical and Surgical Sciences, "Alma Mater" University, Bologna, Italy
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Abstract
Nonalcoholic fatty liver disease (NAFLD) is the most prevalent liver diseases and can progress to advanced fibrosis and end-stage liver disease. Thus, intensive research has been performed to develop noninvasive methods for the diagnosis of nonalcoholic steatohepatitis (NASH) and fibrosis. Currently, no single noninvasive tool covers all of the stages of pathologies and conditions of NAFLD, and the cost and feasibility of known techniques are also important issues. Blood biomarkers for NAFLD may be useful to select subjects who need ultrasonography (US) screening for NAFLD, and noninvasive tools for assessing fibrosis may be helpful to exclude the probability of significant fibrosis and to predict advanced fibrosis, thus guiding the decision of whether to perform liver biopsy in patients with NAFLD. Among various methods, magnetic resonance-based methods have been shown to perform better than other methods in assessing steatosis as well as in detecting hepatic fibrosis. Many genetic markers are associated with the development and progression of NAFLD. Further well-designed studies are needed to determine which biomarker panels, imaging studies, genetic marker panels, or combinations thereof perform well for diagnosing NAFLD, differentiating NASH and fibrosis, and following-up NAFLD, respectively.
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Affiliation(s)
- Dae Ho Lee
- Department of Internal Medicine, Gachon University Gil Medical Center, Gachon University College of Medicine, Incheon, Korea
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Lee BW, Lee YH, Park CY, Rhee EJ, Lee WY, Kim NH, Choi KM, Park KG, Choi YK, Cha BS, Lee DH. Non-Alcoholic Fatty Liver Disease in Patients with Type 2 Diabetes Mellitus: A Position Statement of the Fatty Liver Research Group of the Korean Diabetes Association. Diabetes Metab J 2020; 44:382-401. [PMID: 32431115 PMCID: PMC7332334 DOI: 10.4093/dmj.2020.0010] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2020] [Accepted: 02/24/2020] [Indexed: 12/14/2022] Open
Abstract
This clinical practice position statement, a product of the Fatty Liver Research Group of the Korean Diabetes Association, proposes recommendations for the diagnosis, progression and/or severity assessment, management, and follow-up of non-alcoholic fatty liver disease (NAFLD) in patients with type 2 diabetes mellitus (T2DM). Patients with both T2DM and NAFLD have an increased risk of non-alcoholic steatohepatitis (NASH) and fibrosis and a higher risk of cardiovascular diseases and diabetic complications compared to those without NAFLD. With regards to the evaluation of patients with T2DM and NAFLD, ultrasonography-based stepwise approaches using noninvasive biomarker models such as fibrosis-4 or the NAFLD fibrosis score as well as imaging studies such as vibration-controlled transient elastography with controlled attenuation parameter or magnetic resonance imaging-proton density fat fraction are recommended. After the diagnosis of NAFLD, the stage of fibrosis needs to be assessed appropriately. For management, weight reduction achieved by lifestyle modification has proven beneficial and is recommended in combination with antidiabetic agent(s). Evidence that some antidiabetic agents improve NAFLD/NASH with fibrosis in patients with T2DM is emerging. However, there are currently no definite pharmacologic treatments for NAFLD in patients with T2DM. For specific cases, bariatric surgery may be an option if indicated.
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Affiliation(s)
- Byung Wan Lee
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Yong Ho Lee
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Cheol Young Park
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Eun Jung Rhee
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Won Young Lee
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Nan Hee Kim
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Korea University College of Medicine, Seoul, Korea
| | - Kyung Mook Choi
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Korea University College of Medicine, Seoul, Korea
| | - Keun Gyu Park
- Division of Endocrinology and Metabolism, Department of Internal Medicine, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Yeon Kyung Choi
- Division of Endocrinology and Metabolism, Department of Internal Medicine, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Bong Soo Cha
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea.
| | - Dae Ho Lee
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Gachon University Gil Medical Center, Gachon University College of Medicine, Incheon, Korea.
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Johansen P, Howard D, Bishop R, Moreno SI, Buchholtz K. Systematic Literature Review and Critical Appraisal of Health Economic Models Used in Cost-Effectiveness Analyses in Non-Alcoholic Steatohepatitis: Potential for Improvements. PHARMACOECONOMICS 2020; 38:485-497. [PMID: 31919793 DOI: 10.1007/s40273-019-00881-7] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/21/2023]
Abstract
BACKGROUND Non-alcoholic steatohepatitis (NASH) is a severe, typically progressive form of non-alcoholic fatty liver disease (NAFLD). The global prevalence of NASH is increasing, driven partly by the global increase in obesity and type 2 diabetes mellitus (T2DM), such that NASH is now a leading cause of cirrhosis. There is currently an unmet clinical need for efficacious and cost-effective treatments for NASH; no pharmacologic agents have an approved indication for NASH. OBJECTIVE Our objective was to summarise and critically appraise published health economic models of NASH, to evaluate their quality and suitability for use in the assessment of novel treatments for NASH, and to identify knowledge gaps, challenges and opportunities for future modelling. METHODS A systematic literature review was performed using the MEDLINE, Embase, Cochrane Library and EconLit databases to identify published health economic analyses in patients with NAFLD or NASH. Supplementary hand searches of grey literature were also performed. Articles published up to November 2019 were included in the review. Quality assessment of identified studies was also performed. RESULTS A total of 19 articles comprising 16 unique models including either NAFLD as a whole or NASH alone were included in the review. Structurally, most models had a state-transition component; in terms of health states, two different approaches to early disease states were used, modelling either progression through fibrosis stages or NAFLD/NASH-specific health states. Conditions that frequently co-exist with NASH, such as obesity, T2DM and cardiovascular disease were not captured in models identified here. Late-stage complications such as cirrhosis, decompensated cirrhosis and hepatocellular carcinoma were consistently included, but input data (e.g. costs, utilities and transition probabilities) for late-stage complications were frequently sourced from other liver disease areas. The quality of included studies was heterogenous, and only a small proportion of studies reported internal and external validation processes. CONCLUSION The health economic models identified in this review are associated with limitations primarily driven by a lack of NASH-specific data. Identified models also largely overlooked the intricate association between NASH and other conditions, including obesity and T2DM, and did not capture the increased risk of cardiovascular events associated with NASH. High-quality, transparent, validated health economic models of NASH will be required to evaluate the cost effectiveness of treatments currently in development, particularly compounds that may target other non-hepatic outcomes.
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Stahl EP, Dhindsa DS, Lee SK, Sandesara PB, Chalasani NP, Sperling LS. Nonalcoholic Fatty Liver Disease and the Heart: JACC State-of-the-Art Review. J Am Coll Cardiol 2020; 73:948-963. [PMID: 30819364 DOI: 10.1016/j.jacc.2018.11.050] [Citation(s) in RCA: 224] [Impact Index Per Article: 56.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2018] [Revised: 11/14/2018] [Accepted: 11/26/2018] [Indexed: 02/07/2023]
Abstract
Nonalcoholic fatty liver disease (NAFLD) and cardiovascular disease (CVD) are both manifestations of end-organ damage of the metabolic syndrome. Through multiple pathophysiological mechanisms, CVD and NAFLD are associated with each other. Systemic inflammation, endothelial dysfunction, hepatic insulin resistance, oxidative stress, and altered lipid metabolism are some of the mechanisms by which NAFLD increases the risk of CVD. Patients with NAFLD develop increased atherosclerosis, cardiomyopathy, and arrhythmia, which clinically result in cardiovascular morbidity and mortality. Defining the mechanisms linking these 2 diseases offers the opportunity to further develop targeted therapies. The aim of this comprehensive review is to examine the association between CVD and NAFLD and discuss the overlapping management approaches.
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Affiliation(s)
- Eric P Stahl
- Department of Internal Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Devinder S Dhindsa
- Emory Clinical Cardiovascular Research Institute, Division of Cardiology, Emory University School of Medicine, Atlanta, Georgia
| | - Suegene K Lee
- Department of Internal Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Pratik B Sandesara
- Emory Clinical Cardiovascular Research Institute, Division of Cardiology, Emory University School of Medicine, Atlanta, Georgia
| | - Naga P Chalasani
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, Indiana
| | - Laurence S Sperling
- Emory Clinical Cardiovascular Research Institute, Division of Cardiology, Emory University School of Medicine, Atlanta, Georgia.
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Rikhi R, Singh T, Modaresi Esfeh J. Work up of fatty liver by primary care physicians, review. Ann Med Surg (Lond) 2020; 50:41-48. [PMID: 31993196 PMCID: PMC6976911 DOI: 10.1016/j.amsu.2020.01.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2019] [Revised: 12/17/2019] [Accepted: 01/03/2020] [Indexed: 02/08/2023] Open
Abstract
Nonalcoholic fatty liver disease (NAFLD) is an overarching term that refers to abnormal deposition of lipids in the liver and is used to describe the spectrum of disease ranging from hepatic steatosis to nonalcoholic steatohepatitis to cirrhosis. NAFLD is the most common cause of chronic liver disease and the second most common cause of cirrhosis. Although the pathophysiology is not completely understood, there is a strong link between NAFLD and metabolic syndrome. This review focuses on the workup of NAFLD in the primary care setting, from differential diagnoses to assessing fibrosis via predictive models that use commonly used laboratory values, biomarkers, and imaging. The purpose of this review article is to provide a set of screening and diagnostic tools for all primary care physicians in order to better manage patients with NAFLD. Nonalcoholic fatty liver disease is the most common cause of chronic liver disease. Primary care providers have an important role in diagnosis. Prediction models and imaging have helped estimate fibrosis. Main treatment involves lifestyle modifications and managing comorbid conditions.
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Affiliation(s)
- Rishi Rikhi
- Cleveland Clinic, Department of Internal Medicine, 9500 Euclid Avenue, Cleveland, OH, 44195, USA
| | - Tavankit Singh
- Cleveland Clinic, Department of Gastroenterology, Hepatology & Nutrition, 9500 Euclid Avenue, Cleveland, OH, 44195, USA
| | - Jamak Modaresi Esfeh
- Cleveland Clinic, Department of Gastroenterology, Hepatology & Nutrition, 9500 Euclid Avenue, Cleveland, OH, 44195, USA
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Cleveland ER, Ning H, Vos MB, Lewis CE, Rinella ME, Carr JJ, Lloyd-Jones DM, VanWagner LB. Low Awareness of Nonalcoholic Fatty Liver Disease in a Population-Based Cohort Sample: the CARDIA Study. J Gen Intern Med 2019; 34:2772-2778. [PMID: 31595464 PMCID: PMC6854130 DOI: 10.1007/s11606-019-05340-9] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2019] [Revised: 07/11/2019] [Accepted: 08/21/2019] [Indexed: 12/16/2022]
Abstract
BACKGROUND Nonalcoholic fatty liver disease (NAFLD) is the most common chronic liver disease in the United States, yet little is known about NAFLD awareness in individuals with incidental fatty liver on imaging. OBJECTIVE To assess the level of awareness of imaging-defined NAFLD among individuals with and without metabolic risk factors. DESIGN Cross-sectional analysis within a prospective longitudinal population-based cohort study conducted in four U.S. cities. PARTICIPANTS Adults age 43 to 55 years enrolled in the Coronary Artery Risk Development in Young Adults (CARDIA) Study who underwent computed tomography and a personal health questionnaire at the year 25 exam (2010-2011, n = 2788). MAIN MEASURES NAFLD was defined as liver attenuation ≤ 51 Hounsfield units after exclusion of other causes of liver fat. Participants were considered "NAFLD aware" if they reported being told previously by a doctor or nurse that they had "fatty liver." KEY RESULTS NAFLD prevalence was 23.9%. Only 16 of 667 (2.4%) participants with CT-defined NAFLD were aware of a NAFLD diagnosis. NAFLD aware participants were more likely to be white (81.3% vs. 53.5%, p = 0.03) and have the metabolic syndrome (87.5% vs. 59.3%, p = 0.02) and/or hypertension (75.0% vs. 50.2%, p = 0.05). In multivariable analyses adjusted for demographics, metabolic syndrome and hypertension remained predictive of NAFLD awareness. CONCLUSION There is low awareness of NAFLD among individuals with hepatic steatosis on imaging, even among those with metabolic risk factors. These findings highlight an opportunity to raise public and practitioner awareness of NAFLD with the goal of increasing diagnosis and implementing early treatment strategies.
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Affiliation(s)
- Erin R Cleveland
- Department of Medicine-Division of Gastroenterology & Hepatology, Northwestern University Feinberg School of Medicine, 676 N. St. Clair St., Suite 1400, Chicago, IL, 60611, USA
| | - Hongyan Ning
- Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, 60611, USA
| | - Miriam B Vos
- Department of Pediatrics-Division of Gastroenterology, Hepatology & Nutrition, Emory University, Atlanta, GA, 30322, USA
| | - Cora E Lewis
- Department of Medicine-Division of Preventive Medicine, University of Alabama Birmingham, Birmingham, AL, 35294, USA
| | - Mary E Rinella
- Department of Medicine-Division of Gastroenterology & Hepatology, Northwestern University Feinberg School of Medicine, 676 N. St. Clair St., Suite 1400, Chicago, IL, 60611, USA
| | - John Jeffrey Carr
- Department of Radiology, Vanderbilt University, Nashville, TN, 37235, USA
| | - Donald M Lloyd-Jones
- Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, 60611, USA
- Department of Medicine-Division of Cardiology, Northwestern University Feinberg School of Medicine, Chicago, IL, 60611, USA
| | - Lisa B VanWagner
- Department of Medicine-Division of Gastroenterology & Hepatology, Northwestern University Feinberg School of Medicine, 676 N. St. Clair St., Suite 1400, Chicago, IL, 60611, USA.
- Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, 60611, USA.
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Meringer H, Shibolet O, Deutsch L. Hepatocellular carcinoma in the post-hepatitis C virus era: Should we change the paradigm? World J Gastroenterol 2019; 25:3929-3940. [PMID: 31413528 PMCID: PMC6689810 DOI: 10.3748/wjg.v25.i29.3929] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2019] [Revised: 05/29/2019] [Accepted: 07/03/2019] [Indexed: 02/06/2023] Open
Abstract
Hepatocellular carcinoma (HCC) is a common and deadly malignancy. The disease usually develops on a background of chronic liver disease. Until recently, the most common etiology was infection with the hepatitis C virus (HCV). The advent of direct-acting antiviral (DAA) therapies has been a major breakthrough in HCV treatment. Sustained virologic response can now be achieved in almost all treated patients, even in patients with a high risk for the development of HCC, such as the elderly or those with significant fibrosis. Early reports raised concerns of a high risk for HCC occurrence after DAA therapy both in patients with previous resection of tumors and those without previous tumors. As the World Health Organization’s goals for eradication of HCV are being endorsed worldwide, the elimination of HCV seems feasible. Simultaneous to the decrease in the burden of cirrhosis from HCV, non-alcoholic fatty liver disease (NAFLD) incidence has been increasing dramatically including significant increased incidence of cirrhosis and HCC in these patients. Surprisingly, a substantial proportion of patients with NAFLD were shown to develop HCC even in the absence of cirrhosis. Furthermore, HCC treatment and potential complications are known to be influenced by liver steatosis. These changes in etiology and epidemiology of HCC suggest the beginning of a new era: The post–HCV era. Changes may eventually undermine current practices of early detection, surveillance and management of HCC. We focused on the risk of HCC occurrence and recurrence in the post–HCV era, the surveillance needed after DAA therapy and current studies in HCC patients with NAFLD.
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Affiliation(s)
- Hadar Meringer
- Department of Gastroenterology and Hepatology, Tel Aviv Sourasky Medical Center and the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 6423906, Israel
| | - Oren Shibolet
- Department of Gastroenterology and Hepatology, Tel Aviv Sourasky Medical Center and the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 6423906, Israel
| | - Liat Deutsch
- Department of Gastroenterology and Hepatology, Tel Aviv Sourasky Medical Center and the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 6423906, Israel
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Pandyarajan V, Gish RG, Alkhouri N, Noureddin M. Screening for Nonalcoholic Fatty Liver Disease in the Primary Care Clinic. Gastroenterol Hepatol (N Y) 2019; 15:357-365. [PMID: 31391806 PMCID: PMC6676352] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
Nonalcoholic fatty liver disease (NAFLD) is a spectrum of diseases ranging from simple hepatic steatosis to nonalcoholic steatohepatitis (NASH) to advanced fibrosis and cirrhosis as well as liver cancer. Despite the significant morbidity associated with NAFLD, there are no global consensus guidelines to screen for liver fibrosis in patients considered high risk, including patients older than 50 years with type 2 diabetes or metabolic syndrome. Multiple therapies are currently being investigated and may soon receive regulatory approval for use in the clinic. It is suggested that patients at high risk for NAFLD be screened in the outpatient setting. This article aims to supply primary care providers (PCPs) with the knowledge and tools needed to properly evaluate a patient at high risk of developing significant liver disease from NASH. A tripartite algorithm is described to help PCPs identify patients with NAFLD using liver enzymes and abdominal ultrasound, assess the presence of advanced liver fibrosis using clinical prediction rules, and, if appropriate, determine when to refer patients to specialist care.
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Affiliation(s)
- Vijay Pandyarajan
- Dr Pandyarajan is a research fellow in the Division of Digestive and Liver Diseases in the Department of Medicine at the Cedars-Sinai Medical Center in Los Angeles, California. Dr Gish is a consulting professor of medicine in the Division of Gastroenterology and Hepatology in the Department of Medicine at Stanford University Medical Center in Stanford, California. Dr Alkhouri is director of the Metabolic Center at the Texas Liver Institute in San Antonio, Texas, and an associate professor of medicine in the Division of Gastroenterology at the University of Texas Health System in San Antonio, Texas. Dr Noureddin is director of the Cedars-Sinai Fatty Liver Program in the Division of Digestive and Liver Diseases in the Department of Medicine at the Comprehensive Transplant Center of the Cedars-Sinai Medical Center
| | - Robert G Gish
- Dr Pandyarajan is a research fellow in the Division of Digestive and Liver Diseases in the Department of Medicine at the Cedars-Sinai Medical Center in Los Angeles, California. Dr Gish is a consulting professor of medicine in the Division of Gastroenterology and Hepatology in the Department of Medicine at Stanford University Medical Center in Stanford, California. Dr Alkhouri is director of the Metabolic Center at the Texas Liver Institute in San Antonio, Texas, and an associate professor of medicine in the Division of Gastroenterology at the University of Texas Health System in San Antonio, Texas. Dr Noureddin is director of the Cedars-Sinai Fatty Liver Program in the Division of Digestive and Liver Diseases in the Department of Medicine at the Comprehensive Transplant Center of the Cedars-Sinai Medical Center
| | - Naim Alkhouri
- Dr Pandyarajan is a research fellow in the Division of Digestive and Liver Diseases in the Department of Medicine at the Cedars-Sinai Medical Center in Los Angeles, California. Dr Gish is a consulting professor of medicine in the Division of Gastroenterology and Hepatology in the Department of Medicine at Stanford University Medical Center in Stanford, California. Dr Alkhouri is director of the Metabolic Center at the Texas Liver Institute in San Antonio, Texas, and an associate professor of medicine in the Division of Gastroenterology at the University of Texas Health System in San Antonio, Texas. Dr Noureddin is director of the Cedars-Sinai Fatty Liver Program in the Division of Digestive and Liver Diseases in the Department of Medicine at the Comprehensive Transplant Center of the Cedars-Sinai Medical Center
| | - Mazen Noureddin
- Dr Pandyarajan is a research fellow in the Division of Digestive and Liver Diseases in the Department of Medicine at the Cedars-Sinai Medical Center in Los Angeles, California. Dr Gish is a consulting professor of medicine in the Division of Gastroenterology and Hepatology in the Department of Medicine at Stanford University Medical Center in Stanford, California. Dr Alkhouri is director of the Metabolic Center at the Texas Liver Institute in San Antonio, Texas, and an associate professor of medicine in the Division of Gastroenterology at the University of Texas Health System in San Antonio, Texas. Dr Noureddin is director of the Cedars-Sinai Fatty Liver Program in the Division of Digestive and Liver Diseases in the Department of Medicine at the Comprehensive Transplant Center of the Cedars-Sinai Medical Center
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Povsic M, Wong OY, Perry R, Bottomley J. A Structured Literature Review of the Epidemiology and Disease Burden of Non-Alcoholic Steatohepatitis (NASH). Adv Ther 2019; 36:1574-1594. [PMID: 31065991 PMCID: PMC6824389 DOI: 10.1007/s12325-019-00960-3] [Citation(s) in RCA: 74] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2019] [Indexed: 02/07/2023]
Abstract
INTRODUCTION Non-Alcoholic Steatohepatitis (NASH) is a chronic, progressive disease characterized by fatty liver and liver cell injury, advancing to fibrosis, cirrhosis and hepatocellular carcinoma (HCC). Diagnosis involves liver biopsy; however, as a result of its high cost and invasiveness, NASH remains underdiagnosed, and accurate burden of disease (BoD) data are lacking. Our aim was to understand the epidemiological and BoD landscape in NASH and identify knowledge gaps. METHODS The Ovid search engine was used to conduct a structured review, following quality systematic principles. It included publications that reported on epidemiology, quality of life (QoL) and BoD outcomes in NASH adults. Searches were limited to English language studies published between January 2007 and September 2017. Additional grey literature searches were conducted. A total of 53 references were selected; 38 were peer-reviewed and 15 were grey literature sources. RESULTS NASH is estimated to affect 3-5% of the global population, most suffering from several comorbidities. Advancing fibrosis drives clinical outcomes, with approximately 20% of patients developing cirrhosis and/or HCC, the latter being a leading cause of death in NASH. A recent model predicted the 15-year survival of advanced fibrosis patients at F3 and F4 as 51.0% and 28.4%, respectively. The limited data consistently show that NASH patients experience significantly poorer QoL and higher costs compared to non-NASH patients. CONCLUSION This first broad-ranging examination of NASH literature revealed a paucity of evidence, with poor-quality, small studies found. The overwhelming impact of NASH and its patient and healthcare burden is evident. Further evidence is needed to improve our understanding of NASH, especially as fibrosis stages advance. FUNDING Gilead Science Inc.
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El Hadi H, Di Vincenzo A, Vettor R, Rossato M. Cardio-Metabolic Disorders in Non-Alcoholic Fatty Liver Disease. Int J Mol Sci 2019; 20:ijms20092215. [PMID: 31064058 PMCID: PMC6539803 DOI: 10.3390/ijms20092215] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2019] [Revised: 04/19/2019] [Accepted: 04/28/2019] [Indexed: 12/16/2022] Open
Abstract
With the progressive epidemics of obesity, non-alcoholic fatty liver disease (NAFLD) has become the most common cause of chronic liver disease in adults and children. The increasing prevalence and incidence of NAFLD with advanced fibrosis is concerning because patients appear to experience higher non-liver-related morbidity and mortality than the general population. Recent clinical evidence suggests that NAFLD is directly associated with an increased risk of cardio-metabolic disorders. This mini review describes briefly the current understanding of the pathogenesis of NAFLD, summarizing the link between NAFLD and cardio-metabolic complications, focusing mainly upon ischemic stroke, type 2 diabetes mellitus (DM), hypertension, chronic kidney disease (CKD) and cardiac arrhythmias. In addition, it describes briefly the current understanding of the pathogenesis of NAFLD.
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Affiliation(s)
- Hamza El Hadi
- Internal Medicine 3, Department of Medicine DIMED, University of Padova, 35122 Padova, Italy.
- Department of Medicine, Klinikum Rheine, 48431 Rheine, Germany.
| | - Angelo Di Vincenzo
- Internal Medicine 3, Department of Medicine DIMED, University of Padova, 35122 Padova, Italy.
| | - Roberto Vettor
- Internal Medicine 3, Department of Medicine DIMED, University of Padova, 35122 Padova, Italy.
| | - Marco Rossato
- Internal Medicine 3, Department of Medicine DIMED, University of Padova, 35122 Padova, Italy.
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Tsochatzis EA, Newsome PN. Non-alcoholic fatty liver disease and the interface between primary and secondary care. Lancet Gastroenterol Hepatol 2019; 3:509-517. [PMID: 29893235 DOI: 10.1016/s2468-1253(18)30077-3] [Citation(s) in RCA: 92] [Impact Index Per Article: 18.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2018] [Revised: 02/22/2018] [Accepted: 02/23/2018] [Indexed: 02/06/2023]
Abstract
Non-alcoholic fatty liver disease (NAFLD) has a prevalence of 25-30% in unselected populations and has become the main reason for referrals to hepatology services. From the perspective of liver disease, NAFLD has a high prevalence but low severity. Screening studies in people at risk for NAFLD have shown a prevalence of advanced fibrosis of 5%, which underlines the need for robust pathways for risk stratification in primary care, with subsequent referrals as required. In this Review, we discuss the interface between primary and secondary care with regards to risk stratification and management of patients with NAFLD. We focus on selected issues of epidemiology and natural history and discuss the burden of disease in primary care, the evidence on screening for NAFLD, the rationale for testing for advanced fibrosis, and the optimal management of the disease in primary care.
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Affiliation(s)
- Emmanuel A Tsochatzis
- Sheila Sherlock Liver Unit and UCL Institute for Liver and Digestive Health, Royal Free Hospital and University College London, London, UK.
| | - Philip N Newsome
- National Institute for Health Research, Liver Biomedical Research Unit and Liver Unit, University Hospitals Birmingham NHS Foundation Trust and Centre for Liver Research, Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
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Konerman MA, Walden P, Joseph M, Jackson EA, Lok AS, Rubenfire M. Impact of a structured lifestyle programme on patients with metabolic syndrome complicated by non-alcoholic fatty liver disease. Aliment Pharmacol Ther 2019; 49:296-307. [PMID: 30561027 DOI: 10.1111/apt.15063] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2018] [Revised: 07/17/2018] [Accepted: 10/26/2018] [Indexed: 12/11/2022]
Abstract
BACKGROUND Lifestyle interventions are first-line therapy for non-alcoholic fatty liver disease (NAFLD). AIMS To examine the prevalence of NAFLD among participants of the University of Michigan Metabolic Fitness (MetFit) Programme and to assess the impact of this programme on weight, metabolic and liver-related parameters among patients with and without NAFLD. METHODS Adults who completed the programme between 2008 and 2016 were included. Clinical and laboratory data were collected at enrolment, and at 12 and 24 weeks. NAFLD was defined based on liver biopsy, imaging or clinical diagnosis. RESULTS The cohort (N = 403; 253 12-week, 150 24-week) consisted primarily of middle-aged (median 54 years) white (88%) men (63%) with severe obesity (median BMI 37.4). 47.6% met criteria for NAFLD. At baseline, NAFLD patients were younger (52 vs 55 years), had higher weights and more metabolic derangements (higher fasting insulin and triglyceride, lower high-density lipoprotein-cholesterol). At programme completion, 30% achieved weight reduction ≥5%, 62% resolution of hypertriglyceridaemia, 33% resolution of low HDL, 27% resolution of impaired fasting glucose and 43% normalisation of alanine aminotransferase. Endpoints were unaffected by NAFLD. Longer programme duration (OR 6.7, 95% CI 3.6-12.3) and white race (OR 3.83, 95% CI 1.04-1.76) were independent predictors of ≥5% weight loss. CONCLUSIONS Nearly half of the patients referred to a structured lifestyle programme for metabolic syndrome had NAFLD. Although baseline metabolic derangements were more pronounced among NAFLD patients, the programme was equally efficacious in achieving weight loss and resolving metabolic syndrome components. Programme duration was the most important predictor of response.
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Affiliation(s)
- Monica A Konerman
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan
| | - Patrick Walden
- Division of Cardiology, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan
| | - Megan Joseph
- Division of Cardiology, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan
| | - Elizabeth A Jackson
- Division of Cardiology, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan
| | - Anna S Lok
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan
| | - Melvyn Rubenfire
- Division of Cardiology, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan
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Younossi ZM. Patient-Reported Outcomes and the Economic Effects of Nonalcoholic Fatty Liver Disease and Nonalcoholic Steatohepatitis: The Value Proposition. Hepatology 2018; 68:2405-2412. [PMID: 30070714 DOI: 10.1002/hep.30125] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2018] [Accepted: 05/11/2018] [Indexed: 12/25/2022]
Abstract
Nonalcoholic fatty liver disease (NAFLD) and nonalcoholic steatohepatitis (NASH) can progress to cirrhosis, hepatocellular carcinoma (HCC), death, or liver transplantation. NASH has also been associated with impaired health-related quality of life and poses a significant economic burden. Due to the negative clinical and patient-reported outcomes and economic burden of NAFLD, it is necessary to review this disease through the lens of value-based care, in which value is proportional to clinical and quality outcomes and inversely proportional to the costs of delivering these outcomes. I review the components of outcomes measured for patients with NAFLD and NASH and relate them to the value proposition, with the aim to deliver optimal patient-centered care.
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Affiliation(s)
- Zobair M Younossi
- Betty and Guy Beatty Center for Integrated Research, Falls Church, VA
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Jensen T, Wieland A, Cree-Green M, Nadeau K, Sullivan S. Clinical workup of fatty liver for the primary care provider. Postgrad Med 2018; 131:19-30. [PMID: 30496690 DOI: 10.1080/00325481.2019.1546532] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Nonalcoholic fatty liver disease (NAFLD) is quickly emerging as a global epidemic in parallel with the rise in obesity and the Metabolic Syndrome. NAFLD, once seen simply as a passive consequence of the Metabolic Syndrome (MetS), has been found to interact with other features of MetS to exacerbate insulin resistance, diabetes, and cardiovascular disease. NAFLD is also becoming the top indication for liver transplant and an important risk factor for hepatocellular carcinoma. Treatment of this disorder is limited mainly to lifestyle modifications to promote weight loss along with consideration for off-label use of certain medications, but recent progression in clinical trials means more effective treatments are on the horizon. Therefore, the primary care provider must be prepared to recognize and determine the severity of this disorder in order to optimize management. In this review, we will discuss risk factors for NAFLD, workup and differential, and finally, offer recommendations on screening.
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Affiliation(s)
- Thomas Jensen
- a Department of Endocrinology , University of Colorado School of Medicine , Aurora , CO , USA
| | - Amanda Wieland
- b Department of Hepatology , University of Colorado School of Medicine , Aurora , CO , USA
| | - Melanie Cree-Green
- c Department of Pediatric Endocrinology , University of Colorado School of Medicine , Aurora , CO , USA
| | - Kristen Nadeau
- c Department of Pediatric Endocrinology , University of Colorado School of Medicine , Aurora , CO , USA
| | - Shelby Sullivan
- d Department of Gastroenterology , University of Colorado Denver , Aurora , CO , USA
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Recommendations for the management of non-alcoholic fatty liver disease (NAFLD). Clin Exp Hepatol 2018; 4:153-157. [PMID: 30324139 PMCID: PMC6185924 DOI: 10.5114/ceh.2018.78118] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2018] [Accepted: 07/20/2018] [Indexed: 02/06/2023] Open
Abstract
The Polish Group of Experts for Non-Alcoholic Fatty Liver Disease (PGE-NAFLD) is a multidisciplinary team of hepatology experts established by the Polish Association for the Study of Liver and the Polish Society of Epidemiology and Infectious Diseases. The recommendations for the management of non-alcoholic fatty liver disease have been developed by a group of experts in hepatology under the auspices of the Polish Association for the Study of Liver and the Polish Society of Epidemiology and Infectious Diseases. The recommendations are intended to help physicians understand the most current knowledge of NAFLD and apply it in clinical practice. Depending on the clinical situation, it may be necessary to individualize the management.
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