NAFLD/NASH Diagnosis in Primary Care: 8 Questions
A high index of suspicion for NAFLD may help primary care providers identify patients at highest risk. Try these 8 questions based on guideline recommendations.
By some estimates, >75% of patients with nonalcoholic fatty liver disease (NAFLD) are undiagnosed and only 3% of those a high risk for progression to fibrosis are referred to specialists.
Although screening in the general population for NAFLD remains controversial, primary care providers remain the clinicians most likely to encounter the disease in their patients and are urged to have a high index of suspicion for NAFLD in patients with type 2 diabetes and elements of metabolic syndrome.
Take this quick quiz to test your knowledge of the American Association for the Study of Liver Diseases guidance statements for NAFLD/NASH diagnosis.
1. According to AASLD practice guidance, what is a reasonable threshold for significant alcohol consumption in the evaluation of patients with suspected NAFLD?
Answer: B. >21 standard drinks/wk in men, >14 standard drinks/wk in women. The AAFLD notes that, by definition, NAFLD indicates a lack of evidence for ongoing or recent consumption of significant amounts of alcohol but the definition of significant alcohol consumption in the literature has been inconsistent.
2. Patients with incidental hepatic steatosis (HS) detected on imaging who lack liver‐related symptoms or signs and have normal liver biochemistries should be assessed for which of the above?
Answer: D. All of the above. Patients with unsuspected HS detected on imaging who do have symptoms or signs attributable to liver disease or abnormal liver chemistries should be evaluated as though they have suspected NAFLD and worked up accordingly.
3. True or False: The AASLD practice guidance recommends routine screening for NAFLD in high‐risk groups attending primary care, diabetes, and obesity clinics.
Answer: B. False. Routine screening for NAFLD in high‐risk groups in these settings is not advised because of uncertainties with diagnostic tests and treatment options and a lack of knowledge of screening’s long‐term benefits and cost‐effectiveness. Systematic screening of family members for NAFLD also is not recommended. What is recommended: maintaining a high index of suspicion for NAFLD and NASH in patients with type 2 diabetes mellitus.
4.True or False: The diagnosis of NAFLD requires that there are no coexisting causes of chronic liver disease (CLD).
Answer: A. True. Coexisting etiologies for CLD that should be excluded include hemochromatosis, autoimmune liver disease, chronic viral hepatitis, alpha‐1 antitrypsin deficiency, Wilson disease, and drug‐induced liver injury. NAFLD diagnosis also requires HS by imaging or histology, no significant alcohol consumption, and no competing etiologies for HS.
5. Which of the above is the most reliable approach for identifying the presence of steatohepatitis (SH) and fibrosis in patients with NAFLD?
Answer: E. Liver biopsy. Although most reliable, biopsy is limited by cost, sampling error, and procedure‐related morbidity and mortality. Serum aminotransferase levels and imaging tests do not reliably reflect the spectrum of liver histology in patients with NAFLD. There has been interest in developing clinical prediction rules and noninvasive biomarkers for identifying SH in patients with NAFLD.
7. The goals for histopathologic evaluation of liver biopsy in a patient with suspected NAFLD include which of the above?
Answer: C. Both. Clinically useful pathology reporting should include a distinction between NAFL, NAFL with inflammation, and NASH. A comment on severity may be useful. The presence or absence of fibrosis should be described; if fibrosis is present, a statement related to location, amount, and parenchymal remodeling is warranted.
8. NASH is associated with a high prevalence of which of the above?
Answer: D. A, B, and C. Noninvasive functional cardiac testing is recommended in patients with NASH cirrhosis, with progression to coronary angiography when the findings are abnormal or inconclusive. NASH is the most rapidly growing indication for simultaneous liver-kidney transplantation in the US. Because of the high prevalence of sarcopenia among patients with NASH, serum creatinine may overestimate glomerular filtration rate.