Call to action on rapidly increasing rates of NAFLD and NASH

By Rebecca Jenkins
Nonalcoholic fatty liver disease (NAFLD) is rapidly becoming the most common cause of chronic liver disease worldwide, yet there is no single global guiding strategy for managing the condition, an expert panel warns.

There was an urgent need to develop and implement effective screening, diagnosis and treatment strategies for NAFLD and nonalcoholic steatohepatitis (NASH), particularly among emerging at-risk cohorts such as patients with obesity or type 2 diabetes, according to the call-to-action paper copublished in Gastroenterology and three other journals.

‘This goal cannot be achieved if the different specialties engaged in managing this burgeoning population continue to work in silos,’ the expert authors wrote.

The paper’s recommendations came from a conference of 32 international experts in gastroenterology, hepatology, endocrinology and primary care, convened by the American Gastroenterological Association, in collaboration with seven other professional associations.

‘Effective screening for and timely diagnosis of NAFLD may prevent progression to NASH and associated complications,’ the expert authors said.

‘Because PCPs [primary care professionals] are on the front lines of managing individuals with NAFLD, screening patients at increased risk, stratifying patients based on their risk of advanced fibrosis and positioning themselves to provide effective management and referrals are important.’

Clinical practice guidelines did not recommend screening the general population, but case finding for NASH and significant fibrosis was advised for key high-risk groups, such as those with moderate to severe obesity (BMI >35 kg/m2), type 2 diabetes of more than 10 years’ duration or in people older than 50 years, or metabolic syndrome.

Consultant hepatologist Associate Professor Leon Adams, of the University of Western Australia’s Faculty of Medicine and Perth’s Sir Charles Gairdner Hospital, was among the international experts involved in the conference.

He told Medicine Today that an estimated one in four Australians had NAFLD.

‘As a result of decades of rising obesity and diabetes rates in Australia, we are now seeing the liver-related consequences with increasing rates of hepatocellular carcinoma, cirrhosis and requirement for liver transplantation,’ he said.

‘There are federal initiatives for obesity and diabetes but they lack a unified response for the liver manifestation, namely NASH. We need increased public and practitioner awareness of the disease matched with resources to effectively assess disease severity and treat its complications.’

Consensus guidelines for the assessment of NASH in primary care were being developed by the Gastroenterology Society of Australia and this needed to be followed up with practical management guidelines and resources.

‘All patients with NAFLD (as we lack the ability to discern who has NASH without a liver biopsy) should undergo a noninvasive assessment of disease severity (i.e. fibrosis) using either a serum-based test or elastography. Those with significant fibrosis are at risk of developing liver-related complications and should be prioritised for more intensive management of their metabolic risk factors and considered for specialist referral,’ Professor Adams said.

Weight loss was incredibly effective at reversing NASH and remained the best available treatment, he added.
Gastroenterol 2021; doi: 10.1053/j.gastro.2021.04.074.