Identifying Patients with Nonalcoholic Fatty Liver Disease in Primary Care: How and for What Benefit?
Abstract
:1. Introduction
2. Pathophysiology of NAFLD
- Age: 40, BMI: 32.3 kg/m2, waist circumference: 42 inches, blood pressure: 138/86 mmHg, and consuming 7 units of alcohol per week;
- Cholesterol: 210 mg/dL, triglyceride: 174 mg/dL, high-density lipoprotein (HDL)-cholesterol: 31 mg/dL, and low-density lipoprotein (LDL)-cholesterol: 144 mg/dL;
- Alanine aminotransferase (ALT): 54 U/L, aspartate aminotransferase (AST): 44 U/L, and platelets: 220 K;
- Hemoglobin A1c (HbA1c): 6.1%;
- He is not taking any medications.
3. When to Pursue a NAFLD Diagnosis
3.1. Pursuing a NAFLD Diagnosis following Abnormalities in Aminotransferases or in Liver Imaging
3.2. Pursuing a NAFLD Diagnosis in High-Risk Patients
4. How to Pursue a Diagnosis
4.1. Conventional US
4.2. CAP Method
4.3. MRI Methods
4.4. Noninvasive Scores
- Previous values: Age: 38, BMI: 27.0 kg/m2, waist circumference: 38 inches, blood pressure: 136/87 mmHg, and consuming 7 units of alcohol per week;
- −
- Current values: Age: 40, BMI: 32.3 kg/m2, waist circumference: 42 inches, blood pressure: 138/86 mmHg, and consuming 7 units of alcohol per week;
- Previous values: Cholesterol: 105 mg/dL, triglyceride: 32 mg/dL, and HDL-cholesterol: 22 mg/dL;
- −
- Current values: Cholesterol: 210 mg/dL, triglyceride: 174 mg/dL, HDL-cholesterol: 31 mg/dL, and LDL-cholesterol: 144 mg/dL;
- Previous values: ALT: 28 U/L and AST: 24 U/L;
- −
- Current values: ALT: 54 U/L, AST: 44 U/L, and platelets: 220 K.
- Atherosclerotic cardiovascular disease (ASCVD) risk score: 2.8%, with a 10-year risk of an ASCVD event;
- Negative viral hepatitis B and C testing;
- Liver ultrasound (US) demonstrating hepatic steatosis;
- Fibrosis-4 (Fib-4): 1.09 (low risk).
5. Interventions: What Are the Options?
5.1. Weight-Loss Interventions
5.2. Cardiovascular Risk Management
- BMI: 29.7 kg/m2, waist circumference: 39.5 inches, blood pressure: 126/78 mmHg, and consuming 3 units of alcohol per week;
- Cholesterol: 190 mg/dL, triglyceride: 158 mg/dL, HDL-cholesterol: 35 mg/dL, and LDL-cholesterol: 123 mg/dL;
- ALT: 32 U/L, AST: 30 U/L, and platelets: 225 K;
- HbA1c: 5.8%;
- Fib-4: 0.94 (low risk);
- ASCVD risk score: 1.6%, with a 10-year risk of an ASCVD event.
- BMI: 37.0 kg/m2, waist circumference: 44 inches, blood pressure: 151/88 mmHg, and consuming 10 units of alcohol per week;
- Cholesterol: 225 mg/dL, triglyceride: 220 mg/dL, HDL-cholesterol: 30 mg/dL, and LDL-cholesterol: 151 mg/dL;
- ALT: 64 U/L, AST: 60 U/L, and platelets: 165 K;
- HbA1c: 6.4%;
- Fib-4: 2.05 (indeterminate risk);
- ASCVD risk: 6.2%, with 10-year risk of an ASCVD event.
5.3. Fibrosis Risk Assessments
Noninvasive Scores for Fibrosis
5.4. Referral to a Hepatologist
- VCTE: 9.9 kPa (high risk).
6. Conclusions
Supplementary Materials
Author Contributions
Funding
Data Availability Statement
Acknowledgments
Conflicts of Interest
References
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Model | Risk/Prediction of Disease/Disease Stage | Predictors |
---|---|---|
ASCVD Risk Estimator | 10-year ASCVD risk intended for patients with LDL-cholesterol < 190 mg/dL (4.92 mmol/L), without ASCVD | Current age (years) |
Sex (male/female) | ||
Race (White/African American/other) | ||
Systolic blood pressure (mmHg) | ||
Diastolic blood pressure (mmHg) | ||
Total cholesterol (mg/dL) | ||
HDL-cholesterol (mg/dL) | ||
LDL-cholesterol (mg/dL) | ||
History of diabetes (yes/no) | ||
Smoker (current/former/never) | ||
On hypertension treatment (yes/no) | ||
On a statin (yes/no) | ||
On aspirin therapy (yes/no) | ||
HeartScore® | 10-year risk of first-onset cardiovascular disease in European populations | Risk region (low risk/moderate risk/high risk/very high risk) |
Age (years) | ||
Sex (male/female) | ||
Systolic blood pressure (mmHg) | ||
Total cholesterol (mmol/L or mg/dL) | ||
HDL-cholesterol (mmol/L) | ||
Current smoker (yes/no) | ||
Fibrosis-4 score | Prediction of liver fibrosis and cirrhosis | (Age (years) × AST (IU/L))/(Platelet count (109/L) × (square root (ALT (IU/L))) |
NAFLD fibrosis score | Prediction of advanced fibrosis | −1.675 + 0.037 × age (years) + 0.094 × BMI (kg/m2) + 1.13 × IFG/diabetes (yes = 1, no = 0) + 0.99 × AST/ALT ratio − 0.013 × platelet (×109/L) − 0.66 × albumin (g/dL) |
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Schreiner, A.D.; Sattar, N. Identifying Patients with Nonalcoholic Fatty Liver Disease in Primary Care: How and for What Benefit? J. Clin. Med. 2023, 12, 4001. https://doi.org/10.3390/jcm12124001
Schreiner AD, Sattar N. Identifying Patients with Nonalcoholic Fatty Liver Disease in Primary Care: How and for What Benefit? Journal of Clinical Medicine. 2023; 12(12):4001. https://doi.org/10.3390/jcm12124001
Chicago/Turabian StyleSchreiner, Andrew D., and Naveed Sattar. 2023. "Identifying Patients with Nonalcoholic Fatty Liver Disease in Primary Care: How and for What Benefit?" Journal of Clinical Medicine 12, no. 12: 4001. https://doi.org/10.3390/jcm12124001