Performance of American Gastroenterological Association Clinical Care Pathway for the risk stratification of patients with nonalcoholic fatty liver disease in the US population

Abstract

Background and aims: The American Gastroenterological Association (AGA) recently launched the Clinical Care Pathway for the Risk Stratification and Management of Patients with NAFLD to identify adults with significant fibrosis. We aimed to examine this pathway's performance in the US population. Approach and Results: Using the 2017-2018 National Health and Nutrition Examination Survey data, we identified participants aged ≥ 18 with available Fibrosis-4 (FIB-4) score and liver stiffness measurement (LSM) in the absence of other liver diseases. Based on the AGA clinical pathway, FIB-4 < 1.3 and LSM < 8 kilopascals (kPa) by vibration-controlled transient elastography (VCTE) are associated with low risk of significant fibrosis.Using these cutoffs, we examined the pathway performance using negative predictive value (NPV) and positive predictive value (PPV) and explored alternative risk-stratification strategies. There were 2322 participants with available data (projected to 94.2 million US adults). The NPV of LSM ≥ 8 kPa among those with FIB-4 < 1.3 was 90%, whereas the PPV among those with FIB-4 1.3-2.67 was 13%. As diabetes was a strong predictor of fibrosis, we propose a simple, alternative strategy to eliminate the indeterminate FIB-4 range and perform VCTE in those with FIB-4 ≥ 1.3 and diabetes. This strategy would decrease the number of VCTEs from 14.5 to 4.9 million and increase PPV from 13% to 33% without compromising the NPV among those who did not undergo VCTE. Conclusion:The implementation of the current AGA clinical pathway would lead to overutilization of VCTE. An alternative strategy using FIB-4 ≥ 1.

Association of family income to poverty ratio and vibration-controlled transient elastography quantified degree of hepatic steatosis in U.S. adolescents

“…In addition, several studies have shown that the degree of hepatic steatosis calculated by liver enzymes or indices may be statistically biased and may significantly underestimate the number of participants with NAFLD in epidemiological studies ( 36 ). VCTE, as recommended by the American Gastroenterological Association for risk stratification and management of patients with NAFLD, is highly accurate in diagnosing the degree of hepatic steatosis and the degree of fibrosis ( 37 , 38 ). Therefore, we used VCTE data to avoid diagnostic inaccuracies and the inability to quantify the degree of hepatic steatosis in the current study.…”

Validation of AGA clinical care pathway and AASLD practice guidance for nonalcoholic fatty liver disease in a prospective cohort of patients with type 2 diabetes

“…Utilizing NHANES data, Udompap and colleagues evaluated the performance of the AGA Clinical Pathway and demonstrated limited positive predicted value. [25] However, the primary outcome of their study was the PPV of FIB-4 while using VCTE values as the reference. Given that VCTE is a step in the pathway, this approach is unable to test the performance of the full pathway.…”

Screening for At-Risk Nonalcoholic Fatty Liver Disease in the Primary Care Setting

“…significant fibrosis is higher in referral centers and the sensitivity of FIB-4 cutoffs of <1.3 may be inadequate to exclude advanced fibrosis in such settings. [59] Third, VCTE and FIB-4 sometimes show discordant results, and it is not always clear how these discrepancies should be interpreted, which can result in both low-yield hepatology referrals and conversely missed cases of possible hepatic fibrosis [74,75]. Further real-world research on this topic is warranted.…”

“…59 Third, VCTE and FIB-4 sometimes show discordant results, and it is not always clear how these discrepancies should be interpreted, which can result in both low-yield hepatology referrals and conversely missed cases of possible hepatic fibrosis. 74,75 Further real-world research on this topic is warranted.…”