The Impact of Nonalcoholic Fatty Liver Disease in Primary Care: A Population Health Perspective

Dokmak, Amr; Lizaola-Mayo, Blanca; Trivedi, Hirsh D.

doi:10.1016/j.amjmed.2020.08.010

Cited by 21 publications

(21 citation statements)

References 54 publications

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“…Efforts to implement reliable noninvasive fibrosis risk assessment of primary care patients with NAFLD must also evolve. FIB-4 and NFS address this need in NAFLD registries, but their performance in primary care is less well known 4,5,13,26. A recent study applying FIB-4 to primary care patients with NAFLD demonstrated the utility of this approach, reducing unnecessary referrals by 80% and improving the detection of advanced fibrosis and cirrhosis in a primary care population 4.…”

Section: Discussionmentioning

confidence: 99%

“…[7][8][9] Guidelines suggest either FIB-4 or NFS calculation as an acceptable initial approach for fibrosis risk stratification, with second-step testing (eg, enhanced liver fibrosis, VCTE) for results categorized as indeterminate risk or high risk. [9][10][11][12][13] Before PCPs implement these NAFLD care pathways, we need to better understand how noninvasive fibrosis risk assessments perform in the primary care setting.…”

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confidence: 99%

“…Due to the accessibility, performance, and ease of calculating serologic assessments, including the Fibrosis-4 Index (FIB-4) and NAFLD Fibrosis Score (NFS), guidelines on approaching NAFLD and abnormal liver chemistries now incorporate these scores to assist primary care providers (PCPs) in referring patients at risk for advanced fibrosis to hepatology specialists 7–9. Guidelines suggest either FIB-4 or NFS calculation as an acceptable initial approach for fibrosis risk stratification, with second-step testing (eg, enhanced liver fibrosis, VCTE) for results categorized as indeterminate risk or high risk 9–13. Before PCPs implement these NAFLD care pathways, we need to better understand how noninvasive fibrosis risk assessments perform in the primary care setting.…”

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confidence: 99%

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Identifying Patients at Risk for Fibrosis in a Primary Care NAFLD Cohort

Schreiner

Livingston²,

Zhang³

et al. 2021

Journal of Clinical Gastroenterology

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Goals and Background: Using natural language processing to create a nonalcoholic fatty liver disease (NAFLD) cohort in primary care, we assessed advanced fibrosis risk with the Fibrosis-4 Index (FIB-4) and NAFLD Fibrosis Score (NFS) and evaluated risk score agreement. Materials and Methods:In this retrospective study of adults with radiographic evidence of hepatic steatosis, we calculated patientlevel FIB-4 and NFS scores and categorized them by fibrosis risk. Risk category and risk score agreement was analyzed using weighted κ, Pearson correlation, and Bland-Altman analysis. A multinomial logistic regression model evaluated associations between clinical variables and discrepant FIB-4 and NFS results.Results: Of the 767 patient cohorts, 71% had a FIB-4 or NFS score in the indeterminate-risk or high-risk category for fibrosis. Risk categories disagreed in 43%, and scores would have resulted in different clinical decisions in 30% of the sample. The weighted κ statistic for risk category agreement was 0.41 [95% confidence interval (CI): 0.36-0.46] and the Pearson correlation coefficient for log FIB-4 and NFS was 0.66 (95% CI: 0.62-0.70). The multinomial logistic regression analysis identified black race (odds ratio = 2.64, 95% CI: 1.84-3.78) and hemoglobin A1c (odds ratio = 1.37, 95% CI: 1.23-1.52) with higher odds of having an NFS risk category exceeding FIB-4. Conclusions:In a primary care NAFLD cohort, many patients had elevated FIB-4 and NFS risk scores and these risk categories were often in disagreement. The choice between FIB-4 and NFS for fibrosis risk assessment can impact clinical decision-making and may contribute to disparities of care.

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Section: Discussionmentioning

confidence: 99%

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confidence: 99%

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confidence: 99%

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Identifying Patients at Risk for Fibrosis in a Primary Care NAFLD Cohort

Schreiner

Livingston²,

Zhang³

et al. 2021

Journal of Clinical Gastroenterology

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“…Because patients at risk for NAFLD may frequently have significant fibrosis, which can be overlooked on common ultrasound, especially when normal liver enzymes are associated, supplementary screening approaches should be considered, either in the general population or only in at-risk individuals represented by patients with obesity, T2DM, and MS [ 143 ]. It is, therefore, logical to presume that the utility of novel non-invasive assessment tools for NAFLD is of utmost importance, but we must acknowledge for now that their predictive ability is insufficiently demonstrated in diabetes populations [ 144 ]. At present, ADA recommends that all patients with prediabetes/T2DM and increased liver enzymes or steatosis on ultrasound should be evaluated for the presence of NAFLD, while the other guidelines have discordant approaches [ 36 ].…”

Section: Gaps In Knowledgementioning

confidence: 99%

Ultrasound-Based Hepatic Elastography in Non-Alcoholic Fatty Liver Disease: Focus on Patients with Type 2 Diabetes

et al. 2022

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Non-alcoholic fatty liver disease (NAFLD) is the most prevalent liver disease and is the hepatic expression of metabolic syndrome. The development of non-invasive methods for the diagnosis of hepatic steatosis and advanced fibrosis in high-risk patients, especially those with type 2 diabetes mellitus, is highly needed to replace the invasive method of liver biopsy. Elastographic methods can bring significant added value to screening and diagnostic procedures for NAFLD in patients with diabetes, thus contributing to improved NAFLD management. Pharmacological development and forthcoming therapeutic measures that address NAFLD should also be based on new, non-invasive, and reliable tools that assess NAFLD in at-risk patients and be able to properly guide treatment in individuals with both diabetes and NAFLD. This is the first review aiming to outline and discuss recent studies on ultrasound-based hepatic elastography, focusing on NAFLD assessment in patients with diabetes.

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“…NAFLD is frequently associated with dyslipidemia, type 2 diabetes, and obesity, and is considered to be a manifestation of metabolic syndrome ( 4 ). Primary care systems faced the increase in the burden of the previously mentioned diseases and are responsible for managing cases with low risk of progression of NAFLD, but patients at high risk are referred to gastroenterology ( 5 ). When the medical systems are dealing with complex cases, such as the situation of advanced chronic kidney disease (CKD) or dialysis patients, the management of NAFLD includes the nephrologists.…”

Section: Introductionmentioning

confidence: 99%

Non-alcoholic fatty liver disease in diabetes mellitus patients on chronic hemodialysis – A case series addressing cardiovascular and mortality risks

Stoica

Tribus²,

Marin³

et al. 2023

Front. Clin. Diabetes Healthc.

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Non-alcoholic fatty liver disease (NAFLD) has an important role in the pathogenesis of cardiovascular diseases in the population with diabetes and it is highly prevalent in end-stage renal disease (ESRD) patients. This case series describes NAFLD associated factors and survival in type 2 diabetes patients (T2DM) who have ESRD treated with hemodialysis. NAFLD prevalence in patients with T2DM and ESRD is 69.2%. A high number of patients (15 out of 18) have obesity evaluated by calculating body mass index (BMI) and bioimpedance measurements. Patients with NAFLD have higher cardiovascular mortality risk, 13 of 18 patients were already diagnosed with coronary heart disease, 6 of 18 had cerebrovascular disease, and 6 of 18 had peripheral artery disease. Fourteen patients were treated with insulin, two patients with sitagliptin (renal adjusted dose of 25mg/day) and two patients with medical nutrition therapy, with an HbA1c ranging from 4.4 to 9.0%. After one-year follow-up 7 of 18 patients died, the causes having roughly equal proportions: myocardial infarction, SARS-CoV2 infection, and pulmonary edema. In conclusion, our population of type 2 diabetic patients with ESRD in hemodialysis had a prevalence of ultrasound-diagnosed NAFLD of 69.2%. Also, this population had a high death rate at one-year follow-up, cardiovascular causes being among the most common.

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The Impact of Nonalcoholic Fatty Liver Disease in Primary Care: A Population Health Perspective

Cited by 21 publications

References 54 publications

Identifying Patients at Risk for Fibrosis in a Primary Care NAFLD Cohort

Identifying Patients at Risk for Fibrosis in a Primary Care NAFLD Cohort

Ultrasound-Based Hepatic Elastography in Non-Alcoholic Fatty Liver Disease: Focus on Patients with Type 2 Diabetes

Non-alcoholic fatty liver disease in diabetes mellitus patients on chronic hemodialysis – A case series addressing cardiovascular and mortality risks

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