Recommendations for using noninvasive testing strategies and certain criteria when working with patients to make an accurate, definitive diagnosis of advanced fibrosis caused by nonalcoholic steatohepatitis.
Norman Sussman, MD: Because of some of the drawbacks of liver biopsy, many people are using liver stiffness measurements. Those can be done by a variety of techniques. They are not 100% accurate, but they have the advantage of being safe, are noninvasive, and are something that you can repeat. So if you do an intervention and then you start to see improvement, that would encourage you to say, “This seems to be working.”
Mazen Noureddin, MD: One of the questions is, can these noninvasive tests diagnose and stage NAFLD [nonalcoholic fatty liver disease] and nonalcoholic steatohepatitis accurately? Nonalcoholic fatty liver disease is a spectrum. It starts as simple steatosis, that goes to nonalcoholic steatohepatitis [NASH], which is inflammation, steatosis, and cell injury on top of the steatosis. People feel, or it’s known that liver biopsy is the only way to diagnose nonalcoholic steatohepatitis. Nevertheless, research has shown that fibrosis is the most important prognostic factor in this disease. That actually can predict advanced fibrosis and cirrhosis. Therefore, a lot of people feel that the most crucial part is to stage these patients and know their fibrosis stage. And thus, noninvasive testing can replace liver biopsy and tell us which patients with advanced fibrosis can or should be tested.
One of the examples is, if you use transient elastography or the FIB-4 [fibrosis 4] test, you can get fairly accurate results. Sometimes, there are some discrepancies. However, this area of research has been really active in the last 2 years, and we now know that if there is doubt or if there are tests that fall in the gray zone, you can do another test, a noninvasive test, to increase your confidence about the results. That’s what we call a combination of noninvasive testing, or sequential testing. Many experts in the field feel that if you combine these noninvasive testing strategies, you can get very good results with very high accuracy to diagnose advanced fibrosis. Some of the tests are really accurate, such as MR [magnetic resonance] elastography, but some people don’t have access to them. Therefore, the combination strategy as well as the sequential strategy have been shown to be very useful, even for clinical practices in the future.
When you have a patient with advanced NASH and fibrosis who now comes to your clinic, 1 of the questions asked is, which kinds of tests do you want to use? And do you want to be thorough and complete? As mentioned, NASH and advanced fibrosis have been associated with many comorbidities, such as diabetes, dyslipidemia, hypertension, and obesity. Before we look at anything, we need to rule out other causes of liver disease. There is a known panel for most gastroenterologists, hepatologists, and primary care. In addition, people usually get imaging, such as ultrasound, without any structure abnormalities—lesions, as well as thrombosis to the liver. Once you have this covered and tested for, you have a diagnosis of nonalcoholic fatty liver disease. Of course, as mentioned, you did noninvasive testing to diagnose advanced fibrosis.
It will be good that people will also start looking at comorbidities such as diabetes, hypertension, and dyslipidemia. In my practice, I check hemoglobin A1C [glycated hemoglobin]. I check lipid panels. I look at their blood pressure. I don’t necessarily manage those myself, but at least I make the patient aware that they should let their primary care physician know about these comorbidities, because controlling these conditions has been shown to be helpful in the overall health of the patient.