Page 17 - EASL POSTGRADUATE COURSE
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Table 1. Risk factors associated with NAFLD.
Conditions with established association Conditions with emerging association
• Obesity • PCOS
• T2DM • Hypothyroidism
• Dyslipidemia • Obstructive Sleep apnoea
• MetS* • Hypopituitarism
• Hypogonadism
• Pancreato-duodenal resection
• Vitamin D deficiency
*The Adult Treatment Panel III clinical definition of the MetS requires the presence of three or more of
the following features: (1) waist circumference >102 cm in men or >88 cm in women; (2) triglyceride
level ≥150 mg/dL; (3) HDL cholesterol level <40 mg/dL in men and <50 mg/dL in women; (4) systolic
blood pressure ≥130 mm Hg or diastolic pressure ≥85 mm Hg; (5) fasting plasma glucose level ≥110
mg/dL.
Patients with NAFLD generally display a number of other metabolic and endocrine co-morbidities
(Table 1). It is very important to systematically obtain the history of these risk factors. Although not
systematically investigated, it is generally believed that the presence of multiple risk factors heightens the
risk for advanced NAFLD syndrome.
Who should be screened for NASH? [1-3]
It is probably reasonable to categorize the evaluation for NASH into two tiers. The first tier involves
non-invasive risk scores and transient elastography (if available) and second tier involves a percutaneous
liver biopsy.
It is reasonable to consider every patient with NAFLD for tier-1 evaluation. Some methods to consider
for tier-1 evaluation are:
a) Evaluation of co-morbidities: longstanding T2DM and MetS certainly increase the prevalence of
NASH in patients with NAFLD.
b) Presence of rare co-morbidities such as PCOS, obstructive sleep apnoea, pan-hypopituitarism
(especially growth hormone deficiency), and pancreato-duodenal resection.
c) Patients with metabolic risk factors but also receiving tamoxifen.
d) Easily calculable risk scores – NAFLD fibrosis score, FIB-4, APRI, BARD, Fibrometer NAFLD, or
Hepascore. These are described in detail in Practice Guidelines [2]. They are generally comparable
against each other and it probably is reasonable to choose one or two methods and apply them
consistently in individual practices.
e) Transient elastography (Fibroscan) is widely available in developed countries and was recently
approved in the United States (for HCV). Although M probe is associated with a high failure rate,
the new machine-mandated algorithm that forces XL probe as needed appears to have overcome
this. More work is needed in terms of various cut-off points for ruling-in or ruling-out advanced
fibrosis. It has been suggested that LSM <7.9 kPa (M probe) or <7.2 kPa (XL probe) exclude the
presence of advanced fibrosis whereas LSM >9.6 kPa (M probe) or >9.3 kPa (XL probe) establishes
the presence of advanced fibrosis.
The International Liver Congress™ 2015 • Vienna, Austria • April 22–23, 2015 17
Conditions with established association Conditions with emerging association
• Obesity • PCOS
• T2DM • Hypothyroidism
• Dyslipidemia • Obstructive Sleep apnoea
• MetS* • Hypopituitarism
• Hypogonadism
• Pancreato-duodenal resection
• Vitamin D deficiency
*The Adult Treatment Panel III clinical definition of the MetS requires the presence of three or more of
the following features: (1) waist circumference >102 cm in men or >88 cm in women; (2) triglyceride
level ≥150 mg/dL; (3) HDL cholesterol level <40 mg/dL in men and <50 mg/dL in women; (4) systolic
blood pressure ≥130 mm Hg or diastolic pressure ≥85 mm Hg; (5) fasting plasma glucose level ≥110
mg/dL.
Patients with NAFLD generally display a number of other metabolic and endocrine co-morbidities
(Table 1). It is very important to systematically obtain the history of these risk factors. Although not
systematically investigated, it is generally believed that the presence of multiple risk factors heightens the
risk for advanced NAFLD syndrome.
Who should be screened for NASH? [1-3]
It is probably reasonable to categorize the evaluation for NASH into two tiers. The first tier involves
non-invasive risk scores and transient elastography (if available) and second tier involves a percutaneous
liver biopsy.
It is reasonable to consider every patient with NAFLD for tier-1 evaluation. Some methods to consider
for tier-1 evaluation are:
a) Evaluation of co-morbidities: longstanding T2DM and MetS certainly increase the prevalence of
NASH in patients with NAFLD.
b) Presence of rare co-morbidities such as PCOS, obstructive sleep apnoea, pan-hypopituitarism
(especially growth hormone deficiency), and pancreato-duodenal resection.
c) Patients with metabolic risk factors but also receiving tamoxifen.
d) Easily calculable risk scores – NAFLD fibrosis score, FIB-4, APRI, BARD, Fibrometer NAFLD, or
Hepascore. These are described in detail in Practice Guidelines [2]. They are generally comparable
against each other and it probably is reasonable to choose one or two methods and apply them
consistently in individual practices.
e) Transient elastography (Fibroscan) is widely available in developed countries and was recently
approved in the United States (for HCV). Although M probe is associated with a high failure rate,
the new machine-mandated algorithm that forces XL probe as needed appears to have overcome
this. More work is needed in terms of various cut-off points for ruling-in or ruling-out advanced
fibrosis. It has been suggested that LSM <7.9 kPa (M probe) or <7.2 kPa (XL probe) exclude the
presence of advanced fibrosis whereas LSM >9.6 kPa (M probe) or >9.3 kPa (XL probe) establishes
the presence of advanced fibrosis.
The International Liver Congress™ 2015 • Vienna, Austria • April 22–23, 2015 17
