A 2-step fast-track elastometry service for advanced workup of nonalcoholic fatty liver disease (NAFLD) patients – single-center real-world experience of outpatient clinical practice

Abstract

Introduction and aims Nonalcoholic fatty liver disease (NAFLD) is increasing globally with an estimated prevalence of approximately 25 %. Nonalcoholic steatohepatitis as the progressive disease entity often leads to fibrosis and end-stage disease. The magnitude of NAFLD patients are not diagnosed and have no access to further clinical assessment. Diagnostic pathways for individual risk evaluation fitting with available resources are of utmost importance in real-world clinical practice.

Methods Retrospective analysis of 1346 anonymized outpatient datasets at Würzburg University Hospital, Germany. Transient elastography (TE) with controlled attenuation parameter and laboratory-based risk scores (NFS, FIB-4) were the main diagnostic workup tools for risk stratification.

Results After preselection based on questionnaire information NAFLD still accounts for one-fifth of patients in the liver outpatient service. More than 80 % of NAFLD patients receive their first-time diagnosis in our unit. Laboratory-based risk scores and TE are valuable tools for second-step risk assessment as shown in our clinical data analysis. Moreover, 65 % of NAFLD patients use inpatient services for at least 1 day. The policy to perform liver biopsy in high-risk patients above the recommended threshold of 9.6 kPa if any clinical doubt exists regarding the diagnosis of cirrhosis leads to a histological down staging in almost 80 %.

Conclusion Questionnaire-based referral from primary care followed by broadly available fast-track TE and eventually liver biopsy for selected patients is the standard practice in our unit. This approach represents a feasible model to handle the large gap between availability and clinical need for TE facilities.

Zusammenfassung

Einführung und Zielsetzung Die nichtalkoholische Fettlebererkrankung (NAFLD) nimmt weltweit zu und erreicht mittlerweile eine Prävalenz von etwa 25 %. Die nichtalkoholische Steatohepatitis (NASH) als fortschreitende Erkrankungsentität führt oft zur Fibrose bis hin zur Zirrhose. Die Mehrheit der NAFLD-Patienten wird weder diagnostiziert, noch haben sie Zugang zu weiteren medizinischen Maßnahmen. Diagnostische Algorithmen zur individuellen Risikoabschätzung, die mit den verfügbaren Ressourcen vereinbar sind, werden im klinischen Ambulanzalltag dringlich benötigt.

Methoden Es wurde eine retrospektive Analyse von 1346 anonymisierten Ambulanzdatensätzen am Universitätsklinikum Würzburg durchgeführt. Die transiente Elastografie (TE) mit Controlled Attenuation Parameter (CAP) und laborbasierten Risikoscores (NFS, FIB-4) wurde als primäres Diagnoseverfahren zur Risikostratifizierung eingesetzt.

Ergebnisse Nach Präselektion basierend auf einem Zuweisungsfragebogen umfasst die NAFLD ein Fünftel der Patienten in der Leberambulanz. Über 80 % der NAFLD-Patienten erhalten die erstmalige Diagnose in unserer Abteilung. Laborbasierte Risikoscores und eine breit verfügbare TE sind dabei hilfreiche Methoden der weiterführenden Risikoabschätzung. 65 % der NAFLD-Patienten werden im Verlauf für mindestens einen Tag hospitalisiert. Die Strategie, eine Leberbiopsie bei Hochrisikopatienten über dem Grenzwert von 9,6 kPa durchzuführen, wenn klinisch Zweifel an der Diagnose einer Zirrhose bestehen, führt bei nahezu 80 % zur histologischen Herabstufung des Fibrosegrades.

Schlussfolgerung Die auf einem Zuweisungsfragebogen basierende Vorstellung von Patienten aus der Primärversorgung zur breit und rasch verfügbaren TE ist das Standardvorgehen in unserer Abteilung. Für selektionierte Patienten folgt im Einzelfall eine direkt veranlasste Leberbiopsie. Diese Vorgehensweise hat sich als hilfreich erwiesen, um die Lücke zwischen Bedarf und Verfügbarkeit an weiterführender NAFLD-Diagnostik inklusive ambulanter TE zu schließen.

Key words

nonalcoholic fatty liver disease (NAFLD) - nonalcoholic steatohepatitis (NASH) - transient elastography (TE) - controlled attenuation parameter (CAP) - diagnostic algorithm - risk assessment - NAFLD fibrosis score (NFS) and fibrosis-4 index (FIB-4) - outpatient clinic - referral form

Schlüsselwörter

Nicht-alkoholische Fettlebererkrankung (NAFLD) - Nicht-alkoholische Steatohepatitis (NASH) - Transiente Elastografie (TE) - Controlled Attenuation Parameter (CAP) - diagnostischer Algorithmus - Risikobeurteilung - NAFLD-Fibrose Score (NFS) - Fibrosis-4 index (FIB-4) - Ambulanz - Vorstellungsformular

^* Joint first authors.

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