Guest Commentary

Noninvasive Point-of-Care Examinations for Liver Disease can Enhance Patient Engagement, Improve Outcomes

AUTHOR:
Robert G. Gish, MD
Medical Director, Hepatitis B Foundation, Doylestown, PA

CITATION:
Gish RG. Noninvasive point-of-care examinations for liver disease can enhance patient engagement, improve outcomes. Consultant360. Published online January 5, 2021.

 

Community health centers provide coordinated primary and preventive health care services to an estimated 29 million underserved individuals across the country.1 One way that physicians at community health centers can help prevent the burden of disease is by identifying the best approaches for preventing nonalcoholic fatty liver disease (NAFLD), a condition characterized by different hepatic abnormalities ranging from liver steatosis to cirrhosis. Therefore, it is important to understand the connection between liver disease and cardiometabolic disorders, as well as the growing and critical need for early detection, prevention, and treatment of liver disease.

A growing number of Federally Qualified Health Care (FQHC) clinics have adopted innovative, noninvasive tools for liver health examinations at the point of care. This is important given the alarming increase in liver disease, which impacts a significant number of adult patients seeking care at FQHCs.

Liver Disease and Cardiometabolic Disorders

Recent clinical evidence suggests that NAFLD is associated with an increased risk of cardiometabolic disorders.2 NAFLD has also been directly linked to multiple cardiometabolic disorders, including ischemic stroke, insulin resistance, hypertension, chronic kidney disease, and cardiac arrhythmias.

Associated with the increased prevalence of obesity and metabolic syndrome worldwide, it is no surprise that NAFLD has reached epidemic levels in the last few decades, with a global prevalence of about 24%.2 The high prevalence of cardiometabolic comorbidities and high liver-related mortality among patient populations at community health centers raises a critical challenge for providers.

First, a large number of NAFLD conditions lead to liver fibrosis via nonalcoholic steatohepatitis (NASH) and, in some cases, cirrhosis, liver cancer, liver transplant, and death. Adding to the challenge, NASH is asymptomatic in its early stages and is frequently underdiagnosed and underreported.  

Identifying At-Risk Patients

Patients at the highest risk for NAFLD or NASH have obesity, type 2 diabetes, hyperlipidemia, and/or metabolic syndrome.3 Depending on genetic factors, access to health care, or the prevalence of chronic diseases, Hispanic and Latinx populations are at highest risk for developing NAFLD.4

In particular, patients at community health centers have higher rates of chronic conditions than the general population, primarily because type 2 diabetes accelerates liver disease in patients with NAFLD.1 In fact, NAFLD is an independent predictor associated with a greater than 2-fold increase in developing type 2 diabetes.

Researchers have found that NAFLD, hepatitis C, liver cancer, and liver transplants are prevalent in 40% to 80% of people with type 2 diabetes and in 30% to 90% of people with obesity.5 Moreover, the prevalence rates of steatosis and steatohepatitis are 85% and 40%, respectively, among patients with severe obesity.6

A “whole person” approach to patient engagement can be effective for helping patients manage behavioral changes that lead to better outcomes. Because the most effective prevention is lifestyle changes and strict control of metabolic risk factors, early detection is critical. Patients can be managed well by primary care physicians, but patients with NAFLD and advanced liver fibrosis should be managed by a specialist.7

Role of Early Detection and Noninvasive Tools

Physicians at community health centers play an important part in reversing the nation’s liver disease epidemic, but early detection and monitoring of NAFLD/NASH are key. Liver biopsy is considered the best available standard of reference but has some limitations, including sampling error, high cost, and risk of complications. Also, it is not practical to perform liver biopsies on all patients with NAFLD.8 Use of a noninvasive tool at the point of care to examine liver health provides information that can improve individual health outcomes, lower payer costs by avoiding expensive invasive interventions, and enhance the financial performance of a physician’s practice.

A recent study9 examined the cost-effectiveness of different cirrhosis screening strategies, including 3 noninvasive tests—fibrosis-4 (FIB-4), vibration-controlled transient elastography (VCTE), and magnetic resonance elastography (MRE)—for the detection of cirrhosis in patients with NAFLD. In terms of avoiding liver biopsy, FIB-4 + VCTE and FIB-4 + MRE had similar diagnostic accuracies, ranging from 87.5% to 89.3% and 90.6% to 92.4%, respectively, for a cirrhosis diagnosis, though FIB-4 + MRE had a slightly higher cost.

In my practice, we use a point-of-care, noninvasive tool that is approved by the US Food and Drug Administration. It is a specialized ultrasound machine that measures fibrosis and steatosis in the liver. While blood tests measure circulating markers of inflammation, such as alanine aminotransferase (ALT) and aspartate aminotransferase (AST), this tool measures physical properties of stiffness and liver fat and provides reproducible results. This allows for both diagnosis and monitoring of liver stiffness and liver fat, as well as identifying cirrhosis in people with NAFLD to support care management across key components of the metabolic syndrome.

This examination validates the determination of elastography with controlled attenuation parameter as an important aspect of a patient’s workup, along with a full abdominal ultrasound that includes special liver cancer biomarkers, a liver panel that includes liver enzymes and liver function, a chemistry panel, and a complete blood cell count, as well as AST to platelet ratio index and FIB-4 NAFLD score calculations. 

Education and Treatment

Diet and exercise are the first line of therapy for NAFLD. In the early stages of NAFLD, a well-balanced diet and weight loss of at least 7% can make a difference.10 Patients are also prescribed vitamin E plus aggressive management of hypertension, diabetes, and lipid disorders.

Patient engagement is the key to successful treatment. A liver specialist should consult the patient for at least 15 minutes, and the rest of the care team should spend 15 to 30 minutes with the patient. The idea is to educate patients through the use of models, diagrams, figures, and pictures to give them a better understanding of cirrhosis and liver cancer, as well as the 5 risk factors of metabolic syndrome.

Patients should also be informed whether they are at increased risk for stroke; myocardial infarction; cirrhosis; bone, spine, knee, or hip disease; degenerative joint disease; renal disease; and at least 13 different cancers, including liver cancer. In addition, patients should be informed about the impact on their health if they do not follow the treatment regimen and should sign a weight loss contract at their initial visit. A follow-up visit ensures that they are following the weight loss program, consulting with a dietician or nutritionist, and adhering to the program.

It is always helpful to share the patient’s liver examination score with them to demonstrate any change in steatosis and/or if you need to augment treatment. Diabetes should be treated aggressively, insulin therapy should be halted if possible, and metformin should be prescribed to increase renal function. This level of aggressive diabetes management can improve outcomes related to NASH.

References:

  1. Community Health Center Chartbook 2020. National Association of Community Health Centers. Published online January 2020. Accessed December 2020. https://www.nachc.org/research-and-data/research-fact-sheets-and-infographics/chartbook-2020-final/
  2. El Hadi H, Di Vincenzo A, Rossato M. Cardio-metabolic disorders in non-alcoholic fatty liver disease. Int J Mol Sci. 2019;20(9):2215. https://dx.doi.org/10.3390%2Fijms20092215
  3. NASH Causes & Risk Factors. American Liver Foundation. Updated 2020. Accessed December 2020. https://liverfoundation.org/for-patients/about-the-liver/diseases-of-the-liver/nonalcoholic-steatohepatitis-information-center/nash-causes-risk-factors/
  4. Kallwitz ER, Daviglus ML, Allison MA, et al. Prevalence of suspected non-alcoholic fatty liver disease in Hispanic/Latino individuals differs by heritage. Clin Gastroenterol Hepatol. 2015;13(3):569-576. https://dx.doi.org/10.1016%2Fj.cgh.2014.08.037
  5. Know The Facts: NAFLD-NASH. Echosens. Published online May 4, 2020. Accessed December 2020. https://echosens.us/know-the-facts-nafld-nash/
  6. Fabbrini E, Sullivan S, Klein S. Obesity and nonalcoholic fatty liver disease: biochemical, metabolic and clinical implications. Hepatology. 2010;51(2):679-689. https://doi.org/10.1002/hep.23280
  7. Ngu JH, Goh GBB, Poh Z, Soetikno R. Managing non-alcoholic fatty liver disease. Singapore Med J. 2016;57(7):368-371. https://dx.doi.org/10.11622%2Fsmedj.2016119
  8. Sumida Y, Nakajima A, Itoh Y. Limitations of liver biopsy and non-invasive diagnostic tests for the diagnosis of nonalcoholic fatty liver disease/nonalcoholic steatohepatitis. World J Gastroenterol. 2014;20(2):475-485. http://dx.doi.org/10.3748/wjg.v20.i2.475
  9. Vilar-Gomez E, Lou Z, Kong N, Vuppalanchi R, Imperiale T, Chalasani N. Clin Gastroenterol Hepatol. 2020;18(10):2305-2314. https://doi.org/10.1016/j.cgh.2020.04.017
  10. Perdomo CM, Frühbeck G, Escalada J. Impact of nutritional changes on nonalcoholic fatty liver disease. Nutrients. 2019;11(3):677. https://dx.doi.org/10.3390%2Fnu11030677