Expert Roundtable: Identifying Patients at Risk of NASH and MASLD

Alan Bonder, MD, Hirsh Trivedi, MD, and Gordon Jiang, MD, discuss the importance of identifying features of metabolic syndrome when assessing patients for potential metabolic dysfunction-associated liver disease--and starting the process at the primary care level

Alan Bonder, MD, is medical director of liver transplantation at Beth Israel Deaconess Medical Center and associate professor of medicine at Harvard University Medical School in Boston, Massachusetts. Hirsh Trivedi, MD, is an assistant professor of medicine and hepatologist at Cedars-Sinai Medical Center in Los Angeles, California. Gordon Jiang, MD, is an assistant professor of medicine at Harvard University Medical School and head of the Jiang Lab at Beth Israel Deaconess Medical Center, which researches the pathophysiology of fatty liver diseases.

TRANSCRIPT:

Welcome everyone. This video is to talk about the nuances of metabolic-associated liver disease. I am Alan Bonder, I am the medical director of transplant. I'm delighted to be accompanied by two of my really good friends and colleagues in the hepatology world. So want to introduce you to Dr. Jiang. Well thank you Dr. Jiang.  And Dr. Trivedi—thank you, Dr Trivedi.

I want to emphasize that this is an overview of MASLD and for staging as well as assessment and prognosis of patients who come to our clinics for regular visits for these conditions. So let me start with Dr. Jiang. So looking at patients, how do we know if a patient has a possible diagnosis of MASLD, or metabolic-associated fatty liver disorder?

Dr Jiang:

Yeah, I think the new MASLD nomenclature for MASLD made the diagnosis more relevant to its name. It's basically linking metabolic syndrome with this condition. So when you evaluate a patient, basically for somebody with a clinical presentation of metabolic syndrome will certainly raise the concern of MASLD. So this includes high BMI features of metabolic syndrome such as hypertension, glucose intolerance, high triglyceride, and low HDL. If somebody having these features, certainly you should look for met and met-related complications. If patient has a family history of fatty liver disease as well as complications, that certainly should raise a red flag and you should look for that as well.

Dr Bonder:

Thank you. And I think Dr. Trivedi, you were part of our algorithm that we basically sent to our primary care providers. Can you go over about is there any specific ways to get our primary care world to kind of engage in this kind of new diagnosis and to try to get people to diagnose at an early stage so we don't see the complications of liver disease of this type of population?

Dr Trivedi:

Yeah, that's a great question. I think this screening for MASLD should really begin at the primary care level and I think it starts by increasing awareness amongst primary care physicians through mediums like this platform and video that we're doing today. So when you're seeing a patient, as Dr. Jiang mentioned with metabolic risk factors, whether it's in the primary care clinic or in the gastroenterology clinic, you want to be able to have quick repeatable tests that can quickly screen for advanced features of liver disease. When it comes to MASLD, so there's one test that we can commonly use called the FIB-4 score, which is a test that we had used in the cohort in Boston previously. And that test basically comprises the AST/ALT platelet counts and the patient's age. And that can be very easily calculated in the primary care setting with just simple basic metabolic panel of tests.

And that can help inform strategies and referral pattern going forward. For instance, if the FIB 4 score is low, below 1.3, then the primary care physician can be reassured that it's okay for this patient to just continue to follow in their clinic and just mitigate the metabolic risk factors in order to prevent future advanced liver fibrosis. But if there is a score in the indeterminate range or in the advanced range above that 1.3, that would trigger either a referral to the specialist for secondary fibrosis assessment and more detailed mitigation of the metabolic risk factors and really risk stratifying the patient's level of fibrosis as it pertains to MASLD is important and informs subsequent practices.

Dr Bonder:

And this is very useful going to the algorithms from the AGA, the American Gastroenterological Association, and the AASLD. So Dr. Jiang, can you comment about or following up what Dr. Trivedi said, is there an algorithm or anything that we recommend either primary care providers, gastroenterologists or community physicians? What would be the next step about evaluating and staging these patients? We know they are at increased risk of advanced fibrosis from their metabolic associated fatty liver disease?

Dr Jiang:

Yeah, so Dr. Trivedi really brought up a very important concept that there are so many people have fatty liver, especially MASLD. What we really need to focus on are those patients at risk or already demonstrating fibrosis. Multiple researchers have demonstrated that liver fibrosis is the most important predictor for outcomes. Not just the liver-related outcome, but also outcome in mortality in general. And in terms of methods of determining how much fibrosis the patient may have, I think it is really a situation that you have to evaluate what tools you have and what expertise you have in your particular practice setting. There are multiple ways of estimating liver fibrosis. I will start with the most simple way that is based on blood test. Dr Trivedi mentioned a very useful score, a FIB-4 score. You can also look at the AST-LT ratio or the evidence of thrombocytopenia short of calculating a FIB-4 four. If you see an increased a ST to LT ratio or somebody developing cytopenia, you should be concerned about advanced fibrosis and thinking about next level fibrosis workup. There are also ways to establish fibrosis using commercial fibrosis tests. These tests usually are a little bit more accurate based on validation studies in terms of predicting liver fibrosis compared to FIB-4. These are like FibroTests, and ELF [Enhanced Liver Fibrosis] score. These are available in Quest or LabCorp.

You can also use the elastography. A common way of elastography is transient, but there are also elastography using ultrasound depending on what kind of technology you have access to. Elastography are really easy cost-effective ways to estimate the liver fibrosis. And the most importantly, this is noninvasive, other than invasive liver fibrosis estimation is through MR Elastography. It will be a bit more expensive and more involved, but it gives you information of liver fibrosis not just at one small part of the liver but the entire liver. So certainly it has advantages.

And finally we always have the option of doing a liver biopsy given we have so many different tools and liver biopsy is not always needed. But if you have questions and if you're getting conflicting results, liver biopsy is always an option that you can really definitively say it's still the gold standard we use in clinical trials and in a lot of research studies to determine how much fibrosis the patient has and also has the advantage of looking at etiology and making sure that there's no other competing causes for liver disease.

Dr Bonder:

This is very useful. So let me go back to you Dr. Trivedi. We have really kind of very good tools to assess for staging. Are there any particular type of patients, for example, either underlying comorbidities or race ethnicity type of patients that we are concerned they could be presenting a more advanced disease or they should be kind of screening more often than the regular population? Is there any data or anything that we can advise the primary care or the general gastroenterologist to do in this type of cases?

Dr Trivedi:

Right, yes. And I agree understanding the tools we have at our disposal is very important when we're trying to determine what's based, what's best for the patient sitting in front of us. To answer your question, certain ethnicities do have a higher risk of MASLD and related fibrosis and those happen to be those of Hispanic ethnicity, for example. They have certain genetic polymorphisms that do increase their risk of developing MASLD and related complications. So definitely having a high index of suspicion in these patients who come into your clinic is important. Alternatively, Southeast Asians or South Asians can have lean MASLD even though their BMI is normal or on the lower end of normal; lean MASLD does have a significant increased risk of poor cardiovascular outcomes. So it is important to be aware of this.

And then thirdly, as Dr. Jiang recently mentioned about family history, I think that's very important. Any patient who you're seeing in the primary care or community setting, you should elicit their family history and that should include whether there's a history of MASLD because that does portend an increased risk in that patient sitting in front of you if there's a family history. So those are certain characteristics that I would keep an eye out for when screening for these patients.

WATCH FOR PART 2 ON STAGING NASH/MASLD AND THERAPEUTIC OPTIONS-- COMING SOON!