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Metabolic Dysfunction Associated Steatotic Liver Disease

 

 

Introduction

  • Non-alcoholic fatty liver disease (NAFLD) is now called Metabolic dysfunction-associated steatotic liver disease (MASLD) to prevent stigmatisation
  • Fatty liver (steatosis) is seen in both alcohol-related liver disease and metabolic-associated fatty liver disease.
  • MASLD is very common, with the majority of patients being aged 40-60 years.

 

Red Flag Features

  • Synthetic failure – jaundice, low albumin, ascites, prolonged INR, encephalopathy

 

Key Features of Assessment

History:

  • Risk factors: obesity(BMI > 25) , type 2 DM, insulin resistance, hypertension, hyperlipidaemia 
  • Exclude other causes:
    • Medications: corticosteroids, amiodarone, and methotrexate (plus others)
    • Consider hepatitis C, HIV, coeliac disease, malnutrition as alternative causes of fatty liver
    • Rare Monogenic disease – secondary care diagnosis – (eg Wilson’s disease, LCAT deficiency, inborn errors off metabolism)
  • MASLD can coexist with increased alcohol intake thus calculate alcohol intake

 

Examination:

  • Check BP and BMI
  • Check for signs of advanced liver disease clinically i.e. hepatomegaly, ascites, spider naevi, jaundice, palmar erythema, encephalopathy, gynaecomastia

 

Investigations

  • Bloods – choose raised fatty liver orderset on ICE (includes: FBC, LFTs, AST, GGT, Hep B&C, liver autoantibodies, immunoglobulins, ferritin, lipids, HbA1c and Fib-4).
  • USS abdomen

 

Diagnosis:

  1. Suspect MASLD or steatosis if either:
    A) USS shows fatty liver disease (note liver USS may be normal in up to 15% of patients).

OR

    B) Raised ALT with AST:ALT ratio >0.8 and high BMI (a high AST:ALT ratio is not relevant with a normal BMI)

2. Assess risk of advanced  fibrosis using either:
    A) NAFLD score

>-1.455 (high risk) = routine referral for direct access Fibroscan (+ ultrasound abdomen)

<-1.455 (low risk) – manage in primary care

    B) Fib-4 score:better for lean individuals (BMI <25) as unaffected by BMI

(calculated by lab as part of “raised ALT” or “Fib-4” ordersets)

<1.3 – low risk. Lifestyle advice and routine follow-up in primary care
> 1.3 – Intermediate high risk. Refer routine for direct access fibroscan (+USS abdo)

*Note the Fib-4 score is not validated where a patient has a normal transaminases

- These cut-offs do not apply to patients on methotrexate

- Higher scores have a higher chance of indicating advanced fibrosis in older individuals

- Application for fatty liver disease or viral hepatitis.

 

Management

  1. Give RCHT leaflet on MAFLD



Primary care management (for those with low risk (after NAFLD/Fib-4 score):

  • Encourage weight loss: recommended target weight loss of 10% over 6 months (rapid weight loss should be avoided due to the risk of worsening liver inflammation and fibrosis)
  • Annually review cardiovascular risk (depending on clinical judgement) – check BP, QRISK and consider a statin (2/3rd of mortality for MAFLD is cardiovascular)
  • Treat diabetes
  • Alcohol advice
  • Re-assess fibrosis risk every 3 years: look for signs of advanced liver disease and fibrosis risk (FBC, LFTs, Hba1c and BMI). If worse re-calculate the Fib-4 or NAFLD score.

 

Manage patients following fibroscan according to their score:

  • <10.0kPa – Hepatology will give the patient a copy of their fibroscan report and lifestyle advice.
  • Lifestyle management in primary care as above
  • Only re-refer for fibroscan after 3 years if significant deterioration (sig. weight gain, increase in alcohol, diabetes or LFTs) - as risk <1% for those with a score <10kPa.  Do not re-calculate NAFLD/Fib-4 score.
  • 10-11.9kPa – hepatology will recall for fibroscan in 2 years.
  • >12kPa – Hepatology will review in outpatients for further assessment

 

Advice and Guidance

  • Please send advice and guidance requests via e-RS. Further information available here

 


Referral

Urgent referral to hepatology:

  • Features of synthetic failure – raised INR, low albumin, ascites, encephalopathy
  • Jaundice (refer to rapid access jaundice clinic).

 

Referral for direct access fibroscan with MASLD (all five criteria)

  • Asymptomatic  (no ascites / jaundice / encephalopathy)
  • USS shows no other significant disease other than fatty liver
  • Negative HCV / HBV serology  
  • NAFLD score > -1.455 or Fib 4 score > 1.3
  • Negative liver autoantibodies  or Positive ANA with  Ig G < 16 g/l & ALT < 200 iu/l

Or

  • High risk drinker with alcohol consumption >50 units/week (men) or >35units/week (women)

 

Routine hepatology referral

Those potential MASLD patients who are asymptomatic & do not meet criteria for direct access fibroscan

 

Repeat fibroscan

  • Patients with a previous fibroscan result <10kPa and after 3 years have a significant deterioration  in risk factors (i.e. increased BMI, diabetes, alcohol, LFTs)

 

 

For East-facing Cornwall practices. Please see South & West Devon DRSS Referral Guidelines

 

 

Supporting Information

For professionals:

 

For patients:

 

References

  • Rinella ME, Lazarus JV, Ratziu V, et al NAFLD Nomenclature consensus group. A multisociety Delphi consensus statement on new fatty liver disease nomenclature. Hepatology. 2023 Dec 1;78(6):1966-1986. doi: 10.1097/HEP.0000000000000520. Epub 2023 Jun 24. PMID: 37363821; PMCID: PMC10653297.
  • Angulo P, Hui JM, Marchesini G et al. The NAFLD fibrosis score A noninvasive system that identifies liver fibrosis in patients with NAFLD Hepatology 2007;45(4):846-854 doi:10.1002/hep.21496
  • Sterling RK, Lissen E, Clumeck N, et. al. Development of a simple noninvasive index to predict significant fibrosis patients with HIV/HCV co-infection. Hepatology 2006;43:1317-1325.
  • McPherson S, Stewart SF, Henderson E et al. Simple non-invasive fibrosis scoring systems can reliably exclude advanced fibrosis in patients with non-alcoholic fatty liver disease. Gut 2010;59:1265–9 doi:10.1136/gut.2010.216077

 

 

Page Review Information

Review date

14/02/25

Next review date

14/02/27

GP speciality lead

Dr Madeleine Attridge

Contributors

Dr Hyder Hussaini (Consultant Hepatologist RCHT)

Anna Barton (Principal Clinical Biochemist)