What are the next steps for a non-alcoholic patient with a liver stiffness value of 6.49 kilopascals (kPa), indicating mild to moderate fibrosis?

From the Guidelines

For a liver stiffness value of 6.49 kPa suggesting mild to moderate fibrosis in a non-alcohol user, the next steps should include lifestyle modification, such as weight loss, dietary changes, and physical exercise, as well as optimal management of comorbidities, to prevent further liver damage and potentially reverse fibrosis. According to the most recent guidelines 1, case-finding strategies for metabolic dysfunction-associated steatotic liver disease (MASLD) with liver fibrosis should be applied in individuals with cardiometabolic risk factors, abnormal liver enzymes, and/or radiological signs of hepatic steatosis. A stepwise approach using blood-based scores and imaging techniques, such as transient elastography, is suitable to rule-out/in advanced fibrosis.

Key Recommendations

• Schedule follow-up blood tests including liver function tests (ALT, AST, bilirubin, albumin), complete blood count, and specific tests for viral hepatitis (HBV, HCV), autoimmune hepatitis, and metabolic conditions like hemochromatosis and Wilson's disease.
• Consider screening for non-alcoholic fatty liver disease (NAFLD) or non-alcoholic steatohepatitis (NASH) with lipid profile and diabetes screening.
• Lifestyle modifications are crucial, including:
  • Weight loss if overweight, with a target of 5-10% of total body weight to decrease hepatic steatosis and potentially regress fibrosis 1.
  • Regular exercise, with a target of 150-300 minutes of moderate-intensity or 75-150 minutes of vigorous-intensity aerobic exercise per week 1.
  • A Mediterranean-style diet low in processed foods and sugars, and high in fruits, vegetables, and whole grains.
• Plan for repeat elastography in 6-12 months to monitor progression.

Management of Comorbidities

• Optimal management of comorbidities, including use of incretin-based therapies (e.g. semaglutide, tirzepatide) for type 2 diabetes or obesity, if indicated 1.
• Bariatric surgery is also an option in individuals with MASLD and obesity.
• If locally approved and dependent on the label, adults with non-cirrhotic MASH and significant liver fibrosis (stage >2) should be considered for a MASH-targeted treatment with resmetirom, which demonstrated histological effectiveness on steatohepatitis and fibrosis with an acceptable safety and tolerability profile 1.

From the Research

Liver Stiffness Value Interpretation

• The liver stiffness value of 6.49 kPa suggests mild to moderate fibrosis 2, 3, 4, 5.
• This value is higher than the mean liver stiffness value of 5.49 kPa found in apparently healthy subjects 6.

Next Steps for Non-Alcoholic Fatty Liver Disease (NAFLD)

• Lifestyle modifications, such as weight loss, exercise, and a healthy diet, are the basis for prevention and treatment of NAFLD-associated fibrosis 2, 3, 5.
• Weight loss through diet and exercise is the primary treatment for NAFLD 3.
• Other treatments, such as bariatric surgery, vitamin E supplements, and pharmacologic therapy with thiazolidinediones or glucagon-like peptide-1 analogues, have shown potential benefit, but data are limited 3.
• Non-invasive diagnostic tools, such as elastography tests, can be used to identify patients who are likely to have fibrosis that will progress to cirrhosis 3, 4.

Considerations for Further Evaluation

• Liver biopsy should be considered for patients at increased risk of fibrosis and when other liver disorders cannot be excluded with non-invasive tests 3, 4.
• Patients with cirrhosis should be screened for hepatocellular carcinoma and oesophageal varices 5.
• The presence of metabolic syndrome, which is characterized by insulin resistance, hypertension, and dyslipidemia, may influence liver stiffness values and should be considered in the evaluation and management of NAFLD 6.