Is grade 2 fatty liver disease indicated for FibroScan?

FibroScan for Grade 2 Fatty Liver Disease

Yes, FibroScan is indicated for patients with grade 2 fatty liver disease as it helps assess the presence of clinically significant fibrosis, which is crucial for determining prognosis and management decisions. 1

Rationale for FibroScan in Grade 2 Fatty Liver

• Grade 2 fatty liver disease represents moderate steatosis, which puts patients at increased risk for developing fibrosis that can progress to advanced liver disease 1
• FibroScan (transient elastography) provides a non-invasive assessment of liver stiffness, which correlates with the degree of fibrosis present 1
• The Youden cutoff value of 8.2 kPa (rounded to 8.0 kPa for clinical use) on FibroScan helps identify clinically significant fibrosis (≥F2), which includes grade 2 fatty liver with fibrosis 1

Clinical Care Pathway for NAFLD Assessment

Step 1: Initial Risk Stratification

• Begin with simple fibrosis scores such as FIB-4 to initially stratify patients 1
• FIB-4 <1.3 (<2.0 in those >65 years) reliably excludes advanced fibrosis with ≥90% negative predictive value 1
• FIB-4 >2.67 indicates high risk for advanced fibrosis (60-80% positive predictive value) 1
• Patients with intermediate FIB-4 scores (1.3-2.67) should proceed to FibroScan 1

Step 2: FibroScan Assessment

• FibroScan results are measured in kilopascals (kPa) and reflect risk for clinically significant fibrosis 1
• For patients with grade 2 fatty liver, FibroScan provides crucial information about fibrosis stage 1
• Interpretation of results:
  • <8.0 kPa: Low risk for clinically significant fibrosis (F2-F4) 1
  • 8.0-12.0 kPa: Indeterminate risk, may need additional testing 1

  • 12.0 kPa: High risk for advanced fibrosis, referral to hepatology recommended 1

Benefits of FibroScan in Grade 2 Fatty Liver

• High diagnostic accuracy for liver fibrosis assessment with AUROCs of 0.82-0.86 for significant fibrosis (≥F2) 2, 3
• Non-invasive alternative to liver biopsy, which has sampling variability issues (25-60% discordance between biopsies from same patient) 1
• Allows for monitoring of disease progression or regression over time 1, 4
• Can be performed rapidly (5 minutes) in outpatient settings with immediate results 1
• Sequential testing using FIB-4 followed by FibroScan for patients with indeterminate scores is more accurate than using either test alone 1

Technical Considerations

• Only procedures with ≥10 successful measurements are considered reliable 1
• Success rate should be at least 60% and interquartile range less than 30% of median value 1
• XL probe may be needed for patients with obesity to improve success rates 4
• FibroScan has limitations in patients with:
  • Ascites
  • Severe obesity
  • Narrow intercostal spaces
  • Acute hepatitis
  • Extrahepatic biliary tract obstruction 1

Clinical Implications

• Grade 2 fatty liver with significant fibrosis (≥F2) is associated with increased risk of liver-related morbidity and mortality 1
• Early identification of fibrosis allows for more aggressive management to prevent disease progression 1
• FibroScan results can guide referral decisions to hepatology specialists 1
• Patients with LSM <8.0 kPa can be monitored with repeat surveillance testing in 2-3 years 1
• Patients with LSM >12.0 kPa should be referred to hepatology for consideration of liver biopsy or additional testing 1

FibroScan is an essential tool in the evaluation of patients with grade 2 fatty liver disease, providing valuable information about fibrosis that guides management decisions and helps predict clinical outcomes.