How to manage advanced liver fibrosis with a FibroScan CAP (controlled attenuation parameter) of 267?

Management of Advanced Liver Fibrosis with FibroScan CAP of 267

A FibroScan CAP (controlled attenuation parameter) value of 267 indicates moderate hepatic steatosis, requiring comprehensive fibrosis assessment and appropriate management based on the degree of fibrosis present. 1

Understanding CAP Score and Fibrosis Assessment

• CAP score of 267 indicates moderate steatosis (grade 2 fatty liver), which puts the patient at increased risk for developing progressive fibrosis 1
• CAP alone does not measure fibrosis; liver stiffness measurement (LSM) from the FibroScan is needed to assess fibrosis stage 2, 1
• Advancing liver fibrosis is the key predictor of liver-related events and mortality in patients with fatty liver disease 2
• Patients with advanced fibrosis and cirrhosis (equivalent to Brunt fibrosis stage 3 or 4) are at increased risk of complications, decompensation, liver transplantation, and death 2

Recommended Management Algorithm

Step 1: Complete Fibrosis Assessment

• Review the liver stiffness measurement (LSM) from the FibroScan, which should have been performed alongside the CAP measurement 2, 1
• Calculate FIB-4 index and NAFLD Fibrosis Score (NFS) as complementary assessments 2
  • FIB-4 = Age (years) × AST [U/L] / (platelets [10^9/L] × (ALT [U/L])^1/2) 2
  • Low risk: FIB-4 < 1.3 (< 2.0 if over 65 years) 2
  • High risk: FIB-4 > 2.67 2

Step 2: Risk Stratification Based on Fibrosis Assessment

• Low risk for advanced fibrosis: 2

  • LSM < 8.0 kPa on FibroScan AND
  • FIB-4 < 1.3 (or < 2.0 if over 65 years) OR NFS < -1.455 (or < 0.12 if over 65 years)
  • Management: Primary care follow-up with lifestyle modifications and metabolic risk factor management

• Intermediate risk: 2

  • LSM 8.0-10.0 kPa OR
  • FIB-4 between 1.3-2.67 OR NFS between -1.455 and 0.676
  • Management: Consider additional testing such as ELF test or referral to hepatology

• High risk for advanced fibrosis: 2

  • LSM > 10.0 kPa OR
  • FIB-4 > 2.67 OR NFS > 0.676
  • Management: Refer to hepatologist for specialized care

Step 3: Management Based on Risk Level

For Low Risk Patients:

• Implement lifestyle modifications focusing on weight loss (7-10% of body weight) 2
• Manage metabolic risk factors (diabetes, hypertension, dyslipidemia) 2
• Repeat fibrosis assessment in 2-3 years 1

For Intermediate Risk Patients:

• Consider additional testing with ELF test 2
  • ELF < 9.8: Monitor with primary care 2
  • ELF ≥ 9.8: Refer to hepatology 2
• If ELF testing unavailable, consider referral to hepatology for further evaluation 2

For High Risk Patients:

• Refer to hepatologist for specialized care 2
• Consider liver biopsy if non-invasive tests are discordant or to confirm the diagnosis 2
• Implement aggressive management of metabolic risk factors 2
• Screen for complications of advanced liver disease 2

Important Considerations and Pitfalls

• Non-invasive tests have limitations in certain populations: 1

  • FIB-4 and NFS have not been validated in patients under 35 years of age 2
  • FibroScan has limitations in patients with severe obesity, narrow intercostal spaces, or ascites 1

• When using FibroScan results, ensure: 1

  • ≥10 successful measurements were obtained
  • Success rate is at least 60%
  • Interquartile range is less than 30% of median value

• If FibroScan results and serological markers are discordant, consider: 2

  • Additional testing with other modalities (MRE if available)
  • Referral to hepatology for further evaluation
  • Liver biopsy in selected cases

• For patients with ELF scores between 9.2-10.4, additional non-invasive tests should be performed to confirm the likelihood of stage 2-3 fibrosis 2

• Patients with LSM > 15 kPa may have cirrhosis and require different management approaches 2

By following this algorithm, you can appropriately manage patients with moderate hepatic steatosis (CAP 267) based on their fibrosis risk, ensuring those with advanced fibrosis receive timely specialist care while avoiding unnecessary referrals for those with minimal fibrosis.