What to assess in a patient with chronic liver disease (CLD) due to non-alcoholic fatty liver disease (NAFLD) during prerounds?

Comprehensive Assessment for Patients with NAFLD During Prerounds

During prerounds of a patient with chronic liver disease due to non-alcoholic fatty liver disease (NAFLD), you should systematically assess for disease severity, metabolic comorbidities, and complications using a structured approach that prioritizes identification of advanced fibrosis and cirrhosis.

Initial Clinical Assessment

• Evaluate alcohol consumption history (significant consumption defined as >21 drinks/week for men, >14 drinks/week for women) to confirm NAFLD diagnosis and rule out alcoholic liver disease 1
• Review complete medication history, including prescribed medications, over-the-counter drugs, and supplements that may contribute to hepatic steatosis (e.g., amiodarone, tamoxifen) or accelerate disease progression (e.g., methotrexate) 1
• Assess for symptoms attributable to liver disease, including fatigue, right upper quadrant discomfort, and signs of hepatic decompensation 1
• Document dietary habits and physical activity levels, as poor diet and limited physical activity are common in NAFLD patients 1

Laboratory Assessment

• Review liver biochemistry panel (ALT, AST, GGT, alkaline phosphatase, bilirubin, albumin, INR) to assess liver function and disease activity 1
• Check metabolic parameters including fasting glucose, HbA1c, lipid profile, and uric acid to evaluate for metabolic syndrome components 1
• Calculate non-invasive fibrosis scores (e.g., NAFLD Fibrosis Score, FIB-4) to assess for advanced fibrosis 1
• Review complete blood count for thrombocytopenia, which may suggest portal hypertension 1
• Check serum ferritin and transferrin saturation, as elevated levels may indicate need for hemochromatosis testing 1

Imaging Assessment

• Review recent liver imaging (ultrasound, CT, or MRI) to confirm hepatic steatosis and assess for features of cirrhosis or portal hypertension 1
• Note results of any liver stiffness measurements (transient elastography, MR elastography) to evaluate fibrosis stage 1

Complication Screening

• For patients with advanced fibrosis or cirrhosis, check if appropriate screening for hepatocellular carcinoma has been performed (typically ultrasound every 6 months) 1
• For cirrhotic patients, review if screening for esophageal varices has been completed 1
• Assess for signs of hepatic decompensation (ascites, encephalopathy, jaundice) 1

Cardiovascular Risk Assessment

• Evaluate cardiovascular risk factors, as cardiovascular disease is the leading cause of death in NAFLD patients 1
• Check if systematic cardiovascular risk assessment (e.g., QRISK-3 score) has been performed 1

Treatment Assessment

• Review adherence to lifestyle modifications (weight loss, Mediterranean diet, physical activity) 1
• Assess management of metabolic comorbidities (diabetes, hypertension, dyslipidemia) 1
• Document participation in any clinical trials for NASH therapies 1

Follow-up Planning

• For NAFL patients without worsening of metabolic risk factors, note if monitoring at 2-3 year intervals is planned 1
• For patients with NASH and/or fibrosis, check if annual monitoring is scheduled 1
• For patients with NASH cirrhosis, verify if 6-month interval monitoring is arranged 1

Special Considerations

• For patients with indeterminate fibrosis risk by initial non-invasive testing, check if second-line testing (transient elastography, ELF test) has been performed 1
• For patients with suspected advanced fibrosis, review if liver biopsy has been considered to confirm diagnosis and stage disease 1