From the Guidelines
Patients with non-alcoholic steatohepatitis (NASH) should be referred to a specialist when they have advanced fibrosis (stage F3 or F4), cirrhosis, or elevated liver enzymes (ALT/AST) that persist despite lifestyle modifications for 3-6 months, as indicated by the most recent guidelines 1.
Key Considerations for Referral
- Advanced fibrosis (stage F3 or F4) is a critical indicator for referral, as it significantly increases the risk of liver-related complications and mortality 1.
- Cirrhosis is another key factor that necessitates specialist referral due to the high risk of decompensation and the need for specific management strategies, including screening for hepatocellular carcinoma (HCC) and esophageal varices 1.
- Elevated liver enzymes (ALT/AST) that persist despite lifestyle modifications for 3-6 months suggest ongoing liver injury and the potential for disease progression, warranting further evaluation by a specialist 1.
Role of Non-Invasive Tests
- The Fibrosis-4 Index (FIB-4) is recommended as a first-line, point-of-care test for assessing the risk of advanced hepatic fibrosis, with a value of <1.3 indicating low risk and >2.67 indicating high risk 1.
- For patients with intermediate risk (FIB-4 between 1.3 and 2.67), secondary assessments such as enhanced liver fibrosis (ELF), vibration-controlled elastography (VCTE), or magnetic resonance elastography (MRE) can be used to further stratify risk 1.
Importance of Early Referral
Early referral to a specialist is crucial because NASH can progress silently to cirrhosis and hepatocellular carcinoma, and specialists can provide comprehensive evaluation, consider liver biopsy when appropriate, and implement targeted therapies that primary care physicians may not be equipped to manage 1.
Multidisciplinary Care
Specialists can also coordinate multidisciplinary care involving nutritionists, endocrinologists, and cardiologists to address the metabolic components of NASH, which is essential for managing the disease and preventing complications 1.
From the Research
Referral to Specialist for NASH
When considering referral to a specialist for Non-Alcoholic Steatohepatitis (NASH), several factors come into play. The decision is often based on the severity of the disease, the presence of advanced fibrosis, and the patient's overall health status.
- Advanced Fibrosis: Patients with advanced fibrosis are at a higher risk of developing cirrhosis and other complications, and thus may benefit from specialist care 2, 3, 4.
- Noninvasive Tests: Noninvasive tests such as the Fibrosis-4 (FIB-4) score, Aspartate Aminotransferase to Platelet Ratio (APRI), and Enhanced Liver Fibrosis (ELF) test can be used to assess the severity of fibrosis and guide referral decisions 5, 6, 3, 4.
- Referral Pathways: A sequential test strategy of FIB-4 followed by the ELF test in indeterminate cases may be an efficient approach for identifying patients with advanced fibrosis and reducing futile referrals 3.
- Patient Characteristics: Patients with obesity, type 2 diabetes, and cardiometabolic risk factors are at higher risk of developing NASH and may benefit from early referral to a specialist 2.
- Liver Biopsy: While liver biopsy is the gold standard for diagnosing NASH, noninvasive tests can help identify patients who are likely to have advanced fibrosis and may require specialist care 5, 6, 4.
Key Considerations
- The presence of advanced fibrosis is a key factor in determining the need for specialist care.
- Noninvasive tests can be used to assess the severity of fibrosis and guide referral decisions.
- A sequential test strategy may be an efficient approach for identifying patients with advanced fibrosis.
- Patient characteristics, such as obesity and type 2 diabetes, can increase the risk of developing NASH and may warrant early referral to a specialist.