From the Guidelines
Elevated alpha-fetoprotein (AFP) levels in patients with non-alcoholic fatty liver disease (NAFLD) should prompt further evaluation to rule out hepatocellular carcinoma (HCC), particularly in those with advanced fibrosis or cirrhosis, as recommended by recent guidelines 1. When AFP is mildly elevated in NAFLD patients (typically less than 20 ng/mL), it often reflects ongoing liver inflammation and hepatocyte regeneration rather than malignancy. However, any elevation of AFP should prompt appropriate follow-up to rule out HCC. The recommended approach is to perform liver imaging with ultrasound, CT, or MRI to evaluate for liver masses. If the AFP is significantly elevated (>200 ng/mL) or continues to rise on serial measurements, more extensive evaluation including multiphase CT or MRI should be considered. For NAFLD patients with elevated AFP but negative imaging, regular monitoring of AFP levels every 3-6 months along with periodic imaging is advisable, particularly for those with advanced fibrosis, as suggested by recent studies 1. Key considerations in the management of NAFLD patients with elevated AFP include:
- Liver imaging with ultrasound, CT, or MRI to evaluate for liver masses
- Regular monitoring of AFP levels every 3-6 months along with periodic imaging for those with advanced fibrosis
- Consideration of lifestyle modifications, such as weight loss and improved glycemic control, to reduce liver inflammation and potentially decrease AFP levels
- Referral to a specialist for dedicated HCC surveillance, variceal screening, and clinical trial enrollment, as needed, based on the patient's risk profile and disease stage, as recommended by recent guidelines 1.
From the Research
Elevated AFP in NAFLD
- Elevated alpha-fetoprotein (AFP) is a biomarker that can be associated with hepatocellular carcinoma (HCC) in patients with nonalcoholic fatty liver disease (NAFLD) 2
- However, AFP is not sufficiently sensitive for HCC screening, and other biomarkers such as the GALAD score, which combines sex, age, lectin-bound AFP, AFP, and des-carboxyprothrombin, may show better diagnostic performance 2
- NAFLD is a common liver disease that can progress to NASH, advanced fibrosis, cirrhosis, and liver failure, and is closely associated with metabolic disorders such as obesity, dyslipidaemia, hypertension, and hyperglycaemia 3, 4, 5
- Advanced liver fibrosis is a key prognostic marker for liver-related outcomes and overall mortality in patients with NAFLD, and can be assessed with combinations of non-invasive tests 6, 5
- While there is currently no approved therapy for NAFLD, lifestyle interventions such as weight loss, dietary modification, and treatment of underlying metabolic syndrome remain the mainstays of therapy once the diagnosis is established 3, 4, 5