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Review
. 2020 Oct 21;26(39):5919-5943.
doi: 10.3748/wjg.v26.i39.5919.

Clinical assessment and management of liver fibrosis in non-alcoholic fatty liver disease

Alejandro Campos-Murguía  1 , Astrid Ruiz-Margáin  1 , José A González-Regueiro  1 , Ricardo U Macías-Rodríguez  1
Affiliations
Review

Clinical assessment and management of liver fibrosis in non-alcoholic fatty liver disease

Alejandro Campos-Murguía et al. World J Gastroenterol. .

Abstract

Non-alcoholic fatty liver disease (NAFLD) is among the most frequent etiologies of cirrhosis worldwide, and it is associated with features of metabolic syndrome; the key factor influencing its prognosis is the progression of liver fibrosis. This review aimed to propose a practical and stepwise approach to the evaluation and management of liver fibrosis in patients with NAFLD, analyzing the currently available literature. In the assessment of NAFLD patients, it is important to identify clinical, genetic, and environmental determinants of fibrosis development and its progression. To properly detect fibrosis, it is important to take into account the available methods and their supporting scientific evidence to guide the approach and the sequential selection of the best available biochemical scores, followed by a complementary imaging study (transient elastography, magnetic resonance elastography or acoustic radiation force impulse) and finally a liver biopsy, when needed. To help with the selection of the most appropriate method a Fagan's nomogram analysis is provided in this review, describing the diagnostic yield of each method and their post-test probability of detecting liver fibrosis. Finally, treatment should always include diet and exercise, as well as controlling the components of the metabolic syndrome, +/- vitamin E, considering the presence of sleep apnea, and when available, allocate those patients with advanced fibrosis or high risk of progression into clinical trials. The final end of this approach should be to establish an opportune diagnosis and treatment of liver fibrosis in patients with NAFLD, aiming to decrease/stop its progression and improve their prognosis.

Keywords: Clinical assessment; Diagnosis; Liver fibrosis; Non-alcoholic fatty liver disease; Test accuracy; Treatment.

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Conflict of interest statement

Conflict-of-interest statement: All authors declare no conflicts of interest related to this article.

Figures

Figure 1
Figure 1
Fagan′s nomogram for (A) transient elastography and (B) magnetic resonance elastography studies.
Figure 2
Figure 2
Fagan′s nomogram for all diagnostic methods. ARFI: Acoustic radiation force impulse; FIB-4: Fibrosis-4 index; NFS: Non-alcoholic fatty liver disease fibrosis score; APRI: Aspartate aminotransferase to platelet ratio index; MRE: Magnetic resonance elastography; TE: Transient elastography; HFS: Hepamet fibrosis score.
Figure 3
Figure 3
Diagnostic flow-chart to assess liver fibrosis in patients with non-alcoholic fatty liver disease. NAFLD: Non-alcoholic fatty liver disease; T2DM: Type 2 diabetes mellitus; IR: Insulin resistance; OSA: Obstructive sleep apnoea; DLP: Dyslipidemia; HFS: Hepamet fibrosis score; NFS: Non-alcoholic fatty liver disease fibrosis score; FIB-4: Fibrosis-4 index; APRI: Aspartate aminotransferase to platelet ratio index; AF: Advanced fibrosis; TE: Transient elastography; MRE: Magnetic resonance elastography; BMI: Body mass index; ALT: Alanine aminotransferase.
Figure 4
Figure 4
Management flow-chart for patients with non-alcoholic fatty liver disease advanced fibrosis. We suggest vitamin E as it has demonstrated higher transplant-free survival and lower rates of hepatic decompensation. 1Other drugs such as cenicriviroc, obethicholic acid, dapagliflozin, and selonsertib have shown benefit in clinical trials and must be considered as well, especially as results continue to show beneficial results. NAFLD: Non-alcoholic fatty liver disease; RAS: Renin-angiotensin system; T2DM: Type 2 diabetes mellitus; CPAP: Continuous positive airway pressure; BW: Body weight.
See this image and copyright information in PMC

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