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Identifying Nonalcoholic Fatty Liver Disease Advanced Fibrosis in the Veterans Health Administration

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A Correction to this article was published on 24 July 2018

This article has been updated

Abstract

Background

Nonalcoholic fatty liver disease (NAFLD) is the most common cause of chronic liver disease. Severe NAFLD with advanced fibrosis results in substantial morbidity and mortality. Associated with metabolic syndrome, NAFLD is often initially clinically silent, yet intensive lifestyle intervention with 7% or greater weight loss can improve or resolve NAFLD. Using a Veterans Health Administration (VHA) liver biopsy cohort, we evaluated simple noninvasive fibrosis scoring systems to identify NAFLD with advanced fibrosis (or severe disease) to assist providers.

Methods

In our retrospective study of a national VHA sample of patients with biopsy-proven NAFLD or normal liver (2005–2015), we segregated patients by fibrosis stage (0–4). Non-NAFLD liver disease was excluded. We evaluated the diagnostic accuracy of the NAFLD fibrosis score (NFS), fibrosis-4 calculator (FIB-4), aspartate aminotransferase-to-alanine aminotransferase ratio (AST/ALT ratio), AST-to-platelet ratio index (APRI), and body mass index, AST/ALT ratio, and diabetes (BARD) score by age groups.

Results

We included 329 patients with well-defined liver histology (296 NAFLD and 33 normal controls without fibrosis), in which 92 (28%) had advanced (stage 3–4) fibrosis. Across all age groups, NFS and FIB-4 best predicted advanced fibrosis (NFS with 0.676 threshold: AUROC 0.71–0.76, LR + 2.30–22.05, OR 6.00–39.58; FIB-4 with 2.67 threshold: AUROC of 0.62–0.80, LR + 4.70–27.45, OR 16.34–59.65).

Conclusions

While NFS and FIB-4 scores exhibit good diagnostic accuracy, FIB-4 is optimal in identifying NAFLD advanced fibrosis in the VHA. Easily implemented as a point-of-care clinical test, FIB-4 can be useful in directing patients that are most likely to have advanced fibrosis to GI/hepatology consultation and follow-up.

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Change history

  • 24 July 2018

    The original version of the article unfortunately contained errors in Table 3, Risk Factor column headings “Age > 50 (n = 115),” “Age > 50–64 (n = 154),” and “Age > 65 + (n = 60).”

Abbreviations

AUROC:

Area under the ROC

ALT:

Alanine aminotransferase

AST:

Aspartate aminotransferase

APRI:

AST-to-platelet ratio index

BARD score:

Body mass index, AST/ALT ratio, and diabetes

AUDIT-C:

Alcohol Use Disorders Identification Test Alcohol Consumption Questions

BMI:

Body mass index

FIB-4:

Fibrosis-4 calculator

HCC:

Hepatocellular carcinoma

NAFL:

Nonalcoholic fatty liver

NAFLD:

Nonalcoholic fatty liver disease

NFS:

NAFLD fibrosis score

NASH:

Nonalcoholic steatohepatitis

ROC:

Receiver operating characteristic curve

VHA:

Veterans Health Administration

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Funding

This work was supported in part by resources from the Veterans Affairs (VA) Cooperative Studies Program Epidemiology Center, Durham, and the VA Ann Arbor Healthcare Systems.

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Authors and Affiliations

  1. Department of Medicine, Duke University Medical Center, Durham Veterans Administration Medical Center, Box 3913, Durham, NC, 27710, USA

    Yuval A. Patel, Cynthia A. Moylan, Steve Choi, Ayako Suzuki, Dawn Provenzale & Christine M. Hunt

  2. Sanford School of Public Policy, Duke University, Durham, NC, USA

    Elizabeth J. Gifford

  3. Department of Medicine, University of Michigan, Ann Arbor, MI, USA

    Lisa M. Glass

  4. VA Ann Arbor Healthcare Systems, Ann Arbor, MI, USA

    Lisa M. Glass

  5. Cooperative Studies Program Epidemiology Center, Durham Veterans Administration Medical Center, Durham, NC, USA

    Marsha J. Turner, Byungjoo Han, Dawn Provenzale & Christine M. Hunt

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  1. Yuval A. Patel
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All authors had access to the data and a role in writing/preparing the manuscript.

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Correspondence to Yuval A. Patel.

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The views expressed in this paper are those of the authors and do not necessarily represent the policies or position of, nor imply endorsement from, the Department of Veterans Affairs, or US Government. Christine M. Hunt has received consultancy fees from Otsuka and Indivior.

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Patel, Y.A., Gifford, E.J., Glass, L.M. et al. Identifying Nonalcoholic Fatty Liver Disease Advanced Fibrosis in the Veterans Health Administration. Dig Dis Sci 63, 2259–2266 (2018). https://doi.org/10.1007/s10620-018-5123-3

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