← Healthier World with Quest Diagnostics
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Foreign welcome to Healthier World with Quest Diagnostics. Our goal is to prompt action from Insight as we keep you up to date on current clinical and diagnostic topics in cardiovascular, metabolic, endocrine and wellness medicine. Welcome to a special episode series called Instant Insights, a podcast episode designed to give you quick and highly impactful clinical pearls in just a few minutes. I'm Dr. Mason Latsko and today we're breaking down how we talk about and screen for fatty liver disease, a condition that affects 1 in 3Americans and more than 70% of patients with type 2 diabetes. For years we've called it NAFLD, non alcoholic fatty Liver Disease, a term that is largely based on defining a disease state by what it isn't. But that's changing. An international group of liver experts now recommends the name masold Metabolic Dysfunction Associated Steatotic Liver Disease, and the name change to MASLD focuses on what causes the disease. Metabolic dysfunction insulin resistance type 2 diabetes obesity, dyslipidemia this name change reduces stigma, improves clarity, and better aligns with cardiometabolic comorbidities. And similar to all cardiometabolic conditions, the process of MASLD is slow and it might take decades for a disease to progress. First, fat accumulates in liver cells and this process is called steatosis. Next, inflammation is introduced in those liver cells that are accumulating fat, and that was formerly called NASH and it's now renamed to mash. The next stage of liver disease is fibrosis and this is a process of scar tissue forming as the liver tries to repair itself. Once that scarring becomes widespread, that is termed cirrhosis and cirrhosis is permanent scarring that impairs liver function. And finally, a subset of patients may suffer from end stage liver disease or hepatocellular carcinoma. Unfortunately, the majority of patients with MASL don't have symptoms until significant damage is already done. That's why early stratification is so important. Now, to stratify our patients along the continuum of risk, we have tools like the FIB 4 score and the ELF score. These tools are so powerful because they help us identify disease at the fibrosis stage when intervention is still meaningful. First up, let's talk about the fib4 score. The fib4 stands for fibrosis 4 index and this is a simple, non invasive calculation using just four variables. It's age, AST, ALT, and platelet count. The FIB4 is recommended by medical societies for all patients with certain conditions, including prediabetes, type 2 diabetes, obesity, elevated liver enzymes, or more than two cardiometabolic risk factors. The score gives you the risk of having advanced fibrosis. So if a patient has a fib 4 score less than 1.3, they're at low risk and need to be monitored in primary care for comorbid cardiometabolic conditions. A FIB4 that results between 1.3 and 2.67 is considered indeterminate risk for developing advanced fibrosis and anyone with A score above 2.67 is considered high risk of having advanced fibrosis. The fib4 score can be easily calculated using an online calculator or even more conveniently can be added to a standard CMP through Quest Diagnostics. That way you get an actual fib4 result right there on the lab report giving you early insight into your patient's liver fibrosis risk. This will help save you time in order to focus on managing the underlying metabolic condition and it will also prevent missed screening opportunities. And the Fib 4 has a high negative predictive value and should be viewed as a rule out test given that this score will identify patients who are not at risk for liver fibrosis and cirrhosis. The next question becomes what do we do about the patients who do have indeterminate or high risk fib4 scores? And that's where the ELF test comes in. ELF stands for Enhanced liver Fibrosis and measures direct biomarkers of fibrosis using three serum proteins, hyaluronic acid, procollagen 3N terminal peptide and tissue inhibitor of melatoproteinase 1 and the ELF score predicts advanced fibrosis and even future risks for liver related events. The ELF score is often used in place of a liver stiffness measurement done by elastography because it is the only FDA indicated serum test that can be used as a prognostic test for MAST and mash. Therefore, this is the recommended screening tool by the aace, the ADA and the aasld. So let's put this all together. First, we identify a patient who has elevated risk metabolic risk factors including diabetes, obesity, dyslipidemia or elevated liver enzymes. For those patients you will order the FIB4. If the FIB4 is low, that patient is at low risk for liver fibrosis and should be monitored in primary care for their comorbid cardiometabolic diseases. If the FIB4 score is greater than 1.3, these are the patients that need to proceed to the secondary risk assessment using that ELF score. The ELF score results will help the provider determine what to do about that patient. If the ELF score is high, that's when the results will suggest referral. If the ELF score is intermediate, those patients should consider imaging and aggressive risk management. And if the ELF score is low less than 9.8, the those patients should continue in primary care with close monitoring of their fibrosis risk. Remember that knowledge is power. Identification of MASTLD should be used as a clinical red flag for cardiovascular, metabolic and renal disease. If you screen for mastld using the fib4 and alf, you're not just protecting the liver, you're identifying risk for heart failure, for atherosclerosis, for kidney damage, and most apparently the metabolic root cause of masld. As we've said before on this podcast, identifying risk in one organ identifies risk in others, and early prevention can save a life. That's a wrap on this episode of Healthier World with Quest Diagnostics. Please follow us on your favorite podcast app and be sure to check out Quest Diagnostics Clinical Education center for more resources, including educational webinars and research publications. Thank you for joining us today as we work to create a healthier world, one life at a time.