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Digestive Diseases and Sciences

, Volume 63, Issue 9, pp 2259–2266 | Cite as

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

  • Yuval A. PatelEmail author
  • Elizabeth J. Gifford
  • Lisa M. Glass
  • Marsha J. Turner
  • Byungjoo Han
  • Cynthia A. Moylan
  • Steve Choi
  • Ayako Suzuki
  • Dawn Provenzale
  • Christine M. Hunt
Original Article

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.

Keywords

Fatty liver Nonalcoholic steatohepatitis Fibrosis Fibrosis prediction score 

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

Notes

Author’s contribution

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

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.

Compliance with ethical standards

Conflict of interest

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.

Supplementary material

10620_2018_5123_MOESM1_ESM.docx (26 kb)
Supplementary material 1 (DOCX 25 kb)

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Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2018

Authors and Affiliations

  • Yuval A. Patel
    • 1
    Email author
  • Elizabeth J. Gifford
    • 2
  • Lisa M. Glass
    • 3
    • 4
  • Marsha J. Turner
    • 5
  • Byungjoo Han
    • 5
  • Cynthia A. Moylan
    • 1
  • Steve Choi
    • 1
  • Ayako Suzuki
    • 1
  • Dawn Provenzale
    • 1
    • 5
  • Christine M. Hunt
    • 1
    • 5
  1. 1.Department of MedicineDuke University Medical Center, Durham Veterans Administration Medical CenterDurhamUSA
  2. 2.Sanford School of Public PolicyDuke UniversityDurhamUSA
  3. 3.Department of MedicineUniversity of MichiganAnn ArborUSA
  4. 4.VA Ann Arbor Healthcare SystemsAnn ArborUSA
  5. 5.Cooperative Studies Program Epidemiology CenterDurham Veterans Administration Medical CenterDurhamUSA

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