EASL–EASD–EASO clinical practice guidelines for the management of non-alcoholic fatty liver disease in severely obese people: do they lead to over-referral?
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We aimed to assess the application of the recent European Association for the Study of the Liver (EASL)–European Association for the Study of Diabetes (EASD)–European Association for the Study of Obesity (EASO) clinical practice guidelines for the management of non-alcoholic fatty liver disease (NAFLD) in severely obese individuals in routine clinical practice.
We performed a single-centre retrospective observational study of 385 patients referred for severe obesity (BMI ≥ 35 kg/m2) to our Endocrinology, Diabetes and Nutrition department, between 1 November 2014 and 31 December 2015. The recent EASL–EASD–EASO clinical practice guidelines for the management of NAFLD were retrospectively applied to the cohort using, successively, the NAFLD fibrosis score (NFS) and a combination of the NFS and transient elastography (TE) measurement in a subgroup of individuals.
We identified 313 (81.3%) individuals with NAFLD in the cohort. The application of the EASL–EASD–EASO guidelines using NFS would lead to referral to a specialist for up to 289 individuals (75.1%) in the cohort. The combination of NFS and TE measurement reclassified 28 (25%) individuals from the medium/high risk group to low risk and would lead to the referral of 261 (67.7%) individuals to a specialist. These proportions appear to be excessive given the expected prevalence of advanced fibrosis and non-alcoholic steatohepatitis (NASH) of around 10% and 30%, respectively, in the severely obese population.
This is the first study to assess the strategy proposed by the EASL–EASD–EASO clinical practice guidelines for the management of NAFLD in severely obese individuals. The retrospective application of the guidelines in a cohort representing the routine clinical practice in our department would lead to an excessive number of specialist referrals and would also lead to an unjustified increase in health costs. Biomarkers and specific strategy for the screening of NASH and advanced fibrosis in morbidly obese individuals are thus crucially needed and would help to improve the actual guidelines.
KeywordsFibrosis NAFLD fibrosis score Non-alcoholic fatty liver disease Non-alcoholic steatohepatitis Obesity Transient elastography
European Association for the Study of the Liver
European Association for the Study of Obesity
Non-alcoholic fatty liver disease
NAFLD fibrosis score
Shear wave elastography
We thank the staff of the department of Endocrinology and Nutrition, Radiology and Biology, Lyon Sud University Hospital for their helpful assistance.
The datasets are available from the corresponding author on reasonable request.
This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.
Duality of interest
The authors declare that there is no duality of interest associated with this manuscript.
All authors made substantial contributions to the conception and design or acquisition, analysis and interpretation of data. All authors drafted the article or revised it critically for important intellectual content. All authors approved the final version of the manuscript to be published. CCa is the guarantor of this work.
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