Screening for nonalcoholic fatty liver disease in the primary care clinic

Nonalcoholic fatty liver disease (NAFLD) is a spectrum of diseases ranging from simple hepatic steatosis to nonalcoholic steatohepatitis (NASH) to advanced fibrosis and cirrhosis as well as liver cancer. Despite the significant morbidity associated with NAFLD, there are no global consensus guidelines to screen for liver fibrosis in patients considered high risk, including patients older than 50 years with type 2 diabetes or metabolic syndrome. Multiple therapies are currently being investigated and may soon receive regulatory approval for use in the clinic. It is suggested that patients at high risk for NAFLD be screened in the outpatient setting. This article aims to supply primary care providers (PCPs) with the knowledge and tools needed to properly evaluate a patient at high risk of developing significant liver disease from NASH. A tripartite algorithm is described to help PCPs identify patients with NAFLD using liver enzymes and abdominal ultrasound, assess the presence of advanced liver fibrosis using clinical prediction rules, and, if appropriate, determine when to refer patients to specialist care.