Nonalcoholic Fatty Liver Disease Clinical Practice Guidelines (AACE, 2022)

American Association of Clinical Endocrinology

These are some of the highlights of the guidelines without analysis or commentary. For more information, go directly to the guidelines by clicking the link in the reference.

June 01, 2022

Guidelines on the management of nonalcoholic fatty liver disease (NAFLD) were published in May 2022 by the American Association of Clinical Endocrinology in Endocrine Practice[1,2]; they were cosponsored by the American Association for the Study of Liver Diseases.

The guidelines are designed to help clinicians screen and identify patients at risk for NAFLD in the primary care setting so they may receive appropriate treatment promptly.

Screen all patients at high risk for NAFLD, including those with prediabetes, type 2 diabetes, obesity, and/or at least two cardiometabolic risk factors, or those with hepatic steatosis identified on imaging, and/or elevated plasma aminotransferase levels that persist for longer than 6 months.

Evaluate those undergoing bariatric surgery for the presence and severity of nonalcoholic steatohepatitis (NASH); liver biopsy should be recommended for patients whose presurgical stratification suggests indeterminate or high risk for liver fibrosis.

Use the fibrosis-4 (FIB-4) index, which is calculated using the patient's age, AST level, platelet (PLT) count, and ALT level: FIB-4 score = age (years) x AST (U/L)/PLT (109/L) x ALT ½ (U/L). The FIB-4 index classifies patients as being at low, intermediate, or high risk for liver fibrosis. The FIB-4 is not recommended for pediatric patients because the age part of the equation is not accurate for them; liver enzyme tests are appropriate for pediatric patients at high risk resulting from clinical factors.

Patients with low risk can be managed in primary care or endocrinology settings with an emphasis on management of obesity and prevention of cardiovascular disease. Studies about whether NAFLD is an independent risk factor for CVD and whether this risk increases as NAFLD progresses to more severe disease have shown mixed results, but lifestyle modifications (eg, diet and exercise) and medications can help improve cardiometabolic health and reduce the increased cardiovascular risk linked with NAFLD.

For those at intermediate risk, a second noninvasive test, such as a liver stiffness measurement by elastography or an enhanced liver fibrosis (ELF) test, is recommended. Referral to a liver specialist for additional testing, including possible biopsy, is advised for those with high risk or whose risk is still unclear after two non-invasive tests.

Individuals with high risk on the FIB-4 require a hepatology referral. Those in intermediate- and high-risk groups require multidisciplinary management that includes a hepatologist, endocrinologist, and others for prevention of cardiovascular disease and development of cirrhosis.

For more information, please see Fatty Liver and Pathology of Nonalcoholic Steatohepatitis.


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