Weill Cornell Medicine.
Weill Cornell Medicine, Department of Gastroenterology and Hepatology, New York, NY.
J Clin Gastroenterol. 2023 Oct 1;57(9):956-961. doi: 10.1097/MCG.0000000000001784.
BACKGROUND/OBJECTIVE: Patients with metabolic syndrome (MetS) are likely to have nonalcoholic fatty liver disease (NAFLD), which can progress to advanced fibrosis. Early recognition of those at highest risk may ameliorate outcomes. Noninvasive liver fibrosis assessment through validated scoring systems such as the fibrosis-4 (FIB-4) index is helpful to identify these high-risk patients, with the process ideally beginning in the primary care setting. The primary objective of this study was to determine rates of disease recognition and initial management of patients with NAFLD and advanced fibrosis in a diverse primary care setting. The secondary objective was to define demographic and clinical predictors of NAFLD identification and management in this population.
Medical charts from patients seen at three university-based primary care practices in New York City from January 2016 to December 2019 were reviewed. Inclusion criteria consisted of: age 18 years and above, persistent alanine transaminase (ALT) elevation (2 values ≥40 IU/mL ≥6 mo apart), and body mass index ≥30 kg/m 2 . Patients with viral hepatitis or alcohol misuse were excluded. Patients were defined as likely having NAFLD if they met 2 of the following criteria indicating MetS: systolic blood pressure >135 mm Hg or diastolic blood pressure >85 mm Hg or active treatment for hypertension; high-density lipoprotein <40 g/dL; triglycerides >150 mg/dL or active treatment for hyperlipidemia; or hemoglobin A1c ≥5.7% or active treatment for insulin resistance. The primary study endpoints were the frequency of providers' recognition of NAFLD and referral to specialist and/or for imaging based on visit diagnosis codes or chart documentation. The secondary endpoints were frequency of detecting those with NAFLD and advanced fibrosis utilizing previously defined FIB-4 index cutoffs as well as predictors of disease recognition and management. Analysis was completed using descriptive statistics and logistical regression modeling.
A total of 295 patients were identified as having persistently elevated ALT, a body mass index ≥30 kg/m 2 , and MetS consistent with likely NAFLD diagnosis. In patients meeting these criteria, ALT elevation was documented by primary care providers in 129 patients (43.7%), NAFLD was noted in chart documentation in 76 patients (25.8%), and a NAFLD ICD-10 diagnosis was assigned to 7 patients (2.4%). 50 patients (16.9%) were referred for ultrasound. Among 51 patients (17.2%) at high risk for advanced fibrosis based on FIB-4 >3.25, 23 patients (45.1%) had NAFLD recognized by their provider and 3 (5.9%) were referred to a specialist. On logistic regression, female gender, dyslipidemia, and private insurance were predictors of disease identification by the primary care physician.
ALT elevation and NAFLD are under recognized among patients with MetS in the primary care setting. Importantly, while 17.2% of patients with likely NAFLD in our cohort were high risk for advanced fibrosis, less than half of this group had a NAFLD diagnosis recognized by their primary care provider and only three were referred to a liver specialist. Further investigation of disease recognition and management algorithms in the primary care setting are necessary to enhance NAFLD detection, implement clinical care pathways, and reduce disease progression and complications.
背景/目的：患有代谢综合征（MetS）的患者可能患有非酒精性脂肪性肝病（NAFLD），其病情可能进展为晚期纤维化。早期识别高危患者可能改善预后。通过纤维化-4（FIB-4）指数等经过验证的评分系统进行非侵入性肝纤维化评估有助于识别这些高危患者，理想情况下应在初级保健环境中开始进行评估。本研究的主要目的是确定在多样化的初级保健环境中，NAFLD 伴晚期纤维化患者的疾病识别率和初始管理率。次要目的是确定该人群中 NAFLD 识别和管理的人口统计学和临床预测因素。
从 2016 年 1 月至 2019 年 12 月在纽约市的三家大学附属初级保健诊所就诊的患者的病历中进行了回顾。纳入标准包括：年龄 18 岁及以上，持续丙氨酸氨基转移酶（ALT）升高（2 次 ALT 值≥40 IU/mL，间隔≥6 个月），体重指数（BMI）≥30 kg/m 2 。患有病毒性肝炎或酒精滥用的患者被排除在外。如果患者符合以下 2 项标准中的任意 2 项，表明其患有 MetS，那么他们可能患有 NAFLD：收缩压>135 mmHg 或舒张压>85 mmHg 或正在接受高血压治疗；高密度脂蛋白<40 g/dL；甘油三酯>150 mg/dL 或正在接受高血脂治疗；或糖化血红蛋白（HbA1c）≥5.7%或正在接受胰岛素抵抗治疗。主要研究终点是提供者识别 NAFLD 并根据就诊诊断代码或病历记录将患者转介给专家进行检查或进行影像学检查的频率。次要终点是利用先前定义的 FIB-4 指数切点检测那些患有 NAFLD 和晚期纤维化的患者的频率，以及识别和管理疾病的预测因素。分析采用描述性统计和逻辑回归建模。
共有 295 名患者被确定为持续存在 ALT 升高、BMI≥30 kg/m 2 以及与可能的 NAFLD 诊断一致的 MetS。在符合这些标准的患者中，129 名（43.7%）患者的初级保健提供者记录了 ALT 升高，76 名（25.8%）患者的病历中记录了 NAFLD，7 名（2.4%）患者的病历中分配了 NAFLD ICD-10 诊断。50 名（16.9%）患者接受了超声检查。在 51 名（17.2%）根据 FIB-4>3.25 有进展为晚期纤维化高风险的患者中，23 名（45.1%）患者的提供者识别出了 NAFLD，3 名（5.9%）患者被转介给专家。在逻辑回归中，女性、血脂异常和私人保险是初级保健医生识别疾病的预测因素。
在初级保健环境中，MetS 患者的 ALT 升高和 NAFLD 未得到充分认识。重要的是，尽管我们队列中有 17.2%的可能患有 NAFLD 的患者存在晚期纤维化的高风险，但只有不到一半的患者的 NAFLD 诊断得到了他们的初级保健提供者的认可，只有 3 名患者被转介给了肝脏专家。需要进一步研究初级保健环境中的疾病识别和管理算法，以提高 NAFLD 的检出率，实施临床护理路径，并减少疾病进展和并发症。
