Screening of Extrahepatic Manifestations of Nonalcoholic Fatty Liver Disease: Are We Doing a Good Job?

Abstract

Introduction: Recent studies have proposed that nonalcoholic fatty liver disease (NAFLD) is associated with extrahepatic manifestations (EHMs). Patients with NAFLD should be screened on a yearly basis for type 2 diabetes (DM2), chronic kidney disease (CKD), and dyslipidemia and should be evaluated for hypothyroidism, osteoporosis, obstructive sleep apnea (OSA) and colon cancer. The aim of this study was to evaluate whether practitioners are appropriately screening for EHMs of NAFLD. Methods: Consecutive patients with biopsy proven NAFLD were included in this retrospective study. Patients with nonalcoholic steatohepatitis (NASH) were further identified using histological findings of inflammation and hepatocellular ballooning. Demographic, clinical and laboratory data were collected from the medical record system. EHMs of NAFLD included DM2, CKD, dyslipidemia, hypothyroidism, OSA, osteoporosis and colon cancer. Prevalence of appropriate screening of these manifestations by either primary care physicians or by hepatologist was calculated. Results: A total of 177 subjects were included, 67% had NASH (n=118) with average NAFLD Activity Score (NAS) 4.4 +/- 1.7. Overall, 60% of patients were non smokers and 41% had a family history of cardiovascular disease. While subjects with bland steatosis and NASH had similar body mass index (32.1 and 33.1 kg/m2 respectively) and prevalence of dyslipidemia (78% in both groups); central obesity, DM2, and hypertension were more prevalent in patients with NASH compared to those with steatosis (p < 0.05 for all). Both NASH and steatosis groups were more likely to be started on insulin, a hypoglycemic agent or a statin over time as evidenced by the medication list at time of diagnosis of NAFLD and at the last follow up visit. After confirmation of NAFLD by liver biopsy, 69.5% of subjects were at least screened once for diabetes while 56.5% were yearly screened for diabetes. Similarly, 72.3% were at least screened once for CKD but only 57.6% were yearly screened. For dyslipidemia, 76.3% of subjects were at least screened once and 56.4 % were yearly screened. The proportion of NAFLD patients that were screened at least one time for the following EHMs was as follows: 52% for hypothyroidism, 20.3% for OSA, 45.8% for colon cancer, and 44.6% for osteoporosis. Conclusion: NAFLD patients are not being screened adequately for EHMs including DM2, CKD, dyslipidemia, osteoporosis, OSA, hypothyroidism and colon cancer.Figure 1