Table 2

UK NAFLD Group Recommendations for implementation

Guideline domainProposed actions for implementationImpactResearch priorities
Identification of NAFLD in high-risk groupsScreening primary care populations with known type 2 diabetes for significant NAFLD with liver fibrosis as part of the existing diabetes QOFIncreased NAFLD diagnosis in high-risk patients with type 2 diabetesDoes earlier diagnosis of NASH with liver fibrosis alter outcomes in patients with T2DM?
DiagnosisReview and streamline referral pathways for assessment of abnormal LFTs. Perform routine diagnostic investigations to establish NAFLD diagnosis, including abdominal ultrasound and non-invasive liver screen blood tests (hepatitis B and C serology), ALT, AST, ferritin, autoantibody profile and immunoglobulins) in primary careStreamline referral pathways to decrease number of hospital outpatient appointmentsEvaluation of community-based programmes for NAFLD diagnosis and risk stratification
Staging for advanced diseasePerform a non-invasive test with high negative predictive value to exclude advanced liver fibrosis in primary care, or at point of referral for assessment to secondary care. Fib 4, NFS, ELF and transient elastography all suitable depending on local availabilityFacilitates discharge of low-risk cases, and decision to biopsy and follow-up intermediate and high-risk casesEvaluate the diagnostic performance and cost-effectiveness of non-invasive fibrosis risk scores versus ELF versus transient elastography
Liver biopsyOffer liver biopsy to those with intermediate and high-risk scores to diagnose NASH with fibrosis, or reclassify as low risk, and reporting using standardised criteriaDefinitive NASH diagnosis, access to clinical trials and those that may benefit for future licensed therapiesEvaluation of biomarkers and imaging as an alternative to biopsy for NASH diagnosis and staging
Extrahepatic conditionsProactive management of features of the metabolic syndrome by both primary and secondary careImproved cardiovascular risk reductionSpecific evidence base on which insulin sensitisers, lipid-lowering therapies and antihypertensive are best in NAFLD cases
Lifestyle interventionSet target of 10% weight loss by diet and exercise as first-line treatment for all cases of NAFLD.
Increase access to tier 2 and 3 weight management services to deliver weight loss as first-line NAFLD treatment
Improved efficacy of lifestyle intervention to treat NASH.
Define lifestyle non-responders who may benefit from trials and future therapies
What factors influence response/non-response to lifestyle intervention?
TrialsIndividuals with NASH and ≥F2 fibrosis should be offered access to clinical trials, and long-term follow-up in secondary care to assess fibrosis progressionEvidence base for NASH specific therapiesWhat interventions have greatest efficacy, in which populations? Factors that determine response and non-response
  • ELF, Enhanced Liver Fibrosis; NAFLD, non-alcoholic fatty liver disease; NASH, non-alcoholic steatohepatitis; NFS, NAFLD Fibrosis Score; QOF, Quality Outcomes Framework; T2DM, type 2 diabetes mellitus.