UK NAFLD Group Recommendations for implementation
| Guideline domain | Proposed actions for implementation | Impact | Research priorities |
|---|---|---|---|
| Identification of NAFLD in high-risk groups | Screening primary care populations with known type 2 diabetes for significant NAFLD with liver fibrosis as part of the existing diabetes QOF | Increased NAFLD diagnosis in high-risk patients with type 2 diabetes | Does earlier diagnosis of NASH with liver fibrosis alter outcomes in patients with T2DM? |
| Diagnosis | Review 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 care | Streamline referral pathways to decrease number of hospital outpatient appointments | Evaluation of community-based programmes for NAFLD diagnosis and risk stratification |
| Staging for advanced disease | Perform 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 availability | Facilitates discharge of low-risk cases, and decision to biopsy and follow-up intermediate and high-risk cases | Evaluate the diagnostic performance and cost-effectiveness of non-invasive fibrosis risk scores versus ELF versus transient elastography |
| Liver biopsy | Offer liver biopsy to those with intermediate and high-risk scores to diagnose NASH with fibrosis, or reclassify as low risk, and reporting using standardised criteria | Definitive NASH diagnosis, access to clinical trials and those that may benefit for future licensed therapies | Evaluation of biomarkers and imaging as an alternative to biopsy for NASH diagnosis and staging |
| Extrahepatic conditions | Proactive management of features of the metabolic syndrome by both primary and secondary care | Improved cardiovascular risk reduction | Specific evidence base on which insulin sensitisers, lipid-lowering therapies and antihypertensive are best in NAFLD cases |
| Lifestyle intervention | Set 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? |
| Trials | Individuals with NASH and ≥F2 fibrosis should be offered access to clinical trials, and long-term follow-up in secondary care to assess fibrosis progression | Evidence base for NASH specific therapies | What 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.