The most common chronic liver disease in the world

This transcript has been edited for clarity.

Matthew F. Watteau, MD: welcome home The Curbsiders. I'm Dr. Matthew Frank Watteau. I'm here with my great friend and American primary care physician, Dr. Paul Nelson Williams. Paul, what is MASLD?

Dr. Paul N. Williams: MASLD is a fatty liver disease associated with metabolic dysfunction.

Watto: We talked about a very simple way to test people's MASLD. If I see mild elevations in liver enzymes, what should I test for and how is alcohol considered?

Williams: Before making a definitive diagnosis of MASLD, it is necessary to exclude other causes of liver inflammation, i.e. those that cause an increase in transaminases in the patient. Alcohol has a synergistic effect with anything that can harm your liver.

Start by measuring someone's alcohol intake to see if it's causing liver inflammation. Phosphatidyl ethanol levels are a serological test to determine chronic heavy alcohol use. It's the new kid on the block. I've seen it ordered primarily by hepatologists. This is how you can tell if someone has had fairly consistent alcohol consumption up to four weeks after the fact. The cutoff for a positive test is 20 ng/mL.

Dr. Tapper frames the test as follows: He's not using the test to catch people lying about their drinking. He tells his patients that he orders this test for all patients with liver inflammation because alcohol is a common culprit. This test helps patients better understand factors that may be affecting their liver function.

If the test is positive, we discuss it; if the test is not positive, we move on to the next possible cause. Other common causes of liver inflammation are relatively easy to treat.

Watto: For example, instead of ordering tests for ceruloplasmin or alpha-1 antitrypsin, Dr. Tapper recommends testing for hepatitis B and hepatitis C first. Hepatitis C can be treated. Although there is no cure for hepatitis B, it is important to know if a person is infected. There it is. Your primary care physician should feel comfortable ordering these tests.

Really high ALT levels (e.g. in the 200s) are not usually caused by fatty liver disease. In such cases, we send an expanded panel that includes tests for autoimmune hepatitis ANA, anti-smooth muscle antibodies, and IgG levels. Otherwise, most of these patients do not require further testing.

What is a FIB4 score and how is it considered?

Williams: The FIB4 score estimates the degree of fibrosis based on ALT and AST levels, platelet count, and patient age. These data are formula. If the FIB4 score is low (meaning there is not much fibrosis present), we can stop there and counsel about lifestyle changes and address reversible factors.

If the FIB4 score is above a certain threshold (1.3 in young adults and 2.0 in older adults), a more specific way to determine the extent of fibrosis must be found, usually through imaging tests.

Elastography can be performed using either ultrasound or MRI. An ultrasound is usually ordered, but Dr. Tapper recommends an MRI for patients with a BMI greater than 40. In these patients, MRI is probably more effective to determine the extent of liver fibrosis.

Watto: Patients with low FIB4 scores probably do not need elastography, whereas patients with high FIB4 scores do. When it comes to interpreting ultrasound-based elastography results, Dr. Tapper taught me the “5-second rule.”

Elastography results are reported in kilopascals (kPa). Findings below 5 kPa are normal. 40% of people with a 10 kPa result may have advanced liver disease. Above 15 kPa, cirrhosis is likely, and at 25 kPa, cirrhosis is very likely. Finally, if the result is >25 kPa, portal hypertension is likely and you may need to discuss starting the patient on medications to prevent variceal bleeding.

We are moving towards more non-invasive testing and avoiding biopsies. Cutoff values ​​for MRI-based elastography are also available. Both of these tests can help determine the stage of your liver.

What can you tell people about dieting?

Williams: Losing weight helps. Fibrosis can be reversed by losing weight. Losing weight can really help your liver and bring it closer to a healthy baseline. A loss of 7.5% of body weight can reduce steatohepatitis, and a loss of about 10% of body weight can actually eliminate fibrosis. This is amazing.

We all know that weight loss is very effective for many conditions. It's just very difficult to achieve. As primary care physicians, we must leverage our arsenal to achieve that goal. This often includes certain medications.

Watto: I like to give my patients a number of 10%. Because if a patient weighs 220 pounds, they need to lose 22 pounds. If you weigh 300 pounds, that's 30 pounds. Most people who weigh 300 pounds think they need to lose 100 pounds to get any health benefits, but it's much less than that. So I think that's helpful.

But now a new drug has been approved. It's a thyroid memetic drug called Resmetilom. It was from. MAESTRO-NASH Trial. It helped me reverse my fibrosis without losing weight.

This will be used more and more in the future. The exact location of the drug is still unknown, and Dr. Tapper, a liver specialist, hasn't even had a chance to prescribe it yet. Of course, it was just recently approved.

Dr Tapper is one of our most famous guests. Listen to the entire podcast here.