How fatty liver disease and NASH—as well as the comorbidities associated with them—highlighted this year's discussions.
Donna Cryer, JD
At the American Association for the Study of Liver Diseases (AASLD; The Liver Meeting) in San Francisco, CA, this month, discussion—as always—centered on a wide swarth of hepatologic conditions. That’s not to say more particular discussions headlined the annual meeting.
In an interview with MD Magazine®, Donna Cryer, JD, president and chief executive officer of the Global Liver Institute, shared some takeaway messages from the Liver Meeting—including how fatty liver disease, nonalcoholic steatohepatitis (NASH), and the comorbidities associated dominated talks. Solutions to addressing presented issues could very well highlight future Liver Meetings.
MD Mag: Could you share your favorite headline news to come out of the Liver Meeting this year?
Cryer: The spotlight was definitely on fatty liver disease and NASH. It highlighted the scope of the problem, how much activity there is in the space, the diversity of the industry, and approaches that are coming into that. By that I mean there are researchers who have come from the diabetes space, the obesity space, who have treated scarring among other diseases including lung diseases, those who can apply that knowledge to the NASH space.
What I hope that members come out of the meeting with is that there needs to be a new approach, a much more integrated approach, than they ever really had to do for a liver disease before. It's certainly one of the same things in talking to the other liver patient advocates, one of the things we most asked our friends in hepatology is how can we help them reach out to primary care? How can we help advance the relationship building between the liver specialists, endocrinologists, lipidologists, specialists in cardiovascular disease? Those patients have so much underlying, undiagnosed liver disease that we’re never going to be able to go to address this problem unless we’re doing this in a far more integrative fashion than we’ve ever had to in the past.
Can you speak to the prevalence of comorbidities in liver disease, and why it is important to progress understanding of it?
Current estimates are that up to 80% of patients with type 2 diabetes have some form of fatty liver disease or NASH. It has to be on the radar screen for endocrinologists. Most of those patients are not connected—they don’t have a gastroenterologist or hepatologist. I think we also need to recognize that if endocrinologists are their leading physician, then they may need to remain the quarterback of their team, but have a hepatologist at least in a consulting relationship. Patients are asking their doctors, “What do I need to think about, in terms of my liver health, in my overall treatment plan?”
When you’re making a treatment plan for a patient’s cholesterol, you have to make sure you’re addressing and possibly managing liver disease. If diabetes is the top-treated condition, then how do we address the parts of metabolic syndrome including fatty liver disease and NASH in these patients?
When I think about what we’re asking of primary care physicians to do, we understand we don’t have a simple biomarker and there are many, many steps in terms of screening before we recommend a liver biopsy. But an easy step internal medicine or primary care physicians can take is, if a patient has 2 or more of these risk factors—diabetes, obesity, hypertension, high cholesterol, and a few others—then they should be looking at those liver enzymes closer. They may or may not be elevated, but I think that’s part of the conversation, that most primary care physicians don’t realize that a patient can have early advanced fatty liver disease and no liver enzymes.
From there, they should be moving to ultrasound or imaging if they have those risk factors. We understand that not everyone will go to hepatologists, but there’s about 80 million people who are outside that hepatology scope that need to be on the radar screen.
Is a team-based network of specialists and physicians something that GLI advocates for?
Yes. We have a clinical workflow group which includes internal medicine, endocrinology, cardiovascular disease, lipid metabolism, and minority hepatology, to figure out what the best direction of care looks like, what’s the right threshold for referring a patient, and for helping us identify other forms of support—who else needs to be a part of this? Because we certainly can’t expect the physicians to carry all of this.
Are there racial and gender disparities in liver disease rates?
Absolutely. We see more men developing NASH, just as we do in liver cancer. This best correlates with the rates seen in obesity and diabetes, with a few more tweaks. The Hispanic population has a particular gene which makes them a bit more susceptible, and it does seem that some unidentified genetic aspects of being African American makes them a bit more protected from advanced cases of NASH. We certainly see Asian-Pacific Islander populations might be developing NASH and fatty liver disease at lower BMI than we see in a Caucasian population.
It might be that, looking at lean body mass, instead of BMI, might be a more useful metric to follow it. The other thing, coming out of the Liver Meeting, was the recommendation that we need to get beyond the biopsy and noninvasive testing. I think a lot of the advice given to physicians now is, “Use what you have.” Physicians should go to their imaging department and ask what liver imaging they may have available. They might have a fiber scan machine, which is a quick ultrasound-like test, or they might have an MRI machine which is more typically used.
That would be an important thing to know, because it’d be easier from the workload perspective, much less composition than a full biopsy, much less patient burden, and if physicians really want to be contributing to the reduction of number of people undiagnosed, just not worrying about the future’s new gold standard and using the machines they have now could help us today.
Looking forward to the next few years though, what do you hope is the biggest development to come from the Liver Meeting?
I hope there are more non-hepatologists attending the meeting. I hope we will have demonstrated the pervasive nature and sheer number of liver patients affected who are in other practices—which would make physicians feel they would need to go, but also feel welcomed enough by their hepatology colleagues to consider this is their meeting as well. I think it’s the thing that will move the field forward faster from a healthcare delivery and practice standpoint, in the same way that I think the research is moving faster because we’re having other research industries coming in. That’d be the most exciting thing to see.