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A Comprehensive Fatty Liver Program .pptx
1. Dr Manoj K S, MD RD, DNB RD , DMRD .
Pioneer Metro Scans ,Trivandrum ,KIMS HEALTH ,Trivandrum
Insights from a single centre
A Comprehensive Fatty Liver
Program
3. World Stats
The Numbers
NAFLD is the most common chronic liver disease in the U.S.,
affecting roughly 25% of adults.
Most people with NAFLD have a fatty liver without
inflammation. However, 20% of people with NAFLD develop
NASH—liver inflammation that can seriously harm the organ.
It is estimated that over 115 million adults around the world are
impacted by NASH.About 5% of the US population, or about 15
million Americans, develops NASH .
Nonalcoholic fatty liver disease (NAFLD) is
a leading cause of liver disease
worldwide. It affects 25% of the global
adult population, with a range of 13.5% in
Africa and 31.8% in the Middle East
By 2030, the number of people in China with NASH is
expected to reach 48.26 million.
In Europe, Spain had 1.8 million cases in 2016, with the
number expected to increase 49% by 2030. German
cases of NASH stood at 3.33 million in 2016 and are
projected to climb 43% by 2030.
5. Aetiology
NASH -Progress
NAFLD is an overarching term that includes all disease grades and stages and
refers to a population in which ≥ 5% of hepatocytes display macrovesicular
steatosis in the absence of a readily identified alternative cause of steatosis (eg,
medications, starvation, monogenic disorders) in individuals who drink little or no
alcohol (defined as < 20 g/d for women and <30 g/d for men).
The spectrum of disease includes NAFL, characterized by macrovesicular hepatic
steatosis that may be accompanied by mild inflammation, and NASH, which is
additionally characterized by the presence of inflammation and cellular injury
(ballooning), with or without fibrosis, and finally cirrhosis, which is characterized by
bands of fibrous septa leading to the formation of cirrhotic nodules, in which the earlier
features of NASH may no longer be fully appreciated on a liver biopsy.
7. The NAFLD nomenclature is changing.
Consensus Nomenclature
7
Hepatic steatosis is defined as intracellular fat accumulation in the liver that constitutes at
least 5% of liver weight. Prolonged hepatic lipid storage may lead to liver metabolic
dysfunction, inflammation, and advanced forms of fatty liver disease
10. Abnormal LFT No significant alcohol consumption
History & Examination Exclude drug induced liver injury
Exclude other aetiologies of liver
disease
Non Invasive Liver Tests Blood tests (raised GGT,AST,WST
Ultrasound confirmation of liver
steatosis
Investigate severity of liver fibrosis Enhanced liver fibrosis (ELF)
Magnetic resonance elastography
(MRE)
VCTE, SWE ,ARFI
Fibrosis-4 ( FIB-4) ,Fibrotest,AST
Platelet
ratio (APRI)
Liver Biopsy (NAS, SAF,NASH CRN NAFLD activity
score Score )
NASH
NAFLD
IMAGING
A simplified
Algorithm for
NASH diagnosis
11. NASH Clinical Research Network histological scoring system
NITs have emerged as
valuable tools for
predicting adverse liver
related outcomes -hitherto
an important function of
liver biopsies
Liver biopsies for grading
and staging of NASH are not
consistently performed in
clinical practice and should
be reserved for specific
clinical scenarios
AASLD Practice Guidelines on
the clinical assessment and
management of NAFLD
Hepatology 2023;77:1797-1835
13. Clinical Care Pathway for the Risk Stratification and Management of Patients With Nonalcoholic Fatty Liver Disease
Fasiha Kanwal Jay H. Shubrook Leon A. Adams Hashem B. El-Serag Kenneth Cusi
Published:September 20, 2021DOI:https://doi.org/10.1053/j.gastro.2021.07.049
14. > 50 Crore Indians have
Fatty Liver disease
> 50 Crore Indians are
Obese
India has a 40.3% obesity
prevalence rate. This rate varies
by region, with the south having
the highest rate at 46.51% and
the east having the lowest at
32.96%. Obesity is also higher
among women than men, and in
urban areas than rural areas
19. Sarcopenia ,Total Abdominal Muscle mass (TAM)
Risk scoring with all the above data
Mobile App and Online Data
VAT/SAT quantification
Additional Steps
20. Package -1
1. Questionnaire for preparing personal advise on Diet,
Exercise etc
2. Labs, Physical measurements
3. Ultrasound and Shearwave Elastography
4. Biomarkers
5. Risk scoring with all the above data
Visceral adipose tissue (VAT/SCAT)
6. Biomarkers
7. Risk scoring with all the above data
Package - 2
1. Questionnaire for preparing personal advise on
Diet, Exercise etc
2. Labs, Physical measurements
3. Ultrasound and Shearwave
4. MRI Fat quantification
5. Biomarkers
6. Risk scoring with all the above data
Visceral adipose tissue and Subcutaneous
adipose tissue
Package-3
1. Questionnaire for preparing personal advise on Diet, Exercise etc
2. Labs, Physical measurements
3. Ultrasound and Shearwave Elastography
4. MRI Fat quantification and MR Elastography
5. Visceral adipose tissue and Subcutaneous adipose tissue (VAT/SCAT)
6. Biomarkers
7. Risk scoring with all the above data
FATTY LIVER PROGRAM - PACKAGES
Package - 4
1. Questionnaire for preparing personal advise on Diet, Exercise
etc.
2. Labs, Physical measurements
3. Ultrasound and Shearwave Elastography
4. MRI Fat quantification and MR Elastography
5. Visceral adipose tissue and Subcutaneous adipose tissue
(VAT/SCAT)
6. Sarcopenia. Total abdominal muscle (TAM)
7. Biomarkers
8. Risk scoring with all the above data
9. Physician consultation
10. Apps
11. DEXA -whole body muscle / fat estimation
22. Comprehensive Fatty Liver Program
Patient Questionnaire
Beverages and Supplements:
What kind of beverages do you prefer to drink mostly?
Do you take any vitamin/mineral/nutritional supplements?
Do you take snacks in between meals?
Do you add sugar to meals?
Exercise and Physical Activity:
Do you exercise/practice any specific program?
Which physical exercise do you practice, and for how many hours
each time?
What are your personal barriers to exercise?
Are you able to carry out self-care activities yourself, or do you
feel sick?
Do you walk for at least 30 minutes daily/sometimes/never?
What household activities do you do at home?
What are your leisure activities?
If working, does your work require any physical activities?
How many days did you engage in moderate physical activities
like gardening in the past week?
Dietary Habits:
How many times a week do you eat bakery products?
How many times a week do you eat out?
What type of eating places do you frequently visit?
Do you skip meals? If yes, which one do you usually
skip?
What do you prefer to eat for dinner?
Do you control your diet as part of any ritual?
What food types are included in your diet
(vegetables, fruits, chicken, other meats)?
23. Habits and Lifestyle:
Do you smoke? If yes, how many cigarettes per day?
Do you drink alcohol? If yes, how often and how many drinks on
average?
How many hours do you sleep each night?
Do you snore loudly while sleeping?
Do you have any sleep disorders?
Do you feel drowsy during the daytime?
Medical History:
Do you have hypertension?
Do you have Diabetes mellitus?
Any history of dyslipidemia now?
Have you checked your cholesterol level
recently? Was it normal?
Have you ever had hepatitis?
Did you have any cardiovascular diseases
like heart attack or stroke?
Did you have any history of liver diseases?
Do you intake any medication/drug on a
regular basis?
Do you have a history of acanthosis
nigricans?
Have you ever had obesity problems?
Do you have a past history of any
metabolic syndrome such as
high blood pressure, high blood sugar,
excess body fat around the
waist, and abnormal cholesterol levels?
Family History:
Do any of your relatives suffer from diabetes mellitus?
Do any of your close relatives have hypertension?
Do any of your close relatives have cholesterol issues?
Do any of your relatives have cardiovascular diseases?
Do any of your close relatives suffer from any liver disease?
24. Through a Tablet the
Questionnaire
can be administered
Printed
Questionnaire
can be used
The
Questionnaire
can be administered
in person with trained staff
28. Fatty Liver - Special Lab
Tests
Homocysteine
High sensitive C-reactive protein (hsCRP)
Apolipoprotein A-I
Apolipoprotein B
Lp(a)-lipoprotein
Tumour necrosis factor-alfa (TNF-α)
Adiponectin l
Cytokeratin-18 (CK-18) fragment
Type IV collagen 7S domain
Hyaluronic acid (HA)
Fasting C-peptide
32. Total fat area TAT
Visceral Fat area VAT
Subcutanous fat area SAT
CT/MR BASED VAT/SAT/TAT
33. Grade 0: PDFF less than 6.4%
Grade 1 PDFF equal to or greater than 6.4% and less than 16.3%
Grade 2 PDFF equal to or greater than 16.3% and less than 21.7%
Grade 3 PDFF equal to or greater than 21.7%
MR FAT QUANTIFICATION
34. MR Elastographic Stiffness Stage of Fibrosis
Less than 2.5 Normal
2.5–2.9 Normal or chronic inflammation
2.9–3.5 Stage 1–2
3.5 - 4.0 Stage 2-3
4.0 - 5.0 Stage 3-4
More than 5.0 Stage 4
MR ELASTOGRAPHY
47. PDFF Calculation Method
• Placement of one large single-section ROI in
the anterior, posterior, medial, and lateral
segments of the liver, avoiding bigger vessels
and bile ducts, has been proposed as an
acceptable alternative
Radiology: Volume 301: Number 2—November 2021 n radiology.rsna.org
MR FAT QUANTIFICATION
48.
49.
50. Sequence
Name TR TE TI FOV THICKNESS FREQUENCY PHASE NEX BANDWIDTH Scan Time Min
Ideal IQ-MR
PDFF Axial 6.5 3 42 10 160 160 1 111.1 01:00
T2 SSFSE
Coronal 1000 1.9 38 4 352 224 1 125 03:30
Prep scan 3 plane Localiser 02:00
Patient In-
Out time 03: 00
Total 09: 30
MR Fat quantification Sequences
10 MINUTE MRI : MR PDFF & MR ELASTOGRAPHY
51. MR PDFF Fat quantification -
Segment wise analysis
ROIs Placed in various segments and tabulated to find out average
52. Segment VII Segment VIII Segment V Segment VI
Segment II Segment III Segment IV Segment I
Right lobe Left lobe
Total Average
MR PDFF Fat quantification -
Segment wise analysis
Segment wise analysis helps to find out the regional variability , relatively spared areas etc
53. SLD Grading
Fatty liver was graded with PDFF according to the following
criteria:
Grade 0: PDFF less than 6.4%,
Grade 1: PDFF equal to or greater than 6.4% and less than 16.3%,
Grade 2: PDFF equal to or greater than 16.3% and less than 21.7%
Grade 3: PDFF equal to or greater than 21.7%
Ref : https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3632805/
54. RESULTS
In more than 95 % subjects , the study could be completed in less than 10 minutes .
SLD
Grade I in 26 =54.1%
Grade II in 12 = 25%
Grade III in 10 = 20.8%
Two patients excluded after study since features of CLD noted
Higher number of patients with SLD Grade III observed , may be due to the clinical stetting -need not
reflect actual prevalence in population .
56. LAI LIVER ATTENUATION INDEX
A non-contrast enhanced or plain CT scan
(NECT) diagnoses and quantifies HS based
on the attenuation values of spleen and liver
in HU.
This is called the liver attenuation index
(LAI).
LAI of above +5 indicates a normal liver,
while a LAI of 0 to −5 is indicative of 10–30%
steatosis .
NECT is more accurate than other CT
modalities. However, increased copper, iron,
or glycogen content, edema and inflammation
may lead to false-negative results
62. NAFLD FIBROSIS SCORE (NFS)
NAFLD fibrosis score (NFS), is a composite score of age, hyperglycemia, body mass index, platelet
count, albumin, and aspartate aminotransferase and alanine aminotransferase (AST/ ALT) ratio and
was found to independently identify NAFLD patients with and without advanced fibrosis at initial
NAFLD diagnosis
NAFLD fibrosis score = -1.675 + 0.037 × age (year) + 0.094 × BMI (kg/m2) + 1.13 × IFG/diabetes
(yes = 1, no = 0) + 0.99 × AST/ALT ratio - 0.013 × platelet count (×109/L) - 0.66 × albumin (g/dL)[9].
People who have a NAFLD fibrosis score above 0.676 are the most likely to have advanced liver
fibrosis. If you have a score below -1.455, you're unlikely to have advanced liver fibrosis. The scores
in between are considered indeterminate
64. FATTY LIVER INDEX (FLI)
The fatty liver index (FLI), which is an algorithm based on waist circumference, body mass
index (BMI), triglyceride, and gamma-
glutamyl-transferase (GGT), was initially developed to detect fatty liver in Western countries
FLI was calculated using the following formula:
FLI = [e(0.953 × ln(triglycerides) + 0.139 × BMI + 0.718 × ln(γGTP) + 0.053 × WC − 15.745)]/ [1 +
e(0.953 ×ln(triglycerides) +0.139 × BMI + 0.718 × ln(γGTP) + 0.053 × WC − 15.745)] × 100.
Repeated evaluations of NAFLD status based on FLI measurements could help physicians identify higher-risk groups in terms of mortality, MI, and
stroke. The association between FLI worsening or improvement and outcomes also suggests clinical benefits of the prevention and treatment of
NAFLD.
65. FIBROSIS 4 SCORE (FIB-4 )
The Fibrosis 4 score is a non-invasive scoring system based on several laboratory tests
(AST/ALT/Platelets) that help to non- invasively estimate the amount of scarring in the liver. This
score has been studied in liver disease due to Hepatitis C and NASH.
FIB-4 below 1.30 is considered as low-risk for advanced fibrosis; a value of FIB-4 over 2.67
is considered as high-risk for advanced fibrosis; and FIB-4 values between 1.30 and 2.67
are considered as intermediate-risk of advanced fibrosis for ages 36-64. For ages > 64 the cut-
off for low-risk goes to < 2.
http://gihep.com/calculators/hepatology/fibrosis-4-score/
https://www.mdcalc.com/calc/2200/fibrosis-4-fib-4-index-liver- fibrosis
66. APRI SCORE
APRI has been previously validated as an efficient score to predict liver fibrosis in viral hepatitis patients
with a cut-off of 0.5 for fibrosis and 1.5 for cirrhosis.
APRI score interpretation:
Significant fibrosis: APRI threshold of 0.7 (77% sensitive and
72% specific)
Severe fibrosis: APRI threshold of 1.0 (61% sensitive and 64%
specific)
Cirrhosis: APRI threshold of 1.0 (76% sensitive and 72%
specific).
67. APRI SCORE
There are no universal cut-off values for the APRI score, as it is not
sufficiently sensitive to rule out significant diseases (especially with
midrange values). The lower the APRI score (<0.5), the greater the
negative predictive value, and ability to rule out cirrhosis.
The higher the value (>1.5) the greater the positive predictive value and ability to rule in cirrhosis
https://www.mdcalc.com/calc/3094/ast-platelet-ratio-index-apri
https://www.omnicalculator.com/health/apri
77. Magnetic resonance-based
biomarkers in nonalcoholic fatty
liver disease and nonalcoholic
steatohepatitis
Cyrielle Caussy, Lars Johansson
Endocrinol Diab Metab. 2020;3:e00134.
| 1 of 9 https://doi.org/10.1002/edm2.134
80. Diagnostic accuracy of elastography and magnetic
resonance imaging in patients with NAFLD
• The following index tests were assessed in this
review: VCTE (FibroScan®, Echosens, Paris,
France), pSWE (Virtual Touch Quantification
(VTQ); Siemens Healthineers, Erlangen,
Germany), 2DSWE (Aixplorer®; SuperSonic
Imagine, Aix-enProvence, France), MRE
(Resoundant, Rochester, USA), cT1 measured
using LMS (Perspectum, Oxford, UK), DWI, and
deMIL
81. Diagnostic accuracy of elastography and magnetic
resonance imaging in patients with NAFLD
• In conclusion, in patients with NAFLD where liver stiffness can
be measured successfully, VCTE, MRE, pSWE and 2DSWE have
a good diagnostic accuracy for the assessment of fibrosis, but
only MRE and pSWE meet the minimum acceptable criteria of
at least 80% sensitivity and specificity for the diagnosis of
advanced fibrosis. These promising results however, are likely
tobe overestimates of the true diagnostic accuracy as
intention-todiagnose analyses and validation of pre-specified
cut-offs are lacking from the literature. Future studies, like the
LITMUS Imaging Study being conducted in Europe and the USA
currently, should also evaluate the newer 2DSWE and MRI
techniques, and provide data on head-to-head comparisons of
the various techniques
87. TECHNIQUES BASED ON CALCULATION OF
THE ATTENUATION COEFFICIENT
CAP
Controlled attenuation parameter
2-D attenuation imaging (ATI)
Attenuation coefficient (ATT)
US-guided attenuation parameter
(UGAP)
US-derived fat fraction (UDFF)
Fibroscan system (Echosens, Paris,
France)
Aplio i800 systems (Canon Medical
Systems, Japan)
Aloka-Arietta systems (Fujifilm)
LOGIQ E9 series (General Electric,
USA)
Acuson S3000 or Sequoia US platform
(Siemens Healthineers)
104. Shearwave Elastography holds the key
MRI Fat Quantification/MRE is the best
Fatty Liver Program can be introduced in any hospital /institution
Followup is essential
A Diet/Exercise/Relaxation program should be
an integral part
USG having SWE and utilising Serum Biomarkers
105. Acknowledgements
IMA Trivandrum Branch
IMA National Conference Org Committee
Dr Sreejith N Kumar
Dr N.Sulphi
Dr Vijayakrishnan
Dr Althaf Ali
Pioneer Metro Scans ,Tvm
KIMS Health Tvm
Thank You ALL