When to Refer Patients to Hepatology for MASLD/MASH
The expert panel on MASLD and MASH continues its discussion with guidance on when a patients with suspected steatotic liver disease should be referred to a hepatology specialist, and how these patients are best treated.
Nezam Afdhal, MD, is Chief of Gastroenterology and Hepatology at Beth Israel Deaconess Medical Center and a professor of medicine at Harvard Medical School in Boston, Massachusetts. Meena Bansal, MD, is Chief of the division of Liver Diseases and Director of the MASH Center of Excellence at Mt Sinai Medical Center in New York, New York. Zobair Younossi, MD, is chairman and professor of the Liver and Obesity Research Program at INOVA Health in Fairfax, Virginia, and chairman of the Global NASH Council.
TRANSCRIPT:
Dr Afdhal: So primary care makes the screening or the case finding finds a case and what should they do then? They've found the case and really the key is does that patient really need to go to hepatology and what is the goal of that patient going to hepatology? What do we offer? Because this is often a question that I'm asked by primary care physicians.
Dr Younossi:
Well, I think the issue here has to do with capacity, interest, and engagement. If you have a primary care individual, a physician or provider who's really interested to manage all aspect of cardiometabolic sort of complication of the patient, well power to them. And I think they should manage these patients, but they should know how to actually manage at least with the medication that they're not used to. So they may be very used to using GLP-1 receptor agonist that's now approved for treatment of MASH, at least one of them, semaglutide, but they should also know how to use the other drug that's approved and that's resmetirom. I think that's what the primary care should do. Now, if they are not comfortable, if they're not comfortable with dealing with this, because the reality of the practice is that they are dealing with lots of patients, lots of complicated issues, and they may not want to or have the time, then I think connecting to a provider that is interested, either endocrinologist or gastroenterologist, and more and more in our practices is really our APPs, our advanced practitioners will be taking care of these patients and manage them.
I think having that group available is actually critical because of shortage of manpower in the United States. We need to make sure that we have really the very advanced patients with cirrhosis or even complication of cirrhosis. Those are the ones that would need a hepatologist, but the rest of our patients can be managed by our APPs. The one point that's really important to remember, this is a disease of metabolic abnormality. This is a group of diseases that come together. So as a hepatologist, my job is not only to look at liver. We need to look at, they used to call CKM or cardiovascular, kidney, and metabolic sort of diseases. Now we call it, at least I call it CKLM. So you have liver there too, so that when you're improving patient's outcome, you're not only improving their liver outcome, but also their cardiovascular outcome, which is number one cause of death in these patients, kidney outcome and other metabolic sort of abnormality.
And I think that should be our goal as we move forward in this field. And this requires sometimes that we come together, that we come together around what I call a metabolic clinic that could be under one roof, or it could be virtual. You can create these metabolic clinics with the appropriate subspecialties of primary care, endocrinology, hepatology, GI, or even nutrition and exercise and behavioral health connected somehow so that the patient is not going from one place to another place and sort of bouncing back and forth, that they get the best care. We have the best model of this in hepatology, which is liver transplantation. Patients who are a candidate for liver transplant, they come and see the entire team. In this context, a metabolic clinic that addresses all those issues of retinopathy, nephropathy, cardiovascular complication, but also liver complication in a coordinated way will serve the patient the best.
Dr Afdhal:
Yeah. I think that you clearly state the importance of realizing that for most of us when we take care of these patients, we're also in some ways a lipidologist, a diabetologist, a cardiovascular physician. We have to do a lot of this. And I find that a lot of these patients also rely on us to provide that thing, but developing networks and developing expertise in these areas is also going to be important for us. Okay. So the patient's being sent to us, the patient has an elevated liver stiffness of 9 kilopascals, or let's say 10 kilopascals above that threshold of 8 kilopascals that suggests that there is a significant fibrosis, at least stage 2. Do we need a liver biopsy anymore? Certainly in my practice, I rarely do liver biopsies unless there's a real strong indication such as a mismatch in some of the results that they don't coalesce well together. Or if I'm worried about another concomitant liver disease that might be there, then I would do it. But the old days of needing to do a liver biopsy for these patients, I believe is gone. The use of NITs has replaced that. Well, what does anybody else think?
Dr Bansal:
Absolutely. I mean, I agree. The only time you need to do, you don't need a liver biopsy to stage the disease. You need a liver biopsy to diagnose the disease if you're not sure. And so if you're trying to see if there's autoimmune hepatitis or something else going on, otherwise simply to say that they have significant fibrosis, there's no need for a liver biopsy. And I think we also need to get away from needing to categorize somebody. What's the difference if they have F2 or they have F3? They have F2 to F3, they're somewhere in there and they require therapy. And so really, do they have enough liver fibrosis that justifies a liver targeted therapy? Yes or no?
