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Risk factors for nonalcoholic steatohepatitis, advanced fibrosis in Asian patients

Jairia Dela Cruz
10 Feb 2018

In Asian patients with nonalcoholic fatty liver disease (NAFLD), more severe liver disease is associated with factors such as older age, obesity, diabetes, dyslipidaemia, higher alanine transaminase (ALT) and aspartate transaminase (AST) levels, and lower platelet count, according to a team of investigators.

Nonalcoholic steatohepatitis (NASH) and advanced fibrosis can be suspected or ruled out based on factors identified in this study, they added. This is of paramount importance as the current practice of diagnosing more severe liver disease is based on histopathological examination of a liver biopsy specimen, with the liver biopsy procedure being invasive and should not be applied to all NAFLD patients.

The investigators from eight Asian countries—including Singapore, Hong Kong, Malaysia, Japan and Korea—had used the Gut and Obesity Asia (GO ASIA) Workgroup as a platform to share their data on biopsy-proven NAFLD patients, determine factors associated with NASH and advanced fibrosis, and look into the medical management of NAFLD in the region.

A total of 1,008 patients were included (62.9 percent had NASH; 17.2 percent had advanced fibrosis), among whom 483 were assigned into a training cohort (mean age 45.4 years; 59.2 percent male) and 525 into a validation cohort (mean age 48.5 years; 53.9 percent).

In the training cohort, factors including body mass index ≥30 kg/m2 (odds ratio [OR], 3.506; p<0.001), diabetes mellitus (OR, 1.581; p=0.038), dyslipidaemia (OR, 1.674; p=0.037), ALT ≥88 U/L (OR, 1.856; p=0.041) and AST ≥38 U/L (OR, 1.805; p=0.025) emerged as independent predictors of NASH. Those associated with advanced fibrosis included age ≥55 years old (OR, 4.693; p<0.001), diabetes mellitus (OR, 2.046; p=0.015) and platelet count <150 9 109 /L (OR, 2.572; p=0.034). [Aliment Pharmacol Ther 2018;doi:10.1111/apt.14506]

The aforementioned factors constituted the Asia-Pacific NASH and NAFLD advanced fibrosis risk scores. A high score yielded a positive predictive value of 80–83 percent for NASH and a low score yielded a negative predictive value of 95–96 percent for advanced fibrosis in the training and validation cohorts.

In terms of NAFLD management, the current data indicated limited utilization of structured lifestyle programme and treatment with vitamin E or pioglitazone. This is despite the fact that the cohort involved biopsy-proven NAFLD patients, with majority of patients having NASH.

“It is important to note [though] that the treatment strategies in different countries are influenced by the healthcare structure and evidence. For example, reimbursement may range from almost fully supported by the government (eg, Hong Kong), copayment system (eg, Singapore), insurance-driven (eg, Korea) to limited support (eg, the Philippines),” the investigators said.

“Unfortunately, short of lifestyle interventions and isolated drug trials, Asian centres have not been much involved in drug development for NASH. The lack of local data may also affect the choice of therapies,” they added.

To address such lack, the investigators suggested that clinicians and researchers with interest in NAFLD in the region use the GO ASIA Workgroup as a platform to consolidate and expand the current understanding of the disease through combining and sharing of data from previous, current and future work.

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