A multidisciplinary approach to the management of NAFLD is associated with improvement in markers of liver and cardio-metabolic health

Non-alcoholic fatty liver disease (NAFLD) is a globally prevalent health problem, associated in its more severe forms with increased liver-related and cardiovascular-related morbidity and mortality. We established a multidisciplinary metabolic hepatology clinic in 2014 and have analysed the clinical data to evaluate the effectiveness of this service. Patients with NAFLD (n=165) who had attended two or more appointments were included. Prespecified clinical data were collected prospectively at clinic appointments and analysed retrospectively. Interventions offered included lifestyle advice, signposting to weight loss services and pharmacological treatment of diabetes and cardiovascular risk factors. Median follow-up was 13 months (range: 2–34). 59% (n=97) of patients had type 2 diabetes mellitus (T2DM). 53% (n=87) underwent liver biopsy of whom 18% (n=16) had cirrhosis. Median alanine aminotransferase (ALT) reduced by 11 IU/L (p<0.0001), median weight reduced by 3.3 kg (p=0.0005). There were significant reductions in HbA1c, total cholesterol and liver stiffness. Specifically, in patients with T2DM, HbA1c decreased by 4 mmol/mol (p=0.01) with significant reductions in ALT, weight and total cholesterol. Relative cardiovascular risk assessed by the QRISK3 score reduced in the whole cohort and in those with T2DM. Health economic modelling suggested the clinic intervention among those patients with poorly controlled T2DM was cost-effective. In conclusion, a multidisciplinary approach to the management of patients with NAFLD in this observational cohort study was associated with improvements in liver-related and cardio-metabolic related health parameters and with evidence of cost-effectiveness in patients with poorly controlled T2DM.

[1]  R. Ehman,et al.  Magnetic Resonance vs Transient Elastography Analysis of Patients With Nonalcoholic Fatty Liver Disease: A Systematic Review and Pooled Analysis of Individual Participants , 2019, Clinical gastroenterology and hepatology : the official clinical practice journal of the American Gastroenterological Association.

[2]  S. Arnold,et al.  Cardiovascular Outcomes and Mortality in Type 2 Diabetes with Associated Cardio-Renal-Metabolic Comorbidities , 2018, Diabetes.

[3]  A. Mithal,et al.  Effect of Empagliflozin on Liver Fat in Patients With Type 2 Diabetes and Nonalcoholic Fatty Liver Disease: A Randomized Controlled Trial (E-LIFT Trial) , 2018, Diabetes Care.

[4]  P. Keskinocak,et al.  Alanine Aminotransferase as a Monitoring Biomarker in Children with Nonalcoholic Fatty Liver Disease: A Secondary Analysis Using TONIC Trial Data , 2018, Children.

[5]  E. Sbardella,et al.  Prevalence and severity of non‐alcoholic fatty liver disease are underestimated in clinical practice: impact of a dedicated screening approach at a large university teaching hospital , 2018, Diabetic medicine : a journal of the British Diabetic Association.

[6]  Michael Charlton,et al.  The diagnosis and management of nonalcoholic fatty liver disease: Practice guidance from the American Association for the Study of Liver Diseases , 2018, Hepatology.

[7]  L. Williams,et al.  Effectiveness of Dietetic Consultations in Primary Health Care: A Systematic Review of Randomized Controlled Trials. , 2017, Journal of the Academy of Nutrition and Dietetics.

[8]  Pharmacologic Approaches to Glycemic Treatment : Standards of Medical Care in Diabetes d 2018 , 2017 .

[9]  P. Newsome,et al.  Review article: new treatments in non‐alcoholic fatty liver disease , 2017, Alimentary pharmacology & therapeutics.

[10]  K. Mahaffey,et al.  Canagliflozin and Cardiovascular and Renal Events in Type 2 Diabetes , 2017, The New England journal of medicine.

[11]  V. Wong,et al.  Increased risk of mortality by fibrosis stage in nonalcoholic fatty liver disease: Systematic review and meta‐analysis , 2017, Hepatology.

[12]  P. Newsome,et al.  The Role of a Dedicated Non-Alcoholic Fatty Liver Disease Clinic in 2016 , 2017, Digestive Diseases.

[13]  D. Panagiotakos,et al.  Effects of lifestyle interventions on clinical characteristics of patients with non-alcoholic fatty liver disease: A meta-analysis. , 2017, Metabolism: clinical and experimental.

[14]  T. Vilsbøll,et al.  Semaglutide and Cardiovascular Outcomes in Patients with Type 2 Diabetes. , 2017, The New England journal of medicine.

[15]  Lawrence A Leiter,et al.  Semaglutide and Cardiovascular Outcomes in Patients with Type 2 Diabetes. , 2016, The New England journal of medicine.

[16]  H. Tilg,et al.  EASL-EASD-EASO Clinical Practice Guidelines for the management of non-alcoholic fatty liver disease. , 2016, Journal of hepatology.

[17]  Li-hui Yan,et al.  Assessment of the relationship between non‐alcoholic fatty liver disease and diabetic complications , 2016, Journal of diabetes investigation.

[18]  T. Ohki,et al.  Effectiveness of Ipragliflozin, a Sodium-Glucose Co-transporter 2 Inhibitor, as a Second-line Treatment for Non-Alcoholic Fatty Liver Disease Patients with Type 2 Diabetes Mellitus Who Do Not Respond to Incretin-Based Therapies Including Glucagon-like Peptide-1 Analogs and Dipeptidyl Peptidase-4 Inh , 2016, Clinical Drug Investigation.

[19]  Rachel M. Brown,et al.  Liraglutide safety and efficacy in patients with non-alcoholic steatohepatitis (LEAN): a multicentre, double-blind, randomised, placebo-controlled phase 2 study , 2016, The Lancet.

[20]  European Association for the Study of the Liver,et al.  EASL-EASD-EASO Clinical Practice Guidelines for the Management of Non-Alcoholic Fatty Liver Disease , 2016, Obesity Facts.

[21]  B. Zinman,et al.  Empagliflozin, Cardiovascular Outcomes, and Mortality in Type 2 Diabetes. , 2015, The New England journal of medicine.

[22]  S. Friedman,et al.  Weight Loss Through Lifestyle Modification Significantly Reduces Features of Nonalcoholic Steatohepatitis. , 2015, Gastroenterology.

[23]  E. Bjornsson,et al.  Liver Fibrosis, but No Other Histologic Features, Is Associated With Long-term Outcomes of Patients With Nonalcoholic Fatty Liver Disease. , 2015, Gastroenterology.

[24]  A. Burt,et al.  Evidence of NAFLD progression from steatosis to fibrosing-steatohepatitis using paired biopsies: implications for prognosis and clinical management. , 2015, Journal of hepatology.

[25]  Mats Fredrikson,et al.  Fibrosis stage is the strongest predictor for disease‐specific mortality in NAFLD after up to 33 years of follow‐up , 2015, Hepatology.

[26]  K. Cusi,et al.  High Prevalence of Nonalcoholic Fatty Liver Disease in Patients With Type 2 Diabetes Mellitus and Normal Plasma Aminotransferase Levels. , 2014, The Journal of clinical endocrinology and metabolism.

[27]  M. Rau,et al.  Non-alcoholic fatty liver disease: epidemiology, clinical course, investigation, and treatment. , 2014, Deutsches Arzteblatt international.

[28]  M. Thursz,et al.  Piloting a multidisciplinary clinic for the management of non-alcoholic fatty liver disease: initial 5-year experience , 2013, Frontline Gastroenterology.

[29]  Adrian P Mander,et al.  Primary care referral to a commercial provider for weight loss treatment versus standard care: a randomised controlled trial , 2011, The Lancet.

[30]  A. Baranova,et al.  Systematic review: the epidemiology and natural history of non‐alcoholic fatty liver disease and non‐alcoholic steatohepatitis in adults , 2011, Alimentary pharmacology & therapeutics.

[31]  A. Montgomery,et al.  Diet or diet plus physical activity versus usual care in patients with newly diagnosed type 2 diabetes: the Early ACTID randomised controlled trial , 2011, The Lancet.

[32]  T. Yoshikawa,et al.  Intervention with Delivery of Diabetic Meals Improves Glycemic Control in Patients with Type 2 Diabetes Mellitus , 2007, Journal of clinical biochemistry and nutrition.

[33]  J. Montaner,et al.  Development of a simple noninvasive index to predict significant fibrosis in patients with HIV/HCV coinfection , 2006, Hepatology.

[34]  G. Targher,et al.  Increased prevalence of cardiovascular disease in Type 2 diabetic patients with non‐alcoholic fatty liver disease , 2006, Diabetic medicine : a journal of the British Diabetic Association.

[35]  K. Lundbaek,et al.  European Association for the study of diabetes , 1969, Diabetologia.

[36]  P Johnstone,et al.  Dietary advice for treatment of type 2 diabetes mellitus in adults. , 2007, The Cochrane database of systematic reviews.

[37]  K. Lindor,et al.  Non‐alcoholic fatty liver disease , 2002, Journal of gastroenterology and hepatology.

[38]  B. Neuschwander‐Tetri,et al.  Nonalcoholic steatohepatitis: a proposal for grading and staging the histological lesions , 1999, American Journal of Gastroenterology.