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This week, Surfing the NASH Tsunami returns to a subject we have explored from time to time over the past two years: helping patients with cirrhosis. While the immediate stimulus for doing so was the semaglutide late-breaker at #ILC2022, our more general interest is that many patients with cirrhosis will start to decompensate and decline in a fairly short period of time. This conversation focuses on what Roger Green describes as a "pincer movement" in technological development: high-end technology to empower better diagnosis, staging and treatment and low-end technology to capture more patients, capture them earlier in disease and keep them engaged in the process.

The conversation starts with Roger posing a question of whether the major need in improving cirrhosis diagnosis and treatment is a human systems or a medical technology issue. After some conversation, the answer turns out to be "both."

Louise Campbell responds first. She focuses on human systems needs: send the right letter, engage the patient and provide the proper and necessary information to educate the patient and keep them involved. She goes on to note that (i) these needs appear to be global in scope although the challenge takes different forms in different countries; and (ii) for patients with progressive disease, "not feeling worse" is an outcome they will pursue aggressively. 

This observation, coming after earlier discussions about medical treatment issues, leads Roger to make his "pincer movement" comment. Jörn Schattenberg agrees that there is a "disparity" between investment in high-end medical technologies and physician and hospital office systems that rely on older technology and inadequate systems. He states that he considers it important to invest in health structure improvements as well as advancing technologies.

Roger asks Lars what role high-end technologies will play in advancing patient care. Lars suggests that technology's major role will be in driving better decisions about which drugs to develop and how. He goes on to state that advances in clinical practice need to be simple, affordable and practical. The example Lars gives is an effort years ago to persuade Swedish patients with dyslipidemia and cardiovascular disease to focus on Apo B instead of LDL. The task became impossible because, in spite of more compelling data on Apo B, the concept of LDL-lowering as the therapeutic target was so well embedded that it proved impossible to dispel, or even modify meaningfully. 

As this conversation winds down, Roger asks Lars to describe work he is doing that will benefit patients. Lars talks about exploring the effects of cirrhosis on other organ systems, specifically the heart and kidney. Jörn follows up with a question about deploying standard imaging (his example is back pain) to identify previously undiagnosed liver issues. Lars responds by discussing an AI-aided study he is working on with 30,000 patients looking at multi-organ imaging issues using CT. He suggests that in the future, simply having a section of liver in the CT will provide this kind of guidance.