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Late last week, AASLD published new practice guidance on the clinical assessment and management of NAFLD. The Surfers convene with Ken Cusi, who contributed to the previous iteration published in 2018, to explore its key features and implications. The updated document reflects the many advances pertinent to any practitioner caring for patients with NAFLD. This conversation introduces differentiating factors which define a Guidance document versus Guidelines.

The conversation starts with Ken introducing the new guidance by placing it in the context of the last five years of thinking about screening and treatment of Fatty Liver patients. He highlights significant events including both let downs in terms of drug development and the emerging optimism surrounding new candidates in the NASH therapeutics pipeline. He notes that this guidance offers an affirmative consensus on the screening of patients with Type 2 diabetes - a contentious topic for the committee Ken participated in formulating the preceding guidance. In this initial high-level overview it already becomes evident that the new practice guidance is comprehensive in a myriad of applications, presaging it to be a highly effective resource.

Jörn Schattenberg joins to voice his initial impression and suggests this document offers an excellent viewpoint as to how the field is moving forward. He points to Table 7 - a summary of key concepts to guide clinical practice - as a particularly comprehensive point of reference for the latest recommendations. Roger Green also commends Table 7, highlighting four bullet points embedded which are dubbed Pearls for the assessment of NAFLD: 

• Aminotransferase levels are frequently normal in patients with advanced liver disease due to NASH and should not be used in isolation to exclude the presence of NASH with clinically significant fibrosis.
• Normative values for ALT reported by most laboratories exceed what is considered a true normal. As a general rule, ALT >30 U/L should be considered abnormal.
• Although standard ultrasound can detect hepatic steatosis, it is not recommended as a tool to identify hepatic steatosis due to low sensitivity across the NAFLD spectrum.
• CAP as a point-of-care technique may be used to identify steatosis. MRI-PDFF can additionally quantify steatosis. 

Ken notes that this document will “rectify some confusion from past guidelines." Specifically, it holds special value for primary care professionals who may not be familiar with the field but whose role is expected to grow dramatically over time. One key point: the role of front-line treaters will not be simply to screen for fat in the liver, but to identify patients in high-risk subgroups with clinically significant fibrosis. He notes that we can support these patients today through a combination of lifestyle interventions and currently available anti-obesity and diabetic medications.

As the session winds down, Jörn previews more detailed discourse around follow-up data on NITs and how best to establish evidence for progressing patients. Lastly, Louise Campbell adds her ideas on using this document to further support and develop local pathways and areas of care. In example, she would like to see updated guidelines from NICE following access to FibroScan in the community setting.