Surfing the MASH Tsunami

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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.

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Late last week, AASLD published new practice guidance on the clinical assessment and management of NAFLD. To explore its key features and implications, the surfers convene with Ken Cusi, who contributed to the previous iteration published in 2018. The updated document reflects the many advances pertinent to any practitioner caring for patients with NAFLD. Notably, and as detailed in this episode, it emphasizes advances in noninvasive risk stratification and therapeutics. The group covers at-depth a range of topics to underscore the basis of progress in the field while offering compelling insights on the emerging path forward in combating Fatty Liver diseases.

Among a plethora of other discussion points unpacked, the panelists expand on the following major themes:

06:21

Roger Green opens by asking Ken to highlight how a Guidance differs from a Guideline. Ken goes on to provide a robust introduction that contextualizes this publication and states "a lot has happened in five years." Jörn Schattenberg and Louise Campbell follow with their initial impressions, each commending what they describe as an excellent framework for moving the field forward. 

15:24

The panelists dive into the guidance’s account of using biomarkers and NITs to either exclude advanced disease or identify those with a high probability of cirrhosis. They focus mainly on the utility of FIB-4 and the dynamics of ALT cut points. Louise comments on the universal importance of including AST and ALT in blood profiles. 

24:01

Conversation shifts toward the impact this guidance may have on patients: will it make a difference and if so, how? Ken outlines options for treating patients today and drives a critical message: “the time is now.” 

31:39

Jörn and Louise discuss what sort of impact the AASLD guidance may have outside of the US. While Jörn notes the utility of this document for developing EASL guidelines, Louise is wary that NICE will remain restricted to referencing data obtained exclusively within the UK. 

38:15

As the session winds down, Roger announces that Ken will be co-hosting a new podcast series with him. The NASH Tsunami in Diabetes: Getting Ahead of the Rising Tide is tailored for healthcare professionals who treat diabetic patients, the patients themselves and their caregivers. Finally, Roger returns to one last question centered around the guidance: how will this shape progress in coming years?


If you enjoy this episode or have questions on the new guidance, we kindly ask that you submit reviews wherever you download our discussions. Alternatively, you can write us directly at [email protected]. We also encourage our audience to explore more on the Rising Tide series before it airs next week. Most important of all, we whole-heartedly thank you for your continued support as we set out to put a major dent in Fatty Liver disease in 2023 and beyond.


Stay safe and surf on!

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The entire Fatty Liver community benefits from NASH Patient Advocacy and the work of our advocates, but relatively few of us understand what advocates do or how we benefit from their work. Leading German patient advocate Achim Kautz and Global Liver Institute Vice President of Policy and Public Affairs Andrew Scott discuss how they came to Fatty Liver patient advocacy, their priorities and activities that support our community, and the unique challenges of their fascinating work.

This conversation From the Vault winds up focusing on two key areas to focus future organizing and advocacy. The first is to think locally. Achim and Andrew point out that they can find success working with local and regional governments and then build up from this success to a national discussion. The second is clear, consistent communication between all stakeholders in the Fatty Liver community and between the community and the payers and government forces we need to persuade.

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If you enjoy these episodes, we kindly ask you to leave a review on your preferred listening platform. We also encourage our audience to write us questions to include your on-ground experiences and ideas in the weekly discourse. Most important of all, we whole-heartedly thank you for the continued support as we set out to put a major dent in Fatty Liver disease in 2023 and beyond. Stay safe and surf on! 

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In an introduction to Fatty Liver in Australia, Louise Campbell is joined by Tony Rahman, Director of Gastroenterology & Hepatology at The Prince Charles Hospital in Brisbane and Adjunct Professor in the College of Medicine and Dentistry at James Cook University.

Louise leads this final conversation by highlighting the prospect of imminent drug approvals in the Fatty Liver space. She asks Tony for impressions on Australia’s positioning to identify its patient population and its ability to distribute limited resources in response to accessing expensive new drugs. Tony describes the approval pathway in Australia and suggests that the ultimate challenge will involve finding what he terms the “hidden cohorts” of patients who would benefit from these drugs. This will take time and money. Louise points to the Predictive Health Intelligence project outlined in S4E5, which sounds promising but will be challenged by Australia’s lack of state-of-the-art electronic records. Tony hopes within the next ten years this can be an area of massive improvement.

The last part of this discussion focuses on the future of Fatty Liver for Australia. Louise asks for what Tony envisions in the next 2-3 years for the field. Tony first highlights optimism around use of semaglutide and other GLP-1s as a major wall of defense. He then looks to the mission of driving education in public health and for hepatology and gastroenterology societies to heavily petition for the fact that NAFLD and NASH is an escalating dilemma in need of addressing now.

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In an introduction to Fatty Liver in Australia, Louise Campbell is joined by Tony Rahman, Director of Gastroenterology & Hepatology at The Prince Charles Hospital in Brisbane and Adjunct Professor in the College of Medicine and Dentistry at James Cook University.

Louise starts this conversation with an anecdote from her experiences in Australia providing virtual clinics to those living 6 to 10 hours drive away from their nearest consultation. She follows with a question to Tony on whether GPs want to buy into NAFLD and NASH in the same way that they responded to successful Hepatitis C programs. Tony replies yes, but alludes to some challenges in doing so. He notes the influence of how a problem and solution are presented has on the uptake of interest and whether the benefits posed are considered worthwhile. He explains that GPs in Australia are paid per patient and time away for education can be perceived as a loss of income. He suggests that rather than solely “bombarding GPs with education,” change will more readily be adopted if there is a robust plan in place. Conducting various environmental tests - even as simple as a GP focus group - considerably improves uptake of a newly introduced initiative. He continues on to describe a traffic light system adopted by the Prince Charles Hospital that utilizes FibroScan to assess the likelihood of a patient to develop liver disease in a given time. Louise comments on the importance of seeking constant refinement in establishing such systems.

Discussion shifts to the topic of guidelines and use of FIB-4 in the primary care setting. Louise asks whether use of FIB-4 is a part of any Australian protocol and, if not, is there any traction for its positioning as a readily available tool for risk stratification. Tony maintains it is making headway along with calculating an AST to Platelet Ratio Index (APRI), a popular measurement in the efforts of moving patients along Hepatitis C treatment. Today, he is wary that GPs who are seeing a large number of patients may not have the time or prioritize making calculations. At this point, Louise points to the idea of joint referrals in light of emerging recommendations from the cardiology community on risk assessment of NAFLD. She notes the combined uptake of FIB-4 and FibroScan as something potentially valuable to an initiative such as Heart of Australia. Tony points out that establishing convincing clarity around the links between Fatty Liver disease and cardiovascular outcomes is conducive to the protocol-led Australian doctors. At the end of the session, Tony illustrates potential challenges in Australia not having a FibroScan medicare billing code and comments on factors which affect accessibility.

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In an introduction to Fatty Liver in Australia, Louise Campbell is joined by Tony Rahman, Director of Gastroenterology & Hepatology at The Prince Charles Hospital in Brisbane and Adjunct Professor in the College of Medicine and Dentistry at James Cook University.

This conversation starts with Louise asking about the prevalence and composition of Australia’s Fatty Liver population. Specifically, she wonders what percent of this group are Aboriginal peoples. Tony suggests that while the data is scarce, an ongoing project on diabetes with James Cook University has recruited a cohort of First Nations patients. Within this cohort, it has been determined that instances of Fatty Liver disease are “moderately high.” He expands focus to the whole of Australia, citing the Australian Institute of Health and Welfare which reports an alarming rise in prevalence. The country is estimated to skyrocket from a quarter of the population having NAFLD to as high as 40% by 2030. Tony casts doubt on the accuracy of these numbers and suggests that prevalence is likely to be much higher already due to rates of obesity.

Louise notes that during her most recent visit to Australia, she found high liver fat in roughly one-third of an 80-person cohort that came from “relatively high socioeconomic background" and considered itself “relatively fit and healthy.” More alarming to her, all of the 9% of patients with elevated liver stiffening were postmenopausal women.

The remainder of the conversation focuses on a program Tony contributes to called Heart of Australia, the country’s first mobile medical program delivering specialist services to regional and remote communities. He explains the inception of the initiative and how he helped to introduce FibroScan as a part of its services. Again, this program focuses on roughly 7 million people - 28% of Australia’s population - who live in rural or remote areas. The session concludes with Louise’s comments on the importance of delivering health care solutions to these populations by expanding accessibility to services and promoting education on liver health.

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In an introduction to Fatty Liver in Australia, Louise Campbell is joined by Tony Rahman, Director of Gastroenterology & Hepatology at The Prince Charles Hospital in Brisbane and Adjunct Professor in the College of Medicine and Dentistry at James Cook University.

This opening conversation starts by following the path that took Tony from his training in London and his Doctor of Philosophy in Medicine from Imperial College to his work in Australia today. Tony asserts that he has been fortunate to be part of a generation which has seen sweeping progress in the treatability of Hepatitis C and goes on to discuss how to apply this experience to the onslaught of liver disease that Australia is grappling with today. An important theme of the extended episode emerges: Australia faces considerable and unique challenges associated with providing for large, rural-based populations. As the subsequent conversations unfold, the duo explore various approaches to serving this community that comprises 7 million people, or around 28% of Australians. In this session, Tony previews telehealth solutions and a traffic light system oriented toward serving this subpopulation. He notes that with these remote measures in place, the patients physically presenting for consultation are distilled to those with progressed Fatty Liver diseases. Finally, an interesting trend is underscored: the alcohol-related cohort is shrinking and the last ten years has paid increasing attention to refining available tools to provide for an alarming surge in NAFLD and NASH. 

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This week on the podcast, Louise Campbell leads the Surf in a one-on-one interview with Tony Rahman on what’s happening for Fatty Liver in Australia. Tony is the Director of Gastroenterology & Hepatology at The Prince Charles Hospital in Brisbane and Adjunct Professor in the College of Medicine and Dentistry at James Cook University. The episode begins with an introduction to Tony's career, outlining a journey of how he became involved in fighting Fatty Liver disease.

Louise leads by investigating the uncertainties around prevalence of NAFLD and NASH in Australia. Not only is it unclear exactly how many people have Fatty Liver there, but also who comprises this total population. Specifically, she wonders what percent of this group are Aboriginal peoples. While his personal experience at one hospital does not lend perspective to this question, Tony points to an ongoing project on diabetes with James Cook University. A considerable cohort of First Nations patients were recruited and it was determined that instances of Fatty Liver disease in this group were “moderately high.” In terms of the whole of Australia, Tony underscores insights from the Australian Institute of Health and Welfare which reports an alarming rise in prevalence. It is estimated that the country will increase from 20-25% of a population with NAFLD to as high as 40% by 2030. Tony casts doubt on the accuracy of the current numbers, suggesting that prevalence is likely to be much higher already due to rates of obesity. He adds that with a broadened definition from NAFLD to MAFLD, the inclusion of those who are not overweight but possess other metabolic risk factors will only surge figures higher yet.

Focus next shifts to a program Tony contributes to called Heart of Australia, the country’s first mobile medical program delivering specialist services to regional and remote communities. He explains the inception of the initiative and how he helped to introduce FibroScan as a part of its services. Around 7 million people - 28% of Australia’s population - live in rural or remote areas. Louise comments on the importance of delivering health care solutions to these populations and expanding accessibility and promoting education. She draws comparison to her own experiences working remotely in Australia to provide virtual clinics to those living 6 to 10 hours drive away from their nearest consultation. When asked whether GPs want to buy into NAFLD and NASH in the same way that they responded to Hepatitis C programs, Tony says yes. He notes the influence of how a problem and solution are presented has on the uptake of interest and whether the benefits posed are considered worthwhile. GPs in Australia are paid per patient and time away for education can be a loss of income. He suggests that rather than solely “bombarding GPs with education,” change will more readily be adopted if there is a robust plan in place. He goes on to explain a traffic light system adopted by the Prince Charles Hospital that utilizes FibroScan to assess the likelihood of a patient to develop liver disease in coming years. The main takeaway: establishing a good model requires refinement.

As the session winds down, they continue on to explore the role of FIB-4 in Australia and the link between Fatty Liver disease and cardiovascular outcomes. This leads to ideas around private versus public sector health care dynamics and creating equitable access to FibroScans. Lastly, Louise and Tony consider the prospect of a drug approval and whether Australia is prepared to identify the patients most in need.

If you enjoy this episode, we kindly ask that you submit a review wherever you download our weekly discourse. Thank you for listening, stay safe and surf on!

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One of the most important challenges facing Fatty Liver stakeholders involves improving early diagnosis for patients with clinically relevant or advanced fibrosis (F2/3). Today, a significant percentage of patients learn they are living with cirrhosis in the Emergency Department during a decompensating event. Four in ten of these patients in the UK do not leave the hospital. In this episode From the Vault,  panelists review a model that Ian Rowe and Richard Parker developed to determine the most cost-effective strategy for F2/3 diagnosis.

As this conversation starts, Louise Campbell notes that John Dillon reported in Barcelona that slightly over half of patients identified as having Fatty Liver via iLFT never returned for their appointments. Ian Rowe points out that this will reduce the costs in the model due to missed diagnoses but questions whether this cost reduction is truly beneficial since missed patient visits translate into non-treatment. More important, he reminds us that iLFT is under constant improvement so that data collected earlier in its lifecycle might not accurately reflect its costs and benefits today.

Upon Roger Green’s invitation for other questions Louise Campbell asks whether “we” (presumably the UK NHS) should do a better job supporting positive diet and exercise activity for healthcare professionals inside the system. On a more serious note, this leads Ian and Louise to focus on the policy issues that can support patients better (particularly those in the workforce). Ian points out that alcohol is issue #1 for many of these patients. He and Louise go on to point out the importance of public policy around things like soda and sweet food advertising in shifting consumers’ focus or craving for bad foods. Roger suggests that this is a two-element issue: stopping advertising for soda and sweets will reduce disease over time but we also need to treat patients who already have developed disease. As he puts it, policy can “put your foot on the hose,” but even if we stop the in-flow of new Fatty Liver and metabolic patients, we still have “the patients in the hose” and they will need therapy.

As a final thought before wrap-up, Ian shares his belief (which Louise also holds) that VCTE might be more effective in causing changes in patient behavior than blood tests, even if they point up the exact same patient need. The difference: feedback from VCTE comes in real-time where patients get face-to-face feedback and respond, whereas bloodwork results comeback to the patient several days later and delivered impersonally.

From here, the group moves to the wrap-up question, which addresses research we should be doing and action steps/changes in behavior we should be promoting.

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Surfing NASH is joined by Tim Jobson, Co-founder of Predictive Health Intelligence, to discuss a system by which historic blood test results are combined and analyzed to flag patients in need of intervention. This wrap-up conversation revisits many of the same themes explored in the preceding sessions: data aggregation, data transparency and patient enthusiasm to name a few. An important note emerges from Roger Green. He suggests that such an enormous initiative does not have to be thought of as exceedingly complicated. Instead, this project could be conceptualized as taking action on the complex task of organizing vast quantities of data. There is a need to account for, align, compute and otherwise use and test the existing data in pursuit of improving patient care.

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To learn more about Tim and Predictive Health Intelligence, be sure to visit their website. If you enjoyed this episode, we kindly ask you to leave a review on your preferred listening platform. We also encourage our audience to write us questions to include your on-ground experiences and ideas in the weekly discourse. Most important of all, we whole-heartedly thank you for the continued support as we set out to put a major dent in Fatty Liver disease in 2023 and beyond.