Referral pathways for NAFLD fibrosis in primary care – No longer a ‘needle in a haystack’

Non-alcoholic fatty liver disease (NAFLD) is the commonest form of liver disease in primary care, with rates up to 25%.1 This figure, however, encompasses the whole spectrum of NAFLD from simple steatosis, non-alcoholic steatohepatitis (NASH) through to advanced fibrosis/cirrhosis. Due to the strong associ-ation with liver-related morbidity and premature death,2,3 fibrosis has become the main focus in secondary care for risk stratification, targeted lifestyle and metabolic risk management and drug trial recruitment. Indeed, all recent liver guidelines (EASL-EASD-EASO,4 AASLD,5 BSG,6 NICE)7 are in agreement in recommending screening for advanced fibrosis (histological stage Kleiner F3-4) in patients diagnosed with NAFLD. The man-agement of patients with NAFLD in primary care, however, lacks consistency and is ad hoc, with an excess dependence on sec-ondary care liver services, for what is in the majority a bystan-der to obesity and diabetes. In the absence of established diagnostic pathways, identification of patients at risk of liver disease progression in primary care is very challenging and is compounded by the fact that only 1 in 20 patients with NAFLD have advanced fibrosis/cirrhosis in this setting.8