Detecting at-risk steatotic liver disease and liver fibrosis in the community

Advanced liver fibrosis and "At-Risk" metabolic dysfunction-associated steatohepatitis (At-Risk MASH) are present in 5% and 10%, respectively, of community-based patients with steatotic liver disease and metabolic risk factors and/or excess alcohol consumption. Identification of these patients is critical to guide prognosis and management due to their increased risk of liver decompensation and HCC. In addition, identification of At-Risk MASH will assist in targeting those eligible for pharmacotherapy. Screening pathways for detecting advanced liver fibrosis, consisting of sequential Fibrosis-4 Index and elastography or direct liver fibrosis biomarkers in patients with clinical risk factors, are recommended; however have suboptimal sensitivity and specificity. Biomarkers based on serum and/or elastography for At-Risk MASH have been developed in specialist centres; however lack broad validation, particularly in the community. Currently a range of barriers have retarded adoption of liver fibrosis screening in primary care, including knowledge gaps regarding non-invasive testing, cost, and limited access of non-invasive tests, and lack of integrated ordering and reporting systems. Once target patients are identified, robust pathways for linkage to specialist care are needed. Despite these challenges, studies performed in primary care have confirmed that liver fibrosis screening programs increase the detection of unrecognized advanced liver disease and may reduce unnecessary specialist referrals. Furthermore, some data suggest that community-based screening of liver fibrosis in patients with metabolic dysfunction and alcohol-associated steatotic liver disease is cost-effective. Widespread implementation of systematic evidence-based diagnostic pathways in the community is needed to reduce liver-related morbidity related to steatotic liver disease.