The Nara Declaration: A New Collaborative Flow for Chronic Liver Disease Between Primary Care Physicians and...

Chronic liver disease (CLD), including metabolic dysfunction-associated steatotic liver disease (MASLD), has emerged as a major public health concern. As CLD often progresses silently to cirrhosis and hepatocellular carcinoma, early detection and timely intervention are crucial. A significant gap exists between clinical risk perception and low public awareness regarding elevated alanine aminotransferase (ALT) levels. To address this discrepancy, the Japan Society of Hepatology launched the "Nara Declaration," a nationwide initiative promoting a new clinical action: "Consult a primary care physician if ALT level is > 30 U/L." The Nara Declaration proposes a clear clinical pathway. Individuals with ALT > 30 U/L are directed to a primary care physician who assesses the underlying etiology, including viral hepatitis, MASLD, alcohol-related liver disease, or autoimmune liver diseases. For patients with suspected MASLD, physicians utilize the FIB-4 index or platelet count to stratify the risk of advanced fibrosis. Patients identified as high risk are then referred to a gastroenterologist/hepatologist for further evaluation and management. This structured approach is significant, as it establishes a systematic and collaborative framework between primary care physicians and gastroenterologists/hepatologists. This system enables the early detection of CLD and facilitates timely intervention for individuals at risk of disease progression. Accordingly, this declaration has the potential not only to reduce CLD-related mortality and medical costs but also to improve healthy lifespans and social productivity. This special article outlines the Nara Declaration, providing a comprehensive overview. Furthermore, we introduce recent clinical studies that examine the impact of the Nara Declaration.