Use of simple scoring systems for a public health approach in the management of non‐alcoholic fatty liver disease patients

BACKGROUND AND AIM: Advanced fibrosis is the most important predictor of liver‐related mortality in non‐alcoholic fatty liver disease (NAFLD). The aim of this study was to compare the diagnostic performance of noninvasive scoring systems in identifying advanced fibrosis in a Malaysian NAFLD cohort and propose a simplified strategy for the management of NAFLD in a primary care setting. METHODS: We enrolled and reviewed 122 biopsy‐proven NAFLD patients. Advanced fibrosis was defined as fibrosis stages 3–4. Noninvasive assessments included aspartate aminotransferase/alanine aminotransferase (AST/ALT) ratio, AST‐to‐platelet ratio index (APRI), AST/ALT ratio, diabetes (BARD) score, fibrosis‐4 (FIB‐4) score, and NAFLD fibrosis score. RESULTS: FIB‐4 score had the highest area under the receiver operating characteristic curve (AUROC) and negative predictive value (NPV) of 0.86 and 94.3%, respectively, for the diagnosis of advanced fibrosis. FIB‐4 score < 1.3 ruled out advanced fibrosis in 72% of the patients, with 6% being understaged. Further stratification of the indeterminate group patients by other non‐alcoholic steatohepatitis (NASH) clinical predictors, such as abnormal gamma‐glutamyl transpeptidase (GGT) level and presence diabetes mellitus (DM), could further reduce the number of patients who are unlikely to have advanced fibrosis by 52% and 35%, respectively. CONCLUSION: We found that FIB‐4 score outperforms other scoring systems based on AUROC and NPV. The use of a simple scoring system such as FIB‐4 as first‐line triage to risk‐stratify NAFLD patients in the primary care setting, with further stratification of those in the indeterminate group using clinical predictors of NASH, can help in the development of a simplified strategy for a public health approach in the management of NAFLD.