Assessing strategies to target screening for advanced liver fibrosis among overweight and obese patients

AIM: The optimal screening strategy for advanced liver fibrosis in overweight and obese patients is unknown. The aim of this study is to compare the performance of different strategies to select patients at high risk of advanced liver fibrosis for screening using non-invasive tools. METHODS: All patients underwent: liver (1)H-MRS and percutaneous liver biopsy (in those with nonalcoholic fatty liver disease [NAFLD]). Unique selection strategies were compared to determine the best screening algorithm: (A) A “metabolic approach”: selecting patients based on HOMA-IR ≥ 3; (B) A “diabetes approach”: selecting only patients with type 2 diabetes; (C) An “imaging approach”: selecting patients with hepatic steatosis based on (1)H-MRS; (D) A “liver biochemistry approach”: selecting patients with elevated ALT (i.e., ≥ 30 IU/L for males and ≥ 19 IU/L for females); and (E) Universal screening of overweight and obese patients. FIB-4 index, NAFLD fibrosis score, and APRI were applied as screening strategies. RESULTS: A total of 275 patients were included in the study. Patients with advanced fibrosis (n = 29) were matched for age, gender, ethnicity, and BMI. Selecting patients by ALT elevation provided the most effective strategy, limiting the false positive rate while maintaining the sensitivity compared to universal screening. Selecting patients by any other strategy did not contribute to increasing the sensitivity of the approach and resulted in more false positive results. CONCLUSION: Universal screening of overweight/obese patients for advanced fibrosis with non-invasive tools is unwarranted, as selection strategies based on elevated ALT levels lead to the same sensitivity with a lower false positive rate (i.e., fewer patients that would require a liver biopsy or referral to hepatology).