Performance of American Gastroenterological Association Clinical Care Pathway for the risk stratification of patients with nonalcoholic fatty liver disease in the US population
Abstract
Background and aims: The American Gastroenterological Association (AGA) recently launched the Clinical Care Pathway for the Risk Stratification and Management of Patients with NAFLD to identify adults with significant fibrosis. We aimed to examine this pathway’s performance in the US population. Approach and Results: Using the 2017–2018 National Health and Nutrition Examination Survey data, we identified participants aged ≥18 with available Fibrosis‐4 (FIB‐4) score and liver stiffness measurement (LSM) in the absence of other liver diseases. Based on the AGA clinical pathway, FIB‐4 < 1.3 and LSM < 8 kilopascals (kPa) by vibration‐controlled transient elastography (VCTE) are associated with low risk of significant fibrosis. Using these cutoffs, we examined the pathway performance using negative predictive value (NPV) and positive predictive value (PPV) and explored alternative risk‐stratification strategies. There were 2322 participants with available data (projected to 94.2 million US adults). The NPV of LSM ≥ 8 kPa among those with FIB‐4 < 1.3 was 90%, whereas the PPV among those with FIB‐4 1.3–2.67 was 13%. As diabetes was a strong predictor of fibrosis, we propose a simple, alternative strategy to eliminate the indeterminate FIB‐4 range and perform VCTE in those with FIB‐4 ≥ 1.3 and diabetes. This strategy would decrease the number of VCTEs from 14.5 to 4.9 million and increase PPV from 13% to 33% without compromising the NPV among those who did not undergo VCTE. Conclusion: The implementation of the current AGA clinical pathway would lead to overutilization of VCTE. An alternative strategy using FIB‐4 ≥ 1.3 and diabetes to select adults undergoing second‐line testing will improve this pathway’s performance and minimize unnecessary VCTEs.
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Non-invasive modalities being scrutinized include blood tests such as FIB-4, ELF, and Pro-C3/Pro-C5.
“They range from blood tests based on standard lab parameters such as fibrosis-4 (FIB-4) (292, 293), to proprietary tests such as enhanced liver fibrosis test (ELF) (294) and type III collagen propeptide (Pro-C3)/ type V collagen propeptide (Pro-C5) (295).”
From Found in translation—Fibrosis in metabolic dysfunction–associated steatohepatitis (MASH) (2023) · cites this paper as [292]
Current clinical practice is moving towards multimodality non-invasive diagnostic testing to identify patients at highest risk for advanced fibrosis suitable for trial enrollment or HCC screening.
“Current clinical practice is moving towards the use of multimodality non-invasive diagnostic testing to identify patients at highest risk for advanced fibrosis who may be suitable for either enrollment in a clinical trial or screening for hepatocellular carcinoma (292, 293, 311).”
From Found in translation—Fibrosis in metabolic dysfunction–associated steatohepatitis (MASH) (2023) · cites this paper as [292]
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- Authors
- Udompap, P., Therneau, T. M., Canning, R. E., Benson, J. T., & Allen, A. M.
- Affiliations
- Mayo Clinic (US)
- Corresponding author
- Allen, Alina M.
- Venue
- Hepatology
- Published
- 2023-02-17
- Volume
- 77
- Issue
- 3
- Pages
- 931-941
- ISSN
- 0270-9139 (ISSN-L)
- OpenAlex
- W4292560094
- Cited by
- 37
- References
- 23
- Citations by year
- 2026: 5 · 2025: 13 · 2024: 9 · 2023: 10
- FWCI
- 5.78
- Type
- journal article
- Language
- en
- Open access
- closed
- Licence
- Locations
- Hepatology (publishedVersion)
- PubMed (publishedVersion)
- Funders
- National Institute of Diabetes and Digestive and Kidney Diseases (R03DK128127, K23DK115594)
- Topics
- Health Sciences › Medicine › Epidemiology › Liver Disease Diagnosis and Treatment
- Health Sciences › Medicine › Hepatology › Liver Diseases and Immunity
- Health Sciences › Medicine › Hepatology › Liver Disease and Transplantation
- Keywords
- non-alcoholic fatty liver disease, liver fibrosis, risk stratification, Fibrosis-4 score, vibration-controlled transient elastography, liver stiffness measurement, diabetes mellitus, predictive value
- MeSH terms
- Adult, Biopsy, Diabetes Mellitus, Fibrosis, Humans, Liver, Liver Cirrhosis, Nutrition Surveys, Prospective Studies, Severity of Illness Index, United States, Risk Assessment, Critical Pathways, Elasticity Imaging Techniques, Non-alcoholic Fatty Liver Disease
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