January 25, 2018 - A new Practice Guideline and Practice Guidance in Hepatology will
help improve the diagnosis and treatment of patients with liver cancer as well as
patients with non-alcoholic fatty liver disease (NAFLD), which can lead to liver cancer
and is characterized by the build-up of extra fat in liver cells often due to obesity
and diabetes.
Around the globe, there is an increasing burden of NAFLD and liver cancer, or hepatocellular
carcinoma (HCC). A guidance document developed by a panel of experts to help clinicians
understand and implement the most recent evidence related to NAFLD was commissioned
by the American Association for the Study of Liver Diseases (AASLD). As an update
to the Practice Guideline published in 2012 in conjunction with the American Gastroenterology
Association and the American College of Gastroenterology, it provides more details
about the value of lifestyle modification as a treatment of NAFLD and offers additional
guidance concerning when to consider weight-loss surgery.
“Regarding diagnosis, this document provides guidance to clinicians with up-to-date
information about working up individuals with suspected NAFLD, including when to consider
liver biopsy. It also elaborates non-invasive tests for NAFLD,” said lead author Naga
Chalasani, MD, FAASLD, of the Indiana University School of Medicine. “Over the past
5 years since the 2012 Guideline, there have been important developments in our understanding
related to noninvasive assessment with vibration controlled transient elastography
and magnetic resonance elastography.”
Experts present official recommendations of the AASLD on the surveillance, diagnosis,
and treatment of HCC in an updated Practice Guideline. The guideline focuses on a
broad spectrum of clinical practice, including surveillance of patients with cirrhosis
(or liver scarring) for HCC, establishing the diagnosis of HCC, and various therapeutic
options for the treatment of HCC. The current guideline was developed in compliance
with the Institute of Medicine standards for trustworthy practice guidelines using
the Grading of Recommendation Assessment, Development and Evaluation (GRADE) approach.
Multiple systematic reviews of the literature were conducted to support the recommendations
in this practice guideline. An enhanced understanding of the guidelines can be obtained
by reading the applicable portions of the systematic reviews.
“The updated HCC guideline is really focused on screening, diagnosis, and treatment
of HCC. Our writing group worked to identify and address the most important clinical
questions using what’s called the Grading of Recommendation Assessment, Development
and Evaluation (or GRADE) approach with systematic reviews to answer these key questions,”
said lead author Julie Heimbach, MD, of the Mayo Clinic, in Rochester, MN. “When compared
with the previous guideline, notable changes include a surveillance guideline to recommend
ultrasound plus alpha-fetoprotein—a standard tumor marker for HCC—instead of ultrasound
alone, as well as the incorporation of recent studies for HCC informing the role of
liver-directed therapies and newer systemic therapies-lenvatinib, regorafenib, and
nivolumab.”
The three new systematic reviews were performed to provide the evidence base to attempt
to answer some of the key questions addressed in the new HCC guideline. One investigates
the available evidence on the optimal imaging for the diagnosis of HCC. Another analyzes
the published data on treatments for advanced stage HCC, while the final new systematic
review focuses on the evidence supporting the use of bridging therapies for waitlisted
liver transplant candidates with HCC.
Full citation: Chalasani, N., Younossi, Z., Lavine, J. E., Charlton, M., Cusi, K.,
Rinella, M., Harrison, S. A., Brunt, E. M. and Sanyal, A. J. (2018), The diagnosis
and management of nonalcoholic fatty liver disease: Practice guidance from the American
Association for the Study of Liver Diseases. Hepatology, 67: 328-357. doi:10.1002/hep.29367
Copyright © 2018 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.,
reproduced with permission.