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  • 1. Aims and Scope

    Gut and Liver is an international journal of gastroenterology, focusing on the gastrointestinal tract, liver, biliary tree, pancreas, motility, and neurogastroenterology. Gut atnd Liver delivers up-to-date, authoritative papers on both clinical and research-based topics in gastroenterology. The Journal publishes original articles, case reports, brief communications, letters to the editor and invited review articles in the field of gastroenterology. The Journal is operated by internationally renowned editorial boards and designed to provide a global opportunity to promote academic developments in the field of gastroenterology and hepatology. +MORE

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    Yong Chan Lee Professor of Medicine
    Director, Gastrointestinal Research Laboratory
    Veterans Affairs Medical Center, Univ. California San Francisco
    San Francisco, USA

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    Deputy Editor
    Jong Pil Im Seoul National University College of Medicine, Seoul, Korea
    Robert S. Bresalier University of Texas M. D. Anderson Cancer Center, Houston, USA
    Steven H. Itzkowitz Mount Sinai Medical Center, NY, USA
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    All papers submitted to Gut and Liver are reviewed by the editorial team before being sent out for an external peer review to rule out papers that have low priority, insufficient originality, scientific flaws, or the absence of a message of importance to the readers of the Journal. A decision about these papers will usually be made within two or three weeks.
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Three-Step Algorithm for Screening High-Risk Group of Metabolic Dysfunction-Associated Steatotic Liver Disease in General Population

Joo Hyun Oh1 , Dae Won Jun2,3

1Department of Internal Medicine, Nowon Eulji Medical Center, Eulji University College of Medicine, Seoul, Korea; 2Hanyang Institute of Bioscience and Biotechnology, Hanyang University, Seoul, Korea; 3Department of Internal Medicine, Hanyang University College of Medicine, Seoul, Korea

Correspondence to: Dae Won Jun
ORCID https://orcid.org/0000-0002-2875-6139
E-mail noshin@hanyang.ac.kr

See “Proposal of a Novel Serological Algorithm Combining FIB-4 and Serum M2BPGi for Advanced Fibrosis in Nonalcoholic Fatty Liver Disease” by Sang Yi Moon, et al. on page 283, Vol. 18, No. 2, 2024

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Gut Liver 2024;18(2):197-198. https://doi.org/10.5009/gnl240083

Published online March 15, 2024, Published date March 15, 2024

Copyright © Gut and Liver.

Recently, there has been a shift in the nomenclature of fatty liver disease from nonalcoholic fatty liver disease, which previously excluded other conditions, to steatotic liver disease. This new terminology serves as an umbrella term that acknowledges the coexistence of various diseases. Specifically, the updated term is metabolic dysfunction-associated steatotic liver disease (MASLD). It is reported that the prevalence of MASLD is approximately 30%.1 The unmet need in MASLD disease is to establish an effective linkage-to-care pathway that identifies high-risk groups requiring treatment among MASLD patients and efficiently refers them to specialists.2 Currently, most treatment guidelines recommend a two-step algorithm based on fibrosis index based on four factors (FIB-4), but there are several unresolved issues with this approach.3 First, the FIB-4-based screening test for identifying high-risk groups requires further data into real practice in the general population, particularly in settings with a low prevalence of fibrosis. Recent studies have indicated that the accuracy of the FIB-4-based two-step algorithm conducted in primary care clinics with a low prevalence of advanced hepatic fibrosis was unsatisfactory.4 In the case of FIB-4, while the negative predictive value is relatively high, the sensitivity is somewhat low, leading to a risk of missing a significant number of patients with advanced hepatic fibrosis. When applying FIB-4 to the general population with a low prevalence of advanced hepatic fibrosis, high sensitivity becomes more crucial than a high negative predictive value. To address this, it may be beneficial to consider lowering the cutoff of FIB-4 or integrating additional non-invasive tests (NITs) in the screening process for linkage to care in the general population. Secondly, in FIB-4-based screening, it is recommended that the intermediate to high-risk group be referred to tertiary centers. However, a study conducted based on a health check-up cohort found that the proportion of the intermediate to high-risk group is approximately 30% to 35%.5 Considering that MASLD accounts for approximately 30% of the total population, the estimated number of referred subjects to tertiary centers would be around 9% of the total population. Given the constraints of the national healthcare system, this could lead to an excessive burden on referral centers. Additionally, considering that the positive predictive value in referred patients is less than 7%, there is a need to explore more effective strategies for identifying high-risk groups among MASLD patients in the general population.6

Recently, Moon et al.7 reported in a study that advanced hepatic fibrosis can be predicted more effectively when Mac2 binding protein glycosylation isomer (M2BPGi) is used in conjunction with the FIB-4 test. When considering the high-risk group screening for MASLD algorithm, two key factors must be kept in mind. Firstly, over 80% of MASLD cases are managed in primary care settings. Secondly, to reduce the social burden, it's imperative to not only ensure linkage to care but also minimize unnecessary referral rates. NITs that predict intrahepatic fibrosis using serological biomarkers like M2BPGi and Enhanced Liver Fibrosis score are pivotal for the current FIB-4 and imaging-based three-step algorithm system for several reasons. Firstly, in groups with a low prevalence of advanced hepatic fibrosis, such as the general population, the sensitivity and positive predictive value of FIB-4 are notably low. Therefore, sequential or combined testing of NITs becomes necessary to compensate for this limitation in FIB-4 performance.8 There is currently no data indicating whether the proposed FIB-4 can be directly applied in the general population, where the prevalence of advanced hepatic fibrosis is estimated to be less than 5%. Many previous studies suggest that applying the current FIB-4 cutoff in the general population may be challenging, thus indicating the need for additional NIT tests that can complement it with a lower cutoff. Currently, there are NIT tests based on blood tests and NIT tests based on imaging. In settings requiring mass screening, such as primary care or health check-ups, serological NITs are considered more feasible than image-based testing. Secondly, given that vibration-controlled transient elastography or magnetic resonance elastography is not accessible to most primary care clinics or primary physicians responsible for managing the majority of MASLD patients, the incorporation of additional serological NITs into a 'three-step screening algorithm' is anticipated to mitigate the social burden by reducing unnecessary vibration-controlled transient elastography or magnetic resonance elastography tests and referrals. Moreover, when periodically monitoring the intermediate FIB-4 group in the primary care setting (typically every 1 to 2 years), it is believed that this approach can facilitate timely referrals when warranted.

In conclusion, additional serologic NIT tests such as Enhanced Liver Fibrosis, including M2BPGi, are anticipated to play a crucial role in identifying high-risk patients in the primary care setting, where MASLD patients are primarily managed and treated. Furthermore, the current two-step screening algorithm, primarily based on tertiary centers with a high prevalence of advanced hepatic fibrosis, needs to be customized to regions with a low prevalence of advanced hepatic fibrosis and limited access to medical resources.

This work was supported by the Korea Drug Development Fund funded by the Ministry of Science and ICT, Ministry of Trade, Industry, and Energy, and Ministry of Health and Welfare (RS-2021-DD121073), Republic of Korea.

No potential conflict of interest relevant to this article was reported.

  1. Lee CM, Yoon EL, Kim M, et al. Prevalence, distribution, and hepatic fibrosis burden of the different subtypes of steatotic liver disease in primary care settings. Hepatology. Epub 2023 Nov 1. https://doi.org/10.1097/HEP.0000000000000664
    CrossRef
  2. Yoon EL, Jun DW. Waiting for the changes after the adoption of steatotic liver disease. Clin Mol Hepatol 2023;29:844-850.
    Pubmed KoreaMed CrossRef
  3. Yoo JJ, Kim W, Kim MY, et al. Recent research trends and updates on nonalcoholic fatty liver disease. Clin Mol Hepatol 2019;25:1-11.
    Pubmed KoreaMed CrossRef
  4. Graupera I, Thiele M, Serra-Burriel M, et al. Low accuracy of FIB-4 and NAFLD fibrosis scores for screening for liver fibrosis in the population. Clin Gastroenterol Hepatol 2022;20:2567-2576.
    Pubmed CrossRef
  5. Park H, Yoon EL, Kim M, et al. Comparison of diagnostic performance between FIB-4 and NFS in metabolic-associated fatty liver disease era. Hepatol Res 2022;52:247-254.
    Pubmed CrossRef
  6. Park H, Yoon EL, Kim M, et al. Diagnostic performance of the fibrosis-4 index and the NAFLD fibrosis score for screening at-risk individuals in a health check-up setting. Hepatol Commun 2023;7:e0249.
    CrossRef
  7. Moon SY, Baek YH, Jang SY, et al. Proposal of a novel serological algorithm combining FIB-4 and serum M2BPGi for advanced fibrosis in nonalcoholic fatty liver disease. Gut Liver 2024;18:283-293.
    Pubmed CrossRef
  8. Kim M, Jun DW, Park H, Kang BK, Sumida Y. Sequential combination of FIB-4 followed by M2BPGi enhanced diagnostic performance for advanced hepatic fibrosis in an average risk population. J Clin Med 2020;9:1119.
    Pubmed KoreaMed CrossRef

Article

Editorial

Gut and Liver 2024; 18(2): 197-198

Published online March 15, 2024 https://doi.org/10.5009/gnl240083

Copyright © Gut and Liver.

Three-Step Algorithm for Screening High-Risk Group of Metabolic Dysfunction-Associated Steatotic Liver Disease in General Population

Joo Hyun Oh1 , Dae Won Jun2,3

1Department of Internal Medicine, Nowon Eulji Medical Center, Eulji University College of Medicine, Seoul, Korea; 2Hanyang Institute of Bioscience and Biotechnology, Hanyang University, Seoul, Korea; 3Department of Internal Medicine, Hanyang University College of Medicine, Seoul, Korea

Correspondence to:Dae Won Jun
ORCID https://orcid.org/0000-0002-2875-6139
E-mail noshin@hanyang.ac.kr

See “Proposal of a Novel Serological Algorithm Combining FIB-4 and Serum M2BPGi for Advanced Fibrosis in Nonalcoholic Fatty Liver Disease” by Sang Yi Moon, et al. on page 283, Vol. 18, No. 2, 2024

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Body

Recently, there has been a shift in the nomenclature of fatty liver disease from nonalcoholic fatty liver disease, which previously excluded other conditions, to steatotic liver disease. This new terminology serves as an umbrella term that acknowledges the coexistence of various diseases. Specifically, the updated term is metabolic dysfunction-associated steatotic liver disease (MASLD). It is reported that the prevalence of MASLD is approximately 30%.1 The unmet need in MASLD disease is to establish an effective linkage-to-care pathway that identifies high-risk groups requiring treatment among MASLD patients and efficiently refers them to specialists.2 Currently, most treatment guidelines recommend a two-step algorithm based on fibrosis index based on four factors (FIB-4), but there are several unresolved issues with this approach.3 First, the FIB-4-based screening test for identifying high-risk groups requires further data into real practice in the general population, particularly in settings with a low prevalence of fibrosis. Recent studies have indicated that the accuracy of the FIB-4-based two-step algorithm conducted in primary care clinics with a low prevalence of advanced hepatic fibrosis was unsatisfactory.4 In the case of FIB-4, while the negative predictive value is relatively high, the sensitivity is somewhat low, leading to a risk of missing a significant number of patients with advanced hepatic fibrosis. When applying FIB-4 to the general population with a low prevalence of advanced hepatic fibrosis, high sensitivity becomes more crucial than a high negative predictive value. To address this, it may be beneficial to consider lowering the cutoff of FIB-4 or integrating additional non-invasive tests (NITs) in the screening process for linkage to care in the general population. Secondly, in FIB-4-based screening, it is recommended that the intermediate to high-risk group be referred to tertiary centers. However, a study conducted based on a health check-up cohort found that the proportion of the intermediate to high-risk group is approximately 30% to 35%.5 Considering that MASLD accounts for approximately 30% of the total population, the estimated number of referred subjects to tertiary centers would be around 9% of the total population. Given the constraints of the national healthcare system, this could lead to an excessive burden on referral centers. Additionally, considering that the positive predictive value in referred patients is less than 7%, there is a need to explore more effective strategies for identifying high-risk groups among MASLD patients in the general population.6

Recently, Moon et al.7 reported in a study that advanced hepatic fibrosis can be predicted more effectively when Mac2 binding protein glycosylation isomer (M2BPGi) is used in conjunction with the FIB-4 test. When considering the high-risk group screening for MASLD algorithm, two key factors must be kept in mind. Firstly, over 80% of MASLD cases are managed in primary care settings. Secondly, to reduce the social burden, it's imperative to not only ensure linkage to care but also minimize unnecessary referral rates. NITs that predict intrahepatic fibrosis using serological biomarkers like M2BPGi and Enhanced Liver Fibrosis score are pivotal for the current FIB-4 and imaging-based three-step algorithm system for several reasons. Firstly, in groups with a low prevalence of advanced hepatic fibrosis, such as the general population, the sensitivity and positive predictive value of FIB-4 are notably low. Therefore, sequential or combined testing of NITs becomes necessary to compensate for this limitation in FIB-4 performance.8 There is currently no data indicating whether the proposed FIB-4 can be directly applied in the general population, where the prevalence of advanced hepatic fibrosis is estimated to be less than 5%. Many previous studies suggest that applying the current FIB-4 cutoff in the general population may be challenging, thus indicating the need for additional NIT tests that can complement it with a lower cutoff. Currently, there are NIT tests based on blood tests and NIT tests based on imaging. In settings requiring mass screening, such as primary care or health check-ups, serological NITs are considered more feasible than image-based testing. Secondly, given that vibration-controlled transient elastography or magnetic resonance elastography is not accessible to most primary care clinics or primary physicians responsible for managing the majority of MASLD patients, the incorporation of additional serological NITs into a 'three-step screening algorithm' is anticipated to mitigate the social burden by reducing unnecessary vibration-controlled transient elastography or magnetic resonance elastography tests and referrals. Moreover, when periodically monitoring the intermediate FIB-4 group in the primary care setting (typically every 1 to 2 years), it is believed that this approach can facilitate timely referrals when warranted.

In conclusion, additional serologic NIT tests such as Enhanced Liver Fibrosis, including M2BPGi, are anticipated to play a crucial role in identifying high-risk patients in the primary care setting, where MASLD patients are primarily managed and treated. Furthermore, the current two-step screening algorithm, primarily based on tertiary centers with a high prevalence of advanced hepatic fibrosis, needs to be customized to regions with a low prevalence of advanced hepatic fibrosis and limited access to medical resources.

ACKNOWLEDGEMENTS

This work was supported by the Korea Drug Development Fund funded by the Ministry of Science and ICT, Ministry of Trade, Industry, and Energy, and Ministry of Health and Welfare (RS-2021-DD121073), Republic of Korea.

CONFLICTS OF INTEREST

No potential conflict of interest relevant to this article was reported.

References

  1. Lee CM, Yoon EL, Kim M, et al. Prevalence, distribution, and hepatic fibrosis burden of the different subtypes of steatotic liver disease in primary care settings. Hepatology. Epub 2023 Nov 1. https://doi.org/10.1097/HEP.0000000000000664
    CrossRef
  2. Yoon EL, Jun DW. Waiting for the changes after the adoption of steatotic liver disease. Clin Mol Hepatol 2023;29:844-850.
    Pubmed KoreaMed CrossRef
  3. Yoo JJ, Kim W, Kim MY, et al. Recent research trends and updates on nonalcoholic fatty liver disease. Clin Mol Hepatol 2019;25:1-11.
    Pubmed KoreaMed CrossRef
  4. Graupera I, Thiele M, Serra-Burriel M, et al. Low accuracy of FIB-4 and NAFLD fibrosis scores for screening for liver fibrosis in the population. Clin Gastroenterol Hepatol 2022;20:2567-2576.
    Pubmed CrossRef
  5. Park H, Yoon EL, Kim M, et al. Comparison of diagnostic performance between FIB-4 and NFS in metabolic-associated fatty liver disease era. Hepatol Res 2022;52:247-254.
    Pubmed CrossRef
  6. Park H, Yoon EL, Kim M, et al. Diagnostic performance of the fibrosis-4 index and the NAFLD fibrosis score for screening at-risk individuals in a health check-up setting. Hepatol Commun 2023;7:e0249.
    CrossRef
  7. Moon SY, Baek YH, Jang SY, et al. Proposal of a novel serological algorithm combining FIB-4 and serum M2BPGi for advanced fibrosis in nonalcoholic fatty liver disease. Gut Liver 2024;18:283-293.
    Pubmed CrossRef
  8. Kim M, Jun DW, Park H, Kang BK, Sumida Y. Sequential combination of FIB-4 followed by M2BPGi enhanced diagnostic performance for advanced hepatic fibrosis in an average risk population. J Clin Med 2020;9:1119.
    Pubmed KoreaMed CrossRef
Gut and Liver

Vol.18 No.2
March, 2024

pISSN 1976-2283
eISSN 2005-1212

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