Nonalcoholic Fatty Liver Disease Underrecognized in Patients at Risk for Advanced Disease

The prevalence of NAFLD continues to increase in the US population and warrants greater disease recognition.

Persistent alanine transaminase (ALT) elevation and nonalcoholic fatty liver disease (NAFLD) are underdiagnosed in the primary care setting, according to study results published in the Journal of Clinical Gastroenterology.

Researchers conducted a retrospective, cross-sectional cohort study across 3 university hospital-based primary care practices in the United States. Study participants had a mean [SD] age of 55.2[13.2] years; 71.2% were women; had a mean body mass index (BMI) of 35.7[5.0] kg/m2; and demonstrated persistent ALT elevation measurements of 40 IU/mL or more at least 6 months apart.

Most patients had dyslipidemia (86.4%), hypertension (81.4%), and some degree of insulin resistance (72.2%) with over half (51.9%) having diagnosed diabetes.

Following calculation of fibrosis-4 (FIB-4) indexes using available electronic medical record data, 17.3% of these patients scored greater than 3.25, indicating high probability of advanced liver fibrosis, while 65.4% scored between 1.45 and 3.25, indicating an indeterminate risk of advanced liver fibrosis. Patients with scores less than 1.45 (12.9%) made up the smallest subgroup who unlikely had advanced liver fibrosis.

When the researchers compared these FIB-4 index scores with provider documentation, documentation referenced diagnosis of fatty liver disease in only 25.8% of the patients, while 43.7% of patients had documented elevated ALT levels, and the medical records for only 7 (2.4%) patients had ICD-10 codes that corresponded to fatty liver disease. Providers referred 50 of the 295 patients (16.9%) for ultrasound imaging to rule out liver fibrosis.

Providers accurately identified 23 of the 51 patients (45.1%) who scored as high risk for advanced liver fibrosis on the FIB-4 index and only 3 (5.9%) of the 51 were referred to see a specialist.

Factors predictive of primary care physician identification of NAFLD included female sex, comorbid dyslipidemia, and private insurance of patients.

“Continued poor recognition of NAFLD in the primary care population, even in those at highest risk of disease progression and complications, highlights the need for added partnerships between subspecialists and first-line medical providers as well as quality improvement initiatives to implement diagnostic care models into clinical practice,” the authors stated. “Primary care providers should be aware prevalence of NAFLD is rising in the US population, and early disease recognition and risk stratification is important to reduce morbidity associated with the disease.”

Study limitations include the retrospective, cross-sectional design and incomplete laboratory data leading to the inability to calculate FIB-4 scores for all patients included in the study.


No JS, Buckholz A, Han C, et al. Identifying high-risk patients with nonalcoholic fatty liver disease: An opportunity for intervention within the primary care setting. J Clin Gastroenterol. Published online October 20, 2022. doi:10.1097/MCG.0000000000001784