Primary Care Management of Patients With NAFLD

The human liver shown in stages of liver disease.
Clinicians debated whether it would be appropriate to screen for NAFLD in a primary care setting, how to monitor NAFLD, and the recommended interventions for managing NAFLD.

Currently in the United States, nonalcoholic fatty liver disease (NAFLD) is present in approximately one third of the adult population. In a report in the Annals of Internal Medicine, clinicians Dr Gordon Jiang and Dr Elliot Tapper discussed the application of the recently updated screening guidelines for NAFLD, which were published by the American Association for the Study of Liver Diseases. Through the example of a case study, the clinicians debated whether it would be appropriate to screen for NAFLD in a primary care setting, how to monitor NAFLD, and the recommended interventions for managing NAFLD. 

The case in question involved the care of a 59-year-old patient, Mr L, with presumptive NAFLD by way of increased hepatic aminotransferase levels. He displayed no symptoms of hepatic disease. Notably, Mr L had normal vital signs and normal hemoglobin A1C  and ferritin levels, but had a BMI of 28.6 kg/m². Mr L was further found to have a benign abdomen and a diffusely echogenic liver. He was also found negative for both hepatitis B and C viruses. His medical history included hypertension, seasonal allergies, insomnia, and variable hypercholesterolemia.

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Dr Jiang recommended that screening for NAFLD in the primary care setting should focus on evaluating the hepatic fibrosis progression in at-risk patients, preferably with non-invasive techniques. In the case of Mr L, who is overweight and has metabolic syndrome but lacks significant fibrosis, Dr Jiang recommended confirming a lack of fibrosis progression via vibration-controlled transient elastography (VCTE) on an annual basis. Dr Jiang further recommended Mr L reduce alcohol intake, drink coffee without sugar, follow a low-sugar and low-carbohydrate diet, and start exercising; in addition, statin therapy could also be used to manage hypercholesterolemia.

Whereas screening for NAFLD itself adds limited value in the primary care setting, Dr Tapper recommended screening only patients with diabetes for advanced fibrosis using the Fibrosis-4 index followed by VCTE to track progression. Because Mr L presented with a low Fibrosis-4 index score during his initial evaluation, and his VCTE results 10 years later confirmed a lack of disease progression, Dr Tapper indicated that no additional monitoring was needed. Furthermore, Dr Tapper suggested that Mr L should consider tailored interventions facilitating weight loss and exercise, and should limit alcohol consumption.

Disclosure: One study author declared affiliations with the pharmaceutical industry. Please see the original reference for a full list of authors’ disclosures.


Libman H, Jiang G, Tapper EB, Reynolds EE. How would you manage this patient with nonalcoholic fatty liver disease?: grand rounds discussion from Beth Israel Deaconess Medical CenterAnn Intern Med. 2019;171:199-207.