Management of Advanced Liver Fibrosis

Understanding CAP Score and Fibrosis Assessment

• A CAP score of 267 indicates moderate steatosis, which puts the patient at increased risk for developing progressive fibrosis 1
• CAP alone does not measure fibrosis; liver stiffness measurement (LSM) from the FibroScan is needed to assess fibrosis stage 2, 1
• Advancing liver fibrosis is the key predictor of liver-related events and mortality in patients with fatty liver disease 2
• Patients with advanced fibrosis and cirrhosis are at increased risk of complications, decompensation, liver transplantation, and death 2

Recommended Management Algorithm

Step 1: Complete Fibrosis Assessment

• Review the liver stiffness measurement (LSM) from the FibroScan, which should have been performed alongside the CAP measurement 2, 1
• Calculate FIB-4 index and NAFLD Fibrosis Score (NFS) as complementary assessments 2, 3
  • FIB-4 = Age (years) × AST [U/L] / (platelets [10^9/L] × (ALT [U/L])^1/2) 4
  • Low risk: FIB-4 < 1.3 (< 2.0 if over 65 years) 2, 4
  • High risk: FIB-4 > 2.67 4

Step 2: Risk Stratification Based on Fibrosis Assessment

• Low risk for advanced fibrosis:
  • LSM < 8.0 kPa on FibroScan AND 1
  • FIB-4 < 1.3 (or < 2.0 if over 65 years) OR NFS < -1.455 (or < 0.12 if over 65 years) 1
  • Management: Primary care follow-up with lifestyle modifications and metabolic risk factor management 2
• Intermediate risk:
  • LSM 8.0-10.0 kPa OR 1
  • FIB-4 between 1.3-2.67 OR NFS between -1.455 and 0.676 3
  • Management: Consider additional testing such as ELF test or referral to hepatology 2
• High risk for advanced fibrosis:
  • LSM > 10.0 kPa OR 1
  • FIB-4 > 2.67 OR NFS > 0.676 3
  • Management: Refer to hepatologist for specialized care 1

Step 3: Management Based on Risk Level

For Low Risk Patients:

• Implement lifestyle modifications focusing on weight loss (7-10% of body weight) 2, 3
• Manage metabolic risk factors (diabetes, hypertension, dyslipidemia) 3
• Repeat fibrosis assessment in 2-3 years 1

For Intermediate Risk Patients:

• Consider additional testing with ELF test 2, 6
  • ELF < 9.8: Monitor with primary care 6
  • ELF ≥ 9.8: Refer to hepatology 6
• If ELF testing unavailable, consider referral to hepatology for further evaluation 2

For High Risk Patients:

• Refer to hepatologist for specialized care 2, 3
• Consider liver biopsy if non-invasive tests are discordant or to confirm the diagnosis 3, 7
• Implement aggressive management of metabolic risk factors 3
• Screen for complications of advanced liver disease 3

Important Considerations and Pitfalls

• Non-invasive tests have limitations in certain populations:
  • FIB-4 and NFS have not been validated in patients under 35 years of age 2
  • FibroScan has limitations in patients with severe obesity, narrow intercostal spaces, or ascites 1
• When using FibroScan results, ensure:
  • ≥10 successful measurements were obtained 1
  • Success rate is at least 60% 1
  • Interquartile range is less than 30% of median value 1
• If FibroScan results and serological markers are discordant, consider:
  • Additional testing with other modalities (MRE if available) 7
  • Referral to hepatology for further evaluation 7
  • Liver biopsy in selected cases 7
• For patients with ELF scores between 9.2-10.4, additional non-invasive tests should be performed to confirm the likelihood of stage 2-3 fibrosis 8, 6
• Patients with LSM > 15 kPa may have cirrhosis and require different management approaches 8, 6