非酒精性脂肪性肝病患者最佳诊疗的风险分层

Risk stratifying non-alcoholic fatty liver disease patients for optimal care

非酒精性脂肪性肝病(NAFLD)影响了全球约30%的成年人口,是肝硬化和肝细胞癌的重要病因。与其他慢性肝病不同,NAFLD大部分由初级保健医师和非肝病专科医师诊治。尽管NAFLD的绝对患病人群数量庞大,但是仅有一小部分患者最终会发生肝病相关并发症。因此,正确选用无创性检查手段、为肝病专科医师及诊治NAFLD患者的其他医师建立一套诊疗路径至关重要。在此背景下,美国胃肠病学会成立了多学科诊疗小组,为识别伴有进展期肝纤维化的NAFLD患者提供临床诊疗路径指导。这条路径包括以下4个关键步骤:①初级保健医师和非肝病专科医师识别高危患者;②根据病史和体格检查进行初步评估;③利用无创性纤维化评分筛选伴进展期纤维化的NAFLD患者;④对无创性纤维化评分后风险不确定的患者进行特异性纤维化测试,如振动控制瞬时弹性成像。本文将阐述这些推荐意见的理论基础,并指出进一步的研究方向和需要改进的领域。

Non-alcoholic fatty liver disease(NAFLD)affects around 30%of the global adult population and is an important cause of cirrhosis and hepatocellular carcinoma.Compared with other chronic liver diseases,NAFLD is mostly seen by primary care physicians and non-hepatologists.Though the absolute number is huge,only a small fraction of patients will eventually develop liver-related complications.Therefore,it is important to use noninvasive tests wisely and develop a care model that involves not only hepatologists but also other colleagues seeing patients with NAFLD.With this background,the American Gastroenterological Association commissioned a multidisciplinary group to provide guidance on a clinical care pathway for identifying patients with advanced liver fibrosis due to NAFLD.The 4 key steps of this pathway include①identifying patients at risk at primary care or non-hepatology settings,②initial assessment with history taking and physical examination,③screening for advanced fibrosis using simple fibrosis score,and④specific fibrosis test such as vibration controlled transient elastography in patients with indeterminate fibrosis scores.This article discusses the rationale of the recommendations and highlights areas needing further data and refinement.