Piloting a Multidisciplinary Clinic to Manage NAFLD
Objective A multidisciplinary approach is advocated for the management of Non-Alcoholic Fatty Liver Disease (NAFLD), but few clinical data exist to support this. The objective of this study was to investigate the effectiveness of a multidisciplinary NAFLD clinic using surrogate markers of liver injury and cardiovascular risk.
Design Retrospective survey of clinical practice.
Setting The multidisciplinary NAFLD clinic in a secondary/tertiary care setting with hepatology, diabetology, dietetic and exercise therapy input: initial 5-years' experience (2007–2012).
Patients 180 patients with NAFLD but without hepatic comorbidities were followed up for a median of 19.5 (range 3–57) months. 52% had type 2 diabetes mellitus, 48% were Europoid Caucasian, 17% were South Asian.
Interventions Multiple clinical interventions were employed including lifestyle (diet and exercise) advice, pharmacological intervention for cardiovascular risk factors, weight loss and exercise therapy.
Main outcome measures Change in alanine aminotransferase (ALT), weight, HbA1c, lipid profile and blood pressure.
Results Median ALT fell from 61 (12–270) U/l to 50 (11–221) U/l, −18%, p<0.001, and weight fell from 90.5 (42.7–175.0) kg to 87.3 (45.9–175.3) kg, −3.5%, p<0.001. There were significant improvements in total cholesterol overall, triglycerides (among dyslipidaemic patients), HbA1c (among diabetic patients) and systolic blood pressure (among hypertensive patients). 24% of patients achieved ≥7% weight loss during follow-up and 17% maintained this weight loss throughout.
Conclusions Improvement in liver biochemistry and cardiovascular risk factors was seen in patients attending the multidisciplinary NAFLD clinic. Refinement of this approach is warranted in light of these data, novel therapies and a growing evidence base.
Non-alcoholic fatty liver disease (NAFLD) is a burgeoning public health problem, associated with the global epidemic of obesity and type 2 diabetes mellitus (DM). Estimates of prevalence depend on case definition and the populations studied, but exceed 20% in many adult populations. A proportion have non-alcoholic steatohepatitis (NASH) with or without advanced fibrosis which is associated with increased liver-related, and cardiovascular morbidity and mortality, related to the development of the chronic liver disease and association with the metabolic syndrome of abdominal obesity, insulin resistance or type 2 DM, dyslipidaemia and hypertension. An increasing proportion of liver transplantation in the USA and Europe is carried out as a result of NAFLD/NASH, and while the rate of disease progression is relatively slow, global trends in DM and obesity mean that the impact of NAFLD/NASH is set to increase.
Current therapy aims to optimise both cardiovascular and liver-related risk factors as there is no recognised direct pharmacological therapy to address all aspects of the disease. Lifestyle changes driven by dietary intervention and exercise are the first line of therapy to induce and maintain weight loss, with the aim of reducing fat mass, hyperinsulinaemia and insulin resistance, thus decreasing lipotoxic liver damage and multisystem metabolic consequences. Pharmacological therapy is predominantly aimed at reducing cardiovascular risk, but there is evidence that both vitamin E and pioglitazone improve biochemical and histological endpoints. Numerous longitudinal studies have demonstrated the benefit of lifestyle interventions on surrogate endpoints, such as liver biochemistry, hepatic lipid assessed by magnetic resonance techniques, and confirmed in a randomised controlled trial using histological endpoints. A multidisciplinary, personalised approach is advocated to achieve these goals, although evidence to support this is limited. Real clinical data are required to establish a benchmark of current clinical practice to which other interventions may be compared.
The multidisciplinary, personalised approach to managing NAFLD/NASH has been adopted since 2007 in a secondary/tertiary care setting (Imperial College Healthcare NHS Trust). This clinic aims to provide a holistic and patient-centred approach, involving diagnosis, staging, lifestyle intervention (diet and exercise), treatment of metabolic, cardiovascular risk factors and resultant liver disease.
Thus, the aim of this study was to investigate the effectiveness of the multidisciplinary NAFLD clinic through the assessment of surrogate markers of liver injury and cardiovascular risk.
Abstract and Introduction
Abstract
Objective A multidisciplinary approach is advocated for the management of Non-Alcoholic Fatty Liver Disease (NAFLD), but few clinical data exist to support this. The objective of this study was to investigate the effectiveness of a multidisciplinary NAFLD clinic using surrogate markers of liver injury and cardiovascular risk.
Design Retrospective survey of clinical practice.
Setting The multidisciplinary NAFLD clinic in a secondary/tertiary care setting with hepatology, diabetology, dietetic and exercise therapy input: initial 5-years' experience (2007–2012).
Patients 180 patients with NAFLD but without hepatic comorbidities were followed up for a median of 19.5 (range 3–57) months. 52% had type 2 diabetes mellitus, 48% were Europoid Caucasian, 17% were South Asian.
Interventions Multiple clinical interventions were employed including lifestyle (diet and exercise) advice, pharmacological intervention for cardiovascular risk factors, weight loss and exercise therapy.
Main outcome measures Change in alanine aminotransferase (ALT), weight, HbA1c, lipid profile and blood pressure.
Results Median ALT fell from 61 (12–270) U/l to 50 (11–221) U/l, −18%, p<0.001, and weight fell from 90.5 (42.7–175.0) kg to 87.3 (45.9–175.3) kg, −3.5%, p<0.001. There were significant improvements in total cholesterol overall, triglycerides (among dyslipidaemic patients), HbA1c (among diabetic patients) and systolic blood pressure (among hypertensive patients). 24% of patients achieved ≥7% weight loss during follow-up and 17% maintained this weight loss throughout.
Conclusions Improvement in liver biochemistry and cardiovascular risk factors was seen in patients attending the multidisciplinary NAFLD clinic. Refinement of this approach is warranted in light of these data, novel therapies and a growing evidence base.
Introduction
Non-alcoholic fatty liver disease (NAFLD) is a burgeoning public health problem, associated with the global epidemic of obesity and type 2 diabetes mellitus (DM). Estimates of prevalence depend on case definition and the populations studied, but exceed 20% in many adult populations. A proportion have non-alcoholic steatohepatitis (NASH) with or without advanced fibrosis which is associated with increased liver-related, and cardiovascular morbidity and mortality, related to the development of the chronic liver disease and association with the metabolic syndrome of abdominal obesity, insulin resistance or type 2 DM, dyslipidaemia and hypertension. An increasing proportion of liver transplantation in the USA and Europe is carried out as a result of NAFLD/NASH, and while the rate of disease progression is relatively slow, global trends in DM and obesity mean that the impact of NAFLD/NASH is set to increase.
Current therapy aims to optimise both cardiovascular and liver-related risk factors as there is no recognised direct pharmacological therapy to address all aspects of the disease. Lifestyle changes driven by dietary intervention and exercise are the first line of therapy to induce and maintain weight loss, with the aim of reducing fat mass, hyperinsulinaemia and insulin resistance, thus decreasing lipotoxic liver damage and multisystem metabolic consequences. Pharmacological therapy is predominantly aimed at reducing cardiovascular risk, but there is evidence that both vitamin E and pioglitazone improve biochemical and histological endpoints. Numerous longitudinal studies have demonstrated the benefit of lifestyle interventions on surrogate endpoints, such as liver biochemistry, hepatic lipid assessed by magnetic resonance techniques, and confirmed in a randomised controlled trial using histological endpoints. A multidisciplinary, personalised approach is advocated to achieve these goals, although evidence to support this is limited. Real clinical data are required to establish a benchmark of current clinical practice to which other interventions may be compared.
The multidisciplinary, personalised approach to managing NAFLD/NASH has been adopted since 2007 in a secondary/tertiary care setting (Imperial College Healthcare NHS Trust). This clinic aims to provide a holistic and patient-centred approach, involving diagnosis, staging, lifestyle intervention (diet and exercise), treatment of metabolic, cardiovascular risk factors and resultant liver disease.
Thus, the aim of this study was to investigate the effectiveness of the multidisciplinary NAFLD clinic through the assessment of surrogate markers of liver injury and cardiovascular risk.
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