November/December 2021

Assessing Hepatitis and Fatty Liver Disease
By Stephen Harrison, MD
Today’s Geriatric Medicine
Vol. 14 No. 6 P. 14

Noninvasive Screening at the Point of Care

When it comes to addressing. hepatitis C and liver disease, geriatric clinicians should take a “whole-person” approach to patient engagement and support behavioral changes that will lead to better outcomes and higher quality of life.

A large proportion of persons chronically infected with the hepatitis C virus (HCV) in the United States are now about 50 to 70 years old and have lived with HCV infection for roughly 25 to 45 years. The diagnosis of HCV in this group can identify those with long-duration chronic disease who are at risk of the most advanced forms of liver disease.

Geriatric clinicians are well positioned to support patients who may be facing one or more chronic diseases, including HCV, nonalcoholic fatty liver disease (NAFLD)—the accumulation of excess fat in the liver of people who drink little or no alcohol—and its more severe form, nonalcoholic steatohepatitis (NASH).

Nearly one-third of Americans have asymptomatic liver disease, also known as fatty liver disease (FLD), approximately 85 million Americans have NAFLD, and 20% have NASH. Liver disease often leads to the development of other issues, such as advanced fibrosis, cardiovascular events, and, in extreme cases, liver cancer, liver transplantation, and death.

Given the significant impact of advanced liver disease on health and quality of life for older Americans as well as the cost of care, geriatricians should seek innovative ways to identify liver disease earlier to provide effective interventions that help prevent disease progression in patients with these asymptomatic, preventable diseases.

Liver Disease and HCV
More than one-third of HCV-infected individuals progress to develop advanced fibrosis and cirrhosis, and, among those with cirrhosis, about 3% to 5% per year develop decompensated cirrhosis and/or hepatocellular carcinoma.

One study of how NAFLD affects patients with HCV who were treated and cured found that NAFLD identified in patients prior to treatment persisted after their HCV infection was cured. Among those with NAFLD before treatment, 6.25% still had significant liver scarring after the infection was cured.

Millions of Americans who are living with HCV will develop a chronic infection that, if left untreated, can cause serious health problems, including liver disease, cirrhosis, liver failure, and liver cancer. Because people with HCV often have no symptoms, the Centers for Disease Control and Prevention (CDC) recommends that all adults as well as anyone with ongoing risk and certain medical conditions and pregnant women get tested for the disease.

A growing number of geriatric clinicians recognize the important role they can play in educating their patients about the hidden epidemic of HCV, encouraging at-risk individuals to get tested and raising awareness about the nation’s significant and growing FLD epidemic.

NAFLD and Metabolic Syndrome
NAFLD’s comorbid factors, including diabetes and obesity, often indicate potential progression to more serious liver disease. Insulin resistance represents a primary cause of NAFLD and is a major component of metabolic syndrome. The prevalence of metabolic syndrome is increasing worldwide, especially among the elderly. Due to multiple age-related physiologic mechanisms, older adults face increased risk of developing intra-abdominal obesity and metabolic syndrome, including NASH. Metabolic syndrome consists of obesity, insulin resistance, dyslipidemia, and hypertension, leading to increased risk of cardiovascular disease and renal events. Because of this, awareness of metabolic syndrome should be emphasized by geriatric clinicians, who must focus on proactive and preventive efforts.

Aging causes insulin resistance and an increased secretion of proinflammatory cytokines that can subsequently result in metabolic syndrome and type 2 diabetes. NAFLD among older adults is also linked to frailty, multimorbidity, and dementia.

People with NAFLD were found to have higher rates of cancer, with the greatest increase observed for gastrointestinal cancers, according to findings presented at the 2018 AASLD Liver Meeting. These findings suggest that NAFLD related to obesity may be a key driver of the increased risk of cancer. Traditionally, viral hepatitis was assumed the primary factor responsible for rising incidence of liver cancer in the United States. But data from one study suggests that in patients 68 and older, metabolic disease was the most significant and fastest-growing contributor to increasing cancer rates.

Women at Greater Risk
It’s also important for physicians to share information about the higher risk of cirrhosis among female patients, even those who don’t drink or drink a small amount. The risk of developing cirrhosis changes as women age due primarily to underlying liver and autoimmune diseases as well as specific medicine or drug-related issues.

This is a unique trait for women that requires vigilance throughout their entire lives, not only as they get older. When women gain weight, fat accumulates in the liver cells, creating a toxic environment for the liver that can lead to fibrosis, then cirrhosis, and eventually cancer. Fatty liver is quickly becoming the No. 1 reason for liver transplants. Unfortunately, women are more likely than are men to die on the waiting list for a liver transplant and to have acute liver failure.

High Costs of Liver Disease
Ten-year market projections for the direct costs of FLD are estimated to reach more than $1 trillion. One study determined that the mean total annual per patient costs for NASH were $3,306, $5,883, and $6,592 for direct medical, direct nonmedical, and indirect costs, respectively. Costs increased with fibrosis and decompensation, driven by hospitalization and comorbidities, while indirect costs were driven by work loss.

NAFLD without advanced fibrosis has a 1.1% five-year mortality rate, and advanced fibrosis has an 18% mortality rate. NAFLD alone costs on average $19,000 per year, while cirrhosis ranges from $26,000 to $66,000 per year depending on degree of damage.

Impact of Obesity on FLD
The aging population in the United States is expected to more than double by 2050, increasing from 40.2 million to 88.5 million people. In tandem with this increase in elderly individuals is the high prevalence of those who both are older and have obesity. Between 2010 and 2050, the number of Hispanic people 65 years and older will increase from 2.9 million to 17.5 million and the number of non-Hispanic individuals 65 years and older will increase from 37.4 million to 71 million. These numbers of elderly individuals with obesity are also expected to increase as the population ages. Increased longevity does not necessarily mean added years of healthy living, but rather can mean more years of chronic illness.

What’s more, liver disease rates have risen alongside obesity rates in the United States. In 2000, 30.5% of American adults had obesity, meaning they had a body mass index of 30 or higher. That rate increased through 2015–2016, helping to spur related health issues such as diabetes, cardiovascular disease, and some cancers. Recent data from the CDC show that the obesity rate reached 42.4% in 2017–2018—surpassing 40% for the first time.

Obesity has been classified as a chronic disease by several organizations, including the American Medical Association. Obesity is not simply a matter of overeating but rather should be viewed as a complex medical issue that increases the risk of heart disease, diabetes, high blood pressure, and certain cancers.

The CDC defines chronic diseases as conditions that last one year or more and require ongoing medical attention, limit activities of daily living, or both. Of the $3.3 trillion spent annually on medical care for chronic conditions, obesity alone is associated with $1.4 trillion.

Obesity can devastate vital organs, especially the liver, causing insulin resistance that leads to buildup of blood sugar and increases the amount of free fatty acids circulating in the blood and inside the liver cells.

Prevention and Treatment
Fortunately, NAFLD can be reversible if caught in the early stages. Research suggests that weight management is the best approach to controlling or reversing NAFLD. Even a loss of 3% to 5% of body weight can improve liver health. Also, exercise and diet therapy for older adults can reduce the fat accumulation in the liver and improve hyperlipidemia, hypertension, and insulin resistance.

For elderly patients, the identification of advanced fibrosis and cirrhosis is essential for risk factor reductions, medical management, and improvement in daily activities and quality of life.

An optimized treatment strategy for NAFLD requires a multidisciplinary approach. A nonpharmacological approach to treatment, such as diet, proper calorie intake, and physical exercise, should be tailored individually and encompass the physical limitations of most older adults.

Liver Health Exam at the Point of Care
When it comes to addressing HCV and liver disease, geriatric clinicians should take a “whole-person” approach to patient engagement and support behavioral changes that will lead to better outcomes and higher quality of life.

Vibration-controlled transient elastography (VCTE) tools provide rapid results and test scores that are extremely helpful in providing additional information for geriatricians, empowering them with data and information they can use in real time to refer patients to a specialist or recommend changes to their overall care plans, if needed. VCTE tools are covered by Medicare, Medicaid, and many private insurance plans, and can be operated by a medical assistant for immediate interpretation by a health care professional.

Current approaches for identifying fibrotic NASH tend to be complicated, expensive, and potentially wasteful. A recent expert review conducted through the Chronic Liver Disease Foundation suggests a streamlined approach to prevention, diagnosis, and treatment of the disease that is also cost-effective.

It’s also effective to stratify NAFLD/NASH risk in clinical practice. Algorithms that use serum biomarkers offer the strongest evidence for identifying fibrosis in NAFLD. In addition, clinicians can stratify risk in patients with NAFLD using noninvasive tests such as NAFLD Fibrosis Score, Fibrosis-4 Index, or liver stiffness measured by elastography.

Researchers identified VCTE as a helpful direct biomarker of liver stiffness and fat in point of care. Other direct biomarkers include magnetic resonance elastography and ultrasound-based 2-D shear wave elastography, often available in specialist or radiology departments. What’s more, researchers identified combinations of direct biomarkers with circulating blood biomarkers as cost-effective ways to identify the probability of active fibrotic NASH among people suspected of having NAFLD.

The Role of Geriatricians
Geriatric clinicians can leverage a noninvasive tool to quickly provide a quantitative assessment of liver stiffness and liver fat at the point of care to make the detection of liver disease and long-term care for individuals with NAFLD and NASH more effective.

At the point of care, these tools can provide a simple, validated, and reliable exam that creates savings for stakeholders. It does this by early identification of patients with FLD for proactive intervention and behavior change to slow disease progression. For those identified with liver fibrosis, these exams can also reduce the aggregate volume of some current diagnosis methods, such as liver biopsy.

One study found that early identification of patients with FLD through broad placement of VCTE/controlled attenuation parameter (CAP) devices offers cost savings to payers. The scenario testing articulated in the study demonstrated positive net savings within two to three years after device deployment. Across a five-year timespan, researchers estimate net savings up to $2.64 per member per month for Medicare payers and up to $1.91 per member per month for commercial payers. This information is critically important for geriatric physicians and helps them understand how a point of care examination can not only assess, monitor, and help to halt the progression of FLD but also improve the quality of specialist referrals, thus reducing waste from unnecessary and often invasive testing.

The most effective noninvasive liver exam tools are highly mobile and can be operated by a medical assistant and interpreted by the health care professional. They produce numeric measurements rather than images for simplified interpretation and consistency of measurement. This enables clinicians to monitor changes in liver tissue over time. Experts anticipate that rapid tools that provide consistent liver measurements will be used as a routine part of care management.

— Stephen Harrison, MD, a gastroenterologist and hepatologist, is medical director of Pinnacle Clinical Research and a visiting professor of hepatology at the University of Oxford.