Lisa Richards, MSN, FNP-BC: Using Noninvasive Tests to Identify Fibrosis in MASH

While liver biopsy has long been viewed as the gold standard for histologically diagnosing metabolic dysfunction-associated steatohepatitis (MASH) and fibrosis, several limitations hinder its use in clinical practice. The development of numerous noninvasive tests (NITs) has sharply reduced the need for liver biopsy by allowing for the detection and staging of fibrosis without a liver sample.¹

Among the defining features of MASH, the extent of fibrosis is the strongest predictor of patient mortality and has become the focal point of therapeutic development efforts. Given its significant impact on outcomes, especially at stage 2 and stage 3, and the fact that resmetirom (Rezdiffra), the only currently approved MASH medication, is only indicated for patients with moderate to advanced fibrosis, identifying these at-risk patients and providing them with timely treatment is essential for improving outcomes.^1,2

Lisa Richards, MSN, FNP-BC, associate director of clinical research operations at UC San Diego's NAFLD Research Center, gave a presentation on identifying FIB 2/3 patients with NITs at the 2024 annual Gastroenterology and Hepatology Advanced Practice Providers (GHAPP) conference in National Harbor, Maryland.

“I think the FIB-4 is a routine test that all of us can use in primary care and specialty care because it helps us identify cutoffs where we think the patient is and what other steps need to be done,” Richards told HCPLive.

However, she was careful to note that MASH requires a histological diagnosis. Acknowledging that most patients do not want to get a liver biopsy, Richards explained how she tries to avoid doing them unless it is clinically indicated, instead leaning on a combination of different modalities to determine their risk but recognizing they are not 100% accurate.

Beyond accuracy, Richards described several other limitations to currently available NITs. With FibroScan in particular, she cited the need for patients to be fasting and high rates of failure with BMI > 35, elevated aminotransferases, alcohol use, and ascites.

Richards went on to emphasize the need for different modalities for stratifying patients with imaging that are not impacted by BMI, pointing out obesity is a concern in many patients with MASLD but can limit the accuracy of FibroScan and hinder patients’ ability to go into an MRI machine.

“Noninvasive tests are a great tool for healthcare providers, specifically those that are in GI and hepatology, to rule in or rule out significant disease, advanced disease, and cirrhosis,” Richards said. “None of them are 100%, but you can use them sequentially to help you come up with a diagnosis of significant liver fibrosis or advanced fibrosis or cirrhosis.”

References

1. ^{Wang S, Friedman SL. Found in translation-Fibrosis in metabolic dysfunction-associated steatohepatitis (MASH). Sci Transl Med. 2023;15(716):eadi0759. doi:10.1126/scitranslmed.adi0759}
2. ^{Brooks, A. Resmetirom (Rezdiffra) Receives Historic FDA Approval for Noncirrhotic NASH. HCPLive. March 14, 2024. Accessed September 12, 2024. https://www.hcplive.com/view/resmetirom-rezdiffra-receives-historic-fda-approval-for-noncirrhotic-nash}