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DOI: 10.1055/a-1957-5671
Intersektorales Management von Patienten mit unklarer Leberwerterhöhung und nichtalkoholischer Fettlebererkrankung (NAFLD)
Intersectoral management of patients with abnormal liver enzymes and non-alcoholic fatty liver disease (NAFLD)Supported by: Ministerium für Wissenschaft, Forschung und Kunst Baden-Württemberg: Klinische Kooperationseinheit Healthy Metabolism, Medizinische Fakultät Mannheim, Universität Heidelberg, Mannheim
Zusammenfassung
Die Prävalenz der Fettlebererkrankung hat in den letzten Jahren auch in Deutschland erheblich zugenommen. Sie gehört mit geschätzten 18 Mio. betroffenen Bundesbürgern mittlerweile zu den großen Volkskrankheiten. Sie gilt ferner als ein relevanter unabhängiger Risikofaktor für weitere kardiovaskuläre Volkskrankheiten wie Herzinfarkt oder Schlaganfall. Schließlich begünstigt ein Diabetes mellitus die Entstehung einer Fettleber und eines ungünstigeren Verlaufs der Fettlebererkrankung. Vor dem Hintergrund der hohen Prävalenz und Komplikationen kommt das deutsche Gesundheitssystem bei der Versorgung dieser Patienten an die Grenzen seiner Ressourcen.
Daher ist eine enge Abstimmung und Vernetzung aller an der Behandlung dieser Patienten beteiligten Fachgebiete und Versorgungsbereiche essenziell notwendig. In einem Expertenkonsensus unter Einbindung niedergelassener Kollegen und Krankenhausärzten der Gastroenterologie, Endokrinologie, Kardiologie, Hausärzten und Labormedizinern sowie in enger Abstimmung mit Patientenvertretern haben wir ein Konzept der Versorgung dieser Patienten im deutschen Gesundheitssystem entworfen. Darin werden auch notwendige Entwicklungen adressiert. Neben dem Nutzen als praxisnahem Leitfaden soll dies auch die gesundheitspolitische Arbeit unterstützen, insbesondere bei der Erarbeitung von praktischen Versorgungslösungen auf medizinischer Ebene.
Abstract
The prevalence of fatty liver disease has increased significantly in Germany in recent years. With an estimated 18 million German citizens being affected, it is now among the most prevalent diseases. Furthermore, it is also considered a relevant and independent risk factor for other common cardiovascular diseases such as heart attack or stroke. Finally, diabetes mellitus promotes the development of and an unfavorable course of fatty liver disease. Given the high prevalence and complications, the German healthcare system is reaching its limits.
Therefore, close coordination of all healthcare providers and specialists involved in the treatment of these patients is essential. In an expert consensus involving private practice and hospital doctors from the fields of gastroenterology, endocrinology, cardiology, general practitioners and laboratory physicians, as well as in close coordination with patient representatives, we have designed a concept for the care of these patients in the German healthcare system. Necessary developments are also addressed. In addition to being useful as a practical guideline, this should also support health policy work, especially in the development of practical care solutions at the medical level.
Schlüsselwörter
Fettleber - NAFLD - NASH - Diabetes - Übergewicht - Adipositas - Konsensus - LeitliniePublication History
Received: 15 March 2022
Accepted after revision: 22 August 2022
Article published online:
15 February 2023
© 2023. The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial-License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. (https://creativecommons.org/licenses/by-nc-nd/4.0/).
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Literature
- 1 Estes C, Anstee QM, Arias-Loste MT. et al. Modeling NAFLD disease burden in China, France, Germany, Italy, Japan, Spain, United Kingdom, and United States for the period 2016–2030. J Hepatol 2018; 69: 896-904
- 2 Cusi K. Treatment of patients with type 2 diabetes and non-alcoholic fatty liver disease: current approaches and future directions. Diabetologia 2016; 59: 1112-1120
- 3 Ballestri S, Zona S, Targher G. et al. Nonalcoholic fatty liver disease is associated with an almost twofold increased risk of incident type 2 diabetes and metabolic syndrome. Evidence from a systematic review and meta-analysis. J Gastroenterol Hepatol 2016; 31: 936-944
- 4 Pennisi G, Celsa C, Giammanco A. et al. The Burden of Hepatocellular Carcinoma in Non-Alcoholic Fatty Liver Disease: Screening Issue and Future Perspectives. Int J Mol Sci 2019; 20
- 5 Pimpin L, Cortez-Pinto H. et al. Burden of liver disease in Europe: Epidemiology and analysis of risk factors to identify prevention policies. J Hepatol 2018; 69: 718-735
- 6 Huber Y, Schulz A, Schmidtmann I. et al. Prevalence and Risk Factors of Advanced Liver Fibrosis in a Population-Based Study in Germany. Hepatol Commun 2022;
- 7 Canbay A, Kachru N, Haas JS. et al. Healthcare resource utilization and costs among nonalcoholic fatty liver disease patients in Germany. Ann Transl Med 2021; 9: 615
- 8 Luxon BA. So you want to be a hepatologist?. Gastroenterology 2013; 145: 1182-1185
- 9 Younossi Z, Tacke F, Arrese M. et al. Global Perspectives on Nonalcoholic Fatty Liver Disease and Nonalcoholic Steatohepatitis. Hepatology 2019; 69: 2672-2682
- 10 Alsenbesy M, Rau M, Weiss J. et al. A 2-step fast-track elastometry service for advanced workup of nonalcoholic fatty liver disease (NAFLD) patients – single-center real-world experience of outpatient clinical practice. Z Gastroenterol 2019; 57: 1209-1217
- 11 Canbay A, Kachru N, Haas JS. et al. Patterns and predictors of mortality and disease progression among patients with non-alcoholic fatty liver disease. Aliment Pharmacol Ther 2020; 52: 1185-1194
- 12 Vallet-Pichard A, Mallet V, Nalpas B. et al. FIB-4: an inexpensive and accurate marker of fibrosis in HCV infection. comparison with liver biopsy and fibrotest. Hepatology 2007; 46: 32-36
- 13 European Association for the Study of the Liver. Electronic address eee, Clinical Practice Guideline P, Chair, representative EGB, Panel m: EASL Clinical Practice Guidelines on non-invasive tests for evaluation of liver disease severity and prognosis – 2021 update. J Hepatol 2021; 75: 659– 689.
- 14 Younossi ZM, Golabi P, de Avila L. et al. The global epidemiology of NAFLD and NASH in patients with type 2 diabetes: A systematic review and meta-analysis. J Hepatol 2019; 71: 793-801
- 15 Kalsch J, Bechmann LP, Heider D. et al. Normal liver enzymes are correlated with severity of metabolic syndrome in a large population based cohort. Sci Rep 2015; 5: 13058
- 16 Diabetes-Hilfe DDGDudD: Deutscher Gesundheitsbericht Diabetes 2021. https://www.deutsche-diabetes-gesellschaft.de/fileadmin/user_upload/06_Gesundheitspolitik/03_Veroeffentlichungen/05_Gesundheitsbericht/20201107_Gesundheitsbericht2021.pdf
- 17 Stefan N, Roden M. Diabetes und Fettleber. Diabetologie 2020; 15 (Suppl. 01) S156-S159
- 18 Mazzolini G, Sowa JP, Atorrasagasti C. et al. Significance of Simple Steatosis: An Update on the Clinical and Molecular Evidence. Cells 2020; 9
- 19 American Diabetes A. 4. Comprehensive Medical Evaluation and Assessment of Comorbidities: Standards of Medical Care in Diabetes-2020. Diabetes Care 2020; 43: S37-S47
- 20 Lee J, Vali Y, Boursier J. et al. Prognostic accuracy of FIB-4, NAFLD fibrosis score and APRI for NAFLD-related events: A systematic review. Liver Int 2021; 41: 261-270
- 21 Ahmed MH, Husain NE, Almobarak AO. Nonalcoholic Fatty liver disease and risk of diabetes and cardiovascular disease: what is important for primary care physicians?. J Family Med Prim Care 2015; 4: 45-52
- 22 Sumida Y, Yoneda M, Tokushige K. et al. FIB-4 First in the Diagnostic Algorithm of Metabolic-Dysfunction-Associated Fatty Liver Disease in the Era of the Global Metabodemic. Life (Basel) 2021; 11
- 23 Anstee QM, Castera L, Loomba R. Impact of non-invasive biomarkers on hepatology practice: Past, present and future. J Hepatol 2022; 76: 1362-1378
- 24 Anstee QM, Berentzen TL, Nitze LM. et al. Non-invasive fibrosis scores as prognostic biomarkers of liver events, cardiovascular events and all cause mortality in people with obesity and/or type 2 diabetes in the UK: a longitudinal cohort study. ILC 2022 London: OS025.
- 25 Roeb E, Canbay A, Bantel H. et al. Leitlinie der aktualisierten S2k-Leitlinie nicht-alkoholische Fettlebererkrankung der Deutschen Gesellschaft für Gastroenterologie, Verdauungs- und Stoffwechselkrankheiten (DGVS). 2022
- 26 McPherson S, Hardy T, Dufour JF. et al. Age as a Confounding Factor for the Accurate Non-Invasive Diagnosis of Advanced NAFLD Fibrosis. Am J Gastroenterol 2017; 112: 740-751
- 27 Dietrich CF, Shi L, Lowe A. et al. Conventional ultrasound for diagnosis of hepatic steatosis is better than believed. Z Gastroenterol 2021;
- 28 Ferraioli G, Berzigotti A, Barr RG. et al. Quantification of Liver Fat Content with Ultrasound: A WFUMB Position Paper. Ultrasound Med Biol 2021; 47: 2803-2820
- 29 Hernaez R, Lazo M, Bonekamp S. et al. Diagnostic accuracy and reliability of ultrasonography for the detection of fatty liver: a meta-analysis. Hepatology 2011; 54: 1082-1090
- 30 Parkes J, Roderick P, Harris S. et al. Enhanced liver fibrosis test can predict clinical outcomes in patients with chronic liver disease. Gut 2010; 59: 1245-1251
- 31 Aberg F, Danford CJ, Thiele M. et al. A Dynamic Aspartate-to-Alanine Aminotransferase Ratio Provides Valid Predictions of Incident Severe Liver Disease. Hepatol Commun 2021; 5: 1021-1035
- 32 Kautz A, Dorner R, Antoni C. et al. Self-testing for liver disease – response to an online liver test questionnaire. Scand J Gastroenterol 2020; 55: 67-73
- 33 Lee TH, Kim WR, Benson JT. et al. Serum aminotransferase activity and mortality risk in a United States community. Hepatology 2008; 47: 880-887
- 34 Bundesausschuss G. 2021.
- 35 Noureddin M, Jones C, Alkhouri N. et al. Screening for Nonalcoholic Fatty Liver Disease in Persons with Type 2 Diabetes in the United States Is Cost-effective: A Comprehensive Cost-Utility Analysis. Gastroenterology 2020; 159: 1985-1987 e4
- 36 Tacke F, Weiskirchen R. Non-alcoholic fatty liver disease (NAFLD)/non-alcoholic steatohepatitis (NASH)-related liver fibrosis: mechanisms, treatment and prevention. Ann Transl Med 2021; 9: 729
- 37 Roeb E, Steffen HM, Bantel H. et al. S2k Guideline non-alcoholic fatty liver disease. Z Gastroenterol 2015; 53: 668-723
- 38 Greten TF, Malek NP, Schmidt S. et al. Diagnosis of and therapy for hepatocellular carcinoma. Z Gastroenterol 2013; 51: 1269-1326
- 39 Best J, Bechmann LP, Sowa JP. et al. GALAD Score Detects Early Hepatocellular Carcinoma in an International Cohort of Patients With Nonalcoholic Steatohepatitis. Clin Gastroenterol Hepatol 2020; 18: 728-35 e4
- 40 de Franchis R, Baveno VIF. Expanding consensus in portal hypertension: Report of the Baveno VI Consensus Workshop: Stratifying risk and individualizing care for portal hypertension. J Hepatol 2015; 63: 743-752
- 41 Gerbes AL, Labenz J, Appenrodt B. et al. Updated S2k-Guideline "Complications of liver cirrhosis". German Society of Gastroenterology (DGVS). Z Gastroenterol 2019; 57: e168
- 42 European Association for the Study of the Liver. Electronic address eee, European Association for the Study of the L: EASL Clinical Practice Guidelines for the management of patients with decompensated cirrhosis. J Hepatol 2018; 69: 406-460
- 43 Fotbolcu H, Zorlu E. Nonalcoholic fatty liver disease as a multi-systemic disease. World J Gastroenterol 2016; 22: 4079-4090
- 44 Kusnik A, Hunter N, Rasbach E. et al. Co-Medication and Nutrition in Hepatocellular Carcinoma: Potenzially Preventative Strategies in Hepatocellular Carcinoma. Dig Dis 2021; 39: 526-533
- 45 Mantovani A, Petracca G, Beatrice G. et al. Glucagon-Like Peptide-1 Receptor Agonists for Treatment of Nonalcoholic Fatty Liver Disease and Nonalcoholic Steatohepatitis: An Updated Meta-Analysis of Randomized Controlled Trials. Metabolites 2021; 11
- 46 Lamos EM, Kristan M, Siamashvili M. et al. Effects of anti-diabetic treatments in type 2 diabetes and fatty liver disease. Expert Rev Clin Pharmacol 2021; 14: 837-852
- 47 Johnston MP, Patel J, Byrne CD. Update on cardiovascular risk in nonalcoholic fatty liver disease. Curr Opin Cardiol 2021; 36: 478-486
- 48 Tamaki N, Kurosaki M, Takahashi Y. et al. Liver fibrosis and fatty liver as independent risk factors for cardiovascular disease. J Gastroenterol Hepatol 2021; 36: 2960-2966