Tailored Model of Care for Patients with Metabolic Dysfunction-Associated Steatotic Liver Disease

Mohamed El-Kassas; Abeer Awad; Mohamed Elbadry; Juan Pablo Arab

doi:10.1055/a-2253-9181

Seminars in Liver Disease, Table of Contents

Semin Liver Dis 2024; 44(01): 054-068
DOI: 10.1055/a-2253-9181

Review Article

Tailored Model of Care for Patients with Metabolic Dysfunction-Associated Steatotic Liver Disease

Mohamed El-Kassas

¹Endemic Medicine Department, Faculty of Medicine, Helwan University, Cairo, Egypt

²Steatotic Liver Disease Study Foundation in Middle East and North Africa (SLMENA), Cairo, Egypt

,

Abeer Awad

³Internal Medicine Department, Faculty of Medicine, Cairo University, Cairo, Egypt

,

Mohamed Elbadry

¹Endemic Medicine Department, Faculty of Medicine, Helwan University, Cairo, Egypt

²Steatotic Liver Disease Study Foundation in Middle East and North Africa (SLMENA), Cairo, Egypt

,

Juan Pablo Arab

⁴Division of Gastroenterology, Department of Medicine, Schulich School of Medicine, Western University and London Health Sciences Centre, London, Ontario, Canada

⁵Department of Epidemiology and Biostatistics, Schulich School of Medicine, Western University, London, Ontario, Canada

⁶Department of Gastroenterology, School of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile

› Author Affiliations

Abstract

Metabolic dysfunction-associated steatotic liver disease (MASLD), formerly known as nonalcoholic fatty liver disease (NAFLD), is increasing globally, creating a growing public health concern. However, this disease is often not diagnosed, and accurate data on its epidemiology are limited in many geographical regions, making it challenging to provide proper care and implement effective national plans. To combat the increasing disease burden, screening and diagnosis must reach a significant number of high-risk subjects. Addressing MASLD as a health care challenge requires a multidisciplinary approach involving prevention, diagnosis, treatment, and care, with collaboration between multiple stakeholders in the health care system. This approach must be guided by national and global strategies, to be combined with efficient models of care developed through a bottom-up process. This review article highlights the pillars of the MASLD model of care (MoC), including screening, risk stratification, and establishing a clinical care pathway for management, in addition to discussing the impact of nomenclature change on the proposed MoC.

Keywords

Metabolic dysfunction-associated steatotic liver disease - steatotic liver disease - nonalcoholic fatty liver disease - risk stratification - model of care

Full Text

References

References
1 El-Kassas M, Cabezas J, Coz PI, Zheng MH, Arab JP, Awad A. Nonalcoholic fatty liver disease: current global burden. Semin Liver Dis 2022; 42 (03) 401-412
2 Rinella ME, Lazarus JV, Ratziu V. et al; NAFLD Nomenclature consensus group. A multisociety Delphi consensus statement on new fatty liver disease nomenclature. J Hepatol 2023; 79 (06) 1542-1556
3 Hoofnagle JH, Doo E, Ratziu V. et al. Letter to the editor: a multi-society Delphi consensus statement on new fatty liver disease nomenclature. Hepatology 2023; 78 (06) 1966-1986
4 Chalasani N, Younossi Z, Lavine JE. et al. The diagnosis and management of nonalcoholic fatty liver disease: practice guidance from the American Association for the Study of Liver Diseases. Hepatology 2018; 67 (01) 328-357
5 Riazi K, Azhari H, Charette JH. et al. The prevalence and incidence of NAFLD worldwide: a systematic review and meta-analysis. Lancet Gastroenterol Hepatol 2022; 7 (09) 851-861
6 Afshin A, Forouzanfar MH, Reitsma MB. et al; GBD 2015 Obesity Collaborators. Health effects of overweight and obesity in 195 countries over 25 years. N Engl J Med 2017; 377 (01) 13-27
7 Stefan N, Cusi K. A global view of the interplay between non-alcoholic fatty liver disease and diabetes. Lancet Diabetes Endocrinol 2022; 10 (04) 284-296
8 Teng ML, Ng CH, Huang DQ. et al. Global incidence and prevalence of nonalcoholic fatty liver disease. Clin Mol Hepatol 2023; 29: S32-S42
9 Younossi ZM, Koenig AB, Abdelatif D, Fazel Y, Henry L, Wymer M. Global epidemiology of nonalcoholic fatty liver disease-Meta-analytic assessment of prevalence, incidence, and outcomes. Hepatology 2016; 64 (01) 73-84
10 Ong J, Alswat K, Hamid S, El-Kassas M. Nonalcoholic fatty liver disease in Asia, Africa, and Middle East Region. Clin Liver Dis 2023; 27 (02) 287-299
11 Schattenberg JM, Allen AM, Jarvis H. et al. A multistakeholder approach to innovations in NAFLD care. Commun Med (Lond) 2023; 3 (01) 1
12 Eslam M, Newsome PN, Sarin SK. et al. A new definition for metabolic dysfunction-associated fatty liver disease: an international expert consensus statement. J Hepatol 2020; 73 (01) 202-209
13 Eslam M, Alkhouri N, Vajro P. et al. Defining paediatric metabolic (dysfunction)-associated fatty liver disease: an international expert consensus statement. Lancet Gastroenterol Hepatol 2021; 6 (10) 864-873
14 Eslam M, Sarin SK, Wong VW. et al. The Asian Pacific Association for the Study of the Liver clinical practice guidelines for the diagnosis and management of metabolic associated fatty liver disease. Hepatol Int 2020; 14 (06) 889-919
15 Shiha G, Alswat K, Al Khatry M. et al. Nomenclature and definition of metabolic-associated fatty liver disease: a consensus from the Middle East and north Africa. Lancet Gastroenterol Hepatol 2021; 6 (01) 57-64
16 Shiha G, Korenjak M, Eskridge W. et al. Redefining fatty liver disease: an international patient perspective. Lancet Gastroenterol Hepatol 2021; 6 (01) 73-79
17 Zheng KI, Fan JG, Shi JP. et al. From NAFLD to MAFLD: a “redefining” moment for fatty liver disease. Chin Med J (Engl) 2020; 133 (19) 2271-2273
18 Younossi ZM, Rinella ME, Sanyal AJ. et al. From NAFLD to MAFLD: implications of a premature change in terminology. Hepatology 2021; 73 (03) 1194-1198
19 Ratziu V, Rinella M, Beuers U. et al. The times they are a-changin' (for NAFLD as well). J Hepatol 2020; 73 (06) 1307-1309
20 Younossi ZM, Golabi P, Paik JM, Henry A, Van Dongen C, Henry L. The global epidemiology of nonalcoholic fatty liver disease (NAFLD) and nonalcoholic steatohepatitis (NASH): a systematic review. Hepatology 2023; 77 (04) 1335-1347
21 Golabi P, Otgonsuren M, Cable R. et al. Non-alcoholic fatty liver disease (NAFLD) is associated with impairment of health related quality of life (HRQOL). Health Qual Life Outcomes 2016; 14: 18
22 Younossi ZM, Henry L. Economic and quality-of-life implications of non-alcoholic fatty liver disease. PharmacoEconomics 2015; 33 (12) 1245-1253
23 Hancock SL, Ryan OF, Marion V. et al. Feedback of patient-reported outcomes to healthcare professionals for comparing health service performance: a scoping review. BMJ Open 2020; Nov 23; 10 (11) e038190
24 Gnanasakthy A, Mordin M, Clark M, DeMuro C, Fehnel S, Copley-Merriman C. A review of patient-reported outcome labels in the United States: 2006 to 2010. Value Health 2012; 15 (03) 437-442
25 Younossi ZM. Review article: current management of non-alcoholic fatty liver disease and non-alcoholic steatohepatitis. Aliment Pharmacol Ther 2008; 28 (01) 2-12
26 van der Plas SM, Hansen BE, de Boer JB. et al. Generic and disease-specific health related quality of life of liver patients with various aetiologies: a survey. Qual Life Res 2007; 16 (03) 375-388
27 Younossi ZM, Boparai N, Price LL, Kiwi ML, McCormick M, Guyatt G. Health-related quality of life in chronic liver disease: the impact of type and severity of disease. Am J Gastroenterol 2001; 96 (07) 2199-2205
28 Younossi ZM. Patient-reported outcomes and the economic effects of nonalcoholic fatty liver disease and nonalcoholic steatohepatitis: the value proposition. Hepatology 2018; 68 (06) 2405-2412
29 Murag S, Ahmed A, Kim D. Recent epidemiology of nonalcoholic fatty liver disease. Gut Liver 2021; 15 (02) 206-216
30 Kim D, Cholankeril G, Li AA. et al. Trends in hospitalizations for chronic liver disease-related liver failure in the United States, 2005-2014. Liver Int 2019; 39 (09) 1661-1671
31 Axley P, Ahmed Z, Arora S. et al. NASH is the most rapidly growing etiology for acute-on-chronic liver failure-related hospitalization and disease burden in the United States: a population-based study. Liver Transpl 2019; 25 (05) 695-705
32 Allen AM, Van Houten HK, Sangaralingham LR, Talwalkar JA, McCoy RG. Healthcare cost and utilization in nonalcoholic fatty liver disease: real-world data from a large U.S. claims database. Hepatology 2018; 68 (06) 2230-2238
33 Yoo ER, Ahmed A, Kim D. Economic burden and healthcare utilization in nonalcoholic fatty liver disease. Hepatobiliary Surg Nutr 2019; 8 (02) 181-183
34 Hagström H, Nasr P, Ekstedt M. et al. Health care costs of patients with biopsy-confirmed nonalcoholic fatty liver disease are nearly twice those of matched controls. Clin Gastroenterol Hepatol 2020; 18 (07) 1592-1599.e8
35 Adams LA, Lymp JF, St Sauver J. et al. The natural history of nonalcoholic fatty liver disease: a population-based cohort study. Gastroenterology 2005; 129 (01) 113-121
36 Kwak MS, Kim D. Long-term outcomes of nonalcoholic fatty liver disease. Curr Hepat Rep 2015; 14 (02) 69-76
37 Alvarez CS, Graubard BI, Thistle JE, Petrick JL, McGlynn KA. Attributable fractions of nonalcoholic fatty liver disease for mortality in the United States: results from the third national health and nutrition examination survey with 27 years of follow-up. Hepatology 2020; 72 (02) 430-440
38 Kim D, Kim WR, Kim HJ, Therneau TM. Association between noninvasive fibrosis markers and mortality among adults with nonalcoholic fatty liver disease in the United States. Hepatology 2013; 57 (04) 1357-1365
39 Hassen G, Singh A, Belete G. et al. Nonalcoholic fatty liver disease: an emerging modern-day risk factor for cardiovascular disease. Cureus 2022; 14 (05) e25495
40 Angulo P, Kleiner DE, Dam-Larsen S. et al. Liver fibrosis, but no other histologic features, is associated with long-term outcomes of patients with nonalcoholic fatty liver disease. Gastroenterology 2015; 149 (02) 389-97.e10
41 Younes R, Caviglia GP, Govaere O. et al. Long-term outcomes and predictive ability of non-invasive scoring systems in patients with non-alcoholic fatty liver disease. J Hepatol 2021; 75 (04) 786-794
42 Younossi ZM, Stepanova M, Rafiq N. et al. Pathologic criteria for nonalcoholic steatohepatitis: interprotocol agreement and ability to predict liver-related mortality. Hepatology 2011; 53 (06) 1874-1882
43 Sanyal AJ, Harrison SA, Ratziu V. et al. The natural history of advanced fibrosis due to nonalcoholic steatohepatitis: data from the simtuzumab trials. Hepatology 2019; 70 (06) 1913-1927
44 Dulai PS, Singh S, Patel J. et al. Increased risk of mortality by fibrosis stage in nonalcoholic fatty liver disease: systematic review and meta-analysis. Hepatology 2017; 65 (05) 1557-1565
45 Boursier J, Shreay S, Fabron C, Torreton E, Fraysse J. Hospitalization costs and risk of mortality in adults with nonalcoholic steatohepatitis: analysis of a French national hospital database. EClinicalMedicine 2020; 25: 100445
46 Ong JP, Elariny H, Collantes R. et al. Predictors of nonalcoholic steatohepatitis and advanced fibrosis in morbidly obese patients. Obes Surg 2005; 15 (03) 310-315
47 Lazo M, Clark JM. The epidemiology of nonalcoholic fatty liver disease: a global perspective. Semin Liver Dis 2008; 28 (04) 339-350
48 Liu J, Tian Y, Fu X. et al. Estimating global prevalence, incidence, and outcomes of non-alcoholic fatty liver disease from 2000 to 2021: systematic review and meta-analysis. Chin Med J (Engl) 2022; 135 (14) 1682-1691
49 Salaheldin M, Aly H, Lau L, Afify S, El-Kassas M. Nonalcoholic fatty liver disease-related hepatocellular carcinoma: the next threat after viral hepatitis. Diagnostics (Basel) 2023; 13 (16) 2631
50 Calzadilla-Bertot L, Jeffrey GP, Jacques B. et al. Increasing incidence of nonalcoholic steatohepatitis as an indication for liver transplantation in Australia and New Zealand. Liver Transpl 2019; 25 (01) 25-34
51 Lazarus JV, Ekstedt M, Marchesini G. et al; EASL International Liver Foundation NAFLD Policy Review Collaborators. A cross-sectional study of the public health response to non-alcoholic fatty liver disease in Europe. J Hepatol 2020; 72 (01) 14-24
52 Díaz LA, Fuentes-López E, Ayares G. et al. The establishment of public health policies and the burden of non-alcoholic fatty liver disease in the Americas. Lancet Gastroenterol Hepatol 2022; 7 (06) 552-559
53 Ando Y, Jou JH. Nonalcoholic fatty liver disease and recent guideline updates. Clin Liver Dis (Hoboken) 2021; 17 (01) 23-28
54 Rinella ME, Neuschwander-Tetri BA, Siddiqui MS. et al. AASLD practice guidance on the clinical assessment and management of nonalcoholic fatty liver disease. Hepatology 2023; 77 (05) 1797-1835
55 National Guideline Centre (UK). Nonalcoholic Fatty Liver Disease: Assessment and Management. London: National Institute for Health and Care Excellence (NICE); July 2016 . Accessed February 2024 at: www.nice.org.uk/guidance/ng49
56 ElSayed NA, Aleppo G, Aroda VR. et al., on behalf of the American Diabetes Association. Summary of Revisions: Standards of Care in Diabetes-2023. Diabetes Care 2023; Jan 1; 46 (Suppl 1): S5-S9
57 European Association for the Study of the Liver (EASL)European Association for the Study of Diabetes (EASD). European Association for the Study of Obesity (EASO). EASL-EASD-EASO Clinical Practice Guidelines for the management of nonalcoholic fatty liver disease. J Hepatol 2016; 64 (06) 1388-1402
58 Wong VW, Chan WK, Chitturi S. et al. Asia-Pacific Working Party on Non-alcoholic Fatty Liver Disease guidelines 2017—Part 1: definition, risk factors and assessment. J Gastroenterol Hepatol 2018; 33 (01) 70-85
59 Dasarathy S, Dasarathy J, Khiyami A, Joseph R, Lopez R, McCullough AJ. Validity of real time ultrasound in the diagnosis of hepatic steatosis: a prospective study. J Hepatol 2009; 51 (06) 1061-1067
60 Martinou E, Pericleous M, Stefanova I, Kaur V, Angelidi AM. Diagnostic modalities of non-alcoholic fatty liver disease: from biochemical biomarkers to multi-omics non-invasive approaches. Diagnostics (Basel) 2022; 12 (02) 407
61 Younossi ZM, Stepanova M, Younossi Y. et al. Epidemiology of chronic liver diseases in the USA in the past three decades. Gut 2020; 69 (03) 564-568
62 Vernon G, Baranova A, Younossi ZM. Systematic review: the epidemiology and natural history of non-alcoholic fatty liver disease and non-alcoholic steatohepatitis in adults. Aliment Pharmacol Ther 2011; 34 (03) 274-285
63 Estes C, Razavi H, Loomba R, Younossi Z, Sanyal AJ. Modeling the epidemic of nonalcoholic fatty liver disease demonstrates an exponential increase in burden of disease. Hepatology 2018; 67 (01) 123-133
64 Serra-Burriel M, Graupera I, Torán P. et al; investigators of the LiverScreen Consortium. Transient elastography for screening of liver fibrosis: cost-effectiveness analysis from six prospective cohorts in Europe and Asia. J Hepatol 2019; 71 (06) 1141-1151
65 Srivastava A, Jong S, Gola A. et al. Cost-comparison analysis of FIB-4, ELF and fibroscan in community pathways for non-alcoholic fatty liver disease. BMC Gastroenterol 2019; 19 (01) 122
66 Basu R, Noureddin M, Clark JM. Nonalcoholic fatty liver disease: review of management for primary care providers. Mayo Clin Proc 2022; 97 (09) 1700-1716
67 Gawrieh S, Wilson LA, Cummings OW. et al; NASH Clinical Research Network. Histologic findings of advanced fibrosis and cirrhosis in patients with nonalcoholic fatty liver disease who have normal aminotransferase levels. Am J Gastroenterol 2019; 114 (10) 1626-1635
68 Kanwal F, Shubrook JH, Adams LA. et al. Clinical care pathway for the risk stratification and management of patients with nonalcoholic fatty liver disease. Gastroenterology 2021; 161 (05) 1657-1669
69 Allen AM, Younossi ZM, Tsochatzis EA. et al. Measuring NAFLD models of care. Nat Rev Gastroenterol Hepatol 2023; 20 (10) 626-627
70 Targher G, Tilg H, Byrne CD. Non-alcoholic fatty liver disease: a multisystem disease requiring a multidisciplinary and holistic approach. Lancet Gastroenterol Hepatol 2021; 6 (07) 578-588
71 Cusi K, Isaacs S, Barb D. et al. American Association of Clinical Endocrinology Clinical Practice Guideline for the Diagnosis and Management of Nonalcoholic Fatty Liver Disease in Primary Care and Endocrinology Clinical Settings: co-sponsored by the American Association for the Study of Liver Diseases (AASLD). Endocr Pract 2022; 28 (05) 528-562
72 Lazarus JV, Anstee QM, Hagström H. et al. Defining comprehensive models of care for NAFLD. Nat Rev Gastroenterol Hepatol 2021; 18 (10) 717-729
73 Shrestha A, Pradhananga S. Holistic approach in the management of nonalcoholic fatty liver disease. Euroasian J Hepatogastroenterol 2022; 12 (Suppl. 01) S51-S58
74 Francque SM, Marchesini G, Kautz A. et al. Non-alcoholic fatty liver disease: a patient guideline. JHEP Rep Innov Hepatol 2021; 3 (05) 100322
75 Malespin MH, Barritt IV AS, Watkins SE. et al. Weight loss and weight regain in usual clinical practice: results from the TARGET-NASH observational cohort. Clin Gastroenterol Hepatol 2022; 20 (10) 2393-2395.e4
76 Nguyen VH, Yeo YH, Zou B. et al. Discrepancies between actual weight, weight perception and weight loss intention amongst persons with NAFLD. J Intern Med 2021; 289 (06) 840-850
77 Anstee QM, Hallsworth K, Lynch N. et al. Real-world management of non-alcoholic steatohepatitis differs from clinical practice guideline recommendations and across regions. JHEP Rep Innov Hepatol 2021; 4 (01) 100411
78 Kumar S, Wong R, Newberry C, Yeung M, Peña JM, Sharaiha RZ. Multidisciplinary clinic models: a paradigm of care for management of NAFLD. Hepatology 2021; 74 (06) 3472-3478
79 Commins I, Clayton-Chubb D, Melton S, Majeed A, Kemp W, Roberts SK. Initial outcomes of a dedicated multidisciplinary non-alcoholic fatty liver disease clinic: a retrospective cohort study. Intern Med J 2023; 53 (11) 2065-2072
80 Mantovani A, Byrne CD, Benfari G, Bonapace S, Simon TG, Targher G. Risk of heart failure in patients with nonalcoholic fatty liver disease: JACC review topic of the week. J Am Coll Cardiol 2022; 79 (02) 180-191
81 Carrieri P, Mourad A, Marcellin F. et al. Knowledge of liver fibrosis stage among adults with NAFLD/NASH improves adherence to lifestyle changes. Liver Int 2022; 42 (05) 984-994
82 Mari A, Omari S, Abu Baker F. et al. Non-alcoholic fatty liver disease: a survey of involvement of primary care physicians. Minerva Gastroenterol Dietol 2019; 65 (04) 255-258
83 Duell PB, Welty FK, Miller M. et al; American Heart Association Council on Arteriosclerosis, Thrombosis and Vascular Biology; Council on Hypertension; Council on the Kidney in Cardiovascular Disease; Council on Lifestyle and Cardiometabolic Health; and Council on Peripheral Vascular Disease. Nonalcoholic fatty liver disease and cardiovascular risk: a scientific statement from the American Heart Association. Arterioscler Thromb Vasc Biol 2022; 42 (06) e168-e185
84 van Driel ML, De Sutter AI, Christiaens TC, De Maeseneer JM. Quality of care: the need for medical, contextual and policy evidence in primary care. J Eval Clin Pract 2005; 11 (05) 417-429
85 Braveman P, Gruskin S. Defining equity in health. J Epidemiol Community Health 2003; 57 (04) 254-258
86 Orach CG. Health equity: challenges in low income countries. Afr Health Sci 2009; 9 (Suppl. 02) S49-S51
87 Yang DT. Urban-biased policies and rising income inequality in China. Am Econ Rev 1999; 89 (02) 306-310
88 Loubiere S, Moatti JP. Economic evaluation of point-of-care diagnostic technologies for infectious diseases. Clin Microbiol Infect 2010; 16 (08) 1070-1076
89 Goldie SJ, Yazdanpanah Y, Losina E. et al. Cost-effectiveness of HIV treatment in resource-poor settings—the case of Côte d'Ivoire. N Engl J Med 2006; 355 (11) 1141-1153
90 Horton S, Fleming KA, Kuti M. et al. The top 25 laboratory tests by volume and revenue in five different countries. Am J Clin Pathol 2019; 151 (05) 446-451
91 Huang G, Wallace DF, Powell EE, Rahman T, Clark PJ, Subramaniam VN. Gene variants implicated in steatotic liver disease: opportunities for diagnostics and therapeutics. Biomedicines 2023; 11 (10) 2809
92 Perez-Diaz-Del-Campo N, Dileo E, Castelnuovo G. et al. A nutrigenetic precision approach for the management of non-alcoholic fatty liver disease. Clin Nutr 2023; 42 (11) 2181-2187
93 Cherubini A, Casirati E, Tomasi M, Valenti L. PNPLA3 as a therapeutic target for fatty liver disease: the evidence to date. Expert Opin Ther Targets 2021; 25 (12) 1033-1043
94 Francque SM. Towards precision medicine in non-alcoholic fatty liver disease. Rev Endocr Metab Disord 2023; 24 (05) 885-899
95 Valenzuela-Vallejo L, Sanoudou D, Mantzoros CS. Precision medicine in fatty liver disease/non-alcoholic fatty liver disease. J Pers Med 2023; 13 (05) 830
96 Puchades R, Said-Criado I. Telemedicine in clinical practice: barriers and risks. Med Clín (Barc) 2024; 162 (03) 123-125
97 Tincopa MA, Lyden A, Wong J, Jackson EA, Richardson C, Lok AS. Impact of a pilot structured mobile technology based lifestyle intervention for patients with nonalcoholic fatty liver disease. Dig Dis Sci 2022; 67 (02) 481-491
98 Kwon OY, Choi JY, Jang Y. The effectiveness of eHealth interventions on lifestyle modification in patients with nonalcoholic fatty liver disease: systematic review and meta-analysis. J Med Internet Res 2023; 25: e37487
99 Farahat TM, Ungan M, Vilaseca J. et al. The paradigm shift from NAFLD to MAFLD: a global primary care viewpoint. Liver Int 2022; 42 (06) 1259-1267
100 Feng G, Valenti L, Wong VW. et al. Recompensation in cirrhosis: unravelling the evolving natural history of nonalcoholic fatty liver disease. Nat Rev Gastroenterol Hepatol 2024; 21 (01) 46-56
101 Tesema AG, Ajisegiri WS, Abimbola S. et al. How well are non-communicable disease services being integrated into primary health care in Africa: a review of progress against World Health Organization's African regional targets. PLoS One 2020; 15 (10) e0240984
102 Langlois EV, McKenzie A, Schneider H, Mecaskey JW. Measures to strengthen primary health-care systems in low- and middle-income countries. Bull World Health Organ 2020; 98 (11) 781-791
103 Kallman JB, Arsalla A, Park V. et al. Screening for hepatitis B, C and non-alcoholic fatty liver disease: a survey of community-based physicians. Aliment Pharmacol Ther 2009; 29 (09) 1019-1024
104 Dietrich CG, Rau M, Geier A. Screening for nonalcoholic fatty liver disease-when, who and how?. World J Gastroenterol 2021; 27 (35) 5803-5821
105 Islam KB, Brandman D, Chu JN, Goldman ML, Fox RK. Primary care providers and nonalcoholic fatty liver disease: a needs assessment survey. Dig Dis Sci 2023; 68 (02) 434-438
106 Forlano R, Sigon G, Mullish BH, Yee M, Manousou P. Screening for NAFLD—current knowledge and challenges. Metabolites 2023; 13 (04) 536
107 Casler K, Trees K, Bosak K. Readiness for the epidemic: the adult nonalcoholic fatty liver disease toolkit for primary care nurse practitioners. J Am Assoc Nurse Pract 2020; 32 (04) 323-331
108 Wong VWS, Zelber-Sagi S, Cusi K. et al. Management of NAFLD in primary care settings. Liver Int 2022; 42 (11) 2377-2389
109 Younossi ZM, Ong JP, Takahashi H. et al; Global Nonalcoholic Steatohepatitis Council. A global survey of physicians knowledge about nonalcoholic fatty liver disease. Clin Gastroenterol Hepatol 2022; 20 (06) e1456-e1468
110 Driessen S, de Jong VD, van Son KC. et al. A global survey of health care workers' awareness of non-alcoholic fatty liver disease: the AwareNASH survey. United European Gastroenterol J 2023; 11 (07) 654-662