Diagnosis and Monitoring in MASLD/MASH

Drs Fontana, Abdelmalek, and Arab review potential confounders for liver stiffness tests—from food or alcohol to even a cup of coffee—and the best methods to use for both diagnosis and continued monitoring for patients with MASLD or MASH, including VCTE, MRE, and FibroScan.

VCTE Interpretation: Confounders, Discordant Results, and Steatosis Follow-Up

• Vibration-controlled transient elastography (VCTE) liver stiffness above 8 kPa may be confounded by recent meals or alcohol. Repeat assessment after at least 3 hours of fasting; avoid alcohol before reassessing elevated stiffness.
• MR elastography can clarify poor-quality VCTE assessments or discordant noninvasive tests, including FIB-4, FibroScan, and ELF.
• High controlled attenuation parameter (CAP) scores with normal stiffness warrant steatosis education, nutrition support, lifestyle changes, and primary care follow-up. Reassess in 2–3 years; normal stiffness should not imply benign steatosis.

Dr Fontana: It sounds like VCTE is your go-to quick immediate results in your clinic. You get stiffness measurement in kilopascals and you get the CAP score. Now, Manal, tell me a little bit more some of the caveats and nuances. So when someone shows up to your clinic today, you want to do a VCTE and they just had a donut or just a cup of coffee an hour before, is that a problem? And then also we talked about this kind of blurring between MASLD and Met ALD and how much they drank and a positive PEth. So tell me a little bit about eating and doing a VCTE, and tell me also about alcohol use. If someone drank the last week, football season is starting up here. Is this a problem, eating and alcohol? How do you deal with that?

Dr Abdelmalek: Well, they certainly are confounders potentially to the VCTE liver stiffness assessment. And particularly if that assessment is above the threshold of 8, you have to wonder, is that accurate or is this being confounded by a recent meal and/or alcohol consumption? We know that alcohol induces significant fat inflammation and potentially can transiently even increase portal pressure. So that is probably a stronger confounder even than a recent meal. So I do try to bring patients back for clarity when they've been fasting at least 3 hours or have them sit in the waiting room and bring them back to do that FibroScan after at least 3 hours. I'm not as concerned about that fasting when that liver stiffness is dramatically low. So sometimes I'll test it and then I'll just say if it's low, and I'm getting a very good quartile ratio and beautiful shear waves, it's reassuring independent of that cup of coffee that they may have had.

But you have to try to get the best quality assessments, particularly when dealing with potential false positive results because these imaging biomarkers perform very well for their negative predictive value, not as well for their positive. So I am more of a stickler about fasting and no alcohol when the stiffness is elevated so I can get an ascertainment. As follow up for what JP has mentioned, I agree, I utilize MR elastography under the same circumstances. If I have a poor quality transient elastography, I have wide distribution of the interquartile ratio or sometimes just failure to capture a good shear wave that happens about maybe 10% of the time depending on body mass index and truncal obesity, in which case those patients may warrant an MR elastography. I also will do it in circumstances where I'm getting two very discordant NITs, whether that's FIB-4, FibroScan, ELF and FibroScan. When I really need a more sensitive tiebreaker to my clinical ascertainment of risk and the other biomarkers are not giving me that, I may default to MR elastography.

Dr Fontana: Yeah, I tend to use it as the tiebreaker for discrepant results. My hunch is that someone has advanced fibrosis, but they have a normal FibroScan. They have a low platelet count, their MCV is high. I kind of wonder if I'm missing something. So I tend to use it selectively and I think that's the way most of us practice. So one other just final question here before we move on to treatment. When you get the FibroScan results, you get the stiffness in kilopascals, which JP was alluding to with some of the cut points, but you also get a CAP score. So what do you do if you have a normal stiffness but a high CAP score? So is that someone who you continue to follow because the CAP reflects the amount of steatosis in the liver? Is that someone you need to follow and treat or do you only tend to follow patients with concerning stiffness scores? Tell us about what you do practically when you get the data back.

Dr Abdelmalek: That is somebody that I may not need to follow myself as a hepatologist. However, I do take that opportunity to educate the patient on what this means, the implications of having significant hepatic steatosis, the risk of steatohepatitis, pull in nutrition, ensure there's no other risk factor for hepatic steatosis. I screen for celiac and sleep apnea, ask about alcohol, and I refer them back to their primary care doctor for holistic antimetabolic lifestyle alterations. And I tell them to come back and see me in about 2 to 3 years and let's retest. But I don't mention that this is benign. This is not benign. And I don't leave them with the understanding that this may not change over time because it certainly needs to be followed and needs to be reassessed. So the dogma of benign fat in the liver, which we all too often hear when we see patients in a liver clinic, they told me not to worry about this years ago. They told me I didn't need to do anything. That has to be debunked and I have a detailed conversation of need for follow-up and serial assessments over the years.

Dr Fontana: So it sounds like if they've gotten to you in a VCTE, and even if the stiffness is okay, but the CAP score is higher, they need education about diet, lifestyle, exercise, reducing alcohol, because in a way it's sort of false reassurance and you don't know what their trajectory is based upon a single time point, whereas 2 to 3 years later you'll know are they stable or not? That resonates, I think, with most of us.