VANCOUVER, B.C.—A large proportion of the U.S. adult population living with chronic liver disease may be completely unaware of their condition, according to data presented at the 2023 annual meeting of the American College of Gastroenterology.

Results of the National Health and Nutrition Examination Survey (NHANES) showed that 93% of participants contacted were unaware of their diagnosis of metabolic dysfunction–associated steatotic liver disease (MASLD), and 8.8% were found to have advanced liver disease or fibrosis related to MASLD (abstract P0950).

“People unaware of their fatty liver disease comprise a big risk group,” said lead investigator David S. Kim, MD, from the Department of Internal Medicine at Rutgers New Jersey Medical School, in Newark. “These results highlight the need for improved strategies for early detection and intervention to prevent the silent progression of [MASLD] to advanced stages.”

The asymptomatic nature of MASLD in its early stages often leads to late diagnosis, after significant liver damage may have occurred. Some studies estimate between 48% and 100% of MASLD patients are asymptomatic, and their condition is only discovered while screening for other medical conditions.

For this study, Dr. Kim and his co-investigators used NHANES survey data collected between 2017 and early 2020 (pre-pandemic) to assess the prevalence of unawareness about MASLD among U.S. adults and its correlation with advanced fibrosis. The researchers evaluated advanced fibrosis using transient elastography. MASLD was defined by controlled attenuation parameter (CAP) scores of 248 dB/m or higher, and advanced fibrosis and cirrhosis were defined by liver stiffness measurements of 9.6 and 11 kPa, respectively.

Surprising Levels of Advanced Fibrosis and Cirrhosis

Initial results showed that 6.6% of the 3,180 people surveyed who had MASLD were aware of their disease, while 93.4% of participants (n=2,981) were unaware. The incidence of MASLD fibrosis and cirrhosis was not statistically different in the unknown and known MASLD groups (8.8% vs. 13.2% and 6.6% vs. 10.7%, respectively).

The patients who were aware of MASLD had higher levels of aspartate aminotransferase (AST) and alanine aminotransferase (ALT) compared with the unknown MASLD group.

“The significantly higher levels of AST and ALT among patients with unknown versus known [MASLD] is in line with the hypothesis that most initial presenting symptoms or lab test abnormalities in [MASLD] patients would be elevated liver enzymes,” said Dr. Kim, underscoring the asymptomatic nature of the initial disease.

Body mass index, glycohemoglobin and CAP scores were independent predictors of advanced fibrosis, while BMI, platelet count and CAP scores were independent predictors of cirrhosis.

Among patients who were unaware of their liver disease, higher CAP scores, BMI and glycohemoglobin were associated with increased odds of advanced fibrosis. Conversely, only higher CAP scores were associated with higher odds of advanced fibrosis in participants who were aware of their liver disease.

According to Dr. Kim, these findings suggest that metabolic syndrome has a large impact on the progression of fibrosis, especially in patients with undiagnosed MASLD.

“These data show the importance of screening for early detection of [MASLD], especially in patients with a high BMI or glycohemoglobin,” Dr. Kim said. “Given the surprising levels of advanced fibrosis and cirrhosis, more research is needed” to facilitate earlier diagnosis.

Need to Build Awareness

“The low rates of awareness of MASLD presented in this study confirm multiple previous reports, including that from the CARDIA study in which awareness was even lower, around 2%” (J Gen Intern Med 2019;34[12]:2772-2778), said Jonathan G. Stine, MD, MSc, FACP, the director of the fatty liver program and director of research at Penn State Health Liver Center, in Hershey, Pa. “Many factors contribute to low patient awareness of their diagnosis, including up until recently a lack of screening consensus or guidelines, the relatively asymptomatic or nonspecific symptoms of MASLD, and poor understanding of MASLD among patients and some healthcare providers, especially those who are outside of hepatology and gastroenterology,” added Dr. Stine, who was not involved in the study.

“Clearly, there is still much work to be done to raise awareness of MASLD, and a strong comprehensive public health response will be needed to address this leading cause of liver disease worldwide,” he told Gastroenterology & Endoscopy News.

Vincent L. Chen, MD, a gastroenterologist at the University of Michigan Health–Ann Arbor, who also was not involved in the research, underscored the vague and/or minimal symptoms associated with MASLD that contribute to the lack of awareness. “This study highlights how underdiagnosed MASLD is, including [in those] who already have liver scarring from it. That represents a missed opportunity to prevent advanced liver disease before it’s too late,” he said.

“We need to do a better job of building awareness of the importance of MASLD among patients and primary care providers,” Dr. Chen told Gastroenterology & Endoscopy News. “This is especially critical now that there are recommendations that we should be screening for liver scarring in people with risk factors for MASLD. It’s widely expected that we’ll finally have FDA-approved treatments for MASLD in the near future, which could potentially help a lot of people,” he concluded, “but you can’t treat people unless you diagnose them first.”

—Chase Doyle

Drs. Chen, Kim and Stine reported no relevant financial disclosures.