S. Driessen¹, K.C. van Son^{1, 2}, G.L. Haverkamp^1,3, M.J. Denters^1,3, S.J. Pinto-Sietsma¹, N.M.J. Hanssen¹, M. Castro Cabezas^4,5, R.B. Takkenberg¹, H. Schers^2,6, M. Nieuwdorp¹, J.P. Drenth¹, M.E. Tushuizen⁷, A.G. Holleboom¹

Affiliations:

1. Amsterdam UMC, 2. Radboudumc, 3. Zaans Medisch Centrum, 4. Julius Clinical,

5. Franciscus Gasthuis, 6. Huisartsenpraktijk Thermion, 7. LUMC

s.driessen2@amsterdamumc.nl

Background:

Non-invasive liver tests (NITs) can detect advanced fibrotic MASLD and reduce unnecessary referrals. Yet data comparing numbers-needed-to-screen (NNS) in multiple lines of care are scarce. Therefore we introduced NLA2, the first Dutch MASLD care path, encompassing primary, secondary and tertiary clinics.

Methods:

Patients at cardiometabolic risk for MASLD were recruited from GPs, regional clinics and a UMC, whilst excluding other liver diseases. Simultaneous FIB4, Enhanced Liver Fibrosis (ELF)-test and vibration-controlled transient elastography (VCTE/FibroScan®) allowed testing of NIT combinations. FIB4 ≥3.25 and/or Liver Stiffness Measurement(LSM) ≥8.0 kPa indicated potential advanced fibrosis, prompting referral to hepatology. Referral patterns were compared to regular care between 2016-2023 using a predefined evaluation standard.

Results:

634 participants entered NLA2, 267 from primary, 136 from secondary and 229 from tertiary care. After exclusions, 604 were analysed. Median age was 60 years (51-68), 45.5% were women, 50.8% had obesity and 45.0% had T2DM. 54.1% had CAP ≥287 dB/m, indicating steatosis. 15.0% had LSM ≥8.0 kPa, yielding a NNS of 6.7. NNS was even lower in T2DM compared to non-diabetics; 4.3 vs 11.2. NNS decreased across lines of care: 11.1, 5.5 and 5.1 for primary, secondary and tertiary care respectively, inversely related to cardiometabolic comorbidities (mean number 2.2, 2.4, 2.9). ELF was available for 386 participants. 17.9% had ELF ≥9.8, yielding NNS of 5.6. Of 90 patients at risk for advanced fibrosis, 63 were referred to hepatology. Compared to regular care, NLA2 improved correct referrals 4-fold (RR 4.09; 95% CI 2.83-5.91). Unnecessary referral-rates decreased from 86% to 43%. In a 2-tiered algorithm in case of intermediate FIB4 (1.3-3.25), VCTE as second test would refer 6.5%; using ELF would refer 11.5%.

Conclusion:

The first Dutch MASLD care path study shows incrementally lower NNS for potential advanced liver fibrosis across multiple lines of care and significantly improved referral patterns. NNS in T2DM were remarkably lower compared to non-diabetics.