title: Severe asymptomatic non-alcoholic fatty liver disease in routine diabetes care; a multi-disciplinary team approach to diagnosis and management.
abstract: OBJECTIVE
  To prospectively use a non-invasive algorithm to identify asymptomatic, advanced non-alcoholic fatty liver disease (NAFLD) in a secondary care diabetes clinic and to determine the short-term effect of a multi-disciplinary team (MDT) approach in a liver clinic.
  
  
  METHODS
  NAFLD Fibrosis Score (NFS) was calculated in 64 asymptomatic patients with type 2 diabetes. Advanced fibrosis was identified using transient elastography and confirmed with liver biopsy. In a subsequent retrospective study, 95 patients newly referred to the NAFLD MDT clinic were investigated and the impact of the MDT approach assessed.
  
  
  RESULTS
  25/64 (39.0%) of patients with diabetes had a low NFS (<-1.455). 39/64 (61.0%) patients had a high or indeterminate NFS and were referred for review in the NAFLD MDT clinic, of which 23/39 attended for assessment. 19/23 (82.6%) were diagnosed with NAFLD, of which 6/19 (31.6%) patients had a positive transient elastography (≥8 kPa). Liver biopsy confirmed advanced fibrosis in 5/6 cases, with moderate fibrosis in 1 case. In the retrospective study, 65/95 (68.4%) new referrals to the NAFLD MDT clinic had a diagnosis of NAFLD. Over a median 98 days (IQR 70-182) follow-up, there was a significant improvement in weight (-0.8 kg; P = 0.024), total cholesterol (-0.2 mmol/L; P = 0.044), ALT (alanine transmaminase, -12.5 IU/L; P < 0.001) and GGT (gammu-glutamyl transferase, -13.0 IU/L; P < 0.0001). 7/28 (25%) of patients with diabetes achieved >5% weight loss.
  
  
  CONCLUSIONS
  A significant proportion of asymptomatic patients attending type 2 diabetes clinics have undiagnosed advanced NAFLD fibrosis. An MDT approach to NAFLD results in short-term improvements in metabolic and liver parameters.
authors.affiliation: Wellcome Trust Clinical Research Fellow, Centre for Liver Research and NIHR Biomedical Research Unit in Liver Disease, Institute of Biomedical Research, University of Birmingham, Queen Elizabeth Hospital, Birmingham B15 2TT, UK. mattyarm2010@googlemail.com.
authors.forename: Matthew J
authors.initials: MJ
authors.lastname: Armstrong
authors.forename: Jonathan M
authors.initials: JM
authors.lastname: Hazlehurst
authors.forename: Richard
authors.initials: R
authors.lastname: Parker
authors.forename: Elena
authors.initials: E
authors.lastname: Koushiappi
authors.forename: Jake
authors.initials: J
authors.lastname: Mann
authors.forename: Sheeba
authors.initials: S
authors.lastname: Khan
authors.forename: Angela
authors.initials: A
authors.lastname: Philips
authors.forename: Liz
authors.initials: L
authors.lastname: Chandler
authors.forename: Jill
authors.initials: J
authors.lastname: Johnson
authors.forename: Maria
authors.initials: M
authors.lastname: Round
authors.forename: Geoffrey
authors.initials: G
authors.lastname: Haydon
authors.forename: Mohammad A
authors.initials: MA
authors.lastname: Karamat
authors.forename: Philip N
authors.initials: PN
authors.lastname: Newsome
authors.forename: Jeremy W
authors.initials: JW
authors.lastname: Tomlinson
mesh_terms: D000328:Adult; D000368:Aged; D001706:Biopsy; D003924:Diabetes Mellitus, Type 2 / Q000150:complications* / Q000628:therapy; D054459:Elasticity Imaging Techniques; D004739:England; D005234:Fatty Liver / Q000150:complications* / Q000175:diagnosis* / Q000628:therapy; D005260:Female; D006801:Humans; D008099:Liver / Q000473:pathology; D008297:Male; D008875:Middle Aged; D065626:Non-alcoholic Fatty Liver Disease; D010348:Patient Care Team / Q000458:organization & administration*; D011446:Prospective Studies; D063728:Secondary Care Centers; D012720:Severity of Illness Index