title: EASL-EASD-EASO clinical practice guidelines for the management of non-alcoholic fatty liver disease in severely obese people: do they lead to over-referral?
abstract: We aimed to assess the application of the recent 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) clinical practice guidelines for the management of non-alcoholic fatty liver disease (NAFLD) in severely obese individuals in routine clinical practice.
  
  
  
  We performed a single-centre retrospective observational study of 385 patients referred for severe obesity (BMI ≥ 35 kg/m2) to our Endocrinology, Diabetes and Nutrition department, between 1 November 2014 and 31 December 2015. The recent EASL-EASD-EASO clinical practice guidelines for the management of NAFLD were retrospectively applied to the cohort using, successively, the NAFLD fibrosis score (NFS) and a combination of the NFS and transient elastography (TE) measurement in a subgroup of individuals.
  
  
  
  We identified 313 (81.3%) individuals with NAFLD in the cohort. The application of the EASL-EASD-EASO guidelines using NFS would lead to referral to a specialist for up to 289 individuals (75.1%) in the cohort. The combination of NFS and TE measurement reclassified 28 (25%) individuals from the medium/high risk group to low risk and would lead to the referral of 261 (67.7%) individuals to a specialist. These proportions appear to be excessive given the expected prevalence of advanced fibrosis and non-alcoholic steatohepatitis (NASH) of around 10% and 30%, respectively, in the severely obese population.
  
  
  
  This is the first study to assess the strategy proposed by the EASL-EASD-EASO clinical practice guidelines for the management of NAFLD in severely obese individuals. The retrospective application of the guidelines in a cohort representing the routine clinical practice in our department would lead to an excessive number of specialist referrals and would also lead to an unjustified increase in health costs. Biomarkers and specific strategy for the screening of NASH and advanced fibrosis in morbidly obese individuals are thus crucially needed and would help to improve the actual guidelines.
authors.affiliation: Biochemistry Department, Lyon Sud Hospital, Hospices Civils de Lyon, Claude-Bernard Lyon 1 University, Pierre Bénite, France.
authors.forename: Emilie
authors.initials: E
authors.lastname: Blond
authors.affiliation: Department of Endocrinologie, Diabète, Nutrition, Centre Intégré de l'Obésité Rhône-Alpes, Fédération Hospitalo-Universitaire DO-iT, Lyon Sud Hospital, Hospices Civils de Lyon, Claude-Bernard Lyon 1 University, 165 Chemin du Grand Revoyet, 69495, Pierre-Bénite Cedex, France.|Laboratoire CarMeN, Unité Inserm U1060 - INRA 1235 - INSA-Lyon, Pierre Bénite, France.
authors.forename: Emmanuel
authors.initials: E
authors.lastname: Disse
authors.affiliation: Biochemistry Department, Lyon Sud Hospital, Hospices Civils de Lyon, Claude-Bernard Lyon 1 University, Pierre Bénite, France.
authors.forename: Charlotte
authors.initials: C
authors.lastname: Cuerq
authors.affiliation: Biochemistry Department, Lyon Sud Hospital, Hospices Civils de Lyon, Claude-Bernard Lyon 1 University, Pierre Bénite, France.
authors.forename: Jocelyne
authors.initials: J
authors.lastname: Drai
authors.affiliation: Department of Radiology, E. Herriot University Hospital, Hospices Civils de Lyon, Claude-Bernard Lyon 1 University, Lyon, France.
authors.forename: Pierre-Jean
authors.initials: PJ
authors.lastname: Valette
authors.affiliation: Department of Endocrinologie, Diabète, Nutrition, Centre Intégré de l'Obésité Rhône-Alpes, Fédération Hospitalo-Universitaire DO-iT, Lyon Sud Hospital, Hospices Civils de Lyon, Claude-Bernard Lyon 1 University, 165 Chemin du Grand Revoyet, 69495, Pierre-Bénite Cedex, France.|Laboratoire CarMeN, Unité Inserm U1060 - INRA 1235 - INSA-Lyon, Pierre Bénite, France.
authors.forename: Martine
authors.initials: M
authors.lastname: Laville
authors.affiliation: Department of Endocrinologie, Diabète, Nutrition, Centre Intégré de l'Obésité Rhône-Alpes, Fédération Hospitalo-Universitaire DO-iT, Lyon Sud Hospital, Hospices Civils de Lyon, Claude-Bernard Lyon 1 University, 165 Chemin du Grand Revoyet, 69495, Pierre-Bénite Cedex, France.|Laboratoire CarMeN, Unité Inserm U1060 - INRA 1235 - INSA-Lyon, Pierre Bénite, France.
authors.forename: Charles
authors.initials: C
authors.lastname: Thivolet
authors.affiliation: Department of Endocrinologie, Diabète, Nutrition, Centre Intégré de l'Obésité Rhône-Alpes, Fédération Hospitalo-Universitaire DO-iT, Lyon Sud Hospital, Hospices Civils de Lyon, Claude-Bernard Lyon 1 University, 165 Chemin du Grand Revoyet, 69495, Pierre-Bénite Cedex, France.|Laboratoire CarMeN, Unité Inserm U1060 - INRA 1235 - INSA-Lyon, Pierre Bénite, France.
authors.forename: Chantal
authors.initials: C
authors.lastname: Simon
authors.affiliation: Department of Endocrinologie, Diabète, Nutrition, Centre Intégré de l'Obésité Rhône-Alpes, Fédération Hospitalo-Universitaire DO-iT, Lyon Sud Hospital, Hospices Civils de Lyon, Claude-Bernard Lyon 1 University, 165 Chemin du Grand Revoyet, 69495, Pierre-Bénite Cedex, France. cyrielle.caussy@chu-lyon.fr.|Laboratoire CarMeN, Unité Inserm U1060 - INRA 1235 - INSA-Lyon, Pierre Bénite, France. cyrielle.caussy@chu-lyon.fr.
authors.forename: Cyrielle
authors.initials: C
authors.lastname: Caussy
mesh_terms: D000328:Adult; D015415:Biomarkers / Q000378:metabolism; D001706:Biopsy; D015992:Body Mass Index; D015331:Cohort Studies; D054459:Elasticity Imaging Techniques; D005060:Europe; D005260:Female; D005355:Fibrosis / Q000473:pathology / Q000503:physiopathology; D006801:Humans; D008103:Liver Cirrhosis; D008297:Male; D000069342:Medical Overuse; D008875:Middle Aged; D065626:Non-alcoholic Fatty Liver Disease / Q000150:complications* / Q000628:therapy*; D009767:Obesity, Morbid / Q000150:complications* / Q000628:therapy*; D017410:Practice Guidelines as Topic; D012017:Referral and Consultation; D012189:Retrospective Studies; D012955:Societies, Medical
chemical_list: D015415:Biomarkers
keywords: Fibrosis; NAFLD fibrosis score; Non-alcoholic fatty liver disease; Non-alcoholic steatohepatitis; Obesity; Transient elastography