How should I approach the assessment of liver function in a patient with suspected NAFLD?

Approach to assessment of liver function in suspected NAFLD:

• Do not rely on routine liver blood tests (LFTs) to diagnose NAFLD or to assess for advanced liver fibrosis, as they may be normal even in progressive disease.
• Take a detailed alcohol history to exclude alcohol-related liver disease.
• Use liver ultrasound to detect hepatic steatosis if NAFLD is suspected, especially in people with type 2 diabetes or metabolic syndrome who do not misuse alcohol.
• Assess risk of advanced liver fibrosis using non-invasive tests such as the enhanced liver fibrosis (ELF) test, NAFLD fibrosis score (NFS), or FIB-4 score rather than routine LFTs.
• Refer patients with high risk of advanced fibrosis (e.g., ELF score ≥10.51) or clinical signs of advanced liver disease to a hepatology specialist for further assessment, which may include transient elastography (FibroScan) or liver biopsy.
• For patients at low risk of advanced fibrosis, manage in primary care with lifestyle advice and reassess fibrosis risk every 3 years using non-invasive tests.
• Monitor and manage associated metabolic risk factors (type 2 diabetes, hypertension, dyslipidaemia) and cardiovascular risk as part of holistic care.

This approach ensures accurate assessment of liver disease severity while avoiding over-reliance on LFTs, which can be misleading in NAFLD.

References: ¹,²,³