Patel, Preya Janubhai; (2025) Awareness and recognition of non-alcoholic fatty liver disease and the utility of non-invasive biomarkers in risk stratifying liver fibrosis. Doctoral thesis (Ph.D), UCL (University College London).

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Abstract

Non-alcoholic fatty liver disease (NAFLD) is a leading cause of chronic liver disease in many developed countries and affects up to 30% of the general population. The aims of this thesis are to investigate the current awareness and recognition of non-alcoholic fatty liver disease and to assess the utility of non-invasive biomarkers of liver fibrosis in risk-stratifying liver disease in a high-risk population. This thesis comprises 3 individual studies: • Assessment of index presentations of NAFLD patients being assessed for liver transplantation; • A survey investigating Australian primary care clinicians’ knowledge of the management of NAFLD; and • An assessment of the utility of a stepwise approach to targeted testing of a population at high-risk of significant liver fibrosis due to NAFLD with non-invasive biomarkers of disease. This thesis found that 64.2% of patients with NAFLD being assessed for liver transplantation presented with decompensated liver disease. The GP survey found that over 50% of respondents considered the prevalence of NAFLD to be ≤10% in the general population. The chapters assessing the utility of a risk stratification pathway found that the NAFLD fibrosis score and Fibrosis-4 scores had a high negative predictive value (>90%) for excluding advanced fibrosis defined by liver stiffness measurement (LSM) or the Enhanced Liver Fibrosis test (ELF). However, 84.1% of patients had an indeterminate or high score requiring further assessment, amongst whom advanced fibrosis (LSM≥8.2kPa and ELF≥9.8) was present in 31.3% and 28.6% of patients respectively. The study also identified that rising age and a greater BMI were independently associated with higher fibrosis scores as determined by ELF or LSM respectively. This thesis highlights patients with NAFLD often present with advanced disease due to poor recognition of the condition. A stepwise targeted testing pathway can identify those patients at significant risk of liver fibrosis permitting instigation of appropriate clinical management.

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