Bartlett, Johanna M. Ascher

INTRODUCTION: Nonalcoholic fatty liver disease (NAFLD) has become the most common form of chronic liver disease. Determining the severity of NAFLD using the presence of nonalcoholic steatohepatitis (NASH) and stage of liver fibrosis is important, yet liver biopsy remains the gold standard despite limitations to its use. This study surveyed pediatric gastroenterologists across the United States to determine which guidelines are used to determine the severity of NAFLD in children, which patients undergo liver biopsy, and how these guidelines compare to each other and to clinical practice. METHODS: 140 pediatric gastroenterologists were surveyed electronically regarding current diagnostic practices for NAFLD. Responses were reviewed in Survey Monkey and compared to current North American Society for Pediatric Gastroenterology, Hepatology and Nutrition (NASPGHAN), American Association for the Study of Liver Diseases (AASLD) and European Society for Pediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN) guidelines regarding liver biopsy for evaluation of NAFLD. RESULTS: 140 surveys were distributed with 54 responses, a 38.6% response rate. Participants included pediatric gastroenterologists, hepatologists and transplant hepatologists. 96.2% reported familiarity with NASPGHAN guidelines, 22.6% with ESPGHAN and 39.6% with AASLD. 88.7% of responders desired a generalized consensus regarding proper diagnosis. Pediatric gastroenterologists referred obese patients with abnormal liver enzymes suspected to have NAFLD 22% of the time, pediatric hepatologists 27.2%, and transplant hepatologists 39.9% (one-way ANOVA with P -value of 0.324). 61.5% of responders reported using Fibroscan and 59.6% used MR elastography to assess severity of NAFLD and presence of liver fibrosis when not pursuing liver biopsy. 92.5% of responders believed the presence of autoimmune antibodies was important in deciding when to proceed to liver biopsy, as well as 88.7% using abnormal screening labs and 75.5% using imaging suggestive of liver fibrosis. CONCLUSION: Comparison between the criteria that providers believed warranted a liver biopsy versus those included in society guidelines differed. The presence of autoimmune antibodies, abnormal screening labs, and liver fibrosis suggested on imaging all appeared to be important factors regardless of current guidelines. Providers also seem to rely on Fibroscan and MR elastography over liver ultrasound despite the lack of validated cutoff values in children.