Liver biopsy for NASH diagnosis

Shira Zelber-Sagi, PhD, RD, is a professor and head of the School of Public Health at the University of Haifa, Israel.

When should a patient with hepatic steatosis be referred for liver biopsy necessary to diagnose nonalcoholic steatohepatitis (NASH)?

In many cases liver biopsy is not necessary because we have now noninvasive tests, which are highly validated. For the diagnosis of steatosis, we have abdominal ultrasound and controlled attenuation parameter (CAP). For the diagnosis of advanced fibrosis, we have FibroScan, which is a good imaging method, highly validated, noninvasive at all. And we have some markers, like the FIB-4 score.

The only problem is that we don’t have noninvasive methods to diagnose nonalcoholic steatohepatitis (NASH) and for that we need a liver biopsy. But in most cases we don’t need to know if a patient actually has NASH.

The leading reason to know whether a patient has NASH is for clinical trials or for future medications. Right now there are no medications for the treatment of nonalcoholic fatty liver disease (NAFLD), but in the future, when there will be medications targeting the treatment of NASH, we may want to do liver biopsy to diagnose NASH in these patients. But these are just the only reasons that I can think about.

When the physician decides to send [the patient] for liver biopsy, it is usually because they’re uncertain of the diagnosis. If there is uncertainty of the diagnosis of NAFLD and they think there is another underlying disease, they might send [the patient] for liver biopsy, testing for hemochromatosis, for example, or for autoimmune liver disease. If they’re uncertain, then they will send for liver biopsy. Or if they want to recruit the patient to a clinical trial looking for medication for NAFLD, then they must do a liver biopsy.