Liver fibrosis screening
We were the first primary care office in California to treat a patient with Rezdiffra for liver fibrosis identified on the guideline-recommended Fibroscan liver ultrasound now provided in our office. We are one of the first primary care offices in the Bay Area to provide the Fibroscan ultrasound in-house. The FDA has just approved Wegovy (August 2025) for liver fibrosis, becoming the second approved medication after Rezdiffra (March 2024).
Liver fibrosis is a dangerous disease and very common and nearly always asymptomatic – you don’t feel anything abnormal. Liver fibrosis is the first major independent risk factor for heart attack in decades and can lead to liver failure called cirrhosis which can require a liver transplant and can also cause liver cancer. Besides alcohol, simply the accumulation of fat in the liver called fatty liver (“liver steatosis”) can cause the inflammation of the liver cells called fibrosis that can cause cirrhosis.
80 to 100 million Americans, 34% of US population, have fatty liver (steatosis) and 7% have liver fibrosis. 70% of those with diabetes have fatty liver. Already liver cirrhosis (liver failure) due to liver fat is the leading cause of liver transplantation in the United States, ahead of alcohol-caused cirrhosis in women and soon to be for men. It is projected that in year 2050 so many people will need liver transplants that there won't be enough donor livers or hospitals to do the procedures.
Risk factors for liver fibrosis are obesity (BMI 30+), diabetes, prediabetes, alcohol use, insulin resistance, abnormal cholesterol or triglycerides, high ALT or AST lab result, lack of exercise, age over 40 and hypertension (high blood pressure).
If you have any of the above risk factors, you need to find out whether you may have liver fibrosis by checking your FIB-4 score yourself, entering your most recent standard lab results (ALT, AST and platelets) here: https://www.mdcalc.com/calc/2200/fibrosis-4-fib-4-index-liver-fibrosis and if above 1.0, have the most highly-recommended confirmatory test, the Fibroscan liver ultrasound in our office to find out whether you have fatty liver (steatosis) or liver fibrosis. See below why I and many other doctors use the FIB-4 cutoff of 1.0*.
The Fibroscan ultrasound is FDA approved, convenient (20-30 minutes in our office), inexpensive, covered by insurance and recommended by all guidelines for liver fibrosis testing.
The Fibroscan is covered by insurance in the presence of risk factors. If youhave not met your deductible the cost is $140 to $280 for commercial insurance and $140 for Medicare. A required subsequent remote results discussion visit (billed as a standard 99213 or 99214 office visit depending on discussion complexity) is covered but subject to deductible.
We send your report and the results visit note to your primary care physician and schedule any recheck Fibroscans required based on your having liver steatosis (fat) or liver fibrosis, at our office in the future.
We provide Fibroscan (and IMT) testing and results discussion visit without further primary care services to patients of any age but only provide further primary care services to patients age 18 through 69 at the time of joining the practice. We accept only PPO commercial, traditional Medicare or PPO Medicare Advantage, but do not accept Medi-Cal (out of pocket not legally allowed for Medi-Cal but OK for all other insurance) or HMO of any kind. Asking insurance whether BASS Medical Group tax ID 562-605-608 is in-network is required to determine insurance network participation.
* Rather than using the old definition of MASH of elevated ALT, the more appropriate measure is elevated FIB-4, for the following reason: FIB-4 correlates better than elevated ALT with future negative liver-related outcomes such as bleeding varices and hepatic encephalopathy. Multiple guidelines recommend following an elevated FIB-4 value with a Fibroscan test to confirm and quantify the presence of hepatic fibrosis.
A FIB-4 value of 1.0 or greater is a more medically correct definition of MASH than a value of 1.3 or greater, for the following reasons:
- The resmetirom MAESTRO-NASH study found FIB-4 values of 1.0 to 1.8, average of 1.3, among study participants, who all had biopsy proven hepatic fibrosis. Therefore, 50% of these patients with fibrosis would have been missed using a FIB-4 cutoff of 1.3. A Phase 3, Randomized, Controlled Trial of Resmetirom in NASH with Liver Fibrosis Authors: Stephen A. Harrison, M.D., Pierre Bedossa, M.D., Ph.D., Cynthia D. Guy, M.D., Jörn M. Schattenberg, M.D. Published February 7, 2024 N Engl J Med 2024;390:497-509 DOI: 10.1056/NEJMoa2309000 VOL. 390 NO. 6
- https://doi.org/10.1053/j.gastro.2023.06.013 Gastroenterology 2023;165:1080–1088. AGA Clinical Practice Update on the Role of Noninvasive Biomarkers in the Evaluation and Management of Nonalcoholic Fatty Liver Disease: Expert Review. Julia J. Wattacheril,1,2,* Manal F. Abdelmalek,3,* Joseph K. Lim,4 and Arun J. Sanyal5
Page 1082, first full paragraph, states that the performance of a FIB-4 cutoff of 1.24 showed a specificity for the absence of advanced fibrosis of 71.2%, indicating 28.8% of patients with advanced fibrosis would be classified as normal due to a FIB-4 value less than 1.24. The percent of early hepatic fibrosis patients mis-classified as normal with a FIB-4 cutoff of 1.24 would of course be higher. This is unacceptable for a screening test for such a dangerous and treatable condition as hepatic fibrosis, which should detect a wider group of patients who may have hepatic fibrosis, given that the more definitive non-invasive imaging Fibroscan test is safe, inexpensive and easily accessible to confirm and quantify the presence of hepatic fibrosis.
