EASL Campus

FS, a male patient of Caucasian descent, 62 years old, diagnosed with type 2 diabetes at the age of 48, current BMI 29 kg/m², treated with metformin and empagliflozin, HbA1c 6.3% (45 mmol/mol), has chronically but only slightly elevated transaminases. He consumes 2 units of alcohol in the weekend, sporadically also on a weekday, not exceeding 6 units/week. A recent check shows a platelet count of 125 10e9/L. Subsequent abdominal ultrasound shows a slightly enlarged liver, hyperechogenicity of the parenchyma suggesting steatosis, a liver stiffness by VCTE of 26 kPa, CAP 328 dB/m and a spleen size of 15 cm.

Which of the following is the most appropriate management?

A. The cirrhosis should be confirmed, at least by a spleen stiffness measurement or, ideally, by a HVPG measurement (which could be combined with a biopsy) to inform not only screening for HCC but also diagnosis and subsequent management of clinically significant portal hypertension.

B. The patient most likely has MASH and hence semaglutide can be started to treat MASH and prevent evolution to liver-related events.

C. A GLP1RA can be considered for weight loss, but maintaining a protein intake of at least 1.5 g/kg adjusted body weight alongside a progressive physical training programme is mandatory. Patient should be encouraged to abstain from any alcohol consumption.

D. Given the benefits of weight loss on portal hypertension, bariatric endoscopy or surgery can be considered after assessment of the presence of clinically significant portal hypertension, the latter being a relative contra-indication to such an intervention.

E. HCC screening should be installed. There is no indication for a GLP1RA, treatment with empagliflozin and metformin can be continued. If a PEth test confirms the absence of significant alcohol use, the current consumption of alcohol, although to discourage, can be tolerated. A mediterranean diet and increased physical activity should be recommended and ideally supported by a multidisciplinary team.