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Best Practice Guideline for the Nurse's role in caring for people with, or at risk of Metabolic Dysfunction-Associated Fatty Liver Disease (MAFLD) - Survey

The AHA have created a draft best practice guideline for the nurse’s role in caring for people with, or at risk of Metabolic dysfunction-associated fatty liver disease (MAFLD). Please review each section below and add any comments you would like to be considered. Suggestions can be made until midnight on Sunday 7 June. AHA will also be holding a webinar to discuss the guidelines on Wednesday 3 June at 6pm AEDT. To register for the link, please visit our website.
The Nurse's role in MAFLD care.
Nurses play a vital role in identifying people with, or at risk of MAFLD including those who have progressed to advanced chronic liver disease. They provide culturally appropriate, person-centred education and care tailored to the individual’s diagnosis, disease severity, comorbidities, background, health literacy and cognitive status.

AHA members encountering people with, or at risk of MAFLD are located across various healthcare settings and work collaboratively within the multidisciplinary team (for example hepatologists, gastroenterologists, general physicians, general practitioners (GPs), dietitians, exercise physiologist, Aboriginal healthcare workers and other allied health professionals) and implement management and treatment plans within their scope of practice.

When recommendations in this guideline fall outside of their scope, nurses should collaborate with other appropriate healthcare team members to ensure safe and effective implementation and management.

Do you agree with this statement?
1. Identify people at risk.

Please advise if you agree with the elements of care below:
Nurses play a key role in identifying people living with:

  • Obesity (including central obesity) and/or type 2 diabetes (T2DM), or
  • A combination of two or more metabolic risk factors (e.g. they have or are on medication for hypertension, dyslipidaemia, impaired fasting glucose levels or prediabetes, central adiposity based on waist circumference).
2. Test people at risk.

Please advise if you agree with the elements of care below:
Nurses can advocate for both the opportunistic and systematic screening of those with risk factors for MAFLD. This includes encouraging patients to maintain regular contact with a GP/Primary Care Nurse Practitioner (NP) to ensure appropriate risk assessments and investigations for MAFLD are completed.

Nurses can facilitate the following investigations, support patient attendance for testing and appointments, as well as documenting, reviewing, communicating and escalating reported findings. Nurses should interpret results only where this falls within their scope of practice.

Detect steatosis with:
  • Liver ultrasound which is widely available and will often be the test that leads to a referral. Ultrasound has good sensitivity (85%) for identifying hepatic steatosis and should be the first-line test to diagnose in those at risk.
  • Controlled Attenuation Parameter (CAP) score using vibration-controlled transient elastography (VCTE or Fibroscan®) which has good sensitivity in detecting moderate hepatic steatosis (84%) and is typically available in hospital liver clinics and in some community settings.
The presence of hepatic steatosis does not always mean liver scarring or fibrosis and often that is not the case. However a fibrosis assessment should occur.

Assess for fibrosis using non-invasive fibrosis tests:
  • Calculate a FIB-4 score using results for ALT, AST and platelet count plus the patient’s age (use QR code for link to online calculator) or,
  • Facilitate direct serum fibrosis testing if available (such as Enhanced Liver Fibrosis (ELF) score or Hepascore) though they are not covered by Medicare rebates.
  • Use an imaging-based elastography test such as: VCTE (Fibroscan®)- typically available in hospital liver clinics and in some community settings; or facilitate the use of other methods available from community radiology providers such as shear wave elastography (SWE) or acoustic radiation force impulse (ARFI) though none of these are currently covered by Medicare rebates.
3. Assess people diagnosed with MAFLD.

Please advise if you agree with the elements of care below:
Within their scope, nurses can identify and assess existing comorbidities associated with MAFLD and also assess for other causes of liver disease (e.g. alcohol, medications, drug induced liver injury, viral hepatitis, iron overload, autoimmune disease and others) with thorough history taking and facilitating appropriate laboratory testing only where this falls within their scope of practice and in accordance with their healthcare facility policy.

Refer people with evidence of advanced chronic liver disease (based on clinical, biochemical or sonographic markers, or VCTE) to a clinician with expertise in liver disease.

Measure and record Body Mass Index (BMI), waist circumference and vital signs to assess for evidence of co-existing conditions such as obesity and hypertension.

Assess people with MAFLD living with obesity as per the Australian Obesity Management algorithm.

Assess for undiagnosed T2DM by facilitating testing for, or reviewing serum fasting glucose and/or HbA1c levels.

Assess for current or future risk for cardiovascular disease using Australian guidelines.

Assess for and exclude chronic kidney disease (facilitating testing for urine albumin/creatinine ratio and blood estimated glomerular filtration rate or eGFR) and obstructive sleep apnoea (using the Epworth Sleepiness Scale, STOP-Bang and OSA-50 questionnaires.

Assess for barriers to engagement in care considering social determinants of health to develop management strategies and a person-centred approach to MAFLD care.

Assess access to (and security around) housing, transport and internet as well as assessing poverty risk, work/life balance, education, family/carer responsibilities and social supports.

Assess coping strategies and mental health needs, with referral to appropriate supports as needed.

Assess vaccination history and recommend vaccinations in line with state/territory and national guidelines.
4. Educate people diagnosed with MAFLD.

Please advise if you agree with the elements of care below:
Nurses can provide culturally appropriate education, avoiding medical jargon, and tailoring information to the person’s level of health literacy. Where needed, translated materials and visual aids should be used to support understanding and engagement. Topics could include:
  • Exploring religious and cultural beliefs and addressing misconceptions about liver health.
  • Assessing and understanding the patient’s experiences of stigma relating to liver disease, body weight and alcohol use.
  • The natural history of MAFLD and the potential progression to HCC, with or without advanced chronic liver disease.
  • The link between MAFLD and cardiometabolic and renal conditions.
  • The ongoing monitoring requirements checking for fibrosis progression and potentially undertaking hepatocellular carcinoma (HCC) surveillance where indicated.
  • The signs and symptoms of worsening liver disease and when to seek urgent care.
  • The MAFLD nutritional principles (e.g. Mediterranean-style diet) physical activity goals and impact of weight loss (as outlined in the MAFLD patient resource from GESA.
  • Behavioural and lifestyle changes (e.g. alcohol reduction, smoking cessation·, increased physical activity – see TREATMENT & CARE section).
5. Provide treatment & care

Please advise if you agree with the elements of care below:
Nurses can provide MAFLD‑related care and implement strategies to prevent disease progression, including optimal cardiometabolic control and sustained lifestyle interventions (such as dietary and behavioural modification +/- pharmacotherapy), ideally in collaboration with guidance from an Accredited Dietitian and/or Exercise Physiologist. Treatment targets include (in part, outlined in the MAFLD patient resource from GESA):

Weight loss
  • ≥5% of current body weight to reduce levels of hepatic steatosis.
  • 7-10 % of current body weight to reduce levels of hepatic inflammation.
  • >10% of current body weight to improve/reduce fibrosis formation.
  • Converting these percentages to kilograms will help improve patient understanding and provide them with a target to aim for.
Diet
  • Eat a plant-rich healthy diet such as the Mediterranean-style diet, include vegetables, fruits, wholegrains, legumes, nuts and seeds, olive oil, oily fish and moderate dairy and white meat.
  • Consider short term low-fat and/or low-carbohydrate dietary approaches to support weight loss.
  • Limit the consumption of red met, ultra-processed foods, saturated fats and refined grains (such as carbonated drinks, fast foods, packaged snacks, biscuits, confectionary, sugary cereals and reconstituted meat products).
  • Limit food and beverages with a high added fructose content.
Physical activity and exercise
  • Aim for 150-240 minutes per week (2hrs 30mins – 4hrs) of moderate-to vigorous-intensity aerobic exercise (e.g. walking, swimming, cycling). As little as 135 minutes per week (2hrs 15min) can result in a reduction in hepatic steatosis .
  • In addition to aerobic exercise, aim to incorporate 2-3 resistance training/muscle strengthening exercises per week.
  • Prioritise resistance training for people actively losing weight (e.g. through diet or on pharmacotherapy) or for those with sarcopenia or frailty risk, to maintain/improve lean mass, neuromuscular strength, and functional capacity.
  • Tailor physical activity based on the person’s ability and preferences.
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Cont.

Alcohol intake
  • Alcohol causes fatty change in the liver that is indistinguishable from MAFLD and can cause liver disease on its own (Alcohol-related liver disease) or in combination with MAFLD (termed “MetALD”).
  • Individuals should be assessed, not just for intake but the risk of alcohol dependence, using a validated test such as the Alcohol Use Identification Test with people at high risk of alcohol dependence being referred.
  • People with MAFLD, even if not at high risk of alcohol dependence, should regularly monitor and reduce their alcohol intake if greater than safe daily or weekly limits.
  • For Australians without any health risk at all, the National Health and Medical Research Council currently recommends people consume no more than 10 standard drinks (100g of alcohol) per week and ≤4 standard drinks per day.
  • There is no health benefit from alcohol, and any more than one standard drink (10g alcohol) per day appears to cause progressive harm. There is increasing contention about guidelines condoning higher alcohol intake, and national alcohol consumption guidelines have been called into question, including in Australia. Be cautious about assessing alcohol problems and advising around alcohol intake.
  • For many people, any alcohol at all may cause harm to the liver, particularly if there is cirrhosis, and people with significant hepatic fibrosis (F2 and above) are advised to abstain from consuming alcohol. A harm reduction approach can be taken where complete abstinence is not achievable, though always consider referring patients to discuss further with their GP or an alcohol and drug counsellor or specialist service.
  • Discuss the carcinogenic effects of alcohol if appropriate, highlighting that even small amounts of alcohol increase cancer risk for a variety of cancers.
Medication-related care (within scope of practice)

  • Take a medication history and explain the benefits and side effects of cardiometabolic medications (including antihypertensives, statins, GLP-1 receptor agonists, GIP/GLP-1 receptor agonists, SGLT2 inhibitors, other weight-loss medicines) and address any liver-related concerns.
  • Co-prescribe pharmacological agents targeting weight loss and cardiometabolic/renal conditions, with diet and exercise advice.
  • Monitor patients for adverse effects and address/escalate if required.
  • Support medication adherence and treating to target for blood pressure, cholesterol, fasting glucose/HbA1c as per current guidelines.
  • Work with prescribing clinicians and pharmacists to ensure compliance with therapies.
Other non-pharmacological and holistic approaches

  • Provide support to patients being assessed for or undergoing weight-loss surgery or refer to a health professional with experience in this area.
  • Promote and encourage self-care with patients.
  • Involve the interdisciplinary team to address social isolation, financial/work/housing issues and emotional or mental health needs.
  • Discuss advance care planning and palliative care referral where disease is advanced and/or prognosis is limited.
  • Monitor unintentional weight loss and muscle loss (sarcopenia). If available, Bioelectrical Impedance Analysis (BIA) or Dual-Energy X-ray Absorptiometry (DEXA) scan can be used to monitor bone density and estimate body mass composition.
6. Support HCC Surveillance

Please advise if you agree with the elements of care below:
Nurses play an important role in:
  • Monitoring engagement in and adherence to HCC surveillance for those with advanced chronic liver disease.
  • Supporting, and where appropriate providing six‑monthly HCC surveillance via imaging (+/- serum Alpha Fetoprotein (AFP))
  • In the case of HCC, support and facilitate access to suitable HCC therapy.
7. Support MAFLD Monitoring & Adherence.

Please advise if you agree with the elements of care below:
Nurses support people living with MAFLD across various healthcare services by coordinating monitoring and facilitating adherence to treatment plans by:
  • Repeating a fibrosis assessment every 3 years for those at low risk of progression to advanced fibrosis.
  • Repeating a fibrosis assessment annually for those with advanced chronic liver disease.
  • Developing a MAFLD monitoring plan for older people, on a case-by-case basis and in the presence of various other cardiometabolic/renal conditions which have similar monitoring cycles and investigations.
  • Completing BMI and/or waist circumference annually.
  • Monitoring for development of T2DM as per current Australian guidelines.
  • Monitoring for cardiometabolic risk (including obesity, hypertension, T2DM, hypercholesterolaemia, renal impairment).
  • Promoting adherence to care plans and prescribed MAFLD treatment and addressing any barriers.
  • Exploring supportive strategies (family, community, employer, allied health, mental health, health tracking apps) aimed at supporting a person with long-term engagement in treatment and with care recommendations.
8. Advocate.

Please advise if you agree with the elements of care below:
Nurses can:

  • Assess and address barriers to care.
  • Promote and encourage the use of community-based self-management strategies (such as self-monitoring of weight, waist circumference, blood pressure, glycaemic control, food diary, physical activity logs, personalised goal setting, and food/exercise stimulus controls, engagement with health promotional programs).
  • Explore and develop flexible models of care to better support people moving between various health settings and location.
8. Support the management of Advanced Liver Disease (if present)

Please advise if you agree with the elements of care below:
In line with AHA Advanced Liver Disease guidelines, nurses can:
  • Assess for portal hypertension, jaundice, oedema and ascites, hepatic encephalopathy, bone disease, nutritional needs, and pain management.
  • Organise and support attendance at specialist and imaging appointments, and for procedures.
  • Provide telephone/telehealth support to help manage symptoms, navigate appointments and address health concerns early.
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