New liver disease tools help diagnose, treat older adults early

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The basics:

• MASLD is most common liver disease in the U.S.
• New drugs and tech give doctors alternatives to detect, treat disease
• Early detection can reverse fibrosis and prevent liver failure

Previously known as non-alcoholic fatty liver disease (NAFLD), metabolic dysfunction-associated steatotic liver disease is common in older adults. As people age, they often experience increased insulin resistance, visceral fat accumulation and reduced physical activity — all of which contribute to liver fat buildup. For older individuals, the mild liver fat that accumulates over decades can wind up progressing to chronic permanent liver damage, liver cancer and the need for a life-saving liver transplant.

Dr. Andrew Boxer, a gastroenterologist at Gastroenterology Associates of New Jersey, described MASLD as a “20, 30-year disease.”

“These things are slow. They take time. So, if you start becoming obese, having cholesterol problems or whatever at 40, this is going to affect you at like 60, 70,” said Boxer, who is certified by the American Board of Internal Medicine in gastroenterology and internal medicine.

“I see a lot of people in their 60s, 70s and 80s … and we’re finding that they’re cirrhotic, that they have advanced liver disease and things have just been ignored or not known to be looked at. And now we have a big problem on our hands that if we looked at five years ago and dealt with it … it would not be a problem,” Boxer said.

As the most common liver disease in the U.S., MASLD affects more than half of all Americans. However, less than 1% of adults are even aware that they have it — especially because it’s largely asymptomatic, according to a recently released study by health care company Kaiser Permanente.

One of the more severe forms of the condition, metabolic dysfunction-associated steatohepatitis (MASH), develops when fat buildup causes liver damage and inflammation. If it progresses to cirrhosis, extensive scarring and damage becomes much more difficult to reverse. Additionally, the risk of liver failure or liver cancer increases greatly.

Boxer said, “40% of Americans are estimated to have some form and 40% of that are estimated to have significant fibrosis that we should be treating to prevent liver failure. Those are big numbers.”

He went on to say that patients are usually surprised to be diagnosed. “You may see some stuff on blood tests – but that’s about it. Even with liver disease and even if someone’s cirrhotic, they’ll have no symptoms until we get what we call decompensated cirrhosis,” he explained. “This is a very, very silent disease.”

According to Yale Medicine, between 6 million and 8 million people in the U.S. have MASH with moderate to advanced liver scarring. By 2030, it is projected that 100 million Americans will have the disease and it will become the leading indication for liver transplantation in U.S. adults, surpassing hepatitis C.

Boxer said, “One way to think about this is as heart disease of the liver. The stuff you worry about with heart disease – fried food, fatty food, highly caloric, processed foods, smoking, sedentary lifestyle, things like that – are all things that affect the liver.”

While the American Association for the Study of Liver Diseases does not officially recommend routine screening of all patients for fibrosis, the organization encourages doctors to actively check individuals who have risk factors, such as obesity, diabetes and metabolic syndrome.

Because those patients are considered higher-than-usual risk for MASH, screening could help detect fibrosis early and ultimately prevent liver failure down the line.

The most accurate way to check for fibrosis is by performing a liver biopsy to examine tissue samples. Although it is considered the diagnostic standard, the procedure is invasive and carries the risk of complications like bleeding or infection.

But there are a growing number of alternatives doctors can turn to that are noninvasive and provide much of the same information without requiring needle insertion into the liver. Such tools include performing elastography testing using specialized ultrasound (FibroScan) or MRI-based diagnostics to measure liver stiffness and fat content. Specialized blood tests – or a combination of routine blood tests – can also help determine possible liver scarring in patients with MASLD.

The ‘gamechanger’

Since the key drivers of MASLD are conditions that can be improved via lifestyle changes – such as Type 2 diabetes, obesity, hypertension and abnormal cholesterol levels – diet and exercise has been the only way to treat the disease.

However that changed in March 2024, when the U.S. Food and Drug Administration approved resmetirom. The pill treats MASH with moderate to advanced liver scarring (fibrosis). Sold under the brand name Rezdiffra, it can help reduce the amount of fat that is collected in the liver. The treatment is designed to be used alongside dietary changes and exercise.

Boxer described the drug as a gamechanger. “Before that, there was not much you could do. You tell people to diet, exercise or have weight loss surgery – things like that,” he said, adding, “This medicine is very effective and safe.”

Boxer also pointed to the technologies that have made imaging “much easier and more available,” saying, “The technology to look wasn’t really so prevalent until recently.”

For example, after FibroScan gained FDA clearance in 2013, the transient elastography has gained wide clinical use across the U.S. A non-invasive tool, FibroScan measures liver stiffness, which helps evaluate the degree of scarring and fatty changes in liver tissue.

GANJ recently became one of the first practices in New Jersey to acquire Velacur, a breakthrough ultrasound solution that provides real-time, artificial intelligence-guided quantification of crucial markers for chronic liver disease.

Developed by Canadian health technology company Sonic Incytes, Velacur aims to make liver imaging both affordable and accessible at the point of care. A handheld, point of care ultrasound solution, the machine quantifies liver disease using technology similar to MRI elastography combined with 3D tissue sampling.

Besides being non-invasive and comfortable, undergoing a screening with Velacur takes about less than 10 minutes and can be performed in a doctor’s office.

According to Sonic Incytes, Velacur provides consistently accurate results that enable a clear picture of liver health in real time, so doctors can be confident in the diagnosis, treatment and care of patients.

After securing FDA approval in July 2020, Velacur began its U.S. rollout at Northwell Health, the largest health care provider in New York state. At the time of its launch, Sonic Incytes pointed to the “urgent need for a cost-effective, quick and accurate diagnostic solution” given the “continued growth in patients and emergence of potential new therapies.”

With MASLD considered the fastest growing and largest segment of chronic liver disease, Boxer said GANJ “thought it was important enough” for the practice to bring Velacur to patients in New Jersey.

GANJ’S integrated group practice is made up of 50 doctors across 28 offices in seven counties in New Jersey. According to Boxer, it has acquired four Velacur machines so far.

“We think it will help prevent a lot of disease moving forward,” he said.

After performing a “quick, painless scan,” doctors can determine how much fat is in the liver and how much scarring there is, Boxer said.

“And then based on that, you can do something to reduce that risk of cirrhosis and liver failure,” said Boxer. He added that a patient care plan could also include making lifestyle changes, prescribing Rezdiffra, or conducting regular monitoring of liver function and fibrosis risk.

“It’s safe, easy, noninvasive and has no risk. And, it’s something that could provide great information that could stop liver failure in its tracks – not only stop but reverse,” Boxer said. “Once you become cirrhotic, things are too late … but if we just find some fibrosis before cirrhosis, we could reverse all this.”