Fatty Liver Disease Referral Guidelines

Indications for Referral 

• Persistent elevation of ALT >2× upper limit of normal (ULN) on at least 2 occasions, 3-6 months apart
• ALT ≥80 U/L at any time
• Hepatic steatosis noted on imaging (ultrasound) with risk factors for MASLD
• Presence of obesity (BMI ≥95th percentile) or overweight (BMI ≥85th percentile) with cardiometabolic risk factors

Required Pre-referral Workup

• Repeat ALT, AST, GGT, fractionated bilirubin, albumin, INR
• Metabolic screening: HbA1c, fasting lipids
• Baseline abdominal ultrasound within past 12 months

Referral Process

• Submit referral including growth charts, lab results and imaging reports
• Document lifestyle history (dietary habits, activity level, screen time)
• Include family history of metabolic syndrome, diabetes or fatty liver disease

Clinic Workflow

• Comprehensive hepatology evaluation including dedicated dietitian services and Spanish language interpreter
• Fibrosis risk assessment (noninvasive markers including elastography)
• Individualized lifestyle and metabolic counseling

Follow-Up

• Follow-up every 3-6 months depending on ALT trend
• Shared care with primary provider

Indications for Referral to General Hepatology Clinic

Providers should refer pediatric patients with suspected or confirmed liver disease other than MASLD to general hepatology clinic, NOT MASLD clinic.

• Imaging findings concerning for advanced liver disease, including splenomegaly or signs of portal hypertension
• Clinical signs suggestive of advanced liver involvement, such as jaundice, firm hepatomegaly or splenomegaly
• Laboratory evidence of possible fibrosis or synthetic dysfunction, including:
  • Platelet count <150,000/µL
  • INR >1.3
  • Low albumin