Evolution of Our Cardiometabolic

Clinical Approach
[Name]
[Date]
car·di·o·met·a·bol·ic | adjective 
Concerning both cardiovascular disease (CVD) and
metabolic disorders such as type 2 diabetes (T2DM),
chronic kidney disease (CKD), and nonalcoholic fatty
liver disease (NAFLD)
 Dramatic rise in US obesity rates1
Percentage of obese (BMI ≥30) adults
1990 2018

Data indicate that the prevalence of obesity in the United States is now 42.4%.2

1. Robert Wood Johnson Foundation. Adult obesity rates. State of Childhood Obesity. Accessed December 10, 2021. https://stateofchildhoodobesity.org/adult-obesity/ 2. Hales CM, et al. Prevalence of obesity and severe obesity
among adults: United States, 2017–2018. NCHS Data Brief, no 360. National Center for Health Statistics. 2020. Accessed December 10, 2021. https://www.cdc.gov/nchs/products/databriefs/db360.htm

3
Obesity and diabetes: risk factors for CVD
By 2030, the prevalence of
obesity is expected to soar to Cardiovascular mortality trends2

50%
1

1. Ward ZJ, et al. N Engl J Med. 2019;381(25):2440-2450. doi: 10.1056/NEJMsa1909301 2. Virani SS, et al. Circulation. 2021;143(8):e254-e743. doi: 10.1161/CIR.0000000000000950

4
 The root of the problem is shared risk factors

CVD T2DM

Above the surface,

NAFLD you see the
CKD
CLINICAL
MANIFESTATIONS
of the problem.

Obesity
Dig deeper with diagnostic
Family insights to find the
History Lifestyle
ROOT CAUSE.
Age
Metabolic
dysfunction
5
 Diagnostics insights across cardiometabolic continuum
Prevention-focused clinical approach
Metabolic dysfunction
• Metabolic Risk Panel
• Insulin Resistance
Panel with Score

Cardiovascular disease Type 2 diabetes

Cardiometabolic • Advanced lipid testing

• Inflammation testing
• Diabetes risk panels
• Newly diagnosed and
• Cardiogenetic testing monitoring panel
Prevention, diagnosis, and management of • Heart failure testing
heart disease and metabolic-associated
conditions

• Unique diagnostic approach aligns with

thought leaders at key industry organizations
• Interconnected, not siloed, approach focused
on the whole patient
• Focused on metabolic dysfunction Fatty liver disease
foundation to assess wellness and fibrosis
Chronic kidney disease
• FIB-4 Index Panel
• Kidney Profile
• Helps healthcare providers risk-stratify their • Enhanced Liver
• Cystatin C
high-risk patients Fibrosis (ELF) score
• NAFLD Fibrosis
Score
6
 Improve clinical outcomes through early
identification and intervention
A comprehensive test menu spanning the continuum provides the opportunity to apply timely
evidence-based preventive strategies.
Disease continuum
Risk for disease Disease diagnosis Disease management

Glomerulus Obesity/dyslipidemia/ Metabolic

Prediabetes Type 2 diabetes
insulin resistance syndrome

Nonalcoholic
Nonalcoholic fatty liver Fibrosis Cirrhosis
steatohepatitis

High risk for end-stage

Microalbuminuria Chronic kidney disease
renal disease

Oxidation/ Subclinical coronary Stable/unstable coronary Myocardial

Heart failure
inflammation artery disease artery disease infarction/stroke

7
 Cardiometabolic value proposition and
clinical approach
Powering affordable care + clinical education + risk interpretation
Clinical VP by disease state Risk-stratification tools Ease of interpretation through enhanced reporting Clinical education

Insulin Resistance
Panel with Score Metabolic Risk Panel
Sample Report
Metabolic Risk Panel

Advanced lipids
Commercial clinical value prop presentation Advanced Lipids
Sample Report
Inflammation markers
Early identification of patients at
increased cardiometabolic risk
Kidney Profile Kidney Profile
Sample Report

FIB-4 Index Panel

Enhanced Liver
Fibrosis (ELF)score NASH Enhanced
Report

8
 Powering Affordable Care
Help identify hidden risk of heart disease and metabolic-associated conditions earlier

9
 Shine a light on patients at increased risk
for cardiometabolic disease.

10
Type 2 Diabetes
Reference Progression of Metabolic Dysfunction
from the printed kit
 Why the epidemic of T2DM?

88 million 34 million 27 million

are at risk for type 2 are estimated to cases of T2DM have been
diabetes (T2DM) have T2DM diagnosed1

US adult population 2017-20182

24.8% Obese Overweight

42.5%
1.6%
Underweight Normal BMI
31.1%

If metabolic dysfunction is identified at any stage, assessment of CVD, CKD, and NAFLD risk may be warranted.

1. Centers for Disease Control and Prevention. National Diabetes Statistics Report, 2020. US Department of Health and Human Services; 2020. 2. Fryar CD, et al. Prevalence of overweight, obesity, and
severe obesity among adults aged 20 and over: United States, 1960–1962 through 2017–2018. NCHS Health E-Stats. 2020.

12
 Pathophysiology: progression from insulin
resistance to T2DM
Healthy (insulin sensitive) Insulin resistance Prediabetes Type 2 diabetes
Pancreas

Insulin

Circulating blood
Glucose

Target cell
Insulin Glucose
receptor transporter

13
 Indicators of risk for T2DM1
Polycystic ovarian
Physical inactivity Hypertension
syndrome

Elevated fasting blood Elevated triglyceride and/or

glucose or impaired low HDL level Multiple skin tags2
glucose tolerance

Overweight and
obesity, particularly
Family history of diabetes >45 Age older than 45 years
abdominal adiposity

History of heart attack or

Acanthosis nigricans
History of adverse stroke
pregnancy outcomes,
such as gestational
diabetes or
Ethnic heritage
preeclampsia

1. Ley SH, et al. Diabetes in America. 3rd ed. 2018: NIDDKD. Chapter 13.  2. Duff M, et al. Clin Diabetes. 2015;33(1):40-48. doi: 10.2337/diaclin.33.1.40

14
 A preemptive approach to improving
clinical outcomes

IDENTIFY | ACT | PREVENT

Identification of metabolic risk at an early stage allows implementation of
evidence-based strategies that can prevent or delay disease progression.
Preemptive intervention can minimize the risk for developing associated
cardiometabolic conditions such as CVD, CKD, and NAFLD/nonalcoholic
steatohepatitis.
 Hyperinsulinemia is implicated in the development of NAFLD1,2 and contributes to
CVD3
 Hyperglycemia can contribute to CKD4 and CVD5

If metabolic dysfunction is identified at any stage, assessment of CVD, CKD,

and NAFLD risk may be warranted.

1. Rhee EJ, et al. Am J Med. 2011;124(1):69-76. 2. Bril F, et al. J Clin Endocrinol Metab. 2021;106(11):e4360-e4371. 3. Reaven G. Arterioscler Thromb Vasc Biol. 2012;32(8):1754-1759. 4. National Kidney Foundation. Diabetes and kidney disease.
Accessed January 30, 2022. https://www.kidney.org/atoz/content/Diabetes-and-Kidney-Disease-Stages1-4. 5. National Institutes of Health. National Institute of Diabetes and Digestive and Kidney Diseases. Diabetes, heart disease, and stroke.
Accessed January 30, 2022. https://www.niddk.nih.gov/health-information/diabetes/overview/preventing-problems/heart-disease-stroke.

15
 Laboratory measurements that help define risk
Obesity/dyslipidemia/ Metabolic
Prediabetes Type 2 diabetes
insulin resistance syndrome

Risk for disease Disease diagnosis Disease management

Test codes* The following tests may help: Panel components may
be ordered separately:
Quest Cleveland Lipid Panel: Cholesterol,
Diagnostics HeartLab Biomarker Identify metabolic risk Diagnose or manage T2DM Total (91717, C117);
Accounts Accounts Triglycerides (91718,
36509 1388 Insulin Resistance Panel with Score x C119); HDL Cholesterol
93103 NA Insulin, Intact, LC/MS/MS x x (91719, C118)
Metabolic Risk Panel:
Glycemic based

91731 C146 Insulin Immunoassay (IA) x x Cholesterol, Total (91717,

23475 C505 Glucose Tolerance Test, 3 Specimens (75g) x x C117); Triglycerides
372 C136 C-Peptide Immunoassay (IA) x (91718, C119); HDL
Cholesterol (91719, C118)
91947 C101 Glucose x
Lipid Panel (91716,
91732 C145 Hemoglobin A1c x C906), Hemoglobin A1c
91716 C906 Lipid Panel x (91732, C145),
91604 1346 Lipoprotein Fractionation, Ion Mobility x Apolipoprotein B (91726,
Lipid based

C123), Insulin, Intact,

37847 37847 Lipoprotein Fractionation, NMR x
LC/MS/MS (93103),
91726 C123 Apolipoprotein B (ApoB) x Insulin Resistance Panel
92769 C335 Oxidized LDL (OxLDL) x with Score (36509, 1388)
39447 39447 Metabolic Risk Panel x x
15060 C314 Adiponectin x
Other

90367 90367 Leptin x

91735 C339 Vitamin D, 25-Hydroxy x

16
Cardiovascular
Disease
Reference Progression of Atherosclerosis from
the printed kit
 Why the magnitude of the CVD epidemic?

202 million 153 million 26 million

are at risk for cardiovascular are estimated to cases of CVD have been
disease (CVD)1 have CVD² diagnosed3

Trends in obesity and type 2 diabetes prevalence in Cardiovascular mortality trends3

the United States4,5
45% 42% 10%
40% 35%
35% 32% 8%
30%
30%
25% 6%
20% 4%
15%
10% 2%
5%
0% 0%
Prevalence, obesity Prevalence, diabetes
2000 2006 2012 2018 2000 2006 2012 2018

1. Michos ED, Khan SS. Further understanding of ideal cardiovascular health score metrics and cardiovascular disease. Expert Rev Cardiovasc Ther. 2021 Jul;19(7):607-617. 2. McClelland RL, et al. Circulation. 2006;113(1):30-37. doi: 10.1161/CIRCULATIONAHA.105.580696
3. Virani SS, et al. Circulation. 2021;143(8):e254-e743. doi: 10.1161/CIR.0000000000000950 4. Hales CM, et al. NCHS Data Brief, no 360. National Center for Health Statistics. NCHS. 2020. Accessed December 10, 2021.
https://www.cdc.gov/nchs/products/databriefs/db360.htm 5. Centers for Disease Control and Prevention. National Diabetes Statistics Report, 2020. US Department of Health and Human Services; 2020.

18
 CVD mortality in three metabolic diseases

Nonalcoholic fatty liver disease1 Chronic kidney disease2 Type 2 diabetes3

30%
40%
45%
55%
60%
70%

Mortality from CVD All other causes of death Mortality from CVD Non-CVD mortality Mortality from CVD Non-CVD mortality

1. Przybyszewski EM, et al. Clin Liver Dis. 2021;17(1):19-22. doi: 10.1002/cld.1017 2. United States Renal Data System. 2020 USRDS Annual Data Report: Epidemiology of kidney disease in the
United States. NIH, NIDDKD. 3. Laakso M. Diabetes Care. 2010;33(2):442-449. doi: 10.2337/dc09-0749

19
 Pathophysiology: progression of atherosclerosis
Atherosclerosis, the primary contributor to cardiovascular disease, is associated with specific
inflammatory biomarkers that can be measured to evaluate the risk of cardiovascular disease.

Adventitia 1. Healthy blood vessel

Media
2. Oxidation
Intima
(endothelium)​ 3. Plaque accumulation
and endothelial
damage
White blood cell
4. Disease activity and
vulnerable plaque
5. Plaque rupture
6. Myocardial
Intimal thickening infarction/stroke
Blood clot
Plaque

Calcified plaque Lp-PLA2 Plaque rupture Stiffening wall

Vulnerable plaque Macrophage Myeloperoxidase (MPO)​

20
 Acute coronary syndrome:
“Sudden” appearance of a decades-long process

• Although the manifestation of

CVD is often sudden, the
progression from the initial
atherosclerotic lesion (fatty
streak) to symptomatic
disease spans decades
• Standard CVD risk
assessment tools (eg, lipid
panel) often do not identify the
long, clinically silent period of
atherosclerotic progression

21
 Indicators of risk for CVD1
Family history premature Dyslipidemia
Hypertension
CVD

Elevated BMI Nonalcoholic fatty liver

(overweight/obese) Sedentary lifestyle disease

Poor dental hygiene/ Chronic inflammatory

Metabolic dysfunction conditions/autoimmune
(insulin resistance, type 2 periodontal disease2
disease
diabetes)
Adverse pregnancy
Smoking outcomes, such as Chronic kidney disease
gestational diabetes,
preeclampsia
Age (men, >45 y; women, Sleep duration; poor
Mental stress; depression
>55 y) sleep quality

1. Virani SS, et al. Circulation. 2021;143(8):e254-e743. doi: 10.1161/CIR.0000000000000950 2. Buhlin K, et al. J Clin Periodontol. 2011;38(11):1107-1014. doi: 10.1111/j.1600-051X.2011.01775.

22
 A preemptive approach to improve clinical outcomes

IDENTIFY | ACT | PREVENT

Advanced lipid and inflammation markers improve risk stratification to
uncover hidden risk beyond what is typically identified by a lipid panel.
Identify cardiovascular risk at an early stage to leverage evidence-based
strategies to delay disease progression and prevent major adverse
cardiovascular events.
If cardiovascular disease is identified at any stage, assess risk for related
cardiometabolic conditions, including T2DM, CKD, and NAFLD.

23
 Laboratory measurements to help define risk
Oxidation/ Subclinical coronary Stable/unstable coronary Myocardial
Heart failure
inflammation artery disease artery disease infarction/stroke

Disease diagnosis and management Heart failure diagnosis

Risk for disease
and management

Panel components may be

Test codes* The following tests may help: ordered separately:
Lipid Panel: Cholesterol,
Quest Cleveland Total (91717, C117);
Identify, diagnose, or manage
Diagnostics HeartLab Biomarker Identify risk of CVD Diagnose or manage CVD Triglycerides (91718, C119);
heart failure HDL Cholesterol (91719,
Accounts Accounts
C118)
91716 C906 Lipid Panel x x x Lipid Panel with Reflex to
Direct LDL: Cholesterol,
92061 C909 Lipid Panel with Reflex to Direct LDL x x x
Total (91717, C117);
91604 1346 Lipoprotein Fractionation, Ion Mobility x x Triglycerides (91718, C119);
37847 37847 Lipoprotein Fractionation, NMR x x HDL Cholesterol (91719,
Lipids

C118). If triglyceride result is

91726 C123 Apolipoprotein B (Apo B) x x >400 mg/dL, Direct LDL
91727 C511 ApoB/ApoA1 Ratio x x Cholesterol will be
performed at an additional
36406 1341 sdLDL x x
charge 
91729 91729 Lipoprotein (a)  x x ApoB/ApoA1 Ratio:
 NA 37812 HDL Function Panel with HDLfx pCAD Score x x Apolipoprotein B (91727,
C123), Apolipoprotein A1
92771 C261 F2-Isoprostane/Creatinine Ratio x (91724, C122)
92769 C335 Oxidized LDL (OxLDL) x HDL Function Panel with
Inflammation

HDLfx pCAD score: AALP

 NA C919 Microalbumin/Creatinine Ratio x
ApoA-I (37838); AALP ApoC-
91737 C121 hs-CRP x x I (37864); AALP ApoC-II
94153 C301 ADMA/SDMA x x (37865); AALP ApoC-III
(37866); AALP ApoC-IV
94218 94218 Lp-PLA2 Activity x x (37867)
92814 C133 Myeloperoxidase (MPO) x x
92701 C302 OmegaCheck® x
19826 C295 Coenzyme Q10 x
91733 C308 Homocysteine x
91743 C334 Fibrinogen Antigen, Nephelometry x
Other

94154 C524 TMAO (Trimethylamine N-oxide) x

16174 C922 AspirinWorks® 11-Dehydrothromboxane B2 (11-dhTXB2) with Creatinine x x
38685 38685 Troponin T, High Sensitivity (hs-TnT) x
91739 C125 NT-ProBNP x x x
91823 91823 ST2, Soluble x x
92768 C315 Galectin-3 x

24
Chronic Kidney
Disease
Reference Progression of Chronic Kidney Disease
from the printed kit
 Chronic kidney disease: scope of the problem

80 million 37 million Nearly 40%

are at risk for chronic kidney are afflicted with CKD1 of those with stage 4 CKD
disease (CKD)1 remain unaware of their
diagnosis2

Factors underlying the increase in CKD

Causes of kidney disease in
the United States • Increasing prevalence of type 2 diabetes mellitus (T2DM) and
hypertension (45% in 2018, up from 42% in 20133); upward trends
in obesity and cardiovascular disease (CVD)
39% • Despite efforts to raise awareness and reduce CKD progression, the
35% prevalence of CKD stages 1-4 increased from 11.8% to 14.2% over
the past 25 years4
26% • Screening is crucial, as 9 in 10 adults with CKD don’t know they
have it, causing late-stage diagnosis5 and 1 in 4 patients to "crash"
into dialysis6
Diabetes Hypertension
Other or unknown cause
1. Centers for Disease Control and Prevention. Chronic Kidney Disease in the United States, 2019. US Department of Health and Human Services; 2019. 2. United States Renal Data System. 2020 Annual Data Report. Accessed February 1, 2022.
https://adr.usrds.org/2020/chronic-kidney-disease/1-ckd-in-the-general-population 3. Ostchega Y, et al. NCHS Data Brief, no. 364. 2020. 4. Centers for Disease Control and Prevention. Chronic Kidney Disease Surveillance System—United States.
http://www.cdc.gov/ckd 5. Centers for Disease Control and Prevention. Chronic Kidney Disease in the United States, 2021. US Department of Health and Human Services. 6. Hassan R, et al. Can J Kidney Health Dis. 2019;6:2054358119831684. doi:
10.1177/2054358119831684
26
 Pathophysiology: progression of CKD
Kidney with Kidney with
Healthy kidney
albuminuria eGFR decrease
Diabetes and hypertension Compensatory
Glomeruli trigger glomerular injury. hyperfiltration fails;
Functional glomeruli ↑serum creatinine
compensate by ↑GFR
Glomerulus

Creatinine Creatinine Creatinine

Albumin Albumin Albumin

Healthy kidney does not leak Albumin leaks into urine (reflected in Progressive ↓ in GFR →
albumin. ↑uACR). ↑serum creatinine, ↑urine albumin

27 GFR, glomerular filtration rate; eGFR, estimated GFR; uACR, urine albumin-to-creatinine ratio.
 Kidney disease progression: systemic effects
↓Hgb ↑PO43-
Kidney decline with
complications ↓EPO Release of PO43- by bone →
↑serum PO43-

↓Vit D

↓EPO → anemia ↓Ca2+ →

↓Conversion to ↑PTH compensatory
active vitamin D release of PTH

↓Ca2+

↓Vitamin D → ↓intestinal Ca2+

absorption → hypocalcemia

28 EPO, erythropoietin; PTH, parathyroid hormone.

 Risk factors for CKD1

Diabetes Previous kidney damage

Hypertension Advanced age

Cardiovascular disease Smoking

Obesity Frequent use of medications that

can damage the kidneys

Family history of CKD Ethnic heritage

1. KDIGO CKD Work Group. Kidney Int Suppl. 2013;3(1):1-150.

29
 Classification of CKD based on GFR and
albuminuria categories

Stage-based referral

PCP manages low risk

PCP manages moderately increased

risk

Nephrologist referral, PCP manages high

risk

Nephrologist manages very high risk

1. KDIGO CKD Work Group. Kidney Int Suppls. 2013;3(1):1-150.

30
 A preemptive approach to improve clinical outcomes

IDENTIFY | ACT | PREVENT

Incorporate urine albumin-to-creatinine ratio (uACR) with eGFR blood test
to assess renal function.
With these complementary measurements as context, utilize the National
Kidney Foundation risk map for staging, follow-up, and specialty referral
recommendations.
Leverage evidence-based management of contributory conditions.
If any stage of CKD is identified, assess risk for associated
cardiometabolic conditions.

31
 Kidney function test updated to address healthcare disparities1
New eGFR (kidney function) calculation unveiled in September 2021 removes
race as a coefficient
Historical calculation of kidney function
always calculated a 13% higher value
(indicating greater kidney function) for
African Americans
35% of US dialysis patients are African
American or Black; race-based eGFR may
underestimate risk and limit access to
transplants

1.Delgado C, Baweja M, Crews DC, et al. A Unifying Approach for GFR Estimation:Recommendations of the NKF-ASN TaskForce on Reassessing the Inclusion ofRace in
Diagnosing Kidney Disease. Am JKidney Dis. 2022;79(2):268-288.e1.doi:10.1053/j.ajkd.2021.08.003.
32
 Cystatin C as an alternative to Creatinine for eGFR 1

Like creatinine, high levels of Cystatin C in

the blood indicate kidney disease
Creatinine is generated only by muscle cells
and is susceptible to bias due to above or
below average muscle mass, diet, and
certain supplements
Cystatin C is generated by nearly all cells
and may be less susceptible to bias in
certain patient populations1,2

33
 Laboratory measurements to help define risk
High risk for end-stage
Microalbuminuria Chronic kidney disease
renal disease

Risk for disease Disease diagnosis Disease management

Test codes* The following tests may help: Panel components

may be ordered
Manage kidney separately:
Quest Cleveland
Identify early risk Confirm kidney disease and measure Kidney Profile: eGFR
Diagnostics HeartLab Biomarker
for kidney damage damage the extent of kidney (375), Albumin,
Accounts Accounts
decline Random Urine with
Creatinine (6517)
375 C108 Creatinine with eGFR x x x

6517 NA Urine Albumin/Creatinine Ratio (uACR) x x x

39165 NA Kidney Profile (eGFR + uACR) x x x

94588 94588 Cystatin C with eGFR x x

510 C211 Hemoglobin x

310 C105 Carbon Dioxide x

733 C104 Potassium, Serum x

17306 C339 Vitamin D, 25-Hydroxy x

16558 C1572 Vitamin D, 1,25-Dihydroxy x

8837 C309 & C102 PTH, Intact and Calcium x

718 C116 Phosphate (as Phosphorus) x

34
Liver Disease
Reference Progression of Nonalcoholic Fatty
Liver Disease from the printed kit
 Factors contributing to prevalence and
outcomes of NAFLD

100 million 80 million <10%

are at risk for liver disease1 are afflicted with of cases of liver disease have
liver disease1 been diagnosed2

• Rising rates of metabolic dysfunction, obesity, • Early NAFLD is clinically silent 

and type 2 diabetes mellitus (T2DM) contribute • Advanced stages (fibrosis/cirrhosis) can result in 
to increased prevalence of nonalcoholic fatty − liver failure, ultimately requiring transplant
liver disease (NAFLD) − liver cancer
− Hyperinsulinemia has been shown to − risk for coronary artery disease
contribute to the development of NAFLD3,4

1. Younossi ZM, et al. Hepatology. 2016;64(1):73‐84. doi: 10.1002/hep.28431 2. Alexander M, et al. BMC Med. 2018;16(1):130. doi: 10.1186/s12916-018-1103-x
3. Rhee EJ, et al. Am J Med. 2011;124(1):69-76. 4. Bril F, et al. J Clin Endocrinol Metab. 2021;106(11):e4360-e4371.

36
 Pathophysiology: progression of NAFLD
Healthy liver Steatosis (fatty liver) Early nonalcoholic Late NASH with fibrosis
steatohepatitis (NASH)

Bile duct

Hepatic vein
Lobule
Central vein Hepatic artery

Extracellular matrix
forming fibrosis Activated stellate cell
Sinusoid Hepatocytes

Activated Kupffer cell

Central vein Ballooned hepatocyte
Lipid droplets in hepatocyte

37
 Indicators of risk for NAFLD

Insulin resistance, BMI ≥25.0 kg/m2

prediabetes, and type 2
diabetes

History of chronic elevation

Components of metabolic
of aspartate transaminase
syndrome
(AST) or alanine
 Central/abdominal obesity transaminase (ALT)
 Elevated triglyceride level
 Low HDL cholesterol History of fatty liver
identified by any radiologic
 Hypertension
modality or liver biopsy
 High fasting glucose

38
 FIB-4 index: A recommended screening test to
assess risk of advanced liver fibrosis
What is it?

Publicly available score to assess likelihood of advanced liver fibrosis

Components: AST, ALT, platelet count, patient age

Clinical utility
Rule out patients at low risk of advanced fibrosis from unnecessary specialized care

How to obtain
Quest offers 3 panel options which calculate and report the FIB-4 index:

Test name Test code Reported components

• FIB-4 index and interpretation

Liver fibrosis, fibrosis-4 (FIB-4) index panel 30555
• AST, ALT, platelet count

Liver fibrosis, hepatic function panel with • FIB-4 index and interpretation
30710
fibrosis-4 (FIB-4) index • Hepatic function panel, platelet count

Comprehensive metabolic panel with fibrosis-4 • FIB-4 index and interpretation

10372
(FIB-4) index • Comprehensive metabolic panel, platelet count

39
 Potential testing pathway to stratify risk of NAFLD
progression
Primary Care Visit

1 or more factors identifies risk of NAFLD: FIB-4 index:

• Insulin Resistance, Prediabetes and Low risk of Manage metabolic risk,
Type 2 diabetes 0-1.3
advanced fibrosis monitor liver status
• Metabolic syndrome components
• BMI ≥30 Indeterminate or If provider determines
Enhanced liver fibrosis score
• Liver enzymes elevated high risk of ≥1.3 advanced fibrosis
• Fatty liver identified via imaging advanced fibrosis
≥9.80-<11.30 ≥11.30

Mid risk for High risk for

progression and progression and
liver-related liver-related
events events

Referral to
specialist

40
 A preemptive approach to improve clinical outcomes

IDENTIFY | ACT | PREVENT

Identify NAFLD early to prevent or even reverse disease progression.
Leverage disease markers for risk stratification, treatment, and specialist
referral as indicated.
If NAFLD is identified at any stage, assessment of associated
cardiometabolic conditions including CVD, T2DM, and CKD may be
warranted.

41
 Laboratory measurements to help define risk
Nonalcoholic
Nonalcoholic fatty liver Fibrosis Cirrhosis
steatohepatitis

Risk for disease Disease diagnosis Disease management

Test codes* The following tests may help identify: Panel components may be ordered separately:
Comprehensive Metabolic Panel: Urea Nitrogen (BUN) (294,
C107), Creatinine (375, C108) with GFR Estimated, BUN/Creatinine
Quest Cleveland Late NASH with
Risk for fatty Early NASH Ratio (calculated) (296, 2968), Glucose (483, C101), Potassium,
Diagnostics HeartLab Biomarker advanced fibrosis Serum (733, C104), Sodium (836, C103), Calcium (303, C102),
liver (fibrosis F0-F2)
Accounts Accounts to cirrhosis (F3-F4) Carbon Dioxide (310, C105), Chloride (330, C106), Total Protein
(754, C110), Albumin (223, C109), Globulin (calculated),
93103 NA Insulin, Intact, LC/MS/MS x Albumin/Globulin Ratio (calculated), Total Bilirubin (287, C114),
Alkaline Phosphatase (234, C111), AST (822, C113), ALT (823,
C112)
92769 C335 Oxidized LDL (OxLDL) x x
FIB-4 Index Panel: AST (822, C113); ALT (823, C112); and Platelet
Count (723, 1380)
823 C112 Alanine Aminotransferase (ALT) x x Comprehensive Metabolic Panel with FIB-4 Index: Urea Nitrogen
(BUN) (294, C107), Creatinine (375, C108) with GFR Estimated,
822 C113 Aspartate Aminotransferase (AST) x x BUN/Creatinine Ratio (calculated) (296, 2968), Glucose (483, C101),
Potassium, Serum (733, C104), Sodium (836, C103), Calcium (303,
C102), Carbon Dioxide (310, C105), Chloride (330, C106), Total
10231 C901 Comprehensive Metabolic Panel x x Protein (754, C110), Albumin (223, C109), Globulin (calculated),
Albumin/Globulin Ratio (calculated), Total Bilirubin (287, C114),
30555 30555 Liver Fibrosis FIB-4 Index Panel x Alkaline Phosphatase (234, C111), AST (822, C113), ALT (823,
C112), Platelet Count (723, 1380) 
10372 10372 Comprehensive Metabolic Panel with FIB-4 Index x Liver Fibrosis Hepatic Function Panel with FIB-4 Index: Total
Protein (754, C110), Albumin (223, C109), Globulin (calculated),
Albumin/Globulin Ratio (calculated), Total Bilirubin (287, C114),
30710 30710 Liver Fibrosis, Hepatic Function Panel with FIB-4 Index x Direct Bilirubin (285, C115), Indirect Bilirubin (calculated), Alkaline
Phosphatase (234), AST (822, C113), ALT (823, C112), Platelet
91979 NA NAFLD Fibrosis Score x Count (723, 1380) 
NAFLD Fibrosis Score: Calculated Components, Personal Factors,
Contact representative for more Glucose (483, C101), AST (822, C113), ALT (823, C112), Platelet
Enhanced Liver Fibrosis (ELF) Score x Count, EDTA (723, 1380), Albumin (223, C109)
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