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  • Nonalcoholic Fatty Liver Disease: A Silent Killer

    Millions of Americans are at risk for nonalcoholic fatty liver disease (NAFLD), which is the leading cause of chronic liver disease in Western cultures. NAFLD affects an estimated 80 to 100 million people in the United States. The prevalence of NAFLD is highest among obese individuals and those with type 2 diabetes mellitus (T2DM). Rising obesity rates across the United States lay the framework for an enormous economic and healthcare burden due to NAFLD and related diseases in coming years, but most people with NAFLD do not know they have a potentially life-threatening illness.

    NAFLD occurs when fat build-up is present in the liver. Patients with T2DM, metabolic syndrome (MetS), polycystic ovary syndrome (PCOS), dyslipidemia, and high body mass index are at increased risk of developing NAFLD. This chronic liver disease can progress to an inflammatory condition called nonalcoholic steatohepatitis (NASH), which, if left untreated, can progress to fibrosis and eventual cirrhosis of the liver. These patients are also more likely to develop hepatocellular carcinoma. NAFLD is often asymptomatic or occurs with some amount of fatigue. Patients and clinicians often do not know that NAFLD is present until it is discovered by chance during another, unrelated, medical screen.

    Upwards of 60% to 75% of patients with T2DM have NAFLD that they might not know about. Incidental findings in routine lab work may show elevated liver enzymes, but most patients (~ 80%) with NAFLD have normal liver values. Multiple practice guidelines recommend screening at-risk patients, and while a liver biopsy is needed to diagnose NASH, recently approved noninvasive methods of determining fibrosis, such as vibration-controlled transient elastography (VCTE), or FibroScan, as well as clinical calculations of NAFLD fibrosis score (NFS) and fibrosis-4 index (FIB-4) are available to assist clinicians in determining which patients need to be referred for biopsy.

    A major risk factor for developing NAFLD and NASH is obesity. Therefore, weight loss and exercise are key to preventing progression to NASH and reducing inflammation that may already be present in the liver. In fact, as little as 3% to 5% weight loss is associated with histological improvement in NAFLD. Weight loss and exercise are also key to reducing the common comorbidities seen in patients with NAFLD, such as cardiovascular disease, T2DM, and MetS. Numerous pharmaceuticals and noninvasive diagnostic techniques are being pursued to identify and treat patients with NAFLD and NASH in novel ways.

    References
    1. Cusi K, Sanyal AJ, Zhang S, et al. Non-alcoholic fatty liver disease (NAFLD) prevalence and its metabolic associations in patients with type 1 and type 2 diabetes. Diabetes Obes Metab. 2017;19:1630-1634. 2. Chalasani N, Younossi Z, Lavine JE, et al. The diagnosis and management of nonalcoholic fatty liver disease: Practice guidance from the American Association for the Study of Liver Diseases. Hepatology. 2018;67:328-357. 3. EASL, EASD, EASO. EASL-EASD-EASO Clinical Practice Guidelines for the management of non-alcoholic fatty liver disease. J Hepatol. 2016;64:1388-1402. 4. Centers for Disease Control and Prevention. Adult Obesity Prevalence. Available at: https://www.cdc.gov/obesity/data/prevalence-maps.html. Accessed February 8, 2019.