What is the approach to screening and management of fatty liver disease, including Non-Alcoholic Fatty Liver Disease (NAFLD) and Non-Alcoholic Steatohepatitis (NASH)?

From the Guidelines

Screening for fatty liver disease, including NAFLD and NASH, should begin with risk factor assessment, focusing on individuals with obesity, type 2 diabetes, metabolic syndrome, or unexplained liver enzyme elevations, as recommended by the most recent guidelines 1. The initial evaluation should include liver function tests (ALT, AST), complete metabolic panel, and imaging such as ultrasound, which can detect steatosis when fat content exceeds 20-30% 1. For suspected NASH, non-invasive tests like FIB-4, NAFLD fibrosis score, or elastography (FibroScan) can assess fibrosis severity 1. Liver biopsy remains the gold standard for diagnosis and staging but is reserved for cases where the diagnosis is uncertain or advanced disease is suspected 1. Management primarily involves lifestyle modifications, including weight loss of 7-10% through caloric restriction and regular exercise, which can improve steatosis and inflammation 1. No medications are FDA-approved specifically for NAFLD/NASH, though vitamin E (800 IU daily) may benefit non-diabetic NASH patients 1. For comorbidities, pioglitazone can be considered in diabetic patients with biopsy-proven NASH 1. GLP-1 receptor agonists like semaglutide show promise for NASH treatment 1. Management of cardiovascular risk factors is crucial as these patients have increased cardiovascular mortality 1. Regular monitoring with liver enzymes and non-invasive fibrosis assessment every 1-2 years is recommended, with more frequent follow-up for advanced fibrosis 1. Some key points to consider in the management of NAFLD and NASH include:

• All NAFLD patients should undergo interventions aimed at promoting healthier lifestyles and strict control of metabolic risk factors associated with NAFLD 1
• Pharmacotherapy should be reserved for NASH patients possibly in randomized controlled trials 1
• Concurrent metabolic risk factors associated with NAFLD should be managed as clinically required and drugs given as needed 1
• Bariatric surgery, if otherwise indicated, is considered a valid option for obese patients with NAFLD/NASH 1
• Heavy alcohol consumption should be discouraged, and light-moderate alcohol consumption may exert favorable metabolic effects and, perhaps, on liver outcomes, but its use as a preventive/therapeutic strategy for NAFLD is not recommended due to the lack of randomized controlled trials 1. This approach addresses the spectrum of fatty liver disease by identifying at-risk patients, staging disease severity, and implementing appropriate interventions to prevent progression to cirrhosis and liver-related complications 1.

From the Research

Approach to Screening for Fatty Liver Disease

• Screening for Non-Alcoholic Fatty Liver Disease (NAFLD) is not currently recommended, even in high-risk patients, as stated in 2.
• However, some studies suggest that screening programs should be implemented, at least in countries with a high prevalence of the disease, as mentioned in 3.
• Patients at high risk for NAFLD, such as those with obesity, metabolic syndrome, and type 2 diabetes mellitus, should be screened in the outpatient setting, as suggested in 4.

Diagnosis and Management of NAFLD

• NAFLD should be suspected in patients with elevated liver enzymes or hepatic steatosis on abdominal imaging, and risk scores or elastography tests can be used to identify those who are likely to have fibrosis, as stated in 2.
• Liver biopsy should be considered for patients at increased risk of fibrosis and when other liver disorders cannot be excluded with noninvasive tests, as mentioned in 2.
• Weight loss through diet and exercise is the primary treatment for NAFLD, and other treatments, such as bariatric surgery, vitamin E supplements, and pharmacologic therapy, have shown potential benefit, as stated in 2 and 5.

Non-Alcoholic Steatohepatitis (NASH)

• NASH is a more severe form of NAFLD, characterized by hepatocellular injury and inflammation, and patients with NASH are at higher risk of death from cardiovascular disease, cancer, and end-stage liver disease, as mentioned in 2.
• Accurate diagnosis of NASH and NAFLD is mandatory, and histologic evaluation with liver biopsy remains the gold standard, as stated in 5.

Non-Invasive Tests (NITs) and Screening Tools

• NITs, such as serum indices and liver biopsy, can help identify high-risk patients who may benefit from specialty referral and MASH-directed therapy, as mentioned in 6.
• Several targeted steatotic liver disease (SLD) screening tools and novel therapies are under development, as stated in 6.