What is the relationship between Steatosis (fatty liver disease) and autoimmune diseases?

From the Guidelines

Steatosis (fatty liver disease) is closely linked with autoimmune diseases, particularly autoimmune hepatitis, primary biliary cholangitis, and systemic lupus erythematosus, and managing both conditions simultaneously is crucial for improving patient outcomes. The relationship between steatosis and autoimmune diseases is complex, involving shared inflammatory pathways that can trigger or worsen fat accumulation in the liver through cytokine production and metabolic dysregulation 1.

Key Considerations

• Patients with celiac disease and NAFLD/NASH should follow a gluten-free diet to improve liver enzymes and histology, and to prevent progression to cirrhosis, in addition to improving intestinal pathology 1.
• Diabetes is a major risk factor for developing non-alcoholic steatohepatitis (NASH), disease progression, and worse liver outcomes, with recent studies estimating that NAFLD is prevalent in over 70% of people with type 2 diabetes 1.
• The management approach should address both conditions simultaneously, with lifestyle modifications being essential for fatty liver, including weight loss, Mediterranean diet, regular exercise, and avoiding alcohol 1.
• For autoimmune diseases, immunosuppressive medications like prednisone and azathioprine are typically used, while for fatty liver, vitamin E may benefit non-diabetic patients with non-alcoholic steatohepatitis 1.

Recommendations

• Lifestyle modification, including weight loss, dietary changes, physical exercise, and discouraging alcohol consumption, is advised for adults with metabolic dysfunction-associated steatotic liver disease (MASLD) 1.
• Optimal management of comorbidities, including use of incretin-based therapies for type 2 diabetes or obesity, if indicated, is also recommended 1.
• Bariatric surgery is an option in individuals with MASLD and obesity, and adults with non-cirrhotic MASH and significant liver fibrosis should be considered for a−MASH-targeted treatment with resmetirom, if locally approved and dependent on the label 1.

From the Research

Relationship Between Steatosis and Autoimmune Diseases

The relationship between steatosis (fatty liver disease) and autoimmune diseases is complex and has been investigated in several studies.

• Steatosis is commonly found in patients with autoimmune liver diseases, such as autoimmune hepatitis (AIH) and primary biliary cholangitis (PBC) 2.
• The controlled attenuation parameter (CAP) can be used as a non-invasive diagnostic method to evaluate hepatic steatosis in patients with autoimmune liver diseases 2.
• Patients with AIH concomitant with non-alcoholic fatty liver disease (NAFLD) tend to be older and have higher serum IgG levels and liver stiffness measurement (LSM) values compared to those with NAFLD presenting with autoimmune markers 2.

Overlap Between Steatosis and Autoimmune Hepatitis

• The diagnosis of AIH can be challenging, and some patients with a previous diagnosis of NAFLD may actually have AIH alone 3.
• The presence of autoimmune markers in patients with NAFLD does not necessarily indicate the presence of AIH, and a closer look at the underlying pathology is sometimes needed to establish an accurate diagnosis 3.

Pathogenesis and Therapeutic Options

• Metabolic dysfunction-associated steatotic liver disease (MASLD) is a term that encompasses non-alcoholic fatty liver disease (NAFLD) and other conditions characterized by abnormal lipid accumulation in the liver 4, 5.
• The pathogenesis of MASLD involves a complex interplay between local and systemic factors, including insulin resistance, inflammation, and oxidative stress 4.
• Therapeutic options for MASLD include lifestyle changes, pharmacological interventions, and innovative approaches targeting the gut-liver axis and systemic pathways 4, 5.

Clinical Implications

• Steatotic liver disease is a major public health concern, affecting around 30% of the global population and contributing to the development of cirrhosis and other liver-related complications 5.
• Early detection and diagnosis of liver fibrosis are crucial for preventing disease progression and improving patient outcomes 5.
• A collaborative diagnostic framework between primary care and liver specialists is proposed for the early detection of liver fibrosis and the management of steatotic liver disease 5.