From the Guidelines
Hepatic steatosis with low transaminases should not be considered benign and requires comprehensive management to prevent progression to more severe liver disease, including lifestyle modifications and optimal management of comorbidities, as recommended by the latest clinical practice guidelines 1. The presence of hepatic steatosis, even with low transaminases, indicates an increased risk of developing metabolic dysfunction-associated steatohepatitis (MASH), fibrosis, cirrhosis, and hepatocellular carcinoma (HCC) 1. Key aspects of management include:
- Lifestyle modification, such as weight loss, dietary changes, and physical exercise, to address metabolic risk factors
- Optimal management of comorbidities, including the use of incretin-based therapies for type 2 diabetes or obesity, if indicated 1
- Consideration of bariatric surgery in individuals with obesity and hepatic steatosis
- Regular monitoring with non-invasive tests, such as the fibrosis-4 index (FIB-4) and transient elastography, to rule out advanced fibrosis 1
- Potential use of MASH-targeted treatments, such as resmetirom, in adults with non-cirrhotic MASH and significant liver fibrosis, if locally approved and dependent on the label 1 It is essential to note that low transaminase levels do not always correlate with disease severity, and regular monitoring with liver function tests every 6-12 months is advisable to assess disease progression 1. Addressing metabolic risk factors, such as diabetes, hypertension, and dyslipidemia, is also crucial for comprehensive management 1.
From the Research
Implications of Hepatic Steatosis with Low Transaminases
- Hepatic steatosis, even with low transaminases, is associated with a higher risk of cardiovascular disease (CVD) and metabolic syndrome (MS) 2.
- The presence of hepatic steatosis can lead to liver cancer, cirrhosis, and portal hypertension 3.
- Non-alcoholic fatty liver disease (NAFLD), a condition characterized by hepatic steatosis, signifies an increased risk of liver fibrosis and cirrhosis, type 2 diabetes, and CVD 4.
- Hepatic steatosis is frequently detected during cross-sectional imaging, and non-invasive imaging modalities such as ultrasound, computed tomography (CT), and magnetic resonance imaging (MRI) can detect fat infiltration in the liver 3.
Metabolic Risks
- Patients with hepatic steatosis are at higher cardiovascular and metabolic risk without differences in transaminases levels compared to those without steatosis 2.
- Hepatic steatosis is associated with factors of metabolic syndrome, including obesity, type 2 diabetes, and dyslipidemia 5.
- The Mediterranean diet has been shown to improve hepatic steatosis and insulin sensitivity in individuals with NAFLD, even without weight loss 4, 6.
Lifestyle Modifications
- Lifestyle modifications, such as the Mediterranean diet, can slow the evolution from NAFLD to steatohepatitis and improve hepatic steatosis, oxidative stress, and inflammation 4, 6.
- A randomized controlled trial found that the Mediterranean diet reduced hepatic steatosis, oxidative stress, and inflammation in adolescents with NAFLD, compared to a low-fat diet 6.