Can fatty liver disease progress to cirrhosis?

Fatty Liver Disease Progression to Cirrhosis

Yes, fatty liver disease can progress to cirrhosis, with progression rates varying based on the type of fatty liver disease and presence of risk factors. 1

Progression of Alcoholic Fatty Liver Disease (ALD)

• Alcoholic fatty liver (steatosis) is the initial presentation of liver injury due to chronic alcohol consumption, seen in 80-90% of heavy drinkers 1
• With continued alcohol consumption (≥400 g/week), 30% of alcoholic fatty liver cases progress to cirrhosis, and 37% progress to fibrosis or cirrhosis 1
• Even in patients with fatty liver or steatohepatitis but without liver fibrosis, 38-56% will eventually progress to liver cirrhosis with continued alcohol consumption 1
• Long-term excessive drinking results in a 15-30% lifetime risk of alcoholic liver cirrhosis 1
• In a study of patients with "pure" alcoholic fatty liver followed for 10.5 years, 9 developed cirrhosis and 7 developed fibrosis, with continued high alcohol consumption being the primary risk factor 2

Progression of Non-Alcoholic Fatty Liver Disease (NAFLD)

• NAFLD encompasses a spectrum from simple fatty liver (NAFL) to non-alcoholic steatohepatitis (NASH) to cirrhosis 1
• The risk of progression from NAFL to cirrhosis is minimal compared to NASH 1
• NASH can progress to cirrhosis, liver failure, and rarely liver cancer 1
• In a Medicare data analysis, the cumulative risk of progression from NAFLD to cirrhosis was 39% over 8 years of follow-up 3
• The rate of progression from NASH to cirrhosis varies by race and region, with an average of 21-26% of patients progressing to cirrhosis in eight years 1

Risk Factors for Progression to Cirrhosis

Metabolic Risk Factors

• Each additional metabolic trait increases the risk of progression to cirrhosis and hepatocellular carcinoma (HCC) in patients with NAFLD 4
• Patients with both hypertension and dyslipidemia had a 1.8-fold higher risk of progression to cirrhosis/HCC compared to patients with no metabolic traits 4
• The risk was 2.6-fold higher in patients with diabetes, obesity, dyslipidemia, and hypertension 4
• Diabetes is the strongest predictor for progression to HCC in NAFLD patients 4

Histological Risk Factors

• In alcoholic fatty liver, the presence of mixed macro/microvesicular fat and giant mitochondria on liver biopsy are independent predictors of progression to cirrhosis 2
• In NAFLD, the degree of liver fibrosis is the strongest predictor of mortality 5

Clinical Outcomes and Mortality

• The overall mortality rate is higher in NAFLD patient groups than in normal control groups 1
• The most common cause of death in patients with NAFLD/NASH is cardiovascular disease 1, 5
• Liver-related mortality increases specifically in patients with NASH (not NAFL) and advancing fibrosis 1, 5
• The cumulative risk of mortality for NAFLD, NAFLD cirrhosis, decompensated cirrhosis, and HCC was 12.6%, 31.1%, 51.4%, and 76.2%, respectively 3
• In compensated alcoholic liver cirrhosis, the 5-year survival rate approaches 90% with abstinence but decreases to less than 70% with continued drinking 1
• In decompensated alcoholic liver cirrhosis, the 5-year survival rate is 60% with abstinence and 30% with continued drinking 1

Clinical Implications

• Abstaining from alcohol prevents progression of ALD, improves survival rate, and decreases the need for liver transplantation 1
• NASH has become the third most common cause of hepatocellular carcinoma in the United States 5
• NASH is now the second most common reason for liver transplantation 5
• Patients with fatty liver disease should be monitored for progression to cirrhosis, especially those with risk factors 1
• Addressing metabolic risk factors (obesity, diabetes, dyslipidemia) is essential to improve liver health and reduce the risk of progression 5