Is Fatty Liver Concerning?
Yes, fatty liver disease is concerning and requires risk stratification and management, as it affects approximately 25-30% of adults in developed countries and can progress to cirrhosis, liver failure, hepatocellular carcinoma, and is associated with increased cardiovascular mortality. 1
Why Fatty Liver Disease Matters
Fatty liver disease represents a spectrum of serious conditions with significant morbidity and mortality implications:
NAFLD ranges from simple steatosis to nonalcoholic steatohepatitis (NASH), which occurs in approximately 30% of NAFLD patients and significantly increases risk of cirrhosis and its complications including hepatocellular carcinoma and liver failure. 1
Individuals with NAFLD have increased overall mortality compared to the general population, with common causes of death including cardiovascular disease (the leading cause before cirrhosis develops), malignancy, and liver-related complications. 1, 2
NAFLD is predicted to become the main risk factor for hepatocellular carcinoma and has become a common indication for liver transplantation. 1
The prevalence of advanced fibrosis/cirrhosis is projected to double to 1 million individuals by 2030 in the UK alone, yet the majority of patients remain undiagnosed. 1
High-Risk Populations Requiring Immediate Attention
Three groups are at greatest risk and warrant systematic screening: 1
All patients with type 2 diabetes should be screened, as up to 70% have NAFLD, and 20% have clinically significant fibrosis (≥F2). This screening approach is cost-effective. 1
Patients with 2 or more metabolic risk factors (central obesity, hypertriglyceridemia, low HDL, hypertension, or prediabetes) have a stepwise increase in progression risk to cirrhosis or hepatocellular carcinoma with each additional metabolic trait. 1
Patients with incidental hepatic steatosis on imaging or elevated aminotransferases, as 11% may have advanced fibrosis, particularly those with elevated liver enzymes. 1
Critical Risk Stratification Required
The degree of fibrosis is the most important determinant of liver and non-liver outcomes, making identification of clinically significant fibrosis (≥F2) essential: 1
Use FIB-4 score as initial screening (calculated from age, ALT, AST, and platelets): scores <1.3 indicate low risk, 1.3-2.67 intermediate risk, and >2.67 high risk. 1, 2
Patients with indeterminate or high FIB-4 scores require additional risk stratification with transient elastography (liver stiffness measurement), with values <8.0 kPa indicating low risk, 8.0-12.0 kPa intermediate risk, and >12.0 kPa high risk. 1, 2
Intermediate and high-risk patients should be referred to hepatology for specialized management. 1, 2
Patients with liver stiffness ≥20 kPa or thrombocytopenia require screening for gastroesophageal varices. 2
Disease Progression and Complications
Type 2 diabetes is associated with a greater than 2-fold increase in risk of developing severe liver disease (adjusted HR 2.25,95% CI 1.83-2.76). 3
NAFLD increases risk of chronic kidney disease, particularly when liver fibrosis is present, and is strongly linked with cardiometabolic disease and lifestyle-related cancers. 1, 4
Management Imperative
Weight loss of 5-10% is recommended, with 5% improving steatosis and 7-10% improving steatohepatitis and fibrosis. 2
A Mediterranean diet is strongly recommended, featuring daily vegetables, fruits, fiber-rich cereals, nuts, fish or white meat, and olive oil, while limiting simple sugars, red meat, processed meats, and ultra-processed foods. 1, 2
Complete alcohol abstinence is recommended, as even low alcohol intake doubles the risk for adverse liver-related outcomes in NAFLD patients. 2
At least 150-300 minutes of moderate-intensity or 75-150 minutes of vigorous-intensity exercise per week is recommended. 2, 4
Common Pitfalls to Avoid
Neglecting cardiovascular risk assessment is a critical error, as cardiovascular disease is the main driver of mortality in NAFLD patients before cirrhosis develops. 2
Failing to screen high-risk populations systematically leads to missed opportunities for early intervention when disease is still reversible. 1
Assuming normal liver enzymes exclude significant disease is dangerous, as patients should be screened even with normal aminotransferases if they have diabetes or metabolic risk factors. 1