Given the pervasiveness of Non-alcoholic Fatty Liver Disease (NAFLD), updated practice guidelines are worth a look (Hepatology 2012; 55: 2005-23, also in Gastroenterology 2012; 142: 1592-1609)). While the review includes updated information on incidence, prevalence, risk groups, natural history, the focus remains on specific graded recommendations.
These AGA/AASLD/ACG guidelines do not recommend screening adults due to uncertainties surrounding diagnostic tests and treatment. This includes high risk populations such as diabetics and bariatric patients. In addition, unlike recent obesity guidelines from the AAP (Pediatrics 2007; 120: S164-192), these guidelines do not recommend screening children for NAFLD.
Specific management recommendations:
- Exclude competing etiologies in patients with suspected NAFLD: iron studies, autoantibodies, Wilson’s, viral hepatitis, celiac serology, muscle disease
- Consider liver biopsy in higher risk patients: metabolic syndrome patients, patients with higher NAFLD Fibrosis score, or before treatment
- Serum/plasma CK18 is promising biomarker. Not recommended for routine practice at this time.
- Weight loss (3-5%) helps steatosis and greater losses (up to 10%) may be needed to improve necroinflammation.
- Metformin –not recommended for liver disease in NASH/NAFLD.
- Pioglitazone can be used to treat steatohepatitis; however, “long-term safety and efficacy of pioglitazone in patients with NASH is not established.”
- Vitamin E at 800 units/day improves liver histology in biopsy-proven NASH. Not recommended without biopsy-confirmed NASH, in diabetic patients, or patients with cirrhosis. Concern with Vitamin E in adults has been an association with increased all-cause mortality in some studies (but not in others).
- Avoid alcohol in patients with NAFLD
Website to download PDF version:
Another opinion on which patients to biopsy: