NAFLD

• People with NAFLD and advanced liver fibrosis (ELF score of 10.51 or above) a transient elastography to diagnose cirrhosis

  Offer retesting every 2 years
• Patients with compensated cirrhosis should have a MELD score every 6 months - a score of 12 or more is an indicator that the person is at high risk of complications of cirrhosis
• Offer an ultrasound and measurement of serum alpha-fetoprotein every 6 months as surveillance for hepatocellular carcinoma for patients with cirrhosis
• Non-alcoholic fatty liver disease (NAFLD) is characterised by excessive fat in the liver cells, specifically triglycerides. These fat deposits interfere with the functioning of the liver cells. The early stages of NAFLD can be asymptomatic. However, it can progress to hepatitis and liver cirrhosis
• The stages of non-alcoholic fatty liver disease are:

  1. Non-alcoholic fatty liver disease
  2. Non-alcoholic steatohepatitis (NASH)
  3. Fibrosis
  4. Cirrhosis
• Non-alcoholic steatohepatitis (NASH) defines a subgroup of NAFLD where there is a risk of progression to advanced liver fibrosis, cirrhosis and hepatocellular cancer
• NAFLD is strongly associated with insulin resistance and metabolic syndrome - hypertension, obesity and diabetes
• Patients with NAFLD are often asymptomatic but may present with general signs such as fatigue and right upper quadrant pain
• Signs of NAFLD on exam:

  • Hepatomegaly
  • Obesity
  • High blood pressure
  • Features of chronic liver disease or decompensated cirrhosis
• Liver ultrasound can confirm the diagnosis of hepatic steatosis - seen as increased echogenicity

  It does not indicate the severity of fibrosis - patients with an ELF score of 10.51 or above should be referred to hepatology and receive transient elastography (fibroscan)
• Options for assessing fibrosis in NAFLD:

  • Enhanced liver fibrosis (ELF) blood test - 10.51 or above
  • NAFLD fibrosis score
  • Fibrosis 4 (FIB-4)
• Diagnosis of NAFLD:

  • Risk factors present
  • Persistent elevation of LFTs for at least 3 months (AST and ALT)
  • Absence of excess alcohol intake
  • USS consistent with fatty liver changes
  • Negative blood tests for other causes of hepatic disease
• Management involves:

  • Weight loss 
  • Healthy diet (Mediterranean diet is recommended)
  • Exercise
  • Avoid/limit alcohol intake 
  • Stop smoking
  • Control of diabetes, blood pressure and cholesterol
  • Refer patients where scoring tests indicate liver fibrosis to a liver specialist
  • Specialist management may include vitamin E, pioglitazone, bariatric surgery and liver transplantation
• If the scores are high, advanced fibrosis cannot be ruled out. In this situation, patients are usually referred for a second line test such as transient elastrography, which is a non-invasive measure of liver stiffness also known as a Fibroscan. Patients who have a very high FIB-4 score may be directly organised for a biopsy by the hepatology team.
• Insulin resistance:

  • Promotes increased breakdown of peripheral adipose tissue (lipolysis), increased synthesis of triglycerides and increased uptake of fatty acids
  • Contributes to the accumulation of toxic lipids within the liver and the development of hepatic steatosis
• Diagnosis is confirmed with a liver biopsy