Advice by Trisha Pasricha, MD, MPH May 22, 2023 at 6:00 a.m. EDT
Q: What is fatty liver disease? How do I know if I have it, and what can I do about it?
A: Fatty liver disease is a condition in which normal tissue in the liver is replaced by fat. About one in five Americans has nonalcoholic fatty liver disease, or NAFLD. Unlike alcoholic liver disease, it isn’t associated with increased alcohol use.
NAFLD is closely linked to obesity and metabolic abnormalities, such as high blood pressure, insulin resistance and elevated triglycerides. With rates of risk factors like obesity continuing to rise, including in childhood, about 100 million people in the United States are projected to have NAFLD by 2030. The condition tends to runs in families, and Hispanic Americans are disproportionately affected.
Most people aren’t aware they have NAFLD and won’t develop serious complications from it. But the American Association for the Study of Liver Diseases recommends screening for liver scarring in patients with classic risk factors like type II diabetes.
While there are no approved medications yet, a few interventions can help. The most effective is weight loss and a healthy diet, which can even help reverse NAFLD. Here are some of the complications that can arise, as well as diagnosis and treatment options.
How fatty liver disease is diagnosed
Most patients with NAFLD have no symptoms, although some may experience fatigue or vague abdominal discomfort. Other people get evaluated for NAFLD when their doctor finds they have abnormal liver enzymes on a blood test called a comprehensive metabolic panel.
For example, people with NAFLD often have an elevation in two enzymes produced by the liver, aspartate aminotransferase (AST) and alanine aminotransferase (ALT). Another test in which people with NAFLD may have abnormalities is serum ferritin, a protein in the blood that rises when the liver is inflamed. After excluding other causes of liver injury, NAFLD is usually diagnosed with an imaging study like an ultrasound or CT scan, where doctors can see if your liver has a high amount of fat. A liver biopsy is considered the gold standard to make the diagnosis, particularly if it’s still not clear what’s going on after imaging tests. Your doctor may also order other tests, like elastography, to see whether you have any liver scarring to help stage your disease.
Complications of fatty liver disease
People with fatty liver are at increased risk of liver cancer and death from cardiovascular disease.
It’s estimated that a fifth of people with NAFLD develop the next stage of the disease, which is inflammation in their livers, known as nonalcoholic steatohepatitis, or NASH.
This inflammation increases the risk of liver scarring. The end-stage form of liver scarring is called cirrhosis, one of the most devastating consequences of NASH.A dysfunctional liver can be life-threatening. As a result of cirrhosis, patients can experience massive bleeding from ruptured veins in their esophagus, impairment in brain function due to the buildup of toxins in the blood stream, spontaneous infections of their abdomen and kidney failure.
Cirrhosis is the most common reason for a liver transplant. While outcomes in liver transplant are generally great, it involves a major surgery and often requires lifelong immunosuppressive medications to ensure the new liver doesn’t get rejected.
Also, the current process of determining who can receive a liver transplant is highly selective and fraught with ethical dilemmas. Racial and socioeconomic disparities continue to plague the system: For example, Black patients are four times less likely than White patients to receive liver transplants. With thousands of people on the wait list, many people die each year while awaiting an offer for a new liver.
Treatments for fatty liver disease
Treatment for NAFLD is limited, although effective potential therapeutics may be on the horizon. Here are a few ways doctors recommend managing NAFLD:
Weight loss: This is the most established recommendation. The goal is to lose a total of 3-5 percent of body weight (or an even higher 7-10 percent of body weight for those with NASH). Studies have found that weight loss from a low-calorie diet and exercise can help reverse fatty liver disease and scarring. That said, it’s very hard to achieve and maintain weight loss alone. If diet and exercise are unsuccessful after six months, talk to your doctor about other options, such as medications for weight loss.
Abstinence from alcohol: Heavy alcohol use is associated with progression of liver disease, and given the unclear effect of milder use, total abstinence is generally advised to avoid the risk of the disease advancing.
Medicine: While there still aren’t any specific drugs approved by the Food and Drug Administration to treat NAFLD or NASH, there are some potential benefits to certain medications in the right patient. These may include vitamin E supplementation or pioglitazone, which is typically used to treat diabetes. However, further research is needed, and the risks and benefits should be discussed with your physician. Because of the association with diabetes and cardiovascular disease, patients with these comorbidities should be treated accordingly.
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