How should we manage patients with non‐alcoholic fatty liver disease in 2007?

Abstract

Evidence-based management guidelines for non-alcoholic fatty liver disease (NAFLD) are lacking in the Asia-Pacific region or elsewhere. This review reports the results of a systematic literature search and expert opinions. TheAsia-Pacific Working Party on NAFLD (APWP-NAFLD) has generated practical recommendations on management of NAFLD in this region. NAFLD should be suspected when there are metabolic risk factors and/or characteristic changes on hepatic ultrasonography. Diagnosis by ultrasonography, assessment of liver function and complications, exclusion of other liver diseases and screening for metabolic syndrome comprise initial assessment. Liver biopsy should be considered when there is diagnostic uncertainty, for patients at risk of advanced fibrosis, for those enrolled in clinical trials and at laparoscopy for another purpose. Lifestyle measures such as dietary restrictions and increased physical activity (aerobic exercise) should be encouraged, although the best management strategy to achieve this has yet to be defined. Complications of metabolic syndrome should be screened for regularly. Use of statins to treat hypercholesterolemia is safe and recommended; frequent alanine aminotransferase (ALT) monitoring is not required. Obese patients who do not respond to lifestyle measures should be referred to centers specializing in obesity management; consideration should be given to bariatric surgery or gastric ballooning. The role of pharmacotherapy remains investigational and is not recommended for routine clinical practice. Non-alcoholic fatty liver disease should be recognized as part of the metabolic syndrome and managed in a multidisciplinary approach that addresses liver disease in the context of risk factors for diabetes and premature cardiovascular disease. Lifestyle changes are the first line and mainstay of management.

Asian Pacific Association for the Study of the Liver consensus recommendations on hepatocellular carcinoma

“…There is currently a level II evidence to support the beneficial role of dietary restriction (mainly aimed at improving insulin sensitivity) and exercise in the management of NAFLD [131].…”

Metabolic and histological features of non‐alcoholic fatty liver disease patients with different serum alanine aminotransferase levels

“…This is consistent with the recommendations of the Asia-Pacific Working Party on NAFLD. 20 Liver biopsy should be considered in NAFLD patients with high-risk characteristics such as diabetes and obesity. The ALT level does not affect decisions on evaluation and management.…”

“…The length of liver samples was 18 AE 3 mm (median, 17; interquartile range, [16][17][18][19][20], and the number of portal tracts per sample was 7 AE 2 (median 6; interquartile range, 5-8). The ALT level had moderate correlation with steatosis grade (R = 0.32, P < 0.001), fibrosis stage (R = 0.20, P = 0.008) and the NAFLD activity score (R = 0.28, P < 0.001).…”

“…obesity and diabetes). 20 We excluded male patients who consumed more than 20 grams of alcohol per day and females who consumed more than 10 g per day. Patients with coexisting liver disease, namely chronic viral hepatitis, autoimmune hepatitis, primary biliary cirrhosis, primary sclerosing cholangitis, Wilson's disease, hemochromatosis, a1-antitrypsin deficiency, biliary obstruction and drug-induced liver disease were excluded.…”

Fat and Fiber: How the Controlled Attenuation Parameter Complements Noninvasive Assessment of Liver Fibrosis

“…A key challenge faced by clinicians who manage NA-FLD is to establish the diagnosis and to differentiate simple steatosis from advanced disease [4]. Furthermore, steatosis often coexists in other chronic liver diseases such as chronic hepatitis C [5].…”