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Controversies in the Diagnosis and Management of NAFLD and NASH
Mary E Rinella1, Rohit Loomba1, Stephen H Caldwell1
1Dr Rinella is an associate professor of medicine in the Division of Gastroenterology and Hepatology at Northwestern University Feinberg School of Medicine in Chicago, Illinois. Dr Loomba is an associate professor of clinical medicine at the University of California, San Diego in La Jolla, California. Dr Caldwell is a professor of medicine in gastroenterology and hepatology and the director of hepatology at the University of Virginia in Charlottesville, Virginia. Dr Kowdley is the director of the Liver Center of Excellence at the Digestive Disease Institute at Virginia Mason Medical Center in Seattle, Washington. Dr Charlton is the medical director of the Liver Transplant Program at Intermountain Medical Center in Salt Lake City, Utah. Dr Tetri is a professor of medicine in the Division of Gastroenterology and Hepatology at St. Louis University in St. Louis, Missouri. Dr Harrison is associate dean of San Antonio Uniformed Services Health Education Consortium, professor of medicine at Uniformed Services University of the Health Sciences, and director of medical education at Brooke Army Medical Center in San Antonio, Texas.
Abstract:
Nonalcoholic fatty liver disease (NAFLD) is recognized as the most common cause of chronic liver disease in the United States. Nonalcoholic steatohepatitis (NASH) occurs in a subset of patients with NAFLD and is characterized by the presence of hepa-tocellular injury, which is progressive in a substantial proportion of cases and can lead to cirrhosis and all of its complications. Although the diagnosis of NAFLD can be made through imaging studies or liver biopsy, the diagnosis of NASH still requires histologic confirmation. Liver biopsy should be performed in the presence of risk factors for advanced disease. Measures aimed at promoting weight loss, a healthier lifestyle, and optimization of metabolic risk factors remain the cornerstone of management of NAFLD. Therapeutic agents that are presently considered the most promising in NAFLD are effective in less than 50% of patients. Among patients with biopsy-proven NASH, treatment with pharmacologic agents should be considered; however, the role of specific agents in NASH still needs further study. Despite a wealth of research over the past 15 years, many controversies remain with respect to the diagnosis and management of NAFLD and NASH as well as the influence of alcohol on liver disease progression in these patients.
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