Page 40 - EASL POSTGRADUATE COURSE
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The current American guidelines endorse the use of the NAFLD fibrosis score to identify patients with
a higher likelihood of having advanced fibrosis or cirrhosis. The score has also recently been shown to
predict long-term mortality in NAFLD patients. However, since BMI is an integral component of the
score, it is unclear if calibration is needed for populations with different BMI cut-offs.
Transient elastography by Fibroscan is another population, non-invasive test of liver fibrosis in Europe
and Asia [6]. Indeed, measurement failure with this technique is less likely in lean patients with NAFLD.
In addition, the latest Fibroscan model allows concomitant measurement of liver stiffness and the
controlled attenuation parameter (CAP). CAP measures ultrasound attenuation in the liver and can be
used to estimate the degree of hepatic steatosis. Further studies are needed to establish if serial CAP
measurements can accurately reflect changes in hepatic steatosis.
Management
Lifestyle modification is the cornerstone of NAFLD/NASH management. In lean patients with NAFLD,
healthy diet and regular exercise are often sufficient in inducing disease remission [10]. While a weight
reduction of more than 10% from baseline has the greatest effect on NAFLD, modest weight reduction
of as little as 3-5% can also improve hepatic steatosis. The current American guidelines support the use
of vitamin E or pioglitazone in patients with NASH and no diabetes or cirrhosis.While these two agents
have been well studied using histological and biochemical endpoints, they have not been specifically
evaluated in lean patients with NASH. For obvious reasons, bariatric surgery is not indicated in lean
patients with NASH.
References
[1] Williams CD, Stengel J, Asike MI, et al. Prevalence of nonalcoholic fatty liver disease and
nonalcoholic steatohepatitis among a largely middle-aged population utilizing ultrasound and
liver biopsy: a prospective study. Gastroenterology 2011;140:124-131.
[2] Wong VW, Chu WC,Wong GL, et al. Prevalence of non-alcoholic fatty liver disease and advanced
fibrosis in Hong Kong Chinese: a population study using proton-magnetic resonance spectroscopy
and transient elastography. Gut 2012;61:409-415.
[3] Das K, Das K, Mukherjee PS, et al. Nonobese population in a developing country has a high
prevalence of nonalcoholic fatty liver and significant liver disease. Hepatology 2010;51:1593-
1602.
[4] KwonYM, Oh SW, Hwang SS, et al.Association of nonalcoholic fatty liver disease with components
of metabolic syndrome according to body mass index in Korean adults. Am J Gastroenterol
2012;107:1852-1858.
[5] Liu CJ. Prevalence and risk factors for non-alcoholic fatty liver disease in Asian people who are
not obese. J Gastroenterol Hepatol 2012;27:1555-1560.
[6] Wong VW, Vergniol J, Wong GL, et al. Diagnosis of fibrosis and cirrhosis using liver stiffness
measurement in nonalcoholic fatty liver disease. Hepatology 2010;51:454-462.
[7] Petersen KF, Dufour S, Hariri A, et al. Apolipoprotein C3 gene variants in nonalcoholic fatty liver
disease. N Engl J Med 2010;362:1082-1089.
[8] Kechagias S, Ernersson A, Dahlqvist O, et al. Fast-food-based hyper-alimentation can induce rapid
and profound elevation of serum alanine aminotransferase in healthy subjects. Gut 2008;57:649-
654.
[9] WongVW,Wong GL,Yeung DK, et al. Incidence of non-alcoholic fatty liver disease in Hong Kong:
A population study with paired proton-magnetic resonance spectroscopy. J Hepatol 2015;62:182-
189.
[10] Wong VW, Chan RS, Wong GL, et al. Community-based lifestyle modification programme for
non-alcoholic fatty liver disease: a randomized controlled trial. J Hepatol 2013;59:536-542.
40 Postgraduate Course Syllabus • Metabolic Liver Disease
a higher likelihood of having advanced fibrosis or cirrhosis. The score has also recently been shown to
predict long-term mortality in NAFLD patients. However, since BMI is an integral component of the
score, it is unclear if calibration is needed for populations with different BMI cut-offs.
Transient elastography by Fibroscan is another population, non-invasive test of liver fibrosis in Europe
and Asia [6]. Indeed, measurement failure with this technique is less likely in lean patients with NAFLD.
In addition, the latest Fibroscan model allows concomitant measurement of liver stiffness and the
controlled attenuation parameter (CAP). CAP measures ultrasound attenuation in the liver and can be
used to estimate the degree of hepatic steatosis. Further studies are needed to establish if serial CAP
measurements can accurately reflect changes in hepatic steatosis.
Management
Lifestyle modification is the cornerstone of NAFLD/NASH management. In lean patients with NAFLD,
healthy diet and regular exercise are often sufficient in inducing disease remission [10]. While a weight
reduction of more than 10% from baseline has the greatest effect on NAFLD, modest weight reduction
of as little as 3-5% can also improve hepatic steatosis. The current American guidelines support the use
of vitamin E or pioglitazone in patients with NASH and no diabetes or cirrhosis.While these two agents
have been well studied using histological and biochemical endpoints, they have not been specifically
evaluated in lean patients with NASH. For obvious reasons, bariatric surgery is not indicated in lean
patients with NASH.
References
[1] Williams CD, Stengel J, Asike MI, et al. Prevalence of nonalcoholic fatty liver disease and
nonalcoholic steatohepatitis among a largely middle-aged population utilizing ultrasound and
liver biopsy: a prospective study. Gastroenterology 2011;140:124-131.
[2] Wong VW, Chu WC,Wong GL, et al. Prevalence of non-alcoholic fatty liver disease and advanced
fibrosis in Hong Kong Chinese: a population study using proton-magnetic resonance spectroscopy
and transient elastography. Gut 2012;61:409-415.
[3] Das K, Das K, Mukherjee PS, et al. Nonobese population in a developing country has a high
prevalence of nonalcoholic fatty liver and significant liver disease. Hepatology 2010;51:1593-
1602.
[4] KwonYM, Oh SW, Hwang SS, et al.Association of nonalcoholic fatty liver disease with components
of metabolic syndrome according to body mass index in Korean adults. Am J Gastroenterol
2012;107:1852-1858.
[5] Liu CJ. Prevalence and risk factors for non-alcoholic fatty liver disease in Asian people who are
not obese. J Gastroenterol Hepatol 2012;27:1555-1560.
[6] Wong VW, Vergniol J, Wong GL, et al. Diagnosis of fibrosis and cirrhosis using liver stiffness
measurement in nonalcoholic fatty liver disease. Hepatology 2010;51:454-462.
[7] Petersen KF, Dufour S, Hariri A, et al. Apolipoprotein C3 gene variants in nonalcoholic fatty liver
disease. N Engl J Med 2010;362:1082-1089.
[8] Kechagias S, Ernersson A, Dahlqvist O, et al. Fast-food-based hyper-alimentation can induce rapid
and profound elevation of serum alanine aminotransferase in healthy subjects. Gut 2008;57:649-
654.
[9] WongVW,Wong GL,Yeung DK, et al. Incidence of non-alcoholic fatty liver disease in Hong Kong:
A population study with paired proton-magnetic resonance spectroscopy. J Hepatol 2015;62:182-
189.
[10] Wong VW, Chan RS, Wong GL, et al. Community-based lifestyle modification programme for
non-alcoholic fatty liver disease: a randomized controlled trial. J Hepatol 2013;59:536-542.
40 Postgraduate Course Syllabus • Metabolic Liver Disease
