NAFLD Flashcards
Definition of NAFLD
> 5% of hepatocytes steatotic - fatty infiltration of liver in absence of secondary cause
Liver manifestation obesity and metabolic syndrome
Staging of NAFLD
Hepatic steatosis only
Steatohepatitis +/- fibrosis - NASH
Cirrhosis
What is NASH
Steatohepatitis +/- fibrosis
Fat and hepatocellular injury and inflammation
can still regress from fibrosis
Prognosis of cirrhosis
- 45% risk of decompensation in 10 years
- 2% risk HCC/year
- 20% mortality - 10 years
Pathogenesis of NAFLD
- Visceral obesity → insulin resistnace
- Increase lipolysis in peripheral tissues → more free fatty acids in blood in the liver
- Lipogenesis - more fat produced in liver, also decreased export
- Gut microbiota, oxidative stress and genetics, age, geneder, ethnicity → inflammation
Factors affecting NAFLD progression
T2DM
Weight gain
Poor DM contol
Metabolic syndrome
Inacitivity
Diet - high fat, sugar, fructose
Increasing age
Genetics - PNPLA3, TM5F6
Sleep apnoea
Factors slowing NASH progression
Weight loss
Exercise
Mediterranean diet
DM control
Coffee
WHo suspect NAFLD in
- All overwieght/obese individuals
- Older sedentary
- T2DM/metabolic syndrome
How is NAFLD identified
Raised liver enxymes but ofetn normal
Imaging of steatosis
Imagine evidence of cirrhosis or liver cancer
What is criteria for NAFLD diagnosis
Raised ALT+/or GGT + steartosis on imaging
OR evidence of insuline resistance/central obesity/metabolic facotrs
How to rule out other differentials in NAFLD
No hisotry of alcogol excess
Pre-exisitng liver disease
Hepatotoxic drugs
Negative liver screen for other diseases eg virus
Liver biopsy if uncertain diagnosis
What does a raised ALT fall with
Advancing fibroris
Age
What is most common LFT abnormality in NAFLD
Raised GGT
Next - ALT, IgA, ferritin w normal TS
What aminotransferase increases with fibrosis
AST
Imaging for NAFLD
US
MRI - PDFF
MR spectrocsopy
What is CAP
Controlled attenuation parameter
Bedside measure of steatosis
Staging of fribrosis
F0-1
F2-3
F4
Managment of FO-1 fibrosis
Lifestyle advice, treat metabolic syndrome
Reassess FIB4/TE 3 years
F2-3 manamgenet
Lifestyle + metabolic treat
NAFLD direct therapy
F4 fibrosis managmenet
NAFLD direct therapy
HCC and varices screen
lifestyle + treat metabolic
Tests for fibrosis
Scores -
FIB-4
NAFLD fibrosis score
ELF test
Fibrotest
ProC3
What level means fibrosis on a transient elastograhy and suggests liver biopsy
> 8kPa
Imaging for fibroris
Transient elastography
Acoustic force radiation imaging - ARFI
Mr ELASTOGRAPHY
Clinical scores for fibroriss
AST:ALT ratio >0.8 = advanced fibroris
FIB-4 score
What FIB-4 scores suggest transient elastography
> 1.3 if under 65
2 if over 65
What is conisidered in FIB4
- Age
- AST
- ALT
- Platelet count
- 0.3 = no fibrosis
What FIB4 diagnoses fibrosis level
> 2.67 if under 65
3.25 if over 65
Treatment for NAFLD
Weight loss - 10% goal
Exercise
Manage CVS risk
Weight loss help in NAFLD
Orlistat
Clinic visits
Support schemes/programmes, diets etc
Bariatric surgery if BMI >40 or >35 + comorbidity (caution in cirrhosis)
What medications are good for NAFLD that treat diabetes
Metformin - reduce HCC
Pioglitazone, liraglutide - reduce steatosis + slows fibrosis progression
Pioglitazone side effects
weight gain, increased risk bladder cancer, reduced bone density
Maangement of metabolic syndrome in NAFLD
Treat DM - metformin, pioglizine, liraglutide
HPTN - ARBs/ACEis (antifibrotic)
Dyslipidemia - statins
Sleep apnoea
Smoking cessation
Treatment for F3 NASH non diabetic vs diabetic
Vit E if non diabetic
Assess ALT response after 6 monhts - should decline
Diabetic - GLP-1, piaglitzone or empaglaflozin
What blood test can test for advanced fibrosis
Enhanced liver fibrosis - ELF blood test
What does ELF blood test test
hyaluronic acid + procollagen III + tissue inhibitor of metalloproteinase 1.
What investigations used together to for diagnosis of NAFLD
FIB-4 or NAFLD fibrosis
+ fibroscan (transient elastography)
