NAFLD & NASH Flashcards
malnutrition can’t cause chronic liver disease. True or false
true, malnutrition alone can cause severe fatty liver but it isn’t known to cause chronic liver disease
which tool is used for screening of malnutrition in patients with NAFLD/NASH
NRS 2002
what do the questions of the NRS screening tool address?
- BMI
- weight loss
- nutritional intake
- comorbidities (illness)
what are the 2 main screening sections of the NRS 2002
- nutritional disorder
- illness severity
how can sarcopenia be assessed?
using Dual energy X-ray absorptiometry (DXA) or CT imaging
which patients will be screened for sarcopenia?
mostly patients with cirrhosis, liver cancer, planned for liver transplant
patients with NAFLD or NASH are screened for sarcopenia. True or false
False, only those with severe cirrhosis, liver cancer, need for livre transplant
what is the first line treatment for overweight/obese NAFL/NASH patients
lifestyle interventions leading to weight loss in conjunction with physical activity
what are the benefits of losing 7-10% of the weight in overweight/obese NAFL/NASH patients
it will improve steatosis and liver biochemistry [irrespective of how weight loss is achieved]
what are the benefits of losing >10% of the weight in overweight/obese NAFL/NASH patients
improve fibrosis
what does the ESPEN guideline regarding weight loss suggest
a hypocaloric diet should be followed according to current obesity guidelines irrespective of the macronutrient composition [large range of CHO and fat during weight loss as long as diet provides high content of protein] => people have to adhere to diet to then continue with it and maintain weight loss
what kind of evidence is there for the diet and exercise, lifestyle intervention recommendation
STRONG evidence coming from observational and experimental studies showing positive effects on liver outcomes
to see significant effect on NASH resolution and fibrosis regression, how much weight loss should be achieved?
7-10%
what are the 4 As in the Canadian adult obesity clinical practice guideline that must be followed
- ask
- assess
- agree
- assist
when dealing with patients that have NAFL and NASH which type of diet or dietary pattern do we usually recommend?
mediterranean diet
when dealing with patients that have NAFL and NASH what type of intervention do we implement
INTENSIVE lifestyle intervention with a MULTIDISCIPLINARY TEAM
what are the key messages regarding the obesity guidelines for NAFL/NASH
- weight should NOT be the endpoint, we want to focus on health improvement => liver enzymes and other cardio metabolic markers, steatosis, fibrosis
- education
- best diet is one that is SUSTAINABLE
what are the benefits of a high protein diet during weight loss
- greater reduction in body weight, fat mass, and serum TG
- less reduction in lean mass and REE
what is the best diet for weight maintenant after weight loss
high protein + low GI foods
what are the Canadian physical activity guidelines
general, not specific to NASH/NAFL
- 150min of moderate-vigorous aerobic PA per week
- muscle and bone strengthening 2days/week
what are the benefits of aerobic PA (30-60min of moderate-vigorous intensity on most days)
- achieve reduction in abdominal visceral fat and ectopic fat such as LIVEr and heart fat
the Mediterranean diet is high in which nutrients? and low in which nutrients?
- high in: MUFA, omega-3/6, polyphenols, dietary fibre, plant proteins
- low in: saturated/trans fats, animal protein, simple sugars
what is one food in the mediterranean diet that could not be dissociated from whole diet? why?
olive oil, because it provides oleic/MUFA and antioxidants that are beneficial in NAFL and NASH
is a low CHO diet recommended for NASH/NAFL? why or why not?
No because there is much less evidence, with much smaller sample size, alot of neutral evidence
Vitamin E supplementation is recommended for which population
to non-diabetic adults with histologically confirmed NASH
what is the recommended supplement content of vitamin E
800 IU of alpha-tocopherol daily
although omega-3 FA supplementation seems to have a positive effect on liver outcomes, why isn’t it a strong recommendation?
no optimal dose was determined
what source of omega-3 FA is recommended for NASH/NAFL
dietary omega-3
what are the observed positive effects of 3-4cups of coffee per day
positive outcome on fibrosis, steatosis, liver dimension, bright liver
how does fructose affect NAFLD
excess fructose will lead to de novo lipogenesis in liver + alter the gut microbiome increasing permeability of intestine and causing more inflammation leading to aggravation of NAFL to NASH
recommendation of alcohol in NASH/NAFL
ABSTAIN
-> strong robust recommendation
is taking pre/probiotics recommended by ESPEN?
yes, although there is no strong evidence as there are no side effects and some positive benefits have been observed (decrease in liver enzymes, decrease in intrahepatic TG, decreased inflammation)
is taking antioxidants recommended by ESPEN?
No due to lack of data
what treatment has the strongest benefits in NASH patients
weight loss
a _____ treatment strategy is necessary for treating NAFL and NASH
multimodal
what are the major liver functions (8)
- bile formation
- metabolism of drugs
- CHO metabolism
- lipids and lipoproteins production
- amino acids metabolism
- protein production and secretion
- metabolism of iron, copper, and trace elements
- haem biosynthesis
what is the functional unit of the liver
acinus
what makes up the portal triad
the portal vein, arteriole and bile ductule
what are the 4 different liver function tests
- aspartate aminotransferase AST
- alanine aminotransferase ALT
- AST/ALT ration
- alkaline phosphatase ALP
what is AST and what is it used for
AST is an enzyme found throughout the body but predominantly in the heart and liver cells. its useful in detecting liver damage due to hepatitis, drugs toxic to the liver, cirrhosis and alcoholism
what is ALT and how is it used in liver function tests
enzyme found mostly in the cells of the liver and kidney ->when the liver is damaged, ALT is released into the blood stream, it is useful to detect liver damage due to hepatitis and drugs or other substances toxic to the liver
significance of ALP
it can indicate blockage of one or more bile ducts, liver cancer, hepatitis, cirrhosis, or when hepatotoxic drugs are taken
in alcoholic liver disease ____ is higher than ____
AST > ALT => ratio >1
In viral hepatitis ____ is higher than ____
ALT is higher than AST => ratio <1
which liver function test is more specific to the liver
ALT
elevations in hepatocellular enzymes (AST and ALT) indicate _______
parenchymal injury
cholestatic enzymes (ALP, GGT, bilirubin) indicate _____
disease to biliary system
what is the difference in ALT elevation between acute hepatitis and chronic hepatitis
acute: >10 fold increase
chronic: 1.5-10 fool increase
what is the difference in treatment between acute hepatitis and chronic hepatitis
acute: supportive treatment
chronic: address aetiology, what caused chronic hepatitis [treat virus]
what are the common causes of acute hepatitis
- drug-induced [no tests available, exclusion diagnosis]
- Hepatitis A
- Hepatitis B
what are the common causes of chronic hepatitis
- NAFL or NASH
- hepatitis C
- hepatitis B
- Alcoholic liver disease
what are the common causes of cholestasis
- PBC/PSK
- Large duct obstruction
patients dealing with cholestatis are quite ____ in last stages of disease -> need of ____
wasted
need of nutritional support
conjugated hyperbilirubinemia indicates _____
pure obstruction
definition of cirrhosis
a diffuse process characterized by liver necrosis and fibrosis and conversion of normal liver architecture into structurally abnormal nodules that lack normal lobular organization
what is the pathology of cirrhosis
- nodularity
- fibrosis (deposition of dense fibrous septa, deposition of collagen)
- abnormal liver architecture
- hepatocyte abnormalities
- irregular surface, yellowish color, small, firm
the portal vein brings blood to _____ from _____
to the liver from intestine and bowel
what are the consequences of nodularity in liver cirrhosis
portal hypertension: there is increased resistance to blood flow coming in through the portal vein into the liver causing increase in pressure and backflow into all small vessels that originate from portal vein
what is the most important event when there is liver cirrhosis
portal hypertension
what are the consequences of liver cirrhosis
portal hypertension and liver insufficiency
what are the complications of portal hypertension
- variceal hemorrhage
- ascites [spontaneous bacterial peritonitis and hepatorenal syndrome]
- hepatic encephalopathy
- congestive splenomegaly
what are the complications of liver insufficiency
- encephalopathy
- jaundice
definition of portal hypertension and cutoff
an increase in portal venous pressure, >12mmHg
what are the three different aetiology of portal hypertension
- intrahepatic - 80%, cirrhosis [scar tissue blocks blood flow and slows liver functions]
- prehepatic - portal vein thrombosis
- post hepatic [rare]
what are the mechanisms of ascites in cirrhosis
- portal hypertension
- hypoalbuminemia [albumin keeps fluid inside vessels]
- arterial vasodialtion
- hyperaldosteronism; ADH
what causes hepatic encephalopathy
the ammonia, glutamine methionine, nitrogen, GABA go to the diseased liver from gut which fails to metabolize ammonia NH3 and enters blood stream and crosses blood Brian barrier
to avoid hepatic encephalopathy it is recommended to decrease protein intake to reduce ammonia accumulation. true or false
false, it was recommended but now we don’t because these patients are at high risk of malnutrition
what is the driver of mortality in patients with liver disease
sarcopenia
which classification method is used to assess severity of cirrhosis and what are the factors taken into account
Child-Turcotte-Pugh classification
- encephalopathy
- ascites
- bilirubin
- albumin
- prothrombin time
why are liver function tests done/useful
to orient towards aetiology of liver disease (hepatocellular or cholestatic enzymes)
what is the relationship between NAFLD and NASH
they both have a fatty overload => hepatic steatosis, with no significant alcohol intake
however NASH also have inflammation in addition to fat accumulation
what are the established risk factors of NASH
- obesity
- T2DM
- dyslipidemia
- metabolic syndrome
- hypertension
why is there an urge to transition from NAFLD to Metabolic Associated Fatty liver disease MAFLD
NAFLD is a diagnosis of exclusion where as MAFLD is a positive diagnosis caused by overweight/obesity, diabetes or >2 metabolic risk abnormalities
=> accent is put on metabolic abnormalities
what is the most frequent factor of NAFLD
obesity
what are the different stages from NAFL to hepatocellular carcinoma
- NAFL: fat accumulation in liver
- NASH: fat + inflammation, scarring
- fibrosis
- Cirrhosis: scar tissue replaces liver cells
- Hepatocellular carcinoma
NAFLD is not just about the liver, it is a ______ disease
multi-system disease [causes chronic inflammation in the body - CVD, osteoporosis, cancer]
Most commonly, patients with NAFLD die from liver. true or flase
false, they die from heart attack usually
what are the 2 main drivers of NASH
INSULIN resistance AND OXIDATIVE stress
what does the perfect storm refer to in the case of NASH
presence of T2DM [independent risk factor for development of NASH] presence of NASH [independent risk factor for development of T2DM]
which is the most important genetic contributor in NASH development
PNPLA3 (encodes adiponutrin)
how does the gut dysbiosis/ microbiome play a role in NASH
it causes intestinal permeability and absorption of some nutrients that are deleterious for NASH such as fructose and fat
what are the factors used to diagnose NASH
inflammation and steatosis
what factor is looked at to give a prognosis of NASH
liver fibrosis staging and cirrhosis
there are not many visible symptoms associated with NAFLD thus it is referred to as a silent killer. true or false
true, NAFLD is frequent and frequently asymptomatic
=> 79% with NAFLD have normal ALT levels
if a patient has normal transaminases, can I exclude NASH?
no
how do you evaluate NAFLD/NASH/fibrosis
- biopsy [showing steatosis, hepatocyte ballooning and lobular inflammation]
- imaging
- biomarkers
what is taken into account in the FIB-4 score and what is it used for
FIB-4 score includes age, AST, ALT, platelets
it is used to rule out advanced fibrosis if <1.3
which patients should receive pharmacotherapy
- NASH
- NASH with fibrosis
- advanced fibrosis
- NASH-related cirrhosis
which are the recommended pharmacotherapies for NASH
- vitamin E
- pioglitazone
which pharmacotherapies are not recommended to treat NASH but can be used to treat risk factors of NASH
- metformin [treat T2D]
- statin [treat dyslipidemia and reduce CV risk ]
- omega-3 FA [treat hyperTG]
____ lower risk of portal hypertension in cirrhosis
statins
in adults with need to minimize weight gain or promote wight loss, guidelines recommend ____ and _____
GLP-1 RAs (semaglutide) and SGLT2
what are the 2 end points of clinical trial for NASH
- reduction of inflmmaiton
- reduction in fibrosis
which patients should be screened for NSH/NAFLD/fibrosis
- T2D/ prediabetes
- obese
- HIV +
- elevated ALT or fatty liver
- person at high CVD risk
- polycystic ovary syndrome PCOS
- inflammatory bowel disease
____ is the most frequent liver disease in western countries
NAFLD
what is the strongest prognostic predictor of NAFLD/NASH
liver fibrosis stage
what are the general treatment recommendations
- diet + exercise
- pharmacologic therapy in those with ASH/lier fibrosis
