FATTY LIVER DISEASE (NAFLD) (NASH) A GROWING

Transcription

1 NON ALCOHOLIC FATTY LIVER DISEASE () & NON ALCOHOLIC S T E ATO H E PAT I T I S () ADDRESSING A GROWING SILENT EPIDEMIC

2 Prevalence of & USA Prevalence in Middle Age Patients San Antonio, Texas (Williams et al, Gastroenterology 2011; 140:124-31) Prevalence (%) Dallas Heart Study Prevalence Numbers (Browning et al, Hepatology 2004;40: ). 58.3% 46% 45% 40 30% 44.4% 33% 35.1% % 24% % Overall Hispanic Caucasian African American Overall among diagnosed World-wide prevalence of : 20-30% 13-44% in Middle Eastern countries Approx. 20% in Asian countries Approx. 30 % in European countries world-wide prevalence unknown (estimate from U.S study: 6-8%) / Prevalence among Patients with Diabetes : 80-90% : 56-69% Advanced Fibrosis: 37-50% Obese Patients Studies show that among bariatric surgery patients prevalence of is 70-90% and is 25-30%

3 Non-Alcoholic Fatty Liver Disease () 1. None to very minimal progression to fibrosis 2. No of death compared with the general population ~70-75% Possible sampling variability with some of progression ~7.2% over 6.5 years ~20-25% f death compared with general population 1. Cardiovascular 2. Malignancy 3. Liver-related with fibrosis portends worse prognosis 1. Fibrosis progression a/w DM, severe IR, weight gain>5kg, rising ALT, AST ed from Torres DM et al ~11% over 15 years, but significant variability 19-45% over 7-10 years Isolated Steatosis Non- with Mild Fibrosis with Advanced Fibrosis Hepatocellular Carcinoma is an umbrella term that encompasses the spectrum of fatty liver disease, from isolated steatosis to cirrhosis and liver cancer with underlying. inflammation

4 Natural History of 1. None to very minimal progression to fibrosis Isolated Fatty Liver 1. None to very minimal progress 2. No of death compared with the to fibrosis Isolated Fatty Liver general population ~70-75% 2. No of death compared w general population Fatty Liver with Mild Inflammation ~70-75% Fatty Liver with Mild Inflammation Possible sampling variability with ~7.2% over 6.5 years some of progression Possible sampling variability with ~7.2% some of progression ~20-25% HCC ~20-25% over 6.5 years ~11% over 15 years, but significant variability ~11% over 15 years, but significant variability HCC 1. of death compared with general population 1. Cardiovascular 19-45% over 7-10 years 2. Malignancy 1. of death compared with general population 3. Liver-related 1. Cardiovascular 19-45% over with fibrosis portends worse prognosis 2. Malignancy Decompensation 1. Fibrosis progression a/w DM, 3. Liver-related severe IR, weight gain>5kg, 2. with fibrosis portends worse prognosis rising ALT, AST Decompensat 1. Fibrosis progression a/w DM, severe IR, weight gain>5kg, Modified from Torres DM et al. Features, diagnosis, and treatment of. Clin Gastro Hepatol 2012;10: rising ALT, AST Modified from Torres DM et al. Features, diagnosis, and treatment of. Clin Gastro Hepatol 2012;10:8 Progression of isolated steatosis to cirrhosis is very rare progress but at a slower rate than with Fibrosis is at greater or greatest for disease progression Patients with and metabolic syndrome are also an enriched population for disease progression / is now the second leading cause for liver transplantation in the U.S. Hierarchy of Histologic Features Associated with Disease Progression and Mortality A Predictors Fibrosis, stage 1 Fibrosis, stage 2 Fibrosis, stage 3 Fibrosis, stage 4 Age (years) Diabetes (yes) Smoking Never Former Current Statins use (yes) Increased mortality or LT Hazard Ratio 0 Increased of liver-related events B Predictors Fibrosis, stage 1 Fibrosis, stage 2 Fibrosis, stage 3 Fibrosis, stage Decreased Increased Hazard Ratio Decreased Increased C Major Prognostic Factors Ballooning Portal inflammation inflammation

5 & Mortality Non-Alcoholic Fatty Liver Disease () Top 3 Causes 1. Cardiovascular Disease () 2. All cause malignancy 3. Liver-related death Conditions Associated with Cardiovascular disease Hyperlipidemia Hypothyroidism Isolated Steatosis OSA Vitamin D deficiency Non- Diabetes Hypertension Adenomatous polyps with Mild Fibrosis PCOS Metabolic Syndrome with Modified from Torres DM et al. Features, diagnosis, and treatment of. Clin Gastro Hepatol 2012; 32: Advanced Fibrosis Diagnosis 1. AASLD practice guidelines require liver biopsy to diagnos 2. Liver enzymes can be normal in up to 60% of patients with Hepatocellular Carcinoma 3. rule out Red Flags Increasing Probability for when Deciding Whom Biopsy is anto umbrella term that encompasses the spectrum of fatty liver disease, from isolated steatosis to cirrhosis and liver cancer with underlying.

6 Treatment A. remain the top priority. Ultimate goal is to achieve 10% weight loss as this has been shown to improve all histopathologic parameters of. B. Consideration in non-diabetics can be given to vitamin E at doses of IU daily. C. Consideration can also be given to those patients with diabetes to add pioglitazone 30-45mg daily. D. In addition to diet and exercise, consideration can also be given to referral for a clinical trial as there are many treatment trials underway. : Key Considerations 1. is the liver manifestation of metabolic diseases. patients are often obese, have type 2 diabetes, and cardiovascular disease. 2. and its complications: treating is the appropriate approach to stop 3. Liver biopsy is required to make the diagnosis of. 4. How to reverse : stop the disease 5. therapies should be safe easy to underlying liver disease and comorbid conditions associated with such as insulin resistance, diabetes, and hyperlipidemia.