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WGO releases guidelines for NASH, NAFLD
Nonalcoholic fatty liver disease is the No. 1 cause of liver disease in Western countries, according to research data, and there is insufficient evidence on how to best diagnose and treat the disease.
The World Gastroenterology Organization (WGO) has drafted and released global guidelines to assist clinicians in combating the disease.
Diagnosis
No solid criteria exist on how clinicians should diagnose nonalcoholic steatohepatitis (NASH), the most severe form of nonalcoholic fatty liver disease (NAFLD), according to the guidelines. The WGO, an association of worldwide experts, recommends clinicians test for NASH if a patient has hypertension, type 2 diabetes, sleep apnea, a family history of the disease, obesity, hyperlipidemia, sedentary lifestyle and is of nonblack ethnicity.
Liver biopsy is recommended in patients who have risk factors for NASH or other liver diseases. NASH is closely related to insulin resistance, obesity and metabolic syndrome, however, not all patients with one or more of these conditions has NASH/NAFLD, and not all patients with NASH/NAFLD have one or all of these conditions.
Treatment
The WGO recommends diet and exercise, including: avoiding fructose and trans-fats while increasing dietary omega-3/omega-6 polyunsaturated fatty acids; a 25% caloric decrease in a patient’s normal diet (based on age and sex) and a goal of 5% to 10% weight loss; bariatric surgery for patients with morbid obesity; and moderate exercise three to four times weekly.
Experimental therapy such as antioxidants and antifibrotic agents should only be considered in patients who successfully make lifestyle changes, but do not lose 5% to 10% of weight over 6 months to 1 year. Liver transplantation is successful in patients diagnosed with liver failure, however, NASH can recur and morbidly obese patients often are excluded as transplantation candidates.
“Ultimately, NAFLD and NASH are diagnoses of exclusion and require careful consideration of other diagnoses,” the researchers wrote. “Just as the clinician cannot diagnose NASH on the basis of clinical data alone, the pathologist can document the histologic lesions of steatohepatitis, but cannot reliably distinguish those of nonalcoholic origin from those of alcoholic origin.”
Disclosure: The researchers report no relevant financial disclosures.
Perspective
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This is an important milestone in the diagnosis and management of non-alcoholic fatty liver disease (NAFLD) and non-alcoholic steatohepatitis (NASH). The World Gastroenterology Organization (WGO) Global guidelines are only the 2nd set of standards published on NAFLD and NASH after the [American Association for the Study of Liver Diseases] published its guidelines in 2012 [Chalasani N. Hepatology. 2012;55:2005-2023.].
NAFLD has emerged as a major health problem in the last decade in parallel with the increasing epidemic of obesity. It has been recognized as the hepatic manifestation of metabolic syndrome and is the most common reason for referral to hepatologists today. The disease has a variable histological course, with some people only accumulating fat in the liver and not progressing beyond simple steatosis, while a subpopulation of patients progresses to the more advanced stage of NASH in which inflammation and cell injury occur.
NASH can lead to liver cirrhosis and hepatocellular carcinoma (HCC) and is expected to be the leading cause of liver transplant and liver-associated mortality in the coming decade. These guidelines highlight the prevalence, with 6 million individuals in the US with NASH and 600,000 with NASH-related cirrhosis. The prevalence of NAFLD is usually higher in a few subpopulations such as morbidly obese individuals (75-92%) and Hispanics (45%).
The WGO guidelines emphasize the role of liver biopsy to grade and stage the disease especially in those with potential risk factors or signs of cirrhosis (e.g., abnormal ALT for 6 months, AST> ALT, low albumin or platelet). This comes in agreement with previous published data [Noureddin M. Clinical Liver Disease. 2012;1:103–106.].
The authors have discussed the work up and diagnosis in detail and emphasized the role of advanced imaging such as CT scan or MRI, which can quantify liver fat. These imaging techniques have become increasingly helpful in diagnosis, follow up and assessment of treatment response in clinical trials [Noureddin M. Hepatology. 2013; 58:1930-1940; Reeder SB. Hepatology. 2013;58:1877-80.]. Finally, they discuss the role of exercise and weight loss as the first step of the disease’s management. They address the failure rate of weight loss and exercise and suggest alternative medical treatments such as vitamin E and pentoxifylline. They also highlight the role of bariatric surgery in morbidly obese patients. The authors suggest continuing enrollment in clinical trials as there are no available data on long-term effects for any treatment.