The ubiquity of “hepatic steatosis” and the growing mentions of “non-alcoholic fatty liver disease” (NAFLD) are impossible to ignore in the medical landscape. Metabolic dysfunction-associated steatotic liver disease (MASLD) and steatohepatitis (MASH) are on the global rise, mirroring the surge in obesity and metabolic risk factors.
While it might be tempting to downplay the significance of this metabolic disease, the reality is that MASLD can stealthily progress to cirrhosis, decompensated liver disease, hepatocellular carcinoma (HCC), and even death. MASH cirrhosis has now become the leading reason for liver transplantation in individuals over 65.
Spotting the At-Risk: Who Needs Specialty Care?
Normal serum transaminase levels aren’t reliable indicators of clinically significant liver disease, especially in patients with diabetes, MASH, and advanced liver fibrosis. The presence of steatohepatitis or fibrosis becomes the crucial predictor for disease progression. Aggressive therapy is warranted for those with MASH and at least stage 2 fibrosis (F2), given their higher risk of liver-related morbidity and mortality.
Identifying patients with hepatic steatosis at significant risk for advanced fibrosis involves assessing key risk factors such as type 2 diabetes, medically complicated obesity, substantial alcohol use, and a family history of cirrhosis. A first-degree relative with MASH cirrhosis elevates a patient’s risk of advanced fibrosis by a staggering 12 times. Utilizing non-invasive tests (NITs) like vibration-controlled transient elastography (VCTE) or the Enhanced Liver Fibrosis (ELF) blood test helps quantify and stage fibrosis in this high-risk group.
For the largely asymptomatic or undiagnosed cohort, employing an easy and cost-effective NIT like the Fibrosis-4 Index (FIB-4) helps identify low-risk patients who can be managed by primary care physicians or specialists overseeing metabolic disease. Regular monitoring, particularly for those with at least two metabolic risk factors, is essential. If testing indicates a moderate or high risk of advanced disease, additional assessments like VCTE, magnetic resonance elastography (MRE), or ELF are recommended. Referral to a gastroenterology/hepatology clinic is then advised for confirmatory evaluation and prevention of complications associated with advanced fibrosis.
Patient Care Beyond Specialized Clinics
Risk stratification does not diminish the role of other healthcare providers in modifying MASLD disease. Given its tight connection with metabolic comorbidities like insulin resistance, dyslipidemia, hypertension, and central obesity, an incidental finding of hepatic steatosis should prompt screening for these metabolic conditions. Treatments that benefit one often improve the other, even in the absence of FDA-approved medications for MASLD.
Providers should feel confident in initiating treatments such as SGLT2 inhibitors and GLP-1 receptor agonists, approved for associated comorbidities. Moderate to high-intensity statins are safe in MASLD patients with dyslipidemia, reducing cardiovascular disease and potentially decreasing the risk of HCC and decompensated liver disease. Lifestyle modifications, emphasizing diet and exercise, are paramount. Overweight and obese patients should be guided toward caloric deficit diets, with consideration for the cardiovascular benefits of the
Mediterranean diet. Weight loss of 10% body weight is sufficient to improve MASH and reduce fibrosis.
All providers can assess alcohol intake, a crucial yet under-recognized aspect of MASLD management. Alcohol accelerates fibrosis and liver injury, increasing the likelihood of advanced fibrosis even when not the primary cause of liver disease.
In the face of the overwhelming prevalence of MASLD, it’s clear that a multidisciplinary effort is required to effectively address this epidemic. Don’t shy away from discussing “fatty liver” with your patients; it’s a collective effort to tackle this growing health challenge.
References
Rinella ME, Neuschwander-Tetri BA, Siddiqui MS, Abdelmalek MF, Caldwell S, Barb D, Kleiner DE, Loomba R. AASLD Practice Guidance on the clinical assessment and management of nonalcoholic fatty liver disease. Hepatology. 2023 May 1;77(5):1797-1835.
Devarbhavi H, Asrani SK, Arab JP, Nartey YA, Pose E, Kamath PS. Global burden of liver disease: 2023 update. J Hepatol. 2023 Aug;79(2):516-537.
Dr. Gordon Robbins
An Atlanta native, Dr. Robbins graduated magna cum laudeand Phi Beta Kappa from the University of Georgia and received his medical degree from Emory University School of Medicine, where he also completed his residency. Dr. Robbins completed both a fellowship in gastroenterology and hepatology and an advanced fellowship in therapeutic en-doscopy at the University of Maryland Medical Center in Baltimore. He joined Atlanta Gastroenterology Associates in 2023 and has a special interest in the diagnosis and treatment of pancreaticobiliary diseases. Dr. Robbins is Board Certified, Internal Medicine and Gastroenterology and works in the Kennestone (Marietta) office.
