Diagnosis and management of Non-Alcoholic Steatohepatitis (NASH) & Non-Alcoholic Fatty Liver Disease (NAFLD)
Sanjay Bhagany (Consultant physician/honorary senior lecturer in infectious diseases/HIV medicine, Royal Free Hospital, London)
Emmanuel Tsochatzis (senior clinical lecturer and consultant hepatologist at the UCL Institute for Liver and Digestive Health, Royal Free Hospital, London)
Abnormal liver function (LFT) tests and fatty liver are common and often frustrating conditions seen in general practice. I see a significant number of refugees who have abnormal LFTs as well as managing patients with HIV with abnormal LFTs so I was keen to get up early and get to this 7:30am lecture!
Emmanuel made the important point that you can’t always trust the LFTs. Patients can have severe disease with normal LFTs and grossly abnormal LFTs with just fatty liver. It is important to remember that 25% of general population have fatty liver and of those 10% develop cirrhosis.
Fibroscan is important for assessing liver disease although for rural towns like mine, access can be an issue.
Steatosis can cause over-estimation of stiffness in fibroscan. A fibroscan result of >7 is worrying in fatty liver.
Important strategies for everyone with abnormal LFTs associated with fatty liver include addressing CVD risk factors, there is some evidence this will improve fatty liver. We should be considering fatty liver as part of metabolic syndrome, commonly managed in general practice. Extending this to people living with HIV is important as HIV infection itself is fibrogenic.
NASH/NAFLD prevalence in people living HIV is up to 50%. Causes are multifactorial and include HAART therapy plus virus protein inflammation plus lifestyle. Nadir CD4 count and a history of use of older HIV drugs are risk factors for liver disease.
Emmanuel talked about some of the difficulties in making an accurate diagnosis of fatty liver including ultrasound and biological markers as well as non-invasive assessments, all of which have their limitations.
Treatment essentially is about reducing weight including bariatric surgery if appropriate. Emmanuel talked about the experimental use of maroviroc.
In summary, it is important to think of NASH/NAFLD in people living with HIV and reducing cardiovascular risk and monitoring of progression are the mainstay of management.