Nonalcoholic fatty liver disease: DISCUSSION (Part 1)

In: Nonalcoholic fatty liver disease

11 Jul 2012

We have described a series of adult patients with liver biopsies compatible with NAFLD who were investigated in outpatient hepatology and gastroenterology clinics for increased liver enzymes. We found that NAFLD was present throughout a wide ranges of ages (20 to 64 years). Further, our data showed that NAFLD in young patients (20 to 40 years) was predominantly associated with being overweight and the absence of fibrosis on liver biopsies. In contrast, NAFLD in older patients (older than 40 years) was more likely to be associated with being overweight and with biopsies positive for inflammation or fibrosis. Finally, the presence of diabetes was associated with biopsies compatible with NASH regardless of age.

The patients described in this study share many characteristics with patients in previously reported series of NAFLD. Unlike in most studies, however, patients in our cohort had a broad age range, from 24 to 64 years. This age distribution most likely reflects the design of the study, where patients were recruited exclusively from outpatient clinics. This provided an opportunity to assess the degree of liver fibrosis in NAFLD with age. Our results show that the degree of liver fibrosis in NAFLD is closely correlated with advancing age. Despite this general trend, however, we identified several young patients (less than 35 years) who had typical features of NASH, showing that age is not the only determining factor for the development of NASH. This is supported by recent publications that have described NASH in children with obesity. cheapest price for the levaquin

Our results in this outpatient cohort are in agreement with previous reports, in that a significant rise in ALT alone is associated with steatosis only, while in patients with NASH a rise in both AST and ALT is consistently observed. However, we did not find in this small retrospective cohort that the ratio of AST to ALT could be used to predict the presence of liver fibrosis in individual patients. Ultrasound examination of the liver detected fat in only 37.5% of patients with biopsies limited to steatosis compared with 86.7% of patients with fat plus fibrosis or inflammation. The patients who were missed on ultrasound had only mild to moderate steatosis. These results are in agreement with previous reports and show that an ultrasound examination has low sensitivity in the diagnosis of NAFLD. We examined the incidence of obesity and diabetes in our cohort in light of several series that disputed the high incidence of these disorders in NASH. Over 90% of NAFLD patients in our series had a BMI greater than 26 or were clearly described as being overweight, and over 40% were obese (BMI greater than 30). The incidence of hyperlipidemia and hypercholesterolemia was also high (greater than 80%), albeit only 50% of the patients were assessed in our series (data not shown). The incidence of diabetes correlated strongly (100% in our series) with advanced liver disease. The incidence of diabetes was low (23.3%) in patients with NASH without cirrhosis and was absent in patients with no fibrosis. Given the retrospective nature of the study, however, we cannot comment on whether glycemic control or noncompliance with diabetes treatment — buy diabetes drugs — was associated with liver fibrosis. Our study supports an important role for diabetes in the progression of NAFLD to NASH and subsequently to cirrhosis.

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