The indications for recommending a liver biopsy for suspected NAFLD remains controversial, with most practitioners not recommending a biopsy in asymptomatic patients with mildly increased liver enzymes. The argument against biopsy is that the information provided would change little in deciding on a treatment plan for these patients. On the other hand, advocates of liver biopsy argue that patients at increased risk of progressing to end-stage liver failure can be identified. In the Edmonton area, only a minority of patients had a liver biopsy as part of their investigation for the diagnosis of NAFLD. Given the reluctance to perform a liver biopsy for the diagnosis of NAFLD, we acknowledge that the data collected in this study reflect a population of patients who may have been relatively resistant to conservative management of NAFLD. This is reflected in the high proportion of patients with NASH.
The various mechanisms responsible for the development of NAFLD and its progression to NASH were reviewed recently. A key event in the initiation of hepatic lipogenesis in NAFLD appears to be insulin resistance as shown by investigators using the two-step hyper-insulinemic euglycemic clamp technique. Our data, which show that diabetes is an important factor in the development of fibrosis in patients with NAFLD, are consistent with these studies, which described the unequivocal presence of insulin resistance in NAFLD, as well as with evidence by Marceau et al of a correlation between the development of diabetes and more advanced liver fibrosis in patients with syndrome X. Most studies show that being overweight or obese is an important contributing factor to insulin resistance; however, other studies that have also described NASH in normal weight patients argue that other, as yet unidentified mechanisms including a possible genetic predisposition may be important in the development of insulin resistance as well. Isn’t it nice to know you will soon be able to shop for your drugs online with the best pharmacy that will take great care of you? You do have this opportunity to order cipro now that you have the best pharmacy waiting for your decision and offering cheapest drugs of best quality.
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