NON-ALCOHOLIC FATTY LIVER DISEASE (NAFLD)
NON-ALCOHOLIC FATTY LIVER DISEASE
(NAFLD)
& NON-ALCOHOLIC STEATOHEPATITIS
(NASH)
ADDRESSING A GROWING SILENT
EPIDEMIC
Prevalence (%)
PREVALENCE OF NAFLD/NASH
USA Prevalence in Middle Age Patients
San Antonio, Texas (Williams et al., Gastroenterology
2011; 140:124-31)
Dallas Heart Study Prevalence Numbers (Browning et al., Hepatology 2004;40:1387-95)
60
58.3%
46%
40
30%
20
45%
44.6% 33%
35.1% 24%
12.2%
29.9%
0
NAFLD Overall
NAFLD Hispanic
NAFLD Caucasian
NAFLD African American
NASH Overall
NASH among diagnosed NAFLD
Worldwide prevalence of NAFLD: 20-30%
13-44% in Middle Eastern countries Approx. 20% in Asian countries Approx. 30% in European countries NASH worldwide prevalence unknown (estimate from U.S. study: 6-8%)
NAFLD/NASH Prevalence among Patients with diabetes
NAFLD 80-90%
NASH 56-69%
ADVANCED FIBROSIS
37-50%
NAFLD/NASH Prevalence among obese Patients
Prevalence among bariatric surgery patients
NAFLD 70-90%
NASH 25-30%
NON-ALCOHOLIC FATTY LIVER DISEASE (NAFLD)
ISOLATED STEATOSIS
NON-NASH NAFLD
CVD
NASH WITH MILD FIBROSIS
NASH WITH ADVANCED FIBROSIS
CIRRHOSIS
HEPATOCELLULAR CARCINOMA
NAFLD is an umbrella term that encompasses the spectrum of fatty liver disease, from isolated steatosis
to cirrhosis and liver cancer with underlying CVD risk.
NATURAL HISTORY OF NAFLD
~70-75%
Isolated Fatty Liver
Fatty Liver with Mild inflammation
1- None to very minimal progression to fibrosis 2- No risk of death compared with the general population
Possible sampling variability with some risk of progression
NAFLD
~20-25%
~11% over 15 years, but significant variability
NASH
1- risk of death compared with general population 1- Cardiovascular 2- Malignancy 3- Liver-related
2- NASH with fibrosis portends worse prognosis 1- Fibrosis progression a/w DM, severe IR, weight gain>5kg, rising ALT, AST
NASH Cirrhosis
HCC ~7.2% over 6.5 years
Decompensation ~19-45% over 7-10 years
Modified from Torres DM et al. Features, diagnosis, and treatment of NAFLD. Clin Gastro Hepatol 2012;10:837-858
Progression of isolated steatosis to cirrhosis is very rare Fatty liver with inflammation but not NASH may progress but at a slower rate than NASH NASH with fibrosis is at greater risk for disease progression Patients with NASH and metabolic syndrome are also an enriched population for disease progression NAFLD/NASH is now the second leading cause for liver transplantation in the U.S.
Hierarchy of Histologic Features
Associated with disease progression and mortality
A
INCREASED MORTALITY
OR LT
B
INCREASED RISK OF
LIVER-RELATED EVENTS
C
Predictors
Fibrosis, stage 1 Fibrosis, stage 2 Fibrosis, stage 3 Fibrosis, stage 4 Age (years) Diabetes (yes) Smoking
Never Former Current Statins use (yes)
Hazard Ratio
95% Cl of HR
1.18, 2.81 1.20, 3.03 1.16, 3.12 3.35, 12.04 1.05, 1.08 1.11, 2.30
P value
.007 .007 .01 ................
................
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