Table 3 Summary of AASLD practice guidelines for the screening, evaluation, and treatment of NAFLD [89]
Screening | Routine Screening for NAFLD in high-risk groups attending primary care, diabetes, or obesity clinics is not advised because of uncertainties surrounding diagnostic tests and treatment options, along with lack of knowledge related to long-term benefits and cost-effectiveness of screening |
There should be a high index of suspicion for NAFLD and NASH in patients with type 2 diabetes | |
Systematic screening of family members for NAFLD is not recommended | |
Evaluation | Patients with unsuspected hepatic steatosis detected on imaging who have symptoms or signs attributable to liver disease or have abnormal liver chemistries should be evaluated as though they have suspected NAFLD and worked up accordingly |
Patients with incidental hepatic steatosis detected on imaging who lack any liver-related symptoms or signs and have normal liver biochemistries should be assessed for metabolic risk factors (e.g., obesity, diabetes mellitus, or dyslipidemia) and alternate causes for hepatic steatosis, such as significant alcohol consumption or medications | |
When evaluating a patient with suspected NAFLD, it is essential to exclude competing etiologies for steatosis and coexisting common chronic liver disease | |
In patients with suspected NAFLD, persistently high serum ferritin, and increased iron saturation, especially in the context of homozygote or heterozygote C282Y HFE mutation, a liver biopsy should be considered | |
High serum titers of autoantibodies in association with other features suggestive of autoimmune liver disease (> 5 upper limit of normal aminotransferases, high globulins, or high total protein to albumin ratio) should prompt a work-up for autoimmune liver disease | |
Initial evaluation of patients with suspected NAFLD should carefully consider the presence of commonly associated comorbidities such as obesity, dyslipidemia, insulin resistance or diabetes, hypothyroidism, polycystic ovary syndrome, and sleep apnea | |
Treatment | Weight loss generally reduces hepatic steatosis, achieved either by hypocaloric diet alone or in conjunction with increased physical activity. A combination of a hypocaloric diet (daily reduction by 500–1000 kcal) and moderate-intensity exercise is likely to provide the best likelihood of sustaining weight loss over time |
Weight loss of at least 3–5% of body weight appears necessary to improve steatosis, but a greater weight loss (7–10%) is needed to improve the majority of the histopathological features of NASH, including fibrosis | |
Pharmacological treatments, such as pioglitazone and Vitamin E, aimed primarily at improving liver disease should generally be limited to those with biopsy-proven NASH and fibrosis. Bariatric surgery can be considered in otherwise eligible obese individuals with NAFLD or NASH |