Indian National Association for Study of the Liver (INASL) Guidance Paper on Nomenclature, Diagnosis and Treatment of Nonalcoholic Fatty Liver Disease (NAFLD)

Abstract

Nonalcoholic fatty liver disease (NAFLD) is a major cause of chronic liver disease globally and in India. The already high burden of NAFLD in India is expected to further increase in the future in parallel with the ongoing epidemics of obesity and type 2 diabetes mellitus. Given the high prevalence of NAFLD in the community, it is crucial to identify those at risk of progressive liver disease to streamline referral and guide proper management. Existing guidelines on NAFLD by various international societies fail to capture the entire landscape of NAFLD in India and are often difficult to incorporate in clinical practice due to fundamental differences in sociocultural aspects and health infrastructure available in India. A lot of progress has been made in the field of NAFLD in the 7 years since the initial position paper by the Indian National Association for the Study of Liver on NAFLD in 2015. Further, the ongoing debate on the nomenclature of NAFLD is creating undue confusion among clinical practitioners. The ensuing comprehensive review provides consensus-based, guidance statements on the nomenclature, diagnosis, and treatment of NAFLD that are practically implementable in the Indian setting.

Keywords: AASLD, American Association for the Study of Liver Diseases; ALD, alcohol-associated liver disease; ALT, alanine aminotransferase; APRI, AST-platelet ratio index; AST, aspartate aminotransferase; BMI, body mass index; CAP, controlled attenuation parameter; CHB, chronic Hepatitis B; CHC, chronic Hepatitis C; CK-18, Cytokeratin-18; CKD, chronic kidney disease; CRN, Clinical Research Network; CVD, cardiovascular disease; DAFLD/DASH, dual etiology fatty liver disease or steatohepatitis; EBMT, endoscopic bariatric metabolic therapy; ELF, enhanced liver fibrosis; FAST, FibroScan-AST; FIB-4, fibrosis-4; FLIP, fatty liver inhibition of progression; FXR, farnesoid X receptor; GLP-1, glucagon-like peptide-1; HCC, hepatocellular carcinoma; INASL, Indian National Association for Study of the Liver; LAI, liver attenuation index; LSM, liver stiffness measurement; MAFLD; MAFLD, metabolic dysfunction-associated fatty liver disease; MR-PDFF, magnetic resonance – proton density fat fraction; MRE, magnetic resonance elastography; MetS, metabolic syndrome; NAFL:, nonalcoholic fatty liver; NAFLD, nonalcoholic fatty liver disease; NAS, NAFLD activity score; NASH; NASH, nonalcoholic steatohepatitis; NCD, noncommunicable diseases; NCPF, noncirrhotic portal fibrosis; NFS, NAFLD fibrosis score; NHL, non-Hodgkin's lymphoma; NPCDCS, National Programme for Prevention and Control of Cancer, Diabetes, Cardiovascular Diseases and Stroke; OCA, obeticholic acid; PPAR, peroxisome proliferator activated receptor; PTMS, post-transplant metabolic syndrome; SAF, steatosis, activity, and fibrosis; SGLT-2, sodium-glucose cotransporter-2; SWE, shear wave elastography; T2DM, DM: type 2 diabetes mellitus; USG, ultrasound; VAT, visceral adipose tissue; VCTE, vibration controlled transient elastography; fatty liver; hepatic steatosis; nonalcoholic steatohepatitis.

Figure 1

Risk stratification and management algorithm in nonalcoholic fatty liver disease.