Non-Alcoholic Fatty Liver Disease (NAFLD) Management in the Community

Abstract

Non-alcoholic fatty liver disease (NAFLD) has frequently been associated with obesity, type 2 diabetes (T2D), and dyslipidemia, all of which are shared by increased insulin resistance. It has become the most common liver disorder in Korea as well as in developed countries and is therefore associated with an increased health burden of morbidity and mortality. It has an association with T2D, and T2D increases the risk of cirrhosis and related complications. NAFLD encompasses a disease continuum from simple steatosis to non-alcoholic steatohepatitis which is characterized by faster fibrosis progression. Although its liver-related complication is estimated to be, at most, 10%, it will be a leading cause of cirrhosis and hepatocellular carcinoma soon in Korea. Although the main causes of death in people with NAFLD are cardiovascular disease and extra-hepatic malignancy, advanced liver fibrosis is a key prognostic marker for liver-related outcomes and can be assessed with combinations of non-invasive tests in the community. A number of components of metabolic syndrome involved could be another important prognostic information of NAFLD assessed easily in the routine care of the community. There is a few approved therapies for NAFLD, although several drugs, including antioxidants, attract practitioners' attention. Because of the modest effect of the present therapeutics, let alone complex pathophysiology and substantial heterogeneity of disease phenotypes, combination treatment is a viable option for many patients with NAFLD in the Korean community. Comprehensive approach taking healthy lifestyle and weight reduction into account remain a mainstay to the prevention and treatment of NAFLD.

Keywords: community; diabetes; liver fibrosis; metabolic syndrome; non-alcoholic fatty liver disease.

Figure 1

Schematic presentation of pathogenesis of MAFLD and possible mechanisms of action of available treatment strategies. The imbalance in lipid metabolism due to overnutrition leads to the formation of lipotoxic lipids that contribute to oxidative and endoplasmic reticulum stress, inflammasome activation and apoptotic cell death, and stimulation of inflammation, tissue regeneration, and fibrogenesis. The pathogenic pathways of MAFLD influenced by metabolic, genetic, and microbiome-related factors were also depicted. The crosstalk between the liver and other organs (particularly adipose tissue and the gut) via FGF19 and FGF21 might also contribute to metabolic dysregulation and inflammation in MAFLD.

Figure 2

Consecutive assessment of the severity of MAFLD in the community. Inexpensive, simple fibrosis scores (NAFLD fibrosis score or FIB-4) can be counted as a first step to identify individuals at low risk of advanced fibrosis, who can be managed in the community. Individuals with high-risk scores require additional assessment with Fibro-scan or might require referral to university hospitals (secondary care) for investigation or management of advanced fibrosis. Patients without advanced fibrosis at initial assessment might require ongoing monitoring to identify progressive liver disease and retesting 3–5 years after the initial assessment.