Care for patients with nonalcoholic fatty liver disease (NAFLD) requires a holistic, multidisciplinary approach. These findings, from a narrative review, were published in Lancet Gastroenterology and Hepatology.

Publication databases were searched from inception to December 6, 2020 for studies on NAFLD and diabetes, cardiovascular disease, chronic kidney disease, or extrahepatic cancers.

NAFLD is associated with increased risk for liver-related complications, type 2 diabetes, chronic kidney disease, extrahepatic cancers, cardiovascular disease, and arrhythmias.


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The underlying pathophysiology of NAFLD is complex, involving metabolic disturbances, chronic inflammation, lipotoxicity, insulin resistance, and intestinal dysfunction.

The increase in adipose tissue likely contributes to the chronic inflammation associated with NAFLD. The expansion and dysfunction of adipose tissue causes increased production of proinflammatory cytokines and a decrease in anti-inflammatory adipokines. In addition, chronic inflammation is the driving force for many cancers, due to its tumor-promoting effects. Proinflammatory cytokines have been found to induce arrhythmias in diabetic model mice.

Poor hepatic health has the potential to affect many systems of the body. This feature requires clinicians to be familiar with signs and symptoms of diseases of many organ systems. Patients should be evaluated for risk factors of diabetes, cardiovascular disease, and chronic kidney disease and be assessed regularly by ultrasound for evidence of hepatocellular carcinoma.

The management of NAFLD should include a team of internists, cardiologists, nephrologists, diabetologists, hepatologists, dietitians, and general practitioners.

Patients with type 2 diabetes and chronic kidney disease may be managed with metformin and glucagon-like peptide-1 analogues, sodium-glucose transport protein 2 inhibitors, or pioglitazone. For patients with increased cardiovascular disease risk, statin therapies may be considered. Patient with a diagnosis of cardiovascular disease may be prescribed angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, or low-dose aspirin.

Additional research is needed to determine whether patients with noncirrhotic, nonalcoholic steatohepatitis require hepatocellular carcinoma surveillance. It also remains unclear what the long-term effects of metformin therapy on rates of hepatocellular carcinoma are, as well as the impact of statin therapy on hepatic health. The review authors advocated for guidelines to be updated such that screening patients with NAFLD for comorbidities is clearly defined and streamlined.

The currently available literature on comorbidities among patients with NAFLD indicate this cohort is at an increased risk for multiple comorbidities, spanning the body’s organ systems. As such, a holistic, multidisciplinary approach is needed in order to manage the diverse symptoms associated with these comorbidities.

Reference

Targher G, Tilg H, Byrne CD. Non-alcoholic fatty liver disease: a multisystem disease requiring a multidisciplinary and holistic approach. Lancet Gastroenterol Hepatol. Published online May 4, 2021. doi: 10.1016/S2468-1253(21)00020-0