Amreen Dinani, MD

I spoke to a patient, a 63-year-old woman who immigrated to the United States from Central America in 1978, about her experience living with liver disease. She is now an 

 NAFLD patient advocate who was diagnosed with autoimmune hepatitis and NAFLD in 2005. After experiencing the devastation of her diagnosis, she has managed to learn to live with the disease and wants to help others achieve better quality of life.

Our patient had been diagnosed with autoimmune hepatitis for several years and doing well. She developed pain in her upper right abdomen and saw three specialists. They assumed she was an alcoholic even though she told them she didn’t drink. She talked to her primary care physician who sent her to a liver specialist. 

The doctor spent 90 minutes talking to her and, based on blood work every three months and ultrasounds every six months, determined that her autoimmune hepatitis medication- prednisone, was causing fatty liver. It took three liver biopsies to confirm the diagnosis of NAFLD on top of autoimmune hepatitis.

Helpful Tips About Healthy Diet and Finding Support

This woman has made huge changes to her lifestyle. Sheexercises regularly, meditates, drinks plenty of water and has changedher eating habits by following a healthy diet and avoiding sugary drinks, such as soda and concentrated juice drinks. She prepares her own food and only takes medicine prescribed by a physician, who do so with caution because she has been at the last stage of liver cirrhosis for the last three years.

Though difficult, she has learned to avoid greasy foods found in fast food restaurants, eats abundant greens, incorporates fruit into her breakfast and vegetables for lunch. She’s learned to prepare food in different ways by sautéing, baking or grilling her food using olive oil. She does not fry her food, which she may have done previously. She avoids additives and salt, relying instead on herbs and spices.

Before trying new foods, she and her caregivers research its possible impact on the liver. When she buys groceries, she avoids red meat, high fructose corn syrup and anything with more than five ingredients. She also practices portion control and learned that the palm of your hand is the amount of meat you should eat, which for her is mostly fish, chicken and occasionally lobster.

She advises people tofollow their doctors’ orders and, once diagnosed, find a support group to learn and share information with others living with the same disease. People can find information online from organizations, such as the 

, and Facebook groups, such as Living with Cirrhosis, Living with Fatty Liver/NASH.

She is a true reflection of what it is to live with chronic liver diseases and how changing in your lifestyle can improve liver health and overall health.

Articles

This article is the final installment of four articles exploring the epidemic of liver disease called nonalcoholic fatty liver disease and its more severe form, nonalcoholic steatohepatitis.

The Multiple, Complex Challenges of Living with and Managing Liver Disease

Nonalcoholic fatty liver disease (NAFLD), is a result of fat deposition in the liver in the absence of little or no alcohol. It’s global impact is undeniable, affecting 25% of the world’s population.1 It’s more serious form, non-alcoholic steatohepatitis (NASH), can affect up to 6-8% of the world’s population1 typically associated with liver scarring, cirrhosis and complications of cirrhosis and liver failure.

The cornerstone of treatment for NAFLD is lifestyle changes. Once a patient has been identified with this disease, education on lifestyle modifications, including weight loss, staying active and making healthier food choices, is the first step in treatment. Simple changes, such as eliminating sweetened beverages like sodas and fruit juices, are recommended and patients should be encouraged to be more active. 

The focus should not be “which diet?” or “which exercise?” but realistic goals to achieve weight loss, through modifying food intake accompanied with positive reinforcement and encouragement along the way.

Other aspects of lifestyle areas of focus include smoking cessation for smokers and cutting back on alcohol use for those who drink. Both smoking and alcohol can accelerate disease progression and contribute to liver fibrosis.

Weight loss is typically fast in the beginning and a plateau can be reached a few months after making changes to eating and fitness habits. Patients should be encouraged to continue efforts related to modifying eating habits, food choices and increasing and creating variation in exercise routines.

Patients should work with their primary care physicians to manage other medical problems, such as high blood pressure, type 2 diabetes and high cholesterol. Several diabetic medications have been shown to be effective in persons with type 2 diabetes and NAFLD.Cholesterol lowering medications (such as statins) are safe and can reduce inflammation in the liver,

as well as have a positive impact on the natural history and complications of cirrhosis.

Currently, there are no approved medical therapies, but a number of compounds exist at various stages of development to treat NAFLD at different points in the disease progression.

For now, a patient-centric chronic care management program may be the most cost-effective approach to improve NAFLD and liver scarring.

Part 4 of this series looks at the patient perspective of managing liver disease.

Clinicians, researchers, and experts interested replying to this submission, or submitting their own work to HCPLive, can contact the editorial team

Vargas JI, Arrese M, Shah VH, Arab JP. Use of Statins in Patients with Chronic Liver Disease and Cirrhosis: Current Views and Prospects. 

. 2017;19(9):43. doi:10.1007/s11894-017-0584-7. Accessed July 28, 2020.

This article is the third in a series of four articles exploring the epidemic of liver disease called nonalcoholic fatty liver disease and its more severe form, nonalcoholic steatohepatitis.

Understanding Current and Future Treatments for Liver Disease

Nonalcoholic fatty liver disease (NAFLD) and its more serious form, non-alcoholic steatohepatitis (NASH), is gaining world-wide attention. Patients with NASH are more likely to have obesity and type 2 diabetes—two conditions that are highly prevalent among the general population. 

Obesity and type 2 diabetes mellitus is reportedly even higher in the US veteran population. Identifying NAFLD poses a serious challenge, due to the lack of specific signs of symptoms, making diagnosis, management and follow up in the general population and veteran population challenging. 

The Veterans Health Administration (VHA) has implemented several innovative strategies to manage liver disease. This has been illustrated with success in identifying, treating and curing a significant portion of veterans with chronic hepatitis C infection. Now, major efforts are being undertaken to implement an effective population health management strategy for veterans with NAFLD that may present a path forward for the rest of country.

Liver biopsy remains the standard to diagnose NAFLD and identify the key features of NASH, (steatosis, inflammation, liver cell injury) and amount of liver scarring (liver fibrosis). However, liver biopsy is an impractical tool for NAFLD diagnosis. One in four Americans could be affected – meaning there are far too many people with NAFLD and NASH to biopsy. 

The liver biopsy procedure is invasive, can be associated with patient discomfort or pain, and can result in complications such as bleeding. Additionally, there can be variation in interpretation of the biopsy results by pathologists, which is not ideal for disease monitoring and treatment decisions.

For these reasons, non-invasive tests (NITs) are being adopted more widely to avoid reliance on liver biopsies.

A number of NITs are now available and canbe broadly categorized into blood and imaging-based tests or biomarkers. The two most commonly used blood tests are fibrosis-4 index (FIB-4) and NAFLD fibrosis score (NFS). Both can be relatively easy to calculate by utilizing an application (App) or calculator, by inputting routine lab results (aspartate aminotransferase [AST], alanine aminotransferase [ALT], platelet count, albumin) and some standard patient information, such as age, BMI and presence or absence of diabetes.

Vibration controlled transient elastography (VCTE), or FibroScan, is an imaging-based technology, that is becoming more widely available to assess liver stiffness. FibroScan can assess liver stiffness which correlates with liver scarring, while simultaneously measuring degree of steatosis with controlled attenuated parameter (CAP). 

FibroScan has been shown to be effective in detecting NAFLD and liver scarring. It also provides instantaneous results that are reproducible and has created excitement as a point-of-care test. FibroScan is covered by Medicare, Medicaid, and many insurance plans.

Both types of NITs described above can categorize patients into low, moderate or high risk of having liver scarring, with best performance in ruling out advanced liver scarring.

Primary care physicians and caregivers should be aware of the high prevalence of NAFLD, not only in the general population, but amongst veterans as well. The key message is that patients must be better informed about how their liver functions, the impact of their behavior on liver health, how lifestyle modification can prevent and reverse liver damage if caught in the early stages and the value of carefully managing liver disease to prevent progression into cirrhosis or cancer.

Part 3 of this series looks at current and future treatments for liver disease.

is an Assistant Professor in the Department of Medicine, Division of Liver Diseases. Dr. Dinani’s clinical and research interests are in nonalcoholic fatty liver disease (NAFLD). She is an investigator for many ongoing clinical trials in NALFD.

This article is the second in a series of four articles exploring the epidemic of liver disease called nonalcoholic fatty liver disease and its more severe form, nonalcoholic steatohepatitis.