Nonalcoholic fatty liver disease (NAFLD) is gaining more attention as a chronic medical condition, affecting approximately 25% of the worldwide population and 100 million individuals in the United States.

 NAFLD, is an umbrella term for a range of liver conditions that occurs as a result of fat in the liver. 

This is in the absence of excessive alcohol use or other causes of fatty liver disease. Its more serious form is called non-alcoholic steatohepatitis (NASH),

 which affects 6-8% of the global population and is expected to increase 63% by 2030.

NAFLD can lead to inflammation of the liver, liver tissue damage and liver scarring (fibrosis), which can progress to cirrhosis and liver cancer (hepatocellular carcinoma). NAFLD is on track to become the leading cause of liver transplantation in the United States.

Patients with NASH typically have no or few symptoms, especially in the early stages of the disease. When a patient feels well, it can be challenging for physicians and caregivers to convince the patient that they may have a dangerous condition.

Obesity and type 2 diabetes mellitus are the leading risk factors for NAFLD. The rising population of NAFLD, closely mirrors the growing epidemic of obesity and type 2 diabetes mellitus.

Presence of metabolic syndrome is also a risk factor for the development of NAFLD. 

Several genetic predisposing factors are related to NAFLD and NASH; these genetic factors are most prevalent in Hispanics

 and associated with more aggressive disease. In individuals who do not develop cirrhosis, the leading causes of death are related to cardiovascular disease and non-liver related cancers.

The most accurate way to diagnose NAFLD and NASH and liver scarring is with a liver biopsy. This is invasive, can be expensive and has potential side effects. The need for non-invasive tests and point-of-care testing to diagnose and monitor assessment of liver fat and liver scarring are critical to helping identify individuals with NASH at risk of progression to cirrhosis.

Primary care physicians can play a central role in identifying at risk individuals because many patients with comorbidities, such as type 2 diabetes, are cared for by primary care physicians. In addition, they can assist in managing comorbidities such as obesity, type 2 diabetes and cardiovascular disease. Other subspecialties that see these patients are endocrinology, cardiology and bariatric medicine. There is a need to raise awareness on liver health.

The key message for caregivers is that NAFLD is manageable, and potentially reversible if caught in its early stages. Diet and exercise are the most effective treatments, but poor adherence often makes this a challenge for many people.

Part 2 of this series looks at current diagnostic tools and new non-invasive tests for liver disease. It will run on September 13.

 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.

 is the Hepatology Section Head at the Ochsner MultiOrgan Transplant Institute. He has published literature related to his research around advanced liver disease and its complications, such as portal hypertension and cirrhotic cardiomyopathy. His current research has focused on adult deceased and living donor liver transplantation and quality of life issues in liver patients.

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

Perumpail BJ, Khan MA, Yoo ER, Cholankeril G, Kim D, Ahmed A. Clinical epidemiology and disease burden of nonalcoholic fatty liver disease. 

. 2017;23(47):8263-8276. doi:10.3748/wjg.v23.i47.8263. 

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5743497/

https://liverfoundation.org/for-patients/about-the-liver/diseases-of-the-liver/non-alcoholic-fatty-liver-disease/#facts-at-a-glance

https://www.the-nash-education-program.com/what-is-nash/how-prevalent-is-nash/

 Centers for Disease Control and Prevention (2018). 

Behavioral Risk Factor Surveillance System

Pan JJ, Fallon MB. Gender and racial differences in nonalcoholic fatty liver disease. 

. 2014;6(5):274-283. doi:10.4254/wjh.v6.i5.274; accessed July 28, 2020.

This article is the first in a series of 4 articles exploring the epidemic of liver disease called nonalcoholic fatty liver disease and its more severe form, nonalcoholic steatohepatitis.

The Battle Against Growing Burden of “Silent” Liver Disease Begins with Early Detection

Amreen Dinani, MD; George Therapondos, MD

New research finds that early preemptive kidney transplants do not reduce the risk of death, according to a Yale School of Medicine (YSM) study published in 

End-stage kidney disease (ESKD), also known as renal or kidney failure, can occur because of diabetes and high blood pressure, among other reasons. A patient with kidney failure needs a transplant when they begin dialysis, or possibly before. Since dialysis puts stress on the body and weakens the immune system, it is commonly believed that those with ESKD would have better outcomes if they receive a kidney transplant preemptively—before receiving dialysis.

, associate professor of medicine (nephrology) at YSM and medical director of the Living Kidney Donor Program at Yale, examined records over the span of two decades to evaluate the current state of preemptive kidney transplants in the United States, focusing on mortality benefit. Kumar and his colleagues were interested in finding out whether there was a benefit to performing a transplant earlier versus later from both deceased and living donors.

“If you receive an organ from the deceased donor list, you don’t have control over when you will get the organ,” Kumar says. “On the other hand, if there is a living donor, and you have more control over timing, the question is, when is it most beneficial to get the transplant?”

Our study shows that waiting until you really need a transplant is when you should get one. Otherwise, you're losing that time on your own kidney.
Abhishek Kumar, MBBS

The findings present no difference in outcome of mortality for those who received a kidney transplant earlier when they had a higher estimated glomerular filtration rate (eGFR), a measure of kidney function, or later as eGFR worsened. Therefore, Kumar says, patients should wait if they have a choice. “It’s all about the timing,” says Kumar. “Our study shows that waiting until you really need a transplant is when you should get one. Otherwise, you're losing that time on your own kidney.

“Sometimes I tell patients the best time to get a transplant is the day you need dialysis,” he adds.

Dialysis exposure of up to 6 months does not negatively impact long-term outcomes if a transplantation is performed within that period, Kumar says.

However, the optimal time for dialysis and transplantation depends on the individual and is difficult to predict, says Kumar, who notes that the transition from care of chronic kidney disease to dialysis is costly and resource-intensive. “We should always avoid dialysis if we can, but performing a transplant early is not the solution."

Nephrology is one of ten sections in the Yale Department of Internal Medicine. Committed to excellence in patient care, research, and education, the section’s faculty and trainees aim to be national and international leaders in academic nephrology. To learn more, visit

New research from Yale School of Medicine indicates that early preemptive kidney transplants do not reduce mortality risk in end-stage kidney disease (ESKD) patients. The study, led by Abhishek Kumar, MBBS, analyzed two decades of data to assess the timing of transplants from both deceased and living donors. Findings suggest no mortality benefit from early transplants when kidney function is relatively better. Patients are advised to wait until transplantation is necessary, as dialysis exposure up to six months does not adversely affect long-term outcomes if transplantation occurs within that timeframe.

Does Early Preemptive Kidney Transplantation Reduce Risk of Death?

Amy Anderson

Experts conclude this series highlighting what is on the horizon of retinal disease care. 

Perspectives on the Future of Retinal Disease Management

In this final segment, the participants share their excitement for the future of retina care this year and beyond. Across the panel, experts express enthusiasm for the constant evolution of therapies, techniques, and technologies in the field of retina. They touch on the ongoing trials and current research, acknowledging the challenges and complexities of developing new drugs but remains optimistic about potential breakthroughs. Experts circle back to gene therapy, emphasizing the potential for game-changing developments once challenges like inflammation are addressed. The physicians across the panel are excited at the prospect of higher durability agents to continue improving patient quality of life.

This summary was AI-generated and edited for clarity.

David Eichenbaum, MD

Key Takeaways and Considerations for the Use of BTK Inhibitors in CSU Treatment

Video content above is prompted by the following:

What are some key takeaways on the potential use of BTK inhibitors in the treatment of CSU that you’d like to share with clinicians managing this condition?

Panelists discuss how Bruton tyrosine kinase (BTK) inhibitors represent a promising new therapeutic class for chronic spontaneous urticaria (CSU) by offering rapid symptom control through targeted inhibition of both mast cell and B cell pathways, with newer agents like remibrutinib showing high selectivity, favorable safety, and robust efficacy in clinical trials that could position them as an important oral therapy option between antihistamines and biologics.

Giselle Mosnaim, MD, MS 

Targeting Disease Modification for Psoriasis and Psoriatic Arthritis

17:30 - Defining Minimal Disease Activity

35:35 - Preventing Progression from PSO to PSA

Medical experts engage in a discussion surrounding the treatment and management of patients diagnosed with psoriasis and psoriatic arthritis.

Kostas N. Botsoglou, MD

 vaccinations has evolved over the years. We have successfully made HIV part of the primary care visit, but many patients are still hesitant to undergo testing due to the stigma associated with the disease. Similarly, fears persist about the COVID-19 vaccine – primarily because some patients unfortunately still don’t trust our science-based institutions. 

Yet for most people, solid trust in their primary care doctor has not wavered. For that reason, clinicians have a great opportunity to increase COVID-19 vaccinations and testing for HIV. It begins with a candid conversation; but starting that dialogue can be difficult. From our experience, here are a few key approaches that can help open the door.

Being open and honest with patients must always be our top priority. Many patients doubt the safety of the COVID vaccines when seeing friends and family members fall sick after vaccination. As clinicians, we have to remind patients that vaccines were never meant to prevent infections 100% of the time. Instead, their greatest use is preventing 

 infections, hospitalizations, even deaths. But in the messaging to patients, we may have oversold the capability of vaccines. 

Similarly, the stigma and misinformation surrounding HIV has led many to question why vaccines have been quickly developed for emergent infections such as COVID-19 and Monkeypox, yet we still don’t have a vaccine for HIV. This has spurred even more distrust and fueled skepticism about the origins of HIV.

When we as clinicians provide explanation, we help debunk these dangerous myths and misunderstandings. Honesty builds trust, and every subsequent conversation becomes a little easier.

Your patients see you as a highly reliable source of information. They will look to you for direction and trust your guidance. But if they have questions, they’ll be able to quickly tell if you aren’t sure of the answers. We always have to do our best to stay up to date on new research, guidelines, and recommendations. But obviously, we won’t always have all of the answers.

One way to build trust is to actually look up the information with your patient right there in the exam room. So when starting a conversation about HIV testing, you can actually show the patient the latest recommendations of the U.S. Preventive Services Task Force for testing based on patient demographics. You can show them which specific guidelines are recommended for them. And when you want to discuss COVID vaccines, show them the CDC.gov website, walk them through the recommendations, and guide them toward the answers.

When it comes to HIV and COVID-19 discussions, it’s crucial that patients don’t feel targeted. Questions should never feel accusatory or taboo, and the best way to avoid this is to make testing and screening questions part of your routine in every primary care visit. Patients will then come to expect this discussion, and even if they aren’t willing to undergo testing or screening, it won’t cause any ill feelings between you and the patient.

The CDC recommends that we keep our feet on the gas pedal, continually having conversations with patients about the dangers of COVID-19. This should also be the approach with HIV testing. We hope that we can reach a point when COVID vaccines and HIV testing become routine topics just like screenings for breast cancer, diabetes, and other diseases. 

There are efforts to help inform clinicians about navigating conversations with patients on these topics. For instance, the "Two in One: HIV + COVID Screening and Testing Model" from George Washington University has launched a training series for all clinicians to routinize HIV screening and COVID-19 vaccine screening for all of their patients. The next free webinar in the training series will take place in May. More information can be found on the 

We must help our patients by sharpening our skills in using the simple but powerful tools of patience, transparency, and honesty based on evidence.

Annette Gadegbeku, MD, is Associate Dean of Community Health at Drexel University College of Medicine and an Associate Professor in the Department of Family, Community & Preventive Medicine and Chief of the Division of Community Health. She is on the advisory board for George Washington University’s 

Two in One HIV +COVID Screening and Testing Model.

Leon McCrea, MD, MPH, is the Senior Associate Dean of Diversity, Equity & Inclusion at Drexel University College of Medicine and an Associate Professor in the Department of Family, Community & Preventive Medicine. He is on the advisory board for George Washington University’s 

Clinicians and experts interested in replying to this piece or submitting an article to HCPLive can 

The Power of the Primary Care Visit to Combat COVID-19 and HIV

Leon McCrea, MD, MPH

Aprocitentan in Practice: Real-World Insights from the Front Lines

Real-world clinical experience with aprocitentan demonstrates its effectiveness in patients with truly resistant hypertension who have failed multiple conventional therapies. Dr Cohen describes treating a patient already on 4 antihypertensive medications who experienced remarkable blood pressure improvement within 1 month of adding aprocitentan to her regimen. The patient achieved blood pressure readings that had not been seen with previous treatment combinations, demonstrating the medication’s ability to provide additional therapeutic benefit in heavily pretreated patients.

The side effect profile of aprocitentan appears manageable in clinical practice, with fluid retention being the most commonly observed adverse effect. Dr Cohen’s patient experienced mild ankle swelling that was successfully managed with as-needed diuretic dose adjustments rather than requiring medication discontinuation. This approach allows patients to continue benefiting from the blood pressure-lowering effects while managing predictable adverse effects through existing therapeutic relationships and medication adjustments.

One of the most valuable characteristics of aprocitentan in clinical practice is its ability to provide significant blood pressure reduction without causing excessive hypotension or overcorrection. Many advanced antihypertensive therapies risk causing blood pressure to drop too dramatically, leading to fatigue, kidney under-perfusion, and other complications. Dr Cohen appreciated that aprocitentan effectively “took the edge off” elevated blood pressures while maintaining stable, appropriate blood pressure ranges that didn’t compromise patient well-being or organ perfusion.

A panelist discusses real-world clinical experience with aprocitentan showing remarkable blood pressure improvements in heavily pretreated patients, with manageable side effects like mild fluid retention that can be addressed through diuretic adjustments.

Marc Cohen, MD, FACC

Comparing Screening Methods for Heart Failure in Patients with Diabetes, with Mohammad Shahzeb Khan, MD

 in Philadelphia, PA, Mohammad Shahzeb Khan, MD, an assistant professor of medicine at Baylor College of Medicine, presented the results from his pooled cohort analysis comparing methods of measuring risk of 

atherosclerotic cardiovascular disease (ASCVD)

A variety of screening techniques for determining HF risk in patients with diabetes have been developed, from echocardiography to clinical risk scores and cardiac biomarkers. However, no direct comparison of screening approaches, alone or in combination with each other, has been conducted. Therefore, despite the rapidly increasing prevalence of HF among patients with diabetes, the optimal screening strategy to predict the disease in a primary prevention population is unknown.

To that end, Khan and colleagues collected deidentified data from various previous studies, including the Atherosclerosis Risk in Communities (ARIC) and Chronic Renal Insufficiency Cohort (CRIC) studies. These cohorts were collectively comprised of 6293 patients – 77.7% of these did not have prevalent ASCVD and were evaluated for HF.

Existing screening strategies were applied among patients without a history of ASCVD, divided up between 1-step and 2-step screenings. The former group included echocardiography, troponin assessments, B-type natriuretic peptide (BNP) assessments, and so on. The latter group involved combining N-terminal pro-BNP (NT-proBNP) screening with the other named methods.

“What we found [that] was really interesting is that if we’re using 1-step screening strategies like NT-proBNP, we are missing a lot of heart failure events,” Khan told 

. “For example, if we were only using NT-proBNP as a screening tool, we would miss almost 30-40% of the heart failure events that were occurring in low risk NT-proBNP growth, meaning that even if the NT-proBNP is less than 125, a decent number of events were occurring in that patient population.”

Khan noted that combination screening, such as with NT-proBNP and the WATCH-DM score, resulted in a much lower percentage of patients missed between all 6 included cohorts.

“We also studied 2-step screening strategies, in which we used a risk score like WATCH-DM and NT-proBNP and we found that when we combined two approaches together, whether it be a biomarker and risk score, the number of patients that were left out were significantly less,” Khan said. “There were only 10-15% of patients that were missing. Indirectly, we’re predicting 85% of the heart failure events.”

Looking ahead, Khan discussed potential issues with the study’s generalizability and scope.

“We took 6 cohorts, we had 6000 patients, so there’s obviously a generalizability issue. We might not be able to generalize these findings to different continents like Asia and Africa, because patient pools are very different across the globe,” Khan said. “We also did not have a proper adjudication for heart failure incidents. It was mainly heart failure hospitalization, so we might have missed diagnoses of heart failure which were done as an outpatient.”

Khan does note, however, that the results from this trial are sufficient to indicate that 1-step screening is no longer sufficient to determine heart failure risk in patients with type 2 diabetes on a larger scale.

“The most important takeaway for this is that using 1-step screening strategies might not be enough to screen for patients with heart failure,” Khan told 

. “We’ll have to use a layered strategy, at least 2-step screening in which, for earlier stratification, you can use a risk score like WATCH-DM and then use a biomarker selectively.”

Khan reports the following disclosures: Bayer

Patel KV, Segar MW, Klonoff DC, et al. Optimal Screening for Predicting and Preventing the Risk of Heart Failure Among Adults With Diabetes Without Atherosclerotic Cardiovascular Disease: A Pooled Cohort Analysis. Circulation. 2024;149(4):293-304. doi:10.1161/CIRCULATIONAHA.123.067530

Khan’s presentation indicates that combination screening is the optimal method of identifying heart failure risk while minimizing the percentage of cases missed.

Mohammad Shahzeb Khan, MD

 In the start of early 2020 we did things different at Duke in our practice because patients weren’t afraid to change therapies or start new therapies or even continue their therapy. How has the pandemic affected you as far as keeping patients on drug and compliant, starting new medications and seeing them in clinic, and then tell us about your mix of video, telemed [telemedicine] to in person visits?

It’s been a challenging time. In the beginning, we had a lot of education for our patients to let them know that from the data we had from New York, places like NYU [New York University], Columbia, that it was safe to stay on medication. It was better to have inflammation controlled than your body trying to fight the disease and then trying to fight COVID-19. Once we got our patients educated enough on that fact, infusion went on as always. We didn’t miss a beat. If you weren’t coming in for an infusion, then we did a lot of video visits. They must come in at least every 6 months for a real appointment because you must touch patients. There’s no question. We can educate patients though and change medications on a video visit, I thought that was helpful. I’m glad that we had that option because it’s not safe to bring in people. Not everybody is vaccinated. With omicron especially patients are getting sick, even with 3 vaccines. We’re going to keep patients apart as much as possible, but patients are sticking with their medication because the data is out there, and we use evidence-based medicine and educate our patients and have good patients.

For the first 2 weeks of the pandemic, we were at home of course, just getting telemed [telemedicine] set up because we didn’t use it in our practice before the pandemic, which now I see was unfortunate. Once we got telemed running, I was 3 days in person in the office. We continued to see patients and they were coming in and then it was a wonderful day at home with telemed [telemedicine] up until June 1st, 2021. Duke [University] said, “OK, we’re all going back into clinic,” when we thought the numbers were going to go down and stay down. What I elected to do in June was I wanted to keep at least a half of day at clinic for my patients who are stable, and I could see them every 6 months in person but do some telemed [telemedicine]. Telemed [telemedicine] has become an important part of my practice and I will continue to utilize that. What percentage are you doing telemed [telemedicine] versus in-person visits?

Currently, the only people I’m letting in the office are people who need an injection or are coming in for infusions. Everybody else, because the numbers have been terrible, we have been doing video visits or phone visits if they can do a video just for the protection of our infusion patients and our other immunocompromised patients.

I will say that our infusion suite has been busy since the beginning of the pandemic. We’re fortunate to have individual bays and private rooms where the door slides and they’re soundproof and patients don’t have to worry about sharing germs, but we are just so backed up, continue to be backed up with infusions. So patients really were not afraid to come in during the pandemic to get their infusion. The same for you that you’ve experienced, right?

Yes. Once they were educated and knew that it was safer for them to be in control, we never missed a beat which is great. The only thing certain if somebody was getting a subq [subcutaneous injection] in the office we would go out to the car to make it more comfortable for a few of our medications that we use in psoriatic arthritis [PsA]. It’s a simple injection but other than that we try to keep patients as safe as possible. We don’t have the advantage of individual rooms. We have a big infusion suite. We had to decrease our number of chairs to give proper spacing, but we ran longer hours. We did everything we needed to do to make sure that everybody was accommodated.

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Before closing out their discussion on psoriatic arthritis management, two experts consider how the COVID-19 pandemic has affected their practice.

Managing PsA During the COVID-19 Pandemic

Nancy Eisenberger, MSN, FNP-C

To watch the video series component of this episode, click here.

In this MEDcast® episode, Diana Isaacs, PharmD, BCPS, BC-ADM, CDCES, and Natalie Bellini, DNP, FNP-BC, BC-ADM, CDCES, interview Sumita Singh to discuss her family’s journey as they navigated the challenges of their daughter’s T1D diagnosis and decided to enroll her in a clinical trial for a T1D treatment.

Authors