Materiały źródłowe

• #1 Non-alcoholic fatty liver disease: a practical approach to diagnosis and staging | Frontline Gastroenterology

  https://fg.bmj.com/content/5/3/211

  Non-alcoholic fatty liver disease (NAFLD) is now the commonest cause of abnormal liver function tests (LFTs) in the UK with approximately a third of the population being affected. […] Many patients with NAFLD remain undiagnosed, and recognising those at risk is the first step. […] Although liver biopsy is the gold standard method for diagnosing and staging NAFLD, the majority of patients can be effectively diagnosed non-invasively with tests that are routinely available in the clinic today. […] A diagnosis of NAFLD requires that there is evidence of hepatic steatosis on imaging or histology, and other causes of liver disease or steatosis have been excluded. […] NAFLD is usually asymptomatic, so diagnosis usually follows the incidental finding of abnormal liver enzymes or steatosis on imaging.

• #2

  https://journals.lww.com/cld/fulltext/2022/06000/the_diagnosis_and_management_of_nonalcoholic_fatty.3.aspx

  Nonalcoholic fatty liver disease (NAFLD) is defined by the presence of fat in the liver without evidence of other causes of fat accumulation in the liver such as alcohol use, hepatitis C, or certain medications. […] Currently, about 25% of the global population has a diagnosis of NAFLD. […] Guideline statement: Patients with unsuspected Hepatic steatosis (HS) detected on imaging who have symptoms or signs attributable to liver disease or have abnormal liver chemistries should be evaluated as though they have suspected NAFLD and worked up accordingly. […] Initial evaluation of patients with suspected NAFLD should carefully consider the presence of commonly associated comorbidities such as obesity, dyslipidemia, diabetes, hypothyroidism, polycystic ovary syndrome, and sleep apnea. […] Patient Summary: Fatty liver is commonly seen on liver ultrasounds or other forms of radiographic studies. When this happens with an increase in liver blood tests (aspartate aminotransferase [AST] and alanine aminotransferase [ALT]), patients should be evaluated for NAFLD.

• #3 Diagnostic Modalities of Non-Alcoholic Fatty Liver Disease: From Biochemical Biomarkers to Multi-Omics Non-Invasive Approaches

  https://www.mdpi.com/2075-4418/12/2/407

  Non-Alcoholic Fatty Liver Disease (NAFLD) is currently the most common cause of chronic liver disease worldwide, and its prevalence is increasing globally. […] To date, liver biopsy remains the gold standard procedure for the diagnosis of NASH and staging of NAFLD. […] However, due to its invasive nature, research on non-invasive tests is rapidly increasing with significant advances having been achieved during the last decades in the diagnostic field. […] For the diagnosis of NAFLD, the ultrasound remains the first-line modality, despite being less reliable if HS is <20%. [...] There is a recognised ongoing need for a non-invasive tool that could accurately identify NASH and also discern low- and high-risk individuals for advanced fibrosis, as high-risk patients would need closer surveillance and management.

• #4 Diagnosis of NAFLD – Non-Alcoholic Fatty Liver Disease – NCBI Bookshelf

  https://www.ncbi.nlm.nih.gov/books/NBK384715/

  Historically, the presence of NAFLD has been suspected in those presenting with abnormal liver blood tests or evidence of fatty changes on ultrasound. […] However, the full spectrum of NAFLD (from simple steatosis to steatohepatitis, cirrhosis and liver-related morbidity) can also be present with normal liver tests. […] Early detection of NAFLD may be useful to identify those with potentially silent progressive fatty liver disease. […] Diagnostic practice varies widely and includes clinical, biochemical and radiographic tests. […] Currently, liver biopsy remains the gold standard for NAFLD diagnosis but it is impractical as a diagnostic tool because it is invasive and expensive. […] As such, there is a need for highly sensitive and specific diagnostic tests that can be commonly used by clinicians in primary, secondary and tertiary care.

• #5 Nonalcoholic Fatty Liver Disease: Diagnosis and Management | AAFP

  https://www.aafp.org/pubs/afp/issues/2013/0701/p35.html/1000

  Nonalcoholic fatty liver disease is characterized by excessive fat accumulation in the liver (hepatic steatosis). […] The diagnosis is usually made after an incidental discovery of unexplained elevation of liver enzyme levels or when steatosis is noted on imaging (e.g., ultrasonography). […] No single laboratory test is diagnostic, but tests of liver function, tests for metabolic syndrome, and tests to exclude other causes of abnormal liver enzyme levels are routinely performed. […] Liver biopsy remains the criterion standard for the diagnosis of nonalcoholic steatohepatitis. […] Screening for nonalcoholic fatty liver disease is not recommended in the general population. […] Patients with nonalcoholic fatty liver disease should be evaluated for metabolic syndrome and insulin resistance.

• #6 Real-world data reveal a diagnostic gap in non-alcoholic fatty liver disease | BMC Medicine | Full Text

  https://bmcmedicine.biomedcentral.com/articles/10.1186/s12916-018-1103-x

  Non-alcoholic fatty liver disease (NAFLD) is the most common cause of liver disease worldwide. It affects an estimated 20% of the general population, based on cohort studies of varying size and heterogeneous selection. However, the prevalence and incidence of recorded NAFLD diagnoses in unselected real-world health-care records is unknown. […] In the largest primary-care record study of its kind to date, rates of recorded NAFLD are much lower than expected suggesting under-diagnosis and under-recording. Despite this, we have identified rising incidence and prevalence of the diagnosis. Improved recognition of NAFLD may identify people who will benefit from risk factor modification or emerging therapies to prevent progression to cardiometabolic and hepatic complications. […] A pragmatic approach is to focus on real-world patients for whom the diagnosis of NAFLD has been made during routine clinical care. A diagnosis of NAFLD is often made following abnormal imaging of the liver or elevated serum liver enzymes (so-called liver function tests) and involves exclusion of other causes of liver injury, such as excess alcohol consumption and viral hepatitis.

• #7 Nonalcoholic Fatty Liver Disease | Columbia Surgery

  https://columbiasurgery.org/conditions-and-treatments/nonalcoholic-fatty-liver-disease

  The diagnosis of NAFLD requires the presence of fat in the liver as seen by imaging studies or histology (obtained via a biopsy, or small piece of the liver) and the exclusion of other causes of fat accumulation. Many things can disrupt the livers metabolic activity and it is important to exclude those things as the treatment depends on the underlying cause of the problem. Currently the only way to distinguish between non-NASH NAFLD and NASH is a liver biopsy, however several risk calculators and biomarkers have been devised to help determine whether a biopsy is needed. […] The Columbia Liver Disease and Transplantation Center has experts who specialize in treating nonalcoholic fatty liver disease. Call (877) 548-3763 to schedule an appointment. You can also use our online form to request an appointment with our team.

• #8 Diagnosis of NAFLD & NASH – NIDDK

  https://www.niddk.nih.gov/health-information/liver-disease/nafld-nash/diagnosis

  Doctors use your medical history, a physical exam, and tests to diagnose nonalcoholic fatty liver disease, or NAFLD (also referred to as metabolic dysfunction-associated steatotic liver disease, or MASLD). […] Your doctor will ask if you have a history of health conditions that make you more likely to develop NAFLD. […] During a physical exam, a doctor usually examines your body and checks your weight and height to calculate your body mass index. […] Doctors use blood tests, imaging tests, and sometimes liver biopsy to diagnose NAFLD and to tell the difference between NAFL and NASH. […] Your doctor may suspect you have NAFLD if your blood test shows increased levels of the liver enzymes alanine aminotransferase (ALT) and aspartate aminotransferase (AST). […] Routine imaging tests can show fat in your liver. […] Liver biopsy is the only test that can prove a diagnosis of NASH and show clearly how severe the disease is.

• #9 Fatty liver disease – Wikipedia

  https://en.wikipedia.org/wiki/Fatty_liver_disease

  Medical condition […] Diagnostic method Based on the medical history supported by blood tests, medical imaging, liver biopsy […] Diagnosis is based on the medical history supported by blood tests, medical imaging, and occasionally liver biopsy. […] Criteria for nonalcoholic fatty liver disease: consumption of ethanol less than 20 g/day for women and 30 g/day for men. […] Elevated liver enzymes are found in as many as 50% of patients with simple steatosis. […] Simple blood tests may help to determine the magnitude of the disease by assessing the degree of liver fibrosis. […] Imaging studies are often obtained during the evaluation process. […] Histological diagnosis by liver biopsy is the most accurate measure of fibrosis and liver fat progression as of 2018.

• #10

  https://journals.lww.com/cld/fulltext/2022/06000/the_diagnosis_and_management_of_nonalcoholic_fatty.3.aspx

  Key Point: People with metabolic diseases such as type 2 diabetes, obesity, or metabolic syndrome are at high risk for NAFLD. However screening is not currently recommended. […] Guideline statement: When evaluating a patient with suspected NAFLD, it is essential to exclude competing etiologies for steatosis and coexisting Common CLD. […] Patient summary: Several liver diseases can cause a fatty liver or elevated liver enzymes. NAFLD can only be diagnosed once other forms of chronic liver disease are ruled out. […] Key Point: When evaluating patients with NAFLD, it is important to rule out other causes of fatty liver and evaluate for other common causes of chronic liver disease. […] Guideline Statement: There should be a high index of suspicion for NAFLD and NASH in patients with Type 2 Diabetes.

• #11 Nonalcoholic fatty liver disease – Diagnosis and treatment – Mayo Clinic

  https://www.mayoclinic.org/diseases-conditions/nonalcoholic-fatty-liver-disease/diagnosis-treatment/drc-20354573

  Because NAFLD typically causes no symptoms, it is often found when tests done for other reasons point to a liver problem. For example, a blood test done during a yearly exam may show high levels of liver enzymes, which can lead to more testing and a NAFLD diagnosis. […] Tests done to diagnosis NAFLD, rule out other diseases and see how bad liver damage is include: […] Imaging tests used to diagnose NAFLD include: […] If other tests show signs of more-advanced liver disease or NASH, or if your test results are unclear, your doctor may suggest a liver biopsy. Liver biopsy is the best way to diagnose NASH and clearly shows the amount of liver damage. […] Your doctor is likely to ask you a number of questions, such as: Have you had any symptoms, such as yellowing of the eyes or skin and pain or swelling around your waist? […] If your doctor suspects a liver problem, such as nonalcoholic fatty liver disease, you may be referred to a doctor who specializes in the liver, called a hepatologist.

• #12 Diagnosis of NAFLD – Non-Alcoholic Fatty Liver Disease – NCBI Bookshelf

  https://www.ncbi.nlm.nih.gov/books/NBK384715/

  Historically, the presence of NAFLD has been suspected in those presenting with abnormal liver blood tests or evidence of fatty changes on ultrasound. […] However, the full spectrum of NAFLD (from simple steatosis to steatohepatitis, cirrhosis and liver-related morbidity) can also be present with normal liver tests. […] Early detection of NAFLD may be useful to identify those with potentially silent progressive fatty liver disease. […] Diagnostic practice varies widely and includes clinical, biochemical and radiographic tests. […] Currently, liver biopsy remains the gold standard for NAFLD diagnosis but it is impractical as a diagnostic tool because it is invasive and expensive. […] As such, there is a need for highly sensitive and specific diagnostic tests that can be commonly used by clinicians in primary, secondary and tertiary care.

• #13 Diagnosis of NAFLD & NASH – NIDDK

  https://www.niddk.nih.gov/health-information/liver-disease/nafld-nash/diagnosis

  Doctors use your medical history, a physical exam, and tests to diagnose nonalcoholic fatty liver disease, or NAFLD (also referred to as metabolic dysfunction-associated steatotic liver disease, or MASLD). […] Your doctor will ask if you have a history of health conditions that make you more likely to develop NAFLD. […] During a physical exam, a doctor usually examines your body and checks your weight and height to calculate your body mass index. […] Doctors use blood tests, imaging tests, and sometimes liver biopsy to diagnose NAFLD and to tell the difference between NAFL and NASH. […] Your doctor may suspect you have NAFLD if your blood test shows increased levels of the liver enzymes alanine aminotransferase (ALT) and aspartate aminotransferase (AST). […] Routine imaging tests can show fat in your liver. […] Liver biopsy is the only test that can prove a diagnosis of NASH and show clearly how severe the disease is.

• #14 Fatty liver disease A practical guide for GPs

  https://www.racgp.org.au/afp/2013/july/fatty-liver-disease

  Non-alcoholic fatty liver disease (NAFLD), encompassing both simple steatosis and non-alcoholic steato-hepatitis (NASH), is the most common cause of liver disease in Australia. […] To provide an approach to the identification of NAFLD in general practice, the distinction between simple steatosis and NASH, and the management of these two conditions. […] The most common presentation of NAFLD will be incidental finding of abnormal LFTs. Typical findings in NAFLD are raised ALT and AST, with a preserved ALT: AST ratio of 1.5, raised gamma glutamyl transferase (GGT) and, occasionally, raised alkaline phosphatase (ALP). These findings commonly occur in the setting of features of the MetSy. […] A definitive diagnosis of NAFLD depends on three factors: evidence of fatty infiltration from either imaging (ultrasound, magnetic resonance imaging [MRI]) or histology (liver biopsy), exclusion of significant alcohol consumption, exclusion of other causes of hepatic steatosis (eg. medications, surgery, metabolic disorders).

• #15 Non-alcoholic fatty liver disease: a practical approach to diagnosis and staging | Frontline Gastroenterology

  https://fg.bmj.com/content/5/3/211

  If abnormal LFTs are present, this is usually mildly raised transaminases (ALT aspartate transaminase (AST)) and/or gamma-glutamyltransferase. […] However, 80% of patients have normal-range ALT levels (males 40IU/L and females 31IU/L), and even if elevated, the ALT typically falls (and AST may rise) as fibrosis progresses to cirrhosis. […] The NAFLD Liver Fat Score is calculated using the presence of the metabolic syndrome, type 2 diabetes, fasting serum insulin, fasting serum AST and the AST/ALT ratio (AAR). […] Once suspected clinically, fatty infiltration of the liver can be confirmed with imaging. […] Ultrasonography is widely used as a first-line investigation for hepatic steatosis that provides a qualitative assessment of fatty infiltration of the liver. […] Although frequently not required for diagnosis, a liver biopsy is the definitive investigation for NAFLD and provides an assessment of hepatic steatosis, hepatocellular injury, inflammation and fibrosis.

• #16 Non-alcoholic fatty liver disease: a practical approach to diagnosis and staging | Frontline Gastroenterology

  https://fg.bmj.com/content/5/3/211

  If abnormal LFTs are present, this is usually mildly raised transaminases (ALT aspartate transaminase (AST)) and/or gamma-glutamyltransferase. […] However, 80% of patients have normal-range ALT levels (males 40IU/L and females 31IU/L), and even if elevated, the ALT typically falls (and AST may rise) as fibrosis progresses to cirrhosis. […] The NAFLD Liver Fat Score is calculated using the presence of the metabolic syndrome, type 2 diabetes, fasting serum insulin, fasting serum AST and the AST/ALT ratio (AAR). […] Once suspected clinically, fatty infiltration of the liver can be confirmed with imaging. […] Ultrasonography is widely used as a first-line investigation for hepatic steatosis that provides a qualitative assessment of fatty infiltration of the liver. […] Although frequently not required for diagnosis, a liver biopsy is the definitive investigation for NAFLD and provides an assessment of hepatic steatosis, hepatocellular injury, inflammation and fibrosis.

• #17

  https://journals.lww.com/cld/fulltext/2022/06000/the_diagnosis_and_management_of_nonalcoholic_fatty.3.aspx

  Nonalcoholic fatty liver disease (NAFLD) is defined by the presence of fat in the liver without evidence of other causes of fat accumulation in the liver such as alcohol use, hepatitis C, or certain medications. […] Currently, about 25% of the global population has a diagnosis of NAFLD. […] Guideline statement: Patients with unsuspected Hepatic steatosis (HS) detected on imaging who have symptoms or signs attributable to liver disease or have abnormal liver chemistries should be evaluated as though they have suspected NAFLD and worked up accordingly. […] Initial evaluation of patients with suspected NAFLD should carefully consider the presence of commonly associated comorbidities such as obesity, dyslipidemia, diabetes, hypothyroidism, polycystic ovary syndrome, and sleep apnea. […] Patient Summary: Fatty liver is commonly seen on liver ultrasounds or other forms of radiographic studies. When this happens with an increase in liver blood tests (aspartate aminotransferase [AST] and alanine aminotransferase [ALT]), patients should be evaluated for NAFLD.

• #18

  https://journals.lww.com/cld/fulltext/2022/06000/the_diagnosis_and_management_of_nonalcoholic_fatty.3.aspx

  Key Point: People with metabolic diseases such as type 2 diabetes, obesity, or metabolic syndrome are at high risk for NAFLD. However screening is not currently recommended. […] Guideline statement: When evaluating a patient with suspected NAFLD, it is essential to exclude competing etiologies for steatosis and coexisting Common CLD. […] Patient summary: Several liver diseases can cause a fatty liver or elevated liver enzymes. NAFLD can only be diagnosed once other forms of chronic liver disease are ruled out. […] Key Point: When evaluating patients with NAFLD, it is important to rule out other causes of fatty liver and evaluate for other common causes of chronic liver disease. […] Guideline Statement: There should be a high index of suspicion for NAFLD and NASH in patients with Type 2 Diabetes.

• #19 Nonalcoholic Fatty Liver Disease: Diagnosis and Management | AAFP

  https://www.aafp.org/pubs/afp/issues/2013/0701/p35.html/1000

  Ultrasonography is the first-line imaging technique for patients with suspected nonalcoholic fatty liver disease. […] Liver biopsy is the criterion standard for diagnosis and prognosis of nonalcoholic fatty liver disease. […] No single laboratory test is diagnostic for nonalcoholic fatty liver disease. […] Imaging studies assess liver and spleen anatomy, and the presence of hepatic steatosis. […] Noninvasive tests for fibrosis may reduce the need for liver biopsy in patients with nonalcoholic fatty liver disease. […] Liver biopsy should be considered in atypical clinical situations (e.g., patients with normal BMI or highly elevated liver enzyme levels).

• #20 Non-alcoholic fatty liver disease: a practical approach to diagnosis and staging | Frontline Gastroenterology

  https://fg.bmj.com/content/5/3/211

  The presence of hepatocyte ballooning degeneration in association with steatosis is the key histological feature that distinguishes NASH from simple steatosis. […] However, the majority of patients with NAFLD can be diagnosed and staged adequately using non-invasive strategies. […] Knowledge of whether a patient has simple steatosis or NASH is very important prognostically. […] Unfortunately there is no widely available simple blood test or imaging modality that can differentiate simple steatosis from NASH. […] Staging fibrosis is essential in all patients with NAFLD to identify subjects with advanced fibrosis who are at risk of liver-related complications. […] These tests provide an indirect measure of fibrosis and are potentially appealing non-invasive markers of fibrosis as they are inexpensive and are performed in all patients with liver disease.

• #21 Fatty Liver Disease: Blood Tests for Diagnosis

  https://www.healthline.com/health/blood-tests-for-fatty-liver

  The specific tests for diagnosing MASLD include: Alanine transaminase (ALT) test, International normalized ratio (INR) test, Albumin test, Complete blood count (CBC), FibroSURE test. […] Typical ALT levels fall between 0 and 35 units per liter (IU/L), though each lab may have a slightly different range. A result outside this range doesnt mean you have MASLD, but it does warrant more investigation via ultrasound (FibroScan, a type of liver ultrasound), MRI, and CT scan. […] Your doctor may also use the results from your ALT along with your age and platelet count to calculate your Fibrosis-4 Index (FIB-4). The FIB-4 score helps indicate how advanced scarring on your liver, known as liver fibrosis, may be. A score over 2.67 in people with MASLD helps predict advanced fibrosis up to 80% of the time.

• #22 Metabolic Dysfunction-Associated Steatotic Liver Disease Diagnosis – Viral Hepatitis and Liver Disease

  https://www.hepatitis.va.gov/nafl/diagnosis.asp

  FIB-4 Score 2.67 in patients with NAFLD has 80% positive predictive value for detecting advanced fibrosis. These patients should be further assessed for a diagnosis and referred to GI if indicated. […] A diagnosis of NAFLD should be considered in patients with metabolic syndrome, obesity, and/or diabetes, who have elevated liver transaminase (ALT or AST) and no other identified cause of liver disease. […] Chronic alcohol use can contribute to liver fat accumulation and fibrosis progression in patients with risk factors for NAFLD. […] Patients with NAFLD should be assessed for alcohol use and be encouraged to abstain from alcohol.

• #23 Non-invasive diagnosis: non-alcoholic fatty liver disease and alcoholic liver disease – Altamirano – Translational Gastroenterology and Hepatology

  https://tgh.amegroups.org/article/view/5631/html

  Thus, identification of fibrosis and features of NASH including steatosis is essential to identify patients requiring specific treatment and/or closer monitoring due to associated risk for progressive liver disease. […] The most frequently used biomarkers in clinical practice are summarized in Table 1, and their characteristics are explained below. […] The NAFLD Fibrosis Score (NFS) incorporates age, hyperglycemia, BMI, platelet count, serum albumin, and AST/ALT ratio, and in the pivotal study had AUC of 0.88 (0.850.92) and NPV of 93% to exclude F3-F4 fibrosis at NFS 1.455. […] Fibrosis-4 (FIB-4) uses age, AST, ALT and platelet count, and in the pivotal study on 832 biopsied patients with HIV and HCV coinfection, a cut off 3.25 had positive predictive value (PPV) of 68% and specificity of 97% in the diagnosis of advanced fibrosis.

• #24 Non-alcoholic fatty liver disease and diabetes: diagnosis, assessment and management – The Pharmaceutical Journal

  https://pharmaceutical-journal.com/article/ld/non-alcoholic-fatty-liver-disease-and-diabetes-diagnosis-assessment-and-management

  Current NICE guidance on NAFLD, published in 2016, does not advocate routine screening using liver enzymes because there is no evidence to suggest that this is a useful approach. […] Imaging studies may be used to look for hepatic steatosis, necessary for a diagnosis of NAFLD. […] Currently, the only way to reliably assess levels of inflammation and fibrosis in the liver is with histology of a biopsy sample, although this is rarely practical in routine clinical practice. […] Liver fibrosis markers are available to help determine which patients may be at higher risk for advanced fibrosis. […] NICE recommends use of the enhanced liver fibrosis (ELF) test as a non-invasive way to help to identify high-risk patients.

• #25

  https://link.springer.com/article/10.1007/s11606-021-07197-3

  Nonalcoholic fatty liver disease (NAFLD) is underdiagnosed in primary care despite a high prevalence (25%) and strong ties to metabolic syndrome. Advanced liver fibrosis from NAFLD is associated with poor outcomes, and non-invasive tests including the Fibrosis-4 Index (FIB-4), NAFLD Fibrosis Score (NFS), and AST-to-Platelet Ratio Index (APRI) can predict advanced fibrosis risk. […] Only 25% of this cohort received a NAFLD diagnosis and 917% of undiagnosed patients had high-risk advanced fibrosis scores. These findings emphasize the degree of NAFLD underdiagnosis in primary care and indicate that providers are missing advanced disease. […] These findings reinforce the need to improve NAFLD diagnosis in primary care, especially for patients at high risk for advanced fibrosis.

• #26 Practical Diagnosis and Staging of Nonalcoholic Fatty Liver Disease: A Narrative Review – European Medical Journal

  https://www.emjreviews.com/hepatology/article/practical-diagnosis-and-staging-of-nonalcoholic-fatty-liver-disease-a-narrative-review/

  Most individuals with NAFLD are asymptomatic and present incidentally with raised liver enzymes or evidence of steatosis on imaging; if symptoms do occur, they include right upper quadrant pain or fatigue. […] Once suspected clinically, the presence of hepatic steatosis should be confirmed on imaging. […] In most cases, NAFLD can be confidently diagnosed without the need for a liver biopsy in individuals with steatosis on imaging or in those with raised liver enzymes and metabolic risk factors, after the exclusion of other causes. […] Once a diagnosis of NAFLD has been made, it is vital to stage the disease to assess prognosis and determine if specific treatment (in addition to lifestyle changes) for NAFLD is required. […] The NFS and FIB-4 scores are the most widely used simple noninvasive scores and are recommended in European guidelines. […] Overall, despite their limitations, the FIB-4 score and NFS offer a good first-line test to stage liver fibrosis and if individuals have a low score (using appropriate age corrected cut-offs), advanced fibrosis can reliably be excluded.

• #27 Nonalcoholic Fatty Liver Disease: Diagnosis and Management | AAFP

  https://www.aafp.org/pubs/afp/issues/2013/0701/p35.html/1000

  Ultrasonography is the first-line imaging technique for patients with suspected nonalcoholic fatty liver disease. […] Liver biopsy is the criterion standard for diagnosis and prognosis of nonalcoholic fatty liver disease. […] No single laboratory test is diagnostic for nonalcoholic fatty liver disease. […] Imaging studies assess liver and spleen anatomy, and the presence of hepatic steatosis. […] Noninvasive tests for fibrosis may reduce the need for liver biopsy in patients with nonalcoholic fatty liver disease. […] Liver biopsy should be considered in atypical clinical situations (e.g., patients with normal BMI or highly elevated liver enzyme levels).

• #28 Nonalcoholic Fatty Liver Disease: Diagnosis and Management | AAFP

  https://www.aafp.org/pubs/afp/issues/2013/0701/p35.html/1000

  Ultrasonography is the first-line imaging technique for patients with suspected nonalcoholic fatty liver disease. […] Liver biopsy is the criterion standard for diagnosis and prognosis of nonalcoholic fatty liver disease. […] No single laboratory test is diagnostic for nonalcoholic fatty liver disease. […] Imaging studies assess liver and spleen anatomy, and the presence of hepatic steatosis. […] Noninvasive tests for fibrosis may reduce the need for liver biopsy in patients with nonalcoholic fatty liver disease. […] Liver biopsy should be considered in atypical clinical situations (e.g., patients with normal BMI or highly elevated liver enzyme levels).

• #29 Noninvasive diagnosis of nonalcoholic fatty liver disease | Annals of Hepatology

  https://www.elsevier.es/es-revista-annals-hepatology-16-articulo-noninvasive-diagnosis-nonalcoholic-fatty-liver-S166526811931823X

  The most commonly used imaging modality for the diagnosis of NAFLD is US, in which steatosis manifests as a diffuse increase in hepatic echogenicity (the so-called bright liver). […] Despite the high prevalence of NAFLD, relatively few studies have examined novel, noninvasive measures for the prediction of hepatic steatosis. […] An emerging imaging modality for the quantitative assessment of hepatic steatosis is proton magnetic resonance spectroscopy (1H MRS). […] NASH is characterized by hepatic steatosis with inflammation, evidence of liver cell injury (eg. ballooning degeneration, necrosis), and fibrosis. […] A large number of biochemical markers have been assessed for the evaluation of hepatic fibrosis across a diverse spectrum of liver diseases. […] Transient elastography (TE; Fibroscan, Echosens, Paris, France) is a relatively novel approach to measuring liver stiffness – a surrogate for liver fibrosis – that has gained increasing clinical use.

• #30 Fatty liver disease A practical guide for GPs

  https://www.racgp.org.au/afp/2013/july/fatty-liver-disease

  Confirming hepatic fatty infiltration using ultrasound is important. Specificity is high (95%), but the sensitivity of ultrasound for detecting fatty infiltration is lower (85%). […] The risk of fibrosis and progressive liver disease in NAFLD increases with severity of insulin resistance. […] Staging liver disease and detecting cirrhosis is the most important aspect of assessing fatty liver disease. […] Non-invasive tools for estimating the degree of fibrosis include transient elastography (FibroScan), acoustic radiation force impulse (ARFI), and non-invasive biomarker algorithms such as NAFLD Fibrosis Score, FibroTest and Hepascore. […] NAFLD should be considered when abnormal LFTs are found, particularly in the presence of features of the MetSy. […] General practitioners are vital in identifying patients at risk of NAFLD, and encouraging initiation and maintenance of appropriate lifestyle changes.

• #31 Diagnostic Modalities of Non-Alcoholic Fatty Liver Disease: From Biochemical Biomarkers to Multi-Omics Non-Invasive Approaches

  https://www.mdpi.com/2075-4418/12/2/407

  Non-Alcoholic Fatty Liver Disease (NAFLD) is currently the most common cause of chronic liver disease worldwide, and its prevalence is increasing globally. […] To date, liver biopsy remains the gold standard procedure for the diagnosis of NASH and staging of NAFLD. […] However, due to its invasive nature, research on non-invasive tests is rapidly increasing with significant advances having been achieved during the last decades in the diagnostic field. […] For the diagnosis of NAFLD, the ultrasound remains the first-line modality, despite being less reliable if HS is <20%. [...] There is a recognised ongoing need for a non-invasive tool that could accurately identify NASH and also discern low- and high-risk individuals for advanced fibrosis, as high-risk patients would need closer surveillance and management.

• #32 Non-alcoholic fatty liver disease: a practical approach to diagnosis and staging | Frontline Gastroenterology

  https://fg.bmj.com/content/5/3/211

  The presence of hepatocyte ballooning degeneration in association with steatosis is the key histological feature that distinguishes NASH from simple steatosis. […] However, the majority of patients with NAFLD can be diagnosed and staged adequately using non-invasive strategies. […] Knowledge of whether a patient has simple steatosis or NASH is very important prognostically. […] Unfortunately there is no widely available simple blood test or imaging modality that can differentiate simple steatosis from NASH. […] Staging fibrosis is essential in all patients with NAFLD to identify subjects with advanced fibrosis who are at risk of liver-related complications. […] These tests provide an indirect measure of fibrosis and are potentially appealing non-invasive markers of fibrosis as they are inexpensive and are performed in all patients with liver disease.

• #33 Non-invasive diagnosis: non-alcoholic fatty liver disease and alcoholic liver disease – Altamirano – Translational Gastroenterology and Hepatology

  https://tgh.amegroups.org/article/view/5631/html

  Assessment of fibrosis: blood-based biomarkers to assess fibrosis in NAFLD can be categorized into indirect biomarkers (using patient demographics, standard of care laboratory values on liver chemistry and platelet counts) and direct biomarkers (using specific laboratory tests measuring extracellular matrix deposition and turnover). […] Although multiple methods, mostly based on ultrasound and magnetic resonance technology, have been evaluated, we will restrict our analysis to the three most frequently validated. […] Transient elastography (TE) or vibration controlled transient elastography is available as a point-of-care tool that is reproducible and easy to operate, and it provides objective staging data interpretable by hepatologists. […] The test result (liver stiffness measurement or LSM) is reported in kilopascal (kPa) units, with cut-off limits available to separate stages of fibrosis in NAFLD.

• #34 Non-invasive diagnosis: non-alcoholic fatty liver disease and alcoholic liver disease – Altamirano – Translational Gastroenterology and Hepatology

  https://tgh.amegroups.org/article/view/5631/html

  Although still controversial, in selected cases we begin HCC screening in patients with F3 with 6-monthly ultrasound or another method when ultrasound quality is inadequate. […] In NAFLD patients in need of a surgical procedure (liver resection or bariatric) a similar finding would preclude surgery due to the presence of clinically significant portal hypertension. […] When approaching patients with presumed NAFLD, we suggest using NFS or FIB-4 and LSM/CAP or MRE/PDFF to stage patients, given their demonstrated accuracy both in cross-sectional and longitudinal studies. […] Research on ALD is less abundant than that on NAFLD, however, ELF and FibroTest have been proven useful in assessing fibrosis staging, and we recommend testing for fibrosis and steatosis with LSM/CAP as well.

• #35 Steatotic (Fatty) Liver Disease: Symptoms & Treatment

  https://my.clevelandclinic.org/health/diseases/15831-fatty-liver-disease

  How is steatotic (fatty) liver disease diagnosed? […] To make a diagnosis, your provider may perform: A medical history that includes questions about your conditions, how much alcohol you drink and which medicines you’re taking. A physical exam to check for signs of inflammation, like an enlarged liver, or signs of cirrhosis, like jaundice. Imaging procedures, including an ultrasound, CT scan (computed tomography scan) or MRI (magnetic resonance imaging), to check your liver for signs of inflammation and scarring. They may order a specialized ultrasound called FibroScan to learn the amount of fat and scar tissue in your liver. A liver biopsy (tissue sample) to determine how far the liver disease has progressed. A liver biopsy is the only way to distinguish MASLD from MASH.

• #36 Noninvasive Diagnosis of NAFLD and NASH

  https://www.mdpi.com/2073-4409/9/4/1005

  The aim of this review is to outline emerging biomarkers that can serve as early diagnostic tools to identify patients with nonalcoholic fatty liver disease (NAFLD) and nonalcoholic steatohepatitis (NASH) and, among them, the subgroup of best candidates for clinical trials on emerging compounds. […] So far, magnetic resonance imaging-derived proton density fat fraction (MRI-PDFF) appears to be the most accurate for fatty liver diagnosis. In clinical practice, the main question is how to diagnose NASH early. […] There are new promising biomarkers that can help in diagnosing early stages of NASH, yet they include variables not routinely tested. […] In the setting of NASH, most studies confirm that, in spite of several well-known limitations, transient elastography or point shear wave elastography can help in enriching the pool of patients that should be screened for investigational treatments.

• #37 Diagnosis of NAFLD – Non-Alcoholic Fatty Liver Disease – NCBI Bookshelf

  https://www.ncbi.nlm.nih.gov/books/NBK384715/

  The aim of this review is to objectively evaluate existing invasive and non-invasive tests to accurately diagnose NAFLD in adults, young people and children. […] The GDG concluded that the identified studies provided evidence for all 4 of the imaging techniques under review (CAP, MRI, MRS and abdominal ultrasound) as being sufficiently effective tests for detecting both greater than or equal to 5% and greater than or equal to 30% steatosis in adults. […] The opinion of the GDG was that MRI and MRS appeared to be the most accurate imaging techniques for diagnosing NAFLD in adults. […] The GDG also reviewed the evidence for non-imaging based diagnostic tests for NAFLD in adults. […] Of these, it appeared that the FLI test was the most effective. […] The GDG felt that SteatoTest and NAFLD-LFS appeared to be much less effective tests for diagnosing NAFLD in adults.

• #38 Non-invasive diagnosis: non-alcoholic fatty liver disease and alcoholic liver disease – Altamirano – Translational Gastroenterology and Hepatology

  https://tgh.amegroups.org/article/view/5631/html

  The accuracy of 2D-MRE for diagnosis of advanced fibrosis or cirrhosis has been documented in a recent meta-analysis, and this is independent of BMI, gender, and degree of inflammation. […] In NAFLD, fibrosis stage is the most important liver biopsy parameter identifying progressive liver disease and predicting a higher risk of mortality and liver transplantation. […] Non-invasive imaging methods are valuable tools for this purpose. […] Fibrosis plays a central role in prognosticating NAFLD, whereas steatosis has an inverse association with fibrosis and thus its prognostic role is limited to early stages of the disease. […] The presence of F2 with steatosis or F3 (advanced fibrosis) without steatosis calls for a liver biopsy, although in patients who are reluctant to undergo this procedure starting treatment is a reasonable option.

• #39 Noninvasive diagnosis of nonalcoholic fatty liver disease | Annals of Hepatology

  https://www.elsevier.es/es-revista-annals-hepatology-16-articulo-noninvasive-diagnosis-nonalcoholic-fatty-liver-S166526811931823X

  The most commonly used imaging modality for the diagnosis of NAFLD is US, in which steatosis manifests as a diffuse increase in hepatic echogenicity (the so-called bright liver). […] Despite the high prevalence of NAFLD, relatively few studies have examined novel, noninvasive measures for the prediction of hepatic steatosis. […] An emerging imaging modality for the quantitative assessment of hepatic steatosis is proton magnetic resonance spectroscopy (1H MRS). […] NASH is characterized by hepatic steatosis with inflammation, evidence of liver cell injury (eg. ballooning degeneration, necrosis), and fibrosis. […] A large number of biochemical markers have been assessed for the evaluation of hepatic fibrosis across a diverse spectrum of liver diseases. […] Transient elastography (TE; Fibroscan, Echosens, Paris, France) is a relatively novel approach to measuring liver stiffness – a surrogate for liver fibrosis – that has gained increasing clinical use.

• #40 Diagnostic Modalities of Non-Alcoholic Fatty Liver Disease: From Biochemical Biomarkers to Multi-Omics Non-Invasive Approaches

  https://www.mdpi.com/2075-4418/12/2/407

  Non-Alcoholic Fatty Liver Disease (NAFLD) is currently the most common cause of chronic liver disease worldwide, and its prevalence is increasing globally. […] To date, liver biopsy remains the gold standard procedure for the diagnosis of NASH and staging of NAFLD. […] However, due to its invasive nature, research on non-invasive tests is rapidly increasing with significant advances having been achieved during the last decades in the diagnostic field. […] For the diagnosis of NAFLD, the ultrasound remains the first-line modality, despite being less reliable if HS is <20%. [...] There is a recognised ongoing need for a non-invasive tool that could accurately identify NASH and also discern low- and high-risk individuals for advanced fibrosis, as high-risk patients would need closer surveillance and management.

• #41 Non-alcoholic fatty liver disease (NAFLD): a review of pathophysiology, clinical management and effects of weight loss | BMC Endocrine Disorders | Full Text

  https://bmcendocrdisord.biomedcentral.com/articles/10.1186/s12902-022-00980-1

  Given the increasing prevalence of diabetes and obesity worldwide, the deleterious effects of non-alcoholic fatty liver disease (NAFLD) are becoming a growing challenge for public health. […] In these patients, advanced fibrosis is the major predictor of morbidity and liver-related mortality, and an accurate diagnosis of NASH and NAFLD is mandatory. Histologic evaluation with liver biopsy remains the gold standard to diagnose NAFLD. Diagnosis of NAFLD is defined as presence of hepatic steatosis, ballooning and lobular inflammation with or without fibrosis. […] In terms of diagnostic tests, the gold standard to investigate any form of liver inflammation e.g. damage is a liver biopsy. In the diagnosis of NAFLD and related disorders, liver biopsies can be extremely helpful and its findings can range from triglyceride deposition as droplets in the hepatocyte to more extensive forms of non-alcoholic steatohepatitis (NASH).

• #42 NAFLD & NASH – Symptoms, Causes, Differences & Treatment Options PACE Hospitals – Best Hospitals in Hitech City, Hyderabad, India | Near Madhapur, Kukatpally, KPHB, Kondapur, Gachibowli, Jubilee Hills, Banjara HillsPACE Hospitals Contact

  https://www.pacehospital.com/non-alcoholic-fatty-liver-disease-causes-symptoms-diagnosis-and-treatment

  Doctors may advise some of these tests to identify severity of NAFLD / NASH. […] Liver biopsy: It’s a type of liver tissue examination procedure in which a needle is used to remove a small piece of liver tissue for examination under a microscope, is the gold standard for diagnosing non-alcoholic fatty liver disease. […] The role of liver biopsy in the diagnosis of NAFLD, mainly NASH remains important in some circumstances, especially if the diagnosis is questionable. […] When a person is diagnosed with non-alcoholic fatty liver disease, it is important that they see a hepatologist doctor who has specialized knowledge in this area. […] Regardless of the technique used to estimate the degree of fibrosis, expert interpretation is essential to ensure that the information obtained is useful in making treatment decisions. […] The current Medical Society recommend that adults 18 to 64 years of age get at least 150 minutes of moderate to vigorous aerobic physical activity per week in sessions of at least 10 minutes, to achieve health benefits.

• #43 Non-alcoholic fatty liver disease (NAFLD): a review of pathophysiology, clinical management and effects of weight loss | BMC Endocrine Disorders | Full Text

  https://bmcendocrdisord.biomedcentral.com/articles/10.1186/s12902-022-00980-1

  NAFLD managements US guidelines define NAFLD as steatosis with 5% fat infiltration in imaging or histology and b) no alcohol, drug, or viral-induced steatosis. NAFLD patients may present with elevated liver enzymes. […] Very often a diagnosis like NASH or NAFLD is discovered due to abnormal liver function tests such as aminotransferases (ALT and AST) or incidental finding of hepatic steatosis on radiologic abdominal finding. […] The liver biopsy is the Gold standard for diagnosis of NASH or NAFLD. Performing a liver biopsy on every patient with suspected NAFLD remains controversial. The general indications for performing a liver biopsy in patients with NAFLD confirm or exclude the diagnosis. […] The NAFLD Activity Score (NAS) is a validated score that is used to grade disease activity in patients with NAFLD. The NAS has several components and each of them has a minimum and maximum score; steatosis (0 to 3), lobular inflammation (0 to 3), hepatocellular ballooning (0 to 2).

• #44 Non-alcoholic fatty liver disease: a practical approach to diagnosis and staging | Frontline Gastroenterology

  https://fg.bmj.com/content/5/3/211

  The presence of hepatocyte ballooning degeneration in association with steatosis is the key histological feature that distinguishes NASH from simple steatosis. […] However, the majority of patients with NAFLD can be diagnosed and staged adequately using non-invasive strategies. […] Knowledge of whether a patient has simple steatosis or NASH is very important prognostically. […] Unfortunately there is no widely available simple blood test or imaging modality that can differentiate simple steatosis from NASH. […] Staging fibrosis is essential in all patients with NAFLD to identify subjects with advanced fibrosis who are at risk of liver-related complications. […] These tests provide an indirect measure of fibrosis and are potentially appealing non-invasive markers of fibrosis as they are inexpensive and are performed in all patients with liver disease.

• #45 Noninvasive Diagnosis of NAFLD and NASH

  https://www.mdpi.com/2073-4409/9/4/1005

  To date, one biomarker alone is not able to non- or minimally invasively identify patients with NASH and mild to moderate fibrosis. […] Currently, no pharmacologic therapy is approved for treatment of NASH. […] Therefore, early predictors need to be investigated. […] Liver biopsy is the current gold standard in diagnosis and prognosis; nevertheless, it is an expensive and invasive procedure with high sampling error and risk of complications including pain; bleeding; and, in very rare cases, death. […] Because of poor patient acceptance of this invasive standard technique, there is an urgent need for reliable, accurate, and non- or minimally invasive biomarkers. […] While a number of non- or minimally invasive tests are able to rule out fibrosis or cirrhosis, no single test to identify steatosis, to early diagnose NASH, or to predict the disease progression is available.

• #46 Non-Alcoholic Fatty Liver Disease (NAFLD): Diagnosis & Treatment | NewYork-Presbyterian

  https://www.nyp.org/digestive/liver-diseases/fatty-liver-disease-non-alcoholic/treatment

  How is NAFLD Diagnosed? NAFLD may be identified from a routine medical test or evaluation for other conditions. The first signs may be elevated liver enzymes or fat in the liver seen on an ultrasound. Your doctor can order blood tests to look for other causes of liver disease. In addition, your doctor will assess your medical history, conduct a physical exam, and order tests. […] Blood tests may indicate that there is fat +/- inflammation in the liver. Many patients with NAFLD may have mild to moderate elevations in liver enzymes (alanine aminotransferase testALT and aspartate aminotransferase testAST). […] If liver enzymes are elevated, your doctor may order additional tests to find the cause of the inflammation and diagnose non-alcoholic fatty liver disease. […] Your doctor may perform a liver biopsy to determine the severity of fatty liver disease. […] A piece of liver tissue is removed for examination during a liver biopsy. This is usually an outpatient procedure using a local anesthetic to lessen pain.

• #47 Diagnosis and management of non-alcoholic fatty liver disease (NAFLD) – American Gastroenterological AssociationAGA Logo_Horizontal

  https://gastro.org/clinical-guidance/diagnosis-and-management-of-non-alcoholic-fatty-liver-disease-nafld/

  9. High serum titers of autoantibodies in association with other features suggestive of autoimmune liver disease (very high aminotransferases, high globulin) should prompt a more complete work-up for autoimmune liver disease. […] 10. As the metabolic syndrome predicts the presence of steatohepatitis in patients with NAFLD, its presence can be used to target patients for a liver biopsy. […] 11. NAFLD Fibrosis Score is a clinically useful tool for identifying NAFLD patients with higher likelihood of having bridging fibrosis and/or cirrhosis. […] 12. Although serum/plasma CK18 is a promising biomarker for identifying steatohepatitis, it is premature to recommend in routine clinical practice. […] 13. Liver biopsy should be considered in patients with NAFLD who are at increased risk to have steatohepatitis and advanced fibrosis.

• #48 Nonalcoholic Fatty Liver Disease: Diagnosis and Management | AAFP

  https://www.aafp.org/pubs/afp/issues/2013/0701/p35.html/1000

  Ultrasonography is the first-line imaging technique for patients with suspected nonalcoholic fatty liver disease. […] Liver biopsy is the criterion standard for diagnosis and prognosis of nonalcoholic fatty liver disease. […] No single laboratory test is diagnostic for nonalcoholic fatty liver disease. […] Imaging studies assess liver and spleen anatomy, and the presence of hepatic steatosis. […] Noninvasive tests for fibrosis may reduce the need for liver biopsy in patients with nonalcoholic fatty liver disease. […] Liver biopsy should be considered in atypical clinical situations (e.g., patients with normal BMI or highly elevated liver enzyme levels).

• #49 Diagnosis and management of non-alcoholic fatty liver disease (NAFLD) – American Gastroenterological AssociationAGA Logo_Horizontal

  https://gastro.org/clinical-guidance/diagnosis-and-management-of-non-alcoholic-fatty-liver-disease-nafld/

  43. Intensive lifestyle modification improves aminotransferases and liver histology in children with NAFLD and thus should be the first line of treatment. […] 44. Metformin at 500 mg twice daily offers no benefit to children with NAFLD and thus should not be prescribed. The effect of metformin administered at a higher dose is not known. […] 45. Vitamin E 800 IU/day (RRR α–tocopherol) offers histological benefits to children with biopsy-proven NASH or borderline NASH but confirmatory studies are needed before it’s use can be recommended in clinical practice.

• #50 Nonalcoholic Fatty Liver Disease in Diabetes. Part I: Epidemiology and Diagnosis

  https://www.e-dmj.org/journal/view.php?number=629

  In individuals with and without diabetes, a two-step process should be used to diagnose NAFLD: (1) existence of hepatic steatosis, either by imaging or histology; and (2) exclusion of secondary causes of liver steatosis as described in Table 1. […] Despite its invasive nature and sampling variability, liver biopsy remains the gold standard to assess hepatic steatosis, inflammation, and fibrosis in patients with NAFLD. […] To overcome its high costs and risks, alternative noninvasive imaging, clinical, and laboratory modalities have been developed and validated to diagnose NAFLD. Currently, ultrasonography (US), computed tomography (CT), magnetic resonance imaging (MRI), MRS, and transient elastography (TE) are widely available tools to measure hepatic steatosis. […] Ultrasonography US is the recommended first line screening method for patients with T2DM by the European NAFLD guidelines. […] Although many imaging modalities and biomarker-based prediction models have been developed to evaluate NAFLD disease status, more investigation is required before their application in routine clinical care.

• #51 Practical Diagnosis and Staging of Nonalcoholic Fatty Liver Disease: A Narrative Review – European Medical Journal

  https://www.emjreviews.com/hepatology/article/practical-diagnosis-and-staging-of-nonalcoholic-fatty-liver-disease-a-narrative-review/

  Most individuals with NAFLD are asymptomatic and present incidentally with raised liver enzymes or evidence of steatosis on imaging; if symptoms do occur, they include right upper quadrant pain or fatigue. […] Once suspected clinically, the presence of hepatic steatosis should be confirmed on imaging. […] In most cases, NAFLD can be confidently diagnosed without the need for a liver biopsy in individuals with steatosis on imaging or in those with raised liver enzymes and metabolic risk factors, after the exclusion of other causes. […] Once a diagnosis of NAFLD has been made, it is vital to stage the disease to assess prognosis and determine if specific treatment (in addition to lifestyle changes) for NAFLD is required. […] The NFS and FIB-4 scores are the most widely used simple noninvasive scores and are recommended in European guidelines. […] Overall, despite their limitations, the FIB-4 score and NFS offer a good first-line test to stage liver fibrosis and if individuals have a low score (using appropriate age corrected cut-offs), advanced fibrosis can reliably be excluded.

• #52 Diagnosis and management of nonalcoholic fatty liver disease (NAFLD) in lean individuals – American Gastroenterological AssociationAGA Logo_Horizontal

  https://gastro.org/clinical-guidance/diagnosis-and-management-of-nonalcoholic-fatty-liver-disease-nafld-in-lean-individuals/

  10. Serum indices (NAFLD fibrosis score and Fibrosis-4 score) and imaging techniques (transient elastography and magnetic resonance elastography) may be used as alternatives to liver biopsy for fibrosis staging and patient follow-up. These tests can be performed at the time of diagnosis and repeated at intervals of 6 months to 2 years, depending on fibrosis stage and the patient’s response to intervention. […] 11. If noninvasive tests (eg, Fibrosis-4 and NAFLD fibrosis score) are indeterminate, a second noninvasive test (eg, transient elastography or magnetic resonance elastography) should be performed to confirm the stage and prognosis of NAFLD. […] 12. In lean patients with NAFLD, lifestyle intervention, including exercise, diet modification and avoidance of fructose- and sugar-sweetened drinks, to target a modest weight loss of 3%–5% is suggested.

• #53 MASLD, NAFLD and fatty liver disease – British Liver Trust

  https://britishlivertrust.org.uk/information-and-support/liver-conditions/masld-nafld-and-fatty-liver-disease/

  It is very important that the amount of scarring in your liver is tested as part of your MASLD or NAFLD diagnosis. This is the main sign of how advanced your liver disease is. […] There are 2 main ways to check if you’re likely to have advanced fibrosis (stage 3 or 4) without doing a biopsy blood tests or a liver scan (transient elastography eg FibroScan). […] Many doctors use a scoring system that pools results from several routine blood tests. Common fibrosis scoring systems include: The Fibrosis (FIB)-4 score which uses 3 blood tests and your age […] A high risk means that you probably have advanced fibrosis. It’s likely you have later stage MASLD and you may have cirrhosis. You will be referred to a specialist liver doctor (hepatologist or gastroenterologist) who will do further tests and manage your care from then on.

• #54 Diagnostic Modalities of Non-Alcoholic Fatty Liver Disease: From Biochemical Biomarkers to Multi-Omics Non-Invasive Approaches

  https://www.mdpi.com/2075-4418/12/2/407

  The most common cause of death in NAFLD patients is cardiovascular disease (CVD), whilst liver-related mortality takes third place after cancer. […] The global prevalence of NAFLD is estimated at 24%, whilst NASH affects approximately 1.5% to 6.5% of adults worldwide. […] The reported rate of progression is one fibrosis stage every 14 years in NAFLD and every 7 years in NASH, which is doubled in arterial hypertension. […] Current guidelines recommend against systematic screening for NAFLD in the general population. […] However, screening in high-risk groups, such as patients with metabolic disorders (T2DM, obesity, hypertension, dyslipidaemia), is still open for debate. […] The present review article provides a comprehensive overview of the currently available and emerging non-invasive diagnostic tools used in assessing NAFLD, also highlighting the importance of accurate and validated diagnostic tools.

• #55 Diagnosis and management of non-alcoholic fatty liver disease (NAFLD) – American Gastroenterological AssociationAGA Logo_Horizontal

  https://gastro.org/clinical-guidance/diagnosis-and-management-of-non-alcoholic-fatty-liver-disease-nafld/

  19. Metformin has no significant effect on liver histology and is not recommended as a specific treatment for liver disease in adults with nonalcoholic steatohepatitis (NASH). […] 20. Pioglitazone can be used to treat steatohepatitis in patients with biopsy-proven NASH. However, it should be noted that majority of the patients who participated in clinical trials that investigated pioglitazone for NASH were non-diabetic and that long term safety and efficacy of pioglitazone in patients with NASH is not established. […] 21. Vitamin E (α-tocopherol) administered at daily dose of 800 IU/day improves liver histology in non-diabetic adults with biopsy-proven NASH and therefore it should be considered as a first-line pharmacotherapy for this patient population. […] 22. Until further data supporting its effectiveness become available, vitamin E is not recommended to treat NASH in diabetic patients, NAFLD without liver biopsy, NASH cirrhosis or cryptogenic cirrhosis.

• #56 Diagnosis and management of nonalcoholic fatty liver disease (NAFLD) in lean individuals – American Gastroenterological AssociationAGA Logo_Horizontal

  https://gastro.org/clinical-guidance/diagnosis-and-management-of-nonalcoholic-fatty-liver-disease-nafld-in-lean-individuals/

  Diagnosis and management of nonalcoholic fatty liver disease (NAFLD) in lean individuals […] Experts provide 15 best practices for the diagnosis and treatment of lean individuals with NAFLD. […] 1. Lean NAFLD should be diagnosed in individuals with NAFLD and body mass index <25 kg/m2 (non-Asian race) or body mass index <23 kg/m2 (Asian race). [...] 2. Lean individuals with NAFLD should be evaluated routinely for comorbid conditions, such as type 2 diabetes mellitus, dyslipidemia and hypertension. [...] 3. Lean individuals with NAFLD should be risk stratified for hepatic fibrosis to identify those with advanced fibrosis or cirrhosis. [...] 4. Lean individuals in the general population should not undergo routine screening for NAFLD; however, screening should be considered for individuals older than 40 years with type 2 diabetes mellitus.

• #57 Diagnosis and management of nonalcoholic fatty liver disease (NAFLD) in lean individuals – American Gastroenterological AssociationAGA Logo_Horizontal

  https://gastro.org/clinical-guidance/diagnosis-and-management-of-nonalcoholic-fatty-liver-disease-nafld-in-lean-individuals/

  Diagnosis and management of nonalcoholic fatty liver disease (NAFLD) in lean individuals […] Experts provide 15 best practices for the diagnosis and treatment of lean individuals with NAFLD. […] 1. Lean NAFLD should be diagnosed in individuals with NAFLD and body mass index <25 kg/m2 (non-Asian race) or body mass index <23 kg/m2 (Asian race). [...] 2. Lean individuals with NAFLD should be evaluated routinely for comorbid conditions, such as type 2 diabetes mellitus, dyslipidemia and hypertension. [...] 3. Lean individuals with NAFLD should be risk stratified for hepatic fibrosis to identify those with advanced fibrosis or cirrhosis. [...] 4. Lean individuals in the general population should not undergo routine screening for NAFLD; however, screening should be considered for individuals older than 40 years with type 2 diabetes mellitus.

• #58 Non-alcoholic fatty liver disease: a practical approach to diagnosis and staging | Frontline Gastroenterology

  https://fg.bmj.com/content/5/3/211

  The presence of hepatocyte ballooning degeneration in association with steatosis is the key histological feature that distinguishes NASH from simple steatosis. […] However, the majority of patients with NAFLD can be diagnosed and staged adequately using non-invasive strategies. […] Knowledge of whether a patient has simple steatosis or NASH is very important prognostically. […] Unfortunately there is no widely available simple blood test or imaging modality that can differentiate simple steatosis from NASH. […] Staging fibrosis is essential in all patients with NAFLD to identify subjects with advanced fibrosis who are at risk of liver-related complications. […] These tests provide an indirect measure of fibrosis and are potentially appealing non-invasive markers of fibrosis as they are inexpensive and are performed in all patients with liver disease.

• #59 Diagnosis of NAFLD – Non-Alcoholic Fatty Liver Disease – Nash24x7

  https://www.nash24x7.com/diagnosis/

  A person will be diagnosed with NAFLD only if there is fat accumulation in liver in imaging studies (ultrasound and CT) with no significant consumption of alcohol, no other competing reasons for fatty Liver and no other co –existing liver diseases. […] To know the whether the degree of fibrosis is advanced, bridging fibrosis (stage 3) or cirrhosis (stage 4) your doctor will use the following […] NASH cannot be diagnosed by blood tests and imaging studies. At present, the only reliable way of diagnosing whether a person with fatty liver has NASH is by a liver biopsy. […] Liver Biopsy is considered only in NAFLD patients with […] NASH can be diagnosed only by a biopsy and only if the tested piece of liver shows infiltration of the liver with fat along with inflammation and different degrees of scarring. […] Your doctor may recommend you for blood tests (liver function tests), and other tests if you have risk factors for NAFLD/NASH and will proceed further depending on the test results.

• #60 NASH Diagnosis: Testing Methods & Procedures

  https://liverfoundation.org/liver-diseases/fatty-liver-disease/nonalcoholic-steatohepatitis-nash/nash-diagnosis/

  If your medical evaluation shows no alternative causes for liver disease (such as medications, viral hepatitis, or excessive use of alcohol) and imaging studies of your liver show fat and liver stiffness, NASH is suspected. […] If your doctor feels that further confirmation is needed to make a definitive diagnosis of NASH, a liver biopsy may be ordered. […] NASH is diagnosed when examination of the tissue with a microscope shows fat along with inflammation and damage to liver cells. […] Please call our helpline at 1-800-GO-LIVER if you have questions after speaking with your healthcare professional. […] Ask your doctor to explain all your test results and their implications, and don’t hesitate to ask questions. This will help you have a better understanding of your diagnosis and why your healthcare provider is recommending a particular course of treatment going forward.

• #61 Non-alcoholic fatty liver disease: a practical approach to diagnosis and staging | Frontline Gastroenterology

  https://fg.bmj.com/content/5/3/211

  The presence of hepatocyte ballooning degeneration in association with steatosis is the key histological feature that distinguishes NASH from simple steatosis. […] However, the majority of patients with NAFLD can be diagnosed and staged adequately using non-invasive strategies. […] Knowledge of whether a patient has simple steatosis or NASH is very important prognostically. […] Unfortunately there is no widely available simple blood test or imaging modality that can differentiate simple steatosis from NASH. […] Staging fibrosis is essential in all patients with NAFLD to identify subjects with advanced fibrosis who are at risk of liver-related complications. […] These tests provide an indirect measure of fibrosis and are potentially appealing non-invasive markers of fibrosis as they are inexpensive and are performed in all patients with liver disease.

• #62 Diagnosis and management of non-alcoholic fatty liver disease (NAFLD) – American Gastroenterological AssociationAGA Logo_Horizontal

  https://gastro.org/clinical-guidance/diagnosis-and-management-of-non-alcoholic-fatty-liver-disease-nafld/

  9. High serum titers of autoantibodies in association with other features suggestive of autoimmune liver disease (very high aminotransferases, high globulin) should prompt a more complete work-up for autoimmune liver disease. […] 10. As the metabolic syndrome predicts the presence of steatohepatitis in patients with NAFLD, its presence can be used to target patients for a liver biopsy. […] 11. NAFLD Fibrosis Score is a clinically useful tool for identifying NAFLD patients with higher likelihood of having bridging fibrosis and/or cirrhosis. […] 12. Although serum/plasma CK18 is a promising biomarker for identifying steatohepatitis, it is premature to recommend in routine clinical practice. […] 13. Liver biopsy should be considered in patients with NAFLD who are at increased risk to have steatohepatitis and advanced fibrosis.

• #63 Recent advances in non-invasive diagnosis and medical management of non-alcoholic fatty liver disease in adult | Egyptian Liver Journal | Full Text

  https://eglj.springeropen.com/articles/10.1186/s43066-020-00043-x

  Fatty liver index is a suitable and simple predictor for hepatic steatosis. […] Hepatic steatosis index (HSI): It is a simple, effective NAFLD screening tool derived by a logistic regression model. […] NASH can progress to cirrhosis and its complications such as portal hypertension, liver failure, and hepatocellular carcinoma. […] The gold standard for diagnosis of NASH is liver biopsy. […] Serum cytokeratin (CK)-18: It is a marker of hepatocyte apoptosis, most widely investigated for diagnosis of NASH and is the most consistent single parameter for differentiating steatosis from NASH. […] Though liver biopsy is the gold standard test to detect NAFLD and to identify different stages of hepatic steatosis and fibrosis, multiple non-invasive tests are also available nowadays.

• #64 Non-invasive diagnosis: non-alcoholic fatty liver disease and alcoholic liver disease – Altamirano – Translational Gastroenterology and Hepatology

  https://tgh.amegroups.org/article/view/5631/html

  The accuracy of 2D-MRE for diagnosis of advanced fibrosis or cirrhosis has been documented in a recent meta-analysis, and this is independent of BMI, gender, and degree of inflammation. […] In NAFLD, fibrosis stage is the most important liver biopsy parameter identifying progressive liver disease and predicting a higher risk of mortality and liver transplantation. […] Non-invasive imaging methods are valuable tools for this purpose. […] Fibrosis plays a central role in prognosticating NAFLD, whereas steatosis has an inverse association with fibrosis and thus its prognostic role is limited to early stages of the disease. […] The presence of F2 with steatosis or F3 (advanced fibrosis) without steatosis calls for a liver biopsy, although in patients who are reluctant to undergo this procedure starting treatment is a reasonable option.

• #65 Diagnosis and management of nonalcoholic fatty liver disease (NAFLD) in lean individuals – American Gastroenterological AssociationAGA Logo_Horizontal

  https://gastro.org/clinical-guidance/diagnosis-and-management-of-nonalcoholic-fatty-liver-disease-nafld-in-lean-individuals/

  10. Serum indices (NAFLD fibrosis score and Fibrosis-4 score) and imaging techniques (transient elastography and magnetic resonance elastography) may be used as alternatives to liver biopsy for fibrosis staging and patient follow-up. These tests can be performed at the time of diagnosis and repeated at intervals of 6 months to 2 years, depending on fibrosis stage and the patient’s response to intervention. […] 11. If noninvasive tests (eg, Fibrosis-4 and NAFLD fibrosis score) are indeterminate, a second noninvasive test (eg, transient elastography or magnetic resonance elastography) should be performed to confirm the stage and prognosis of NAFLD. […] 12. In lean patients with NAFLD, lifestyle intervention, including exercise, diet modification and avoidance of fructose- and sugar-sweetened drinks, to target a modest weight loss of 3%–5% is suggested.

• #66 Recent advances in non-invasive diagnosis and medical management of non-alcoholic fatty liver disease in adult | Egyptian Liver Journal | Full Text

  https://eglj.springeropen.com/articles/10.1186/s43066-020-00043-x

  Liver biopsy is the gold standard test for diagnosis, grading, and histological assessment of NAFLD, and a four-point histopathologic grading system is used to assess severity of steatosis that ranges from 0 to 3, depending on presence of the percentage of fat-containing hepatocytes. But the value of a liver biopsy for the diagnosis of NAFLD in routine clinical practice is controversial, especially in the presence of a generally good prognosis for most patients with NAFLD, the lack of an established form of effective therapy, and the risks and costs associated with the liver biopsy. […] Before considering the diagnosis of NAFLD, alcoholic fatty liver has to be excluded. […] There is no single laboratory marker that can be used for the diagnosis of NAFLD. […] The NAFLD liver fat score is estimated by using the presence of the metabolic syndrome, type 2 diabetes, fasting serum insulin level, fasting serum AST, and the AST/ALT ratio.

• #67 Diagnosis and management of nonalcoholic fatty liver disease (NAFLD) in lean individuals – American Gastroenterological AssociationAGA Logo_Horizontal

  https://gastro.org/clinical-guidance/diagnosis-and-management-of-nonalcoholic-fatty-liver-disease-nafld-in-lean-individuals/

  10. Serum indices (NAFLD fibrosis score and Fibrosis-4 score) and imaging techniques (transient elastography and magnetic resonance elastography) may be used as alternatives to liver biopsy for fibrosis staging and patient follow-up. These tests can be performed at the time of diagnosis and repeated at intervals of 6 months to 2 years, depending on fibrosis stage and the patient’s response to intervention. […] 11. If noninvasive tests (eg, Fibrosis-4 and NAFLD fibrosis score) are indeterminate, a second noninvasive test (eg, transient elastography or magnetic resonance elastography) should be performed to confirm the stage and prognosis of NAFLD. […] 12. In lean patients with NAFLD, lifestyle intervention, including exercise, diet modification and avoidance of fructose- and sugar-sweetened drinks, to target a modest weight loss of 3%–5% is suggested.

• #68 Practical Diagnosis and Staging of Nonalcoholic Fatty Liver Disease: A Narrative Review – European Medical Journal

  https://www.emjreviews.com/hepatology/article/practical-diagnosis-and-staging-of-nonalcoholic-fatty-liver-disease-a-narrative-review/

  Most individuals with NAFLD are asymptomatic and present incidentally with raised liver enzymes or evidence of steatosis on imaging; if symptoms do occur, they include right upper quadrant pain or fatigue. […] Once suspected clinically, the presence of hepatic steatosis should be confirmed on imaging. […] In most cases, NAFLD can be confidently diagnosed without the need for a liver biopsy in individuals with steatosis on imaging or in those with raised liver enzymes and metabolic risk factors, after the exclusion of other causes. […] Once a diagnosis of NAFLD has been made, it is vital to stage the disease to assess prognosis and determine if specific treatment (in addition to lifestyle changes) for NAFLD is required. […] The NFS and FIB-4 scores are the most widely used simple noninvasive scores and are recommended in European guidelines. […] Overall, despite their limitations, the FIB-4 score and NFS offer a good first-line test to stage liver fibrosis and if individuals have a low score (using appropriate age corrected cut-offs), advanced fibrosis can reliably be excluded.

• #69 Clinical Care Guidelines & Guidances in NAFLD/NASH – Global Liver Institute

  https://globalliver.org/clinical-care-guidelines-and-guidances-in-nafld-nash/

  People at risk for NAFLD should be identified. […] People at risk should undergo noninvasive testing for liver fibrosis using fibrosis-4 (FIB-4) and liver stiffness measurement (LSM). […] Management of NAFLD or NASH should be done with multidisciplinary healthcare teams that include a primary care physician, hepatologist, gastroenterologist, and endocrinologist, as needed. […] People at high risk for NAFLD and advanced fibrosis should be screened. […] NAFLD and liver fibrosis risk can be calculated and predicted using the FIB-4 test. […] Those with persistently high liver enzymes, hepatic steatosis, or evidence of advanced liver disease should be referred to a specialist. […] Individuals with obesity and NAFLD should receive lifestyle counseling, including for weight loss. […] Individuals with moderate or high risk of advanced disease should undergo risk assessment with FIB-4.

• #70 Diagnosis and management of non-alcoholic fatty liver disease (NAFLD) – American Gastroenterological AssociationAGA Logo_Horizontal

  https://gastro.org/clinical-guidance/diagnosis-and-management-of-non-alcoholic-fatty-liver-disease-nafld/

  14. The presence of metabolic syndrome and the NAFLD Fibrosis Score may be used for identifying patients who are at risk for steatohepatitis and advanced fibrosis. […] 15. Liver biopsy should be considered in patients with suspected NAFLD in whom competing etiologies for hepatic steatosis and co-existing chronic liver diseases cannot be excluded without a liver biopsy. […] 16. Weight loss generally reduces hepatic steatosis, achieved either by hypocaloric diet alone or in conjunction with increased physical activity. […] 17. Loss of at least 3-5% of body weight appears necessary to improve steatosis, but a greater weight loss (up to 10%) may be needed to improve necroinflammation. […] 18. Exercise alone in adults with NAFLD may reduce hepatic steatosis but its ability to improve other aspects of liver histology remains unknown.

• #71 Diagnosis and Characterization of Non-Alcoholic Fatty Liver Disease | IntechOpen

  https://www.intechopen.com/chapters/58896

  Given these limitations, non-invasive methods have been developed for the diagnosis of NASH and fibrosis as a first option to examine NAFLD patients and to help determine which require a liver biopsy. […] The principal metabolic factor of the risk of NAFLD progression is DM2. […] Therefore, patients with NASH and significant fibrosis, which is indicative of important cellular damage, are also at risk of developing this liver tumor. […] With all this information, we recommend recalculating NFS and/or FIB-4 every 4-5 years for patients with NAFL without risk factors or if the patient develops DM2; in patients with NASH without significant fibrosis, we recommend an annual follow-up with a calculation of NFS and/or FIB-4 and carrying out TE and ultrasound, and in patients with significant fibrosis, a 6-monthly follow-up is recommended with special interest in screening for HCC.

• #72 Diagnosis and management of non-alcoholic fatty liver disease (NAFLD) – American Gastroenterological AssociationAGA Logo_Horizontal

  https://gastro.org/clinical-guidance/diagnosis-and-management-of-non-alcoholic-fatty-liver-disease-nafld/

  34. Patients with NASH cirrhosis should be screened for gastroesophageal varices according to the American Association for the Study of Liver Diseases (AASLD)/American College of Gastroenterology (ACG) practice guidelines. […] 35. Patients with NASH cirrhosis should be considered for HCC screening according to the AASLD/ACG practice guidelines. […] 36. Current evidence does not support routinely repeating a liver biopsy in patients with NAFL or NASH. […] 37. Children with fatty liver who are very young or not overweight should be tested for monogenic causes of chronic liver disease such as fatty acid oxidation defects, lysosomal storage diseases and peroxisomal disorders, in addition to those causes considered for adults. […] 38. Low serum titers of autoantibodies are often present in children with NAFLD, but higher titers, particularly in association with higher serum aminotransferases and high globulin should prompt a liver biopsy to evaluate for possible autoimmune hepatitis.

• #73

  https://journals.lww.com/cld/fulltext/2022/06000/the_diagnosis_and_management_of_nonalcoholic_fatty.3.aspx

  Key Point: There are medical treatments for patients with NASH that can be used in conjunction with losing weight. […] Guideline statement: Patients with NASH cirrhosis should be screened for gastroesophageal varices according to the AASLD and ACG practice guidelines. […] Key Point: NASH can lead to cirrhosis which requires patients to have tests that screen for liver cancer and varices in the esophagus. […] Guideline statement: Children with fatty liver who are very young or not overweight should be tested for monogenic causes of CLD such as fatty acid oxidation defects, lysosomal storage diseases, and peroxisomal disorders, in addition to those causes considered for adults. […] Key Point: Children are treated the same as adults for NAFLD.

• #74 Diagnosis and management of nonalcoholic fatty liver disease (NAFLD) in lean individuals – American Gastroenterological AssociationAGA Logo_Horizontal

  https://gastro.org/clinical-guidance/diagnosis-and-management-of-nonalcoholic-fatty-liver-disease-nafld-in-lean-individuals/

  Diagnosis and management of nonalcoholic fatty liver disease (NAFLD) in lean individuals […] Experts provide 15 best practices for the diagnosis and treatment of lean individuals with NAFLD. […] 1. Lean NAFLD should be diagnosed in individuals with NAFLD and body mass index <25 kg/m2 (non-Asian race) or body mass index <23 kg/m2 (Asian race). [...] 2. Lean individuals with NAFLD should be evaluated routinely for comorbid conditions, such as type 2 diabetes mellitus, dyslipidemia and hypertension. [...] 3. Lean individuals with NAFLD should be risk stratified for hepatic fibrosis to identify those with advanced fibrosis or cirrhosis. [...] 4. Lean individuals in the general population should not undergo routine screening for NAFLD; however, screening should be considered for individuals older than 40 years with type 2 diabetes mellitus.

• #75 Diagnosis and management of nonalcoholic fatty liver disease (NAFLD) in lean individuals – American Gastroenterological AssociationAGA Logo_Horizontal

  https://gastro.org/clinical-guidance/diagnosis-and-management-of-nonalcoholic-fatty-liver-disease-nafld-in-lean-individuals/

  5. NAFLD should be considered in lean individuals with metabolic diseases (such as type 2 diabetes mellitus, dyslipidemia and hypertension), elevated liver biochemical tests or incidentally noted hepatic steatosis. […] 6. Clinicians should query patients routinely regarding alcohol consumption patterns in all patients with lean NAFLD. […] 7. In patients with lean NAFLD, other causes of liver disease should be ruled out, including other causes of fatty liver, such as HIV, lipodystrophy, lysosomal acid lipase deficiency, familial hypobetalipoproteinemia and medication-induced hepatic steatosis (methotrexate, amiodarone, tamoxifen and steroids). […] 8. Current evidence is inadequate to support routine testing for genetic variants in patients with lean NAFLD. […] 9. Liver biopsy, as the reference standard, should be considered if there is uncertainty regarding contributing causes of liver injury and/or the stage of liver fibrosis.

• #76 Diagnosis and management of non-alcoholic fatty liver disease (NAFLD) – American Gastroenterological AssociationAGA Logo_Horizontal

  https://gastro.org/clinical-guidance/diagnosis-and-management-of-non-alcoholic-fatty-liver-disease-nafld/

  34. Patients with NASH cirrhosis should be screened for gastroesophageal varices according to the American Association for the Study of Liver Diseases (AASLD)/American College of Gastroenterology (ACG) practice guidelines. […] 35. Patients with NASH cirrhosis should be considered for HCC screening according to the AASLD/ACG practice guidelines. […] 36. Current evidence does not support routinely repeating a liver biopsy in patients with NAFL or NASH. […] 37. Children with fatty liver who are very young or not overweight should be tested for monogenic causes of chronic liver disease such as fatty acid oxidation defects, lysosomal storage diseases and peroxisomal disorders, in addition to those causes considered for adults. […] 38. Low serum titers of autoantibodies are often present in children with NAFLD, but higher titers, particularly in association with higher serum aminotransferases and high globulin should prompt a liver biopsy to evaluate for possible autoimmune hepatitis.

• #77

  https://journals.lww.com/cld/fulltext/2022/06000/the_diagnosis_and_management_of_nonalcoholic_fatty.3.aspx

  Key Point: There are medical treatments for patients with NASH that can be used in conjunction with losing weight. […] Guideline statement: Patients with NASH cirrhosis should be screened for gastroesophageal varices according to the AASLD and ACG practice guidelines. […] Key Point: NASH can lead to cirrhosis which requires patients to have tests that screen for liver cancer and varices in the esophagus. […] Guideline statement: Children with fatty liver who are very young or not overweight should be tested for monogenic causes of CLD such as fatty acid oxidation defects, lysosomal storage diseases, and peroxisomal disorders, in addition to those causes considered for adults. […] Key Point: Children are treated the same as adults for NAFLD.

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