The spectrum of nonalcoholic fatty liver disease

NASH is a highly prevalent disorder in Western society and will likely become more prominent as the epidemic of obesity continues. The cause of NASH is uncertain, but an association with obesity, hypertension, hyperlipidemia, diabetes, and female gender exists. Initial presentation may be with asymptomatic elevation of liver enzymes or incidental radiologic evidence of steatosis. Some individuals presenting with cirrhosis may in fact have had longstanding NASH. This population likely explains a large proportion of individuals diagnosed with cryptogenic cirrhosis. Often, a liver biopsy is required to establish the diagnosis and obtain prognostic information. While no specific therapy currently exists for this condition, there are several promising agents under investigation. However, some of the limitations for studying this disease include its slowly progressive nature, the absence of a reliable, easily obtained gold standard in measuring disease progression, and the absence of large controlled trials to date. Follow-up is required for individuals with NASH, as it may progress to a fibrotic or cirrhotic stage. In this case, consideration should be given to referral for liver transplantation, but this may depend on the patient being an acceptable candidate. Specific risks in this population include morbid obesity, undetected cardiac disease, undetected vascular disease, and severe complications of diabetes and hypertension. Because NASH can recur, risk factors for the disease, such as diabetes and hypertension, should be aggressively managed both before and after liver transplantation.