MASLD, aka Non-Alcohol Fatty Liver Disease (NAFLD or NASH)

OVERVIEW

NASH stands for Non-alcoholic steatohepatitis, which is a type of liver disease. It is a condition where there is an accumulation of excess fat in the liver, along with inflammation and liver cell damage. NASH occurs in people who do not drink excessive amounts of alcohol, but who have other risk factors such as obesity, type 2 diabetes, high cholesterol, and metabolic syndrome.  As of 2024, most healthcare providers are using the term "Metabolic Dysfunction Associated Steatotic Liver Disease" as an umbrella term for fatty liver or NASH.

In NASH, the accumulation of excess fat in the liver can lead to inflammation and damage to liver cells, which can progress over time and lead to liver fibrosis (scarring) and cirrhosis (severe scarring). This can lead to serious health problems, including liver failure, liver cancer, and even death.

There are no specific symptoms of NASH, and the condition is often discovered incidentally during routine blood tests or medical imaging. The most effective way to prevent or treat NASH is to maintain a healthy lifestyle by maintaining a healthy weight, following a balanced diet, exercising regularly, and avoiding excessive alcohol consumption. If NASH is diagnosed, your doctor may also recommend medications to help manage any underlying conditions, such as diabetes or high cholesterol, and to help reduce inflammation in the liver.

NASH is a serious condition that can lead to long-term liver damage and other health problems. It is important to maintain a healthy lifestyle and seek medical attention if you have any concerns about your liver health.

WHAT CAN I DO TO PREVENT MORE LIVER INJURY?

The best treatment for NASH is weight loss.  This was perhaps best shown in a study of nearly 300 individuals who underwent a liver biopsy and worked at weight loss, with another biopsy after 1 year.   Of those who lost 10% or more of their body weight, all had some improvement in inflammation of the liver and nearly half (45%) had an improvement in the amount of scar tissue (fibrosis) in the liver.  Some improvement was seen in those who lost less weight as well.  Because of this, developing a weight loss plan that combines reduced caloric intake and increased physical activity is the cornerstone of treatment for NASH.

Bariatric surgery (an operation to help with weight loss, often by decreasing the size of the stomach) is also an excellent option for many people.  In one study of people with obesity and NASH undergoing bariatric surgery, NASH disappeared in nearly 85% of people one year after their surgery (Lassailly et al, 2015).  

Coffee consumption of at least 3 cups a day has been associated with less severe liver disease in individuals with NASH and is recommended.  High fructose corn syrup is especially damaging to the liver, so anyone with NASH should completely avoid sodas and other drinks containing this.

Although there are no medications currently approved by the Food and Drug Administration (FDA) for treatment of NASH, a few medications have been approved for other indications that have been shown to have some benefit.  Vitamin E, pioglitazone, and semaglutide are all medications that can be considered by your physician based off of the most recent clinical guidelines.

 
WHAT SHOULD I DISCUSS WITH MY DOCTOR?

The following items should be discussed regularly with your healthcare provider:

1. Screening for and management of diabetes, hypertension, and high cholesterol.  These frequently are seen in individuals with NASH and contribute to heart disease, the most common cause of death for people with NASH.  

2. Strategies for weight loss.  Your healthcare provider can discuss things like referral to a dietician, medications for weight loss, and when it may make sense to consider bariatric surgery.

3. Medications for NASH.  As mentioned above, you can discuss the risks and benefits of vitamin E, pioglitazone, and semaglutide with your healthcare provider.  

4. Fibrosis staging.  It is very important to have an understanding of how much damage has already been done to the liver.  This can be done with some simple online calculators looking at your blood tests (such as the FIB-4 score or NAFLD fibrosis score), as well as with special imaging tests such as a fibroscan, or even a biopsy of the liver.  Those with significant scar tissue will need to be watched closely, whereas those without any scar tissue may not need to see a liver specialist regularly.

5. Your alcohol intake and strategies to quit or minimize alcohol use to prevent additional liver damage.

6. Vaccinations.  In general, individuals with liver disease should receive vaccinations for hepatitis A and B, TDAP, yearly influenza vaccination, and be up to date with COVID vaccinations.  Individuals with cirrhosis should also receive pneumonia vaccinations.  A complete list of recommended vaccinations can be obtained from the CDC website on Vaccinations for those with liver disease.  Any of these infections can cause your liver to become much sicker if you are not appropriately protected from vaccination.

WHAT RESOURCES ARE AVAILABLE TO HELP ME?