NAFLD is quite common and going to be the leading cause of liver transplant in future

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 JPMC symposium proceedings

NAFLD is quite common and going to be the leading
cause of liver transplant in future

 Pioglitazone will be the drug of choice in diabetics having
fatty liver disease-Prof. Khalid Mahmood

Focus on management of hypertension, diabetes, eliminate
Smoking and treat dyslipidemias- Prof. Masroor

KARACHI: Prof. Khalid Mahmood a noted physician who recently retired and Dean and Head of the Dept. of Medicine from Dow University of Health Sciences was one of the invited guest speakers at the JPMC’s 52nd annual symposium. He also chaired this session devoted to Medicine. His presentation was on Non Alcoholic Fatty Liver Disease (NAFLD) which was an excellent detailed review of the subject. NAFLD-NASH, Prof. Khalid Mahmood opined has now become an epidemic and it is going to be a major cause of cirrhosis of liver in the days to come. It is going to be rampant all over the world and those suffering from it will require liver transplant. With the availability of oral medication for HCV, it is hoped this will be eradicated from the developing countries by the year 2030 while numerous preparations for HBV are also currently in the pipeline.

Continuing Prof. Khalid Mahmood said that alcoholic fatty liver disease is seen very common in our practice and it eventually leads to cirrhosis of liver. Its Global prevalence is more than 25% of NAFLD. Its prevalence is high in Middle East, Iran but low in Africa. As regards western countries, its prevalence is about 30-40%. It is going to be the leading cause of liver transplant in future. NASH prevalence is about 3-5%. NAFLD is high risk for developing Hepatocellular carcinoma and NASH patients have increased liver related mortality. Speaking about progression of NASH Prof. Khalid Mahmood said that it leads to cardiovascular disease, hepatocellular carcinoma and hepatic decompensation. It is seen more in patients over the age of fifty years and those who have diabetes, obesity, dyslipidemia. Metabolic syndrome is in fact a major risk factor. There is emerging association with PCOS, hypothyroidism, Cushing’s syndrome, obstructive sleep apnea which are all associated with this. Most obese patients can have fatty liver disease.

Talking about the symptoms of NAFLD, he mentioned ascites, GI Bleeding, pruritus, jaundice, edema, and hepatomegaly. All over weight and obese patients should be suspected to have this disease and go through screening. Patients with metabolic syndrome, those suffering from Type -2 diabetes must be screened for NAFLD. Presence of liver injury, evidence of increased hepatic fat can be seen on ultrasound, CT and MRI but he hastened to add that these days everyone was doing Ultrasound without any training, hence one has to be extremely careful as to who is reporting and be careful about false reporting. It must be ensured that the report is signed by an experienced person trained in ultrasonography before starting treatment. Many times the reports are false. Abdomen should be investigated by CT and MRI. Do not forget to take history of alcohol and drugs the patient are taking. It is important to take the patient into confidence before starting treatment. Steroids, Tamoxifen, Methotrexate can all cause fatty liver. Exclude HBV and HCV. Do liver biopsy to establish presence of NASH. Sometimes liver enzymes can be normal. Liver biopsy still remains a gold standard to find out cirrhosis. He also discussed in detail how to identify fibrosis of liver and then start treatment without liver biopsy, when to do liver biopsy i.e. patients with advanced fibrosis with metabolic syndrome. He also talked about risk stratification of NASH and management of NAFLD based on disease stage. Drug therapy could be quite effective in early stages but in later stages there is increased mortality.

Continuing Prof. Khalid Mahmood remarked that a 10% reduction in body weight can reverse fatty liver. Patients should be advised to avoid fructose containing foods and beverages. Exercise is also quite useful to treat fatty liver disease. Weight loss works. Metformin is not effective in fatty liver disease but drugs like pioglitazone works. Liraglutide and many other similar drugs are quite effective. Vitamin E is also very useful. TZDS are effective in NASH if given for two years but be careful for hypoglycemia in these patients. Most of these patients have dyslipidemia but statins are safe in fatty liver disease and they can be used safely. Pioglitazone can lead to fluid retention, weight gain and edema. There is also a possibility of Congestive Heart Failure with the use of pioglitazone. Patients taking Vitamin E for long are at risk of developing prostate cancer. Liraglutide improves NASH and it has promising results. Bariatric surgery may be performed in eligible obese patients with NASH or NAFLD. Screening for HCC is also recommended, Prof. Khalid Mahmood added.

Responding to various questions during the discussion Prof. Khalid Mahmood said that metformin does not lead to any improvement in NASH or NAFLD. Pioglitazone is a better insulin sensitizer. There is no study of Vitamin E in diabetics suffering from NASH. In my practice I use it with pioglitazone in obese patients who are suffering from diabetes. In patients with diabetes having fatty liver disease, pioglitazone will be the drug of choice, he remarked.

Earlier Prof. Masroor Ahmad spoke on dyslipidemias. He pointed out that heart disease account for 35% of the disease burden globally. Almost 72% of the patients have sedentary life style and 42% have family history of disease. Smoking and dyslipidemias were the other important risk factors. We need to focus on management of hypertension, diabetes, eliminate smoking and treat dyslipidemias. Total cholesterol, he said, may be misleading in patients with diabetes. He emphasized the importance of healthy diet, regular physical activity, maintaining healthy body weight and control of blood pressure. Target LDL should always be less than 70 in high risk cases and HbA1c should be less than seven in diabetics. Dietary fibers should be increased. Use of olive oil should be promoted. Nuts and fish is healthy. Advise patients to avoid sugary drinks. Use of statins is good. Life style changes is still the most cost effective way to manage dyslipidemias and statins can be used to reduce blood pressure, he added.

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