NAFLD practice guidance issued for screening, treatment

The guidance, from the American Association for the Study of Liver Diseases, notes that routine screening for nonalcoholic fatty liver disease (NAFLD) in a primary care setting or obesity clinics is not typically recommended due to uncertainties in long-term benefits and cost-effectiveness.


The American Association for the Study of Liver Diseases recently released a practice guidance document suggesting preferred approaches to the diagnostic, therapeutic, and preventive aspects of care for nonalcoholic fatty liver disease (NAFLD).

The guidance, which provides detailed analyses of screening and treatment procedures, was published online July 17 by Hepatology. Among the 53 recommendations are the following:

  • While NAFLD indicates the lack of recent or regular alcohol consumption, a consensus meeting reviewing inconsistent data on alcohol consumption in NAFLD defined 21 standard drinks per week for men and 14 standard drinks per week for women as presenting an outstanding risk.
  • Unsuspected or incidental hepatic steatosis detected on imaging should lead to further assessment of related causes. Patients should be evaluated as though they have suspected NAFLD and worked up accordingly. It is reasonable to assess for metabolic risk factors such as obesity, glucose intolerance, or dyslipidemia, as well as alternate causes for hepatic steatosis such as significant alcohol consumption or medications.
  • Routine screening in a primary care setting or obesity clinics is not typically recommended due to uncertainties in long-term benefits and cost-effectiveness, although initial evaluation of patients with suspected NAFLD should focus on competing comorbidities and coexisting liver disease.
  • Tools such as the NAFLD Fibrosis Score and vibration-controlled transient elastography are recommended for identifying patients with higher likelihood of having or developing advanced fibrosis or cirrhosis.
  • Liver biopsy is recommended in patients with NAFLD who are at increased risk for steatohepatitis or advanced fibrosis as determined by fibrosis score, elastography, or competing causes.
  • Pharmacological treatments should generally be limited to patients with biopsy-proven nonalcoholic steatohepatitis and fibrosis.
  • Loss of at least 3% to 5% of body weight appears necessary to improve hepatic steatosis, but 7% to 10% may be needed to improve necroinflammation.
  • Other potential interventions to decrease risk for NAFLD progression and to improve liver disease include lifestyle interventions, a daily dose of 800 IU of vitamin E in adults without diabetes, and bariatric surgery among patients with obesity.
  • Patients with NAFLD should be monitored for cardiovascular risks as NAFLD increases the risk for cardiovascular morbidity and mortality. Aggressive modification of cardiovascular risk factors should be considered in all patients with NAFLD.
  • Patients with NAFLD should be screened for gastroesophageal varices, and patients with NAFLD-related cirrhosis should be considered for hepatocellular screening.

The guidance was based on a formal review of recently published international literature, the American College of Physicians' Manual for Assessing Health Practices and Designing Practice Guidelines, and the expertise of authors and independent reviewers.