What is the prognosis of fatty liver disease?

Updated: Apr 12, 2018
  • Author: Emily Tommolino, MD; Chief Editor: BS Anand, MD  more...
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Steatosis may be reversible with weight loss, cessation of alcohol use, or both. It was once believed to be a benign condition that only rarely progressed to chronic liver disease; however, steatohepatitis may progress to liver fibrosis and cirrhosis and may result in liver-related morbidity and mortality.

Simple alcoholic steatosis is rarely fatal. With complete abstinence, histologic changes generally return to normal within 2-4 weeks. Continued alcohol consumption may result in more advanced forms of liver disease, either alcoholic hepatitis or cirrhosis. Although alcoholic steatosis usually is considered a benign lesion with a favorable prognosis once alcohol consumption is discontinued, several prognostic factors have been described in the literature that may indicate advancement to more severe lesions in patients who continue to drink.

For example, in a study from England that followed 88 patients with fatty liver for a mean of 10.5 years, 9 of the patients developed cirrhosis, and 7 developed fibrosis; all but 1 of these 16 patients had continued to use alcohol. [82] Histologic predictors of progression at the time of fatty liver included the presence of mixed macrovesicular/microvesicular fat and giant mitochondria.

Patients with alcoholic fatty liver are at high risk of the development of cirrhosis and increased mortality associated with the severity of steatosis in the index liver biopsy. The presence of histologic cholestasis in association with alcoholic steatosis does not appear to be of prognostic significance in determining the risk of progression to cirrhosis. More recently, investigators of a retrospective study noted that, despite a lower incidence of hepatocellular carcinoma, alcoholic liver disease (ALD) confers a worse prognosis in patients with cirrhosis than those with chronic hepatitis C infection or nonalcoholic fatty liver disease (NAFLD)-related cirrhosis. [98]

A study from Denmark that used the Danish National Registry noted an increase in mortality among patients with a hospital discharge diagnosis of alcoholic fatty liver; this increase remained after the censoring of patients with a diagnosis of cirrhosis. [15]

Long-term natural history studies of patients with NAFLD who undergo repeat biopsies have shown that 30% progress, 30% remain stable, and 30% improve over a 3-year period without pharmacologic intervention. [83] Abnormal glucose tolerance testing is an independent risk factor for progression of nonalcoholic steatohepatitis (NASH). [84]

A natural history study from Olmsted County, Minnesota, revealed that over the 10-year study period, mortality was 10% higher in NAFLD patients than in control subjects. [18] Malignancy and heart disease were the top two causes of death. Liver-related disease was the third leading cause of death (13%) for NAFLD patients but only the 13th most common cause of death (<1%) for control subjects.

In a study by Bhala et al evaluating mortality in 500 patients with chronic hepatitis C or NASH, patients with hepatitis C were more likely to die of liver-related disease; however, long-term mortality for NASH was equivalent to that for hepatitis C, probably because of the increase in cardiovascular causes of death found in the NASH patients. [85]

Fibrosis or cirrhosis of the liver is present in 15%-50% of patients with NASH. Approximately 30% of patients with fibrosis develop cirrhosis after 10 years. Many cases of cryptogenic cirrhosis may represent so-called burnt-out NASH because a high percentage of such cases are associated with obesity, type II diabetes, or hyperlipidemia.

Some patients with drug-induced fatty liver present dramatically with rapid evolution of hepatic failure. Some patients with inborn errors of metabolism (eg, tyrosinemia) may rapidly progress to cirrhosis.

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