Nonalcoholic Fatty Liver Disease

Implications for Clinical Practice and Health Promotion

Bethany Croke, FNP-BC; Deborah Sampson, FNP-BC

Disclosures

Journal for Nurse Practitioners. 2012;8(1):45-50. 

In This Article

Clinical Controversies

Controversies exist regarding NAFLD diagnosis and classification. For example, there are no precise cutoff levels for the amount of alcohol intake that distinguishes between NAFLD and AFLD. Greater than 20 g/day is the generally accepted level that classifies AFLD, but there are no officially published and accepted guidelines. Furthermore, patient self-report of alcohol consumption may be a poor indicator of intake. Distinction between alcoholic liver disease and NAFLD is not always obvious, even if the patient only drinks small amounts of alcohol. In this instance, it is reasonable to ask the patient to abstain from alcohol and then reassess for a definitive diagnosis.

The use of liver biopsy in clinical practice also causes debate among health care providers. Most patients with NAFLD have a good prognosis; therefore, the risks of a liver biopsy seem to outweigh the clinical benefits. However, liver biopsy remains the only definitive way to distinguish fatty liver from NASH. The risks and benefits of biopsy therefore must be considered on an individual basis, taking into account the patient's risk for disease progression (high risk: BMI > 39, advanced age, AST/ALT ratio > 1), the optimal timing of the biopsy in relation to the diagnosis, and the potential for watchful waiting. Current research is examining the possibility of detecting disease severity through laboratory markers, namely AST, ALT, gamma-glutamyl transpeptidase (GGT), and insulin levels.[18]

Use of unnecessary invasive procedures in children has also been a concern in regard to NAFLD and liver biopsy. Despite attempts to predict disease severity through AST and GGT levels, liver biopsy remains the best tool for discerning between NAFLD and NASH in children.[19] Other findings suggest that disease severity can possibly be predicted in the pediatric population by central obesity, elevated insulin levels, and lipid abnormalities.[20]

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