Top Highlights in NAFLD/NASH: The Liver Meeting 2014

Author's Note: Significant advances in the diagnosis and management of patients with liver disease were presented at The Liver Meeting® 2014, which is the annual meeting of the American Association for the Study of Liver Diseases (AASLD). Investigators highlighted progress in the understanding of common issues, including the availability of novel diagnostic and therapeutic options, as well as valid screening methodology to ensure optimal outcomes for patients. It is an exciting time for hepatology; the research presented promises to alter clinical practice in the near future. Some of the concepts that emerged from the outstanding presentations on fatty liver disease are highlighted here.

A Focus on Fatty Liver

With prospects for a cure for hepatitis C now a reality, a focus on the emerging major cause of chronic liver disease—fatty liver—is needed. Studies presented at The Liver Meeting 2014 offered insight into the mechanism, diagnosis, and treatment of nonalcoholic fatty liver disease (NAFLD) and nonalcoholic steatohepatitis (NASH).

To further define the pathophysiology of these disorders, and to explain the individual variation and susceptibility, Bril and colleagues^[1] assessed the role of specific genetic factors. Single-nucleotide polymorphisms in previously postulated genes—PNPLA3 (patatin-like phospholipase domain-containing protein 3), APOC3 (apolipoprotein C3), and PPARG (peroxisome proliferator-activated receptor gamma)—were analyzed. They reported that PPARG rs17817276 was associated with a higher prevalence of NASH. And although PNPLA3 polymorphisms were associated with liver fat content, no significant association was observed with insulin resistance or with severity of NASH.

This study by Bril and colleagues, along with related observations reported at this year's meeting, will inform translational studies of therapeutic agents aimed at specific molecular targets.

Guidelines? What Guidelines?

AASLD, jointly with the American College of Gastroenterology (ACG) and the American Gastroenterological Association (AGA), published guidelines for the management of NAFLD and NASH; however, little is known about how physicians in the United States diagnose the diseases or whether published guidelines are being followed.

Using a 23-question survey, Lominadze and colleagues^[2] assessed the current diagnostic patterns for NAFLD and NASH among academic gastroenterologists and hepatologists in the United States. They found that although liver biopsy remains the gold standard to establish a diagnosis, it is performed routinely by fewer than 25% of respondents. About 50% of the queried providers rely solely on elevated aminotransferase levels in deciding to perform a liver biopsy.

Another survey about NASH was sent to 9514 physicians from specialties typically involved in the management of NASH: gastroenterologists, hepatologists, endocrinologists, and internists/primary care providers.^[3] The aim was to understand the degree of awareness of clinical guidelines and the current practices in the diagnosis of NASH. A significant majority of physicians reported a high awareness of the practice guidelines; however, only a minority of patients actually undergoes liver biopsy to confirm NASH, contrary to practice guidelines. The vast majority of patients are prescribed medications despite the lack of a confirmed diagnosis or significant data to support the intervention. Alcohol thresholds to exclude NASH were also lower than expected.

These surveys, the findings of which were very similar, indicate that patients are being underdiagnosed, even in academic practices, and point out knowledge gaps in the implementation of the practice guidelines and a need to develop noninvasive diagnostic tools.

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