NASH‐related cirrhosis: An occult liver disease burden

Nonalcoholic fatty liver disease (NAFLD) is reaching epidemic proportions. It is currently the most common cause of chronic liver disease worldwide, with a prevalence of 25%-30% of the general population. Recent estimates indicate that over 64 million people may have NAFLD in the United States while Europe has an estimated 53 million affected individuals. These figures point to a daunting and enormous disease burden of NAFLD that is closely related to the obesity epidemic and has an impact on mortality as patients with NAFLD exhibit an increased risk of death compared to the general population. Although cardiovascular disease is the leading cause of death in patients with NAFLD, the development of nonalcoholic steatohepatitis (NASH), the progressive form of NAFLD that affects 10%-15% of patients with the disease, determines the increased rates of liver-related mortality due to the development of cirrhosis and its complications, including hepatocellular carcinoma (HCC). Despite its high prevalence and potentially serious consequences, awareness about NAFLD is limited among nonspecialists. Several studies have shown that NAFLD is not regarded as a clinically important diagnosis by a significant proportion of providers. These providers underestimate disease prevalence among their patients and do not identify those factors associated with more serious or advanced disease; the latter will lead to unfocused management, limited referral of patients to hepatology clinics, and eventually to a lack of recognition of advanced liver disease. Since patients with cirrhosis represent an at-risk population for complications such as portal hypertensionassociated complications and HCC, an untimely diagnosis may impact a patient’s outcome. In the first issue of Hepatology Communications, Bertot et al. report their results of a retrospective study of a prospectively collected cohort of 100 patients with NAFLD-related cirrhosis. Their aim is to establish the mode of diagnosis (incidental versus intentional) and its association with liver-related complications, particularly HCC. Interestingly, in two thirds of patients, cirrhosis was diagnosed incidentally and was more likely to have concomitant HCC than in those patients who had been diagnosed intentionally with cirrhosis (12% versus 0%, respectively, P < 0.05). In addition, when reviewing their medical records, a significant proportion of these patients had thrombocytopenia and splenomegaly as markers of chronic liver disease. Moreover, when available noninvasive fibrosis scores were calculated, results pointed to the presence of advanced fibrosis in a significant percentage of individuals included in the study. Thus, this work shows that the diagnosis of cirrhosis and advanced fibrosis in the setting of NAFLD is frequently missed by physicians and that several simple scores would have helped to provide an earlier diagnosis. Abbreviations: GI, gastrointestinal; HCC, hepatocellular carcinoma; NAFLD, nonalcoholic fatty liver disease; NASH, nonalcoholic steatohepatitis.