Non-alcoholic fatty liver disease in diabetes: When to refer to the hepatologist?

Abstract

Non-alcoholic fatty liver disease (NAFLD) has become one of the most common chronic liver diseases worldwide. A strong relationship exists between NAFLD and diabetes mellitus. There is growing evidence of a mechanistically complex and strong association between the two diseases. Current data also shows that one disease actually leads to worsening of the other and vice versa. Understanding of the various pathophysiological mechanisms involved, natural history and spectrum of these two diseases is essential not only for early diagnosis and management but also for prevention of severe disease forms. Despite the tremendous progress made in recent times in acquiring knowledge about these highly prevalent diseases, the guidelines and recommendations for screening and management of diabetics with NAFLD remain ambiguous. An interdisciplinary approach is required to not only raise awareness of the prevalence of NAFLD in diabetics but also for better patient management. This can help attenuate the development of significant complications, such as cirrhosis, decompensation and hepatocellular carcinoma in these patients, thereby halting NAFLD in its tracks. This review focuses on the pivotal role of primary care physicians and endocrinologists in identification of NAFLD in diabetics in early stages and the role of proactive screening for prompt referral to hepatologist.

Keywords: Fibrosis, Diabetes, Insulin resistance, Non-alcoholic fatty liver disease, Non-alcoholic steatohepatitis, Steatosis

Core Tip: With prevalence of non-alcoholic fatty liver disease (NAFLD) in diabetics being substantial, there is a need for its increased awareness and knowledge in the primary care physicians and endocrinologists. It is important to understand that these patients have the propensity to develop more severe forms of liver diseases, and their early identification and management can help in providing a stitch in time. We have reviewed in detail, the currently available societal guidance on screening of NAFLD in diabetics, especially with regards to high-risk patients that require hepatologist’s referral. We have even proposed a screening protocol for these patients based on available literature. This will not only help the treating physicians in identifying the disease in its incipient stages but also help in patient’s timely referral.