Brother & Sister Liver

A review article in the New England Journal of Medicine tells us about the increased cardiovascular risk in people who have non-alcoholic fatty liver disease. Non alcoholic fatty liver disease comprises a spectrum of conditions where fat accumulates in the liver to produce conditions like hepatic steatosis (simple accumulation of fat in the liver), non alcoholic steatohepatitis (or NASH, where the fat accumulation is associated with hepatitis) and cirrhosis liver. NASH is the condition where there is overt inflammation in the liver caused by the fat. It is this inflammation, overt or subclinical, that is believed to be responsible for producing those inflammatory cytokines that damage the liver (leading to cirrhosis) and the endothelium of blood vessels (leading to atherosclerosis and ischemic organ damage). Even before overt cardiovascular disease develops, people with NASH have subclinical evidence of increased atherosclerosis in their vessels as shown by an increased carotid intimal-medial thickness.

The diagnosis of non alcoholic fatty liver disease is often made by an ultrasound examination of the liver. The diagnosis of NASH is made when, in addition, there are elevated liver enzymes. Of course, one needs to exclude other causes (for example, viral causes) of elevated liver enzymes. Speaking of elevated liver enzymes, studies have found that an elevated gamma glutamyl transferase is more significantly correlated with cardiovascular disease than elevated levels of alanine transaminase.

Many people with non alcoholic fatty liver disease have features of the metabolic syndrome (abdominal obesity, hypertension, atherogenic dyslipidemia and abnormalities in plasma glucose). The metabolic syndrome has within it many risk factors for cardiovascular disease and so, it is not surprising that the treatment of non alcoholic fatty liver disease also focuses on treating these risk factors. In particular, treatment with insulin sensitisers (Metformin, Pioglitazone) are recommended for glucose abnormalities associated with non alcoholic fatty liver disease. Life style modification for weight reduction and to reduce abdominal obesity is also to be emphasised. Pioglitazone and Vitamin E may also be useful in reducing the inflammation and fat in this condition even though there is no evidence yet that these can prevent cirrhosis.

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