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Introduction In June 2021, the Korean Society for the Study of Liver Diseases (KASL) issued guidelines for the management of non-alcoholic fatty liver disease (NAFLD).
This article is an update of the 2013 guidelines.
The main content relates to the diagnosis and treatment of NAFLD.
According to the GRADE system Grade the quality of evidence and the strength of recommendations
.
1.
The diagnosis of NAFLD (1) Who are the target populations for NAFLD screening? How to screen? 1.
Patients with persistent elevated liver enzymes or diabetes should be screened for NAFLD (A1)
.
2.
Patients with metabolic syndrome (closely related to insulin resistance, obesity and other risk factors for NAFLD) may consider NAFLD screening (B1)
.
3.
Abdominal ultrasound is a preliminary screening method (B1)
.
(2) What non-invasive surrogate indicators can be used to diagnose liver steatosis? 1.
Abdominal ultrasound, controlled attenuation parameters (CAP), non-enhanced CT, magnetic resonance spectroscopy (MRS) and magnetic resonance imaging proton density fat content determination (MRI-PDFF) are feasible ways to diagnose liver steatosis (A1)
.
2.
If radiological examination is not feasible, a combined examination of liver steatosis can be used to assess liver steatosis (B1)
.
(3) What non-invasive surrogate indicators can be used to diagnose non-alcoholic steatohepatitis (NASH)? 1.
The non-invasive diagnostic methods of NASH are still limited, so the diagnosis should be confirmed by liver biopsy (A1)
.
(4) What non-invasive surrogate indicators can be used to assess liver fibrosis? 1.
Instantaneous elastography, point shear wave elastography (point SWE), two-dimensional shear wave elastography (2D SWE), magnetic resonance elastography (MRE) and other radiological examinations are helpful for the assessment of liver fibrosis (A1)
.
2.
If radiological examination is not feasible, combined examinations such as NAFLD fibrosis score (NFS) or FIB-4 index can be used to diagnose liver fibrosis (B1)
.
(5) What tests can be used to identify advanced fibrosis? 1.
Prioritize the use of transient elastography, FIB-4, NFS and other non-invasive methods to distinguish advanced liver fibrosis (A1)
.
2.
Serological examination, imaging examination and liver biopsy can be used as additional liver fibrosis assessment methods (B1)
.
(6) What are the indications for liver biopsy? 1.
Patients with suspected NASH or advanced liver fibrosis should consider liver biopsy (B1)
.
2.
When coexisting chronic liver disease and its severity cannot be ruled out, liver biopsy (B1) should be considered
.
(7) How to prevent hepatocellular carcinoma (HCC)? 1.
Patients with NAFLD-related cirrhosis need to be monitored for HCC (A1)
.
2.
In order to reduce the occurrence of HCC in NAFLD patients, it is recommended that patients quit smoking, quit drinking, and lose weight (B1)
.
2.
Treatment of NAFLD (1) Who should receive treatment and what is the purpose of treatment? 1.
NAFLD patients need to change their life>
.
2.
Patients with NASH or liver fibrosis need to receive management or treatment to improve liver histology (A1)
.
(2) What are the changes in life>1.
For NAFLD patients who are overweight or obese, weight loss of more than 5%-7% can reduce the fat content in the liver, and weight loss of more than 7%-10% is required to improve liver inflammation and fibrosis (A1)
.
2.
In order to reduce the fat content in the liver, the patient needs to reduce the total energy intake of more than 500 kcal per day (A1)
.
3.
In order to reduce the amount of fat in the liver, patients need to do moderate-intensity exercise for more than 30 minutes at least 3 times a week (B1)
.
(3) What are the effects of moderate or small amounts of alcohol consumption? 1.
NAFLD patients should pay attention to drinking moderately or in small amounts (B1)
.
(4) What are the types, indications, efficacy and side effects of the drugs used to treat NAFLD? 1.
Pioglitazone can improve NASH confirmed by liver biopsy (with or without diabetes), but the safety of long-term treatment should be considered (B1)
.
2.
For patients with NAFLD and diabetes, metformin can be used as the first-line treatment for diabetes (B1)
.
3.
Large doses of vitamin E (800 IU/d) can improve NASH confirmed by liver biopsy in non-diabetic patients, but safety should be considered for long-term administration (B1)
.
4.
Due to the high incidence and mortality of cardiovascular disease in NAFLD patients, it is necessary to actively control the risk factors of cardiovascular disease (A1)
.
5.
In the case of abnormal blood lipids in NAFLD patients, statins can be used to prevent cardiovascular disease (B1)
.
6.
It is not recommended to use omega-3 fatty acids to treat NASH, but omega-3 fatty acids can be used to treat NAFLD with hypertriglyceridemia (B1)
.
(5) What are the indications and postoperative management methods for bariatric surgery? 1.
For patients with NASH and obesity who are ineffective in drug treatment and life>
.
2.
For patients with liver cirrhosis, the effectiveness and safety of bariatric surgery have yet to be confirmed (B1)
.
(6) What are the indications of liver transplantation (LT) and the management method after LT? 1.
According to the clinical practice guidelines for liver transplantation, NASH patients with end-stage liver disease or HCC may consider liver transplantation (A1)
.
References: Kang SH, Lee HW, Yoo JJ, et al.
KASL clinical practice guidelines: Management of nonalcoholic fatty liver disease[J].
Clin Mol Hepatol.
2021 Jun 22.
This article is an update of the 2013 guidelines.
The main content relates to the diagnosis and treatment of NAFLD.
According to the GRADE system Grade the quality of evidence and the strength of recommendations
.
1.
The diagnosis of NAFLD (1) Who are the target populations for NAFLD screening? How to screen? 1.
Patients with persistent elevated liver enzymes or diabetes should be screened for NAFLD (A1)
.
2.
Patients with metabolic syndrome (closely related to insulin resistance, obesity and other risk factors for NAFLD) may consider NAFLD screening (B1)
.
3.
Abdominal ultrasound is a preliminary screening method (B1)
.
(2) What non-invasive surrogate indicators can be used to diagnose liver steatosis? 1.
Abdominal ultrasound, controlled attenuation parameters (CAP), non-enhanced CT, magnetic resonance spectroscopy (MRS) and magnetic resonance imaging proton density fat content determination (MRI-PDFF) are feasible ways to diagnose liver steatosis (A1)
.
2.
If radiological examination is not feasible, a combined examination of liver steatosis can be used to assess liver steatosis (B1)
.
(3) What non-invasive surrogate indicators can be used to diagnose non-alcoholic steatohepatitis (NASH)? 1.
The non-invasive diagnostic methods of NASH are still limited, so the diagnosis should be confirmed by liver biopsy (A1)
.
(4) What non-invasive surrogate indicators can be used to assess liver fibrosis? 1.
Instantaneous elastography, point shear wave elastography (point SWE), two-dimensional shear wave elastography (2D SWE), magnetic resonance elastography (MRE) and other radiological examinations are helpful for the assessment of liver fibrosis (A1)
.
2.
If radiological examination is not feasible, combined examinations such as NAFLD fibrosis score (NFS) or FIB-4 index can be used to diagnose liver fibrosis (B1)
.
(5) What tests can be used to identify advanced fibrosis? 1.
Prioritize the use of transient elastography, FIB-4, NFS and other non-invasive methods to distinguish advanced liver fibrosis (A1)
.
2.
Serological examination, imaging examination and liver biopsy can be used as additional liver fibrosis assessment methods (B1)
.
(6) What are the indications for liver biopsy? 1.
Patients with suspected NASH or advanced liver fibrosis should consider liver biopsy (B1)
.
2.
When coexisting chronic liver disease and its severity cannot be ruled out, liver biopsy (B1) should be considered
.
(7) How to prevent hepatocellular carcinoma (HCC)? 1.
Patients with NAFLD-related cirrhosis need to be monitored for HCC (A1)
.
2.
In order to reduce the occurrence of HCC in NAFLD patients, it is recommended that patients quit smoking, quit drinking, and lose weight (B1)
.
2.
Treatment of NAFLD (1) Who should receive treatment and what is the purpose of treatment? 1.
NAFLD patients need to change their life>
.
2.
Patients with NASH or liver fibrosis need to receive management or treatment to improve liver histology (A1)
.
(2) What are the changes in life>1.
For NAFLD patients who are overweight or obese, weight loss of more than 5%-7% can reduce the fat content in the liver, and weight loss of more than 7%-10% is required to improve liver inflammation and fibrosis (A1)
.
2.
In order to reduce the fat content in the liver, the patient needs to reduce the total energy intake of more than 500 kcal per day (A1)
.
3.
In order to reduce the amount of fat in the liver, patients need to do moderate-intensity exercise for more than 30 minutes at least 3 times a week (B1)
.
(3) What are the effects of moderate or small amounts of alcohol consumption? 1.
NAFLD patients should pay attention to drinking moderately or in small amounts (B1)
.
(4) What are the types, indications, efficacy and side effects of the drugs used to treat NAFLD? 1.
Pioglitazone can improve NASH confirmed by liver biopsy (with or without diabetes), but the safety of long-term treatment should be considered (B1)
.
2.
For patients with NAFLD and diabetes, metformin can be used as the first-line treatment for diabetes (B1)
.
3.
Large doses of vitamin E (800 IU/d) can improve NASH confirmed by liver biopsy in non-diabetic patients, but safety should be considered for long-term administration (B1)
.
4.
Due to the high incidence and mortality of cardiovascular disease in NAFLD patients, it is necessary to actively control the risk factors of cardiovascular disease (A1)
.
5.
In the case of abnormal blood lipids in NAFLD patients, statins can be used to prevent cardiovascular disease (B1)
.
6.
It is not recommended to use omega-3 fatty acids to treat NASH, but omega-3 fatty acids can be used to treat NAFLD with hypertriglyceridemia (B1)
.
(5) What are the indications and postoperative management methods for bariatric surgery? 1.
For patients with NASH and obesity who are ineffective in drug treatment and life>
.
2.
For patients with liver cirrhosis, the effectiveness and safety of bariatric surgery have yet to be confirmed (B1)
.
(6) What are the indications of liver transplantation (LT) and the management method after LT? 1.
According to the clinical practice guidelines for liver transplantation, NASH patients with end-stage liver disease or HCC may consider liver transplantation (A1)
.
References: Kang SH, Lee HW, Yoo JJ, et al.
KASL clinical practice guidelines: Management of nonalcoholic fatty liver disease[J].
Clin Mol Hepatol.
2021 Jun 22.
