Time to Include Nonalcoholic Steatohepatitis in the Management of Patients With Type 2 Diabetes
Kenneth Cusi
Abstract
Nonalcoholic fatty liver disease (NAFLD) is today the most common cause of chronic liver disease and second only to viral hepatitis as a cause of liver transplantation in the U.S. (1,2). It encompasses conditions from simple steatosis (NAFL), believed to be associated with slow disease progression, to the more severe and progressive form known as nonalcoholic steatohepatitis (NASH). NASH is characterized by hepatocellular injury in the form of hepatocyte ballooning (necrosis) and predominantly lobular inflammation. The severity of hepatic fibrosis is defined in stages. They range from stage F0, or no fibrosis, to mild (stage F1), moderate (stage F2, with zone 3 sinusoidal fibrosis plus periportal fibrosis), or advanced fibrosis, with bridging fibrosis (stage F3) or cirrhosis (stage F4). NASH may lead to cirrhosis and to the development of hepatocellular carcinoma, but even moderate-to-severe fibrosis (F2-F3) is associated with higher mortality (1,2). Advanced liver fibrosis and cirrhosis occur more often in obesity but, in particular, in patients with type 2 diabetes (T2D) (3). Endocrinologists should be aware that patients with NAFLD are also at a two- to threefold increased risk of both progression from prediabetes to diabetes and development of cardiovascular disease (4,5). Taken together, there is a consensus that patients with T2D and NASH are at a much higher risk of hepatic and extrahepatic morbidity and premature death than in the absence of liver disease. Within this context, Younossi et al. (6) report in the current issue of Diabetes Care an important study on the clinical and economic burden of NASH in patients with T2D in the U.S. This is so far the most comprehensive effort to systematically outline the magnitude of the problem in patients with diabetes. The authors used 2017 annual direct medical costs attributed to diagnosed diabetes reported by the …