Journal of Diabetes 4 (2012) 266–280

REVIEW ARTICLE

Non-alcoholic fatty liver disease

Ana C. TUYAMA1 and Charissa Y. CHANG2
1
Laboratory of Biochemical Genetics and Metabolism, Rockefeller University and 2Division of Liver Diseases, Mount Sinai Medical Center,
New York, New York, USA

Correspondence
Ana C. Tuyama, Laboratory of Biochemical
Genetics and Metabolism, Rockefeller
University, 1230 York Avenue, New York,
NY 10065, USA.
Tel: +1 212 263 6741
Fax: +1 212 263 4129
Email: atuyama@mail.rockefeller.edu
Received: 2 February 2012; revised 15 April
2012; accepted 28 April 2012.
doi: 10.1111/j.1753-0407.2012.00204.x
Abstract
Non-alcoholic fatty liver disease (NAFLD) is the most common chronic
liver disease in the Western world. It is closely associated with metabolic
syndrome. The alarming epidemics of diabetes and obesity have fueled an
increasing prevalence of NAFLD, particularly among these high-risk
groups. Histologically, NAFLD encompasses a disease spectrum ranging
from simple steatosis to non-alcoholic steatohepatitis (NASH), which is
characterized by hepatocyte injury, inflammation, and variable degrees of
fibrosis on liver biopsy. Non-alcoholic steatohepatitis can progress to cir-
rhosis in a fraction of patients. There is currently little understanding of
risk factors for disease progression and the disease pathogenesis has not
been fully defined. Liver biopsy remains the gold standard for diagnosis.
Weight loss, dietary modification, and the treatment of underlying meta-
bolic syndrome remain the mainstays of therapy once the diagnosis is
established. There are no well-established pharmacological agents for treat-
ment of NASH, although this is a subject of ongoing research.
Keywords: insulin resistance, metabolic syndrome, non-alcoholic fatty liver,
non-alcoholic steatohepatitis.

for cirrhosis resulting from NAFLD. The number of

Introduction
Chronic liver disease (CLD) is the 12th leading cause
of mortality in the US and is the fifth leading cause of
death among adults aged 44–64 years.1 Non-alcoholic
fatty liver disease (NAFLD) is currently the most com-
mon CLD in the Western world,2 particularly in
patients with obesity and diabetes.
The term ‘‘NAFLD’’ is used to describe a spectrum
best defined by liver biopsy findings ranging from
deposition of triglycerides as lipid droplets in the cyto-
plasm of hepatocytes, namely simple steatosis, to the
more aggressive form of non-alcoholic steatohepatitis
(NASH), which is characterized by additional features
of hepatocyte injury, inflammation, and variable
degrees of fibrosis. Although simple steatosis appears
to follow a non-progressive course, a subset of patients
develop NASH, which is of concern owing to the
potential progression to end-stage complications of
liver cirrhosis2 and hepatocellular carcinoma3 (HCC).
Approximately 10% of liver transplants in the US are
transplants due to underlying NAFLD is rising.4
Epidemiology
The overall prevalence of CLD has risen steadily over
recent decades according to the National Health and
Nutrition Examination Survey (NHANES) database.5,6
Although the prevalence rates of alcoholic liver disease
and viral hepatitis have remained stable, NAFLD and
its associated comorbidities (obesity, diabetes, and
insulin resistance) have increased substantially. Preva-
lence estimates of NAFLD vary according to the diag-
nostic modality used to establish the diagnosis. Given
that most patients are asymptomatic and do not
undergo a liver biopsy, the reported prevalence rates
are likely to underestimate the real problem.
Reports from biopsies of non-obese potential liver
transplant donors, considered healthy, are one estimate
of the true prevalence of NAFLD in the general popu-
lation. These studies have reported NAFLD rates of

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A.C. TUYAMA and C.Y. CHANG
14–53% (overall 43%) and NASH rates of 2–34%
(overall 15%).7–11 More importantly, the presence of
NAFLD and ⁄ or NASH results in the disqualification
of 12–20% of potential liver donors in the US.
In an autopsy series from Canada,12 the prevalence
of NAFLD and NASH in lean subjects was 7% and
3%, respectively. Other autopsy studies have reported
prevalence rates as high as 16% for NAFLD in the
general population,13,14 but some of the cases were
attributed to alcohol consumption.
Non-invasive imaging modalities such as ultrasound
and magnetic resonance spectroscopy (MRS) provide
another estimate of the prevalence of NAFLD. Two
population-based studies from Spain and Italy reported
a prevalence of NAFLD of 26% and 20%, respec-
tively,15,16 based on ultrasound. Similar numbers have
been reported in India17 (17%) and Japan18 (30%). As a
more sensitive modality for detecting hepatic steatosis,
MRS has been used investigationally to diagnose NA-
FLD. Initial studies from the Dallas Heart Study
reported slightly higher prevalence rates of 33–34%
based on MRS.19 More recently, a prospective study of
middle-aged US adults reported an alarming prevalence
of 46% for NAFLD based on ultrasonography.2 The
prevalence of NASH among the entire cohort was 12%;
however, 30% of patients with a positive ultrasound
had biopsy findings consistent with NASH.
Among patients with NAFLD, the prevalence of
NASH will vary according to the associated comorbid-
ities. In a recent review of 934 biopsies of non-cirrhotic
adults with NAFLD from the NASH-Clinical
Research Network (NASH-CRN) consortium, 58%
had features of steatohepatitis.20 Advanced fibrosis
and cirrhosis is thought to develop in 10–15% of
patients with NASH.21
Associated risk factors
The overall rates of NAFLD and ⁄ or NASH in the
general population do not take into account the associ-
ated factors that increase the risk of an individual of
developing steatosis and progressive disease. Hepatic
fat content varies substantially among individuals with
equivalent adiposity, indicating that other factors con-
tribute to this condition.2
Gender
Once believed to be a disease of middle-aged, non-
drinking women, recent population-based studies have
suggested that men may have higher rates of NAFLD
than women, especially before 60 years of age.3,22 It
seems that NAFLD occur earlier in men than in
women, with the prevalence peaking in the fourth
ª 2012 Ruijin Hospital, Shanghai Jiaotong University School of Medicine and Wiley Publishing Asia Pty Ltd
Non-alcoholic fatty liver disease
decade in men compared with the sixth decade in
women.23 These studies suggest different disease
behavior and pathogenesis between men and women.
Age
Similar to metabolic syndrome, the prevalence of
NAFLD and NASH tends to increase with age. Fur-
thermore, older patients with NAFLD are at risk of
disease progression and fibrosis.24–27 However, given
the impact of aging on the progression of most CLD,
it is difficult to separate the effects of associated com-
orbidities on the natural history of NAFLD from
those of the duration of the disease or age itself.
Ethnicity
Ethnic differences in the prevalence of NAFLD have
been demonstrated in population-based studies in the
US. In general, Hispanics have the highest prevalence
rates (45%), followed by Caucasians (33%) and Afri-
can Americans (24%).2,22,28 Hispanics are also at
increased risk of NASH and cirrhosis compared with
African Americans, and have higher liver-related mor-
tality rates.3,22,29 Asians and south Asians have been
shown to develop hepatic steatosis at much lower body
mass indices (BMI) than individuals in the West.30,31
Metabolic syndrome
It is thought that NAFLD is the liver manifestation of
metabolic syndrome, defined by Adult Treatment
Panel (ATP) III criteria32 as the presence of a combi-
nation of at least three of the following: central
obesity, hypertension, hypertriglyceridemia, low high-
density lipoprotein (HDL), and hyperglycemia. Meta-
bolic syndrome is present in 34–65% of patients with
NAFLD.33–35 Among individuals with NAFLD, fea-
tures of metabolic syndrome are associated with more
advanced and progressive disease, as well as with a
three-fold higher risk of NASH and fibrosis after cor-
rection for sex, age and BMI.33–35 Interestingly, the
presence of NAFLD is also an early predictor of the
later development of metabolic disorders, particularly
in normal-weight individuals.36
Obesity
Obesity is a strong predictor of NAFLD, with a paral-
lel increase in the rates of NAFLD and NASH with
rising BMI.2 It has been reported that NAFLD is pres-
ent in approximately 71–93% of patients undergoing
bariatric surgery, with 25–41% showing features of
NASH and 6–9% with advanced fibrosis and cirrho-
sis.37–42 Similar rates have been reported for patients
undergoing liver biopsies in obesity clinics,12,43 as well
as from autopsy series.12
267
Non-alcoholic fatty liver disease
The higher rates of NASH among obese patients sug-
gest a role for obesity in disease progression. In fact,
increased adiposity correlates with progression to NASH
and cirrhosis.12,38,44–46 This is further confirmed by
regression of histological severity and normalization of
liver enzymes after weight loss.47–57 The patterns of body
fat distribution may be particularly more important in
predicting disease severity and progression than BMI.58
Central obesity, as measured by waist circumference and
waist-to-hip ratio, has been suggested as a stronger pre-
dictor of NAFLD,59 NASH60 and cirrhosis.61 Visceral
adipose mass determined by magnetic resonance is a pre-
dictor of hepatic inflammation and fibrosis.62 More
recently, the presence of dorsocervical lipohypertrophy
(similar to the cervical hump seen in Cushing’s syn-
drome) has been shown to be strongly associated with
histological severity in patients with NASH.63
Diabetes mellitus
Insulin resistance (IR) is the hallmark of the metabolic
syndrome. Hyperglycemia, hyperinsulinemia, and IR
based on Homeostatic Model Assessment (HOMA) or
Quantitative Insulin Sensitivity Check Index (QUICK-
I) scores have been independently associated with clini-
cal progression to NASH and cirrhosis.39,42,64
The presence of NAFLD is correlated with the
degree of peripheral and hepatic IR,65,66 which is more
severe in individuals with NASH compared with sub-
jects with simple steatosis, independent of global or
regional adiposity.67,68 Ultrasound-diagnosed NAFLD
increased the risk of diabetes 2.5-fold.36 The reverse is
also true, with increases in fasting blood glucose and
insulin levels leading to a higher overall prevalence of
NAFLD, which is estimated to be 63–69% in patients
with diabetes.58,69–71 In addition, in a cohort of NA-
FLD patients with diabetes, the risk of developing cir-
rhosis was three-fold greater compared with that in
non-diabetics, and the presence of diabetes increased
liver-related mortality 22-fold.72,73 Finally, treatment
with oral hypoglycemic agents has been associated
with regression of steatosis and features of NASH.74
Cardiovascular disease
The importance of the liver in the regulation of metab-
olism has been increasingly recognized over the years.
Patients with metabolic syndrome typically have ath-
erogenic dyslipidemia,75 which is characterized by high
triacylglycerol, low HDL, increased small dense low-
density lipoprotein (LDL) particles, and increased apo-
lipoprotein B100 concentrations.76
The strong association between NAFLD and meta-
bolic syndrome established an interest in the connec-
tion between NAFLD and cardiovascular diseases
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A.C. TUYAMA and C.Y. CHANG
(CVD).77,78 Patients with NAFLD have increased
overall and CVD-related mortality compared with the
general population.25,79 In addition, studies have dem-
onstrated an increased risk for incident cardiovascular
events in patients with NAFLD compared with non-
NAFLD controls, independent of traditional risk fac-
tors.25,70,79–88 In fact, NAFLD histology, particularly
NASH, is correlated with early markers of atheroscle-
rosis, such as endothelial dysfunction89 and carotid
intima–media thickness.90 Based on the Framingham
risk score, patients with NAFLD have a higher 10-year
probability of CVD events, which is greater for
NASH.89 In patients at risk of CVD based on tradi-
tional risk factors, NAFLD imparts an additional risk
for CVD and may be a marker of current, future or
progressive CVD.83,91
Polycystic ovarian syndrome
The prevalence of polycystic ovarian syndrome (PCOS)
is estimated to be 5–10% in women of reproductive
age and PCOS preferentially affects obese women
(prevalence 28% vs 5% in obese and lean women,
respectively).92 Polycystic ovarian syndrome increases
the risk of NAFLD, with a 36–55% prevalence of liver
steatosis93–95 and a 44% prevalence of NASH96 in
affected women. In addition, NAFLD increases the
risk of PCOS in women of reproductive age, with one
study reporting a diagnosis of PCOS in 71% of women
with NAFLD.97 Despite these associations, the under-
lying mechanisms have not been defined clearly (for a
recent review, see Baranova et al.92).
As outlined for each specific condition, the risk of
NAFLD and NASH appears to be increased in sub-
groups of patients based on epidemiological data. One
important question that arises is whether patients at
risk should undergo screening for NAFLD. The ques-
tion becomes more complicated when determining the
appropriate screening test (liver ultrasound, liver
enzymes, liver biopsy) given the limitations and risks
imposed by each of them. There are currently no
screening recommendations for NAFLD in high-risk
groups.
Pediatric NAFLD
Currently, NAFLD is the most common cause of liver
disease in children and is estimated to affect up to 38%
of obese and 5% of normal or overweight children.98 In
an autopsy study of adolescents, 17.3% were found to
have NAFLD, which was more prevalent in boys of
Asian and Hispanic descent.98 The associated risk fac-
tors, clinical presentation, and diagnosis for pediatric
NAFLD are similar to those of the adult population.
A.C. TUYAMA and C.Y. CHANG
Given the lack of long term data, the natural history of
pediatric NAFLD has not been clearly defined.99 Of
note, the histological findings in the pediatric popula-
tion may differ, particularly in Hispanic boys, with a
pattern of fibrosis and inflammation that is predomi-
nantly portal based, rather than Zone 3.100,101 Treat-
ment (see below) should involve dietary and lifestyle
interventions, which can be difficult to achieve.
Diagnosis
Clinical manifestations
Liver steatosis is often incidentally detected on imaging
of the liver and is greatly overlooked by most physi-
cians. Most patients present for care of associated
conditions, such as obesity, diabetes mellitus, or dysli-
pidemia, and are mostly asymptomatic from the liver
perspective. It is not until they develop abnormal liver
enzymes and ⁄ or liver-related complications that the
diagnosis is brought to attention and a systematic
work-up is initiated. In fact, evaluation for fatty liver
is often precipitated by abnormal liver enzymes
detected on routine evaluation or prior to initiating
therapy with any potentially hepatotoxic medication.
Symptoms and signs associated with NAFLD
include fatigue, right upper quadrant pain, hepatomeg-
aly, acanthosis nigricans, and lipomatosis. Cirrhotic
patients may present with any manifestations of end-
stage liver disease.
The diagnosis is confirmed by findings on liver
biopsy in the absence of other forms of CLD and the
exclusion of daily alcohol consumption >30 g in men
and >20 g in women.
Non-alcoholic fatty liver disease may be separated
into two types. The primary type of NAFLD is associ-
ated with features of metabolic syndrome and is thought
to be secondary to IR, whereas the secondary type of
NAFLD can result from conditions that lead to steato-
sis, such as infections (hepatitis C genotype 3, HIV),
medications and toxins, or acquired and inherited meta-
bolic derangements (lipodystrophy, total parenteral
nutrition, cachexia, intestinal bypass surgery). The medi-
cations and toxins that have been associated with liver
steatosis include glucocorticoids, tamoxifen, tetracycline,
amiodarone, methotrexate, valproic acid, vinyl chloride,
anabolic steroids, and estrogens at doses higher than
used for hormone-replacement therapy.102–104
Laboratory abnormalities
In patients with NAFLD, elevations of alanine amino-
transferase (ALT) are more common than elevations of
aspartate aminotransferase (AST). The ALT levels tend
ª 2012 Ruijin Hospital, Shanghai Jiaotong University School of Medicine and Wiley Publishing Asia Pty Ltd
Non-alcoholic fatty liver disease
to be higher in NASH than in simple steatosis. However,
liver enzymes as a diagnostic modality have poor sensitiv-
ity (0.3–0.63) and specificity (0.38–0.63) compared with
ultrasonography105 or liver biopsy.106,107 In population-
based cohorts, ALT levels were within normal limits in as
many as 80% of patients with NAFLD.2
Imaging
Several modalities have been used to diagnose NAFLD
non-invasively with variable sensitivity and specificity,
including ultrasonography, computed tomography (CT),
magnetic resonance imaging (MRI), and MRS.
Although useful for the diagnostic evaluation of a patient
with suspected NAFLD, they are of limited use because
of their inability to differentiate simple steatosis from
NASH or to determine the presence and stage of fibrosis.
This poses a diagnostic challenge, because NASH and
fibrosis are of greater concern given the risk of progres-
sion to cirrhosis and its related complications.
Ultrasound is the most readily available imaging
modality for the diagnosis of fatty liver. Ultrasound
findings of NAFLD include hepatomegaly, diffuse
increased echogenicity of the liver parenchyma, blur-
ring of intrahepatic vessels, and loss of echoes of the
posterior hepatic segments. A review of studies com-
paring the role of ultrasound in diagnosing histologi-
cally proven NAFLD reported an overall sensitivity
and specificity for the detection of moderate to severe
steatosis (‡20–30% steatosis) of 84% and 93%, respec-
tively, with an accuracy of 0.93.108 Ultrasound sensitiv-
ity varies considerably with liver fat content and to
technical limitations in morbidly obese patients.
In a recent meta-analysis of the performance of differ-
ent imaging modalities in diagnosing biopsy-proven NA-
FLD, CT was equivalent if not inferior to ultrasound.109
In addition, CT carries the disadvantage of radiation
exposure. Magnetic resonance imaging and MRS per-
form better than ultrasound or CT, particularly in detect-
ing lower degrees of steatosis. However, they are costly
and not widely available. Furthermore, MRS offers the
advantage of providing a safe and quantitative assess-
ment of hepatic triglyceride content by directly measur-
ing protons in acyl groups of liver tissue triglycerides.110
Transient elastography, an emerging technique that mea-
sures liver stiffness, has been used for the non-invasive
assessment of hepatic fibrosis. The use of this technique
in the NAFLD population has been limited by its lower
reliability in the presence of severe steatosis and the
reduced performance of the standard M probe in obese
patients.111 More recently, improved diagnostic accuracy
has been achieved with the Fibroscan XL (Echosens,
Paris, France) probe.112,113
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Non-alcoholic fatty liver disease
Liver biopsy
A liver biopsy remains the gold standard for the diag-
nosis of NASH and for fibrosis staging. Establishing a
definitive diagnosis of NASH is important for identify-
ing individuals at risk of progression to advanced
fibrosis and cirrhosis.
However, there are limitations associated with the use
of liver biopsies. First, a biopsy represents 1 ⁄ 50 000–
1 ⁄ 65 000 of the liver and is subject to sampling errors.114
Studies on paired liver biopsies in patients with NAFLD
demonstrate substantial discordance for most histologi-
cal features, highlighting the uneven distribution of the
disease.115,116 This is also true for surgical biopsies of the
left and right lobes of the liver.117 Liver biopsies are sub-
ject to intra- and inter-observer variability in the grading
of steatosis (j statistics of 0.74–0.98), fibrosis staging
(0.68–0.85), and NASH diagnosis (0.66–0.90).115,117
Complications include pain, bleeding, transient bactere-
mia, bile peritonitis, and perforation, as well as a
1:10 000–12 000 mortality risk.118
Given the expense, inconvenience, limitations, and
risks associated with a liver biopsy, it is unsuitable for the
screening of the general population for such a prevalent
condition. In the absence of practice guidelines, the deci-
sion to proceed to a liver biopsy is left to the discretion of
the physician in individual cases. A recent position state-
ment from the European Association for the Study of the
Liver (EASL) recommended that a routine liver biopsy
be performed in high-risk patients undergoing antiobesi-
ty surgery and cholecystectomy.119
Histological findings
Liver steatosis is defined by the accumulation of fat in
the liver exceeding 5–10% of its weight or by the pres-
ence of cytoplasmic triglyceride droplets in >5% of
hepatocytes.3,114 Steatosis in NAFLD is macrovesicu-
lar and starts at acinar Zone 3 (perivenular), but mixed
or even microvesicular steatosis may be present as well.
Steatosis can be graded on the basis of the extent of
the involvement of the hepatocytes as follows: mild, 0–
33%; moderate, 33–66%; and severe, >66%.120,121
Because fibrosis in NASH progresses to cirrhosis, stea-
tosis may not be readily identifiables, thus accounting
for cases of cryptogenic cirrhosis.122,123
Since the description of NASH by Ludwig et al.,124
the histological criteria for diagnosis have evolved with
the intent to standardize the findings. Non-alcoholic
steatohepatitis is characterized by the presence of mac-
rosteatosis, ballooning degeneration of hepatocytes,
and lobular inflammation, typically in Zone 3. Fibrosis
is not required for the diagnosis but usually starts in
270 ª 2012 Ruijin Hospital, Shanghai Jiaotong University School of Medicine and Wiley Publishing Asia Pty Ltd
A.C. TUYAMA and C.Y. CHANG
acinar Zone 3 and has a perisinusoidal or ‘‘chicken
wire’’ pattern. In 1999, Brunt et al.120 proposed a sys-
tem to assess the global necroinflammatory activity
(grading) and extent of fibrosis (staging) to standardize
the histological features and develop a scoring system
for NASH. More recently, the National Institute of
Diabetes and Digestive and Kidney Diseases (NID-
DK)-sponsored NASH-CRN developed and validated
the NASH activity score (NAS)121 with the aim of
standardizing the features of the full spectrum of NA-
FLD in order to quantify and define histologic end-
points for therapeutic intervention trials. The NAS is
based on the sum of individual scores for steatosis,
lobular inflammation, and hepatocellular ballooning.
The validity of NAS in diagnosing NASH was recently
evaluated in a study by Brunt et al.,125 who concluded
that, although closely related, NAS ‡5 cannot be used
reliably to establish a diagnosis of NASH.
Scoring systems ⁄ non-invasive biomarkers
In an attempt to overcome the limitations of current
diagnostic modalities, which are unable to differentiate
NAFLD from NASH and cannot determine the extent of
fibrosis and the risk of progression, as well as to address
the need for a reliable test that can be used in both patient
care and research, several scoring systems and non-inva-
sive biomarkers have emerged (for reviews, see Adams
and Feldstein126 and Wieckowska and Feldstein127). The
biomarkers are based on the current understanding of
the pathophysiology of NAFLD and include markers of
apoptosis (cytokeratin-18), collagen breakdown (serum
prolidase enzyme activity), oxidative stress and lipid per-
oxidation, cytokines (tumor necrosis factor [TNF]-a,
interleukin [IL]-6), and adipokines (adiponectin). How-
ever, none has been sufficiently validated and incorpo-
rated into clinical practice and their usefulness remains to
be determined.
Pathogenesis
The liver plays a central role in the regulation of metabo-
lism. Excessive accumulation of intrahepatic triglyce-
rides, the hallmark of NAFLD, has been associated with
changes in glucose, fatty acid, and lipoprotein metabo-
lism, as well as inflammation. Given the many vital activ-
ities performed by the liver, additional metabolic and
hormonal functions are likely affected.
Hepatic steatosis results from an imbalance between
free fatty acid (FFA) uptake and synthesis (input) and
fatty acid oxidation and triglyceride (TG) secretion
into very-LDL (output). The presence of a net positive
energy balance leads to the accumulation of fat in the
A.C. TUYAMA and C.Y. CHANG
form of TG and lipid droplets within hepatocytes.
Hepatic TG arise from three sources: (i) dietary fats
(packaged into TG-rich chylomicrons); (ii) de novo
lipogenesis (DNL), regulated by several nuclear
transcription factors, such as sterol regulatory element-
binding protein-1c,128 carbohydrate regulatory ele-
ment-binding protein, liver X receptor a, farsenoid X
receptor, and peroxisome proliferator-activated recep-
tors;129 and (iii) peripheral adipose tissue lipolysis.
Both IR and obesity are associated with increased
delivery of FFA to the liver because of increased
peripheral lipolysis in the former and increased adipo-
cyte mass in the latter.130 The rate of hepatic FFA
uptake appears to be unregulated and proportional to
plasma FFA concentrations.131 The contribution of
each step to the hepatocyte TG pool can be broken
down to the majority of FFA originating from lipoly-
sis of peripheral adipose tissue132 as opposed to dietary
sources,133 visceral adipose tissue lipolysis,134 or
DNL.135 The fate of FFA taken up by hepatocytes is
one of three: (i) oxidation in the mitochondria to gen-
erate ATP; (ii) re-esterified to TG and stored in lipid
droplets; or (iii) re-esterified into TG, packaged, and
secreted as VLDL.
In NAFLD, abnormalities in both fatty acid uptake
and lipogenesis have been reported, with increased
peripheral lipolysis, higher post-prandial lipemia and
FFA concentrations, and increased expression of genes
involved in DNL.3,136,137 Interestingly, rates of fatty
acid oxidation138,139 and VLDL secretion140,141 appear
to be increased in these patients.142 However, the
excess VLDL export is not adequate to compensate
for the excess TG input and the net result is steatosis.
In fact, a study by Fabbrini et al.141 showed that the
increase in hepatic VLDL secretion reaches a plateau
level, beyond which rises in intrahepatic TG will not
result in enhanced TG export through VLDL. It is
unclear at which step the hepatocytes lose the ability
to further enhance lipoprotein secretion.
Steatosis is a compensatory, adaptive mechanism that
is clinically silent. However, it affects cellular and molec-
ular functions that sensitize the liver to any additional
insults. Once the balance is tipped over, the result is a
complex and poorly understood interaction between he-
patocytes, hepatic stellate cells, and leukocytes within the
liver that leads to NASH and the development of apopto-
sis, inflammation, and liver fibrosis. What leads to the
progression to NASH has not been completely defined.
Systemic inflammation (increases in TNF-a and IL-6 and
decreases in adiponectin), oxidative and endoplasmic
reticulum stress, and mitochondrial dysfunction clearly
play an integral role in disease pathogenesis.136,143 The
question remains as to which factors trigger these com-
ª 2012 Ruijin Hospital, Shanghai Jiaotong University School of Medicine and Wiley Publishing Asia Pty Ltd
Non-alcoholic fatty liver disease
• Obesity
• Insulin resistance
• Genetic predisposition
• Peripheral lipolysis
• Dietary fat
• De novo lipogenesis
Steatosis • Lipotoxicity
• Oxidative stress, ER stress
• Inflammation (IL-6, TNF-α)
• Hyperinsulinemia, hyperglycemia
• Gut microbiota
NASH
Figure 1 The Liver plays a central role in the regulation of metab-
olism. Obesity, insulin resistance (IR), and genetic factors set the
stage, leading to triglyceride accumulation in hepatocytes as a
result of increased fatty acid delivery from both dietary sources and
peripheral lipolysis. Hyperinsulinemia leads to increased de novo
lipogenesis, despite the presence of IR. Once steatosis develops,
the liver is susceptible to further insults, such as lipotoxicity, inflam-
mation, oxidative and endoplasmic reticulum (ER) stress, which
result in cell injury and the development of non-alcoholic steatohep-
atitis (NASH). IL-6, interleukin 6; TNF-a, tumur necrosis factor-a.
mon pathways. The type of lipids accumulated plays an
important role in lipotoxicity. Accumulation of TG per se
does not appear to be harmful; however, excess free fatty
acids144,145 and cholesterol146–148 can result in hepatocyte
injury. Insulin resistance, reflected by hyperinsulinemia
and hyperglycemia, clearly affects lipid metabolism,142 in
addition to promoting further inflammation and fibro-
sis.149 More recently, the gut microbiota has been impli-
cated in both the pathogenesis of NAFLD and the
progression to NASH through metabolic derangements
and proinflammatory effects (Figure 1).150
Genetics of NAFLD
Family and interethnic studies have provided evidence
for a genetic component in NAFLD. Case series of
index patients with biopsy-proven NASH, NASH cir-
rhosis, and cryptogenic cirrhosis (CC) have demon-
strated the coexistence of varied forms of NAFLD
among kindreds.151,152 Siblings and parents of over-
weight children with biopsy-proven NAFLD are more
likely to have elevated liver fat fraction on MRI and
abnormal liver enzymes than relatives of overweight
children without NAFLD, resulting in an estimated
271
Non-alcoholic fatty liver disease
heritability for NAFLD of 39%.153 Twin studies have
also indicated a heritability trait for liver fat content,
serum ALT, and fasting insulin levels.154 However, the
observed familial clustering of NAFLD could result
from common environmental exposure or heritability
of conditions associated with NAFLD, such as obesity
and diabetes. A study by Browning et al.2 demon-
strated differences in susceptibility to NAFLD diag-
nosed by MRS among Americans of diverse ethnic
backgrounds despite similar rates of obesity, diabetes
mellitus and insulin resistance. Hispanics had the high-
est rates of hepatic steatosis compared with Caucasians
and African Americans.
Genome-wide association studies
Genome-wide association studies (GWAS) have led to
the identification of several variants associated with
NAFLD.3,155 The variant that most strongly correlates
with hepatic fat content was identified in a genome-
wide survey of 9229 non-synonymous sequence varia-
tions of individuals of various ancestries from the
Dallas Heart Study.156 The single variant (rs738409)
results in a missense mutation (Ile148 fi Met148;
I148M) in the patatin-like phospholipase domain-con-
taining 3 (PNPLA3) gene that encodes for adiponu-
trin. The association with hepatic fat content was
independent of BMI, diabetes mellitus, and ethanol
use. The variant allele was more frequently identified
in Hispanics (0.49), followed by European Americans
(0.23) and African Americans (0.17). In addition to
this loss of function mutation, another allele was iden-
tified (rs6006460) that was correlated with lower hepa-
tic fat content and was more frequently observed in
African Americans.156 In that study, these two alleles
could explain 72% of the ethnic differences in the fre-
quency of hepatic steatosis.156 Currently, the physio-
logical role of PNPLA3 and the mechanism leading to
steatosis are the subject of intense investigation.
Gene and microRNA profiling
The advent of microarrays has enabled the relative
expression of a broad range of genes to be analyzed in
RNA samples from human tissues. The characteriza-
tion of gene expression patterns associated with a spe-
cific disease state can help elucidate genes and
pathways that may contribute to disease pathogenesis.
Studies from patients undergoing liver biopsies have
compared the global liver gene expression in simple
steatosis, NASH, cirrhosis and ‘‘normal’’ livers. They
have reported differential expression of genes involved
in lipid metabolism, mitochondrial function, oxidative
272 ª 2012 Ruijin Hospital, Shanghai Jiaotong University School of Medicine and Wiley Publishing Asia Pty Ltd
A.C. TUYAMA and C.Y. CHANG
stress, insulin signaling, cell death, and hepatic fibro-
sis.157–162 One study evaluated microRNA expression
in NASH compared with normal controls and identi-
fied microRNAs that target genes regulating lipid
metabolism, cell growth and differentiation, apoptosis,
and inflammation.163 Despite pointing to pathways
that are known to be altered in NASH, there was little
concordance among the genes identified. This can be
attributed, in part, to variations in sample size, differ-
ent group comparisons, patient populations studied,
and microarray platforms used with variable numbers
of interrogated transcripts. Furthermore, these samples
represent the expression pattern of hepatocytes, which
are overrepresented among RNA species collected
from a liver biopsy. Because non-parenchymal cells,
such as hepatic stellate cells, Kupffer cells, endothelial
cells, and leukocytes, represent <30% of the total
liver, differences in gene expression in each specific
population were probably not detected given the sensi-
tivity of the assay. A separate analysis among specific
cell populations within the liver will provide greater
insight into the cross-talk among cells at different
stages of NAFLD.
Natural history and prognosis
The natural history of NAFLD has been explored in
cross-sectional studies, case series of patients with
paired liver biopsies, and longitudinal cohorts from
both tertiary and community-based centers. However,
the studies are limited by referral and selection biases,
heterogeneity in the definition of NAFLD, populations
studied, interval between biopsies, and duration of fol-
low up. Nonetheless, a few conclusions can be extrapo-
lated. Patients with NAFLD have increased overall
mortality from both cardiovascular and cancer-related
deaths. Of note, NAFLD patients have increased liver-
related mortality, which is the third leading cause of
death among these patients in contrast with the general
population, where liver disease represents the 12th
leading cause of death.24,25,79,164
Progression of NAFLD may be predicted by the
severity of the histological findings at the initial
biopsy, with the presence of inflammation on a
baseline biopsy increasing the likelihood of the
development of advanced fibrosis by 2.5-fold.79,165
Fibrosis progression is observed in 32–41% of
patients.25,79,166,167
Although patients with simple steatosis have a more
benign course and comparable mortality rates as the
general population,168,169 patients with NASH can
develop the entire spectrum of complications asso-
ciated with CLDs: progressive fibrosis, cirrhosis,
A.C. TUYAMA and C.Y. CHANG
end-stage liver disease (ESLD), and HCC. Approxi-
mately 10% of individuals with NASH are likely to
progress to cirrhosis over the course of 10 years. A
recent multi-center international prospective study
assessed the outcome of patients with biopsy-proven
NAFLD with advanced fibrosis or cirrhosis compared
with patients with chronic hepatitis C virus (HCV) at
equivalent disease stages.170 That study showed that
well-compensated NAFLD is associated with lower
rates of liver-related complications, but similar mortal-
ity rates. Prior case-control studies had reported lower
rates of decompensation and mortality in advanced
NASH compared with chronic HCV.171,172 Although
the incidence of HCC is also probably lower in
NAFLD patients compared with those with HCV,173
patients with NASH and cirrhosis are clearly at risk of
developing HCC and warrant imaging at regular inter-
vals for HCC screening. More recently, cases of HCC
have been reported in patients with NAFLD without
advanced fibrosis or cirrhosis.174 Although the rela-
tionship and mechanisms associating simple steatosis
and NASH to HCC have not been clearly defined,
these reports raise great concern owing to the high and
rising prevalence of NAFLD.
Treatment
In light of the current understanding of associated risk
factors and pathophysiology of NAFLD, several treat-
ment modalities have been investigated with variable
success rates.175–177 Therapies targeting medical or sur-
gical weight loss in the overweight population have
reported significant improvement in metabolic parame-
ters, steatosis, NASH and fibrosis.178 Studies suggest
that a reduction in body weight of 5% and >7%
results in improvements in steatosis179 and NAS,180,181
respectively. Despite the central role of IR in the path-
ogenesis of NAFLD, insulin sensitizers have only pro-
vided marginal benefit. Studies have demonstrated that
pioglitazone improves all histological findings.182–184
However, the widespread use of thiazolidinediones is
not justifiable given the undefined length of therapy,
associated weight gain, and relapse following discon-
tinuation of treatment.185,186 Other therapies, such as
lipid-lowering agents, pentoxifylline, and l-carnitine,
have been shown to result in some benefit, however
adequate data to support firm recommendation on
their use are lacking.175 The role of antioxidants such
as vitamin E has been demonstrated by the Pioglitaz-
one versus Vitamin E versus Placebo for the Treatment
of Nondiabetic Patients with Nonalcoholic Steatohepa-
titis (PIVENS) trial,184 which compared 800 IU ⁄ day
vitamin E with 30 mg ⁄ day pioglitazone. The primary
ª 2012 Ruijin Hospital, Shanghai Jiaotong University School of Medicine and Wiley Publishing Asia Pty Ltd
Non-alcoholic fatty liver disease
endpoint of an improvement in histological features of
NASH was achieved in the vitamin E arm (43% vs
19% on placebo), but not for pioglitazone (34% vs
19% on placebo). The findings were independent of
changes in insulin sensitivity or weight loss. The trial
concluded that vitamin E was superior to placebo for
the treatment of non-diabetics with NASH. However,
other studies with anti-oxidants have reported inconsis-
tent results167,179,187 and the long-term use of high
doses of vitamin E has been associated with increased
mortality.188 There is currently no approved pharma-
cological therapy for NAFLD and ⁄ or NASH.
Conclusion
Non-alcoholic fatty liver disease is the most common
CLD in the Western world and is closely associated with
the alarming diabetes and obesity epidemics. The preva-
lence of NAFLD, NASH, and NASH-related cirrhosis
has risen steadily over recent decades. Despite intense
research, the pathogenesis of NAFLD has not been
clearly defined and there is little understanding of what
leads to disease progression in a subset of patients. Of
concern are the silent clinical presentation and the lack of
a non-invasive diagnostic test to identify and stage these
patients. Furthermore, given the marginal success of
medical therapy, and associated cardiovascular comor-
bidities that often exclude patients for transplant listing,
it is crucial to identify patients early in the course of the
disease in order to optimize treatment of underlying com-
orbidities and slow disease progression. Increased aware-
ness among physicians caring for patients at risk of
NAFLD may help in the diagnosis and management of
these patients in a multidiscliplinary manner.
References
1. Minino AM. Death in the United States, 2009. NCHS
Data Brief. 2011; 64: 1–8.
2. Browning JD, Szczepaniak LS, Dobbins R et al. Prev-
alence of hepatic steatosis in an urban population in
the United States: Impact of ethnicity. Hepatology.
2004; 40: 1387–95.
3. Cohen JC, Horton JD, Hobbs HH. Human fatty liver
disease: Old questions and new insights. Science. 2011;
332: 1519–23.
4. Angulo P. Nonalcoholic fatty liver disease and liver
transplantation. Liver Transpl. 2006; 12: 523–34.
5. Vernon G, Baranova A, Younossi ZM. Systematic
review: The epidemiology and natural history of non-
alcoholic fatty liver disease and non-alcoholic steato-
hepatitis in adults. Aliment Pharmacol Ther. 2011; 34:
274–85.
273
Non-alcoholic fatty liver disease
6. Younossi ZM, Stepanova M, Afendy M et al. Changes
in the prevalence of the most common causes of
chronic liver diseases in the United States from 1988
to 2008. Clin Gastroenterol Hepatol. 2011; 9: 524–30.
7. Minervini MI, Ruppert K, Fontes P et al. Liver biopsy
findings from healthy potential living liver donors:
Reasons for disqualification, silent diseases and corre-
lation with liver injury tests. J Hepatol. 2009; 50: 501–
10.
8. Lee JY, Kim KM, Lee SG et al. Prevalence and risk
factors of non-alcoholic fatty liver disease in potential
living liver donors in Korea: A review of 589 consecu-
tive liver biopsies in a single center. J Hepatol. 2007;
47: 239–44.
9. Tran TT, Changsri C, Shackleton CR et al. Living
donor liver transplantation: Histological abnormalities
found on liver biopsies of apparently healthy potential
donors. J Gastroenterol Hepatol. 2006; 21: 381–3.
10. Ryan CK, Johnson LA, Germin BI, Marcos A. One
hundred consecutive hepatic biopsies in the workup of
living donors for right lobe liver transplantation. Liver
Transpl. 2002; 8: 1114–22.
11. Nadalin S, Malago M, Valentin-Gamazo C et al. Pre-
operative donor liver biopsy for adult living donor
liver transplantation: Risks and benefits. Liver Transpl.
2005; 11: 980–6.
12. Wanless IR, Lentz JS. Fatty liver hepatitis (steatohep-
atitis) and obesity: An autopsy study with analysis of
risk factors. Hepatology. 1990; 12: 1106–10.
13. Ground KE. Liver pathology in aircrew. Aviat Space
Environ Med. 1982; 53: 14–8.
14. Amarapurkar A, Ghansar T. Fatty liver: Experience
from western India. Ann Hepatol. 2007; 6: 37–40.
15. Caballeria L, Pera G, Auladell MA et al. Prevalence
and factors associated with the presence of nonalco-
holic fatty liver disease in an adult population in
Spain. Eur J Gastroenterol Hepatol. 2010; 22: 24–32.
16. Bedogni G, Miglioli L, Masutti F, Tiribelli C, Marche-
sini G, Bellentani S. Prevalence of and risk factors for
nonalcoholic fatty liver disease: The Dionysos nutri-
tion and liver study. Hepatology. 2005; 42: 44–52.
17. Amarapurkar D, Kamani P, Patel N et al. Prevalence
of non-alcoholic fatty liver disease: Population based
study. Ann Hepatol. 2007; 6: 161–3.
18. Kojima S, Watanabe N, Numata M, Ogawa T, Matsu-
zaki S. Increase in the prevalence of fatty liver in
Japan over the past 12 years: Analysis of clinical back-
ground. J Gastroenterol. 2003; 38: 954–61.
19. Szczepaniak LS, Nurenberg P, Leonard D et al. Mag-
netic resonance spectroscopy to measure hepatic tri-
glyceride content: Prevalence of hepatic steatosis in the
general population. Am J Physiol Endocrinol Metab.
2005; 288: E462–8.
20. Brunt EM, Kleiner DE, Wilson LA, Belt P, Neusch-
wander-Tetri BA. Nonalcoholic fatty liver disease
274 ª 2012 Ruijin Hospital, Shanghai Jiaotong University School of Medicine and Wiley Publishing Asia Pty Ltd
A.C. TUYAMA and C.Y. CHANG
(NAFLD) activity score and the histopathologic
diagnosis in NAFLD: Distinct clinicopathologic mean-
ings. Hepatology. 2011; 53: 810–20.
21. Argo CK, Caldwell SH. Epidemiology and natural his-
tory of non-alcoholic steatohepatitis. Clin Liver Dis.
2009; 13: 511–31.
22. Williams CD, Stengel J, Asike MI et al. Prevalence of
nonalcoholic fatty liver disease and nonalcoholic ste-
atohepatitis among a largely middle-aged population
utilizing ultrasound and liver biopsy: A prospective
study. Gastroenterology. 2011; 140: 124–31.
23. Ruhl CE, Everhart JE. Determinants of the association
of overweight with elevated serum alanine aminotrans-
ferase activity in the United States. Gastroenterology.
2003; 124: 71–9.
24. Ong JP, Pitts A, Younossi ZM. Increased overall mor-
tality and liver-related mortality in non-alcoholic fatty
liver disease. J Hepatol. 2008; 49: 608–12.
25. Adams LA, Lymp JF, St Sauver J et al. The natural his-
tory of nonalcoholic fatty liver disease: A population-
based cohort study. Gastroenterology. 2005; 129: 113–21.
26. Lonardo A, Lombardini S, Scaglioni F et al. Fatty liver,
carotid disease and gallstones: A study of age-related
associations. World J Gastroenterol. 2006; 12: 5826–33.
27. Frith J, Day CP, Henderson E, Burt AD, Newton JL.
Non-alcoholic fatty liver disease in older people. Ger-
ontology. 2009; 55: 607–13.
28. Kallwitz ER, Kumar M, Aggarwal R et al. Ethnicity
and nonalcoholic fatty liver disease in an obesity
clinic: The impact of triglycerides. Dig Dis Sci. 2008;
53: 1358–63.
29. Solga SF, Clark JM, Alkhuraishi AR et al. Race and
comorbid factors predict nonalcoholic fatty liver dis-
ease histopathology in severely obese patients. Surg
Obes Relat Dis. 2005; 1: 6–11.
30. Petersen KF, Dufour S, Feng J et al. Increased preva-
lence of insulin resistance and nonalcoholic fatty liver
disease in Asian-Indian men. Proc Natl Acad Sci U S A.
2006; 103: 18273–7.
31. Chitturi S, Farrell GC, Hashimoto E, Saibara T, Lau
GK, Sollano JD. Non-alcoholic fatty liver disease in
the Asia–Pacific region: Definitions and overview of
proposed guidelines. J Gastroenterol Hepatol. 2007; 22:
778–87.
32. Third Report of the National Cholesterol Education
Program (NCEP) Expert Panel on Detection, Evalua-
tion, and Treatment of High Blood Cholesterol in
Adults (Adult Treatment Panel III) final report. Circu-
lation. 2002; 106: 3143–421.
33. Kang H, Greenson JK, Omo JT et al. Metabolic syn-
drome is associated with greater histologic severity,
higher carbohydrate, and lower fat diet in patients
with NAFLD. Am J Gastroenterol. 2006; 101: 2247–53.
34. Ryan MC, Wilson AM, Slavin J, Best JD, Jenkins AJ,
Desmond PV. Associations between liver histology and
A.C. TUYAMA and C.Y. CHANG
severity of the metabolic syndrome in subjects with
nonalcoholic fatty liver disease. Diabetes Care. 2005;
28: 1222–4.
35. Marchesini G, Bugianesi E, Forlani G et al. Nonalco-
holic fatty liver, steatohepatitis, and the metabolic syn-
drome. Hepatology. 2003; 37: 917–23.
36. Adams LA, Waters OR, Knuiman MW, Elliott RR, Oly-
nyk JK. NAFLD as a risk factor for the development of
diabetes and the metabolic syndrome: An eleven-year
follow-up study. Am J Gastroenterol. 2009; 104: 861–7.
37. Helling TS, Helzberg JH, Nachnani JS, Gurram K.
Predictors of nonalcoholic steatohepatitis in patients
undergoing bariatric surgery: When is liver biopsy
indicated? Surg Obes Relat Dis. 2008; 4: 612–7.
38. Ratziu V, Giral P, Charlotte F et al. Liver fibrosis in
overweight patients. Gastroenterology. 2000; 118: 1117–
23.
39. Dixon JB, Bhathal PS, O’Brien PE. Nonalcoholic fatty
liver disease: Predictors of nonalcoholic steatohepatitis
and liver fibrosis in the severely obese. Gastroenterol-
ogy. 2001; 121: 91–100.
40. Abrams GA, Kunde SS, Lazenby AJ, Clements RH.
Portal fibrosis and hepatic steatosis in morbidly obese
subjects: A spectrum of nonalcoholic fatty liver dis-
ease. Hepatology. 2004; 40: 475–83.
41. Ong JP, Elariny H, Collantes R et al. Predictors of
nonalcoholic steatohepatitis and advanced fibrosis in
morbidly obese patients. Obes Surg. 2005; 15: 310–5.
42. Gholam PM, Flancbaum L, Machan JT, Charney DA,
Kotler DP. Nonalcoholic fatty liver disease in severely
obese subjects. Am J Gastroenterol. 2007; 102: 399–408.
43. Marceau P, Biron S, Hould FS et al. Liver pathology
and the metabolic syndrome X in severe obesity.
J Clin Endocrinol Metab. 1999; 84: 1513–7.
44. Angulo P, Keach JC, Batts KP, Lindor KD. Indepen-
dent predictors of liver fibrosis in patients with nonal-
coholic steatohepatitis. Hepatology. 1999; 30: 1356–62.
45. Palekar NA, Naus R, Larson SP, Ward J, Harrison
SA. Clinical model for distinguishing nonalcoholic
steatohepatitis from simple steatosis in patients with
nonalcoholic fatty liver disease. Liver Int. 2006; 26:
151–6.
46. Park KS, Lee YS, Park HW et al. Factors associated or
related to with pathological severity of nonalcoholic fatty
liver disease. Korean J Intern Med. 2004; 19: 19–26.
47. Chavez-Tapia NC, Tellez-Avila FI, Barrientos-Gut-
ierrez T, Mendez-Sanchez N, Lizardi-Cervera J, Uribe
M. Bariatric surgery for non-alcoholic steatohepatitis
in obese patients. Cochrane Database Syst Rev. 2010;
1: CD007340.
48. Ranlov I, Hardt F. Regression of liver steatosis
following gastroplasty or gastric bypass for morbid
obesity. Digestion. 1990; 47: 208–14.
49. Dixon JB, Bhathal PS, Hughes NR, O’Brien PE.
Nonalcoholic fatty liver disease: Improvement in liver
ª 2012 Ruijin Hospital, Shanghai Jiaotong University School of Medicine and Wiley Publishing Asia Pty Ltd
Non-alcoholic fatty liver disease
histological analysis with weight loss. Hepatology.
2004; 39: 1647–54.
50. Clark JM, Alkhuraishi AR, Solga SF, Alli P, Diehl
AM, Magnuson TH. Roux-en-Y gastric bypass
improves liver histology in patients with non-alcoholic
fatty liver disease. Obes Res. 2005; 13: 1180–6.
51. Mattar SG, Velcu LM, Rabinovitz M et al. Surgically-
induced weight loss significantly improves nonalcoholic
fatty liver disease and the metabolic syndrome. Ann
Surg. 2005; 242: 610–7.
52. Mottin CC, Moretto M, Padoin AV et al. Histological
behavior of hepatic steatosis in morbidly obese
patients after weight loss induced by bariatric surgery.
Obes Surg. 2005; 15: 788–93.
53. Barker KB, Palekar NA, Bowers SP, Goldberg JE,
Pulcini JP, Harrison SA. Non-alcoholic steatohepatitis:
Effect of Roux-en-Y gastric bypass surgery. Am J Gas-
troenterol. 2006; 101: 368–73.
54. de Almeida SR, Rocha PR, Sanches MD et al.
Roux-en-Y gastric bypass improves the nonalcoholic
steatohepatitis (NASH) of morbid obesity. Obes Surg.
2006; 16: 270–8.
55. Dixon JB, Bhathal PS, O’Brien PE. Weight loss and
non-alcoholic fatty liver disease: Falls in c-glutamyl
transferase concentrations are associated with
histologic improvement. Obes Surg. 2006; 16: 1278–
86.
56. Klein S, Mittendorfer B, Eagon JC et al. Gastric
bypass surgery improves metabolic and hepatic abnor-
malities associated with nonalcoholic fatty liver disease.
Gastroenterology. 2006; 130: 1564–72.
57. Furuya CK Jr, de Oliveira CP, de Mello ES et al.
Effects of bariatric surgery on nonalcoholic fatty liver
disease: Preliminary findings after 2 years. J Gastroen-
terol Hepatol. 2007; 22: 510–4.
58. Kelley DE, McKolanis TM, Hegazi RA, Kuller LH,
Kalhan SC. Fatty liver in type 2 diabetes mellitus:
Relation to regional adiposity, fatty acids, and insulin
resistance. Am J Physiol Endocrinol Metab. 2003; 285:
E906–16.
59. Park SH, Kim BI, Kim SH et al. Body fat distribution
and insulin resistance: Beyond obesity in nonalcoholic
fatty liver disease among overweight men. J Am Coll
Nutr. 2007; 26: 321–6.
60. Rocha R, Cotrim HP, Carvalho FM, Siqueira AC,
Braga H, Freitas LA. Body mass index and waist cir-
cumference in non-alcoholic fatty liver disease. J Hum
Nutr Diet. 2005; 18: 365–70.
61. Ioannou GN, Weiss NS, Boyko EJ et al. Is central
obesity associated with cirrhosis-related death or hos-
pitalization? A population-based, cohort study Clin
Gastroenterol Hepatol. 2005; 3: 67–74.
62. van der Poorten D, Milner KL, Hui J et al. Visceral
fat: A key mediator of steatohepatitis in metabolic
liver disease. Hepatology. 2008; 48: 449–57.
275
Non-alcoholic fatty liver disease
63. Cheung O, Kapoor A, Puri P et al. The impact of fat
distribution on the severity of nonalcoholic fatty liver
disease and metabolic syndrome. Hepatology. 2007; 46:
1091–100.
64. Bugianesi E, Manzini P, D’Antico S et al. Relative
contribution of iron burden, HFE mutations, and
insulin resistance to fibrosis in nonalcoholic fatty liver.
Hepatology. 2004; 39: 179–87.
65. Bugianesi E, Moscatiello S, Ciaravella MF, Marchesini
G. Insulin resistance in nonalcoholic fatty liver disease.
Curr Pharm Des. 2010; 16: 1941–51.
66. Seppala-Lindroos A, Vehkavaara S, Hakkinen AM
et al. Fat accumulation in the liver is associated with
defects in insulin suppression of glucose production
and serum free fatty acids independent of obesity
in normal men. J Clin Endocrinol Metab. 2002; 87:
3023–8.
67. Korenblat KM, Fabbrini E, Mohammed BS, Klein S.
Liver, muscle, and adipose tissue insulin action is
directly related to intrahepatic triglyceride content in
obese subjects. Gastroenterology. 2008; 134: 1369–75.
68. Gastaldelli A, Cusi K, Pettiti M et al. Relationship
between hepatic ⁄ visceral fat and hepatic insulin resis-
tance in nondiabetic and type 2 diabetic subjects.
Gastroenterology. 2007; 133: 496–506.
69. Jimba S, Nakagami T, Takahashi M et al. Prevalence
of non-alcoholic fatty liver disease and its association
with impaired glucose metabolism in Japanese adults.
Diabet Med. 2005; 22: 1141–5.
70. Targher G, Bertolini L, Rodella S et al. Nonalcoholic
fatty liver disease is independently associated with an
increased incidence of cardiovascular events in type 2
diabetic patients. Diabetes Care. 2007; 30: 2119–21.
71. Leite NC, Salles GF, Araujo AL, Villela-Nogueira
CA, Cardoso CR. Prevalence and associated factors of
non-alcoholic fatty liver disease in patients with type-2
diabetes mellitus. Liver Int. 2009; 29: 113–9.
72. Younossi ZM, Gramlich T, Matteoni CA, Boparai N,
McCullough AJ. Nonalcoholic fatty liver disease in
patients with type 2 diabetes. Clin Gastroenterol Hepatol.
2004; 2: 262–5.
73. Trombetta M, Spiazzi G, Zoppini G, Muggeo M.
Review article: Type 2 diabetes and chronic liver dis-
ease in the Verona diabetes study. Aliment Pharmacol
Ther. 2005; 22 (Suppl. 2): 24–7.
74. Shyangdan D, Clar C, Ghouri N et al. Insulin sensitisers
in the treatment of non-alcoholic fatty liver disease: A
systematic review. Health Technol Assess. 2011; 15: 1–
110.
75. Avramoglu RK, Basciano H, Adeli K. Lipid and lipo-
protein dysregulation in insulin resistant states. Clin
Chim Acta. 2006; 368: 1–19.
76. Sniderman AD, Faraj M. Apolipoprotein B, apolipo-
protein A-I, insulin resistance and the metabolic syn-
drome. Curr Opin Lipidol. 2007; 18: 633–7.
276 ª 2012 Ruijin Hospital, Shanghai Jiaotong University School of Medicine and Wiley Publishing Asia Pty Ltd
A.C. TUYAMA and C.Y. CHANG
77. Targher G, Marra F, Marchesini G. Increased risk of
cardiovascular disease in non-alcoholic fatty liver dis-
ease: Causal effect or epiphenomenon? Diabetologia.
2008; 51: 1947–53.
78. Ghouri N, Preiss D, Sattar N. Liver enzymes, nonal-
coholic fatty liver disease, and incident cardiovascular
disease: A narrative review and clinical perspective of
prospective data. Hepatology. 2010; 52: 1156–61.
79. Ekstedt M, Franzen LE, Mathiesen UL et al. Long-
term follow-up of patients with NAFLD and elevated
liver enzymes. Hepatology. 2006; 44: 865–73.
80. Gastaldelli A, Kozakova M, Hojlund K et al. Fatty
liver is associated with insulin resistance, risk of coro-
nary heart disease, and early atherosclerosis in a large
European population. Hepatology. 2009; 49: 1537–44.
81. Schindhelm RK, Dekker JM, Nijpels G et al. Alanine
aminotransferase predicts coronary heart disease
events: A 10-year follow-up of the Hoorn Study.
Atherosclerosis. 2007; 191: 391–6.
82. Lin YC, Lo HM, Chen JD. Sonographic fatty liver,
overweight and ischemic heart disease. World J Gastro-
enterol. 2005; 11: 4838–42.
83. Targher G, Bertolini L, Padovani R et al. Prevalence
of nonalcoholic fatty liver disease and its association
with cardiovascular disease among type 2 diabetic
patients. Diabetes Care. 2007; 30: 1212–8.
84. Wannamethee SG, Lennon L, Shaper AG. The value
of gamma-glutamyltransferase in cardiovascular risk
prediction in men without diagnosed cardiovascular
disease or diabetes. Atherosclerosis. 2008; 201: 168–75.
85. Mirbagheri SA, Rashidi A, Abdi S, Saedi D, Abouzari
M. Liver: An alarm for the heart? Liver Int. 2007; 27:
891–4.
86. Strasak AM, Kelleher CC, Klenk J et al. Longitudinal
change in serum gamma-glutamyltransferase and car-
diovascular disease mortality: A prospective popula-
tion-based study in 76,113 Austrian adults. Arterioscler
Thromb Vasc Biol. 2008; 28: 1857–65.
87. Lee DH, Buijsse B, Steffen L, Holtzman J, Luepker R,
Jacobs DR Jr. Association between serum gamma-
glutamyltransferase and cardiovascular mortality varies
by age: The Minnesota Heart Survey. Eur J Cardio-
vasc Prev Rehabil. 2009; 16: 16–20.
88. Jepsen P, Vilstrup H, Mellemkjaer L et al. Prognosis
of patients with a diagnosis of fatty liver: A registry-
based cohort study. Hepatogastroenterology. 2003; 50:
2101–4.
89. Villanova N, Moscatiello S, Ramilli S et al. Endothe-
lial dysfunction and cardiovascular risk profile in non-
alcoholic fatty liver disease. Hepatology. 2005; 42: 473–
80.
90. Targher G, Bertolini L, Padovani R et al. Relations
between carotid artery wall thickness and liver histol-
ogy in subjects with nonalcoholic fatty liver disease.
Diabetes Care. 2006; 29: 1325–30.
A.C. TUYAMA and C.Y. CHANG
91. Targher G, Bertolini L, Poli F et al. Nonalcoholic fatty
liver disease and risk of future cardiovascular events
among type 2 diabetic patients. Diabetes. 2005; 54: 3541–
6.
92. Baranova A, Tran TP, Birerdinc A, Younossi ZM.
Systematic review: Association of polycystic ovary syn-
drome with metabolic syndrome and non-alcoholic
fatty liver disease. Aliment Pharmacol Ther. 2011; 33:
801–14.
93. Vassilatou E, Lafoyianni S, Vryonidou A et al.
Increased androgen bioavailability is associated with
non-alcoholic fatty liver disease in women with poly-
cystic ovary syndrome. Hum Reprod. 2010; 25: 212–20.
94. Cerda C, Perez-Ayuso RM, Riquelme A et al. Nonal-
coholic fatty liver disease in women with polycystic
ovary syndrome. J Hepatol. 2007; 47: 412–7.
95. Gambarin-Gelwan M, Kinkhabwala SV, Schiano TD,
Bodian C, Yeh HC, Futterweit W. Prevalence of non-
alcoholic fatty liver disease in women with polycystic
ovary syndrome. Clin Gastroenterol Hepatol. 2007; 5:
496–501.
96. Hossain N, Stepanova M, Afendy A et al. Non-alco-
holic steatohepatitis (NASH) in patients with polycys-
tic ovarian syndrome (PCOS). Scand J Gastroenterol.
2011; 46: 479–84.
97. Brzozowska MM, Ostapowicz G, Weltman MD. An
association between non-alcoholic fatty liver disease
and polycystic ovarian syndrome. J Gastroenterol
Hepatol. 2009; 24: 243–7.
98. Schwimmer JB, Deutsch R, Kahen T, Lavine JE, Stan-
ley C, Behling C. Prevalence of fatty liver in children
and adolescents. Pediatrics. 2006; 118: 1388–93.
99. Mencin AA, Lavine JE. Advances in pediatric non-
alcoholic fatty liver disease. Pediatr Clin North Am.
2011; 58: 1375–92.
100. Schwimmer JB, Behling C, Newbury R et al. Histopa-
thology of pediatric nonalcoholic fatty liver disease.
Hepatology. 2005; 42: 641–9.
101. Carter-Kent C, Yerian LM, Brunt EM et al. Nonalco-
holic steatohepatitis in children: A multicenter clinico-
pathological study. Hepatology. 2009; 50: 1113–20.
102. Chitturi S, Farrell GC. Etiopathogenesis of nonalco-
holic steatohepatitis. Semin Liver Dis. 2001; 21: 27–41.
103. Fromenty B, Pessayre D. Impaired mitochondrial
function in microvesicular steatosis. Effects of drugs,
ethanol, hormones and cytokines. J Hepatol. 1997; 26
(Suppl. 2): 43–53.
104. Farrell GC. Drugs and steatohepatitis. Semin Liver
Dis. 2002; 22: 185–94.
105. Neuschwander-Tetri BA, Clark JM, Bass NM et al.
Clinical, laboratory and histological associations in
adults with nonalcoholic fatty liver disease. Hepatolo-
gy. 2010; 52: 913–24.
106. Mofrad P, Contos MJ, Haque M et al. Clinical and
histologic spectrum of nonalcoholic fatty liver disease
ª 2012 Ruijin Hospital, Shanghai Jiaotong University School of Medicine and Wiley Publishing Asia Pty Ltd
Non-alcoholic fatty liver disease
associated with normal ALT values. Hepatology. 2003;
37: 1286–92.
107. Sorrentino P, Tarantino G, Conca P et al. Silent non-
alcoholic fatty liver disease: A clinical–histological
study. J Hepatol. 2004; 41: 751–7.
108. Hernaez R, Lazo M, Bonekamp S et al. Diagnostic
accuracy and reliability of ultrasonography for the
detection of fatty liver: A meta-analysis. Hepatology.
2011; 54: 1082–90.
109. Bohte AE, van Werven JR, Bipat S, Stoker J. The
diagnostic accuracy of US, CT, MRI and 1H-MRS for
the evaluation of hepatic steatosis compared with liver
biopsy: A meta-analysis. Eur Radiol. 2011; 21: 87–97.
110. Szczepaniak LS, Babcock EE, Schick F et al. Measure-
ment of intracellular triglyceride stores by H spectros-
copy: Validation in vivo. Am J Physiol. 1999; 276:
E977–89.
111. Petta S, Di Marco V, Camma C, Butera G, Cabibi D,
Craxi A. Reliability of liver stiffness measurement in
non-alcoholic fatty liver disease: The effects of body
mass index. Aliment Pharmacol Ther. 2011; 33: 1350–60.
112. de Ledinghen V, Wong VW, Vergniol J et al. Diagno-
sis of liver fibrosis and cirrhosis using liver stiffness
measurement: Comparison between M and XL probe
of FibroScan. J Hepatol. 2012; 56: 833–9.
113. Myers RP, Pomier-Layrargues G, Kirsch R et al. Fea-
sibility and diagnostic performance of the FibroScan
XL probe for liver stiffness measurement in overweight
and obese patients. Hepatology. 2012; 55: 199–208.
114. Brunt EM, Tiniakos DG. Histopathology of nonalco-
holic fatty liver disease. World J Gastroenterol. 2010;
16: 5286–96.
115. Ratziu V, Charlotte F, Heurtier A et al. Sampling
variability of liver biopsy in nonalcoholic fatty liver
disease. Gastroenterology. 2005; 128: 1898–906.
116. Janiec DJ, Jacobson ER, Freeth A, Spaulding L, Blas-
zyk H. Histologic variation of grade and stage of non-
alcoholic fatty liver disease in liver biopsies. Obes
Surg. 2005; 15: 497–501.
117. Merriman RB, Ferrell LD, Patti MG et al. Correlation
of paired liver biopsies in morbidly obese patients with
suspected nonalcoholic fatty liver disease. Hepatology.
2006; 44: 874–80.
118. Rockey DC, Caldwell SH, Goodman ZD, Nelson RC,
Smith AD. Liver biopsy. Hepatology. 2009; 49: 1017–44.
119. Ratziu V, Bellentani S, Cortez-Pinto H, Day C,
Marchesini G. A position statement on NAFLD ⁄
NASH based on the EASL 2009 special conference.
J Hepatol. 2010; 53: 372–84.
120. Brunt EM, Janney CG, Di Bisceglie AM, Neuschwan-
der-Tetri BA, Bacon BR. Nonalcoholic steatohepatitis:
A proposal for grading and staging the histological
lesions. Am J Gastroenterol. 1999; 94: 2467–74.
121. Kleiner DE, Brunt EM, Van Natta M et al. Design
and validation of a histological scoring system for
277
Non-alcoholic fatty liver disease
nonalcoholic fatty liver disease. Hepatology. 2005; 41:
1313–21.
122. Poonawala A, Nair SP, Thuluvath PJ. Prevalence of
obesity and diabetes in patients with cryptogenic cir-
rhosis: A case-control study. Hepatology. 2000; 32:
689–92.
123. Caldwell SH, Oelsner DH, Iezzoni JC, Hespenheide
EE, Battle EH, Driscoll CJ. Cryptogenic cirrhosis:
Clinical characterization and risk factors for underly-
ing disease. Hepatology. 1999; 29: 664–9.
124. Ludwig J, Viggiano TR, McGill DB, Oh BJ. Nonalco-
holic steatohepatitis: Mayo Clinic experiences with a
hitherto unnamed disease. Mayo Clin Proc. 1980; 55:
434–8.
125. Brunt EM, Kleiner DE, Behling C et al. Misuse of
scoring systems. Hepatology. 2011; 54: 369–70.
126. Adams LA, Feldstein AE. Non-invasive diagnosis of
nonalcoholic fatty liver and nonalcoholic steatohepatitis.
J Dig Dis. 2011; 12: 10–6.
127. Wieckowska A, Feldstein AE. Diagnosis of nonalco-
holic fatty liver disease: Invasive versus noninvasive.
Semin Liver Dis. 2008; 28: 386–95.
128. Li S, Brown MS, Goldstein JL. Bifurcation of insulin
signaling pathway in rat liver: MTORC1 required for
stimulation of lipogenesis, but not inhibition of gluco-
neogenesis. Proc Natl Acad Sci U S A. 2010; 107:
3441–6.
129. Musso G, Gambino R, Cassader M. Recent insights
into hepatic lipid metabolism in non-alcoholic fatty liver
disease (NAFLD). Prog Lipid Res. 2009; 48: 1–26.
130. Mittendorfer B, Magkos F, Fabbrini E, Mohammed
BS, Klein S. Relationship between body fat mass and
free fatty acid kinetics in men and women. Obesity.
2009; 17: 1872–7.
131. Wahren J, Sato Y, Ostman J, Hagenfeldt L, Felig P.
Turnover and splanchnic metabolism of free fatty
acids and ketones in insulin-dependent diabetics at rest
and in response to exercise. J Clin Invest. 1984; 73:
1367–76.
132. Donnelly KL, Smith CI, Schwarzenberg SJ, Jessurun
J, Boldt MD, Parks EJ. Sources of fatty acids stored
in liver and secreted via lipoproteins in patients with
nonalcoholic fatty liver disease. J Clin Invest. 2005;
115: 1343–51.
133. Redgrave TG. Formation of cholesteryl ester-rich par-
ticulate lipid during metabolism of chylomicrons.
J Clin Invest. 1970; 49: 465–71.
134. Nielsen S, Guo Z, Johnson CM, Hensrud DD, Jensen
MD. Splanchnic lipolysis in human obesity. J Clin
Invest. 2004; 113: 1582–8.
135. Diraison F, Moulin P, Beylot M. Contribution of
hepatic de novo lipogenesis and reesterification of
plasma non esterified fatty acids to plasma triglyceride
synthesis during non-alcoholic fatty liver disease.
Diabetes Metab. 2003; 29: 478–85.
278 ª 2012 Ruijin Hospital, Shanghai Jiaotong University School of Medicine and Wiley Publishing Asia Pty Ltd
A.C. TUYAMA and C.Y. CHANG
136. Browning JD, Horton JD. Molecular mediators of
hepatic steatosis and liver injury. J Clin Invest. 2004;
114: 147–52.
137. Fabbrini E, Sullivan S, Klein S. Obesity and nonalco-
holic fatty liver disease: Biochemical, metabolic, and
clinical implications. Hepatology. 2010; 51: 679–89.
138. Kohjima M, Enjoji M, Higuchi N et al. Re-evaluation
of fatty acid metabolism-related gene expression in
nonalcoholic fatty liver disease. Int J Mol Med. 2007;
20: 351–8.
139. Kotronen A, Seppala-Lindroos A, Vehkavaara S et al.
Liver fat and lipid oxidation in humans. Liver Int.
2009; 29: 1439–46.
140. Adiels M, Taskinen MR, Packard C et al. Overproduc-
tion of large VLDL particles is driven by increased liver
fat content in man. Diabetologia. 2006; 49: 755–65.
141. Fabbrini E, Mohammed BS, Magkos F, Korenblat
KM, Patterson BW, Klein S. Alterations in adipose
tissue and hepatic lipid kinetics in obese men and
women with nonalcoholic fatty liver disease. Gastro-
enterology. 2008; 134: 424–31.
142. Choi SH, Ginsberg HN. Increased very low density
lipoprotein (VLDL) secretion, hepatic steatosis, and
insulin resistance. Trends Endocrinol Metab. 2011; 22:
353–63.
143. Feldstein AE. Novel insights into the pathophysiology
of nonalcoholic fatty liver disease. Semin Liver Dis.
2010; 30: 391–401.
144. Yamaguchi K, Yang L, McCall S et al. Inhibiting tri-
glyceride synthesis improves hepatic steatosis but exac-
erbates liver damage and fibrosis in obese mice with
nonalcoholic steatohepatitis. Hepatology. 2007; 45:
1366–74.
145. Li ZZ, Berk M, McIntyre TM, Feldstein AE. Hepatic
lipid partitioning and liver damage in nonalcoholic
fatty liver disease: Role of stearoyl-CoA desaturase.
J Biol Chem. 2009; 284: 5637–44.
146. Mari M, Caballero F, Colell A et al. Mitochondrial
free cholesterol loading sensitizes to TNF- and Fas-
mediated steatohepatitis. Cell Metab. 2006; 4: 185–98.
147. Wouters K, van Gorp PJ, Bieghs V et al. Dietary
cholesterol, rather than liver steatosis, leads to hepatic
inflammation in hyperlipidemic mouse models of
nonalcoholic steatohepatitis. Hepatology. 2008; 48:
474–86.
148. Teratani T, Tomita K, Suzuki T et al. A high-choles-
terol diet exacerbates liver fibrosis in mice via accumu-
lation of free cholesterol in hepatic stellate cells.
Gastroenterology. 2012; 142: 152–64.
149. Ota T, Takamura T, Kurita S et al. Insulin resistance
accelerates a dietary rat model of nonalcoholic steato-
hepatitis. Gastroenterology. 2007; 132: 282–93.
150. Abu-Shanab A, Quigley EM. The role of the gut
microbiota in nonalcoholic fatty liver disease. Nat Rev
Gastroenterol Hepatol. 2010; 7: 691–701.
A.C. TUYAMA and C.Y. CHANG
151. Struben VM, Hespenheide EE, Caldwell SH. Nonalco-
holic steatohepatitis and cryptogenic cirrhosis within
kindreds. Am J Med. 2000; 108: 9–13.
152. Willner IR, Waters B, Patil SR, Reuben A, Morelli J,
Riely CA. Ninety patients with nonalcoholic steato-
hepatitis: Insulin resistance, familial tendency, and
severity of disease. Am J Gastroenterol. 2001; 96:
2957–61.
153. Schwimmer JB, Celedon MA, Lavine JE et al. Herita-
bility of nonalcoholic fatty liver disease. Gastroenterol-
ogy. 2009; 136: 1585–92.
154. Makkonen J, Pietilainen KH, Rissanen A, Kaprio J,
Yki-Jarvinen H. Genetic factors contribute to varia-
tion in serum alanine aminotransferase activity inde-
pendent of obesity and alcohol: A study in
monozygotic and dizygotic twins. J Hepatol. 2009; 50:
1035–42.
155. Daly AK, Ballestri S, Carulli L, Loria P, Day CP.
Genetic determinants of susceptibility and severity in
nonalcoholic fatty liver disease. Expert Rev Gastro-
enterol Hepatol. 2011; 5: 253–63.
156. Romeo S, Kozlitina J, Xing C et al. Genetic variation
in PNPLA3 confers susceptibility to nonalcoholic fatty
liver disease. Nat Genet. 2008; 40: 1461–5.
157. Gawrieh S, Baye TM, Carless M et al. Hepatic gene
networks in morbidly obese patients with nonalcoholic
fatty liver disease. Obes Surg. 2010; 20: 1698–709.
158. Sreekumar R, Rosado B, Rasmussen D, Charlton M.
Hepatic gene expression in histologically progressive
nonalcoholic steatohepatitis. Hepatology. 2003; 38: 244–
51.
159. Stepanova M, Hossain N, Afendy A et al. Hepatic
gene expression of Caucasian and African-American
patients with obesity-related non-alcoholic fatty liver
disease. Obes Surg. 2010; 20: 640–50.
160. Yoneda M, Endo H, Mawatari H et al. Gene expres-
sion profiling of non-alcoholic steatohepatitis using
gene set enrichment analysis. Hepatol Res. 2008; 38:
1204–12.
161. Younossi ZM, Baranova A, Ziegler K et al. A geno-
mic and proteomic study of the spectrum of nonalco-
holic fatty liver disease. Hepatology. 2005; 42: 665–74.
162. Younossi ZM, Gorreta F, Ong JP et al. Hepatic gene
expression in patients with obesity-related non-alco-
holic steatohepatitis. Liver Int. 2005; 25: 760–71.
163. Cheung O, Puri P, Eicken C et al. Nonalcoholic ste-
atohepatitis is associated with altered hepatic micro-
RNA expression. Hepatology. 2008; 48: 1810–20.
164. Rafiq N, Bai C, Fang Y et al. Long-term follow-up of
patients with nonalcoholic fatty liver. Clin Gastroenter-
ol Hepatol. 2009; 7: 234–8.
165. Argo CK, Northup PG, Al-Osaimi AM, Caldwell SH.
Systematic review of risk factors for fibrosis progres-
sion in non-alcoholic steatohepatitis. J Hepatol. 2009;
51: 371–9.
ª 2012 Ruijin Hospital, Shanghai Jiaotong University School of Medicine and Wiley Publishing Asia Pty Ltd
Non-alcoholic fatty liver disease
166. Fassio E, Alvarez E, Dominguez N, Landeira G,
Longo C. Natural history of nonalcoholic steatohepa-
titis: A longitudinal study of repeat liver biopsies.
Hepatology. 2004; 40: 820–6.
167. Harrison SA, Torgerson S, Hayashi P, Ward J, Schen-
ker S. Vitamin E and vitamin C treatment improves
fibrosis in patients with nonalcoholic steatohepatitis.
Am J Gastroenterol. 2003; 98: 2485–90.
168. Teli MR, James OF, Burt AD, Bennett MK, Day CP.
The natural history of nonalcoholic fatty liver: A fol-
low-up study. Hepatology. 1995; 22: 1714–9.
169. Dam-Larsen S, Becker U, Franzmann MB, Larsen K,
Christoffersen P, Bendtsen F. Final results of a long-
term, clinical follow-up in fatty liver patients. Scand J
Gastroenterol. 2009; 44: 1236–43.
170. Bhala N, Angulo P, van der Poorten D et al. The nat-
ural history of nonalcoholic fatty liver disease with
advanced fibrosis or cirrhosis: An international collab-
orative study. Hepatology. 2011; 54: 1208–16.
171. Hui JM, Kench JG, Chitturi S et al. Long-term out-
comes of cirrhosis in nonalcoholic steatohepatitis
compared with hepatitis C. Hepatology. 2003; 38:
420–7.
172. Sanyal AJ, Banas C, Sargeant C et al. Similarities and
differences in outcomes of cirrhosis due to nonalco-
holic steatohepatitis and hepatitis C. Hepatology. 2006;
43: 682–9.
173. Ascha MS, Hanouneh IA, Lopez R, Tamimi TA,
Feldstein AF, Zein NN. The incidence and risk factors
of hepatocellular carcinoma in patients with nonalco-
holic steatohepatitis. Hepatology. 2010; 51: 1972–8.
174. Baffy G, Brunt EM, Caldwell SH. Hepatocellular car-
cinoma in non-alcoholic fatty liver disease: An emerg-
ing menace. J Hepatol. 2012; 56: 1384–91.
175. Musso G, Gambino R, Cassader M, Pagano G. A
meta-analysis of randomized trials for the treatment of
nonalcoholic fatty liver disease. Hepatology. 2010; 52:
79–104.
176. Musso G, Gambino R, Cassader M. Emerging molec-
ular targets for the treatment of nonalcoholic fatty
liver disease. Annu Rev Med. 2010; 61: 375–92.
177. Mahady SE, Webster AC, Walker S, Sanyal A,
George J. The role of thiazolidinediones in non-alco-
holic steatohepatitis – a systematic review and meta
analysis. J Hepatol. 2011; 55: 1383–90.
178. Mummadi RR, Kasturi KS, Chennareddygari S, Sood
GK. Effect of bariatric surgery on nonalcoholic fatty
liver disease: Systematic review and meta-analysis. Clin
Gastroenterol Hepatol. 2008; 6: 1396–402.
179. Nobili V, Manco M, Devito R et al. Lifestyle interven-
tion and antioxidant therapy in children with nonalco-
holic fatty liver disease: A randomized, controlled trial.
Hepatology. 2008; 48: 119–28.
180. Promrat K, Kleiner DE, Niemeier HM et al. Random-
ized controlled trial testing the effects of weight loss
279
Non-alcoholic fatty liver disease
on nonalcoholic steatohepatitis. Hepatology. 2010; 51:
121–9.
181. Harrison SA, Fecht W, Brunt EM, Neuschwander-
Tetri BA. Orlistat for overweight subjects with non-
alcoholic steatohepatitis: A randomized, prospective
trial. Hepatology. 2009; 49: 80–6.
182. Belfort R, Harrison SA, Brown K et al. A placebo-con-
trolled trial of pioglitazone in subjects with nonalcoholic
steatohepatitis. N Engl J Med. 2006; 355: 2297–307.
183. Aithal GP, Thomas JA, Kaye PV et al. Randomized,
placebo-controlled trial of pioglitazone in nondiabetic
subjects with nonalcoholic steatohepatitis. Gastroenter-
ology. 2008; 135: 1176–84.
184. Sanyal AJ, Chalasani N, Kowdley KV et al. Pioglitaz-
one, vitamin E, or placebo for nonalcoholic steato-
hepatitis. N Engl J Med. 2010; 362: 1675–85.
280 ª 2012 Ruijin Hospital, Shanghai Jiaotong University School of Medicine and Wiley Publishing Asia Pty Ltd
A.C. TUYAMA and C.Y. CHANG
185. Lutchman G, Modi A, Kleiner DE et al. The effects of
discontinuing pioglitazone in patients with nonalco-
holic steatohepatitis. Hepatology. 2007; 46: 424–9.
186. Ratziu V, Charlotte F, Bernhardt C et al. Long-term
efficacy of rosiglitazone in nonalcoholic steatohepatitis:
Results of the fatty liver improvement by rosiglitazone
therapy (FLIRT 2) extension trial. Hepatology. 2010;
51: 445–53.
187. Bugianesi E, Gentilcore E, Manini R et al. A random-
ized controlled trial of metformin versus vitamin E
or prescriptive diet in nonalcoholic fatty liver disease.
Am J Gastroenterol. 2005; 100: 1082–90.
188. Miller ER 3rd, Pastor-Barriuso R, Dalal D, Rie-
mersma RA, Appel LJ, Guallar E. Meta-analysis:
High-dosage vitamin E supplementation may increase
all-cause mortality. Ann Intern Med. 2005; 142: 37–46.