Nonalcoholic steatohepatitis (NASH) is the second most
common U.S. indication for liver transplantation, trailing only hepatitis
C. We expect to see a fall-off in
hepatitis C in the future but the transplant surgeons will still be busy: patients
with NASH are going to replace them.
There is substantial evidence linking NASH to obesity,
diabetes and the metabolic syndrome. Non-alcoholic fatty liver disease (human foie gras) progresses to NASH in 40% of
patients. NASH occurs when the liver cells are damaged by sludge inside the
cells and stop working correctly. These cells then die and are replaced with
scar tissue. Liver cirrhosis is an accumulation of scar tissue that can lead to
organ failure or liver cancer. While the liver has an amazing capacity to regenerate,
these scar areas cannot do so.
The metabolic syndrome is rampant: abdominal obesity, high
blood pressure, diabetes and elevated cholesterol. Check out the lunchtime
crowd at a local fast food emporium – there will be at least one person there
who will need a liver transplant in the future, if he doesn’t succumb to heart
disease first.
Several experts are recommending that morbidly obese
patients who have poorly controlled diabetes have routine screening for liver
cancer, since these patients may skip the ‘intermediate step’ of developing
cirrhosis. But how to screen? And will it change outcomes?
It is clear that life-style modifications are important. A
7-10% weight loss results in a 50% drop in liver fat. The role of medication in
preventing NASH is less clear. In addition to diet and exercise, medications
should be used to manage the hypertension, diabetes and high cholesterol that encompass the metabolic syndrome.
The total cost of a liver transplant is more than $500,000
for the first year. Perhaps we should have warning labels on fast food
wrappers.
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