Question: I have been a bit chunky all my life. I went for my annual checkup few years ago and was surprised when the doctor told me I have a condition — NASH. I was advised to lose weight. I could not lose weight, and now they say I have developed cirrhosis of liver and if the treatment does not help, I may need a liver transplant. Fortunately, my cousin has agreed to donate her liver if I need it. I am worried about her. What will happen to her after the donation of liver and how will the liver transplant help me? I never thought being overweight carries this risk. — Angie, of St. Marys
Angie! The liver is an important organ of the body. The liver is located on the right side of the abdomen below the diaphragm behind the ribs. It is the chemical mill that produces varied substances needed by the body. It produces glucose, a source of energy; proteins, the building blocks for growth and repair; blood-clotting factors; bile, a fluid stored in the gallbladder and necessary for the absorption of fats and vitamins. The liver stores important substances like vitamins and minerals. It also acts as a filter, removing impurities from the blood. Finally, the liver metabolizes and detoxifies substances ingested by the body.
Non-Alcoholic Fatty Liver Disease is the most common chronic liver condition in the United States. It is estimated that about one in four of adults in the U.S. have NAFLD. It is because obesity is quite common. Of those with NAFLD, about 20 percent have nonalcoholic steatohepatitis also sometimes called NASH. Five percent of adults in the U.S may have it. Most people with NAFLD have simply fatty liver.
Fatty liver disease is a condition in which excess fat is stored inside liver cells, making it harder for the liver to function. One cause of fat buildup in the liver is heavy regular alcohol use, referred to as alcoholic fatty liver disease. This is a common but preventable disease and is the earliest stage of alcohol-related liver disease.
When the buildup of fat in the liver is not related to significant alcohol consumption, the condition is called NASH.
Obesity has recently been recognized as a risk factor in nonalcoholic hepatitis and cirrhosis. Being chunky increases your risk of conditions that may lead to nonalcoholic fatty liver disease and NASH and eventually to cirrhosis.
You did not have any symptoms for a long time because most people with NASH have no symptoms.
Your doctor might have suspected that you have NASH from the results of a routine blood tests. Some chemicals called enzymes normally stored in the liver are released in the blood and that leads to suspicion of NASH. Sometimes routine a picture like liver ultrasound, CT or MRI scan are done for an unrelated condition and NASH is diagnosed.
Some people after years of fatty liver start developing inflammation of the liver and scarring, leading to cirrhosis of the liver. There is a new test called elastography done to check the progress of scarring of the liver.
Some people need a liver biopsy. During this test, a doctor removes a small sample of tissue from the liver and the sample is looked under a microscope to see if NASH is present. A liver biopsy is the only test that can tell for sure if you have NASH.
How is NASH treated? NASH is not typically treated directly. But it can get better when other medical conditions that caused NASH get treated. For example, losing weight and controlling high blood sugar and cholesterol can help improve NASH. The liver may recover by weight loss. Abstinence from alcohol may help patients with NAFLD.
With that in mind, your doctor may:
• Help you lose weight if you are overweight, if your doctor recommends it. Plan to lose weight safely. It is important not to lose weight too quickly. Do not use crash diets. Do not lose more than 3 1/2 pounds a week. It may be safe to lose a minimum of five to seven percent of body weight at a rate of 1 to 2 pounds per week. You may do it through lifestyle modifications including dietary therapy and exercise.
• Sometimes bariatric surgery may be recommended when you find it difficult to lose weight.
• Treat your high blood sugar if you have high blood sugar.
• Treat your high cholesterol if you have high cholesterol.
Making these changes has many benefits besides helping with NASH. These changes can also reduce your chances of having a heart attack or stroke. That is important because people with NASH are often also at risk for heart disease and stroke.
If you take a medicine that could be causing NASH, your doctor will stop or change that medicine.
If you have a severe form of NASH but do not also have diabetes or heart disease, your doctor might suggest that you take vitamin E. Do not take vitamin E unless your doctor recommends it. Too much vitamin E may be dangerous.
If there is diabetes with NASH some medicines like metformin, pioglitazone or liraglutide may be tried.
NASH might get worse over time, causing cirrhosis. Cirrhosis can cause different symptoms, such as swelling in the legs, trouble breathing or feeling tired. If you get cirrhosis, your doctor may talk with you about different possible treatments.
Liver transplants can benefit patients with advanced cirrhosis. However, the new liver will eventually become diseased unless the underlying cause of cirrhosis is removed.
Liver transplantation or hepatic transplantation is the replacement of a diseased liver with the healthy liver from another person. You are lucky to have your cousin ready to donate her liver for transplantation. Usually there is a long waiting list to find a donor. Some people plan to donate different organs of the body after death and a liver is found that way.
The most common technique of liver transplantation is where the patient’s liver is removed and replaced by portions of liver from the donor liver. Your cousin will regenerate her liver after she donates part of her liver to you.
Hopefully, you may improve and not need the liver transplant.
NASH is largely a preventable disease. A good lifestyle may prevent NASH. A good daily routine of adequate sleep, daily prayer, stress reduction, exercise including yoga, meditation, balanced nutrition, maintaining normal weight and avoidance use of habits harmful to the body by making good choices will prevent many diseases. We may try to teach good lifestyle to the children, also.
Suman Kumar Mishr MD, Fellow of American College of Endocrinology, Cridersville