Diagnosis and management of non-alcoholic fatty liver disease.

Non-alcoholic fatty liver disease (NAFLD) is the most common chronic liver disease in Western industrialised countries. The prevalence of NAFLD is increasing in parallel with the global rise in obesity and type 2 diabetes mellitus. NAFLD represents a spectrum of liver disease severity. NAFLD begins with accumulation of triacylglycerols in the liver (steatosis), and is defined by hepatic fatty infiltration amounting to greater than 5% by liver weight or the presence of over 5% of hepatocytes loaded with large fat vacuoles. In almost a quarter of affected individuals, steatosis progresses with the development of liver inflammation to non-alcoholic steatohepatitis (NASH). NASH is a potentially progressive liver condition and with ongoing liver injury and cell death can result in fibrosis. Progressive liver fibrosis may lead to the development of cirrhosis in a small proportion of patients. With the growing prevalence of NAFLD, there is an increasing need for a robust, accurate and non-invasive approach to diagnosing the different stages of this condition. This review will focus on (1) the biochemical tests and imaging techniques used to diagnose the different stages of NAFLD; and (2) a selection of the current management approaches focusing on lifestyle interventions and pharmacological therapies for NAFLD.

Recent advances in NAFLD: current areas of contention.

This brief review focuses on two contentious issues within the field of non-alcoholic fatty liver disease (NAFLD); the first is the recent effort to redefine NAFLD as metabolic (dysfunction)-associated fatty liver disease (MAFLD). The modification of "NAFLD" to "MAFLD" is expected to highlight the role of metabolic factors in the disease aetiology, which is hoped to improve patient understanding of the disease, facilitate patient-physician communication and highlight the importance of public health interventions in prevention and management. The diagnostic criteria for MAFLD allow it to coexist with other forms of liver disease, which recognises that metabolic dysfunction contributes towards disease progression in other liver pathologies, such as alcoholic liver disease. However, there remain concerns that renaming NAFLD may be premature without fully considering the broader implications, from diagnostic criteria to trial endpoints; therefore, the new definition has not yet been accepted by major societies. Another contentious issue within the field is the gap in our understanding of how patients undergoing therapeutic interventions should be monitored to assess amelioration/attenuation or the worsening of their liver disease. Biomarker scoring systems (such as the ELF test and FIB-4 test) and imaging techniques (such as transient elastography [TE] and magnetic resonance imaging [MRI] techniques) are proven to be reasonably accurate, and comparable with histology, in the diagnosis of NAFLD and evaluation of disease severity; however, their use in monitoring the response of disease to therapeutic interventions is not well established. Whilst biomarker scoring systems and TE are limited by poor diagnostic accuracy in detecting moderate fibrosis (e.g. F2 liver fibrosis defined by histology), more accurate MRI techniques are not practical for routine patient follow-up due to their expense and limited availability. More work is required to determine the most appropriate method by which therapeutic interventions for NAFLD should be monitored in clinical practice.

The role of the gut microbiome and diet in the pathogenesis of non-alcoholic fatty liver disease.

Non-alcoholic fatty liver disease (NAFLD) is the leading cause of chronic liver disease, with a prevalence that is increasing in parallel with the global rise in obesity and type 2 diabetes mellitus. The pathogenesis of NAFLD is complex and multifactorial, involving environmental, genetic and metabolic factors. The role of the diet and the gut microbiome is gaining interest as a significant factor in NAFLD pathogenesis. Dietary factors induce alterations in the composition of the gut microbiome (dysbiosis), commonly reflected by a reduction of the beneficial species and an increase in pathogenic microbiota. Due to the close relationship between the gut and liver, altering the gut microbiome can affect liver functions; promoting hepatic steatosis and inflammation. This review summarises the current evidence supporting an association between NAFLD and the gut microbiome and dietary factors. The review also explores potential underlying mechanisms underpinning these associations and whether manipulation of the gut microbiome is a potential therapeutic strategy to prevent or treat NAFLD.

Renal cell carcinoma presenting with malignant ascites.

It is rare for renal cell carcinoma to involve the peritoneum and cause malignant ascites. Furthermore, it is uncommon for malignant ascites to be a presenting feature of this cancer. An unusual case of renal cell carcinoma presenting with malignant ascites is reported, and its response to sunitinib described.