Euroasian journal of hepato-gastroenterology

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2022 | July | Volume 12 | Issue S1

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Original Article

Shivaram P Singh, Prajna Anirvan, Amna S Butt, Ananta Shrestha, Anuradha S Dassanayake, Bashir A Shaikh, Mamun A Mahtab

NAFLD vs MAFLD: South Asian NAFLD Patients don't Favor Name Change

[Year:2022] [Month:July] [Volume:12] [Number:S1] [Pages:4] [Pages No:S1 - S4]

Keywords: NASH, Nomenclature, patients’ sentiments, South Asia, Steatohepatitis

   DOI: 10.5005/jp-journals-10018-1363  |  Open Access | 


Aim: There have been vociferous attempts to change the name of Nonalcoholic Fatty Liver Disease (NAFLD) to Metabolic Associated Fatty Liver Disease (MAFLD). Of the many arguments put forth in support of this, an important one is the presumed demand by patient groups insisting on the change. However, this claim does not have credible evidence to support it. Therefore, we decided to conduct a survey among South Asian NAFLD patients to understand their perspectives with regard to the change in nomenclature. Materials and methods: The study was conducted at multiple centers across South Asia from January 2021 to June 2021. Patients were surveyed using an 8-question survey questionnaire and responses were categorized by multiple-choice format. Results: Of 218 patients surveyed, 80.3% of the patients were not aware of the entity “NAFLD” before they were first diagnosed. Although 74.3% of patients admitted to being questioned about alcohol intake at the time of the first diagnosis, 75.9% of female patients were not questioned regarding this. After being labelled NAFLD, 92.1% of patients were never questioned again about alcohol intake. While 86.3% of patients found the term “NAFLD” consoling, 83% did not feel that “Non” in NAFLD trivialized their problem. In addition, only 6.9% of patients were scared of developing cardiovascular disease. Conclusion: The term “NAFLD” destigmatizes patients of the taboo associated with alcohol use. It was found to be consoling to most patients and they did not feel it trivialized their problem. A change of name without considering patients’ perspectives and peculiarities specific to different populations will have enormous ramifications for both patients and physicians. Clinical significance: Our survey clearly shows that patients are happy with the term “NAFLD” and it effectively destigmatizes them from the taboo of alcohol. This would lead to higher compliance with management and greater patient participation in future studies and trials.


Original Article

Ben L Da, Jinendra Satiya, Rajiv P Heda, Yu Jiang, Lawrence F Lau, Ahmed Fahmy, Aaron Winnick, Nitzan Roth, Elliot Grodstein, Paul J Thuluvath, Ashwani K Singal, Thomas D Schiano, Lewis W Teperman, Sanjaya K Satapathy

Outcomes after Liver Transplantation with Steatotic Grafts: Redefining Acceptable Cutoffs for Steatotic Grafts

[Year:2022] [Month:July] [Volume:12] [Number:S1] [Pages:10] [Pages No:S5 - S14]

Keywords: Allografts, Donor selection, Fatty liver, Liver transplantation, Tissue and organ procurement

   DOI: 10.5005/jp-journals-10018-1361  |  Open Access | 


Background: Graft macrosteatosis can predispose to a higher risk of graft loss so we sought to redefine acceptable cutoffs for graft steatosis. Methods: Data of 26,103 donors who underwent liver transplantation (LT) between January 2004 and December 2018 from the UNOS-STAR database were utilized. A high-risk steatotic (HRS) graft and a low-risk steatotic (LRS) graft were defined as ≥20% and <20% macrosteatosis, respectively. High-risk steatotic grafts were further classified as grafts with 20–29% (G1S grafts), 30–39% (G2S grafts), and ≥40% steatosis (G3S grafts). Outcomes between groups were compared. Results: LRS grafts had excellent graft (93.3 and 87.7%) and overall survival (95.4 and 90.5%) at 90 days and 1 year. Compared to LRS grafts, G1S, G2S, and G3S grafts had worse graft and overall survival at 90 days and 1-year (p <0.001). There was no difference in graft or overall survival of G1S or G3S grafts compared to G2S grafts until after adjustment in which G3S grafts were found to be associated with an increased risk of graft loss—aHR 1.27 (1.03–1.57), p = 0.02. Discussion: Liver grafts can be categorized into three categories: (1) <20% or “very low risk”, (2) 20–39% or “low-to-moderate risk”, and usually acceptable, and (3) ≥40% steatosis or “moderate-to-high risk”.


Original Article

Shivaram P Singh, Manas K Panigrahi, Anish Patel, Lavanya Viswanathan, Mitali M Rath, Sanjib K Kar, Stephen A Harrison

Comparison of Clinical, Biochemical, and Histopathologic Profiles between NAFLD in Asian-Indians and United States Adults

[Year:2022] [Month:July] [Volume:12] [Number:S1] [Pages:4] [Pages No:S15 - S18]

Keywords: Epidemiology, Ethnicity, Ethnology, NAFLD, Nonalcoholic fatty liver disease, Nonalcoholic steatohepatitis

   DOI: 10.5005/jp-journals-10018-1362  |  Open Access | 


Background and aims: Nonalcoholic fatty liver disease (NAFLD) is very common in both Asian and Western countries. Geographic variation leads to differences in epidemiological and demographic characters of NAFLD patients. Studies conducted upon different ethnic groups in the United States (US) show a higher prevalence of NAFLD in Hispanics and African-Americans. There is however, a paucity of studies involving Asians. It has been observed that Asian-Indian NAFLD patients have unique characteristics compared to their counterparts in the West. This study is the first attempt at comparing the characteristics of Asian-Indian and US NAFLD patients. Materials and methods: A retrospective analysis of clinical, biochemical, and histological data was performed for 633 Asian-Indian NAFLD patients and 451 US NAFLD patients. Clinical parameters [age, gender, body mass index (BMI), diabetes, hypertension, etc.], biochemical tests (liver function tests, lipid profile, and fasting blood sugar), hepatic ultrasound and hepatic histology were compared between the two cohorts. Results: Eighty-two percent of US NAFLD patients were more than 40 years of age compared to 51.3% of Asian-Indian patients (p <0.01). US (male 56.3%) and Asian-Indian (male 81.7%) (p <0.01) patients differed from each other as regards gender prevalence. Rates of obesity were greater in the US patients compared to Asian-Indians (BMI 32.6 ± 5.3 kg/m2 vs 26.2 ± 3.4 kg/m2). There was a higher prevalence of both diabetes and hypertension (diabetes 42.1% vs 33%, and hypertension 56.8% vs 29.7%, p ≤0.01) in US patients. ALT levels were also significantly higher in US NAFLD patients compared to Asian-Indians (ALT 82.78 ± 71.30 vs 53.66 ± 37, p ≤0.01). A higher proportion of US patients were found to have the more advanced liver disease at the time of diagnosis compared to Asian-Indians (Stage 3 fibrosis 10.42% vs 0%, and Stage 4 fibrosis 2.66% vs 0%, p <0.01). Conclusion: Asian-Indian and US NAFLD patients differ significantly on several parameters. Further studies need to be carried out to understand the mechanistic basis of these differences better.



Manisha Bangar, Sherna Menezes, Shobna Bhatia, Nazish Butt, Jhumur Ghosh, Jayani Harshika Manchanayake

Gender Differences in Nonalcoholic Fatty Liver Disease

[Year:2022] [Month:July] [Volume:12] [Number:S1] [Pages:7] [Pages No:S19 - S25]

Keywords: Fibrosis, Gender, Gender difference, Liver cancer, Menopause, Metabolic syndrome, Molecular pathogenesis, Nonalcoholic steatohepatitis, Prevalence, Sex hormones

   DOI: 10.5005/jp-journals-10018-1370  |  Open Access | 


Nonalcoholic fatty liver disease (NAFLD) has currently emerged as the most common liver disorder in both developed and developing countries. It has been observed that NAFLD exhibits sexual dimorphism, and there is limited understanding on the sex differences in adults with NAFLD. Nonalcoholic fatty liver disease shows marked differences in prevalence and severity with regards to gender. There are considerable biological disparities between males and females attributed to differences in the chromosomal makeup and sex hormone levels, distinct from the gender differences resulting from the sociocultural influences that lead to differences in lifestyle, which have a significant impact on the pathogenesis of this complex disorder. A multitude of factors contributes to the gender disparities seen and need to be researched in-depth to better understand the mechanisms behind them and the therapeutic measures that can be taken. In this article, we will review the gender disparities seen in NAFLD, as well as recent studies highlighting certain gender-specific factors contributing to its varying prevalence and severity.



Saurabh Mishra, Harish Bhujade, Amna Subhan Butt

Work-up for Incidentally Detected NAFLD: How Far is It Worth?

[Year:2022] [Month:July] [Volume:12] [Number:S1] [Pages:11] [Pages No:S26 - S36]

Keywords: Acoustic radiation force impulse, Incidental NAFLD, Liver fibrosis, Metabolic (Dysfunction)-associated fatty liver disease, Magnetic resonance imaging-proton density fat fraction, Nonalcoholic fatty liver disease, Nonalcoholic steatohepatitis, Transient elastography

   DOI: 10.5005/jp-journals-10018-1364  |  Open Access | 


The incidence of nonalcoholic fatty liver disease (NAFLD) has seen a steep rise in parallel with the global obesity and metabolic syndrome epidemic. The presence of NAFLD contributes to significant socioeconomic burden due to healthcare costs, progression of liver disease as non-alcoholic steatohepatitis (NASH), and later cirrhosis and hepatocellular carcinoma (HCC). With the advent of widely available imaging, it is also being detected as an incidental diagnosis in individuals with systemic disease like metabolic syndrome, diabetes, chronic cardiac disease, polycystic ovarian syndrome, etc. or in asymptomatic persons on presurgical evaluation or even annual health assessments. Gastroenterologists, hepatologists, physicians and surgeons need to be updated about the new diagnostic criteria of Metabolic (dysfunction)-associated fatty liver disease, noninvasive tests (NITs) of liver fibrosis, new tools of elastography, and identification of those with high-risk disease. In this review, we appraise the relevance of new diagnostic definitions, steatosis and fibrosis estimation tests, advanced imaging like magnetic resonance elastography and proton density fat fraction and discuss the diagnostic algorithm for incidentally detected NAFLD.



Reshu Khandelwal, Anuradha Supun Dassanayake

Nonalcoholic Fatty Liver Disease in Diabetics: The Role of Hepatologist

[Year:2022] [Month:July] [Volume:12] [Number:S1] [Pages:4] [Pages No:S37 - S40]

Keywords: Antidiabetic drugs, Diabetes, Fibrosis, Hepatologist, Nonalcoholic fatty liver disease, Nonalcoholic steatohepatitis

   DOI: 10.5005/jp-journals-10018-1376  |  Open Access | 


Diabetes mellitus is one of the most prevalent metabolic diseases worldwide, causing an enormous burden on the economies of both developed and developing nations. Nonalcoholic fatty liver disease (NAFLD) is very closely associated with diabetes, and the two diseases are known to cause an increase in morbidity and mortality. Timely referral of a diabetic with NAFLD to a hepatologist can definitely delay disease progression and the related complications. Despite the magnitude, there are no guidelines that recommend a screening algorithm that must be followed for evaluating NAFLD in at-risk diabetics at the primary care level and their further referral to hepatologists. Nonalcoholic fatty liver disease management needs heightened awareness among primary care physicians/endocrinologists and hepatologists, and a collaborative care approach is paramount in these patients. Certain antidiabetic drugs are found to be beneficial in the treatment of NAFLD patients with diabetes, however, none of them are FDA approved.



Abdullah M Ozercan, Hasan Ozkan

Vibration-controlled Transient Elastography in NAFLD: Review Study

[Year:2022] [Month:July] [Volume:12] [Number:S1] [Pages:5] [Pages No:S41 - S45]

Keywords: Fibrosis, Nonalcoholic fatty liver disease, Steatosis, Transient elastography

   DOI: 10.5005/jp-journals-10018-1365  |  Open Access | 


Aim: In this study, we aimed to provide information about transient elastography, a noninvasive method that shows liver steatosis and fibrosis, and to review diagnostic accuracy studies in the literature. Background: Nonalcoholic fatty liver disease (NAFLD) is the most common cause of chronic liver diseases. It has a wide clinical spectrum, ranging from asymptomatic steatosis to cirrhosis with complications that can lead to mortality. Although its frequency varies geographically, it is believed that one out of every four people in the world has NAFLD. Recently, the number of studies about the noninvasive diagnosis of NAFLD and liver fibrosis is increasing. Vibration-controlled transient elastography (VCTE) is a method used for about two decades and provides important information in determining steatosis and fibrosis in the liver. Review results: Area under curve (AUC) levels for ≥S1 are between 0.8 and 0.95 in studies showing the accuracy of the CAP score in detecting steatosis. Sensitivity is between 68 and 87% and specificity is 74 and 91%. AUC levels for steatosis ≥S2 range from 0.73 to 0.88. Sensitivity is between 77 and 85% and specificity is 59 and 81%. For detecting ≥S3, AUC levels were 0.69 to 0.94 and the sensitivity and specificity were 71 to 88%, and 58 to 89%, respectively. In studies, evaluating the effectiveness of elastography in determining the level of fibrosis in patients with NAFLD: AUC was between 0.79 and 0.87, sensitivity was 62 and 94%, and specificity was 61 and 100% for F ≥2. Area under curve was 0.76 to 0.98, sensitivity was 65 to 100% and specificity was 75 to 97% for ≥F3. Area under curve was ranged from 0.91 to 0.99 and sensitivity was 78 to 100% and specificity was 76 to 98% for ≥F4. The studies about the comparison of FibroScan and novel transient elastography device (FibroTouch) reported that results are correlated (r = 0.5–0.6) and the AUC of FibroTouch to detect fibrosis is nearly 0.8. Conclusion: AUROC in studies are mostly above 0.80 in detecting steatosis and detecting the presence of fibrosis in patients diagnosed with NAFLD indicates the reliability of the data obtained. Transient elastography is suggested by the international guidelines for diagnosing NAFLD, especially the decision of biopsy. FibroTouch was found correlated with FibroScan but further studies are necessary to indicate that FibroTouch can be used instead of FibroScan.



Partho Pratik Roy, Mohammad Abdur Rahim, SM Sabrina Yesmin, Sunan Bin Islam

Treatment of Nonalcoholic Steatohepatitis by Obeticholic Acid: Current Status

[Year:2022] [Month:July] [Volume:12] [Number:S1] [Pages:5] [Pages No:S46 - S50]

Keywords: Farnesoid-X-receptor, Nonalcoholic fatty liver disease, Nonalcoholic steatohepatitis, Novel drug, Obeticholic acid

   DOI: 10.5005/jp-journals-10018-1360  |  Open Access | 


Nonalcoholic fatty liver disease (NAFLD) is one of the major and prevalent liver diseases from the national and global perspectives. It appears that considerable numbers of the general population have been suffering from NAFLD. When a patient with NAFLD also exhibits inflammation of the liver, the condition is regarded as nonalcoholic steatohepatitis (NASH). Nonalcoholic steatohepatitis is a pathological entity that may progress to cirrhosis of the liver (LC) and hepatocellular carcinoma (HCC). It is acceptable by all that the health burden of NAFLD and NASH is tremendous. Due to the increased prevalence of these pathologies, extensive research has been conducted regarding pathogenesis, diagnostic tools, and staging of the diseases. However, adequate and approved pharmacotherapy for these pathologies is lacking. The farnesoid receptor (FXR) is a bile acid-activated receptor. It regulates lipid, glucose, bile acid metabolism. Farnesoid receptor is also endowed with anti-inflammatory and anti-fibrotic properties on the liver. Obeticholic acid (OCA), a potent and selective FXR ligand, may become a promising molecule to combat NASH and advanced fibrosis. The present review briefly discusses the current recommendation of NASH management with available pharmacological treatments. The scope of OCA with a focus on recent data of major randomized controlled trials (RCTs) is discussed. On the basis of current data and recent interim analysis, OCA seems to improve insulin resistance, steatohepatitis, levels of alanine transaminase (ALT) and fibrosis in NASH. Dose-related adverse effects like pruritus and dyslipidemia may limit its usage. Also, its usage may be restricted in patients with NASH cirrhosis. More adequately powered RCTs that would contain NASH patients with different and heterogeneous properties would be required to develop consensus about these issues. The safety profile of different doses of OCA needs to be established in these patients as well as there remain considerable queries about these.



Ananta Shrestha, Shrijana Pradhananga

Holistic Approach in the Management of Nonalcoholic Fatty Liver Disease

[Year:2022] [Month:July] [Volume:12] [Number:S1] [Pages:8] [Pages No:S51 - S58]

Keywords: Holistic approach, Lifestyle intervention, Multistysemic disease, Nonalcoholic fatty liver disease

   DOI: 10.5005/jp-journals-10018-1359  |  Open Access | 


Nonalcoholic fatty liver disease (NAFLD), in a few decades, is expected to be the commonest cause of end-stage liver disease and liver cancer surpassing all other etiologies. Urbanization and modern lifestyle have led to global epidemic of NAFLD with alarming prevalence rates across the globe. Its multisystemic involvement manifests as metabolic syndrome, diabetes, cardiovascular disease, end-stage liver disease, and hepatic and extrahepatic malignancies. The absence of promising therapy for halting disease progression in NAFLD is a challenge that is not only limited to liver disease but also other organs involved. It is unrealistic to expect any significant impact of pharmacotherapies in overall survival of NAFLD patients, given that the morbidity and mortality in these patients are contributed by conditions other than that of liver. Liver-centric approach in managing NAFLD will be futile unless the problem is dealt in a holistic manner. Lifestyle modifications have been repeatedly appraised in prevention and treatment of various diseases linked to metabolic syndrome including NAFLD. Despite being inexpensive and highly efficacious in prevention and treatment of different manifestations of NAFLD, lifestyle intervention often fails to gather sufficient interest among patients and physicians alike. This review intends to highlight pleiotropic nature of this disease, limitations of currently available pharmacotherapies and evidence that emphasizing lifestyle intervention is the only way to holistically deal in patients with NAFLD.



Hasan Ozkan, SP Singh


[Year:2022] [Month:July] [Volume:12] [Number:S1] [Pages:1] [Pages No:00 - 00]

   DOI: 10.5005/ejohg-12-S1-Siv  |  Open Access |  How to cite  | 


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