Routine screening for NAFLD/NASH is currently not recommended. Optimal follow-up has not been established. 2-3 years has been suggested. (Author note: Compliance is challenging for interventions scheduled to occur every 2-3 years. NAFLD is a chronic liver disease and appropriate vaccination is important including hepatitis A&B and pneumococcal vaccine regardless of age. 


>5% loss in weight has been shown to improve steatosis in NAFLD. >10% decreases inflammation and fibrosis in NASH. Patients should target a 500 Cal daily deficit by reducing carbohydrates (esp. fructose), increasing daily protein, and avoiding unhealthy fats. Exercise has an important beneficial effect independent of weight loss. Patients should reduce or eliminate alcohol. Features of MetS should be aggressively treated to reduce the risk of CVD. Limited pharmacotherapies for NASH are available and in development. Appropriate identification of patients that will most benefit is essential.


FIB-4 <1.45 has a negative predictive value of advanced fibrosis of 90%. The calculation includes age, platelet count, AST, and ALT (There is an app for that!). Other non-invasive tools are available (NAFLD Fibrosis Score (NFS), AST Platelet Ratio Index (APRI), and serum biomarkers) but offer no practical advantage in the algorithm proposed here.


FibroScan loses reliability with BMI>40. Magnetic Resonance Elastography (MRE) is also approved but costly and can be difficult to access. US or CT elastography methods provide practical alternatives. In some cases, a liver biopsy may be required for a reliable diagnosis of NASH.


Liver biochemistry can be normal in NAFLD/NASH. Typically, AST/ALT <1/ AST/ALT >2 is seen with alcohol use.

Metabolical Syndrom definition varies:

1. Abdominal Obesity

2. Hypertension

3. Insulin resistance or Diabetes

4. Dyslipidemia (low HDL, elevated triglyceride


Patients with Metabolic Syndrome increases the risk of:

1. NAFLD/NASH/Fibrosis/Cirrhosis

2. Hepatocellular Carcinoma (HCC)

3. Cholangiocarcinoma

4. Chronic Kidney Disease (CKD)

5. Sleep Apnea

6. Gout and Hyperuricemia

7. Polycystic Ovarian Syndrome (PCOS)