The diagnosis and management of nonalcoholic fatty liver disease: Practice guidance from the American Association for the Study of Liver Diseases

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Abstract

Potential conflict of interest: Dr. Chalasani consults for and received grants from Eli Lilly. He consults for NuSirt, AbbVie, Afimmune, Tobira, Madrigal, Shire, Cempra, Ardelyx, Axovant, and Amarin. He received grants from Intercept, Gilead, Galectin, and Cumberland. Dr. Younossi consults for Bristol‐Myers Squibb, Gilead, Intercept, Allergan, and GlaxoSmithKline. He advises for Vertex and Janssen. Dr. Brunt advises for Gilead. Dr. Charlton consults for and received grants from Gilead, Intercept, NGM Bio, Genfit, and Novartis. He received grants from Conatus. Dr. Cusi consults for and received grants from Novo Nordisk. He consults for Tobira. He received grants from Cirius, Novartis, Janssen, Zydus, Nordic, and Lilly. Dr. Rinella consults for Intercept, Gilead, Genfit, Novartis, NGM Bio, and Nusirt. She advises for Fibrogen, Immuron, Enanta, and AbbVie. Dr. Harrison consults for Madrigal, NGM Bio, Genfit, Echosens, Prometheus, Cirius, Perspectum, and HistoIndex. He advises for Garland, Intercept, Novartis, and Pfizer. He is on the speakers' bureau for AbbVie, Gilead, and Alexion. Dr. Sanyal consults for and received grants from Salix, Conatus, Galectin, Gilead, malinckrodt, Echosens‐Sandhill, Novartis, and Sequana. He consults for and is employed by Sanyal Bio. He consults for and owns stock in GenFit, Hemoshear, Durect, and Indalo. He consults for Immuron, Intercept, Pfizer, Boehringer Ingleheim, Nimbus, Nitto Denko, Lilly, Novo Nordisk, Fractyl, Allergan, Chemomab, Affimmune, Teva, and Ardelyx. He received grants from Bristol‐Myers Squibb and Merck. He received royalties from UptoDate. He owns stock in Exhalenz, Arkana, and NewCo LLC. The funding for the development of this Practice Guidance was provided by the American Association for the Study of Liver Diseases. This practice guidance was approved by the American Association for the Study of Liver Diseases on June 15, 2017. Preamble This guidance provides a data‐supported approach to the diagnostic, therapeutic, and preventive aspects of nonalcoholic fatty liver disease (NAFLD) care. A “Guidance” document is different from a “Guideline.” Guidelines are developed by a multidisciplinary panel of experts and rate the quality (level) of the evidence and the strength of each recommendation using the Grading of Recommendations, Assessment Development, and Evaluation system. A guidance document is developed by a panel of experts in the topic, and guidance statements, not recommendations, are put forward to help clinicians understand and implement the most recent evidence. This Practice Guidance was commissioned by the American Association for the Study of Liver Diseases (AASLD) and is an update to the Practice Guideline published in 2012 in conjunction with the American Gastroenterology Association and the American College of Gastroenterology (ACG).1 Sections where there have been no notable newer publications are not modified, so some paragraphs remain unchanged. This narrative review and guidance statements are based on the following: (1) a formal review and analysis of the recently published world literature on the topic (Medline search up to August 2016); (2) the American College of Physicians' Manual for Assessing Health Practices and Designing Practice Guidelines2; (3) guideline policies of the AASLD; and (4) the experience of the authors and independent reviewers with regard to NAFLD. This practice guidance is intended for use by physicians and other health professionals. As clinically appropriate, guidance statements should be tailored for individual patients. Specific guidance statements are evidence based whenever possible, and, when such evidence is not available or is inconsistent, guidance statements are made based on the consensus opinion of the authors.3 This is a practice guidance for clinicians rather than a review article, and interested readers can refer to several recent comprehensive reviews.4 Because this guidance document is lengthy, to make it easier for the reader, a list of all guidance statements and recommendations are provided in a tabular form there be (1) evidence of by or and (2) of of such use of a or the of is with such and can be nonalcoholic fatty liver or nonalcoholic is the of evidence of in the form of is the of and with with or this guidance document be to or or of fatty liver of of and the of in from fatty liver to to of evidence of in the form of of the or evidence of The of to and liver is of with and with or This can to liver and liver of with or evidence of or of with no with are with such and of and is a to in liver in with in is A of and and of in the is a of the of in the A have of from are a for of by was a of for of by was the of using and was to be a of for an of of developed by to an rate of The for in the of are A from using of an rate for of the of such this most the of A from an rate of A recent the of from to be the rate from the is to be to the there is a of publications the of in the are in a recent of the of The the of by is The of is from the and the rate is from As the for a liver liver is not in of the there is no of the or of there have been some to the of by The the of in the are in the The of liver for a is to be The of liver a for is from to the of in the and of in of are not in with of the of This and of been this provides a list of the and and and independent of are with and is the most and for NAFLD. the of from to and is with NAFLD. this the of with have is a of in with some have to of have is to the of and this and can in a the of in with or the of in with NAFLD. this and and are in with NAFLD. The of in with been to be a a the based on to and to The rate of was the rate for with the to and to was the rate in the with the was and The of to and the of and of liver disease to with Association of the of or of the (1) than in or than in (2) or (3) than in and than in (4) or or or and or been a for NAFLD. the of in is than in The of and on have the to have a of have a of the of and to be to be is most of the recent the for be by the to the the of the from to and of the have the of with is evidence with with some of are for such and have the following: with have to The most of in with is disease independent of other is the of in the it is the or of with is the of in with with have an a recent and and to be and and and The for and for to be and The most of with is to or are of is the of in the to the of with the the of the of been to a with are have a have and are to from liver than other of from a of from the not have other was with in the of This of in is to most with have is This of with have a of and with the with or in the of in of the for liver disease is of the recent in with a rate of the of in to with a rate of and in with to with a recent of with and a of an of rate not different from with This is with of with with or liver is the of and the of in the are with As of liver disease is the development of The rate was to be of with of the to to liver to and to it is the for in is the of with the and of the of evidence for or recent of of the of in with is A consensus for be in and in a liver to the on and a is of the of in published literature been Guidance or recent on in and on in is a for when with NAFLD. Evaluation of and for other than liver or A recent of with be for based on the the and and for this have not been Guidance with on have or to liver disease or have liver should be have and up with on or and have liver should be for or and for such or for in and can be there should be for with or not with have of the available evidence of and of there are in the and of NAFLD. A analysis using a for in with is not of with available liver can be in with not be to liver or are is experts recently have for for liver disease in with not Guidance for in or is not this of and with of to and of should be a of for and in with such or or can be to or for or of of a of with have a a of with and for and the of liver was and fatty liver was in of of with in the of and the of have been from no in a to in a of an of in using to and and not and, the of and was and Guidance of for is not Evaluation of the The of (1) there is by or (2) there is no (3) there are no for and (4) there are no of of are disease and a with it is to for liver and liver can in with not the of liver of this are and is a of not it can disease the are of was with in a of and are in a with should be in the with in with and the is Liver should be in the of and a to the or of and to in a with NAFLD. of and are in with and are to be an of no liver to a of from the in or in and not with disease or other are should be for the of or and Guidance a with it is to for and with and in the of or a liver should be of in with other of liver disease or to should a for liver of with should the of such or and Assessment of and in The of is is can to liver and liver Liver is the most approach for the of and in with it is is by and and and such and not the of liver in with NAFLD. there been in and for in with is the of this practice of the of and and the and of in with by or by is an for and is in The use of to is a for in an the of in with in is The of is a for the of in with is with of the of an of such and to the of liver with and such and are the for of have been for the of in with This is not available in a The for the of in to Liver and or and The is based on available and and is using the published a of of the an the of for with or A and to a and to the of is an based on and with are with are to have A recent and liver and (1) than other such and and (2) for in with The panel of of of and an of with and for or This panel been recently approved for use in is not available for use in the liver was recently approved by the and for use in and with liver recent the of in with using an on the of in with from the The liver for was with and The for was in of the the on the of using an with in with The rate for in this was The for for and was The recently experience with in with in the using a with an or rate for a liver was is for of in with the by than for or in or for and and have several with and in with for in is not Guidance with the of and can be to for a liver or are clinically for with of or or are clinically for in with NAFLD. to a Liver in Liver the for liver in with NAFLD. is for and some and it should be in the most from and Guidance Liver should be in with are of The of or or liver by or be for are for Liver should be in with in for and the of be a liver of The of are of with the of not by The for of liver in a with or the and on of the is the to from on of and The for have been by the by not with or and or not all for with of or in or and and of have no or of up to is or is and is with and is of in from in in be or in and and be in is readers refer to other recent publications for of of fatty liver disease in and are for of in from the and from the Liver of the and for The was developed a of in from a the the for for use in and from with the of and in with other of liver there is a for and for with based and to the of in and and The by a of was with in and when a a Guidance should a with and with and and A on or be Specific such be The or of should be a to and is of The of should of liver disease the such and with or have from a liver liver disease should be to with and Guidance liver disease should be to with and of and been to with NAFLD. 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A the of in for of of the and of The the on with received with of the liver developed the was to and the or in of and in not to be and with are on of to the of in is in of of or of by health than of with for with not be and for of by As in with of such and are for and of with of of for in health in for and there are no to with in this the of an for liver disease with and in with and with in the with other the to the of in of fatty or and in are in a of with and, on some liver is to and the of use or is in and for are the no panel of or can and in Guidance with fatty liver are or not should be for of such fatty and in to for of are in with in with or to should a liver to and Because of a of a formal recommendation be made with regard to for in with and A The to a liver in a to the of be the with and the the with an of than or of to of there is an in or of all with to a liver it be to are to have or to with for liver on in of and of have been to for The of the to of with based on of As in development of or to for or disease is of and are can be to in with a of and with is in in with an of of the or of with of a liver a with and the Guidance Liver in with should be in in the is or in there is of or A liver to a of should be on for of with can from in some in of and there is a in This is by or and in the of The and to be different in with Guidance liver should the in with to NAFLD. for are by a of and on to The is to a quality of and and liver and of should be made to from Because most have this is the in with in in and by in most with NAFLD. of the to this using and Because liver not the of the the of on liver not be with to or and not liver in in and the of with and in an or in to on of or the of to aspects of in is are to the of for should with a to quality of and of of American Association and in As in for or have in or liver on and A using in a the of or to in to with the of of was not different the there in and of with to this a no on liver or liver The from the of to this the in of or of was not the a in on to been some to fatty to in a of and to in for in in Guidance and liver in with and should be the of no to with and should not be to or The of a is not to some with of in is be to in and should be with each in

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