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Nonalcoholic SteatohepatitisA Review

Educational Objective
To review the diagnosis and management of nonalcoholic steatohepatitis (NASH).
1 Credit CME

Importance  Nonalcoholic steatohepatitis (NASH) is the inflammatory subtype of nonalcoholic fatty liver disease (NAFLD) and is associated with disease progression, development of cirrhosis, and need for liver transplant. Despite its importance, NASH is underrecognized in clinical practice.

Observations  NASH affects an estimated 3% to 6% of the US population and the prevalence is increasing. NASH is strongly associated with obesity, dyslipidemia, type 2 diabetes, and metabolic syndrome. Although a number of noninvasive tests and scoring systems exist to characterize NAFLD and NASH, liver biopsy is the only accepted method for diagnosis of NASH. Currently, no NASH-specific therapies are approved by the US Food and Drug Administration. Lifestyle modification is the mainstay of treatment, including dietary changes and exercise, with the primary goal being weight loss. Substantial improvement in histologic outcomes, including fibrosis, is directly correlated with increasing weight loss. In some cases, bariatric surgery may be indicated to achieve and maintain the necessary degree of weight loss required for therapeutic effect. An estimated 20% of patients with NASH will develop cirrhosis, and NASH is predicted to become the leading indication for liver transplants in the US. The mortality rate among patients with NASH is substantially higher than the general population or patients without this inflammatory subtype of NAFLD, with annual all-cause mortality rate of 25.56 per 1000 person-years and a liver-specific mortality rate of 11.77 per 1000 person-years.

Conclusions and Relevance  Nonalcoholic steatohepatitis affects 3% to 6% of the US population, is more prevalent in patients with metabolic disease and obesity, progresses to cirrhosis in approximately 20% of cases, and is associated with increased rates of liver-specific and overall mortality. Early identification and targeted treatment of patients with nonalcoholic steatohepatitis are needed to improve patient outcomes, including directing patients toward intensive lifestyle modification to promote weight loss and referral for bariatric surgery as indicated for management of obesity and metabolic disease.

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Article Information

Corresponding Author: Sayeed Ikramuddin, MD, MHA, University of Minnesota, Department of Surgery, 420 Delaware St, SE, MMC 195, Minneapolis, MN 55455 (

Accepted for Publication: February 14, 2020.

Correction: This article was corrected on April 28, 2020, to fix a typographical error in the Figure 1 legend to properly identify symptoms attributed to NASH.

Conflict of Interest Disclosures: Dr Hameed reported receiving grants from Gilead, Intercept, Conatus, and Genfit. Dr Ikramuddin reported receiving grant support from ReShape Life Sciences and equipment from Medtronic. No other disclosures were reported.

Funding/Support: Drs Ikramuddin and Crawford are supported by grant R21 DK122832 from the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK), National Institutes of Health (NIH).

Role of the Funder/Sponsor: The NIDDK and NIH had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

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