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The Dangers of Fatty liver…It may catch you unawares

Dr M Shafi Kuchay

R K Gupta, a fine gentleman, is living with type 2 diabetes and hypertension since age 50. He is also known to have fatty liver, first seen on ultrasonography when he was 45 years of age.

He has been controlling his diabetes and hypertension well, following all the advices of his doctor. It is, therefore, no surprise that even after 17 years of diabetes and hypertension, he has no complications like diabetic eye disease or diabetic kidney disease.

Mr. Gupta will celebrate his 67th birthday in the coming week. So far, so good.
Last week, he got his routine blood testing done.

He was surprised to see that his hemoglobin and platelet counts were low. He consulted his doctor, who suggested a few other investigations including ultrasound of his abdomen. Ultrasound revealed shrunken liver.

The doctor suspected liver disease and referred him to a liver specialist. After many more investigations, he was confirmed to have cirrhosis of liver. The diagnosis was a bolt from the blue for Mr. Gupta. He was confused and stunned.

He has been controlling his diabetes and hypertension so well, he had never imagined that he would develop a disease like cirrhosis of liver. The liver specialist came to the conclusion that his long-term fatty liver had given rise to cirrhosis of liver.

R P Gupta has been having fatty liver since age 45. He was told by many, including his doctor, that it was a harmless condition. He had never bothered about his fatty liver. How could this seemingly innocuous condition would destroy his liver?

A decade ago, fatty liver was considered a benign condition. Research in recent years proved, beyond any doubt, that fatty liver can progress to a more severe condition called nonalcoholic steatohepatitis (NASH). NASH signifies that fat droplets has given rise to inflammation in the liver.

In a few individuals, NASH can, over years, progress to cirrhosis of liver. Cirrhosis means scarring of liver, which ultimately leads to liver failure.

When fat builds up in liver cells (hepatocytes), it is called fatty liver. It is a disease because a liver cell is not a store house for fat. Fat droplets build up in the liver because there is excess of fat in the body.

This occurs due to long-term over-nutrition and underactivity. In the modern era, because of always-sit-in-a-chair type lifestyle and energy-dense food environment, fatty liver disease has hit epidemic proportions. Globally, fatty liver is the most common liver disease. In the industrialized world, fatty liver disease is the number one cause for liver transplantation.

Fatty liver disease, like type 2 diabetes, is a life-style disorder. As is true with type 2 diabetes, fatty liver increases your chances of being hit by a heart attack or stroke. It also impairs your kidney functioning. But unlike type 2 diabetes, there is not a single medicine approved for treating fatty liver disease. This is because no medicine has been proven beneficial beyond doubt for this disease.

However, there are some strategies/medicines that may help to some extent. Life-style modification (diet and exercise) has been shown to reduce liver fat in a number of studies. Weight loss of more than 10 per cent is required for reducing fat and inflammation in the liver. But long-lasting lifestyle changes are not sustained for prolonged period of time. Although diet and exercise are advised to all diabetes patients, only a small proportion of patients are actually able to adhere to the advice. Having said this, you must, however, never stop following a healthy lifestyle. A good diet and regular exercise not only reduce liver fat, but also improve almost all organs and give you overall fitness.

A diabetes medicine, pioglitazone, has been shown to improve fatty liver disease. However, in the famous PIVANS study, the improvement was modest. Another reason for its lack of use in fatty liver disease is its undesirable side-effects. Pioglitazone increases body weight that most patients do not like. It also causes fluid retention that is not desired in patients with type 2 diabetes who are already at risk for heart failure. These are the reasons pioglitazone is not a favorite medicine among most experts as well as patients.
Liraglutide is a daily injectable medicine that has been approved for type 2 diabetes. This medicine reduces body weight as well. In fatty liver studies, liraglutide reduced liver fat and improved inflammation of liver. Although liraglutide improves fatty liver disease, but being an injectable and a costly drug, its patient acceptability is poor.
Gliflozins (empagliflozin, Dapagliflozin) are new anti-diabetes medicine. As this medicine causes loss of glucose through urine, its long-term use leads to chronic calorie loss and thereby weight loss. Many members of this group have been shown to reduce liver fat. In diabetes patients who also have fatty liver, these medicines can be useful. It would be like ‘one arrow two targets’ strategy.
There are many other drugs that are in pipeline for fatty liver disease. These medicines have been designed to reduce inflammation and fibrosis that fatty liver gives rise to. But, before a new medicine gets approved for fatty liver, it must pass the test of efficacy and safety.
Meanwhile, Mr. Gupta is doing well on medicines. His hemoglobin and platelets have improved a bit. He might require liver transplantation for cirrhosis of liver if he develops recurring complications. Unlike Mr. Gupta, you don’t have to wait for complications to occur. If you have fatty liver disease, talk to your doctor about it. Follow healthy dietary patterns and exercise regularly
(The author is a consultant endocrinologist and researcher working in Medanta The Medicity Hospital, Gurugram and can be reached at [email protected])