Individualized treatment options for patients with non-cirrhotic and cirrhotic liver disease

Abstract

The obesity pandemic has led to a significant increase in patients with metabolic dysfunction-associated fatty liver disease (MAFLD). While dyslipidemia, type 2 diabetes mellitus and cardiovascular diseases guide treatment in patients without signs of liver fibrosis, liver related morbidity and mortality becomes relevant for MAFLD’s progressive form, non-alcoholic steatohepatitis (NASH), and upon development of liver fibrosis. Statins should be prescribed in patients without significant fibrosis despite concomitant liver diseases but are underutilized in the real-world setting. Bariatric surgery, especially Y-Roux bypass, has been proven to be superior to conservative and/or medical treatment for weight loss and resolution of obesity-associated diseases, but comes at a low but existent risk of surgical complications, reoperations and very rarely, paradoxical progression of NASH. Once end-stage liver disease develops, obese patients benefit from liver transplantation (LT), but may be at increased risk of perioperative infectious complications. After LT, metabolic comorbidities are commonly observed, irrespective of the underlying liver disease, but MAFLD/NASH patients are at even higher risk of disease recurrence. Few studies with low patient numbers evaluated if, and when, bariatric surgery may be an option to avoid disease recurrence but more high-quality studies are needed to establish clear recommendations. In this review, we summarize the most recent literature on treatment options for MAFLD and NASH and highlight important considerations to tailor therapy to individual patient’s needs in light of their risk profile.

Keywords: Metabolic dysfunction-associated fatty liver disease; Non-alcoholic fatty liver disease; Portal hypertension; Cirrhosis; Bariatric surgery; Metabolism

Core Tip: No single therapy fits all needs, sometimes resulting in complex clinical decision making. While some etiologies can distinctly be characterized, a multifactorial disease such as metabolic dysfunction-associated fatty liver disease requires thorough assessment of comorbidities and severity of concomitant fibrosis to assess a patient’s overall risk. While (guided) physical exercise is usually safe and well tolerated and strict treatment of diabetes and dyslipidemia is warranted, patients often fail to change their lifestyle, resulting in life-long drug dependency for comorbidities. Bariatric surgery has therefore become a valid option for obese patients and should be offered in eligible patients before liver fibrosis develops.