Review

Nonalcoholic Fatty Liver Disease:

Making the Diagnosis
Tooba Tariq, M.D.,* and Archita P. Desai, M.D.†

CLINICAL CONSULT 58% of individuals with diabetes. Although the prevalence

A 35-year-old man with diabetes and a body mass index
(BMI) of 40 was found to have increased echogenicity con-
sistent with fatty liver on ultrasound performed for right
upper quadrant pain. The pain is now resolved, and liver
blood tests are normal. What is the differential diagnosis?
What further testing, if any, is recommended?
MAKING THE DIAGNOSIS OF NAFLD
When imaging findings consistent with hepatic s­ teatosis
(HS) are noted, the diagnosis of nonalcoholic fatty liver
­disease (NAFLD) should be strongly suspected in the p
­ resence
of obesity and diabetes mellitus. The global prevalence rate
of NAFLD is estimated to be approximately 25%, with a
recent systematic review finding NAFLD to be prevalent in
is high, secondary causes of hepatic fat accumulation must
be ruled out to make the diagnosis of NAFLD.1,2
Figure 1 reviews the diagnostic work-up recommended
to investigate causes of HS seen on imaging.2-5
Secondary Causes of Hepatic Steatosis
HS characterized by excessive fat deposition in the liver is
the initial response to excessive drinking in >90% of cases.
It is the major secondary cause of fatty liver and occurs due
to accelerated hepatic lipogenesis, increased fatty acid trans-
port into the liver from the plasma, defective secretion of li-
poproteins (e.g., very low-density lipoproteins) from the liver
into the plasma, and reduced mitochondrial fatty acid oxida-
tion.6 Other competing causes of HS, including hepatitis C,
Wilson’s disease, medications (such as steroids, antiretroviral

Abbreviations: ALT, alanine aminotransferase; APRI, AST to Platelet Ratio Index; AST, aspartate aminotransferase; AUROC, area
under the receiver operating characteristic curve; BARD, BMI, body mass index; CK-18, cytokeratin-18; CRN, Clinical Research
Network; FIB-4, Fibrosis-4; GGT, Gamma-glutamyl transferase; HS, hepatic steatosis; MRE, magnetic resonance elastography;
NAFLD, nonalcoholic fatty liver disease; NAS, NAFLD activity score; NASH, nonalcoholic steatohepatitis; NFS, NAFLD fibrosis
score; NICE, National Institute for Health Care Excellence; NPV, negative predictive value; TE, transient elastography; VCTE,
vibration-controlled transient elastography.
From the * Division of Geriatrics, Indiana University School of Medicine, Indianapolis, IN; and † Division of Gastroenterology and
Hepatology, Indiana University School of Medicine, Indianapolis, IN.
Potential conflict of interest: Nothing to report.
Received October 3, 2019; accepted January 8, 2020.

View this article online at wileyonlinelibrary.com

© 2020 by the American Association for the Study of Liver Diseases

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| Clinical Liver Disease, VOL 16, NO 2, AUGUST 2020 An Official Learning Resource of AASLD
Review NAFLD Diagnosis Tariq and Desai

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FIG 1  Evaluation of NAFLD in an asymptomatic patient with normal liver function tests. Suggested diagnostic algorithm to investigate
causes of HS seen on imaging. In those individuals with risk factors for fatty liver disease, a stepwise approach using noninvasive testing
to screen for the presence of NASH and liver fibrosis can identify patients at highest risk for complications of HS seen on imaging.

therapy, amiodarone, and tamoxifen) and lipid disorder,
should be excluded before making a diagnosis of NAFLD.2
NAFLD is also associated with increased serum ferri-
tin levels, which is indicative of underlying inflammation
and insulin resistance. In these cases, a transferrin satu-
ration of <45% excludes hemochromatosis.4 In addition,
significant titers of autoantibodies are frequently encoun-
tered in patients with NAFLD. A study of well-character-
ized individuals with NAFLD found that nearly 20% had
antinuclear antibody >1:160 and/or anti–smooth muscle
antibody >1:40 in the absence of autoimmune hepatitis.
Although a liver biopsy may be needed to definitively rule
out coexisting autoimmune hepatitis in the right clinical
scenario, these autoantibodies were associated with more
advanced histological features of NASH in patients with
NAFLD alone.7
Beyond Simple Steatosis
Once the diagnosis of NAFLD is made, it is important
to differentiate between simple steatosis and nonalcoholic
steatohepatitis (NASH) for prognosis. Although invasive,
liver biopsy remains the gold standard for the diagnosis of
NAFLD and provides information about HS, hepatocellular
inflammation, and fibrosis. NAFLD activity score (NAS) is
a well-established scoring system for the histological as-
sessment of NAFLD. The NAS provides a composite score
based on the degree of steatosis, lobular inflammation,
hepatocyte ballooning, and fibrosis. A score >5 suggests
probable or definite NASH, and <3 indicates that NASH is
unlikely.4 Risks of liver biopsy include risk for death in 1 of
10,000, which limits the routine use of liver biopsy for di-
agnosis of NASH. Other major complications are bleeding
requiring transfusion, pneumothorax, hemothorax, and
perforation of another organ.8

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Review NAFLD Diagnosis Tariq and Desai

Noninvasive Diagnosis of NASH conducted on a morbidly obese population demonstrated

In those with HS and risk factors for NASH and/or liver
fibrosis, well-established noninvasive tests can further
risk-stratify patients with the goal of targeting those who
would benefit from liver biopsy, as well as aggressive man-
agement of their metabolic syndrome. Currently, the ma-
jority of patients with NAFLD can be diagnosed and staged
using noninvasive strategies.4,5,9
Elevated Alanine Aminotransferase for Diagnosis
of NASH
Often, a clinician’s main indicator to order further diagnos-
tic work-up for liver injury is abnormal liver transaminases,
such as an elevated alanine aminotransferase (ALT) level.
Unfortunately, population studies demonstrate that current
normal ranges of liver enzymes are too high, which might
miss a significant number of individuals with underlying liver
disease, leading to missed opportunities for intervention.10
In NAFLD, the diagnostic utility of ALT activity remains in-
sufficient with a sensitivity of 45%.3 Transaminase levels are
within normal limits in approximately 25% to 50% of pa-
tients with NAFLD and only mildly elevated in the remain-
ing 50% to 75% of patients. In fact, the entire histological
spectrum of NAFLD from macrovesicular steatosis to cirrhosis
may exist without elevation of ALT levels.
that the CK-18 levels decreased significantly after bariatric
surgery in patients with NASH.5 Although biomarkers such
as CK-18 may aid in the diagnosis of NASH versus simple
steatosis, their performance alone has not been validated in
prospective studies, and they are not available commercially.9
Predictive Models for the Diagnosis of NASH
Instead of biomarkers alone, combining clinical features
with serum markers may lead to a more accurate predic-
tion of NASH. It is well established that the risk for NAFLD
and NASH increases in the presence of metabolic syn-
drome. In addition, with increasing the number of meta-
bolic risk factors, there is a higher risk for progressive liver
disease.2 Hence metabolic risk factor profiling can be used
to identify patients with NASH until definitive diagnostic
tests are available.4 Capitalizing on the diagnostic accuracy
of both biomarkers and metabolic profiling has led to the
development of several predictive models to determine the
presence NASH. Examples include the NASHTest, NASH
Clinical Research Network (CRN) model, National Institute
for Health Care Excellence (NICE) model, NAFLD diagnostic
panel, and oxNASH risk score. As with biomarkers, these
models have demonstrated accuracy in predicting the
presence of NASH but have not been externally validated
in prospective cohort studies (Table 1).9,11

Biomarkers for Diagnosis of NASH

Potential biomarkers for the diagnosis of NASH have been
identified. They typically represent the key mechanisms be-
lieved to be involved in NASH pathogenesis, such as inflam-
mation, oxidative stress, apoptosis, and insulin resistance.5
One such marker is cleaved cytokeratin-18 (CK-18) frag-
ment, which is released during apoptosis and is significantly
elevated in patients with biopsy-proven NASH. A study
IDENTIFYING LIVER FIBROSIS IN NAFLD
Identifying those with fibrosis and staging the level
of fibrosis is key in determining prognosis and guiding
management.12 This is especially true for those individu-
als with advanced fibrosis who are at increased risk for
cirrhosis-related complications who need early, aggressive
management.

TABLE 1. NONINVASIVE TESTS TO DETERMINE THE PRESENCE OF NASH

Diagnostic Ability
Test (AUROC) Comments
CK-18 biomarker 0.82 Breakdown product during apoptosis of hepatocytes. Modest sensitivity/specificity in multiethnic cohort (58%-68%).
Not commercially available alone
NASHTest 0.78 Components include age, sex, height, weight, cholesterol, triglycerides, AST, ALT, bilirubin, haptoglobin
α2-macroglobulin, apolipoprotein A1
NASH CRN model 0.79 Components include AST level, ALT level, AST/ALT ratio, demographics (age, race, gender, and ethnicity), comorbidi-
ties (hypertension, type 2 diabetes, BMI, waist circumference, waist/hip ratio, and acanthosis nigricans), and other
laboratory tests
NICE model 0.83 Components include metabolic syndrome, ALT, and CK-18
NAFLD diagnostic panel 0.81 Based on diabetes, gender, BMI, triglycerides, M30 (CK-18 fragments as a marker of apoptosis), and M65 plus M30
(total CK-18 and CK-18 fragments as a marker of necrosis)
OxNASH risk score 0.79 Score is calculated from age, BMI, AST level, and the ratio of 13-hydroxy octadecadienoic acid to linoleic acid

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Review NAFLD Diagnosis Tariq and Desai

TABLE 2. NONINVASIVE TESTS FOR DETECTION OF LIVER FIBROSIS

Test Diagnostic Ability (AUROC) Comments
Enhanced liver fibrosis panel 0.87 Detects markers of matrix turnover, which includes tissue inhibitor metalloproteinase 1, N-terminal
propeptide of type III procollagen, and hyaluronic acid
Fibrometer 0.82 Includes ALT, AST, GGT, platelets, prothrombin time index, α2-macroglobulin, hyaluronic acid, ferritin,
glucose, and urea
FibroTest 0.81 Components include age, sex, bilirubin, GGT, haptoglobin, α2-macroglobulin, and apolipoprotein A1
BARD score 0.81 Components include BMI, AST/ALT ratio, and diabetes
NFS 0.84 Validated scoring system; components include age, diabetes, BMI, AST, ALT, platelets, and albumin
FIB-4 index 0.84 Reliably excludes advanced fibrosis because of high NPV. Components include age, AST, and
platelets
APRI 0.67 Initially developed for use in hepatitis C virus. Not specific for NAFLD
VCTE 0.83-0.95 Results may be invalid in obese patients (BMI >35 kg/m2); hence a FibroScan XL probe is
developed to overcome this problem
MRE 0.92 Widespread clinical adoption is limited because of its high cost and low availability

Similar to predicting the presence of NASH, generic and studies. Hence a low liver stiffness measure can reliably
disease-specific models have been developed to predict exclude advanced fibrosis.9
liver fibrosis (Table 2).2,11,13 An example of a disease-
A magnetic resonance equivalent of transient elastog-
specific model is the NAFLD fibrosis score (NFS). NFS is a
raphy (TE) has recently demonstrated excellent diagnostic
validated scoring system for identifying advanced fibrosis
accuracy with sensitivity and specificity of 98% and 99%,
in patients with NAFLD. An example of a generic model is
respectively, for detecting all grades of fibrosis. Magnetic
the Fibrosis-4 (FIB-4) index, which was originally developed
resonance elastography (MRE)-measured hepatic stiffness
for staging liver fibrosis in hepatitis C virus infection but
has the potential to identify NASH before fibrosis onset
also has an area under the receiver operating characteristic
and has better diagnostic accuracy than VCTE in both
curve (AUROC) of 0.84 for diagnosing advanced fibrosis.11
obese and nonobese patients.13
Table 2 summarizes these models.
A recent study that compared various risk scores and
It is important to note that clinical history alone can
elastography (MRE and TE) against liver histology showed
help identify high-risk patients. For example, presence
that NFS and FIB-4 were better than other indices, such as
of obesity, type 2 diabetes, age older than 45 years, an
BARD score, AST to Platelet Ratio Index (APRI), and AST/ALT
elevated aspartate aminotransferase (AST)/ALT ratio, hy-
ratio, and as good as MRE for predicting advanced fibrosis
pertension, and hyperlipidemia increase the risk for pro-
in patients with biopsy-proven NAFLD.2
gressive fibrosis and cirrhosis. Furthermore, the severity
of NAFLD correlates directly with the severity of the met-
abolic syndrome, and the presence of more metabolic
CONCLUSION
risk factors is associated with increased risk for NASH
and advanced fibrosis. Therefore, some would advo- The finding of HS in individuals with the clinical fea-
cate using these clinical features alone to triage patients tures of metabolic syndrome warrants further evaluation.
who need further screening for NASH and NASH-related Physicians should be vigilant about the possibility of NASH,
fibrosis.3 as well as advanced stages of NAFLD, despite normal ALT
levels, particularly in those with features of metabolic syn-
Radiological Assessment of Liver Fibrosis drome. We suggest that noninvasive tests should be un-
dertaken initially to rule out the presence of NASH and
Vibration-controlled transient elastography (VCTE) or
advanced fibrosis, and in case of indeterminate results, a
FibroScan is an ultrasound-based, noninvasive method of
liver biopsy should be performed.
measurement of liver stiffness due to deposition of fibrous
tissue in hepatic parenchyma. It has been shown to per- CORRESPONDENCE
form better than a number of noninvasive scoring systems
Archita P. Desai, M.D., Assistant Professor of Medicine, Indiana
in the staging of fibrosis with a high negative predictive University, Division of Gastroenterology and Hepatology, 702 Rotary
value (NPV) for greater than stage 3 fibrosis according to Circle, Suite 225, Indianapolis, IN 46202. E-mail: desaiar@iu.edu

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Review
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