Recommendations 10. As the metabolic syndrome predicts the presence of steatohepatitis GSK3235025 in patients with NAFLD, its presence can be used to target patients for a liver biopsy. (Strength – 1, Evidence – B) 11. NAFLD Fibrosis Score is a clinically useful tool for identifying

NAFLD patients with higher likelihood of having bridging fibrosis and/or cirrhosis. (Strength – 1, Evidence – B) 12. Although serum/plasma CK18 is a promising biomarker for identifying steatohepatitis, it is premature to recommend in routine clinical practice. (Strength – 1, Evidence – B) Liver biopsy remains the gold standard for characterizing liver histology in patients with NAFLD. However, it is expensive and carries some morbidity and very rare mortality risk. Thus, it should be performed in those who would benefit the most from selleckchem diagnostic, therapeutic guidance, and prognostic perspectives. Recommendations 13. Liver biopsy should be considered in patients with NAFLD who are at increased risk to have steatohepatitis and advanced fibrosis. (Strength – 1, Evidence – B) 14. The presence

of metabolic syndrome and the NAFLD Fibrosis Score may be used for identifying patients who are at risk for steatohepatitis and advanced fibrosis. (Strength – 1, Evidence – B) 15. Liver biopsy should be considered in patients with suspected NAFLD in whom competing etiologies for hepatic

steatosis and co-existing chronic liver diseases cannot be excluded without a liver biopsy. (Strength – 1, Evidence – B) The management of patients with NAFLD consists of treating liver disease as well as the associated metabolic co-morbidities such as obesity, hyperlipidemia, insulin resistance and T2DM. As patients with NAFLD without steatohepatitis have excellent prognosis from a liver standpoint, treatments aimed at improving liver disease should be limited to those with NASH. Many studies indicate that lifestyle modification may reduce aminotransferases and improve hepatic steatosis when measured either by ultrasound73-80 or MR imaging and spectroscopy.81-94 In a meta-analysis of 15 early case series and clinical studies spanning between 1967 through 2000, most studies reported reductions in aminotransferases either and hepatic steatosis by ultrasound across a broad spectrum of diets of different caloric restriction intensities and macronutrient composition (low vs. high carbohydrate, low vs. high fat, saturated vs. unsaturated fat diets).95 However, these early studies were inconclusive as a result of being small, largely uncontrolled and few using histology as the primary endpoint. More recent uncontrolled studies also showed an improvement in aminotransferases and hepatic steatosis on histology with lifestyle modification.