Nonalcoholic Fatty Liver Disease Diagnosis and Management

Clinical Presentation and Diagnosis

The American Diabetes Association recommends screening adults with prediabetes for NAFLD, particularly those with cardiometabolic risk factors 5, 6, 7
Prediabetes is a major risk factor for NAFLD, with strong mechanistic links through insulin resistance and metabolic dysfunction 4, 2, 3
The transaminase pattern of ALT > AST with an AST:ALT ratio of <1 is characteristic of early-stage NAFLD 1, 2, 3
NAFLD prevalence exceeds 70% in patients with type 2 diabetes and prediabetes, making it the most common cause of elevated liver enzymes in this population 5, 6, 7

Calculate the FIB-4 index using age, ALT, AST, and platelet count to risk-stratify for clinically significant fibrosis 5, 6, 7, 8
Exclude other causes of liver disease by checking hepatitis B surface antigen, hepatitis C antibody, and assessing alcohol consumption using validated screening tools (AUDIT or AUDIT-C) 4, 1, 3, 8
Obtain complete metabolic panel and CBC if not already done, to assess for other liver dysfunction markers and calculate fibrosis scores 8

The AST:ALT ratio may reverse (>1) in later stages of disease or with progression to cirrhosis, so AST:ALT >1 does not exclude NAFLD 1, 2, 3
Approximately 50% of patients with NAFLD have normal liver chemistries, and a normal or near-normal ALT does not exclude nonalcoholic steatohepatitis (NASH) 1, 2, 3
Wilson disease should be considered in any patient under 40 with unexplained liver enzyme elevations, though the pattern of modest elevations with ALT > AST is less typical for Wilson disease 9