Fatty liver disease is a growing, silent epidemic, especially among younger patients, says UB physician

BUFFALO, N.Y. – Once almost exclusively seen in older adults, fatty liver disease, which can be fatal if untreated, is now one of the world’s fastest-growing diseases. And it’s increasingly occurring in young people as well. The condition, where fat accumulates in the liver, causing inflammation and damage, is considered a “silent disease” since there are typically no symptoms until the advanced stages.

Many patients at high risk

Anyone with hypertension, cardiovascular disease, high cholesterol and triglyceride levels (hyperlipidemia), obesity or diabetes is at risk for fatty liver disease, says Anthony (Tony) D. Martinez, MD, clinical associate professor of medicine in the Jacobs School of Medicine and Biomedical Sciences at the University at Buffalo and a physician with UBMD Internal Medicine.

Martinez founded and directs La Bodega, the liver clinic with a unique mission at Erie County Medical Center.

“The clinic is really like a bodega, where patients can get whatever services they need,” he says, “but bodega also means a community gathering space. People feel it when they come here. We’re a very welcoming place. No white coats allowed.”

And not surprisingly, no one calls Martinez “Doctor;” he is Tony to everyone. Part of La Bodega’s mission is to provide comprehensive treatment to any patient with liver disease, whether they have hepatitis C, HIV or substance use disorder. All these patients are at high risk for fatty liver disease, also known as Metabolic Dysfunction-Associated Steatohepatitis (MASH).

“We’ve always co-managed hepatitis C and addiction because there’s so much overlap,” says Martinez. “It’s rare to have a program where all the advanced practice providers are cross-trained in addiction and hepatology, but it’s a requirement here. It’s also just a lot easier, so folks don’t have to go from one specialist to another. We’re a one-stop shop.”

Interrelated factors

Now he is taking that holistic approach to address what is becoming a dramatic increase — even an epidemic — in fatty liver disease, due to the obesity epidemic, dietary habits, lack of physical activity in our daily lives, food insecurity and the higher prevalence of diabetes and cardiovascular disease.

 “Fatty liver disease is intertwined with all of these things,” says Martinez. “One doesn’t necessarily cause the other, but they are interrelated.”

In addition, new research reveals that patients of Hispanic, Latino and Chicano descent can have genetic mutations that put them at much higher risk, even if they are at a normal weight or don’t have any of the typical comorbidities.

“About a quarter of patients with the disease have what we call lean MASH, and they have normal weight, but based on genetics and other factors, they can have fatty liver disease,” says Martinez. “In some cases, they even have advanced disease.”

The disease is typically asymptomatic until patients develop advanced fibrosis (scarring in the liver); thus people often don’t know they have it. Symptoms of advanced disease include fatigue, jaundice, itchiness and, in end-stage disease, swelling in the legs or abdomen. Once a patient gets to a particular stage of fibrosis, they are also at increased risk for developing liver cancer.

“All of this is completely preventable,” says Martinez. “You just have to identify it early.”

From Fib 4 to Fibroscan

His advice: Anyone with a risk factor, such as cardiovascular disease, diabetes, hypertension, hyperlipidemia or obesity should ask their doctor about the “Fib 4.” That’s a simple calculation based on a patient’s age, platelet count and liver enzymes that can quickly estimate an individual’s risk for fatty liver disease. Patients with access to their lab results can even calculate it themselves; some websites will provide the calculation online if patients enter the values.

And while the Fib 4 has long been the quick, non-invasive way to assess risk for fatty liver disease, La Bodega is increasingly using the Fibroscan, a non-invasive modality similar to an ultrasound that uses shear wave elastography to determine liver health.

“Fibroscan has become the hepatologist’s stethoscope,” says Martinez. The machine uses ultrasound waves to detect the stiffness of the liver; stiffness correlates with fibrosis. Because Fibroscan can accurately evaluate a patient’s fibrosis stage and the degree of fat within the liver, Martinez recommends that primary care physicians, cardiologists and endocrinologists have their patients with comorbidities get a baseline Fibroscan test.

“With Fibroscan, we can see who has more advanced disease and who could potentially benefit from being seen, so we can initiate treatment as needed,” he says.

Promising new medications for liver disease are also coming onto the market. Resmetiron, which was the first FDA-approved treatment for MASH with fibrosis stages 2 and 3, works directly in the liver and can reverse fibrosis and steatosis (fatty liver). More recently, the GLP-1 drug semaglutide was approved for fatty liver disease. Improved outcomes for fatty liver disease always depend on diet and lifestyle modifications, as well as treatment.

“We are trying to change the screening paradigm and focus on early detection,” Martinez says.

Fatty liver disease is also a costly issue for the health care system. Once an individual develops advanced fibrosis and cirrhosis, costs approach $40,000 a year, per patient. If the patient develops liver cancer, the cost doubles. And if a transplant is needed, that cost balloons to nearly $1 million a year, per patient.

“With early identification and treatment, we not only prevent these downstream complications but there’s huge cost savings, too,” says Martinez.