Gå direkt till huvudinnehållet

Fettleversjukdom, icke-alkoholrelaterad (NAFLD)

Senast uppdaterad: Senast reviderad:
Sakkunnig:
Definition:
Tillstånd med ökad fetthalt (steatos) i levern hos personer som inte dricker eller endast dricker måttliga mängder alkohol. Kan delas in i icke-alkoholrelaterad fettlever (non-alcoholic fatty liver, NAFL) och icke-alkoholrelaterad steatohepatit (non-alcoholic steatohepatitis, NASH).
Förekomst:
Den vanligaste leversjukdomen i västvärlden med en prevalens på 20–30 %.
Symtom:
De flesta med NAFLD är symtomfria. Vissa presenterar med trötthet och sällan rapporterar patienter smärta i höger övre del av buken.
Kliniska fynd:
Vanligtvis fetma. Eventuellt andra tecken på metabolt syndrom (hypertoni) samt manifest typ 2-diabetes.
Diagnostik:
I vanliga fall hittas NAFLD vid utredning av patologiska leverprover eller som bifynd. Ultraljud är en trygg och billig metod för diagnostik av NAFLD. Vid konstaterad NAFLD är det viktigt att bedöma kardiovaskulära riskfaktorer.
Behandling:
Behandling av det metabola syndromet, där viktminskning anses vara den viktigaste åtgärden. Hos patienter typ 2-diabetes kan läkemedelsbehandling med metformin och eventuellt pioglitazon vara aktuell.
  1. Wilkins T, Tadkod A, Hepburn I, Schade RR. Nonalcoholic fatty liver disease: diagnosis and management. Am Fam Physician 2013; 88: 35-42. pmid:23939604 PubMed  
  2. Svensk gastroenterologisk förening (2019). Patologiska leverprover, sammanfattning och bakgrundsdokumentation. svenskgastroenterologi.se  
  3. Rinella ME. Nonalcoholic fatty liver disease: a systematic review. JAMA. 2015;313(22):2263-2273. PubMed  
  4. Svensk Gastroenterologisk Förening. Utredning och handläggning av fettleversjukdom, nationell riktlinje. 2020-01-20 (Hämtad 2020-10-14).
  5. Kaya E, Yilmaz Y. Metabolic-associated Fatty Liver Disease (MAFLD): A Multi-systemic Disease Beyond the Liver. J Clin Transl Hepatol. 2022 Apr 28;10(2):329-338. PMID:35528971. PubMed  
  6. Stål P. Liver fibrosis in non-alcoholic fatty lliver disease - diagnostic challenge with prognostic significance. World J Gastroenterol 2015; 21: 11077-87. PMID:26494963. PubMed  
  7. Riazi K, Azhari H, Charette JH, et al. The prevalence and incidence of NAFLD worldwide: a systematic review and meta-analysis. Lancet Gastroenterol Hepatol 2022. pmid:35798021 PubMed  
  8. Diehl AM, Day C. Cause, pathogenesis, and treatment of Non-alcoholic steatohepatitis. N Eng J Med 2017; 377: 2063-72. pmid:29166236 PubMed  
  9. Kanwal F, Shubrook JH, Adams LA, et al. Clinical Care Pathway for the Risk Stratification and Management of Patients With Nonalcoholic Fatty Liver Disease. Gastroenterology 2021; 161: 1657-69. pmid:34602251 PubMed  
  10. Williams CD, Stengel J, Asike MI, et al. Prevalence of nonalcoholic fatty liver disease and nonalcoholic steatohepatitis among a largely middle-aged population utilizing ultrasound and liver biopsy: a prospective study. Gastroenterology 2011; 140: 124-31. pmid:20858492 PubMed  
  11. Hagström H, Hoffstedt J, Reynisdottir S. Nya riktlinjer för fettlever fokuserar på tidig upptäckt. Läkartidningen. 2017;114:EFMD. www.lakartidningen.se  
  12. Sheka AC, Adeyi O, Thompson J, Hameed B, Crawford PA, Ikramuddin S. Nonalcoholic Steatohepatitis: A Review. JAMA. 2020;323(12):1175-1183. PMID:32207804. PubMed  
  13. Quek J, Chan KE, Wong ZY, et al. Global prevalence of non-alcoholic fatty liver disease and non-alcoholic steatohepatitis in the overweight and obese population: a systematic review and meta-analysis. Lancet Gastroenterol Hepatol 2023. pmid:36400097 PubMed  
  14. Baker JL, Farpour-Lambert NJ, Nowicka P, Pietrobelli A, Weiss R. Evaluation of the overweight/obese child - practical tips for the primary health care provider: recommendations from the Childhood Obesity Task Force of the European Association for the Study of Obessity. Obes Facts 2010; 3: 131-7. PubMed  
  15. Lavine JE, Schwimmer JB, Van Natta ML, et al. Effect of vitamin E or metformin for treatment of nonalcoholic fatty liver disease in children and adolescents. JAMA 2011; 305: 1659-68. Journal of the American Medical Association  
  16. DiNicolantonio JJ, Subramonian AM, O'Keefe JH. Added fructose as a principal driver on non-alcoholic fatty liver disease: a public health crisis. Open Heart 2017. pmid:29118995 PubMed  
  17. European Association for the Study of the Liver (EASL), European Association for the Study of Diabetes (EASD) and European Association for the Study of Obesity (EASO). EASL–EASD–EASO Clinical Practice Guidelines for the management of non-alcoholic fatty liver disease. J Hepatology 2016; 64(6): 1388-1402. pmid:27062661 PubMed  
  18. Chalasani N, Younossi Z, Lavine JE. The Diagnosis and Management of Nonalcoholic Fatty Liver Disease: Practice Guidance From the American Association for the Study of Liver Diseases. Hepatology 2018; 67(1): 328-357. pmid:28714183 PubMed  
  19. Maximos M, Bril F, Portillo Sanchez P, et al. The role of liver fat and insulin resistance as determinants of plasma aminotransferase elevation in nonalcoholic fatty liver disease. Hepatology. 2015;61(1):153-160. PMID:25145475. PubMed  
  20. Ajmera VH, Liu A, Singh S, et al. Clinical utility of an increase in magnetic resonance elastography in predicting fibrosis progression in NAFLD. Hepatology 2019. pmid:31556124 PubMed  
  21. Boursier J, Vergniol J, Guillet A, et al. Diagnostic accuracy and prognostic significance of blood fibrosis tests and liver stiffness measurement by FibroScan in non-alcoholic fatty liver disease. J Hepatol 2016; 65(3): 570-8. pmid:27151181 PubMed  
  22. Promrat K, Kleiner DE, Niemeier HM, et al. Randomized controlled trial testing the effects of weight loss on nonalcoholic steatohepatitis. Hepatology 2010; 51: 121. PubMed  
  23. Koutoukidis DA, Astbury NM, Tudor KE, et al. Association of Weight Loss Interventions With Changes in Biomarkers of Nonalcoholic Fatty Liver Disease A Systematic Review and Meta-analysis. JAMA Intern Med 2019. pmid:31260026. www.ncbi.nlm.nih.gov  
  24. Holmer M, Lindqvist C, Petersson S. Treatment of NAFLD with intermittent calorie restriction or low-carb high-fat diet – a randomized controlled trial. JHEP 2021. Publicated before print. DOI:10.1016/j.jhepr.2021.100256.
  25. Francque SM, Bedossa P, Ratziu V, et al. A Randomized, Controlled Trial of the Pan-PPAR Agonist Lanifibranor in NASH. N Engl J Med 2021; 385: 1547-58. pmid:34670042 PubMed  
  26. Younossi ZM, Ratziu V, Loomba R, et al. Obeticholic acid for the treatment of non-alcoholic steatohepatitis: interim analysis from a multicentre, randomised, placebo-controlled phase 3 trial. Lancet 2019; 394: 2184-96. pmid:31813633 PubMed  
  27. Shouhed D, Steggerda J, Burch M, Noureddin M. The role of bariatric surgery in nonalcoholic fatty liver disease and nonalcoholic steatohepatitis. Expert Rev Gastroenterol Hepatol 2018; 9: 797-811. pmid:28712339 PubMed  
  28. Elsaid MI, Li Y, Bridges JFP, et al. Association of Bariatric Surgery With Cardiovascular Outcomes in Adults With Severe Obesity and Nonalcoholic Fatty Liver Disease. JAMA Netw Open 2022; 5: e2235003. PMID:36205997. PubMed  
  29. Simon TG, Henson J, Osganian S, et al. Daily Aspirin Use Associated With Reduced Risk For Fibrosis Progression In Patients With Nonalcoholic Fatty Liver Disease. Clin Gastroenterol Hepatol 2019. pmid:31077838 PubMed  
  30. Dulai PS, Singh S, Patel J, et al. Increased risk of mortality by fibrosis stage in nonalcoholic fatty liver disease: Systematic review and meta-analysis. Hepatology 2017; 65(5): 1557-1565. pmid:28130788 PubMed  
  31. Simon TG, Roelstraete B, Khalili H, et al. Mortality in biopsy-confirmed nonalcoholic fatty liver disease: results from a nationwide cohort. Gut 2020. Published online 19 oct 2020. doi:10.1136/gutjnl-2020-322786 DOI  
  32. Angulo P, Keach JC, Batts KP, et al. Independent predictors of liver fibrosis in patients with nonalcoholic steatohepatitis. Hepatology 1999; 30: 1356. pmid:10573511 PubMed  
  33. Sanyal A, Natta MLV, Clark J, et al. Prospective Study of Outcomes in Adults with Nonalcoholic Fatty Liver Disease. N Engl J Med 2021; 385: 1559-69. pmid:34670043 PubMed  
  • Remy Waardenburg, specialist i allmänmedicin, medicinsk redaktör Medibas
  • Hanns-Ulrich Marschall, professor och universitetssjukhusöverläkare, Medicinkliniken gastrosektionen, Sahlgrenska Universitetssjukhuset, Göteborg