There is a silent epidemic of Metabolic-Associated Fatty Liver Disease (MAFLD) in Ireland and patients with type 2 diabetes, obesity, and high cholesterol are at greater risk of developing this disease which, if undiagnosed and left untreated, may lead to cirrhosis of the liver.

International Clinical Practice Guidelines now recommend that screening for MAFLD should be part of routine work-up in patients with type 2 diabetes, obesity, and metabolic syndrome.

Your liver is a vital organ that performs many essential functions. It is the largest solid organ in the body, and is located under your rib cage on the upper right side. Your liver processes everything you eat, drink, breathe, and absorb through your skin. It turns nutrients into energy your body can use, and removes harmful substances from your blood.

Fatty liver disease rarely causes symptoms until the liver disease is advanced. Fatty liver usually is found or suspected when:

• Abnormal liver tests are found on routine blood testing
• Fat is seen on ultrasound examination of the abdomen, performed for other reasons such as the diagnosis of gallstones
• The liver is enlarged on physical examination of a patient

If there is any doubt regarding the diagnosis or if there is a need to determine the severity of liver damage, a liver biopsy may be performed. A non-invasive, painless alternative to a liver biopsy is the FibroScan® test.

Fat can build up in the liver due to alcohol consumption and by increasing body weight. When fat makes up more than 10% of the liver’s weight, it is called Fatty Liver Disease. If the extra fat is not caused by drinking too much alcohol, the disease is called Metabolic-associated Fatty Liver Disease (MAFLD).

People with certain medical conditions are at higher risk for developing MAFLD, including:

• Type 2 Diabetes
• Obesity
• High Cholesterol
• High Blood Pressure
• High Triglycerides

Yes, studies indicate that approximately 25% of the adult population in most countries in Europe and the US have MAFLD, and the incidence is increasing in parallel with increasing rates of diabetes and obesity.

In Ireland, approximately 225,000 people have diabetes (mostly type 2 diabetes), and up to 80% of patients with type 2 diabetes have fat in their liver. Two thirds of diabetes patients older than 50 years are estimated to have MAFLD with advanced liver scarring or fibrosis.

If someone has MAFLD for a long time, the liver can become damaged from scarring of the liver (fibrosis). If this involves all of the liver and becomes irreversible, it is called cirrhosis.

Patients with type 2 diabetes who do not drink alcohol can still develop cirrhosis because of fat related inflammation and scarring. This sub-type of MAFLD is called MASH, or Metabolic-associated Steatohepatitis, and has a higher risk for liver scarring and progression to liver failure compared to patients who have simple fat in their liver with no inflammation.

MAFLD and MASH do not always cause cirrhosis; however, over 20–30 years, cirrhosis can occur. Cirrhosis is a risk factor for liver failure and liver cancer.

Like many liver diseases, MAFLD and MASH are “silent” diseases, which means that people who have them often do not feel sick until they have significant liver damage. Because the awareness of the risk of liver disease due to MAFLD in patients with diabetes is low, patients may not be screened for liver problems. Sometimes, MAFLD is diagnosed when tests are done for other reasons (medical insurance, occupational health screen). MAFLD often causes no symptoms. If symptoms do occur, they tend to be non-specific such as fatigue, a dull ache in the upper right abdomen, poor concentration, and achy joints.

A liver ultrasound scan is often the first test to diagnose MAFLD but it cannot detect how much scar tissue (fibrosis) has developed.

Liver blood tests (GGT, ALT) may be elevated  in MAFLD patients but research has shown that up to 80% of patients with MAFLD and liver damage can have normal liver blood tests. So liver blood tests are not a sensitive test for screening diabetic patients for MAFLD.

A liver biopsy is an accurate test but may be painful.

A FibroScan® assessment is a painless non-invasive alternative to detecting liver fat and fibrosis (scarring). International Clinical Guidelines recommended the FibroScan® assessment as a validated non-invasive procedure for the identification of patients at risk of MAFLD.

Weight reduction is the key factor in treating NAFLD. Studies have proven that losing 7–10% body weight reduces liver fat, reduces liver inflammation and liver scarring.

Patients with diabetes and or high cholesterol should control these conditions. Uncontrolled diabetes or high cholesterol can lead to progressive liver disease.