Understanding NASH progression

NASH (non‑alcoholic steatohepatitis) is a progressive condition, meaning that without intervention, it may get worse over time. Keep in mind that even if you’re not experiencing any specific symptoms, your NASH could be causing scarring of the liver, known as fibrosis. As fibrosis gets worse, scar tissue builds up in the liver, making it more and more difficult for the liver to do its job.

A closer look at the liver

  • Healthy liver
    • Little to no fat
    • No inflammation
    • No liver cell injury
  • Fatty liver
    • Fat buildup
    • No inflammation
    • No liver cell injury
  • NASH liver
    • Fat buildup
    • Inflammation
    • Liver cell injury
      • With NASH, fibrosis may be developing in the liver. Without intervention, liver damage will continue to get even worse.

Why stopping fibrosis matters

Over time, fibrosis can progress to advanced fibrosis—a state where scarring has spread throughout the liver. Advanced fibrosis includes cirrhosis, which is extreme scarring or hardening of the liver. Once you progress to advanced fibrosis, you’re at higher risk of experiencing serious health issues like liver cancer and liver failure, which requires a transplant.

  • NASH liver
    with fibrosis 
    • Fat buildup
    • Inflammation
    • Liver cell damage
    • Fibrosis (scarring)
  • NASH liver with
    advanced fibrosis
    without cirrhosis*
    • Fat buildup
    • Inflammation
    • Liver cell damage
    • Advanced fibrosis (scarring)
  • NASH liver with
    advanced fibrosis
    with cirrhosis*
    • Fat buildup
    • Inflammation
    • Liver cell damage
    • Cirrhosis (extreme scarring or hardening of the liver)

*Cirrhosis is a form of advanced fibrosis where the liver shows extreme scarring or hardening.

If you have fibrosis due to NASH, stopping the progression of fibrosis—or reversing it—must be your primary goal.

Tracking NASH and fibrosis progression

If you’ve been diagnosed with NASH, it’s a good idea to visit your doctor or liver specialist regularly to assess your overall liver health and track NASH progression. Even if your doctor measured your liver damage in the past, NASH is a progressive disease, so it’s a good idea to ask if fibrosis has developed—or gotten worse—since your last test. Liver health and fibrosis testing can be done in a number of ways, generally breaking down into 2 categories:

  • Non-invasive testing: generally does not require breaking the skin beyond taking a blood sample
  • Invasive testing: requires inserting a medical instrument into the liver

Non‑invasive testing options

Liver Function
Tests (LFTs)

LFTs are blood tests that help determine and track the overall health of your liver.

LFTs measure the levels of certain enzymes, proteins, and other substances in your blood, including the following:

  • ALT (alanine transaminase)
  • AST (aspartate transaminase)
  • ALP (alkaline phosphatase)
  • Bilirubin

Based on the levels of the above substances in your blood, your doctor may perform more tests to determine if you have NASH or some other condition. LFTs alone can’t determine if you have NASH or if fibrosis due to NASH is progressing, but they may help your doctor paint a more complete picture of what’s going on. Additionally, some LFTs may also be part of the calculation for composite scoring, which is used to determine the presence of advanced fibrosis.

Composite Scoring/
Serum Tests

Composite scoring includes different serum tests (blood tests) to detect advanced fibrosis, making composite scoring a key part of diagnosis and a good way to track progression of fibrosis due to NASH. More and more doctors are using composite scoring methods because they are widely available and relatively low cost.

Depending on the composite score used, your doctor will enter personal data (like your age) and the results of a number of other tests (like LFTs, your body mass index, and your platelet count) into a formula to estimate your amount of liver fibrosis.

Examples of composite scoring include the following:

  • The non‑alcoholic fatty liver disease fibrosis score (NFS)
  • Fibrosis-4 (FIB-4)
  • The AST to platelet ratio index (APRI)
  • FibroSure® (known as FibroTest® outside of the US)

Imaging Tests

Imaging tests use technology to “look” inside your body to help determine how far fibrosis due to NASH has progressed.

Some imaging tests (such as ultrasound) show the amount of fat in your liver while others are able to measure liver stiffness, which correlates with fibrosis.

Examples of imaging tests include the following:

  • FibroScan® (ultrasound‑based elastography)
  • MRE (magnetic resonance elastography)

Invasive testing options

Biopsy

A needle is inserted into the liver to withdraw liver tissue, which is then examined using a microscope.

Liver biopsies—though painful and invasive—are the standard way to diagnose NASH and fibrosis. But over the past few years, doctors have become more comfortable with non-invasive options for tracking progression of fibrosis due to NASH.

Ask your doctor or liver specialist about non-invasive tests and if they may be right for tracking your liver health. If you’re not yet working with a liver specialist, find one here.

Remember: Regular doctor visits are key to tracking progression of fibrosis due to NASH.

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