NAFLD in the 20’s. From Epidemiology to Management (PART - II). Editorial

This second part of the single-topic issue entitled “NAFLD in the 20’s. From epidemiology to management” concludes this special issue of CPD. Nonalcoholic fatty liver disease (NAFLD) is an “umbrella” definition, which describes the whole range of pathological liver changes spanning from simple steatosis to nonalcoholic steatohepatitis (NASH). NASH may be associated with fibrosis, which carries an increased risk of progressing to either cirrhosis or hepatocellular carcinoma (HCC), which, in this case, is defined as NAFLD-related HCC. Given that NAFLD affects up to a quarter of the general adult population in Europe and USA and owing to the global decline of other causes of chronic liver disease, such as viral hepatitis, NAFLD is rapidly becoming the leading cause of HCC worldwide. In addition to its liver-related burden, NAFLD is also associated with an increased risk of adverse cardiovascular events and other extra-hepatic diseases. Therefore, the prediction of the natural history of this common and burdensome liver disease is key in implementing personalized management and follow-up strategies. On this background, Tovoli et al. from the group led by Professor Piscaglia in Bologna, Italy, have examined published studies pertinent to characterizing those features of NAFLD-related HCC useful in distinguishing this specific etiology of HCC from cases of HCC owing to other non-NAFLD etiologies in humans [1]. In their systematic review, these authors were able to retrieve a total of 244 eligible original papers. Data have shown that NAFLD-related HCC may often escape the surveillance programs given that it is difficult to precisely identify the population at high-risk, and that NAFLD-related HCC may also occur amongst patients with non-cirrhotic NASH. These specific features will result in delayed diagnoses, more limited access to radical management options and, eventually, in a reduced life expectancy which is not due to inherently more aggressive behavior of HCC. On these grounds, it is expected that additional efforts to further improve prevention, surveillance protocols and identification of drugs modifying the course of NAFLD will beneficially impact healthcare expenditures and clinical outcomes of patients with NAFLD-related HCC [1]. Dr. Ballestri et al. from Modena, Italy, have highlighted the importance of diagnosing NAFLD through non-invasive imaging techniques [2]. In their extensive review of the literature, the authors examined the added value of conventional liver ultrasonography when performed with semi-quantitative scores. These simple ultrasonographic scores can effectively rate the severity of steatosis and its progression over time (indicating those subjects, who should undergo second-line imaging techniques or liver biopsy), while also acting as accurate sensors of cardio- metabolic health [2]. Along the same line, Dr Pennisi et al. from the group led by Prof. Petta, Palermo, Italy, have extensively discussed the main limitations of liver biopsy for the diagnosis of NAFLD. These include the invasiveness and potentially life-threatening, albeit rare complications of this method, as well as its poor acceptability, sampling variability and costs [3]. On these grounds, the authors have critically discussed the clinical importance of differentiating simple steatosis from NASH as well as of non-invasively assessing liver fibrosis [3]. We are grateful to the CPD Editorial Team for granting us the honor to serve as Guest Editors of this single-topic issue. We also thank all those Colleagues who accepted to contribute their outstanding articles to the present monography to which we wish great success.