NASH and diabetes

Last edited 06/2020 and last reviewed 09/2021

Non-alcoholic fatty liver disease (NAFLD) includes a wide spectrum of liver pathology, ranging from fatty liver alone to the more severe nonalcoholic steatohepatitis (1)
  • NAFLD is the most common cause of chronically elevated LFTs in the United States in both diabetic and nondiabetic individuals
    • with respect to patients with NAFLD, 60-95% are obese, 28-55% have type 2 diabetes, and 20-92% have hyperlipidemia (2)
    • if NAFLD develops in people who are not heavy drinkers then the condition generally has a benign clinical course (3,4)
      • NAFLD is a cause of hepatic inflammation histologically resembling that of alcohol-induced liver disease but usually slowly progressive and of low-grade severity. ..However, the disorder may ultimately result in cirrhosis (4)
    • there is evidence of associations between NAFLD and obesity, dyslipidaemia and insulin resistance (4,5)
    • NAFLD generally results in an asymptomatic elevation of liver enzyme levels (6), including ALT and AST - ALT is primarily found in the liver whereas AST is also found in other tissues and is a less specific marker of liver integrity
    • in the setting of marker-negative elevated LFTs, the most likely histological diagnosis is fatty metamorphosis of the liver with occasional associated fibrosis (6)
    • significant iron accumulation is not seen in NAFLD (7)

A suggested schemata regarding the assessment of NAFLD in type 2 diabetes has been outlined (8):

Click here for link to NAFLD fibrosis score Online calculator


  1. Angulo P. Nonalcoholic fatty liver disease. N Engl J Med 2002;346: 1221-31.
  2. Harris EH.Elevated Liver Function Tests in Type 2 Diabetes.Clinical Diabetes 2005; 23:115-119.
  3. Matteoni CA, Younossi ZM, Gramlich T, Boparai N, Liu YC, McCullough AJ. Nonalcoholic fatty liver disease: a spectrum of clinical and pathological severity. Gastroenterology 1999;116: 1413-9.
  4. Powell EE, Cooksley WG, Hanson R, Searle J, Halliday JW, Powell LW. The natural history of nonalcoholic steatohepatitis. a follow-up study of forty-two patients for up to 21 years. Hepatology 1990;11: 74-80.
  5. Marchesini G, Bugianesi E, Forlani G, Cerrelli F, Lenzi M, Manini R, Bop M et al. Nonalcoholic fatty liver, steatohepatitis, and the metabolic syndrome. Hepatology 2003;37: 917-23.
  6. Daniel S, Ben Menachem T, Vasudevan G, Ma CK, Blumenkehl M. Prospective evaluation of unexplained chronic liver transaminase abnormalities in asymptomatic and symptomatic patients. Am J Gastroenterol 1999;94: 3010-4.
  7. Hepatology. 1999 Oct;30(4):847-50.
  8. The North West London Health and Care Partnership. North West London Diabetes Guidelines (Accessed 16/6/2020).