An 45 year old Asian male presents to your clinic to establish care. His weight is 155 lbs and his height is 5 ft 3 inches. He is taking metformin 500mg BID for metabolic syndrome diagnosed 3 years ago (HgB A1C was 6.0) and he also uses a CPAP for sleep apnea diagnosed 5 years ago. He recently underwent a cardiac stent a year ago for 85% occlusion of the left anterior descending artery. He saw a hepatologist six months ago for elevated AST/ALT (AST= 35/ALT=62) and underwent biopsy which showed steatosis with inflammation and stage 1 liver fibrosis. His hepatologist wants to see him back in 3 years and recommended healthy diet and exercise and close management of his metabolic comorbidities. You checked his AST/ALT today and found them to be 25 IU/I and 32IU/I respectively.
This case study illustrates a patient with the phenomenon of non-obese NAFLD. The case study also illustrates the strong correlation between NASH and cardiovascular disease. This patient’s BMI of 27.5 kg/m2 puts him in the obese range for his race (but he would only be in the overweight range if he were Caucasian race). Based on his liver biopsy, he has NASH (steatosis and inflammation) with stage 1 fibrosis. He will be monitored for progression of fibrosis by his hepatologist every 3 years since fibrosis progression is a slow process. His AST and ALT are in a normal range (29 to 33 IU/l for males, 19 to 25 IU/l for females) today but were not 6 months ago even though he has known NASH. This illustrates the concept that AST/ALT are not a reliable indicator of the presence or absence of NASH/advanced fibrosis.