Copyright ©The Author(s) 2021. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Gastroenterol. May 21, 2021; 27(19): 2281-2298
Published online May 21, 2021. doi: 10.3748/wjg.v27.i19.2281
Individualized treatment options for patients with non-cirrhotic and cirrhotic liver disease
Lukas Hartl, Joshua Elias, Gerhard Prager, Thomas Reiberger, Lukas W Unger
Lukas Hartl, Thomas Reiberger, Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna A-1090, Austria
Lukas Hartl, Thomas Reiberger, Vienna Hepatic Hemodynamic Lab, Medical University of Vienna, Vienna A-1090, Austria
Joshua Elias, Lukas W Unger, Cambridge Institute of Therapeutic Immunology and Infectious Disease, Jeffrey Cheah Biomedical Centre, University of Cambridge, Cambridge CB2 0AW, United Kingdom
Joshua Elias, Division of Gastroenterology and Hepatology, Department of Medicine, University of Cambridge, Addenbrooke’s Hospital, Cambridge CB2 0QQ, United Kingdom
Gerhard Prager, Lukas W Unger, Division of Visceral Surgery, Department of General Surgery, Medical University of Vienna, Vienna A-1090, Austria
Author contributions: Hartl L, Elias J and Unger LW performed literature review, prepared figures and tables and wrote the manuscript; Prager G and Reiberger T gave important intellectual input; all authors contributed intellectually, critically revised the manuscript and approved the final version of the manuscript.
Supported by Austrian Science Fund FWF, No. J4396; and Wellcome Trust PhD Fellowship for Clinicians, No. UNS59491.
Conflict-of-interest statement: LH, JE, GP and LWU declare no conflicts of interest related to this manuscript. TR received grant support from Abbvie, Boehringer-Ingelheim, Gilead, MSD, Philips Healthcare, Gore; speaking honoraria from Abbvie, Gilead, Gore, Intercept, Roche, MSD; consulting/advisory board fee from Abbvie, Bayer, Boehringer-Ingelheim, Gilead, Intercept, MSD, Siemens; and travel support from Abbvie, Boehringer-Ingelheim, Gilead and Roche.
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See:
Corresponding author: Lukas W Unger, MD, PhD, Doctor, Division of Visceral Surgery, Department of General Surgery, Medical University of Vienna, Währinger Gürtel 18-20, Vienna A-1090, Austria.
Received: January 24, 2021
Peer-review started: January 24, 2021
First decision: March 7, 2021
Revised: March 19, 2021
Accepted: April 25, 2021
Article in press: April 25, 2021
Published online: May 21, 2021

The obesity pandemic has led to a significant increase in patients with metabolic dysfunction-associated fatty liver disease (MAFLD). While dyslipidemia, type 2 diabetes mellitus and cardiovascular diseases guide treatment in patients without signs of liver fibrosis, liver related morbidity and mortality becomes relevant for MAFLD’s progressive form, non-alcoholic steatohepatitis (NASH), and upon development of liver fibrosis. Statins should be prescribed in patients without significant fibrosis despite concomitant liver diseases but are underutilized in the real-world setting. Bariatric surgery, especially Y-Roux bypass, has been proven to be superior to conservative and/or medical treatment for weight loss and resolution of obesity-associated diseases, but comes at a low but existent risk of surgical complications, reoperations and very rarely, paradoxical progression of NASH. Once end-stage liver disease develops, obese patients benefit from liver transplantation (LT), but may be at increased risk of perioperative infectious complications. After LT, metabolic comorbidities are commonly observed, irrespective of the underlying liver disease, but MAFLD/NASH patients are at even higher risk of disease recurrence. Few studies with low patient numbers evaluated if, and when, bariatric surgery may be an option to avoid disease recurrence but more high-quality studies are needed to establish clear recommendations. In this review, we summarize the most recent literature on treatment options for MAFLD and NASH and highlight important considerations to tailor therapy to individual patient’s needs in light of their risk profile.

Keywords: Metabolic dysfunction-associated fatty liver disease, Non-alcoholic fatty liver disease, Portal hypertension, Cirrhosis, Bariatric surgery, Metabolism

Core Tip: No single therapy fits all needs, sometimes resulting in complex clinical decision making. While some etiologies can distinctly be characterized, a multifactorial disease such as metabolic dysfunction-associated fatty liver disease requires thorough assessment of comorbidities and severity of concomitant fibrosis to assess a patient’s overall risk. While (guided) physical exercise is usually safe and well tolerated and strict treatment of diabetes and dyslipidemia is warranted, patients often fail to change their lifestyle, resulting in life-long drug dependency for comorbidities. Bariatric surgery has therefore become a valid option for obese patients and should be offered in eligible patients before liver fibrosis develops.