The Pointy End of the NAFLD Iceberg: Cirrhosis, Portal Hypertension, and Liver Failure

This chapter discusses the progression of non-alcoholic steatohepatitis (NASH) to advanced fibrosis and cirrhosis, which occurs within the broader disease spectrum of non-alcoholic fatty liver disease (NAFLD). NASH appears to progress slowly to cirrhosis in a substantial number of patients, although the exact rate of disease progression has been difficult to predict. The leading cause of death in NASH remains vascular disease, although after progression to cirrhosis, liver-related complications become the major determinant of mortality. The occurrence of decompensated liver disease and hepatocellular carcinoma (HCC) appears to occur less frequently in NASH cirrhosis than in patients with cirrhosis due to hepatitis C, although overall mortality rates remain similar. Finally, NASH cirrhosis is expected to become the most common indication for liver transplant in future decades, with posttransplant survival in selected patients similar to that due to other common liver diseases, despite the recurrence of NAFLD in most patients.