Intended for healthcare professionals

Rapid response to:

Editor's Choice

Non-alcoholic fatty liver disease

BMJ 2011; 343 doi: (Published 20 July 2011) Cite this as: BMJ 2011;343:d4652

Rapid Response:

Pediatric NAFLD: management of a silent killer

Pediatric NAFLD: management of a silent killer

Anna Alisi and Valerio Nobili

Autoimmunity and Metabolic Liver Diseases, Liver Research Unit, Bambino
Ges? Children's Hospital and Research Institute, S. Onofrio 4 Square,
00165 Rome, Italy

Correspondence to: V. Nobili

We read in the BMJ this very interesting and valuable Editor's Choice. As
well underlined by Fiona Godlee (BMJ 2011;343:d4652 doi:
10.1136/bmj.d4652), during the past two decades non-alcoholic fatty liver
disease (NAFLD) has escalated to be top of the chronic liver disease
list in several western countries. This escalation is particularly
dangerous in children, who are not only at risk of developing NAFLD; but
when they are exposed to other etiological cofactors (i.e. alcohol and
drugs consumption) during the critical time of adolescence, they
become more predisposed to developing severe organ damage (i.e. cirrhosis) when
they get older1. Even more worrying is the fact that it is now widely
accepted that NAFLD is not simply a disease of liver-resident cells, but
it is part of a cluster of several other cardiometabolic factors (e.g.
central obesity, insulin resistance, glucose intolerance, dyslipidemia,
hypertension, hyperinsulinemia and microalbuminuria) representing
metabolic syndrome. Therefore, even though the concept of the hepato-cardiometabolic syndrome is still subject to debate due to lack of
information, the association between NAFLD and metabolic syndrome also
puts the children at risk of developing cardiovascular disease in adulthood2.

For all these reasons it is reasonable why several worldwide government
organizations have launched preventive and/or therapeutic programs against
NAFLD. These strategies are mainly based on lifestyle changes and diet
because they are the most recognized useful interventions against NAFLD.

Lifestyle changes and diet are concepts that children and their parents
accept with reluctance, and often a quite long time elapses before
these therapeutic interventions are actually adopted. Unfortunately, NAFLD
is also a silent killer that remains asymptomatic until it is at an
advanced stage, and during the tortuous cycle required to set lifestyle
changes and diet in place it continues to progress. Thus, at the present state of
our knowledge, we have to focalize two challenges. The first one is to
develop a non-invasive screening tool applicable to all obese patients
with abnormal liver tests suspected to have NAFDL, and in the meantime,
while we wait for non-pharmacological therapy to be really effective
something needs to be done. Therefore, we believe that the use of
therapeutic interventions, able to stop NAFLD progression and safeguard
patients from possible irreversible organ damage, should be the
strategy adopted at the early phase of NAFLD management. As we
recently suggested,3 the right way to treat NAFLD in children, but
probably also in adults, due to the multi-factoriality of this disease,
could be a multi-targeted approach.


1. Nobili V, Pinzani M. Alcoholic and Non-alcoholic Fatty Liver in
Adolescents: A Worrisome Convergence. Alcohol Alcohol. 2011 Jun 22. [Epub
ahead of print]

2. Alisi A, Cianfarani S, Manco M, Agostoni C, Nobili V. Non-alcoholic
fatty liver disease and metabolic syndrome in adolescents: Pathogenetic
role of genetic background and intrauterine environment. Ann Med. 2011 Feb
28. [Epub ahead of print]

3. Alisi A, Nobili V. Nonalcoholic fatty liver disease: Targeted therapy
in children-what is the right way? Nat Rev Gastroenterol Hepatol. 2011 Jul
12. doi: 10.1038/nrgastro.2011.117. [Epub ahead of print]

Competing interests: No competing interests

22 July 2011
Valerio Nobili
Chief of Liver Research Unit
Anna Alisi, Liver Unit Researcher
Bambino Gesu Children Hospital