Fatty liver vs Fibrosis

[nareshdinesh]

Is fatty liver and fibrosis related? Does the former come ahead of the latter?
My liver is 10% fatty (MRE results) and has stiffness of 2.3 kpa (MRE results)
But liver biopsy revealed fibrosis stage 1/6 (Ishak scale).
My viral count (HBVDNA)  has been below 20 for 3 years. And HBSAG quantitative has been steadily coming down (last year 6 iu/ml to 1 iu/ml now)

Is it fair to assume that my fibrosis must have been a product of active virus a couple of years ago?
Is it right that at such low level of virus- it must not be damaging liver?

[nareshdinesh]

You can look at this for MRE vs Fibroscan

http://cds.ismrm.org/ismrm-2007/files/00216.pdf

[Bravesoul]

Fibrosis is scar tissue your liver makes during repeated/chronic injury to the liver cells. Our liver has a tremendous ability to regenerate itself after the causative agent of injury subsides. It's likely your once "active" infection generated a significant  amount of fibrosis which has been slowly regressing over the years as your liver continues to heal. Since you're an inactive Carrier as shown by your very low viral load and HbsAg levels, it's unlikely the virus would cause you any further liver damage. However, the fatty liver may or may not damage your liver depending on whether you develop a condition called NASH, which is characterized by infiltration of fatty mass inside the liver, causing inflammation. It's important to note not all fatty liver cases result in NASH, but NASH tends to develop in the setting of a fatty liver. Your doctor would help you figure out if you have NASH by running an LFT test on you and checking if your ALT levels are elevated.

[Bravesoul]

How old are you if I might ask?

[nareshdinesh]

40

[nareshdinesh]

@liverpatient- my doc says that MRE is the gold standard to detect the stiffness of liver as unlike in Fibroscan which captures stiffness of only a certain part of liver, MRE does it for the whole liver.
I have also read reports on it. Do you have other views?

[Bravesoul]

I don't think there's yet a medicine approved for NASH but there are many under clinical development. Intact one of the drugs in clinical trials for hepatitis B effectively treats NASH as well.
NASH is usually a slow process and only around 20% of patients proceed to cirhosis, usually after decades. You don't need to worry much. Just watch your diet and manage your diabetes in the best way you can.

[nareshdinesh]

Thanks Bravesoul... how invaluable your insights have been! I have some very good doctor friends but they won't put these things in perspective (the way u have done)! Some strange person in another time zone comes to offer such generous help. Why do we all do this- altruistic Gene, may be??

[Bravesoul]

You're very welcome man. It's just that being part of a community living with HBV, I find  great satisfaction in helping others, and expect help in return should I require it as well. We should all help and look after each other because we are a minority and the disease is very complex, so we tend to value opinions from People who could relate to us!

[nareshdinesh]

That's true! Disease is very very complex and I realise that docs don't comprehend it well. The standard template simply don't seem to work.

Look at my case.. one doc (who is excessively focused on LFT)says- relax because my liver enzymes are normal.

The other says MRE is a better way to assess the scarring. Since it's only 2.3kpa.. my liver is normal.

I ask them why my biopsy shows fibrosis then? No one answers!!

[Bravesoul]

Yeah I understand your concern. I'm in a similar boat. I got diagnosed 2 months ago, my viral load was 140iu and alt was 19, yet my fibrosan showed f1-f2 fibrosis and I'm only 24. I have a normal BMI and am non diabetic,  no fat accumulation over the liver using USG yet still have significant fibrosis. I don't wanna take a risk thus I'm considering going on treatment to prevent further worsening of the liver. Personally I have very high hopes for a cure coming out in the next decade so hopefully I won't be on the medicines forever.

[nareshdinesh]

What's your HBSAG count? Though HBVDNA is a right metric to look at for viral replication.. HBSAG quantitative is a metric to assess the amount of virus in liver.

The current guidelines don't suggest treatment if your HBVDNA is less than 2000 and ALT/AST is normal.

[Bravesoul]

I haven't had a HbsAg quantitative test done yet but will do this week. And I will base my decision for treatment on this result. If it's above 1000iu    I will start treatment otherwise I won't.
I know current guidelines don't recommend treatment in my situation but my fibroscan results are worrisome, especially because I can't trace the damage to a cause other than HBV. I might go on treatment for a few years to see if my fibroscan lowers overtime and eventually withdraw treatment. If I'm genuinely inactive, it's unlikely the virus would reactivate upon cessation of treatment cuz it wasn't active to begin with.

[nareshdinesh]

That's a bad news for me. There is no medicine for it?
My doc says that he may recommend vitamin E if my liver stiffness worsens or Liver function test shows up some abnormality.
I hear that near 10% population in US and India suffer from NASH.
Is it fair to assume that my Fibrosis is a product of NASH instead of HBV?

[Bravesoul]

NASH has nothing to do with Hepatitis B. It's a condition mostly seen in people that have metabolic syndrome ( diabetes, obesity). Fatty liver and not fibrosis always precedes NASH, since it's the accumulation of 'fat' over the liver that causes the damage. However fibrosis usually worsens the damage by NASH as more fat penetrates through the fibrotic liver tissues.

[nareshdinesh]

Is NASH an independent disease Or it's a produce of HBV or fatty liver? Or there could be some other cause of it?

My sugar levels have never been very high for past 5 years and my liver wasn't fatty until dec15.

Does it precede fibrosis - always?

[Liverpatient]

Hi, have you ever had FibroScan; you've mentioned MRE scan, but as far as I know, the FibroScan is the one used to determine the degree of fibrosis, while ultrasound is used to see any hcc risks in the liver.

[Bravesoul]

Any elastrography method can accurately detect liver stiffness because they all employ the same principle.

[nareshdinesh]

http://www.scbtmr.org/Portals/9/2016%20Syllabus/Wednesday/Fibrosis%20Quantification-MR%20Elastography_Venkatesh.pdf?ver=2016-08-23-104142-173

His may be helpful too to understand the MRE outputs.

[Liverpatient]

Hi, thanks for the link, it is indeed helpful, but it surprises me a bit because here in this forum, it has been FibroScan that gets mentioned often about the non-invasive analysis of liver fibrosis. I think FibroScan is a quite easier, quicker, and less expenssive method than MRE, with comparable end results.

[Bravesoul]

It is a little surprising though that your ALT is in the 20s while your biopsy and ultrasound shows liver inflammation. But neverthess, you should do what you can to reverse your fatty liver which should take care of NASH as well.

[nareshdinesh]

Thanks Bravesoul. Another question- it will be gr8 if u can answer this:

I am diabetic but absolutely in control (hba1c 5.7 for past 4 years). I am underweight.

My ultra sound diagnosis: mild hepatomagaly (15.9 cm... this is a name for increase in the size of liver. My liver size was 13.5 cm last year). Is that too related to NASH? Does the increase in size make it riskier?
My MRE' diagnosis: 2.3 kpa stiffness. Fat- 7-10%.

My Liver enzymes are in order. ALT/AST in 20s.

[Bravesoul]

Yes, hepatomegaly is a result of liver inflammation since your liver is swollen. At this time, it's safe to assume your liver inflammation is due to NASH and not HBV. Diabetes is a huge risk factor for NASH since a vast majority of diabetic patients develop this condition, so continue to practise good control over your sugar levels, look after your diet and incorporate exercise into your schedule. If you lose the 'fat' on your liver,  you will get rid of NASH as well.

[Bravesoul]

And yes, NASH is as dangerous as "active" Hepatitis B and if you don't 'manage' it, you can progress to cirrhosis and/or liver cancer.

[nareshdinesh]

Thanks @bravesoul. My Biopsy reports' diagnosis reads as follows:

Chronic hepatitis b associate with mild non alcoholic steaohepatitis. Mild activity. Portal fibrosis (Ishak stage 2/6) along with perivenular collagenisation.
Modified HAI (hepatic activity index) 4/18

[Bravesoul]

Your liver biopsy confirms you have NASH (acronym for Non-Alcoholic Steatohepatitis), although mild. I would suggest you immediately make a few lifestyle changes that would potentially reverse this condition. Firstly, a diet low in simple carbs and fat and high in vegetables, fruit and moderate in protein is ideal. Exercising is the anther great way to lose the fat on your liver. Also if you're diabetic, you need to manage your sugar levels better. Good luck!

[nareshdinesh]

No answer to this?