Evidence based literature review of clinical management of non-alcoholic fatty liver disease in real world settings
DOI:
https://doi.org/10.18203/2319-2003.ijbcp20171651Keywords:
Non-alcoholic fatty liver disease, Non-alcoholic steatohepatitis, Ursodeoxycholic acidAbstract
The aim of the present review is to understand the gap between real world clinical practices, guidelines recommendations and to propose minimum essentials that can be followed in clinical practice in NAFLD patients in India. A detailed literature search of published medical reports in English language was performed on electronic databases such as PubMed and Cochrane, from 2000 to 2016 using relevant search terms. The search yielded 25 relevant articles whose full texts were retrieved and evaluated. Non-alcoholic fatty liver disease (NAFLD) is an emerging cause of liver disease in India. It is observed that physicians under appreciate the overlap between NAFLD and metabolic risk factors, thus missing a significant proportion of high-risk NAFLD patients. Lifestyle intervention is generally considered the first line therapy for patients with NAFLD without steatohepatitis while pharmacotherapy (in addition to lifestyle intervention) is suggested for patients with non-alcoholic steatohepatitis (NASH). Current therapies are directed towards improving the metabolic parameters which contribute to disease pathogenesis. Pharmacological therapies for NAFLD and NASH include antioxidants such as vitamin E and ursodeoxycholic acid; insulin sensitizers such as metformin and thiazolidinones, weight loss drugs like orlistat and consideration of bariatric surgery for morbidly obese patients. High degree of suspicion is necessary for diagnosing NAFLD in patients with metabolic risk factors. Further studies are required from India as genotype/clinico-pathological profile of Indian NAFLD patients differ from the western population. Further, prospective studies will fill the various missing links associated with management of NAFLD in Indian patients in a more effective manner.
Metrics
References
Duseja A. Nonalcoholic fatty liver disease in India – a lot done, yet more required!. Indian J Gastroenterol. 2010;29:217-25.
Ekstedt M, Franzen L, Mathiesen U, Thorelius L, Holmqvist M, Bodemar G et al. Long-term follow-up of patients with NAFLD and elevated liver enzymes. Hepatol. 2006;44:865-73.
EASL-EASD-EASO Clinical practice guidelines for the management of non-alcoholic fatty liver disease. J Hepatol. 2016;64:1388-402.
Ayata G, Gordon F, Lewis W, Pomfret E, Pomposelli J, Jenkins R et al. Cryptogenic cirrhosis: clinicopathologic findings at and after liver transplantation. Hum Pathol. 2002;33:1098-104.
Shimada M, Hashimoto E, Taniai M, Hasegawa K, Okuda H, Hayashi N et al. Hepatocellular carcinoma in patients with non-alcoholic steatohepatitis. J Hepatol. 2002;37:154‑60.
Ludwig J, Viggiano T, McGill D, Oh B. Nonalcoholic steatohepatitis: Mayo clinic experience with a hitherto unnamed disease. Mayo Clin Proc. 1980;55:434-8.
Sanyal A. American Gastroenterological Association. AGA technical review on nonalcoholic fatty liver disease. Gastroenterol. 2002;123:1705-25.
Neuschwander-Tetri B, Caldwell S. Nonalcoholic steatohepatitis: summary of an AASLD single topic conference. Hepatol. 2003;37:1202-19.
Das K, Das K, Mukherjee P, Ghosh A, Ghosh S, Mridha A et al. Nonobese population in a developing country has a high prevalence of nonalcoholic fatty liver and significant liver disease. Hepatol. 2010;51:1593-602.
Bellentani S, Saccoccio G, Masutti F, Croce L, Brandi G, Sasso F et al. Prevalence of and risk factors for hepatic steatosis in Northern Italy. Ann Intern Med. 2000;132:112-7.
Madan K, Batra Y, Gupta S, Chander B, Rajan K, Tewatia M, et al. Non-alcoholic fatty liver disease may not be a severe disease at presentation among Asian Indians. World J Gastroenterol. 2006;12:3400-5.
Duseja A, Das A, Das R, Dhiman R, Chawla Y, Bhansali A et al. The clinicopathological profile of Indian patients with nonalcoholic fatty liver disease (NAFLD) is different from that in the west. Dig Dis Sci. 2007;52:2368-74.
Petersen K, Dufour S, Feng J, Befroy D, Dziura J, Man C, et al. Increased prevalence of insulin resistance and nonalcoholic fatty liver disease in Asian-Indian men. Proc Nat Acad Sci. 2006;103:18273-7.
Weiss R, Dziura J, Burgert T, Tamborlane W, Taksali S, Yeckel C et al. Obesity and the metabolic syndrome in children and adolescents. N Engl J Med. 2004;350:2362-74.
Nascimbeni F, Pais R, Bellentani S, Day C, Ratziu V, Loria P et al. From NAFLD in clinical practice to answers from guidelines. J Hepatol. 2013;59:859-71.
Bacon B, Farahvash M, Janney C, Neuschwander-Tetri B. Nonalcoholic steatohepatitis: an expanded clinical entity. Gastroenterol. 1994;107:1103-9.
Angulo P. Nonalcoholic fatty liver disease. N Eng J Med. 2002;346(16):1221-31.
Tilg H, Diehl A. Cytokines in alcoholic and nonalcoholic steatohepatitis. N Eng J Med. 2000;343:1467-76.
Duseja A, Murlidharan R, Bhansali A, Sharma S, Das A, Das R et al. Assessment of insulin resistance and effect of metformin in nonalcoholic steatohepatitis: a preliminary report. Indian J Gastroenterol. 2004;23:12-5.
Dhiman R, Duseja A. Nonalcoholic fatty liver disease. Medicine Update. 2005;94:469-75.
Day C, James O. Steatohepatitis: a tale of two “hits”?. Gastroenterol. 1998;114:842-5.
Dowman J, Tomlinson J, Newsome P. Pathogenesis of non-alcoholic fatty liver disease. Q J Med. 2010;103:71-83.
Singh S, Panigrahi M. Guidelines for Assessment and Management of Nonalcoholic Fatty Liver Disease in Indians, Chapter 55. Available at http://www.apiindia.org/medicine_update_2013/chap55.pdf. Accessed on 14th January 2017.
Byrne C, Targher G. EASL-EASD-EASO Clinical Practice Guidelines for the management of non-alcoholic fatty liver disease: is universal screening appropriate?. Diabetologia 2016;59:1141-4.
Duseja A, Singh S, Saraswat V, Acharya S, Chawla Y, Chowdhury S et al. Non-alcoholic fatty liver disease and metabolic syndrome-position paper of the Indian national association for the study of the liver, endocrine society of India, Indian college of cardiology and Indian society of gastroenterology. J Clin Exp Hepatol. 2015;5:51-68.
Loguercio C, Tiso A, Cotticelli G, Blanco C, Arpino G, Laringe M et al. Management of chronic liver disease by general practitioners in southern Italy: unmet educational needs. Dig Liver Dis. 2011;43:736-41.
Farrell G, Chitturi S, Lau G, Sollano J, Asia Working Party on NAFLD. Guidelines for the assessment and management of Non-Alcoholic Fatty Liver Disease in the Asia-Pacific Region. J Gastroenterol Hepatol. 2007;22:775-7.
WHO Expert Consultation. Appropriate body-mass index for Asian populations and its implications for policy and intervention strategies. Lancet. 2004;363:157-63.
Grattagliano I, D’Ambrosio G, Palmieri V, Moschetta A, Palasciano G, Portincasa P. Steatostop Project’ Group. Improving nonalcoholic gatty liver disease management by general practioners: a critical evaluation and impact of of an educational training program. J Gastrointest Liver Dis. 2008;17:389-94.
Falck-Ytter Y, Younossi Z, Marchesini G, McCullough A. Clinical features and natural history of nonalcoholic steatosis syndromes. Semin Liver Dis. 2001;21:17-26.
Mishra P, Younossi Z. Abdominal ultrasound for diagnosis of nonalcoholic fatty liver disease (NAFLD). Am J Gastroenterol. 2007;102:2716-7.
Strauss S, Gavish E, Gottlieb P, Katsnelson L. Interobserver and intraobserver variability in the sonographic assessment of fatty liver. AJR Am J Roentgenol. 2007;189:W320-3.
Davidson L, Kuk J, Church T, Ross R. Protocol for measurement of liver fat by computed tomography. J Appl Physiol. 2006;100:864-8.
Szczepaniak L, Nurenberg P, Leonard D, Browning J, Reingold J, Grundy S et al. Magnetic resonance spectroscopy to measure hepatic triglyceride content: prevalence of hepatic steatosis in the general population. Am J Physiol Endocrinol Metab. 2005;288:E462-8.
Wong V, Chu W, Wong G, Chan R, Chim A, Ong A, et al. Prevalence of non-alcoholic fatty liver disease and advanced fibrosis in Hong Kong Chinese: a population study using proton-magnetic resonance spectroscopy and transient elastography. Gut. 2016;61:409-15.
Ratziu V, Cadranel J, Serfaty L, Denis J, Renou C, Delassalle P, et al. A survey of patterns of practice and perception of NAFLD in a large sample of practicing gatsroenterologists in France. J Hepatol. 2012;57:376-83.
Arora A, Sharma P. Non-invasive diagnosis of fibrosis in non-alcoholic fatty liver disease. J Clin Exp Hepatol. 2012;2:145-55.
Chalasani N, Younossi Z, Lavine J, Diehl A, Brunt E, Cusi K, et al. The diagnosis and management of non-alcoholic fatty liver disease: practice guideline by the American association for the study of liver diseases, American college of gastroenterology, and the American gastroenterological association. Hepatol. 2012;55:2005-23.
Bergqvist C, Skoien R, Horsfall L, Clouston A, Jonsson J, Powell E. Awareness and opinions of non-alcoholic fatty liver disease by hospital specialists. Intern Med J. 2013;43:247-53.
Zelber-Sagi S, Ratziu V, Oren R. Nutrition and physical activity in NAFLD: an overview of the epidemiological evidence. World J Gastroenterol. 2011;17:3377-89.
Sreenivasa Baba C, Alexander G, Kalyani B, Pandey R, Rastogi S, Pandey A, et al. Effect of exercise and dietary modification on serum aminotransferase levels in patients with non-alcoholic steatohepatitis. J Gastroenterol Hepatol. 2006;21:191-8.
Ueno T, Sugawara H, Sujaku K, Hashimoto O, Tsuji R, Tamaki S, et al. Therapeutic effects of restricted diet and exercise in obese patients with fatty liver. J Hepatol. 1997;27:103-7.
Suzuki A, Lindor K, St Saver J, Lymp J, Mendes F, Muto A, et al. Effect of changes on body weight and lifestyle in non-alcoholic fatty liver disease. J Hepatolo. 2005;43:1060-6.
Bhat G, Baba C, Pandey A, Kumari N, Choudhari G. Life style modification improves insulin resistance and liver histology in patients with non-alcoholic fatty liver disease. World J Hepatol. 2012;4:209-17.
Musso G, Bo S, Cassader M, Michieli F, Gambino R. Impact of sterol regulatory element-binding factor-1c polymorphism on incidence of nonalcoholic fatty liver disease and on the severity of liver disease and of glucose and lipid dysmetabolism. Am J Clin Nutr. 2013;28:895-906.
Amarpurkar D. Approach to NAFLD in India in Non-Alcoholic Fatty Liver Disease. Khanna S (Ed). ECAB Clinical update Gatsroenterology Hepatology. New Delhi: Elsevier 2010;57-75.
Simopoulos A. Dietary omega-3 fatty acid deficiency and high fructose intake in the development of metabolic syndrome, brain metabolic abnormalities, and non-alcopholic fatty liver disease. Nutrients. 2013;5:2901-23.
Capanni M, Calella F, Biagini M, Genise S, Raimondi L, Bedogni G, et al. Prologed n-3 polyunsaturated fatty acid supplementation ameliorates hepatic steatosis in patients with non-alcoholic fatty liver disease: a pilot study. Aliment Pharmacol Ther. 2006;23:1143-51.
Nair S. Nonalcoholic fatty liver disease from the perspective of an internist. The Ochsner J. 2002;4:92-7.
Tamura Y, Tanaka Y, Sato F, Choi J, Watada H, Niwa M, et al. Effects of diet and exercise on muscle and liver intracellular lipid contents and insulin sensitivity in type 2 diabetic patients. J Clin Endocrinol Metab. 2005;90:3191-6.
Kantartzis K, Thamer C, Peter A, Machann J, Schick F, Schraml C et al. High cardiorespiratory fitness is an independent predictor of the reduction in liver fat during a lifestyle intervention in non-alcoholic fatty liver disease. Gut. 2009;21:1281-8.
Newton JL. Systematic symptoms in non-alcoholic fatty liver disease. Dig Dis. 2010;28:214-9.
Price JK, Srivastava R, Bai C, Diao G, Gerber LH, Younossi ZM. Comparision of activity level among patients with chronic liver disease. Disabil Rehabil. 2013;35:907-12.
Gerber CE, Blissmer B, Deschenes MR, Franklin BA, Lamonte MJ, Lee IM et al. Quantity and quality of exercise for developing and maintaining cardiorespiratory, muscoskeletal, and neuromotor fitness in apparently healthy adults: guidance for prescribing exercise. Med Sci Sports Exerc. 2011;43:1334-59.
Foxx-Orenstein AE. New and emerging therapies for the treatment of irritable bowel syndrome: an update for gastroenterologists. Therap Adv Gastroenterol. 2016;9:394-407.
Lavine JE, Schwimmer JB, Van Natta ML, et al. Effect of vitamin E or metformin for treatment of nonalcoholic fatty liver disease in children and adolescents: the TONIC randomized controlled trial. JAMA. 2011;305:1659-68.
Sanyal AJ, Chalasani N, Kowdley KV, Mc Cullough A, Diehl AM, Bass NM, et al. Pioglitazone, Vitamin E, or placebo for nonalcoholic steatohepatitis. N Engl J Med. 2010;362:1675-85.
Pathil A, Mueller J, Warth A, Chamulitrat W, Stremmel W. Ursodeoxycholyl lysophosphatidylethanolamide improves steatosis and inflammation in murine models of nonalcoholic fatty liver disease. Hepatol. 2012;55:1369-77.
Musso G, Anty R, Petta S. Antioxidant therapy and drugs interfering with lipid metabolism: could they be effective in NAFLD patients? Curr Pharm Des. 2013;19:5297-313.
Ishizaki K, Imada T, Tsurufuji M. Hepatoprotective bile acid ‘Ursodeoxycholic acid (UDCA)’ Property and difference as bile acids. Hepatol Res. 2005;33:174-7.
Kotb MA. Molecular mechanisms of Ursodeoxycholic acid toxicity and side effects: Ursodeoxycholic acid freezes regeneration and induces hibernation mode. Int J Mol Sci. 2012;13:8882-914.
Feldstein AE, Canbay A, Angulo P, Taniai M, Burgart LJ, Lindor KD, et al. Hepatocyte apoptosis and fas expression are prominent features of human nonalcoholic steatohepatitis. Gastroenterology 2003;125:437-43
Amaral JD, Viana RJ, Ramalho RM, Steer C, Rodrigues C. Bile acids: regulation of apoptosis by ursodeoxycholic acid. J Lipid Res. 2009;50:1721-34.
Neuman M, Angulo P, Malkiewicz I, Jorgensen R, Shear N, Dickson ER et al. Tumor necrosis factor-alpha and transforming growth factor-beta reflect severity of liver damage in primary biliary cirrhosis. J Gastroenterol Hepatol. 2002;17:196-202.
Laurin J, Lindor KD, Crippin JS, Gossard A, Gores G, Ludwig J, et al.Ursodeoxycholic acid or clofibrate in the treatment of non-alcohol-induced steatohepatitis: a pilot study. Hepatol. 1996;23:1464-7.
Ratziu V, de Ledinghen V, Oberti F, Mathurin P, Wartelle-Bladou C, Renou C, et al. A randomized controlled trial of high-dose Ursodeoxycholic acid for non-alcoholic steatohepatitis. J Hepatol. 2011;54:1011-9.
Singh SP, Das HS, Panda C. A pilot study of high dose Ursodeoxycholic acid [UDCA] in the treatment of nonalcoholic steatohepatitis [NASH]. Indian J Gastroenterol. 2007;26:A90.
Troisi G, Crisciotti F, Gianturco V, D’Ottavio E, Lo lacono C, Farmosa V, et al . The treatment with ursodeoxycholic acid in elderly patients affected by NAFLD and metabolic syndrome: a case-control study. Clin Ter. 2013;164:203-7.
Xiang Z, Chen Y, Ma KF, Ye YF, Zheng L, Yang YD, et al. The role of ursodeoxycholic acid in non-alcoholic steatohepatitis: a systematic review. BMC Gastroenterol. 2013;13:140.
Yki-Jarvinen H. Thiazolidinediones. New Engl J Med. 2004;351:1106-18.
Neuschwander-Tetri BA, Brunt EM, Weheier KR, Oliver D, Bacon BR. Improved nonalcoholic steatohepatitis after 48 weeks of treatment with PPAR-gamma ligand rosiglitazone. Hepatol. 2003;38:1008-17.
Ratziu V, Giral P, Jacqueminet S, Charlotte F, Hartemann-Heurtier A, Serfaty L et al. Rosiglitazone for nonalcoholic steatohepatitis: one –year results of the randomized placebo controlled fatty liver improvement with rosiglitazone therapy (FLIRT) Trial. Gastroenterol. 2008;135:100-10.
Belfort R, Harrison SA, Brown K, Darland C, Finch J, Hardies J et al. A placebo- controlled trial of pioglitazone in subjects with nonalcoholic steatohepatitis. N Engl J Med. 2006;355:2297-307.
Aithal GP, Thomas JA, Kaye VP, Lawson A, Ryder SD, Spendlove I et al. Randomized, placebo-controlled trial of pioglitazone in nondiabetic subjects with nonalcoholic steatohepatitis. Gastroenterol. 2008;135:1176-84.
Chalasani NP, Sanyal AJ, Kowdley KV, Robuck PR, Hoofnagle J, Kleiner DE et al. Pioglitazone versus vitamin E versus placebo for the treatment of nondiabetic patients with non-alcoholic steatohepatitis: PIVENS trial design. Contemp Clin. Trials 2009;30:88-96.
Dormandy JA, Charbonnel B, Eckland DJ, Erdmann E, Massi-Benedetti M, Moules IK et al. Secondary prevention of macrovascular events in patients with type 2 diabetes in the PROactive study (PROspective pioglitazone Clinical trial in Macrovascular events): a randomized controlled trial. Lancet. 2005;366:1279-89
Azoulay L, Yin H, Filion KB, Assayag J, Majdan A, Pollark MN et al. the use of pioglitazone and the risk of bladder cancer in people with type 2 diabetes: nested case-control study. BMJ. 2012;344:e3645.
Duman DG, Ozdemir F, Birben E, Keskin O, Ekşioğlu-Demiralp E, Celikel C et al. Effects of pentoxifylline on TNF-alpha production by peripheral blood mononuclear cells in patients with nonalcoholic steatohepatitis. Dig Dis Sci. 2007;52:2520-4.
Buranawati W, Thoun-U-Thaisri P, Pramoolsinsup C, Wisedopas N, Atamasirikul K, Udomsubpayakul U et al. Pentoxifylline for treatment of nonalcoholic fatty liver disease (NAFLD): a randomized, placebocontrolled study. Thai J Gastroenterol. 2007;8:57-63.
Lee YM, Sutedja DS, Wai CT, Dan YY, Aung MO, Zhou L et al. A randomized controlled pilot study of pentoxifylline in patients with non-alcoholic steatohepatitis (NASH). Hepatol Int. 2008;2:196-201.
Van Wagner LB, Koppe SW, Brunt EM, Gottstein J, Gardikiotes K, Green RM et al. Pentoxifylline for the treatment of non-alcoholic steatohepatitis: a randomized controlled trial. Ann Hepatol. 2011;10:277-86.
Zein CO, Yerian LM, Gogate P, Lopez R, Kirwan JP, Feldstein AE et al. Pentoxifylline improves nonalcoholic steatohepatitis: a randomized placebo-controlled trial. Hepatol. 2011;54:1610-9.
Roglans N, Sanguino E, Peris C, Alegret M, Vázquez M, Adzet T et al. Atorvastatin treatment induced peroxisome proliferator-activated receptor alpha expression and decreased plasma nonesterified fatty acids and liver triglyceride in fructose-fed rats. J Pharmacol Exp Ther. 2002;302:232-9.
Viollet B, Guigas B, Sanz Garcia N, Leclerc J, Foretz M, Andreelli F. Cellular and molecular mechanisms of metformin: an overview. Clin Sci. 2012;122:253-70.
Chalasani N, Younossi Z, Lavine JE, Diehl AM, Brunt EM, Cusi K, et al. The diagnosis and management of non-alcoholic fatty liver disease: practice guideline by the American gastroenterological association, American association for the study of liver diseases, and American college of gastroenterology. Gastroenterol. 2012;142:1592-609.
Chalasani N, Younossi Z, Lavine JE, Diehl AM, Brunt EM, Cusi K et al. The diagnosis and management of non-alcoholic fatty liver disease: practice guideline by the American association for the study of liver diseases, American college of gastroenterology, and the American gastroenterological association. Am J Gastroenterol. 2012;107:811-26.
Harrison SA, Fecht W, Brunt EM, Neuschwander-Tetri BA. Orlistat for overweight subjects with nonalcoholic steatohepatitis: a randomized, prospective trial. Hepatol. 2009;49:80-6.
Adorini L, Pruzanski M, Shapiro D. Farnesoid X receptor targeting to treat nonalcoholic steatohepatitis. Drug Discov Today. 2012;17:988-97.
Zhang Y, Kast-Woelbern HR, Edwards PA. Natural structural variants of the nuclear receptor farnesoid X receptor affect transcriptional activation. J Biol Chem. 2003;278:104-10.
Cariou B, Staels B. GFT505 for the treatment of nonalcoholic steatohepatitis and type 2 diabetes. Expert Opin Investig Drugs. 2014;23:1441-8.
Cariou B, Zair Y, Staels B, Bruckert E. Effects of the new dual PPAR alpha/delta agonist GFT505 on lipid and glucose homeostasis in abdominally obese patients with combined dyslipidemia or impaired glucose metabolism. Diab Care. 2011;34:2008-14.
Ding X, Saxena NK, Lin S, Gupta NA, Anania FA. Exendin-4,a glucagon-like protein-1 (GLP-1) receptor agonist, re-verses hepatic steatosis in ob/ob mice. Hepatol. 2006;43:173-81.
Ben-Shlomo S, Zvibel I, Shnell M, Shlomai A, Chepurko E, Halpern Z et al. Glucagon-like peptide-1 reduces hepatic lipogenesis via activation of AMP-activated protein kinase. J Hepatol. 2011;54:1214-23.
Gupta NA, Mells J, Dunham RM, Grakoui A, Handy J, Saxena NK et al. Glucagon-like peptide-1 receptor is present on human hepatocytes and has a direct role in decreasing hepatic steatosis in vitro by modulating elements of the insulin signaling pathway. Hepatol. 2010;51:1584-92.
Dobrzyn A, Dobrzyn P, Lee SH, Miyazaki M, Cohen P, Asilmaz E et al. Stearoyl-CoA desaturase-1 deficien-cy reduces ceramide synthesis by downregulating serine palmitoyltransferase and increasing beta-oxidation in skeletal muscle. Am J Physiol Endocrinol Metab. 2005;288:E599-E607.
Younossi ZM, Reyes MJ, Mishra A, Mehta R, Henry L. Systematic review with meta-analysis: non-alcoholic steatohepatitis - a case for personalised treatment based on pathogenic targets. Aliment Pharmacol Ther. 2014;39:3-14.
Stephen S, Baranova A, Younossi ZM. Nonalcoholic fatty liver disease and bariatric surgery. Expert Rev Gastroenterol Hepatol. 2012;6:163-71.
Tai CM, Huang CK, Hwang JC. Improvement of nonalcoholic fatty liver disease after bariatric surgery in morbidly obese Chinese patients. Obes Surg. 2012;22:1016-21.
Mummadi RR, Kasturi KS, Chennareddygair S, Sood GK. Effect of bariatric surgery on nonalcoholic fatty liver disease: systematic review and meta-analysis. Clinical Gastroenterol Hepatol. 2008;6:1396-402.
Chavez-Tapia NC, Tellez-Avila FI, Barrientose-Gutierrez T, Mendez-Sanchez N, Lizardi-Cervera J, Uribe M. Bariatric surgery for non-alcoholic steatohepatitis in obese patients. Cochrane Database Syst Rev. 2010;20:CD007340.
Ratziu V, Bellentani S, Cortez-Pinto H, Day C, Marchesini G. A position statement on NAFLD/NASH based on the EASL 2009 special conference. J Hepatol. 2010;53:372-84.
Misra A, Misra R. Asian Indians and insulin resistance syndrome: global perspective. Metab Syndr Relat Disord. 2003;1:277-83.
Corrado RL, Torres DM, Harrison SA. Review of treatment options for nonalcoholic fatty liver disease. Med Clin North Am. 2014;98:55-72.
Downloads
Published
How to Cite
Issue
Section
