Digestive Diseases and Sciences

, Volume 58, Issue 10, pp 3017–3023 | Cite as

Predictors of All-Cause Mortality and Liver-Related Mortality in Patients with Non-Alcoholic Fatty Liver Disease (NAFLD)

  • Maria Stepanova
  • Nila Rafiq
  • Hala Makhlouf
  • Ritambhara Agrawal
  • Ishmeet Kaur
  • Zahra Younoszai
  • Arthur McCullough
  • Zachary Goodman
  • Zobair M. YounossiEmail author
Original Article



Non-alcoholic steatohepatitis (NASH) patients are at increased risk for progression to cirrhosis. The aim of this study was to assess all-cause and liver-specific mortality in a cohort of non-alcoholic fatty liver disease (NAFLD) patients.


Biopsy-proven NAFLD patients with and without NASH from two historic databases were included. Clinico-demographic information from the time of biopsy was available. Mortality data were obtained from National Death Index-Plus and used for estimating overall and cause-specific mortality. The non-parametric Kaplan–Meier method with log-rank test and multivariate analyses with Cox proportional hazard model were used to compare cohorts.


Two hundred eighty-nine NAFLD patients were included (50.3 ± 14.5 years old, 39.4 % male, 78.6 % Caucasian, 46.0 % obese, 26.0 % diabetic, 5.9 % with family history of liver diseases). Of these, 59.2 % had NASH whereas 40.8 % had non-NASH NAFLD. NASH patients were predominantly female, had higher aspartate aminotranserase, alanine aminotransferase and fasting serum glucose. During follow-up (median 150 months, maximum 342 months), patients with NASH had higher probability of mortality from liver-related causes than non-NASH NAFLD patients (p value = 0.0026). In the entire NAFLD cohort, older age [aHR = 1.07 (95 % CI = 1.05–1.10)] and presence of type II diabetes [aHR = 2.09 (1.39–3.14)] were independent predictors of overall mortality. However, in addition to age [aHR = 1.06 (1.02–1.10)] having histologic NASH [aHR = 9.16 (2.10–9.88)] was found to be an independent predictor of liver-related mortality. Additionally, presence of type II diabetes was associated with liver-related mortality [aHR = 2.19 (1.00–4.81)].


This long-term follow-up of NAFLD patients confirms that NASH patients have higher risk of liver-related mortality than non-NASH. Additionally, patients with NAFLD and type II diabetes are at highest risk for overall and liver-related mortality.


Non-alcoholic fatty liver disease (NAFLD) Follow-up study Non-alcoholic steatohepatitis (NASH) Mortality 



Non-alcoholic fatty liver disease


Non-alcoholic steatohepatitis


Body mass index


Center for disease control


National death index


Alanine aminotransferase


Aspartate aminotranserase


Liver-related mortality


Adjusted hazard ratio

95 % CI

95 % Confidence interval



This study has been supported in part by the Liver Disease Outcomes Fund of the Center for Liver Diseases at Inova Fairfax Hospital, Inova Health System, Falls Church, VA.

Conflict of interest



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Copyright information

© Springer Science+Business Media New York 2013

Authors and Affiliations

  • Maria Stepanova
    • 1
    • 4
  • Nila Rafiq
    • 1
  • Hala Makhlouf
    • 2
  • Ritambhara Agrawal
    • 1
  • Ishmeet Kaur
    • 1
  • Zahra Younoszai
    • 1
  • Arthur McCullough
    • 3
  • Zachary Goodman
    • 1
    • 4
  • Zobair M. Younossi
    • 1
    • 4
    Email author
  1. 1.Center for Liver Diseases at Inova Fairfax HospitalFalls ChurchUSA
  2. 2.Armed Forces Institutes of PathologyWashingtonUSA
  3. 3.Department of GastroenterologyCleveland Clinic FoundationClevelandUSA
  4. 4.Betty and Guy Beatty Center for Integrated ResearchInova Health SystemFalls ChurchUSA

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