NASH with type 2 DM

A 25-year-old female nurse with poorly controlled type 2 diabetes, obesity and elevated liver function tests (LFTs) was referred to an outpatient diabetes clinic. Her glycated hemoglobin A1c (HbA1c) was 8.9%, and her fasting plasma glucose was 7.3 mmol/l. Her LFTs showed an ALT of 196 U/l, an AST of 132 U/l, and an ALP of 127 U/l. Lipids were elevated, and abdominal ultrasound showed diffuse hepatic steatosis. Metformin and insulin were initiated, and statins were discontinued. After 8 weeks, HbA1c markedly improved to 6.3%, but LFTs remained elevated. A liver biopsy was performed, and the histologic report revealed a NAFLD activity score of 5 and a fibrosis score of 2 (Figure 1).1