Hepatitis C and Fatty Liver Disease: Is There a Link?
Having hep C can increase your odds of this other tricky liver condition. Get the facts on risk factors and treatment options.
If you have hepatitis C, the fun doesn’t stop with one illness. Often, this liver disease is linked to several other health conditions, including nonalcoholic fatty liver disease (NAFLD). Understanding how the two are connected can help you learn the symptoms to look out for, plus the best ways to get treatment if the need arises. We asked the experts for more details about NAFLD and how it’s connected to hepatitis C. These are the need-to-know facts about living with both of these diseases.
What Is Fatty Liver Disease?
As the name implies, fatty liver disease occurs when fat deposits build up in your liver. “The fat in the liver can damage it, causing inflammation and scarring,” explains Rena Fox, M.D., a professor of general internal medicine at the University of California, San Francisco, and a UCSF Health hepatitis specialist. Although doctors still aren’t sure exactly what causes it, NAFLD is linked to obesity, insulin resistance, high blood sugar, and high triglycerides levels.
There are different types of fatty liver disease, but NAFLD is the most common, affecting 30% to 40% of adults in the United States, according to the National Institutes of Health (NIH). While some types of fatty liver disease are linked to heavy alcohol use, people with NAFLD are not over-drinkers.
One of the challenging things about this disease is that it can be hard to detect, since it often has no obvious symptoms until the liver damage is already extensive. “When someone is at a very advanced stage, they may have some pain in the upper-right part of the abdomen, and they may feel tired,” says Dr. Fox. “At a very late stage, they could have fluid in the abdomen, and they could develop yellowing of the eyes and skin. We want to help patients avoid getting to this point.”
There’s also a more aggressive subtype of NAFLD called nonalcoholic steatohepatitis (NASH), which is generally diagnosed via liver biopsy. “Patients with NASH are really at risk for progression of disease,” says Rohit Satoskar, M.D., a transplant hepatology specialist at MedStar Georgetown University Hospital in Washington, D.C. This subtype is less common, accounting for about 20% of people with NAFLD. It’s not clear why some people develop NASH, but if left untreated, NASH can lead to serious health problems like cirrhosis or liver cancer.
The NAFLD and Hepatitis C Connection
Why should you care about fatty liver disease if you have hepatitis C? While one condition doesn’t necessarily cause the other, there is an important link. “Even without hepatitis C, patients can have fatty liver disease—they can be separate entities,” says Dr. Satoskar. “However, in patients that do have a hepatitis C infection, there is a higher prevalence of fatty liver disease than in the general population.”
In fact, up to 50% of people with hep C also have fatty liver disease. “We believe that the hepatitis virus itself does something to the metabolism of fats within the liver that can lead to more fat deposition,” he says.
This increased risk might have something to do with your particular strain—or genotype—of hep C virus. “If a patient with hepatitis C has what’s called ‘genotype 3,’ they are a little bit more likely to get fatty liver disease,” Dr. Fox says.
About 10% to 20% of people with hepatitis C are infected with genotype 3, according to a 2018 study in Annals of Gastroenterology. And while experts don’t know for sure why genotype 3 leads to fatty liver disease more often than other genotypes, it’s likely related to a unique reaction that occurs between the genotype 3 virus and the cells in the liver that leads to greater expression of fatty acid enzymes. Those with hep C genotype 3 who do get fatty liver disease are also more likely to see the disease worsen faster, leading to liver fibrosis.
Even without this particular genotype, people with hep C can get fatty liver disease for other reasons. “Any hepatitis patient could get fatty liver disease from all of the other conditions that put one at risk,” says Dr. Fox, namely being overweight and having high blood sugar or cholesterol issues.
Any type of liver disease is a stressor on your health but having both hepatitis C and NAFLD at the same time can increase the damage. “If someone has hepatitis C and they have an additional liver complication on top of that—whether it’s another viral hepatitis, fatty liver disease, or excessive use of alcohol—it can make the disease progress quicker,” Dr. Satoskar explains. “Patients can develop progressive scarring or fibrosis of the liver in a shorter period of time than if they had hepatitis C alone.”
The good news, says Dr. Satoskar, is that almost everyone with hepatitis C today who gets treatment is cured. And that may have a positive domino effect on your fatty liver disease. If the two disease are connected, he explains, by curing hep C, there is likely to be an improvement in the fatty liver disease. “But even if you do not see that, treating and curing the hepatitis C will greatly reduce the likelihood that the patient would develop progressive liver disease over time,” he adds.
As for treating the NAFLD itself, targeting underlying risk factors is the mainstay of treatment. Losing weight and improving your diet are the best ways to stop NAFLD from progressing. “It’s not easy, but it is the best treatment for fatty liver currently,” says Dr. Fox. “Managing and controlling diabetes and cholesterol is also very important.”
Aside from more exercise and less calories, there are also two medications available that may be used to treat NASH, the aggressive subtype of NAFLD. One of the medications is vitamin E-based and the other is Actos (pioglitazone), a drug used to treat diabetes. Other drugs are currently being studied for future use against NASH.
What to Know If You Have Hep C
When you’re diagnosed with hepatitis C, your doctor might bring up NAFLD and ways to reduce your risk, Dr. Fox says. If they don’t, it’s a good idea to bring it up with them yourself. “If patients can avoid developing fatty liver disease, they’re going to benefit their hepatitis C in terms of limiting damage to the liver,” Dr. Fox says.
If you do have NAFLD along with hep C, treating both conditions will help lessen the toll on your liver and overall health in the long run. “The damage can go on for decades and patients could be unaware that they have fatty liver disease unless their clinician is looking for it,” Dr. Fox says. “It’s worth knowing about because you may be able to make some modifications to avoid liver damage that might otherwise go on.”
NAFLD Overview: Mayo Clinic. (2019). “Nonalcoholic Fatty Liver Disease.” mayoclinic.org/diseases-conditions/nonalcoholic-fatty-liver-disease/symptoms-causes/syc-20354567
Fatty Liver Disease Information: National Institutes of Health. (2020). “Fatty Liver Disease.” medlineplus.gov/fattyliverdisease.html
Hepatitis C Genotype 3 Study: Annals of Gastroenterology. (2018). “Hepatitis C virus genotype 3: clinical features, current and emerging viral inhibitors, future challenges.” ncbi.nlm.nih.gov/pmc/articles/PMC6102453/
NAFLD and NASH Stats: National Institutes of Health. (2016). “Definition & Facts of NAFLD & NASH.” niddk.nih.gov/health-information/liver-disease/nafld-nash/definition-facts