The slide above illustrates an important point: the progression of liver damage in the context of NAFLD or NASH is not fully understood, mainly due to the reliance on liver biopsy to track changes in liver injury. Moreover, most of the datasets that have been reported were from single centre studies from specialist units, where repeat biopsies occurred in response to clinical events. This inevitably results in bias, because repeat biopsies are driven by clinical concerns in many patients, providing a non-representative understanding of the overall rate of disease progression. Singh and colleagues analysed the rate of histological fibrosis progression (to higher stages of disease) in adults with NAFLD and found that the rate differed depending on the severity of baseline disease. In patients with more indolent disease at the outset, progress appeared to be slower, whereas in patients with NASH at baseline, fibrosis progressed more rapidly. These data are helpful to inform the field, but it should be noted that all rates of progression were still slow. The time taken to advance by one stage of liver fibrosis was 7 years in fast progressing disease (NASH) versus 14 years in slow progressing disease (NAFLD).

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