Autoimmune hepatitis and fatty liver disease are two distinct liver conditions that can occasionally occur together, presenting unique challenges for diagnosis and management. Autoimmune hepatitis is a chronic inflammatory condition where the immune system attacks liver cells, whilst fatty liver disease involves excess fat accumulation in the liver, often linked to metabolic factors. Understanding how these conditions interact, particularly when they coexist, is essential for effective treatment. This article explores the relationship between autoimmune hepatitis and fatty liver, their combined symptoms, diagnostic approaches, and comprehensive management strategies to preserve liver health.
Summary: Autoimmune hepatitis and fatty liver disease can occur together in approximately 15–30% of AIH patients, often complicated by metabolic risk factors or corticosteroid treatment effects.
- Autoimmune hepatitis is a chronic inflammatory liver disease where the immune system attacks healthy liver cells, requiring immunosuppressive treatment with corticosteroids and azathioprine.
- Fatty liver disease involves excess fat accumulation in liver cells and affects 25–30% of the UK population, primarily driven by obesity and metabolic syndrome.
- Corticosteroid therapy for autoimmune hepatitis can contribute to metabolic changes including weight gain and insulin resistance, potentially worsening fatty liver disease.
- Diagnosis requires blood tests including liver function tests, autoantibodies (ANA, SMA, LKM), immunoglobulin G levels, and non-invasive fibrosis assessment using FIB-4 and ELF scores.
- Treatment combines immunosuppression for autoimmune hepatitis with lifestyle modifications for fatty liver, including weight loss of 7–10% body weight and regular physical activity.
- Regular monitoring with blood tests, imaging, and hepatologist follow-up is essential to assess treatment response and detect complications such as cirrhosis or hepatocellular carcinoma.
Table of Contents
- Understanding Autoimmune Hepatitis and Fatty Liver Disease
- Can You Have Autoimmune Hepatitis and Fatty Liver Together?
- Symptoms and Diagnosis of Both Liver Conditions
- Treatment Options for Autoimmune Hepatitis with Fatty Liver
- Managing Your Liver Health: Lifestyle and Monitoring
- Frequently Asked Questions
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Understanding Autoimmune Hepatitis and Fatty Liver Disease
Autoimmune hepatitis (AIH) and fatty liver disease are two distinct liver conditions that can affect individuals separately or, in some cases, simultaneously. Understanding the fundamental differences between these conditions is essential for appropriate management and monitoring.
Autoimmune hepatitis is a chronic inflammatory liver disease in which the body's immune system mistakenly attacks healthy liver cells. This autoimmune process leads to progressive liver inflammation and, if left untreated, can result in cirrhosis and liver failure. AIH affects approximately 10–20 people per 100,000 in the UK and is more common in women than men. The condition can occur at any age, though it often presents in two peaks: during adolescence and between ages 40–60. The exact cause remains unclear, but genetic predisposition and environmental triggers are thought to play a role.
Fatty liver disease, also known as hepatic steatosis, occurs when excess fat accumulates in liver cells. There are two main types: non-alcoholic fatty liver disease (NAFLD)—increasingly termed metabolic dysfunction-associated steatotic liver disease (MASLD)—which is not related to alcohol consumption, and alcohol-related liver disease (ARLD), which results from excessive alcohol intake. NAFLD affects approximately 25–30% of the general population in the UK, largely driven by rising rates of obesity, type 2 diabetes, and metabolic syndrome. Whilst simple fatty liver is often benign, it can progress to non-alcoholic steatohepatitis (NASH), now termed metabolic dysfunction-associated steatohepatitis (MASH), characterised by inflammation and liver cell damage.
Both conditions can lead to serious liver complications if not properly managed, making early detection and appropriate treatment crucial for preserving liver function and overall health. Further information is available from the NHS website pages on autoimmune hepatitis and non-alcoholic fatty liver disease, and from the British Liver Trust.
Can You Have Autoimmune Hepatitis and Fatty Liver Together?
Yes, it is possible to have both autoimmune hepatitis and fatty liver disease concurrently, though this combination is less common than either condition occurring alone. The coexistence of these two liver conditions presents unique diagnostic and management challenges for healthcare professionals.
Recent research suggests that patients with autoimmune hepatitis may develop fatty liver disease, particularly if they have metabolic risk factors such as obesity, insulin resistance, or type 2 diabetes. Studies have shown that approximately 15–30% of patients with AIH may have concurrent hepatic steatosis. The presence of fatty liver in AIH patients can complicate the clinical picture, as both conditions contribute to liver inflammation and potential progression to fibrosis.
The relationship between these conditions is not fully understood, but several mechanisms may explain their coexistence. Corticosteroid therapy, which is the mainstay treatment for autoimmune hepatitis, can contribute to metabolic changes including weight gain, insulin resistance, and dyslipidaemia—all risk factors for developing fatty liver disease. To minimise these effects, steroid-sparing strategies are employed, such as early introduction of azathioprine or, in selected non-cirrhotic patients, the use of budesonide as an alternative to prednisolone. Additionally, some patients may have underlying metabolic syndrome that predisposes them to NAFLD independently of their autoimmune condition.
There is no evidence suggesting that autoimmune hepatitis directly causes fatty liver disease or vice versa. However, the presence of both conditions may indicate shared risk factors or the metabolic consequences of immunosuppressive treatment. It is important to note that having both conditions may affect disease progression and treatment response, making individualised care essential.
At the time of AIH diagnosis, your healthcare team should systematically assess metabolic risk factors including body mass index (BMI), waist circumference, blood pressure, blood glucose or HbA1c, and lipid profile, and manage these appropriately.
If you have been diagnosed with autoimmune hepatitis and are concerned about fatty liver disease, or if you have fatty liver and develop symptoms suggestive of AIH, discuss these concerns with your GP or hepatologist for appropriate investigation and monitoring.
Symptoms and Diagnosis of Both Liver Conditions
Both autoimmune hepatitis and fatty liver disease can present with overlapping symptoms, though they may also remain asymptomatic for extended periods, making diagnosis challenging without appropriate investigation.
Common symptoms that may occur with either or both conditions include:
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Fatigue and general malaise
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Abdominal discomfort, particularly in the upper right quadrant
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Jaundice (yellowing of the skin and eyes)
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Dark urine and pale stools
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Loss of appetite and unintentional weight loss
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Nausea
Autoimmune hepatitis may additionally present with joint pain, skin rashes, or other autoimmune manifestations. In contrast, simple fatty liver disease is often asymptomatic and discovered incidentally during imaging for other reasons. However, when NAFLD progresses to NASH, symptoms may become more apparent.
Diagnostic investigations for these conditions typically include:
Blood tests form the cornerstone of initial assessment. Liver function tests (LFTs) showing elevated transaminases (ALT and AST) may indicate liver inflammation. A comprehensive screen should exclude other causes of liver disease, including viral hepatitis (hepatitis B and C), detailed alcohol history (units per week), medication and herbal/supplement use, iron studies (ferritin and transferrin saturation to exclude haemochromatosis), and, where indicated, coeliac serology and thyroid function tests.
For autoimmune hepatitis, specific autoantibodies are measured, including antinuclear antibodies (ANA), anti-smooth muscle antibodies (SMA), and anti-liver kidney microsomal antibodies (LKM). Elevated immunoglobulin G (IgG) levels also support an AIH diagnosis.
For NAFLD, NICE guideline NG49 recommends non-invasive risk stratification to identify advanced fibrosis. This involves calculating the FIB-4 score (or NAFLD Fibrosis Score) using age, transaminases, and platelet count. If the FIB-4 suggests possible advanced fibrosis, an Enhanced Liver Fibrosis (ELF) blood test is performed. Patients with high ELF scores indicating advanced fibrosis should be referred to hepatology for specialist assessment and consideration of liver biopsy.
Imaging studies, particularly ultrasound, can detect hepatic steatosis and assess liver architecture. More advanced imaging such as FibroScan (transient elastography) can quantify both liver stiffness (indicating fibrosis) and fat content non-invasively.
Liver biopsy remains the gold standard for definitive diagnosis of autoimmune hepatitis and is recommended to confirm the diagnosis and assess disease severity. In NAFLD, biopsy is not routinely required but may be considered when there is diagnostic uncertainty, when non-invasive tests suggest advanced fibrosis, or to guide management decisions. Histological examination can identify the characteristic features of autoimmune hepatitis (interface hepatitis, plasma cell infiltration) alongside steatosis, allowing accurate assessment of inflammation, fat content, and fibrosis stage.
Treatment Options for Autoimmune Hepatitis with Fatty Liver
Managing patients with both autoimmune hepatitis and fatty liver disease requires a comprehensive, individualised approach that addresses the autoimmune inflammation whilst simultaneously tackling metabolic risk factors.
Immunosuppressive therapy for autoimmune hepatitis remains the primary treatment priority. The standard first-line treatment consists of corticosteroids (prednisolone, typically 0.5–1 mg/kg daily, commonly 30 mg) combined with azathioprine (1–2 mg/kg daily), a steroid-sparing agent. Prednisolone works by suppressing the aberrant immune response attacking liver cells, whilst azathioprine allows for lower corticosteroid doses, reducing long-term side effects. Prednisolone is gradually tapered as liver inflammation improves, guided by normalisation of transaminases (ALT and AST) and IgG levels.
Before starting azathioprine, testing for thiopurine methyltransferase (TPMT) and NUDT15 enzyme activity is essential, as deficiency increases the risk of severe bone marrow suppression. Close monitoring of full blood count (FBC) and liver function tests (LFTs) is required, typically weekly to fortnightly initially, then at increasing intervals once stable.
For selected patients with non-cirrhotic autoimmune hepatitis, budesonide may be considered as an alternative to prednisolone, as it has fewer metabolic side effects.
For patients who cannot tolerate azathioprine due to side effects or enzyme deficiency, alternative immunosuppressants such as mycophenolate mofetil may be considered. Mycophenolate is used off-label in AIH and is highly teratogenic; women of childbearing potential must use effective contraception and comply with the MHRA Pregnancy Prevention Programme. In refractory cases, additional agents including tacrolimus or ciclosporin may be required.
The challenge in patients with concurrent fatty liver disease is that corticosteroids can exacerbate metabolic dysfunction, potentially worsening hepatic steatosis. Therefore, treatment strategies must balance effective immunosuppression with metabolic management, using steroid-sparing approaches wherever possible.
Bone protection is important for patients on long-term corticosteroids. Your doctor will advise on calcium and vitamin D supplementation and may recommend bone density scanning and bisphosphonates if osteoporosis risk is high.
Vaccination is recommended for patients on immunosuppressive therapy. Ensure you receive annual influenza vaccination, pneumococcal vaccination, and hepatitis A and B vaccination if not already immune. Live vaccines should be avoided whilst on significant immunosuppression.
Addressing fatty liver disease in this context focuses on lifestyle modification and managing underlying metabolic conditions:
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Weight management: Gradual weight loss of 7–10% of body weight has been shown to improve hepatic steatosis and reduce inflammation in NAFLD. Aim for a steady weight loss of approximately 0.5–1 kg per week.
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Dietary modification: A balanced, calorie-controlled diet low in refined carbohydrates and saturated fats, such as a Mediterranean-style diet.
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Physical activity: Regular exercise (at least 150 minutes of moderate-intensity activity weekly).
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Glycaemic control: Optimising management of type 2 diabetes if present.
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Lipid management: Treating dyslipidaemia with statins when indicated. Statins are generally safe in NAFLD and compensated chronic liver disease; baseline and periodic monitoring of LFTs is advised. If you have decompensated liver disease, discuss statin use with your hepatologist.
Currently, there are no licensed pharmacological treatments specifically for NAFLD in the UK, though several agents are under investigation.
Monitoring and follow-up are essential. Regular blood tests assess treatment response (ALT, AST, and IgG levels) and detect adverse effects of immunosuppression (FBC, LFTs). Periodic imaging and non-invasive fibrosis assessment help track disease progression. Patients should be under the care of a hepatologist with expertise in managing complex liver disease.
If you experience any suspected side effects from your medications, report them via the MHRA Yellow Card Scheme at https://yellowcard.mhra.gov.uk or through the Yellow Card app.
Managing Your Liver Health: Lifestyle and Monitoring
Effective long-term management of autoimmune hepatitis and fatty liver disease extends beyond medication to encompass lifestyle modifications, regular monitoring, and patient education about potential complications.
Lifestyle modifications play a crucial role in managing both conditions:
Dietary considerations are particularly important. Adopt a Mediterranean-style diet rich in vegetables, fruits, whole grains, lean proteins, and healthy fats (such as olive oil and oily fish). Limit processed foods, refined sugars, and saturated fats. Reduce salt intake if you have fluid retention. Maintain adequate protein intake to support liver regeneration and overall health—typically 1.2–1.5 g per kg of body weight daily. Protein restriction is generally not recommended, even in advanced liver disease, unless specifically advised by your specialist. Consider referral to a dietitian for personalised nutritional advice.
Alcohol consumption: Many people with liver disease are advised to avoid alcohol completely. If you do drink, stay well within the UK Chief Medical Officers' low-risk drinking guidelines (no more than 14 units per week, spread over at least three days). Discuss alcohol use with your hepatologist or GP to receive advice tailored to your individual circumstances.
Physical activity benefits both conditions by improving insulin sensitivity, promoting weight loss, and reducing hepatic fat content. Aim for at least 150 minutes of moderate-intensity aerobic exercise weekly, combined with resistance training twice weekly. Activities such as brisk walking, swimming, or cycling are excellent choices.
Weight management is critical for those with fatty liver disease. Gradual weight loss of 7–10% of body weight can significantly reduce liver fat and inflammation. Aim for a steady, sustainable weight loss of approximately 0.5–1 kg per week.
Regular monitoring is essential for detecting disease progression or treatment complications:
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Attend all scheduled appointments with your GP and hepatologist.
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Undergo regular blood tests to monitor liver function (ALT, AST, and IgG levels for AIH activity), full blood count, and medication side effects. Early in treatment, monitoring may be weekly to fortnightly; intervals are extended once disease is stable.
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Periodic imaging (ultrasound or FibroScan) to assess liver fat content and fibrosis.
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Bone density scans if on long-term corticosteroids.
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If cirrhosis develops, six-monthly ultrasound surveillance for hepatocellular carcinoma (liver cancer) is recommended.
Infection precautions: Immunosuppressive medications increase your risk of infection. Seek medical advice promptly if you develop fever, persistent cough, urinary symptoms, or any signs of infection. Ensure you are up to date with recommended vaccinations (influenza, pneumococcal, hepatitis A and B). Avoid live vaccines whilst on significant immunosuppression.
When to seek urgent medical attention: Call 999 or attend A&E immediately if you experience vomiting blood, black tarry stools (melaena), severe confusion, or significant abdominal swelling with pain. Contact your GP or hepatologist promptly if you experience worsening jaundice, new or severe abdominal pain, or other concerning symptoms. These may indicate disease progression or complications requiring urgent assessment.
Medication adherence is vital. Take immunosuppressive medications exactly as prescribed, even when feeling well. Never stop or reduce medications without consulting your healthcare team, as this can trigger disease flares. Be aware of potential drug interactions and inform all healthcare providers about your liver condition and current medications.
By combining appropriate medical treatment with proactive lifestyle management and regular monitoring, most patients with autoimmune hepatitis and fatty liver disease can achieve good disease control and maintain quality of life. Further support and information are available from the British Liver Trust and NHS resources.
Frequently Asked Questions
Can autoimmune hepatitis cause fatty liver disease?
Autoimmune hepatitis does not directly cause fatty liver disease, but the two conditions can coexist. Corticosteroid treatment for autoimmune hepatitis can contribute to metabolic changes such as weight gain and insulin resistance, which are risk factors for developing fatty liver disease.
What are the first signs that I might have both autoimmune hepatitis and fatty liver?
Both conditions often cause fatigue, abdominal discomfort in the upper right side, and may be asymptomatic initially. Elevated liver enzymes on blood tests, particularly transaminases (ALT and AST), often prompt further investigation including autoantibody testing and imaging to identify both conditions.
How do doctors diagnose autoimmune hepatitis and fatty liver together?
Diagnosis involves blood tests measuring liver function, autoantibodies (ANA, SMA, LKM), and immunoglobulin G levels for autoimmune hepatitis, alongside FIB-4 and ELF scores to assess fibrosis in fatty liver disease. Imaging such as ultrasound or FibroScan detects fat accumulation and liver stiffness, whilst liver biopsy may be performed to confirm both diagnoses and assess severity.
Will taking steroids for autoimmune hepatitis make my fatty liver worse?
Corticosteroids can potentially worsen fatty liver by causing weight gain, insulin resistance, and metabolic changes. To minimise this risk, doctors use steroid-sparing strategies such as early introduction of azathioprine or, in selected non-cirrhotic patients, budesonide as an alternative to prednisolone.
What lifestyle changes help manage both autoimmune hepatitis and fatty liver?
Gradual weight loss of 7–10% body weight, a Mediterranean-style diet low in refined carbohydrates and saturated fats, and at least 150 minutes of moderate-intensity exercise weekly are essential. These changes improve hepatic steatosis and insulin sensitivity whilst supporting overall liver health during immunosuppressive treatment.
How often should I have blood tests if I have both liver conditions?
Monitoring frequency depends on disease stability and treatment phase, typically weekly to fortnightly when starting immunosuppression, then at increasing intervals once stable. Regular blood tests assess liver function (ALT, AST, IgG), full blood count, and medication side effects, with periodic imaging to track fibrosis progression.
The health-related content published on this site is based on credible scientific sources and is periodically reviewed to ensure accuracy and relevance. Although we aim to reflect the most current medical knowledge, the material is meant for general education and awareness only.
The information on this site is not a substitute for professional medical advice. For any health concerns, please speak with a qualified medical professional. By using this information, you acknowledge responsibility for any decisions made and understand we are not liable for any consequences that may result.
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