Does Fatty Liver Lead to Cirrhosis?
Fatty liver disease, now called steatotic liver disease, happens when too much fat builds up in your liver. Over time, this extra fat can cause inflammation and harm the healthy parts of your liver. It may lead to severe scarring called cirrhosis. This is a permanent condition that affects your liver's ability to function.
Not everyone with fatty liver will get cirrhosis, but your risk goes up if you have metabolic-dysfunction associated liver disease (MASLD). MASLD is linked to metabolic risk factors like obesity, type 2 diabetes, high cholesterol, and high blood pressure. It doesn’t result from alcohol use, which is why it used to be called non-alcoholic fatty liver disease (NAFLD).
MASLD can present as:
- Simple fatty liver, which is excess fat in your liver with little to no inflammation
- Metabolic dysfunction-associated steatohepatitis (MASH), which is excess fat with inflammation (affects around 20% to 30% of people with MASLD)
If you have MASLD, you have a 3% to 5% risk of getting cirrhosis; if you have MASH, your risk rises to 10% to 25%. What that means is that your overall risk of getting cirrhosis from fatty liver is low, but inflammation greatly increases the chances of serious liver damage.
Rarely, other causes of fatty liver can lead to cirrhosis, including:
- Alcohol-related liver disease (ALD). You can have have both ALD and MASLD.
- Long-term treatment with steroids, certain anti-HIV drugs, and other medications
- A health condition you’re born with, like Wilson disease
Whatever the cause of your fatty liver, you can also take steps to prevent progression to cirrhosis. Your doctor can give you a better idea of what to expect and work with you to develop a treatment plan.
Fatty Liver-to-Cirrhosis Timeline
All chronic liver diseases can lead to fibrosis and cirrhosis, but the progression timeline varies greatly from person to person. Some stay at the simple fatty liver stage, while others go through the stages more quickly.
Fatty liver typically progresses to cirrhosis in four stages:
- Fatty liver (hepatic steatosis): Excess fat in the liver
- Inflammation (steatohepatitis): Fat buildup causes inflammation and liver damage
- Fibrosis: Scarring and stiffening of the liver
- Cirrhosis: Severe, permanent liver damage
Stages of fibrosis
You may hear your doctor talk about fatty liver in terms of fibrosis stage. This refers to the level of scar tissue you have in your liver.
Fibrosis stages include:
- F0: No scarring (healthy liver)
- F1: Minimal scarring
- F2: Moderate scarring
- F3 Widespread scarring
- F4: Severe scarring or cirrhosis
Fatty liver usually progresses slowly over many years for most people. Even with MASH, it can take about six or seven years to reach the next stage of scarring. But the more scar tissue you have, the higher your chances are of things speeding up.
If you have MASLD and it goes untreated, research shows:
- It can take six to 10 years for MASLD to progress to another fibrosis stage, including MASH.
- Once you have MASH, it can take another 10 to 20 years to develop cirrhosis.
- Around 20% of people with MASH may see their fibrosis improve or stay the same.
Factors Affecting Fatty Liver Progression
There’s no way to predict exactly who will get fatty liver or if it will progress to cirrhosis -- and how quickly. But certain factors play a role:
Genes. Your genes determine how your body stores and processes fat in your liver, and you’re more likely to get fatty liver if you’re related to someone who has it.
Studies show that genetic factors may cause as much as 20% to 70% of MASLD cases.
Two main genes linked to fatty liver are:
- PNPLA3. Found most often in Hispanic people, this gene greatly increases your chances of storing too much fat in your liver. It also raises your odds of getting liver inflammation, scarring, and severe liver damage like cirrhosis.
- TM6SF2. Studies show this gene boosts your odds of getting fatty liver or cirrhosis regardless of your age, how much you weigh, or whether you have type 2 diabetes.
The MBOAT7, GCKR, and APOB genes also raise your odds of MASLD and its complications. Scientists may discover more fatty liver-related genes in the future. Research is ongoing in this area.
Lifestyle choices. Certain lifestyle habits are linked to poor liver health, including:
- Chronic, heavy drinking (more than three or four drinks a day for men and two or three for women)
- Not getting enough exercise
- Drinking sugary drinks
- Following a diet high in saturated fat (like the kind in red meat)
- Eating more calories than your body can use
- Smoking
Existing health conditions. The following so-called cardiometabolic risk factors are closely linked to MASLD, and your chances of liver damage or go up if you have more than one.
If left untreated, the following health conditions boost the odds you’ll progress from fatty liver to cirrhosis:
- Type 2 diabetes
- Insulin resistance
- High blood pressure
- Elevated ALT levels (a marker of liver health)
- High levels of fat in the blood (cholesterol or triglycerides)
- Low levels of “good” cholesterol (HDL)
- Severe obesity
Other health problems that can raise your chances of fatty liver include:
- Having obesity along with a lot of belly fat
- Polycystic ovary syndrome (PCOS)
- Obstructive sleep apnea
- Underactive thyroid (hypothyroidism)
- Underactive pituitary gland (hypopituitarism)
Race and ethnicity. Studies show that people who are Hispanic or Latino are the most likely group to get fatty liver disease (22.9%), followed by people who are White (14.4%) and those who are Black (13%).
There are racial differences in who progresses from fatty liver to cirrhosis.
While anyone with fatty liver can get severe liver damage, here’s what some research says:
- White people are the most likely group to develop cirrhosis from fatty liver.
- Non-Hispanic Black people are the least likely group to go from fatty liver to cirrhosis.
- Hispanic and White people with fatty liver are more likely to get diagnosed with cirrhosis younger than age 40, when compared to Black people.
Does age affect fatty liver progression and cirrhosis risk?
Researchers haven't found a consistent link between age and how fast liver scarring progresses. But cirrhosis is usually diagnosed in people around the age of 60. Older adults are also more likely to have other liver-related health problems, like liver cancer.
Signs Your Fatty Liver Is Progressing
Extra fat in your liver doesn’t always cause health problems. Even if you get inflammation, you may not have symptoms early on. But as you start to get more liver damage, there are some signs to watch for.
General signs and symptoms of liver damage may include:
- Tiredness, even when you get enough sleep
- Feeling like you’re getting sick
- Pain or fullness in the upper right side of your belly
- Weight loss without trying
Once your fatty liver progresses to MASH or cirrhosis, your liver may not be able to work properly. When that happens, you may have the above symptoms, along with:
- Itchy skin
- Muscle tiredness or weakness
- Feeling sick to your stomach or throwing up
- Belly swelling due to fluid buildup (ascites)
- Blood vessels you can see beneath your skin
- Red palms
- Feeling like you can’t catch your breath
You may also get:
- Yellowing of your skin or eyes (jaundice)
- Very itchy skin
- Easy bleeding or bruising
- Confusion
- Swelling in your lower legs, ankles, or feet (edema)
- Dark pee
If you get cirrhosis, your liver may stop working. This is called end-stage liver disease. You’ll need a liver transplant if this happens.
How to Prevent Fatty Liver Disease Progression
There are steps you can take to protect your liver or help it heal. If you get medical treatment or make lifestyle changes early enough, there’s a good chance you might stop progression to cirrhosis or reverse fatty liver.
If you have MASLD, here are some things your doctor might suggest you do:
Maintain a healthy weight. Around 10% to 15% of people with MASLD are within a healthy weight range. But if you have overweight or obesity, weight loss is probably the first thing your doctor will recommend.
Here’s why:
- A loss of 3% to 5% of your body weight can cut fat in your liver.
- A loss of 7% to 10% can lessen inflammation linked to MASH
- A loss of at least 10% can decrease or reverse scarring and fibrosis.
Follow a nutritious diet. While there's not a specific fatty liver diet, experts generally agree that the Mediterranean diet is good for liver health. This eating plan focuses on fresh foods like green leafy vegetables, fruit, whole grains, nuts, beans, and lean proteins.
Here are some more eating tips to keep your liver healthy:
- Limit sugary drinks like soda, sports drinks, or juice.
- Limit or avoid red meat.
- Replace saturated fats with unsaturated fats, like olive oil.
- Eat fatty fish a couple of times a week.
Studies show regular coffee drinkers are less likely to get MASLD, and coffee may slow the progression of liver scarring. Your doctor might recommend you drink 2 or 3 cups of black coffee a day specifically for liver health. Ask how much caffeine is safe for you.
Avoid alcohol. There’s no safe amount of alcohol recommended for people who have MASLD.
If your fatty liver is solely caused by alcohol use, you may be able to get rid of the excess fat within weeks – but you’ll need to quit drinking completely.
Be active. People who do moderate to vigorous physical activity are much less likely to get fatty liver. Regular exercise (at least 30 minutes a day, five days a week) may help reduce fat and inflammation in the liver, even if you don’t lose weight doing it.
Treat other health conditions. Work with your doctor to manage medical conditions that can worsen fatty liver, including obesity, type 2 diabetes, high cholesterol, or high blood pressure.
Consider medications. A drug called resmetirom (Rezdiffra) has been approved to treat adults with MASH who have moderate to advanced liver scarring (but not cirrhosis). Newer weight loss medications, such as GLP-1 agonists, may also help. Ask your doctor if they’re right for you.
Get regular checkups. Your doctor can review your medications to make sure none are making fatty liver worse. They might also do some tests to see if your liver has changed. This could include blood tests, an MRI, or a special scan that measures liver fat and scarring (FibroScan).
Recap
Fatty liver disease, also called steatotic liver disease, usually doesn’t cause symptoms at first. But over time, too much fat in your liver can cause inflammation and lead to scarring that doesn’t heal (cirrhosis).
Eating a balanced diet, staying active, and maintaining a healthy weight can help slow or even reverse fatty liver disease. Along with regular medical care, these lifestyle changes can cut fat in your liver, reduce inflammation, and repair mild damage.
It’s also important to manage health problems like obesity, type 2 diabetes, high cholesterol, or high blood pressure. If you drink alcohol, it’s best for your liver if you stop.
How long does it take for fatty liver to develop into cirrhosis?
It can take 10 to 30 years for fatty liver to turn into cirrhosis. How fast you’ll progress depends on things like your genes, lifestyle habits, and if you have untreated health problems, especially type 2 diabetes, obesity, high blood pressure, and high cholesterol. Alcohol use can also speed up cirrhosis.
What percentage of fatty liver turns to cirrhosis?
About 3% to 5% of people with metabolic dysfunction-associated steatotic liver disease (MASLD) eventually get cirrhosis. This includes around 20% of people with MASH, those with fatty liver who already have moderate to advanced liver inflammation or scarring.
What are the stages of fatty liver to cirrhosis?
Simple fatty liver is the earliest stage – when you have excess fat in your liver with little to no inflammation. Over time, you may get mild to moderate inflammation (when MASLD becomes MASH), scarring (fibrosis), and severe liver damage that doesn’t heal (cirrhosis).
Show Sources
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SOURCES:
Bubu A. Banini, MD, PhD, assistant professor of medicine (digestive diseases); translational research director, Metabolic Health and Weight Loss Program, Yale School of Medicine; associate director, clinical and translational core, Yale Liver Center.
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