College of Gastroenterology states that few data guide which of the various chelating agents is best (Tran, 2016). These include penicillamine, zinc, and trientine, and any theoretical risks are outweighed by the risks of discontinuing therapy. he latter include not only hepatic decompensation, but also injury to the placenta and fetal liver. Accordingly, the American College continue their chelation therapy, although a dose reduction of 25 to 50 percent should be considered to promote wound heal ing in the event of a surgical delivery. As a reminder, copper ions regulate the activity of proteins essential to wound repair.
his condition is frequently comorbid with obesity and is the most common chronic liver disease in the United States (Diehl, 2017). Its most severe form-nonacoholic steatohepatitis (NASH)-is an increasingly recognized condition that may occasionally progress to hepatic cirrhosis. Nonalcoholic fatty liver disease (NAFLD) is a macrovesicular fatty liver condition that resembles alcohol-induced liver injury but is seen without this substance abuse. Obesity, type 2 diabetes, and hyperlipidemiasyndrome X-frequently coexist (Chap. 48 p. 938). The current hypothesis suggests that these conditions may interact with other unknown etiological agents to cause multiple insults or "hits" leading to hepatic injury. For example, half of persons with type 2 diabetes have NAFLD, and insulin resistance has been postulated to act as one possible "hit" (Buzzetti, 2016). Browning and associates (2004) used MR spectroscopy to determine the prevalence ofNAFLD in Dallas County and found that approximately a third of adults were afected. This varied by ethnicity, with 45 percent of Hispanics, 33 percent of whites, and 24 percent of blacks being afected. Most people-80 percent-found to have steatosis had normal liver enzymes. In a study of obese adolescents undergoing bariatric surgery, more than a third had fatty liver without hepatitis, whereas an additional 20 percent had borderline or definite NASH (Xanthakos, 2015).
Liver damage follows a progressive continuum from NAFLD to NASH and then to hepatic ibrosis that may progress to cirrhosis (Goh, 2016). Still, in most persons, the disease is usually asymptomatic, and it is a frequent explanation for elevated serum transaminase levels found in blood donors and during
Hepatic, Biliary, and Pancreatic Disorders 1067 other routine screening. Indeed, NAFLD is the cause of ele vated asymptomatic transaminase levels in up to 90 percent of cases in which other liver disease is ultimately excluded. It also is the most common cause of abnormal liver tests among adults in this country. Currently, weight loss along with control of diabetes and dyslipidemia is the only recommended treatment.
Fatty liver iniltration is probably much more common than realized in obese and diabetic gravidas. During the past decade, we encountered an increasing number of pregnant women with these disorders. Once severe liver injury, that is, acute fatty liver of pregnancy, is excluded, gravidas with fatty liver iniltra tion have no greater rates of adverse outcomes relative to liver involvement compared with pregnant women of similar weight.
That said, some emerging data indicate that this condition may portend adverse pregnancy outcomes. In 110 pregnancies with
NAFLD from the Swedish Medical Birth and the National