A Q&A with Dr. Michael Charlton about the UChicago Medicine Metabolic & Fatty Liver Disease Clinic

UChicago hepatology team
The UChicago hepatology team (L-R) Dr. Andrew Aronsohn, Dr. Anjana Pillai, Dr. K. Gautham Reddy, Dr. Michael R. Charlton, Dr. Sonali Paul, Dr. Helen S. Te (Photo by Nancy Wong)

Fatty liver disease is a name for a range of liver conditions where too much fat is stored in liver cells. The condition is sometimes called nonalcoholic fatty liver disease, because it’s not caused by excessive drinking unlike other liver disorders. A more severe form called nonalcoholic steatohepatitis, or NASH, can cause inflammation, scarring and irreversible damage that may lead to cirrhosis and liver failure.

Fatty liver disease affects between 90 to 100 million people in the United States, making it the nation’s most common chronic liver condition. Patients often suffer from other conditions as well, including heart disease, hypertension, type 2 diabetes and other endocrine problems.

That's why the University of Chicago Medicine established a new Metabolic & Fatty Liver Disease Clinic. Under the direction of Sonali Paul, MD, assistant professor of medicine, the clinic brings together specialists from several areas to orchestrate care for patients. We spoke to Michael Charlton, MBBS, director of the Center for Liver Diseases and co-director of the Transplantation Institute at UChicago Medicine, about the clinic’s mission.

UChicago Medicine: What causes fatty liver disease?

Michael Charlton: It's no secret to anyone that we struggle with weight. The number of people who are overweight and have fat in their liver is now estimated to be between 90 to 100 million. It's almost a third of the country.

There may be a third of people in the country who have some form of this disease, but the great majority have never been treated.
Most people don't develop liver-related complications like cirrhosis or liver cancer, but because there are so many people at risk, fatty liver disease is now one of the common reasons for people to need to undergo liver transplantation. And it's increasing rapidly.

It's a complex disease, and people who struggle with weight usually have different things going on. It's easy to focus on the liver, but they may also have type 2 diabetes, hypertension and lipid trouble.

Are there other factors that can lead to developing the disease?

There is one gene in particular, called PNPLA3, that is linked to increased risk for the disease. People of different ethnic backgrounds have different frequencies of liver disease, and it's almost entirely based on the different frequency of this gene.

Diet is also very important. The Mediterranean diet, which emphasizes fruits and vegetables, whole grains, legumes, lean meat and healthy fats like olive oil, is very protective for this kind of liver disease. If you have a fast food diet with a lot of saturated fats, cholesterol and fructose, that's where you see severe, progressive forms of this illness.

What does the UChicago Medicine Metabolic Liver Clinic offer for patients?

The patient just has to make one call. On their first visit, they see three different specialists: an endocrinologist, a hepatologist (liver specialist) and a nutritionist. We have access to state-of-the-art imaging and non-invasive procedures with our Center for Endoscopic Research and Therapeutics (CERT) that are not available at many places in the country. We can arrange to have all these things taken care of in one visit, which might otherwise take three or four trips to the doctor. That’s a huge benefit for people who have travelled a long way or need to take time off work.

Our nutritionists will take a thorough history of their eating habits, and after the initial visit they continue to follow up about diet. They also provide a journal so patients can accurately describe what they're eating, so our nutritionists can spot any more issues.

The best analogy is when you have fatty liver disease, it's a marker of a broader health concern that maybe you weren't aware of. What patients really need is an orchestra of caregivers, and this clinic will serve as the conductor for that orchestra. We'll bring together the right people to give them the care they need.

What about more advanced treatments or surgical options?

For patients who meet certain criteria, we have access to clinical studies for the most promising new therapies under development. There are many trials underway for fatty liver disease, and we try to pick the ones that are most likely to benefit our patients.

We have new ways of approaching weight loss too, with UChicago Medicine’s endoscopic or non-surgical approaches to weight loss. We're going to bring all of these things together to be a lens that will focus on the patient in one setting.

What patients benefit the most from the clinic?

The most immediate benefit will be for someone who has had some progression of disease where we can reverse the course. Having said that, we want to see everyone who can benefit from what this clinic has to offer.

It can take years, because it requires changes in lifestyle, diet, etc. But we've seen some exciting clinical trial data with an injectable treatment that takes the fat out of the liver in 16 weeks.
Our preference is not to wait for someone to have more advanced disease, but to engage patients early so we can help them with education and diagnosis. But we're also helping people with end-stage liver disease that may not be reversible. We have technologies to give them the best chance at reversing their illness, and we have a great liver transplant unit for patients whom reversal is not possible. Liver transplantation is, of course, our last resort.

What's the timeframe for treatment?

Typically, it can take years, because it requires changes in lifestyle, diet, etc. But we've seen some exciting clinical trial data with an injectable treatment that takes the fat out of the liver in 16 weeks, inflammation is decreased, and scar tissue is decreased too. These rapidly effective therapies are on the horizon, but they're still in the developmental phase. For now, I think of it like hypertension or heart disease, where once you demonstrate the ability to treat a disease, treatment may be for the long term. The potential for fatty liver disease to recur or progress is something we'll always have to be mindful of.

What's your goal for this clinic in the near future?

The goal for the UChicago Medicine Metabolic Liver Clinic is clear: to be a national paradigm for managing the health crisis of fatty liver disease. There was a recent analysis presented at a health conference showing that the lifetime cost of health care for people with fatty liver disease is about $950 billion. That's a conservative estimate. It's a health crisis that's going to take prevention and, on occasion, intervention, but we're also looking for nutritional and lifestyle changes to engage in preventive health.

There may be a third of people in the country who have some form of this disease, but the great majority have never been treated. My goal is to come up with ways to identify people and make their treatment much more predictable and effective than it has been so far.

The great thing about UChicago Medicine is that we have all the important pieces. We have remarkable groups that often do their thing independently, but this clinic is an example of how we can bring them together. We have great access to imaging. We have the CERT program. We have a world-class endocrine team and outreach clinics in different parts of the community. This is an example how UChicago can bring together these resources to benefit patients.

Metabolic & Fatty Liver Disease Clinic

UChicago Medicine's Metabolic and Fatty Liver Disease Clinic is the first program in Chicago and one of the first in the nation to bring together a team of specialists to pioneer the prevention and treatment of nonalcoholic fatty liver disease and nonalcoholic steatohepatitis (NASH) in adults.

Learn more about fatty liver disease treatment

Sonali Paul, MD

Sonali Paul, MD, is the Director of the Metabolic & Fatty Liver Disease Clinic. As a hepatologist, Dr. Paul specializes in the care of patients with liver disease, with a particular interest in hepatitis B, autoimmune and cholestatic liver diseases, and liver transplantation.

Learn more about Dr. Paul

Michael Charlton, MBBS

Dr. Charlton is an internationally renowned specialist in liver diseases and transplant medicine. Listed among "America's Top Doctors" and "Best Doctors in America," he has particular expertise in the diagnosis, treatment and management of nonalcoholic fatty liver disease.

See Dr. Charlton's Bio