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Paediatric non-alcoholic fatty liver disease: an approach to pathological evaluation
  1. Chiyun Wang1,
  2. Anita K Pai2,
  3. Juan Putra3
  1. 1 Department of Pathology, Memorial Sloan Kettering Cancer Center, New York City, New York, USA
  2. 2 Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
  3. 3 Department of Pathology, Boston Children's Hospital, Boston, Massachusetts, USA
  1. Correspondence to Dr Juan Putra, Department of Pathology, Boston Children's Hospital, Boston, 02115, Massachusetts, USA; juan.putra{at}


Non-alcoholic fatty liver disease (NAFLD) is becoming an increasingly important healthcare issue along with the rising rates of obesity worldwide. It is the most common chronic liver disease in the paediatric population and the fastest growing indication for liver transplant in young adults. The pathogenesis is complex with contributions from multiple factors and genetic predisposition. While non-invasive laboratory tests and imaging modalities are being increasingly used, the liver biopsy continues to play a crucial role in the diagnosis and prognosis of NAFLD. Histologically, the assessment of paediatric fatty liver disease requires special considerations with respect to a periportal predominant pattern seen in prepubertal patients, as well as a different set of disease processes in the differential diagnosis. In this review, we provide a summary of current knowledge on the epidemiology, pathogenesis and clinical course of paediatric NAFLD as well as the clinical guidelines on diagnosis and management. We discuss the indications and limitations of liver biopsy, histological patterns seen in paediatric NAFLD, other entities to be considered in the differential diagnosis, and conclude with appropriate triaging of liver biopsies and essential elements of pathology reporting.

  • Pediatrics

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  • Handling editor Runjan Chetty.

  • Twitter @path_putra

  • Contributors CW reviewed the literature and drafted the manuscript. AKP reviewed and revised the manuscript. JP reviewed the literature, acquired histological images and revised the final version, which was approved by all authors.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; internally peer reviewed.