Like diabetes, Fatty liver disease is also considered a Silent Killer disease because people don’t feel any symptoms in the initial stage of fatty liver disease. It slowly comes into your body and causes chronic liver disease. The severity of the fatty liver disease depends on fatty liver grades. Your liver condition will become more vulnerable if fatty liver grades get increase. Fatty liver disease is a metabolic disease where fat gets stored in your hepatocytes or liver cells that, cause inflammation. There are two main types of fatty liver disease – alcoholic fatty liver disease (AFLD) and non-alcoholic fatty liver disease (NAFLD). Fatty liver disease is generally graded based on the amount of fat stored and the degree of liver damage. This is called Fatty Liver Grades. Simply, this fatty liver grade represents stages of fatty liver. There are four grades of fatty liver – Grade 1, Grade 2, Grade 3 and Grade 4. Fatty liver disease is a silent disease; it comes with no signs or symptoms. NAFLD (non-inflammatory or Grade 1 fatty liver) is asymptomatic, meaning you don’t feel any symptoms. Still, you may have fatigue, thirst, anxiety, upper abdominal pain, bloating or discomfort, etc. These are the most common symptoms of NAFLD. As the disease progresses, symptoms start appearing, usually in advance grading of fatty liver disease such as NASH (inflammatory fatty liver) If left untreated, you may have a more severe liver condition that gets more complicated. Although the exact cause of fatty liver is still unclear, but there are certain possible reasons to cause fatty liver. A bad lifestyle is the most significant risk factor for developing NAFLD (Non-alcoholic fatty liver disease). The good news is that you can reverse your fatty liver disease and even cure it. If you get diagnosed early, it can be treated because some fatty liver grades are reversible, such as grade 1, grade 2 and grade 3. But if you get liver cirrhosis or grade 4 fatty liver, that is irreversible. At this stage, your liver cells cannot reduce fat and can’t return to a healthy liver. This post will discuss fatty liver grades, types, causes, pathology, symptoms, complications, diagnostic tests and treatment.

1. Fatty Liver Grades Explained: How To Reverse
It?
Posted By SUMIT SHARMA
Contents
➢ Introduction
➢ What does fatty liver mean?
➢ How many grades of fatty liver are there? What are the histological features of fatty liver?
❖ Grade 1 fatty liver (Steatosis stage)
❖ Grade 2 fatty liver (NASH)
❖ Grade 3 fatty liver (Fibrosis stage)
❖ Grade 4 fatty liver (Cirrhosis stage)
➢ What are the signs and symptoms of fatty liver grades?
❖ 1. Ascites and pedal oedema

2. ❖ 2. Portal hypertension
❖ 3. Jaundice
❖ 4. Hepatic encephalopathy
❖ 5. Oesophageal varices
❖ 6. Red palms
➢ What are the causes and risk factors of fatty liver?
❖ 1. Eating excess calories
❖ 2. Insulin resistance
❖ 3. Alcoholism
❖ 4. Hepatitis-induced fatty liver
❖ 5. Drug-induced fatty liver
❖ 6. Genetic predisposition
➢ What is the pathophysiology of fatty liver grades?
➢ Does fatty liver cause high SGOT/SGPT in LFT lab findings?
❖ SGPT and SGOT level in Non-alcoholic fatty liver disease (NAFLD)
❖ SGPT and SGOT levels in alcoholic fatty liver disease (AFLD)
➢ How to check fatty liver grades in ultrasound?
➢ Can Liver fatty be cured?
❖ 1. Weight loss
❖ 2. Diet modification
❖ 3. Avoid alcohol
❖ 4. Control diabetes

3. ❖ 5. Natural remedies
❖ 6. Supplements
❖ 7. Medicines
❖ 8. Liver transplant
➢ Conclusion
➢ FAQ
❖ Q 1. Which fatty liver grade is dangerous?
❖ Q 2. Is grade 1 fatty liver dangerous?
❖ Q 3. Is fatty liver grade 2 serious?
❖ Q 4. Is fatty liver grade 3 serious?
Introduction
Fatty liver grades are generally stages of fatty liver disease.
You will be shocked to know that 9 to 32% population suffers from non-alcoholic
fatty liver disease in India
According to a review and meta-analysis study published in The Lancet 2022,
32·4% population are exposed to fatty liver disease worldwide.
You can understand how fatty liver disease is increasing at an alarming rate.
Like diabetes, Fatty liver disease is also considered a Silent Killer disease because
people don’t feel any symptoms in the initial stage of fatty liver disease.
Therefore, it slowly comes into your body and causes chronic liver disease.
The severity of the fatty liver disease depends on fatty liver grades. Your liver
condition will become more vulnerable if fatty liver grades get increase.

4. This post will discuss fatty liver grades, types, causes, pathology, symptoms and
complications.
I’ll also share some tips on how to reverse fatty liver disease?
Let’s get started.
What does fatty liver mean?
Fatty liver disease is a metabolic disease where fat gets stored in your hepatocytes
or liver cells that, cause inflammation.
If we say simply, too much fat deposition in your liver may lead to fatty liver
disease.
In a healthy person, a small amount of fat is stored in the liver in a triglyceride
form (up to 5%). You will have fatty liver disease if it exceeds 5%.
It is also known as Hepatic Steatosis. Here, Steatosis means fat accumulation in
liver cells.
There are two main types of fatty liver disease – alcoholic fatty liver disease
(AFLD) and non-alcoholic fatty liver disease (NAFLD).
If you have ever taken too excess alcohol for a long time. This can be capable of
damaging your liver. This type of liver disease is called Alcoholic Fatty Liver
Disease (AFLD), also known as Alcoholic Steatohepatitis.
On the contrary, you may also have the fatty liver disease even if you don’t take
alcohol. It could be due to lifestyle changes and having a poor diet. This type of
liver disease is called Non-alcoholic Fatty Liver Disease (NAFLD).

5. How many grades of fatty liver are there? What are the
histological features of fatty liver?
Fatty liver disease is generally graded based on the amount of fat stored and the
degree of liver damage. This is called Fatty Liver Grades.
Simply, this fatty liver grade represents stages of fatty liver. There are four grades
of fatty liver – Grade 1, Grade 2, Grade 3 and Grade 4.
A liver biopsy is considered a gold-standard test to identify the grade of fatty liver.
Suppose you get a biopsy done of your fatty liver. You see the microscopic view of
fatty liver cells in your report.
Let’s understand fatty liver histology and look at the differences between fatty liver
grades on the microscopic level.

6. Grade 1 fatty liver (Steatosis stage)
It is a mild form of fatty liver that simple fat accumulation in your liver cells.
Sometimes, this first stage of fatty liver is called Simple fatty Liver or Steatosis.
This Grade 1 fatty liver has only small fat vacuoles (or liposomes) without
inflammation or scars.
You can see a lot of tiny fat droplets in liver cells that seems to be inflated balloon.
This type of structure is called Fat-Filled Hepatocytes.
You may have triglyceride (or fat) content between 5%–33% in grade 1 fatty liver.
In official medical terms, this non-inflammatory fatty liver is called NAFLD
(Non-alcoholic fatty liver disease).
Although NAFLD is not life-threatening, but it can significantly cause chronic
liver disease.
Grade 2 fatty liver (NASH)
This is the second stage of your fatty liver. Your grade 1 fatty liver may convert
into a Grade 2 fatty liver, which is a more severe liver condition.
In this stage, your liver starts depositing high-fat content. As a result, liver cells get
inflamed and, eventually, damaged.
You may see fat content of 34%–66% in your biopsy report. You will also find
large fat droplets that seem to be swollen hepatocytes.
The size of fat vacuoles increases with the progression of fatty liver.
When fat molecules damage the liver cells and lead to inflammation, the condition
is called non-alcoholic steatohepatitis (NASH).
Simply, the inflammatory condition of fatty liver is called NASH. Whereas the
non-inflammatory fatty liver is called NAFLD.

7. Grade 3 fatty liver (Fibrosis stage)
Grade 3 fatty liver is more severe and dangerous than all fatty liver grading.
At this stage, fat molecules start accumulating in entire liver cells.
Due to this invading of fat content, you may see colossal hepatocyte ballooning (or
large fat vacuole) in a microscopic structure in your biopsy report.
You may have more than 66% fat content in this grade 3 fatty liver.
This excess fat deposition in your liver cells leads to severe inflammation and liver
damage. Later, it converts into liver fibrosis and stiffness.
This third stage of fatty liver is called Fibrotic fatty liver.
Grade 4 fatty liver (Cirrhosis stage)
Grade 4 is the final stage of your fatty liver.
At this stage, your liver cells make many large fatty cysts that dissolve in liver cells
and form scars.
As far as the concern of fat content, it is very high (more than >66%).
These things do not let your liver works properly. As a result, your liver stops
functioning.
This is an irreversible stage of fatty liver. Here, the liver can’t recover its normal
phase. This stage is called End-stage liver disease.
It is also known as Hepatic (Liver) Cirrhosis or Liver failure.

8. What are the signs and symptoms of fatty liver grades?
Fatty liver disease is a silent disease; it comes with no signs or symptoms.
NAFLD (non-inflammatory or Grade 1 fatty liver) is asymptomatic, meaning you
don’t feel any symptoms.
Still, you may have fatigue, thirst, anxiety, upper abdominal pain, bloating or
discomfort, etc. These are the most common symptoms of NAFLD.
As the disease progresses, symptoms start appearing, usually in advance grading of
fatty liver disease such as NASH (inflammatory fatty liver)
If left untreated, you may have a more severe liver condition that gets more
complicated.

9. I have mentioned the critical signs, symptoms and complications for grade 3 and 4
fatty liver disease (liver cirrhosis).
1. Ascites and pedal oedema
You must have heard about albumin. This is an essential protein that releases from
your healthy liver.
Albumin acts as an osmotic gradient. It has a crucial function that pulls the water
from tissue and drains it into blood vessels.
Suppose you have a grade 4 fatty liver (or liver cirrhosis). You get your LFT done
and find a low albumin level that indicates water accumulation in your interstitial
tissue, such as the peritoneal cavity.
This water accumulation in tissue develops into ascites and pedal oedema.
In pedal oedema, you will feel swelling and puffiness in your legs. While you may
have a bulge in your entire abdomen during ascites.
2. Portal hypertension
It is a leading complication of an advanced stage of fatty liver disease. Your liver
receives all nutritious blood (which comes from the digestive tract, spleen, and
pancreas) by the portal vein.
Fatty liver disease resists blood flow and stresses the portal vein.
This causes increased blood pressure called Portal hypertension.
3. Jaundice
Liver cells generally convert the unconjugated bilirubin to conjugated bilirubin.

10. In liver cirrhosis, your liver cells do not work, and they stop the bilirubin
conjugation.
As a result, the unconjugated bilirubin returns to the bloodstream that deposits in
the skin and the eye’s sclera. You will have increased conjugated bilirubin in your
LFT report.
The higher level of bilirubin in your blood indicates jaundice.
4. Hepatic encephalopathy
The liver is a big detox organ. It has crucial role in deamination and urea
production.
In a healthy person, the liver converts ammonia (a toxic compound) into urea (a
non-toxic compound) by the urea cycle.
But with high fatty liver disease (or Liver failure), your liver cannot convert
ammonia to urea, which causes high ammonia levels in your blood.
This increased ammonia level crosses the blood-brain barrier and enters your brain,
which leads to hepatic encephalopathy.
In this condition, you might have confusion, loss of brain function, thinking
problems, etc.
5. Oesophageal varices
If your blood vessels to the liver are blocked by scar tissue. Then, the tiny
capillaries start to leak and rupture. As a result, it causes severe bleeding in the
oesophagus that can be life-threatening complications.
You may get pale/black colour stool and blood in vomiting.

11. 6. Red palms
It is caused by dilated capillaries in the palm. Since your liver is not producing
clotting factors. Thus, you may get microscopic bleeding and redness on the
surface of your palms.
What are the causes and risk factors of fatty liver?
Although the exact cause of fatty liver is still unclear, but there are certain possible
reasons to cause fatty liver.
A bad lifestyle is the most significant risk factor for developing NAFLD
(Non-alcoholic fatty liver disease).
Let’s see what other risk factors influence the progression of fatty liver grades or
NAFLD.
1. Eating excess calories
The number one cause of the fatty liver disease is diet.
Carbohydrates are not your friend in fatty liver disease.
This means that if you eat carbohydrates from vegetables, fruits etc., it is fine, but
taking carbohydrates from processed foods (such as bread, pasta, sugary foods etc.)
is not good for your health, especially in fatty liver condition.
2. Insulin resistance
Insulin resistance is a second major cause of fatty liver disease. It is strongly
associated with NAFLD.

12. If your body cells don’t respond to insulin, it returns to blood, leading to
hyperinsulinemia. This higher insulin level in your blood after rejecting by body
cells is called Insulin resistance.
This means glucose can’t enter your cells during insulin resistance conditions. This
higher blood glucose level may cause hyperglycaemia (or diabetes mellitus).
The high glucose and insulin level in your blood may deposit in your liver cells
that, cause fatty liver.
All in all, uncontrolled diabetes can be a decisive risk factor for developing fatty
liver disease.
3. Alcoholism
Too much alcohol consumption is also another cause of fatty liver. This type of
fatty liver is called AFLD (Alcoholic Fatty Liver disease).
According to a study in 2017, you would be at higher risk if you consume alcohol
40 to 80 grams per day for males and 20 to 40 grams per day for females.
The standard drink of alcohol is 14 gm/day.
When alcohol gets metabolised in your cells, it gets converted into acetaldehyde by
the alcohol dehydrogenase enzyme. Eventually, it transforms into acetate from
acetaldehyde by aldehyde dehydrogenase enzyme.
Alcohol → Acetaldehyde→ Acetate
Acetaldehyde is a primary culprit, stimulating Ito cells and releasing fat. These fats
get accumulate in your liver, which causes fatty liver. It is also known as Alcoholic
steatohepatitis.
4. Hepatitis-induced fatty liver

13. If you have liver inflammation due to some viruses, that results in hepatitis.
Hepatitis is one of the reasons to cause of fatty liver disease. As per a study,
hepatitis B and C are strongly associated with NAFLD.
Fatty liver may also be due to autoimmune hepatitis.
5. Drug-induced fatty liver
Some drugs can accumulate in your liver and cause NASH fatty liver. These drugs
are –
● An antiarrhythmic drug like amiodarone
● Steroid medicines like prednisolone
● Antiepileptic drugs such as valproate
● Anticancer medications like methotrexate, tamoxifen, cisplatin and
irinotecan
● Antiretroviral agents like lamivudine, zidovudine etc.
6. Genetic predisposition
If someone has had this problem in your family, you will be more prone to fatty
liver.
Studies reveal that there may be involvement of a gene called PNPLA3,
responsible for a high risk of developing NAFLD.
Hemochromatosis is one of the genetic problems that cause fatty liver.

14. What is the pathophysiology of fatty liver grades?
Let’s understand fatty liver pathology and see how fat deposits in your liver cells.
Ito cells play a significant role in worsening fatty liver disease.
If you see the structure of a lobule in the liver. Ito cells are present in the space of
Disse (a small area between hepatocytes and sinusoids).
Ito cells are generally fat-storing cells or vitamin A. These cells are also called
Hepatic stellate cells or Perisinusoidal cells.
Suppose you have an advanced stage of fatty liver diseases such as grade 3 and
grade 4. In that condition, the inflammatory mediators (such as adipokines,
cytokines, etc.) stimulate the Ito cells.
These Ito cells lose their fat and get deposited in your liver cells. Over time, it
becomes very aggressive and dangerous. Then it converts into myofibroblast and
starts secreting collagen.
Due to this collagen, the liver becomes generalised fibrotic and constricts the
capillaries around sinusoids.
These factors reduce the blood flow in liver cells, which results in necrosis and
liver cell death.

15. Does fatty liver cause high SGOT/SGPT in LFT lab
findings?
When fats (more than 5%) get stored in your liver cells, they become fat-filled
hepatocytes. As a result, hepatocytes start bursting and cause inflammation.
These things may force your liver cells to leak liver enzymes. Due to this, SGOT
(or AST) and SGPT (or ALT) levels increase in your blood.
Suppose you have been suggested a liver function test by a doctor. If you get
higher SGOT and SGPT levels in your blood test report, it might indicate fatty
liver disease.
The level of SGOT and SGPT depends on the severity and type of fatty liver
disease.

16. SGPT and SGOT level in Non-alcoholic fatty liver disease (NAFLD)
In non-alcoholic fatty liver disease, SGPT level is higher than SGOT because
SGPT is more specific for liver disease.
You can see the mild elevation of SGOT (45 IU/L) and SGPT (60 IU/L) in grade 1
fatty liver disease.
The SGPT level increases in inflammatory fatty conditions such as NASH (Grade
2 and Grade 3 fatty liver).
SGPT and SGOT levels in alcoholic fatty liver disease (AFLD)
On the contrary, SGOT is two times higher than SGPT in alcoholic fatty liver
disease.
But if someone has grade 4 fatty liver disease (or liver cirrhosis). In that case,
SGOT is much higher than SGPT because liver cirrhosis may also damage other
body parts like the heart, brain etc.
How to check fatty liver grades in ultrasound?
Ultrasound is an imaging diagnostic tool that produces high-frequency sound
waves and gives you a live picture of your inside body. It is also called
Sonography.
The results of the ultrasound report represent an echogenicity form.
It would help if you remembered fluid is always black, and tissue is Gray. It does
not penetrate bone, so you will see white colour.
The low echogenicity indicates dark colour images in ultrasound are called
hypoechogenic. It could be fluid.

17. In contrast, the high echogenicity indicates lighter colour images in ultrasound
reports called hyperechogenic. This hyperechogenic is a major finding in your
report.
The high echogenicity in the liver indicates the presence of fat content. This fat
content in the liver reflects in light colour images in your ultrasound report.
● Grade 1 fatty liver – slightly increased hepatic echogenicity with clearly
visible diaphragm
● Grade 2 fatty liver – moderate diffuse increased hepatic echogenicity with
impaired portal vein
● Grade 3 fatty liver – a marked increase of hepatic echogenicity with no
visualisation of the portal vein and diaphragm
It also depends on echotexture (homogenous or coarse) and liver surface (smooth
and nodular).
If there is a high SGPT and SGOT level with increased echogenic liver and
positive clinical signs, that indicates fatty liver disease.
These clinical tests help your doctor to find fatty liver grades.
Can Liver fatty be cured?
The good news is that you can reverse your fatty liver disease and even cure it.
If you get diagnosed early, it can be treated because some fatty liver grades are
reversible, such as grade 1, grade 2 and grade 3.

18. This means your liver reduces the excess fat itself and returns to the healthy liver
stage.
But if you get liver cirrhosis or grade 4 fatty liver, that is irreversible. At this stage,
your liver cells cannot reduce fat and can’t return to a healthy liver.
Liver transplantation is the only option for liver failure condition.
If we talk about life expectancy with fatty liver disease. An advanced stage of fatty
liver disease hampers the quality of life and decreases survival.
Although, there is no such proper medicine available for fatty liver disease. It
would be best if you manage your risk factors to prevent fatty liver disease.
You can do the following things to reduce fatty liver conditions –
1. Weight loss
Losing weight is the fastest way to decrease fatty liver conditions.
According to a study, your liver fat content can improve by up to 10 % through
exercise or weight loss.
Generally, exercise helps to cut down fat from your liver.
2. Diet modification
Taking less calorie food helps to reduce fat content from your liver.
You should avoid high glycaemic index foods such as Pizza, burgers, chips, ice
creams, bread and other processed foods.
You need to manage your fatty liver diet plan. You must include low glycaemic
index foods such as vegetables, fruits, nuts, seeds, brown bread etc.
Fasting is also an excellent way to improve your fatty liver condition.

19. 3. Avoid alcohol
Stopping alcohol is the best way to reduce fatty liver disease.
As you know, alcohol is one of the reasons for developing fatty liver. You should
not take alcohol for any liver disease, whether NAFLD or FLD.
4. Control diabetes
If you have diabetes, you should control your blood glucose level. We have seen
how high blood glucose levels induce fatty liver.
You should get your blood glucose level, and HBA1C checked. It will help if you
take your antidiabetic medicines at the proper time.
5. Natural remedies
Researchers found that regular caffeine and green tea intake significantly reduces
hepatic fibrosis in NAFLD. These beverages act as an antioxidant that regenerates
your healthy liver cells.
Some studies reveal that vitamin Eacts as a liver protective agent. It is a potent
antioxidant that helps to reduce oxidative stress in NAFLD.
6. Supplements
You can take some essential supplements that help to reduce your fatty liver. These
are –
● Glutathione (acts as detoxifier and antioxidant)
● Berberine (anti-dyslipidaemia effect)

20. ● Alpha lipoic acid (reduce insulin resistance)
● Omega 3 fatty acid (reduce triglyceride content)
7. Medicines
Although, there is no such new treatment for fatty liver disease. In the advanced
stage, you may be prescribed some medicines to prevent the worsening of fatty
liver. For example-
● Diuretics – to prevent ascites and edema
● Vitamin K – to improve coagulopathy
● L-ornithine L-aspartate (LOLA) – good evidence in hepatic encephalopathy
● Antibiotics (e.g., amoxicillin) – to prevent infections
● Antidiabetics – to control blood glucose level
● Antihypertensive (e.g., ACE inhibitors) – to control blood pressure
● Hypolipidemic agents or lipid-lowering drugs
8. Liver transplant
Suppose you have the final stage of fatty liver. You can say Grade 4 fatty liver or
liver cirrhosis.
This is an irreversible stage of fatty liver, where 90-95% of liver cells get damaged.
In that case, a liver transplant is the only way.

21. Conclusion
Living a sedentary lifestyle contributes to fatty liver disease. You just need to
change your lifestyle to reverse the fatty liver grades.
It is always better to stop fatty liver disease early because if it worsens, you will
have many serious complications that could be fatal.
It was the information about fatty liver disease. In this post, we have learned about
different fatty liver grades, symptoms, causes, diagnostic tests, and treatment
options.
You must consult your doctor if you have a fatty liver condition.
Please share this post on social media if you found this informative.
FAQ
Q 1. Which fatty liver grade is dangerous?
It is always a concern whenever your liver gets inflammation with fat
accumulation, known as inflammatory fatty liver. Grade 3 fatty liver is considered
the most dangerous stage among all fatty liver grades. If grade 3 fatty liver is
untreated, it may convert into fatal liver cirrhosis.
Q 2. Is grade 1 fatty liver dangerous?
You don’t need to worry too much if you have grade 1 fatty liver. In this stage,
only fat deposition in your liver cells without inflammation. It does not cause
major problems, and it is usually asymptomatic. It can be reversed by simple diet
modification.

22. Q 3. Is fatty liver grade 2 serious?
Yes. It can be serious because fatty liver grade 2 brings fat deposition and
inflammation towards your liver. It is known as NASH. Fortunately, simple diet
modification and lifestyle change can reverse your fatty liver grade 2 to a healthy
liver.
Q 4. Is fatty liver grade 3 serious?
Yes. Fatty liver grade 3 is the most dangerous stage in all fatty liver grades. This
fatty liver stage may cause serious complications such as ascites, oedema, portal
hypertension, jaundice, etc. Luckily, it is also a reversible stage. You can reverse
your grade 3 fatty liver into a healthy liver.
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