Figure 1 Proposed algorithm for the management of suspected non-alcoholic fatty liver disease (NAFLD) in high-risk individuals Figure 1 | Proposed algorithm for the management of suspected non-alcoholic fatty liver disease (NAFLD) in high-risk individuals. This algorithm was developed using available evidence and guidelines, as well as personal opinion where uncertainty exists and evidence is unavailable. Patients with metabolic risk factors or chronic kidney disease (CKD) should undergo diagnostic procedures for the diagnosis of NAFLD, which relies on the demonstration of excessive liver fat. Serum liver enzyme levels are not reliable indicators for the screening and diagnosis of NAFLD and should, therefore, not be used without further investigation in clinical practice. Liver ultrasonography is the preferred first-line diagnostic procedure for diagnosing NAFLD. After excluding other causes of hepatic steatosis, such as excessive alcohol consumption, viral hepatitis, haemochromatosis, autoimmune hepatitis or the use of drugs that induce hepatic steatosis (for example, amiodarone, steroids, diltiazem or retroviral agents), the presence of liver fibrosis is assessed non-invasively using hepatic fibrosis scores, such as the NAFLD fibrosis score, the enhanced liver fibrosis (ELF) score or the fibrosis-4 (FIB-4) score, and transient elastography (for example, using FibroScan or other imaging techniques that assess liver stiffness) to select patients for liver biopsy, upper gastrointestinal endoscopy or long-term routine surveillance (including for hepatocellular carcinoma if cirrhosis or nonalcoholic steatohepatitis is present). ALT, alanine aminotransferase. Targher, G. & Byrne, C. D. (2017) Non-alcoholic fatty liver disease: an emerging driving force in chronic kidney disease Nat. Rev. Nephrol. doi:10.1038/nrneph.2017.16