Metabolic-associated fatty liver disease: New nomenclature and approach with hot debate

An international panel recently proposed an update to the terminology and diagnostic criteria for fatty liver disease. The experts proposed a change in the nomenclature from non-alcoholic fatty liver disease (NAFLD) to metabolic (dysfunction)-associated fatty liver disease (MAFLD). This single-letter change, we believe, heralds the dawn of a new era in clinical practice and in clinical and basic research as well. The new nomenclature with the easily applicable approach has stimulated the enthusiasm of the researchers worldwide, resulting in a large number of publications over the past two years. Several recent studies have provided tremendous evidence of the superiority of the MAFLD criteria over the NAFLD criteria. Many studies in different geographic areas of the world including the United States, Europe, and Asia on a large number of patients proved that the utility of MAFLD criteria was higher than that of the NAFLD criteria in different aspects of fatty liver diseases. Consequently, many societies, physician and nurse groups, health stakeholders, representatives of regulatory sciences, and others endorsed the new nomenclature. Here we highlight the endorsement of the new name by different societies and groups and the outcome of different studies on the new nomenclature in addition to a short discussion of the debate by some experts.

Redefinition of Fatty Liver Disease from NAFLD to MAFLD through the Lens of Drug Development and Regulatory Science

Metabolic (dysfunction)-associated fatty liver disease (MAFLD) affects a third of the population and is a leading cause of liver-related death. Since no effective treatments exist, novel approaches to drug development are required. Unfortunately, outdated terminology and definitions of the disease are hampering efforts to develop new drugs and treatments. An international consensus panel has put forth an influential proposal for the disease to be renamed from nonalcoholic fatty liver disease (NAFLD) to MAFLD, including a proposal for how the disease should be diagnosed. As allies with the many stakeholders in MAFLD care-including patients, patients' advocates, clinicians, researchers, nurse and allied health groups, regional societies, and others-we are aware of the negative consequences of the NAFLD term and definition. We share the sense of urgency for change and will act in new ways to achieve our goals. Although there is much work to be done to overcome clinical inertia and reverse worrisome recent trends, the MAFLD initiative provides a firm foundation to build on. It provides a roadmap for moving forward toward more efficient care and affordable, sustainable drug and device innovation in MAFLD care. We hope it will bring promising new opportunities for a brighter future for MAFLD care and improve care and outcomes for patients of one of the globe's largest and costliest public health burdens. From this viewpoint, we have revisited this initiative through the perspectives of drug development and regulatory science.

MAFLD considerations as a part of the global hepatitis C elimination effort: an international perspective

BACKGROUND

The World Health Organization (WHO) set a goal to eliminate hepatitis C (HCV) infection globally by 2030, with specific targets to reduce new viral hepatitis infections by 80% and reduce related deaths by 65%. However, an overlooked aspect that may hinder these efforts is the impact other liver diseases could have by continuing to drive liver disease progression and offset the beneficial impact of DAAs on end-stage liver disease and hepatocellular carcinoma (HCC). In particular, the decrease in HCV prevalence has been countered by a marked increase in the prevalence of metabolic-associated fatty liver disease (MAFLD).

AIMS

To review the potential interaction of HCV and MAFLD.

METHODS

We have reviewed the literature relating to an arrange of interaction of HCV, metabolic dysfunction and MAFLD.

RESULTS

In this viewpoint, international experts suggest a holistic and multidisciplinary approach for the management of the growing number of treated HCV patients who achieved SVR, taking into consideration the overlooked impact of MAFLD for reducing morbidity and mortality in people who have had HCV.

CONCLUSIONS

This will strengthen and improve the continuum of care cascade for patients with liver disease(s) and holds the potential to alleviate the cost burden of disease; and increase quality of life for patients following DAAs treatment.

The NAFLD-MAFLD debate: Eminence vs evidence

Debates are inevitable in science and could be a powerful tool for addressing controversial topics as it promotes critical thinking and inspires individuals to consider alternate viewpoints. However, debates can help only to identify the issues that need to be clarified to address this question, but it can never help resolve the controversy itself. In the era of evidence-based medicine, the need for an evidence-based debate is mandatory. Polarising opinions and major debate have recently arisen in hepatology on the nomenclature and diagnostic criteria for fatty liver disease associated with metabolic dysfunction (non alcoholic fatty liver disease [NAFLD]-metabolic (dysfunction) associated fatty liver disease [MAFLD] debate). The aim of this viewpoint is to suggest a way to settle the debate through evidence. Descriptive review using PubMed to identify literature on the evidence and eminence-based medicine and studies comparing MAFLD and NAFLD criteria. The emerging studies comparing the performance of diagnostic criteria of NAFLD and MAFLD represent the dawn of a new era for reframing the ongoing debate by acquisition of the mandatory evidence that will both resolve the debate and lead to novel avenues of research. In conclusion, the time has come to hold debate and focus on gathering and building the evidence to settle it. It does not matter who wins the debate and once there is robust evidence, we should all follow it wherever it leads.

History of Nonalcoholic Fatty Liver Disease

Based on the assumption that characterizing the history of a disease will help in improving practice while offering a clue to research, this article aims at reviewing the history of nonalcoholic fatty liver disease (NAFLD) in adults and children. To this end, we address the history of NAFLD histopathology, which begins in 1980 with Ludwig's seminal studies, although previous studies date back to the 19th century. Moreover, the principal milestones in the definition of genetic NAFLD are summarized. Next, a specific account is given of the evolution, over time, of our understanding of the association of NAFLD with metabolic syndrome, spanning from the outdated concept of "NAFLD as a manifestation of the Metabolic Syndrome", to the more appropriate consideration that NAFLD has, with metabolic syndrome, a mutual and bi-directional relationship. In addition, we also report on the evolution from first intuitions to more recent studies, supporting NAFLD as an independent risk factor for cardiovascular disease. This association probably has deep roots, going back to ancient Middle Eastern cultures, wherein the liver had a significance similar to that which the heart holds in contemporary society. Conversely, the notions that NAFLD is a forerunner of hepatocellular carcinoma and extra-hepatic cancers is definitely more modern. Interestingly, guidelines issued by hepatological societies have lagged behind the identification of NAFLD by decades. A comparative analysis of these documents defines both shared attitudes (e.g., ultrasonography and lifestyle changes as the first approaches) and diverging key points (e.g., the threshold of alcohol consumption, screening methods, optimal non-invasive assessment of liver fibrosis and drug treatment options). Finally, the principal historical steps in the general, cellular and molecular pathogenesis of NAFLD are reviewed. We conclude that an in-depth understanding of the history of the disease permits us to better comprehend the disease itself, as well as to anticipate the lines of development of future NAFLD research.

What's in a name? Renaming 'NAFLD' to 'MAFLD'

In medicine, language matters and the words used to name and describe a disease can have a profound impact on patients and their families. Over the last two decades, many criticisms have been voiced about the nomenclature and definition of non-alcoholic fatty liver disease (NAFLD) in regards not only to the prominent role that alcohol plays in the definition but also on the negative impacts of the nomenclature including trivialization, stigmatization and less consideration of the disease in health policy. Recently, a consensus of international experts proposed that the disease acronym be changed from NAFLD to metabolic (dysfunction) associated fatty liver disease or 'MAFLD'. This change goes far beyond a mere semantic revision and may be the first step that catalyses the process to better conceptualize the disease for health promotion, patient orientation, case identification, ongoing clinical trials and for health services delivery. Here we review the history of, and definitions of MAFLD in the context of advancing our understanding of the pathogenesis of the disease. We also address the reasons, signals, promises, challenges and the way going forward from the name change from various stakeholder perspectives.

Efficacy and safety of sofosbuvir plus simeprevir therapy in Egyptian patients with chronic hepatitis C: a real-world experience

BACKGROUND

Simeprevir plus sofosbuvir (SIM/SOF) regimen was recommended by professional guidelines for certain patients with HCV genotype 1 infection and there is lack of data about this regimen in patients with genotype 4 infection.

AIM

To evaluate the efficacy and safety of this regimen in Egyptian patients with chronic HCV genotype 4 infection in the real world.

METHODS

Multicentre observational study included 583 patients with HCV genotype 4 infection who began 12 weeks of treatment with SIM plus SOF. Demographic, clinical and virological data as well as adverse outcomes were collected. Treatment naïve patients were 342 (59%) of all included patients, 45% of patients had severe fibrosis (F3 and F4) while 55% had mild fibrosis (F1 and F2) and the primary outcome was sustained virological response (SVR).

RESULTS

The overall SVR rate was 95.7% (558 out of 583 patients). In total, SVR12 in naïve patients with mild fibrosis score (F1 and F2) was achieved in 98.9% (94/95) for F1 and 98.1% (105/107) for F2, while naïve patients with severe fibrosis (F3 and F4) achieved SVR of 97.7% (86/88) for F3 and (42/52) 80.8% for F4. SVR in patients with previous interferon treatment achieved in 100% (45/45) for patients with F1 and 98.7% (74/75) for F2. While 94.7% (72/76) in experienced patients with F3; and 88.9% (40/45) for F4 achieved SVR12. Notable side effects included rash in 21 patients, photosensitivity in 18 patients, pruritus in 44 patients and hyperbilirubinemia in 42 patients.

CONCLUSIONS

A 12-week regimen of simeprevir/sofosbuvir was efficacious and well tolerated by treatment-naïve and treatment-experienced patients with chronic HCV genotype 4.

Biomarkers of Barrett's esophagus

Barrett’s esophagus is the strongest risk for esophageal adenocarcinoma (EAC). Metaplasia in patients with BE may progress to dysplasia and then invasive carcinoma. Well-defined diagnostic, progressive, predictive, and prognostic biomarkers are needed to identify the presence of the disease, estimate the risk of malignant transformation, and predict the therapeutic outcome and survival of EAC patients. There are many predictive and prognostic markers that lack substantial validation, and do not allow stratification of patients with gastroesophageal reflux disease in clinical practice for outcome and effectiveness of therapy. In this short review we summarize the current knowledge regarding possible biomarkers, focusing on the pathophysiologic mechanisms to improve prognostic and therapeutic approaches.

Hepato-cardiac disorders

Understanding the mutual relationship between the liver and the heart is important for both hepatologists and cardiologists. Hepato-cardiac diseases can be classified into heart diseases affecting the liver, liver diseases affecting the heart, and conditions affecting the heart and the liver at the same time. Differential diagnoses of liver injury are extremely important in a cardiologist’s clinical practice calling for collaboration between cardiologists and hepatologists due to the many other diseases that can affect the liver and mimic haemodynamic injury. Acute and chronic heart failure may lead to acute ischemic hepatitis or chronic congestive hepatopathy. Treatment in these cases should be directed to the primary heart disease. In patients with advanced liver disease, cirrhotic cardiomyopathy may develop including hemodynamic changes, diastolic and systolic dysfunctions, reduced cardiac performance and electrophysiological abnormalities. Cardiac evaluation is important for patients with liver diseases especially before and after liver transplantation. Liver transplantation may lead to the improvement of all cardiac changes and the reversal of cirrhotic cardiomyopathy. There are systemic diseases that may affect both the liver and the heart concomitantly including congenital, metabolic and inflammatory diseases as well as alcoholism. This review highlights these hepatocardiac diseases

Chronic hepatitis C-associated thrombocytopenia: aetiology and management

Thrombocytopenia is perhaps the most common haematological abnormality in patients with chronic hepatitis C virus (HCV) infection. In these patients, the presence of thrombocytopenia may be a limiting factor when considering antiviral therapy and may be associated with decreased sustained virological response rates. Thrombocytopenia may interfere with diagnostic procedures such as liver biopsy, because of risk of bleeding. Pathogenetic mechanisms include hypersplenism secondary to portal hypertension, bone marrow suppression resulting from either HCV itself or interferon treatment, and aberrations of the immune system resulting in the formation of anti-platelet antibodies and/or immune-complexes that bind to platelets and facilitate their premature clearance. The ability to increase platelet levels could significantly reduce the need for platelet transfusions and facilitate the use of interferon-based antiviral therapy and other medically indicated treatments in patients with liver disease. Therapeutic options include pharmacological and non-pharmacological therapies. This review summarizes the available data on these therapeutic options.

Hematopoietic stem cell mobilization into the peripheral circulation in patients with chronic liver diseases

OBJECTIVE

The present study was aimed to investigate and compare the kinetics of bone marrow-derived hematopoietic stem cells (BMHSC) migration in the peripheral blood and liver in response to liver injury in patients with chronic liver disease (CLD).

METHODS

In all, 45 CLD patients staged with Child-Pugh A, B and C and 15 healthy participants were evaluated for the concentration of circulating BMHSC by a flow cytometric analysis of CD133(+) /CD34(+) cells. In addition, homing BMHSC and hepatic progenitors were assessed by the immunohistochemical detection of CD133(+) and OV6(+) cells in liver biopsy specimens from Child-Pugh A and B patients.

RESULTS

No significant difference in the percentage of circulating CD133(+) /CD34(+) cells was observed among all groups of patients. In liver tissues, OV6(+) cells increased significantly in Child-Pugh B cases (P < 0.05), while CD133(+) cells were distributed sparsely in the periportal region in Child-Pugh A and B patients. OV6(+) cells were significantly correlated with CD34(+) cells but not with CD133(+) cells in Child-Pugh A and B patients (P < 0.01 and P < 0.05, respectively).

CONCLUSIONS

Various degrees of severity in CLD neither evoked the mobilization of BMHSC into the circulation nor triggered their homing into liver tissue, thus excluding extrahepatic stem cell-mediated repair. The recovery process seems to be dependent on proliferating endogenous liver progenitors (OV6(+) cells).

Incidence and risk factors of retinopathy in Egyptian patients with chronic hepatitis C virus treated with pegylated interferon plus ribavirin

BACKGROUND

Data are scarce on ocular complications in Egyptian patients with chronic hepatitis C treated with pegylated interferon and ribavirin therapy. The aim of this study was to investigate the development of retinal lesions induced by interferon therapy for chronic hepatitis C.

METHODS

We prospectively analyzed 84 patients with chronic hepatitis C (total 168 eyes), who underwent combination pegylated interferon and ribavirin therapy for 48 weeks. Visual acuity, color vision, and visual field were measured, and a fundus assessment was made at baseline, at 12, 24, and 48 weeks post the commencement of treatment, and at follow-up, 1 month after treatment. Past medical and ocular histories, visual symptoms, and the results of a full ophthalmologic assessment were recorded for each patient.

RESULTS

Twenty-two patients (26%) developed retinopathy. Retinal hemorrhage was observed in eight patients. Four patients complained of visual disturbance. Retinopathy disappeared in 16 patients (73%) despite the continuation of combination therapy. However, retinopathy persisted in six patients with retinal hemorrhage and three of them stopped treatment. A comparison of the clinical backgrounds between the patients with and without retinopathy showed no significant differences with regard to gender, HCV RNA level, white blood cell count, platelet count, hemoglobin level, or fibrosis score. However patients with retinopathy were of older age, had a higher prevalence of hypertension and diabetes mellitus, and more often did not respond to therapy. Multiple logistic regression analysis revealed that hypertension and diabetes were factors predicting retinopathy.

CONCLUSION

Retinopathy associated with interferon α-2a and ribavirin combination therapy tends to develop in patients of older age with hypertension and diabetes.

Hepatitis C virus (genotype 4)-associated mixed cryoglobulinemia vasculitis: effects of antiviral treatment

OBJECTIVE

Type II mixed cryoglobulinemia (MC) is a systemic vasculitis usually associated with hepatitis C virus (HCV). The present trial was performed to investigate the efficacy of therapy with pegylated interferon alfa-2a (PEG-IFN alfa-2a) plus ribavirin in patients with HCV-related MC vasculitis and evaluate the factors associated with clinical remission of MC.

METHODS

A total of 46 consecutive patients with HCV-related Type II MC received PEG-IFN alfa-2a (standard dose 180 mg/week) subcutaneously plus oral ribavirin (800-1,200 mg/day) for 48 weeks. The response to treatment was analyzed by comparing clinical, immunologic, and virologic parameters at the initial evaluation with those observed at the end of follow-up. Logistic regression was used to assess the factors associated with clinical remission.

RESULTS

A total of 22 patients (48%) had a sustained virologic response and were complete clinical responders. Serum cryoglobulin disappeared in 26 of 46 patients (56%), and complement levels normalized in 70% of the patients. In univariate analysis, factors associated with complete clinical response were early virologic response at 4 weeks [OR 1.4 (95% CI 0.1-17.1)], proteinuria [OR 1.4 (95% CI 0.2-8.2)] and the fibrosis score [OR 1.09 (95% CI 0.6-1.9)], peripheral neuropathy [OR 0.9 (95% CI 0.1-6.5)], arthralgia [OR 0.7 (95% CI 0.1-3.9)], sicca syndrome [OR 0.6 (95% CI 0.1-3.2)], cryoglobulin [OR 0.2 (95% CI 0.07-1.09)], and purpura [OR 0.1 (95% CI 0.01-1.3)]. In multivariate analysis, only cryoglobulinemia was independently associated with complete clinical response. No patient had side effects for which discontinuation of therapy was required.

CONCLUSION

The results indicated that treatment with PEG-IFN alfa-2a plus ribavirin can achieve a complete clinical response in patients with HCV-related MC. Complete clinical response correlates with the eradication of HCV.

Cystatin C: a predictor of hepatorenal syndrome in patients with liver cirrhosis

BACKGROUND

Recent studies suggest that serum cystatin C (CysC) is a more sensitive marker of renal functions than serum creatinine (Cr).

AIM

Evaluation of the clinical significance of cystatin C as a predictor of hepatorenal syndrome (HRS) in patients with liver cirrhosis, ascites, and normal serum Cr level.

METHODS

Eighty patients with cirrhotic ascites were enrolled in this study (53 men and 27 women; age: 59.5 ± 7.5 years). All patients were subjected to full clinical assessment and laboratory investigations focussing on renal functions, glomerular filtration rate, and measurement of serum cystatin level.

RESULTS

The Serum Cr and CysC levels were 1.04 ± 0.1 and 1.8 ± 0.8 mg/L, respectively. HRS developed in 18 patients during the follow-up period (6 months). Type 1 HRS was found in 5 patients and type 2 HRS was found in 13 patients with no significant difference between both types regarding baseline characteristics. Age (p < 0.001), albumin (p < 0.001), sodium (p < 0.005), cystatin C (p < 0.001), and e-GFRMDRD (estimated glomerular filtration rate-modification of the diet in renal disease) (p < 0.007) were significant dependent predictive factors for the development of HRS. The CysC level was the most independent predictive factor for HRS (OR, 2.1; 95% CI, 0.75-0.97; p < 0.002). Eighteen patients died during the follow-up period. Age (p < 0.001), INR (p < 0.001), e-GFRMDRD (p < 0.03), sodium (p < 0.01), MELD score (p < 0.05), albumin (p < 0.001), and CysC (p < 0.001) levels were significant dependent factors for predicting mortality. CysC (OR, 5.3; p < 0.006) level and INR (OR, 1.01; p < 0.006) were the most independent factors for predicting mortality.

CONCLUSION

Serum CysC level may be considered a predictor of HRS and mortality in patients with liver cirrhosis and ascites.

Is irritable bowel syndrome associated with chronic hepatitis C?

BACKGROUND AND AIM

Hepatitis C virus (HCV) is a common chronic infection that is widely associated with symptoms of fatigue and abdominal pain. The aim of the present study was to determine the prevalence of irritable bowel syndrome (IBS) among patients with hepatitis C compared to controls.

METHODS

This study included 258 patients with chronic hepatitis C, 36 patients with chronic hepatitis B, and 160 healthy volunteers. Clinical and laboratory data were recorded for every patient. All patients and controls were administered a questionnaire of IBS according to Rome III criteria.

RESULTS

The percentage of patients with IBS was significantly higher in patients with chronic HCV (66%, 170/258) than chronic hepatitis B virus (HBV; 22%, 8/36) and normal controls (18%, 28/160 patients; P < 0.001 and P < 0.001, respectively). There was no significant difference between chronic HBV and normal controls. In chronic HCV patients, IBS with constipation was the predominant type (51%, 86/170) followed by mixed IBS (73/170, 43%). In patients with chronic HCV, the percentage of females with IBS (91%) was significantly higher than those without IBS (9%; P < 0.001), and the percentage of patients with a high fibrosis score (F2-3) was significantly higher in patients with IBS (45%) than in patients without IBS (6%; P < 0.001). There was no difference regarding age, alanine aminotransferase level, or HCV viremia. A multivariate regression analysis revealed a significant association between sex, fibrosis score, and IBS.

CONCLUSION

IBS is more prevalent in patients with chronic hepatitis C. Female patients with chronic HCV and those with higher fibrosis scores are more likely to have IBS.

Renal duplex Doppler ultrasound in patients with HCV related liver cirrhosis

AIM

To study the renal resistive index (RI) and pulsatility index (PI) measured by renal Doppler in various stages of liver cirrhosis and their values to detect cirrhotic patients at risk for developing the hepatorenal syndrome.

METHODS

This study included 60 cirrhotic patients divided into 4 groups (15 patients each): compensated liver cirrhosis (group A), diuretic responsive ascites (group B), refractory ascites (group C), hepatorenal syndrome (group D) and ten healthy persons as the control group (E). All patients were subjected to detailed history taking and clinical examination. Laboratory investigations included simple urine analysis, complete blood picture, liver function tests, blood urea and serum creatinine, serum sodium and serum potassium, 24-hour urine collection for sodium concentration, creatinine concentration and protein concentration. Ultrasonographic examination and renal duplex Doppler ultrasonography were undertaken to assess the RI and PI.

RESULTS

The RI of both interlobar and arcuate arteries was significantly higher in all patient groups than in the control group (p<0.01). The RI was significantly higher in patients with refractory ascites than in patients with diuretic responsive ascites, and also in patients with diuretic responsive ascites than in patients with compensated cirrhosis (p<0.01); in patients with hepatorenal syndrome than in patients with diuretic responsive ascites and patients with compensated cirrhosis (p<0.0001). The PI was significantly higher in all patients groups than in the control group (p<0.01) and in patients with refractory ascites than in patients with diuretic responsive ascites and was also higher in patients with responsive ascites than in patients with compensated cirrhosis (p<0.0001). Also, the PI was significantly higher in patients with hepatorenal syndrome than in patients with responsive ascites and patients with compensated cirrhosis (p<0.0001). Creatinine clearance in patients with the hepatorenal syndrome was significantly lower than that of other different groups (p<0.0001) but there was no significant change in creatinine clearance between patients with compensated cirrhosis and control group. While creatinine clearance in patients with diuretic responsive ascites was significantly higher than that in patients with compensated cirrhosis (p<0.05) there was no significant change between patients with diuretic responsive ascites and patients with refractory ascites.

CONCLUSION

Both renal resistive index and pulsatility index increase with the degree of hepatic decompensation. Renal duplex ultrasound which is a non-invasive, simple and easy method to study intrarenal hemodynamics in patients with liver cirrhosis may predict patients at risk of hepatorenal impairment.

Barrett’s esophagus: Prevalence and risk factors in patients with chronic GERD in Upper Egypt

AIM: To determine the prevalence and possible risk factors of Barrett’s esophagus (BE) in patients with chronic gastroesophageal reflux disease (GERD) in El Minya and Assuit, Upper Egypt.

METHODS: One thousand consecutive patients with chronic GERD symptoms were included in the study over 2 years. They were subjected to history taking including a questionnaire for GERD symptoms, clinical examination and upper digestive tract endoscopy. Endoscopic signs suggestive of columnar-lined esophagus (CLE) were defined as mucosal tongues or an upward shift of the squamocolumnar junction. BE was diagnosed by pathological examination when specialized intestinal metaplasia was detected histologically in suspected CLE. pH was monitored in 40 patients.

RESULTS: BE was present in 7.3% of patients with chronic GERD symptoms, with a mean age of 48.3 ± 8.2 years, which was significantly higher than patients with GERD without BE (37.4 ± 13.6 years). Adenocarcinoma was detected in eight cases (0.8%), six of them in BE patients. There was no significant difference between patients with BE and GERD regarding sex, smoking, alcohol consumption or symptoms of GERD. Patients with BE had significantly longer esophageal acid exposure time in the supine position, measured by pH monitoring.

CONCLUSION: The prevalence of BE in patients with GERD who were referred for endoscopy was 7.3%. BE seems to be associated with older age and more in patients with nocturnal gastroesophageal reflux.