The natural history of nonalcoholic fatty liver: a follow-up study

Nonalcohol-induced fatty liver is widely believed to be a benign condition with little or no risk of disease progression. There have been occasional reports of progression to cirrhosis but none in the absence of preexisting fibrosis on the index biopsy specimen even when co-existing hepatitis was present (steatohepatitis). From our histological database (1978 to 1985), we identified 161 patients with fatty liver seen at our institution and traced the case notes of 156. One hundred five patients were initially excluded as having an alcohol-induced cause, and the remaining 51 either were seen in the clinic (37) or had died, in which cases copies of their death certificates were obtained (14). A further 7 patients were excluded after clinic attendance gave evidence of alcohol excess and another 4 after review of their initial biopsy showed the presence of fibrosis or steatohepatitis. The apparent cause of the steatosis in the 40 included patients with strictly nonalcohol-induced pure fatty liver was obesity in 12, diabetes in 4 (1 obese patient), and cachexia associated with extrahepatic malignancy in 6. Four of the remaining 19 had serological evidence of an autoimmune disorder, but none of these had any clinical or histological features of autoimmune liver disease. Nine patients had evidence of hyperlipidemia, 3 of whom were also obese. At a median follow-up of 11 years (7 to 16), 12 of 26 living patients had abnormal results of liver blood tests and had repeat liver biopsies performed. None had progressed to steatohepatitis or cirrhosis; 1 obese patient had developed mild fibrosis 9.8 years after her index biopsy.(ABSTRACT TRUNCATED AT 250 WORDS)

Determinants of progression to cirrhosis or fibrosis in pure alcoholic fatty liver

"Pure" alcoholic fatty liver has been widely assumed to be "benign" with very low risk of progression to cirrhosis. Studies thus far have included either patients with coexisting recognised precursor lesions of cirrhosis or have been restricted to short-term histological follow-up. We have followed 88 patients, first seen between 1978 and 1985, with a histological diagnosis of pure alcoholic fatty liver and no evidence of fibrosis or alcoholic hepatitis, for a median of 10.5 years, to determine any factors predictive of disease progression. Of the 88, at follow-up nine had developed cirrhosis and a further seven fibrosis. Eight of nine patients with cirrhosis had continuing alcohol consumption of more than 40 units per week at follow-up; in the other patients, consumption was unknown. Independent histological predictors of progression on index biopsy were: presence of mixed macro/microvesicular fat, and presence of giant mitochondria. We can no longer regard alcoholic fatty liver as benign. In the presence of continuing high alcohol consumption the above histological features identified those at high risk (47-61%) of disease progression. Therefore, patients with these features should be counselled intensively regarding their alcohol consumption.

Ranitidine increases the bioavailability of postprandial ethanol by the reduction of first pass metabolism

Blood ethanol concentrations after separate oral dosing and intravenous infusion of ethanol (0.15 g/kg) were measured in 16 control subjects and 13 subjects treated with ranitidine. All subjects underwent routine upper gastrointestinal endoscopy. Peak blood ethanol concentrations, and area under the blood ethanol/time curve, were significantly higher in the ranitidine group after oral, but not intravenous, ethanol administration. The first pass metabolism, as calculated by the difference between the area under the curves, was significantly lower in the ranitidine group. In addition, all subjects withdrawn from ranitidine (n = 6) had a significant reduction in peak blood ethanol concentration and area under the curve after repeat dosing with oral ethanol. Both groups were well matched for age, sex, indications for endoscopy, findings at endoscopy, and gastric histology. These findings show that ranitidine increases the bioavailability of low dose ethanol and has possible short term forensic, and longterm physical implications for moderate drinkers who are taking the drug.

The effect of gastritis on human gastric alcohol dehydrogenase activity and ethanol metabolism

BACKGROUND

Gastric mucosal alcohol dehydrogenase (ADH) may decrease the bioavailability of ingested ethanol. Because this enzyme is found in highest concentrations in the superficial gastric mucosa, diffuse abnormalities of this tissue could lead to a decrease in the first pass metabolism of ethanol.

METHODS

Thirty-three adult subjects undergoing routine upper gastrointestinal endoscopy had gastric biopsies performed for assessment of gastric histology and the measurement of gastric ADH activity. Twenty of these subjects underwent separate oral dosing and intravenous infusion of ethanol (0.15 g/kg body weight) in order to determine the first pass metabolism, and hence bioavailability, of ethanol.

RESULTS

Gastric histology was normal in 10 of the biopsies, showed chronic gastritis alone in 13 and significant glandular atrophy (i.e. atrophic gastritis) in a further 10. Gastric ADH activity in specimens with normal gastric histology was significantly higher than those with chronic gastritis (P = 0.02), and was further decreased in those specimens with significant atrophy (P < 0.00001). However, no correlation was found between gastric ADH activity and the first pass metabolism of ethanol (r = 0.09, P = 0.9).

CONCLUSIONS

These results suggest that although gastric ADH activity was decreased in individuals with abnormal gastric mucosa, ethanol bioavailability was not affected by gastric ADH activity. These data support the view that gastric ADH does not play a significant role in the first pass metabolism of alcohol.

Alcohol--risks and mechanisms of damage

The first part of this one-day conference, held at the Royal College of Physicians in December 1993, was devoted to the relationship between alcohol consumption and the health of the nation, in particular the complex effects of alcohol intake on mortality and its widely publicised protective effect against death from coronary artery disease. This led to a discussion of the rationale for the currently recommended 'safe limits' for alcohol consumption and the controversial issue of whether, in view of the beneficial cardiovascular effects of light alcohol intake, teetotallers should be encouraged to drink. The second part of the conference dealt with the biological and biochemical effects of alcohol on the liver. While excessive alcohol consumption is clearly associated with the development of liver disease, advanced liver disease occurs in only a minority of heavy drinkers. Recent advances in our understanding of the pathogenesis of alcoholic liver disease are now beginning to offer biochemical explanations for individual susceptibility and provide a more rational basis for the design of new long term treatment modalities.

The activity of the metabolic form of hepatic phosphatidate phosphohydrolase correlates with the severity of alcoholic fatty liver in human beings

Increased esterification of fatty acids to triglyceride is common to most of the mechanisms proposed to explain the causation of alcoholic fatty liver. However, it is unclear whether this is caused by increased substrate supply or whether direct stimulation of the enzymes of the esterification pathway occurs after excessive alcohol intake. The rate-limiting step in triglyceride synthesis is catalyzed by the enzyme phosphatidate phosphohydrolase, which is present in the cytosol and microsomes and is sensitive to inhibition by N-ethylmaleimide. This enzyme is physically distinct from a second form of phosphatidate phosphohydrolase that is located predominantly in the plasma membrane, is insensitive to N-ethylmaleimide inhibition and has a putative role in cell-signaling. We have investigated whether the activity of the N-ethylmaleimide-sensitive ("metabolic") form of phosphatidate phosphohydrolase is increased in patients with alcoholic liver disease and whether any increased activity correlates with the severity of steatosis. N-ethylmaleimide-sensitive and -insensitive phosphatidate phosphohydrolase activities were measured in needle liver biopsy specimens from 42 alcoholic patients and 6 patients with primary biliary cirrhosis and in wedge biopsy specimens from 6 normal patients undergoing routine cholecystectomy. Steatosis was "scored" on coded slides from 0 to 3. N-ethylmaleimide-sensitive activity was higher in alcoholic biopsy specimens scoring 3 (3.25 +/- 0.4 units/mg protein, n = 10) than in those scoring either 0 (1.21 +/- 0.2, n = 14) or 1 to 2 (1.58 +/- 0.2, n = 18), and it was also higher than in biopsy specimens from normal and primary biliary cirrhosis patients (1.65 +/- 0.3, n = 12; p < 0.0001, analysis of variance).(ABSTRACT TRUNCATED AT 250 WORDS)

Plasma membrane form of phosphatidate phosphohydrolase: a possible role in signal transduction during liver fibrogenesis

1. Several growth factors important in liver regeneration and fibrosis stimulate phospholipase D in plasma membranes via a receptor/G-protein-coupled mechanism resulting in hydrolysis of phosphatidylcholine to phosphatidate. Phosphatidate can be further hydrolysed to diacylglycerol by phosphatidate phosphohydrolase. Phosphatidate and diacylglycerol can act as 'second-messengers' and regulation of phosphatidate phosphohydrolase activity could control the balance between them. 2. A form of phosphatidate phosphohydrolase, located in the plasma membrane and insensitive to inhibition by N-ethylmaleimide, has recently been identified that is distinct from the 'metabolic' form, which is present in the cytosol and microsomes and is sensitive to N-ethylmaleimide. 3. We have investigated the hypothesis that the balance between regeneration and fibrosis is, in part, determined by the activity of plasma membrane phosphatidate phosphohydrolase through its effect on the phosphatidate/diacylglycerol ratio. N-Ethylmaleimide-insensitive and -sensitive phosphatidate phosphohydrolase activities were measured in three hepatic conditions characterized by regeneration and/or fibrosis: alcoholic liver disease in humans (regeneration and fibrosis) and rat livers after either acute CCl-4-induced injury (regeneration) or common bile duct ligation (fibrosis). 4. In patients with alcoholic liver disease, N-ethylmaleimide-insensitive phosphatidate phosphohydrolase activity was higher in cirrhotic biopsies (5.82 +/- 0.3 nmol of Pi min-1 mg-1 of protein, n = 19) than in non-cirrhotic biopsies (2.17 +/- 0.2, n = 23) or in wedge biopsies from healthy subjects undergoing routine cholecystectomy (2.16 +/- 0.5, n = 6).(ABSTRACT TRUNCATED AT 250 WORDS)

QT prolongation and sudden cardiac death in patients with alcoholic liver disease

Cardiovascular death is the most important cause of mortality in alcoholics, yet alcohol may protect against ischaemic heart disease. This could be explained if deaths were a consequence of alcohol-related arrhythmias rather than of coronary atheroma. In many conditions, abnormalities of the QT interval are markers of arrhythmia and for risk of sudden death. We examined the relation between QT intervals and mortality in patients with alcoholic liver disease. Simultaneous 12-lead electrocardiographic recordings were obtained from 69 patients with histologically proven alcoholic liver disease (without evidence of structural heart disease), and from 40 healthy non-drinking controls matched for age and sex. Patients were abstinent for at least 7 days before investigation to exclude acute effects of alcohol. QT intervals were corrected for rate with Bazett's and cube root formulae to define QTc and QTcub, respectively. Unlike QTc, QTcub was independent of rate. Patients were followed for up to four years. For those who died, the cause was determined from case records and postmortem reports. Maximum QT intervals were longer in alcoholics than in controls (QTcub 450 vs 439, p = 0.016). This difference was not explained by variations in electrolytes. QT intervals were prolonged in the 14 patients who died compared with survivors (QTcub 471 vs 446, p = 0.007). This difference was mainly due to the long QT intervals in the 6 patients with sudden cardiac deaths (QTcub 493). The only other factor independently associated with death was sex. QT interval prolongation occurs in some patients with alcoholic liver disease and is associated with an adverse prognosis, especially sudden cardiac death. QT measurement should be included in the initial assessment of alcoholic patients, particularly in those considered for liver transplantation.

No evidence for involvement of type 1 collagen structural genes in 'genetic predisposition' to alcoholic cirrhosis

Type 1 collagen is the predominant collagen in cirrhotic livers. Each type 1 collagen molecule contains three subunits, two are identical (the alpha 1 chains) and the sequence of the third (alpha 2) is very similar. They are encoded at the non-synthenic loci, COL1A1 and COL1A2 and restriction site dimorphisms have been described at each locus. Genetic factors have been invoked as a basis for increased susceptibility to alcoholic cirrhosis. One hypothesis is that genetically determined differences in type 1 collagen may be involved in this predisposition. We have examined this by analysing restriction fragment length polymorphisms at each type 1 collagen locus in leucocyte DNA from 56 unrelated patients with alcoholic cirrhosis and 74 local unrelated healthy controls. Based on the presence or absence of these restriction site dimorphisms four possible haplotypes were generated at COL1A1 and COL1A2. We found no significant difference in allele frequencies between alcoholic cirrhotics and controls and, unlike a previous small study, we found no particular haplotype of either gene was associated with alcoholic cirrhosis. Our study provides no evidence for involvement of type 1 collagen structural genes in a genetic predisposition to cirrhosis in alcoholics.

Physical evidence for the presence of two forms of phosphatidate phosphohydrolase in rat liver

Phosphatidate phosphohydrolase (PAP)-catalysed dephosphorylation of phosphatidic acid to diacylglycerol is an important step in glycerolipid metabolism and cell-signalling. Gel filtration chromatography on Superose 6 and anion-exchange chromatography on Mono Q of rat liver subcellular fractions has provided physical evidence for the presence of two distinct forms of PAP activity. One form was sensitive to inhibition by N-ethylmaleimide (NEM), had an apparent M(r) of 540,000 and was eluted from the anion-exchange column by 0.35 M NaCl, while the other was insensitive to inhibition by NEM, had an apparent M(r) of 240,000 and was eluted from the anion-exchange column by 0.15 M NaCl. Studies on the subcellular distribution of these two enzymes, using 5'-nucleotidase as a plasma membrane marker, demonstrated that the NEM-sensitive form was predominantly cytosolic but translocated to the microsomal membranes in response to oleate. The NEM-insensitive form was predominantly located in the plasma membrane but a small proportion (approx. 10%) of total cell activity was present on the endoplasmic reticulum. The implications of these results for the likely roles of the two different forms of PAP in fatty acid esterification and cell-signalling are discussed.

QT dispersion in sinus beats and ventricular extrasystoles in normal hearts

OBJECTIVE

Recent studies have suggested that QT interlead variability (dispersion) on the surface electrocardiogram may have potential as a measure of recovery time dispersion. To test this hypothesis further QT dispersion occurring in sinus beats was compared with that in ventricular extrasystoles.

DESIGN

Simultaneous electrocardiograms were recorded at 50 mm/s during sinus rhythm in a drug free state while ventricular extrastimuli were introduced by programmed right ventricular stimulation at different coupling intervals. QT dispersion, defined as the difference between the maximum and minimum QT, was calculated separately for the extrasystoles and preceding and following sinus complexes. To correct for the influence of the number of measurable leads on QT dispersion, an "adjusted" QT dispersion calculated as QT dispersion/square root of the number of measurable leads, was used to compare sinus complexes and extrasystoles.

PATIENTS

Nine patients were studied who were undergoing electrophysiological study for investigation of palpitation and were found to have electrically normal ventricles.

RESULTS

At all coupling intervals tested "adjusted" QT dispersion was significantly greater in the ventricular extrasystoles than in either the preceding or following sinus complexes. For the coupling interval 350 ms, the 95% confidence intervals for the difference between means was 52 to 78 ms (preceding sinus complex) and 56 to 82 ms (following sinus complex) (p less than 0.00001). There was no correlation between the coupling interval and the magnitude of the "adjusted" QT dispersion.

CONCLUSION

These results accord fully with expected differences in ventricular recovery time dispersion and offer further support for the hypothesis that QT dispersion reflects regional variation in ventricular recovery. If substantiated by invasive studies, these findings have wide implications for both the usefulness and the method of QT measurement.

Investigation of the role of polymorphisms at the alcohol and aldehyde dehydrogenase loci in genetic predisposition to alcohol-related end-organ damage

Little is known about factors determining individual susceptibility to the physical complications of alcohol abuse but genetically determined differences in ethanol metabolism may be important. The oxidative metabolism of alcohol is catalyzed by alcohol and aldehyde dehydrogenase. Polymorphisms have been observed at two of the five loci encoding alcohol dehydrogenase subunits: ADH2 (producing three beta subunits) and ADH3 (producing two tau subunits) and also at the locus encoding the metabolically important form of aldehyde dehydrogenase, ALDH2. We have compared ADH2, ADH3 and ALDH2 allele frequencies in patients with alcohol-related cirrhosis (n = 59) and chronic pancreatitis (n = 13) with 79 local healthy control subjects. The different alleles were detected with allele-specific oligonucleotide probes after amplification of leukocyte DNA by the polymerase chain reaction. All patients and all but one control subject were homozygous ADH2*1, encoding the beta 1 subunit. No ADH2*3 alleles were detected. All 34 patients and 39 control subjects tested were homozygous ALDH2*1 encoding the active enzyme. ADH3 allele frequencies were different in patients and control subjects. ADH3*1 frequency: control subjects, 55.1%; cirrhotic patients, 62.7%; chronic pancreatitis patients, 65.4%. The difference between the patient groups combined and the control subjects was significant (p less than 0.05; G-test of Sokal and Rohlf) if it was assumed that the allele frequency in our control population was a reasonable estimate of our local population allele frequency. These results suggest that genetically determined differences in alcohol metabolism may, in part, explain predisposition to alcohol-related end-organ damage.

Reduction in QT dispersion by sotalol following myocardial infarction

Increased dispersion of ventricular recovery time is believed to be a substrate for serious ventricular arrhythmias. Class III antiarrhythmic drugs probably operate by decreasing dispersion through homogeneous prolongation of recovery time. A single surface QT value gives no information on recovery time dispersion but interlead variation in QT may be relevant. QTc dispersion was measured in 67 patients post myocardial infarction randomized to treatment with either sotalol or placebo. QTc dispersion was calculated as the difference between the maximum and minimum QTc in any surface electrocardiogram lead. Both maximum QTc and QTc dispersion varied considerably following infarction but throughout the 6-month follow-up period maximum QTc was significantly greater (P less than 0.05) and QTc dispersion significantly less (P less than 0.05) in patients on sotalol compared with placebo. These findings are in accord with expected changes in ventricular recovery time and provide strong support for the hypothesis that surface electrocardiogram QT variation reflects regional differences in ventricular recovery time.

QT dispersion: an indication of arrhythmia risk in patients with long QT intervals

Homogeneity of recovery time protects against arrhythmias whereas dispersion of recovery time is arrhythmogenic. A single surface electrocardiographic QT interval gives no information on recovery time dispersion but the difference between the maximum and minimum body surface QT interval may be relevant. This hypothesis was tested by measuring the dispersion of the corrected QT interval (QTc) in 10 patients with an arrhythmogenic long QT interval (Romano Ward and Jervell and Lange-Nielsen syndromes or drug arrhythmogenicity) and in 14 patients without arrhythmias in whom the QT interval was prolonged by sotalol. QTc dispersion was significantly greater in the arrhythmogenic QT group than in the sotalol QT group. In patients with prolonged QT intervals, QT dispersion distinguished between those with ventricular arrhythmias and those without. This supports the hypothesis that QT dispersion reflects spatial differences in myocardial recovery time. QT dispersion may be useful in the assessment of both arrhythmia risk and the efficacy of antiarrhythmic drugs.