Approach to the pathogenesis and treatment of nonalcoholic steatohepatitis

The relationship between copper and steatosis in Wilson's disease

BACKGROUND AND AIMS

The histological similarities seen in Wilson's disease (WD) and non-alcoholic steatohepatitis (NASH) led us to verify possible correlations between glucose and/or lipid and/or iron metabolism alterations and hepatic steatosis in WD patients.

METHODS

Thirty-five WD patients (20 females, 15 males, mean age 40.1 ± 5.4 years), and 44 NASH patients (25 females, 19 males, mean age 42.8 ± 6.7 years) were enrolled in the study. BMI, total/HDL/LDL-cholesterol, triglycerides and glucose serum levels were established in all subjects. HOMA index was calculated. Percutaneous liver biopsy with quantitative evaluation of steatosis and copper tissue content was performed in all WD patients and in NASH control group.

RESULTS

Significant difference was seen in baseline serum levels of glucose, HOMA index, total cholesterol, triglycerides, and ferritin between the WD group and NASH group (P<0.05) but steatosis scored was similar between two groups. No correlation between the level of steatosis and metabolic factors studied was highlighted. In WD, hepatic parenchymal copper concentration was 753 ± 65.3 mcg/g dry weight against 54.5 ± 16.9 mcg/g dry weight in NASH patients (P<0.05). Higher liver copper concentrations were seen in patients with severe steatosis compared to those with mild (P=0.004) and moderate, (P=0.038) steatosis. Positive significant correlation between liver copper content and steatosis scores (r=0.87; r(2)=0.76) was observed.

CONCLUSIONS

The hepatic steatosis in WD is not induced by metabolic comorbidities but by the accumulation of copper in the liver tissue. The hypothesise that the metabolic alterations could be co-factors in the pathogenesis of steatosis in these patients cannot be excluded.

Non-alcoholic fatty liver disease is not related to the incidence of diabetic nephropathy in Type 2 Diabetes

To analyze the association between non-alcoholic fatty liver disease (NAFLD) and the incidence of diabetic nephropathy in patients with type 2 diabetes, the incidence of diabetic nephropathy was assessed in 413 type 2 diabetic patients, by testing the 24 h urinary albumin excretion rate (UAER). The NAFLD was diagnosed based on patient's medical history and liver ultrasound. The difference in diabetic nephropathy incidence between patients with and without NAFLD was tested by X². Multivariate logistic regression analysis was used to assess the factors associated with diabetic nephropathy among type 2 diabetic patients. Total 363 out of 413 type 2 diabetic patients were enrolled in this study. The incidences of NAFLD and diabetic nephropathy in participants were approximately 56% (202/363) and 38% (137/363) respectively, and there was no significant difference in the prevalence of diabetic nephropathy between patients with and without NAFLD (37.1% vs. 38.5%, p = 0.787). The duration of diabetes (odds ratio [OR] 1.065, 95% confidence interval [CI] 1.014--1.120, p = 0.012), waist circumference (OR 1.077, 95% CI 1.040--1.116, p = 0.000), and fasting blood glucose (FBG; OR 1.136, 95% CI 1.023--1.1262, p = 0.017) were significantly associated with diabetic nephropathy, whereas sex, high blood pressure, total cholesterol (TC), triglyceride (TG), and ankle brachial pressure index (ABI) were not significantly associated with the disorder. The present results suggest that NAFLD is not related to the incidence of diabetic nephropathy in type 2 diabetes, but the duration of diabetes, waist circumference, and FBG are important factors for diabetic nephropathy in type 2 diabetes.

Hepatic insulin signaling changes: possible mechanism in prenatal hypoxia-increased susceptibility of fatty liver in adulthood

Nonalcoholic fatty liver disease (NAFLD) is strongly linked to insulin resistance. Prenatal hypoxia (PH) is a risk factor in programming of insulin resistance, glucose intolerance, and metabolic dysfunctions in later life, although the mechanisms are unclear. In this study, the role of metabolic and histological changes as well as the hepatic insulin signaling mechanisms were determined in increasing susceptibility of NAFLD in the fetus and offspring exposed to PH. Pregnant rats exposed to hypoxia (O(2) 10%) during pregnancy demonstrated decreased fetal body and liver weight as well as liver to body weight ratio, whereas these changes were not observed in the offspring. However, male liver to body weight ratio increased after PH stress. Microscopic analysis demonstrated that exposure to PH resulted in distorted architecture of the hepatic parenchyma cells with reduced cellularity in the fetus and offspring. Blood glucose and insulin levels were lower with enhanced insulin sensitivity and increased expression of hepatic insulin-signaling elements in the fetus. Furthermore, insulin resistance, impaired glucose homeostasis, and altered expression of insulin-signaling elements occurred in the offspring. Postnatal hypoxia increased hepatic lipid droplets and triglyceride in liver, whereas expressions of insulin-signaling elements were less in the offspring exposed to PH except glucose transporters 2. The results indicated that PH contributed to hepatocyte heteroplasia and metabolic changes that enhanced vulnerability for NAFLD in the offspring, probably via affecting insulin signaling pathway, including glucose transporters 2.

The effect of cocoa, soy, oats and fish oil on metabolic syndrome in rats

BACKGROUND

The effect of functional foods alone or in combination (cocoa + soy + oats + fish oil) on hepatic damage in rats affected with metabolic syndrome was investigated.

RESULTS

Rats that were given cocoa showed a decrease in the levels of triglycerides (TGs) and glucose (63 and 32% respectively) as well as a decrease in blood pressure (15%). Animals fed with soy showed a reduction of 21% in total cholesterol, 15% in blood pressure and 44% in TGs, while feeding oats reduced the concentration of TGs by 53% (P < 0.5). Fish oil caused a reduction in TGs (56%) and glucose (26%). The effect on blood pressure was statistically significant for the groups supplemented with cocoa, soy, cocoa + oats and the total mix. The main finding was a reduction in liver steatosis in animals supplemented with cocoa + oats (from 30 to 4.7% steatosis). Cocoa or fish oil alone did not protect the liver from damage, while cocoa + fish oil did.

CONCLUSION

The most relevant effects were that the cocoa + oats mix decreased steatosis by a very large percentage, as did the cocoa + fish oil mix and the mix of all four functional foods.

The potential role of prebiotic fibre for treatment and management of non-alcoholic fatty liver disease and associated obesity and insulin resistance

Non-alcoholic fatty liver disease (NAFLD) and the more severe non-alcoholic steatohepatitis (NASH) represent a spectrum of diseases involving hepatic fat accumulation and histological features essentially identical to alcoholic liver disease; however, they occur in the absence of excessive alcohol intake. They typically arise in conjunction with one or more features of the metabolic syndrome. Lifestyle mediated weight loss remains the primary mode of therapy for NAFLD and NASH, but this is often ineffective and adjunctive medical and surgical treatments are presently lacking. Prebiotic fibres are a group of non-digestible carbohydrates that modulate the human microbiota in a manner that is advantageous to host health. Rodent studies suggest that dietary supplementation with prebiotic fibres positively impacts NAFLD by modifying the gut microbiota, reducing body fat, and improving glucoregulation. Future research should focus on placebo-controlled, human, clinical trials using histological endpoints to address the effects of prebiotics on NAFLD and NASH. The aim of this review is to summarize current knowledge about prebiotics as an emerging therapeutic target for NAFLD.

Food restriction and refeeding induces changes in lipid pathways and fat deposition in the adipose and hepatic tissues in rats with diet-induced obesity

The aim of this study was to determine the effects of successive cycles of a moderately restrictive diet and refeeding with a high-fat diet on the metabolism of the adipose and hepatic tissues of obese rats. Rats were assigned to the following groups: a chow diet; a high-fat diet; a moderate caloric restriction; or a moderate caloric restriction plus refeeding. Some animals in each group were given [1-(14)C]triolein intragastrically, while others received an intraperitoneal injection of 3 mCi (3)H(2)O. All animals were killed by decapitation. The retroperitoneal, visceral epididymal and omental white adipose tissues, brown adipose tissue, liver and blood were immediately removed. The lipid uptake from the diet, in vivo rate of lipogenesis, percentage of fat, lipid profile and leptin concentration were analysed. The high-fat diet promoted an increase in fatty liver (P ≤ 0.05), adiposity mass (P ≤ 0.05) and the plasma concentration of leptin (P ≤ 0.05) and a decreased lipid uptake in white adipose tissue depots (P ≤ 0.05) in relation to the chow diet. The moderate caloric restriction did not reverse the changes promoted by the high-fat diet but induced a small decrease in adiposity, which was reversed after refeeding, and the animals maintained a dyslipidaemic profile and high fat deposition in the liver. We can conclude that the high-fat diet and subsequent moderate caloric restriction plus refeeding increased the risks of developing visceral obesity, dyslipidaemia and non-alcoholic fatty liver disease, which suggests that this type of experimental protocol can be used to study mechanisms related to the metabolic syndrome.

Usefulness of differentiating metabolic syndrome into visceral fat type and subcutaneous fat type using ultrasonography in Japanese males

BACKGROUND

Although metabolic syndrome (MS) is likely to be associated with nonalcoholic fatty liver disease (NAFLD), visceral fat type MS and subcutaneous fat type MS have not been distinguished. In this study, we divided persons with MS into those with visceral and subcutaneous fat types by ultrasonography (US), and elucidated differences between these types of MS in Japanese males.

METHODS

The subjects were 628 males with MS who underwent a medical checkup including abdominal US. We examined for the presence of fatty liver and investigated biochemical parameters, and we also made a distinction between visceral and subcutaneous fat types of MS by US.

RESULTS

Total cholesterol (T-CHO), low-density lipoprotein cholesterol (LDL-C), alanine aminotransferase (ALT), aspartate aminotransferase (AST), and the frequency of fatty liver were significantly higher in visceral fat type MS than in subcutaneous fat type MS. On logistic regression analysis with NAFLD (in our study, fatty liver with ALT ≥31 IU/l was defined as NAFLD) as a dependent variable, the age, body mass index (BMI), AST, and visceral fat type MS were significant risk factors for NAFLD. BMI, AST, and visceral fat type MS were predictors of an increased prevalence of NAFLD [odds ratios (ORs) = 1.903, 12.06, and 2.617; 95% confidence intervals (CIs) = 1.122-3.228, 7.053-20.61, and 1.741-3.935; p = 0.017, <0.001, and <0.001, respectively).

CONCLUSIONS

Japanese males with visceral fat type MS are more likely to have dyslipidemia, fatty liver, and liver dysfunction than those with subcutaneous fat type MS. Visceral fat type MS is one of the most significant risk factors for NAFLD in Japanese males with MS.

Gut microbiota and diabetes: from pathogenesis to therapeutic perspective

More than several hundreds of millions of people will be diabetic and obese over the next decades in front of which the actual therapeutic approaches aim at treating the consequences rather than causes of the impaired metabolism. This strategy is not efficient and new paradigms should be found. The wide analysis of the genome cannot predict or explain more than 10-20% of the disease, whereas changes in feeding and social behavior have certainly a major impact. However, the molecular mechanisms linking environmental factors and genetic susceptibility were so far not envisioned until the recent discovery of a hidden source of genomic diversity, i.e., the metagenome. More than 3 million genes from several hundreds of species constitute our intestinal microbiome. First key experiments have demonstrated that this biome can by itself transfer metabolic disease. The mechanisms are unknown but could be involved in the modulation of energy harvesting capacity by the host as well as the low-grade inflammation and the corresponding immune response on adipose tissue plasticity, hepatic steatosis, insulin resistance and even the secondary cardiovascular events. Secreted bacterial factors reach the circulating blood, and even full bacteria from intestinal microbiota can reach tissues where inflammation is triggered. The last 5 years have demonstrated that intestinal microbiota, at its molecular level, is a causal factor early in the development of the diseases. Nonetheless, much more need to be uncovered in order to identify first, new predictive biomarkers so that preventive strategies based on pre- and probiotics, and second, new therapeutic strategies against the cause rather than the consequence of hyperglycemia and body weight gain.

Probiotics for patients with hepatic encephalopathy

BACKGROUND

Hepatic encephalopathy is a disorder of brain function as a result of liver failure and/or portosystemic shunt. Both hepatic encephalopathy (clinically overt) and minimal hepatic encephalopathy (not clinically overt) significantly impair patient's quality of life and daily functioning and represent a significant burden on health care resources. Probiotics are live microorganisms, which when administered in adequate amounts may confer a health benefit on the host.

OBJECTIVES

To quantify the beneficial and harmful effects of any probiotic in any dosage, compared with placebo or no intervention, or with any other treatment for patients with any grade of acute or chronic hepatic encephalopathy as assessed from randomised trials.

SEARCH METHODS

We searched the The Cochrane Hepato-Biliary Group Controlled Trials Register, The Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library, MEDLINE, EMBASE, Science Citation Index Expanded, conference proceedings, reference lists of included trials and the WHO international clinical trials registry until April 2011 registry platform to identify new and ongoing trials.

SELECTION CRITERIA

We included randomised trials that compared probiotics in any dosage with placebo or no intervention, or with any other treatment in patients with hepatic encephalopathy.

DATA COLLECTION AND ANALYSIS

Three authors independently assessed the risk of bias of the included trials and extracted data on relevant outcomes, with differences resolved by consensus. We conducted random-effects model meta-analysis due to obvious heterogeneity of patients and interventions. A P value of 0.05 or less was defined as significant. Dichotomous outcomes are expressed as risk ratio (RR) and continuous outcomes as mean difference (MD) with 95% confidence intervals (CI).

MAIN RESULTS

We included seven trials of which 550 participants were randomised. Four of the seven trials compared a probiotic with placebo or no treatment in 245 participants, another trial compared a probiotic with lactulose in 40 participants , and the remaining two trials compared a probiotic with both placebo and lactulose in 265 participants. Each trial used different types of probiotics. Duration of administration of the experimental intervention varied from 10 days to 180 days. Two trials were industry funded, and five were unclear about origin of funding. All trials had high risk of bias. When probiotics were compared with no treatment, there was no significant difference in all-cause mortality (2 trials, 105 participants; 1/57 (2%) versus 1/48 (2%): RR 0.72; 95% CI 0.08 to 6.60), lack of recovery (4 trials, 206 participants; 54/107 (50%) versus 68/99 (69%): RR 0.72; 95% CI 0.49 to 1.05), adverse events (3 trials, 145 participants; 2/77 (3%) versus 6/68 (9%): RR 0.34; 95% CI 0.08 to 1.42), quality of life (1 trial, 20 participants contributed to the physical quality of life measurement, 20 participants contributed to the mental quality of life: MD Physical 0.00; 95% CI -5.47 to 5.47; MD Mental 4.00; 95% CI -1.82 to 9.82), or change of/or withdrawal from treatment (3 trials, 175 participants; 11/92 (12%) versus 7/83 (8%): RR 1.28; 95% CI 0.52 to 3.19). No trial reported sepsis or duration of hospital stay as an outcome. Plasma ammonia concentration was significantly lower for participants treated with probiotic at one month (3 trials, 226 participants: MD -2.99 μmol/L; 95% CI -5.70 to -0.29) but not at two months (3 trials, 181 participants: MD -1.82 μmol/L; 95% CI -14.04 to 10.41). Plasma ammonia decreased the most in the participants treated with probiotic at three months (1 trial, 73 participants: MD -6.79 μmol/L; 95% CI -10.39 to -3.19). When probiotics were compared with lactulose no trial reported all-cause mortality, quality of life, duration of hospital stay, or septicaemia. There were no significant differences in lack of recovery (3 trials, 173 participants; 47/87 (54%) versus 44/86 (51%): RR 1.05; 95% CI 0.75 to 1.47), adverse events (2 trials, 111 participants; 3/56 (5%) versus 6/55 (11%): RR 0.57; 95% CI 0.06 to 5.74), change of/or withdrawal from treatment at one month (3 trials, 190 participants; 8/95 (8%) versus 7/95 (7%): RR 1.10; 95% CI 0.40 to 3.03), plasma ammonia concentration (2 trials, 93 participants: MD -6.61 μmol/L; 95% CI -30.05 to 16.84), or change in plasma ammonia concentration (1 trial, 77 participants: MD 1.16 μmol/L; 95% CI -1.96 to 4.28).

AUTHORS' CONCLUSIONS

The trials we located suffered from a high risk of systematic errors ('bias') and high risk of random errors ('play of chance'). While probiotics appear to reduce plasma ammonia concentration when compared with placebo or no intervention, we are unable to conclude that probiotics are efficacious in altering clinically relevant outcomes. Demonstration of unequivocal efficacy is needed before probiotics can be endorsed as effective therapy for hepatic encephalopathy. Further randomised clinical trials are needed.

Serum sex hormone-binding globulin levels are independently associated with nonalcoholic fatty liver disease in people with type 2 diabetes

AIM

To clarify the association between serum sex hormone-binding globulin (SHBG) levels and nonalcoholic fatty liver disease (NAFLD) in patients with type 2 diabetes.

METHODS

Two hundred seventy nine patients with type 2 diabetes were consecutively enrolled and metabolic parameters were checked. High-grade NAFLD was defined as moderate or severe fatty liver disease, measured using liver ultrasound. SHBG, testosterone, and estradiol levels were measured.

RESULTS

SHBG levels were lower in patients with high-grade NAFLD than in those with normal ultrasound and decreased significantly based on the severity of fatty liver disease. SHBG levels were negatively correlated with hypertension, body mass index (BMI), waist circumference, high-grade NAFLD, triglycerides, alanine aminotransferase (ALT), γ-glutamyltransferase (γGT), homeostasis model assessment-estimated insulin resistance (HOMA-IR), and C-reactive protein (CRP) and were positively correlated with testosterone and estradiol levels. The odds ratios (ORs) predicting the presence of high-grade NAFLD in men and women decreased significantly with increasing SHBG tertile. The ORs remained significant even after further adjusting for BMI, waist circumference, hypertension, triglycerides, γGT, ALT, CRP, HOMA-IR, testosterone, estradiol, and anti-diabetic medications.

CONCLUSIONS

Serum SHBG levels were independently associated with the high-grade NAFLD in patients with type 2 diabetes.

Ursodeoxycholic acid dose-dependently improves liver injury in rats fed a methionine- and choline-deficient diet

AIM

  The data on the beneficial effect of ursodeoxycholic acid (UDCA) in non-alcoholic steatohepatitis (NASH) are controversial. The difference of opinion is connected with UDCA dosage to be used. Therefore, we evaluated the dose-dependent efficacy of UDCA in experimental NASH.

METHODS

  Male Wistar rats were fed the methionine- and choline-deficient (MCD) diet for 10 weeks. Rats were administrated UDCA (10, 20, 40 and 80 mg/kg bodyweight intragastrically) after 6 weeks of the MCD diet.

RESULTS

  Animals fed the MCD diet developed severe steatohepatitis. Treatment with UDCA dose-dependently decreased liver damage, but only high-dose UDCA (80 mg/kg) significantly diminished ultrastructural changes in addition to preventing steatosis, ballooning and inflammatory changes in the liver. The activities of serum marker enzymes and the content of liver triglyceride and blood glucose were increased in MCD diet-fed rats, but decreased in all the UDCA-treated groups. Serum insulin concentration was decreased whereas the quantitative insulin sensitivity check index did not changed in MCD diet-fed groups. Serum tumor necrosis factor-α content was strongly increased after MCD diet and normalized in the UDCA-treated rats, with the most pronounced effect in the highest dose groups, 40 and 80 mg/kg. The contents of endogenous ethanol in blood and intestinal mucus were increased in MCD diet-fed rats which were significantly lowered by UDCA (40 and 80 mg/kg per day).

CONCLUSION

  The present data demonstrate a beneficial effect of UDCA that manifested by the decrease of liver steatosis, inflammatory signs and serum tumor necrosis factor-α content especially of the highest 40 and 80 mg/kg day doses.

Probiotics in hepatology

The paper provides a basic review of intestinal microflora and its importance in liver diseases. The intestinal microflora has many important functions, above all to maintain the microbial barrier against established as well as potential pathogens. Furthermore, it influences the motility and perfusion of the intestinal wall, stimulates the intestinal immune system and therefore also the so-called common mucosal immune system, reducing bacterial translocation and producing vitamins. Immune homeostasis at mucosal level results from a controlled response to intestinal luminal antigens. In liver cirrhosis, there are many changes in its function, mostly an increase in bacterial overgrowth and translocation. In this review, probiotics and their indications in hepatology are generally discussed. According to recent knowledge, these preparations are indicated in clinical practice only for cases of hepatic encephalopathy. Probiotics are able to decrease the permeability of the intestinal wall, and decrease bacterial translocation and endotoxemia in animal models as well as in clinical studies, which is extremely important in the prevention of complications of liver cirrhosis and infection after liver transplantation. Probiotics could limit oxidative and inflammatory liver damage and, in some situations, improve the histological state, and thus non-alcoholic steatohepatitis could be considered as another possible indication.

Gut microbiota and inflammation

Systemic and local inflammation in relation to the resident microbiota of the human gastro-intestinal (GI) tract and administration of probiotics are the main themes of the present review. The dominating taxa of the human GI tract and their potential for aggravating or suppressing inflammation are described. The review focuses on human trials with probiotics and does not include in vitro studies and animal experimental models. The applications of probiotics considered are systemic immune-modulation, the metabolic syndrome, liver injury, inflammatory bowel disease, colorectal cancer and radiation-induced enteritis. When the major genomic differences between different types of probiotics are taken into account, it is to be expected that the human body can respond differently to the different species and strains of probiotics. This fact is often neglected in discussions of the outcome of clinical trials with probiotics.

Dietary whey protein lowers the risk for metabolic disease in mice fed a high-fat diet

Consuming a high-fat (HF) diet produces excessive weight gain, adiposity, and metabolic complications associated with risk for developing type 2 diabetes and fatty liver disease. This study evaluated the influence of whey protein isolate (WPI) on systemic energy balance and metabolic changes in mice fed a HF diet. Female C57BL/6J mice received for 11 wk a HF diet, with or without 100 g WPI/L drinking water. Energy consumption and glucose and lipid metabolism were examined. WPI mice had lower rates of body weight gain and percent body fat and greater lean body mass, although energy consumption was unchanged. These results were consistent with WPI mice having higher basal metabolic rates, respiratory quotients, and hepatic mitochondrial respiration. Health implications for WPI were reflected in early biomarkers for fatty liver disease and type 2 diabetes. Livers from WPI mice had significantly fewer hepatic lipid droplet numbers and less deposition of nonpolar lipids. Furthermore, WPI improved glucose tolerance and insulin sensitivity. We conclude that in mice receiving a HF diet, consumption of WPI results in higher basal metabolic rates and altered metabolism of dietary lipids. Because WPI mice had less hepatosteatosis and insulin resistance, WPI dietary supplements may be effective in slowing the development of fatty liver disease and type 2 diabetes.

Histopathological diagnosis of non-alcoholic and alcoholic fatty liver disease

The diagnostic procedures in patients with suspected fatty liver disease-with or without known alcohol consumption-should be standardized and generally accepted. We therefore present a guideline, summarizing the current concepts of etiology, diagnostic as well as differential diagnostic of patients with fatty liver disease. Alcoholic as well as and non-alcoholic fatty liver are characterised by lipid deposition in hepatocytes. The diagnosis of steatosis is made when lipid deposition exceeds 5% of hepatocytes, while involvement of more than 50% is called "fatty liver". An additional inflammatory reaction leads to alcoholic (ASH) or non-alcoholic steatohepatitis (NASH). Steatohepatitis is present when both inflammatory infiltrates of mixed cells in the small liver lobules as well as liver cell injury in terms of ballooning can be detected. Liver biopsy represents the "golden standard" for confirming diagnosis and determining inflammatory activity and potential fibrosis of fatty liver disease. The differential diagnosis of ASH vs. NASH cannot be made on the basis of histological criteria alone. Steatosis, inflammatory changes and hepatocytic injury can be semiquantified as a "Brunt Score" or "NAS" (NAFLD activity score), providing the basis on which to decide whether or not steatohepatitis is present. People at increased risk of developing a fatty liver possess an increased risk of developing chemotherapy-associated steatohepatitis. Histologically, pediatric NASH differs from adult NASH and is often only clinically manifest through a mild if persistent elevation in transaminases.

Histopathological diagnosis of non-alcoholic and alcoholic fatty liver disease

The diagnostic procedures in patients with suspected fatty liver disease-with or without known alcohol consumption-should be standardized and generally accepted. We therefore present a guideline, summarizing the current concepts of etiology, diagnostic as well as differential diagnostic of patients with fatty liver disease. Alcoholic as well as and non-alcoholic fatty liver are characterised by lipid deposition in hepatocytes. The diagnosis of steatosis is made when lipid deposition exceeds 5% of hepatocytes, while involvement of more than 50% is called "fatty liver". An additional inflammatory reaction leads to alcoholic (ASH) or non-alcoholic steatohepatitis (NASH). Steatohepatitis is present when both inflammatory infiltrates of mixed cells in the small liver lobules as well as liver cell injury in terms of ballooning can be detected. Liver biopsy represents the "golden standard" for confirming diagnosis and determining inflammatory activity and potential fibrosis of fatty liver disease. The differential diagnosis of ASH vs. NASH cannot be made on the basis of histological criteria alone. Steatosis, inflammatory changes and hepatocytic injury can be semiquantified as a "Brunt Score" or "NAS" (NAFLD activity score), providing the basis on which to decide whether or not steatohepatitis is present. People at increased risk of developing a fatty liver possess an increased risk of developing chemotherapy-associated steatohepatitis. Histologically, pediatric NASH differs from adult NASH and is often only clinically manifest through a mild if persistent elevation in transaminases.

Histopathological diagnosis of non-alcoholic and alcoholic fatty liver disease

The diagnostic procedures in patients with suspected fatty liver disease-with or without known alcohol consumption-should be standardized and generally accepted. We therefore present a guideline, summarizing the current concepts of etiology, diagnostic as well as differential diagnostic of patients with fatty liver disease. Alcoholic as well as and non-alcoholic fatty liver are characterised by lipid deposition in hepatocytes. The diagnosis of steatosis is made when lipid deposition exceeds 5% of hepatocytes, while involvement of more than 50% is called "fatty liver". An additional inflammatory reaction leads to alcoholic (ASH) or non-alcoholic steatohepatitis (NASH). Steatohepatitis is present when both inflammatory infiltrates of mixed cells in the small liver lobules as well as liver cell injury in terms of ballooning can be detected. Liver biopsy represents the "golden standard" for confirming diagnosis and determining inflammatory activity and potential fibrosis of fatty liver disease. The differential diagnosis of ASH vs. NASH cannot be made on the basis of histological criteria alone. Steatosis, inflammatory changes and hepatocytic injury can be semiquantified as a "Brunt Score" or "NAS" (NAFLD activity score), providing the basis on which to decide whether or not steatohepatitis is present. People at increased risk of developing a fatty liver possess an increased risk of developing chemotherapy-associated steatohepatitis. Histologically, pediatric NASH differs from adult NASH and is often only clinically manifest through a mild if persistent elevation in transaminases.

Update: metabolic and cardiovascular consequences of bariatric surgery

Obesity is a disease state with polygenic inheritance, the phenotypic penetrance of which has been greatly expanded by the attributes of modern civilization. More than two-thirds of obese persons have comorbidities, many of which are characteristic of cardiometabolic risk syndrome (CMRS) in addition to other life-quality-reducing complaints. The CMRS is associated with increased cardiovascular events and mortality. Individuals with a body mass index greater than 35 infrequently achieve or maintain weight loss adequate to resolve these metabolic and anatomic issues by lifestyle or pharmacologic strategies. Data suggest that some of these patients may be better served by bariatric surgery.

Fistular onion stalk extract reduces NF-κB expression and TNF-α secretion in steatotic HepG2 cells

AIM: To investigate the effects of fistular onion stalk extract on NF-κB expression and TNF-α secretion in steatotic HepG2 cells and to explore possible molecular mechanisms involved.

METHODS: HepG2 cells were induced with free fatty acids to create a cell model of hepatic steatosis. Intracellular lipid droplets were detected by oil red O staining. Cell proliferation was determined by MTT assay. The expression of NF-κB mRNA and protein was detected by RT-PCR and Western blot, respectively. NF-κB activity was detected by electrophoretic mobility shift assay (EMSA). TNF-α level was measured by ELISA.

RESULTS: After treatment with free fatty acids for 24 h, steatosis was successfully induced in HepG2 cells. Triglyceride (TG) content was significantly higher in model cells than in control cells (0.22 mmoL/L ± 0.03 mmoL/L vs 0.07 mmoL/L ± 0.05 mmoL/L, P < 0.01). Treatment with different doses of fistular onion stalk extract significantly improved cell proliferation (0.35 ± 0.04, 0.38 ± 0.03, 0.43 ± 0.07 vs 0.29 ± 0.07, all P < 0.05 or 0.01). The levels of NF-κB mRNA and protein expression (1.10 ± 0.06 vs 0.67 ± 0.06; 0.41 ± 0.03 vs 0.27 ± 0.04, P < 0.01) as well as TNF-α secretion (P < 0.01) were significantly higher in model cells than in control cells. Treatment with different doses of fistular onion stalk extract significantly reduced the levels of the above parameters (0.97 ± 0.05, 0.94 ± 0.09, 0.88 ± 0.08 vs 1.10 ± 0.06; 0.33 ± 0.06, 0.24 ± 0.06, 0.26 ± 0.05 vs 0.41 ± 0.03; 65.38 ng/L ± 9.55 ng/L, 59.93 ng/L ± 7.52 ng/L, 45.05 ng/L ± 9.22 ng/L vs 76.92 ng/L ± 8.40 ng/L, all P < 0.05 or 0.01).

CONCLUSION: Fistular onion stalk extract has significant protective effects against steatosis in HepG2 cells possibly by inhibiting NF-κB expression and reducing TNF-α secretion.

Protective effects of Lactobacillus paracasei F19 in a rat model of oxidative and metabolic hepatic injury

The liver is susceptible to such oxidative and metabolic stresses as ischemia-reperfusion (I/R) and fatty acid accumulation. Probiotics are viable microorganisms that restore the gut microbiota and exert a beneficial effect on the liver by inhibiting bacterial enzymes, stimulating immunity, and protecting intestinal permeability. We evaluated Lactobacillus paracasei F19 (LP-F19), for its potential protective effect, in an experimental model of I/R (30 min ischemia and 60 min reperfusion) in rats fed a standard diet or a steatogen [methionine/choline-deficient (MCD)] diet. Both groups consisted of 7 sham-operated rats, 10 rats that underwent I/R, and 10 that underwent I/R plus 8 wk of probiotic dietary supplementation. In rats fed a standard diet, I/R induced a decrease in sinusoid perfusion (P < 0.001), severe liver inflammation, and necrosis besides an increase of tissue levels of malondialdehyde (P < 0.001), tumor necrosis factor-alpha (P < 0.001), interleukin (IL)-1beta (P < 0.001), and IL-6 (P < 0.001) and of serum levels of transaminase (P < 0.001) and lipopolysaccharides (P < 0.001) vs. sham-operated rats. I/R also induced a decrease in Bacterioides, Bifidobacterium, and Lactobacillus spps (P < 0.01, P < 0.001, and P < 0.001, respectively) and an increase in Enterococcus and Enterobacteriaceae (P < 0.01 and P < 0.001, respectively) on intestinal mucosa. The severity of liver and gut microbiota alterations induced by I/R was even greater in rats with liver inflammation and steatosis, i.e., MCD-fed animals. LP-F19 supplementation significantly reduced the harmful effects of I/R on the liver and on gut microbiota in both groups of rats, although the effect was slightly less in MCD-fed animals. In conclusion, LP-F19 supplementation, by restoring gut microbiota, attenuated I/R-related liver injury, particularly in the absence of steatosis.

[Histopathological diagnosis of non-alcoholic and alcoholic fatty liver disease. Grade 2 consensus-based guidelines]

Both alcoholic (AFL) and non-alcoholic fatty liver (NAFL) are characterized by lipid deposition in hepatocytes. The diagnosis of steatosis is made when lipid deposition exceeds 5% of hepatocytes, while involvement of more than 50% is called "fatty liver ". An additional inflammatory reaction leads to alcoholic (ASH) or non-alcoholic steatohepatitis (NASH). Steatohepatitis is present when both inflammatory infiltrates of mixed cells in the small liver lobules as well as liver cell injury in terms of ballooning can be detected.Liver biopsy represents the "gold standard" for confirming diagnosis and determining inflammatory activity and potential fibrosis of fatty liver disease.The differential diagnosis of ASH-NASH cannot be made on the basis of histological criteria alone. Steatosis, inflammatory changes and hepatocytic injury can be semiquantified as a "Brunt Score" or "NAS" (NAFLD activity score), providing the basis on which to decide whether or not steatohepatitis is present.People at increased risk of developing a fatty liver possess an increased risk of developing chemotherapy-associated steatohepatitis (CASH).Histologically, pediatric NASH differs from adult NASH and is often only clinically manifest through a mild if persistent elevation in transaminases.

Histopathological and ultrastructural studies on the effects of electromagnetic fields on the liver of preincubated white Leghorn chicken embryo

There are several reports indicating a linkage between exposures to 50-60 Hz electromagnetic fields and abnormalities in the early stages of embryonic development of chicken embryos. The present study was designed to demonstrate whether electromagnetic fields could be an environmental factor invoking histopathological and ultra-structural changes in livers of preincubated chicken embryos exposed to EMFs. Following other researchers and our previous results from different groups of Developmental Biology at the Animal Sciences, Faculty of Biological Sciences, Shahid-Beheshti University, effects of most effective intensities (1.33, 2.66, 5.52, and 7.32 mT) of electromagnetic fields (EMFs, 50 Hz ) on livers of pre-incubated white leghorn chicken embryos were investigated . 150 healthy, fresh, and fertilized eggs (55-65 gr) were divided into 6 groups of experimental(1-4, n = 30), control (n = 60), and sham (n = 50). Experimental eggs (inside coil) were exposed to 4 different intensities (1.33, 2.66, 5.52, and 7.32 mT). Sham groups were located inside same coil, with no exposure, for 24 h before incubation. Control, sham, and experimental groups (1-4) were then incubated in an incubator (38 +/- 0.5 degrees C, 60% humidity) for 17 days. At the end of this period, livers of experimental, sham, and control groups were processed for light and transmission electrom microscopes (TEM and SEM) studies. So, livers of 17-day old chicken embryos were removed by C-sections, fixed in formalin 10%, stained with H&E and reticulin, and studied under light microscope. Others were prepared for electron microscopes (TEM and SEM) investigations. Morphological observations indicated exencephalic embryos, embryos with asymmetrical faces, crossed beak, shorter upper beak, deformed hind limbs, gastroschesis, anophthalmia, and microphthalmia. H&E and reticulin stainings, TEMS, and SEMs studies indicated EMFs would create hepato-cytes with fibrotic bands, severe steatohepatitis, vacuolizations, swollen and extremely electron-dense mitochondria, reduced invisible cristae, crystalized mitochondria with degenerated cristae, myelin-like figures, macrophages engulfing adjacent cells, dentated nuclei, nuclei with irregular envelopes, degenerated hepatocytes, abnormal lipid accumulations, lipid droplets pushing hepatocytes' nuclei to the corner of the cells, abundant cellular infiltrations cellular infiltrations inside sinusoid and around central veins, disrupted reticulin plexus, and release of chromatin into cytosol,, with partially regular water layers. An elevated oxyradical generation and, subsequently, cell membrane disruptions were the reasons for electromagnetic fields inducing cell damages.

Hepatic steatosis, carotid atherosclerosis and metabolic syndrome: the STEATO Study

PURPOSE

Hepatic steatosis is frequently observed in subjects with metabolic syndrome (MS). In type 2 diabetics, it is independently associated with cardiovascular diseases. In order to confirm and extend this finding, a large group of patients with risk factors for atherosclerosis was studied.

METHODS

Carotid atherosclerosis was investigated by echo-Doppler, and hepatic steatosis by ultrasound and transaminase values. Strict exclusion criteria were chosen in order to avoid secondary forms of fatty liver and interference on transaminase values.

RESULTS

Among 970 enrolled patients, about 20% were diabetics, half had MS and 76% presented echographic hepatic steatosis. In multivariate analyses, fatty liver and MS were associated with carotid atherosclerosis [odds ratio (95% confidence intervals) 2.15 (1.27-3.63) and 1.72(1.12-2.64), respectively], whereas HOMA index was not. Aspartate aminotransferase and alanine aminotransferase were not independently associated with carotid atherosclerosis, whereas gamma-glutamyl transferase showed a link with atherosclerosis beyond MS and steatosis presence. The analyses of the 780 non diabetics recruited showed similar results.

CONCLUSIONS

The results of the present study demonstrate that hepatic steatosis measured by echography is associated with carotid atherosclerosis in a large population mostly carrying cardiovascular or metabolic risk factors, independently of MS, cardiovascular diseases, diabetes mellitus and/or insulin resistance.

The role of proliferator-activated receptor gamma coactivator-1alpha in the fatty-acid-dependent transcriptional control of interleukin-10 in hepatic cells of rodents

Interleukin-10 (IL-10) is an endogenous factor that restrains hepatic insulin resistance in diet-induced steatosis. Reducing IL-10 expression increases proinflammatory activity in the steatotic liver and worsens insulin resistance. As the transcriptional coactivator proliferator-activated receptor gamma coactivator-1alpha (PGC-1alpha) plays a central role in dysfunctional hepatocytic activity in diet-induced steatosis, we hypothesized that at least part of the action of PGC-1alpha could be mediated by reducing the transcription of the IL-10 gene. Here, we used immunoblotting, real-time polymerase chain reaction, immunocytochemistry, and chromatin immunoprecipitation assay to investigate the role of PGC-1alpha in the control of IL-10 expression in hepatic cells. First, we show that, in the intact steatotic liver, the expressions of IL-10 and PGC-1alpha are increased. Inhibiting PGC-1alpha expression by antisense oligonucleotide increases IL-10 expression and reduces the steatotic phenotype. In cultured hepatocytes, the treatment with saturated and unsaturated fatty acids increased IL-10 expression. This was accompanied by increased association of PGC-1alpha with c-Maf and p50-nuclear factor (NF) kappaB, 2 transcription factors known to modulate IL-10 expression. In addition, after fatty acid treatment, PGC-1alpha, c-Maf, and p50-NFkappaB migrate from the cytosol to the nuclei of hepatocytes and bind to the IL-10 promoter region. Inhibiting NFkappaB activation with salicylate reduces IL-10 expression and the association of PGC-1alpha with p50-NFkappaB. Thus, PGC-1alpha emerges as a potential transcriptional regulator of the inflammatory phenomenon taking place in the steatotic liver.

Serum ornithine carbamyltransferase reflects hepatic damage in diabetic obese mice

BACKGROUND AND AIM

As ornithine carbamyltransferase (OCT) has proved to be a sensitive serum marker in the detection of hepatotoxicity in several models, it is important to confirm its application to the diagnosis of non-alcoholic fatty liver disease.

METHODS

C57BL/6, KK-Ta and KK-Ay mice were fed a high-fat diet for 8 weeks and serum enzyme markers were examined. Serum OCT and alanine aminotransferase (ALT) were also measured in diabetic obese ob/ob and db/db mice fed a normal diet. Liver damage in these mice was evaluated by the hepatic content of tumor necrosis factor-alpha.

RESULTS

Serum levels of OCT increased in KK-Ay fed a high-fat diet compared with the normal diet-fed group, whereas C57BL/6 and KK-Ta mice were not affected. In ob/ob mice, the relative increase was always greater in OCT than in ALT. In contrast, in db/db mice, the relative increase was always greater in ALT. Hepatic tumor necrosis factor-alpha was significantly elevated in ob/ob mice, but not in db/db mice.

CONCLUSIONS

Serum OCT seemed to reflect tumor necrosis factor-alpha-mediated hepatic damage when compared with ALT in diabetic obese mice and could be useful in the application for non-alcoholic fatty liver disease with features of metabolic syndrome, such as obesity and diabetes.

Probiotics and gut health: A special focus on liver diseases

Probiotic bacteria have well-established beneficial effects in the management of diarrhoeal diseases. Newer evidence suggests that probiotics have the potential to reduce the risk of developing inflammatory bowel diseases and intestinal bacterial overgrowth after gut surgery. In liver health, the main benefits of probiotics might occur through preventing the production and/or uptake of lipopolysaccharides in the gut, and therefore reducing levels of low-grade inflammation. Specific immune stimulation by probiotics through processes involving dendritic cells might also be beneficial to the host immunological status and help prevent pathogen translocation. Hepatic fat metabolism also seems to be influenced by the presence of commensal bacteria, and potentially by probiotics; although the mechanisms by which probiotic might act on the liver are still unclear. However, this might be of major importance in the future because low-grade inflammation, hepatic fat infiltration, and hepatitis might become more prevalent as a result of high fat intake and the increased prevalence of obesity.

High-sensitivity C-reactive protein and liver enzymes in individuals with Metabolic Syndrome in Talca, Chile

Metabolic syndrome (MS) is a core set of disorders, including abdominal obesity, dyslipidemia, hypertension and hypertriglyceridemia that together predict the development of diabetes type 2 and cardiovascular disease. This study investigated the relationship between liver enzyme levels and high-sensitivity C-reactive protein (hs-CRP) in subjects with and without MS. Alanine-aminotransferase (ALAT), aspartate-aminotransferase (ASAT), γ-glutamyl transferase (GGT) and hs-CRP were measured in 510 subjects, aged 40 to 65 years old. Patients were selected from 1007 subjects from the Research Program for Cardiovascular Disease Risk Factors in Talca, Chile. Results showed that women with MS presented higher liver enzyme levels than those who did not have MS. This was not observed in male patients for the enzymes ALAT and ASAT. However, GGT and hs-PCR levels were higher in male and female patients with MS than in those without MS. In conclusion, it is important to search for the presence of MS when diagnosing fatty liver. Moreover, the presence of liver disease in patients with MS should be further investigated.

Mitochondrial DNA variants in the pathogenesis of type 2 diabetes - relevance of asian population studies

Mitochondrial dysfunction involves defective insulin secretion by pancreatic beta-cells, and insulin resistance in insulin-sensitive tissues such as muscle and adipose tissue. Mitochondria are recognized as the most important cellular source of energy, and the major generator of intracellular reactive oxygen species (ROS). Intracellular antioxidative systems have been developed to cope with increased oxidative damage. In case of minor oxidative stress, the cells may increase the number of mitochondria to produce more energy. A mechanism called mitochondrial biogenesis, involving several transcription factors and regulators, controls the quantity of mitochondria. When oxidative damage is advanced beyond the repair capacity of antioxidative systems, then oxidative stress can lead to cell death. Therefore, this organelle is central to cell life or death. Available evidence increasingly shows genetic linkage between mitochondrial DNA (mtDNA) alterations and type 2 diabetes (T2D). Based on previous studies, the mtDNA 16189 variant is associated with metabolic syndrome, higher fasting insulin concentration, insulin resistance index and lacunar cerebral infarction. These data support the involvement of mitochondrial genetic variation in the pathogenesis of T2D. Importantly, phylogeographic studies of the human mtDNAs have revealed that the human mtDNA tree is rooted in Africa and radiates into different geographic regions and can be grouped as haplogroups. The Asian populations carry very different mtDNA haplogroups as compared to European populations. Therefore, it is critically important to determine the role of mtDNA polymorphisms in T2D.

Serum cholinesterase activity in the diagnosis of nonalcoholic fatty liver disease in type 2 diabetic patients

The aim of the study was to compare the serum cholinesterase activities of a group of type 2 diabetic patients showing clinical evidence of nonalcoholic fatty liver disease to those of age and sex-matched type 2 diabetics who showed no evidence of liver disease, and healthy control subjects to determine, if serum cholinesterase can be used to diagnose nonalcoholic fatty liver disease in type 2 diabetic patients. Mean serum cholinesterase activity in diabetics with nonalcoholic fatty liver disease was found to be statistically significantly lower than in diabetics without liver disease and in healthy subjects. There was no statistically significant difference between the mean values of serum cholinesterase activities of non-liver disease diabetics and healthy control subjects. It was found that serum cholinesterase activity of 1640IU/L or less differentiated type 2 diabetic subjects with nonalcoholic fatty liver disease from diabetic subjects who were free of liver disease with a diagnostic sensitivity of 87.5% and specificity of 75%. It is suggested that routine monitoring of serum cholinesterase activities from the time of diagnosis of type 2 diabetes mellitus may reveal the earliest time for the change in serum cholinesterase activities in diabetics that signals the onset of nonalcoholic fatty liver disease.

Prevalence of non-alcoholic fatty liver disease in urban south Indians in relation to different grades of glucose intolerance and metabolic syndrome

AIM

To estimate prevalence of non-alcoholic fatty liver disease (NAFLD) and its association with glucose intolerance (type 2 diabetes (DM), prediabetes) and metabolic syndrome (MS) in urban south Indians.

METHODS

This study was carried out in 541 subjects (response rate 92%) of the original sample of 26,001 subjects in the Chennai Urban Rural Epidemiology Study maintaining the representativeness. Anthropometry and lipid estimations were done in all and oral glucose tolerance test in all, except self-reported diabetic subjects. NAFLD was diagnosed by ultrasonography and MS by modified Adult Treatment Panel III (ATP III) criteria. DM, impaired glucose tolerance (IGT) and impaired fasting glucose (IFG) were defined using WHO consulting group criteria.

RESULTS

Overall prevalence of NAFLD was 32% (173/541 subjects) (men: 35.1%, women: 29.1%, p=0.140). Prevalence of most cardio-metabolic risk factors was significantly higher in NAFLD subjects. Prevalence of NAFLD (54.5%) was higher in subjects with DM compared to those with prediabetes (IGT or IFG) (33%), isolated IGT (32.4%), isolated IFG (27.3%) and normal glucose tolerance (NGT) (22.5%) (DM vs. prediabetes: p<0.05, DM vs. NGT: p<0.001, prediabetes vs. NGT: p<0.05). Even after adjusting for age, gender and waist circumference, NAFLD was associated with diabetes (OR: 2.9, 95% C.I.: 1.9-4.6, p<0.001) and MS (OR: 2.0, 95% C.I.: 1.3-3.1, p<0.001).

CONCLUSION

NAFLD is present in a third of urban Asian Indians and its prevalence increases with increasing severity of glucose intolerance and in MS. This is the first population-based prevalence of NAFLD from south Asia which faces the brunt of the diabetes epidemic.

Marked elevation of serum mitochondrion-derived markers in mild models of non-alcoholic steatohepatitis in rats

BACKGROUND AND AIM

In order to find sensitive serum markers in non-alcoholic steatohepatitis, liver-specific injury markers were thoroughly examined in mild models of NASH in rats.

METHODS

Wistar and Sprague-Dawley rats were fed a choline-deficient diet for 4 weeks, and serum activities of liver-specific enzyme markers were examined. In the drug-induced steatohepatitis model, tetracycline (0.4 mmol/kg) was given i.p. to rats and the course of hepatotoxicity was evaluated with serum markers, together with the accumulation of total lipid and thiobarbituric acid-reactive substances in the liver.

RESULTS

In Wistar rats, serum activities of most enzymes tested were significantly increased. In Sprague-Dawley rats, in contrast, the serum level of ornithine carbamyltransferase and glutamate dehydrogenase were markedly elevated in the choline-deficient diet group compared with the control diet groups, whereas other markers were not significantly increased. In the tetracycline-induced steatohepatitis model, the extent of the increase was much higher in mitochondrial markers and the peak of the increase in these markers corresponded with the increase of hepatic total lipid and thiobarbituric acid-reactive substance.

CONCLUSIONS

These observations show that serum mitochondrial enzyme markers are potent markers for non-alcoholic steatohepatitis in rats and are possibly applicable to humans.

Maternal high-fat diet triggers lipotoxicity in the fetal livers of nonhuman primates

Maternal obesity is thought to increase the offspring's risk of juvenile obesity and metabolic diseases; however, the mechanism(s) whereby excess maternal nutrition affects fetal development remain poorly understood. Here, we investigated in nonhuman primates the effect of chronic high-fat diet (HFD) on the development of fetal metabolic systems. We found that fetal offspring from both lean and obese mothers chronically consuming a HFD had a 3-fold increase in liver triglycerides (TGs). In addition, fetal offspring from HFD-fed mothers (O-HFD) showed increased evidence of hepatic oxidative stress early in the third trimester, consistent with the development of nonalcoholic fatty liver disease (NAFLD). O-HFD animals also exhibited elevated hepatic expression of gluconeogenic enzymes and transcription factors. Furthermore, fetal glycerol levels were 2-fold higher in O-HFD animals than in control fetal offspring and correlated with maternal levels. The increased fetal hepatic TG levels persisted at P180, concurrent with a 2-fold increase in percent body fat. Importantly, reversing the maternal HFD to a low-fat diet during a subsequent pregnancy improved fetal hepatic TG levels and partially normalized gluconeogenic enzyme expression, without changing maternal body weight. These results suggest that a developing fetus is highly vulnerable to excess lipids, independent of maternal diabetes and/or obesity, and that exposure to this may increase the risk of pediatric NAFLD.

Causes and metabolic consequences of Fatty liver

Type 2 diabetes and cardiovascular disease represent a serious threat to the health of the population worldwide. Although overall adiposity and particularly visceral adiposity are established risk factors for these diseases, in the recent years fatty liver emerged as an additional and independent factor. However, the pathophysiology of fat accumulation in the liver and the cross-talk of fatty liver with other tissues involved in metabolism in humans are not fully understood. Here we discuss the mechanisms involved in the pathogenesis of hepatic fat accumulation, particularly the roles of body fat distribution, nutrition, exercise, genetics, and gene-environment interaction. Furthermore, the effects of fatty liver on glucose and lipid metabolism, specifically via induction of subclinical inflammation and secretion of humoral factors, are highlighted. Finally, new aspects regarding the dissociation of fatty liver and insulin resistance are addressed.

Metabolic syndrome as a risk factor for nonalcoholic fatty liver disease

BACKGROUND

Metabolic syndrome has been linked to nonalcoholic fatty liver disease (NAFLD).

OBJECTIVES

The purpose of the current study was to evaluate metabolic syndrome as a risk factor for NAFLD in Taiwanese adults.

METHODS

A cross-sectional study was conducted in which 876 subjects were enrolled. The diagnosis of NAFLD was made by abdominal ultrasonography. The Asia-Pacific modification of the National Cholesterol Education Program (NCEP) Adult Treatment Panel (ATP) III guidelines was used to establish the diagnosis of metabolic syndrome.

RESULTS

NAFLD was diagnosed in 373 (42.6%) of the study population. Metabolic syndrome was diagnosed in 202 (23.1%) of the study population, and it was independently associated with NAFLD (odds ratio [OR] = 2.37; P < 0.001). Among the components of metabolic syndrome, hypertriglyceridemia (OR = 2.24; P < 0.001), hyperglycemia (OR = 2.23; P = 0.001), increased waist circumference (OR = 1.76; P = 0.013), and the diagnostic components of metabolic syndrome were independently associated with NAFLD.

CONCLUSION

Metabolic syndrome and some of its diagnostic components are independent risk factors for NAFLD.

Sirt1 protects against high-fat diet-induced metabolic damage

The identification of new pharmacological approaches to effectively prevent, treat, and cure the metabolic syndrome is of crucial importance. Excessive exposure to dietary lipids causes inflammatory responses, deranges the homeostasis of cellular metabolism, and is believed to constitute a key initiator of the metabolic syndrome. Mammalian Sirt1 is a protein deacetylase that has been involved in resveratrol-mediated protection from high-fat diet-induced metabolic damage, but direct proof for the implication of Sirt1 has remained elusive. Here, we report that mice with moderate overexpression of Sirt1 under the control of its natural promoter exhibit fat mass gain similar to wild-type controls when exposed to a high-fat diet. Higher energy expenditure appears to be compensated by a parallel increase in food intake. Interestingly, transgenic Sirt1 mice under a high-fat diet show lower lipid-induced inflammation along with better glucose tolerance, and are almost entirely protected from hepatic steatosis. We present data indicating that such beneficial effects of Sirt1 are due to at least two mechanisms: induction of antioxidant proteins MnSOD and Nrf1, possibly via stimulation of PGC1alpha, and lower activation of proinflammatory cytokines, such as TNFalpha and IL-6, via down-modulation of NFkappaB activity. Together, these results provide direct proof of the protective potential of Sirt1 against the metabolic consequences of chronic exposure to a high-fat diet.

Role of dietary carbohydrates and macronutrients in the pathogenesis of nonalcoholic fatty liver disease

PURPOSE OF REVIEW

The prevalence of nonalcoholic fatty liver disease is increasing worldwide and there is strong evidence that dietary factors play a role in its pathogenesis. The present review aims to provide a better understanding of how carbohydrates and other macronutrients may affect the disease.

RECENT FINDINGS

The effects of carbohydrates on the development of nonalcoholic fatty liver disease differ depending upon the carbohydrate type; high-glycemic index foods are related to increased hepatic fat in both rodents and humans. Similarly, simple carbohydrates, such as fructose, stimulate hepatic de-novo lipogenesis and decrease lipid oxidation, thus leading to increased fat deposition. The underlying mechanisms may involve the activation of transcription factors. Fat intake broadly leads to hepatic fat deposition in rodents but few data are available on humans. Both carbohydrates and fat trigger inflammatory factors, which are closely related to metabolic disorders and nonalcoholic fatty liver disease. Lifestyle interventions appear to be the most appropriate first-line treatment for nonalcoholic fatty liver disease.

SUMMARY

There is strong evidence that the diet may affect the development of nonalcoholic fatty liver disease. Although simple carbohydrates are clearly shown to have deleterious effects in humans, the role of fat remains controversial. Further studies will be required to evaluate the effects of macronutrient composition on the development of nonalcoholic fatty liver disease.

Nonalcoholic fatty liver disease in a district general hospital: clinical presentation and risk factors

INTRODUCTION

Nonalcoholic fatty liver disease (NAFLD) affects one-fifth of the adult population and is currently the commonest liver problem in the western world. The prevalence of NAFLD is likely to rise over the coming decades in parallel to the obesity and diabetes epidemics. A retrospective study was undertaken in a UK. district general hospital (DGH) to determine the clinical and laboratory features of patients with NAFLD.

METHODS AND FINDINGS

A total of 48 patients with NAFLD were identified. Most (54%) were asymptomatic on presentation and 90% had an echogenic liver on ultrasonography (USS). Liver tests were elevated in the majority, but did not distinguish between simple steatosis and steatohepatitis. Having features of the metabolic syndrome and a low platelet count (P = 0.028) may help identify patients with advanced hepatic fibrosis.

CONCLUSIONS

NAFLD is common in the DGH and should be considered in all patients with metabolic risk factors. A liver biopsy should be considered in those with low platelets, type II diabetes mellitus, and the metabolic syndrome.

Mutation of mitochondrial DNA in livers from patients with alcoholic hepatitis and nonalcoholic steatohepatitis

BACKGROUND

In alcoholic hepatitis (Al-Hep) and nonalcoholic steatohepatitis (NASH), triglycerides accumulate in hepatocytes. We examined the hypothesis that mutations in mitochondrial DNA may take place by mitochondrial overwork, resulting in dysfunction of mitochondria.

SUBJECTS AND METHODS

Subjects of this research were 8 cases each of Al-Hep, NASH, and fatty liver (FL). Total DNA was extracted from the biopsied liver samples. DNA fragments were amplified by PCR and DNA sequences determined in the control and coding regions of mitochondrion.

RESULTS

When the numbers of mutations per 1,000 bases of mitochondrial DNA were compared between each group, no significant differences were found among D-loop, HV1, and HV2 mitochondrial DNA regions. However, there were significantly more mutations in ND1 and COII of Al-Hep and NASH than in FL, and mutations were comparatively at random. Neither a region in which mutations were focused nor differences among the groups were recognized. When details of the base mutation in a control region were investigated by group, the transition type of mutation between T:A<<->>C:G occurred in at least 70%. Also, a transition-type mutation was found mostly in a coding region, which was similar to the mutation pattern in the control region, except for the ND1 and COII regions where there were hardly any mutations.

CONCLUSIONS

As gene mutations of mitochondrial DNA appeared frequently in Al-Hep, and also in NASH, mitochondrial dysfunction caused by mutation in mitochondrial DNA may be involved in the pathogenesis of both diseases.

Non-alcoholic fatty liver disease is independently associated with an increased prevalence of chronic kidney disease and proliferative/laser-treated retinopathy in type 2 diabetic patients

AIMS/HYPOTHESIS

Non-alcoholic fatty liver disease (NAFLD) is associated with an increased risk of cardiovascular disease in type 2 diabetes. Currently, there is a lack of information on associations between NAFLD and microvascular complications of diabetes. We assessed the associations between NAFLD and both chronic kidney disease (CKD) and retinopathy in a large cohort of type 2 diabetic individuals using a cross-sectional design.

METHODS

Prevalence rates of retinopathy (by ophthalmoscopy) and CKD (defined as overt proteinuria and/or estimated GFR <or= 60 ml min(-1) 1.73 m(-2)) were assessed in 2,103 type 2 diabetic individuals who were free of diagnosed cardiovascular disease and viral hepatitis. NAFLD was ascertained by patient history, blood sampling and liver ultrasound.

RESULTS

NAFLD patients had higher (p<0.001) age- and sex-adjusted prevalence rates of both non-proliferative (39 vs 34%) and proliferative/laser-treated retinopathy (11 vs 5%), and CKD (15 vs 9%) than counterparts without NAFLD. In logistic regression analysis, NAFLD was associated with increased rates of CKD (odds ratio 1.87; 95% CI 1.3-4.1, p=0.020) and proliferative/laser-treated retinopathy (odds ratio 1.75; 1.1-3.7, p=0.031) independently of age, sex, BMI, waist circumference, hypertension, diabetes duration, HbA(1c), lipids, smoking status and medications use.

CONCLUSIONS/INTERPRETATION

Our findings suggest that NAFLD is associated with an increased prevalence of CKD and proliferative/laser-treated retinopathy in type 2 diabetic individuals independently of numerous baseline confounding factors. Further studies are required to confirm the reproducibility of these results and to evaluate whether NAFLD contributes to the development or progression of CKD and retinopathy.

Endocannabinoid system overactivity and the metabolic syndrome: prospects for treatment

The endocannabinoid system (ECS) plays a physiologic role in modulating energy balance, feeding behavior, lipoprotein metabolism, insulin sensitivity, and glucose homeostasis, which when dysregulated can all contribute to cardiometabolic risk. Evidence has suggested that the ECS is overactive in human obesity and in animal models of genetic and diet-induced obesity. ECS stimulation centrally and peripherally drives metabolic processes that mimic the metabolic syndrome. These findings have led to the development of potential novel therapeutic targets, including the drug rimonabant, a selective CB1 receptor antagonist, which has been shown to promote weight loss, reduce inflammation, improve dyslipidemia, and improve glucose homeostasis.

Establishment of a cellular model of non-alcoholic fatty liver and its biological characteristics

AIM: To establish non-alcoholic fatty liver and non-alcoholic steatohepatitis models at a cellular level.

METHODS: Liver cells HL-7702 were cultured with RPMI-1640 medium containing long chain fat emulsion, which is a nutritional emulsion used in the clinic. Cells were subcultured for two generations to obtain non-alcoholic steatohepatitis models. The similarities between the cellular and animal models were evaluated, especially the utility of the cellular model.

RESULTS: After 48 hours in culture, the TG content in HL-7702 cells cultured in RPMI-1640 medium containing long chain fat emulsion increased remarkably, while there were few variations in biochemical indices such as ALT. When these cells were subcultured for two generations, they showed inflammatory injury.

CONCLUSION: Cellular models of non-alcoholic fatty liver and non-alcoholic steatohepatitis in vivo can be generated in a short time by mixing medium with long chain fat emulsion.

Therapeutic potential of curcumin in non-alcoholic steatohepatitis

Non-alcoholic steatohepatitis (NASH) may be associated with a number of clinical conditions, but it occurs most commonly in patients with insulin resistance. There is as yet no established disease-modifying treatment, and a safe and broadly available agent that targets hepatic steatosis, insulin resistance, inflammation and fibrosis is necessary. The polyphenolic compound curcumin exhibits antioxidant and anti-inflammatory properties, inhibits NF-κB and activates PPAR-γ. In rodents, curcumin prevents dietary-induced hepatic steatosis, hepatic stellate cell activation and production of fibrotic proteins, and ameliorates steatohepatitis induced by the intake of alcohol or a methionine–choline-deficient diet. Indirect evidence suggests that curcumin may improve insulin sensitivity in diabetes and inflammatory states. The present paper reviews the numerous cellular and animal studies indicating that curcumin attenuates many of the pathophysiological processes involved in the development and progression of NASH. It is suggested that basic and clinical studies on curcumin in the development and progression of NASH are indicated.

Significant correlations between severe fatty liver and risk factors for metabolic syndrome

BACKGROUND AND AIM

It is known that ultrasonography (US) cannot differentiate between non-alcoholic fatty liver disease (NAFLD) and steatohepatitis. However, US can accurately estimate the severity of the steatosis. The clinical significance of severe hepatic fatty change by US has not been explored. The aim of this study was to investigate the relationship between the severity of the fatty liver, classified by US, and the degree of metabolic disorders with insulin resistance.

METHODS

In 16 486 Taiwanese patients, severity of fatty change on US was classified as follows: group A (n = 6950), absence of fatty change; group B (n = 8694), mild; and group C (n = 842), severe fatty liver change. Biometabolic parameters included body mass index (BMI), blood pressure (BP), fasting plasma glucose, triglycerides, cholesterol, aspartate aminotransferase (AST), alanine aminotransferase (ALT), and serum creatinine. Nominal logistic regression analysis was used to estimate the odds ratio for different degrees of fatty liver.

RESULTS

The frequencies of obesity, hypertension, glucose intolerance and hypertriglyceridemia were all significantly higher in group C than in group A or B (P < 0.0001), and the mean values of BMI, BP, fasting glucose, triglyceride and ALT were also higher in group C (P < 0.0001). High BMI (>or=30 kg/m(2)) appears to be the most important factor for progression from mild to severe fatty liver in both sexes.

CONCLUSIONS

The presence of severe fatty liver by US correlated significantly with the prevalence and degree of hypertension, abnormal glucose and triglyceride metabolism. Patients with severe fatty liver could be at an increased risk of atherosclerotic cardiovascular disease and should be screened regularly for metabolic disorders. The physician may also evaluate ALT and hepatic fat content by US in patients with metabolic syndrome. Evaluating the severity of fatty liver by US may be useful because it correlates with the status of hyperinsulinemia, the risks of developing cardiovascular disease, and the threshold for oxidative stress.

Cannabinoid-1 receptor antagonists in type-2 diabetes

Type-2 diabetes is closely related to abdominal obesity and is generally associated with other cardiometabolic risk factors, resulting in a risk of major cardiovascular disease. Several animal and human observations suggest that the endocannabinoid system is over-active in the presence of abdominal obesity and/or diabetes. Both central and peripheral endocannabinoid actions, via the activation of CB1 receptors, promote weight gain and associated metabolic changes. Rimonabant, the first selective CB(1) receptor blocker in clinical use, has been shown to reduce body weight, waist circumference, triglycerides, blood pressure, insulin resistance index and C-reactive protein levels, and to increase high-density lipoprotein (HDL) cholesterol and adiponectin concentrations in both non-diabetic and diabetic overweight/obese patients. In addition, a 0.5-0.7% reduction in HbA1c levels was observed in metformin- or sulphonylurea-treated patients with type-2 diabetes and in drug-naïve diabetic patients. Almost half of the metabolic changes, including HbA1c reduction, could not be explained by weight loss, suggesting that there are direct peripheral effects. Rimonabant was generally well-tolerated, and the safety profile was similar in diabetic and non-diabetic patients, with a higher incidence of depressed mood disorders, nausea and dizziness. In conclusion, the potential role of rimonabant in overweight/obese patients with type-2 diabetes and at high risk of cardiovascular disease deserves much consideration.

Plasminogen activator inhibitor-1 and thrombin activatable fibrinolysis inhibitor levels in non-alcoholic steatohepatitis

AIM

This study was conducted to demonstrate the plasminogen activator inhibitor- 1 (PAI-1) and thrombin activatable fibrinolysis inhibitor antigen (TAFI-Ag) levels in non-alcoholic steatohepatitis (NASH).

MATERIALS AND METHODS

Twenty-seven patients with biopsy-proven NASH and 18 healthy controls (HC) were recruited for the study. Anthropometric data, liver histology (no.=20) and laboratory parameters including PAI-1 and TAFI-Ag assessments were recorded.

RESULTS

When compared with HC, patients with NASH had higher body weight, higher waist circumference, elevated blood pressure, higher fasting plasma glucose (FPG) levels and higher homeostasis model assessment (HOMA) scores. The mean plasma PAI-1 levels of patients was found to be higher than HC (87.60 ng/ml vs 30.84 ng/ml p=0.000) and mean plasma TAFI-Ag levels of patients was found to be significantly lower (8.69 microg/ml vs 12.19 microg/ml p=0.000). PAI-1 levels were correlated with systolic blood pressure, age, body weight, transaminases, waist circumference, FPG, body mass index, and HOMA score. TAFI-Ag levels were found to be negatively correlated with transaminases, waist circumference, and body weight. In multiple regression analysis, BMI was the independent variable effecting PAI-1 levels. We did not show any association between PAI-1, TAFI-Ag, disease activity score and fibrosis score. HOMA was the independent variable effecting liver fibrosis in our patients.

CONCLUSION

In this study we demonstrated that patients with biopsy-proven NASH had higher PAI-1 and lower TAFI-Ag expression than HC. Elevated levels of PAI-1 in NASH is the consequence of insulin resistance state. Lower TAFI-Ag levels may be related to the overactivation of TAFI pathway resulting in TAFI-Ag depletion. Furthermore, liver function disturbances may impair TAFI production in NASH. We also showed that NASH patients even with slight elevations of transaminases feature marked insulin resistance and components of metabolic syndrome.

N-acetylcysteine attenuates oxidative stress and liver pathology in rats with non-alcoholic steatohepatitis

AIM: To evaluate attenuating properties of N-acetylcysteine (NAC) on oxidative stress and liver pathology in rats with non-alcoholic steatohepatitis (NASH).

METHODS: Male Sprague-Dawley rats were randomly divided into three groups. Group 1 (control, n = 8) was free accessed to regular dry rat chow (RC) for 6 wk. Group 2 (NASH, n = 8) was fed with 100% fat diet for 6 wk. Group 3 (NASH + NAC₂₀, n = 9) was fed with 100% fat diet plus 20 mg/kg per day of NAC orally for 6 wk. All rats were sacrificed to collect blood and liver samples at the end of the study.

RESULTS: The levels of total glutathione (GSH) and hepatic malondialdehyde (MDA) were increased significantly in the NASH group as compared with the control group (GSH; 2066.7 ± 93.2 vs 1337.5 ± 31.5 μmol/L and MDA; 209.9± 43.9 vs 3.8 ±1.7 μmol/g protein, respectively, P < 0.05). Liver histopathology from group 2 showed moderate to severe macrovesicular steatosis, hepatocyte ballooning, and necroinflammation. NAC treatment improved the level of GSH (1394.8 ± 81.2 μmol/L, P < 0.05), it did not affect MDA (150.1 ± 27.0 μmol/g protein), but led to a decrease in fat deposition and necroinflammation.

CONCLUSION: NAC treatment could attenuate oxidative stress and improve liver histology in rats with NASH.