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Leite NC, Villela-Nogueira CA, Cardoso CRL, Salles GF. Non-alcoholic fatty liver disease and diabetes: From physiopathological interplay to diagnosis and treatment. World J Gastroenterol 2014; 20:8377-8392. [PMID: 25024596 PMCID: PMC4093691 DOI: 10.3748/wjg.v20.i26.8377] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2013] [Revised: 12/01/2013] [Accepted: 01/20/2014] [Indexed: 02/06/2023] Open
Abstract
Non-alcoholic fatty liver disease (NAFLD) is highly prevalent in patients with diabetes mellitus and increasing evidence suggests that patients with type 2 diabetes are at a particularly high risk for developing the progressive forms of NAFLD, non-alcoholic steatohepatitis and associated advanced liver fibrosis. Moreover, diabetes is an independent risk factor for NAFLD progression, and for hepatocellular carcinoma development and liver-related mortality in prospective studies. Notwithstanding, patients with NAFLD have an elevated prevalence of prediabetes. Recent studies have shown that NAFLD presence predicts the development of type 2 diabetes. Diabetes and NAFLD have mutual pathogenetic mechanisms and it is possible that genetic and environmental factors interact with metabolic derangements to accelerate NAFLD progression in diabetic patients. The diagnosis of the more advanced stages of NAFLD in diabetic patients shares the same challenges as in non-diabetic patients and it includes imaging and serological methods, although histopathological evaluation is still considered the gold standard diagnostic method. An effective established treatment is not yet available for patients with steatohepatitis and fibrosis and randomized clinical trials including only diabetic patients are lacking. We sought to outline the published data including epidemiology, pathogenesis, diagnosis and treatment of NAFLD in diabetic patients, in order to better understand the interplay between these two prevalent diseases and identify the gaps that still need to be fulfilled in the management of NAFLD in patients with diabetes mellitus.
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152
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Liu H, Lu HY. Nonalcoholic fatty liver disease and cardiovascular disease. World J Gastroenterol 2014; 20:8407-8415. [PMID: 25024598 PMCID: PMC4093693 DOI: 10.3748/wjg.v20.i26.8407] [Citation(s) in RCA: 75] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2013] [Revised: 01/04/2014] [Accepted: 04/09/2014] [Indexed: 02/06/2023] Open
Abstract
Nonalcoholic fatty liver disease (NAFLD) and cardiovascular disease (CVD) are two diseases that are common in the general population. To date, many studies have been conducted and demonstrate a direct link between NAFLD and CVD, but the exact mechanisms for this complex relationship are not well established. A systematic search of the PubMed database revealed that several common mechanisms are involved in many of the local and systemic manifestations of NAFLD and lead to an increased cardiovascular risk. The possible mechanisms linking NAFLD and CVD include inflammation, oxidative stress, insulin resistance, ectopic adipose tissue distribution, dyslipidemia, endothelial dysfunction, and adiponectin, among others. The clinical implication is that patients with NAFLD are at an increased risk of CVD and should undergo periodic cardiovascular risk assessment.
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153
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Jia X, Suzuki Y, Naito H, Yetti H, Kitamori K, Hayashi Y, Kaneko R, Nomura M, Yamori Y, Zaitsu K, Kato M, Ishii A, Nakajima T. A possible role of chenodeoxycholic acid and glycine-conjugated bile acids in fibrotic steatohepatitis in a dietary rat model. Dig Dis Sci 2014; 59:1490-501. [PMID: 24448653 DOI: 10.1007/s10620-014-3028-3] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2013] [Accepted: 01/03/2014] [Indexed: 12/22/2022]
Abstract
BACKGROUND AND AIMS Our previous study indicated that hepatic bile acids (BAs) may have deposited and stimulated the pathogenesis of a high fat-cholesterol (HFC) diet-induced fibrotic steatohepatitis in stroke-prone spontaneously hypertensive 5/Dmcr rats, based on dysregulated BA homeostasis pathways. We aimed to further characterize BA profiles in liver and evaluate their relationships to liver injury using this model. METHODS Hepatic 21 BA levels were determined by ultra-performance liquid chromatography-tandem mass spectrometry, and their correlations with macrovesicular steatosis score, serum alanine aminotransferase (ALT) level and quantified fibrotic area were assessed using Spearman and Pearson correlations. RESULTS Compared to control, BAs highly accumulated in HFC-fed rat liver at 2 weeks: cholic acid (CA), deoxycholic acid (DCA) and chenodeoxycholic acid (CDCA) were major species, thereafter, levels of CA and DCA declined, but CDCA species persistently increased, which induced a decrease in total CA/total CDCA ratio at 8 and 14 weeks. CDCA species positively, while total CA/total CDCA negatively, correlated with macrovesicular steatosis score, serum ALT and quantified fibrotic area. Unlike control, total ursodeoxycholic acid was minor in HFC-fed rat liver, and inversely correlated to aforementioned indicators of liver injury; total glyco-BAs, rather than tauro-BAs, were predominant in HFC-fed rat liver, and positively correlated with macrovesicular steatosis score. Moreover, its ratio to total tauro-BAs positively correlated with each parameter of liver injury, while inverse associations were detected for total tauro-BAs. CONCLUSIONS Hepatic BA accumulation may potentiate liver disease. CDCA and glyco-BAs play a more important role in the pathogenesis of fibrotic steatohepatitis.
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Affiliation(s)
- Xiaofang Jia
- Department of Occupational and Environmental Health, Nagoya University Graduate School of Medicine, Nagoya, 466-8550, Japan
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Khullar V, Dolganiuc A, Firpi RJ. Pre-and-post transplant considerations in patients with nonalcoholic fatty liver disease. World J Transplant 2014; 4:81-92. [PMID: 25032097 PMCID: PMC4094954 DOI: 10.5500/wjt.v4.i2.81] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2013] [Revised: 02/17/2014] [Accepted: 03/12/2014] [Indexed: 02/05/2023] Open
Abstract
Non-alcoholic fatty liver disease (NAFLD) is currently the third most common indication for liver transplantation in the United States. With the growing incidence of obesity, NAFLD is expected to become the most common indication for liver transplantation over the next few decades. As the number of patients who have undergone transplantation for NAFLD increases, unique challenges have emerged in the management and long-term outcomes in patients. Risk factors such as obesity, hypertension, diabetes, and hyperlipidemia continue to play an important role in the pathogenesis of the disease and its recurrence. Patients who undergo liver transplantation for NAFLD have similar long-term survival as patients who undergo liver transplantation for other indications. Research shows that post-transplantation recurrence of NAFLD is commonplace with some patients progressing to recurrent non-alcoholic steatohepatitis and cirrhosis. While treatment of comorbidities is important, there is no consensus on the management of modifiable risk factors or the role of pharmacotherapy and immunosuppression in patients who develop recurrent or de novo NAFLD post-transplant. This review provides an outline of NAFLD as indication for liver transplantation with a focus on the epidemiology, pathophysiology and risk factors associated with this disease. It also provides a brief review on the pre-transplant considerations and post-transplant factors including patient characteristics, role of obesity and metabolic syndrome, recurrence and de novo NAFLD, outcomes post-liver transplantation, choice of medications, and options for immunosuppression.
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155
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Sun WM, Wang YP, Duan YQ, Shang HX, Cheng WD. Radix Hedysari polysaccharide suppresses lipid metabolism dysfunction in a rat model of non‑alcoholic fatty liver disease via adenosine monophosphate‑activated protein kinase pathway activation. Mol Med Rep 2014; 10:1237-44. [PMID: 24927063 PMCID: PMC4121409 DOI: 10.3892/mmr.2014.2327] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2013] [Accepted: 06/11/2014] [Indexed: 12/23/2022] Open
Abstract
Oxidative stress and excess hepatic lipid accumulation contribute to non-alcoholic fatty liver disease. Radix Hedysari polysaccharides (RHP) have attracted interest due to their antioxidant properties and immunomodulatory effects. However, the effect of RHP on hepatic lipid metabolism remains to be elucidated. In the present study, the response of Sprague-Dawley rat livers to a high-fat diet and RHP treatment was investigated by evaluating body weight, liver histology, hepatic lipid content, adenosine monophosphate-activated protein kinase (AMPK) activity and lipid metabolism gene transcriptional profiles. The present study demonstrated that RHP ameliorated lipid metabolism disorders, regulated hepatic lipid content, improved liver inflammation and damage, activated AMPK via phosphorylation, upregulated peroxisome proliferator-activated receptor α and downregulated the mRNA expression of sterol regulatory element binding protein-1c in rat livers, which reduced lipogenesis and increased lipolysis. Taken together, these results suggested that RHP effectively ameliorates lipid metabolism disorders in rat livers; thus, RHP may be a potential therapeutic agent in the prevention of hepatic steatosis.
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Affiliation(s)
- Wei-Ming Sun
- Institute of Integrated Chinese and Western Medicine, School of Basic Medical Sciences, Lanzhou University, Lanzhou, Gansu 730000, P.R. China
| | - Yu-Ping Wang
- Key Laboratory for Gastrointestinal Diseases of Gansu Province, Lanzhou University, Lanzhou, Gansu 730000, P.R. China
| | - Yong-Qiang Duan
- Institute of Integrated Chinese and Western Medicine, School of Basic Medical Sciences, Lanzhou University, Lanzhou, Gansu 730000, P.R. China
| | - Hong-Xia Shang
- Department of Basic Courses, Gansu College of Traditional Chinese Medicine, Lanzhou, Gansu 730000, P.R. China
| | - Wei-Dong Cheng
- Institute of Integrated Chinese and Western Medicine, School of Basic Medical Sciences, Lanzhou University, Lanzhou, Gansu 730000, P.R. China
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156
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Munteanu MA, Mircea PA. From NAFLD to Cardiovascular Disease. Is it (Still) the Metabolic Syndrome? ACTA ACUST UNITED AC 2014; 87:80-6. [PMID: 26528002 PMCID: PMC4620846 DOI: 10.15386/cjmed-277] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2014] [Accepted: 06/04/2014] [Indexed: 12/28/2022]
Abstract
Non-alcoholic fatty liver disease (NAFLD) is the most prevalent liver disease in developed countries. The incidence of NAFLD in the general population is 30–38% deppending on the geographical area and the diagnostic method used. NAFLD is considered to be the liver manifestation of the metabolic syndrome. A better understanding of the natural evolution would have practical consequences related mainly to the need of early and aggressive diagnosis, active monitoring and therapeutic solutions. Cardiovascular disease appears to be the main cause of death in these patients. The mechanisms linking NAFLD with cardiovascular disease are not fully understood yet, but attention was focused primarily on insulin resistance. The visceral adipose tissue, the epicardial adipose tissue, the systemic inflammatory response syndrome, the lipid profile, the procoagulants factors, the oxidative stress, and type 2 diabetes mellitus, they all might play a role in the link between NAFLD and cardiovascular disease. Currently, there isn’t any medication specifically recommended for the treatment of NAFLD. Although the mechanisms underlying the association between NAFLD and cardiovascular disease are not fully known, attention must be paid to this association, given that these patients are more likely to die due to heart disease rather than liver disease.
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Affiliation(s)
- Mihai Alexandru Munteanu
- Department of Internal Medicine, 1 Medical Clinic - Internal Medicine, Cardiology and Gastroenterology, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania
| | - Petru Adrian Mircea
- Department of Internal Medicine, 1 Medical Clinic - Internal Medicine, Cardiology and Gastroenterology, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania
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157
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Takaki A, Kawai D, Yamamoto K. Molecular mechanisms and new treatment strategies for non-alcoholic steatohepatitis (NASH). Int J Mol Sci 2014; 15:7352-79. [PMID: 24786095 PMCID: PMC4057677 DOI: 10.3390/ijms15057352] [Citation(s) in RCA: 90] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2014] [Revised: 03/28/2014] [Accepted: 04/10/2014] [Indexed: 02/07/2023] Open
Abstract
Non-alcoholic steatohepatitis (NASH) is a severe form of non-alcoholic fatty liver disease (NAFLD), in which most patients exhibit non-progressive, non-alcoholic fatty liver (NAFL) attributable to simple steatosis. Multiple hits, including genetic differences, fat accumulation, insulin resistance and intestinal microbiota changes, account for the progression of NASH. NAFLD is strongly associated with obesity, which induces adipokine secretion, endoplasmic reticulum (ER) and oxidative stress at the cellular level, which in turn induces hepatic steatosis, inflammation and fibrosis. Among these factors, gut microbiota are acknowledged as having an important role in initiating this multifactorial disease. Oxidative stress is considered to be a key contributor in the progression from NAFL to NASH. Macrophage infiltration is apparent in NAFL and NASH, while T-cell infiltration is apparent in NASH. Although several clinical trials have shown that antioxidative therapy with vitamin E can effectively control hepatitis pathology in the short term, the long-term effects remain obscure and have often proved to be ineffective in many other diseases. Several long-term antioxidant protocols have failed to reduce mortality. New treatment modalities that incorporate current understanding of NAFLD molecular pathogenesis must be considered.
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Affiliation(s)
- Akinobu Takaki
- Department of Gastroenterology and Hepatology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, 2-5-1 Shikata-cho, Kita-ku, Okayama 700-8558, Japan.
| | - Daisuke Kawai
- Department of Gastroenterology and Hepatology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, 2-5-1 Shikata-cho, Kita-ku, Okayama 700-8558, Japan.
| | - Kazuhide Yamamoto
- Department of Gastroenterology and Hepatology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, 2-5-1 Shikata-cho, Kita-ku, Okayama 700-8558, Japan.
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158
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Abstract
The article is intended to provide an overview of the strengths and limits of controlled trials of pharmacologic treatment of nonalcoholic fatty liver disease. No drug has so far been approved, although validated on histologic outcomes. Several new drugs are under scrutiny, acting with different mechanisms along the chain of events from fatty liver to fibrosis, cirrhosis, and hepatocellular carcinoma. The article investigates which drug, if any, should be preferred for a tailored intervention in individual patients, according to age, comorbidities, and disease severity, and if treatment should be continued lifelong, to prevent disease progression and long-term occurrence of cirrhosis.
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159
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Holterman A, Gurria J, Tanpure S, DiSomma N. Nonalcoholic fatty liver disease and bariatric surgery in adolescents. Semin Pediatr Surg 2014; 23:49-57. [PMID: 24491369 DOI: 10.1053/j.sempedsurg.2013.10.016] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Obesity is a multi-organ system disease with underlying insulin resistance and systemic chronic inflammation. Nonalcoholic fatty liver disease (NAFLD) is a hepatic manifestation of the underlying metabolic dysfunction. This review provides a highlight of the current understanding of NAFLD pathogenesis and disease characteristics, with updates on the challenges of NAFLD management in obese and severely obese (SO) patients and recommendations for the pediatric surgeons' role in the care of SO adolescents.
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Affiliation(s)
- AiXuan Holterman
- Department of Surgery, University of Illinois College of Medicine, Peoria, Illinois; Pediatric Surgery, Children's Hospital of Illinois, University of Illinois College of Medicine, Peoria, Illinois.
| | - Juan Gurria
- Department of Surgery, University of Illinois College of Medicine, Peoria, Illinois
| | - Smita Tanpure
- Department of Surgery, University of Illinois College of Medicine, Peoria, Illinois; Pediatric Surgery, Children's Hospital of Illinois, University of Illinois College of Medicine, Peoria, Illinois
| | - Nerina DiSomma
- Department of Surgery, University of Illinois College of Medicine, Peoria, Illinois; Pediatric Surgery, Children's Hospital of Illinois, University of Illinois College of Medicine, Peoria, Illinois
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160
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Ohno T, Nishigaki Y, Yamada T, Wakahara Y, Sakai H, Yoshimura K, Shimizu M, Usui T, Saito M, Yasuda I, Tsurumi H, Tomita E, Moriwaki H. Effects of pioglitazone on nonalcoholic steatohepatitis in a patient with anorexia nervosa: A case report. Exp Ther Med 2014; 7:811-815. [PMID: 24669237 PMCID: PMC3961108 DOI: 10.3892/etm.2014.1509] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2013] [Accepted: 01/17/2014] [Indexed: 12/21/2022] Open
Abstract
Diseases associated with metabolic syndromes are of major concern in developed countries. Nonalcoholic steatohepatitis (NASH) is one of the manifestations of metabolic syndrome in the liver. Previous studies have shown that NASH is also caused by malnutrition. In the present study, a case of malnutrition-associated NASH in a 66-year-old female with anorexia nervosa is reported. The patient had a body mass index (BMI) of only 11.1 kg/m2 and serum alanine aminotransferase levels of 1,495 IU/l. Steatohepatitis with fibrosis was confirmed by percutaneous liver needle biopsy. Total parenteral nutrition was conducted at first, followed by the administration of Stronger Neo-Minophagen C (a glycyrrhizin-containing preparation), ursodeoxycholic acid and prednisolone. The abnormal elevation of aminotransferase levels of the patient was prolonged and total bilirubin levels increased. Pioglitazone (15 mg/day), which has been identified to be effective for nonalcoholic steatohepatitis, was then administered. This resulted in marked reductions in aminotransferase and bilirubin levels within three months. Histological improvement of the liver was also confirmed by percutaneous liver needle biopsy after one year. The observations in the present case suggest that pioglitazone may be useful for the treatment of malnutrition-associated NASH.
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Affiliation(s)
- Tomohiko Ohno
- Department of Medicine, Gifu University Graduate School of Medicine, Gifu 501-1194, Japan
| | - Yoichi Nishigaki
- Second Department of Internal Medicine, Gifu Municipal Hospital, Gifu 500-8513, Japan
| | - Tetsuya Yamada
- Department of Clinical Laboratory, Gifu Municipal Hospital, Gifu 500-8513, Japan
| | - Yuko Wakahara
- Department of Internal Medicine, Seki Central Hospital, Gifu 500-3919, Japan
| | - Hiroyasu Sakai
- Department of Medicine, Gifu University Graduate School of Medicine, Gifu 501-1194, Japan
| | - Kotaro Yoshimura
- Department of Internal Medicine, Seki Central Hospital, Gifu 500-3919, Japan
| | - Masahito Shimizu
- Department of Medicine, Gifu University Graduate School of Medicine, Gifu 501-1194, Japan
| | - Toshio Usui
- Department of Internal Medicine, Seki Central Hospital, Gifu 500-3919, Japan
| | - Masaya Saito
- Department of Internal Medicine, Seki Central Hospital, Gifu 500-3919, Japan
| | - Ichiro Yasuda
- Department of Medicine, Gifu University Graduate School of Medicine, Gifu 501-1194, Japan
| | - Hisashi Tsurumi
- Department of Medicine, Gifu University Graduate School of Medicine, Gifu 501-1194, Japan
| | - Eiichi Tomita
- Second Department of Internal Medicine, Gifu Municipal Hospital, Gifu 500-8513, Japan
| | - Hisataka Moriwaki
- Department of Medicine, Gifu University Graduate School of Medicine, Gifu 501-1194, Japan
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161
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Younossi ZM, Reyes MJ, Mishra A, Mehta R, Henry L. Systematic review with meta-analysis: non-alcoholic steatohepatitis - a case for personalised treatment based on pathogenic targets. Aliment Pharmacol Ther 2014; 39:3-14. [PMID: 24206433 DOI: 10.1111/apt.12543] [Citation(s) in RCA: 60] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2013] [Revised: 08/06/2013] [Accepted: 10/11/2013] [Indexed: 02/06/2023]
Abstract
BACKGROUND Non-alcoholic fatty liver disease (NAFLD) is an umbrella term, which encompasses simple steatosis and non-alcoholic steatohepatitis (NASH). The entire spectrum of NAFLD has been associated with metabolic syndrome. NASH is associated with increased mortality compared with that of the general population. Many therapeutic options for NASH have been studied. However, there is very little evidence supporting the efficacy of most regimens for the treatment of NASH. AIM To provide a review focusing on the current therapeutic options available for patients with NASH as well as to briefly introduce possible future interventions. METHODS A MEDLINE, Pubmed and Cochrane Review database search using a combination of keywords, which included non-alcoholic fatty liver disease, non-alcoholic hepatic steatosis, NAFLD, NASH, treatment, therapeutics, vitamin E, orlistat and bariatric surgery. An overall summary of the articles was developed for each section of discussion in this review. RESULTS NASH associated with metabolic syndrome can progress advanced fibrosis and cirrhosis. Weight loss and lifestyle modification have been shown to improve NASH. Other medications used for weight loss and metabolic syndrome have been evaluated, such as orlistat, metformin and thiazolidinediones. Alternative regimens using ursodeoxycholic acid, statins and probiotics as well as bariatric surgery have been evaluated, but have not been recommended as first-line treatment for NASH. Vitamin E for NASH patients without diabetes seems to be promising. The lack of effective treatment for NASH suggests the heterogeneity of patients presenting with the NASH phenotype. The best treatment strategy for these patients may be to identify their pathogenic target and develop personalised treatment protocols. CONCLUSIONS Currently, there are few options available for the management of NASH. Future targeted treatment strategies based on the pathogenic pathways may be needed to develop effective treatment for patients with NASH.
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Affiliation(s)
- Z M Younossi
- Department of Medicine, Center for Liver Diseases, Inova Fairfax Hospital, Falls Church, VA, USA; Betty and Guy Beatty Center for Integrated Research, Inova Health System, Falls Church, VA, USA
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162
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KASL clinical practice guidelines: management of nonalcoholic fatty liver disease. Clin Mol Hepatol 2013; 19:325-48. [PMID: 24459637 PMCID: PMC3894432 DOI: 10.3350/cmh.2013.19.4.325] [Citation(s) in RCA: 93] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2013] [Accepted: 11/07/2013] [Indexed: 02/06/2023] Open
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163
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Abstract
The rationale for specific pharmacologic therapy in nonalcoholic steatohepatitis (NASH) is determined by the potential for disease progression and the difficulties, in many patients, to successfully implement diet and lifestyle changes in the long term. Because they correct insulin resistance, insulin-sensitizing agents are attractive candidates for the treatment of NASH. However, two randomized studies have shown that vitamin E, despite having no effect on insulin sensitivity, achieves interesting histological and biochemical efficacy. This review provides an insight into the therapeutic efficacy and safety issues of different pharmacological agents tested in human NASH.
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Affiliation(s)
- Maeva Guillaume
- Service d'Hépatologie et Gastro-entérologie, INSERM 1048 and Université Paul Sabatier, Hôpital Purpan, Centre Hospitalier Universitaire de Toulouse, Toulouse, France. .,Service d'Hépatologie et Gastro-entérologie, Hôpital Purpan, Pavillon Dieulafoy, 4ème étage, Place du Docteur Baylac, TSA 40031, 31059, Toulouse Cedex 9, France.
| | - Vlad Ratziu
- INSERM U938, Hospital Pitié Salpêtrière, CdR Saint-Antoine and Université Pierre et Marie Curie, Paris, France. .,Service d'Hépatologie et Gastro-entérologie, Hôpital Pitié-Salpêtrière, 47-83, Boulevard de l'hôpital, 75651, Paris Cedex 13, France.
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164
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Abstract
NASH is a common liver disease that increases liver-related mortality and reduces survival. The need for optimal management of NASH is therefore a priority for today's practicing hepatologist. The rationale for specific pharmacological therapy for NASH is based on the potential for disease progression and the difficulties that many patients have successfully implementing, in the long term, diet and lifestyle changes. Even in those that succeed, limited evidence exists that severe liver injury in patients with NASH can be reversed by diet and lifestyle measures alone. This Review provides a personal and critical assessment of the histological efficacy and safety of agents tested in randomized trials in patients with NASH.
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Affiliation(s)
- Vlad Ratziu
- Department of Hepatology and Gastroenterology, Hôpital Pitié Salpêtrière, 47-83 Boulevard de l'Hôpital, CdR Saint-Antoine, Paris 75651, France.
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165
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Takaki A, Kawai D, Yamamoto K. Multiple hits, including oxidative stress, as pathogenesis and treatment target in non-alcoholic steatohepatitis (NASH). Int J Mol Sci 2013; 14:20704-28. [PMID: 24132155 PMCID: PMC3821639 DOI: 10.3390/ijms141020704] [Citation(s) in RCA: 293] [Impact Index Per Article: 26.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2013] [Revised: 09/18/2013] [Accepted: 09/29/2013] [Indexed: 12/12/2022] Open
Abstract
Multiple parallel hits, including genetic differences, insulin resistance and intestinal microbiota, account for the progression of non-alcoholic steatohepatitis (NASH). Multiple hits induce adipokine secretion, endoplasmic reticulum (ER) and oxidative stress at the cellular level that subsequently induce hepatic steatosis, inflammation and fibrosis, among which oxidative stress is considered a key contributor to progression from simple fatty liver to NASH. Although several clinical trials have shown that anti-oxidative therapy can effectively control hepatitis activities in the short term, the long-term effect remains obscure. Several trials of long-term anti-oxidant protocols aimed at treating cerebrovascular diseases or cancer development have failed to produce a benefit. This might be explained by the non-selective anti-oxidative properties of these drugs. Molecular hydrogen is an effective antioxidant that reduces only cytotoxic reactive oxygen species (ROS) and several diseases associated with oxidative stress are sensitive to hydrogen. The progress of NASH to hepatocellular carcinoma can be controlled using hydrogen-rich water. Thus, targeting mitochondrial oxidative stress might be a good candidate for NASH treatment. Long term clinical intervention is needed to control this complex lifestyle-related disease.
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Affiliation(s)
- Akinobu Takaki
- Department of Gastroenterology and Hepatology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, 2-5-1 Shikata-cho, Kita-ku, Okayama City, Okayama 700-8558, Japan.
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166
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Sumida Y, Niki E, Naito Y, Yoshikawa T. Involvement of free radicals and oxidative stress in NAFLD/NASH. Free Radic Res 2013; 47:869-80. [PMID: 24004441 DOI: 10.3109/10715762.2013.837577] [Citation(s) in RCA: 211] [Impact Index Per Article: 19.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Non-alcoholic fatty liver disease (NAFLD) is now the most common liver disease affecting high proportion of the population worldwide. NAFLD encompasses a large spectrum of conditions ranging from fatty liver to non-alcoholic steatohepatitis (NASH), which can progress to cirrhosis and cancer. NAFLD is considered as a multifactorial disease in relation to the pathogenic mechanisms. Oxidative stress has been implicated in the pathogenesis of NAFLD and NASH and the involvement of reactive oxygen species (ROS) has been suggested. Many studies show the association between the levels of lipid oxidation products and disease state. However, often neither oxidative stress nor ROS has been characterized, despite oxidative stress is mediated by multiple active species by different mechanisms and the same lipid oxidation products are produced by different active species. Further, the effects of various antioxidants have been assessed in human and animal studies, but the effects of drugs are determined by the type of active species, suggesting the importance of characterizing the active species involved. This review article is focused on the role of free radicals and free radical-mediated lipid peroxidation in the pathogenesis of NAFLD and NASH, taking characteristic features of free radical-mediated oxidation into consideration. The detailed analysis of lipid oxidation products shows the involvement of free radicals in the pathogenesis of NAFLD and NASH. Potential beneficial effects of antioxidants such as vitamin E are discussed.
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Affiliation(s)
- Y Sumida
- Department of Gastroenterology and Hepatology, Kyoto Prefectural University of Medicine , Kyoto , Japan
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167
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The role of ursodeoxycholic acid in non-alcoholic steatohepatitis: a systematic review. BMC Gastroenterol 2013; 13:140. [PMID: 24053454 PMCID: PMC3848865 DOI: 10.1186/1471-230x-13-140] [Citation(s) in RCA: 77] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2012] [Accepted: 09/17/2013] [Indexed: 12/11/2022] Open
Abstract
Background Non-alcoholic steatohepatitis (NASH) is a condition that occurs during the progression of non-alcoholic fatty liver disease. Effective therapy for NASH is still lacking. In this study, we investigated the effects of Ursodeoxycholic acid (UDCA) in the treatment of NASH. Methods Western and Chinese databases were searched by independent investigators using appropriate MESH headings to identify randomized, controlled Western and Chinese clinical trials, published between January 1990 and October 2012, testing the effects of UDCA in patients with NASH. Patient characteristics and trial endpoints were analyzed, with quality assessment according to widely acknowledged criteria. P < 0.05 was defined as statistically significant in all trials. Results Twelve qualified randomized clinical trials, including six from China and involving 1160 subjects, were selected. Seven of these trials assessed the effects of UDCA Monotherapy, with the other five testing combinations of UDCA with vitamin E, polyene phosphatidylcholine, silymarin, glycyrrhizin and tiopronin. The duration of therapy ranged from 3 to 24 months, with two studies using high doses of UDCA (23–35 mg/kg/d). The average quality point was 2.69, and was significantly lower in articles from China than in those from Western countries (2.2 ± 0.4 vs. 3.8 ± 1.1, respectively, p < 0.05). UDCA Monotherapy significantly improved liver function in five studies and improved steatosis and fibrosis in two studies. All five studies assessing UDCA combination therapy showed significant improvements liver function, while two studies also improved steatosis and inflammation. One study of high-dose UDCA showed significant improvements in ALT, γGT and liver fibrosis, whereas the other study showed no significant change in ALT and liver pathology. Conclusions UDCA therapy is effective in NASH, especially when combined with other drugs. However, the low quality of these studies and the heterogeneity of their results precluded further meta-analysis. Additional carefully designed clinical trials are needed, especially in China.
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Mudaliar S, Henry RR, Sanyal AJ, Morrow L, Marschall HU, Kipnes M, Adorini L, Sciacca CI, Clopton P, Castelloe E, Dillon P, Pruzanski M, Shapiro D. Efficacy and safety of the farnesoid X receptor agonist obeticholic acid in patients with type 2 diabetes and nonalcoholic fatty liver disease. Gastroenterology 2013; 145:574-82.e1. [PMID: 23727264 DOI: 10.1053/j.gastro.2013.05.042] [Citation(s) in RCA: 695] [Impact Index Per Article: 63.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2013] [Revised: 04/30/2013] [Accepted: 05/22/2013] [Indexed: 02/06/2023]
Abstract
BACKGROUND & AIMS Obeticholic acid (OCA; INT-747, 6α-ethyl-chenodeoxycholic acid) is a semisynthetic derivative of the primary human bile acid chenodeoxycholic acid, the natural agonist of the farnesoid X receptor, which is a nuclear hormone receptor that regulates glucose and lipid metabolism. In animal models, OCA decreases insulin resistance and hepatic steatosis. METHODS We performed a double-blind, placebo-controlled, proof-of-concept study to evaluate the effects of OCA on insulin sensitivity in patients with nonalcoholic fatty liver disease and type 2 diabetes mellitus. Patients were randomly assigned to groups given placebo (n = 23), 25 mg OCA (n = 20), or 50 mg OCA (n = 21) once daily for 6 weeks. A 2-stage hyperinsulinemic-euglycemic insulin clamp was used to measure insulin sensitivity before and after the 6-week treatment period. We also measured levels of liver enzymes, lipid analytes, fibroblast growth factor 19, 7α-hydroxy-4-cholesten-3-one (a BA precursor), endogenous bile acids, and markers of liver fibrosis. RESULTS When patients were given a low-dose insulin infusion, insulin sensitivity increased by 28.0% from baseline in the group treated with 25 mg OCA (P = .019) and 20.1% from baseline in the group treated with 50 mg OCA (P = .060). Insulin sensitivity increased by 24.5% (P = .011) in combined OCA groups, whereas it decreased by 5.5% in the placebo group. A similar pattern was observed in patients given a high-dose insulin infusion. The OCA groups had significant reductions in levels of γ-glutamyltransferase and alanine aminotransferase and dose-related weight loss. They also had increased serum levels of low-density lipoprotein cholesterol and fibroblast growth factor 19, associated with decreased levels of 7α-hydroxy-4-cholesten-3-one and endogenous bile acids, indicating activation of farnesoid X receptor. Markers of liver fibrosis decreased significantly in the group treated with 25 mg OCA. Adverse experiences were similar among groups. CONCLUSIONS In this phase 2 trial, administration of 25 or 50 mg OCA for 6 weeks was well tolerated, increased insulin sensitivity, and reduced markers of liver inflammation and fibrosis in patients with type 2 diabetes mellitus and nonalcoholic fatty liver disease. Longer and larger studies are warranted. ClinicalTrials.gov, Number: NCT00501592.
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Tomeno W, Yoneda M, Imajo K, Ogawa Y, Kessoku T, Saito S, Eguchi Y, Nakajima A. Emerging drugs for non-alcoholic steatohepatitis. Expert Opin Emerg Drugs 2013; 18:279-90. [PMID: 23848366 DOI: 10.1517/14728214.2013.811232] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
INTRODUCTION The prevalence of non-alcoholic fatty liver disease (NAFLD) and non-alcoholic steatohepatitis (NASH) is increasing along with the worldwide epidemic of obesity and their strong association with metabolic syndrome. Currently existing pharmacological therapies include anti-oxidants, insulin-sensitizing agents, lipid-lowering drugs and cytoprotective agents, but there is a lack of consensus regarding the most effective and appropriate pharmacologic therapies for NASH. Clinical trials examining new therapeutic drugs for NASH that act via various mechanisms are being performed in several countries, and these drugs may strongly influence current NASH treatment. AREAS COVERED This article provides a review of recent data on the safety and efficacy of existing and emerging agents for the treatment of NASH. EXPERT OPINION Ideally, treatment for NASH should not only improve liver disease, but also reduce the risks of adverse cardiovascular outcomes and the development of diabetes and cancers. However, this goal is likely to be too high in the context of clinical trials designed to obtain approval for the treatment of liver disease. The only way to achieve the goal is to accumulate the results of these relatively short-term clinical trials.
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Affiliation(s)
- Wataru Tomeno
- Yokohama City University Graduate School of Medicine, Division of Gastroenterology, 3-9 Fuku-ura, Yokohama, Japan
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Chang E, Park CY, Park SW. Role of thiazolidinediones, insulin sensitizers, in non-alcoholic fatty liver disease. J Diabetes Investig 2013; 4:517-24. [PMID: 24843703 PMCID: PMC4020244 DOI: 10.1111/jdi.12107] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2013] [Revised: 03/18/2013] [Accepted: 03/26/2013] [Indexed: 12/22/2022] Open
Abstract
The prevalence of metabolic syndrome, obesity and insulin resistance has become an epidemic in the world. A strong association exists between metabolic syndrome and non-alcoholic fatty liver disease (NAFLD), though the etiology of NAFLD is still unclear. This close association leads to numerous clinical studies to investigate the effects of insulin sensitizers, thiazolidinediones (TZDs), on hepatic fat accumulation. Thiazolidinediones affect glucose and lipid metabolism in insulin-sensitive tissues, which in turn reduces the lipid content in the liver by modulating several mediators. In the present review, we discuss key modulators - adiponectin and sirtulin-adenosine monophosphate activated protein kinase signaling - as the mechanisms responsible for NAFLD related to metabolic syndrome.
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Affiliation(s)
- Eugene Chang
- Diabetes Research Institute Kangbuk Samsung Hospital Sungkyunkwan University School of Medicine Seoul Korea
| | - Cheol-Young Park
- Division of Endocrinology and Metabolism Department of Internal Medicine Kangbuk Samsung Hospital Sungkyunkwan University School of Medicine Seoul Korea
| | - Sung Woo Park
- Division of Endocrinology and Metabolism Department of Internal Medicine Kangbuk Samsung Hospital Sungkyunkwan University School of Medicine Seoul Korea
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Vajro P, Paolella G, Pierri L, D'Aniello R. Treatment of NASH with ursodeoxycholic acid: pros and cons. More information in children. Clin Res Hepatol Gastroenterol 2013; 37:e93-4. [PMID: 23562789 DOI: 10.1016/j.clinre.2013.02.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2013] [Accepted: 02/20/2013] [Indexed: 02/06/2023]
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Ahmad Z, Subramanyam L, Szczepaniak L, Simha V, Adams-Huet B, Garg A. Cholic acid for hepatic steatosis in patients with lipodystrophy: a randomized, controlled trial. Eur J Endocrinol 2013; 168:771-8. [PMID: 23447519 PMCID: PMC3902034 DOI: 10.1530/eje-12-0969] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVE Hepatic steatosis is a common complication in patients with lipodystrophies and can lead to cirrhosis. There is no proven effective therapy for hepatic steatosis, but cholic acid (CA), a farnesoid X receptor agonist, has previously been shown to reduce hepatic triglyceride (TG) content in mice and serum TG in humans. Our objective was to assess clinical efficacy and tolerability of CA therapy in patients with lipodystrophy and hepatic steatosis. DESIGN A randomized, double-blind, placebo-controlled, crossover study. METHODS Eighteen patients with genetic or autoimmune lipodystrophies and elevated hepatic TG content participated in the study. The intervention was CA (15 mg/kg per day) compared with placebo for a period of 6 months each. Hepatic TG content, the primary outcome variable, was measured with (1)H magnetic resonance spectroscopy at baseline and at 3 and 6 months during each study period. Levels of serum alanine aminotransferase (ALT), aspartate aminotransferase (AST), gamma-glutamyl transpeptidase (GGT), and TG were secondary end points of the study. RESULTS Compared with placebo, CA did not reduce (median (interquartile range) hepatic TG content (14.8% (9.4-19.0%) vs 15.9% (10.5-26.5%) respectively; P=0.42) or serum TG ((340 mg/dl (233-433 mg/dl) vs 390 mg/dl (233-595 mg/dl) respectively; P=0.45)). CA therapy also did not change AST, ALT, or GGT levels. Two patients developed diarrhea and excessive flatus while taking CA and these symptoms resolved after reducing the dose of CA. CONCLUSION CA was well tolerated but did not reduce hepatic TG content in patients with lipodystrophy.
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Affiliation(s)
- Zahid Ahmad
- Division of Nutrition and Metabolic Diseases, Center for Human Nutrition, UT Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX 75390
- Department of Internal Medicine, UT Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX 75390
| | - Lalitha Subramanyam
- Division of Nutrition and Metabolic Diseases, Center for Human Nutrition, UT Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX 75390
| | - Lidia Szczepaniak
- Department of Internal Medicine, UT Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX 75390
| | - Vinaya Simha
- Division of Nutrition and Metabolic Diseases, Center for Human Nutrition, UT Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX 75390
| | - Beverley Adams-Huet
- Department of Clinical Sciences, UT Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX 75390
- Department of Internal Medicine, UT Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX 75390
| | - Abhimanyu Garg
- Division of Nutrition and Metabolic Diseases, Center for Human Nutrition, UT Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX 75390
- Department of Internal Medicine, UT Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX 75390
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Mavrogiannaki AN, Migdalis IN. Nonalcoholic Fatty liver disease, diabetes mellitus and cardiovascular disease: newer data. Int J Endocrinol 2013; 2013:450639. [PMID: 23653642 PMCID: PMC3638654 DOI: 10.1155/2013/450639] [Citation(s) in RCA: 55] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2013] [Accepted: 03/12/2013] [Indexed: 02/07/2023] Open
Abstract
Nonalcoholic fatty liver disease (NAFLD) is the most common, chronic liver disease worldwide. Within this spectrum, steatosis alone is apparently benign, while nonalcoholic steatohepatitis may progress to cirrhosis and hepatocellular carcinoma. NAFLD is strongly associated with obesity, dyslipidemia, type 2 diabetes mellitus, and cardiovascular disease. The pathogenesis of hepatic steatosis is not clearly known, but its main characteristics are considered insulin resistance, mitochondrial dysfunction, increased free fatty acids reflux from adipose tissue to the liver, hepatocyte lipotoxicity, stimulation of chronic necroinflammation, and fibrogenic response. With recent advances in technology, advanced imaging techniques provide important information for diagnosis. There is a significant research effort in developing noninvasive monitoring of disease progression to fibrosis and response to therapy with potential novel biomarkers, in order to facilitate diagnosis for the detection of advanced cirrhosis and to minimize the need of liver biopsy. The identification of NAFLD should be sought as part of the routine assessment of type 2 diabetics, as sought the microvascular complications and cardiovascular disease, because it is essential for the early diagnosis and proper intervention. Diet, exercise training, and weight loss provide significant clinical benefits and must be considered of first line for treating NAFLD.
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Affiliation(s)
- A. N. Mavrogiannaki
- 2nd Medical Department and Diabetes Center, NIMTS Hospital, 12 Monis Petraki, 11521 Athens, Greece
| | - I. N. Migdalis
- 2nd Medical Department and Diabetes Center, NIMTS Hospital, 12 Monis Petraki, 11521 Athens, Greece
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Xiao J, Guo R, Fung ML, Liong EC, Tipoe GL. Therapeutic approaches to non-alcoholic fatty liver disease: past achievements and future challenges. Hepatobiliary Pancreat Dis Int 2013; 12:125-35. [PMID: 23558065 DOI: 10.1016/s1499-3872(13)60021-1] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND Non-alcoholic fatty liver disease (NAFLD) is a leading cause of chronic liver injury and mortality in Western countries and China. However, as to date, there is no direct and effective therapy for this disease. The aim of this review is to analyze the key progress and challenges of main current therapeutic approaches in NAFLD. DATA SOURCE We carried out a PubMed search of English-language articles relevant to NAFLD therapy. RESULTS There are two major therapeutic strategies for NAFLD treatment: (1) lifestyle interventions (including weight reduction, dietary modification and physical exercise) and (2) pharmaceutical therapies. Lifestyle interventions, particularly chronic and moderate intensity exercise, are the most effective and recognized clinical therapies for NAFLD. For pharmaceutical therapies, although their effects and mechanisms have been extensively investigated in laboratory studies, they still need further tests and investigations in clinical human trials. CONCLUSION Future advancement of NAFLD therapy should focus on the mechanistic studies on cell based and animal models and human clinical trials of exercise, as well as the combination of lifestyle intervention and pharmaceutical therapy specifically targeting main signaling pathways related to lipid metabolism, oxidative stress and inflammation.
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Affiliation(s)
- Jia Xiao
- Department of Anatomy, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong, China
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175
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Williams KH, Shackel NA, Gorrell MD, McLennan SV, Twigg SM. Diabetes and nonalcoholic Fatty liver disease: a pathogenic duo. Endocr Rev 2013; 34:84-129. [PMID: 23238855 DOI: 10.1210/er.2012-1009] [Citation(s) in RCA: 168] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Recent data increasingly support a complex interplay between the metabolic condition diabetes mellitus and the pathologically defined nonalcoholic fatty liver disease (NAFLD). NAFLD predicts the development of type 2 diabetes and vice versa, and each condition may serve as a progression factor for the other. Although the association of diabetes and NAFLD is likely to be partly the result of a "common soil," it is also probable that diabetes interacts with NAFLD through specific pathogenic mechanisms. In particular, through interrelated metabolic pathways currently only partly understood, diabetes appears to accelerate the progression of NAFLD to nonalcoholic steatohepatitis, defined by the presence of necroinflammation, with varying degrees of liver fibrosis. In the research setting, obstacles that have made the identification of clinically significant NAFLD, and particularly nonalcoholic steatohepatitis, difficult are being addressed with the use of new imaging techniques combined with risk algorithms derived from peripheral blood profiling. These techniques are likely to be used in the diabetes population in the near future. This review examines the pathogenic links between NAFLD and diabetes by exploring the epidemiological evidence in humans and also through newer animal models. Emerging technology to help screen noninvasively for differing pathological forms of NAFLD and the potential role of preventive and therapeutic approaches for NAFLD in the setting of diabetes are also examined.
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Affiliation(s)
- K H Williams
- Sydney Medical School and the Bosch Institute, The University of Sydney, Sydney, New South Wales 2006, Australia
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176
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Masuoka HC, Chalasani N. Nonalcoholic fatty liver disease: an emerging threat to obese and diabetic individuals. Ann N Y Acad Sci 2013; 1281:106-22. [PMID: 23363012 PMCID: PMC3646408 DOI: 10.1111/nyas.12016] [Citation(s) in RCA: 194] [Impact Index Per Article: 17.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Nonalcoholic fatty liver disease (NAFLD) is the most common liver disease in the Western world and its incidence is increasing rapidly. NAFLD is a spectrum ranging from simple steatosis, which is relatively benign hepatically, to nonalcoholic steatohepatitis (NASH), which can progress to cirrhosis. Obesity, insulin resistance, type 2 diabetes mellitus, and dyslipidemia are the most important risk factors for NAFLD. Due to heavy enrichment with metabolic risk factors, individuals with NAFLD are at significantly higher risk for cardiovascular disease. Individuals with NAFLD have higher incidence of type 2 diabetes. The diagnosis of NAFLD requires imaging evidence of hepatic steatosis in the absence of competing etiologies including significant alcohol consumption. Liver biopsy remains the gold standard for diagnosing NASH and for determining prognosis. Weight loss remains a cornerstone of treatment. Weight loss of ∼5% is believed to improve steatosis, whereas ∼10% weight loss is necessary to improve steatohepatitis. A number of pharmacologic therapies have been investigated to treat NASH, and agents such as vitamin E and thiazolidinediones have shown promise in select patient subgroups.
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Affiliation(s)
- Howard C Masuoka
- Division of Gastroenterology and Hepatology, Department of Medicine, Indiana University School of Medicine, Indianapolis, IN 46202, USA
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Malinowski SS, Byrd JS, Bell AM, Wofford MR, Riche DM. Pharmacologic therapy for nonalcoholic fatty liver disease in adults. Pharmacotherapy 2013; 33:223-42. [PMID: 23359475 DOI: 10.1002/phar.1190] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Nonalcoholic fatty liver disease (NAFLD) is characterized by the accumulation of triglycerides in hepatocytes in the absence of excessive alcohol intake, ranging in severity from simple steatosis to nonalcoholic steatohepatitis (NASH). Nonalcoholic steatohepatitis can ultimately progress to cirrhosis and hepatocellular carcinoma. NAFLD is associated with cardiometabolic risk factors and is the most common chronic liver disease among adults in the Western Hemisphere. Although simple steatosis is generally considered a self-limiting disease, evidence suggests an increased risk of cardiovascular disease, and, less conclusively, mortality, among individuals with NAFLD and/or NASH. The current standard of care for the treatment of patients with NAFLD focuses on lifestyle interventions, particularly diet and exercise. There is a lack of consensus regarding the most effective and appropriate pharmacologic therapy. A PubMed search was conducted using the medical subject heading terms "fatty liver" and "steatohepatitis." This review focuses on the current pharmacologic options available for treating adults with NAFLD and/or NASH. Continued investigation of drugs or combinations that improve NAFLD progression is crucial. Clinicians, particularly pharmacists, must take an active role in identification and appropriate selection of pharmacotherapy for NAFLD.
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Affiliation(s)
- Scott S Malinowski
- Department of Pharmacy Practice, School of Pharmacy, University of Mississippi, Jackson, USA
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178
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Rahimi RS, Landaverde C. Nonalcoholic fatty liver disease and the metabolic syndrome: clinical implications and treatment. Nutr Clin Pract 2013; 28:40-51. [PMID: 23286927 DOI: 10.1177/0884533612470464] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
The prevalence of nonalcoholic fatty liver disease (NAFLD) is expected to rise along with the global obesity epidemic. As NAFLD is the most common cause of chronic liver disease in the United States, it has become a major health concern. It affects all ethnicities, with the highest prevalence among the Hispanic population. Individuals with nonalcoholic steatohepatitis (NASH), the more serious form of NAFLD, are at increased risk of developing cirrhosis, hepatic decompensation, and hepatocellular carcinoma. Since NAFLD is intricately associated with the metabolic syndrome and insulin resistance, increased risk of cardiovascular disease and mortality become a real concern. It has recently been shown that current nutrition trends, such as increased consumption of high-fructose corn syrup and certain types of fats, may have an important role in the increased NAFLD prevalence. As there are no ideal treatment options available for NAFLD, a multifaceted treatment approach should be tailored to each individual patient.
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Affiliation(s)
- Robert S Rahimi
- Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas, TX 75246, USA
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179
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Cho T, Kim YJ, Paik SS. The efficacy of pharmacological treatment in pediatric nonalcoholic Fatty liver disease. Pediatr Gastroenterol Hepatol Nutr 2012; 15:256-65. [PMID: 24010096 PMCID: PMC3746059 DOI: 10.5223/pghn.2012.15.4.256] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2012] [Revised: 09/17/2012] [Accepted: 09/24/2012] [Indexed: 01/08/2023] Open
Abstract
PURPOSE With growing number of obese children, the prevalence of nonalcoholic fatty liver disease (NAFLD) in pediatric population is increasing. Nonalcoholic steatohepatitis (NASH) is a severe form of NAFLD, and can cause morbid complications. It is important to identify patients in order to grade pathologic severities and treat those children who possibly have NASH. This study was performed to evaluate whether the pharmacological therapy is also effective as well as the body weight reduction in pediatric NAFLD. METHODS Among the 52 children presenting with obesity and hepatopathy, NAFLD was diagnosed through liver biopsy in 29 children, who were 7 to 14 years of age, from January 2006 to December 2011. The patients were advised to reduce their body weight through diverse methods. Medication with Ursodeoxycholic acid (UDCA) and vitamin E was performed in children whose liver functions did not improve or their weight reductions were not successful. The therapeutic effects were monitored and assessed via the biochemical profiles and the physical measurements. RESULTS The therapy of vitamin E and UDCA combined with body mass index (BMI) reduction showed significantly higher rate of improvement in clinical profiles, which could be seen in data of aspartate aminotransferase (AST), alanine aminotransferase (ALT), AST/ALT ratio, alkaline phosphatase, total bilirubin and γ-glutamyl transpeptidase. Children whose BMI were successfully reduced showed favorable clinical improvements without any medication, but those without BMI reduction did not show any improvement despite medications. CONCLUSION This study showed that the first line of therapy should be the BMI reduction in NAFLD and drug therapy combined with BMI reduction could have additive therapeutic effect in children with NAFLD.
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Affiliation(s)
- Taeshik Cho
- Department of Pediatrics, Hanyang University College of Medicine, Seoul, Korea
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180
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Yilmaz Y. Review article: is non-alcoholic fatty liver disease a spectrum, or are steatosis and non-alcoholic steatohepatitis distinct conditions? Aliment Pharmacol Ther 2012; 36:815-23. [PMID: 22966992 DOI: 10.1111/apt.12046] [Citation(s) in RCA: 144] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2012] [Revised: 08/17/2012] [Accepted: 08/22/2012] [Indexed: 12/12/2022]
Abstract
BACKGROUND Non-alcoholic fatty liver disease (NAFLD) is currently conceptualised as a clinical spectrum that results from a ‘multiple-hit’ process which begins with simple steatosis and subsequently renders the hepatocytes susceptible to a variety of insults. Ultimately, more serious liver injuries like non-alcoholic steatohepatitis (NASH) and cirrhosis may develop. Although the metabolic syndrome is considered the crucial player in the pathogenesis of NAFLD, recent studies have highlighted novel pathophysiological mechanisms in this clinical entity. AIM To discuss the pathophysiology of NAFLD based on the hypothesis that simple steatosis and NASH are discrete entities rather than two points on a spectrum. METHODS A literature search was conducted in August 2012 on PubMed, Ovid Embase, Ovid Medline and Scopus using the following search terms: steatosis, non-alcoholic steatohepatitis, pathophysiology, fatty liver, natural history and genetics. RESULTS Simple steatosis and NASH appear as two distinct pathophysiological entities and progression from pure fatty liver to NASH appears to be so rare as to warrant publication. The possible pathogenetic pathways specifically related to NASH are highlighted. CONCLUSIONS Although simple steatosis and non-alcoholic steatohepatitis are currently viewed as two histological subtypes of the unique spectrum of non-alcoholic fatty liver disease, the two conditions are likely distinct not only from a histological but also from a pathophysiological standpoint. Efforts to distinguish simple steatosis from non-alcoholic steatohepatitis using non-invasive modalities should be informed by the current pathophysiology of these two clinical entities.
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Affiliation(s)
- Y Yilmaz
- Institute of Gastroenterology, Marmara University, Maltepe, Istanbul, Turkey.
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181
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Abstract
The aim of this study was to evaluate the effects of ursodeoxycholic acid on patients with nonalcoholic steatohepatitis using meta-analysis. PubMed, EMBASE, Web of Science, Cochrane Library, Chinese Biomedical Databases, and article references were searched. We included randomized controlled trials using liver biopsy as a reference standard. We identified three eligible studies. Among histological responses, only lobular inflammation improved in the high-dose ursodeoxycholic acid subgroup compared with the control group [mean deviation (MD): -0.23 (-0.40, -0.06), P=0.008]. However, fibrosis may tend to increase [MD: 0.08 (-0.04, 0.20), P=0.17]. Among biochemical responses, γ-glutamyl transpeptidase reduction was significantly greater in the ursodeoxycholic acid group than in the placebo group, and the reduction tendency was only shown in the high-dose subgroup [MD: -35.58 (-52.60, -18.56), P<0.0001]. Serum total bilirubin increased in the high-dose ursodeoxycholic acid subgroup compared with the control group [MD: 0.43 (0.14, 0.72), P=0.004]. Ursodeoxycholic acid-treated patients did not differ significantly from control patients with regard to alanine transaminase, aspartate aminotransferase, and alkaline phosphatase activities. Adverse events were nonspecific and considered of no major clinical relevance. Ursodeoxycholic acid in monotherapy has no substantial positive effect on nonalcoholic steatohepatitis.
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Nie B, Park HM, Kazantzis M, Lin M, Henkin A, Ng S, Song S, Chen Y, Tran H, Lai R, Her C, Maher JJ, Forman BM, Stahl A. Specific bile acids inhibit hepatic fatty acid uptake in mice. Hepatology 2012; 56:1300-10. [PMID: 22531947 PMCID: PMC3445775 DOI: 10.1002/hep.25797] [Citation(s) in RCA: 55] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
UNLABELLED Bile acids are known to play important roles as detergents in the absorption of hydrophobic nutrients and as signaling molecules in the regulation of metabolism. We tested the novel hypothesis that naturally occurring bile acids interfere with protein-mediated hepatic long chain free fatty acid (LCFA) uptake. To this end, stable cell lines expressing fatty acid transporters as well as primary hepatocytes from mouse and human livers were incubated with primary and secondary bile acids to determine their effects on LCFA uptake rates. We identified ursodeoxycholic acid (UDCA) and deoxycholic acid (DCA) as the two most potent inhibitors of the liver-specific fatty acid transport protein 5 (FATP5). Both UDCA and DCA were able to inhibit LCFA uptake by primary hepatocytes in a FATP5-dependent manner. Subsequently, mice were treated with these secondary bile acids in vivo to assess their ability to inhibit diet-induced hepatic triglyceride accumulation. Administration of DCA in vivo via injection or as part of a high-fat diet significantly inhibited hepatic fatty acid uptake and reduced liver triglycerides by more than 50%. CONCLUSION The data demonstrate a novel role for specific bile acids, and the secondary bile acid DCA in particular, in the regulation of hepatic LCFA uptake. The results illuminate a previously unappreciated means by which specific bile acids, such as UDCA and DCA, can impact hepatic triglyceride metabolism and may lead to novel approaches to combat obesity-associated fatty liver disease.
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Affiliation(s)
- Biao Nie
- Department of Nutritional Science and Toxicology, University of California Berkeley, Berkeley, CA 94720
| | - Hyo Min Park
- Department of Nutritional Science and Toxicology, University of California Berkeley, Berkeley, CA 94720
| | - Melissa Kazantzis
- Department of Nutritional Science and Toxicology, University of California Berkeley, Berkeley, CA 94720
| | - Min Lin
- Diabetes Center, City of Hope, 1500 East Duarte Road, Duarte, CA 91010
| | - Amy Henkin
- Department of Nutritional Science and Toxicology, University of California Berkeley, Berkeley, CA 94720
| | - Stephanie Ng
- Department of Nutritional Science and Toxicology, University of California Berkeley, Berkeley, CA 94720
| | - Sujin Song
- Department of Nutritional Science and Toxicology, University of California Berkeley, Berkeley, CA 94720
| | - Yuli Chen
- Department of Nutritional Science and Toxicology, University of California Berkeley, Berkeley, CA 94720
| | - Heather Tran
- Department of Nutritional Science and Toxicology, University of California Berkeley, Berkeley, CA 94720
| | - Robin Lai
- Department of Nutritional Science and Toxicology, University of California Berkeley, Berkeley, CA 94720
| | - Chris Her
- Department of Medicine and Liver Center, University of California San Francisco, 1001 Potrero Ave., San Francisco, CA 94110
| | - Jacquelyn J. Maher
- Department of Medicine and Liver Center, University of California San Francisco, 1001 Potrero Ave., San Francisco, CA 94110
| | - Barry M. Forman
- Diabetes Center, City of Hope, 1500 East Duarte Road, Duarte, CA 91010
| | - Andreas Stahl
- Department of Nutritional Science and Toxicology, University of California Berkeley, Berkeley, CA 94720
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183
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Liu CJ. Prevalence and risk factors for non-alcoholic fatty liver disease in Asian people who are not obese. J Gastroenterol Hepatol 2012; 27:1555-60. [PMID: 22741595 DOI: 10.1111/j.1440-1746.2012.07222.x] [Citation(s) in RCA: 150] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Fatty liver (hepatic steatosis) is prevalent in industrialized countries. It is typically linked to obesity, central obesity and the presence of metabolic syndrome. With the introduction of a Westernized lifestyle and the increasing frequency of obesity in the Asia-Pacific region, the prevalence of non-alcoholic fatty liver disease (NAFLD) has been increasing over the past two decades. The risk factors are similar to those in other ethnic populations; but it is important to adopt the regional (ethnic-specific) anthropometric criteria to define overweight, obesity (including central obesity) and metabolic syndrome. To be noted, even using strict ethnic-specific criteria, a high percentage (15-21%) of Asia-Pacific NAFLD subjects in some series have been found to be non-obese, i.e. to have a normal body mass index (BMI) (17.5-22.4 kg/m(2)) or to be overweight (BMI 22.5-24.9 kg/m(2)). Differential distribution of visceral adipose tissue, recent increase in body weight, intake of high cholesterol diet and genetic background are factors likely associated with the development of NAFLD in these non-obese (but often overweight) Asia-Pacific subjects. Furthermore, insulin resistance may be the underlying key mechanism. In addition, since NAFLD may be the hepatic manifestation of metabolic syndrome, the presence of NAFLD is a predictor of future type 2 diabetes, metabolic syndrome and cardiovascular disease. Therefore, interventions at the public health level are indicated to halt the trend of overweight as well as obesity in Asia-Pacific region, particularly among those with relevant family history. Since the pathophysiology of NAFLD is closely related to metabolic derangement, lifestyle modification remains the cornerstone of management.
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Affiliation(s)
- Chun-Jen Liu
- Graduate Institute of Clinical Medicine, National Taiwan University College of Medicine and National Taiwan University Hospital, Taipei, Taiwan.
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184
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Affiliation(s)
- Vlad Ratziu
- Pitié Salpêtrière HospitalPierre et Marie Curie UniversityParisFrance
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185
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Abstract
Ursodeoxycholic acid (UDCA) is one of hepatologists'oldest friends, always ready to help, throughout the years, in numerous and various liver and biliary tract diseases. On paper, it has had an impeccable track record of cytoprotection in vitro and in vivo due to its pleiotropic effects on many pathways leading to cell injury. Most of its hepatoprotective effects demonstrated under experimental conditions proved able to counteract pathogenic mechanisms involved in the transition from steatosis to steatohepatitis, and early clinical studies suggested a potentially beneficial effect in non-alcoholic steatohepatitis (NASH) as well. Yet, only scant data on the efficacy of UDCA specifically in experimental models of steatosis/NASH are available, and the few available randomized controlled clinical studies have substantial methodological issues and are discussed in this review. Thus, at this point, there is not enough evidence to either confirm or reject the efficacy of UDCA in NASH, although many NASH patients clearly experience biochemical improvements with prolonged UDCA treatment. Also, a few new UDCA derivatives have shown promising activity in preclinical models and may be worth testing in clinical trials.
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Affiliation(s)
- Vlad Ratziu
- Service d'Hépato-gastro-entérologie, Hôpital Pitié-Salpêtrière, 47-83, boulevard de l'Hôpital, 75651 Paris Cedex 13, France.
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186
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Abstract
Non-alcoholic steatohepatitis (NASH) has a prevalence of 1% in Western countries. Its causes as well as its medical treatment are, to date, still debated. Recently, studies of agents suggested to have antiapoptotic, insulin-sensitizing or anti-inflammatory effects in patients with NASH have been conducted, one of which is ursodeoxycholic acid (UDCA), a tertiary bile acid. Between 1994 and 2008, four prospective randomized, double-blind, placebo-controlled studies of the treatment of NASH with UDCA were conducted. The first study, by Lindor et al., compared the impact of 13-15 mg/kg/day of UDCA to a placebo. The second study by Dufour et al. had an additional third arm that administered combination therapy with UDCA and vitamin E. The third and fourth studies by Leuschner et al. and by Ratziu et al. evaluated high doses of UDCA at 25-35 mg/kg/day, and used liver biopsies and serum liver enzyme levels to evaluate the impact of UDCA. With the exception of Ratziu et al.'s study, which was lacking a second liver biopsy, none of these studies showed any significant differences in the treatment of NASH with UDCA compared with a placebo. However, Dufour et al. did observe a significant improvement of NASH with the combination (UDCA/VitE) vs placebo therapy, whereas UDCA monotherapy was not effective in the treatment of NASH. Nevertheless, the effects of other bile acids and combination therapies need to be explored.
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Affiliation(s)
- Fabia Liechti
- University Clinic for Visceral Surgery and Medicine, Inselspital, University of Berne, 3010 Bern Switzerland
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187
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Ratziu V, Cadranel JF, Serfaty L, Denis J, Renou C, Delassalle P, Bernhardt C, Perlemuter G. A survey of patterns of practice and perception of NAFLD in a large sample of practicing gastroenterologists in France. J Hepatol 2012; 57:376-83. [PMID: 22521354 DOI: 10.1016/j.jhep.2012.03.019] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2011] [Revised: 03/18/2012] [Accepted: 03/20/2012] [Indexed: 02/06/2023]
Abstract
BACKGROUND & AIMS Most studies on non-alcoholic fatty liver disease (NAFLD) originate from tertiary care centers with an academic interest. How this emerging entity is accepted and managed by a wider body of gastroenterologists is unknown, despite significant implications for the diagnosis of at-risk subjects and the utilization of healthcare resources. METHODS We conducted a survey among 352 French, board-certified gastroenterologists from a large variety of practices to understand the clinical burden, perceived severity, and management patterns of NAFLD. RESULTS Half of participants saw >30 new cases (equal to HCV) of NAFLD and 40% >5 new cases of NASH-cirrhosis yearly. Only 20% of patients were referred by endocrinologists; conversely, gastroenterologists overwhelmingly referred NAFLD patients for assessment of metabolic co-morbidities. In patients with metabolic risk factors, a majority of physicians considered the diagnosis of NAFLD, even if other liver diseases co-existed. The diagnosis heavily relies on aminotransferases, hence patients with normal ALT are usually not diagnosed. Liver biopsy is performed for fibrosis staging but not for the diagnosis/grading of steatohepatitis, and mainly decided based on non-invasive fibrosis procedures. Pharmacological treatment is used despite a lack of clear evidence of efficacy. Physicians monitor patients themselves, usually twice a year. CONCLUSIONS NAFLD is recognized and accepted as a disease in itself with potentially severe outcomes. Most at-risk patients are currently missed because of non-referral by endocrinologists and no exploration of those with normal aminotransferases. The medical need for the diagnosis and treatment of NAFLD is real in the community of gastroenterologists at large.
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Affiliation(s)
- Vlad Ratziu
- Université Pierre et Marie Curie, Assistance Publique Hôpitaux de Paris, Hôpital Pitié-Salpêtrière, INSERM UMR_S 938, France.
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188
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Torres DM, Williams CD, Harrison SA. Features, diagnosis, and treatment of nonalcoholic fatty liver disease. Clin Gastroenterol Hepatol 2012; 10:837-58. [PMID: 22446927 DOI: 10.1016/j.cgh.2012.03.011] [Citation(s) in RCA: 182] [Impact Index Per Article: 15.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2012] [Accepted: 03/13/2012] [Indexed: 02/06/2023]
Abstract
As the global incidence of obesity has increased, nonalcoholic fatty liver disease (NAFLD) has become a worldwide health concern. NAFLD occurs in children and adults of all ethnicities and includes isolated fatty liver and nonalcoholic steatohepatitis (NASH). Patients with NASH are at risk for developing cirrhosis, hepatic decompensation, and hepatocellular carcinoma and have increased all-cause mortality. NAFLD is associated with a variety of clinical conditions and is an independent risk factor for hepatocellular carcinoma. The pathogenesis of NAFLD and the specific steps that lead to NASH and advanced fibrosis are not fully understood, although researchers have found that a combination of environmental, genetic, and metabolic factors lead to advanced disease. There have been improvements in noninvasive radiographic methods to diagnose NAFLD, especially for advanced disease. However, liver biopsy is still the standard method of diagnosis for NASH. There are many challenges to treating patients with NASH, and no therapies have been approved by the U.S. Food and Drug Administration; multimodal approaches are being developed and becoming the standard of care. We review pathogenesis and treatment approaches for the West's largest liver-related public health concern.
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Affiliation(s)
- Dawn M Torres
- Division of Gastroenterology, Department of Medicine, Walter Reed National Military Medical Center, Bethesda, MD 20892, USA
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189
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Non-alcoholic steatohepatitis: an overview including treatments with herbals as alternative therapeutics. J Appl Biomed 2012. [DOI: 10.2478/v10136-012-0008-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
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190
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Molecular mechanisms of ursodeoxycholic acid toxicity & side effects: ursodeoxycholic acid freezes regeneration & induces hibernation mode. Int J Mol Sci 2012; 13:8882-8914. [PMID: 22942741 PMCID: PMC3430272 DOI: 10.3390/ijms13078882] [Citation(s) in RCA: 62] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2012] [Revised: 07/03/2012] [Accepted: 07/06/2012] [Indexed: 12/14/2022] Open
Abstract
Ursodeoxycholic acid (UDCA) is a steroid bile acid approved for primary biliary cirrhosis (PBC). UDCA is reported to have “hepato-protective properties”. Yet, UDCA has “unanticipated” toxicity, pronounced by more than double number of deaths, and eligibility for liver transplantation compared to the control group in 28 mg/kg/day in primary sclerosing cholangitis, necessitating trial halt in North America. UDCA is associated with increase in hepatocellular carcinoma in PBC especially when it fails to achieve biochemical response (10 and 15 years incidence of 9% and 20% respectively). “Unanticipated” UDCA toxicity includes hepatitis, pruritus, cholangitis, ascites, vanishing bile duct syndrome, liver cell failure, death, severe watery diarrhea, pneumonia, dysuria, immune-suppression, mutagenic effects and withdrawal syndrome upon sudden halt. UDCA inhibits DNA repair, co-enzyme A, cyclic AMP, p53, phagocytosis, and inhibits induction of nitric oxide synthatase. It is genotoxic, exerts aneugenic activity, and arrests apoptosis even after cellular phosphatidylserine externalization. UDCA toxicity is related to its interference with drug detoxification, being hydrophilic and anti-apoptotic, has a long half-life, has transcriptional mutational abilities, down-regulates cellular functions, has a very narrow difference between the recommended (13 mg/kg/day) and toxic dose (28 mg/kg/day), and it typically transforms into lithocholic acid that induces DNA strand breakage, it is uniquely co-mutagenic, and promotes cell transformation. UDCA beyond PBC is unjustified.
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191
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Kim MY, Cho MY, Baik SK, Jeong PH, Suk KT, Jang YO, Yea CJ, Kim JW, Kim HS, Kwon SO, Yoo BS, Kim JY, Eom MS, Cha SH, Chang SJ. Beneficial effects of candesartan, an angiotensin-blocking agent, on compensated alcoholic liver fibrosis - a randomized open-label controlled study. Liver Int 2012; 32:977-87. [PMID: 22364262 DOI: 10.1111/j.1478-3231.2012.02774.x] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2011] [Accepted: 01/28/2012] [Indexed: 12/12/2022]
Abstract
BACKGROUND Recent studies have shown that the renin-angiotensin system is implicated in hepatic fibrogenesis in vitro and in vivo. However, no study was done in humans with alcoholic liver disease. AIM To investigate the antifibrotic effect of angiotensin II type 1 receptor (AT1-R) blocking agents (ARB) in patients with alcoholic liver disease. METHODS The primary outcome was improvement in patients' histological features. Eighty-five patients with compensated alcoholic liver fibrosis (≥ F2) which was confirmed by baseline liver biopsy were randomized (intention-to-treat (ITT)) to receive either ARB, candesartan (8 mg/day) with ursodeoxycholic acid (UDCA) (600 mg/day) (n = 42) or UDCA alone (n = 43) as control for 6 months and follow-up liver biopsies were conducted. RESULTS According to the Laennec fibrosis system, candesartan showed significantly higher rates of histological improvements (ITT, 33.3% vs. 11.6%, P = 0.020). In addition, the fibrosis score was significantly reduced from 3.4 ± 1.4 to 3.1 ± 1.5 (P = 0.005) in the candesartan group. Candesartan also reduced the area of fibrosis and α-smooth muscle actin positive from 11.3 ± 6.0 to 8.3 ± 4.7 and 28.7 ± 10.5 to 23.9 ± 10.3 (%), and the hydroxyproline levels (μg/g liver tissue) from 7.8 ± 2.4 to 6.3 ± 1.7 respectively (P < 0.05). In addition, the relative expression of transforming growth factor-β1(TGF-β1), collagen-1, AT1-R, tissue inhibitor of metalloproteinase 1 (TIMP-1), metalloproteinases2 (MMP2), Rac1 and p22phox by real-time RT-PCR decreased in the candesartan group (P < 0.05). Mean arterial blood pressure in the candesartan group decreased mildly but significantly (P < 0.001). No significant complications and side effects were observed during the present study. CONCLUSIONS Administration of ARB in compensated alcoholic liver disease induces improvement of fibrosis in histological and quantitative measurements.
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Affiliation(s)
- Moon Young Kim
- Department of Internal Medicine, Yonsei University Wonju College of Medicine, Wonju, South Korea
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192
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Chalasani N, Younossi Z, Lavine JE, Diehl AM, Brunt EM, Cusi K, Charlton M, Sanyal AJ. The diagnosis and management of non-alcoholic fatty liver disease: Practice guideline by the American Association for the Study of Liver Diseases, American College of Gastroenterology, and the American Gastroenterological Association. Am J Gastroenterol 2012; 107:811-26. [PMID: 22641309 DOI: 10.1038/ajg.2012.128] [Citation(s) in RCA: 290] [Impact Index Per Article: 24.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Affiliation(s)
- Naga Chalasani
- Indiana University School of Medicine, Indianapolis, 46202, USA.
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193
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Le TA, Loomba R. Management of Non-alcoholic Fatty Liver Disease and Steatohepatitis. J Clin Exp Hepatol 2012; 2:156-73. [PMID: 25755424 PMCID: PMC3940181 DOI: 10.1016/s0973-6883(12)60104-2] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2012] [Accepted: 05/08/2012] [Indexed: 12/12/2022] Open
Abstract
Non-alcoholic fatty liver disease (NAFLD) is the most common cause of abnormal liver enzymes and chronic liver disease in the US with expected rise in incidence paralleling the epidemic of obesity. A subset of patients with NAFLD have the progressive form of NAFLD that is termed non-alcoholic steatohepatitis (NASH), which is characterized by specific features on liver histology including hepatocellular ballooning degeneration, lobular inflammation, and zone-3 steatosis with or without peri-sinusoidal fibrosis. Non-alcoholic steatohepatitis can progress to cirrhosis and result in liver-related death. Insulin resistance is commonly seen in patients with NASH and often co-exists with other features of the metabolic syndrome including hypertension, hyperlipidemia, and obesity. Although weight loss through lifestyle modifications including dietary changes and increased physical exercise remains the backbone of management of NASH, it has proved challenging for patients to achieve and maintain weight loss goals. Thus, it is often necessary to couple lifestyle changes with another pharmacologic treatment for NASH. Insulin sensitizers including the biguanides (metformin), thiazolidinediones (pioglitazone and rosiglitazone), and glucagon-like peptide-1 receptor agonists (exenatide) are large groups of medications that have been studied for the treatment of NASH. Other agents with anti-inflammatory, anti-apoptotic, or anti-fibrotic properties which have been studied in NASH include vitamin E, pentoxifylline, betaine, and ursodeoxycholic acid. This review will provide a detailed summary on the clinical data behind the full spectrum of treatments that exist for NASH and suggest management recommendations.
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Key Words
- ALT, alanine aminotransferase
- AST, aspartate aminotransferase
- Alk-phos, alkaline phosphatase
- BMI, body mass index
- Colesevelam
- DEXA, dual-energy X-ray absorptiometry
- GGT, gamma-glutamyl transferase
- HDL, high-density lipoprotein
- HOMA, homeostatic model assessment
- LDL, low-density lipoprotein
- NAFLD, non-alcoholic fatty liver disease
- NAS, NAFLD activity score
- NASH, non-alcoholic steatohepatitis
- QUICKI, quantitative insulin sensitivity check index
- S-adenosylmethionine
- TG, triglyceride
- exenatide
- ezetimibe
- metformin
- pentoxifylline
- statins
- thiazolidinediones
- ursodeoxycholic acid
- vitamin E
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Affiliation(s)
- Thuy-Anh Le
- Division of Gastroenterology, Department of Medicine, University of California, San Diego, La Jolla, CA 92093, USA
| | - Rohit Loomba
- Division of Epidemiology, Department of Family and Preventive Medicine, University of California, San Diego, La Jolla, CA 92093, USA,Address for correspondence: Rohit Loomba, Division of Gastroenterology and Epidemiology, University of California at San Diego School of Medicine, UC 303, MC-063, 9500 Gilman Drive, La Jolla, CA 92093, USA
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194
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Chalasani N, Younossi Z, Lavine JE, Diehl AM, Brunt EM, Cusi K, Charlton M, Sanyal AJ. The diagnosis and management of non-alcoholic fatty liver disease: practice Guideline by the American Association for the Study of Liver Diseases, American College of Gastroenterology, and the American Gastroenterological Association. Hepatology 2012; 55:2005-23. [PMID: 22488764 DOI: 10.1002/hep.25762] [Citation(s) in RCA: 2503] [Impact Index Per Article: 208.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Affiliation(s)
- Naga Chalasani
- Indiana University School of Medicine, Indianapolis, IN, USA.
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195
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Beaton MD. Current treatment options for nonalcoholic fatty liver disease and nonalcoholic steatohepatitis. CANADIAN JOURNAL OF GASTROENTEROLOGY = JOURNAL CANADIEN DE GASTROENTEROLOGIE 2012; 26:353-7. [PMID: 22720278 PMCID: PMC3378283 DOI: 10.1155/2012/725468] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/09/2011] [Accepted: 09/22/2011] [Indexed: 12/12/2022]
Abstract
Nonalcoholic fatty liver disease is the leading cause of liver disease in western society. It is a cause of end-stage liver disease, with increased mortality secondary to cirrhosis and its complications. It is also recognized that cardiovascular disease is a significant cause of death in these patients. Significant work evaluating various treatments has been performed in recent years; however, to date, no ideal therapy exists. Lifestyle modification remains the cornerstone of management. The present article reviews the current status of various treatment modalities evaluated in nonalcoholic fatty liver disease.
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Affiliation(s)
- Melanie D Beaton
- Department of Medicine, Unversity of Western Ontario, London, Ontario, Canada.
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196
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Chalasani N, Younossi Z, Lavine JE, Diehl AM, Brunt EM, Cusi K, Charlton M, Sanyal AJ. The diagnosis and management of non-alcoholic fatty liver disease: practice guideline by the American Gastroenterological Association, American Association for the Study of Liver Diseases, and American College of Gastroenterology. Gastroenterology 2012; 142:1592-609. [PMID: 22656328 DOI: 10.1053/j.gastro.2012.04.001] [Citation(s) in RCA: 1275] [Impact Index Per Article: 106.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2012] [Indexed: 02/06/2023]
Affiliation(s)
- Naga Chalasani
- Indiana University School of Medicine, Indianapolis, IN 46202, USA.
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197
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Pathil A, Mueller J, Warth A, Chamulitrat W, Stremmel W. Ursodeoxycholyl lysophosphatidylethanolamide improves steatosis and inflammation in murine models of nonalcoholic fatty liver disease. Hepatology 2012; 55:1369-78. [PMID: 22183915 DOI: 10.1002/hep.25531] [Citation(s) in RCA: 58] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2011] [Accepted: 11/23/2011] [Indexed: 01/18/2023]
Abstract
UNLABELLED Hepatic fat accumulation and changes in lipid composition are hallmarks of nonalcoholic fatty liver disease (NAFLD). As an experimental approach for treatment of NAFLD, we synthesized the bile acid-phospholipid conjugate ursodeoxycholyl lysophosphatidylethanolamide (UDCA-LPE). Previous work demonstrated profound hepatoprotective properties of the conjugate in vitro and in vivo. Here we investigated the effects of UDCA-LPE in two nutritional mouse models of NAFLD. C57BL/6 mice were fed a high-fat diet (HFD) for 28 weeks, resulting in steatosis with hyperlipidemia. In a second model, mice received a methionin-choline-deficient (MCD) diet for up to 11 weeks, which induced advanced nonalcoholic steatohepatitis (NASH). Establishment of liver injury was followed by intraperitoneal injections of 30 mg/kg UDCA-LPE three times a week for different time periods. UDCA-LPE ameliorated both HFD- and MCD-induced increases in alanine aminotransferase (ALT) values near to normalization. As for metabolic parameters, UDCA-LPE reduced elevated serum triglyceride and cholesterol values in HFD mice. Liver histology showed improvement of steatosis in HFD and MCD mice concomitant with reductions in hepatic triglyceride and cholesterol levels. Additionally, the conjugate lowered serum caspase-8 activity in both models and decreased lipid hydroperoxides in MCD mice. Abundance of proinflammatory lysophosphatidylcholine (LPC), which was detectable in both HFD and MCD mice, was reduced by UDCA-LPE. Quantitative reverse transcriptase-polymerase chain reaction qRT-PCR of liver specimens revealed that UDCA-LPE strongly down-regulated inflammatory genes and modified the expression of genes involved in lipid metabolism. CONCLUSION The current study demonstrates that UDCA-LPE improves hepatic injury at different stages of NAFLD. By concurrently lowering hepatic lipid overloading as well as susceptibility of hepatocytes toward inflammatory stimuli, the conjugate may be able to ameliorate disease progression. Thus, UDCA-LPE represents a promising compound suitable for the treatment of NAFLD.
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Affiliation(s)
- Anita Pathil
- Department of Internal Medicine IV, Gastroenterology and Hepatology, University of Heidelberg, Heidelberg, Germany
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198
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Musso G, Cassader M, Rosina F, Gambino R. Impact of current treatments on liver disease, glucose metabolism and cardiovascular risk in non-alcoholic fatty liver disease (NAFLD): a systematic review and meta-analysis of randomised trials. Diabetologia 2012; 55:885-904. [PMID: 22278337 DOI: 10.1007/s00125-011-2446-4] [Citation(s) in RCA: 449] [Impact Index Per Article: 37.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2011] [Accepted: 12/02/2011] [Indexed: 12/13/2022]
Abstract
AIMS/HYPOTHESIS Non-alcoholic fatty liver disease (NAFLD) encompasses a spectrum ranging from simple steatosis to non-alcoholic steatohepatitis (NASH): NAFLD causes an increased risk of cardiovascular disease, diabetes and liver-related complications (the latter confined to NASH). The effect of proposed treatments on liver disease, glucose metabolism and cardiovascular risk in NAFLD is unknown. We reviewed the evidence for the management of liver disease and cardio-metabolic risk in NAFLD. METHODS Publications through November 2011 were systematically reviewed by two authors. Outcomes evaluated though standard methods were: histological/radiological/biochemical features of NAFLD, variables of glucose metabolism and cardiovascular risk factors. Seventy-eight randomised trials were included (38 in NASH, 40 in NAFLD): 41% assessed post-treatment histology, 71% assessed glucose metabolism and 88% assessed cardiovascular risk factors. Lifestyle intervention, thiazolidinediones, metformin and antioxidants were most extensively evaluated. RESULTS Lifestyle-induced weight loss was safe and improved cardio-metabolic risk profile; a weight loss ≥7% improved histological disease activity, but was achieved by <50% patients. Statins and polyunsaturated fatty acids improved steatosis, but their effects on liver histology are unknown. Thiazolidinediones improved histological disease activity, glucose, lipid and inflammatory variables and delayed fibrosis progression. Pioglitazone also improved blood pressure. Weight gain (up to 4.8%) was common. Antioxidants yielded mixed histological results: vitamin E improved histological disease activity when administered for 2 years, but increased insulin resistance and plasma triacylglycerols. CONCLUSIONS/INTERPRETATION Weight loss is safe, and improves liver histology and cardio-metabolic profile. For patients not responding to lifestyle intervention, pioglitazone improves histological disease activity, slows fibrosis progression and extensively ameliorates cardio-metabolic endpoints. Further randomised controlled trials (RCTs) of adequate size and duration will assess long-term safety and efficacy of proposed treatments on clinical outcomes.
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Affiliation(s)
- G Musso
- Gradenigo Hospital, C.so Regina Margherita 8, Turin, Italy.
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199
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Farrell GC, van Rooyen D, Gan L, Chitturi S. NASH is an Inflammatory Disorder: Pathogenic, Prognostic and Therapeutic Implications. Gut Liver 2012; 6:149-71. [PMID: 22570745 PMCID: PMC3343154 DOI: 10.5009/gnl.2012.6.2.149] [Citation(s) in RCA: 283] [Impact Index Per Article: 23.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2012] [Accepted: 01/18/2012] [Indexed: 12/12/2022] Open
Abstract
While non-alcoholic fatty liver disease (NAFLD) is highly prevalent (15% to 45%) in modern societies, only 10% to 25% of cases develop hepatic fibrosis leading to cirrhosis, end-stage liver disease or hepatocellular carcinoma. Apart from pre-existing fibrosis, the strongest predictor of fibrotic progression in NAFLD is steatohepatitis or non-alcoholic steatohepatitis (NASH). The critical features other than steatosis are hepatocellular degeneration (ballooning, Mallory hyaline) and mixed inflammatory cell infiltration. While much is understood about the relationship of steatosis to metabolic factors (over-nutrition, insulin resistance, hyperglycemia, metabolic syndrome, hypoadiponectinemia), less is known about inflammatory recruitment, despite its importance for the perpetuation of liver injury and fibrogenesis. In this review, we present evidence that liver inflammation has prognostic significance in NAFLD. We then consider the origins and components of liver inflammation in NASH. Hepatocytes injured by toxic lipid molecules (lipotoxicity) play a central role in the recruitment of innate immunity involving Toll-like receptors (TLRs), Kupffer cells (KCs), lymphocytes and neutrophils and possibly inflammasome. The key pro-inflammatory signaling pathways in NASH are nuclear factor-kappa B (NF-κB) and c-Jun N-terminal kinase (JNK). The downstream effectors include adhesion molecules, chemokines, cytokines and the activation of cell death pathways leading to apoptosis. The upstream activators of NF-κB and JNK are more contentious and may depend on the experimental model used. TLRs are strong contenders. It remains possible that inflammation in NASH originates outside the liver and in the gut microbiota that prime KC/TLR responses, inflamed adipose tissue and circulating inflammatory cells. We briefly review these mechanistic considerations and project their implications for the effective treatment of NASH.
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Affiliation(s)
- Geoffrey C. Farrell
- Gastroenterology and Hepatology Unit, The Canberra Hospital, Australian National University Medical School, Garran, Australia
| | - Derrick van Rooyen
- Gastroenterology and Hepatology Unit, The Canberra Hospital, Australian National University Medical School, Garran, Australia
| | - Lay Gan
- Gastroenterology and Hepatology Unit, The Canberra Hospital, Australian National University Medical School, Garran, Australia
| | - Shivrakumar Chitturi
- Gastroenterology and Hepatology Unit, The Canberra Hospital, Australian National University Medical School, Garran, Australia
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200
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Pietu F, Guillaud O, Walter T, Vallin M, Hervieu V, Scoazec JY, Dumortier J. Ursodeoxycholic acid with vitamin E in patients with nonalcoholic steatohepatitis: long-term results. Clin Res Hepatol Gastroenterol 2012; 36:146-55. [PMID: 22154224 DOI: 10.1016/j.clinre.2011.10.011] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2011] [Revised: 10/05/2011] [Accepted: 10/19/2011] [Indexed: 02/07/2023]
Abstract
BACKGROUND The combination of ursodeoxycholic acid (UDCA) and vitamin E is a therapeutic option for nonalcoholic steatohepatitis (NASH) but randomized controlled studies have produced inconsistent results. The objective of this study was to report the long-term tolerability and efficacy of this combination in our ten-year single center experience. METHODS The study group included 101 adult patients with persistent elevation of serum aminotransferases (AST and ALT) and/or γ glutamyl-transferase (GGT), in whom a histological diagnosis of NASH was made from January 1998 to January 2009, and who were treated with a combination of UDCA with vitamin E. RESULTS Median body mass index (30 kg/m(2)) remained unchanged during the study. UDCA and vitamin E were well tolerated (5% withdrawal for side effects). Mean serum AST, ALT and GGT levels (expressed as times of Upper Normal Limit) diminished significantly (1.39 ± 0.74 to 0.78 ± 0.34 for AST, 1.72 ± 0.92 to 0.91 ± 0.69 for AST and 3.25 ± 2.85 to 1.30 ± 1.30 for GGT). AST, ALT and GGT reached normal range in 80%, 70% and 65% of the patients, respectively. From the ten patients who had a second liver biopsy during follow-up, NAS score improved in seven, and worsened in one. CONCLUSIONS The combination of UDCA with vitamin E significantly improves liver function tests in long-term and is very well tolerated.
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Affiliation(s)
- Florence Pietu
- Hospices civils de Lyon pavillon H, hôpital Édouard- Herriot, fédération des spécialités digestives, 69437 Lyon cedex 03, France
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