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Hernandez GV, Smith VA, Melnyk M, Burd MA, Sprayberry KA, Edwards MS, Peterson DG, Bennet DC, Fanter RK, Columbus DA, Steibel JP, Glanz H, Immoos C, Rice MS, Santiago-Rodriguez TM, Blank J, VanderKelen JJ, Kitts CL, Piccolo BD, La Frano MR, Burrin DG, Maj M, Manjarin R. Dysregulated FXR-FGF19 signaling and choline metabolism are associated with gut dysbiosis and hyperplasia in a novel pig model of pediatric NASH. Am J Physiol Gastrointest Liver Physiol 2020; 318:G582-G609. [PMID: 32003601 PMCID: PMC7099491 DOI: 10.1152/ajpgi.00344.2019] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2019] [Revised: 01/21/2020] [Accepted: 01/25/2020] [Indexed: 02/08/2023]
Abstract
To investigate the role of bile acids (BAs) in the pathogenesis of diet-induced nonalcoholic steatohepatitis (NASH), we fed a "Western-style diet" [high fructose, high fat (HFF)] enriched with fructose, cholesterol, and saturated fat for 10 wk to juvenile Iberian pigs. We also supplemented probiotics with in vitro BA deconjugating activity to evaluate their potential therapeutic effect in NASH. Liver lipid and function, cytokines, and hormones were analyzed using commercially available kits. Metabolites, BAs, and fatty acids were measured by liquid chromatography-mass spectrometry. Histology and gene and protein expression analyses were performed using standard protocols. HFF-fed pigs developed NASH, cholestasis, and impaired enterohepatic Farnesoid-X receptor (FXR)-fibroblast growth factor 19 (FGF19) signaling in the absence of obesity and insulin resistance. Choline depletion in HFF livers was associated with decreased lipoprotein and cholesterol in serum and an increase of choline-containing phospholipids in colon contents and trimethylamine-N-oxide in the liver. Additionally, gut dysbiosis and hyperplasia increased with the severity of NASH, and were correlated with increased colonic levels of choline metabolites and secondary BAs. Supplementation of probiotics in the HFF diet enhanced NASH, inhibited hepatic autophagy, increased excretion of taurine and choline, and decreased gut microbial diversity. In conclusion, dysregulation of BA homeostasis was associated with injury and choline depletion in the liver, as well as increased biliary secretion, gut metabolism and excretion of choline-based phospholipids. Choline depletion limited lipoprotein synthesis, resulting in hepatic steatosis, whereas secondary BAs and choline-containing phospholipids in colon may have promoted dysbiosis, hyperplasia, and trimethylamine synthesis, causing further damage to the liver.NEW & NOTEWORTHY Impaired Farnesoid-X receptor (FXR)-fibroblast growth factor 19 (FGF19) signaling and cholestasis has been described in nonalcoholic fatty liver disease (NAFLD) patients. However, therapeutic interventions with FXR agonists have produced contradictory results. In a swine model of pediatric nonalcoholic steatohepatitis (NASH), we show that the uncoupling of intestinal FXR-FGF19 signaling and a decrease in FGF19 levels are associated with a choline-deficient phenotype of NASH and increased choline excretion in the gut, with the subsequent dysbiosis, colonic hyperplasia, and accumulation of trimethylamine-N-oxide in the liver.
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Affiliation(s)
- Gabriella V Hernandez
- Department of Animal Science, California Polytechnic State University, San Luis Obispo, California
| | - Victoria A Smith
- Department of Animal Science, California Polytechnic State University, San Luis Obispo, California
| | - Megan Melnyk
- Department of Biological Sciences, California Polytechnic State University, San Luis Obispo, California
| | - Matthew A Burd
- Department of Animal Science, California Polytechnic State University, San Luis Obispo, California
| | - Kimberly A Sprayberry
- Department of Animal Science, California Polytechnic State University, San Luis Obispo, California
| | - Mark S Edwards
- Department of Animal Science, California Polytechnic State University, San Luis Obispo, California
| | - Daniel G Peterson
- Department of Animal Science, California Polytechnic State University, San Luis Obispo, California
| | - Darin C Bennet
- Department of Animal Science, California Polytechnic State University, San Luis Obispo, California
| | - Rob K Fanter
- Center for Health Research, California Polytechnic State University, San Luis Obispo, California
| | | | - Juan P Steibel
- Department of Animal Science and Department of Fisheries and Wildlife, Michigan State University, East Lansing, Michigan
| | - Hunter Glanz
- Department of Statistics, California Polytechnic State University, San Luis Obispo, California
| | - Chad Immoos
- Department of Chemistry and Biochemistry, California Polytechnic State University, San Luis Obispo, California
| | - Margaret S Rice
- Department of Chemistry and Biochemistry, California Polytechnic State University, San Luis Obispo, California
| | | | - Jason Blank
- Department of Biological Sciences, California Polytechnic State University, San Luis Obispo, California
| | - Jennifer J VanderKelen
- Center for Applications in Biotechnology, California Polytechnic State University, San Luis Obispo, California
| | - Christopher L Kitts
- Center for Applications in Biotechnology, California Polytechnic State University, San Luis Obispo, California
| | - Brian D Piccolo
- United States Department of Agriculture-Agricultural Research Services, Arkansas Children's Nutrition Center, Little Rock, Arkansas
- Department of Pediatrics, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Michael R La Frano
- Department of Food Science and Nutrition, California Polytechnic State University, San Luis Obispo, California
- Center for Health Research, California Polytechnic State University, San Luis Obispo, California
| | - Douglas G Burrin
- United States Department of Agriculture-Agricultural Research Services, Children's Nutrition Research Center, Section of Pediatric Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Baylor College of Medicine, Houston, Texas
| | - Magdalena Maj
- Department of Biological Sciences, California Polytechnic State University, San Luis Obispo, California
- Center for Applications in Biotechnology, California Polytechnic State University, San Luis Obispo, California
| | - Rodrigo Manjarin
- Department of Animal Science, California Polytechnic State University, San Luis Obispo, California
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152
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Ko J, Cho J, Petrov MS. Low serum amylase, lipase, and trypsin as biomarkers of metabolic disorders: A systematic review and meta-analysis. Diabetes Res Clin Pract 2020; 159:107974. [PMID: 31811884 DOI: 10.1016/j.diabres.2019.107974] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2019] [Revised: 11/07/2019] [Accepted: 12/02/2019] [Indexed: 12/16/2022]
Abstract
AIMS While there is plentiful evidence on elevated serum levels of amylase, lipase, and trypsin in acute illness, low serum levels of these digestive enzymes have been studied infrequently. The aim was to systematically review published studies on the relationship between low serum levels of amylase, lipase, or trypsin and metabolic disorders. METHODS The search was conducted in MEDLINE and Scopus databases. Studies in humans were included if they reported on the association between serum levels of amylase, lipase, or trypsin within normal range and metabolic disorders. Random-effects meta-analysis was conducted. RESULTS A total of 20 studies encompassing 20,916 participants were included. Compared with healthy individuals, individuals with type 2 diabetes mellitus (mean difference = -5.3; p < 0.001), metabolic syndrome (mean difference = -5.1; p < 0.001), and overweight/obesity (mean difference = -0.8; p = 0.02) had significantly lower serum levels of amylase. Both individuals with type 1 diabetes mellitus (mean difference = -1.8; p < 0.001) and type 2 diabetes mellitus (mean difference = -0.8; p < 0.001) had significantly lower serum levels of lipase compared with healthy individuals. Data on serum trypsin were not suitable for meta-analysis. In the pooled analysis, individuals with type 2 diabetes mellitus had 3.1-times lower serum levels of amylase, 2.9-times lower serum levels of lipase, and 2.5-times lower serum levels of trypsin levels than the upper limits of normal for the three digestive enzymes. CONCLUSION Low serum levels of amylase and lipase are significantly associated with type 2 diabetes mellitus, type 1 diabetes mellitus, excess adiposity, and metabolic syndrome. The role of digestive enzymes in the pathogenesis of metabolic disorders warrants further investigations.
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Affiliation(s)
- Juyeon Ko
- School of Medicine, University of Auckland, Auckland, New Zealand
| | - Jaelim Cho
- School of Medicine, University of Auckland, Auckland, New Zealand
| | - Maxim S Petrov
- School of Medicine, University of Auckland, Auckland, New Zealand.
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153
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Hu H, Lin A, Kong M, Yao X, Yin M, Xia H, Ma J, Liu H. Intestinal microbiome and NAFLD: molecular insights and therapeutic perspectives. J Gastroenterol 2020; 55:142-158. [PMID: 31845054 PMCID: PMC6981320 DOI: 10.1007/s00535-019-01649-8] [Citation(s) in RCA: 98] [Impact Index Per Article: 24.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2019] [Accepted: 11/19/2019] [Indexed: 02/07/2023]
Abstract
Non-alcoholic fatty liver disease (NAFLD) is the hepatic manifestation of dysregulated lipid and glucose metabolism, which is often associated with obesity, dyslipidemia and insulin resistance. In view of the high morbidity and health risks of NAFLD, the lack of effective cure has drawn great attention. In recent years, a line of evidence has suggested a close linkage between the intestine and liver diseases such as NAFLD. We summarized the composition and characteristics of intestinal microbes and reviewed molecular insights into the intestinal microbiome in development and progression of NAFLD. Intestinal microbes mainly include bacteria, archaea, viruses and fungi, and the crosstalk between non-bacterial intestinal microbes and human liver diseases should be paid more attention. Intestinal microbiota imbalance may not only increase the intestinal permeability to gut microbes but also lead to liver exposure to harmful substances that promote hepatic lipogenesis and fibrosis. Furthermore, we focused on reviewing the latest "gut-liver axis"-targeting treatment, including the application of antibiotics, probiotics, prebiotics, synbiotics, farnesoid X receptor agonists, bile acid sequestrants, gut-derived hormones, adsorbents and fecal microbiota transplantation for NAFLD. In this review, we also discussed the potential mechanisms of "gut-liver axis" manipulation and efficacy of these therapeutic strategies for NAFLD treatment.
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Affiliation(s)
- Haiming Hu
- grid.257143.60000 0004 1772 1285Hubei University of Chinese Medicine, Wuhan, Hubei China
| | - Aizhen Lin
- grid.477392.cHubei Provincial Hospital of Traditional Chinese Medicine, Wuhan, Hubei China
| | - Mingwang Kong
- grid.257143.60000 0004 1772 1285Hubei University of Chinese Medicine, Wuhan, Hubei China
| | - Xiaowei Yao
- grid.257143.60000 0004 1772 1285Hubei University of Chinese Medicine, Wuhan, Hubei China
| | - Mingzhu Yin
- grid.257143.60000 0004 1772 1285Hubei University of Chinese Medicine, Wuhan, Hubei China
| | - Hui Xia
- grid.257143.60000 0004 1772 1285Hubei University of Chinese Medicine, Wuhan, Hubei China
| | - Jun Ma
- grid.257143.60000 0004 1772 1285Hubei University of Chinese Medicine, Wuhan, Hubei China
| | - Hongtao Liu
- grid.257143.60000 0004 1772 1285Hubei University of Chinese Medicine, Wuhan, Hubei China
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154
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Goodus MT, McTigue DM. Hepatic dysfunction after spinal cord injury: A vicious cycle of central and peripheral pathology? Exp Neurol 2019; 325:113160. [PMID: 31863731 DOI: 10.1016/j.expneurol.2019.113160] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2019] [Revised: 11/17/2019] [Accepted: 12/18/2019] [Indexed: 02/06/2023]
Abstract
The liver is essential for numerous physiological processes, including filtering blood from the intestines, metabolizing fats, proteins, carbohydrates and drugs, and regulating iron storage and release. The liver is also an important immune organ and plays a critical role in response to infection and injury throughout the body. Liver functions are regulated by autonomic parasympathetic innervation from the brainstem and sympathetic innervation from the thoracic spinal cord. Thus, spinal cord injury (SCI) at or above thoracic levels disrupts major regulatory mechanisms for hepatic functions. Work in rodents and humans shows that SCI induces liver pathology, including hepatic inflammation and fat accumulation characteristic of a serious form of non-alcoholic fatty liver disease (NAFLD) called non-alcoholic steatohepatitis (NASH). This hepatic pathology is associated with and likely contributes to indices of metabolic dysfunction often noted in SCI individuals, such as insulin resistance and hyperlipidemia. These occur at greater rates in the SCI population and can negatively impact health and quality of life. In this review, we will: 1) Discuss acute and chronic changes in human and rodent liver pathology and function after SCI; 2) Describe how these hepatic changes affect systemic inflammation, iron regulation and metabolic dysfunction after SCI; 3) Describe how disruption of the hepatic autonomic nervous system may be a key culprit in post-injury chronic liver pathology; and 4) Preview ongoing and future research that aims to elucidate mechanisms driving liver and metabolic dysfunction after SCI.
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Affiliation(s)
- Matthew T Goodus
- The Belford Center for Spinal Cord Injury, The Ohio State University, Columbus, OH, USA; Department of Neuroscience, Wexner Medical Center, The Ohio State University, Columbus, OH, USA.
| | - Dana M McTigue
- The Belford Center for Spinal Cord Injury, The Ohio State University, Columbus, OH, USA; Department of Neuroscience, Wexner Medical Center, The Ohio State University, Columbus, OH, USA.
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155
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Non-alcoholic fatty liver diseases: from role of gut microbiota to microbial-based therapies. Eur J Clin Microbiol Infect Dis 2019; 39:613-627. [PMID: 31828683 DOI: 10.1007/s10096-019-03746-1] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2019] [Accepted: 10/23/2019] [Indexed: 02/06/2023]
Abstract
Non-alcoholic fatty liver disease (NAFLD) is the well-known disease of the liver in adults and children throughout the world. The main manifestations related to NAFLD are an unusual storage of lipid in hepatocytes (hepatic steatosis) and progression of inflammation for non-alcoholic steatohepatitis (NASH). NAFLD is described as a multifactorial complication due to the genetic predisposition, metabolic functions, inflammatory, gut microbiota (GM), and environmental factors. The GM dysregulation among these factors is correlated to NAFLD development. In recent decades, advanced microbial profiling methods are continuing to shed light on the nature of the changes in the GM caused by NASH and NAFLD. In the current review, we aim to perform a literature review in different library databases and electronic searches (Science Direct, PubMed, and Google Scholar) which were randomly obtained. This will be done in order to provide an overview of the relation between GM and NAFLD, and the role of prebiotics, probiotics, and fecal microbiota transplantation (FMT), as potential therapeutic challenges for NAFLD.
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156
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Systematic Review with Meta-Analysis: The Effects of Probiotics in Nonalcoholic Fatty Liver Disease. Gastroenterol Res Pract 2019; 2019:1484598. [PMID: 31885541 PMCID: PMC6927028 DOI: 10.1155/2019/1484598] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2019] [Revised: 11/06/2019] [Accepted: 11/18/2019] [Indexed: 01/30/2023] Open
Abstract
Background and Aims Probiotics was considered as a potential therapy for nonalcoholic fatty liver disease (NAFLD) without approval and comprehensive assessment in recent years, which call for a meta-analysis. Methods We performed electronic and manual searches including English and Chinese databases published before April 2019, with the use of mesh term and free text of "nonalcoholic fatty liver disease" and "probiotics." Clinical trials evaluating the efficacy of probiotic therapy in NAFLD patients were included according to the eligibility criteria. With the use of random effects models, clinical outcomes were presented as weighted mean difference (WMD) with 95% confidence interval (CI), while heterogeneity and meta-regression were also assessed. Results 28 clinical trials enrolling 1555 criterion proven NAFLD patients with the use of probiotics from 4 to 28 weeks were included. Overall, probiotic therapy had beneficial effects on body mass index (WMD: -1.46, 95% CI: [-2.44, -0.48]), alanine aminotransferase (WMD: -13.40, 95% CI: [-17.03, -9.77]), aspartate transaminase (WMD: -13.54, 95% CI: [-17.86, -9.22]), gamma-glutamyl transpeptidase (WMD: -9.88, 95% CI: [-17.77, -1.99]), insulin (WMD: -1.32, 95% CI: [-2.43, -0.21]), homeostasis model assessment-insulin resistance (WMD: -0.42, 95% CI: [-0.73, -0.12]), and total cholesterol (WMD: -15.38, 95% CI: [-26.50, -4.25]), but not in fasting blood sugar, lipid profiles, or tumor necrosis factor-alpha. Conclusion The systematic review and meta-analysis support that probiotics are superior to placebo in NAFLD patients and could be utilized as a common complementary therapeutic approach.
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157
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Liu L, Li P, Liu Y, Zhang Y. Efficacy of Probiotics and Synbiotics in Patients with Nonalcoholic Fatty Liver Disease: A Meta-Analysis. Dig Dis Sci 2019; 64:3402-3412. [PMID: 31203554 DOI: 10.1007/s10620-019-05699-z] [Citation(s) in RCA: 65] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2018] [Accepted: 06/04/2019] [Indexed: 12/13/2022]
Abstract
BACKGROUND AND AIM Extensive epidemiological evidence suggests that nonalcoholic fatty liver disease (NAFLD) is the primary chronic liver disease worldwide. However, some studies have showed conflicting results on the effects of probiotics and synbiotics supplementation. Therefore, we conducted a systematic review and meta-analysis to investigate the effectiveness of the supplementation in subjects with NAFLD. METHODS We searched systematically PubMed, Cochrane, and Embase databases up to April 2018 and checked manually the bibliography of the original articles. The quality of the studies was evaluated using the Cochrane Risk of Bias Tool. RESULTS This study analyzed 15 randomized, controlled trials involving 782 patients with NAFLD. Probiotics and synbiotics supplementation could significantly improve liver steatosis, alanine aminotransferase, aspartate aminotransferase, triglyceride, total cholesterol, high-density lipoprotein, low-density lipoprotein, homeostasis model assessment-insulin resistance, liver stiffness and tumor necrosis factor-alpha (all P < 0.05). But the supplementation could not ameliorate body mass index (mean difference [MD] = -0.00; 95% confidence interval [CI]: -0.22 to 0.22, P = 0.99), waist circumference (MD = -0.01; 95% CI -0.03 to 0.02, P = 0.57) and fasting blood sugar (standard mean difference [SMD] = -0.10; 95% CI -0.32 to 0.12, P = 0.39). CONCLUSION We present clear evidence for the benefit of probiotics and synbiotics supplementation for liver steatosis, liver enzymes, lipid profiles and liver stiffness in patients with NAFLD.
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Affiliation(s)
- Liang Liu
- School of Graduate, Tianjin Medical University, Tianjin, China.,Department of Hepatology, Tianjin Second People's Hospital, Tianjin, China
| | - Ping Li
- Department of Hepatology, Tianjin Second People's Hospital, Tianjin, China. .,Tianjin Research Institute of Liver Diseases, Tianjin, China.
| | - Yiqi Liu
- School of Graduate, Tianjin Medical University, Tianjin, China
| | - Yilian Zhang
- School of Graduate, Tianjin Medical University, Tianjin, China
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158
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Role of Probiotics in Non-alcoholic Fatty Liver Disease: Does Gut Microbiota Matter? Nutrients 2019; 11:nu11112837. [PMID: 31752378 PMCID: PMC6893593 DOI: 10.3390/nu11112837] [Citation(s) in RCA: 39] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2019] [Revised: 11/14/2019] [Accepted: 11/15/2019] [Indexed: 12/20/2022] Open
Abstract
Non-alcoholic fatty liver disease (NAFLD) is the hepatic consequence of metabolic syndrome, which often also includes obesity, diabetes, and dyslipidemia. The connection between gut microbiota (GM) and NAFLD has attracted significant attention in recent years. Data has shown that GM affects hepatic lipid metabolism and influences the balance between pro/anti-inflammatory effectors in the liver. Although studies reveal the association between GM dysbiosis and NAFLD, decoding the mechanisms of gut dysbiosis resulting in NAFLD remains challenging. The potential pathophysiology that links GM dysbiosis to NAFLD can be summarized as: (1) disrupting the balance between energy harvest and expenditure, (2) promoting hepatic inflammation (impairing intestinal integrity, facilitating endotoxemia, and initiating inflammatory cascades with cytokines releasing), and (3) altered biochemistry metabolism and GM-related metabolites (i.e., bile acid, short-chain fatty acids, aromatic amino acid derivatives, branched-chain amino acids, choline, ethanol). Due to the hypothesis that probiotics/synbiotics could normalize GM and reverse dysbiosis, there have been efforts to investigate the therapeutic effect of probiotics/synbiotics in patients with NAFLD. Recent randomized clinical trials suggest that probiotics/synbiotics could improve transaminases, hepatic steatosis, and reduce hepatic inflammation. Despite these promising results, future studies are necessary to understand the full role GM plays in NAFLD development and progression. Additionally, further data is needed to unravel probiotics/synbiotics efficacy, safety, and sustainability as a novel pharmacologic approaches to NAFLD.
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159
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Gut Microbiota and Obesity: A Role for Probiotics. Nutrients 2019; 11:nu11112690. [PMID: 31703257 PMCID: PMC6893459 DOI: 10.3390/nu11112690] [Citation(s) in RCA: 309] [Impact Index Per Article: 61.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2019] [Revised: 09/23/2019] [Accepted: 09/24/2019] [Indexed: 02/07/2023] Open
Abstract
Nowadays, obesity is one of the most prevalent human health problems. Research from the last 30 years has clarified the role of the imbalance between energy intake and expenditure, unhealthy lifestyle, and genetic variability in the development of obesity. More recently, the composition and metabolic functions of gut microbiota have been proposed as being able to affect obesity development. Here, we will report the current knowledge on the definition, composition, and functions of intestinal microbiota. We have performed an extensive review of the literature, searching for the following keywords: metabolism, gut microbiota, dysbiosis, obesity. There is evidence for the association between gut bacteria and obesity both in infancy and in adults. There are several genetic, metabolic, and inflammatory pathophysiological mechanisms involved in the interplay between gut microbes and obesity. Microbial changes in the human gut can be considered a factor involved in obesity development in humans. The modulation of the bacterial strains in the digestive tract can help to reshape the metabolic profile in the human obese host as suggested by several data from animal and human studies. Thus, a deep revision of the evidence pertaining to the use probiotics, prebiotics, and antibiotics in obese patients is conceivable
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160
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Meroni M, Longo M, Dongiovanni P. The Role of Probiotics in Nonalcoholic Fatty Liver Disease: A New Insight into Therapeutic Strategies. Nutrients 2019; 11:nu11112642. [PMID: 31689910 PMCID: PMC6893730 DOI: 10.3390/nu11112642] [Citation(s) in RCA: 77] [Impact Index Per Article: 15.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2019] [Revised: 10/25/2019] [Accepted: 10/28/2019] [Indexed: 12/12/2022] Open
Abstract
Nonalcoholic fatty liver disease (NAFLD) encompasses a broad spectrum of pathological hepatic conditions ranging from simple steatosis to nonalcoholic steatohepatitis (NASH), which may predispose to liver cirrhosis and hepatocellular carcinoma (HCC). Due to the epidemic obesity, NAFLD is representing a global health issue and the leading cause of liver damage worldwide. The pathogenesis of NAFLD is closely related to insulin resistance (IR), adiposity and physical inactivity as well as genetic and epigenetic factors corroborate to the development and progression of hepatic steatosis and liver injury. Emerging evidence has outlined the implication of gut microbiota and gut-derived endotoxins as actively contributors to NAFLD pathophysiology probably due to the tight anatomo-functional crosstalk between the gut and the liver. Obesity, nutrition and environmental factors might alter intestinal permeability producing a favorable micro-environment for bacterial overgrowth, mucosal inflammation and translocation of both invasive pathogens and harmful byproducts, which, in turn, influence hepatic fat composition and exacerbated pro-inflammatory and fibrotic processes. To date, no therapeutic interventions are available for NAFLD prevention and management, except for modifications in lifestyle, diet and physical exercise even though they show discouraging results due to the poor compliance of patients. The premise of this review is to discuss the role of gut–liver axis in NAFLD and emphasize the beneficial effects of probiotics on gut microbiota composition as a novel attractive therapeutic strategy to introduce in clinical practice.
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Affiliation(s)
- Marica Meroni
- General Medicine and Metabolic Diseases, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Pad. Granelli, via F Sforza 35, 20122 Milan, Italy.
- Department of Pathophysiology and Transplantation, Università degli Studi di Milano, 20122 Milano, Italy.
| | - Miriam Longo
- General Medicine and Metabolic Diseases, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Pad. Granelli, via F Sforza 35, 20122 Milan, Italy.
- Department of Clinical Sciences and Community Health, Università degli Studi di Milano, 20122 Milano, Italy.
| | - Paola Dongiovanni
- General Medicine and Metabolic Diseases, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Pad. Granelli, via F Sforza 35, 20122 Milan, Italy.
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161
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Abstract
PURPOSE OF REVIEW There is growing evidence encouraging the use of probiotics in many conditions in children. However, given the wide number of probiotics available and contradictory data in the literature, the health-care provider is often faced with uncertainness about whether or not to use probiotics and which one(s) to choose. We here review current hypotheses regarding the efficacy and safety of probiotics and evaluate the available data on the use of probiotics in most common diseases in children. Considering that probiotics have strain-specific effects, we will focus on individual probiotic strains rather than on probiotics in general. RECENT FINDINGS Strain-specific efficacy was clearly demonstrated with Lactobacillus rhamnosus GG and Saccharomyces boulardii I-745 in the treatment of acute infectious diarrhea, Lactobacillus reuteri DSM 17938 in infantile colics, Lactobacillus rhamnosus GG, and VSL#3 in irritable bowel syndrome. In addition, encouraging results are seen for use of probiotics in necrotizing enterocolitis, food allergy, and nonalcoholic fatty liver disease. However, the data available for constipation are to be considered somewhat equivocal. SUMMARY The clinical relevance of these findings indicates that healthcare providers need to take strain-specificity and disease specificity of probiotics into consideration when recommending probiotic for their patients.
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162
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Tang Y, Huang J, Zhang WY, Qin S, Yang YX, Ren H, Yang QB, Hu H. Effects of probiotics on nonalcoholic fatty liver disease: a systematic review and meta-analysis. Therap Adv Gastroenterol 2019; 12:1756284819878046. [PMID: 31598135 PMCID: PMC6764034 DOI: 10.1177/1756284819878046] [Citation(s) in RCA: 50] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2019] [Accepted: 08/23/2019] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Nonalcoholic fatty liver disease (NAFLD) has become prevalent in recent decades, especially in developed countries, and approaches for the prevention and treatment of NAFLD are not clear. The aim of this research was to analyze and summarize randomized controlled trials that investigated the effects of probiotics on NAFLD. METHODS Seven databases (PubMed, Embase, the Web of Science, the Cochrane Library, China National Knowledge Infrastructure, Wan Fang Data, and VIP Database) were searched. Then, eligible studies were identified. Finally, proper data extraction, synthesis and analysis were performed by trained researchers. RESULTS Anthropometric parameters: with use of probiotics weight was reduced by 2.31 kg, and body mass index (BMI) was reduced by 1.08 kg/m2. Liver function: probiotic treatment reduced the alanine aminotransferase level by 7.22 U/l, the aspartate aminotransferase level by 7.22 U/l, the alkaline phosphatase level by 25.87 U/l, and the glutamyl transpeptidase level by -5.76 U/l. Lipid profiles: total cholesterol, low-density lipoprotein cholesterol, and triglycerides were significantly decreased after probiotic treatment. Their overall effects (shown as standard mean difference) were -0.73, -0.54, and -0.36, respectively. Plasma glucose: probiotics reduced the plasma glucose level by 4.45 mg/dl and the insulin level by 0.63. Cytokines: probiotic treatment decreased tumor necrosis factor alpha by 0.62 and leptin by 1.14. Degree of liver fat infiltration (DFI): the related risk of probiotics for restoring DFI was 2.47 (95% confidence interval, 1.61-3.81, p < 0.001). CONCLUSION Probiotic treatment or supplementation is a promising therapeutic method for NAFLD.
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Affiliation(s)
- Yao Tang
- Department of Clinical Nutrition, The Second
Affiliated Hospital of Chongqing Medical University, Chongqing, China,Institute for Viral Hepatitis, Key Laboratory of
Molecular Biology for Infectious Diseases (Ministry of Education),
Department of Infectious Diseases, The Second Affiliated Hospital of
Chongqing Medical University, Chongqing, China
| | - Juan Huang
- Department of Clinical Nutrition, The Second
Affiliated Hospital of Chongqing Medical University, Chongqing, China,Institute for Viral Hepatitis, Key Laboratory of
Molecular Biology for Infectious Diseases (Ministry of Education),
Department of Infectious Diseases, The Second Affiliated Hospital of
Chongqing Medical University, Chongqing, China
| | - Wen yue Zhang
- Department of Clinical Nutrition, The Second
Affiliated Hospital of Chongqing Medical University, Chongqing, China,Institute for Viral Hepatitis, Key Laboratory of
Molecular Biology for Infectious Diseases (Ministry of Education),
Department of Infectious Diseases, The Second Affiliated Hospital of
Chongqing Medical University, Chongqing, China
| | - Si Qin
- Center for Endocrine Diseases, The Third
Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Yi xuan Yang
- Institute for Viral Hepatitis, Key Laboratory of
Molecular Biology for Infectious Diseases (Ministry of Education),
Department of Infectious Diseases, The Second Affiliated Hospital of
Chongqing Medical University, Chongqing, China
| | - Hong Ren
- Institute for Viral Hepatitis, Key Laboratory of
Molecular Biology for Infectious Diseases (Ministry of Education),
Department of Infectious Diseases, The Second Affiliated Hospital of
Chongqing Medical University, Chongqing, China
| | - Qin-bing Yang
- Department of Clinical Nutrition, Tsinghua
University, Beijing, China
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163
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Loman BR, Hernández-Saavedra D, An R, Rector RS. Prebiotic and probiotic treatment of nonalcoholic fatty liver disease: a systematic review and meta-analysis. Nutr Rev 2019; 76:822-839. [PMID: 30113661 DOI: 10.1093/nutrit/nuy031] [Citation(s) in RCA: 93] [Impact Index Per Article: 18.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Context Nonalcoholic fatty liver disease (NAFLD) is a highly prevalent and underdiagnosed comorbidity of many chronic diseases that is associated with altered intestinal bacterial communities. This association has prompted research into alternative treatments aimed at modulating intestinal microbiota. Given the novelty of these treatments, scarce evidence regarding their effectiveness in clinical populations exists. Objective This meta-analysis sought to systemically review and quantitatively synthesize evidence on prebiotic, probiotic, and synbiotic therapies for patients with NAFLD in randomized controlled trials. Data sources PRISMA guidelines ensured transparent reporting of evidence. PICOS criteria defined the research question for the systematic review. A systematic keyword search in PubMed and EMBASE identified 25 studies: 9 assessed prebiotic, 11 assessed probiotic, and 7 assessed symbiotic therapies for a total of 1309 patients. Data extraction Basic population characteristics, the primary variables of aspartate aminotransferase (AST) and alanine aminotransferase (ALT) (utilized for NAFLD diagnosis), and the secondary variables of body mass index (BMI), gamma-glutamyl transferase (γ-GT), tumor necrosis factor alpha (TNF-α), C-reactive protein (CRP), total cholesterol, high-density lipoprotein cholesterol (HDL-c), low-density lipoprotein cholesterol (LDL-c), and triglyceridges (TAG) were extracted. Pooled effect sizes of these variables were calculated by meta-analysis. No publication bias was identified using Begg's and Egger's tests or Cochrane bias assessment tool. Results Meta-analysis indicated that microbial therapies significantly reduced BMI (-0.37 kg/m2; 95% confidence interval [CI], -0.46 to -0.28; P < 0.001), hepatic enzymes (ALT, -6.9 U/L [95%CI, -9.4 to -4.3]; AST, -4.6 U/L [95%CI, -6.6 to -2.7]; γ-GT, -7.9 U/L [95%CI, -11.4 to -4.4]; P < 0.001), serum cholesterol (-10.1 mg/dL 95%CI, -13.6 to -6.6; P < 0.001), LDL-c (-4.5 mg/dL; 95%CI, -8.9 to -0.17; P < 0.001), and TAG (-10.1 mg/dL; 95%CI, -18.0 to -2.3; P < 0.001), but not inflammation (TNF-α, -2.0 ng/mL; [95%CI, -4.7 to 0.61]; CRP, -0.74 mg/L [95%CI, -1.9 to 0.37]). Subgroup analysis by treatment category indicated similar effects of prebiotics and probiotics on BMI and liver enzymes but not total cholesterol, HDL-c, and LDL-c. Conclusion This meta-analysis supports the potential use of microbial therapies in the treatment of NAFLD and sheds light on their potential mode of action. Further research into these treatments should consider the limitations of biomarkers currently used for the diagnosis and progression of NAFLD, in addition to the inherent challenges of personalized microbial-based therapies.
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Affiliation(s)
- Brett R Loman
- Division of Nutritional Sciences, College of Agricultural, Consumer and Environmental Sciences, University of Illinois, Urbana-Champaign, Illinois.,Center for Microbial Pathogenesis, The Research Institute at Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Diego Hernández-Saavedra
- Division of Nutritional Sciences, College of Agricultural, Consumer and Environmental Sciences, University of Illinois, Urbana-Champaign, Illinois, USA
| | - Ruopeng An
- Department of Kinesiology and Community Health, College of Applied Health Sciences, University of Illinois at Urbana-Champaign, Champaign, Illinois, USA
| | - R Scott Rector
- Department of Medicine, Division of Gastroenterology and Hepatology, and Department of Nutrition and Exercise Physiology, University of Missouri-Columbia, Columbia, Missouri, USA
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164
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Koopman N, Molinaro A, Nieuwdorp M, Holleboom AG. Review article: can bugs be drugs? The potential of probiotics and prebiotics as treatment for non-alcoholic fatty liver disease. Aliment Pharmacol Ther 2019; 50:628-639. [PMID: 31373710 DOI: 10.1111/apt.15416] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2019] [Revised: 05/06/2019] [Accepted: 06/23/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND Non-alcoholic fatty liver disease (NAFLD) has become the most common chronic liver condition. A major current research effort is ongoing to find potential strategies to treat NAFLD-non-alcoholic steatohepatitis (NASH), with special attention to the gut microbiota. Multiple animal studies and pilot clinical trials are assessing different gut microbiota modulating strategies such as faecal microbiota transplantation, antibiotics, probiotics, prebiotics and synbiotics. AIM To review the role of microbiota in NAFLD-NASH and determine whether pro- and prebiotics have potential as treatment METHODS: Information was obtained from critically reviewing literature on PubMed on targeting the gut microbiota in NAFLD. Search terms included NAFLD, NASH, non-alcoholic fatty liver disease, steatohepatitis; combined with microbiome, microbiota, gut bacteria, probiotics and prebiotics. RESULTS Animal studies and the first emerging studies in humans show promising results for both the common probiotics Lactobacillus, Bifidobacterium and Streptococci as for short chain fatty acid (SCFA) butyrate-producing bacteria. Also, prebiotics have positive effects on different mechanisms underlying NAFLD-NASH. CONCLUSIONS The most promising strategies thus far developed to alter the microbiome in NAFLD-NASH are probiotics and prebiotics. However, pre- and probiotic treatment of NAFLD-NASH is relatively new and still under development. Actual understanding of the involved mechanisms is lacking and changes in the intestinal microbiota composition after treatment are rarely measured. Furthermore, large clinical trials with comparative endpoints are unavailable. Personalised treatment based on metagenomics gut microbiota analysis will probably be part of the future diagnosis and treatment of NAFLD-NASH.
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Affiliation(s)
- Nienke Koopman
- Department of Molecular Biology and Microbial Food Safety, Swammerdam Institute for Life Sciences, University of Amsterdam, Amsterdam, The Netherlands
| | - Antonio Molinaro
- Wallenberg Laboratory, Department of Molecular and Clinical Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Max Nieuwdorp
- Vascular Medicine, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Adriaan G Holleboom
- Vascular Medicine, Amsterdam University Medical Center, Amsterdam, The Netherlands
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165
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NAFLD in children: new genes, new diagnostic modalities and new drugs. Nat Rev Gastroenterol Hepatol 2019; 16:517-530. [PMID: 31278377 DOI: 10.1038/s41575-019-0169-z] [Citation(s) in RCA: 184] [Impact Index Per Article: 36.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/04/2019] [Indexed: 12/13/2022]
Abstract
Nonalcoholic fatty liver disease (NAFLD) has rapidly become the most common form of chronic liver disease in children and adolescents. Over the past 5 years, developments have revolutionized our understanding of the genetic factors, natural history, diagnostic modalities and therapeutic targets for this disease. New polymorphisms, such as those in PNPLA3, TM6SF2, MBOAT7 and GCKR, have been identified and used to predict the development and severity of NAFLD in both adults and children, and their interaction with environmental factors has been elucidated. Studies have demonstrated the true burden of paediatric NAFLD and its progression to end-stage liver disease in adulthood. In particular, nonalcoholic steatohepatitis can progress to advanced fibrosis and cirrhosis, emphasizing the importance of early diagnosis. Non-invasive imaging tests, such as transient elastography, will probably replace liver biopsy for the diagnosis of nonalcoholic steatohepatitis and the assessment of fibrosis severity in the near future. The therapeutic landscape is also expanding rapidly with the development of drugs that can modify liver steatosis, inflammation and fibrosis, indicating that pharmacotherapy for NAFLD will become available in the future. In this Review, we summarize current knowledge and new advances related to the pathogenesis and management of paediatric NAFLD.
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166
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Di Sessa A, Cirillo G, Guarino S, Marzuillo P, Miraglia Del Giudice E. Pediatric non-alcoholic fatty liver disease: current perspectives on diagnosis and management. PEDIATRIC HEALTH MEDICINE AND THERAPEUTICS 2019; 10:89-97. [PMID: 31692530 PMCID: PMC6711552 DOI: 10.2147/phmt.s188989] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/07/2019] [Accepted: 08/13/2019] [Indexed: 12/14/2022]
Abstract
Non-alcoholic fatty liver disease (NAFLD) represents the most common cause of chronic liver disease in childhood. To date, the “multiple-hit” hypothesis is largely recognized as an explanation of NAFLD pathogenesis and progression. Obesity and features of the metabolic syndrome have been closely linked to NAFLD development. Due to the increased prevalence of obesity worldwide, NAFLD has reached epidemic proportions over time. Given its unfavorable cardiometabolic burden (such as cardiovascular and metabolic consequences), it represents a worrying phenomenon needing a more comprehensive and successful management. Laboratory tests and classical imaging techniques play a pivotal role in NAFLD diagnosis, but novel noninvasive alternative methods to diagnose and monitor NAFLD have been investigated. Currently, lifestyle modifications remain the mainstay treatment, although its efficacy is poor because of the lack of compliance. Pediatric research is focusing on multiple alternative treatments targeting the main pathogenic factors such as insulin-resistance, dyslipidemia, gut-liver axis and microbiota, oxidative stress, and proinflammatory pathways. Results from these studies are promising but larger validation is needed. Innovative therapeutic approaches might add an important piece in the complex knowledge of pediatric NAFLD. We aimed to summarize recent insights into NAFLD diagnosis and treatment in children, with a focus on possible future perspectives in pediatric research.
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Affiliation(s)
- Anna Di Sessa
- Department of Woman, Child and General and Specialized Surgery, University of Studies of Campania "Luigi Vanvitelli", Napoli 80138, Italy
| | - Grazia Cirillo
- Department of Woman, Child and General and Specialized Surgery, University of Studies of Campania "Luigi Vanvitelli", Napoli 80138, Italy
| | - Stefano Guarino
- Department of Woman, Child and General and Specialized Surgery, University of Studies of Campania "Luigi Vanvitelli", Napoli 80138, Italy
| | - Pierluigi Marzuillo
- Department of Woman, Child and General and Specialized Surgery, University of Studies of Campania "Luigi Vanvitelli", Napoli 80138, Italy
| | - Emanuele Miraglia Del Giudice
- Department of Woman, Child and General and Specialized Surgery, University of Studies of Campania "Luigi Vanvitelli", Napoli 80138, Italy
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167
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Duseja A, Acharya SK, Mehta M, Chhabra S, Rana S, Das A, Dattagupta S, Dhiman RK, Chawla YK. High potency multistrain probiotic improves liver histology in non-alcoholic fatty liver disease (NAFLD): a randomised, double-blind, proof of concept study. BMJ Open Gastroenterol 2019; 6:e000315. [PMID: 31423319 PMCID: PMC6688701 DOI: 10.1136/bmjgast-2019-000315] [Citation(s) in RCA: 65] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2019] [Revised: 07/05/2019] [Accepted: 07/19/2019] [Indexed: 12/17/2022] Open
Abstract
Objective Pharmacological treatment of non-alcoholic fatty liver disease (NAFLD) is still evolving. Probiotics could be a promising treatment option, but their effectiveness needs to be established. The present study aimed to evaluate the efficacy of a high potency multistrain probiotic in adult patients with NAFLD. Methods Thirty-nine liver biopsy-proven patients with NAFLD were randomised in a double-blind fashion to either lifestyle modifications plus an oral multistrain probiotic (675 billion bacteria daily, n=19) or identical placebo (n=20) for 1 year. Lifestyle modifications included regular exercise for all and control of overweight/obesity (with additional dietary restrictions), hypertension and hyperlipidaemia in those with these risk factors. Primary objective of the study was the histological improvement in NAFLD activity score (NAS) and its components and secondary objectives were improvement in alanine transaminase (ALT) and cytokine profile. Results Thirty (76.9%) out of 39 patients with NAFLD completed the study with 1 year of follow-up. A repeat liver biopsy at 1 year could be done in 10 patients (52.6%) in probiotic group and five patients (25%) in placebo group. In comparison to baseline, hepatocyte ballooning (p=0.036), lobular inflammation (p=0.003) and NAS score (p=0.007) improved significantly at 1 year in the probiotic group. When compared with placebo, the NAS score improved significantly in the probiotic group (p=0.004), along with improvements in hepatocyte ballooning (p=0.05) and hepatic fibrosis (p=0.018). A significant improvement in levels of ALT (p=0.046), leptin (p=0.006), tumour necrosis factor-α (p=0.016) and endotoxins (p=0.017) was observed in probiotic group in comparison to placebo at 1 year. No significant adverse events were reported in the study. Conclusion Patients with NAFLD managed with lifestyle modifications and multistrain probiotic showed significant improvement in liver histology, ALT and cytokines. Trial registration number The clinical trial is registered with CLINICAL TRIAL REGISTRYINDIA (CTRI); http://ctri.nic.in, No. CTRI/2008/091/000074
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Affiliation(s)
- Ajay Duseja
- Department of Hepatology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Subrat K Acharya
- Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi, India
| | - Manu Mehta
- Department of Hepatology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Shruti Chhabra
- Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi, India
| | | | - Satyavati Rana
- Department of Gastroenterology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Ashim Das
- Department of Histopathology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | | | - Radha K Dhiman
- Department of Hepatology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Yogesh K Chawla
- Department of Hepatology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
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168
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Yan S, Tian Z, Li M, Li B, Cui W. Effects of probiotic supplementation on the regulation of blood lipid levels in overweight or obese subjects: a meta-analysis. Food Funct 2019; 10:1747-1759. [PMID: 30860222 DOI: 10.1039/c8fo02163e] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Obesity is a risk factor for many deadly diseases. Meanwhile, the prevalence of obesity has been continuously increasing in many countries. Probiotics are defined as live microorganisms that confer health benefits on hosts. Probiotic supplementation could reduce body weight, body mass index (BMI) and fat percentage. However, it is unclear whether supplementation with probiotics is beneficial to lower blood lipid levels for obese or overweight people. METHODS In this study, a comprehensive search across multiple databases was performed to identify studies that focused on the effects of probiotics on blood lipid levels in overweight or obese subjects. The meta-analysis included studies that compared the variations in blood lipid (total cholesterol (TC), low density lipoprotein (LDL), high density lipoprotein (HDL) and triglyceride (TG)) concentrations between overweight and obese subjects who were supplemented with probiotics versus the controls who were not supplemented with probiotics. RESULTS Our findings indicated that probiotic supplementation in obese or overweight people was associated with significantly larger reductions in TC and LDL levels compared to a lack of probiotic supplementation in the control subjects. However, there was no significant difference in the variations between HDL and TG concentrations. CONCLUSION Probiotic supplementation reduced TC and LDL concentrations in obese or overweight people. Additional data from large clinical trials are required to confirm the efficacy and safety of probiotics in the regulation of blood lipid levels in obese or overweight people.
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Affiliation(s)
- Shoumeng Yan
- Department of Epidemiology and Biostatistics, School of Public Health, Jilin University, Changchun, 130021, P. R. China.
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169
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Schwenger KJ, Clermont-Dejean N, Allard JP. The role of the gut microbiome in chronic liver disease: the clinical evidence revised. JHEP Rep 2019; 1:214-226. [PMID: 32039372 PMCID: PMC7001555 DOI: 10.1016/j.jhepr.2019.04.004] [Citation(s) in RCA: 76] [Impact Index Per Article: 15.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2019] [Revised: 04/08/2019] [Accepted: 04/27/2019] [Indexed: 02/07/2023] Open
Abstract
Recent research has suggested a role for the intestinal microbiota in the pathogenesis and potential treatment of a wide range of liver diseases. The intestinal microbiota and bacterial products may contribute to the development of liver diseases through multiple mechanisms including increased intestinal permeability, chronic systemic inflammation, production of short-chain fatty acids and changes in metabolism. This suggests a potential role for pre-, pro- and synbiotic products in the prevention or treatment of some liver diseases. In addition, there is emerging evidence on the effects of faecal microbial transplant. Herein, we discuss the relationship between the intestinal microbiota and liver diseases, as well as reviewing intestinal microbiota-based treatment options that are currently being investigated.
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Affiliation(s)
- Katherine Jp Schwenger
- Toronto General Hospital, University Health Network, Toronto, Canada.,Department of Medicine, University of Toronto, Toronto, Canada
| | | | - Johane P Allard
- Toronto General Hospital, University Health Network, Toronto, Canada.,Department of Medicine, University of Toronto, Toronto, Canada.,Department of Nutritional Sciences, University of Toronto, Toronto, Canada
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170
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Kim JC, Jeon JY, Yang WS, Kim CH, Eom DW. Combined Amelioration of Ginsenoside (Rg1, Rb1, and Rg3)-enriched Korean Red Ginseng and Probiotic Lactobacillus on Non-alcoholic Fatty Liver Disease. Curr Pharm Biotechnol 2019; 20:222-231. [PMID: 30854954 DOI: 10.2174/1389201020666190311143554] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2018] [Revised: 11/15/2018] [Accepted: 02/15/2019] [Indexed: 02/06/2023]
Abstract
BACKGROUND Red ginseng is a traditional medicine that has been used to treat numerous metabolic and inflammatory diseases. Probiotic administration has been established to have beneficial effects in non-alcoholic fatty liver disease (NAFLD). The purpose of this study was to determine whether a combination of Korean red ginseng (KRG) and probiotics could synergistically reduce NAFLD and liver inflammation compared with the effects reported for each individual product. METHOD db/db and C57BL/6 mice were fed a normal chow diet and high-fat diet (HFD), respectively, and were treated with KRG, probiotics, or both. Samples were examined for lipid content, kinase protein phosphorylation, and gene expression patterns. RESULTS KRG- and probiotic-treated HFD-fed mice exhibited a reduction in body weight and a decrease in inflammatory cytokine secretion compared with the non-treated control mice. The same treatment was less successful in improving NAFLD parameters in the db/db mice while the combination of both products did not enhance their therapeutic potential. CONCLUSION The results of this study indicate that KRG and probiotics administration ameliorated NAFLD symptoms in a mouse model of dyslipidemia by reducing weight gain and liver inflammation. Coadministration of both products did not enhance their efficacy, and further research should be conducted to clarify their mechanisms of action.
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Affiliation(s)
- Jin-Chul Kim
- Natural Product Research Institute, Korea Institute of Science and Technology, Gangneung, Korea
| | - Joo-Yeong Jeon
- Natural Product Research Institute, Korea Institute of Science and Technology, Gangneung, Korea
| | | | - Cheorl-Ho Kim
- Department of Biological Sciences, SungKyunKwan University, Suwon, Kyungki-do, Korea
| | - Dae-Woon Eom
- Department of Pathology, Gangneung Asan Hospital, University of Ulsan College of Medicine, Gangneung, Korea
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171
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Zhu K, Tan F, Mu J, Yi R, Zhou X, Zhao X. Anti-Obesity Effects of Lactobacillus fermentum CQPC05 Isolated from Sichuan Pickle in High-Fat Diet-Induced Obese Mice through PPAR-α Signaling Pathway. Microorganisms 2019; 7:microorganisms7070194. [PMID: 31284674 PMCID: PMC6680547 DOI: 10.3390/microorganisms7070194] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2019] [Revised: 06/29/2019] [Accepted: 07/03/2019] [Indexed: 01/21/2023] Open
Abstract
Sichuan pickle is a traditional fermented food in China which is produced by the spontaneous fermentation of Chinese cabbage. In this study, the anti-obesity effects of a new lactic acid bacterium (Lactobacillus fermentum CQPC05, LF-CQPC05) isolated from Sichuan pickles were assessed in vivo. An obese animal model was established in mice by inducing obesity with high-fat diet. Both serum and tissues were collected from the mice, and then subjected to qPCR and Western blot analyses. The results showed that LF-CQPC05 could decrease the values of hepatosomatic, epididymal fat, and perirenal fat indices that were induced by a high-fat diet in mice. Moreover, LF-CQPC05 reduced the levels of alanine aminotransferase (ALT), aspartate aminotransaminase (AST), total cholesterol (TC), triglyceride (TG), and low-density lipoprotein cholesterol (LDL-C), and increased the level of high-density lipoprotein cholesterol (HDL-C) in both serum samples and liver tissues of obese mice fed with a high-fat diet. Pathological observations demonstrated that LF-CQPC05 could alleviate the obesity-induced pathological changes in the liver tissue of mice, and reduce the degree of adipocyte enlargement. The results of qPCR and Western blot analyses further indicated that LF-CQPC05 upregulated the mRNA and protein expression levels of lipoprotein lipase (LPL), PPAR-α: peroxisome proliferator-activated receptor-alpha (PPAR-α), (cholesterol 7 alpha-hydroxylase) CYP7A1, and carnitine palmitoyltransferase 1 (CPT1A), and downregulated the expression levels of peroxisome proliferator-activated receptor-gamma (PPAR-γ) and CCAAT enhancer-binding protein alpha (C/EBP-α) in both liver tissue and epididymal adipose tissue. Taken altogether, this study reveals that LF-CQPC05 can effectively inhibit high-fat diet-induced obesity. Its anti-obesity effect is comparable to that of l-carnitine, and is superior to that of Lactobacillus delbrueckii subsp. bulgaricus, a common strain used in the dairy industry. Therefore, LF-CQPC05 is a high-quality microbial strain with probiotic potential.
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Affiliation(s)
- Kai Zhu
- Chongqing Collaborative Innovation Center for Functional Food, Chongqing University of Education, Chongqing 400067, China
- Children's Research Institute, Chongqing University of Education, Chongqing 400067, China
- Chongqing Engineering Research Center of Functional Food, Chongqing University of Education, Chongqing 400067, China
- Chongqing Engineering Laboratory for Research and Development of Functional Food, Chongqing University of Education, Chongqing 400067, China
| | - Fang Tan
- Department of Public Health, Our Lady of Fatima University, Valenzuela 838, Philippines
| | - Jianfei Mu
- Chongqing Collaborative Innovation Center for Functional Food, Chongqing University of Education, Chongqing 400067, China
- College of Food Science, Southwest University, Chongqing 400715, China
| | - Ruokun Yi
- Chongqing Collaborative Innovation Center for Functional Food, Chongqing University of Education, Chongqing 400067, China
- Chongqing Engineering Research Center of Functional Food, Chongqing University of Education, Chongqing 400067, China
- Chongqing Engineering Laboratory for Research and Development of Functional Food, Chongqing University of Education, Chongqing 400067, China
| | - Xianrong Zhou
- Chongqing Collaborative Innovation Center for Functional Food, Chongqing University of Education, Chongqing 400067, China
- College of Food Science, Southwest University, Chongqing 400715, China
| | - Xin Zhao
- Chongqing Collaborative Innovation Center for Functional Food, Chongqing University of Education, Chongqing 400067, China.
- Children's Research Institute, Chongqing University of Education, Chongqing 400067, China.
- Chongqing Engineering Research Center of Functional Food, Chongqing University of Education, Chongqing 400067, China.
- Chongqing Engineering Laboratory for Research and Development of Functional Food, Chongqing University of Education, Chongqing 400067, China.
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172
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Jayakumar S, Loomba R. Review article: emerging role of the gut microbiome in the progression of nonalcoholic fatty liver disease and potential therapeutic implications. Aliment Pharmacol Ther 2019; 50:144-158. [PMID: 31149745 PMCID: PMC6771496 DOI: 10.1111/apt.15314] [Citation(s) in RCA: 45] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2018] [Revised: 10/24/2018] [Accepted: 04/30/2019] [Indexed: 02/06/2023]
Abstract
BACKGROUND Nonalcoholic fatty liver disease (NAFLD) is a prevalent disorder associated with obesity and diabetes. Few treatment options are effective for patients with NAFLD, but connections between the gut microbiome and NAFLD and NAFLD-associated conditions suggest that modulation of the gut microbiota could be a novel therapeutic option. AIM To examine the effect of the gut microbiota on pathophysiologic causes of NAFLD and assess the potential of microbiota-targeting therapies for NAFLD. METHODS A PubMed search of the literature was performed; relevant articles were included. RESULTS The composition of bacteria in the gastrointestinal tract can enhance fat deposition, modulate energy metabolism and alter inflammatory processes. Emerging evidence suggests a role for the gut microbiome in obesity and metabolic syndrome. NAFLD is often considered the hepatic manifestation of metabolic syndrome, and there has been tremendous progress in understanding the association of gut microbiome composition with NAFLD disease severity. We discuss the role of the gut microbiome in NAFLD pathophysiology and whether the microbiome composition can differentiate the two categories of NAFLD: nonalcoholic fatty liver (NAFL, the non-progressive form) vs nonalcoholic steatohepatitis (NASH, the progressive form). The association between gut microbiome and fibrosis progression in NAFLD is also discussed. Finally, we review whether modulation of the gut microbiome plays a role in improving treatment outcomes for patients with NAFLD. CONCLUSIONS Multiple pathophysiologic pathways connect the gut microbiome with the pathophysiology of NAFLD. Therefore, therapeutics that effectively target the gut microbiome may be beneficial for the treatment of patients with NAFLD.
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Affiliation(s)
- Saumya Jayakumar
- Division of Gastroenterology and Hepatology, Department of MedicineNAFLD Research Center, University of California at San DiegoLa JollaCalifornia
| | - Rohit Loomba
- Division of Gastroenterology and Hepatology, Department of MedicineNAFLD Research Center, University of California at San DiegoLa JollaCalifornia,Division of Epidemiology, Department of Family Medicine and Public HealthUniversity of California at San DiegoLa JollaCalifornia
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173
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Mann JP, Tang GY, Nobili V, Armstrong MJ. Evaluations of Lifestyle, Dietary, and Pharmacologic Treatments for Pediatric Nonalcoholic Fatty Liver Disease: A Systematic Review. Clin Gastroenterol Hepatol 2019; 17:1457-1476.e7. [PMID: 29857146 DOI: 10.1016/j.cgh.2018.05.023] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2018] [Revised: 05/06/2018] [Accepted: 05/20/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS There are no approved treatments for pediatric nonalcoholic fatty liver disease (NAFLD) and there is a lack of consensus on the best outcome measure for randomized controlled trials. We performed a systematic review of treatments tested for pediatric NAFLD, the degree of heterogeneity in trial design, and endpoints analyzed in these studies. METHODS We searched publication databases and clinical trial registries through January 7, 2018 for randomized controlled trials (published and underway) of children (<18 years) with NAFLD. We assessed improvements in histologic features, radiologic and biochemical markers of reduced fibrosis, metabolic syndrome parameters, and adverse events. The quality of the trials was assessed using a modified version of the Cochrane risk of bias tool. RESULTS Our final analysis included 21 randomized controlled trials, comprising 1307 participants (mean age, 12.6 years; 63% male; mean duration of intervention, 8 months). Most studies evaluated weight loss with lifestyle intervention (n=8), oral polyunsaturated fatty acid treatment (PUFAs, n=6), or oral antioxidant treatment (n=7). Biomarkers of NAFLD decreased with weight loss, but most studies did not include histologic data. Trials of antioxidants were heterogeneous; some reported reduced histologic features of steatohepatitis with no effect on triglycerides or insulin resistance. PUFAs and probiotics reduced radiologic markers of steatosis, insulin resistance, and levels of triglycerides. Only 38% of the trials had biopsy-proven NAFLD as an inclusion criterion. There was heterogeneity in trial primary endpoints; 10 studies (48%) used levels of aminotransferases or ultrasonography findings as a primary endpoint and only 3 trials (14%) used histologic features as the primary endpoint. We identified 13 randomized controlled trials that are underway in children with NAFLD. None of the protocols include collection of liver biopsies; 9 trials (69%) will use magnetic resonance imaging quantification of steatosis as a primary outcome. CONCLUSIONS In a systematic review of published and active randomized controlled trials of children with NAFLD, we found a large amount of heterogeneity in study endpoints and inclusion criteria. Few trials included histologic analyses. Antioxidants appear to reduce some features of steatohepatitis. Effects of treatment with lifestyle modification, PUFAs, or probiotics have not been validated with histologic analysis. Trials that are underway quantify steatosis magnetic resonance imaging-outcomes are anticipated.
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Affiliation(s)
- Jake Peter Mann
- Metabolic Research Laboratories, Institute of Metabolic Science, University of Cambridge, Cambridge, United Kingdom; Department of Paediatrics, University of Cambridge, Cambridge, United Kingdom.
| | - George Yizhou Tang
- Clinical School of Medicine, Addenbrooke's Hospital, Cambridge, United Kingdom
| | - Valerio Nobili
- Department of Pediatrics, University "La Sapienza," Rome, Italy; Hepatology, Gastroenterology, and Nutrition, Bambino Gesù Hospital, Rome, Italy
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174
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Zhou R, Fan X, Schnabl B. Role of the intestinal microbiome in liver fibrosis development and new treatment strategies. Transl Res 2019; 209:22-38. [PMID: 30853445 DOI: 10.1016/j.trsl.2019.02.005] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2018] [Revised: 01/26/2019] [Accepted: 02/14/2019] [Indexed: 02/06/2023]
Abstract
Liver cirrhosis is a major cause of morbidity and mortality worldwide. The most common chronic liver diseases in western countries are alcohol-associated liver disease (ALD) and non-alcoholic fatty liver disease (NAFLD). Although these diseases have different causes, liver fibrosis develops via shared mechanisms. The liver and intestinal microbiome are linked by the portal vein and have bidirectional interactions. Changes in the intestinal microbiome contribute to the pathogenesis and progression of liver diseases including ALD, NAFLD, viral hepatitis and cholestatic disorders, based on studies in patients and animal models. Intestinal microbial dysbiosis has been associated with liver cirrhosis and its complications. We review the mechanisms by which alterations in the microbiome contribute to liver fibrosis and discuss microbiome-based treatment approaches.
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Affiliation(s)
- Rongrong Zhou
- Department of Infectious Diseases, Xiangya Hospital, Central South University, and Key Laboratory of Viral Hepatitis, Changsha, Hunan, China; Department of Medicine, University of California San Diego, La Jolla, California
| | - Xuegong Fan
- Department of Infectious Diseases, Xiangya Hospital, Central South University, and Key Laboratory of Viral Hepatitis, Changsha, Hunan, China
| | - Bernd Schnabl
- Department of Medicine, University of California San Diego, La Jolla, California; Department of Medicine, VA San Diego Healthcare System, San Diego, California.
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175
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Sharpton SR, Maraj B, Harding-Theobald E, Vittinghoff E, Terrault NA. Gut microbiome-targeted therapies in nonalcoholic fatty liver disease: a systematic review, meta-analysis, and meta-regression. Am J Clin Nutr 2019; 110:139-149. [PMID: 31124558 PMCID: PMC6599739 DOI: 10.1093/ajcn/nqz042] [Citation(s) in RCA: 115] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2018] [Accepted: 02/27/2019] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Preclinical evidence suggests that modulation of the gut microbiome could represent a new therapeutic target in nonalcoholic fatty liver disease (NAFLD). OBJECTIVES The aim of this study was to evaluate the most current evidence for liver-specific and metabolic effects of microbiome-targeted therapies (MTTs) in persons with NAFLD. METHODS We searched multiple electronic databases for randomized controlled trials (RCTs) published from January 1, 2005 to December 1, 2018 that enrolled persons with NAFLD who received MTT rather than placebo or usual care. MTT was defined as antibiotics, probiotics, synbiotics, or fecal microbiota transplantation (FMT). Clinical outcomes were pooled with the use of random-effects models and heterogeneity was assessed with the I2 statistic. A random-effects meta-regression was performed to determine sources of heterogeneity in prevalence estimates between studies. RESULTS Twenty-one RCTs (1252 participants) were included; 9 evaluated probiotics and 12 evaluated synbiotics, with treatment duration ranging from 8 to 28 wk. No RCTs examined the efficacy of antibiotics or FMT. Probiotics/synbiotics were associated with a significant reduction in alanine aminotransferase activity [ALT, weighted mean difference (WMD): -11.23 IU/L; 95% CI: -15.02, -7.44 IU/L] and liver stiffness measurement (LSM) by elastography (reflecting inflammation and fibrosis) (WMD: -0.70 kPa; 95% CI: -1.00, -0.40 kPa), although analyses showed heterogeneity (I2 = 90.6% and I2 = 93.4%, respectively). Probiotics/synbiotics were also associated with increased odds of improvement in hepatic steatosis, as graded by ultrasound (OR: 2.40; 95% CI: 1.50, 3.84; I2 = 22.4%). No RCTs examined sequential liver biopsy findings. Probiotics (WMD: -1.84; 95% CI: -3.30, -0.38; I2 = 23.6%), but not synbiotics (WMD: -0.85; 95% CI: -2.17, 0.47; I2 = 96.6%), were associated with a significant reduction in body mass index. CONCLUSIONS The use of probiotics/synbiotics was associated with improvement in liver-specific markers of hepatic inflammation, LSM, and steatosis in persons with NAFLD. Although promising, given the heterogeneity in pooled analyses, additional well-designed RCTs are needed to define the efficacy of probiotics/synbiotics for treatment of NAFLD. This study was registered with PROSPERO as CRD42018091455.
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Affiliation(s)
| | | | | | - Eric Vittinghoff
- Biostatistics and Epidemiology, University of California San Francisco, San Francisco, CA
| | - Norah A Terrault
- Keck Medicine at University of Southern California, Los Angeles, CA,Address correspondence to NAT (e-mail: )
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Mohammadi H, Ghavami A, Hadi A, Askari G, Symonds M, Miraghajani M. Effects of pro-/synbiotic supplementation on anthropometric and metabolic indices in overweight or obese children and adolescents: A systematic review and meta-analysis. Complement Ther Med 2019; 44:269-276. [PMID: 31126565 DOI: 10.1016/j.ctim.2019.05.008] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2019] [Accepted: 05/07/2019] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND & AIMS Existing evidence on the possible effects of pro-/synbiotics on overweight or obese children and adolescents has not been fully established. Therefore, the present review was undertaken to evaluate the overall effects of pro-/synbiotics supplementation on anthropometric indices and metabolic indices in overweight or obese children and adolescents. METHODS A systematic computerized literature search of PubMed, Scopus, ISI Web of science and Google Scholar databases was conducted up to November 2018. All RCTs using pro-/synbiotics supplements in overweight or obese children and adolescents included in this systematic review and meta-analysis. RESULTS Overall 9 randomized trials including 410 subjects were identified for the present meta-analysis. Pooled analysis did not illustrate any significant changes in BMI z-score, waist circumference, weight, body fat, fasting blood sugar and lipid profiles (triglyceride, total cholesterol, high-density lipoprotein cholesterol, and low-density lipoprotein cholesterol) after supplementation with pro-/synbiotics for 4-16 weeks. However, subgroup analysis by intervention type revealed a significant reduction of BMI z-score in synbiotic subgroups. CONCLUSION Based on our findings, modulation of gut microbiota composition through pro-/ synbiotic supplements did not have favorable effects to manage overweight or obese children and adolescents. Further large-scale studies are warranted to confirm present findings.
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Affiliation(s)
- Hamed Mohammadi
- Student Research Committee, Department of Clinical Nutrition, School of Nutrition and Food Science, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Abed Ghavami
- Student Research Committee, Department of Clinical Nutrition, School of Nutrition and Food Science, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Amir Hadi
- Halal Research Center of IRI, FDA, Tehran, Iran.
| | - Gholamreza Askari
- Food Security Research Center, Department of Community Nutrition, School of Nutrition and Food Science, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Michael Symonds
- The Early Life Research Unit, Academic Division of Child Health, Obstetrics and Gynaecology, and Nottingham Digestive Disease Centre and Biomedical Research Centre, The School of Medicine, University of Nottingham, Nottingham, NG7 2UH, Iran
| | - Maryam Miraghajani
- Cancer Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran; The Early Life Research Unit, Academic Division of Child Health, Obstetrics and Gynaecology, and Nottingham Digestive Disease Centre and Biomedical Research Centre, The School of Medicine, University of Nottingham, Nottingham, NG7 2UH, Iran.
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Draijer L, Benninga M, Koot B. Pediatric NAFLD: an overview and recent developments in diagnostics and treatment. Expert Rev Gastroenterol Hepatol 2019; 13:447-461. [PMID: 30875479 DOI: 10.1080/17474124.2019.1595589] [Citation(s) in RCA: 59] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Non-alcoholic fatty liver disease (NAFLD) is the most common chronic liver disease in children and adults in industrialized countries. Besides liver-related morbidity, NAFLD is also associated with an increased risk of cardiovascular disease, type 2 diabetes and mortality at adult age. However, despite the high prevalence and serious complications, diagnosing and staging of disease remains complicated due to a lack of accurate screening tools and non-invasive methods to detect fibrosis. Areas covered: Recent insights in epidemiology, pathogenesis, diagnostic evaluation and treatment options in pediatric NAFLD are being reviewed, with a particular focus on new developments in diagnostic tools. Expert opinion: Due to their long life span, children with NAFLD are particularly at risk of complications in their lifetime. Therefore, an effective screening strategy for children to identify those with NAFLD at risk of complications is urgently needed. This is further underscored by new pharmacological therapies that are expected to become available in the next 5 years. Momentarily no accurate non-invasive method for diagnosing pediatric NAFLD is available. New promising biomarkers and imaging tools could hopefully provide better screening tools and could contribute to the development of a successful management plan to identify children with NAFLD.
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Affiliation(s)
- Laura Draijer
- a Department of Pediatric Gastroenterology and Nutrition , Amsterdam University Medical Centers, Location Academic Medical Center/Emma Children's Hospital , Amsterdam , The Netherlands
| | - Marc Benninga
- a Department of Pediatric Gastroenterology and Nutrition , Amsterdam University Medical Centers, Location Academic Medical Center/Emma Children's Hospital , Amsterdam , The Netherlands
| | - Bart Koot
- a Department of Pediatric Gastroenterology and Nutrition , Amsterdam University Medical Centers, Location Academic Medical Center/Emma Children's Hospital , Amsterdam , The Netherlands
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Safari Z, Gérard P. The links between the gut microbiome and non-alcoholic fatty liver disease (NAFLD). Cell Mol Life Sci 2019; 76:1541-1558. [PMID: 30683985 PMCID: PMC11105223 DOI: 10.1007/s00018-019-03011-w] [Citation(s) in RCA: 286] [Impact Index Per Article: 57.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2018] [Revised: 12/11/2018] [Accepted: 01/15/2019] [Indexed: 12/11/2022]
Abstract
NAFLD is currently the main cause of chronic liver disease in developed countries, and the number of NAFLD patients is growing worldwide. NAFLD often has similar symptoms to other metabolic disorders, including type 2 diabetes and obesity. Recently, the role of the gut microbiota in the pathophysiology of many diseases has been revealed. Regarding NAFLD, experiments using gut microbiota transplants to germ-free animal models showed that fatty liver disease development is determined by gut bacteria. Moreover, the perturbation of the composition of the gut microbiota has been observed in patients suffering from NAFLD. Numerous mechanisms relating the gut microbiome to NAFLD have been proposed, including the dysbiosis-induced dysregulation of gut endothelial barrier function that allows for the translocation of bacterial components and leads to hepatic inflammation. In addition, the various metabolites produced by the gut microbiota may impact the liver and thus modulate NAFLD susceptibility. Therefore, the manipulation of the gut microbiome by probiotics, prebiotics or synbiotics was shown to improve liver phenotype in NAFLD patients as well as in rodent models. Hence, further knowledge about the interactions among dysbiosis, environmental factors, and diet and their impacts on the gut-liver axis can improve the treatment of this life-threatening liver disease and its related disorders.
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Affiliation(s)
- Zahra Safari
- Micalis Institute, INRA, UMR1319, Equipe AMIPEM, AgroParisTech, Université Paris-Saclay, Building 442, Domaine de Vilvert, 78350, Jouy-en-Josas, France
- Institute of Pathology, Medical University of Graz, Graz, Austria
| | - Philippe Gérard
- Micalis Institute, INRA, UMR1319, Equipe AMIPEM, AgroParisTech, Université Paris-Saclay, Building 442, Domaine de Vilvert, 78350, Jouy-en-Josas, France.
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179
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Dong TS, Jacobs JP. Nonalcoholic fatty liver disease and the gut microbiome: Are bacteria responsible for fatty liver? Exp Biol Med (Maywood) 2019; 244:408-418. [PMID: 30871368 PMCID: PMC6547005 DOI: 10.1177/1535370219836739] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
IMPACT STATEMENT This invited minireview for the upcoming thematic issue on the microbiome addresses the role of the microbiome in nonalcoholic fatty liver disease (NAFLD). The incidence of NAFLD has increased greatly in recent years in parallel with the rise in obesity and is now believed to have a population prevalence of 20-40%. It is anticipated to soon become the primary cause of liver-related morbidity and mortality, and unfortunately, there are few treatment options. Therefore, there is a critical need for improved understanding of NAFLD pathophysiology to provide new avenues for therapeutic intervention. In this paper, we have reviewed evidence from human and animal model studies that have associated microbiome composition and microbial metabolites with development and progression of NAFLD. We have also discussed proposed mechanisms by which the microbiome could contribute to NAFLD pathogenesis and addressed future directions for this field.
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Affiliation(s)
- Tien S Dong
- Division of Gastroenterology, Hepatology and Parenteral Nutrition, VA Greater Los Angeles Healthcare System, Los Angeles, CA 90025, USA
- The Vatche and Tamar Manoukian Division of Digestive Diseases, Department of Medicine, David Geffen School of Medicine at University of California Los Angeles, Los Angeles, CA 90095, USA
| | - Jonathan P Jacobs
- Division of Gastroenterology, Hepatology and Parenteral Nutrition, VA Greater Los Angeles Healthcare System, Los Angeles, CA 90025, USA
- The Vatche and Tamar Manoukian Division of Digestive Diseases, Department of Medicine, David Geffen School of Medicine at University of California Los Angeles, Los Angeles, CA 90095, USA
- University of California Los Angeles Microbiome Center, David Geffen School of Medicine, Los Angeles, CA 90095, USA
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180
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Koutnikova H, Genser B, Monteiro-Sepulveda M, Faurie JM, Rizkalla S, Schrezenmeir J, Clément K. Impact of bacterial probiotics on obesity, diabetes and non-alcoholic fatty liver disease related variables: a systematic review and meta-analysis of randomised controlled trials. BMJ Open 2019; 9:e017995. [PMID: 30928918 PMCID: PMC6475231 DOI: 10.1136/bmjopen-2017-017995] [Citation(s) in RCA: 141] [Impact Index Per Article: 28.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
OBJECTIVE To systematically review the effect of oral intake of bacterial probiotics on 15 variables related to obesity, diabetes and non-alcoholic fatty liver disease. DESIGN Systematic review and meta-analysis. DATA SOURCES Medline, EMBASE and COCHRANE from 1990 to June 2018. ELIGIBILITY CRITERIA Randomised controlled trials (≥14 days) excluding hypercholesterolaemia, alcoholic liver disease, polycystic ovary syndrome and children <3 years. RESULTS One hundred and five articles met inclusion criteria, representing 6826 subjects. In overweight but not obese subjects, probiotics induced improvements in: body weight (k=25 trials, d=-0.94 kg mean difference, 95% CI -1.17 to -0.70, I²=0.0%), body mass index (k=32, d=-0.55 kg/m², 95% CI -0.86 to -0.23, I²=91.9%), waist circumference (k=13, d=-1.31 cm, 95% CI -1.79 to -0.83, I²=14.5%), body fat mass (k=11, d=-0.96 kg, 95% CI -1.21 to -0.71, I²=0.0%) and visceral adipose tissue mass (k=5, d=-6.30 cm², 95% CI -9.05 to -3.56, I²=0.0%). In type 2 diabetics, probiotics reduced fasting glucose (k=19, d=-0.66 mmol/L, 95% CI -1.00 to -0.31, I²=27.7%), glycated haemoglobin (k=13, d=-0.28 pp, 95% CI -0.46 to -0.11, I²=54.1%), insulin (k=13, d=-1.66 mU/L, 95% CI -2.70 to -0.61, I²=37.8%) and homeostatic model of insulin resistance (k=10, d=-1.05 pp, 95% CI -1.48 to -0.61, I²=18.2%). In subjects with fatty liver diseases, probiotics reduced alanine (k=12, d=-10.2 U/L, 95% CI -14.3 to -6.0, I²=93.50%) and aspartate aminotransferases (k=10, d=-9.9 U/L, 95% CI -14.1 to -5.8, I²=96.1%). These improvements were mostly observed with bifidobacteria (Bifidobacterium breve, B. longum), Streptococcus salivarius subsp. thermophilus and lactobacilli (Lactobacillus acidophilus, L. casei, L. delbrueckii) containing mixtures and influenced by trials conducted in one country. CONCLUSIONS The intake of probiotics resulted in minor but consistent improvements in several metabolic risk factors in subjects with metabolic diseases. TRIAL REGISTRATION NUMBER CRD42016033273.
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Affiliation(s)
| | - Bernd Genser
- BGStats Consulting, Vienna, Austria
- Mannheimer Institut fur Public Health, Ruprecht Karls Universitat Heidelberg, Mannheim, Baden-Württemberg, Germany
| | - Milena Monteiro-Sepulveda
- Nutrition Department, Pitie-Salpêtrière hospital, Institute of Cardiometabolism and Nutrition, Assistance Publique-Hôpitaux de Paris, Paris, France
| | | | - Salwa Rizkalla
- Nutrition Department, Pitie-Salpêtrière hospital, Institute of Cardiometabolism and Nutrition, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Jürgen Schrezenmeir
- Clinical Research Center Kiel, Johannes Gutenberg Universitat Universitatsmedizin, Mainz, Rheinland-Pfalz, Germany
| | - Karine Clément
- Nutrition Department, Pitie-Salpêtrière hospital, Institute of Cardiometabolism and Nutrition, Assistance Publique-Hôpitaux de Paris, Paris, France
- Sorbonne Université, Institut National de la Santé et de la Recherche Médicale (INSERM), NutriOmiCs team, UMR S 1269, Paris, France
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181
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Campo L, Eiseler S, Apfel T, Pyrsopoulos N. Fatty Liver Disease and Gut Microbiota: A Comprehensive Update. J Clin Transl Hepatol 2019; 7:56-60. [PMID: 30944821 PMCID: PMC6441642 DOI: 10.14218/jcth.2018.00008] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2018] [Revised: 09/17/2018] [Accepted: 10/03/2018] [Indexed: 02/06/2023] Open
Abstract
Nonalcoholic fatty liver disease (NAFLD) is the accumulation of fat in the liver in the absence of secondary causes. NAFLD is a multifactorial disease that results from the interaction of genetic predisposition and metabolic, inflammatory and environmental factors. Among these factors, dysregulation of gut microbiome has been linked to the development of fatty liver disease. The microbiome composition can be modified by dietary habits leading to gut microbiome dysbiosis, especially when a diet is rich in saturated fats, animal products and fructose sugars. Different species of bacteria in the gut metabolize nutrients differently, triggering different pathways that contribute to the accumulation of fat within the liver and triggering inflammatory cascades that promote liver damage. In this review, we summarize the current understanding of the roles of gut microbiota in mediating NAFLD development and discuss possible gut microbiota-targeted therapies for NAFLD. We summarize experimental and clinical evidence, and draw conclusions on the therapeutic potential of manipulating gut microbiota to decrease the incidence and prevalence of fatty liver disease.
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Affiliation(s)
- Lyna Campo
- Division of Gastroenterology and Hepatology, University Hospital, Rutgers New Jersey Medical School, Newark, NJ, USA
| | - Sara Eiseler
- Division of Gastroenterology and Hepatology, University Hospital, Rutgers New Jersey Medical School, Newark, NJ, USA
| | - Tehilla Apfel
- Division of Gastroenterology and Hepatology, University Hospital, Rutgers New Jersey Medical School, Newark, NJ, USA
| | - Nikolaos Pyrsopoulos
- Division of Gastroenterology and Hepatology, University Hospital, Rutgers New Jersey Medical School, Newark, NJ, USA
- *Correspondence to: Nikolaos Pyrsopoulos, Gastroenterology and Hepatology, University Hospital, Rutgers New Jersey Med. Sch. 185 S Orange Ave, Newark, NJ 07103, USA. Tel: +1-973-972-5252, Fax: +1-973-972-3144, E-mail:
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182
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Cerdó T, García-Santos JA, G Bermúdez M, Campoy C. The Role of Probiotics and Prebiotics in the Prevention and Treatment of Obesity. Nutrients 2019; 11:E635. [PMID: 30875987 PMCID: PMC6470608 DOI: 10.3390/nu11030635] [Citation(s) in RCA: 186] [Impact Index Per Article: 37.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2019] [Revised: 03/06/2019] [Accepted: 03/11/2019] [Indexed: 02/06/2023] Open
Abstract
Obesity is a global pandemic complex to treat due to its multifactorial pathogenesis-an unhealthy lifestyle, neuronal and hormonal mechanisms, and genetic and epigenetic factors are involved. Scientific evidence supports the idea that obesity and metabolic consequences are strongly related to changes in both the function and composition of gut microbiota, which exert an essential role in modulating energy metabolism. Modifications of gut microbiota composition have been associated with variations in body weight and body mass index. Lifestyle modifications remain as primary therapy for obesity and related metabolic disorders. New therapeutic strategies to treat/prevent obesity have been proposed, based on pre- and/or probiotic modulation of gut microbiota to mimic that found in healthy non-obese subjects. Based on human and animal studies, this review aimed to discuss mechanisms through which gut microbiota could act as a key modifier of obesity and related metabolic complications. Evidence from animal studies and human clinical trials suggesting potential beneficial effects of prebiotic and various probiotic strains on those physical, biochemical, and metabolic parameters related to obesity is presented. As a conclusion, a deeper knowledge about pre-/probiotic mechanisms of action, in combination with adequately powered, randomized controlled follow-up studies, will facilitate the clinical application and development of personalized healthcare strategies.
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Affiliation(s)
- Tomás Cerdó
- Department of Pediatrics, School of Medicine, University of Granada, Avda. Investigación 11, 18016 Granada, Spain.
- EURISTIKOS Excellence Centre for Paediatric Research, Biomedical Research Centre, University of Granada, 18016 Granada, Spain.
- Instituto de Investigación Biosanitaria ibs, GRANADA, Health Sciences Technological Park, 18012 Granada, Spain.
| | - José Antonio García-Santos
- Department of Pediatrics, School of Medicine, University of Granada, Avda. Investigación 11, 18016 Granada, Spain.
- EURISTIKOS Excellence Centre for Paediatric Research, Biomedical Research Centre, University of Granada, 18016 Granada, Spain.
- Instituto de Investigación Biosanitaria ibs, GRANADA, Health Sciences Technological Park, 18012 Granada, Spain.
| | - Mercedes G Bermúdez
- Department of Pediatrics, School of Medicine, University of Granada, Avda. Investigación 11, 18016 Granada, Spain.
- EURISTIKOS Excellence Centre for Paediatric Research, Biomedical Research Centre, University of Granada, 18016 Granada, Spain.
- Instituto de Investigación Biosanitaria ibs, GRANADA, Health Sciences Technological Park, 18012 Granada, Spain.
| | - Cristina Campoy
- Department of Pediatrics, School of Medicine, University of Granada, Avda. Investigación 11, 18016 Granada, Spain.
- EURISTIKOS Excellence Centre for Paediatric Research, Biomedical Research Centre, University of Granada, 18016 Granada, Spain.
- Instituto de Investigación Biosanitaria ibs, GRANADA, Health Sciences Technological Park, 18012 Granada, Spain.
- Spanish Network of Biomedical Research in Epidemiology and Public Health (CIBERESP), Granada's node, Carlos III Health Institute of Health Carlos III, 28029 Madrid, Spain.
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183
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Uchiyama K, Naito Y, Takagi T. Intestinal microbiome as a novel therapeutic target for local and systemic inflammation. Pharmacol Ther 2019; 199:164-172. [PMID: 30877020 DOI: 10.1016/j.pharmthera.2019.03.006] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2018] [Accepted: 03/06/2019] [Indexed: 12/19/2022]
Abstract
Recently, the pathogenesis of systemic inflammatory disease such as inflammatory bowel disease (IBD), multiple sclerosis (MS), systemic inflammatory arthritis, asthma, and non-alcoholic fatty liver disease has been reported to be related to the dysbiosis of gut microbiota. The contribution of special bacteria for the development of those diseases has been elucidated by disease animal models such as germ-free mice. Besides, the contribution by several bacteria for the pathogenesis of those diseases has been suggested by detailed analysis of the 16 small ribosomal subunit RNA (16S rRNA) from stool samples of the patients. Gut microbiota-targeted treatment for systemic inflammatory diseases such as fecal microbiota transplant (FMT), and probiotics has been now reported. Though there are several issues to be understood, these treatments have been highlighted as an innovative approach to intractable systemic inflammatory disease. In the present review, recent reports regarding the relation between gut microbiota and systemic inflammatory diseases are discussed with treatments to target gut microbiota.
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Affiliation(s)
- Kazuhiko Uchiyama
- Molecular Gastroenterology and Hepatology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto 602-8566, Japan.
| | - Yuji Naito
- Molecular Gastroenterology and Hepatology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto 602-8566, Japan
| | - Tomohisa Takagi
- Molecular Gastroenterology and Hepatology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto 602-8566, Japan; Department for Medical Innovation and Translational Medical Science, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto 602-8566, Japan
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Álvarez-Mercado AI, Navarro-Oliveros M, Robles-Sánchez C, Plaza-Díaz J, Sáez-Lara MJ, Muñoz-Quezada S, Fontana L, Abadía-Molina F. Microbial Population Changes and Their Relationship with Human Health and Disease. Microorganisms 2019; 7:E68. [PMID: 30832423 PMCID: PMC6463060 DOI: 10.3390/microorganisms7030068] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2019] [Revised: 02/26/2019] [Accepted: 02/27/2019] [Indexed: 12/11/2022] Open
Abstract
Specific microbial profiles and changes in intestinal microbiota have been widely demonstrated to be associated with the pathogenesis of a number of extra-intestinal (obesity and metabolic syndrome) and intestinal (inflammatory bowel disease) diseases as well as other metabolic disorders, such as non-alcoholic fatty liver disease and type 2 diabetes. Thus, maintaining a healthy gut ecosystem could aid in avoiding the early onset and development of these diseases. Furthermore, it is mandatory to evaluate the alterations in the microbiota associated with pathophysiological conditions and how to counteract them to restore intestinal homeostasis. This review highlights and critically discusses recent literature focused on identifying changes in and developing gut microbiota-targeted interventions (probiotics, prebiotics, diet, and fecal microbiota transplantation, among others) for the above-mentioned pathologies. We also discuss future directions and promising approaches to counteract unhealthy alterations in the gut microbiota. Altogether, we conclude that research in this field is currently in its infancy, which may be due to the large number of factors that can elicit such alterations, the variety of related pathologies, and the heterogeneity of the population involved. Further research on the effects of probiotics, prebiotics, or fecal transplantations on the composition of the human gut microbiome is necessary.
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Affiliation(s)
- Ana Isabel Álvarez-Mercado
- Department of Biochemistry and Molecular Biology II, School of Pharmacy, University of Granada, 18071 Granada, Spain.
- Institute of Nutrition and Food Technology "José Mataix," Center of Biomedical Research, University of Granada, Avda. del Conocimiento s/n. 18016 Armilla, Granada, Spain.
| | - Miguel Navarro-Oliveros
- Institute of Nutrition and Food Technology "José Mataix," Center of Biomedical Research, University of Granada, Avda. del Conocimiento s/n. 18016 Armilla, Granada, Spain.
| | - Cándido Robles-Sánchez
- Department of Biochemistry and Molecular Biology II, School of Pharmacy, University of Granada, 18071 Granada, Spain.
- Institute of Nutrition and Food Technology "José Mataix," Center of Biomedical Research, University of Granada, Avda. del Conocimiento s/n. 18016 Armilla, Granada, Spain.
| | - Julio Plaza-Díaz
- Department of Biochemistry and Molecular Biology II, School of Pharmacy, University of Granada, 18071 Granada, Spain.
- Institute of Nutrition and Food Technology "José Mataix," Center of Biomedical Research, University of Granada, Avda. del Conocimiento s/n. 18016 Armilla, Granada, Spain.
- Instituto de Investigación Biosanitaria IBS.GRANADA, Complejo Hospitalario Universitario de Granada, 18014 Granada, Spain.
| | - María José Sáez-Lara
- Department of Biochemistry and Molecular Biology I, School of Sciences, University of Granada, 18071 Granada, Spain.
| | - Sergio Muñoz-Quezada
- Departamento de Farmacia, Facultad de Química y de Farmacia, Pontificia Universidad Católica de Chile, Santiago 6094411, Chile.
- National Agency for Medicines (ANAMED), Public Health Institute, Santiago 7780050, Chile.
| | - Luis Fontana
- Department of Biochemistry and Molecular Biology II, School of Pharmacy, University of Granada, 18071 Granada, Spain.
- Institute of Nutrition and Food Technology "José Mataix," Center of Biomedical Research, University of Granada, Avda. del Conocimiento s/n. 18016 Armilla, Granada, Spain.
- Instituto de Investigación Biosanitaria IBS.GRANADA, Complejo Hospitalario Universitario de Granada, 18014 Granada, Spain.
| | - Francisco Abadía-Molina
- Institute of Nutrition and Food Technology "José Mataix," Center of Biomedical Research, University of Granada, Avda. del Conocimiento s/n. 18016 Armilla, Granada, Spain.
- Department of Cell Biology, School of Sciences, University of Granada, 18071 Granada, Spain.
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185
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Rates of and Factors Associated With Placebo Response in Trials of Pharmacotherapies for Nonalcoholic Steatohepatitis: Systematic Review and Meta-analysis. Clin Gastroenterol Hepatol 2019; 17:616-629.e26. [PMID: 29913275 DOI: 10.1016/j.cgh.2018.06.011] [Citation(s) in RCA: 84] [Impact Index Per Article: 16.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2017] [Revised: 06/06/2018] [Accepted: 06/09/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS It is important to know the extent of the placebo effect in designing randomized controlled trials for patients with nonalcoholic steatohepatitis (NASH), to accurately calculate sample size and define treatment endpoints. METHODS We performed a systematic review and meta-analysis of the placebo groups from randomized controlled trials of adults with NASH that provided histologic and/or magnetic resonance image-based assessments. We identified trials through a comprehensive search of MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, and Scopus, from each database's inception through January 2, 2018. RESULTS We identified 39 randomized controlled trials, comprising 1463 patients who received placebo. Histologic assessment data (the nonalcoholic fatty liver disease activity scores, NAS) were available from 956 patients; magnetic resonance spectroscopy data were available from 295 patients and magnetic resonance proton density fat fraction measurements from 61 patients. Overall, 25% of patients given placebo had an improvement in NAS by 2 or more points (95% CI, 21%-29%) with a small amount of heterogeneity (I2 = 27%). There were improvements by at least 1 point in steatosis scores of 33% ± 3% of patients, in hepatocyte ballooning scores of 30% ± 3% of patients, in lobular inflammation scores of 32% ± 3% of patients, and in fibrosis scores of 21% ± 3% of patients, with a moderate amount of heterogeneity among trials (I2 range, 51%-63%). Patients given placebo had a statistically significant improvement in NAS (by 0.72 ± 0.19), with a large amount of heterogeneity (I2 = 96%). Univariate and multivariate meta-regression showed that trials with a higher baseline NAS, those conducted in South America, and those in which patients had a decrease in body mass index, were associated with greater improvements in NAS among patients given placebo. Patients given placebo had significant reductions in intrahepatic triglyceride, measured by magnetic resonance spectroscopy (by 1.45% ± 0.54%) with moderate heterogeneity (I2 = 40%), and in magnetic resonance proton density fat fraction (by 2.43 ± 0.89), without heterogeneity (I2 = 0). Mean serum levels of alanine and aspartate aminotransferases decreased significantly (by 11.7 ± 3.8 U/L and 5.9 ± 2.1 U/L, respectively; P < .01 for both). CONCLUSIONS In a meta-analysis of randomized controlled trials of NASH, patients given placebo have significant histologic, radiologic, and biochemical responses. The placebo response should be considered in designing trials of agents for treatment of NASH.
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Abstract
Liver cancer is the sixth most common cancer worldwide, and the third most common cause of cancer-related death. Hepatocellular carcinoma (HCC), which accounts for more than 90% of primary liver cancers, is an important public health problem. In addition to cirrhosis caused by hepatitis B viral (HBV) or hepatitis C viral (HCV) infection, non-alcoholic fatty liver disease (NAFLD) is becoming a major risk factor for liver cancer because of the prevalence of obesity. Non-alcoholic steatohepatitis (NASH) will likely become the leading indication for liver transplantation in the future. It is well recognized that gut microbiota is a key environmental factor in the pathogenesis of liver disease and cancer. The interplay between gut microbiota and liver disease has been investigated in animal and clinical studies. In this article, we summarize the roles of gut microbiota in the development of liver disease as well as gut microbiota-targeted therapies.
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Affiliation(s)
- Lijun Wang
- Department of Medical Pathology and Laboratory Medicine, University of California, Davis, Sacramento, CA, USA,The College of Life Science, Yangtze University, Jingzhou, Hubei, China
| | - Yu-Jui Yvonne Wan
- Department of Medical Pathology and Laboratory Medicine, University of California, Davis, Sacramento, CA, USA,Corresponding author. Department of medical Pathology and Laboratory Medicine, University of California, Davis, Sacramento, CA, USA. (Y.-J.Y. Wan)
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187
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Suk KT, Kim DJ. Gut microbiota: novel therapeutic target for nonalcoholic fatty liver disease. Expert Rev Gastroenterol Hepatol 2019; 13:193-204. [PMID: 30791767 DOI: 10.1080/17474124.2019.1569513] [Citation(s) in RCA: 70] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Nonalcoholic fatty liver disease (NAFLD) is one of the most common and increasing liver diseases worldwide with a prevalence of 20-33%. NAFLD may progress to fibrosis, compensated cirrhosis, advanced cirrhosis, or hepatocellular carcinoma. Despite the increasing prevalence of NAFLD, definitive medical treatment has not been established, with the exception of lifestyle modification with exercise. Because of the direct connection via portal vein between the intestines and the liver (gut-gut microbiota-liver axis), gut microbiota and associated dysbiosis have been known as regulators in the pathophysiology of NAFLD. Area covered: New therapeutic approaches for modulation of gut microbiota have been proposed and the effectiveness of new therapies including probiotics, prebiotics, synbiotics, bile acid regulation, absorbent, and fecal microbiota transplantation have been demonstrated in recent several studies. This review focuses on the available evidences for new therapies modulating gut microbiota in the management and the prevention of NAFLD. Expert commentary: Gut-gut microbiota-liver axis may play an important role in the etiology of many liver diseases, including NAFLD. It is logical to seek the manipulation of this axis, and further studies are required to understand the underlying precise mechanisms of microbiota-modulation on NAFLD.
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Affiliation(s)
- Ki Tae Suk
- a Division of Gastroenterology and Hepatology , Hallym University College of Medicine , Chuncheon , South Korea
| | - Dong Joon Kim
- a Division of Gastroenterology and Hepatology , Hallym University College of Medicine , Chuncheon , South Korea
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188
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Ohtani N, Kawada N. Role of the Gut-Liver Axis in Liver Inflammation, Fibrosis, and Cancer: A Special Focus on the Gut Microbiota Relationship. Hepatol Commun 2019; 3:456-470. [PMID: 30976737 PMCID: PMC6442695 DOI: 10.1002/hep4.1331] [Citation(s) in RCA: 111] [Impact Index Per Article: 22.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2018] [Accepted: 02/11/2019] [Indexed: 12/20/2022] Open
Abstract
The gut and the liver are anatomically and physiologically connected, and this “gut–liver axis” exerts various influences on liver pathology. The gut microbiota consists of various microorganisms that normally coexist in the human gut and have a role of maintaining the homeostasis of the host. However, once homeostasis is disturbed, metabolites and components derived from the gut microbiota translocate to the liver and induce pathologic effects in the liver. In this review, we introduce and discuss the mechanisms of liver inflammation, fibrosis, and cancer that are influenced by gut microbial components and metabolites; we include recent advances in molecular‐based therapeutics and novel mechanistic findings associated with the gut–liver axis and gut microbiota.
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Affiliation(s)
- Naoko Ohtani
- Department of Pathophysiology Osaka City University, Graduate School of Medicine Osaka Japan
| | - Norifumi Kawada
- Department of Hepatology Osaka City University, Graduate School of Medicine Osaka Japan
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189
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Gut peptide and neuroendocrine regulation of hepatic lipid and lipoprotein metabolism in health and disease. Biochim Biophys Acta Mol Cell Biol Lipids 2019; 1864:326-334. [DOI: 10.1016/j.bbalip.2018.12.010] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2018] [Revised: 12/04/2018] [Accepted: 12/15/2018] [Indexed: 02/08/2023]
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190
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Perumpail BJ, Li AA, John N, Sallam S, Shah ND, Kwong W, Cholankeril G, Kim D, Ahmed A. The Therapeutic Implications of the Gut Microbiome and Probiotics in Patients with NAFLD. Diseases 2019; 7:diseases7010027. [PMID: 30823570 PMCID: PMC6473757 DOI: 10.3390/diseases7010027] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2018] [Revised: 02/21/2019] [Accepted: 02/24/2019] [Indexed: 02/07/2023] Open
Abstract
Recent breakthrough in our understanding pertaining to the pathogenesis of nonalcoholic fatty liver disease (NAFLD) has pointed to dysregulation or derangement of the gut microbiome, also known as dysbiosis. This has led to growing interest in probiotic supplementation as a potential treatment method for NAFLD due to its ability to retard and/or reverse dysbiosis and restore normal gut flora. A thorough review of medical literature was completed from inception through July 10, 2018 on the PubMed database by searching for key terms such as NAFLD, probiotics, dysbiosis, synbiotics, and nonalcoholic steatohepatitis (NASH). All studies reviewed indicate that probiotics had a beneficial effect in patients with NAFLD and its subset NASH. Results varied between studies, but there was evidence demonstrating improvement in liver enzymes, hepatic inflammation, hepatic steatosis, and hepatic fibrosis. No major adverse effects were noted. Currently, there are no guidelines addressing the use of probiotics in the setting of NAFLD. In conclusion, probiotics appear to be a promising option in the treatment of NAFLD. Future research is necessary to assess the efficacy of probiotics in patients with NAFLD.
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Affiliation(s)
| | - Andrew A Li
- Department of Medicine, Stanford University School of Medicine, Stanford, CA 94305, USA.
| | - Nimy John
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, CA 94305, USA.
| | - Sandy Sallam
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, CA 94305, USA.
| | - Neha D Shah
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, CA 94305, USA.
| | - Waiyee Kwong
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, CA 94305, USA.
| | - George Cholankeril
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, CA 94305, USA.
| | - Donghee Kim
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, CA 94305, USA.
| | - Aijaz Ahmed
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, CA 94305, USA.
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191
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Update on pathogenesis, diagnostics and therapy of nonalcoholic fatty liver disease in children. Clin Exp Hepatol 2019; 5:11-21. [PMID: 30915402 PMCID: PMC6431091 DOI: 10.5114/ceh.2019.83152] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2018] [Accepted: 01/31/2019] [Indexed: 12/21/2022] Open
Abstract
Nonalcoholic fatty liver disease (NAFLD) represents the most common cause of chronic liver disease. Increasing prevalence of NAFLD in children may be the cause of unfavorable metabolic implications and development of end stage liver disease. NAFLD is a “multiple-hit” disease mediated by several metabolic, environmental, genetic and microbiological mechanisms. Additionally, lipotoxicity, oxidative stress and inflammation predispose to progressive liver damage. According to current guidelines, liver biopsy is an imperfect gold standard for NAFLD diagnosis, but due to its invasive character its use is limited in children and it should be performed only in children who need exclusion of coexisting diseases. Noninvasive methods should be preferred and current research is focused on serum markers and novel imaging or elastographic techniques. Therapeutic approaches for NAFLD are currently focused on lifestyle modification, insulin resistance, dyslipidemia, oxidative stress and the gut microbiome. However, a number of clinical studies on novel therapeutic molecules are ongoing.
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192
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Contribution of the gut microbiota to the regulation of host metabolism and energy balance: a focus on the gut–liver axis. Proc Nutr Soc 2019; 78:319-328. [DOI: 10.1017/s0029665118002756] [Citation(s) in RCA: 54] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
This review presents mechanistic studies performed in vitro and in animal models, as well as data obtained in patients that contribute to a better understanding of the impact of nutrients interacting with the gut microbiota on metabolic and behavioural alterations linked to obesity. The gut microbiota composition and function are altered in several pathological conditions including obesity and related diseases i.e. non-alcoholic fatty liver diseases (NAFLD). The gut–liver axis is clearly influenced by alterations of the gut barrier that drives inflammation. In addition, recent papers propose that specific metabolites issued from the metabolic cooperation between the gut microbes and host enzymes, modulate inflammation and gene expression in the liver. This review illustrates how dietary intervention with prebiotics or probiotics influences host energy metabolism and inflammation. Indeed, intervention studies are currently underway in obese and NAFLD patients to unravel the relevance of the changes in gut microbiota composition in the management of metabolic and behavioural disorders by nutrients interacting with the gut microbiota. In conclusion, diet is among the main triggers of NAFLD and the gut microbiota is modified accordingly, underlining the importance of the concomitant study of the nutrients and microbial impact on liver health and metabolism, in order to propose innovative, clinically relevant, therapeutic approaches.
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193
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Ejtahed HS, Angoorani P, Soroush AR, Atlasi R, Hasani-Ranjbar S, Mortazavian AM, Larijani B. Probiotics supplementation for the obesity management; A systematic review of animal studies and clinical trials. J Funct Foods 2019. [DOI: 10.1016/j.jff.2018.10.039] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
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194
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Fornari E, Maffeis C. Treatment of Metabolic Syndrome in Children. Front Endocrinol (Lausanne) 2019; 10:702. [PMID: 31681173 PMCID: PMC6803446 DOI: 10.3389/fendo.2019.00702] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2019] [Accepted: 09/27/2019] [Indexed: 02/06/2023] Open
Abstract
The Metabolic Syndrome may be tentatively defined as the clustering of several metabolic risk factors in the same individual. A progressively higher number of children and adolescents is affected by this syndrome worldwide, mainly as a consequence of the constant increase of the prevalence of obesity and sedentary habits. As obesity, the chance that the metabolic syndrome traks into adulthood is high. Moreover, the evidence of an association between the duration of the exposition to metabolic risk factors and morbidity and mortality justifies early treatment and prevention of the metabolic syndrome in both children and adolescents. Treatment includes behavioral interventions, adequate nutrition and physical activity, and, if necessary, pharmacological treatments aimed at reducing excessive weight, dyslipidemia, hypertension, and glucose impairments. A multidisciplinary and staged approach to treatment, which includes pediatrician, mental health practitioner, dietician, and nurses, is crucial. Usually, the reduction of fat mass promotes an overall improvement of all the components of the metabolic syndrome. Nevertheless, every single component of the metabolic syndrome should be treated as quickly as possible, by using the best current practice. Drugs may be necessary for treating hypertension, type 2 diabetes mellitus and dyslipidemia. In selected cases of gross obesity resistant to treatment, surgical therapy may be also performed.
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195
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NAFLD and Liver Transplantation in Children—Working Group Report From the ILTS Single Topic Conference on NAFLD. Transplantation 2019; 103:68-70. [DOI: 10.1097/tp.0000000000002490] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
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196
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Porras D, Nistal E, Martínez-Flórez S, González-Gallego J, García-Mediavilla MV, Sánchez-Campos S. Intestinal Microbiota Modulation in Obesity-Related Non-alcoholic Fatty Liver Disease. Front Physiol 2018; 9:1813. [PMID: 30618824 PMCID: PMC6305464 DOI: 10.3389/fphys.2018.01813] [Citation(s) in RCA: 62] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2018] [Accepted: 12/05/2018] [Indexed: 12/12/2022] Open
Abstract
Obesity and associated comorbidities, including non-alcoholic fatty liver disease (NAFLD), are a major concern to public well-being worldwide due to their high prevalence among the population, and its tendency on the rise point to as important threats in the future. Therapeutic approaches for obesity-associated disorders have been circumscribed to lifestyle modifications and pharmacological therapies have demonstrated limited efficacy. Over the last few years, different studies have shown a significant role of intestinal microbiota (IM) on obesity establishment and NAFLD development. Therefore, modulation of IM emerges as a promising therapeutic strategy for obesity-associated diseases. Administration of prebiotic and probiotic compounds, fecal microbiota transplantation (FMT) and exercise protocols have shown a modulatory action over the IM. In this review we provide an overview of current approaches targeting IM which have shown their capacity to counteract NAFLD and metabolic syndrome features in human patients and animal models.
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Affiliation(s)
- David Porras
- Institute of Biomedicine, University of León, León, Spain
| | - Esther Nistal
- Institute of Biomedicine, University of León, León, Spain.,Department of Gastroenterology, Complejo Asistencial Universitario de León, León, Spain
| | | | - Javier González-Gallego
- Institute of Biomedicine, University of León, León, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, Madrid, Spain
| | - María Victoria García-Mediavilla
- Institute of Biomedicine, University of León, León, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, Madrid, Spain
| | - Sonia Sánchez-Campos
- Institute of Biomedicine, University of León, León, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, Madrid, Spain
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197
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Yang YJ, Ni YH. Gut microbiota and pediatric obesity/non-alcoholic fatty liver disease. J Formos Med Assoc 2018; 118 Suppl 1:S55-S61. [PMID: 30509561 DOI: 10.1016/j.jfma.2018.11.006] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2018] [Accepted: 11/15/2018] [Indexed: 02/06/2023] Open
Abstract
Huge amount microorganisms resides in human intestine, and many contribute to the maturation and homeostasis of immune system. The diversity of gut ecology are affected by the gestational age, delivery type, feeding sources, and antibiotics use in neonates. Recent studies pointed out that disturbance of gut microbiota, so called dysbiosis, could result in several pediatric diseases including obesity, non-alcoholic fatty liver disease (NAFLD), metabolic syndromes, allergic diseases, and inflammatory bowel diseases. However, there are no single species can be proven to play a key factor in pediatric obesity and NAFLD at present. Various probiotics may confer benefit to these gut microbiota-related pediatric diseases. The clinical application is still limited. This review article aimed to elucidate evidently the relationship between gut microbiota and pediatric obesity/NAFLD and to discuss the potential probiotics use in pediatric obesity and NAFLD.
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Affiliation(s)
- Yao-Jong Yang
- Department of Pediatrics, Institute of Clinical Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan.
| | - Yen-Hsuan Ni
- Department of Pediatrics, National Taiwan University Hospital, Taipei, Taiwan; Hepatitis Research Center, National Taiwan University Hospital, Taipei, Taiwan.
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198
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Braun HA, Faasse SA, Vos MB. Advances in Pediatric Fatty Liver Disease: Pathogenesis, Diagnosis, and Treatment. Gastroenterol Clin North Am 2018; 47:949-968. [PMID: 30337043 DOI: 10.1016/j.gtc.2018.07.016] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Pediatric nonalcoholic fatty liver disease is an increasingly prevalent disease, but its pathophysiology is not fully elucidated, diagnosis is difficult and invasive, and therapeutic options are limited. This article addresses the recent advancements made in understanding the pathophysiology of nonalcoholic fatty liver disease, the development of less invasive diagnostic modalities, and emerging therapeutic options, including ongoing clinical trials in children.
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Affiliation(s)
- Hayley A Braun
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Emory University School of Medicine, 1760 Haygood Drive North East, Atlanta, GA 30322, USA.
| | - Sarah A Faasse
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Emory University School of Medicine, 1760 Haygood Drive North East, Atlanta, GA 30322, USA; Division of Gastroenterology, Hepatology, and Nutrition, Children's Healthcare of Atlanta, 1405 Clifton Road, Atlanta, GA 30329, USA
| | - Miriam B Vos
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Emory University School of Medicine, 1760 Haygood Drive North East, Atlanta, GA 30322, USA; Division of Gastroenterology, Hepatology, and Nutrition, Children's Healthcare of Atlanta, 1405 Clifton Road, Atlanta, GA 30329, USA
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199
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Abstract
Non-alcoholic fatty liver disease (NAFLD) is an increasingly important cause of chronic liver disease globally. Similar to metabolic syndrome and obesity, NAFLD is associated with alternations in the gut microbiota and its related biological pathways. While the exact pathophysiology of NAFLD remains largely unknown, changes in intestinal inflammation, gut permeability, energy harvest, anaerobic fermentation and insulin resistance have been described. In this chapter, we review the relationship between the gut microbiota, obesity and NAFLD, and highlight potential ways to modify the gut microbiota to help managing NAFLD patients.
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Affiliation(s)
- Louis H S Lau
- Institute of Digestive Disease, State Key Laboratory of Digestive Diseases, Department of Medicine & Therapeutics and LKS Institute of Health Sciences, The Chinese University of Hong Kong, Hong Kong, Hong Kong
| | - Sunny H Wong
- Institute of Digestive Disease, State Key Laboratory of Digestive Diseases, Department of Medicine & Therapeutics and LKS Institute of Health Sciences, The Chinese University of Hong Kong, Hong Kong, Hong Kong.
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200
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Jones RB, Alderete TL, Martin AA, Geary BA, Hwang DH, Palmer SL, Goran MI. Probiotic supplementation increases obesity with no detectable effects on liver fat or gut microbiota in obese Hispanic adolescents: a 16-week, randomized, placebo-controlled trial. Pediatr Obes 2018; 13:705-714. [PMID: 29493105 PMCID: PMC6113106 DOI: 10.1111/ijpo.12273] [Citation(s) in RCA: 50] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2017] [Revised: 01/08/2018] [Accepted: 01/19/2018] [Indexed: 12/15/2022]
Abstract
BACKGROUND Numerous studies have shown that there are links between obesity, liver fat and the gut microbiome. However, there are mixed results on whether probiotics could impact the gut microbiome and/or help to decrease liver fat and obesity outcomes. OBJECTIVE This study aimed to determine whether a probiotic supplement (VSL#3® ) intervention altered gut microbiota and/or gut hormones associated with appetite regulation. The secondary aim of this study was to determine whether VSL#3® altered body composition and liver fat and fibrosis. METHODS We conducted a double-blind, randomized placebo-controlled trial in 19 obese Latino adolescents. The intervention consisted of three packets per day of VSL#3® or a matched placebo for 16 weeks. Pre-intervention and post-intervention measures included gut microbial abundance, gut appetite regulating hormones, anthropometrics, body composition, liver fat and liver fibrosis. We conducted linear models to determine whether there were any significant differences in the changes in these outcomes following VSL#3® intervention. RESULTS Compared with placebo, adolescents that received VSL#3 had significant increases in total adiposity (%) (+1.7 ± 0.6 vs. -1.3 ± 0.5, p < 0.01) and trunk adiposity (%) (+3.3 ± 0.8 vs. -1.8 ± 0.8, p < 0.01) with no significant effects on liver fat/fibrosis, insulin/glucose, gut microbial abundances or gut hormones. CONCLUSION VSL#3 supplementation may lead to increased adiposity in obese Latino adolescents with no significant detectable changes in gut microbiota, gut appetite-regulating hormones, liver fat and fibrosis and dietary intake. However, it is important to note that recruitment efforts were terminated early and the sample size fell short of what was planned for this trial.
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Affiliation(s)
- Roshonda B Jones
- Department of Preventive Medicine, University of Southern California, Los Angeles, CA
| | - Tanya L Alderete
- Department of Preventive Medicine, University of Southern California, Los Angeles, CA
| | - Ashley A Martin
- Department of Preventive Medicine, University of Southern California, Los Angeles, CA
| | - Bree A Geary
- Department of Preventive Medicine, University of Southern California, Los Angeles, CA
| | - Darryl H Hwang
- Department of Radiology, University of Southern California, Los Angeles, CA
| | - Suzanne L Palmer
- Department of Radiology, University of Southern California, Los Angeles, CA
| | - Michael I Goran
- Department of Preventive Medicine, University of Southern California, Los Angeles, CA
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