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Abstract
Hepatocellular carcinoma (HCC) is a major contributor to cancer incidence and mortality. There is a wide variation, however, in the global distribution of HCC. Eighty percent of the burden is borne by countries in Asia and sub-Saharan Africa. In most high-risk countries, principal risk factors include infection with hepatitis B virus and dietary exposure to aflatoxin B(1). In contrast, hepatitis C virus and alcohol consumption are more important risk factors in low-risk countries. In recent years, the incidence of HCC has decreased in some high-risk countries and increased in some low-risk countries. Reasons for both trends are not completely understood, but are likely related to public health efforts in Asia and the increase in hepatitis C virus infection in low-risk countries. Vaccination programs against hepatitis B virus will likely decrease the HCC rate even further in decades to come.
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Affiliation(s)
- Katherine A McGlynn
- HREB/DCEG, National Cancer Institute, EPS-7060, 6120 Executive Boulevard, Rockville, MD 20892, USA.
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252
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Lirussi F, Mastropasqua E, Orando S, Orlando R. Probiotics for non-alcoholic fatty liver disease and/or steatohepatitis. THE COCHRANE DATABASE OF SYSTEMATIC REVIEWS 2005. [DOI: 10.1002/14651858.cd005165] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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253
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Suzuki A, Angulo P, Lymp J, St Sauver J, Muto A, Okada T, Lindor K. Chronological development of elevated aminotransferases in a nonalcoholic population. Hepatology 2005; 41:64-71. [PMID: 15690483 DOI: 10.1002/hep.20543] [Citation(s) in RCA: 149] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
The incidence and risk factors of nonalcoholic fatty liver disease (NAFLD) have never been prospectively determined. To determine the frequency and risk factors of NAFLD and chronological ordering between NAFLD, weight gain, and features of insulin resistance, a historical cohort study was conducted in a Japanese workplace. A cohort free of previous liver injury, alcohol consumption of more than 140 g/wk, and hepatitis B or C infection (529 of 1537 subjects), and a subcohort of 287 subjects free of insulin resistance-related features were identified. Elevated aminotransferases in nonalcoholics were used as a surrogate for NAFLD. High aminotransferases together with weight gain of more than 2 kg and insulin resistance-related features in the subcohort were sought for up to 5 years. The incidence of high aminotransferases was 31 per 1000 person-years (71 events). A significant interaction occurred between age and sex in the development of high aminotransferases. In subjects younger than age 40 years, male sex (hazard ratio [HR]: 4.6), elevated body mass index (HR: 2.1), hypertension (HR: 2.6), and low high-density lipoprotein cholesterol (HR: 2.8) increased the risk of high aminotransferases, whereas age (HR: 0.6 for each 5 years) decreased the risk. In subjects older than age 40 years, glucose intolerance (HR: 5.3) was the only significant risk factor. In the subcohort, weight gain preceded high aminotransferases and other insulin resistance-related features, which appeared sequentially in order of low high-density lipoprotein cholesterol, hypertriglyceridemia/hypertransaminasemia/hypertension, and glucose intolerance. In conclusion, this cohort study clearly showed chronological ordering and an association between development of elevated aminotransferases and risk factors of NAFLD.
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Affiliation(s)
- Ayako Suzuki
- Department of Gastroenterology and Hepatology, Mayo Clinic and Foundation, Rochester, MN 55905, USA
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254
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Cortez-Pinto H, Camilo ME. Non-alcoholic fatty liver disease/non-alcoholic steatohepatitis (NAFLD/NASH): diagnosis and clinical course. Best Pract Res Clin Gastroenterol 2004; 18:1089-104. [PMID: 15561640 DOI: 10.1016/j.bpg.2004.06.021] [Citation(s) in RCA: 60] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Non-alcoholic fatty liver disease (NAFLD) is a frequent syndrome encompassing fatty liver alone and steatohepatitis (NASH). Often asymptomatic, the suspicion arises because of abnormal aminotransferases or a bright liver on abdominal ultrasound. It should be suspected during evaluation of associated conditions as obesity, diabetes or dyslipidaemia. The diagnostic evaluation must exclude other potential causes of liver disease and may include a liver biopsy, the only method able to confirm features of necroinflammation and fibrosis that define NASH and its prognostic implications. Indeed, the presence of necroinflammation has been associated with a significant risk of progression to cirrhosis and eventually hepatocellular carcinoma. Age >45 years, obesity and diabetes have also been associated with an increased risk of liver fibrosis and progression to cirrhosis. Given the high prevalence of NAFLD, general measures of life-style changes, focusing on exercise, diet, and total alcohol abstinence, should be implemented before a liver biopsy is considered.
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Affiliation(s)
- Helena Cortez-Pinto
- Centro de Gastrenterologia, Hospital de Santa Maria, Av. Prof. Egas Moniz, 1649-035 Lisboa, Portugal.
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255
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Gawrieh S, Opara EC, Koch TR. Oxidative Stress in Nonalcoholic Fatty Liver Disease: Pathogenesis and Antioxidant Therapies. J Investig Med 2004. [DOI: 10.1177/108155890405200822] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Nonalcoholic fatty liver disease is a common cause of chronic liver disease, a common finding on liver biopsy in those patients with abnormal blood transaminase levels, and a common cause of cryptogenic cirrhosis in the United States. The prevalence of this disorder is expected to rise with the increase in obesity, and the clinical spectrum can range from simple steatosis (fatty liver) to cirrhosis of the liver. Insulin resistance is thought to be pivotal for the development of steatosis, and oxidative stress may be a potential factor that can promote hepatic necroinflammation and fibrosis. Preliminary studies have examined the role of oxidative stress and antioxidants in animal and human studies of this disorder. Efforts to improve the hepatic antioxidant system could be achieved by optimizing the patient's diet, by supplementation with precursors for antioxidants, or by supplementation with essential metals and/or antioxidants. Randomized, controlled trials are required to examine these potential approaches using patients with this disorder.
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Affiliation(s)
- Samer Gawrieh
- Division of Gastroenterology and Hepatology, Medical College of Wisconsin, Milwaukee, WI
| | - Emmanuel C. Opara
- Pritzker Institute of Medical Engineering, Illinois Institute of Technology, Chicago, IL
| | - Timothy R. Koch
- Section of Gastroenterology, Washington Hospital Center, Washington, DC
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256
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Abstract
Epidemiological studies have shown that obesity is a risk factor for hepatocellular carcinoma. Similar studies further indicate that diabetes is also a major risk factor. Both obesity and diabetes are frequently associated with nonalcoholic fatty liver disease, and case reports have shown progression of nonalcoholic fatty liver disease to cirrhosis and hepatocellular carcinoma. Although no study has clearly tied all of these variables together, it is likely that the association of hepatocellular carcinoma with obesity represents the progression of underlying nonalcoholic fatty liver disease to cirrhosis. The mechanism most likely involves replicative senescence of steatotic mature hepatocytes and compensatory hyperplasia of progenitor (oval) cells as a reaction to chronic injury due to ongoing nonalcoholic steatohepatitis and resultant hepatic fibrosis. Growth factors associated with chronic inflammation, type 2 diabetes, and DNA mutations as a result of lipid peroxidation probably play significant roles in clonal expansion and hepatocellular carcinoma progression. It remains unclear whether cirrhosis is a prerequisite for the development of hepatocellular carcinoma or whether hepatocellular carcinoma can develop in fatty liver in the absence of cirrhosis. However, well-documented case reports suggest that most cases of hepatocellular carcinoma arise in the setting of nonalcoholic steatohepatitis with cirrhosis. Whether therapy aimed at nonalcoholic fatty liver disease reduces the risk of hepatocellular carcinoma remains to be shown. Prophylactic measures and the role of cancer surveillance have not been adequately investigated, but current evidence suggests a risk for hepatocellular carcinoma in nonalcoholic steatohepatitis-related cirrhosis that rivals that of hepatocellular carcinoma in hepatitis C virus-related cirrhosis, particularly in older male patients.
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Affiliation(s)
- Stephen H Caldwell
- Division of Gastroenterology and Hepatology, University of Virginia Health System, P.O. Box 800708, Charlottesville, Virginia 22908-0708, USA.
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257
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Harrison SA, Neuschwander-Tetri BA. Nonalcoholic fatty liver disease and nonalcoholic steatohepatitis. Clin Liver Dis 2004; 8:861-79, ix. [PMID: 15464659 DOI: 10.1016/j.cld.2004.06.008] [Citation(s) in RCA: 84] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Nonalcoholic fatty liver disease (NAFLD) is a well-recognized form of chronic liver disease affecting both children and adults that has gained increased recognition. Recently NAFLD has been associated with insulin resistance and its incidence and prevalence is likely increasing, paralleling the rise in obesity and diabetes mellitus in the United States. The article includes current thoughts on the natural history and pathogenesis of NAFLD and describes current trends in the diagnosis and treatment of this condition.
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Affiliation(s)
- Stephen A Harrison
- Department of Gastroenterology and Hepatology, Brooke Army Medical Center, 3851 Roger Brooke Drive, Fort Sam Houston, TX 78234, USA.
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258
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Abstract
Assessments of liver biopsies are important in the diagnosis and management of non-alcoholic fatty liver disease. Histology remains the 'gold standard' for making the important distinction between simple steatosis, which is generally non-progressive and readily reversible, and steatohepatitis, which has the potential to progress to severe fibrosis or cirrhosis. Liver biopsy may also identify other causes of liver disease in patients thought to have fatty liver disease and vice versa. Histological grading and staging of fatty liver disease require further study but these are potentially important approaches for studying disease severity and progression, particularly in the context of clinical trials to assess novel therapeutic approaches.
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259
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Fassio E, Alvarez E, Domínguez N, Landeira G, Longo C. Natural history of nonalcoholic steatohepatitis: a longitudinal study of repeat liver biopsies. Hepatology 2004; 40:820-6. [PMID: 15382171 DOI: 10.1002/hep.20410] [Citation(s) in RCA: 134] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Nonalcoholic steatohepatitis may cause severe fibrosis, cirrhosis, and hepatocellular carcinoma, but supporting evidence is based on indirect data. Few publications have examined the results of repeat liver biopsies to evaluate progression of fibrosis. The aims of this study were to assess rate of fibrosis progression in untreated patients with nonalcoholic steatohepatitis and to identify associated variables. Among 106 patients, a second liver biopsy was proposed to those who had undergone their first liver biopsy at least 3 years before. None of them had been given pharmacological therapy. Liver biopsy samples were evaluated blindly. Variables were compared between patients with (group P) and without (group NP) fibrosis progression, using a Wilcoxon rank-sum test for numerical variables and a difference of two binomial proportions for categorical ones. Twenty-two patients (median age, 45 years; age range, 20-69 years; 13 women; diabetes in 8 patients, obesity in 10 patients) underwent a second liver biopsy 4.3 years (range, 3.0-14.3 years) after the first. Fibrosis progression was found in 7 patients in group P (31.8%), no progression was found in 15 patients in group NP. There were no differences between both groups regarding age, gender, diabetes, hyperlipidemia, ALT levels, AST-to-ALT ratio levels, albumin levels, prothrombin activity, steatosis, or inflammation. Obesity was significantly more prevalent in group P (86%) than in group NP (27%; P =.01). Basal body mass index was higher in group P (median, 33.2; range, 29.1-38.2) than in group NP (median, 29.0; range, 24.0-38.1; P =.024). Time between biopsies was not different between groups. In conclusion, progression of liver fibrosis was found in a third of nonalcoholic steatohepatitis patients 4.3 years after the first liver biopsy, and obesity and body mass index were the only associated factors with such progression.
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Affiliation(s)
- Eduardo Fassio
- Hepatology Unit, Gastroenterology Service, Hospital Nacional Profesor Alejandro Posadas, El Palomar, Buenos Aires, Argentina
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260
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Lonardo A, Bagni A, Tarugi P, Loria P. The wide spectrum of steatohepatitis: a report of four cases and a review of the literature. Eur J Gastroenterol Hepatol 2004; 16:1043-50. [PMID: 15371930 DOI: 10.1097/00042737-200410000-00015] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
We report on four cases displaying the wide range of aetiological risk factors (presence or absence of family history of dyslipidaemia and cryptogenic cirrhosis, from subnormal body mass index through morbid obesity, from absent through hepatotoxic alcohol consumption), laboratory test results (from subnormal through elevated uric acid and ferritin values), ultrasonographic changes (from normal findings through 'bright liver' with or without attenuation of ultrasound beam and absence/presence of focal lesions), and histological severity of steatohepatitis (fibrosis appearing to be inversely related to the amount of liver fat but zone 3 accentuation of lesions and ballooning being observed in all cases). Cases illustrate the concepts of overlapping aetiologies of steatohepatitis (hepatitis C, diabetes and lipodystrophy); the relationships between cryptogenic cirrhosis, familial cirrhosis, non-alcoholic fatty liver disease and hepatocellular carcinoma; familial hypobetalipoproteinaemia as an aetiology of steatohepatitis; and alcoholic liver disease in the obese. These issues, which are worthy of future investigation, are reviewed.
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Affiliation(s)
- Amedeo Lonardo
- Unità Operativa di Medicina Interna e Gastroenterologia, Ospedale Civile di Modena, Università di Modena e Reggio Emilia, Italy.
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261
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262
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Dikdan GS, Saba SC, Dela Torre AN, Roth J, Wang S, Koneru B. Role of oxidative stress in the increased activation of signal transducers and activators of transcription-3 in the fatty livers of obese Zucker rats. Surgery 2004; 136:677-85. [PMID: 15349118 DOI: 10.1016/j.surg.2004.02.005] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND Fatty livers have chronic oxidative stress, which could activate several transcription factors. We hypothesized that fatty livers of obese rats have increased activation of signal transducers and activators of transcription-1 and transcription-3 (Stat-1 and Stat-3) and that tocopherol treatment will decrease Stat activation. METHODS Obese (Ob) and lean (Ln) Zucker rats with or without tocopherol treatment were used. Western blots of liver nuclear and cytoplasmic extracts to assess phosphorylated and total Stat-3 and tyrosine kinases Jak-2 and Tyk-2, immunohistochemistry to assess distribution of phosphoStat-3, and gel shift assays to assess Stat and nuclear factor kappa B binding were performed. Interleukin-6 serum levels and hepatic transcripts were determined by immunoassay and reverse polymerase chain reaction with Southern blotting, respectively. RESULTS Livers of Ob animals had increased nuclear phosphoStat-3, decreased cytoplasmic Stat-3, and increased Stat-3 binding. Serum interleukin-6 was not measurable in either Ob or Ln animals and hepatic transcript levels were not significantly different. Tocopherol administration decreased nuclear phosphoStat-3, increased cytoplasmic Stat-3, and decreased Stat-3 binding activity. CONCLUSIONS Chronic oxidative stress in fatty livers is associated with increased Stat-3 activation and decreased cytosolic Stat-3. Tocopherol treatment decreases Stat-3 activation and increases cytosolic Stat-3. Tocopherol-induced changes in Stat-3 may play a role in its beneficial effects in hepatic ischemia in fatty livers.
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Affiliation(s)
- George S Dikdan
- Departments of Surgery, New Jersey Medical School, University of Medicine and Dentistry of New Jersey, Newark, NJ, USA
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263
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Sanjeevi A, Lyden E, Sunderman B, Weseman R, Ashwathnarayan R, Mukherjee S. Outcomes of liver transplantation for cryptogenic cirrhosis: a single-center study of 71 patients. Transplant Proc 2004; 35:2977-80. [PMID: 14697954 DOI: 10.1016/j.transproceed.2003.10.059] [Citation(s) in RCA: 38] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
UNLABELLED Cryptogenic cirrhosis (CC) is emerging as an important indication for orthotoptic liver transplantation (OLT) in the United States. Our aim was to identify risk factors associated with nonalcoholic steatohepatitis (NASH) in patients with CC and to evaluate outcomes following OLT. PATIENTS AND METHODS A chart review was performed on patients transplanted for CC at the University of Nebraska Medical Center between October 1993 and May 2003. RESULTS Seventy-one patients were identified (37 were men and 34 women). Average age was 53.5 years. Mean cholesterol and triglyceride levels increased from 174.8 to 222.3 mg/dL (P <.05) and from 162.60 to 279.66 mg/dL (P <.05), respectively. The prevalence of diabetes mellitus also increased from 37.14% to 54.93% (P <.05). Incidental hepatocellular carcinoma was present in six patients and high-grade dysplasia in one patient. Steatohepatitis developed in eight patients and recurrent cryptogenic disease in four, of whom one required retransplantation for decompensated liver disease. Rejection occurred in 24 patients. Cumulative incidence of graft failure at 1 year was 4% (95% CI 0% to 10%) and at 5 years was 7% (95% CI 0% to 18%). Survival at 1 year was 85% (95% CI 77% to 94%) and at 5 years was 73% (95% CI between 61% to 86%). CONCLUSIONS Cryptogenic liver disease is an important cause of decompensated cirrhosis; NASH appears to be an intermediate stage in the development of this disease in a subset of patients. Short-term and 5-year survival rates in this series appear comparable to other liver transplant recipients, supporting liver transplantation as an acceptable treatment for CC.
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Affiliation(s)
- A Sanjeevi
- Section of Gastroenterology and Hepatology, University of Nebraska Medical Center, Omaha, NE 68198-3285, USA
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264
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Contos MJ, Choudhury J, Mills AS, Sanyal AJ. The histologic spectrum of nonalcoholic fatty liver disease. Clin Liver Dis 2004; 8:481-500, vii. [PMID: 15331059 DOI: 10.1016/j.cld.2004.04.013] [Citation(s) in RCA: 49] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Nonalcoholic fatty liver disease (NAFLD) represents a range of histologic lesions in the liver that occur in individuals who do not consume alcohol in quantities that generally are considered to be harmful. The histologic spectrum of NAFLD includes isolated predominantly macrovesicular steatosis alone at one end and steatohepatitis at the other. Nonalcoholic steatohepatitis can progress to cirrhosis and now also is considered to be a precursor of cryptogenic cirrhosis. This article provides an understanding of the histologic features of NAFLD and the potential pitfalls in the histologic assessment of this condition.
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Affiliation(s)
- Melissa J Contos
- Department of Pathology, Virginia Commonwealth University, Box 980662, Richmond, VA 23298, USA.
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265
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Diehl AM. Tumor necrosis factor and its potential role in insulin resistance and nonalcoholic fatty liver disease. Clin Liver Dis 2004; 8:619-38, x. [PMID: 15331067 DOI: 10.1016/j.cld.2004.04.012] [Citation(s) in RCA: 79] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Nonalcoholic fatty liver disease (NAFLD) is a spectrum of hepatic pathology that resembles alcohol-induced fatty liver disease(AFLD), but which develops in individuals who are not heavy drinkers. In people, NAFLD is associated strongly with obesity,insulin resistance, and dysmetabolic syndrome, but the exact mechanisms that promote liver disease in this clinical context remain poorly understood. The proinflammatory cytokine, funor necrosis factor alpha is known to be a key mediator of AFLD. This article discusses clinical and experimental evidence that tumor necrosis factor plays a role in the pathogenesis of insulin resistance syndromes, including nonalcoholic fatty syndromes, including nonalcoholic fatty liver disease.
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Affiliation(s)
- Anna Mae Diehl
- The Johns Hopkins University School of Medicine, Department of Medicine, Division of Gastroenterology, Ross Research Building, Room 918, 720 Rutland Avenue, Baltimore, MD, 21205-2109, USA.
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266
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McCullough AJ. The clinical features, diagnosis and natural history of nonalcoholic fatty liver disease. Clin Liver Dis 2004; 8:521-33, viii. [PMID: 15331061 DOI: 10.1016/j.cld.2004.04.004] [Citation(s) in RCA: 385] [Impact Index Per Article: 19.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Nonalcoholic fatty liver disease (NAFLD) has emerged as the most common chronic liver disease in the United States. The histologic spectrum of NAFLD ranges from steatosis liver alone to nonalcoholic steatohepatitis (NASH), which is the most serious form of NAFLD. NASH is a progressive fibrotic disease, in which cirrhosis and liver-related death occur in up to 20% and 12%, respectively, over a 10-year period. NASH-associated cirrhosis also can develop into subacute liver failure, progress to hepatocellular carcinoma, and reoccur post-transplantation. In contrast, steatosis alone has a more benign clinical course, although progression to cirrhosis has occurred in 3% of these patients. The major risk factors for fibrosis include diabetes or obesity, an aspartate aminotransferase/alanine aminotransferase ratio of greater than 1, age older than 50, and hepatic histology.
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Affiliation(s)
- Arthur J McCullough
- Case Western Reserve University, 2500 Metro Health Drive, Cleveland, OH 44109, USA
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267
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Nair S, Diehl AM, Wiseman M, Farr GH, Perrillo RP. Metformin in the treatment of non-alcoholic steatohepatitis: a pilot open label trial. Aliment Pharmacol Ther 2004; 20:23-8. [PMID: 15225167 DOI: 10.1111/j.1365-2036.2004.02025.x] [Citation(s) in RCA: 242] [Impact Index Per Article: 12.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Insulin sensitizing agents may be useful in treatment of non-alcoholic fatty liver disease. AIM A pilot study to evaluate the efficacy and safety of metformin in non-alcoholic fatty liver disease. METHODS In an open labelled study, patients with histologically confirmed non-alcoholic fatty liver disease were given metformin (20 mg/kg) for 1 year. Insulin resistance (by log homeostasis assessment model analysis for insulin resistance and Quantitative Insulin Sensitivity Check Index) and post-treatment hepatic histology were compared with pre-treatment histology. RESULTS Fifteen patients completed 1 year of treatment. During the initial 3 months, there was improvement in alanine aminotransferase and aspartate aminotransferase (P-value 0.01 and 0.02, respectively) along with improvement in insulin sensitivity. However, after 3 months, there was no further improvement in insulin sensitivity and there was gradual rise in aspartate aminotransferase and alanine aminotransferase back to pre-treatment levels. Among the 10 patients with post-treatment biopsy, three (33%), showed improvement in steatosis, two (20%) showed improvement in inflammation score and one (10%) showed improvement in fibrosis. CONCLUSION Metformin treatment was associated with only a transient improvement in liver chemistries. A progressive, sustainable reduction in insulin sensitivity was not noted during treatment.
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Affiliation(s)
- S Nair
- Section of Gastroenterology and Hepatology, Ochsner Clinic Foundation, New Orleans, LA 70121, USA.
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268
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Bergasa NV, Mehlman J, Bir K. Aerobic exercise: a potential therapeutic intervention for patients with liver disease. Med Hypotheses 2004; 62:935-41. [PMID: 15142652 DOI: 10.1016/j.mehy.2003.12.041] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2003] [Accepted: 12/05/2003] [Indexed: 12/31/2022]
Abstract
Fatigue is a symptom of liver disease. Indirect evidence suggests that this type of fatigue is centrally mediated. Non-alcoholic steatohepatitis (NASH), which may lead to cirrhosis, is associated with insulin resistance. An activated hypothalamic pituitary adrenal axis results in increased secretion of cortisol releasing hormone, cortisol and catecholamines. Prolonged exposure to high levels of cortisol is associated with insulin resistance, as exemplified by the metabolic syndrome. Accumulation in visceral fat is an independent factor associated with insulin resistance. Central (visceral) fat is less sensitive to insulin than the rest of body fat and the central nervous system and not peripheral insulin, appears to regulate lipolysis in visceral fat by, at least in part, adrenergic mechanisms. Aerobic training has documented beneficial effects on mental health and fatigue secondary to chronic illness. In addition, aerobic training increases insulin sensitivity. Thus, aerobic training may decrease fatigue in liver disease and improve NASH.
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Affiliation(s)
- Nora V Bergasa
- Columbia University College of Physicians and Surgeons, 630 W 168 Street, P&S 10-508 New York, NY 10032, USA.
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269
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Cadranel JF, Jouannaud V, Loison S. [Improving insulin resistance: certain progress in the management of patients with non-alcoholic steatohepatitis...but the story continues]. ACTA ACUST UNITED AC 2004; 28:265-7. [PMID: 15094675 DOI: 10.1016/s0399-8320(04)94916-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
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270
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Bardella MT, Valenti L, Pagliari C, Peracchi M, Farè M, Fracanzani AL, Fargion S. Searching for coeliac disease in patients with non-alcoholic fatty liver disease. Dig Liver Dis 2004; 36:333-6. [PMID: 15191202 DOI: 10.1016/j.dld.2004.01.012] [Citation(s) in RCA: 60] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND A non-negligible percentage of patients with non-alcoholic fatty liver disease, a leading cause of hepatic progressive disorder related to insulin resistance, have no metabolic risk factors, and abnormal intestinal permeability has been suggested to be involved in the pathogenesis of the liver damage. Coeliac disease, a curable disorder characterised by inflammatory mucosal damage, may show hepatic histological features similar to steatohepatitis. Conflicting data have been reported on the prevalence of coeliac disease in non-alcoholic steatohepatitis. AIM To search for coeliac disease in a series of patients with non-alcoholic fatty liver disease by screening with anti-tissue transglutaminase and anti-endomysium antibodies. PATIENTS AND METHODS Fifty-nine consecutive patients with hypertransaminasemia and non-alcoholic fatty liver disease, 38 (64%) with steatohepatitis. Anti-endomysium antibodies were assayed by indirect immunofluorescence, IgA anti-tissue transglutaminase by ELISA. Patients who tested positive underwent HLA DQ typing and endoscopy. RESULTS Tissue transglutaminase antibodies were positive in six (10%) patients and anti-endomysium in two (3.4%); only two (3.4%), positive for both anti-endomysium positive and anti-transglutaminase, resulted to have coeliac disease based on histological findings. After 6 months of gluten-free diet, liver enzymes normalised. CONCLUSIONS The prevalence of silent coeliac disease is 3.4% in patients with non-alcoholic fatty liver. The inclusion of anti-endomysium antibodies test in studying patients with non-alcoholic fatty liver and persistent biochemical abnormalities has to be taken into account, since positivity for tissue transglutaminase antibodies, in the absence of confirmatory anti-endomysium antibodies, is not sufficient to perform diagnostic endoscopy.
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Affiliation(s)
- M T Bardella
- Department Medical Sciences, IRCCS Ospedale Maggiore Policlinico di Milano, University of Milan, Via F. Sforza, 35, 20122 Milan, Italy.
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271
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Abstract
Hereditary haemochromatosis is the most common inherited disorder in white populations, whereas non-alcoholic steatohepatitis (NASH) is becoming the most common reason for referral for investigation of abnormal liver function tests (LFTs). This report describes two sisters, from similar environments, who were referred to the clinic after being found to be C282Y homozygotes and to have abnormal LFTs. One sister had developed features of haemochromatosis and the other had developed NASH. These cases illustrate the potential non-penetrance of HFE gene mutations and the need to investigate abnormal LFTs fully, even when there is a positive genetic test at the outset.
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Affiliation(s)
- D R Gaya
- Department of Gastroenterology, Hairmyres Hospital, Lanarkshire G75 8RG, UK.
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272
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Caldwell SH, Crespo DM. The spectrum expanded: cryptogenic cirrhosis and the natural history of non-alcoholic fatty liver disease. J Hepatol 2004; 40:578-84. [PMID: 15030972 DOI: 10.1016/j.jhep.2004.02.013] [Citation(s) in RCA: 190] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Affiliation(s)
- Stephen H Caldwell
- The Division of Gastroenterology and Hepatology, Box 800708, University of Virginia Health System, Charlottesville, VA 22908-0708, USA.
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273
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Ratziu V, Imbert-Bismut F, Messous D, Poynard T. The elusiveness of "normal" ALT in fatty liver. Hepatology 2004; 39:1172; author reply 1173. [PMID: 15057921 DOI: 10.1002/hep.20187] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
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274
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Rubbia-Brandt L, Fabris P, Paganin S, Leandro G, Male PJ, Giostra E, Carlotto A, Bozzola L, Smedile A, Negro F. Steatosis affects chronic hepatitis C progression in a genotype specific way. Gut 2004; 53:406-12. [PMID: 14960525 PMCID: PMC1773989 DOI: 10.1136/gut.2003.018770] [Citation(s) in RCA: 214] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND AND AIMS Liver steatosis is frequent in chronic hepatitis C, particularly in patients infected with hepatitis C virus (HCV) genotype 3. The aim of this study was to determine the relationship between steatosis and fibrosis in chronic hepatitis C as a function of viral genotype. METHODS A multivariable logistic regression analysis was carried out in 755 chronic hepatitis C patients (mean body mass index (BMI) 24.11 kg/m(2); 178 with genotype 3), consecutively admitted to three referral hospitals. Liver histology showed steatosis in 315 and fibrosis in 605 patients, of whom 187 had cirrhosis (78 compensated and 109 decompensated). RESULTS Steatosis was independently associated with fibrosis (p<0.001), genotype 3 (p<0.001), BMI (p<0.001), ongoing alcohol abuse (p<0.001), and age (p = 0.001). Fibrosis was associated with the Metavir activity score (p<0.001), age (p<0.001), steatosis (p = 0.001), past alcohol abuse for >5 years (p = 0.015), and BMI (p = 0.034). When regression analysis was repeated on patients divided according to viral genotype (that is, 3 v non-3) to identify type specific risk factors, steatosis was associated with ongoing alcohol abuse (p<0.001) and age (p = 0.01) only in non-3 genotype infected patients and with Metavir activity (p = 0.044) only in genotype 3 infected patients. Similarly, fibrosis was associated with steatosis only in genotype 3 infected individuals (p = 0.018), and with past alcohol abuse (p = 0.003) and (marginally) diabetes (p = 0.078) only in non-3 genotype infected patients. CONCLUSIONS Steatosis influences chronic hepatitis C progression in a genotype specific way. Patients infected with genotype 3 and histologically confirmed steatosis should not be deferred from effective antiviral therapy.
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Affiliation(s)
- L Rubbia-Brandt
- Division of Clinical Pathology, Hôpitaux Universitaires, Genève, Switzerland
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275
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276
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Marchesini G, Bugianesi E, Forlani G, Marzocchi R, Zannoni C, Vanni E, Manini R, Rizzetto M, Melchionda N. Non-alcoholic steatohepatitis in patients cared in metabolic units. Diabetes Res Clin Pract 2004; 63:143-51. [PMID: 14739055 DOI: 10.1016/j.diabres.2003.09.007] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
The clinical significance of liver disease is frequently underestimated in patients with metabolic disorders. In patients followed up in a metabolic unit for diabetes, obesity or hyperlipidemia (n=147), we studied the prevalence and the severity of liver disease, and its relationship with the metabolic syndrome (MS). Cases cared for in a liver unit (n=179) were used as controls. Patients in the metabolic series were older and had a higher prevalence of coronary heart disease. Criteria for the metabolic syndrome were fulfilled in 64% and 22% of cases, respectively (P<0.0001). Liver biopsy was obtained in 44 and 66% of cases. Metabolic patients had a more severe steatosis score (P<0.0001), whereas the scores of fibrosis and necroinflammation were less severe (P=0.0059 and 0.0007, respectively). Histological criteria for non-alcoholic steatohepatitis (NASH) were present in 82% of metabolic cases and 68% cases in the liver series (P=0.057). Liver disease in patients routinely cared for in metabolic units is similar to that observed in patients cared for in liver units, and potentially may progress to terminal liver failure. Liver biopsy is recommended for diagnostic and prognostic purposes, as well as for testing treatment effects in controlled trials.
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Affiliation(s)
- Giulio Marchesini
- Unit of Metabolic Diseases, Department of Internal Medicine and Gastroenterology, University of Bologna, Alma Mater Studiorum, Via Massarenti 9, Policlinico S. Orsola, I-40138 Bologna, Italy.
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277
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Regimbeau JM, Colombat M, Mognol P, Durand F, Abdalla E, Degott C, Degos F, Farges O, Belghiti J. Obesity and diabetes as a risk factor for hepatocellular carcinoma. Liver Transpl 2004; 10:S69-73. [PMID: 14762843 DOI: 10.1002/lt.20033] [Citation(s) in RCA: 146] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Ten percent of patients who undergo resection for hepatocellular carcinoma (HCC) associated with chronic liver disease have no detectable cause for this underlying liver disease. Recent studies have shown that patients with cryptogenic chronic liver disease frequently have risk factors for nonalcoholic fatty liver disease (NAFLD). This study examines the incidence of risk factors for NAFLD in patients with chronic liver disease who underwent resection for HCC. Among 210 patients with chronic liver disease who underwent resection for HCC, 18 (8.6%) had no identifiable cause for the underlying liver disease. These patients were assessed for obesity, diabetes mellitus, and histological features of the tumor and the adjacent liver parenchyma. Comparisons were made with matched patients with alcohol- and chronic-viral-hepatitis-related HCC. The prevalence of obesity (50% vs. 17% vs. 14%), diabetes (56% vs. 17% vs. 11%), aspartate aminotransferase/alanine aminotransferase ratio<1 (50% vs. 19% vs. 17%), and steatosis>20% (61% vs. 17% vs. 19%) was significantly higher in patients with cryptogenic liver disease than in patients with alcohol abuse and chronic viral hepatitis (P<0.0001 for each). Well-differentiated tumors were significantly more common in patients with cryptogenic liver disease (89% vs. 64% in patients with alcohol-related HCC vs. 55% in patients with chronic viral hepatitis-related HCC, P<0.0001). In conclusion, the hypothesis that obesity and diabetes mellitus may be important risk factors for cryptogenic chronic liver disease in patients with HCC is supported by the analysis of surgically treated patients. Whether HCC is primarily related to obesity and diabetes mellitus or secondarily to a NAFLD-like parenchymal lesions remains to be clarified.
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Affiliation(s)
- Jean M Regimbeau
- Fédération Médico-Chirurgicale d'Hépato-Gastro-Entérologie, Department of Surgery, Hospital Beaujon, Assistance Publique-Hôpitaux de Paris and Faculty of Medicine Xavier Bichat, University Paris VII, Paris, France
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278
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Lonardo A, Adinolfi LE, Loria P, Carulli N, Ruggiero G, Day CP. Steatosis and hepatitis C virus: mechanisms and significance for hepatic and extrahepatic disease. Gastroenterology 2004; 126:586-97. [PMID: 14762795 DOI: 10.1053/j.gastro.2003.11.020] [Citation(s) in RCA: 325] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Nonalcoholic fatty liver disease (NAFLD) and hepatitis C virus (HCV)-related liver disease are common in the general population, but their concurrence is 2- to 3-fold higher than would be expected by chance alone. In patients with chronic HCV infection, steatosis is attributable to a variable combination of the mechanisms considered to play a role in the pathogenesis of NAFLD--insulin resistance in the obese and in the lean subject--along with a direct effect of HCV on hepatic lipid metabolism that leads to triglyceride accumulation through inhibition of export proteins that are required for very low density lipoprotein (VLDL) assembly and secretion. Accumulating evidence suggests that steatosis contributes to the progression of fibrosis in HCV-related disease in a pattern similar to that observed in NAFLD. Potential mechanisms of this effect include the increased sensitivity of steatotic livers to oxidative stress and cytokine-mediated injury. Steatosis-related hepatic insulin resistance may also play a role through the profibrogenic effects of the compensatory hyperinsulinemia and provides a potential explanation for the association between HCV and type 2 diabetes mellitus. Indeed, an appreciation of the importance of fat in HCV has recently led to trials of adjuvant therapy for HCV directed at steatosis-associated disease mechanisms, with encouraging results reported for various modalities, including weight loss and antioxidants. Future therapy should be aimed at exploiting the interactions of HCV with host insulin and lipid metabolism, particularly in nonresponders to standard antiviral schedules.
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Affiliation(s)
- Amedeo Lonardo
- Division of Internal Medicine and Gastroenterology, Modena City Hospital, Italy.
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279
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El-Serag HB, Tran T, Everhart JE. Diabetes increases the risk of chronic liver disease and hepatocellular carcinoma. Gastroenterology 2004; 126:460-8. [PMID: 14762783 DOI: 10.1053/j.gastro.2003.10.065] [Citation(s) in RCA: 864] [Impact Index Per Article: 43.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS An association between diabetes and chronic liver disease has been reported. However, the temporal relationship between these conditions remains unknown. METHODS We identified all patients with a hospital discharge diagnosis of diabetes between 1985 and 1990 using the computerized records of the Department of Veterans Affairs. We randomly assigned 3 patients without diabetes for every patient with diabetes. We excluded patients with concomitant liver disease. The remaining cohort was followed through 2000 for the occurrence of chronic nonalcoholic liver disease (CNLD) and hepatocellular carcinoma (HCC). Hazard rate ratios (HRR) were determined in Cox proportional hazard survival analysis. RESULTS The study cohort comprised 173,643 patients with diabetes and 650,620 patients without diabetes. Most were men (98%). Patients with diabetes were older (62 vs. 54 years) than patients without diabetes. The incidence of chronic nonalcoholic liver disease was significantly higher among patients with diabetes (incidence rate: 18.13 vs. 9.55 per 10,000 person-years, respectively, P < 0.0001). Similar results were obtained for HCC (incidence rate: 2.39 vs. 0.87 per 10,000 person-years, respectively, P < 0.0001). Diabetes was associated with an HRR of 1.98 (95% CI: 1.88 to 2.09, P < 0.0001) of CNLD and an HRR of 2.16 (1.86 to 2.52, P < 0.0001) of hepatocellular carcinoma. Diabetes carried the highest risk among patients with longer than 10 years of follow-up. CONCLUSIONS Among men with diabetes, the risk of CNLD and HCC is doubled. This increase in risk is independent of alcoholic liver disease, viral hepatitis, or demographic features.
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Affiliation(s)
- Hashem B El-Serag
- Section of Gastroenterology, Houston Departmentof Veterans Affais Medical Center and Baylor College of Medicine, Houston, TX 77030, USA.
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280
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Bugianesi E, Manzini P, D'Antico S, Vanni E, Longo F, Leone N, Massarenti P, Piga A, Marchesini G, Rizzetto M. Relative contribution of iron burden, HFE mutations, and insulin resistance to fibrosis in nonalcoholic fatty liver. Hepatology 2004; 39:179-87. [PMID: 14752836 DOI: 10.1002/hep.20023] [Citation(s) in RCA: 290] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
The mechanism(s) determining the progression from fatty liver to steatohepatitis is currently unknown. Our goal was to define the relative impact of iron overload, genetic mutations of HFE, and insulin resistance on the severity of liver fibrosis in a population of subjects with nonalcoholic fatty liver disease (NAFLD) who had low prevalence of obesity and no overt symptoms of diabetes. In a cohort of 263 prospectively enrolled patients with NAFLD, 7.4% of patients had signs of peripheral iron overload and 9% had signs of hepatic iron overload, but 21.1% had hyperferritinemia. The prevalence of C282Y and H63D HFE mutations was similar to the general population and mutations were not associated with iron overload. Although subjects were on average only moderately overweight, insulin sensitivity, measured both in the fasting state and in response to oral glucose, was lower. Univariate analysis demonstrated that the presence of severe fibrosis was independently associated with older age, female sex, overweight, aspartate/alanine aminotransferase ratio, serum ferritin level, fasting glucose and insulin levels, decreased insulin sensitivity, and with histologic features (degree of necroinflammation and steatosis). After adjustment for body mass index (BMI), age, sex, and degree of steatosis, ferritin levels (odds ratio [OR] = 1.77; 95% CI = 1.21- 2.58; P =.0032) and the oral glucose insulin sensitivity (OR = 0.53; CI = 0.33-0.87; P =.0113) were independent predictors of severe fibrosis. In conclusion, the current study indicates that insulin resistance is a major, independent risk factor for advanced fibrosis in patients with NAFLD. Increased ferritin levels are markers of severe histologic damage, but not of iron overload. Iron burden and HFE mutations do not contribute significantly to hepatic fibrosis in the majority of patients with NAFLD.
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Affiliation(s)
- Elisabetta Bugianesi
- Division of Gastro-Hepatology, Department of Internal Medicine, University of Turin, Turin, Italy.
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281
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Zafrani ES. Non-alcoholic fatty liver disease: an emerging pathological spectrum. Virchows Arch 2003; 444:3-12. [PMID: 14685853 DOI: 10.1007/s00428-003-0943-7] [Citation(s) in RCA: 60] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2003] [Accepted: 11/04/2003] [Indexed: 02/06/2023]
Abstract
The spectrum of pathological lesions observed in non-alcoholic fatty liver disease (NAFLD) is wide and strongly resembles that of alcohol-induced liver disease. It ranges from fatty liver to steatohepatitis, progressive fibrosis and cirrhosis. Hepatocellular carcinoma is a possible complication of NAFLD, but whether it is related to frequently associated metabolic disorders (e.g., overweight, diabetes) or to underlying cirrhosis is unclear. This disease is the result of a multi-factorial process in which insulin resistance seems to play a major role in the initial accumulation of fat in the liver, whereas multiple causes of mitochondrial dysfunction and oxidative stress can induce the secondary occurrence of necroinflammatory lesions and fibrosis. Genetic factors might explain why only some patients with simple steatosis will develop steatohepatitis and fibrosis. Due to the increasing prevalence of obesity in Western countries, NAFLD will possibly be a public health problem and the liver disease of the future.
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Affiliation(s)
- Elie Serge Zafrani
- Département de Pathologie, Hôpital Henri Mondor, 94010 Créteil cedex, France.
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282
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Malnick SDH, Beergabel M, Knobler H. Non-alcoholic fatty liver: a common manifestation of a metabolic disorder. QJM 2003; 96:699-709. [PMID: 14500857 DOI: 10.1093/qjmed/hcg120] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Affiliation(s)
- S D H Malnick
- Department of Internal Medicine C, Kaplan Medical Centre, Hadassah and the Hebrew University School of Medicine, Rehovot 76100, Israel.
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283
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Hui JM, Kench JG, Chitturi S, Sud A, Farrell GC, Byth K, Hall P, Khan M, George J. Long-term outcomes of cirrhosis in nonalcoholic steatohepatitis compared with hepatitis C. Hepatology 2003; 38:420-7. [PMID: 12883486 DOI: 10.1053/jhep.2003.50320] [Citation(s) in RCA: 332] [Impact Index Per Article: 15.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Data on the long-term outcome of nonalcoholic steatohepatitis (NASH)-associated cirrhosis are few, and most reports describe cases of cryptogenic cirrhosis associated with risk factors for NASH but without histologic definition. In this prospective cohort study, we describe the long-term morbidity and mortality of 23 patients with NASH-associated cirrhosis defined by strict clinicopathologic criteria. Outcomes were compared with 46 age- and gender-matched patients with cirrhosis from chronic hepatitis C virus (HCV) infection: 23 untreated and 23 nonresponders to antiviral therapy. During follow-up (mean, 84 months; median, 60 months; range, 5-177 months), 9 of the 23 NASH-associated cirrhosis cases developed liver-related morbidity (8 ascites and/or encephalopathy, 1 variceal bleeding). The probability of complication-free survival was 83%, 77%, and 48% at 1, 3, and 10 years, respectively, and the cumulative probability of overall survival was 95%, 90%, and 84% at 1, 3, and 10 years, respectively. Five deaths were from liver failure, 1 from a non-liver-related cause. By multivariate analysis, bilirubin (P =.02) and platelet (P =.04) were independent predictors of complication-free survival; bilirubin (P =.05) was the only predictor for overall survival. After controlling for these factors, there was no difference in complication-free or overall survival between the NASH-cirrhosis cohort and either group of HCV-cirrhosis. However, 8 cases of liver cancer occurred in the HCV-cirrhosis groups compared with none among NASH cases. In conclusion, liver failure is the main cause of morbidity and mortality in NASH-associated cirrhosis. The prognosis is either similar or less severe than HCV-cirrhosis, except that HCC appears less common.
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Affiliation(s)
- Jason M Hui
- Storr Liver Unit, Westmead Millennium Institute, and Department of Gastroenterology and Hepatology, Westmead Hospital, University of Sydney, NSW, Australia
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284
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Anagnostopoulos GK, Arvanitidis D, Tsiakos S, Margantinis G, Grigoriadis K, Kostopoulos P. Is hepatocellular carcinoma part of the natural history of nonalcoholic steatohepatitis? J Clin Gastroenterol 2003; 37:88-9. [PMID: 12811221 DOI: 10.1097/00004836-200307000-00025] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/09/2022]
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285
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Affiliation(s)
- Gerardo Clemente Ricote
- Instituto de Hepatología Clínica-Experimental y Trasplante Hepático. Unidad Funcional Interhospitalaria Gregorio Marañón-Santa Cristina. Madrid. España. g
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286
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Caldwell SH, Zaidman JS, Hespenheide EE. The liver and statin drug therapy: uncertain navigation in the sea of risk-benefit. Pharmacoepidemiol Drug Saf 2003; 12:303-6. [PMID: 12812010 DOI: 10.1002/pds.833] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
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287
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Saxena NK, Saliba G, Floyd JJ, Anania FA. Leptin induces increased alpha2(I) collagen gene expression in cultured rat hepatic stellate cells. J Cell Biochem 2003; 89:311-20. [PMID: 12704794 PMCID: PMC2925439 DOI: 10.1002/jcb.10494] [Citation(s) in RCA: 70] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
Leptin is a 16-kDa hormone with an array of biologic actions. We, and others, have demonstrated that leptin is critical to the development of liver fibrogenesis both in vitro and in the lean littermates of ob/ob mice exposed to carbon tetrachloride (CCl(4)). Controversy exists as to whether leptin can act as a direct cytokine in the development of increased collagen expression, and whether ob/ob mice are resistant to potential injury from CCl(4). Here, we provide evidence that strongly suggests that leptin acts to increase nascent production of mRNA for the alpha2(I) collagen gene based upon ribonuclease protection analysis (RPA). Actinomycin D, but not cyclohexamide, or the pan-neutralizing antibody to transforming growth factor beta one (TGFbeta1), significantly diminished the effect of leptin on total alpha2(I) collagen mRNA levels. Further evidence that leptin acts directly on HSCs to alter gene expression in liver wounding is demonstrated by enhanced binding of phosphorylated signal transduction and activator of transcription factor 3 (pStat3) to a cis-inducible element (SIE) oligonucleotide by electrophoretic mobility shift assay (EMSA). This consensus sequence is responsible for production of a critical collagen transcription factor, AP-1. Finally, we have demonstrated from the ob/ob mouse model that these animals are at least as sensitive to CCl(4) as their respective lean animals as assessed by serum alanine aminotransferase (ALT) measurements. Taken together, the current data provide a continued framework that leptin is a profibrogenic cytokine and plays a key role in liver fibrosis.
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Affiliation(s)
| | | | | | - Frank A. Anania
- Correspondence to: Frank A. Anania, Hepatology Section, Division of Gastroenterology, Department of Medicine, University of Maryland School of Medicine, Room N3W50, 22 South Greene Street, Baltimore, MD 21201.
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288
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Abstract
Fatty liver disease that develops in the absence of alcohol abuse is recognized increasingly as a major health burden. This report summarizes the presentations and discussions at a Single Topic Conference held September 20-22, 2002, and sponsored by the American Association for the Study of Liver Diseases. The conference focused on fatty liver disorders. Estimates based on imaging and autopsy studies suggest that about 20% to 30% of adults in the United States and other Western countries have excess fat accumulation in the liver. About 10% of these individuals, or fully 2% to 3% of adults, are estimated to meet current diagnostic criteria for nonalcoholic steatohepatitis (NASH). Sustained liver injury leads to progressive fibrosis and cirrhosis in a fraction, possibly up to one third, of those with NASH, and NASH may be a cause of cryptogenic cirrhosis. NASH is now a significant health issue for obese children as well, leading to cirrhosis in some. The diagnostic criteria for NASH continue to evolve and rely on the histologic findings of steatosis, hepatocellular injury (ballooning, Mallory bodies), and the pattern of fibrosis. Generally recognized indications for biopsy include establishing the diagnosis and staging of the injury, but strict guidelines do not exist. Liver enzymes are insensitive and cannot be used reliably to confirm the diagnosis or stage the extent of fibrosis. Older age, obesity, and diabetes are predictive of fibrosis. The pathogenesis of NASH is multifactorial. Insulin resistance may be an important factor in the accumulation of hepatocellular fat, whereas excess intracellular fatty acids, oxidant stress, adenosine triphosphate (ATP) depletion, and mitochondrial dysfunction may be important causes of hepatocellular injury in the steatotic liver. Efforts are underway to refine the role of insulin resistance in NASH and determine whether improving insulin sensitivity pharmacologically is an effective treatment. An altered lifestyle may be a more effective means of improving insulin sensitivity. The research agenda for the future includes establishing the role of insulin resistance and abnormal lipoprotein metabolism in NASH, determining the pathogenesis of cellular injury, defining predisposing genetic abnormalities, identifying better noninvasive predictors of disease, and defining effective therapy.
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289
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290
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Marchesini G, Bugianesi E, Forlani G, Cerrelli F, Lenzi M, Manini R, Natale S, Vanni E, Villanova N, Melchionda N, Rizzetto M. Nonalcoholic fatty liver, steatohepatitis, and the metabolic syndrome. Hepatology 2003; 37:917-23. [PMID: 12668987 DOI: 10.1053/jhep.2003.50161] [Citation(s) in RCA: 1866] [Impact Index Per Article: 88.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Nonalcoholic fatty liver disease (NAFLD) has been associated with the insulin-resistance syndrome, at present defined as the metabolic syndrome, whose limits were recently set. We assessed the prevalence of the metabolic syndrome in 304 consecutive NAFLD patients without overt diabetes, on the basis of 3 or more criteria out of 5 defined by the U.S. National Institutes of Health (waist circumference, glucose, high-density lipoprotein [HDL]-cholesterol, triglycerides, and arterial pressure). The prevalence of the metabolic syndrome increased with increasing body mass index, from 18% in normal-weight subjects to 67% in obesity. Insulin resistance (Homeostasis Model Assessment method) was significantly associated with the metabolic syndrome (odds ratio [OR], 2.5; 95% CI, 1.5-4.2; P <.001). Liver biopsy was available in 163 cases (54%). A total of 120 patients (73.6%) were classified as having nonalcoholic steatohepatitis (NASH); 88% of them had a metabolic syndrome (vs. 53% of patients with pure fatty liver; P <.0001). Logistic regression analysis confirmed that the presence of metabolic syndrome carried a high risk of NASH among NAFLD subjects (OR, 3.2; 95% CI, 1.2-8.9; P =.026) after correction for sex, age, and body mass. In particular, the syndrome was associated with a high risk of severe fibrosis (OR, 3.5; 95% CI, 1.1-11.2; P =.032). In conclusion, the presence of multiple metabolic disorders is associated with a potentially progressive, severe liver disease. The increasing prevalence of obesity, coupled with diabetes, dyslipidemia, hypertension, and ultimately the metabolic syndrome puts a very large population at risk of forthcoming liver failure in the next decades.
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Affiliation(s)
- Giulio Marchesini
- Unit of Metabolic Diseases and Department of Internal Medicine, Alma Mater Studiorum University of Bologna, Bologna, Italy.
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291
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Valenti L, Dongiovanni P, Fracanzani AL, Santorelli G, Fatta E, Bertelli C, Taioli E, Fiorelli G, Fargion S. Increased susceptibility to nonalcoholic fatty liver disease in heterozygotes for the mutation responsible for hereditary hemochromatosis. Dig Liver Dis 2003; 35:172-8. [PMID: 12779071 DOI: 10.1016/s1590-8658(03)00025-2] [Citation(s) in RCA: 66] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Insulin resistance is a key feature of nonalcoholic fatty liver disease. Patients with hereditary hemochromatosis, a disease characterized by progressive iron overload due, in most cases, to homozygosity for C282Y mutation in the HFE gene, have often decreased insulin sensitivity and release. AIMS To determine whether increased iron parameters/heterozygosity for the mutations of the HFE gene confer susceptibility to nonalcoholic fatty liver disease. PATIENTS One hundred and thirty-four consecutive Italian patients with clinical and ultrasonographic diagnosis of nonalcoholic fatty liver disease (82 with hyperferritinemia), half confirmed by liver biopsy. METHODS Insulin was determined by radioimmunoassay. HFE gene mutations were determined by polymerase chain reaction and restriction fragment length polymorphism analysis. RESULTS (1) Prevalence of C282Y HFE mutation was significantly higher in patients with nonalcoholic fatty liver disease compared to controls, the difference being more striking in patients with hyperferritinemia than in those without. (2) The presence of mild iron overload was associated with a lower insulin release. (3) Carriers of C282Y mutation developed nonalcoholic fatty liver disease despite lower body mass index and triglycerides. CONCLUSION The mild iron overload associated with heterozygosity for C282Y HFE mutation confers susceptibility to nonalcoholic fatty liver disease, causing relative insulin deficiency.
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Affiliation(s)
- L Valenti
- Department of Internal Medicine, Ospedale Maggiore IRCCS, University of Milan, Milan, Italy
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292
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Abstract
Non-alcoholic steatohepatitis (NASH), is a critical link in the chain of metabolic fatty liver disorders that spans steatosis to cryptogenic cirrhosis. It is the hepatic manifestation of the insulin resistance (or metabolic) syndrome, and provides a clue to understanding fibrotic progression of other chronic liver diseases, particularly hepatitis C. Non-alcoholic steatohepatitis is often the first clinical indication of insulin resistance, with its complications of high blood pressure, coronary heart disease and type 2 diabetes. Among those with risk factors, NASH is common: present in at least 20% of obese adults or children with or without type 2 diabetes, and at least 5% of those overweight. With emerging urbanization, increasing affluence and behavioral changes of physical inactivity and high fat/energy-excessive diet, type 2 diabetes has become common in Asia and the western Pacific rim. The rates range from 7-40%, which in countries like Japan represents a 3-20-fold increase (depending on age) over the last 20 years. The increase is associated with central adiposity, insulin resistance, hepatic steatosis and NASH. After cancer, cirrhosis from NASH is now the second most common age-related cause of death in type 2 diabetes. Reversing these trends must become a public health priority; the first awakenings were evident in Taiwan at the time of this meeting. In order to stimulate clinicians to think more about the importance of metabolic liver disease for development of cirrhosis, this review will cover clinical and laboratory features, natural history and an approach to diagnosis and management of NASH. Some emerging concepts on pathogenesis will be mentioned briefly, but the emphasis will be on the potency of lifestyle adjustments (physical activity and diet) to prevent or reverse fatty liver disorders.
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Affiliation(s)
- Geoffrey C Farrell
- Storr Liver Unit, Westmead Millennium Institute, University of Sydney at Westmead Hospital, New South Wales, Australia.
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293
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294
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Affiliation(s)
- C P Day
- Centre for Liver Research, Medical School, Newcastle upon Tyne, UK.
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295
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Abstract
Non-alcoholic steatohepatitis (NASH) is a disease of emerging identity and importance. It is frequently associated with obesity, especially visceral fat, and is intimately related to fatty liver and markers of the insulin resistance syndrome. Both the prevalence and the severity of liver steatosis are related to body mass index, waist circumference, hyperinsulinaemia, hypertriglyceridaemia and impaired glucose tolerance or type 2 diabetes. The identification of obese patients who may progress from steatosis to NASH and from NASH to fibrosis/cirrhosis is an important clinical challenge. Substantial weight loss is accompanied by a marked attenuation of insulin resistance and related metabolic syndrome and, concomitantly, by a remarkable regression of liver steatosis in most patients, although increased inflammation may be detected in some subjects. Thus, NASH may be considered as another disease of affluence, as is the insulin resistance syndrome, and perhaps being part of it, especially in obese patients.
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Affiliation(s)
- André J Scheen
- Division of Diabetes, Nutrition & Metabolic Disorders, Department of Medicine, CHU Sart Tilman, Liège, Belgium
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296
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Affiliation(s)
- Abraham J Sorom
- Division of Transplantation Surgery, Mayo Clinic, Rochester, MN, USA
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297
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Affiliation(s)
- Arun J Sanyal
- Department of Internal Medicine Virginia Commonwealth University Medical College of Virginia Richmond, Virginia, USA
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298
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Yoo HY, Thuluvath PJ. The effect of insulin-dependent diabetes mellitus on outcome of liver transplantation. Transplantation 2002; 74:1007-12. [PMID: 12394846 DOI: 10.1097/00007890-200210150-00019] [Citation(s) in RCA: 101] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
BACKGROUND It is not known whether there was a difference in outcome between insulin-dependent diabetes mellitus (type 1) and non-insulin dependent diabetes mellitus (type 2) after liver transplantation. METHODS The outcome of liver transplantation in adult patients with type 1 (n=1,629) and type 2 (n=1,618) was compared to those without diabetes mellitus (DM) (nondiabetics, n=17,974) using the United Network for Organ Sharing database from 1994 to 2001, after excluding patients who had living donor or multiple organs or who underwent retransplantation, and those with incomplete data. RESULTS Cryptogenic cirrhosis, hypertension, and coronary artery disease (CAD) were two to three times more common in types 1 and 2 compared with nondiabetics. Five-year patient and graft survivals by Kaplan-Meier analysis were significantly lower for type 1 (P <0.0001) compared with type 2 or nondiabetics; only patient survival was lower for type 2 ( P=0.04). Cox regression survival analysis, after adjusting for confounding variables, showed a lower 1-year, 2-year, and 5-year patient and graft survival in patients with type 1 compared with nondiabetics; however, type 2 was not an independent predictor of survival. Preexisting CAD, and not hypertension, was also an independent predictor of poor 5-year survival. Patients who had both DM and CAD had a lower survival compared with those with either DM or CAD. CONCLUSIONS Type 1 and CAD are both independent predictors of poor outcome after liver transplantation. Liver transplant recipients with type 1 or CAD have approximately 40% lower 5-year survival compared with patients without DM or CAD.
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Affiliation(s)
- Hwan Y Yoo
- Department of Medicine, Johns Hopkins University Hospital, Baltimore, MD 21205, USA.
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299
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Abstract
Pathologists have long been involved in clinical diagnosis and investigative studies of various forms of liver disease, including alcoholic liver disease. The concept that progressive fatty liver disease may result from causes other than alcohol toxicity can be noted in the literature. However, acceptance of this as a bona fide form of liver disease has been credited to an in-depth study published in 1980 of patients gathered from cases in the files of the pathology department of the Mayo Clinic in whom liver biopsies showed histological similarities to alcoholic steatohepatitis, but for whom clinical evidence of alcohol use was absent. Subsequent studies of the natural history and pathogenesis of non-alcoholic steatohepatitis have relied on detailed histopathological correlations. This chapter will elucidate the constellation of microscopic findings, the issues of concern for pathological evaluation and the knowledge to date of their significance in various forms of fatty liver disease.
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Affiliation(s)
- Elizabeth M Brunt
- Department of Pathology, Saint Louis University School of Medicine, 4th Floor, 3635 Vista Avenue, St. Louis, MO 63110, USA
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300
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Clouston AD, Powell EE. Interaction of non-alcoholic fatty liver disease with other liver diseases. Best Pract Res Clin Gastroenterol 2002; 16:767-81. [PMID: 12406444 DOI: 10.1053/bega.2002.0329] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Obesity-related steatosis is an increasingly common histological finding in liver biopsies and may co-exist with other chronic liver diseases. Although non-alcoholic fatty liver disease (NAFLD) without true steatohepatitis is generally a benign condition, when another liver disease is present, steatosis may exacerbate the liver damage. In this review, we discuss the interaction of obesity-related steatosis with chronic hepatitis C, alcoholic liver disease, disorders of hepatic iron storage and drug-induced liver disease. The role of weight reduction in minimizing liver injury in patients with chronic hepatitis C is discussed. Finally, we discuss the problems associated with orthotopic liver transplantation for patients with NAFLD.
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Affiliation(s)
- Andrew D Clouston
- The University of Queensland and Sullivan Nicolaides Pathology, Brisbane, Australia
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