Non-alcoholic fatty liver disease: an emerging pathological spectrum

The "Domino effect" in MASLD: The inflammatory cascade of steatohepatitis

Metabolic dysfunction-associated steatotic liver disease (MASLD) is an increasingly common complication of obesity, affecting over a quarter of the global adult population. A key event in the pathophysiology of MASLD is the development of metabolic-associated steatohepatitis (MASH), which greatly increases the chances of developing cirrhosis and hepatocellular carcinoma. The underlying cause of MASH is multifactorial, but accumulating evidence indicates that the inflammatory process in the hepatic microenvironment typically follows a pattern that can be roughly divided into three stages: (1) Detection of hepatocyte stress by tissue-resident immune cells including γδ T cells and CD4-CD8- double-negative T cells, followed by their secretion of pro-inflammatory mediators, most notably IL-17A. (2) Recruitment of pro-inflammatory cells, mostly of the myeloid lineage, and initiation of inflammation through secretion of effector-type cytokines such as TNF, TGF-β, and IL-1β. (3) Escalation of the inflammatory response by recruitment of lymphocytes including Th17, CD8 T, and B cells leading to chronic inflammation, hepatic stellate cell activation, and fibrosis. Here we will discuss these three stages and how they are consecutively linked like falling domino tiles to the pathophysiology of MASH. Moreover, we will highlight the clinical potential of inflammation as a biomarker and therapeutic target for the treatment of MASLD.

The association of systemic inflammatory biomarkers with non-alcoholic fatty liver disease: a large population-based cross-sectional study

Purpose

The aim of this study was to explore the relationship between non-alcoholic fatty liver disease (NAFLD) and the two blood inflammatory markers including the systemic immune-inflammation (SII) index, and the system inflammation response index (SIRI).

Methods

The National Health and Nutrition Examination Survey data between the year of 2017-2018 was used for this cross-sectional study. In order to analyze the association of SII index, and SIRI and risk of NAFLD, we used multivariable logistic regression models, restricted cubic spline (RCS) plot, and subgroup analysis to analyze the data.

Results

In total, there were 1,199 individuals who participated in the survey. As shown by the RCS plot, SII index, and SIRI were linked with NAFLD risk in a U-shaped pattern. With regard to known confounding variables, when comparing the lowest quartile, the odds ratio with 95 % confidence interval for prevalence of NAFLD across the quartiles of SII index and SIRI were (0.89 (0.57, 1.41), 0.56 (0.35, 0.89) and 1.01 (0.64, 1.59)), and (0.77 (0.48, 1.23), 0.79 (0.50, 1.24) and 0.94 (0.60, 1.47)), respectively. Additionally, SII index, and SIRI and NAFLD risk also were U-curve correlated among the participants in age ≥60 years, female, without hypertension, and BMI of ≥30 kg/m2.

Conclusions

There was a U-shaped association of SII index and SIRI with prevalence of NAFLD, indicating that SII index and SIRI should be monitored dynamically.

Chromatographic Analyses of Spirulina (Arthrospira platensis) and Mechanism of Its Protective Effects against Experimental Obesity and Hepatic Steatosis in Rats

Background and Objectives: Obesity is currently a major health problem due to fatty acid accumulation and excess intake of energy, which leads to an increase in oxidative stress, particularly in the liver. The main goal of this study is to evaluate the protective effects of spirulina (SP) against cafeteria diet (CD)-induced obesity, oxidative stress, and lipotoxicity in rats. Materials and Methods: The rats were divided into four groups and received daily treatments for eight weeks as follows: control group fed a standard diet (SD 360 g/d); cafeteria diet group (CD 360 g/d); spirulina group (SP 500 mg/kg); and CD + SP group (500 mg/kg, b.w., p.o.) according to body weight (b.w.) per oral (p.o.). Results: Our results show that treatment with a CD increased the weights of the body, liver, and abdominal fat. Additionally, severe hepatic alteration, disturbances in the metabolic parameters of serum, and lipotoxicity associated with oxidative stress in response to the CD-induced obesity were observed. However, SP treatment significantly reduced the liver alteration of CD feed and lipid profile disorder associated with obesity. Conclusions: Our findings suggest that spirulina has a marked potential therapeutic effect against obesity and mitigates disturbances in liver function parameters, histological alterations, and oxidative stress status.

Association of Systemic Immune-Inflammation Index with Non-Alcoholic Fatty Liver Disease: A Population-Based Cross-Sectional Study

Background

The aim of this study was to explore the relationship between systemic immune-inflammation (SII) index with non-alcoholic fatty liver disease (NAFLD) in the general population of the United States (U.S.).

Methods

We conducted a cross-sectional study of subjects in the National Health and Nutrition Examination Survey 2017-2018. For the analysis of the association between SII index and risk of NAFLD, the restricted cubic spline (RCS) plot, we performed multivariable logistic regression models and subgroup analysis. In addition, generalized additive models with smooth functions were conducted for the relationship between the SII index and the ZJU index, the BARD score, and the NAFLD fibrosis score.

Results

There were a total of 1197 individuals in our study. Taking into account known confounding variables, compared with the lowest quartiles, the odds ratios with 95% confidence intervals for NAFLD across the quartiles were 0.923 (0.585, 1.455), 0.563 (0.351, 0.901), and 1.061 (0.669, 1.682), respectively. As shown by the RCS plot, the SII index was linked with NAFLD risk in a U-shaped pattern. Based on the results of subgroup analysis, SII index and NAFLD risk were U-curve correlated among participants in all age groups, male or female, with or without hypertension, with diabetes mellitus, and with a BMI of <30 or >30 kg/m2. The SII index was linearly positive with the ZJU index but negative with the NAFLD fibrosis score. However, the SII index and BARD score showed a trend of first decreasing, then increasing, and then decreasing.

Conclusion

The U-shaped relationships exist between SII index and risk of NAFLD, which highlighted that we should focus on the dynamic change of SII index.

Serum cadmium is associated with hepatic steatosis and fibrosis: Korean national health and nutrition examination survey data IV-VII

Although cadmium (Cd) is correlated with elevated levels of hepatic amino transferases, its influence on the degree of liver steatosis and fibrosis are unknown yet. We aimed to investigate the associations between the serum level of Cd and degree of liver steatosis/fibrosis.Clinical data were obtained from Korean National Health and Nutrition Examination Surveys IV-VII. Alanine aminotransferase (ALT) elevation was defined as ≥ 33 IU/L for men and ≥ 25 IU/L for women. Significant steatosis was defined as a hepatic steatosis index ≥ 36, while significant fibrosis was defined as a fibrosis index (FIB-4) ≥ 2.67 and as an aspartate aminotransferase and platelet ratio index ≥ 0.7. Adjusted odds ratios and 95% confidence intervals were calculated after adjustment.The levels of serum Cd were assessable in 15,783 subjects. The serum cadmium concentrations were significantly associated with ALT elevation, significant liver steatosis and fibrosis. Multivariate logistic regression analysis demonstrated serum Cd level in the forth quartile had a positive correlation with ALT elevation, hepatic steatosis index ≥ 36, FIB-4 ≥ 2.67 and aspartate aminotransferase-to-platelet ratio ≥ 0.7 using the first quartile of serum Cd level as the reference, (adjusted odds ratios 1.90, 1.26, 1.73, and 2.53, respectively; P values <.001).The serum level of Cd was associated with liver steatosis and fibrosis. The evaluation of serum Cd may help for assessing an unexplained liver steatosis and fibrosis, and further prospective studies are needed to confirm our findings.

E3 ubiquitin ligase Grail promotes hepatic steatosis through Sirt1 inhibition

In obese adults, nonalcoholic fatty liver disease (NAFLD) is accompanied by multiple metabolic dysfunctions. Although upregulated hepatic fatty acid synthesis has been identified as a crucial mediator of NAFLD development, the underlying mechanisms are yet to be elucidated. In this study, we reported upregulated expression of gene related to anergy in lymphocytes (GRAIL) in the livers of humans and mice with hepatic steatosis. Grail ablation markedly alleviated the high-fat diet-induced hepatic fat accumulation and expression of genes related to the lipid metabolism, in vitro and in vivo. Conversely, overexpression of GRAIL exacerbated lipid accumulation and enhanced the expression of lipid metabolic genes in mice and liver cells. Our results demonstrated that Grail regulated the lipid accumulation in hepatic steatosis via interaction with sirtuin 1. Thus, Grail poses as a significant molecular regulator in the development of NAFLD.

Effect of sour tea supplementation on liver enzymes, lipid profile, blood pressure, and antioxidant status in patients with non-alcoholic fatty liver disease: A double-blind randomized controlled clinical trial

The aim of this study was to evaluate the efficacy of sour tea supplementation in patients with nonalcoholic fatty liver disease (NAFLD). Seventy NAFLD patients were enrolled in this randomized, double-blind, placebo-controlled clinical trial. Participants received sour tea in the form of a 450 mg capsule or a placebo capsule daily for 8 weeks. Anthropometric indices, liver enzymes, lipid profile, blood pressure, and antioxidant status were evaluated at the baseline and at the end of the study. Sixty-one participants completed the study. After 8 weeks, sour tea administration significantly decreased serum triglyceride (TG) (p = .03), alanine aminotransferase (ALT) (p = .01), and aspartate aminotransferase (AST) (p = .004) levels compared with the placebo. In addition, sour tea supplementation resulted in a significant reduction in systolic blood pressure (SBP) (p = .03) and diastolic blood pressure (DBP) (p = .04), and a significant increase in serum total antioxidant capacity (TAC) levels (p ˂ .001) compared with the placebo. However, no significant changes in anthropometric measures, total cholesterol (TC), low-density lipoprotein cholesterol (LDL-c), and high-density lipoprotein cholesterol (HDL-c) levels were observed after sour tea supplementation compared with the placebo (p > .05). Sour tea supplementation may be effective in improving serum TG, liver enzymes, and blood pressure in patients diagnosed with NAFLD. Further studies are needed to address the exact mechanism of action of these effects.

Medications in type-2 diabetics and their association with liver fibrosis

BACKGROUND

The prevalence of nonalcoholic fatty liver disease (NAFLD) is significantly rising worldwide. Type-2 diabetes (T2D) is a major risk factor for NAFLD progression.

AIM

To assess the association of commonly used medications to advanced fibrosis (AF) in patients with biopsy-proven NAFLD and T2D.

METHODS

We used the International Classification of Disease 9^th Revision Clinical Modification coding system to identify patients with T2D and included patients who underwent liver biopsy for suspected NAFLD between January 1, 2000 to December 31, 2015. We compared demographics, clinical characteristics, and differences in pattern of medication use in patients who had biopsy-proven AF to those without it. A univariate and multivariate analysis was performed to assess the association of different classes of medication with the presence of AF.

RESULTS

A total of 1183 patients were included in the final analysis, out of which 32% (n = 381) had AF on liver biopsy. Mean age of entire cohort was 52 years and majority were females (65%) and Caucasians (85%). Among patients with AF, 51% were on oral hypoglycemics, 30% were on insulin, 66% were on antihypertensives and 27% were on lipid lowering agents for the median duration of 19 mo, 10 mo, 26 mo, and 24 mo respectively. Medications associated with decreased risk of AF included metformin, liraglutide, lisinopril, hydrochlorothiazide, atorvastatin and simvastatin while the use of furosemide and spironolactone were associated with higher prevalence of AF.

CONCLUSION

In our cohort of T2D with biopsy proven NAFLD, the patients who were receiving metformin, liraglutide, lisinopril, hydrochlorothiazide, atorvastatin and simvastatin were less likely to have AF on biopsy, while patients who were receiving furosemide and spironolactone had a higher likelihood of having AF when they underwent liver biopsy. Future studies are needed to confirm these findings and to establish measures for prevention of NAFLD progression in patients with T2D.

Dual SGLT1/SGLT2 Inhibitor Phlorizin Ameliorates Non-Alcoholic Fatty Liver Disease and Hepatic Glucose Production in Type 2 Diabetic Mice

PURPOSE

NAFLD is a hepatic component of type 2 diabetes mellitus (T2D), in which impaired hepatic glucose production plays an important role. Inhibitors of sodium glucose transporter 2 (SGLT2) reduce glycemia and exert beneficial effects on diabetic complications. Recently, dual SGLT1/2 inhibition has been proposed to be more effective in reducing glycemia. We hypothesized that improving hepatic glucose metabolism induced by SGLT1/2 inhibition could be accompanied by beneficial effects on NAFLD progression.

METHODS

Glycemic homeostasis, hepatic glucose production and NAFLD features were investigated in obese T2D mice, treated with SGLT1/2 inhibitor phlorizin for 1 week.

RESULTS

T2D increased glycemia; insulinemia; hepatic expression of phosphoenolpyruvate carboxykinase (PEPCK), glucose-6-phosphatase (G6Pase) and glucose transporter 2 (Slc2a2 gene); hepatocyte nuclear factors 1A/4A/3B-binding activity in Slc2a2; endogenous glucose production; liver weight, plasma transaminase concentration as well as hepatic inflammation markers, and induced histological signals of non-alcoholic steatohepatitis (NASH, according to NASH-CRN Pathology Committee System). Phlorizin treatment restored all these parameters (mean NASH score reduced from 5.25 to 2.75 P<0.001); however, plasma transaminase concentration was partially reverted and some hepatic inflammation markers remained unaltered.

CONCLUSION

NAFLD accompanies altered hepatic glucose metabolism in T2D mice and that greatly ameliorated through short-term treatment with the dual SGLT1/2 inhibitor. This suggests that altered hepatic glucose metabolism participates in T2D-related NAFLD and highlights the pharmacological inhibition of SGLTs as a useful approach not only for controlling glycemia but also for mitigating development and/or progression of NAFLD.

Hepatoprotective and Renoprotective Properties of Lovastatin-Loaded Ginger and Garlic Oil Nanoemulsomes: Insights into Serum Biological Parameters

Background and Objectives: Dyslipidemia is gaining much attention among healthcare professionals because of its high association with the malfunctioning of a number of normal physiological and metabolic processes in the body. Obesity is directly interconnected with dyslipidemia and is said to be a denouement of hyperlipidemia and, if left untreated, may lead to intense damage to organs that are directly involved in fat metabolism. The objective of this study was to investigate the synergistic antiobesity and anti-hyperlipidemic activities along with hepato- and renoprotective potential of nanoemulsomes (NES) of lovastatin (LTN)-loaded ginger (GR) and garlic (GL) oils. Materials and Methods: LTN nanoemulsomes co-encapsulated with GR oil and GL oil were prepared by a thin hydration technique. Eight-week-old male Wistar rats weighing 200-250 g were induced with hyperlipidemia via a high-fat diet (HFD) comprising 40% beef tallow. Body weight, serum biochemical lipid parameters, and those for liver and kidney functions, serum TC, LDL-C, vLDL-C, HDL-C, TG, atherogenic index (AI), ALT, AFT, ALP, γ-GT, total protein (TP), serum albumin and globulin ratio (A/G), serum creatinine, blood urea nitrogen (BUN) and blood urea, and histopathology of hematoxylin and eosin (H&E) stained liver and kidney sections of all aforementioned groups were examined in the treated animals. Results: Nanoemulsomes of LTN-loaded GR and GL oils provided synergistic effects with LTN, exerted better ameliorative actions in reducing serum TC, LDL-C, vLDL-C, triglycerides, and AI, and improved serum HDL-C levels. Serum ALT, AST, ALP, and γ-GT levels were in the normal range for nanoemulsome groups. H&E stained liver and kidney sections of these animals confirmed better hepatoprotective and renoprotective effects than LTN alone. Serum biochemical parameters for renal functions also claimed to be in the moderate range for nanoemulsome-treated groups. Conclusion: This study demonstrated that nanoemulsomes of LTN-loaded GR and GL oils synergistically provided better antihyperlipidemic, hepatoprotective, and renoprotective effects as compared to LTN alone.

The protective effect and mechanism of the FXR agonist obeticholic acid via targeting gut microbiota in non-alcoholic fatty liver disease

Background: It is reported that various diseases such as non-alcoholic fatty liver disease (NAFLD) are associated with imbalance of microbiome. And FXR has been well investigated in liver diseases.

Purpose: The objective of this study was to identify the role of farnesoid X receptor agonist obeticholic acid via targeting gut microbiota in NAFLD.

Patients and methods: Male C57BL/6 mice were fed either a normal-chow diet or a high-fat diet (HFD). Obeticholic acid(30mg/(kg·d)) and/or a combination of antibiotics were administered orally by gavage to mice for 12 weeks. Gut microbiota profiles were established through 16S rRNA amplicon sequencing. The effects of obeticholic acid on liver inflammation, the gut barrier, endotoxemia, gut microbiome and composition of the bile acid were also investigated.

Results: Obeticholic acid treatment can significantly improve obesity, circulation metabolism disorders, liver inflammation and fibrosis, and intestinal barrier damage caused by HFD. Removal of normal commensal bacteria can weaken the effect of obeticholic acid. The gut microbial structure was changed, and abundance of Blautia was increased significantly after treated with obeticholic acid. After obeticholic acid treatment, the concentration of taurine-bound bile acid caused by HFD was reduced in the liver.

Conclusion: Taken together, these data suggest that obeticholic acid has aprotective effect on NAFLD via changing the components of gut microbiota, specifically increasing the abundance of Blautia.

Spirulina effect on modulation of toxins provided by food, impact on hepatic and renal functions

Spirulina platensis, is an alga rich in phycocyanin (potent antioxidant), is effective in regulating the balance of oxidative stress. The objective of this study is to observe the impact of ingestion of a highly oxidised vegetable oil, by rats of Wistar strain. Finally, we observe the effect of Spirulina used as an antioxidant treatment, on rats having ingested a diet rich in highly oxidised oil. Physiological, biochemical and histological studies have been carried out; the oxidative stress parameters evaluated and a dosing of Cytochrome P450 2E1 was finally carried out. Following the introduction of highly oxidised vegetable oil, rats showed deterioration in their metabolic state, an imbalance in the balance of oxidative stress, an increase in serum concentrations of Cytochrome P450 2E1 and significant hepatic lesions. The administration of a daily dose of Spirulina reduces the deleterious effect of oxidative stress induced by a diet enriched with lipid peroxides.

Long-Term Feeding of Soy Protein Attenuates Choline Deficient-Induced Adverse Effects in Wild Type Mice and Prohibitin 1 Deficient Mice Response More Sensitively

Non-alcoholic fatty liver disease (NAFLD) is the most common chronic liver disease, however the exact cause of NAFLD remains unknown. Methionine, an essential amino acid, is the first limiting amino acid of soy protein, and its deficiency is suggested to cause hepatocyte damage and NAFLD. The objective of this study is to examine the changes in NAFLD susceptibility with soy protein consumption and deterioration due to prohibitin 1 (PHB1) deficiency, an important protein in hepatic mitochondrial function. In this study, liver-specific phb1 +/- mice and wild-type mice were fed a normal diet, choline-deficient diet (CDD), or soy protein diet without choline (SPD) for 16 weeks. Using hematoxylin and eosin staining, we showed that SPD attenuates symptoms of hepatocyte damage and lipid accumulation induced by CDD in mouse liver. The liver damage in mice fed the SPD was alleviated by decreasing lipogenic markers and by increasing anti-inflammatory markers. Furthermore, mRNA expression of genes involved in hepatic methionine metabolism was significantly lower in liver-specific phb1 +/- mice fed with a SPD compared with wild-type mice fed with a SPD. These data suggest a CDD can cause non-alcohol related liver damage, which can be attenuated by a SPD in wild-type mice. These phenomena were not observed in liver-specific phb1 +/- mice. It may therefore be concluded that SPD attenuates CDD-induced liver damage in wild-type mice, and that PHB1 deficiency blocks the beneficial effects of SPD against CDD-induced liver damage.

Triticum aestivum ethanolic extract improves non-alcoholic fatty liver disease in mice fed a choline-deficient or high-fat diet

BACKGROUND

Although non-alcoholic fatty liver disease (NAFLD) has become more prevalent with the rapid increase of obesity worldwide, no specific treatment has been developed. Several studies have shown that wheatgrass extract Triticum aestivum (TA) improves lipid metabolism. In the present study, we evaluated the efficacy of GM-T (an ethanolic TA extract) in a murine NAFLD model. Mice were separated into 12 groups (n = 10): two groups of normal diet, choline-deficient diet (CDD) or high-fat diet (HFD) with vehicle, CCD or HFD with silymarin (400 mg kg^-1 day^-1 ), and CCD or HFD with GM-T (100, 200 or 400 mg kg^-1 day^-1 ). The study was performed for 8 weeks for the CDD groups and 12 weeks for the HFD groups.

RESULTS

In the CDD-fed mice, GM-T improved serum liver enzyme activities and liver inflammation score compared to vehicle. In the HFD-fed mice, GM-T improved blood lipid profiles, liver inflammation score, steatosis score and obesity compared to vehicle.

CONCLUSION

The present study demonstrated that GM-T effectively improved NAFLD in mice via a mechanism that improved insulin resistance and lipid metabolism, suggesting the possibility of a functional dietary supplement to improve liver health, overall metabolic syndrome and obesity. © 2018 Society of Chemical Industry.

Serum vitamin E as a significant prognostic factor in patients with dyslipidemia disorders

OBJECTIVES

Obesity and overweight are among the main causes of cardiovascular disease (CVD) mortality. Dyslipidemia, fatty liver index, is strongly related to CVD. Vitamin E as an antioxidant protects the hepatic cells against oxidative stress and prevents fatty liver disease. The aim of the current study is to evaluate the relationship between anthropometric parameters and fasted lipid profile with serum vitamin E levels.

STUDY DESIGN

A randomized trial was designed based on data from the Mashhad stroke and heart atherosclerotic disorders (MASHAD: 2010-2020).

METHODS

363 CVD subjects (173 males and 190 females) was selected at random, among 9704 subjects in three regions of Mashhad, northeast of Iran to investigate the specific correlations among their serum vitamin E, lipid profile (TG, HDL-C, LDL-C and TC), and anthropometric features (height, weight, BMI, hip and waist circumferences.

RESULT

The results indicated the significant relationships between vitamin E, and fasting serum lipid profile in subjects. Serum vitamin E was negatively correlated to TC, TG, and LDL-C and positively related to HDL-C. Also, statistically negative correlations were found between vitamin E and anthropometric parameters (weight, waist and hip circumference, middle Arm, and Systolic Blood Pressure). Moreover, vitamin E ratios such as vitamin E/(TC + TG) and vitamin E/TC values as standardized vitamin E, had significant negative correlation with BMI, the whole of anthropometric parameters, and dyslipidemia risk factors including TC, TG and LDL-C.

CONCLUSION

We found that vitamin E profile was significantly lower in the dyslipidemia subjects. It is generally suggested that vitamin E monitoring might be used as a useful prognostic and therapeutic agent in dyslipidemia disorder.

Unmet needs in pediatric NAFLD research: what do we need to prioritize for the future?

Pediatric nonalcoholic fatty liver disease (NAFLD) is common disorder that has complex pathophysiology and unquantified clinical significance. Though there have been major advances in the field, there is much yet to be understood. Areas covered: PubMed/MEDLINE and Embase were searched for articles related to pediatric NAFLD and nonalcoholic steatohepatitis (NASH) between January 1998 and January 2018. The areas considered to be 'unmet needs' were the relationship between the intestinal microbiome and perinatal events, clinical event risk stratification, and mechanisms underlying portal inflammation. Expert commentary: In utero and ex utero factors have been associated with NAFLD and also with the intestinal microbiome, but it is not yet known how intestinal dysbiosis can be reversed and whether intervention in high-risk neonates could alter their propensity for the metabolic syndrome. Children with NAFLD are at increased risk of cardiovascular, diabetic, and hepatic diseases, but it is unclear how best to stratify children into appropriate risk groups for targeted interventions. Finally, the immune processes underlying pediatric NASH are thought to differ to those in adult NASH, yet the events surrounding activation of periportal lymphocytes are poorly understood. Deepening our understanding of these topics may lead to novel therapeutic targets.

Both 3,5-Diiodo-L-Thyronine and 3,5,3'-Triiodo-L-Thyronine Prevent Short-term Hepatic Lipid Accumulation via Distinct Mechanisms in Rats Being Fed a High-Fat Diet

3,3′,5-triiodo-L-thyronine (T3) improves hepatic lipid accumulation by increasing lipid catabolism but it also increases lipogenesis, which at first glance appears contradictory. Recent studies have shown that 3,5-diiodothyronine (T2), a natural thyroid hormone derivative, also has the capacity to stimulate hepatic lipid catabolism, however, little is known about its possible effects on lipogenic gene expression. Because genes classically involved in hepatic lipogenesis such as SPOT14, acetyl-CoA-carboxylase (ACC), and fatty acid synthase (FAS) contain thyroid hormone response elements (TREs), we studied their transcriptional regulation, focusing on TRE-mediated effects of T3 compared to T2 in rats receiving high-fat diet (HFD) for 1 week. HFD rats showed a marked lipid accumulation in the liver, which was significantly reduced upon simultaneous administration of either T3 or T2 with the diet. When administered to HFD rats, T2, in contrast with T3, markedly downregulated the expression of the above-mentioned genes. T2 downregulated expression of the transcription factors carbohydrate-response element-binding protein (ChREBP) and sterol regulatory element binding protein-1c (SREBP-1c) involved in activation of transcription of these genes, which explains the suppressed expression of their target genes involved in lipogenesis. T3, however, did not repress expression of the TRE-containing ChREBP gene but repressed SREBP-1c expression. Despite suppression of SREBP-1c expression by T3 (which can be explained by the presence of nTRE in its promoter), the target genes were not suppressed, but normalized to HFD reference levels or even upregulated (ACC), partly due to the presence of TREs on the promoters of these genes and partly to the lack of suppression of ChREBP. Thus, T2 and T3 probably act by different molecular mechanisms to achieve inhibition of hepatic lipid accumulation.

Different combinations of maternal and postnatal diet are reflected in changes of hepatic parenchyma and hepatic TNF-alpha expression in male rat offspring

Obesity is related to increased TNF-alpha production in different tissues. TNF-alpha is connected to mitochondrial dysfunction in the liver and also development of fatty infiltration of the liver. Also, postnatal change from normal to high-fat diet causes a significant increase in TNF-alpha serum levels. The aim of this research was to determine how maternal diet and switching male offspring to a different dietary regime after lactation influences rat liver. Ten female Sprague Dawley rats at nine weeks of age were randomly divided in two groups and fed either standard laboratory chow or high-fat diet during six weeks, and then mated with the same male subject. After birth and lactation male offspring from both groups were further divided into four subgroups depending on their subsequent diet. At 22 weeks of age, the animals were weighted, sacrificed and major organs were collected and weighted. Immunohistochemistry for TNF-alpha was performed on liver, and liver samples were analyzed for pathohistological changes. The group in which mothers were fed standard chow and offspring high-fat diet had the most pronounced changes: heaviest liver, poorest histopathological findings and strongest TNF-alpha immunohistochemical staining of liver parenchyma. High-fat diet during pregnancy and lactation and switching to high-fat diet postnatally affects liver weight, histological structure and TNF-alpha expression in male offspring.

Cytokeratin-18 and uric acid predicts disease severity in Taiwanese nonalcoholic steatohepatitis patients

BACKGROUND & AIMS

Identification of disease severity remains a challenge in the management of non-alcoholic steatohepatitis (NASH). Cytokeratin-18 (CK18), is a recently developed non-invasive biomarker for NASH. We aimed to assess the performance of CK18 in disease severity prediction among Taiwanese NASH patients.

METHODS

A total of 76 biopsy-proven NASH patients (54 males, age = 41.0 ± 13.5 years) were consecutively recruited. The optimal cutoff values of CK18 for each stage of fibrosis were correlated with their histopathological manifestations.

RESULTS

There were 23 (30.3%) patients of Metavir fibrosis stage 0 (F0), 32 (42.1%) patients of F1, 14 (18.4%) patients of F2, and 7 (9.2%) patients of F3-4, respectively. The CK18 levels among those patients of F0, F1, F2, F3-4 were 86.7 ± 75.6 U/L, 122.4 ± 123.8 U/L, 160.7 ± 120.4 U/L, and 507.3 ± 343 U/L, respectively (trend for P<0.001). The adjusted optimal cutoff value for F2 prediction was 312.5 U/L, yielding the sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and the accuracy of 96.4%, 28.6%, 77.9%, 75%, and 77.6%, respectively (P = 0.009). For the prediction of advanced fibrosis (F3-4), the adjusted optimal cutoff value was 374.5 U/L, yielding the sensitivity, specificity, PPV, NPV, and the accuracy of 97.1%, 54.1%, 95.7%, 66.7%, and 77.6%, respectively (P = 0.003). Among those patients without hyperuricemia, the PPV, NPV, and accuracy of CK18 reached 100%, 95.8%, and 96%, respectively (P<0.001).

CONCLUSIONS

CK18 combined with uric acid measurement is a promising non-invasive biomarker for prediction of disease severity in NASH patients.

TRIAL REGISTRATION

ClinicalTrials.gov NCT01068444.

The Relationship between Type 2 Diabetes Mellitus and Non-Alcoholic Fatty Liver Disease Measured by Controlled Attenuation Parameter

PURPOSE

The severity of non-alcoholic fatty liver disease (NAFLD) in type 2 diabetes mellitus (T2DM) population compared with that in normal glucose tolerance (NGT) individuals has not yet been quantitatively assessed. We investigated the prevalence and the severity of NAFLD in a T2DM population using controlled attenuation parameter (CAP).

MATERIALS AND METHODS

Subjects who underwent testing for biomarkers related to T2DM and CAP using Fibroscan® during a regular health check-up were enrolled. CAP values of 250 dB/m and 300 dB/m were selected as the cutoffs for the presence of NAFLD and for moderate to severe NAFLD, respectively. Biomarkers related to T2DM included fasting glucose/insulin, fasting C-peptide, hemoglobin A1c (HbA1c), glycoalbumin, and homeostasis model assessment of insulin resistance of insulin resistance (HOMA-IR).

RESULTS

Among 340 study participants (T2DM, n=66; pre-diabetes, n=202; NGT, n=72), the proportion of subjects with NAFLD increased according to the glucose tolerance status (31.9% in NGT; 47.0% in pre-diabetes; 57.6% in T2DM). The median CAP value was significantly higher in subjects with T2DM (265 dB/m) than in those with pre-diabetes (245 dB/m) or NGT (231 dB/m) (all p<0.05). Logistic regression analysis showed that subjects with moderate to severe NAFLD had a 2.8-fold (odds ratio) higher risk of having T2DM than those without NAFLD (p=0.02; 95% confidence interval, 1.21-6.64), and positive correlations between the CAP value and HOMA-IR (ρ0.407) or fasting C-peptide (ρ0.402) were demonstrated.

CONCLUSION

Subjects with T2DM had a higher prevalence of severe NAFLD than those with NGT. Increased hepatic steatosis was significantly associated with the presence of T2DM, and insulin resistance induced by hepatic fat may be an important mechanistic connection.

Time-course metabolic changes in high-fat diet-induced obesity rats: A pilot study using hyperpolarized (13)C dynamic MRS

The purpose of this study was to investigate the time-course metabolic changes based on hyperpolarized (13)C magnetic resonance spectroscopy (MRS) in high-fat diet (HFD)-induced obesity rats and the correlation between metabolic and serum enzyme levels. Sprague-Dawley rats were fed either HFD (60% fat) or normal diet (10% fat) for 6weeks. A HyperSense DNP was used to hyperpolarize [1-(13)C] pyruvic acid and the hyperpolarized (13)C MRS was examined every 2weeks in the course of 6weeks using a 3T GE MR750 scanner. The body weight of HFD-induced obese rats was significantly increased compared to normal rats at the 6th week after the onset of feeding (p=0.05). Simultaneously, the HFD-induced obese rats showed significantly increased levels of serum alanine aminotransferase (ALT), aspartate aminotransferase (AST), lactate dehydrogenase (LDH), and low-density lipoprotein (LDL)-cholesterol compared to normal rats (p≤0.05). In the dynamic (13)C MR spectra acquired at the 6th week, the obese rats showed significantly increased ratios of [1-(13)C] lactate/[1-(13)C] pyruvate and [1-(13)C] alanine/[1-(13)C] pyruvate (p=0.05). The (13)C spectral outcomes are positively correlated with the enzyme levels of ALT and LDH in the HFD-induced obesity. The [1-(13)C] lactate and [1-(13)C] alanine are potentially considered as noninvasive biomarkers for the HFD-induced obesity.

Insulin resistance in development and progression of nonalcoholic fatty liver disease

Although insulin resistance (IR) is strongly associated with nonalcoholic fatty liver disease (NAFLD), the association of IR and NAFLD is not universal and correlation between IR and severity of NAFLD is still controversial. In this review, we summarize recent evidence that partially dissociates insulin resistance from NAFLD. It has also been reported that single-nucleotide polymorphisms in the diacylglycerol acyltransferase gene, rather than IR, account for the variability in liver fat content. Polymorphisms of the patatin-like phospholipase 3 gene have also been reported to be associated with NAFLD without metabolic syndrome, which suggests that genetic conditions that promote the development of fatty changes in the liver may occur independently of IR. Moreover, environmental factors such as nutrition and physical activity as well as small intestinal bacterial overgrowth have been linked to the pathogenesis of NAFLD, although some of the data are conflicting. Therefore, findings from both genetically engineered animal models and humans with genetic conditions, as well as recent studies that have explored the role of environmental factors, have confirmed the view that NAFLD is a polygenic disease process caused by both genetic and environmental factors. Therefore, IR is not the sole predictor of the pathogenesis of NAFLD.

Safety and long-term effect of the probiotic FK-23 in patients with hepatitis C virus infection

A clinical trial was conducted on 39 adult HCV-positive subjects to determine the safety and long-term effect of the probiotic FK-23 (heat-treated Enterococcus faecalis strain FK-23). Asymptomatic anti-HCV positive adults who fulfilled the selection criteria and gave voluntary consent were recruited from attendees of the Hepatitis Carrier Clinic, Department of Medical Research (Lower Myanmar). Each subject was given 2,700 mg of FK-23 per day by oral route. Blood samples were taken at enrollment and every 3 months and tested for alanine aminotransferase (ALT) and aspartate transaminase (AST). Viral load, urea, total protein, hemoglobin and platelet count were determined every 6 months. Among the subjects, 23 completed 36 months, 31 completed 24 months, 35 completed 12 months and 37 completed 6 months of probiotic therapy. Significant decreases in mean ALT levels were observed at 3 months (34. 9 ± 15.1 IU/l) as compared with the initial level (64.8 ± 17.5 IU/l) and persisted up to 36 months (43.7 ± 25.2 IU/l). Decrease of AST was detected after 9 months (46.2 ± 21.7 IU/l) of probiotic therapy as compared with the initial level (64.3 ± 28.7 IU/l). FK-23 was safe based on the stable levels of biochemical and hematological parameters and the absence of untoward side effects. The FK-23 preparation was well tolerated and accepted by the subjects.

Potential Therapeutic Agents for the Treatment of Fatty Degeneration of Liver and Atheromatous Plaques: An Experimental Study in Rats

Background:

Since long high fat diet (HFD) is being blamed for causing fatty degeneration of liver and formation of atheromatous plaques. At present, no proper pharmacotherapy is available for both the conditions. In this study, different substances containing monounsaturated fatty acids were used to observe their protective effects in the HFD induced damage to liver and coronary vessels.

Objectives:

To discover effective therapeutic agents for HFD induced fatty degeneration of liver and atheromatous plaques.

Materials and Methods:

The study was conducted from September 2015 to April 2016. In this study, rats were divided into nine groups according to dietary regimen. Each group comprised six rats. Saturated fat was given in the form of butter, and unsaturated fat was given in the form of corn oil, olive oil, Nigella sativa oil, and crushed garlic. Serum samples were taken to estimate lipid profile, liver functions, cardiac functions, and kidney functions. Visceras were removed after animal sacrifice, and histopathological examination was done.

Results and Conclusion:

During the study period, the weight of animals changed significantly in some groups. Those animals which were given crushed garlic along with high saturated fat diet, showed protection against accumulation of lipids in the hepatocytes. Olive oil and Nigella sativa oil were comparatively less effective.

SUMMARY

Consumption of Garlic, Nigella Sativa and Olive oil significantly improved/revised the Fatty Degeneration of liver induced by intake of High Fat Diet.

No fat deposition was found in the liver when Garlic, Nigella Sativa and Olive oil, were given concomitantly with HFD.

Hepatocytes functioned better even in comparison to control and a decrease in liver enzymes was found with use of Garlic.

Use of Garlic, Nigella Sativa and Olive oil, prevented the plaque formation in the vessels and decreased serum lipids.

Beneficial effects of Garlic were significant in comparison to Nigella Sativa and Olive oil.

Abbreviations used: HFD: High Fat Diet; NS: Nigella Sativa; TQ: Thymoquinone; KFMRC: King Fahad Medical Research Center; BUN: Blood Urea Nitrogen; BNF: Buffered Neutral Formalin; G: Group

The identification of nuclear receptors associated with hepatic steatosis to develop and extend adverse outcome pathways

The development of adverse outcome pathways (AOPs) is becoming a key component of twenty-first century toxicology. AOPs provide a conceptual framework that links the molecular initiating event to an adverse outcome through organized toxicological knowledge, bridging the gap from chemistry to toxicological effect. As nuclear receptors (NRs) play essential roles for many physiological processes within the body, they are used regularly as drug targets for therapies to treat many diseases including diabetes, cancer and neurodegenerative diseases. Due to the heightened development of NR ligands, there is increased need for the identification of related AOPs to facilitate their risk assessment. Many NR ligands have been linked specifically to steatosis. This article reviews and summarizes the role of NR and their importance with links between NR examined to identify plausible putative AOPs. The following NRs are shown to induce hepatic steatosis upon ligand binding: aryl hydrocarbon receptor, constitutive androstane receptor, oestrogen receptor, glucocorticoid receptor, farnesoid X receptor, liver X receptor, peroxisome proliferator-activated receptor, pregnane X receptor and the retinoic acid receptor. A preliminary, putative AOP was formed for NR binding linked to hepatic steatosis as the adverse outcome.

Hyperuricemia Inversely Correlates with Disease Severity in Taiwanese Nonalcoholic Steatohepatitis Patients

Background & Aims

Asians are more susceptible to non-alcoholic steatohepatitis (NASH) as well as metabolic disorder than other ethnicities. We aimed to assess the interaction between metabolic factors and fibrosis in Taiwanese NASH patients.

Methods

A total of 130 biopsy-proven Taiwanese NASH patients (94 males, age = 43.0 ± 13.0 years) were consecutively enrolled. Their demographic, metabolic profiles and histopathological manifestations were analyzed.

Results

Twenty-four (18.5%) NASH patients were non-obese. Thirty-three (25.4%) patients had significant fibrosis (F2) or more: 22 (16.9%) patients were of F2, whilst 11 (8.5%) patients were of advanced fibrosis (F3-4). The prevalence of metabolic syndrome, diabetes and hypertension were 60.8%, 39.4%, and 61.5%, respectively. There was a significant inverse correlation between hyperuricemia and fibrosis stages, ranging from 48.4% of F0-1, 33.3% of F2, and 9.1% of F3-4, respectively (P = 0.01, linear trend). Multivariate logistic regression analysis showed that a decreased serum albumin level (OR = 40.0, 95% CI = 4.5–300, P = 0.001) and normal uric acid level (OR = 5.6, 95% CI = 1.5–21.7, P = 0.01) were the significant factors associated with significant fibrosis.

Conclusions

Hyperuricemia inversely predicts fibrosis stages. Females might carry a more disease severity than males in Taiwanese NASH patients.

The combined effects of serum lipids, BMI, and fatty liver on 18F-FDG uptake in the liver in a large population from China: an 18F-FDG-PET/CT study

OBJECTIVES

The aim of the study was to investigate the combined effects of serum lipids, BMI, and fatty liver on the liver uptake of fluorine-18 fluorodeoxyglucose ((18)F-FDG).

METHODS

A total of 676 individuals were retrospectively studied. The mean standardized uptake value (SUV) was used to quantify liver (18)F-FDG uptake. Univariate analyses and multivariate regression models identified variables that predicted the mean liver SUV before and after dichotomizing participants into low and high BMI groups.

RESULTS

The mean liver SUV (1.831 ± 0.417) differed significantly among nutritional categories (P = 0.005) and degrees of fatty liver (P < 0.001). An increase in mean liver SUV was noted in individuals with mild and moderate fatty liver compared with normal individuals and in overweight individuals compared with underweight individuals, whereas a downward trend was identified in both individuals with severe fatty liver and those who were obese. BMI had the strongest association with severity of fatty liver (r = 0.443, P < 0.001). Triglyceride, HDL, apolipoprotein-A, age, and BMI were independent variables predicting liver SUV mean in the whole population, whereas fatty liver severity presented as an independent variable only in the low BMI population (P = 0.031).

CONCLUSION

BMI, age, triglyceride, HDL, and apolipoprotein-A were independent variables predicting liver (18)F-FDG uptake. Mild and moderate degree of fatty liver had a positive effect on liver (18)F-FDG uptake, whereas a severe degree of fatty liver negatively affected (18)F-FDG uptake. Attention should be paid to liver metabolism in patients with fatty liver before using liver as the comparator in determining focal (18)F-FDG uptake elsewhere within the abdomen.

Free fatty acids shift insulin-induced hepatocyte proliferation towards CD95-dependent apoptosis

Insulin is known to induce hepatocyte swelling, which triggers via integrins and c-Src kinase an activation of the epidermal growth factor receptor (EGFR) and subsequent cell proliferation (1). Free fatty acids (FFAs) are known to induce lipoapoptosis in liver cells in a c-Jun-NH2-terminal kinase (JNK)-dependent, but death receptor-independent way (2). As non-alcoholic steatohepatitis (NASH) is associated with hyperinsulinemia and increased FFA-blood levels, the interplay between insulin and FFA was studied with regard to hepatocyte proliferation and apoptosis in isolated rat and mouse hepatocytes. Saturated long chain FFAs induced apoptosis and JNK activation in primary rat hepatocytes, but did not activate the CD95 (Fas, APO-1) system, whereas insulin triggered EGFR activation and hepatocyte proliferation. Coadministration of insulin and FFAs, however, abolished hepatocyte proliferation and triggered CD95-dependent apoptosis due to a JNK-dependent association of the activated EGFR with CD95, subsequent CD95 tyrosine phosphorylation and formation of the death-inducing signaling complex (DISC). JNK inhibition restored the proliferative insulin effect in presence of FFAs and prevented EGFR/CD95 association, CD95 tyrosine phosphorylation and DISC formation. Likewise, in presence of FFAs insulin increased apoptosis in hepatocytes from wild type but not from Alb-Cre-FAS(fl/fl) mice, which lack functional CD95. It is concluded that FFAs can shift insulin-induced hepatocyte proliferation toward hepatocyte apoptosis by triggering a JNK signal, which allows activated EGFR to associate with CD95 and to trigger CD95-dependent apoptosis. Such phenomena may contribute to the pathogenesis of NASH.

Beneficial effects of heat-treated Enterococcus faecalis FK-23 on high-fat diet-induced hepatic steatosis in mice

A high-fat diet (HFD) is one of the causes of hepatic steatosis. We previously demonstrated that Enterococcus faecalis FK-23 (FK-23), a type of lactic acid bacteria, exhibits an anti-obesity effect in mice fed a HFD. In the present study, we examined the effects of FK-23 on HFD-induced hepatic steatosis. Male C57BL/6 mice were divided into four groups and given one of four treatments: standard diet (SD); standard diet supplemented with FK-23 (SD+FK); HFD; or HFD supplemented with FK-23 (HFD+FK). For the administration of FK-23, the drinking water was supplemented with FK-23 at a concentration of 2% (w/w). After 11 weeks, histological findings revealed hepatic steatosis in the liver of HFD-fed mice; however, this effect was attenuated by the administration of FK-23. The expression levels of genes involved in fatty acid oxidation in the liver tissue were significantly reduced in the HFD group compared with the SD group, but FK-23 supplementation tended to up-regulate the expression levels of these genes. Our findings show that the inhibitory effect of FK-23 against hepatic steatosis in HFD-fed mice can be explained by the prevention of fat accumulation in the liver through the modulation of the activities of genes involved in hepatic fatty acid oxidation.

Is increased red cell distribution width an indicating marker of nonalcoholic steatohepatitis and fibrotic stage?

AIM: To evaluate the red cell distribution width (RDW) as an indicator of the presence of non-alcoholic steatohepatitis (NASH) and its association with fibrotic scores.

METHODS: A retrospective study was carried out that included sixty-two biopsy proven NASH, 32 simple steatosis patients and 30 healthy controls. The correlation between the clinical and histopathological features of NASH patients and RDW values was evaluated. Liver fibrosis scores were measured using a 0 to 4 point scale and were divided in to two groups; fibrosis scores 0-1 were termed mild and fibrosis scores 2-4 were termed advanced fibrosis. RDW values were compared between NASH, simple steatosis and healthy controls. Univariate and multivariate analyses were performed to evaluate the independent predicting factors for the presence of liver fibrosis caused by NASH.

RESULTS: Patients with NASH had higher RDW values compared with simple steatosis and healthy control groups [14.28% ± 0.25% vs 13.37% ± 0.12%, 12.96% ± 0.14% (P < 0.01), respectively]. Patients with advanced fibrosis had higher RDW values than the mild fibrosis group (15.86% ± 0.4% vs 13.63% ± 0.67%, P < 0.01, respectively). RDW also correlated with fibrotic scores (r = 0.579 and P < 0.01). The variables that were significant in the univariate analysis were evaluated in multivariate logistic regression analysis, and RDW was an independent predicting factor of NASH (OR = 1.75, 95%CI: 1.129-2.711, P < 0.05).

CONCLUSION: RDW a new non-invasive marker that can be used to demonstrate the presence of NASH and indicate advanced fibrotic scores.

Herbal medicines for fatty liver diseases

BACKGROUND

Fatty liver disease is potentially a reversible condition that may lead to end-stage liver disease. Since herbal medicines such as Crataegus pinnatifida and Salvia miltiorrhiza have increasingly been used in the management of fatty liver disease, a systematic review on herbal medicine for fatty liver disease is needed.

OBJECTIVES

To assess the beneficial and harmful effects of herbal medicines for people with alcoholic or non-alcoholic fatty liver disease.

SEARCH METHODS

We searched The Cochrane Hepato-Biliary Group Controlled Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL) (Issue 3, 2012), MEDLINE, EMBASE, and Science Citation Index Expanded to 1 March 2012. We also searched the Chinese BioMedical Database, Traditional Chinese Medical Literature Analysis and Retrieval System, China National Knowledge Infrastructure, Chinese VIP Information, Chinese Academic Conference Papers Database and Chinese Dissertation Database, and the Allied and Complementary Medicine Database to 2 March 2012.

SELECTION CRITERIA

We included randomised clinical trials comparing herbal medicines with placebo, no treatment, a pharmacological intervention, or a non-pharmacological intervention such as diet or lifestyle, or Western interventions in participants with fatty liver disease.

DATA COLLECTION AND ANALYSIS

Two review authors extracted data independently. We used the 'risk of bias' tool to assess the risk of bias of the included trials. We assessed the following domains: random sequence generation, allocation concealment, blinding, incomplete outcome data, selective outcome reporting, and other sources of bias. We presented the effects estimates as risk ratios (RR) with 95% confidence intervals (CI) or as mean differences (MD) with 95% CI, depending on the variables of the outcome measures.

MAIN RESULTS

We included 77 randomised clinical trials, which included 6753 participants with fatty liver disease. The risks of bias (overestimation of benefits and underestimation of harms) was high in all trials. The mean sample size was 88 participants (ranging from 40 to 200 participants) per trial. Seventy-five different herbal medicine products were tested. Herbal medicines tested in the randomised trials included single-herb products (Gynostemma pentaphyllum, Panax notoginseng, and Prunus armeniaca), proprietary herbal medicines commercially available, and combination formulas prescribed by practitioners. The most commonly used herbs were Crataegus pinnatifida,Salvia miltiorrhiza,Alisma orientalis,Bupleurum Chinense,Cassia obtusifolia, Astragalus membranaceous, and Rheum palmatum. None of the trials reported death, hepatic-related morbidity, quality of life, or costs. A large number of trials reported positive effects on putative surrogate outcomes such as serum aspartate aminotransferase, alanine aminotransferase, glutamyltransferase, alkaline phosphatases, ultrasound, and computed tomography scan. Twenty-seven trials reported adverse effects and found no significant difference between herbal medicines versus control. However, the risk of bias of the included trials was high.The outcomes were ultrasound findings in 22 trials, liver computed tomography findings in eight trials, aspartate aminotransferase levels in 64 trials, alanine aminotransferase activity in 77 trials, and glutamyltransferase activities in 44 trials. Six herbal medicines showed statistically significant beneficial effects on ultrasound, four on liver computed tomography, 42 on aspartate aminotransferase activity, 49 on alanine aminotransferase activity, three on alkaline phosphatases activity, and 32 on glutamyltransferase activity compared with control interventions.

AUTHORS' CONCLUSIONS

Some herbal medicines seemed to have positive effects on aspartate aminotransferase, alanine aminotransferase, ultrasound, and computed tomography. We found no significant difference on adverse effects between herbal medicine and control groups. The findings are not conclusive due to the high risk of bias of the included trials and the limited number of trials testing individual herbal medicines. Accordingly, there is also high risk of random errors.

Convergent mechanisms for dysregulation of mitochondrial quality control in metabolic disease: implications for mitochondrial therapeutics

Mitochondrial dysfunction is associated with a broad range of pathologies including diabetes, ethanol toxicity, metabolic syndrome and cardiac failure. It is now becoming clear that maintaining mitochondrial quality through a balance between biogenesis, reserve capacity and mitophagy is critical in determining the response to metabolic or xenobiotic stress. In diseases associated with metabolic stress, such as Type II diabetes and non-alcoholic and alcoholic steatosis, the mitochondria are subjected to multiple 'hits' such as hypoxia and oxidative and nitrative stress, which can overwhelm the mitochondrial quality control pathways. In addition, the underlying mitochondrial genetics that evolved to accommodate high-energy demand, low-calorie supply environments may now be maladapted to modern lifestyles (low-energy demand, high-calorie environments). The pro-oxidant and pro-inflammatory environment of a sedentary western lifestyle has been associated with modified redox cell signalling pathways such as steatosis, hypoxic signalling, inflammation and fibrosis. These data suggest that loss of mitochondrial quality control is intimately associated with the aberrant activation of redox cell signalling pathways under pathological conditions. In the present short review, we discuss evidence from alcoholic liver disease supporting this concept, the insights obtained from experimental models and the application of bioenergetic-based therapeutics in the context of maintaining mitochondrial quality.

Review article: is non-alcoholic fatty liver disease a spectrum, or are steatosis and non-alcoholic steatohepatitis distinct conditions?

BACKGROUND

Non-alcoholic fatty liver disease (NAFLD) is currently conceptualised as a clinical spectrum that results from a ‘multiple-hit’ process which begins with simple steatosis and subsequently renders the hepatocytes susceptible to a variety of insults. Ultimately, more serious liver injuries like non-alcoholic steatohepatitis (NASH) and cirrhosis may develop. Although the metabolic syndrome is considered the crucial player in the pathogenesis of NAFLD, recent studies have highlighted novel pathophysiological mechanisms in this clinical entity.

AIM

To discuss the pathophysiology of NAFLD based on the hypothesis that simple steatosis and NASH are discrete entities rather than two points on a spectrum.

METHODS

A literature search was conducted in August 2012 on PubMed, Ovid Embase, Ovid Medline and Scopus using the following search terms: steatosis, non-alcoholic steatohepatitis, pathophysiology, fatty liver, natural history and genetics.

RESULTS

Simple steatosis and NASH appear as two distinct pathophysiological entities and progression from pure fatty liver to NASH appears to be so rare as to warrant publication. The possible pathogenetic pathways specifically related to NASH are highlighted.

CONCLUSIONS

Although simple steatosis and non-alcoholic steatohepatitis are currently viewed as two histological subtypes of the unique spectrum of non-alcoholic fatty liver disease, the two conditions are likely distinct not only from a histological but also from a pathophysiological standpoint. Efforts to distinguish simple steatosis from non-alcoholic steatohepatitis using non-invasive modalities should be informed by the current pathophysiology of these two clinical entities.

The negative impact of fatty liver on maximum standard uptake value of liver on FDG PET

PURPOSE

The purpose of the study is to evaluate the impact of fatty liver on maximum standard uptake value (SUVmax) of liver on 2-fluoro-2-deoxy-d-glucose (FDG) positron emission tomography (PET).

MATERIALS AND METHODS

A total of 173 consecutive healthy subjects were retrospectively recruited for analysis. Subjects with acute renal disease, chronic renal disease, or malignancy were excluded. Demographic data were collected from chart records. All subjects performed whole-body FDG PET, sonography of liver, and glutamic pyruvic transaminase (GPT) level. The SUVmax of liver on FDG PET was calculated. The relationship between the severity of fatty liver and SUVmax of liver on FDG PET was analyzed.

RESULTS

There were significant differences in SUVmax of liver on FDG PET in four groups: no fatty liver, mild-degree, moderate-degree, and severe-degree fatty liver on sonography diagnosis (P=.041). After adjusting for possible covariates age, sex, body mass index, and GPT, there was a significantly negative correlation between the severity of fatty liver and SUVmax of liver on FDG PET (β=-.20, P<.001).

CONCLUSION

Based on the results of this study, the liver cannot be used as a comparator of extrahepatic foci of equivocal increased FDG activity in patients with fatty liver disease.

Steatosis of indeterminate cause in a pediatric group: is it a primary mitochondrial hepatopathy?

CONTEXT AND OBJECTIVE

In children, hepatic steatosis may be related to inborn errors of metabolism (IEMs) or to non-alcoholic fatty liver disease (NAFLD). The aim of this study was to assess and characterize steatosis of indeterminate cause through morphological and morphometric analysis of liver tissue.

DESIGN AND SETTING

Cross-sectional study at the Departments of Pathology of Faculdade de Ciências Médicas, Universidade Estadual de Campinas (FCM-Unicamp) and Faculdade de Medicina de Botucatu, Universidade Estadual Paulista (FMB-Unesp).

METHODS

Eighteen consecutive liver biopsies obtained from 16 patients of ages ranging from 3 months to 12 years and nine months that were inserted in a database in the study period were analyzed using optical microscopy and transmission electron microscopy. Through electron microscopy, the mitochondrial density and mean mitochondrial surface area were determined in hepatocytes. Ten patients ranging in age from 1 to 14 years were used as a control group.

RESULTS

"Pure" steatosis was detected, unaccompanied by fibrosis or any other histological alteration. Microvesicular steatosis predominated, with a significant increase in mean mitochondrial surface area.

CONCLUSION

Microvesicular steatosis may be related to primary mitochondrial hepatopathy, especially due to reduction of β-oxidation or partial stagnation of oxidative phosphorylation. For these reasons, this form of steatosis (which should not be called "pure") is likely to represent an initial stage in the broad spectrum of NAFLD. We have drawn attention to cases of steatosis in the pediatric group, in which the microvesicular form predominates, since this may be associated with mitochondrial disorders.

Correlation of hepatic vein Doppler waveform and hepatic artery resistance index with the severity of nonalcoholic fatty liver disease

PURPOSE

The study was conducted to evaluate the effect of various degrees of fatty infiltration in patients with nonalcoholic fatty liver disease on hepatic artery resistance index and hepatic vein waveform patterns.

METHODS

After identification and grading of fatty infiltration, 60 patients and 20 normal healthy subjects were examined using color and spectral Doppler sonography. The level of fatty liver infiltration was ascertained and graded by biopsy in patients and excluded by MRI in controls. The patients were allocated to four study groups consecutively, until the required number was reached, according to infiltration level as follows: normal (group A), mild (group B), moderate (group C), and severe (group D). The hepatic vein waveforms were classified into the three following groups: triphasic, biphasic, and monophasic waveform. The hepatic artery resistance index was calculated as the mean of three different measurements.

RESULTS

The incidence of monophasic and biphasic hepatic vein waveform was 2 (10%) for group B, 11 (55%) for group C, 16 (80%) for group D, and none for group A. The difference in the distribution of triphasic Doppler waveform pattern between the patients and the control group was significant (p < 0.001). Hepatic artery resistance index was 0.81 (+ or - 0.02), 0.78 (+ or - 0.03), 0.73 (+ or - 0.03), and 0.68 (+ or - 0.05), respectively, in groups A, B, C, and D and was significantly different between groups (p < 0.001).

CONCLUSION

As the severity of nonalcoholic fatty infiltration increases, the incidence of abnormal hepatic vein waveforms increases and hepatic artery resistance index decreases.

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

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

PPARalpha: energy combustion, hypolipidemia, inflammation and cancer

The peroxisome proliferator-activated receptor alpha (PPARalpha, or NR1C1) is a nuclear hormone receptor activated by a structurally diverse array of synthetic chemicals known as peroxisome proliferators. Endogenous activation of PPARalpha in liver has also been observed in certain gene knockout mouse models of lipid metabolism, implying the existence of enzymes that either generate (synthesize) or degrade endogenous PPARalpha agonists. For example, substrates involved in fatty acid oxidation can function as PPARalpha ligands. PPARalpha serves as a xenobiotic and lipid sensor to regulate energy combustion, hepatic steatosis, lipoprotein synthesis, inflammation and liver cancer. Mainly, PPARalpha modulates the activities of all three fatty acid oxidation systems, namely mitochondrial and peroxisomal beta-oxidation and microsomal omega-oxidation, and thus plays a key role in energy expenditure. Sustained activation of PPARalpha by either exogenous or endogenous agonists leads to the development of hepatocellular carcinoma resulting from sustained oxidative and possibly endoplasmic reticulum stress and liver cell proliferation. PPARalpha requires transcription coactivator PPAR-binding protein (PBP)/mediator subunit 1(MED1) for its transcriptional activity.

Noninvasive quantitation of human liver steatosis using magnetic resonance and bioassay methods

The purpose was to evaluate the ability of three magnetic resonance (MR) techniques to detect liver steatosis and to determine which noninvasive technique (MR, bioassays) or combination of techniques is optimal for the quantification of hepatic fat using histopathology as a reference. Twenty patients with histopathologically proven steatosis and 24 control subjects underwent single-voxel proton MR spectroscopy (MRS; 3 voxels), dual-echo in phase/out of phase MR imaging (DEI) and diffusion-weighted MR imaging (DWI) examinations of the liver. Blood or urine bioassays were also performed for steatosis patients. Both MRS and DEI data allowed to detect steatosis with a high sensitivity (0.95 for MRS; 1 for DEI) and specificity (1 for MRS; 0.875 for DEI) but not DWI. Strong correlations were found between fat fraction (FF) measured by MRS, DEI and histopathology segmentation as well as with low density lipoprotein (LDL) and cholesterol concentrations. A Bland-Altman analysis showed a good agreement between the FF measured by MRS and DEI. Partial correlation analyses failed to improve the correlation with segmentation FF when MRS or DEI data were combined with bioassay results. Therefore, FF from MRS or DEI appear to be the best parameters to both detect steatosis and accurately quantify fat liver noninvasively.

Does nonalcoholic fatty liver disease predispose patients to hepatocellular carcinoma in the absence of cirrhosis?

CONTEXT

Hepatocellular carcinoma (HCC) is recognized as a complication of cirrhosis related to nonalcoholic fatty liver disease (NAFLD). Diabetes and the metabolic syndrome are also associated with HCC. However, it is not clear whether NAFLD predisposes patients to HCC in the absence of cirrhosis.

OBJECTIVE

To seek evidence that HCC can develop in NAFLD unaccompanied by cirrhosis.

DESIGN

Retrospective case study was performed on cases from 2004 to 2007 at the University of Illinois at Chicago Medical Center, using the key words hepatocellular carcinoma, liver explant, and liver resection. The diagnosis of HCC was identified and confirmed by hematoxylin-eosin-stained slides in 50 cases. Cause of liver disease was determined by review of liver histology, clinical history, and laboratory data.

RESULTS

Three patients presented with advanced HCC with features of metabolic syndrome, including an elevated body mass index. Each patient had bland steatosis on liver biopsy, without fibrosis or cirrhosis. None of the 3 patients had evidence of any cause for liver disease other than NAFLD.

CONCLUSIONS

The cases presented here suggest that NAFLD may predispose patients to HCC in the absence of cirrhosis. Further studies are needed to confirm this potentially important observation.

Nutritional lipid-induced oxidative stress leads to mitochondrial dysfunction followed by necrotic death in FaO hepatocytes

OBJECTIVE

Mitochondrial dysfunction and hepatocyte cell death have been reported in fatty liver and non-alcoholic steatohepatitis. Our aim in this study was to evaluate whether direct exposure of hepatocytes to extracellular fat could facilitate such deleterious effects.

METHODS

FaO hepatic cells treated with fat was used as an in vitro model for steatosis. FaO hepatocytes were exposed to 0.1% triacylglycerols using commercially available lipid emulsion (LE) for various periods and studied for production of reactive oxygen species (ROS), mitochondrial function, and cell death parameters. To study the type of cell death, high-mobility group box chromosomal protein 1cellular levels, DNA fragmentation, and caspase activity were evaluated.

RESULTS

Cells incubated with LE for 6 h exhibited a marked increase in the production of intracellular ROS. Using treatments with peroxisome proliferator-activated receptor activators, mitochondrial electron-transfer chain inhibitor, and different sources of LE that did or did not contain medium-chain triacylglycerols, the mitochondria were found to be the source of ROS. LE treatment resulted in phosphorylation of adenosine monophosphate-activated protein kinase, accompanied by a decrease in adenosine triphosphate levels. Changes in intracellular ROS and energy levels were followed by cell death. FaO hepatocytes showed a significant reduction in high-mobility group box chromosomal protein-1 and little DNA fragmentation. Incubation with LE for 24 h did not change caspase-3 activity, indicating that hepatocyte death was necrotic. The antioxidant N-acetylcysteine was able to attenuate the changes in intracellular energy levels and ROS levels and to prevent cell death after exposure to LE.

CONCLUSION

These results suggest that exposure of FaO cells to LE leads to an increase in mitochondrial ROS production and a decrease in cellular energy levels followed by necrotic cell death.

Pioglitazone retrieves hepatic antioxidant DNA repair in a mice model of high fat diet

Background

Pioglitazone was reported to improve hepatic steatosis and necroinflammation in human studies. To investigate whether the hepato-protective effect of pioglitazone was associated with an improvement of antioxidant defense mechanism, oxidative DNA damage and repair activity were determined in a high fat diet model. Male C57BL/6 mice were respectively fed with a 30% fat diet, the same diet with pioglitazone 100 mg/kg/day, or a chow diet as control for 8 weeks. Tissue oxidative stress was indicated by malondialdehyde concentration. Oxidative DNA damage was detected by immunohistochemical 8-oxoG staining. Enzymatic antioxidant defense was detected by the real-time PCR of superoxide dismutase (Sod1, Sod2) and DNA glycosylase (Ogg1, MutY). Oxidative DNA repair was detected by immunohistochemical staining and western blotting of OGG1 expression.

Results

Our results show that hepatic steatosis was induced by a high-fat diet and improved by adding pioglitazone. Malondialdehyde concentration and 8-oxoG staining were strongly increased in the high-fat diet group, but attenuated by pioglitazone. Gene expressions of antioxidant defense mechanism: Sod1, Sod2, Ogg1 and MutY significantly decreased in the high-fat diet group but reversed by pioglitazone co-administration.

Conclusion

The attenuation of hepatic oxidative DNA damage by pioglitazone in a high-fat diet may be mediated by up-regulation of the antioxidant defense mechanism and oxidative DNA repair activity. The diminution of oxidative damage may explain the clinical benefit of pioglitazone treatment in patients with non-alcoholic fatty liver disease.

Differential alterations in mitochondrial function induced by a choline-deficient diet: understanding fatty liver disease progression

Non-alcoholic fatty liver disease (NAFLD) is an increasingly reported pathology, characterized by fat accumulation within the hepatocyte. Growing evidences suggest specific effects on mitochondrial metabolism, but it is still unclear the relationship between fatty liver progression and mitochondrial function. In the present work we have investigated the impact of fatty liver on mitochondrial bioenergetic functions and susceptibility to mitochondrial permeability transition (MPT) induction in animals fed a choline-deficient diet (CDD) for 4, 8, 12 or 16 weeks. Mitochondria isolated from CDD animals always exhibited higher state 4 respiration. Mitochondrial membrane potential was decreased in CDD animals at 4 and 16 weeks. At 12 weeks, oxidative phosphorylation was more efficient in CDD animals, suggesting a possible early response trying to revert the deleterious effect of increased triglyceride storage in the liver. However, mitochondrial dysfunction was evident in CDD animals at 16 weeks as indicated by decreased RCR and ADP/O, with a corresponding decrease in respiratory chain enzymes activities. Such loss of respiratory efficiency was associated with accumulation of protein oxidation products, in tissue and mitochondrial fraction. Additionally, although no differences in ATPase activity, the lag phase was increased in mitochondria from CDD animals at 16 weeks, associated with decreased content of the adenine nucleotide translocator. Increased susceptibility to calcium-induced MPT was evident in CDD animals at all time points. These results suggest a dynamic mechanism for the development of NALFD associated with altered mitochondrial function.

Metabolic disorders and storage diseases

Primary metabolic disorders and storage diseases are caused by endogenous factors, usually a gene mutation. Since the congenital defect is predominantly or exclusively located in the liver, the resulting diseases also become manifest in this organ.

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

BACKGROUND AND AIM

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Hepatocyte steatosis in HCV patients promotes fibrosis by enhancing TGF-beta liver expression

AIM

The objective of this study was to examine the relationship between TGF-beta expression in steatotic liver and the stage and yearly progression rate of fibrosis in chronic hepatitis C (CHC) patients.

METHODS

We examined 44 CHC fatty liver patients, using 76 non-steatotic CHC patients as controls. The stage of hepatic fibrosis was assessed on a score scale. TGF-beta expression was determined with the use of monoclonal serum and the ABC three-step method.

RESULTS

We demonstrated a positive correlation of steatosis with the stage of fibrosis (P < 0.05). No relationship of thiskind was found with the yearly progression rate of fibrosis (P > 0.09). In steatotic biopsies, TGF-beta expression index in portal spaces and lobules was found to be higher as compared to TGF-beta expression in biopsies without steatosis (P < 0.05).

CONCLUSION

In CHC patients steatosis induces the development of fibrosis by elevating the hepatic expression of TGF-beta.

Increased age, male gender, and cirrhosis, but not steatosis or a positive viral serology, negatively impact the life expectancy of patients who undergo liver biopsy

Most survival studies of chronic liver disease avoid including more than one condition, often present in patients with liver disease; survival analysis of patients with liver disease in general was undertaken. Over a 9-year period, the survival experience of 365 patients who underwent liver biopsy, with a median follow-up of 3 years, was assessed. Log rank tests and Cox regression were used to evaluate risk factors. The Flemington-Harrington G(rho) family of tests compared the number of deaths expected in the U.S. population in general, adjusted for age, sex, and year of biopsy, to the observed number of deaths in the patients with cirrhosis and to the observed number of deaths in patients without cirrhosis. Twenty-two (6%) patients died. Cirrhosis (HR = 2.9; 95% c.i.: 1.2-6.7), male sex (HR = 2.7; 95% c.i.: 1.1-6.6), and an additional 20 years of age at biopsy (HR = 2.9; 95% c.i:. 1.4-6.2) each negatively impacted survival. Patients with cirrhosis experienced 4.58 times the number of expected deaths (p < 0.00001). Patients without cirrhosis experienced 1.66 times the number of expected deaths (p = 0.15). Steatosis and a positive viral serology did not increase the risk of death. Male gender, increased age, and cirrhosis increased the risk of death; increased steatosis and positive viral serologic studies did not.

Hepatic steatosis is associated with increased frequency of hepatocellular carcinoma in patients with hepatitis C-related cirrhosis

BACKGROUND

Chronic hepatitis C can result in fatty changes in the liver. Previous studies have suggested that hepatic steatosis is a risk factor for hepatocellular carcinoma in patients with hepatitis C virus (HCV) infection. The authors sought to determine whether hepatic steatosis is associated with hepatocellular carcinoma (HCC) in a cohort of patients with hepatitis C-related cirrhosis.

METHODS

The authors retrospectively identified 94 consecutive patients with hepatitis C cirrhosis who underwent liver transplantation from 1992 to 2005 and had pathology available for review. Of these, 32 had evidence of HCC, and 62 had no HCC on explant histology. All explant specimens were graded again for steatosis by a single, blinded pathologist. Steatosis, age, sex, body mass index, HCV RNA, HCV genotype, Model for End-Stage Liver Disease (MELD) score, chronic alcohol use, and diabetes were examined in univariate and multivariate analyses for association with HCC.

RESULTS

In total, 69% of patients in the HCC group and 50% of patients in the control group had evidence of steatosis (1+) on histology. Odds ratios for the development of HCC for each grade of steatosis compared with grade 0 were as follows: grade 1 (1.61 [0.6-4.3]), grade 2 (3.68 [1.1-12.8]), and grade 3 or 4 (8.02 [0.6-108.3]) (P = .03 for the trend). In univariate analysis, there was a significant association between increasing steatosis grade (P = .03), older age (56 years vs 49 years; P < .02), higher aspartate aminotransferase (122.5 U/L vs 91.5 U/L; P = .005), higher alanine aminotransferase (95.8 U/L vs 57.2 U/L; P = .002), higher alpha-fetoprotein (113.5 ng/mL vs 17.8 ng/mL; P < .001), lower median HCV RNA (239,000 IU/mL vs 496,500 IU/mL; P = .02), higher biologic MELD score (21.8 vs 20.3; P = .03), and risk of HCC. In multivariate analysis, age (P = .02), AFP (P = .007), and steatosis (P = .045) were significantly associated with HCC.

CONCLUSIONS

In patients with HCV-related cirrhosis, the presence of hepatic steatosis is independently associated with the development of hepatocellular carcinoma. These findings suggest that steatosis poses an additional risk for HCC and that increased vigilance should be practiced in surveillance of persons with both HCV and steatosis.