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Lin H, Baker JW, Meister K, Lak KL, Martin Del Campo SE, Smith A, Needleman B, Nadzam G, Ying LD, Varban O, Reyes AM, Breckenbridge J, Tabone L, Gentles C, Echeverri C, Jones SB, Gould J, Vosburg W, Jones DB, Edwards M, Nimeri A, Kindel T, Petrick A. American society for metabolic and bariatric surgery: intra-operative care pathway for minimally invasive Roux-en-Y gastric bypass. Surg Obes Relat Dis 2024:S1550-7289(24)00668-3. [PMID: 39097472 DOI: 10.1016/j.soard.2024.06.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2024] [Accepted: 06/11/2024] [Indexed: 08/05/2024]
Abstract
BACKGROUND Clinical care pathways help guide and provide structure to clinicians and providers to improve healthcare delivery and quality. The Quality Improvement and Patient Safety Committee (QIPS) of the American Society for Metabolic and Bariatric Surgery (ASMBS) has previously published care pathways for the performance of laparoscopic sleeve gastrectomy (LSG) and pre-operative care of patients undergoing Roux-en-Y gastric bypass (RYGB). OBJECTIVE This current RYGB care pathway was created to address intraoperative care, defined as care occurring on the day of surgery from the preoperative holding area, through the operating room, and into the postanesthesia care unit (PACU). METHODS PubMed queries were performed from January 2001 to December 2019 and reviewed according to Level of Evidence regarding specific key questions developed by the committee. RESULTS Evidence-based recommendations are made for care of patients undergoing RYGB including the pre-operative holding area, intra-operative management and performance of RYGB, and concurrent procedures. CONCLUSIONS This document may provide guidance based on recent evidence to bariatric surgeons and providers for the intra-operative care for minimally invasive RYGB.
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Affiliation(s)
- Henry Lin
- Department of Surgery, Signature Healthcare, Brockton, Massachusetts.
| | - John W Baker
- Department of Surgery, Tulane University School of Medicine, New Orleans, Louisiana
| | | | - Kathleen L Lak
- Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin
| | | | - April Smith
- Department of Pharmacy, Creighton University School of Pharmacy and Health Professions, Omaha, Nebraska
| | | | - Geoffrey Nadzam
- Department of Surgery, Yale School of Medicine, New Haven, Connecticut
| | - Lee D Ying
- Department of Surgery, Yale New Haven Hospital, New Haven, Connecticut
| | - Oliver Varban
- Department of Surgery, Henry Ford Hospital, Detroit, Michigan
| | - Angel Manuel Reyes
- Department of General Surgery, St. Michael Medical Center, Silverdale, Washington
| | - Jamie Breckenbridge
- Department of General Surgery, Fort Belvoir Community Hospital, Fort Belvoir, Virginia
| | - Lawrence Tabone
- Department of Surgery, West Virginia University, Morgantown, West Virginia
| | - Charmaine Gentles
- Department of Surgery, Northshore University Hospital, Manhasset, New York
| | | | - Stephanie B Jones
- Department of Anesthesiology, Northwell Health, New Hyde Park, New York
| | - Jon Gould
- Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Wesley Vosburg
- Department of Surgery, Grand Strand Medical Center, Myrtle Beach, South Carolina
| | - Daniel B Jones
- Department of Surgery, Rutgers New Jersey Medical School, Newark, New Jersey
| | | | - Abdelrahman Nimeri
- Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - Tammy Kindel
- Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Anthony Petrick
- Department of Surgery, Geisinger Medical Center, Danville, Pennsylvania
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Sharma D, Anand G, Meena S, Bhardwaj V. Compare the Combined Diagnostic Accuracy of Transient Elastography and Visual Liver Score in Assessing Non-Alcoholic Fatty Liver Disease (NAFLD) and Compare it with Liver Biopsy in Morbidly Obese Patients Undergoing Bariatric Surgery: An Observational Study. Obes Surg 2024; 34:1247-1256. [PMID: 38411879 DOI: 10.1007/s11695-024-07106-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2023] [Revised: 02/13/2024] [Accepted: 02/15/2024] [Indexed: 02/28/2024]
Abstract
INTRODUCTION A liver biopsy is the gold standard for the diagnosis of non-alcoholic fatty liver disease (NAFLD) and non-alcoholic steatohepatitis (NASH). Here, we combine preoperative transient elastography (TE) and intraoperative standardized visual liver score (VLS) which is compared with intraoperative liver biopsy for prediction of NAFLD and NASH in patients undergoing bariatric surgery. AIM Evaluate the combined diagnostic accuracy of TE and VLS in assessing NAFLD or NASH and compare it with liver biopsy in patients undergoing bariatric surgery. METHODS In a prospective cohort of 70 morbidly obese undergoing bariatric surgery, preoperative TE and intraoperative VLS were calculated. Findings of TE and VLS were compared with histology from intraoperative liver biopsy. RESULTS Histologically, 44 (62.85%) had NAFLD (≥ S1). Significant steatosis was seen in 20 (28.57%) while significant fibrosis was visible in 18 (25.71%). Area Under the Receiver Operating Characteristics (AUROC) TE for diagnosis of NAFLD was excellent (0.844, p = 0.001). At the optimal cutoff of 8.1, the positive predictive value (PPV) was 92.9%, and diagnostic accuracy was 90.6%. VLS had a sensitivity of 90.9% for NAFLD. The combined sensitivity of TE + VLS was 95.5% for ruling out NAFLD. Fourteen (20%) had NASH. VLS had a diagnostic accuracy of 97% in identifying NASH in comparison to TE. AUROC-VLS was 0.987, p ≤ 0.001, and a sensitivity of 100%. The overall sensitivity of combined TE and VLS was 100% with a negative predictive value (NPV) of 100%. CONCLUSION TE when combined with intraoperative VLS is comparable to liver biopsy and can be used for the diagnosis of NAFLD and NASH in patients undergoing bariatric surgery.
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Affiliation(s)
- Deborshi Sharma
- Department of Surgery, Lady Hardinge Medical College, Atal Bihari Vajpayee Institute of Medical Sciences and Dr. Ram Manohar Lohia Hospital, New Delhi, 110001, India.
| | - Gautam Anand
- Department of Surgery, Lady Hardinge Medical College, Atal Bihari Vajpayee Institute of Medical Sciences and Dr. Ram Manohar Lohia Hospital, New Delhi, 110001, India
| | - Sanjay Meena
- Department of Surgery, Lady Hardinge Medical College, Atal Bihari Vajpayee Institute of Medical Sciences and Dr. Ram Manohar Lohia Hospital, New Delhi, 110001, India
| | - Vaishali Bhardwaj
- Department of Gastroenterology, Lady Hardinge Medical College, Atal Bihari Vajpayee Institute of Medical Sciences and Dr. Ram Manohar Lohia Hospital, New Delhi, 110001, India
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Pan Y, Zhang Y, Ouyang H, Gong T, Zhang Z, Cao X, Fu Y. Targeted Delivery of Celastrol via Chondroitin Sulfate Derived Hybrid Micelles for Alleviating Symptoms in Nonalcoholic Fatty Liver Disease. ACS APPLIED BIO MATERIALS 2023; 6:4877-4893. [PMID: 37890075 DOI: 10.1021/acsabm.3c00612] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/29/2023]
Abstract
Nonalcoholic fatty liver disease (NAFLD) is caused by an accumulation of excess fat in the liver leading to oxidative stress and liver cell injury, as well as overproduction of inflammatory cytokines. CD44 has been identified as a potential therapeutic target in the development of NAFLD to nonalcoholic steatohepatitis. Here, chondroitin sulfate (CS) is selected to construct a CD44-targeted delivery system for the treatment of NAFLD. Specifically, two CS-derived amphiphilic materials including CS conjugated with either 4-aminophenylboronic acid pinacol ester (CS-PBE) or phenformin (CS-PFM) were synthesized, respectively. The presence of PBE moieties on CS-PBE rendered the vehicle with enhanced loading capacity and scavenging potential against reactive oxygen species, while the presence of guanidine moieties on CS-PFM enhanced the internalization of vehicles in the differentiated hepatocytes. Next, celastrol (CLT) was encapsulated in the hybrid micelle to afford CS-Hybrid/CLT, which demonstrates sufficient stability, enhanced cellular uptake efficiencies in differentiated HepG2 cells, and therapeutic potential to alleviate lipid accumulation in differentiated HepG2 cells. In a high-fat-diet-induced NAFLD rat model, CS-Hybrid/CLT micelles demonstrated the capacity to dramatically decrease hepatic lipid accumulation and free fatty acid levels with greatly improved pathologic liver histology and downregulated hepatic inflammation levels. These results suggest that CS-based amphiphilic micelles may offer a promising strategy to effectively deliver therapeutic cargos to the liver for the treatment of NAFLD.
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Affiliation(s)
- Yi Pan
- Key Laboratory of Drug-Targeting and Drug Delivery System of the Education Ministry and Sichuan Province, Sichuan Engineering Laboratory for Plant-Sourced Drug and Sichuan Research Center for Drug Precision Industrial Technology, West China School of Pharmacy, Sichuan University, Chengdu 610041, China
| | - Yunxiao Zhang
- Key Laboratory of Drug-Targeting and Drug Delivery System of the Education Ministry and Sichuan Province, Sichuan Engineering Laboratory for Plant-Sourced Drug and Sichuan Research Center for Drug Precision Industrial Technology, West China School of Pharmacy, Sichuan University, Chengdu 610041, China
| | - Hongling Ouyang
- Key Laboratory of Drug-Targeting and Drug Delivery System of the Education Ministry and Sichuan Province, Sichuan Engineering Laboratory for Plant-Sourced Drug and Sichuan Research Center for Drug Precision Industrial Technology, West China School of Pharmacy, Sichuan University, Chengdu 610041, China
| | - Tao Gong
- Key Laboratory of Drug-Targeting and Drug Delivery System of the Education Ministry and Sichuan Province, Sichuan Engineering Laboratory for Plant-Sourced Drug and Sichuan Research Center for Drug Precision Industrial Technology, West China School of Pharmacy, Sichuan University, Chengdu 610041, China
| | - Zhirong Zhang
- Key Laboratory of Drug-Targeting and Drug Delivery System of the Education Ministry and Sichuan Province, Sichuan Engineering Laboratory for Plant-Sourced Drug and Sichuan Research Center for Drug Precision Industrial Technology, West China School of Pharmacy, Sichuan University, Chengdu 610041, China
| | - Xi Cao
- Department of Pharmacy, First Affiliated Hospital of Anhui Medical University, Hefei 230022, China
- Grade 3 Pharmaceutical Chemistry Laboratory of State Administrate of Traditional Chinese Medicine, Hefei 230022, China
| | - Yao Fu
- Key Laboratory of Drug-Targeting and Drug Delivery System of the Education Ministry and Sichuan Province, Sichuan Engineering Laboratory for Plant-Sourced Drug and Sichuan Research Center for Drug Precision Industrial Technology, West China School of Pharmacy, Sichuan University, Chengdu 610041, China
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Sampaio-Neto J, Nicoluzzi JE, Luvison Gomes da Silva L, Billó L, de Pádua Peppe-Neto A, Dall´ Asta L, P. de Moraes T, Fragoso GR. Prospective Study to Analyze the Concordance Between a Standardized Visual Method With Pathology to stratify Nonalcoholic Fatty Liver Disease in Cadaveric Liver Grafts Evaluated for Transplantation. Transplant Direct 2023; 9:e1540. [PMID: 37899779 PMCID: PMC10602502 DOI: 10.1097/txd.0000000000001540] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2023] [Revised: 08/08/2023] [Accepted: 08/09/2023] [Indexed: 10/31/2023] Open
Abstract
Background The main challenge of liver transplantation is the discrepancy in demand and availability. Marginal grafts or full organs from donors with expansion criteria have been considered to reduce the shortage and assist a greater number of patients. Nonalcoholic fatty liver disease (NAFLD) is one of the most important defining criteria for expanded criteria organs. The present study proposes that an organized visual analysis method could correctly identify and classify NAFLD and organ viability without the need for liver biopsy and its logistical concerns. Methods Pictures from the grafts were taken at a standardized method (same distance, light conditions, and register device) before and after the perfusion. The visual liver score (VLS) was applied by transplant surgeons; biopsies of the grafts were analyzed by a pathologist in a double-blind design. Score performance and interobserver agreement for NAFLD detection and grading, as graft viability evaluation, were calculated. Results Fifty-seven grafts were analyzed. At least 1 previous expansion criterion was presented by 59.64% of donors. The prevalence of NAFLD was 94.73%, with 31.57% borderline nonalcoholic steatohepatitis and 5.26% nonalcoholic steatohepatitis. Steatosis was identified with 48.68% (preperfusion) and 64.03% (postperfusion) accuracy. NAFLD stratification was performed with 49.53% (preperfusion) and 46.29% (postperfusion) accuracy. Viability related to NAFLD was identified with 51.96% (preperfusion) and 48.52% (postperfusion) accuracy. Interobserver agreement was moderate for total VLS and poor for individual components of VLS. Conclusions Although a standardized method was not reliable enough for visual evaluation of NALFD compared with pathology, efforts should be made to expand access to biopsy. Further studies are needed to understand whether the VLS needs to be adapted or even excluded in the liver transplant scenario, to assess the importance of ectoscopy related to posttransplant clinical outcomes, and to determine its role in graft selection.
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Affiliation(s)
- José Sampaio-Neto
- School of Medicine, Pontifícia Universidade Católica do Paraná (PUCPR), Curitiba, Paraná, Brazil
- Department of Transplantation, Santa Casa de Misericórdia de Curitiba, Curitiba, Paraná, Brazil
- School of Medicine, Faculdades Pequeno Príncipe, Curitiba, Paraná, Brazil
| | - João E.L. Nicoluzzi
- School of Medicine, Pontifícia Universidade Católica do Paraná (PUCPR), Curitiba, Paraná, Brazil
- Department of Transplantation, Hospital e Maternidade Angelina Caron, Curitiba, Paraná, Brazil
| | | | - Leandro Billó
- Department of Transplantation, Santa Casa de Misericórdia de Curitiba, Curitiba, Paraná, Brazil
| | | | - Luíza Dall´ Asta
- School of Medicine, Pontifícia Universidade Católica do Paraná (PUCPR), Curitiba, Paraná, Brazil
| | - Thyago P. de Moraes
- School of Medicine, Pontifícia Universidade Católica do Paraná (PUCPR), Curitiba, Paraná, Brazil
- Department of Transplantation, Santa Casa de Misericórdia de Curitiba, Curitiba, Paraná, Brazil
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Barbois S, Stürm N, Aron-Wisnewsky J, Clément K, Bedossa P, Genser L, Hilleret MN, Costentin C, Reche F, Arvieux C, Borel AL. Decision Tree for the Performance of Intraoperative Liver Biopsy During Bariatric Surgery. Obes Surg 2021; 31:2641-2648. [PMID: 33665755 DOI: 10.1007/s11695-021-05309-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Revised: 02/21/2021] [Accepted: 02/23/2021] [Indexed: 12/18/2022]
Abstract
BACKGROUND AND AIMS Bariatric surgery provides a useful opportunity to perform intraoperative liver biopsy to screen for non-alcoholic steatohepatitis (NASH). There is currently no consensus on whether intraoperative liver biopsy should be systematically performed. The aim of this study was to develop and validate a decision tree to guide that choice. APPROACH AND RESULTS This prospective study included 102 consecutive patients from the severe obesity outcome network (SOON) cohort in whom liver biopsy was systematically performed during bariatric surgery. A classification and regression tree (CART) was created to identify the nodes that best classified patients with and without NASH. External validation was performed. Seventy-one biopsies were of sufficient quality for analysis (median body mass index 43.3 [40.7; 48.0] kg/m2). NASH was diagnosed in 32.4% of cases. None of the patients with no steatosis on ultrasound had NASH. The only CART node that differentiated between a "high-risk" and a "low-risk" of NASH was alanine aminotransferase (ALT). ALT>53IU/L predicted NASH with a positive predictive value (PPV) of 68% and a negative predictive value (NPP) of 89%, a sensitivity of 77%, and a specificity of 84%. In the external cohort (n=258), PPV was 68%, NPV was 62%, sensitivity was 27%, and specificity was 90%. CONCLUSIONS The present work supports intraoperative liver biopsy to screen for NASH in patients with ALT>53IU/L; however, patients with no steatosis on ultrasound should not undergo biopsy. The CART failed to identify an algorithm with a good sensitivity to screen for NASH in patients with ultrasonography-proven steatosis and ALT≤53IU/L.
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Affiliation(s)
- Sandrine Barbois
- Department of Digestive Surgery, University Hospital Grenoble Alpes, 38043, Grenoble, France. .,Hypoxia Physiopathology (HP2) Laboratory, INSERM U1042, Grenoble Alpes University, 38043, Grenoble, France.
| | - N Stürm
- Department of Anatomopathology, University Hospital Grenoble Alpes, 38043, Grenoble, France
| | - J Aron-Wisnewsky
- INSERM, NutriOmics Research Unit, Sorbonne Université, Paris, France.,Assistance Publique Hôpitaux de Paris, Nutrition Department, Pitié-Salpêtrière Hospital, Sorbonne Université, Paris, France
| | - K Clément
- INSERM, NutriOmics Research Unit, Sorbonne Université, Paris, France.,Assistance Publique Hôpitaux de Paris, Nutrition Department, Pitié-Salpêtrière Hospital, Sorbonne Université, Paris, France
| | - P Bedossa
- Institute of Cellular Medicine, University of Newcastle, Newcastle upon Tyne, UK
| | - Laurent Genser
- INSERM, NutriOmics Research Unit, Sorbonne Université, Paris, France.,Assistance Publique Hôpitaux de Paris, Digestive Surgery Department, Pitié-Salpêtrière Hospital, Sorbonne Université, Paris, France
| | - M N Hilleret
- Department of Hepatology, University Hospital Grenoble Alpes, 38043, Grenoble, France
| | - C Costentin
- Department of Hepatology, University Hospital Grenoble Alpes, 38043, Grenoble, France
| | - F Reche
- Department of Digestive Surgery, University Hospital Grenoble Alpes, 38043, Grenoble, France
| | - C Arvieux
- Department of Digestive Surgery, University Hospital Grenoble Alpes, 38043, Grenoble, France
| | - A L Borel
- Hypoxia Physiopathology (HP2) Laboratory, INSERM U1042, Grenoble Alpes University, 38043, Grenoble, France.,Department of Nutrition, University Hospital Grenoble Alpes, 38043, Grenoble, France
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Clapp B, Dodoo C, Kim J, Castro C, Wicker E, Mandania R, Davis B. Safety of liver biopsy at the time of bariatric surgery: an analysis of the MBSAQIP database. Surg Endosc 2021; 36:413-421. [PMID: 33483847 DOI: 10.1007/s00464-021-08297-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Accepted: 01/05/2021] [Indexed: 02/05/2023]
Abstract
BACKGROUND The majority of patients undergoing bariatric surgery have hepatic steatosis. Liver biopsy is not technically difficult to perform at the time of metabolic and bariatric surgery (MBS), but there may be concerns for bleeding complications. The safety of liver biopsy (LBx) at the time of MBS has been studied in single institutional studies but has not been studied on a national level. METHODS The MBSAQIP database for 2015-2018 was examined. The codes for Roux-en-Y gastric bypass (RYGB) of 43644 and sleeve gastrectomy (SG) 43775 were used along with 47000 (percutaneous liver biopsy), 47001 (percutaneous liver biopsy at time of other procedure), and 47379 (unlisted laparoscopic procedure, liver). Outcomes such as operative time, complications, and length of stay were examined. Propensity-matched analysis was performed to evaluate for adjusted associations. RESULTS There were 546,532 patients that met our inclusion criteria. Of those, 21,367 (3.9%) underwent LBx. Only 5.5% (8012) of patients undergoing RYGB had a LBx and 3.3% (13,355) of SG patients. Patients who underwent a LBx had a longer operative time before (103 min vs 84 min, p < 0.001) and after propensity matching [regression coefficient (RC): 10.7 (8.87, 12.5)]. There was no increase in length of stay. There was an increased risk in mortality in the unadjusted analysis (prevalence ratio = 1.61, p = 0.02), but when propensity-matched analysis was done, there was no statistically significant difference between the two groups. Concerning bleeding or transfusion, there was no difference in bleeding or rates of transfusion (p= 0.22, p = 0.21). CONCLUSION Liver biopsy at the time of MBS is safe. It adds operative time, but there is no increase in length of stay, bleeding complications, morbidity, or death.
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Affiliation(s)
- Benjamin Clapp
- Department of Surgery, Texas Tech Health Sciences Center Paul Foster School of Medicine, 1700 N. Mesa, El Paso, TX, 79902, USA.
| | - Christopher Dodoo
- Department of Surgery, Texas Tech Health Sciences Center Paul Foster School of Medicine, 1700 N. Mesa, El Paso, TX, 79902, USA
| | - Jisoo Kim
- Department of Surgery, Texas Tech Health Sciences Center Paul Foster School of Medicine, 1700 N. Mesa, El Paso, TX, 79902, USA
| | - Christian Castro
- Department of Surgery, Texas Tech Health Sciences Center Paul Foster School of Medicine, 1700 N. Mesa, El Paso, TX, 79902, USA
| | - Ellen Wicker
- Department of Surgery, Texas Tech Health Sciences Center Paul Foster School of Medicine, 1700 N. Mesa, El Paso, TX, 79902, USA
| | - Roshni Mandania
- Department of Surgery, Texas Tech Health Sciences Center Paul Foster School of Medicine, 1700 N. Mesa, El Paso, TX, 79902, USA
| | - Brian Davis
- Department of Surgery, Texas Tech Health Sciences Center Paul Foster School of Medicine, 1700 N. Mesa, El Paso, TX, 79902, USA
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Watt MJ, Miotto PM, De Nardo W, Montgomery MK. The Liver as an Endocrine Organ-Linking NAFLD and Insulin Resistance. Endocr Rev 2019; 40:1367-1393. [PMID: 31098621 DOI: 10.1210/er.2019-00034] [Citation(s) in RCA: 332] [Impact Index Per Article: 66.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2019] [Accepted: 04/04/2019] [Indexed: 02/06/2023]
Abstract
The liver is a dynamic organ that plays critical roles in many physiological processes, including the regulation of systemic glucose and lipid metabolism. Dysfunctional hepatic lipid metabolism is a cause of nonalcoholic fatty liver disease (NAFLD), the most common chronic liver disorder worldwide, and is closely associated with insulin resistance and type 2 diabetes. Through the use of advanced mass spectrometry "omics" approaches and detailed experimentation in cells, mice, and humans, we now understand that the liver secretes a wide array of proteins, metabolites, and noncoding RNAs (miRNAs) and that many of these secreted factors exert powerful effects on metabolic processes both in the liver and in peripheral tissues. In this review, we summarize the rapidly evolving field of "hepatokine" biology with a particular focus on delineating previously unappreciated communication between the liver and other tissues in the body. We describe the NAFLD-induced changes in secretion of liver proteins, lipids, other metabolites, and miRNAs, and how these molecules alter metabolism in liver, muscle, adipose tissue, and pancreas to induce insulin resistance. We also synthesize the limited information that indicates that extracellular vesicles, and in particular exosomes, may be an important mechanism for intertissue communication in normal physiology and in promoting metabolic dysregulation in NAFLD.
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Affiliation(s)
- Matthew J Watt
- Department of Physiology, University of Melbourne, Melbourne, Victoria, Australia
| | - Paula M Miotto
- Department of Physiology, University of Melbourne, Melbourne, Victoria, Australia
| | - William De Nardo
- Department of Physiology, University of Melbourne, Melbourne, Victoria, Australia
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