Current histological classification of NAFLD: Strength and limitations. Hepatol Int. 2013;7 Suppl 2:765-770. [PMID: 26202292 DOI: 10.1007/s12072-013-9446-z]

Metabolic signatures of metabolic dysfunction-associated steatotic liver disease in severely obese patients

BACKROUND

Metabolic dysfunction-associated steatotic liver disease (MASLD) can lead to liver fibrosis, cirrhosis, and hepatocellular carcinoma. Still, most patients with MASLD die from cardiovascular diseases indicating metabolic alterations related to both liver and cardiovascular pathology.

AIMS AND METHODS

The aim of this study was to assess biologic pathways behind MASLD progression from steatosis to metabolic dysfunction-associated steatohepatitis (MASH) using non-targeted liquid chromatography-mass spectrometry analysis in 106 severely obese individuals (78 women, mean age 47.7 7 ± 9.2 years, body mass index 41.8 ± 4.3 kg/m²) undergoing laparoscopic Roux-en-Y gastric bypass.

RESULTS

We identified several metabolites that are associated with MASLD progression. Most importantly, we observed a decrease of lysophosphatidylcholines LPC(18:2), LPC(18:3), and LPC(20:3) and increase of xanthine when comparing those with steatosis to those with MASH. We found that indole propionic acid and threonine were negatively correlated to fibrosis, but not with the metabolic disturbances associated with cardiovascular risk. Xanthine, ketoleucine, and tryptophan were positively correlated to lobular inflammation and ballooning but also with insulin resistance, and dyslipidemia, respectively. The results did not change when taking into account the most important genetic risk factors of MASLD.

CONCLUSIONS

Our findings suggest that there are several separate biological pathways, some of them independent of insulin resistance and dyslipidemia, associating with MASLD.

Impact of the diagnosis of metabolic dysfunction-associated fatty liver disease and non-alcoholic fatty liver disease in patients undergoing liver transplantation for hepatocellular carcinoma

Purpose

Whether the diagnosis of non-alcoholic fatty liver disease or metabolic dysfunction-associated fatty disease has a different impact on liver transplant recipients with hepatocellular carcinoma is not yet clear.

Methods

Data from a two-center retrospective cohort study were collected to compare and investigate the differences between non-alcoholic fatty liver disease and metabolic dysfunction-associated fatty liver disease in clinicopathologic parameters and prognosis among liver transplant recipients with hepatocellular carcinoma.

Results

A total of 268 liver transplant recipients with hepatocellular carcinoma were included. The prevalence among pre- and post-transplant metabolic dysfunction-associated fatty liver disease was 10.82% and 30.22%, while for non-alcoholic fatty liver disease, it was 7.09% and 26.87%, respectively. The clinicopathological parameters were similar between the two pre-transplant groups. In contrast, the post-transplant group with metabolic dysfunction-associated fatty liver disease exhibited a higher prevalence of diabetes mellitus and a greater body mass index. However, the other parameters were similar between the two post-transplant groups (p > 0.05). Factors such as the largest tumor size > 4 cm, microvascular invasion, lack of tumor capsule, post-transplant metabolic dysfunction-associated fatty liver disease, and decreased post-transplant lymphocyte percentage were related to an increased risk of recurrence.

Conclusion

In patients undergone liver transplantation for hepatocellular carcinoma, the diagnosis of metabolic dysfunction-associated fatty disease is more strongly associated with metabolic abnormalities than the diagnosis of non-alcoholic fatty liver disease and is an independent predictor of hepatocellular carcinoma recurrence.

[State of the art on the pathophysiology, diagnosis and treatment of non-alcoholic steatohepatitis (NASH)]

NAFLD or non-alcoholic fatty liver disease is one of the complications of obesity and diabetes, the prevalence of which is increasing. The causes of the pathology and its development towards its severe form, NASH or non-alcoholic steatohepatitis, are multiple and still poorly understood. Many different pharmacological classes are being tested in clinical trials to treat NASH, but no pharmaceutical treatment is currently on the market. Moreover, the diagnosis of certainty is only possible by liver biopsy and histological analysis, an invasive procedure with high risk for the patient. It is therefore necessary to better understand the natural history of the disease in order to identify therapeutic targets, but also to identify markers for the diagnosis and monitoring of the disease using a blood sample, which will allow an improvement in patient management.

Replacing Foods with a High-Glycemic Index and High in Saturated Fat by Alternatives with a Low Glycemic Index and Low Saturated Fat Reduces Hepatic Fat, Even in Isocaloric and Macronutrient Matched Conditions

BACKGROUND

Current guidelines aim to limit the dietary glycemic index (GI) and intake of saturated fatty acids (SFA). Several studies have shown favorable effects of low-GI or low-SFA diets on intrahepatic lipid content (IHL), but these studies were performed under overfeeding conditions or extreme differences in GI or SFA to maximize the contrast between diets. By combining changes in GI and SFA, we can mimic how people can improve their diet in a realistic setting.

OBJECTIVES

We investigated the effect on liver fat content and substrate metabolism of both reducing GI and replacing SFA with polyunsaturated fat in practically realistic amounts under isocaloric conditions.

DESIGN AND METHODS

In a randomized crossover study, thirteen overweight participants consumed two diets, one high in GI and SFA (high GI/SFA) and one low in GI and SFA (low GI/SFA) with identical macronutrient composition, for two weeks each. Diets were equal in caloric content, consisted of habitual food items, and had a macronutrient composition that can be easily achieved in daily life. At the end of each intervention, IHL content/composition and liver glycogen were measured by magnetic resonance spectroscopy. Additionally, fasted and postprandial hepatic de novo lipogenesis and glycemic and metabolic responses were investigated.

RESULTS

IHL was significantly lower (-28%) after the two-week low-GI/SFA diet (2.4 ± 0.5% 95% CI [1.4, 3.4]) than after the two-week high-GI/SFA diet (3.3 ± 0.6% 95% CI [1.9, 4.7], p < 0.05). Although hepatic glycogen content, hepatic de novo lipogenesis, hepatic lipid composition, and substrate oxidation during the night were similar between the two diets, the glycemic response to the low-GI/SFA diet was reduced (p < 0.05).

CONCLUSIONS

Changes in macronutrient quality can already have drastic effects on liver fat content and postprandial glycemia after two weeks and even when energy content and the percentage of total fat and carbohydrate remains unchanged.

The nonalcoholic steatohepatitis extended hepatocyte ballooning score: histologic classification and clinical significance

BACKGROUND AND AIMS

The NAFLD activity score was developed to measure histologic changes in NAFLD during therapeutic trials. Hepatocyte ballooning (HB) is the most specific feature in steatohepatitis diagnosis, yet the impact of variations in HB has not been incorporated.

APPROACH AND RESULTS

Liver biopsies from patients enrolled in the NASH Clinical Research Network with an initial diagnosis of NASH or NAFL (n=1688) were evaluated to distinguish classic hepatocyte ballooning (cHB) from smaller, nonclassic hepatocyte ballooning (nHB), and also to designate severe ballooning and assign an extended hepatocyte ballooning (eB) score [0 points, no ballooning (NB); 1 point, few or many nHB; 2 points, few cHB; 3 points, many cHB; 4 points, severe cHB] to the biopsy assessment. The eB score was reproducible among NASH CRN liver pathologists (weighted kappa 0.76) and was significantly associated with older age (mean 52.1 y, cHB; 48.5 y, nHB, p<0.001), gender (72.3% female, cHB; 54.5% female, nHB, p<0.001), diabetes (49.8% diabetes, cHB; 28.2% diabetes, nHB, p<0.001), metabolic syndrome (68.5% metabolic syndrome, nHB; 50.2% metabolic syndrome, NB, p<0.001), and body mass index [33.2, 34.2, 35 mean body mass index (kg/m2); NB, nHB, and cHB, respectively, p<0.05]. Finally, fibrosis stage, as a marker of disease severity, was significantly correlated with the eB score (p<0.001).

CONCLUSIONS

The eB score allows for a reproducible and more precise delineation of the range of ballooned hepatocyte morphology and corresponds with both clinical features of NASH and fibrosis stage.

Extracellular Vesicles and Fatty Liver

Fatty liver is a complex pathological process caused by multiple etiologies. In recent years, the incidence of fatty liver has been increasing year by year, and it has developed into a common chronic disease that seriously affects people's health around the world. It is an important risk factor for liver cirrhosis, liver cancer, and a variety of extrahepatic chronic diseases. Therefore, the early diagnosis and early therapy of fatty liver are important. Except for invasive liver biopsy, there is still a lack of reliable diagnosis and staging methods. Extracellular vesicles are small double-layer lipid membrane vesicles derived from most types of cells. They play an important role in intercellular communication and participate in the occurrence and development of many diseases. Since extracellular vesicles can carry a variety of biologically active substances after they are released by cells, they have received widespread attention. The occurrence and development of fatty liver are also closely related to extracellular vesicles. In addition, extracellular vesicles are expected to provide a new direction for the diagnosis of fatty liver. This article reviews the relationship between extracellular vesicles and fatty liver, laying a theoretical foundation for the development of new strategies for the diagnosis and therapy of fatty liver.

The effect of a fruit-rich diet on liver biomarkers, insulin resistance, and lipid profile in patients with non-alcoholic fatty liver disease: a randomized clinical trial

BACKGROUND

Despite confirmed dietary approaches to improve the Non-Alcoholic Fatty Liver Disease (NAFLD), the effect of fruits on NAFLD is not clear. The present study aimed to investigate the effect of a fruit rich diet (FRD) on liver steatosis, liver enzymes, Insulin resistance, and lipid profile in patients with NAFLD.

METHODS

Eighty adults with NAFLD participated in this randomized controlled trial. The participants were randomly assigned to the FRD group with consumption of at least 4 servings of fruits daily or the control group with fruits consumption of less than 2 servings/day. The grade of steatosis, serum levels of liver enzymes including alanine aminotransferase (ALT), aspartate aminotransferase (AST), alkaline phosphatase (ALP), and gamma-glutamyl transferase (GGT), total cholesterol (TC), triglyceride (TG), low-density lipoprotein (LDL), high-density lipoprotein (HDL), glucose, and homeostatic model assessment for insulin resistance (HOMA-IR) were measured at the baseline and at the end of the study.

RESULTS

After 6 months of intervention, the FRD group had significantly higher BMI (31.40 ± 2.61 vs. 25.68 ± 2.54, p < .001), WC (113.5 ± 10.7 vs. 100.5 ± 7.5, p < .001), the grade of steatosis, ALT (89.1 ± 92.9 vs. 32.0 ± 19.2, p < .001), AST (74.5 ± 107.8 vs. 24.0 ± 8.5, p < .001), ALP (273.4 ± 128.5 vs. 155.0 ± 43.9, p < .001), GGT (92.7 ± 16.2 vs. 21.2 ± 7.7, p < .001), TC (206.1 ± 40.5 vs. 172.7 ± 42.4, p < .01), LDL (126.9 ± 32.3 vs. 99.8 ± 29.8, p < .001), glucose (115.5 ± 30.0 vs. 97.7 ± 19.0, p < .01), and insulin resistance (7.36 ± 4.37 vs. 2.66 ± 1.27, p < .001), and lower HDL (41.4 ± 8.9 vs. 53.8 ± 15.1, p < .001) compared to the control group. Adjusting for BMI and calorie intake did not change the results.

CONCLUSION

The results of the present study indicated that consumption of fruits more than 4 servings/day exacerbates steatosis, dyslipidemia, and glycemic control in NAFLD patients. Further studies are needed to identify the underlying mechanisms of the effects of fruits on NAFLD.

CLINICAL TRIAL REGISTRATION

This trial was registered at Iranian randomized clinical trial website with IRCT registration no. IRCT20201010048982N1on October 15, 2020.

Frequency of non-alcoholic fatty liver disease in patients with type-2 diabetes mellitus and its associated risk factors

Objective:

Non-Alcoholic Fatty Liver Disease (NAFLD) is emerging as a major public health problem globally especially in patients with Type-2 Diabetes mellitus (T2DM). This study aimed to assess the frequency of NAFLD in patients with T2DM and to study its associated risk factors.

Methods:

This descriptive study was conducted from April 2020 to October 2020 at the Hayatabad Medical Complex, Peshawar. Adult patients with T2DM were included in the study and underwent abdominal ultrasound for the identification of NAFLD. All the relevant clinical and biochemical characteristics were measured.

Results:

Out of 384 participants, 236 patients (61.5%) had NAFLD on ultrasound. Patients with NAFLD had higher mean BMI, higher HbA1c, increased waist circumference, raised ALT, higher triglyceride, and low HDL. Logistic regression analysis revealed a statistically significant association with central obesity (OR = 5.448, 95% CI = 1.416-20.959, p = 0.014), higher BMI (OR = 4.435, 95% CI = 2.127-9.246, p < 0.0001), higher HbA1c [> 11%] (OR = 3.602, 95% CI = 1.438-9.019, p = 0.006), and elevated ALT (OR = 3.211, 95% CI = 1.509-6.835, p = 0.002). The highest odds for NAFLD were found for hypertriglyceridemia (OR = 11.624, 95% CI = 5.405-24.998, p < 0.0001) and low HDL (OR = 11.543, 95% CI = 2.590-51.439, p = 0.001), respectively.

Conclusions:

High frequency of NAFLD along with its associated clinical and laboratory risk factors were revealed. This underpins the significance of screening T2DM patients for NAFLD and assessment for and modification of its associated risk factors in routine clinical practice.

Subclinical atherosclerosis and arterial stiffness in nonalcoholic fatty liver disease: A case-control study in Algerian population

BACKGROUND & AIMS

Nonalcoholic fatty liver disease (NAFLD) was described for the first time in 1980, and became within a few years one of the most frequent causes of chronic liver disease. However, during the last decade, many studies suggested a strong relationship between NAFLD and cardiovascular diseases including carotid atherosclerosis evoking the hypothesis that NAFLD is a factor or a marker of cardiovascular risk. In Algeria, data on this subject are rare or inexistent. The objective of our work was to study the relationship between NAFLD and atherosclerosis in an Algerian population without diabetes.

PATIENTS AND METHODS

It is a case-control study with a strict matching by age and sex. Non-diabetic participants between 30 and 70 years of age were consecutively included in the department of internal medicine of the public hospital of El Biar. The diagnosis of NAFLD was made by ultrasound and hepatic elasticity was assessed by FibroScan®. We collected the data of the carotid ultrasound, the carotid-femoral pulse wave velocity (cfPWV), ankle-brachial pressure index and arterial pressure (consultation and ambulatory monitoring). Non parametric statistical methods (chi 2 McNemar for the percentages, t Friedman test for medium) were used and the association between variables was estimated by odds ratio (OR). These analyses were performed using SPSS 21.0 software (IBM).

RESULTS

213 patients with NAFLD, with a mean age of 48.5 years±10.14 (100 men/113 women) were matched to 213 controls. The presence of carotid atherosclerotic plaque (CAP) was higher in NAFLD than in controls (31.92% (n=68) vs. 7.05% (n=15), P<0.001). In multivariate analysis, the CAP (OR 8.6, 95% CI [3.6-20.5], P<0.001), high Intima media thickness (OR 2.8, 95% CI [1.4-5.4], P=0.002), CRP≥6mg/l (OR 14.7, 95% CI [5.9-36.9], P=0.001), abdominal obesity (OR 3.8, 95% CI [1.4-9.7], P=0.05), high cfPWV (OR 4.4, 95% CI [2.4-8.1], P<0.001), elevated alanine aminotransferase(OR 4.0, 95% CI [1.6-9.8], P=0.002), overall obesity (OR 2.0, 95% CI [1.0-3.8], P=0.03), dyslipidemia (OR 2.0, 95% CI [1.0-3.8], P=0.02), and elevated GGT (OR 2.8, 95% [1.1-7.1] were independently associated to NAFLD.

CONCLUSION

Our study suggests that NAFLD is significantly associated with carotid atherosclerosis and arterial stiffness. These results may have implications in the management of patients with NAFLD in terms of cardiovascular prevention.

From the origin of NASH to the future of metabolic fatty liver disease

Non-alcoholic fatty liver disease (NAFLD) has become the most common cause of chronic liver disease worldwide. Understanding the pathological and molecular hallmarks from its first description to definitions of disease entities, classifications and molecular phenotypes is crucial for both appropriate clinical management and research in this complex disease. We provide an overview through almost two hundred years of clinical research from the beginnings as a nebulous disease entity of unknown origin in the 19th century to the most frequent and vigorously investigated liver disease today. The clinical discrimination between alcohol-related liver disease and NAFLD was uncommon until the 1950s and likely contributed to the late acceptance of NAFLD as a metabolic disease entity for long time. Although the term 'fatty liver hepatitis' first appeared in 1962, it was in 1980 that the term 'non-alcoholic steatohepatitis' (NASH) was coined and the histopathological hallmarks that are still valid today were defined. The 2005 NASH Clinical Research Network scoring was the first globally accepted grading and staging system for the full spectrum of NAFLD and is still used to semiquantify main histological features. In 2021, liver biopsy remains the only diagnostic procedure that can reliably assess the presence of NASH and early fibrosis but increasing efforts are made towards non-invasive testing and molecular classification of NAFLD subtypes.

Combined methods of optical spectroscopy and artificial intelligence in the assessment of experimentally induced non-alcoholic fatty liver

BACKGROUND AND OBJECTIVE

Due to the existing prevalence of nonalcoholic fatty liver disease (NAFLD) and its relation to the epidemic of obesity in the general population, it is imperative to develop detection and evaluation methods of the early stages of the disease with improved efficacy over the current diagnostic approaches. We aimed to obtain an improved diagnosis, combining methods of optical spectroscopy -diffuse reflectance and fluorescence- with statistical data analysis applied to detect early stages of NAFLD.

METHODS

Statistical analysis scheme based on quadratic discriminant analysis followed by canonical discriminant analysis were applied to the diffuse reflectance data combined with endogenous fluorescence spectral data excited at one of these wavelengths: 330, 365, 385, 405 or 415 nm. The statistical scheme was also applied to the combinations of fluorescence spectrum (405 nm) with each one of the other fluorescence spectra. Details of the developed software, including the application of machine learning algorithms to the combination of spectral data followed by classification statistical schemes, are discussed.

RESULTS

Steatosis progression was differentiated with little classification error (≤1.3%) by using diffuse reflectance and endogenous fluorescence at different wavelengths. Similar results were obtained using fluorescence at 405 nm and one of the other fluorescence spectra (classification error ≤1.0%). Adding the corresponding areas under the curves to the above combinations of spectra diminished errors to 0.6% and 0.3% or less, respectively. The best results for the compounded reflectance-plus-fluorescence spectra were obtained with fluorescence spectra excited at 415 nm with a total classification error of 0.2%; for the combination of the 405nm-excited fluorescence spectrum with another fluorescence spectrum, the best results were achieved for 385 nm, for which total relative classification error amounted 0.4%. The consideration of the area under the spectral curves further improved both classifiers, reducing the error to 0.0% in both cases.

CONCLUSION

Spectrometric techniques combined with statistical processing are a promising tool to improve steatosis classification through a label free approach. However, statistical schemes here applied, might result complex for the everyday medical practice, the designed software including machine learning algorithms is able to render automatic classification of samples according to their steatosis grade with low error.

[Liver-specific diagnostic for non-alcoholic fatty liver disease (NAFLD) - time to replace liver biopsy?]

Non-alcoholic fatty liver disease (NAFLD) is one of the most common liver diseases. In Germany, the prevalence in the adult population is estimated at 24 % and the incidence is increasing. Prognostically, the distinction between early and advanced stages of the disease is important. In particular, the extent of scarring considered as liver fibrosis is of prognostic significance. Patients with advanced fibrosis and cirrhosis show increased mortality. Liver fibrosis develops as a consequence of a persistent inflammation of the liver tissue over time. Since inflammation and fibrosis are histological features, liver biopsy is considered the reference method in the diagnosis of NAFLD. More recently, non-invasive diagnostic methods for staging (of fibrosis) and grading (activity) of the disease are being developed and validated. The current review summarizes new developments in non-invasive liver diagnostics.

Plasma BCAA Changes in Patients With NAFLD Are Sex Dependent

CONTEXT

Plasma branched chain amino acid (BCAA) concentrations correlate positively with body mass index (BMI), measures of insulin resistance (IR), and severity of nonalcoholic fatty liver disease (NAFLD). Moreover, plasma BCAA concentrations also differ between the sexes, which display different susceptibilities to cardio-metabolic diseases.

OBJECTIVE

Assess whether plasma BCAA concentrations associate with NAFLD severity independently of BMI, IR, and sex.

PATIENTS

Patients visiting the obesity clinic of the Antwerp University Hospital were consecutively recruited from 2006 to 2014.

DESIGN AND SETTING

A cross-sectional study cohort of 112 obese patients (59 women and 53 men) was divided into 4 groups according to NAFLD severity. Groups were matched for sex, age, BMI, homeostatic model assessment of IR, and hemoglobin A1c.

MAIN OUTCOME MEASURES

Fasting plasma BCAA concentrations were measured by tandem mass spectrometry using the aTRAQ™ method.

RESULTS

In the study cohort, a modest positive correlation was observed between plasma BCAA concentrations and NAFLD severity, as well as a strong effect of sex on plasma BCAA levels. Subgroup analysis by sex revealed that while plasma BCAA concentrations increased with severity of NAFLD in women, they tended to decrease in men. Additionally, only women displayed significantly increased plasma BCAAs with increasing fibrosis.

CONCLUSION

Plasma BCAA concentrations display sex-dimorphic changes with increasing severity of NAFLD, independently of BMI, IR, and age. Additionally, plasma BCAA are associated with significant fibrosis in women, but not in men. These results highlight the importance of a careful consideration of sex as a major confounding factor in cross-sectional studies of NAFLD.

Evaluation of the effectiveness of ultrasound shear elastography and liver steatometry

Detection of liver fibrosis and steatosis at early stages is a difficult task for clinical practice, due to the lack of early signs in routine radiation diagnostics. Aim. To evaluate the efficacy of ultrasound shear elastography and ultrasound steatometry of the liver with the use of domestic ultrasonic diagnostic system Angiodin-Sono/N-Ultra. Materials and methods. 264 people held ultrasound elastography and ultrasound steatometry. 38 patients underwent percutaneous puncture liver biopsy and subsequent pathophysiological examination. Results. High correlation of fibrosis obtained at the Angiodin-Sono/N-Ultra and the leading ultrasonic systems with shear elastography was revealed. Cross-sectional comparative analysis of elasticity with the results of liver steatometry was conducted. Conclusions. Results obtained in all groups correlate with the data obtained in studies on Fibroscan. When working with system Angiodin we got a simultaneous comparative analysis of elasticity with the results of liver steatosis. Results appear to be much more stable and compact than those obtained in studies on the Fibroscan. A new diagnostic criterion was revealed the phenomenon of independence of fibrosis and steatosis indices.

Precise fibrosis staging with shear wave elastography in chronic hepatitis B depends on liver inflammation and steatosis

BACKGROUND

Two-dimensional shear wave elastography (2D-SWE) is the latest generation of ultrasound elastography for the non-invasive assessment of liver fibrosis in chronic hepatitis B (CHB). We aimed to identify confounders of 2D-SWE in fibrosis grading.

METHODS

A prospective cohort of 440 CHB patients (286 with liver biopsy and 154 with clinical decompensated cirrhosis) was consecutively enrolled from a clinical trial (registration number: ChiCTR-DCD-15006000) aimed at optimizing 2D-SWE assessments from 2015 to 2018. All patients underwent 2D-SWE examination, anthropometric measurement, and serum biomarker assessment. Steatosis was graded by the magnetic resonance imaging-derived proton density fat fraction (MRI-PDFF).

RESULTS

Overall, the prevalence of incorrect fibrosis staging by 2D-SWE was 26.1% (n = 115), with 43.5% of patients under-staged and 56.5% over-staged. In multivariate analysis, the steatosis degree was an independent predictor of 2D-SWE discordance in the overall cohort, with moderate-severe steatosis for underestimation (odds ratio, [OR] = 4.3, 95% confidence interval [CI] 1.2-18.2, p = 0.049) and overestimation (OR = 8.2, 95% CI 2.9-23.5, p < 0.001), and mild steatosis for overestimation (OR = 3.7, 95% CI 1.5-9.0, p = 0.004). In patients with liver biopsy, both histological inflammation activity over 2 (OR = 5.0, 95% CI 2.0-25.3, p = 0.048) and moderate-severe steatosis (OR = 5.2, 95% CI 2.1-13.4, p < 0.001) were independent factors associated with discordance. For the risk of 2D-SWE mis-staging, a nomogram that integrated these confounders was established and the area under the receiver operating characteristic curve of the model was 0.861.

CONCLUSIONS

Steatosis and inflammation activities were confounders for 2D-SWE. The combination of these confounders could predict mis-staging risks of CHB-related fibrosis with 2D-SWE and may be valuable to decision-making on liver biopsy for fibrosis staging.

Effect of orlistat on liver fat content in patients with nonalcoholic fatty liver disease with obesity: assessment using magnetic resonance imaging-derived proton density fat fraction

BACKGROUND

The liver effect of orlistat as a weight control treatment in patients with nonalcoholic fatty liver disease (NAFLD) with obesity remains undetermined. This study quantified liver fat improvement by orlistat in a Chinese cohort with NAFLD accompanied by obesity, diagnosed by a lower body mass index threshold than that for White patients.

MATERIALS AND METHODS

We conducted a parallel-group, open-label, 24-week, randomized clinical trial registered at the Chinese Clinical Trial Registry (ChiCTR-IPR-17012258). Obese participants with NAFLD were randomized 1:1.5 to the intervention group with orlistat or conventional care. Liver fat quantification was assessed by magnetic resonance imaging-based proton density fat fraction with Dixon sequence.

RESULTS

Overall, 170 (n = 68, orlistat 120 mg three times/day and n = 102, conventional therapy) and 130 patients with NAFLD (n = 56, orlistat and n = 74, conventional therapy) were included for intention-to-treat (ITT) and per-protocol (PP) analysis, respectively. Orlistat reduced liver fat content to a greater degree than conventional care [-5.45% versus -1.96%, p < 0.001 (ITT analysis) and -6.66% versus -2.68%, p < 0.001 (PP analysis)]. The 6-month rate of decrease in steatosis grades was higher in the orlistat group [45.6% versus 22.5% (ITT analysis), 57.4% versus 30.3% (PP analysis), both p < 0.001]. Multivariate logistic regression analysis identified orlistat treatment [odds ratio (OR) = 2.4; 95% confidence interval (CI) 1.1-5.6, p = 0.036] as an independent predictor of steatosis improvement. Among patients with orlistat therapy, weight loss (OR = 1.2, 95% CI 1.1-1.4, p = 0.040) and severe steatosis (OR = 6.7, 95% CI: 1.1-40.3, p = 0.03) remained predictive of steatosis improvement.

CONCLUSIONS

Orlistat can effectively promote steatosis improvement and may serve as a treatment option for controlling NAFLD.

CHINESE CLINICAL TRIAL REGISTRY IDENTIFIER

ChiCTR-IPR-17012258.

Towards a standard diet-induced and biopsy-confirmed mouse model of non-alcoholic steatohepatitis: Impact of dietary fat source

BACKGROUND

The trans-fat containing AMLN (amylin liver non-alcoholic steatohepatitis, NASH) diet has been extensively validated in C57BL/6J mice with or without the Lep^ob/Lep^ob (ob/ob) mutation in the leptin gene for reliably inducing metabolic and liver histopathological changes recapitulating hallmarks of NASH. Due to a recent ban on trans-fats as food additive, there is a marked need for developing a new diet capable of promoting a compatible level of disease in ob/ob and C57BL/6J mice.

AIM

To develop a biopsy-confirmed mouse model of NASH based on an obesogenic diet with trans-fat substituted by saturated fat.

METHODS

Male ob/ob mice were fed AMLN diet or a modified AMLN diet with trans-fat (Primex shortening) substituted by equivalent amounts of palm oil [Gubra amylin NASH, (GAN) diet] for 8, 12 and 16 wk. C57BL/6J mice were fed the same diets for 28 wk. AMLN and GAN diets had similar caloric content (40% fat kcal), fructose (22%) and cholesterol (2%) level.

RESULTS

The GAN diet was more obesogenic compared to the AMLN diet and impaired glucose tolerance. Biopsy-confirmed steatosis, lobular inflammation, hepatocyte ballooning, fibrotic liver lesions and hepatic transcriptome changes were similar in ob/ob mice fed the GAN or AMLN diet. C57BL/6J mice developed a mild to moderate fibrotic NASH phenotype when fed the same diets.

CONCLUSION

Substitution of Primex with palm oil promotes a similar phenotype of biopsy-confirmed NASH in ob/ob and C57BL/6J mice, making GAN diet-induced obese mouse models suitable for characterizing novel NASH treatments.

Study of Methionine Choline Deficient Diet-Induced Steatosis in Mice Using Endogenous Fluorescence Spectroscopy

Non-alcoholic fatty liver disease is a highly prevalent condition worldwide that increases the risk to develop liver fibrosis, cirrhosis, and hepatocellular carcinoma. Thus, it is imperative to develop novel diagnostic tools that together with liver biopsy help to differentiate mild and advanced degrees of steatosis. Ex-vivo liver samples were collected from mice fed a methionine-choline deficient diet for two or eight weeks, and from a control group. The degree of hepatic steatosis was histologically evaluated, and fat content was assessed by Oil-Red O staining. On the other hand, fluorescence spectroscopy was used for the assessment of the steatosis progression. Fluorescence spectra were recorded at excitation wavelengths of 330, 365, 385, 405, and 415 nm by establishing surface contact of the fiber optic probe with the liver specimens. A multi-variate statistical approach based on principal component analysis followed by quadratic discriminant analysis was applied to spectral data to obtain classifiers able to distinguish mild and moderate stages of steatosis at the different excitation wavelengths. Receiver Operating Characteristic (ROC) curves were computed to compare classifier’s performances for each one of the five excitation wavelengths and steatosis stages. Optimal sensitivity and specificity were calculated from the corresponding ROC curves using the Youden index. Intensity in the endogenous fluorescence spectra at the given wavelengths progressively increased according to the time of exposure to diet. The area under the curve of the spectra was able to discriminate control liver samples from those with steatosis and differentiate among the time of exposure to the diet for most of the used excitation wavelengths. High specificities and sensitivities were obtained for every case; however, fluorescence spectra obtained by exciting with 405 nm yielded the best results distinguishing between the mentioned classes with a total classification error of 1.5% and optimal sensitivities and specificities better than 98.6% and 99.3%, respectively.

Quantification of hepatic steatosis in histologic images by deep learning method

OBJECTIVE

To develop and test a novel method for automatic quantification of hepatic steatosis in histologic images based on the deep learning scheme designed to predict the fat ratio directly, which aims to improve accuracy in diagnosis of non-alcoholic fatty liver disease (NAFLD) with objective assessment of the severity of hepatic steatosis instead of subjective visual estimation.

MATERIALS AND METHODS

Thirty-six 8-week old New Zealand white rabbits of both sexes were fed with high-cholesterol, high-fat diet and sacrificed under deep anesthesia at various time points to obtain the pathological specimen. All rabbits were performed by multislice computed tomography for surveillance to measure density changes of liver parenchyma. A deep learning scheme using a convolutional neural network was developed to directly predict the liver fat ratio based on the pathological images. The average error value, standard deviation, and accuracy (error <5%) were evaluated and compared between the deep learning scheme and manual segmentation results. The Pearson's correlation coefficient was also calculated in this study.

RESULTS

The deep learning scheme performs successfully on rabbit liver histologic data, showing a high degree of accuracy and stability. The average error value, standard deviation, and accuracy (error <5%) were 3.21%, 4.02%, and 79.10% for the cropped images, 2.22%, 1.92%, and 88.34% for the original images, respectively. The strong positive correlation was also observed for cropped images (R = 0.9227) and original images (R = 0.9255) in comparison to labeled fat ratio.

CONCLUSIONS

This new deep learning scheme may aid in the quantification of steatosis in the liver and facilitate its treatment by providing an earlier clinical diagnosis.

NAFLD evaluation: Which is more appropriate, multislice computed tomography or ultrasound real-time shear wave elastography?

OBJECTIVE

This study aims to assess the value of ultrasound real-time shear wave elastography (US-SWE) for evaluation of nonalcoholic fatty liver disease (NAFLD) in a rabbit model compared with multislice computed tomography (MSCT).

MATERIAL AND METHODS

Twenty-six rabbits were fed with high-fat, high-cholesterol diet and six rabbits were fed with a standard diet. All rabbits were performed with MSCT and US-SWE at various time points to measure changes in liver parenchyma. The diagnostic efficiency of US-SWE was analyzed using receiver operating characteristics (ROC) curves compared with MSCT based on the liver pathology.

RESULTS

The statistically significant differences in the areas under the ROC curves between using MSCT and US-SWE modalities were detected to discriminate between normal vs. NAFLD or higher severity pathology. Similarly, for normal or NAFLD vs. borderline or NASH livers, statistically significant differences between using US-SWE and MSCT modalities were also detected for nonalcoholic steatohepatitis (NASH) vs. lower severity pathology.

CONCLUSIONS

MSCT, but not US-SWE, had a better ability to differentiate normal or NAFLD livers from higher severity NAFLD livers. However, the diagnostic efficiency of US-SWE was superior to that of MSCT for differentiating NASH from normal or lower severity NAFLD.

Diffuse reflectance spectroscopy accurately discriminates early and advanced grades of fatty liver in mice

Nonalcoholic fatty liver disease (NAFLD) ranges from steatosis to nonalcoholic steatohepatitis and cirrhosis. Liver biopsy, considered the gold standard to diagnose NAFLD, shows significantly high rates of interobserver variability. Thus there is a need to develop tools that accurately categorize mild and advanced grades of steatosis in order to identify patients at higher risk of developing chronic liver disease. Diffuse reflectance spectroscopy (DRS) has proved to be useful in grading liver fibrosis and cirrhosis, without having been implemented for steatosis. We aim to categorize early and advanced stages of liver steatosis in a methionine-choline deficient (MCD) mouse model. C57bl/6 mice are fed either methionine-choline control or MCD diet during 2 or 8 weeks to induce mild and advanced steatosis. Liver samples are obtained and steatosis is evaluated by oil red O staining. Diffuse reflectance spectra are directly measured on ex vivo liver specimens, in a wavelength range of 400 to 800 nm. DRS is able to discriminate between early or advanced steatosis and healthy hepatic tissue with negligible error while showing high average sensitivity and specificity (0.94 and 0.95, respectively). Our results suggest that liver steatosis can be accurately evaluated by DRS, highlighting the importance of applied spectroscopic methods in assessing NAFLD.

Steatohepatitis Is Not Associated with an Increased Risk for Fibrosis Progression in Nonalcoholic Fatty Liver Disease

Introduction

Nonalcoholic fatty liver disease (NAFLD) is the most common liver disease globally. The majority of NAFLD patients have fatty liver without inflammation (nonalcoholic fatty liver, NAFL), whereas a minority develop steatohepatitis (nonalcoholic steatohepatitis, NASH). Only NASH and not NAFL has been considered to increase the risk for fibrosis progression. The present study investigates risk factors for fibrosis progression in patients with NAFLD, and if fibrosis progression associates with subsequent mortality.

Material and Methods

All patients with at least two liver biopsies more than a year apart at our hospital between 1971 and 2016 were identified. Data on plausible risk factors for fibrosis progression were collected. Biopsies were scored for the presence of NASH and fibrosis stage. Regression models were used to investigate the association between baseline NASH and fibrosis progression and fibrosis progression with future mortality.

Results

60 patients had undergone serial biopsies (median interval between biopsies 8.4 years, range 1–33 years), with 26 patients (43%) having fibrosis progression. We found no significant risk factors for progression of fibrosis except time between biopsies. Among patients with fibrosis progression, 54% had NAFL and 46% had NASH at baseline. There was a trend for an association between fibrosis progression per se and increased mortality (hazard ratio 2.83, 95% CI 1.0–8.1, p = 0.05).

Conclusions

In this study on NAFLD, baseline steatohepatitis was not associated with an increased risk for fibrosis progression. NAFLD patients without steatohepatitis may develop progressive fibrosis, and those with progressive fibrosis appear to have a higher mortality risk irrespective of baseline NASH status.

Nonalcoholic fatty liver disease in patients with type 2 diabetes mellitus and its association with cardiovascular disease

INTRODUCTION

Non-alcoholic fatty liver disease (NAFLD) encompasses a wide spectrum of liver disease that ranges from hepatic steatosis to non-alcoholic steatohepatitis. Obesity and diabetes mellitus are the prime risk factors for NAFLD. The aim of this study was to find out the prevalence of NAFLD among patients with type 2 diabetes mellitus and to detect the association of NAFLD with cardiovascular disease in them.

STUDY DESIGN

Prospective observational study.

MATERIAL AND METHODS

The study was conducted on 300 patients with type 2 diabetes mellitus attending the outpatient department of a tertiary care teaching hospital. All patients underwent hepatic ultrasonography to look for hepatic steatosis. Among the 300 patients, 124 were divided into NAFLD and non-NAFLD groups based on the ultrasound findings. These patients were subjected to electrocardiogram, 2D echocardiogram, carotid intima media thickness (CIMT) measurement and ankle brachial pressure index measurement along with measurement of markers of oxidative stress.

RESULTS

Hepatic steatosis was present in 61% of diabetic patients in this study. Cardiovascular disease was not found to be significantly associated in diabetic patients with NAFLD. However, cardiovascular risk factors like CIMT, high sensitivity c-reactive protein (hs-CRP) and malondialdehyde (MDA) were elevated in these patients. hs-CRP and MDA levels were found to be significantly associated with the severity of NAFLD.

CONCLUSION

There is a high prevalence of NAFLD in type 2 diabetic patients. No correlation was detected between the presence of NAFLD and cardiovascular disease in them; although there was an association between cardiovascular risk factors and NAFLD.

Microbiota, Liver Diseases, and Alcohol

Being overweight and obesity are the leading causes of liver disease in Western countries. Liver damage induced by being overweight can range from steatosis, harmless in its simple form, to steatohepatitis, fibrosis, cirrhosis, and hepatocellular carcinoma. Alcohol consumption is an additional major cause of liver disease. Not all individuals who are overweight or excessively consume alcohol develop nonalcoholic fatty liver diseases (NAFLD) or alcoholic liver disease (ALD) and advanced liver disease. The role of the intestinal microbiota (IM) in the susceptibility to liver disease in this context has been the subject of recent studies. ALD and NAFLD appear to be influenced by the composition of the IM, and dysbiosis is associated with ALD and NAFLD in rodent models and human patient cohorts. Several microbial metabolites, such as short-chain fatty acids and bile acids, are specifically associated with dysbiosis. Recent studies have highlighted the causal role of the IM in the development of liver diseases, and the use of probiotics or prebiotics improves some parameters associated with liver disease. Several studies have made progress in deciphering the mechanisms associated with the modulation of the IM. These data have demonstrated the intimate relationship between the IM and metabolic liver disease, suggesting that targeting the gut microbiota could be a new preventive or therapeutic strategy for these diseases.

Non-alcoholic fatty liver disease - histological scoring systems: a large cohort single-center, evaluation study

Non-alcoholic fatty liver disease (NAFLD) is an increasingly common cause of chronic liver disease. Till date, liver biopsy remains the gold standard for identification and quantification of the wide histological spectra of NAFLD. Histological scorings are very useful and widely applied for the diagnosis and management in clinical trials and follow-up studies of non-alcoholic steatohepatitis (NASH). However, in view of scarce published literature, there is a need to evaluate them in large cohort of NAFLD. This study was aimed to evaluate the two histological scoring systems (NAS-CRN, SAF) in the diagnosis of NAFLD and to assess the role of histological characteristics as injury markers in NAFLD. Retrospective histological study of liver biopsies of 1000 patients diagnosed as NAFLD, between 2010 and 2016, was conducted. Histopathologic evaluation and semiquantiative scoring based on NAS-CRN and SAF algorithm and their correlation with serum aminotransferase and fibrosis were performed. Liver biopsies were classified according to the NAS-CRN scoring, as NAS <3 (not NASH) in 72 (7.2%), NAS 3-4 (borderline NASH) in 310 (31%), and NAS ≥5 (definite NASH) in 618 (61.8%), and SAF classified 117 (11.7%) not NASH and 883 (88.3%) definite NASH. There was excellent concordance for definite NASH and not NASH; however, 88.06% of borderline NASH was classified as NASH by SAF. 76.39% by NAS and 78.63% by SAF algorithm who were diagnosed as not NASH showed the presence of fibrosis; however, higher stages of fibrosis were significantly more prevalent in definite NASH, excluding burnt-out cirrhosis. Serum ALT was significantly associated with increasing stages of fibrosis (p < 0.001) and the three categories (not NASH, borderline NASH, and definite NASH) when classified as with/without fibrosis (p < 0.001). Steatosis of higher grades, more ballooned cells, and more foci of Lobular Inflammation were found in significantly higher proportion of patients with NASH (p < 0.001), with higher fibrosis stages (p < 0.001) and higher serum ALT levels (p < 0.001). NAFLD classifications based on histological scoring NAS-CRN and SAF algorithm are concordant for the category of definite NASH and not NASH, while borderline NASH shows discrepant interpretation. There was highly significant correlation between the NAS and SAF categories with high grades of histological characteristics, with serum ALT and with higher stages of fibrosis. Exclusion of fibrosis is a limitation with both scores.

Correlation between severity of ultrasonographic nonalcoholic fatty liver disease and cardiometabolic risk among Filipino wellness patients

Introduction: Nonalcoholic fatty liver disease (NAFLD) is a prevalent condition which is known to be related to factors that predispose to the development of coronary artery disease as well as development of metabolic syndrome. The study aimed to determine the association between ultrasound-based grading of hepatic steatosis with metabolic profile and estimated cardiovascular risk using the Framingham Risk Score (FRS).

Methods: This was a cross-sectional study on 100 Filipino patients without established cardiovascular disease who underwent a general wellness health evaluation. Cases with NAFLD diagnosed on the basis of ultrasound grading were analyzed. Comparison of demographics and metabolic parameters between grades of hepatic steatosis was performed using Kruskal Wallis test. FRS was used to assess cardiovascular risk with Spearman rank test for correlation with the degree of NAFLD.

Results: Mean age was 47 ± 9.6 years, with 70% males. Mean body mass index (BMI) was 28.7 ± 5.1. Most patients had grade I NAFLD (53%), 34% were grade II, and 13% were grade III. BMI (P =0.034), liver enzymes (alanine aminotransferase [ALT], P = 0.001; aspartate aminotransferase [AST], P = 0.00), triglycerides (P = 0.047), and fasting blood sugar [FBS] (P = 0.049) were associated with fatty liver grade. No association was noted with total cholesterol (P = 0.569), high density lipoprotein (HDL) (P = 0.220), and low density lipoprotein (LDL) (P = 0.792). Using the FRS 43% were stratified as low (<10% risk), 45% as intermediate (10%-20% risk) and 12% as high risk (>20% risk). Severity of fatty liver was directly correlated with the FRS (Spearman rank 0.741, P = 0.009).

Conclusion: Ultrasound-based grading of the severity of NAFLD is associated with abnormalities in the metabolic profile of patients. The FRS is correlated with increasing severity of NAFLD based on ultrasound. These findings suggest that the presence of NAFLD may be a marker for the presence of increased cardiovascular risk and may help identify patients who may benefit from more aggressive therapies to prevent development of adverse cardiovascular events.

Tomato Juice Consumption Modifies the Urinary Peptide Profile in Sprague-Dawley Rats with Induced Hepatic Steatosis

Non-alcoholic fatty liver disease (NAFLD) is the most common liver disorder in Western countries, with a high prevalence, and has been shown to increase the risk of type 2 diabetes, cardiovascular disease (CVD), etc. Tomato products contain several natural antioxidants, including lycopene—which has displayed a preventive effect on the development of steatosis and CVD. Accordingly, the aim of the present work was to evaluate the effect of tomato juice consumption on the urinary peptide profile in rats with NAFLD induced by an atherogenic diet and to identify potential peptide biomarkers for diagnosis. Urine samples, collected weekly for four weeks, were analyzed by capillary electrophoresis (CE) coupled to a mass spectrometer (MS). A partial least squares-discriminant analysis (PLS-DA) was carried out to explore the association between differential peptides and treatments. Among the 888 peptides initially identified, a total of 55 were obtained as potential biomarkers. Rats with steatosis after tomato juice intake showed a profile intermediate between that of healthy rats and that of rats with induced hepatic steatosis. Accordingly, tomato products could be considered as a dietary strategy for the impairment of NAFLD, although further research should be carried out to develop a specific biomarkers panel for NAFLD.

Paediatric non-alcoholic fatty liver disease: an overview

Non-alcoholic fatty liver disease (NAFLD) is a progressive disease that encompasses a spectrum of liver diseases, ranging from simple steatosis to non-alcoholic steatohepatitis (NASH). Data related to survival in children are scarce, but these data firmly associate NAFLD with higher risks of hepatic and non-hepatic morbidities and mortalities compared with the general population. More recently, the association between NAFLD and cardiovascular disease among children has increasingly been recognized. Given that obesity is a major risk factor for the disease, paediatric NAFLD is becoming a global issue, paralleling the dramatic rise in obesity worldwide. NASH, which is more common in obese children, has the potential to advance to liver fibrosis and failure. It is unclear why certain patients undergo such transformation but this susceptibility is likely related to an interaction between a genetically susceptible host and the surrounding environment. Currently, treatment is largely conservative and includes lifestyle modification, attainable through healthy weight reduction via diet and exercise. In this review, current knowledge about NAFLD in children is summarized. This review aims to increase the awareness of the medical community about a hidden public health issue and to identify current gaps in the literature while providing directions for future research.

Proteomic and genomic studies of non-alcoholic fatty liver disease - clues in the pathogenesis

Non-alcoholic fatty liver disease (NAFLD) is a widely prevalent hepatic disorder that covers wide spectrum of liver pathology. NAFLD is strongly associated with liver inflammation, metabolic hyperlipidaemia and insulin resistance. Frequently, NAFLD has been considered as the hepatic manifestation of metabolic syndrome. The pathophysiology of NAFLD has not been fully elucidated. Some patients can remain in the stage of simple steatosis, which generally is a benign condition; whereas others can develop liver inflammation and progress into non-alcoholic steatohepatitis, fibrosis, cirrhosis and hepatocellular carcinoma. The mechanism behind the progression is still not fully understood. Much ongoing proteomic researches have focused on discovering the unbiased circulating biochemical markers to allow early detection and treatment of NAFLD. Comprehensive genomic studies have also begun to provide new insights into the gene polymorphism to understand patient-disease variations. Therefore, NAFLD is considered a complex and mutifactorial disease phenotype resulting from environmental exposures acting on a susceptible polygenic background. This paper reviewed the current status of proteomic and genomic studies that have contributed to the understanding of NAFLD pathogenesis. For proteomics section, this review highlighted functional proteins that involved in: (1) transportation; (2) metabolic pathway; (3) acute phase reaction; (4) anti-inflammatory; (5) extracellular matrix; and (6) immune system. In the genomic studies, this review will discuss genes which involved in: (1) lipolysis; (2) adipokines; and (3) cytokines production.