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Cuthbertson DJ, Keating SE, Pugh CJA, Owen PJ, Kemp GJ, Umpleby M, Geyer NG, Chinchilli VM, Stine JG. Exercise improves surrogate measures of liver histological response in metabolic dysfunction-associated steatotic liver disease. Liver Int 2024; 44:2368-2381. [PMID: 38847589 PMCID: PMC11365804 DOI: 10.1111/liv.15947] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2024] [Revised: 04/06/2024] [Accepted: 04/10/2024] [Indexed: 06/12/2024]
Abstract
BACKGROUND AND AIMS Exercise is recommended for the management of metabolic dysfunction-associated steatotic liver disease (MASLD), yet effects on liver histology remain unknown, especially without significant weight loss. We aimed to examine changes in surrogate measures of liver histological response with exercise training. METHODS We conducted a post hoc pooled analysis of three randomised controlled trials (duration: 12-20 weeks) comparing aerobic exercise interventions with controls. The primary outcome measure was a ≥30% relative reduction in (MRI-measured) liver fat, as a surrogate measure of liver histological response (the threshold necessary for fibrosis improvement). Secondary outcome measures were changes in other biomarkers of liver fibrosis, anthropometry, body composition and aerobic fitness. RESULTS Eighty-eight adults (exercise: 54, control: 34; male: 67%) were included with mean (SD) age 51 (11) years and body mass index 33.3 (5.2) kg/m2. Following the intervention, exercise had ~5-fold (OR [95%CI]: 4.86 [1.72, 13.8], p = .002) greater odds of ≥30% relative reduction in MRI-measured liver fat compared with control. This paralleled the improvements in anthropometry (waist and hip circumference reduction), body composition (body fat, visceral and subcutaneous adipose tissue) and aerobic fitness (V̇O2peak, ventilatory threshold and exercise capacity). Importantly, these effects were independent of clinically significant body weight loss (<3% body weight). CONCLUSION Exercise training led to clinically meaningful improvements in surrogate serum- and imaging-based measures of liver histological change, without clinically meaningful body weight reduction. These data reinforce the weight-neutral benefit of exercise training and suggest that aerobic training may improve liver fibrosis in patients with MASLD.
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Affiliation(s)
- Daniel J Cuthbertson
- Department of Cardiovascular and Metabolic Medicine, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK
- Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
| | - Shelley E Keating
- School of Human Movement and Nutrition Sciences, The University of Queensland, St Lucia, Queensland, Australia
| | - Christopher J A Pugh
- School of Sport and Health Sciences, Cardiff Metropolitan University, Cardiff, UK
- Centre for Health, Activity and Wellbeing Research, Cardiff Metropolitan University, Cardiff, UK
| | - Patrick J Owen
- Institute for Physical Activity and Nutrition (IPAN), School of Exercise and Nutrition Sciences, Deakin University, Geelong, Victoria, Australia
| | - Graham J Kemp
- Department of Musculoskeletal and Ageing Science, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK
| | - Margot Umpleby
- Diabetes and Metabolic Medicine, University of Surrey, Guildford, UK
| | - Nathaniel G Geyer
- Department of Public Health Sciences, Penn State Health Milton S. Hershey Medical Center, Hershey, Pennsylvania, USA
| | - Vernon M Chinchilli
- Department of Public Health Sciences, Penn State Health Milton S. Hershey Medical Center, Hershey, Pennsylvania, USA
| | - Jonathan G Stine
- Department of Public Health Sciences, Penn State Health Milton S. Hershey Medical Center, Hershey, Pennsylvania, USA
- Division of Gastroenterology and Hepatology, Department of Medicine, Penn State Health Milton S. Hershey Medical Center, Hershey, Pennsylvania, USA
- Liver Center, Penn State Health Milton S. Hershey Medical Center, Hershey, Pennsylvania, USA
- Cancer Institute, Penn State Health Milton S. Hershey Medical Center, Hershey, Pennsylvania, USA
- Fatty Liver Program, Penn State Health Milton S. Hershey Medical Center, Hershey, Pennsylvania, USA
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Pericàs JM, Anstee QM, Augustin S, Bataller R, Berzigotti A, Ciudin A, Francque S, Abraldes JG, Hernández-Gea V, Pons M, Reiberger T, Rowe IA, Rydqvist P, Schabel E, Tacke F, Tsochatzis EA, Genescà J. A roadmap for clinical trials in MASH-related compensated cirrhosis. Nat Rev Gastroenterol Hepatol 2024:10.1038/s41575-024-00955-8. [PMID: 39020089 DOI: 10.1038/s41575-024-00955-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/03/2024] [Indexed: 07/19/2024]
Abstract
Although metabolic dysfunction-associated steatohepatitis (MASH) is rapidly becoming a leading cause of cirrhosis worldwide, therapeutic options are limited and the number of clinical trials in MASH-related compensated cirrhosis is low as compared to those conducted in earlier disease stages. Moreover, designing clinical trials in MASH cirrhosis presents a series of challenges regarding the understanding and conceptualization of the natural history, regulatory considerations, inclusion criteria, recruitment, end points and trial duration, among others. The first international workshop on the state of the art and future direction of clinical trials in MASH-related compensated cirrhosis was held in April 2023 at Vall d'Hebron University Hospital in Barcelona (Spain) and was attended by a group of international experts on clinical trials from academia, regulatory agencies and industry, encompassing expertise in MASH, cirrhosis, portal hypertension, and regulatory affairs. The presented Roadmap summarizes important content of the workshop on current status, regulatory requirements and end points in MASH-related compensated cirrhosis clinical trials, exploring alternative study designs and highlighting the challenges that should be considered for upcoming studies on MASH cirrhosis.
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Affiliation(s)
- Juan M Pericàs
- Liver Unit, Division of Digestive Diseases, Vall d'Hebron University Hospital, Vall d'Hebron Institute of Research (VHIR), Vall d'Hebron Barcelona Hospital Campus, Universitat Autònoma de Barcelona, Barcelona, Spain.
- Centros de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Instituto de Salud Carlos III, Madrid, Spain.
| | - Quentin M Anstee
- Translational & Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK
- Newcastle NIHR Biomedical Research Center, Newcastle upon Tyne Hospitals NHS Trust, Newcastle upon Tyne, UK
| | | | - Ramón Bataller
- Liver Unit, Hospital Clinic Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Universitat Barcelona, Barcelona, Spain
| | - Annalisa Berzigotti
- Department of Visceral Surgery and Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Andreea Ciudin
- Endocrinology and Nutrition Department, Morbid Obesity Unit Coordinator, Vall d'Hebron University Hospital, Barcelona, Spain
- Centros de Investigación Biomédica en Red de Diabetes y Enfermedades Metabólicas asociadas (CIBERdem), Instituto de Salud Carlos III, Madrid, Spain
| | - Sven Francque
- Department of Gastroenterology and Hepatology, Antwerp University Hospital, InflaMed Centre of Excellence, Laboratory for Experimental Medicine and Paediatrics, Translational Sciences in Inflammation and Immunology, Faculty of Medicine and Health Sciences, University of Antwerp, Wilrijk, Belgium
| | - Juan G Abraldes
- Division of Gastroenterology (Liver Unit), University of Alberta, Edmonton, Canada
| | - Virginia Hernández-Gea
- Centros de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Instituto de Salud Carlos III, Madrid, Spain
- Liver Unit, Hospital Clinic Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Universitat Barcelona, Barcelona, Spain
| | - Mònica Pons
- Liver Unit, Division of Digestive Diseases, Vall d'Hebron University Hospital, Vall d'Hebron Institute of Research (VHIR), Vall d'Hebron Barcelona Hospital Campus, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Thomas Reiberger
- Division of Gastroenterology and Hepatology, Department of Medicine III, Medical University of Vienna, Vienna, Austria
| | - Ian A Rowe
- Leeds Institute for Medical Research, University of Leeds, Leeds, UK
| | - Peter Rydqvist
- Medical Department, Madrigal Pharmaceuticals, West Conshohocken, PA, USA
| | - Elmer Schabel
- Federal Institute for Drugs and Medical Devices, Bonn, Germany
| | - Frank Tacke
- Department of Hepatology and Gastroenterology, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Emmanuel A Tsochatzis
- UCL Institute for Liver and Digestive Health, Royal Free Hospital and UCL, London, UK
| | - Joan Genescà
- Liver Unit, Division of Digestive Diseases, Vall d'Hebron University Hospital, Vall d'Hebron Institute of Research (VHIR), Vall d'Hebron Barcelona Hospital Campus, Universitat Autònoma de Barcelona, Barcelona, Spain
- Centros de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Instituto de Salud Carlos III, Madrid, Spain
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3
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Kjaergaard M, Lindvig KP, Thorhauge KH, Johansen S, Hansen JK, Andersen P, Hansen CD, Schnefeld HL, Bech KT, Torp N, Israelsen M, Detlefsen S, Graupera I, Gines P, Krag A, Thiele M. Screening for Fibrosis Promotes Lifestyle Changes: A Prospective Cohort Study in 4796 Individuals. Clin Gastroenterol Hepatol 2024; 22:1037-1047.e9. [PMID: 38154729 DOI: 10.1016/j.cgh.2023.12.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2023] [Revised: 11/20/2023] [Accepted: 12/12/2023] [Indexed: 12/30/2023]
Abstract
BACKGROUND AND AIMS Early detection of liver fibrosis is believed to promote lifestyle changes. We evaluated self-reported changes in alcohol intake, diet, exercise, and weight after participating in a screening study for liver fibrosis. METHODS We conducted a prospective screening study of individuals at risk of alcohol-related liver disease (ALD) or metabolic dysfunction-associated steatotic liver disease (MASLD). We provided lifestyle advice to all participants and evaluated lifestyle changes by questionnaires after 1 week and 6 months, with re-examination of a subgroup after 2 years. RESULTS A total of 1850 at risk of ALD and 2946 at risk of MASLD were included, of whom 383 (8%) were screening positive (transient elastography ≥8 kPa). A total of 84% replied to the 6-month questionnaire. In ALD participants, excessive drinking decreased from 46% to 32% after 6 months. Only 15% reported increased drinking, without differences between screening positive and negative individuals (P = .698). In high-risk drinkers, a positive screening test predicted abstinence or decreased alcohol use after 6 months (odds ratio, 2.45; 95% confidence interval, 1.32-4.57; P = .005). After 2 years, excessive drinking decreased from 52% to 41% in a subgroup of 752 individuals and a positive screening test predicted abstinence or decreased alcohol use after 2 years (odds ratio, 1.84; 95% confidence interval, 1.09-3.11, P = .023). MASLD participants showed similar improvements: 35% improved their diet, 22% exercised more, and 13% reported a weight loss ≥5% after 6 months. CONCLUSIONS Screening for liver fibrosis is associated with sustained improvements in alcohol consumption, diet, weight, and exercise in at-risk ALD and MASLD. The changes are most pronounced in screening positive participants but not limited to this group.
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Affiliation(s)
- Maria Kjaergaard
- Fibrosis Fatty Liver and Steatohepatitis Research Centre, Department of Gastroenterology and Hepatology, Odense University Hospital, Odense, Denmark; Institute of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Katrine Prier Lindvig
- Fibrosis Fatty Liver and Steatohepatitis Research Centre, Department of Gastroenterology and Hepatology, Odense University Hospital, Odense, Denmark; Institute of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Katrine Holtz Thorhauge
- Fibrosis Fatty Liver and Steatohepatitis Research Centre, Department of Gastroenterology and Hepatology, Odense University Hospital, Odense, Denmark; Institute of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Stine Johansen
- Fibrosis Fatty Liver and Steatohepatitis Research Centre, Department of Gastroenterology and Hepatology, Odense University Hospital, Odense, Denmark; Institute of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Johanne Kragh Hansen
- Fibrosis Fatty Liver and Steatohepatitis Research Centre, Department of Gastroenterology and Hepatology, Odense University Hospital, Odense, Denmark; Institute of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Peter Andersen
- Fibrosis Fatty Liver and Steatohepatitis Research Centre, Department of Gastroenterology and Hepatology, Odense University Hospital, Odense, Denmark
| | - Camilla Dalby Hansen
- Fibrosis Fatty Liver and Steatohepatitis Research Centre, Department of Gastroenterology and Hepatology, Odense University Hospital, Odense, Denmark; Institute of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Helle Lindholm Schnefeld
- Fibrosis Fatty Liver and Steatohepatitis Research Centre, Department of Gastroenterology and Hepatology, Odense University Hospital, Odense, Denmark
| | - Katrine Tholstrup Bech
- Fibrosis Fatty Liver and Steatohepatitis Research Centre, Department of Gastroenterology and Hepatology, Odense University Hospital, Odense, Denmark
| | - Nikolaj Torp
- Fibrosis Fatty Liver and Steatohepatitis Research Centre, Department of Gastroenterology and Hepatology, Odense University Hospital, Odense, Denmark; Institute of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Mads Israelsen
- Fibrosis Fatty Liver and Steatohepatitis Research Centre, Department of Gastroenterology and Hepatology, Odense University Hospital, Odense, Denmark; Institute of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Sönke Detlefsen
- Institute of Clinical Research, University of Southern Denmark, Odense, Denmark; Department of Pathology, Odense University Hospital, Odense, Denmark
| | - Isabel Graupera
- Liver Unit Hospital Clínic, Institut D'investigacions Biomédiques August Pi i Sunyer, Barcelona, Spain; Centro de Investigación En Red de Enfermedades Hepáticas y Digestivas, Faculty of Medicine and Health Sciences, University of Barcelona, Barcelona, Spain
| | - Pere Gines
- Liver Unit Hospital Clínic, Institut D'investigacions Biomédiques August Pi i Sunyer, Barcelona, Spain; Centro de Investigación En Red de Enfermedades Hepáticas y Digestivas, Faculty of Medicine and Health Sciences, University of Barcelona, Barcelona, Spain
| | - Aleksander Krag
- Fibrosis Fatty Liver and Steatohepatitis Research Centre, Department of Gastroenterology and Hepatology, Odense University Hospital, Odense, Denmark; Institute of Clinical Research, University of Southern Denmark, Odense, Denmark.
| | - Maja Thiele
- Fibrosis Fatty Liver and Steatohepatitis Research Centre, Department of Gastroenterology and Hepatology, Odense University Hospital, Odense, Denmark; Institute of Clinical Research, University of Southern Denmark, Odense, Denmark
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Sanyal AJ, Loomba R, Anstee QM, Ratziu V, Kowdley KV, Rinella ME, Harrison SA, Resnick MB, Capozza T, Sawhney S, Shelat N, Younossi ZM. Utility of pathologist panels for achieving consensus in NASH histologic scoring in clinical trials: Data from a phase 3 study. Hepatol Commun 2024; 8:e0325. [PMID: 38126958 PMCID: PMC10749704 DOI: 10.1097/hc9.0000000000000325] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Accepted: 09/21/2023] [Indexed: 12/23/2023] Open
Abstract
BACKGROUND Liver histopathologic assessment is the accepted surrogate endpoint in NASH trials; however, the scoring of NASH Clinical Research Network (CRN) histologic parameters is limited by intraobserver and interobserver variability. We designed a consensus panel approach to minimize variability when using this scoring system. We assessed agreement between readers, estimated linear weighted kappas between 2 panels, compared them with published pairwise kappa estimates, and addressed how agreement or disagreement might impact the precision and validity of the surrogate efficacy endpoint in NASH trials. METHODS Two panels, each comprising 3 liver fellowship-trained pathologists who underwent NASH histology training, independently evaluated scanned whole slide images, scoring fibrosis, inflammation, hepatocyte ballooning, and steatosis from baseline and month 18 biopsies for 100 patients from the precirrhotic NASH study REGENERATE. The consensus score for each parameter was defined as agreement by ≥2 pathologists. If consensus was not reached, all 3 pathologists read the slide jointly to achieve a consensus score. RESULTS Between the 2 panels, the consensus was 97%-99% for steatosis, 91%-93% for fibrosis, 88%-92% for hepatocyte ballooning, and 84%-91% for inflammation. Linear weighted kappa scores between panels were similar to published NASH CRN values. CONCLUSIONS A panel of 3 trained pathologists independently scoring 4 NASH CRN histology parameters produced high consensus rates. Interpanel kappa values were comparable to NASH CRN metrics, supporting the accuracy and reproducibility of this method. The high concordance for fibrosis scoring was reassuring, as fibrosis is predictive of liver-specific outcomes and all-cause mortality.
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Affiliation(s)
- Arun J. Sanyal
- Department of Internal Medicine, Division of Gastroenterology, Hepatology and Nutrition, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Rohit Loomba
- Division of Gastroenterology and Hepatology, Department of Medicine, University of California San Diego, La Jolla, California, USA
| | - Quentin M. Anstee
- Translational & Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK
| | - Vlad Ratziu
- Sorbonne Université, Institute of Cardiometabolism and Nutrition, Pitié Salpêtriére University Hospital, Paris, France
| | | | - Mary E. Rinella
- Pritzker School of Medicine, University of Chicago, Chicago, Illinois, USA
| | | | - Murray B. Resnick
- Department of Pathology and Laboratory Medicine, Brown University, Providence, Rhode Island, USA
| | - Thomas Capozza
- Intercept Pharmaceuticals, Inc., Morristown, New Jersey, USA
| | | | - Nirav Shelat
- Intercept Pharmaceuticals, Inc., Morristown, New Jersey, USA
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5
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Kendall TJ, Jimenez-Ramos M, Turner F, Ramachandran P, Minnier J, McColgan MD, Alam M, Ellis H, Dunbar DR, Kohnen G, Konanahalli P, Oien KA, Bandiera L, Menolascina F, Juncker-Jensen A, Alexander D, Mayor C, Guha IN, Fallowfield JA. An integrated gene-to-outcome multimodal database for metabolic dysfunction-associated steatotic liver disease. Nat Med 2023; 29:2939-2953. [PMID: 37903863 PMCID: PMC10667096 DOI: 10.1038/s41591-023-02602-2] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Accepted: 09/20/2023] [Indexed: 11/01/2023]
Abstract
Metabolic dysfunction-associated steatotic liver disease (MASLD) is the commonest cause of chronic liver disease worldwide and represents an unmet precision medicine challenge. We established a retrospective national cohort of 940 histologically defined patients (55.4% men, 44.6% women; median body mass index 31.3; 32% with type 2 diabetes) covering the complete MASLD severity spectrum, and created a secure, searchable, open resource (SteatoSITE). In 668 cases and 39 controls, we generated hepatic bulk RNA sequencing data and performed differential gene expression and pathway analysis, including exploration of gender-specific differences. A web-based gene browser was also developed. We integrated histopathological assessments, transcriptomic data and 5.67 million days of time-stamped longitudinal electronic health record data to define disease-stage-specific gene expression signatures, pathogenic hepatic cell subpopulations and master regulator networks associated with adverse outcomes in MASLD. We constructed a 15-gene transcriptional risk score to predict future hepatic decompensation events (area under the receiver operating characteristic curve 0.86, 0.81 and 0.83 for 1-, 3- and 5-year risk, respectively). Additionally, thyroid hormone receptor beta regulon activity was identified as a critical suppressor of disease progression. SteatoSITE supports rational biomarker and drug development and facilitates precision medicine approaches for patients with MASLD.
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Affiliation(s)
- Timothy J Kendall
- Institute for Regeneration and Repair, University of Edinburgh, Edinburgh, UK
- Edinburgh Pathology, University of Edinburgh, Edinburgh, UK
| | - Maria Jimenez-Ramos
- Institute for Regeneration and Repair, University of Edinburgh, Edinburgh, UK
| | - Frances Turner
- Edinburgh Genomics (Bioinformatics), University of Edinburgh, Edinburgh, UK
| | | | - Jessica Minnier
- OHSU-PSU School of Public Health, Oregon Health & Sciences University, Portland, OR, USA
- Knight Cancer Institute Biostatistics Shared Resource, Oregon Health & Sciences University, Portland, OR, USA
| | - Michael D McColgan
- Precision Medicine Scotland-Innovation Centre (PMS-IC), University of Glasgow, Glasgow, UK
| | - Masood Alam
- Precision Medicine Scotland-Innovation Centre (PMS-IC), University of Glasgow, Glasgow, UK
| | - Harriet Ellis
- Precision Medicine Scotland-Innovation Centre (PMS-IC), University of Glasgow, Glasgow, UK
| | - Donald R Dunbar
- Edinburgh Genomics (Bioinformatics), University of Edinburgh, Edinburgh, UK
| | - Gabriele Kohnen
- Pathology Department, Queen Elizabeth University Hospital, Glasgow, UK
| | | | - Karin A Oien
- Pathology Department, Queen Elizabeth University Hospital, Glasgow, UK
| | - Lucia Bandiera
- School of Engineering, Institute of Bioengineering, University of Edinburgh, Edinburgh, UK
- Centre for Engineering Biology, University of Edinburgh, Edinburgh, UK
| | - Filippo Menolascina
- School of Engineering, Institute of Bioengineering, University of Edinburgh, Edinburgh, UK
- Centre for Engineering Biology, University of Edinburgh, Edinburgh, UK
| | | | | | - Charlie Mayor
- NHS Greater Glasgow and Clyde Safe Haven, Glasgow, UK
| | - Indra Neil Guha
- National Institute of Health Research (NIHR) Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and University of Nottingham, Nottingham, UK
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6
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Brennan PN, Elsharkawy AM, Kendall TJ, Loomba R, Mann DA, Fallowfield JA. Antifibrotic therapy in nonalcoholic steatohepatitis: time for a human-centric approach. Nat Rev Gastroenterol Hepatol 2023; 20:679-688. [PMID: 37268740 PMCID: PMC10236408 DOI: 10.1038/s41575-023-00796-x] [Citation(s) in RCA: 20] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/09/2023] [Indexed: 06/04/2023]
Abstract
Nonalcoholic steatohepatitis (NASH) might soon become the leading cause of end-stage liver disease and indication for liver transplantation worldwide. Fibrosis severity is the only histological predictor of liver-related morbidity and mortality in NASH identified to date. Moreover, fibrosis regression is associated with improved clinical outcomes. However, despite numerous clinical trials of plausible drug candidates, an approved antifibrotic therapy remains elusive. Increased understanding of NASH susceptibility and pathogenesis, emerging human multiomics profiling, integration of electronic health record data and modern pharmacology techniques hold enormous promise in delivering a paradigm shift in antifibrotic drug development in NASH. There is a strong rationale for drug combinations to boost efficacy, and precision medicine strategies targeting key genetic modifiers of NASH are emerging. In this Perspective, we discuss why antifibrotic effects observed in NASH pharmacotherapy trials have been underwhelming and outline potential approaches to improve the likelihood of future clinical success.
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Affiliation(s)
- Paul N Brennan
- Institute for Regeneration & Repair, University of Edinburgh, Edinburgh, UK
- Division of Molecular and Clinical Medicine, University of Dundee, Dundee, UK
| | - Ahmed M Elsharkawy
- Liver Unit and NIHR Biomedical Research Centre, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Timothy J Kendall
- Institute for Regeneration & Repair, University of Edinburgh, Edinburgh, UK
- Edinburgh Pathology, University of Edinburgh, Edinburgh, UK
| | - Rohit Loomba
- NAFLD Research Centre, Division of Gastroenterology and Hepatology, UC San Diego School of Medicine, La Jolla, CA, USA
| | - Derek A Mann
- Fibrosis Research Group, Newcastle University, Newcastle, UK.
- Department of Gastroenterology and Hepatology, School of Medicine, Koç University, Istanbul, Turkey.
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7
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Goodman ZD. Role of Liver Biopsy in Clinical Trials and Clinical Management of Nonalcoholic Fatty Liver Disease. Clin Liver Dis 2023; 27:353-362. [PMID: 37024212 DOI: 10.1016/j.cld.2023.01.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/08/2023]
Abstract
Nonalcoholic fatty liver disease and nonalcoholic steatohepatitis constitute a spectrum of histologic lesions characterized by varying degrees of hepatocellular injury and fat accumulation with inflammation and scarring. Fibrosis associated with this disease may progress to cirrhosis and its complications. As there are no approved therapies, clinical trials to assess potential forms of drug therapy are conducted to assess drugs for efficacy and safety before submission to regulatory review. Liver biopsies are performed and evaluated to confirm the diagnosis of nonalcoholic steatohepatitis and to assess fibrosis stage for inclusion in trials.
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Affiliation(s)
- Zachary D Goodman
- Center of Liver Diseases, Inova Fairfax Hospital, 3300 Gallows Road, Falls Church, VA 22042, USA.
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8
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Noureddin M, Wong VWS. A Revisit of the Natural History of Nonalcoholic Fatty Liver Disease. Clin Gastroenterol Hepatol 2022; 21:1152-1153. [PMID: 36031092 DOI: 10.1016/j.cgh.2022.08.019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2022] [Accepted: 08/17/2022] [Indexed: 01/22/2023]
Affiliation(s)
- Mazen Noureddin
- Houston Research Institute, Houston Methodist, Houston, Texas; Houston Methodist Hospital, Houston, Texas
| | - Vincent Wai-Sun Wong
- State Key Laboratory of Digestive Disease, Institute of Digestive Disease, The Chinese University of Hong Kong, Hong Kong; Medical Data Analytics Centre, Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong.
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9
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Bofill Roig M, Krotka P, Burman CF, Glimm E, Gold SM, Hees K, Jacko P, Koenig F, Magirr D, Mesenbrink P, Viele K, Posch M. On model-based time trend adjustments in platform trials with non-concurrent controls. BMC Med Res Methodol 2022; 22:228. [PMID: 35971069 PMCID: PMC9380382 DOI: 10.1186/s12874-022-01683-w] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2021] [Accepted: 07/12/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Platform trials can evaluate the efficacy of several experimental treatments compared to a control. The number of experimental treatments is not fixed, as arms may be added or removed as the trial progresses. Platform trials are more efficient than independent parallel group trials because of using shared control groups. However, for a treatment entering the trial at a later time point, the control group is divided into concurrent controls, consisting of patients randomised to control when that treatment arm is in the platform, and non-concurrent controls, patients randomised before. Using non-concurrent controls in addition to concurrent controls can improve the trial's efficiency by increasing power and reducing the required sample size, but can introduce bias due to time trends. METHODS We focus on a platform trial with two treatment arms and a common control arm. Assuming that the second treatment arm is added at a later time, we assess the robustness of recently proposed model-based approaches to adjust for time trends when utilizing non-concurrent controls. In particular, we consider approaches where time trends are modeled either as linear in time or as a step function, with steps at time points where treatments enter or leave the platform trial. For trials with continuous or binary outcomes, we investigate the type 1 error rate and power of testing the efficacy of the newly added arm, as well as the bias and root mean squared error of treatment effect estimates under a range of scenarios. In addition to scenarios where time trends are equal across arms, we investigate settings with different time trends or time trends that are not additive in the scale of the model. RESULTS A step function model, fitted on data from all treatment arms, gives increased power while controlling the type 1 error, as long as the time trends are equal for the different arms and additive on the model scale. This holds even if the shape of the time trend deviates from a step function when patients are allocated to arms by block randomisation. However, if time trends differ between arms or are not additive to treatment effects in the scale of the model, the type 1 error rate may be inflated. CONCLUSIONS The efficiency gained by using step function models to incorporate non-concurrent controls can outweigh potential risks of biases, especially in settings with small sample sizes. Such biases may arise if the model assumptions of equality and additivity of time trends are not satisfied. However, the specifics of the trial, scientific plausibility of different time trends, and robustness of results should be carefully considered.
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Affiliation(s)
- Marta Bofill Roig
- Center for Medical Statistics, Informatics and Intelligent Systems, Medical University of Vienna, Vienna, Austria
| | - Pavla Krotka
- Center for Medical Statistics, Informatics and Intelligent Systems, Medical University of Vienna, Vienna, Austria
| | - Carl-Fredrik Burman
- Statistical Innovation, Data Science & Artificial Intelligence, AstraZeneca, Gothenburg, Sweden
| | - Ekkehard Glimm
- Advanced Methodology and Data Science, Novartis Pharma AG, Basel, Switzerland
- Institute of Biometry and Medical Informatics, University of Magdeburg, Magdeburg, Germany
| | - Stefan M Gold
- Klinik für Psychiatrie und Psychotherapie, Campus Benjamin Franklin, Charité - Universitätsmedizin Berlin, Berlin, Germany
- Medizinische Klinik m.S. Psychosomatik, Campus Benjamin Franklin, Charité - Universitätsmedizin Berlin, Berlin, Germany
- Institut für Neuroimmunologie und Multiple Sklerose (INIMS), Zentrum für Molekulare Neurobiologie, Universitätsklinikum Hamburg Eppendorf, Hamburg, Germany
| | - Katharina Hees
- Section of Biostatistics, Paul-Ehrlich-Institut, Langen, Germany
| | - Peter Jacko
- Berry Consultants, Abingdon, UK
- Lancaster University, Lancaster, UK
| | - Franz Koenig
- Center for Medical Statistics, Informatics and Intelligent Systems, Medical University of Vienna, Vienna, Austria
| | - Dominic Magirr
- Advanced Methodology and Data Science, Novartis Pharma AG, Basel, Switzerland
| | - Peter Mesenbrink
- Analytics Global Drug Development, Novartis Pharmaceuticals Corporation, East Hanover, NJ, USA
| | | | - Martin Posch
- Center for Medical Statistics, Informatics and Intelligent Systems, Medical University of Vienna, Vienna, Austria.
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10
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Siler SQ. Applications of Quantitative Systems Pharmacology (QSP) in Drug Development for NAFLD and NASH and Its Regulatory Application. Pharm Res 2022; 39:1789-1802. [PMID: 35610402 PMCID: PMC9314276 DOI: 10.1007/s11095-022-03295-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Accepted: 05/17/2022] [Indexed: 02/08/2023]
Abstract
Nonalcoholic steatohepatitis (NASH) is a widely prevalent disease, but approved pharmaceutical treatments are not available. As such, there is great activity within the pharmaceutical industry to accelerate drug development in this area and improve the quality of life and reduce mortality for NASH patients. The use of quantitative systems pharmacology (QSP) can help make this overall process more efficient. This mechanism-based mathematical modeling approach describes both the pathophysiology of a disease and how pharmacological interventions can modify pathophysiologic mechanisms. Multiple capabilities are provided by QSP modeling, including the use of model predictions to optimize clinical studies. The use of this approach has grown over the last 20 years, motivating discussions between modelers and regulators to agree upon methodologic standards. These include model transparency, documentation, and inclusion of clinical pharmacodynamic biomarkers. Several QSP models have been developed that describe NASH pathophysiology to varying extents. One specific application of NAFLDsym, a QSP model of NASH, is described in this manuscript. Simulations were performed to help understand if patient behaviors could help explain the relatively high rate of fibrosis stage reductions in placebo cohorts. Simulated food intake and body weight fluctuated periodically over time. The relatively slow turnover of liver collagen allowed persistent reductions in predicted fibrosis stage despite return to baseline for liver fat, plasma ALT, and the NAFLD activity score. Mechanistic insights such as this that have been derived from QSP models can help expedite the development of safe and effective treatments for NASH patients.
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Affiliation(s)
- Scott Q Siler
- DILIsym Services, a Division of Simulations Plus, 510-862-6027, 6 Davis Drive, PO Box 12317, Research Triangle Park, North Carolina, 27709, USA.
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11
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Current status and challenges in the drug treatment for fibrotic nonalcoholic steatohepatitis. Acta Pharmacol Sin 2022; 43:1191-1199. [PMID: 34907360 PMCID: PMC9061812 DOI: 10.1038/s41401-021-00822-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2021] [Accepted: 11/10/2021] [Indexed: 12/12/2022] Open
Abstract
Currently, nonalcoholic steatohepatitis (NASH) is one of the most common forms of chronic hepatitis, increasing the burden of health care worldwide. In patients with NASH, the fibrosis stage is the most predictive factor of long-term events. However, there are still no drugs approved by the Food and Drug Administration of the United States for treating biopsy-proven NASH with fibrosis or cirrhosis. Although some novel drugs have shown promise in preclinical studies and led to improvement in terms of hepatic fat content and steatohepatitis, a considerable proportion of them have failed to achieve histological endpoints of fibrosis improvement. Due to the large number of NASH patients and adverse clinical outcomes, the search for novel drugs is necessary. In this review, we discuss current definitions for the evaluation of treatment efficacy in fibrosis improvement for NASH patients, and we summarize novel agents in the pipeline from different mechanisms and phases of trial. We also critically review the challenges we face in the development of novel agents for fibrotic NASH and NASH cirrhosis.
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