Predictors of steatohepatitis and advanced fibrosis in non-alcoholic fatty liver disease

The Effects of Melatonin in Patients with Nonalcoholic Fatty Liver Disease: A Randomized Controlled Trial

Background:

This study was designed to evaluate the effect of melatonin on nonalcoholic fatty liver disease (NAFLD) in compared to placebo.

Materials and Methods:

A total of 100 patients with histopathological diagnosis NAFLD in two groups of case and control received oral melatonin or placebo thrice daily for 3 months. Collected data were weight, waist, systolic blood pressure (SBP), diastolic blood pressure (DBP), alanine aminotransferase (ALT), aspartate aminotransferase (AST), high sensitive C-reactive protein (hsCRP), fatty liver grade, and side effects which were measured at baseline and after treatment period using standard clinical chemistry techniques.

Results:

Before treatment the mean of weight, waist, SBP, DBP, ALT, AST, and hsCRP between cases and controls were similar (P > 0.5). After treatment, only the differences in the mean of hsCRP in cases was significantly lower than controls (P = 0.003). In case group, all variables after treatment were significantly decreased compare to baseline (P > 0.5) and only AST after treatment was similar to before treatment (P > 0.5). The mean of a decrease in the level of weight, waist, SBP, and ALT were not statistically significant between groups (P > 0.5). In the case group in compare to control group the level of DBP, AST, and hsCRP significantly more decreased. After treatment fatty, liver grade was statistically improved in more cases than controls (P = 0.001). Side effects were similar between the two groups.

Conclusion:

Melatonin significantly decreases liver enzymes, so the use of melatonin in patients with NAFLD can be effective.

Association between diabetes mellitus and cirrhosis mortality: the Singapore Chinese Health Study

BACKGROUND & AIM

Diabetes mellitus has been linked to cirrhosis-related mortality in Western populations, but less is known about this relationship in Asian populations. We studied the impact of diabetes on the risk of cirrhosis mortality in a population-based cohort among Chinese in Singapore.

METHODS

We used data collected and analysed from the Singapore Chinese Health Study, a prospective community-based cohort of 63 275 subjects aged 45-74 years during enrolment between 1993 and 1998. Information on diet, lifestyle and medical history was collected via structured questionnaire. Mortality cases from cirrhosis in the cohort were identified via linkage with nationwide death registry up to 31 December 2014. Cox proportional regression models were used to estimate the associations with adjustment for risk factors of cirrhosis.

RESULTS

After a mean follow-up of 16.9 years, there were 133 deaths from cirrhosis. Diabetes was associated with an increased risk of cirrhosis mortality (hazard ratio [HR]: 2.80; 95% confidence interval [CI]: 2.04-3.83), and for both viral (HR: 2.20; 95% CI: 1.18-4.11) and non-viral hepatitis-related cirrhosis mortality (HR: 3.06; 95% CI: 2.13-4.41). The association between diabetes and non-viral hepatitis-related cirrhosis mortality was stronger among participants of body mass index (BMI) less than 23 kg/m² (HR: 7.11; 95% CI: 3.42-14.79) compared to heavier individuals (HR: 2.28; 95% CI: 1.20-4.35) (P_interaction =0.02).

CONCLUSION

Diabetes is a risk factor for cirrhosis mortality, especially for non-viral hepatitis-related cirrhosis in population with BMI considered low or normal in Asia.

Quality of life 10 years after liver transplantation: The impact of graft histology

AIM

To evaluate the relationship between the state of transplanted liver graft and the recipient quality of life (QOL) of histologically proven lesions in a 10-year post liver transplantation (LT) cohort of patients.

METHODS

Seventy-two recipients with a functional first graft at 10 years post-LT underwent liver biopsy and completed a QOL questionnaire. Logistic regression analysis was used to explore associations between histological, clinical and QOL criteria.

RESULTS

Ten years after LT, fibrosis was detected in 53% of patients, and affected the general health perception, while ductopenia, present in 36%, affected the well-being (P = 0.05). Hepatic steatosis (HS) was present in 33% of patients and was associated with the worst QOL score on multiple domains. When compared to patients without HS, patients with HS had significantly higher incidence of fibrosis (P = 0.03), hepatitis C virus (HCV) infection (P = 0.007), and more patients had retired from their job (P = 0.03). Recurrent or de novo HCV-associated fibrosis and patient retirement as objective variables, and abdominal pain or discomfort and joint aches or pains as subjective variables, emerged as independent determinants of HS.

CONCLUSION

Long-term liver graft lesions, mainly HS presumably as a surrogate marker of HCV infection, may have a substantial impact on QOL 10 years after LT.

Comprehensive Metabolic Profiling of Age-Related Mitochondrial Dysfunction in the High-Fat-Fed ob/ob Mouse Heart

The ectopic deposition of fat is thought to lead to lipotoxicity and has been associated with mitochondrial dysfunction and diabetic cardiomyopathy. We have measured mitochondrial respiratory capacities in the hearts of ob/ob and wild-type mice on either a regular chow (RCD) or high-fat (HFD) diet across four age groups to investigate the impact of diet and age on mitochondrial function alongside a comprehensive strategy for metabolic profiling of the tissue. Myocardial mitochondrial dysfunction was only evident in ob/ob mice on RCD at 14 months, but it was detectable at 3 months on the HFD. Liquid chromatography-mass spectrometry (LC-MS) was used to study the profiles of acylcarnitines and the accumulation of triglycerides, but neither class of lipid was associated with mitochondrial dysfunction. However, a targeted LC-MS/MS analysis of markers of oxidative stress demonstrated increases in GSSG/GSH and 8-oxoguanine, in addition to the accumulation of diacylglycerols, which are lipid species linked to lipotoxicity. Our results demonstrate that myocardial mitochondria in ob/ob mice on RCD maintained a similar respiratory capacity to that of wild type until a late stage in aging. However, on a HFD, unlike wild-type mice, ob/ob mice failed to increase mitochondrial respiration, which may be associated with a complex I defect following increased oxidative damage.

Oxidative stress: New insights on the association of non-alcoholic fatty liver disease and atherosclerosis

Non-alcoholic fatty liver disease (NAFLD) represents the most common and emerging chronic liver disease worldwide. It includes a wide spectrum of liver diseases ranging from simple fatty liver to non-alcoholic steatohepatitis (NASH), which may progress to fibrosis and more severe liver complications such as cirrhosis, hepatocellular carcinoma and liver mortality. NAFLD is strongly associated with obesity, insulin resistance, hypertension, and dyslipidaemia, and is now regarded as the liver manifestation of the metabolic syndrome. The increased mortality of patients with NAFLD is primarily a result of cardiovascular disease and, to a lesser extent, to liver related diseases. Increased oxidative stress has been reported in both patients with NAFLD and patient with cardiovascular risk factors. Thus, oxidative stress represents a shared pathophysiological disorder between the two conditions. Several therapeutic strategies targeting oxidative stress reduction in patients with NAFLD have been proposed, with conflicting results. In particular, vitamin E supplementation has been suggested for the treatment of non-diabetic, non-cirrhotic adults with active NASH, although this recommendation is based only on the results of a single randomized controlled trial. Other antioxidant treatments suggested are resveratrol, silybin, L-carnitine and pentoxiphylline. No trial so far, has evaluated the cardiovascular effects of antioxidant treatment in patients with NAFLD. New, large-scale studies including as end-point also the assessment of the atherosclerosis markers are needed.

Ultrasound, anthropometry and bioimpedance: a comparison in predicting fat deposition in non-alcoholic fatty liver disease

PURPOSE

The aim of our study was the evaluation of anthropometric measurements [waist circumference and sagittal abdominal diameter (SAD)] and abdominal bioelectrical impedance analysis (BIA) (ViScan, TANITA) in comparison to several abdominal ultrasonographic (US) measurements to estimate visceral fat deposition and liver steatosis in a population of 105 subjects.

METHODS

All 105 patients underwent a complete anthropometric evaluation, blood sample for the determination of total cholesterol, HDL cholesterol, triglycerides, glucose, insulin, high-sensitivity C-reactive protein, BIA and US measurements (peritoneal, pre-peritoneal, peri-renal, para-renal and peri-hepatic fat thickness).

RESULTS

All the ultrasonographic markers considered in our study are related to the presence of non-alcoholic fatty liver disease (NAFLD), and so is true for SAD. Comparing ROC curves, peritoneal fat tissue thickness, SAD and ViScan visceral index are significantly better than waist circumference in predicting the presence of NAFLD (AUC 0.79 ± 0.04; 0.81 ± 0.05; 0.82 ± 0.04 vs 0.76 ± 0.05, respectively).

CONCLUSIONS

According to our data, various methods may be useful in evaluating NAFLD, but only ViScan visceral index, US peritoneal fat thickness and SAD are better than waist circumference. Among them, SAD is the most promising, due to its small cost and time consumption.

Pattern and profile of chronic liver disease in acute on chronic liver failure

The etiology of the chronic liver disease (CLD) in patients with acute on chronic liver failure (ACLF) may vary from region to region. The major cause of underlying CLD is viral (hepatitis B and C) in the East, while it is alcohol related in the West and in some parts of the Indian subcontinent. Autoimmune liver disease and Wilson's disease are the major underlying etiologies in the pediatric age group. The patients with CLD without cirrhosis should be included when defining ACLF. Non-alcoholic fatty liver disease related chronic liver insult in patients with known risk factors for progressive disease should be taken as a chronic liver disease in the setting of ACLF, whereas fatty liver with normal aminotransferases in low risk patients should not. The patients with CLD and previous decompensation should be excluded. Diagnosis of chronic liver disease in the setting of ACLF is made by history, physical examination and previously available or recent laboratory, endoscopic or radiological investigations. A liver biopsy through the transjugular route may help in cases where the presence of underlying CLD or its cause is not clear. The need of liver biopsy in ACLF should, however, be individualized. Standardization of liver biopsy assessment is essential for a uniform approach to the diagnosis and treatment of CLD and acute insult. Tools to measure liver stiffness may aid in identifying patients with advanced fibrosis. Studies are needed to validate the performance of these tests in the setting of ACLF.

Prevalence and factors associated with dyslipidemia after liver transplantation

OBJECTIVE

to determine the prevalence of abnormal total cholesterol (TC), low density lipoprotein (LDL), high density lipoprotein (HDL) and triglycerides in patients undergoing liver transplantation (LTx) and to identify predictors of these disorders.

METHODS

cross-sectional study to assess the prevalence of dyslipidemia in patients undergoing LTx. Demographic, socioeconomic, clinical, anthropometric and dietetic data were collected to determine the association with dyslipidemia using univariate and multivariate statistical analysis.

RESULTS

136 patients were evaluated, 68.1% of which had at least one type of dyslipidemia. The triglyceride level was high in 32.4% of cases, with low HDL in 49.3% of patients and high LDL levels in only 8.8%. High total cholesterol was observed in 16.2% of the study population and was associated with the recommendation for transplantation due to ethanolic cirrhosis (OR = 2.7) and a greater number of hours slept per night (OR = 1.5).

CONCLUSION

many patients presented dyslipidemia after transplantation, demonstrating the need for interventions in relation to modifiable factors associated with dyslipidemias that can mitigate or prevent these disorders.

Improved hepatic lipid composition following short-term exercise in nonalcoholic fatty liver disease

CONTEXT

Hepatic steatosis, insulin resistance, inflammation, low levels of polyunsaturated lipids, and adiponectin are implicated in the development and progression of nonalcoholic fatty liver disease (NAFLD).

OBJECTIVE

We examined the effects of short-term aerobic exercise on these metabolic risk factors.

DESIGN AND PARTICIPANTS

Obese individuals (N = 17, 34.3 ± 1.0 kg/m²) with clinically confirmed NAFLD were enrolled in a short-term aerobic exercise program that consisted of 7 consecutive days of treadmill walking at ~85% of maximal heart rate for 60 minutes per day. Preintervention and postintervention measures included hepatic triglyceride content, and a lipid saturation index and polyunsaturated lipid index (PUI) of the liver, obtained by (1)H magnetic resonance spectroscopy (N = 14). Insulin sensitivity was estimated from an oral glucose tolerance test (OGTT), and mononuclear cells were isolated to assess reactive oxygen species production during the OGTT. Circulating glucose, insulin, and high molecular weight (HMW) adiponectin were determined from plasma.

MAIN OUTCOME

Short-term aerobic exercise training improved hepatic lipid composition in patients with NAFLD.

RESULTS

Exercise training resulted in an increase in liver PUI (P < .05), increased insulin sensitivity (Matsuda Index: P < .05), HMW adiponectin (P < .05), and maximal oxygen consumption (P < .05). Reactive oxygen species production during the OGTT was reduced following exercise training (P < .05). HMW adiponectin was increased after the exercise program and the increase was positively correlated with the increase in liver PUI (r = 0.52, P = .05). Body weight remained stable during the program (P > .05).

CONCLUSION

Short-term exercise can target hepatic lipid composition, which may reduce the risk of NAFLD progression. The improvement in hepatic lipid composition may be driven by adiponectin.

Endoplasmic reticulum stress in nonalcoholic fatty liver disease

The underlying causes of nonalcoholic fatty liver disease are unclear, although recent evidence has implicated the endoplasmic reticulum in both the development of steatosis and progression to nonalcoholic steatohepatitis. Disruption of endoplasmic reticulum homeostasis, often termed ER stress, has been observed in liver and adipose tissue of humans with nonalcoholic fatty liver disease and/or obesity. Importantly, the signaling pathway activated by disruption of endoplasmic reticulum homeostasis, the unfolded protein response, has been linked to lipid and membrane biosynthesis, insulin action, inflammation, and apoptosis. Therefore, understanding the mechanisms that disrupt endoplasmic reticulum homeostasis in nonalcoholic fatty liver disease and the role of the unfolded protein response in the broader context of chronic, metabolic diseases have become topics of intense investigation. The present review examines the endoplasmic reticulum and the unfolded protein response in the context of nonalcoholic fatty liver disease.

Non-alcoholic fatty liver disease and obesity: not all about body mass index

Patients with nonalcoholic fatty liver (NAFLD) are typically obese and confounded by the metabolic syndrome. The body mass index (BMI) is often used as a surrogate marker of obesity defined as a BMI >30 λkg/m(2). However, it is now apparent that it is the distribution of body fat (not total fat) that is associated with NAFLD. Many patients (as many as 25%) with NAFLD are nonobese. This is particularly true in Asians who have a significantly increased risk of cardiovascular disease and diabetes even among those with a normal BMI. It is important for clinicians to be aware that these "metabolically obese" NAFLD patients should be monitored for the metabolic syndrome and its associated adverse outcomes irrespective of their BMI.

Role of ceramides in nonalcoholic fatty liver disease

Nonalcoholic fatty liver disease (NAFLD) is a chronic disease with a histological spectrum ranging from steatosis alone, to nonalcoholic steatohepatitis (NASH). The latter is associated with an increased risk for progression to cirrhosis. Ceramides are a lipid species that exert biological effects through cellular proliferation, differentiation, and cell death, and interact with several pathways involved in insulin resistance, oxidative stress, inflammation, and apoptosis, all of which are linked to NAFLD. We propose a mechanism through which ceramides contribute to the development of NAFLD and progression to NASH, due in part to second messenger effects via tumor necrosis factor (TNF)-α. A better understanding of the role of ceramides in steatohepatitis has both diagnostic and therapeutic implications for the treatment of fatty liver disease.

Management of nonalcoholic steatohepatitis: an evidence-based approach

Nonalcoholic fatty liver disease (NAFLD) and its progressive form, nonalcoholic steatohepatitis (NASH), are an increasingly common cause of chronic liver disease in the developed world, with NASH projected to be the leading cause of liver transplantation in the United States by 2020. This review of NASH management addresses current data from the perspective of levels of evidence for therapeutic options in NASH, including lifestyle modification, drug therapies, and bariatric surgery. In particular, behavioral therapies to assist patients in adopting lifestyle changes are highlighted and a research agenda for future NASH management is presented.

The role of thiazolidinediones in non-alcoholic steatohepatitis - a systematic review and meta analysis

BACKGROUND & AIMS

Non alcoholic steatohepatitis (NASH) has no approved pharmacological therapy. Insulin sensitisers such as thiazolidinediones ameliorate insulin resistance and are a potential therapeutic option. We performed a systematic review and meta-analysis of the effect of thiazolidinediones on histological and biochemical variables in NASH.

METHODS

Two reviewers searched Medline, Embase, Cochrane Central, international meeting abstracts, reference lists, and contacted experts. Inclusion criteria were randomized trials of people with NASH receiving thiazolidinediones, compared with placebo or other treatments. Methodological quality was assessed in domains suggested by the Cochrane Collaboration. The primary outcome was histological improvement (fibrosis, steatosis, inflammation, hepatocellular ballooning, and NAS score). Secondary outcomes included change in alanine transaminase, insulin resistance, body mass index, weight, and adverse events. Meta-analysis used random effects with dichotomous outcomes as relative risk (RR) and continuous outcomes as mean difference (MD), both with 95% confidence intervals (CI).

RESULTS

Of seven randomized trials (n=489) with histological outcomes, four were placebo controlled (n=355). Methodological quality was variable although better for placebo controlled studies. Treated participants showed improvement in fibrosis (RR 1.38, CI 1.01-1.89), steatosis (RR 2.03, CI 1.57-2.62), inflammation (RR 1.71, CI 1.32-2.21), and hepatocellular ballooning (RR 1.62, CI 1.15-2.28). Treatment increased weight by an average of 4.4 kg (CI 2.6-5.2 kg). Adverse event reporting was inconsistent and only one trial assessed quality of life.

CONCLUSIONS

Thiazolidinediones modestly improve histological variables including fibrosis and hepatocellular ballooning, but at the cost of significant weight gain. Trials of longer duration and reporting of patient oriented outcomes would be informative.

An Endocrine Perspective of Nonalcoholic Fatty Liver Disease (NAFLD)

Endocrinologists are encountering patients with obesity-related complications such as metabolic syndrome (MetS) and type 2 diabetes mellitus (T2DM) on a daily basis. Nonalcoholic fatty liver disease (NAFLD) is a liver condition characterized by insulin resistance, hepatic steatosis and frequently T2DM. This is now the most common chronic liver condition in adults and is present in the majority of obese subjects. Liver fat accumulation may range from simple steatosis to severe steatohepatitis with hepatocyte necroinflammation (or nonalcoholic steatohepatitis [NASH]). Although the natural history is incompletely understood, NAFLD may lead to serious medical consequences ranging from cirrhosis and hepatocellular carcinoma to earlier onset of T2DM and cardiovascular disease (CVD). The diagnosis of NAFLD may be challenging because signs and symptoms are frequently absent or nonspecific, and thus easily missed. Liver aminotransferases may be helpful if elevated, but most times are normal in the presence of the disease. Liver imaging may assist in the diagnosis (ultrasound or MRI and spectroscopy) but a definitive diagnosis of NASH still requires a liver biopsy. This may change in the near future as novel biomarkers become available. Treatment of NAFLD includes aggressive management of associated cardiovascular risk factors and many times control of T2DM. Pioglitazone and vitamin E appear promising for patients with NASH, although long-term studies are unavailable. In summary, this review hopes to address the common clinical dilemmas that endocrinologists face in the diagnosis and management of NAFLD and increase awareness of a potentially serious medical condition.

Noninvasive predictors for liver fibrosis in patients with nonalcoholic steatohepatitis

AIM

To evaluate certain anthropometric, clinical and laboratory features indicating liver fibrosis in nonalcoholic steatohepatitis and to establish the noninvasive markers for liver fibrosis.

METHODS

Eighty-one patients (40 male, 41 female) who were diagnosed with fatty liver by ultrasonographic examination and fulfilled the inclusion criteria participated in the study. Anamnesis, anthropometric, clinical and laboratory features of all cases were recorded and then liver biopsy was performed after obtaining patient consent. Steatosis, necroinflammation and liver fibrosis were examined according to age ≥ 45, gender, body mass index, central obesity, aspartate aminotransferase (AST)/alanine aminotransferase (ALT) > 1, γ-glutamyltransferase (GGT)/ALT > 1, platelet count, insulin, c-peptide levels and the presence of hypertension, diabetes, hypertriglyceridemia and insulin resistance.

RESULTS

Eighty-one patients with non-alcoholic steatohepatitis (NASH) enrolled in the study. 69 of 81 patients were diagnosed with NASH, 11 were diagnosed with simple fatty liver and 1 was diagnosed with cirrhosis. AST/ALT > 1, GGT/ALT > 11, high serum ferritin and fasting insulin levels, the presence of diabetes, hypertension, hypertriglyceridemia and insulin resistance seemed to enhance the severity of steatosis, necroinflammation and fibrosis but these results were not statistically significant.

CONCLUSION

Liver steatosis and fibrosis can occur in individuals with normal weight. There was no significant concordance between severity of liver histology and the presence of predictors for liver fibrosis including metabolic risk factors.

Endoplasmic reticulum stress and the unfolded protein response in nonalcoholic fatty liver disease

The underlying causes of nonalcoholic fatty liver disease (NAFLD) are unclear, although recent evidence has implicated the endoplasmic reticulum (ER) in both the development of steatosis and progression to nonalcoholic steatohepatitis. Disruption of ER homeostasis, often termed "ER stress," has been observed in liver and adipose tissue of humans with NAFLD and/or obesity. Importantly, the signaling pathway activated by disruption of ER homeostasis, the unfolded protein response, has been linked to lipid biosynthesis, insulin action, inflammation, and apoptosis. Therefore, understanding the mechanisms that disrupt ER homeostasis in NAFLD and the role of ER-mediated signaling have become topics of intense investigation. The present review will examine the ER and the unfolded protein response in the context of NAFLD.

A simple clinical scoring system using ferritin, fasting insulin, and type IV collagen 7S for predicting steatohepatitis in nonalcoholic fatty liver disease

BACKGROUND

Liver histology is the gold standard for the diagnosis of nonalcoholic steatohepatitis (NASH). Noninvasive, simple, reproducible, and reliable biomarkers are greatly needed to differentiate NASH from nonalcoholic fatty liver disease (NAFLD).

METHODS

To construct a scoring system for predicting NASH, 177 Japanese patients with biopsy-proven NAFLD were enrolled. To validate the scoring system, 442 biopsy-proven NAFLD patients from eight hepatology centers in Japan were also enrolled.

RESULTS

In the estimation group, 98 (55%) patients had NASH. Serum ferritin [≥200 ng/ml (female) or ≥300 ng/ml (male)], fasting insulin (≥10 μU/ml), and type IV collagen 7S (≥5.0 ng/ml) were selected as independent variables associated with NASH, by multilogistic regression analysis. These three variables were combined in a weighted sum [serum ferritin ≥200 ng/ml (female) or ≥300 ng/ml (male) = 1 point, fasting insulin ≥10 μU/ml = 1 point, and type IV collagen 7S ≥5.0 ng/ml = 2 points] to form an easily calculated composite score for predicting NASH, called the NAFIC score. The area under the receiver operating characteristic (AUROC) curve for predicting NASH was 0.851 in the estimation group and 0.782 in the validation group. The NAFIC AUROC was the greatest among several previously established scoring systems for detecting NASH, but also for predicting severe fibrosis.

CONCLUSIONS

NAFIC score can predict NASH in Japanese NAFLD patients with sufficient accuracy and simplicity to be considered for clinical use.

Pathology of nonalcoholic fatty liver disease

Nonalcoholic fatty liver disease (NAFLD) is a significant complication of obesity and is recognized as the hepatic manifestation of the metabolic syndrome. The process occurs in adults and children and is characterized by the presence of increased amounts of fat in the liver (steatosis). With inflammation, cell death and scarring (fibrosis), the process may result in end-stage liver disease, or be a precursor for hepatocellular carcinoma. Excess hepatic fat is now recognized as an independent marker for increased cardiovascular risk. Even though imaging studies and laboratory-based tests are accurate at detecting significant steatosis and/or advanced fibrosis, respectively, the diagnosis and characterization of NAFLD ultimately depend on histopathologic evaluation, as the parenchymal alterations that comprise the spectrum of injury in NAFLD include patterns as well as specific lesions. Histologic findings in children may differ from those in adults. In this Review, the histologic features that are diagnostic and discriminatory between steatosis and steatohepatitis, the significance of the distinction between steatosis and steatohepatitis, the types and locations of fibrosis, and the histologic variances between adult and pediatric NAFLD are discussed. Clinical advantages as well as potential drawbacks of liver biopsy are presented. Current pathophysiologic concepts relevant to histologic findings are discussed.