Derivation and validation of a scoring system for predicting nonalcoholic steatohepatitis in Taiwanese patients with severe obesity

Development, Validation, and Application of a Scoring Model for Non-alcoholic Steatohepatitis

PURPOSE

The aim of this study was to explore risk factors of NASH and then develop a non-invasive scoring model in Chinese patients with obesity. A scoring system was then applied to assess the effect of sleeve gastrectomy on NASH.

METHODS

A total of 243 patients with obesity were included and divided into NASH group and non-NASH group according to the pathological results of liver biopsy. Logistic regression was used to determine risk factors of NASH. A scoring model was derived by risk factors of NASH. Then, postoperative follow-up was performed in 70 patients.

RESULTS

Among the 243 patients, 118 (48.56%) patients showed NASH. Multivariate logistic regression identified aspartate aminotransferase (AST) (>21.50 IU/L), high-density lipoprotein cholesterol (HDL-C) (<1.155mmol/L), and homeostasis model assessment (HOMA-IR) (>9.368) as independent risk factors of NASH. The model included above risk factors showed a negative predictive value (NPV) of 70.38% in the low-risk category and a positive predictive value (PPV) of 85.71% in the high-risk category, with the area under the receiver operator curve (AUROC) of 0.737. Bariatric surgery resulted in a sharp decline in AST and HOMA-IR and a significant increase of HDL-C. The points of scoring model were improved at 6 months after surgery.

CONCLUSION

A non-invasive scoring model was derived by the risk factors of NASH included AST, HDL-C, and HOMA-IR and applied to the postoperative follow-up. After sleeve gastrectomy, the above risk factors and points of scoring model were significantly improved.

Trajectory of NAFLD characteristics after Roux-en-Y gastric bypass: a five-year historical cohort study

BACKGROUND

The long-term effects of bariatric surgery on the course of non-alcoholic fatty hepatopathy (NAFLD) are not fully understood.

OBJECTIVE

To analyze the evolution of NAFLD characteristics through noninvasive markers after Roux-en-Y gastric bypass (RYGB) over a five-year period.

DESIGN AND SETTING

Historical cohort study; tertiary-level university hospital.

METHODS

The evolution of NAFLD-related characteristics was evaluated among 49 individuals who underwent RYGB, with a five-year follow-up. Steatosis was evaluated through the hepatic steatosis index (HSI), steatohepatitis through the clinical score for non-alcoholic steatohepatitis (C-NASH) and fibrosis through the NAFLD fibrosis score (NFS).

RESULTS

91.8% of the individuals were female. The mean age was 38.3 ± 10 years and average body mass index (BMI), 37.4 ± 2.3 kg/m2. HSI significantly decreased from 47.15 ± 4.27 to 36.03 ± 3.72 at 12 months (P &lt; 0.01), without other significant changes up to 60 months. C-NASH significantly decreased from 0.75 ± 1.25 to 0.29 ± 0.7 at 12 months (P &lt; 0.01), without other significant changes up to 60 months. NFS decreased from 1.14 ± 1.23 to 0.27 ± 0.99 at 12 months (P &lt; 0.01), and then followed a slightly ascending course, with a marked increase by 60 months (0.82 ± 0.89), but still lower than at baseline (P &lt; 0.05). HSI variation strongly correlated with the five-year percentage total weight loss (R = 0.8; P &lt; 0.0001).

CONCLUSION

RYGB led to significant improvement of steatosis, steatohepatitis and fibrosis after five years. Fibrosis was the most refractory abnormality, with a slightly ascending trend after two years. Steatosis improvement directly correlated with weight loss.

Comparison of reader agreement, correlation with liver biopsy, and time-burden sampling strategies for liver proton density fat fraction measured using magnetic resonance imaging in patients with obesity: a secondary cross-sectional study

Background

The magnetic resonance imaging (MRI)-based proton density fat fraction (PDFF) has become popular for quantifying liver fat content. However, the variability of the region-of-interest (ROI) sampling strategy may result in a lack of standardisation of this technology. In an effort to establish an accurate and effective PDFF measurement scheme, this study assessed the pathological correlation, the reader agreement, and time-burden of different sampling strategies with variable ROI size, location, and number.

Methods

Six-echo spoiled gradient-recalled-echo magnitude-based fat quantification was performed for 50 patients with obesity, using a 3.0-T MRI scanner. Two readers used different ROI sampling strategies to measure liver PDFF, three times. Intra-reader and inter-reader agreement was evaluated using intra-class correlation coefficients and Bland‒Altman analysis. Pearson correlations were used to assess the correlation between PDFFs and liver biopsy. Time-burden was recorded.

Results

For pathological correlations, the correlations for the strategy of using three large ROIs in Couinaud segment 3 (S3 3L-ROI) were significantly greater than those for all sampling strategies at the whole-liver level (P < 0.05). For inter-reader agreement, the sampling strategies at the segmental level for S3 3L-ROI and using three large ROIs in Couinaud segment 6 (S6 3L-ROI) and the sampling strategies at the whole-liver level for three small ROIs per Couinaud segment (27S-ROI), one large ROI per Couinaud segment (9L-ROI), and three large ROIs per Couinaud segment (27S-ROI) had limits of agreement (LOA) < 1.5%. For intra-reader agreement, the sampling strategies at the whole-liver level for 27S-ROI, 9L-ROI, and 27L-ROI had both intraclass coefficients > 0.995 and LOAs < 1.5%. The change in the time-burden was the largest (100.80 s) when 9L-ROI was changed to 27L-ROI.

Conclusions

For hepatic PDFF measurement without liver puncture biopsy as the gold standard, and for general hepatic PDFF assessment, 9L-ROI sampling strategy at the whole-liver level should be used preferentially. For hepatic PDFF with liver puncture biopsy as the gold standard, 3L-ROI sampling strategy at the puncture site segment is recommended.

SHOULD ROUTINE LIVER BIOPSY BE CONSIDERED IN BARIATRIC SURGICAL PRACTICE? AN ANALYSIS OF THE LIMITATIONS OF NON-INVASIVE NAFLD MARKERS

ABSTRACT Background Non-invasive markers are useful and practical tools for assessing non-alcoholic fatty liver disease (NAFLD), but liver biopsy remains the gold-standard method. Liver biopsy can be easily obtained on individuals undergoing bariatric surgery, but there is no ultimate evidence on the relationship between costs, risks and benefits of its systematic performance. Objective To compare the diagnostic accuracy of non-invasive methods with liver biopsy for detection and staging of NAFLD in obese individuals undergoing bariatric surgery. Methods This is a cross-sectional, observational and descriptive study which enrolled individuals who underwent bariatric surgery from 2018 through 2019 at a public tertiary university hospital. Ultrasound scan, hepatic steatosis index, Clinical Non-Alcoholic Steatohepatitis Score (C-NASH), hypertension, alanine aminotransferase (ALT) and insulin resistance (HAIR), aspartate aminotransferase (AST) to Platelet Ratio Index (APRI), NAFLD Fibrosis Score (NFS) and body mass index, AST/ALT ratio, and diabetes (BARD) were the methods compared with the histopathological examination of wedge liver biopsies collected during surgery. Results Of 104 individuals analyzed, 91 (87.5%) were female. The mean age was 34.9±9.7 years. There was no biopsy-related morbidity. The respective overall accuracies of each marker analyzed were: ultrasound scan (79.81% for steatosis), hepatic steatosis index (79.81% for steatosis), HAIR (40.23% for steatohepatitis), C-NASH (22.99% for steatohepatitis), APRI (94.23% for advanced fibrosis), NFS (94.23% for advanced fibrosis), and BARD (16.35% for advanced fibrosis). Discussion Given the high prevalence of liver disease within this population, even the most accurate markers did not present enough discretionary power to detect and/or rule out the NAFLD aspects they were designed to assess in comparison with liver biopsy, which is safe and easy to obtain in these patients. Conclusion Wedge liver biopsy during bariatric surgery helps to diagnose and stage NAFLD, presents low risks and acceptable costs; given the limitations of non-invasive methods, it is justifiable and should be considered in bariatric routine.

Prevalence and predictors of non-alcoholic steatohepatitis in patients with morbid obesity

BACKGROUND

Non-alcoholic fatty liver disease (NAFLD) is highly prevalent in morbid obesity (MO). A considerable proportion of patients with MO have non-alcoholic steatohepatitis (NASH). Liver biopsy (LB) is the only procedure that reliably differentiates NASH from other stages of NAFLD, but its invasive nature prevents it from being generalisable. Hence, non-invasive assessment is critical in this group of patients.

OBJECTIVES

To report NAFLD/NASH prevalence in a cohort of patients with MO and to identify predictors of NASH.

METHODS

Fifty-two consecutive patients subjected to bariatric surgery in a University hospital in Spain underwent LB. Anthropometric, clinical and biochemical variables were registered. According of the results of the LB, individuals were classified by whether they had NASH or not. Multiple logistic regression analysis was performed to identify independent factors associated with NASH.

RESULTS

NAFLD was reported in 94.2% of the patients, simple steatosis was present in 51.92% and NASH in 42.31%. Meanwhile, 17.3% of patients exhibited significant fibrosis (≥F2). HIGHT score for NASH risk was established using five independent predictors: systemic Hypertension, Insulin resistance, Gamma-glutamyl transferase, High density lipoprotein cholesterol and alanine Transaminase. This score ranges from 0 to 7 and was used to predict NASH in our cohort (area under the receiver operator characteristic curve 0.846). A score of 4 or greater implied high risk (sensitivity 77.3%, specificity 73.3%, positive predictive value 68%, negative predictive value 81.5%, accuracy 75%).

CONCLUSIONS

NAFLD is practically a constant in MO with a considerable proportion of patients presenting NASH. The combination of five independent predictors in a scoring system may help the clinician optimise the selection of patients with MO for LB.

Prevalence and predictors of non-alcoholic steatohepatitis in patients with morbid obesity

BACKGROUND

Non-alcoholic fatty liver disease (NAFLD) is highly prevalent in morbid obesity (MO). A considerable proportion of patients with MO have non-alcoholic steatohepatitis (NASH). Liver biopsy (LB) is the only procedure that reliably differentiates NASH from other stages of NAFLD, but its invasive nature prevents it from being generalisable. Hence, non-invasive assessment is critical in this group of patients.

OBJECTIVES

To report NAFLD/NASH prevalence in a cohort of patients with MO and to identify predictors of NASH.

METHODS

Fifty-two consecutive patients subjected to bariatric surgery in a University hospital in Spain underwent LB. Anthropometric, clinical and biochemical variables were registered. According of the results of the LB, individuals were classified by whether they had NASH or not. Multiple logistic regression analysis was performed to identify independent factors associated with NASH.

RESULTS

NAFLD was reported in 94.2% of the patients, simple steatosis was present in 51.92% and NASH in 42.31%. Meanwhile, 17.3% of patients exhibited significant fibrosis (≥F2). HIGHT score for NASH risk was established using five independent predictors: systemic Hypertension, Insulin resistance, Gamma-glutamyl transferase, High density lipoprotein cholesterol and alanine Transaminase. This score ranges from 0 to 7 and was used to predict NASH in our cohort (area under the receiver operator characteristic curve 0.846). A score of 4 or greater implied high risk (sensitivity 77.3%, specificity 73.3%, positive predictive value 68%, negative predictive value 81.5%, accuracy 75%).

CONCLUSIONS

NAFLD is practically a constant in MO with a considerable proportion of patients presenting NASH. The combination of five independent predictors in a scoring system may help the clinician optimise the selection of patients with MO for LB.

Fibroscan-Based Score to Predict Significant Liver Fibrosis in Morbidly Obese Patients with Nonalcoholic Fatty Liver Disease

BACKGROUND

The prevalence rate of nonalcoholic fatty liver disease (NAFLD) has been reported in 74 to 90% of morbidly obese patients. This study aims to develop a scoring system that predicts significant liver fibrosis in morbidly obese patients.

METHODS

This prospective cohort study involved 123 morbidly obese patients who underwent metabolic surgery at Taipei Medical University Hospital between October 2016 and June 2018. Wedge liver biopsy was performed during surgery, and significant liver fibrosis was defined as a fibrosis score ≧ 2. Ultrasonography and transient elastography were performed prior to surgery to assess the risk factors associated with significant liver fibrosis.

RESULTS

Mean patient age was 35.5 years, mean body mass index (BMI) was 40.6 kg/m2, and 87 (70.7%) were female. Fibrosis staging revealed 28 (22.8%) at stage 2, 14 (11.4%) at stage 3, and 2 (1.6%) at stage 4. Patients were then separated into training (n = 73) and validation (n = 50) cohorts. Multivariate analysis revealed a liver stiffness measurement (LSM) > 7 kPa and aspartate aminotransferase/platelet ratio index (APRI) > 0.40 as independent factors associated with significant liver fibrosis among the training cohort. Fibroscan-base score weighted sum of (1 for presence of APRI > 0.40) + (2 for presence of LSM > 7 kPa) yielded the highest area under receiver operating curve (0.854, P = 0.0001; 0.785, P = 0.0002) compared with other non-invasive markers in the training and validation cohorts, respectively.

CONCLUSION

We developed a simple, clinical scoring system incorporating Fibroscan and APRI to predict significant liver fibrosis in morbidly obese patients.

Noninvasive evaluation of nonalcoholic fatty liver disease: Current evidence and practice

With the increasing number of individuals with diabetes and obesity, nonalcoholic fatty liver disease (NAFLD) is becoming increasingly prevalent, affecting one-quarter of adults worldwide. The spectrum of NAFLD ranges from simple steatosis or nonalcoholic fatty liver (NAFL) to nonalcoholic steatohepatitis (NASH). NAFLD, especially NASH, may progress to fibrosis, leading to cirrhosis and hepatocellular carcinoma. NAFLD can impose a severe economic burden, and patients with NAFLD-related terminal or deteriorative liver diseases have become one of the main groups receiving liver transplantation. The increasing prevalence of NAFLD and the severe outcomes of NASH make it necessary to use effective methods to identify NAFLD. Although recognized as the gold standard, biopsy is limited by its sampling bias, poor acceptability, and severe complications, such as mortality, bleeding, and pain. Therefore, noninvasive methods are urgently needed to avoid biopsy for diagnosing NAFLD. This review discusses the current noninvasive methods for assessing NAFLD, including steatosis, NASH, and NAFLD-related fibrosis, and explores the advantages and disadvantages of measurement tools. In addition, we analyze potential noninvasive biomarkers for tracking disease processes and monitoring treatment effects, and explore effective algorithms consisting of imaging and nonimaging biomarkers for diagnosing advanced fibrosis and reducing unnecessary biopsies in clinical practice.

Long-term effect of bariatric surgery on resolution of nonalcoholic steatohepatitis (NASH): An external validation and application of a clinical NASH score

BACKGROUND

Nonalcoholic steatohepatitis (NASH) is an important etiology of end-stage liver disease. Long-term effect of bariatric surgery in improvement of NASH is not clear.

OBJECTIVES

To validate a scoring system for predicting NASH in morbidly obese patients and using it to evaluate the long-term effect of bariatric surgery on NASH.

SETTING

Tertiary referral hospital, Taiwan.

METHODS

A new 5-point clinical NASH (C-NASH) score incorporating body mass index, alanine aminotransferase, and triglyceride was validated in a group of 307 bariatric patients (mean age 30.2 years, incorporating body mass index 45.0 kg/m²) with concurrent liver biopsy from 2003 to 2008. Remission of NASH in 5741 obese patients undergoing bariatric/metabolic surgery with long-term follow-up was then evaluated using the C-NASH score.

RESULTS

Among 307 patients with liver biopsy, the prevalence of NASH was 44.0%. At baseline, the NASH group had significantly worse fasting glucose levels, triglycerides, uric acid, aspartate aminotransferase, alanine aminotransferase, gamma glutamyl transferase, and glycated hemoglobin. The diagnostic sensitivity of C-NASH score was 84.4%, and the accuracy was 68.4%. Among 5741 bariatric patients, the prevalence of high risk for NASH evaluated by C-NASH score was 40.9%. Postoperative follow-up showed good weight loss and almost complete remission of high risk for NASH up to 10 years. Patients with gastric banding had less weight loss, higher mean level of C-NASH score, and a higher incidence of high risk for NASH compared with other procedures at follow-up.

CONCLUSION

This study demonstrated that improvement in C-NASH score suggesting remission of NASH is durable up to 10 years in all kinds of bariatric procedures.