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Drozdov I, Szubert B, Rowe IA, Kendall TJ, Fallowfield JA. Accurate prediction of all-cause mortality in patients with metabolic dysfunction-associated steatotic liver disease using electronic health records. Ann Hepatol 2024:101528. [PMID: 38971372 DOI: 10.1016/j.aohep.2024.101528] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2024] [Accepted: 06/13/2024] [Indexed: 07/08/2024]
Abstract
INTRODUCTION AND OBJECTIVES Despite the huge clinical burden of MASLD, validated tools for early risk stratification are lacking, and heterogeneous disease expression and a highly variable rate of progression to clinical outcomes result in prognostic uncertainty. We aimed to investigate longitudinal electronic health record-based outcome prediction in MASLD using a state-of-the-art machine learning model. PATIENTS AND METHODS n = 940 patients with histologically-defined MASLD were used to develop a deep-learning model for all-cause mortality prediction. Patient timelines, spanning 12 years, were fully-annotated with demographic/clinical characteristics, ICD-9 and -10 codes, blood test results, prescribing data, and secondary care activity. A Transformer neural network (TNN) was trained to output concomitant probabilities of 12-, 24-, and 36-month all-cause mortality. In-sample performance was assessed using 5-fold cross-validation. Out-of-sample performance was assessed in an independent set of n = 528 MASLD patients. RESULTS In-sample model performance achieved AUROC curve 0.74-0.90 (95 % CI: 0.72-0.94), sensitivity 64 %-82 %, specificity 75 %-92 % and Positive Predictive Value (PPV) 94 %-98 %. Out-of-sample model validation had AUROC 0.70-0.86 (95 % CI: 0.67-0.90), sensitivity 69 %-70 %, specificity 96 %-97 % and PPV 75 %-77 %. Key predictive factors, identified using coefficients of determination, were age, presence of type 2 diabetes, and history of hospital admissions with length of stay >14 days. CONCLUSIONS A TNN, applied to routinely-collected longitudinal electronic health records, achieved good performance in prediction of 12-, 24-, and 36-month all-cause mortality in patients with MASLD. Extrapolation of our technique to population-level data will enable scalable and accurate risk stratification to identify people most likely to benefit from anticipatory health care and personalized interventions.
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Affiliation(s)
| | | | - Ian A Rowe
- Leeds Institute of Medical Research, University of Leeds, UK; Leeds Liver Unit, St James's University Hospital, Leeds Teaching Hospitals, UK
| | - Timothy J Kendall
- Edinburgh Pathology, University of Edinburgh, Edinburgh, UK; Centre for Inflammation Research, Institute for Regeneration and Repair, University of Edinburgh, Edinburgh, UK
| | - Jonathan A Fallowfield
- Centre for Inflammation Research, Institute for Regeneration and Repair, University of Edinburgh, Edinburgh, UK.
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2
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He Q, He W, Dong H, Guo Y, Yuan G, Shi X, Wang D, Lu F. Role of liver sinusoidal endothelial cell in metabolic dysfunction-associated fatty liver disease. Cell Commun Signal 2024; 22:346. [PMID: 38943171 PMCID: PMC11214243 DOI: 10.1186/s12964-024-01720-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2024] [Accepted: 06/20/2024] [Indexed: 07/01/2024] Open
Abstract
Liver sinusoidal endothelial cells (LSECs) are highly specialized endothelial cells that represent the interface between blood cells on one side and hepatocytes on the other side. LSECs not only form a barrier within the hepatic sinus, but also play important physiological functions such as regulating hepatic vascular pressure, anti-inflammatory and anti-fibrotic. Pathologically, pathogenic factors can induce LSECs capillarization, that is, loss of fenestra and dysfunction, which are conducive to early steatosis, lay the foundation for the progression of metabolic dysfunction-associated fatty liver disease (MAFLD), and accelerate metabolic dysfunction-associated steatohepatitis (MASH) and liver fibrosis. The unique localization, phenotype, and function of LSECs make them potential candidates for reducing liver injury, inflammation, and preventing or reversing fibrosis in the future.
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Affiliation(s)
- Qiongyao He
- Institute of Integrated Traditional Chinese and Western Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China
| | - Wu He
- Division of Cardiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China
- Hubei Key Laboratory of Genetics and Molecular Mechanisms of Cardiological Disorders, Wuhan, 430030, China
| | - Hui Dong
- Department of Integrated Traditional Chinese and Western Medicine, Tongji Medical College, Tongji Hospital, Huazhong University of Science and Technology, Wuhan, 430030, China
| | - Yujin Guo
- Institute of Integrated Traditional Chinese and Western Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China
| | - Gang Yuan
- Department of Endocrinology, Department of Internal Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China
| | - Xiaoli Shi
- Department of Endocrinology, Department of Internal Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China
| | - Dingkun Wang
- Department of Integrated Traditional Chinese and Western Medicine, Tongji Medical College, Tongji Hospital, Huazhong University of Science and Technology, Wuhan, 430030, China.
| | - Fuer Lu
- Department of Integrated Traditional Chinese and Western Medicine, Tongji Medical College, Tongji Hospital, Huazhong University of Science and Technology, Wuhan, 430030, China.
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3
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Abeysekera KWM, Shearer J, Tavabie OD, Dillon JF, Rowe IA. #FGDebate: Should we focus on detecting patients at risk of liver disease in the community? Frontline Gastroenterol 2022; 14:343-345. [PMID: 37409342 PMCID: PMC11138178 DOI: 10.1136/flgastro-2022-102330] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Accepted: 11/20/2022] [Indexed: 12/03/2022] Open
Affiliation(s)
- Kushala WM Abeysekera
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | | | - Oliver D Tavabie
- The Sheila Sherlock Liver Centre, Royal Free Hospital, London, UK
| | - John F Dillon
- Division of Clinical and Molecular Medicine, University of Dundee, Ninewells Hospital and Medical School, Dundee, UK
| | - Ian A Rowe
- Leeds Institute for Medical Research, University of Leeds & Leeds Liver Unit, St James's University Hospital, Leeds, UK
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4
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Gosalia D, Ratziu V, Stanicic F, Vukicevic D, Zah V, Gunn N, Halegoua-DeMarzio D, Tran T. Accuracy of Noninvasive Diagnostic Tests for the Detection of Significant and Advanced Fibrosis Stages in Nonalcoholic Fatty Liver Disease: A Systematic Literature Review of the US Studies. Diagnostics (Basel) 2022; 12:2608. [PMID: 36359453 PMCID: PMC9689671 DOI: 10.3390/diagnostics12112608] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Revised: 10/18/2022] [Accepted: 10/24/2022] [Indexed: 04/05/2024] Open
Abstract
BACKGROUND The purpose of this systematic literature review (SLR) was to evaluate the accuracy of noninvasive diagnostic tools in detecting significant or advanced (F2/F3) fibrosis among patients with nonalcoholic fatty liver (NAFL) in the US healthcare context. METHODS The SLR was conducted in PubMed and Web of Science, with an additional hand search of public domains and citations, in line with the PRISMA statement. The study included US-based original research on diagnostic test sensitivity, specificity and accuracy. RESULTS Twenty studies were included in qualitative evidence synthesis. Imaging techniques with the highest diagnostic accuracy in F2/F3 detection and differentiation were magnetic resonance elastography and vibration-controlled transient elastography. The most promising standard blood biomarkers were NAFLD fibrosis score and FIB-4. The novel diagnostic tools showed good overall accuracy, particularly a score composed of body mass index, GGT, 25-OH-vitamin D, and platelet count. The novel approaches in liver fibrosis detection successfully combine imaging techniques and blood biomarkers. CONCLUSIONS While noninvasive techniques could overcome some limitations of liver biopsy, a tool that would provide a sufficiently sensitive and reliable estimate of changes in fibrosis development and regression is still missing.
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Affiliation(s)
- Dhaval Gosalia
- Department of Commercial Strategy and Operations, Glympse Bio, Cambridge, MA 02140, USA
| | - Vlad Ratziu
- Department of Medicine, Medicine Sorbonne University, 75013 Paris, France
| | - Filip Stanicic
- Health Economics and Outcomes Research Department, ZRx Outcomes Research Inc., Mississauga, ON L5A 2X7, Canada
| | - Djurdja Vukicevic
- Health Economics and Outcomes Research Department, ZRx Outcomes Research Inc., Mississauga, ON L5A 2X7, Canada
| | - Vladimir Zah
- Health Economics and Outcomes Research Department, ZRx Outcomes Research Inc., Mississauga, ON L5A 2X7, Canada
| | - Nadege Gunn
- Department of Hepatology, Impact Research Institute, Waco, TX 76710, USA
| | - Dina Halegoua-DeMarzio
- Department of Medicine, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA 19107, USA
| | - Tram Tran
- Department of Medicine, UCLA Santa Monica Medical Center, Santa Monica, CA 90404, USA
- Department of Medicine, UCLA David Geffen School of Medicine, Los Angeles, CA 90095, USA
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5
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Åberg F, Luukkonen PK, But A, Salomaa V, Britton A, Petersen KM, Bojesen SE, Balling M, Nordestgaard BG, Puukka P, Männistö S, Lundqvist A, Perola M, Jula A, Färkkilä M. Development and validation of a model to predict incident chronic liver disease in the general population: The CLivD score. J Hepatol 2022; 77:302-311. [PMID: 35271949 DOI: 10.1016/j.jhep.2022.02.021] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Revised: 02/07/2022] [Accepted: 02/15/2022] [Indexed: 12/19/2022]
Abstract
BACKGROUND & AIMS Current screening strategies for chronic liver disease focus on detection of subclinical advanced liver fibrosis but cannot identify those at high future risk of severe liver disease. Our aim was to develop and validate a risk prediction model for incident chronic liver disease in the general population based on widely available factors. METHODS Multivariable Cox regression analyses were used to develop prediction models for liver-related outcomes with and without laboratory measures (Modellab and Modelnon-lab) in 25,760 individuals aged 40-70 years. Their data were sourced from the Finnish population-based health examination surveys FINRISK 1992-2012 and Health 2000 (derivation cohort). The models were externally validated in the Whitehall II (n = 5,058) and Copenhagen City Heart Study (CCHS) (n = 3,049) cohorts. RESULTS The absolute rate of incident liver outcomes per 100,000 person-years ranged from 53 to 144. The final prediction model included age, sex, alcohol use (drinks/week), waist-hip ratio, diabetes, and smoking, and Modellab also included gamma-glutamyltransferase values. Internally validated Wolbers' C-statistics were 0.77 for Modellab and 0.75 for Modelnon-lab, while apparent 15-year AUCs were 0.84 (95% CI 0.75-0.93) and 0.82 (95% CI 0.74-0.91). The models identified a small proportion (<2%) of the population with >10% absolute 15-year risk for liver events. Of all liver events, only 10% occurred in participants in the lowest risk category. In the validation cohorts, 15-year AUCs were 0.78 (Modellab) and 0.65 (Modelnon-lab) in the CCHS cohort, and 0.78 (Modelnon-lab) in the Whitehall II cohort. CONCLUSIONS Based on widely available risk factors, the Chronic Liver Disease (CLivD) score can be used to predict risk of future advanced liver disease in the general population. LAY SUMMARY Liver disease often progresses silently without symptoms and thus the diagnosis is often delayed until severe complications occur and prognosis becomes poor. In order to identify individuals in the general population who have a high risk of developing severe liver disease in the future, we developed and validated a Chronic Liver Disease (CLivD) risk prediction score, based on age, sex, alcohol use, waist-hip ratio, diabetes, and smoking, with or without measurement of the liver enzyme gamma-glutamyltransferase. The CLivD score can be used as part of health counseling, and for planning further liver investigations and follow-up.
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Affiliation(s)
- Fredrik Åberg
- Transplantation and Liver Surgery, Helsinki University Hospital, University of Helsinki, Helsinki, Finland.
| | - Panu K Luukkonen
- Minerva Foundation Institute for Medical Research, Helsinki, Finland; Department of Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland; Department of Internal Medicine, Yale University, New Haven, CT, USA
| | - Anna But
- Biostatistics Consulting, Department of Public Health, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | | | - Annie Britton
- Institute of Epidemiology and Health Care, University College London, London, UK
| | - Kasper Meidahl Petersen
- Department of Clinical Biochemistry, Herlev and Gentofte Hospital, Copenhagen University Hospital, Herlev, Denmark
| | - Stig Egil Bojesen
- Department of Clinical Biochemistry, Herlev and Gentofte Hospital, Copenhagen University Hospital, Herlev, Denmark; Copenhagen City Heart Study, Frederiksberg Hospital, Copenhagen University Hospital, Frederiksberg, Denmark; Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Denmark
| | - Mie Balling
- Department of Clinical Biochemistry, Herlev and Gentofte Hospital, Copenhagen University Hospital, Herlev, Denmark; Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Denmark
| | - Børge G Nordestgaard
- Department of Clinical Biochemistry, Herlev and Gentofte Hospital, Copenhagen University Hospital, Herlev, Denmark; Copenhagen City Heart Study, Frederiksberg Hospital, Copenhagen University Hospital, Frederiksberg, Denmark; Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Denmark
| | - Pauli Puukka
- Clinicum, University of Helsinki, Helsinki, Finland
| | | | | | | | - Antti Jula
- Finnish Institute for Health and Welfare, Finland
| | - Martti Färkkilä
- Helsinki University and Helsinki University Hospital, Abdominal Center, Helsinki, Finland
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6
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Sajid IM, Frost K, Paul AK. 'Diagnostic downshift': clinical and system consequences of extrapolating secondary care testing tactics to primary care. BMJ Evid Based Med 2022; 27:141-148. [PMID: 34099498 DOI: 10.1136/bmjebm-2020-111629] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/09/2021] [Indexed: 12/21/2022]
Abstract
Numerous drivers push specialist diagnostic approaches down to primary care ('diagnostic downshift'), intuitively welcomed by clinicians and patients. However, primary care's different population and processes result in under-recognised, unintended consequences. Testing performs poorer in primary care, with indication creep due to earlier, more undifferentiated presentation and reduced accuracy due to spectrum bias and the 'false-positive paradox'. In low-prevalence settings, tests without near-100% specificity have their useful yield eclipsed by greater incidental or false-positive findings. Ensuing cascades and multiplier effects can generate clinician workload, patient anxiety, further low-value tests, referrals, treatments and a potentially nocebic population 'disease' burden of unclear benefit. Increased diagnostics earlier in pathways can burden patients and stretch general practice (GP) workloads, inducing downstream service utilisation and unintended 'market failure' effects. Evidence is tenuous for reducing secondary care referrals, providing patient reassurance or meaningfully improving clinical outcomes. Subsequently, inflated investment in per capita testing, at a lower level in a healthcare system, may deliver diminishing or even negative economic returns. Test cost poorly represents 'value', neglecting under-recognised downstream consequences, which must be balanced against therapeutic yield. With lower positive predictive values, more tests are required per true diagnosis and cost-effectiveness is rarely robust. With fixed secondary care capacity, novel primary care testing is an added cost pressure, rarely reducing hospital activity. GP testing strategies require real-world evaluation, in primary care populations, of all downstream consequences. Test formularies should be scrutinised in view of the setting of care, with interventions to focus rational testing towards those with higher pretest probabilities, while improving interpretation and communication of results.
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Affiliation(s)
- Imran Mohammed Sajid
- NHS West London Clinical Commissioning Group, London, UK
- University of Global Health Equity, Kigali, Rwanda
| | - Kathleen Frost
- NHS Central London Clinical Commissioning Group, London, UK
| | - Ash K Paul
- NHS South West London Health and Care Partnership STP, London, UK
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7
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One not like the other: The weakness of the blood sugar-MAFLD analogy. J Hepatol 2022; 76:482-484. [PMID: 34678406 DOI: 10.1016/j.jhep.2021.10.010] [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: 09/21/2021] [Revised: 10/01/2021] [Accepted: 10/06/2021] [Indexed: 01/18/2023]
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8
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Kotha S, Berry P. Multiple investigations for a very common disorder: Finding the right balance in NAFLD. J Hepatol 2021; 75:1501-1502. [PMID: 34228993 DOI: 10.1016/j.jhep.2021.06.032] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Revised: 06/22/2021] [Accepted: 06/23/2021] [Indexed: 01/08/2023]
Affiliation(s)
- Sreelakshmi Kotha
- Department of Gastroenterology, Guy's and St Thomas' Foundation Trust, London, United Kingdom.
| | - Philip Berry
- Department of Gastroenterology, Guy's and St Thomas' Foundation Trust, London, United Kingdom
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9
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Schattenberg JM, Anstee QM, Caussy C, Bugianesi E, Popovic B. Differences between current clinical guidelines for screening, diagnosis and management of nonalcoholic fatty liver disease and real-world practice: a targeted literature review. Expert Rev Gastroenterol Hepatol 2021; 15:1253-1266. [PMID: 34493137 DOI: 10.1080/17474124.2021.1974295] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
INTRODUCTION Nonalcoholic fatty liver disease (NAFLD) is the most common liver disease and is associated with obesity and metabolic comorbidities. Liver steatosis can progress to nonalcoholic steatohepatitis (NASH) exhibiting a relevant risk of fibrosis and ultimately liver failure. To date, no approved treatment for NASH to reduce its clinical and humanistic burden has been developed. AREAS COVERED We undertook a literature review to identify English language, national and international clinical guidelines for NAFLD regarding diagnosis, assessment and management, and determined their points of agreement and difference. Additionally, we investigated published literature relating to real-world management of NAFLD and NASH. EXPERT OPINION National (China, England/Wales, Italy, the USA) and international society (Asia-Pacific, Europe, World Gastroenterology Organization) guidelines were identified and analyzed. All guidelines addressed identifying and diagnosing subjects with likely NAFLD, as well as assessment and management of individuals with risk factors for advanced disease, including fibrosis. Real-world practice reveals widespread suboptimal awareness and implementation of guidelines. In the absence of proven therapeutics, such gaps risk failure to recognize patients in need of specialist care and monitoring, highlighting the need for clear, easy-to-apply care pathways to aid in reducing the clinical and humanistic burden of NAFLD and NASH.
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Affiliation(s)
- Jörn M Schattenberg
- Director of Metabolic Liver Research Program, Department of Medicine, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
| | - Quentin M Anstee
- Faculty of Medical Sciences, Chair of Experimental Hepatology, Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK.,Liver Disease Deputy Theme Lead, Newcastle Nihr Biomedical Research Centre, Newcastle upon Tyne Hospitals Nhs Trust, Newcastle upon Tyne, UK
| | - Cyrielle Caussy
- Associate Professor, Département Endocrinologie, Diabète Et Nutrition, Hospices Civils De Lyon, Hôpital Lyon Sud, Lyon, France
| | - Elisabetta Bugianesi
- Department of Medical Sciences, Division of Gastroenterology, Deputy Director and Scientific Director, University of Torino, Torino, Italy
| | - Branko Popovic
- Global Medical Lead Digestive Health, Consumer Healthcare, Medical Affairs, Sanofi-Aventis Deutschland GmbH, Frankfurt, Germany
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10
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Powell EE, Wong VWS, Rinella M. Non-alcoholic fatty liver disease. Lancet 2021; 397:2212-2224. [PMID: 33894145 DOI: 10.1016/s0140-6736(20)32511-3] [Citation(s) in RCA: 1068] [Impact Index Per Article: 356.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Revised: 11/04/2020] [Accepted: 11/13/2020] [Indexed: 02/07/2023]
Abstract
Non-alcoholic fatty liver disease (NAFLD) has a global prevalence of 25% and is a leading cause of cirrhosis and hepatocellular carcinoma. NAFLD encompasses a disease continuum from steatosis with or without mild inflammation (non-alcoholic fatty liver), to non-alcoholic steatohepatitis (NASH), which is characterised by necroinflammation and faster fibrosis progression than non-alcoholic fatty liver. NAFLD has a bidirectional association with components of the metabolic syndrome, and type 2 diabetes increases the risk of cirrhosis and related complications. Although the leading causes of death in people with NAFLD are cardiovascular disease and extrahepatic malignancy, advanced liver fibrosis is a key prognostic marker for liver-related outcomes and overall mortality, and can be assessed with combinations of non-invasive tests. Patients with cirrhosis should be screened for hepatocellular carcinoma and oesophageal varices. There is currently no approved therapy for NAFLD, although several drugs are in advanced stages of development. Because of the complex pathophysiology and substantial heterogeneity of disease phenotypes, combination treatment is likely to be required for many patients with NAFLD. Healthy lifestyle and weight reduction remain crucial to the prevention and treatment of NAFLD.
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Affiliation(s)
- Elizabeth E Powell
- Centre for Liver Disease Research, Faculty of Medicine, University of Queensland, Translational Research Institute, Brisbane, QLD, Australia; Department of Gastroenterology and Hepatology, Princess Alexandra Hospital, Brisbane, QLD, Australia.
| | - Vincent Wai-Sun Wong
- Department of Medicine and Therapeutics, Chinese University of Hong Kong, Hong Kong Special Administrative Region, China; State Key Laboratory of Digestive Disease, Chinese University of Hong Kong, Hong Kong Special Administrative Region, China
| | - Mary Rinella
- Northwestern University, Feinberg School of Medicine, Chicago, IL, USA
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11
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Roskilly A, Hicks A, Taylor EJ, Jones R, Parker R, Rowe IA. Fibrosis progression rate in a systematic review of placebo-treated nonalcoholic steatohepatitis. Liver Int 2021; 41:982-995. [PMID: 33283415 DOI: 10.1111/liv.14749] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2020] [Revised: 10/06/2020] [Accepted: 10/28/2020] [Indexed: 12/13/2022]
Abstract
BACKGROUND & AIMS Liver fibrosis is the critical determinant of liver-related outcomes in persons with nonalcoholic fatty liver disease. The rate that fibrosis develops determines the time taken to reach cirrhosis and consequent clinical outcomes. Estimates of the fibrosis progression rate (FPR) are uncertain having been defined in small observational series that rely largely on nonstandardised repeat biopsy in selected patients. The aim of this study was to evaluate the FPR in placebo-treated participants with nonalcoholic steatohepatitis (NASH) in randomised controlled trials (RCTs). METHODS Systematic review and meta-analysis of RCTs in NASH with data on fibrosis change extracted. Calculated fibrosis progression rates were pooled in meta-analysis. The pooled estimate was then used to model the proportion of hypothetical cohorts starting with no fibrosis at the age of 30 who develop cirrhosis. RESULTS A total of 35 trials including 1419 placebo-treated participants who underwent repeat liver biopsy were evaluated. Considering all trials, the overall FPR was 0.00 stages per year, increasing to 0.03 stages per year in both trials at low risk of bias and trials including >50 placebo-treated participants. This estimate was markedly lower than the value derived from previously pooled analyses of observational data. Using a FPR of 0.03 resulted in a substantial reduction in the proportion of patients developing cirrhosis compared with the FPR derived from observational studies (13% vs 28%). CONCLUSIONS The FPR in placebo-treated participants in RCTs is lower than that described from observational data. Slower fibrosis progression predicts fewer persons with NASH will progress to cirrhosis than previously estimated.
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Affiliation(s)
- Anna Roskilly
- Leeds Liver Unit, St James's University Hospital, Leeds, UK
| | - Amy Hicks
- Leeds Liver Unit, St James's University Hospital, Leeds, UK
| | | | - Rebecca Jones
- Leeds Liver Unit, St James's University Hospital, Leeds, UK
| | - Richard Parker
- Leeds Liver Unit, St James's University Hospital, Leeds, UK
| | - Ian A Rowe
- Leeds Liver Unit, St James's University Hospital, Leeds, UK.,Leeds Institute for Medical Research and Leeds Institute for Data Analytics, University of Leeds, Leeds, UK
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12
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Lu P, Yang G, Jiang L, He W, Wu W, Qi L, Shen S, Rao J, Zhang P, Xue Z, Jiang C, Fan G, Zhu X. Characterizing disease progression of nonalcoholic steatohepatitis in Leptin-deficient rats by integrated transcriptome analysis. Exp Biol Med (Maywood) 2020; 246:678-687. [PMID: 33302736 DOI: 10.1177/1535370220976530] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Nonalcoholic steatohepatitis (NASH) is an aggressive liver disease threatening human health, yet no medicine is developed to treat this disease. In this study, we first discovered that Leptin mutant rats (LepΔI14/ΔI14) exhibit characteristic NASH phenotypes including steatosis, lymphocyte infiltration, and ballooning after postnatal week 16. We then examined NASH progression by performing an integrated analysis of hepatic transcriptome in Leptin-deficient rats from postnatal 4 to 48 weeks. Initially, simple steatosis in LepΔI14/ΔI14 rats were observed with increased expression of the genes encoding for rate-limiting enzymes in lipid metabolism such as acetyl-CoA carboxylase and fatty acid synthase. When NASH phenotypes became well developed at postnatal week 16, we found gene expression changes in insulin resistance, inflammation, reactive oxygen species and endoplasmic reticulum stress. As NASH phenotypes further progressed with age, we observed elevated expression of cytokines and chemokines including C-C motif chemokine ligand 2, tumor necrosis factor ɑ, interleukin-6, and interleukin-1β together with activation of the c-Jun N-terminal kinase and nuclear factor-κB pathways. Histologically, livers in LepΔI14/ΔI14 rats exhibited increased cell infiltration of MPO+ neutrophils, CD8+ T cells, CD68+ hepatic macrophages, and CCR2+ inflammatory monocyte-derived macrophages associated with macrophage polarization from M2 to M1. Subsequent cross-species comparison of transcriptomes in human, rat, and mouse NASH models indicated that Leptin-deficient rats bear more similarities to human NASH patients than previously established mouse NASH models. Taken together, our study suggests that LepΔI14/ΔI14 rats are a valuable pre-clinical rodent model to evaluate NASH drug safety and efficacy.
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Affiliation(s)
- Ping Lu
- Tongji Stem Cell Research Center, School of Medicine, Tongji University, Shanghai 200092, China.,Translational Center for Stem Cell Research, Tongji Hospital, Department of Regenerative Medicine, School of Medicine, Tongji University, Shanghai 200065, China
| | - Guang Yang
- Institute of Translational Research, Tongji Hospital, the School of Life Sciences and Technology, Shanghai Key Laboratory of Signaling and Disease Research, Tongji University, Shanghai 200092, China
| | - Lichun Jiang
- Shanghai Institute for Advanced Immunochemical Studies, ShanghaiTech University, Shanghai 201210, China
| | - Wen He
- Tongji Stem Cell Research Center, School of Medicine, Tongji University, Shanghai 200092, China.,Translational Center for Stem Cell Research, Tongji Hospital, Department of Regenerative Medicine, School of Medicine, Tongji University, Shanghai 200065, China
| | - Wanwan Wu
- Shanghai Pulmonary Hospital, School of Medicine, Tongji University, Shanghai 200433, China
| | - Lingbin Qi
- Tongji Stem Cell Research Center, School of Medicine, Tongji University, Shanghai 200092, China.,Translational Center for Stem Cell Research, Tongji Hospital, Department of Regenerative Medicine, School of Medicine, Tongji University, Shanghai 200065, China
| | - Shijun Shen
- Institute of Translational Research, Tongji Hospital, the School of Life Sciences and Technology, Shanghai Key Laboratory of Signaling and Disease Research, Tongji University, Shanghai 200092, China
| | - Junhua Rao
- Guangdong Key Laboratory of Animal Conservation and Resource Utilization, Guangdong Public Laboratory of Wild Animal Conservation and Utilization, Guangdong Institute of Applied Biological Resources, Guangzhou 510260, China
| | - Peng Zhang
- Shanghai Pulmonary Hospital, School of Medicine, Tongji University, Shanghai 200433, China
| | - Zhigang Xue
- Tongji Stem Cell Research Center, School of Medicine, Tongji University, Shanghai 200092, China.,Translational Center for Stem Cell Research, Tongji Hospital, Department of Regenerative Medicine, School of Medicine, Tongji University, Shanghai 200065, China
| | - Cizhong Jiang
- Institute of Translational Research, Tongji Hospital, the School of Life Sciences and Technology, Shanghai Key Laboratory of Signaling and Disease Research, Tongji University, Shanghai 200092, China.,The Research Center of Stem Cells and Ageing, Tsingtao Advanced Research Institute, Tongji University, Tsingdao 266071, China
| | - Guoping Fan
- Shanghai Institute for Advanced Immunochemical Studies, ShanghaiTech University, Shanghai 201210, China.,Department of Human Genetics, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA 90095, USA
| | - Xianmin Zhu
- Shanghai Institute for Advanced Immunochemical Studies, ShanghaiTech University, Shanghai 201210, China.,Shanghai Pulmonary Hospital, School of Medicine, Tongji University, Shanghai 200433, China
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13
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Mann JP, Carter P, Armstrong MJ, Abdelaziz HK, Uppal H, Patel B, Chandran S, More R, Newsome PN, Potluri R. Hospital admission with non-alcoholic fatty liver disease is associated with increased all-cause mortality independent of cardiovascular risk factors. PLoS One 2020; 15:e0241357. [PMID: 33108366 PMCID: PMC7591046 DOI: 10.1371/journal.pone.0241357] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2019] [Accepted: 10/13/2020] [Indexed: 12/14/2022] Open
Abstract
Non-alcoholic fatty liver disease (NAFLD) is common and strongly associated with the metabolic syndrome. Though NAFLD may progress to end-stage liver disease, the top cause of mortality in NAFLD is cardiovascular disease (CVD). Most of the data on liver-related mortality in NAFLD derives from specialist liver centres. It is not clear if the higher reported mortality rates in individuals with non-cirrhotic NAFLD are entirely accounted for by complications of atherosclerosis and diabetes. Therefore, we aimed to describe the CVD burden and mortality in NAFLD when adjusting for metabolic risk factors using a ‘real world’ cohort. We performed a retrospective study of patients followed-up after an admission to non-specialist hospitals with a NAFLD-spectrum diagnosis. Non-cirrhotic NAFLD and NAFLD-cirrhosis patients were defined by ICD-10 codes. Cases were age-/sex-matched with non-NAFLD hospitalised patients. All-cause mortality over 14-years follow-up after discharge was compared between groups using Cox proportional hazard models adjusted for demographics, CVD, and metabolic syndrome components. We identified 1,802 patients with NAFLD-diagnoses: 1,091 with non-cirrhotic NAFLD and 711 with NAFLD-cirrhosis, matched to 24,737 controls. There was an increasing burden of CVD with progression of NAFLD: for congestive heart failure 3.5% control, 4.2% non-cirrhotic NAFLD, 6.6% NAFLD-cirrhosis; and for atrial fibrillation 4.7% control, 5.9% non-cirrhotic NAFLD, 12.1% NAFLD-cirrhosis. Over 14-years follow-up, crude mortality rates were 14.7% control, 13.7% non-cirrhotic NAFLD, and 40.5% NAFLD-cirrhosis. However, after adjusting for demographics, non-cirrhotic NAFLD (HR 1.3 (95% CI 1.1–1.5)) as well as NAFLD-cirrhosis (HR 3.7 (95% CI 3.0–4.5)) patients had higher mortality compared to controls. These differences remained after adjusting for CVD and metabolic syndrome components: non-cirrhotic NAFLD (HR 1.2 (95% CI 1.0–1.4)) and NAFLD-cirrhosis (HR 3.4 (95% CI 2.8–4.2)). In conclusion, from a large non-specialist registry of hospitalised patients, those with non-cirrhotic NAFLD had increased overall mortality compared to controls even after adjusting for CVD.
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Affiliation(s)
- Jake P. Mann
- MRC Epidemiology Unit, Institute of Metabolic Science, University of Cambridge, Cambridge, United Kingdom
- Department of Paediatrics, University of Cambridge, Cambridge, United Kingdom
- ACALM Study Unit in collaboration with Aston Medical School, Aston University, Birmingham, United Kingdom
- * E-mail:
| | - Paul Carter
- ACALM Study Unit in collaboration with Aston Medical School, Aston University, Birmingham, United Kingdom
- Division of Cardiovascular Medicine, Department of Medicine, University of Cambridge, Cambridge, United Kingdom
| | - Matthew J. Armstrong
- Liver Unit, University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
| | - Hesham K. Abdelaziz
- Lancashire Cardiac Centre, Blackpool Victoria Hospital, Blackpool, United Kingdom
- Department of Cardiovascular Medicine, Ain Shams University Hospital, Cairo, Egypt
| | - Hardeep Uppal
- ACALM Study Unit in collaboration with Aston Medical School, Aston University, Birmingham, United Kingdom
| | - Billal Patel
- Lancashire Cardiac Centre, Blackpool Victoria Hospital, Blackpool, United Kingdom
| | - Suresh Chandran
- Department of Medicine, Pennine Acute Hospitals NHS Trust, Manchester, United Kingdom
| | - Ranjit More
- Lancashire Cardiac Centre, Blackpool Victoria Hospital, Blackpool, United Kingdom
| | - Philip N. Newsome
- National Institute for Health Research Liver Biomedical Research Unit at University Hospitals Birmingham NHS Foundation Trust and the University of Birmingham, Birmingham, United Kingdom
- Centre for Liver Research, Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, United Kingdom
| | - Rahul Potluri
- ACALM Study Unit in collaboration with Aston Medical School, Aston University, Birmingham, United Kingdom
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14
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Rowe IA. Decision making for liver biopsy in NASH, not so FAST? Lancet Gastroenterol Hepatol 2020; 5:332-334. [PMID: 32027859 DOI: 10.1016/s2468-1253(19)30406-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2019] [Accepted: 11/18/2019] [Indexed: 12/15/2022]
Affiliation(s)
- Ian A Rowe
- Leeds Institute for Medical Research and Leeds Institute for Data Analytics, University of Leeds, UK.
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15
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Saoi M, Sasaki K, Sagawa H, Abe K, Kogiso T, Tokushige K, Hashimoto E, Ohashi Y, Britz-McKibbin P. High Throughput Screening of Serum γ-Glutamyl Dipeptides for Risk Assessment of Nonalcoholic Steatohepatitis with Impaired Glutathione Salvage Pathway. J Proteome Res 2019; 19:2689-2699. [PMID: 31483669 DOI: 10.1021/acs.jproteome.9b00405] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Nonalcoholic fatty liver disease (NAFLD) is the most common preventable chronic liver disorder in developed countries, the prevalence of which is increasing worldwide due to its association with obesity and type 2 diabetes. However, the exact mechanisms of NAFLD pathophysiology remain poorly understood including its progression to the more severe nonalcoholic steatohepatitis (NASH). New advances for early detection and monitoring of NASH progression are limited due to the lack of specific blood biomarkers, thus requiring invasive liver biopsies for histopathology. Herein, multisegment injection-capillary electrophoresis-tandem mass spectrometry (MSI-CE-MS/MS) is validated as a high throughput, robust, and quantitative platform for targeted analysis of a panel of 16 serum γ-glutamyl dipeptides from a cohort of NASH adult patients from Japan (median age = 53 years, median BMI = 27 kg/m2, n = 116). Multiplexed separations based on MSI-CE-MS/MS enable the design of unique data workflows that rely on customizable serial sample injection formats for accurate determination of γ-glutamyl dipeptides with quality control. Also, the introduction of a liquid coolant device to the capillary outlet improves long-term migration time stability in CE. Unsupervised pattern recognition methods revealed two distinctive NASH subgroups based on their contrasting γ-glutamyl dipeptide status despite patients having similar clinical phenotypes and NASH activity scores (median NAS ≈ 6.0). There was an inverse correlation between serum γ-glutamyl dipeptide concentrations and γ-glutamyltransferease (GGT) enzyme activity (r = -0.46; p = 2.5 × 10-7), which was indicative of a low-risk (n = 64) as compared to a high-risk (n = 52) patient subgroup with impaired glutathione salvage pathway and likely poor clinical prognosis. Our findings highlight the key role of defects in the γ-glutamyl cycle for differentiation of NASH patients, which may enable better risk assessment of long-term survivorship as a complement to standard liver enzyme screens and histopathology.
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Affiliation(s)
- Michelle Saoi
- Department of Chemistry and Chemical Biology, McMaster University, Hamilton, Ontario L8S 4M1, Canada
| | - Kazunori Sasaki
- Human Metabolome Technologies, Tsuruoka, Yamagata 997-0052, Japan
| | - Hitoshi Sagawa
- Human Metabolome Technologies, Tsuruoka, Yamagata 997-0052, Japan
| | - Kaori Abe
- Human Metabolome Technologies, Tsuruoka, Yamagata 997-0052, Japan
| | - Tomomi Kogiso
- Department of Internal Medicine and Gastroenterology, Tokyo Women's Medical University, Tokyo 162-8666, Japan
| | - Katsutoshi Tokushige
- Department of Internal Medicine and Gastroenterology, Tokyo Women's Medical University, Tokyo 162-8666, Japan
| | - Etsuko Hashimoto
- Department of Internal Medicine and Gastroenterology, Tokyo Women's Medical University, Tokyo 162-8666, Japan
| | - Yoshiaki Ohashi
- Human Metabolome Technologies, Tsuruoka, Yamagata 997-0052, Japan
| | - Philip Britz-McKibbin
- Department of Chemistry and Chemical Biology, McMaster University, Hamilton, Ontario L8S 4M1, Canada
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16
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The diagnosis of nonalcoholic fatty liver disease should carry important prognostic information. Nat Rev Gastroenterol Hepatol 2019; 16:449-450. [PMID: 31197261 DOI: 10.1038/s41575-019-0168-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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17
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Abstract
PURPOSE OF REVIEW To summarize recent findings regarding the characterization of lipoprotein disturbances in nonalcoholic fatty liver disease (NAFLD) and their relationship with cardiovascular disease (CVD) and make recommendations for the management of this situation. RECENT FINDINGS Advanced lipoprotein profile (using NMR spectroscopy) has shown profound lipoprotein derangements which are overlooked with conventional analyses: increased number and size of very low-density lipoproteins particles, increased number of low-density lipoprotein particles (especially small sized), smaller high-density lipoprotein particles, and an increase in the triglyceride content of all these lipoproteins. Other changes such as impaired functionality of high-density lipoprotein particles have also been observed. Beyond low-density lipoprotein-related parameters, the importance of triglyceride-rich lipoproteins in the pathogenesis of atherosclerosis has recently gained interest. Several studies suggest that these lipoproteins may have an independent role in CVD in NAFLD populations. Although outcome studies with lipid-lowering drugs in NAFLD are lacking, treatment with both statins, and especially, triglyceride-lowering drugs could be promising for these populations at high residual cardiovascular risk. SUMMARY In addition to being the main determinant of dyslipidemia, disturbances in triglyceride-rich lipoproteins are thought to be the key factor of increased CVD risk in NAFLD. Treatments specifically aimed at modifying these derangements warrant further study in this high-risk population.
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Affiliation(s)
- Antonio J Amor
- Endocrinology and Nutrition Department, Institut d'Investigacions Biomèdiques August Pi Sunyer (IDIBAPS), Hospital Clínic, Barcelona
- Centro de Investigación Biomédica en Red Fisiopatología de la Obesidad y Nutrición (CIBEROBN), Instituto de Salud Carlos III (ISCIII), Madrid
| | - Verónica Perea
- Endocrinology and Nutrition Department, Hospital Universitari Mútua de Terrassa, Terrassa, Spain
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18
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Stefan N, Häring HU, Cusi K. Non-alcoholic fatty liver disease: causes, diagnosis, cardiometabolic consequences, and treatment strategies. Lancet Diabetes Endocrinol 2019; 7:313-324. [PMID: 30174213 DOI: 10.1016/s2213-8587(18)30154-2] [Citation(s) in RCA: 508] [Impact Index Per Article: 101.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2018] [Revised: 05/02/2018] [Accepted: 05/04/2018] [Indexed: 02/06/2023]
Abstract
The prevalence of non-alcoholic fatty liver disease (NAFLD) is increasing worldwide. In some patients with NAFLD, isolated steatosis can progress to advanced stages with non-alcoholic steatohepatitis (NASH) and fibrosis, increasing the risk of cirrhosis and hepatocellular carcinoma. Furthermore, NAFLD is believed to be involved in the pathogenesis of common disorders such as type 2 diabetes and cardiovascular disease. In this Review, we highlight novel concepts related to diagnosis, risk prediction, and treatment of NAFLD. First, because NAFLD is a heterogeneous disease, the advanced stages of which seem to be strongly affected by comorbidities such as insulin resistance and type 2 diabetes, early use of reliable, non-invasive diagnostic tools is needed, particularly in patients with insulin resistance or diabetes, to allow the identification of patients at different disease stages. Second, although the strongest genetic risk alleles for NAFLD (ie, the 148Met allele in PNPLA3 and the 167Lys allele in TM6SF2) are associated with increased liver fat content and progression to NASH and cirrhosis, these alleles are also unexpectedly associated with an apparent protection from cardiovascular disease. If consistent across diverse populations, this discordance in NAFLD-related risk prediction between hepatic and extrahepatic disease might need to be accounted for in the management of NAFLD. Third, drug treatments assessed in NAFLD seem to differ with respect to cardiometabolic and antifibrotic efficacy, suggesting the need to better identify and tailor the most appropriate treatment approach, or to use a combination of approaches. These emerging concepts could contribute to the development of a multidisciplinary approach for endocrinologists and hepatologists working together in the management of NAFLD.
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Affiliation(s)
- Norbert Stefan
- Department of Internal Medicine IV, University Hospital Tübingen, Tübingen, Germany; Institute of Diabetes Research and Metabolic Diseases, Helmholtz Centre Munich, University of Tübingen, Tübingen, Germany; German Centre for Diabetes Research, Tübingen, Germany.
| | - Hans-Ulrich Häring
- Department of Internal Medicine IV, University Hospital Tübingen, Tübingen, Germany; Institute of Diabetes Research and Metabolic Diseases, Helmholtz Centre Munich, University of Tübingen, Tübingen, Germany; German Centre for Diabetes Research, Tübingen, Germany
| | - Kenneth Cusi
- Division of Endocrinology, Diabetes and Metabolism, University of Florida, Gainesville, FL, USA; Division of Endocrinology, Malcom Randall Veterans Administration, Medical Center, Gainesville, FL, USA
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19
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From sugar to liver fat and public health: systems biology driven studies in understanding non-alcoholic fatty liver disease pathogenesis. Proc Nutr Soc 2019; 78:290-304. [PMID: 30924429 DOI: 10.1017/s0029665119000570] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Non-alcoholic fatty liver disease (NAFLD) is now a major public health concern with an estimated prevalence of 25-30% of adults in many countries. Strongly associated with obesity and the metabolic syndrome, the pathogenesis of NAFLD is dependent on complex interactions between genetic and environmental factors that are not completely understood. Weight loss through diet and lifestyle modification underpins clinical management; however, the roles of individual dietary nutrients (e.g. saturated and n-3 fatty acids; fructose, vitamin D, vitamin E) in the pathogenesis or treatment of NAFLD are only partially understood. Systems biology offers valuable interdisciplinary methods that are arguably ideal for application to the studying of chronic diseases such as NAFLD, and the roles of nutrition and diet in their molecular pathogenesis. Although present in silico models are incomplete, computational tools are rapidly evolving and human metabolism can now be simulated at the genome scale. This paper will review NAFLD and its pathogenesis, including the roles of genetics and nutrition in the development and progression of disease. In addition, the paper introduces the concept of systems biology and reviews recent work utilising genome-scale metabolic networks and developing multi-scale models of liver metabolism relevant to NAFLD. A future is envisioned where individual genetic, proteomic and metabolomic information can be integrated computationally with clinical data, yielding mechanistic insight into the pathogenesis of chronic diseases such as NAFLD, and informing personalised nutrition and stratified medicine approaches for improving prognosis.
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20
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Tsochatzis EA, Newsome PN. Non-alcoholic fatty liver disease and the interface between primary and secondary care. Lancet Gastroenterol Hepatol 2019; 3:509-517. [PMID: 29893235 DOI: 10.1016/s2468-1253(18)30077-3] [Citation(s) in RCA: 92] [Impact Index Per Article: 18.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2018] [Revised: 02/22/2018] [Accepted: 02/23/2018] [Indexed: 02/06/2023]
Abstract
Non-alcoholic fatty liver disease (NAFLD) has a prevalence of 25-30% in unselected populations and has become the main reason for referrals to hepatology services. From the perspective of liver disease, NAFLD has a high prevalence but low severity. Screening studies in people at risk for NAFLD have shown a prevalence of advanced fibrosis of 5%, which underlines the need for robust pathways for risk stratification in primary care, with subsequent referrals as required. In this Review, we discuss the interface between primary and secondary care with regards to risk stratification and management of patients with NAFLD. We focus on selected issues of epidemiology and natural history and discuss the burden of disease in primary care, the evidence on screening for NAFLD, the rationale for testing for advanced fibrosis, and the optimal management of the disease in primary care.
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Affiliation(s)
- Emmanuel A Tsochatzis
- Sheila Sherlock Liver Unit and UCL Institute for Liver and Digestive Health, Royal Free Hospital and University College London, London, UK.
| | - Philip N Newsome
- National Institute for Health Research, Liver Biomedical Research Unit and Liver Unit, University Hospitals Birmingham NHS Foundation Trust and Centre for Liver Research, Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
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21
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Ratziu V. The painful reality of end-stage liver disease in NASH. Lancet Gastroenterol Hepatol 2018; 3:8-10. [PMID: 29254618 DOI: 10.1016/s2468-1253(17)30365-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2017] [Accepted: 10/27/2017] [Indexed: 12/15/2022]
Affiliation(s)
- Vlad Ratziu
- Hospital Pitié-Salpêtrière, Université Pierre et Marie Curie and Institute for Cardiometabolism and Nutrition, Paris, France.
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22
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Affiliation(s)
- Jake P Mann
- Department of Paediatrics, University of Cambridge, Cambridge UK; Metabolic Research Laboratories, Institute of Metabolic Science, Addenbrooke's Hospital, Hills Road, Cambridge CB2 0QQ, UK.
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