Cognitive lifetime drinking history in nonalcoholic fatty liver disease: some cases may be alcohol related

Very Low Alcohol Consumption Is Associated with Lower Prevalence of Cirrhosis and Hepatocellular Carcinoma in Patients with Non-Alcoholic Fatty Liver Disease

The role of moderate alcohol consumption in the evolution of NAFLD is still debated. The aim of this study is to evaluate the impact of current and lifelong alcohol consumption in patients with NAFLD. From 2015 to 2020, we enrolled 276 consecutive patients fulfilling criteria of NAFLD (alcohol consumption up to 140 g/week for women and 210 g/week for men). According to their current alcohol intake per week, patients were divided in: abstainers, very low consumers (C1: <70 g/week) and moderate consumers (C2). We created a new tool, called LACU (Lifetime Alcohol Consuming Unit) to estimate the alcohol exposure across lifetime: 1 LACU was defined as 7 alcohol units per week for 1 drinking year. Patients were divided into lifelong abstainers and consumers and the latter furtherly divided into quartiles: Q1-Q4. Stratification according to alcohol intake, both current and cumulative as estimated by LACU, showed that very low consumers (C1 and Q1-Q3) displayed lower frequency of cirrhosis and hepatocellular carcinoma compared to abstainers and moderate consumers (C2 and Q4). We can speculate that up to one glass of wine daily in the context of a Mediterranean diet may be a long-term useful approach in selected NAFLD patients.

Does moderate alcohol consumption accelerate the progression of liver disease in NAFLD? A systematic review and narrative synthesis

OBJECTIVES

Liver disease is a leading cause of premature death, partly driven by the increasing incidence of non-alcohol-related fatty liver disease (NAFLD). Many people with a diagnosis of NAFLD drink moderate amounts of alcohol. There is limited guidance for clinicians looking to advise these patients on the effect this will have on their liver disease progression. This review synthesises the evidence on moderate alcohol consumption and its potential to predict liver disease progression in people with diagnosed NAFLD.

METHODS

A systematic review of longitudinal observational cohort studies was conducted. Databases (Medline, Embase, The Cochrane Library and ClinicalTrials.gov) were searched up to September 2020. Studies were included that reported progression of liver disease in adults with NAFLD, looking at moderate levels of alcohol consumption as the exposure of interest. Risk of bias was assessed using the Quality in Prognostic factor Studies tool.

RESULTS

Of 4578 unique citations, 6 met the inclusion criteria. Pooling of data was not possible due to heterogeneity and studies were analysed using narrative synthesis. Evidence suggested that any level of alcohol consumption is associated with worsening of liver outcomes in NAFLD, even for drinking within recommended limits. Well conducted population based studies estimated up to a doubling of incident liver disease outcomes in patients with NAFLD drinking at moderate levels.

CONCLUSIONS

This review found that any level of alcohol intake in NAFLD may be harmful to liver health.Study heterogeneity in definitions of alcohol exposure as well as in outcomes limited quantitative pooling of results. Use of standardised definitions for exposure and outcomes would support future meta-analysis.Based on this synthesis of the most up to date longitudinal evidence, clinicians seeing patients with NAFLD should currently advise abstinence from alcohol.

PROSPERO REGISTRATION NUMBER

The protocol was registered with PROSPERO (#CRD42020168022).

Alcohol consumption in patients with nonalcoholic fatty liver disease: yes, or no?

Excessive alcohol intake is an established risk factor for chronic liver disease. At the same time, moderate alcohol intake appears to reduce cardiovascular morbidity. Accordingly, recommendations for alcohol intake in patients with nonalcoholic fatty liver disease (NAFLD), who are at increased risk for liver-related and cardiovascular events, are a point of debate. Some studies have shown beneficial effects of alcohol on cardiovascular and overall mortality in this specific subset of patients. Nonetheless, even light alcohol intake appears to aggravate liver disease and increase the risk of hepatocellular cancer. Therefore, patients with nonalcoholic steatohepatitis or advanced fibrosis should be advised against consuming alcohol. On the other hand, only light alcohol consumption (<10 g/day) might be permitted in patients without significant hepatic fibrosis, provided that they are carefully followed-up. As the research field focusing on NAFLD keeps widening, more prospective studies regarding this specific subject are expected, and may provide a basis for less ambiguous recommendations.

Risks of Light and Moderate Alcohol Use in Fatty Liver Disease: Follow-Up of Population Cohorts

BACKGROUND AND AIMS

The effects of alcohol use in nonalcoholic fatty liver disease are unclear. We investigated the impact of alcohol use in fatty liver disease on incident liver, cardiovascular, and malignant disease, as well as death.

APPROACH AND RESULTS

Our study comprised 8,345 persons with hepatic steatosis (fatty liver index >60) who participated in health-examination surveys (FINRISK 1992-2012 or Health 2000), with available data on baseline alcohol intake. Main exclusions were baseline clinical liver disease, viral hepatitis, ethanol intake >50 g/day, and current abstainers. Data were linked with national registers for hospital admissions, malignancies, and death regarding liver, cardiovascular, and malignant disease, as well as all-cause death. Adjustment were for multiple confounders. Alcohol consumption showed a dose-dependent risk increase for incident advanced liver disease and malignancies. Consuming 10-19 g/day of alcohol in general or 0-9 g/day as nonwine beverages doubled the risk for advanced liver disease compared to lifetime abstainers. In contrast, alcohol intake up to 49 g/day was associated with a 22%-40% reduction of incident cardiovascular disease (CVD). We observed a J-shaped association between alcohol intake and all-cause death with a maximal risk reduction of 21% (95% confidence interval, 5%-34%) at alcohol intake of 0-9 g/day compared to lifetime abstainers. However, these benefits on CVD and mortality were only observed in never smokers. Alcohol intake >30 g/day yielded increased risk estimates for mortality compared to lifetime abstainers. In a subpopulation with longitudinal data, alcohol intake remained stable over time in >80% of subjects.

CONCLUSIONS

Even low alcohol intake in fatty liver disease is associated with increased risks for advanced liver disease and cancer. Low to moderate alcohol use is associated with reduced mortality and CVD risk but only among never smokers.

Fatty Liver and the Forensic Pathologist

Fatty liver is a common finding in clinical practice and at autopsy. It is most commonly seen associated with alcohol abuse and in non-alcoholic fatty liver disease (NAFLD). It may also be seen in many other conditions in both adults and children. It is now recognized that NAFLD, like alcoholic liver disease, may lead to end stage liver disease. Nonalcoholic fatty liver disease is associated with increased mortality from other disorders, particularly cardiovascular diseases. Fatty liver may be seen in many conditions that concern autopsy pathologists, including drug toxicity, anorexia, hepatic ischemia, and heatstroke. In infants, steatosis is common in sudden unexpected deaths. Fatty liver has been associated with sudden death and this review examines the pathology and role of fatty liver in sudden death. Acad Forensic Pathol. 2018 8(2): 296-310.

The bidirectional impacts of alcohol consumption and the metabolic syndrome: Cofactors for progressive fatty liver disease

Current medical practice artificially dichotomises a diagnosis of fatty liver disease into one of two common forms: alcoholic liver disease (ALD) and non-alcoholic fatty liver disease (NAFLD). Together, these account for the majority of chronic liver diseases worldwide. In recent years, there has been a dramatic increase in the prevalence of obesity and metabolic syndrome within the general population. These factors now coexist with alcohol consumption in a substantial proportion of the population. Each exposure sensitises the liver to the injurious effects of the other; an interaction that drives and potentially accelerates the genesis of liver disease. We review the epidemiological evidence and scientific literature that considers how alcohol consumption interacts with components of the metabolic syndrome to exert synergistic or supra-additive effects on the development and progression of liver disease, before discussing how these interactions may be addressed in clinical practice.

Risk of chronic liver disease in post-menopausal women due to body mass index, alcohol and their interaction: a prospective nested cohort study within the United Kingdom Collaborative Trial of Ovarian Cancer Screening (UKCTOCS)

Background

We investigated the risk of chronic liver disease (CLD) due to alcohol consumption and body mass index (BMI) and the effects of their interaction in a prospective cohort study of women recruited to the UKCTOCS trial.

Methods

95,126 post-menopausal women without documented CLD were stratified into 12 groups defined by combinations of BMI (normal, overweight, obese) and alcohol consumption (none, <1–15, 16–20 and ≥21 units/week), and followed for an average of 5.1 years. Hazard ratios (HR) were calculated for incident liver-related events (LRE).

Results

First LREs were reported in 325 (0.34%) participants. Compared to women with normal BMI, HR = 1.44 (95% CI; 1.10–1.87) in the overweight group and HR = 2.25 (95% CI; 1.70–2.97) in the obese group, adjusted for alcohol and potential confounders. Compared to those abstinent from alcohol, HR = 0.70 (95% CI; 0.55–0.88) for <1–15 units/week, 0.93 (95% CI; 0.50–1.73) for 16–20 units/week and 1.82 (95% CI; 0.97–3.39) for ≥21 units/week adjusted for BMI and potential confounders. Compared to women with normal BMI drinking no alcohol, HR for LRE in obese women consuming ≥21 units/week was 2.86 (95% CI; 0.67–12.42), 1.58 (95% CI; 0.96–2.61) for obese women drinking <1–15 units/week and 1.93 (95% CI; 0.66–5.62) in those with normal BMI consuming ≥21 units/week after adjustment for potential confounders. We found no significant interaction between BMI and alcohol.

Conclusion

High BMI and alcohol consumption and abstinence are risk factors for CLD in post-menopausal women. However, BMI and alcohol do not demonstrate significant interaction in this group.

Trial registration

UKCTOCS is registered as an International Standard Randomised Controlled Trial, number ISRCTN22488978. Registered 06/04/2000.

Electronic supplementary material

The online version of this article (doi:10.1186/s12889-017-4518-y) contains supplementary material, which is available to authorized users.

Is moderate alcohol use in nonalcoholic fatty liver disease good or bad? A critical review

Moderate alcohol consumption in patients with nonalcoholic fatty liver disease (NAFLD) is common, yet the effects on cardiovascular and liver health are unclear. Moderate alcohol use is associated with improved insulin sensitivity and decreased cardiovascular mortality in the general population, but whether similar benefits would be observed in persons with NAFLD remains largely unstudied. There is significant overlap in the pathogenesis of alcoholic liver disease (ALD) and NAFLD, although studies of ALD have focused on pathological alcohol intake and few mechanistic studies of moderate alcohol use in NAFLD exist. We undertook a critical review of the effect of moderate alcohol use on cardiovascular and liver disease in patients with NAFLD. A total of seven observational studies met the criteria for inclusion (one for cardiovascular endpoints and six for liver endpoints). Insufficient studies have assessed the association of moderate alcohol use with cardiovascular outcomes. There was a positive association between moderate alcohol use and decreased NASH and fibrosis; however, heavy episodic drinking may accelerate fibrosis progression and moderate alcohol use may increase the risk of hepatocellular carcinoma in patients with advanced fibrosis. Significant methodological limitations were present, including incomplete adjustment for confounding factors and failure to measure lifetime use or the pattern of alcohol intake. Thus, a strong recommendation of benefit of moderate alcohol use in NAFLD cannot be made. There remains a need for additional high-quality longitudinal studies that evaluate both cardiovascular and liver outcomes among NAFLD patients with moderate or lesser degrees of alcohol use. (Hepatology 2017;65:2090-2099).

Alcohol Consumption in Concomitant Liver Disease: How Much is Too Much?

Purpose of Review

High consumption of alcohol can lead to cirrhosis. The risk of a low to moderate consumption of alcohol in the setting of a concurrent liver disease is less clear. The aim of this review is to sum the evidence on the risk of adverse outcomes in patients with liver diseases other than alcoholic liver disease who consume alcohol.

Recent Findings

High alcohol consumption is strongly associated with adverse outcomes in most liver diseases. For hepatitis C, some evidence points to an increased risk for fibrosis progression also with low amounts. For non-alcoholic fatty liver disease, most studies indicate an inverse association between fibrosis and alcohol consumption, but methodological limitations reduce inference.

Summary

High alcohol consumption is associated with an increased risk of fibrosis progression and other adverse outcomes, while less is clear regarding low to moderate consumption. Obtaining high-level evidence on this topic ought to be the objective of future studies. Currently, an individual risk profile should be obtained in patients with liver disease who consume alcohol.

Proposed cut-off value of the intrahepatic lipid content for metabolically normal persons assessed by proton magnetic resonance spectroscopy in a Japanese population

AIMS

To determine the threshold intrahepatic lipid (IHL) content separating metabolically normal from abnormal in a Japanese population based on proton magnetic resonance spectroscopy ((1)H-MRS).

METHODS

A total of 305 Japanese subjects aged 20-69years were investigated. The subjects underwent general examination, blood tests, and (1)H-MRS of the liver after an overnight fast. They completed a questionnaire about daily drinking habits and their daily alcohol intake was calculated.

RESULTS

The median IHL content was 4.7% in men and 1.7% in women, and it increased along with the number of features of metabolic syndrome (MetS). The optimum IHL cut-off value for separating normal subjects from those with at least one feature of MetS was 6.5% in men (AUC of ROC: 0.727, 95%-CI: 0.649-0.804) and 1.8% in women (0.765, 0.685-0.844). Alcohol intake was not correlated with the IHL content according to multiple logistic regression analysis.

CONCLUSION

This study demonstrated a close association of IHL with features of MetS and identified IHL content cut-off values for metabolic normality in Japanese subjects.

NAFLD Prevalence in a Young Cadaveric Organ Donor Population

BACKGROUND

Liver transplantation is a critical survival point for patients with end stage liver diseases. It can dramatically increase patients' survival if the donor liver is intact. One aspect of liver health is absence of steatosis. Nonalcoholic Steato Hepatitis (NASH) and Nonalcoholic Fatty Liver Disease (NAFLD) are increasing among young adults and patients living with chronic liver diseases.

OBJECTIVES

In this study, we determined the prevalence of NALFD in livers of brain-dead donors in Imam-Khomeini hospital Complex, Tehran, Iran. We assumed that the calculated prevalence would represent NAFLD prevalence in Iranian population in the age range of 20-60 years.

MATERIALS AND METHODS

All eligible brain dead liver transplant donors were enrolled in the survey from March 21, 2011 to March 21, 2013 in Imam-Khomeini hospital Complex. Eligible participants were donors aged 20 to 60 years without any obvious history of liver disease. Liver needle biopsy was performed at the end of the transplant operation; time zero biopsy. We calculated the prevalence of NAFLD among brain-dead donors. Moreover, the frequency of NASH was calculated based on the NAS (NAFLD Activity Score).

RESULTS

Among 116 cases, two were diagnosed as probable NASH. There was a significant association between NAFLD and male gender (P = 0.04). Moreover, we found a higher steatosis level in male gender. There was a significant association between NAFLD and BMI (P = 0.05). Those with BMI more than 27 had severe steatosis.

CONCLUSIONS

Our comprehensive literature review showed that our study was the first investigation in Iran and the region, which determined the prevalence of NAFLD based on tissue diagnosis. We believe that the prevalence of NAFLD/NASH in our donors can represent the overall prevalence in this age group in Iran.

Impact of lifetime alcohol quit attempts and medicated detoxifications on time to relapse during an index alcohol detoxification

Previous work has shown that multiple medication-treated alcohol detoxifications are associated with poorer treatment outcomes during subsequent detoxifications. Little is known about the impact of nonmedicated attempts to stop drinking outside the realm of these medically supervised detoxifications on acute detoxification outcomes. This study included 58 subjects enrolled in an outpatient detoxification study. Subjects were asked why and how often they quit alcohol for 3 days or longer during their drinking lifetime using concepts derived from the Cognitive Lifetime Drinking History. The effect of previous attempts at abstinence (both medicated and nonmedicated) on time to relapse during an index detoxification was examined. After the index detoxification, older individuals relapsed later than younger individuals and the number of previous medicated detoxifications rather than total lifetime quit attempts per se was related to quicker relapse. Contrary to expectation, those who reported fewer previous nonmedicated quit attempts tended to relapse sooner than those who reported more past quit attempts. This study supports and extends previous work that suggests that the number of previous medicated detoxifications, rather than the total number of past attempts at abstinence, predicts higher and sooner risk for early relapse drinking during outpatient alcohol detoxification.

Multicausality in fatty liver disease: Is there a rationale to distinguish between alcoholic and non-alcoholic origin?

Apart from alcohol, there are other factors that may induce complications, which resemble alcohol-related liver disorders. In particular, obesity has been brought into focus as a risk factor for fatty liver disease. The term “non-alcoholic” fatty liver disease is commonly used to distinguish between obesity-related and alcohol-related hepatic steatosis. This review uses the epidemiological perspective to critically assess whether it is necessary and useful to differentiate between alcoholic and “non-alcoholic” fatty liver disease. The MEDLINE database was searched using the PubMed search engine, and a review of reference lists from original research and review articles was conducted. The concept to distinguish between alcoholic and “non-alcoholic” fatty liver disease is mainly based on specific pathomechanisms. This concept has, however, several limitations including the common overlap between alcohol misuse and obesity-related metabolic disorders and the non-consideration of additional causal factors. Both entities share similar histopathological patterns. Studies demonstrating differences in clinical presentation and outcome are often biased by selection. Risk factor reduction is the main principle of prevention and treatment of both disease forms. In conclusion, alcoholic and “non-alcoholic” fatty liver diseases are one and the same disease caused by different risk factors. A shift from artificial categories to a more general approach to fatty liver disease as a multicausal disorder may optimize preventive strategies and help clinicians more effectively treat patients at the individual level.

The burden of disease and the cost of illness attributable to alcohol drinking--results of a national study

BACKGROUND AND AIMS

The World Health Organization estimated that 3.2% of the burden of disease around the world is attributable to the consumption of alcohol. The aim of this study is to estimate the burden of disease attributable to alcohol consumption in Portugal.

METHODS

Burden and costs of diseases attributable to alcohol drinking were estimated based on demographic and health statistics available for 2005, using the Disability-Adjusted Life Years (DALY) lost generated by death or disability.

RESULTS

In Portugal, 3.8% of deaths are attributable to alcohol (4,059 of 107,839). After measuring the DALY generated by mortality data, the proportion of disease attributable to alcohol was 5.0%, with men having 5.6% of deaths and 6.2% of disease burden, while female figures were, respectively, 1.8 and 2.4%. Considering the sum of death and disability DALYs, liver diseases represented the main source of the burden attributable to alcohol with 31.5% of total DALYs, followed by traffic accidents (28.2%) and several types of cancer (19.2%). As for the cost of illness incurred by the health system, our results indicate that 95.1 millions euros are attributable to alcohol-related disease admissions (liver diseases, cancer, traffic accidents, and external causes) while the ambulatory costs of alcohol-related diseases were estimated in 95.9 million euros, totaling 191.0 million euros direct costs, representing 0.13% of Gross Domestic Product and 1.25% of total national health expenditures. An alternative analysis was carried out using higher consumption levels so as to replicate aggregate alcohol consumption statistics. In this case, DALYs lost increased by 11.7% and health costs by 23%.

CONCLUSION

Our results confirm that alcohol is an important health risk factor in Portugal and a heavy economic burden for the health system, with hepatic diseases ranking first as a source of burden of disease attributable to alcohol.

Final results of a long-term, clinical follow-up in fatty liver patients

OBJECTIVE

There is increasing focus on non-alcoholic fatty liver disease (NAFLD). The aim of the present study was to conduct a long-term clinical follow-up of patients with biopsy-confirmed fatty liver without inflammation or significant fibrosis (pure fatty liver), to analyse for potential risk factors at the time of index liver biopsy important for survival and the development of cirrhosis and to describe the causes of death.

MATERIAL AND METHODS

Patients were linked through their personal identification number to the Danish National Registry of Patients and the Register of Causes of Death. All admissions, discharge diagnoses and causes of death during follow-up were collected. All surviving patients were invited to a clinical follow-up.

RESULTS

The follow-up period was 20.4 and 21.0 years, respectively, for the NAFLD and alcoholic fatty liver disease (AFLD) groups. Two NAFLD patients (1.2%) developed cirrhosis during the follow-up period versus 54 (22%) AFLD patients. Sixty-four percent of 178 surviving patients out of an original cohort of 417 patients attended the clinical follow-up. In NAFLD patients, none of the risk factors studied was significant in relation to the risk of death. Patients with AFLD died primarily from cirrhosis and other alcohol-related disorders, whereas in patients with NAFLD the main causes of death were cardiovascular disease and cancer.

CONCLUSIONS

For patients with pure non-alcoholic fatty liver, survival was good and independent of the histological, clinical and biochemical characteristics at the time of biopsy; the main causes of death were cardiovascular disease and cancer.

Cryptogenic cirrhosis: what are we missing?

Cryptogenic cirrhosis remains a common clinical condition although recent advances have allowed for a better understanding of underlying conditions and associations. The evolving terminology applied to this condition has resulted in some confusion and persistent variation among pathologists and clinicians. Typical patients are middle aged with only minor liver enzyme abnormalities. Presentations range from incidentally discovered cirrhosis to complications of advanced portal hypertension and hepatocellular cancer. Clinicopathologic analysis of these patients indicates that the leading causes include previously unrecognized nonalcoholic steatohepatitis, silent autoimmune hepatitis, non-B, non-C viral hepatitis, and occult past ethanol exposure. In this article, we review these associations as well as a proposed classification system for cryptogenic cirrhosis and other lesser known genetic and syndromic associations that warrant consideration when evaluating these individuals.

Identifying non-alcoholic fatty liver disease among asymptomatic overweight and obese individuals by clinical and biochemical characteristics

OBJECTIVE

To determine the prevalence of liver steatosis among asymptomatic individuals attending an out-patient clinic for a problem of overweight, and to define the discriminatory value of several characteristics for predicting liver steatosis among them.

DESIGN AND PARTICIPANTS

Consecutive patients Swith a body mass index (BMI) of > or =25 kg/m2 who consented to undergo liver ultrasound and blood tests were recruited for inclusion. Receiver operating characteristic (ROC) curves were generated and statistical indices of diagnostic performance and their corresponding 95% confidence intervals (95% CI) were computed. Logistic regression analyses were performed to determine whether a combination of characteristics could improve diagnostic accuracy.

RESULTS

We enrolled sixty-eight subjects (mean BMI, 37.5 kg/m2), of whom 39 (57.4%) had liver steatosis on ultrasound. Logistic regression analyses indicated that only 3 variables were significantly and independently correlated with liver steatosis: female gender, low adiponectin levels, and high insulin resistance index. A composite index for predicting liver steatosis was calculated by summing the risk factors of female gender, low adiponectin, and insulin resistance index (FAIR score). The accuracy of this score was determined by ROC analysis to be 0.85 (95% CI, 0.74-0.96; P < 0.001). The presence of two or more risk factors (FAIR score > or =2) had a sensitivity, specificity, positive predictive value, and negative predictive value of 77%, 91%, 92%, and 74%, respectively. The likelihood ratio for a positive result was 8.43.

CONCLUSIONS

Among asymptomatic overweight individuals attending an out-patient clinic, the prevalence of liver steatosis on ultrasound is 57%. Female gender, the insulin resistance index, and low adiponectin are significant and independent predictors of liver steatosis. A combination of these three factors allows sensitivity and specificity for non alcoholic fatty liver of 77% and 91%, respectively.

Epidemiology and natural history of non-alcoholic steatohepatitis

Non-alcoholic fatty liver disease (NAFLD) is the most common chronic liver condition in many parts of the world. This article describes the epidemiology and natural history of this disorder. It also describes current diagnostic and treatment methods and describes future implications NAFLD may have.

Alcohol consumption is associated with progression of hepatic fibrosis in non-alcoholic fatty liver disease

OBJECTIVE

Moderate alcohol consumption has been reported to be inversely associated with cardiovascular disease and total mortality. The importance of non-alcoholic fatty liver disease (NAFLD) is increasing and many NAFLD patients suffer from cardiovascular disease. In these patients, moderate alcohol consumption could be beneficial. The aim of this study was to investigate whether low alcohol intake, consistent with the diagnosis of NAFLD, is associated with fibrosis progression in established NAFLD.

MATERIAL AND METHODS

Seventy-one patients originally referred because of chronically elevated liver enzymes and diagnosed with biopsy-proven NAFLD were re-evaluated. A validated questionnaire combined with an oral interview was used to assess weekly alcohol consumption and the frequency of episodic drinking. Significant fibrosis progression in NAFLD was defined as progression of more than one fibrosis stage or development of endstage liver disease during follow-up.

RESULTS

Mean follow-up (SD) was 13.8 (1.2) years between liver biopsies. At follow-up, 17 patients (24%) fulfilled the criteria for significant fibrosis progression. The proportion of patients reporting heavy episodic drinking at least once a month was higher among those with significant fibrosis progression (p=0.003) and a trend towards higher weekly alcohol consumption was also seen (p=0.061). In a multivariate binary logistic regression analysis, heavy episodic drinking (p<0.001) and insulin resistance (p<0.01) were independently associated with significant fibrosis progression.

CONCLUSIONS

Moderate alcohol consumption, consistent with the diagnosis of NAFLD to be set, is associated with fibrosis progression in NAFLD. These patients should be advised to refrain from heavy episodic drinking.

Understanding and treating patients with alcoholic cirrhosis: an update

Alcoholic cirrhosis represents the terminal stage of alcoholic liver disease (ALD) and one of the main causes of death among alcohol abusers. The aim of this review was to provide an update on alcoholic cirrhosis, with an emphasis on recent findings. Increased alcohol consumption in developing countries is expected to increase cirrhosis mortality. There is a need, therefore, to develop new approaches to the prevention of ALD, including more attention to co-factors that may increase risk of ALD (i.e., obesity and diabetes, chronic HCV infection, and smoking). Furthermore, a better understanding of the pathological mechanisms on the basis of alcohol cirrhosis represents a cornerstone in order to develop new pharmacological treatments. Inflammatory and immune responses along with oxidative stress and alterations in adipokine secretion might contribute in different ways to the evolution of alcohol-induced fibrosis/cirrhosis. As of this date, patients with severe alcoholic hepatitis with a Maddrey Discriminant Factor (MDF) 32 should be offered pentoxifylline and/or corticosteroids unless contraindications exist. For ambulatory patients, S-adenosylmethionine (SAMe) may be considered in a motivated patient with nutritional support. Current studies do not support use of anti-tumor necrosis factor (TNF)-alpha antibody. Finally, achieving total alcohol abstinence should represent the main aim in the management of patients affected by any stage of cirrhosis. In the last decades, several drugs able to increase abstinence and prevent alcohol relapse have been evaluated and some of them have obtained approval for alcohol dependence. Patients with alcoholic cirrhosis; however, are usually excluded from such treatments. A recent study demonstrated the efficacy and safety of baclofen in inducing and maintaining alcohol abstinence in cirrhotic alcohol-dependent patients with cirrhosis. All together the information available suggests the need of a multimodal approach in the clinical management of these patients.

Measurement of food and alcohol intake in relation to chronic liver disease

It is well established that the consumption of alcohol is implicated in both the cause and progression of chronic liver disease. The quantity of drink that is consumed, the pattern of drinking and type of alcoholic beverages consumed are all possible factors in disease aetiology. The impact of specific dietary components on the cause and progression of chronic liver disease is unclear although it is known that obesity, and hence the over-consumption of energy, is a predictor of fatty liver. Work to elucidate the role of both diet and alcohol in the aetiology of liver disease is hindered by the methods currently available to measure dietary (including alcohol) intake. The validity and reliability of retrospective methods of assessing diet are limited by their reliance on memory and, for the 24 h recall, the short-time period of intake assessed and its inability to assess variability across the week. Prospective methods which measure food and drink intake at the time of consumption, and include weighed or estimated food diaries, are useful for prospective cohort studies but are expensive and have a high respondent burden. For estimation of alcohol intake retrospectively, the Cognitive Lifetime Drinking questionnaire, which prompts responses using a lifetime calendar, is a useful tool but still depends on memory. More work is required to develop valid, reliable and easily administered tools for measurement of both diet and alcohol.

How should we manage patients with non-alcoholic fatty liver disease in 2007?

Evidence-based management guidelines for non-alcoholic fatty liver disease (NAFLD) are lacking in the Asia-Pacific region or elsewhere. This review reports the results of a systematic literature search and expert opinions. The Asia-Pacific Working Party on NAFLD (APWP-NAFLD) has generated practical recommendations on management of NAFLD in this region. NAFLD should be suspected when there are metabolic risk factors and/or characteristic changes on hepatic ultrasonography. Diagnosis by ultrasonography, assessment of liver function and complications, exclusion of other liver diseases and screening for metabolic syndrome comprise initial assessment. Liver biopsy should be considered when there is diagnostic uncertainty, for patients at risk of advanced fibrosis, for those enrolled in clinical trials and at laparoscopy for another purpose. Lifestyle measures such as dietary restrictions and increased physical activity (aerobic exercise) should be encouraged, although the best management strategy to achieve this has yet to be defined. Complications of metabolic syndrome should be screened for regularly. Use of statins to treat hypercholesterolemia is safe and recommended; frequent alanine aminotransferase (ALT) monitoring is not required. Obese patients who do not respond to lifestyle measures should be referred to centers specializing in obesity management; consideration should be given to bariatric surgery or gastric ballooning. The role of pharmacotherapy remains investigational and is not recommended for routine clinical practice. Non-alcoholic fatty liver disease should be recognized as part of the metabolic syndrome and managed in a multidisciplinary approach that addresses liver disease in the context of risk factors for diabetes and premature cardiovascular disease. Lifestyle changes are the first line and mainstay of management.

Non-alcoholic fatty liver disease in the Asia-Pacific region: definitions and overview of proposed guidelines

Non-alcoholic fatty liver disease (NAFLD) is the most common liver disorder in Western industrialized countries, affecting 20-40% of the general population. Large population-based surveys in China, Japan, and Korea indicate that the prevalence of NAFLD is now 12% to 24% in population subgroups, depending on age, gender, ethnicity, and location (urban versus rural). There is strong evidence that the prevalence of NAFLD has increased recently in parallel with regional trends in obesity, type 2 diabetes, and metabolic syndrome; and that further increases are likely. The relationship between NAFLD, central obesity, diabetes, and metabolic syndrome is clearly evident in retrospective and prospective Asian studies, but the strength of association with these metabolic risk factors is only appreciated when regional definitions of anthropometry are used. Pathological definition of NAFLD, particularly its activity and the extent of liver fibrosis, requires histological examination, but liver biopsy is often not appropriate in this disorder for logistic reasons. An alternative set of operational definitions is proposed here. Clinicians need guidelines as how best to diagnose and manage NAFLD and its associated metabolic disorders in countries with scant healthcare resources. The Asia-Pacific Working Party (APWP) for NAFLD was convened to collate evidence and deliberate these issues. Draft proposals were presented and discussed at Asia-Pacific Digestive Week at Cebu, Philippines, in late November 2006, and are published separately in this issue of the Journal as an Executive Summary. The present document reviews the reasoning and evidence behind the APWP-NAFLD proposals for definition, assessment, and management of NAFLD in the Asia-Pacific region.

Alcoholic liver disease

Alcohol excess is associated with a spectrum of disease ranging from simple steatosis through steatohepatitis to cirrhosis and, in some, hepatocellular carcinoma. Alcoholic steatohepatitis itself has a variable histological picture, but a constant feature is the presence of ballooning degeneration of hepatocytes. Recent studies have emphasized the importance of apoptosis as a mechanism of cell death in this condition. It is accompanied by varying degrees of perivenular, centrilobular, and pericellular fibrosis. When severe and associated with perivenular liver cell necrosis (central sclerosing hyaline necrosis), there may be precirrhotic portal hypertension. The pattern of fibrosis may initially be diffuse with little nodule formation, but in time there is frequently the development of a micronodular cirrhosis. In approximately 15% of patients with established cirrhosis, hepatocellular carcinoma develops; several precursor lesions are now recognized which can be detected histologically. Several authors have drawn attention to additional components of the spectrum of alcoholic liver disease, including vascular changes, portal tract inflammation and fibrosis, ductular reaction, and iron overload. The morphology of alcoholic liver disease can be significantly affected by abstinence; furthermore, the clinical and morphological phenotype can be significantly influenced by the presence of comorbid conditions such as nonalcoholic fatty liver disease or viral hepatitis. Biopsy appearances can provide important prognostic information in alcoholic liver disease, and this review incorporates a proposed grading and staging schema for assessment of histological severity.

Nonalcoholic fatty liver disease: from steatosis to cirrhosis

Nonalcoholic steatohepatitis (NASH), the lynchpin between steatosis and cirrhosis in the spectrum of nonalcoholic fatty liver disorders (NAFLD), was barely recognized in 1981. NAFLD is now present in 17% to 33% of Americans, has a worldwide distribution, and parallels the frequency of central adiposity, obesity, insulin resistance, metabolic syndrome and type 2 diabetes. NASH could be present in one third of NAFLD cases. Age, activity of steatohepatitis, and established fibrosis predispose to cirrhosis, which has a 7- to 10-year liver-related mortality of 12% to 25%. Many cases of cryptogenic cirrhosis are likely endstage NASH. While endstage NAFLD currently accounts for 4% to 10% of liver transplants, this may soon rise. Pathogenic concepts for NAFLD/NASH must account for the strong links with overnutrition and underactivity, insulin resistance, and genetic factors. Lipotoxicity, oxidative stress, cytokines, and other proinflammatory mediators may each play a role in transition of steatosis to NASH. The present "gold standard" management of NASH is modest weight reduction, particularly correction of central obesity achieved by combining dietary measures with increased physical activity. Whether achieved by "lifestyle adjustment" or anti-obesity surgery, this improves insulin resistance and reverses steatosis, hepatocellular injury, inflammation, and fibrosis. The same potential for "unwinding" fibrotic NASH is indicated by studies of the peroxisome proliferation activator receptor (PPAR)-gamma agonist "glitazones," but these agents may improve liver disease at the expense of worsening obesity. Future challenges are to approach NAFLD as a preventive public health initiative and to motivate affected persons to adopt a healthier lifestyle.

Prevalence and risk factors of non-alcoholic fatty liver disease among Korean adults

BACKGROUND AND AIM

Differences in the prevalence of non-alcoholic fatty liver disease (NAFLD) between Eastern and Western populations are primarily attributable to differences in definitions and biased population selection. Thus, the aim of the present study was to accurately determine the actual prevalence of NAFLD by sonography and to characterize the risk factors for NAFLD.

METHODS

The present cross-sectional study was performed with data obtained from 6,648 subjects, all of whom were older than 20 years of age (3,530 men and 3,118 women). The term 'non-drinker' was applied to men who consumed less than 30 g alcohol/day and to women who consumed less than 20 g alcohol/day. Non-alcoholic fatty liver disease was defined as a sonographically detected fatty liver in the absence of viral hepatitis in a non-drinker.

RESULTS

Of the 1,613 subjects who were diagnosed with sonographic fatty liver, 1,240 were non-drinkers and had no viral hepatitis. Overall, the unadjusted and age-adjusted prevalences of NAFLD were 18.7% (23% in men, 13.7% in women) and 16.1% (21.6% in men, 11.2% in women), respectively. Multivariate analysis revealed that several risk factors were profoundly associated with the prevalence of NAFLD, including obesity, insulin resistance, hyperlipidemia and hyperglycemia in both genders, as well as age, menopausal status and estrogen medication in women only.

CONCLUSIONS

These results demonstrate that the prevalence of NAFLD in Korean adults, according to sonographic surveys, is comparable to that seen in more developed countries. From the perspective of increasing obesity, the high prevalence rates noted in the study may herald an increased burden of chronic liver disease in the Korean population.

Nonalcoholic steatohepatitis: pathologic features and differential diagnosis

The worldwide epidemic of obesity has raised the awareness of nonalcoholic fatty liver disease (NAFLD) from that of a curiosity to one of a potentially progressive liver disease with risk for cirrhosis and hepatocellular carcinoma. This overview is focused on the histopathology of the spectrum of fatty liver disease, and discusses the role of liver biopsy, differential diagnoses, and new techniques in development. When pertinent, pathophysiology of this metabolic liver disease and recent treatment considerations have been mentioned as well.

Factors Associated with Ribavirin-Induced Anemia

Background:

During treatment of hepatitis C, ribavirin-induced anemia (RIA) requires reduction of the ribavirin dose or initiation of erythropoietin in up to 20% of patients. RIA usually occurs in the first 8 weeks of treatment, and a decrease >3 g/dL or a nadir <10 g/dL is considered significant.

Objective:

To prospectively examine factors associated with RIA in a population of patients with hepatitis C.

Methods:

Consecutive patients with hepatitis C (hepatitis B virus and HIV negative) underwent treatment with pegylated interferon and weight-based ribavirin. Prospectively gathered data included demographics, alcohol consumption, and hepatitis C virus risk factors. Patients underwent laboratory studies at baseline and at intervals of 4–8 weeks after starting treatment.

Results:

One hundred eight patients were enrolled. Of these, 30 (27.8%) experienced a >3 g/dL fall in hemoglobin levels in the first 8 weeks; in 10 (33%) patients, the change occurred by week 4. The initial hemoglobin level was higher in those with a decrease compared with those without a fall (15.3 vs 14.1 g/dL; p < 0.001). In addition, for patients with a decrease, the iron saturation was higher (44.6% vs 30.1%; p = 0.002). Finally, those with fibrosis stage 6/6 (cirrhosis) had a greater percent fall in hemoglobin (27.0% vs 14.0%; p = 0.009) than those with less severe fibrosis. By logistic regression analysis, only iron saturation was associated with RIA (p = 0.002).

Conclusions:

In our patients, initial hemoglobin, serum iron, and fibrosis were associated with a potentially clinically important decrease in hemoglobin. In approximately one-third of the population, RIA occurred in the first 4 weeks of treatment. No patient had a severe complication.

Alcohol and the liver

PURPOSE OF REVIEW

To highlight salient recent discoveries and results of clinical trials in alcoholic liver disease (ALD). The burden of care for ALD patients is hefty and the prevalence of alcohol abuse may be increasing in both the developed and the underdeveloped world.

RECENT FINDINGS

Molecular mechanisms of alcoholism are being identified but not of the predisposition to alcoholic liver injury, except perhaps for polymorphism of a cytotoxic T-cell antigen. The Mayo End-stage Liver Disease (MELD) score performs well in assessing the prognosis of ALD; serological biomarkers for predicting ALD outcome are of uncertain value. Concomitant liver disease (e.g., obesity, hepatitis C, and iron overload) aggravates the severity of ALD; conversely, alcohol abuse may be a cryptic co-factor in some cases of non-alcoholic fatty liver. For alcoholic hepatitis, nutritional support is the mainstay of treatment; steroids are considered by some (but not all) as safe and effective therapy, whereas manipulations of tumor necrosis factor-alpha activity have been disappointing, or of unproven benefit at best. In liver transplantation for ALD, methods are being devised to monitor recidivism and to ameliorate its risk and that of co-morbid psychiatric conditions.

SUMMARY

Much of the pathogenesis of ALD has been identified and headway has been made in predicting its prognosis. However, much remains to be done to elucidate the molecular genetics of the risk of developing ALD and in formulating safe, effective therapies for alcoholic hepatitis.

Correlation of alcohol consumption with liver histological features in non-cirrhotic patients

BACKGROUND AND AIMS

The association between alcohol consumption and the risk of liver disease remains unclear. The aim of our study was to determine liver morphological features directly related to the mean lifetime daily alcohol intake (LTDAI) in non-cirrhotic patients.

METHODS

Medical records of all consecutive patients who reported alcohol consumption up to the time of hospital admission and who had undergone a liver biopsy in the Gastroenterology Unit of the University Hospital Centre of Tirana (Albania), were reviewed. Patients with established cirrhosis and/or with other possible causes of liver damage were excluded by the study.

RESULTS

The histological features revealed in the biopsy samples of 51 non-cirrhotic patients were: steatosis in 46 patients (91%), six of whom (13%) showed also alcoholic foamy degeneration; alteration of hepatocytes in 40 patients (78%), diffuse mononuclear inflammation in 37 patients (73%), polymorphonuclear inflammation in 11 patients (22%) and perivenular fibrosis in 18 patients (35%). Diffuse steatosis was directly correlated with alcohol consumption (P<0.01). No association was found between alcohol consumption and the presence of degenerative alterations of hepatocytes, Mallory bodies or hepatocellular necrosis. Fibrosis was more prevalent in patients who reported a LTDAI > or = 80 g in comparison with patients who reported a LTDAI > or = 40 to <80 g (48% vs 25%; P<0.05).

CONCLUSION

In non-cirrhotic patients liver steatosis and fibrosis were more common features among patients who reported a higher alcoholic consumption, but no clear-cut association between typical histological features of alcoholic liver disease and alcohol consumption was found.

Non-alcoholic fatty liver disease/non-alcoholic steatohepatitis (NAFLD/NASH): diagnosis and clinical course

Non-alcoholic fatty liver disease (NAFLD) is a frequent syndrome encompassing fatty liver alone and steatohepatitis (NASH). Often asymptomatic, the suspicion arises because of abnormal aminotransferases or a bright liver on abdominal ultrasound. It should be suspected during evaluation of associated conditions as obesity, diabetes or dyslipidaemia. The diagnostic evaluation must exclude other potential causes of liver disease and may include a liver biopsy, the only method able to confirm features of necroinflammation and fibrosis that define NASH and its prognostic implications. Indeed, the presence of necroinflammation has been associated with a significant risk of progression to cirrhosis and eventually hepatocellular carcinoma. Age >45 years, obesity and diabetes have also been associated with an increased risk of liver fibrosis and progression to cirrhosis. Given the high prevalence of NAFLD, general measures of life-style changes, focusing on exercise, diet, and total alcohol abstinence, should be implemented before a liver biopsy is considered.

Nonalcoholic fatty liver disease and nonalcoholic steatohepatitis

Nonalcoholic fatty liver disease (NAFLD) is a well-recognized form of chronic liver disease affecting both children and adults that has gained increased recognition. Recently NAFLD has been associated with insulin resistance and its incidence and prevalence is likely increasing, paralleling the rise in obesity and diabetes mellitus in the United States. The article includes current thoughts on the natural history and pathogenesis of NAFLD and describes current trends in the diagnosis and treatment of this condition.