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Conroy C, Radulescu A, Attia SL, Shelman N, Lee JT, Monticelli RG, Hall S, Kohli R, Softic S. The combined pioglitazone and topiramate therapy for management of pediatric patients with severe MASLD. Saudi J Gastroenterol 2024; 30:252-259. [PMID: 38726916 DOI: 10.4103/sjg.sjg_428_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2023] [Accepted: 03/14/2024] [Indexed: 07/30/2024] Open
Abstract
BACKGROUND Metabolic dysfunction associated steatotic liver disease (MASLD) is the most common cause of chronic hepatitis in adult and pediatric patients. Adolescents with severe MASLD can demonstrate a more aggressive disease phenotype as they more commonly develop liver fibrosis than BMI matched adults. Therefore, MASLD is the fastest growing indication for liver transplants in young adults. METHODS Pioglitazone has been shown to improve liver histology in adult patients with MASLD, and in some studies, it attenuated liver fibrosis. Despite its perceived efficacy, pioglitazone is not widely used, likely due to its side effect profile, specifically increased weight gain. Topiramate lowers body weight in adolescents and in combination with phentermine, is one of the few FDA-approved medications for the management of obesity in children over 12 years of age. We performed a retrospective review of the outcomes in pediatric patients with severe MASLD, treated with the combined pioglitazone and topiramate therapy. RESULTS Here, we report a case series of seven adolescents with severe MASLD and ≥F2 liver fibrosis treated with the combined pioglitazone and topiramate therapy. The combined therapy improved mean serum ALT from 165 ± 80 U/L to 89 ± 62 U/L after 12 months mean duration of treatment. One patient who completed 24 months of the combined therapy demonstrated a decrease in liver stiffness from 8.9 kPa to 5.6 kPa, as assessed by FibroScan elastography. There was a significant increase in body weight during this time, however, body mass index as a percentage of the 95 th percentile adjusted for age and gender did not increase significantly, 151 ± 29% vs. 152 ± 28%. Moreover, waist circumference, mid-upper arm circumference, percent body fat, and muscle mass were not significantly different before and after treatment. Serum lipid levels and hemoglobin A1c also did not change with the treatment. CONCLUSION In summary, this case series provides encouraging results about the efficacy of the combined pioglitazone and topiramate therapy for the management of adolescents with severe MASLD, which should be further explored in clinical studies.
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Affiliation(s)
- Callen Conroy
- University of Kentucky College of Medicine, Lexington, KY, USA
| | - Aurelia Radulescu
- Department of Pediatrics, University of Kentucky College of Medicine and Kentucky Children's Hospital, Lexington, KY, USA
| | - Suzanna L Attia
- Department of Pediatrics, Division of Pediatric Gastroenterology, University of Kentucky College of Medicine and Kentucky Children's Hospital, Lexington, Kentucky, USA
| | - Nathan Shelman
- Department of Pathology and Laboratory Medicine, University of Kentucky College of Medicine, Lexington, KY, USA
| | - James T Lee
- Abdominal and Emergency Radiology Divisions, Department of Radiology, University of Kentucky, Lexington, KY, USA
| | - Roberto Galuppo Monticelli
- Department of Radiology-Division of Vascular and Interventional Radiology, University of Kentucky, Lexington, KY, USA
| | - Sara Hall
- Department of Anesthesiology, University of Kentucky HealthCare, Lexington, KY, USA
| | - Rohit Kohli
- Division of Gastroenterology, Hepatology and Nutrition, Children's Hospital Los Angeles, Los Angeles, California, USA
| | - Samir Softic
- Department of Pediatrics, Division of Pediatric Gastroenterology, University of Kentucky College of Medicine and Kentucky Children's Hospital, Lexington, Kentucky, USA
- Department of Pharmacology and Nutritional Sciences, University of Kentucky College of Medicine, Lexington, Kentucky, USA
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Park SH, Helsley RN, Fadhul T, Willoughby JL, Noetzli L, Tu HC, Solheim MH, Fujisaka S, Pan H, Dreyfuss JM, Bons J, Rose J, King CD, Schilling B, Lusis AJ, Pan C, Gupta M, Kulkarni RN, Fitzgerald K, Kern PA, Divanovic S, Kahn CR, Softic S. Fructose Induced KHK-C Increases ER Stress and Modulates Hepatic Transcriptome to Drive Liver Disease in Diet-Induced and Genetic Models of NAFLD. BIORXIV : THE PREPRINT SERVER FOR BIOLOGY 2023:2023.01.27.525605. [PMID: 36747758 PMCID: PMC9900898 DOI: 10.1101/2023.01.27.525605] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
Non-alcoholic fatty liver disease (NAFLD) is a liver manifestation of metabolic syndrome, and is estimated to affect one billion individuals worldwide. An increased intake of a high-fat diet (HFD) and sugar-sweetened beverages are risk-factors for NAFLD development, but how their combined intake promotes progression to a more severe form of liver injury is unknown. Here we show that fructose metabolism via ketohexokinase (KHK) C isoform increases endoplasmic reticulum (ER) stress in a dose dependent fashion, so when fructose is coupled with a HFD intake it leads to unresolved ER stress. Conversely, a liver-specific knockdown of KHK in C57BL/6J male mice consuming fructose on a HFD is adequate to improve the NAFLD activity score and exert a profound effect on the hepatic transcriptome. Overexpression of KHK-C in cultured hepatocytes is sufficient to induce ER stress in fructose free media. Upregulation of KHK-C is also observed in genetically obesity ob/ob, db/db and lipodystrophic FIRKO male mice, whereas KHK knockdown in these mice improves metabolic function. Additionally, in over 100 inbred strains of male or female mice hepatic KHK expression correlates positively with adiposity, insulin resistance, and liver triglycerides. Similarly, in 241 human subjects and their controls, hepatic Khk expression is upregulated in early, but not late stages of NAFLD. In summary, we describe a novel role of KHK-C in triggering ER stress, which offers a mechanistic understanding of how the combined intake of fructose and a HFD propagates the development of metabolic complications.
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Affiliation(s)
- Se-Hyung Park
- Department of Pediatrics, Division of Pediatric Gastroenterology, University of Kentucky College of Medicine, Lexington, KY. 40536
| | - Robert N. Helsley
- Department of Pediatrics, Division of Pediatric Gastroenterology, University of Kentucky College of Medicine, Lexington, KY. 40536
| | - Taghreed Fadhul
- Department of Pediatrics, Division of Pediatric Gastroenterology, University of Kentucky College of Medicine, Lexington, KY. 40536
| | | | | | - Ho-Chou Tu
- Alnylam Pharmaceuticals Inc., Cambridge, MA. 02142
| | - Marie H. Solheim
- Section on Integrative Physiology and Metabolism, Joslin Diabetes Center, Harvard Medical School, Boston, MA. 02215
- Department of Neuronal Control of Metabolism, Max Planck Institute for Metabolism Research, 50931 Cologne, Germany
| | - Shiho Fujisaka
- Section on Integrative Physiology and Metabolism, Joslin Diabetes Center, Harvard Medical School, Boston, MA. 02215
- First Department of Internal Medicine, University of Toyama, Toyama 930-0194, Japan
| | - Hui Pan
- Bioinformatics and Biostatistics Core, Joslin Diabetes Center, Harvard Medical School, Boston, MA
| | - Jonathan M. Dreyfuss
- Bioinformatics and Biostatistics Core, Joslin Diabetes Center, Harvard Medical School, Boston, MA
| | - Joanna Bons
- Proteomics and Aging Center, Buck Institute for Research on Aging, Novato, CA 94945
| | - Jacob Rose
- Proteomics and Aging Center, Buck Institute for Research on Aging, Novato, CA 94945
| | - Christina D. King
- Proteomics and Aging Center, Buck Institute for Research on Aging, Novato, CA 94945
| | - Birgit Schilling
- Proteomics and Aging Center, Buck Institute for Research on Aging, Novato, CA 94945
| | - Aldons J. Lusis
- Department of Medicine/Division of Cardiology, Department of Human Genetics, A2-237 Center for the Health Sciences, University of California, Los Angeles, Los Angeles, CA USA
| | - Calvin Pan
- Department of Medicine/Division of Cardiology, Department of Human Genetics, A2-237 Center for the Health Sciences, University of California, Los Angeles, Los Angeles, CA USA
| | - Manoj Gupta
- Section of Islet Cell and Regenerative Biology, Joslin Diabetes Center; Harvard Stem Cell Institute, Harvard Medical School, Boston, MA 02215
| | - Rohit N. Kulkarni
- Section of Islet Cell and Regenerative Biology, Joslin Diabetes Center; Harvard Stem Cell Institute, Harvard Medical School, Boston, MA 02215
| | | | - Philip A. Kern
- Department of Medicine, Division of Endocrinology, University of Kentucky College of Medicine, Lexington, KY. 40536
| | - Senad Divanovic
- Department of Pediatrics, University of Cincinnati College of Medicine, Division of Immunobiology, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH 45229
| | - C. Ronald Kahn
- Section on Integrative Physiology and Metabolism, Joslin Diabetes Center, Harvard Medical School, Boston, MA. 02215
| | - Samir Softic
- Department of Pediatrics, Division of Pediatric Gastroenterology, University of Kentucky College of Medicine, Lexington, KY. 40536
- Section on Integrative Physiology and Metabolism, Joslin Diabetes Center, Harvard Medical School, Boston, MA. 02215
- Department of Pharmacology and Nutritional Sciences, University of Kentucky College of Medicine, Lexington, KY. 40536
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Byrne CD. Banting memorial lecture 2022: 'Type 2 diabetes and nonalcoholic fatty liver disease: Partners in crime'. Diabet Med 2022; 39:e14912. [PMID: 35790023 PMCID: PMC9546361 DOI: 10.1111/dme.14912] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2022] [Revised: 06/14/2022] [Accepted: 06/29/2022] [Indexed: 11/28/2022]
Abstract
Nonalcoholic fatty liver disease (NAFLD) was first described in the 1980s, but in the 21st century, NAFLD has become a very common condition. The explanation for this relatively recent problem is in large part due to the recent epidemic of obesity and type 2 diabetes (T2DM) increasing the risk of NAFLD. NAFLD is a silent condition that may not become manifest until severe liver damage (fibrosis or cirrhosis) has occurred. Consequently, NAFLD and its complications often remain undiagnosed. Research evidence shows that NAFLD is extremely common and some estimates suggest that it occurs in up to 70% of people with T2DM. In the last 5 years, it has become evident that NAFLD not only increases the risk of cirrhosis, primary liver cancer and end-stage liver disease, but NAFLD is also an important multisystem disease that has major implications beyond the liver. NAFLD increases the risk of incident T2DM, cardiovascular disease, chronic kidney disease and certain extra-hepatic cancers, and NAFLD and T2DM form part of a vicious spiral of worsening diseases, where one condition affects the other and vice versa. Diabetes markedly increases the risk of liver fibrosis and liver fibrosis is the most important risk factor for hepatocellular carcinoma. It is now possible to diagnose liver fibrosis with non-invasive tools and therefore it is important to have clear care pathways for the management of NAFLD in patients with T2DM. This review summarises key recent research that was discussed as part of the Banting lecture at the annual scientific conference in 2022.
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Affiliation(s)
- Christopher D. Byrne
- Division of Endocrinology & MetabolismUniversity Hospital Southampton and University of SouthamptonSouthamptonUK
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Softic S, Kohli R. Pediatric NASH therapies: A speedbump on the road to success. Hepatology 2022; 76:292-294. [PMID: 35000211 DOI: 10.1002/hep.32322] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Accepted: 01/04/2022] [Indexed: 12/12/2022]
Affiliation(s)
- Samir Softic
- Department of Pediatrics, Division of Pediatric Gastroenterology, University of Kentucky College of Medicine and Kentucky Children's Hospital, Lexington, Kentucky, USA.,Department of Pharmacology and Nutritional Sciences, University of Kentucky College of Medicine, Lexington, Kentucky, USA.,Section on Integrative Physiology and Metabolism, Joslin Diabetes Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Rohit Kohli
- Division of Gastroenterology, Hepatology and Nutrition, Children's Hospital Los Angeles, Los Angeles, California, USA
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Dietary Counseling Aimed at Reducing Sugar Intake Yields the Greatest Improvement in Management of Weight and Metabolic Dysfunction in Children with Obesity. Nutrients 2022; 14:nu14071500. [PMID: 35406113 PMCID: PMC9003198 DOI: 10.3390/nu14071500] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2022] [Revised: 03/27/2022] [Accepted: 04/01/2022] [Indexed: 02/04/2023] Open
Abstract
Pediatric obesity is a significant public health problem, the negative outcomes of which will challenge individual well-being and societal resources for decades to come. The objective of this study was to determine the effects of dietary counseling on weight management and metabolic abnormalities in children with obesity. One hundred and sixty-five patients aged 2−18 years old were studied over a two and a half year period. Data collected included demographic information, anthropometric assessment, laboratory measurements, and self-reported eating behaviors. Dietary counseling was provided at each visit. The data was analyzed from the first and last visits and the subjects were retrospectively divided into responders and non-responders based on a decrease in their BMI. After receiving dietary guidance, BMI decreased in 44% of the children, and these participants were classified as responders (BMI-R; n = 72). However, BMI did not improve in 56% of the participants, and these were classified as non-responders (BMI-NR; n = 93). At the initial visit, anthropometric measurements and dietary habits were similar between the groups. At the time of the last visit, mean change in BMI was −1.47 (SD 1.31) for BMI-R and +2.40 (SD 9.79) for BMI-NR. Analysis of food intake revealed that BMI-R significantly improved their dietary habits (p = 0.002) by reducing the intake of sugar-sweetened beverages (p = 0.019), processed foods (p = 0.002), sweets (p < 0.001), and unhealthy snacks (p = 0.009), as compared with BMI-NR. There was no change in the intake of second helpings, portion sizes, skipping meals, frequency of meals eaten at school, condiment use, intake of fruits and vegetables and consumption of whole grains between the groups. BMI-R also achieved an improvement in fasted glucose (p = 0.021), triglycerides (p < 0.001), and total cholesterol (p = 0.023), as compared to BMI-NR. In conclusion, children with obesity who were able to decrease their BMI implemented a significant reduction in consumption of foods with high sugar content. Focusing on reducing sugar intake may yield the biggest impact in terms of weight management and the improvement of metabolic abnormalities.
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