Review article: diagnosis and treatment of non-alcoholic fatty liver disease

Inhibition of Drp1-Filamin Protein Complex Prevents Hepatic Lipid Droplet Accumulation by Increasing Mitochondria-Lipid Droplet Contact

Lipid droplet (LD) accumulation in hepatocytes is one of the major symptoms associated with fatty liver disease. Mitochondria play a key role in catabolizing fatty acids for energy production through β-oxidation. The interplay between mitochondria and LD assumes a crucial role in lipid metabolism, while it is obscure how mitochondrial morphology affects systemic lipid metabolism in the liver. We previously reported that cilnidipine, an already existing anti-hypertensive drug, can prevent pathological mitochondrial fission by inhibiting protein-protein interaction between dynamin-related protein 1 (Drp1) and filamin, an actin-binding protein. Here, we found that cilnidipine and its new dihydropyridine (DHP) derivative, 1,4-DHP, which lacks Ca2+ channel-blocking action of cilnidipine, prevent the palmitic acid-induced Drp1-filamin interaction, LD accumulation and cytotoxicity of human hepatic HepG2 cells. Cilnidipine and 1,4-DHP also suppressed the LD accumulation accompanied by reducing mitochondrial contact with LD in obese model and high-fat diet-fed mouse livers. These results propose that targeting the Drp1-filamin interaction become a new strategy for the prevention or treatment of fatty liver disease.

Development and validation of a non-invasive model for predicting significant fibrosis based on patients with nonalcoholic fatty liver disease in the United States

Background

Liver fibrosis is closely related to abnormal liver function and liver cancer. Accurate noninvasive assessment of liver fibrosis is of great significance for preventing disease progression and treatment decisions. The purpose of this study was to develop and validate a non-invasive predictive model for the asses`sment of significant fibrosis in patients with non-alcoholic fatty liver disease.

Methods

Information on all participants for 2017-2018 was extracted from the NHANES database. The eligible patients with significant fibrosis (n=123) and non-significant fibrosis (n=898) were selected to form the original dataset. Variable selection was performed using least absolute shrinkage and selection operator (Lasso) regression, and multivariate logistic regression analysis was used to develop a prediction model. The utility of the model is assessed in terms of its discrimination, calibration and clinical usability. Bootstrap-resampling internal validation was used to measure the accuracy of the prediction model.

Results

This study established a new model consisting of 9 common clinical indicators and developed an online calculator to show the model. Compared with the previously proposed liver fibrosis scoring system, this model showed the best discrimination and predictive performance in the training cohort (0.812,95%CI 0.769-0.855) and the validation cohort (0.805,95%CI 0.762-0.847), with the highest area under curve. Specificity(0.823), sensitivity(0.699), positive likelihood ratio(3.949) and negative likelihood ratio(0.366) were equally excellent. The calibration plot of the predicted probability and the actual occurrence probability of significant fibrosis shows excellent consistency, indicating that the model calibration is outstanding. Combined with decision curve analysis, this model has a great benefit in the range of 0.1-0.8 threshold probability, and has a good application value for the diagnosis of clinical significant fibrosis.

Conclusion

This study proposes a new non-invasive diagnostic model that combines clinical indicators to provide an accurate and convenient individualized diagnosis of significant fibrosis in patients with non-alcoholic fatty liver disease.

The Influence of Ambient Temperature on Adipose Tissue Homeostasis, Metabolic Diseases and Cancers

Adipose tissue is a recognized energy storage organ during excessive energy intake and an endocrine and thermoregulator, which interacts with other tissues to regulate systemic metabolism. Adipose tissue dysfunction is observed in most obese mouse models and humans. However, most studies using mouse models were conducted at room temperature (RT), where mice were chronically exposed to mild cold. In this condition, energy use is prioritized for thermogenesis to maintain body temperature in mice. It also leads to the activation of the sympathetic nervous system, followed by the activation of β-adrenergic signaling. As humans live primarily in their thermoneutral (TN) zone, RT housing for mice limits the interpretation of disease studies from mouse models to humans. Therefore, housing mice in their TN zone (~28–30 °C) can be considered to mimic humans physiologically. However, factors such as temperature ranges and TN pre-acclimatization periods should be examined to obtain reliable results. In this review, we discuss how adipose tissue responds to housing temperature and the outcomes of the TN zone in metabolic disease studies. This review highlights the critical role of TN housing in mouse models for studying adipose tissue function and human metabolic diseases.

Dietary Vitamin C Intake Is Associated With Improved Liver Function and Glucose Metabolism in Chinese Adults

Background

Non-alcoholic fatty liver disease (NAFLD) is one of the most prevalent chronic liver diseases worldwide. Dietary vitamin C intake might play an important role in reducing the risk of NAFLD. This study assesses the relationship between dietary vitamin C intake and diagnostic biomarkers of NAFLD.

Methods

The data from the 2009 China Health and Nutrition Survey (CHNS), nine provinces across four diverse regions (Northeast, East Coast, Central, and West) were included in the study. The dietary vitamin C intake of participants was calculated based on 3-day 24-h diet questionnaires at the individual level. The associations of dietary vitamin C intake and the biochemical indicators of liver function and glucose/lipid metabolism were determined.

Results

A total of 8,307 participants were included in the final analysis. The mean dietary vitamin C intake for the overall, male and female subjects was 79.8 ± 58.6, 81.6 ± 55.3, and 78.2 ± 61.2 mg/day, respectively. The prevalence of inadequate dietary vitamin C intake for the overall, male and female subjects was 24.4, 26.5, and 22.6%, respectively. Intake of vitamin C was associated with both lower concentrations of plasma ferritin and hemoglobin A1c (HbA1c). Higher dietary vitamin C intake was associated with higher albumin, even further adjusted for body mass index (BMI), residence, and smoking status. No improvement in lipid metabolism was found.

Conclusion

This study demonstrated that higher dietary vitamin C intake is a benefit for improving glucose metabolism and liver function in which reducing ferritin, a biomarker of iron accumulation, may be involved.

Investigation of Changes in Liver Microanatomy in the Steatosis Model Created by Permanent Canula in Rats

Objective: The knowledge of nonalcoholic fatty liver disease (NAFLD) and Nonalcoholic Steatohepatitis (NASH) is limited to the findings from available suitable models for this disease. A number of rodent models have been described in which relevant liver pathology develops in an appropriate metabolic context. In this experimental study, it was aimed to create a new liver fat model by giving fat from the portal vein of rats and to visualize the changes in the liver with advanced microscopic techniques. Methods: 28 female rats were used in the study. Permanent intraabdominal cannulas were inserted into the portal vein of the rats. Rats were randomly divided four group. Intralipid 20% substance was injected through cannula to the experimental groups during the test period. Control group received saline at the same rate. At the end of the experiment, the animals were visualized with a laser speckle microscope and livers were divided into sections according to the stereological method. The sections were painted with Hematoxylin-Eosin, Oil red o, Masson trichoma, Bodipy, Nile red. Sections were evaluated under a microscope. Results: Ballooning, inflammation and fibrosis were observed in the 2 week intralipid group. In the 1 week intralipid group, the rate of parenchyma decreased while the sinusoid rate increased, and sinusoid rate increased significantly in the 2 week intralipid (p˂0.05). Conclusion: According to the findings, steatohepatitis was detected in the 2 week intralipid, whereas only steatosis was observed in the 1 week intralipid. Thus, it was concluded that the newly formed rat model causes steatosis.

The Effect of Laparoscopic Sleeve Gastrectomy and Gastric Bypass Surgery on Non-Alcoholic Steatohepatitis in Iranian Patients with Obesity

BACKGROUND Non-alcoholic steatohepatitis (NASH) is a serious comorbidity in patients with obesity and because of the high risk of cirrhosis and the extreme mortality rate of NASH, approaching effective treatment methods, and improvements are crucial. Following few studies comparing the impact of laparoscopic gastric bypass (LGB) and laparoscopic sleeve gastrectomy (LSG) surgery on NASH, our study was conducted to assess the effect of these two surgical methods separately in patients with NASH through ultrasonography, and concurrently, on other factors such as lipid profiles and blood pressure to reduce the complications of complex obesity surgeries on patients and also provide a solution to prevent NASH-related cirrhosis. METHODS This study was performed at Imam Khomeini Hospital Complex; Vali-e-Asr Hospital affiliated to Tehran University of Medical Sciences.All patients with obesity who had undergone bariatric surgery at Vali-e-Asr Hospital during 2017 and 2018 were included in this prospective cohort study. Weight, body mass index (BMI), blood pressure, Alanine transaminase(ALT), Aspartate transaminase(AST),lipid profile and Fasting blood sugar(FBS)were evaluated before and one year after surgery. The patients underwent an ultrasound examination before surgery to determine the fatty liver grade. The type of operation (sleeve or bypass) was governed by the patient him/herself after receiving thorough clarifications about the available methods, their complications, and expected outcomes. In addition, by the separation of fatty liver grading with ultrasound modality, the correlation between ultrasound grading, laboratory results, and the rate of weight loss in patients who undergone both sleeve and bypass surgeries were evaluated and compared during a one-year follow-up. RESULTS In this study, 44 patients were included. 22 patients underwent laparoscopic sleeve gastrectomy (LSG), and 22 patients underwent laparoscopic gastric bypass (LGB) surgery. The mean age of the patients was 40.45 ± 12.01 years. 35 patients (79.5%) were women, and 9 patients (20.5%) were men. Most patients (81.8%) had grade I and II in terms of preoperative liver ultrasonography results. Bariatric surgery (LSG and LGB) greatly enhanced NASH's hepatic status in liver ultrasonography. Since the liver status of patients with preoperative ultrasonography was not significantly different between the two groups, there was no substantial distinction among the two groups in this regard, postoperatively. Weight and BMI, lipid profile, liver enzymes, FBS, and mean arterial blood pressure (MAP) were significantly reduced individually in both groups and all patients one year after surgery. None of the postoperative variables and their modifications had a prominent difference between the two groups except for High-density lipoprotein(HDL)level after surgery. The postoperative HDL was considerably higher in the LGB group (p = 0.014). However, the changes in HDL were not statistically different between both groups. The levels of AST, ALT, total cholesterol, LDL, and FBS were associated with the NASH grade. CONCLUSION Both types of LSG and LGB bariatric surgeries have been shown to significantly reduce BMI and improve lipid profiles, liver enzymes, and blood glucose levels in patients one year after surgery. The NASH status was also ameliorated considerably. The two types of surgery were not remarkably different in these modifications. Besides, there was a significant correlation between AST, ALT, total cholesterol, LDL, and FBS levels with the NASH grade.

Exenatide ameliorates experimental non-alcoholic fatty liver in rats via suppression of toll-like receptor 4/NFκB signaling: Comparison to metformin

AIMS

Non-alcoholic fatty liver disease (NAFLD) is a common liver disease. This study aimed to evaluate the role of exenatide compared with metformin in halting the progression of fatty liver stimulated by a high-fat diet (HiFD) in rats.

MAIN METHODS

Thirty male Wistar rats were allocated into 6 groups, 5 rats per each group. Group I: maintained on normal diet (normal group) for fourteen weeks. The other five groups were kept on HiFD throughout the experiment, HiFD was administered beside pharmacological treatments/or vehicle. Group II: (NAFLD control group), group III: received metformin (60 mg/kg/day, P.O.), group IV-VI: received exenatide (10, 20, and 40 μg/kg/day, S.C.) respectively for 7 weeks. At the end of the therapeutic period, fasting blood glucose was determined, and body weight was registered. Rats were sacrificed, and blood samples were taken to measure serum insulin, lipids, and liver enzymes. The liver index and homeostasis model of insulin resistance (HOMA-IR) index were calculated. Further, livers were dissected for histopathological examination and Western blot analysis.

KEY FINDINGS

NAFLD control group showed hyperglycemia, hyperinsulinemia, increased liver enzymes, hypertriglyceridemia, elevated hepatic lipid peroxides, and inflammatory mediators (interlukin 6, nuclear factor-κB, tumor necrosis factor-α and Toll-like receptor4) in addition to hepatic fatty degeneration. In a dose-dependent manner, exenatide significantly improved most of the above mentioned markers in comparsion with NAFLD at P≤0.05.

SIGNIFICANCE

The current results suggest that exenatide is equivalent to metformin in controlling insulin resistance, body weight gain, improving liver function, suppressing inflammation, and attenuating NAFLD progression in male rats.

The Eicosanoids, Redox-Regulated Lipid Mediators in Immunometabolic Disorders

SIGNIFICANCE

The oxidation of arachidonic acid via cyclooxygenase (COX) and lipoxygenase (LOX) activity to produce eicosanoids during inflammation is a well-known biosynthetic pathway. These lipid mediators are involved in fever, pain, and thrombosis and are produced from multiple cells as well as cell/cell interactions, for example, immune cells and epithelial/endothelial cells. Metabolic disorders, including hyperlipidemia, hypertension, and diabetes, are linked with chronic low-grade inflammation, impacting the immune system and promoting a variety of chronic diseases. Recent Advances: Multiple studies have corroborated the important function of eicosanoids and their receptors in (non)-inflammatory cells in immunometabolic disorders (e.g., insulin resistance, obesity, and cardiovascular and nonalcoholic fatty liver diseases). In this context, LOX and COX products are involved in both pro- and anti-inflammatory responses. In addition, recent work has elucidated the potent function of specialized proresolving mediators (i.e., lipoxins and resolvins) in resolving inflammation, protecting organs, and stimulating tissue repair and remodeling.

CRITICAL ISSUES

Inhibiting/stimulating selected eicosanoid pathways may result in anti-inflammatory and proresolution responses leading to multiple beneficial effects, including the abrogation of reactive oxygen species production, increased speed of resolution, and overall improvement of diseases related to immunometabolic perturbations.

FUTURE DIRECTIONS

Despite many achievements, it is crucial to understand the molecular and cellular mechanisms underlying immunological/metabolic cross talk to offer substantial therapeutic promise. Antioxid. Redox Signal. 29, 275-296.

Apolipoprotein A5 gene polymorphisms are associated with non-alcoholic fatty liver disease

BACKGROUND

Several studies have reported that apolipoprotein A5 (APOA5) is involved in the development of non-alcoholic fatty liver disease (NAFLD). However, no research has been performed regarding the association between APOA5 polymorphisms and the risk of NAFLD. This study aimed to explore the association between APOA5 gene polymorphisms and NAFLD in a Chinese Han population.

METHODS

Genotypes of the SNPs (rs10750097, rs1263173, rs17120035, rs3135507 and rs662799) of APOA5 in 232 NAFLD patients and 188 healthy controls were determined using polymerase chain reaction (PCR) analysis. Clinical characteristics were measured using biochemical methods.

RESULTS

The five single nucleotide polymorphisms (SNPs) (rs10750097, rs1263173, rs17120035, rs3135507 and rs662799) of APOA5 showed no significant association with NAFLD (P > 0.05). The rs10750097 with G allele showed a higher serum level of alkaline phosphatase (ALP) compared with C allele in overall series and NAFLD patients (P < 0.05). The rs1263173(A/A) carriers showed a higher level of glucose compared to the non-carriers in overall series (P < 0.05). The rs17120035(T/T) carriers showed a lower plasma TG level in overall series and NAFLD patients (P < 0.05), and the rs662799(G/G) carriers showed higher levels of plasma triglyceride (TG), ALP, and lower level of high-density lipoprotein (HDL) compared to non-carriers in NAFLD patients (P < 0.05). No significant difference were observed on the clinic parameters of APOA5 rs3135507(T/T) carriers in both group of overall series and NAFLD patients (P > 0.05).

CONCLUSIONS

The five SNPs (rs10750097, rs1263173, rs17120035, rs3135507 and rs662799) of APOA5 gene are not associated with the risk of NAFLD in the Chinese Han population. The genotypes of rs10750097(G/G), rs1263173(A/A), rs17120035(T/T), and rs662799(G/G) performed a significant effect on clinic characteristics in overall series and NAFLD patients, indicating that these polymorphisms may be associated with NAFLD.

Association of sugar sweetened beverages consumption with non-alcoholic fatty liver disease: a systematic review and meta-analysis

PURPOSE

The relationship between consumption of sugar sweetened beverages (SSB) and NAFLD has been reported in several epidemiological studies, but the results are inconsistent. The present systematic review and meta-analysis of observational studies was carried out to assess the relationship between sugar sweetened beverages consumption and NAFLD.

METHODS

Online databases were searched systematically through December, 2016 for studies investigating association between SSB consumption and NAFLD but limited to observational studies in human. Pooled odds ratio (OR) and 95% confidence intervals were calculated using Der-Simonian and Laird method while random effects meta-analysis was used, taking into account conceptual heterogeneity. Heterogeneity was assessed with the Cochran Q statistic and quantified with the I² statistic.

RESULTS

Of the 1015 identified articles, 42 were reviewed in depth and six studies (four cross-sectional, one case-control, and one cohort) met the criteria for inclusion in our systematic review with 6326 participants and 1361 cases of NAFLD in both men and women. Finally, four cross-sectional studies were included in the meta-analysis. Higher intake of SSBs (highest compared to lowest categories) was significantly associated with NAFLD, with a 40% increased Odds of NAFLD after adjusting for important potential confounders (pooled odds ratio 1.40; 95% CI 1.07, 1.82). There was no evidence for significant heterogeneity across studies [P = 0.226 (Q statistics), I² = 31.0%]. A significant positive association between SSB consumption and NAFLD was observed consistently in a sensitivity analysis [range of summary ORs 1.39-1.49]. There was no evidence of publication bias for the association between SSB and NAFLD.

CONCLUSIONS

This meta-analysis supports a positive significant association between higher consumption of SSB and NAFLD in both men and women. These findings strengthen the evidence that intake of SSBs should be limited to reduce fatty liver disease.

Clinical and metabolic effects associated with weight changes and obeticholic acid in non-alcoholic steatohepatitis

BACKGROUND

In a 72-week, randomised controlled trial of obeticholic acid (OCA) in non-alcoholic steatohepatitis (NASH), OCA was superior to placebo in improving serum ALT levels and liver histology. OCA therapy also reduced weight.

AIMS

Because weight loss by itself can improve histology, to perform a post hoc analysis of the effects of weight loss and OCA treatment in improving clinical and metabolic features of NASH.

METHODS

The analysis was limited to the 200 patients with baseline and end-of-treatment liver biopsies. Weight loss was defined as a relative decline from baseline of 2% or more at treatment end.

RESULTS

Weight loss occurred in 44% (45/102) of OCA and 32% (31/98) of placebo-treated patients (P = 0.08). The NAFLD Activity score (NAS) improved more in those with than without weight loss in both the OCA- (-2.4 vs -1.2, P<0.001) and placebo-treated patients (-1.2 vs -0.5, P = 0.03). ALT levels also improved in those with vs without weight loss in OCA- (-43 vs -34 U/L, P = 0.12) and placebo-treated patients (-29 vs -10 U/L, P = 0.02). However, among those who lost weight, OCA was associated with opposite effects from placebo on changes in alkaline phosphatase (+21 vs -12 U/L, P<0.001), total (+13 vs -14 mg/dL, P = 0.02) and LDL cholesterol (+18 vs -12 mg/dL, P = 0.01), and HbA1c (+0.1 vs -0.4%, P = 0.01).

CONCLUSIONS

OCA leads to weight loss in up to 44% of patients with NASH, and OCA therapy and weight loss have additive benefits on serum aminotransferases and histology. However, favourable effects of weight loss on alkaline phosphatase, lipids and blood glucose seen in placebo-treated patients were absent or reversed on OCA treatment. These findings stress the importance of assessing concomitant metabolic effects of new therapies of NASH. Clinical trial number: NCT01265498.

Protective effect of rimonabant, a canabinoid receptor 1 antagonist, on nonalcoholic fatty liver disease in a rat model through modulation of the hepatic expression of activin A and follistatin

Non-alcoholic fatty liver disease (NAFLD) is a major cause of liver morbidity and mortality, and there is still no proven effective therapy. The endocannabinoid system plays an important role in various liver diseases. Activin A is a member of the transforming growth factor beta (TGF-β) superfamily and inhibits hepatocyte growth. Follistatin antagonizes the biological actions of activin A. This study was designed to investigate the effect of rimonabant (a potent cannabinoid receptor1 (CB1) antagonist) on NAFLD induced with a choline-deficient (CD) diet in rats, as well as to detect whether it can alter the hepatic expression of activin A and follistatin. Forty rats were distributed among 4 groups: the control group, the rimonabant treatment group (normal rats that received rimonabant); the CD diet group (NAFLD induced with a CD diet); and the CD diet + rimonabant group (NAFLD treated with rimonabant). It was found that the CD diet caused significant increase in liver index, serum levels of liver enzymes, malondialdehyde (MDA), TGF-β1, activin A, and CB1 expression in liver tissue, with a significant decrease in glutathione peroxidase (GSH-Px) and follistatin mRNA expression in liver tissues. The administration of rimonabant significantly improved all of the studied parameters compared with the group fed the CD diet alone. Histopathological examination supported these results. We concluded that rimonabant significantly counteracted NAFLD induced with the CD diet by decreasing oxidative stress and hepatic expression of TGF-β1, and modulating the hepatic expression of activin A and follistatin.

Comparison of fenofibrate and pioglitazone effects on patients with nonalcoholic fatty liver disease

INTRODUCTION

Nonalcoholic fatty liver disease (NAFLD) is known to be a health-related problem; there is no proven treatment for NAFLD. However, a wide range of possible therapies have been proposed and studied. In the current study, we aimed to compare the therapeutic effects of fenofibrate and pioglitazone on NAFLD.

PATIENTS AND METHODS

In this randomized clinical trial study (ethic number: ZUMS.REC.1393.133), patients with NAFLD and alanine aminotransferase in range of 1-1.5 folds of normal and BMI (25-35) were studied. Blood lipids and liver enzymes were measured. The patients were divided randomly into three groups (recipient of fenofibrate, pioglitazone, and exercise). After the patients completed the course of treatment, liver enzymes were measured.

RESULTS

According to the results of this study, 90 patients with NAFLD were divided into three groups of 30 patients. All variables at the beginning of the study showed no significant difference among the three groups, but after the treatment period, the results showed that the levels of alanine aminotransferase, aspartate transaminase, systolic blood pressure, diastolic blood pressure, and BMI changed significantly: the levels decreased in all groups.

CONCLUSION

This study showed beneficial effects of fenofibrate and pioglitazone in patients with fatty liver. Further studies with larger study populations on the effects of these drugs on fatty liver, lipid profile, blood glucose, and insulin are suggested.

Nonalcoholic fatty liver disease: Diagnostic biomarkers

Nonalcoholic fatty liver disease is a common medical condition worldwide and its prevalence has increased notably in the past few years due to the increases in prevalence of obesity and metabolic syndrome. However, diagnosis of this disease is still a matter of debate because of disease variations and pathophysiologic alterations. Specific single markers have gained considerable attention recently, among them markers related to hepatic pathophysiology, inflammation, adipocytokines and so forth. But, it seems that no single marker is sufficient for diagnosis and staging of the disease, and applying a panel including different types of tests may be more useful.

Embrionary way to create a fatty liver in portal hypertension

Portal hypertension in the rat by triple partial portal vein ligation produces an array of splanchnic and systemic disorders, including hepatic steatosis. In the current review these alterations are considered components of a systemic inflammatory response that would develop through three overlapping phenotypes: The neurogenic, the immune and the endocrine. These three inflammatory phenotypes could resemble the functions expressed during embryonic development of mammals. In turn, the inflammatory phenotypes would be represented in the embryo by two functional axes, that is, a coelomic-amniotic axis and a trophoblastic yolk-sac or vitelline axis. In this sense, the inflammatory response developed after triple partial portal vein ligation in the rat would integrate both functional embryonic axes on the liver interstitial space of Disse. If so, this fact would favor the successive development of steatosis, steatohepatitis and fibrosis. Firstly, these recapitulated embryonic functions would produce the evolution of liver steatosis. In this way, this fat liver could represent a yolk-sac-like in portal hypertensive rats. After that, the systemic recapitulation of these embryonic functions in experimental prehepatic portal hypertension would consequently induce a gastrulation-like response in which a hepatic wound healing reaction or fibrosis occur. In conclusion, studying the mechanisms involved in embryonic development could provide key results for a better understanding of the nonalcoholic fatty liver disease etiopathogeny.

Bioprinted 3D Primary Liver Tissues Allow Assessment of Organ-Level Response to Clinical Drug Induced Toxicity In Vitro

Modeling clinically relevant tissue responses using cell models poses a significant challenge for drug development, in particular for drug induced liver injury (DILI). This is mainly because existing liver models lack longevity and tissue-level complexity which limits their utility in predictive toxicology. In this study, we established and characterized novel bioprinted human liver tissue mimetics comprised of patient-derived hepatocytes and non-parenchymal cells in a defined architecture. Scaffold-free assembly of different cell types in an in vivo-relevant architecture allowed for histologic analysis that revealed distinct intercellular hepatocyte junctions, CD31+ endothelial networks, and desmin positive, smooth muscle actin negative quiescent stellates. Unlike what was seen in 2D hepatocyte cultures, the tissues maintained levels of ATP, Albumin as well as expression and drug-induced enzyme activity of Cytochrome P450s over 4 weeks in culture. To assess the ability of the 3D liver cultures to model tissue-level DILI, dose responses of Trovafloxacin, a drug whose hepatotoxic potential could not be assessed by standard pre-clinical models, were compared to the structurally related non-toxic drug Levofloxacin. Trovafloxacin induced significant, dose-dependent toxicity at clinically relevant doses (≤ 4uM). Interestingly, Trovafloxacin toxicity was observed without lipopolysaccharide stimulation and in the absence of resident macrophages in contrast to earlier reports. Together, these results demonstrate that 3D bioprinted liver tissues can both effectively model DILI and distinguish between highly related compounds with differential profile. Thus, the combination of patient-derived primary cells with bioprinting technology here for the first time demonstrates superior performance in terms of mimicking human drug response in a known target organ at the tissue level.

Association Between LYPLAL1 rs12137855 Polymorphism With Ultrasound-Defined Non-Alcoholic Fatty Liver Disease in a Chinese Han Population

BACKGROUND

Recent genome-wide association studies (GWAS) identified that gene Lysophospholipase-like 1 (LYPLAL1) rs12137855 associated with non-alcoholic fatty liver disease (NAFLD). No research has been performed regarding the association between LYPLAL1 and NAFLD in China.

OBJECTIVES

The aim of the present study was to investigate the association between the gene LYPLAL1 rs12137855 and NAFLD, and the effect on serum lipid profiles in a Chinese Han population.

PATIENTS AND METHODS

LYPLAL1 rs12137855 gene was genotyped in 184 patients with NAFLD and 114 healthy controls using sequencing and polymerase chain reaction analysis (PCR). We tested serum lipid profiles using biochemical methods.

RESULTS

No significant differences in genotype and allele frequencies of LYPLAL1 rs12137855 was found between the NAFLD group and the controls group (P > 0.05). Subjects with the variant LYPLAL1 rs12137855 CC genotype had a higher mean weight, body mass index (BMI) and low density lipoprotein (LDL).

CONCLUSIONS

Our results showed for the first time that LYPLAL1 gene is not associated with a risk of NAFLD development in the Chinese Han population. The variant carriers of overall subjects significantly increased weight, BMI and LDL.

Essential phospholipids as a supportive adjunct in the management of patients with NAFLD

BACKGROUND AND STUDY AIMS

Treatment of nonalcoholic fatty liver (NAFLD) is important because NAFLD patients have a 1.7-fold increase in standardised age and gender matched mortality. Currently treatment is based on life style modification and managing comorbid associating disease. Other medications remain experimental. Essential phospholipid (EPL) is a nutrient for the liver, helping to maintain vitality of cell membranes where the vast majority of liver activities are regulated. We performed a randomised open label study to evaluate EPL as an adjuvant nutrient to the treatment of primary NAFLD or NAFLD with comorbid disease.

PATIENTS AND METHOD

Three groups of NAFLD patients were recruited: lone (n=113), diabetes mellitus type 2 (n=107) and mixed hyperlipidaemia (n=104). Diagnosis was established by excluding other chronic liver diseases. A standard diet and physical activity plan were advised to all patients. 1800mg of EPL a day was given for 24weeks, followed by 900mg for 48weeks.

RESULTS

Essential phospholipid EPL led to a significant improvement of symptoms and a mean reduction of ALT of 50.8IU and AST of 46.1IU per patient (p<0.01). Abdominal ultrasonography indicated normalisation in 4.6% and a shift from grade II to grade I in 24% of patients. Liver stiffness measurement indicated an improvement in 21.1%, with a mean reduction in the LSM of 3.1K Pascal/patient. Reducing the dosage after six months led to a limited relapse in 43.8-63.2% of patients, for lone and NAFLD with co-morbid conditions.

CONCLUSION

Essential phospholipid (EPL) as a nutritional supplement resulted in a significant improvement in clinical parameters and transaminases for all NAFLD patients. Ultrasound and LSM revealed modest improvement. There is a need for uninterrupted maintenance to avoid relapse.

Non-alcoholic fatty liver disease resolution following sleeve gastrectomy

BACKGROUND

Non-alcoholic fatty liver disease (NAFLD), a disease highly prevalent among the morbidly obese population, is one of the most common causes of chronic liver disease today. The purpose of this study was to observe the effect of laparoscopic sleeve gastrectomy (LSG) on the resolution of NAFLD.

METHODS

A retrospective study was conducted of 84 patients diagnosed with NAFLD prior to undergoing LSG. The diagnosis of NAFLD was achieved based on transabdominal ultrasonographic imaging as per the 2012 joint guidelines for the diagnosis of NAFLD (American Gastroenterological Association, American Association for the Study of Liver Diseases, and American College of Gastroenterology). The patients had follow-up anthropometric measurements and were re-evaluated with postoperative ultrasounds at different time frames to assess the resolution of the disease.

RESULTS

The median age of the patients was 44 (17-62), and 66.7 % were female. Average time since surgery was 3.3 years (range 1-5 years). The mean pre- and postoperative BMIs were 46.6 ± 7.8 and 33.0 ± 7.1, respectively, with a mean percent excess weight loss (%EWL) of 55.7 % ± 23.0. A total of 47 (56 %) patients showed complete resolution of NAFLD postoperatively. Multivariate analysis showed a significant resolution of NAFLD in patients achieving >50 % EWL (OR 10.1; p < 0.001) after controlling for age and sex.

CONCLUSIONS

Weight loss after LSG effectively resolved NAFLD in more than half of the obese patients in this study and can prove to be a useful tool in tackling the disease in the future.

Prevalence of non-alcoholic fatty liver disease in four different weight related patient groups: association with small bowel length and risk factors

BACKGROUND

Non-alcoholic steatohepatitis (NASH) is an obesity associated common cause of liver inflammation and there are concerns that it may turn out to be the most common cause of liver failure as prevalence of obesity increases. We determined the prevalence of NASH in relation to gender and body mass index (BMI). Furthermore, we assessed the association of NASH with the length of the small bowel.

METHODS

124 liver samples obtained during routine operations were examined looking for NAFLD Activity Score (nonalcoholic fatty liver disease). The length of small bowel was measured intraoperatively. For evaluation, patients were divided into four groups according to their BMI (group 1: normal weight, group 2: overweight, group 3: grade I/II morbidly obese, and group 4 grade III morbidly obese patients).

RESULTS

BMI showed a strong positive correlation with risk of NASH and a weak positive correlation with small bowel length. No normal weight patient was at risk of NASH, whereas in group 2 14% had uncertain and 32% definite NASH. In group 3 11% had uncertain and 27% definite NASH. In group 4 nearly two-thirds were classified as uncertain or definite NASH. Median length of small bowel in all patients was 450 cm (range 226-860 cm). Within group 4, patients with definite/uncertain NASH had a longer small bowel than patients without NASH.

CONCLUSIONS

Prevalence of NASH is high in morbidly obese. Small bowel length could influence the complex etiology of the disease.

Altered regulation of hepatic efflux transporters disrupts acetaminophen disposition in pediatric nonalcoholic steatohepatitis

Nonalcoholic fatty liver disease (NAFLD) is the most common chronic liver disease, representing a spectrum of liver pathologies that include simple hepatic steatosis and the more advanced nonalcoholic steatohepatitis (NASH). The current study was conducted to determine whether pediatric NASH also results in altered disposition of acetaminophen (APAP) and its two primary metabolites, APAP-sulfate and APAP-glucuronide. Pediatric patients with hepatic steatosis (n = 9) or NASH (n = 3) and healthy patients (n = 12) were recruited in a small pilot study design. All patients received a single 1000-mg dose of APAP. Blood and urine samples were collected at 1, 2, and 4 hours postdose, and APAP and APAP metabolites were determined by high-performance liquid chromatography. Moreover, human liver tissues from patients diagnosed with various stages of NAFLD were acquired from the Liver Tissue Cell Distribution System to investigate the regulation of the membrane transporters, multidrug resistance-associated protein 2 and 3 (MRP2 and MRP3, respectively). Patients with the more severe disease (i.e., NASH) had increased serum and urinary levels of APAP-glucuronide along with decreased serum levels of APAP-sulfate. Moreover, an induction of hepatic MRP3 and altered canalicular localization of the biliary efflux transporter, MRP2, describes the likely mechanism for the observed increase in plasma retention of APAP-glucuronide, whereas altered regulation of sulfur activation genes may explain decreased sulfonation activity in NASH. APAP-glucuronide and APAP-sulfate disposition is altered in NASH and is likely due to hepatic membrane transporter dysregulation as well as altered intracellular sulfur activation.

Management of nonalcoholic fatty liver disease: an evidence-based clinical practice review

AIM

To build a consensus among Chilean specialists on the appropriate management of patients with nonalcoholic fatty liver disease (NAFLD) in clinical practice.

METHODS

NAFLD has now reached epidemic proportions worldwide. The optimal treatment for NAFLD has not been established due to a lack of evidence-based recommendations. An expert panel of members of the Chilean Gastroenterological Society and the Chilean Hepatology Association conducted a structured analysis of the current literature on NAFLD therapy. The quality of the evidence and the level of recommendations supporting each statement were assessed according to the recommendations of the United States Preventive Services Task Force. A modified three-round Delphi technique was used to reach a consensus among the experts.

RESULTS

A group of thirteen experts was established. The survey included 17 open-ended questions that were distributed among the experts, who assessed the articles associated with each question. The levels of agreement achieved by the panel were 93.8% in the first round and 100% in the second and third rounds. The final recommendations support the indication of lifestyle changes, including diet and exercise, for all patients with NAFLD. Proven pharmacological therapies include only vitamin E and pioglitazone, which can be used in nondiabetic patients with biopsy-proven nonalcoholic steatohepatitis (the progressive form of NAFLD), although the long-term safety and efficacy of these therapies have not yet been established.

CONCLUSION

Current NAFLD management is rapidly evolving, and new pathophysiology-based therapies are expected to be introduced in the near future. All NAFLD patients should be evaluated using a three-focused approach that considers the risks of liver disease, diabetes and cardiovascular events.

Molecular pathways in non-alcoholic fatty liver disease

Non-alcoholic fatty liver disease (NAFLD) is a clinicopathological change characterized by the accumulation of triglycerides in hepatocytes and has frequently been associated with obesity, type 2 diabetes mellitus, hyperlipidemia, and insulin resistance. It is an increasingly recognized condition that has become the most common liver disorder in developed countries, affecting over one-third of the population and is associated with increased cardiovascular- and liver-related mortality. NAFLD is a spectrum of disorders, beginning as simple steatosis. In about 15% of all NAFLD cases, simple steatosis can evolve into non-alcoholic steatohepatitis, a medley of inflammation, hepatocellular injury, and fibrosis, often resulting in cirrhosis and even hepatocellular cancer. However, the molecular mechanism underlying NAFLD progression is not completely understood. Its pathogenesis has often been interpreted by the “double-hit” hypothesis. The primary insult or the “first hit” includes lipid accumulation in the liver, followed by a “second hit” in which proinflammatory mediators induce inflammation, hepatocellular injury, and fibrosis. Nowadays, a more complex model suggests that fatty acids (FAs) and their metabolites may be the true lipotoxic agents that contribute to NAFLD progression; a multiple parallel hits hypothesis has also been suggested. In NAFLD patients, insulin resistance leads to hepatic steatosis via multiple mechanisms. Despite the excess hepatic accumulation of FAs in NAFLD, it has been described that not only de novo FA synthesis is increased, but FAs are also taken up from the serum. Furthermore, a decrease in mitochondrial FA oxidation and secretion of very-low-density lipoproteins has been reported. This review discusses the molecular mechanisms that underlie the pathophysiological changes of hepatic lipid metabolism that contribute to NAFLD.

Factors affecting the accuracy of controlled attenuation parameter (CAP) in assessing hepatic steatosis in patients with chronic liver disease

Background & Aims

Controlled attenuation parameter (CAP) can measure hepatic steatosis. However, factors affecting its accuracy have not been described yet. This study investigated predictors of discordance between liver biopsy (LB) and CAP.

Methods

A total of 161 consecutive patients with chronic liver disease who underwent LB and CAP were enrolled prospectively. Histological steatosis was graded as S0 (<5%), S1 (5–33%), S2 (34–66%), and S3 (>66% of hepatocytes). Cutoff CAP values were calculated from our cohort (250, 301, and 325 dB/m for ≥S1, ≥S2, and S3). Discordance was defined as a discrepancy of at least two steatosis stages between LB and CAP.

Results

The median age (102 males and 59 females) was 49 years. Repartition of histological steatosis was as follows; S0 26.1% (n = 42), S1 49.7% (n = 80), S2 20.5% (n = 33), and S3 3.7% (n = 6). In multivariate linear regression analysis, CAP value was independently associated with steatosis grade along with body mass index (BMI) and interquartile range/median of CAP value (IQR/M_CAP) (all P<0.05). Discordance was identified in 13 (8.1%) patients. In multivariate analysis, histological S3 (odd ratio [OR], 9.573; 95% confidence interval [CI], 1.207–75.931; P = 0.033) and CAP value (OR, 1.020; 95% CI, 1.006–1.034; P = 0.006) were significantly associated with discordance, when adjusting for BMI, IQR/M_CAP, and necroinflammation, reflected by histological activity or ALT level.

Conclusions

Patients with high grade steatosis or high CAP values have a higher risk of discordance between LB and CAP. Further studies are needed to improve the accuracy of CAP interpretation, especially in patients with higher CAP values.

Steatosis and steatohepatitis: complex disorders

Non-alcoholic fatty liver disease (NAFLD) which includes steatosis and steatohepatitis, in particular non-alcoholic steatohepatitis (NASH), is a rising health problem world-wide and should be separated from alcoholic steatohepatitis (ASH). NAFLD is regarded as hepatic manifestation of the metabolic syndrome (MetSy), being tightly linked to obesity and type 2 diabetes mellitus (T2DM). Development of steatosis, liver fibrosis and cirrhosis often progresses towards hepatocellular carcinogenesis and frequently results in the indication for liver transplantation, underlining the clinical significance of this disease complex. Work on different murine models and several human patients studies led to the identification of different molecular key players as well as epigenetic factors like miRNAs and SNPs, which have a promoting or protecting function in AFLD/ASH or NAFLD/NASH. To which extent they might be translated into human biology and pathogenesis is still questionable and needs further investigation regarding diagnostic parameters, drug development and a better understanding of the genetic impact. In this review we give an overview about the currently available knowledge and recent findings regarding the development and progression of this disease.

Evaluation of the utility of serum prolidase as a marker for liver fibrosis

BACKGROUND

Liver dysfunction is common and often unrecognized. Liver biopsy is the gold standard in the assessment of liver fibrosis, but has disadvantages. We assessed the diagnostic accuracy of serum prolidase enzyme activity (SPA) in predicting the presence and degree of liver fibrosis, as compared with liver biopsy. Further, we evaluated the effect of hemolysis on measured SPA levels.

METHODS

We undertook a prospective case control study. Thirty eight outpatients without apparent liver illness and 20 patients with liver pathology scheduled to undergo liver biopsy had their SPA levels measured.

RESULTS

Patients undergoing liver biopsy had higher SPA levels (361 (268) IU/l [median (interquartile range)]) compared with controls (169 (160) (P < 0.001)). A SPA cutoff value of 200 IU/l yielded a sensitivity of 89%, specificity of 59%, an odds ratio of 11.5, negative predictive value of 92%, and a positive predictive value of 50%. Hemolysis causes an apparent increase in SPA levels.

CONCLUSION

Higher SPA levels in patients undergoing liver biopsies compared with controls may reflect the presence of liver fibrosis. SPA levels could not be used to stage the degree of fibrosis. SPA measurement may be useful in the diagnostic workup of suspected liver disease.

Not only type 2 diabetes but also prediabetes is associated with portal inflammation and fibrosis in patients with non-alcoholic fatty liver disease

AIMS

Growing evidence suggests that not only type 2 diabetes (T2D) but also prediabetes (PD) is common in patients with non-alcoholic fatty liver disease (NAFLD). However, few data exist on how PD impacts the histological characteristics of NAFLD patients. In this exploratory study, we sought to investigate the associations of PD and T2D with the severity of the histological features in patients with NAFLD.

METHODS

The population consisted of 280 patients with biopsy-proven NAFLD. The associations of PD and T2D with the severity of histological features of NAFLD were analyzed using multiple logistic (or ordinal logistic) regression models after adjustment for confounding factors.

RESULTS

PD and T2D was noted in 102 (36.4%) and 92 (32.8%) of patients, respectively. Of the 92 patients with T2D, ten (10.9%) were diagnosed de novo after the OGTT. PD and T2D were significantly associated with more severe portal inflammation (P<0.01); the adjusted odds ratios (ORs) of PD and T2D for having a higher grade of portal inflammation were 1.8 [95% CI, 1.1, 3.2] and 2.6 [95% CI, 1.3, 5.8]), respectively. A similar relationship was observed for liver fibrosis (P<0.001); specifically, the adjusted ORs of PD and T2D for having a higher grade of hepatic fibrosis were 2.4 [95% CI, 1.3, 3.7] and 3.8 [95% CI, 1.9, 6.1]), respectively.

CONCLUSION

Not only T2D but also PD is independently associated with portal inflammation and fibrosis in NAFLD patients. PD may be useful as a clinical indicator of patients who are likely to have already more severe histological findings.

Pioglitazone, quercetin and hydroxy citric acid effect on hepatic biomarkers in Non Alcoholic Steatohepatitis

BACKGROUND

Non alcoholic steatohepatitis (NASH), severe form of diseases belonging to the spectrum of the Non alcoholic fatty liver disease (NAFLD). It is an asymptomatic disease which leads to fibrosis and finally to cirrhosis, an end stage liver disease.

OBJECTIVE

To study the effect of pioglitazone, quercetin and hydroxy citric acid on hepatic biomarkers and various biochemical parameters in experimentally induced non alcoholic steatohepatitis (NASH).

MATERIALS AND METHODS

Male Wister rats were divided into 8 groups. The activities of alkaline phosphatase (ALP), aspartate transaminase (AST), alanine transaminase (ALT), lactate dehydrogenase (LDH) and γ-Glutamyl Transferase (GGT) were assayed in serum. The levels of various other biochemical parameters such as serum albumin, total bilirubin, creatinine, urea, uric acid and glucose were also estimated in experimental NASH.

RESULTS

The NASH group produced severe liver injury by significantly increasing the serum levels of ALT, AST, GGT and LDH compared with that of the control. However, the experimental NASH rats treated with pioglitazone, with quercetin and with hydroxy citric acid showed an obvious decrease in ALT, AST, GGT and LDH levels when compared with that of NASH induced group. A significant increase in the levels of albumin, creatinine, urea, uric acid, glucose and total bilirubin was noticed in experimentally induced NASH group (group 2) when compared to rats in control group (group 1).

CONCLUSION

It could be inferred from this study that, pioglitazone, quercetin and hydroxy citric acid may afford protection to the liver against NASH, as evidenced by the results of this study on the levels of various biochemical parameters such as glucose, urea, uric acid, creatinine and bilirubin. Whereas from the results of hepatic marker enzymes, it is evident that optimal protection was observed after quercetin treatment against experimental NASH whereas pioglitazone and hydroxy citric acid also confers protection to some extent against NASH.

Thyroid hormone analogues and derivatives: Actions in fatty liver

Fatty liver or nonalcoholic fatty liver disease (NAFLD), a problem of increasing clinical significance and prevalence worldwide, is associated with increased risk for the development of cirrhosis and hepatocellular carcinoma. Although several therapeutic approaches can be used in the context of NAFLD, dietary and physical activities are still the most frequently used strategies. Some pharmacological agents show promising results although no conclusions can be drawn from recent clinical trials. Thyroid hormones [THs; thyroxine (T4) and 3,3′,5-triiodo-L-thyronine (T3)] coordinate a diverse array of physiological events during development and lipid/energy homeostasis and have some potentially therapeutic actions which include inducing weight loss, and lowering plasma cholesterol levels and tissue adiposity. The thyroid hormones exert their physiological effects by binding to specific nuclear receptors [thyroid hormone receptors (TR)] of which the TRβ isoform is liver specific and has been considered a putative target for the treatment of dyslipidemia and fatty liver. In view of this, the aim of the review is (1) to provide an overview of the action of T3 on lipid metabolism with implications for liver steatosis and (2) to provide an update on the current knowledge concerning the administration of TRβ selective thyromimetics (GC-1 and MB07811), as well as of 3,5-diiodo-L-thyronine and its novel functional analogue TRC150094 in animal models of overweight and related disorders including primarily fatty liver.

Clinical approaches to non-alcoholic fatty liver disease

Non-alcoholic fatty liver disease (NAFLD) ranges from simple steatosis to nonalcoholic steatohepatitis (NASH), leading to fibrosis and potentially cirrhosis, and it is one of the most common causes of liver disease worldwide. NAFLD is associated with other medical conditions such as metabolic syndrome, obesity, cardiovascular disease and diabetes. NASH can only be diagnosed through liver biopsy, but noninvasive techniques have been developed to identify patients who are most likely to have NASH or fibrosis, reducing the need for liver biopsy and risk to patients. Disease progression varies between individuals and is linked to a number of risk factors. Mechanisms involved in the pathogenesis are associated with diet and lifestyle, influx of free fatty acids to the liver from adipose tissue due to insulin resistance, hepatic oxidative stress, cytokines production, reduced very low-density lipoprotein secretion and intestinal microbiome. Weight loss through improved diet and increased physical activity has been the cornerstone therapy of NAFLD. Recent therapies such as pioglitazone and vitamin E have been shown to be beneficial. Omega 3 polyunsaturated fatty acids and statins may offer additional benefits. Bariatric surgery should be considered in morbidly obese patients. More research is needed to assess the impact of these treatments on a long-term basis. The objective of this article is to briefly review the diagnosis, management and treatment of this disease in order to aid clinicians in managing these patients.

Clinical approaches to non-alcoholic fatty liver disease

Non-alcoholic fatty liver disease (NAFLD) ranges from simple steatosis to nonalcoholic steatohepatitis (NASH), leading to fibrosis and potentially cirrhosis, and it is one of the most common causes of liver disease worldwide. NAFLD is associated with other medical conditions such as metabolic syndrome, obesity, cardiovascular disease and diabetes. NASH can only be diagnosed through liver biopsy, but noninvasive techniques have been developed to identify patients who are most likely to have NASH or fibrosis, reducing the need for liver biopsy and risk to patients. Disease progression varies between individuals and is linked to a number of risk factors. Mechanisms involved in the pathogenesis are associated with diet and lifestyle, influx of free fatty acids to the liver from adipose tissue due to insulin resistance, hepatic oxidative stress, cytokines production, reduced very low-density lipoprotein secretion and intestinal microbiome. Weight loss through improved diet and increased physical activity has been the cornerstone therapy of NAFLD. Recent therapies such as pioglitazone and vitamin E have been shown to be beneficial. Omega 3 polyunsaturated fatty acids and statins may offer additional benefits. Bariatric surgery should be considered in morbidly obese patients. More research is needed to assess the impact of these treatments on a long-term basis. The objective of this article is to briefly review the diagnosis, management and treatment of this disease in order to aid clinicians in managing these patients.

Fatty liver in childhood

Fatty liver is a growing health problem worldwide. It might evolve to nonalcoholic steatohepatitis, cirrhosis and cause hepatocellular carcinoma. This disease, which has increased because of eating habits, changes in food content and lifestyle, affects people from childhood. The most important risk factors are obesity and insulin resistance. Besides these factors, gender, ethnicity, genetic predisposition and some medical problems are also important. Cirrhosis in children is rare but is reported. Nonalcoholic fatty liver disease (NAFLD) has no specific symptoms or signs but should be considered in obese children. NAFLD does not have a proven treatment. Weight loss with family based treatments is the most acceptable management. Exercise and an applicable diet with low glycemic index and appropriate calorie intake are preferred. Drugs are promising but not sufficient in children for today.

NAFLD fibrosis score: A prognostic predictor for mortality and liver complications among NAFLD patients

AIM: To study whether the severity of liver fibrosis estimated by the nonalcoholic fatty liver disease (NAFLD) fibrosis score can predict all-cause mortality, cardiac complications, and/or liver complications of patients with NAFLD over long-term follow-up.

METHODS: A cohort of well-characterized patients with NAFLD diagnosed during the period of 1980-2000 was identified through the Rochester Epidemiology Project. The NAFLD fibrosis score (NFS) was used to separate NAFLD patients with and without advanced liver fibrosis. We used the NFS score to classify the probability of fibrosis as < -1.5 for low probability, > -1.5 to < 0.67 for intermediate probability, and > 0.67 for high probability. Primary endpoints included all-cause death and cardiovascular- and/or liver-related mortality. From the 479 patients with NAFLD assessed, 302 patients (63%) greater than 18 years old were included. All patients were followed, and medical charts were reviewed until August 31, 2009 or the date when the first primary endpoint occurred. By using a standardized case record form, we recorded a detailed history and physical examination and the use of statins and metformin during the follow-up period.

RESULTS: A total of 302/479 (63%) NAFLD patients (mean age: 47 ± 13 year) were included with a follow-up period of 12.0 ± 3.9 year. A low probability of advanced fibrosis (NFS < -1.5 at baseline) was found in 181 patients (60%), while an intermediate or high probability of advanced fibrosis (NSF > -1.5) was found in 121 patients (40%). At the end of the follow-up period, 55 patients (18%) developed primary endpoints. A total of 39 patients (13%) died during the follow-up. The leading causes of death were non-hepatic malignancy (n = 13/39; 33.3%), coronary heart disease (CHD) (n = 8/39; 20.5%), and liver-related mortality (n = 5/39; 12.8%). Thirty patients had new-onset CHD, whereas 8 of 30 patients (27%) died from CHD-related causes during the follow-up. In a multivariate analysis, a higher NFS at baseline and the presence of new-onset CHD were significantly predictive of death (OR = 2.6 and 9.2, respectively; P < 0.0001). Our study showed a significant, graded relationship between the NFS, as classified into 3 subgroups (low, intermediate and high probability of liver fibrosis), and the occurrence of primary endpoints. The use of metformin or simvastatin for at least 3 mo during the follow-up was associated with fewer deaths in patients with NAFLD (OR = 0.2 and 0.03, respectively; P < 0.05). Additionally, the rate of annual NFS change in patients with an intermediate or high probability of advanced liver fibrosis was significantly lower than those patients with a low probability of advanced liver fibrosis (0.06 vs 0.09, P = 0.004). The annual NFS change in patients who died was significantly higher than those in patients who survived (0.14 vs 0.07, P = 0.03). At the end of the follow-up, we classified the patients into 3 subgroups according to the progression pattern of liver fibrosis by comparing the NFS at baseline to the NFS at the end of the follow-up period. Most patients were in the stable-fibrosis (60%) and progressive-fibrosis (37%) groups, whereas only 3% were in the regressive fibrosis.

CONCLUSION: A higher NAFLD fibrosis score at baseline and a new onset of CHD were significantly predictive of death in patients with NAFLD.

Hepatic steatosis with relation to increased expression of peroxisome proliferator-activated receptor-γ in insulin resistant mice

We have isolated insulin resistant mice (ddY-H mice) which are spontaneously induced even if fed with the standard chow pellets. Since marked accumulation of triglycerides (TG) in liver was observed, the present study investigated causes of hepatic TG accumulation in ddY-H mice fed with the standard chow pellets. In ddY-H mice, hepatic TG content increased from seven-weeks of age, and further marked accumulation of TG was observed at 20-weeks of age. Histologically, fat droplets appeared in pericentral parenchymal cells of the liver from nine-weeks of age, and the size and number of droplets were increased in hepatic lobules at 15-weeks of age, suggesting hepatic steatosis was spontaneously induced. Although secretion of TG from liver to blood in ddY-H mice was not increased, fat absorption from the digestive tract was significantly enhanced. The mRNA expressions of peroxisome proliferator-activated receptor γ (PPARγ) involved in fat accumulation and fatty acid translocase (CD36) involved in the transportation of fatty acid into the liver were markedly increased. However, gene expressions of factors involved in lipogenesis, β-oxidation of fatty acid and lipoprotein secretion were not changed. Pioglitazone (9 mg/kg), the PPARγ agonist, administered for six weeks deteriorated hepatic steatosis in ddY-H mice. Although pioglitazone did not affect gene expressions of PPARγ in the liver, CD36 and fat-specific protein 27 (fsp27), targets of PPARγ, were markedly elevated. These results suggest that, in the livers of ddY-H mice, hepatic steatosis is induced by increased incorporation of fatty acid into the liver via increased PPARγ expression.

Review article: is non-alcoholic fatty liver disease a spectrum, or are steatosis and non-alcoholic steatohepatitis distinct conditions?

BACKGROUND

Non-alcoholic fatty liver disease (NAFLD) is currently conceptualised as a clinical spectrum that results from a ‘multiple-hit’ process which begins with simple steatosis and subsequently renders the hepatocytes susceptible to a variety of insults. Ultimately, more serious liver injuries like non-alcoholic steatohepatitis (NASH) and cirrhosis may develop. Although the metabolic syndrome is considered the crucial player in the pathogenesis of NAFLD, recent studies have highlighted novel pathophysiological mechanisms in this clinical entity.

AIM

To discuss the pathophysiology of NAFLD based on the hypothesis that simple steatosis and NASH are discrete entities rather than two points on a spectrum.

METHODS

A literature search was conducted in August 2012 on PubMed, Ovid Embase, Ovid Medline and Scopus using the following search terms: steatosis, non-alcoholic steatohepatitis, pathophysiology, fatty liver, natural history and genetics.

RESULTS

Simple steatosis and NASH appear as two distinct pathophysiological entities and progression from pure fatty liver to NASH appears to be so rare as to warrant publication. The possible pathogenetic pathways specifically related to NASH are highlighted.

CONCLUSIONS

Although simple steatosis and non-alcoholic steatohepatitis are currently viewed as two histological subtypes of the unique spectrum of non-alcoholic fatty liver disease, the two conditions are likely distinct not only from a histological but also from a pathophysiological standpoint. Efforts to distinguish simple steatosis from non-alcoholic steatohepatitis using non-invasive modalities should be informed by the current pathophysiology of these two clinical entities.

Liver T1ρ MRI measurement in healthy human subjects at 3 T: a preliminary study with a two-dimensional fast-field echo sequence

OBJECTIVES

The aim of this study was to explore the technical feasibility of T(1)ρ MRI for the liver, and to determine the normal range of liver T(1)ρ in healthy subjects at clinical 3 T.

METHODS

There were 15 healthy volunteers. Three representative axial slices were selected to cut through the upper, middle and lower liver. A rotary echo spin-lock pulse was implemented in a two-dimensional fast-field echo sequence. Spin-lock frequency was 500 Hz, and the spin-lock times of 1, 10, 20, 30, 40 and 50 ms were used for T(1)ρ mapping. The images were acquired slice by slice during breath-holding. Regions of interest (ROIs; n=5) were manually placed on each slice of the liver parenchyma region, excluding artefacts and vessels. The mean value of these ROIs (n=15) was regarded as the liver T(1)ρ value for the subject. Six subjects were scanned once at fasting status; six subjects were scanned once 2 h post meal; three subjects were scanned twice at fasting status; and seven subjects were scanned twice 2 h post meal.

RESULTS

When two readers measured the same 10 data sets, the interreader reproducibility (ICC: intraclass correlation coefficient) was 0.955. With the 10 subjects scanned twice, the ICC for scan-rescan reproducibility was 0.764. There was no significant difference for the liver T(1)ρ value at the fasting status (43.08±1.41 ms) and post-meal status (42.97±2.38 ms, p=0.867). Pooling together all the 32 scans in this study, the normal liver T(1)ρ value ranged from 38.6 to 48.3 ms (mean 43.0 ms, median 42.6 ms).

CONCLUSION

It is feasible to obtain consistent liver T(1)ρ measurement for human subjects at 3 T.

Review article: non-alcoholic fatty liver disease and osteoporosis--clinical and molecular crosstalk

BACKGROUND

Low bone mineral density (BMD) has been reported in both paediatric and adult patients with non-alcoholic fatty liver disease (NAFLD). The mechanisms behind the reduced BMD in NAFLD are still not completely understood.

AIM

To provide a critical overview of the pathophysiological pathways linking NAFLD, reduced BMD and osteoporosis, with a special focus on the alterations of soluble mediators which could link fat accumulation in the liver with bone health. The MEDLINE database was searched by a combination of keywords: non-alcoholic fatty liver disease OR hepatic steatosis OR metabolic syndrome OR insulin resistance AND bone mineral density OR osteoporosis OR bone AND biomarkers OR serum marker.

RESULTS

Several factors that may influence bone mineralisation and the increased risk of osteoporosis in NAFLD can be discussed. These include the release of cytokines from the inflamed liver which may influence the bone microenvironment, vitamin D deficiency, and limited physical activity. Circulating markers of bone metabolism, including osteopontin, osteoprotegerin, osteocalcin and fetuin-A, have been found to be altered in patients with NAFLD.

CONCLUSION

A better understanding of the mechanisms that link bone metabolism and the liver may open a new frontier to fight two highly prevalent conditions like NAFLD and osteoporosis.

Effect of soy protein supplementation in patients with chronic hepatitis C: a randomized clinical trial

AIM

To evaluate the effects of soy supplementation on insulin resistance, fatty liver and alanine aminotransferase (ALT) levels in non-diabetic patients with chronic hepatitis C (CHC).

METHODS

In a prospective, randomized and single-blinded clinical trial, we compared patients with CHC who had casein as a supplement (n = 80) (control group), with patients who consumed a soy supplement diet (n = 80) [intervention group (IG)]. Both groups received 32 g/d of protein for 12 wk.

RESULTS

Patients' baseline features showed that 48.1% were overweight, 43.7% had abdominal fat accumulation, 34.7% had hepatic steatosis and 36.3% had an homeostasis model assessment index of insulin resistance (HOMA-IR) ≥ 3.0. Descriptive analysis showed that protein supplementation diet reduced hepatic steatosis in both groups; however, significant reductions in ALT levels occurred in the soy group. Multiple regression modeling indicated that in the presence of severe fibrosis (F3/F4), γ glutamyl transferase elevation and high density lipoprotein (HDL) reduction, the intervention group had 75% less chance of developing hepatic steatosis (OR= 0.25; 95% CI: 0.06-0.82) and 55% less chance of presenting with an ALT level ≥ 1.5 × the upper limit of normal (ULN) (OR = 0.45, 95% CI: 0.22-0.89). Soy treatment did not have any effect on insulin resistance (OR = 1.92; 95% CI: 0.80-4.83), which might be attributed to the fact that the HOMA-IR values at baseline in most of our patients were in the normal range. Advanced hepatic fibrosis, an ALT level > 1.5 × ULN and visceral fat were predictors of an HOMA-IR ≥ 3. The IG group had a reduced risk of an ALT level > 1.5 × ULN. An HOMA-IR ≥ 3.0 and HDL < 35 mg/dL were also risk factors for increased ALT.

CONCLUSION

Soy supplementation decreased ALT levels and thus may improve liver inflammation in hepatitis C virus (HCV) patients; it also reduced hepatic steatosis in a subgroup of patients but did not change insulin resistance. It should be considered in the nutritional care of HCV patients.