Bariatric surgery as potential treatment for nonalcoholic fatty liver disease: a future treatment by choice or by chance?

Liver fibrosis in NAFLD/NASH: from pathophysiology towards diagnostic and therapeutic strategies

Liver fibrosis, as an excess deposition of extracellular matrix (ECM) components, results from chronic liver injury as well as persistent activation of inflammatory response and of fibrogenesis. Liver fibrosis is a major determinant for chronic liver disease (CLD) progression and in the last two decades our understanding on the major molecular and cellular mechanisms underlying the fibrogenic progression of CLD has dramatically improved, boosting pre-clinical studies and clinical trials designed to find novel therapeutic approaches. From these studies several critical concepts have emerged, starting to reveal the complexity of the pro-fibrotic microenvironment which involves very complex, dynamic and interrelated interactions between different hepatic and extrahepatic cell populations. This review will offer first a recapitulation of established and novel pathophysiological basic principles and concepts by intentionally focus the attention on NAFLD/NASH, a metabolic-related form of CLD with a high impact on the general population and emerging as a leading cause of CLD worldwide. NAFLD/NASH-related pro-inflammatory and profibrogenic mechanisms will be analysed as well as novel information on cells, mediators and signalling pathways which have taken advantage from novel methodological approaches and techniques (single cell genomics, imaging mass cytometry, novel in vitro two- and three-dimensional models, etc.). We will next offer an overview on recent advancement in diagnostic and prognostic tools, including serum biomarkers and polygenic scores, to support the analysis of liver biopsies. Finally, this review will provide an analysis of current and emerging therapies for the treatment of NAFLD/NASH patients.

Recompensation in cirrhosis: unravelling the evolving natural history of nonalcoholic fatty liver disease

Recompensation has gained increasing attention in the field of cirrhosis, particularly in chronic liver disease with a definite aetiology. The current global prevalence of obesity and nonalcoholic fatty liver disease (NAFLD) is increasing, but there is currently a lack of a clear definition for recompensation in NAFLD-related cirrhosis. Here, we provide an up-to-date perspective on the natural history of NAFLD, emphasizing the reversible nature of the disease, summarizing possible mechanisms underlying recompensation in NAFLD, discussing challenges that need to be addressed and outlining future research directions in the field. Recompensation is a promising goal in patients with NAFLD-related cirrhosis, and further studies are needed to explore its underlying mechanisms and uncover its clinical features.

Neprilysin activity is increased in metabolic dysfunction-associated steatotic liver disease and normalizes after bariatric surgery or GLP-1 therapy

Inhibitors of neprilysin improve glycemia in patients with heart failure and type 2 diabetes (T2D). The effect of weight loss by diet, surgery, or pharmacotherapy on neprilysin activity (NEPa) is unknown. We investigated circulating NEPa and neprilysin protein concentrations in obesity, T2D, metabolic dysfunction-associated steatotic liver disease (MASLD), and following bariatric surgery, or GLP-1-receptor-agonist therapy. NEPa, but not neprilysin protein, was enhanced in obesity, T2D, and MASLD. Notably, MASLD associated with NEPa independently of BMI and HbA1c. NEPa decreased after bariatric surgery with a concurrent increase in OGTT-stimulated GLP-1. Diet-induced weight loss did not affect NEPa, but individuals randomized to 52-week weight maintenance with liraglutide (1.2 mg/day) decreased NEPa, consistent with another study following 6-week liraglutide (3 mg/day). A 90-min GLP-1 infusion did not alter NEPa. Thus, MASLD may drive exaggerated NEPa, and lowered NEPa following bariatric surgery or liraglutide therapy may contribute to the reported improved cardiometabolic effects.

Diagnostic Value of Non-invasive Liver Function Tests in Liver Fibrosis and Changes in These Parameters Post-metabolic Surgery

PURPOSE

This study aimed to ascertain the diagnostic accuracy of non-invasive liver function tests in liver fibrosis and assess their changes after metabolic surgery.

MATERIALS AND METHODS

1005 individuals with severe obesity who were referred for metabolic surgery were analysed. All participants had blood samples taken for liver enzymes and lipid profile. In addition, hepatic indexes, including AAR, APRI, NFS and Fibrosis-4 (FIB4), were checked. Furthermore, all participants underwent two-dimensional shear wave elastography (2D-SWE). All investigations were repeated 6-8 months after metabolic surgery. The receiver operating characteristic (ROC) curve and the area under the ROC curve was utilised to determine the optimal cut-off values for baseline study parameters. Logistic regression was applied to predict the relationship between study parameters-as predictors-and change in 2D-SWE.

RESULTS

AST/ALT (AAR) was the most sensitive (79%) pre-operative non-invasive serological marker for detecting liver fibrosis, whereas NAFLD Fibrosis Score (NFS) was the most specific (84%). AST/upper limit of the normal AST range × 100/platelets (× 10⁹/L) (APRI) showed a positive correlation with 2D-SWE post-metabolic surgery (p-value = 0.021). Regression analysis from both adjusted and unadjusted models showed that baseline AAR was a predictor of postoperative liver status in terms of hepatic fibrosis.

CONCLUSION

AAR has a high sensitivity, whereas NFS exhibits a high specificity in diagnosing liver fibrosis. The authors recommend using both investigations in conjunction with 2D-SWE to increase the likelihood of detecting liver fibrosis.

Metabolic Role of Autophagy in the Pathogenesis and Development of NAFLD

Non-alcoholic fatty liver disease (NAFLD) is a spectrum of liver disease, ranging from simple steatosis to hepatitis, fibrosis, cirrhosis, and hepatocellular carcinoma (HCC). Liver fibrosis, which portends a poor prognosis in NAFLD, is characterized by the excessive accumulation of extracellular matrix (ECM) proteins resulting from abnormal wound repair response and metabolic disorders. Various metabolic factors play crucial roles in the progression of NAFLD, including abnormal lipid, bile acid, and endotoxin metabolism, leading to chronic inflammation and hepatic stellate cell (HSC) activation. Autophagy is a conserved process within cells that removes unnecessary or dysfunctional components through a lysosome-dependent regulated mechanism. Accumulating evidence has shown the importance of autophagy in NAFLD and its close relation to NAFLD progression. Thus, regulation of autophagy appears to be beneficial in treating NAFLD and could become an important therapeutic target.

Liver fibrosis quantification

Liver fibrosis (LF) is the wound healing response to chronic liver injury. LF is the endpoint of chronic liver disease (CLD) regardless of etiology and the single most important determinant of long-term liver-related clinical outcomes. Quantification of LF is important for staging, to evaluate response to treatment and to predict outcomes. LF is traditionally staged by liver biopsy. However, liver biopsy is invasive and suffers from sampling errors when biopsy size is inadequate; therefore, non-invasive tests (NITs) have found important roles in clinical care. NITs include simple laboratory-based serum tests, panels of serum tests, and imaging biomarkers. NITs are validated against the liver biopsy and will be used in the future for evaluation of nearly all CLDs with invasive liver biopsy reserved for some cases. Both serum tests and some imaging biomarkers such as elastography are currently used clinically as surrogate markers for LF. Several other imaging biomarkers are still considered research and awaiting clinical application in the future. As the evaluation of imaging biomarkers will likely become the norm in the future, understanding pathogenesis of LF is important. Knowledge of properties measured by imaging biomarkers and its correlation with LF is important to understand the application of NITs by abdominal radiologists. In this review, we present a brief overview of pathogenesis of LF, spatiotemporal evolution of LF in different CLD, and severity assessment with liver biopsy. This will be followed by a brief discussion on properties measured by imaging biomarkers and their relationship to the LF.

The Risk Factors of Nonalcoholic Fatty Liver Disease in Morbidly Obese Patients Undergoing Bariatric Surgery in Iran

Background and Aims. Nonalcoholic fatty liver disease (NAFLD) is common in severely obese individuals undergoing bariatric surgery. Assessing the prevalence and severity of NAFLD seems crucial since it may affect the prevention or development of more severe forms of fatty liver. Methods. This cross-sectional study was conducted on 228 severely obese individuals undergoing bariatric surgery. Abdominal ultrasonography was done, and clinical and biochemical factors (liver enzymes, lipid profile, and fasting blood sugar (FBS)) were assessed. Results. The mean body mass index (BMI) was $43.45\pm 5.92$  kg/m2. The prevalence of NAFLD was 49.12% (mild steatosis: 37.5%, moderate steatosis: 36.6%, and severe steatosis: 25.8%). The main risk factors of NAFLD were weight ( $p=0.002$ ), BMI ( $p=0.003$ ), alanine aminotransferase (ALT) ( $p<0.001$ ), aspartate aminotransferase (AST) ( $p<0.001$ ), serum triglycerides (TGs) ( $p=0.004$ ), and FBS ( $p=0.039$ ). The results revealed a statistically significant decrease in the mean level of high-density lipoprotein cholesterol (HDL-C) ( $p=0.044$ ). However, no significant association was found between the severity of liver steatosis and the presence of comorbidities such as hypertension, diabetes, hypothyroidism, and dyslipidemia. Conclusions. More severe NAFLD was associated with increased weight and BMI. Elevated ALT, AST, TG, and FBS levels and decreased HDL-C levels were also the risk factors of NAFLD and its progress to more severe conditions.

The egyptian clinical practice guidelines for the diagnosis and management of metabolic associated fatty liver disease

The landscape of chronic liver disease in Egypt has drastically changed over the past few decades. The prevalence of metabolic-associated fatty liver disease (MAFLD) has risen to alarming levels. Despite the magnitude of the problem, no regional guidelines have been developed to tackle this disease. This document provides the clinical practice guidelines of the key Egyptian opinion leaders on MAFLD screening, diagnosis, and management, and covers various aspects in the management of MAFLD. The document considers our local situations and the burden of clinical management for the healthcare sector and is proposed for daily clinical practical use. Particular reference to special groups was done whenever necessary.

Short-term outcome of bariatric surgery on nonalcoholic fatty liver disease: a Korean perspective

Purpose

Obesity is associated with nonalcoholic fatty liver disease, one of the most common causes of chronic liver disease. We aimed to demonstrate the effectiveness of bariatric surgery for hepatic steatosis and fibrosis in Korean patients.

Methods

A total of 32 consecutive patients were enrolled in this study. Hepatic steatosis and liver fibrosis were assessed before surgery and 6 months after surgery using transient elastography and serologic panels.

Results

Thirteen patients (40.6%) were male and 19 (59.4%) were female, with a mean age of 39.3 ± 11.3 years. The body mass index was significant at the 6th month: 39.1 ± 6.7 and 30.3 ± 4.7 kg/m² (P < 0.001), respectively. The mean preoperative controlled attenuation parameter and liver stiffness measurement values were 325.4 ± 55.9 dB/m and 7.4 ± 4.8 kPa, respectively, before surgery, and they decreased to 267.1 ± 45.1 dB/m and 5.3 ± 2.3 kPa, respectively, 6 months postoperatively (P < 0.001, respectively).

Conclusion

These results suggest that bariatric surgery is associated with a significant improvement in liver steatosis and fibrosis. Bariatric surgery has a beneficial effect on nonalcoholic fatty liver disease in patients with morbid obesity in Korea.

Neutrophil extracellular traps induced by pro-inflammatory cytokines enhance procoagulant activity in NASH patients

BACKGROUND

Nonalcoholic steatohepatitis (NASH) patients are at a high risk of developing venous thromboembolism, with a high rate of morbidity and mortality. The role of neutrophil extracellular traps (NETs) in procoagulant activity (PCA) in patients with NASH remains unclear. Our study aimed to investigate the formation of NETs in NASH patients stimulated by specific pro-inflammatory factors. Moreover, we evaluated the pivotal role of NETs in the induction of hypercoagulability in NASH and the interaction between NETs and endothelial injury.

METHOD

The levels of the NETs biomarkers were evaluated in the plasma samples of 27 NASH patients and 18 healthy subjects. The formation of NETs was visualized using immunofluorescence microscopy. The PCA of the NETs was assessed using coagulation time, purified coagulation complex, and fibrin formation assays. Confocal microscopy was further used to evaluate the interactions between the NETs and HUVECs.

RESULTS

The levels of NETs markers in the plasma of NASH patients were significantly higher than healthy controls. NETs derived from NASH enhanced thrombin and fibrin formation and significantly reduced CT (p<0.05). The mixture of IL-6 and TNF-α triggered the NETs release in the plasma rather than them alone. Additionally, the NETs exerted cytotoxic effects on the endothelial cells, converting them to a procoagulant and pro-inflammatory phenotype, and DNase I could reverse these effects.

CONCLUSION

Our results revealed the primary role of NETs in promoting the hypercoagulable state in NASH patients. Methods that prevent the formation of NETs may be a novel approach for the prevention and treatment of NASH.

Recurrent Diabetic Ketoacidosis following Bariatric Surgery: The Role of Micronutrients

We report a case of a 29-year-old woman admitted twice to our hospital with diabetic ketoacidosis (DKA) within 45 days following her bariatric surgery. The first admission required intensive care during her postoperative days after bariatric surgery. Subsequently, she continued to report high level of ketones on a daily basis. At her second admission, she presented with all three criteria of DKA. She was treated with a standard protocol for DKA, but ketones plasma level remained high despite significant improvement in pH and glycemic control. The administration of thiamine replacement was associated with normalization of the hyperketonemia. Thiamine deficiency can be associated with bariatric surgery and can lead to high ketone level in individuals with type 1 diabetes.

Sustainability of diet-based moderate calorie restriction among obese patients with metabolic-associated fatty liver disease

BACKGROUND AND AIM

The long-term sustainability of weight loss continues to be a subject of investigation. This study was designed to examine the effects of weight loss and the long-term sustainability of lifestyle modifications among obese patients with metabolic-associated fatty liver disease (MAFLD).

MATERIALS AND METHODS

A total of 40 patients who were prescribed a hypocaloric diet (~500 calories reduction for each patient), and who were followed up for 12 weeks in 4 face-to-face interviews were enrolled in the study. The patients were contacted at the 36^th month, and their current weight was recorded.

RESULTS

The mean weight at baseline of 87±13 kg decreased to 79±11 kg after 12 weeks of intervention (p<0.001). The mean weight at the 36^th month did not significantly differ from that measured at the baseline (p=0.563). The mean controlled attenuation parameter decreased from 320±13 dB/m to 273±37 dB/m (p<0.001), while the median liver stiffness measurement decreased from 8.7 kPa (3.6-45.7 kPa) to 5.7 kPa (2.2-29.9 kPa) (p<0.001).

CONCLUSION

Strict follow-up through nutritional consultation can help achieve weight loss in obese patients with MAFLD. However, for long-term results, the collaboration of nutritionists and gastroenterologists is essential to prevent weight regain.

Target Therapies for NASH/NAFLD: From the Molecular Aspect to the Pharmacological and Surgical Alternatives

Non-alcoholic fatty liver disease represents an increasing cause of chronic hepatic disease in recent years. This condition usually arises in patients with multiple comorbidities, the so-called metabolic syndrome. The therapeutic options are multiple, ranging from lifestyle modifications, pharmacological options, to liver transplantation in selected cases. The choice of the most beneficial one and their interactions can be challenging. It is mandatory to stratify the patients according to the severity of their disease to tailor the available treatments. In our contribution, we review the most recent pharmacological target therapies, the role of bariatric surgery, and the impact of liver transplantation on the NAFLD outcome.

Bariatric surgery: blessing or sometimes curse for the liver?

INTRODUCTION

Nowadays morbid obesity has become a worldwide health issue and the use of bariatric surgery undoubtedly results not only in weight reduction but also in the improvement of comorbidities. Although bariatric surgery is the optimal choice for metabolic syndrome resolution and hepatic function improvement, there is evidence that in rare cases it may lead to aggressive steatohepatitis, acute liver failure, fibrosis, and deterioration of the overall prognosis, without having fully understood the underlying pathophysiological mechanisms.

CASE REPORT

In this case report we present a 45-year-old female patient with morbid obesity, body mass index 80, who underwent long-limb Roux en Y gastric bypass (LL-RYGB) and was admitted to the emergency department with jaundice and impaired liver function laboratory tests on postoperative day 90. The examinations revealed elevated bilirubin and transaminases, with prolonged prothrombin time and low albumin levels. A liver biopsy was performed and showed active steatohepatitis. The hepatic values were gradually further impaired and the decision for surgery, in order to reverse the hepatic dysfunction, was taken. A gastrostomy in the bypassed stomach was performed and the activation of the closed biliopancreatic loop led to clinical improvement and amelioration of the prognosis.

CONCLUSIONS

Patients at high risk for hepatic failure after bariatric surgery should be better evaluated preoperatively and a tailor-made approach should be applied in order to avoid such a disastrous complication.

Long-term outcomes of Roux-en-Y gastric bypass or sleeve gastrectomy in patients with cirrhosis; before, during or after liver transplantation: A single center's experience

BACKGROUND

The increasing prevalence of morbid obesity (MO) results in parallel growth of obesity-associated liver diseases necessitating liver transplantation (LT).

OBJECTIVE

To examine the feasibility and safety of Roux-en-Y gastric bypass or sleeve gastrectomy in the setting of LT.

METHODS

This retrospective chart review included the data on all the MO candidates before and after LT who underwent bariatric surgery (BS) in our institution between 04/2013-09/2016. The reported outcomes were weight change and early and late postoperative complications (mean follow-up: 43 ± 11.1 months).

RESULTS

Eighteen MO peri-LT patients (10 females, 8 males, average age 48 years) were included in the study. Ten had cirrhosis (mean Model of End-stage Liver Disease [MELD] score of 12.5 ± 6.42), three underwent concurrent LT and BS (mean MELD score 23.7 ± 0.58), and five had LT (mean of 56 months from LT). The mean percentage of total and excess weight loss was 31% and 81%, respectively. Six of the eight patients with type 2 diabetes mellitus became normoglycemic after BS. Three patients sustained perioperative complications. Two cirrhotic patients died 1 and 4.5 years after BS with decompensation.

CONCLUSIONS

Bariatric surgery appears to effectively address obesity in cirrhotic and LT patients. The surgical risk is higher than that of the regular BS population.

Effect of bariatric surgery on fatty liver disease in obese patients: A prospective one year follow-up study

BACKGROUND

Non-alcoholic fatty liver disease (NAFLD), often associated with obesity and metabolic syndrome, manifests itself as steatosis, hepatic fibrosis, cirrhosis, or even end-stage liver disease. NAFLD causes inflammation, insulin resistance and cardiovascular complications. The current study aimed to evaluate the beneficial effects of bariatric surgery on biochemical parameters of hepatic functions in obese patients by comparing them before and one-year after the surgery.

METHODS

A total of 72 morbidly obese patients underwent bariatric surgery between 2016 and 2018. The incidence of diabetes mellitus in this group was 29%, median body weight was 124.5 kg (109.0-140.0) and mean body mass index (BMI) was 44.38 ± 6.770 kg/m². The used surgical procedures included gastric bypass, sleeve gastrectomy, laparoscopic gastric plication, and single anastomosis duodeno-ileal bypass-sleeve gastrectomy. Biochemical parameters including ALT/AST ratio (AAR), NAFLD fibrosis score (NFS), hepatic fibrosis index (FIB-4) and Fatty Liver Index (FLI) were evaluated in all patients at the time of surgery and one year after the intervention.

RESULTS

Significant improvement after the intervention was observed in 64 patients. A significant reduction in body weight (P<0.0001), waist circumference (P<0.0001), and body mass index (P<0.0001) were observed. NAFLD liver fibrosis index changed significantly (P<0.0001), suggesting a trend of improvement from advanced fibrosis towards stages 0-2. The FIB-4 fibrosis index indicated significant improvement (P=0.0136). Besides, a significant decline in hepatic steatosis (P<0.0001) was observed after bariatric surgery as compared to the pre-surgery fatty liver conditions.

CONCLUSION

Among the strategies to overcome NAFLD-associated impediments, bariatric surgery can be considered effective in reducing obesity and metabolic co-morbidities.

TRIAL REGISTRATION

ClinicalTrials.gov (NCT04569396).

The Role of Gut Microbiota in Duodenal-Jejunal Bypass Surgery-Induced Improvement of Hepatic Steatosis in HFD-Fed Rats

Bariatric surgery including duodenal-jejunal bypass surgery (DJB) improves insulin sensitivity and reduces obesity-associated inflammation. However, the underlying mechanism for such an improvement is still incompletely understood. Our objective was to investigate the role of the gut microbiota in DJB-associated improvement of hepatic steatosis in high fat diet (HFD)-fed rats. To study this, hepatic steatosis was induced in male adult Sprague-Dawley rats by feeding them with a 60% HFD. At 8 weeks after HFD feeding, the rats were subjected to either DJB or sham operation. HFD was resumed 1 week after the surgery for 3 more weeks. In additional groups of animals, feces were collected from HFD-DJB rats at 2 weeks after DJB. These feces were then transplanted to HFD-fed rats without DJB at 8 weeks after HFD feeding. Hepatic steatosis and fecal microbiota were analyzed at 4 weeks after surgery or fecal transplantation. Our results showed that DJB alleviated hepatic steatosis in HFD-fed rats. Fecal microbiota analysis showed that HFD-fed and standard diet-fed rats clustered differently. DJB induced substantial compositional changes in the gut microbiota. The fecal microbiota of HFD-fed rats received fecal transplant from DJB rats overlapped with that of HFD-DJB rats. Treatment of rats with HFD-induced liver lesions by fecal transplant from DJB-operated HFD-fed rats also attenuated hepatic steatosis. Thus, alterations in the gut microbiota after DJB surgery are sufficient to attenuate hepatic steatosis in HFD-fed rats. Targeting the gut microbiota could be a promising approach for preventing or treating human NAFLD.

Sleeve Gastrectomy Is Associated with a Greater Reduction in Plasma Liver Enzymes Than Bypass Surgeries-A Registry-Based Two-Year Follow-Up Analysis

Bariatric surgeries may lead to an improvement in metabolic fatty liver disease, and a reduction in the levels of the hepatic enzyme Alanine Aminotransferase (ALT). We compared the effects of Sleeve Gastrectomy (SG), Roux en Y Gastric Bypass (RYGB) and One Anastomosis Gastric Bypass (OAGB) on the levels of ALT by analysis of two-year follow-up data from 4980 patients in the Israeli Bariatric Registry that included laboratory tests and demographic information. Pre-operative characteristics of patients, and particularly levels of liver enzymes, were similar across surgery types. Regression modeling and retrospective matching showed that SG was superior to RYGB and OAGB in reducing ALT levels, and in reducing the fraction of patients with abnormally high ALT levels. Two-year post-surgery, an increase in ALT levels from normal to abnormal levels was observed in 5% of SG patients, and in 18% and 23% of RYGB and OAGB patients. In conclusion, SG leads to a greater reduction in ALT levels compared with bypass surgeries and a lower incidence of post-surgical elevation of ALT levels. Further studies are required to identify the cause for the rise in liver enzymes, and to determine whether ALT levels correlate with liver pathology especially following bariatric surgery.

Molecular and cellular mechanisms of liver fibrosis and its regression

Chronic liver injury leads to liver inflammation and fibrosis, through which activated myofibroblasts in the liver secrete extracellular matrix proteins that generate the fibrous scar. The primary source of these myofibroblasts are the resident hepatic stellate cells. Clinical and experimental liver fibrosis regresses when the causative agent is removed, which is associated with the elimination of these activated myofibroblasts and resorption of the fibrous scar. Understanding the mechanisms of liver fibrosis regression could identify new therapeutic targets to treat liver fibrosis. This Review summarizes studies of the molecular mechanisms underlying the reversibility of liver fibrosis, including apoptosis and the inactivation of hepatic stellate cells, the crosstalk between the liver and the systems that orchestrate the recruitment of bone marrow-derived macrophages (and other inflammatory cells) driving fibrosis resolution, and the interactions between various cell types that lead to the intracellular signalling that induces fibrosis or its regression. We also discuss strategies to target hepatic myofibroblasts (for example, via apoptosis or inactivation) and the myeloid cells that degrade the matrix (for example, via their recruitment to fibrotic liver) to facilitate fibrosis resolution and liver regeneration.

The Asian Pacific Association for the Study of the Liver clinical practice guidelines for the diagnosis and management of metabolic associated fatty liver disease

Metabolic associated fatty liver disease (MAFLD) is the principal worldwide cause of liver disease and affects nearly a quarter of the global population. The objective of this work was to present the clinical practice guidelines of the Asian Pacific Association for the Study of the Liver (APASL) on MAFLD. The guidelines cover various aspects of MAFLD including its epidemiology, diagnosis, screening, assessment, and treatment. The document is intended for practical use and for setting the stage for advancing clinical practice, knowledge, and research of MAFLD in adults, with specific reference to special groups as necessary. The guidelines also seek to improve patient care and awareness of the disease and assist stakeholders in the decision-making process by providing evidence-based data. The guidelines take into consideration the burden of clinical management for the healthcare sector.

The metabolic and liver-related outcomes of bariatric surgery in adult patients with insulin-treated type 2 diabetes and nonalcoholic fatty liver disease at high risk of liver fibrosis

BACKGROUND

Nonalcoholic fatty liver disease (NAFLD) has become the most common cause of chronic liver disease, with a prevalence estimated to between 20% and 30% of the general population and approximately 70% of stage 2 obese people with type 2 diabetes (T2D) with normal liver enzymes.

OBJECTIVES

To investigate the metabolic and liver-related outcomes of bariatric surgery among patients with insulin-treated T2D and NAFLD who are at high risk of liver fibrosis.

SETTING

More than 600 locations within the United Kingdom.

METHODS

The study comprises a retrospective cohort comparison of patients with NAFLD and a fibrosis 4 (Fib-4) score > 1.45 who received a bariatric intervention versus comparable patients who received no bariatric intervention. Metabolic outcomes (glycated hemoglobin [HbA1C] level, weight, body mass index [BMI], and Fib-4 score) and composite liver-related outcomes (cirrhosis, portal hypertension, liver failure, and hepatoma) were compared between groups over a period of 5 years. The outcomes were adjusted for baseline and time-varying covariates.

RESULTS

The study sample included 4108 patients, 45 of whom underwent bariatric surgery. The mean age at baseline was 62.4 ± 12.4 years; 43.8% of patients were female; the mean weight was 89.5 ± 20.8 kg; the mean BMI was 31.7 ± 7.6 kg/m²; and the mean HbA1C level was 68.4 ± 16.7 mmol/mol. In addition, the median Fib-4 score was 2.3 (interquartile range, 1.7-4.2). During the 5 years during which follow-up outcomes were recorded, the weight and BMI reductions were significantly lowered compared with baseline in the bariatric surgery group. Similarly, the HbA1C levels were lower in the bariatric surgery group, with statistically significant differences observed in the first and second postintervention years (bariatric surgery versus non-bariatric surgery patient levels at 1 year, 63.1 mmol/mol versus 68.1 mmol/mol, respectively [P = .042], and at 2 years, 62.7 mmol/mol versus 68.1 mmol/mol, respectively [P = .028]). No significant difference was observed between groups in the proportion of patients with liver fibrosis or the likelihood of developing composite liver disease during the follow-up period (bariatric surgery group, 8.9%; non-bariatric surgery group, 4.7%; X² = 1.75; P = .18).

CONCLUSION

Bariatric surgery amongst patients with insulin-treated T2D with NAFLD who were at high risk of liver fibrosis was associated with significant improvements in metabolic outcomes. No significant adverse effects were observed with regards to liver-related outcomes.

The impact of bariatric surgery on in-patient clinical outcomes among patients with autoimmune hepatitis

Autoimmune hepatitis (AIH) is a form of liver inflammation in which immune cells target hepatocytes, inducing chronic inflammatory states. Bariatric surgery (BS) was shown to reduce inflammation in severely obese patients. We hypothesize that obese patients with AIH and BS have lower prevalence of liver-related complications and in-patient mortality compared to those without BS.The National Inpatient Sample from 2007 to 2013 was queried for hospitalizations of adults over 18 years of age with a diagnosis of AIH. Of those, hospitalizations with BS were selected as cases and those with morbid obesity as controls. Case-control 1:2 matching was done based on sex, age, race, and comorbidities. Primary outcomes were prevalence of liver-related complications and in-patient mortality. Independent risk factors of in-patient clinical outcomes were identified using multivariate regression analysis.From 137,834 hospitalizations with a diagnosis of AIH, 688 with BS were selected as cases, and 1295 were matched as controls. The prevalence of ascites was higher in the BS group compared to the control (odds ratio 1.73, 95% confidence interval (CI) 1.27-2.36). The prevalence of cirrhosis (36.8% vs 33.2%), portal hypertension (7.4% vs 10.0%), hepatic encephalopathy (10.6% vs 8.7%), and varices and variceal bleeding (3.9% vs 5.5%) was not statistically different from case controls, (P > .05).BS was an independent risk factor for ascites (adjusted odds ratio (aOR) 1.87; 95% CI 1.36-2.56) and hepatic encephalopathy (aOR 1.42; 95% CI 1.03-1.97) but was an independent protective factor against in-patient mortality (aOR 0.21, 95% CI 0.08-0.55) once adjusted for age, sex, race, and comorbidities.

Mechanisms of nonalcoholic fatty liver disease and implications for surgery

Background

Nonalcoholic fatty liver disease (NAFLD) has become the most common form of chronic liver disease in both adults and children worldwide. Understanding the pathogenic mechanisms behind NAFLD provides the basis for identifying risk factors, such as metabolic syndrome, pancreatoduodenectomy, and host genetics, that lead to the onset and progression of the disease. The progression from steatosis to more severe forms, such as steatohepatitis, fibrosis, and cirrhosis, leads to an increased number of liver and non-liver complications.

Purpose

NAFLD-associated end-stage liver disease (ESLD) and hepatocellular carcinoma (HCC) often require surgery as the only curative treatment. In particular, the presence of NAFLD together with the coexisting metabolic comorbidities that usually occur in these patients requires careful preoperative diagnosis and peri-/postoperative management. Bariatric surgery, liver resection, and liver transplantation (LT) have shown favorable results for weight loss, HCC, and ESLD in patients with NAFLD. The LT demand and the increasing spread of NAFLD in the donor pool reinforce the already existing lack of donor organs.

Conclusion

In this review, we will discuss the diverse mechanisms underlying NAFLD, its implications for surgery, and the challenges for patient management.

Clinical considerations in the management of non-alcoholic steatohepatitis cirrhosis pre- and post-transplant: A multi-system challenge

Non-alcoholic steatohepatitis (NASH) is the most common chronic liver disease worldwide, and the fastest growing indication for liver transplantation in the United States. NASH is now the leading etiology for liver transplantation in women, the second leading indication for men, and the most common cause amongst recipients aged 65 years and older. Patients with end-stage liver disease related to NASH represent a unique and challenging patient population due the high incidence of associated comorbid diseases, including obesity, type 2 diabetes (T2D), and hypertension. These challenges manifest in the pre-liver transplantation period with increased waitlist times and waitlist mortality. Furthermore, these patients carry considerable risk of morbidity and mortality both before after liver transplantation, with high rates of T2D, cardiovascular disease, chronic kidney disease, poor nutrition, and disease recurrence. Successful transplantation for these patients requires identification and management of their comorbidities in the face of liver failure. Multidisciplinary evaluations include a thorough pre-transplant workup with a complete cardiac evaluation, control of diabetes, nutritional support, and even, potentially, consultation with a bariatric surgeon. This article provides a comprehensive review of the conditions and challenges facing patients with NASH cirrhosis undergoing liver transplantation and provides recommendations for evaluation and management to optimize them before liver transplantation to produce successful outcomes.

An Overview of Lipid Metabolism and Nonalcoholic Fatty Liver Disease

The occurrence of nonalcoholic fatty liver disease (NAFLD) is associated with major abnormalities of hepatic lipid metabolism. We propose that lipid abnormalities directly or indirectly contribute to NAFLD, especially fatty acid accumulation, arachidonic acid metabolic disturbance, and ceramide overload. The effects of lipid intake and accumulation on NAFLD and NAFLD treatment are explained with theoretical and experimental details. Overall, these findings provide further understanding of lipid metabolism in NAFLD and may lead to novel therapies.

Comparison of the severity of non-alcoholic fatty liver disease in diabetic and non-diabetic obese patients

INTRODUCTION

nonalcoholic fatty liver disease presents a broad spectrum of histopathological alterations, from steatosis to liver cirrhosis. Patients with diabetes mellitus (DM) present increased incidence and severity of NAFLD.

OBJECTIVE

determine the prevalence and severity of NAFLD in diabetic and non-diabetic obese patients undergoing bariatric surgery.

METHOD

the evaluation of liver biopsies was carried out through NAFLD activity score (NAS) in order to evaluate degree of hepatic steatosis, presence of ballooning, inflammatory activity and degree of fibrosis.

RESULTS

a total of 154 patients who have undergone bariatric surgery with intraoperative biopsy were observed and divided into two BMI ranges: from 35 to 44.9 and from 45 to 54.9. 32 (20.8%) from 154 patients were diabetic and 122 (79.2%) were non-diabetic. Patients with DM were significantly older than patients without the disease, presenting 41.29 ± 9.40 years vs 36.71 ± 10.13 years in the group with BMI of 35 to 44.9 (p=0.049); and 45.13 ± 7.10 years vs 37.00 ± 9.24 years in the group with BMI of 45 to 54.9 (p=0.024). In the histological evaluation, patients with DM from the BMI group of 35 to 44.9 had a strong association with higher prevalence and severity of steatosis, balloning, inflammation, fibrosis and steatohepatitis.

CONCLUSION

the present study confirms the high prevalence of NAFLD in patients with Morbid Obesity. Prevalence and severity increase proportionally to BMI and who have DM as comorbidity.

Laparoscopic Sleeve Gastrectomy After Orthotopic Liver Transplantation, Video Reported

INTRODUCTION

The immunosuppressive therapy for life after liver transplantation (LT) is considered as a risk factor for obesity. Seven percent of the transplanted patients develop severe or morbid obesity. The obesity induces non-alcoholic steatohepatitis (NASH), which is a major risk factor for liver cirrhosis and hepatocellular carcinoma, without forgetting the cardiovascular risk and the devastating impact of obesity on quality of life of the transplanted patients. Consequently, obesity exposes these patients to future transplant loss. Bariatric surgery has been proposed for transplant patients to reduce the obesity-related comorbidities and to improve survival. We report in this video the surgical technique of laparoscopic sleeve gastrectomy (LSG) after LT.

METHODS

We have performed between 2008 and 2017 the sleeve gastrectomy (SG) after LT in nine patients. Six procedures (66%) were performed totally by laparoscopy and three by upfront laparotomy. All the patients had a standard preoperative evaluation for obesity. All the procedures were assisted by a hepatic surgeon. Postoperatively patients were transferred to the liver ICU for 24 h then to the liver unit ward.

RESULT

The median BMI was 41.9 kg/m² (range 38-46.1 kg/m²). Median operative time was 120 min (range, 90-240 min). No intra-operative complications occurred. The median length of hospital stay was 7 days (range, 4-81 days). The postoperative course of the majority of the patients was uneventful except for one patient who develops a staple line leak.

CONCLUSION

LSG after LT is technically feasible. Larger series are needed to improve the safety of the procedure in this high-risk population.

A retrospective case control study identifies peripheral blood mononuclear cell albumin RNA expression as a biomarker for non-alcoholic fatty liver disease

PURPOSE

Non-alcoholic fatty liver disease (NAFLD) improves after bariatric surgery. The aim of this study was to determine whether peripheral blood mononuclear cell albumin gene expression was related to NAFLD and whether albumin (ALB) and alpha fetoprotein (AFP) expression could be detected in whole blood and visceral adipose tissue.

METHODS

Using a retrospective case control study design, RNA isolated from peripheral blood mononuclear cells from patients prior to undergoing bariatric surgery was used for pooled microarray analysis. Quantitative polymerase chain reaction (QPCR) was used to analyze whole blood and visceral adipose tissue. Liver histology was obtained via intra-operative biopsy and clinical data extracted from the electronic health record.

RESULTS

The albumin (ALB) gene was the second most up-regulated found in microarray analysis of peripheral blood mononuclear cell RNA from patients with hepatic lobular inflammation versus normal liver histology. Transcript levels of ALB were significantly different across those with normal (n = 50), steatosis (n = 50), lobular inflammation (n = 50), and peri-sinusoidal fibrosis (n = 50) liver histologies, with lobular inflammation 3.9 times higher than those with normal histology (p < 0.017). Albumin expression levels decreased in 11/13 patients in paired samples obtained prior to and at 1 year after Roux-en-Y gastric bypass surgery. ALB expression could be detected in 23 visceral adipose tissue samples obtained intra-operatively and in 18/19 available paired whole blood samples. No significant correlation was found between ALB expression in visceral adipose tissue and whole blood RNA samples. Alpha fetoprotein expression as a marker of early hepatocytic differentiation was detected in 17/17 available VAT RNA samples, but in only 2/17 whole blood RNA samples.

CONCLUSION

Albumin RNA expression from blood cells may serve as a biomarker of NAFLD. Albumin and alpha fetoprotein appear to be ubiquitously expressed in visceral adipose tissue in patients with extreme obesity.

Bariatric Surgery as an Efficient Treatment for Non-Alcoholic Fatty Liver Disease in a Prospective Study with 1-Year Follow-up : BariScan Study

BACKGROUND

Bariatric surgery gains attention as a potential treatment for non-alcoholic fatty liver disease (NAFLD). The present study aimed to evaluate improvement of NAFLD after the two most common bariatric procedures with validated non-invasive instruments.

MATERIAL AND METHODS

N = 100 patients scheduled for laparoscopic sleeve gastrectomy (LSG) or Roux-en-Y gastric bypass (RYGB) were included. NAFLD was evaluated preoperatively and postoperatively with liver stiffness measurement by transient elastography and laboratory-based fibrosis scores. Clinical data included body mass index (BMI), total weight loss (%TWL), excess weight loss (%EWL), age, gender, comorbidities, and the Edmonton obesity staging system (EOSS).

RESULTS

There were significant improvements of BMI, %TWL, %EWL, and EOSS after bariatric surgery. Liver stiffness was significantly improved from pre- to postoperative (12.9 ± 10.4 vs. 7.1 ± 3.7 kPa, p < 0.001) at median follow-up of 12.5 months. Additionally, there were significant improvements of liver fibrosis scores (aspartate aminotransferase (AST)/alanine aminotransferase (ALT) ratio 0.8 ± 0.3 vs. 1.1 ± 0.4, p < 0.001; NAFLD fibrosis score - 1.0 ± 1.8 vs. - 1.7 ± 1.3, p < 0.001; APRI score 0.3 ± 0.2 vs. 0.3 ± 0.1, p = 0.009; BARD score 2.3 ± 1.2 vs. 2.8 ± 1.1, p = 0.008) and laboratory parameters (ALT, AST, and GGT). After adjustment for baseline liver stiffness, RYGB showed higher improvements than LSG, and there was no gender difference. Improvement of liver stiffness was not correlated to improvement of BMI, %TWL, %EWL, or EOSS.

CONCLUSIONS

NAFLD seems to be improved by bariatric surgery as measured by validated non-invasive instruments. Furthermore, it appears that RYGB is more effective than LSG. No correlation could be detected between NAFLD and weight loss. The present study highlights the potential of bariatric surgery for successful treatment of NAFLD. Further research is required to understand the exact mechanisms.

Changes of Circulating Extracellular Vesicles from the Liver after Roux-en-Y Bariatric Surgery

Circulating extracellular vesicles are small particles enclosed by a phospholipid bilayer. Vesicles deriving directly from the cellular membrane by an active budding process retain cell origin specific proteins and RNA. These vesicles carry pathophysiological information from their parental cell and hold the potential to allow analysis of organs without the need for a biopsy. We included in our study 27 patients undergoing bariatric surgery. Hepatic extracellular vesicles were determined by flow cytometry. mRNA specific for hepatic cellular origin was determined in the extracellular vesicle fraction using qPCR. Surgery led to a massive reduction of weight and overall hepatic stress as determined by alanine transaminase (ALT), aspartate transaminase (AST) and γ-glutamyltransferase (GGT). Total extracellular vesicle numbers were reduced after bariatric surgery. Liver specific vesicles identified by HepPar1 or asialoglycoprotein receptor (ASGPR) were significantly reduced after bariatric surgery in both AnnexinV⁺ and AnnexinV⁻ subgroups. When analyzing circulating liver-specific mRNAs, we found reduced levels of these mRNAs after surgery even though total circulating RNA remained unchanged. We conclude that circulating hepatic extracellular vesicles are detectable in samples from patients undergoing gastric bypass surgery. These vesicles are reduced after a reduction of hepatic stress also observed with classic liver enzyme measurements. We conclude that ASGPR or HepPar positive vesicles hold the potential to serve as liver specific vesicle markers.

Evolution of 29 Anthropometric, Nutritional, and Cardiometabolic Parameters Among Morbidly Obese Adolescents 2 Years Post Sleeve Gastrectomy

Background

Laparoscopic sleeve gastrectomy (LSG) is a popular treatment for adolescent morbid obesity. Research on LSG outcomes among adolescents assessed a narrow range of anthropometric, nutritional, or cardiometabolic parameters, leading to an incomplete picture of these changes. We examined a wide variety of anthropometric, nutritional, and cardiometabolic parameters among adolescents before and after LSG.

Methods

We retrospectively reviewed medical charts of all obese adolescents who underwent LSG at Hamad Medical Corporation, Qatar, between January 2011 and June 2015 (N = 102). We assessed preoperative levels and postoperative changes in 4 anthropometric, 15 nutritional, and 10 cardiometabolic parameters.

Results

The study sample comprised 79 patients with complete information (36 males, mean age 15.99 ± 1.1 years). At a mean of 24.2 months post-LSG, we observed (1) significantly reduced mean weight and body mass index by 51.82 ± 28.1 kg and 17 ± 6.24 kg/m², respectively; (2) the highest prevalence of post-LSG deficiencies pertained to vitamin D, albumin, and ferritin (89.3, 38, and 33.3%, respectively); (3) low hemoglobin levels (29.3%) only in females; (4) trace elements were not deficient; (4) significant reductions in percentage of adolescents with elevated low-density lipoprotein (from 66.1 to 38.9%), alanine aminotransferase (from 45.3 to 10.9%), and aspartate aminotransferase (from 24.1 to 8.6%) levels; (5) 100% remission of prediabetes cases; and (6) 80% remission of type 2 diabetes cases.

Conclusions

LSG achieved significant weight loss and improvement of cardiometabolic risk factors among adolescents. However, the slight worsening of preexisting nutritional deficiencies warrants careful preoperative surveillance and appropriate postoperative nutritional supplementation.

Significant Liver-Related Morbidity After Bariatric Surgery and Its Reversal-a Case Series

Background

Nonalcoholic fatty liver disease (NAFLD) occurs in up to 80% of patients with obesity. Current data suggest an improvement of NAFLD after established bariatric procedures.

Objectives

This study investigated liver function impairment after Roux-en-Y gastric bypass (RYGB) and one-anastomosis gastric bypass (OAGB).

Setting

University Hospital, Bariatric Surgery Unit

Methods

In this single-center case series, consecutive in- and outpatients after bariatric surgery who presented with severe liver dysfunction from March 2014 to February 2017 were included and followed until March 2017.

Results

In total, 10 patients (m:f = 2:8; median age 48 years, range 22–66 years) were included. Liver dysfunction occurred after a median postoperative time of 15 months (range 2–88 months). Median %excess weight loss at that time was 110.6% (range 85.2–155.5%). Liver steatosis/fibrosis occurred in 70%, cirrhosis in 30% of patients, and led to fatigue (90%), ascites (70%), hepatic encephalopathy (30%), and upper gastrointestinal bleeding (20%). Elevation of transaminases, impairment of coagulation parameters, thrombocytopenia, and hypoalbuminemia were present in 70, 80, 70, and 100%, respectively. In eight patients, lengthening of the alimentary/common limb led to an improvement or complete remission of symptoms. In one patient, liver transplantation was required, one patient deceased due to septic shock and decompensated liver disease.

Conclusions

Severe liver dysfunction may also occur after bariatric procedures such as OAGB and RYGB. A comprehensive, meticulous follow-up for early identification of postoperative liver impairment should be aspired. Bypass length reduction led to a fast improvement in all patients.

Non-alcoholic fatty liver disease and obesity: the role of the gut bacteria

Non-alcoholic fatty-liver disease (NAFLD) is now considered one of the leading causes of liver disease worldwide and is associated with metabolic syndrome and obesity. There are several factors contributing to the disease state. Recent research suggests that the intestinal microbiota (IM) and bacterial products may play a role through several mechanisms which include increased energy uptake, intestinal permeability and chronic inflammation. In addition to diet and exercise, treatment options targeting the IM are being investigated and include the use of pre-, pro- and synbiotics as well as the possibility of fecal microbial transfers. This literature review explores the relationship between NAFLD and the IM as well as highlight new IM treatment options that may become available in the near future.

Changes in Bile Acid Profile After Laparoscopic Sleeve Gastrectomy are Associated with Improvements in Metabolic Profile and Fatty Liver Disease

BACKGROUND

Bile acids (BA) modulate lipid and glucose metabolism in a feedback loop through production of fibroblast growth factor (FGF) 19 in the terminal ileum. Changes in BA after bariatric surgery may lead to improvements in the metabolic syndrome, including fatty liver disease. This study investigated the relationship between BA and metabolic and inflammatory profiles after laparoscopic sleeve gastrectomy (LSG).

METHODS

Patients undergoing LSG had fasting blood samples taken pre-operatively and 6 months post-surgery. Liver injury was measured using cytokeratin (CK) 18 fragments. BA were measured using liquid chromatography tandem-mass spectrometry. FGF-19 was measured using enzyme-linked immunosorbent assay.

RESULTS

The study included 18 patients (12 females), with mean age 46.3 years (SEM ± 2.9) and BMI 60.1 kg/m(2) (±2.6). After 6 months, patients lost 39.8 kg (±3.1; p < 0.001). Fourteen patients (78 %) had steatosis. FGF-19 increased from median 128.1 (IQR 89.4-210.1) to 177.1 (121.8-288.9, p = 0.045) at 6 months. Although total BA did not change, primary glycine- and taurine-conjugated BA, cholic acid decreased, and secondary BA, glycine-conjugated urodeoxycholic acid increased over the study period. These changes are associated with reduction in insulin resistance, pro-inflammatory cytokines and CK-18 levels.

CONCLUSIONS

The profile of individual BA is altered after LSG. These changes occur in the presence of reductions in inflammatory cytokines and markers of liver injury. This study supports evidence from recent animal models that LSG may have an effect on fatty liver through changes in BA metabolism.

Impact of bariatric surgery on non-alcoholic fatty liver disease

Introduction; p to 300 million people have the body mass index (BMI) greater than 30 kg/m2. Obesity is the cause of many serious diseases, such as type 2 diabetes, hypertension, and non-alcoholic fatty liver disease (NAFLD). Bariatric surgery is the only effective method of achieving weight loss in patients with morbid obesity.

OBJECTIVES

The aim of the study was to assess the impact of bariatric surgery on non-alcoholic fatty liver disease in patients operated on due to morbid obesity.

MATERIAL AND METHODS

We included 20 patients who were qualified for bariatric procedures based on BMI &gt; 40 kg/ m2 or BMI &gt; 35kg/m2 with the presence of comorbidities. The average body weight in the group was 143.85kg, with an average BMI of 49.16kg/m2. Before the procedure, we evaluated the severity of non-alcoholic fatty liver disease in each patient using the Sheriff-Saadeh ultrasound scale. We also evaluated the levels of liver enzymes. Follow-up evaluation was performed twelve months after surgery.

RESULTS

Twelve months after surgery, the average weight was 102.34 kg. The mean %WL was 33.01%, %EWL was 58.8%, and %EBMIL was 61.37%. All patients showed remission of fatty liver disease. Liver damage, evaluated with ultrasound imaging, decreased from an average of 1.85 on the Sheriff-Saadeh scale, before surgery, to 0.15 twelve months after surgery (p &lt; 0.001). As regards liver enzymes, the level of alanine aminotransferase decreased from 64.5 (U/l) to 27.95 (U/l) (p &lt; 0.001), and the level of aspartate aminotransferase decreased from 54.4 (U/l) to 27.2 (U/l).

CONCLUSIONS

Bariatric procedures not only lead to a significant and lasting weight loss, but they also contribute to the reduction of fatty liver disease and improve liver function.

Outcome of liver transplantation in patients with prior bariatric surgery

Nonalcoholic fatty liver disease is becoming the leading cause of disease resulting in liver transplantation (LT). As a result of this trend, more LT candidates are presenting with prior history of bariatric surgery (BS). Over the last decade, 960 patients underwent LT at our institution; 11 (1.1%) had prior BS. The most common type of BS was Roux-en-Y gastric bypass (n = 9) with 1 sleeve gastrectomy and 1 jejunoileal bypass. A total of 9 patients underwent LT alone, and 2 underwent simultaneous liver-kidney transplantation. The most common indication for LT was nonalcoholic steatohepatitis (n = 10) with 5 having additional diagnosis of alcoholic liver disease. The 30-day reoperation rate was 36.4% (n = 4); indications were bile duct repair (n = 3) and wound repair (n = 1). In the first 6 months after LT, biliary complications were seen in 54.5% (n = 6) of the patients. Both patient and graft survival rates at 1 and 2 years were 81.8% (n = 9) and 72.7% (n = 8), respectively. A total of 8 patients (72.7%) had indications for liver biopsy after LT; significant macrovesicular steatosis was found in 2 (18.2%). In patients with a history of alcohol consumption, 2 (40.0%) relapsed after LT. Two patients (18.2%) had a history of diet-controlled diabetes before LT; 1 of these patients became insulin dependent after LT. Mean body mass index (BMI) at LT was 31.0 ± 5.7 kg/m² . Mean BMI at 1, 6, and 12 months after LT was 28.3 ± 5.8, 28.0 ± 3.2, and 31.0 ± 6.6 kg/m² , respectively. Mean preoperative albumin was 2.6 ± 0.6 mg/dL. Patients showed improvement in albumin after LT, with mean albumin of 2.7 ± 0.6 and 3.2 ± 0.5 mg/dL at 1 and 3 months, respectively. The liver profile was stable after LT, with mean aspartate aminotransferase of 32.9 ± 18.4 and 26.6 ± 19.8 IU/L and alanine aminotransferase of 28.0 ± 17.5 and 30.2 ± 17.0 IU/L at 6 and 12 months, respectively. In conclusion, outcomes of LT patients with prior BS are comparable with other transplant recipients with regards to patient and graft survival and post-LT complication rates. Liver Transplantation 23 1415-1421 2017 AASLD.

Non-Alcoholic Fatty Liver Disease in Africa and Middle East: An Attempt to Predict the Present and Future Implications on the Healthcare System

Non-alcoholic fatty liver disease (NAFLD) encompasses a group of hepatic diseases that range in severity. NAFLD is increasingly recognized as an epidemic among different populations, including those in Africa and the Middle East. The objective of this narrative review is to document the prevalence of and risk factors for NAFLD in Africa and the Middle East and the potential implications on the healthcare systems. An in-depth search on Google Scholar, Medline and PubMed was conducted using the terms "non-alcoholic fatty liver disease" and "non-alcoholic steatohepatitis", in addition to "prevalence and risk factors for NAFLD", with special emphasis on Africa and the Middle East countries. There were three types of epidemiological studies that included prevalence, risk factors and management/complications of NAFLD. There was noticeable variation in the prevalence of NAFLD among different countries, based on the variation in the prevalence of risk factors (type 2 diabetes, obesity, metabolic syndrome and dyslipidemia) and the diagnostic tool used in the study. However, the highest prevalence rate was reported in some Middle East countries. In Africa, there were few studies about NAFLD and most reported variable prevalence rates. There is an increasing prevalence of NAFLD as a result of the increasing risk factors, particularly in the Middle East, while in Africa, the situation is still unclear. Health providers in these regions are faced with many challenges that need urgent plans.

Current management of non-alcoholic fatty liver disease

Non-alcoholic fatty liver disease (NAFLD) is characterized by hepatic accumulation of lipid in patients who do not consume alcohol in amounts generally considered harmful to the liver. NAFLD is becoming a major liver disease in Eastern countries and it is related to insulin resistance and metabolic syndrome. Treatment has focused on improving insulin sensitivity, protecting the liver from oxidative stress, decreasing obesity and improving diabetes mellitus, dyslipidemia, hepatic inflammation and fibrosis. Lifestyle modification involving diet and enhanced physical activity associated with the treatment of underlying metabolic are the main stain in the current management of NAFLD. Insulin-sensitizing agents and antioxidants, especially thiazolidinediones and vitamin E, seem to be the most promising pharmacologic treatment for non-alcoholic steatohepatitis, but further long-term multicenter studies to assess safety are recommended.

Treatment options for nonalcoholic steatohepatitis - a safety evaluation

INTRODUCTION

There is an urgent as yet unmet need to develop highly effective and safe therapeutics for nonalcoholic fatty liver disease (NAFLD). The remarkable progress in understanding NAFLD pathogenesis allowed the identification of injury pathways which may be recruited as therapy targets. Areas covered: This article reviews the safety and tolerability data of the NAFLD therapies and explains the mechanistic basis for each of the established and investigational drugs. Treatment targets include: weight loss, anti-metabolic agents such as lipid lowering and anti-diabetic drugs, inflammation, fibrosis and others such as targeting gut microbiota, immune modulation and apoptosis. Expert opinion: Current therapies continue to remain suboptimal. Weight loss is effective but hard to achieve. Traditional and endoscopic bariatric procedures are promising although more randomized trials are needed and the long-term safety remains to be established. Clinical trials have demonstrated the efficacy of several drugs for the treatment of NASH. Of these, there remains some uncertainty about the long-term safety of vitamin E. Pioglitazone is associated with osteopenia, fluid retention and weight gain. Obeticholic acid causes pruritus in a substantial proportion of subjects and elafibranor has been associated with transient rises in creatinine. Several exciting therapies are under development and results of clinical and post-marketing trials will help elucidate their safety.

Changes in adiposity and other cardiometabolic risk factors following Roux-en-Y gastric bypass: A 12-month prospective cohort study in Chinese patients

AIM

We aimed to investigate the changes in adiposity and other cardiometabolic risk factors in the year following Roux-en-Y gastric bypass (RYGB) in patients of Chinese ethnicity.

METHODS

The study recruited 209 patients who met the indications for bariatric surgery. Adiposity and cardiometabolic risk factors were assessed at baseline and over the 12 months following surgery in all participants. SPSS® software was used for statistical analysis.

RESULTS

The mean body mass index (BMI) was 29.98 kg/m² at baseline and steadily decreased to 25.32 kg/m² at 12 months, giving a relative change of -15.5% (p < 0.001). All of the lipid profile fractions except high-density lipoprotein (HDL) declined during the first 12 months of follow up; serum HDL increased during this time (all ANOVA p < 0.001). The mean fasting plasma glucose was 9.49 mmol/L at baseline and gradually decreased to 5.69 mmol/L at 12 months, giving a relative change of -40.0% (p < 0.001).

CONCLUSION

Following the RYGB procedure, changes in measures of adiposity were paralleled by a significant improvement in cardiometabolic factors for 12 months after surgery.

Hepatic CD36 downregulation parallels steatosis improvement in morbidly obese undergoing bariatric surgery

BACKGROUND

The notion that hepatic expression of genes involved in lipid metabolism is altered in obese patients is relatively new and its relationship with hepatic steatosis and cardiometabolic alterations remains unclear.

OBJECTIVE

We assessed the impact of Roux-en-Y gastric bypass surgery (RYGB) on the expression profile of genes related to metabolic syndrome in liver biopsies from morbidly obese individuals using a custom-made, focused cDNA microarray, and assessed the relationship between the expression profile and hepatic steatosis regression.

MATERIALS AND METHODS

Plasma and liver samples were obtained from patients at baseline and 12 months after surgery. Samples were assayed for chemical and gene expression analyses, as appropriate. Gene expression profiles were assessed using custom-made, focused TaqMan low-density array cards.

RESULTS

RYGB-induced weight loss produced a favorable reduction in fat deposits, insulin resistance (estimated by homeostasis model assessment of insulin resistance (HOMA-IR)), and plasma and hepatic lipid levels. Compared with the baseline values, the gene expression levels of key targets of lipid metabolism were significantly altered: CD36 was significantly downregulated (-40%; P=0.001), whereas APOB (+27%; P=0.032) and SCARB1 (+37%; P=0.040) were upregulated in response to surgery-induced weight reduction. We also observed a favorable reduction in the expression of the PAI1 gene (-80%; P=0.007) and a significant increase in the expression of the PPARA (+60%; P=0.014) and PPARGC1 genes (+36%; P=0.015). Notably, the relative fold decrease in the expression of the CD36 gene was directly associated with a concomitant reduction in the cholesterol (Spearman's r=0.92; P=0.001) and phospholipid (Spearman's r=0.76; P=0.04) contents in this tissue.

CONCLUSIONS

For the first time, RYGB-induced weight loss was shown to promote a favorable downregulation of CD36 expression, which was proportional to a favorable reduction in the hepatic cholesterol and phospholipid contents in our morbidly obese subjects following surgery.

Nonalcoholic fatty liver disease and bariatric surgery: a comprehensive review

CONTEXT AND OBJECTIVE:

Nonalcoholic fatty liver disease (NAFLD) has been increasingly diagnosed worldwide and is now recognized as a source of public health concern. It comprises a wide spectrum of histological features that range from simple steatosis to severe forms of fibrosis, steatohepatitis and even cirrhosis. The impact of bariatric surgery on the course of NAFLD in individuals with obesity has been extensively studied.

DESIGN AND SETTING:

Narrative review; public university hospital.

METHODS:

A comprehensive review was conducted based on an online search on the electronic databases MEDLINE and LILACS using the MeSH terms "fatty liver" and "bariatric surgery".

RESULTS:

The exact mechanisms that lead to improvement in NAFLD following bariatric surgery are not completely understood. Since Roux-en-Y gastric bypass (RYGB) is the bariatric surgical procedure most performed worldwide, it is also the one from which the effects on NAFLD have been most studied, although there is also consistent evidence regarding the effects from gastric banding, sleeve gastrectomy and biliopancreatic diversions.

CONCLUSION:

According to the currently available evidence, bariatric surgery leads to significant improvement in NAFLD. Further research, especially by means of randomized controlled trials enrolling larger cohorts of individuals, is needed to determine the optimal procedure for this group of subjects.

Simultaneous living donor liver transplant with sleeve gastrectomy for metabolic syndrome and NASH-related ESLD-First report from India

Nonalcoholic steatohepatitis (NASH) with morbid obesity and metabolic syndrome is now a common cause of end-stage liver disease (ESLD). These patients are high-risk candidates for liver transplant, and require bariatric surgery to prevent recurrent disease in the new liver. Data reports bariatric surgery after transplant, which maybe difficult because of adhesions between the stomach and liver in living donor liver transplant (LDLT) recipient. We report the first case of combined LDLT with sleeve gastrectomy (SG) from India. A morbidly obese diabetic woman with NASH-related ESLD was planned for combined right lobe LDLT with open SG, in view of failed diet therapy, musculo-skeletal complaints, and restricted mobility. Postoperatively, with liver graft functioning adequately, bariatric diet restrictions resulted in maximum reduction of 25% weight, achieving a target BMI below 30 kg/m² within 2 months, along with complete cure of diabetes and better ambulation. Thus, combination of LDLT and bariatric surgery in the same sitting is safe and effective in management of metabolic syndrome and associated NASH-related ESLD.

Pediatric Obesity-Assessment, Treatment, and Prevention: An Endocrine Society Clinical Practice Guideline

COSPONSORING ASSOCIATIONS

The European Society of Endocrinology and the Pediatric Endocrine Society. This guideline was funded by the Endocrine Society.

OBJECTIVE

To formulate clinical practice guidelines for the assessment, treatment, and prevention of pediatric obesity.

PARTICIPANTS

The participants include an Endocrine Society-appointed Task Force of 6 experts, a methodologist, and a medical writer.

EVIDENCE

This evidence-based guideline was developed using the Grading of Recommendations, Assessment, Development, and Evaluation approach to describe the strength of recommendations and the quality of evidence. The Task Force commissioned 2 systematic reviews and used the best available evidence from other published systematic reviews and individual studies.

CONSENSUS PROCESS

One group meeting, several conference calls, and e-mail communications enabled consensus. Endocrine Society committees and members and co-sponsoring organizations reviewed and commented on preliminary drafts of this guideline.

CONCLUSION

Pediatric obesity remains an ongoing serious international health concern affecting ∼17% of US children and adolescents, threatening their adult health and longevity. Pediatric obesity has its basis in genetic susceptibilities influenced by a permissive environment starting in utero and extending through childhood and adolescence. Endocrine etiologies for obesity are rare and usually are accompanied by attenuated growth patterns. Pediatric comorbidities are common and long-term health complications often result; screening for comorbidities of obesity should be applied in a hierarchal, logical manner for early identification before more serious complications result. Genetic screening for rare syndromes is indicated only in the presence of specific historical or physical features. The psychological toll of pediatric obesity on the individual and family necessitates screening for mental health issues and counseling as indicated. The prevention of pediatric obesity by promoting healthful diet, activity, and environment should be a primary goal, as achieving effective, long-lasting results with lifestyle modification once obesity occurs is difficult. Although some behavioral and pharmacotherapy studies report modest success, additional research into accessible and effective methods for preventing and treating pediatric obesity is needed. The use of weight loss medications during childhood and adolescence should be restricted to clinical trials. Increasing evidence demonstrates the effectiveness of bariatric surgery in the most seriously affected mature teenagers who have failed lifestyle modification, but the use of surgery requires experienced teams with resources for long-term follow-up. Adolescents undergoing lifestyle therapy, medication regimens, or bariatric surgery for obesity will need cohesive planning to help them effectively transition to adult care, with continued necessary monitoring, support, and intervention. Transition programs for obesity are an uncharted area requiring further research for efficacy. Despite a significant increase in research on pediatric obesity since the initial publication of these guidelines 8 years ago, further study is needed of the genetic and biological factors that increase the risk of weight gain and influence the response to therapeutic interventions. Also needed are more studies to better understand the genetic and biological factors that cause an obese individual to manifest one comorbidity vs another or to be free of comorbidities. Furthermore, continued investigation into the most effective methods of preventing and treating obesity and into methods for changing environmental and economic factors that will lead to worldwide cultural changes in diet and activity should be priorities. Particular attention to determining ways to effect systemic changes in food environments and total daily mobility, as well as methods for sustaining healthy body mass index changes, is of importance.