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Cao L, An Y, Liu H, Jiang J, Liu W, Zhou Y, Shi M, Dai W, Lv Y, Zhao Y, Lu Y, Chen L, Xia Y. Global epidemiology of type 2 diabetes in patients with NAFLD or MAFLD: a systematic review and meta-analysis. BMC Med 2024; 22:101. [PMID: 38448943 PMCID: PMC10919055 DOI: 10.1186/s12916-024-03315-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Accepted: 02/23/2024] [Indexed: 03/08/2024] Open
Abstract
BACKGROUND Non-alcoholic fatty liver disease (NAFLD) and metabolic-associated fatty liver disease (MAFLD) shares common pathophysiological mechanisms with type 2 diabetes, making them significant risk factors for type 2 diabetes. The present study aimed to assess the epidemiological feature of type 2 diabetes in patients with NAFLD or MAFLD at global levels. METHODS Published studies were searched for terms that included type 2 diabetes, and NAFLD or MAFLD using PubMed, EMBASE, MEDLINE, and Web of Science databases from their inception to December 2022. The pooled global and regional prevalence and incidence density of type 2 diabetes in patients with NAFLD or MAFLD were evaluated using random-effects meta-analysis. Potential sources of heterogeneity were investigated using stratified meta-analysis and meta-regression. RESULTS A total of 395 studies (6,878,568 participants with NAFLD; 1,172,637 participants with MAFLD) from 40 countries or areas were included in the meta-analysis. The pooled prevalence of type 2 diabetes among NAFLD or MAFLD patients was 28.3% (95% confidence interval 25.2-31.6%) and 26.2% (23.9-28.6%) globally. The incidence density of type 2 diabetes in NAFLD or MAFLD patients was 24.6 per 1000-person year (20.7 to 29.2) and 26.9 per 1000-person year (7.3 to 44.4), respectively. CONCLUSIONS The present study describes the global prevalence and incidence of type 2 diabetes in patients with NAFLD or MAFLD. The study findings serve as a valuable resource to assess the global clinical and economic impact of type 2 diabetes in patients with NAFLD or MAFLD.
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Affiliation(s)
- Limin Cao
- The Third Central Hospital of Tianjin, Tianjin, China
| | - Yu An
- Department of Endocrinology, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Huiyuan Liu
- Department of Clinical Epidemiology, Shengjing Hospital of China Medical University, No. 36, San Hao Street, Shenyang, Liaoning, 110004, China
- Liaoning Key Laboratory of Precision Medical Research On Major Chronic Disease, Liaoning Province, Shenyang, China
| | - Jinguo Jiang
- Department of Clinical Epidemiology, Shengjing Hospital of China Medical University, No. 36, San Hao Street, Shenyang, Liaoning, 110004, China
- Liaoning Key Laboratory of Precision Medical Research On Major Chronic Disease, Liaoning Province, Shenyang, China
| | - Wenqi Liu
- Department of Clinical Epidemiology, Shengjing Hospital of China Medical University, No. 36, San Hao Street, Shenyang, Liaoning, 110004, China
- Liaoning Key Laboratory of Precision Medical Research On Major Chronic Disease, Liaoning Province, Shenyang, China
| | - Yuhan Zhou
- Department of Clinical Epidemiology, Shengjing Hospital of China Medical University, No. 36, San Hao Street, Shenyang, Liaoning, 110004, China
- Liaoning Key Laboratory of Precision Medical Research On Major Chronic Disease, Liaoning Province, Shenyang, China
| | - Mengyuan Shi
- Department of Clinical Epidemiology, Shengjing Hospital of China Medical University, No. 36, San Hao Street, Shenyang, Liaoning, 110004, China
- Liaoning Key Laboratory of Precision Medical Research On Major Chronic Disease, Liaoning Province, Shenyang, China
| | - Wei Dai
- Department of Clinical Epidemiology, Shengjing Hospital of China Medical University, No. 36, San Hao Street, Shenyang, Liaoning, 110004, China
- Liaoning Key Laboratory of Precision Medical Research On Major Chronic Disease, Liaoning Province, Shenyang, China
| | - Yanling Lv
- Department of Nutrition and Food Hygiene, Hubei Key Laboratory of Food Nutrition and Safety, School of Public Health, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China
| | - Yuhong Zhao
- Department of Clinical Epidemiology, Shengjing Hospital of China Medical University, No. 36, San Hao Street, Shenyang, Liaoning, 110004, China
- Liaoning Key Laboratory of Precision Medical Research On Major Chronic Disease, Liaoning Province, Shenyang, China
| | - Yanhui Lu
- School of Nursing, Peking University, 38 Xueyuan Rd, Haidian District, Beijing, 100191, China.
| | - Liangkai Chen
- Department of Nutrition and Food Hygiene, Hubei Key Laboratory of Food Nutrition and Safety, School of Public Health, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China.
| | - Yang Xia
- Department of Clinical Epidemiology, Shengjing Hospital of China Medical University, No. 36, San Hao Street, Shenyang, Liaoning, 110004, China.
- Liaoning Key Laboratory of Precision Medical Research On Major Chronic Disease, Liaoning Province, Shenyang, China.
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Ding Y, Yanagi K, Yang F, Callaway E, Cheng C, Hensel ME, Menon R, Alaniz RC, Lee K, Jayaraman A. Oral supplementation of gut microbial metabolite indole-3-acetate alleviates diet-induced steatosis and inflammation in mice. eLife 2024; 12:RP87458. [PMID: 38412016 PMCID: PMC10942630 DOI: 10.7554/elife.87458] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/28/2024] Open
Abstract
Non-alcoholic fatty liver disease (NAFLD) is the most common chronic liver disease in Western countries. There is growing evidence that dysbiosis of the intestinal microbiota and disruption of microbiota-host interactions contribute to the pathology of NAFLD. We previously demonstrated that gut microbiota-derived tryptophan metabolite indole-3-acetate (I3A) was decreased in both cecum and liver of high-fat diet-fed mice and attenuated the expression of inflammatory cytokines in macrophages and Tnfa and fatty acid-induced inflammatory responses in an aryl-hydrocarbon receptor (AhR)-dependent manner in hepatocytes. In this study, we investigated the effect of orally administered I3A in a mouse model of diet-induced NAFLD. Western diet (WD)-fed mice given sugar water (SW) with I3A showed dramatically decreased serum ALT, hepatic triglycerides (TG), liver steatosis, hepatocyte ballooning, lobular inflammation, and hepatic production of inflammatory cytokines, compared to WD-fed mice given only SW. Metagenomic analysis show that I3A administration did not significantly modify the intestinal microbiome, suggesting that I3A's beneficial effects likely reflect the metabolite's direct actions on the liver. Administration of I3A partially reversed WD-induced alterations of liver metabolome and proteome, notably, decreasing expression of several enzymes in hepatic lipogenesis and β-oxidation. Mechanistically, we also show that AMP-activated protein kinase (AMPK) mediates the anti-inflammatory effects of I3A in macrophages. The potency of I3A in alleviating liver steatosis and inflammation clearly demonstrates its potential as a therapeutic modality for preventing the progression of steatosis to non-alcoholic steatohepatitis (NASH).
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Affiliation(s)
- Yufang Ding
- Artie McFerrin Department of Chemical Engineering, Texas A&M UniversityCollege StationUnited States
| | - Karin Yanagi
- Department of Chemical and Biological Engineering, Tufts UniversityMedfordUnited States
| | - Fang Yang
- Artie McFerrin Department of Chemical Engineering, Texas A&M UniversityCollege StationUnited States
| | - Evelyn Callaway
- Artie McFerrin Department of Chemical Engineering, Texas A&M UniversityCollege StationUnited States
| | - Clint Cheng
- Artie McFerrin Department of Chemical Engineering, Texas A&M UniversityCollege StationUnited States
| | - Martha E Hensel
- Department of Pathobiology, College of Veterinary Medicine and Biomedical Sciences, Texas A&M UniversityCollege StationUnited States
| | - Rani Menon
- Artie McFerrin Department of Chemical Engineering, Texas A&M UniversityCollege StationUnited States
| | - Robert C Alaniz
- Department of Microbial Pathogenesis and Immunology, College of Medicine, Texas Health Science Center, Texas A&M UniversityBryanUnited States
| | - Kyongbum Lee
- Department of Chemical and Biological Engineering, Tufts UniversityMedfordUnited States
| | - Arul Jayaraman
- Artie McFerrin Department of Chemical Engineering, Texas A&M UniversityCollege StationUnited States
- Department of Microbial Pathogenesis and Immunology, College of Medicine, Texas Health Science Center, Texas A&M UniversityBryanUnited States
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Kim H, Lee DS, An TH, Park HJ, Kim WK, Bae KH, Oh KJ. Metabolic Spectrum of Liver Failure in Type 2 Diabetes and Obesity: From NAFLD to NASH to HCC. Int J Mol Sci 2021; 22:ijms22094495. [PMID: 33925827 PMCID: PMC8123490 DOI: 10.3390/ijms22094495] [Citation(s) in RCA: 52] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2021] [Revised: 04/22/2021] [Accepted: 04/23/2021] [Indexed: 02/06/2023] Open
Abstract
Liver disease is the spectrum of liver damage ranging from simple steatosis called as nonalcoholic fatty liver disease (NAFLD) to hepatocellular carcinoma (HCC). Clinically, NAFLD and type 2 diabetes coexist. Type 2 diabetes contributes to biological processes driving the severity of NAFLD, the primary cause for development of chronic liver diseases. In the last 20 years, the rate of non-viral NAFLD/NASH-derived HCC has been increasing rapidly. As there are currently no suitable drugs for treatment of NAFLD and NASH, a class of thiazolidinediones (TZDs) drugs for the treatment of type 2 diabetes is sometimes used to improve liver failure despite the risk of side effects. Therefore, diagnosis, prevention, and treatment of the development and progression of NAFLD and NASH are important issues. In this review, we will discuss the pathogenesis of NAFLD/NASH and NAFLD/NASH-derived HCC and the current promising pharmacological therapies of NAFLD/NASH. Further, we will provide insights into "adipose-derived adipokines" and "liver-derived hepatokines" as diagnostic and therapeutic targets from NAFLD to HCC.
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Affiliation(s)
- Hyunmi Kim
- Metabolic Regulation Research Center, Korea Research Institute of Bioscience and Biotechnology (KRIBB), 125 Gwahak-ro, Yuseong-gu, Daejeon 34141, Korea; (H.K.); (D.S.L.); (T.H.A.); (H.-J.P.); (W.K.K.)
- Department of Functional Genomics, KRIBB School of Bioscience, Korea University of Science and Technology (UST), 217 Gajeong-ro, Yuseong-gu, Daejeon 34141, Korea
| | - Da Som Lee
- Metabolic Regulation Research Center, Korea Research Institute of Bioscience and Biotechnology (KRIBB), 125 Gwahak-ro, Yuseong-gu, Daejeon 34141, Korea; (H.K.); (D.S.L.); (T.H.A.); (H.-J.P.); (W.K.K.)
| | - Tae Hyeon An
- Metabolic Regulation Research Center, Korea Research Institute of Bioscience and Biotechnology (KRIBB), 125 Gwahak-ro, Yuseong-gu, Daejeon 34141, Korea; (H.K.); (D.S.L.); (T.H.A.); (H.-J.P.); (W.K.K.)
- Department of Functional Genomics, KRIBB School of Bioscience, Korea University of Science and Technology (UST), 217 Gajeong-ro, Yuseong-gu, Daejeon 34141, Korea
| | - Hyun-Ju Park
- Metabolic Regulation Research Center, Korea Research Institute of Bioscience and Biotechnology (KRIBB), 125 Gwahak-ro, Yuseong-gu, Daejeon 34141, Korea; (H.K.); (D.S.L.); (T.H.A.); (H.-J.P.); (W.K.K.)
- Department of Functional Genomics, KRIBB School of Bioscience, Korea University of Science and Technology (UST), 217 Gajeong-ro, Yuseong-gu, Daejeon 34141, Korea
| | - Won Kon Kim
- Metabolic Regulation Research Center, Korea Research Institute of Bioscience and Biotechnology (KRIBB), 125 Gwahak-ro, Yuseong-gu, Daejeon 34141, Korea; (H.K.); (D.S.L.); (T.H.A.); (H.-J.P.); (W.K.K.)
- Department of Functional Genomics, KRIBB School of Bioscience, Korea University of Science and Technology (UST), 217 Gajeong-ro, Yuseong-gu, Daejeon 34141, Korea
| | - Kwang-Hee Bae
- Metabolic Regulation Research Center, Korea Research Institute of Bioscience and Biotechnology (KRIBB), 125 Gwahak-ro, Yuseong-gu, Daejeon 34141, Korea; (H.K.); (D.S.L.); (T.H.A.); (H.-J.P.); (W.K.K.)
- Department of Functional Genomics, KRIBB School of Bioscience, Korea University of Science and Technology (UST), 217 Gajeong-ro, Yuseong-gu, Daejeon 34141, Korea
- Correspondence: (K.-H.B.); (K.-J.O.); Tel.: +82-42-860-4268 (K.-H.B.); +82-42-879-8265 (K.-J.O.)
| | - Kyoung-Jin Oh
- Metabolic Regulation Research Center, Korea Research Institute of Bioscience and Biotechnology (KRIBB), 125 Gwahak-ro, Yuseong-gu, Daejeon 34141, Korea; (H.K.); (D.S.L.); (T.H.A.); (H.-J.P.); (W.K.K.)
- Department of Functional Genomics, KRIBB School of Bioscience, Korea University of Science and Technology (UST), 217 Gajeong-ro, Yuseong-gu, Daejeon 34141, Korea
- Correspondence: (K.-H.B.); (K.-J.O.); Tel.: +82-42-860-4268 (K.-H.B.); +82-42-879-8265 (K.-J.O.)
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Ferro D, Baratta F, Pastori D, Cocomello N, Colantoni A, Angelico F, Del Ben M. New Insights into the Pathogenesis of Non-Alcoholic Fatty Liver Disease: Gut-Derived Lipopolysaccharides and Oxidative Stress. Nutrients 2020; 12:nu12092762. [PMID: 32927776 PMCID: PMC7551294 DOI: 10.3390/nu12092762] [Citation(s) in RCA: 84] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2020] [Revised: 09/01/2020] [Accepted: 09/07/2020] [Indexed: 02/07/2023] Open
Abstract
Non-alcoholic fatty liver disease (NAFLD) is the most common chronic liver disease worldwide. The intricate NAFLD pathogenesis is summarized by the multiple-hits hypothesis, which combines all the environmental and genetic factors that promote the development of NAFLD into a single scenario. Among these, bacterial lipopolysaccharides (LPS) are derived from the overgrowth of Gram-negative bacteria and translocated mainly as a consequence of enhanced intestinal permeability. Furthermore, oxidative stress is increased in NAFLD as a consequence of reactive oxygen species (ROS) overproduction and a shortage of endogenous antioxidant molecules, and it is promoted by the interaction between LPS and the Toll-like receptor 4 system. Interestingly, oxidative stress, which has previously been described as being overexpressed in cardiovascular disease, could represent the link between LPS and the increased cardiovascular risk in NAFLD subjects. To date, the only effective strategy for the treatment of NAFLD and non-alcoholic steatohepatitis (NASH) is the loss of at least 5% body weight in overweight and/or obese subjects. However, the dose-dependent effects of multispecies probiotic supplementation on the serum LPS level and cardiometabolic profile in obese postmenopausal women were demonstrated. In addition, many antibiotics have regulatory effects on intestinal microbiota and were able to reduce serum aspartate aminotransferase (AST), alanine aminotransferase (ALT), and tumor necrosis factor alpha (TNF-α) in NASH animal models. Regarding the oxidant status, a Mediterranean diet has been reported to reduce oxidant stress, while vitamin E at high daily dosages induced the resolution of NASH in 36% of treated patients. Silymarin had the positive effect of reducing transaminase levels in NAFLD patients and long-term treatment may also decrease fibrosis and slow liver disease progression in NASH. Finally, the influence of nutraceuticals on gut microbiota and oxidant stress in NAFLD patients has not yet been well elucidated and there are insufficient data either to support or refuse their use in these subjects.
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Affiliation(s)
- Domenico Ferro
- I Clinica Medica, Department of Clinical, Internal, Anesthetic and Cardiovascular Sciences, Sapienza University of Rome, 00185 Rome, Italy; (D.F.); (D.P.); (N.C.); (A.C.); (M.D.B.)
| | - Francesco Baratta
- I Clinica Medica, Department of Clinical, Internal, Anesthetic and Cardiovascular Sciences, Sapienza University of Rome, 00185 Rome, Italy; (D.F.); (D.P.); (N.C.); (A.C.); (M.D.B.)
- Correspondence: ; Tel.: +39-0649972249
| | - Daniele Pastori
- I Clinica Medica, Department of Clinical, Internal, Anesthetic and Cardiovascular Sciences, Sapienza University of Rome, 00185 Rome, Italy; (D.F.); (D.P.); (N.C.); (A.C.); (M.D.B.)
| | - Nicholas Cocomello
- I Clinica Medica, Department of Clinical, Internal, Anesthetic and Cardiovascular Sciences, Sapienza University of Rome, 00185 Rome, Italy; (D.F.); (D.P.); (N.C.); (A.C.); (M.D.B.)
| | - Alessandra Colantoni
- I Clinica Medica, Department of Clinical, Internal, Anesthetic and Cardiovascular Sciences, Sapienza University of Rome, 00185 Rome, Italy; (D.F.); (D.P.); (N.C.); (A.C.); (M.D.B.)
| | - Francesco Angelico
- Department of Public Health and Infectious Diseases, Sapienza University of Rome, 00185 Rome, Italy;
| | - Maria Del Ben
- I Clinica Medica, Department of Clinical, Internal, Anesthetic and Cardiovascular Sciences, Sapienza University of Rome, 00185 Rome, Italy; (D.F.); (D.P.); (N.C.); (A.C.); (M.D.B.)
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Baratta F, Pastori D, Bartimoccia S, Cammisotto V, Cocomello N, Colantoni A, Nocella C, Carnevale R, Ferro D, Angelico F, Violi F, Del Ben M. Poor Adherence to Mediterranean Diet and Serum Lipopolysaccharide are Associated with Oxidative Stress in Patients with Non-Alcoholic Fatty Liver Disease. Nutrients 2020; 12:nu12061732. [PMID: 32531941 PMCID: PMC7352324 DOI: 10.3390/nu12061732] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2020] [Revised: 06/05/2020] [Accepted: 06/07/2020] [Indexed: 12/17/2022] Open
Abstract
Oxidative stress plays a pivotal role in non-alcoholic fatty liver disease (NAFLD). Factors inducing oxidative stress in NAFLD may be several; however, a relationship with the adherence to Mediterranean Diet (Med-diet) and with serum lipopolysaccharide (LPS) has been poorly investigated in this setting. The aim was to investigate factors associated with impaired oxidative stress in NAFLD, focusing on the potential role of LPS and Med-diet. We enrolled 238 consecutive outpatients from the PLINIO study, in whom we measured the soluble Nox2-derived peptide (sNox2-dp), a marker of systemic oxidative stress, and serum LPS. Adherence to Med-diet was investigated by a nine-item validated dietary questionnaire. Serum sNox2-dp and LPS were higher in patients with NAFLD compared to those without (25.0 vs. 9.0 pg/mL, p < 0.001 and 62.0 vs. 44.9 pg/mL, p < 0.001, respectively). In patients with NAFLD, the highest sNox2-dp tertile was associated with the top serum LPS tertile (Odds Ratio (OR): 4.71; p < 0.001), APRI > 0.7 (OR: 6.96; p = 0.005) and Med-diet-score > 6 (OR: 0.14; p = 0.026). Analyzing individual foods, the daily consumption of wine (OR: 0.29, p = 0.046) and the adequate weekly consumption of fish (OR: 0.32, p = 0.030) inversely correlated with the top sNox2-dp tertile. In conclusion, patients with NAFLD showed impaired oxidative stress. Levels of sNox2 correlated with serum LPS and with low adherence to Med-Diet.
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Affiliation(s)
- Francesco Baratta
- I Clinica Medica, Department of Clinical Internal, Anestesiological and Cardiovascular Sciences, Sapienza University of Rome, 00185 Roma, Italy; (F.B.); (D.P.); (S.B.); (V.C.); (N.C.); (A.C.); (C.N.); (D.F.); (F.V.); (M.D.B.)
| | - Daniele Pastori
- I Clinica Medica, Department of Clinical Internal, Anestesiological and Cardiovascular Sciences, Sapienza University of Rome, 00185 Roma, Italy; (F.B.); (D.P.); (S.B.); (V.C.); (N.C.); (A.C.); (C.N.); (D.F.); (F.V.); (M.D.B.)
| | - Simona Bartimoccia
- I Clinica Medica, Department of Clinical Internal, Anestesiological and Cardiovascular Sciences, Sapienza University of Rome, 00185 Roma, Italy; (F.B.); (D.P.); (S.B.); (V.C.); (N.C.); (A.C.); (C.N.); (D.F.); (F.V.); (M.D.B.)
| | - Vittoria Cammisotto
- I Clinica Medica, Department of Clinical Internal, Anestesiological and Cardiovascular Sciences, Sapienza University of Rome, 00185 Roma, Italy; (F.B.); (D.P.); (S.B.); (V.C.); (N.C.); (A.C.); (C.N.); (D.F.); (F.V.); (M.D.B.)
| | - Nicholas Cocomello
- I Clinica Medica, Department of Clinical Internal, Anestesiological and Cardiovascular Sciences, Sapienza University of Rome, 00185 Roma, Italy; (F.B.); (D.P.); (S.B.); (V.C.); (N.C.); (A.C.); (C.N.); (D.F.); (F.V.); (M.D.B.)
| | - Alessandra Colantoni
- I Clinica Medica, Department of Clinical Internal, Anestesiological and Cardiovascular Sciences, Sapienza University of Rome, 00185 Roma, Italy; (F.B.); (D.P.); (S.B.); (V.C.); (N.C.); (A.C.); (C.N.); (D.F.); (F.V.); (M.D.B.)
| | - Cristina Nocella
- I Clinica Medica, Department of Clinical Internal, Anestesiological and Cardiovascular Sciences, Sapienza University of Rome, 00185 Roma, Italy; (F.B.); (D.P.); (S.B.); (V.C.); (N.C.); (A.C.); (C.N.); (D.F.); (F.V.); (M.D.B.)
| | - Roberto Carnevale
- Department of Medical-Surgical Sciences and Biotechnologies, Sapienza University of Rome, 04015 Latina, Italy;
- Mediterranea Cardio Centro, 80122 Napoli, Italy
| | - Domenico Ferro
- I Clinica Medica, Department of Clinical Internal, Anestesiological and Cardiovascular Sciences, Sapienza University of Rome, 00185 Roma, Italy; (F.B.); (D.P.); (S.B.); (V.C.); (N.C.); (A.C.); (C.N.); (D.F.); (F.V.); (M.D.B.)
| | - Francesco Angelico
- Department of Public Health and Infectious Diseases, Sapienza University of Rome, 00185 Roma, Italy
- Correspondence: ; Tel.: +39-064-997-2249
| | - Francesco Violi
- I Clinica Medica, Department of Clinical Internal, Anestesiological and Cardiovascular Sciences, Sapienza University of Rome, 00185 Roma, Italy; (F.B.); (D.P.); (S.B.); (V.C.); (N.C.); (A.C.); (C.N.); (D.F.); (F.V.); (M.D.B.)
- Mediterranea Cardio Centro, 80122 Napoli, Italy
| | - Maria Del Ben
- I Clinica Medica, Department of Clinical Internal, Anestesiological and Cardiovascular Sciences, Sapienza University of Rome, 00185 Roma, Italy; (F.B.); (D.P.); (S.B.); (V.C.); (N.C.); (A.C.); (C.N.); (D.F.); (F.V.); (M.D.B.)
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Hodson L, Gunn PJ. The regulation of hepatic fatty acid synthesis and partitioning: the effect of nutritional state. Nat Rev Endocrinol 2019; 15:689-700. [PMID: 31554932 DOI: 10.1038/s41574-019-0256-9] [Citation(s) in RCA: 133] [Impact Index Per Article: 26.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Nonalcoholic fatty liver disease (NAFLD) is an increasing global public health burden. NAFLD is strongly associated with type 2 diabetes mellitus, obesity and cardiovascular disease and begins with intrahepatic triacylglycerol accumulation. Under healthy conditions, the liver regulates lipid metabolism to meet systemic energy needs in the fed and fasted states. The processes of fatty acid uptake, fatty acid synthesis and the intracellular partitioning of fatty acids into storage, oxidation and secretion pathways are tightly regulated. When one or more of these processes becomes dysregulated, excess lipid accumulation can occur. Although genetic and environmental factors have been implicated in the development of NAFLD, it remains unclear why an imbalance in these pathways begins. The regulation of fatty acid partitioning occurs at several points, including during triacylglycerol synthesis, lipid droplet formation and lipolysis. These processes are influenced by enzyme function, intake of dietary fats and sugars and whole-body metabolism, and are further affected by the presence of obesity or insulin resistance. Insight into how the liver controls fatty acid metabolism in health and how these processes might be affected in disease would offer the potential for new therapeutic treatments for NAFLD to be developed.
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Affiliation(s)
- Leanne Hodson
- Oxford Centre for Diabetes, Endocrinology and Metabolism, Radcliffe Department of Medicine, University of Oxford, Headington, Oxford, UK.
- Oxford NIHR Biomedical Research Centre, Churchill Hospital, Headington, Oxford, UK.
| | - Pippa J Gunn
- Oxford Centre for Diabetes, Endocrinology and Metabolism, Radcliffe Department of Medicine, University of Oxford, Headington, Oxford, UK
- Oxford NIHR Biomedical Research Centre, Churchill Hospital, Headington, Oxford, UK
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Del Ben M, Overi D, Polimeni L, Carpino G, Labbadia G, Baratta F, Pastori D, Noce V, Gaudio E, Angelico F, Mancone C. Overexpression of the Vitronectin V10 Subunit in Patients with Nonalcoholic Steatohepatitis: Implications for Noninvasive Diagnosis of NASH. Int J Mol Sci 2018; 19:ijms19020603. [PMID: 29463024 PMCID: PMC5855825 DOI: 10.3390/ijms19020603] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2018] [Revised: 02/13/2018] [Accepted: 02/16/2018] [Indexed: 12/12/2022] Open
Abstract
Nonalcoholic steatohepatitis (NASH) is the critical stage of nonalcoholic fatty liver disease (NAFLD). The persistence of necroinflammatory lesions and fibrogenesis in NASH is the leading cause of liver cirrhosis and, ultimately, hepatocellular carcinoma. To date, the histological examination of liver biopsies, albeit invasive, remains the means to distinguish NASH from simple steatosis (NAFL). Therefore, a noninvasive diagnosis by serum biomarkers is eagerly needed. Here, by a proteomic approach, we analysed the soluble low-molecular-weight protein fragments flushed out from the liver tissue of NAFL and NASH patients. On the basis of the assumption that steatohepatitis leads to the remodelling of the liver extracellular matrix (ECM), NASH-specific fragments were in silico analysed for their involvement in the ECM molecular composition. The 10 kDa C-terminal fragment of the ECM protein vitronectin (VTN) was then selected as a promising circulating biomarker in discriminating NASH. The analysis of sera of patients provided these major findings: the circulating VTN fragment (i) is overexpressed in NASH patients and positively correlates with the NASH activity score (NAS); (ii) originates from the disulfide bond reduction between the V10 and the V65 subunits. In conclusion, V10 determination in the serum could represent a reliable tool for the noninvasive discrimination of NASH from simple steatosis.
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Affiliation(s)
- Maria Del Ben
- Department of Internal Medicine and Medical Specialties, Sapienza University of Rome, Viale del Policlinico 155, 00161 Rome, Italy.
| | - Diletta Overi
- Department of Anatomical, Histological, Forensic Medicine and Orthopedics Sciences, Sapienza University of Rome, Via Borelli 50, 00161 Rome, Italy.
| | - Licia Polimeni
- Department of Internal Medicine and Medical Specialties, Sapienza University of Rome, Viale del Policlinico 155, 00161 Rome, Italy.
| | - Guido Carpino
- Department of Movement, Human and Health Sciences, Division of Health Sciences, University of Rome "Foro Italico", Piazza Lauro De Bosis 6, 00135 Rome, Italy.
| | - Giancarlo Labbadia
- Department of Internal Medicine and Medical Specialties, Sapienza University of Rome, Viale del Policlinico 155, 00161 Rome, Italy.
| | - Francesco Baratta
- Department of Internal Medicine and Medical Specialties, Sapienza University of Rome, Viale del Policlinico 155, 00161 Rome, Italy.
- Department of Anatomical, Histological, Forensic Medicine and Orthopedics Sciences, Sapienza University of Rome, Via Borelli 50, 00161 Rome, Italy.
| | - Daniele Pastori
- Department of Internal Medicine and Medical Specialties, Sapienza University of Rome, Viale del Policlinico 155, 00161 Rome, Italy.
- Department of Anatomical, Histological, Forensic Medicine and Orthopedics Sciences, Sapienza University of Rome, Via Borelli 50, 00161 Rome, Italy.
| | - Valeria Noce
- Department of Cellular Biotechnologies and Haematology, Sapienza University of Rome, Viale del Policlinico 155, 00161 Rome, Italy.
| | - Eugenio Gaudio
- Department of Anatomical, Histological, Forensic Medicine and Orthopedics Sciences, Sapienza University of Rome, Via Borelli 50, 00161 Rome, Italy.
| | - Francesco Angelico
- Department of Public Health and Infectious Diseases, Sapienza University of Rome, Viale del Policlinico 155, 00161 Rome, Italy.
| | - Carmine Mancone
- Department of Cellular Biotechnologies and Haematology, Sapienza University of Rome, Viale del Policlinico 155, 00161 Rome, Italy.
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Spahis S, Delvin E, Borys JM, Levy E. Oxidative Stress as a Critical Factor in Nonalcoholic Fatty Liver Disease Pathogenesis. Antioxid Redox Signal 2017; 26:519-541. [PMID: 27452109 DOI: 10.1089/ars.2016.6776] [Citation(s) in RCA: 258] [Impact Index Per Article: 36.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
SIGNIFICANCE Nonalcoholic fatty liver disease (NAFLD), characterized by liver triacylglycerol build-up, has been growing in the global world in concert with the raised prevalence of cardiometabolic disorders, including obesity, diabetes, and hyperlipemia. Redox imbalance has been suggested to be highly relevant to NAFLD pathogenesis. Recent Advances: As a major health problem, NAFLD progresses to the more severe nonalcoholic steatohepatitis (NASH) condition and predisposes susceptible individuals to liver and cardiovascular disease. Although NAFLD represents the predominant cause of chronic liver disorders, the mechanisms of its development and progression remain incompletely understood, even if various scientific groups ascribed them to the occurrence of insulin resistance, dyslipidemia, inflammation, and apoptosis. Nevertheless, oxidative stress (OxS) more and more appears as the most important pathological event during NAFLD development and the hallmark between simple steatosis and NASH manifestation. CRITICAL ISSUES The purpose of this article is to summarize recent developments in the understanding of NAFLD, essentially focusing on OxS as a major pathogenetic mechanism. Various attempts to translate reactive oxygen species (ROS) scavenging by antioxidants into experimental and clinical studies have yielded mostly encouraging results. FUTURE DIRECTIONS Although augmented concentrations of ROS and faulty antioxidant defense have been associated to NAFLD and related complications, mechanisms of action and proofs of principle should be highlighted to support the causative role of OxS and to translate its concept into the clinic. Antioxid. Redox Signal. 26, 519-541.
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Affiliation(s)
- Schohraya Spahis
- 1 GI-Nutrition Unit, Research Centre, CHU Ste-Justine, Université de Montréal , Montreal, Quebec, Canada .,2 Department of Nutrition, Université de Montréal , Montreal, Quebec, Canada
| | - Edgard Delvin
- 1 GI-Nutrition Unit, Research Centre, CHU Ste-Justine, Université de Montréal , Montreal, Quebec, Canada .,3 Department of Biochemistry, Université de Montréal , Montreal, Quebec, Canada
| | | | - Emile Levy
- 1 GI-Nutrition Unit, Research Centre, CHU Ste-Justine, Université de Montréal , Montreal, Quebec, Canada .,2 Department of Nutrition, Université de Montréal , Montreal, Quebec, Canada .,4 EPODE International Network , Paris, France
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Kamfar S, Alavian SM, Houshmand M, Yadegarazari R, Seifi Zarei B, Khalaj A, Shabab N, Saidijam M. Liver Mitochondrial DNA Copy Number and Deletion Levels May Contribute to Nonalcoholic Fatty Liver Disease Susceptibility. HEPATITIS MONTHLY 2016; 16:e40774. [PMID: 28123441 PMCID: PMC5237470 DOI: 10.5812/hepatmon.40774] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/14/2016] [Revised: 09/23/2016] [Accepted: 11/05/2016] [Indexed: 12/11/2022]
Abstract
BACKGROUND There is growing evidence that deficiencies observed in the mitochondrial DNA (mtDNA) functions could play an important role in the pathogenesis of non-alcoholic fatty liver disease (NAFLD). We hypothesized that genetic variations in mtDNA could affect the mitochondrial function and contribute to the NAFLD susceptibility. OBJECTIVES In this study, the possible association of the mtDNA copy number and 4,977-bp deletion levels with NAFLD susceptibility in a sample of Iranian population was evaluated. METHODS This case-control study included 43 NAFLD patients and 20 control subjects. Genomic DNA was extracted from fresh liver tissue samples by using a DNA isolation kit. The mtDNA copy number and mtDNA deletion levels were measured by quantitative real-time PCR and multiplex PCR. RESULTS The relative expression of mtDNA copy number was 3.7 fold higher in NAFLD patients than healthy controls (P < 0.0001). The results remained significant after adjustment for age, BMI, and gender (P = 0.02). In addition, the mtDNA copy number was 4.3 (P < 0.0001) and 3.2-fold (P < 0.0001) higher in nonalcoholic fatty liver (NAFL) and non-alcoholic steatohepatitis (NASH) patients than healthy controls, respectively. Finally, the results showed that the 4,977-bp deletion is not detected in any of liver tissue samples obtained from the 20 control subjects whereas 8 out of 43 NAFLD patients (18.6%) showed the 4,977 -bp deletion in their liver tissues (P = 0.039). CONCLUSIONS This study indicated an association between mtDNA content in the liver tissue and NAFLD susceptibility that may be a consequence of compensatory response to the cumulative exposures to oxidative damage.
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Affiliation(s)
- Sharareh Kamfar
- Department of Molecular Medicine and Genetics, School of Medicine, Hamadan University of Medical Sciences, Hamadan, IR Iran
- Research Center for Molecular Medicine, Hamadan University of Medical Sciences, Hamadan, IR Iran
| | - Seyed Moayed Alavian
- Baqiyatallah Research Center for Gastroenterology and Liver Diseases (BRCGL), Baqiyatallah University of Medical Sciences, Tehran, IR Iran
- Middle East Liver Diseases (MELD) Center, Tehran, IR Iran
| | - Massoud Houshmand
- Department of Medical Genetics, National Institute for Genetic Engineering and Biotechnology, Tehran, IR Iran
| | - Reza Yadegarazari
- Shohada Hospital of Harsin, Kermanshah University of Medical Sciences, Kermanshah, IR Iran
| | - Bahram Seifi Zarei
- School of Medicine, Shahid Beheshti Hospital, Hamadan University of Medical Sciences, Hamadan, IR Iran
| | - Alireza Khalaj
- Obesity Treatment Center, Department of Surgery, Shahed University, Tehran, IR Iran
| | - Noshin Shabab
- Research Center for Molecular Medicine, Hamadan University of Medical Sciences, Hamadan, IR Iran
| | - Massoud Saidijam
- Department of Molecular Medicine and Genetics, School of Medicine, Hamadan University of Medical Sciences, Hamadan, IR Iran
- Research Center for Molecular Medicine, Hamadan University of Medical Sciences, Hamadan, IR Iran
- Corresponding Author: Massoud Saidijam, Research Center for Molecular Medicine, Hamadan University of Medical Sciences, Hamadan, IR Iran. Tel: +98-8138380462, Fax: +98-8138380464, E-mail:
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10
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Loffredo L, Del Ben M, Perri L, Carnevale R, Nocella C, Catasca E, Baratta F, Ceci F, Polimeni L, Gozzo P, Violi F, Angelico F. Effects of dark chocolate on NOX-2-generated oxidative stress in patients with non-alcoholic steatohepatitis. Aliment Pharmacol Ther 2016; 44:279-86. [PMID: 27265388 DOI: 10.1111/apt.13687] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2016] [Revised: 03/31/2016] [Accepted: 05/13/2016] [Indexed: 12/20/2022]
Abstract
BACKGROUND Activation of nicotinamide adenine dinucleotide phosphate (NADPH) oxidase is considered a pathogenetic mechanism determining fibrosis and disease progression in non-alcoholic steatohepatitis (NASH). Polyphenols exert antioxidant action and inhibit NADPH oxidase in humans. AIM To analyse the effect of cocoa polyphenols on NADPH oxidase isoform 2 (NOX2) activation, oxidative stress and hepatocyte apoptosis in a population affected by NASH. METHODS In a cross-sectional study comparing 19 NASH and 19 controls, oxidative stress, as assessed by serum NOX2 activity and F2-isoprostanes, and hepatocyte apoptosis, as assessed by serum cytokeratin-18 (CK-18) levels, were measured. Furthermore, the 19 NASH patients were randomly allocated in a crossover design to 40 g/day of dark chocolate (>85% cocoa) or 40 g/day of milk chocolate (<35% cocoa), for 2 weeks. sNOX2-dp, serum isoprostanes and CK-18 were assessed at baseline and after 2 weeks of chocolate intake. RESULTS Compared to controls, NASH patients had higher sNOX2-dp, serum isoprostanes and CK-18 levels. A significant difference for treatments was found in subjects with respect to sNOX2-dp, serum isoprostanes and serum CK-18. The pairwise comparisons showed that, compared to baseline, after 14 days of dark chocolate intake, a significant reduction in sNOX2-dp serum isoprostanes and CK-18 M30 was found. No change was observed after milk chocolate ingestion. A simple linear regression analysis showed that ∆ of sNOX2-dp was associated with ∆ of serum isoprostanes. CONCLUSION Cocoa polyphenols exert an antioxidant activity via NOX2 down-regulation in NASH patients.
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Affiliation(s)
- L Loffredo
- Department of Internal Medicine and Medical Specialties, I Clinica Medica, Sapienza University of Rome, Rome, Italy
| | - M Del Ben
- Department of Internal Medicine and Medical Specialties, I Clinica Medica, Sapienza University of Rome, Rome, Italy
| | - L Perri
- Department of Internal Medicine and Medical Specialties, I Clinica Medica, Sapienza University of Rome, Rome, Italy
| | - R Carnevale
- Department of Internal Medicine and Medical Specialties, I Clinica Medica, Sapienza University of Rome, Rome, Italy
| | - C Nocella
- Department of Internal Medicine and Medical Specialties, I Clinica Medica, Sapienza University of Rome, Rome, Italy
| | - E Catasca
- Department of Internal Medicine and Medical Specialties, I Clinica Medica, Sapienza University of Rome, Rome, Italy
| | - F Baratta
- Department of Internal Medicine and Medical Specialties, I Clinica Medica, Sapienza University of Rome, Rome, Italy
| | - F Ceci
- Department of Cellular Biotechnologies and Hematology, Sapienza University of Rome, Rome, Italy
| | - L Polimeni
- Department of Internal Medicine and Medical Specialties, I Clinica Medica, Sapienza University of Rome, Rome, Italy
| | - P Gozzo
- Department of Surgery "Pietro Valdoni", University of Rome "La Sapienza", Rome, Italy
| | - F Violi
- Department of Internal Medicine and Medical Specialties, I Clinica Medica, Sapienza University of Rome, Rome, Italy
| | - F Angelico
- Department of Public Health and Infectious Diseases, Sapienza University, Rome, Italy
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Ding G, Li Z, Zhang L, Ma H, Li H. Circulating full-length cytokeratin 18 for predicting prognosis of hepatitis B virus-related acute-on-chronic liver failure patients with lamivudine treatment. Hepatol Res 2016; 46:329-34. [PMID: 26138382 DOI: 10.1111/hepr.12549] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2015] [Revised: 06/27/2015] [Accepted: 06/30/2015] [Indexed: 02/08/2023]
Abstract
AIM The predictive value of circulating full-length cytokeratin 18 (M65) on prognosis of hepatitis B virus-related liver failure is still not well investigated. The aim of this study was to reveal the association between serum M65 levels and outcomes of hepatitis B virus-related acute-on-chronic liver failure, and to further clarify clinical significance of M65 in lamivudine treatment. METHODS Ninety-six patients with hepatitis B virus-related acute-on-chronic liver failure were recruited between January 2011 and December 2013, and 52 of them received lamivudine treatment. Blood were obtained from participants at admission, and M65 were determined by enzyme-linked immunosorbent assay. Other necessary data were collected from medical records. RESULTS The liver failure patients were divided into high and low level groups according to the serum M65 levels. After 24-week follow up, survival incidences were significantly higher in the low level group than that in the high level group (odds ratio [OR] = 0.3, 95% confidence interval = 0.1-0.7). In addition, the survival incidences and albumin levels improved in the patients with lamivudine treatment compared with the patients without lamivudine treatment in the low level group (OR = 5.4, 95% CI = 1.1-26.0 and OR = 4.2, 95% CI = 1.3-13.2). A similar improvement was not observed in the high level group. CONCLUSION The study suggested that the circulating M65 may serve as a relatively independent prognostic parameter for liver failure. If prospectively validated in further studies, M65 measurement may also be a useful method for optimizing antiviral therapy.
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Affiliation(s)
| | - Zhi Li
- Intensive Care Unit, Binzhou Medical University Hospital, Binzhou, Shandong Province, China
| | | | - Hui Ma
- Departments of Gerontology, Binzhou Medical University Hospital, Binzhou, Shandong Province, China
| | - Hui Li
- Department of Infectious Disease
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Pastori D, Pignatelli P, Carnevale R, Violi F. Nox-2 up-regulation and platelet activation: Novel insights. Prostaglandins Other Lipid Mediat 2015; 120:50-5. [DOI: 10.1016/j.prostaglandins.2015.03.010] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2015] [Revised: 03/24/2015] [Accepted: 03/27/2015] [Indexed: 12/26/2022]
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13
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Polimeni L, Del Ben M, Baratta F, Perri L, Albanese F, Pastori D, Violi F, Angelico F. Oxidative stress: New insights on the association of non-alcoholic fatty liver disease and atherosclerosis. World J Hepatol 2015; 7:1325-1336. [PMID: 26052378 PMCID: PMC4450196 DOI: 10.4254/wjh.v7.i10.1325] [Citation(s) in RCA: 138] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2014] [Revised: 12/01/2014] [Accepted: 03/18/2015] [Indexed: 02/06/2023] Open
Abstract
Non-alcoholic fatty liver disease (NAFLD) represents the most common and emerging chronic liver disease worldwide. It includes a wide spectrum of liver diseases ranging from simple fatty liver to non-alcoholic steatohepatitis (NASH), which may progress to fibrosis and more severe liver complications such as cirrhosis, hepatocellular carcinoma and liver mortality. NAFLD is strongly associated with obesity, insulin resistance, hypertension, and dyslipidaemia, and is now regarded as the liver manifestation of the metabolic syndrome. The increased mortality of patients with NAFLD is primarily a result of cardiovascular disease and, to a lesser extent, to liver related diseases. Increased oxidative stress has been reported in both patients with NAFLD and patient with cardiovascular risk factors. Thus, oxidative stress represents a shared pathophysiological disorder between the two conditions. Several therapeutic strategies targeting oxidative stress reduction in patients with NAFLD have been proposed, with conflicting results. In particular, vitamin E supplementation has been suggested for the treatment of non-diabetic, non-cirrhotic adults with active NASH, although this recommendation is based only on the results of a single randomized controlled trial. Other antioxidant treatments suggested are resveratrol, silybin, L-carnitine and pentoxiphylline. No trial so far, has evaluated the cardiovascular effects of antioxidant treatment in patients with NAFLD. New, large-scale studies including as end-point also the assessment of the atherosclerosis markers are needed.
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Ben MD, Polimeni L, Baratta F, Pastori D, Loffredo L, Angelico F. Modern approach to the clinical management of non-alcoholic fatty liver disease. World J Gastroenterol 2014; 20:8341-8350. [PMID: 25024593 PMCID: PMC4093688 DOI: 10.3748/wjg.v20.i26.8341] [Citation(s) in RCA: 55] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2013] [Revised: 01/15/2014] [Accepted: 03/10/2014] [Indexed: 02/06/2023] Open
Abstract
Non-alcoholic fatty liver disease (NAFLD) is the most common and emerging form of chronic liver disease worldwide. It includes a wide spectrum of liver diseases ranging from simple fatty liver to steatohepatitis, which may progress to cirrhosis, liver cancer, and liver mortality. Common metabolic diseases, which are well established cardiovascular risk factors, have been associated to NAFLD and cardiovascular disease is the single most important cause of morbidity and mortality in this patient population. The pathogenesis of NAFLD appears multifactorial and many mechanisms have been proposed as possible causes of fatty liver infiltration. Management of fatty liver has become a major challenge to healthcare systems as the consequence of the increasing rates of obesity worldwide. First-line management focuses on lifestyle modifications. Moderate weight reduction either by dietary restriction or by increased habitual physical activity is safe and highly recommended. Several therapeutic interventions have been proposed. These include insulin sensitizer agents, lipid lowering drugs, antioxidants such as vitamin E and supplementation of vitamin D3. However, therapeutic strategies have been largely empirical so far, and experimental trials have mostly been carried out in uncontrolled settings with small sample sizes. Metabolic conditions such as diabetes mellitus, obesity, hypertension and hyperlipidemia, should be strongly considered and a multidisciplinary approach should be personalized for individual patients. Treatment of co-morbidities should be regarded as of paramount importance in the management of these patients. The purpose of this review is to examine different approaches for the clinical management of non-alcoholic fatty liver disease.
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