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Osman HA, Tag-Adeen M, Abdelaal UM, Elgezawy E, Nasif KA, Nafady A. Different aspects of immunological profile in patients with Non-Alcoholic Fatty liver disease. Acta Gastroenterol Belg 2024; 87:274-281. [PMID: 39210759 DOI: 10.51821/87.2.12205] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/04/2024]
Abstract
Background NAFLD is thought to affect approximately one-fourth of the world's population. Therefore, we evaluated the role of serum complement and immunoglobulins in the NAFLD pathogenesis. Patients and methods 200 participants were used in this study, divided into two groups; Group I: 100 NAFLD patients and Group II: 100 healthy volunteers. The diagnosis of NAFLD is based on non-invasive methods, following the EASL guideline 2022. IgG, IgM, IgA, C3, and C4 assays were performed on all participants. Results When the immunological profiles of patients with NAFLD and healthy controls were compared, it was found that the mean IgA in NAFLD patients was (4.20±5.07), whereas the mean IgA in healthy controls was (2.22±1.05) (P=0.000). Additionally, a significant increase in IgG was found in NAFLD patients (17.08±3.87) compared with healthy controls (11.59±3.34), with a P value of (p<0.001). complement C3 and complement C4 levels significantly increased in nonalcoholic fatty liver disease patients (1.28± 0.61 and 0.40 ± 0.19, respectively), compared to healthy controls (0.90 ±0.27 and 0.30 ±0.12, respectively), with a significant P value (p<0.001 for each). Conclusions Elevated IgA, IgG, C3 and C4 exist in patients with NAFLD and could be associated with fatty liver development and progression of hepatic fibrosis in patients with NAFLD.
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Affiliation(s)
- H A Osman
- Department of Tropical Medicine and Gastroenterology, Qena Faculty of Medicine, South Valley University, Qena, Egypt
| | - M Tag-Adeen
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, Qena Faculty of Medicine, South Valley University, Qena, Egypt
| | - U M Abdelaal
- Department of Internal Medicine, Gastroenterology Unit, Sohag University, Egypt
| | - E Elgezawy
- Department of Clinical Pathology, Faculty of Medicine, Assiut University, Egypt
| | - K A Nasif
- Department of Clinical Biochemistry, College of Medicine, King Khalid University, Abha, KSA, Department of Biochemistry, Faculty of Medicine, Minia University, Egypt
| | - A Nafady
- Department of Clinical and Chemical Pathology, Qena Faculty of Medicine, South Valley University, Qena, Egypt
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Palmer M, Kleiner DE, Goodman Z, Brunt E, Avigan MI, Regev A, Hayashi PH, Lewis JH, Mehta R, Harrison SA, Siciliano M, McWherter CA, Vuppalanchi R, Behling C, Miller V, Chalasani N, Sanyal AJ. Liver biopsy for assessment of suspected drug-induced liver injury in metabolic dysfunction-associated steatohepatitis clinical trials: Expert consensus from the Liver Forum. Aliment Pharmacol Ther 2024; 59:201-216. [PMID: 37877759 DOI: 10.1111/apt.17762] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Revised: 05/25/2023] [Accepted: 10/03/2023] [Indexed: 10/26/2023]
Abstract
BACKGROUND Causality assessment of suspected drug-induced liver injury (DILI) during metabolic dysfunction-associated steatohepatitis (MASH) clinical trials can be challenging, and liver biopsies are not routinely performed as part of this evaluation. While the field is moving away from liver biopsy as a diagnostic and prognostic tool, information not identified by non-invasive testing may be provided on histology. AIM To address the appropriate utilisation of liver biopsy as part of DILI causality assessment in this setting. METHODS From 2020 to 2022, the Liver Forum convened a series of webinars on issues pertaining to liver biopsy during MASH trials. The Histology Working Group was formed to generate a series of consensus documents addressing these challenges. This manuscript focuses on liver biopsy as part of DILI causality assessment. RESULTS Expert opinion, guidance and recommendations on the role of liver biopsy as part of causality assessment of suspected DILI occurring during clinical trials for a drug(s) being developed for MASH are provided. Lessons learned from prior MASH programs are reviewed and gaps identified. CONCLUSIONS Although there are no pathognomonic features, histologic evaluation of suspected DILI during MASH clinical trials may alter patient management, define the pattern and severity of injury, detect findings that favour a diagnosis of DILI versus MASH progression, identify prognostic features, characterise the clinicopathological phenotype of DILI, and/or define lesions that influence decisions about trial discontinuation and further development of the drug.
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Affiliation(s)
| | - David E Kleiner
- Laboratory of Pathology, National Cancer Institute, Bethesda, Maryland, USA
| | - Zachary Goodman
- Center for Liver Diseases, Inova Fairfax Hospital, Falls Church, Virginia, USA
| | - Elizabeth Brunt
- Pathology and Immunology, Washington University School of Medicine, St Louis, Missouri, USA
| | - Mark I Avigan
- Center for Drug Evaluation and Research, Food and Drug Administration, Silver Spring, Maryland, USA
| | | | - Paul H Hayashi
- Division of Hepatology and Nutrition, Food and Drug Administration, Silver Spring, Maryland, USA
| | - James H Lewis
- Division of Gastroenterology, Georgetown University Hospital, Washington, District of Columbia, USA
| | - Ruby Mehta
- Center for Drug Evaluation and Research Office of New Drugs, Office of Inflammation and Immunity, Division of Hepatology and Nutrition, US Food and Drug Administration, Silver Spring, Maryland, USA
| | | | - Massimo Siciliano
- Fatebenefratelli Gemelli Isola - Rome, Sacred Heart Catholic Univesity, Rome, Italy
| | - Charles A McWherter
- Research and Development, CymaBay Therapeutics, Inc., Newark, California, USA
| | - Raj Vuppalanchi
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | | | - Veronica Miller
- University of California Berkeley, School of Public Health, Forum for Collaborative Research, Washington, District of Columbia, USA
| | - Naga Chalasani
- Indiana University School of Medicine, Indiana University Health, Indianapolis, Indiana, USA
| | - Arun J Sanyal
- Stravitz-Sanyal Institute for Liver Disease and Metabolic Health, Virginia Commonwealth University School of Medicine, Richmond, Virginia, USA
- Department of Internal Medicine, Virginia Commonwealth University School of Medicine, Richmond, Virginia, USA
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Zhu L, Ma J, Jin D, Zhang Y, Wu S, Xu A, Gu Y, An Y, Miao Y. Flower-like WSe 2 used as bio-matrix in ultrasensitive label-free electrochemical immunosensor for human immunoglobulin G determination. ANAL SCI 2023:10.1007/s44211-023-00351-3. [PMID: 37227625 DOI: 10.1007/s44211-023-00351-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2023] [Accepted: 04/16/2023] [Indexed: 05/26/2023]
Abstract
The abnormal concentrations of human immunoglobulin G (hIgG) refers to many kinds of diseases. Analytical methods with the characteristics of rapid response, easy operation and high sensitivity should be designed to accurately determinate the hIgG levels in human serum. In this work, a label-free electrochemical immunosensor based on WSe2/rGO was developed to sensitively detect human immunoglobulin G. First, the flower-like transition metal dichalcogenides (TMDCs) Tungsten Diselenide (WSe2) with large effective specific surface area and porous structure was synthesized by hydrothermal synthesis. As a bio-matrix, the flower-like WSe2 efficiently increased the active sites for loading antibodies. Meanwhile, reduced graphene oxide (rGO) obtained by tannic acid reduction was used to improve the current response of the sensing interface. WSe2 was combined with rGO and the electrochemical active surface area (ECSA) of the sensing interface was enlarged to 2.1 times that of GCE. Finally, the combination of flower-like WSe2 and rGO broadened the detection range and reduced the detection limit of the sensing platform. The immunosensor exhibited a high sensitivity with a wide linear range of 0.01-1000 ng/mL and low detection limit of 4.72 pg/mL. The real sample analysis of hIgG were conducted under optimal conditions, and the spiked recovery rates were between 95.5 and 104.1%. Moreover, satisfactory results were obtained by testing the stability, specificity and reproducibility of the immunosensor. Therefore, it can be concluded that the as-proposed immunosensor has the application potential of clinical analyze of hIgG in human serum.
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Affiliation(s)
- Leijing Zhu
- Institute of Bismuth and Rhenium, School of Materials and Chemistry, University of Shanghai for Science and Technology, Shanghai, 200093, China
| | - Jing Ma
- Department of Pharmacy, Xinhua Hospital, School of Medicine, Shanghai Jiaotong University, 1665 Kongjiang Road, Shanghai, 200092, China
| | - Danli Jin
- Institute of Bismuth and Rhenium, School of Materials and Chemistry, University of Shanghai for Science and Technology, Shanghai, 200093, China
| | - Yongjian Zhang
- Institute of Bismuth and Rhenium, School of Materials and Chemistry, University of Shanghai for Science and Technology, Shanghai, 200093, China
| | - Siyu Wu
- Institute of Bismuth and Rhenium, School of Materials and Chemistry, University of Shanghai for Science and Technology, Shanghai, 200093, China
| | - Ajing Xu
- Department of Pharmacy, Xinhua Hospital, School of Medicine, Shanghai Jiaotong University, 1665 Kongjiang Road, Shanghai, 200092, China
| | - Yingying Gu
- Institute of Bismuth and Rhenium, School of Materials and Chemistry, University of Shanghai for Science and Technology, Shanghai, 200093, China
| | - Yarui An
- Institute of Bismuth and Rhenium, School of Materials and Chemistry, University of Shanghai for Science and Technology, Shanghai, 200093, China.
| | - Yuqing Miao
- Institute of Bismuth and Rhenium, School of Materials and Chemistry, University of Shanghai for Science and Technology, Shanghai, 200093, China
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Zhang X, Jain D. The many faces and pathologic diagnostic challenges of autoimmune hepatitis. Hum Pathol 2023; 132:114-125. [PMID: 35753409 DOI: 10.1016/j.humpath.2022.06.019] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2022] [Revised: 06/16/2022] [Accepted: 06/17/2022] [Indexed: 02/07/2023]
Abstract
Autoimmune hepatitis (AIH) is an immune-mediated chronic inflammatory liver disease, characterized by hypergammaglobulinemia, the presence of specific autoantibodies, and typical abnormalities in liver histology. Prompt diagnosis and initiation of immunosuppressive treatment are necessary for both chronic and acute onset AIH to prevent progression to end-stage liver disease or fatal liver failure. However, the diagnosis of AIH is challenging mainly because of its heterogeneous clinical, serological and pathological features. Although portal lymphoplasmacytosis and interface hepatitis are the most typical histological features of AIH, many other histological features can be observed in AIH, including emperipolesis, hepatocyte rosettes, and Kupffer cell hyaline globules. Recent studies have questioned emperipolesis and hepatocyte rosette formation as typical features of AIH, and atypical clinical and histological presentations have also been recognized. This led an international working group to propose the modified AIH diagnostic criteria. However, it is well recognized that there are no pathognomonic characteristics that can be used to diagnose AIH and careful clinicopathological correlation is required to arrive at the correct diagnosis. The aim of this review is to summarize the histological features of AIH, its varied histopathologic spectrum, recent updates and major differential diagnoses in routine clinical practice.
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Affiliation(s)
- Xuchen Zhang
- Department of Pathology, Yale School of Medicine, New Haven, CT, 06520, United States.
| | - Dhanpat Jain
- Department of Pathology, Yale School of Medicine, New Haven, CT, 06520, United States.
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Kwan SY, Slayden AN, Coronado AR, Marquez RC, Chen H, Wei P, Savage MI, Vornik LA, Fox JT, Sei S, Liang D, Stevenson HL, Wilkerson GK, Gagea M, Brown PH, Beretta L. Treatment Strategies and Mechanisms Associated with the Prevention of NASH-Associated HCC by a Toll-like Receptor 4 Inhibitor. Cancer Prev Res (Phila) 2023; 16:17-28. [PMID: 36162136 PMCID: PMC9812917 DOI: 10.1158/1940-6207.capr-22-0332] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2022] [Revised: 09/08/2022] [Accepted: 09/22/2022] [Indexed: 01/12/2023]
Abstract
We evaluated the cancer preventive efficacy of TAK-242, an inhibitor of Toll-like receptor 4 (TLR4), in a mouse model of hepatocellular carcinoma (HCC) occurring in the context of nonalcoholic steatohepatitis (NASH). We also assessed the cellular events associated with the preventive treatment efficacy. We tested oral administration of TAK-242, at clinically relevant but toxicity-reducing doses and scheduling, in mice with hepatocyte-specific deletion of Pten (HepPten-). The optimal dose and oral gavage formulation of TAK-242 were determined to be 30 mg/kg in 5% DMSO in 30% 2-hydroxypropyl-β-cyclodextrin. Daily oral administration of 30 mg/kg TAK-242 over 18 weeks was well tolerated and resulted in reduced development of tumors (lesions > 7.5 mm3) in HepPten- mice. This effect was accompanied by reduced macrovesicular steatosis and serum levels of alanine aminotransferase. In addition, 30 mg/kg TAK-242 daily treatment of small preexisting adenomas (lesions < 7.5 mm3) over 18 weeks, significantly reduced their progression to HCC. RNA sequencing identified 220 hepatic genes significantly altered upon TAK-242 treatment, that significantly correlated with tumor burden. Finally, cell deconvolution analysis revealed that TAK-242 treatment resulted in reduced hepatic populations of endothelial cells and myeloid-derived immune cells (Kupffer cells, Siglec-H high dendritic cells, and neutrophilic granule protein high neutrophils), while the proportion of mt-Nd4 high hepatocytes significantly increased, suggesting a decrease in hepatic inflammation and concomitant increase in mitochondrial function and oxidative phosphorylation upon TLR4 inhibition. In conclusion, this study identified treatment strategies and novel molecular and cellular mechanisms associated with the prevention of HCC in the context of NASH that merit further investigations. PREVENTION RELEVANCE Means to prevent development of HCC or progression of small adenomas to HCC in patients with NASH are urgently needed to reduce the growing mortality due to HCC. We characterized the chemopreventive effect of oral administration of the TLR4 inhibitor TAK-242 in a model of NASH-associated HCC.
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Affiliation(s)
- Suet-Ying Kwan
- Department of Molecular and Cellular Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Alyssa N. Slayden
- Department of Molecular and Cellular Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Aubrey R. Coronado
- Department of Molecular and Cellular Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Rosamaria C. Marquez
- Department of Molecular and Cellular Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Huiqin Chen
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Peng Wei
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Michelle I. Savage
- Department of Clinical Cancer Prevention, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Lana A. Vornik
- Department of Clinical Cancer Prevention, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Jennifer T. Fox
- Chemopreventive Agent Development Research Group, Division of Cancer Prevention, National Cancer Institute, Rockville, Maryland, USA
| | - Shizuko Sei
- Chemopreventive Agent Development Research Group, Division of Cancer Prevention, National Cancer Institute, Rockville, Maryland, USA
| | - Dong Liang
- Department of Pharmaceutical Sciences, College of Pharmacy and Health Sciences, Texas Southern University, Houston, Texas, USA
| | - Heather L. Stevenson
- Department of Pathology, The University of Texas Medical Branch, Galveston, Texas, USA
| | - Gregory K. Wilkerson
- Keeling Center for Comparative Medicine and Research, University of Texas, MD Anderson Cancer Center, Bastrop, Texas, USA
| | - Mihai Gagea
- Department of Veterinary Medicine & Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Powel H. Brown
- Department of Clinical Cancer Prevention, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Laura Beretta
- Department of Molecular and Cellular Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
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Wang M, Singal AG, Parikh N, Kono Y, Marrero J, Mehta A. A Biomarker Panel Based upon AFP, Fucosylated Kininogen and PEG-Precipitated IgG Is Highly Accurate for the Early Detection Hepatocellular Carcinoma in Patients with Cirrhosis in Phase II and Phase III Biomarker Evaluation. Cancers (Basel) 2022; 14:5970. [PMID: 36497452 PMCID: PMC9740205 DOI: 10.3390/cancers14235970] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Revised: 11/07/2022] [Accepted: 11/23/2022] [Indexed: 12/12/2022] Open
Abstract
We have previously identified alterations in glycosylation on serum proteins from patients with HCC and developed plate-based assays using lectins to detect the change in glycosylation. However, heterophilic antibodies, which increase with non-malignant liver disease, compromised these assays. To address this, we developed a method of polyethylene glycol (PEG) precipitation that removed the contaminating IgG and IgM but allowed for the lectin detection of the relevant glycoprotein. We found that this PEG-precipitated material itself could differentiate between cirrhosis and HCC. In the analysis of three training cohorts and one validation cohort, consisting of 571 patients, PEG-IgG had AUC values that ranged from 0.713 to 0.810. In the validation cohort, which contained samples from patients at a time of 1-6 months prior to HCC detection or 7+ months prior to detection, the AUC of this marker remained consistent (0.813 and 0.846, respectively). When this marker was incorporated into a biomarker algorithm that also consisted of AFP and fucosylated kininogen, the AUROC increased to 0.816-0.883 in the training cohort and was 0.909 in the external validation cohort. Biomarker performance was also examined though the analysis of partial ROC curves, at false positive values less than 10% (90-ROC), ≤20% (80-ROC) or ≤30% (70-ROC), which highlighted the algorithm's improvement over the individual markers at clinically relevant specificity values.
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Affiliation(s)
- Mengjun Wang
- Basic Science Building Room 310, Department of Cell and Molecular Pharmacology, Medical University of South Carolina, 173 Ashley Avenue, Charleston, SC 29425, USA
| | - Amit G. Singal
- Division of Digestive and Liver Diseases, University of Texas Southwestern, 5959 Harry Hines Blvd POB I Suite 420B, Dallas, TX 75201, USA
| | - Neehar Parikh
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI 48109, USA
| | - Yuko Kono
- Division of Gastroenterology, University of California at San Diego, 9500 Gilman Drive, La Jolla, CA 92093, USA
| | - Jorge Marrero
- Division of Gastroenterology, University of Pennsylvania, 3400 Civic Center Boulevard South Pavilion, 4th Floor, Philadelphia, PA 19104, USA
| | - Anand Mehta
- Basic Science Building Room 310, Department of Cell and Molecular Pharmacology, Medical University of South Carolina, 173 Ashley Avenue, Charleston, SC 29425, USA
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Pezzino S, Sofia M, Faletra G, Mazzone C, Litrico G, La Greca G, Latteri S. Gut-Liver Axis and Non-Alcoholic Fatty Liver Disease: A Vicious Circle of Dysfunctions Orchestrated by the Gut Microbiome. BIOLOGY 2022; 11:1622. [PMID: 36358323 PMCID: PMC9687983 DOI: 10.3390/biology11111622] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/15/2022] [Revised: 11/03/2022] [Accepted: 11/04/2022] [Indexed: 09/24/2023]
Abstract
Non-alcoholic fatty liver disease (NAFLD) is a prevalent, multifactorial, and poorly understood liver disease with an increasing incidence worldwide. NAFLD is typically asymptomatic and coupled with other symptoms of metabolic syndrome. The prevalence of NAFLD is rising in tandem with the prevalence of obesity. In the Western hemisphere, NAFLD is one of the most prevalent causes of liver disease and liver transplantation. Recent research suggests that gut microbiome dysbiosis may play a significant role in the pathogenesis of NAFLD by dysregulating the gut-liver axis. The so-called "gut-liver axis" refers to the communication and feedback loop between the digestive system and the liver. Several pathological mechanisms characterized the alteration of the gut-liver axis, such as the impairment of the gut barrier and the increase of the intestinal permeability which result in endotoxemia and inflammation, and changes in bile acid profiles and metabolite levels produced by the gut microbiome. This review will explore the role of gut-liver axis disruption, mediated by gut microbiome dysbiosis, on NAFLD development.
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Affiliation(s)
| | | | | | | | | | | | - Saverio Latteri
- Department of Surgical Sciences and Advanced Technologies “G. F. Ingrassia”, Cannizzaro Hospital, University of Catania, 95126 Catania, Italy
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Prevalence and Significance of Antinuclear Antibodies in Biopsy-Proven Nonalcoholic Fatty Liver Disease: A Systematic Review and Meta-Analysis. DISEASE MARKERS 2022; 2022:8446170. [PMID: 35990246 PMCID: PMC9391168 DOI: 10.1155/2022/8446170] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Revised: 06/06/2022] [Accepted: 06/30/2022] [Indexed: 12/27/2022]
Abstract
Aim Associations between antinuclear antibodies (ANAs) and disease severity in nonalcoholic fatty liver disease (NAFLD) remain unclear. This study aimed to provide reliable estimates of ANA prevalence in subjects with biopsy-proven NAFLD and to investigate whether its associations with liver disease severity were established. Methods Observational studies measuring ANA in NAFLD patients were derived from the PubMed, Embase, and Web of Science databases from inception to March 30, 2022. The effect size was presented as the pooled risk difference, unstandardized mean differences (MDs), and odds ratio (OR) with a 95% confidence interval (CI). Results Thirteen articles involving 2331 patients were finally included. Among the subjects with biopsy-proven NAFLD, the overall prevalence of ANA positivity was high as 23% (95% CI: 19%-28%), but there were no statistically significant differences between ANA-positive and ANA-negative NAFLD patients in the levels of liver enzymes and blood lipids, grades of hepatocellular ballooning, lobular and portal inflammation, or risks of moderate-severe steatosis and significant fibrosis. However, the subgroup analysis showed that different geographic regions led to diverse results. ANA positivity was associated with a significantly elevated risk of significant fibrosis in the Eastern population (OR = 2.30, 95% CI: 1.30-4.06) but not in the Western population (OR = 1.00, 95% CI: 0.54-1.83). Conclusions Serum ANA was present in approximately one-quarter of subjects with biopsy-proven NAFLD, but it conferred a greater risk of significant fibrosis only in Eastern but not Western populations.
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