Nonalcoholic fatty liver disease: Noninvasive methods of diagnosing hepatic steatosis

Low-calorie diets are effective for weight loss in patients undergoing benign upper gastrointestinal surgery: a systematic review and meta-analysis

BACKGROUND

Obesity may increase surgical complexity in patients undergoing abdominal surgery by limiting visualization and increasing the risk of peri-operative complications. A preoperative reduction in weight and liver volume may improve surgical outcomes. The aim of our study was to evaluate the efficacy of a low-calorie diet (LCD) versus a very low-calorie diet (VLCD) in reducing weight and liver volume prior to laparoscopic surgery.

METHODS

A systematic search was conducted using the following inclusion criteria: obese patients undergoing preoperative weight loss using a VLCD or LCD, evaluation of liver volume reduction, and the use of an imaging modality before and after the diet.

RESULTS

A total of 814 patients from 21 different studies were included in this systematic review and meta-analysis, with 544 female patients (66.8%) and a mean age range between 24 and 54 years old. There was a total mean weight loss of 6.42% and mean liver volume reduction of 16.7%. Meta-analysis demonstrated that a preoperative diet (LCD or VLCD) significantly reduced weight [SMD = - 0.68; 95% CI (- 0.93, - 0.42), I2 = 82%, p ≤ 0.01] and liver volume [SMD = - 2.03; 95% CI (- 4.00, - 0.06), I2 = 94%, p ≤ 0.01]. When assessed individually, a VLCD led to significant weight reduction [SMD = - 0.79; CI (- 1.24; - 0.34), p ≤ 0.01, I2 = 90%], as did an LCD [SMD = - 0.60; CI (- 0.90; - 0.29), p ≤ 0.01, I2 = 68%). Similarly, there was a significant reduction in liver volume following a VLCD [SMD = - 1.40; CI (- 2.77, - 0.03), p ≤ 0.01, I2 = 96%], and an LCD [SMD = - 2.66; CI (- 6.13, 0.81), p ≤ 0.01, I2 = 93%]. However, there was no significant difference between the two regimens.

CONCLUSIONS

Preoperative restrictive calorie diets are effective in reducing weight and liver volume prior to laparoscopic surgery. Whilst a VLCD was better than an LCD at reducing both weight and liver volume, the difference was not significant.

Point-of-care device for the noninvasive assessment of hepatic macrosteatosis in liver donors

BACKGROUND

Quantification of macrosteatosis (MS) in the liver is important given that it has shown to directly correlate with adverse post-liver transplant (LT) outcomes. With advances in medical technology and an implicit understanding of pathology, noninvasive methods of quantitatively assessing MS are in various stages of development. Each of these methods is based on the physical principles of differences between a fat-laden hepatocyte and a normal one.

METHODS

In this regard, after a proof-of-concept study on a prototype for a simple, real-time, handheld device using the principle of diffuse reflectance spectroscopy, this study presents an upgraded point-of-care (POC) device for the noninvasive assessment of hepatic MS in liver donors.

RESULTS

The device was validated on cohort of donor livers and showed a sensitivity (0.0021 V/% fat) and highly correlated (r = 0.9868, P < .0001) with gold-standard liver biopsy. Results showed that this upgraded POC device provides a reliable method for the noninvasive assessment of hepatic MS, which is crucial for selecting suitable donor livers for LT.

CONCLUSION

The device has the potential to be an invaluable apparatus at the hands of the organ-retrieving surgeon. It is noninvasive, portable (handheld), and economic; provides real-time readings of the percentage of MS; and can be efficaciously handled by any member of the organ-retrieving team.

Exploration of Perturbed Liver Fibrosis-Related Factors and Collagen Type I in Animal Model of Non-Alcoholic Fatty Liver Disease

To determine their involvement in the onset of the disease, we investigated the changing levels of liver fibrosis-related proteins, namely, type-I collagen, α-smooth muscle actin (α-SMA), and transforming growth factor β1 and β3 (TGF-β1, β3). The four groups of Sprague-Dawley (SD) rats were involved in the study, namely, (i) normal control group, (ii) high-fat diet group (HFD), (iii) carbon tetrachloride (CCl4) group, and (iv) NAFLD group (animal model) which were chosen at random. The NAFLD model received HFD combined with subcutaneous injection of small doses of CCl4. Histopathological examination confirmed extent of liver fibrosis, while other immunological and molecular methods were used to evaluate expression and distribution of α-SMA, type I collagen TGF-β1 and TGF-β3, at both m-RNA and protein levels. In contrast to the normal control group, the NAFLD group showed moderately elevated expressions of TGF-β1, α-SMA, and type I collagen, which was proportional on temporal scale of NAFLD persistence in the model (P < 0.05). In the early phage of NAFLD, enhancement in the mRNA transcripts and, henceforth, protein expression of TGF-β3 was observed. However, these were found to be downregulated in case of liver fibrosis (P < 0.05). This NAFLD rat model shows the histopathologic changes of human NAFLD and is suitable for the study of NAFLD pathogenesis. These findings suggest that type I collagen and the liver fibrosis-related factors TGF- β1, TGF- β3, and α-SMA may be significant contributors to NAFLD. Although NAFLD model is previously demonstrated by other researchers, our study is novel in terms of exploration of involvement of fibrosis-related factors and in particular aforementioned proteins at the early stage of NAFLD vis-à-vis dynamics of type-I collagen distribution.

Anthocyanins: Potential phytochemical candidates for the amelioration of non-alcoholic fatty liver disease

Nonalcoholic fatty liver disease (NAFLD) is described by too much hepatic fat deposition causing steatosis, which further develops into nonalcoholic steatohepatitis (NASH), defined by necroinflammation and fibrosis, progressing further to hepatic cirrhosis, hepatocellular carcinoma, and liver failure. NAFLD is linked to different aspects of the metabolic syndrome like obesity, insulin resistance, hypertension, and dyslipidemia, and its pathogenesis involves several elements including diet, obesity, disruption of lipid homeostasis, and a high buildup of triglycerides and other lipids in liver cells. It is therefore linked to an increase in the susceptibility to developing diabetes mellitus and cardiovascular diseases. Several interventions exist regarding its management, but the availability of natural sources through diet will be a benefit in dealing with the disorder due to the immensely growing dependence of the population worldwide on natural sources owing to their ability to treat the root cause of the disease. Anthocyanins (ACNs) are naturally occurring polyphenolic pigments that exist in the form of glycosides, which are the glucosides of anthocyanidins and are produced from flavonoids via the phenyl propanoid pathway. To understand their mode of action in NAFLD and their therapeutic potential, the literature on in vitro, in vivo, and clinical trials on naturally occurring ACN-rich sources was exhaustively reviewed. It was concluded that ACNs show their potential in the treatment of NAFLD through their antioxidant properties and their efficacy to control lipid metabolism, glucose homeostasis, transcription factors, and inflammation. This led to the conclusion that ACNs possess efficacy in the amelioration of NAFLD and the various features associated with it. However, additional clinical trials are required to justify the potential of ACNs in NAFLD.

Association of Diabetic Retinopathy with Midlife Hepatic Steatosis Diagnosed by Elastography and Hepatic Steatosis Index in Type 2 Diabetes in an Indian Population

Aims: People with type 2 diabetes mellitus are at increased risk of developing hepatic steatosis. We determined the prevalence of hepatic steatosis in middle-aged patients with and without diabetic retinopathy (DR) in an Indian population. We feel this information is critical, with trends of increasing chronic liver disease-related mortality at younger ages. Method: Institution-based analytical cross-sectional study with 114 middle-aged type 2 diabetes patients; 57 in each group with <15 years of duration of DM and without excessive drinking. Hepatic steatosis was determined by the hepatic steatosis index (HSI), hepatic ultrasonography (USG), and elastography. Result: The HSI in DR (37.9 ± 3.9) was more (P = 0.012) than in without diabetic retinopathy (NODR) (36.3 ± 3.3). There was no difference between two groups in liver span (P = 0.829) or in the prevalence of fatty liver (P = 0.562) as determined by conventional USG. Elastography value (kPa) was more (P = 0.001) in DR (6.51 ± 1.85) than in NODR (5.14 ± 1.60). On elastography, 50.9% in DR had a likelihood ratio (Metavir score for a stiffness value) for stage 2 Metavir score. In DR, 11.8% of those missed by USG had a likelihood ratio for ≥ stage 2 Metavir score on elastography. The presence of DR was independently correlated with kPa value (P < 0.001). Conclusion: A significantly higher prevalence of hepatic steatosis was observed in DR in this population. DR can be a useful biomarker for early hepatic screening in midlife, particularly with hepatic elastography, so that timely diagnosis of hepatic steatosis can be made.

Influence of nonalcoholic fatty liver disease on inflammatory bowel disease hospitalizations in the United States

Background

The reported prevalence of nonalcoholic fatty liver disease (NAFLD) in patients with inflammatory bowel disease (IBD) is 32%. We assessed the influence of NAFLD on IBD hospitalizations in the United States (US).

Methods

We utilized the National Inpatient Sample database, from 2016-2019, to identify the total IBD hospitalizations in the US and we further subdivided them according to the presence or absence of NAFLD. Hospitalization characteristics, comorbidities and outcomes were compared. Statistical significance was set at P<0.05.

Results

There were 1,272,260 IBD hospitalizations in the US, of which 5.04% involved NAFLD. For IBD hospitalizations with NAFLD, the mean age was 50-64 years, and the proportion of males was 46.97%. IBD hospitalizations with NAFLD had a lower proportion of African Americans (8.7% vs. 11.38%, P<0.001). Comorbidities such as hypertension (50.34% vs. 44.04%, P<0.001) and obesity (18.77% vs. 11.81%, P<0.001) were significantly higher in the NAFLD cohort. Overall, based on the Charlson Comorbidity Index, patients with NAFLD had a higher number of comorbidities (52.77% vs. 20.66%, P<0.001). Mortality was higher in the NAFLD compared to the non-NAFLD cohort (3.14% vs. 1.44%, P<0.001). Patients with NAFLD also incurred significantly higher hospital charges ($69,536 vs. $55,467, p<0.001) and had a longer mean length of stay (6.10 vs. 5.27 days, P<0.001) compared to the cohort without NAFLD. Complications and inpatient procedure requirements were also higher in the NAFLD cohort.

Conclusion

Our study revealed greater mortality, morbidity, and healthcare resource utilization in patients with IBD who were hospitalized with a concomitant diagnosis of NAFLD.

Blueberry Consumption and Changes in Obesity and Diabetes Mellitus Outcomes: A Systematic Review

Low-grade inflammation and oxidative stress are key mechanisms involved in obesity and related disorders. Polyphenols from blueberry (BB) and bilberries (BiB) might protect against oxidative damage and inflammation. To summarize the effects of BiB or BB consumption in parameters related to obesity and its comorbidities, a search of the literature was performed in PubMed, Embase, and Cochrane Library repositories to identify all studies that evaluated associations of whole BB or BiB with obesity and associated disorders. Thirty-one studies were eligible for inclusion in this review: eight clinical trials and 23 animal studies. In humans, BB consumption only consistently decreased oxidative stress and improved endothelial function. In rodents, BB or BiB consumption caused positive effects on glucose tolerance, nuclear factor-kappa B (Nf-κb) activity, oxidative stress, and triglyceride (TG) content in the liver and hepatic steatosis. The high content of anthocyanins present in BB and BiB seems to attenuate oxidative stress. The decrease in oxidative stress may have a positive impact on glucose tolerance and endothelial function. Moreover, in rodents, these berries seem to protect against hepatic steatosis, through the decreased accumulation of hepatic TGs. BB and BiB might also attenuate inflammation by decreasing Nf-κb activity and immune cell recruitment into the adipose tissue.

MUFA in metabolic syndrome and associated risk factors: is MUFA the opposite side of the PUFA coin?

Omega-9 fatty acids represent some of the main mono-unsaturated fatty acids (MUFA) found in plant and animal sources. They can be synthesized endogenously in the human body, but they do not fully provide all the body's requirements. Consequently, they are considered as partially essential fatty acids. MUFA represent a healthier alternative to saturated animal fats and have several health benefits, including the prevention of metabolic syndrome (MetS) and its complications. This review concentrates on the major MUFA pharmacological activities in the context of MetS management, including alleviating cardiovascular disease (CVD) and dyslipidemia, central obesity, non-alcoholic fatty liver disease (NAFLD), and type 2 diabetes mellitus (T2DM). The beneficial effects of MUFA for CVD were found to be consistent with those of polyunsaturated fatty acids (PUFA) for the alleviation of systolic and diastolic blood pressure and high low density lipoprotein cholesterol (LDLc) and triacylglcerol (TAG) levels, albeit MUFA had a more favorable effect on decreasing night systolic blood pressure (SBP). To reduce the obesity profile, the use of MUFA was found to induce a higher oxidation rate with a higher energy expenditure, compared with PUFA. For NAFLD, PUFA was found to be a better potential drug candidate for the improvement of liver steatosis in children than MUFA. Any advantageous outcomes from using MUFA for diabetes and insulin resistance (IR) compared to using PUFA were found to be either non-significant or resulted from a small number of meta-analyses. Such an increase in the number of studies of the mechanisms of action require more clinical and epidemiological studies to confirm the beneficial outcomes, especially over a long-term treatment period.

Nonalcoholic fatty liver disease in lean and obese patients in Saudi patients from a single center

Background:

Fatty liver is a disease caused by the accumulation of fat in the liver. It is one of the major risk factors for developing cirrhosis and hepatocellular carcinoma. Saudi Arabia is one of the most prevalent countries in diabetes and obesity; the overall prevalence of diabetes is 23.7% and obesity is 35.6%.

Aim:

To study the correlation between fatty liver finding on abdominal ultrasound (US) and their clinical and biochemical profile including BMI, blood glucose level, lipid profile, liver function tests, and blood pressure in both group lean and obese patients.

Methods:

Cross-sectional study of 346 fatty liver ultrasound-proven patients were enrolled in the study from January to May 2016 in King Saud Hospital- Qassim, Saudi Arabia.

Results:

Mean age of the participants was 50.3 years. Female participants were 55% of the cohort. Participants were divided based on their BMI: BMI <25 (lean), BMI of 25–30 (overweight and mild obesity), and BMI >30 (morbid obesity). We found that cholesterol (P = 0.007) and low-density lipoprotein (LDL) (P = 0.015) were higher in lean compared to others (5 and 3.1), respectively. Gamma-glutamyl transferase (GGT) was higher in mildly obese patients (113.2) and ALT, which was higher in lean patients (60.4). In addition, 34.5% of the overall patients had Diabetes Mellitus (DM). We found that HbA1c was lower in lean (7.3) compared to morbidly obese patients (7.6). Platelets counts were higher in morbidly obese patients (278) compared to other groups.

Conclusion:

High cholesterol and LDL strongly correlated with lean fatty liver patients. There was a significant relationship between the female gender and the risk of development of fatty liver. However, liver enzymes were within the normal range, except GGT, which was higher in all the groups, with the highest value in mildly obese patients. Therefore, they are not sensitive for diagnosing fatty liver patients.

Association of hepatic steatosis derived from ultrasound and quantitative MRI with prediabetes in the general population

The aim of our study was to investigate the association of hepatic steatosis derived from quantitative ultrasound and magnetic resonance imaging (MRI) with prediabetes in a large population-based study conducted in Northeast Germany. Hepatic steatosis was assessed through transabdominal ultrasound and quantitative MRI. For analysis we included 1622 subjects with MRI who participated in an oral glucose tolerance test and reported no known type 2 diabetes mellitus (T2DM). We classified participants as proposed by the American Diabetes Association: isolated impaired fasting glucose (i-IFG), isolated impaired glucose tolerance (i-IGT), combined IFG and IGT (IFG + IGT), and undiagnosed T2DM. Regression models were adjusted for age, sex body mass index and alcohol consumption. We observed positive associations of hepatic steatosis with glycated hemoglobin, fasting glucose and insulin, 2-h glucose and insulin, as well as homeostasis model assessment-insulin resistance index. Similarly, individuals having hepatic steatosis as defined by MRI had a higher relative risk ratio (RR) to be in the prediabetes groups i-IFG (RR = 1.6; 95% confidence interval (CI) 1.2; 2.2), i-IGT (RR = 3.3, 95% CI 2.0; 5.6) and IFG + IGT (RR = 2.5, 95% CI 1.6; 3.9) or to have undiagnosed T2DM (RR = 4.8, 95% CI 2.6; 9.0). All associations were attenuated when defining hepatic steatosis by ultrasound. Hepatic steatosis is associated with prediabetes and undiagnosed T2DM in the general population. Quantitative liver MRI revealed stronger associations with prediabetes and undiagnosed T2DM compared to ultrasound, which indicates the higher sensitivity and specificity of MRI to determine hepatic steatosis.

Gender-specific differences in clinical and metabolic variables associated with NAFLD in a Mexican pediatric population

INTRODUCTION AND OBJECTIVES

Non-alcoholic fatty liver disease (NAFLD) is the most common liver disease in children and it is more prevalent in Hispanic males. The gender differences can be explained by body fat distribution, lifestyle, or sex hormone metabolism. We evaluated anthropometric and metabolic differences by gender in children with and without NAFLD.

METHODS

We included 194 participants (eutrophic, overweight, and individuals with obesity). The presence of NAFLD was determined using ultrasonography, and we evaluated the association between this disease with metabolic and anthropometric variables by gender.

RESULTS

The mean age was 10.64±2.54 years. The frequency of NAFLD in boys was 24.51% and in girls was 11.96% (OR=2.39; 95%CI=1.10-5.19; p=0.025). For girls, NAFLD was significantly associated with triglycerides (p=0.012), homeostatic model assessment of insulin resistance (HOMA-IR) (p=0.048), and the visceral adiposity index (VAI) (p=0.024). The variables related to NAFLD in a gender-specific manner were body mass index (BMI) (p=0.001), waist circumference (WC) (p<0.001), HDL cholesterol (p=0.021), alanine aminotransferase (ALT) (p<0.001), and aspartate aminotransferase (AST) (p=0.002).

CONCLUSIONS

In our study NAFLD is more frequent in boys, only ALT, and no other clinical or metabolic variables, were associated with NAFLD in these patients. HOMA-IR, VAI, triglyceride levels, and ALT were associated with NAFLD only in girls. The ALT cut-off points for the development of NAFLD in our study were 28.5U/L in females and 27.5U/L in males. Our findings showed that NAFLD should be intentionally screened in patients with obesity, particularly in boys.

Quantification of liver fat content with ultrasonographic attenuation measurement function: Correlation with unenhanced multidimensional computerized tomography

PURPOSE

To evaluate the efficacy of attenuation measurement function (ATT), a newly developed quantitative ultrasonography(US) method based on measurement of the attenuation coefficient, using unenhanced computerized tomography(CT) attenuation values as a reference standard, for the detection and measurement of hepatosteatosis.

MATERIAL AND METHODS

A total of 98 patients were analyzed. The diagnostic ability of ATT was evaluated using receiver operating characteristic (ROC) curve analysis, and the correlation between liver attenuation index (LAI), the liver-to-spleen attenuation ratio (CT^L/S), liver attenuation value (CT^L), and ATT was determined.

RESULTS

ATT is negatively correlated with LAI (r = -0.571, p < 0.001), CT^L/S (r = -0.532, p < 0.001), and mean CT^L (r = -0.50, p < 0.001). A significant difference was found between ATT values of patients with different grades of hepatosteatosis (p < 0.001). A significant difference was found between ATT values of patients with LAI < -10 and LAI > -10, CT^L < 40 and CT^L > 40, and CT^L/S < 1 and CT^L/S > 1 (p < 0.001). An ATT ≥ 0.665 showed a sensitivity of 100% and a specificity of 90% in diagnosing moderate-severe steatosis. The corresponding area under the ROC curve(AUROC) was 0.935. The intraclass correlation coefficient for the interobserver variability of ATT was 0.907 (95% CI, 0.85-0.95).

CONCLUSION

In conclusion, ATT values for evaluation of hepatosteatosis was closely correlated with the degree of hepatosteatosis and liver fat content. It can be used as a noninvasive method in the diagnosis and follow-up.

Early detection of metabolic changes in drug-induced steatosis using metabolomics approaches

Steatosis is the accumulation of triglycerides in hepatic cells wherein fats exceed 5% of the entire liver weight. Although steatotic liver damage is reversible due to the liver's regenerative capability, protracted damage often and typically leads to irreversible conditions such as cirrhosis and hepatocellular carcinoma (HCC). Therefore, early steatotic detection is critical for preventing progression to advanced liver diseases. This also becomes particularly important given the higher prevalence of drug usage, as drugs are a frequent cause of liver damage. Currently, the recommendation to diagnose steatosis is using liver enzymes and performing a liver biopsy. Liver biopsy remains the gold standard method of detection, but the procedure is invasive and an unreliable diagnostic tool. Non-invasive, specific and sensitive diagnostic solutions such as biomarkers are therefore needed for the early detection of steatosis. Our aim is to identify changes in urinary metabolites in tetracycline-induced hepatic steatotic rats at different stages of the diseases using metabolomic-based techniques. Sprague Dawley male rats are treated by intraperitoneal injection (I.P.) with either 62.5 mg kg⁻¹ or 125 mg kg⁻¹ tetracycline, an antibiotic previously known to induce steatosis. We analyse the metabolic profile of the urinary tetracycline induced hepatic steatotic rats using ¹H nuclear magnetic resonance (NMR), 2D ¹H–¹H TOCSY (total correlation spectroscopy) and electrospray liquid chromatography-mass spectrometry (ESI-LC-MS/MS) based metabolomics. The combined analysis of haematoxylin & eosin (H&E), oil red O (ORO) and direct measurement of triglyceride content in the liver tissues of the control samples against 125 mg kg⁻¹ and 62.5 mg kg⁻¹ treated samples, reveals that 125 mg kg⁻¹ tetracycline exposure potentially induces steatosis. The combination of ¹H NMR, 2D ¹H–¹H TOCSY and ESI-LC-MS/MS alongside multivariate statistical analysis, detected a total of 6 urinary metabolites changes, across 6 metabolic pathways. Furthermore, lysine concentration correlates with liver damage as tetracycline dose concentration increases, whilst both H&E and ORO fail to detect hepatocellular damage at the lowest dose concentration. We conclude that the combination of ¹H NMR and ESI-LC-MS/MS suggests that these are suitable platforms for studying the pathogenesis of steatosis development, prior to morphological alterations observed in staining techniques and offer a more detailed description of the severity of the steatotic disease.

Urinary metabolic profiling of tetracycline induced hepatic steatotic rats were investigated using ¹H nuclear magnetic resonance, 2D ¹H–¹H total correlation spectroscopy and electrospray liquid chromatography-mass spectrometry based metabolomics.

Wavelet-based Computationally-Efficient Computer-Aided Characterization of Liver Steatosis using Conventional B-mode Ultrasound Images

Hepatic steatosis occurs when lipids accumulate in the liver leading to steatohepatitis, which can evolve into cirrhosis and consequently may end with hepatocellular carcinoma. Several automatic classification algorithms have been proposed to detect liver diseases. However, some algorithms are manufacturer-dependent, while others require extensive calculations and consequently prolonged computational time. This may limit the development of real-time and manufacturer-independent computer-aided detection of liver steatosis. This work demonstrates the feasibility of a computationally-efficient and manufacturer-independent wavelet-based computer-aided liver steatosis detection system using conventional B-mode ultrasound (US) imaging. Seven features were extracted from the approximation part of the second-level wavelet packet transform (WPT) of US images. The proposed technique was tested on two datasets of ex-vivo mice livers with and without gelatin embedding, in addition to a third dataset of in-vivo human livers acquired using two different US machines. Using the gelatin-embedded mice liver dataset, the technique exhibited 98.8% accuracy, 97.8% sensitivity, and 100% specificity, and the frame classification time was reduced from 0.4814 s using original US images to 0.1444 s after WPT preprocessing. When the other mice liver dataset was used, the technique showed 85.74% accuracy, 84.4% sensitivity, and 88.5% specificity, and the frame classification time was reduced from 0.5612s to 0.2903 s. Using human liver image data, the best classifier exhibited 92.5% accuracy, 93.0% sensitivity, 91.0% specificity, and the classification time was reduced from 0.660 s to 0.146 s. This technique can be useful for developing computationally-efficient and manufacturer-independent noninvasive CAD systems for fatty liver detection.

Non-Invasive Assessment Method Using Thoracic-Abdominal Profile Image Acquisition and Mathematical Modeling with Bezier Curves

The study was performed at Brasov County Hospital, in the Internal Medicine, Diabetes, Gastroenterology and Cardiology Wards with the collaboration of Transylvania University of Brasov, as a study approved by the Ethical Board of the university. The study aimed at assessing the connection between the anthropometric parameters of abdominal adiposity (measured by means of an original experiment designed to determine the curvature of the thoracic-abdominal adiposity for the patients and processed by help of a mathematical model based upon Bezier curves geometry) and the fat load of the liver (assessed by ultrasound by measuring the diameters of both hepatic lobes) for the patients diagnosed with Non-Alcoholic Fatty Liver Disease (NAFLD). The existence of ten types of thoracic-abdominal curves profiles were statistically analyzed in order to evaluate in a simple manner the liver size in NAFLD. The method of diagnosis is based on an easily reproduced experiment, it is original, innovative, non-invasive, and cost-effective. Can be implemented anywhere in the world, there is no need for investment, only for determining the profile of the belly.

Comparative Study of Orange and its Main Bioactive Constituents as Remedy for Non-alcoholic Fatty Liver in Rats

BACKGROUND AND OBJECTIVES

Non-alcoholic fatty liver disease (NAFLD) is accused as inducer of both cardiovascular and chronic liver diseases. The aim of the present study was to evaluate the therapeutic effect of combined freeze dried orange juice with its dried pulp supplemented with methionine, as functional food, in comparison to orange bioactive constituents, as parallel formula, in NAFLD rat model.

MATERIALS AND METHODS

Proximate composition, dietary fibers, minerals, total phenolics, fatty acids and phytosterols were determined in the orange functional food. The NAFLD was induced in rats through feeding high fructose diet. The prepared functional food and its parallel formula were evaluated in NAFLD rats through determination of liver fat and plasma lipid profile, malondialdehyde, tumor necrosis factor-α, leptin, insulin and glucose as well as liver and kidney function with histopathological examination of the liver. Insulin resistance (IR) and total cholesterol/high density lipoprotein cholesterol were calculated.

RESULTS

Orange functional food was shown to contain 9.17% dietary fibers, 1.4% potassium, 1.4 phenolic content as mg gallic acid/g, oleic acid as the major fatty acid (29.75% of total fatty acids) and 11.97% phytosterols from unsaponifiable matter. The studied formulas produced reduction of liver and plasma lipids, inflammatory and oxidative stress biomarkers, IR and leptin with improving liver function and histopathology pointing to potential management of NAFLD.

CONCLUSION

Orange functional food and its parallel formula were promising in management of NAFLD; with superiority to orange functional food. Phenolic compounds, dietary fibers, phytosterols and mono and poly-unsaturated fatty acids could be responsible to the bioactivity of orange formula.

Effects of Delta-tocotrienol Supplementation on Liver Enzymes, Inflammation, Oxidative stress and Hepatic Steatosis in Patients with Nonalcoholic Fatty Liver Disease

BACKGROUND/AIMS

Non-alcoholic fatty liver disease (NAFLD) is a growing public health problem worldwide and is associated with increased morbidity and mortality. Currently, there is no definitive treatment for this disease. δ-Tocotrienol has potent anti-inflammatory and antioxidant properties and may reduce liver injury in NAFLD. The present study aims to evaluate the efficacy and safety of δ-tocotrienol in the treatment of NAFLD.

MATERIALS AND METHODS

The present study was a randomized, double-blind, placebo-controlled pilot study conducted in patients aged > 20 years, belonging to both sexes, having ultrasound-proven fatty liver disease, having a fatty liver index (FLI) of ≥ 60, and persistent elevation of alanine transaminase. A total of 71 patients were assigned to receive either oral δ-tocotrienol (n=35, 300 mg twice daily) or placebo (n=36) for 12 weeks. At the baseline and at the end of the study, clinical and biochemical parameters, including lipid profile, liver function tests, high-sensitivity C-reactive protein (hs-CRP), and malondialdehyde (MDA) were measured. Body mass index and FLI were calculated, and ultrasound grading of hepatic steatosis was performed.

RESULTS

Out of 71 enrolled patients, 64 patients, 31 in the δ-tocotrienol group and 33 in the placebo group, completed the study. After 12 weeks of supplementation, δ-tocotrienol showed greater efficacy than placebo by decreasing serum aminotransferases, hs-CRP, MDA, and FLI score (p<0.001). However, it did not improve hepatic steatosis on ultrasound examination. No adverse effects were reported.

CONCLUSION

δ-Tocotrienol was safe, and it effectively improved aminotransferase levels and inflammatory and oxidative stress markers in patients with NAFLD. Large-scale randomized clinical trials are warranted to further support these findings.

A comparison of hepatic steatosis index, controlled attenuation parameter and ultrasound as noninvasive diagnostic tools for steatosis in chronic hepatitis B

AIMS

To evaluate the value of noninvasive tools for diagnosis of hepatic steatosis in patients with chronic hepatitis B (CHB).

METHODS

Consecutive treatment-naïve patients with CHB with body mass index less than 30kg/m² who underwent liver biopsy, ultrasound and FibroScan^® were enrolled. The diagnostic performance of controlled attenuation parameter (CAP), hepatic steatosis index (HSI) and ultrasound for hepatic steatosis compared with liver biopsy was assessed. The areas under receiver operating characteristics curves (AUROCs) were calculated to determine the diagnostic efficacy, with comparisons using the DeLong test.

RESULTS

CAP and HSI accuracies were significantly higher than that of ultrasound to detect patients with biopsy-proven mild steatosis (S1, 65.3%, 56.5%, respectively, vs. 17.7%, χ²=46.305, 31.736, both P<0.05)and moderate-severe (S2-3) steatosis (92.3%, 100%, respectively, vs. 53.8%, χ²=4.887, 7.800, P=0.037, 0.007, respectively). Both CAP and HSI had lower underestimation rates of steatosis grade than ultrasound (12%, 14.8%, respectively, vs. 29.5%, χ²=9.765, 6.452; P<0.05 for both), but they exhibited higher overestimation rates (30.5%, 38.2%, respectively, vs. 12.4%, χ²=39.222, 70.986; both P<0.05). The AUROCs of CAP and HSI were 0.780 (95% confidence intervals [CIs] 0.735-0.822) and 0.655 (95%CI 0.604-0.704) for S ≥1, 0.932 (95%CI 0.902-0.956) and 0.755 (95%CI 0.707-0.799) for S ≥2, 0.990 (95%CI 0.974-0.998) and 0.786 (95% CI 0.740-0.827) for S3, respectively.

CONCLUSION

CAP might be more accurate for detecting hepatic steatosis than HSI and ultrasound in patients with CHB, but further studies are needed to reduce the overestimation rates.

Childhood predictors of adult fatty liver. The Cardiovascular Risk in Young Finns Study

BACKGROUND & AIMS

Fatty liver is a potentially preventable cause of serious liver diseases. This longitudinal study aimed to identify childhood risk factors of fatty liver in adulthood in a population-based group of Finnish adults.

METHODS

Study cohort included 2,042 individuals from the Cardiovascular Risk in Young Finns Study aged 3-18years at baseline in 1980. During the latest follow-up in 2011, the liver was scanned by ultrasound. In addition to physical and environmental factors related to fatty liver, we examined whether the genetic risk posed by a single nucleotide polymorphism in the patatin-like phospholipase domain-containing protein 3 gene (PNPLA3) (rs738409) strengthens prediction of adult fatty liver.

RESULTS

Independent childhood predictors of adult fatty liver were small for gestational age, (odds ratio=1.71, 95% confidence interval=1.07-2.72), variant in PNPLA3 (1.63, 1.29-2.07 per one risk allele), variant in the transmembrane 6 superfamily 2 gene (TM6SF2) (1.57, 1.08-2.30), BMI (1.30, 1.07-1.59 per standard deviation) and insulin (1.25, 1.05-1.49 per standard deviation). Childhood blood pressure, physical activity, C-reactive protein, smoking, serum lipid levels or parental lifestyle factors did not predict fatty liver. Risk assessment based on childhood age, sex, BMI, insulin levels, birth weight, TM6SF2 and PNPLA3 was superior in predicting fatty liver compared with the approach using only age, sex, BMI and insulin levels (C statistics, 0.725 vs. 0.749; p=0.002).

CONCLUSIONS

Childhood risk factors on the development of fatty liver were small for gestational age, high insulin and high BMI. Prediction of adult fatty liver was enhanced by taking into account genetic variants in PNPLA3 and TM6SF2 genes.

LAY SUMMARY

The increase in pediatric obesity emphasizes the importance of identification of children and adolescents at high risk of fatty liver in adulthood. We used data from the longitudinal Cardiovascular Risk in Young Finns Study to examine the associations of childhood (3-18years) risk variables with fatty liver assessed in adulthood at the age of 34-49years. The findings suggest that a multifactorial approach with both lifestyle and genetic factors included would improve early identification of children with a high risk of adult fatty liver.

Preoperative Methods to Reduce Liver Volume in Bariatric Surgery: a Systematic Review

Background

Patients qualified for gastric bypass surgery have an enlarged and fatty liver. An essential step in gastric bypass surgery is elevation of the left liver lobe to expose the gastroesophageal junction. An enlarged and fatty liver complicates the surgical procedure and increases the risk for laceration of the liver. The aim of our study was to evaluate methods to reduce liver volume in patients prior to gastric bypass surgery.

Methods

A systematic literature search of multiple databases, including PubMed, EMBASE.com, and the Cochrane Library and a hand search of reference lists, was performed. We used the search terms morbid obesity and liver, including their synonyms and controlled terms. Inclusion criteria were as follows: patients with morbid obesity who qualified for bariatric surgery, the use of a preoperative treatment to reduce liver volume, and the use of imaging techniques before and after treatment.

Results

In total, 281 patients in 11 different studies were included. Preoperative diets reduced liver size by an average of 14 %, alternative methods including nutritional supplements, reduced liver size between 20 and 43 %, and an intragastric balloon by 32 %.

Conclusions

This review showed that nutritional supplements and intragastric balloon are more effective than low calorie diets in reducing liver volume prior to gastric bypass surgery. However, low calorie diet is the preferable method to reduce liver volume, considering the level of evidence and practical applicability. There is a need for well-designed randomized studies with sufficient power in order to confirm the effectiveness of preoperative methods to reduce liver volume.

Prevalence and sonographic changes compatible with fatty liver disease in patients referred for abdominal ultrasound examination in Aracaju, SE

Objective

To estimate the prevalence and evaluate sonographic findings compatible with changes consistent with hepatic steatosis in patients referred for abdominal ultrasonography at four reference centers in Aracaju, SE, Brazil.

Materials and Methods

Prospective, descriptive survey, with analytical and quantitative approach, comprising abdominal ultrasonography scans performed with a convex, dynamic 3.75 MHz transducer. Liver dimensions and parenchymal echotexture were evaluated, classifying hepatic steatosis into grades (1, 2 or 3). The SPSS^® 22.0 software was used for statistical analysis, adopting p < 0.05 as significance level.

Results

A total of 800 individuals (561 women and 239 men) were evaluated. The prevalence of steatosis was 29.1%, and the male patients were most affected, presenting with more advanced grades of disease (p = 0.021), as follows: 119 grade 1 (51.0%); 94 grade 2 (40.4%); and 20 grade 3 (8.6%). The median age patients' was 46 years.

Conclusion

In the present study sample, the prevalence of hepatic steatosis was high, particularly in the male patients. Ultrasonography is suggested as a first choice for the diagnosis of this condition, considering its wide availability, low cost and absence of side effects or risks to the patient.

Endocrine causes of nonalcoholic fatty liver disease

Nonalcoholic fatty liver disease (NAFLD) is the most common cause of chronic liver disease in the industrialized world. The prevalence of NAFLD is increasing, becoming a substantial public health burden. NAFLD includes a broad spectrum of disorders, from simple conditions such as steatosis to severe manifestations such as fibrosis and cirrhosis. The relationship of NAFLD with metabolic alterations such as type 2 diabetes is well described and related to insulin resistance, with NAFLD being recognized as the hepatic manifestation of metabolic syndrome. However, NAFLD may also coincide with endocrine diseases such as polycystic ovary syndrome, hypothyroidism, growth hormone deficiency or hypercortisolism. It is therefore essential to remember, when discovering altered liver enzymes or hepatic steatosis on radiological exams, that endocrine diseases can cause NAFLD. Indeed, the overall prognosis of NAFLD may be modified by treatment of the underlying endocrine pathology. In this review, we will discuss endocrine diseases that can cause NALFD. Underlying pathophysiological mechanisms will be presented and specific treatments will be reviewed.

Fatty liver formation in fulminant type 1 diabetes

Summary

A 32-year-old woman presented with 3days of epigastric pain and was admitted to our hospital (day 3 of disease). We diagnosed acute pancreatitis based on epigastric abdominal pain, hyperamylasemia, and an inflammatory reaction of withdrawn blood, pancreatic enlargement, and so on. Her condition improved with treatment; however, on day 8, she had decreased level of consciousness. Laboratory results led to a diagnosis of fulminant type 1 diabetes mellitus (FT1DM) with concomitant diabetic ketoacidosis. Insulin therapy improved her blood glucose levels as well as her symptoms. Fatty liver with liver dysfunction was observed on day 14, which improved by day 24. Blood levels of free fatty acids (FFAs) increased rapidly from 440μEq/L (normal range: 140–850μEq/L) on day 4 to 2097μEq/L on days 7–8 (onset of FT1DM) and subsequently decreased to 246μEq/L at the onset of fatty liver. The rapid decrease in insulin at the onset of FT1DM likely freed fatty acids derived from triglycerides in peripheral adipocytes into the bloodstream. Insulin therapy rapidly transferred FFAs from the periphery to the liver. In addition, insulin promotes the de novo synthesis of triglycerides in the liver, using newly acquired FFAs as substrates. At the same time, inhibitory effects of insulin on VLDL secretion outside of the liver promote the accumulation of triglycerides in the liver, leading to fatty liver. We describe the process by which liver dysfunction and severe fatty liver occurs after the onset of FT1DM, from the perspective of disturbed fatty acid metabolism.

Learning Points

FT1DM is rare but should be considered in patients with pancreatitis and a decreased level of consciousness. Fatty liver should be considered in patients with FT1DM when liver dysfunction is observed. Insulin is involved in mechanisms that promote fatty liver formation. Pathophysiological changes in fatty acid metabolism may provide clues on lipid metabolism in the early phases of FT1DM.