Probiotics as a novel treatment for non-alcoholic Fatty liver disease; a systematic review on the current evidences

Association between gut microbiota and locomotive syndrome risk in healthy Japanese adults: a cross-sectional study

This cross-sectional study examined the association between gut microbiota composition and locomotive syndrome in 568 healthy Japanese adults (36.8% male, median age 58.5 years) using data from the Kanagawa "ME-BYO" Prospective Cohort Study. Locomotive syndrome was assessed using the 5-question Geriatric Locomotive Function Scale (GLFS-5). Linear discriminant analysis effect size showed an enrichment of Actinobacteria and depletion of Firmicutes in GLFS-5 positive individuals. Classification tree analysis identified three terminal nodes as GLFS-5 positive, with one node involving Holdemania. Participants aged ≥70.0 and <78.0 years who did not consume probiotic foods and had ≥0.04% relative abundance of Holdemania were classified as at risk for locomotive syndrome. Our findings suggest a potential association between gut microbiota, particularly higher Holdemania abundance, and locomotive syndrome in older adults. This study provides insights into the complex relationship between gut microbiome composition and musculoskeletal health in aging populations. However, the cross-sectional design limits causal inference.

The effect of holding a workshop (group and face-to-face training method) on nutrition adjustment on anthropometric indices in children with chronic liver disease

BACKGROUND

Complications of chronic liver disease (CLD) in children play an important role in mortality and disability. This disease is one of the health problems of the country and due to its chronic and irreversible disease, it needs care and treatment education programs. Therefore, this study was performed to determine the effect of nutrition adjustment training program on anthropometric indices in children with CLD.

MATERIALS AND METHODS

This clinical trial study was performed on 75 children (45 in the intervention group and 30 in the control group) with CLD in the nutrition clinic of Ghaem Educational-Research Center in Mashhad. Children and caregivers with inclusion criteria entered the study after completing written consent. Anthropometric indices (abdominal circumference, body water level, body fat, height, weight, body mass index, arm circumference) were measured and recorded in children at the beginning of the study. Children and their caregivers were randomly divided into control and intervention groups. The intervention group underwent nutritional adjustment (calculation of energy and carbohydrates, lipids and proteins, vitamins and minerals, calculation and selection of diet) training (face to face) for 6 sessions (each session 90-120 min, three times a week for 2 weeks). Twelve weeks after the start of the study, children in both intervention and control groups were evaluated for anthropometric indices. The collected data were analyzed by SPSS software version 16 and descriptive and analytical statistical tests (Mann-Whitney and Wilcoxon).

RESULTS

The results of Wilcoxon statistical test showed that children in the intervention group at the end of the study compared to the beginning of the study had significant changes in scores around the abdomen (P = 0.001), total body water (P = 0.009), total fat (0.001 > P), height (P = 0.001), weight (P < 0.001), body mass index (P < 0.001), arm circumference (P < 0.001). The mean scores at the end of the study increased compared to the beginning of the study, but the mean scores of the studied indices in the control group did not change significantly.

CONCLUSION

The results of this study showed that diet adjustment training program can be effective on anthropometric indices of children with CLD. For this purpose, the use of this educational method is recommended to improve the anthropometric indices of these children.

Human microbiome and metabolic health: An overview of systematic reviews

To summarize the microbiome's role in metabolic disorders (insulin resistance, hyperglycemia, type 2 diabetes, obesity, hyperlipidemia, hypertension, nonalcoholic fatty liver disease [NAFLD], and metabolic syndrome), systematic reviews on observational or interventional studies (prebiotics/probiotics/synbiotics/transplant) were searched in MEDLINE and Embase until September 2020. The 87 selected systematic reviews included 57 meta-analyses. Methodological quality (AMSTAR2) was moderate in 62%, 12% low, and 26% critically low. Observational studies on obesity (10 reviews) reported less gut bacterial diversity with higher Fusobacterium, Lactobacillus reuteri, Bacteroides fragilis, and Staphylococcus aureus, whereas lower Methanobrevibacter, Lactobacillus plantarum, Akkermansia muciniphila, and Bifidobacterium animalis compared with nonobese. For diabetes (n = 1), the same was found for Fusobacterium and A. muciniphila, whereas higher Ruminococcus and lower Faecalibacterium, Roseburia, Bacteroides vulgatus, and several Bifidobacterium spp. For NAFLD (n = 2), lower Firmicutes, Rikenellaceae, Ruminococcaceae, whereas higher Escherichia and Lactobacillus were detected. Discriminating bacteria overlapped between metabolic disorders, those with high abundance being often involved in inflammation, whereas those with low abundance being used as probiotics. Meta-analyses (n = 54) on interventional studies reported 522 associations: 54% was statistically significant with intermediate effect size and moderate between-study heterogeneity. Meta-evidence was highest for probiotics and lowest for fecal transplant. Future avenues include better methodological quality/comparability, testing functional differences, new intervention strategies, and considerating other body habitats and kingdoms.

RNA-Seq unveiled section-specific host response to lack of gut microbiota in mouse intestine

To identify host responses induced by commensal microbiota in intestine, transcriptomes of four sections of the intestine were compared between germ-free (GF) mice and conventional (CV) controls using RNA-Seq. Cuffdiff revealed that jejunum had the highest number of differentially expressed genes (over 2000) between CV and GF mice, followed by large intestine (LI), duodenum, and ileum. Gene set association analysis identified section-specific alterations in pathways associated with the absence of commensal microbiota. For example, in GF mice, cytochrome P450 (Cyp)-mediated xenobiotic metabolism was preferably down-regulated in duodenum and ileum, whereas intermediary metabolism pathways such as protein digestion and amino acid metabolism were preferably up-regulated in duodenum, jejunum, and LI. In GF mice, carboxypeptidase A1 (Cpa1), which is important for protein digestion, was the top most up-regulated gene within the entire transcriptome in duodenum (53-fold) and LI (142-fold). Conversely, fatty acid binding protein 6 (Fabp6/Ibabp), which is important for bile acid intestinal reabsorption, was the top most down-regulated gene in jejunum (358-fold), and the drug-metabolizing enzyme Cyp1a1 was the top most down-regulated gene in ileum (40-fold). Section-specific host transcriptomic response to the absence of intestinal microbiota was also observed for other important physiological pathways such as cell junction, the absorption of small molecules, bile acid homeostasis, and immune response. In conclusion, the present study has revealed section-specific host gene transcriptional alterations in GF mice, highlighting the importance of intestinal microbiota in facilitating the physiological and drug responses of the host intestine.

The effect of nutritional education program on micronutrient intake in children with chronic liver disease: A clinical trial

BACKGROUND

Chronic liver disease (CLD) is one of the most common chronic diseases in the world that threatens the health of children due to its many complications such as malnutrition and problems related to growth and development. Paying attention to nutrition and lifestyle modification in these children is of special importance. Therefore, the aim of this study was to determine the effect of nutritional education program on micronutrient intake in children with CLD.

MATERIALS AND METHODS

The present study is a two-group randomized clinical trial that was performed by available sampling and referred to Ghaem Children's Hospital in Mashhad in 2016. In this study, 77 children with CLD who met the inclusion criteria (45 children in the intervention group and 32 children in the control group) were studied. The intervention included six workshops and training on proper diet, post-workshop phone calls, and regular face-to-face counseling sessions (first 4 weeks once a week and second 4 weeks once every 2 weeks) on adherence to the above diet. Patients in the control group received routine care. The collection tools in the study included demographic information questionnaires, body composition device, and diet plan form in the form of 24-h recall forms. Data analysis was performed using descriptive statistical tests and Mann-Whitney and Wilcoxon statistical tests using SPSS software version 16.

RESULTS

Based on the results of the study, the mean age of the research units was 7.8 ± 3.6 years. The mean duration of CLD was 4.6 ± 1.8 years in the intervention group and 5.1 ± 1.9 years in the control group. The mean crude intake of most minerals after the intervention was significantly higher than before the intervention, except for the crude intake of retinol, thiamine, riboflavin, folate, Vitamin C, iodine, and Vitamin B12. Furthermore, in relation to the modified intake of micronutrients, the mean modified intake of most micronutrients after the intervention showed a significant increase compared to before, except for retinol, Vitamin D, niacin, B12, and iodine.

CONCLUSION

Considering the effect of providing a nutritional education program to improve micronutrient intake in children with CLD and emphasizing the importance of adequate micronutrient intake in improving the health of children, special nutrition programs should be provided to these children with special attention. In this regard, nurses can play an important role in improving the quality of nutrition of children by providing nutrition programs with appropriate follow-up.

The effects of Bacillus coagulans supplementation in patients with non-alcoholic fatty liver disease: A randomized, placebo-controlled, clinical trial

BACKGROUND

The aim of this study was to evaluate the effects of supplementation with 10⁹ spores of Bacillus coagulans (GBI-30) plus inulin in patients with non-alcoholic fatty liver disease (NAFLD).

METHODS

In a randomized, double-blind, placebo-controlled clinical trial, fifty three patients with NAFLD were randomly assigned to receive either a synbiotic or a placebo capsule for 12 weeks. The primary outcome was reduction in steatosis score in Fibroscan exam.

RESULTS

At the end of study, serum alanine aminotransferase and γ glutamine transaminase decreased significantly more in synbiotic group compared to placebo group (p = 0.001, and p = 0.004, respectively). Synbiotic supplementation significantly reduced serum tumor necrosis factor-α (p = 0.03) and nuclear factor-κB activity (p = 0.04). Moreover, hepatic steatosis reduced significantly more in synbiotic group compared to placebo group (p < 0.001).

CONCLUSION

Our results indicate that 12 weeks supplementation with B. coagulans plus inulin is beneficial for treatment of NAFLD and its related inflammation without any significant effects on related cardiovascular risk factors.

CLINICAL TRIALS

This trial was registered at irct.ir with number of IRCT20100524004010N23.

Effects of surface-deacetylated chitin nanofibers on non-alcoholic steatohepatitis model rats and their gut microbiota

Nonalcoholic steatohepatitis (NASH), a more advanced form of nonalcoholic fatty liver disease (NAFLD), is associated with increased cardiovascular and liver-related mortality. Stroke-prone spontaneously hypertensive rats (SHRSP5/Dmcr) that are fed a high-fat and high-cholesterol diet develop hepatic lesions that are similar to those observed in human NASH pathology. We investigated the hepatic protective and antioxidant effects of surface-deacetylated chitin nanofibers (SDACNFs) that were administered to SHRSP5/Dmcr rats for 8 weeks. The administration of SDACNFs (80 mg/kg/day) resulted in a significant decrease in hepatic injury, oxidative stress, compared with the non-treatment. The SDACNFs also caused a reduction in the population of harmful members of the Morganella and Prevotella genus, and increased the abundance of the Blautia genus, a useful bacterium in gut microbiota. We therefore conclude that SDACNF exerts anti-hepatic and antioxidative effects not only by adsorbing lipid substances but also by reforming the community of intestinal microflora in the intestinal tract.

Diet Consisting of Balanced Yogurt, Fruit, and Vegetables Modifies the Gut Microbiota and Protects Mice against Nonalcoholic Fatty Liver Disease

BACKGROUND

Calorie restriction (CR) is a therapeutically effective method for nonalcoholic fatty liver disease. However, the compliance of the CR method is relatively poor. New CR methods are needed.

METHODS AND RESULTS

Each week, mice are given a 5-day high-fat diet (HFD) ad libitum plus 2 days of an intermittent calorie restriction (ICR) diet (50% calorie restriction) consisting of yogurt, fruit, and vegetables, for 16 weeks. The effect of the ICR diet model on the fatty liver of mice is examined. Compared with continuous HFD-fed mice, the mice feeding HFD+ICR have lower body weight and hepatic steatosis, reduced serum lipid and transaminase levels, increased fatty acid oxidation gene of Cpt1a, and decreased hepatic lipid synthesis gene of Pparγ and Srebf-1c, as well as improved insulin resistance and lower level of inflammation. Moreover, ICR reverses the dysbacteriosis in HFD group, including the lower Shannon diversity indexes and lower abundance of Lactobacillus.

CONCLUSION

An ICR diet consisting of yogurt, fruit, and vegetables attenuates the development of HFD-induced hepatic steatosis in mice. Furthermore, HFD+ICR diet is associated with a different fecal microbiota that tends to be more similar to normal diet controls.

Intestinally derived bacterial products stimulate development of nonalcoholic steatohepatitis

Fatty livers are susceptible to factors that cause inflammation and fibrosis, but fat deposition and the inflammatory response can be dissociated. While nonalcoholic fatty liver disease (NAFLD), caused by pathologic fat accumulation inside the liver, can remain stable for several years, in other cases NAFLD progresses to nonalcoholic steatohepatitis (NASH), which is characterized by fat accumulation and inflammation and is not a benign condition. In this review, we discuss the NASH host cells and microbial mechanisms that stimulate inflammation and predispose the liver to hepatocyte injury and fibrotic stages via increased lipid deposition. We highlight the interactions between intestine-derived bacterial products, such as lipopolysaccharide, and nutritional models of NAFLD and/or obese individuals. The results of modulating enteric microbiota suggest that gut-derived endotoxins may be essential determinants of fibrotic progression and regression in NASH.

Effects of shenling baizhu powder herbal formula on intestinal microbiota in high-fat diet-induced NAFLD rats

BACKGROUND

Worldwide, non-alcoholic fatty liver disease (NAFLD) is a common chronic liver disease closely associated with obesity, diabetes and other metabolic diseases. Shenling Baizhu powder (SLBZP), a formulation of a variety of natural medicinal plants, has hepatoprotective properties and clinical efficacy in treating non-infectious intestinal disease. SLBZP has improved NAFLD symptoms; however, its mechanism of action is unknown.

METHODS

We established an NAFLD model in rats given a high-fat diet (HFD), administered different interventions and measured serum biochemical indices and inflammatory factors. Liver tissues were stained with hematoxylin and eosin (HE) and oil red O, and colon tissues were analyzed by immunohistochemistry. The expression profiles of liver TLR4 pathway related protein was confirmed by western blotting. Changes in intestinal microbiota composition were analyzed using a 16S rDNA sequencing technique.

RESULTS

Of note, SLBZP effectively reduced body weight in HFD-fed rats (p < 0.05). Serum biochemical analysis indicated that SLBZP decreased the serum level of total cholesterol (TC) and improved liver function. Additionally, SLBZP decreased the serum level of endotoxin, tumor necrosis factor α (TNF-α), interleukin-1β (IL-β) (p < 0.05), and decreased the expression of TLR4 pathway related protein. Pathological examination showed that SLBZP alleviates hepatic steatosis and repairs colon mucosa. Microbiome analysis revealed that SLBZP improved the abundance of intestinal microbiota. In taxonomy-based analysis, compared with control rats, SLBZP-treated rats showed obvious changes in intestinal microbiota composition. Moreover, SLBZP increased the relative abundance of short-chain fatty acid (SCFA)-producing bacteria, including Bifidobacterium and Anaerostipes.

CONCLUSION

Taken together, these results suggest that the effects of SLBZP against NAFLD may be related to the increased abundance of beneficial gut microbiota and decreased levels of LPS in the portal vein.

Gut Microbiota and Nonalcoholic Fatty Liver Disease: Insights on Mechanisms and Therapy

The gut microbiota plays critical roles in development of obese-related metabolic diseases such as nonalcoholic fatty liver disease (NAFLD), type 2 diabetes(T2D), and insulin resistance(IR), highlighting the potential of gut microbiota-targeted therapies in these diseases. There are various ways that gut microbiota can be manipulated, including through use of probiotics, prebiotics, synbiotics, antibiotics, and some active components from herbal medicines. In this review, we review the main roles of gut microbiota in mediating the development of NAFLD, and the advances in gut microbiota-targeted therapies for NAFLD in both the experimental and clinical studies, as well as the conclusions on the prospect of gut microbiota-targeted therapies in the future.

Effects of Probiotics on Nonalcoholic Fatty Liver Disease in Obese Children and Adolescents

OBJECTIVES

This study aims to evaluate the effects of some probiotics on sonographic and biochemical nonalcoholic fatty liver disease (NAFLD).

METHODS

This randomized triple-blind trial was conducted among 64 obese children with sonographic NAFLD. They were randomly allocated to receive probiotic capsule (containing Lactobacillus acidophilus ATCC B3208, 3 × 10 colony forming units [CFU]; Bifidobacterium lactis DSMZ 32269, 6 × 10 CFU; Bifidobacterium bifidum ATCC SD6576, 2 × 10 CFU; Lactobacillus rhamnosus DSMZ 21690, 2 × 10 CFU) or placebo for 12 weeks.

RESULTS

After intervention, in the probiotic group the mean levels of alanine aminotransferase decreased from 32.8 (19.6) to 23.1 (9.9) U/L (P = 0.02) and mean aspartate aminotransferase decreased from 32.2 (15.7) to 24.3 (7.7) U/L (P = 0.02). Likewise the mean cholesterol, low-density lipoprotein-C, and triglycerides as well as waist circumference decreased in the intervention group, without significant change in weight, body mass index, and body mass index z score. After the trial, normal liver sonography was reported in 17 (53.1%) and 5 (16.5%) of patients in the intervention and placebo groups, respectively.

CONCLUSIONS

The present findings suggest that a course of the abovementioned probiotic compound can be effective in improving pediatric NAFLD.

Probiotics and Liver Disease: Where Are We Now and Where Are We Going?

Probiotics are live, nonpathogenic bacteria capable of colonizing the colonic mucosa. The most common probiotics include strains of Lactobacillus or Bifidobacteria, which are part of the normal gastrointestinal microbiota. Initial studies of selected probiotic species have suggested potential efficacy in several gastrointestinal diseases including inflammatory bowel diseases (particularly pouchitis), antibiotic-related diarrhea, Clostridium difficile toxin-induced colitis, infectious diarrhea, irritable bowel syndrome, and allergy. The so-called "gut-liver axis" involves complex interaction between the liver parenchyma and gut microbiota. There is growing evidence to suggest that alteration in gut microbial components may affect the liver and can be a precipitating cofactor in development and modulating of chronic liver damage through ethanol, production of ammonia and endotoxin. This may allow for a better understanding of its role in the pathogenesis of verities of liver diseases and help to identify a microbial target for prevention and treatment of such diseases. This paper discusses the growing evidence that highlights the relationship between gut microbiota and development, prevention and treatment of numbers of liver diseases.

Non-alcoholic fatty liver disease in 2016

INTRODUCTION

Non-alcoholic fatty liver disease is the commonest cause of liver disease worldwide, and is rapidly becoming the leading indication for liver transplantation.

SOURCES OF DATA

Original articles, reviews and meta-analyses, guidelines.

AREAS OF AGREEMENT

NAFLD strongly correlates with obesity and insulin resistance; currently, the best management strategy is weight loss and treatment of the metabolic syndrome.

AREAS OF CONTROVERSY

Recent data suggest that the presence of fibrosis and not non-alcoholic steatohepatitis (NASH) is the predictor of clinical outcome.

GROWING POINTS

Many phase 2 and 3 trials are underway. Drugs hoped to be effective are obeticholic acid, elafibranor, glucagon-like peptide-1 analogues and CCR2/5 inhibitors.

AREAS TIMELY FOR DEVELOPING RESEARCH

Improved understanding of the pathophysiology of NAFLD should help us identify which patients progress to significant liver disease and to develop therapies to target this population.

Prediction and Diagnosis of Non-Alcoholic Fatty Liver Disease (NAFLD) and Identification of Its Associated Factors Using the Classification Tree Method

Background

Non-alcoholic fatty liver disease (NAFLD) is the most common form of liver disease in many parts of the world.

Objectives

The aim of the present study was to identify the most important factors influencing NAFLD using a classification tree (CT) to predict the probability of NAFLD.

Patients and Methods

This cross-sectional study was conducted in Kavar, a town in the south of Fars province, Iran. A total of 1,600 individuals were selected for the study via the stratified method and multiple-stage cluster random sampling. A total of 30 demographic and clinical variables were measured for each individual. Participants were divided into two datasets: testing and training. We used the training dataset (1,120 individuals) to build the CT and the testing dataset (480 individuals) to assess the CT. The CT was also used to estimate class and to predict fatty liver occurrence.

Results

NAFLD was diagnosed in 22% of the individuals in the sample. Our findings revealed that the following variables, based on univariate analysis, had a significant association with NAFLD: marital status, history of hepatitis B vaccine, history of surgery, body mass index (BMI), waist-hip ratio (WHR), systolic blood pressure (SBP), diastolic blood pressure (DBP), high-density lipoprotein (HDL), triglycerides (TG), alanine aminotransferase (ALT), cholesterol (CHO0, aspartate aminotransferase (AST), glucose (GLU), albumin (AL), and age (P < 0.05). The main affecting variables for predicting NAFLD based on the CT and in order of importance were as follows: BMI, WHR, triglycerides, glucose, SBP, and alanine aminotransferase. The goodness of fit model based on the training and testing datasets were as follows: prediction accuracy (80%, 75%), sensitivity (74%, 73%), specificity (83%, 77%), and the area under the receiver operating characteristic (ROC) curve (78%, 75%), respectively.

Conclusions

The CT is a suitable and easy-to-interpret approach for decision-making and predicting NAFLD.

Diet, Microbiota, Obesity, and NAFLD: A Dangerous Quartet

Recently, the importance of the gut-liver-adipose tissue axis has become evident. Nonalcoholic fatty liver disease (NAFLD) is the hepatic disease of a systemic metabolic disorder that radiates from energy-surplus induced adiposopathy. The gut microbiota has tremendous influences in our whole-body metabolism, and is crucial for our well-being and health. Microorganisms precede humans in more than 400 million years and our guest flora evolved with us in order to help us face aggressor microorganisms, to help us maximize the energy that can be extracted from nutrients, and to produce essential nutrients/vitamins that we are not equipped to produce. However, our gut microbiota can be disturbed, dysbiota, and become itself a source of stress and injury. Dysbiota may adversely impact metabolism and immune responses favoring obesity and obesity-related disorders such as insulin resistance/diabetes mellitus and NAFLD. In this review, we will summarize the latest evidence of the role of microbiota/dysbiota in diet-induced obesity and NAFLD, as well as the potential therapeutic role of targeting the microbiota in this set.

The Effect of Symbiotic Supplementation on Liver Enzymes, C-reactive Protein and Ultrasound Findings in Patients with Non-alcoholic Fatty Liver Disease: A Clinical Trial

Background:

Regarding to the growing prevalence of nonalcoholic fatty liver disease (NAFLD), concentrating on various strategies to its prevention and management seems necessary. The aim of this study was to determine the effects of symbiotic on C-reactive protein (CRP), liver enzymes, and ultrasound findings in patients with NAFLD.

Methods:

Eighty NAFLD patients were enrolled in this randomized, double-blind, placebo-controlled clinical trial. Participants received symbiotic in form of a 500 mg capsule (containing seven species of probiotic bacteria and fructooligosaccharides) or a placebo capsule daily for 8 weeks. Ultrasound grading, CRP, and liver enzymes were evaluated at the baseline and the end of the study.

Results:

In the symbiotic group, ultrasound grade decreased significantly compared to baseline (P < 0.005) but symbiotic supplementation was not associated with changes in alanine aminotransferase (ALT) and aspartate transaminase (AST) levels. In the placebo group, there was no significant change in steatosis grade whereas ALT and AST levels were significantly increased (P = 0.002, P = 0.02, respectively). CRP values remained static in either group.

Conclusions:

Symbiotic supplementation improved steatosis in NAFLD patients and might be useful in the management of NAFLD or protective against its progression.

Nonalcoholic Fatty Liver Disease in Pediatrics

A 16-year-old Hispanic girl with an elevated body mass index in an otherwise normal state of health presented for her well-child examination. She had signs of metabolic syndrome and insulin resistance including increased waist circumference and acanthosis nigricans. Laboratory results revealed elevated transaminases with otherwise normal hepatic function. Based on the physical examination and laboratory results, she was diagnosed with nonalcoholic fatty liver disease (NAFLD). After further evaluation, she eventually underwent a liver biopsy. The biopsy revealed nonalcoholic steatohepatitis (NASH) with stage 2 fibrosis. This article reviews the definition of NAFLD and NASH, an increasingly prevalent cause of pediatric chronic liver disease associated with obesity and metabolic syndrome. The article also outlines the epidemiology, risk factors, and natural history of NAFLD, which may help identify and prevent high-risk pediatric patients from progressing to irreversible liver disease. Understanding the diagnostic and treatment options offers the best chance at preventing and reversing the early stages of this disease.

Treatment of nonalcoholic fatty liver disease: Where do we stand? an overview

Nonalcoholic fatty liver disease (NAFLD) is currently the most common liver disease worldwide, the prevalence of which had progressively increased over the past 10 years where other liver diseases remained at the same prevalence rates or are expected to decrease as in the case of hepatitis C virus (HCV). The treatment of NAFLD is of prime concern to health care professionals and patients due to the significant mortality and morbidity it implies; the problem is further escalated by the fact that standard of care medications targeting NAFLD remain experimental and without evidence base. Treatment nowadays is focused on lifestyle modification and managing the comorbid associated diseases, with a possible role for some hepatic protective agents. This review presents all the medications that had been proposed and used for the treatment of NAFLD with or without scientific rationale and includes agents for weight loss, insulin sensitizers, drugs that reduce blood lipids, glucagon-mimetics, drugs that may reduce fibrosis, angiotensin receptor blockers, and medicines believed to reduce endoplasmic reticular stress such as vitamin E, ursodeoxycholic acid, and S-adenosyl methionine. A quick review of the newer agents that proved to be promising such as obeticholic acid and GFT505 and the medicines that are still in the pipeline is also presented.

Gut microbiota disturbance and non-alcoholic fatty liver disease

Non-alcoholic fatty liver disease (NAFLD), also called fatty liver, is the most common chronic liver disease. Although the prevalence of NAFLD is increasing, the mechanisms underlying its pathogenesis are incompletely understood. So far, there has been no effective approach for its prevention and treatment. With the development of next generation sequencing technology, recent studies have shown that gut microbiota alterations including changes in the composition of gut flora, bacterial translocation and small intestinal bacterial overgrowth, play roles in the development of NAFLD. Besides destruction of the intestinal barrier, the most important pathogenic mechanism of gut microbiota distrubance is the facilitation of bacteria and their toxic products to reach the liver through the gut liver-axis. The hepatic immune system is activated through pattern recognition receptors, such as Toll-like and NOD-like receptor signaling pathways. The release of pro-inflammatory cytokines including tumor necrosis factor and interleukins results in liver injury, which progresses to NAFLD. Application of probiotics, antibiotics and fecal microbiota transplantation has shown efficiency, which provides new targets for the prevention and treatment of NAFLD.

Urinary (1)H-NMR-based metabolic profiling of children with NAFLD undergoing VSL#3 treatment

BACKGROUND

Nowadays, non-alcoholic fatty liver disease (NAFLD) is one of the most common chronic liver diseases in children. Our recent clinical trial demonstrated that dietary and VSL#3-based interventions may improve fatty liver by ultrasound and body mass index (BMI) after 4 months.

OBJECTIVES

As in this short-term trial, as in others, it is impracticable to monitor response to therapy or treatment by liver biopsy, we aimed to identify a panel of potential non-invasive metabolic biomarkers by a urinary metabolic profiling.

METHODS

Urine samples from a group of 31 pediatric NAFLD patients, enrolled in a VSL#3 clinical trial, were analyzed by high-resolution proton nuclear magnetic resonance spectroscopy in combination with analysis of variance-Simultaneous Component Analysis model and multivariate data analyses. Urinary metabolic profiles were interpreted in terms of clinical patient feature, treatment and chronology pattern correlations.

RESULTS

VSL#3 treatment induced changes in NAFLD urinary metabolic phenotype mainly at level of host amino-acid metabolism (that is, valine, tyrosine, 3-amino-isobutyrate or β-aminoisobutyric acid (BAIBA)), nucleic acid degradation (pseudouridine), creatinine metabolism (methylguanidine) and secondarily at the level of gut microbial amino-acid metabolism (that is, 2-hydroxyisobutyrate from valine degradation). Furthermore, some of these metabolites correlated with clinical primary and secondary trial end points after VSL#3 treatment: tyrosine and the organic acid U4 positively with alanine aminotransferase (R=0.399, P=0.026) and BMI (R=0.36, P=0.045); BAIBA and tyrosine negatively with active glucagon-like-peptide 1 (R=-0.51, P=0.003; R=-0.41, P=0.021, respectively).

CONCLUSIONS

VSL#3 treatment-dependent urinary metabotypes of NAFLD children may be considered as non-invasive effective biomarkers to evaluate the response to treatment.

Hepatic and fecal metabolomic analysis of the effects of Lactobacillus rhamnosus GG on alcoholic fatty liver disease in mice

The interactions among the gut, liver, and immune system play an important role in liver disease. Probiotics have been used for the treatment and prevention of many pathological conditions, including liver diseases. Comprehensive two-dimensional gas chromatography time-of-flight mass spectrometry (GC×GC-TOF MS) was used herein, in conjunction with chemometric data analysis, to identify metabolites significantly affected by probiotics in mice fed with or without alcohol. The metabolomics analysis indicates that the levels of fatty acids increased in mouse liver and decreased in mouse feces when mice were chronically exposed to alcohol. Supplementing the alcohol-fed mice with culture supernatant from Lactobacillus rhamnosus GG (LGGs) normalized these alcohol-induced abnormalities and prevented alcoholic liver disease (ALD). These results agree well with previous studies. In addition to diet-derived long chain fatty acids (LCFAs), LGGs may positively modify the gut's bacterial population to stimulate LCFA synthesis, which has been shown to enhance intestinal barrier function, reduce endotoxemia, and prevent ALD. We also found that several amino acids, including l-isoleucine, a branched chain amino acid, were downregulated in the liver and fecal samples from animals exposed to alcohol and that the levels of these amino acids were corrected by LGGs. These results demonstrate that LGGs alleviates alcohol-induced fatty liver by mechanisms involving increasing intestinal and decreasing hepatic fatty acids and increasing amino acid concentration.

Focus on emerging drugs for the treatment of patients with non-alcoholic fatty liver disease

Non-alcoholic fatty liver disease (NAFLD) has become the most common liver disorder in Western countries and is increasingly being recognized in developing nations. Fatty liver disease encompasses a spectrum of hepatic pathology, ranging from simple steatosis to non-alcoholic steatohepatitis, cirrhosis, hepatocellular carcinoma and end-stage liver disease. Moreover, NAFLD is often associated with other metabolic conditions, such as diabetes mellitus type 2, dyslipidemia and visceral obesity. The most recent guidelines suggest the management and treatment of patients with NAFLD considering both the liver disease and the associated metabolic co-morbidities. Diet and physical exercise are considered the first line of treatment for patients with NAFLD, but their results on therapeutic efficacy are often contrasting. Behavior therapy is necessary most of the time to achieve a sufficient result. Pharmacological therapy includes a wide variety of classes of molecules with different therapeutic targets and, often, little evidence supporting the real efficacy. Despite the abundance of clinical trials, NAFLD therapy remains a challenge for the scientific community, and there are no licensed therapies for NAFLD. Urgently, new pharmacological approaches are needed. Here, we will focus on the challenges facing actual therapeutic strategies and the most recent investigated molecules.

Effect of probiotic administration on the intestinal microbiota, current knowledge and potential applications

Although it is now known that the human body is colonized by a wide variety of microbial populations in different parts (such as the mouth, pharynx and respiratory system, the skin, the gastro- and urogenital tracts), many effects of the complex interactions between the human host and microbial symbionts are still not completely understood. The dysbiosis of the gastrointestinal tract microbiota is considered to be one of the most important contributing factors in the development of many gastrointestinal diseases such as inflammatory bowel disease, irritable bowel syndrome and colorectal cancer, as well as systemic diseases like obesity, diabetes, atherosclerosis and non-alcoholic fatty liver disease. Fecal microbial transplantations appear to be promising therapies for dysbiosis-associated diseases; however, probiotic microorganisms have been growing in popularity due to increasing numbers of studies proving that certain strains present health promoting properties, among them the beneficial balance of the intestinal microbiota. Inflammatory bowel diseases and obesity are the pathologies in which there are more studies showing this beneficial association using animal models and even in human clinical trials. In this review, the association of the human gut microbiota and human health will be discussed along with the benefits that probiotics can confer on this symbiotic activity and on the prevention or treatment of associated diseases.

Modern approach to the clinical management of non-alcoholic fatty liver disease

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.

Bile acid dysregulation, gut dysbiosis, and gastrointestinal cancer

Because of increasingly widespread sedentary lifestyles and diets high in fat and sugar, the global diabetes and obesity epidemic continues to grow unabated. A substantial body of evidence has been accumulated which associates diabetes and obesity to dramatically higher risk of cancer development, particularly in the liver and gastrointestinal tract. Additionally, diabetic and obese individuals have been shown to suffer from dysregulation of bile acid (BA) homeostasis and dysbiosis of the intestinal microbiome. Abnormally elevated levels of cytotoxic secondary BAs and a pro-inflammatory shift in gut microbial profile have individually been linked to numerous enterohepatic diseases including cancer. However, recent findings have implicated a detrimental interplay between BA dysregulation and intestinal dysbiosis that promotes carcinogenesis along the gut-liver axis. This review seeks to examine the currently investigated interactions between the regulation of BA metabolism and activity of the intestinal microbiota and how these interactions can drive cancer formation in the context of diabesity. The precarcinogenic effects of BA dysregulation and gut dysbiosis including excessive inflammation, heightened oxidative DNA damage, and increased cell proliferation are discussed. Furthermore, by focusing on the mediatory roles of BA nuclear receptor farnesoid x receptor, ileal transporter apical sodium dependent BA transporter, and G-coupled protein receptor TGR5, this review attempts to connect BA dysregulation, gut dysbiosis, and enterohepatic carcinogenesis at a mechanistic level. A better understanding of the intricate interplay between BA homeostasis and gut microbiome can yield novel avenues to combat the impending rise in diabesity-related cancers.

Effects of resveratrol in experimental and clinical non-alcoholic fatty liver disease

The prevalence of obesity and related conditions like non-alcoholic fatty liver disease (NAFLD) is increasing worldwide and therapeutic options are limited. Alternative treatment options are therefore intensively sought after. An interesting candidate is the natural polyphenol resveratrol (RSV) that activates adenosinmonophosphate-activated protein kinase (AMPK) and silent information regulation-2 homolog 1 (SIRT1). In addition, RSV has known anti-oxidant and anti-inflammatory effects. Here, we review the current evidence for RSV-mediated effects on NAFLD and address the different aspects of NAFLD and non-alcoholic steatohepatitis (NASH) pathogenesis with respect to free fatty acid (FFA) flux from adipose tissue, hepatic de novo lipogenesis, inadequate FFA β-oxidation and additional intra- and extrahepatic inflammatory and oxidant hits. We review the in vivo evidence from animal studies and clinical trials. The abundance of animal studies reports a decrease in hepatic triglyceride accumulation, liver weight and a general improvement in histological fatty liver changes, along with a reduction in circulating insulin, glucose and lipid levels. Some studies document AMPK or SIRT1 activation, and modulation of relevant markers of hepatic lipogenesis, inflammation and oxidation status. However, AMPK/SIRT1-independent actions are also likely. Clinical trials are scarce and have primarily been performed with a focus on overweight/obese participants without a focus on NAFLD/NASH and histological liver changes. Future clinical studies with appropriate design are needed to clarify the true impact of RSV treatment in NAFLD/NASH patients.

Dietary habits and behaviors associated with nonalcoholic fatty liver disease

Nonalcoholic fatty liver disease (NAFLD) is one of the most frequent causes of health problems in Western (industrialized) countries. Moreover, the incidence of infantile NAFLD is increasing, with some of these patients progressing to nonalcoholic steatohepatitis. These trends depend on dietary habits and life-style. In particular, overeating and its associated obesity affect the development of NAFLD. Nutritional problems in patients with NAFLD include excess intake of energy, carbohydrates, and lipids, and shortages of polyunsaturated fatty acids, vitamins, and minerals. Although nutritional therapeutic approaches are required for prophylaxis and treatment of NAFLD, continuous nutrition therapy is difficult for many patients because of their dietary habits and lifestyle, and because the motivation for treatment differs among patients. Thus, it is necessary to assess the nutritional background and to identify nutritional problems in each patient with NAFLD. When assessing dietary habits, it is important to individually evaluate those that are consumed excessively or insufficiently, as well as inappropriate eating behaviors. Successful nutrition therapy requires patient education, based on assessments of individual nutrients, and continuing the treatment. In this article, we update knowledge about NAFLD, review the important aspects of nutritional assessment targeting treatment success, and present some concrete nutritional care plans which can be applied generally.

Meta-omic platforms to assist in the understanding of NAFLD gut microbiota alterations: tools and applications

Non-alcoholic fatty liver disease (NAFLD) is the most common cause of chronic liver disease worldwide as a result of the increasing prevalence of obesity, starting from early life stages. It is characterized by a spectrum of liver diseases ranging from simple fatty liver (NAFL) to steatohepatitis (NASH), with a possible progression to fibrosis, thus increasing liver-related morbidity and mortality. NAFLD development is driven by the co-action of several risk factors, including obesity and metabolic syndrome, which may be both genetically induced and diet-related. Recently, particular attention has been paid to the gut-liver axis, which may play a physio-pathological role in the onset and progression of the disease. The gut microbiota is intended to act as a bioreactor that can guarantee autonomous metabolic and immunological functions and that can drive functional strategies within the environment of the body in response to external stimuli. The complexity of the gut microbiota suggests that it behaves as an organ. Therefore, the concept of the gut-liver axis must be complemented with the gut-microbiota-liver network due to the high intricacy of the microbiota components and metabolic activities; these activities form the active diet-driven power plant of the host. Such complexity can only be revealed using systems biology, which can integrate clinical phenomics and gut microbiota data.

Non-alcoholic fatty liver disease, diet and gut microbiota

Non-alcoholic fatty liver disease (NAFLD) is a severe liver disease that is increasing in prevalence with the worldwide epidemic of obesity and its related insulin-resistance state. Evidence for the role of the gut microbiota in energy storage and the subsequent development of obesity and some of its related diseases is now well established. More recently, a new role of gut microbiota has emerged in NAFLD. The gut microbiota is involved in gut permeability, low-grade inflammation and immune balance, it modulates dietary choline metabolism, regulates bile acid metabolism and produces endogenous ethanol. All of these factors are molecular mechanisms by which the microbiota can induce NAFLD or its progression toward overt non-alcoholic steatohepatitis. Modification of the gut microbiota composition and/or its biochemical capacity by specific dietary or pharmacological interventions may advantageously affect host metabolism. Large-scale intervention trials, investigating the potential benefit of prebiotics and probiotics in improving cardiometabolic health in high-risk populations, are fervently awaited.