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Jamshidi N, Feizi A, Sirlin CB, Lavine JE, Kuo MD. Multi-Modality, Multi-Dimensional Characterization of Pediatric Non-Alcoholic Fatty Liver Disease. Metabolites 2023; 13:929. [PMID: 37623872 PMCID: PMC10456937 DOI: 10.3390/metabo13080929] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Revised: 07/29/2023] [Accepted: 08/02/2023] [Indexed: 08/26/2023] Open
Abstract
Non-alcoholic fatty liver disease is a multifaceted disease that progresses through multiple phases; it involves metabolic as well as structural changes. These alterations can be measured directly or indirectly through blood, non-invasive imaging, and/or tissue analyses. While some studies have evaluated the correlations between two sets of measurements (e.g., histopathology with cross-sectional imaging or blood biomarkers), the interrelationships, if any, among histopathology, clinical blood profiles, cross-sectional imaging, and metabolomics in a pediatric cohort remain unknown. We created a multiparametric clinical MRI-histopathologic NMR network map of pediatric NAFLD through multimodal correlation networks, in order to gain insight into how these different sets of measurements are related. We found that leptin and other blood markers were correlated with many other measurements; however, upon filtering out the blood biomarkers, the network was decomposed into three independent hubs centered around histopathological features, each with associated MRI and plasma metabolites. These multi-modality maps could serve as a framework for characterizing disease status and progression and could potentially guide medical interventions.
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Affiliation(s)
- Neema Jamshidi
- Department of Radiological Sciences, David Geffen School of Medicine, University of California, Los Angeles, CA 90095, USA
| | - Alborz Feizi
- School of Medicine, Yale University, New Haven, CT 06520, USA
| | - Claude B. Sirlin
- Department of Radiology, University of California, San Diego, CA 92093, USA
| | - Joel E. Lavine
- Department of Pediatrics, Columbia University, New York, NY 10027, USA
| | - Michael D. Kuo
- Medical AI Laboratory Program, The University of Hong Kong, Hong Kong SAR, China
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Sanyal AJ, Williams SA, Lavine JE, Neuschwander-Tetri BA, Alexander L, Ostroff R, Biegel H, Kowdley KV, Chalasani N, Dasarathy S, Diehl AM, Loomba R, Hameed B, Behling C, Kleiner DE, Karpen SJ, Williams J, Jia Y, Yates KP, Tonascia J. Defining the serum proteomic signature of hepatic steatosis, inflammation, ballooning and fibrosis in non-alcoholic fatty liver disease. J Hepatol 2023; 78:693-703. [PMID: 36528237 PMCID: PMC10165617 DOI: 10.1016/j.jhep.2022.11.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Revised: 11/01/2022] [Accepted: 11/23/2022] [Indexed: 12/15/2022]
Abstract
BACKGROUND & AIMS Despite recent progress, non-invasive tests for the diagnostic assessment and monitoring of non-alcoholic fatty liver disease (NAFLD) remain an unmet need. Herein, we aimed to identify diagnostic signatures of the key histological features of NAFLD. METHODS Using modified-aptamer proteomics, we assayed 5,220 proteins in each of 2,852 single serum samples from 636 individuals with histologically confirmed NAFLD. We developed and validated dichotomized protein-phenotype models to identify clinically relevant severities of steatosis (grade 0 vs. 1-3), hepatocellular ballooning (0 vs. 1 or 2), lobular inflammation (0-1 vs. 2-3) and fibrosis (stages 0-1 vs. 2-4). RESULTS The AUCs of the four protein models, based on 37 analytes (18 not previously linked to NAFLD), for the diagnosis of their respective components (at a clinically relevant severity) in training/paired validation sets were: fibrosis (AUC 0.92/0.85); steatosis (AUC 0.95/0.79), inflammation (AUC 0.83/0.72), and ballooning (AUC 0.87/0.83). An additional outcome, at-risk NASH, defined as steatohepatitis with NAFLD activity score ≥4 (with a score of at least 1 for each of its components) and fibrosis stage ≥2, was predicted by multiplying the outputs of each individual component model (AUC 0.93/0.85). We further evaluated their ability to detect change in histology following treatment with placebo, pioglitazone, vitamin E or obeticholic acid. Component model scores significantly improved in the active therapies vs. placebo, and differential effects of vitamin E, pioglitazone, and obeticholic acid were identified. CONCLUSIONS Serum protein scanning identified signatures corresponding to the key components of liver biopsy in NAFLD. The models developed were sufficiently sensitive to characterize the longitudinal change for three different drug interventions. These data support continued validation of these proteomic models to enable a "liquid biopsy"-based assessment of NAFLD. CLINICAL TRIAL NUMBER Not applicable. IMPACT AND IMPLICATIONS An aptamer-based protein scan of serum proteins was performed to identify diagnostic signatures of the key histological features of non-alcoholic fatty liver disease (NAFLD), for which no approved non-invasive diagnostic tools are currently available. We also identified specific protein signatures related to the presence and severity of NAFLD and its histological components that were also sensitive to change over time. These are fundamental initial steps in establishing a serum proteome-based diagnostic signature of NASH and provide the rationale for using these signatures to test treatment response and to identify several novel targets for evaluation in the pathogenesis of NAFLD.
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Affiliation(s)
- Arun J Sanyal
- Stravitz-Sanyal Institute for Liver Disease and Metabolic Health, Virginia Commonwealth University School of Medicine, Richmond, VA, USA.
| | | | - Joel E Lavine
- Dept. of Pediatrics, Columbia University, New York, NY, USA
| | | | | | | | | | | | - Naga Chalasani
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Srinivasan Dasarathy
- Division of Gastroenterology and Hepatology, Cleveland Clinic, Cleveland, OH, USA
| | - Anna Mae Diehl
- Division of Gastroenterology and Hepatology, Duke University School of Medicine, Durham, NC, USA
| | - Rohit Loomba
- NAFLD Research Center, University of California San Diego School of Medicine, San Diego, CA, USA
| | - Bilal Hameed
- Division of Gastroenterology and Hepatology, University of California San Francisco School of Medicine, San Francisco, CA, USA
| | - Cynthia Behling
- NAFLD Research Center, University of California San Diego School of Medicine, San Diego, CA, USA
| | - David E Kleiner
- Laboratory of Pathology, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA
| | - Saul J Karpen
- Dept. of Pediatrics, Emory University School of Medicine, Atlanta, GA, USA
| | | | - Yi Jia
- Clinical R&D, SomaLogic Inc., Boulder, CO, USA
| | - Katherine P Yates
- Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | - James Tonascia
- Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
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3
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Shen W, Middleton MS, Cunha GM, Delgado TI, Wolfson T, Gamst A, Fowler KJ, Alazraki A, Trout AT, Ohliger MA, Shah SN, Bashir MR, Kleiner DE, Loomba R, Neuschwander-Tetri BA, Sanyal AJ, Zhou J, Sirlin CB, Lavine JE. Changes in abdominal adipose tissue depots assessed by MRI correlate with hepatic histologic improvement in non-alcoholic steatohepatitis. J Hepatol 2023; 78:238-246. [PMID: 36368598 PMCID: PMC9852022 DOI: 10.1016/j.jhep.2022.10.027] [Citation(s) in RCA: 13] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Revised: 10/10/2022] [Accepted: 10/12/2022] [Indexed: 11/09/2022]
Abstract
BACKGROUND & AIMS Non-alcoholic steatohepatitis (NASH) is prevalent in adults with obesity and can progress to cirrhosis. In a secondary analysis of prospectively acquired data from the multicenter, randomized, placebo-controlled FLINT trial, we investigated the relationship between reduction in adipose tissue compartment volumes and hepatic histologic improvement. METHODS Adult participants in the FLINT trial with paired liver biopsies and abdominal MRI exams at baseline and end-of-treatment (72 weeks) were included (n = 76). Adipose tissue compartment volumes were obtained using MRI. RESULTS Treatment and placebo groups did not differ in baseline adipose tissue volumes, or in change in adipose tissue volumes longitudinally (p = 0.107 to 0.745). Deep subcutaneous adipose tissue (dSAT) and visceral adipose tissue volume reductions were associated with histologic improvement in NASH (i.e., NAS [non-alcoholic fatty liver disease activity score] reductions of ≥2 points, at least 1 point from lobular inflammation and hepatocellular ballooning, and no worsening of fibrosis) (p = 0.031, and 0.030, respectively). In a stepwise logistic regression procedure, which included demographics, treatment group, baseline histology, baseline and changes in adipose tissue volumes, MRI hepatic proton density fat fraction (PDFF), and serum aminotransferases as potential predictors, reductions in dSAT and PDFF were associated with histologic improvement in NASH (regression coefficient = -2.001 and -0.083, p = 0.044 and 0.033, respectively). CONCLUSIONS In adults with NASH in the FLINT trial, those with greater longitudinal reductions in dSAT and potentially visceral adipose tissue volumes showed greater hepatic histologic improvements, independent of reductions in hepatic PDFF. CLINICAL TRIAL NUMBER NCT01265498. IMPACT AND IMPLICATIONS Although central obesity has been identified as a risk factor for obesity-related disorders including insulin resistance and cardiovascular disease, the role of central obesity in non-alcoholic steatohepatitis (NASH) warrants further clarification. Our results highlight that a reduction in central obesity, specifically deep subcutaneous adipose tissue and visceral adipose tissue, may be related to histologic improvement in NASH. The findings from this analysis should increase awareness of the importance of lifestyle intervention in NASH for clinical researchers and clinicians. Future studies and clinical practice may design interventions that assess the reduction of deep subcutaneous adipose tissue and visceral adipose tissue as outcome measures, rather than simply weight reduction.
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Affiliation(s)
- Wei Shen
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Columbia University Irving Medical Center, New York, NY, USA;; Institute of Human Nutrition, College of Physicians & Surgeons, Columbia University Irving Medical Center; NY, USA;; Columbia Magnetic Resonance Research Center (CMRRC), Columbia University, USA.
| | - Michael S Middleton
- Liver Imaging Group, Department of Radiology, UCSD School of Medicine, San Diego, CA, USA
| | | | - Timoteo I Delgado
- Liver Imaging Group, Department of Radiology, UCSD School of Medicine, San Diego, CA, USA
| | - Tanya Wolfson
- Computational and Applied Statistics Laboratory (CASL), San Diego Supercomputer Center at UCSD, San Diego, CA, USA
| | - Anthony Gamst
- Computational and Applied Statistics Laboratory (CASL), San Diego Supercomputer Center at UCSD, San Diego, CA, USA;; Department of Mathematics, UCSD, San Diego, CA, USA
| | - Kathryn J Fowler
- Liver Imaging Group, Department of Radiology, UCSD School of Medicine, San Diego, CA, USA
| | - Adina Alazraki
- Emory University School of Medicine, Department of Radiology and Imaging Sciences and Children's Healthcare of Atlanta, Atlanta, GA, USA
| | - Andrew T Trout
- Department of Radiology, Cincinnati Children's Hospital Medical Center and Department of Radiology, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Michael A Ohliger
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, CA, USA
| | - Shetal N Shah
- Section of Abdominal Imaging and Nuclear Medicine Department, Imaging Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Mustafa R Bashir
- Department of Radiology, Duke University Medical Center, Durham, North Carolina, USA;; Center for Advanced Magnetic Resonance Development, (CAMRD), Department of Radiology, Duke University Medical Center, Durham, NC, USA;; Division of Gastroenterology, Department of Medicine, Duke University Medical Center, Durham, NC, USA
| | - David E Kleiner
- Laboratory of Pathology, National Cancer Institute, Bethesda, MD, USA
| | - Rohit Loomba
- NAFLD Research Center, Division of Gastroenterology, Department of Medicine, University of California-San Diego, La Jolla, CA, USA
| | | | | | - Jane Zhou
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Columbia University Irving Medical Center, New York, NY, USA
| | - Claude B Sirlin
- Liver Imaging Group, Department of Radiology, UCSD School of Medicine, San Diego, CA, USA
| | - Joel E Lavine
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Columbia University Irving Medical Center, New York, NY, USA;; Institute of Human Nutrition, College of Physicians & Surgeons, Columbia University Irving Medical Center; NY, USA
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Berg EA, Huang Z, Wang Y, Baidal JW, Fennoy I, Lavine JE, Zitsman J, Shen W. Magnetic Resonance Imaging to Assess Body Composition Change in Adolescents With Obesity After Sleeve Gastrectomy. J Pediatr Gastroenterol Nutr 2022; 75:761-767. [PMID: 36070531 PMCID: PMC9675718 DOI: 10.1097/mpg.0000000000003607] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVES Metabolic and bariatric surgery is the most effective weight loss treatment for severe obesity. The number of adolescents undergoing sleeve gastrectomy is increasing. We investigated changes in body composition in adolescents undergoing sleeve gastrectomy 12-26 weeks post-operatively using whole-body magnetic resonance imaging (WB-MRI). METHODS This prospective cohort study assessed changes in adipose tissue compartments (ie, visceral, subcutaneous, and intermuscular) and muscle in 18 obese adolescents, ages 14-19, 89% female, with body mass index z -score of 2.6 ± 0.25 (range 2.16-3.2). All underwent WB-MRI 1.5-17 weeks pre-operatively and 12-26 weeks post-operatively. RESULTS Pre- and post-operative WB-MRI showed decreases in all adipose tissue compartments, as well as decreased skeletal muscle and liver fat fraction ( P < 0.0001). The post-operative percentage loss of adipose tissue in subcutaneous, visceral, and intermuscular compartments (89.0%, 5.8%, 5.2%, respectively) was similar to the pre-operative percentages of corresponding adipose tissue compartments (90.5%, 5.0%, 4.5%, respectively). Of note, participants with obstructive sleep apnea had significantly higher pre-operative volume of subcutaneous and intermuscular adipose tissue than participants without obstructive sleep apnea ( P = 0.003). CONCLUSIONS We found, contrary to what is reported to occur in adults, that pre-operative percentage loss of adipose tissue in subcutaneous, visceral, and intermuscular compartments was similar to the post-operative percentage loss of corresponding adipose tissue compartments in adolescents 12-26 weeks after sleeve gastrectomy.
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Affiliation(s)
- Elizabeth A. Berg
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Vagelos College of Physicians and Surgeons, Columbia University Irving Medical Center
| | - Zixing Huang
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Vagelos College of Physicians and Surgeons, Columbia University Irving Medical Center
| | - Youya Wang
- Institute of Human Nutrition, Vagelos College of Physicians and Surgeons, Columbia University Irving Medical Center
| | - Jennifer Woo Baidal
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Vagelos College of Physicians and Surgeons, Columbia University Irving Medical Center
| | - Ilene Fennoy
- Division of Pediatric Endocrinology, Department of Pediatrics, Vagelos College of Physicians and Surgeons, Columbia University Irving Medical Center
| | - Joel E. Lavine
- Institute of Human Nutrition, Vagelos College of Physicians and Surgeons, Columbia University Irving Medical Center
| | - Jeffrey Zitsman
- Division of Pediatric Surgery, Vagelos College of Physicians and Surgeons, Columbia University Irving Medical Center
| | - Wei Shen
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Vagelos College of Physicians and Surgeons, Columbia University Irving Medical Center
- Institute of Human Nutrition, Vagelos College of Physicians and Surgeons, Columbia University Irving Medical Center
- Columbia Magnetic Resonance Research Center (CMRRC), Columbia University
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5
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Vos MB, Van Natta ML, Blondet NM, Dasarathy S, Fishbein M, Hertel P, Jain AK, Karpen SJ, Lavine JE, Mohammad S, Miriel LA, Molleston JP, Mouzaki M, Sanyal A, Sharkey EP, Schwimmer JB, Tonascia J, Wilson LA, Xanthakos SA. Randomized placebo-controlled trial of losartan for pediatric NAFLD. Hepatology 2022; 76:429-444. [PMID: 35133671 PMCID: PMC9288975 DOI: 10.1002/hep.32403] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2021] [Revised: 11/18/2021] [Accepted: 12/04/2021] [Indexed: 01/28/2023]
Abstract
BACKGROUND AND AIMS To date, no pharmacotherapy exists for pediatric NAFLD. Losartan, an angiotensin II receptor blocker, has been proposed as a treatment due to its antifibrotic effects. APPROACH AND RESULTS The Nonalcoholic Steatohepatitis Clinical Research Network conducted a multicenter, double-masked, placebo-controlled, randomized clinical trial in children with histologically confirmed NAFLD at 10 sites (September 2018 to April 2020). Inclusion criteria were age 8-17 years, histologic NAFLD activity score ≥ 3, and serum alanine aminotransferase (ALT) ≥ 50 U/l. Children received 100 mg of losartan or placebo orally once daily for 24 weeks. The primary outcome was change in ALT levels from baseline to 24 weeks, and the preset sample size was n = 110. Treatment effects were assessed using linear regression of change in treatment group adjusted for baseline value. Eighty-three participants (81% male, 80% Hispanic) were randomized to losartan (n = 43) or placebo (n = 40). During an enrollment pause, necessitated by the 2019 coronavirus pandemic, an unplanned interim analysis showed low probability (7%) of significant group difference. The Data and Safety Monitoring Board recommended early study termination. Baseline characteristics were similar between groups. The 24-week change in ALT did not differ significantly between losartan versus placebo groups (adjusted mean difference: 1.1 U/l; 95% CI = -30.6, 32.7; p = 0.95), although alkaline phosphatase decreased significantly in the losartan group (adjusted mean difference: -23.4 U/l; 95% CI = -41.5, -5.3; p = 0.01). Systolic blood pressure decreased in the losartan group but increased in placebo (adjusted mean difference: -7.5 mm Hg; 95% CI = -12.2, -2.8; p = 0.002). Compliance by pill counts and numbers and types of adverse events did not differ by group. CONCLUSIONS Losartan did not significantly reduce ALT in children with NAFLD when compared with placebo.
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Affiliation(s)
- Miriam B Vos
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, Georgia, USA
| | - Mark L Van Natta
- Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Niviann M Blondet
- Division of Pediatric Gastroenterology and Hepatology, Seattle Children's Hospital, University of Washington, Seattle, Washington, USA
| | - Srinivasan Dasarathy
- Division of Gastroenterology, Hepatology and Nutrition, Cleveland Clinic, Cleveland, Ohio, USA
| | - Mark Fishbein
- Department of Pediatrics, Feinberg Medical School of Northwestern University, Chicago, Illinois, USA
| | - Paula Hertel
- Division of Gastroenterology, Hepatology and Nutrition, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas, USA
| | - Ajay K Jain
- Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, St. Louis University, St. Louis, Missouri, USA
| | - Saul J Karpen
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, Georgia, USA
| | - Joel E Lavine
- Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Columbia University Vagelos College of Physicians and Surgeons, New York, New York, USA
| | - Saeed Mohammad
- Department of Pediatrics, Feinberg Medical School of Northwestern University, Chicago, Illinois, USA
| | - Laura A Miriel
- Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Jean P Molleston
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Indiana University School of Medicine/Riley Hospital for Children, Indianapolis, Indiana, USA
| | - Marialena Mouzaki
- Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Arun Sanyal
- Department of Internal Medicine, Division of Gastroenterology, Hepatology and Nutrition, Virginia Commonwealth University School of Medicine, Richmond, Virginia, USA
| | - Emily P Sharkey
- Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Jeffrey B Schwimmer
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, University of California San Diego School of Medicine, La Jolla, California, USA
| | - James Tonascia
- Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Laura A Wilson
- Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Stavra A Xanthakos
- Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
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Yu J, Zhu C, Wang X, Kim K, Bartolome A, Dongiovanni P, Yates KP, Valenti L, Carrer M, Sadowski T, Qiang L, Tabas I, Lavine JE, Pajvani UB. Hepatocyte TLR4 triggers inter-hepatocyte Jagged1/Notch signaling to determine NASH-induced fibrosis. Sci Transl Med 2021; 13:eabe1692. [PMID: 34162749 PMCID: PMC8792974 DOI: 10.1126/scitranslmed.abe1692] [Citation(s) in RCA: 45] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2020] [Revised: 02/19/2021] [Accepted: 05/26/2021] [Indexed: 12/19/2022]
Abstract
Aberrant hepatocyte Notch activity is critical to the development of nonalcoholic steatohepatitis (NASH)-induced liver fibrosis, but mechanisms underlying Notch reactivation in developed liver are unclear. Here, we identified that increased expression of the Notch ligand Jagged1 (JAG1) tracked with Notch activation and nonalcoholic fatty liver disease (NAFLD) activity score (NAS) in human liver biopsy specimens and mouse NASH models. The increase in Jag1 was mediated by hepatocyte Toll-like receptor 4 (TLR4)-nuclear factor κB (NF-κB) signaling in pericentral hepatocytes. Hepatocyte-specific Jag1 overexpression exacerbated fibrosis in mice fed a high-fat diet or a NASH-provoking diet rich in palmitate, cholesterol, and sucrose and reversed the protection afforded by hepatocyte-specific TLR4 deletion, whereas hepatocyte-specific Jag1 knockout mice were protected from NASH-induced liver fibrosis. To test therapeutic potential of this biology, we designed a Jag1-directed antisense oligonucleotide (ASO) and a hepatocyte-specific N-acetylgalactosamine (GalNAc)-modified siRNA, both of which reduced NASH diet-induced liver fibrosis in mice. Overall, these data demonstrate that increased hepatocyte Jagged1 is the proximal hit for Notch-induced liver fibrosis in mice and suggest translational potential of Jagged1 inhibitors in patients with NASH.
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Affiliation(s)
- Junjie Yu
- Department of Medicine, Columbia University, New York, NY 10032, USA
| | - Changyu Zhu
- Department of Medicine, Columbia University, New York, NY 10032, USA
| | - Xiaobo Wang
- Department of Medicine, Columbia University, New York, NY 10032, USA
| | - KyeongJin Kim
- Department of Medicine, Columbia University, New York, NY 10032, USA
| | - Alberto Bartolome
- Department of Medicine, Columbia University, New York, NY 10032, USA
| | - Paola Dongiovanni
- General Medicine and Metabolic Diseases, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan 20122, Italy
| | - Katherine P Yates
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD 21205, USA
| | - Luca Valenti
- Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan 20122, Italy
- Translational Medicine, Department of Transfusion Medicine and Hematology, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan 20122, Italy
| | | | | | - Li Qiang
- Department of Pathology and Cell Biology, Columbia University, New York, NY 10032, USA
| | - Ira Tabas
- Department of Medicine, Columbia University, New York, NY 10032, USA
- Department of Pathology and Cell Biology, Columbia University, New York, NY 10032, USA
- Department of Physiology, Columbia University, New York, NY 10032, USA
| | - Joel E Lavine
- Department of Pediatrics, Columbia University, New York, NY 10032, USA
| | - Utpal B Pajvani
- Department of Medicine, Columbia University, New York, NY 10032, USA.
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7
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Newton KP, Lavine JE, Wilson L, Behling C, Vos MB, Molleston JP, Rosenthal P, Miloh T, Fishbein MH, Jain AK, Murray KF, Schwimmer JB. Alanine Aminotransferase and Gamma-Glutamyl Transpeptidase Predict Histologic Improvement in Pediatric Nonalcoholic Steatohepatitis. Hepatology 2021; 73:937-951. [PMID: 32416645 PMCID: PMC7669708 DOI: 10.1002/hep.31317] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2019] [Revised: 03/25/2020] [Accepted: 04/27/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND AIMS Predictive, noninvasive tools are needed to monitor key features of nonalcoholic fatty liver disease (NAFLD) in children that relate to improvement in liver histology. The purpose of this study was to evaluate the relationship between liver chemistries and liver histology using data from the CyNCh (Cysteamine Bitartrate Delayed-Release for the Treatment of NAFLD in Children) clinical trial. APPROACH AND RESULTS This study included 146 children. Improvement in liver histology, defined as decrease in nonalcoholic fatty liver disease (NAFLD) Activity Score ≥2 points without worsening of fibrosis, occurred in 43 participants (30%). There were 46 participants with borderline zone 1 nonalcoholic steatohepatitis (NASH) at baseline, with resolution in 28% (12 of 46). Multivariate models were constructed using baseline and change in alanine aminotransferase (ALT), aspartate aminotransferase (AST), and gamma-glutamyl transferase (GGT) at 52 weeks, for improvement in (1) liver histology primary outcome, (2) borderline zone 1 NASH, and (3) fibrosis. For improvement in histology, the model (P < 0.0001) retained baseline and change in GGT (area under the receiver operating characteristic [AUROC], 0.79; 95% confidence interval [CI], 0.71-0.87). For borderline zone 1 NASH, the model (P = 0.0004) retained baseline and change in ALT (AUROC, 0.80; 95% CI, 0.67-0.93). For fibrosis, the model (P < 0.001) retained baseline and change in ALT (AUROC, 0.80; 95% CI, 0.67-0.93). Additional clinical parameters were added to the models using Akaike's information criterion selection, and significantly boosted performance: improvement in histology with AUROC of 0.89 (95% CI, 0.82-0.95), borderline zone 1 NASH with AUROC of 0.91 (95% CI, 0.83-0.99), and fibrosis with AUROC of 0.89 (95% CI, 0.82-0.94). Models were validated using data from the TONIC (Treatment of Nonalcoholic Fatty Liver Disease in Children) trial. CONCLUSIONS In children with NAFLD, dynamic changes in serum ALT and GGT are associated with change in liver histology and appear to be powerful indicators of histological response.
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Affiliation(s)
- Kimberly P Newton
- Division of Gastroenterology, Hepatology, and NutritionDepartment of PediatricsUniversity of California San Diego School of MedicineLa JollaCA.,Division of GastroenterologyDepartment of PediatricsRady Children's HospitalSan DiegoCA
| | - Joel E Lavine
- Division of Pediatric Gastroenterology, Hepatology and NutritionDepartment of PediatricsColumbia UniversityNew YorkNY
| | - Laura Wilson
- Department of EpidemiologyBloomberg School of Public HealthJohns Hopkins UniversityBaltimoreMD.,Department of MedicineJohns Hopkins UniversitySchool of MedicineBaltimoreMD
| | - Cynthia Behling
- Division of Gastroenterology, Hepatology, and NutritionDepartment of PediatricsUniversity of California San Diego School of MedicineLa JollaCA.,Department of PathologySharp Medical CenterSan DiegoCA
| | - Miriam B Vos
- Department of PediatricsEmory University School of Medicine and Children's Healthcare of AtlantaAtlantaGA
| | | | - Philip Rosenthal
- Departments of Pediatrics & SurgeryUniversity of CaliforniaSan FranciscoCA
| | - Tamir Miloh
- Department of PediatricsTexas Children's HospitalHoustonTX
| | - Mark H Fishbein
- Department of PediatricsAnn & Robert H. Lurie Children's Hospital of ChicagoChicagoIL
| | - Ajay K Jain
- Department of PediatricsSaint Louis UniversitySt. LouisMI
| | - Karen F Murray
- Department of PediatricsCleveland Clinic Children's HospitalClevelandOH
| | - Jeffrey B Schwimmer
- Division of Gastroenterology, Hepatology, and NutritionDepartment of PediatricsUniversity of California San Diego School of MedicineLa JollaCA.,Division of GastroenterologyDepartment of PediatricsRady Children's HospitalSan DiegoCA
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Xanthakos SA, Lavine JE, Yates KP, Schwimmer JB, Molleston JP, Rosenthal P, Murray KF, Vos MB, Jain AK, Scheimann AO, Miloh T, Fishbein M, Behling CA, Brunt EM, Sanyal AJ, Tonascia J. Progression of Fatty Liver Disease in Children Receiving Standard of Care Lifestyle Advice. Gastroenterology 2020; 159:1731-1751.e10. [PMID: 32712103 PMCID: PMC7680281 DOI: 10.1053/j.gastro.2020.07.034] [Citation(s) in RCA: 44] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2019] [Revised: 06/19/2020] [Accepted: 07/19/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND & AIMS Nonalcoholic fatty liver disease (NAFLD) is the most common pediatric chronic liver disease. Little is known about outcomes in recognized youth. METHODS We compared paired liver biopsies from 122 of 139 children with NAFLD (74% male; 64% white; 71% Hispanic; mean age, 13 ± 3 years; age range, 8-17 years) who received placebo and standard of care lifestyle advice in 2 double-blind, randomized clinical trials within the nonalcoholic steatohepatitis (NASH) clinical research network from 2005 through 2015. We analyzed histologic changes with respect to baseline and longitudinal change in clinical variables using regression analysis. RESULTS At enrollment, 31% of the children had definite NASH, 34% had borderline zone 1 NASH, 13% had borderline zone 3 NASH, and 21% had fatty liver but not NASH. Over a mean period of 1.6 ± 0.4 years, borderline or definite NASH resolved in 29% of the children, whereas 18% of the children with fatty liver or borderline NASH developed definite NASH. Fibrosis improved in 34% of the children but worsened in 23%. Any progression to definite NASH and/or in fibrosis was associated with adolescent age, and higher waist circumference, levels of alanine or aspartate aminotransferase, total and low-density lipoprotein cholesterol at baseline (<0.05), and over follow-up time, with increasing level of alanine aminotransferase, hemoglobin A1C (P<.05), gamma-glutamyl transferase and development of type 2 diabetes (P<.01). Increasing level of gamma-glutamyl transferase was also associated with reduced odds of any improvement (P = .003). CONCLUSIONS One-third of children with NAFLD enrolled in placebo groups of clinical trials had histologic features of progression within 2 years, in association with increasing obesity and serum levels of aminotransferases and loss of glucose homeostasis.
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Affiliation(s)
- Stavra A. Xanthakos
- Division of Gastroenterology, Hepatology and Nutrition, Cincinnati Children’s Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Joel E. Lavine
- Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Columbia Vagelos College of Physicians and Surgeons, New York, New York
| | | | - Jeffrey B. Schwimmer
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, University of California San Diego School of Medicine, La Jolla, California
| | - Jean P. Molleston
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Indiana University School of Medicine/Riley Hospital for Children, Indianapolis, Indiana
| | - Philip Rosenthal
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, University of California, Benioff Children’s Hospital, San Francisco, California
| | - Karen F. Murray
- Pediatrics Institute, Cleveland Clinic Children’s, Cleveland, Ohio
| | - Miriam B. Vos
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Emory University School of Medicine, Children’s Healthcare of Atlanta, Atlanta, Georgia
| | - Ajay K. Jain
- Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, St. Louis University, St. Louis, Missouri
| | | | - Tamir Miloh
- Miami Transplant Institute, University of Miami Miller School of Medicine, Miami, Florida
| | - Mark Fishbein
- Department of Pediatrics, Feinberg Medical School of Northwestern University, Chicago, Illinois
| | - Cynthia A. Behling
- Department of Pathology, Sharp Memorial Hospital; Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, University of California, San Diego, California
| | - Elizabeth M. Brunt
- Department of Pathology and Immunology, Washington University, St. Louis, Missouri
| | - Arun J. Sanyal
- Department of Internal Medicine, Division of Gastroenterology, Hepatology and Nutrition, Virginia Commonwealth University School of Medicine, Richmond, Virginia
| | - James Tonascia
- Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
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Mueller NT, Liu T, Mitchel EB, Yates KP, Suzuki A, Behling C, Lavine JE. Sex Hormone Relations to Histologic Severity of Pediatric Nonalcoholic Fatty Liver Disease. J Clin Endocrinol Metab 2020; 105:5896884. [PMID: 32840311 PMCID: PMC7494240 DOI: 10.1210/clinem/dgaa574] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Accepted: 08/18/2020] [Indexed: 01/09/2023]
Abstract
CONTEXT Sex hormones have been linked with presence and severity of nonalcoholic fatty liver disease (NAFLD) in adults, but it is unknown if they affect severity of pediatric NAFLD. OBJECTIVE To examine associations of circulating SHBG, estrogens, and androgens with key histologic features of pediatric, biopsy-confirmed NAFLD. DESIGN Baseline assessment of longitudinal cohorts and randomized clinical trials. SETTING Nonalcoholic Steatohepatitis Clinical Research Network. PATIENTS Children and adolescents ≤18 years with liver biopsy-confirmed NAFLD in the United States. MAIN OUTCOME MEASURES We assayed SHBG, estrone, estradiol, dehydroepiandrosterone (DHEAS), androstenedione, and testosterone in relation to grade/stage of steatosis, portal inflammation, hepatic ballooning, fibrosis, and nonalcoholic steatohepatitis (NASH) severity using linear regression. RESULTS Mean age of 573 children at the time of biopsy was 13.1 years (SD 2.8). Lower SHBG was inversely associated with steatosis severity in boys and girls (P = 0.001), and with portal inflammation in girls only (P for sex interaction <0.001). Higher testosterone was related to improved features of steatosis and fibrosis (P for sex interaction = 0.003 and 0.01, respectively) in boys, but detrimental in girls. In boys and girls, higher estrone, estradiol, and testosterone were associated with lower portal inflammation grade; higher estradiol was positively associated with hepatic ballooning severity; DHEAS was inversely associated with hepatic ballooning and NASH severity (all P < 0.05). Androstenedione was not associated with NAFLD features. CONCLUSIONS Largely consistent with findings in adults, sex hormones are associated with distinct histologic features of NAFLD in children and adolescents. These hormone levels relate to differences with gender and pubertal change.
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Affiliation(s)
- Noel T Mueller
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
- Welch Center for Prevention, Epidemiology and Clinical Research, Johns Hopkins University, Baltimore, Maryland, USA
| | - Tiange Liu
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Elana B Mitchel
- Department of Pediatrics, Columbia Vagelos College of Physicians and Surgeons, New York, New York, USA
| | - Katherine P Yates
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Ayako Suzuki
- Department of Medicine, Duke University, Durham, North Carolina, USA
| | - Cynthia Behling
- Department of Pathology, Sharp Memorial Hospital, San Diego, California, USA
| | - Joel E Lavine
- Department of Pediatrics, Columbia Vagelos College of Physicians and Surgeons, New York, New York, USA
- Correspondence and Reprint Requests: Joel E. Lavine, MD, PhD, 622 W. 168th St, PH17-105H, Department of Pediatrics, Columbia Vagelos College of Physicians and Surgeons, New York, NY 10032. E-mail:
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10
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Loomba R, Neuschwander-Tetri BA, Sanyal A, Chalasani N, Diehl AM, Terrault N, Kowdley K, Dasarathy S, Kleiner D, Behling C, Lavine J, Van Natta M, Middleton M, Tonascia J, Sirlin C, Allende D, Dasarathy S, McCullough AJ, Penumatsa R, Dasarathy J, Lavine JE, Abdelmalek MF, Bashir M, Buie S, Diehl AM, Guy C, Kigongo C, Kopping M, Malik D, Piercy D, Chalasani N, Cummings OW, Gawrieh S, Ragozzino L, Sandrasegaran K, Vuppalanchi R, Brunt EM, Cattoor T, Carpenter D, Freebersyser J, King D, Lai J, Neuschwander‐Tetri BA, Siegner J, Stewart S, Torretta S, Wriston K, Gonzalez MC, Davila J, Jhaveri M, Kowdley KV, Mukhtar N, Ness E, Poitevin M, Quist B, Soo S, Ang B, Behling C, Bhatt A, Loomba R, Middleton MS, Sirlin C, Akhter MF, Bass NM, Brandman D, Gill R, Hameed B, Maher J, Terrault N, Ungermann A, Yeh M, Boyett S, Contos MJ, Kirwin S, Luketic VA, Puri P, Sanyal AJ, Schlosser J, Siddiqui MS, Yost‐Schomer L, Brunt EM, Fowler K, Kleiner DE, Doo EC, Hall S, Hoofnagle JH, Robuck PR, Sherker AH, Torrance R, Belt P, Clark JM, Dodge J, Donithan M, Isaacson M, Lazo M, Meinert J, Miriel L, Sharkey EP, Smith J, Smith M, Sternberg A, Tonascia J, Van Natta ML, Wagoner A, Wilson LA, Yamada G, Yates K, Covarrubias Y, Gamst A, Hamilton G, Henderson W, Hooker J, Lavine JE, Loomba R, Middleton MS, Schlein A, Schwimmer JB, Shen W, Sirlin C, Wolfson T. Multicenter Validation of Association Between Decline in MRI-PDFF and Histologic Response in NASH. Hepatology 2020; 72:1219-1229. [PMID: 31965579 PMCID: PMC8055244 DOI: 10.1002/hep.31121] [Citation(s) in RCA: 72] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2019] [Accepted: 12/23/2019] [Indexed: 02/05/2023]
Abstract
BACKGROUND AND AIMS Emerging data from a single-center study suggests that a 30% relative reduction in liver fat content as assessed by magnetic resonance imaging-proton density fat fraction (MRI-PDFF) from baseline may be associated with histologic improvement in nonalcoholic steatohepatitis (NASH). There are limited multicenter data comparing an active drug versus placebo on the association between the quantity of liver fat reduction assessed by MRI-PDFF and histologic response in NASH. This study aims to examine the association between 30% relative reduction in MRI-PDFF and histologic response in obeticholic acid (OCA) versus placebo-treated patients in the FLINT (farnesoid X receptor ligand obeticholic acid in NASH trial). APPROACH AND RESULTS This is a secondary analysis of the FLINT trial including 78 patients with MRI-PDFF measured before and after treatment along with paired liver histology assessment. Histologic response was defined as a 2-point improvement in nonalcoholic fatty liver disease activity score without worsening of fibrosis. OCA (25 mg orally once daily) was better than placebo in improving MRI-PDFF by an absolute difference of -3.4% (95% confidence interval [CI], -6.5 to -0.2%, P value = 0.04) and relative difference of -17% (95% CI, -34 to 0%, P value = 0.05). The optimal cutoff point for relative decline in MRI-PDFF for histologic response was 30% (using Youden's index). The rate of histologic response in those who achieved less than 30% decline in MRI-PDFF versus those who achieved a 30% or greater decline in MRI-PDFF (MRI-PDFF responders) relative to baseline was 19% versus 50%, respectively. Compared with MRI-PDFF nonresponders, MRI-PDFF responders demonstrated both a statistically and clinically significant higher odds 4.86 (95% CI, 1.4-12.8, P value < 0.009) of histologic response, including significant improvements in both steatosis and ballooning. CONCLUSION OCA was better than placebo in reducing liver fat. This multicenter trial provides data regarding the association between 30% decline in MRI-PDFF relative to baseline and histologic response in NASH.
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Affiliation(s)
- Rohit Loomba
- University of California San Diego, La Jolla, CA, USA
| | | | - Arun Sanyal
- Virginia Commonwealth University, Richmond, VA, USA
| | | | | | - Norah Terrault
- University of California San Francisco, San Francisco, CA USA
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Abstract
Nonalcoholic fatty liver disease (NAFLD) represents a spectrum of disease that can range from isolated macrovesicular hepatocellular steatosis to nonalcoholic steatohepatitis (NASH) with or without fibrosis to cirrhosis. The prevalence of NAFLD has increased over several decades, mirroring the global obesity pandemic. NAFLD currently represents the most common etiology of chronic liver disease in children and adolescents worldwide. Disease presentation in childhood strongly suggests that these children may have unique susceptibilities and more severe long-term consequences. Emerging data demonstrate that the pathogenesis of early-onset NAFLD is secondary to a complex interplay involving genetic, metabolic, environmental, and microbiological factors. Such influences may begin
in utero. Dietary and lifestyle modifications remain the primary effective therapeutic interventions, although long-term efficacy is limited by poor adoption or adherence. Advances in the development and validation of non-invasive biomarkers and imaging modalities will facilitate diagnosis for affected children and adolescents and facilitate long-term natural history studies and the development of therapeutic interventions.
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Affiliation(s)
- Jennifer Vittorio
- 1. Division of Pediatric Gastroenterology, Hepatology and Nutrition, Columbia University Vagelos College of Physicians and Surgeons, New York, USA
| | - Joel E Lavine
- 1. Division of Pediatric Gastroenterology, Hepatology and Nutrition, Columbia University Vagelos College of Physicians and Surgeons, New York, USA
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12
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Goldner D, Lavine JE. Nonalcoholic Fatty Liver Disease in Children: Unique Considerations and Challenges. Gastroenterology 2020; 158:1967-1983.e1. [PMID: 32201176 DOI: 10.1053/j.gastro.2020.01.048] [Citation(s) in RCA: 63] [Impact Index Per Article: 15.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2019] [Revised: 12/30/2019] [Accepted: 01/05/2020] [Indexed: 02/06/2023]
Abstract
Nonalcoholic fatty liver disease (NAFLD) is increasing in prevalence in concert with the global epidemic of obesity and is being diagnosed at increasingly younger ages. The unique histologic features and early presentation of disease in pediatrics suggest that children and adults may differ with regard to etiopathogenesis, with children displaying a greater vulnerability to genetic and environmental factors. Of significant relevance to pediatrics, in utero and perinatal stressors may alter the lifelong health trajectory of a child, increasing the risk of NAFLD and other cardiometabolic diseases. The development and progression of disease in childhood is likely to carry increased risk of long-term morbidity. Novel biomarkers and therapeutic agents are needed to avoid the otherwise inevitable health and societal consequences of this rapidly expanding pediatric population.
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Affiliation(s)
- Dana Goldner
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Columbia University Medical Center, New York, New York
| | - Joel E Lavine
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Columbia University Medical Center, New York, New York.
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13
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Affiliation(s)
- Jennifer M Vittorio
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Columbia University Vagelos College of Physicians and Surgeons, New York, NY
| | - Joel E Lavine
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Columbia University Vagelos College of Physicians and Surgeons, New York, NY
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14
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VOS MIRIAMB, Dimick-Santos L, Mehta R, Omokaro SO, Taminiau J, Schabel E, Kleiner DE, Szitanyi P, Socha P, Schwimmer JB, Noviello S, Silberg DG, Torstenson R, Miller V, Lavine JE, Baldyga W, Banerjee R, Behling C, Boulos S, Burgess G, Calboli D, Charles E, Christian R, Cohen-Bacrie C, Cosma-Roman D, Danzer CP, Delaet I, Delegge M, Dimick-Santos L, DiProspero N, Donohue K, Fischer L, Fitzpatrick E, Fried M, Hagerty D, Hale P, Hildick K, Hum D, Jamil K, Jiang L, Karpen S, Kelly M, Kleiner DE, Kohli R, Kordy K, Krieger N, Lavine J, Lee L, Lefebvre E, Lopez P, Lyons E, Malahias L, Megnien S, Mehta R, Mesenbrink P, Miller V, Minnick P, Murray C, Nghiem T, Nicholson N, Noviello S, Omokaro SO, Pang W, Percival L, Peres D, Powell M, Roman D, Root M, Sampson C, Sanyal A, Schabel E, Schwarz K, Schwimmer JB, Seyedkazemi S, Shapiro D, Shringarpure R, Silberg D, Smith E, Socha P, Squires R, Szitanyi P, Taminiau J, Torstenson R, Treem W, Vig P, Vos M, Yamashita M, Zemel M. Factors to Consider in Development of Drugs for Pediatric Nonalcoholic Fatty Liver Disease. Gastroenterology 2019; 157:1448-1456.e1. [PMID: 31520612 PMCID: PMC8996263 DOI: 10.1053/j.gastro.2019.08.048] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2019] [Revised: 08/13/2019] [Accepted: 08/17/2019] [Indexed: 02/07/2023]
Affiliation(s)
- MIRIAM B. VOS
- Emory University School of Medicine, Atlanta, Georgia
| | | | - Ruby Mehta
- US Food and Drug Administration, Bethesda, Maryland
| | | | | | - Elmer Schabel
- Bundesinstitut für Arzneimittel und Medizinprodukte, Bonn, Germany
| | - David E Kleiner
- National Cancer Institute, Center for Cancer Research, Bethesda, Maryland
| | - Peter Szitanyi
- General University Hospital, Charles University, Prague, Czech Republic
| | - Piotr Socha
- Children's Memorial Health Institute, Warsaw, Poland
| | - Jeffrey B Schwimmer
- University of California, San Diego School of Medicine, La Jolla, California
| | | | | | | | | | - Joel E Lavine
- Columbia University Medical Center, New York, New York.
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15
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Kleiner DE, Brunt EM, Wilson LA, Behling C, Guy C, Contos M, Cummings O, Yeh M, Gill R, Chalasani N, Neuschwander-Tetri BA, Diehl AM, Dasarathy S, Terrault N, Kowdley K, Loomba R, Belt P, Tonascia J, Lavine JE, Sanyal AJ. Association of Histologic Disease Activity With Progression of Nonalcoholic Fatty Liver Disease. JAMA Netw Open 2019; 2:e1912565. [PMID: 31584681 PMCID: PMC6784786 DOI: 10.1001/jamanetworkopen.2019.12565] [Citation(s) in RCA: 212] [Impact Index Per Article: 42.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
IMPORTANCE The histologic evolution of the full spectrum of nonalcoholic fatty liver disease (NAFLD) and factors associated with progression or regression remain to be definitively established. OBJECTIVE To evaluate the histologic evolution of NAFLD and the factors associated with changes in disease severity over time. DESIGN, SETTING, AND PARTICIPANTS A prospective cohort substudy from the Nonalcoholic Steatohepatitis Clinical Research Network (NASH CRN) NAFLD Database study, a noninterventional registry, was performed at 8 university medical research centers. Masked assessment of liver histologic specimens was performed, using a prespecified protocol to score individual biopsies. Participants included 446 adults with NAFLD enrolled in the NASH CRN Database studies between October 27, 2004, and September 13, 2013, who underwent 2 liver biopsies 1 or more year apart. Data analysis was performed from October 2016 to October 2018. MAIN OUTCOMES AND MEASURES Progression and regression of fibrosis stage, using clinical, laboratory, and histologic findings, including the NAFLD activity score (NAS) (sum of scores for steatosis, lobular inflammation, and ballooning; range, 0-8, with 8 indicating more severe disease). RESULTS A total of 446 adults (mean [SD] age, 47 [11] years; 294 [65.9%] women) with NAFLD (NAFL, 86 [19.3%]), borderline NASH (84 [18.8%]), and definite NASH (276 [61.9%]) were studied. Over a mean (SD) interval of 4.9 (2.8) years between biopsies, NAFL resolved in 11 patients (12.8%) and progressed to steatohepatitis in 36 patients (41.9%). Steatohepatitis resolved in 24 (28.6%) of the patients with borderline NASH and 61 (22.1%) of those with definite NASH. Fibrosis progression or regression by at least 1 stage occurred in 132 (30%) and 151 [34%] participants, respectively. Metabolic syndrome (20 [95%] vs 108 [72%]; P = .03), baseline NAS (mean [SD], 5.0 [1.4] vs 4.3 [1.6]; P = .005), and smaller reduction in NAS (-0.2 [2] vs -0.9 [2]; P < .001) were associated with progression to advanced (stage 3-4) fibrosis vs those without progression to stage 3 to 4 fibrosis. Fibrosis regression was associated with lower baseline insulin level (20 vs 33 μU/mL; P = .02) and decrease in all NAS components (steatosis grade -0.8 [0.1] vs -0.3 [0.9]; P < .001; lobular inflammation -0.5 [0.8] vs -0.2 [0.9]; P < .001; ballooning -0.7 [1.1] vs -0.1 [0.9]; P < .001). Only baseline aspartate aminotransferase (AST) levels were associated with fibrosis regression vs no change and progression vs no change on multivariable regression: baseline AST (regression: conditional odds ratio [cOR], 0.6 per 10 U/L AST; 95% CI, 0.4-0.7; P < .001; progression: cOR, 1.3; 95% CI, 1.1-1.5; P = .002). Changes in the AST level, alanine aminotransferase (ALT) level, and NAS were also associated with fibrosis regression and progression (ΔAST level: regression, cOR, 0.9; 95% CI, 0.6-1.2; P = .47; progression, cOR, 1.3; 95% CI, 1.0-1.6; P = .02; ΔALT level: regression, cOR, 0.7 per 10 U/L AST; 95% CI, 0.5-0.9; P = .002; progression, cOR, 1.0 per 10 U/L AST; 95% CI, 0.9-1.2; P = .93; ΔNAS: regression, cOR, 0.7; 95% CI, 0.6-0.9; P = .001; progression, cOR, 1.3; 95% CI, 1.1-1.5; P = .01). CONCLUSIONS AND RELEVANCE Improvement or worsening of disease activity may be associated with fibrosis regression or progression, respectively, in NAFLD.
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Affiliation(s)
- David E. Kleiner
- Laboratory of Pathology, National Cancer Institute, National Institutes of Health, Bethesda, Maryland
| | - Elizabeth M. Brunt
- Department of Pathology and Immunology, Washington University School of Medicine in St Louis, St Louis, Missouri
| | - Laura A. Wilson
- Department of Epidemiology, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland
| | - Cynthia Behling
- Department of Pathology, University of California San Diego School of Medicine, San Diego
| | - Cynthia Guy
- Department of Pathology, Duke University, Durham, North Carolina
| | - Melissa Contos
- Department of Pathology, Virginia Commonwealth University School of Medicine, Richmond
| | - Oscar Cummings
- Department of Pathology, Indiana University School of Medicine, Indianapolis
| | - Matthew Yeh
- Department of Pathology, University of Washington, Seattle
| | - Ryan Gill
- Department of Pathology, University of California San Francisco School of Medicine, San Francisco
| | - Naga Chalasani
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis
| | | | - Anna Mae Diehl
- Department of Gastroenterology, Duke University, Durham, North Carolina
| | - Srinivasan Dasarathy
- Department of Gastroenterology and Hepatology, Cleveland Clinic, Cleveland, Ohio
| | - Norah Terrault
- Division of Gastroenterology and Liver, University of Southern California, Los Angeles
| | - Kris Kowdley
- Liver Care Network and Organ Care Research, Swedish Medical Center, Seattle, Washington
| | - Rohit Loomba
- Division of Gastroenterology, University of California San Diego School of Medicine, San Diego
| | - Patricia Belt
- Department of Epidemiology, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland
| | - James Tonascia
- Department of Epidemiology, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland
- Department of Biostatistics, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland
| | - Joel E. Lavine
- Division of Pediatric Gastroenterology, Department of Pediatrics, Columbia University, New York, New York
| | - Arun J. Sanyal
- Division of Gastroenterology and Hepatology, Virginia Commonwealth University School of Medicine, Richmond
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16
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Schwimmer JB, Johnson JS, Angeles JE, Behling C, Belt PH, Borecki I, Bross C, Durelle J, Goyal NP, Hamilton G, Holtz ML, Lavine JE, Mitreva M, Newton KP, Pan A, Simpson PM, Sirlin CB, Sodergren E, Tyagi R, Yates KP, Weinstock G, Salzman NH. Microbiome Signatures Associated With Steatohepatitis and Moderate to Severe Fibrosis in Children With Nonalcoholic Fatty Liver Disease. Gastroenterology 2019; 157:1109-1122. [PMID: 31255652 PMCID: PMC6756995 DOI: 10.1053/j.gastro.2019.06.028] [Citation(s) in RCA: 151] [Impact Index Per Article: 30.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2018] [Revised: 06/14/2019] [Accepted: 06/21/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS The intestinal microbiome might affect the development and severity of nonalcoholic fatty liver disease (NAFLD). We analyzed microbiomes of children with and without NAFLD. METHODS We performed a prospective, observational, cross-sectional study of 87 children (age range, 8-17 years) with biopsy-proven NAFLD and 37 children with obesity without NAFLD (controls). Fecal samples were collected and microbiome composition and functions were assessed using 16S ribosomal RNA amplicon sequencing and metagenomic shotgun sequencing. Microbial taxa were identified using zero-inflated negative binomial modeling. Genes contributing to bacterial pathways were identified using gene set enrichment analysis. RESULTS Fecal microbiomes of children with NAFLD had lower α-diversity than those of control children (3.32 vs 3.52, P = .016). Fecal microbiomes from children with nonalcoholic steatohepatitis (NASH) had the lowest α-diversity (control, 3.52; NAFLD, 3.36; borderline NASH, 3.37; NASH, 2.97; P = .001). High abundance of Prevotella copri was associated with more severe fibrosis (P = .036). Genes for lipopolysaccharide biosynthesis were enriched in microbiomes from children with NASH (P < .001). Classification and regression tree model with level of alanine aminotransferase and relative abundance of the lipopolysaccharide pathway gene encoding 3-deoxy-d-manno-octulosonate 8-phosphate-phosphatase identified patients with NASH with an area under the receiver operating characteristic curve value of 0.92. Genes involved in flagellar assembly were enriched in the fecal microbiomes of patients with moderate to severe fibrosis (P < .001). Classification and regression tree models based on level of alanine aminotransferase and abundance of genes encoding flagellar biosynthesis protein had good accuracy for identifying case children with moderate to severe fibrosis (area under the receiver operating characteristic curve, 0.87). CONCLUSIONS In an analysis of fecal microbiomes of children with NAFLD, we associated NAFLD and NASH with intestinal dysbiosis. NAFLD and its severity were associated with greater abundance of genes encoding inflammatory bacterial products. Alterations to the intestinal microbiome might contribute to the pathogenesis of NAFLD and be used as markers of disease or severity.
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Affiliation(s)
- Jeffrey B. Schwimmer
- Division of Gastroenterology, Hepatology, and Nutrition,
Department of Pediatrics, University of California, San Diego School of Medicine, La
Jolla, CA,Department of Gastroenterology, Rady Children’s
Hospital San Diego, San Diego, CA
| | | | - Jorge E. Angeles
- Division of Gastroenterology, Hepatology, and Nutrition,
Department of Pediatrics, University of California, San Diego School of Medicine, La
Jolla, CA
| | - Cynthia Behling
- Division of Gastroenterology, Hepatology, and Nutrition,
Department of Pediatrics, University of California, San Diego School of Medicine, La
Jolla, CA,Department of Pathology, Sharp Medical Center, San Diego,
CA
| | | | - Ingrid Borecki
- The McDonnell Genome Institute, Washington University in
St. Louis, St. Louis, MO
| | - Craig Bross
- Division of Gastroenterology, Hepatology, and Nutrition,
Department of Pediatrics, University of California, San Diego School of Medicine, La
Jolla, CA
| | - Janis Durelle
- Division of Gastroenterology, Hepatology, and Nutrition,
Department of Pediatrics, University of California, San Diego School of Medicine, La
Jolla, CA
| | - Nidhi P. Goyal
- Division of Gastroenterology, Hepatology, and Nutrition,
Department of Pediatrics, University of California, San Diego School of Medicine, La
Jolla, CA
| | - Gavin Hamilton
- Liver Imaging Group, Department of Radiology, University
of California, San Diego, CA
| | - Mary L. Holtz
- Department of Pediatrics, Division of Gastroenterology;
and Center for Microbiome Research, Medical College of Wisconsin, Milwaukee,
WI
| | - Joel E. Lavine
- Department of Pediatrics, Division of Pediatric
Gastroenterology, Hepatology and Nutrition, Columbia University, New York NY
| | - Makedonka Mitreva
- The McDonnell Genome Institute, Washington University in
St. Louis, St. Louis, MO
| | - Kimberly P. Newton
- Division of Gastroenterology, Hepatology, and Nutrition,
Department of Pediatrics, University of California, San Diego School of Medicine, La
Jolla, CA,Department of Gastroenterology, Rady Children’s
Hospital San Diego, San Diego, CA
| | - Amy Pan
- Department of Pediatrics, Division of Quantitative
Health Sciences; and Center for Microbiome Research, The Medical College of
Wisconsin, Milwaukee, WI
| | - Pippa M. Simpson
- Department of Pediatrics, Division of Quantitative
Health Sciences; and Center for Microbiome Research, The Medical College of
Wisconsin, Milwaukee, WI
| | - Claude B. Sirlin
- Liver Imaging Group, Department of Radiology, University
of California, San Diego, CA
| | | | - Rahul Tyagi
- The McDonnell Genome Institute, Washington University in
St. Louis, St. Louis, MO
| | | | | | - Nita H. Salzman
- Department of Pediatrics, Division of Gastroenterology;
and Center for Microbiome Research, Medical College of Wisconsin, Milwaukee,
WI
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17
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Zhu C, Kim K, Wang X, Bartolome A, Salomao M, Dongiovanni P, Meroni M, Graham MJ, Yates KP, Diehl AM, Schwabe RF, Tabas I, Valenti L, Lavine JE, Pajvani UB. Hepatocyte Notch activation induces liver fibrosis in nonalcoholic steatohepatitis. Sci Transl Med 2018; 10:10/468/eaat0344. [PMID: 30463916 PMCID: PMC6822168 DOI: 10.1126/scitranslmed.aat0344] [Citation(s) in RCA: 139] [Impact Index Per Article: 23.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2018] [Revised: 06/03/2018] [Accepted: 10/31/2018] [Indexed: 01/07/2023]
Abstract
Fibrosis is the major determinant of morbidity and mortality in patients with nonalcoholic steatohepatitis (NASH) but has no approved pharmacotherapy in part because of incomplete understanding of its pathogenic mechanisms. Here, we report that hepatocyte Notch activity tracks with disease severity and treatment response in patients with NASH and is similarly increased in a mouse model of diet-induced NASH and liver fibrosis. Hepatocyte-specific Notch loss-of-function mouse models showed attenuated NASH-associated liver fibrosis, demonstrating causality to obesity-induced liver pathology. Conversely, forced activation of hepatocyte Notch induced fibrosis in both chow- and NASH diet-fed mice by increasing Sox9-dependent Osteopontin (Opn) expression and secretion from hepatocytes, which activate resident hepatic stellate cells. In a cross-sectional study, we found that OPN explains the positive correlation between liver Notch activity and fibrosis stage in patients. Further, we developed a Notch inhibitor [Nicastrin antisense oligonucleotide (Ncst ASO)] that reduced fibrosis in NASH diet-fed mice. In summary, these studies demonstrate the pathological role and therapeutic accessibility of the maladaptive hepatocyte Notch response in NASH-associated liver fibrosis.
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Affiliation(s)
- Changyu Zhu
- Department of Medicine, Columbia University, New York, NY 10032, USA
| | - KyeongJin Kim
- Department of Medicine, Columbia University, New York, NY 10032, USA
| | - Xiaobo Wang
- Department of Medicine, Columbia University, New York, NY 10032, USA
| | - Alberto Bartolome
- Department of Medicine, Columbia University, New York, NY 10032, USA
| | - Marcela Salomao
- Department of Pathology, Mayo Clinic, Phoenix, AZ 85054, USA
| | - Paola Dongiovanni
- Department of Pathophysiology and Transplantation, Università degli Studi Milano, and Internal Medicine and Metabolic Diseases, Fondazione IRCCS Ca’ Granda Ospedale Policlinico, Milan 20122, Italy
| | - Marica Meroni
- Department of Pathophysiology and Transplantation, Università degli Studi Milano, and Internal Medicine and Metabolic Diseases, Fondazione IRCCS Ca’ Granda Ospedale Policlinico, Milan 20122, Italy
| | | | - Katherine P. Yates
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD 21205, USA
| | - Anna Mae Diehl
- Division of Gastroenterology, Department of Medicine, Duke University Medical Center, Durham, NC 27710, USA
| | - Robert F. Schwabe
- Department of Medicine, Columbia University, New York, NY 10032, USA
| | - Ira Tabas
- Department of Medicine, Columbia University, New York, NY 10032, USA
| | - Luca Valenti
- Department of Pathophysiology and Transplantation, Università degli Studi Milano, and Internal Medicine and Metabolic Diseases, Fondazione IRCCS Ca’ Granda Ospedale Policlinico, Milan 20122, Italy
| | - Joel E. Lavine
- Department of Pediatrics, Columbia University, New York, NY 10032, USA
| | - Utpal B. Pajvani
- Department of Medicine, Columbia University, New York, NY 10032, USA.,Corresponding author.
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18
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Bashir MR, Wolfson T, Gamst AC, Fowler KJ, Ohliger M, Shah SN, Alazraki A, Trout AT, Behling C, Allende DS, Loomba R, Sanyal A, Schwimmer J, Lavine JE, Shen W, Tonascia J, Van Natta ML, Mamidipalli A, Hooker J, Kowdley KV, Middleton MS, Sirlin CB. Hepatic R2* is more strongly associated with proton density fat fraction than histologic liver iron scores in patients with nonalcoholic fatty liver disease. J Magn Reson Imaging 2018; 49:1456-1466. [PMID: 30318834 DOI: 10.1002/jmri.26312] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2018] [Accepted: 08/09/2018] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND The liver R2* value is widely used as a measure of liver iron but may be confounded by the presence of hepatic steatosis and other covariates. PURPOSE To identify the most influential covariates for liver R2* values in patients with nonalcoholic fatty liver disease (NAFLD). STUDY TYPE Retrospective analysis of prospectively acquired data. POPULATION Baseline data from 204 subjects enrolled in NAFLD/NASH (nonalcoholic steatohepatitis) treatment trials. FIELD STRENGTH 1.5T and 3T; chemical-shift encoded multiecho gradient echo. ASSESSMENT Correlation between liver proton density fat fraction and R2*; assessment for demographic, metabolic, laboratory, MRI-derived, and histological covariates of liver R2*. STATISTICAL TESTS Pearson's and Spearman's correlations; univariate analysis; gradient boosting machines (GBM) multivariable machine-learning method. RESULTS Hepatic proton density fat fraction (PDFF) was the most strongly correlated covariate for R2* at both 1.5T (r = 0.652, P < 0.0001) and at 3T (r = 0.586, P < 0.0001). In the GBM analysis, hepatic PDFF was the most influential covariate for hepatic R2*, with relative influences (RIs) of 61.3% at 1.5T and 47.5% at 3T; less influential covariates had RIs of up to 11.5% at 1.5T and 16.7% at 3T. Nonhepatocellular iron was weakly associated with R2* at 3T only (RI 6.7%), and hepatocellular iron was not associated with R2* at either field strength. DATA CONCLUSION Hepatic PDFF is the most influential covariate for R2* at both 1.5T and 3T; nonhepatocellular iron deposition is weakly associated with liver R2* at 3T only. LEVEL OF EVIDENCE 4 Technical Efficacy: Stage 2 J. Magn. Reson. Imaging 2019;49:1456-1466.
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Affiliation(s)
- Mustafa R Bashir
- Department of Radiology, Duke University Medical Center, Durham, North Carolina, USA.,Center for Advanced Magnetic Resonance Development (CAMRD), Department of Radiology, Duke University Medical Center, Durham, North Carolina, USA.,Division of Gastroenterology, Department of Medicine, Duke University Medical Center, Durham, North Carolina
| | - Tanya Wolfson
- Computational and Applied Statistics Laboratory (CASL), San Diego Supercomputing Center (SDSC), University of California-San Diego, San Diego, California, USA
| | - Anthony C Gamst
- Computational and Applied Statistics Laboratory (CASL), San Diego Supercomputing Center (SDSC), University of California-San Diego, San Diego, California, USA
| | - Kathryn J Fowler
- Department of Radiology, Washington University, St. Louis, Missouri, USA
| | - Michael Ohliger
- Departments of Radiology and Biomedical Engineering, University of California-San Francisco, San Francisco, California, USA
| | - Shetal N Shah
- Section of Abdominal Imaging and Nuclear Medicine Department, Imaging Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Adina Alazraki
- Departments of Radiology and Pediatrics, Emory University School of Medicine/Children's Healthcare of Atlanta, Atlanta, Georgia, USA
| | - Andrew T Trout
- Department of Radiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Cynthia Behling
- Department of Pathology, University of California-San Diego, La Jolla, California, USA
| | | | - Rohit Loomba
- NAFLD Research Center, Division of Gastroenterology, Department of Medicine, University of California-San Diego, La Jolla, California, USA
| | - Arun Sanyal
- Division of Gastroenterology, Hepatology and Nutrition, Department of Internal Medicine, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Jeffrey Schwimmer
- Department of Pediatrics, University of California-San Diego, San Diego, California, USA
| | - Joel E Lavine
- Department of Pediatrics, Columbia College of Physicians and Surgeons, New York, New York, USA
| | - Wei Shen
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Department of Pediatrics and the Institute of Human Nutrition, Columbia University Medical Center, New York, New York, USA
| | - James Tonascia
- Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, USA
| | - Mark L Van Natta
- Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, USA
| | - Adrija Mamidipalli
- Liver Imaging Group, Department of Radiology, University of California, San Diego, San Diego, California, USA
| | - Jonathan Hooker
- Liver Imaging Group, Department of Radiology, University of California, San Diego, San Diego, California, USA
| | - Kris V Kowdley
- Liver Care Network and Organ Care Research, Swedish Medical Center, Seattle, Washington, USA
| | - Michael S Middleton
- Liver Imaging Group, Department of Radiology, University of California, San Diego, San Diego, California, USA
| | - Claude B Sirlin
- Liver Imaging Group, Department of Radiology, University of California, San Diego, San Diego, California, USA
| | -
- Department of Radiology, Duke University Medical Center, Durham, North Carolina, USA
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19
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Elbel EE, Lavine JE, Downes M, Van Natta M, Yu R, Schwimmer JB, Behling C, Brunt EM, Tonascia J, Evans R. Hepatic Nuclear Receptor Expression Associates with Features of Histology in Pediatric Nonalcoholic Fatty Liver Disease. Hepatol Commun 2018; 2:1213-1226. [PMID: 30288476 PMCID: PMC6167075 DOI: 10.1002/hep4.1232] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2018] [Accepted: 06/18/2018] [Indexed: 01/10/2023] Open
Abstract
Nonalcoholic fatty liver disease (NAFLD) is the most common cause of chronic liver disease in children and adults. This study examined the relationship between hepatic nuclear receptor (NR) expression and histologic features of NAFLD. Drugs targeting a variety of NRs for nonalcoholic steatohepatitis (NASH) are in clinical trials. Liver messenger RNA was isolated from 40 children (10-19 years) undergoing end-of-treatment biopsy in the Treatment of NAFLD in Children (TONIC) trial. High-throughput quantitative polymerase chain reaction assayed NR messenger RNA. Cluster analysis was used to group 36 NRs, and NR levels were related to histologic measures of specific NAFLD features. Cluster analysis determined five groupings of NRs. Significant (P < 0.05) differential expressions of specific NRs associated with histologic measures include farnesoid X receptor alpha and retinoic acid receptor (RARβ and RARβ) for steatosis; estrogen receptor alpha (ERα) and peroxisome proliferator-activated receptor gamma 3 (PPARγ3) for hepatocellular ballooning; ER and PPARγ2 for lobular inflammation; PPARα/δ/γ1/γ2, ERα, constitutive androstane receptor, chicken ovalbumin upstream promoter transcription factor 1, RARα, RARβ1, retinoid X receptor, pregnane X receptor, thyroid hormone receptors α and β, and nuclear receptor related-1 for fibrosis; and ERα and RARβ/β1/α for diagnosis of NASH. Conclusion: Differential expression of specific NRs correlates with histologic severity of specific NAFLD features. These NRs are pleiotropic transactivators regulating basal metabolic functions and inflammatory responses. Derangement of activity of these receptors in NAFLD provides a rationale for exploiting their ability with receptor-specific ligands to ameliorate NASH and its consequences.
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Affiliation(s)
- Erin E Elbel
- Department of Pediatrics Columbia University New York NY
| | - Joel E Lavine
- Department of Pediatrics Columbia University New York NY
| | - Michael Downes
- Gene Expression Laboratory The Salk Institute La Jolla CA
| | - Mark Van Natta
- Bloomberg School of Public Health Johns Hopkins University Baltimore MD
| | - Ruth Yu
- Gene Expression Laboratory The Salk Institute La Jolla CA
| | | | - Cynthia Behling
- Department of Pediatrics University of California,San Diego San Diego CA
| | - Elizabeth M Brunt
- Department of Pathology and Immunology Washington University St. Louis MO
| | - James Tonascia
- Bloomberg School of Public Health Johns Hopkins University Baltimore MD
| | - Ronald Evans
- Gene Expression Laboratory The Salk Institute La Jolla CA
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20
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Fernandes DM, Pantangi V, Azam M, Salomao M, Iuga AC, Lefkowitch JH, Gill J, Morotti R, Lavine JE, Mencin AA. Pediatric Nonalcoholic Fatty Liver Disease in New York City: An Autopsy Study. J Pediatr 2018; 200:174-180. [PMID: 29903531 DOI: 10.1016/j.jpeds.2018.04.047] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2018] [Revised: 03/26/2018] [Accepted: 04/20/2018] [Indexed: 02/07/2023]
Abstract
OBJECTIVE To assess the prevalence and severity of nonalcoholic liver disease (NAFLD) in children in a diverse population sample in New York City. STUDY DESIGN Liver specimens were examined from children 2-19 years old who died of unexpected causes within 48 hours of medical presentation and underwent autopsy in New York City from 2005 to 2010. Records were reviewed for age, sex, weight, height, and race. Two hepatopathologists evaluated each liver specimen to determine pathologic diagnosis. RESULTS The final study cohort (n = 582) was 50% black, 33% Hispanic, 12% white, 3% Asian, and 2% other; 36% had a body mass index >85%. There were 26 cases of NAFLD (4.5%) of which 10 had nonalcoholic steatohepatitis (1.7%). There were no cases with severe fibrosis or cirrhosis. One percent (3/290) of black children had NAFLD and none had nonalcoholic steatohepatitis. White and Hispanic children had the highest percentages of NAFLD at 8.3% and 7.9%, respectively. In multiple logistic regression models, we observed that body mass index z-score (P < .001) was associated with NAFLD, and that white (P = .003) and Hispanic (P = .005) children had higher odds of having NAFLD compared with black children. CONCLUSIONS This review of liver tissue demonstrates a lower prevalence and severity of NAFLD in black children compared with the general obese pediatric population. Hispanic children did not have a significantly increased rate of NAFLD compared with white children, most likely related to the large proportion of Caribbean Hispanic children in New York City.
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Affiliation(s)
| | | | - Muhammad Azam
- St. George's University Hospital, London, United Kingdom
| | | | - Alina C Iuga
- Columbia University Medical Center, New York, NY
| | | | - James Gill
- Office of the Chief Medical Examiner, Farmington, CT
| | | | | | - Ali A Mencin
- Columbia University Medical Center, New York, NY.
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21
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Wattacheril J, Shea PR, Mohammad S, Behling C, Aggarwal V, Wilson LA, Yates KP, Ito J, Fishbein M, Stong N, Lavine JE, Goldstein DB. Exome sequencing of an adolescent with nonalcoholic fatty liver disease identifies a clinically actionable case of Wilson disease. Cold Spring Harb Mol Case Stud 2018; 4:mcs.a003087. [PMID: 30026388 PMCID: PMC6169823 DOI: 10.1101/mcs.a003087] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2018] [Accepted: 06/04/2018] [Indexed: 12/12/2022] Open
Abstract
Diagnostic whole-exome sequencing has proven highly successful in a range of rare diseases, particularly early-onset genetic conditions. In more common conditions, however, exome sequencing for diagnostic purposes remains the exception. Here we describe a patient initially diagnosed with a common, complex liver disease, nonalcoholic fatty liver disease (NAFLD), who was determined to have Wilson disease (WD) upon research-related exome sequencing. The patient presented as a 14.5-yr-old adolescent with chronically elevated aminotransferases, normal ceruloplasmin, and histologic examination consistent with NAFLD with advanced fibrosis. He was enrolled in a large longitudinal study of patients with NAFLD and was found to have WD by exome sequencing performed 4 yr later. This new diagnosis, confirmed clinically by 24 h urine copper quantification, led to a change in the therapy from lifestyle counseling to directed treatment with d-penicillamine, a copper chelating agent. In this case, the likelihood of making the correct diagnosis and thereby choosing the appropriate treatment was increased by exome sequencing and careful interpretation. This example illustrates the utility of exome sequencing diagnostically in more common conditions not currently considered as targets for genome-wide evaluation and adds to a growing body of evidence that patients diagnosed with more common conditions often in fact have rarer genetically determined syndromes that have escaped clinical detection.
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Affiliation(s)
- Julia Wattacheril
- Department of Medicine, Center for Liver Disease and Transplantation, Columbia University College of Physicians and Surgeons, New York Presbyterian Hospital, New York, New York 10032, USA
| | - Patrick R Shea
- Institute of Genomic Medicine, Columbia University College of Physicians and Surgeons, New York, New York 10032, USA
| | - Saeed Mohammad
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Ann and Robert Lurie Children's Hospital of Chicago, Chicago, Illinois 60611, USA
| | - Cynthia Behling
- Department of Pathology, University of California, San Diego, La Jolla, California 90293, USA
| | - Vimla Aggarwal
- Department of Pathology and Cell Biology, Institute of Genomic Medicine, Columbia University College of Physicians and Surgeons, New York, New York 10032, USA
| | - Laura A Wilson
- Department of Epidemiology, Johns Hopkins University, Baltimore, Maryland 21218, USA
| | - Katherine P Yates
- Department of Epidemiology, Johns Hopkins University, Baltimore, Maryland 21218, USA
| | - Joy Ito
- Ann and Robert Lurie Children's Hospital of Chicago, Chicago, Illinois 60611, USA
| | - Mark Fishbein
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Ann and Robert Lurie Children's Hospital of Chicago, Chicago, Illinois 60611, USA
| | - Nicholas Stong
- Institute of Genomic Medicine, Columbia University College of Physicians and Surgeons, New York, New York 10032, USA
| | - Joel E Lavine
- Department of Pediatrics, Columbia University College of Physicians and Surgeons, Children's Hospital of New York, New York, New York 10032, USA
| | - David B Goldstein
- Institute of Genomic Medicine, Columbia University College of Physicians and Surgeons, New York, New York 10032, USA
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22
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Harlow KE, Africa JA, Wells A, Belt PH, Behling CA, Jain AK, Molleston JP, Newton KP, Rosenthal P, Vos MB, Xanthakos SA, Lavine JE, Schwimmer JB. Clinically Actionable Hypercholesterolemia and Hypertriglyceridemia in Children with Nonalcoholic Fatty Liver Disease. J Pediatr 2018; 198:76-83.e2. [PMID: 29661561 PMCID: PMC6019181 DOI: 10.1016/j.jpeds.2018.02.038] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2017] [Revised: 01/19/2018] [Accepted: 02/14/2018] [Indexed: 02/08/2023]
Abstract
OBJECTIVE To determine the percentage of children with nonalcoholic fatty liver disease (NAFLD) in whom intervention for low-density lipoprotein cholesterol or triglycerides was indicated based on National Heart, Lung, and Blood Institute guidelines. STUDY DESIGN This multicenter, longitudinal cohort study included children with NAFLD enrolled in the National Institute of Diabetes and Digestive and Kidney Diseases Nonalcoholic Steatohepatitis Clinical Research Network. Fasting lipid profiles were obtained at diagnosis. Standardized dietary recommendations were provided. After 1 year, lipid profiles were repeated and interpreted according to National Heart, Lung, and Blood Institute Expert Panel on Integrated Guidelines for Cardiovascular Health and Risk Reduction. Main outcomes were meeting criteria for clinically actionable dyslipidemia at baseline, and either achieving lipid goal at follow-up or meeting criteria for ongoing intervention. RESULTS There were 585 participants, with a mean age of 12.8 years. The prevalence of children warranting intervention for low-density lipoprotein cholesterol at baseline was 14%. After 1 year of recommended dietary changes, 51% achieved goal low-density lipoprotein cholesterol, 27% qualified for enhanced dietary and lifestyle modifications, and 22% met criteria for pharmacologic intervention. Elevated triglycerides were more prevalent, with 51% meeting criteria for intervention. At 1 year, 25% achieved goal triglycerides with diet and lifestyle changes, 38% met criteria for advanced dietary modifications, and 37% qualified for antihyperlipidemic medications. CONCLUSIONS More than one-half of children with NAFLD met intervention thresholds for dyslipidemia. Based on the burden of clinically relevant dyslipidemia, lipid screening in children with NAFLD is warranted. Clinicians caring for children with NAFLD should be familiar with lipid management.
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Affiliation(s)
- Kathryn E Harlow
- Department of Pediatrics, Division of Gastroenterology, Hepatology, and Nutrition, University of California San Diego School of Medicine, La Jolla, CA; Department of Pediatrics, Division of Gastroenterology, Rady Children's Hospital, San Diego, CA
| | - Jonathan A Africa
- Department of Pediatrics, Division of Gastroenterology, Hepatology, and Nutrition, University of California San Diego School of Medicine, La Jolla, CA; Department of Pediatrics, Division of Gastroenterology, Rady Children's Hospital, San Diego, CA
| | - Alan Wells
- Department of Pediatrics, Division of Dysmorphology and Teratology, University of California, San Diego, CA
| | - Patricia H Belt
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Cynthia A Behling
- Department of Pediatrics, Division of Gastroenterology, Hepatology, and Nutrition, University of California San Diego School of Medicine, La Jolla, CA; Department of Pathology, Sharp Medical Center, San Diego, CA
| | - Ajay K Jain
- Department of Pediatrics, St. Louis University, St. Louis, MO
| | - Jean P Molleston
- Department of Pediatrics, Division of Pediatric Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Indiana University School of Medicine/Riley Hospital for Children, Indianapolis, IN
| | - Kimberly P Newton
- Department of Pediatrics, Division of Gastroenterology, Hepatology, and Nutrition, University of California San Diego School of Medicine, La Jolla, CA; Department of Pediatrics, Division of Gastroenterology, Rady Children's Hospital, San Diego, CA
| | - Philip Rosenthal
- Department of Pediatrics, Division of Gastroenterology, Hepatology, and Nutrition, University of California, San Francisco Benioff Children's Hospital, San Francisco, CA
| | - Miriam B Vos
- Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, GA
| | - Stavra A Xanthakos
- Steatohepatitis Center, Division of Pediatric Gastroenterology, Hepatology and Nutrition, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Joel E Lavine
- Department of Pediatrics, Division of Pediatric Gastroenterology, Hepatology and Nutrition, Columbia University, New York, NY
| | - Jeffrey B Schwimmer
- Department of Pediatrics, Division of Gastroenterology, Hepatology, and Nutrition, University of California San Diego School of Medicine, La Jolla, CA; Department of Pediatrics, Division of Gastroenterology, Rady Children's Hospital, San Diego, CA.
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23
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Younossi ZM, Loomba R, Anstee QM, Rinella ME, Bugianesi E, Marchesini G, Neuschwander-Tetri BA, Serfaty L, Negro F, Caldwell SH, Ratziu V, Corey KE, Friedman SL, Abdelmalek MF, Harrison SA, Sanyal AJ, Lavine JE, Mathurin P, Charlton MR, Goodman ZD, Chalasani NP, Kowdley KV, George J, Lindor K. Diagnostic modalities for nonalcoholic fatty liver disease, nonalcoholic steatohepatitis, and associated fibrosis. Hepatology 2018. [PMID: 29222917 DOI: 10.1002/hep.29721 10.1002/hep.29721] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Nonalcoholic fatty liver disease (NAFLD) is a spectrum comprised of isolated steatosis, nonalcoholic steatohepatitis (NASH), advanced fibrosis, and cirrhosis. The majority of NAFLD subjects do not have NASH and do not carry a significant risk for liver-related adverse outcomes (cirrhosis and mortality). Globally, the prevalence of NAFLD is approximately 25%. In Asia, a gradient of high to low prevalence rates is noted from urban to rural areas. Given the prevalence of NAFLD, the clinical and economic burden of NAFLD and NASH can be substantial. With increasing recognition of NASH as an important liver disease, the diagnosis of NASH still requires a liver biopsy that is suboptimal. Although liver biopsy is the most accurate modality to diagnose and stage the severity of NASH, this method suffers from being invasive, costly, associated with potential complications, and plagued with interobserver variability of individual pathological features. A number of noninvasive modalities to diagnose NASH and stage liver fibrosis are being developed. These modalities include predictive models (NAFLD fibrosis score) and serum biomarkers such as enhanced liver fibrosis (ELF). Other tests are based on radiological techniques, such as transient elastography (TE) or magnetic resonance elastography (MRE), which are used to estimate liver stiffness as a potential surrogate of hepatic fibrosis. Although a dynamic field of research, most of these diagnostic modalities have area under the curve ranging between 0.76 and 0.90%, with MRE having the best predictive performance. In summary, developing safe and easily accessible noninvasive modalities to accurately diagnose and monitor NASH and associated fibrosis is of utmost importance in clinical practice and clinical research. These tests are not only important to risk stratify subjects at the greatest risk for progressive liver disease, but also to serve as appropriate surrogate endpoints for therapeutic clinical trials of NASH. (Hepatology 2018;68:349-360).
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Affiliation(s)
- Zobair M Younossi
- Department of Medicine and Betty and Guy Beatty Center for Integrated Research, Claude Moore, Inova Health Systems, Falls Church, VA
| | - Rohit Loomba
- NAFLD Research Center, University of California at San Diego, La Jolla, CA
| | - Quentin M Anstee
- Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Mary E Rinella
- University of Torino, Department of Medical Sciences, Torino, Italy
| | | | - Giulio Marchesini
- Division of Gastroenterology and Hepatology, Saint Louis University, St. Louis, MO
| | | | | | - Francesco Negro
- Division of Gastroenterology and Hepatology, University of Virginia, Charlottesville, VA
| | - Stephen H Caldwell
- Institute of Cardiometabolim and Nutrition (ICAN) and Hospital Pitié Salpêtrière, de L'Hopital, Paris, France
| | - Vlad Ratziu
- Massachusetts General Hospital, Cambridge, MA
| | - Kathleen E Corey
- Icahn School of Medicine at Mount Sinai, Division of Liver Diseases, New York, NY
| | - Scott L Friedman
- Division of Gastroenterology and Hepatology, Duke University, Durham, NC
| | | | - Stephen A Harrison
- Division of Gastroenterology, Virginia Commonwealth University, Richmond, VA
| | - Arun J Sanyal
- Department of Pediatrics, Columbia College of Physicians and Surgeons, New York, NY
| | - Joel E Lavine
- Hôpital Claude Huriez Rue Michel Polonowski, Lille, France
| | | | - Michael R Charlton
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, IN
| | - Zachary D Goodman
- Department of Medicine and Betty and Guy Beatty Center for Integrated Research, Claude Moore, Inova Health Systems, Falls Church, VA
| | - Naga P Chalasani
- Institute of Cellular Medicine, Faculty of Medical Sciences, Newcastle University, Newcastle Upon Tyne, United Kingdom
| | | | - Jacob George
- Storr Liver Centre, Westmead Institute for Medical Research, Westmead Hospital and University of Sydney, Sydney, Australia
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24
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Younossi ZM, Loomba R, Rinella ME, Bugianesi E, Marchesini G, Neuschwander-Tetri BA, Serfaty L, Negro F, Caldwell SH, Ratziu V, Corey KE, Friedman SL, Abdelmalek MF, Harrison SA, Sanyal AJ, Lavine JE, Mathurin P, Charlton MR, Chalasani NP, Anstee QM, Kowdley KV, George J, Goodman ZD, Lindor K. Current and future therapeutic regimens for nonalcoholic fatty liver disease and nonalcoholic steatohepatitis. Hepatology 2018; 68:361-371. [PMID: 29222911 PMCID: PMC6508084 DOI: 10.1002/hep.29724] [Citation(s) in RCA: 236] [Impact Index Per Article: 39.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2017] [Revised: 10/17/2017] [Accepted: 12/06/2017] [Indexed: 12/11/2022]
Abstract
UNLABELLED Nonalcoholic fatty liver disease (NAFLD) and its progressive form non-alcoholic steatohepatitis (NASH), are rapidly becoming among the top causes of cirrhosis, hepatocellular carcinoma, and indications for liver transplantation. Other than lifestyle modification through diet and exercise, there are currently no other approved treatments for NASH/NAFLD. Although weight loss can be effective, it is difficult to achieve and sustain. In contrast, bariatric surgery can improve metabolic conditions associated with NAFLD, and has been shown to improve liver histology. To have approved regimens for the treatment of NASH/NAFLD, several issues must be addressed. First, all stakeholders must agree on the most appropriate clinical trial endpoints for NASH. Currently, resolution of NASH (without worsening fibrosis) or reduction of fibrosis stage (without worsening NASH) are the accepted endpoints by the regulatory authorities. It is important to recognize the prognostic implication of histologic features of NASH. In this context, although histologic NASH has been associated with advanced fibrosis, it is not an independent predictor of long-term mortality. In contrast, there are significant data to suggest that fibrosis stage is the only robust and independent predictor of liver-related mortality. In addition to the primary endpoints, several important secondary endpoints, including noninvasive biomarkers, long-term outcomes, and patient-reported outcomes must be considered. In 2018, a few phase 3 clinical trials for the treatment of NASH have been initiated. Additionally, a number of phase 2a and 2b clinical trials targeting different pathogenic pathways in NASH are in the pipeline of emerging therapies. CONCLUSION Over the next 5 years, some of these regimens are expected to provide potential new treatment options for patients with NASH/NAFLD. (Hepatology 2018;68:361-371).
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Affiliation(s)
- Zobair M. Younossi
- Department of Medicine and Betty and Guy Beatty Center for Integrated Research, Claude Moore, Inova Health Systems, Falls Church, VA
| | - Rohit Loomba
- Department of Gastroenterology, University of California at San Diego, La Jolla, CA
| | - Mary E. Rinella
- Department of Gastroenterology, Northwestern University Feinberg School of Medicine, Chicago, IL
| | | | | | | | | | - Francesco Negro
- Department of Gastroenterology, University Hospitals of Geneva, Geneva, Switzerland
| | - Stephen H. Caldwell
- Division of Gastroenterology and Hepatology, University of Virginia, Charlottesville, VA
| | - Vlad Ratziu
- Institute of Cardiometabolism and Nutrition and Hospital Pitié Salpêtrière, de L’Hopital, Paris, France
| | - Kathleen E. Corey
- Division of Gastroenterology, Massachusetts General Hospital, Cambridge, MA
| | - Scott L. Friedman
- Division of Liver Diseases, Icahn School of Medicine at Mount Sinai, New York, NY
| | | | | | - Arun J. Sanyal
- Division of Gastroenterology, Virginia Commonwealth University, Richmond, VA
| | - Joel E. Lavine
- Department of Pediatrics, Columbia College of Physicians and Surgeons, New York, NY
| | | | | | - Naga P. Chalasani
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, IN
| | - Quentin M. Anstee
- Institute of Cellular Medicine, Newcastle University, New Castle, UK
| | - Kris V. Kowdley
- Liver Care Network and Organ Care Research, Swedish Medical Center, Seattle, WA
| | - Jacob George
- Department of Gastroenterology & Hepatology, Westmead Hospital and Sydney West Local Health District, Sydney, Australia
| | - Zachary D. Goodman
- Department of Medicine and Betty and Guy Beatty Center for Integrated Research, Claude Moore, Inova Health Systems, Falls Church, VA
| | - Keith Lindor
- College of Health Solutions, Arizona State University, Phoenix, AZ
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25
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Younossi ZM, Loomba R, Anstee QM, Rinella ME, Bugianesi E, Marchesini G, Neuschwander-Tetri BA, Serfaty L, Negro F, Caldwell SH, Ratziu V, Corey KE, Friedman SL, Abdelmalek MF, Harrison SA, Sanyal AJ, Lavine JE, Mathurin P, Charlton MR, Goodman ZD, Chalasani NP, Kowdley KV, George J, Lindor K. Diagnostic modalities for nonalcoholic fatty liver disease, nonalcoholic steatohepatitis, and associated fibrosis. Hepatology 2018; 68:349-360. [PMID: 29222917 PMCID: PMC6511364 DOI: 10.1002/hep.29721] [Citation(s) in RCA: 250] [Impact Index Per Article: 41.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2017] [Revised: 11/16/2017] [Accepted: 12/06/2017] [Indexed: 12/11/2022]
Abstract
Nonalcoholic fatty liver disease (NAFLD) is a spectrum comprised of isolated steatosis, nonalcoholic steatohepatitis (NASH), advanced fibrosis, and cirrhosis. The majority of NAFLD subjects do not have NASH and do not carry a significant risk for liver-related adverse outcomes (cirrhosis and mortality). Globally, the prevalence of NAFLD is approximately 25%. In Asia, a gradient of high to low prevalence rates is noted from urban to rural areas. Given the prevalence of NAFLD, the clinical and economic burden of NAFLD and NASH can be substantial. With increasing recognition of NASH as an important liver disease, the diagnosis of NASH still requires a liver biopsy that is suboptimal. Although liver biopsy is the most accurate modality to diagnose and stage the severity of NASH, this method suffers from being invasive, costly, associated with potential complications, and plagued with interobserver variability of individual pathological features. A number of noninvasive modalities to diagnose NASH and stage liver fibrosis are being developed. These modalities include predictive models (NAFLD fibrosis score) and serum biomarkers such as enhanced liver fibrosis (ELF). Other tests are based on radiological techniques, such as transient elastography (TE) or magnetic resonance elastography (MRE), which are used to estimate liver stiffness as a potential surrogate of hepatic fibrosis. Although a dynamic field of research, most of these diagnostic modalities have area under the curve ranging between 0.76 and 0.90%, with MRE having the best predictive performance. In summary, developing safe and easily accessible noninvasive modalities to accurately diagnose and monitor NASH and associated fibrosis is of utmost importance in clinical practice and clinical research. These tests are not only important to risk stratify subjects at the greatest risk for progressive liver disease, but also to serve as appropriate surrogate endpoints for therapeutic clinical trials of NASH. (Hepatology 2018;68:349-360).
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Affiliation(s)
- Zobair M. Younossi
- Department of Medicine and Betty and Guy Beatty Center for Integrated Research, Claude Moore, Inova Health Systems, Falls Church, VA
| | - Rohit Loomba
- NAFLD Research Center, University of California at San Diego, La Jolla, CA
| | | | - Mary E. Rinella
- University of Torino, Department of Medical Sciences, Torino, Italy
| | | | - Giulio Marchesini
- Division of Gastroenterology and Hepatology, Saint Louis University, St. Louis, MO
| | | | | | - Francesco Negro
- Division of Gastroenterology and Hepatology, University of Virginia, Charlottesville, VA
| | - Stephen H. Caldwell
- Institute of Cardiometabolim and Nutrition (ICAN) and Hospital Pitié Salpêtrière, de L’Hopital, Paris, France
| | - Vlad Ratziu
- Massachusetts General Hospital, Cambridge, MA
| | - Kathleen E. Corey
- Icahn School of Medicine at Mount Sinai, Division of Liver Diseases, New York, NY
| | - Scott L. Friedman
- Division of Gastroenterology and Hepatology, Duke University, Durham, NC
| | | | - Stephen A. Harrison
- Division of Gastroenterology, Virginia Commonwealth University, Richmond, VA
| | - Arun J. Sanyal
- Department of Pediatrics, Columbia College of Physicians and Surgeons, New York, NY
| | - Joel E. Lavine
- Hôpital Claude Huriez Rue Michel Polonowski, Lille, France
| | | | - Michael R. Charlton
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, IN
| | - Zachary D. Goodman
- Department of Medicine and Betty and Guy Beatty Center for Integrated Research, Claude Moore, Inova Health Systems, Falls Church, VA
| | - Naga P. Chalasani
- Institute of Cellular Medicine, Faculty of Medical Sciences, Newcastle University, Newcastle Upon Tyne, United Kingdom
| | | | - Jacob George
- Storr Liver Centre, Westmead Institute for Medical Research, Westmead Hospital and University of Sydney, Sydney, Australia
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26
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Woo Baidal JA, Elbel EE, Lavine JE, Rifas-Shiman SL, Gillman MW, Oken E, Taveras EM. Associations of Early to Mid-Childhood Adiposity with Elevated Mid-Childhood Alanine Aminotransferase Levels in the Project Viva Cohort. J Pediatr 2018; 197:121-127.e1. [PMID: 29627190 PMCID: PMC5970959 DOI: 10.1016/j.jpeds.2018.01.069] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2017] [Revised: 01/09/2018] [Accepted: 01/26/2018] [Indexed: 01/10/2023]
Abstract
OBJECTIVES To examine the longitudinal relationship of early to mid-childhood adiposity measures with mid-childhood alanine aminotransferase (ALT) levels. STUDY DESIGN We studied 635 children in the Project Viva cohort. Research staff measured weight, height, skinfolds thicknesses, and waist and hip circumferences at early (median 3.2 years) and mid-childhood (median 7.7 years) visits. At mid-childhood, we collected blood for ALT analysis. We used established sex-specific ALT cut-offs to define elevated ALT. In multivariable linear and logistic regression models, we assessed the association of adiposity measures from early to mid-childhood with mid-childhood ALT level, adjusting for confounders. RESULTS Children were 48% female, 59% white, 21% black, 6% Hispanic/Latino, and 3% Asian. At early childhood, 29% had overweight/obesity and mean waist circumference was 51.5 (SD 3.8) cm. At mid-childhood, mean ALT was 20.3 (SD 7.3) units/L, and 23% had an elevated ALT. In multivariable-adjusted regression models, each additional 10-cm greater waist circumference at early childhood was associated with 1.99 (95% CI 1.19-3.33) greater odds of elevated ALT at mid-childhood. Greater increases from early to mid-childhood in body mass index z score, sum of subscapular and triceps skinfold thicknesses, waist circumference, and hip circumference were associated with greater ALT at mid-childhood. CONCLUSIONS In this prospective cohort, greater waist circumference at early childhood and greater increases in adiposity measures from early to mid-childhood were associated with greater ALT levels at mid-childhood.
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Affiliation(s)
- Jennifer A Woo Baidal
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Columbia University Medical Center, New York, NY.
| | - Erin E Elbel
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Columbia University Medical Center, New York, NY
| | - Joel E Lavine
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Columbia University Medical Center, New York, NY
| | - Sheryl L Rifas-Shiman
- Division of Chronic Disease Research Across the Lifecourse, Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, MA
| | - Matthew W Gillman
- Division of Chronic Disease Research Across the Lifecourse, Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, MA
| | - Emily Oken
- Division of Chronic Disease Research Across the Lifecourse, Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, MA
| | - Elsie M Taveras
- Division of General Academic Pediatrics, Department of Pediatrics, Massachusetts General Hospital, Boston, MA
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27
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Rausch JC, Lavine JE, Chalasani N, Guo X, Kwon S, Schwimmer JB, Molleston JP, Loomba R, Brunt EM, da Chen YDI, Goodarzi MO, Taylor KD, Yates KP, Rotter JI. Genetic Variants Associated With Obesity and Insulin Resistance in Hispanic Boys With Nonalcoholic Fatty Liver Disease. J Pediatr Gastroenterol Nutr 2018; 66:789-796. [PMID: 29470286 PMCID: PMC5916321 DOI: 10.1097/mpg.0000000000001926] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
BACKGROUND AND OBJECTIVES Nonalcoholic fatty liver disease (NAFLD) disproportionately affects Hispanic boys. Further, obesity and insulin resistance are major risk factors for NAFLD. No gene localization studies had been performed on children with biopsy-proven NAFLD. This study aims to identify genomic variants associated with increased adiposity and insulin resistance in a population of children with varying histologic severity of NAFLD. METHODS We conducted a genome-wide association scan (GWAS) including 624,297 single-nucleotide polymorphisms (SNPs) distributed among all 22 autosomal chromosomes in 234 Hispanic boys (up to 18 years of age) who were consecutively recruited in a prospective cohort study in the Nonalcoholic Steatohepatitis Clinical Research Network Studies. Traits were examined quantitatively using linear regression. SNPs with P value <10 and a minor allele frequency >5% were considered potentially significant. RESULTS Evaluated subjects had a median age of 12.0 years, body mass index (BMI) of 31.4, and hemoglobin A1C (Hgb A1C) of 5.3. The prevalence of NAFL, borderline NASH, and definite NASH were 23%, 53%, and 22%, respectively. The GWAS identified 10 SNPs that were associated with BMI z score, 6 within chromosome 2, and 1 within CAMK1D, which has a potential role in liver gluconeogenesis. In addition, the GWAS identified 9 novel variants associated with insulin resistance: HOMA-IR (6) and HbA1c (3). CONCLUSIONS This study of Hispanic boys with biopsy-proven NAFLD with increased risk for the metabolic syndrome revealed novel genetic variants that are associated with obesity and insulin resistance.
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Affiliation(s)
| | | | | | - Xiuqing Guo
- Institute for Translational Genomics and Population Science and Pediatrics, LA BioMed at Harbor-UCLA Medical Center, Los Angeles, CA
| | - Soonil Kwon
- Institute for Translational Genomics and Population Science and Pediatrics, LA BioMed at Harbor-UCLA Medical Center, Los Angeles, CA
| | | | | | - Rohit Loomba
- Medicine, University of California, San Diego, San Diego, CA
| | | | - Yii-Der I da Chen
- Institute for Translational Genomics and Population Science and Pediatrics, LA BioMed at Harbor-UCLA Medical Center, Los Angeles, CA
| | - Mark O Goodarzi
- Division of Endocrinology, Diabetes and Metabolism, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Kent D Taylor
- Institute for Translational Genomics and Population Science and Pediatrics, LA BioMed at Harbor-UCLA Medical Center, Los Angeles, CA
| | - Katherine P Yates
- Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD
| | - Jerome I Rotter
- Institute for Translational Genomics and Population Science and Pediatrics, LA BioMed at Harbor-UCLA Medical Center, Los Angeles, CA
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28
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Africa JA, Behling CA, Brunt EM, Zhang N, Luo Y, Wells A, Hou J, Belt PH, Kohil R, Lavine JE, Molleston JP, Newton KP, Whitington PF, Schwimmer JB. In Children With Nonalcoholic Fatty Liver Disease, Zone 1 Steatosis Is Associated With Advanced Fibrosis. Clin Gastroenterol Hepatol 2018; 16:438-446.e1. [PMID: 28286193 PMCID: PMC5589478 DOI: 10.1016/j.cgh.2017.02.030] [Citation(s) in RCA: 46] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2016] [Revised: 01/26/2017] [Accepted: 02/14/2017] [Indexed: 02/06/2023]
Abstract
BACKGROUND & AIMS Focal zone 1 steatosis, although rare in adults with nonalcoholic fatty liver disease (NAFLD), does occur in children with NAFLD. We investigated whether focal zone 1 steatosis and focal zone 3 steatosis are distinct subphenotypes of pediatric NAFLD. We aimed to determine associations between the zonality of steatosis and demographic, clinical, and histologic features in children with NAFLD. METHODS We performed a cross-sectional study of baseline data from 813 children (age <18 years; mean age, 12.8 ± 2.7 years). The subjects had biopsy-proven NAFLD and were enrolled in the Nonalcoholic Steatohepatitis Clinical Research Network. Liver histology was reviewed using the Nonalcoholic Steatohepatitis Clinical Research Network scoring system. RESULTS Zone 1 steatosis was present in 18% of children with NAFLD (n = 146) and zone 3 steatosis was present in 32% (n = 244). Children with zone 1 steatosis were significantly younger (10 vs 14 years; P < .001) and a significantly higher proportion had any fibrosis (81% vs 51%; P < .001) or advanced fibrosis (13% vs 5%; P < .001) compared with children with zone 3 steatosis. In contrast, children with zone 3 steatosis were significantly more likely to have steatohepatitis (30% vs 6% in children with zone 1 steatosis; P < .001). CONCLUSIONS Children with zone 1 or zone 3 distribution of steatosis have an important subphenotype of pediatric NAFLD. Children with zone 1 steatosis are more likely to have advanced fibrosis and children with zone 3 steatosis are more likely to have steatohepatitis. To achieve a comprehensive understanding of pediatric NAFLD, studies of pathophysiology, natural history, and response to treatment should account for the zonality of steatosis.
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Affiliation(s)
- Jonathan A. Africa
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, University of California, San Diego School of Medicine, La Jolla, California,Department of Gastroenterology, Rady Children’s Hospital San Diego, San Diego, California
| | - Cynthia A. Behling
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, University of California, San Diego School of Medicine, La Jolla, California,Department of Pathology, Sharp Memorial Hospital, San Diego, CA
| | | | - Nan Zhang
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, University of California, San Diego School of Medicine, La Jolla, California
| | - Yunjun Luo
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, University of California, San Diego School of Medicine, La Jolla, California
| | - Alan Wells
- Clinical and Translational Research Institute, University of California San Diego School of Medicine, La Jolla, California
| | - Jiayi Hou
- Clinical and Translational Research Institute, University of California San Diego School of Medicine, La Jolla, California
| | | | - Rohit Kohil
- Division of Gastroenterology, Hepatology, and Nutrition, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH
| | - Joel E. Lavine
- Department of Pediatrics, Columbia University, New York, NY
| | - Jean P. Molleston
- Department of Pediatrics, Indiana University, Indianapolis, IN,James Whitcomb Riley Hospital, Indianapolis, IN
| | - Kimberly P. Newton
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, University of California, San Diego School of Medicine, La Jolla, California,Department of Gastroenterology, Rady Children’s Hospital San Diego, San Diego, California
| | | | - Jeffrey B. Schwimmer
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, University of California, San Diego School of Medicine, La Jolla, California,Department of Gastroenterology, Rady Children’s Hospital San Diego, San Diego, California
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29
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Middleton MS, Van Natta ML, Heba ER, Alazraki A, Trout AT, Masand P, Brunt EM, Kleiner DE, Doo E, Tonascia J, Lavine JE, Shen W, Hamilton G, Schwimmer JB, Sirlin CB. Diagnostic accuracy of magnetic resonance imaging hepatic proton density fat fraction in pediatric nonalcoholic fatty liver disease. Hepatology 2018; 67:858-872. [PMID: 29028128 PMCID: PMC6211296 DOI: 10.1002/hep.29596] [Citation(s) in RCA: 98] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2017] [Revised: 09/11/2017] [Accepted: 10/12/2017] [Indexed: 12/11/2022]
Abstract
UNLABELLED We assessed the performance of magnetic resonance imaging (MRI) proton density fat fraction (PDFF) in children to stratify hepatic steatosis grade before and after treatment in the Cysteamine Bitartrate Delayed-Release for the Treatment of Nonalcoholic Fatty Liver Disease in Children (CyNCh) trial, using centrally scored histology as reference. Participants had multiecho 1.5 Tesla (T) or 3T MRI on scanners from three manufacturers. Of 169 enrolled children, 110 (65%) and 83 (49%) had MRI and liver biopsy at baseline and at end of treatment (EOT; 52 weeks), respectively. At baseline, 17% (19 of 110), 28% (31 of 110), and 55% (60 of 110) of liver biopsies showed grades 1, 2, and 3 histological steatosis; corresponding PDFF (mean ± SD) values were 10.9 ± 4.1%, 18.4 ± 6.2%, and 25.7 ± 9.7%, respectively. PDFF classified grade 1 versus 2-3 and 1-2 versus 3 steatosis with areas under receiving operator characteristic curves (AUROCs) of 0.87 (95% confidence interval [CI], 0.80, 0.94) and 0.79 (0.70, 0.87), respectively. PDFF cutoffs at 90% specificity were 17.5% for grades 2-3 steatosis and 23.3% for grade 3 steatosis. At EOT, 47% (39 of 83), 41% (34 of 83), and 12% (10 of 83) of biopsies showed improved, unchanged, and worsened steatosis grade, respectively, with corresponding PDFF (mean ± SD) changes of -7.8 ± 6.3%, -1.2 ± 7.8%, and 4.9 ± 5.0%, respectively. PDFF change classified steatosis grade improvement and worsening with AUROCs (95% CIs) of 0.76 (0.66, 0.87) and 0.83 (0.73, 0.92), respectively. PDFF change cut-off values at 90% specificity were -11.0% and +5.5% for improvement and worsening. CONCLUSION MRI-estimated PDFF has high diagnostic accuracy to both classify and predict histological steatosis grade and change in histological steatosis grade in children with NAFLD. (Hepatology 2018;67:858-872).
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Affiliation(s)
- Michael S. Middleton
- Liver Imaging Group, Department of Radiology, UCSD School of Medicine, San Diego, California
| | - Mark L. Van Natta
- Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Elhamy R. Heba
- Liver Imaging Group, Department of Radiology, UCSD School of Medicine, San Diego, California
| | - Adina Alazraki
- Emory University School of Medicine, Department of Radiology and Imaging Sciences, Atlanta, Georgia
| | - Andrew T. Trout
- Cincinnati Children’s Hospital, Department of Radiology, Cincinnati, Ohio
| | | | | | | | - Edward Doo
- Liver Diseases Section, Digestive Diseases Branch, National Institute of Diabetes and Digestive and Kidney Diseases
| | - James Tonascia
- Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Joel E. Lavine
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Columbia University Medical Center, New York, New York
| | - Wei Shen
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Columbia University Medical Center, New York, New York
| | - Gavin Hamilton
- Liver Imaging Group, Department of Radiology, UCSD School of Medicine, San Diego, California
| | - Jeffrey B. Schwimmer
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, University of California San Diego School of Medicine, La Jolla, California; and Department of Gastroenterology, Rady Children’s Hospital, San Diego, California
| | - Claude B. Sirlin
- Liver Imaging Group, Department of Radiology, UCSD School of Medicine, San Diego, California
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30
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Chalasani N, Younossi Z, Lavine JE, Charlton M, Cusi K, Rinella M, Harrison SA, Brunt EM, Sanyal AJ. The diagnosis and management of nonalcoholic fatty liver disease: Practice guidance from the American Association for the Study of Liver Diseases. Hepatology 2018; 67:328-357. [PMID: 28714183 DOI: 10.1002/hep.29367] [Citation(s) in RCA: 4089] [Impact Index Per Article: 681.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2017] [Accepted: 06/29/2017] [Indexed: 02/06/2023]
Affiliation(s)
| | - Zobair Younossi
- Center for Liver Disease and Department of Medicine, Inova Fairfax Hospital, Falls Church, VA
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31
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Younossi ZM, Loomba R, Anstee QM, Rinella ME, Bugianesi E, Marchesini G, Neuschwander-Tetri BA, Serfaty L, Negro F, Caldwell SH, Ratziu V, Corey KE, Friedman SL, Abdelmalek MF, Harrison SA, Sanyal AJ, Lavine JE, Mathurin P, Charlton MR, Goodman ZD, Chalasani NP, Kowdley KV, George J, Lindor K. Diagnostic modalities for nonalcoholic fatty liver disease, nonalcoholic steatohepatitis, and associated fibrosis. Hepatology 2017. [PMID: 29222917 DOI: 10.1002/hep.29721+10.1002/hep.29721] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Nonalcoholic fatty liver disease (NAFLD) is a spectrum comprised of isolated steatosis, nonalcoholic steatohepatitis (NASH), advanced fibrosis, and cirrhosis. The majority of NAFLD subjects do not have NASH and do not carry a significant risk for liver-related adverse outcomes (cirrhosis and mortality). Globally, the prevalence of NAFLD is approximately 25%. In Asia, a gradient of high to low prevalence rates is noted from urban to rural areas. Given the prevalence of NAFLD, the clinical and economic burden of NAFLD and NASH can be substantial. With increasing recognition of NASH as an important liver disease, the diagnosis of NASH still requires a liver biopsy that is suboptimal. Although liver biopsy is the most accurate modality to diagnose and stage the severity of NASH, this method suffers from being invasive, costly, associated with potential complications, and plagued with interobserver variability of individual pathological features. A number of noninvasive modalities to diagnose NASH and stage liver fibrosis are being developed. These modalities include predictive models (NAFLD fibrosis score) and serum biomarkers such as enhanced liver fibrosis (ELF). Other tests are based on radiological techniques, such as transient elastography (TE) or magnetic resonance elastography (MRE), which are used to estimate liver stiffness as a potential surrogate of hepatic fibrosis. Although a dynamic field of research, most of these diagnostic modalities have area under the curve ranging between 0.76 and 0.90%, with MRE having the best predictive performance. In summary, developing safe and easily accessible noninvasive modalities to accurately diagnose and monitor NASH and associated fibrosis is of utmost importance in clinical practice and clinical research. These tests are not only important to risk stratify subjects at the greatest risk for progressive liver disease, but also to serve as appropriate surrogate endpoints for therapeutic clinical trials of NASH. (Hepatology 2018;68:349-360).
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Affiliation(s)
- Zobair M Younossi
- Department of Medicine and Betty and Guy Beatty Center for Integrated Research, Claude Moore, Inova Health Systems, Falls Church, VA
| | - Rohit Loomba
- NAFLD Research Center, University of California at San Diego, La Jolla, CA
| | - Quentin M Anstee
- Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Mary E Rinella
- University of Torino, Department of Medical Sciences, Torino, Italy
| | | | - Giulio Marchesini
- Division of Gastroenterology and Hepatology, Saint Louis University, St. Louis, MO
| | | | | | - Francesco Negro
- Division of Gastroenterology and Hepatology, University of Virginia, Charlottesville, VA
| | - Stephen H Caldwell
- Institute of Cardiometabolim and Nutrition (ICAN) and Hospital Pitié Salpêtrière, de L'Hopital, Paris, France
| | - Vlad Ratziu
- Massachusetts General Hospital, Cambridge, MA
| | - Kathleen E Corey
- Icahn School of Medicine at Mount Sinai, Division of Liver Diseases, New York, NY
| | - Scott L Friedman
- Division of Gastroenterology and Hepatology, Duke University, Durham, NC
| | | | - Stephen A Harrison
- Division of Gastroenterology, Virginia Commonwealth University, Richmond, VA
| | - Arun J Sanyal
- Department of Pediatrics, Columbia College of Physicians and Surgeons, New York, NY
| | - Joel E Lavine
- Hôpital Claude Huriez Rue Michel Polonowski, Lille, France
| | | | - Michael R Charlton
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, IN
| | - Zachary D Goodman
- Department of Medicine and Betty and Guy Beatty Center for Integrated Research, Claude Moore, Inova Health Systems, Falls Church, VA
| | - Naga P Chalasani
- Institute of Cellular Medicine, Faculty of Medical Sciences, Newcastle University, Newcastle Upon Tyne, United Kingdom
| | | | - Jacob George
- Storr Liver Centre, Westmead Institute for Medical Research, Westmead Hospital and University of Sydney, Sydney, Australia
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Li H, Canet MJ, Clarke JD, Billheimer D, Xanthakos SA, Lavine JE, Erickson RP, Cherrington NJ. Pediatric Cytochrome P450 Activity Alterations in Nonalcoholic Steatohepatitis. Drug Metab Dispos 2017; 45:1317-1325. [PMID: 28986475 PMCID: PMC5697442 DOI: 10.1124/dmd.117.077644] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2017] [Accepted: 09/28/2017] [Indexed: 01/01/2023] Open
Abstract
Variable drug responses depend on individual variation in the activity of drug-metabolizing enzymes, including cytochrome P450 enzymes (CYP). As the most common chronic liver disease in children and adults, nonalcoholic steatohepatitis (NASH) has been identified as a source of significant interindividual variation in hepatic drug metabolism. Compared with adults, children present age-related differences in pharmacokinetics and pharmacodynamics. The purpose of this study was to determine the impact of fatty liver disease severity on the activity of a variety of CYP enzymes in children and adolescents. Healthy and nonalcoholic fatty liver disease pediatric subjects aged 12-21 years inclusive received an oral cocktail of four probe drugs: caffeine (CYP1A2, 100 mg), omeprazole (CYP2C19, 20 mg), losartan (CYP2C9, 25 mg), and midazolam (CYP3A4, 2 mg). Venous blood and urine were collected before administration and 1, 2, 4, and 6 hours after administration. Concentrations of the parent drugs and CYP-specific metabolites were quantified in plasma and urine using liquid chromatography with tandem mass spectrometry. In plasma, the decreased metabolic area under the curve (AUC) ratio, defined as the metabolite AUC to parent AUC, of omeprazole indicated significant decreases of CYP2C19 (P = 0.002) enzymatic activities in NASH adolescents, while the urine analyses did not show significant differences and were highly variable. A comparison between the present in vivo pediatric studies and a previous ex vivo study in adults indicates distinct differences in the activities of CYP1A2 and CYP2C9. These data demonstrate that pediatric NASH presents an altered pattern of CYP activity and NASH should be considered as a confounder of drug metabolism for certain CYP enzymes. These differences could lead to future investigations that may reveal unexpected variable drug responses that should be considered in pediatric dosage recommendations.
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Affiliation(s)
- Hui Li
- Department of Pharmacology and Toxicology (H.L., M.J.C., J.D.C., N.J.C.), Department of Epidemiology and Biostatistics (D.B.), and Department of Pediatrics (R.P.E.), University of Arizona, Tucson, Arizona; Cincinnati Children's Hospital, University of Cincinnati, Cincinnati, Ohio (S.A.X.); Columbia University, New York, New York (J.E.L.)
| | - Mark J Canet
- Department of Pharmacology and Toxicology (H.L., M.J.C., J.D.C., N.J.C.), Department of Epidemiology and Biostatistics (D.B.), and Department of Pediatrics (R.P.E.), University of Arizona, Tucson, Arizona; Cincinnati Children's Hospital, University of Cincinnati, Cincinnati, Ohio (S.A.X.); Columbia University, New York, New York (J.E.L.)
| | - John D Clarke
- Department of Pharmacology and Toxicology (H.L., M.J.C., J.D.C., N.J.C.), Department of Epidemiology and Biostatistics (D.B.), and Department of Pediatrics (R.P.E.), University of Arizona, Tucson, Arizona; Cincinnati Children's Hospital, University of Cincinnati, Cincinnati, Ohio (S.A.X.); Columbia University, New York, New York (J.E.L.)
| | - Dean Billheimer
- Department of Pharmacology and Toxicology (H.L., M.J.C., J.D.C., N.J.C.), Department of Epidemiology and Biostatistics (D.B.), and Department of Pediatrics (R.P.E.), University of Arizona, Tucson, Arizona; Cincinnati Children's Hospital, University of Cincinnati, Cincinnati, Ohio (S.A.X.); Columbia University, New York, New York (J.E.L.)
| | - Stavra A Xanthakos
- Department of Pharmacology and Toxicology (H.L., M.J.C., J.D.C., N.J.C.), Department of Epidemiology and Biostatistics (D.B.), and Department of Pediatrics (R.P.E.), University of Arizona, Tucson, Arizona; Cincinnati Children's Hospital, University of Cincinnati, Cincinnati, Ohio (S.A.X.); Columbia University, New York, New York (J.E.L.)
| | - Joel E Lavine
- Department of Pharmacology and Toxicology (H.L., M.J.C., J.D.C., N.J.C.), Department of Epidemiology and Biostatistics (D.B.), and Department of Pediatrics (R.P.E.), University of Arizona, Tucson, Arizona; Cincinnati Children's Hospital, University of Cincinnati, Cincinnati, Ohio (S.A.X.); Columbia University, New York, New York (J.E.L.)
| | - Robert P Erickson
- Department of Pharmacology and Toxicology (H.L., M.J.C., J.D.C., N.J.C.), Department of Epidemiology and Biostatistics (D.B.), and Department of Pediatrics (R.P.E.), University of Arizona, Tucson, Arizona; Cincinnati Children's Hospital, University of Cincinnati, Cincinnati, Ohio (S.A.X.); Columbia University, New York, New York (J.E.L.)
| | - Nathan J Cherrington
- Department of Pharmacology and Toxicology (H.L., M.J.C., J.D.C., N.J.C.), Department of Epidemiology and Biostatistics (D.B.), and Department of Pediatrics (R.P.E.), University of Arizona, Tucson, Arizona; Cincinnati Children's Hospital, University of Cincinnati, Cincinnati, Ohio (S.A.X.); Columbia University, New York, New York (J.E.L.)
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Schwimmer JB, Behling C, Angeles JE, Paiz M, Durelle J, Africa J, Newton KP, Brunt EM, Lavine JE, Abrams SH, Masand P, Krishnamurthy R, Wong K, Ehman RL, Yin M, Glaser KJ, Dzyubak B, Wolfson T, Gamst AC, Hooker J, Haufe W, Schlein A, Hamilton G, Middleton MS, Sirlin CB. Magnetic resonance elastography measured shear stiffness as a biomarker of fibrosis in pediatric nonalcoholic fatty liver disease. Hepatology 2017; 66:1474-1485. [PMID: 28493388 PMCID: PMC5650504 DOI: 10.1002/hep.29241] [Citation(s) in RCA: 89] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2016] [Revised: 03/23/2017] [Accepted: 04/24/2017] [Indexed: 12/14/2022]
Abstract
UNLABELLED Magnetic resonance elastography (MRE) is a promising technique for noninvasive assessment of fibrosis, a major determinant of outcome in nonalcoholic fatty liver disease (NAFLD). However, data in children are limited. The purpose of this study was to determine the accuracy of MRE for the detection of fibrosis and advanced fibrosis in children with NAFLD and to assess agreement between manual and novel automated reading methods. We performed a prospective, multicenter study of two-dimensional (2D) MRE in children with NAFLD. MR elastograms were analyzed manually at two reading centers, and using a new automated technique. Analysis using each approach was done independently. Correlations were determined between MRE analysis methods and fibrosis stage. Thresholds for classifying the presence of fibrosis and of advanced fibrosis were computed and cross-validated. In 90 children with a mean age of 13.1 ± 2.4 years, median hepatic stiffness was 2.35 kPa. Stiffness values derived by each reading center were strongly correlated with each other (r = 0.83). All three analyses were significantly correlated with fibrosis stage (center 1, ρ = 0.53; center 2, ρ = 0.55; and automated analysis, ρ = 0.52; P < 0.001). Overall cross-validated accuracy for detecting any fibrosis was 72.2% for all methods (95% confidence interval [CI], 61.8%-81.1%). Overall cross-validated accuracy for assessing advanced fibrosis was 88.9% (95% CI, 80.5%-94.5%) for center 1, 90.0% (95% CI, 81.9%-95.3%) for center 2, and 86.7% (95% CI, 77.9%-92.9%) for automated analysis. CONCLUSION 2D MRE can estimate hepatic stiffness in children with NAFLD. Further refinement and validation of automated analysis techniques will be an important step in standardizing MRE. How to best integrate MRE into clinical protocols for the assessment of NAFLD in children will require prospective evaluation. (Hepatology 2017;66:1474-1485).
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Affiliation(s)
- Jeffrey B. Schwimmer
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, University of California, San Diego School of Medicine, San Diego, California,Department of Gastroenterology, Rady Children’s Hospital San Diego, San Diego, California,Liver Imaging Group, Department of Radiology, University of California, San Diego School of Medicine, San Diego, California
| | - Cynthia Behling
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, University of California, San Diego School of Medicine, San Diego, California
| | - Jorge Eduardo Angeles
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, University of California, San Diego School of Medicine, San Diego, California
| | - Melissa Paiz
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, University of California, San Diego School of Medicine, San Diego, California
| | - Janis Durelle
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, University of California, San Diego School of Medicine, San Diego, California
| | - Jonathan Africa
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, University of California, San Diego School of Medicine, San Diego, California
| | - Kimberly P. Newton
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, University of California, San Diego School of Medicine, San Diego, California,Department of Gastroenterology, Rady Children’s Hospital San Diego, San Diego, California
| | - Elizabeth M. Brunt
- Department of Pathology and Immunology, Washington University, St. Louis, Missouri
| | | | - Stephanie H. Abrams
- Columbia University, New York, NY,Baylor College of Medicine, Houston, Texas,Houston Methodist Hospital, Houston, Texas
| | | | | | - Kelvin Wong
- Miller Children’s & Women’s Hospital Long Beach, California
| | | | - Meng Yin
- Mayo Clinic, Rochester, Minnesota
| | | | | | - Tanya Wolfson
- Computational and Applied Statistics Laboratory (CASL), San Diego Supercomputer Center, University of California, San Diego, California
| | - Anthony C. Gamst
- Computational and Applied Statistics Laboratory (CASL), San Diego Supercomputer Center, University of California, San Diego, California
| | - Jonathan Hooker
- Liver Imaging Group, Department of Radiology, University of California, San Diego School of Medicine, San Diego, California
| | - William Haufe
- Liver Imaging Group, Department of Radiology, University of California, San Diego School of Medicine, San Diego, California
| | - Alexandra Schlein
- Liver Imaging Group, Department of Radiology, University of California, San Diego School of Medicine, San Diego, California
| | - Gavin Hamilton
- Liver Imaging Group, Department of Radiology, University of California, San Diego School of Medicine, San Diego, California
| | - Michael S. Middleton
- Liver Imaging Group, Department of Radiology, University of California, San Diego School of Medicine, San Diego, California
| | - Claude B. Sirlin
- Liver Imaging Group, Department of Radiology, University of California, San Diego School of Medicine, San Diego, California
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Middleton MS, Heba ER, Hooker CA, Bashir MR, Fowler KJ, Sandrasegaran K, Brunt EM, Kleiner DE, Doo E, Van Natta ML, Tonascia J, Lavine JE, Neuschwander-Tetri BA, Sanyal A, Loomba R, Sirlin CB. Agreement Between Magnetic Resonance Imaging Proton Density Fat Fraction Measurements and Pathologist-Assigned Steatosis Grades of Liver Biopsies From Adults With Nonalcoholic Steatohepatitis. Gastroenterology 2017; 153. [PMID: 28624576 PMCID: PMC5695870 DOI: 10.1053/j.gastro.2017.06.005] [Citation(s) in RCA: 188] [Impact Index Per Article: 26.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND & AIMS We assessed the diagnostic performance of magnetic resonance imaging (MRI) proton density fat fraction (PDFF) in grading hepatic steatosis and change in hepatic steatosis in adults with nonalcoholic steatohepatitis (NASH) in a multi-center study, using central histology as reference. METHODS We collected data from 113 adults with NASH participating in a multi-center, randomized, double-masked, placebo-controlled, phase 2b trial to compare the efficacy cross-sectionally and longitudinally of obeticholic acid vs placebo. Hepatic steatosis was assessed at baseline and after 72 weeks of obeticholic acid or placebo by liver biopsy and MRI (scanners from different manufacturers, at 1.5T or 3T). We compared steatosis estimates by PDFF vs histology. Histologic steatosis grade was scored in consensus by a pathology committee. Cross-validated receiver operating characteristic (ROC) analyses were performed. RESULTS At baseline, 34% of subjects had steatosis grade 0 or 1, 39% had steatosis grade 2, and 27% had steatosis grade 3; corresponding mean PDFF values were 9.8%±3.7%, 18.1%±4.3%, and 30.1%±8.1%. PDFF classified steatosis grade 0-1 vs 2-3 with an area under the ROC curve (AUROC) of 0.95 (95% CI, 0.91-0.98), and grade 0-2 vs grade 3 steatosis with an AUROC of 0.96 (95% CI, 0.93-0.99). PDFF cut-off values at 90% specificity were 16.3% for grades 2-3 and 21.7% for grade 3, with corresponding sensitivities of 83% and 84%. After 72 weeks' of obeticholic vs placebo, 42% of subjects had a reduced steatosis grade (mean reduction in PDFF from baseline of 7.4%±8.7%), 49% had no change in steatosis grade (mean increase in PDFF from baseline of 0.3%±6.3%), and 9% had an increased steatosis grade (mean increase in PDFF from baseline of 7.7%±6.0%). PDFF change identified subjects with reduced steatosis grade with an AUROC of 0.81 (95% CI, 0.71-0.91) and increased steatosis grade with an AUROC of 0.81 (95% CI, 0.63-0.99). A PDFF reduction of 5.15% identified subjects with reduced steatosis grade with 90% specificity and 58% sensitivity, whereas a PDFF increase of 5.6% identified those with increased steatosis grade with 90% specificity and 57% sensitivity. CONCLUSIONS Based on data from a phase 2 randomized controlled trial of adults with NASH, PDFF estimated by MRI scanners of different field strength and at different sites, accurately classifies grades and changes in hepatic steatosis when histologic analysis of biopsies is used as a reference.
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Affiliation(s)
| | - Elhamy R. Heba
- Department of Radiology, UCSD School of Medicine, San Diego, California
| | | | - Mustafa R. Bashir
- Department of Radiology, Duke University Medical Center, 3808, Durham, North Carolina
| | | | - Kumar Sandrasegaran
- Department of Radiology, Indiana University School of Medicine, Indianapolis, Indiana
| | | | | | - Edward Doo
- Liver Diseases Section, Digestive Diseases Branch, National Institute of Diabetes and Digestive and Kidney Diseases
| | - Mark L. Van Natta
- Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - James Tonascia
- Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Joel E. Lavine
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Columbia University Medical Center, New York, New York
| | | | - Arun Sanyal
- Virginia Commonwealth University School of Medicine, Richmond, Virginia
| | - Rohit Loomba
- NAFLD Translational Research Unit, Division of Gastroenterology, UCSD School of Medicine, San Diego, California
| | - Claude B. Sirlin
- Department of Radiology, UCSD School of Medicine, San Diego, California
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35
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Perito ER, Ajmera V, Bass NM, Rosenthal P, Lavine JE, Schwimmer JB, Yates KP, Diehl AM, Molleston JP, Murray KF, Scheimann A, Gill R, Glidden D, Aouizerat B. Association Between Cytokines and Liver Histology in Children with Nonalcoholic Fatty Liver Disease. Hepatol Commun 2017; 1:609-622. [PMID: 29130075 PMCID: PMC5679472 DOI: 10.1002/hep4.1068] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Background Reliable non-invasive markers to characterize inflammation, hepatocellular ballooning, and fibrosis in nonalcoholic fatty liver disease (NAFLD) are lacking. We investigated the relationship between plasma cytokine levels and features of NAFLD histology to gain insight into cellular pathways driving NASH and to identify potential non-invasive discriminators of NAFLD severity and pattern. Methods Cytokines were measured from plasma obtained at enrollment in pediatric participants in NASH Clinical Research Network studies with liver biopsy-proven NAFLD. Cytokines were chosen a priori as possible discriminators of NASH and its components. Minimization of Akaike Information Criterion (AIC) was used to determine cytokines retained in multivariable models. Results Of 235 subjects, 31% had "Definite NASH" on liver histology, 43% had "Borderline NASH", and 25% had NAFLD but not NASH. Total plasminogen activator inhibitor 1 (PAI1) and activated PAI1 levels were higher in pediatric participants with Definite NASH and with lobular inflammation. Interleukin-8 (IL-8) was higher in those with stage 3-4 fibrosis and lobular inflammation. sIL-2rα was higher in children with stage 3-4 fibrosis and portal inflammation. In multivariable analysis, PAI1 variables were discriminators of Borderline/Definite NASH, definite NASH, lobular inflammation and ballooning. IL-8 increased with steatosis and fibrosis severity; sIL-2rα increased with fibrosis severity and portal inflammation. IL-7 decreased with portal inflammation and fibrosis severity. Conclusions Plasma cytokines associated with histology varied considerably among NASH features, suggesting promising avenues for investigation. Future, more targeted analysis is needed to identify the role of these markers in NAFLD and to evaluate their potential as non-invasive discriminators of disease severity.
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Affiliation(s)
- Emily R Perito
- University of California, San Francisco, San Francisco, CA
| | - Veeral Ajmera
- University of California, San Francisco, San Francisco, CA
| | - Nathan M Bass
- University of California, San Francisco, San Francisco, CA
| | | | | | | | | | | | | | | | | | - Ryan Gill
- University of California, San Francisco, San Francisco, CA
| | - David Glidden
- University of California, San Francisco, San Francisco, CA
| | - Bradley Aouizerat
- University of California, San Francisco, San Francisco, CA.,New York University, New York, NY
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36
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Abstract
Nonalcoholic fatty liver disease (NAFLD) represents a spectrum of disease. Its increasing prevalence is a direct result of historically high rates of obesity. Hepatocyte lipid accumulation is the first step in a cascade of metabolic and inflammatory events thought to precipitate NAFLD. Histologic findings provide insight into these events. Lifestyle modification remains the primary therapy in children. Current recommendations include vitamin E treatment in those with biopsy-proven NASH. Trials of novel drugs are ongoing in adults. As efficacy/safety are established, these therapies may be tenable for use in children. At the current time, biopsy-driven histology endpoints are necessary to establish whether future therapies can improve pediatric or adult-type NASH in children.
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Affiliation(s)
- Sarah E Fleet
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Columbia University Medical Center, 622 West 168th Street, PH17-119, New York, NY 10032, USA
| | - Jay H Lefkowitch
- Department of Pathology, Columbia University Medical Center, 630 West 168th Street, PH 15W 1574, New York, NY 10032, USA
| | - Joel E Lavine
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Columbia University Medical Center, 622 West 168th Street, PH17-105F, New York, NY 10032, USA.
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37
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Schwimmer JB, Lavine JE, Wilson LA, Neuschwander-Tetri BA, Xanthakos SA, Kohli R, Barlow SE, Vos MB, Karpen SJ, Molleston JP, Whitington PF, Rosenthal P, Jain AK, Murray KF, Brunt EM, Kleiner DE, Van Natta ML, Clark JM, Tonascia J, Doo E. In Children With Nonalcoholic Fatty Liver Disease, Cysteamine Bitartrate Delayed Release Improves Liver Enzymes but Does Not Reduce Disease Activity Scores. Gastroenterology 2016; 151:1141-1154.e9. [PMID: 27569726 PMCID: PMC5124386 DOI: 10.1053/j.gastro.2016.08.027] [Citation(s) in RCA: 85] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2016] [Revised: 08/17/2016] [Accepted: 08/18/2016] [Indexed: 01/14/2023]
Abstract
BACKGROUND & AIMS No treatment for nonalcoholic fatty liver disease (NAFLD) has been approved by regulatory agencies. We performed a randomized controlled trial to determine whether 52 weeks of cysteamine bitartrate delayed release (CBDR) reduces the severity of liver disease in children with NAFLD. METHODS We performed a double-masked trial of 169 children with NAFLD activity scores of 4 or higher at 10 centers. From June 2012 to January 2014, the patients were assigned randomly to receive CBDR or placebo twice daily (300 mg for patients weighing ≤65 kg, 375 mg for patients weighing >65 to 80 kg, and 450 mg for patients weighing >80 kg) for 52 weeks. The primary outcome from the intention-to-treat analysis was improvement in liver histology over 52 weeks, defined as a decrease in the NAFLD activity score of 2 points or more without worsening fibrosis; patients without biopsy specimens from week 52 (17 in the CBDR group and 6 in the placebo group) were considered nonresponders. We calculated the relative risks (RR) of improvement using a stratified Cochran-Mantel-Haenszel analysis. RESULTS There was no significant difference between groups in the primary outcome (28% of children in the CBDR group vs 22% in the placebo group; RR, 1.3; 95% confidence interval [CI], 0.8-2.1; P = .34). However, children receiving CBDR had significant changes in prespecified secondary outcomes: reduced mean levels of alanine aminotransferase (reduction, 53 ± 88 U/L vs 8 ± 77 U/L in the placebo group; P = .02) and aspartate aminotransferase (reduction, 31 ± 52 vs 4 ± 36 U/L in the placebo group; P = .008), and a larger proportion had reduced lobular inflammation (36% in the CBDR group vs 21% in the placebo group; RR, 1.8; 95% CI, 1.1-2.9; P = .03). In a post hoc analysis of children weighing 65 kg or less, those taking CBDR had a 4-fold better chance of histologic improvement (observed in 50% of children in the CBDR group vs 13% in the placebo group; RR, 4.0; 95% CI, 1.3-12.3; P = .005). CONCLUSIONS In a randomized trial, we found that 1 year of CBDR did not reduce overall histologic markers of NAFLD compared with placebo in children. Children receiving CBDR, however, had significant reductions in serum aminotransferase levels and lobular inflammation. ClinicalTrials.gov no: NCT01529268.
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Affiliation(s)
- Jeffrey B Schwimmer
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, University of California San Diego School of Medicine, La Jolla, California; Department of Gastroenterology, Rady Children's Hospital, San Diego, California.
| | - Joel E Lavine
- Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Columbia University, and Morgan Stanley Children's Hospital of New York Presbyterian, New York, New York
| | - Laura A Wilson
- Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | | | - Stavra A Xanthakos
- Steatohepatitis Center, Division of Pediatric Gastroenterology, Hepatology and Nutrition, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Rohit Kohli
- Steatohepatitis Center, Division of Pediatric Gastroenterology, Hepatology and Nutrition, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Sarah E Barlow
- Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Baylor College of Medicine and Texas Children's Hospital, Houston, Texas
| | - Miriam B Vos
- Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, Georgia
| | - Saul J Karpen
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, Georgia
| | - Jean P Molleston
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Indiana University School of Medicine/Riley Hospital for Children, Indianapolis, Indiana
| | - Peter F Whitington
- Department of Pediatrics, Feinberg Medical School of Northwestern University and the Ann and Robert H Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Philip Rosenthal
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, University of California, San Francisco Benioff Children's Hospital, San Francisco, California
| | - Ajay K Jain
- Department of Pediatrics, St. Louis University, St. Louis, Missouri
| | - Karen F Murray
- Division of Gastroenterology and Hepatology, Department of Pediatrics, University of Washington School of Medicine and Seattle Children's, Seattle, Washington
| | - Elizabeth M Brunt
- Department of Pathology, Washington University in St. Louis, St. Louis, Missouri
| | | | - Mark L Van Natta
- Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Jeanne M Clark
- Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - James Tonascia
- Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Edward Doo
- Liver Diseases Branch, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, Maryland
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Abstract
Nonalcoholic fatty liver disease (NAFLD) is the most common chronic liver disease worldwide and recently emerged as the most rapidly increasing indication for liver transplant. Although obesity is a risk factor for NAFLD, overlap between these two entities is incompletely understood. We highlight recent insights into the pathogenesis of human NAFLD in relation to obesity and discuss advances in the diagnosis and treatment of NAFLD.
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Affiliation(s)
- Jennifer A Woo Baidal
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Columbia University Medical Center, New York, NY 10032, USA
| | - Joel E Lavine
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Columbia University Medical Center, New York, NY 10032, USA.
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39
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Newton KP, Hou J, Crimmins NA, Lavine JE, Barlow SE, Xanthakos SA, Africa J, Behling C, Donithan M, Clark JM, Schwimmer JB. Prevalence of Prediabetes and Type 2 Diabetes in Children With Nonalcoholic Fatty Liver Disease. JAMA Pediatr 2016; 170:e161971. [PMID: 27478956 PMCID: PMC5479314 DOI: 10.1001/jamapediatrics.2016.1971] [Citation(s) in RCA: 160] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
IMPORTANCE Nonalcoholic fatty liver disease (NAFLD) is a major chronic liver disease in children in the United States and is associated with insulin resistance. In adults, NAFLD is also associated with type 2 diabetes. To our knowledge, the prevalence of type 2 diabetes in children with NAFLD is unknown. OBJECTIVE To determine the prevalence of type 2 diabetes and prediabetes in children with NAFLD and assess type 2 diabetes and prediabetes as risk factors for nonalcoholic steatohepatitis (NASH). DESIGN, SETTING, AND PARTICIPANTS This was a multicenter, cross-sectional study at 12 pediatric clinical centers across the United States participating in the National Institute of Diabetes and Digestive and Kidney Diseases NASH Clinical Research Network. Children younger than 18 years with biopsy-confirmed NAFLD enrolled in the NASH Clinical Research Network. MAIN OUTCOMES AND MEASURES The presence of type 2 diabetes and prediabetes as determined by American Diabetes Association screening criteria using clinical history and fasting laboratory values. RESULTS There were 675 children with NAFLD included in the study with a mean age of 12.6 years and mean body mass index (calculated as weight in kilograms divided by height in meters squared) of 32.5. Most of the children were boys (480 of 675) and Hispanic (445 of 675).The estimated prevalence of prediabetes was 23.4% (95% CI, 20.2%-26.6%), and the estimated prevalence of type 2 diabetes was 6.5% (95% CI, 4.6%-8.4%). Girls with NAFLD had 1.6 (95% CI, 1.04-2.40) times greater odds of having prediabetes and 5.0 (95% CI, 2.49-9.98) times greater odds of having type 2 diabetes than boys with NAFLD. The prevalence of NASH was higher in those with type 2 diabetes (43.2%) compared with prediabetes (34.2%) or normal glucose (22%) (P < .001). The odds of having NASH were significantly higher in those with prediabetes (OR, 1.9; 95% CI, 1.21-2.9) or type 2 diabetes (OR, 3.1; 95% CI, 1.5-6.2) compared with those with normal glucose. CONCLUSIONS AND RELEVANCE In this study, nearly 30% of children with NAFLD also had type 2 diabetes or prediabetes. These children had greater odds of having NASH and thus were at greater long-term risk for adverse hepatic outcomes.
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Affiliation(s)
- Kimberly P. Newton
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, University of California San Diego School of Medicine, La Jolla, California,Department of Gastroenterology, Rady Children’s Hospital, San Diego, California
| | - Jiayi Hou
- Clinical and Translational Research Institute, University of California San Diego School of Medicine, La Jolla, California
| | - Nancy A. Crimmins
- Division of Endocrinology, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio,Department of Pediatrics, University of Cincinnati, Cincinnati, Ohio
| | - Joel E. Lavine
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Columbia University, New York, NY
| | - Sarah E. Barlow
- Department of Pediatrics, Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Baylor College of Medicine, Houston, TX
| | - Stavra A. Xanthakos
- Department of Pediatrics, University of Cincinnati, Cincinnati, Ohio,Division of Gastroenterology, Hepatology and Nutrition, Cincinnati Children’s Hospital Medical Center
| | - Jonathan Africa
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, University of California San Diego School of Medicine, La Jolla, California,Department of Gastroenterology, Rady Children’s Hospital, San Diego, California
| | - Cynthia Behling
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, University of California San Diego School of Medicine, La Jolla, California,Division of Gastroenterology, Hepatology and Nutrition, Cincinnati Children’s Hospital Medical Center
| | - Michele Donithan
- Department of Epidemiology, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD
| | - Jeanne M. Clark
- Department of Epidemiology, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD,Department of Medicine, Johns Hopkins University, School of Medicine, Baltimore, MD
| | - Jeffrey B. Schwimmer
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, University of California San Diego School of Medicine, La Jolla, California,Department of Gastroenterology, Rady Children’s Hospital, San Diego, California,Liver Imaging Group, Department of Radiology, University of California San Diego School of Medicine, San Diego, California
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40
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Achmad E, Yokoo T, Hamilton G, Heba ER, Hooker JC, Changchien C, Schroeder M, Wolfson T, Gamst A, Schwimmer JB, Lavine JE, Sirlin CB, Middleton MS. Feasibility of and agreement between MR imaging and spectroscopic estimation of hepatic proton density fat fraction in children with known or suspected nonalcoholic fatty liver disease. ACTA ACUST UNITED AC 2016. [PMID: 26205992 DOI: 10.1007/s00261-015-0506-9] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
PURPOSE To assess feasibility of and agreement between magnetic resonance imaging (MRI) and magnetic resonance spectroscopy (MRS) for estimating hepatic proton density fat fraction (PDFF) in children with known or suspected nonalcoholic fatty liver disease (NAFLD). MATERIALS AND METHODS Children were included in this study from two previous research studies in each of which three MRI and three MRS acquisitions were obtained. Sequence acceptability, and MRI- and MRS-estimated PDFF were evaluated. Agreement of MRI- with MRS-estimated hepatic PDFF was assessed by linear regression and Bland-Altman analysis. Age, sex, BMI-Z score, acquisition time, and artifact score effects on MRI- and MRS-estimated PDFF agreement were assessed by multiple linear regression. RESULTS Eighty-six children (61 boys and 25 girls) were included in this study. Slope and intercept from regressing MRS-PDFF on MRI-PDFF were 0.969 and 1.591%, respectively, and the Bland-Altman bias and 95% limits of agreement were 1.17% ± 2.61%. MRI motion artifact score was higher in boys than girls (by 0.21, p = 0.021). Higher BMI-Z score was associated with lower agreement between MRS and MRI (p = 0.045). CONCLUSION Hepatic PDFF estimation by both MRI and MRS is feasible, and MRI- and MRS-estimated PDFF agree closely in children with known or suspected NAFLD.
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Affiliation(s)
- Emil Achmad
- Liver Imaging Group, Department of Radiology, School of Medicine, University of California, San Diego, San Diego, CA, USA
| | - Takeshi Yokoo
- Liver Imaging Group, Department of Radiology, School of Medicine, University of California, San Diego, San Diego, CA, USA
- Department of Radiology and Advanced Imaging Research Center, UT Southwestern School of Medicine, Dallas, TX, USA
| | - Gavin Hamilton
- Liver Imaging Group, Department of Radiology, School of Medicine, University of California, San Diego, San Diego, CA, USA
| | - Elhamy R Heba
- Liver Imaging Group, Department of Radiology, School of Medicine, University of California, San Diego, San Diego, CA, USA
| | - Jonathan C Hooker
- Liver Imaging Group, Department of Radiology, School of Medicine, University of California, San Diego, San Diego, CA, USA
| | - Christopher Changchien
- Liver Imaging Group, Department of Radiology, School of Medicine, University of California, San Diego, San Diego, CA, USA
| | - Michael Schroeder
- Liver Imaging Group, Department of Radiology, School of Medicine, University of California, San Diego, San Diego, CA, USA
| | - Tanya Wolfson
- Computational and Applied Statistics Laboratory (CASL), San Diego Supercomputing Center (SDSC), University of California, San Diego, San Diego, CA, USA
| | - Anthony Gamst
- Computational and Applied Statistics Laboratory (CASL), San Diego Supercomputing Center (SDSC), University of California, San Diego, San Diego, CA, USA
| | - Jeffrey B Schwimmer
- Liver Imaging Group, Department of Radiology, School of Medicine, University of California, San Diego, San Diego, CA, USA
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, School of Medicine, University of California, San Diego, San Diego, CA, USA
- Department of Gastroenterology, Rady Children's Hospital San Diego, San Diego, CA, USA
| | - Joel E Lavine
- Department of Pediatrics, Columbia University, New York, NY, USA
| | - Claude B Sirlin
- Liver Imaging Group, Department of Radiology, School of Medicine, University of California, San Diego, San Diego, CA, USA
| | - Michael S Middleton
- Liver Imaging Group, Department of Radiology, School of Medicine, University of California, San Diego, San Diego, CA, USA.
- UCSD Department of Radiology, UCSD MRI Institute, 410 West Dickinson Street, San Diego, CA, 92103-8749, USA.
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41
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Klair JS, Yang JD, Abdelmalek MF, Guy CD, Gill RM, Yates K, Unalp-Arida A, Lavine JE, Clark JM, Diehl AM, Suzuki A. A longer duration of estrogen deficiency increases fibrosis risk among postmenopausal women with nonalcoholic fatty liver disease. Hepatology 2016; 64:85-91. [PMID: 26919573 PMCID: PMC4917418 DOI: 10.1002/hep.28514] [Citation(s) in RCA: 114] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2015] [Revised: 01/17/2016] [Accepted: 02/24/2016] [Indexed: 12/14/2022]
Abstract
UNLABELLED Postmenopausal women with nonalcoholic steatohepatitis are at an increased risk of hepatic fibrosis compared with premenopausal women. Whether duration of estrogen deficiency in postmenopausal state dictates an individual's fibrosis risk remains uninvestigated. We assessed the associations of age at menopause and time from menopause with fibrosis severity in postmenopausal women with nonalcoholic fatty liver disease. Data from 488 postmenopausal women with (1) histologic diagnosis of nonalcoholic fatty liver disease and (2) self-reported information on age at menopause were analyzed. The associations of premature menopause (age at menopause of <40 years) and time from menopause (age at study enrollment - age at menopause, years) with fibrosis severity (stage 0-4) were assessed using multiple ordinal logistic regression models with and without adjusting for clinical confounders. Among the participants (age at menopause 43.7 ± 8.6 years), women with premature menopause (29.3%) were younger at enrollment (P < 0.001) and used hormone replacement therapy more often (P < 0.003). After adjusting for age at enrollment, race, waist circumference standardized by body mass index, current smoking, current alcohol use, hypertension, diabetes/impaired fasting glucose, homeostatic model assessment of insulin resistance, and hormone replacement therapy, premature menopause was associated with an increased likelihood of having more severe fibrosis (adjusted cumulative odds ratio = 1.9, 95% confidence interval 1.3-2.7, P = 0.001), while time from menopause was directly associated with an increased likelihood of having more severe fibrosis (adjusted cumulative odds ratio for 5-year unit = 1.2, 95% confidence interval 1.1-1.3, P = 0.002). CONCLUSION Duration of estrogen deficiency in postmenopausal state confers fibrosis risk among postmenopausal women with nonalcoholic fatty liver disease. (Hepatology 2016;64:85-91).
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Affiliation(s)
- Jagpal Singh Klair
- Department of Medicine, University of Arkansas for Medical
Sciences, Little Rock, AR
| | - Ju Dong Yang
- Division of Gastroenterology and Hepatology, Mayo Clinic
College of Medicine, Rochester, MN
| | | | | | - Ryan M. Gill
- Dept. of Pathology, University of California San Francisco,
San Francisco, CA
| | - Katherine Yates
- NASH CRN Data Coordinating Center, Johns Hopkins Bloomberg
School of Public Health, Baltimore, MD
| | - Aynur Unalp-Arida
- Division of Digestive Diseases and Nutrition, National
Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of
Health, Bethesda, MD
| | | | - Jeanne M. Clark
- Division of General Internal Medicine, Johns Hopkins
Bloomberg School of Public Health, Baltimore, MD
| | - Anna Mae Diehl
- Gastroenterology and Hepatology, Duke University, Durham,
NC
| | - Ayako Suzuki
- Gastroenterology and Hepatology, Duke University, Durham,
NC,Gastroenterology, Central Arkansas Veterans Healthcare
System, Little Rock, AR,Gastroenterology and Hepatology, University of Arkansas
for Medical Sciences, Little Rock, AR
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42
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Neuschwander-Tetri BA, Loomba R, Sanyal AJ, Lavine JE, Van Natta ML, Abdelmalek MF, Chalasani N, Dasarathy S, Diehl AM, Hameed B, Kowdley KV, McCullough A, Terrault N, Clark JM, Tonascia J, Brunt EM, Kleiner DE, Doo E. Farnesoid X nuclear receptor ligand obeticholic acid for non-cirrhotic, non-alcoholic steatohepatitis (FLINT): a multicentre, randomised, placebo-controlled trial. Lancet 2015; 385:956-65. [PMID: 25468160 PMCID: PMC4447192 DOI: 10.1016/s0140-6736(14)61933-4] [Citation(s) in RCA: 1613] [Impact Index Per Article: 179.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND The bile acid derivative 6-ethylchenodeoxycholic acid (obeticholic acid) is a potent activator of the farnesoid X nuclear receptor that reduces liver fat and fibrosis in animal models of fatty liver disease. We assessed the efficacy of obeticholic acid in adult patients with non-alcoholic steatohepatitis. METHODS We did a multicentre, double-blind, placebo-controlled, parallel group, randomised clinical trial at medical centres in the USA in patients with non-cirrhotic, non-alcoholic steatohepatitis to assess treatment with obeticholic acid given orally (25 mg daily) or placebo for 72 weeks. Patients were randomly assigned 1:1 using a computer-generated, centrally administered procedure, stratified by clinical centre and diabetes status. The primary outcome measure was improvement in centrally scored liver histology defined as a decrease in non-alcoholic fatty liver disease activity score by at least 2 points without worsening of fibrosis from baseline to the end of treatment. A planned interim analysis of change in alanine aminotransferase at 24 weeks undertaken before end-of-treatment (72 weeks) biopsies supported the decision to continue the trial (relative change in alanine aminotransferase -24%, 95% CI -45 to -3). A planned interim analysis of the primary outcome showed improved efficacy of obeticholic acid (p=0·0024) and supported a decision not to do end-of-treatment biopsies and end treatment early in 64 patients, but to continue the trial to obtain the 24-week post-treatment measures. Analyses were done by intention-to-treat. This trial was registered with ClinicalTrials.gov, number NCT01265498. FINDINGS Between March 16, 2011, and Dec 3, 2012, 141 patients were randomly assigned to receive obeticholic acid and 142 to placebo. 50 (45%) of 110 patients in the obeticholic acid group who were meant to have biopsies at baseline and 72 weeks had improved liver histology compared with 23 (21%) of 109 such patients in the placebo group (relative risk 1·9, 95% CI 1·3 to 2·8; p=0·0002). 33 (23%) of 141 patients in the obeticholic acid developed pruritus compared with nine (6%) of 142 in the placebo group. INTERPRETATION Obeticholic acid improved the histological features of non-alcoholic steatohepatitis, but its long-term benefits and safety need further clarification. FUNDING National Institute of Diabetes and Digestive and Kidney Diseases, Intercept Pharmaceuticals.
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Affiliation(s)
| | - Rohit Loomba
- University of California San Diego, La Jolla, CA, USA
| | | | | | | | | | | | | | | | - Bilal Hameed
- University of California San Francisco, San Francisco, CA USA
| | | | | | - Norah Terrault
- University of California San Francisco, San Francisco, CA USA
| | | | | | | | | | - Edward Doo
- The National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD, USA
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43
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Vuppalanchi R, Jain AK, Deppe R, Yates K, Comerford M, Masuoka HC, Neuschwander-Tetri BA, Loomba R, Brunt EM, Kleiner DE, Molleston JP, Schwimmer JB, Lavine JE, Tonascia J, Chalasani N. Relationship between changes in serum levels of keratin 18 and changes in liver histology in children and adults with nonalcoholic fatty liver disease. Clin Gastroenterol Hepatol 2014; 12:2121-30.e1-2. [PMID: 24846279 PMCID: PMC4830682 DOI: 10.1016/j.cgh.2014.05.010] [Citation(s) in RCA: 84] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2014] [Accepted: 05/08/2014] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Cross-sectional studies have associated serum levels of the keratin 18 (K18) fragment with histologic features of liver in individuals with nonalcoholic fatty liver disease (NAFLD). We investigated the relationship between changes in serum levels of K18 and changes in liver histology in adults and children with NAFLD. METHODS We measured levels of K18 in stored serum samples collected at baseline and various time points from 231 adults with nonalcoholic steatohepatitis and 152 children with NAFLD who participated in 2 separate prospective randomized clinical trials. Liver biopsy specimens collected at baseline and week 96 were reviewed centrally. RESULTS There were greater decreases in serum levels of K18 in adults with histologic improvement at week 96 than in those without histologic improvement at week 16 (decrease, 193 ± 293 vs 139 ± 467 U/L; P < .001), week 48 (decrease, 232 ± 360 vs 113 ± 425 U/L; P < .001), or week 96 (decrease, 269 ± 368 vs 97 ± 400 U/L; P < .001). There were greater decreases in serum levels of K18 in children with histologic improvements than in those without histologic improvements at week 48 (decrease, 197 ± 467 vs 47 ± 350 U/L; P = .005) and week 96 (decrease, 206 ± 432 vs 2 ± 474 U/L; P < .001). However, reductions in serum levels of K18 were not better than reductions in levels of alanine aminotransferase in identifying adults with histologic improvement (area under the receiver operator characteristic [AUROC], 0.71; 95% confidence interval [CI], 0.63-0.80; vs AUROC, 0.68; 95% CI, 0.61-0.79; P = .34) or children (AUROC, 0.72; 95% CI, 0.63-0.81; vs AUROC, 0.79; 95% CI, 0.70-0.87; P = .42). CONCLUSIONS Decreases in serum levels of K18 are associated strongly with improved liver histologies in adults or children with NAFLD. However, reductions in K18 do not perform better than those in alanine aminotransferase level in identifying histologic changes in NAFLD.
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Affiliation(s)
- Raj Vuppalanchi
- Department of Medicine, Indiana University School of Medicine, Indianapolis, IN
| | | | - Ross Deppe
- Department of Medicine, Indiana University School of Medicine, Indianapolis, IN
| | - Katherine Yates
- Bloomberg School of Public Health, The Johns Hopkins University, Baltimore, MD
| | - Megan Comerford
- Department of Medicine, Indiana University School of Medicine, Indianapolis, IN
| | - Howard C. Masuoka
- Department of Medicine, Indiana University School of Medicine, Indianapolis, IN
| | | | - Rohit Loomba
- University of California, San Diego, San Diego, CA
| | | | - David E. Kleiner
- Laboratory of Pathology, National Cancer Institute, Bethesda, MD
| | - Jean P. Molleston
- Department of Medicine, Indiana University School of Medicine, Indianapolis, IN
| | - Jeffrey B. Schwimmer
- Department of Pediatrics University of California, San Diego and Department of Gastroenterology, Rady Children's Hospital, San Diego. CA
| | - Joel E. Lavine
- Department of Pediatrics, Columbia University, New York, NY
| | - James Tonascia
- Bloomberg School of Public Health, The Johns Hopkins University, Baltimore, MD
| | - Naga Chalasani
- Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana.
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44
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Mitchel EB, Lavine JE. Review article: the management of paediatric nonalcoholic fatty liver disease. Aliment Pharmacol Ther 2014; 40:1155-70. [PMID: 25267322 DOI: 10.1111/apt.12972] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2014] [Revised: 06/16/2014] [Accepted: 09/09/2014] [Indexed: 02/07/2023]
Abstract
BACKGROUND Paediatric nonalcoholic fatty liver disease (NAFLD) is a major public health concern given the recent increase in its prevalence and link to obesity and other metabolic comorbidities. Current treatment strategies involve lifestyle changes. Other surgical and pharmacologic interventions have been proposed; however, limited randomised controlled trials (RCTs) in the paediatric population restrict their use. AIM To review the current management of paediatric NAFLD, including lifestyle and pharmacologic interventions, and to formulate recommendations for study design for future studies. METHODS A MEDLINE, Pubmed and Cochrane Review database search used a combination of keywords, including NAFLD, nonalcoholic steatohepatitis (NASH), paediatric, treatments, lifestyle changes, bariatric surgery, orlistat, metformin, thiazolidinediones, vitamin E, cysteamine bitartrate, ursodeoxycholic acid (UDCA), probiotics, omega-3 fatty acids, pentoxyfylline, farnesoid X receptor agonist and toll-like receptor modifiers. The articles were selected based on their relevance to the review. RESULTS Lifestyle interventions involving diet and exercise remain first-line treatment for paediatric NAFLD. Bariatric surgery, orlistat, insulin sensitisers and UDCA have been evaluated but are not recommended as first or second-line therapy. Medications such as cysteamine bitartrate, probiotics, polyunsaturated fats and pentoxyfilline share beneficial effects in trials, however, there is a paucity of adequately powered RCTs in which liver histology is evaluated. Vitamin E has been shown to be effective and safe in improving NASH histology in children. CONCLUSIONS Lifestyle intervention should be first-line treatment for paediatric NAFLD. Vitamin E should be considered for those with biopsy-proven NASH or borderline NASH failing first-line therapy. Other therapeutics show promising results but require larger RCTs with convincing endpoints. Improved screening techniques, objective validated inclusion criteria and outcome measures as well as rigour in study design are necessary for propelling therapeutic discovery.
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Affiliation(s)
- E B Mitchel
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Columbia University, New York, NY, USA
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45
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Molleston JP, Schwimmer JB, Yates KP, Murray KF, Cummings OW, Lavine JE, Brunt EM, Scheimann AO, Unalp-Arida A. Histological abnormalities in children with nonalcoholic fatty liver disease and normal or mildly elevated alanine aminotransferase levels. J Pediatr 2014; 164:707-713.e3. [PMID: 24360992 PMCID: PMC3962701 DOI: 10.1016/j.jpeds.2013.10.071] [Citation(s) in RCA: 115] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2013] [Revised: 09/18/2013] [Accepted: 10/24/2013] [Indexed: 02/06/2023]
Abstract
OBJECTIVE To investigate the histological spectrum of nonalcoholic fatty liver disease (NAFLD) in children with normal, mildly elevated (26-50 U/L boys, 23-44 U/L girls), or elevated (>50 U/L in boys, >44 U/L in girls) serum alanine aminotransferase (ALT) levels. STUDY DESIGN The Nonalcoholic Steatohepatitis Clinical Research Network enrolls children aged 5-18 years with NAFLD. We analyzed baseline clinical and histological data from 91 children with suspected NAFLD and normal or mildly elevated ALT and liver biopsy analysis within 180 days of ALT measurement, and compared them with data from 392 children with elevated ALT. RESULTS Seventeen of the 91 children with suspected NAFLD (19%) had a normal ALT level, and 74 (81%) had a mildly elevated ALT level. Overall, 45% of the biopsy specimens analyzed had steatosis ≥33%, 22% had grade ≥2 lobular inflammation, 81% had portal inflammation, 29% had ballooned hepatocytes, 35% had "suspicious/borderline" steatohepatitis, 8% had definite nonalcoholic steatohepatitis, 34% had an NAFLD activity score ≥4, and 46% had fibrosis (38% mild/moderate and 8% bridging/cirrhosis). Marked steatosis (50% vs 24%) and fibrosis (54% vs 12%) were significantly more common in the patients with mildly elevated ALT compared with those with normal ALT, with no difference in ballooning, inflammation, or NAFLD activity score ≥4 between the 2 groups. Fibrosis stage 3/4 was seen in none of the children with normal ALT, in 9% of those with mildly elevated ALT, and in 15% of those with elevated ALT. CONCLUSION Liver biopsy specimens from children with NAFLD with normal or mildly elevated ALT levels show significant histological abnormalities, including advanced fibrosis in children with mildly elevated ALT. Thus, measurement of ALT may underestimate liver injury in NAFLD. The use of appropriate ALT cutoff levels can help identify children at risk for more severe disease.
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Affiliation(s)
- Jean P Molleston
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Indiana University School of Medicine, Indianapolis, IN.
| | - Jeffrey B Schwimmer
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, University of California, San Diego School of Medicine; Department of Gastroenterology, Rady Children's Hospital San Diego; Liver Imaging Group, Department of Radiology, University of California, San Diego School of Medicine
| | | | - Karen F Murray
- Pediatric Gastroenterology, Hepatology and Nutrition, Seattle Children’s Hospital
| | - Oscar W Cummings
- Department of Pathology and Laboratory Medicine, Pediatrics, Indiana University School of Medicine
| | - Joel E. Lavine
- Pediatric Gastroenterology, Hepatology and Nutrition, Columbia University
| | - Elizabeth M Brunt
- Department of Pathology and Immunology, Washington University School of Medicine
| | - Ann O Scheimann
- Pediatric Gastroenterology and Nutrition, Johns Hopkins Children’s Center
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46
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Taylor SA, Lavine JE. Gastroenterology and Nutrition. Fetal and Neonatal Secrets 2014. [PMCID: PMC7161401 DOI: 10.1016/b978-0-323-09139-8.00010-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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47
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Abstract
Nonalcoholic fatty liver disease (NAFLD) is the most common chronic liver disease in adults and children. A number of genetic and environmental factors are known to predispose individuals to NAFLD. Certain dietary sugars, particularly fructose, are suspected to contribute to the development of NAFLD and its progression. The increasing quantity of fructose in the diet comes from sugar additives (most commonly sucrose and high fructose corn syrup) in beverages and processed foods. Substantial links have been demonstrated between increased fructose consumption and obesity, dyslipidemia, and insulin resistance. Growing evidence suggests that fructose contributes to the development and severity of NAFLD. In human studies, fructose is associated with increasing hepatic fat, inflammation, and possibly fibrosis. Whether fructose alone can cause NAFLD or if it serves only as a contributor when consumed excessively in the setting of insulin resistance, positive energy balance, and sedentary lifestyle is unknown. Sufficient evidence exists to support clinical recommendations that fructose intake be limited through decreasing foods and drinks high in added (fructose-containing) sugars.
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Affiliation(s)
- Miriam B Vos
- Pediatrics, Emory University School of Medicine, Atlanta, GA, USA
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48
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Setchell KDR, Heubi JE, Shah S, Lavine JE, Suskind D, Al-Edreesi M, Potter C, Russell DW, O'Connell NC, Wolfe B, Jha P, Zhang W, Bove KE, Knisely AS, Hofmann AF, Rosenthal P, Bull LN. Genetic defects in bile acid conjugation cause fat-soluble vitamin deficiency. Gastroenterology 2013; 144:945-955.e6; quiz e14-5. [PMID: 23415802 PMCID: PMC4175397 DOI: 10.1053/j.gastro.2013.02.004] [Citation(s) in RCA: 82] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2012] [Revised: 01/29/2013] [Accepted: 02/06/2013] [Indexed: 12/31/2022]
Abstract
BACKGROUND & AIMS The final step in bile acid synthesis involves conjugation with glycine and taurine, which promotes a high intraluminal micellar concentration to facilitate lipid absorption. We investigated the clinical, biochemical, molecular, and morphologic features of a genetic defect in bile acid conjugation in 10 pediatric patients with fat-soluble vitamin deficiency, some with growth failure or transient neonatal cholestatic hepatitis. METHODS We identified the genetic defect that causes this disorder using mass spectrometry analysis of urine, bile, and serum samples and sequence analysis of the genes encoding bile acid-CoA:amino acid N-acyltransferase (BAAT) and bile acid-CoA ligase (SLC27A5). RESULTS Levels of urinary bile acids were increased (432 ± 248 μmol/L) and predominantly excreted in unconjugated forms (79.4% ± 3.9%) and as sulfates and glucuronides. Glycine or taurine conjugates were absent in the urine, bile, and serum. Unconjugated bile acids accounted for 95.7% ± 5.8% of the bile acids in duodenal bile, with cholic acid accounting for 82.4% ± 5.5% of the total. Duodenal bile acid concentrations were 12.1 ± 5.9 mmol/L, which is too low for efficient lipid absorption. The biochemical profile was consistent with defective bile acid amidation. Molecular analysis of BAAT confirmed 4 different homozygous mutations in 8 patients tested. CONCLUSIONS Based on a study of 10 pediatric patients, genetic defects that disrupt bile acid amidation cause fat-soluble vitamin deficiency and growth failure, indicating the importance of bile acid conjugation in lipid absorption. Some patients developed liver disease with features of a cholangiopathy. These findings indicate that patients with idiopathic neonatal cholestasis or later onset of unexplained fat-soluble vitamin deficiency should be screened for defects in bile acid conjugation.
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Affiliation(s)
- Kenneth D. R. Setchell
- Department of Pathology and Laboratory Medicine, Children's Hospital Medical Center, Cincinnati, OH 45229
| | - James E. Heubi
- Division of Gastroenterology and Nutrition, Children's Hospital Medical Center, Cincinnati, OH 45229
| | - Sohela Shah
- UCSF Liver Center Laboratory and Institute for Human Genetics, University of California, San Francisco Medical Center, San Francisco, CA 94143
| | - Joel E. Lavine
- Department of Gastroenterology, Hepatology and Nutrition, Morgan Stanley Children's Hospital/Columbia University, NY, NY 10032
| | - David Suskind
- Department of Gastroenterology and Hepatology, Seattle Children's Hospital and University of Washington Medical School of Medicine, Seattle, WA 98105
| | - Mohammed Al-Edreesi
- Pediatric Specialty Services Division, Dhahran Health Center, Saudi Aramco, Dhahran, Saudi Arabia
| | - Carol Potter
- Department of Gastroenterology and Nutrition, Nationwide Children's Hospital, The Ohio State University, Columbus, OH 43205
| | - David W. Russell
- Department of Molecular Genetics, University of Texas Southwestern Medical Center, Dallas, TX 75390
| | - Nancy C. O'Connell
- Department of Pathology and Laboratory Medicine, Children's Hospital Medical Center, Cincinnati, OH 45229
| | - Brian Wolfe
- Department of Pathology and Laboratory Medicine, Children's Hospital Medical Center, Cincinnati, OH 45229
| | - Pinky Jha
- Department of Pathology and Laboratory Medicine, Children's Hospital Medical Center, Cincinnati, OH 45229
| | - Wujuan Zhang
- Department of Pathology and Laboratory Medicine, Children's Hospital Medical Center, Cincinnati, OH 45229
| | - Kevin E. Bove
- Department of Pathology and Laboratory Medicine, Children's Hospital Medical Center, Cincinnati, OH 45229
| | - Alex S. Knisely
- Institute of Liver Studies, King's College Hospital, Denmark Hill, London SE5 9RS, UK
| | - Alan F. Hofmann
- Department of Medicine, University of California San Diego, San Diego, CA 92093-063
| | - Philip Rosenthal
- UCSF Liver Center Laboratory and Institute for Human Genetics, University of California, San Francisco Medical Center, San Francisco, CA 94143,Departments of Pediatrics and Surgery, University of California, San Francisco Medical Center, San Francisco, CA 94143
| | - Laura N. Bull
- UCSF Liver Center Laboratory and Institute for Human Genetics, University of California, San Francisco Medical Center, San Francisco, CA 94143
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Tang A, Tan J, Sun M, Hamilton G, Bydder M, Wolfson T, Gamst AC, Middleton M, Brunt EM, Loomba R, Lavine JE, Schwimmer JB, Sirlin CB. Nonalcoholic fatty liver disease: MR imaging of liver proton density fat fraction to assess hepatic steatosis. Radiology 2013; 267:422-31. [PMID: 23382291 DOI: 10.1148/radiol.12120896] [Citation(s) in RCA: 366] [Impact Index Per Article: 33.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
PURPOSE To evaluate the diagnostic performance of magnetic resonance (MR) imaging-estimated proton density fat fraction (PDFF) for assessing hepatic steatosis in nonalcoholic fatty liver disease (NAFLD) by using centrally scored histopathologic validation as the reference standard. MATERIALS AND METHODS This prospectively designed, cross-sectional, internal review board-approved, HIPAA-compliant study was conducted in 77 patients who had NAFLD and liver biopsy. MR imaging-PDFF was estimated from magnitude-based low flip angle multiecho gradient-recalled echo images after T2* correction and multifrequency fat modeling. Histopathologic scoring was obtained by consensus of the Nonalcoholic Steatohepatitis (NASH) Clinical Research Network Pathology Committee. Spearman correlation, additivity and variance stabilization for regression for exploring the effect of a number of potential confounders, and receiver operating characteristic analyses were performed. RESULTS Liver MR imaging-PDFF was systematically higher, with higher histologic steatosis grade (P < .001), and was significantly correlated with histologic steatosis grade (ρ = 0.69, P < .001). The correlation was not confounded by age, sex, lobular inflammation, hepatocellular ballooning, NASH diagnosis, fibrosis, or magnetic field strength (P = .65). Area under the receiver operating characteristic curves was 0.989 (95% confidence interval: 0.968, 1.000) for distinguishing patients with steatosis grade 0 (n = 5) from those with grade 1 or higher (n = 72), 0.825 (95% confidence interval: 0.734, 0.915) to distinguish those with grade 1 or lower (n = 31) from those with grade 2 or higher (n = 46), and 0.893 (95% confidence interval: 0.809, 0.977) to distinguish those with grade 2 or lower (n = 58) from those with grade 3 (n = 19). CONCLUSION MR imaging-PDFF showed promise for assessment of hepatic steatosis grade in patients with NAFLD. For validation, further studies with larger sample sizes are needed.
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Affiliation(s)
- An Tang
- Liver Imaging Group, Department of Radiology, University of California San Diego, 408 Dickinson St, San Diego, CA 92103-8226, USA
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Affiliation(s)
- Joel E Lavine
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Columbia University College of Physicians and Surgeons, New York, New York, USA
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