1
|
Abstract
PURPOSE OF REVIEW The purpose of this review is to summarize commonly encountered nutritional deficiencies in children and their implications. Considering data suggesting that the majority of children with the United States consume unhealthy diets, the growing interest in the consumption of limiting diets, as well as the insidious clinical presentation of nutritional deficiencies, this is a timely and highly relevant review. RECENT FINDINGS The underlying socioeconomic and medical circumstances that predispose to nutritional deficiencies in the Western world are covered. The high index of suspicion required to recognize nutritional deficiencies and the limitations of available testing are also discussed. Finally, the need for the development of accurate nutritional biomarkers is presented as a future research priority. SUMMARY Nutritional deficiencies are not uncommon, even in high resource countries. Clinicians should remain vigilant and include nutritional deficiencies in the differential diagnoses of patients presenting with nonspecific symptoms.
Collapse
Affiliation(s)
- Farhana Ali
- Primary Children's Hospital, University of Utah
| | - Marialena Mouzaki
- Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| |
Collapse
|
2
|
Mouzaki M, Woo JG, Divanovic S. Gestational and Developmental Contributors of Pediatric MASLD. Semin Liver Dis 2024; 44:43-53. [PMID: 38423068 DOI: 10.1055/s-0044-1782210] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/02/2024]
Abstract
Pediatric metabolic dysfunction-associated steatotic liver disease (MASLD) is common and can be seen as early as in utero. A growing body of literature suggests that gestational and early life exposures modify the risk of MASLD development in children. These include maternal risk factors, such as poor cardiometabolic health (e.g., obesity, gestational diabetes, rapid weight gain during pregnancy, and MASLD), as well as periconceptional dietary exposures, degree of physical activity, intestinal microbiome, and smoking. Paternal factors, such as diet and obesity, also appear to play a role. Beyond gestation, early life dietary exposures, as well as the rate of infant weight gain, may further modify the risk of future MASLD development. The mechanisms linking parental health and environmental exposures to pediatric MASLD are complex and not entirely understood. In conclusion, investigating gestational and developmental contributors to MASLD is critical and may identify future interventional targets for disease prevention.
Collapse
Affiliation(s)
- Marialena Mouzaki
- Divisions of Gastroenterology, Hepatology and Nutrition, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Jessica G Woo
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
- Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Senad Divanovic
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
- Division of Immunobiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| |
Collapse
|
3
|
Orkin S, Zhao X, Setchell KDR, Carr E, Arce-Clachar AC, Bramlage K, Huang R, Fei L, Beck AF, Fawaz R, Valentino PL, Xanthakos SA, Mouzaki M. Food Insecurity and Pediatric Nonalcoholic Fatty Liver Disease Severity. J Pediatr 2024; 265:113818. [PMID: 37931698 DOI: 10.1016/j.jpeds.2023.113818] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Revised: 10/03/2023] [Accepted: 11/01/2023] [Indexed: 11/08/2023]
Abstract
OBJECTIVE To determine the association between food insecurity and pediatric nonalcoholic fatty liver disease (NAFLD). METHODS Cross-sectional study of patients < 21 years of age with histologically confirmed NAFLD. The Household Food Security Survey Module was administered to determine food insecurity status. Skin lipidomics were performed to explore pathophysiologic mechanisms. RESULTS Seventy-three patients with histologically confirmed NAFLD completed the Household Food Security Survey Module. Of these, the majority were male (81%) and non-Hispanic (53%), with a mean age at biopsy of 13 ± 3 years. Food insecurity was seen in 42% (n = 31). Comparison of features between food insecure and food secure subgroups revealed no differences in sex, ethnicity, BMI z-score, aminotransferases, or histologic severity. However, children experiencing food insecurity presented on average 2 years before their food secure counterparts (12.3 ± 3.0 vs 14.4 ± 3.6 years, P = .015). A subset of 31 patients provided skin samples. Skin lipidomics revealed that food insecurity was associated with down-regulated features from the lipoamino acid class of lipids, previously linked to inflammation and adipocyte differentiation. CONCLUSIONS Food insecurity is highly prevalent in children with NAFLD and is associated with earlier presentation. Lipidomic analyses suggest a possible pathophysiologic link that warrants further exploration.
Collapse
Affiliation(s)
- Sarah Orkin
- Division of Gastroenterology, Hepatology and Nutrition, Cincinnati Children's Hospital Medical Center, Cincinnati, OH; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Xueheng Zhao
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH; Division of Pathology and Laboratory Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Kenneth D R Setchell
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH; Division of Pathology and Laboratory Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Emily Carr
- Division of Pediatric Gastroenterology and Hepatology, Yale New Haven Children's Hospital, New Haven, CT
| | - Ana Catalina Arce-Clachar
- Division of Gastroenterology, Hepatology and Nutrition, Cincinnati Children's Hospital Medical Center, Cincinnati, OH; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Kristin Bramlage
- Division of Gastroenterology, Hepatology and Nutrition, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Rong Huang
- Division of Pathology and Laboratory Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Lin Fei
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH; Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Andrew F Beck
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH; James M. Anderson Center for Health Systems Excellence, Cincinnati Children's Hospital Medical Center, Cincinnati, OH; Division of General and Community Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH; Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Rima Fawaz
- Division of Pediatric Gastroenterology and Hepatology, Yale New Haven Children's Hospital, New Haven, CT; Department of Pediatrics, Yale University School of Medicine, New Haven, CT
| | - Pamela L Valentino
- Department of Pediatrics, Yale University School of Medicine, New Haven, CT; Division of Pediatric Gastroenterology and Hepatology, Seattle Children's Hospital, Seattle, WA; Department of Pediatrics, University of Washington School of Medicine, Seattle, WA
| | - Stavra A Xanthakos
- Division of Gastroenterology, Hepatology and Nutrition, Cincinnati Children's Hospital Medical Center, Cincinnati, OH; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Marialena Mouzaki
- Division of Gastroenterology, Hepatology and Nutrition, Cincinnati Children's Hospital Medical Center, Cincinnati, OH; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH.
| |
Collapse
|
4
|
Wayland JL, Doll JR, Lawson MJ, Stankiewicz TE, Oates JR, Sawada K, Damen MSMA, Alarcon PC, Haslam DB, Trout AT, DeFranco EA, Klepper CM, Woo JG, Moreno-Fernandez ME, Mouzaki M, Divanovic S. Thermoneutral Housing Enables Studies of Vertical Transmission of Obesogenic Diet-Driven Metabolic Diseases. Nutrients 2023; 15:4958. [PMID: 38068816 PMCID: PMC10708424 DOI: 10.3390/nu15234958] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2023] [Revised: 11/19/2023] [Accepted: 11/22/2023] [Indexed: 12/18/2023] Open
Abstract
Vertical transmission of obesity is a critical contributor to the unabated obesity pandemic and the associated surge in metabolic diseases. Existing experimental models insufficiently recapitulate "human-like" obesity phenotypes, limiting the discovery of how severe obesity in pregnancy instructs vertical transmission of obesity. Here, via utility of thermoneutral housing and obesogenic diet feeding coupled to syngeneic mating of WT obese female and lean male mice on a C57BL/6 background, we present a tractable, more "human-like" approach to specifically investigate how maternal obesity contributes to offspring health. Using this model, we found that maternal obesity decreased neonatal survival, increased offspring adiposity, and accelerated offspring predisposition to obesity and metabolic disease. We also show that severe maternal obesity was sufficient to skew offspring microbiome and create a proinflammatory gestational environment that correlated with inflammatory changes in the offspring in utero and adulthood. Analysis of a human birth cohort study of mothers with and without obesity and their infants was consistent with mouse study findings of maternal inflammation and offspring weight gain propensity. Together, our results show that dietary induction of obesity in female mice coupled to thermoneutral housing can be used for future mechanistic interrogations of obesity and metabolic disease in pregnancy and vertical transmission of pathogenic traits.
Collapse
Affiliation(s)
- Jennifer L. Wayland
- Immunology Graduate Program, University of Cincinnati College of Medicine, Cincinnati, OH 45220, USA
- Medical Scientist Training Program, University of Cincinnati College of Medicine, Cincinnati, OH 45220, USA
- Division of Immunobiology, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH 45229, USA
| | - Jessica R. Doll
- Division of Immunobiology, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH 45229, USA
| | - Matthew J. Lawson
- Division of Immunobiology, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH 45229, USA
| | - Traci E. Stankiewicz
- Division of Immunobiology, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH 45229, USA
| | - Jarren R. Oates
- Immunology Graduate Program, University of Cincinnati College of Medicine, Cincinnati, OH 45220, USA
- Division of Immunobiology, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH 45229, USA
| | - Keisuke Sawada
- Immunology Graduate Program, University of Cincinnati College of Medicine, Cincinnati, OH 45220, USA
- Medical Scientist Training Program, University of Cincinnati College of Medicine, Cincinnati, OH 45220, USA
- Division of Immunobiology, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH 45229, USA
| | - Michelle S. M. A. Damen
- Division of Immunobiology, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH 45229, USA
| | - Pablo C. Alarcon
- Immunology Graduate Program, University of Cincinnati College of Medicine, Cincinnati, OH 45220, USA
- Medical Scientist Training Program, University of Cincinnati College of Medicine, Cincinnati, OH 45220, USA
- Division of Immunobiology, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH 45229, USA
| | - David B. Haslam
- Division of Infectious Diseases, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH 45229, USA
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH 45220, USA
| | - Andrew T. Trout
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH 45220, USA
- Department of Radiology, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH 45229, USA
- Department of Radiology, University of Cincinnati College of Medicine, Cincinnati, OH 45220, USA
| | - Emily A. DeFranco
- Department of Obstetrics and Gynecology, University of Cincinnati College of Medicine, Cincinnati, OH 45220, USA
| | - Corie M. Klepper
- Division of Gastroenterology, Hepatology and Nutrition, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH 45229, USA
| | - Jessica G. Woo
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH 45220, USA
- Division of Biostatistics and Epidemiology, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH 45229, USA
| | - Maria E. Moreno-Fernandez
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH 45220, USA
- Division of Gastroenterology, Hepatology and Nutrition, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH 45229, USA
| | - Marialena Mouzaki
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH 45220, USA
- Division of Gastroenterology, Hepatology and Nutrition, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH 45229, USA
| | - Senad Divanovic
- Immunology Graduate Program, University of Cincinnati College of Medicine, Cincinnati, OH 45220, USA
- Medical Scientist Training Program, University of Cincinnati College of Medicine, Cincinnati, OH 45220, USA
- Division of Immunobiology, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH 45229, USA
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH 45220, USA
- Center for Inflammation and Tolerance, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH 45229, USA
| |
Collapse
|
5
|
Wang A, Blackford AL, Behling C, Wilson LA, Newton KP, Xanthakos SA, Fishbein MH, Vos MB, Mouzaki M, Molleston JP, Jain AK, Hertel P, Harlow Adams K, Schwimmer JB. Development of Fibro-PeN, a clinical prediction model for moderate-to-severe fibrosis in children with nonalcoholic fatty liver disease. Hepatology 2023:01515467-990000000-00609. [PMID: 37870272 PMCID: PMC11035485 DOI: 10.1097/hep.0000000000000644] [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] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Accepted: 09/23/2023] [Indexed: 10/24/2023]
Abstract
BACKGROUND AND AIMS Liver fibrosis is common in children with NAFLD and is an important determinant of outcomes. High-performing noninvasive models to assess fibrosis in children are needed. The objectives of this study were to evaluate the performance of existing pediatric and adult fibrosis prediction models and to develop a clinical prediction rule for identifying moderate-to-severe fibrosis in children with NAFLD. APPROACH AND RESULTS We enrolled children with biopsy-proven NAFLD in the Nonalcoholic Steatohepatitis Clinical Research Network within 90 days of liver biopsy. We staged liver fibrosis in consensus using the Nonalcoholic Steatohepatitis Clinical Research Network scoring system. We evaluated existing pediatric and adult models for fibrosis and developed a new pediatric model using the least absolute shrinkage and selection operator with linear and spline terms for discriminating moderate-to-severe fibrosis from none or mild fibrosis. The model was internally validated with 10-fold cross-validation. We evaluated 1055 children with NAFLD, of whom 26% had moderate-to-severe fibrosis. Existing models performed poorly in classifying fibrosis in children, with area under the receiver operator curves (AUC) ranging from 0.57 to 0.64. In contrast, our new model, fibrosis in pediatric NAFLD was derived from fourteen common clinical variables and had an AUC of 0.79 (95% CI: 0.77-0.81) with 72% sensitivity and 76% specificity for identifying moderate-to-severe fibrosis. CONCLUSION Existing fibrosis prediction models have limited clinical utility in children with NAFLD. Fibrosis in pediatric NAFLD offers improved performance characteristics for risk stratification by identifying moderate-to-severe fibrosis in children with NAFLD.
Collapse
Affiliation(s)
- Andrew Wang
- Department of Pediatrics, Division of Gastroenterology, Hepatology, and Nutrition, University of California San Diego School of Medicine, La Jolla, California, USA
- Department of Gastroenterology, Rady Children's Hospital, San Diego, California, USA
| | - Amanda L Blackford
- Department of Oncology, Division of Quantitative Sciences, School of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
| | - Cynthia Behling
- Department of Pediatrics, Division of Gastroenterology, Hepatology, and Nutrition, University of California San Diego School of Medicine, La Jolla, California, USA
| | - Laura A Wilson
- Department of Epidemiology, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, USA
| | - Kimberly P Newton
- Department of Pediatrics, Division of Gastroenterology, Hepatology, and Nutrition, University of California San Diego School of Medicine, La Jolla, California, USA
- Department of Gastroenterology, Rady Children's Hospital, San Diego, California, USA
| | - Stavra A Xanthakos
- Department of Pediatrics, Division of Gastroenterology, Hepatology and Nutrition, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Mark H Fishbein
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Northwestern University, Feinberg School of Medicine, Chicago, Illinois, USA
| | - Miriam B Vos
- Emory University and Children's Healthcare of Atlanta, Atlanta, Georgia, USA
| | - Marialena Mouzaki
- Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Jean P Molleston
- Riley Hospital for Children, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Ajay K Jain
- Department of Pediatrics, Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Saint Louis University, St. Louis, Missouri, USA
| | - Paula Hertel
- Department of Pediatrics, Division of Gastroenterology, Hepatology and Nutrition, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas, USA
| | - Kathryn Harlow Adams
- Riley Hospital for Children, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Jeffrey B Schwimmer
- Department of Pediatrics, Division of Gastroenterology, Hepatology, and Nutrition, University of California San Diego School of Medicine, La Jolla, California, USA
- Department of Gastroenterology, Rady Children's Hospital, San Diego, California, USA
| |
Collapse
|
6
|
P V Alves V, T Trout A, Dewit M, Mouzaki M, Arce-Clachar AC, S Bramlage K, R Dillman J, A Xanthakos S. Clinical Performance of Transient Elastography With Comparison to Quantitative Magnetic Resonance Imaging, Ultrasound, and Biopsy in Children and Adolescents With Known or Suspected Fatty Liver Disease. Child Obes 2023; 19:461-469. [PMID: 36269577 DOI: 10.1089/chi.2022.0136] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Background: Performance of vibration-controlled transient elastography (VCTE) is inadequately validated in pediatric nonalcoholic fatty liver disease (NAFLD). We aimed to assess the technical performance of VCTE in pediatric NAFLD and define the agreement between VCTE and reference standards of imaging and/or biopsy. Methods: This prospective study recruited participants with known or suspected NAFLD who underwent a research VCTE examination (FibroScan Mini 430). Ten valid VCTE liver stiffness measurements (kPa) and controlled attenuation parameter (CAP) (dB/m) measurements were obtained for each participant. Available clinically acquired MR elastography and magnetic resonance imaging proton density fat fraction (PDFF), liver ultrasound shear wave elastography, and biopsy served as references standards. Results: Eighty-four consecutive participants were included (55 males, mean age 15.0 ± 3.5 years, mean BMI 36.6 ± 9.4 kg/m2). VCTE examinations were complete in 80/83 participants. 37/83 participants were examined with an XL probe. There was no significant correlation between CAP and PDFF [n = 16; r = 0.17 (95% confidence interval [CI]: -0.34 to 0.61), p = 0.5] or between VCTE liver stiffness and MR elastography stiffness [n = 27; r = 0.31 (95% CI: -0.07 to 0.62), p = 0.10]. For prediction of any fibrosis stage ≥1 on biopsy (n = 9/15 participants), VCTE median liver stiffness >5.1 kPA had an area under receiver operating characteristic curve of 0.52 (95% CI: 0.26-0.78) with a sensitivity of 88.9% and specificity of 16.6% (p > 0.99). Conclusions: Complete VCTE examinations could be obtained in most pediatric patients with NAFLD. Neither VCTE liver stiffness nor CAP correlated well with measures of liver fat or stiffness by established imaging modalities and biopsy.
Collapse
Affiliation(s)
- Vinicius P V Alves
- Department of Radiology and Hepatology and Nutrition, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Andrew T Trout
- Department of Radiology and Hepatology and Nutrition, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
- Department of Radiology and University of Cincinnati College of Medicine, Cincinnati, OH, USA
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Morgan Dewit
- Department of Radiology and Hepatology and Nutrition, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Marialena Mouzaki
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
- Division of Gastroenterology, Hepatology and Nutrition, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Ana Catalina Arce-Clachar
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
- Division of Gastroenterology, Hepatology and Nutrition, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Kristin S Bramlage
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
- Division of Gastroenterology, Hepatology and Nutrition, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Jonathan R Dillman
- Department of Radiology and Hepatology and Nutrition, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
- Department of Radiology and University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Stavra A Xanthakos
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
- Division of Gastroenterology, Hepatology and Nutrition, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| |
Collapse
|
7
|
Green S, Mouzaki M, Abu Ata N, Trout AT. Prevalence of incidental sonographic findings of hepatic steatosis in children under 4 years of age. Pediatr Radiol 2023; 53:2221-2228. [PMID: 37563321 DOI: 10.1007/s00247-023-05729-z] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Revised: 07/14/2023] [Accepted: 07/18/2023] [Indexed: 08/12/2023]
Abstract
BACKGROUND The age of onset of nonalcoholic fatty liver disease (NAFLD) and its prevalence in young children is incompletely understood. OBJECTIVE We sought to evaluate the prevalence of ultrasound findings of hepatic steatosis in a cohort of children less than 4 years of age. MATERIALS AND METHODS This is an institutional review board-approved retrospective review of ultrasounds performed on children less than 4 years of age from January 2022 to August 2022 at a single quaternary care center. Two independent blinded reviewers evaluated for qualitative and semi-quantitative findings of hepatic steatosis. Per prior literature, hepatorenal index (HRI)>1.75 was used as a threshold suggestive of hepatic steatosis. Chi-square, Mann-Whitney U test, and logistic regression analyses were performed for univariable and multivariable statistical analyses. Kappa statistics were used to assess agreement between reviewers. RESULTS Eighty-five males and 102 females, median age of 1.1 years (interquartile range 2.1 years), were included. Qualitative findings of hepatic steatosis were seen in 26/187 (14%; 95% CI 10-20%). An HRI>1.75 was present in 15/187 (8%; 95% CI: 5-13%) of examinations, including 11 females and 4 males, and 7/123 (6%) participants <2 years old. Among participants with overweight or obesity, 8/43 (19%) had HRI>1.75 vs. 7/144 (5%) participants without overweight or obesity (P=0.004). Each percentile increase in anthropometrics percentile (weight-to-length or BMI, depending on age) was associated with 22 increased odds of HRI>1.75 (P=0.02). CONCLUSION Prevalence of sonographic findings of hepatic steatosis in an unselected sample of preschool-age children is 8-14%, and are more common in participants with overweight/obesity.
Collapse
Affiliation(s)
- Shannon Green
- Department of Radiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA.
| | - Marialena Mouzaki
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Nadeen Abu Ata
- Department of Radiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Andrew T Trout
- Department of Radiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
- Department of Radiology, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| |
Collapse
|
8
|
Khan MZ, Klepper C, Orkin S, Arce-Clachar AC, Bramlage K, Fei L, Miethke A, Kohli R, Xanthakos S, Mouzaki M. Presence of Alpha 1 Antitrypsin Risk Variants is Not Associated With Histologic Severity of Pediatric NAFLD. J Pediatr Gastroenterol Nutr 2023; 77:166-170. [PMID: 37229749 PMCID: PMC10524978 DOI: 10.1097/mpg.0000000000003845] [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] [Indexed: 05/27/2023]
Abstract
BACKGROUND Among adults with nonalcoholic fatty liver disease (NAFLD), alpha-1-antitrypsin (A1AT) heterozygosity has been linked to advanced liver disease; pediatric data remain unclear. OBJECTIVE The objective of this study is to determine whether A1AT PiZ or PiS variants are associated with liver disease severity in youth with NAFLD. METHODS Retrospective study of youth with confirmed NAFLD. Multivariable logistic regression used to determine independent associations between A1AT risk variants and histologic severity [NAFLD activity score (NAS) ≥5 and/or significant fibrosis (stage ≥2)]. RESULTS The cohort included 269 patients, mean age 12 [±3] years with NAFLD and A1AT phenotyping (n = 260) and/or A1AT levels (n = 261). The mean NAS of the cohort was 4.2 [±1.5]; 50% had any, and 18% had significant fibrosis. Most (86%) had the MM A1AT phenotype, while 7% had the MS and 3% the MZ phenotype (the rest had other, nonpathogenic variants). Mean A1AT level was 123 mg/dL [±20]. A1AT levels did not differ by low versus high NAS (122 ± 2 vs 126 ± 19 mg/dL, P = 0.12) or by no/mild versus significant fibrosis (123 ± 20 vs 126 ± 20 mg/dL, P = 0.23, respectively). Carriers and noncarriers of the PiS or PiZ variants had similar NAS (mean NAS 3.8 ± 1.6 vs 4.2 ± 1.4; P = 0.25, respectively). Fibrosis severity did not differ by carrier vs noncarrier group: 38% versus 52% had any fibrosis ( P = 0.17) and 14% versus 18% had significant fibrosis ( P = 0.80, respectively). Multivariable modeling showed no association between A1AT risk variants and histologic severity. CONCLUSION While not uncommon, carriage of the A1AT PiZ or PiS risk variants was not associated with histologic severity in children with NAFLD.
Collapse
Affiliation(s)
- Maya Zahid Khan
- Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, United States
| | - Corie Klepper
- Division of Gastroenterology, Hepatology and Nutrition, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, United States
| | - Sarah Orkin
- Division of Gastroenterology, Hepatology and Nutrition, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, United States
- University of Cincinnati College of Medicine
| | - Ana Catalina Arce-Clachar
- Division of Gastroenterology, Hepatology and Nutrition, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, United States
- University of Cincinnati College of Medicine
| | - Kristen Bramlage
- Division of Gastroenterology, Hepatology and Nutrition, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, United States
- University of Cincinnati College of Medicine
| | - Lin Fei
- Division of Gastroenterology, Hepatology and Nutrition, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, United States
- University of Cincinnati College of Medicine
| | - Alexander Miethke
- Division of Gastroenterology, Hepatology and Nutrition, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, United States
- University of Cincinnati College of Medicine
| | - Rohit Kohli
- Department of Gastroenterology, Hepatology and Nutrition, Children’s Hospital of Los Angeles, Los Angeles, CA, United States
| | - Stavra Xanthakos
- Division of Gastroenterology, Hepatology and Nutrition, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, United States
- University of Cincinnati College of Medicine
| | - Marialena Mouzaki
- Division of Gastroenterology, Hepatology and Nutrition, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, United States
- University of Cincinnati College of Medicine
| |
Collapse
|
9
|
Mouzaki M, Xanthakos S. Reply. J Pediatr 2023; 259:113467. [PMID: 37179013 DOI: 10.1016/j.jpeds.2023.113467] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [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: 04/26/2023] [Accepted: 04/30/2023] [Indexed: 05/15/2023]
Affiliation(s)
- Marialena Mouzaki
- Division of Gastroenterology, Hepatology and Nutrition, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Stavra Xanthakos
- Division of Gastroenterology, Hepatology and Nutrition, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH
| |
Collapse
|
10
|
Ali F, Cole CR, Hornung L, Mouzaki M, Wasserman H, Kalkwarf HJ. Age-related trajectory of bone density in children with intestinal failure: A longitudinal retrospective cohort study. JPEN J Parenter Enteral Nutr 2023; 47:736-745. [PMID: 37227158 PMCID: PMC10875680 DOI: 10.1002/jpen.2525] [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] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Accepted: 05/23/2023] [Indexed: 05/26/2023]
Abstract
BACKGROUND Longitudinal changes in bone health in children with intestinal failure (IF) are unclear. We aimed to better understand the trajectory of bone mineral status over time in children with IF and identify clinical factors that influence the trajectory. METHODS Clinical records of patients attending the Intestinal Rehabilitation Center of Cincinnati Children's Hospital Medical Center between 2012 and 2021 were reviewed. Children diagnosed with IF before age 3 years with at least two lumbar spine dual-energy x-ray absorptiometry scans were included. We abstracted information on medical history, parenteral nutrition, bone density, and growth. We calculated bone density z scores with and without adjustment for height z scores. RESULTS Thirty-four children with IF met inclusion criteria. Children were shorter than average with a mean height z score of -1.5 ± 1.3. The mean bone density z score was -1.5 ± 1.3 with 25 of the cohort having a z score < -2.0. After height adjustment, the mean bone density z score was -0.42 ± 1.4 with 11% below -2.0. Most dual-energy x-ray absorptiometry scans (60%) had a feeding tube artifact. Bone density z scores increased slightly with age and lower parenteral nutrition dependency and were higher in scans without an artifact. Etiologies of IF, line infections, prematurity, and vitamin D status were not associated with height-adjusted bone density z scores. CONCLUSION Children with IF were shorter than expected for age. Deficits in bone mineral status were less common when adjusting for short stature. Etiologies of IF, prematurity, and vitamin D deficiency were not associated with bone density.
Collapse
Affiliation(s)
- Farhana Ali
- Division of Gastroenterology, Hepatology and Nutrition, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Conrad R. Cole
- Division of Gastroenterology, Hepatology and Nutrition, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
- Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, Ohio, USA
| | - Lindsey Hornung
- Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Marialena Mouzaki
- Division of Gastroenterology, Hepatology and Nutrition, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
- Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, Ohio, USA
| | - Halley Wasserman
- Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, Ohio, USA
- Division of Endocrinology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Heidi J. Kalkwarf
- Division of Gastroenterology, Hepatology and Nutrition, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
- Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, Ohio, USA
| |
Collapse
|
11
|
Mouzaki M, Dupuis A, Avolio J, Griffin K, Ratjen F, Tullis E, Gonska T. Weight increase in people with cystic fibrosis on CFTR modulator therapy is mainly due to increase in fat mass. Front Pharmacol 2023; 14:1157459. [PMID: 37521467 PMCID: PMC10372433 DOI: 10.3389/fphar.2023.1157459] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2023] [Accepted: 06/27/2023] [Indexed: 08/01/2023] Open
Abstract
Background: Ivacaftor, the first CFTR modulator drug, leads to significant long-term improvement in lung function and weight gain. The mechanism as well as the long-term impact of ivacaftor on weight, resting energy expenditure (REE) and body composition remains to be explored. Methods: This prospective observational study included 18 people with CF (pwCF) (age: median (range) 20 (6-58) years) carrying at least one CFTR gating mutation commencing ivacaftor. Assessments of body composition, REE and laboratory investigations were performed at baseline and 6, 12 and 24 months after treatment initiation. Results: Treatment with ivacaftor was associated with a significantly positive change in BMI z-score at 24 months. Fat mass (mean (95% CL) of 6.5 kg (4.0; 9.0) from baseline, p = 0.0001), but not fat-free mass changed under ivacaftor treatment. There was a significant positive correlation between weight and fat mass change. Overall, there was no significant change in measured REE from baseline (mean (95% CL) of 108 kcal/d (-12; 228), p = 0.07) in our cohort. Pancreatic function and other nutritional markers did not change with treatment, with the exception of an increase in serum vitamin A levels (p = 0.006). Conclusion: The weight gain observed in ivacaftor treated pwCF is predominantly secondary to increases in fat mass warranting early counseling of people starting on CFTR-modulating treatment with respect to healthy diet and physical exercise.
Collapse
Affiliation(s)
- Marialena Mouzaki
- Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, Cinncinati, OH, United States
| | - Annie Dupuis
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | - Julie Avolio
- Department of Pediatrics, University of Toronto, Hospital for Sick Children, Toronto, ON, Canada
| | - Katherine Griffin
- Department of Medicine, University of Toronto and St. Michael’s Hospital, Toronto, ON, Canada
| | - Felix Ratjen
- Department of Pediatrics, University of Toronto, Hospital for Sick Children, Toronto, ON, Canada
| | - Elizabeth Tullis
- Department of Medicine, University of Toronto and St. Michael’s Hospital, Toronto, ON, Canada
| | - Tanja Gonska
- Department of Pediatrics, University of Toronto, Hospital for Sick Children, Toronto, ON, Canada
| |
Collapse
|
12
|
Klepper C, Crimmins NA, Orkin S, Sun Q, Fei L, Xanthakos S, Mouzaki M. Nonalcoholic Fatty Liver Disease in Young Children with Obesity. Child Obes 2023; 19:179-185. [PMID: 35639419 PMCID: PMC10122212 DOI: 10.1089/chi.2022.0048] [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] [Indexed: 11/12/2022]
Abstract
Background: To evaluate the prevalence of suspected nonalcoholic fatty liver disease (NAFLD) in young children with obesity and determine associated risk factors. Methods: Retrospective single-center study of children with obesity, ages 2-6 years. Suspected NAFLD was defined as an alanine aminotransferase (ALT) >30 U/L. Multivariable analyses were performed to determine predictors of elevated ALT. Results: Among 237 children 2-6 years old, 35% had elevated ALT. Multivariable analysis showed that higher BMI z score [odds ratio (OR): 1.5 confidence interval (95% CI: 1.04-1.92)] and higher gamma-glutamyl transferase (GGT) [OR: 21.3 (95% CI: 3.7-121.1)] predicted elevated ALT. Of those with ≥2 ALT levels, 38% (n = 33/86) had a persistently elevated ALT (median ALT >30 U/L). Only 7% of patients with ALT >30 U/L underwent further testing to evaluate for alternative causes of liver disease. Conclusion: Suspected NAFLD is common in young children with obesity and predicted by obesity severity and GGT. Other cardiometabolic markers were equivalent between those with normal vs. elevated ALT, suggesting NAFLD onset may precede development of comorbidities. Earlier screening will enable prompt diagnosis and intervention, which may prevent or delay the onset of cardiometabolic diseases commonly associated with NAFLD in adolescence and adulthood.
Collapse
Affiliation(s)
- Corie Klepper
- Division of Gastroenterology, Hepatology and Nutrition, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Nancy A. Crimmins
- Division of Endocrinology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Sarah Orkin
- Division of Gastroenterology, Hepatology and Nutrition, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Qin Sun
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
- Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Lin Fei
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
- Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Stavra Xanthakos
- Division of Gastroenterology, Hepatology and Nutrition, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Marialena Mouzaki
- Division of Gastroenterology, Hepatology and Nutrition, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| |
Collapse
|
13
|
Abstract
Background: Alternative BMI metrics are superior to BMI z score (BMIz) in tracking obesity but have not been evaluated in patients with nonalcoholic fatty liver disease (NAFLD). Our objective was to evaluate whether BMI-adjusted z score (BMIaz) or BMI expressed as a percentage of the 95th percentile (%BMIp95) are better predictors of degree of alanine aminotransferase (ALT) elevation, a surrogate for NAFLD severity, compared with BMIz in patients with NAFLD. Methods: A retrospective study of 776 subjects aged 2-18 years with BMIz > 1.0 followed in a NAFLD subspecialty clinic was conducted. Regression analysis was used to determine predictors of elevated ALT. Results: There was no association between BMIz, BMIaz, or %BMIp95 and degree of ALT elevation using linear or logistic regression. Conclusion: These results do not support the use of alternative BMI metrics for evaluating NAFLD severity. Future studies should investigate longitudinal assessments and correlation with histology.
Collapse
Affiliation(s)
- Corie M. Klepper
- Divisions of Gastroenterology, Hepatology, and Nutrition, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Tarush Khurana
- Department of Internal Medicine, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Qin Sun
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
- Divisions of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Lin Fei
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
- Divisions of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Nancy A. Crimmins
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
- Divisions of Endocrinology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Robert Siegel
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
- Divisions of Cardiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Marialena Mouzaki
- Divisions of Gastroenterology, Hepatology, and Nutrition, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| |
Collapse
|
14
|
Khurana T, Klepper C, Fei L, Sun Q, Bramlage K, Arce-Clachar AC, Xanthakos S, Mouzaki M. Clinically Meaningful Body Mass Index Change Impacts Pediatric Nonalcoholic Fatty Liver Disease. J Pediatr 2022; 250:61-66.e1. [PMID: 35835225 PMCID: PMC10008467 DOI: 10.1016/j.jpeds.2022.07.004] [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: 02/16/2022] [Revised: 07/02/2022] [Accepted: 07/06/2022] [Indexed: 10/17/2022]
Abstract
OBJECTIVE To investigate the prevalence and characteristics of children with nonalcoholic fatty liver disease (NAFLD) who reduce their body mass index (BMI) z-score (BMIz) by >.25, a goal in obesity medicine, and to determine the BMIz decrease needed for serum aminotransferase normalization. STUDY DESIGN This retrospective, single-center study included patients aged <18 years followed for NAFLD. Patients who had undergone weight loss surgery or had other reasons for weight loss/gain were excluded. Logistic regression was used to determine the odds of achieving a BMIz change of >-.25, as well as predictors of this outcome. RESULTS Of the 784 children who met the study criteria (median age, 13 years; 66% male; 24% Hispanic), 541 had a lowest BMIz at >90 days following the baseline clinic visit. Of these children, 168 (31%) had a BMIz change of >-.25 from baseline over a median of 367 days (IQR, 201-678 days). Decreases in serum aminotransferase and lipid levels were seen in both groups (with and without a BMIz change of >-.25); however, these decreases were more pronounced in children who achieved a BMIz drop of >.25. Hemoglobin A1c concentration did not change in either group. Young age (OR, .861; 95% CI, .81-.92; P < .01) and non-Hispanic ethnicity (OR of non-Hispanic vs Hispanic, .61; 95% CI, .38-.97; P < .04) were predictors of a BMIz change >-.25. The BMIz decrease associated with normalization of serum alanine aminotransferase was .27. CONCLUSIONS A BMIz reduction of >.25 is associated with significant changes in serum aminotransferase levels. These findings can further guide the clinical management of children with NAFLD.
Collapse
Affiliation(s)
- Tarush Khurana
- Department of Internal Medicine, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Corie Klepper
- Division of Gastroenterology, Hepatology and Nutrition, Cincinnati Children's Hospital Medical Center, Cincinnati, OH; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Lin Fei
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH; Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Qin Sun
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH; Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Kristin Bramlage
- Division of Gastroenterology, Hepatology and Nutrition, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Ana Catalina Arce-Clachar
- Division of Gastroenterology, Hepatology and Nutrition, Cincinnati Children's Hospital Medical Center, Cincinnati, OH; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH; Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Stavra Xanthakos
- Division of Gastroenterology, Hepatology and Nutrition, Cincinnati Children's Hospital Medical Center, Cincinnati, OH; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH; Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Marialena Mouzaki
- Division of Gastroenterology, Hepatology and Nutrition, Cincinnati Children's Hospital Medical Center, Cincinnati, OH; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH; Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| |
Collapse
|
15
|
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.
Collapse
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
| | | |
Collapse
|
16
|
Ley SL, Kidwell KM, Van Dyk TR, Orkin S, Odar Stough C, Howarth T, Goetz AR, Xanthakos SA, Bramlage K, Mouzaki M, Arce-Clachar AC, Zeller MH. Insight Into the Adolescent Patient Experience With Nonalcoholic Fatty Liver Disease. J Pediatr Gastroenterol Nutr 2022; 75:88-96. [PMID: 35442241 PMCID: PMC9283213 DOI: 10.1097/mpg.0000000000003461] [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] [Indexed: 12/10/2022]
Abstract
OBJECTIVES Nonalcoholic fatty liver disease (NAFLD) is the leading chronic liver disease in youth, yet little is known about the adolescent patient's experience with NAFLD, which is key for treatment engagement. We examined adolescents' experiences with NAFLD diagnosis, thoughts on how NAFLD affects their daily life, understanding and perceptions of diagnosis and treatment, and impressions of how to improve care. METHODS Utilizing a mixed-method design, adolescents with NAFLD (N = 16; Mean age = 15.8 years; Mean BMI = 37 kg/m 2 ) participated in focus groups. To supplement qualitative data, adolescents and their caregiver completed measures assessing illness perceptions, adolescent quality of life, and eating/activity behaviors. RESULTS Focus group themes suggested reactions to diagnosis varied from unconcerned to anxious. NAFLD diagnosis occurred within the context of other psychological/medical concerns and was not perceived to affect most adolescents' daily lives. Although adolescents understood general contributors to NAFLD, comprehension of their diagnosis varied. Adolescents were more likely to make lifestyle changes when families were supportive, and they preferred tailored recommendations for health behavior change from the healthcare team. Notably, 62.5% of adolescents were more concerned about their weight than NAFLD. Almost half (43.8%) identified as food insecure. CONCLUSIONS Adolescents with NAFLD may benefit from personalized treatment. Care could be enhanced by ensuring comprehension of diagnosis, problem-solving personal, and family barriers and increasing family support. Harnessing adolescents' desire for weight loss may be a more salient driver for change in disease status. Interventions should also address systemic barriers such as food insecurity to ensure equitable care.
Collapse
Affiliation(s)
- Sanita L Ley
- From the Division of Behavioral Medicine & Clinical Psychology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Katherine M Kidwell
- From the Division of Behavioral Medicine & Clinical Psychology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
- Department of Psychology, Syracuse University, Syracuse, NY
| | - Tori R Van Dyk
- Department of Psychology, Loma Linda University, Loma Linda, CA
| | - Sarah Orkin
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH
- Division of Gastroenterology, Hepatology & Nutrition, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | | | - Taylor Howarth
- From the Division of Behavioral Medicine & Clinical Psychology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Amy R Goetz
- From the Division of Behavioral Medicine & Clinical Psychology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
- Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, Houston, TX
| | - Stavra A Xanthakos
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH
- Division of Gastroenterology, Hepatology & Nutrition, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Kristin Bramlage
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH
- Department of Psychology, Loma Linda University, Loma Linda, CA
| | - Marialena Mouzaki
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH
- Division of Gastroenterology, Hepatology & Nutrition, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Ana Catalina Arce-Clachar
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH
- Division of Gastroenterology, Hepatology & Nutrition, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Meg H Zeller
- From the Division of Behavioral Medicine & Clinical Psychology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH
| |
Collapse
|
17
|
Yodoshi T, Orkin S, Trout AT, Catalina Arce-Clachar A, Bramlage K, Liu C, Fei L, Dillman JR, Xanthakos SA, Mouzaki M. Non-Invasive Approaches to Estimate Liver Steatosis and Stiffness in Children With Non-Alcoholic Fatty Liver Disease. J Pediatr Gastroenterol Nutr 2022; 74:495-502. [PMID: 34908012 PMCID: PMC9673005 DOI: 10.1097/mpg.0000000000003371] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [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] [Indexed: 12/27/2022]
Abstract
OBJECTIVES To develop pediatric-specific models that predict liver stiffness and hepatic steatosis in non-alcoholic fatty liver disease (NAFLD), based on clinical and laboratory data. METHODS Children with NAFLD, who had undergone magnetic resonance imaging with proton density fat fraction (MRI-PDFF) for steatosis quantification and/or magnetic resonance elastography (MRE) for liver stiffness assessment were included. We used data from patients imaged between April 2009 to July 2018 to develop a predictive model for fat fraction and stiffness. We validated the performance of the models using data from a second cohort, imaged between 2018 and 2019. RESULTS The first cohort (n = 344) consisted of predominantly non-Hispanic (80%), male (67%) adolescents. MRE data were available for 343 children, while PDFF data were available for 130. In multivariable regression, ethnicity, insulin levels, platelet count, and aspartate aminotransferase independently predicted liver stiffness and these variables were used to develop the predictive model. Similarly, sex, ethnicity, alanine aminotransferase, and triglycerides levels independently predicted liver PDFF and were used in the PDFF model. The AUC of the optimal cutoff for the model that predicted a stiffness of >2.71 kPa was 0.70 and for the model that predicted PDFF >5% was 0.78. The validation group (n = 110) had similar characteristics. The correlation coefficient of the model with the measured liver stiffness was 0.30 and with the measured liver PDFF was 0.26. CONCLUSIONS Pediatric-specific models perform poorly at predicting exact liver stiffness and steatosis; however, in the absence of magnetic resonance imaging can be used to predict the presence of significant steatosis (>5%) and/or significant stiffness (>2.71). Thus, imaging remains an invaluable adjunct to laboratory investigations in determining disease severity.
Collapse
Affiliation(s)
- Toshifumi Yodoshi
- Division of Gastroenterology, Hepatology and Nutrition, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH
- Department of Clinical Research and Quality Management, University of the Ryukyus Graduate School of Medicine, Okinawa Chubu Hospital, Okinawa, Japan
- Department of Pediatrics, Okinawa Chubu Hospital, Okinawa, Japan
| | - Sarah Orkin
- Division of Gastroenterology, Hepatology and Nutrition, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH
- Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH
| | - Andrew T. Trout
- Department of Radiology, University of Cincinnati College of Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH
- Department of Radiology, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH
| | - Ana Catalina Arce-Clachar
- Division of Gastroenterology, Hepatology and Nutrition, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH
- Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH
| | - Kristin Bramlage
- Division of Gastroenterology, Hepatology and Nutrition, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH
| | - Chunyan Liu
- Division of Biostatistics and Epidemiology, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH
| | - Lin Fei
- Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH
- Division of Biostatistics and Epidemiology, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH
| | - Jonathan R. Dillman
- Department of Radiology, University of Cincinnati College of Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH
- Department of Radiology, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH
| | - Stavra A. Xanthakos
- Division of Gastroenterology, Hepatology and Nutrition, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH
- Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH
| | - Marialena Mouzaki
- Division of Gastroenterology, Hepatology and Nutrition, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH
- Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH
| |
Collapse
|
18
|
Radulescu A, Dugan AJ, Killian M, Attia SL, Mouzaki M, Fuchs GJ, Kohli R, Bada H, Kern PA, Softic S. Stratification by obesity class, rather than age, can identify a higher percent of children at risk for non-alcoholic fatty liver disease and metabolic dysfunction. Pediatr Obes 2022; 17:e12862. [PMID: 34662928 DOI: 10.1111/ijpo.12862] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [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: 04/26/2021] [Revised: 09/04/2021] [Accepted: 09/20/2021] [Indexed: 01/19/2023]
Abstract
BACKGROUND An increasing number of clinical practice guidelines recommend screening children with obesity for non-alcoholic fatty liver disease (NAFLD). However, there is limited evidence regarding what parameters should be used to initiate the screening. OBJECTIVE The objective of this study was to determine whether obesity class rather than age group can identify a higher percent of children at risk of NAFLD as assessed by abnormal alanine aminotransferase (ALT). METHODS This is a cross-sectional study in a regional referral clinic for evaluation of obesity. Children were stratified by age group or by obesity class, and data obtained at first visit were analysed. RESULTS Of the 784 children, 482 were ≥10, 209 were 6 to 9 and 93 were 2 to 5 years of age. Abnormal ALT was observed in 32.1%, 46.9% and 61.0% of children with class I, II or III obesity, respectively (p < 0.001), while the risk of abnormal ALT did not differ in very young (2-5), young (6-9), or children older than 10 years. A multivariable analysis showed that class II and class III obesity were associated with 2.1-fold (1.27-3.72) and 4-fold (2.41-6.96) greater odds of abnormal ALT compared with class I obesity. African-American children had lower risk of abnormal ALT (0.27), whereas Hispanic children had higher risk (2.37). Obesity class was a better predictor of abnormal ALT than age, especially in girls. Furthermore, 66.7% of boys (p = 0.009) and 69% of girls (p < 0.001) with abnormal ALT exhibited additional signs of metabolic dysfunction. CONCLUSION Obesity class is more strongly associated with abnormal ALT than age.
Collapse
Affiliation(s)
- Aurelia Radulescu
- Department of Pediatrics, University of Kentucky College of Medicine and Kentucky Children's Hospital, Lexington, Kentucky, USA
| | - Adam J Dugan
- Department of Biostatistics, College of Public Health, University of Kentucky, Lexington, Kentucky, USA
| | - Mary Killian
- Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Suzanna L Attia
- Department of Pediatrics, Division of Pediatric Gastroenterology, Hepatology, and Nutrition, College of Medicine, University of Kentucky, Lexington, Kentucky, USA
| | - Marialena Mouzaki
- Steatohepatitis Center, Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati, Ohio, USA
| | - George J Fuchs
- Department of Pediatrics, Division of Pediatric Gastroenterology, Hepatology, and Nutrition, College of Medicine, University of Kentucky, Lexington, Kentucky, USA
| | - Rohit Kohli
- Division of Gastroenterology, Hepatology and Nutrition, Children's Hospital Los Angeles, Los Angeles, California, USA
| | - Henrietta Bada
- Department of Pediatrics, University of Kentucky College of Medicine and Kentucky Children's Hospital, Lexington, Kentucky, USA
| | - Philip A Kern
- Department of Medicine, Division of Endocrinology, University of Kentucky College of Medicine, Lexington, Kentucky, USA
| | - Samir Softic
- Department of Pediatrics, Division of Pediatric Gastroenterology, Hepatology, and Nutrition, College of Medicine, University of Kentucky, Lexington, Kentucky, USA.,Department of Pharmacology and Nutritional Sciences, University of Kentucky College of Medicine, Lexington, Kentucky, USA.,Section on Integrative Physiology and Metabolism, Joslin Diabetes Center, Harvard Medical School, Boston, Massachusetts, USA
| |
Collapse
|
19
|
Horsley M, Pathak S, Morales D, Lorts A, Mouzaki M. Nutritional Outcomes of Patients with Pediatric and Congenital Heart Disease Requiring Ventricular Assist Device. JPEN J Parenter Enteral Nutr 2022; 46:1553-1558. [DOI: 10.1002/jpen.2351] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2021] [Revised: 01/20/2022] [Accepted: 02/14/2022] [Indexed: 11/06/2022]
Affiliation(s)
| | | | - David Morales
- Department of Surgery, Division of Pediatric Cardiothoracic Surgery
- Division of Cardiology
| | - Angela Lorts
- Department of Clinical Pediatrics
- Division of Cardiology
| | - Marialena Mouzaki
- Department of Clinical Pediatrics
- Division of Gastroenterology, Hepatology and Nutrition Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine
| |
Collapse
|
20
|
Amevor AA, Yodoshi T, Trout AT, Dillman JR, Singh R, Jarvis R, Fei L, Liu C, Taylor A, Miethke A, Mouzaki M. Sarcopenia is highly prevalent in children with autoimmune liver diseases and is linked to visceral fat and parent-perceived general health. Liver Int 2022; 42:394-401. [PMID: 34817929 PMCID: PMC9453636 DOI: 10.1111/liv.15108] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [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: 07/20/2021] [Accepted: 11/22/2021] [Indexed: 02/03/2023]
Abstract
BACKGROUND Patients with autoimmune hepatitis (AIH) and primary or autoimmune sclerosing cholangitis are at nutritional risk; their body composition and has not been extensively studied. We aimed to describe their body composition and identify clinical links. METHODS Using magnetic resonance imaging (MRI), two reviewers segmented total psoas muscle area (tPMSA), visceral fat area (VFA) and subcutaneous fat area (mm2 ) and measured visceral and subcutaneous thickness (mm). Clinical, laboratory and quality of life (QoL; using PedsQL) data were collected. Sarcopenia was defined as tPMSA ≤5th percentile. Analysis of variance, Wilcoxon rank test and multivariable modelling were performed. A paediatric cohort with non-alcoholic fatty liver disease (NAFLD) was used as a comparator following propensity score matching. RESULTS Fifty-eight patients with autoimmune liver disease (AILD) (33 [57%] with AIH) were included: median age 16 years (interquartile range [IQR]: 13-18), 33 (57%) male. Median time from diagnosis to MRI was 15 months (IQR: 2-39 months). Two patients (3%) had a BMIz indicative of mild malnutrition. tPMSA was measurable in 52 subjects (90%). Of those, 25 (48%) had sarcopenia. Sarcopenic patients had a lower blood urea nitrogen compared to non-sarcopenic (median [IQR]: 9.5 [8.0, 12.0] vs 11 [10, 14] mg/dL; P = .023). There was no difference in corticosteroid use between groups. The VFA of sarcopenic patients was higher (3156 [2064, 7492]) vs 2084 [688, 3092]) mm2 ; P = .005). Patient-reported QoL negatively associated with VFA and general health negatively associated with VFA. Compared with NAFLD, the odds ratio for sarcopenia with AILD was 14.5 (95% confidence interval: 2.3-90.7). CONCLUSION In autoimmune liver diseases, sarcopenia is highly prevalent, associated with increased visceral fat and QoL.
Collapse
Affiliation(s)
- Antoinette A. Amevor
- Division of Gastroenterology, Hepatology and Nutrition, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, USA,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Toshifumi Yodoshi
- Division of Gastroenterology, Hepatology and Nutrition, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, USA,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Andrew T. Trout
- Department of Radiology, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, USA,Department of Radiology, University of Cinncinati College of Medicine, Cincinnati, Ohio, USA
| | - Jonathan R. Dillman
- Department of Radiology, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, USA,Department of Radiology, University of Cinncinati College of Medicine, Cincinnati, Ohio, USA
| | - Ruchi Singh
- Division of Gastroenterology, Hepatology and Nutrition, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, USA
| | - Ryan Jarvis
- Division of Gastroenterology, Hepatology and Nutrition, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, USA
| | - Lin Fei
- Division of Biostatistics and Epidemiology, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, USA
| | - Chunyan Liu
- Division of Biostatistics and Epidemiology, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, USA
| | - Amy Taylor
- Division of Gastroenterology, Hepatology and Nutrition, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, USA,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Alexander Miethke
- Division of Gastroenterology, Hepatology and Nutrition, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, USA,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Marialena Mouzaki
- Division of Gastroenterology, Hepatology and Nutrition, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, USA,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| |
Collapse
|
21
|
Orkin S, Yodoshi T, Romantic E, Hitchcock K, Arce-Clachar AC, Bramlage K, Sun Q, Fei L, Xanthakos SA, Trout AT, Mouzaki M. Body composition measured by bioelectrical impedance analysis is a viable alternative to magnetic resonance imaging in children with nonalcoholic fatty liver disease. JPEN J Parenter Enteral Nutr 2022; 46:378-384. [PMID: 33811369 PMCID: PMC8649944 DOI: 10.1002/jpen.2113] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE To determine the relationship between bioelectrical impedance analysis (BIA) and magnetic resonance imaging (MRI) obtained measures of body composition in children with nonalcoholic fatty liver disease (NAFLD). METHODS Youth with obesity and NAFLD who had BIA and abdominal MRI testing were included. BIA measured skeletal muscle mass (SMM), appendicular lean mass (ALM), trunk muscle mass (TMM), and percent body fat. MRI measured total psoas muscle surface area (tPMSA) and fat compartments. Univariate analysis described the relationship between BIA- and MRI-derived measurements. Multivariable regression analyses built a model with body composition measured via MRI. RESULTS 115 patients (82 (71%) male, 38 (33%) Hispanic, median age14 years) were included. There was a strong correlation between tPMSA and SMM, ALM, and TMM (correlation coefficients [CCs]: 0.701, 0.689, 0.708, respectively; all P < .001). Higher SMM, ALM, and TMM were associated with higher tPMSA. This association remained after controlling for age, sex, ethnicity, type 2 diabetes mellitus status, and body mass index z-score. Total fat mass by BIA and MRI-determined total, subcutaneous, and intraperitoneal fat area correlated significantly (CCs: 0.813, 0.808, 0.515, respectively; all P < .001). In univariate regression, higher total fat mass by BIA was associated with increased total fat area and increased fat in each of the four regions measured by MRI. After controlling for confounders, the association between total fat mass by BIA and total fat area by MRI persisted. CONCLUSIONS BIA measures of muscle and fat mass correlate strongly with MRI measures of tPMSA and fat areas in children with obesity and NAFLD.
Collapse
Affiliation(s)
- Sarah Orkin
- Division of Gastroenterology, Hepatology, and Nutrition, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Toshifumi Yodoshi
- Division of Gastroenterology, Hepatology, and Nutrition, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Emily Romantic
- Division of Gastroenterology, Hepatology, and Nutrition, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Kathryn Hitchcock
- Division of Gastroenterology, Hepatology, and Nutrition, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Ana Catalina Arce-Clachar
- Division of Gastroenterology, Hepatology, and Nutrition, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Kristin Bramlage
- Division of Gastroenterology, Hepatology, and Nutrition, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Qin Sun
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA.,Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Lin Fei
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA.,Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Stavra A Xanthakos
- Division of Gastroenterology, Hepatology, and Nutrition, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Andrew T Trout
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA.,Department of Radiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.,Department of Radiology, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Marialena Mouzaki
- Division of Gastroenterology, Hepatology, and Nutrition, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| |
Collapse
|
22
|
Miserachs M, Kean P, Tuira L, Al Nasser Y, De Angelis M, Van Roestel K, Ghanekar A, Cattral M, Mouzaki M, Ng VL, Mtaweh H, Avitzur Y. Standardized Feeding Protocol Improves Delivery and Acceptance of Enteral Nutrition in Children Immediately After Liver Transplantation. Liver Transpl 2021; 27:1443-1453. [PMID: 34018670 DOI: 10.1002/lt.26102] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [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: 11/05/2020] [Revised: 04/10/2021] [Accepted: 04/24/2021] [Indexed: 12/13/2022]
Abstract
Delivery of adequate nutrition after liver transplantation (LT) surgery is an important goal of postoperative care. Existing guidelines recommend early enteral nutrition after abdominal surgery and in the child who is critically ill but data on nutritional interventions after LT in children are sparse. We evaluated the impact of a standardized postoperative feeding protocol on enteral nutrition delivery in children after LT. Data from 49 children (ages 0-18 years) who received a LT prior to feeding protocol implementation were compared with data for 32 children undergoing LT after protocol implementation. The 2 groups did not differ with respect to baseline demographic data. After protocol implementation, enteral nutrition was started earlier (2 versus 3 days after transplant; P = 0.005) and advanced faster when a feeding tube was used (4 versus 8 days; P = 0.03). Protocol implementation was also associated with reduced parenteral nutrition use rates (47% versus 75%; P = 0.01). No adverse events occurred after protocol implementation. Hospital length of stay and readmission rates were not different between the 2 groups. In conclusion, implementation of a postoperative nutrition protocol in children after LT led to optimized nutrient delivery and reduced variability of care.
Collapse
Affiliation(s)
- Mar Miserachs
- Transplant and Regenerative Medicine Centre, University of Toronto, Toronto, Ontario, Canada.,Division of Pediatric Gastroenterology, Hepatology and Nutrition, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada.,Department of Pediatrics, Obstetrics and Gynaecology and Preventative Medicine, Universitat Autònoma de Barcelona, Bellaterra, Barcelona, Spain
| | - Penni Kean
- Transplant and Regenerative Medicine Centre, University of Toronto, Toronto, Ontario, Canada
| | - Lori Tuira
- Department of Critical Care Medicine, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Yasser Al Nasser
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Maria De Angelis
- Transplant and Regenerative Medicine Centre, University of Toronto, Toronto, Ontario, Canada
| | - Krista Van Roestel
- Transplant and Regenerative Medicine Centre, University of Toronto, Toronto, Ontario, Canada
| | - Anand Ghanekar
- Multi-Organ Transplant Program, University Health Network, Toronto, Ontario, Canada.,Department of Surgery, University of Toronto, Ontario, Canada
| | - Mark Cattral
- Multi-Organ Transplant Program, University Health Network, Toronto, Ontario, Canada.,Department of Surgery, University of Toronto, Ontario, Canada
| | - Marialena Mouzaki
- Division of Gastroenterology, Hepatology and Nutrition, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Vicky Lee Ng
- Transplant and Regenerative Medicine Centre, University of Toronto, Toronto, Ontario, Canada.,Division of Pediatric Gastroenterology, Hepatology and Nutrition, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Haifa Mtaweh
- Department of Critical Care Medicine, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Yaron Avitzur
- Transplant and Regenerative Medicine Centre, University of Toronto, Toronto, Ontario, Canada.,Division of Pediatric Gastroenterology, Hepatology and Nutrition, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| |
Collapse
|
23
|
Yodoshi T, Orkin S, Romantic E, Hitchcock K, Clachar ACA, Bramlage K, Sun Q, Fei L, Trout AT, Xanthakos SA, Mouzaki M. Impedance-based measures of muscle mass can be used to predict severity of hepatic steatosis in pediatric nonalcoholic fatty liver disease. Nutrition 2021; 91-92:111447. [PMID: 34583137 DOI: 10.1016/j.nut.2021.111447] [Citation(s) in RCA: 1] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2021] [Revised: 07/25/2021] [Accepted: 08/03/2021] [Indexed: 12/11/2022]
Abstract
OBJECTIVES The objective of this study was to investigate the association between measures of body composition based on bioelectrical impedance analysis (BIA) and histologic severity of liver disease in a pediatric cohort with nonalcoholic fatty liver disease (NAFLD). METHODS This was a cross-sectional study of patients < 20 y old with histologically confirmed NAFLD followed in our Steatohepatitis Center from 2017 to 2019. Contemporaneous body-composition data were obtained using a multifrequency octopolar BIA device (InBody 370, InBody, Seoul, South Korea). BIA data collected were skeletal muscle mass, appendicular muscle mass, and percentage body fat. Skeletal and appendicular muscle mass were corrected for height (dividing by the square of height), generating their respective indices. Univariate linear and logistic regression, followed by multivariable logistic regression analyses, were used. RESULTS Of the 79 children included (27% female, 73% male; 38% Hispanic; median age, 13 y; median body mass index Z-score, 2.43), the median NAFLD Activity Score was 4 (interquartile range, 3-5). In multivariable regression analyses, the skeletal muscle mass index was negatively associated with hepatic steatosis after controlling for confounders (odds ratio, 0.76; 95% confidence interval, 0.62-0.93). Similarly, the appendicular muscle mass index was negatively associated with severity of hepatic steatosis severity (odds ratio, 0.69; 95% confidence interval, 0.53-0.90). In contrast, percentage body fat was not associated with hepatic steatosis. NAFLD Activity Score, lobular inflammation, ballooning scores, and fibrosis stage were not associated with measures of body composition. CONCLUSIONS There is an inverse association between BIA-based measures of muscle mass and severity of hepatic steatosis in children with NAFLD. BIA data could further inform clinical decision making in this context.
Collapse
Affiliation(s)
- Toshifumi Yodoshi
- Division of Gastroenterology, Hepatology and Nutrition, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA; Department of Pediatrics, Okinawa Chubu Hospital, Okinawa, Japan; Department of Clinical Research and Quality Management, University of the Ryukyus Graduate School of Medicine, Okinawa, Japan
| | - Sarah Orkin
- Division of Gastroenterology, Hepatology and Nutrition, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Emily Romantic
- Division of Gastroenterology, Hepatology and Nutrition, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA; Division of Nutrition Therapy, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Kathryn Hitchcock
- Division of Gastroenterology, Hepatology and Nutrition, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA; Division of Nutrition Therapy, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Ana-Catalina Arce Clachar
- Division of Gastroenterology, Hepatology and Nutrition, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Kristin Bramlage
- Division of Gastroenterology, Hepatology and Nutrition, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Qin Sun
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA; Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Lin Fei
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA; Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Andrew T Trout
- Department of Radiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA; Department of Radiology, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Stavra A Xanthakos
- Division of Gastroenterology, Hepatology and Nutrition, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Marialena Mouzaki
- Division of Gastroenterology, Hepatology and Nutrition, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA.
| |
Collapse
|
24
|
Ali F, Mouzaki M. 50 Years Ago in TheJournalofPediatrics: MCTs: Are They what We want Them to Be? J Pediatr 2021; 236:94. [PMID: 34446182 DOI: 10.1016/j.jpeds.2021.05.057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [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] [Indexed: 11/19/2022]
Affiliation(s)
- Farhana Ali
- Gastroenterology, Hepatology and Nutrition, University of California San Diego, Rady Children's Hospital San Diego, San Diego, California
| | - Marialena Mouzaki
- Gastroenterology, Hepatology and Nutrition, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| |
Collapse
|
25
|
McNelis K, Yodoshi T, Divanovic S, Gandhi C, Kim JH, Anton CG, Trout AT, Mouzaki M. Hepatic Steatosis in Infancy: The Beginning of Pediatric Nonalcoholic Fatty Liver Disease? JPGN Rep 2021; 2:e113. [PMID: 37205943 PMCID: PMC10191463 DOI: 10.1097/pg9.0000000000000113] [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] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Accepted: 04/02/2021] [Indexed: 05/21/2023]
Abstract
Nonalcoholic fatty liver disease is clinically silent and the age of its onset is unknown. Fatty liver can occur as early as in utero in the context of an unfavorable maternal metabolic environment. Our objective was to determine the prevalence of hepatic steatosis in a cohort of previously healthy infants less than 3 months of age. Methods Retrospective study of all abdominal computed tomography (CT) scans performed from 2009 to 2019 for the investigation of trauma. Two independent reviewers applied published criteria to determine the presence of hepatic steatosis. Descriptive statistics were used. The groups with and without steatosis were compared using Wilcoxon-Mann Whitney or Fisher exact test. Results Of 119 CT scans available in infants younger than 3 months of age, 65 were performed in previously healthy infants for the investigation of trauma. The included population was predominantly male, non-Hispanic, with a median age of 60 days (interquartile range, 34-73 d). Depending on the criteria used, 23% or 26% of infants had evidence of fatty liver. The prevalence of maternal obesity and/or diabetes was 11% (of the 65 pregnancies) but there was no significant difference in maternal risk factors between infants with and without evidence of steatosis. Conclusions Findings suggest CT evidence of hepatic steatosis in up to a quarter of otherwise healthy infants ≤3 months of age. This may represent early manifestation of pediatric nonalcoholic fatty liver disease. The natural history and pathophysiology of this condition need to be studied to determine optimal detection, prevention and early intervention strategies.
Collapse
Affiliation(s)
- Kera McNelis
- From the Division of Neonatology and Pulmonary Biology, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Toshifumi Yodoshi
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH
- Okinawa Chubu Hospital, Okinawa, Japan
| | - Senad Divanovic
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH
- Division of Immunobiology, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH
- Center for Inflammation and Tolerance, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH
| | - Chandrashekhar Gandhi
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH
| | - Jae H. Kim
- From the Division of Neonatology and Pulmonary Biology, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Christopher G. Anton
- Department of Radiology, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH
| | - Andrew T. Trout
- Department of Radiology, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH
| | - Marialena Mouzaki
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH
| |
Collapse
|
26
|
Barrow F, Khan S, Fredrickson G, Wang H, Dietsche K, Parthiban P, Robert S, Kaiser T, Winer S, Herman A, Adeyi O, Mouzaki M, Khoruts A, Hogquist KA, Staley C, Winer DA, Revelo XS. Microbiota-Driven Activation of Intrahepatic B Cells Aggravates NASH Through Innate and Adaptive Signaling. Hepatology 2021; 74:704-722. [PMID: 33609303 PMCID: PMC8377092 DOI: 10.1002/hep.31755] [Citation(s) in RCA: 79] [Impact Index Per Article: 26.3] [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: 06/17/2020] [Revised: 12/21/2020] [Accepted: 01/08/2021] [Indexed: 12/17/2022]
Abstract
BACKGROUND AND AIMS Nonalcoholic steatohepatitis is rapidly becoming the leading cause of liver failure and indication for liver transplantation. Hepatic inflammation is a key feature of NASH but the immune pathways involved in this process are poorly understood. B lymphocytes are cells of the adaptive immune system that are critical regulators of immune responses. However, the role of B cells in the pathogenesis of NASH and the potential mechanisms leading to their activation in the liver are unclear. APPROACH AND RESULTS In this study, we report that NASH livers accumulate B cells with elevated pro-inflammatory cytokine secretion and antigen-presentation ability. Single-cell and bulk RNA sequencing of intrahepatic B cells from mice with NASH unveiled a transcriptional landscape that reflects their pro-inflammatory function. Accordingly, B-cell deficiency ameliorated NASH progression, and adoptively transferring B cells from NASH livers recapitulates the disease. Mechanistically, B-cell activation during NASH involves signaling through the innate adaptor myeloid differentiation primary response protein 88 (MyD88) as B cell-specific deletion of MyD88 reduced hepatic T cell-mediated inflammation and fibrosis, but not steatosis. In addition, activation of intrahepatic B cells implicates B cell-receptor signaling, delineating a synergy between innate and adaptive mechanisms of antigen recognition. Furthermore, fecal microbiota transplantation of human NAFLD gut microbiotas into recipient mice promoted the progression of NASH by increasing the accumulation and activation of intrahepatic B cells, suggesting that gut microbial factors drive the pathogenic function of B cells during NASH. CONCLUSION Our findings reveal that a gut microbiota-driven activation of intrahepatic B cells leads to hepatic inflammation and fibrosis during the progression of NASH through innate and adaptive immune mechanisms.
Collapse
Affiliation(s)
- Fanta Barrow
- Department of Integrative Biology & PhysiologyUniversity of Minnesota Medical SchoolMinneapolisMN
| | - Saad Khan
- Departments of Immunology and Laboratory Medicine & PathobiologyUniversity of TorontoTorontoONCanada.,Division of Cellular & Molecular BiologyToronto General Hospital Research InstituteUniversity Health NetworkTorontoONCanada
| | - Gavin Fredrickson
- Department of Integrative Biology & PhysiologyUniversity of Minnesota Medical SchoolMinneapolisMN
| | - Haiguang Wang
- Department of Integrative Biology & PhysiologyUniversity of Minnesota Medical SchoolMinneapolisMN
| | - Katrina Dietsche
- Department of Integrative Biology & PhysiologyUniversity of Minnesota Medical SchoolMinneapolisMN
| | - Preethy Parthiban
- Department of Integrative Biology & PhysiologyUniversity of Minnesota Medical SchoolMinneapolisMN
| | - Sacha Robert
- Department of Integrative Biology & PhysiologyUniversity of Minnesota Medical SchoolMinneapolisMN
| | - Thomas Kaiser
- Department of SurgeryUniversity of MinnesotaMinneapolisMN
| | - Shawn Winer
- Departments of Immunology and Laboratory Medicine & PathobiologyUniversity of TorontoTorontoONCanada
| | - Adam Herman
- Minnesota Supercomputing InstituteUniversity of MinnesotaMinneapolisMN
| | - Oyedele Adeyi
- Department of Laboratory Medicine and PathologyUniversity of MinnesotaMinneapolisMN
| | | | - Alexander Khoruts
- Division of Gastroenterology, Hepatology, and NutritionDepartment of MedicineUniversity of MinnesotaMinneapolisMN.,Center for ImmunologyUniversity of MinnesotaMinneapolisMN
| | - Kristin A Hogquist
- Department of Laboratory Medicine and PathologyUniversity of MinnesotaMinneapolisMN.,Center for ImmunologyUniversity of MinnesotaMinneapolisMN
| | | | - Daniel A Winer
- Departments of Immunology and Laboratory Medicine & PathobiologyUniversity of TorontoTorontoONCanada.,Division of Cellular & Molecular BiologyToronto General Hospital Research InstituteUniversity Health NetworkTorontoONCanada.,Buck Institute for Research on AgingNovatoCA
| | - Xavier S Revelo
- Department of Integrative Biology & PhysiologyUniversity of Minnesota Medical SchoolMinneapolisMN.,Center for ImmunologyUniversity of MinnesotaMinneapolisMN
| |
Collapse
|
27
|
Okura H, Yodoshi T, Thapaliya S, Trout AT, Mouzaki M. Under-reporting of Hepatic Steatosis in Children: A Missed Opportunity for Early Detection. J Pediatr 2021; 234:92-98.e2. [PMID: 33745998 DOI: 10.1016/j.jpeds.2021.03.016] [Citation(s) in RCA: 1] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2020] [Revised: 02/15/2021] [Accepted: 03/11/2021] [Indexed: 12/11/2022]
Abstract
OBJECTIVE To determine the prevalence of underreporting of hepatic steatosis found incidentally on computed tomography (CT). STUDY DESIGN Retrospective cross-sectional study including patients <18 years of age who had undergone unenhanced abdominal CT for evaluation of nephrolithiasis. Hepatic and splenic attenuation were measured independently by 2 reviewers. Hepatic steatosis was defined using various previously established criteria (4 original criteria designed to detect moderate/severe steatosis and 3 secondary criteria designed to identify mild steatosis). Radiology reports and clinical notes were reviewed for documentation of steatosis. Serum alanine aminotransferase levels were collected. Kappa statistics were used to assess agreement between reviewers. RESULTS A total of 584 patients were included. Agreement between reviewers' measurements for categorical classification of presence of steatosis was excellent (kappa statistic agreement >87%). The prevalence of hepatic steatosis ranged from 3% to 35%, depending on the criterion. Using absolute liver attenuation <48 Hounsfield units (most likely reflective of the truth, given alanine aminotransferase distribution and body mass index data), the prevalence was 7% (n = 42). Steatosis was reported for only 12 of 42 (28%) of these patients and was documented in clinical notes in only 3 of those cases. CONCLUSIONS Hepatic steatosis is underreported as an incidental finding of CT for nephrolithiasis. Given the prevalence and silent nature of nonalcoholic fatty liver disease, a high level of suspicion is needed, so as not to miss the opportunity to identify steatosis in childhood.
Collapse
Affiliation(s)
- Hiroko Okura
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Cincinnati Children's Hospital Medical Center, Cincinnati, OH; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Toshifumi Yodoshi
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Cincinnati Children's Hospital Medical Center, Cincinnati, OH; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Samjhana Thapaliya
- Department of Radiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Andrew T Trout
- Department of Radiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Marialena Mouzaki
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Cincinnati Children's Hospital Medical Center, Cincinnati, OH; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH.
| |
Collapse
|
28
|
Yodoshi T, Orkin S, Arce-Clachar AC, Bramlage K, Xanthakos SA, Valentino PL, Mouzaki M. Alternative Etiologies of Liver Disease in Children With Suspected NAFLD. Pediatrics 2021; 147:peds.2020-009829. [PMID: 33785637 PMCID: PMC8015155 DOI: 10.1542/peds.2020-009829] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [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] [Accepted: 01/06/2021] [Indexed: 12/11/2022] Open
Abstract
OBJECTIVES To determine the prevalence of alternative causes of liver disease in a cohort of youth with overweight and obesity undergoing evaluation for suspected nonalcoholic fatty liver disease (NAFLD). METHODS Multicenter, retrospective cohort study of patients aged ≤18 years with overweight and obesity and evidence of elevated serum aminotransferases and/or hepatic steatosis on imaging, referred for suspected NAFLD to Cincinnati Children's Hospital Medical Center (2009-2017) or Yale New Haven Children's Hospital (2012-2017). Testing was performed to exclude the following: autoimmune hepatitis (AIH), Wilson disease, viral hepatitis (B and C), thyroid dysfunction, celiac disease, α-1 antitrypsin deficiency, and hemochromatosis. RESULTS A total of 900 children with overweight and obesity (63% boys, 26% Hispanic ethnicity) were referred, with a median age of 13 years (range: 2-18). Most had severe obesity (n = 666; 76%) with a median BMI z score of 2.45 (interquartile range [IQR]: 2.2-2.7). Median alanine aminotransferase level at presentation was 64 U/L (IQR: 42-95). A clinically indicated liver biopsy was performed in 358 children (40%) at a median of 6 months (IQR: 1-14) post initial visit; of those, 46% had confirmed nonalcoholic steatohepatitis. Positive autoantibodies were observed in 13% of the cohort, but none met criteria for AIH. Only 19 (2%) were found to have other causes of liver disease, with no cases of viral hepatitis or Wilson disease detected. CONCLUSIONS In a large, multicenter cohort, the vast majority of children with overweight and obesity with presumed or confirmed NAFLD tested negative for other causes of liver disease. In contrast to a previous pediatric report, no patient was diagnosed with AIH.
Collapse
Affiliation(s)
- Toshifumi Yodoshi
- Division of Gastroenterology, Hepatology and Nutrition, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
| | - Sarah Orkin
- Division of Gastroenterology, Hepatology and Nutrition, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
| | - Ana Catalina Arce-Clachar
- Division of Gastroenterology, Hepatology and Nutrition, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio;,Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, Ohio; and
| | - Kristin Bramlage
- Division of Gastroenterology, Hepatology and Nutrition, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
| | - Stavra A. Xanthakos
- Division of Gastroenterology, Hepatology and Nutrition, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio;,Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, Ohio; and
| | - Pamela L. Valentino
- Section of Gastroenterology and Hepatology, Department of Pediatrics, School of Medicine, Yale University, New Haven, Connecticut
| | - Marialena Mouzaki
- Division of Gastroenterology, Hepatology and Nutrition, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio; .,Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, Ohio; and
| |
Collapse
|
29
|
Yodoshi T, Orkin S, Arce-Clachar AC, Bramlage K, Xanthakos SA, Mouzaki M, Valentino PL. Significance of autoantibody seropositivity in children with obesity and non-alcoholic fatty liver disease. Pediatr Obes 2021; 16:e12696. [PMID: 32638543 PMCID: PMC8006542 DOI: 10.1111/ijpo.12696] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [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: 10/09/2019] [Revised: 05/11/2020] [Accepted: 06/05/2020] [Indexed: 12/16/2022]
Abstract
BACKGROUND Autoantibodies are frequently positive in adults with nonalcoholic fatty liver disease (NAFLD) without concurrent autoimmune hepatitis (AIH). The clinical significance of this is unknown in children. OBJECTIVE To determine the prevalence of autoantibody positivity in pediatric NAFLD and to evaluate its association with disease severity. METHODS Multicenter, retrospective study of patients ≤18 years of age with biopsy-confirmed NAFLD. Descriptive statistics were used and groups were compared using Wilcoxon-Mann Whitney or χ2 testing, and multivariable logistic regression was used for binary or ordinal outcomes. RESULTS One hundred and thirty six patients with a median age of 14 years were included. The median body mass index Z-score was 2.5 (interquartile range 2.2, 2.6). Positive antinuclear antibody (ANA), anti-smooth muscle antibody (ASMA), anti-liver-kidney microsomal antibody, or any combination of autoantibodies were observed in 22%, 14%, 0%, and 33% of patients, respectively. The proportion of patients with a steatosis score ≥2 was significantly higher in those with positive ANA (P = .045). In the multivariable regression analysis, positive ANA was associated with increased odds of steatosis score ≥2 (odds ratio, 5.91; 95% confidential interval, 1.50-23.26), after controlling for potential confounders. No other significant histology differences were seen between the groups. CONCLUSIONS Positive ANA and ASMA are common in children with NAFLD; however, anti-LKM positivity is not. ANA positivity is associated with more severe steatosis.
Collapse
Affiliation(s)
- Toshifumi Yodoshi
- Division of Gastroenterology, Hepatology and Nutrition, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
| | - Sarah Orkin
- Division of Gastroenterology, Hepatology and Nutrition, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
| | - Ana Catalina Arce-Clachar
- Division of Gastroenterology, Hepatology and Nutrition, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Kristin Bramlage
- Division of Gastroenterology, Hepatology and Nutrition, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
| | - Stavra A. Xanthakos
- Division of Gastroenterology, Hepatology and Nutrition, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Marialena Mouzaki
- Division of Gastroenterology, Hepatology and Nutrition, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Pamela L. Valentino
- Section of Gastroenterology and Hepatology, Department of Pediatrics, Yale University School of Medicine, New Haven, Connecticut
| |
Collapse
|
30
|
Orkin S, Yodoshi T, Sun Q, Fei L, Meryum S, Arce-Clachar AC, Bramlage K, Beck AF, Mouzaki M. Can Baseline Characteristics be Used to Predict Liver Disease Outcomes in Pediatric Nonalcoholic Fatty Liver Disease? Obesity (Silver Spring) 2021; 29:171-176. [PMID: 33185977 PMCID: PMC7902314 DOI: 10.1002/oby.22999] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [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: 06/22/2020] [Revised: 07/13/2020] [Accepted: 07/31/2020] [Indexed: 12/16/2022]
Abstract
OBJECTIVE Longitudinal studies on childhood predictors of nonalcoholic fatty liver disease (NAFLD) progression are lacking. The objective of this study was to determine whether baseline clinical or laboratory measures predict liver disease outcomes in a pediatric NAFLD cohort. METHODS A retrospective study of patients with presumed NAFLD was conducted using baseline and follow-up clinical and laboratory measures. Disease outcomes were defined using the mean serum alanine aminotransferase (ALT) levels from 24 to 36 months after the first visit. Logistic regression assessed the relationship between ALT progression/regression and predictor variables. Multivariable regression determined the best model for predicting the ALT outcome. Markov process modeling explored the likelihood for a patient to transition between ALT states. RESULTS Of a total of 816 patients identified, 144 had sufficient data. Regression was seen in 26%, whereas 30% progressed. No baseline clinical or laboratory measurements had a significant effect on disease outcomes. Markov modeling demonstrated that subjects were more likely to either remain in their baseline ALT group or worsen rather than improve. CONCLUSIONS Routinely obtained baseline clinical or laboratory measures cannot help risk-stratify youth with presumed NAFLD in terms of long-term outcomes. Close clinical, radiographic, and histologic evaluation of patients is warranted to determine those at risk of progression.
Collapse
Affiliation(s)
- Sarah Orkin
- Division of Gastroenterology, Hepatology and Nutrition, Cincinnati Children’s Hospital Medical Center
| | - Toshifumi Yodoshi
- Division of Gastroenterology, Hepatology and Nutrition, Cincinnati Children’s Hospital Medical Center
| | - Qin Sun
- Division of Biostatistics and Epidemiology, Cincinnati Children’s Hospital Medical Center
| | - Lin Fei
- Division of Biostatistics and Epidemiology, Cincinnati Children’s Hospital Medical Center
- Department of Pediatrics, University of Cincinnati College of Medicine
| | - Syeda Meryum
- Division of Gastroenterology, Hepatology and Nutrition, Cincinnati Children’s Hospital Medical Center
| | - Ana Catalina Arce-Clachar
- Division of Gastroenterology, Hepatology and Nutrition, Cincinnati Children’s Hospital Medical Center
- Department of Pediatrics, University of Cincinnati College of Medicine
| | - Kristin Bramlage
- Division of Gastroenterology, Hepatology and Nutrition, Cincinnati Children’s Hospital Medical Center
| | - Andrew F. Beck
- Department of Pediatrics, University of Cincinnati College of Medicine
- James M. Anderson Center for Health Systems Excellence, Cincinnati Children’s Hospital Medical Center
- Division of General and Community Pediatrics, Cincinnati Children’s Hospital Medical Center
- Division of Hospital Medicine, Cincinnati Children’s Hospital Medical Center
| | - Marialena Mouzaki
- Division of Gastroenterology, Hepatology and Nutrition, Cincinnati Children’s Hospital Medical Center
- Department of Pediatrics, University of Cincinnati College of Medicine
| |
Collapse
|
31
|
Abstract
Nonalcoholic fatty liver disease (NAFLD) is a highly prevalent, dynamic disease that occurs across the age spectrum and can lead to cirrhosis and hepatocellular carcinoma. There are currently no US Food and Drug Administration (FDA) approved treatments for NAFLD; however, this is a field of active research. This review summarizes emerging pharmacotherapies for the treatment of adult and pediatric NAFLD. Investigated pharmacotherapies predominantly target bile acid signaling, insulin resistance, and lipid handling within the liver. Three drugs have gone on to phase III trials for which results are available. Of those, obeticholic acid is the single agent that demonstrates promise according to the interim analyses of the REGENERATE trial. Obeticholic acid showed reduction of fibrosis in adults with nonalcoholic steatohepatitis (NASH) taking 25 mg daily for 18 months (n = 931, reduction in fibrosis in 25% vs. 12% placebo, P < 0.01). Ongoing phase III trials include REGENERATE and MAESTRO‐NASH, which investigates thyroid hormone receptor‐β agonist MGL‐3196. Outcomes of promising phase II trials in adults with NASH are also available and those have investigated agents, including the fibroblast growth factor (FGF)19 analogue NGM282, the GLP1 agonist liraglutide, the FGF21 analogue Pegbelfermin, the sodium glucose co‐transporter 2 inhibitor Empagliflozin, the ketohexokinase inhibitor PF‐06835919, the acetyl‐coenzyme A carboxylase inhibitor GS‐0976, and the chemokine receptor antagonist Cenicriviroc. Completed and ongoing clinical trials emphasize the need for a more nuanced understanding of the phenotypes of subgroups within NAFLD that may respond to an individualized approach to pharmacotherapy.
Collapse
Affiliation(s)
- Suzanna L Attia
- Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, University of Kentucky College of Medicine, University of Kentucky, Lexington, Kentucky, USA
| | - Samir Softic
- Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, University of Kentucky College of Medicine, University of Kentucky, Lexington, Kentucky, USA.,Department of Pharmacology and Nutritional Sciences, University of Kentucky College of Medicine, Lexington, Kentucky, USA.,Section on Integrative Physiology and Metabolism, Joslin Diabetes Center, Harvard Medical School, Boston, Massachusetts, 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
| |
Collapse
|
32
|
Yodoshi T, Orkin S, Arce Clachar AC, Bramlage K, Sun Q, Fei L, Beck AF, Xanthakos SA, Trout AT, Mouzaki M. Muscle Mass Is Linked to Liver Disease Severity in Pediatric Nonalcoholic Fatty Liver Disease. J Pediatr 2020; 223:93-99.e2. [PMID: 32711755 PMCID: PMC8017767 DOI: 10.1016/j.jpeds.2020.04.046] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [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: 09/16/2019] [Revised: 03/31/2020] [Accepted: 04/16/2020] [Indexed: 12/11/2022]
Abstract
OBJECTIVE To investigate the association between muscle mass and liver disease severity in pediatric patients with non-alcoholic fatty liver disease (NAFLD). STUDY DESIGN This was a retrospective study of patients aged <20 years followed from 2009 to 2018. Muscle mass was estimated in all patients by measuring magnetic resonance imaging-based total psoas muscle surface area (tPMSA) and correcting for height (tPMSA index = tPMSA/height2). Two cohorts were studied, one with histological confirmation of NAFLD (n = 100) and the other with magnetic resonance imaging (MRI) evidence of hepatic steatosis (n = 236). Histology was scored using Nonalcoholic Steatohepatitis Clinical Research Network (NASH CRN) criteria. MRI-measured proton density fat fraction (PDFF) and liver stiffness were collected. Demographic, clinical, and socioeconomic status (using a validated Community Deprivation Index [CDI]) were assessed as covariates. Univariate regression analyses, followed by multivariable regression analyses, were used to determine the relationships between tPMSA index and NAS, MRI-PDFF, and liver stiffness, adjusting for clinical, demographic, and CDI variables. RESULTS In the multivariable regression analyses, higher steatosis score was associated with a lower tPMSA index (OR, 0.73; 95% CI, 0.56-0.96) and younger age (OR, 0.84; 95% CI, 0.73-0.97). Liver PDFF was also significantly associated with the tPMSA index (P = .029), sex (P = .019), and CDI (P = .005). In contrast, liver stiffness was not associated with tPMSA in multivariable analyses. CONCLUSIONS tPMSA index was independently associated with both imaging and histological features of hepatic steatosis severity in children. Future studies should directly explore the presence and directionality of causative links between muscle mass and steatosis, as well as whether interventions that enhance muscle mass can reduce disease severity in children with NAFLD.
Collapse
Affiliation(s)
- Toshifumi Yodoshi
- Division of Gastroenterology, Hepatology, and Nutrition, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH
| | - Sarah Orkin
- Division of Gastroenterology, Hepatology, and Nutrition, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH
| | - Ana-Catalina Arce Clachar
- Division of Gastroenterology, Hepatology, and Nutrition, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH,Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH
| | - Kristin Bramlage
- Division of Gastroenterology, Hepatology, and Nutrition, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH
| | - Qin Sun
- Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH,Division of Biostatistics and Epidemiology, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH
| | - Lin Fei
- Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH,Division of Biostatistics and Epidemiology, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH
| | - Andrew F. Beck
- Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH,James M. Anderson Center for Health Systems Excellence, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH,Division of General and Community Pediatrics, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH,Division of Hospital Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH
| | - Stavra A. Xanthakos
- Division of Gastroenterology, Hepatology, and Nutrition, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH,Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH
| | - Andrew T. Trout
- Department of Radiology, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH
| | - Marialena Mouzaki
- Division of Gastroenterology, Hepatology, and Nutrition, University of Cincinnati College of Medicine, Cincinnati, OH; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH.
| |
Collapse
|
33
|
Yodoshi T, Arce-Clachar AC, Sun Q, Fei L, Bramlage K, Xanthakos SA, Flores F, Mouzaki M. Glomerular Hyperfiltration Is Associated with Liver Disease Severity in Children with Nonalcoholic Fatty Liver Disease. J Pediatr 2020; 222:127-133. [PMID: 32381466 PMCID: PMC8218655 DOI: 10.1016/j.jpeds.2020.03.038] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [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: 12/10/2019] [Revised: 02/20/2020] [Accepted: 03/17/2020] [Indexed: 02/07/2023]
Abstract
OBJECTIVES To determine the prevalence of renal impairment in a large cohort of youths with histologically confirmed nonalcoholic fatty liver disease (NAFLD), and to determine its association with liver disease severity. STUDY DESIGN Clinical, laboratory, and histology data were collected retrospectively in a pediatric cohort with biopsy-confirmed NAFLD at a tertiary care center between 2010 and 2017. Histological NAFLD severity was scored using validated criteria. Glomerular filtration rate (GFR) was calculated and categorized as low (<90 mL/min/1.73 m2), normal (90-136 mL/min/1.73 m2), or high (>136 mL/min/1.73 m2). Univariate and multivariate modeling were used to determine differences between the GFR groups and to control for confounders. RESULTS The cohort comprised 179 patients (82% non-Hispanic; median age; 14 years; IQR, 12-16 years). One-third of the patients had abnormal renal function, including 36 (20%) with glomerular hyperfiltration and 26 (15%) with low GFR. In multivariable logistic regression, compared with normal GFR, hyperfiltration was independently associated with higher NAFLD activity score (aOR, 2.96; 95% CI, 1.49-5.87; P = .002), after adjusting for age, sex, ethnicity, obesity severity, presence of type 2 diabetes mellitus, and medications. CONCLUSIONS In this large cohort with histologically confirmed NAFLD, renal impairment was highly prevalent and associated with liver disease severity, independent of obesity severity. Screening patients with confirmed NAFLD for renal complication is recommended.
Collapse
Affiliation(s)
- Toshifumi Yodoshi
- Division of Gastroenterology, Hepatology, and Nutrition, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH
| | - Ana Catalina Arce-Clachar
- Division of Gastroenterology, Hepatology, and Nutrition, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH,Department of Pediatrics, University of Cincinnati School of Medicine, Cincinnati, OH
| | - Qin Sun
- Division of Biostatistics and Epidemiology, Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH
| | - Lin Fei
- Department of Pediatrics, University of Cincinnati School of Medicine, Cincinnati, OH,Division of Biostatistics and Epidemiology, Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH
| | - Kristin Bramlage
- Division of Gastroenterology, Hepatology, and Nutrition, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH
| | - Stavra A. Xanthakos
- Division of Gastroenterology, Hepatology, and Nutrition, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH,Department of Pediatrics, University of Cincinnati School of Medicine, Cincinnati, OH
| | - Francisco Flores
- Department of Pediatrics, University of Cincinnati School of Medicine, Cincinnati, OH,Division of Nephrology and Hypertension, Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH
| | - Marialena Mouzaki
- Division of Gastroenterology, Hepatology, and Nutrition, Cincinnati Children's Hospital Medical Center, Cincinnati, OH; Department of Pediatrics, University of Cincinnati School of Medicine, Cincinnati, OH.
| |
Collapse
|
34
|
Seth A, Orkin S, Yodoshi T, Liu C, Fei L, Hardy J, Trout AT, Clachar ACA, Bramlage K, Xanthakos S, Mouzaki M. Severe obesity is associated with liver disease severity in pediatric non-alcoholic fatty liver disease. Pediatr Obes 2020; 15:e12581. [PMID: 31657145 PMCID: PMC8006543 DOI: 10.1111/ijpo.12581] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2019] [Accepted: 09/08/2019] [Indexed: 12/30/2022]
Abstract
BACKGROUND Paediatric non-alcoholic fatty liver disease (NAFLD) is highly prevalent among children with obesity. The primary objective of this study was determining whether obesity severity is associated with NAFLD severity. By using paediatric classifications for severe obesity, clinicians may be able to better risk stratify patients, which in turn would guide more effective management and treatment. METHODS Retrospective cohort study including patients followed at Cincinnati Children's Medical Center for NAFLD. Patients were categorized as overweight or class I, II, III obese based on established body mass index (BMI) cut-offs. Liver disease severity was determined using biochemical, imaging (magnetic resonance elastography [MRE]), and histologic evidence of liver injury. RESULTS Three cohorts were studied individually based on the method used to assess disease severity (biochemical n = 767, imaging n = 366, and histology n = 249). Between the three cohorts, there were significant differences in age, proportion of patients with class II and class III obesity, and serum alanine transaminase (ALT) levels. In the biochemistry cohort, the odds of having ALT > 80 U/L were highest in patients with class III obesity (P = .026). In the imaging cohort, liver stiffness was significantly different between BMI groups of patients (P = .001). In the histology cohort, those with class III obesity had significantly higher odds of NAFLD activity score (NAS) ≥ 5 (P = .012). DISCUSSION Obesity severity is associated with liver disease severity. Patients with more severe obesity are more likely to have more advanced liver disease, a finding that can assist in risk stratification, as well as monitoring and treatment approaches.
Collapse
Affiliation(s)
- Aradhna Seth
- Division of Digestive Disease, University of Cincinnati, Cincinnati, Ohio
| | - Sarah Orkin
- Division of Gastroenterology, Hepatology and Nutrition, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Toshifumi Yodoshi
- Division of Gastroenterology, Hepatology and Nutrition, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Chunyan Liu
- Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Lin Fei
- Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Jennifer Hardy
- Division of Gastroenterology, Hepatology and Nutrition, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Andrew T. Trout
- Department of Radiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Ana-Catalina Arce Clachar
- Division of Gastroenterology, Hepatology and Nutrition, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Kristin Bramlage
- Division of Gastroenterology, Hepatology and Nutrition, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Stavra Xanthakos
- Division of Gastroenterology, Hepatology and Nutrition, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Marialena Mouzaki
- Division of Gastroenterology, Hepatology and Nutrition, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| |
Collapse
|
35
|
Yodoshi T, Orkin S, Arce-Clachar AC, Bramlage K, Su W, Fei L, Xanthakos SA, Mouzaki M. Identifying Predictors of Response to Vitamin E for the Treatment of Pediatric Nonalcoholic Steatohepatitis. JPEN J Parenter Enteral Nutr 2020; 44:1301-1307. [PMID: 31985850 DOI: 10.1002/jpen.1766] [Citation(s) in RCA: 1] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2018] [Accepted: 11/04/2019] [Indexed: 12/22/2022]
Abstract
BACKGROUND A subset of patients with nonalcoholic steatohepatitis (NASH) respond to treatment with vitamin E. The characteristics of responders are not known. The objective of this study was to investigate the outcomes of vitamin E use in clinical practice and to determine factors associated with response to treatment. METHODS A pediatric cohort with NASH treated with vitamin E for 6-24 months was studied retrospectively. Vitamin E response was defined as alanine aminotransferase (ALT) normalization or >50% ALT reduction from baseline. Univariate and multivariate logistic regression was used to determine the predictors of response to vitamin E. Available paired liver biopsy data were analyzed to determine histologic response. RESULTS Of the 151 children prescribed vitamin E, 73 met inclusion/exclusion criteria. Of those, 28 (38%) were vitamin E responders. Higher baseline serum alkaline phosphatase (ALP) levels, steatosis grade, and Nonalcoholic Fatty Liver Disease Activity Score (NAS) were associated with response to vitamin E (ALP: odds ratio [OR], 14.1; 95% CI, 1.7-118.6; steatosis: OR 2.5; 95% CI, 1.2-5.0; NAS: OR 1.6; 95% CI, 1.1-2.4). In a multivariate logistic regression model, ALP and steatosis grade rendered an area under the curve of 0.75 (P < .001) for the prediction of response to treatment. Ballooning, NAS, and portal inflammation improved significantly with vitamin E in the subcohort (n = 15) with paired liver biopsies. CONCLUSIONS Vitamin E treatment was associated with significant ALT response in 38% of children. Baseline serum ALP levels and steatosis grade were associated with response to treatment.
Collapse
Affiliation(s)
- Toshifumi Yodoshi
- Division of Gastroenterology, Hepatology and Nutrition, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Sarah Orkin
- Division of Gastroenterology, Hepatology and Nutrition, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Ana Catalina Arce-Clachar
- Division of Gastroenterology, Hepatology and Nutrition, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA.,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Kristin Bramlage
- Division of Gastroenterology, Hepatology and Nutrition, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Weizhe Su
- Department of Mathematical Sciences, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Lin Fei
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA.,Division of Biostatistics and Epidemiology, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Stavra A Xanthakos
- Division of Gastroenterology, Hepatology and Nutrition, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA.,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Marialena Mouzaki
- Division of Gastroenterology, Hepatology and Nutrition, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA.,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| |
Collapse
|
36
|
Trout AT, Hunte DE, Mouzaki M, Xanthakos SA, Su W, Zhang B, Dillman JR. Relationship between abdominal fat stores and liver fat, pancreatic fat, and metabolic comorbidities in a pediatric population with non-alcoholic fatty liver disease. Abdom Radiol (NY) 2019; 44:3107-3114. [PMID: 31312893 DOI: 10.1007/s00261-019-02123-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
PURPOSE To define the relationship between compartmental abdominal fat stores, liver and pancreatic fat fractions, and type 2 diabetes mellitus (T2DM) in children with non-alcoholic fatty liver disease (NAFLD). METHODS This was a retrospective study of patients with NAFLD who underwent abdominal MRI between August 2015 and July 2017. Using an axial multi-echo Dixon-based sequence, liver fat fraction (LFF) and pancreatic fat fraction (PFF) were measured. The fat image was used to quantify abdominal fat depots (thickness, cross-sectional area) at the L2 vertebral level. Multivariable models with stepwise selection were created for prediction of LFF, PFF, and T2DM status based upon variables of clinical interest. RESULTS 86 patients (70% male, 25% Hispanic, 58% Caucasian, 11% African American) with a mean age of 14.2 ± 3.2 years were included. 19 (22%) patients were pre-diabetic or diabetic. Only ethnicity was a predictor of LFF (P = 0.0023) with Hispanic ethnicity associated with the highest LFF. Depending on the model, either total abdominal fat area (P = 0.0003) or patient weight (P = 0.008) were the only predictors of PFF. No patient variable predicted T2DM status. CONCLUSIONS In our population, there was an association between ethnicity and LFF, with the highest LFF in Hispanics. The presence or severity of hepatic steatosis could not be predicted based on patient size or the distribution of abdominal fat in our cohort. Neither LFF nor PFF were predictive of T2DM.
Collapse
Affiliation(s)
- Andrew T Trout
- Department of Radiology, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, MLC 5031, Cincinnati, OH, 45229, USA.
- Department of Radiology, University of Cincinnati Medical Center, Cincinnati, USA.
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, USA.
| | - David E Hunte
- Department of Radiology, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, MLC 5031, Cincinnati, OH, 45229, USA
| | - Marialena Mouzaki
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, USA
- Division of Gastroenterology, Hepatology and Nutrition, Cincinnati Children's Hospital Medical Center, Cincinnati, USA
| | - Stavra A Xanthakos
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, USA
- Division of Gastroenterology, Hepatology and Nutrition, Cincinnati Children's Hospital Medical Center, Cincinnati, USA
| | - Weizhe Su
- Department of Mathematical Sciences, University of Cincinnati, Cincinnati, USA
| | - Bin Zhang
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, USA
- Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, USA
| | - Jonathan R Dillman
- Department of Radiology, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, MLC 5031, Cincinnati, OH, 45229, USA
- Department of Radiology, University of Cincinnati Medical Center, Cincinnati, USA
| |
Collapse
|
37
|
Yodoshi T, Orkin S, Arce-Clachar AC, Bramlage K, Liu C, Fei L, El-Khider F, Dasarathy S, Xanthakos SA, Mouzaki M. Vitamin D deficiency: prevalence and association with liver disease severity in pediatric nonalcoholic fatty liver disease. Eur J Clin Nutr 2019; 74:427-435. [PMID: 31444465 DOI: 10.1038/s41430-019-0493-y] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2019] [Revised: 07/05/2019] [Accepted: 07/31/2019] [Indexed: 11/09/2022]
Abstract
BACKGROUND/OBJECTIVES To determine associations between serum 25-hydroxyvitamin D (25(OH)-D) concentrations and histologic nonalcoholic fatty liver disease (NAFLD) severity. SUBJECTS/METHODS Clinical, laboratory, and histology data were collected retrospectively in a pediatric cohort with biopsy-confirmed NAFLD. Serum 25(OH)-D concentrations were used to define vitamin D deficiency (≤20 ng/ml), insufficiency (21-30 ng/ml), and sufficiency (≥31 ng/ml). RESULTS In all, 234 patients (78% non-Hispanic, median age 14 years) were included. The majority (n = 193) were either vitamin D insufficient (50%) or deficient (32%). Eighty-four patients (36%) reported taking vitamin D supplements at the time of biopsy; serum 25(OH)-D concentrations were not higher in those supplemented. There were no differences in the demographic, clinical, and laboratory characteristics of the three vitamin D status groups. Severity of steatosis, ballooning, lobular/portal inflammation, and NAFLD activity score were also not different between the groups. The proportion of patients with significant fibrosis (stage ≥ 2) was higher in those with insufficiency (29%) compared to those who were sufficient (17%) or deficient (15%, p = 0.04). After controlling for important covariates selected from age, body mass index, ethnicity, vitamin D supplementation, and season, the insufficient group had increased odds of a higher fibrosis score compared to the sufficient group (adjusted OR, 2.04; 95%CI, 1.02-4.08). CONCLUSIONS Vitamin D deficiency and insufficiency are common in children with NAFLD, but not consistently related with histologic disease severity. Prospective longitudinal studies are needed to determine optimal dosing strategies to achieve sufficiency and to determine whether adequate supplementation has an impact on histology.
Collapse
Affiliation(s)
- Toshifumi Yodoshi
- Division of Gastroenterology, Hepatology and Nutrition, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Sarah Orkin
- Division of Gastroenterology, Hepatology and Nutrition, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Ana Catalina Arce-Clachar
- Division of Gastroenterology, Hepatology and Nutrition, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA.,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Kristin Bramlage
- Division of Gastroenterology, Hepatology and Nutrition, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Chunyan Liu
- Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Lin Fei
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA.,Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Faris El-Khider
- Division of Gastroenterology, Departments of Gastroenterology, Hepatology and Pathobiology, Cleveland Clinic, Cleveland, OH, USA
| | - Srinivasan Dasarathy
- Division of Gastroenterology, Departments of Gastroenterology, Hepatology and Pathobiology, Cleveland Clinic, Cleveland, OH, USA
| | - Stavra A Xanthakos
- Division of Gastroenterology, Hepatology and Nutrition, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA.,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Marialena Mouzaki
- Division of Gastroenterology, Hepatology and Nutrition, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA. .,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA.
| |
Collapse
|
38
|
Mouzaki M, Loomba R. Insights into the evolving role of the gut microbiome in nonalcoholic fatty liver disease: rationale and prospects for therapeutic intervention. Therap Adv Gastroenterol 2019; 12:1756284819858470. [PMID: 31258623 PMCID: PMC6591661 DOI: 10.1177/1756284819858470] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2019] [Accepted: 05/08/2019] [Indexed: 02/04/2023] Open
Abstract
Nonalcoholic fatty liver disease (NAFLD) is diagnosed across the age spectrum and contributes to significant morbidity and mortality. The pathophysiology of NAFLD is not entirely understood; however, recent evidence has implicated the intestinal microbiome. Through the effects on host appetite, energy expenditure, digestion, gene expression, intestinal permeability, as well as immune activation, a dysbiotic microbiome can contribute to the development and progression of the hepatocellular steatosis, inflammation and fibrosis seen in the context of NAFLD. As such, intestinal microbiota and products of their metabolism have been targeted as treatment approaches for NAFLD.
Collapse
Affiliation(s)
- Marialena Mouzaki
- Steatohepatitis Center, Cincinnati Children’s
Hospital Medical Center, University of Cincinnati, Cincinnati, OH, USA
| | | |
Collapse
|
39
|
Utz-Melere M, Targa-Ferreira C, Lessa-Horta B, Epifanio M, Mouzaki M, Mattos AA. Non-Alcoholic Fatty Liver Disease in Children and Adolescents: Lifestyle Change - a Systematic Review and Meta-Analysis. Ann Hepatol 2019; 17:345-354. [PMID: 29735796 DOI: 10.5604/01.3001.0011.7380] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [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] [Indexed: 02/04/2023]
Abstract
INTRODUCTION AND AIM This manuscript seeks to analyze the impact of lifestyle changes on body mass index (BMI), aminotransferases and steatosis in children and adolescents with nonalcoholic fatty liver disease (NAFLD). MATERIALS AND METHODS A review of PubMed, BIREME, Scopus, EMBASE, Medline and Web of Science databases 2015 was performed seeking studies addressing the impact of lifestyle interventions on children and/or adolescents with NAFLD. Inclusion were manuscripts written in Portuguese, English and Spanish, as well as age less than 18 years. Two reviewers performed the data extraction independently and differences were resolved by consensus. Outcome measures were BMI, serum aminotransferase levels and the presence of hepatic steatosis. RESULTS The literature search identified 71,012 articles. After excluding 46,397 duplicates and other clearly irrelevant studies, 89 publications were reviewed in detail. Another 55 studies were excluded at this stage. Subsequently, 18 were excluded due to lack of data and three new articles were found in the review of the references of previously identified manuscripts. Therefore, 19 studies that had evaluated 923 subjects (477 boys and 446 girls) aged 6-18 years were included in the review. In most studies, the intervention included aerobic exercise and diet. In nine studies, BMI improved significantly following the intervention. The vast majority of studies reported a benefit from the intervention on aminotransferase levels. Lifestyle changes also had a significant impact on steatosis, reducing the risk by 61%. CONCLUSIONS Lifestyle changes lead to significant improvements in BMI, aminotransferase levels and hepatic steatosis in children and adolescents with NAFLD.
Collapse
Affiliation(s)
- Melina Utz-Melere
- Santo Antônio Hospital, Santa Casa de Misericordia Complex of Porto Alegre/RS, Brazil
| | | | | | - Matias Epifanio
- Santo Antônio Hospital, Santa Casa de Misericordia Complex of Porto Alegre/RS, Brazil
| | - Marialena Mouzaki
- Department of Pediatrics, Division of Gastroenterology, Hepatology and Nutrition, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Angelo A Mattos
- Federal University of Health Sciences of Porto Alegre (UFCSPA), Brazil
| |
Collapse
|
40
|
Mouzaki M, Shah A, Arce-Clachar AC, Hardy J, Bramlage K, Xanthakos SA. Extremely low levels of low-density lipoprotein potentially suggestive of familial hypobetalipoproteinemia: A separate phenotype of NAFLD? J Clin Lipidol 2019; 13:425-431. [DOI: 10.1016/j.jacl.2019.02.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2018] [Revised: 01/23/2019] [Accepted: 02/07/2019] [Indexed: 12/25/2022]
|
41
|
Mouzaki M, Trout AT. Virtual Reality: New Insights Regarding the Prevalence of Nonalcoholic Fatty Liver Disease in Children and Adolescents with Obesity Using Magnetic Resonance Imaging. J Pediatr 2019; 207:8-10. [PMID: 30922506 DOI: 10.1016/j.jpeds.2018.12.025] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2018] [Accepted: 12/06/2018] [Indexed: 12/22/2022]
Affiliation(s)
- 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.
| | - Andrew T Trout
- Department of Radiology, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio
| |
Collapse
|
42
|
Clerc P, Mouzaki M, Goldman RD. Omega-3 for nonalcoholic fatty liver disease in children. Can Fam Physician 2019; 65:34-38. [PMID: 30674511 PMCID: PMC6347303] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
Question An overweight 12-year-old male patient with nonalcoholic fatty liver disease has had little improvement in liver steatosis or triglyceride levels over the past 2 years. Is omega-3 supplementation useful in managing his condition?Answer Nonalcoholic fatty liver disease in children is prevalent in the Canadian population and can lead to liver fibrosis, cirrhosis, transplant, and reduced life expectancy. There is no recommended pharmacologic treatment of nonalcoholic fatty liver disease. Omega-3 fatty acids are associated with small improvements in liver steatosis and triglyceride concentrations. There are conflicting results with regard to liver function test results and insulin resistance, and while there might be histologic improvement revealed on biopsy, there is little evidence that fibrosis is improved. In children who have struggled to be consistent with the changes needed in their diet, particularly those with elevated triglyceride levels, there might be a role for omega-3 supplementation while continuing to focus on the mainstays of treatment (diet and physical activity); however, further research is still needed.
Collapse
|
43
|
Lowe H, Segal S, Mouzaki M, Langos V, Dlamini N. Successful Management of Ketogenic Parenteral Nutrition: A Pediatric Case Study. JPEN J Parenter Enteral Nutr 2018; 43:815-818. [PMID: 30570167 DOI: 10.1002/jpen.1490] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2018] [Accepted: 11/13/2018] [Indexed: 12/15/2022]
Affiliation(s)
- Helen Lowe
- Clinical Dietetics, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Stacey Segal
- Clinical Dietetics, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Marialena Mouzaki
- Cincinnati Children's Hospital Medical Center, Division of Gastroenterology, Hepatology, and Nutrition, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Veronika Langos
- Clinical Dietetics, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Nomazulu Dlamini
- Division of Neurology, The Hospital for Sick Children, Toronto, Ontario, Canada
| |
Collapse
|
44
|
Mouzaki M, Trout AT, Arce-Clachar AC, Bramlage K, Kuhnell P, Dillman JR, Xanthakos S. Assessment of Nonalcoholic Fatty Liver Disease Progression in Children Using Magnetic Resonance Imaging. J Pediatr 2018; 201:86-92. [PMID: 30041934 PMCID: PMC6429948 DOI: 10.1016/j.jpeds.2018.05.024] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [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: 02/01/2018] [Revised: 04/16/2018] [Accepted: 05/15/2018] [Indexed: 12/14/2022]
Abstract
OBJECTIVE To assess liver disease progression using paired magnetic resonance imaging (MRI) measurements of liver fat fraction (FF) and stiffness. STUDY DESIGN Retrospective cohort study including patients with nonalcoholic fatty liver disease who had undergone repeat MRI studies. Descriptive statistics were used, as well as Pearson or Spearman correlation when appropriate. Mixed model analyses were used to determine relationships between liver FF/stiffness and predictor variables. RESULTS Sixty-five patients (80% non-Hispanic, mean age 14 ± 3 years) were included. Time from first to last MRI was 27 ± 14 months. Over time, body mass index z score remained stable, and there were no significant differences in mean serum aminotransferases, insulin, glucose, triglycerides, low-density lipoprotein, and high-density lipoprotein (HDL) levels. However, the proportion of patients with alanine aminotransferase (ALT) < 50 U/L increased. MRI FF and stiffness decreased in 29% and 20% of patients, respectively, and increased in 25% and 22% of patients, respectively. There was a weak positive correlation between FF change and ALT change (r = 0.41, P = .053) and a moderate negative correlation between change in FF and change in serum HDL levels (r = -0.58, P = .004). After adjusting for HDL, increase in serum insulin was the only variable predictive of increase in FF (P = .061). There was no correlation between change in liver stiffness and change in ALT (r = .02, P = .910). CONCLUSIONS MRI-determined hepatic FF and stiffness improved in a minority of patients overtime. ALT levels were not reflective of the change in FF or stiffness. MRI-based imaging is complementary in the assessment of NAFLD progression.
Collapse
Affiliation(s)
- Marialena Mouzaki
- Division of Gastroenterology, Hepatology and Nutrition, Cincinnati Children's Hospital Medical Center, Cincinnati, OH; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH.
| | - Andrew T. Trout
- Department of Radiology, Cincinnati Children’s Hospital Medical Center
| | - Ana Catalina Arce-Clachar
- Division of Gastroenterology, Hepatology and Nutrition, Cincinnati Children’s Hospital Medical Center,Department of Pediatrics, University of Cincinnati College of Medicine
| | - Kristin Bramlage
- Division of Gastroenterology, Hepatology and Nutrition, Cincinnati Children’s Hospital Medical Center,Department of Pediatrics, University of Cincinnati College of Medicine
| | - Pierce Kuhnell
- Department of Biostatistics and Epidemiology, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH
| | | | - Stavra Xanthakos
- Division of Gastroenterology, Hepatology and Nutrition, Cincinnati Children’s Hospital Medical Center,Department of Pediatrics, University of Cincinnati College of Medicine
| |
Collapse
|
45
|
Dhaliwal J, Chavhan GB, Lurz E, Shalabi A, Yuen N, Williams B, Martincevic I, Amirabadi A, Wales PW, Lee W, Ling SC, Mouzaki M. Hepatic steatosis is highly prevalent across the paediatric age spectrum, including in pre-school age children. Aliment Pharmacol Ther 2018; 48:556-563. [PMID: 29998462 DOI: 10.1111/apt.14900] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2018] [Revised: 05/21/2018] [Accepted: 06/16/2018] [Indexed: 02/06/2023]
Abstract
BACKGROUND The prevalence of non-alcoholic fatty liver disease (NAFLD) in children is 8% in the general population, and 34% in the context of obesity. There is a paucity of data on the prevalence of hepatic steatosis in healthy children in Ontario. AIMS To determine the prevalence of hepatic steatosis using abdominal computed tomography (CT) scans in a cohort of previously healthy children across the paediatric age spectrum in Ontario, Canada, and to determine any association between measures of abdominal adiposity and hepatic steatosis. METHODS Retrospective review of the SickKids Trauma Database from 2004-2015. Previously healthy children ages 1-17 years having undergone an abdominal CT scan as a part of routine trauma assessment were included, and those with an intra-abdominal injury excluded. Steatosis was defined as a difference between liver and spleen attenuation ≤-25HU. The percentage of the total area occupied by abdominal subcutaneous adipose and visceral adipose tissue was measured. Anthropometrics and baseline demographics were collected. RESULTS A total of 503 (51% male) children with mean (±SD) age 9.5 ± 4.5 years and weight z-score of 0.37 ± 1.05 were studied. Seventy-seven (15%, 95% CI [12%-18%]) had hepatic steatosis; no differences found between sexes or across age quartiles. The abdominal subcutaneous adipose tissue area was greater in those with hepatic steatosis compared to those without (32% [22-42] vs 24% [17-36], P = 0.003). The visceral adipose tissue area was significantly greater in older children ≥9.8 years with hepatic steatosis (7.7% [5.1-10] vs 6.6% (4.9-8.5), P = 0.04). CONCLUSION Hepatic steatosis was highly prevalent in previously healthy children in Ontario, including children of pre-school age. We found an association between hepatic steatosis and abdominal subcutaneous adipose tissue, and in older children with visceral adipose tissue.
Collapse
Affiliation(s)
- J Dhaliwal
- Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, University of Toronto, Toronto, ON, Canada.,The Hospital for Sick Children, Toronto, ON, Canada
| | - G B Chavhan
- The Hospital for Sick Children, Toronto, ON, Canada.,Department of Radiology, University of Toronto, Toronto, ON, Canada
| | - E Lurz
- Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, University of Toronto, Toronto, ON, Canada.,The Hospital for Sick Children, Toronto, ON, Canada
| | - A Shalabi
- The Hospital for Sick Children, Toronto, ON, Canada.,Department of Radiology, University of Toronto, Toronto, ON, Canada
| | - N Yuen
- The Hospital for Sick Children, Toronto, ON, Canada.,Department of Radiology, University of Toronto, Toronto, ON, Canada
| | - B Williams
- Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, University of Toronto, Toronto, ON, Canada.,The Hospital for Sick Children, Toronto, ON, Canada
| | - I Martincevic
- Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, University of Toronto, Toronto, ON, Canada.,The Hospital for Sick Children, Toronto, ON, Canada
| | - A Amirabadi
- The Hospital for Sick Children, Toronto, ON, Canada.,Department of Radiology, University of Toronto, Toronto, ON, Canada
| | - P W Wales
- The Hospital for Sick Children, Toronto, ON, Canada.,Division of Pediatric General and Thoracic Surgery, Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - W Lee
- The Hospital for Sick Children, Toronto, ON, Canada.,Department of Radiology, University of Toronto, Toronto, ON, Canada
| | - S C Ling
- Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, University of Toronto, Toronto, ON, Canada.,The Hospital for Sick Children, Toronto, ON, Canada
| | - M Mouzaki
- Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati School of Medicine, Cincinnati, OH, USA
| |
Collapse
|
46
|
Abstract
BACKGROUND & AIMS Non-alcoholic fatty liver disease (NAFLD), with its increasing prevalence and association with various co-morbidities, such as diabetes, cardiovascular disease and metabolic syndrome, is a growing concern. Previously thought to predominantly affect obese individuals, NAFLD has been shown to occur in non-obese subjects. This subset of individuals, known to have 'lean NAFLD' or 'non-obese NAFLD', is also growing increasingly prevalent. We summarize the clinical manifestations, pathophysiology and management of lean NAFLD in both adult and pediatric populations. METHODS Two reviewers performed an independent, formal review and analysis of the literature (PubMed and EMBASE search until April 2018). RESULTS AND CONCLUSIONS Patients with lean NAFLD share metabolic features of insulin resistance and dyslipidemia, similar to obese patients with NAFLD. Genetic predisposition, dietary and environmental factors may play a role in the pathogenesis of lean NAFLD. Genetic and metabolic conditions should be considered as well. Currently, there are no formal recommendations for the treatment of adult or pediatric lean NAFLD; however, lifestyle changes aimed at improving overall fitness are likely to have a favorable impact.
Collapse
Affiliation(s)
- Alice Yuxin Wang
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Jasbir Dhaliwal
- Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Marialena Mouzaki
- Cincinnati Children's Hospital, University of Cincinnati, Cincinnati, OH, USA.
| |
Collapse
|
47
|
Dhaliwal J, Chavhan G, Wales P, Mouzaki M. A201 PREVALENCE OF NONALCOHOLIC FATTY LIVER DISEASE IN A COHORT OF HEALTHY CHILDREN IN ONTARIO. J Can Assoc Gastroenterol 2018. [DOI: 10.1093/jcag/gwy008.202] [Citation(s) in RCA: 0] [Impact Index Per Article: 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: 11/15/2022] Open
Abstract
Abstract
Aims
To determine the prevalence of hepatic steatosis in a cohort of previously healthy children and adolescents, with the use of abdominal computer tomography (CT).
Methods
Retrospective review of the Sickkids trauma database from (year 2004 to 2015). Inclusion criteria: previously healthy children ages 1-17yr having undergone an abdominal CT scan as a part of routine trauma assessment. Exclusion criteria: Involvement of spleen and/or liver in the injury, known metabolic condition, concurrent use of medications that could predispose to hepatic steatosis. Steatosis was defined as a liver spleen attenuation index (L/S AI) of <0.8. Anthropometrics and baseline demographics were collected. Statistical analyses were performed using Graphpad Prism 7.
Results
A total of 143 children were included in the analyses with a mean (SD) age of 7.12(4.26) years. 88 children were male (7.10(4.24) years old). The mean (SD) weight z score was 0.48 (0.97). Fifteen percent of the 137 children with a weight z-score between -2 to 2 had evidence of hepatic steatosis on imaging (using liver/spleen index <0.8). Twenty seven percent (6/22) of children with weight z-scores less than the 33rd percentile had L/S AI <0.8. An inverse correlation between weight z-scores and L/S AI was found in children >10 years (P<0.016) (Fig 1); however there was no correlation in pre-pubertal children (P<0.374).
Conclusions
Hepatic steatosis is highly prevalent in this cohort of healthy children in Ontario. Larger population based studies are needed to investigate the prevalence of hepatic steatosis in children across Canada.
Funding Agencies
None
Collapse
Affiliation(s)
- J Dhaliwal
- Hospital for Sick Children, Toronto, Toronto, ON, Canada
| | - G Chavhan
- Hospital for Sick Children, Toronto, Toronto, ON, Canada
| | - P Wales
- The Hospital for Sick Children, Toronto, ON, Canada
| | - M Mouzaki
- Gastroenterology, Toronto General Hospital, Georgetown, ON, Canada
| |
Collapse
|
48
|
Jackson JA, Konomi JV, Mendoza MV, Krasinskas A, Jin R, Caltharp S, Mouzaki M, Vos MB. Performance of fibrosis prediction scores in paediatric non-alcoholic fatty liver disease. J Paediatr Child Health 2018; 54:172-176. [PMID: 28948665 DOI: 10.1111/jpc.13689] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [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: 11/16/2016] [Revised: 05/23/2017] [Accepted: 07/21/2017] [Indexed: 01/29/2023]
Abstract
AIM Non-alcoholic fatty liver disease (NAFLD) is the leading cause of chronic liver disease in children. The phenotype of NAFLD varies widely, and non-invasive predictors of disease severity are scarce and are needed to tailor clinical management. METHODS We compared liver fibrosis by histology with proposed non-invasive predictors of fibrosis, including alanine transaminase (ALT), aspartate transaminase (AST), AST/ALT ratio, AST to platelet ratio index, fibrosis-4, paediatric NAFLD fibrosis index and paediatric NAFLD fibrosis score. RESULTS The area under the curve of scores obtained while predicting fibrosis in children with NAFLD ranged from 0.51 to 0.67. CONCLUSION The tested non-invasive fibrosis scoring systems, some of which were originally designed for adult populations, did not adequately predict fibrosis in a paediatric cohort. Further development of risk prediction scores in children are needed for the management of paediatric patients and will likely need to be developed within a large paediatric data set in order to improve specificity and sensitivity.
Collapse
Affiliation(s)
- Jasmine A Jackson
- Emory University School of Medicine, Atlanta, Georgia, United States
| | - Juna V Konomi
- Department of Paediatric Gastroenterology, Hepatology and Nutrition, Emory University School of Medicine, Emory University, Atlanta, Georgia, United States
| | - Michael V Mendoza
- Department of Paediatric Gastroenterology, Hepatology and Nutrition, Emory University School of Medicine, Emory University, Atlanta, Georgia, United States
| | - Alyssa Krasinskas
- Department of Pathology, Emory University, Atlanta, Georgia, United States
| | - Ran Jin
- Department of Paediatric Gastroenterology, Hepatology and Nutrition, Emory University School of Medicine, Emory University, Atlanta, Georgia, United States
| | - Shelley Caltharp
- Department of Pathology, Emory University, Atlanta, Georgia, United States
| | - Marialena Mouzaki
- Division of Gastroenterology, Hepatology and Nutrition, Department of Paediatrics, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Miriam B Vos
- Department of Paediatric Gastroenterology, Hepatology and Nutrition, Emory University School of Medicine, Emory University, Atlanta, Georgia, United States
| |
Collapse
|
49
|
Gallagher K, Flint A, Mouzaki M, Carpenter A, Haliburton B, Bannister L, Norgrove H, Hoffman L, Mack D, Stintzi A, Marcon M. Blenderized Enteral Nutrition Diet Study: Feasibility, Clinical, and Microbiome Outcomes of Providing Blenderized Feeds Through a Gastric Tube in a Medically Complex Pediatric Population. JPEN J Parenter Enteral Nutr 2018; 42:1046-1060. [DOI: 10.1002/jpen.1049] [Citation(s) in RCA: 58] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2017] [Revised: 10/20/2017] [Accepted: 11/02/2017] [Indexed: 12/26/2022]
Affiliation(s)
- Kelsey Gallagher
- Department of Clinical Dietetics; Hospital for Sick Children; Toronto Ontario Canada
| | - Annika Flint
- Department of Biochemistry, Microbiology and Immunology, Faculty of Medicine; University of Ottawa; Ottawa Ontario Canada
| | - Marialena Mouzaki
- Department of Pediatrics, Division of Gastroenterology, Hepatology and Nutrition, Hospital for Sick Children; University of Toronto; Toronto Ontario Canada
| | - Andrea Carpenter
- Department of Clinical Dietetics; Hospital for Sick Children; Toronto Ontario Canada
| | - Beth Haliburton
- Department of Clinical Dietetics; Hospital for Sick Children; Toronto Ontario Canada
| | - Louise Bannister
- Department of Clinical Dietetics; Hospital for Sick Children; Toronto Ontario Canada
| | - Holly Norgrove
- Department of Nursing; Hospital for Sick Children; Toronto Ontario Canada
| | - Lisa Hoffman
- Rehabilitation Services; Hospital for Sick Children; Toronto Ontario Canada
| | - David Mack
- Department of Pediatrics; Children's Hospital of Eastern Ontario and University of Ottawa; Ottawa Ontario Canada
| | - Alain Stintzi
- Department of Biochemistry, Microbiology and Immunology, Faculty of Medicine; University of Ottawa; Ottawa Ontario Canada
| | - Margaret Marcon
- Department of Pediatrics, Division of Gastroenterology, Hepatology and Nutrition, Hospital for Sick Children; University of Toronto; Toronto Ontario Canada
| |
Collapse
|
50
|
Affiliation(s)
- Marialena Mouzaki
- Division of Gastroenterology, Hepatology and Nutrition Department of Pediatrics Hospital for Sick Children Toronto, Ontario, Canada.
| | - Simon C Ling
- Division of Gastroenterology, Hepatology and Nutrition Department of Pediatrics Hospital for Sick Children Toronto, Ontario, Canada
| |
Collapse
|