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Duseja A, Singh S, De A, Madan K, Rao PN, Shukla A, Choudhuri G, Saigal S, Shalimar, Arora A, Anand AC, Das A, Kumar A, Eapen CE, Devadas K, Shenoy KT, Panigrahi M, Wadhawan M, Rathi M, Kumar M, Choudhary NS, Saraf N, Nath P, Kar S, Alam S, Shah S, Nijhawan S, Acharya SK, Aggarwal V, Saraswat VA, Chawla YK. Indian National Association for Study of the Liver (INASL) Guidance Paper on Nomenclature, Diagnosis and Treatment of Nonalcoholic Fatty Liver Disease (NAFLD). J Clin Exp Hepatol 2023; 13:273-302. [PMID: 36950481 PMCID: PMC10025685 DOI: 10.1016/j.jceh.2022.11.014] [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: 03/24/2022] [Revised: 11/16/2022] [Accepted: 11/29/2022] [Indexed: 03/24/2023] Open
Abstract
Nonalcoholic fatty liver disease (NAFLD) is a major cause of chronic liver disease globally and in India. The already high burden of NAFLD in India is expected to further increase in the future in parallel with the ongoing epidemics of obesity and type 2 diabetes mellitus. Given the high prevalence of NAFLD in the community, it is crucial to identify those at risk of progressive liver disease to streamline referral and guide proper management. Existing guidelines on NAFLD by various international societies fail to capture the entire landscape of NAFLD in India and are often difficult to incorporate in clinical practice due to fundamental differences in sociocultural aspects and health infrastructure available in India. A lot of progress has been made in the field of NAFLD in the 7 years since the initial position paper by the Indian National Association for the Study of Liver on NAFLD in 2015. Further, the ongoing debate on the nomenclature of NAFLD is creating undue confusion among clinical practitioners. The ensuing comprehensive review provides consensus-based, guidance statements on the nomenclature, diagnosis, and treatment of NAFLD that are practically implementable in the Indian setting.
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Key Words
- AASLD, American Association for the Study of Liver Diseases
- ALD, alcohol-associated liver disease
- ALT, alanine aminotransferase
- APRI, AST-platelet ratio index
- AST, aspartate aminotransferase
- BMI, body mass index
- CAP, controlled attenuation parameter
- CHB, chronic Hepatitis B
- CHC, chronic Hepatitis C
- CK-18, Cytokeratin-18
- CKD, chronic kidney disease
- CRN, Clinical Research Network
- CVD, cardiovascular disease
- DAFLD/DASH, dual etiology fatty liver disease or steatohepatitis
- EBMT, endoscopic bariatric metabolic therapy
- ELF, enhanced liver fibrosis
- FAST, FibroScan-AST
- FIB-4, fibrosis-4
- FLIP, fatty liver inhibition of progression
- FXR, farnesoid X receptor
- GLP-1, glucagon-like peptide-1
- HCC, hepatocellular carcinoma
- INASL, Indian National Association for Study of the Liver
- LAI, liver attenuation index
- LSM, liver stiffness measurement
- MAFLD
- MAFLD, metabolic dysfunction-associated fatty liver disease
- MR-PDFF, magnetic resonance – proton density fat fraction
- MRE, magnetic resonance elastography
- MetS, metabolic syndrome
- NAFL:, nonalcoholic fatty liver
- NAFLD, nonalcoholic fatty liver disease
- NAS, NAFLD activity score
- NASH
- NASH, nonalcoholic steatohepatitis
- NCD, noncommunicable diseases
- NCPF, noncirrhotic portal fibrosis
- NFS, NAFLD fibrosis score
- NHL, non-Hodgkin's lymphoma
- NPCDCS, National Programme for Prevention and Control of Cancer, Diabetes, Cardiovascular Diseases and Stroke
- OCA, obeticholic acid
- PPAR, peroxisome proliferator activated receptor
- PTMS, post-transplant metabolic syndrome
- SAF, steatosis, activity, and fibrosis
- SGLT-2, sodium-glucose cotransporter-2
- SWE, shear wave elastography
- T2DM, DM: type 2 diabetes mellitus
- USG, ultrasound
- VAT, visceral adipose tissue
- VCTE, vibration controlled transient elastography
- fatty liver
- hepatic steatosis
- nonalcoholic steatohepatitis
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Affiliation(s)
- Ajay Duseja
- Departmentof Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - S.P. Singh
- Department of Gastroenterology, SCB Medical College, Cuttack, India
| | - Arka De
- Departmentof Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Kaushal Madan
- Max Centre for Gastroenterology, Hepatology and Endoscopy, Max Hospitals, Saket, New Delhi, India
| | - Padaki Nagaraja Rao
- Department of Hepatology, Asian Institute of Gastroenterology, Hyderabad, India
| | - Akash Shukla
- Department of Gastroenterology, Seth GSMC & KEM Hospital, Mumbai, India
| | - Gourdas Choudhuri
- Department of Gastroenterology and Hepato-Biliary Sciences, Fortis Memorial Research Institute, Gurugram, India
| | - Sanjiv Saigal
- Max Centre for Gastroenterology, Hepatology and Endoscopy, Max Hospitals, Saket, New Delhi, India
| | - Shalimar
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, New Delhi, India
| | - Anil Arora
- Institute of Liver, Gastroenterology and Pancreatico-Biliary Sciences, Sir Ganga Ram Hospital, New Delhi, India
| | - Anil C. Anand
- Department of Gastroenterology and Hepatology, Kalinga Institute of Medical Sciences, Bhubaneswar, India
| | - Ashim Das
- Department of Histopathology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Ashish Kumar
- Institute of Liver, Gastroenterology and Pancreatico-Biliary Sciences, Sir Ganga Ram Hospital, New Delhi, India
| | | | - Krishnadas Devadas
- Department of Gastroenterology, Government Medical College, Trivandrum, India
| | | | - Manas Panigrahi
- Department of Gastroenterology, All India Institute of Medical Sciences, Bhubaneswar, India
| | - Manav Wadhawan
- Institute of Liver & Digestive Diseases, BLK Super Speciality Hospital, Delhi, India
| | - Manish Rathi
- Department of Nephrology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Manoj Kumar
- Department of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, India
| | | | - Neeraj Saraf
- Department of Hepatology, Medanta, The Medicity, Gurugram, India
| | - Preetam Nath
- Department of Gastroenterology and Hepatology, Kalinga Institute of Medical Sciences, Bhubaneswar, India
| | - Sanjib Kar
- Department of Gastroenterology and Hepatology, Gastro Liver Care, Cuttack, India
| | - Seema Alam
- Department of PediatricHepatology, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Samir Shah
- Department of Hepatology, Institute of Liver Disease, HPB Surgery and Transplant, Global Hospitals, Mumbai, India
| | - Sandeep Nijhawan
- Department of Gastroenterology, Sawai Man Singh Medical College, Jaipur, India
| | - Subrat K. Acharya
- Department of Gastroenterology and Hepatology, Kalinga Institute of Medical Sciences, Bhubaneswar, India
| | - Vinayak Aggarwal
- Department of Cardiology, Fortis Memorial Research Institute, Gurugram, India
| | - Vivek A. Saraswat
- Department of Hepatology, Pancreatobiliary Sciences and Liver Transplantation, Mahatma Gandhi University of Medical Sciences and Technology, Jaipur, India
| | - Yogesh K. Chawla
- Department of Gastroenterology and Hepatology, Kalinga Institute of Medical Sciences, Bhubaneswar, India
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Romero-Cristóbal M, Clemente-Sánchez A, Ramón E, Téllez L, Canales E, Ortega-Lobete O, Velilla-Aparicio E, Catalina MV, Ibáñez-Samaniego L, Alonso S, Colón A, Matilla AM, Salcedo M, Albillos A, Bañares R, Rincón D. CT-derived liver and spleen volume accurately diagnose clinically significant portal hypertension in patients with hepatocellular carcinoma. JHEP Rep 2022; 5:100645. [PMID: 36691569 PMCID: PMC9860348 DOI: 10.1016/j.jhepr.2022.100645] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2022] [Accepted: 11/12/2022] [Indexed: 12/05/2022] Open
Abstract
Background & Aims Clinically significant portal hypertension (CSPH) is a landmark in the natural history of cirrhosis, influencing clinical decisions in patients with hepatocellular carcinoma (HCC). Previous small series suggested that splanchnic volume measurements may predict portal hypertension. We aimed to evaluate whether volumetry obtained by standard multidetector computerised tomography (MDCT) can predict CSPH in patients with HCC. Methods We included 175 patients with HCC, referred for hepatic venous pressure gradient (HVPG) evaluation, in whom contemporary MDCT was available. Liver volume, spleen volume (SV) and liver segmental volume ratio (LSVR: volume of the segments I-III/volume of the segments IV-VIII) were calculated semi-automatically from MDCT. Other non-invasive tests (NITs) were also employed. Results Volume parameters could be measured in almost 100% of cases with an excellent inter-observer agreement (intraclass correlation coefficient >0.950). SV and LSVR were independently associated with CSPH (HVPG ≥10 mmHg) and did not interact with aetiology. The volume Index (VI), calculated as the product of SV and LSVR, predicted CSPH (AUC 0.83; 95% CI 0.77-0.89). Similar results were observed in an external cohort (n = 23) (AUC 0.87; 95% CI 0.69-1.00). Setting a sensitivity and specificity of 98%, VI could have avoided 35.9% of HVPG measurements. The accuracy of VI was similar to that of other NITs. VI also accurately predicted HVPG greater than 12, 14, 16 and 18 mmHg (AUC 0.81 [95% CI 0.74-0.88], 0.84 [95% CI 0.77-0.91], 0.85 [95% CI 0.77-0.92] and 0.87 [95% CI 0.79-0.94], respectively). Conclusions Quantification of liver and spleen volumes by MDCT is a simple, accurate and reliable method of CSPH estimation in patients with compensated cirrhosis and HCC. Impact and implications An increase in portal pressure strongly impacts outcomes after surgery in patients with early hepatocellular carcinoma (HCC). Direct measurement through hepatic vein catheterization remains the reference standard for portal pressure assessment, but its invasiveness limits its application. Therefore, we evaluated the ability of CT scan-based liver and spleen volume measurements to predict portal hypertension in patients with HCC. Our results indicate that the newly described index, based on quantification of liver and spleen volume, accurately predicts portal hypertension. These results suggest that a single imaging test may be used to diagnose and stage HCC, while providing an accurate estimation of portal hypertension, thus helping to stratify surgical risks.
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Key Words
- CSPH, clinically significant portal hypertension
- DAAs, direct-acting antivirals agents
- HCC, hepatocellular carcinoma
- HVPG, hepatic venous pressure gradient
- LSPS, liver stiffness-spleen size-to-platelet ratio score
- LSVR, liver segmental volume
- LV, liver volume
- LV/SV, liver/spleen volume ratio
- MAFLD, metabolic dysfunction-associated fatty liver disease
- MDCT, multidetector computerised tomography
- NITs, non-invasive tests
- PSR, platelet count to spleen diameter ratio
- SV, spleen volume
- TE, transient elastography
- VI, volume index
- cirrhosis
- cross-sectional imaging
- hepatocellular carcinoma
- non-invasive test
- organ size
- portal hypertension
- predictive model
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Affiliation(s)
| | - Ana Clemente-Sánchez
- Liver Unit and Digestive Department, H.G.U. Gregorio Marañón, Madrid, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Instituto de Salud Carlos III, Madrid, Spain
| | - Enrique Ramón
- Department of Radiology, H.G.U. Gregorio Marañón, Madrid, Spain
| | - Luis Téllez
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Instituto de Salud Carlos III, Madrid, Spain
- Department of Gastroenterology, Hospital Universitario Ramón y Cajal, Universidad de Alcalá, Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Madrid, Spain
| | - Elena Canales
- Department of Radiology, H. U. Ramón y Cajal, Madrid, Spain
| | - Olga Ortega-Lobete
- Liver Unit and Digestive Department, H.G.U. Gregorio Marañón, Madrid, Spain
| | | | - María-Vega Catalina
- Liver Unit and Digestive Department, H.G.U. Gregorio Marañón, Madrid, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Instituto de Salud Carlos III, Madrid, Spain
| | - Luis Ibáñez-Samaniego
- Liver Unit and Digestive Department, H.G.U. Gregorio Marañón, Madrid, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Instituto de Salud Carlos III, Madrid, Spain
| | - Sonia Alonso
- Liver Unit and Digestive Department, H.G.U. Gregorio Marañón, Madrid, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Instituto de Salud Carlos III, Madrid, Spain
| | - Arturo Colón
- Liver Transplant and Hepatobiliary Surgery Unit, H.G.U. Gregorio Marañón, Madrid, Spain
| | - Ana-María Matilla
- Liver Unit and Digestive Department, H.G.U. Gregorio Marañón, Madrid, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Instituto de Salud Carlos III, Madrid, Spain
| | - Magdalena Salcedo
- Liver Unit and Digestive Department, H.G.U. Gregorio Marañón, Madrid, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Instituto de Salud Carlos III, Madrid, Spain
- School of Medicine, Universidad Complutense, Madrid, Spain
| | - Agustín Albillos
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Instituto de Salud Carlos III, Madrid, Spain
- Department of Gastroenterology, Hospital Universitario Ramón y Cajal, Universidad de Alcalá, Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Madrid, Spain
| | - Rafael Bañares
- Liver Unit and Digestive Department, H.G.U. Gregorio Marañón, Madrid, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Instituto de Salud Carlos III, Madrid, Spain
- School of Medicine, Universidad Complutense, Madrid, Spain
- Corresponding author. Address: Liver Unit, Hospital General Universitario Gregorio Marañón, Doctor Esquerdo 46, Madrid, 28007, Spain..
| | - Diego Rincón
- Liver Unit and Digestive Department, H.G.U. Gregorio Marañón, Madrid, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Instituto de Salud Carlos III, Madrid, Spain
- School of Medicine, Universidad Complutense, Madrid, Spain
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Mitchell T, Nayagam JS, Dusheiko G, Agarwal K. Health inequalities in the management of chronic hepatitis B virus infection in patients from sub-Saharan Africa in high-income countries. JHEP Rep 2022; 5:100623. [PMID: 36636709 PMCID: PMC9829705 DOI: 10.1016/j.jhepr.2022.100623] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 08/07/2022] [Revised: 10/21/2022] [Accepted: 10/24/2022] [Indexed: 11/06/2022]
Abstract
Chronic hepatitis B virus disproportionately affects migrant communities in high-income countries, reflecting increased migration from sub-Saharan Africa. Chronic hepatitis B virus is endemic in sub-Saharan Africa, yet the natural history of chronic infection experienced by patients remains incompletely understood, with evidence of variability across genotypes and regions within sub-Saharan Africa. Clinical guidelines recommending treatment thresholds are not specific to sub-Saharan African patients and are based on natural history studies from Western Pacific Asian countries. Access to standard of care treatment is available for sub-Saharan African people with chronic hepatitis B virus infection in high-income countries; however, the evidence base for these treatments was not established in this cohort and areas of uncertainty remain, particularly regarding HCC surveillance and treatment discontinuation. Participation in phase III clinical trials for chronic hepatitis B therapies is almost non-existent amongst sub-Saharan African patients, even when residing in high-income countries that participate in multicentre trials. Engagement with sub-Saharan African patients with chronic hepatitis B in high-income countries is challenging because of the stigma associated with the diagnosis, absence of routine screening systems and the complexities involved in navigating the healthcare system. Nonetheless, improved engagement is critical if we are to achieve global hepatitis B virus elimination.
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Affiliation(s)
- Tim Mitchell
- Institute of Liver Studies, King’s College Hospital, London, United Kingdom,Gastroenterology and Hepatology Department, Royal Perth Hospital, Perth, Australia,Corresponding author. Address: Gastroenterology and Hepatology Department, Level 8 A Block, Royal Perth Hospital, 197 Wellington Street, Perth, Western Australia 6000, Australia; Tel.: +61 8 9224 2179.
| | - Jeremy S. Nayagam
- Institute of Liver Studies, King’s College Hospital, London, United Kingdom,Department of Inflammation Biology, King’s College London, London, UK
| | - Geoffrey Dusheiko
- Institute of Liver Studies, King’s College Hospital, London, United Kingdom,University College London Medical School, London, UK
| | - Kosh Agarwal
- Institute of Liver Studies, King’s College Hospital, London, United Kingdom
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4
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van Kleef LA, Choi HSJ, Brouwer WP, Hansen BE, Patel K, de Man RA, Janssen HLA, de Knegt RJ, Sonneveld MJ. Metabolic dysfunction-associated fatty liver disease increases risk of adverse outcomes in patients with chronic hepatitis B. JHEP Rep 2021; 3:100350. [PMID: 34557660 PMCID: PMC8446794 DOI: 10.1016/j.jhepr.2021.100350] [Citation(s) in RCA: 44] [Impact Index Per Article: 14.7] [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: 05/05/2021] [Revised: 06/29/2021] [Accepted: 07/22/2021] [Indexed: 02/07/2023] Open
Abstract
Background & Aims A recent consensus document has defined metabolic dysfunction-associated fatty liver disease (MAFLD) as hepatic steatosis together with overweight, diabetes, and/or a combination of other metabolic risk factors. The clinical relevance of this novel diagnosis is unknown among patients with chronic hepatitis B (CHB). We studied the association between MAFLD (with or without steatohepatitis) and adverse clinical outcomes in patients with CHB. Methods We performed a retrospective long-term follow-up cohort study at 2 tertiary hospitals in patients with CHB who underwent liver biopsy. Biopsies were reassessed for steatosis, degree of fibrosis, and presence of steatohepatitis. Associations with event-free hepatocellular carcinoma (HCC)-free and transplant-free survival were explored. Results In our cohort, 1076 patients were included, median follow-up was 9.8 years (25th-75th percentile: 6.6-14.0), and 107 events occurred in 78 patients, comprising death (n = 43), HCC (n = 36), liver decompensation (n = 21), and/or liver transplantation (n = 7). MAFLD was present in 296 (27.5%) patients and was associated with reduced event-free (adjusted hazard ratio [aHR] 2.00, 95% CI 1.26-3.19), HCC-free (aHR 1.93, 95% CI 1.17-3.21), and transplant-free survival (aHR 1.80, 95% CI 0.98-3.29) in multivariable analysis. Among patients with MAFLD, the presence of steatohepatitis (p = 0.95, log-rank test) was not associated with adverse outcomes. Conclusions The presence of MAFLD in patients with CHB was associated with an increased risk for liver-related clinical events and death. Among patients with MAFLD, steatohepatitis did not increase the risk of adverse outcomes. Our findings highlight the importance of metabolic dysfunction in patients with CHB. Lay summary Recently, metabolic dysfunction-associated fatty liver disease (MAFLD) has been defined as fatty liver disease with signs of metabolic dysfunction. Among patients with chronic hepatitis B, MAFLD was associated with liver-related events and death. Metabolic health assessment should be encouraged among patients with chronic hepatitis B, especially in those with fatty liver disease.
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Key Words
- ALT, alanine aminotransferase
- Adverse clinical outcomes
- CHB
- CHB, chronic hepatitis B
- Chronic hepatitis B
- FLD, fatty liver disease
- HBV
- HCC
- HCC, hepatocellular carcinoma
- HR, hazard rate
- Hepatitis B
- Hepatocellular carcinoma
- MAFLD
- MAFLD, metabolic dysfunction-associated fatty liver disease
- Metabolic dysfunction-associated fatty liver disease
- NAFLD, non-alcoholic fatty liver disease
- NAS, NAFLD activity score
- NASH, non-alcoholic steatohepatitis
- NHANES, National Health and Nutrition Examination Survey
- P25–P75, 25th–75th percentile
- Steatohepatitis
- Survival
- ULN, upper limit of normal
- aHR, adjusted hazard rate
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Affiliation(s)
- Laurens A van Kleef
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Centre, Rotterdam, The Netherlands
| | - Hannah S J Choi
- Toronto Centre for Liver Disease, University Health Network, Toronto, Canada
| | - Willem P Brouwer
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Centre, Rotterdam, The Netherlands
| | - Bettina E Hansen
- Toronto Centre for Liver Disease, University Health Network, Toronto, Canada
| | - Keyur Patel
- Toronto Centre for Liver Disease, University Health Network, Toronto, Canada
| | - Robert A de Man
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Centre, Rotterdam, The Netherlands
| | - Harry L A Janssen
- Toronto Centre for Liver Disease, University Health Network, Toronto, Canada
| | - Robert J de Knegt
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Centre, Rotterdam, The Netherlands
| | - Milan J Sonneveld
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Centre, Rotterdam, The Netherlands
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Nachit M, Lanthier N, Rodriguez J, Neyrinck AM, Cani PD, Bindels LB, Hiel S, Pachikian BD, Trefois P, Thissen JP, Delzenne NM. A dynamic association between myosteatosis and liver stiffness: Results from a prospective interventional study in obese patients. JHEP Rep 2021; 3:100323. [PMID: 34355155 PMCID: PMC8321935 DOI: 10.1016/j.jhepr.2021.100323] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [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: 10/16/2020] [Revised: 05/14/2021] [Accepted: 05/24/2021] [Indexed: 12/12/2022] Open
Abstract
Background & Aims Retrospective cross-sectional studies linked sarcopenia and myosteatosis with metabolic dysfunction-associated fatty liver disease (MAFLD). Here, we wanted to clarify the dynamic relationship between sarcopenia, myosteatosis, and MAFLD. Methods A cohort of 48 obese patients was randomised for a dietary intervention consisting of 16 g/day of inulin (prebiotic) or maltodextrin (placebo) supplementation. Before and after the intervention, we evaluated liver steatosis and stiffness with transient elastography (TE); we assessed skeletal muscle index (SMI) and skeletal muscle fat index (SMFI) (a surrogate for absolute fat content in muscle) using computed tomography (CT) and bioelectrical impedance analysis (BIA). Results At baseline, sarcopenia was uncommon in patients with MAFLD (4/48, 8.3%). SMFI was higher in patients with high liver stiffness than in those with low liver stiffness (640.6 ± 114.3 cm2/ Hounsfield unit [HU] vs. 507.9 ± 103.0 cm2/HU, p = 0.001). In multivariate analysis, SMFI was robustly associated with liver stiffness even when adjusted for multiple confounders (binary logistic regression, p <0.05). After intervention, patients with inulin supplementation lost weight, but this was not associated with a decrease in liver stiffness. Remarkably, upon intervention (being inulin or maltodextrin), patients who lowered their SMFI, but not those who increased SMI, had a 12.7% decrease in liver stiffness (before = 6.36 ± 2.15 vs. after = 5.55 ± 1.97 kPa, p = 0.04). Conclusions Myosteatosis, but not sarcopenia, is strongly and independently associated with liver stiffness in obese patients with MAFLD. After intervention, patients in which the degree of myosteatosis decreased reduced their liver stiffness, irrespective of body weight loss or prebiotic treatment. The potential contribution of myosteatosis to liver disease progression should be investigated. Clinical Trials registration number NCT03852069. Lay summary The fat content in skeletal muscles (or myosteatosis) is strongly associated with liver stiffness in obese patients with MAFLD. After a dietary intervention, patients in which the degree of myosteatosis decreased also reduced their liver stiffness. The potential contribution of myosteatosis to liver disease progression should be investigated. Low-radiation CT scan enables muscle evaluation (quantity and composition). Muscle mass is not low in patients with MAFLD and high liver stiffness. In contrast, myosteatosis is strongly associated with liver stiffness. Lower myosteatosis after dietary intervention is associated with improved MAFLD.
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Key Words
- ALM, appendicular lean mass
- ALT, alanine aminotransferase
- AST, aspartate aminotransferase
- BIA, bioelectrical impedance analysis
- BMI, body mass index
- CAP, controlled attenuation parameter
- CT scan
- CT, computed tomography
- CTDIvol, volume CT dose index
- DEXA, dual-energy X-ray absorptiometry
- DLP, dose–length product
- FFM, fat-free mass
- HT, hypertension
- HU, Hounsfield unit
- HbA1c, haemoglobin A1c
- ITF, inulin-type fructans
- L3, third lumbar level
- Liver
- M0, baseline
- M3, end of the 3-month intervention
- MAFL, metabolic associated fatty liver
- MAFLD, metabolic dysfunction-associated fatty liver disease
- MRI, magnetic resonance imaging
- Muscle fat
- Myosteatosis
- NASH, non-alcoholic steatohepatitis
- PMI, psoas muscle index
- SMD, skeletal muscle density
- SMDpsoas, psoas muscle density
- SMFI, skeletal muscle fat index
- SMFIpsoas, psoas fat index
- SMI, skeletal muscle index
- SMIbw, SMI scaled on body weight
- SMIht2, SMI scaled on height squared
- Sarcopenia
- TE, transient elastography
- γGT, γ-glutamyl transferase
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Affiliation(s)
- Maxime Nachit
- Laboratory of Hepato-Gastroenterology, Institut de Recherche Expérimentale et Clinique, UCLouvain, Université catholique de Louvain, Brussels, Belgium.,Department of Imaging and Pathology, KU Leuven, Leuven, Belgium
| | - Nicolas Lanthier
- Laboratory of Hepato-Gastroenterology, Institut de Recherche Expérimentale et Clinique, UCLouvain, Université catholique de Louvain, Brussels, Belgium.,Service d'Hépato-Gastroentérologie, Cliniques universitaires Saint-Luc, UCLouvain, Université catholique de Louvain, Brussels, Belgium
| | - Julie Rodriguez
- Metabolism and Nutrition Research Group, Louvain Drug Research Institute, UCLouvain, Université catholique de Louvain, Brussels, Belgium
| | - Audrey M Neyrinck
- Metabolism and Nutrition Research Group, Louvain Drug Research Institute, UCLouvain, Université catholique de Louvain, Brussels, Belgium
| | - Patrice D Cani
- Metabolism and Nutrition Research Group, Louvain Drug Research Institute, UCLouvain, Université catholique de Louvain, Brussels, Belgium.,WELBIO - Walloon Excellence in Life Sciences and BIOtechnology, UCLouvain, Université catholique de Louvain, Brussels, Belgium
| | - Laure B Bindels
- Metabolism and Nutrition Research Group, Louvain Drug Research Institute, UCLouvain, Université catholique de Louvain, Brussels, Belgium
| | - Sophie Hiel
- Metabolism and Nutrition Research Group, Louvain Drug Research Institute, UCLouvain, Université catholique de Louvain, Brussels, Belgium
| | - Barbara D Pachikian
- Centre d'Investigation Clinique en Nutrition, UCLouvain, Université catholique de Louvain, Louvain-La-Neuve, Belgium
| | - Pierre Trefois
- Medical Imaging Department, Cliniques universitaires St-Luc, UCLouvain, Université catholique de Louvain, Brussels, Belgium
| | - Jean-Paul Thissen
- Pole of Endocrinology, Diabetes and Nutrition, Institut de Recherche Expérimentale et Clinique, UCLouvain, Université catholique de Louvain, Brussels, Belgium.,Service d'Endocrinologie, diabétologie et nutrition, Cliniques universitaires Saint-Luc, UCLouvain, Université catholique de Louvain, Brussels, Belgium
| | - Nathalie M Delzenne
- Metabolism and Nutrition Research Group, Louvain Drug Research Institute, UCLouvain, Université catholique de Louvain, Brussels, Belgium
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Kurosaki S, Nakagawa H, Hayata Y, Kawamura S, Matsushita Y, Yamada T, Uchino K, Hayakawa Y, Suzuki N, Hata M, Tsuboi M, Kinoshita H, Tanaka Y, Nakatsuka T, Hirata Y, Tateishi K, Koike K. Cell fate analysis of zone 3 hepatocytes in liver injury and tumorigenesis. JHEP Rep 2021; 3:100315. [PMID: 34345813 PMCID: PMC8319533 DOI: 10.1016/j.jhepr.2021.100315] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2020] [Revised: 05/04/2021] [Accepted: 05/07/2021] [Indexed: 12/13/2022] Open
Abstract
Background & Aims Liver lobules are typically subdivided into 3 metabolic zones: zones 1, 2, and 3. However, the contribution of zonal differences in hepatocytes to liver regeneration, as well as to carcinogenic susceptibility, remains unclear. Methods We developed a new method for sustained genetic labelling of zone 3 hepatocytes and performed fate tracing to monitor these cells in multiple mouse liver tumour models. Results We first examined changes in the zonal distribution of the Wnt target gene Axin2 over time using Axin2-CreERT2;Rosa26-Lox-Stop-Lox-tdTomato mice (Axin2;tdTomato). We found that following tamoxifen administration at 3 weeks of age, approximately one-third of total hepatocytes that correspond to zone 3 were labelled in Axin2;tdTomato mice; the tdTomato+ cell distribution closely matched that of the zone 3 marker CYP2E1. Cell fate analysis revealed that zone 3 hepatocytes maintained their own lineage but rarely proliferated beyond their liver zonation during homoeostasis; this indicated that our protocol enabled persistent genetic labelling of zone 3 hepatocytes. Using this system, we found that zone 3 hepatocytes generally had high neoplastic potential, which was promoted by constitutive activation of Wnt/β-catenin signalling in the pericentral area. However, the frequency of zone 3 hepatocyte-derived tumours varied depending on the regeneration pattern of the liver parenchyma in response to liver injury. Notably, Axin2-expressing hepatocytes undergoing chronic liver injury significantly contributed to liver regeneration and possessed high neoplastic potential. Additionally, we revealed that the metabolic phenotypes of liver tumours were acquired during tumorigenesis, irrespective of their spatial origin. Conclusions Hepatocytes receiving Wnt/β-catenin signalling from their microenvironment have high neoplastic potential, and Wnt/β-catenin signalling is a potential drug target for the prevention of hepatocellular carcinoma. Lay summary Lineage tracing revealed that zone 3 hepatocytes residing in the pericentral niche have high neoplastic potential. Under chronic liver injury, hepatocytes receiving Wnt/β-catenin signalling broadly exist across all hepatic zones and significantly contribute to liver tumorigenesis as well as liver regeneration. Wnt/β-catenin signalling is a potential drug target for the prevention of hepatocellular carcinoma. We developed a new method for sustained genetic labelling of Zone 3 hepatocytes. Lineage tracing revealed that Zone 3 hepatocytes generally have high neoplastic potential. The frequency of Zone 3 hepatocyte-derived tumours varied depending on the regeneration pattern of liver parenchyma. Under chronic liver injury, hepatocytes receiving Wnt/β-catenin signalling significantly contributed to tumorigenesis. Wnt/β-catenin signalling is a potential drug target for the prevention of HCC.
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Key Words
- CDAHFD, choline-deficient l-amino acid-defined, high-fat diet
- CPS1, carbamoyl phosphate synthetase 1
- CYP2E1, cytochrome P450 subfamily 2E1
- DEN, diethylnitrosamine
- GS, glutamine synthetase
- HAL, histidine ammonia lyase
- HCC, hepatocellular carcinoma
- HFD, high-fat diet
- Hepatocellular carcinoma
- IF, immunofluorescence
- ISH, in situ hybridisation
- Liver regeneration
- MAFLD, metabolic dysfunction-associated fatty liver disease
- MUP, major urinary protein
- Metabolic dysfunction-associated fatty liver disease
- Metabolic zonation
- ND, normal diet
- PIK3CATg, hepatocyte-specific transgenic mice harbouring mutant PIK3CA variant
- PP, periportal
- PV, perivenous
- RFP, red fluorescent protein
- TAM, tamoxifen
- TUNEL, terminal deoxynucleotidyl transferase-mediated deoxyuridine triphosphate nick-end labelling
- WT, wild-type
- Wnt/β-catenin signal
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Affiliation(s)
| | - Hayato Nakagawa
- Department of Gastroenterology, The University of Tokyo, Tokyo, Japan
| | - Yuki Hayata
- Department of Gastroenterology, The University of Tokyo, Tokyo, Japan
| | - Satoshi Kawamura
- Department of Gastroenterology, The University of Tokyo, Tokyo, Japan
| | - Yuki Matsushita
- Department of Gastroenterology, The University of Tokyo, Tokyo, Japan
| | - Tomoharu Yamada
- Department of Gastroenterology, The University of Tokyo, Tokyo, Japan
| | - Koji Uchino
- Department of Gastroenterology, The University of Tokyo, Tokyo, Japan
| | - Yoku Hayakawa
- Department of Gastroenterology, The University of Tokyo, Tokyo, Japan
| | - Nobumi Suzuki
- Department of Gastroenterology, The University of Tokyo, Tokyo, Japan
| | - Masahiro Hata
- Department of Gastroenterology, The University of Tokyo, Tokyo, Japan
| | - Mayo Tsuboi
- Department of Gastroenterology, The University of Tokyo, Tokyo, Japan
| | - Hiroto Kinoshita
- Division of Gastroenterology, Institute for Adult Diseases, Asahi Life Foundation, Tokyo, Japan
| | - Yasuo Tanaka
- Department of Gastroenterology, The University of Tokyo, Tokyo, Japan
| | - Takuma Nakatsuka
- Department of Gastroenterology, The University of Tokyo, Tokyo, Japan
| | - Yoshihiro Hirata
- Division of Advanced Genome Medicine, The Institute of Medical Science, The University of Tokyo, Tokyo, Japan
| | - Keisuke Tateishi
- Department of Gastroenterology, The University of Tokyo, Tokyo, Japan
| | - Kazuhiko Koike
- Department of Gastroenterology, The University of Tokyo, Tokyo, Japan
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Burra P, Becchetti C, Germani G. NAFLD and liver transplantation: Disease burden, current management and future challenges. JHEP Rep 2020; 2:100192. [PMID: 33163950 PMCID: PMC7607500 DOI: 10.1016/j.jhepr.2020.100192] [Citation(s) in RCA: 85] [Impact Index Per Article: 21.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2020] [Revised: 08/06/2020] [Accepted: 08/13/2020] [Indexed: 02/07/2023] Open
Abstract
Non-alcoholic fatty liver disease (NAFLD), specifically its progressive form non-alcoholic steatohepatitis (NASH), represents the fastest growing indication for liver transplantation in Western countries. Diabetes mellitus, morbid obesity and cardiovascular disease are frequently present in patients with NAFLD who are candidates for liver transplantation. These factors require specific evaluation, including a detailed pre-surgical risk stratification, in order to improve outcomes after liver transplantation. Moreover, in the post-transplantation setting, the incidence of cardiovascular events and metabolic complications can be amplified by immunosuppressive therapy, which is a well-known driver of metabolic alterations. Indeed, patients with NASH are more prone to developing early post-transplant complications and, in the long-term, de novo malignancy and cardiovascular events, corresponding to higher mortality rates. Therefore, a tailored multidisciplinary approach is required for these patients, both before and after liver transplantation. Appropriate candidate selection, lifestyle modifications and specific assessment in the pre-transplant setting, as well as pharmacological strategies, adjustment of immunosuppression and a healthy lifestyle in the post-transplant setting, play a key role in correct management.
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Key Words
- CKD, chronic kidney disease
- CNI, calcineurin inhibitors
- DM, diabetes mellitus
- DPP-4, dipeptidyl peptidase-4
- ELTR, European Liver Transplant Registry
- ESLD, end-stage liver disease
- GLP1 RAs, glucagon-like peptide-1 receptor agonists
- Graft survival
- HCC, hepatocellular carcinoma
- HR, hazard ratio
- Hypertension
- IRR, incidence rate ratio
- Immunosuppressant
- LT, liver transplant
- MAFLD, metabolic dysfunction-associated fatty liver disease
- Metabolic complication
- NAFLD, non-alcoholic fatty liver disease
- NASH, non-alcoholic steatohepatitis
- New-onset diabetes after transplantation
- Non-alcoholic fatty liver disease
- Non-alcoholic steatohepatitis
- OR, odds ratio
- Obesity
- Patient survival
- SGLT2, sodium-glucose co-transporter-2
- Solid organ transplantation
- UNOS, United Network for Organ Sharing
- mTORi, mammalian target of rapamycin inhibitors
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Affiliation(s)
- Patrizia Burra
- Multivisceral Transplant Unit, Department of Surgery, Oncology and Gastroenterology, University Hospital Padua, University of Padua, Padua, Italy
- Corresponding author. Address: Multivisceral Transplant Unit, Department of Surgery, Oncology and Gastroenterology, Padua University Hospital. Tel.: +39 0498212892; fax: + 390498217848.
| | - Chiara Becchetti
- Multivisceral Transplant Unit, Department of Surgery, Oncology and Gastroenterology, University Hospital Padua, University of Padua, Padua, Italy
- Hepatology, Department of Visceral Surgery and Medicine, Inselspital, University Hospital Bern, Department of Biomedical Research, University of Bern, Bern, Switzerland
| | - Giacomo Germani
- Multivisceral Transplant Unit, Department of Surgery, Oncology and Gastroenterology, University Hospital Padua, University of Padua, Padua, Italy
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