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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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Larsen FT, Hansen D, Terkelsen MK, Bendixen SM, Avolio F, Wernberg CW, Lauridsen MM, Grønkjaer LL, Jacobsen BG, Klinggaard EG, Mandrup S, Di Caterino T, Siersbæk MS, Indira Chandran V, Graversen JH, Krag A, Grøntved L, Ravnskjaer K. Stellate cell expression of SPARC-related modular calcium-binding protein 2 is associated with human non-alcoholic fatty liver disease severity. JHEP Rep 2023; 5:100615. [PMID: 36687468 PMCID: PMC9850195 DOI: 10.1016/j.jhepr.2022.100615] [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: 07/05/2022] [Revised: 09/30/2022] [Accepted: 10/15/2022] [Indexed: 11/07/2022] Open
Abstract
Background & Aims Histological assessment of liver biopsies is the gold standard for diagnosis of non-alcoholic steatohepatitis (NASH), the progressive form of non-alcoholic fatty liver disease (NAFLD), despite its well-established limitations. Therefore, non-invasive biomarkers that can offer an integrated view of the liver are needed to improve diagnosis and reduce sampling bias. Hepatic stellate cells (HSCs) are central in the development of hepatic fibrosis, a hallmark of NASH. Secreted HSC-specific proteins may, therefore, reflect disease state in the NASH liver and serve as non-invasive diagnostic biomarkers. Methods We performed RNA-sequencing on liver biopsies from a histologically characterised cohort of obese patients (n = 30, BMI >35 kg/m2) to identify and evaluate HSC-specific genes encoding secreted proteins. Bioinformatics was used to identify potential biomarkers and their expression at single-cell resolution. We validated our findings using single-molecule fluorescence in situ hybridisation (smFISH) and ELISA to detect mRNA in liver tissue and protein levels in plasma, respectively. Results Hepatic expression of SPARC-related modular calcium-binding protein 2 (SMOC2) was increased in NASH compared to no-NAFLD (p.adj <0.001). Single-cell RNA-sequencing data indicated that SMOC2 was primarily expressed by HSCs, which was validated using smFISH. Finally, plasma SMOC2 was elevated in NASH compared to no-NAFLD (p <0.001), with a predictive accuracy of AUROC 0.88. Conclusions Increased SMOC2 in plasma appears to reflect HSC activation, a key cellular event associated with NASH progression, and may serve as a non-invasive biomarker of NASH. Impact and implications Non-alcoholic fatty liver disease (NAFLD) and its progressive form, non-alcoholic steatohepatitis (NASH), are the most common forms of chronic liver diseases. Currently, liver biopsies are the gold standard for diagnosing NAFLD. Blood-based biomarkers to complement liver biopsies for diagnosis of NAFLD are required. We found that activated hepatic stellate cells, a cell type central to NAFLD pathogenesis, upregulate expression of the secreted protein SPARC-related modular calcium-binding protein 2 (SMOC2). SMOC2 was elevated in blood samples from patients with NASH and may hold promise as a blood-based biomarker for the diagnosis of NAFLD.
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Key Words
- AUROC, area under the receiver operating characteristic curve
- ECM, extracellular matrix
- HSC, hepatic stellate cells
- LSM, liver stiffness measurement
- MCP, matricellular protein
- NAFL, non-alcoholic fatty liver
- NAFLD
- NAFLD, non-alcoholic fatty liver disease
- NAS, NAFLD activity score
- NASH
- PCA, principal component analysis
- SAF, steatosis, activity, and fibrosis
- SE, sensitivity
- SMOC2
- SMOC2, SPARC-related modular calcium-binding protein 2
- SP, specificity
- SPARC, secreted protein acidic and cysteine-rich
- VSMCs, vascular smooth muscle cells
- WGCNA, weighted gene co-expression network analysis
- aHSC, activated HSC
- hepatic stellate cells
- non-invasive biomarker
- qHSC, quiescent HSC
- smFISH, single-molecule fluorescence in situ hybridisation
- transcriptomics
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Affiliation(s)
- Frederik T. Larsen
- Department of Biochemistry and Molecular Biology, University of Southern
Denmark, Odense, Denmark
- Center for Functional Genomics and Tissue Plasticity (ATLAS), University of
Southern Denmark, Odense, Denmark
| | - Daniel Hansen
- Department of Biochemistry and Molecular Biology, University of Southern
Denmark, Odense, Denmark
- Center for Functional Genomics and Tissue Plasticity (ATLAS), University of
Southern Denmark, Odense, Denmark
| | - Mike K. Terkelsen
- Department of Biochemistry and Molecular Biology, University of Southern
Denmark, Odense, Denmark
- Center for Functional Genomics and Tissue Plasticity (ATLAS), University of
Southern Denmark, Odense, Denmark
| | - Sofie M. Bendixen
- Department of Biochemistry and Molecular Biology, University of Southern
Denmark, Odense, Denmark
- Center for Functional Genomics and Tissue Plasticity (ATLAS), University of
Southern Denmark, Odense, Denmark
| | - Fabio Avolio
- Department of Biochemistry and Molecular Biology, University of Southern
Denmark, Odense, Denmark
- Center for Functional Genomics and Tissue Plasticity (ATLAS), University of
Southern Denmark, Odense, Denmark
| | - Charlotte W. Wernberg
- Center for Functional Genomics and Tissue Plasticity (ATLAS), University of
Southern Denmark, Odense, Denmark
- Department of Gastroenterology and Hepatology, University Hospital of
Southern Denmark, Esbjerg, Denmark
- Center for Liver Research (FLASH), Department of Gastroenterology and
Hepatology, Odense University Hospital, Odense, Denmark
| | - Mette M. Lauridsen
- Center for Functional Genomics and Tissue Plasticity (ATLAS), University of
Southern Denmark, Odense, Denmark
- Department of Gastroenterology and Hepatology, University Hospital of
Southern Denmark, Esbjerg, Denmark
| | - Lea L. Grønkjaer
- Department of Gastroenterology and Hepatology, University Hospital of
Southern Denmark, Esbjerg, Denmark
| | - Birgitte G. Jacobsen
- Department of Gastroenterology and Hepatology, University Hospital of
Southern Denmark, Esbjerg, Denmark
| | - Ellen G. Klinggaard
- Department of Biochemistry and Molecular Biology, University of Southern
Denmark, Odense, Denmark
- Center for Functional Genomics and Tissue Plasticity (ATLAS), University of
Southern Denmark, Odense, Denmark
| | - Susanne Mandrup
- Department of Biochemistry and Molecular Biology, University of Southern
Denmark, Odense, Denmark
- Center for Functional Genomics and Tissue Plasticity (ATLAS), University of
Southern Denmark, Odense, Denmark
| | - Tina Di Caterino
- Department of Pathology, Odense University Hospital, Odense,
Denmark
| | - Majken S. Siersbæk
- Department of Biochemistry and Molecular Biology, University of Southern
Denmark, Odense, Denmark
- Center for Functional Genomics and Tissue Plasticity (ATLAS), University of
Southern Denmark, Odense, Denmark
| | - Vineesh Indira Chandran
- Center for Functional Genomics and Tissue Plasticity (ATLAS), University of
Southern Denmark, Odense, Denmark
- Department of Molecular Medicine, University of Southern Denmark, Odense,
Denmark
| | - Jonas H. Graversen
- Center for Functional Genomics and Tissue Plasticity (ATLAS), University of
Southern Denmark, Odense, Denmark
- Department of Molecular Medicine, University of Southern Denmark, Odense,
Denmark
| | - Aleksander Krag
- Center for Functional Genomics and Tissue Plasticity (ATLAS), University of
Southern Denmark, Odense, Denmark
- Center for Liver Research (FLASH), Department of Gastroenterology and
Hepatology, Odense University Hospital, Odense, Denmark
| | - Lars Grøntved
- Department of Biochemistry and Molecular Biology, University of Southern
Denmark, Odense, Denmark
- Center for Functional Genomics and Tissue Plasticity (ATLAS), University of
Southern Denmark, Odense, Denmark
| | - Kim Ravnskjaer
- Department of Biochemistry and Molecular Biology, University of Southern
Denmark, Odense, Denmark
- Center for Functional Genomics and Tissue Plasticity (ATLAS), University of
Southern Denmark, Odense, Denmark
- Corresponding author. Address: Department of Biochemistry and Molecular
Biology, Campusvej 55, 5230 Odense M, Denmark. Tel.: +45 65508906/+45
93979317.
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