A combined association of serum uric acid, alanine aminotransferase and waist circumference with non-alcoholic fatty liver disease: a community-based study

Background

Increasing evidence has supported that serum uric acid (SUA), alanine aminotransferase (ALT) and waist circumference (WC) are associated with the occurrence of non-alcoholic fatty liver disease (NAFLD). However, the combined role of these factors in early screening of NAFLD has not been investigated. We aimed to de lineate this role in a community-based population.

Methods

Binary logistic regression was used to explore the correlations of SUA, ALT and WC with NAFLD risk. The goodness of fit and discriminative ability of the model were evaluated by the Hosmer-Lemeshow test and area under the receiver operating characteristic curve (AUROC), respectively.

Results

Logistic regression analysis indicated that elevated SUA (adjusted odds ratio (OR) = 2.44, 95% confidence interval (CI) [1.76-3.38]), ALT (adjusted OR = 4.98, 95% CI [3.41-7.27]) and WC (adjusted OR = 3.22, 95% CI [2.01-5.16]) were facilitating factors for incident NAFLD after fully adjusted for related confounders. In addition, the risk of NAFLD followed linear trend s with increasing levels of these three indicators (all P _trend < 0.001). The risk assessment model consisting of SUA, ALT, WC and demographics showed useful discrimination by AUROC being 0.825 (95% CI [0.811-0.838]) and good performance of calibration (P = 0.561).

Conclusions

SUA, ALT and WC were all associated with NAFLD, independent of known risk factors. The simple model composed of these indicators showed good performance in the Chinese population, which may be applicable for appraisal of NAFLD risk in primary healthcare.

Use of intravenous N-acetylcysteine in acute severe hepatitis due to severe dengue infection: a case series

Background

Dengue fever is a common mosquito borne viral infection. Severe dengue fever associated severe hepatitis carries high mortality. Based on the beneficial effect of N-acetylcysteine (NAC) in paracetamol poisoning and non-acetaminophen induced liver failure, it is used in dengue fever associated hepatitis in clinical practice. We aim to study the reversal of liver enzymes with NAC in the setting of severe hepatitis due to severe dengue infection.

Methods

A retrospective analysis was conducted on hospitalized 30 adults with severe dengue fever with severe hepatitis. These 30 patients had aspartate transaminase (AST) and alanine transaminases (ALT) more than 500 U/L and/or PT INR (prothrombin time and international normalized ratio) more than 1.5. They were treated with NAC infusion of 100 mg/h for 3 to 5 days.

Results

The mean age of the group was 49.9 ± 11.46 years and 18 (60%) patients were males. Nineteen patients (63%) developed dengue shock. Of them 12 patients (40%) developed hepatic encephalopathy. Median AST on the day of administration of NAC was 1125 U/L interquartile range (IQR) 1653.25 while median ALT was 752 (IQR 459.25). There was a statistically significant reduction of both ALT (p = 0.034) and AST (p = 0.049) from day 1 to 4 after NAC infusion. Rise of platelet count between day 1 and day 4 also showed statistically significant difference (p = 0.011) but the reduction of prothrombin time and international normalized ratio (PT/INR) from 1 to day 4 did not show statistical significance difference. Mean duration of treatment with NAC was 3.61 ± 0.75 days while mean length of hospital stay was 6.2 ± 1.27 days. Only one patient died (3.3%). None of the patients reported adverse drug reaction due to NAC.

Conclusion

Majority of patients demonstrated marked clinical and biochemical improvements and they recovered fully. We observed faster and significant recovery of liver enzymes following administration of NAC. Based on the above findings, this study provides preliminary evidence for the beneficial effect of NAC in severe hepatitis in dengue infection with greater survival benefits.

Retrospective study of factors associated with progression and remission/regression of diabetic kidney disease-hypomagnesemia was associated with progression and elevated serum alanine aminotransferase levels were associated with remission or regression

Aim

This study was aimed at retrospectively investigating some common clinical factors, including the serum level of magnesium (Mg), associated with progression and remission/regression of diabetic kidney disease (DKD).

Methods

The subjects were 690 Japanese patients with type 2 diabetes mellitus who were receiving treatment with oral antidiabetic drugs other than SGLT2 inhibitors. Routine clinical data were collected on the first and last day of the observation period. The prognosis of DKD is categorized into four stages according to the Kidney Disease Improving Global Outcomes classification. Progression was defined as transition from any of the lower three risk categories (LR, MIR, HR) at the start of the observation period, to the VHR stage/category at the end of the observation period. Remission/regression was defined as improvement of the risk category by at least one stage from the start to the end of the observation period. Factors associated with progression and regression/remission were investigated using Cox proportional hazards analysis. Furthermore, the factors associated with the annual decrease in eGFR of 5 ml/min/1.73 m² or more were examined by logistic regression analysis. Factors associated with transition of urinary protein negative to trace or positive, or transition of negative or trace to positive, were investigated by Cox proportional hazard analysis.

Results

The observation period was 2251 ± 1614 days. Age (Exp [B] = 1.10, 95% CI; 1.06-1.14; P < 0.01; 1 year old), serum Mg (Exp [B] = 0.82, 95% CI; 0.71-0.95; P < 0.01); 0.1 mg/dl), and serum HbA1c (Exp [B] = 1.03, 95% CI; 1.01-1.05; P < 0.01: 0.1%) were associated with progression of DKD; on the other hand, serum ALT was associated with the likelihood of remission/regression of DKD (Exp [B] = 1.01, 95% CI; 1.002-1.018; P < 0.05; 1 IU/L). The decline in eGFR was associated with higher HbA1c levels, hypomagnesemia, and lower ALT. The new appearance of trace or overt proteinuria was correlated with higher HbA1c levels, advancing age, hypomagnesemia and hypertriglycemia.

Conclusion

Our findings confirmed previous reports that advancing age and serum HbA1c levels were associated with an increased risk of progression of DKD. Lower serum Mg concentrations were also found to be associated with a high risk of progression of DKD, and interventional studies are needed to confirm a causal relationship. Elevated HbA1c levels and hypomagnesemia were common factors in the decline in eGFR and the appearance of trace or overt proteinuria. Lower serum ALT levels were associated with the decline in eGFR. Since serum ALT is known to decrease as the renal function deteriorates, serum ALT is considered to be a marker of renal function.

Supplementary Information

The online version contains supplementary material available at 10.1007/s13340-020-00483-1.

Emerging New Diagnostic Modalities and Therapies of Nonalcoholic Fatty Liver Disease

PURPOSE OF REVIEW

Nonalcoholic fatty liver disease (NAFLD) has emerged as the leading cause of chronic liver disease in both adults and children. In this article, we review recent developments in the screening, diagnosis, and treatment of pediatric NAFLD.

RECENT FINDINGS

Although alanine aminotransferase (ALT) remains the best screening test for NAFLD in children, and liver biopsy is still required for the diagnosis of nonalcoholic steatohepatitis (NASH), other noninvasive biomarker/imaging studies (MRI-PDFF and VCTE) have emerged as diagnostic methods for pediatric NAFLD. Two large clinical therapeutic trials testing vitamin E, metformin, and cysteamine in pediatric NAFLD yielded mostly inconclusive results. Bariatric surgery has begun to be used in adolescents with severe obesity. An adult phase 2 study using obeticholic acid (OCA) to treat NASH patients with fibrosis showed some positive results. As we continue to await the first FDA-approved therapeutic agent for NASH, lifestyle change remains the main modality of treatment. Newer diagnostic and treatment modalities for pediatric NAFLD continue to be in development under FDA guidance.

Effects of non-linear resistance training and curcumin supplementation on the liver biochemical markers levels and structure in older women with non-alcoholic fatty liver disease

BACKGROUND

With increasing age, non-alcoholic fatty liver disease is very common among women with low levels of physical activity. Nonlinear resistance training is one of the new methods to help patients who have low levels of physical activity. Curcumin is an herbal supplement that has anti-inflammatory effects. The present study aimed to examine the effects of nonlinear resistance training and curcumin supplementation on the liver structure and biochemical markers in obese older women with non-alcoholic fatty liver disease.

METHODS

Forty-five obese women with non-alcoholic fatty liver disease were randomly assigned into resistance training (RT), curcumin supplement (C), resistance training with curcumin supplement (RTC), and placebo (P) groups. The RT and RTC groups received 12-weeks of nonlinear resistance training while the C and P groups had a normal sedentary lifestyle. Daily, the C and RTC groups received a curcumin capsule while the P and RT groups were given a placebo capsule. Blood sampling and ultrasonography were taken before and after the protocol.

RESULTS

Alanine aminotransferase (ALT) and aspartate aminotransferase (AST) levels significantly decreased in the RT and RTC groups (P ≤ 0.05) but not in the C and P groups (P > 0.05). Alkaline phosphatase (ALP), total bilirubin (TB) levels, platelet counts (PLT), and liver structure did not significantly change in all groups (P > 0.05). Resistance training alone and with curcumin supplementation could significantly improve liver function while taking curcumin alone did not have any significant effect on it.

CONCLUSION

12-week non-linear resistance training has beneficial effects on non-alcoholic fatty liver disease in older obese women.

The outcomes of transient elevation of maternal liver enzymes preceding laser treatment for twin-twin transfusion syndrome

BACKGROUND

A proportion of twin-twin transfusion syndrome (TTTS) patients may have elevated liver enzymes (ELEzs) before fetoscopic laser therapy, but the incidence of ELEzs before laser therapy and the association with the perinatal outcomes after laser therapy remain unclear.

METHODS

From October 2008 to April 2015, 93 patients with TTTS who received fetoscopic laser therapy at our hospital were included in this study, and aspartate aminotransferase (AST) and alanine aminotransferase (ALT) levels were measured within 24 h before therapy. If ELEzs (AST > 34 U/L or ALT > 36 U/L) were observed before therapy, the AST and ALT levels were evaluated within 24 h after therapy. The pre-operative characteristics and post-therapy outcomes were compared between patients with and without ELEzs.

RESULTS

Among 93 TTTS patients before laser operation, 18 patients (were found with ELEzs (19.4%) before laser therapy. In 17 (94.4%) of the 18 cases, their liver enzymes values dropped after laser surgery. Maternal body mass index, age, gestational age of laser therapy, hemoglobin level before laser therapy and survival rates after laser therapy were not significantly different between TTTS with and without ELEzs. The maternal hemoglobin dropped significantly from 10.8 [1.6] g/dL before surgery to 9.6 [1.5] g/dL after laser therapy in TTTS with ELEzs (p < 0.001).

CONCLUSION

An elevated liver enzyme was not associated with poor perinatal outcomes in patients with TTTS after laser therapy. The authors suspected that the reduced liver enzymes values after laser therapy could partly arise from the hemo-dilution effect.

Does L-carnitine supplementation affect serum levels of enzymes mainly produced by liver? A systematic review and meta-analysis of randomized controlled clinical trials

BACKGROUND AND AIMS

L-carnitine supplementation is proposed to reduce liver enzymes levels; however, previous findings were equivocal. The current systematic review and meta-analysis of randomized controlled clinical trials (RCTs) were performed to assess the effect of L-carnitine supplementation on serum levels of enzymes mainly produced by liver [alanine aminotransferase (ALT), aspartate aminotransferase (AST), and gamma-glutamyl transpeptidase (GGTP)].

METHODS

Online databases as well as the reference lists of relevant studies were searched from inception up to June 2019. The risk of bias in individual studies was assessed using Cochrane Collaboration's tool. Data were pooled using the random-effects model and expressed as mean differences (MDs) with 95% confidence intervals (CIs).

RESULTS

In total, 18 RCTs (1161 participants) met the eligibility criteria. L-carnitine supplementation dose ranged from 500 to 4000 mg/day. L-carnitine supplementation significantly reduced serum ALT (MD = - 8.65 IU/L, 95% CI - 13.40, - 3.90), AST (MD = - 8.52 IU/L, 95% CI - 12.16, - 4.89), and GGTP (MD = - 8.80 IU/L, 95% CI - 13.67, - 3.92) levels. The subgroup analysis showed that L-carnitine might be more effective in reducing the enzymes when supplemented in higher doses (≥ 2000 mg/day), for longer durations (> 12 weeks), and among patients with liver diseases. The meta-evidence was graded as "moderate" for ALT and AST, and "low" for GGTP according to NutriGrade scoring system.

CONCLUSION

L-carnitine supplementation significantly improves circulating ALT, AST and GGTP levels; therefore, it might positively affect liver function, especially among patients with liver diseases. Further high-quality RCTs are recommended to confirm our results.

The relationship between 25-hydroxyvitamin D concentration and liver enzymes in overweight or obese adults: Cross-sectional and interventional outcomes

Vitamin D deficiency is prevalent in individuals with non-alcoholic fatty liver disease (NAFLD) and non-alcoholic steatohepatitis. However, there is limited and inconsistent data on the effect of vitamin D supplementation on liver function. Hepatic enzymes have been used as surrogate markers for NAFLD and have been associated with metabolic syndrome. We examined the relationships between 25-hydroxyvitamin D (25(OH)D) and γ-glutamyl transferase (GGT), alanine aminotransferase (ALT), alkaline phosphatase (ALP) in 120 drug-naïve individuals with no history of liver disease. In addition, the effect of vitamin D supplementation (100,000 loading dose of cholecalciferol followed by 4000IU daily for 16 weeks) on hepatic enzymes was investigated in a subgroup of 54 vitamin D-deficient overweight or obese individuals (28 randomised to cholecalciferol and 26 to placebo). Hepatic enzymes, anthropometric parameters, lipid profile, insulin sensitivity (hyperinsulinaemic-euglycaemic clamp, M value) and high sensitivity C-reactive protein (hs-CRP) were measured before and after the intervention. In the cross-sectional study, levels of GGT and ALT were higher in men compared to women (both p=0.001). There were no significant differences in GGT, ALT and ALP between vitamin D categories (25(OH)D<25nmol/L, 25-50nmol/L, and >50nmol/L) and no relationships were found between the three enzymes and 25(OH)D before and after adjustment for age, sex, BMI, WHR, and insulin sensitivity (all p>0.5). In the randomised trial, 25(OH)D concentrations increased in the vitamin D group (mean change 57.0±21.3nmol/L) compared to the placebo group (mean change 1.9±15.1nmol/L). Mean changes in GGT, ALT and ALP were not significantly different between vitamin D and placebo groups (all p>0.2). Change in 25(OH)D concentration was not correlated with changes in GGT, ALT and ALP before and after adjustments for age and sex (all p>0.1). In summary, 25(OH)D concentrations were not related to hepatic enzymes in drug-naive adults with no history of liver disease, and vitamin D supplementation had no effect on the serum levels of hepatic enzymes in vitamin D-deficient and overweight or obese, otherwise healthy individuals. Hence, vitamin D supplementation is unlikely to prevent incident NAFLD.

Genetic variants in COL13A1, ADIPOQ and SAMM50, in addition to the PNPLA3 gene, confer susceptibility to elevated transaminase levels in an admixed Mexican population

Non-alcoholic fatty liver disease (NAFLD) is the accumulation of extra fat in liver cells not caused by alcohol. Elevated transaminase levels are common indicators of liver disease, including NAFLD. Previously, we demonstrated that PNPLA3 (rs738409), LYPLAL1 (rs12137855), PPP1R3B (rs4240624), and GCKR (rs780094) are associated with elevated transaminase levels in overweight/obese Mexican adults. We investigated the association between 288 SNPs identified in genome-wide association studies and risk of elevated transaminase levels in an admixed Mexican-Mestizo sample of 178 cases of NAFLD and 454 healthy controls. The rs2896019, rs12483959, and rs3810622 SNPs in PNPLA3 and rs1227756 in COL13A1 were associated with elevated alanine aminotransferase (ALT, ≥40IU/L). A polygenic risk score (PRS) based on six SNPs in the ADIPOQ, COL13A1, PNPLA3, and SAMM50 genes was also associated with elevated ALT. Individuals carrying 9-12 risk alleles had 65.8% and 48.5% higher ALT and aspartate aminotransferase (AST) levels, respectively, than those with 1-4 risk alleles. The PRS showed the greatest risk of elevated ALT levels, with a higher level of significance than the individual variants. Our findings suggest a significant association between variants in COL13A1, ADIPOQ, SAMM50, and PNPLA3, and risk of NAFLD/elevated transaminase levels in Mexican adults with an admixed ancestry. This is the first study to examine high-density single nucleotide screening for genetic variations in a Mexican-Mestizo population. The extent of the effect of these variations on the development and progression of NAFLD in Latino populations requires further analysis.

Assessing liver proteins and enzymes of medical workers exposed to ionizing radiation (IR)

The cross-sectional study was conducted to examine hepatic function via liver enzymes/proteins assessments, along with the estimation of an inflammatory response from C-reactive protein (CRP)-which is a liver-synthesized protein. The liver function tests with aspartate aminotransferase (AST), alanine aminotransferase (ALT), alkaline phosphatase (ALP) and bilirubin (BBN), and CRP test were conducted for radiation-exposed workers-REW (n = 32) and radiation-unexposed workers-RUW (n = 21). The annual average effective doses (AAED) were measured from thermoluminescent dosimeter. A t test and bivariate correlation analyses were applied. Only one worker had a high AST value (50 U/L), one worker had a negligible high ALT value (43 U/L) and only one worker had a negligible high bilirubin value (1.3 g/dL). There were normal levels of CRP (up to 6 mg/L) in all individuals. There existed a nonsignificant difference (p < 0.050) between the mean values of liver enzymes and proteins in all exposed and unexposed workers. Nonsignificant weak correlations are reported in liver enzymes/proteins parameters: AST, ALT, ALP, BBN, CRP with the AAED range (whole-body: 0.91-3.39 mSv) during 2011-2015. The normal values of liver enzymes/proteins' (AST, ALT, ALP, BBN, CRP) values may ensure a good hepatic health of radiation-exposed medical workers with AAED range mentioned. We found that low ionizing radiation doses did not alter the liver function test parameters and did not affect the concentration of an inflammatory response protein, i.e., CRP.

Production of infectious dromedary camel hepatitis E virus by a reverse genetic system: Potential for zoonotic infection

BACKGROUND & AIMS

The pathogenicity, epidemiology and replication mechanism of dromedary camel hepatitis E virus (DcHEV), a novel hepatitis E virus (HEV), has been unclear. Here we used a reverse genetic system to produce DcHEV and examined the possibility of zoonotic infection.

METHODS

Capped genomic RNA derived from a synthetic DcHEV cDNA was transfected into human hepatocarcinoma cells PLC/PRF/5. The DcHEV capsid protein and RNA were detected by an enzyme-linked immunosorbent assay (ELISA) or RT-qPCR. A neutralization test for DcHEV was carried out by using antisera against HEV-like particles. DcHEV was used to inoculate two cynomolgus monkeys to examine the potential for cross-species infection.

RESULTS

The transfection of PLC/PRF/5 cells with capped DcHEV RNA resulted in the production of infectious DcHEV. The genome sequence analysis demonstrated that both nucleotide and amino acid changes accumulated during the passages in PLC/PRF/5 cells. The cynomolgus monkeys showed serological signs of infection when DcHEV was intravenously inoculated. DcHEV was neutralized by not only anti-DcHEV-LPs antibody, but also anti-genotype 1 (G1), G3 and G4 HEV-LPs antibodies. Moreover, the monkeys immunized with DcHEV escaped the G3 HEV challenge, indicating that the serotype of DcHEV is similar to those of other human HEVs.

CONCLUSIONS

Infectious DcHEV was produced using a reverse genetic system and propagated in PLC/PRF/5 cells. The antigenicity and immunogenicity of DcHEV are similar to those of G1, G3 and G4 HEV. DcHEV was experimentally transmitted to primates, demonstrating the possibility of a zoonotic infection by DcHEV.

LAY SUMMARY

Dromedary camel hepatitis E virus (DcHEV) was produced by a reverse genetic system and grows well in PLC/PRF/5 cells. Cynomolgus monkeys experimentally infected with DcHEV indicated serological signs of infection, suggesting that DcHEV has the potential to cause zoonotic HEV infection.

Association between PNPLA3 (rs738409), LYPLAL1 (rs12137855), PPP1R3B (rs4240624), GCKR (rs780094), and elevated transaminase levels in overweight/obese Mexican adults

There is scarce information about the link between specific single-nucleotide polymorphisms (SNPs) and risk of liver disease among Latinos, despite the disproportionate burden of disease among this population. Our aim was to investigate nine SNPs in or near the following genes: PNPLA3, LYPLAL1, PPP1R3B, GCKR, NCAN, IRS1, PPARG, and ADIPOR2 and examine their association with persistently elevated alanine aminotransferase (ALT) or aspartate aminotransferase (AST) levels in Mexican adults. Data and samples were collected from 741 participants in the Mexican Health Worker Cohort Study, in Cuernavaca, Mexico. We identified 207 cases who had persistently elevated levels of ALT or AST (≥40 U/L) and 534 controls with at least two consecutive normal ALT or AST results in a 6 month period, during 2004-2006 and 2011-2013. TaqMan assays were used to genotype the SNPs. The risk allele of PNPLA3 rs738409 was found to be associated with persistently elevated levels of ALT or AST, adjusting for age, sex, BMI, type 2 diabetes, and ancestry: (OR 2.28, 95 % CI 1.13, 4.58). A significant association was found between the LYPLAL1, PPP1R3B, and GCKR risk alleles and elevated ALT or AST levels among overweight/obese adults. These results suggest that among Mexicans, the PNPLA3 (rs738409), LYPLAL1 (rs12137855), PPP1R3B (rs4240624), and GCKR (rs780094) polymorphisms may be associated with a greater risk of chronic liver disease among overweight adults. This study is the first to examine these nine SNPs in a sample of adults in Mexico.

Estimation of Upper Limit of Normal for Serum Alanine Transaminase in Healthy South Indian Population

Alanine aminotransferase (ALT) is the most common and cost effective screening test for asymptomatic liver disease. There is paucity of data on normal ALT among healthy individuals in India. An observational cross sectional study was conducted from January to July 2013 to estimate the upper limit of normal for ALT in healthy south Indian population. Adults undergoing voluntary or pre-employment health screening were included. Those with current and past alcoholism or smoking, acute illness or hospitalization during preceding 12 months, non-steroidal anti-inflammatory or over the counter medication use within a month, current or past intake of herbal medications, any chronic medical illness, abnormal body mass index (BMI), fatty liver in ultrasound, abnormality in haemoglobin, platelet count, blood sugar, creatinine, lipid profile and thyroid function test and positive serology (Hepatitis B, C or HIV) were excluded. A total of 2600 subjects were screened. 344 were included for analysis. Mean age was 35 years in men and 34.83 years in women, with a mean BMI of 22.2 kg/m² in men and 21.8 kg/m² in women. The mean ALT in men and women were 21.87 ± 2.9 (97.5th percentile 28 U/L) and 19.35 ± 3.3 (97.5th percentile 24 U/L) respectively. In conclusion, mean and upper limit of ALT (97.5th percentile) in south Indian men was 21.87 and 28 IU/L and women were 19.35 and 24 IU/L respectively. There is a need to re-consider ALT levels in our population for better detection of individuals at risk for liver disease.