The epidemiology of non-alcoholic fatty liver disease

Comparison of non-invasive liver reserve and fibrosis models: Implications for surgery and prognosis for hepatocellular carcinoma

AIM

This study aimed to assess the clinical utility of preoperative evaluation of liver fibrosis using platelet-albumin-bilirubin (PALBI) grade, Fibrosis-4 index (FIB-4), and aspartate transaminase-to-platelet ratio index (APRI) for hepatocellular carcinoma (HCC) patients and explore the clinical impact of these models with regard to perioperative risks and HCC prognosis.

METHODS

Between January 2003 and December 2018, 305 consecutive patients who underwent hepatectomy for HCC were enrolled.

RESULTS

The APRI showed the most robust diagnostic performance through each fibrosis stage among three models (PALBI, FIB-4, and APRI): fibrosis stage 3 (f3), area under the curve [AUC] = 0.55, 0.72, and 0.76; and f4, AUC = 0.51, 0.71, and 0.76, respectively). In addition, survival analysis revealed that all three models were significantly associated with HCC prognosis. PALBI (grade 1 vs. 2, 3): recurrence-free survival (RFS): median survival time (MST), 34 vs. 17 months, 0.007; overall survival (OS): MST, 115 vs. 68, 0.02. FIB-4 (grade 1, 2 vs. 3): RFS: MST, 34 vs. 22, 0.004, OS: MST, 120 vs. 63, 0.0001. APRI (grade 1, 2 vs. 3), RFS: MST, 30 vs. 20, 0.0005; OS: MST, 107 vs. 55, 0.0003. Among three scoring systems, only PALBI grade was significantly associated with both operative time (median, 303 vs. 340 min, 0.01) and intraoperative blood loss (median, 581 vs. 859 mL, 0.03).

CONCLUSIONS

This study showed robust performances of selected liver reserve and fibrosis models to predict HCC prognosis. Of them, PALBI might be used for assessing perioperative risks for hepatectomy for HCC.

Electroacupuncture Versus Aerobic Interval Training on Liver Functions in Patients with Nonalcoholic Fatty Liver

Background: Nonalcoholic fatty liver disease (NAFLD) is considered one of the most common and most important conditions affecting the liver, because of its increasing prevalence all over the world. It is usually associated with elevated liver enzymes and ranges from simple steatosis to liver cirrhosis. This study was conducted to compare the effects of electroacupuncture (EA) versus aerobic interval training (AIT) exercise and how they affect liver functions in people suffering from nonalcoholic fatty liver. Methods: This study was carried out on 50 female patients suffering from NAFLD with age ranging from 30 to 55 years; they were randomly divided into two equal groups: group A received (EA) stimulation at points of liver 3 (LR3), liver 14 (LR14), gall bladder 34 (GB34), and stomach 36 (ST36), whereas group B received AIT exercise. All patients in both groups A and B received 3 sessions per week for 6 weeks (receiving noninterrupted 18 sessions) in addition to their standard medications. Evaluation of all patients in both groups A and B was carried out before and after the treatment program by measuring the levels of alanine aminotransferase (ALT), aspartate aminotransferase (AST), triglycerides (TGs), and C-reactive protein (CRP). Results: There is a significant decrease (p < 0.05) of ALT, AST, TGs, and CRP within each group, A and B, after 6 weeks of treatment sessions. A significant difference post-treatment was found between both groups in ALT, AST, and TGs (p < 0.05). However, there was no significant difference in CRP (p > 0.05) between both groups post-treatment. Conclusions: It can be concluded that both EA and AIT exercise are potent modalities that improve liver functions in people with NAFLD with better effect toward EA.

Role of the PNPLA3 polymorphism rs738409 on silymarin + vitamin E response in subjects with non-alcoholic fatty liver disease

BACKGROUND

non-alcoholic fatty liver disease (NAFLD) is the most common cause of chronic liver disease in developed countries. Lifestyle changes are the pillar of the treatment, although a pharmacological approach is sometimes required in the case of a failure to respond/adhere to the diet.

OBJECTIVE

the aim of this study was to evaluate the effect of silymarin and the influence of the patatin-like phospholipase domain-containing protein 3 (PNPLA3) variant on the response to treatment in patients with NAFLD in a pilot study.

METHODS

a total of 54 patients with a NAFLD proven biopsy were enrolled in an open prospective study and were treated with Eurosil 85® (silymarin + vitamin E) for six months. Biochemical parameters and cardiovascular risk factors (diabetes mellitus, dyslipidemia, hypertriglyceridemia, arterial hypertension and HOMA-IR > 2.5) were recorded before and after six months of treatment. Non-invasive indexes (fatty liver index, lipid accumulation product and NAFLD-fibrosis score) were also calculated. The rs738409 PNPLA3 gene polymorphism status was also determined.

RESULTS

significant statistical changes from baseline values after six months of treatment were observed in transaminases levels but not in non-invasive index markers. Twenty patients (37.1%) were G allele carriers and had a higher percentage of lobular inflammation and ballooning on the basal liver biopsy. Patients with the G allele had a smaller decrease in transaminases levels after treatment with silymarin + vitamin E than non-G-allele carriers.

CONCLUSIONS

treatment with silymarin + vitamin E produced a decrease in transaminases after six months of treatment without an accompanying weight loss. PNPLA3 G-allele carriers responded poorly to the treatment.

Development and Progression of Non-Alcoholic Fatty Liver Disease: The Role of Advanced Glycation End Products

Non-alcoholic fatty liver disease (NAFLD) affects up to 30% of the adult population and is now a major cause of liver disease-related premature illness and deaths in the world. Treatment is largely based on lifestyle modification, which is difficult to achieve in most patients. Progression of simple fatty liver or steatosis to its severe form non-alcoholic steatohepatitis (NASH) and liver fibrosis has been explained by a 'two-hit hypothesis'. Whilst simple steatosis is considered the first hit, its transformation to NASH may be driven by a second hit. Of several factors that constitute the second hit, advanced glycation end products (AGEs), which are formed when reducing-sugars react with proteins or lipids, have been implicated as major candidates that drive steatosis to NASH via the receptor for AGEs (RAGE). Both endogenous and processed food-derived (exogenous) AGEs can activate RAGE, mainly present on Kupffer cells and hepatic stellate cells, thus propagating NAFLD progression. This review focuses on the pathophysiology of NAFLD with special emphasis on the role of food-derived AGEs in NAFLD progression to NASH and liver fibrosis. Moreover, the effect of dietary manipulation to reduce AGE content in food or the therapies targeting AGE/RAGE pathway on disease progression is also discussed.

Systematic review and meta-analysis of controlled intervention studies on the effectiveness of long-chain omega-3 fatty acids in patients with nonalcoholic fatty liver disease

Context

Treatment options for nonalcoholic fatty liver disease (NAFLD) are needed.

Objective

The aim of this review was to systematically assess the effects of omega-3 long-chain polyunsaturated fatty acids (n-3 LC-PUFAs), particularly eicosapentaenoic acid and docosahexaenoic acid, on liver-related and metabolic outcomes in adult and pediatric patients with NAFLD.

Data Sources

The online information service ProQuest Dialog was used to search 8 literature databases.

Study Selection

Controlled intervention studies in which the independent effects of n-3 LC-PUFAs could be isolated were eligible for inclusion.

Data Extraction

The 18 unique studies that met the criteria for inclusion were divided into 2 sets, and data transcriptions and study quality assessments were conducted in duplicate. Each effect size was expressed as the weighted mean difference and 95%CI, using a random-effects model and the inverse of the variance as a weighting factor.

Results

Based on the meta-analyses, supplementation with n-3 LC-PUFAs resulted in statistically significant improvements in 6 of 13 metabolic risk factors, in levels of 2 of 3 liver enzymes, in liver fat content (assessed via magnetic resonance imaging/spectroscopy), and in steatosis score (assessed via ultrasonography). Histological measures of disease [which were assessed only in patients with nonalcoholic steatohepatitis (NASH)] were unaffected by n-3 LC-PUFA supplementation.

Conclusions

Omega-3 LC-PUFAs are useful in the dietary management of patients with NAFLD. Additional trials are needed to better understand the effects of n-3 LC-PUFAs on histological outcomes in patients with NASH.

Systematic Review Registration

PROSPERO CRD42017055951.

Intelligent liver function testing (iLFT): A trial of automated diagnosis and staging of liver disease in primary care

BACKGROUND & AIMS

Liver function tests (LFTs) are frequently requested blood tests which may indicate liver disease. LFTs are commonly abnormal, the causes of which can be complex and are frequently under investigated. This can lead to missed opportunities to diagnose and treat liver disease at an early stage. We developed an automated investigation algorithm, intelligent liver function testing (iLFT), with the aim of increasing the early diagnosis of liver disease in a cost-effective manner.

METHODS

We developed an automated system that further investigated abnormal LFTs on initial testing samples to generate a probable diagnosis and management plan. We integrated this automated investigation algorithm into the laboratory management system, based on minimal diagnostic criteria, liver fibrosis estimation, and reflex testing for causes of liver disease. This algorithm then generated a diagnosis and/or management plan. A stepped-wedged trial design was utilised to compare LFT outcomes in general practices in the 6 months before and after introduction of the iLFT system. Diagnostic outcomes were collated and compared.

RESULTS

Of eligible patients with abnormal LFTs, 490 were recruited to the control group and 64 were recruited to the intervention group. The primary diagnostic outcome was based on the general practitioner diagnosis, which agreed with the iLFT diagnosis in 67% of cases. In the iLFT group, the diagnosis of liver disease was increased by 43%. Additionally, there were significant increases in the rates of GP visits after diagnosis and the number of referrals to secondary care in the iLFT group. iLFT was cost-effective with a low initial incremental cost-effectiveness ratio of £284 per correct diagnosis, and a saving to the NHS of £3,216 per patient lifetime.

CONCLUSIONS

iLFT increases liver disease diagnoses, improves quality of care, and is highly cost-effective. This can be achieved with minor changes to working practices and exploitation of functionality existing within modern laboratory diagnostics systems.

LAY SUMMARY

There is a growing epidemic of advanced liver disease, this could be offset by early detection and management. Checking liver blood tests (LFTs) should be an opportunity to diagnose liver problems, but abnormal results are often incompletely investigated. In this study we were able to substantially increase the diagnostic yield of the abnormal LFTs using the automated intelligent LFT system. With the addition of referral recommendations and management plans, this strategy provides optimum investigation and management of LFTs and is cost saving to the NHS.

Cyclophilin Inhibitor NV556 Reduces Fibrosis and Hepatocellular Carcinoma Development in Mice With Non-Alcoholic Steatohepatitis

Hepatocellular carcinoma (HCC), the third major cause of cancer mortality, can result from non-alcoholic steatohepatitis (NASH). Due to limited efficacy of drugs approved for HCC and no drug available yet for NASH, identification of new effective treatments is crucial. Here, we investigated whether NV556, a cyclophilin inhibitor derived from sanglifehrins, would decrease the development of NASH and HCC in a preclinical mouse model. For our experiment, male mice were administered streptozotocin to disrupt pancreatic cells and nourished with high-fat diet since 3 weeks of age. Afterward, NV556 or vehicle was orally administered daily for 6 weeks before the 14-week-old time point for the development of NASH, or 10 weeks before the 30-week-old time point for the establishment of HCC. Body weight, blood glucose level, and liver weight were recorded. Moreover, for NASH, livers were histologically examined for inflammation and steatosis. Collagen was measured by Sirius Red staining of hepatic tissues. Systemic cytokine levels in serum were detected by multiplex assays. For HCC, nodules of livers were measured and scored according to a developed system with number and size of nodules as criteria. NV556 significantly decreased collagen deposition (p = 0.0281), but did not alter inflammation, steatosis, body and liver weight, and systemic cytokine production compared to control mice with NASH symptoms. For HCC, NV556 statistically reduced the number (p = 0.0091) and diameter of tumorous nodules (p = 0.0264), along with liver weight (p = 0.0026) of mice.Our study suggests NV556 as a promising candidate for treatment of NASH-derived fibrosis and HCC.

RAGE is a Potential Cause of Onset and Progression of Nonalcoholic Fatty Liver Disease

OBJECTIVE

Fatty liver is a rising global health concern, significantly increasing the burden of health care cost. Nonalcoholic fatty liver disease (NAFLD) has a correlation with metabolic syndrome and its complications.

METHOD

We reviewed the literature regarding the mechanisms of developing NAFLD through AGE-RAGE signaling.

RESULTS

NAFLD, metabolic syndrome, and production of advanced glycation end-products (AGEs) share many common risk factors and appear to be connected. AGE induces production of the receptor for AGE (RAGE). AGE-RAGE interaction contributes to fat accumulation in the liver leading to inflammation, fibrosis, insulin resistance, and other complications of the fatty liver disease. The immune system, especially macrophages, has an important defense mechanism against RAGE pathway activities.

CONCLUSION

Soluble form of RAGE (sRAGE) has the capability to reduce inflammation by blocking the interaction of AGE with RAGE. However, sRAGE has some limitations, and the best method of usage is probably autotransplantation of transfected stem cells or monocytes, as a precursor of macrophages and Kupffer cells, with a virus that carries sRAGE to alleviate the harmful effects of AGE-RAGE signaling in the settings of fatty liver disease.

Automated Liver Fat Quantification at Nonenhanced Abdominal CT for Population-based Steatosis Assessment

Background Nonalcoholic fatty liver disease and its consequences are a growing public health concern requiring cross-sectional imaging for noninvasive diagnosis and quantification of liver fat. Purpose To investigate a deep learning-based automated liver fat quantification tool at nonenhanced CT for establishing the prevalence of steatosis in a large screening cohort. Materials and Methods In this retrospective study, a fully automated liver segmentation algorithm was applied to noncontrast abdominal CT examinations from consecutive asymptomatic adults by using three-dimensional convolutional neural networks, including a subcohort with follow-up scans. Automated volume-based liver attenuation was analyzed, including conversion to CT fat fraction, and compared with manual measurement in a large subset of scans. Results A total of 11 669 CT scans in 9552 adults (mean age ± standard deviation, 57.2 years ± 7.9; 5314 women and 4238 men; median body mass index [BMI], 27.8 kg/m²) were evaluated, including 2117 follow-up scans in 1862 adults (mean age, 59.2 years; 971 women and 891 men; mean interval, 5.5 years). Algorithm failure occurred in seven scans. Mean CT liver attenuation was 55 HU ± 10, corresponding to CT fat fraction of 6.4% (slightly fattier in men than in women [7.4% ± 6.0 vs 5.8% ± 5.7%; P < .001]). Mean liver Hounsfield unit varied little by age (<4 HU difference among all age groups) and only weak correlation was seen with BMI (r² = 0.14). By category, 47.9% (5584 of 11 669) had negligible or no liver fat (CT fat fraction <5%), 42.4% (4948 of 11 669) had mild steatosis (CT fat fraction of 5%-14%), 8.8% (1025 of 11 669) had moderate steatosis (CT fat fraction of 14%-28%), and 1% (112 of 11 669) had severe steatosis (CT fat fraction >28%). Excellent agreement was seen between automated and manual measurements, with a mean difference of 2.7 HU (median, 3 HU) and r² of 0.92. Among the subcohort with longitudinal follow-up, mean change was only -3 HU ± 9, but 43.3% (806 of 1861) of patients changed steatosis category between first and last scans. Conclusion This fully automated CT-based liver fat quantification tool allows for population-based assessment of hepatic steatosis and nonalcoholic fatty liver disease, with objective data that match well with manual measurement. The prevalence of at least mild steatosis was greater than 50% in this asymptomatic screening cohort. © RSNA, 2019.

Atherogenic index of plasma is a novel and strong predictor associated with fatty liver: a cross-sectional study in the Chinese Han population

Background

Atherogenic index of plasma (AIP) has been reported to be an important predictor for coronary artery disease and obesity. However, few studies has yet systematically evaluated the association between AIP and Fatty Liver (FL) and its advantage in FL prediction compared with BMI, waist, SBP, DBP, BG, ALT and AST.

Methods

A total of 7838 participants aged from 19 to 93 years were included in this study. Height, weight, waist, SBP, DBP, BG, ALT and AST were measured. Difference analyses, odds ratio calculation, logistic and predictive analyses were used to evaluate the association and discrimination ability between AIP, BMI, waist, SBP, DBP, BG, ALT, AST and FL.

Results

Compared with non-FL, AIP in FL people showed a significant increase. Subjects in the higher quartiles of AIP had a significantly increased risk of fatty liver compared with those in the lowest quartile (P < 0.01) after adjustment of gender and age. ORs were grown faster in female and youth group. AIP contributed most in the logistic eq. (B = 2.64, P < 0.01) and showed high ability in risk prediction for FL (AUC = 0.810, P < 0.01).

Conclusions

AIP might be a novel and strong predictor associated with FL in Chinese Han population. Higher AIP level was positively and strongly associated with FL.

Electronic supplementary material

The online version of this article (10.1186/s12944-019-1112-6) contains supplementary material, which is available to authorized users.

Vitamin D status and non-alcoholic fatty liver disease in patients with type 1 diabetes

PURPOSE

In patients with type 1 diabetes (T1D), the prevalence of non-alcoholic fatty liver disease (NAFLD) ranges from 10 to 53% and contrasting evidence suggests that vitamin D deficiency may favor liver fat accumulation. Here, we investigated the association between vitamin D status and NAFLD in adults with T1D.

METHODS

220 consecutive adult T1D patients on multiple daily injections or continuous subcutaneous insulin infusion and not taking calcium or vitamin D supplements were included. Patient characteristics, 25(OH)D serum levels, and metabolic parameters were analyzed. Vitamin D status was defined as sufficiency ( ≥ 75 nmol/L; 30 ng/ml), insufficiency (50-75 nmol/L; 20-30 ng/ml), or deficiency ( < 50 nmol/L; 20 ng/ml). NAFLD was diagnosed at ultrasound examination and graded 0-3.

RESULTS

NAFLD was present in 57 patients (29.5%): 51 grade 1, 5 grade 2, and 1 grade 3. Median 25(OH)D levels were 53 nmol/L (IQR 38-70) in patients with NAFLD and 50 nmol/L (34-69) in patients without (p = 0.46). At multivariable analysis, NAFLD was not associated with 25(OH)D levels (p = 0.42) or vitamin D deficiency (p = 0.55), while BMI (OR 1.16, 95% CI 1.07-1.27) and serum triglycerides (OR 1.02, 95% CI 1.01-1.03) were independently associated with NAFLD.

CONCLUSIONS

Vitamin D status appears to have no link with low-grade NAFLD in patients with type 1 diabetes.

Validation of Chronic Liver Disease Questionnaire for Nonalcoholic Steatohepatitis in Patients With Biopsy-Proven Nonalcoholic Steatohepatitis

BACKGROUND & AIMS

The chronic liver disease questionnaire for nonalcoholic steatohepatitis (CLDQ-NASH) was developed in a systematic manner for assessment of patient-reported outcomes. This instrument collects data on 36 items grouped into 6 domains: abdominal symptoms, activity/energy, emotional health, fatigue, systemic symptoms, and worry. We aimed to validate the CLDQ-NASH in a large group of patients with NASH.

METHODS

We collected data from patients with biopsy-proven NASH enrolled in 2 international phase 3 trials of selonsertib (NCT03053050 and NCT03053063). Our final analysis comprised 1667 patients who completed the CLDQ-NASH (age, 58 ± 9 y; 40% male; 52% with cirrhosis; and 69% with type 2 diabetes). The CLDQ-NASH was administered before treatment initiation. A standard patient-reported outcome instrument validation pipeline with internal consistency and validity assessment was applied.

RESULTS

The domains of CLDQ-NASH showed good to excellent internal consistency: the Cronbach's α values were 0.80 to 0.94 and item-to-own-domain correlations were greater than 0.50 for 33 of 36 items. All items correlated to the greatest extent with their own domains (discriminant validity). Known-group validity tests indicated that the instrument consistently discriminated between patients with NASH based on the presence of cirrhosis (vs bridging fibrosis; all but 1 P value < .02), obesity (all but 1 P value < .001), psychiatric comorbidities (all P values < .0001), fatigue (all P values < .001), and type 2 diabetes (all but 1 P value < .01). Of the CLDQ-NASH domains, the highest correlated domains with the Short Form-36 were as follows: physical functioning for activity (rho = 0.70), mental health for emotional (rho = 0.72), vitality for fatigue (rho = 0.75), and body pain for systemic (rho = 0.72) (all P values < .0001). In contrast, the domains of abdominal and worry, which are disease-specific, did not correlate with the domains in the Short Form-36 (all rho ≤ 0.50).

CONCLUSIONS

We validated the CLDQ-NASH by an analysis of data from 1667 patients with biopsy-proven NASH enrolled in phase 3 trials, observing excellent psychometric characteristics of the instrument.

Interleukin-1 Family Cytokines: Keystones in Liver Inflammatory Diseases

The pyrogenic property being the first activity described, members of the interleukin-1 superfamily (IL-1α, IL-1β, IL-18, and the newest members: IL-33, IL-36, IL-37, and IL-38) are now known to be involved in several inflammatory diseases such as obesity, atherosclerosis, cancer, viral and parasite infections, and auto-inflammatory syndromes as well as liver diseases. Inflammation processes are keystones of chronic liver diseases, of which the etiology may be viral or toxic, as in alcoholic or non-alcoholic liver diseases. Inflammation is also at stake in acute liver failure involving massive necrosis, and in ischemia-reperfusion injury in the setting of liver transplantation. The role of the IL-1 superfamily of cytokines and receptors in liver diseases can be either protective or pro-inflammatory, depending on timing and the environment. Our review provides an overview of current understanding of the IL-1 family members in liver inflammation, highlighting recent key investigations, and therapeutic perspectives. We have tried to apply the concept of trained immunity to liver diseases, based on the role of the members of the IL-1 superfamily, first of all IL-1β but also IL-18 and IL-33, in modulating innate lymphoid immunity carried by natural killer cells, innate lymphoid cells or innate T-αβ lymphocytes.

Surveillance and diagnosis of hepatocellular carcinoma: A systematic review

BACKGROUND

Hepatocellular carcinoma (HCC) appears in most of cases in patients with advanced liver disease and is currently the primary cause of death in this population. Surveillance of HCC has been proposed and recommended in clinical guidelines to obtain earlier diagnosis, but it is still controversial and is not accepted worldwide.

AIM

To review the actual evidence to support the surveillance programs in patients with cirrhosis as well as the diagnosis procedure.

METHODS

Systematic review of recent literature of surveillance (tools, interval, cost-benefit, target population) and the role of imaging diagnosis (radiological non-invasive diagnosis, optimal modality and agents) of HCC.

RESULTS

The benefits of surveillance of HCC, mainly with ultrasonography, have been assessed in several prospective and retrospective analysis, although the percentage of patients diagnosed in surveillance programs is still low. Surveillance of HCC permits diagnosis in early stages allows better access to curative treatment and increases life expectancy in patients with cirrhosis. HCC is a tumor with special radiological characteristics in computed tomography and magnetic resonance imaging, which allows highly accurate diagnosis without routine biopsy confirmation. The actual recommendation is to perform biopsy only in indeterminate nodules.

CONCLUSION

The evidence supports the recommendation of performing surveillance of HCC in patients with cirrhosis susceptible of treatment, using ultrasonography every 6 mo. The diagnosis evaluation of HCC can be established based on noninvasive imaging criteria in patients with cirrhosis.

Mouse models of hereditary hemochromatosis do not develop early liver fibrosis in response to a high fat diet

Hepatic iron overload, a hallmark of hereditary hemochromatosis, triggers progressive liver disease. There is also increasing evidence for a pathogenic role of iron in non-alcoholic fatty liver disease (NAFLD), which may progress to non-alcoholic steatohepatitis (NASH), fibrosis, cirrhosis and hepatocellular cancer. Mouse models of hereditary hemochromatosis and NAFLD can be used to explore potential interactions between iron and lipid metabolic pathways. Hfe-/- mice, a model of moderate iron overload, were reported to develop early liver fibrosis in response to a high fat diet. However, this was not the case with Hjv-/- mice, a model of severe iron overload. These data raised the possibility that the Hfe gene may protect against liver injury independently of its iron regulatory function. Herein, we addressed this hypothesis in a comparative study utilizing wild type, Hfe-/-, Hjv-/- and double Hfe-/-Hjv-/- mice. The animals, all in C57BL/6J background, were fed with high fat diets for 14 weeks and developed hepatic steatosis, associated with iron overload. Hfe co-ablation did not sensitize steatotic Hjv-deficient mice to liver injury. Moreover, we did not observe any signs of liver inflammation or fibrosis even in single steatotic Hfe-/- mice. Ultrastructural studies revealed a reduced lipid and glycogen content in Hjv-/- hepatocytes, indicative of a metabolic defect. Interestingly, glycogen levels were restored in double Hfe-/-Hjv-/- mice, which is consistent with a metabolic function of Hfe. We conclude that hepatocellular iron excess does not aggravate diet-induced steatosis to steatohepatitis or early liver fibrosis in mouse models of hereditary hemochromatosis, irrespectively of the presence or lack of Hfe.

Hepatocellular carcinoma and metabolic syndrome: The times are changing and so should we

Although hepatocellular carcinoma (HCC) is as prevalent as ever as a cancer-related mortality, and some would even argue that it is increasing, the pattern of its etiologies has been changing. Specifically, the domination of viral hepatitis C virus is being overcome, partly because of the emergence of the antiviral treatments, and partly because of the significant increase, especially in developed countries, of the combination of obesity, diabetes, metabolic syndrome, non-alcoholic fatty liver disease and non-alcoholic steatohepatitis. This editorial will explore the interconnection of this group of diseases and how they are linked to HCC. More importantly, it will argue that this shift in HCC etiology essentially means that we have to change how we approach the treatment of HCC, by changing our focus (and resources) to earlier stages of the disease development in order to prevent the appearance and progression of HCC.

Exercise Programming for Nonalcoholic Fatty Liver Disease

NONALCOHOLIC FATTY LIVER DISEASE (NAFLD) IS THE MOST COMMON LIVER DISEASE IN THE UNITED STATES AND ABROAD DUE TO A WESTERN DIET AND A DECREASE IN PHYSICAL ACTIVITY. WEIGHT LOSS AND EXERCISE IMPROVE THE FATTY LIVER AND ASSOCIATED COMORBIDITIES; HOWEVER, PROGRAMMING IS HIGHLY INDIVIDUALIZED CONSIDERING ITS HIGH PREVALENCE, AND THEREFORE, SEVERAL PROGRAMMING OPTIONS CAN BE CONSIDERED. A VIDEO ABSTRACT DESCRIBING THIS ARTICLE CAN BE FOUND IN SUPPLEMENTAL DIGITAL CONTENT 1 (SEE VIDEO, HTTP://LINKS.LWW.COM/SCJ/A253).

Fibroblast growth factor 21 is independently associated with severe hepatic steatosis in non-obese HIV-infected patients

BACKGROUND

Severe hepatic steatosis shows a high prevalence and contributes to morbidity and mortality in human immunodeficiency virus (HIV) infected patients. Known risk factors include obesity, dyslipidaemia and features of metabolic syndrome. Fibroblast growth factor 21 (FGF-21) is involved with hepatic glucose and lipid metabolism. This study aimed to evaluate FGF-21 as a biomarker for severe hepatic steatosis in non-obese HIV-infected patients.

METHODS

This is a prospective, cross-sectional, monocentric study including HIV-infected out-patients. Hepatic steatosis was measured via controlled attenuation parameter (CAP) using FibroScan 502 touch (ECHOSENS, France). Severe hepatic steatosis was defined at CAP ≥ 253 dB/m. Peripheral blood samples were collected and plasma was analysed for FGF-21. Demographic and clinical characteristics were collected from patient's health records.

RESULTS

In total, 73 non-obese HIV-monoinfected patients were included in this study. Prevalence of severe hepatic steatosis was 41%. Patients with severe hepatic steatosis showed significantly higher levels of FGF-21. Univariate analysis revealed FGF-21, BMI, hyperlipidaemia, ALT levels and arterial hypertension as significant, while multivariate analysis showed only FGF-21, arterial hypertension and ALT levels as significant independent risk factors for severe hepatic steatosis.

CONCLUSION

This study presents FGF-21 as an independent and stronger predictor of severe hepatic steatosis than blood lipids in HIV-infected patients. Moreover, arterial hypertension and ALT levels predict severe steatosis even in non-obese HIV-monoinfected patients. Furthermore, this study supports existing metabolic risk factors and expands them to non-obese HIV-infected patients.

Hesperidin improves hepatic steatosis, hepatic enzymes, and metabolic and inflammatory parameters in patients with nonalcoholic fatty liver disease: A randomized, placebo-controlled, double-blind clinical trial

This study aimed to evaluate the effects of hesperidin on nonalcoholic fatty liver disease (NAFLD) characteristics. In this randomized, double-blind, controlled clinical trial, 50 NAFLD patients were supplemented with either 1-g hesperidin capsule or identical placebo capsule for 12 weeks. During the intervention, both groups were advised to follow healthy lifestyle habits including dietary and physical activity recommendations. At the end of the study, hesperidin supplementation, compared with placebo, was associated with a significant reduction in alanine aminotransferase (p = .005), γ-glutamyltransferase (p = .004), total cholesterol (p = .016), triglyceride (p = .049), hepatic steatosis (p = .041), high-sensitivity C-reactive protein (p = .029), tumor necrosis factor-α, and nuclear factor-κB (NF-κB). In conclusion, our results indicate that hesperidin supplementation accompanied with lifestyle modification is superior to lifestyle modification alone in management of NAFLD at least partially through inhibiting NF-κB activation and improving lipid profile. Further studies with higher dose of hesperidin are required to find the optimal dose.

Quantification of steatosis in alcoholic and nonalcoholic fatty liver disease: Evaluation of four MR techniques versus biopsy

PURPOSE

Given the growing prevalence of obesity and metabolic syndrome, the management of hepatic steatosis, especially its quantification, is a major issue. We assessed the quantification of liver steatosis using four different MR methods, in order to determine the one that is best correlated with the reference method which consists of histological measurement by liver biopsy.

METHOD

Seventy-one successive patients requiring liver biopsy for acute or chronic liver disease were enrolled prospectively between March 2017 and March 2018, 11 were excluded and 60 were reported. Liver MR (1.5 T) was organised in order to be performed the same day, using four different steatosis quantification techniques (3-echo MRI, 6-echo MRI, 11-echo MRI and MR Spectroscopy). Quantitative histological and imaging data were compared. In a secondary analysis, we studied the possible influence of alcohol drinking, hepatic iron overload, and the presence of liver fibrosis.

RESULTS

All four MR techniques were found to have excellent correlations with the histological measurements: 3-echo MRI (r = 0.852, p < 0.001), 6-echo MRI (r = 0.819, p < 0.001), 11-echo MRI (r = 0.818, p < 0.001) and MR Spectroscopy (r = 0,812, p < 0,001). Interestingly, we also found that the presence of alcohol consumption, iron overload and fibrosis did not interfere with measurements, whichever technique was used.

CONCLUSION

In the evaluation of hepatic steatosis, our study showed very good correlations of all four MR techniques with the histological standard. There was no confounding factor in a representative group of patients with associated liver conditions such as alcohol consumption, fibrosis and iron overload, for each technique. All four MR techniques may be used in daily practice.

Low vitamin D level was associated with metabolic syndrome and high leptin level in subjects with nonalcoholic fatty liver disease: a community-based study

Background

This study aimed to evaluate the association between serum vitamin D levels and nonalcoholic fatty liver disease (NAFLD) parameters, such as metabolic syndrome (MS), inflammatory cytokines (tumor necrosis factor, high sensitive C-reactive protein) and adipokines (adiponectin, leptin).

Methods

From August 2013 to August 2016, a community-based study was performed in the north-eastern region of Taiwan. All subjects received a demographic survey, blood testing and abdominal ultrasonography (US). The vitamin D level was evaluated by quartile divide or used the classification of deficiency (< 20 ng/ml), insufficiency (20–30 ng/ml) and sufficiency (> 30 ng/ml).

Results

Subjects were divided into NAFLD group and normal control (subjects number = 564 in each group) following abdominal US study and matching age and gender. The mean age was 57.1 years in NAFLD group and 57.5 in control group. Subjects in NAFLD group had a lower mean vitamin D than those in the control group (28.5 ± 9.5 ng/ml vs. 29.9 ± 10.2 ng/ml, P = 0.018). Subjects with serum vitamin D deficiency or insufficiency had higher odds for MS than those with sufficient vitamin D levels [deficiency vs. sufficiency, adjusted odds ratio (aOR) =1.860 (95% CI = 1.234–2.804), P = 0.003; insufficiency vs. sufficiency, aOR = 1.669 (95% CI = 1.237–2.251), P = 0.001]. Similarly, subjects in the lowest quartile of vitamin D had higher odds for MS than those in the highest quartile of vitamin D (aOR = 2.792, 95% CI = 1.719–4.538, P < 0.001). Vitamin D level was positively correlated with age and male, but negatively correlated with serum leptin level.

Conclusion

Subjects with low vitamin D level had higher odds for MS, but higher levels of leptin, compared to those with high vitamin D levels.

Body weight-dependent and independent improvement in lipid metabolism after Roux-en-Y gastric bypass in ApoE*3Leiden.CETP mice

BACKGROUND/OBJECTIVES

The incidence of obesity and metabolic syndrome (MetS) has rapidly increased worldwide. Roux-en-Y gastric bypass (RYGB) achieves long-term weight loss and improves MetS-associated comorbidities. Using a mouse model with a humanized lipoprotein metabolism, we elucidated whether improvements in lipid and glucose metabolism after RYGB surgery are body weight loss-dependent or not.

SUBJECTS/METHODS

Male ApoE*3Leiden.CETP (ApoE3L.CETP) mice fed Western type diet for 6 weeks underwent RYGB or Sham surgery. Sham groups were either fed ad libitum or were body weight-matched (BWm) to the RYGB mice to discriminate surgical effects from body weight loss-associated effects. Before and after surgery, plasma was collected to assess the metabolic profile, and glucose tolerance and insulin sensitivity were tested. Twenty days after surgery, mice were sacrificed, and liver was collected to assess metabolic, histological and global gene expression changes after surgery.

RESULTS

RYGB induced a marked reduction in body weight, which was also achieved by severe food restriction in BWm mice, and total fat mass compared to Sham ad libitum mice (Sham AL). Total cholesterol, non-high-density lipoprotein cholesterol (non-HDL-C) and ceramide were strongly reduced 20 days after surgery in RYGB compared to BWm mice. Glucose tolerance and insulin sensitivity improved 13 days after surgery similarly in RYGB and BWm mice. Liver histology confirmed lipid reduction in RYGB and BWm mice while the transcriptomics data indicated altered genes expression in lipid metabolism.

CONCLUSIONS

RYGB surgery improves glucose metabolism and greatly ameliorates lipid metabolism in part in a body weight-dependent manner. Given that ApoE3L.CETP mice were extensively studied to describe the MetS, and given that RYGB improved ceramide after surgery, our data confirmed the usefulness of ApoE3L.CETP mice after RYGB in deciphering the metabolic improvements to treat the MetS.

Exposure to air pollution during pregnancy and newborn liver function

Exposure to air pollution has been associated with a wide range of adverse health outcomes. However, the available evidence on the impact of air pollution exposures on liver enzymes is still scarce. The aim of the present study was to assess the relationship between exposure to ambient PM₁, PM_2.5 and PM₁₀ during pregnancy and serum level of aspartate aminotransferase (AST), alanine aminotransferase (ALT), alkaline phosphatase (ALP) and gamma-glutamyl transferase (GGT) in cord blood samples of newborns. Moreover, the association between total street length in different buffers and distance to major roads at the maternal residential address and liver enzymes were investigated. This cross-sectional study was based on data from a sample of 150 newborns, from Sabzevar, Iran. Land use regression models were used to estimate concentrations of air pollutants at home during pregnancy. Multiple linear regression was developed to estimate association of AST, ALT, ALP and GGT with air pollution controlled for relevant covariates. In fully adjusted models, increase in PM₁ and PM_2.5 as well as PM₁₀ were associated with higher levels of AST, ALT and GGT. Moreover, there was a significant association between total street length in a 100 m buffer at residential address with AST, ALT and GGT. Each meter increase in distance to major roads was associated with -0.017 (95% confidence interval (CI): -0.028, -0.006) decrease in AST. Overall, our findings were supportive for association between PMs exposure during pregnancy and increase in liver enzymes in newborns. Further studies are needed to confirm these findings in other settings and populations.

The effects of oleoylethanolamide, an endogenous PPAR-α agonist, on risk factors for NAFLD: A systematic review

Non-alcoholic fatty liver disease (NAFLD) is the most prevalent chronic liver disease. Recently, some novel compounds have been investigated for the prevention and treatment of NAFLD. Oleoylethanolamide (OEA), an endogenous PPAR-α agonist, has exhibited a plethora of pharmacological properties for the treatment of obesity and other obesity-associated metabolic complications. This systematic review was performed with a focus on the effects of OEA on the risk factors for NAFLD. PubMed, Scopus, Embase, ProQuest, and Google Scholar databases were searched up to December 2018 using relevant keywords. All articles written in English evaluating the effects of OEA on the risk factors for NAFLD were eligible for the review. The evidence reviewed in this article illustrates that OEA regulates multiple biological processes associated with NAFLD, including lipid metabolism, inflammation, oxidative stress, and energy homeostasis through different mechanisms. In summary, many beneficial effects of OEA have led to the understanding that OEA may be an effective therapeutic strategy for the management of NAFLD. Although a wide range of studies have demonstrated the most useful effects of OEA on NAFLD and the associated risk factors, further clinical trials, from both in vivo studies and in vitro experiments, are warranted to verify these outcomes.

Does Turmeric/curcumin Supplementation Change Anthropometric Indices in Patients with Non-alcoholic Fatty Liver Disease? A Systematic Review and Meta-analysis of Randomized Controlled Trials

Curcumin is the principal polylphenol of turmeric that has been used to treat various disorders. However, its anti-obesity effects in patients with non-alcoholic fatty liver disease (NAFLD) remain controversial. Therefore, we aimed to perform a meta-analysis on the effects of supplementation with turmeric/curcumin on body weight, body mass index (BMI) and waist circumference (WC) in these patients. PubMed, Scopus, Cochrane Library, and ISI Web of Science were searched until January 2019, without any restrictions. Clinical trials that reported body weight, BMI and WC in patients with NAFLD were included. Weighted mean differences (WMDs) were pooled using a random-effects model. Eight studies (449 participants) fulfilled the eligibility criteria of the present meta-analysis. Overall, meta-analysis could not show any beneficial effect of turmeric/curcumin supplementation on body weight (WMD, -0.54 kg; 95% confidence interval [CI], -2.40, 1.31; p = 0.56; I2 = 0.0%), BMI (WMD, -0.21 kg/m2; 95% CI, -0.71, 0.28; p = 0.39; I2 = 0.0%) and WC (WMD, -0.88 cm; 95% CI, -3.76, 2.00; p = 0.54; I2 = 0.0%). Subgroup analysis based on participants' baseline BMI, type of intervention, and study duration did not show any significant association in all subgroups. The results showed that turmeric/curcumin supplementation had no significant effect on body weight, BMI and WC in patients with NAFLD. Further studies with large-scale are needed to find out possible anti-obesity effects of turmeric/curcumin.

Hepatocellular carcinoma in the noncirrhotic liver: a literature review

Development of hepatocellular carcinoma (HCC) is usually preceded by chronic liver injury and ongoing liver diseases. Liver cirrhosis reflects the outcome of long-term liver injury and is associated with an increased risk of developing HCC. However, HCC also arises in individuals without cirrhosis and bears several characteristics distinct from HCC in the cirrhotic liver. The molecular characteristics, prognosis, and surveillance of noncirrhotic HCC have not been adequately studied. In this review, we update readers and researchers in the field with the latest understanding of the epidemiology, etiology, clinical features, diagnosis, treatment strategies, prognosis, and surveillance of noncirrhotic HCC.

Diallyl disulfide attenuates non‑alcoholic steatohepatitis by suppressing key regulators of lipid metabolism, lipid peroxidation and inflammation in mice

Non‑alcoholic steatohepatitis (NASH) is a common clinicopathological condition. Currently, the pathogenesis of NASH remains unknown, and no optimal therapy option currently exists. It has previously been demonstrated that diallyl disulfide (DADS) was capable of attenuating liver dysfunction, as DADS supplementation had a positive impact on liver regeneration, proliferation and oxidative damage. Thus, DADS could serve as a potential therapeutic agent that can protect against the effects of NASH. The present study aimed to evaluate the effect of DADS on NASH and to understand the associated underlying molecular mechanisms. A methionine‑ and choline‑deficient diet (MCD) and high‑fat diet (HFD) are the two common animal models that induce NASH. C57BL/6J mice were fed an MCD for 4 weeks, or an HFD for 20 weeks, in the present study. The mice were treated with or without DADS (20, 50 and 100 mg/kg) for 4 or 20 weeks. For the histopathological examination, hematoxylin and eosin staining, oil red O staining and immunohistochemical analyses were performed using the liver sections. Biochemical assays and ELISA were performed to measure the serum biochemical indicators of hepatic function and inflammatory indicators, respectively. Reverse transcription‑quantitative PCR, immunofluorescence and western blotting were used to detect expression levels of the genes involved in the molecular mechanisms underlying DADS protection. MCD or HFD induced the histological features of NASH in mice, including significant vacuolated hepatocytes, marked inflammatory cell infiltration and severe micro‑ and macro‑vesicular steatosis. Serum alanine transferase and aspartate aminotransferase levels, as well as the contents of liver triglyceride and total cholesterol, were significantly increased in these two models. DADS attenuated these histological and biochemical changes. DADS ameliorated hepatic steatosis by regulating sterol regulatory element‑binding transcription factor 1, apolipoprotein A1, cyclic AMP‑responsive element‑binding protein H and fibroblast growth factor 21. Furthermore, DADS was revealed to prevent lipotoxicity via peroxisome proliferator‑activated receptor α elevation and stearoyl‑coenzyme A desaturase 1 inhibition in HFD‑fed mice. In addition, DADS markedly inhibited lipid peroxidation by modulating malondialdehyde and superoxide dismutase, and it also decreased tumor necrosis factor‑α production, interleukin‑6 production and macrophage influx, as well as suppressing nuclear factor‑κB activation, indicating suppression of MCD‑induced hepatic inflammation. Taken together, the results have shown that DADS exerts beneficial effects on MCD‑ or HFD‑induced NASH by suppressing key regulators of lipid metabolism, lipid peroxidation and inflammation.

Acupuncture Regulating Gut Microbiota in Abdominal Obese Rats Induced by High-Fat Diet

Objective

To investigate the effects of acupuncture on metabolic health and gut microbiota dysbiosis in diet-induced abdominal obese model.

Materials and Methods

Male Sprague-Dawley rats were randomly distributed into normal chow diet (NCD) group and high-fat diet (HFD) group. After 12 weeks of HFD feeding, an abdominal obese rat model was established. The abdominal obese rats were further assigned to acupuncture group (n=7) and nontreated HFD group (n=7). Acupuncture was applied to bilateral GB 26 of rats for 8 weeks. Subsequently, the body weight, waist circumference (WC), visceral fat mass, and liver weight were measured weekly in all rats. Metabolic parameters such as total cholesterol, triglyceride, alanine aminotransferase, aspartate transaminase, and blood glucose were measured by an automatic biochemical analyzer. The serum levels of insulin (INS) were determined using Rat INS ELISA Kit. Analysis of gut microbiota was carried out by 16S rRNA gene sequencing.

Results

Acupuncture decreased the body weight, WC, and visceral adipose tissues of HFD-induced abdominal obese rats. In addition, insulin sensitivity, glucose homeostasis, and lipid metabolism were improved by this treatment. Furthermore, electroacupuncture effectively modified the composition of gut microbiota, mainly via decreasing Firmicutes/Bacteroidetes ratio and increasing Prevotella_9 abundance.

Conclusions

Electroacupuncture can ameliorate abdominal obesity and prevent metabolic disorders in HFD-induced abdominal obese rats, via the modulation of gut microbiota.

In New-Onset Diabetes Mellitus, Metformin Reduces Fat Accumulation in the Liver, But Not in the Pancreas or Pericardium

Background: Nonalcoholic fatty pancreas and liver disease (NAFPD and NAFLD) and pericardial adipose tissue (PAT) are often associated with type 2 diabetes mellitus (T2DM). Our aim was to evaluate the incidence rate of NAFLD and NAFPD, PAT size, and the effect of metformin treatment on NAFLD, NAFPD, and PAT in new-onset T2DM (NODM). Methods: Seventeen patients with NODM and 10 subjects used as a control group were involved in the study. Computed tomography (CT) and laboratory tests were performed before the beginning of metformin therapy and 4 months afterward. PAT and the amount of fat in the pancreas and liver were determined by X-ray attenuation during unenhanced CT examination and compared with the values for the control subjects. Results: Metabolic parameters improved significantly after metformin therapy. NAFLD was diagnosed in 64.7% of the patients with NODM and in 10% of the control subjects. The radiation absorption of the liver was significantly lower in the patients with NODM compared with the control group and significantly higher after metformin therapy compared with the baseline values. Only six patients (35.3%) had NAFLD after metformin therapy. NAFPD was diagnosed in 82.3% of the patients with NODM and in 20% of the control subjects. The radiation absorption of the pancreas was significantly lower in the patients with NODM compared with the control group but did not change significantly after treatment. PAT size was significantly larger in the patients with NODM and did not change significantly after metformin treatment. Conclusions: NAFLD, NAFPD, and increased PAT were detected in the majority of patients with NODM. Metformin therapy decreased the amount of fat in the liver in parallel with an improvement in the metabolic parameters and may, thus, be beneficial for preventing the late consequences of NAFLD.

Bromide alleviates fatty acid-induced lipid accumulation in mouse primary hepatocytes through the activation of PPARα signals

Increased plasma free fatty acids (FFAs) and liver triglyceride (TG) accumulations have been implicated in the pathogenesis of hepatic steatosis. On the other hand, trace elements function as essential cofactors that are involved in various biochemical processes in mammals, including metabolic homeostasis. Notably, clinical and animal studies suggest that the plasma levels of bromide negatively correlate with those of TG, total cholesterol (TC) and high‐density lipoprotein‐cholesterol (HDL‐C). However, the effect of bromide on lipid accumulation and the direct molecular target responsible for its action remains unknown. Oil red O (ORO) and Nile red staining were used to detect the effect of bromide on lipid accumulation in mouse primary hepatocytes (PHs) treated with different doses of sodium bromide (NaBr) in the presence of FFAs (0.4 mM oleate/palmitic acid 1:1). Spectrophotometric and fluorometric analyses were performed to assess cellular TG concentrations and rates of fatty acid oxidation (FAO), respectively, in mouse PHs. We found that bromide decreased FFA‐induced lipid accumulation and increased FFA‐inhibited oxygen consumptions in mouse PHs in a dose‐dependent manner via activation of PPARα. Mechanical studies demonstrated that bromide decreased the phosphorylation levels of JNK. More importantly, the PPARα‐specific inhibitor GW6471 partially abolished the beneficial effects of bromide on mouse PHs. Bromide alleviates FFA‐induced excessive lipid storage and increases rates of FAO through the activation of PPARα/JNK signals in mouse PHs. Therefore, bromide may serve as a novel drug in the treatment of hepatic steatosis.

Significant changes in hepatic transcriptome and circulating miRNAs are associated with diet-induced metabolic syndrome in apoE3L.CETP mice

Long-term exposure to excess dietary fat leads to obesity and the metabolic syndrome (MetS). The purpose of the present study was to identify global changes in liver gene expression and circulating miRNAs in a humanized mouse model of diet-induced MetS. Male apoE3L.CETP mice received a high-fat diet (HFD) or a low-fat diet (LFD) for different time periods and the progression of MetS pathology was monitored. A separate group of mice was divided into responders (R) or nonresponders (NR) and received HFD for 16 weeks. We found that mice receiving the HFD developed manifestations of MetS and displayed an increasing number of differentially expressed transcripts at 4, 8, and 12 weeks compared with mice receiving the LFD. Significantly changed genes were functionally annotated to metabolic diseases and pathway analysis revealed the downregulation of genes in cholesterol and fatty acid biosynthesis and upregulation of genes related to lipid droplet formation, which was in line with the development of hepatic steatosis. In the serum of the apoE3L.CETP mice we identified three miRNAs that were upregulated specifically in the HFD group. We found that responder mice have a distinct gene signature that differentiates them from nonresponders. Comparison of the two diet intervention studies revealed a limited number of common differentially expressed genes but the expression of these common genes was affected in a similar way in both studies. In conclusion, the characteristic hepatic gene signatures and serum miRNAs identified in the present study provide novel insights to MetS pathology and could be exploited for diagnostic or therapeutic purposes.

Oxidative Stress and Non-Alcoholic Fatty Liver Disease: Effects of Omega-3 Fatty Acid Supplementation

Aging is a complex phenomenon characterized by the progressive loss of tissue and organ function. The oxidative-stress theory of aging postulates that age-associated functional losses are due to the accumulation of ROS-induced damage. Liver function impairment and non-alcoholic fatty liver disease (NAFLD) are common among the elderly. NAFLD can progress to non-alcoholic steatohepatitis (NASH) and evolve to hepatic cirrhosis or hepatic carcinoma. Oxidative stress, lipotoxicity, and inflammation play a key role in the progression of NAFLD. A growing body of evidence supports the therapeutic potential of omega-3 polyunsaturated fatty acids (n-3 PUFA), mainly docosahaexenoic (DHA) and eicosapentaenoic acid (EPA), on metabolic diseases based on their antioxidant and anti-inflammatory properties. Here, we performed a systematic review of clinical trials analyzing the efficacy of n-3 PUFA on both systemic oxidative stress and on NAFLD/NASH features in adults. As a matter of fact, it remains controversial whether n-3 PUFA are effective to counteract oxidative stress. On the other hand, data suggest that n-3 PUFA supplementation may be effective in the early stages of NAFLD, but not in patients with more severe NAFLD or NASH. Future perspectives and relevant aspects that should be considered when planning new randomized controlled trials are also discussed.

Reproductive Endocrinology of Nonalcoholic Fatty Liver Disease

The liver and the reproductive system interact in a multifaceted bidirectional fashion. Sex steroid signaling influences hepatic endobiotic and xenobiotic metabolism and contributes to the pathogenesis of functional and structural disorders of the liver. In turn, liver function affects the reproductive axis via modulating sex steroid metabolism and transport to tissues via sex hormone-binding globulin (SHBG). The liver senses the body's metabolic status and adapts its energy homeostasis in a sex-dependent fashion, a dimorphism signaled by the sex steroid milieu and possibly related to the metabolic costs of reproduction. Sex steroids impact the pathogenesis of nonalcoholic fatty liver disease, including development of hepatic steatosis, fibrosis, and carcinogenesis. Preclinical studies in male rodents demonstrate that androgens protect against hepatic steatosis and insulin resistance both via androgen receptor signaling and, following aromatization to estradiol, estrogen receptor signaling, through regulating genes involved in hepatic lipogenesis and glucose metabolism. In female rodents in contrast to males, androgens promote hepatic steatosis and dysglycemia, whereas estradiol is similarly protective against liver disease. In men, hepatic steatosis is associated with modest reductions in circulating testosterone, in part consequent to a reduction in circulating SHBG. Testosterone treatment has not been demonstrated to improve hepatic steatosis in randomized controlled clinical trials. Consistent with sex-dimorphic preclinical findings, androgens promote hepatic steatosis and dysglycemia in women, whereas endogenous estradiol appears protective in both men and women. In both sexes, androgens promote hepatic fibrosis and the development of hepatocellular carcinoma, whereas estradiol is protective.

Clinical and Pathogenetic Parallels of Nonalcoholic Fatty Liver Disease and Gallstone Disease

Aim:to analyze the data that has so far been accumulated on the pathogenetic association of gallstone disease (GD) and non-alcoholic fatty liver disease (NAFLD), as well as to assess the effect of cholecystectomy on the NAFLD course.

Key findings.The relationship between GD and NAFLD is very complex and seems to be mutually aggravating. There is no doubt that there is an increased risk of GB in NAFLD patients, which is primarily associated with common pathogenetic mechanisms. These include central and peripheral insulin resistance, changes in the expression of transcription factors (liver X-receptor and farnesoid X-receptor) and the bile acid membrane receptors (TGR5). Conversely, the effect of GD on the NAFLD course is assumed, although the pathogenetic factors of this association are still unknown. In recent years, convincing data has emerged concerning the role of cholecystectomy in the NAFLD progression, which may be connected with the development of small intestinal bacterial overgrowth, as well as with the disruption of the endocrine balance and the signal function of bile acids.

Conclusion.The connection between NAFLD, GD and cholecystectomy is complex and multifaceted. The study of this connection will allow new methods of treatment to be developed.

Fatty liver is a risk factor for liver metastasis in Chinese patients with non-small cell lung cancer

Background

The hepatic microenvironment, which may include chronic inflammation and fibrosis, is considered to contribute to the development of liver metastases. Hepatic steatosis (HS) might cause liver inflammation and fibrosis. However, to date, no studies have investigated the impact of HS on liver metastasis in patients with non-small cell lung cancer (NSCLC).

Methods

A retrospective cohort study was performed on patients who received NSCLC treatment at two hospitals affiliated with the Southern Medical University from January 2005 to December 2015. The patients were grouped according to the presence of HS. The clinicopathological features of patients between the two groups were compared. The effect of HS on liver metastasis and overall metastasis was evaluated, adjusting for other confounders using Cox regression analyses.

Results

In total, 1,873 patients with NSCLC with no distant metastases were included in this study, and 408 (21.8%) patients were diagnosed with HS (at the time of diagnosis or before diagnosis). Liver metastases occurred in 166 (8.9%) patients. Liver metastasis-free survival was significantly worse in the study (HS) group (hazard ratio (HR) 1.42; (95% CI [1.03–1.96]); P = 0.031). Multivariate regression analysis demonstrated that HS was an independent risk factor for liver metastasis (HR 1.43; 95% CI [1.02–2.01]; P = 0.039). However, HS was not associated with overall metastasis of NSCLC (HR 0.99; 95% CI [0.84–1.17]; P = 0.895).

Conclusion

Hepatic steatosis was an independent predictor of liver metastasis from in patients with NSCLC.

Intestinal microbiome as a novel therapeutic target for local and systemic inflammation

Recently, the pathogenesis of systemic inflammatory disease such as inflammatory bowel disease (IBD), multiple sclerosis (MS), systemic inflammatory arthritis, asthma, and non-alcoholic fatty liver disease has been reported to be related to the dysbiosis of gut microbiota. The contribution of special bacteria for the development of those diseases has been elucidated by disease animal models such as germ-free mice. Besides, the contribution by several bacteria for the pathogenesis of those diseases has been suggested by detailed analysis of the 16 small ribosomal subunit RNA (16S rRNA) from stool samples of the patients. Gut microbiota-targeted treatment for systemic inflammatory diseases such as fecal microbiota transplant (FMT), and probiotics has been now reported. Though there are several issues to be understood, these treatments have been highlighted as an innovative approach to intractable systemic inflammatory disease. In the present review, recent reports regarding the relation between gut microbiota and systemic inflammatory diseases are discussed with treatments to target gut microbiota.

Low fat but not soy protein isolate was an effective intervention to reduce nonalcoholic fatty liver disease progression in C57BL/6J mice: monitored by a novel quantitative ultrasound (QUS) method

Untreated nonalcoholic fatty liver disease (NAFLD) and nonalcoholic steatohepatitis (NASH) lead to irreversible liver damage. We hypothesized that a low-fat diet (LFD) or a high-fat diet (HFD) with soy protein isolate (SPI) would be an effective intervention to halt or reverse NAFLD progression. To test these hypotheses, we conducted 2 studies. In the first study, we fed an HFD to 7-week-old C57BL/6J mice to induce NAFLD compared to an LFD (control). Hepatic steatosis was monitored by quantitative ultrasound (QUS) scans (in vivo and ex vivo). Animals were euthanized after 0, 2, 4, and 6 weeks of feeding. In the second study, 7-week-old mice were randomized onto an LFD or HFD with SPI intervention after 4 weeks of feeding HFD. Animals from each group were scanned with QUS and euthanized after 4, 9, and 12 weeks of feeding. Animals fed the HFD developed NAFLD (100%) and NASH (80%) characterized by increased liver weight, lipid accumulation, and histological scores for inflammation by 4 weeks in the first study. In the second study, the LFD ameliorated this NAFLD phenotype after 5 weeks of feeding; however, the SPI intervention failed to significantly attenuate NAFLD. QUS parameters were significantly increased with the HFDs (P < .05) and steatosis grade (P < .05) and were positively correlated with hepatic lipid concentrations. In conclusion, dietary modification may be effective at reversing NAFLD and NASH at early stages. Furthermore, QUS may become a valuable tool to track hepatic steatosis. Additional studies are needed to further evaluate the effectiveness of these interventions.

Molecular Pathogenesis of Cholangiocarcinoma

BACKGROUND

Cholangiocarcinomas are a heterogeneous group of malignancies arising from a number of cells of origin along the biliary tree. Although most cases in Western countries are sporadic, large population-based studies have identified a number of risk factors. This review summarises the evidence behind reported risk factors and current understanding of the molecular pathogenesis of cholangiocarcinoma, with a focus on inflammation and cholestasis as the driving forces in cholangiocarcinoma development.

RISK FACTORS FOR CHOLANGIOCARCINOGENESIS

Cholestatic liver diseases (e.g. primary sclerosing cholangitis and fibropolycystic liver diseases), liver cirrhosis, and biliary stone disease all increase the risk of cholangiocarcinoma. Certain bacterial, viral or parasitic infections such as hepatitis B and C and liver flukes also increase cholangiocarcinoma risk. Other risk factors include inflammatory disorders (such as inflammatory bowel disease and chronic pancreatitis), toxins (e.g. alcohol and tobacco), metabolic conditions (diabetes, obesity and non-alcoholic fatty liver disease) and a number of genetic disorders.

MOLECULAR PATHOGENESIS OF CHOLANGIOCARCINOMA

Regardless of aetiology, most risk factors cause chronic inflammation or cholestasis. Chronic inflammation leads to increased exposure of cholangiocytes to the inflammatory mediators interleukin-6, Tumour Necrosis Factor-ɑ, Cyclo-oxygenase-2 and Wnt, resulting in progressive mutations in tumour suppressor genes, proto-oncogenes and DNA mismatch-repair genes. Accumulating bile acids from cholestasis lead to reduced pH, increased apoptosis and activation of ERK1/2, Akt and NF-κB pathways that encourage cell proliferation, migration and survival. Other mediators upregulated in cholangiocarcinoma include Transforming Growth Factor-β, Vascular Endothelial Growth Factor, Hepatocyte Growth Factor and several microRNAs. Increased expression of the cell surface receptor c-Met, the glucose transporter GLUT-1 and the sodium iodide symporter lead to tumour growth, angiogenesis and cell migration. Stromal changes are also observed, resulting in alterations to the extracellular matrix composition and recruitment of fibroblasts and macrophages that create a microenvironment promoting cell survival, invasion and metastasis.

CONCLUSION

Regardless of aetiology, most risk factors for cholangiocarcinoma cause chronic inflammation and/or cholestasis, leading to the activation of common intracellular pathways that result in reactive cell proliferation, genetic/epigenetic mutations and cholangiocarcinogenesis. An understanding of the molecular pathogenesis of cholangiocarcinoma is vital when developing new diagnostic biomarkers and targeted therapies for this disease.

Interaction Between AGTR1 and PPARγ Gene Polymorphisms on the Risk of Nonalcoholic Fatty Liver Disease

AIMS

Nonalcoholic fatty liver disease (NAFLD) is an important public health issue worldwide. Several recent studies have reported that peroxisome proliferator-activated receptor-γ (PPARγ) and angiotensin II type 1 receptor (AGTR1) variants are associated with NAFLD occurrence, but the results have been inconsistent. The aim of this study was to analyze the interactions between PPARγ and AGTR1 polymorphisms and their associations with NAFLD in Chinese adults.

METHODS

Seven single nucleotide polymorphisms (SNPs) of the PPARγ gene and 5 SNPs of the AGTR1 gene were selected and genotyped in 1591 unrelated Chinese adults. The SNPAssoc package of R was used to examine the relationships between the selected SNPs and NAFLD.

RESULTS

After adjusting the covariance, the results from the overdominant model showed that participants carrying the T/C genotype of rs2638360 in AGTR1 have a decreased risk of NAFLD compared with those with T/T-C/C genotypes (odds ratio: 0.70, 95% confidence interval: 0.49-1.00). However, our results showed that none of the selected PPARγ variants were significantly associated with the risk of NAFLD after applying a false discovery rate correction. Among the 12 selected SNPs from PPARγ and AGTR1, model-based multifactor dimensionality reduction (MB-MDR) analyses for gene-gene interactions revealed that all the models were significantly associated with the increased risk of NAFLD (p < 0.05) except the 2-, 10-, 11-, and 12-locus models. Further, among the 10 SNPs negatively associated with NAFLD, the four-locus model (rs13431696 and rs3856806 in PPARγ, and rs5182, rs1492100 in ATGR1) and the five-locus model (rs9817428, rs1175543, rs13433696, and rs2920502 in PPARγ, and rs1492100 in ATGR1) were closely related with NAFLD susceptibility (p = 0.019 and p = 0.048, respectively).

CONCLUSION

Our present study suggests that interactions among multiple AGTR1 and PPARγ polymorphisms are associated with the risk of NAFLD in the Chinese population.

Metabolic Syndrome in Patients with Non-alcoholic Fatty Liver Disease: A Community Based Cross-sectional study

Background Non-alcoholic fatty liver disease (NAFLD) is the deposition of fat inside liver cells in the absence of secondary causes. It is considered as a hepatic complication of metabolic syndrome. The metabolic syndrome consists of dyslipidemia, hypertension, diabetes, and obesity. This study aims to determine the prevalence of metabolic syndrome in Nepalese patients with NAFLD from mid-Western part of Nepal. Method This was a descriptive cross-sectional study. Three different sites were chosen in and around Butwal sub-metropolitan city of Rupandehi district, Nepal. A one-day health camp for the screening of fatty liver disease by ultrasonography (USG) was conducted at these sites. Participants with fatty liver were then classified into three grades by USG and the presence of metabolic syndrome was assessed by the National Cholesterol Education Program Adult Treatment Panel III (NCEP-ATPIII) criteria. Results A total of 385 participants with NAFLD were evaluated. Presence of metabolic syndrome by NCEP-ATPIII criteria was found to be in 57.6% participants; whereas, at least one component of metabolic syndrome was found in 91.4% of participants with radiologic features of fatty liver. Higher proportion of patients with NAFLD were males. Increased waist circumference followed by low high-density lipoprotein (HDL) level were the most common components of metabolic syndrome in participants with NAFLD. Conclusions Metabolic syndrome is common in Nepalese community patients with NAFLD.

Hepatic Steatosis Assessment Using Quantitative Ultrasound Parametric Imaging Based on Backscatter Envelope Statistics

Hepatic steatosis is a key manifestation of non-alcoholic fatty liver disease (NAFLD). Early detection of hepatic steatosis is of critical importance. Currently, liver biopsy is the clinical golden standard for hepatic steatosis assessment. However, liver biopsy is invasive and associated with sampling errors. Ultrasound has been recommended as a first-line diagnostic test for the management of NAFLD. However, B-mode ultrasound is qualitative and can be affected by factors including image post-processing parameters. Quantitative ultrasound (QUS) aims to extract quantified acoustic parameters from the ultrasound backscattered signals for ultrasound tissue characterization and can be a complement to conventional B-mode ultrasound. QUS envelope statistics techniques, both statistical model-based and non-model-based, have shown potential for hepatic steatosis characterization. However, a state-of-the-art review of hepatic steatosis assessment using envelope statistics techniques is still lacking. In this paper, envelope statistics-based QUS parametric imaging techniques for characterizing hepatic steatosis are reviewed and discussed. The reviewed ultrasound envelope statistics parametric imaging techniques include acoustic structure quantification imaging, ultrasound Nakagami imaging, homodyned-K imaging, kurtosis imaging, and entropy imaging. Future developments are suggested.

Role of intestinal microbiota in the formation of non-alcoholic fatty liver disease

The article provides an overview of modern views on the role of intestinal microbiota in the formation of non-alcoholic fatty liver disease. The general questions of the pathogenesis of the syndrome of excessive bacterial growth in the intestine, the participation of opportunistic microflora, the deficit of representatives of normal microflora, changes in the species composition of bile acids in the pathogenesis of nonalcoholic fatty liver disease are considered.

YAP and TAZ Heterogeneity in Primary Liver Cancer: An Analysis of Its Prognostic and Diagnostic Role

Primary liver cancer comprises a diverse group of liver tumors. The heterogeneity of these tumors is seen as one of the obstacles to finding an effective therapy. The Hippo pathway, with its downstream transcriptional co-activator Yes-associated protein (YAP) and transcriptional co-activator with PDZ-binding motif (TAZ), has a decisive role in the carcinogenesis of primary liver cancer. Therefore, we examined the expression pattern of YAP and TAZ in 141 patients with hepatocellular carcinoma keratin 19 positive (HCC K19⁺), hepatocellular carcinoma keratin 19 negative (HCC K19⁻), combined hepatocellular–cholangiocarcinoma carcinoma (cHCC-CCA), or cholangiocarcinoma (CCA). All cHCC-CCA and CCA patients showed high expression levels for YAP and TAZ, while only some patients of the HCC group were positive. Notably, we found that a histoscore of both markers is useful in the challenging diagnosis of cHCC-CCA. In addition, positivity for YAP and TAZ was observed in the hepatocellular and cholangiocellular components of cHCC-CCA, which suggests a single cell origin in cHCC-CCA. Within the K19⁻ HCC group, our results demonstrate that the expression of YAP is a statistically significant predictor of poor prognosis when observed in the cytoplasm. Nuclear expression of TAZ is an even more specific and independent predictor of poor disease-free survival and overall survival of K19⁻ HCC patients. Our results thus identify different levels of YAP/TAZ expression in various liver cancers that can be used for diagnostics.

The OMICs Window into Nonalcoholic Fatty Liver Disease (NAFLD)

Nonalcoholic fatty liver disease (NAFLD) is a common cause of hepatic abnormalities worldwide. Nonalcoholic steatohepatitis (NASH) is part of the spectrum of NAFLD and leads to progressive liver disease, such as cirrhosis and hepatocellular carcinoma. In NASH patient, fibrosis represents the major predictor of liver-related mortality; therefore, it is important to have an early and accurate diagnosis of NASH. The current gold standard for the diagnosis of NASH is still liver biopsy. The development of biomarkers able to predict disease severity, prognosis, as well as response to therapy without the need for a biopsy is the focus of most up-to-date genomic, transcriptomic, proteomic, and metabolomic research. In the future, patients might be diagnosed and treated according to their molecular signatures. In this short review, we discuss how information from genomics, proteomics, and metabolomics contribute to the understanding of NAFLD pathogenesis.

NAFLD Induction Delays Postoperative Liver Regeneration of ALPPS in Rats

BACKGROUND

Associating liver partition and portal vein ligation (ALPPS) is a promising two-step hepatectomy that is beneficial for accumulative regeneration of the future liver remnant (FLR) and avoids postoperative liver failure.

AIMS

Our study aimed to evaluate whether nonalcoholic fatty liver disease affected the liver regeneration induced by ALPPS.

METHODS

Sprague-Dawley rats fed a high-fat diet were used to construct the NAFLD model. ALPPS were performed, and blood and future liver remnant samples were collected at postoperative days 1 (POD1), POD3, and POD7.

RESULTS

The hepatic regeneration rate (HRR) of ALPPS was higher than that of portal vein ligation (PVL) at POD3 and POD7 (p < 0.05), and the number of Ki-67-positive hepatocytes (POD3) and CD68-positive Kupffer cells (POD7) per visual field was higher in the ALPPS group than in the PVL group (p < 0.05). The serum TNF-α, hepatocyte growth factor protein, and the serum IL-6 level were higher in the ALPPS group than in the PVL group at POD3 and POD7. Compared with those of the standard laboratory diet (SLD)-fed rats, the rats with NAFLD exhibited a decrease in the HRR, Ki-67-positive hepatocytes, and CD68-positive Kupffer cells in the FLR. The number of CD68-positive Kupffer cells was lower in rats with NAFLD than that in SLD-fed rats; noteworthily, the serum level of IL-6 and TNF-α changed dramatically after surgeries.

CONCLUSIONS

NAFLD induction delayed liver regeneration induced by the ALPPS procedure, which might be associated with hepatocyte proliferation and the number of Kupffer cells.

Multiparametric ultrasound in liver diseases: an overview for the practising clinician

Ultrasound (US) is usually the first and most commonly used tool in the diagnostic algorithm for liver disease. It is widely available, non-invasive and offers a real-time assessment of the liver in several anatomic planes, using different US modalities such as greyscale imaging, Doppler, elastography and contrast-enhanced US. This multiparametric ultrasound (MPUS) provides more information of the examined structures and allows for a faster and more accurate diagnosis, usually at the point of care, thus reducing the requirement for some invasive and more expensive methods. Current data on the MPUS in hepatology are summarised in this review, mostly focused on its use for non-invasive staging of liver fibrosis, detection and classification of portal hypertension and oesophageal varices, prognosis in chronic liver diseases and characterisation of focal liver lesions (FLLs). Based on the available data, we propose practical algorithms for clinical use of MPUS in chronic liver disease and FLL.

The Mexican consensus on nonalcoholic fatty liver disease

Nonalcoholic fatty liver disease (NAFLD) affects nearly one third of the population worldwide. Mexico is one of the countries whose population has several risk factors for the disease and its prevalence could surpass 50%. If immediate action is not taken to counteract what is now considered a national health problem, the medium-term panorama will be very bleak. This serious situation prompted the Asociación Mexicana de Gastroenterología and the Asociación Mexicana de Hepatología to produce the Mexican Consensus on Fatty Liver Disease. It is an up-to-date and detailed review of the epidemiology, pathophysiology, clinical forms, diagnosis, and treatment of the disease, whose aim is to provide the Mexican physician with a useful tool for the prevention and management of nonalcoholic fatty liver disease.