Prevalence of fatty liver in Japanese children and relationship to obesity. An epidemiological ultrasonographic survey

Role of pan immune inflammatory value in the evaluation of hepatosteatosis in children and adolescents with obesity

OBJECTIVES

Inflammation is a feature of non-alcoholic fatty liver disease progression and plays an important role in hepatic steatosis and fibrosis. Since there are no studies in the literature showing the relationship between hepatosteatosis with the systemic immune-inflammation index (SII) and pan-immune inflammation value (PIV), we aimed to evaluate the relationship between these biomarkers and hepatosteatosis in childhood.

METHODS

We included 133 consecutive obese children and adolescents aged 6-18 years into this single-center, retrospective, and cross-sectional study. Anthropometric, physical examination, radiological and laboratory data were obtained and recorded from the file records of each case.

RESULTS

When we grouped the patient population according to the grade of hepatosteatosis, there was a statistically significant difference between the groups in terms of SII and PIV values (p<0.05, for both). In the analyzes performed to identify independent predictors of hepatosteatosis pubertal status (p=0.019) and PIV value (p<0.001) were found to be significant as independent predictors. Moreover, in the analysis performed to predict severity of hepatic steatosis, regression analysis was performed by dividing the groups into groups with and without severe adiposity. As a result of this analysis, HOMA-IR (p=0.019) and PIV value (p=0.028) were found to be significant in the prediction of severe hepatic adiposity.

CONCLUSIONS

Our findings showed that increased PIV levels were associated with the presence and severity of hepatic steatosis, but not with SII.

Correlation between Transient Elastography (Fibroscan®) and Ultrasonographic and Computed Tomographic Grading in Pediatric Nonalcoholic Steatohepatitis

PURPOSE

This study aimed to examine the advantages and usefulness of transient elastography (Fibroscan^®) in diagnosing non-alcoholic steatohepatitis in children and adolescents compared to those of abdominal computed tomography and liver ultrasonography.

METHODS

Forty-six children and adolescent participants aged between 6 and 16 years who underwent transient elastography (Fibroscan^®) as well as liver ultrasonography or abdominal computed tomography were included. Thirty-nine participants underwent liver ultrasonography and 11 underwent computed tomography. The physical measurements, blood test results, presence of metabolic syndrome, and the degree of liver steatosis and liver fibrosis were analyzed, and their correlations with transient elastography (Fibroscan^®), abdominal computed tomography, and liver ultrasonography, as well as the correlations between examinations, were analyzed.

RESULTS

Thirty-six participants (78.3%) were boys, and the mean age was 12.29±2.57 years, with a mean body mass index of 27.88±4.28. In the 46 participants, the mean values for aspartate aminotransferase, alanine aminotransferase, and total bilirubin were 89.87±118.69 IU/L, 138.54±141.79 IU/L, and 0.77±0.61 mg/dL, respectively. Although transient elastography (Fibroscan^®) and abdominal computed tomography grading had a statistically significant positive correlation with aspartate aminotransferase and alanine aminotransferase values, the correlations between the results of grading performed by transient elastography (Fibroscan^®), abdominal computed tomography, and liver ultrasonography were not statistically.

CONCLUSION

We confirmed that each examination was correlated with the results of some blood tests, suggesting the usefulness and possibility of diagnosis and treatment of steatohepatitis mediated by transient elastography (Fibroscan^®) in the department of pediatrics.

Longitudinal study of body mass index and percentage of overweight in Japanese children grouped by maturity

Childhood obesity is a known risk factor for adult diseases, making its evaluation highly important. However, the evaluation is complex because there is no gold standard method. Body mass index (BMI) and percentage of overweight (POW) are widely used in Japan. However, they have the following limitations: it is difficult to set cutoffs for BMI because it dynamically varies in childhood, and POW has not been studied extensively, especially regarding its difference during maturity. Therefore, our study analyzed BMI/POW in Japanese children grouped by maturity. We used longitudinal school check-up data collected from elementary and junior high schools in 20 municipalities. We made percentile curves of BMI/POW and calculated the percentage of participants considered overweight/obese by sex, age, and maturity. Maximum increment age (MIA) was calculated using the graphical fitting method. We included 35,461 subjects aged 15 in 2018. Early-maturing children had higher BMI. The difference among maturity groups decreased by shifting the percentile curves by differences in MIA. Therefore, the use of BMI might lead to the overestimation of overweight/obesity in early-maturing children and underestimation in late-maturing children. The POW percentile curves were "N"-shaped around the MIA, indicating the inappropriate evaluation during this period. The percentile curves of children categorized as overweight/obese were also "N"-shaped, confirming that MIA affects the evaluation of childhood obesity. The possibility of overestimation/underestimation needs verification with the data of accurate age, pubertal changes, and adult diseases. In conclusion, it is difficult to evaluate childhood obesity only with height and weight.

Total cholesterol to high-density lipoprotein ratio and nonalcoholic fatty liver disease in a population with chronic hepatitis B

BACKGROUND

Nonalcoholic fatty liver disease (NAFLD) is characterized by hypertriglyceridemia, increased low-density lipoprotein cholesterol levels, and reduced high-density lipoprotein cholesterol (HDL-C) particles. Previous studies have shown that the total cholesterol to high-density lipoprotein cholesterol ratio (TC/HDL-C) was superior to other lipid metabolism biomarkers for predicting NAFLD risk and could be a new indicator of NAFLD. However, the association between TC/HDL-C and NAFLD in patients with hepatitis B virus (HBV) has not yet been determined.

AIM

To investigate the association between TC/HDL-C and NAFLD in a population with chronic hepatitis B (CHB).

METHODS

In this study, 183 HBV-infected patients were enrolled. All participants underwent blood chemistry examinations and abdominal ultrasound. Univariate and multivariate logistic regression models, curve fitting analysis, and threshold calculation were used to assess the relationship between TC/HDL-C and NAFLD.

RESULTS

The overall prevalence of NAFLD was 17.49% (n = 32) in the 183 CHB participants. The TC/HDL-C of non-NAFLD and NAFLD patients were 3.83 ± 0.75 and 4.44 ± 0.77, respectively (P < 0.01). Logistic regression analysis showed that TC/HDL-C was not associated with NAFLD after adjusting for other pertinent clinical variables. However, at an optimal cutoff point of 4.9, a non-linear correlation between TC/HDL-C and NAFLD was detected. The effect size of the left and right sides of the inflection point were 5.4 (95% confidence interval: 2.3-12.6, P < 0.01) and 0.5 (95% confidence interval: 0.1-2.2, P = 0.39), respectively. On the left side of the inflection point, TC/HDL-C was positively associated with NAFLD. However, no significant association was observed on the right side of the inflection point.

CONCLUSION

This study demonstrated a non-linear correlation between TC/HDL-C and NAFLD in a population with CHB. TC/HDL-C was positively associated with NAFLD when TC/HDL-C was less than 4.9 but not when TC/HDL-C was more than 4.9.

Prospective assessment of liver stiffness by shear wave elastography in childhood obesity: a pilot study

PURPOSE

The increased incidence of childhood obesity and related non-alcoholic fatty liver disease (NAFLD) has determined the need to identify a non-invasive technique to diagnose and monitor NAFLD. Two-dimensional shear wave elastography (2D-SWE) has emerged as a reliable, non-invasive, tool to evaluate liver tissue elasticity in clinical practice. Aims of this study were to longitudinally evaluate 2D-SWE changes in relation to weight loss, metabolic profile, and body composition modifications and to investigate the correlation between 2D-SWE variation and clinical and biochemical indices of cardio-metabolic risk in obese children.

METHODS

Thirty-three children underwent anthropometric, bioimpedenziometric, fasting biochemical assessments, ultrasound, and SWE evaluations, at baseline (V0) and after a 12-months of follow-up (V12). Diet and physical activity programs have been prescribed to all patients according to European Society of Endocrinology and Pediatric Endocrine Society recommendations. Adherence to the prescribed diet and physical activity program was checked every 3 months during the 12-month of follow-up. Variation of all parameters was evaluated in intragroup and intergroup comparison analysis in children, who had not lost weight (Group A) and those who had lost weight (Group B) at V12. Study population was also analyzed dividing it into two groups with respect to 2D-SWE liver elasticity value ≤10.6 kPa or >10.6 kPa.

RESULTS

A significant reduction of mean 2D-SWE value was demonstrated both in the entire cohort (p = 0.002) and in Group B children (p = 0.004). Intragroup comparison analysis, between V0 and V12, documented a significant decrease of 2D-SWE and BMI SDS and a significant improvement of metabolic profile (decrease of HOMA-IR, HbA1c, oral glucose tolerance test 120-min glucose and insulin, triglycerides, triglycerides/HDL-ratio, transaminases, uric acid, and increase of Matsuda-index and HDL) in children of Group B but not in those of Group A. Intergroup comparison analysis showed significant differences for BMI, BMI SDS, transaminases and several parameters of glucose and lipid metabolism, between Group A and Group B children after 12-months of follow-up. No significant differences were documented with regard to clinical and biochemical variables by dividing the population in accordance with the 2D-SWE cut-off of 10.6 kPa.

CONCLUSIONS

These results suggested a relation between weight loss, metabolic profile improvement and 2D-SWE value reduction. SWE could play a significant role in the non-invasive assessment of NAFLD in children and adolescents with obesity.

Triglyceride to high-density lipoprotein cholesterol ratio is an independent predictor of liver fibrosis among pediatrics non-alcoholic fatty liver disease

BACKGROUND

Insulin resistance (IR), one of the key components of the metabolic syndrome, is recognized as the pathophysiological hallmark of non-alcoholic fatty liver disease (NAFLD). This study aims to investigate the relationship between surrogate markers of IR and the severity of NAFLD among overweight or obese children.

METHODOLOGY

A total of 56 consecutive children aged 6 to 18 years old were recruited from the pediatric obesity and type 2 diabetes mellitus (T2DM) clinic in University Malaya Medical Centre (UMMC) from 2016 to 2019. Data on anthropometric measurements, clinical components of metabolic syndrome and fasting serum insulin were collected. Triglyceride to high-density lipoprotein cholesterol ratio (TG: HDL-C), Homeostatic Model Assessment for Insulin Resistance (HOMA-IR) and Single Point Insulin Sensitivity Estimator (SPISE) were calculated. Transient elastography was performed with hepatic steatosis and liver fibrosis assessed by controlled attenuation parameter (CAP) and liver stiffness measurement (LSM), respectively.

RESULTS

A total of 44 children (78.6%) had liver steatosis and 35.7% had presence of significant liver fibrosis (stage F≥2). Majority (89.3%) are obese and 24 children (42.9%) were diagnosed with metabolic syndrome. Higher number of children with T2DM and significant liver fibrosis were associated with higher tertiles of TG: HDL-C ratio (p<0.05). Top tertile of TG: HDL-C ratio was an independent predictor of liver fibrosis (OR=8.14, 95%CI: 1.24-53.36, p=0.029). ROC analysis showed that the area under the curve (AUC) of HOMA-IR (0.77) and TG: HDL-C ratio (0.71) were greater than that of metabolic syndrome (0.70), T2DM (0.62) and SPISE (0.22). The optimal cut-off values of HOMA-IR and TG: HDL-C ratio for detecting liver fibrosis among children with NAFLD are 5.20 and 1.58, respectively.

CONCLUSION

Children with NAFLD and higher TG: HDL-C ratio are more likely to have liver fibrosis. TG: HDL-C ratio is a promising tool to risk stratify those with NAFLD who are at risk of developing advanced liver disease.

Prevalence and risk factors of steatosis and advanced fibrosis using transient elastography in the United States’ adolescent population

BACKGROUND

Non-alcoholic fatty liver disease (NAFLD) is the leading cause of chronic liver disease in children and adolescents.

AIM

To determine the prevalence and risk factors of steatosis and advanced fibrosis using transient elastography (TE) in the United States’ adolescent population.

METHODS

Using the National Health and Nutrition Examination Survey 2017-2018, adolescent participants aged 13 to 17 years who underwent TE and controlled attenuation parameter (CAP) were included in this study. Forty-one factors associated with liver steatosis and fibrosis were collected. Univariate and multivariate linear regression analysis were used to identify statistically significant predictors.

RESULTS

Seven hundred and forty participants met inclusion criteria. Steatosis (S1-S3), based on CAP, and advanced fibrosis (F3-F4), based on TE, were present in 27% and 2.84% of the study population, respectively. Independent predictors of steatosis grade included log of alanine aminotransferase, insulin resistance, waist-to-height ratio, and body mass index. Independent predictors of fibrosis grade included steatosis grade, non-Hispanic black race, smoking history, and systolic blood pressure.

CONCLUSION

This study demonstrated a high prevalence of steatosis in the United States’ adolescent population. Almost 3% of United States’ adolescents had advanced fibrosis. These findings are concerning because a younger age of onset of NAFLD can lead to an earlier development of severe disease, including steatohepatitis, cirrhosis, and liver decompensation.

Conventional ultrasound for diagnosis of hepatic steatosis is better than believed

BACKGROUND

Hepatic steatosis is a condition frequently encountered in clinical practice, with potential progression towards fibrosis, cirrhosis, and hepatocellular carcinoma. Detection and staging of hepatic steatosis are of most importance in nonalcoholic fatty liver disease (NAFLD), a disease with a high prevalence of more than 1 billion individuals affected. Ultrasound (US) is one of the most used noninvasive imaging techniques used in the diagnosis of hepatic steatosis. Detection of hepatic steatosis with US relies on several conventional US parameters, which will be described. US is the first-choice imaging in adults at risk for hepatic steatosis. The use of some scoring systems may add additional accuracy especially in assessing the severity of hepatic steatosis.

SUMMARY

In the presented paper, we discuss screening and risk stratification, ultrasound features for diagnosing hepatic steatosis, B-mode criteria, focal fatty patterns and Doppler features of the hepatic vessels, and the value of the different US signs for the diagnosis of liver steatosis including classifying the severity of steatosis using different US scores. Limitations of conventional B-mode and Doppler features in the evaluation of hepatic steatosis are also discussed, including those in grading and assessing the complications of steatosis, namely fibrosis and nonalcoholic steatohepatitis.

KEY MESSAGES

Ultrasound is the first-line imaging examination for the screening and follow-up of patients with liver steatosis. The use of some scoring systems may add additional accuracy in assessing the severity of steatosis. Conventional B-mode and Doppler ultrasound have limitations in grading and assessing the complications of steatosis.

Role of the Gut Microbiota in Regulating Non-alcoholic Fatty Liver Disease in Children and Adolescents

Non-alcoholic fatty liver disease (NAFLD) is the most common form of chronic liver disease in children and adolescents. Although obesity is the leading cause of NAFLD, the etiologies of NAFLD are multifactorial (e.g., high-fat diet, a lack of exercise, gender, maternal obesity, the antibiotic use), and each of these factors leads to dysbiosis of the gut microbiota community. The gut microbiota is a key player in the development and regulation of the gut mucosal immune system as well as the regulation of both NAFLD and obesity. Dysbiosis of the gut microbiota promotes the development of NAFLD via alteration of gut-liver homeostasis, including disruption of the gut barrier, portal transport of bacterial endotoxin (lipopolysaccharide) to the liver, altered bile acid profiles, and decreased concentrations of short-chain fatty acids. In terms of prevention and treatment, conventional approaches (e.g., dietary and exercise interventions) against obesity and NAFLD have been confirmed to recover the dysbiosis and dysbiosis-mediated altered metabolism. In addition, increased understanding of the importance of gut microbiota-mediated homeostasis in the prevention of NAFLD suggests the potential effectiveness of gut microbiota-targeted preventive and therapeutic strategies (e.g., probiotics and fecal transplantation) against NAFLD in children and adolescents. This review comprehensively summarizes our current knowledge of the gut microbiota, focusing on its interaction with NAFLD and its potential therapeutic role in obese children and adolescents with this disorder.

The Peculiar Trialogue between Pediatric Obesity, Systemic Inflammatory Status, and Immunity

Pediatric obesity is not only an energetic imbalance, but also a chronic complex multisystem disorder that might impair both the life length and quality. Its pandemic status should increase worldwide awareness regarding the long-term life-threatening associated complications. Obesity related complications, such as cardiovascular, metabolic, or hepatic ones, affect both short and long-term wellbeing, and they do not spare pediatric subjects, defined as life-threatening consequences of the systemic inflammatory status triggered by the adipose tissue. The energetic imbalance of obesity clearly results in adipocytes hypertrophy and hyperplasia expressing different degrees of chronic inflammation. Adipose tissue might be considered an immune organ due to its rich content in a complex array of immune cells, among which the formerly mentioned macrophages, neutrophils, mast cells, but also eosinophils along with T and B cells, acting together to maintain the tissue homeostasis in normal weight individuals. Adipokines belong to the class of innate immunity humoral effectors, and they play a crucial role in amplifying the immune responses with a subsequent trigger effect on leukocyte activation. The usefulness of complete cellular blood count parameters, such as leukocytes, lymphocytes, neutrophils, erythrocytes, and platelets as predictors of obesity-triggered inflammation, was also proved in pediatric patients with overweight or obesity. The dogma that adipose tissue is a simple energy storage tissue is no longer accepted since it has been proved that it also has an incontestable multifunctional role acting like a true standalone organ resembling to endocrine or immune organs.

Non-Alcoholic Fatty Liver Disease: Metabolic, Genetic, Epigenetic and Environmental Risk Factors

Non-alcoholic fatty liver disease (NAFLD) is one of the most frequent causes of chronic liver disease in the Western world, probably due to the growing prevalence of obesity, metabolic diseases, and exposure to some environmental agents. In certain patients, simple hepatic steatosis can progress to non-alcoholic steatohepatitis (NASH), which can sometimes lead to liver cirrhosis and its complications including hepatocellular carcinoma. Understanding the mechanisms that cause the progression of NAFLD to NASH is crucial to be able to control the advancement of the disease. The main hypothesis considers that it is due to multiple factors that act together on genetically predisposed subjects to suffer from NAFLD including insulin resistance, nutritional factors, gut microbiota, and genetic and epigenetic factors. In this article, we will discuss the epidemiology of NAFLD, and we overview several topics that influence the development of the disease from simple steatosis to liver cirrhosis and its possible complications.

Hepcidin Levels and Pathological Characteristics in Children with Fatty Liver Disease

PURPOSE

Hepcidin levels have previously been reported to be correlated with liver damage. However, the association between hepcidin levels and liver fibrosis in children with fatty liver disease remains unclear. This study therefore aimed to investigate the pathophysiology of fibrosis in children with fatty liver disease and its association with hepcidin levels.

METHODS

This retrospective case series included 12 boys aged 6-17 years who were diagnosed with nonalcoholic fatty liver disease (NAFLD) or nonalcoholic steatohepatitis (NASH) at the Tokyo Medical University Hospital. Sixteen liver biopsy samples from 12 subjects were analyzed. Serum hepcidin levels were assayed using enzyme-linked immunosorbent assay. Immunostaining for hepcidin was performed, and the samples were stratified by staining intensity.

RESULTS

Serum hepcidin levels were higher in pediatric NAFLD/NASH patients than in controls. Conversely, a significant inverse correlation was observed between hepcidin immunostaining and Brunt grade scores and between hepcidin scores and gamma-glutamyltranspeptidase, hyaluronic acid, and leukocyte levels. We observed inverse correlations with a high correlation coefficient of >0.4 between hepcidin immunostaining and aspartate aminotransferase, alanine aminotransferase, total bile acid, and platelet count.

CONCLUSION

There was a significant inverse correlation between hepcidin immunoreactivity and fibrosis in pediatric NAFLD patients; however, serum hepcidin levels were significantly higher, suggesting that these patients experienced a reduction in the hepcidin-producing ability of the liver in response to iron levels, leading to subsequent fibrosis. Therefore, hepcidin levels can be used as markers to identify the progression of fibrosis in patients with NAFLD.

Non-Alcoholic Fatty Liver Disease in Obese Youth With Insulin Resistance and Type 2 Diabetes

Currently, Non-Alcoholic Fatty Liver Disease (NAFLD) is the most prevalent form of chronic liver disease in children and adolescents worldwide. Simultaneously to the epidemic spreading of childhood obesity, the rate of affected young has dramatically increased in the last decades with an estimated prevalence of NAFLD of 3%-10% in pediatric subjects in the world. The continuous improvement in NAFLD knowledge has significantly defined several risk factors associated to the natural history of this complex liver alteration. Among them, Insulin Resistance (IR) is certainly one of the main features. As well, not surprisingly, abnormal glucose tolerance (prediabetes and diabetes) is highly prevalent among children/adolescents with biopsy-proven NAFLD. In addition, other factors such as genetic, ethnicity, gender, age, puberty and lifestyle might affect the development and progression of hepatic alterations. However, available data are still lacking to confirm whether IR is a risk factor or a consequence of hepatic steatosis. There is also evidence that NAFLD is the hepatic manifestation of Metabolic Syndrome (MetS). In fact, NAFLD often coexist with central obesity, impaired glucose tolerance, dyslipidemia, and hypertension, which represent the main features of MetS. In this Review, main aspects of the natural history and risk factors of the disease are summarized in children and adolescents. In addition, the most relevant scientific evidence about the association between NAFLD and metabolic dysregulation, focusing on clinical, pathogenetic, and histological implication will be provided with some focuses on the main treatment options.

The gap between overweight and obesity status in children - (STROBE-compliant article)

Overweight might represent only the early stage of obesity or it might act as a trigger of self-awareness turning into an ideal chance for preventing further obesity development.The aim of this study was to assess the differences between overweight and obese children in terms of anthropometric, low-grade systemic inflammation, liver impairment and atherosclerotic risk.We performed a study on 132 children aged between 5 and 18 years, divided according to the BMI into 2 groups: group 1 to 76 obese children, and group 2 to 56 overweight children, assessing anthropometric, laboratory and elastography parameters.We obtained significantly higher values of anthropometric parameters in obese children versus overweight ones. We found higher levels of leukocytes, lymphocytes, AST, ALT, and E median (P = .0345, P = .0103, P < .0001, P = .0008 and P < .0001) in the obese group as compared to the overweight one. BMI was positively correlated with neutrophils, NLR, ESR, glycemia, anthropometric parameters, and E median (P = .0007/<.0001/.0018/.0044/<.0001/<.0001/<.0001/<.0001/<.0001/.0204); and negatively with lymphocytes and HDL-cholesterol (r = -0.2747/-0.2181, P = .0116/.0120).Our study underlined significant differences between overweight and obese children in terms of inflammatory status and liver impairment suggesting that the risk is directly related to the increase in BMI.

Effects of obesity reduction on transient elastography-based parameters in pediatric non-alcoholic fatty liver disease

AIM

To clarify the effects of obesity reduction on non-alcoholic fatty liver disease (NAFLD) in obese children.

METHODS

Twenty-six obese pediatric NAFLD patients (median age, 13.0 years; range, 6.4-16.6 years), who underwent obesity management supported by regular hospital visits and/or hospital admission, were studied to explore how reductions in weight and body mass index (BMI) percentile affected two transient elastography-based parameters: controlled attenuation parameter (CAP) and liver stiffness (LS), which reflect the degree of hepatic fat deposition and liver fibrosis, respectively.

RESULTS

Univariate analysis revealed that CAP reduction was correlated positively with baseline CAP and reductions in weight and BMI percentile (r = 0.320-0.525), whereas LS reduction was correlated positively with baseline LS and reductions in weight, BMI percentile, aspartate transaminase, and alanine aminotransferase (r = 0.385-0.625). Multivariate analysis revealed that baseline CAP and reduction in weight were significantly associated with CAP reduction, whereas reduction in weight and alanine aminotransferase were significantly associated with LS reduction. Short-term weight control by hospital admission (24.9 ± 9.5 days) provided significantly higher reductions in weight and BMI percentile (both P < 0.001) and was associated with reductions of CAP and LS (P = 0.04 and 0.01) compared with regular hospital visit-supported self-directed weight management (0.9 ± 0.8 years).

CONCLUSIONS

Weight reduction in obese pediatric NAFLD patients resulted in reduced hepatic fat deposition and liver stiffness. Weight control by short-term hospital admission is an alternative approach to regular hospital visit-supported self-directed weight management in NAFLD patients who fail to reduce obesity.

The change in prevalence of suspected non-alcoholic fatty liver disease in Korean adolescents from 2001 to 2017

AIM

Data on trends in the prevalence of suspected non-alcoholic fatty liver disease (NAFLD) in adolescents are scarce, especially in the Asia-Pacific region. The purpose of this study was to determine whether the prevalence of suspected NAFLD changed between 2001-2005 and 2015-2017.

METHODS

Data were extracted from the Korea National Health and Nutrition Examination Survey (2001-2005 to 2015-2017, n = 4448). Suspected NAFLD was defined by an elevated alanine aminotransferase (ALT) level of >26 IU/L in boys and >22 IU/L in girls. In addition, the analysis was repeated using the Korean cut-off levels for ALT of 33 IU/L for boys and 25 IU/L for girls.

RESULTS

The prevalence of suspected NAFLD increased, with a relative increase of 44% from 7.8% (95% CI 6.6-9.2%) in 2001-2005 to 11.2% (95% CI 9.7-12.9%) in 2015-2017 (p = 0.001). This increase was evident in both boys (10.6 vs 14.7%, p = 0.01) and girls (4.6 vs 7.4%, p = 0.02). Increases were also observed in obesity (7.3 vs 10.6%), central obesity (10.0 vs 12.8%) and ALT level (14.9 vs 16.7 IU/L). The prevalence of suspected NAFLD was approximately 40-45% in obese/central obese adolescents in 2015-2017. Using the Korean cut-off levels, the prevalence of suspected NAFLD has increased, with a relative increase of 55%, from 4.6% (95% CI 3.7-5.7%) in 2001-2005 to 7.2% (95% CI 6.1-8.5%) in 2015-2017 (p = 0.01).

CONCLUSIONS

The prevalence of suspected NAFLD continues to increase in Korean adolescents.

ABBREVIATIONS

ALT, alanine aminotransferase; BMI, body mass index; KNHANES, Korea National Health and Nutrition Examination Survey; NAFLD, non-alcoholic fatty liver disease.

Ultrasound elastography in patients with fatty liver disease

Hepatic steatosis, or fatty liver disease, occurs due to the accumulation of lipids in hepatocytes. When it becomes chronic, lobular inflammation develops and the disease can evolve to hepatic fibrosis, liver cirrhosis, or hepatocellular carcinoma. Early diagnosis is desirable because patients diagnosed in the early stage of the disease respond better to treatment. In the early stages of fatty liver disease, the physical examination is often unremarkable. Fatty liver disease and hepatic fibrosis can be diagnosed and monitored through laboratory tests, imaging, and biopsy. Among the imaging methods, ultrasound stands out as an effective means of diagnosing and following patients with liver disease. Ultrasound used in conjunction with elastography (ultrasound elastography) has recently shown great utility in the follow-up of such patients. Ultrasound elastography studies the degree of deformation (stiffness) of an organ or lesion, so that when there is hardening, fibrosis, or cirrhosis of the liver, those alterations are well demonstrated. In this review article, we discuss the application of the different types of ultrasound elastography for liver studies: transient elastography, point shear wave elastography, and two-dimensional shear wave elastography. Although magnetic resonance elastography may also be used in the analysis of liver fibrosis, it will not be addressed in this article.

Revision of serum ALT upper limits of normal facilitates assessment of mild liver injury in obese children with non-alcoholic fatty liver disease

Background

The serum alanine aminotransferase (ALT) level is a critical parameter for evaluating liver injury in non‐alcoholic fatty liver disease (NAFLD). However, the currently accepted upper limits of normal (ULN) for serum ALT (ULN‐ALT) are debated, as they may be excessively high.

Methods

A total of 1638 children aged 6‐16 years, comprising 507 children with normal BMI (500 healthy children and 7 children with NAFLD), 199 overweight children, and 932 obese children, were included in the analysis. We re‐evaluated the ULN‐ALT in 500 healthy Chinese children using the 95th percentiles of serum ALT levels as revised ULN‐ALT. Fatty liver was identified by ultrasound examination.

Results

Significant positive correlations between serum ALT levels and body mass index (BMI) were detected in overweight boys (r = .399, P < .001), obese boys (r = .398, P < .001), and obese girls (r = .392, P < .001). The prevalence percentages of NAFLD were 93.6%, 75.8%, and 37.9% in obese boys with serum ALT levels of >50, 25‐50, and ≤25 U/L and were 81.6%, 67.9%, and 20.6% in obese girls with serum ALT levels of >40, 20‐40, and ≤20 U/L, respectively.

Conclusion

Serum ALT levels significantly correlated with abnormal BMI values in children, suggesting a rigorous BMI threshold is needed to establish the cutoffs for serum ULN‐ALT in children. Besides, the revised serum ULN‐ALT can uncover mild liver injury in obese children with NAFLD.

The assessment of liver fibrosis in children with obesity on two methods: transient and two dimensional shear wave elastography

The aim of this study was to assess the liver stiffness values in children with obesity versus healthy children on 2D-SWE and TE taking into account different laboratory parameters. We performed a case-control study on 287 children aged between 3 to 18 years, admitted in a Romanian Pediatric Tertiary Hospital, which we divided according to the body mass index (BMI) into two groups: the study group-77 children with obesity, and control group-210 children with normal weight. All children underwent anamnesis, clinical exam, laboratory parameters, ultrasound exam, and elastography. Children with obesity presented higher values of platelets, AST, ALT, and AAR as compared to control group (p = 0.0005/p = 0.0065/p < 0.0001/p < 0.0001). We found no significant differences for APRI between the two groups (p = 0.9827), although the values were higher in children with obesity. Significantly higher values of liver stiffness in children with obesity on both 2D-SWE and TE (p = 0.0314/p < 0.0001) were obtained. Similarly, the velocity values measured by 2D-SWE were also significantly higher in the study group (p < 0.0001). Our findings revealed significantly higher levels of platelets, transaminases, AAR, and liver stiffness values on both TE and 2D-SWE in children with obesity. 2D-SWE and TE might represent useful non-invasive methods for predicting liver impairment associated to pediatric obesity.

Obese boys with low concentrations of high-density lipoprotein cholesterol are at greater risk of hepatosteatosis

PURPOSE

Non-alcoholic fatty liver disease (NAFLD) and associated morbidities have become a major public health problem, with a global three-fold increase in incidence among obese children over the last three decades. Although the gold standard for diagnosis of NAFLD is liver biopsy, it is not widely used in children. Imaging techniques, including magnetic resonance imaging (MRI) and ultrasound (US), can provide information on liver fat deposition, however, with variable sensitivity. A number of other predictors are therefore being investigated for pediatric screening and diagnostic purposes. The aim of this study was to assess easily measured parameters to prompt further investigation into NAFLD in obese children.

METHODS

Obese children/adolescents with a body mass index (BMI) percentile > 95 were enrolled in the study (n = 353). After a 12-hour fast, venous glucose, insulin, cholesterol, triglycerides (TG), high-density lipoprotein (HDL), low-density lipoprotein (LDL), and uric acid were measured and a full blood count was performed in all subjects. TG/LDL ratio, AST/platelet ratio index (APRI score), and homeostatic model of assessment for insulin resistance (HOMA-IR) were calculated. All patients underwent an abdominal US examination to assess hepatosteatosis.

RESULTS

Of 353 patients, median age 12.5 (range, 6-17.9) years, 210 patients (59%) had US-proven hepatosteatosis. Female gender reduced the risk of steatosis 2.08-fold (p = 0.005), a one-unit increase in HDL reduced the risk of steatosis 1.02-fold (p = 0.042), and a one-unit increase in BMI led to a 1.11-fold (p = 0.002) increase in the risk of steatosis.

CONCLUSION

Gender, BMI, and HDL were found to be predictors of steatosis. Male patients with low HDL and high BMI are at greater risk of steatosis and should be carefully examined for the presence of NAFLD.

NAFLD in children: new genes, new diagnostic modalities and new drugs

Nonalcoholic fatty liver disease (NAFLD) has rapidly become the most common form of chronic liver disease in children and adolescents. Over the past 5 years, developments have revolutionized our understanding of the genetic factors, natural history, diagnostic modalities and therapeutic targets for this disease. New polymorphisms, such as those in PNPLA3, TM6SF2, MBOAT7 and GCKR, have been identified and used to predict the development and severity of NAFLD in both adults and children, and their interaction with environmental factors has been elucidated. Studies have demonstrated the true burden of paediatric NAFLD and its progression to end-stage liver disease in adulthood. In particular, nonalcoholic steatohepatitis can progress to advanced fibrosis and cirrhosis, emphasizing the importance of early diagnosis. Non-invasive imaging tests, such as transient elastography, will probably replace liver biopsy for the diagnosis of nonalcoholic steatohepatitis and the assessment of fibrosis severity in the near future. The therapeutic landscape is also expanding rapidly with the development of drugs that can modify liver steatosis, inflammation and fibrosis, indicating that pharmacotherapy for NAFLD will become available in the future. In this Review, we summarize current knowledge and new advances related to the pathogenesis and management of paediatric NAFLD.

Usefulness of Transient Elastography for Non-Invasive Diagnosis of Liver Fibrosis in Pediatric Non-Alcoholic Steatohepatitis

BACKGROUND

Transient elastography (FibroScan®) is a non-invasive and rapid method for assessing liver fibrosis. While the feasibility and usefulness of FibroScan® have been proven in adults, few studies have focused on pediatric populations. We aimed to determine the feasibility and usefulness of FibroScan® in Korean children.

METHODS

FibroScan® examinations were performed in 106 children (age, 5-15 years) who visited the Konyang University Hospital between June and September 2018. Liver steatosis was measured in terms of the controlled attenuation parameter (CAP), while hepatic fibrosis was evaluated in terms of the liver stiffness measurement (LSM). Children were stratified into obese and non-obese controls, according to body mass index (≥ or < 95th percentile, respectively).

RESULTS

The obese group was characterized by significantly higher levels of aspartate aminotransferase (AST, 57.00 ± 48.47 vs. 26.40 ± 11.80 IU/L; P < 0.001) and alanine aminotransferase (ALT, 91.27 ± 97.67 vs. 16.28 ± 9.78 IU/L; P < 0.001), frequency of hypertension and abdominal obesity (abdominal circumference > 95% percentile) (P < 0.001), CAP (244.4-340.98 dB/m), and LSM (3.85-7.77 kPa) (P < 0.001). On FibroScan®, 30 of 59 obese children had fibrosis (LSM > 5.5 kPa), whereas the remaining 29 did not (LSM < 5.5 kPa). Obese children with fibrosis had higher levels of AST (73.57 ± 56.00 vs. 39.86 ± 31.93 IU/L; P = 0.009), ALT (132.47 ± 113.88 vs. 48.66 ± 51.29 IU/L; P = 0.001), and gamma-glutamyl transferase (106.67 ± 69.31 vs. 28.80 ± 24.26 IU/L; P = 0.042) compared to obese children without fibrosis. LSM had high and significant correlation (P < 0.05) with AST, ALT, homeostasis model assessment for insulin resistance, and AST-to-platelet ratio index.

CONCLUSION

FibroScan® is clinically feasible and facilitates non-invasive, rapid, reproducible, and reliable detection of hepatic steatosis and liver fibrosis in the Korean pediatric population.

Comparison of CT and magnetic resonance mDIXON-Quant sequence in the diagnosis of mild hepatic steatosis

OBJECTIVE:

To determine the diagnostic performance of CT in the assessment of mild hepatic steatosis by comparison with MR mDIXON-Quant as a reference standard, and to explore their clinical applications.

METHODS:

In this prospective study 169 volunteers were included. Each subject underwent CT and MR mDIXON-Quant examinations. Hepatic steatosis evaluations were performed via liver attenuation alone (CT L), liver to spleen attenuation ratio (CT L/S), difference between liver and spleen attenuation (CT L-S), and MR mDIXON-Quant imaging. The effectiveness of CT L, CT L/S, and CT L-S in diagnosing hepatic steatosis severity of ≥5%, ≥10%, and ≥15% was compared, using mDIXON-Quant results as standard.

RESULTS:

65 subjects exhibited mild hepatic steatosis. Hepatic steatosis measurement with mDIXON-Quant was strongly correlated with the three CT methods. Using cutoff value, the sensitivity and specificity of diagnosing hepatic steatosis ≥5, ≥10, and ≥15% were 64.6, 91.3, 100%, and 90.4, 89.7, 93.0% for CT L; 50.8, 87.0, 100%, and 96.2, 98.6, 97.5% for CT L/S; and 67.7, 87.0, 100%, and 81.7, 98.6, 97.5% for CT L-S, respectively. ROC analysis indicated that 58.9, 56.5, and 52.8 HU for CT L; 1.06, 0.98, and 0.90 HU for CT L/S; and 6.21,-1.04, and -4.93 HU for CT L-S were cutoff values for diagnosing hepatic steatosis ≥5%,≥10%, and ≥15%, respectively.

CONCLUSIONS:

The three CT methods exhibit better agreements with mDIXON-Quant imaging for diagnosing hepatic steatosis ≥10%. Hence, CT and mDIXON-Quant could serve as suitable tools for the accurate quantification of mild hepatic steatosis.

SIGNIFICANT FINDS OF THE STUDY:

The close agreement between the three different CT methods (based on our cutoff values) and mDIXON-Quant imaging suggests that CT could accurately diagnose hepatic steatosis ≥10%. Thus, CT and mDIXON-Quant imaging can accurately measure mild hepatic steatosis.

WHAT THIS STUDY ADDS:

Only few studies have compared hepatic steatosis quantification between CT and mDIXON-Quant. We are the first to determine the diagnostic performance of unenhanced CT for quantitatively assessing mild hepatic steatosis, in reference to magnetic resonance mDIXON-Quant imaging.

Fatty Liver and the Forensic Pathologist

Fatty liver is a common finding in clinical practice and at autopsy. It is most commonly seen associated with alcohol abuse and in non-alcoholic fatty liver disease (NAFLD). It may also be seen in many other conditions in both adults and children. It is now recognized that NAFLD, like alcoholic liver disease, may lead to end stage liver disease. Nonalcoholic fatty liver disease is associated with increased mortality from other disorders, particularly cardiovascular diseases. Fatty liver may be seen in many conditions that concern autopsy pathologists, including drug toxicity, anorexia, hepatic ischemia, and heatstroke. In infants, steatosis is common in sudden unexpected deaths. Fatty liver has been associated with sudden death and this review examines the pathology and role of fatty liver in sudden death. Acad Forensic Pathol. 2018 8(2): 296-310.

Investigation of Blood Betatrophin Levels in Obese Children with Non-Alcoholic Fatty Liver Disease

PURPOSE

The prevalence of obesity has significantly increased among children and adolescents worldwide and is becoming an important health care problem in parallel with the increased prevalence of obesity pediatric non-alcoholic fatty liver disease. Betatrophin is a newly define hormone that is commonly secreted by liver and plays role in glucose tolerance. This study aimed to investigate the relationship between serum betatrophin levels and non-alcoholic fatty liver disease in obese children.

METHODS

The study included 40 obese children with a body mass index (BMI) above 95th centile, and 35 non-obese subjects with a BMI 3-85th centile, whose age and gender were similar to those of the patient group. For the evaluation of metabolic parameters fasting serum glucose, insulin, alanine aminotransferase, aspartate aminotransferase, lipid profile and serum betatrophin levels were measured. Total cholesterol: high-density lipoprotein cholesterol and low-density lipoprotein cholesterol: high-density lipoprotein cholesterol ratios were calculated as "atherogenic indices."

RESULTS

Serum betatrophin levels of the obese subjects were similar to that of non-obese subjects (p=0.90). Betatrophin levels were not correlated with the metabolic parameters.

CONCLUSION

In the present study, levels of betatrophin are not different between obese and insulin resistant children and non-obese subjects, and they are not correlated with atherogenic indices. To elucidate the exact role of betatrophin in obesity, further studies are required to identify the betatrophin receptor and/or other possible cofactors.

Dietitian-led lifestyle modification programme for obese Chinese adolescents with non-alcoholic fatty liver disease: a randomized controlled study

BACKGROUND

The prevalence of non-alcoholic fatty liver disease (NAFLD) in children is increasing. This study evaluated the efficacy of a dietitian-led lifestyle modification programme (D-LMP) to reduce NAFLD in obese adolescents.

METHODS

Subjects with intra-hepatic triglyceride content (IHTC) equal to or greater than 5% diagnosed by proton-magnetic resonance spectroscopy (¹H-MRS) were enroled and randomly assigned to either the D-LMP intervention or conventional paediatrician-led consultation (P-CON) group. Subjects in the P-CON group received usual care consisting of a consultation by a paediatrician with the child and parents every 16 weeks. Intention-to-treat analysis was used for data analysis.

RESULTS

Fifty-two subjects were recruited, with 26 in each group. After the initiation phase (at week-16), there was a greater difference in the change in the IHTC and BMI z-score in the D-LMP group (P = 0.029 and <0.001, respectively) and there was a decrease in dietary intake of fat content (P = 0.019). After 52 weeks of the maintenance phase, both groups had reductions of IHTC to 2-3% and there was no intergroup difference in the rate of reduction. During the maintenance phase, parents' involvement was minimal in the D-LMP group, with only three parents accompanying their children to attend the dietitian sessions. In contrast, over 90% of the parents in the P-CON group regularly accompanied their children to attend the consultations suggesting the possibility that regular parental and paediatrician involvement may contribute to increasing awareness on fatty liver complications. Multivariate analysis showed that only reduction in body fat remained as an independent factor associated with remission of NAFLD at the end of both study phases.

CONCLUSIONS

A dietitian-led lifestyle modification intervention reduced IHTC, BMI z-score and body fat in obese Chinese adolescents with NAFLD. To sustain the effect of this intervention, regular parental and paediatrician involvement may be important.

Mexican consensus on lysosomal acid lipase deficiency diagnosis

INTRODUCTION

Lysosomal acid lipase deficiency (LAL-D) causes progressive cholesteryl ester and triglyceride accumulation in the lysosomes of hepatocytes and monocyte-macrophage system cells, resulting in a systemic disease with various manifestations that may go unnoticed. It is indispensable to recognize the deficiency, which can present in patients at any age, so that specific treatment can be given. The aim of the present review was to offer a guide for physicians in understanding the fundamental diagnostic aspects of LAL-D, to successfully aid in its identification.

METHODS

The review was designed by a group of Mexican experts and is presented as an orienting algorithm for the pediatrician, internist, gastroenterologist, endocrinologist, geneticist, pathologist, radiologist, and other specialists that could come across this disease in their patients. An up-to-date review of the literature in relation to the clinical manifestations of LAL-D and its diagnosis was performed. The statements were formulated based on said review and were then voted upon. The structured quantitative method employed for reaching consensus was the nominal group technique.

RESULTS

A practical algorithm of the diagnostic process in LAL-D patients was proposed, based on clinical and laboratory data indicative of the disease and in accordance with the consensus established for each recommendation.

CONCLUSION

The algorithm provides a sequence of clinical actions from different studies for optimizing the diagnostic process of patients suspected of having LAL-D.

Non-alcoholic fatty liver disease and its associations among adolescents in an urban, Sri Lankan community

BACKGROUND

Nonalcoholic fatty liver disease (NAFLD) is a common problem across the world. We aimed to determine the prevalence of NAFLD and its associations in Sri Lankan adolescents living in an urban Sri Lankan community.

METHOD

The study population consisted of the birth cohort of the year 2000, residing in the Ragama Medical Officer of Health area. Socio-demographic and anthropometric data [anthropometric measurements, blood pressure and total body fat distribution] of these adolescents were collected by trained data collectors. Fasting blood sugar, serum insulin, fasting serum lipids and serum alanine aminotransferase (ALT) levels were measured and an abdominal ultrasound was performed. NAFLD was diagnosed on established ultrasound criteria for fatty liver and absent alcohol consumption.

RESULTS

The study sample consisted of 499 adolescents [263 (51.8%) girls]. Forty two (8.4%) had NAFLD. NAFLD was significantly associated with being breast fed for less than 4 months (33.3% vs. 17.1 in controls, p = 0.02), higher waist circumference (prevalence risk ratio 83.3/20.3, 4.1, p < 0.0001), higher body mass index (prevalence risk ratio 40.5/4.8, 8.4, p < 0/0001),higher HOMA-IR (3.7 vs. 1.9, p < 0.0001) and high triglycerides (prevalence risk ratio 14.3/5.8, 2.5, p = 0.033). Adolescents with NAFLD also had a higher amount of total body fat (p < 0.001) and subcutaneous fat (p < 0.001) than those without NAFLD. The number of children with metabolic derangements was higher among adolescents with NAFLD than those without (85.8 vs 26.3 in controls, p < 0.0001), but a family history of hypertension, diabetes, myocardial infarction or dyslipidaemia were not.

CONCLUSION

Prevalence of NAFLD was high in Sri Lankan adolescents, and was associated with metabolic derangements, especially obesity, insulin resistance and early cessation of breast feeding.

Infant nutrition and maternal obesity influence the risk of non-alcoholic fatty liver disease in adolescents

BACKGROUND & AIMS

The pathway to non-alcoholic fatty liver disease (NAFLD) in adolescents may have its origins in adiposity gains, nutrition and sedentary lifestyle established during childhood. There is inadequate knowledge regarding the associations between infant nutrition and subsequent NAFLD. We examined the association of maternal factors and infant nutrition, with the subsequent diagnosis of NAFLD in adolescents.

METHODS

Adolescents aged 17years in the Western Australian Pregnancy (Raine) Cohort study had fatty liver assessment using liver ultrasound. Prospectively recorded data on maternal pregnancy and infant feeding were examined against a NAFLD outcome during late adolescence.

RESULTS

NAFLD was diagnosed in 15.2% of the 1,170 adolescents examined. Ninety-four percent had been breastfed as infants. The duration of breastfeeding before starting supplementary milk was ⩾4months in 54.4% and ⩾6months in 40.6%. Breastfeeding without supplementary milk ⩾6months (adjusted odds ratio [OR]: 0.64; 95% confidence interval [CI]: 0.43-0.94, p=0.02), maternal pre-pregnancy obesity (adjusted OR: 2.29; 95% CI: 1.21-4.32, p=0.01) and adolescent obesity (adjusted OR: 9.08; 95% CI: 6.26-13.17, p<0.001) were associated with NAFLD independent of a Western dietary pattern at 17years of age. Adolescents with NAFLD who had been breastfed for ⩾6months had a less adverse metabolic profile compared with adolescents breastfed for <6months. Supplementary milk intake starting before 6months was associated with a higher prevalence and ultrasound severity of NAFLD compared with intake starting after 6months (17.7% vs. 11.2%, p=0.003 and 7.8% vs. 3.4%, p=0.005 respectively).

CONCLUSION

Though NAFLD is generally mediated through adiposity gains, breastfeeding for at least 6months, avoidance of early supplementary formula milk feeding, and normal maternal pre-pregnancy BMI may reduce the odds of a NAFLD diagnosis during adolescence.

LAY SUMMARY

Non-alcoholic fatty liver disease (NAFLD) is a common liver disorder in which there is too much fat in the liver of people who do not consume excessive amounts of alcohol. In this large study, we found that infants who consumed breast milk for less than 6months before starting infant formula milk, infants who were obese as teenagers or had mothers who were obese at the start of pregnancy, were much more likely to have NAFLD at 17years of age. Based on our findings we consider that reducing the risk of NAFLD in teenagers needs to start before birth, by encouraging normal body mass index before pregnancy, as well as breastfeeding without infant formula milk consumption for the first 6months of life.

The effects of diet and lifestyle interventions on insulin resistance in patients with nonalcoholic fatty liver disease: a systematic review

Nonalcoholic fatty liver disease (NAFLD) results from excessive fat accumulation in the liver in the absence of excessive alcohol consumption. Insulin resistance (IR) is proposed to be an underlying pathogenic factor in the development and progression of disease. There are currently no proven pharmacotherapies and weight loss is the only prescribed treatment despite a lack of evidence to support a specific diet or lifestyle therapy. The aim of this review is to evaluate the efficacy of dietary lifestyle interventions on IR measured by Homeostasis model assessment in patients with NAFLD. A systematic electronic search of Medline, Scopus, The Cochrane Library, CINAHL and PubMed databases (1999-2015) was performed by two independent reviewers. Randomized control trials evaluating the efficacy of diet and lifestyle interventions on IR in adults diagnosed with NAFLD were included. A total of 6441 articles were identified; eight randomized control trials fulfilled the inclusion criteria. Three studies involved dietary interventions and five incorporated diet and exercise. The majority of intervention groups resulted in significant reductions in IR, with no significant changes observed in the control groups. Lifestyle interventions compared with controls reduced IR measured by homeostasis model assessment. All diet and diet and lifestyle intervention trials were efficient in reducing IR in participants with NAFLD. A lack of literature and variation across interventions warrants the need for extensive research to establish firm dietary lifestyle recommendations.

Emerging Gastrointestinal and Liver Diseases in Asia Pacific: Implications to Health Care in the Region (World Gastroenterology Organization: Asian Pacific Association of Gastroenterology Distinguished Global Lecture 2015)

Colorectal cancer (CRC), gastroesophageal reflux disease (GERD), inflammatory bowel disease (IBD), and nonalcoholic fatty liver disease are considered important emerging diseases in the Asia Pacific (AP) region. The incidence rate of CRC is the highest among gastrointestinal cancers in the region surpassing that of gastric cancer. However, population CRC screening is limited by availability of adequate health resources and financing. GERD is a highly prevalent disease in AP with the prevalence of GERD symptoms and reflux esophagitis reported to be increasing. The usage of proton pump inhibitors has also been reported to be high. The incidence and prevalence of IBD is not as high as in the west but is now an increasingly recognizable disease in the AP region. Being a complicated disease, IBD will pose a huge financial burden with the increasing use of expensive biological drugs. In tandem with the exponential increase in obesity and diabetes mellitus in AP, nonalcoholic fatty liver disease will become the most important liver disease in the region in the coming years. These emerging diseases reflect the continued fast-paced socioeconomic development in the region with marked lifestyle changes and increasing affluence.

A scoping review of epidemiologic risk factors for pediatric obesity: Implications for future childhood obesity and dental caries prevention research

RESEARCH QUESTIONS

What are the non-modifiable (socioeconomic, genetic) and modifiable factors (physical activity, dietary behaviors) related to childhood (under age 12) obesity? How can this knowledge be applied to oral health professionals' efforts to prevent or manage dental caries in children?

OBJECTIVES

Studies have identified risk factors for childhood obesity. The purpose of this scoping review was to develop a conceptual model to identify non-modifiable and modifiable risk factors for childhood obesity and to illustrate how these findings are relevant in developing interventions aimed at preventing obesity and dental caries in children.

METHODS

The authors searched PubMed and Embase and limited the study to English-language publications. A total of 2,572 studies were identified. After de-duplication, 2,479 studies remained and were downloaded into a citation-management tool. Two authors screened the titles and abstracts for relevance. Two hundred and sixty studies remained and were retrieved for a full-text review, and 80 studies were excluded, resulting in 180 studies included in the scoping review. An inductive content analytic methods was used to organize all statistically significant obesity risk factors into seven domains, which were classified as non-modifiable or modifiable; then a conceptual model of common risk factors associated with childhood obesity and dental caries was developed.

RESULTS

Non-modifiable obesity risk factors include biological and developmental (e.g., genes, developmental conditions, puberty), sociodemographic and household (e.g., race/ethnicity, socioeconomic status, parent education, unemployment), cultural (e.g., degree of acculturation), and community (e.g., neighborhood composition). Modifiable risk factors included behavioral (e.g., diet, physical activity, weight), psychosocial (e.g., maternal stress, family functioning, parenting practices, child temperament), and medical (e.g., parent smoking, maternal health, child health).

CONCLUSIONS

Identifying common risk factors has important implications for future oral health research aimed at preventing childhood obesity and dental caries. Epidemiologic knowledge gleaned from the literature can be used to develop rigorous interventions and programs aimed at preventing these highly prevalent diseases and improving health outcomes for children.

Fatty liver and FGF21 physiology

Non alcoholic fatty liver disease is linked to obesity and the metabolic syndrome. As rates of obesity rise it has become the major etiology of liver dysfunction. Despite intense study the molecular mechanisms contributing to the onset of fatty liver remain debatable. Furthermore, few therapies exist and as a result dietary therapy is commonly prescribed and remains problematic. Fibroblast growth factor is a complex metabolic regulator that is synthesized in multiple organs including the liver, with resulting complex systemic effects. Several lines of evidence suggest that effects in the liver lead to decreased fat accumulation and that treatment results in reduced inflammation and fibrosis. Understanding the physiology of FGF21 is important to the understanding of liver disease and may also provide targets for future therapy.

Probiotic Therapy in Patients with Nonalcoholic Steatohepatitis in Zagazig University Hospitals

Aim:

Nonalcoholic fatty liver disease (NAFLD) is probably the most common liver disorder in the world. A subgroup of NAFLD patients is characterized by injury to the hepatocytes and inflammation in addition to excessive fat (steatohepatitis), the latter condition is nominated nonalcoholic steatohepatitis (NASH). This work aimed to evaluate the role of probiotics on the outcome of NASH in patients admitted to the Tropical Medicine Department, Faculty of Medicine, Zagazig University (inpatients and outpatients).

Materials and methods:

This study was performed on 30 patients (17 males and 13 females), with body mass index from 30 to 35 and average age of 44 years with bright fatty liver in ultrasonography and raised alanine transaminase (ALT) and aspartate transaminase (AST) and positive liver biopsy findings. The patients were divided into group I (case group) that included 15 patients who received probiotics and group II of 15 patients as control group who did not receive probiotics; the study was conducted between November 2014 and April 2016. Clinical assessment, laboratory evaluation, pelvic-abdominal ultrasound, and liver biopsy of all cases were carried out.

Results:

In this study, there was significant decrease in liver enzymes (ALT and AST) and no statistically significant other laboratory findings. Also there was relief for dyspepsia in some patients.

Conclusion:

Probiotics treatment is effective, safe, well-tolerated, inexpensive, appropriate for long-term use, and optimally, works at multiple levels to downregulate inflammatory mediators, and therefore, probiotics could be an option in the treatment of NASH.

How to cite this article: Monem SMA. Probiotic Therapy in Patients with Nonalcoholic Steatohepatitis in Zagazig University Hospitals. Euroasian J Hepato-Gastroenterol 2017;7(1):101-106.

Liver acoustic radiation force impulse (ARFI) in childhood obesity: comparison and correlation with biochemical markers

PURPOSE

To compare and correlate the diagnostic efficiency of acoustic radiation force impulse (ARFI) elastography with biochemical markers for assessing hepatic changes in overweight and obese children.

METHODS

This prospective study was approved by the institutional ethics committee. It included 54 overweight and obese children and 50 normal children (as a control group) in the age range 5-18 years. For all children, we performed grayscale ultrasonography to diagnose fatty liver, ARFI elastography to measure liver stiffness, and biochemical evaluation for aspartate aminotransferase (AST), alanine aminotransferase (ALT), and serum triglyceride (TG) levels.

RESULTS

Of the 54 obese children, AST was elevated in 13 (24.1%) and ALT was elevated in 16 (29.6%); however, only 4 (25%) of these 16 obese children with abnormal aminotransferase levels had an AST/ALT ratio >0.8. Furthermore, all children with abnormal aminotransferase levels with AST/ALT ratio >0.8 also had abnormal readings of ARFI elastography. The TG was elevated (>150 mg/dL) in 2 out of 54 (3.7%) obese children. None of the normal children showed abnormal levels of aminotransferase and TG. Three out of 54 (5.6%) obese children did not show fatty liver changes, while 29 (53.7%) showed grade-I fatty liver changes, and 22 (40.7%) showed grade-II fatty liver changes. The mean (SD) ARFI value was 1.13 m/s (SD 0.199) for obese children and 1.02 m/s (SD 0.11) for children in the control group. Of the 54 obese children, 49 (90.7%) showed ARFI values of <1.19 m/s (normal), 4 (7.4%) had ARFI values from >1.19 to <1.75 m/s, and 1 (1.9%) had an ARFI value >1.75 m/s. Four children with an increased ARFI value also had an AST/ALT ratio >0.8. However, one obese child with a raised ARFI value did not have an elevated AST/ALT ratio, and none of his aminotransferase levels were abnormal. All normal children had ARFI values <1.19 m/s.

CONCLUSION

ARFI elastography shows excellent correlation with AST/ALT ratios in obese children and may be used as a noninvasive tool to detect nonalcoholic fatty liver disease (NAFLD) and associated hepatic changes, especially in pediatric patients, for whom liver biopsy is not always feasible.

Acyl/free carnitine ratio is a risk factor for hepatic steatosis after pancreatoduodenectomy and total pancreatectomy

OBJECTIVES

Hepatic steatosis, one of the most frequent long-term complications of pancreatectomy, influences not only hepatic function but also survival rate. However, its risk factors and pathogenesis have not been established. The purpose of this study was to clarify the risk factors for hepatic steatosis after pancreatectomy.

METHODS

In this retrospective study of 21 patients who had undergone pancreatectomy (19 cases of pancreatoduodenectomy and 2 cases of total pancreatectomy), serum carnitine concentrations, fractions of carnitine, and hepatic attenuation on computed tomography images were analyzed with the aim of identifying risk factors for hepatic steatosis.

RESULTS

Thirteen (61.9%) of the 21 patients were diagnosed as having hypocarnitinemia after pancreatectomy. Average hepatic attenuation was as low as 42.2HU (±21.3 SD). A high ratio of acyl/free carnitine was associated with less pronounced hepatic attenuation according to both univariate (P < 0.001) and multivariate (P = 0.020) regression analyses.

CONCLUSIONS

The serum carnitine concentrations were low after pancreatectomy in some patients. The statistical analyses suggest that a high ratio of acyl/free carnitine is an independent risk factor for hepatic steatosis after pancreatectomy.

Non-Alcoholic Fatty Liver Disease

Non-alcoholic fatty liver disease (NAFLD) comprises a disease spectrum ranging from benign hepatic steatosis to non-alcoholic steatohepatitis with inflammation (NASH) and liver cirrhosis. NAFLD is now recognised as the hepatic manifestation of the metabolic syndrome. Simple steatosis is benign, whereas NASH can progress to cirrhosis with its resultant complications. Liver biopsy remains the gold standard in the diagnosis of NAFLD/NASH. Lifestyle and dietary modifications to achieve sustained weight loss is the cornerstone of NAFLD/NASH treatment.

Non-alcoholic fatty liver disease (Nafld) in obese children- effect of refined carbohydrates in diet

Background

The incidence of childhood obesity has increased progressively and, associated with this, nonalcoholic fatty liver disease (NAFLD) has often been diagnosed in this age group. To determine the risk factors associated with NAFLD in obese children, with special emphasis on diet.

Methods

A prospective cross-sectional study was conducted with obese children referred to the endocrinology outpatient clinic. Questions about dietary habits and physical activity were applied. In addition, two 24 h food recalls were collected. Anthropometric measurements, biochemical tests and abdominal ultrasound were obtained. The study was approved by the institutional review board of Irmandade Santa Casa de Misericórdia de Porto Alegre Hospital (ISCMPA). A 5% statistical significance level was considered statistically significant.

Results

Of 55 patients initially allocated, 39 were evaluated and 8 (20.5%) had a diagnosis of NAFLD, which was more prevalent among boys (87.5%). Logistic regression analysis showed that the predictive factors independently associated with the presence of NAFLD were male gender (OR: 1.62; 95% CI: 1.08– 2.44; p = 0.038); high amount of refined carbohydrates in the diet (OR: 2.17; 95% CI: 1.05 – 6.82; p = 0.038) and absence of routine physical activity (OR: 3.35; 95% CI:1.97 – 0.006; p = 0.006).

Conclusions

The prevalence of NAFLD in obese children in our series was high. Furthermore, the high amount of refined carbohydrates in the diet, male gender and sedentary lifestyle were significant risk factors for its occurrence.

Relationship between Abdominal Aortic Intima Media Thickness and Central Obesity in Children

BACKGROUND

Childhood obesity is one of the important risk factors for early atherosclerosis. We aimed to evaluate the effect of obesity on abdominal aortic intima media thickness (aaIMT) in children.

METHODS

We consecutively recruited 60 obese and 28 healthy children from the outpatient clinic of pediatrics. In all patients, BMI, waist circumference (WC) and hip circumference (HC) were measured, and fasting serum lipid profile, plasma glucose and plasma insulin were studied. Homeostasis model assessment-estimated insulin resistance (HOMA-IR) was calculated for the obese group. All children underwent ultrasonography to evaluate hepatosteatosis and to measure aaIMT.

RESULTS

There was a significant difference between the groups in terms of aaIMT, insulin, glucose, HOMA-IR, total cholesterol, low-density lipoprotein, triglyceride and hepatosteatosis. aaIMT was 1.12 ± 0.25 and 0.61 ± 0.18 mm in the obese and nonobese groups, respectively (p < 0.001). In the obese group, there was a positive correlation between aaIMT and WC, WC/height ratio, BMI, HC and hepatosteatosis (p < 0.05 for all), with the highest significance for WC.

CONCLUSIONS

This study showed that aaIMT was significantly higher in obese children than in nonobese children, and that WC was a strong predictor for aaIMT. Early detection of an increased aaIMT in obese children may guide the follow-up of these patients in terms of developing atherosclerosis and its complications.

Micronutrient Antioxidants and Nonalcoholic Fatty Liver Disease

Nonalcoholic fatty liver disease (NAFLD) is one of the most important chronic liver diseases worldwide and has garnered increasing attention in recent decades. NAFLD is characterized by a wide range of liver changes, from simple steatosis to nonalcoholic steatohepatitis, cirrhosis, and hepatocellular carcinoma. The blurred pathogenesis of NAFLD is very complicated and involves lipid accumulation, insulin resistance, inflammation, and fibrogenesis. NAFLD is closely associated with complications such as obesity, diabetes, steatohepatitis, and liver fibrosis. During the progression of NAFLD, reactive oxygen species (ROS) are activated and induce oxidative stress. Recent attempts at establishing effective NAFLD therapy have identified potential micronutrient antioxidants that may reduce the accumulation of ROS and finally ameliorate the disease. In this review, we present the molecular mechanisms involved in the pathogenesis of NAFLD and introduce some dietary antioxidants that may be used to prevent or cure NAFLD, such as vitamin D, E, and astaxanthin.

Quantification of hepatic and visceral fat by CT and MR imaging: relevance to the obesity epidemic, metabolic syndrome and NAFLD

Trends in obesity have continued to increase in the developed world over the past few decades, along with related conditions such as metabolic syndrome, which is strongly associated with this epidemic. Novel and innovative methods to assess relevant obesity-related biomarkers are needed to determine the clinical significance, allow for surveillance and intervene if appropriate. Aggregations of specific types of fat, specifically hepatic and visceral adiposity, are now known to be correlated with these conditions, and there are a variety of imaging techniques to identify and quantify their distributions and provide diagnostic information. These methods are particularly salient for metabolic syndrome, which is related to both hepatic and visceral adiposity but currently not defined by it. Simpler non-specific fat measurements, such as body weight, abdominal circumference and body mass index are more frequently used but lack the ability to characterize fat location. In addition, non-alcoholic fatty liver disease (NAFLD) is a related condition that carries relevance not only for obesity-related diseases but also for the progression of the liver-specific disease, including non-alcoholic steatohepatitis and cirrhosis, albeit at a much lower frequency. Recent CT and MRI techniques have emerged to potentially optimize diagnosing metabolic syndrome and NAFLD through non-invasive quantification of visceral fat and hepatic steatosis with high accuracy. These imaging modalities should aid us in further understanding the relationship of hepatic and visceral fat to the obesity-related conditions such as metabolic syndrome, NAFLD and cardiovascular disease.

Comparison of the Phenotype and Approach to Pediatric vs Adult Patients With Nonalcoholic Fatty Liver Disease

Nonalcoholic fatty liver disease (NAFLD) is one of the main chronic noncommunicable diseases in Westernized societies; its worldwide prevalence has doubled during the last 20 years. NAFLD has serious health implications not only for adults, but also for children. However, pediatric NAFLD is not only an important global problem in itself, but it is likely to be associated with increases in comorbidities, such as metabolic syndrome and cardiovascular diseases. There are several differences between NAFLD in children and adults, and it is not clear whether the disease observed in children is the initial phase of a process that progresses with age. The increasing prevalence of pediatric NAFLD has serious implications for the future adult population requiring appropriate action. Studies of NAFLD progression, pathogenesis, and management should evaluate disease phenotypes in children and follow these over the patient's lifetime. We review the similarities and differences of NAFLD between children and adults.

Transient Elastography-Based Liver Profiles in a Hospital-Based Pediatric Population in Japan

Background & Aims

The utility of transient elastography (FibroScan) is well studied in adults but not in children. We sought to assess the feasibility of performing FibroScans and the characteristics of FibroScan-based liver profiles in Japanese obese and non-obese children.

Methods

FibroScan examinations were performed in pediatric patients (age, 1–18 yr) who visited Osaka City University Hospital. Liver steatosis measured by controlled attenuation parameter (CAP), and hepatic fibrosis evaluated as the liver stiffness measurement (LSM), were compared among obese subjects (BMI percentile ≥90%), non-obese healthy controls, and non-obese patients with liver disease.

Results

Among 214 children examined, FibroScans were performed successfully in 201 children (93.9%; median, 11.5 yr; range, 1.3–17.6 yr; 115 male). CAP values (mean±SD) were higher in the obese group (n = 52, 285±60 dB/m) compared with the liver disease (n = 40, 202±62, P<0.001) and the control (n = 107, 179±41, P<0.001) group. LSM values were significantly higher in the obese group (5.5±2.3 kPa) than in the control (3.9±0.9, P<0.001), but there were no significant differences in LSM between the liver disease group (5.4±4.2) and either the obese or control group. LSM was highly correlated with CAP in the obese group (ρ = 0.511) but not in the control (ρ = 0.129) or liver disease (ρ = 0.170) groups.

Conclusions

Childhood obesity carries a high risk of hepatic steatosis associated with increased liver stiffness. FibroScan methodology provides simultaneous determination of CAP and LSM, is feasible in children of any age, and is a non-invasive and effective screening method for hepatic steatosis and liver fibrosis in Japanese obese children.

Magnetic resonance imaging reveals altered distribution of hepatic fat in children with type 1 diabetes compared to controls

INTRODUCTION

Children with type 1 diabetes have been identified as a risk group for non-alcoholic fatty liver disease (NAFLD). The aim was to compare total hepatic fat fraction and fat distribution across Couinaud segments in children with type 1 diabetes and controls and the relation of hepatic fat to plasma and anthropometric parameters.

METHODS

Hepatic fat fraction and fat distribution across Couinaud segments were measured with magnetic resonance imaging (MRI) in 22 children with type 1 diabetes and 32 controls. Blood tests and anthropometric data were collected.

RESULTS

No children had NAFLD. Children with type 1 diabetes had a slightly lower hepatic fat fraction (median 1.3%) than controls (median 1.8%), and their fat had a different segmental distribution. The fat fraction of segment V was the most representative of the liver as a whole. An incidental finding was that diabetes patients treated with multiple daily injections of insulin (MDI) had a fat distribution more similar to controls than patients with continuous subcutaneous insulin infusion (CSII).

CONCLUSIONS

In children with type 1 diabetes, NAFLD may be less common than recent studies have suggested. Children with type 1 diabetes may have a lower fat fraction and a different fat distribution in the liver than controls. Diabetes treatment with MDI or CSII may affect liver fat, but this needs to be confirmed in a larger sample of patients. The heterogeneity of hepatic fat infiltration may affect results when liver biopsy is used for diagnosing fatty liver.

Sonographically measured suprailiac adipose tissue is a useful predictor of non-alcoholic fatty liver disease in obese children and adolescents

OBJECTIVE

The objective of the present study was to identify ultrasonographic and anthropometric parameters that are highly associated with the presence of non-alcoholic fatty liver disease (NAFLD) in overweight children and adolescents.

METHODS

A total of 447 overweight children and adolescents (body mass index, 32.4 ± 5.2 kg m(-2) ; mean age, 14.2 ± 1.9 years; range 10.1-20.3 years) were analysed. Subjects underwent ultrasound examination of the liver as well as ultrasonographic measurement of the amount of adipose tissue overlying the biceps brachii and triceps brachii muscles, and of subscapular, suprailiac and abdominal subcutaneous adipose tissue and intra-abdominal depth. Anthropometric parameters such as body mass index, waist and hip circumference were documented.

RESULTS

The prevalence of NAFLD was 27.1%; it was significantly associated with the above-cited anthropometric parameters (P < 0.001). Ultrasonographic findings identified a significant association between NAFLD and the amount of subscapular, suprailiac and abdominal subcutaneous adipose tissue (P < 0.001) as well as between NAFLD and intra-abdominal depth (P < 0.001). Stepwise logistic regression analysis showed only intra-abdominal depth for both gender and the deposit of subcutaneous suprailiac adipose tissue in females to be independent predictors of NAFLD.

CONCLUSIONS

In overweight children and adolescents, we identified intra-abdominal depth for both gender and the ultrasonographically easily determined subcutaneous suprailiac adipose tissue in females as independent predictor of NAFLD.