Non-alcoholic fatty liver disease/non-alcoholic steatohepatitis (NAFLD/NASH): diagnosis and clinical course

The effect of empagliflozin on non-alcoholic fatty liver disease-related parameters in patients with type 2 diabetes mellitus: a randomized controlled trial

BACKGROUND AND OBJECTIVE

The effects of Empagliflozin on liver health in patients with Type 2 Diabetes Mellitus (T2DM) have not been fully elucidated. This study aimed to assess the impact of Empagliflozin on liver steatosis and related biomarkers in T2DM patients.

METHODS

A before-after clinical trial was conducted with 119 T2DM patients aged 20 to 70 with fatty liver, recruited from Laghman Hakim Hospital, Tehran, Iran. Participants were administered Empagliflozin for 6 months, with clinical and laboratory assessments conducted at baseline, 3 months, and 6 months. Liver function was evaluated through blood tests and imaging, including ultrasound and Magnetic resonance imaging (MRI), to assess hepatic steatosis. Biomarkers such as HbA1c, fasting blood glucose, insulin, lipid profile, and liver enzymes were measured. Insulin resistance was estimated using the Homeostatic Model Assessment for Insulin Resistance (HOMA-IR) formula. Data were analyzed using SPSS 26 and STATA 14.

RESULTS

A total of 119 patients (Intervention (N = 69), Control (N = 50)) were participated. The intervention group demonstrated a significant reduction in liver fat grade compared to the control group, with 17.5% of patients showing a reduction from grade 3 to grade 1 on MRI and 6% in the control group. The odds of worsening fatty liver in the control group were 48 times higher (95% CI: 15.5, 148.5) on MRI and 52 times higher (95% CI: 15.2, 178.1) on ultrasound, compared to the intervention group (NNT = 2). After 6 months, the intervention group showed significantly lower risks for ALT (RR: 0.72, 95% CI: 0.62-0.84), AST, and alkaline phosphatase (Alkp) abnormalities. Liver enzyme levels (ALT, AST, GGT) and systolic blood pressure (SBP) decreased significantly in the Empagliflozin group, with mean differences of -15.33 (95% CI: -18.8, -11.88) for ALT, -12.82 (95% CI: -15.5, -10.13) for AST, and - 6.31 (95% CI: -8.65, -3.97) for systolic blood pressure (SBP).

CONCLUSION

These findings suggest that Empagliflozin could be an effective adjunctive therapy for managing liver dysfunction in T2DM patients with NAFLD.

TRIAL REGISTRATION

Registered retrospectively in the Iranian Registry of Clinical Trials (IRCT20210811052150N1) on April 16,2023 Access at https://irct.behdasht.gov.ir/search/result?query=IRCT20210811052150N1 .

Unraveling the Association of Liver Steatosis and Fibrosis with Vitamin B12: A Cross-Sectional Study

BACKGROUND

There are conflicting studies reporting both an increase and a decrease in vitamin B12 (VB12) levels in non-alcoholic fatty liver disease (NAFLD). In this study, we aimed to dissect the effects of steatosis and fibrosis on VB12.

METHODS

This is a cross-sectional study including all patients with a vibration-controlled transient elastography (VCTE) performed at the Hospital Miguel Servet (Zaragoza, Spain) between 2019 and 2022 for a chronic liver disease and having a recent blood test for VB12 levels. Liver fibrosis was assessed by VCTE and hepatic steatosis by ultrasonography and/or through controlled attenuation parameter (CAP).

RESULTS

1195 patients (NAFLD n = 441, other chronic liver disease n = 754) were included. Median age was 57 years, 53% female. Patients with NAFLD had lower levels of VB12 compared to the rest of chronic liver diseases (289 vs. 313 pg/mL, p < 0.001). A significant negative correlation was observed between VB12 levels and hepatic steatosis measured by CAP (r = -0.13, p < 0.001). A significant positive correlation was observed between VB12 levels and liver stiffness in patients with NAFLD in both sexes (men r = 0.31, p < 0.001 and women r = 0.15, p = 0.016). A significant association between VB12 levels and liver fibrosis in cirrhosis stage was observed in patients with NAFLD (OR 1.06, 95% CI, 1.025-1.098, p = 0.001).

CONCLUSION

VB12 levels were lower with greater hepatic steatosis. In NAFLD, VB12 levels were lower compared to other chronic liver diseases but their levels increased with higher liver stiffness and in cirrhosis stage.

Comparison of four non-alcoholic fatty liver disease detection scores in a Caucasian population

BACKGROUND

Non-alcoholic fatty liver disease (NAFLD) is a common disorder, with an estimated prevalence ranging from 20% to 35% in the general population. Several scores based on easily measurable biochemical and clinical parameters, including the fatty liver index (FLI), hepatic steatosis index (HSI), lipid accumulation product (LAP), and NAFLD liver fat score (LFS), have been developed for the detection of NAFLD. However, comparative information regarding the efficacy of these scores for predicting NAFLD in population-based samples comprising normal and high-risk individuals is lacking.

AIM

To evaluate four NAFLD detection scores in two samples with different NAFLD risks.

METHODS

NAFLD screening was performed in a population-based sample of 50-year-old individuals in Uppsala, Sweden [n = 310; Prospective investigation of obesity, energy and metabolism (POEM) study] and a high-risk population comprising patients with a body mass index > 25 kg/m² and either high plasma triglycerides (≥ 1.7 mmol/L) or type 2 diabetes (n = 310; EFFECT studies). NAFLD was defined as liver fat > 5.5% using magnetic resonance imaging-proton density fat fraction. FLI, HSI, LAP, and NAFLD LFS were assessed. A logistic regression model was used to evaluate the effectiveness of the different scores.

RESULTS

The prevalence of NAFLD was 23% in POEM. FLI showed the highest receiver operating characteristic area under the curve (ROC AUC; 0.82) and was significantly better than the LAP score (P = 0.005 vs LAP, P = 0.08 vs LFS, P = 0.12 vs HSI) for detection of NAFLD. The other three indices performed equally in POEM (0.77-0.78). The prevalence of NAFLD was 74% in EFFECT; LFS performed best (ROC AUC 0.80) in this sample. The ROC AUC for LFS (0.80) was significantly higher than that for FLI (P = 0.0019) and LAP (P = 0.0022), but not HSI (P = 0.11). We performed a sensitivity analysis with stratification for the two high-risk subgroups (patients with diabetes or hypertriglyceridemia) from the EFFECT studies. LAP performed best in patients with hypertriglyceridemia. No major differences were observed between the other scores.

CONCLUSION

The four investigated NAFLD scores performed differently in the populationbased vs high-risk setting. FLI was preferable in the population-based setting, while LFS performed best in the high-risk setting.

Evaluation of nonalcoholic fatty liver disease using magnetic resonance in obese children and adolescents

OBJECTIVE

To determine the frequency of nonalcoholic fatty liver disease using nuclear magnetic resonance as a noninvasive method.

METHODOLOGY

This was a cross-sectional study conducted on 50 children and adolescents followed up at an outpatient obesity clinic. The subjects were submitted to physical examination, laboratory tests (transaminases, liver function tests, lipid profile, glycemia, and basal insulin) and abdominal nuclear magnetic resonance (calculation of hepatic, visceral, and subcutaneous fat).

RESULTS

Nonalcoholic fatty liver disease was diagnosed in 14 (28%) participants, as a severe condition in eight (percent fat >18%), and as non-severe in four (percent fat from 9% to 18%). Fatty liver was associated with male gender, triglycerides, AST, ALT, AST/ALT ratio, and acanthosis nigricans. Homeostasis model assessment of insulin resistance and metabolic syndrome did not show an association with fatty liver.

CONCLUSION

The frequency of nonalcoholic fatty liver disease in the present population of children and adolescents was lower than that reported in the international literature. It is suggested that nuclear magnetic resonance is an imaging exam that can be applied to children and adolescents, thus representing an effective noninvasive tool for the diagnosis of nonalcoholic fatty liver disease in this age range. However, further national multicenter studies with longitudinal design are needed for a better analysis of the correlation between nonalcoholic fatty liver disease and its risk factors, as well as its consequences.

FXR controls CHOP expression in steatohepatitis

The farnesoid X receptor (FXR) and C/EBP homologous protein (CHOP) have critical functions in hepatic lipid metabolism. Here, we aimed to explore a potential relationship between FXR and CHOP. We fed wild‐type (WT) and FXR KO mice a MCD diet (model of steatohepatitis) and found that Chop mRNA expression is upregulated in WT but not FXR KO mice. The absence of FXR aggravates hepatic inflammation after MCD feeding. In HepG2 cells, we found that Chop expression is regulated in a FXR/Retinoid X receptor (RXR)‐dependent manner. We identified a FXR/RXR‐binding site in the human CHOP promoter, demonstrating a highly conserved regulatory pathway. Our study shows that FXR/RXR regulates Chop expression in a mouse model of steatohepatitis, providing novel insights into pathogenesis of this disorder.

Aristolochia manshuriensis Kom ethyl acetate extract protects against high-fat diet-induced non-alcoholic steatohepatitis by regulating kinase phosphorylation in mouse

Aristolochia manshuriensis Kom (AMK) is an herb used as a traditional medicine; however, it causes side effects such as nephrotoxicity and carcinogenicity. Nevertheless, AMK can be applied in specific ways medicinally, including via ingestion of low doses for short periods of time. Non-alcoholic steatohepatitis (NASH) induced the hepatocyte injury and inflammation. The protective effects of AMK against NASH are unclear; therefore, in this study, the protective effects of AMK ethyl acetate extract were investigated in a high-fat diet (HFD)-induced NASH model. We found decreased hepatic steatosis and inflammation, as well as increased levels of lipoproteins during AMK extract treatment. We also observed decreased hepatic lipid peroxidation and triglycerides, as well as suppressed hepatic expression of lipogenic genes in extract-treated livers. Treatment with extract decreased the activation of c-jun N-terminal kinase 1/2 (JNK1/2) and increased the phosphorylation of extracellular signal-regulated kinase 1/2 (ERK1/2). These results demonstrate that the protective effect of the extract against HFD-induced NASH occurred via reductions in reactive oxygen species production, inflammation suppression, and apoptosis related to the suppression of JNK1/2 activation and increased ERK1/2 phosphorylation. Taken together, these results indicate that that ethyl acetate extract of AMK has potential therapeutic effects in the HFD-induced NASH mouse model.

Role of Renin-Angiotensin-converting Enzyme Level and ACE Gene Polymorphism in Patients with Nonalcoholic Fatty Liver Disease

Introduction

In this study, we aimed to investigate the histological and clinical effect of angiotensin-converting enzyme (ACE) and ACE gene polymorphism in nonalcoholic fatty liver disease (NAFLD) and their roles in the progression of the disease.

Materials and methods

Liver function tests, body mass index, waist circumference, lipid parameters, fasting blood glucose (FBG), hemoglobin A1c (HbA1c), homeostasis model assessment-IR (HOMA-IR), ACE, and ACE gene polymorphism were evaluated in the NAFLD group and control group. The study group was evaluated by dividing the group into four subgroups by ACE gene polymorphism (D/D homozygous, I/I homozygous, D/I heterozygous, I/D heterozygous). Liver biopsies were evaluated according to Brunt Classification.

Results

A total of 31 patients who were diagnosed with NAFLD and 40 healthy individuals were included in the study. The ACE level was found to be 11.69 ± 1.99 in the NAFLD group and 11.52 ± 1.72 in the control group (p = 0.70). There was a negative correlation between ACE levels and HOMA-IR levels (p = 0.008, r= −0.512). Biochemical parameters were not different among ACE gene polimorphism subgroups, except FBG (between D/D, I/D and D/I, I/D; p = 0.02). When the ACE levels were compared in terms of grade and stage, no significant difference was found (for stage and grade p = 0.68). The ACE gene polymorphism subgroups did not differ by histopathologic findings; grade and stage (for grade p = 0.42, for stage p = 0.92).

Conclusion

In this study, we could not find a correlation of ACE and ACE gene polymorphism with metabolic risk factors and the disease severity in NAFLD.

How to cite this article

Tekatas DD, Bahcecioglu IH, Ispiroglu M, Sahin A, Ilhan N, Yalniz M, Demirel U. Role of Renin–Angiotensin-converting Enzyme Level and ACE Gene Polymorphism in Patients with Nonalcoholic Fatty Liver Disease. Euroasian J Hepato-Gastroenterol 2016;6(2):137-142.

Circulating adiponectin levels in type 2 diabetes mellitus patients with or without non-alcoholic fatty liver disease: Results of a small, open-label, randomized controlled intervention trial in a subgroup receiving short-term exenatide

AIM

Diabetes mellitus type 2 (DMT2) and non-alcoholic fatty liver disease (NAFLD) are both characterized by decreased circulating adiponectin. Recently, glucagon-like peptide-1 receptor agonists have been shown to induce adiponectin's expression. However, their interaction on clinical grounds needs to be further elucidated.

METHODS

DMT2 patients with abnormal aminotransferases were screened for NAFLD and subjected to liver biopsy (group A, n=17). A subgroup of patients (n=110), after assessed for eligibility criteria, was blindly randomized to receive either 6-month exenatide supplementation on glargine insulin (group B) or intense, self-regulated, insulin therapy alone (group C).

RESULTS

Baseline patient characteristics: 49(38.6%) males, aged 63.1 ± 7.5 years-old, BMI 32.9 ± 4.9 kg/m(2), HbA1c 8.1 ± 1.2% (65 ± 14 mmol/mol), median ALT 23 U/L (range 5-126), AST 20 U/L (7-72). Group A had biopsy-proven NAFLD with a median Activity Score of 5 and fibrosis stage 3. Presence of NAFLD was accompanied by a significant decline in adiponectin (p<0.001), which was negatively correlated with the degree of ALT in all groups (Spearman's correlation, rs=-0.644, p<0.001). In the subgroup intervention trial, adiponectin was significantly raised in both groups B and C (t-Student for paired samples, p=0.001) by Δ=+24.2% (interquartile range 14.8-53.2%). This elevation was not associated with the type of intervention but with weight loss, glycemic control and reduction of C-reactive protein (one-way ANCOVA).

CONCLUSION

Supplementation of exenatide to glargine insulin compared to standard insulin was: (i) effective in inducing weight loss, (ii) non-inferior in lowering HbA1c and (iii) non-inferior in increasing circulating adiponectin. Higher adiponectin was associated with lower ALT, suggesting a hepato-protective role for this cytokine.

Noninvasive Assessment of Fibrosis in Patients with Nonalcoholic Fatty Liver Disease

Nonalcoholic fatty liver disease (NAFLD) is prevalent in 20-25% of the general population and is associated with metabolic risk factors such as obesity, diabetes mellitus, and dyslipidemia. Histologically, NAFLD ranges from simple steatosis to nonalcoholic steatohepatitis (NASH), fibrosis, and cirrhosis. As NASH develops in only 10-15% of patients with NAFLD, it is not practical to biopsy all patients who present with NAFLD. Noninvasive fibrosis tests have been extensively developed recently and offer alternatives for staging fibrosis. Despite their increasing use, such tests cannot adequately differentiate simple steatosis from NASH. At present, such tests can be used as first line tests to rule out patients without advanced fibrosis and thus prevent unnecessary secondary care referrals in a significant number of patients. In this review we present the evidence for the use of noninvasive fibrosis tests in patients with NAFLD.

Role of vitamin D in children with hepatosteatosis

BACKGROUND

The increasing incidence of obesity in children is a significant risk factor for nonalcoholic fatty liver disease and obesity-associated morbidity. Vitamin D has a major role in bone mineral metabolism and has antimicrobial, antioxidant properties. In this study we aimed to investigate the role of vitamin D in children with obesity with hepatosteatosis.

METHODS

A total of 101 children with obesity were included in this study. Hepatosteatosis was diagnosed and graded using ultrasonography. Serum levels of 25-hydroxyvitamin D (25-(OH) vitamin D), calcium, phosphate, alkaline phosphatase, and parathormone were tested. Two-sided t test and Pearson χ tests were used for the relation between vitamin D and hepatosteatosis.

RESULTS

In our study group, 45.5% were girls (n=46) and the mean age was 11.5 ± 2.8 years (range 3-17 years). Hepatosteatosis was identified in 58 children (57.4%). The diagnosis of grade 1 and grade 2 hepatosteatosis was made in 41 (40.6%) and 17 (16.8%) children, respectively. Median serum 25-(OH) vitamin D levels in children without hepatosteatosis was 16.4 ng/mL (interquartile range 12.4-24.8 ng/mL), whereas children with grade 1 and grade 2 hepatosteatosis had 25-(OH) vitamin D levels of 14.2 ng/mL (interquartile range 9.5-21.2 ng/mL) and 11.5 ng/mL (interquartile range 7.5-16.7 ng/mL), respectively (P=0.005). There was a positive correlation between insulin resistance and the grade of hepatosteatosis (P=0.03).

CONCLUSIONS

Serum vitamin D levels in children with obesity with hepatosteatosis are significantly lower than vitamin D levels in children with obesity without hepatosteatosis. In this observational study we only refer to the association of vitamin D deficiency/insufficiency with hepatosteatosis.

Skeletal muscle and organ masses differ in overweight adults with type 2 diabetes

Whether lean body mass (LBM) composition, especially skeletal muscle and abdominal organs, differs in adults with type 2 diabetes (T2DM) compared with nondiabetic healthy controls has not been investigated. A subset of African-American and Caucasian participants with T2DM from the Look AHEAD (Action for Health in Diabetes) trial had body composition assessed and compared with a sample of healthy controls. Skeletal muscle mass (SMM), liver, kidneys, and spleen mass were quantified using a contiguous slice magnetic resonance imaging (MRI) protocol. Cardiac mass was quantified by either a cardiac gated MRI protocol or by echocardiography. MRI volumes were converted to mass using assumed densities. Dual-energy X-ray absorptiometry assessed LBM. Using general linear models adjusted for height, weight, sex, age, race, and interactions of diabetes status with race or sex, persons with T2DM (n = 95) had less LBM (49.7 vs. 51.6 kg) and SMM (24.1 vs. 25.4 kg) and larger kidneys (0.40 vs. 0.36 kg) than controls (n = 76) (all P < 0.01). Caucasians with T2DM had larger livers (1.90 vs. 1.60 kg, P < 0.0001) and spleens (0.29 vs. 0.22 kg, P < 0.01), and T2DM men had less cardiac mass than controls (0.25 vs. 0.30 kg, P < 0.001). In this sample, T2DM is characterized by less relative skeletal muscle and cardiac mass in conjunction with larger kidneys, liver, and spleen. Further investigation is needed to establish the causes and metabolic consequences of these race- and sex-specific organ mass differences in T2DM.

Serum adiponectin, leptin, resistin and RBP4 levels in obese and metabolic syndrome children with nonalcoholic fatty liver disease

AIM

To investigate the relationship of adiponectin, leptin, resistin and RBP4 levels in obese and metabolic syndrome children with nonalcoholic fatty liver disease (NAFLD).

PATIENTS & METHODS

Group I consisted of 63 obese children with liver steatosis, group II consisted of 12 obese children with elevated serum ALT activity from group I, and group III included 85 obese children without liver steatosis.

RESULTS

Leptin levels were higher in the NAFLD children than in the control group. Serum RBP4 levels in obese children with NAFLD were higher than those in obese children without NAFLD and controls. Adiponectin and resistin levels were negatively correlated and RBP4 levels positively correlated with ALT activity and ultrasonographic grading.

CONCLUSION

These data suggest that adiponectin, resistin and RBP4 may have a role in the pathogenesis of NAFLD in obese children. Adiponectin, leptin, resistin and RBP4 may be suitable markers for predicting metabolic syndrome and NAFLD.

Clinical approaches to non-alcoholic fatty liver disease

Non-alcoholic fatty liver disease (NAFLD) ranges from simple steatosis to nonalcoholic steatohepatitis (NASH), leading to fibrosis and potentially cirrhosis, and it is one of the most common causes of liver disease worldwide. NAFLD is associated with other medical conditions such as metabolic syndrome, obesity, cardiovascular disease and diabetes. NASH can only be diagnosed through liver biopsy, but noninvasive techniques have been developed to identify patients who are most likely to have NASH or fibrosis, reducing the need for liver biopsy and risk to patients. Disease progression varies between individuals and is linked to a number of risk factors. Mechanisms involved in the pathogenesis are associated with diet and lifestyle, influx of free fatty acids to the liver from adipose tissue due to insulin resistance, hepatic oxidative stress, cytokines production, reduced very low-density lipoprotein secretion and intestinal microbiome. Weight loss through improved diet and increased physical activity has been the cornerstone therapy of NAFLD. Recent therapies such as pioglitazone and vitamin E have been shown to be beneficial. Omega 3 polyunsaturated fatty acids and statins may offer additional benefits. Bariatric surgery should be considered in morbidly obese patients. More research is needed to assess the impact of these treatments on a long-term basis. The objective of this article is to briefly review the diagnosis, management and treatment of this disease in order to aid clinicians in managing these patients.

Clinical approaches to non-alcoholic fatty liver disease

Non-alcoholic fatty liver disease (NAFLD) ranges from simple steatosis to nonalcoholic steatohepatitis (NASH), leading to fibrosis and potentially cirrhosis, and it is one of the most common causes of liver disease worldwide. NAFLD is associated with other medical conditions such as metabolic syndrome, obesity, cardiovascular disease and diabetes. NASH can only be diagnosed through liver biopsy, but noninvasive techniques have been developed to identify patients who are most likely to have NASH or fibrosis, reducing the need for liver biopsy and risk to patients. Disease progression varies between individuals and is linked to a number of risk factors. Mechanisms involved in the pathogenesis are associated with diet and lifestyle, influx of free fatty acids to the liver from adipose tissue due to insulin resistance, hepatic oxidative stress, cytokines production, reduced very low-density lipoprotein secretion and intestinal microbiome. Weight loss through improved diet and increased physical activity has been the cornerstone therapy of NAFLD. Recent therapies such as pioglitazone and vitamin E have been shown to be beneficial. Omega 3 polyunsaturated fatty acids and statins may offer additional benefits. Bariatric surgery should be considered in morbidly obese patients. More research is needed to assess the impact of these treatments on a long-term basis. The objective of this article is to briefly review the diagnosis, management and treatment of this disease in order to aid clinicians in managing these patients.

Triterpenoid-Rich Fraction from Ilex hainanensis Merr. Attenuates Non-Alcoholic Fatty Liver Disease Induced by High Fat Diet in Rats

Non-alcoholic fatty liver disease (NAFLD) has become a major challenge to the healthcare system. This study was designed to evaluate the effect of the triterpenoid-rich fraction (TF) from Ilex hainanensis Merr. on NAFLD. Male Sprague-Dawley (SD) rats were fed a normal diet (control) or high fat diet (NAFLD model). After four weeks, the high fat diet group was orally administrated TF (250 mg/kg) for another two weeks. High fat diet fed rats displayed hyperlipidemia and a decline in liver function compared with control. However, administration with TF could effectively improve these symptoms, as demonstrated by decreasing the plasma levels of triglyceride (p <0.05), total cholesterol (p < 0.01), low-density lipoprotein cholesterol (p < 0.05), alanine transaminase (p < 0.05), aspartate aminotransferase (p < 0.01), liver index (p < 0.05) and insulin resistance index (p < 0.05) while increasing the high-density lipoprotein cholesterol (p < 0.05). Meanwhile, histopathological examination of livers also showed that TF could reduce the incidence of liver lesions induced by high fat diet. Furthermore, TF could alleviate oxidative stress and inflammation status indicated by the decline malondialdehyde and superoxide dismutase levels (p < 0.01, both) and levels of interleukin 6 and tumor necrosis factor-α (p < 0.05). In addition, immunohistochemistry showed TF evidently elevated the peroxisome proliferator-activated receptor (PPARα) expression (p < 0.01), while it diminished the Cytochrome P450 2E1 (CYP2E1) expression (p < 0.01) in liver. These results demonstrate that TF has potential ability to protect liver against NAFLD by regulating lipids metabolism and alleviating insulin resistance, inflammation and oxidative stress. This effect might be associated with regulating PPARα and CYP2E1 expression.

Fatty liver score and 15-year incidence of type 2 diabetes

PURPOSE

Both non-alcoholic fatty liver (NAFL) and alcoholic fatty liver (AFL) are strongly associated with obesity, metabolic syndrome, and type 2 diabetes mellitus (T2DM). Recently, also the vitamin D level has been associated with these and may also be associated with fatty liver (FL). Liver function tests (LFTs) are insensitive markers of FL, but use of scores may help in identifying subjects with FL. We studied how LFTs and the FL score predict the development of T2DM in subjects with AFL versus NAFL and low versus high vitamin D levels.

METHODS

A cohort study based on 4,517 participants, aged 40-79, from the representative Mini-Finland Health Survey was carried out. During a follow-up of 15 years, 217 T2DM cases occurred. LFTs were determined from serum samples, and the FL score was formed using BMI, fasting glucose, HDL cholesterol, and GGT concentrations.

RESULTS

The risk of T2DM incidence in the highest versus lowest quartile was twofold for the LFTs and ninefold for the FL score. A total of 77 % (95 % confidence interval: 57-87 %) of the T2DM cases could have been prevented if all individuals' FL scores had been at the level of the first quartile. Heavy alcohol consumption and low serum vitamin D concentrations were associated with an increased risk of T2DM among individuals with high FL scores.

CONCLUSIONS

The FL score is a useful tool for diagnosing FL in epidemiological studies. A high FL score predicts increased risk of T2DM, especially when combined with heavy alcohol consumption or low vitamin D levels.

A multi-ethnic study of a PNPLA3 gene variant and its association with disease severity in non-alcoholic fatty liver disease

The adiponutrin (PNPLA3) rs738409 polymorphism has been found to be associated with susceptibility to non-alcoholic fatty liver disease (NAFLD) in various cohorts. We further investigated the association of this polymorphism with non-alcoholic steatohepatitis (NASH) severity and with histological features of NAFLD. A total of 144 biopsy-proven NAFLD patients and 198 controls were genotyped for PNPLA3 gene polymorphism (rs738409 C>G). The biopsy specimens were histologically graded by a qualified pathologist. We observed an association of G allele with susceptibility to NAFLD in the pooled subjects (OR 2.34, 95% CI 1.69–3.24, p < 0.0001), and following stratification, in each of the three ethnic subgroups, namely Chinese, Indian and Malay (OR 1.94, 95% CI 1.12–3.37, p = 0.018; OR 3.51, 95% CI 1.69–7.26, p = 0.001 and OR 2.05, 95% CI 1.25–3.35, p = 0.005, respectively). The G allele is associated with susceptibility to NASH (OR 2.64, 95% CI 1.85–3.75, p < 0.0001), with NASH severity (OR 1.85, 95% CI 1.05–3.26, p = 0.035) and with presence of fibrosis (OR 1.95, 95% CI 1.17–3.26, p = 0.013) but not with simple steatosis nor with other histological parameters. Although the serum triglyceride level is significantly higher in NAFLD patients compared to controls, the G allele is associated with decreased level of triglycerides (p = 0.029) in the NAFLD patients. Overall, the rs738409 G allele is associated with severity of NASH and occurence of fibrosis in patients with NAFLD.

Erythrocyte antioxidant defenses as a potential biomarker of liver mitochondrial status in different oxidative conditions

The need for minimally invasive biomarkers to predict the progression of non-alcoholic fatty liver disease to non-alcoholic steatohepatitis is a priority. Oxidative stress and mitochondrial dysfunction contribute in this physiopathological process. The aim of this study was to analyze the potential role of erythrocytes as surrogate biomarkers of hepatic mitochondrial oxidative status in an animal model under different dietary oxidative conditions. Interestingly, we found that erythrocyte antioxidant status correlated with triglyceride content (p < 0.05-p < 0.001), thiobarbituric acid reactive species levels (p < 0.001) and with liver mitochondrial antioxidant levels (p < 0.001). These data suggest that erythrocyte antioxidant defenses could be used as sensitive and minimally invasive biomarkers of mitochondrial status in diverse oxidative conditions.

Cytokeratins in hepatitis

Experimental and clinical evidence suggests that cytokeratins (CK), among other physiological functions, are expressed in hepatocytes and can be released in the bloodstream after acute or chronic inflammatory liver injury. Interest in CK in viral and nonviral hepatitis has been rapidly increasing during the last years, especially as they have been proposed as circulating biomarkers of hepatocyte necrosis and apoptosis. In the present review, we sought to summarize and discuss the alterations in circulating CK levels in different form viral and nonviral hepatitis, as well as their potential relation with liver histology. Understanding the mechanisms of hepatitis impact on CK and vice versa is a promising area of research that will positively enhance our understanding of the complexity of acute and chronic inflammatory liver injury.

Paraoxonase-1 activity, malondialdehyde and glutathione peroxidase in non-alcoholic fatty liver disease and the effect of atorvastatin

BACKGROUND AND STUDY AIMS

The prevalence of non-alcoholic fatty liver disease (NAFLD) appears to be increasing. The aim of the present study was to investigate the relationship between hepatic antioxidant paraoxonase 1 (PON1) activity, lipid peroxidation and antioxidant enzymes in patients with NAFLD and the effect of atorvastatin.

PATIENTS AND METHODS

This study was conducted on 50 patients with NAFLD and 20 normal subjects matched for age and sex. All of them were subjected to the following investigations: abdominal ultrasonography, serum PON1 activity level, liver function tests, serum lipid profile, fasting and postprandial blood glucose and serum levels of malondialdehyde (MDA) and glutathione peroxidase (GP). NAFLD patients were further randomly classified into two groups (25 patients each), groups Ia and Ib. Only group Ia received atorvastatin 40mg tablet for 8months.

RESULTS

Obesity, dyslipidaemia and impaired glucose tolerance were prevalent in group I. There was a significant decrease in serum PON1 activity with a significant increase in MDA and GP activity (i.e., there is a significant increase in lipid peroxidation rate) in group I compared with group II. After atorvastatin therapy, there was a significant increase in serum PNO1 activity and significant decrease in serum MDA levels.

CONCLUSION

Patients with NAFLD show enhanced oxidative stress which may lead to non-alcoholic steatohepatitis (NASH). Reduced PON1 activity and increased MDA could be considered a biochemical marker for lipid peroxidation, which require follow-up in patients with NAFLD. Atorvastatin may have a role in prevention of, or delay, the transformation of liver steatosis into NASH.

The Finnish Diabetes Risk Score (FINDRISC) as a screening tool for hepatic steatosis

INTRODUCTION. Hepatic steatosis due to non-alcoholic fatty liver disease is associated with obesity, dyslipidemia, insulin resistance, and type 2 diabetes. The Finnish Diabetes Risk Score (FINDRISC) is a prognostic screening tool to detect people at risk for type 2 diabetes without the use of any blood test. The objective of this study was to evaluate whether FINDRISC can also be used to screen for the presence of hepatic steatosis. PATIENTS AND METHODS. Steatosis was determined by ultrasound. The study sample consisted of 821 non-diabetic subjects without previous hepatic disease; 81% were men (mean age 45 ± 9 years) and 19% women (mean age 41 ± 10 years). RESULTS. Steatosis was present in 44% of men and 10% of women. The odds ratio for one unit increase in the FINDRISC associated with the risk of steatosis was 1.30 (95% CI 1.25-1.35), similar for men and women. The area under the receiver operating characteristics curve for steatosis was 0.80 (95% CI 0.77-0.83); 0.80 in men (95% CI 0.77-0.83) and 0.83 (95% CI 0.73-0.93) in women. CONCLUSIONS. Our data suggest that the FINDRISC could be a useful primary screening tool for the presence of steatosis.

Which clinical and sonographic parameters may be useful to discriminate NASH from steatosis?

BACKGROUND

The natural history of nonalcoholic steatohepatitis (NASH) includes the passage through steatosis.

GOAL

To retrospectively evaluate the usefulness of sonographic parameters compared to histological diagnosis when differentiating steatosis from NASH.

STUDY

This retrospective study reviewed records of patients with steatosis from databases of our Departments, selecting only those who had been diagnosed by sonography and liver biopsy [64 males (63.82%); 30 females (36.18%)].

RESULTS

Attenuation of the echo amplitude (P<0.05; odds ratio (OR): 3.43; confidence interval (CI): 1.02-11.57), focal fat sparing (P<0.05; OR: 3; CI: 1.02-11.88) and splenic diameter (P<0.05; OR: 1.66; CI: 1.04-3.26) were independent predictors of NASH. A significantly higher association of attenuation of the echo amplitude, enlarged splenic diameter, and presence of focal fat sparing was observed in NASH patients (P<0.01).

CONCLUSIONS

It is very difficult to build a predictive system to distinguish NASH from steatosis based on sonographic scores. However, it is already possible to differentiate NASH from steatosis by combining 3 simple sonographic parameters: attenuation of the echo amplitude, enlarged splenic diameter, and presence of focal fat sparing.

Non-alcoholic and alcoholic fatty liver disease - two diseases of affluence associated with the metabolic syndrome and type 2 diabetes: the FIN-D2D survey

Background

Non-alcoholic fatty liver disease (NAFLD) is known to be associated with the metabolic syndrome (MetS) and abnormal glucose tolerance. Whether alcoholic fatty liver disease (AFLD) is associated with similar metabolic abnormalities has not been examined in a population-based study. We aimed at assessing the prevalences of NAFLD and AFLD, and to examine to what extent these conditions are associated with MetS and abnormal glucose tolerance.

Methods

The cohort included 2766 Finnish subjects (45-74 years) from the population-based FIN-D2D survey. Features of insulin resistance, components of the MetS, glucose tolerance status by oral glucose tolerance test, serum liver enzyme concentrations, and daily alcohol consumption were assessed.

Results

Subjects with NAFLD and AFLD were equally obese and had similar fasting and insulin concentrations. The prevalences of NAFLD and AFLD were 21% (95% CI: 19%-22%) and 7% (95% CI: 6%-8%). The MetS was slightly more prevalent in AFLD (73%) than in NAFLD (70%, p = 0.028), and type 2 diabetes was similarly prevalent in NAFLD and AFLD (24-25%). The MetS and type 2 diabetes were more prevalent in subjects with NAFLD or AFLD compared to subjects with normal LFTs (53% and 14%, p < 0.0001 for both).

Discussion and conclusion

In Finnish middle-aged population, the prevalence of NAFLD is 3-fold higher than that of AFLD. The prevalences of MetS and type 2 diabetes are, however, significantly increased in both NAFLD and AFLD compared to subjects with normal LFTs. Subjects with AFLD are thus similarly metabolically unhealthy as subjects with NAFLD.

Prediction of non-alcoholic fatty liver disease and liver fat using metabolic and genetic factors

BACKGROUND & AIMS

Our aims were to develop a method to accurately predict non-alcoholic fatty liver disease (NAFLD) and liver fat content based on routinely available clinical and laboratory data and to test whether knowledge of the recently discovered genetic variant in the PNPLA3 gene (rs738409) increases accuracy of the prediction.

METHODS

Liver fat content was measured using proton magnetic resonance spectroscopy in 470 subjects, who were randomly divided into estimation (two thirds of the subjects, n = 313) and validation (one third of the subjects, n = 157) groups. Multivariate logistic and linear regression analyses were used to create an NAFLD liver fat score to diagnose NAFLD and liver fat equation to estimate liver fat percentage in each individual.

RESULTS

The presence of the metabolic syndrome and type 2 diabetes, fasting serum (fS) insulin, fS-aspartate aminotransferase (AST), and the AST/alanine aminotransferase ratio were independent predictors of NAFLD. The score had an area under the receiver operating characteristic curve of 0.87 in the estimation and 0.86 in the validation group. The optimal cut-off point of -0.640 predicted increased liver fat content with sensitivity of 86% and specificity of 71%. Addition of the genetic information to the score improved the accuracy of the prediction by only <1%. Using the same variables, we developed a liver fat equation from which liver fat percentage of each individual could be estimated.

CONCLUSIONS

The NAFLD liver fat score and liver fat equation provide simple and noninvasive tools to predict NAFLD and liver fat content.

Teucrium polium in prevention of steatohepatitis in rats

BACKGROUND

In this study, we tried to evaluate whether the ethyl acetate (EtOAc) extract of Teucrium polium, with a high antioxidant activity, is able to prevent the incidence of nonalcoholic steatohepatitis.

METHODS

Nonalcoholic steatohepatitis was induced in male N-Mary rats using a methionine/choline-deficient (MCD) diet. Rats were given normal diet (A), normal diet+EtOAc extract (B), MCD diet (C) and MCD diet+EtOAc (D).

RESULTS

The MCD diet led to grade 1 liver steatosis, inflammation and ballooning degeneration. In group D, these factors abated to grade 0 in 80% of the rats. In groups receiving the EtOAc extract, lipoprotein profiles had significantly improved relative to those not receiving the extract. Also, a dramatic reduction was observed in the sera alkaline phosphatase, aspartate aminotransferase and alanine aminoteransferase activities. The activities of the liver superoxide dismutase, glutathione peroxidase and glutathione reductase enzymes were also enhanced.

CONCLUSION

The EtOAc extract could reverse the adverse effects of the MCD diet.

Low serum adiponectin levels are predictive of advanced hepatic fibrosis in patients with NAFLD

BACKGROUND

Adiponectin, an adipocytokine-mediating insulin action, has recently been found to be involved in the pathogenesis of nonalcoholic fatty liver disease (NAFLD). The aim of this study was to assess possible associations between serum adiponectin levels and factors of the metabolic syndrome or histologic parameters in biopsy-proven NAFLD.

METHODS

Patients with persistently abnormal liver function tests satisfying inclusion criteria were subjected to liver biopsy. Fibrosis stage and the NAFLD activity score were recorded for each patient. Body mass index, waist-to-hip ratio, factors of the metabolic syndrome (central obesity, hyperglycemia, hypertriglyceridemia, low high-density lipoprotein, and hypertension), and biochemical tests were also recorded. Insulin resistance was calculated by the homeostasis model assessment method. Serum adiponectin concentration was measured by an enzyme-linked immunosorbent assay.

RESULTS

Forty-two NAFLD patients, including 9 with compensated cirrhosis, were included in the study. The presence of each factor of the metabolic syndrome was associated with hypoadiponectinemia. Adiponectin negatively correlated with homeostasis model assessment (r=-0.551, P=0.001). Adiponectin concentration was negatively associated with higher stages of fibrosis (one-wayanalysis of variance, P=0.007), and was not associated with NAFLD activity score. Using multivariate logistic regression, adiponectin concentration, aspartate aminotransferase/alanine aminotransferase ratio, and the presence of waist-to-hip ratio >1 were independent predictors of advanced fibrosis. The receiver operating characteristic curve for detecting advanced fibrosis using a combination of the independent variables had an area under the curve of 0.902+/-0.054, P<0.0001.

CONCLUSIONS

Low serum adiponectin levels in NAFLD patients are suggestive of advanced fibrosis. Therefore, assessment of serum adiponectin levels may be useful in clinical follow-up.

Effects of therapeutic lifestyle program on ultrasound-diagnosed nonalcoholic fatty liver disease

BACKGROUND

To investigate the effects of varied therapeutic lifestyle programs on patients with ultrasound-diagnosed nonalcoholic fatty liver disease (NAFLD).

METHODS

A prospective, case-controlled study was conducted. A total of 54 subjects with NAFLD were subdivided into 3 groups: (1) diet plus exercise group (DPE group, n = 16); (2) exercise group (E group, n = 23); and (3) control group (C group, n = 15). The DPE group received a low-calorie balanced diet and regular high-intensity stationary bicycle exercise program for 10 weeks, while the E group received the same exercise protocol as the DPE group but without any changes in diet. Anthropometric indices, biochemical data, physical fitness data and liver ultrasound findings were recorded. A generalized estimating equation method was used to determine the differences among groups.

RESULTS

Compared with the C group, the DPE group demonstrated significant improvements in anthropometric indices, total cholesterol, insulin sensitivity, liver biochemistry, ultrasound finding and physical fitness, while the E group showed significant improvements in anthropometric indices, insulin sensitivity status, ultrasound finding and physical fitness but not liver biochemistry. Compared with the E group, the DPE group showed greater reduction in anthropometric indices (body mass index, body weight, abdominal circumference, hip circumference), total cholesterol, alanine aminotransferase, and gamma-glutamyltransferase.

CONCLUSION

Our data suggest that both 10-week diet-plus-exercise and exercise-only therapeutic lifestyle programs are effective for improving anthropometric indices, insulin sensitivity, ultrasound findings and physical fitness in ultrasound-diagnosed NAFLD patients. However, the range of improvement in patients on the diet-plus-exercise program is more obvious than that in patients on the exercise-only program. Moreover, the diet-plus-exercise program resulted in significant improvement in liver biochemistry, but the exercise-only program did not. In summary, diet plus exercise is more efficacious than exercise alone in the lifestyle modification treatment of NAFLD.

Targeting liver myofibroblasts: a novel approach in anti-fibrogenic therapy

Chronic liver disease results in a liver-scarring response termed fibrosis. Excessive scarring leads to cirrhosis, which is associated with high morbidity and mortality. The only treatment for liver cirrhosis is liver transplantation; therefore, much attention has been directed toward therapies that will slow or reverse fibrosis. Although anti-fibrogenic therapies have been shown to be effective in experimental animal models, licensed therapies have yet to emerge. A potential problem for any anti-fibrogenic therapy in the liver is the existence of the body’s major drug metabolising cell (the hepatocyte) adjacent to the primary fibrosis-causing cell, the myofibroblast. This article reviews the development of a human recombinant single-chain antibody (scAb) that binds to the surface of myofibroblasts. This antibody binds specifically to myofibroblasts in fibrotic mouse livers. When conjugated with a compound that stimulates myofibroblast apoptosis, the antibody directs the specific apoptosis of myofibroblasts with greater specificity and efficacy than the free compound. The antibody also reduces the adverse effect of liver macrophage apoptosis and—in contrast to the free compound—reversed fibrosis in the sustained injury model used. These data suggest that specifically stimulating the apoptosis of liver myofibroblasts using a targeting antibody has potential in the treatment of liver fibrosis.

Non-alcoholic fatty liver disease: an overview of prevalence, diagnosis, pathogenesis and treatment considerations

The global increase in the prevalence of obesity has heralded a rise in associated liver injury namely NAFLD (non-alcoholic fatty liver disease). It is estimated that 20–30% of adult populations in developed countries have NAFLD and, although high quality data is currently lacking, the condition is clearly increasing in children also. NAFLD should be suspected in those with commonly available simple clinical signs and biochemistry consistent with insulin resistance. A small number of individuals with NAFLD, often considered a relatively benign condition, will progress to more severe stages of liver disease including NASH (non-alcoholic steatohepatitis) with or without fibrosis, cirrhosis and occasionally hepatocellular carcinoma. NAFLD is also commonly associated with an increased risk of developing Type 2 diabetes and treatable features of insulin resistance such as dyslipidaemia and dysglycaemia. Histological examination of liver tissue remains the only proven method to distinguish between simple steatosis and NASH, a condition far more likely to progress to cirrhosis. Identification of an imaging technique or non-invasive marker to achieve this distinction is therefore much sought after and would allow larger clinical trials and better clinical assessment. Case series and pilot studies of lifestyle advice, insulin sensitizers and other medications have shown improvements in liver histology and serum liver enzymes but robust randomized controlled studies are needed. Furthermore, the cost/benefit ratio of any new therapies, and any potential harms, must be evaluated carefully before being clinically advocated.

Proteomics in liver fibrosis is more than meets the eye

Liver fibrosis is a serious health issue for many liver patients and is currently diagnosed using liver biopsy. The erroneous nature of this technique urges the search for better, noninvasive alternatives. In this regard, proteomics has been described as a useful biomarker discovery tool and has become increasingly applied in the study of liver fibrosis. Experimental and clinical studies have already provided deeper insights in the molecular pathways of liver fibrosis and even confirmed previous findings. Recent advances in proteomic strategies and tools enable multiple fractionation, multiple protein identifications and parallel analyses of multiple samples. Despite its increasing popularity, proteomics still faces certain pitfalls concerning preanalytical variability, protein coverage and statistic reliability. Proteomics is still evolving, but will undoubtedly contribute to a better understanding of the basics of the pathology and certainly offer opportunities in liver fibrosis diagnostics and therapeutics.

Chronic prehepatic portal hypertension in the rat: is it a type of metabolic inflammatory syndrome?

BACKGROUND

A progressive development of hepatic steatosis with an increase in the lipid hepatocyte content and the formation of megamitochondria have been demonstrated in rats with prehepatic portal hypertension. The aim of this study is to verify the existence of liver and serum lipid metabolism impairments in rats with long-term (2 years) portal hypertension.

METHODS

Male Wistar rats: Control (n = 10) and with prehepatic portal hypertension by triple partial portal vein ligation (n = 9) were used. Liver content of Triglycerides (TG), phospholipids (PL) and cholesterol and serum cholesterol, lipoproteins (HDL and LDL), TG, glucose and Lipid Binding Protein (LBP) were assayed with specific colorimetric commercial kits. Serum levels of insulin and somatostatin were assayed by RIA.

RESULTS

The liver content of TG (6.30 +/- 1.95 vs. 4.17 +/- 0.59 microg/ml; p < 0.01) and cholesterol (1.48 +/- 0.15 vs. 1.10 +/- 0.13 microg/ml; p < 0.001) increased in rats with portal hypertension. The serum levels of cholesterol (97.00+26.02 vs. 114.78 +/- 37.72 mg/dl), TG (153.41 +/- 80.39 vs. 324.39 +/- 134.9 mg/dl; p < 0.01), HDL (20.45 +/- 5.14 vs. 55.15 +/- 17.47 mg/dl; p < 0.001) and somatostatin (1.32 +/- 0.31 vs. 1.59 +0.37 mg/dl) decreased, whereas LDL (37.83 +/- 15.39 vs. 16.77 +/- 6.81 mg/dl; p < 0.001) and LBP (308.47 +/- 194.53 vs. 60.27 +/- 42.96 ng/ml; p < 0.001) increased.

CONCLUSION

Portal hypertension in the rat presents changes in the lipid and carbohydrate metabolisms similar to those produced in chronic inflammatory conditions and sepsis in humans. These underlying alterations could be involved in the development of hepatic steatosis and, therefore, in those described in the metabolic syndrome in humans.

Relationship between abnormal glycometabolism and ultra-sensitive C-reactive protein in non-alcoholic fatty liver

AIM: To study the relationship between abnormal glycometabolism and ultra-sensitive C-reactive protein (hsCRP) in non-alcoholic fatty liver (NAFLD).

METHODS: One hundred and ninety-one NAFLD patients were divided into normal glucose metabolism group and abnormal glucose metabolism group according to the oral glucose tolerance test (OGTT). Their serum hsCRP levels were measured.

RESULTS: The serum hsCRP levels in the abnormal glucose metabolism group were higher than those in the normal glucose metabolism group(4.01 ± 1.45 vs 0.96 ± 0.41, P < 0.01), which were positively correlated with the glucose tolerance (r = 0.74, P < 0.01).

CONCLUSION: Serum hsCRP levels are related with abnormal glycometabolism in NAFLD patients.

HIV-positive patients with nonalcoholic fatty liver disease have a lower body mass index and are more physically active than HIV-negative patients

OBJECTIVE

To determine whether the clinical and metabolic features associated with nonalcoholic fatty liver disease (NAFLD) are similar between HIV-positive and HIV-negative male subjects.

METHODS

Twenty-six HIV-positive and 25 HIV-negative subjects with liver biopsy-proven NAFLD were compared for liver histology (extent of steatosis, steatosis grading, and fibrosis staging), blood biochemistry (glucose, insulin, C-peptide, hemoglobin A1c, and lipid profile), insulin resistance (IR) using a homeostasis model assessment, anthropometry (body mass index [BMI], waist circumference, and arm muscle area), dietary intake, and physical activity.

RESULTS

The 2 groups were similar for age, liver histology, and IR. HIV-positive patients had a lower BMI (26.3 +/- 0.5 vs. 30.2 +/- 1.0 kg/m; P = 0.001) and lower percentage of fat mass (19.4 +/- 0.9 vs. 22.7 +/- 1.2; P = 0.026) when compared with HIV-negative patients. Although caloric intake was similar between groups, HIV-positive patients had a higher physical activity level (8.3 +/- 1.6 vs. 4.1 +/- 0.8 units of exercise per day; P = 0.029). Blood triglycerides were significantly higher (3.14 +/- 0.39 vs. 1.86 +/- 0.20 mmol/L; P = 0.006) in HIV-positive patients.

CONCLUSION

Although NAFLD was similar between the 2 groups, HIV-positive patients had a lower BMI and were more physically active compared with HIV-negative patients. This may suggest that in HIV, NAFLD is associated with factors other than those related to body fatness, such as HIV infection and treatment.

Medex test, a novel modality for liver disease diagnosis: a pilot study

BACKGROUND AND AIMS

Liver diseases are associated with significant morbidity and health- related expenditure. Although cost-effective treatments are available, the disease is often asymptomatic until late in its course. "Medex Test," is the noninvasive detection of liver abnormalities by the measurement of changes in electrical impedance of dermal zones. This method is based on neuroreflexology, a branch of complementary medicine. This study addressed 2 questions: can Medex Test detect liver disease, and can it measure the severity of a known liver disease.

METHODS

This blinded case-control study included 2 parts. First, 113 patients with a known liver disease (hepatitis C, hepatitis B, and nonalcoholic fatty liver disease) and 85 controls with no known liver disease were evaluated by the Medex Test device. Second, necroinflammatory grading of biopsy results of 60 patients with chronic hepatitis C were compared with grade determined by Medex Test.

RESULTS

Medex Test detected with high sensitivity (85%) and specificity (94.1%) the presence of liver disorders. The high rates were similar for the different disorders and were independent of age and sex. Additionally, Medex Test matched the biopsy pathologic grading of necroinflammation in 78% of patients. Positive predictive value was not affected by age and sex and was better for higher degree of necroinflammation.

CONCLUSIONS

This pilot study demonstrated that Medex Test detects with high accuracy the presence of liver disorders and the necroinflammatory grade. This noninvasive, low cost test may in the future become an important tool in the diagnosis and management of liver disorders. We believe the further study of this novel method is warranted.

Effect of losartan on early liver fibrosis development in a rat model of nonalcoholic steatohepatitis

BACKGROUND AND AIM

Nonalcoholic steatohepatitis (NASH) is a metabolic disorder of the liver that may evolve into fibrosis or cirrhosis. Recent studies have shown reduction of experimental liver fibrosis with the use of angiotensin-converting-enzyme inhibitors or angiotensin-receptor antagonists. The aim of this study was to determine whether losartan can influence the early phase of fibrogenesis in an animal model of NASH.

METHODS

To induce NASH, a choline-deficient diet (CDD) was given to Sprague-Dawley rats for 12 weeks. These animals were then compared with a control group receiving choline-supplemented diet (CSD) and a group fed a CDD plus losartan (10 mg/kg/day). Biochemical (serum levels of alanine aminotransferase and aspartate aminotransferase) and histological evaluation of fatty liver was performed by conventional techniques. Hydroxyproline content in liver tissue was assayed by spectrophotometry. In addition, mRNA levels of procollagen I and transforming growth factor (TGF)-beta were assessed by semiquantitative RT-PCR and stellate cell activation by alpha-actin immunofluorescence stain.

RESULTS

After 12 weeks CDD induced a marked elevation of serum aminotranferases, a severe fatty liver infiltration with mild histological inflammation and fibrosis. These findings correlated with a significant increase in mRNA levels of both procollagen I and TGF-beta and significant increased liver hydroxyproline content. No differences were seen between rats receiving CDD alone and rats receiving CDD plus losartan with regard to the biochemical, morphological or molecular alterations induced by the CDD.

CONCLUSION

Losartan does not seem to influence liver injury and fibrogenic events in the CDD model of NASH.

A growing burden: the pathogenesis, investigation and management of non-alcoholic fatty liver disease

Non-alcoholic fatty liver disease (NAFLD) is the most common hepatic disorder in western countries, and its incidence is increasing. This review outlines the significant health burden posed by NAFLD and discusses what is presently known about its pathogenesis, including the roles of the metabolic syndrome, obesity, insulin resistance, hepatic steatosis, reactive oxygen species, inflammatory cytokines and adipocytokines. The way in which NAFLD is clinically diagnosed is described, and areas of uncertainty surrounding its investigation are identified, before discussing the relative merits of the limited treatment options available and looking ahead to potential therapeutic strategies for the future.

The effect of citrus flavonoids on the redox state of alimentary-induced fatty liver in rats

Both chronic venous insufficiency (CVI) and fatty liver may develop at the same time. Hesperidin and diosmin are used for the treatment CVI. There is no information, however, on the effect of these flavonoids in the redox state of fatty liver. In this study, male Wistar albino rats were fed a lipid-rich diet with or without 450 mg diosmin-50 mg hesperidin-containing drug (60 mg kg(-1) body weight/day, per os) for 9 days to determine the impact of treatment on antioxidant defence system of the fatty liver. We detected free SH-group concentration (SHC), hydrogen-donating ability (HDA), and natural scavenger capacity were decreased and hepatic malonaldehyde content and dien conjugate (DC) content in rats with fatty liver were increased compared to the control. After treatment in fatty liver, these parameters (except DC) significantly improved and approached the control value. Our results indicate that diosmin-hesperidin-containing drug may be a useful agent in improving the antioxidant defensive system in alimentary-induced fatty liver disease.

Radioembolization with 90Yttrium microspheres: a state-of-the-art brachytherapy treatment for primary and secondary liver malignancies. Part 1: Technical and methodologic considerations

Microsphere and particle technology represent the next-generation agents that have formed the basis of interventional oncology, an evolving subspecialty of interventional radiology. One of these platforms, yttrium-90 microspheres, is rapidly being adopted in the medical community as an adjunctive therapeutic tool in the management of primary and secondary liver malignancies. Given the complexity of the treatment algorithm of patients who may be candidates for this therapy and the need for clinical guidance, a comprehensive review of the methodologic and technical considerations was undertaken. This experience is based on more than 900 (90)Y infusions performed over a 5-year period.

Hepatic lipid metabolism changes in short- and long-term prehepatic portal hypertensive rats

AIM: To verify the impairment of the hepatic lipid metabolism in prehepatic portal hypertension.

METHODS: The concentrations of free fatty acids, diacylglycerol, triglycerides, and phospholipids were assayed by using D-[U-¹⁴C] glucose incorporation in the different lipid fractions and thin-layer chromatography and cholesterol was measured by spectrophotometry, in liver samples of Wistar rats with partial portal vein ligation at short- (1 mo) and long-term (1 year) (i.e. portal hypertensive rats) and the control rats.

RESULTS: In the portal hypertensive rats, liver phospholipid synthesis significantly decreased (7.42 ± 0.50 vs 4.70 ± 0.44 nCi/g protein; P < 0.01) and was associated with an increased synthesis of free fatty acids (2.08 ± 0.14 vs 3.36 ± 0.33 nCi/g protein; P < 0.05), diacylglycerol (1.93 ± 0.2 vs 2.26 ± 0.28 nCi/g protein), triglycerides (2.40 ± 0.30 vs 4.49 ± 0.15 nCi/g protein) and cholesterol (24.28 ± 2.12 vs 57.66 ± 3.26 mg/g protein; P < 0.01).

CONCLUSION: Prehepatic portal hypertension in rats impairs the liver lipid metabolism. This impairment consists in an increase in lipid deposits (triglycerides, diacylglycerol and cholesterol) in the liver, accompanied by a decrease in phospholipid synthesis.

Severe liver enzyme elevations after three years of olanzapine treatment: a case report and review of olanzapine associated hepatotoxicity

Atypical antipsychotics commonly cause isolated asymptomatic increase in the aminotransferase levels. Among these atypical antipsychotics, mostly transient, asymptomatic increase in hepatic enzymes has been reported with olanzapine, however olanzapine rarely may induce a clinical and/or biological hepatic toxicity. The pathogenesis of olanzapine-associated hepatotoxicity is not well known and is mostly a transient phenomenon. However, substantial and lasting changes may occur and result in symptomatic hepatitis. In the following case report, we report on a 44-year-old female patient diagnosed as Bipolar Disorder Type I, whose liver enzyme levels increased ten fold of normal ranges during the third year of the olanzapine treatment and returned to the normal levels within three weeks after olanzapine discontinuation. Although significant liver enzyme elevations are uncommon during olanzapine treatment, based on reports of serious hepatotoxicity, controlled and longitudinal research are needed to learn side effects of this drug on liver. Clinicians should be aware of possible hepatotoxic effects of atypical antipsychotics and should monitor the liver enzyme levels whenever they feel necessary.

Hepatic lipid accumulation in healthy subjects: a comparative study using spectral fat-selective MRI and volume-localized 1H-MR spectroscopy

Fat-selective MRI was applied to assess the amount and spatial distribution of hepatic lipids (HL) in healthy subjects. The results were compared with those obtained by localized 1H-MR spectroscopy (MRS). Ninety subjects (23-63 years old) underwent single-slice fat-selective MRI with spatial-spectral excitation and volume-localized spectroscopy at 1.5 T. HLs were analyzed in ventral and dorsal regions of interest (ROIs) of the liver in fat-selective images. Spectra were evaluated using the integral signal of methylene and methyl signals. The fat-selective images showed smooth and homogeneous distribution of HL over the entire cross section of the liver. There was, however, a marked interindividual variability in the amount of HL. MRS revealed a lipid signal fraction between 0.5% and 39.3%. The fat content in the ROIs in images correlated well with the spectroscopic results (r >or= 0.95). Both techniques provide sufficient sensitivity for a reliable and quantitative assessment of liver steatosis in subjects without liver disease. 1H-MRS has a higher sensitivity compared to MRI, especially for small amounts of HL, which may be of interest for metabolic interventions. Fat-selective images provide more spatial information about fat distribution, which makes this technique suitable for clinical imaging of patients with liver disease.

Acanthosis Nigricans in Patients with Nonalcoholic Steatohepatitis: An Uncommon Finding

OBJECTIVE

To determine the prevalence and the metabolic characteristics of acanthosis nigricans (AN) in a group of 28 study subjects with biopsy-proven nonalcoholic steatohepatitis (NASH).

METHODS

The study participants (15 female and 13 male patients, 20 of whom were white subjects; mean body mass index, 32.7 +/- 5.7 kg/m2; mean age, 45.7 +/- 11.3 years) underwent an oral glucose tolerance test (OGTT), frequently sampled intravenous glucose tolerance test (FSIGT), and fasting metabolic panels. AN status was clinically determined, and fat mass was measured by dual-energy x-ray absorptiometry.

RESULTS

All study subjects had insulin resistance (IR), and 15 (54%) had the metabolic syndrome (by Adult Treatment Panel III criteria). Of the 28 patients, 4 (14%) had AN (AN+) and 24 did not (AN-). AN+ subjects had a higher body mass index (37.7 +/- 5.6 versus 31.5 +/- 4.3 kg/m2), fat mass (38.9 +/- 4.0 versus 29.2 +/- 2.3 kg), and leptin levels (17.2 +/- 3.9 versus 9.3 +/- 1.6 ng/mL) (P<0.05). They also had significantly higher indices of insulin secretion: fasting and stimulated insulin and C-peptide levels from OGTT and FSIGT. Metabolic syndrome prevalence was 40% in AN- versus 75% in AN+ subjects (not significantly different). Although the AN+ group had significantly lower fasting and OGTT-derived indices of insulin sensitivity in comparison with the AN- group, their FSIGT indices were similar. Waist circumference (a surrogate of visceral adiposity) and cytokine profiles were similar in the AN+ and AN- groups.

CONCLUSION

AN was not highly prevalent in our study cohort with NASH, despite the high prevalence of IR. Hyperinsulinemia and total adiposity, rather than visceral adiposity and IR, were the indices most predictive of AN. The use of AN as an index of IR in patients with NASH appears to have limited diagnostic value.