Non-alcoholic steatohepatitis (NASH): why biopsy?

Evaluation of reference intervals for biomarkers sensitive to alcohol consumption, excess body weight and oxidative stress

BACKGROUND

Unexplained liver enzyme activities are often found in health screening programs and constitute an increasingly common cause for referral to specialized clinics. Recent studies have indicated that both excess body weight and alcohol consumption may lead to metabolic aberrations which are readily reflected in the activities of liver enzymes in circulation.

MATERIALS AND METHODS

We compared various laboratory markers and their upper normal limits in relation to information on alcohol consumption and BMI in a large population of apparently healthy individuals collected from Nordic countries.

RESULTS

Based on the data obtained from normal weight abstainers (BMI 19-25 kg/m(2)) the upper normal limits in men should be 50 U/L for ALT, and 45 U/L (<40 years) and 70 U/L (>or=40 years) for GGT, while the current recommendations are 70 U/L, 80 U/L, and 115 U/L, respectively. Already in comparisons between normal weight abstainers and corresponding moderate drinkers notable impacts (+14% - +74%) on upper limits for these analytes were seen, which further grew when adiposity occurred together with alcohol drinking (+75% - +186%, BMI >or=27 kg/m(2)). In addition to liver enzymes, similar changes were also found for uric acid.

CONCLUSIONS

Alcohol consumption and excess body weight even in apparently healthy individuals have a significant influence on liver enzyme activities, which may be due to a cumulative oxidative stress burden. The metabolic changes induced by adiposity or ethanol intake should be considered in the definition of normal ranges for all laboratory parameters sensitive to oxidative stress.

[Non-alcoholic fatty liver disease in obese persons with diabetes]

BACKGROUND

Obesity, diabetes and different lipid metabolic disorders are the most frequent risk factors for nonalcoholic fatty liver disease, presented with a high variability in clinical and histological findings.

CASE REPORT

We presented a case of 37-year-old male, suffering from type 2 diabetes mellitus, grade III obesity (BMI 45 kg/m2) and multiple metabolic disorders. Abdominal ultrasound revealed hepatomegaly during the last six months. Laboratory diagnostics showed increased serum transaminase levels. Serologic markers for viral hepatitis B and C were negative. The patient denied significant alcohol consumption. Liver biopsy and pathohistologic finding revealed macro- (III grade) and microvesicular (I grade) fatty degeneration, as well as mixed-cell portal infiltration with moderate liver fibrosis, corresponding to the typical presentation of NASH (Non Alcoholic Steatohepatitis).

CONCLUSION

NASH treatment options include the reduction of body mass and an adequate antidiabetic and dislipidemia treatment. The aim of all therapeutic measures was to stop the progression of the disease, to prevent the progression of fibrosis and the development of cirrhosis.

The prevalence of autoantibodies and autoimmune hepatitis in patients with nonalcoholic Fatty liver disease

OBJECTIVES

Autoantibodies may exist in serum of patients with nonalcoholic fatty liver disease (NAFLD) although their prevalence and clinical significance is uncertain. We aimed at examining the prevalence of autoantibodies and autoimmune hepatitis among patients with NAFLD.

METHODS

Prevalence of antinuclear antibodies (ANA), anti-smooth muscle antibodies (anti-SMA), and autoimmune hepatitis (AIH) based on the International AIH Group were determined in 225 patients with liver biopsy-proven NAFLD.

RESULTS

Fifty-one patients [23% (95% CI 17.3-28.2%)] had autoantibodies in serum which is significantly higher than the prevalence in the general population. ANA were present in 46 patients (20%), SMA in 6 (3%), and both antibodies in one patient. Positive autoantibodies were associated with higher fibrosis stage (p= 0.03), higher inflammatory grade (p= 0.02), and higher levels of gammaglobulin (p= 0.01). Prior to liver biopsy, 45 of the 51 (88%) patients with positive autoantibodies fulfilled diagnostic criteria for 'probable' or 'definite' AIH. After liver biopsy, however, only four patients fulfilled diagnostic criteria.

CONCLUSIONS

Routinely measured autoantibodies are present in one quarter of patients with NAFLD and are associated with more severe histological damage. Liver biopsy is required to rule out AIH in most NAFLD patients with positive autoantibodies.