1
|
Jarasvaraparn C, Vilar-Gomez E, Yates KP, Wilson LA, Neuschwander-Tetri B, Loomba R, Cummings O, Vos M, Xanthakos S, Schwimmer J, Molleston JP, Sanyal A, Tonascia J, Chalasani N. Age, BMI, and Type 2 Diabetes Modify the Relationship Between PNPLA3 and Advanced Fibrosis in Children and Adults With NAFLD. Clin Gastroenterol Hepatol 2024; 22:1024-1036.e2. [PMID: 38145725 PMCID: PMC11045318 DOI: 10.1016/j.cgh.2023.12.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2023] [Revised: 11/23/2023] [Accepted: 12/04/2023] [Indexed: 12/27/2023]
Abstract
BACKGROUND & AIMS PNPLA3 G-allele is an important determinant of disease severity in nonalcoholic fatty liver disease (NAFLD). Here, we investigated the effect of age, body mass index (BMI), and type 2 diabetes mellitus (T2DM) on the relationship between PNPLA3 G-allele and advanced fibrosis in adults and children with histologically characterized NAFLD. METHODS A total of 1047 children and 2057 adults were included. DNA was genotyped for rs738409 in duplicate. Primary outcome of interest was advanced fibrosis (fibrosis stage ≥3). Regression analyses were performed after controlling for relevant covariates. An additive model was used to assess the effect of PNPLA3 G-allele (CC vs CG vs GG). RESULTS PNPLA3 G-allele was significantly associated with advanced fibrosis in children (odds ratio [OR], 1.55; 95% confidence interval [CI], 1.16-2.09) and adults (OR, 1.55; 95% CI, 1.16-1.54). Across the cohort, older age significantly increased the risk for advanced fibrosis for PNPLA3 CC (OR, 1.019; 95% CI, 1.013-1.026), CG (OR, 1.024; 95% CI, 1.018-1.030), and GG (OR, 1.03; 95% CI, 1.023-1.037) genotypes. BMI significantly increased the relationship between PNPLA3 genotypes and advanced fibrosis in children and adults. A BMI of 30 kg/m2 was the cutoff beyond which PNPLA3 G-allele had exponential effect on the risk for advanced fibrosis in children and adults. T2DM significantly worsened the relationship between PNPLA3 G-allele and advanced fibrosis in children and adults (interaction P < .01 for both). CONCLUSIONS Age, BMI, and T2DM modify the risk of advanced fibrosis associated with PNPLA3 G-allele. Preventing or reversing T2DM and obesity in persons carrying PNPLA3 G-allele may lower the risk for advanced fibrosis in NAFLD.
Collapse
Affiliation(s)
- Chaowapong Jarasvaraparn
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Indiana University School of Medicine, Indianapolis, Indiana
| | - Eduardo Vilar-Gomez
- Division of Gastroenterology, and Hepatology, Indiana University School of Medicine, Indiana University Health, Indianapolis, Indiana
| | - Katherine P Yates
- Department of Epidemiology, Johns Hopkins University, Baltimore, Maryland
| | - Laura A Wilson
- Department of Epidemiology, Johns Hopkins University, Baltimore, Maryland
| | | | - Rohit Loomba
- Division of Gastroenterology, Hepatology, and Nutrition, University of California, San Diego School of Medicine, La Jolla, California
| | - Oscar Cummings
- Division of Pathology and Laboratory Medicine, Indiana University School of Medicine, Indianapolis, Indiana
| | - Miriam Vos
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Emory University School of Medicine and Children's Healthcare of Atlanta, Atlanta, Georgia
| | - Stavra Xanthakos
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Jeffrey Schwimmer
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, University of California, San Diego School of Medicine, La Jolla, California; Department of Gastroenterology, Rady Children's Hospital San Diego, San Diego, California
| | - Jean P Molleston
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Indiana University School of Medicine, Indianapolis, Indiana
| | - Arun Sanyal
- Division of Gastroenterology, and Hepatology, Virginia Commonwealth University, Richmond, Virginia
| | - James Tonascia
- Department of Biostatistics and Epidemiology, Johns Hopkins University, Baltimore, Maryland
| | - Naga Chalasani
- Division of Gastroenterology, and Hepatology, Indiana University School of Medicine, Indiana University Health, Indianapolis, Indiana.
| |
Collapse
|
2
|
Rinella ME, Terrault N, Neuschwander-Tetri B, Loomba R, Abdelmalek M. Reply: ELF in the risk stratification of NAFLD-Are the ELF thresholds suggested by the AASLD guidelines appropriate? Hepatology 2023; 78:E103-E104. [PMID: 37199166 DOI: 10.1097/hep.0000000000000463] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2023] [Accepted: 05/02/2023] [Indexed: 05/19/2023]
Affiliation(s)
- Mary E Rinella
- The University of Chicago, Pritzker School of Medicine, Chicago, Illinois, USA
| | - Norah Terrault
- University of Southern California, Los Angeles, California, USA
| | | | - Rohit Loomba
- University of California, San Diego, San Diego, California
| | | |
Collapse
|
3
|
Rinella ME, Terrault N, Neuschwander-Tetri B, Loomba R. Reply: People living with HIV and NAFLD and updated guidance on NAFLD screening. Hepatology 2023; 78:E91-E92. [PMID: 37203291 DOI: 10.1097/hep.0000000000000469] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2023] [Accepted: 05/02/2023] [Indexed: 05/20/2023]
Affiliation(s)
- Mary E Rinella
- The University of Chicago Pritzker Scool of Medicine, Chicago, Illinois, USA
| | | | | | - Rohit Loomba
- University of California San Diego, San Diego, California, USA
| |
Collapse
|
4
|
Sanyal AJ, Shankar SS, Yates KP, Bolognese J, Daly E, Dehn CA, Neuschwander-Tetri B, Kowdley K, Vuppalanchi R, Behling C, Tonascia J, Samir A, Sirlin C, Sherlock SP, Fowler K, Heymann H, Kamphaus TN, Loomba R, Calle RA. Diagnostic performance of circulating biomarkers for non-alcoholic steatohepatitis. Nat Med 2023; 29:2656-2664. [PMID: 37679433 PMCID: PMC10579051 DOI: 10.1038/s41591-023-02539-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2023] [Accepted: 08/08/2023] [Indexed: 09/09/2023]
Abstract
There are no approved diagnostic biomarkers for at-risk non-alcoholic steatohepatitis (NASH), defined by the presence of NASH, high histological activity and fibrosis stage ≥2, which is associated with higher incidence of liver-related events and mortality. FNIH-NIMBLE is a multi-stakeholder project to support regulatory approval of NASH-related biomarkers. The diagnostic performance of five blood-based panels was evaluated in an observational (NASH CRN DB2) cohort (n = 1,073) with full spectrum of non-alcoholic fatty liver disease (NAFLD). The panels were intended to diagnose at-risk NASH (NIS4), presence of NASH (OWLiver) or fibrosis stages >2, >3 or 4 (enhanced liver fibrosis (ELF) test, PROC3 and FibroMeter VCTE). The prespecified performance metric was an area under the receiver operating characteristic curve (AUROC) ≥0.7 and superiority over alanine aminotransferase for disease activity and the FIB-4 test for fibrosis severity. Multiple biomarkers met these metrics. NIS4 had an AUROC of 0.81 (95% confidence interval: 0.78-0.84) for at-risk NASH. The AUROCs of the ELF test, PROC3 and FibroMeterVCTE for clinically significant fibrosis (≥stage 2), advanced fibrosis (≥stage 3) or cirrhosis (stage 4), respectively, were all ≥0.8. ELF and FibroMeter VCTE outperformed FIB-4 for all fibrosis endpoints. These data represent a milestone toward qualification of several biomarker panels for at-risk NASH and also fibrosis severity in individuals with NAFLD.
Collapse
Affiliation(s)
- Arun J Sanyal
- Virginia Commonwealth University School of Medicine, Richmond, VA, USA.
| | | | - Katherine P Yates
- Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | | | | | | | | | | | - Raj Vuppalanchi
- Indiana University School of Medicine, Indianapolis, IN, USA
| | - Cynthia Behling
- Department of Pathology, University of California San Diego School of Medicine, San Diego, CA, USA
| | - James Tonascia
- Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | - Anthony Samir
- Center for Ultrasound Research & Translation, Department of Radiology, Massachusetts General Hospital,Harvard Medical School, Boston, MA, USA
| | - Claude Sirlin
- Deptartment of Radiology, University of California San Diego School of Medicine, San Diego, CA, USA
| | | | - Kathryn Fowler
- Deptartment of Radiology, University of California San Diego School of Medicine, San Diego, CA, USA
| | - Helen Heymann
- US Food and Drug Administration, Silver Springs, MD, USA
| | | | - Rohit Loomba
- NAFLD Research Center, Division of Gastroenterology, Department of Medicine, University of California, San Diego, La Jolla, CA, USA
| | | |
Collapse
|
5
|
Sanyal A, Shankar S, Yates K, Bolognese J, Daly E, Dehn C, Neuschwander-Tetri B, Kowdley K, Vuppalanchi R, Behling CA, Tonascia J, Samir A, Sirlin C, Sherlock S, Fowler K, Heymann H, Kamphaus T, Loomba R, Calle R. The Nimble Stage 1 Study Validates Diagnostic Circulating Biomarkers for Nonalcoholic Steatohepatitis. Res Sq 2023:rs.3.rs-2492725. [PMID: 36711803 PMCID: PMC9882658 DOI: 10.21203/rs.3.rs-2492725/v1] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
Background There are no approved noninvasive tests (NIT) for the diagnosis of nonalcoholic steatohepatitis (NASH) and its histological phenotypes. Methods The FNIH-NIMBLE consortium tested 5 serum-based NIT panels for the following intended uses: NIS4: At-risk NASH, a composite of NASH with NAFLD activity score (NAS) ≥ 4 and fibrosis stage ≥ 2, OWLiver: NASH and NAS ≥ 4, enhanced liver fibrosis (ELF), PROC3 and Fibrometer VCTE: fibrosis stages ≥ 2, ≥ 3 or 4. Aliquots from a single blood sample obtained within 90 days of histological confirmation of NAFLD were tested. The prespecified performance metric tested for was a diagnostic AUROC greater than 0.7 and superiority to ALT for diagnosis of NASH or NAS ≥ 4 and to FIB-4 for fibrosis. Results A total of 1073 adults including NASH (n = 848), at-risk NASH (n = 539) and fibrosis stages 0-4 (n = 222, 114, 262, 277 and 198 respectively) were studied. The AUROC of NIS4 for at-risk NASH was 0.81 and superior to ALT and FIB4 (p < 0.001 for both). OWliver diagnosed NASH with sensitivity and specificity of 77.3% and 66.8% respectively. The AUROCs (95% CI) of ELF, PROC3 and Fibrometer VCTE respectively for fibrosis were as follows: ≥ stage 2 fibrosis [0.82 (0.8-0.85), 0.8 (0.77-0.83), and 0.84 (0.79-0.88)], ≥ stage 3 [0.83 (0.8-0.86), 0.76 (0.73-0.79), 0.85 (0.81-0.9), stage 4 [0.85 (0.81-0.89), 0.81 (0.77-0.85), 0.89 (0.84-0.95)]. ELF and Fibrometer VCTE were significantly superior to FIB-4 for all fibrosis endpoints (p < 0.01 for all). Conclusions These data support the further development of NIS4, ELF and Fibrometer VCTE for their intended uses.
Collapse
Affiliation(s)
- Arun Sanyal
- Virginia Commonwealth University School of Medicine
| | | | | | | | | | | | | | | | | | | | - James Tonascia
- Bloomberg School of Public Health, Johns Hopkins University
| | | | | | | | | | | | | | | | | |
Collapse
|
6
|
Brandman D, Boyle M, McPherson S, Van Natta ML, Sanyal AJ, Kowdley K, Neuschwander-Tetri B, Chalasani N, Abdelmalek MF, Terrault NA, McCullough A, Bettencourt R, Caussy C, Kleiner DE, Behling C, Tonascia J, Anstee QM, Loomba R. Letter: non-invasive prediction models to exclude cirrhosis in NAFLD-not everyone fits the mould. Authors' reply. Aliment Pharmacol Ther 2022; 56:182-183. [PMID: 35689309 DOI: 10.1111/apt.16972] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/09/2022]
Affiliation(s)
- Danielle Brandman
- Division of Gastroenterology, Department of Medicine, University of California San Francisco, San Francisco, California, USA
| | - Marie Boyle
- Translational & Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK & Newcastle NIHR Biomedical Research Centre, Newcastle upon Tyne Hospitals NHS Trust, Newcastle upon Tyne, UK
| | - Stuart McPherson
- Translational & Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK & Newcastle NIHR Biomedical Research Centre, Newcastle upon Tyne Hospitals NHS Trust, Newcastle upon Tyne, UK
| | - Mark L Van Natta
- John Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Arun J Sanyal
- Department of Internal Medicine, Medical College of Virginia, Richmond, Virginia, USA
| | | | - Brent Neuschwander-Tetri
- Division of Gastroenterology and Hepatology, Department of Medicine, Saint Louis University, Saint Louis, Missouri, USA
| | - Naga Chalasani
- Division of Gastroenterology and Hepatology, Department of Medicine, Indiana University, Indianapolis, Indiana, USA
| | - Manal F Abdelmalek
- Division of Gastroenterology, Hepatology, and Nutrition, Duke University, Durham, North Carolina, USA
| | - Norah A Terrault
- Division of Gastroenterology and Liver, Keck Medicine, University of Southern California, Los Angeles, California, USA
| | - Art McCullough
- Department of Gastroenterology and Hepatology, Cleveland Clinic, Cleveland, Ohio, USA
| | - Ricki Bettencourt
- NAFLD Research Center, Department of Medicine, University of California San Diego, San Diego, California, USA
| | - Cyrielle Caussy
- NAFLD Research Center, Department of Medicine, University of California San Diego, San Diego, California, USA
| | - David E Kleiner
- Laboratory of Pathology, National Cancer Institute, National Institutes of Health, Bethesda, Maryland, USA
| | - Cynthia Behling
- Analytic Pathology Medical Group, Sharp Memorial Hospital, San Diego, California, USA
| | - James Tonascia
- John Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Quentin M Anstee
- Translational & Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK & Newcastle NIHR Biomedical Research Centre, Newcastle upon Tyne Hospitals NHS Trust, Newcastle upon Tyne, UK
| | - Rohit Loomba
- NAFLD Research Center, Department of Medicine, University of California San Diego, San Diego, California, USA
| |
Collapse
|
7
|
Brandman D, Boyle M, McPherson S, Van Natta ML, Sanyal AJ, Kowdley K, Neuschwander-Tetri B, Chalasani N, Abdelmalek MF, Terrault NA, McCullough A, Bettencourt R, Caussy C, Kleiner DE, Behling C, Tonascia J, Anstee QM, Loomba R. Comparison of clinical prediction rules for ruling out cirrhosis in nonalcoholic fatty liver disease (NAFLD). Aliment Pharmacol Ther 2022; 55:1441-1451. [PMID: 35302256 PMCID: PMC9098681 DOI: 10.1111/apt.16874] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2021] [Revised: 08/31/2021] [Accepted: 02/24/2022] [Indexed: 01/27/2023]
Abstract
BACKGROUND AND AIMS Patients with nonalcoholic fatty liver disease (NAFLD) cirrhosis benefit from referral to subspecialty care. While several clinical prediction rules exist to identify advanced fibrosis, the cutoff for excluding cirrhosis due to NAFLD is unclear. This analysis compared clinical prediction rules for excluding biopsy-proven cirrhosis in NAFLD. METHODS Adult patients were enrolled in the NASH Clinical Research Network (US) and the Newcastle Cohort (UK). Clinical and laboratory data were collected at enrolment, and a liver biopsy was taken within 1 year of enrolment. Optimal cutoffs for each score (eg, FIB-4) to exclude cirrhosis were derived from the US cohort, and sensitivity, specificity, positive predictive value, negative predictive value and AUROC were calculated. The cutoffs were evaluated in the UK cohort. RESULTS 147/1483 (10%) patients in the US cohort had cirrhosis. All prediction rules had similarly high NPV (0.95-0.97). FIB-4 and NAFLD fibrosis scores were the most accurate in characterising patients as having cirrhosis (AUROC 0.84-0.86). 59/494 (12%) patients in the UK cohort had cirrhosis. Prediction rules had high NPV (0.92-0.96), and FIB-4 and NAFLD fibrosis score the most accurate in the prediction of cirrhosis in the UK cohort (AUROC 0.87-0.89). CONCLUSIONS This cross-sectional analysis of large, multicentre international datasets shows that current clinical prediction rules perform well in excluding cirrhosis with appropriately chosen cutoffs. These clinical prediction rules can be used in primary care to identify patients, particularly those who are white, female, and <65, unlikely to have cirrhosis so higher-risk patients maintain access to specialty care.
Collapse
Affiliation(s)
- Danielle Brandman
- Division of Gastroenterology, Department of Medicine, University of California San Francisco, San Francisco, California, USA
| | - Marie Boyle
- Translational & Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK,Newcastle NIHR Biomedical Research Centre, Newcastle upon Tyne Hospitals NHS Trust, Newcastle upon Tyne, UK
| | - Stuart McPherson
- Translational & Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK,Newcastle NIHR Biomedical Research Centre, Newcastle upon Tyne Hospitals NHS Trust, Newcastle upon Tyne, UK
| | - Mark L. Van Natta
- John Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Arun J. Sanyal
- Department of Internal Medicine, Medical College of Virginia, Richmond, Virginia, USA
| | | | - Brent Neuschwander-Tetri
- Division of Gastroenterology and Hepatology, Department of Medicine, Saint Louis University, Saint Louis, Missouri, USA
| | - Naga Chalasani
- Division of Gastroenterology and Hepatology, Department of Medicine, Indiana University, Indianapolis, Indiana, USA
| | - Manal F. Abdelmalek
- Division of Gastroenterology, Hepatology, and Nutrition, Duke University, Durham, North Carolina, USA
| | - Norah A. Terrault
- Division of Gastroenterology and Liver, Keck Medicine, University of Southern California, Los Angeles, California, USA
| | - Art McCullough
- Department of Gastroenterology and Hepatology, Cleveland Clinic, Cleveland, Ohio, USA
| | - Ricki Bettencourt
- NAFLD Research Center, Department of Medicine, University of California San Diego, San Diego, California, USA
| | - Cyrielle Caussy
- NAFLD Research Center, Department of Medicine, University of California San Diego, San Diego, California, USA
| | - David E. Kleiner
- Laboratory of Pathology, National Cancer Institute, National Institutes of Health, Bethesda, Maryland, USA
| | - Cynthia Behling
- Analytic Pathology Medical Group, Sharp Memorial Hospital, San Diego, California, USA
| | - James Tonascia
- John Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Quentin M. Anstee
- Translational & Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK
| | - Rohit Loomba
- NAFLD Research Center, Department of Medicine, University of California San Diego, San Diego, California, USA
| | | |
Collapse
|
8
|
Brunt EM, Clouston AD, Goodman Z, Guy C, Kleiner DE, Lackner C, Tiniakos DG, Wee A, Yeh M, Leow WQ, Chng E, Ren Y, Boon Bee GG, Powell EE, Rinella M, Sanyal AJ, Neuschwander-Tetri B, Younossi Z, Charlton M, Ratziu V, Harrison SA, Tai D, Anstee QM. Complexity of ballooned hepatocyte feature recognition: Defining a training atlas for artificial intelligence-based imaging in NAFLD. J Hepatol 2022; 76:1030-1041. [PMID: 35090960 PMCID: PMC10544770 DOI: 10.1016/j.jhep.2022.01.011] [Citation(s) in RCA: 64] [Impact Index Per Article: 32.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2021] [Revised: 12/21/2021] [Accepted: 01/07/2022] [Indexed: 02/06/2023]
Abstract
BACKGROUND & AIMS Histologically assessed hepatocyte ballooning is a key feature discriminating non-alcoholic steatohepatitis (NASH) from steatosis (NAFL). Reliable identification underpins patient inclusion in clinical trials and serves as a key regulatory-approved surrogate endpoint for drug efficacy. High inter/intra-observer variation in ballooning measured using the NASH CRN semi-quantitative score has been reported yet no actionable solutions have been proposed. METHODS A focused evaluation of hepatocyte ballooning recognition was conducted. Digitized slides were evaluated by 9 internationally recognized expert liver pathologists on 2 separate occasions: each pathologist independently marked every ballooned hepatocyte and later provided an overall non-NASH NAFL/NASH assessment. Interobserver variation was assessed and a 'concordance atlas' of ballooned hepatocytes generated to train second harmonic generation/two-photon excitation fluorescence imaging-based artificial intelligence (AI). RESULTS The Fleiss kappa statistic for overall interobserver agreement for presence/absence of ballooning was 0.197 (95% CI 0.094-0.300), rising to 0.362 (0.258-0.465) with a ≥5-cell threshold. However, the intraclass correlation coefficient for consistency was higher (0.718 [0.511-0.900]), indicating 'moderate' agreement on ballooning burden. 133 ballooned cells were identified using a ≥5/9 majority to train AI ballooning detection (AI-pathologist pairwise concordance 19-42%, comparable to inter-pathologist pairwise concordance of between 8-75%). AI quantified change in ballooned cell burden in response to therapy in a separate slide set. CONCLUSIONS The substantial divergence in hepatocyte ballooning identified amongst expert hepatopathologists suggests that ballooning is a spectrum, too subjective for its presence or complete absence to be unequivocally determined as a trial endpoint. A concordance atlas may be used to train AI assistive technologies to reproducibly quantify ballooned hepatocytes that standardize assessment of therapeutic efficacy. This atlas serves as a reference standard for ongoing work to refine how ballooning is classified by both pathologists and AI. LAY SUMMARY For the first time, we show that, even amongst expert hepatopathologists, there is poor agreement regarding the number of ballooned hepatocytes seen on the same digitized histology images. This has important implications as the presence of ballooning is needed to establish the diagnosis of non-alcoholic steatohepatitis (NASH), and its unequivocal absence is one of the key requirements to show 'NASH resolution' to support drug efficacy in clinical trials. Artificial intelligence-based approaches may provide a more reliable way to assess the range of injury recorded as "hepatocyte ballooning".
Collapse
Affiliation(s)
- Elizabeth M Brunt
- Department of Pathology and Immunology, Washington University School of Medicine, Saint Louis, Missouri, USA.
| | - Andrew D Clouston
- Molecular and Cellular Pathology, University of Queensland and Envoi Specialist Pathologists, Brisbane, Australia
| | - Zachary Goodman
- Pathology Department, and Center for Liver Diseases, Inova Fairfax Hospital, Falls Church, Virginia, USA
| | - Cynthia Guy
- Division of Pathology, Duke University Medical Center, Durham, NC, USA
| | - David E Kleiner
- Laboratory of Pathology; Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, Maryland, USA
| | - Carolin Lackner
- Institute of Pathology, Medical University of Graz, Graz, Austria
| | - Dina G Tiniakos
- Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK; Dept of Pathology, Aretaieion Hospital, National and Kapodistrian University of Athens, Greece
| | - Aileen Wee
- Department of Pathology, Yong Loo Lin School of Medicine, National University of Singapore, National University Hospital, Singapore
| | - Matthew Yeh
- Department of Pathology, University of Washington, Seattle, Washington, USA
| | - Wei Qiang Leow
- Department of Anatomical Pathology, Singapore General Hospital, Singapore & Duke-NUS Medical School, Singapore
| | | | | | - George Goh Boon Bee
- Department of Gastroenterology and Hepatology, Singapore General Hospital, Singapore
| | - Elizabeth E Powell
- Centre for Liver Disease Research, Faculty of Medicine, University of Queensland, Translational Research Institute, Brisbane, Queensland, Australia; Department of Gastroenterology and Hepatology, Princess Alexandra Hospital, Brisbane, Queensland, Australia
| | - Mary Rinella
- Division of Gastroenterology and Hepatology, Feinberg School of Medicine, Northwestern University, Chicago, USA
| | - Arun J Sanyal
- Department of Internal Medicine, School of Medicine, Virginia Commonwealth University, Richmond, Virginia, USA
| | | | - Zobair Younossi
- Betty and Guy Beatty Center for Integrated Research, Inova Health System, Falls Church, Virginia, USA
| | - Michael Charlton
- Center for Liver Diseases, and Transplantation Institute, University of Chicago, Chicago, Illinois, USA
| | - Vlad Ratziu
- Department of Hepatology, Sorbonne University and Pitié-Salpêtrière Hospital, Paris, France
| | - Stephen A Harrison
- Pinnacle Clinical Research, San Antonio, USA; Hepatology, Radcliffe Department of Medicine, University of Oxford, Oxford, UK
| | - Dean Tai
- Department of Anatomical Pathology, Singapore General Hospital, Singapore & Duke-NUS Medical School, Singapore.
| | - Quentin M Anstee
- Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK; Newcastle NIHR Biomedical Research Centre, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK.
| |
Collapse
|
9
|
Eslam M, Sanyal AJ, George J, Neuschwander-Tetri B, Tiribelli C, Kleiner DE, Brunt E, Bugianesi E, Yki-Järvinen H, Grønbæk H, Cortez-Pinto H, George J, Fan J, Valenti L, Abdelmalek M, Romero-Gomez M, Rinella M, Arrese M, Eslam M, Bedossa P, Newsome PN, Anstee QM, Jalan R, Bataller R, Loomba R, Sookoian S, Sarin SK, Harrison S, Kawaguchi T, Wong VWS, Ratziu V, Yilmaz Y, Younossi Z. MAFLD: A Consensus-Driven Proposed Nomenclature for Metabolic Associated Fatty Liver Disease. Gastroenterology 2020; 158:1999-2014.e1. [PMID: 32044314 DOI: 10.1053/j.gastro.2019.11.312] [Citation(s) in RCA: 1612] [Impact Index Per Article: 403.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2019] [Revised: 10/27/2019] [Accepted: 11/05/2019] [Indexed: 12/02/2022]
Abstract
Fatty liver associated with metabolic dysfunction is common, affects a quarter of the population, and has no approved drug therapy. Although pharmacotherapies are in development, response rates appear modest. The heterogeneous pathogenesis of metabolic fatty liver diseases and inaccuracies in terminology and definitions necessitate a reappraisal of nomenclature to inform clinical trial design and drug development. A group of experts sought to integrate current understanding of patient heterogeneity captured under the acronym nonalcoholic fatty liver disease (NAFLD) and provide suggestions on terminology that more accurately reflects pathogenesis and can help in patient stratification for management. Experts reached consensus that NAFLD does not reflect current knowledge, and metabolic (dysfunction) associated fatty liver disease "MAFLD" was suggested as a more appropriate overarching term. This opens the door for efforts from the research community to update the nomenclature and subphenotype the disease to accelerate the translational path to new treatments.
Collapse
Affiliation(s)
- Mohammed Eslam
- Storr Liver Centre, Westmead Institute for Medical Research, Westmead Hospital and University of Sydney, NSW, Australia.
| | - Arun J Sanyal
- Virginia Commonwealth University School of Medicine, Richmond, Virginia.
| | - Jacob George
- Storr Liver Centre, Westmead Institute for Medical Research, Westmead Hospital and University of Sydney, NSW, Australia.
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|