Plasma-kallikrein clearance during liver regeneration after partial hepatectomy in the rat

Abstract: Aims/Background: The liver clears circulating plasma-kallikrein through a receptor-mediated endocytosis process: an initial fast phase is followed by a slow exponential phase. Methods: To determine whether the clearance rate of plasma-kallikrein is affected during liver regeneration, we perfused isolated rat livers with rat plasma-kallikrein (rPK) at 0, 1, 2, 3 and 7 days after partial hepatectomy or sham operation. Results: Liver regeneration was followed by the expression of the proliferating-cell nuclear antigen (PCNA) labeling index. The serum concentration of α₂-macroglobulin, an acute phase protein in rats, was measured. At day 1, the fast phase of rPK clearance rate increased in hepatectomized rats when compared with day 0 (4.9±0.4 and 3.7±0.4 mU/g liver · min, p<0.05). However, at day 2, the rPK fast phase clearance rate dropped significantly (2.6±0.2, p<0.05), when compared with day 1. No difference was found among the sham groups at different days of hepatectomy. These changes seem to be independent of the acute phase reaction. The regenerative liver weight increased continuously during the observation period. PCNA expression increased significantly after hepatectomy, with maximal PCNA-labeling indices at days 1 and 2, declining thereafter. Conclusion: The rPK fast phase clearance rate changes during liver regeneration, with a zenith occurring when PCNA labeling index is maximal (day 1) and a nadir occurring at the mitotic phase (day 2).     

Nonalcoholic steatohepatitis in nonalcoholic fatty liver disease patients of Bangladesh

AIM: To explore the prevalence and risk factors for nonalcoholic steatohepatitis (NASH) in nonalcoholic fatty liver disease (NAFLD) patients. METHODS: We have included 493 patients with sonographic evidence of a fatty change, and 177 of these individuals were evaluated and confirmed after liver biopsy. The exclusion criteria consisted of significant alcohol abuse (< 20 g daily), evidence of hepatitis B and C, evidence of drug-induced fatty liver disease and other specific liver diseases such as hemochromatosis, Wilson’s disease or autoimmune liver disease. The patients were assessed for metabolic syndrome, and biochemical, anthropometric and histopathological evaluations were carried out. The degree of disease activity in the NAFLD patients was evaluated using the NAFLD Activity Score. The data were analyzed by SPSS, version 16.0. RESULTS: Females predominated among the study participants (250, 57.0%), and the mean age was 40.8 ± 10.2 years. The numbers of overweight, obeseⅠ and obese Ⅱ patients were 58 (13.2%), 237 (53.9%) and 93 (21.2%), respectively. However, there were 422 (96.2%) centrally obese patients. NASH was absent in 10 (5.6%) cases, borderline in 92 (52.6%) cases and present in 75 (42.4%) cases. The presence of diabetes could significantly (P = 0.001) differentiate NASH from simple steatosis. The following parameters did not influence the development of NASH: age, sex, basal metabolic index, waist circumference, serum high-density lipoprotein, triglyceride, insulin resistance index, hypertension and metabolic syndrome. The serum gammaglutamyl transpeptidase (GGT) level was significantly higher (P = 0.05, 51.7 ± 32.8 and 40.4 ± 22.6 U/L) in the NASH patients, with a sensitivity of 45% and a specificity of only 68%. The serum alanine aminotransferase and aspartate aminotransferase levels were not able to predict NASH. CONCLUSION: Females were the predominant sufferers of NAFLD in Bangladesh. The prevalence of NASH was high. Diabetes was found to be the main culprit in developing NASH. GGT was the only biochemical marker of NASH. We recommend liver biopsy in NAFLD patients who have diabetes and elevated GGT.     

Evaluation of safety for hepatectomy in a novel mouse model with nonalcoholic-steatohepatitis

AIM To investigate whether the liver resection volume in a newly developed nonalcoholic steatohepatitis(NASH) model influences surgical outcome.METHODS For establishment of a NASH model, mice were fed a high-fat diet for 4 wk, administered CCl_4 for the last 2 wk, and administered T0901317 for the last 5 d. We divided these mice into two groups: A 30% partial hepatectomy(PH) of NASH liver group and a 70% PH of NASH liver group. In addition, a 70% PH of normal liver group served as the control. Each group was evaluated for survival rate, regeneration, apoptosis, necrosis and DNA expression after PH.RESULTS In the 70% PH of NASH group, the survival rate was significantly decreased compared with that in the control and 30% PH of NASH groups(P 0.01). 10 of 32 mice in the NASH 70% PH group died within 48 h after PH. Serum aspartate aminotransferase(AST) levels and total bilirubin(T-Bil) in the NASH 70% PH group were significantly higher than the levels in the other two groups(AST: P 0.05, T-Bil: P 0.01). In both PH of NASH groups, signaling proteins involved in regeneration were expressed at lower levels than those in the control group(P 0.01). The 70% PH of NASH group also exhibited a lower number of Ki-67-positive cells and higher rates of apoptosis and necrosis than the NASH 30% PH group(P 0.01). In addition, DNA microarray assays showed differences in gene expression associated with cell cycle arrest and apoptosis.CONCLUSION The function of the residual liver is impaired in fatty liver compared to normal liver. A larger residual volume is required to maintain liver functions in mice with NASH.     

The triglycerides and glucose (TyG) index: A new marker associated with nonalcoholic steatohepatitis (NASH) in obese patients

AimDiagnosis of nonalcoholic steatohepatitis (NASH) relies on liver biopsy. Noninvasive tools would be useful to target patients to refer for a biopsy. We aimed to determine the diagnostic value of the triglycerides and glucose (TyG) index, an insulin-resistance indicator, to predict NASH.MethodsOur study included grade II-III obese patients aged 18-65 years undergoing bariatric surgery and included in the COMET (COllection of MEtabolic Tissues) biobank (NCT02861781). Liver biopsies performed during bariatric surgery were collected from the biobank along with blood derivatives. Biopsies were analysed according to the steatosis, activity and fibrosis (SAF) scoring system to diagnose NASH, nonalcoholic fatty liver disease (NAFLD), and fibrosis. Logistic regression models were performed to identify factors predicting NASH, NAFLD, and fibrosis.ResultsOf 238 analysed subjects (mean age 43±12 years, 33.6% men), 29% had type 2 diabetes. Steatosis was present in 67.2%, while NASH and advanced fibrosis (stage F3) were diagnosed in 18.1% and 2.9% respectively. TyG index was independently associated with NASH (odds ratio (OR): 4.7 [95% confidence interval: 2.3;9.5] P < 0.0001), NAFLD (OR: 2.0 [1.1;3.7] P = 0.03) and stages 2-3 fibrosis (OR: 4.0 [1.5;10.8] P = 0.007). NASH was also predicted by gamma-glutamyl transferase (GGT) with an area under the ROC curve: 0.79 [0.71;0.87 P = 0.04] for GGT and TyG index combined.ConclusionIn our cohort of severely obese patients, TyG index, when associated with GGT level, exhibited high diagnostic performance to predict NASH. Although validation in larger populations is needed, this result may be of considerable clinical value to predict need for liver biopsy.     

Obesity and NASH in Japan.

BACKGROUND: NASH is expected to be a major target disease in near future, although we are too short in information to realize NASH. In this study, we revealed the prevalence of fatty liver, which is a background disease of NASH, in Kyoto. Then we made histological diagnosis of NASH from chronic liver disorder with fatty liver. MATERIALS AND METHODS: By using the data obtained from medical check-up with more than 1000 subjects per year in Kyoto, the prevalence of fatty liver on ultrasound, serum ALT, body mass index (BMI) were compared between 1994 and 2004. Next 32 patients with elevated ALT and bright liver on ultrasound were biopsied in order to diagnose them as NASH or not. Biochemical, serological and hormonal parameters as well as adipocytokine profiles were also studied. Lastly, liver tissues from those patients were examined to compare the expression of peroxisome proliferator activator receptor (PPAR) alpha and gamma. RESULTS: It was revealed that the prevalence of fatty liver increased from 12.9 to 34.7% over 10 years. The mean ALT and BMI also increased in this period. From 32 patients, 6 cases were excluded for alcohol, autoimmune hepatitis, and drug-induced liver injury, leaving 26 cases to enter the study. Among them, 12 and 8 patients showed grade 1 and grade 2 steatohepatitis, which were consistant with NASH. Various data were compared among simple steatosis, grade 1 steatohepatitis, and grade 2 steatohepatitis, but highly sensitive CRP was the sole parameter with statistical significance. PPAR alpha seems to be expressed higher in patients with steatohepatitis, although PPAR alpha did not show any significance. CONCLUSION: We found the prevalence of fatty liver was increasing over 10 years. The histological examination showed more patients with grade 1 or grade 2 steatohepatitis than expected, which means we might have much more NASH cases undiagnosed. We were unable to propose reliable diagnostic markers to diagnose NASH from this study.     

Serum neopterin levels in patients with non-alcoholic steatohepatitis

Aim:  Neopterin is a marker of cell-mediated immunity. It also has a fundamental role in host-defense reactions, including interactions with reactive oxygen intermediates and the promotion of local and systemic oxidative stress. The present study aimed to assess the importance of serum neopterin levels in patients with non-alcoholic steatohepatitis (NASH).
Methods:  Thirty-nine patients with NASH diagnosed by liver biopsy and 32 healthy adults (controls) were enrolled in the study. Serum neopterin levels were measured with an enzyme-linked immunosorbent assay in addition to other biochemical parameters, including liver enzymes. Histopathological examinations were graded as suggested by both the necroinflammatory activity grading system and the NASH scoring system.
Results:  The mean serum neopterin levels were higher in patients with NASH compared to the controls (24.1 ± 16.4 vs 16.2 ± 9.5, P  = 0.019). The histological examination of liver biopsies revealed that 34 of the patients with NASH had grade 1 steatohepatitis and only five patients had grade 2 steatohepatitis. A higher serum mean neopterin level was detected in grade 2 patients compared to grade 1 (40.6 ± 5.6 vs 21.7 ± 16.1, P  = 0.014). A gradual increase was also observed in serum neopterin levels with the increase of the NASH score.
Conclusion:  The serum neopterin levels were significantly higher in patients with NASH compared to the controls, and levels showed an association with the severity of liver damage.     

非酒精性脂肪性肝炎患者心脏舒张功能变化及其与肝功能的相关性研究

目的了解NASH患者心脏舒张功能。方法采用彩色多普勒超声心动图检查64例单纯性脂肪肝(SFL)、56例脂肪性肝炎(NASH)患者和120例正常对照者。应用E/A比值评价心脏的舒张功能。结果 NASH组心脏舒张功能不全(DCD)的发生率为44.6%,显著高于SFL组的10.9%及正常对照组的5.0%(P0.01);正常对照组、SFL组及NASH组E/A比值分别为1.3±0.2、1.3±0.2和1.0±0.3(P0.01);NASH组ALT、AST和GGT水平比SFL组及正常对照组显著升高(P0.01)。结论 NASH患者常伴有DCD和血清GGT显著升高。     

Digital image analysis of the distribution of proliferating cell nuclear antigen in hepatitis C virus-related chronic hepatitis,cirrhosis, and hepatocellular carcinoma

Viral dynamic studies in chronic hepatitis C virus (HCV) infection indicate a significantly shortened survival of virus-infected cells. Since at the steady state of chronic viral infection, the rate of infected cell elimination equals new cell regeneration, this would imply a high rate of hepatocyte turnover in chronic HCV liver disease. We estimated the fraction of regenerating hepatocytes in liver biopsy sections in chronic HCV liver disease, cirrhosis, and hepatocellular carcinoma (HCC). We used antibodies to proliferating cell nuclear antigen (PCNA) to detect proliferating cell nuclei in liver biopsy specimen from controls and patients with chronic hepatitis, cirrhosis, and HCC. We also used bis-benzimide to label fluorescently all hepatocyte nuclei simultaneously. Using digital image analysis, we calculated the area occupied by PCNA-stained hepatocyte nuclei, as a fraction of the total area occupied by fluorescently labeled hepatocyte nuclei (labeling index; LI). Antibody staining was negligible in the control specimen. The mean ± SE PCNA LI increased from 0.21 ± 0.1 in chronic hepatitis to 0.63 ± 0.15 in HCC. There was no significant difference between chronic hepatitis and cirrhosis. The fraction of cells undergoing regeneration is increased in chronic HCV liver disease, HCV-related cirrhosis, and HCC. Increased hepatocyte turnover could provide the link between chronic HCV liver disease and HCC.     

A Survey of Regenerating Capacity in Patchy Liver and in Nodular Liver—with Special Reference to DNA Synthesis Estimated by BrdU Labeling Index—

Abstract : Laparoscopically, patchy liver and nodular liver were considered as features of regeneration of liver cells. In this study, the regenerating capacity of liver cells obtained by a liver biopsy from laparoscopically identified patchy liver and nodular liver was estimated by Bromodeoxvuridine (BrdU)-anti-BrdU method. BrdU labeling indices (L. I.), of liver cells in biopsy specimens from 6 normal livers, 12 patchy livers, and from 15 nodular livers were examined using an in-vitro labeling technique. Liver biopsy specimens obtained by a Tru-cut needle were immediately incubated for 45 min. in 0.1% BrdU solution in RPMI 1640 at 37°C under a pressure of 3 atmospheres in a mixture of 95% O₂ and 5% CO₂. Immunohistochemical detection of BrdU was performed by the Avidin-Biotin-Peroxidase Complex (ABC) method. The mean BrdU L. I. (±SE) of normal liver, patchy liver, and of nodular liver was 0.25±0.09%, 1.4±0.2%, and 1.7±0.4% respectively. Among the nodular liver, flat shaped ones showed a low level (0.5±0.1%), in contrast to the high level (2.4±0.7%) in the semispherical nodular liver. The BrdU L. I. of both the patchy liver and the nodular liver was significantly higher than that in the normal liver (p<0.001, p<0.01 respectively). Interesting enough, there was a significant difference (p<0.05) between flat shaped nodular livers and semispherical ones. The semispherical nodular liver demonstrated the highest capacity of DNA synthesis in all the groups examined.     

Transitional features of histologic type of non-alcoholic fatty liver disease in Korean young men

Background and Aim: The prevalence of non‐alcoholic fatty liver disease (NAFLD) is increasing in Korea as the dietary pattern and lifestyle become more Westernized and the obese population increases. The spectrum of NAFLD ranges from asymptomatic steatosis to non‐alcoholic steatohepatitis (NASH) and cirrhosis. Schwimmer et al. divided NASH into three types according to the histological characteristics, such as adult type, pediatric type and overlap type. We investigated clinical and histologic features of NAFLD patients in Korean young men. Methods: A total of 64 male patients under age 30 years, diagnosed as NAFLD by a liver biopsy, were reviewed retrospectively. NASH was diagnosed by NAFLD activity score (NAS), and NASH patients were classified with Schwimmer's histological classification. Results: Pathological features of liver biopsy revealed NASH in most cases (59 cases, 92.2%) including 29 cases (45.3%) of borderline NASH and 30 cases (46.9%) of definite NASH. The definite NASH group showed significantly high aspartate aminotransferase/alanine aminotransferase levels compared to the borderline NASH group. There were four cases (6.8%) of pediatric type, 17 cases (28.8%) of adult type, and 38 cases (64.4%) of overlap type in the NASH group. NAS was 3.75 ± 0.05 in the pediatric type, 4.29 ± 1.16 in the adult type and 4.87 ± 1.21 in the overlap type, and the overlap type showed a higher NAS than the pediatric type. The fibrosis stage was significantly higher in the overlap type than the other types. Conclusion: Most Korean young men with NAFLD turned out to have borderline or definite NASH. More than half of the NASH cases showed overlap type in Korean young men.     

Liver steatosis,but not fibrosis,is associated with insulin resistance in nonalcoholic fatty liver disease

Background To address the hypothesis that liver steatosis causes systemic insulin resistance, we sought to determine the liver histological feature that most strongly contributes to insulin resistance in patients with nonalcoholic fatty liver disease (NAFLD). Methods Liver biopsy specimens were obtained from 131 patients with clinically suspected NAFLD. The stage, grade of nonalcoholic steatohepatitis (NASH), and level of steatosis were scored and analyzed in relation to the homeostasis model assessment of insulin resistance (HOMA-IR) and the metabolic clearance rate (MCR), measured using the glucose clamp method. Results In the univariate analysis, the degree of hepatic steatosis (r = 0.458, P < 0.001), stage (r = 0.360, P < 0.001), and grade (r = 0.349, P < 0.01) of NASH were significantly correlated with the HOMA-IR. Multiple regression analysis adjusting for age, sex, body mass index, and each histological score showed that steatosis was significantly and independently associated with HOMA-IR (coefficient = 1.42, P < 0.001), but not with the stage (coefficient = 0.33, P = 0.307) or grade (coefficient = 0.67, P = 0.134) of NASH. Similar independent relationships were observed between steatosis and MCR, but the relationship was weaker (coefficient = −0.98, P = 0.076). Conclusions Steatosis of the liver, but not the stage or the grade of NASH, is associated with insulin resistance in patients with NAFLD.     

Symptoms of Obstructive Sleep Apnea in Patients with Nonalcoholic Fatty Liver Disease

Nonalcoholic fatty liver disease (NAFLD) is a term often used to describe two related conditions: a relatively benign, nonalcoholic fatty liver (NAFL) and potentially aggressive, nonalcoholic steatohepatitis (NASH). Both conditions (NAFL and NASH) occur in the setting of peripheral insulin resistance. Recently, obstructive sleep apnea (OSA) has been proposed as an independent risk factor for insulin resistance. To date, few studies have documented the prevalence of OSA or symptoms of OSA (SOSA) in NAFLD patients. The objectives of this study were (1) to document the prevalence of SOSA in patients with NAFLD and (2) to determine whether prevalence rates for SOSA differ in NAFL versus NASH patients. One hundred ninety biochemically defined NAFLD patients (116 NAFL and 74 NASH), of whom 50 (18 NAFL and 32 NASH) had undergone liver biopsy, completed a Modified Berlin Sleep Apnea Questionnaire for SOSA. Risk factors for NAFLD were also documented in NAFL and NASH patients. Eighty-seven of the 190 (46%) NAFLD patients met questionnaire criteria for SOSA. The prevalence of SOSA was similar in both biochemically (45% versus 49%, respectively; P= 0.66) and histologically (39% versus 63%, respectively; P= 0.11) defined NAFL and NASH patients. Other risk factors for NAFLD such as body mass index, plasma cholesterol and triglyceride levels, and prevalence of diabetes were also similar in the two groups. Approximately one-half of NAFLD patients, whether NAFL or NASH, have SOSA. Further studies are required to determine whether a causal link exists between NAFLD and OSA.     

Increased serum soluble lectin-like oxidized low-density lipoprotein receptor-1 levels in patients with biopsy-proven nonalcoholic fatty liver disease

AIM: To analyze the relationship between the serum lectin-like oxidized low-density lipoprotein receptor-1(LOX-1) levels and clinical and histopathological features of biopsy-confirmed nonalcoholic fatty liver disease(NAFLD) patients.METHODS: Fifty-three consecutive,biopsy-proven NAFLD patients(31 males and 22 females,mean age 42.5 ± 9.6 years) and 26 age- and gender-matched,healthy controls(14 males and 12 females,mean age 39 ± 10.7 years) were included.The patientswith NAFLD were consecutive patients who had been admitted to the hepatology outpatient clinic within the last year and had been diagnosed with NAFLD as the result of liver biopsy.The healthy controls were individuals who attended the outpatient clinic for routine health control and had no known chronic illnesses.The histological evaluation was conducted according t o t he N AF LD ac t ivi ty scoring syst em recommended by The National Institute of Diabetes and Digestive and Kidney Diseases Nonalcoholic Steatohepatitis Clinical Research Network.The serum LOX-1 levels were measured using an ELISA kit(Life Science Inc.USCN.Wuhan,Catalog No.E1859Hu) in both patients and healthy controls.A receiver operating characteristic(ROC) curve analysis was used to identify the optimal cutoff value of LOX-1 and thereby distinguish between patients with nonalcoholic steatohepatitis(NASH) and healthy controls.A P-value 0.05 was considered statistically significant.RESULTS: NAFLD and healthy control groups were similar in terms of age and sex.NAFLD patients consisted of 8 patients with simple steatosis(15%),27 with borderline NASH(51%) and 18 with definitive NASH(34%).Metabolic syndrome was found in 62.2% of the patients with NAFLD.The mean serum LOX-1 level in biopsy-proven NAFLD patients was 8.49 ± 6.43 ng/m L compared to 4.08 ± 4.32 ng/m L in healthy controls(P = 0.001).The LOX-1 levels were significantly different between controls,simple steatosis and NASH(borderline+definite) cases(4.08 ± 4.32 ng/m L,6.1 ± 6.16 ng/m L,8.92 ± 6.45 ng/m L,respectively,P = 0.004).When the cut-off value for the serum LOX-1 level was set at 5.35 ng/m L,and a ROC curve analysis was performed to distinguish between steatohepatitis patients and controls; the sensitivity and specificity of the serum LOX-1 level were 69.8% and 69.2%,respectively.CONCLUSION: The serum LOX-1 levels were significantly higher in NAFLD patients than in healthy controls.Additionally,the serum LOX-1 levels could differentiate between steatohepatitis patients and healthy controls.     

Modification of a simple clinical scoring system as a diagnostic screening tool for non‐alcoholic steatohepatitis in Japanese patients with non‐alcoholic fatty liver disease

Aims/Introduction

We reinvestigated the clinical usefulness of the modified NAFIC scoring system, modified by changing the weightage assigned to the fasting serum insulin level based on the importance of hyperinsulinemia in the pathogenesis of non‐alcoholic steatohepatitis (NASH), in Japanese patients with non‐alcoholic fatty liver disease (NAFLD) who had undergone liver biopsy.

Materials and Methods

The NAFIC score is conventionally calculated as follows: serum ferritin ≥200 ng/mL (female) or ≥300 ng/mL (male), 1 point; serum fasting insulin ≥10 μU/mL, 1 point; and serum type IV collagen 7 s ≥5.0 ng/mL, 2 points. A total of 147 patients with NAFLD who had undergone liver biopsies were included in the estimation group. To validate the modified scoring system, 355 patients from nine hepatology centers in Japan were also enrolled.

Results

In the estimation group, 74 (50.3%) patients were histologically diagnosed as having NASH, whereas the remaining 73 (49.7%) were diagnosed as not having NASH. As the percentage of NASH patients increased not only among participants with serum insulin levels greater than 10 μU/mL, but also in those with serum levels greater than 15 μU/mL, we advocated use of the modified NAFIC score, as follows: serum fasting insulin 10–15 μU/mL, 1 point and ≥15 μU/mL, 2 points. The modified NAFIC score showed improved sensitivity and negative predictive value for the diagnosis of NASH. This finding was also confirmed in the validation group.

Conclusions

The modified NAFIC scoring system could be a clinically useful diagnostic screening tool for NASH.     

Effects of bariatric surgery on nonalcoholic fatty liver disease: preliminary findings after 2 years

Background and Aim: Although nonalcoholic fatty liver disease (NAFLD) is very common among morbidly obese patients, the effect of weight loss after bariatric surgery on inflammation and fibrosis related to NAFLD is still a matter of debate. The aim of this study was to evaluate the impact of Roux‐en‐Y gastric bypass (RYGB) surgery on NAFLD with a follow up of 2 years. Methods: Eighteen consecutive NAFLD patients with body mass index >40 kg/m² undergoing gastroplasty with RYGB were enrolled, and wedge liver biopsy was obtained at the operation. After 2 years, these patients underwent percutaneous liver biopsy. Results: At baseline, 67% of patients had nonalcoholic steatohepatitis (NASH) and 33% had steatosis, according to the NASH Clinical Research Network Scoring System (NAS) for biopsy. Cirrhosis was present in 5.5% of the patients with NASH. After a mean excess weight loss of 60%, steatosis disappeared in 84% and fibrosis disappeared in 75% of the patients. Hepatocellular ballooning disappeared in 50%. A slight lobular inflammatory infiltrate remained in 81%, apparently unrelated to fatty degeneration. As liver biochemical variables had been found within normal limits in 92.3% of patients at initial biopsy, no difference was found 2 years later. Lipid profile and blood sugar plasma concentration were closer to normal in all patients after 2 years (P < 0.05). Conclusions: Aspects of NAFLD including steatohepatitis improved significantly with massive weight loss at 2 years after RYGB surgery. No patient in this series had progression of hepatic fibrosis.     

Predictors of fibrosis in Asian patients with non-alcoholic steatohepatitis

Background and Aim: Non‐alcoholic steatohepatitis (NASH) is increasingly recognized as an important cause of chronic liver disease. However, data on Asians with NASH is lacking in the literature. The aim of the present study was to describe the clinical, biochemical and histological characteristics of NASH in Asians and to determine the predictors for septal fibrosis. Method: Sixty consecutive patients aged over 18 years with elevated serum alanine transferase, sonographic evidence of steatosis, and consent for liver biopsy were included. Patients with chronic hepatitis B or C, alcoholic, autoimmune, genetic, or drug‐induced liver disease were excluded. Clinical, biochemical and histological variables were tested for association with septal liver fibrosis (F2/3). Results: Median age of the cohort was 45.5 years (range 21–75 years) and 63% were male. Ninety percent of patients were obese (body mass index [BMI]≥ 25), 70% had hypertriglyceridemia, 68% had hypercholesterolemia, 58% had metabolic syndrome, 53% had hypertension, 47% had diabetes mellitus (DM), and 18% had obstructive sleep apnea. Sixty‐eight percent had gamma‐glutamyl transferase (GGT) ≥ 2 × upper limit of normal (ULN), 55% had alanine aminotransferase (ALT) ≥ 2 × ULN, and 23% had aspartate aminotransferase (AST) ≥ 2 × ULN. Of the 40 non‐diabetic patients undergoing oral glucose tolerance testing, 45% had normal tests, 30% had impaired glucose tolerance, 23% DM, and 2% impaired fasting glucose. Eighteen patients (30%) had septal fibrosis (F2/3), but none had cirrhosis. Necroinflammatory grade ≥ 2 (odds ratio [OR] 13), AST ≥ 2 × ULN (OR 5.3) and DM (OR 5) were significantly and independently correlated with septal fibrosis. Conclusion: Septal fibrosis is common in Asians with NASH. Necroinflammatory grade ≥ 2, AST ≥ 2 × ULN and DM are independent predictors for septal fibrosis.     

非酒精性脂肪性肝病的临床及病理学特征

目的 探讨我国成人非酒精性脂肪性肝病(NAFLD)不同ALT水平患者的临床及病理学特征.方法 分析2005年1月-2009年3月经肝活体组织检查证实的108例NAFLD患者的人口学、生物化学及病理学资料,并比较血清ALT正常与增高患者的病理学及临床特征. 结果在108例NAFLD中,49例(45.4%)为单纯性脂肪肝(NAFL),57例(52.8%)为非酒精性脂肪性肝炎(NASH),2例(1.9%)为NASH相关肝硬化.ALT和AST水平,NASH患者分别为(156.2±137.7)U/L和(82.2士67.8)U/L,NAFL患者分别为(103.9±93.7)U/L和(52.2±33.4)U/L,t值分别为2.55和3.13,尸值均<0.01,差异有统计学意义.AST/ALT比值NASH患者为0.61±0.30,NAFL患者为0.78土0.77,NASH患者AST/ALT比值低于NAFL患者,t=2.18,p=0.03,差异有统计学意义.ALT增高组中NASH占64.9%(50/77),ALT正常组NASH占29.0%o(9/31),x~2=11.49,p=0.00.ALT增高组炎症程度显著高于ALT正常组,x~2=10.30,P=0.01,差异有统计学意义;但肝脂肪变和纤维化程度在两组之间,x~2=5.52,6.12;P=0.12,0.10,差异无统计学意义.ALT增高组血清AST、y-谷氨酰转肽酶、总胆固醇、载脂蛋白A1、载脂蛋白B和收缩压水平均比ALIT正常组显著增高(t值分别为5.91,2.00,2.30,2.10,3.14,2.43;p值分别为0.00,0.05,0.02,0.04,0.00,0.02),而AST/ALT比值、B超下脾脏肋间厚度则显著降低(t值分别为3.70和2.95;p值分别为0.00和0.01).多元回归分析显示血清ALT增高与病理学NASH相关(OR=2.78,95%CI 1.06～7.3,p=0.04),但血清ALT预测NASH的准确性欠佳,ROC曲线下面积为0.69(95%CI 0.59～0.8,P=0.00).结论 在中国成人NAFLD患者中可以见到完整的疾病谱.ALT升高患者NASH比例更高,血清ALT水平可预测NAFLD患者炎症程度,但不能预测脂肪变和纤维化程度.     

Association of Apolipoprotein E Polymorphisms in Patients with Non-Alcoholic Steatohepatitis

Non-alcoholic fatty liver disease (NAFLD) is the most common cause of abnormal hepatic steatosis in the absence of alcohol abuse worldwide. Non-alcoholic steatohepatitis (NASH) is the most progressive form of NAFLD. The aim of this study was to investigate the role of apolipoprotein E (APOE) polymorphisms in the development of NASH. We analysed 57 NASH patients and 245 healthy controls using a polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP) method in a case–control study. The diagnosis of the patients was based on liver biopsy. The serum levels of glucose, lipids, vitamin B12, folic acid, homocysteine, insulin, total biluribin, total protein, albumin, ferritin, aspartate aminotransferase (AST) and alanine aminotransferase (ALT) were determined in all of the subjects. Body mass index (BMI), waist circumference (WC), AST, ALT, fasting blood sugar (FBS), total cholesterol, triglyceride (TG), low-density lipoprotein (LDL) cholesterol, very low-density lipoprotein (VLDL) cholesterol, insulin and ferritin levels were significantly higher in the 57 patients with NASH compared with the 245 healthy controls. The APOE ε3 allele was overrepresented in the whole group of NASH patients (ε3=97.37% in NASH versus 82.45% in controls). The APOE polymorphism was statistically significantly associated with NASH (χ²=15.741; p=0.008). The APOE3/3 genotype (odds ratio [OR]=7.941; p=0.000) was strongly associated with increased risk for NASH in all NASH patients. Consequently, the APOE3/3 genotype may play a role in the aetiopathogenesis of NASH.     

Hypolactasia is associated with insulin resistance in nonalcoholic steatohepatitis

AIM To assess lactase gene(LCT)-13910CT polymorphisms in Brazilian non-alcoholic fatty liver disease(NAFLD) and nonalcoholic steatohepatitis(NASH) patients in comparison with healthy controls.METHODS This was a transverse observational clinical study with NAFLD patients who were followed at the Hepatology Outpatient Unit of the Hospital das Clínicas, S?o Paulo, Brazil. The polymorphism of lactase non-persistence/lactase persistence(LCT-13910CT) was examined by PCR-restriction fragment length polymorphism technique in 102 liver biopsy-proven NAFLD patients(steatosis in 9 and NASH in 93) and compared to those of 501 unrelated healthy volunteers. Anthropometric, clinical, biochemical and liver histology data were analyzed. Continuous variables were compared using the t or Mann-Whitney tests, and categorical data were compared with the Fisher's exact test. Univariate logistic regression and multivariate logistic regression adjusted for gender and age were performed.RESULTS No differences in the LCT-13910 genotype frequencies were noted between the NAFLD patients(66.67% of the patients with steatosis were CC, 33.33% were CT, and none were TT; 55.91% of the patients with NASH were CC, 39.78% were CT, and 4.3% were TT; P = 0.941) and the healthy controls(59.12% were CC, 35.67% were CT, and 5.21% were TT) or between the steatosis and NASH patients. That is, the distribution of the lactase non-persistence/lactase persistence polymorphism(LCT-13910CT) in the patients with NAFLD was equal to that in the general population. In the NASH patients, the univariate analysis revealed that the lactase nonpersistence(low lactase activity or hypolactasia) phenotype was associated with higher insulin levels(23.47 ± 15.94 μU/m L vs 15.8 ± 8.33 μU/m L, P = 0.027) and a higher frequency of insulin resistance(91.84% vs 72.22%, P = 0.02) compared with the lactase persistence phenotype. There were no associations between the LCT genotypes and diabetes(P = 0.651), dyslipidaemia(P = 0.328), hypertension(P = 0.507) or liver histology in these patients. Moreover, in the NASH patients, hypolactasia was an independent risk factor for insulin resistance even after adjusting for gender and age [OR = 5.0(95%CI: 1.35-20; P = 0.017)].CONCLUSION The LCT-13910 genotype distribution in Brazilian NAFLD patients was the same as that of the general population, but hypolactasia increased the risk of insulin resistance in the NASH patients.     

Noninvasive evaluations of pulmonary circulation, cardiac function, and liver excreting rate at late follow-up following the modified Fontan operation

The purpose of this paper was to define the late postoperative pulmonary circulation and cardiac and liver functions after a modified Fontan operation by radionuclide studies. Eleven patients (5 with single ventricle and 6 with double outlet right ventricle) underwent a modified Fontan operation using a RA-PA anastomosis. These 11 patients ranging in age from 7 to 42 years (mean 17±10 years) were examined at 4.7–12.1 years (mean 8.6±2.4 years) postoperatively and compared with studies in 10 normal adults. Pulmonary circulation, cardiac function and liver excreting function were determined by intravenous administration of Tc-MAA, Tc-PYP, and Tc-PMT, respectively. No extrapulmonary radioactivity was detected by Tc-MAA lung perfusion in patients. Although the cardiac diastolic function of the patients remained normal, the systolic functions (EF=46.4±7.8%, 1/3EF=11.2±4.4%, PER=1.93±0.54/sec) of the patients were significantly decreased compared with those of normal controls (EF=54.7±4.7%, 1/3EF=21.7±2.1%, PER=2.91±0.4/sec), respectively. The mean level of MTT of the patients (9.4±2.7 minutes) was also significantly prolonged compared with that of normal controls (6.1±4.4 minutes). Some of these deteriorated parameters clearly related to higher age at operation and length of intervals since operation. These data suggest that the earlier surgical intervention by the Fontan operation is desired for the complex congenital cardiac anomalies.Presented at the 36th Annual World Congress, International College of Angiology, New York, New York, July 1994.