Type IV collagen 7s domain is an independent clinical marker of the severity of fibrosis in patients with nonalcoholic steatohepatitis before the cirrhotic stage

Background The changes in nonalcoholic fatty liver disease range over a wide spectrum, extending from simple steatosis to nonalcoholic steatohepatitis (NASH). We investigated the clinical usefulness of the type IV collagen 7s domain and hyaluronic acid for predicting the severity of fibrosis before progression to the cirrhotic stage in NASH patients. Methods The type IV collagen 7s domain and hyaluronic acid were measured in 72 patients with histologically verified NASH. Results In a univariate analysis, marked elevation of hyaluronic acid and the type IV collagen 7s domain was observed in the NASH patients with advanced fibrosis compared with those with mild fibrosis (P = 0.0028, P = 0.0006, respectively). For detection of NASH with advanced fibrosis, the area under the receiver-operating characteristic curves for type IV collagen 7s domain and hyaluronic acid were 0.767 and 0.754, respectively. However, multiple regression analysis revealed that the type IV collagen 7s domain, but not hyaluronic acid, was significantly elevated in patients with advanced fibrosis even after adjustment for age, sex, platelet count, prothrombin time, aspartate aminotransferase/alanine aminotransferase ratio, body mass index, and presence of underlying type 2 diabetes mellitus, all of which have previously been reported as useful predictors of advanced fibrosis in patients with NASH (P = 0.0127, P = 0.2804, respectively). Conclusions This is the first report to demonstrate a consistent and profound elevation of the type IV collagen 7s domain in NASH patients with advanced fibrosis (before progression to the stage of cirrhosis) compared with those with mild fibrosis.     

Serum ferritin is an independent predictor of histologic severity and advanced fibrosis in patients with nonalcoholic fatty liver disease

Serum ferritin (SF) levels are commonly elevated in patients with nonalcoholic fatty liver disease (NAFLD) because of systemic inflammation, increased iron stores, or both. The aim of this study was to examine the relationship between elevated SF and NAFLD severity. Demographic, clinical, histologic, laboratory, and anthropometric data were analyzed in 628 adult patients with NAFLD (age, ≥ 18 years) with biopsy-proven NAFLD and an SF measurement within 6 months of their liver biopsy. A threshold SF >1.5 × upper limit of normal (ULN) (i.e., >300 ng/mL in women and >450 ng/mL in men) was significantly associated with male sex, elevated serum alanine aminotransferase, aspartate aminotransferase, iron, transferrin-iron saturation, iron stain grade, and decreased platelets (P < 0.01). Histologic features of NAFLD were more severe among patients with SF >1.5 × ULN, including steatosis, fibrosis, hepatocellular ballooning, and diagnosis of NASH (P < 0.026). On multiple regression analysis, SF >1.5 × ULN was independently associated with advanced hepatic fibrosis (odds ratio [OR], 1.66; 95% confidence interval [CI], 1.05-2.62; P = 0.028) and increased NAFLD Activity Score (NAS) (OR, 1.99; 95% CI, 1.06-3.75; P = 0.033). CONCLUSIONS: A SF >1.5 × ULN is associated with hepatic iron deposition, a diagnosis of NASH, and worsened histologic activity and is an independent predictor of advanced hepatic fibrosis among patients with NAFLD. Furthermore, elevated SF is independently associated with higher NAS, even among patients without hepatic iron deposition. We conclude that SF is useful to identify NAFLD patients at risk for NASH and advanced fibrosis.     

A simple clinical scoring system using ferritin, fasting insulin, and type IV collagen 7S for predicting steatohepatitis in nonalcoholic fatty liver disease

Background

Liver histology is the gold standard for the diagnosis of nonalcoholic steatohepatitis (NASH). Noninvasive, simple, reproducible, and reliable biomarkers are greatly needed to differentiate NASH from nonalcoholic fatty liver disease (NAFLD).

Methods

To construct a scoring system for predicting NASH, 177 Japanese patients with biopsy-proven NAFLD were enrolled. To validate the scoring system, 442 biopsy-proven NAFLD patients from eight hepatology centers in Japan were also enrolled.

Results

In the estimation group, 98 (55%) patients had NASH. Serum ferritin [??200?ng/ml (female) or ??300?ng/ml (male)], fasting insulin (??10???U/ml), and type IV collagen 7S (??5.0?ng/ml) were selected as independent variables associated with NASH, by multilogistic regression analysis. These three variables were combined in a weighted sum [serum ferritin ??200?ng/ml (female) or ??300?ng/ml (male)?=?1 point, fasting insulin ??10???U/ml?=?1 point, and type IV collagen 7S ??5.0?ng/ml?=?2 points] to form an easily calculated composite score for predicting NASH, called the NAFIC score. The area under the receiver operating characteristic (AUROC) curve for predicting NASH was 0.851 in the estimation group and 0.782 in the validation group. The NAFIC AUROC was the greatest among several previously established scoring systems for detecting NASH, but also for predicting severe fibrosis.

Conclusions

NAFIC score can predict NASH in Japanese NAFLD patients with sufficient accuracy and simplicity to be considered for clinical use.     

Hyaluronic acid levels can predict severe fibrosis and platelet counts can predict cirrhosis in patients with nonalcoholic fatty liver disease

BACKGROUND AND AIM: Nonalcoholic fatty liver disease (NAFLD) represents a spectrum of liver disease from simple steatosis to cirrhosis. Therefore, markers for predicting NAFLD with advanced fibrosis are needed. The aim of this study was to establish non-invasive predictive markers of liver fibrosis in NAFLD. METHODS: One hundred and forty-eight patients were diagnosed as having biopsy-proven NAFLD. In order to separately identify severe fibrosis (bridging fibrosis plus cirrhosis) and cirrhosis, the patients were analyzed twice: first, as mild fibrosis versus severe fibrosis; and second, as non-cirrhosis versus cirrhosis. Univariate and multivariate analyses were conducted. The diagnostic ability to detect severe fibrosis and cirrhosis was assessed by the area under the receiver operating characteristic curve. The cut-off values of serum markers to detect severe fibrosis and cirrhosis were determined. RESULTS: Hyaluronic acid was selected as a predictive marker for severe fibrosis. A cut-off value of 42 ng/mL of hyaluronic acid had a 100% predictive value for patients free of severe fibrosis and was associated with an optimal combination of sensitivity (100%, 95% confidence interval [CI] 90-100%) and specificity (89%, 95%CI 80-94%). The platelet count was found to be an independent predictor of cirrhosis. A cut-off value of 16 x 10(4)/microL for the platelet count was associated with an optimal combination of sensitivity (100%, 95%CI 82-100%) and specificity (95%, 95%CI 90-98%). CONCLUSIONS: Hyaluronic acid levels can accurately identify NAFLD patients with severe fibrosis, and the platelet count can identify NAFLD patients with cirrhosis. Thus, these markers offer a good guideline for the assessment of hepatic fibrosis in the many patients with NAFLD.     

Hyaluronic acid, an accurate serum marker for severe hepatic fibrosis in patients with non-alcoholic fatty liver disease.

AIM: To determine whether serum hyaluronic acid reliably predicts the severity of hepatic fibrosis in patients with non-alcoholic fatty liver disease (NAFLD). METHODS: We studied 79 patients with histologically confirmed NAFLD. Hyaluronic acid was measured in serum obtained at the time of liver biopsy. Severity of fibrosis was staged based on Brunt's classification. The prediction levels for fibrosis were determined by area under the receiver operating characteristic curve (AUC). RESULTS: The logarithm of serum hyaluronic acid was significantly different among the stages of fibrosis (P<0.0001, analysis of variance) and had a significant positive correlation with the degrees of fibrosis after adjusting for age and serum albumin (partial r=0.44, P<0.0001). AUCs were 0.67, 0.87, 0.89, and 0.92 for any levels of fibrosis, > or =moderate fibrosis, > or =severe fibrosis, and cirrhosis, all of which were significantly higher than 0.5 (P<0.05). The cut-off value of serum hyaluronic acid of 46.1 mug/l was associated with the highest AUC for severe fibrosis, yielding a sensitivity of 85% and a specificity of 80%. The corresponding positive and negative predictive values were 51% and 96%, when assuming prevalence of severe fibrosis in NAFLD patients of 20% at referral centers. CONCLUSIONS: Measurement of serum hyaluronic acid is useful to identify NAFLD patients with severe fibrosis.     

Noninvasive assessment of liver fibrosis by measurement of stiffness in patients with nonalcoholic fatty liver disease (NAFLD)

BACKGROUND: Liver fibrosis is the main predictor of the progression of nonalcoholic fatty liver disease. Transient elastography (FibroScan), which measures liver stiffness, is a novel, noninvasive method to assess liver fibrosis. AIM: We investigated the usefulness of liver stiffness measurement in the evaluation of liver fibrosis in nonalcoholic fatty liver disease patients. STUDY POPULATION: A total of 97 nonalcoholic fatty liver disease patients. METHODS: Transient elastography was performed for liver stiffness measurement in 97 nonalcoholic fatty liver disease patients. And the relationship between histological parameters and liver stiffness measurement was studied by multivariate analysis. Moreover, we investigated the relationship between liver stiffness measurement and the serum levels of hyaluronic acid and type IV collagen 7s domain. RESULTS: The liver stiffness was well correlated with the stage of liver fibrosis (Kruskal-Wallis test p < 0.0001). The areas under the receiver-operating characteristic curves were 0.927 for > or = F1, 0.865 for > or = F2, 0.904 for > or = F3, 0.991 for > or = F4. Only fibrosis stage was correlated significantly with liver stiffness measurement by multiple regression analysis. Liver stiffness was also strongly correlated with the serum levels of type IV collagen 7s domain (r = 0.525, p < 0.0001) and hyaluronic acid (r = 0.457, p < 0.0001). CONCLUSIONS: Our results show a significant correlation between liver stiffness measurement and fibrosis stage in nonalcoholic fatty liver disease patients, as confirmed by the results of liver biopsy, which remains the gold standard for evaluation of the severity of liver fibrosis in patients with nonalcoholic steatohepatitis.     

Serum markers of liver fibrosis and histologic severity of fibrosis in resected liver

BACKGROUND/AIMS: Serum concentrations of the 7S fragment of type IV collagen (7S collagen), amino-terminal propeptide of type III procollagen (PIIIP), and hyaluronic acid (HA) have been reported to serve as serologic markers of liver fibrosis in hepatitis and cirrhosis. We investigated whether these fibrosis markers reliably reflect histologic changes in the livers of patients with hepatocellular carcinoma. METHODOLOGY: Subjects included 165 patients undergoing liver resection for hepatocellular carcinoma. Most were seropositive for chronic hepatitis B or C. Histopathologic changes in liver tissue resected with the tumor were scored according to Knodell's histologic activity index. Serum was sampled for assays shortly before surgery. RESULTS: Significant correlations were found between hepatitis activity score and 7S collagen, PIIIP, and HA. Concentrations of 7S collagen differed significantly between activity grades, but differences were not significant for PIIIP or HA. Significant correlations were found between fibrosis staging score and all these three markers. When patients were divided according to activity grade, 7S collagen showed stronger correlation with fibrosis staging score than did PIIIP or HA. CONCLUSIONS: The 7S collagen fragment correlated more strongly than PIIIP or HA with stage and activity grade in patients with hepatocellular carcinoma. However, overlapping of results between histologically defined groups appeared to limit clinical diagnostic usefulness of all markers in individual patients.     

Limitations of liver biopsy and non-invasive diagnostic tests for the diagnosis of nonalcoholic fatty liver disease/nonalcoholic steatohepatitis

It is estimated that 30%of the adult population in Japan is affected by nonalcoholic fatty liver disease(NAFLD).Fatty changes of the liver are generally diagnosed using imaging methods such as abdominal ultrasonography(US)and computed tomography(CT),but the sensitivity of these imaging techniques is low in cases of mild steatosis.Alanine aminotransferase levels may be normal in some of these patients,warranting the necessity to establish a set of parameters useful for detecting NAFLD,and the more severe form of the disease,nonalcoholic steatohepatitis(NASH).Although liver biopsy is currently the gold standard for diagnosing progressive NASH,it has many drawbacks,such as sampling error,cost,and risk of complications.Furthermore,it is not realistic to perform liver biopsies on all NAFLD patients.Diagnosis of NASH using various biomarkers,scoring systems and imaging methods,such as elastography,has recently been attempted.The NAFIC score,calculated from the levels of ferritin,fasting insulin,and typeⅣcollagen 7S,is useful for the diagnosis of NASH,while the NAFLD fibrosis score and the FIB-4 index are useful for excluding NASH in cases of advanced fibrosis.This article reviews the limitations and merits of liver biopsy and noninvasive diagnostic tests in the diagnosis of NAFLD/NASH.     

非酒精性脂肪性肝病进展性肝纤维化患者空腹血糖受损和胰岛素抵抗调查

目的 调查非酒精性脂肪性肝病(NAFLD)患者空腹血糖受损(IFG)和胰岛素抵抗情况及其与肝纤维化的关系。方法 2020年5月～2021年5月我院健康管理门诊诊治的NAFLD患者110例,接受口服葡萄糖耐量试验(OGTT)试验。计算稳态模型胰岛素抵抗指数(HOMA-IR),采用放射免疫法测定血清Ⅳ型胶原、Ⅲ型前胶原(PCⅢ)、层黏连蛋白(LN)和透明质酸(HA)。计算NAFLD纤维化评分(NFS),以NFS﹥0.676被定义为存在进展性肝纤维化。应用Logistic回归模型分析影响NAFLD患者发生进展性肝纤维化的因素。结果 经OGTT试验,发现本组糖耐量正常(NGT)者43例,糖耐量异常(IGT)者35例和IFG者32例;IFG组空腹血糖(FPG)、胰岛素(FINS)和HOMA-IR指数分别为(6.6±0.3)mmol/L、(10.9±2.4)μU/mL和3.2±0.9,显著高于IGT组【分别为(5.6±0.7)mmol/L、(8.5±2.2)μU/mL和2.4±0.5,P<0.05】或NGT组【分别为(5.5±0.6)mmol/L、(7.4±1.9)μU/mL和1.8±0.4...     

Usefulness of serum hepatic fibrosis markers in the diagnosis of nonalcoholic steatohepatitis (NASH)

BACKGROUND/AIMS: In the present study, we examined the usefulness of serum hepatic fibrosis markers for the diagnosis of nonalcoholic steatohepatitis (NASH). METHODOLOGY: The subjects were 16 patients with NASH and 9 patients with fatty liver (FL). All were negative for serum HBsAg, HCVAb, antibodies related with autoimmune diseases, alcohol intake, and drug abuse. We measured the biochemical markers for liver function, hepatic fibrosis markers such as type III procollagen N-peptide (PIIIP), type IV collagen (TyIV), hyaluronic acid (HA) and leptin, and compared these data with histological findings of biopsy specimens. In addition, we examined the diagnostic efficiency of fibrosis markers and leptin for NASH using receiver operating characteristic (ROC) curve. Body mass index (BMI), fasting blood sugar, triglyceride, and degree of fat droplets, inflammation, iron deposition and fibrosis were significantly higher in the NASH group compared with the FL group. RESULTS: The diagnostic efficiencies of NASH% (cut-off value) were 68% (100ng/mL) for TyIV, 68% (10ng/mL) for HA, 64% (0.62U/mL) for PIIIP and 56% (8pg/mL) for leptin. CONCLUSIONS: From these results, it is suggested that the serum hepatic fibrosis markers such as TyIV, in addition to liver biopsy, may be useful for the diagnosis of NASH.     

Diagnostic value of a group of biochemical markers of liver fibrosis in patients with non‐alcoholic steatohepatitis

OBJECTIVE:  The objectives of this study were to investigate the use of non‐invasive biochemical markers to evaluate the severity of liver fibrosis in patients with non‐alcoholic steatohepatitis (NASH). METHODS:  This was a cross‐sectional study of patients with histopathologically confirmed NASH between January 2005 and December 2006. The patients’ characteristics were recorded and the body mass index was calculated for each patient. All patients underwent ultrasound‐guided liver biopsy and a fibrosis assessment was performed using the Brunt criteria. The non‐invasive laboratory markers measured were insulin resistance, tumor necrosis factor (TNF‐α), type IV collagen and hyaluronic acid (HA). RESULTS:  Thirty patients were recruited, of whom 18 (60%) were men. Their mean age was 45 ± 13.9 (18–71) years. About 83% of patients had fibrosis stage 1–2. In bivariate analysis, age, TNF‐α and type IV collagen concentrations showed a weak but significant correlation with the fibrosis stage. When the patients were grouped into mild fibrosis (stages 1–2) and advanced fibrosis (stages 3–4), the mean concentrations of HA and type IV collagen were significantly higher in those with advanced fibrosis than those with mild fibrosis (180.8 ± 49.63 vs 543.6 ± 360.45 ng/mL; for HA; P = 0.026 and 125.3 ± 32.11 vs 288.0 ± 171.22 ng/mL for type IV collagen; P = 0.010). CONCLUSION:  Our study showed that the degree of liver fibrosis was significantly correlated with age, TNF‐α and type IV collagen concentrations. The level of HA and type IV collagen could differentiate between mild (F1–2) and advanced fibrosis (F3–4).     

Nonalcoholic fatty liver disease in severely obese subjects

BACKGROUND: Nonalcoholic fatty liver disease (NAFLD) has been consistently associated with obesity and insulin resistance. Nonalcoholic steatohepatitis (NASH) is a histological entity within NAFLD that can progress to cirrhosis. The exact prevalence of NASH in severe obesity is unknown. It is unclear whether differences in insulin sensitivity exist among subjects with NASH and simple fatty liver. OBJECTIVE: To evaluate the prevalence and correlates of NASH and liver fibrosis in a racially diverse cohort of severely obese subjects. DESIGN: Ninety-seven subjects were enrolled. Liver biopsies, indirect markers of insulin resistance, metabolic parameters, and liver function tests were obtained. RESULTS: Thirty-six percent of subjects had NASH and 25% had fibrosis. No cirrhosis was diagnosed on histology. Markers of hyperglycemia, insulin resistance, and the metabolic syndrome but not body mass index were associated with the presence of NASH and fibrosis. Elevated transaminase levels correlated strongly with NASH and fibrosis but 46% subjects with NASH had normal transaminases. Subjects with NASH had more severe insulin resistance when compared to those with simple fatty liver. A signal detection model incorporating AST and the presence of diabetes predicted the presence of NASH while another incorporating ALT and HbA1C predicted the presence of fibrosis. CONCLUSIONS: NAFLD is associated with the metabolic syndrome rather than excess adipose tissue in severe obesity. Insulin resistance is higher in subjects with NASH versus those with simple fatty liver. Statistical models incorporating markers of liver injury and hyperglycemia may be useful in predicting the presence of liver pathology in this population.     

Health-related fitness and physical activity in patients with nonalcoholic fatty liver disease

Nonalcoholic fatty liver disease (NAFLD) has been referred to as the hepatic manifestation of the metabolic syndrome. There is a lower prevalence of metabolic syndrome in individuals with higher health-related fitness (HRF) and physical activity (PA) participation. The relationship between NAFLD severity and HRF or PA is unknown. Our aim was to compare measures of HRF and PA in patients with a histological spectrum of NAFLD severity. Thirty-seven patients with liver biopsy-confirmed NAFLD (18 women/19 men; age = 45.9 +/- 12.7 years) completed assessment of cardiorespiratory fitness (CRF, VO(2peak)), muscle strength (quadriceps peak torque), body composition (%fat), and PA (current and historical questionnaire). Liver histology was used to classify severity by steatosis (mild, moderate, severe), fibrosis stage (stage 1 versus stage 2/3), necroinflammatory activity (NAFLD Activity Score; or=5 NAS2) and diagnosis of NASH by Brunt criteria (NASH versus NotNASH). Analysis of variance and independent t tests were used to determine the differences among groups. Fewer than 20% of patients met recommended guidelines for PA, and 97.3% were classified at increased risk of morbidity and mortality by %fat. No differences were detected in VO(2peak) (x = 26.8 +/- 7.4 mL/g/min) or %fat (x = 38.6 +/- 8.2%) among the steatosis or fibrosis groups. Peak VO(2) was significantly higher in NAS1 versus NAS2 (30.4 +/- 8.2 versus 24.4 +/- 5.7 mL/kg/min, P = 0.013) and NotNASH versus NASH (34.0 +/- 9.5 versus 25.1 +/- 5.7 mL/kg/min, P = 0.048). Conclusion: Patients with NAFLD of differing histological severity have suboptimal HRF. Lifestyle interventions to improve HRF and PA may be beneficial in reducing the associated risk factors and preventing progression of NAFLD.     

Value of fibrosis markers for staging liver fibrosis in patients with precirrhotic alcoholic liver disease

Background: Our aim was to identify markers predictive of fibrosis in alcoholic liver disease (ALD). Percutaneous liver biopsy is the recommended standard for histologic assessment of liver fibrosis. Seven serum markers (tissue inhibitor of matrix metalloproteinase 1 {TIMP1}, tenascin, collagen VI, amino‐terminal propeptide of type III collagen {PIIINP}, matrix metalloproteinases {MMP2}, laminin, and hyaluronic acid {HA}) representing various aspects of collagen and extracellular matrix deposition and degradation, have been proposed as noninvasive surrogates for liver biopsy. Moreover, a diagnostic algorithm including 3 serum markers (TIMP1, PIIINP, HA) and age has been proposed to accurately detect fibrosis with acceptable levels of sensitivity/specificity in a chronic hepatitis C subgroup. Methods: To determine variability of these markers in liver fibrosis with different etiologies, we conducted an evaluation of their correlative properties in a subgroup of patients (n = 247) with biopsy confirmed liver fibrosis resulting from long‐term heavy alcohol consumption. Patients were participants in a recently completed VA multicenter clinical trial followed over 2 years with liver biopsy at baseline and 24 months, and with markers assessed every 3 months. Results: Among the markers measured in this alcoholic subgroup all except collagen VI displayed significant correlation with degrees of fibrosis. Three markers, TIMP1, PIIINP and HA adjusted for age, emerged as the most promising predictors of the degree of fibrosis in a population of alcoholics. However, there was little change over time as related to change in fibrosis. The lower than expected accuracy of these markers based on receiver operating curves (ROC) also showed their limited use in this etiologic subgroup. Conclusion: In alcoholic patients, various markers have limited value in predicting and diagnosing the stages of fibrosis compared to liver biopsy. Thus, further prospective studies are required to better define the usefulness of each marker or their combination which are possibly affected by alcohol metabolism.     

Serum ferritin is a discriminant marker for both fibrosis and inflammation in histologically proven non‐alcoholic fatty liver disease patients

Introduction: Differentiation between steatosis and non‐alcoholic steatohepatitis (NASH) in non‐alcoholic fatty liver disease (NAFLD) is important as NASH progress to cirrhosis. No specific laboratory/imaging technique exists either to diagnose NASH or to select patients for liver biopsy. Patients and methods: We evaluated serum ferritin and the features of metabolic syndrome with respect to histological inflammation and/or fibrosis in NAFLD patients. The Kleiner scoring system was used to classify NAFLD in consecutive liver biopsies. One hundred and eleven patients: median age 52.6, 64 males, obesity 62, diabetes mellitus (DM) 58, arterial hypertension 26 and hyperlipidaemia 40%. Results: Histologically, 40.7 had fatty liver, 30.6% had borderline NASH, 28.7% had NASH and 11% had cirrhosis. Multivariate regression showed that diabetes, serum ferritin concentrations, body mass index (BMI) and AST were independently associated with NASH: together, the areas under the receiver operating characteristic (AUROC) was 0.91 (95% confidence interval 0.86–0.96); fibrosis was associated with ferritin concentrations and BMI: AUROC 0.87, portal inflammation with ferritin and DM: AUROC 0.82, while lobular inflammation was associated with BMI, DM and ferritin: AUROC 0.85. Conclusion: Serum ferritin concentrations and BMI are strongly associated with fibrosis, portal and lobular inflammation in NAFLD patients. Both ferritin and BMI are potential discriminant markers to select patients for liver biopsy and are associated with inflammation and fibrosis.     

Histopathological stages of nonalcoholic fatty liver disease in type 2 diabetes: prevalences and correlated factors

Background/Aims: Nonalcoholic fatty liver disease (NAFLD) is highly prevalent in type 2 diabetes mellitus (T2DM). However, data regarding the prevalence and correlates of its histopathological stages are scarce. The aim was to investigate the prevalence and correlates of the more severe histopathological features of NAFLD, nonalcoholic steatohepatitis (NASH) and advanced fibrosis, in T2DM. Methods: From 125 patients with ultrasonographic evidence of NAFLD, 98 patients underwent liver biopsies, which were examined by two independent pathologists regarding the presence of NASH and graded according to the NASH Clinical Research Network scoring system. Agreement between pathologists was assessed by weighted κ coefficients and independent correlates of NASH and advanced fibrosis (grade ≥2) by multivariate logistic regression. Results: Ninety‐two (94%) patients presented histological NAFLD. Interobserver agreement was substantial to excellent for NASH diagnosis (κ=0.82) and steatosis grading (κ=0.76), and moderate for the NAFLD activity score (κ=0.58) and fibrosis grading (κ=0.52). The prevalence of NASH was 78%, and its independent correlates were hypertriglyceridaemia (P=0.034), high alanine aminotranferase level (P=0.044) and low serum high‐density lipoprotein‐cholesterol (P=0.079). The prevalence of advanced fibrosis ranged from 34% in the best scenario (lowest fibrosis score) to 60% in the worst scenario (highest score). Its independent correlates were a high serum γ‐glutamyl transferase (P=0.002), older age (P=0.022) and male gender (P=0.064). No diabetes‐related clinical characteristic was associated with NASH or advanced liver fibrosis. Conclusions: The prevalence of the severe features of NAFLD is high in T2DM patients. Liver biopsy shall be considered in all diabetic patients with ultrasonographic evidence of NAFLD.     

Non-invasive markers to predict the liver fibrosis in non-alcoholic fatty liver disease.

BACKGROUND/AIM: The aim of this study was to find a non-invasive marker, which could predict liver fibrosis without the need of liver biopsy in non-alcoholic steatohepatitis (NASH). PATIENTS/METHODS: Fifty patients were included. All patients had one or more conditions that characterize the metabolic syndrome and histological proven NASH. Hyaluronic acid (HA), leptin (LT) and laminin (LN) were determined from serum withdrawn at the day of biopsy. RESULTS: Patients were divided into two groups according to the histological findings. The first group consisted of 23 patients with NASH and fibrosis and the second group had 27 patients with NASH, ballooned cells, without fibrosis. Subjects with NASH and fibrosis had statistically significantly higher HA and LN than those with NASH without fibrosis, P<0.001, respectively. In contrast, there was no statistically significant difference between the levels of serum LT in the two groups. The stage of liver fibrosis in the 23 patients of group 1 was related only to the values of hyaluronic acid (P<0.001) and not to the ones of LT and LN. CONCLUSION: Measurement of hyaluronic acid could be a predictive factor of the presence and stage of liver fibrosis in NASH. LN could be used to diagnose liver fibrosis but has no value in staging.     

Low circulating levels of dehydroepiandrosterone in histologically advanced nonalcoholic fatty liver disease

The biological basis of variability in histological progression of nonalcoholic fatty liver disease (NAFLD) is unknown. Dehydroepiandrosterone (DHEA) is the most abundant steroid hormone and has been shown to influence sensitivity to oxidative stress, insulin sensitivity, and expression of peroxisome proliferator-activated receptor alpha and procollagen messenger RNA. Our aim was to determine whether more histologically advanced NAFLD is associated with low circulating levels of DHEA. Serum samples were obtained prospectively at the time of liver biopsy in 439 patients with NAFLD (78 in an initial and 361 in validation cohorts) and in controls with cholestatic liver disease (n = 44). NAFLD was characterized as mild [simple steatosis or nonalcoholic steatohepatitis (NASH) with fibrosis stage 0-2] or advanced (NASH with fibrosis stage 3-4). Serum levels of sulfated DHEA (DHEA-S) were measured by enzyme-linked immunosorbent assay. Patients with advanced NAFLD had lower plasma levels of DHEA-S than patients with mild NAFLD in both the initial (0.25 +/- 0.07 versus 1.1 +/- 0.09 microg/mL, P < 0.001) and validation cohorts (0.47 +/- 0.06 versus 0.99 +/- 0.04 microg/mL, P < 0.001). A "dose effect" of decreasing DHEA-S and incremental fibrosis stage was observed with a mean DHEA-S of 1.03 +/- 0.05, 0.96 +/- 0.07, 0.83 +/- 0.11, 0.66 +/- 0.11, and 0.35 +/- 0.06 microg/mL for fibrosis stages 0, 1, 2, 3, and 4, respectively. All patients in both cohorts in the advanced NAFLD group had low DHEA-S levels, with the majority in the hypoadrenal range. The association between DHEA-S and severity of NAFLD persisted after adjusting for age. A relationship between disease/fibrosis severity and DHEA-S levels was not seen in patients with cholestatic liver diseases. CONCLUSION: More advanced NAFLD, as indicated by the presence of NASH with advanced fibrosis stage, is strongly associated with low circulating DHEA-S. These data provide novel evidence for relative DHEA-S deficiency in patients with histologically advanced NASH.     

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.