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721 Impact of diet and pioglitazone for treatment of NAFLD
08. Alcoholic liver disease, NAFLD and drug induced liver disease
I
• DIAGNOSTIC T HVALUEEOF BIOMARKERS (ASH TEST) FOR THE PREDICTION OF ALCOHOLIC STEATOHEPATITIS IN PATIENTS WITH CHRONIC ALCOHOLIC LIVER DISEASE
D. Thabut 1, S. Naveau 2, F. Charlotte 3, J. Massard 1, V. Ratziu 1, F. ImbertBismuth 4, D. Cazals-Hatem 5, A. Abella 6, D. Messous 4, F. Beuzen 7, M. Munteanu 1, J. Taieb 1, R. Moreau 8, D. Lebrec 8, T. Poynard 1.
1Hepatogastroenterology, Pitid-Salpdtri~re hospital, Paris, France," 2Hepatogastroenterology, Bdclbre hospital, Clamart, France," 3Pathology, Pitid-Salpdtri~re hospital, Paris, France," 4Biochemistry, Pitid-Salpdtri~re hospital, Paris, France," 5Pathology, Beaujon hospital, Clichy, France," 6Biochemistry, Bdcl~re hospital, Paris, France," 7pathology, Bdclkre hospital, Clamart, France," 8INSERM U-481 and Hepatology unit, Hospital Beaujon, Clichy, France Background and Aims: The aim was to identify a panel of biomarkers (AshTest) for the diagnosis of alcoholic steato-hepatitis (ASH), usually made by transvenous liver biopsy, in patients with chronic alcoholic liver disease. This diagnostic test could be particularly useful in severe patients (Maddrey discriminant function >32), when a rapid corticotherapy is needed in case of ASH. Methods: Biomarkers and panels were assessed in a training group of consecutive patients with an alcohol intake >50 g/d, and validated in two independent groups including a prospective one. Diagnosis of ASH (polymorphonuclear infiltrate and hepatocellular necrosis) and its histological severity (4 classes: none, mild, moderate, severe) was assessed blindly. Results: 225 patients were included, 70 in the training group and 155 in validation groups, and 299 controls. AshTest was constructed using a combination of the 6 components of FibroTest-ActiTest plus the aspartate aminotransferase. AshTest area under the ROC curves (AUROC) for moderate severe ASH was 0.90 (SE 0.04) in the training group, 0.88 (0.06) in the prospective validation group and 0.87 (0.04) in the retrospective validation group. The median AshTest value was 0.005 in blood donors, 0.05 in patients without or with mild ASH, 0.64 in moderate ASH, and 0.84 in histologically severe ASH grade 3, (P < 0.05) between all groups. At a 0.50 cut-off the sensitivity of AshTest was 0.92 and 0.72 specificity for the diagnosis of ASH in the prospective validation group. Among patients with a Maddrey-DF > 32, a Ashtest at 0.80 had a 0.95 specificity and 0.96 positive predictive value for the diagnosis of ASH. Conclusions: In heavy drinkers, AshTest is a simple and non-invasive quantitative estimate of liver alcoholic hepatitis. The use of AshTest may reduce the need for liver biopsy, particularly in severe patients, and therefore permit an earlier treatment of alcoholic hepatitis.
I•
IMPACT OF DIET AND PIOGLITAZONE FOR TREATMENT OF NAFLD
G.G. Treiber, A. Csepregi, S. Klauck, M. Leucke, R Malfertheiner.
GI & Hepatology, University Hospital, Magdeburg, Germany Background: Non-alcoholic fatty liver disease (NAFLD) has a wide spectrum, potentially progressing to steatohepatitis, cirrhosis, and hepatocellular cancer. Methods: We included patients with elevation of at least 2 liver enzymes (ALAT or ASAT and g-GT) > 1.5 • UNL. They were subjected to a six months intervention period receiving a calory-reduced diet (aiming at max. 1200kCal/d) and lifestyle modification (alcohol consumption limit 40g/week). If liver enzymes did not improve, patients received pioglitazone 30 mg/d for at least 3 months, thereafter individually adjusted if responding. Results: 447 patients with NAFLD were screened. 267 underwent liver histology and had a full workup for exclusion of other chronic liver diseases.
$265
15/115 (13%) had weight loss ~>5% and normalisation of liver enzymes due to diet only. 50/100 agreed to be treated with pioglitazone alone and returned for follow-up at 12 and 24 weeks, their median histological degree of steatosis was 60%. Biochemical results at 12 and 24 weeks are given in the table. No changes until 24 weeks were seen for BMI, cholesterol, triglycerides, bilirubine, BSR, CrP, creatinine, prothrombine time. Total body fat composition decreased from 40.4% to 34.9% (p <0.05). The cumulative dose of the aminopyrine breath test increased from 6.2% to 8.5% (p < 0.05). Changes during 24 weeks of pioglitazone treatment Median values [UNL]
Baseline
12 weeks
24 weeks
p-value
ALAT [<0.60 gmol/L] ASAT [<0.60 gmol/L] AP [<1.74 gmol/L] g-GT [<0.65 gmol/L] Uric acid [<340 gmol/L] Fasting glucose[<6.4 mmol/L) Glucose (OGTT, 2 hrs post) Fasting insulin [ng/L] Insulin [ng/L] (OGTT, 2 hrs post)
1.53 1.00 1.60 1.81 377 4.9 7.3 85.5 703
0.60 0.59 1.10 0.81 337 5.3 ...
0.75 0.59 1.16 0.82 307 4.8 5.9 81.5 428
<0.0001 <0.0001 ~ 0.004 ~ 0.022 ~ 0.05 NS ~ 0.03 NS ~ 0.0008
Conclusions: Most patients could not achieve a clinically sufficient weight loss by non-medical treatment. In contrast, pioglitazone is an effective treatment for NAFLD.
I~
IDENTIFICATION AND CHARACTERIZATION OF HOMO SAPIENS SUBMERGENCE INDUCED PROTEIN 2 (ESIP-L) IN NAFLD: A DIAGNOSTIC AND MOLECULAR APPROACH
M.E. Tsimako, P. Kroon, P. Wilce. School of Molecular and Microbial Sciences, University of Queensland, St. Lucia, Qld, Australia
Background: The prevalence of obesity in western countries poses high risks for fatty liver changes resulting in benign steatosis to end stage liver cirrhosis. The disorder is often misdiagnosed, and in some cases patients are asymptotic, therefore there is a need for new and improved ways of diagnosing NAFLD. Molecular approaches that involve studying genes and proteins associated with fatty liver and their mechanistic pathways are geared towards the understanding of the NAFLD in an effort to provide a better diagnosis. Aims: The aim of this study was to determine if altered gene and protein expression of eSip-L is diagnostic of NAFLD. Methods: Real Time PCR of adult NASH livers was used to confirm microarray data. Peptide-raised antibodies were used to determine the expression and localization of the protein in liver and hepatoma cell lines. An in vitro fatty cell model was established in lipid loaded HepG2 to investigate the relationship between the protein expression and fat overload. The lipids were probed with a fluorescent lipid probe (see figure).
I
• DIAGNOSTIC T HVALUEEOF BIOMARKERS (ASH TEST) FOR THE PREDICTION OF ALCOHOLIC STEATOHEPATITIS IN PATIENTS WITH CHRONIC ALCOHOLIC LIVER DISEASE
D. Thabut 1, S. Naveau 2, F. Charlotte 3, J. Massard 1, V. Ratziu 1, F. ImbertBismuth 4, D. Cazals-Hatem 5, A. Abella 6, D. Messous 4, F. Beuzen 7, M. Munteanu 1, J. Taieb 1, R. Moreau 8, D. Lebrec 8, T. Poynard 1.
1Hepatogastroenterology, Pitid-Salpdtri~re hospital, Paris, France," 2Hepatogastroenterology, Bdclbre hospital, Clamart, France," 3Pathology, Pitid-Salpdtri~re hospital, Paris, France," 4Biochemistry, Pitid-Salpdtri~re hospital, Paris, France," 5Pathology, Beaujon hospital, Clichy, France," 6Biochemistry, Bdcl~re hospital, Paris, France," 7pathology, Bdclkre hospital, Clamart, France," 8INSERM U-481 and Hepatology unit, Hospital Beaujon, Clichy, France Background and Aims: The aim was to identify a panel of biomarkers (AshTest) for the diagnosis of alcoholic steato-hepatitis (ASH), usually made by transvenous liver biopsy, in patients with chronic alcoholic liver disease. This diagnostic test could be particularly useful in severe patients (Maddrey discriminant function >32), when a rapid corticotherapy is needed in case of ASH. Methods: Biomarkers and panels were assessed in a training group of consecutive patients with an alcohol intake >50 g/d, and validated in two independent groups including a prospective one. Diagnosis of ASH (polymorphonuclear infiltrate and hepatocellular necrosis) and its histological severity (4 classes: none, mild, moderate, severe) was assessed blindly. Results: 225 patients were included, 70 in the training group and 155 in validation groups, and 299 controls. AshTest was constructed using a combination of the 6 components of FibroTest-ActiTest plus the aspartate aminotransferase. AshTest area under the ROC curves (AUROC) for moderate severe ASH was 0.90 (SE 0.04) in the training group, 0.88 (0.06) in the prospective validation group and 0.87 (0.04) in the retrospective validation group. The median AshTest value was 0.005 in blood donors, 0.05 in patients without or with mild ASH, 0.64 in moderate ASH, and 0.84 in histologically severe ASH grade 3, (P < 0.05) between all groups. At a 0.50 cut-off the sensitivity of AshTest was 0.92 and 0.72 specificity for the diagnosis of ASH in the prospective validation group. Among patients with a Maddrey-DF > 32, a Ashtest at 0.80 had a 0.95 specificity and 0.96 positive predictive value for the diagnosis of ASH. Conclusions: In heavy drinkers, AshTest is a simple and non-invasive quantitative estimate of liver alcoholic hepatitis. The use of AshTest may reduce the need for liver biopsy, particularly in severe patients, and therefore permit an earlier treatment of alcoholic hepatitis.
I•
IMPACT OF DIET AND PIOGLITAZONE FOR TREATMENT OF NAFLD
G.G. Treiber, A. Csepregi, S. Klauck, M. Leucke, R Malfertheiner.
GI & Hepatology, University Hospital, Magdeburg, Germany Background: Non-alcoholic fatty liver disease (NAFLD) has a wide spectrum, potentially progressing to steatohepatitis, cirrhosis, and hepatocellular cancer. Methods: We included patients with elevation of at least 2 liver enzymes (ALAT or ASAT and g-GT) > 1.5 • UNL. They were subjected to a six months intervention period receiving a calory-reduced diet (aiming at max. 1200kCal/d) and lifestyle modification (alcohol consumption limit 40g/week). If liver enzymes did not improve, patients received pioglitazone 30 mg/d for at least 3 months, thereafter individually adjusted if responding. Results: 447 patients with NAFLD were screened. 267 underwent liver histology and had a full workup for exclusion of other chronic liver diseases.
$265
15/115 (13%) had weight loss ~>5% and normalisation of liver enzymes due to diet only. 50/100 agreed to be treated with pioglitazone alone and returned for follow-up at 12 and 24 weeks, their median histological degree of steatosis was 60%. Biochemical results at 12 and 24 weeks are given in the table. No changes until 24 weeks were seen for BMI, cholesterol, triglycerides, bilirubine, BSR, CrP, creatinine, prothrombine time. Total body fat composition decreased from 40.4% to 34.9% (p <0.05). The cumulative dose of the aminopyrine breath test increased from 6.2% to 8.5% (p < 0.05). Changes during 24 weeks of pioglitazone treatment Median values [UNL]
Baseline
12 weeks
24 weeks
p-value
ALAT [<0.60 gmol/L] ASAT [<0.60 gmol/L] AP [<1.74 gmol/L] g-GT [<0.65 gmol/L] Uric acid [<340 gmol/L] Fasting glucose[<6.4 mmol/L) Glucose (OGTT, 2 hrs post) Fasting insulin [ng/L] Insulin [ng/L] (OGTT, 2 hrs post)
1.53 1.00 1.60 1.81 377 4.9 7.3 85.5 703
0.60 0.59 1.10 0.81 337 5.3 ...
0.75 0.59 1.16 0.82 307 4.8 5.9 81.5 428
<0.0001 <0.0001 ~ 0.004 ~ 0.022 ~ 0.05 NS ~ 0.03 NS ~ 0.0008
Conclusions: Most patients could not achieve a clinically sufficient weight loss by non-medical treatment. In contrast, pioglitazone is an effective treatment for NAFLD.
I~
IDENTIFICATION AND CHARACTERIZATION OF HOMO SAPIENS SUBMERGENCE INDUCED PROTEIN 2 (ESIP-L) IN NAFLD: A DIAGNOSTIC AND MOLECULAR APPROACH
M.E. Tsimako, P. Kroon, P. Wilce. School of Molecular and Microbial Sciences, University of Queensland, St. Lucia, Qld, Australia
Background: The prevalence of obesity in western countries poses high risks for fatty liver changes resulting in benign steatosis to end stage liver cirrhosis. The disorder is often misdiagnosed, and in some cases patients are asymptotic, therefore there is a need for new and improved ways of diagnosing NAFLD. Molecular approaches that involve studying genes and proteins associated with fatty liver and their mechanistic pathways are geared towards the understanding of the NAFLD in an effort to provide a better diagnosis. Aims: The aim of this study was to determine if altered gene and protein expression of eSip-L is diagnostic of NAFLD. Methods: Real Time PCR of adult NASH livers was used to confirm microarray data. Peptide-raised antibodies were used to determine the expression and localization of the protein in liver and hepatoma cell lines. An in vitro fatty cell model was established in lipid loaded HepG2 to investigate the relationship between the protein expression and fat overload. The lipids were probed with a fluorescent lipid probe (see figure).