2. Prof. Dr. Muhammad Shoaib Shafi
MBBS, FCPS (Pak) FACP
FRCP ( Ireland, Edin, London , Glasgow)
Professor of Medicine, BBH, Rawalpindi

3. Defining NAFLD
A liver biopsy showing moderate to gross macrovesicular fatty change with or without inflammation (lobular or portal), Mallory bodies, fibrosis, or cirrhosis.
Negligible alcohol consumption (less than 40 g of ethanol per week)
History obtained by three physicians independently.
Random blood assays for ethanol should be negative.
If performed, desialylated transferrin in serum should also be negative.
Absence of serologic evidence of hepatitis B or hepatitis C.

4. NAFLD—Spectrum of Disease
Steatosis
Steatohepatitis (NASH)
NASH with Fibrosis
Cirrhosis
NAFLD

5. NAFLD—Why Study it?
Prevalence of NAFLD 13-18% and that of NASH specifically 2-3% (1.2-9%)
Is the leading cause of cryptogenic cirrhosis
Is a disease of all sexes, ethnicities, and age groups (peak 40-59)
Occurs more frequently in females (65 to 83%)

6. Spectrum of NAFLD
Simple hepatic steatosis (NAFLD) is most frequent, usually benign, and asymptomatic
10% have or develop liver injury and necroinflammation which is nonalcoholic steatohepatitis (NASH) and up to 20% of NASH subjects may progress to more advanced liver disease
Cirrhosis may occur in ~ 30% of NASH patients and some may develop hepatocellular carcinoma (increased 2-3 fold in T2DM)
Browning JD et al. Hepatology 2004;40: Powell EA et al. Ann Int Med 2005;143:753

7. Global Prevalence of NAFLD: US
OBS
ALL
OVT
LEAN
Liver biopsy is the gold standard for diagnosis of NAFLD, but ultrasound has been widely used clinically as well as in research studies as a proxy, sensitivity varies 60-99%, specificity 84-95%.
Overall
NAFLD (any type): %
NASH: 2-6%
Morbidly obese
NAFLD: >95%
NASH: 25%
Of patients with NAFLD:
60-95% obese
21-55% DM
20-92% hyperTG
China (1)
India (2)
Japan(3)
Italy (4)
Korea (5)
Korea (5)
Italy (4)
1) Shen L, et al. World J of Gastroenterology 2003; 9:1106.
2) Singh S, et al. Tropical Gastroenterology 2004; 25:76.
3) Omagari Ket al. J of Gastroenterology and Hepatology 2002; 17:1098.
4) Bellentani S, et al.. Ann Int Medicine 2000; 132:112.
5) Kim H, et al. Arch Int Medicine 2004; 164:2169.

8. By 2020

9. NAFLD—Risk Factors Obesity Acquired Metabolic Disorders in 38%
Diabetes Mellitus
Hypertriglyceridemia
Total Parenteral Nutrition ,Rapid weight loss, Acute starvation
Surgery
Jejunoileal Bypass
Extensive Small Bowel Loss
Medications
Corticosteroids; Estrogens
Amiodarone
Methotrexate; Tamoxifen
Diltiazem; Nifedipine
Occupational Exposures
Others
Organic Solvents
Wilson's dis,Abetalipoproteinemia Jejunal diverticulosis

10. Risk factors: Emerging association
Polycystic ovary syndrome
Hypothyroidism
Obstructive sleep apnea
Hypopituitarism
Hypogonadism
Pancreatic-duodenal resection

11. Risk factor: Bacteria overgrowth
Grieco, et al. Hepatology 2009
35 pts with NAFLD bx confirmed
27 pts with celiac disease
24 healthy individuals
Those with FLD had increased intestinal permeability and increased small bowel bacterial overgrowth
Compare, et al Nutrition Metabolism & Cardiovascular Disease Feb 2012
Liver is 1st line of defense against gut-derived antigens
Levels of bacterial lipopolysaccharide (component of GN bacteria) are increased in the circulation in several types of chronic liver disease
Can modulation of gut microbia represent a new way to
treat/prevent NAFLD????

12. NAFLD—Pathogenesis First Hit
Hepatic iron, leptin, anti-oxidant deficiencies, and intestinal bacteria
Second Hit
First Hit
Steatosis
NASH
Lipid peroxidation
Insulin resistance
 Fatty acids

13. NAFLD—Pathogenesis Triglyceride accumulation Insulin resistance
Lipid Peroxidation and Hepatic Lipotoxicity
Cytokine Activation and Fibrosis
Adiponectin and Leptin (Adipocytokines)
Abnormal Lipoprotein Metabolism

14. NAFLD—Symptoms

15. NAFLD—Exam Findings

16. Algorithm for evaluating NAFLD
Accidental discovery Screen those with risk factors AST or AST Symptomatic liver disease elevated normal r/o other causes of liver disease monitor ongoing alcohol yes no Abstain Imaging study Echogenic US or fat on CT May need biopsy

17. NAFLD: DX and Imaging
Liver biopsy is the “gold standard” for diagnosis (?when to Bx)
US: sensitivity 60-99%
specificity 84-95%
100% sensitive in detecting >33% fat on biopsy
Imaging generally underestimates presence of steatosis
No imaging modality allows staging of NAFLD
CT scanning reveals low density hepatic parenchyma with occasional focal areas which may be misread as masses. MRI can differentiate masses and may allow a more quantitative assessment of fatty infiltration of liver
No reliable serum markers have been found to stage NAFLD
Joy D, et al. Eur J Gastroenterol Hepatol 2003; 539.
Saadeh S, Younossi Z, et al. Gastroenterology 2002;123:745
Scatarige JC et al. J Ultrasound Med 1984;3:914.

18. Liver biopsy
Incidental finding on imagery with normal enzymes: no biopsy indicated, monitor.
Presence of metabolic syndrome and persistently elevated biochemistries may benefit from liver biopsy
Patients with biopsy proven NASH cirrhosis should be screened routinely for esophageal varices and HCC

19. NAFLD fibrosis score Age BMI Hyperglycemia Platelet count Albumin AST
ALT

20. NAFLD fibrosis score
< : predictor of absence of significant fibrosis (F0-F2 fibrosis)
≤ to ≤ 0.675: indeterminate score
> 0.675: predictor of presence of significant fibrosis (F3-F4 fibrosis)

21. NAFLD—Histological Spectrum
Cirrhosis
Time Progression
Fibrosis
Lobular Inflammation
Macrovesicular Steatosis

22. Liver biopsy in NASH, Indications
Peripheral stigmata of chronic liver disease
Splenomegaly
Cytopenia
Abnormal iron studies
Diabetes and/or significant obesity in an individual over the age of 45

23. Predictors of More Severe Histology in NASH
Age >40–50 y
Female gender
Degree of obesity or steatosis
Hypertension
Diabetes or insulin resistance
Hypertriglyceridemia
Elevated ALT,AST, γ-GT level
AST:ALT transaminase ratio >1
Elevated immunoglobulin A level

24. Panel of markers/Scoring systems
Identification of steatosis
“NAFLD liver fat score” includes:
Presence of DM
Fasting serum insulin
AST
AST/ALT ratio
“Fatty liver index” includes:
BMI
Waist circumference
Triglyceride
GGT
“Visceral adiposity index” includes:
HDL

25. Panel of markers/Scoring systems
Identification of inflammation
“NASH test” includes:
- Total Bilirubin
GGT
α2 macroglobulin
Apolipoprotein A1
Haptoglobulin
ALT
“HAIR test” includes:
Hypertension
Insulin resistance
‘Parkler model” includes:
- age
gender
AST
BMI
AST/ALT ratio
Hyaluronic acid

26. Panel of markers/Scoring systems Identification of fibrosis
AST/ALT ratio (AAR)
APRI test: uses platelet count and AST
“FIB 4 index” utilizes age, AST, ALT, and platelet count
“NAFLD fibrosis score” includes:
BMI
Presence of DM
Albumin
“Fibrotest” (BioPredictive) tacking into account:
GGT
Haptoglobulin
Bilirubin
Apolipoprotein A1
α2 macroglobulin
“Fibro Spect” tacking into account:
Hyaluronic acid
Tissue inhibited matrix metalloproteinase
Inhibitor1

27. Presence of DM (type2), obesity, hypertension, and aminotrasferase elevation are markers of fibrosis
The utility of these tests are limited in cases with advanced fibrosis
The best result for non invasive staging will be achieved by combining a clinical/biochemical scoring system with elastography

28. Biomarkers for assessment of steatohepatitis and fibrosis
C reactive protein: independent risk factor for the progression of NAFLD
Plasma Pentraxin 3: risk factor for the progression of NAFLD
IL6: indicate inflammmatory activity and the degree of fibrosis
TNF α: risk factor for the progression of NAFLD
Cytokeratin 18: marker of hepatic appoptosis
Polypeptide specific antigen: released during appoptosis
Endothelin 1: is a mediator of fibrosis
Adiponectin: is lower in NASH
Oxidative stress biomarkers ? (superoxide desmutase, glutathione peroxidase, Thioredoxin)
Hyaluronic acid ?
Type 4 collagen 7S domain ?
Laminin ?

29. Fibroscan
Transient elastography that evaluates liver stiffness using pulse-echo ultrasound
Non invasive
More sensitive than serologic markers
Evaluates a larger part of liver
Main weakness is interference with by steatosis with wave velocity
Might be unreliable in obese

31. Acoustic radiation force impulse (ARFI)
Sonoelastography that evaluates liver elasticity
Alternative to Fibroscan
Utilizes acoustic waves to interogate the mechanical stiffness of liver
Can be used during standard US examination of liver
Diagnosis of significant fibrosis
Another modality is magnetic resonance elastography with higher diagnostic accuracy for fibrosis staging especially in obese

32. How to Treat? Second Hit First Hit NASH Insulin resistance
Antioxidants
Insulin Sensitizers
Cytoprotectants
Antihyperlipidemics
Second Hit
First Hit
Steatosis
NASH
Insulin resistance
 Fatty acids
Lipid peroxidation
Weight Loss
Diet/Exercise

33. Lifestyle Interventions
Weight loss by lower caloric intake and increased physical exercise led to improvement in biopsy.
9.3% weight loss: improvement in steatosis, necrosis, and inflammation; not fibrosis
3-5% weight loss improves steatosis but more is needed to improve inflammation
Alcohol consumption:
heavy intake should be avoided
light intake (<1/day) may have benefits**, may not***
Weight loss 1-2 pounds per week
* Promrat, et al. Hepatology 2010
** Dunn, et al. Hepatology 2008
** Gunji. et al. Am J Gastro 2009
** Moriya, et al. Alim Pharm Ther 2011
***Ruhl , et al. Clin Gastro Hepatol 2005

34. Insulin sensitizing agents
Metformin
reduction in IR and enzymes,
no improvement in histology
Thiazolidinediones
Rosiglitazone : improved enzymes and steatosis, but not inflammation
Pioglitazone: +weight gain, but improvement in hepatocellular injury
Uygun, et al Aliment Pharm Ther 2004
Nair, et al Aliment Pharm Ther 2004
Ratziu, et al Gastroenterology 2008
Sanyal, et al NE J Med 2010
Rosiaglitazone: avandia USA restriction due to MI
Pioglitazone: actos: risk of CHF

35. PIVENS Study Pioglitazone , Vitamin E, placebo 96 weeks Adults
with NASH
without DM, cirrhosis, Hep C, heart failure
limited alcohol intake over previous 5 years
Randomized trial
Pio group: 80
Vit E group: 84
Placebo: 83
Sanyal et al, New England J of Medicine 2010

36. PIVEN Conclusions
Vitamin E was superior to placebo in adults with NASH and without DM
Pioglitazone may have a role in treating patients with biopsy-proven NASH, however long term safety and efficacy has not been established
Sanyal et al, New EnglJ of Med 2010

37. AASLD recommendations:
Pio can be used to treat certain patients with biopsy-proven NASH who do not have DM but long term safety and efficacy has not been established
Vitamin E 800 IU/day improves liver histology in NASH pts
Not recommended to treat NASH in those with other chronic liver diseases, diabetics, those with NASH cirrhosis or cryptogenic cirrhosis, NAFLD without biopsy

38. Vitamin E: other concerns
Meta-analysis including 136,000 participants found taking Vitamin E supplements > 400 IU/day had a higher risk of all cause mortality
Vitamin E > 400 IU/day increases risk of prostate cancer in relatively healthy men
Miller et al Annals of Internal Medicine 2005
Klein, et al, JAMA 2011

39. AASLD Recommendation on Statins
“Given lack of evidence that patients with NAFLD and NASH are at increased risk for serious drug-induced liver injury from statins, they can be used to treat dyslipidemia in patients with NAFLD and NASH.”

40. Bariatric surgery No RCTs
Cochrane review 2010: lack of RCTs prevents definitive assessment of risks/benefits
Prospective study
381 adults with severe obesity, fibrosis score<3
Clinical, metabolic, liver biopsy comparisons at 1 year and 5 years
Significant improvement in steatosis, ballooning, resolution of probable/definite NASH at 1 and 5 years
Small but significant increase of fibrosis score at 5 years (96% had improvement)
Mathurin et al Gastroenterology 2009

41. AASLD Pediatric Recommendations
Intensive lifestyle behavior modification, including dietitian consultation, is first line treatment
Metformin 500mg BID offers no benefit
Vitamin E 800 IU/d offers histological benefit but confirmatory studies are needed before it can be recommended in clinical use.