B Wildman-Tobriner et al. Gastoenterol 2018; 155: 1428-35. This retrospective study which pooled data from 3 phase 2a trials with 370 subjects with nonalcoholic fatty liver disease (NAFLD) found that MRI iwth proton density fat fraction (PDFF) “did not accurately identify patients with NAS ≥4 (AUROC – 0.72) or fibrosis stage ≥3 (AUROC =0.66).” Thus, this study indicates that currently liver histology remains the gold standard to determine severity of liver damage in paitents with NAFLD.
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P Nahon et al. Gastroenterol 2018; 155: 1436-1450. This study looks closer at whether direct-acting antivirals (DAA) for hepatitis C could increase the risk of hepatocellular carcinoma (HCC) in patients (n=1270) with cirrhosis. The authors found that the crude 3-year cumulative incidence of HCC were 5.9% in the DAA and 3.1% in the SVR-IFN group. However, after Cox analysis, “we found no statistically significant increase in risk of HCC associated with DAA use (HR 0.89).” The authors indicated that patient characteristics (age, diabetes, reduced liver function) and lower screening intensity were the reasons for the increased crude rates of HCC.
Related blog post: Liver Short Takes December 2017
Love this sign –it indicates the truth of the saying: ‘common sense is not that common’ (attributed to Voltaire)
A recent study (D Kim et al. Gastroenterol 2018; 155: 1154-63) used a CDC database which captures >99% of deaths in the U.S. to analyze mortality trends from 2007 through 2016. Full text link available online: Changing Trends in Etiology-Based Annual Liver Mortality
When looking at all-cause mortality, there has been a significant decline in deaths associated with hepatitis C (HCV) but not in deaths associated with alcoholic liver disease (ALD). The image below shows the trend and the impact of direct-acting antivirals. Deaths associated with nonalcholic fatty liver disease (NAFLD) and due to hepatitis B (HBV) are described in this study as well, though both together account for less than 1/4th deaths associated with ALD. Interestingly, mortality related to NAFLD was increasing slowly over the study period.
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M Mouzaki et al. J Pediatr 2018; 201: 86-92. This study with 65 patients evaluated nonalcoholic fatty liver disease (NAFLD) progression between two MRI studies, with a median time span of 27 months.
- There was no correlation between change in liver stiffness and change in ALT; there was a weak correlation between ALT change and fat fraction.
- MRI fat fraction and stiffness decreased in 29% and 20% of patients respectively and increase in 25% and 22% respectively.
My take: When we find effective therapies, we will need better non-invasive markers to follow NAFLD progression.
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Tea House Trail, near Lake Louise, Banff
Briefly noted: V Ajmera et al. Clin Gastroenterol Hepatol 2018; 16: 1511-20. This study with 285 participants showed that modest alcohol consumption was associated with a lower odds of NASH resolution on biopsy over 4 years compared with no alcohol consumption (OR 0.32). The associated editorial (pg 1404-6) provides a table with 8 studies that reveal conflicting results on this issue.
My take (borrowed from editorial): “Clinicians should not recommend modest drinking” as a way of improving liver health.
Related review article:D Fuster, JH Samet. “Alcohol Use in Patients with Chronic Liver Disease” NEJM 2018; 379: 1251-61. For NAFLD (and all chronic liver disease): “abstinence should be the goal.”
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Lake Moraine, Banff
A recent autopsy study (DM Fernandes et al. J Pediatr 2018; 200: 174-80) examined nonalcoholic fatty liver disease (NAFLD) in a pediatric cohort of 582 (2-19). Approximately 75% were in 14-19 years of age and 50% were black; black pediatric patients (n=290) were over-represented in this sample only 25% of the New York population is black or African American based on the 2010 census.
- Causes of death: 49% homicides, 31% accidents, 10% acute illness, 9% suicide, 1% other
- Overall, NAFLD was present in 4.5%; this low overall prevalence was due in part to the low rate of NAFLD in black children; only 3 of 290 (1%) had NAFLD and none had nonalcoholic steatohepatitis (NASH)
- The rate of NAFLD was 7.9% in hispanics and 8.3% in white patients.
- In this cohort, 36% were overweight or obese. In this subgroup, 14.1% of hispanics and 14.8% of whites had NAFLD.
- Overall, NASH was present in 1.7% of the entire cohort. NASH and fibrosis have been shown in prior studies as the best predictors of disease progression
My take: If black children are not killed by homicide or accidents, it is unlikely that they will die from NAFLD due to its low prevalence.
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Sunshine Meadows, Banff
A recent study (J Ma et al. Gastroenterol 2018; 155: 107-17) shows that a “better diet” was associated with less liver fat.
Among the 1521 participants form a Framingham Heart Study cohort (Mean age 51 years at start of study), the authors assessed diet with a 125-item Harvard food frequency questionnaire and liver fat using liver-phantom ratio (LPR) on CT images between 2002-2005 and then again 2008-2011. They specifically looked at 2 diet scores:
- Mediterranean-style diet score (MDS)
- Alternative Healthy Eating Index (AHEI)
- For each 1 standard deviation increase in MDS, the LPR increased (less liver fat) by 0.57 and the odds for incident fatty liver decreased by 26% (P=.002)
- Similarly, for each 1 standard deviation increase in AHEI, LPR increased by 0.56 and the odds for incident fatty liver decreased by 21% (P=.02)
My take: This study shows that Improved diet quality over 6 years was associated with reduced liver fat accumulation
Lake Louise, Banff
Link: AASLD Guidance for the Diagnosis and Management of Nonalcoholic Fatty Liver Disease
This guidance provides a 2018 review of NAFLD and current diagnostic/management recommendations in both adults and children. Some points from this practice guidance:
- “Liver-related mortality is the second or third cause of death among patients with NAFLD.” Cardiovascular disease remains the number one and cancer-related mortality is in the top three.
- “Routine screening for NAFLD in high-risk groups attending primary care, diabetes, or obesity clinics is not advised at this time because of uncertainties surrounding diagnostic tests and treatment options.” Likewise, screening of family members is not recommended.
- In children: “Because of a paucity of evidence, a formal recommendation cannot be made with regard to screening for NAFLD in children with overweight and obesity.”
- In patients undergoing evaluation with suspected NAFLD, the authors specifically recommend checking ferritin, iron saturation, and autoantibodies that could indicate autoimmune liver disease.
- In patients with suspected NAFLD, the authors recommend evaluation for comorbities including dyslipidemia, diabetes, hypothyroidism, polycystic ovary syndrome, and sleep apnea.
- “Liver biopsy should be considered in patients with NAFLD who are at increased risk of having…advanced fibrosis” and in “whom competing etiologies…cannot be excluded without a liver biopsy.”
- Pharmacologic therapies are not recommended in those without biospy-proven NASH and fibrosis. Specifically, the authors suggest consideration of pioglitazone and vitamin E and recommend against metformin, GLP-1 agonists, omega-3 fatty acids, and ursodeoxycholic acid.
- “Weight loss (7%-10%) is needed to improve the majority of histopathological features of NASH.”
- In patients with cirrhosis due to NASH, screening for varices is recommended and consideration of screening for HCC.
My take: This practice guidance is quite reasonable. At this time, more focus on systemic measures to counter overweight and obesity is crucial. Pharmacologic therapies for NAFLD will need to be effective for the cardiovascular, metabolic, and liver-related problems.
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Bright Angel Trail, Grand Canyon