Pilot study of liraglutide effects in non-alcoholic steatohepatitis and non-alcoholic fatty liver disease with glucose intolerance in Japanese patients (LEAN-J).

AIM: Non-alcoholic fatty liver disease (NAFLD), a hepatic manifestation of metabolic syndrome, is associated with an increased risk of developing lifestyle-related diseases including type 2 diabetes, cardiovascular disease and cerebral vessel disease. No current drug therapy provides the ideal effects of decreasing hepatic inflammation while simultaneously improving liver fibrosis. Liraglutide is a glucagon-like peptide-1 receptor agonist that affects the histological findings in patients with non-alcoholic steatohepatitis (NASH). This study was conducted to evaluate the effect and action of liraglutide for biopsy-proven NASH. METHODS: After lifestyle modification intervention for 24 weeks, subjects whose hemoglobin A1c levels failed to improve to less than 6.0% and/or whose alanine aminotransferase levels were not lower than baseline, received liraglutide at 0.9 mg/body per day for 24 weeks. RESULTS: Of 27 subjects, 26 completed the lifestyle modification intervention. Nineteen subjects received liraglutide therapy for 24 weeks. Body mass index, visceral fat accumulation, aminotransferases and glucose abnormalities improved significantly. Repeated liver biopsy was performed in 10 subjects who continued liraglutide therapy for 96 weeks. Six subjects showed decreased histological inflammation as determined by NASH activity score and stage determined by Brunt classification. We saw no significant adverse events during therapy with liraglutide. CONCLUSION: Our pilot study demonstrated that treatment with liraglutide had a good safety profile and significantly improved liver function and histological features in NASH patients with glucose intolerance.

Upper limit of normal serum alanine aminotransferase levels in Japanese subjects.

AIM: Serum alanine aminotransferase (ALT) is important for screening, diagnosis and management of chronic liver diseases. The incidence of non-alcoholic fatty liver disease (NAFLD)/non-alcoholic steatohepatitis (NASH), which is considered a hepatic manifestation of lifestyle-related diseases, is increasing worldwide. However, the upper limit of the normal ALT level has not yet been established because of not excluding many lifestyle-related diseases. The aim of this study was to evaluate the upper limit of normal serum ALT levels in Japanese subjects. METHODS: We analyzed the serum ALT levels of 11 404 Japanese subjects negative for hepatitis B surface antigen and hepatitis C virus antibody, and who received health check-ups. Lifestyle factors related to ALT levels were determined by multivariate analysis. Subjects with all factors identified by multivariate analysis within the normal range were defined as "healthy" subjects. The 90th percentile of ALT levels in healthy subjects was defined as the upper limit of normal ALT. RESULTS: Whereas alcohol intake was not a significant factor, the following were independently associated with ALT concentration by multivariate analysis: sex; age; body mass index; waist circumference; concentrations of total cholesterol, high-density lipoprotein cholesterol, triglycerides and fasting blood glucose; and fatty liver on ultrasonography. Healthy subjects consisted of 1462 (21.2%) men and 2046 (45.4%) women, and the 90th percentiles of the ALT levels in the two groups were 29 and 23 IU/L, respectively. CONCLUSION: The upper limits of normal ALT when considering lifestyle factors in Japanese subjects were 29 IU/L in men and 23 IU/L in women.

Efficacy of ezetimibe for reducing serum low-density lipoprotein cholesterol levels resistant to lifestyle intervention in patients with non-alcoholic fatty liver disease.

AIM: To investigate the efficacy of ezetimibe and lifestyle intervention for treating patients with non-alcoholic fatty liver disease (NAFLD) and residual dyslipidemia via a combination of ezetimibe and lifestyle intervention. METHODS: Patients with NAFLD with residual dyslipidemia after a 6-month lifestyle intervention program were included. After completion of the 6-month program, the patients received p.o. administration of ezetimibe at 10 mg/day, in addition to lifestyle intervention, for 6 months. RESULTS: Of the 59 patients with NAFLD who had participated in the 6-month lifestyle intervention program between 2007 and 2012, 21 with residual dyslipidemia (10 males and 11 females) were enrolled. Median age was 58 years (range, 27-75), median bodyweight was 63.0 kg (range, 39.4-109.0), median body mass index was 25.4 kg/m2 (range, 18.2-37.1), median alanine aminotransferase was 23 IU/L (14-73), median high-density lipoprotein (HDL) was 58 mg/dL (range, 37-93), median triglycerides (TG) was 105 mg/dL (range, 42-216) and median low-density lipoprotein (LDL) was 153 (66-209) mg/dL. After 6 months of treatment with ezetimibe, serum LDL levels were improved in 15 of 20 (75%) patients (P = 0.0015), while no improvements were observed in the remaining five patient (25%). Ezetimibe was discontinued in one patient who developed skin rash. CONCLUSION: Ezetimibe is effective for treating residual dyslipidemia after lifestyle intervention in patients with NAFLD.

Severity of non-alcoholic steatohepatitis is associated with substitution of adipose tissue in skeletal muscle.

BACKGROUND AND AIMS: The pathogenesis of non-alcoholic fatty liver disease (NAFLD) is now focusing on its organ cross-talk with not only adipose tissue but also systemic skeletal muscle. Cross-sectional and longitudinal studies were conducted to determine the role of intramuscular adipose tissue content (IMAC) measured by computed tomography on the severity of NAFLD/non-alcoholic steatohepatitis (NASH). METHODS: Two hundred eight Japanese patients with NAFLD/NASH diagnosed by liver biopsy were enrolled into a cross-sectional study. Twenty-one patients were enrolled in a longitudinal study and received a programmed diet and exercise intervention, in some cases the combination of pharmacotherapy. We measured IMAC in the multifidus muscle and biochemical parameters, and conducted liver histology to assess NAFLD/NASH status. RESULTS: Histopathological stage in terms of simple steatosis and Brunt's classification was significantly correlated with IMAC (P < 0.01). Multivariate logistic regression analysis indicated that risk factors associated with the severity of NASH were IMAC and aging (IMAC: odds ratio = 2.444, P < 0.05; Age: odds ratio = 2.355, P < 0.05). The interventions improved histopathological changes in 11 patients with NASH as well as IMAC. CONCLUSION: These results suggest that skeletal muscle fat accumulation may have been linked to the pathogenesis and severity of NASH.

Evaluation narcotic analgesic use and survival time in terminal stage liver diseases compared with lung cancer: a retrospective chart review.

Hepatocellular carcinoma (HCC) and liver cirrhosis are fatal diseases. This study aimed to investigate survival time and palliative care in terminal HCC and/or liver cirrhosis compared with lung cancer. Between January 2004 and December 2010, we enrolled 116 patients with terminal cirrhosis and/or HCC or lung cancer admitted to a municipal hospital in Japan; 48 had liver cirrhosis, 35 HCC and 33 lung cancer. By retrospective chart review, we evaluated: (i) rate of usage of narcotic analgesics and (ii) survival time from onset of coma (Glasgow Coma Scale less than 8). Time between coma and death was significantly shorter in the liver disease patients (cirrhosis and/or HCC: 7.0 h) than in lung cancer (44.0 h, p = 0.045). Total bilirubin was higher in HCC compared with cirrhosis (p<0.01). Rate of usage of narcotic analgesics was higher in lung cancer (20/33: 60.6%) than in liver disease (17/83: 20.5%, p<0.01); analgesics were used more frequently in HCC than in liver cirrhosis (p<0.01). These results suggest that liver cirrhosis and HCC patients do not always require palliative care and that survival time from onset of coma due to liver disease was not prolonged compared with lung cancer.

TYK2 Promoter Variant Is Associated with Impaired Insulin Secretion and Lower Insulin Resistance in Japanese Type 2 Diabetes Patients.

Accumulating evidence has suggested that viral infection causes type 1 diabetes due to direct ß-cell damage and the triggering of autoimmune reactivity to ß cells. Here, we elucidated that the tyrosine kinase 2 (Tyk2) gene, encoding an interferon receptor signaling molecule, is responsible for virus-induced diabetes in mice, and its promoter variant confers a risk of type 1 diabetes in humans. This study investigated the relationship between a TYK2 promoter variant (TYK2PV) and insulin secretion in type 2 diabetes patients. TYK2PV status was determined using direct DNA sequencing and its associations with fasting insulin, C-peptide, and homeostatic model assessment of insulin resistance (HOMA-IR) were evaluated in type 2 diabetes patients without sulfonylurea or insulin medication. Of the 172 patients assessed, 18 (10.5%) showed TYK2PV-positivity. Their body mass index (BMI) was significantly lower than in those without the variant (23.4 vs. 25.4 kg/m2, p = 0.025). Fasting insulin (3.9 vs. 6.2 µIU/mL, p = 0.007), C-peptide (1.37 vs. 1.76 ng/mL, p = 0.008), and HOMA-IR (1.39 vs. 2.05, p = 0.006) were lower in those with than in those without the variant. Multivariable analysis identified that TYK2PV was associated with fasting insulin ≤ 5 µIU/mL (odds ratio (OR) 3.63, p = 0.025) and C-peptide ≤ 1.0 ng/mL (OR 3.61, p = 0.028), and also lower insulin resistance (HOMA-IR ≤ 2.5; OR 8.60, p = 0.042). TYK2PV is associated with impaired insulin secretion and low insulin resistance in type 2 diabetes. Type 2 diabetes patients with TYK2PV should be carefully followed in order to receive the appropriate treatment including insulin injections.

Evaluation of acoustic radiation force impulse elastography for fibrosis staging of chronic liver disease: a pilot study.

BACKGROUND: Acoustic radiation force impulse (ARFI) is a new technology integrated into conventional B-mode ultrasonography. ARFI is used to evaluate tissue stiffness in several organs, but this method has not been applied for liver fibrosis. AIM: The aim of this study was to determine whether ARFI elastography is useful for the evaluation of liver fibrosis. METHODS: This study enrolled 55 consecutive patients with chronic liver disease who underwent a liver biopsy for histological assessment of liver fibrosis by the Metavir scoring system. Liver stiffness of the 55 patients and 25 healthy volunteers was evaluated by ARFI elastography and was expressed as the shear wave velocity. Cut-off values were determined using receiver-operating characteristic (ROC) curves. RESULTS: Histological liver fibrosis was evaluated by Metavir scoring; F0: six cases, F1: 14 cases, F2: nine cases, F3: nine cases and F4: 17 cases. Liver stiffness determined by ARFI elastography was correlated with histological liver fibrosis (P<0.0001). The areas under the ROC curves were 0.94 (95% confidence intervals, 0.87-0.99) for F2-F4, 0.94 (0.88-0.99) for F3-F4 and 0.96 (0.91-1.01) for F4. The cut-off values of the shear wave velocity were as follows: >1.34 m/s for F2-F4 (sensitivity 91.4%, specificity 80%); >1.44 m/s for F3-F4 (sensitivity 96.2%, specificity 79.3%); and >1.80 m/s for F4 (sensitivity 94.1%, specificity 86.8%). CONCLUSIONS: Ultrasonic ARFI elastography is a novel, non-invasive and reliable method for the assessment of liver fibrosis in patients with chronic liver disease.

Hepatitis C virus infection enhances insulin resistance induced by visceral fat accumulation.

BACKGROUND/AIMS: To clarify the impact of visceral obesity on hepatitis C virus (HCV)-infected patients, we examined the relationship between insulin resistance development and visceral fat accumulation. METHODS: We analyzed 87 HCV-infected patients with mild fibrosis (stage 1 or 2) in comparison with 125 sex- and age-matched patients with non-alcoholic fatty liver disease (NAFLD). The degree of visceral fat area (VFA; cm(2)) at the umbilical level was measured by abdominal computed tomography and divided into two grades: no visceral obesity, VFA<100 and visceral obesity, VFA>/=100. Insulin resistance was evaluated by homeostasis model assessment of insulin resistance (HOMA-IR) and the quantitative insulin sensitivity check index (QUICKI). Pancreatic beta-cell function was evaluated by homeostasis model assessment of beta-cell function (HOMA-beta). Serum soluble tumour necrosis factor (TNF)-receptors 1 and 2 and adiponectin were measured. RESULTS: Insulin resistance evaluated by HOMA-IR and QUICKI was correlated with visceral fat accumulation, and was higher in HCV patients than in NAFLD patients with visceral obesity. HOMA-beta was higher in HCV patients than in NAFLD patients for each VFA grade. Serum-soluble TNF-receptors 1 and 2 were higher in HCV patients than in NAFLD patients with visceral obesity. CONCLUSIONS: Hepatitis C virus infection is a risk factor for development of insulin resistance, particularly in patients with visceral obesity.

Waist circumference correlates with hepatic fat accumulation in male Japanese patients with non-alcoholic fatty liver disease, but not in females.

BACKGROUND AND AIM: Abdominal obesity, a component of metabolic syndrome, is a major risk factor for non-alcoholic fatty liver disease (NAFLD). In recent worldwide definitions of metabolic syndrome, waist measurement has been proposed as a simple and useful estimate of abdominal obesity, taking into account gender differences in waist circumference. The present cross-sectional study investigated the correlation of hepatic fat accumulation and waist circumference in Japanese NAFLD patients to determine if there are gender differences in this relationship. METHODS: Consecutive patients (n = 2111) who had at least one of two criteria for liver disease (alanine aminotransferase [ALT] level >30 IU/mL and aspartate aminotransferase [AST]/ALT ratio <1) underwent abdominal ultrasonography. Patients positive for hepatitis B virus, hepatitis C virus or autoimmune antibodies and whose alcohol intake was >20 g/day were excluded. Patients with NAFLD underwent abdominal computed tomography. Hepatic fat accumulation was estimated by liver/spleen attenuation ratio (L/S ratio) and visceral adipose accumulation was measured as visceral fat area (VFA) at the umbilical level. RESULTS: Of the 221 NAFLD patients, 103 were females. In males, the relationship between L/S ratio and waist circumference was negative (r =-0.356, P < 0.01), and there was no correlation in the female group. The relationship between L/S ratio and VFA was negative in both groups (males: r = -0.269, P < 0.01; females: r = -0.319, P < 0.01). Subcutaneous fat area/total fat area ratio at the umbilical level was larger in females than in males (P < 0.01). CONCLUSIONS: In NAFLD patients, waist measurement is more susceptible to gender differences than VFA.

Supplementation with branched-chain amino acids ameliorates hypoalbuminemia, prevents sarcopenia, and reduces fat accumulation in the skeletal muscles of patients with liver cirrhosis.

BACKGROUND: Liver cirrhosis induces marked metabolic disorders, protein-energy malnutrition, and sarcopenia. The objective of the study reported here was to investigate the effects of dietary branched-chain amino acids (BCAAs) on systemic glucose metabolism, skeletal muscle, and prognosis of patients with liver cirrhosis. METHODS: Japanese patients with liver cirrhosis (n = 21) were enrolled into a longitudinal study in which their diets were supplemented with BCAAs. We evaluated glucose metabolism and analyzed the skeletal muscle area index (SAI) and intramuscular adipose tissue content (IMAC) using computed tomography. RESULTS: After 48 weeks of supplementation with BCAAs, there were no changes in glucose metabolism and skeletal muscle findings. In patients with ameliorated hypoalbuminemia, IMAC was significantly decreased and SAI was preserved concomitant with decreasing 90- and 120-min post-challenge plasma glucose levels (P < 0.01 each). In patients without increased albumin levels, IMAC was significantly increased and the SAI was significantly decreased (P < 0.01 each). Liver-related event-free survival rates for 72 months were 63.6% in patients with decreased IMAC and 20.0% in patients with increased IMAC. CONCLUSIONS: Amelioration of hypoalbuminemia associated with BCAA supplementation correlated with decreased fat accumulation in skeletal muscle, maintenance of skeletal muscle mass, and improved glucose sensitivity, all factors which may contribute to improving the survival of patients with liver cirrhosis.

Visceral fat accumulation and insulin resistance are important factors in nonalcoholic fatty liver disease.

BACKGROUND: Nonalcoholic fatty liver diseases are often associated with obesity, insulin resistance, and excessive visceral fat accumulation. The aims of this study were (1) to evaluate the relationship between the severity of fatty liver and visceral fat accumulation in nonalcoholic fatty liver diseases, and (2) to investigate the relationships of fatty liver with biochemical data and insulin resistance. METHODS: One hundred twenty-nine subjects (63 women) with fatty liver diagnosed by ultrasonography were enrolled. Subjects positive for hepatitis B virus, hepatitis C virus, or autoimmune antibodies and those whose alcohol intake was over 20 g/day were excluded. The visceral fat area at the umbilical level and the liver-spleen ratio were evaluated by computed tomography. RESULTS: The severity of fatty liver evaluated by ultrasonography showed a significant positive relationship with the visceral fat area and waist circumstance (fatty liver severity: mild, 92.0 +/- 30.9 cm(2); moderate, 122.1 +/- 32.6 cm(2); severe, 161.0 +/- 48.4 cm(2); P < 0.0001). The visceral fat area and liver-spleen ratio were negatively correlated (r = -0.605, P < 0.0001). The severity of fatty liver showed strong positive relationships with serum aspartate aminotransferase, alanine aminotransferase, fasting plasma glucose, fasting plasma insulin, and insulin resistance. The severity of fatty liver was positively related to the visceral fat area in 49 nonobese subjects (body mass index <25). CONCLUSIONS: The severity of fatty liver was positively correlated with visceral fat accumulation and insulin resistance in both obese and nonobese subjects, suggesting that hepatic fat infiltration in nonalcoholic fatty liver disease may be influenced by visceral fat accumulation regardless of body mass index.

Biphasic effect of alcohol intake on the development of fatty liver disease.

BACKGROUND: Fatty liver is an important clinical feature not only in alcoholic and non-alcoholic fatty liver diseases, but in other chronic liver diseases as well. Our aim was to elucidate the effect and relationship between habitual alcohol intake and obesity in the development of fatty liver disease. METHODS: We enrolled 8,029 subjects undergoing abdominal ultrasonography with general medical examinations, and analyzed the factors associated with fatty liver based on daily alcohol intake, body mass index (BMI), and waist circumference. RESULTS: For fatty liver, BMI, waist circumference, total cholesterol, triglycerides, and fasting plasma glucose were significant and independent risk factors. Heavy alcohol intake (50 g/day) was a significant risk factor for fatty liver in women (odds ratio [OR], 3.35). Analysis based on the presence or absence of obesity revealed that moderate alcohol intake was a significant negative risk factor for fatty liver in both male and female obese (BMI ≥25 kg/m(2)) subjects (OR, 0.74 for non-obese and 0.39 for obese patients, respectively). Heavy alcohol intake was also a significant negative risk factor in obese males (0.62). In contrast, heavy alcohol intake was a risk factor in non-obese males (OR, 1.29) and in all females (OR, 2.22 for non-obese and 6.6 for obese patients, respectively). CONCLUSIONS: The influence of alcohol intake on fatty liver differed depending on the level of alcohol consumption, gender, and the presence of obesity, and showed biphasic effects.

The pathological role of visceral fat accumulation in steatosis, inflammation, and progression of nonalcoholic fatty liver disease.

BACKGROUND: Our previous studies have indicated a close association between visceral fat accumulation and hepatic steatosis in nonalcoholic fatty liver disease (NAFLD). This study investigated whether visceral fat accumulation was related to the pathogenesis and disease progression of nonalcoholic steatohepatitis (NASH)/NAFLD. METHODS: First, a total of 550 subjects who underwent a health checkup and measurement of visceral fat accumulation, done with a bioelectrical impedance analyzer (X-SCAN; Owa Medical, Fukuoka, Japan), were included. The relationship between visceral fat accumulation and biochemical parameters was examined. Second, a total of 74 patients with NASH/NAFLD who underwent liver biopsy were reviewed. Visceral fat accumulation was determined by abdominal computed tomography. The association between visceral fat accumulation and the histopathological grade/stage determined by the NAFLD activity score and Brunt's classification was evaluated. RESULTS: There was a significant relationship between visceral fat accumulation and glucose, triglyceride, and alanine aminotransferase (ALT; r = 0.423, P < 0.01). In stepwise regression analysis, visceral fat area (VFA), serum triglyceride level, and serum low-density lipoprotein (LDL)-cholesterol level were selected as predictor variables for serum ALT level, in a continuous manner (serum ALT level = -1.359 + 0.143 × VFA + 0.046 × triglyceride + 0.059 × LDL, R(2) = 0.217, P < 0.001). In patients with NASH, there was no correlation between histological grade and the visceral fat volume. Visceral fat accumulation in patients with stage 3/4 advanced NASH was greater than that in patients with stage 1/2 early NASH (P < 0.05). CONCLUSIONS: These results suggest that visceral fat accumulation plays a role in steatosis and fibrosis in the pathogenesis and prognosis of NAFLD.

Age-related fat deposition in multifidus muscle could be a marker for nonalcoholic fatty liver disease.

BACKGROUND: Although nonalcoholic fatty liver disease (NAFLD) is associated with visceral obesity, the relationship between visceral fat accumulation and skeletal muscle steatosis in patients with NAFLD has not been established. We evaluated: (1) the relationship between multifidus muscular tissue steatosis, visceral fat accumulation, and biochemical data in a cross-sectional study, and (2) the influence of weight reduction on multifidus muscular tissue steatosis in a longitudinal study. METHODS: Three hundred thirty-three NAFLD patients were enrolled. Hepatic steatosis, visceral fat area, and the multifidus muscle/subcutaneous fat attenuation ratio (MM/F ratio) were evaluated by computed tomography. To evaluate how weight reduction produced by diet and exercise affected the MM/F ratio, changes in the MM/F ratio were compared between weight reduction and non-weight reduction groups. RESULTS: There was a gender difference in MM/F ratios. The MM/F ratio was significantly correlated with age (male r = 0.613, P < 0.01; female r = 0.440, P < 0.01). The MM/F ratio was positively correlated with visceral fat area (male: r = 0.262, P < 0.01; female: r = 0.214, P < 0.01). A decrease in the MM/F ratio, concomitant with reduced visceral fat accumulation, led to alleviation of hepatic steatosis in 20 patients with weight reduction, but not in 22 patients without weight reduction. CONCLUSIONS: The MM/F ratio was closely related to aging and visceral fat accumulation. The MM/F ratio was improved by weight reduction, indicating that fat accumulation in the multifidus muscle evaluated by computed tomography might be a therapeutic indicator of NAFLD.

A pilot trial of body weight reduction for nonalcoholic fatty liver disease with a home-based lifestyle modification intervention delivered in collaboration with interdisciplinary medical staff.

BACKGROUND: Nonalcoholic fatty liver disease (NAFLD) is a hepatic manifestation of the metabolic syndrome. The aim of this study was to evaluate a 6-month home-based lifestyle modification intervention delivered in collaboration with physicians, hygienists, registered dietitians, and nurses. METHODS: Outpatients with NAFLD diagnosed by abdominal ultrasonography were eligible for this study. Abdominal computed tomography (CT) scan evaluated liver fat deposition by the liver-spleen ratio (L/S ratio) and visceral fat accumulation as the visceral fat area (VFA; cm(2)). During the 6-month home-based lifestyle modification intervention, each patient was examined by physicians, nurses, hygienists, and registered dietitians, who provided individualized advice to the patients. Patients recorded their daily weight for self-control of weight with recommended diet and exercise regimens. RESULTS: Sixty-seven NAFLD patients were enrolled in this study and 22 patients (32.8%) completed the 6-month intervention. Nineteen of the 22 patients achieved significant improvements in body weight, body mass index (BMI), waist circumference, VFA, L/S ratio, and systolic blood pressure, with improved laboratory data. Overall, 39 patients withdrew from the intervention. The mean age of the patients who withdrew was 50.0 +/- 11.0 years, which was significantly younger than that of the patients who were followed up (60.1 +/- 10.1 years; P < 0.01). CONCLUSIONS: The reduction in body weight achieved by NAFLD patients during the 6-month intervention was associated with improved fat deposition and liver function. This intervention offers a practical approach for treating a large number of NAFLD patients with lifestyle modification therapy.