STEATOHEPATITIS

Richard K. Sterling, MD, MSc, FACP, FACGVCU Hepatology Professor of Medicine

Chief, Section of HepatologyVirginia Commonwealth University

Richmond, VA

Conflicts of Interest in the last 12 months

• Advisory Board – Roche/Genentech, Merck, Vertex, Bayer, Salix, BMS,

Abbott

• Research support – Roche/Genentech, Merck, Bayer, Boehringer

Ingelheim, Vertex, BMS, Abbott

• Speaker – None

• Stock/Financial interest– None

Objectives

• Definitions• Histology• Types of steatohepatitis

– Alcoholic – Non-alcoholic– Drugs

• Pathophysiology• Presentation• Therapy

Definitions

• Steatosis = fatty liver (>5%)– Microvesicular– Macrovesicular– Mixed

• Steatohepatitis = fatty liver with inflammation and cytologic ballooning– Grade

• Degree of inflammation• Pattern

– Fibrosis• Degree• Pattern

Conditions Associated with Steatosis

• Alcohol • Microvesicular• Insulin resistance (NAFLD) TCN• Lipid disorders Valproate• Drugs AFLP

– Amiodarone Rye’s syndrome– Diltiazem HELLP syndrome– Steroids Inborn errors – Tamoxifen– HAART (NRTI/PI)

• HCV (genotype 3)• Weight loss• TPN• Wilson Disease• Idiopathic

• Macrovesicular

Steatohepatitis

• Fatty change (>5%)• Ballooning degeneration• Lobular inflammation• Mallory bodies• Perisinusoidal fibrosis

Steatohepatitis

Macrovesicular

Cytologicballooning

Mallory bodies

Alcoholic Liver Disease

• Fermented beverages have been around since 10,000 B.C.

• In the US:– 7.4% of adults abuse alcohol– 44% of all liver related deaths are attributed to

alcohol

Alcoholic Steatohepatitis

• Alcohol metabolism

EtOH Small bowelStomach ADH- gender ethnicity

LIVER

Microsomal ethanolOxidizing system (MEOS)- CYP 2E1 - Inducible by chronic alcohol

Acetaldehyde

ADHNAD

NADHAcetateALDH

Mitochondria

Liver toxicityLiver toxicity

Pathogenesis of ASH in the Liver

Kupffer Cell

TNF-

LPSOther stimuli

Hepatocyte

TGF- matrix

Hepatic stellate cells

KV Kowdley, MD

Leaky gutPV endotoxemia

Fibrosis

Mechanisms of Alcoholic Liver Injury

LIVER

AcetaldehydeInhibition of mitochondrialbeta-oxidation of fatty acidsOxygen-free radicalsGlutathione depletionAcetaldehyde Adducts

Oxidative StressOxygen-free radicalsDecreased Anti-oxidants

Redox StatusNAD depletionFat accumulation

Cytokines TNFα TGFβ

Hepatitis C

Natural History of Alcoholic Hepatitis

Normal liver

Steatosis

Steatohepatitis

Fibrosis

Cirrhosis

Alcohol (90-100%)

reverse

20% progress

50% progress, 38% with abstinence

~20% of alcoholics

50% reverse

80%

Factors Associated with Liver Injury

• Dose• Duration• Gender• Ethnicity• Other factors

– Obesity– Iron Overload– Viral hepatitis (HCV, HBV) – Genetic (PNPLA3)

Alcohol Threshold

• Men 80 grams (6-pack/day)• Women 40-60 grams (4 drinks/day)

• 12 oz beer• 4 oz drink• Glass of wine

10-12 grams

Alcoholic Liver Disease: Natural History

• Alcoholic hepatitis:– Women more likely to develop cirrhosis– Those with clinically severe hepatitis more

likely to progress to cirrhosis– Perivenular lesions, degree of necrosis

predictors of development of cirrhosis– Acute mortality 10-20% (related to severity,

complications and renal failure)• 50-80% if DF > 32

Alcoholic Liver DiseaseClinical Features

• Symptoms/signs of intoxication• Symptoms/signs of withdrawal• Hepatomegaly• Jaundice• Features of chronic liver disease

– Spiders, dypuytrens contractures• Extrahepatic manifestations: pancreatitis, neurologic disease, etc• Fevers• Leukocytosis (leukemoid reaction)• AST:ALT > 2• Hemolysis: Zieve’s syndrome

• Both AST and ALT are elevated but rarely exceed 300 IU/L (never above 500)• If > 300, think acetaminophen

• AST / ALT ratio > 2 : 1 Cytoplasmic isoenzymes for both cAST and

cALT but mitochondrial isoenzyme only for mAST.

ALT requires pyridoxal phosphate (vit-B6), which is consumed for the metabolism of alcohol.

Alcohol and AST:ALT ratio

Alcoholic Liver Disease Management

• Management of intoxication• Management of withdrawal• Nutrition (key and often overlooked)• Management of metabolic derangements:

– electrolytes: Mg, PO4, K,– thiamine, glucose, folate– vitamin K

Alcoholic liver disease: Steroid treatment

Discriminant function (DF) = 4.6 x (PT-control) + bilirubin (mg)

• Indications for steroids– DF > 32– Encephalopathy

• Contraindications for steroids– Sepsis– GI bleeding– If contraindications, treat and reassess

Comparison of Diagnostic Indiceson Survival

Author N MELD DF Sensitivity % Specificity % AUROC

Sheth 34 >11 86 81 0.82

>32 86 48 0.86

Srikureja 202 >18 85 84 0.89

>32 83 60 0.81

Dunn 73 >21 75 75 0.83

>41 75 69 0.83

Soultati 34 >30 100 94 0.97

>108 100 97 0.98

Adapted from O’Shea et al. Hepatology 2010;51:307-328

Both MELD and DF have similar sensitivity (75-85%) while MELD has higher specificity

Effects of steroids on survival in alcoholic steatohepatitis

Author n Severity

assessment

F/U % Survival

Pred vs placebo

Carithers

Ramond

Mathurin

66

61

122

DF

DF + Bx

DF + Bx

4 wks

8 wks

1 yr

94:65

88:45

70:41

Meta-analysis of 11 randomized studies (Imperiale and McCullough, AIM 1990)• 37% reduction in mortality (95% CI 20-50%)• In those with HE, 34% protective efficacy (95% CI 15-48%)• Minimal protective effect in those without HE• More effective in studies that excluded active GI bleeding

A few more things

• MELD may be better than DF in predicting survival– No threshold for use of steroids (~18)

• Pentoxifylline (400 mg tid)– Not compared to steroids– Seems to be a safe alternative– Not helpful if steroids fail

• If no improvement after 1 week, steroids unlikely to be of benefit (Lily criteria)

• Liver transplantation not an option

Used with Permission: O’Shea et al. Hepatology 2010;51:307-328

Used with Permission: O’Shea et al. Hepatology 2010;51:307-328

1.2-1.5 g/kg protein35-40 kcal/kg energy

Consider transplant

Non-alcoholic Fatty Liver (NAFLD)

• Spectrum of conditions– Simple steatosis (NAFL) NASH

• Most common cause of elevated liver enzymes– 14-34% (NAFLD)– 3% (NASH)

• Associated with insulin resistance (IR)• Decreased adiponectin (and adiponectin resistance)• Increased FFA, leptin and TNF-α• Fat may not be present once cirrhosis develops

– Cryptogenic cirrhosis• Remember

– Non-alcohol = < 21 alcohol drinks/week in men (<3/d) and <14 drinks/week (<2/d) in women

Natural History of NAFLD

NAFLD

Isolated fatty liver

NASH

Cirrhosis

HCC

Decompensation

No increased morbidityor mortality

Increased morbidityand mortality• CVD• Liver-related• Malignancy

>80%

<20%

2-3%/yr

3-5%/yr

1-3%/yr

Adapted from Torres et al. CGH 2012;10:837-858

Nonalcoholic fatty liver disease

H&E stain 20X Masson’s trichrome

SteatohepatitisHepatocyte ballooning (large arrow)Mallory bodies (small arrow)

Perisinusoidal fibrosis

Causes of NAFLD

• The metabolic syndrome• Drugs (steroids, diltiazem, amiodarone, NRTI, PI)• Lipodystrophy (HIV vs others)• Congenital lipid disorders (abetalipoproteinemia)• TPN• Short bowel• Chronic inflammatory disorders• Wilson Disease• HCV (genotype 3)• Hypothyroid

Metabolic Syndrome

Obesity

Diabetes Hypertension

NAFLD

Dyslipidemia

The metabolic syndrome (syndrome-x) ATP III criteria: 3 or more of the following

• Abdominal obesity – (waist > 102 cm for men, > 88 cm for women)

• Triglycerides > 150mg/dl• HDL < 40 mg/dl for men, < 50 mg/dl for women• BP > or = 130/85• Fasting blood glucose > or = 110 mg/dl

Prevalence of the metabolic syndrome in the US

Adapted from Ford et al, JAMA, 287:356-359, 2002

Based on 2000 censusN= 47 million in US

20-29 30-39 40-49 50-59 60-69 >700

10

20

30

40

50malesfemales

Age range (yrs)

Prevalence of NAFLDEthnic Variation

0

10

20

30

40

50

60

Overall Hispanic White AA NASH NASHamongNAFLD

San Antonio (1)

Dallas (2)

1. Gastroenterology 2011;140:124-131 2. Hepatology 2004;40:1387-1395 Adapted from Torres et al. CGH 2012;10:837-858

%

Associations with NAFLD

Author Obesity Diabetes Lipid HTN

Ludwig 90% 25% 67% 15%

Powell 95% 36% 62% ND

Bacon 39% 21% 21% 18%

Angulo 60% 28% 27% ND

Harrison 75% 45% ND 68%

Chitturi 57% 29% ND ND

Adapted from Stengel and Harrison Gastroenterology and Hepatology 2006;2:440-449

Can you predict NASH in those with steatosis?

Adapted from: Hepatology 2010;52:913-924

No NASH NASH p

N 291 404

% Male 45 34 .006

T2DM 17 26 .007

MS 56 66 .01

AST (U/L) 37 55 <.0001

ALT (U/L) 56 74 <.0001

AST/ALT 0.68 0.74 0.03

gGGT (U/L) 40 56 <.0001

HOMA-IR 3.8 5.0 <.0001

Model including labs, demographics AUROC = 0.79

NAFLD: sonographic evidence

• Bright liver• echotexture increased

compared to kidney• vascular blurring

Courtesy of KV Kowdley

NASH and normal ALTAdapted from Mofrad et al, Hepatology, 2003

none portal bridging cirrhosis0

30

60

90

upper limitof normal

stage of fibrosis

ALT

(I.U

./L)

Pathophysiology of NASHThe Players

• Insulin resistance• FFA -> lipotoxicity• Leptin• Adiponectin• Oxidative stress• Cytokines

– TNF-α– IL-6

The “two hit” hypothesis

Insulin Resistance

Lipid accumulation

Reactive oxygen species production

FibrosisNASH

1st hit

Increased MitochondrialOxidative stress 2nd hit

Lipid peroxidationCytokine inductionFAS ligand induction

Mostly TG from excess FFA influx fromhigher rates of lipolysis with increasedleptin and decreased adiponectin withdecreased in FA oxidation

Reduced ability of insulin to suppress endogenous glucoseproduction and increase glucose uptake by fat and muscle.Blunted insulin-mediated suppression of FFA release fromadipocytes and reduced FA oxidation

Clinical Conditions Associated with NAFLD

Cardiovascular Disease

DiabetesPCOS

Increased Ferritin

Adenomatous Colon Polyps

Obstructive SleepApnea

Vitamin DDeficiency

Hypothyroidism

Hyperuricemia

Pancreatic Steatosis

Cirrhosis

HepatocellularCarcinoma

Adapted from Torres et al. CGH 2012;10:837-858

NAFLD

Risk factors for severe fibrosis

Study Risk factors

Angulo (1999) Age, obesity, DM, AST/ALT ratio

Marceau (1999) Age, steatosis, WHR, BMI, DM

Garcia-Monson (2000) Age, steatosis, inflammation

Ratziu (2000) Age, BMI, ALT, TG, inflammation

Dixon (2001) HTN, ALT, c-peptide, IR

Chitturi (2002) Female, DM, inflammation

Harrison (2003) Age, DM, female, AST/ALT ratio

Adapted from Stengel and Harrison Gastroenterology and Hepatology 2006;2:440-449

Non-Invasive Assessment of NAFLD

Model Components Cutoffs AUROC PPV NPV

APRI AST, PLT <0.5 & >1.5 0.73

FIB-4 AST, ALT, Age, PLT <1.3 & >2.67 0.80 80 90

BAAT ALT, BMI, age, TG <2 47 100

BARD AST/ALT>.8, BMI>28, DM

2-4 0.70-0.82 35 96

NAFLDscore* AST, ALT, Age, PLT, BMI, Albumin

<-1.45 & >0.67

0.76-0.88 90 93

European Liver Fibrosis

Age, TIMP1, PIIINP, HA 0.37 80 98-82

Fibrosure Α2macroglobulin, apolipoprotein A1, haptoblobi9n, bilirubin, GGT

0.3 54 90

* >50% will have intermediate range

Weapons of mass destruction

Courtesy of AJ Sanyal

Therapy for NAFLD

• Weight loss (10% may be all it takes)• Diet (low carbohydrates)• Exercise (>30 min/day or 150 min/wk)• Pharmacotherapy

– Insulin sensitizing drugs (no longer recommended)• Thiazolidinediones (TDZ)• Metformin

– Antioxidants• Vitamin E, SAM-E, Betaine

– Anti-TNF• Pentoxyfylline

• Bariatric surgery

TDZ for NAFLD

• Peroxisome proliferator-activator receptor γ (PPAR) agonist

• Improves insulin sensitivity• Decrease hepatic glucose production• Enhance glucose disposal in muscle• Improves steatosis• But

– Weight gain– Increased cardiovascular events long term– No better than vitamin E

Pioglitazone (30 mg/d), Vitamin E (800 IU/d) or Placebo for NASH

Sanyal et al. NEJM 2010

0

10

20

30

40

50

60

70

Steatosis Lob Inflam Ballooning Fibrosis Resolution ofNASH

Placebo

Vit E

Pioglit% I

mpr

ovem

ent

N=83

N=84

N=80

* * * *

* = p<.05

Although the study was not designed or powered to compare vit E toPioglitazone, vit E did as well (or better) with less side effects

Treatments for NASHDietary Effect Comments

Weight loss (7-10%)

Reduce daily calories by 500-750 kcal

Improves histology <50% able to comply

No data on improvement in fibrosis

Reduce high fructose from diet

Increases lipogenesis No prospective data

High Fructose risk for NAFLD

Omega 3 FA Improves TG, may reduce steatosis

Need about 1g/d

Reduced CVD

Coffee (2-3 cups/d) Decrease risk of fibrosis I like coffee

Exercise

30-40 min 4-5 x week Improves LFTs and steatosis Need to combine with diet

Pharmacology

Vitamin E (800-1000 IU/d) Improves fat and inflammation Long term risks

Pioglitazone (30-45mg/d) Improves fat and inflammation Wt gain, long term risks

Pentoxifylline (400 mg tid) Improves NASH and fibrosis Small studies

Surgery

RYGB, Sleeve, other Improves NASH and fibrosis

Caution in cirrhosis

PNPLA3Patatin-Like Phospholipase Domain-Containing Protein 3

• Polymorphism of adiponutrin• Present in 12-14% of NAFLD compared to 3% controls• Acyl-CoA independent pathway of TG synthesis

– MG + MG -> DG + glycerol– MG + DG -> TG + glycerol

• In NAFLD, it is independently associated with– Steatosis– Inflammation– NASH and fibrosis

• Also a risk of developing alcoholic liver injury

Practice Guidelines for NAFLDAASLD, ACG, AGA (AJG 2012)

• NAFLD = <21 drinks/wk in men and 14/wk in women.

• Alcohol use should be minimized.• If NAFLD is detected on imaging without signs or

symptoms and normal enzymes, evaluate for other causes (ETOH, MS), but biopsy is not recommended.

• If NAFLD is detected on imaging with signs or symptoms and abnormal enzymes, evaluate for other causes (ETOH, MS) and consider biopsy.

Practice Guidelines for NAFLDAASLD, ACG, AGA (AJG 2012)

• Screening for NAFLD in high risk groups is not recommended.

• Systematic screening family members is not recommended.

• When evaluating NAFLD, exclude other common liver diseases (HHC, HCV, ETOH, AIH, Wilson).

• Presence of MS may help target those for biopsy.

• NAFLD Fibrosis Score (http://nafldscore.com) may help identify those with NASH.

Practice Guidelines for NAFLDAASLD, ACG, AGA (AJG 2012)

• Weight loss (3-5%) may reduce steatosis.• Weight loss (10%) may improve inflammation.• Exercise (even without weight loss) may improve

steatosis.• Metformin, Urso, omega-3 fatty acids are not

recommended.• Pioglitazone can be used to treat NASH in non-

DM, but safety for long term use a concern.• Vitamin E (800 IU/d) is non-DM can be

considered, but long term safety a concern.

Practice Guidelines for NAFLDAASLD, ACG, AGA (AJG 2012)

• Statins use is safe, but not recommended to treat NASH.

• Bariatric surgery is not recommended as a treatment for NASH, but is not contraindicated as a treatment of obesity in those without cirrhosis.

• Those with cirrhosis should undergo periodic US for HCC and endoscopy for varices.

Case Study 1

1. A 45 year old man is admitted with nausea and jaundice. There is no history of fever. He reports consuming a fifth of vodka per day for the past 15 years. Physical examination reveals tender hepatomegaly and grade 2 PSE. Laboratory tests reveal a serum bilirubin of 6 mg/dl, albumin 3 gm/dl. AST 250 IU/L, ALT 110 IU/L, Alk phos 155 IU/L, PT 20/INR 2.3 and serum creatinine 1.5 mg/dl. The most appropriate for this patient is:

Case Study 1-contd

A. Rifaxamin 400 mg tid

B. prednisolone 32 mg/day

C. Pentoxfylline

D. Referral to a liver transplant center

Case Study 1-contd

A. Rifaxamin 400 mg tid

B. prednisolone 32 mg/day

C. Pentoxfylline

D. Referral to a liver transplant center

The DF is 43 and the MELD is 26. Given PSE, pt should benefit from steroids.

Case 2

A 46 year old man is admitted to the hospital after being found unconscious by his family. He is known to consume more than a fifth of vodka a day for at least two decades. Physical examination reveals no fever. Tender hepatomegaly and splenomegaly are present. Laboratory tests reveal a serum bilirubin of 3 mg/dl, albumin 3 gm/dl. AST 1,550 IU/L, ALT 1210 IU/L, Alk phos 155 IU/L, PT 14 secs and serum creatinine 2.1 mg/dl. There is no leukocytosis.

Case 2 continued

The next appropriate test for this patient is:

a. Doppler ultrasound of the liver

b. ERCP

c. Acetaminophen level

d. CPK level

e. Blood cultures

Case 2 continued

The next appropriate test for this patient is:

a. Doppler ultrasound of the liver

b. ERCP

c. Acetaminophen level

d. CPK level

e. Blood cultures

Case 3

A 40 yo obese male (BMI 35) is found to have NASH. He has tried weight loss and exercise but his liver enzymes remain elevated and he has only lost 10 lbs. Which of the following do you recommend?

a. Start pioglitazone.

b. Start metformin

c. Bariatric surgery

d. Vitamin E

Case 3

A 40 yo obese male (BMI 35) is found to have NASH. He has tried weight loss and exercise but his liver enzymes remain elevated and he has only lost 10 lbs. Which of the following do you recommend?

a. Start pioglitazone.

b. Start metformin

c. Bariatric surgery

d. Vitamin E

Case 4

A 52 yo male with excessive alcohol presents with abdominal pain. Labs show AST 250, ALT 150. Which of the following reasons may explain the AST:ALT ratio?

1. AST requires B6 which is depleted

2. ALT is a mitochondrial enzyme affected more that AST

3. AST is a mitochondrial enzyme affected more that ALT

4. AST is a cytosolic enzyme affected more that ALT

Case 4

A 52 yo male with excessive alcohol presents with abdominal pain. Labs show AST 250, ALT 150. Which of the following reasons may explain the AST:ALT ratio?

1. AST requires B6 which is depleted

2. ALT is a mitochondrial enzyme affected more that AST

3. AST is a mitochondrial enzyme affected more that ALT

4. AST is a cytosolic enzyme affected more that ALT

Case 5

The pathogenesis of alcohol induced liver injury includes:

1. Reduced oxidative stress

2. Increased acetaldehyde

3. Reduced TNF

4. Reduced bacterial translocation

Case 5

The pathogenesis of alcohol induced liver injury includes:

1. Reduced oxidative stress

2. Increased acetaldehyde

3. Reduced TNF

4. NADH depletion