NIHR Southampton

Biomedical Research Centre

NAFLD and extra-hepatic

complications: what tests, which
treatment and why worry?
Christopher Byrne
Professor of Endocrinology and
Metabolism

University of Southampton & University

Hospital Southampton
NIHR Biomedical Research Centre
Southampton
The Southampton Biomedical Research Centre is funded by the National Institute for Health Research (NIHR) and
is a partnership between University Hospital Southampton Foundation Trust and the University of Southampton
 Disclosures

Research support Abbott/Pronova

Research support Chr Hansen
 Content

NAFLD: what is it and does it matter?

The spectrum of liver disease in NAFLD

NAFLD and extra-hepatic complications: Relationships between NAFLD,

obesity, type 2 DM and CVD

NAFLD: what tests?

Case report of person presenting with NAFLD

NAFLD: which treatments?

 Visceral ectopic fat, adipose tissue inflammation and type 2 diabetes

Poor nutrition (e.g.

high fat, high
carbohydrate, high
fructose) LCFAs, hyperinsulinaemia Adipocytokines
Genetic factors
(e.g. PNPLA3
genotype)

Stellate & Kupffer

LCFAs/ cell activation
DAGs
Lipotoxicity inflammation/
TAGs Ceramides/
Di-P PA fibrosis, cirrhosis
Inflammation, oxidative
stress, insulin resistance, and HCC
increased collagen matrix
Lipid
globule/
steatosis

Poor nutrition (e.g.

primary bile acids secondary bile acids
high fat, high
carbohydrate, high
fructose)
J Hepatol. Figure 2 INTESTINE (dysbiosis) Genetic factors
More severe forms of liver disease in NAFLD are
common with type 2 diabetes and diabetes is the
most important predictor of progression

Normal
Liver
NAFLD NASH 20% CIRRHOSIS

30% General population 2-5% General population

70-80% Type 2 diabetes 80% Type 2 diabetes LIVER LIVER CELL
60-95% Obesity 70% Obesity FAILURE CANCER

Metabolic Syndrome. Byrne CD and Wild SH (2ND EDITION 2011);

Levene AP Histopathology 2012
McPherson et al J Hepatology 2015
Progression of liver disease in NAFLD
increased diabetes risk
Normal
liver increased HCC risk

Steatosis

NASH

Cirrhosis

increased CV risk
 Metabolic Syndrome
NAFLD: frequently occurs with Features 2009

Metabolic Syndrome: Waist > 94/80 cm

BP  130/85
a condition of ectopic fat accumulation, insulin resistance and TG  1.7mmol/l
cardiometabolic risk factors Glucose  5.6 mmol/l
HDL < 1.0/1.3 mmol/l

 Triglyceride  BP
 HDL
Cholesterol

NAFLD Central obesity

Vascular inflammation, a
Glucose intolerance & type 2
procoagulant phenotype
diabetes
& heart disease
Byrne C & Wild S eds. Metabolic syndrome Wiley-Blackwell 2011
 Does NAFLD matter?
Southampton-Seoul & Southampton Verona collaborations (2012-date)
• Can simple biochemical and anthropometric measures be used to predict who will develop NAFLD?...............No
• BMC Gastroenterology 2012
• Does NAFLD predict incident diabetes?...................Yes
• Diabetes Care 2012a, JCE&M 2013
• Does NAFLD predict incident hypertension?..............Yes
• Journal of Hepatology 2014
• What is the relationship between NAFLD and pre-clinical atherosclerosis?
• Diabetes Care 2012b, ATVB 2013…………NAFLD is an independent risk factor
• Does fatty liver occur in metabolically healthy obese people.....Yes in some
• NMCD 2013, JCE&M 2015
• Circulating markers of liver function and cardiovascular disease risk……Increased GGT is associated with all cause,
cancer and CVD mortality (probably a marker of oxidative stress and NOT NAFLD or ALD.
• Arterioscler Thromb Vasc Biol. 2015 May 14. pii: ATVBAHA.115.305235. [Epub ahead of print]
• Clinical Chemistry 2015 Jul 7. pii: clinchem.2015.240424
• How should NAFLD be managed in people with diabetes?.......Needs to be identified and treated!
• JCE&M 2013
• NAFLD and incident AF .....NAFLD is an independent risk factor for incident AF
• PLoS One 2014
• NAFLD and aortic and mitral valve calcification ……..increased incidence
• Metabolism 2015 May 1. pii: S0026-0495(15)00108-0. doi: 10.1016/j.metabol.2015.04.003. [Epub ahead of print]
• Increased HDL-C/Apo-AI ratio and CVD mortality…. increased HDL-C/Apo-AI ratio is associated with
increased all cause, cancer and CVD mortality
• Heart. 2015 Apr;101(7):553-8.
 Extra-hepatic complications of NAFLD

• Cardiovascular disease and cardiac disease

• Type 2 diabetes
• Chronic renal failure (defined by eGFR≤60
ml/min or proteinuria)

Byrne C & Targher G J Hepatol 2015

18/06/2013
 Fatty liver, insulin resistance and obesity occur frequently in
people at risk of type 2 DM but not in the normal population
Incident cases of diabetes at 5 y follow up = 223/12853 (1.7%)

OBESITY INSULIN
INSULIN RESISTANCE
OBESITY RESISTANCE

X Y

Fatty liver
Fatty liver
Normal population
Population developing
incident diabetes
X = 10% of normal population have overweight/obesity, IR and fatty liver
X = 50% of people developing incident diabetes at 5 year follow up have Diabetes Care
overweight/obesity, IR and fatty liver April
2012
 When combined insulin resistance, overweight/obesity and fatty liver
markedly increase risk of type 2 diabetes

Numbers and
proportions with Odds Ratio [95% CI]
incident diabetes (%)

Model
Whole cohort 223/12853 (1.7%)
No risk factors 26/6324 (0.4%) 1
Insulin resistance alone 14/945 (1.5%) 3.66[1.89-7.08] <0.001
Overweight/obesity alone 10/1434 (0.7%) 1.29[0.62-2.71]
0.50
Fatty liver alone 13/850 (1.5%) 2.73[1.38-5.41]
0.004 Diabetes Care
Insulin resistance and 21/595 (3.5%) 6.16[3.38-11.22] <0.001 2012
overweight/obesity
Apr;35(4):717-22
Insulin resistance and fatty liver 15/388 (3.9%) 6.73[3.49-12.97] <0.001
Overweight/obesity and fatty liver 20/1032 (1.9%) 3.23[1.78-5.89] <0.001

Insulin resistance, 104/1285 (8.1%) 14.13[8.99-22.2]

overweight/obesity and fatty/liver <0.001

Model adjusted age, sex, alcohol, smoking status, exercise, educational status,
triglyceride and ALT
 Associations between fatty liver, cardiometabolic risk
factors and CAC score >0, derived from a multivariable
regression model containing all variables

10,153 individuals
 What tests? - case report

45 y man
Asymptomatic
Smokes 10/day – 20 years
Type 2 diabetes – 1 year
Sedentary occupation, 14-21 units alcohol/wk
Married, 2 children
‘unfit & stressed at work’
Metformin 2g/day
O/E
BMI 36 kg/m2
‘Increased waist circumference’ 104 cms
Bp 145/90 mmHg

Fasting glucose 9.0 mmol/l

Chol 6.0 mmol/l, LDL = 3.2 mmol/l
Fasting Tg = 4.0 mmol/l
HDLc = 0.8 mmol/l
HbA1c = 9.0 %

NB all five features of MetS

ALT = 50 iu/l ( 5-35 iu/l)
gGT = 50 iu/l ( < 55 iu/l)
LFTs otherwise entirely normal
U&E normal
Urinalysis – trace protein
ACR = 2.5mg/mmol
Ultrasound test diagnoses liver fat only [or possibly ‘Fatty liver index test (BMI
+ waist + TG + GGT + algorithm ≥60’]

‘Echogenic liver texture in keeping with moderate to severe fatty

liver’

Liver fibrosis markers (normal or increased)

Hyaluronic acid (HA) normal, PIIIPNP increased [and TIMP-1]
(HA + PIIINP + TIMP 1 + algorithm = ELF test, Siemens)

Other causes of fatty liver disease

Alcohol intake? - minimal
Iron status - normal
Autoantibodies – slight increases anti smooth cell
IgG
Immunoglobulins - normal
Hepatitis status (? Hep B or C infection) negative
Liver imaging of a man with severe diffuse hepatic fatty
infiltration.
(A) Ultrasound scan
showing diffuse
increased echogenicity
of liver parenchyma
compared to renal
cortex.
(B) Chemical shift MR
Imaging showing
marked hepatic signal
drop-off during out-of-
phase image compared
to in-phase
(C) image, suggesting
significant diffuse fatty
liver.
(D) Single-voxel MR
Spectroscopy
measuring area under
lipid spectrum (2nd
peak) relative to water
spectrum (1st peak),
allowing accurate
quantification of hepatic
fat of 85% in the same
patient.
Non alcoholic fatty liver disease: a condition of ‘ectopic’
fat accumulation and marked tissue insulin resistance

VACUOLATED NUCLEI

H&E STAIN x 40
PERICELLULAR / VENULAR
SINUSOIDAL FIBROSIS

RETICULIN STAIN x 10
 Fibroscan – transient elastography

Liver stiffness
• Assessed by US
(FibroScan®) & more
recently by MRI
• Evaluates velocity of
propagation of a shock
wave within liver tissue
(examines a physical
parameter of liver tissue
which is related to its
elasticity)
• Rationale Normal liver is
viscous not favorable to
wave propagation Fibrosis  Results Stiffness (kPa) Median value of 10
increases hardness of shots 3.9 Kilo Pascals At least 10 shots
tissue favors more rapid
propagation
Success Rate: ≥ 60% IQR * (kPa) Interval
Bedossa P. Liver Int 2009 ; around median Contains 50% of valid shots
29 (s1): 19 – 22. ≤ 25% of median value
 Liver fibrosis markers (e.g., NAFLD fibrosis score http://nafldscore.com/,
Type 2 Diabetes (age, BMI, IGT/DM, AST, ALT, Platelets, Albumin
Fib 4 score, ELF test, Fibrotest) and/or transient elastography (Fibroscan)
ALT > ULN
(19 IU/L for women
>30 IU/L for men)
Abnormal and highly suggestive of advanced liver fibrosis or cirrhosis

Liver ultrasound

Moderate/severe
Liver biopsy
Mild steatosis steatosis
and splenomegaly
Steatosis NASH Upper GI
Exclude other causes fibrosis/
endoscopy
of hepatic steatosis * cirrhosis
Varices present – treat
with surveillance

Treatment
J Clin Endocrinol Metab 2013
Aim for weight loss of at least 4-5% of body weight to reduce hepatic steatosis and weight loss of 10%
to improve hepatic necro-inflammation; aim for good glycemic control (HbA1c <7% for many patients if not contraindicated);
metformin should be the first line hypoglycemic therapy for most patients; consider pioglitazone therapy if not
contraindicated (especially if NASH is present); consider GLP-1 agonists if not contraindicated;
consider bariatric surgery if BMI >35 kg/m 2. Assess 10-year cardiovascular risk and have a low threshold for statin
treatment (treat if the 10-year cardiovascular risk >15%**). Anti-hypertensive treatment if blood pressure >130/80 mmHg
(treatment with ACE-inhibitors or angiotensin receptor II antagonist as first line therapy). Stop smoking and avoid alcohol intake .

Treatment and routine surveillance (including for hepatocellular carcinoma if cirrhosis or NASH is present)
 Treatment?
• Lifestyle
• Weight loss, physical activity (alcohol?)

• Nutrition?
• Drugs
– Metformin- no effect
– GLP-1 agonists –weight loss benefical
– Statins – no effect but safe
– Pioglitazone – may be beneficial but side effects
– Vitamin E - ?hazardous
– Omega-3 fatty acids –possibly
– Probiotics?
– FXR agonists – FLINT trial showed benefit and stopped early
Evidence of benefit of n-3 PUFA treatment for CVD
1.8 g EPA/day
+ statin v. statin
JELIS: Major coronary events

Lancet 2007; 369:1062-3

Will high dose omega-3 PUFA improve liver
disease AND decrease CVD risk in NAFLD?
Study design
Wessex Evaluation of fatty Liver and Cardiovascular markers in NAFLD
(non alcoholic fatty liver disease) with OMacor thErapy Several PICs from
around NAFLD

•Double blind placebo-control trial

•Treatment: Omacor 4 gr per day or 4 g olive oil (placebo)
 Omacor 1 gr capsule (1000mg) of omega-3-acid comprising EPA (460mg)
and DHA (380mg) x 4.
•Duration of intervention: 15-18 months
•Primary outcome: Decrease in liver fat (magnetic resonance spectroscopy-MRS)
• Improvements in two histologically validated liver fibrosis scores

Scorletti E, et al on behalf of the WELCOME* Trial Investigators.

Contemporary Clinical Trials. 2014.
Wessex Evaluation of fatty Liver and Cardiovascular markers in
NAFLD (non alcoholic fatty liver disease) with Omacor therapy
(WELCOME)
PIs: Byrne, Calder. (Scorletti et al Contemp Clin Trials 2014)

Double blind placebo-control trial of n3 PUFA (1.8g EPA/1.5g DHA) for 15-18 months

Placebo n=44 Omacor n=42

Pre Post p Pre Post p
MRS Liver Fat (%) 22.8 20.5 0.01 28.7 18.5 0.04

35% reduction in hepatic fat

- effect greatest in those with
most hepatic fat

Scorletti et al HEPATOLOGY 2014

(Also see McCormick et al Diabetologia 2015 and Scorletti et al J Hepatology 2015)
Is Synbiotic treatment beneficial for NAFLD?
‘INvestigation of SYnbiotic TreatmEnt in NAFLD’
(INSYTE)

Investigation of the effects of a synbiotic on liver fat, disease

biomarkers and intestinal microbiota in non-alcoholic fatty
liver disease

www.clinicaltrials.gov registration number NCT01680640

Local research ethics committee approval has been granted
(REC reference: 12/SC/0614).
 NAFLD and diabetes: does it matter, what tests
and what treatment?
Conclusions:

• NAFLD very common in diabetes: diabetes increases risk of

progression
• NAFLD risk factor for type 2 DM/CVD/HCC/cirrhosis
independently of central obesity and IR and other features of
MetS
• NAFLD – diagnosis begins with abnormal ALT and
ultrasound (detects liver fat only). Biomarkers useful for
severe fibrosis.
• Fibroscan useful for serious fibrosis
• Biopsy still the gold standard
• Lifestyle and management of risk factors and ?FXR agonists
Philip Calder
Geraldine Clough
Acknowledgments
• Bournemouth, Poole, Winchester, IoW,
Loke Bhatia Portsmouth, Basingstoke
Keith McCormick
Debbie Smith • Oxford
Eleonora Scorletti Leanne Hodson and Keith Frayn
Lucinda England
• Surrey
Gillian Wise Margaret Umbleby, Nicola Jackson, F. Shojaee-
Sanchia Triggs Moradie
Bridget Clancy
Gemma Rood • BRC staff
Norma Diaper • WTCRF staff – Jennifer, Enrico and Kerrie
Medical students, Pat Taylor and staff.
Kate Nash/Mark Wright/Nick Sheron Pharmacy (Joanna Cantle)
Nick Curzen
Drubo Rahkit • Seoul. Korea
Angela Darekar, Ki-Chul Sung
Alison Fletcher • Verona, Italy
Jen Bryant, Giovanni Targher
Charles Peebles

Helen Moyses, Karen Long, Ching Cheng, Carrie Bolt Funding Bodies Diabetes UK & NIHR