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those used in phaseIII trials should ideally provide good predictions of long-term prognosis in patients with NASH. However, the proposed histological features that define both definitive and borderline NASH (that is, steatosis, inflammation and hepatocyte ballooning) do not indicate a poor longterm prognosis, either individually or in combination. Moreover, in two studies, the presence of such lesions lacked prognostic value when analyses were adjusted for the presence and severity of liver fibrosis.5,6 Thus, even if a given treatment achieves the primary study end point of resolution or improvement in NASH (defined by the criteria proposed in Sanyal etal.s report 1), the trial results do not unequivocally portend an improvement in prognosis if the intervention does not have a favorable effect on liver fibrosis. In this regard, three large, randomized, double-blind, placebo-controlled trials (one in adults7 and two in children8,9) have used liver histology to evaluate the effects of treatment with vitaminE7,9 or lifestyle interventions, such as weight loss,8 in patients with NASH. The three trials showed substantial improvements in or resolution of some, or all, histological features that define NASH after 2years, which were these studies primary or secondary end points. However, none reported an improvement in liver fibrosis. Along with concern over the increased mortality associated with longterm vitaminE therapy,10 the uncertainty about the long-term effects of this treatment on the prognosis of NASH is one of the reasons why many health-care providers are reluctant to recommend vitaminE for the treatment of NASH. The report by Sanyal etal. 1 provides useful guidance and recommendations that, if adopted, would probably greatly improve the quality of clinical trials in NASH. Trials that incorporate the optimal design elements described by these investigators 1 are likely to yield robust results that can be used to substantiate the claims of beneficial effects that have been made with regard to specific treatment interventions.
Division of Digestive Diseases & Nutrition, Department of Medicine, University of Kentucky Medical Center, 800 Rose Street, Room MN649, Lexington, KY 40536-0298, USA. paul.angulo@uky.edu
Acknowledgments This article was supported in part by R01 grant DK82426 from the NIH to P Angulo. . Competing interests The author declares no competing interests. 1. Sanyal, A.J. etal. Endpoints and clinical trial design for nonalcoholic steatohepatitis. Hepatology 54, 344353 (2011). Musso, G., Gambino, R., Cassader, M. & Pagano, G. Meta-analysis: Natural history of non-alcoholic fatty liver disease (NAFLD) and diagnostic accuracy of non-invasive tests for liver disease severity. Ann. Med. doi:10.3109/ 07853890.2010.518623. Dam-Larse, S. etal. Final results of a longterm, clinical follow-up in fatty liver patients. Scand. J.Gastroenterol. 44, 12361243 (2009). Ekstedt, M. etal. Long-term follow-up of patients with NAFLD and elevated liver enzymes. Hepatology 44, 865873 (2006). Younossi, Z. etal. Pathologic criteria for nonalcoholic steatohepatitis (NASH): Interprotocol agreement and ability to predict liverrelated mortality. Hepatology 53, 18741882 (2011). 6. Angulo, P Diagnosing steatohepatitis and . predicting liver-related mortality in patients with NAFLD: Two distinct concepts. Hepatology 53, 17921794 (2011). 7. Sanyal, A.J. etal. NASH CRN. Pioglitazone, vitaminE, or placebo for nonalcoholic steatohepatitis. N.Engl. J.Med. 362, 16751685 (2010). 8. Nobili, V. etal. Lifestyle intervention and antioxidant therapy in children with nonalcoholic fatty liver disease: a randomized, controlled trial. Hepatology 48, 119128 (2008). 9. Lavine, J.E. etal. Effect of vitaminE or metformin for treatment of nonalcoholic fatty liver disease in children and adolescents: the TONIC randomized controlled trial. JAMA 305, 16591668 (2011). 10. Sanyal, A.J. ACP Journal Club: vitaminE, but not pioglitazone, improved nonalcoholic steatohepatitis in nondiabetic patients. Ann. Intern. Med. 153, JC3JC12 (2010).

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NONALCOHOLIC FATTY LIVER DISEASE

Targeted therapy in children what is the right way?

Anna Alisi and Valerio Nobili

The incidence of nonalcoholic fatty liver disease (NAFLD) in children is growing in parallel with that of obesity; however, to date, no drugs have been approved for its treatment. Results from a 5year clinical trial show that neither metformin nor vitamin E are effective for the treatment of pediatric NAFLD.
Alisi, A. & Nobili, V. Nat. Rev. Gastroenterol. Hepatol. 8, 425426 (2011); published online 12 July 2011; doi:10.1038/nrgastro.2011.117

Various potential therapies that are thought to address the underlying pathogenetic mechanisms of pediatric NAFLD have been extensively investigated in the past two decades, including lipid-lowering agents, insulin sensitizers, antioxidants and cytoprotective agents.1 In small pilot studies, treatment with the insulin sensitizer, metformin, and the antioxidant, vitamin E, improved liver enzyme levels, but did not reduce histological damage in children with NAFLD. 2,3 Concomitantly with these pilot studies, the NASH Clinical Research Network launched the Treatment of NAFLD in Children (TONIC) trial to investigate the use of insulin-sensitizing agents and vitaminE for the treatment of pediatric NAFLD and nonalcoholic steatohepatitis (NASH).4 Lavine and colleagues now report the disappointing final results for this trial; neither metformin nor vitamin E were superior to placebo in achieving a sustained reduction of serum alanine aminotransferase (ALT) levels in these patients.5

The TONIC trial 4,5 included 180 nondiabetic children aged 817years, recruited from 10 clinical centers. All participants had biopsy-proven NAFLD and persistently elevated serum ALT levels. The children received oral metformin (500 mg twice daily), vitamin E (400 IU twice daily), or placebo twice daily for 96weeks. In addition, all three groups of participants received standardized recommendations for the management of diet, weight loss, exercise and various comorbid illnesses. Although improvement of liver histology is usually the main outcome used to evaluate the response of NAFLD to therapy, the primary outcome of the TONIC trial was either normalization of serum ALT levels (40 U/l) or their reduction to 50% of baseline values in the final 48weeks of treatment.4,5 Secondary outcomes included changes in the total NAFLD activity score, fibrosis stage and histological features of NASH, as well as anthropometric parameters, insulin resistance and serum levels of cytokines. Lavine and colleagues
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NEWS & VIEWS

report no difference in the primary end point between the placebo and intervention groups. The researchers also found no significant differences in fibrosis, steatosis or inflammation in the groups treated with metformin or vitamin E versus the placebo group. Interestingly, however, treatment with vitamin E was associated with signifi cantly improved secondary histological outcomes (such as hepatocellular ballooning) in the subgroup of children with biopsy-proven definite or borderline NASH. Although the latter finding is encouraging, the therapeutic role of vitamin E in children with hepatocellular ballooning remains to be elucidated. In a different study, children with NAFLD who were treated for 6months with doconexent (docosahexaenoic acid, an omega-3 fatty acid) and lifestyle interventions have shown sustained reductions in both serum levels of ALT and steatosis on ultrasonography;6 this effect of doconexent could be due to the ability of this natural molecule to interfere various cellular processes, such as lipid metabolism, insulin-resistance, response to oxidative stress and inflammation. However, publication of these findings and the TONIC trial results has not answered the question of how children with NAFLD should be treated. In fact, the current state of our knowledge regarding the use of pharmacological agents to treat pediatric NAFLD is totally unsatisfactory. No pharmaco logical agents have been approved for pediatric NAFLD, and no evidence-based guidelines for its treatment exist. Thus, lifestyle modifications remain the mainstay of therapeutic management for all children with this disorder.

the therapeutic role of vitamin E in children with [NAFLD] remains to be elucidated

liver cell injury (ballooning and fibrosis) might develop. Children with NAFLD or NASH may eventually develop end-stage liver disease with the consequent need for liver transplantation.7 Although mechanisms underlying the molecular pathogenesis of NAFLD and NASH remain to be fully elucidated, development and progression of disease are generally accepted to depend on multiple genetic, epigenetic and environmental factors. These factors create a complex network of interactions that overlap with metabolic syndrome. 8 The multifactorial pathogenesis of NAFLD is widely recognized to involve multiple initiating events. The first step, represented by the intrahepatic accumulation of fatty acids, is closely associated with insulin resistance, which increases the susceptibility of hepatocytes to secondary injuries or insults (including oxidative stress, mitochondrial dysfunction, overproduction and release of proinflammatory cytokines, and endotoxin-mediated activation of the innate immune response). Increased susceptibility to these factors might also explain the progression of NAFLD to NASH.9 We believe that the multifactorial pathogenesis and histological complexity of NAFLD are crucial elements that should be considered in both the design of an adequate therapeutic intervention and in predicting the response to treatment. Lifestyle modifications might hide the effect of the pharmacological treatment, while pharmacological treatments directed at a single target might not produce the best results. For this reason, in combination with improved understanding of the pathophysiological processes that underlie the mechanisms leading to NAFLD and NASH, we consider that multi targeted therapy could be the way forward for treating these children. Such therapy consists of combinations of therapeutic approaches directed against various potential targets. Therapies that simultaneously target clinical features of NAFLD and NASH (such as dietary interventions to reduce obesity) and molecular mechanisms (such as agents that are effective against the secondary injuries or insults described above) could be employed. Furthermore, to define the

efficacy of these multitargeted therapies, multidisciplinary teams of hepatologists, surgeons, endocrinologists, dietitians and psychologists should be commonly adopted. Moreover, new paradigms for the patho genesis of NASH are emerging that describe the crucial role of the gut liver axis, and the manipulation of enteric flora with probiotics or prebiotics has also been proposed as a treatment for adult and pediatric NAFLD.10 Multitargeted therapy could, therefore, be a winning formula to treat simple steatosis as well as prevent its progression to NASH.
Autoimmunity and Metabolic Liver Diseases, Liver Research Unit, Bambino Ges Childrens Hospital and Research Institute, S. Onofrio 4 Square, 00165 Rome, Italy (A. Alisi, V. Nobili). Correspondence to: V. Nobili nobili66@yahoo.it
Acknowledgments The authors wish to thank B. Dallapiccola for his editorial assistance. Competing interests The authors declare no competing interests. 1. Brunt, E.M. Pathology of nonalcoholic fatty liver disease. Nat. Rev. Gastroenterol. Hepatol. 7, 195203 (2010). 2. Nobili, V. etal. Lifestyle intervention and antioxidant therapy in children with nonalcoholic fatty liver disease: a randomized, controlled trial. Hepatology 48, 1928 (2008). 3. Nobili, V. etal. Metformin use in children with nonalcoholic fatty liver disease: an open-label, 24-month, observational pilot study. Clin. Ther. 30, 11681176 (2008). 4. Lavine, J.E. etal. Treatment of nonalcoholic fatty liver disease in children: TONIC trial design. Contemp. Clin. Trials 31, 6270 (2010). 5. Lavine, J.E. etal. Effect of vitamin E or metformin for treatment of nonalcoholic fatty liver disease in children and adolescents: the TONIC randomized controlled trial. JAMA 305, 16591668 (2011). 6. Nobili, V. etal. Docosahexaenoic acid supplementation decreases liver fat content in children with non-alcoholic fatty liver disease: double-blind randomised controlled clinical trial. Arch. Dis. Child. 96, 350353 (2011). 7. Feldstein, A.E. etal. The natural history of non-alcoholic fatty liver disease in children: a follow-up study for up to 20years. Gut 58, 15381544 (2009). 8. Alisi, A., Cianfarani, S., Manco, M., Agostoni,C. & Nobili, V. Non-alcoholic fatty liver disease and metabolic syndrome in adolescents: Pathogenetic role of genetic background and intrauterine environment. Ann. Med. doi:10.3109/07853890.2010.547869. 9. Alisi, A., Locatelli, M. & Nobili, V. Nonalcoholic fatty liver disease in children. Curr. Opin. Clin. Nutr. Metab. Care 13, 397402 (2010). 10. Iacono, A., Raso, G.M., Canani, R.B., Calignano, A. & Meli, R. Probiotics as an emerging therapeutic strategy to treat NAFLD: focus on molecular and biochemical mechanisms. J.Nutr. Biochem. doi:10.1016/ j.jnutbio.2010.10.002.

neither metformin nor vitamin E [achieved] a sustained reduction of serum ALT levels

NAFLD is now the most common cause of liver disease in children and adolescents, as a direct consequence of the rise in childhood obesity. The exact prevalence of pediatric NAFLD is still unknown. However, analyses of serum biomarkers (such as ALT) as well as data from imaging techniques (such as ultrasonography) estimate the global prevalence of NAFLD to be 310% in the general population and >70% in obese individuals. 9 Simple steatosis is a benign form of NAFLD, which can progress to a more advanced form, NASH, in which necroinflammation and
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