GASTROENTEROLOGY 2008;134:16821698

Diagnosis and Therapy of Nonalcoholic Steatohepatitis

Dawn M. Torres

Stephen A. Harrison

Department of Gastroenterology, Fort Sam Houston, Brooke Army Medical Center, San Antonio, Texas

The increasing prevalence of obesity, insulin resistance, and the metabolic syndrome has signicant implications for the future of chronic liver disease. The resultant increase in the number of patients with nonalcoholic fatty liver disease (NAFLD) is expected to translate into increased numbers of patients with end-stage liver disease (cirrhosis), liver failure, and hepatocellular carcinoma. It is particularly important to identify the patients who are at greatest risk of these aforementioned complications of chronic liver disease, those nonalcoholic fatty liver disease patients with nonalcoholic steatohepatitis. Currently liver biopsy is the gold standard for diagnosis, but less invasive, highly accurate, and affordable screening tools are required. These tools may include radiologic or laboratory studies to identify patients noninvasively who may benet from therapeutic interventions. Clinical scoring systems that may be used in general practice as initial screening tools also may prove useful. Most therapeutic modalities available or under development target the major pathways thought essential in the pathogenesis of nonalcoholic steatohepatitis and often are directed at reducing body mass index and improving insulin resistance via pharmacologic, surgical, dietary, or exercise regimens. Other potential therapeutic agents directed at cytoprotection or reduction of brosis are under investigation. This article focuses on diagnosis and therapy available and under development for this chronic liver disease. ecause obesity has become commonplace in todays modern society, the face of chronic liver disease is changing to reect a signicant increase in patients with features of the metabolic syndrome, leading to an increased prevalence of nonalcoholic fatty liver disease (NAFLD). It is estimated that 30% of the adult population in the United States now has NAFLD, with an increasing prevalence to 90% in morbidly obese popula-

tions presenting for bariatric surgery.13 This is worrisome because patients with NAFLD appear to have a higher all-cause mortality in addition to liver-related cause of death and recent data points to an increased risk for cardiovascular disease.4 8 However, in clinical and histopathologic studies, the course of isolated fatty liver appears more indolent and less likely to progress to advanced liver disease.9 Alternatively, a subset of NAFLD patients have a more aggressive form of fatty liver known as nonalcoholic steatohepatitis (NASH), in which patients are at greater risk for progression to cirrhosis, end-stage liver disease, and likely hepatocellular carcinoma. It is estimated that 3% 6% of the United States population has NASH, with upwards of 30% of morbidly obese patients showing features of NASH.3,10 Because of the inordinately high prevalence of NAFLD, it is important to identify those patients with NASH, particularly those at risk for advanced disease. Liver biopsy traditionally has been the gold standard used to make the diagnosis of NASH. However, without adequate biopsy tissue, there is a high degree of sampling variability. Additional problems include the small but inherent risk of complications, potential patient discomfort, and cost. Subsequently, noninvasive tools to correctly identify NAFLD patients who have histopathologic evidence of NASH with or without advanced brosis are in development and include a variety of techniques that vary from composite laboratory and biomarker data to tests that
Abbreviations used in this paper: ADP, adiponectin; BMI, body mass index; CRP, C-reactive protein; CT, computed tomography; HDL, highdensity lipoprotein; LDL, low-density lipoprotein; MR, magnetic resonance; NAFLD, nonalcoholic fatty liver disease; NAS, nonalcoholic fatty liver disease activity score; NASH, nonalcoholic steatohepatitis; NPV, negative predictive value; PPV, positive predictive value; PUFA, polyunsaturated fatty acid; RCT, randomized controlled trial; ROC, receive operating curve; ROS, reactive oxygen species; SFA, saturated fatty acid; TZD, thiazolidinediones; US, ultrasound. 2008 by the AGA Institute 0016-5085/08/$34.00 doi:10.1053/j.gastro.2008.02.077

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Table 1. Radiology Studies in the Diagnosis of NAFLD

Modality US1418 Levovist US34 CT19,20 CT with liver-spleen attenuation ratios21 MR imaging22 MR spectroscopy24 MR elastography38 US elastography36 Sensitivity 49%89% 100% 54%93% 82% NA NA 98% 87% Specicity 75%100% 100% 95% 100% NA NA 99% 91% Comments Identies steatosis only Small preliminary study of 64 patientspotentially useful in NASH patients 30% steatosis, cannot differentiate NASH Better than standard CT for hepatic steatosis 30%; no NASH distinction Highly accurate in determining steatosis 30% Highly accurate for steatosis Good for both steatosis and brosis; early studies only For stage 4 brosis, cannot differentiate NASH (accuracy in obese patients is unknown)

measure hepatic tissue elasticity such as the Fibroscan (Echosens, Paris, France). Establishing the diagnosis of NASH is helpful only if an appropriate care plan can be developed and this includes providing an effective treatment for the disease. These therapeutic modalities should be readily available, safe, effective, and relatively inexpensive. Therapies that target the underlying metabolic syndrome through lifestyle modication, dietary adjustments, exercise regimens, bariatric surgery, or medications are all potential avenues of treatment. Other potential therapeutic targets include cytoprotective and antibrotic agents. This article focuses on the diagnostic and therapeutic tools currently available as well as those under investigation for future clinical use.

Diagnosis
Patients with NAFLD often are asymptomatic and come to attention secondary to mild to moderate increases in hepatic aminotransferase levels or abnormal liver appearance on abdominal imaging. Liver enzyme level increases tend to show an alanine aminotransferase (ALT) predominance and rarely are increased more than 3 times the upper limits of normal.11,12 The alkaline phosphatase level occasionally may be increased mildly, and rarely is the only liver enzyme abnormality identied.13 Conventional radiology studies used in the diagnosis of fatty liver include ultrasound (US), computed tomography (CT), and magnetic resonance (MR) imaging (Table 1). US can identify hepatic steatosis with reasonable accuracy. Typical criteria used to assess for steatosis include hepatorenal echo contrast, liver brightness, deep (posterior beam) attenuation, and vascular blurring. A recent Italian study of 235 patients showed an excellent specicity of 97%, but a lower sensitivity of 64%. This increased to 100% specicity and 89.7% sensitivity when only including patients with at least 30% steatosis.14 Hamaguchi et al15 used a 6-point scoring system based on liver brightness, attenuation, and vascular blurring on US to evaluate for NAFLD and showed 100% specicity and 91.7% sensitivity when compared with liver biopsy.

However, this study was performed in relatively thin patients. When performed in morbidly obese patients, others have shown the sensitivity and specicity to be only 49.1% and 75%, respectively, for identifying steatosis.16 Other studies have emphasized the difculty in distinguishing steatosis from brosis on US and the inability of US to correlate with the other essential hepatic histology required for the diagnosis of NASH.17,18 CT has shown a similar diagnostic yield similar to US. Unenhanced CT is accurate in predicting steatosis of greater than 30%, but has been shown to be much less accurate in predicting lower-grade steatosis.19 Diagnostic accuracy has been improved with unenhanced CT scan using liver:spleen attenuation ratios with up to 100% specicity and 82% sensitivity for hepatic steatosis greater than 30%.19 21 Hepatic steatosis may be quantied from MR imaging based on the signal differences between fat and water and shows good correlation with microscopic fat content.22 Limitations of this modality include expense, inability to use in patients with implantable devices or claustrophobia, and altered values in patient with iron overload.23 Magnetic reasonance spectroscopy is a specialized radiologic study that can measure triglyceride content noninvasively. This technique was used on 2349 patients from the Dallas Heart Study with highly reproducible and accurate results, but widespread application of this technology is limited by cost and availability.24 As a group, radiologic studies have been shown to identify hepatic steatosis accurately and often bring a group of asymptomatic patients to clinical attention. Occasionally, patients with NAFLD are symptomatic and describe a fullness or discomfort in their right upper quadrant that does not appear to be associated with severity of disease. Physical examination generally is normal with the exception of the common nding of hepatomegaly. A novel nding of increased dorsocervical lipohypertrophy in patients with NAFLD was described recently by Cheung et al.25 Interestingly, dorsocervical lipohypertrophy was found to be the single greatest contributor to the severity of histologic ndings of steato-

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hepatitis and may prove to be a useful tool in the diagnosis of NASH. NAFLD patients typically meet criteria for the metabolic syndrome as dened by the American Heart Association and National Heart, Lung, and Blood Institute, with prevalence rates reported from 47% to 71%.26 28 In addition, the presence of the metabolic syndrome has been linked to NASH as well as severe brosis in NAFLD patients on multivariate analysis.29 Dening criteria for the metabolic syndrome (applying the earlier-described society guidelines) include any 3 of the following 5 laboratory and physical examination ndings: increased waist circumference (men, 40 in; women, 35 in), increased triglyceride levels of 150 or higher, reduced high-density lipoprotein (HDL) levels of less than 40 mg/dL in men or less than 50 mg/dL in women, increased blood pressure of greater than 130 mm Hg systolic or greater than 85 mm Hg diastolic, or increased fasting glucose level of greater than 100 mg/dL.30 Lipid and glucose measurements are considered positive if the patient is already on cholesterol- or glucose-lowering medications. Percutaneous liver biopsy remains the standard for distinguishing isolated fatty liver from NASH. Key histopathologic criteria seen with NASH include macrovesicular steatosis, lobular inammation, hepatocyte ballooning, and often perisinusoidal/perivenular brosis as well as MalloryDenk bodies.31 However, agreement among pathologists is not universal. The NAFLD activity score (NAS) is a histologic scoring system that was developed by the National Institutes of Healthsponsored NASH Clinical Research Network, which focuses on steatosis, lobular inammation, and hepatocyte ballooning. A NAS of 5 or greater is consistent with NASH and a score of 2 or less is not associated with NASH, with scores of 3 or 4 falling somewhere in between. The NAS was not intended to be used as a diagnostic tool, but rather to provide a uniform tool for assessing disease severity, ideally in clinical trials.32 Recent data have shown that signicant sampling variability exists for brosis and inammation, although this may be attenuated with good core biopsy samples.33 Unfortunately, adequate biopsy samples remain an issue and given the signicant prevalence of NAFLD coupled with the previously described limitations of biopsy, fewer invasive tests are being developed to identify NASH with or without advanced brosis. These diagnostic modalities can be divided into tests using image analysis and tests that combine biomarker and clinical data.

NAFLD who underwent CT, US, and MR imaging clearly showed that these radiologic studies were unable to accurately discriminate between NASH and isolated fatty liver. All 3 radiologic studies were best able to predict 33% or greater steatosis, but were not accurate in assessing for any features of steatohepatitis. Novel techniques are under development that may prove to be useful radiologic tools to diagnose NASH noninvasively. One such idea involves contrast ultrasound using Levovist (Shering, Berlin, Germany), with delayed images taken at 5- to 10-minute increments for 50 minutes, and has shown great accuracy in diagnosing NASH with a receiver operating curve (ROC) of 100% among the 21 NASH, 33 NAFLD, and 10 healthy patient controls.34 This minimally invasive novel application of US requires further study but shows early promise as a diagnostic tool.

Imaging for NASH Fibrosis

Although efforts to use noninvasive imaging studies to accurately grade NAFLD in terms of NASH have been unsuccessful, the investigations that use imaging to stage brosis in patients, and thus identify those with advanced disease, have shown more promise. Transient elastography is an ultrasound-based technology that is used to measure liver stiffness. In a recent study of 68 patients with NAFLD, a stepwise increase in elasticity was shown with severity of hepatic brosis.35 This study showed good correlation between liver biopsy brosis stages 1 4 and liver stiffness using ROCs with positive predictive values (PPVs) between 64% and 93.5% for the varying stages of brosis. A recent meta-analysis of 9 studies using this technology showed pooled estimates for sensitivity and specicity of 87% and 91%, respectively, for patients with stage IV brosis and 70% sensitivity and 84% specicity for stages IIIV brosis.36 One important caveat that requires further investigation is that steatosis and high body mass index (BMI; 25) has been shown to reduce the reproducibility of this new technology.37 An MR equivalent to transient elastography also has been investigated as a noninvasive means to evaluate for hepatic brosis. A recent study by Yin et al38 showed promising results yielding 98% and 99% sensitivity and specicity, respectively, for identifying the presence of any brosis. Hepatic steatosis also was identied correctly and the degree of steatosis did not seem to confound brosis measurements. One limitation of this initial study was that the liver biopsies were on average 6.5 months apart from the imaging study, but the signicance of this separation is uncertain. Further study into this novel imaging technique is warranted. Both of these elastography techniques require large multicenter trials in conjunction with liver biopsy before they can be applied to regular clinical practice.

Imaging for NASH

An important limitation of all imaging modalities including CT scan, US, and MR imaging is the inability of these techniques to differentiate isolated hepatic steatosis from steatohepatitis. The denitive study by Saadeh et al18 of 90 consecutive patients with biopsy-proven

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Table 2. Noninvasive Biomarkers in NASH

Serum biomarker ROS40,41 Marker of Findings

Leptin4447 Adiponectin4854 High-sensitivity CRP5557

Cytokeratin 185961

Oxidative stress Conicting results: some correlation between NASH and increased level of ROS Insulin Conicting results: higher resistance levels in some studies Insulin ADP lower in NASH sensitivity patients Systemic Conicting results: some inammation increased highsensitivity CRP with NASH compared with NAFLD Hepatic Signicantly higher in apoptosis NASH

Differentiating Isolated Fatty Liver From NASH Biomarkers

Serum biomarkers that could be used as noninvasive tests to distinguish NASH from isolated fatty liver also have been investigated. One or several laboratory tests that could accurately identify, grade, and stage NASH would allow for screening of the large population of patients with NAFLD and avoid invasive and expensive liver biopsies. Several classes of biomarkers are in the initial stages of study that are directed at the pathways believed to be involved in the pathogenesis of NASH (Table 2). Oxidative stress is presumed to be central to the pathogenesis of NASH and therefore biomarkers that measure oxidative stress through reactive oxygen species (ROS) have been looked at as potential surrogate markers of NASH.39 Chalasani et al40 compared serum levels of oxidized low-density lipoprotein (LDL) and thiobarbituric acid-reacting substances in 21 NASH patients with 19 control patients without liver disease of similar age, BMI, and nutritional intake. Signicantly higher levels of lipid peroxidation products were seen in NASH patients, but limitations included a lack of liver biopsy in the control patients and small numbers overall. In contrast, no correlation between oxidative stress and steatosis or brosis was seen in another study of 64 patients with either NAFLD or viral hepatitis.41 These discordant results may reect that hepatic oxidative stress is not reected accurately by serum measurements, but further study is required to render a nal verdict on the utility of measuring serum ROS in NAFLD/NASH patients. Another area of interest has been serum measurements of specic adipocytokines (produced by adipose tissue) such as leptin and adiponectin (ADP).42 Obesity and excess caloric intake enhance up-regulation of leptin resulting in increased free fatty acid delivery to the liver,

contributing to hepatic steatosis.43 Initial investigations showed an association between higher leptin levels and the presence of NASH as well as steatosis grade, although not inammation or brosis.44,45 However, several subsequent studies have failed to show any associations between leptin levels and the presence or absence of hepatic steatosis, inammation, or brosis.46,47 In contrast to leptin, ADP is thought to promote insulin sensitivity and increase glucose utilization and free fatty acid oxidation in the liver. Hui et al48 found signicantly lower serum levels of ADP in patients with NASH when compared with both normal controls and individuals with simple steatosis. Numerous other studies have conrmed that ADP is generally lower in NAFLD patients compared with healthy controls.49 53 Targher et al54 recently showed that ADP levels were associated closely with severity of liver histology to include hepatic steatosis, necroinammation, and brosis. Although all 3 components of hepatic histology were associated with low ADP levels, only steatosis and necroinammation were found to be independent predictors in multivariate analysis. Further study is required to fully delineate the relationship between ADP and severity of liver disease in NAFLD patients. Other markers of systemic inammation such as C-reactive protein (CRP) also have been studied with conicting results. An Australian study found no difference between high-sensitivity CRP levels in patients with simple steatosis and NASH.55 This is in contrast to other studies showing signicant increases in high-sensitivity CRP levels in patients with NASH compared with NAFLD controls.56,57 Given these conicting results, CRP as a marker for hepatic inammation requires further investigation, although its association with other disease processes may limit its clinical usefulness. Hepatic apoptosis is a prominent feature of NASH, and, as such, biomarkers of hepatic apoptosis have been explored as a potential diagnostic tool.58 Wieckowska et al59 showed a striking relationship between plasma levels of caspase-generated cytokeratin-18, a protein involved in one of the nal steps of apoptosis, and the histologic presence of NASH on liver biopsy. Similarly, Yilmaz et al60 measured serum levels of extracellular cytokeratin 18 (M30 antigen and M65 antigen) in patients with NAFLD and varying degrees of severity of NASH. Both of these antigens were found to be signicantly higher in NASH patients with a sensitivity of 60% 69% and a specicity of 87%97% in predicting NASH if the antigen levels were markedly abnormal. The utility of cytokeratin 18 recently was validated independently in a study of 21 pediatric NAFLD patients, which directly correlated the level of cytokeratin-18 to severity of liver disease.61 This modality appears to offer signicant promise as a future diagnostic tool to differentiate isolated fatty liver from NASH.

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Table 3. Macronutrients in NAFLD

Macronutrient Saturated fatty acids Monounsaturated fatty acids PUFAs (n-6) PUFAs (n-3) Trans fatty acids Found In Lard, butter, coconut oil, palm oil Olive oil, nuts, avocados, peanut butter, peanut oil Sunower, corn oil Fish oil, walnuts, salmon, shellsh Fast foods, baked goods, deep fried foods Dairy products (5%) Ruminants (cows/sheep) Margarine Sweetened drinks/sodas, candy Meat, sh, eggs, dairy Whole grains, fruits, and vegetables Action Increases LDL Higher intake decreases LDL, increases HDL Decreases HDL, ? increase oxidative stress Decreases FFA, glucose, insulin, TNF- Increases inammatory markers and LDL (Naturally derived trans FAs do not have above actions) Worsens insulin resistance Uncertain Improve insulin resistance Findings in NASH Higher intake in NASH patients Uncertain High n-6/n-3 ratio in NASH patients Higher intake decreases hepatic steatosis (small studies) Uncertain

Sucrose/fructose Protein Fiber

Higher intake in NASH patients Uncertain Lower intake in NASH

TNF, tumor necrosis factor; ?, conicting data.

Scoring Systems for Identifying NASH From NAFLD

Scoring systems using one or several clinical and/or laboratory parameters to identify patients with NASH from the larger pool of NAFLD patients also have been assessed. Several studies have looked at a variety of variables that might prove suitable (Table 3). Palekar et al62 developed a clinical model that sums 5 risks factors for NASH identied on multivariate logistic regression. These factors include age 50 or older, female sex, aspartate aminotransferase (AST) level of 45 or greater, BMI of 30 or greater, AST/ALT ratio of 0.80 or greater, and hyaluronic acid level of 55 or greater. Combining 3 or more of these factors yielded a sensitivity of 73.7% and a specicity of 65.7% for detecting NASH with an ROC of 0.763. This study provided a relatively simple means of identifying NASH patients but requires further validation in a larger study population. A larger European study assessed the utility of the NASH Test (Biopredictive) to distinguish NASH from isolated fatty liver.63 This complex test including 13 clinical and laboratory parameters was developed using 160 patients in the training group, 97 patients in a multicenter validation group, and 383 control patients. Overall specicity was shown to be 94%, with a much lower sensitivity of 33% and an ROC of 0.79. Further scoring systems are under development that may better identify NAFLD patients with NASH, but will require independent, prospective validation before being applied broadly in clinical practice.

Distinguishing Advanced Fibrosis in NASH

The ability of one or several screening tests to predict hepatic brosis in patients with NAFLD also has been an area of intense interest. Study of potential surrogate markers of brosis have shown success in identifying those with advanced brosis but have been less

accurate in predicting mild to moderate brosis (Table 3).64 One of the early scoring systems developed called the body mass index; age at liver biopsy; alanine aminotransferase; and serum triglycerides (BAAT) score used 4 easily determined clinical variables to assess for hepatic brosis.65 This scoring system showed good PPV in determining advanced brosis but fell short of an ideal screening test to identify mild to moderate disease. The same group expanded their efforts with the development of the FibroTest-FibroSURE (Biopredictive) based on 2macroglobulin, apolipoprotein A1, haptoglobin, total bilirubin, and -glutamyltransferase levels.66 A 90% negative predictive value (NPV) for advanced brosis and a 70% PPV for advanced brosis were noted in nal analysis. The diagnosis of borderline NASH was harder to make with a 72% NPV and 74% PPV. This is an important limitation of the FibroTest-FibroSURE, which translates into one third of total patients enrolled still requiring a liver biopsy. The European Liver Fibrosis study evaluated 1021 patients using 9 surrogate markers of brosis and developed an algorithm using 4 of these markers that showed 90% sensitivity in detecting brosis as well as 92% NPV in ruling out brosis.67 This study was limited in the fact that it combined patients with all types of chronic liver disease and requires further study in NAFLD-specic patient populations. The NAFLD brosis scoring system, developed in collaboration between multiple liver centers, uses 6 commonly measured parameters including age, hyperglycemia, BMI, platelet count, albumin level, and AST/ ALT ratio.68 This scoring system uses a 2-point cut-off system similar to the FibroTest-FibroSURE. By using a low cut-off score (1.455), the NPV for excluding advanced brosis was 93% in the estimation group and 88% in the validation group. When a high cut-off score

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Figure 1. Potential pathophysiologic effects of therapies that are under investigation. The development of hepatic steatosis and subsequent steatohepatitis is multifaceted. Several therapeutic modalities under investigation such as the TZDs, diet, and exercise, and possibly rimonabant, may have pleiotrophic effects in improving NAFLD. *Endocannabinoid receptors have been identied in multiple organs involved in energy homeostasis to include adipocytes, liver, and possibly skeletal muscle and the pancreas.

(0.676) was used, the PPV for predicting advanced brosis was 90% and 82%, respectively. Overall, the NAFLD brosis score predicted advanced brosis with an ROC of 0.82. The authors68 suggest that liver biopsies could therefore be avoided in 75% of patients. A separate validation study of 79 patients found the NPV for excluding advanced brosis to be 93%, but the PPV for predicting advanced brosis was only 42%. This lower PPV translates into fewer patients avoiding liver biopsy.69 Therefore, further validation is necessary before this or any other scoring system can be recommended broadly. A recent review by Guha et al70 tabulated 29 studies that looked at noninvasive markers of hepatic brosis in NAFLD either as primary or secondary end points. This comprehensive review identied the key variables found in the majority of these studies, which included the presence of diabetes, increasing age, increased homeostatic insulin resistance, increased AST/ALT ratio, decreased platelets, hyaluronic acid, and BMI. Although these models are good in predicting advanced brosis at any one time point, they fall short in dening an excellent screening test to identify patients with NASH noninvasively who are at risk of progressing to severe brosis.

Treatment for NASH

Much like the biomarkers being studied to diagnose NASH noninvasively, current therapies are focused on the various pathways thought central in the pathogenesis of this disease (Figure 1). Treatment regimens targeting insulin resistance, oxidative stress, diabetes, hyperlipidemia, obesity, and hepatic brosis all warrant critical appraisal. Multiple modalities to include diet, exercise, surgical interventions, and nally pharmacotherapy require evaluation to determine the most effective treatment algorithms. Although one panacea has not been found and is unlikely to exist, a multimodality treatment regimen may prove effective.

Weight Loss Calorie Reduction

Patients with NAFLD typically are overweight or obese, insulin resistant, and have a consistently higher energy intake when compared with individuals without hepatic steatosis.71 Data have shown that in the setting of obesity, moderate weight loss of approximately 6% via caloric restriction improves insulin resistance and intrahepatic lipid content.72 Furthermore, caloric restriction

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improves serum aminotransferase levels and hepatic histology.7377 The degree of caloric restriction has been questioned. A small study by Anderson et al74 showed that extreme weight loss via starvation leads to worsening liver histology, including brosis. In addition, 2 bariatric surgery studies have shown mild worsening of lobular inammation and brosis in a subset of patients with a mean weight loss of 32 and 38 kg, respectively.78,79 In contrast, others have shown signicant histologic improvement with weight loss through either caloric reduction or bariatric surgery.80 84 Huang et al85 counseled patients to follow a 1400 kcal/day diet for 12 months in 15 biopsyproven NASH patients with a subsequent mean weight loss of 2.9 kg (3% of body weight). Among the 9 of 15 patients (60%) who had a histopathologic improvement on repeat liver biopsy, the average weight loss was 7%. Hepatic brosis did not change signicantly in this small study. No signicant change in brosis also was seen in a meta-analysis of 15 studies that evaluated weight reduction without bariatric surgery in the treatment of nonalcoholic fatty liver.86 Although it would seem that the preponderance of the evidence supports that moderate caloric restriction resulting in modest weight loss is helpful in improving biochemical parameters, insulin sensitivity, and hepatic steatosis, its role in hepatic brosis is less clear. In keeping with the vast majority of todays clinical practices, the recommendations for moderate caloric restriction as an initial therapy in NAFLD patients is supported by data, but well-controlled, larger studies are needed to conclusively show a brosis benet.

Altering Macronutrient Content

Evidence suggests that NASH patients have diets higher in simple carbohydrates and lower ratios of polyunsaturated fatty acids (PUFAs) to saturated fatty acids (SFAs).87,88 Thus, the concept of altering the macronutrient content rather that the total calories of NASH patients also has been investigated. Several areas of diet macronutrient manipulation have been studied to include overall fat vs carbohydrate vs protein intake as well as specic regimens of fatty acids designed to reduce hepatic steatosis and potentially steatohepatitis. The ideal diet composition for NASH patients has not been established, although the general consensus has been that excessive intake of either fat or carbohydrate is harmful. A randomized controlled trial (RCT) of low-fat vs low-carbohydrate diet showed greater weight loss and improved lipid panels in the low-carbohydrate group.89 A small pilot trial of 5 NAFLD patients who followed a low-carbohydrate (20 g/day) diet for 6 months showed histologic improvements in 4 of the 5 patients who had a mean weight loss of 12.8 kg.90 Other studies have shown benet with lower-fat diets. Improvements in hepatic steatosis via MR spectroscopy was shown in 2 recent trials: 1 of 10 obese nondiabetic

women91 and 1 of 8 NAFLD patients.92 A recent comprehensive review by Zivkovic et al93 examined the role of various popular weight-loss diets to include Atkins, Ornish, Zone, and South Beach diet in the treatment of NAFLD. This intriguing article suggested that diets that improve insulin sensitivity, promote foods with low glycemic indices, and yield sustainable weight loss offer the most potential benet, although well-designed clinical trials are lacking. Another concept in the arena of dietary composition modication is the difference in the various types of dietary fat (Table 4). Excess SFAs have been shown to promote endoplasmic reticulum stress, hepatic steatosis, and inammation in animal models, although it remains uncertain if a minimum intake of SFAs are required for optimal metabolism.87,9395 On the other hand, monounsaturated fatty acids such as found in olive oil, peanut butter, nuts, and avocados are thought to be generally benecial because they decrease total cholesterol, triglycerides, serum LDL, and maintain HDL. A small study of 11 insulin-resistant patients showed improvement in insulin resistance and increased adiponectin levels after 1 month of a monounsaturated fatty acid enriched diet.96 Altering the amount of PUFAs in diets also has been studied. When PUFAs have been used to replace SFAs in the diet, signicant cardiovascular benets have been noted.97 Hepatic steatosis in obese mice also has been improved with dietary PUFAs via negative regulation of hepatic lipogenesis.98 The ratio of n-6 to n-3 PUFAs also seems to be important in predicting insulin resistance. An excessive amount of n-6 PUFAs with a high n-6/n-3 ratio was shown in a recent study of 45 NASH patients compared with 856 age- and sex-matched controls.99 N-3 PUFAs such as alpha-linoleic acid (sh oil) appeared to be benecial in 2 small studies in patients with NAFLD with improvement in serum triacylglycerol concentrations, fasting glucose, liver enzyme levels, and hepatic steatosis.100,101 Walnuts are another source of alpha-linoleic acid that has been shown to improve lipid proles in diabetes.102 On the other hand, trans fatty acids occurring in dairy foods as well as hydrogenated margarine products have been less well studied in patients with NAFLD. However, information in healthy subjects suggests that intake of these hydrogenated oils increases inammatory markers and increases the LDL:HDL ratio.103,104 Based on these studies, general recommendations to avoid or reduce the intake of trans fatty acids seems reasonable. The increased intake of sucrose and fructose in Western diets also may play a role in the development of NAFLD. A recent population-based study showed that NAFLD patients consumed almost twice the amount of soft drinks than control counterparts.105 It has been speculated that the high fructose content of nondiet sodas is associated with increased hepatic de novo lipogenesis, hypertriglyceridemia, and hepatic insulin resis-

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Table 4. Pharmacologic Therapies in the Treatment of NASH

Treatment Orlistat Mechanism Weight loss Biochemical effects 2 LFTs and insulin resistance Histologic effects 2 Steatosis, inammation, NAS score 2 Steatosis Comments Improvement in inammation and NAS seen if weight loss 9% Animal data, psychiatric side effects Animal and pilot studies in NAFLD; extensively studied in type 2 diabetes mellitus Side effects: weight gain, peripheral edema, cardiac, fractures, need for maintenance therapy Data conicting; no RCTs

Rimonabant

Weight loss, possible peripheral effects Weight loss

Incretin analogs (exendin-4)

2 Insulin resistance, triglyceride levels, LFTs 1 HDL, adiponectin 2 LFTs, insulin resistance, hemoglobin A1C

2 Steatosis

TZDs

PPAR- agonists

2 LFTs, insulin resistance, and TNF- 1 Adiponectin 2 LFTs and insulin resistance No effect on adiponectin 2 LFTs

2 Steatosis, inammation and brosis

Metformin

1 AMP kinase

Vitamin E

2 Oxidative stress

/ improvement in steatosis, inammation, and brosis Uncertain

Betaine UDCA Pentoxifylline HMG CoA-reductase inhibitors Ezetimibe

2 Oxidative stress Hepatoprotective Hepatoprotective Improve lipid panel Blocks cholesterol absorption in intestine ? Inhibits stellate cells

2 LFTs No change 2 LFTs, TNF- ? LFTs ? LFTs

2 Steatosis, inammation, brosis No change 2 Steatosis, inammation Uncertain 2 Steatosis and brosis

Large trials with histologic follow-up evaluation required Pilot study only Not benecial in large RCT Pilot study only Conicting studies Animal data

Angiotensin-receptor blockers

2 LFTs

2 Fibrosis

Animal and pilot studies

2, decreases; AMP, adenosine 5=-monophosphate; LFT, liver function test; PPAR, peroxisome proliferatoractivated receptor; HMG CoA, 3-hydroxy-3-methylglutaryl-coenzyme A; TNF, tumor necrosis factor.

tance.106 This corresponds to a recent study in a mouse model showing that rapidly absorbed carbohydrates promotes hepatic steatosis when compared with consumption of slowly absorbed carbohydrates with a lower glycemic index.107 This eld of diet composition manipulation represents a new and intriguing area of study in the treatment of NASH that requires further study. Large RCTs are needed before nal recommendations can be made as to the ideal diet for NAFLD patients. The general concept that foods with low glycemic index as well as diets containing more monounsaturated fatty acids and n-3 PUFAs, low SFAs, and limited to no fructose seem to be acceptable general guidelines to offer patients who are agreeable to lifestyle changes in their treatment.

Exercise
Exercise is another area of interest in the eld of lifestyle modication as therapy for NAFLD although there are only limited data available. Most of the evidence that does exist uses exercise in combination with diet to promote weight loss. The general consensus has been that exercise works synergistically with diet modication to produce benecial metabolic effects.108 Suzuki et al109

found that in a population of 348 male patients who received annual health physicals, regular exercise and weight loss over a 1-year period was associated with a signicant improvement in serum aminotransferase levels. Another study that followed up 25 obese NAFLD patients prospectively for 3 months conrmed that regular exercise dened as walking or jogging daily along with a reduced-calorie diet produced signicant improvement in serum aminotransferase levels, fasting glucose, and hepatic steatosis compared with a control population.110 Hickman et al111 followed up 31 NASH patients for 3 months with combined dietary modications and moderate exercise of 150 minutes of aerobic exercise weekly with a mean weight loss of 4% of total body weight. Patients who lost weight experienced improvement in serum aminotransferase levels that were maintained at 15 months of follow-up evaluation provided the weight loss was sustained. Repeat liver biopsy in 14 patients 3 6 months after lifestyle modication showed signicant improvement in steatosis and brosis. This corresponds to a recent study that inversely correlates the presence of NAFLD and a patients physical tness level.112

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Collectively these studies support the general concept that slow gradual weight loss through diet and exercise may prove benecial in the treatment of NASH. Clearly, however, larger RCTs are needed to better dene the optimal exercise regimen as well as the most benecial dietary composition and total calorie intake.

Medical Therapies That Augment Weight Loss

Orlistat. The reversible inhibitor of gastric and pancreatic lipase, orlistat, appears to be the most studied weight loss medication used in the treatment of NASH. This medication is taken with meals and blocks approximately 30% of dietary triglycerides. Early pilot work suggested this medication may be benecial in the treatment of NASH.113,114 Two subsequent randomized controlled trials were performed to further investigate the potentially benecial effects of orlistat in the treatment of NASH.115,116 Six to 9 months of therapy with orlistat vs placebo produced 8% vs 6% total body weight loss, respectively. ZelberSagi et al115 showed steatosis only improved in the orlistat group despite signicant weight loss in each group. Harrison et al116 obtained repeat liver biopsies at 9 months and showed that regardless of regimen, a 9% body weight reduction produced improvement in biochemical markers, serum aminotransferase levels, steatosis, and necroinammation, but no improvement in brosis. The implications of these 2 RCTs were that weight loss is the common pathway through which orlistat may exert a benecial effect. Other weight loss medications are under investigation in search of a medication with minimal side effects and excellent efcacy. These data, combined with diet and exercise studies, suggest that relatively modest amounts of weight loss, on the order of 5%10%, will lead to improvement in both biochemical and histopathologic abnormalities seen in NASH. Rimonabant. Increasing evidence suggests the endocannabinoid system is enhanced in the setting of overweight or obesity. Activation of cannabinoid (CB-1) receptors located both centrally and peripherally (to include organs involved in energy homeostasis such as the liver, adipocytes, and possibly skeletal muscle and pancreas), lead to enhanced weight gain and altered energy metabolism. Inhibition of these receptors has been the subject of recent intense investigation. Although not specically studied in NASH patients to date, several large randomized placebo-controlled trials with the cannabinoid-1 antagonist, rimonabant, in both overweight/obese nondiabetic and diabetic patients have been performed.117 Rimonabant given at a dose of 20 mg/day for 1 year is associated with a weight loss of 4.7 to 5.4 kg and improved waist circumference. Signicant improvement in serum triglyceride levels, HDL levels, insulin resistance, and adiponectin levels also has been shown and seem to be greater than what would be expected with weight loss alone, suggesting an added pe-

ripheral effect. In addition, signicant improvement in serum ALT levels, -glutamyltransferase levels, alkaline phosphatase levels, and hepatic steatosis has been shown in an animal model of NAFLD.118 Multicentered RCTs of rimonabant in human beings with NASH are underway. The recent association of this medication with psychiatric issues to include depression may limit its future use, and it is currently not available in the United States outside of clinical research trials.
Glucagon-like protein-1receptor agonist (incretin analogs). Peptides that are derived from glucagon-

like protein-1receptor agonists such as exenatide also may prove to be potential therapeutic agents in the treatment of NASH. These incretin analogs have been studied extensively in patients with type 2 diabetes mellitus and have been found to promote insulin secretion, suppress inappropriate glucagon secretion, slow gastric emptying, induce satiety, and are associated with modest weight loss. Nausea occurs in up to 57% of patients, typically early in the course of therapy, and can be mitigated with dose titration.119 A recent study in obese mice showed reduced markers of oxidative stress and insulin resistance as well as decreased hepatic steatosis.120 A recent case report of a diabetic male patient with NAFLD treated for 44 weeks with exenatide showed improvement in serum aminotransferase levels and hepatic steatosis.121 Numerous other studies have supported the glycemic benets of exenatide (exendin-4) with further well-designed studies specic to NASH populations required.

Surgical Therapy for Weight Loss

Until medical therapy is developed that effectively promotes and sustains weight loss, surgical therapy will continue to remain a viable alternative in select patient populations. Surgical therapy for obesity has become exceedingly popular in the past decade and has evolved signicantly from the early malabsorptive surgeries. These early surgeries such as the jejunoileal bypass produced dramatic weight loss but were shown to cause signicant worsening of liver disease postoperatively.122,123 Newer surgical techniques such as adjustable gastric banding and Roux-en-Y gastric bypass are overall better tolerated and have been shown to improve metabolic syndrome, insulin resistance, and hepatic histology. Adjustable gastric banding in 22 obese NASH patients produced an average 34-kg weight loss as well as significant improvement in hepatic steatosis, inammation, and brosis at repeat liver biopsy more than 2 years after surgery.82 Roux-en-Y gastric bypass has been used to produce even greater weight loss and its utility in improving NASH has been well studied. A recent study of 19 morbidly obese NASH patients who lost a mean of 52 kg of body weight after Roux-en-Y gastric bypass showed signicant improvement in steatosis, lobular inammation, and brosis on average 21.4 months postoperatively.83 Another study of 70 patients undergoing bariatric

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surgery showed a mean weight loss of 59% at 15 months after surgery and 82% improvement in steatohepatitis and 39% improvement in brosis.124 Others also have shown large metabolic and histologic improvements post gastric bypass with no patients showing worsening of hepatic brosis and 50%75% of patients showing improvement in hepatic brosis.125,126 These studies provide compelling evidence that bariatric surgery, using either adjustable gastric banding or Roux-en-Y gastric bypass, results in substantial weight loss, and is associated with a marked improvement in biochemical and histologic parameters of NASH patients. Subsequently, these invasive therapies should be considered in morbidly obese patients with other medical conditions that cumulatively would warrant the risks of surgical intervention.

Medical Therapies That Improve Metabolic Proles

In a similar manner to the tests under development using specic biomarkers to diagnose NASH based on a common pathway of insulin resistance and oxidative stress, pharmacologic therapies have been evaluated that have targeted these same pathways. As the steps involved in the development of steatohepatitis and brosis are elucidated further, pharmacologic therapies may be better directed to cause histologic and biochemical improvement.

Insulin-Sensitizing Medications
Thiazolidinediones. Thiazolidinediones (TZDs) improve insulin resistance in skeletal muscle, adipose tissue, and the liver through their action as peroxisome proliferatoractivated receptor agonists that increase plasma adiponectin levels and fatty acid oxidation and decrease fatty acid synthesis.127 These agents have been the most studied insulin sensitizers used in the treatment of NASH. Pioglitazone and rosiglitazone are the 2 currently available TZDs and both have been evaluated in small prospective trials. A preliminary study of 22 NASH patients (50% with impaired glucose tolerance or diabetes) treated for 48 weeks with rosiglitazone showed overall improvement in insulin sensitivity and serum aminotransferase levels. Repeat liver biopsy at 48 weeks showed signicant improvement in necroinammation, ballooning, and zone 3 perisinusoidal brosis with 45% (10 patients) no longer meeting criteria for NASH. However, this study lacked a control arm and within 6 months posttherapy serum aminotransferase levels were almost back to pretreatment levels.128 A subsequent randomized, placebo-controlled trial in 63 NASH patients (32% with diabetes) treated for 1 year with rosiglitazone 8 mg/day showed signicantly greater improvement in steatosis compared with placebo, and signicantly less histologic progression in reference to ballooning, inammation, and brosis.129 However,

improvement in steatosis was not seen uniformly in all patients treated with rosiglitazone. Pioglitazone also was evaluated in several small pilot and proof-of-concept trials. An open-label trial in 18 nondiabetic NASH patients treated with 30 mg/day for 48 weeks showed overall histologic improvement in two thirds of patients with signicant improvement in steatosis, cellular injury, parenchymal inammation, and brosis.130 Another pilot study compared pioglitazone 30 mg/day plus vitamin E 400 IU/day with vitamin E alone and showed improvement in steatosis in both groups but improvement in hepatic inammation and brosis in the pioglitazone plus vitamin E arm only.131 A more recent placebo-controlled study by Belfort et al132 in 55 NASH patients with impaired glucose tolerance or type 2 diabetes mellitus provided evidence that therapy with 6 months of a low-calorie diet plus pioglitazone improved biochemical and histologic parameters signicantly more than patients prescribed a low-calorie diet and placebo. Although signicant improvement was seen for steatosis and inammation compared with placebo, brosis improvement did not reach signicance when compared with the placebo group (P .08). These preliminary ndings are supported by another randomized placebocontrolled trial that followed up 74 nondiabetic patients for 12 months and showed signicant improvement in metabolic and histologic parameters, including brosis, in the pioglitazone group when compared with placebo.133 Interestingly, lobular inammation and steatosis were not improved between groups and further investigation is necessary to understand these ndings. Although these studies provided some evidence that the TZDs may be benecial in the short term, the longterm benets remain to be seen. Lutchman et al134 showed that continued therapy may be required to maintain histologic benet. In this study of 21 patients treated for 48 weeks with pioglitazone, liver biopsies were performed at baseline, at end of therapy, and, in 9 patients, 48 weeks after stopping therapy. In the patients who underwent the 3 serial liver biopsies, initial improvement in biochemical and histologic parameters were not maintained at the 48-week posttherapy evaluation, with 7 of 9 patients developing histopathologic evidence of NASH once again, despite no change in average body weight. The side-effect prole of the TZD class of medication also must be addressed. Modest weight gain of approximately 23 kg has been shown routinely and appears to be caused by increased peripheral fat deposition. Some retrospective studies also suggest that TZDs promote bone loss and may contribute to osteoporosis and increased fractures, particularly in postmenopausal women.135 If limited durations of therapy were adequate, this would be less of an issue, but if long-term therapy is necessary to maintain hepatic benet, this must be better addressed. Further investigation is required to denitively address this issue.

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Moreover, a recent meta-analysis of diabetic male patients taking rosiglitazone has suggested an increased risk of cardiovascular events.136 Although this study tabulated an increased risk of myocardial infarction of 43% and cardiovascular death of 64%, it has been widely criticized for its inclusion criteria, methods of statistical analysis, and overall low event rate.137 Other analyses using broader inclusion criteria and different statistical analysis failed to show a signicant increase in myocardial infarction in this same patient population. Furthermore, a similar meta-analysis with pioglitazone showed a 20% reduction in cardiovascular events.138 Additional investigation is required to address the issue denitively. The risk of congestive heart failure exacerbation with the use of TZDs also has been reported and has been attributed to TZD-related uid retention and diastolic dysfunction in susceptible individuals. Subsequently these agents are contraindicated in patients with New York Heart Classication stage 3 4 heart failure. Lago et al139 recently showed an increased risk of congestive heart failure, but did not show increased cardiovascular death among patients taking TZDs. Large prospective trials are ongoing and their results will determine the future of TZDs in the treatment of NASH. Metformin. Metformin is a biguanide that improves insulin sensitivity by decreasing hepatic gluconeogenesis and limiting triacylglycerol production. Animal model data has been promising, with early studies of obese mice given metformin showing improved serum transaminase levels, hepatomegaly, and steatosis.140 Data from human studies are limited. Marchensini et al141 rst showed improvement in insulin sensitivity and serum aminotransferase levels in an open-label trial of 20 patients treated with metformin 1500 mg/day for 4 months. This was followed by a 6-month randomized open-label trial of metformin 850 mg twice daily plus diet vs dietary restriction of 1600 to 1800 kcal/day.142 Signicant improvement was seen in the metformin group compared with the diet-alone group. However, no signicant improvement in necroinammation or brosis was found. A similar open-label trial of metformin given for 1 year in 15 patients showed improvement in serum aminotransferase levels and insulin sensitivity at 3 months, but return of serum aminotransferase levels to pretreatment levels were seen by the completion of the study.143 A subsequent open-label RCT in 110 NAFLD patients was performed in Italy that compared metformin treatment with 2 control groups of vitamin E 800 IU/day or a prescriptive, weight-reducing diet.144 Metformin showed higher rates of aminotransferase normalization. Repeat liver biopsy in 31% of the metformin group showed improvement in steatosis, necroinammation, and brosis, although there was no histologic follow-up evaluation in the control groups. Interestingly, metformin compared with rosiglitazone in a study of 20 patients with type 2 diabetes

showed improvement in insulin resistance and transaminase levels in both groups but decreased hepatic fat as measured by proton spectroscopy in the rosiglitazone group.145 Overall, the insulin-sensitizing medications show the most promise to date in improving histopathology in patients with NASH. Current data suggest that metformin may be less efcacious than the TZD class of medications; however, randomized, placebo-controlled studies with metformin using histopathologic end points have yet to be performed. Interestingly, one difference between the 2 classes of insulin sensitizers is the ability of the TZD class to up-regulate adiponectin expression. Given the multiple effects of adiponectin including upregulation of adenosine 5=-monophosphate (AMP) kinase and peroxisome proliferatoractivated receptor- inhibition, the inability of metformin to positively impact adiponectin expression may have important consequences on the overall effectiveness of this medication in the treatment of NASH, at least when used as monotherapy. Combination therapy with metformin and the TZD class of medications deserves consideration in clinical trials because the untoward weight gain with TZD monotherapy may be mitigated. Antioxidant therapy. The depletion of antioxidants within hepatocytes resulting in impaired ROS inactivation is the basis for antioxidant supplementation as a potential treatment for NASH.146 The lipid-soluble antioxidant, tocopherol (vitamin E), has been shown to inhibit lipid peroxidation and suppress inammatory cytokines such as tumor necrosis factor-, and its use in the treatment of NASH has been studied. One study comparing 6 months of 1000 IU vitamin E and 1000 mg vitamin C daily vs placebo showed signicant improvement in hepatic brosis within the vitamin group but not between groups and no change in serum aminotransferase levels or hepatic inammation.147 Alternatively, others have shown improvement in serum aminotransferase levels and insulin resistance although follow-up histopathology was not assessed.148,149 Betaine, another antioxidant studied in the treatment of NASH, increases S-adenosylmethionine levels and is thought to reduce fat deposition in the liver.143 Marked improvement in serum aminotransferase levels, hepatic steatosis, inammatory activity, and brosis was seen in a pilot trial of 10 NASH patients treated with betaine anhydrous in a 20-mg divided dose daily for 12 months.150 Rigorous follow-up studies are required with particular attention paid to the formulation of betaine used because betaine anhydrous is a medication regulated by the Food and Drug Administration whereas the more readily available betaine hydrochloride is a dietary supplement found in nutrition stores.151 Phlebotomy targeting hepatic iron overload with resultant increased oxidative stress is another potential therapeutic modality that has been investigated in the

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treatment of NASH. In a study of 64 NAFLD patients undergoing therapeutic phlebotomy to a goal of a ferritin level of less than 80 ng/mL for 8 months in addition to lifestyle modication vs lifestyle modication alone, the phlebotomy group showed signicantly improved insulin resistance.152 Serum aminotransferase levels were not signicantly different between the 2 groups and hepatic histology was not assessed in this preliminary study. Larger studies with histologic follow-up evaluation are necessary to determine the utility of this treatment modality. Overall, antioxidants represent a novel class of medications that have shown some promising initial results in the treatment of NASH but further well-designed large RCTs are required and it is likely that these therapies will be used in combination regimens with other agents that affect insulin sensitivity.

Others
Cytoprotective agents. Cytoprotective agents are thought to work by preventing apoptosis and downregulating the inammatory cascade that has been shown to occur in NAFLD patients. Ursodeoxycholic acid (UDCA) is the most studied and initial pilot trials proved promising as a NASH-specic therapy. However, a wellconducted, multicenter, double-blind, placebo-controlled trial of UDCA for 2 years failed to show signicant change in biochemical or histologic parameters.153 Interestingly, Dufour et al154 showed biochemical benet as well as reduced steatosis with the combination of UDCA with vitamin E compared with UDCA plus placebo or double-placebo groups after 2 years of therapy.154 It remains to be seen whether UDCA in combination with other medications may prove clinically efcacious. Pentoxifylline, another cytoprotective agent, exerts its effect through inhibition of tumor necrosis factor-. Twelve months of pentoxifylline 400 mg 3 times daily given in 2 recent pilot trials improved serum aminotransferase levels as well as steatosis and lobular inammation.155,156 Although no dangerous side effects have been noted, the high rates of nausea with this medication resulting in a 50% drop-out rate may limit the clinical utility of this medication. 3-hydroxy-3-methylglutaryl-coenzyme A reductase therapy. Medications that exert benecial effects on

interest in using statins to treat NASH,159 but a more recent study with simvastatin showed no affect on adiponectin or improvement in insulin sensitivity in a group of patients with metabolic syndrome.160 Questions remain in reference to the specic mechanisms of action of these drugs and it may be that they have positive effects beyond altering insulin sensitivity or adipocytokine levels, but these studies have yet to be performed. Ezetimibe. Ezetimibe (Zetia, Kenilworth, NJ) is another lipid-lowering medication that may have hepatic benets in the treatment of NASH. This medication selectively inhibits intestinal cholesterol absorption and in controlled studies with statins appears to lower serum LDL cholesterol by 24% as well as triglycerides by 16%.161 A recent study by Deushi et al162 showed improved insulin resistance and decreased lipid deposition and brosis in obese rats treated with ezetimibe. No clinical trials with this therapy have been published. Angiotensin-receptor blockers. A novel class of medications that have been evaluated in the treatment of NASH are the angiotensin-receptor blockers. These medications, which have been used to treat hypertension and congestive heart failure, have been shown to have liverspecic benecial effects. Obese mice given angiotensinreceptor blockers showed improved serum aminotransferase levels and reduced expression of inammatory cytokines and hepatic brosis through inhibition of hepatic stellate cell activity.163 Two human pilot studies also have been completed and suggest that angiotensinreceptor blockers may improve serum aminotransferase levels and provide histologic benet in NASH patients.164,165 Similar to most of the research conducted in regards to NASH therapy, large placebo-controlled RCTs are required to ascertain if any substantial benet can be achieved with long-term angiotensin-receptor blocker therapy in NASH patients.

Conclusions
The myriad of public health issues related to the obesity epidemic continues to grow as more medical conditions are linked to obesity, insulin resistance, and the metabolic syndrome. The growing incidence of NAFLD, and subsequently NASH, almost certainly will be reected in subsequent increases in cirrhosis and hepatocellular carcinoma in the future. Noninvasive and accurate screening tests to correctly identify patients at risk for disease progression as well as effective treatment regimens must be developed for these high-risk patients. Currently, there is no ideal treatment regimen but those interventions that produce sustained substantial weight loss such as bariatric surgery seem to provide the single most benet. Modest but sustained weight loss, regular exercise, and diet composition modication also appear to ameliorate biochemical and histologic abnormalities. Thus far, medical therapies with the exception of the TZDs have not been subjected to randomized, placebo-

lipid proles offer another potential therapeutic class of medications. The most studied of this family of lipidlowering medicines are the statins, which work through inhibition of 3-hydroxy-3-methylglutaryl-coenzyme A reductase, which catalyses an essential step in cholesterol biosynthesis. Initially statins were noted to cause increases in hepatic transaminase levels in patients when used to treat hyperlipidemia, and therefore were thought to be harmful to liver function. However, recent studies have shown statins to be safe when given to patients with NAFLD.157,158 An early pilot trial with atorvastatin raised

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controlled trials and have shown only modest preliminary benets. The TZDs, although appearing to be effective in reducing steatosis, inammation, and brosis are limited by small proof-of-concept trials and potentially untoward effect proles as well as an apparent need for maintenance therapy. Other therapies directed at insulin resistance, oxidative stress, cytoprotection, and brosis also may offer benet, but further study is required. A multifaceted approach that relies on lifestyle changes, limited weight loss, and pharmacotherapy requires further investigation because no one treatment approach has proved universally applicable to the large general population with NASH.
References
1. Beymer C, Kowdley KV, Larson AA, et al. Prevalence and predictors of asymptomatic liver disease in patients undergoing gastric bypass surgery. Arch Surg 2003;138:1240 1244. 2. Gholam PM, Flanebaum L, Machan JT, et al. Nonalcoholic fatty liver disease in severely obese subjects. Am J Gastroenterol 2007;102:399 408. 3. Machado M, Marques-Vidal P, Cortez-Pinto H. Hepatic histology in obese patients undergoing bariatric surgery. J Hepatol 2006; 45:600 606. 4. Adams LA, Lymp JF, Sauver JS, et al. The natural history of nonalcoholic fatty liver. Gastroenterology 2005;129:113121. 5. Targher G, Bertolini L, Poli F, et al. Nonalcoholic fatty liver disease and risk of future cardiovascular events among type 2 diabetic patients. Diabetes 2005;54:35413546. 6. Hamaguchi M, Kojima T, Takeda N, et al. Nonalcoholic fatty liver disease is a novel predictor of cardiovascular disease. World J Gastroenterol 2007;13:1579 1584. 7. Arslan U, Turkoglu S, Balcioglu S, et al. Association between nonalcoholic fatty liver disease and coronary artery disease. Coron Artery Dis 2007;18:433 436. 8. Liangpunsakul S, Chalasani N. Is hypothyroidism a risk factor for non-alcoholic steatohepatitis? J Clin Gastroenterol 2003;37: 340 343. 9. Harrison SA, Torgerson S, Hayashi P. The natural history of nonalcoholic fatty liver disease: a clinical histopathological study. Am J Gastroenterol 2003;98:20422047. 10. Wanless IR, Lentz JS. Fatty liver hepatitis (steatohepatitis) and obesity: an autopsy study with analysis of risk factors. Hepatology 1990;12:1106 1110. 11. Harrison SA, Neuschwander-Tetri BA. Nonalcoholic fatty liver disease and nonalcoholic steatohepatitis. Clin Liver Dis 2004; 8:861 879. 12. Adams LA, Sanderson S, Lindor KD, et al. The histological course of nonalcoholic fatty liver disease: a longitudinal study of 103 patients with sequential liver biopsies. J Hepatol 2005;42: 132138. 13. Pantsari M, Harrison SA. Nonalcoholic fatty liver disease presenting with an isolated elevated alkaline phosphatase. J Clin Gastroenterol 2006;40:633 635. 14. Palmentieri B, de Sio I, La Mura V, et al. The role of bright liver echo pattern on ultrasound B-mod examination in the diagnosis of liver steatosis. Dig Liver Dis 2006;38:485 489. 15. Hamaguchi M, Kojima T, Itoh Y, et al. The severity of ultrasound ndings in nonalcoholic fatty liver disease reects the metabolic syndrome and visceral fat accumulation. Am J Gastroenterol 2007;102:1 8. 16. Mottin CC, Moretto M, Padoin AV, et al. The role of ultrasound in the diagnosis of hepatic steatosis in morbidly obese patients. Obes Surg 2004;14:635 637.

17. Celle G, Savarino V, Picciotto A, et al. Is hepatic ultrasonography a valid alternative tool to liver biopsy? Report on 507 cases studied with both techniques. Dig Dis Soc 1988;33:467 471. 18. Saadeh S, Younossi ZM, Remer EM, et al. The utility of radiological imaging in nonalcoholic fatty liver disease. Gastroenterology 2002;123:745750. 19. Park SH, Kim PN, Kimg KW, et al. Macrovesicular hepatic steatosis in living liver donors: use of CT for quantitative and qualitative assessment. Radiology 2006;239:105112. 20. Duman DG, Celikel C, Tuney D, et al. Computed tomography in nonalcoholic fatty liver disease: a useful tool for hepatosteatosis assessment? Dig Dis Sci 2006;51:346 351. 21. Lee SW, Park SH, Kim KW, et al. Unenhanced CT for assessment of macrovesicular hepatic steatosis in living liver donors: comparison of visual grading with liver attenuation index. Radiology 2007;244:479 485. 22. Fishbein MK, Gardner KG, Potter CJ, et al. Introduction of fast MR imaging in the assessment of hepatic steatosis. Magn Reson Imaging 1997;15:287293. 23. Charatcharoenwitthaya P, Lindor KD. Role of radiologic modalities in the management of nonalcoholic steatohepatitis. Clin Liver Dis 2007;11:3754. 24. Szczepaniak LS, Nurenberg P, Leonard D, et al. Magnetic resonance spectroscopy to measure hepatic triglyceride content: prevalence of hepatic steatosis in the general population. Am J Physiol 2005;288:E462E468. 25. Cheung O, Kapoor A, Puri P, et al. The impact of fat distribution on the severity of nonalcoholic fatty liver disease and metabolic syndrome. Hepatology 2007;46:10911100. 26. Haukeland JW, Konopski Z, Linnestad P, et al. Abnormal glucose tolerance is a predictor of steatohepatitis and brosis in patients with non-alcoholic fatty liver disease. Scand J Gastroenterol 2005;40:1469 1477. 27. Balkau B. New diagnostic criteria for diabetes and mortality in older adults. DECODE study group, European Diabetes Epidemiology Group. Lancet 1999;353:68 69. 28. Marchesini G, Bugianesi E, Forlani G, et al. Non-alcoholic steatohepatitis in patients cared in metabolic units. Diabetes Res Clin Pract 2004;63:143151. 29. Marchesini G, Bugianesi E, Forlani G, et al. Nonalcoholic fatty liver, steatohepatitis, and the metabolic syndrome. Hepatology 2003;37:917923. 30. Grundy SM, Cleeman JL, Daniels SR, et al. Diagnosis and management of the metabolic syndrome. Circulation 2005;112: 27352752. 31. Brunt EM, Janney CG, DiBisceglie AM, et al. Nonalcoholic steatohepatitis: a proposal for grading and staging the histological lesions. Am J Gastroenterol 1999;94:24672474. 32. Kleiner DE, Brunt EM, Van Natta M, et al. Design and validation of a histological scoring system for nonalcoholic fatty liver disease. Hepatology 2005;41:13131321. 33. Ratziu V, Bugianesi E, Dixon J, et al Histological progression of non-alcoholic fatty disease: a critical reassessment based on liver sampling variability. Aliment Pharmacol Ther 2007;26: 821 830. 34. Iijima H, Moriyasu F, Tsuchiya K, et al. Decrease in accumulation of ultrasound contrast microbubbles in non-alcoholic steatohepatitis. Hepatol Res 2007;37:722730. 35. Yoneda M, Fujita K, Inamori M, et al. Transient elastography in patients with non-alcoholic fatty liver disease (NAFLD). Gut 2007;56:1330 1331. 36. Talwalkar JA, Kurtz DM, Schoenleber SJ, et al. Ultrasound-based transient elastography for the detection of hepatic brosis: systematic review and meta-analysis. Clin Gastroenterol Hepatol 2007;5:1214 1220.

May 2008

DIAGNOSIS AND THERAPY OF NASH

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37. Fraquelli M, Rigamonti C, Casazza G et al. Reproducibility of transient elastography in the evaluation of liver brosis in patients with chronic liver disease. Gut 2007;56:968 973. 38. Yin M, Talwalkar JA, Glaser KJ, et al. Assessment of hepatic brosis with magnetic reasonance elastography. Clin Gastroenterol Hepatol 2007;5:1209 1213. 39. Sanyal AJ, Campbell-Sargent C, Mirshahi F, et al. Nonalcoholic steatohepatitis: association of insulin resistance and mitochondrial abnormalities. Gastroenterology 2001;120:11831192. 40. Chalasani N, Deeg MA, Crabb DW. Systemic levels of lipid peroxidation and its metabolic and dietary correlates in patients with nonalcoholic steatohepatitis. Am J Gastroenterol 2004;99: 14971502. 41. Bonnefont-Rousselot D, Ratziu V, Giral P. Blood oxidative stress markers are unreliable makers of hepatic steatosis. Aliment Pharmacol Ther 2006;23:9198. 42. Tsochatzis E, Papatheodororidis GV, Archimandritis AJ. The evolving role of leptin and adiponectin in chronic liver diseases. Am J Gastroenterol 2006;101:112. 43. Anania FA, Parekh S. Abnormal lipid and glucose metabolism in obesity: implications for nonalcoholic fatty liver disease. Gastroenterology 2007;132:21912207. 44. Uygun A, Kadayifci A, Yesilova Z, et al. Serum leptin levels in patients with nonalcoholic steatohepatitis. Am J Gastroenterol 2000;95:3584 3589. 45. Chitturi S, Farrell G, Forst L, et al. Serum leptin in NASH correlates with hepatitis steatosis but not brosis: a manifestation of lipotoxicity? Hepatology 2002;36:403 409. 46. Nakao K, Nakata K, Ohtsubo N, et al. Association between nonalcoholic fatty liver, markers of obesity, and serum leptin levels in young adults. Am J Gastroenterol 2002;97:1796 1801. 47. Chalasani N, Crabb DW, Cummings OW, et al. Does leptin play a role in the pathogenesis of human nonalcoholic steatohepatitis? Am J Gastroenterol 2003;98:27712776. 48. Hui JM, Hodge A, Farrell GC, et al. Beyond insulin resistance in NASH: TNF-alpha or adiponectin? Hepatology 2004;40:46 54. 49. Musso G, Gambino R, Biroli G, et al. Hypoadiponectinemia predicted the severity of hepatic brosis and pancreatic betacell dysfunction in nondiabetic nonobese patients with nonalcoholic steatohepatitis. Am J Gastroenterol 2005;100:2438 2446. 50. Bugianesi E, Pagotto U, Manini R, et al. Plasma adiponectin in nonalcoholic fatty liver is related to hepatic insulin sensitivity and hepatic fat content of liver, not to liver disease severity. J Clin Endocrinol Metab 2005;90:3498 3504. 51. Kaser S, Moschen A, Canyon A, et al. Adiponectin and its receptors in nonalcoholic steatohepatitis. Gut 2005;54:117 121. 52. Shimada M, Kawahara H, Ozaki K, et al. Usefulness of a combined evaluation of the serum adiponectin level, HOMA-IR, and serum type IV collagen 7S level to predict the early stage of nonalcoholic steatohepatitis. Am J Gastroenterol 2007;102: 19311938. 53. Vuppalanchi R, Marri S, Kolwankar D, et al. Is adiponectin involved in the pathogenesis of nonalcoholic steatohepatitis? A preliminary human study. J Clin Gastroenterol 2005;39:237 242. 54. Targher G, Bertolini L, Rodella S, et al. Associations between plasma adiponectin concentrations and liver histology in patients with nonalcoholic fatty liver disease. Clin Endocrinol 2006;64:679 683. 55. Hui JM, Farrell GC, Kench JG, et al. High sensitivity C-reactive protein values do not reliably predict the severity of histological changes in NAFLD. Hepatology 2004;39:1458 1459. 56. Yoneda M, Mawatari H, Fujita K, et al. High sensitivity C-reactive protein is an independent clinical feature of nonalcoholic ste-

57.

58.

59.

60.

61.

62.

63.

64.

65. 66.

67.

68.

69.

70.

71.

72.

73.

74.

75.

76.

atohepatitis (NASH) and also of the severity of brosis in NASH. J Gastroenterol 2007;42:573582. Targher G. Relationship between high-sensitivity C-reactive protein levels and liver histology in subjects with non-alcoholic fatty liver disease. J Hepatol 2006;45:879 882. Feldstein AE, Canbay A, Angulo P, et al. Hepatic apoptosis and Fas expression are prominent features of human nonalcoholic steatohepatitis. Gastroenterology 2003;125:437 443. Wieckowska A, Zein NN, Yerian LM, et al. In vivo assessment of liver cell apoptosis as a novel biomarker of disease severity in nonalcoholic fatty liver disease. Hepatology 2006;44:2733. Yilmaz Y, Dolar E, Ulakaya E, et al. Soluble forms of extracellular cytokeratin 18 may differentiate simple steatosis from nonalcoholic steatohepatitis. World J Gastroenterol 2007;13: 837 844. Mitry RR, De Bruyne R, Quaglia A, et al. Noninvasive diagnosis of nonalcoholic fatty liver disease using serum biomarkers. Hepatology 2007;46:20472048. Palekar NA, Naus R, Larson SP, et al. Clinical model for distinguishing nonalcoholic steatohepatitis from simple steatosis in patients with nonalcoholic fatty liver disease. Liver Int 2005;26: 151156. Poynard T, Ratziu V, Charlotte F, et al. Diagnostic value of biochemical markers (NASHTest) for the prediction of nonalcohol steatohepatitis in patients with non-alcoholic fatty liver disease. BMC Gastroenterol 2006;6:34. Wieckowska A, McCullough AJ, Feldstein AE. Noninvasive diagnosis and monitoring of nonalcoholic steatohepatitis: present and future. Hepatology 2007;46:582589. Ratziu V, Giral P, Charlotte F, et al. Liver brosis in overweight patients. Gastroenterology 2000;118:11171123. Ratziu V, Massard J, Charlotte F, et al. Diagnostic value of biochemical markers (FibroTest-FibroSURE) for the prediction of liver brosis in patients with non-alcoholic fatty liver disease. BMC Gastroenterol 2006;6:6. Rosenberg WM, Voelker M, Thiel R, et al. Serum markers detect the presence of liver brosis: a cohort study. Gastroenterology 2004;127:1704 1713. Angulo P, Hui JM, Marchesini G, et al. The NAFLD brosis score: a noninvasive system that identies liver brosis in patients with NAFLD. Hepatology 2007;45:846 854. Kang H, Omo J, Joel G, et al. Validation of the NAFLD brosis score in predicting advanced brosis in patients with histologically proven non-alcoholic fatty liver disease. Hepatology 2007; 46:750A. Guha IN, Parkes J, Roderick PR, et al. Non-invasive markers associated with liver brosis in non-alcoholic fatty liver disease. Gut 2006;55:1650 1660. Capristo E, Miele L, Forgione A, et al. Nutritional aspects in patients with non-alcoholic steatohepatitis (NASH). Eur Rev Med Pharmacol Sci 2005;9:265268. Sato F, Tamura Y, Watada H, et al. Effects of diet-induced moderate weight reduction on intrahepatic and intramyocellular triglycerides and glucose metabolism in obese subjects. J Clin Endocrinol Metab 2006;92:3326 3329. Palmer M, Schaffner F. Effect of weight reduction on hepatic abnormalities in overweight patients. Gastroenterology 1990; 99:1408 1413. Anderson T, Gluud C, Franzmann MB, et al. Hepatic effects of dietary weight loss in morbidly obese subjects. J Hepatol 1991; 12:224 229. Okita M, Hayashi M, Sasagawa T, et al. Effect of moderately energy-restricted diet on obese patients with fatty liver. Nutrition 2001;17:542547. Thomas EL, Brynes AE, Hamilton G, et al. Effect of nutritional counseling on hepatic, muscle, and adipose fat tissue content

1696

TORRES AND HARRISON

GASTROENTEROLOGY Vol. 134, No. 6

77.

78.

79.

80. 81.

82.

83.

84.

85.

86.

87.

88.

89.

90.

91.

92.

93.

94.

95.

96.

and distribution in non-alcoholic fatty liver disease. World J Gastroenterol 2006;12:58135819. De Luis DA, Aller R, Izaola O, et al. Effect of a hypocaloric diet in transaminases in nonalcoholic fatty liver disease and obese patients, relation with insulin resistance. Diabetes Res Clin Pract 2008;79:74 78. Luychkx FH, Desaive C, Thiry A, et al. Liver abnormalities in severely obese subjects: effect of drastic weight loss after gastroplasty. Int J Obes Relat Metab Disord 1998;22:222226. Kral JG, Thung SN, Biron S, et al. Effects of surgical treatment of the metabolic syndrome on liver brosis and cirrhosis. Surgery 2004;135:48 58. Fisler JS, Drenick EJ. Starvation and semistarvation diets in the management of obesity. Ann Rev Nutr 1987;7:465 484. de Almeida SR, Rocha PR, Sanches MD, et al. Roux-en-Y gastric bypass improves the nonalcoholic steatohepatitis (NASH) of morbid obesity. Obes Surg 2006;16:270 278. Dixon JB, Bhathal PS, OBrien PE. Weight loss and non-alcoholic fatty liver disease: falls in gamma-glutamyl transferase concentrations are associated with histologic improvement. Obes Surg 2006;16:1278 1286. Barker KB, Palekar NA, Bowers SP, et al. Non-alcoholic steatohepatitis: effect of Roux-en-Y gastric bypass surgery. Am J Gastroenterol 2006;101:368 373. Clark JM, Alkhuraishi AR, Solga SF, et al. Roux-en-Y gastric bypass improves liver histology in patients with non-alcoholic fatty liver disease. Obes Res 2005;13:1180 1186. Huang MA, Greenson JK, Chao C, et al. One-year intense nutritional counseling results in histological improvement in patients with nonalcoholic steatohepatitis: a pilot study. Am J Gastroenterol 2005;100:10721081. Wang RT, Koretz RL, Yee HF. Is weight reduction an effective therapy for nonalcoholic fatty liver disease? A systematic review. Am J Med 2003;115:554 559. Musso G, Gambino R, De Michieli F, et al. Dietary habits and their relations to insulin resistance and postprandial lipemia in nonalcoholic steatohepatitis. Hepatology 2003;37:909 916. Toshimitsu K, Matsuura B, Ohkubo I, et al. Dietary habits and nutrient intake in non-alcoholic steatohepatitis. Nutrition 2007; 23:46 52. Yancy WS, Olsen MK, Guyton JR, et al. A low-carbohydrate, ketogenic diet versus a low fat diet to treat obesity and hyperlipidemia. Ann Intern Med 2004;140:769 777. Tendler D, Lin S, Yancy WS, et al. The effect of low carbohydrate, ketogenic diet on nonalcoholic fatty liver disease: a pilot study. Dig Dis Sci 2007;52:589 593. Westerback J, Lammi K, Hakkienen A, et al. Dietary fat content modies liver fat in overweight nondiabetic subjects. J Clin Endocrinol Metab 2005;90:2804 2809. Petersen KF, Dufour S, Befroy D, et al. Reversal of nonalcoholic hepatic steatosis, hepatic insulin resistance, and hyperglycemia by moderate weight reduction in patients with type 2 diabetes. Diabetes 2005;54:603 608. Zivkovic AM, German JB, Sanyal AJ. Comparative review of diets for the metabolic syndrome: implications for nonalcoholic fatty liver disease. Am J Clin Nutr 2007;86:282300. El-Badry AM, Moritz W, Contaldo C, et al. Prevention of reperfusion injury and microcirculatory failure in macrosteatotic mouse liver by omega-3 fatty acids. Hepatology 2007;45:841 845. Wang D, Wei Y, Pagliassotti MJ. Saturated fatty acids promote endoplasmic reticulum stress and liver injury in rats with hepatic steatosis. Endocrine 2006;147:943951. Paniagua JA, de la Sancristana G, Romero I, et al. Monounsaturated fat-rich diet prevents central body fat distribution and decreases postprandial adiponectin expression induced by a carbohydrate-rich diet in insulin resistant subjects. Diabetes Care 2007;30:17171723.

97. Laaksonen De, Nyyssonen K, Niskanen L, et al. Prediction of cardiovascular mortality in middle-aged men by dietary and serum linoleic and polyunsaturated fatty acids. Arch Intern Med 2005;165:193199. 98. Sekiya M, Yahagi N, Matsuzaka T, et al. Polyunsaturated fatty acids ameliorate hepatic steatosis in obese mice by SREBP-1 suppression. Hepatology 2003;38:1529 1539. 99. Cortez-Pinto H, Jesus L, Barros H, et al. How different is the dietary pattern in non-alcoholic steatohepatitis patients? Clin Nutr 2006;25:816 823. 100. Capanni M, Calella F, Biagini, et al. Prolonged n-3 polyunsaturated fatty acid supplementation ameliorates hepatic steatosis in patients with non-alcoholic fatty liver disease: a pilot study. Aliment Pharmacol Ther 2006;23:11431151. 101. Spadaro L, Magliocco O, Spampinato D, et al. Omega-3 polyunsaturated fatty acids: a pilot trial in non-alcoholic fatty liver disease. J Hepatol 2006;44:S264. 102. Tapsell LC, Gillen LJ, Patch CS, et al. Including walnuts in a low-fat/modied-fat diet improves HDL cholesterol-to-total cholesterol ratios in patients with type 2 diabetes. Diabetes Care 2004;27:27772783. 103. Lopez-Garcia E, Schulze MB, Meigs JB, et al. Consumption of trans fatty acids is related to plasma biomarkers of inammation and endothelial dysfunction. J Nutr 2005;135:562566. 104. Mozaffarian D. Trans fatty acids effects on systemic inammation and endothelial dysfunction. Atheroscler Suppl 2006;7: 29 32. 105. Zelber-Sagi S, Nitzan-Kaluski D, Goldsmith R, et al. Long term nutritional intake and the risk for non-alcoholic fatty liver disease (NAFLD): a population based study. J Hepatol 2007;47: 711717. 106. Le KA, Tappy L, DAlessio DA. Mitochondrial dysfunction and insulin resistance: a matter of lifestyle? Curr Opin Nutr Metab Care 2007;10:494 497. 107. Scribner KB, Pawlak DB, Ludwig DS. Hepatic steatosis and increased adiposity in mice consuming rapidly versus slowly absorbed carbohydrate. Obesity 2007;15:2190 2199. 108. Harrison SA, Day CP. Benets of lifestyle modication in NAFLD. Gut 2007;20:29 43. 109. Suzuki A, Lindor K, St Saver J, et al. Effect of changes on body weight and lifestyle in nonalcoholic fatty liver disease. J Hepatol 2005;43:1060 1066. 110. Ueno T, Sugawara H, Sujaku K, et al. Therapeutic effects of restricted diet and exercise in obese patients with fatty liver. J Hepatol 1997;27:103107. 111. Hickman IJ, Jonsson JR, Prins JB, et al. Modest weight loss and physical activity in overweight patients with chronic liver disease results in sustained improvements in alanine aminotransferase, fasting insulin, and quality of life. Gut 2004;53:413 419. 112. Church TS, Kuk JL, Ross R, et al. Association of cardiorespiratory tness, body mass index, and waist circumference to nonalcoholic fatty liver disease. Gastroenterology 2006;130: 20232030. 113. Harrison SA, Fincke C, Helinski D, et al. A pilot study of orlistat treatment in obese, non-alcoholic steatohepatitis patients. Aliment Pharmacol Ther 2004;20:623 628. 114. Assy N, Hussein O, Abassi Z. Weight loss induced by orlistat reverses fatty inltration and improves hepatic brosis in obese patients with non-alcoholic steatohepatitis. Gut 2007;56:443 444. 115. Zelber-Sagi S, Kessler A, Brazowsky, et al. A double-blind randomized placebo controlled trial of orlistat for treatment of nonalcoholic fatty liver disease. Clin Gastroenterol Hepatol 2006;4:639 644. 116. Harrison SA, Brunt EM, Fecht WJ, et al. Orlistat in the treatment of overweight patients with nonalcoholic steatohepatitis

May 2008

DIAGNOSIS AND THERAPY OF NASH

1697

117. 118.

119. 120.

121.

122.

123.

124.

125.

126.

127.

128.

129.

130.

131.

132.

133.

134.

135. 136.

(NASH): a multi-centered, randomized prospective trial. Gastroenterology 2007;132:T1059. Scheen AJ. Cannabinoid-1 receptor antagonists in type-2 diabetes. Best Pract Res Clin Endocrinol Metab 2007;21:535553. Gary-Bobo M, Elachouri G, Gallas JF, et al. Rimonabant reduces obesity-associated hepatic steatosis and features of metabolic syndrome in obese zucker fa/fa rats. Hepatology 2007;46: 122129. Amori RE, Lau J, Pittas AG. Efcacy and safety of incretin therapy in type 2 diabetes mellitus. JAMA 2007;298:194 206. Ding X, Saxena NK, Lin S, et al. Exendin-4, a glucagon-like protein-1 (GLP-1) receptor agonist, reverses hepatic steatosis in ob/ob mice. Hepatology 2006;43:173181. Tushuizen ME, Bunck MC, Pouwels PJ, et al. Incretin mimetics as a novel therapeutic option for hepatic steatosis. Liver Int 2006;26:10151017. Marubbio AT, Buchwald H, Schwartz MZ, et al. Hepatic lesions of central pericellular brosis in morbid obesity, and after jejunoileal bypass. Am J Clin Pathol 1976;66:684 691. Campbell JM, Hunt TK, Karam JH, et al. Jejunoileal bypass as a treatment of morbid obesity. Arch Intern Med 1976;137:602 610. Mattar SG, Velcu LM, Rabinovitz M, et al. Surgically-induced weight loss signicantly improved nonalcoholic fatty liver disease and the metabolic syndrome. Ann Surg 2005;242:610 620. Furuya CK, de Olivereira CP, de Mello ES, et al. Effects of bariatric surgery on nonalcoholic fatty liver disease: preliminary ndings after 2 years. J Gastroenterol Hepatol 2007;22:510 514. Liu X, Lazenby AJ, Clements RH, et al. Resolution of nonalcoholic steatohepatitis after gastric bypass surgery. Obes Surg 2007;17:486 492. Lutchman G, Promrat K, Kleiner DE, et al. Changes in serum adipokine levels during pioglitazone treatment for nonalcoholic steatohepatitis, relationship to histologic improvement. Clin Gastroenterol Hepatol 2006;4:1048 1052. Neuschwander-Tetri BA, Brunt EM, Wehmeier KR, et al. Improved nonalcoholic steatohepatitis after 48 weeks of treatment with the PPAR-y ligand rosiglitazone. Hepatology 2003;38: 1008 1017. Ratziu V, Charlotte F, Jacqueminet S, et al. A one-year randomized, placebo-controlled, double-blind trial of rosiglitazone in non alcoholic steatohepatitis. Results of the FLIRT pilot trial. J Hepatol 2006;44;A201. Promrat K, Lutchman G, Uwaifo GI, et al. A pilot study of pioglitazone for nonalcoholic steatohepatitis. Hepatology 2004; 39:188 196. Sanyal AJ, Mofrad PS, Contos MJ, et al. A pilot study of vitamin E versus vitamin E and pioglitazone for the treatment of nonalcoholic steatohepatitis. Clin Gastroenterol Hepatol 2004;2: 11071115. Belfort R, Harrison SA, Brown K, et al. A placebo controlled trial of pioglitazone in subjects with nonalcoholic steatohepatitis. N Engl J Med 2006;355:1525. Aithal GP, Thomas JA, Kaye P, et al. A randomized, double blind, placebo controlled trial of one year of pioglitazone in non-diabetic subjects with nonalcoholic steatohepatitis. Hepatology 2007;46:295A. Lutchman G, Modi A, Kleiner DE, et al. The effects of discontinuing pioglitazone in patients with nonalcoholic steatohepatitis. Hepatology 2007;46:424 429. Murphy CE, Rodgers PT. Effects of thiazolidinediones on bone loss and fracture. Ann Pharmacother 2007;41:2014 2018. Nissen SE, Wolski K. Effect of rosiglitazone on the risk of myocardial infarction and death from cardiovascular causes. N Engl J Med 2007;356:24572471.

137. Diamond G, Bax L, Kaul S. Uncertain effects of rosiglitazone on the risk of myocardial infarction and cardiovascular death. Ann Intern Med 2007;147:578 581. 138. Lincoff AM, Wolski K, Nicholls SJ, et al. Pioglitazone and risk of cardiovascular events in patients with type 2 diabetes mellitus. A meta-analysis of randomized trials. JAMA 2007;298:1180 1188. 139. Lago RM, Singh PP, Nesto RW. Congestive heart failure and cardiovascular death in patients with prediabetes and type 2 diabetes given thiazolidinediones: a meta-analysis of randomized clinical trials. Lancet 2007;370:1129 1136. 140. Lin HZ, Yang SQ, Chuckaree C, et al. Metformin reverses fatty liver disease in obese leptin-decient mice. Nat Med 2000;6: 998 1003. 141. Marchensini G, Bianchi G, Tomassetti S, et al. Metformin in non-alcoholic steatohepatitis. Lancet 2001;348:893 894. 142. Uygun A, Kadayifci A, Isik AT, et al. Metformin in the treatment of patients with non-alcoholic steatohepatitis. Aliment Pharmacol Ther 2004;19:537544. 143. Nair S, Diehl AM, Wiseman M, et al. Metformin in the treatment of non-alcoholic steatohepatitis: a pilot open label trial. Aliment Pharmacol Ther 2004;20:2328. 144. Bugianesi E, Gentilcore E, Manini R, et al. A randomized controlled trial of metformin versus vitamin E or prescriptive diet in nonalcoholic fatty liver disease. Am J Gastroenterol 2005;100: 10821090. 145. Tiikkainen M, Hakkinen AM, Korsheninnikova E, et al. Effects of rosiglitazone and metformin on liver fat content, hepatic insulin resistance, insulin clearance, and gene expression in adipose tissue in patients with type 2 diabetes. Diabetes 2005;53: 2169 2176. 146. Mehta K, Van Thiel DH, Shah N, et al. Nonalcoholic fatty liver disease: pathogenesis and the role of antioxidants. Nutr Rev 2002;60:289 293. 147. Harrison SA, Torgerson S, Hayashi P, et al. Vitamin E and C treatment improves brosis in patients with nonalcoholic steatohepatitis. Am J Gastroenterol 2003;98:24852490. 148. Yakaryilmaz F, Guiliter S, Savas B, et al. Effects of vitamin E treatment on peroxisome proliferators activated receptor-a expression and insulin resistance in patients with non-alcoholic steatohepatitis: results of a pilot study. Intern Med J 2007;37: 229 235. 149. Federico A, Trappoliere M, Tuccillo C, et al. A new silybin-vitamin E-phospholipid complex improves insulin resistance and liver damage in patients with non-alcoholic fatty liver disease: preliminary observations. Gut 2006;55:901902. 150. Abdelmalek MF, Angulo P, Jorgenssen R, et al. Betaine, a promising new agent for patients with nonalcoholic steatohepatitis: results of a pilot study. Am J Gastroenterol 2001;96: 27112717. 151. Houghton WC. Betaine and nonalcoholic steatohepatitis. Am J Gastroenterol 2003;98:2803. 152. Valenti L, Fracanzani AL, Dongiovanni P, et al. Iron depletion by phlebotomy improves insulin resistance in patients with nonalcoholic fatty liver disease and hyperferritinemia: evidence from a case-control study. Am J Gastroenterol 2007;102:1251 1258. 153. Lindor KD, Kowdley KV, Heathcote EJ, et al. Ursodeoxycholic acid for treatment of nonalcoholic steatohepatitis: results of a randomized trial. Hepatology 2004;39:770 778. 154. Dufour JF, Oneta CM, Gonvers JJ, et al. Randomised placebocontrolled trial of ursodeoxycholic acid with vitamin E in nonalcoholic steatohepatitis. Clin Gastroenterol Hepatol 2006;4: 15371543. 155. Adams LA, Zeine CO, Angulo P, et al. A pilot trial of pentoxifylline in nonalcoholic steatohepatitis. Am J Gastroenterol 2004;99: 23652368.

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TORRES AND HARRISON

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156. Satapathy SK, Sakhuja P, Malhotra V, et al. Benecial effects of pentoxifylline on hepatic steatosis, brosis and necroinammation in patients with non-alcoholic steatohepatitis. J Gastroenterol Hepatol 2006;22:634 638. 157. Browning JD. Statins and hepatic steatosis: perspectives from the Dallas heart study. Hepatology 2006;44:466 471. 158. Ekstedt M, Franzen LE, Mathiesen UL, et al. Statins in non-alcoholic fatty liver disease and chronically elevated liver enzymes: a histopathological follow-up study. J Hepatol 2007;47:135141. 159. Gomez-Dominguez E, Gisbert JP, Moreno-Monteagudo JA, et al. A pilot study of atorvastatin treatment in dyslipidemidic, non-alcoholic fatty liver patients. Aliment Pharmacol Ther 2006;23:16431647. 160. Devaraj S, Siegel D, Jialal I. Simvastatin (40mg/day), adiponectin levels, and insulin sensitivity in subjects with the metabolic syndrome. Am J Cardiol 2007;100:13971399. 161. Mikhailidis DP, Sibbring GC, Ballantyne CM, et al. Meta-analysis of the cholesterol-lowering effect of ezetimibe added to ongoing statin therapy. Curr Med Res Opin 2007;23:2009 2026. 162. Deushi M, Nomura M, Kawakami A, et al. Ezetimibe improves liver steatosis and insulin resistance in obese rat model of metabolic syndrome. FEBS Lett 2007;581:5664 5670.

163. Hirose A, Ono M, Saibara T, et al. Angiotensin II type 1 receptor blocker inhibits brosis in rat nonalcoholic steatohepatitis. Hepatology 2007;45:13751381. 164. Yokohama S, Yoneda M, Haneda M. Therapeutic efcacy of an angiotensin II receptor antagonist in patients with nonalcoholic steatohepatitis. Hepatology 2004;40:12221225. 165. Yokohama S, Tokusashi Y, Nakamura K, et al. Inhibitory effect of angiotensin II receptor antagonist on hepatic stellate activation in non-alcoholic steatohepatitis. World J Gastroenterol 2006;12:322326.

Received December 24, 2007. Accepted February 25, 2008. Address requests for reprints to: Stephen A. Harrison, MD, Department of Gastroenterology, 3851 Roger Brooke Drive, Fort Sam Houston, Texas 78234. e-mail: stephen.harrison@amedd.army.mil; fax: (210) 916-5611. The opinions or assertions contained herein are the private views of the authors and are not to be construed as ofcial or reecting the view of the Department of the Army or the Department of Defense.