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There is an unmet need for development of non-invasive tests for the diagnostic assessment and monitoring of nonalcoholic fatty liver disease (NAFLD).Using modified-aptamer proteomics, we assayed 5220 proteins in each of 2852 single serum samples from 636 individuals with histologically confirmed NAFLD. We developed and validated dichotomized protein-phenotype models for clinically relevant severity of steatosis (grade 0 vs 1-3), hepatocellular ballooning (0 vs 1 or 2), lobular inflammation (0-1 versus 2-3) and fibrosis (stages 0-1 vs 2-4).Results for the 4 protein models, based on 37 analytes (18 not previously linked to NAFLD), in training/paired validation were: fibrosis (AUC 0.92/0.85); steatosis (AUC 0.95/0.79), inflammation (AUC 0.83/0.72), and ballooning (AUC 0.87/0.83). An additional outcome, at risk NASH, defined as steatohepatitis with NAS ≥ 4 with one or more points in each of the components and fibrosis stage 2 or higher, was created by multiplying the outputs of each individual component model (AUC 0.93/0.85). We further evaluated their ability to detect change in histology following treatment with placebo, pioglitazone, vitamin E or obeticholic acid (OCA). Component model scores significantly improved in the active therapies vs. placebo, and differential effects of vitamin E, pioglitazone, and OCA were identified.Serum protein scanning identified signatures corresponding to the key components of liver biopsy in NAFLD. The models developed were sufficiently sensitive to characterize the longitudinal change for three different drug interventions. These data support continued validation of these proteomic models to enable a "liquid biopsy"-based assessment of NAFLD.Individuals with NASH may have liver inflammation and scarring, along with fat in their liver, all of which are assessed by liver biopsy. In this study, we use an innovative protein scanning technology to develop and validate blood-based signatures of liver damage that have the potential to replace liver biopsy for NASH diagnosis and monitoring response to treatment. These signatures can also provide NASH drug developers with insights into treatment-mediated responses and mechanisms of action.An aptamer-based protein scan of serum proteins was performed to identify diagnostic signatures of the key histological features of nonalcoholic steatohepatitis for which there are no approved non-invasive diagnostic tools currently available. Specific protein signatures related to presence and severity of NASH and its histological components that were also sensitive to change over time were identified. These are fundamental initial steps in establishing a serum-proteome based diagnostic signature of NASH and provide a rationale for using these signatures to test treatment response and to identify several novel targets for evaluation in the pathogenesis of NASH.Not applicable.

The role of liver biopsy in nonalcoholic steatohepatitis (NASH) has evolved along with the increased recognition of the significance of this disease, and the unmet medical need it presents. Drug development and clinical trials are rapidly growing, as are non-invasive tests for markers of steatosis, inflammation, injury and fibrosis. Liver biopsy evaluation remains necessary for both drug development and clinical trials as the most specific means of diagnosis and patient identification for appropriate intervention. This White Paper, sponsored by the American Association for the Study of Liver Disease NASH Task Force, is a focused review of liver biopsy evaluation in fatty liver disease in subjects with presumed NAFLD for practicing clinical hepatologists and pathologists. The goal is to provide succinct and specific means for reporting the histopathologic elements of NASH, distinguishing NASH from nonalcoholic fatty liver without steatohepatitis (NAFL), and from alcoholic steatohepatitis when possible. The discussion includes the special situations of NASH in advanced fibrosisor cirrhosis, and in the pediatric population. Finally, there is discussion of semiquantitative methods of evaluation of lesions of "disease activity" and fibrosis. Tables are present for scoring and a suggested model for final reporting. Figures presented highlight the histopathologic elements of NASH.

Much of the current data on nonalcoholic fatty liver disease (NAFLD) are derived from biopsy‐based studies that may introduce ascertainment and selection bias. Selection of patients for liver biopsy has implications for clinical practice and the reported epidemiology of NAFLD. The aim of this study was to determine patient factors predictive of histologic versus empiric clinical diagnosis of NAFLD in real‐world practice. Adults from TARGET‐NASH were included in this study. Descriptive statistics are provided for the cohort and compare the characteristics of histologic NAFLD versus patients with clinically diagnosed NAFLD, followed by logistic regression and machine‐learning models to describe predictors of liver biopsy. The records of 3,474 subjects were analyzed; median age was 59 years, 59% were female, 75% were White, and median body mass index was 32 kg/m2. Using histologic and/or clinical criteria, a diagnosis of nonalcoholic steatohepatitis was made in 37%, and cirrhosis in 33%. Comorbid conditions included cardiovascular disease (19%), mental health diagnoses (49%), and osteoarthritis (10%). Predictors of a biopsy diagnosis included White race, female sex, diabetes, and elevated alanine aminotransferase (ALT). ALT increased the odds of liver biopsy by 14% per 10‐point rise. Machine‐learning analyses showed non‐White patients with ALT, The aim of this study was to determine patient factors predictive of histologic versus empiric clinical diagnosis of NAFLD in real world practice in adults enrolled in the TARGET‐NASH study. The records of 3,474 subjects were analyzed; median age was 59 years, 59% were female, 75% were white, and median BMI was 32 kg/m2. In this real‐world cohort of patients with NAFLD, two thirds of patients did not have a liver biopsy; these patients were more likely to be non‐white, older, with a normal ALT.

The increasing prevalence and burden of nonalcoholic steatohepatitis (NASH) has spurred the development of new treatments and a need to consider outcomes used for NASH treatment decision making. Development of a NASH core outcome set (COS) can help prioritize outcomes of highest importance by incorporating the perspectives from a variety of decision makers. coreNASH was an initiative to develop a COS for NASH using a modified Delphi consensus process with a multi‐stakeholder voting panel. A candidate outcome list was created based on a literature review and key informant interviews. The candidate outcome list was then condensed and prioritized through three rounds of online voting and through discussion at an in‐person meeting. Outcomes were retained or eliminated based on predetermined consensus criteria, which included special weighting of patients’ opinions in the first two voting rounds. The coreNASH Delphi panel included 53 participants (7 patients, 10 clinicians and researchers, 7 health technology assessors, 22 industry representatives, 2 regulators, and 5 payers) who considered outcomes for two NASH‐related COS: one for NASH without cirrhosis (F2‐F3) and one for NASH with cirrhosis (F4). The initial candidate outcome list for both disease stages included 86 outcomes. The panel agreed on including two core outcomes for NASH without cirrhosis and nine core outcomes for NASH with cirrhosis in the COS. Conclusion: A consensus‐based COS has been developed that can be used across the life cycle of NASH treatments. Outcomes included can contribute to decision making for regulatory, market access, and on‐market decision making. Including the coreNASH COS in clinical development programs will facilitate improved comparisons and help decision makers assess the value of new products.

Liver fibrosis characterizes advanced chronic liver disease, and persistent activation of hepatic stellate cells (HSCs) is the primary cause of excessive hepatic fibrogenesis. CWHM12, an analog of the arginine-glycine-aspartic acid (RGD) amino acid sequence found in specific integrins, improves liver fibrosis; however, the detailed mechanisms remain unclear. This study aimed to clarify the cell signaling mechanisms of CWHM12 in activated HSCs.Immortalized human HSC lines, LX-2 and TWNT-1, were used to evaluate the effects of CWHM12 on intracellular signaling via the disruption of RGD-binding integrins.CWHM12 strongly promoted phosphorylation and inhibited the nuclear accumulation of Yes-associated protein (YAP), which is a critical effector of the Hippo signaling pathway, leading to the inhibition of proliferation, suppression of viability, promotion of apoptosis, and induction of cell cycle arrest at the G1 phase in activated HSCs. Further investigations revealed that inhibition of TGF-β was involved in the consequences of CWHM12. Moreover, CWHM12 suppressed focal adhesion kinase (FAK) phosphorylation; consequently, Src, phosphatidylinositol 3-kinase, pyruvate dehydrogenase kinase 1, and serine-threonine kinase phosphorylation led to the translocation of YAP. These favorable effects of CWHM12 on activated HSCs were reversed by inhibiting FAK.These results indicate that pharmacological inhibition of RGD-binding integrins suppresses activated HSCs by blocking the Hippo signaling pathway, a cellular response which may be valuable in the treatment of hepatic fibrosis.

Background and Aims Whether glycemic control, as opposed to diabetes status, is associated with the severity of NAFLD is open for study. We aimed to evaluate whether degree of glycemic control in the years preceding liver biopsy predicts the histological severity of NASH. Approach and Results Using the Duke NAFLD Clinical Database, we examined patients with biopsy‐proven NAFLD/NASH (n = 713) and the association of liver injury with glycemic control as measured by hemoglobin A1c (HbA1c). The study cohort was predominantly female (59%) and White (84%) with median (interquartile range) age of 50 (42, 58) years; 49% had diabetes (n = 348). Generalized linear regression models adjusted for age, sex, race, diabetes, body mass index, and hyperlipidemia were used to assess the association between mean HbA1c over the year preceding liver biopsy and severity of histological features of NAFLD/NASH. Histological features were graded and staged according to the NASH Clinical Research Network system. Group‐based trajectory analysis was used to examine patients with at least three HbA1c (n = 298) measures over 5 years preceding clinically indicated liver biopsy. Higher mean HbA1c was associated with higher grade of steatosis and ballooned hepatocytes, but not lobular inflammation. Every 1% increase in mean HbA1c was associated with 15% higher odds of increased fibrosis stage (OR, 1.15; 95% CI, 1.01, 1.31). As compared with good glycemic control, moderate control was significantly associated with increased severity of ballooned hepatocytes (OR, 1.74; 95% CI, 1.01, 3.01; P = 0.048) and hepatic fibrosis (HF; OR, 4.59; 95% CI, 2.33, 9.06; P

Background: Unnecessary laboratory tests contribute to the financial burden placed on hospitals, patients, insurers, and taxpayers. In our institution, we noted acute viral hepatitis serologic testing in patients with chronic liver disease, sometimes done repetitively, in the absence of substantially elevated aminotransferase levels. The goal of this study was to determine the frequency of unnecessary testing for acute hepatitis A and B infections and then reduce testing rates by implementing an intervention in the electronic health record. Methods: In a 2-year period, 2 successive interventions questioning the appropriateness of ordering viral hepatitis serology based on transaminase elevation and prior serology results were implemented in the electronic health record system at Saint Louis University Hospital. The first intervention allowed providers to override the warning without providing a reason; the second intervention required justification to proceed with the order. Preintervention and postintervention appropriate and inappropriate testing proportions were compared using Fisher exact test. Results: The electronic reminders resulted in a statistically significant reduction of inappropriate testing rates; however, testing rates remained high whether the provider had to justify overriding the automatic alert or not. Conclusion: Our research demonstrated that the rates of inappropriate testing for acute viral hepatitis at our institution were unnecessarily high and showed that a simple intervention in the medical record system may be useful in reducing inappropriate testing. Our interventions were feasible and implemented at minimal cost. Similar interventions could be used to target other unnecessary tests, but education and additional interventions will likely be required to reduce unnecessary testing further.

Background & AimsGenetic analyses of human NASH have revealed polymorphisms near the membrane bound O-acyl transferase domain containing 7 (MBOAT7) gene associated with worsened liver injury. NAFLD/NASH also appears to decrease MBOAT7 expression or activity independent of these polymorphisms. Thus, we hypothesized that enhancing MBOAT7 function in NASH would improve pathology.Approach & ResultsMale C57BL6/J mice were infected with adeno-associated virus 8 (AAV8) expressing MBOAT7 under control of the hepatocyte-specific thyroid hormone-binding globulin promoter, or control virus expressing green fluorescent protein (GFP). Mice were infected after NASH induction with either choline-deficient high-fat diet or Gubra Amylin NASH diet and compared to low-fat fed control mice. Both NASH diets increased liver weights, liver triglycerides, and plasma alanine and aspartate aminotransferase (ALT and AST) markers of liver injury, which were modestly yet significantly improved by MBOAT7 overexpression. However, NASH liver histology assessed by categorical scoring was not substantially improved by MBOAT7 overexpression. MBOAT7 regulates the formation of phosphatidylinositol (PI) predominantly by arachidonoylation of lysophosphatidylinositol (LPI). Shotgun lipidomics of NASH GFP-control livers suggested decreased MBOAT7 activity in that LPI content was elevated, and both total and arachidonoylated-PI were reduced. Surprisingly, MBOAT7 overexpression did not rescue the content of most arachidonoylated PI species but did normalize or increase the abundance of several oleate and linoleate-containing PI species. Free arachidonic acid was elevated but the MBOAT7 substrate arachidonoyl-CoA was found to be low in all NASH livers compared to low-fat fed mice, likely due to decreased expression of both long-chain acyl-CoA synthetases (ACSL) 1 and 4 in NASH livers compared to controls.ConclusionsThese results suggest MBOAT7 overexpression fails to measurably improve NASH pathology potentially due to insufficient abundance of its arachidonoyl-CoA substrate in fatty livers.

Non-alcoholic steatohepatitis (NASH) is prevalent in adults with obesity and can progress to cirrhosis. In a secondary analysis of prospectively acquired data from the multicenter, randomized, placebo-controlled FLINT trial, we investigated the relationship between reduction in adipose tissue compartment volumes and hepatic histologic improvement.Adult participants in the FLINT trial with paired liver biopsies and abdominal MRI exams at baseline and end-of-treatment (72 weeks) were included (n = 76). Adipose tissue compartment volumes were obtained using MRI.Treatment and placebo groups did not differ in baseline adipose tissue volumes, or in change in adipose tissue volumes longitudinally (p = 0.107 to 0.745). Deep subcutaneous adipose tissue (dSAT) and visceral adipose tissue volume reductions were associated with histologic improvement in NASH (i.e., NAS [non-alcoholic fatty liver disease activity score] reductions of ≥2 points, at least 1 point from lobular inflammation and hepatocellular ballooning, and no worsening of fibrosis) (p = 0.031, and 0.030, respectively). In a stepwise logistic regression procedure, which included demographics, treatment group, baseline histology, baseline and changes in adipose tissue volumes, MRI hepatic proton density fat fraction (PDFF), and serum aminotransferases as potential predictors, reductions in dSAT and PDFF were associated with histologic improvement in NASH (regression coefficient = -2.001 and -0.083, p = 0.044 and 0.033, respectively).In adults with NASH in the FLINT trial, those with greater longitudinal reductions in dSAT and potentially visceral adipose tissue volumes showed greater hepatic histologic improvements, independent of reductions in hepatic PDFF.NCT01265498.Although central obesity has been identified as a risk factor for obesity-related disorders including insulin resistance and cardiovascular disease, the role of central obesity in non-alcoholic steatohepatitis (NASH) warrants further clarification. Our results highlight that a reduction in central obesity, specifically deep subcutaneous adipose tissue and visceral adipose tissue, may be related to histologic improvement in NASH. The findings from this analysis should increase awareness of the importance of lifestyle intervention in NASH for clinical researchers and clinicians. Future studies and clinical practice may design interventions that assess the reduction of deep subcutaneous adipose tissue and visceral adipose tissue as outcome measures, rather than simply weight reduction.

Background The prognoses with respect to mortality and hepatic and nonhepatic outcomes across the histologic spectrum of nonalcoholic fatty liver disease (NAFLD) are not well defined. Methods We prospectively followed a multicenter patient population that included the full histologic spectrum of NAFLD. The incidences of death and other outcomes were compared across baseline histologic characteristics. Results A total of 1773 adults with NAFLD were followed for a median of 4 years. All-cause mortality increased with increasing fibrosis stages (0.32 deaths per 100 person-years for stage F0 to F2 [no, mild, or moderate fibrosis], 0.89 deaths per 100 persons-years for stage F3 [bridging fibrosis], and 1.76 deaths per 100 person-years for stage F4 [cirrhosis]). The incidence of liver-related complications per 100 person-years increased with fibrosis stage (F0 to F2 vs. F3 vs. F4) as follows: variceal hemorrhage (0.00 vs. 0.06 vs. 0.70), ascites (0.04 vs. 0.52 vs. 1.20), encephalopathy (0.02 vs. 0.75 vs. 2.39), and hepatocellular cancer (0.04 vs. 0.34 vs. 0.14). As compared with patients with stage F0 to F2 fibrosis, patients with stage F4 fibrosis also had a higher incidence of type 2 diabetes (7.53 vs. 4.45 events per 100 person-years) and a decrease of more than 40% in the estimated glomerular filtration rate (2.98 vs. 0.97 events per 100 person-years). The incidence of cardiac events and nonhepatic cancers were similar across fibrosis stages. After adjustment for age, sex, race, diabetes status, and baseline histologic severity, the incidence of any hepatic decompensation event (variceal hemorrhage, ascites, or encephalopathy) was associated with increased all-cause mortality (adjusted hazard ratio, 6.8; 95% confidence interval, 2.2 to 21.3). Conclusions In this prospective study involving patients with NAFLD, fibrosis stages F3 and F4 were associated with increased risks of liver-related complications and death. (Funded by the National Institute of Diabetes and Digestive and Kidney Diseases and others; NAFLD DB2 ClinicalTrials.gov number, NCT01030484.).

Non-alcoholic fatty liver disease (NAFLD) affects approximately 8 million Canadians. NAFLD refers to a disease spectrum ranging from bland steatosis to non-alcoholic steatohepatitis (NASH). Nearly 25% of patients with NAFLD develop NASH, which can progress to liver cirrhosis and related end-stage complications. Type 2 diabetes and obesity represent the main risk factors for the disease. The Canadian NASH Network is a national collaborative organization of health care professionals and researchers with a primary interest in enhancing understanding, care, education, and research around NAFLD, with a vision of best practices for this disease state. At the 1st International Workshop of the CanNASH network in April 2021, a joint event with the single topic conference of the Canadian Association for the Study of the Liver (CASL), clinicians, epidemiologists, basic scientists, and community members came together to share their work under the theme of NASH. This symposium also marked the initiation of collaborations between Canadian and other key opinion leaders in the field representative of international liver associations. The main objective is to develop a policy framework that outlines specific targets, suggested activities, and evidence-based best practices to guide provincial, territorial, and federal organizations in developing multidisciplinary models of care and strategies to address this epidemic.

Background & Aims EDP-305 is an oral farnesoid X receptor (FXR) agonist under development for treating nonalcoholic steatohepatitis (NASH). The efficacy, safety, and tolerability of EDP-305 was evaluated in a Phase 2, randomized, double-blind, placebo-controlled study. Methods Non-cirrhotic patients with fibrotic NASH diagnosed by historical biopsy or phenotypically (high body mass index, diagnosis of diabetes (type 2 diabetes/prediabetes), and elevated alanine aminotransferase (ALT) with liver fat content >8% by magnetic resonance imaging-proton density fat fraction (MRI-PDFF), were randomized to EDP-305 1 mg, EDP-305 2.5 mg, or placebo, for 12 weeks. The primary endpoint was mean change from baseline to Week 12 for ALT, and the key secondary endpoint was mean change from baseline to Week 12 in liver fat content. Results Between January 2018 and July 2019, 134 patients were randomized and 132 were evaluated. At Week 12, least squares (LS) mean reduction from baseline for ALT for patients receiving 2.5 mg EDP-305 and 1 mg EDP-305 was -27.9 U/L (95% CI 0.03 to 24.9; p=0.049) and -21.7 U/L (-5.8 to 18.3: p=0.304), respectively, compared to -15.4 U/L for those receiving placebo. Absolute liver fat reduction was -7.1% (2.0-7.5; p=0.0009) with 2.5 mg EDP-305, -3.3% with EDP-305 1 mg, and -2.4% with placebo. The most common (≥5%) adverse events were pruritus, nausea, vomiting, diarrhea, headache, and dizziness. Pruritus occurred in 50.9%, 9.1%, and 4.2% of patients in the 2.5 mg, 1 mg, and placebo groups, respectively, and 20.8% of patients in the 2.5 mg group and 1.8% in the 1 mg group discontinued. Conclusions EDP-305 reduced ALT levels and MRI-PDFF supporting development of EDP-305 in patients with NASH in a longer-term trial assessing liver histology. LAY SUMMARY Non-alcoholic fatty liver disease (NAFLD) is a chronic hepatic diseases that progresses to non-alcoholic steatohepatitis (NASH), leading to an increased risk of cirrhosis and the need for liver transplant. Results from this Phase 2 study support continued development of EDP-305, an oral farnesoid X receptor (FXR) agonist, for the treatment of patients with NASH. ClinicalTrials.gov number NCT03421431

Introduction: Nonalcoholic steatohepatitis (NASH) is a leading cause of liver disease in children and adults, a major contributor to health-care expenditures, and now a leading reason for liver transplantation. Adopting lifestyle modifications with regular exercise and a focus on healthy eating habits is the primary recommendation. However, patients are often unable to achieve and sustain such changes for a variety of social, physical, psychological and genetic reasons. Thus, treatments that can prevent and reverse NASH and its associated fibrosis are a major focus of current drug development.Areas covered: This review covers the current understanding of lipotoxic liver injury in the pathogenesis of NASH and how lifestyle modification and the spectrum of drugs currently in clinical trials address the many pathways leading to the phenotype of NASH.Expert opinion: Contrary to the frequently expressed nihilistic view of our understanding of NASH and disappointment with clinical trial results, much is known about the pathogenesis of NASH and there is much reason to be optimistic that effective therapies will be identified in the next 5-10 years. Achieving this will require continued refinement of clinical trial endpoints, continued engagement of trial sponsors and regulatory authorities, and continued participation of dedicated patients in clinical trials.

The incidence and overall mortality of hepatocellular carcinoma (HCC) in the US have been increasing over the past decade. Venous thromboembolism (VTE) is a leading cause of morbidity and mortality in cancer patients. This study aims at examining the epidemiology, risk factors, and short-term outcomes of VTE in hospitalized patients with HCC. We utilized the National Inpatient Sample for the years 2008–2013. Using the International Classification of Diseases codes, ninth edition, we identified hospitalized adult patients with a prior diagnosis of HCC who were diagnosed with VTE. Weighted multivariate logistic regression models were used to examine the effect of patients’ sociodemographic and clinical characteristics on the occurrence of VTE, and to evaluate the impact of VTE on in-hospital mortality and length of hospital stay. We identified a total of 54,275 hospitalized patients with a prior diagnosis of HCC. The prevalence of VTE in the study cohort was 2.8% (2.5% in 2008 to 3.0% in 2013, a statistically significant increase). Older age, African American ethnicity, history of metastasis, and higher Elixhauser comorbidity index were associated with higher odds of VTE. However, having a prior diagnosis of cirrhosis, hepatitis C, or diabetes mellitus were associated with lower odds of VTE in HCC patients. Furthermore, development of VTE was associated with longer hospital stay and increased in-hospital mortality. Our work highlights significant age, racial, and comorbid factors in the development of VTE in hospitalized patients with HCC in the US. These findings can help in stratification of HCC patients according to their VTE risk. Patients at higher risk of VTE may benefit from more aggressive pharmacologic prophylaxis, an area for future investigation.

Hepatocellular injury and inflammation are believed to be the primary drivers of fibrogenesis that ultimately lead to cirrhosis in patients with nonalcoholic steatohepatitis (NASH). This study sought associations between observed improvements in fibrosis with improvement in specific histologic features, nonalcoholic fatty liver disease activity score (NAS) ≥2, diagnostic category, and primary histologically based outcomes of two adult NASH treatment trials. The primary outcome for the study was fibrosis improvement from baseline to end of treatment, defined as a 1-point or more improvement in fibrosis stage. This is a retrospective analysis of biopsy data collected from the NASH Clinical Research Network Pathology Committee of Pioglitazone versus Vitamin E versus Placebo for the Treatment of Nondiabetic Patients with NASH Trial (PIVENS) and Farnesoid X Receptor Ligand Obeticholic Acid in NASH Treatment Trial (FLINT) baseline and final biopsies. Treatment group-adjusted univariable and multivariable logistic regression models related improvement in fibrosis to improvements in other histologic variables, resolution of steatohepatitis, and improvement in the NAS ≥2. In PIVENS 221 subjects had baseline and 96-week biopsies, and in FLINT 200 subjects had baseline and 72-week biopsies. Improvement in fibrosis was found in 38% of PIVENS and 29% of FLINT biopsies; fibrosis improvement was more likely in treated than placebo subjects in both studies. Controlling for treatment group, fibrosis improvement was associated most strongly with resolution of NASH (PIVENS, odds ratio [OR], 3.9; 95% confidence interval [CI] 2.0-7.6; P < 0.001; FLINT, OR, 8.0; 95% CI 3.1-20.9; P < 0.001), and improved NAS by ≥2 (PIVENS, OR, 2.4; 95% CI 1.3-4.3; P = 0.003; FLINT, OR, 4.2; 95% CI 2.1-8.3; P < 0.001). Improvement in histologic features associated with improved fibrosis for both studies included steatosis, ballooning, Mallory-Denk bodies, and portal, but not lobular, inflammation. Conclusion: These findings support a strong link between histologic resolution of steatohepatitis with improvement in fibrosis in NASH.

Introduction: Vanishing Bile Duct Syndrome (VBDS) and idiopathic cholestasis (IC) have been associated with lymphoma in rare cases. In VBDS, the defining feature on liver biopsy is ductopenia, while in IC there is canalicular cholestasis and mixed inflammatory changes. Existing literature reports a few cases of paraneoplastic cholestasis with pathological features of either VBDS or IC. We describe an unique case of severe cholestasis as the presenting sign of Hodgkin's lymphoma in the absence of bile duct loss or inflammatory changes. Case Description/Methods: 60-year-old man with no past medical history presented to the ED with increasing fatigue and jaundice that started five months earlier. He underwent cholecystectomy and intraoperative liver biopsy four months earlier which showed bland lobular cholestasis and mild lobular injury with no fibrosis, inflammatory changes, abnormal lymphocytic infiltration, or evidence of bile duct loss. An MRI/MRCP 6 weeks before presentation showed multiple small hepatic cysts and no biliary obstruction or ductal dilatation. Ursodiol 14 mg/kg/d was started 2 weeks later but he developed hypotension and presented to the ED. In the ED, vital signs were normal. Physical exam showed jaundice and hepatomegaly. Labs revealed ALP 1002 U/L, AST 81 U/L, ALT 90 U/L, total bilirubin 10.8 mg/dL, and direct bilirubin 8.1 mg/dL. Further work up showed negative AMA, ANA, ASMA and vasculitis serologies, normal ceruloplasmin, and negative viral studies including hepatitis A, B, C, HSV, CMV, HIV and COVID-19. EBV PCR was 69,697 copies/mL with positive IgG suggestive of reactivation of previous infection. Lyme and Ehrlichia serologies were negative. Repeat MRI/MRCP showed normal bile ducts but extensive retroperitoneal lymphadenopathy. Lymph node core needle biopsy revealed classic Hodgkin's lymphoma. He was started on chemotherapy and liver enzymes improved. Discussion: Hodgkin's lymphoma can present with cholestatic liver injury as shown in our patient who was on no medications and had no other identifiable causes of cholestasis. In the existing literature, VBDS and IC have been described as the pathological features for these patients where either ductopenia or canalicular cholestasis and mixed inflammatory changes are seen. Our case is unique because our patient had neither of these features. Bland cholestasis associated with lymphoma should be kept in the differential in someone with otherwise unexplained cholestatic liver injury. (Figure Presented).

Nonalcoholic fatty liver disease (NAFLD) is a growing cause of chronic liver disease. Using a proxy NAFLD definition of chronic alanine aminotransferase elevation (cALT) without other liver diseases, we performed a trans-ancestry genome-wide association study in the Million Veteran Program including 90,408 cALT cases and 128,187 controls. In the Discovery stage, seventy-seven loci exceeded genome-wide significance – including 25 without prior NAFLD or ALT associations – with one additional locus identified in European-American-only and two in African-American-only analyses (P-8). External replication in cohorts with NAFLD defined by histology (7,397 cases, 56,785 controls) or liver fat extracted from radiologic imaging (n=44,289) validated 17 SNPs (P-4) of which 9 were novel (TRIB1, PPARG, MTTP, SERPINA1, FTO, IL1RN, COBLL1, APOH, and IFI30). Pleiotropy analysis showed that 61 of 77 trans-ancestry and all 17 validated SNPs were jointly associated with metabolic and/or inflammatory traits, revealing a complex model of genetic architecture. Our approach integrating cALT, histology and imaging reveals new insights into genetic liability to NAFLD.

International audience; Background & Aims: Increased de novo lipogenesis creates excess intrahepatic fat and lipotoxins, propagating liver damage in nonalcoholic steatohepatitis. TVB-2640, a fatty acid synthase inhibitor, was designed to reduce excess liver fat and directly inhibit inflammatory and fibrogenic pathways. We assessed the safety and efficacy of TVB-2640 in patients with nonalcoholic steatohepatitis in the United States.Methods: 3V2640-CLIN-005 (FASCINATE-1) was a randomized, placebo-controlled, single-blind study at 10 US sites. Adults with ≥8% liver fat, assessed by magnetic resonance imaging proton density fat fraction, and evidence of liver fibrosis by magnetic resonance elastography ≥2.5 kPa or liver biopsy were eligible. Ninety-nine patients were randomized to receive placebo or 25 mg or 50 mg of TVB-2640 (orally, once-daily for 12 weeks). The primary end points of this study were safety and relative change in liver fat after treatment.Results: Liver fat increased in the placebo cohort by 4.5% relative to baseline; in contrast TVB-2640 reduced liver fat by 9.6% in the 25-mg cohort (n = 30; least squares mean: –15.5%; 95% confidence interval, –31.3 to –0.23; P = .053), and 28.1% in the 50-mg cohort (n = 28; least squares mean: –28.0%; 95% confidence interval, –44.5 to –11.6; P = .001). Eleven percent of patients in the placebo group achieved a ≥30% relative reduction of liver fat compared to 23% in the 25-mg group, and 61% in the 50-mg group (P < .001). Secondary analyses showed improvements of metabolic, pro-inflammatory and fibrotic markers. TVB-2640 was well tolerated; adverse events were mostly mild and balanced among the groups.Conclusions: TVB-2640 significantly reduced liver fat and improved biochemical, inflammatory, and fibrotic biomarkers after 12 weeks, in a dose-dependent manner in patients with nonalcoholic steatohepatitis. ClinicalTrials.gov, Number NCT03938246.

Nonalcoholic fatty liver disease (NAFLD) is a growing cause of chronic liver disease. Using a proxy NAFLD definition of chronic elevation of alanine aminotransferase (cALT) levels without other liver diseases, we performed a multiancestry genome-wide association study (GWAS) in the Million Veteran Program (MVP) including 90,408 cALT cases and 128,187 controls. Seventy-seven loci exceeded genome-wide significance, including 25 without prior NAFLD or alanine aminotransferase associations, with one additional locus identified in European American-only and two in African American-only analyses (P < 5 × 10(−8)). External replication in histology-defined NAFLD cohorts (7,397 cases and 56,785 controls) or radiologic imaging cohorts (n = 44,289) replicated 17 single-nucleotide polymorphisms (SNPs) (P < 6.5 × 10(−4)), of which 9 were new (TRIB1, PPARG, MTTP, SERPINA1, FTO, IL1RN, COBLL1, APOH and IFI30). Pleiotropy analysis showed that 61 of 77 multiancestry and all 17 replicated SNPs were jointly associated with metabolic and/or inflammatory traits, revealing a complex model of genetic architecture. Our approach integrating cALT, histology and imaging reveals new insights into genetic liability to NAFLD.

Background Nonalcoholic steatohepatitis (NASH) is the progressive form of nonalcoholic fatty liver disease (NAFLD); no approved therapies for NASH currently exist. Pegbelfermin (PGBF), a human fibroblast growth factor 21 analog, has metabolic effects that may provide benefit for patients with NASH. Design The FALCON 1 and 2 studies are Phase 2b, multicenter, double-blind, placebo-controlled, randomized trials to assess safety and efficacy of PGBF treatment in patients who have histologically-confirmed NASH with stage 3 liver fibrosis (FALCON 1; NCT03486899 ) or compensated cirrhosis (FALCON 2; NCT03486912 ). In both studies, randomized patients receive once weekly subcutaneous injections of PGBF (10, 20, or 40 mg) or placebo during a 48-week treatment period and are then followed for an additional 4 weeks. Endpoints The primary efficacy endpoint for FALCON 1 is the proportion of patients who achieve ≥1 stage improvement in fibrosis (by NASH CRN fibrosis score) without NASH worsening or NASH improvement (≥2 point decrease in NAFLD Activity Score) without fibrosis worsening at Week 24. For FALCON 2, the primary efficacy endpoint is ≥1 stage improvement in fibrosis without NASH worsening at Week 48. Key safety endpoints for both studies include incidence and frequency of adverse events, bone mineral density and immunogenicity. Summary Previous clinical trial data show that PGBF can reduce hepatic fat and improve metabolic factors and biomarkers of hepatic injury and fibrosis. The FALCON studies aim to evaluate PGBF treatment specifically in patients with NASH and advanced fibrosis, who are at greatest risk of poor clinical outcomes over time.

Nonalcoholic fatty liver disease (NAFLD), including its severe form known as steatohepatitis or NASH, are increasingly common in patients with type 2 diabetes mellitus (T2DM) and can progress to cirrhosis. However, there is limited information on their comorbid medical conditions in “real world” practice. Thus, the disease characteristics of patients with NASH or NASH-cirrhosis (cirrhosis), with or without T2DM, was evaluated in TARGET-NASH, an ongoing longitudinal observational study of patients with NAFLD, who are managed according to local standards at 60 community and academic hepatology and endocrinology practices in the United States. Among 3085 patients enrolled with NASH or cirrhosis, 1645 had NASH (47% T2DM) and 1440 had cirrhosis (72% T2DM). Patients with T2DM were older (median 61 vs. 56 years) and had a higher median BMI (34.0 vs. 32.0 kg/m2, p In conclusion, patients with type 2 diabetes and NASH or cirrhosis had more advanced liver disease compared to those without type 2 diabetes. Patients with type 2 diabetes had more than twice the risk of cirrhosis compared to those without type 2 diabetes. These results support a strong link of type 2 diabetes and metabolic risk factors with advanced NASH. Disclosure K. Cusi: Consultant; Self; Allergan plc., AstraZeneca, Bristol-Myers Squibb, Genentech, Inc., Gilead Sciences, Inc., Merck & Co., Inc. Research Support; Self; Cirius Therapeutics, Echosens, Eli Lilly and Company, Inventiva Pharma, Janssen Pharmaceuticals, Inc., Novartis Pharmaceuticals Corporation, Novo Nordisk Inc., Poxel SA, Zydus Pharmaceuticals, Inc. M. Roden: Advisory Panel; Self; Servier. Board Member; Self; Poxel SA. Consultant; Self; Eli Lilly and Company, Gilead Sciences, Inc., ProSciento, TARGET PharmaSolutions. Research Support; Self; Boehringer Ingelheim International GmbH, Novartis Pharma K.K., Sanofi US. Speaker’s Bureau; Self; Novo Nordisk A/S. A.S. Barritt: Consultant; Self; GENFIT, Intercept Pharmaceuticals, Inc., TARGET PharmaSolutions. R.J. Firpi: None. V. Clark: Research Support; Self; GENFIT, Intercept Pharmaceuticals, Inc., Novo Nordisk Inc. S. Klein: Advisory Panel; Self; Danone Nutricia, Merck & Co., Inc. Research Support; Self; Johnson & Johnson, Pfizer Inc. Stock/Shareholder; Self; Aspire Bariatrics. A. Lok: None. P. Newsome: Research Support; Self; Novo Nordisk A/S. K. Corbin: None. M.B. Vos: Advisory Panel; Self; TARGET PharmaSolutions. Consultant; Self; Boehringer Ingelheim (Canada) Ltd., Immuron, Intercept Pharmaceuticals, Inc., Mallinckrodt Pharmaceuticals, Novo Nordisk A/S. Research Support; Self; Bristol Myers Squibb. R. Reddy: Advisory Panel; Self; Ambys, Epigenomics AG, Mallinckrodt Pharmaceuticals, Merck & Co., Inc. Research Support; Self; Conatus Pharmaceuticals, Exact Sciences, Gilead Sciences, Inc., Intercept Pharmaceuticals, Inc., Mallinckrodt Pharmaceuticals, Merck & Co., Inc. C. Schoen: None. A.R. Mospan: Employee; Self; TARGET PharmaSolutions. J.L. Taunk: None. K. Wyne: Advisory Panel; Self; Novo Nordisk Inc. Research Support; Self; Sanofi. B. Neuschwander-Tetri: Advisory Panel; Self; 89Bio, Allysta, ARTham, Blade, Bristol-Myers Squibb, Gelesis, GENFIT, Histoindex, Madrigal Pharmaceuticals, Inc., Medpace, Merck & Co., Inc., Sagimet, Siemens Corporation. Consultant; Self; Arrowhead Pharmaceuticals, Inc., Axcella, DURECT Corporation, Enanta Pharmaceuticals, Inc., Fortress, Indalo, Innovo, Lipocine, Mundipharma International, pH-Pharma, TARGET PharmaSolutions. A. Sanyal: Consultant; Self; Intercept Pharmaceuticals, Inc., Lilly Diabetes, Merck & Co., Inc., Novartis Pharmaceuticals Corporation, Novo Nordisk A/S, Pfizer Inc. Stock/Shareholder; Self; DURECT Corporation, GENFIT, HemoShear, Sanyal Bio, Tiziana Life Sciences plc. Funding TARGET-NASH

Background: Opioid use is a topic of growing concern among patients with nonalcoholic fatty liver disease (NAFLD). Given safety concerns of opioids, proactively identifying subgroups of patients with an increased probability of opioid use may encourage practitioners to recommend alternative therapies for pain, thus reducing the likelihood of opioid misuse. This work assessed the prevalence and patient characteristics associated with opioid use in a real-world cohort of patients with NAFLD. Methods: TARGET-NASH, an observational study of participants at 55 academic and community sites in the United States, includes patients with NAFLD defined by pragmatic case definitions. Opioid use was defined as any documented opioid prescriptions in the year prior to enrollment. The association between patient characteristics and the odds of opioid use were modeled with stepwise multivariable logistic regression and tree ensemble methods (Classification and regression tree/Boosted Tree). Results: The cohort included 3,474 adult patients with NAFLD including 18.0% with documented opioid use. Variables associated with opioid use included presence of cirrhosis (OR 1.51, 95% CI 1.16–1.98), BMI ≥32 kg/m2 (OR 1.29, 95% CI 1.05–1.59), depression (OR 1.87, 95% CI 1.50–2.33), and anxiety (OR 1.59, 95% CI 1.27–1.98). In the boosted tree analysis, history of back pain, depression, and fibromyalgia had the greatest relative importance in predicting opioid use. Conclusion: Prescription opioids were used in nearly 1 of 5 patients with NAFLD. Given the safety concerns of opioids in patients with NAFLD, alternative therapies including low-dose acetaminophen and nonpharmacologic treatments should be considered for these patients.

The presence and stage of liver fibrosis in patients with nonalcoholic steatohepatitis (NASH) is strongly associated with mortality. Thus, both preventing and reversing fibrosis are critically important approaches to prevent death or the need for liver transplantation from NASH. Recently, fibrosis in several mouse models of organ injury was shown to be prevented and reversed with the potent small molecule, arginine‐glycine‐aspartic acid tripeptide (RGD)‐binding, integrin antagonist (3S)‐3‐(3‐bromo‐5‐(tert‐butyl)phenyl)‐3‐(2‐(3‐hydroxy‐5‐((5‐hydroxy‐1,4,5,6‐tetrahydropyrimidin‐2‐yl)amino)benzamido)acetamido)propanoic acid (Center for World Health and Medicine [CWHM]‐12). We hypothesized that RGD‐binding integrins may play an important role in fibrosis progression in NASH. We assessed the efficacy of CWHM‐12 in a choline deficient, amino‐acid defined, high‐fat diet (CDAHFD) mouse model of NASH. Mice were kept on the CDAHFD or a control diet for 10 weeks, and CWHM‐12 was delivered by continuous infusion for the final 4 weeks. The parameters of NASH and liver fibrosis were evaluated before and after drug treatment. Hepatic steatosis, liver injury, and inflammation were significantly induced by the CDAHFD at week 6 and did not change by week 10. Hepatic profibrogenic gene expression was induced by the CDAHFD at week 6, further increased at week 10, and decreased by CWHM‐12. Fibrosis measured by analysis of liver collagen was reduced by CWHM‐12 to levels significantly less than found at 6 weeks, demonstrating the possibility of reversing already established fibrosis despite ongoing injury. Demonstrated mechanisms of the antifibrotic effect of CWHM‐12 included loss of activated hepatic stellate cells through apoptosis and suppression of hepatic profibrotic signal transduction by transforming growth factor β. Conclusion: RGD‐binding integrins may be critical in the development of fibrosis in NASH and may represent potential targets for treating patients with NASH to reverse advanced liver fibrosis.

Objective Obesity and type 2 diabetes mellitus (T2DM) are risk factors for nonalcoholic fatty liver disease, including nonalcoholic steatohepatitis. This study assessed pegbelfermin (BMS-986036), recombinant PEGylated human fibroblast growth factor 21 (FGF21), in patients with obesity and T2DM predisposed to fatty liver. Methods In this randomized, double-blind, placebo-controlled study, patients with T2DM and BMI of 30 to 50 kg/m2 received subcutaneous pegbelfermin (1, 5, or 20 mg daily or 20 mg weekly; n = 96) or placebo (n = 24) for 12 weeks. Primary end points were safety, tolerability, and change in HbA1c. Additional end points included insulin sensitivity, lipids, adiponectin, and disease progression biomarkers. Results There were no significant effects of pegbelfermin versus placebo on HbA1c. Pegbelfermin 20 mg/d significantly improved high-density lipoprotein cholesterol (P = 0.015) and triglycerides (P = 0.037). All pegbelfermin regimens significantly increased adiponectin levels; 20-mg daily and weekly regimens decreased serum PRO-C3. Most adverse events were mild; the most frequent adverse events were injection-site bruising and diarrhea. Conclusions Twelve-week pegbelfermin treatment did not impact HbA1c concentrations, but QW and higher daily doses were associated with improved metabolic parameters and fibrosis biomarkers in patients with obesity and T2DM predisposed to fatty liver. These results support evaluation of pegbelfermin in patients with obesity-related metabolic diseases (e.g., nonalcoholic steatohepatitis).

Nonalcoholic fatty liver disease (NAFLD) and its progressive form non-alcoholic steatohepatitis (NASH), are rapidly becoming among the top causes of cirrhosis, hepatocellular carcinoma, and indications for liver transplantation. Other than lifestyle modification through diet and exercise, there are currently no other approved treatments for NASH/NAFLD. Although weight loss can be effective, it is difficult to achieve and sustain. In contrast, bariatric surgery can improve metabolic conditions associated with NAFLD, and has been shown to improve liver histology. To have approved regimens for the treatment of NASH/NAFLD, several issues must be addressed. First, all stakeholders must agree on the most appropriate clinical trial endpoints for NASH. Currently, resolution of NASH (without worsening fibrosis) or reduction of fibrosis stage (without worsening NASH) are the accepted endpoints by the regulatory authorities. It is important to recognize the prognostic implication of histologic features of NASH. In this context, although histologic NASH has been associated with advanced fibrosis, it is not an independent predictor of long-term mortality. In contrast, there are significant data to suggest that fibrosis stage is the only robust and independent predictor of liver-related mortality. In addition to the primary endpoints, several important secondary endpoints, including noninvasive biomarkers, long-term outcomes, and patient-reported outcomes must be considered. In 2018, a few phase 3 clinical trials for the treatment of NASH have been initiated. Additionally, a number of phase 2a and 2b clinical trials targeting different pathogenic pathways in NASH are in the pipeline of emerging therapies. CONCLUSION: Over the next 5 years, some of these regimens are expected to provide potential new treatment options for patients with NASH/NAFLD. (Hepatology 2018;68:361-371).

Nonalcoholic fatty liver disease (NAFLD) is a spectrum comprised of isolated steatosis, nonalcoholic steatohepatitis (NASH), advanced fibrosis, and cirrhosis. The majority of NAFLD subjects do not have NASH and do not carry a significant risk for liver-related adverse outcomes (cirrhosis and mortality). Globally, the prevalence of NAFLD is approximately 25%. In Asia, a gradient of high to low prevalence rates is noted from urban to rural areas. Given the prevalence of NAFLD, the clinical and economic burden of NAFLD and NASH can be substantial. With increasing recognition of NASH as an important liver disease, the diagnosis of NASH still requires a liver biopsy that is suboptimal. Although liver biopsy is the most accurate modality to diagnose and stage the severity of NASH, this method suffers from being invasive, costly, associated with potential complications, and plagued with interobserver variability of individual pathological features. A number of noninvasive modalities to diagnose NASH and stage liver fibrosis are being developed. These modalities include predictive models (NAFLD fibrosis score) and serum biomarkers such as enhanced liver fibrosis (ELF). Other tests are based on radiological techniques, such as transient elastography (TE) or magnetic resonance elastography (MRE), which are used to estimate liver stiffness as a potential surrogate of hepatic fibrosis. Although a dynamic field of research, most of these diagnostic modalities have area under the curve ranging between 0.76 and 0.90%, with MRE having the best predictive performance. In summary, developing safe and easily accessible noninvasive modalities to accurately diagnose and monitor NASH and associated fibrosis is of utmost importance in clinical practice and clinical research. These tests are not only important to risk stratify subjects at the greatest risk for progressive liver disease, but also to serve as appropriate surrogate endpoints for therapeutic clinical trials of NASH. (Hepatology 2018;68:349-360).

There has been a rise in the prevalence of nonalcoholic fatty liver disease (NAFLD), paralleling a worldwide increase in diabetes and metabolic syndrome. NAFLD, a continuum of liver abnormalities from nonalcoholic fatty liver (NAFL) to nonalcoholic steatohepatitis (NASH), has a variable course but can lead to cirrhosis and liver cancer. Here we review the pathogenic and clinical features of NAFLD, its major comorbidities, clinical progression and risk of complications and in vitro and animal models of NAFLD enabling refinement of therapeutic targets that can accelerate drug development. We also discuss evolving principles of clinical trial design to evaluate drug efficacy and the emerging targets for drug development that involve either single agents or combination therapies intended to arrest or reverse disease progression.

Nonalcoholic steatohepatitis (NASH) is an important cause of liver-related morbidity and mortality. There are no approved therapies, and the results of clinical trials have been difficult to compare due to inconsistent definitions of relevant disease parameters in patients with NASH. The natural course of the disease has not been rigorously characterized, particularly with respect to the contributions of underlying obesity, type 2 diabetes, and other comorbidities and the treatments provided for these comorbidities. Efforts to perform analyses of pooled data are limited by heterogeneous case definitions used across studies to define disease states. There remains a major unmet need in the field to develop standardized definitions for populations for interventional trials. Such definitions are expected to impact how endpoints for clinical trials are constructed. The Liver Forum is a multistakeholder effort including US and European regulatory agencies, academic investigators, professional and patient representative organizations, and industry to catalyze therapeutic development for NASH by developing potential solutions to barriers to development. The Case Definitions Working Group was established by The Liver Forum to evaluate the validity of case definitions for populations to be included in clinical trials for NASH from a regulatory science perspective. Based on such analyses, specific recommendations are provided noting the strengths and weaknesses of the case definitions along with knowledge gaps that require additional study. (Hepatology 2018;67:2001-2012).