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Ursodeoxycholic Acid and Atorvastatin in the Treatment of Nonalcoholic Steatohepatitis

BACKGROUND/AIMS Nonalcoholic steatohepatitis (NASH) is a serious disorder with the potential to gradually progress to cirrhosis. It is generally associated with obesity, diabetes and hyperlipidemia. Currently, there is no established therapy for NASH. The aim of the present study was to evaluate the effectiveness of atorvastatin and ursodeoxycholic acid (UDCA) in the treatment of NASH. METHODS This prospective study included 44 adult patients (24 men, 20 women) with a mean age of 48.90+/-7.69 years and mean body mass index (BMI) of 29.40+/-3.82. Ten patients had a history of diabetes. Serological markers for viral hepatitis were negative in all patients and there was no history of alcohol or drug abuse. Patients who had autoimmune hepatitis were excluded from the study. Liver biopsy was performed before therapy to confirm the diagnosis. Among NASH patients, 17 normolipidemic cases received UDCA 13 to 15 mg/kg/day (group 1), while hyperlipidemic cases (n=27) received atorvastatin 10 mg/day (group 2) for six months. The BMI, serum lipids, liver function tests and liver density, assessed by computerized tomography, were evaluated before and after the treatment period. The BMI, serum aminotransferase levels, histological parameters (steatosis, inflammation, fibrosis scores) and liver densities were not statistically different between the groups at the beginning of therapy. RESULTS The BMI, serum glucose, and triglyceride levels did not change in either group after the treatment period. In group 1, serum alanine aminotransferase (ALT) and gamma-glutamyl-transferase (GGT) levels reduced significantly, and in group 2, serum cholesterol, aspartate aminotransferase, ALT, alkaline phosphatase and GGT levels reduced significantly. Liver densities increased only in group 2, probably as a result of diminishing fat content of liver. The normalization of transaminases was also more prevalent in group 2. Liver steatosis was closely correlated with liver density, but inflammation and fibrosis were not. CONCLUSIONS The use of atorvastatin in NASH patients with hyperlipidemia was found to be both effective and safe. The benefit of statin and UDCA therapy in normolipidemic patients with NASH requires confirmation with further placebo-controlled trials.

Decreased plasma levels of soluble receptor for advanced glycation endproducts (sRAGE) in patients with nonalcoholic fatty liver disease

OBJECTIVES Levels of soluble receptor for advanced glycation endproducts (sRAGE) have been linked to several components of the metabolic syndrome. We tested the hypothesis that plasma levels of sRAGE may be associated with non-alcoholic fatty liver disease. DESIGN AND METHODS We enrolled subjects with definite nonalcoholic steatohepatitis (NASH, n=40), borderline NASH (n=8), simple fatty liver (n=9) and healthy controls (n=14). Plasma levels of sRAGE were measured by ELISA. RESULTS Concentrations of sRAGE were significantly lower in patients with definite NASH (1080+/-392 pg/mL, P<0.01) and borderline NASH (1050+/-278 pg/mL, P<0.05) compared to controls (1480+/-387 pg/mL). Levels of sRAGE were significantly and inversely correlated with ALT (r=-0.30, P<0.05) and AST (r=-0.23, P<0.05). CONCLUSION Plasma levels of sRAGE are significantly reduced in definite and borderline NASH.

The Relationship between c-erbB-2 Oncogene Expression and Clinicopathological Factors in Gastric Cancer

Gastric carcinoma is one of the most common carcinomas and a leading cause of death from cancer in Turkey. The relationship between clinicopathological features of the disease and oncogenes is under investigation. In this retrospective study we investigated the relationships between expression of c-erbB-2 oncoprotein and grade, stage and pathological characteristics of the tumour, and prognosis. Formalin-fixed, paraffin-embedded tissue sections were prepared from gastrectomy specimens from 55 patients with gastric carcinoma. The tissue sections were stained immunohistochemically to reveal c-erbB-2 protein. Six (10%) of the tumours stained positively for c-erbB-2 protein. There was no statistically significant association (P > 0.5) between c-erbB-2 staining and tumour grade, stage or pathological characteristics (necrosis, lymph-node infiltration), or between staining and prognosis. The results suggest that overexpression of c-erb-B-2 protein is not related to the pathological characteristics of the tumour in gastric carcinoma and is not an important prognostic indicator.

Characterization of nonalcoholic fatty liver disease unrelated to the metabolic syndrome

Eur J Clin Invest 2012; 42 (4): 411–418

Serum concentrations of human angiopoietin-like protein 3 in patients with nonalcoholic fatty liver disease: association with insulin resistance.

Objective Insulin resistance is considered a key feature of nonalcoholic fatty liver disease (NAFLD). In this setting, experimental studies have suggested a potential role of angiopoietin-like (ANGPTL) proteins in the pathogenesis of hepatic steatosis and the metabolic syndrome. In this study, we sought to investigate the plasma levels of ANGPTL protein 3 (ANGPTL3) – a liver-derived protein that modulates plasma triglyceride clearance – in patients with definite nonalcoholic steatohepatitis (NASH, n=40), borderline NASH (n=8), simple fatty liver (n=9), and healthy controls without evidence of liver disease (n=14). Methods Levels of ANGPTL3 were measured by enzyme-linked immunosorbent assay and compared in the four study groups. Moreover, concentrations of ANGPTL3 were assessed in relation to the general characteristics of the study participants and the results of liver biopsy. Results Levels of ANGPTL3 were significantly higher in patients with definite NASH (389±110 ng/ml, P<0.05) and borderline NASH (433±70 ng/ml, P<0.05) compared with controls (291±78 ng/ml). No significant differences were found in patients with simple fatty liver (321±119 ng/ml) as compared with controls. In correlation analyses of the entire study cohort, ANGPTL3 was significantly and positively associated with homeostatic model assessment for insulin resistance (r=0.28, P<0.05) but not with histological staging and pathological characteristics of NAFLD. Conclusion Although subject to future confirmation, our data suggest that ANGPTL3 levels are elevated in the more severe forms of NAFLD and could be associated with insulin resistance in this setting.

A "Biomarker Biopsy" for the Diagnosis of NASH: Promises from CK-18 Fragments

To the Editor: We read with great interest the recent article by Younossi and coworkers [1] who developed a diagnostic biomarker set (NASH DiagnosticsTM) for the diagnosis of nonalcoholic steatohepatitis (NASH). The authors investigated a total of 101 patients who had liver biopsies because of suspected NASH. Subsequently, all patients were tested with enzymelinked immunosorbent assay (ELISA)-based assays for a number of potential biomarkers of liver inflammation, including adiponectin, resistin, insulin, glucose, TNF-alpha, IL-6, IL-8, cytokeratin CK-18 (M65 antigen), and caspasecleaved CK-18 (M30 antigen). Interestingly, results showed that levels of M30 antigen predicted histological NASH with 70% sensitivity and 83.7% specificity. Moreover, intact CK18 (M65) yielded 63.6% sensitivity and 89.4% specificity for the diagnosis of NASH. The findings of Younossi et al. [1] confirm and expand the current knowledge on the potential clinical usefulness of different forms of CK18 in patient sera (M30 antigen for apoptosis and M65 antigen for necrosis) in NASH, as previously reported by our [2] and other groups [3]. It is our opinion that two important points in the work by Younossi et al. merit consideration. Firstly, although the authors focused exclusively on the development of a biomarker set, they did not examine whether the diagnostic yield of their panel could be improved by the concomitant use of noninvasive radiological modalities. Although ultrasound, computerized tomography, and magnetic resonance are unable to distinguish NASH or the stage of fibrosis if used alone, it is worth noting that we have previously shown [2] that the combination of M30 antigen measurements and computerized tomography yielded a sensitivity and specificity for the diagnosis of definitive NASH of 86.1% and 83.3%, respectively. These yields were higher than those provided by biomarkers alone [2]. Similarly, the combination of M65 antigen and computerized tomography yielded a sensitivity and specificity for NASH of 83.3% and 83.3%, respectively [2]. Altogether, these data suggest that the evaluation of a biomarker panel in combination with CT could have a greater diagnostic utility for the identification of patients with definitive NASH than the use of biomarkers alone. Another point that should be considered in the study of Younossi and coworkers is that liver biopsy was classified as “no presence of fatty liver disease”, “simple fatty liver”, “steatosis with nonspecific inflammation”, and “NASH”. Notably, patients with steatosis and nonspecific inflammation were excluded from the analysis [1]. The classification system used by Younossi et al. is not in line with that previously proposed by the Nonalcoholic Steatohepatitis Clinical Research Network [4], which distinguishes between definite NASH, borderline NASH, and not NASH (simple fatty liver). Thus, patients with borderline NASH were excluded from the study of Younossi et al. [1], although a considerable number of patients with nonalcoholic fatty liver disease in clinical practice are actually OBES SURG (2008) 18:1507–1508 DOI 10.1007/s11695-008-9639-z

Serum M30 levels: A potential biomarker of severe liver disease in nonalcoholic fatty liver disease and normal aminotransferase levels

We congratulate Fracanzani and colleagues1 on their insightful article identifying factors associated with severe liver disease in patients with nonalcoholic fatty liver disease (NAFLD) and normal aminotransferase levels. First, the authors have convincingly demonstrated that normal alanine aminotransferase (ALT) is not a valuable criterion to exclude patients with NAFLD from liver biopsy.More importantly, they have shown that increased insulin resistance as assessed by the homeostasis model assessment of insulin resistance (HOMA-IR) is a statistically significant and independent predictor of the presence of both nonalcoholic steatohepatitis (NASH) and severe fibrosis among subjects with NAFLD. The authors concluded that determination of insulin resistance in subjects with normal ALT levels may be clinically relevant in the selection of NAFLD cases for histological assessment of disease severity and progression.1 The field of biomarkers is an area of fast growing interest in the setting of NAFLD. A neoepitope in cytokeratin 18, termed M30 antigen, becomes available at an early caspase cleavage event during apoptosis and has been regarded as a biochemical marker of liver injury.2,3 Thus, we sought to determine whether serum M30 levels may be associated with the presence of NASH among NAFLD cases with normal ALT levels. Eighteen patients (four males and 14 females), mean age of 51.0 7.6 years, with liver biopsy-confirmed NAFLD and normal ALT levels ( 40 U/L) were investigated. The diagnosis of NASHwas based on the Kleiner criteria.4 M30 levels were detected by enzyme-linked immunosorbent assay (M30 Apoptosense ELISA kit; Peviva AB, Bromma, Sweden). Compared with patients with NAFLD without NASH (n 12), mean serumM30 levels were significantly raised in the six patients with normal ALT and NASH levels (198.2 37.2 IU/L versus 80.7 19.2 IU/L, P 0.01). In multivariate analysis, M30 levels and HOMA-IR were the only independent predictors of the presence of NASH in patients with NAFLD and normal ALT levels. Besides confirming the elegantproof byFracanzani and coworkers that determining HOMA-IR is clinically useful for identifying patients with NAFLDwhoare candidates for histological assessmentof disease severity,1 our pilot results allow us to postulate thatM30 levelsmay be an additional good index of the presence ofNASH in this patient group. Further studies in larger samples are warranted to confirm our pilot data.

High expression of multidrug resistance-1 (MDR-1) and its relationship with multiple prognostic factors in gastric carcinomas in patients in Turkey.

Drug resistance remains a major problem in the treatment of gastric cancer. In Turkey, gastric carcinoma is the second most common cancer and, because the rate of early diagnosis is low, chemotherapy plays an important role in the treatment of the disease. We aimed to investigate expression of the multidrug resistance-1 gene (MDR-1) and its relationship with multiple prognostic factors in gastric cancers. Between 1996 and 1998, a total of 55 patients (37 men and 19 women; median age 55 years) were studied. Sections from specimens of gastric carcinomas were immunohistochemically stained to detect P-glycoprotein (which is associated with MDR-1 expression). We found MDR-1 expression in 48 (87%) of the patients. None of the multiple prognostic factors, including histological type of tumour, correlated with expression of MDR-1. Patients who had low MDR-1 expression had better survival. We conclude that the expression of MDR-1 in gastric cancer is high in Turkey, and this may be related to poor prognosis.

Expression of p53 protein and prognosis in gastric carcinoma

A study was carried out to assess whether p53 expression is related to tumour type, grade or pathological characteristics, or to prognosis, in gastric cancer. Immunohistochemical studies were performed to detect p53 protein in sections from 55 consecutive gastrectomy or partial gastrectomy specimens. Tumours were classified for T-stage, histopathological grade and pathological characteristics. Immunohistochemical staining detected p53 protein in 11 (19%) of the 55 specimens. There was no statistically significant difference between patients with p53 positively staining tumours and patients with p53 negatively staining tumours with regard to tumour grade, stage or pathological characteristics (lymph-node infiltration, depth of invasion, necrosis, or necrosis of vessels). Survival time was statistically significantly lower in patients with positively staining tumours (mean survival times 12.0 and 23.4 months, respectively). These results suggest that expression of p53 protein is related to poor prognosis in gastric carcinoma.

Proteomic analysis of serum in patients with non-alcoholic steatohepatitis using matrix-assisted laser desorption ionization time-of-flight mass spectrometry

Abstract Objective. We sought to investigate whether serum proteomic pattern analysis obtained using matrix-assisted laser desorption ionization time-of-flight mass spectrometry (MALDI TOF-MS) may help to diagnose non-alcoholic steatohepatitis (NASH) in the setting of non-alcoholic fatty liver disease (NAFLD). Material and methods. We enrolled 80 patients with biopsy-proven NAFLD and 19 healthy comparison subjects. Patients with NAFLD were classified according to their liver histology as having definite NASH (n = 48), borderline NASH (n = 22) or simple steatosis (n = 10). Liver ultrasound scanning was performed to assess the degree of steatosis. Mass spectra of serum samples were obtained using a Ultraflex II mass spectrometer. Results. The highest accuracy for NASH diagnostics was reached using 15 peaks. Corresponding sensitivity and specificity values were 73.95% ± 3.38% and 88.71% ± 1.39%, respectively. However, mass spectra did not allow us to distinguish NASH from simple steatosis. Conclusions. We conclude that proteomic analyses of serum samples from NAFLD patients by MALDI TOF-MS do not seem to have a major clinical value for diagnosing NASH. However, the identification of 15 peaks in our study may help to further elucidate the pathophysiology of NASH and merits further investigation.