รร รร . . รร รร . . รรรรร รรรรร รรรรรรรรรรรรรรร รรรรรรรรรรรรรรร 13 13 รรรรรร รรรรรร 2552 2552
Mar 30, 2015
รศรศ..นพนพ..กิ�ตต� จันทร�เลิ�ศกิ�ตต� จันทร�เลิ�ศฤทธิ์��ฤทธิ์��
13 13 ต�ลิาคม ต�ลิาคม 25522552
Cause of death 2548 - 2550
Cause %
Cerebrovascular disease Ischemic heart disease HIV / AIDS Transport accident COPD Liver Cirrhosis
11.68.17.76.44.84.3
Normal liver
Fatty liver Genetic and metabolic
Hepatitis or
Steatohepatitis
Fibrosis
Infection
Autoimmune
Chemical
Liver Cirrhosis
Cause of Liver Cirrhosis
• Viral hepatitis
• Alcoholic
• Metabolic
• Cardiac cirrhosis
• Cryptogenic
• NAFLD
Non-alcoholic Fatty Liver Disease
Fatty liver disease (Steatosis)
Fatty liver is excessive accumulation of fat insite the liver cell (Hepatocyte)
Fatty liver disease
• Fatty liver is reversible if the patient stops
drinking, other causes • Fatty liver can lead to steatohepatitis
• Steatohepatitis is fatty liver accompanied by
inflammation• Steatohepatitis can lead scarring of the liver and
developed cirrhosis
Symptoms and Signs
• Usually asymptomatic• Right upper quadrant pain or discomfort• Fatigue or maliase• Symptoms of associated condition• Hepatomegaly with or without tenderness• Signs of chronic liver disease
Diagnosis for NAFLD by noninvasive method
1. Ultrasonography
4 sonographic finding by diffuse fatty change in liver - Diffuse hyperechoice echotexture (Bright liver)
- Increased liver echotexture compared with kidney
- Vascular blurring
- Deep attenuation
2. Computerized tomography
3. Magnetic resonance imaging
Diagnosis for NASH
1. Histologic picture of steatohepatitis
2. Convincing evidence of minimal or no alcohol
consumption (< 40 gm/wk)
3. Absence of serologic evidence of viral hepatitis
Powell et al. Hepatology 1990;11:74-80.
Prevalence of NAFLD
• The most common liver disease in developed
countries • 20 – 40% in western industrial countries • 5 – 30% in Asia – Pacific region • Age 40 – 60 yrs, common in men• Alcohol consumption less than 20 gm/week
Prevalence of NASH
Natural History of NAFLD
Normal
Fatty liver
Steatohepatitis
Steatohepatitis with fibrosis
Cirrhosis ( Fat , Fibrosis)
Natural history of NASH
NASH Cirrhosis Liver related death9 - 20% 30 - 40%
Subacute failure HCC Post OLTxRecurrence
2% 8% ?
Clinical course and prognosis
• Clinically stable disorder • Markedly better prognosis than alcoholic steatohepatitis• NAFLD had slightly lower overall survival than expected
for general population • High mortality was associated with
• advancing age • impaired fasting glucose • cirrhosis
• Important cause of cryptogenic cirrhosis especially in• older • diabetic woman
Causes of fatty liver disease
1. Alcoholic fatty liver disease
2. Non-alcoholic fatty liver disease (NAFLD) • Characterized histologically by mainly
macrovesicular hepatic steatosis • Do not consume alcohol more than 20 gm/week
• NAFLD + Inflammation (NASH) ~ Alcoholic hepatitis• Macrovesicular steatosis • Mallory bodies • Ballooning degeneration• Hepatocyte necrosis • Fibrosis
Conditions Associated With Fatty Liver Disease
1. Alcohol
2. Metabolic Syndrome
3. Disorder of lipid metabolism
4. Total parenteral nutrition
5. Severe weight loss
6. Refeeding syndrome
7. Toxic exposure
8. Iatrogenic • Amiodarone • Diltiazem • Tamoxifen• Steroid • Highly active antiretroviral therapy
Pathophysiology of NASH
Insulin Resistance
Hepatic Steatosis
(Oxidative Stress)
NASH
Diabetes
Inflammatorycytokines
Obesity
Lipid Peroxidation
First step
Second step
Major risk factors for NAFLD
• Central obesity
• Diabetes mellitus type 2
• Dyslipidemia
• Metabolic syndrome
Who is metabolic syndrome?
Three Make The Diagnosis• Abdominal obesity
Men > 40”
Women > 35” • Fasting glucose > 110 mg%• Triglyceride > 150 mg%• HDL
Men < 40 mg%
Women < 50 mg%• Blood pressure : > 130 / > 85 mmHg
Prevention and Treatment
Normal liver
Risk factors
PreventionCauses
Fatty liver Treatment
Prevention
Steatohepatitis Treatment
Liver cirrhosis
Management of Fatty liver disease
1. Prevention• Health promotion
• Prevention of cause
• Controlled associated condition
2. Treatment • No proven effective medical therapy for NAFLD • Modify potential risk factors
• Obesity
• DM
• Hyperlipidemia
• Weight reduction• Gradual weight reduction
• 1.6 kg per week
• Total 10%
• Increase physical activity and diet controlled
Diet for NAFLD
None
Therapy for Co-morbidities
Obesity• Diet with or without exercise
• Bariatric surgery
• Cannabinoid receptor antagonist
Hypertriglyceridemia• Gemfibrozil
• Clofibrate
• Statin
Hypertension• Angiotensin II receptor antagonist
Diabetes• Rosiglitozone
Potential medical treatment for NASH
• Vitamin E and C• Hypoglycemia agent
• Metformin• Pioglitazone• Rosiglitazone
• Probucal• Betaine • Ursodeoxycholic acid • Losartan • Pentoxifylline• Orlistat
Treatment trials for NASH
Trial Treatment n Study type Duration
(mos)
Improved outcome
Anti-oxidant
Lavine
Hasegawa
Harrison
Kugelmas
Vitamin E
Vitamin E
Vitamin E & C
Vitamin E
11
10
45
16
Open label
Open label
RCT
Open label
Varied
6
6
3
ALT, AST, Alkphos
ALT, AST, Markers of fibrosis
Fibrosis (?)
Not different from diet & exercise
ProAnti-oxidant
Abdelmalek Betaine 10 Open label 12 ALT, AST, Histology
Anti-cytokine
Satapathy
Adams
Pentoxifylline
Pentoxifylline
18
20
Open label
Open label
6
12
ALT, AST, TNF, insulin resistance,
steatosis
ALT, AST
Liver Disease : Postgraduate Course 2006.
Author, Year Drug Study
Design
Subject
Number
Duration Hepatic
Steatosis
Neuschwander-Tetri, 2003 Rosiglitazone Open-label 30 48 weeks Improved
Promrat, 2004 Pioglitazone Open-lebel 18 48 weeks Improved
Sanyal, 2004 Pioglitazone
+ Vitamin E
RCT 8 6 months Improved
Belfort, ’06 Diet +/-
Pioglitazone
NCT 55 6 months Improved
Bugianesi, 2005 Metformin RCT 55 6 months Improved
Nair, 2004 Metformin Open-label 15 12 months Limited
improvement
RCT : Randomized Clinical Trial ; NCT : Non-Controlled Trial ; N/A : Not available;
No sig difference : No significant difference
Summary of studies using insulin sensitizers reporting effects upon hepatic steatosis
Summary• Fatty liver disease is the most common liver disease in
developed countries• Fatty liver disease can be lead to liver cirrhosis• The major risk factors are obesity, DM type2, dyslipidemia and metabolic syndrome• No proven effective therapy• Treatment are modify risk factors and weight reduction
•