NASH News May 2020
Fatty liver disease (FLD) and non-alcoholic steatohepatitis (NASH) are increasing in prevalence worldwide, creating a major global public health crisis. To adequately educate patients, practitioners and policy makers, there is a need to collect, curate and share relevant information. NASH News, published on behalf of the Global Liver Institute’s NASH Council, intends to meet that need and to facilitate collaboration across the emerging NASH community on a monthly basis.
We would appreciate your feedback and content contributions. Please contact nash@globalliver.org
The Importance of Recognizing NASH Patients in COVID-19 Care
As the world continues to confront the novel coronavirus pandemic, the impact of COVID-19 on specific patient populations such as those with obesity, diabetes, fatty liver disease, and NASH has shown the necessity of providing actionable advice to clinicians and patients to provide optimal care and avoid needless deaths.
The Global Liver Institute is committed to working with researchers and innovators around the world to rapidly assess and inform a robust response to this pandemic. Our unique COVID-19 Response for Patients with Liver Disease, Transplant, or Cancer is continually updated with the latest information and timely responses for liver patients.
As the push to combat NAFLD and NASH continues, research is showing that the common relationship with obesity is stark. Individuals with symptoms of underlying fatty liver disease and NASH are at higher risk and infectious for longer for COVID-19.
Social distancing can be difficult but it is especially important for patients with NASH. It is also important that patients with NASH are represented in clinical trials for COVID-19 and recognized early for treatments as they become available.
Donna R. Cryer, JD
President & CEO
Global Liver Institute
GLI LIVE Weekly
Please join the Global Liver Institute Wednesdays at 12 pm EDT for a regular Facebook Live event. Donna Cryer, Founder, and CEO of GLI will take coronavirus questions from liver patients, caregivers, and other community members. We’re here to help you stay informed.
Patient Perspective
This month’s Patient Perspective features GLI’s Advanced Advocacy Academy Alumni Terri Milton, as recently featured in Hep Magazine.
Terri Milton loves life. The 56-year-old Houstonian of Mexican descent, a former realty executive and school bus driver, blisses out on singing with her church group, baking cookies with her grandkids, and traveling throughout the United States with her husband, Doug.
“You have to have things to look forward to,” she says. “Because sometimes the ‘right now’ sucks!”
She should know. For 20 years, Milton has lived with complications from non-alcoholic steatohepatitis (NASH), an advanced form of fatty liver disease that affects roughly 20 million Americans and, because of a mix of genetics and lifestyle, impacts Latinos at a higher rate.
Milton’s NASH journey began when routine blood tests revealed that her liver enzymes were high. Her primary care provider sent her to a liver specialist, who told her, “You have fatty liver, but don’t worry about it—everyone does.” So Milton didn’t worry and went on with her life.
But by 2015, she was having regular abdominal pain, which was diagnosed as irritable bowel syndrome. Two years later, while in an emergency room for severe pain, she was told she had a gallstone. Surgery to remove it revealed that her liver was rough and nodular with scar tissue, rather than smooth, as a healthy liver should be. Three biopsies later, she was told she had NASH as well as cirrhosis.
GLI Partner Highlight
NASHNET
For this edition of NASH News, GLI is spotlighting one of the newer members of the NASH Council – NASHNET.
NASHNET is a global network of thought leaders dedicated to innovating nonalcoholic steatohepatitis (NASH) care delivery, featuring eight Charter Centers of Excellence, a network of affiliated health systems and industry partners.
NASHNET promotes the discovery, development, and optimization of care pathways and interventions that align key stakeholders to ensure the appropriateness of and linkage to care and enhance the patient experience.
Since NASHNET was founded in 2016, it has been growing a diverse network of high performing, population health-focused member organizations. NASHNET recognized a need for improved NASH care delivery, including identifying patients earlier in their disease progression. Nonalcoholic fatty liver disease (NAFLD) affects more than 30 percent of adults in the United States and is among the most common causes of liver disease. If not diagnosed or managed, NAFLD can cause liver fibrosis and progress to NASH or liver cirrhosis.
NASHNET’s network is solving key challenges across the NASH care continuum by conducting real-world evidence studies to advance research in patient identification, diagnostic pathways, risk stratification, and novel interventions.
NASHNET is powered by The Kinetix Group and headquartered in NYC.
Beyond the Biopsy
Advances in non-invasive assessment of hepatic fibrosis
From ‘Gut’, a leading international journal in gastroenterology and hepatology from the British Society of Gastroenterology
Liver fibrosis should be assessed in all individuals with chronic liver disease as it predicts the risk of future liver-related morbidity and thus the need for treatment, monitoring, and surveillance. Non-invasive fibrosis tests (NITs) overcome many limitations of liver biopsy and are now routinely incorporated into specialist clinical practice.
Genome-wide and Mendelian Randomization Studies of Liver MRI Yield Insights into the Pathogenesis of Steatohepatitis
Recently published in the Journal of Hepatology (2020), this study aims to identify genetic variants influencing liver cT1 and use genetics to understand mechanisms underlying liver fibroinflammatory disease and its link with other metabolic traits and diseases.
It identifies six independent genetic variants associated with liver cT1 that reached GWAS significance threshold. Insulin resistance, type 2 diabetes, non-alcoholic fatty liver, and BMI were causally associated with elevated cT1 whilst favorable adiposity (associated with higher adiposity but lower risk of cardiometabolic disease and lower liver fat) was found to be protective.
The association between two metal ion transporters and cT1 indicates an important new mechanism in steatohepatitis. Future studies are needed to determine whether interventions targeting the identified transporters might prevent liver disease in at-risk individuals.
Updates
Implication of Non-alcoholic Fatty Liver Disease in Patients with COVID-19: A Preliminary Analysis
Liver injury has been observed in COVID-19 patients with incidence ranging from 14–53%. This study examines the liver injury patterns and implication of non-alcoholic fatty liver diseases on clinical outcomes in Chinese patients with COVID-19.
UMN Researchers Bring Little Known Liver Disease into the Spotlight
Nonalcoholic steatohepatitis affects 3% to 6% of Americans. It is initially symptomless and hard to identify in patients.
University of Minnesota researchers are bringing attention to an under-recognized liver disease. The researchers published a review last month about liver disease non-alcoholic steatohepatitis (NASH). NASH is initially symptomless and difficult to identify and is commonly found in patients with metabolic disorders like diabetes, obesity, and high cholesterol.
“This is something that will affect a lot of people and is going to continue to be a major healthcare burden, so there are more people who are going to have NASH in the future than there currently are. It’s not going down, it’s going up,” said Adam Sheka, review co-author and University medical resident.
Association Between Pulmonary Function and Nonalcoholic Fatty Liver Disease in the NHANES III Study
Emerging evidence indicates that nonalcoholic fatty liver disease (NAFLD) is associated with a wide variety of extrahepatic complications. However, the potential association between impaired pulmonary function and NAFLD has been less investigated. This study examined the relationship between pulmonary function and hepatic steatosis in a cross-sectional analysis of the Third National Health and Nutrition Examination Survey (NHANES III).
This study finds that individuals with a greater degree of hepatic steatosis were at greater risk for poor pulmonary function, especially in restrictive patterns. These novel findings demonstrate that impaired pulmonary function is also an extrahepatic complication of NAFLD.
Physical Activity During Leisure Time May Reduce NAFLD Risk: Study
Researchers have found that physical activity, specifically during leisure time and travel-to-work time, is associated with a lower prevalence of non-alcoholic fatty liver disease (NAFLD) in a new study published in the Journal Hepatology.
To assess this, researchers conducted a cross-sectional study of 24,588 adults (mean age, 47.4 years) included in the 2007–2016 U.S. National Health and Nutrition Examination Survey. The study was published in the journal American Association For the study of Liver Diseases.
Coronavirus Infection May Cause Lasting Damage Throughout the Body, Doctors Fear
“COVID-19 is not just a respiratory disorder,” said Dr. Harlan Krumholtz, a cardiologist at Yale University. “It can affect the heart, the liver, the kidneys, the brain, the endocrine system, and the blood system.”
Potential Early Biomarker to Track Development of Non-alcoholic Fatty Liver Disease
Recent research at the Joslin Diabetes Center has uncovered a biomarker in humans tied to the development of NAFLD that might help doctors detect early stages of the disease. The researchers determined this biomarker, a protein known as "neuronal regeneration related protein" (NREP), plays a significant role in the regulation of a pathway that is currently being reviewed in clinical trials as a treatment option for the disease. The study was published in the Journal of "Clinical Investigation."
Health Matters: Treating Fatty Liver Disease in Children
While it typically presents with no symptoms—doctors say fatty liver disease can come with some dangerous side effects. “There are associated conditions, such as diabetes, insulin resistance, hyper cholesterol,” said Dr. Archi Ramaswami, a pediatric gastroenterologist with Golisano Children’s Hospital in Rochester, NY.
Children diagnosed with fatty liver disease are also at risk for liver failure and liver transplant. “Fatty liver disease is a condition that’s more common in those children that are overweight or obese and it's essentially an accumulation of fat in the liver,” she said.
Link between High-fat Diet and Liver Disease Reported
Mice fed a diet rich in saturated fat showed dramatic changes in liver gene expression.
New insights into how the liver adapts to a high-fat diet may lead to novel treatments for obesity-related diseases, such as nonalcoholic fatty liver disease, according to a study by NIEHS researchers. They found that long-term consumption of a diet high in saturated fat led to dramatic reprogramming of gene regulation in the mouse liver.
Non-alcoholic Fatty Liver Disease: 4 Questions About the Diagnostic Challenges in NAFLD
Nonalcoholic fatty liver disease (NAFLD) is one of the most common causes of liver disease in the United States. 30% to 40% of adults have NAFLD and 3% to 12% of adults have nonalcoholic steatohepatitis (NASH) according to the National Institute of Diabetes and Digestive and Kidney Diseases at the National Institutes of Health.
Treatment options for NAFLD and NASH are limited. However, new pharmacologic treatment options are on the horizon, making accurate diagnosis and staging of the disease a priority.
Gastroenterology Consultant spoke with Manal Abdelmalek, MD, MPH, from the Duke University School of Medicine, at the American College of Gastroenterology 2019 Annual Scientific Meeting and Postgraduate Course where she discussed the challenges associated with diagnosing and staging NAFLD and NASH.
COVID-19; Inflammation and Obesity Links
Obesity is the biggest single chronic risk factor for hospital admission in patients with COVID-19 under 60, increasing the risk 2-3-fold. Data from the CDC, supported by clinical studies in China, Europe, and now New York have shown that raised liver enzymes and high blood pressure also add risk, suggesting that over 70 million Americans with obesity, who are therefore at risk of steatohepatitis and metabolic syndrome should take particular precautions.
Upcoming NASH Council Meetings
April 30 – Communications Workgroup
May 7 – Policy Working Group
May 21 – Full NASH Council
TBD – Lifestyle and Clinical Workflow Working Groups
June 12 – International NASH Day
If you would like to be a part of these workgroups, contact nash@globalliver.org
