Nonalcoholic Fatty Liver Disease in Children: Typical and Atypical Disclosure Naim Alkhouri, MD discloses the following relationships with commercial companies: Membership in the Speakers Bureau for Alexion and Intercept. Naim Alkhouri, MD Director of the Metabolic Liver Center Texas Liver Institute Learning Objectives Introduction At the end of this presentation the participant will be able to: 1. Discuss the natural history of fatty liver disease in children and young adults. 2. Summarize the work up for a child with NAFLD. 3. Discuss treatment options for NAFLD. Simple Steatosis (NAFL) NASH/ Fibrosis Cirrhosis Obesity and Adipose Tissue Steatosis 1-2% NASH/ 1-2% Fibrosis Cirrhosis Liver related morbidity and mortality 1
Lipotoxicity Disease Progression to NASH First Hit Steatosis TG FFA Hepatocyte Multiple Hits Apoptosis Cytochrome c ROS Caspase 3 Oxidative stress Kupffer cell Inflammatory Cytokines TNFα IL-6 Alkhouri N et al. Expert Rev Gastroenterol Hepatol. 29 Fibrogenesis / Fibrosis Inflammation Activated HSC Wieckowska et al. Hepatology 27; 46:582-589 Adults Overall: 3% Obese: 5-7% Severely Obese: 85% NAFLD Prevalence DM2: 65-75% Children Overall: 1% 15-19 years: 17% Obese: 5% Loomba et al. Nature Reviews 213. Schwimmer et al. Pediatrics 26. Younossi et al. Hepatology 215. Frequency as indication (%) Frequency of NASH as a Cause of Liver Transplantation (LT) in Adults 2 15 1 5 ALD HBV NASH PSC PBC AIH 21 22 23 24 25 26 27 28 29 Charlton et al. Gastroenterology. 211;141:1249 Young Kids, Old Bodies Natural History of NAFLD in Children A hospital-based cohort study n = 66 children with NAFLD, follow up for up to 2 years 1 Survival (%) 8 6 4 2 Expected Observed p<.1 Obesity is turning a generation of children into biological adults, ageing them before their time 5 1 15 2 Years since diagnosis 2 patients developed NASH-cirrhosis that required LT at 2 and 25 years Feldstein et al. Gut July 29 2
LT for NASH in Children and Young Adults The Frequency of NASH as an Indication for LT in Young Patients Percent of patients 4 3 2 1 Number of cases 25 2 15 1 5 4 Cryptogenic cirrhosis NASH 5 7 12 19 17 14 14 23 22 26 18 1 2 3 4 Age at LT (years) Alkhouri N et al. Transpl Int. 215 21 22 23 24 25 26 27 28 29 21 211 212 Year NASH 1 6 7 6 14 1 2 13 18 14 Cryptogenic cirrhosis 4 4 7 6 7 13 3 4 3 9 8 4 Screening for NAFLD: Pediatric Practice Guidelines AAP: Biannual screening with ALT measurement starting at 1 years of age for children with: BMI 95th percentile. BMI of 85-94th percentile with other risk factors. ESPGHAN: Abdominal US and liver function tests should be performed in all obese children. Boys Girls Barlow SE, et al. Pediatrics. 27 Vajro P, et al. JPGN. 212 Schwimmer JB et al. Gastroenterology. 21 Ultrasonography for NAFLD Liver Biopsy: Easier Said than Done US Cannot Stage the Severity of Fibrosis in Patients with NAFLD Sensitivity (%) 8 6 4 2 5-9% 1-19% 2-29% 3% Degree of Steatosis Lee SS et al. WJG. 214 NAFLD affects 1/1 children 5 million American Children have NAFLD 5 million liver biopsies!!!! 3
Staging the Severity of Fibrosis in NAFLD: VCTE VCTE + CAP: A Powerful Tool Actuator 17 year female referred to the Metabolic Liver Center. Elevated ALT (87 U/L) Fatty infiltration of the liver on US. Weight: 338 lbs. BMI: 62 kg/m2 ( 99.8th%) Case Presentation Assessment of the Child with Suspected NAFLD 1. Rule out other etiologies for elevated liver enzymes/ fatty infiltration of the liver. 2. Evaluate for co-morbidities/ extra-hepatic manifestations of NAFLD. 3. Determine the severity of NAFLD Presence of NASH Presence of liver fibrosis 1. Rule out other etiologies 2. Evaluate for co-morbidities Mencine A and Lavine J. Nat Rev Gastroenterol Hepatol. 215 4
Laboratory Assessment for Children with NAFLD Results Test Results HbA1C 6.2% (<5.7) Fasting Insulin 52 μu/ml (< 2) TG 228 mg/dl (<15) HDL 36 mg/dl (> 4) Vitamin D 25 OH 16.5 ng/ml (>3) PSG + OSA ALT 87 U/L (-45) Liver US Fatty infiltration 3. Determine the Severity of NAFLD VCTE: Liver stiffness at 12 kpa consistent with F3 fibrosis (bridging). Liver biopsy: NASH with bridging fibrosis. NAFLD Treatment Pre-diabetes Simple Steatosis (NAFL) Diabetes NASH/ Fibrosis Diabetes Complications Cirrhosis TONIC: Vitamin E or Metformin for Treatment of Pediatric NAFLD Double-blind, placebo-controlled, randomized, multicenter Phase II trial 81% boys, 61% Hispanic, 42% with baseline NASH, mean BMI 34 kg/m 2, mean baseline ALT 123 U/L Biopsy at Week Biopsy at Week 96 Children aged 8 to 17 years with NAFLD, no diabetes or cirrhosis (N = 173) Vitamin E 4 IU twice daily (n = 58) Placebo (n = 58) Metformin 5 mg twice daily (n = 57) Lavine JE, et al. JAMA. 211;35:1659-1668. 5
Primary Endpoint: Reduction in ALT at Week 96 No significant difference between vitamin E and placebo (P =.7) or metformin and placebo (P =.4) Secondary Endpoint: Resolution of Definite or Borderline NASH at Week 96 Mean Change in ALT (U/L) -2-4 -6 4 12 24 48 72 96 Weeks Vitamin E Placebo Metformin Biopsies at Wk 96 n = 5 n = 47 n = 5 Outcome Vitamin E (n = 43) Placebo (n = 38) Metformin (n = 39) Resolved, % 58 28 41 P value vs placebo.6 --.23 Lavine JE, et al. JAMA. 211;35:1659-1668. The Race to Cure NASH: Two Medications in Phase III RTCS Bile Acids, FXR and NAFLD Obeticholic acid (OCA): FXR agonist Anti-fibrotic Elafibranor: PPAR α-δ agonist Decrease LDL, increase HDL, favorable metabolic profile 6
PPAR α-δ Agonist: A Novel Treatment for NAFLD An international, phase 2 RCT of the dual PPAR α-δ agonist Elafibranor in NASH: GOLDEN Biopsy 9 mos before treatment Biopsy at Week 52 Adults with biopsyproven NASH, NAS 3, Any Fibrosis Stage (N = 274) Elafibranor 8 mg/day (n = 93) Elafibranor 12 mg/day (n = 89) Placebo (n = 92) Primary Endpoint: Reversal of NASH LEAN: Liraglutide for 48 Wks Improvement in patients with moderate to 2 severe NASH 9 Randomized, double-blind phase II trial of overweight pts with NASH 1 Liraglutide (n = 23) Placebo (n = 22) Pts (%) 8 6 4 P =.19 P =.5 P =.65 P =.46 P =.4 39 61 32 14 9 n/n = 9/23 2/22 14/23 7/22 11/23 12/22 6/23 3/22 2/23 8/22 Resolution Improved Improved Improved Worsened of NASH Ballooning Inflammation Fibrosis Fibrosis 48 55 26 36 Slide credit: clinicaloptions.com Armstrong MJ, et al. Lancet. 216;387:679-69. NASH Therapies in Development Take Home Message NAFLD is potentially serious even during childhood and early adulthood. Work up: Rule out other etiologies for CLD Assess for co-morbidities Assess severity NASH-specific therapy are emerging rapidly. Rohit Loomba. Liver Learning. AASLD 215 7
Atypical NASH: Case Presentation 17 year female referred to the Metabolic Liver Center. Elevated ALT (87 U/L) Fatty infiltration of the liver on US. Weight: 138 lbs. BMI: 22.3 kg/m2 Test Results HbA1C 4.8% (<5.7) Fasting 12 μu/ml (< 2) Insulin TG 228 mg/dl (<15) HDL 26 mg/dl (> 4) LDL 21 mg/dl (< 11) Platelet 135K (> 15K) ALT 87 U/L (-45) Liver US Fatty infiltration, massive hepatomegaly 8