The effect of surgically induced weight loss on nonalcoholic fatty liver disease in morbidly obese Indians: “NASHOST” prospective observational trial

doi:10.1016/j.soard.2015.02.006

Surgery for Obesity and Related Diseases

Volume 11, Issue 6, November–December 2015, Pages 1315-1322

https://doi.org/10.1016/j.soard.2015.02.006 Get rights and content

Abstract

Background

Surgically induced weight loss improves nonalcoholic fatty liver disease (NAFLD) in morbidly obese Caucasian patients. Similar data are lacking from India.

Objective

To compare the histologic features of NAFLD in morbidly obese Indian patients before and 6 months after bariatric surgery. Histologic changes were also separately assessed according to the type of bariatric intervention.

Setting

Teaching institution, India; private practice.

Methods

All patients undergoing bariatric surgery from July 2012 to July 2013 underwent a routine liver biopsy at the time of bariatric surgery. If the biopsy specimen indicated NAFLD, patients were asked to undergo a second biopsy after 6 months. Baseline anthropometry, clinical data, biochemistry, and pathology were recorded and repeated at follow-up.

Results

Eighty-eight of 134 index biopsy specimens indicated NAFLD. Thirty patients had paired liver biopsies. Steatosis was present in all, 14 had lobular inflammation, 10 had ballooning degeneration, and 14 had fibrosis. Mean time between the biopsies was 7.1 months (range 6–8 months). At the second biopsy, steatosis had resolution in 19 and improvement in 11, lobular inflammation had resolution in 12 and improvement in 2, ballooning had resolution in 9 and improvement in 1 and fibrosis had resolution in 11 and improvement in 3 (P<0.05 for all). Improvement was greater among those who underwent a sleeve gastrectomy in comparison to a Roux-en-Y gastric bypass, although this difference was not statistically significant. None had worsening of liver histologic results.

Conclusions

Surgically induced weight loss significantly and rapidly improves liver histology in morbidly obese Indians with NAFLD.

Section snippets

Study design

This was a prospective observational trial of a cohort of morbidly obese Indian patients undergoing elective bariatric surgery with liver biopsy paired with a liver biopsy 6 months after surgery at Gem Hospital and Research Centre over a 1-year period. Study methods were in compliance with the Indian Council of Medical Research regulations (Ethical Guidelines for Biomedical Research on Human Participants) and the declaration of Helsinki. The study was approved by the Gem Hospital Ethics

Results

This study included 30 morbidly obese adult patients with NAFLD who underwent elective bariatric surgery with liver biopsy paired with a liver biopsy 6 months after surgery at Gem Hospital and Research Centre between July 2012 and June 2013.

The liver characteristics of the overall cohort at baseline are provided in Table 1. Eighty-eight patients were detected to have NAFLD among the 134 patients biopsied at baseline. The consent rate for rebiopsy in 88 patients with NAFLD was 34% (30/88). A

Discussion

The results of this prospective observational trial of morbidly obese patients undergoing bariatric surgery shows that gradual and significant weight reduction after bariatric surgery rapidly improves or dramatically resolves the spectrum of histologic features seen in NAFLD in Indian patients. There was no observed worsening of liver disease in any of the patients. This improvement was consistent in all irrespective of the type of bariatric surgery performed. There was also a significant

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Obesity and nonalcoholic fatty liver disease (NAFLD) are an increasing health care burden worldwide. Weight loss is currently the best option to alleviate NAFLD and is efficiently achieved by bariatric surgery. Presence of NAFLD seems to be predictive for postoperative weight loss. To date, only few predictive factors for postbariatric weight loss (age, diabetes, psychiatric disorders) are established.
Since liver fibrosis is the pathogenic driver for the progression of liver disease, we investigated its role in predicting postoperative weight loss. This study focuses on the correlation between fibrosis stage and weight loss.
University and university-affiliated cooperation, Germany.
We used a prospective, single-center cohort study including 164 patients who underwent bariatric surgery with simultaneous liver biopsies. Liver fibrosis was determined histologically according to Kleiner score and noninvasively by APRI and FIB-4 score. Percentage of total body weight loss was calculated at 1-year follow up visit.
Thirty-two patients were found without fibrosis, whereas 91 patients showed mild fibrosis (F1), 37 significant fibrosis (F2), and only 4 patients presented advanced fibrosis (F3) at the time of bariatric surgery. Weight loss was similar across different degrees of fibrosis stage. Accordingly, linear regression analysis did not identify predictors of weight loss among fibrosis scores. In multivariable analysis, age and presence of diabetes showed the strongest predictive value.
Baseline presence of fibrosis was not associated with postoperative weight loss, while age and diabetes were independent predictors of weight loss. Bariatric surgery should be applied independently of the fibrosis stage.
The Role Bariatric Surgery and Endobariatric Therapies in Nonalcoholic Steatohepatitis
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Table 4 summarizes the histologic features from RYGB and LSG cohorts separately. There were 264 RYGB patients with paired liver biopsies, from 10 studies [60–66,69–71], with a mean follow-up of 15.2 months, and 232 LSG patients with paired liver biopsies, from 4 studies [67–70], with a mean follow-up of 13.7 months. Mean NAS dropped from 3.2 to 0.8 after RYGB and from 5.1 to 2.3 after LSG.
Dysregulated lipid metabolism links NAFLD to cardiovascular disease
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Non-alcoholic fatty liver disease (NAFLD) is rapidly becoming a global health problem. Cardiovascular diseases (CVD) are the most common cause of mortality in NAFLD patients. NAFLD and CVD share several common risk factors including obesity, insulin resistance, and type 2 diabetes (T2D). Atherogenic dyslipidemia, characterized by plasma hypertriglyceridemia, increased small dense low-density lipoprotein (LDL) particles, and decreased high-density lipoprotein cholesterol (HDL-C) levels, is often observed in NAFLD patients.
In this review, we highlight recent epidemiological studies evaluating the link between NAFLD and CVD risk. We further focus on recent mechanistic insights into the links between NAFLD and altered lipoprotein metabolism. We also discuss current therapeutic strategies for NAFLD and their potential impact on NAFLD-associated CVD risk.
Alterations in hepatic lipid and lipoprotein metabolism are major contributing factors to the increased CVD risk in NAFLD patients, and many promising NASH therapies in development also improve dyslipidemia in clinical trials.
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Despite the fact that there is still insufficient evidence to consider non-alcoholic fatty liver disease (NAFLD) as an stand-alone indication for bariatric surgery, many clinical and histopathological beneficial effects on both NAFLD and non-alcoholic steatohepatitis (NASH) have been shown. Although weight loss seems to be the obvious mechanism, weight-loss independent factors are also believed to be involved. Among them, changes in gut microbiota and bile acids (BA) composition may be playing an unappreciated role in the improvement of NAFLD. In this review we examine the mechanisms and interdependence of the gut microbiota and BA, and their influence on NAFLD pathogenesis and its reversal following bariatric surgery. According to the currently available evidence, gut microbiota has a major influence on BA composition. In fact, both BA and microbiome disturbances (dysbiosis) play a role in the etiopathogenesis of NAFLD and might be potential therapeutic targets. In addition, bariatric surgery can modify the intraluminal ileal environment in a way that causes significant repopulation of the gut microbiota and a reversal of the plasma primary/secondary BA ratio, which, in turn, induces weigh-independent metabolic improvements.
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Original articleThe effect of surgically induced weight loss on nonalcoholic fatty liver disease in morbidly obese Indians: “NASHOST” prospective observational trial

Abstract

Background

Objective

Setting

Methods

Results

Conclusions

Section snippets

Study design

Results

Discussion

Surg Obes Relat Dis

Surg Obes Relat Dis

Gastroenterology

Surgery

Gastroenterology

Am J Gastroenterol

The clinicopathological profile of Indian patients with nonalcoholic fatty liver disease (NAFLD) is different from that in the West

Dig Dis Sci

Nonalcoholic fatty liver disease in India - a lot done, yet more required!

Indian J Gastroenterol

The epidemiology of nonalcoholic fatty liver disease: a global perspective

Semin Liver Dis

Prevalence and predictors of asymptomatic liver disease in patients undergoing gastric bypass surgery

Arch Surg

Nonalcoholic fatty liver disease: hepatic manifestation of obesity and the metabolic syndrome

Postgrad Med

Nonalcoholic fatty liver disease: a manifestation of the metabolic syndrome

Cleve Clin J Med

Weight loss: cornerstone in the treatment of non-alcoholic fatty liver disease

Minerva Gastroenterol Dietol

Weight loss as a treatment for nonalcoholic fatty liver disease

J Clin Gastroenterol

Bariatric surgery and long-term control of morbid obesity

JAMA

Bariatric surgery: a systematic review and meta-analysis

JAMA

Regression of liver steatosis following gastroplasty or gastric bypass for morbid obesity

Digestion

Histological behavior of hepatic steatosis in morbidly obese patients after weight loss induced by bariatric surgery

Obes Surg

Roux-en-Y gastric bypass improves liver histology in patients with non-alcoholic fatty liver disease

Obes Res

Nonalcoholic fatty liver disease: Improvement in liver histological analysis with weight loss

Hepatology

Surgically-induced weight loss significantly improves nonalcoholic fatty liver disease and the metabolic syndrome

Ann Surg

Roux-en-Y gastric bypass improves the nonalcoholic steatohepatitis (NASH) of morbid obesity

Obes Surg

Original article
The effect of surgically induced weight loss on nonalcoholic fatty liver disease in morbidly obese Indians: “NASHOST” prospective observational trial