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Serum biomarkers combined with ultrasonography for early diagnosis of non-alcoholic fatty liver disease confirmed by magnetic resonance spectroscopy

Abstract

Magnetic resonance spectroscopy (MRS) is notably accurate for even minimal degree of hepatic steatosis in non-alcoholic fatty liver disease (NAFLD). But routine use of MRS is limited by its cost and availability. In this study, we developed a diagnostic model combining ultrasonography with biomarkers to identify mild NAFLD, with MRS as the reference standard. A total of 422 eligible subjects were enrolled. The serum levels of fibroblast growth factor 21 (FGF21), cytokeratin 18 M65ED, proteinase 3, neutrophil elastase, alpha-1 antitrypsin, and neutrophil elastase/alpha-1 antitrypsin were measured using ELISA assays. We found that among the six biomarkers, only serum FGF21 was independently associated with intrahepatic triglyceride content (IHTC, standardized β = 0.185, P< 0.001) and was an independent risk factor for mild NAFLD. Thus, we established a Mild NAFLD Model based on FGF21, alanine transaminase, triglycerides, and body mass index. The area under the receiver-operating characteristic curve of the Mild NAFLD Model was 0.853 (95% confidence interval: 0.816–0.886). Furthermore, a two-step approach combining ultrasonography with the Mild NAFLD Model displayed a better sensitivity for diagnosing mild NAFLD compared with each method alone, with a sensitivity of 97.32% and a negative predictive value of 85.48%. This two-step approach combining ultrasonography and the Mild NAFLD Model derived from serum FGF21 improves the diagnosis of mild NAFLD and can be applied to the early diagnosis of NAFLD in clinical practice.

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References

  1. 1.

    Younossi Z, Tacke F, Arrese M, Sharma BC, Mostafa I, Bugianesi E, et al. Global perspectives on non-alcoholic fatty liver disease and non-alcoholic steatohepatitis. Hepatology. 2018;69:2672–82.

    Article  Google Scholar 

  2. 2.

    Kleiner DE, Brunt EM, Van Natta M, Behling C, Contos MJ, Cummings OW, et al. Design and validation of a histological scoring system for nonalcoholic fatty liver disease. Hepatology. 2005;41:1313–21.

    Article  Google Scholar 

  3. 3.

    Adams LA, Sanderson S, Lindor KD, Angulo P. The histological course of nonalcoholic fatty liver disease: a longitudinal study of 103 patients with sequential liver biopsies. J Hepatol. 2005;42:132–8.

    Article  Google Scholar 

  4. 4.

    Chalasani N, Wilson L, Kleiner DE, Cummings OW, Brunt EM, Unalp A. Relationship of steatosis grade and zonal location to histological features of steatohepatitis in adult patients with non-alcoholic fatty liver disease. J Hepatol. 2008;48:829–34.

    Article  Google Scholar 

  5. 5.

    McPherson S, Hardy T, Henderson E, Burt AD, Day CP, Anstee QM. Evidence of NAFLD progression from steatosis to fibrosing-steatohepatitis using paired biopsies: implications for prognosis and clinical management. J Hepatol. 2015;62:1148–55.

    Article  Google Scholar 

  6. 6.

    Wong VW, Wong GL, Choi PC, Chan AW, Li MK, Chan HY, et al. Disease progression of non-alcoholic fatty liver disease: a prospective study with paired liver biopsies at 3 years. Gut. 2010;59:969–74.

    Article  Google Scholar 

  7. 7.

    Anstee QM, Targher G, Day CP. Progression of NAFLD to diabetes mellitus, cardiovascular disease or cirrhosis. Nat Rev Gastroenterol Hepatol. 2013;10:330–44.

    CAS  Article  Google Scholar 

  8. 8.

    Shen X, Cai J, Gao J, Vaidya A, Liu X, Li W, et al. Nonalcoholic fatty liver disease and risk of diabetes: a prospective study in China. Endocr Pract. 2018;24:823–32.

    Article  Google Scholar 

  9. 9.

    Bohte AE, van Werven JR, Bipat S, Stoker J. The diagnostic accuracy of US, CT, MRI and 1H-MRS for the evaluation of hepatic steatosis compared with liver biopsy: a meta-analysis. Eur Radiol. 2011;21:87–97.

    Article  Google Scholar 

  10. 10.

    Takyar V, Nath A, Beri A, Gharib AM, Rotman Y. How healthy are the “Healthy volunteers”? Penetrance of NAFLD in the biomedical research volunteer pool. Hepatology. 2017;66:825–33.

    Article  Google Scholar 

  11. 11.

    Hernaez R, Lazo M, Bonekamp S, Kamel I, Brancati FL, Guallar E, et al. Diagnostic accuracy and reliability of ultrasonography for the detection of fatty liver: a meta-analysis. Hepatology. 2011;54:1082–90.

    Article  Google Scholar 

  12. 12.

    Lee SS, Park SH, Kim HJ, Kim SY, Kim MY, Kim DY, et al. Non-invasive assessment of hepatic steatosis: prospective comparison of the accuracy of imaging examinations. J Hepatol. 2010;52:579–85.

    CAS  Article  Google Scholar 

  13. 13.

    Machado MV, Cortez-Pinto H. Non-invasive diagnosis of non-alcoholic fatty liver disease. A critical appraisal. J Hepatol. 2013;58:1007–19.

    Article  Google Scholar 

  14. 14.

    Hetterich H, Bayerl C, Peters A, Heier M, Linkohr B, Meisinger C, et al. Feasibility of a three-step magnetic resonance imaging approach for the assessment of hepatic steatosis in an asymptomatic study population. Eur Radiol. 2016;26:1895–904.

    Article  Google Scholar 

  15. 15.

    Woo YC, Xu A, Wang Y, Lam KS. Fibroblast growth factor 21 as an emerging metabolic regulator: clinical perspectives. Clin Endocrinol. 2013;78:489–96.

    CAS  Article  Google Scholar 

  16. 16.

    Li H, Dong K, Fang Q, Hou X, Zhou M, Bao Y, et al. High serum level of fibroblast growth factor 21 is an independent predictor of non-alcoholic fatty liver disease: a 3-year prospective study in China. J Hepatol. 2013;58:557–63.

    CAS  Article  Google Scholar 

  17. 17.

    Yan H, Xia M, Chang X, Xu Q, Bian H, Zeng M, et al. Circulating fibroblast growth factor 21 levels are closely associated with hepatic fat content: a cross-sectional study. PLoS One. 2011;6:e24895.

    CAS  Article  Google Scholar 

  18. 18.

    Toonen EJ, Mirea AM, Tack CJ, Stienstra R, Ballak DB, van Diepen JA, et al. Activation of proteinase 3 contributes to non-alcoholic fatty liver disease (NAFLD) and insulin resistance. Mol Med. 2016;22:202–14.

  19. 19.

    Talukdar S, Oh DY, Bandyopadhyay G, Li D, Xu J, McNelis J, et al. Neutrophils mediate insulin resistance in mice fed a high-fat diet through secreted elastase. Nat Med. 2012;18:1407–12.

    CAS  Article  Google Scholar 

  20. 20.

    Mansuy-Aubert V, Zhou QL, Xie X, Gong Z, Huang JY, Khan AR, et al. Imbalance between neutrophil elastase and its inhibitor alpha1-antitrypsin in obesity alters insulin sensitivity, inflammation, and energy expenditure. Cell Metab. 2013;17:534–48.

    CAS  Article  Google Scholar 

  21. 21.

    Zang S, Ma X, Zhuang Z, Liu J, Bian D, Xun Y, et al. Increased ratio of neutrophil elastase to alpha1-antitrypsin is closely associated with liver inflammation in patients with nonalcoholic steatohepatitis. Clin Exp Pharmacol Physiol. 2016;43:13–21.

    CAS  Article  Google Scholar 

  22. 22.

    Alkhouri N, Carter-Kent C, Feldstein AE. Apoptosis in nonalcoholic fatty liver disease: diagnostic and therapeutic implications. Expert Rev Gastroenterol Hepatol. 2011;5:201–12.

    Article  Google Scholar 

  23. 23.

    Szczepaniak LS, Nurenberg P, Leonard D, Browning JD, Reingold JS, Grundy S, et al. Magnetic resonance spectroscopy to measure hepatic triglyceride content: prevalence of hepatic steatosis in the general population. Am J Physiol Endocrinol Metab. 2005;288:E462–8.

    CAS  Article  Google Scholar 

  24. 24.

    Rotman Y, Sanyal AJ. Current and upcoming pharmacotherapy for non-alcoholic fatty liver disease. Gut. 2017;66:180–90.

    CAS  Article  Google Scholar 

  25. 25.

    Fisher FM, Maratos-Flier E. Understanding the physiology of FGF21. Annu Rev Physiol. 2016;78:223–41.

    CAS  Article  Google Scholar 

  26. 26.

    Joka D, Wahl K, Moeller S, Schlue J, Vaske B, Bahr MJ, et al. Prospective biopsy-controlled evaluation of cell death biomarkers for prediction of liver fibrosis and nonalcoholic steatohepatitis. Hepatology. 2012;55:455–64.

    CAS  Article  Google Scholar 

  27. 27.

    Wu G, Li H, Fang Q, Zhang J, Zhang M, Zhang L, et al. Complementary role of fibroblast growth factor 21 and cytokeratin 18 in monitoring the different stages of nonalcoholic fatty liver disease. Sci Rep. 2017;7:5095.

    Article  Google Scholar 

  28. 28.

    Lebeaupin C, Vallee D, Hazari Y, Hetz C, Chevet E, Bailly-Maitre B. Endoplasmic reticulum stress signalling and the pathogenesis of non-alcoholic fatty liver disease. J Hepatol. 2018;69:927–47.

    CAS  Article  Google Scholar 

  29. 29.

    Buzzetti E, Pinzani M, Tsochatzis EA. The multiple-hit pathogenesis of non-alcoholic fatty liver disease (NAFLD). Metabolism. 2016;65:1038–48.

    CAS  Article  Google Scholar 

  30. 30.

    Kromrey ML, Ittermann T, Berning M, Kolb C, Hoffmann RT, Lerch MM, et al. Accuracy of ultrasonography in the assessment of liver fat compared with MRI. Clin Radiol. 2019;74:539–46.

  31. 31.

    de Moura Almeida A, Cotrim HP, Barbosa DB, de Athayde LG, Santos AS, Bitencourt AG, et al. Fatty liver disease in severe obese patients: diagnostic value of abdominal ultrasound. World J Gastroenterol. 2008;14:1415–8.

    Article  Google Scholar 

  32. 32.

    Ozturk A, Grajo JR, Gee MS, Benjamin A, Zubajlo RE, Thomenius KE, et al. Quantitative hepatic fat quantification in non-alcoholic fatty liver disease using ultrasound-based techniques: a review of literature and their diagnostic performance. Ultrasound Med Biol. 2018;44:2461–75.

    Article  Google Scholar 

  33. 33.

    Bedogni G, Bellentani S, Miglioli L, Masutti F, Passalacqua M, Castiglione A, et al. The Fatty Liver Index: a simple and accurate predictor of hepatic steatosis in the general population. BMC Gastroenterol. 2006;6:33.

    Article  Google Scholar 

  34. 34.

    Lee JH, Kim D, Kim HJ, Lee CH, Yang JI, Kim W, et al. Hepatic steatosis index: a simple screening tool reflecting nonalcoholic fatty liver disease. Dig Liver Dis. 2010;42:503–8.

    CAS  Article  Google Scholar 

  35. 35.

    Wong VW, Adams LA, de Ledinghen V, Wong GL. Noninvasive biomarkers in NAFLD and NASH—current progress and future promise. Nat Rev Gastroenterol Hepatol. 2018;15:461–78.

    CAS  Article  Google Scholar 

  36. 36.

    McPherson S, Jonsson JR, Cowin GJ, O’Rourke P, Clouston AD, Volp A, et al. Magnetic resonance imaging and spectroscopy accurately estimate the severity of steatosis provided the stage of fibrosis is considered. J Hepatol. 2009;51:389–97.

    Article  Google Scholar 

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Acknowledgements

This work was supported by the National Natural Science Foundation Major International (Regional) Joint Research Project (81220108006) and an NSFC-NHMRC Joint Research grant (81561128016) to WPJ; the General Program of Natural Science Foundation of China (81870598), the Shanghai Pujiang Program (17PJ1407500), and the Municipal Human Resources Development Program for Outstanding Young Talents in Medical Health Sciences in Shanghai (2017YQ009) to HTL; and the Shanghai Municipal Key Clinical Specialty.

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LLQ and LW performed the data analysis and wrote the manuscript; LLQ, LZ, and JZ contributed to the acquisition of data; LW assisted in statistical analysis; QCF and HTL contributed to data interpretation; JZ and YHL assisted the magnetic resonance spectroscopy examinations; HTL and WPJ were in charge of the overall conception and design of the study. All authors included in the authorship list approved the final manuscript version.

Corresponding authors

Correspondence to Hua-ting Li or Wei-ping Jia.

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The authors declare no competing interests.

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Qian, Ll., Wu, L., Zhang, L. et al. Serum biomarkers combined with ultrasonography for early diagnosis of non-alcoholic fatty liver disease confirmed by magnetic resonance spectroscopy. Acta Pharmacol Sin 41, 554–560 (2020). https://doi.org/10.1038/s41401-019-0321-x

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Keywords

  • fatty liver
  • non-alcoholic fatty liver disease
  • biomarkers
  • diagnostic model
  • fibroblast growth factor 21
  • ultrasonography
  • magnetic resonance spectroscopy

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