Fatty Acid Metabolism Fatty Liver No Alcohol ri

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CASE HISTORY Obese Patient Presents for FoIIow-LJp of Abnormal Liver Function

Tests
had a weight problem ali her life. She has been obese since has function tests discovered on of routine Iaboratory evaluation. The panem childhood, year-old woman returns to her internist for foiiow-up of abnormal hver and despite multiple diets has been unabie to mainlain any weight loss. She has a number of medical problems and complaints that are believed to be secondary to her weight. She has degenerative arthritis of both the knees and ankles, hyperlipi demia, dyspnea with mild leveis of exertion, and excessive fatigue. What are the medical complications no oJ There is his obesity? toryWhat of diabetes, viral hepatitis, galibiadder disease, or alcohol use. might be causing the abnorrnaiity in tiver function The tests? only medicines she takes are a multivitarnin and ibuprofen as needed for Patent Has a Family History of Obesity joint pain. She is married with two children, both of whom are overweight, as is her hus band. She does not work outside the borne. Her famlly history is remarkabie for obesity in both parents and her siblings. Her father died at the age of 61 second ary to comphcations of diabetes, and her rnother is 64 years oid and has hyper tension and coronary artery disease. Her younger brother is 36 years old and is Physical Examination hypertensive, and her sister, age 40, has recentiy been started on medication for On physicai exarnination her weight was 248 pounds (113 kg) and adult-onset diabetes mellitus. height was 5 feet 2 inches (157 cm), with a body rnass index (BMI; weight in kilograms divided by the square of the height in meters) of 45.8, consistent with severe obesity. The blood

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pressure was 144/88 mmHg, heart rale was 84 beats per minute, and respiratory rate was 16 per minute, and she was afebrile. The skin revealed striae (stretch marks) but no rashes or changes in pigmentation; however, therehead, was maceration skin folds under examination the breasis. revealed fuli extraocular The eyes, ears,in nose, and throat motion, fuil visual fields, and normal appearance of lhe fundus. The neck was supple and thick with out thyromegaly. Chestexamination was rmarkable for distant breath sounds but no wheezes or rhonchi. The heart examination revealed a point of maximal impulse (PMI) that was dificult to appreciate because of her body habitus, and distant heart sounds with an 54 gallop sound but no murmurs or rubs. The abdomen was obese with active bowel sounds, and no fluid wave was appreciated. Although the liver was not enlarged there was tender ness to deep palpation in the right upper quadrant. She had venous varicosities of both legs and trace bilateral edema at the ankles. Neurological examination revealed no focal deficits. Whai is the BMI? What range is normal? What are ofobesity? lhe metabolic cctses

Iaboratory Evaluation Reveals MiId Liver Dysfunction

She had undergone an extensive laboratory evaluation that revealed normal serum elec trolytes, blood urea nitrogen (BUN), and creatinine. lhe fasting blood sugar was 96 mg/dl. Complete blood count was remarkable only for a mild anemia, with a hematocrit of 35%, and otherwise normal red blood ceil indices. She had elevations in serum lipids, with a total cholesterol o[ 238 mg/dl (upper limit of normal [ULN]: 200 mg/dl), triglycerides 452mg/dl (ULN: Liver funcrion tests were abnormal on several occasions. 190 mg/dl), HDL 49 rngldl, LDL 158 mg/dl (ULN: 160 mgldl). Most recently the aspartate amino transferase (AST) was 88 IU/l (ULN: 31 IU/l), alanine amino transferase (ALT) was 112 IU/l (ULN: 31 IU/l), total bilirubin (TB) was 1.1 mg/dl (ULN: 1.2 mgldl), and the aI kaline phosphatase was 148 TUA (ULN: 120 IU/l). Blood coagulation tests were normal. Tesls for viral hepatitis A, B, and C and for heterophil antibodies were negative. Thyroid function tests were normal. Serum iron, ferritin, transferrin, and ceruloplasmin were nor mal. Tests for antinuclear antibodies and rheumatoid factor were unremarkable. Why were blood coagulation tests carried oul? Why were tests for serura iron, transferrin, and ceruloplasrnin canied out?

a Scan and Biopsy Reveal Fatty Liver

Ultrasound examination of the abdomen revealed a normal gallbladder, bile ducts, and pancreas. She had a computed tomographic (CT) scan of the abdomen that was remark able for hypodense regions in the liver consistem with steatosis (fatty infiltration of the liver). She had undergone a liver biopsy one week ago. lhe biopsy revealed fatty infiltra tion of the liver with sinusoidal and periceilular fibrosis with ballooning degeneration of hepatocytes and Mallory hyaline. What are lhe causes of nonalcoholicfauy liver disease (NAFLD)? Why was a liver biopsy recommended? What is lhe difference steatohepatitis? between steatosis and

FATTY ACID METABOLISM

Diagnosis and Treatment

A diagnosis of nonalcoholic steatohepatitis (NASH) was made. It was recommended that she go on a calorie-restricted diet in an attempt to decrease her weighL The hyperiipi dernia was treated with HMG-CoA reductase inhibitors (statins) and she was started on ursodeoxycholic acid. What are Lhe niechanisms oJ tiver ceil injury in NASH? What is ursodesoxycholic acid and what is Lhe proposed rnechanism of action in NASH? How do Lhe statins reduce cholesteroi leveis?

DISCUSSION Obesity
Triacyiglycerois serve as an irnportant energy reserve The ability to store energy in the form of fat serves an important physiological function. When food is plentiful excess energy may be stored in the form of triacylgiycerols (TAGs), which may later be mobilized in the form of fatty acids in times of scarce food supplies (see Section 22.1 of Biochernisfly 5e). Adipose tissue is found throughout the body and serves as the major bod iiy fat repository The storage of energy and its release is controlled via numerous endocrine and neural pathways to meet the current energy needs of the organism. For example, the hormone epinephrine (also calied adrenaline) which prepares an organism for the fight-or-flight response, inhibits acetyl-CoA carboxylase, the enzyrne that catalyzes the commitied step in fatty acid syn thesis, as well as activates the lipases, which catalyze the release of atty acids from triacylglyc erois. Thus, epinephrine simultaneously inhibits fatty acid synthesis and stimulates fts release from adipose tissue, thus providing the energy needed to BMI is the most widespread gauge of obesity cope with an immediate threat. Ahhough the ability to store fai promotes survival in times of fluctuating food supplies, in the Western industrialized world7~here food supplies are now plentiful, it has Ied to increased prevalence of obesity, and to associated adverse health consequences. Obesity is defined as excess adipose tissue mass, and the BMI is the most widely used index of obesity (although it is not a direct measure). A BMI of>30 is generally considered to be the threshhold for obe sity; however, medicar problems are also associated with BMls of 2530. In addition, the bod ily distribution of fat is consequential because intra-abdominal and abdominal subcutaneous fat are particuiarly associated with the more serious complications of obesity. Thus, the waist to-hip ratio is helpful in assessing risk, with values > 0.9 in women and> 1.0 in men con sidered abnormal. Obesity is becoming increasingly prevalent in the Western world. A recent survey indicates that 22.5% of the U.S. popuiation is obese. Obesity is linked to a nuniber of medical probiems
,

Obesity is associated with a number a disorders and diseases, such as insulin resistance, dia betes, cardiovascular disease, pulmonar> disease, reproductive disorders, andosteoarthritis. Obese individuais are also at increased risk for galistones and certain types of cancer and, as wiH be discussed further here, are particularly susceptible to hepatic steatosis, which resuits from

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CHAPTER 22

the accumulation of TAGs in hepatocytes. Hepatic steatosis alone is considered airly benign; however, when it progresses and includes inllammation and tissue necrosis it can result in life threatening cirrhosis. II has been estimated that hepatic steatosis is found in up to 75% of obese individuais and is thus ver> common, as well potentially life threatening, this subgroup. This patient and as her obese family members in exhibited a number of features associated with obesity. She has suffered from arthritis in herjoints as weil as liver dysfunction, both her sister and falher have developed diabetes, and her mother and brother suffer from cardio vascular problems.

Nonalcoholic Steatohepattis Deflned by hepatic histopathologic characteristics and Lhe absence oJ alcoholism NASH was first recognized in 1980 by Ludwig and coileagues, who described a
condition in a group of patients who denied excessive alcohoi consumplion, and in which liver biopsy findings were indistinguishabie from patients with alcoholic hepatitis. Most of the patients were women, miidly obese, and exhibited obesityrelated diseases such as diabetes and choiehthiasis (galistones in the gallbladder). NASH is now considered the extreme in a spec trum of NAFLD, which ranges from hepatic steatosis alone ir NASH, which is characterized by hepatic steatosis, inflammation, fibrosis and necrosis, with or without Mallory hyaline (in termediate filament aggregates), or cirrhosis. The prevalence of NASH has yet to be defini tively established; however, it has been reported worldwide, and from 1.2% ir 9% of the general population in the United States has been estimated ir be affected. Pathogenesis The pathogenesis of NASH is still unclear; however, II is known ir occur in the setting of steoiosis. Indeed, insulin resistance, which occurs in the large majority of patients with NAFLD, is thought ir feature prominently in the development of steatosis. Resistance to insulins nor mal suppression of lipolysis would resuli in the release of fatty acids from TAGs stored in adipocytes. The increased circulating leveis a fatty acids would lead ir increased inllux into the liver, where TAGs are formed; this together with decreased hepatic TAG export and ca tabolism have been proposed ir lead ir steatosis. However, steatosis alone does not cause cel lular injury, nor does it affect liver function, and is thus a benign Oxidative stress has been proposed ir the hit more a condition. lt has been proposed that iralead second is pathogenic necessary forms for the NAFLD. Oxidative stress is generated during peroxisomal fatty acid metabolism development of NASH. in the form of perox ide (see Section 22.3.4 ofBiochemistry Se), and evidence also implicates the microsomal (i.e., endoplasmic reticulum) enzyme, cytochrome P450 CYP2E1, in generating reactive oxygen species CR05). CYP2E1 is an oxidase involved in microsomal metabolism of faia> acids. Faia> acids are both inducers and substrates for this enzyme, and lis levei is markedly eievated in patients with NASH. Oxidative stress would then trigger lipid peroxidation, which further causes celiular damage via reactive intermediates. Evidence of lipid peroxidation has been ob served in animal modeis a the disease. The products of lipid peroxidation (such as malon dialdehyde and 4-hydroxynonenol) can induce inflammarion and fibrosis, which may lead ir necrosis, thus accounting for ali the pathological features associated with the livers a those with NASH. Although some evidence exists for this~mechanism of pathogenesis, the precise sequence o evenis is as yet unproven. lndeed, inllammation itself generates ROS, and thus inflammation may precede the generation of oxidative stress.

FATTYACIDMETABOLISM 173

Clinicalfeatures
In most cases NASH is asymptomatic, and the disease is recognized upon follow-up of mildly abnormal liver function tests, as in this pauent. Patients may complain of maiaise and fatigue, and of upper right quadrant abdominal pain or tenderness. Examination may reveal an en iarged liver. Ii has been estimated that between 65% and 100% of patients are female, 69100% are obese, and approximately one third have diabetes (usuaily non-insulin de pendem). Most studies have also found an association with hyperlipidaemia, occuring in 2 1 92% of patients. The mean age varies from 46 to 54 years. Although obesity, and the in sulin resistance associated with ii, are the mosi consistem causal factors, NASH has also been iinked to protein malnutrition, jejuno-ileal bypass, prolonged parenteral nutrition, acute star vation, and various medications. No definitive studies have yec determined prognosis for NASH; however, it has been concluded thac hepatic steatosis alone has a very good progno sis. One study revealed nocests clinical or histopathoiogical progression over a median time pe and riod Laboratory usuaily reveal a mild elevation of the liver enzymes, AST of 11and years inracio a group of patients with steatosis alone.may be used to distinguish ALI, the of AST:ALT is generally <1, which it from alcoholic hep atitis, in which the ratio is typically >1. Serum alkaline phosphatase leveis are also usually siightiy eievated; however, serum bilirubin leveis are usuaily normal, uniess che disease is quite advanced.

Diagnosis
Patients are usuaily diagnosed upon follow-up of abnormal liver function tests. Furcher mdi cacion of che disease may come from uitrasound, magnetic resonance imaging, or CT scans, which may reveal features typical of fatty infiltracion of the liver. However, only a liver biopsy can provide che evidence necessary to definitiveiy diagnose NAFLD. The degree of inilam mation and fibrosis can be revealed only through the biopsy, and is critical co assessing prog nosis. As mencioned above, fatty liver alone is benign; however, advanced NASH can lead ir cirrhosis and death from liver failure. Histologicai feacures associated with NASH are macrovesicular fat, inflammation, ballooning degeneracion of hepatocytes, Mallory hyahne, heparocyte necrosis, fibrosis, and cirrhosis in che mosc advanced cases. Patients are scored on these pathologic features in assessing prognosis.

Treatment
There is no established treatment for NASH, and current therapy focuses on gradual weighc reduction chrough changes in diec and exercise patterns. Weighc loss has been shown ir be beneficial, improving liver function tests and hiscopathology and patients also report ame lioration of the fatigue and malaise associated with the disease. Weighc loss has also been shown co decrease Data on specific therapies are preliminary; however, vicamin E (an antioxidanc) insulin resistance and hyperlipidaemia. suppie mentation has been reporced ir be helpful. ln addition, several studies have shown ur sodeoxycholic acid (USDA) ir be beneficial. This naturally occurring bile acid (derived from the Chinese black bear) primarily acts ir reiieve cholescasis, but has also been shown co be beneficial in a number of chronic liver diseases including NASH. USDA is a particularly hy drophilic bile acid, and improves the flow of bile and appears ir have hepatoproteccive, im munomodulatory and antioxidant properties.

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CI-IAPTER 22

QUESTIONS
1 Why do triacyiglycerois form vesicies inside celis, and why do they not participate in the formation of ceilular membranes? 2 The breakdown of triacylgiycerois is induced when biood-giucose leveis are low so as ir generate the ATP necessary for many essential physiological processes. Identify the point at which each product of faiiy acid oxidation (glycerol, acetyl CoA, NADH, FADH2) en ters energy-generating metabolic processes: giycolysis, the citric acid cycle, or oxidative phosphorylation. 3 Although gradual weight ioss has been shown ir be ver) effective in the treatment of NASH, very low caiorie diets or fasting have been shown ir worsen the condition. How might this be expiained? 4 it has been proposed that nutrient deficiency, in particular, the essential amino acids, may contribuir ir the deveiopment of NASH as a resuk of reduced production of very iow-density lipoproteins (VLDL), which depend upon them for their synthesis. How might reduced leveis ofVLDL lead to hepatic steatosis? 5 The drug troghtazone has been used to treat patients with NASH. What is the bio chemical rationale for lis use? 6 The drug perhexiline is used ir treat angina pecioris, and hepatic side-effects, including NASH, have been found in up ir one third of patients taking the drug. The hepatic tox icity is thought to be a result of mitochondrial injury Why would mitochondrial injury lead ir NASH? 7 Genetically obese oh/oh mice lack leptin, a hormone produced by adipocytes, and are commonly found to have hepatic steatosis. What is the role of leptin in the development of obesity, and is II a factor in the development of obesity in humans? National Heart, Lung and Blood instituir, Guidelines on Overweight and Obesity: Electronic Textbook: wwwnhlbi.nih.gov/guidelines/obesity/e.ixtbk/

FURTHER READING
1 McCullough, A. J. Update on non alcoholic fatty iiver disease. J. Clin. Gastroenierology (2002) 34:255262. 2 Yang, S. Q., et aI. Obesity increases sensitivity ir endotoxin liver injury: implications for the pathogenesis of steatohepatiiis. Proc. NaU. Acad. Sei. (1997) 94:25572562. 3 Chitturi, S., and Farreil, G. C. Etiopathogenesis of non-alcoholic steatohepatitis. Sernin. Liv. Dis. (2001) 21:2741. 4 Kopelman, E G. Obesity as a medical problem. Nature (2000) 404:635643.

For further information, see the following web sites:

American Liver Foundation, NAFLD/NASH: wwwliverfoundation.org/htmLfilz/livheal.dir/lh.Jmdox.dirlih_pdf.dir/NAFL. pdf Centers for Disease Control, Obesity and Overweight: www.cdc.gov/nccdphp/dnpa!obesitv/index.htm