Efficacy of docosahexaenoic acid-choline-vitamin E in paediatric NASH: a randomized controlled clinical trial. Vitamin E and vitamin C treatment improves fibrosis in patients with nonalcoholic steatohepatitis A pilot study of vitamin E versus vitamin E and pioglitazone for the treatment of nonalcoholic steatohepatitis. Highly Purified Eicosapentaenoic Acid Treatment Improves Nonalcoholic Steatohepatitis Docosahexanoic Acid Plus Vitamin D Treatment Improves Features of NAFLD in Children with Serum Vitamin D Deficiency: Results from a Single Centre Trial Randomized placebo-controlled trial of ursodeoxycholic acid with vitamin e in nonalcoholic steatohepatitis. The utility of radiological imaging in nonalcoholic fatty liver disease. Patients with Nonalcoholic Fatty Liver Disease Have a Low Response Rate to Vitamin D Supplementation. Hypovitaminosis D is associated with increased whole body fat mass and greater severity of non-alcoholic fatty liver disease. Ursodeoxycholic acid with vitamin E in patients with nonalcoholic steatohepatitis: long-term results. Effect of vitamin E or metformin for treatment of nonalcoholic fatty liver disease in children and adolescents: the TONIC randomized controlled trial. Cytokines and NASH: a pilot study of the effects of lifestyle modification and vitamin E. Effects of combined low‐dose spironolactone plus vitamin E vs vitamin E monotherapy on insulin resistance, non‐invasive indices of steatosis and fibrosis, and adipokine levels in non‐alcoholic fatty liver disease: a randomized controlled trial Histological improvement of non-alcoholic steatohepatitis with a prebiotic: a pilot clinical trial Long-Term Pioglitazone Treatment for Patients With Nonalcoholic Steatohepatitis and Prediabetes or Type 2 Diabetes Mellitus Lifestyle intervention and antioxidant therapy in children with nonalcoholic fatty liver disease: a randomized, controlled trial. Sampling variability of liver biopsy in nonalcoholic fatty liver disease.
Nonalcoholic steatohepatitis ( NASH ) , a progressive form of nonalcoholic fatty liver disease , is one of the most common hepatic diseases in children . We conducted a r and omized controlled clinical trial on children with biopsy-proven NASH based on a combinatorial nutritional approach compared with placebo . Participants were assigned to lifestyle modification plus placebo or lifestyle modification plus a mix containing docosahexaenoic acid , choline , and vitamin E ( DHA-CHO-VE ) .  Forty children and adolescents participated in the entire trial . The primary outcome was the improvement of liver hyperechogenicity . Secondary outcomes included alterations of alanine aminotransferase ( ALT ) and other metabolic parameters . Furthermore , changes of serum bile acids ( BA ) and plasma fibroblast growth factor 19 ( FGF19 ) levels were evaluated as inverse biomarkers of disease severity . At the end of the study , we observed a significant decrease in severe steatosis in the treatment group ( 50 % to 5 % , p = 0.001 ) . Furthermore , although the anthropometric and biochemical measurements in the placebo and DHA-CHO-VE groups were comparable at baseline , at the end of the study ALT and fasting glucose levels improved only in the treatment group . Finally , we found that BA levels were not influenced whereas FGF19 levels were significantly increased by DHA-CHO-VE . The results suggest that a combination of DHA , VE , and CHO could improve steatosis and reduce ALT and glucose levels in children with NASH . However , further studies are needed to assess the impact of a DHA and VE combination on repair of liver damage in paediatric NASH OBJECTIVE : Nonalcoholic steatohepatitis ( NASH ) is a common cause of liver disease . Although usually indolent , this disease can progress to cirrhosis in some patients . There is currently no proven medical therapy for the treatment of NASH . The aim of our study was to evaluate the efficacy of combination α-tocopherol ( vitamin E ) and vitamin C in reducing histologic inflammation and fibrosis . METHODS : This was a prospect i ve , double-blind , r and omized , placebo-controlled trial with a total enrollment of 49 patients ; 45 patients completed the study . All patients were r and omized to receive either vitamins E and C ( 1000 IU and 1000 mg , respectively ) or placebo daily for 6 months , based on their initial histologic diagnosis of NASH . Additionally , all patients were given st and ard weight-loss counseling and encouraged to follow a low fat diet ( < 30 fat g/day ) . The pre- and posttreatment liver biopsies were review ed by a single pathologist , who was blinded to the patient 's medication . Biopsies were scored based on a modification of the scoring system published by Brunt et al. ( Am J Gastroenterol 1999;94:2467–74 ) . A score of 0–4 was possible for fibrosis , and a score of 0–6 was possible for inflammation and hepatocyte degeneration and necrosis . In addition , body mass index , glycohemoglobin , lipids , and liver enzymes were followed throughout the study . RESULTS : Forty-five patients completed 6 months of therapy without significant side effects  . Vitamin treatment result ed in a statistically significant improvement in fibrosis score ( p = 0.002 ) . No changes were noted in inflammation with treatment . CONCLUSIONS : Vitamin E and vitamin C , in the doses used in this study , were well tolerated and were effective in improving fibrosis scores in NASH patients . No improvement in necroinflammatory activity or ALT was seen with this combination of drug therapy . A larger , multicenter , longer-term trial with vitamin E and vitamin C seems to be warranted BACKGROUND & AIMS Insulin resistance and oxidative stress contribute to the pathogenesis of nonalcoholic steatohepatitis ( NASH ) . We conducted a pilot study for the following reasons : ( 1 ) to test the hypothesis that a combination of an antioxidant ( vitamin E ) and an insulin sensitizer ( pioglitazone ) would be superior to vitamin E alone for the treatment of NASH , and ( 2 ) to define the effects of these interventions on insulin-sensitive metabolic functions and correlate the effects with changes in liver histology . METHODS A r and omized prospect i ve trial was performed to compare the efficacy and safety of vitamin E alone ( 400 IU/day ) vs. vitamin E ( 400 IU/day ) and pioglitazone ( 30 mg/day ) in nondiabetic , noncirrhotic subjects with NASH . Metabolic functions were assessed by a 2-step , hyperinsulinemic ( 10 and 40 mU/m2/min ) euglycemic clamp . RESULTS A total of 10 patients were r and omized to each arm . Two patients on combination therapy discontinued treatment ; one because of pregnancy and the other because of hepatotoxicity . Treatment with vitamin E only produced a significant decrease in steatosis ( mean grade , 2.2 vs. 1.4 ; P < .02 ) . Compared with baseline , combination therapy produced a significant decrease in steatosis ( mean , 2.3 vs. 1 ; P < .002 ) , cytologic ballooning ( 1.3 vs. 0.2 ; P < .01 ) , Mallory 's hyaline ( 0.7 vs. 0.2 ; P < .04 ) , and pericellular fibrosis ( 1.2 vs. 0.6 ; P < .03 ) . Although vitamin E had no significant effects , combination therapy produced a significant increase in metabolic clearance of glucose and a decrease in fasting free fatty acid ( FFA ) and insulin . The decrease in fasting FFA and insulin independently predicted improvement in hepatic steatosis and cytologic ballooning . CONCLUSIONS A combination of vitamin E and pioglitazone produces a greater improvement in NASH histology . The improvement in steatosis and cytologic ballooning are related to treatment-associated decreases in fasting FFA and insulin levels Recent studies have demonstrated that n-3 polyunsaturated fatty acids ameliorate  nonalcoholic fatty liver disease .  Although eicosapentaenoic acid ( EPA ) , one of the major components of n-3 polyunsaturated fatty acids , is widely used as an antilipidemic agent , its single efficacy for nonalcoholic steatohepatitis ( NASH ) remains unclear . As such , we aim ed to evaluate the efficacy and safety of EPA on 23 biopsy-proven NASH patients in a pilot trial . Highly purified EPA ( 2700 mg/d ) was administered for 12 months and efficacy was assessed by biochemical parameters and liver histology . All patients completed the treatment with no adverse events , indicating acceptable tolerance to the treatment . After 12 months , serum alanine aminotransferase levels were significantly improved ( from 79±36 to 50±20 U/L ) , and serum free fatty acids , plasma soluble tumor necrosis factor receptor 1 and 2 levels , and serum ferritin and thioredoxin levels , which may reflect hepatic oxidative stress , were significantly decreased . Body weight , blood glucose , insulin , and adiponectin concentrations remained unchanged . Seven of the 23 patients consented to undergo posttreatment liver biopsy , which showed improvement of hepatic steatosis and fibrosis , hepatocyte ballooning , and lobular inflammation in 6 patients . In conclusion , EPA treatment seems to be safe and efficacious for patients with NASH , largely due to its anti-inflammatory and antioxidative properties . To confirm these results , appropriately powered , controlled trials are needed Background There are no licensed treatments for non alcoholic fatty liver disease ( NAFLD ) in adults or children . In NAFLD , several studies have shown a benefit of omega-3 fatty acid treatment on lipid profile , insulin-sensitivity and hepatic steatosis and it has also been suggested that Vitamin D treatment has potential antifibrotic properties in liver disease . Trial Design To date , however , there are no studies that have tested the combination of Docosahexanoic acid ( DHA ) and vitamin D treatment which may benefit the whole spectrum of disease in NAFLD . Our aim therefore , was to test the effect of daily DHA ( 500 mg ) plus vitamin D ( 800 IU ) treatment , in obese children with biopsy-proven NAFLD and vitamin D deficiency , in a r and omized , double-blind placebo-controlled trial . Methods The 41/43 patients completed the study ( 18-treatment , 23-placebo ) . At 12 months : i ) the main outcome was liver histology improvement , defined by NAS ; ii ) the secondary outcome was amelioration of metabolic parameters .  Results DHA plus vitamin D treatment reduced the NAFLD Activity Score ( NAS ) , in the treatment group ( 5.4 v1.92 ; p<0.001 for baseline versus end of study ) . There was no change in fibrosis score , but a reduction of the activation of hepatic stellate cells ( HSC ) and fibrillar collagen content was noted ( 3.51±1.66 v. 1.59±1.37 ; p = 0.003 ) in treatment group . Moreover , the triglycerides ( 174.5 vs. 102.15 mg/dl ) , ALT ( 40.25 vs. 24.5 UI/l ) and HOMA-IR ( 4.59 vs. 3.42 ) were all decreased with treatment . Conclusion DHA plus vitamin D treatment improved insulin-resistance , lipid profile , ALT and NAS . There was also decreased HSC activation and collagen content with treatment BACKGROUND & AIMS Nonalcoholic steatohepatitis ( NASH ) is a frequent liver disease that can progress to cirrhosis and for which there is no recognized therapy . UDCA and vitamin E have been considered separately as therapeutic options and have not been shown to be effective . This study tested their combination . METHODS Patients with elevated aminotransferase levels and drinking less than 40 g alcohol/week with biopsy-proven NASH were r and omly assigned to receive UDCA 12 - 15 mg.kg-1.day-1 with vitamin E 400 IU twice a day ( UDCA/Vit E ) , UDCA with placebo ( UDCA/P ) , or placebo/placebo ( P/P ) . After 2 years , they underwent a second liver biopsy . Biopsy specimens were collected , blinded , and scored by a single liver pathologist . RESULTS Forty eight patients were included , 15 in the UDCA/Vit E group , 18 in the UDCA/P group , and 15 in the P/P group ; 8 patients dropped out , none because of side effects .  Baseline parameters were not significantly different between the 3 groups . Body mass index remained unchanged during the study . Serum aspartate aminotransferase ( AST ) and alanine aminotransferase ( ALT ) levels diminished significantly in the UDCA/Vit E group . Neither the AST nor the ALT levels improved in the P/P group and only the ALT levels in the UDCA/P group . Histologically , the activity index was unchanged at the end of the study in the P/P and UDCA/P groups , but it was significantly better in the UDCA/Vit E group , mostly as a result of regression of steatosis . CONCLUSIONS Two years of treatment with UDCA in combination with vitamin E improved laboratory values and hepatic steatosis of patients with NASH . Larger trials are warranted BACKGROUND & AIMS This prospect i ve study evaluates the role of radiological modalities in establishing the diagnosis of nonalcoholic steatohepatitis ( NASH ) . METHODS Consecutive patients with biopsy-proven nonalcoholic fatty liver disease ( NAFLD ) were enrolled ( 2000 - 2001 ) . Patients with other liver diseases and significant alcohol consumption ( > 20 g/day ) were excluded . Clinicodemographic data were gathered at the time of liver biopsy . Each biopsy specimen was assessed by a hepatopathologist . Each patient underwent a limited abdominal ultrasonography ( US ) , computerized tomography ( CT ) , and magnetic resonance imaging ( MRI ) . Films were interpreted by a radiologist who used a predetermined radiological protocol . Each radiological study was reread by the same radiologist and a second radiologist . RESULTS Patients with NASH had greater aspartate aminotransferase levels ( P = 0.03 ) , greater ferritin levels ( P = 0.05 ) , more hepatocyte ballooning ( P < 0.0001 ) , and more fibrosis ( P = 0.002 ) . None of the radiological features distinguished between NASH and other types of NAFLD . No radiological modality detected the presence of hepatocyte ballooning , Mallory 's hyaline , or fibrosis , which are important features in the diagnosis of NASH . The presence of > 33 % fat on liver biopsy was optimal for detecting steatosis on radiological imaging . CONCLUSIONS Differences between NASH and nonprogressive NAFLD were not apparent with any radiological modality . Of the pathologic features important for establishing the diagnosis of NASH , only the severity of steatosis was reflected in these radiological modalities . Good intraobserver agreement was evident for each modality ( US , CT , and MRI ) that was superior to interobserver agreement Background : Hypovitaminosis D is associated with an increased severity of nonalcoholic fatty liver disease ( NAFLD ) , but reports on the response to cholecalciferol ( vitamin D3 ) supplementation are conflicting . Objective : The objective of this study was to determine if st and ard vitamin D3 supplementation is effective in NAFLD with hypovitaminosis D. Methods : Sixty-five well-characterized adults [ age ( mean ± SD ) : 51.6 ± 12.3 y ] with biopsy-proven NAFLD were screened . Forty-two patients ( the ratio of men to women was 13:29 ) had hypovitaminosis D ( plasma 25-hydroxyvitamin D [ 25(OH)D ] < 30 ng/mL ) . An observational study was performed in NAFLD patients with hypovitaminosis D treated with 2000 IU cholecalciferol ( vitamin D3 ) daily for 6 mo per clinical practice . Plasma 25(OH)D , hepatic and metabolic panels , and metabolic syndrome components were assessed before and after cholecalciferol supplementation . Body composition was measured by using bioelectrical impedance analysis . The primary outcome measure was plasma 25(OH)D ≥30 ng/mL at the end of the study . Secondary outcomes included change in serum transaminases , fasting plasma glucose , and insulin and homeostasis model assessment of insulin resistance ( HOMA-IR ) . Chi-square , Student 's t tests , correlation coefficient , and multivariate analysis were performed . Results : Twenty-six ( 61.9 % ) patients had nonalcoholic steatohepatitis ( NASH ) , and 16 ( 38.1 % ) had hepatic steatosis . After 6 mo of cholecalciferol supplementation  , plasma 25(OH)D ≥30 ng/mL was observed in 16 subjects ( 38.1 % ; responders ) whereas the remaining 26 patients ( 61.9 % ) were nonresponders with plasma 25(OH)D < 30 ng/mL. Significantly fewer ( P < 0.01 ) patients with NASH were responders ( 4 of 26 , 15.4 % ) than those with hepatic steatosis ( 12 of 16 , 75 % ) . Baseline fasting serum alanine aminotransferase , plasma glucose , and HOMA-IR were similar in the responders and nonresponders , but the NASH score on the liver biopsy was lower ( 16.5 % ) in the responders ( P < 0.001 ) . Nonresponders had a higher fat mass ( 10.5 % ) and lower fat-free mass ( 10.4 % ) than responders did . End-of-treatment alanine aminotransferase and HOMA-IR improved only in responders . The baseline HOMA-IR and histological NASH score were independent predictors of nonresponse to cholecalciferol supplementation . Conclusions : Daily supplementation with 2000 IU cholecalciferol for 6 mo did not correct hypovitaminosis D in the majority of patients with NASH . Further studies are needed to determine if higher doses are effective . This trial was registered at clinical trials.gov as 13 - 00153 BACKGROUND & AIMS Hypovitaminosis D is common in obesity and insulin-resistant states . Increased fat mass in patients with non-alcoholic fatty liver disease ( NAFLD ) may contribute to hypovitaminosis D. To determine the relation among plasma vitamin D concentration , severity of disease and body composition in NAFLD . METHODS  Plasma vitamin D concentration  was quantified in 148 consecutive biopsy-proven patients with NAFLD ( non-alcoholic steatohepatitis - NASH : n = 81 ; and hepatic steatosis : n = 67 ) and healthy controls ( n = 39 ) . NAFLD was scored using the NASH CRN criteria . Body composition was quantified by bioelectrical impedance analysis and abdominal CT image analysis . RESULTS Plasma vitamin D concentration was significantly lower in NAFLD ( 21.2 ± 10.4 ng/ml ) compared with healthy controls ( 35.7 ± 6.0 ng/ml ) . Higher NAFLD activity scores were associated with lower plasma concentration of vitamin D ( r(2 ) = 0.29 ; P < 0.001 ) . Subgroup analysis among patients with NAFLD showed that patients with NASH had significantly lower ( P < 0.01 ) vitamin D levels than those with steatosis alone ( 18.1 ± 8.4 vs. 25.0 ± 11.3 ng/ml ) . Low concentrations of vitamin D were associated with greater severity of steatosis , hepatocyte ballooning and fibrosis ( P < 0.05).On multivariate regression analysis , only severity of hepatocyte ballooning was independently associated ( P = 0.02 ) with low vitamin D concentrations . Plasma vitamin D ( P = 0.004 ) and insulin concentrations ( P = 0.03 ) were independent predictors of the NAFLD activity score on biopsy . Patients with NAFLD had higher fat mass that correlated with low vitamin D ( r(2 ) = 0.26 ; P = 0.008 ) . CONCLUSIONS Low plasma vitamin D concentration is an independent predictor of the severity of NAFLD . Further prospect i ve studies demonstrating the impact of vitamin D replacement in NAFLD patients are required BACKGROUND The combination of ursodeoxycholic acid ( UDCA ) and vitamin E is a therapeutic option for nonalcoholic steatohepatitis ( NASH ) but r and omized controlled studies have produced inconsistent results . The objective of this study was to report the long-term tolerability and efficacy of this combination in our ten-year single center experience . METHODS The study group included 101 adult patients with persistent elevation of serum aminotransferases ( AST and ALT ) and /or γ glutamyl-transferase ( GGT ) , in whom a histological diagnosis of NASH was made from January 1998 to January 2009 , and who were treated with a combination of UDCA with vitamin E.  RESULTS Median body mass index ( 30 kg/m(2 ) ) remained unchanged during the study . UDCA and vitamin E were well tolerated ( 5 % withdrawal for side effects ) . Mean serum AST , ALT and GGT levels ( expressed as times of Upper Normal Limit ) diminished significantly ( 1.39 ± 0.74 to 0.78 ± 0.34 for AST , 1.72 ± 0.92 to 0.91 ± 0.69 for AST and 3.25 ± 2.85 to 1.30 ± 1.30 for GGT ) . AST , ALT and GGT reached normal range in 80 % , 70 % and 65 % of the patients , respectively . From the ten patients who had a second liver biopsy during follow-up , NAS score improved in seven , and worsened in one . CONCLUSIONS The combination of UDCA with vitamin E significantly improves liver function tests in long-term and is very well tolerated CONTEXT Nonalcoholic fatty liver disease ( NAFLD ) is the most common chronic liver disease in US children and adolescents and can present with advanced fibrosis or nonalcoholic steatohepatitis ( NASH ) . No treatment has been established . OBJECTIVE To determine whether children with NAFLD would improve from therapeutic intervention with vitamin E or metformin . DESIGN , SETTING , AND PATIENTS R and omized , double-blind , double-dummy , placebo-controlled clinical trial conducted at 10 university clinical research centers in 173 patients ( aged 8 - 17 years ) with biopsy-confirmed NAFLD conducted between September 2005 and March 2010 . Interventions Daily dosing of 800 IU of vitamin E ( 58 patients ) , 1000 mg of metformin ( 57 patients ) , or placebo ( 58 patients ) for 96 weeks . MAIN OUTCOME MEASURES The primary outcome was sustained reduction in alanine aminotransferase ( ALT ) defined as 50 % or less of the baseline level or 40 U/L or less at visits every 12 weeks from 48 to 96 weeks of treatment . Improvements in histological features of NAFLD and resolution of NASH were secondary outcome measures . RESULTS Sustained reduction in ALT level was similar to placebo ( 10/58 ; 17 % ; 95 % CI , 9 % to 29 % ) in both the vitamin E ( 15/58 ; 26 % ; 95 % CI , 15 % to 39 % ; P = .26 ) and metformin treatment groups ( 9/57 ; 16 % ; 95 % CI , 7 % to 28 % ; P = .83 ) . The mean change in ALT level from baseline to 96 weeks was -35.2 U/L ( 95 % CI , -56.9 to -13.5 ) with placebo vs -48.3 U/L ( 95 % CI , -66.8 to -29.8 ) with vitamin E ( P = .07 ) and -41.7 U/L ( 95 % CI , -62.9 to -20.5 ) with metformin ( P = .40 ) . The mean change at 96 weeks in hepatocellular ballooning scores was 0.1 with placebo ( 95 % CI , -0.2 to 0.3 ) vs -0.5 with vitamin E ( 95 % CI , -0.8 to -0.3 ; P = .006 ) and -0.3 with metformin ( 95 % CI , -0.6 to -0.0 ; P = .04 ) ; and in NAFLD activity score , -0.7 with placebo ( 95 % CI , -1.3 to -0.2 ) vs -1.8 with vitamin E ( 95 % CI , -2.4 to -1.2 ; P = .02 ) and -1.1 with metformin ( 95 % CI , -1.7 to -0.5 ; P = .25 ) . Among children with NASH , the proportion who resolved at 96 weeks was 28 % with placebo ( 95 % CI , 15 % to 45 % ; 11/39 ) vs 58 % with vitamin E ( 95 % CI , 42 % to 73 % ; 25/43 ; P = .006 ) and 41 % with metformin ( 95 % CI , 26 % to 58 % ; 16/39 ; P = .23 ) . Compared with placebo , neither therapy demonstrated significant improvements in other histological features . CONCLUSION Neither vitamin E nor metformin was superior to placebo in attaining the primary outcome of sustained reduction in ALT level in patients with pediatric NAFLD . TRIAL REGISTRATION clinical trials.gov Identifier : NCT00063635 There are few data evaluating plasma and /or peripheral blood monocyte cytokine concentrations/production or attempts to manipulate proinflammatory cytokines in nonalcoholic steatohepatitis ( NASH ) . A pilot project in a general clinical research center evaluated the effects of a step 1 American Heart Association diet plus aerobic exercise with or without 800 IU of vitamin E daily on cytokine profiles and liver enzyme levels in 16 patients with biopsy-proven NASH .  Biochemical assessment of liver function , lipid profiles , and body mass index significantly improved during the first 6 weeks of therapy and remained stable during the following 6 weeks . Plasma hyaluronic acid ( HA ) concentrations decreased in parallel with weight loss . Plasma tumor necrosis factor ( TNF ) concentrations were significantly elevated in patients with NASH and similar to patients with stable alcoholic cirrhosis but not as elevated as in patients with acute alcoholic steatohepatitis ( AH ) . Although plasma TNF , interleukin 8 ( IL-8 ) , and IL-6 concentrations were all significantly elevated compared with control values , only plasma IL-6 levels significantly decreased with therapy . Peripheral blood monocyte TNF , IL-8 , and IL-6 production was significantly elevated in patients with NASH but did not significantly decrease . Independent effects of vitamin E were not observed in this small sample . In conclusion , patients with NASH have dysregulated cytokine metabolism similar to , but less pronounced than abnormalities documented in AH . Cytokine values generally did not decrease significantly with weight loss with or without vitamin E over the duration of the study . Lifestyle modifications ( low-fat diet and exercise ) were associated with improvement in liver enzymes , cholesterol , and plasma HA levels in patients with NASH , whereas the level of vitamin E supplementation used in this short-term pilot study provided no apparent added benefit The beneficial effects of mineralocorticoid receptor blockade by spironolactone have been shown in animal models of non-alcoholic fatty liver disease ( NAFLD ) . The aim of the present 52-week r and omized controlled trial was to compare the effects of low-dose spironolactone and vitamin E combination with those of vitamin E monotherapy on insulin resistance , non-invasive indices of hepatic steatosis and fibrosis , liver function tests , circulating adipokines and hormones in patients with histologically confirmed NAFLD . Homeostasis model of assessment of insulin resistance ( HOMA-IR ) and non-invasive indices of steatosis and fibrosis were calculated . Analysis was intention-to-treat . NAFLD liver fat score , an index of steatosis , decreased significantly in the combination treatment group ( P = .028 ) , but not in the vitamin E group , and the difference for group*time interaction was significant ( P = .047 ) . Alanine aminotransferase-to-platelet ratio index , an index of fibrosis , did not change . Insulin levels and HOMA-IR decreased significantly only within the combination group ( P = .011 and P = .011 , respectively ) . In conclusion , the combined low-dose spironolactone plus vitamin E regimen significantly decreased NAFLD liver fat score . Larger-scale trials are needed to clarify the effect of low-dose spironolactone on hepatic histology Purpose In obesity and diabetes the liver is highly susceptible to abnormal uptake and storage of fat . In certain individuals hepatic steatosis predisposes to the development of non-alcoholic steatohepatitis ( NASH ) , a disease marked by hepatic inflammation and fibrosis . Although the precise pathophysiology of NASH is unknown , it is believed that the gut microbiota-liver axis influences the development of this disease . With few treatment strategies available for NASH , exploration of gut microbiota-targeted interventions is warranted . We investigated the therapeutic potential of a prebiotic supplement to improve histological parameters of NASH . Methods In a placebo-controlled , r and omized pilot trial , 14 individuals with liver-biopsy-confirmed NASH [ non-alcoholic fatty liver activity score ( NAS ) ≥ 5 ] were r and omized to receive oligofructose ( 8 g/day for 12 weeks followed by 16 g/day for 24 weeks ) or isocaloric placebo for 9 months . The primary outcome measure was the change in liver biopsy NAS score and the secondary outcomes included changes in body weight , body composition , glucose tolerance , inflammatory markers , and gut microbiota . Results Independent of weight loss  , oligofructose improved liver steatosis relative to placebo and improved overall NAS score ( P = 0.016 ) . Bifidobacterium was enhanced by oligofructose , whereas bacteria within Clostridium cluster XI and I were reduced with oligofructose ( P < 0.05 ) . There were no adverse side effects that deterred individuals from consuming oligofructose for treatment of this disease . Conclusions Independent of other lifestyle changes , prebiotic supplementation  reduced histologically-confirmed steatosis in patients with NASH . Larger follow-up studies are warranted . Clinical TrialThis trial was registered at Clinical trials.com as NCT03184376 Nonalcoholic fatty liver disease ( NAFLD ) is reaching epidemic proportions worldwide ( 1 ) and is the most common chronic liver condition in obese patients with prediabetes or type 2 diabetes mellitus ( T2DM ) . Histologic findings range from isolated steatosis ( with no or minimal inflammation ) to severe nonalcoholic steatohepatitis ( NASH ) and variable perisinusoidal or perivenular fibrosis ( 2 ) . Patients with T2DM and NASH have the highest risk for cirrhosis and hepatocellular carcinoma ( 3 , 4 ) , and the presence of NAFLD seems to worsen microvascular and macrovascular complications of diabetes ( 57 ) . Given that most patients with T2DM have NAFLD ( 812 ) and many are at risk for NASH even if they have normal liver aminotransferase levels ( 6 , 9 , 13 , 14 ) , it is surprising that few trials have focused on this population . This distinction ( patients with NASH with vs. without T2DM ) is relevant because additional metabolic factors , such as hyperglycemia ( 15 , 16 ) , lower adiponectin levels ( 17 , 18 ) , worse dyslipidemia ( 19 , 20 ) , and more severe insulin resistance and hepatic steatosis ( 10 , 16 , 1821 ) , may account for the higher rates of severe liver disease observed in patients with T2DM ( 22 ) . Although the cause of NASH is multifactorial and treatment remains challenging ( 23 ) , a major factor is the increase in liver triglyceride content caused by chronic release of free fatty acids ( FFAs ) from insulin-resistant dysfunctional adipose tissue ( 7 , 2427 ) . Because thiazolidinediones target insulin resistance and adipose tissue dysfunction or inflammation that promotes hepatic lipotoxicity in NASH ( 7 , 22 , 28 ) ( which is also a prominent feature of T2DM [ 15 ] ) , they may be more helpful for treating steatohepatitis in this population . In predominantly nondiabetic patients with NASH , several studies have reported variable degrees of histologic benefit with thiazolidinediones ( 2933 ) . In the largest study to date in patients without T2DM ( 34 ) , pioglitazone was no better than placebo for the primary outcome but was beneficial for secondary outcomes , such as resolution of NASH . However , in patients with prediabetes or T2DM , the only available r and omized , controlled trial is a relatively small proof-of-concept study ( 35 ) . This is disappointing given that there are 29.1 million adults with diabetes ( > 90 % with T2DM ) and 86 million with prediabetes ( 36 ) in the United States , many of whom are at risk for cirrhosis from NASH . Moreover , because pioglitazone may also halt the progression of prediabetes to T2DM ( 37 ) , defining its role in patients with prediabetes and NASH is critical . Finally , safety concerns about the long-term use of thiazolidinediones remain ( 38 , 39 ) ; therefore , studies with extended thiazolidinedione exposure are needed before a pioglitazone-based approach can be embraced in this population . The aim of our study was to assess the efficacy and safety of long-term pioglitazone treatment in improving liver histologic outcomes in patients with NASH and prediabetes or T2DM . Methods Design Overview This was a single-center , parallel-group , r and omized ( 1:1 allocation ) , placebo-controlled study , conducted between December 2008 ( first patient enrolled ) and December 2014 ( final data collection ) . Participants , investigators , and health care providers were blinded to treatment assignment throughout the study . The Institutional Review Board at the University of Texas Health Science Center at San Antonio ( UTHSCSA ) approved the study , and all participants provided written informed consent before enrollment . In October 2009 , while updating registry data for another study , investigators discovered that this trial , which they thought had been registered by other study personnel , was not registered . At the time of registration ( Clinical Trials.gov : NCT00994682 ) , 29 patients ( of 97 anticipated ) were enrolled in the study . None of these patients had had the follow-up metabolic measurements or liver biopsies ( primary outcome ) that were to be performed at 18 months , and no interim analyses were done before the trial was registered . A recent review of Clinical Trials.gov ( November 2015 ) revealed that the initial trial registration data erroneously stated that patients with normal glucose tolerance would be r and omly assigned to treatment or placebo . Given that the trial 's eligibility criteria required patients to have an abnormal oral glucose tolerance test ( OGTT ) result ( that is , prediabetes or T2DM ) , the investigators never planned to enroll patients with normal glucose tolerance . This error in trial registration was corrected by the principal investigator . The trial registry states that the primary end point is liver histologic outcomes ( Kleiner criteria [ 40 ] ) at 18 months , and these data are presented in Appendix Table 1 . In this article , the primary end point is defined as a reduction of at least 2 points in 2 categories of the NAFLD activity score ( NAS ) without worsening of fibrosis , an outcome that was not specified in the original registration . This end point has been accepted by investigators in this field as representing significant change in liver histologic outcomes in clinical trials involving patients with NASH ( 34 , 4143 ) . Some secondary outcomes that were assessed , such as insulin secretion , prevention of the onset of T2DM or reversal of glucose intolerance , measurement of visceral fat by magnetic resonance imaging , bone density measurement via dual-energy x-ray absorptiometry ( DXA ) , plasma measurements of bone metabolism , and molecular metabolic pathways , are not reported in this article . Appendix Table 1 . Liver Histologic Variables at Baseline and After 18 mo , Based on Observed Data * Setting and Participants Participants were recruited from the general population of San Antonio , Texas , via newspaper advertisements and from the endocrinology and hepatology clinics at UTHSCSA and the Veterans Affairs Medical Center . Persons were eligible for the trial if they had histologically confirmed NASH and either prediabetes or T2DM . All patients had a screening 2-hour OGTT to diagnose or confirm a diagnosis of prediabetes or T2DM . Prediabetes was defined as impaired fasting glucose ( 5.6 to 6.9 mmol/L [ 100 to 125 mg/dL ] ) , impaired glucose tolerance ( 7.8 to 11.1 mmol/L [ 140 to 199 mg/dL ] on an OGTT ) , or a hemoglobin A1c level of 5.7 % to 6.4 % . Exclusion criteria included use of thiazolidinediones or vitamin E ; other causes of liver disease ( 22 ) or abnormal laboratory results ( such as an aspartate aminotransferase [ AST ] or alanine aminotransferase [ ALT ] level 3 times the upper limit of normal [ ULN ] ) ; type 1 diabetes mellitus ; or severe heart , hepatic , or renal disease . Detailed inclusion and exclusion criteria are provided in the Appendix . R and omization and Interventions After initial screening ( medical history , physical examination , laboratory tests , and 75-g OGTT ) , patients began receiving placebo and were instructed by the research dietician ( C.D. ) to keep physical activity and diet constant during the run-in phase ( mean duration , 1 month ) . After completion of baseline metabolic measurements , participants were prescribed a hypocaloric diet ( 500kcal/d deficit from the calculated weight-maintaining diet ) and were r and omly assigned in a 1:1 ratio to either pioglitazone ( Actos [ Takeda Pharmaceuticals ] ) , 30 mg/d ( titrated after 2 months to 45 mg/d ) , or placebo . R and omization ( computer-generated ) and patient allocation were performed by the research pharmacist without stratification and using a block factor of 4 , which was unknown to investigators . Takeda Pharmaceuticals provided pioglitazone and placebo pills with identical physical characteristics , which were stored at the research pharmacy and dispensed in identical bottles . Outcomes and Follow-up The primary outcome was a reduction of at least 2 points in 2 histologic categories of the NAS without worsening of fibrosis after 18 months of therapy . Secondary liver histologic outcomes included resolution of NASH ; improvement in individual histologic scores ; or improvement in a combined histologic outcome , defined as a reduction in ballooning with at least a 2-point improvement in the NAS or an absolute NAS of 3 or lower ( with improvement in steatosis or inflammation ) without worsening of fibrosis . Baseline liver biopsy specimens were read by a team of experienced clinical pathologists to establish or rule out the presence of NASH and thus determine whether patients were included or excluded . At the end of the study , all biopsy specimens were reread by an experienced research pathologist ( F.T. ) , who was blinded to patient identity , intervention assignment , and pretreatment or posttreatment sequence ( 0 , 18 , or 36 months ) . Biopsy specimens were read by the research pathologist 2 times , with good to excellent intraobserver variability ( agreement > 75 % for all histologic parameters ) . Diagnosis of definite NASH was defined as zone 3 accentuation of macrovesicular steatosis ( any grade ) , hepatocellular ballooning ( any degree ) , and lobular inflammatory infiltrates ( any amount ) . The NAS was calculated as the sum of the steatosis , inflammation , and ballooning grade s from the liver biopsy , and histopathologic changes were determined by using st and ard criteria ( 44 ) . Additional secondary outcomes included the following : 1 ) fasting plasma glucose , fasting plasma insulin , FFA , hemoglobin A1c , fasting plasma lipid profile , adiponectin , and cytokeratin-18 concentrations ; 2 ) total body fat percentage , measured by DXA ; 3 ) hepatic triglyceride content , measured by magnetic resonance and proton spectroscopy ( 1H-MRS ) as previously described ( 14 , 16 , 35 , 45 ) ( baseline and 18 months only ) ; 4 ) glucose tolerance and insulin secretion on an OGTT ; 5 ) endogenous glucose production ( EGP ) , rate of glucose disappearance ( R d ) , and insulin-induced suppression of EGP and plasma FFA concentration , all measured during a euglycemic insulin clamp with tritiated glucose and indirect calorimetry ( baseline and 18 months only ) as previously reported ( UNLABELLED No proven treatment exists for nonalcoholic fatty liver disease ( NAFLD ) in children and adolescents . We sought to determine the efficacy of lifestyle intervention with or without antioxidant therapy in pediatric NAFLD . A total of 53 patients ( age 5.7 - 18.8 years , 37 boys ) were included .  Lifestyle intervention consisting of a diet tailored to the patient 's calorie needs , and increased physical activity was prescribed in all . Patients were concomitantly r and omized to alpha-tocopherol 600 IU/day plus ascorbic acid 500 mg/day ( n = 25 ) or placebo ( n = 28 ) , and treated for 24 months . The study was an extension of a previous study aim ed at evaluating the effect of 12-month lifestyle intervention and antioxidant therapy on serum levels of aminotransferases . The primary end point of the present study was change in liver histology on repeated biopsy at 24 months . Secondary end points were changes in body weight , liver enzymes , and insulin sensitivity indices on 2-hour oral glucose tolerance test . The amount of weight lost at 24 months was similar in the placebo and antioxidant groups ( -4.75 [ range , -16 - 4.0 ] versus -5.5 [ range , -12.2 - 0.4 ] kg , respectively , P = 0.9 ) . A significant improvement occurred in the grade of steatosis , lobular inflammation , and hepatocyte ballooning , and in the NAFLD activity score in both groups . Levels of aminotransferases , triglycerides , cholesterol , fasting glucose , and insulin , and insulin sensitivity indices improved significantly as well . The improvement in all these parameters was not significantly different between the two groups . CONCLUSION Lifestyle intervention with diet and increased physical activity induces weight loss and is associated with a significant improvement in liver histology and laboratory abnormalities in pediatric NAFLD . Alpha-tocopherol plus ascorbic acid does not seem to increase the efficacy of lifestyle intervention alone BACKGROUND & AIMS In nonalcoholic fatty liver disease ( NAFLD ) , the distinction between steatosis and steatohepatitis ( NASH ) and the assessment of the severity of the disease rely on liver histology alone . The aim of this study was to assess the sampling error of liver biopsy and its impact on the diagnosis and staging of NASH . METHODS Fifty-one patients with NAFLD underwent percutaneous liver biopsy with 2 sample s collected . The agreement between paired biopsy specimens was assessed by the percentage of discordant results and by the kappa reliability test . RESULTS No features displayed high agreement ; substantial agreement was only seen for steatosis grade ; moderate agreement for hepatocyte ballooning and perisinusoidal fibrosis ; fair agreement for Mallory bodies ; acidophilic bodies and lobular inflammation displayed only slight agreement . Overall , the discordance rate for the presence of hepatocyte ballooning was 18 % , and ballooning would have been missed in 24 % of patients had only 1 biopsy been performed . The negative predictive value of a single biopsy for the diagnosis of NASH was at best 0.74 . Discordance of 1 stage or more was 41 % . Six of 17 patients with bridging fibrosis ( 35 % ) on 1 sample had only mild or no fibrosis on the other and therefore could have been under staged with only 1 biopsy . Intraobserver variability was systematic ally lower than sampling variability and therefore could not account for most of the sampling error . CONCLUSIONS Histologic lesions of NASH are unevenly distributed throughout the liver parenchyma ; therefore , sampling error of liver biopsy can result in substantial misdiagnosis and staging inaccuracies
These studies demonstrated improvement in biochemical profiles , with a decline in or normalization of liver enzymes .
However , some concerns have been raised regarding the use of vitamin E in patients with NASH due to its adverse effects profile and lack of significant improvement in hepatic fibrosis .
There has been a growing interest in the role of vitamin E supplementation in the treatment and /or prevention of nonalcoholic fatty liver ( NAFLD ) .
Furthermore , histological assessment showed favorable outcomes in lobular inflammation and hepatic steatosis following treatment with vitamin E. Current guidelines regarding the use of vitamin E in the setting of NAFLD recommend that vitamin E-based treatment be restricted to biopsy-proven nondiabetic patients with NASH only .