Abstract
Background
Although therapeutic intervention for nonalcoholic steatohepatitis (NASH) at an early stage is important owing to the progressive nature of the disease, diagnosis using noninvasive methods remains difficult. We previously demonstrated NASH specific impairment of choline metabolism and the use of fasting plasma free choline (fCh) levels for NASH diagnosis. Here, we investigated the utility of an oral choline tolerance test (OCTT), based on disordered choline metabolism, as a novel noninvasive method for NASH diagnosis.
Methods
Sixty-five patients with biopsy proven nonalcoholic fatty liver disease (NAFLD) and 17 healthy controls were enrolled. Blood samples were obtained from all subjects five times during the OCTT (before and 1, 2, 3, and 4 h after oral loading with 260 mg choline).
Results
Four-hour fCh levels after oral loading choline were markedly increased in NASH patients, compared with non-NASH subjects. For detecting NASH, compared with non-NASH subjects, the area under the curve for 4-h fCh levels was 0.829 on receiver operating characteristic (ROC) analysis. The cut-off level for NASH diagnosis was ≥0.16 mg/dL, and the sensitivity, specificity, positive predictive value, and negative predictive value were 80.1, 82.6, 78.4, and 84.4 %, respectively. Moreover, 4-h fCh levels were significantly associated with the disease activity based on NAFLD activity score in patients with NAFLD.
Conclusions
Four-hour fCh levels obtained by an OCTT reflect a NASH specific disorder of choline metabolism, suggesting that the OCTT is a novel and useful noninvasive method for diagnosing NASH at an early stage with sufficient accuracy for clinical practice.
Abbreviations
- ALT:
-
Alanine aminotransferase
- AST:
-
Aspartate aminotransferase
- AUROC:
-
Area under the receiver operating characteristic curve
- CT:
-
Computed tomography
- DM:
-
Diabetes mellitus
- fCh:
-
Free choline
- FPG:
-
Fasting plasma glucose
- HOMA-IR:
-
Homeostasis model for the assessment of insulin resistance
- HPLC:
-
High performance liquid chromatography
- MTTP:
-
Microsomal triglyceride transfer protein
- NAFLD:
-
Nonalcoholic fatty liver disease
- NAS:
-
Nonalcoholic fatty liver disease activity score
- NASH:
-
Nonalcoholic steatohepatitis
- NPV:
-
Negative predictive value
- OCTT:
-
Oral choline tolerance test
- PPV:
-
Positive predictive value
- ROC:
-
Receiver operating characteristic
- SD:
-
Standard deviation
- Se:
-
Sensitivity
- Sp:
-
Specificity
- SS:
-
Simple steatosis
- TG:
-
Triglyceride
- VLDL:
-
Very low density lipoprotein
References
Farrell GC, Larter CZ. Nonalcoholic fatty liver disease: from steatosis to cirrhosis. Hepatology. 2006;43:99–112.
Lazo M, Clark JM. The epidemiology of nonalcoholic fatty liver disease: a global perspective. Semin Liver Dis. 2008;28:339–50.
Hamaguchi M, Kojima T, Takeda N, Nagata C, Takeda J, Sarui H, Kawahito Y, et al. The metabolic syndrome as a predictor of nonalcoholic fatty liver disease. Ann Intern Med. 2005;143:722–8.
Younossi ZM, Gramlich T, Liu YC, Matteoni C, Petrelli M, Goldblum J, Rybicki L. Non-alcoholic fatty liver: assessment of variability in the pathologic interpretations. Mod Pathol. 1998;11:560–5.
Matteoni C, Younossi ZM, Gramlich T, Boparani L, Liu YC, McCullough AJ. A non-alcoholic fatty liver disease: a spectrum of clinical and pathologic severity. Gastroenterology. 1999;116:1413–9.
Guha IN, Parkes J, Roderick P, Chattopadhyay D, Cross R, Harris S, Kaye P, et al. Noninvasive markers of fibrosis in nonalcoholic fatty liver disease: validating the European liver fibrosis panel and exploring simple markers. Hepatology. 2009;47:455–60.
Baranova A, Younossi ZM. The future is around the corner: noninvasive diagnosis of the progressive nonalcoholic steatohepatitis. Hepatology. 2008;47:373–5.
Wieckowska A, Feldstein AE. Diagnosis of nonalcoholic fatty liver disease: invasive versus noninvasive. Semin Liver Dis. 2008;28:386–95.
Fujita K, Nozaki Y, Wada K, Yoneda M, Fujimoto Y, Fujitake M, Endo H, et al. Dysfunctional very-low density lipoprotein synthesis and release is a key factor in nonalcoholic steatohepatitis pathogenesis. Hepatology. 2009;50:772–80.
Imajo K, Fujita K, Yoneda M, Shinohara Y, Suzuki K, Mawatari H, Takahashi J, et al. Plasma free choline is a novel non-invasive biomarker for early-stage non-alcoholic steatohepatitis: a multi-center validation study. Hepatol Res. 2012;42:757–66.
Matteoni CA, Younossi ZM, Gramlich T, Boparai N, Liu YC, McCullough AJ. Nonalcoholic fatty liver disease: a spectrum of clinical and pathological severity. Gastroenterology. 1999;116:1413–9.
Brunt EM. Nonalcoholic steatohepatitis: definition and pathology. Semin Liver Dis. 2001;21:3–16.
Brunt EM, Janney CG, Di Bisceglie AM, Neuschwander-Tetri BA, Bacon BR. Nonalcoholic steatohepatitis: a proposal for grading and staging the histological lesions. Am J Gastroenterol. 1999;94:2467–74.
Yoshizumi T, Nakamura T, Yamane M, Islam AH, Menju M, Yamasaki K, Arai T, et al. Abdominal fat: standardized technique for measurement at CT. Radiology. 1999;211:283–6.
Matthews DR, Hosker JP, Rudenski AS, Naylor BA, Treacher DF, Turner RC. Homeostasis model assessment: insulin resistance and beta-cell function from fasting plasma glucose and insulin concentrations in man. Diabetologia. 1985;28:412–9.
American Diabetes Association. Report of the expert committee on the diagnosis and classification of diabetes mellitus. Diabetes Care. 1997;20:1183–97.
Usui S, Hara Y, Hosaki S, Okazaki M. A new on-line dual enzymatic method for simultaneous quantification of cholesterol and triglycerides in lipoproteins by HPLC. J Lipid Res. 2002;43:805–14.
Sanyal AJ, Brunt EM, Kleiner DE, Kowdley KV, Chalasani N, Lavine JE, et al. Endpoints and clinical trial design for nonalcoholic steatohepatitis. Hepatology. 2011;54:344–53.
Brunt EM. Nonalcoholic steatohepatitis: definition and pathology. Semin Liver Dis. 2001;21:3–16.
Kleiner DE, Brunt EM, Van Natta M, Behling C, Contos MJ, Cummings OW, Ferrell LD, et al. Design and validation of a histological scoring system for nonalcoholic fatty liver disease. Hepatology. 2005;41:1313–21.
Hui JM, Kench JG, Chitturi S, Sud A, Farrell GC, Byth K, Hall P, et al. Long-term outcomes of cirrhosis in nonalcoholic steatohepatitis compared with hepatitis C. Hepatology. 2003;38:420–7.
Ludwig J, Viggiano TR, McGill DB, Oh BJ. Nonalcoholic steatohepatitis: Mayo Clinic experiences with a hitherto unnamed disease. Mayo Clin Proc. 1980;55:434–8.
Zeisel SH, Blusztajn JK. Choline and human nutrition. Annu Rev Nutr. 1994;14:269–96.
Ekstedt M, Franzen LE, Mathiesen UL, Thorelius L, Holmqvist M, Bodemar G, Kechagias S. Long-term follow-up of patients with NAFLD and elevated liver enzymes. Hepatology. 2006;44:865–73.
Wieckowska A, McCullough AJ, Feldstein AE. Noninvasive diagnosis and monitoring of nonalcoholic steatohepatitis: present and future. Hepatology. 2007;46:582–9.
Guha IN, Parkes J, Roderick P, Chattopadhyay D, Cross R, Harris S, Kaye P. Noninvasive markers of fibrosis in nonalcoholic fatty liver disease: validating the European liver fibrosis panel and exploring simple markers. Hepatology. 2009;47:455–60.
Chalasani N, Deeg MA, Crabb DW. Systemic levels of lipid peroxidation and its metabolic and dietary correlates in patients with nonalcoholic steatohepatitis. Am J Gastroenterol. 2004;99:1497–502.
Solga SF, Alkhuraishe A, Cope K, Tabesh A, Clark JM, Torbenson M, Schwartz P. Breath biomarkers and non-alcoholic fatty liver disease: preliminary observations. Biomarkers. 2006;11:174–83.
Hui JM, Farrell GC, Kench JG, George J. High sensitivity C-reactive protein values do not reliably predict the severity of histological changes in NAFLD. Hepatology. 2004;39:1458–9.
Yoneda M, Mawatari H, Fujita K, Iida H, Yonemitsu K, Kato S, Takahashi H, et al. High-sensitivity C-reactive protein is an independent clinical feature of nonalcoholic steatohepatitis (NASH) and also of the severity of fibrosis in NASH. J Gastroenterol. 2007;42:573–82.
Yoneda M, Uchiyama T, Kato S, Endo H, Fujita K, Yoneda K, Mawatari H, et al. Plasma pentraxin 3 is a novel marker for nonalcoholic steatohepatitis (NASH). BMC Gastroenterol. 2008;8:53–61.
Wieckowska A, Zein NN, Yerian LM, Lopez AR, McCullough AJ, Feldstein AE. In vivo assessment of liver cell apoptosis as a novel biomarker of disease sensitivity in nonalcoholic fatty liver disease. Hepatology. 2006;44:27–33.
Feldstein AE, Wieckowska A, Lopez AR, Liu YC, Zein NN, McCullough AJ. Cytokeratin-18 fragment levels as noninvasive biomarkers for nonalcoholic steatohepatitis: a multicenter validation study. Hepatology. 2009;50:1072–8.
Yoneda M, Mawatari H, Fujita K, Yonemitsu K, Kato S, Takahashi H, Kirikoshi H, et al. Type IV collagen 7s domain is an independent clinical marker of the severity of fibrosis in patients with nonalcoholic steatohepatitis before the cirrhotic stage. J Gastroenterol. 2007;42:375–81.
Kaneda H, Hashimoto E, Yatsuji S, Tokushige K, Shiratori K. Hyaluronic acid levels can predict severe fibrosis and platelet counts can predict cirrhosis in patients with nonalcoholic fatty liver disease. J Gastroenterol Hepatol. 2006;21:1459–65.
Ratziu V, Charlotte F, Heurtier A, Gombert S, Giral P, Bruckert E, et al. Sampling variability of liver biopsy in nonalcoholic fatty liver disease. Gastroenterology. 2005;128:1898–906.
Acknowledgments
The skillful technical assistance of Machiko Hiraga is gratefully acknowledged. This work was supported in part by a grant program “Collaborative Development of Innovative Seeds” from the Japan Science and Technology Agency to Atsushi Nakajima.
Conflict of interest
The authors declare that they have no conflict of interest.
Author information
Authors and Affiliations
Corresponding author
Electronic supplementary material
Below is the link to the electronic supplementary material.
Rights and permissions
About this article
Cite this article
Imajo, K., Yoneda, M., Fujita, K. et al. Oral choline tolerance test as a novel noninvasive method for predicting nonalcoholic steatohepatitis. J Gastroenterol 49, 295–304 (2014). https://doi.org/10.1007/s00535-013-0776-3
Received:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s00535-013-0776-3