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Erschienen in:
02.01.2019 | Letter to the Editor
Crashing NASH in Patients Listed for Bariatric Surgery
Erschienen in: Obesity Surgery | Ausgabe 3/2019
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We read with great interest the publication of Ooi et al. describing the prevalence of NAFLD and NASH in a bariatric population [1]. They discussed the fact that there is a large variation in NASH prevalence in bariatric studies ranging from 7.3 to 56%. In their cohort, they found a NASH prevalence of 17.1%, which was lower than expected based on previous literature. This lower than expected NASH prevalence was in line with our observation. We intraoperatively collected liver needle and wedge biopsies from 20 obese patients undergoing bariatric surgery (Table 1). Patients with significant alcohol use (> 14 standard beverages a week for men and > 7 for women), secondary causes of hepatic fat accumulation, and chronic inflammatory diseases other than NASH were excluded. Strikingly, NASH, defined as the combined presence of steatosis, lobular inflammation, and hepatocyte ballooning, was not present in any of our obese patients, and the maximal NAFLD activity score was only 3 (Table 2).
Table 1
Patient characteristics
|
Total group (n = 20)
|
|
|---|---|
|
Age (years)
|
51 (37.8–57.0)
|
|
Female gender
|
13/20 (65%)
|
|
BMI before crash (kg/m2)
|
41.2 (40.1–42.5)
|
|
BMI after crash (kg/m2)
|
38.6 (37.5–40.3)
|
|
Weight loss (kg)
|
8.0 (6.0–8.8)
|
|
Weight loss (%)
|
6.2 (5.3–7.6)
|
|
Hypertension
|
9/20 (45%)
|
|
Type 2 diabetes
|
4/20 (25%)
|
|
Dyslipidemia
|
6/20 (30%)
|
|
Obstructive sleep apnea
|
8/20 (40%)
|
|
Total cholesterol (5.0–6.4 mmol/L)
|
4.3 (4.0–4.6)
|
|
LDL cholesterol (3.5–4.4 mmol/L)
|
2.7 (2.2–2.9)
|
|
HDL-cholesterol (> 0.9 mmol/L)
|
1.0 (0.8–1.2)
|
|
Triglycerides (0.80–1.94 mmol/L)
|
1.3 (0.9–2.3)
|
|
ALT (F < 34, M < 45 U/L)
|
31.0 (19.0–39.8)
|
|
AST (F < 31, M < 35 U/L)
|
26.5 (19.0–30.8)
|
|
GGT (F < 38, M < 55 U/L)
|
22.5 (17.3–28.0)
|
|
ALP (F < 98, M < 115 U/L)
|
82.5 (73.3–96.8)
|
|
Fasting glucose (3.1–6.1 mmol/L)
|
5.4 (5.0–5.9)
|
|
HbA1C (25–44 mmol/mol)
|
35.0 (33.0–42.8)
|
Table 2
Pathological analysis
|
Patient
|
Steatosis
|
Lobular inflammation
|
Portal inflammation
|
Ballooning*
|
Fibrosis
|
NAS
|
SAF
|
|---|---|---|---|---|---|---|---|
|
1
|
0
|
0
|
0
|
0
|
0
|
0
|
S0A0F0
|
|
2
|
0
|
0
|
0
|
0
|
0
|
0
|
S0A0F0
|
|
3
|
0
|
0
|
0
|
0
|
1
|
0
|
S0A0F1
|
|
4
|
0
|
1
|
0
|
0
|
0
|
1
|
S0A1F0
|
|
5
|
0
|
1
|
0
|
0
|
0
|
1
|
S0A1F0
|
|
6
|
0
|
1
|
1
|
0
|
0
|
0
|
S0A1F0
|
|
7
|
0
|
1
|
2
|
0
|
1
|
1
|
S0A2F1
|
|
8
|
1
|
0
|
1
|
0
|
1
|
1
|
S1A0F1
|
|
9
|
1
|
1
|
0
|
0
|
2
|
2
|
S1A1F2
|
|
10
|
1
|
1
|
1
|
0
|
0
|
2
|
S1A1F0
|
|
11
|
1
|
1
|
1
|
0
|
1
|
2
|
S1A1F1
|
|
12
|
1
|
1
|
1
|
0
|
1
|
2
|
S1A1F1
|
|
13
|
1
|
1
|
1
|
0
|
1
|
2
|
S1A1F1
|
|
14
|
1
|
1
|
2
|
0
|
1
|
2
|
S1A1F1
|
|
15
|
1
|
1
|
2
|
0
|
2
|
2
|
S1A1F2
|
|
16
|
1
|
1
|
2
|
0
|
2
|
2
|
S1A1F2
|
|
17
|
1
|
2
|
2
|
0
|
2
|
3
|
S1A2F2
|
|
18
|
2
|
1
|
0
|
0
|
1
|
3
|
S2A1F1
|
|
19
|
2
|
1
|
0
|
0
|
1
|
3
|
S2A1F1
|
|
20
|
2
|
1
|
0
|
0
|
1
|
3
|
S2A1F1
|