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Nonalcoholic fatty liver disease NAFLD in children

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What is nonalcoholic fatty liver disease, what is the prevalence among children ,the definition of NAFLD,What are the relationship between obesity and over weight with the development of NAFLD,what are the sequences ,what is NASH,Who are at risk , How to diagnosis NAFLD what is the differential diagnosis ,what is the treatment

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Nonalcoholic fatty liver disease NAFLD in children

  1. 1. Prof. Dr. Saad S Al Ani Senior Pediatric Consultant Saad’s Kids Clinic Anahbaghdad@gmail.com 8/30/2020NAFLD Prof. Dr. Saad S Al Ani 1 *Nonalcoholic Fatty Liver Disease( NAFLD) Clinical tips
  2. 2. 8/30/2020NAFLD Prof. Dr. Saad S Al Ani 2 *Introduction Childhood obesity can adversely affect nearly every organ system with increased mortality in adult life from a wide variety of systemic diseases Nobili V, Alisi A, Newton KP, Schwimmer JB. Comparison of the Phenotype and Approach to Pediatric vs Adult Patients With Nonalcoholic Fatty Liver Disease. Gastroenterology. 2016;150:1798– 1810
  3. 3. 8/30/2020NAFLD Prof. Dr. Saad S Al Ani 3 *Introduction (Cont.) The worldwide prevalence of nonalcoholic fatty liver disease (NAFLD) has increased with potential serious health implications following the current epidemic of obesity. Ng M, Fleming T, Robinson M, Thomson B, Graetz N, Margono C, Mullany EC, Biryukov S, Abbafati C, Abera SF, et al. Global, regional, and national prevalence of overweight and obesity in children and adults during 1980-2013: a systematic analysis for the Global Burden of Disease Study 2013. Lancet. 2014;384:766–781.
  4. 4. 8/30/2020NAFLD Prof. Dr. Saad S Al Ani 4 *Introduction (Cont.) There is a widespread tendency to draw alarming scenarios also for childhood NAFLD (1) (1)Pediatric Nonalcoholic Fatty Liver Disease: the Rise of a Lethal Disease Among Mexican American Hispanic Children.Betancourt- Garcia MM, Arguelles A, Montes J, Hernandez A, Singh M, Forse RA Obes Surg. 2017 Jan; 27(1):236-244. http://pediatric-house-calls.djmed.net/wp-content/uploads/2013/09/graphic-fatty-liver.jpg
  5. 5. 8/30/2020NAFLD Prof. Dr. Saad S Al Ani 5 *Nonalcoholic Fatty Liver Disease ( NAFLD) A spectrum of liver diseases strongly associated with obesity, is the most common chronic liver disease in children Della Corte C, Mazzotta AR, Nobili V. Fatty liver disease and obesity in youth. Curr Open Endocrinol Obes . 2016;23(1):66–71
  6. 6. 8/30/2020NAFLD Prof. Dr. Saad S Al Ani 6 *NAFLD Could be : *Fatty liver alone or extreme: *Nonalcoholic steatohepatitis (NASH)
  7. 7. 8/30/2020NAFLD Prof. Dr. Saad S Al Ani 7 *Sequence of NAFLD https://www.stockwinners.com/blog/tag/nonalcoholic-fatty-liver-disease-nafld/
  8. 8. 8/30/2020NAFLD Prof. Dr. Saad S Al Ani 8 *Nonalcoholic steatohepatitis NASH A triad of : 1. Fatty infiltration 2. Inflammation 3. Fibrosis Yan Y, Hou D, Zhao X, et al. Childhood adiposity and nonalcoholic fatty liver disease in adulthood. Pediatrics . 2017;139(4):e20162738.
  9. 9. 8/30/2020NAFLD Prof. Dr. Saad S Al Ani 9 * NASH *NASH is the severe form of Non- Alcoholic Fatty Liver Disease (NAFLD). It can lead to liver cancer, cirrhosis, and liver transplants.
  10. 10. 8/30/2020NAFLD Prof. Dr. Saad S Al Ani 10 *Nonalcoholic steatohepatitis NASH (Cont.) In children ,it has 2 distinct histologic types: 1. Type 1 NASH * Resembles adult histologic findings - steatosis and balloon degeneration of hepatocytes and/or peripheral fibrosis Diehl AM, Day C. Cause, pathogenesis, and treatment of nonalcoholic steatohepatitis. N Engl J Med . 2017;377(21):2063–2072.
  11. 11. 8/30/2020NAFLD Prof. Dr. Saad S Al Ani 11 *Nonalcoholic steatohepatitis NASH (Cont.) 2. Type 2 NASH - steatosis and portal inflammation Diehl AM, Day C. Cause, pathogenesis, and treatment of nonalcoholic steatohepatitis. N Engl J Med . 2017;377(21):2063–2072.
  12. 12. 8/30/2020NAFLD Prof. Dr. Saad S Al Ani 12 *! *Many patients with NAFLD are asymptomatic *38% of obese children aged 2-19 yr. old have NAFLD on autopsy Schwimmer JB. Clinical advances in pediatric nonalcoholic fatty liver disease. Hepatology . 2016;63(5):1718–1725
  13. 13. 8/30/2020NAFLD Prof. Dr. Saad S Al Ani 13 *! *A normal serum aminotransferase (ALT) level is present in 21-23% of pediatric patients with NAFLD *Elevated ALT levels are not sensitive or specific markers for NAFLD Schwimmer JB. Clinical advances in pediatric nonalcoholic fatty liver disease. Hepatology . 2016;63(5):1718–1725
  14. 14. 8/30/2020NAFLD Prof. Dr. Saad S Al Ani 14 *!(cont.) *Ultrasound detects NAFLD but liver biopsy may be required for a delimiting diagnosis Schwimmer JB. Clinical advances in pediatric nonalcoholic fatty liver disease. Hepatology . 2016;63(5):1718–1725
  15. 15. 8/30/2020NAFLD Prof. Dr. Saad S Al Ani 15 *Risk factors *Obesity *Male gender *White or Hispanic ethnicity *Hypertriglyceridemia *Insulin resistance Yan Y, Hou D, Zhao X, et al. Childhood adiposity and nonalcoholic fatty liver disease in adulthood. Pediatrics . 2017;139(4):e20162738.
  16. 16. 8/30/2020NAFLD Prof. Dr. Saad S Al Ani 16 *? Children with NAFLD should be screened for comorbid conditions , including: * diabetes * hypertension * dyslipidemia * obstructive sleep apnea Carbone LJ, Angus PW, Yeomans ND. Incretin-based therapies for the treatment of non-alcoholic fatty liver disease: a systematic review and meta-analysis. J Gastroenterol Hepatol . 2016;31(1):23–31 [PMID] 26111358
  17. 17. 8/30/2020NAFLD Prof. Dr. Saad S Al Ani 17 *! *Obese and overweight children with other risk factors >3 yr. of age should be screened for NAFLD by: - Checking ALT level - Liver ultrasound even though neither is highly sensitive or specific Della Corte C, Mazzotta AR, Nobili V. Fatty liver disease and obesity in youth. Curr Open Endocrinol Obes . 2016;23(1):66–71
  18. 18. 8/30/2020NAFLD Prof. Dr. Saad S Al Ani 18 *Histopathological DD Lyosomal acid lipase deficiency (LAL-D) *Autosomal recessive disorder *Mutation in LIPA . Diehl AM, Day C. Cause, pathogenesis, and treatment of nonalcoholic steatohepatitis. N Engl J Med . 2017;377(21):2063–2072
  19. 19. 8/30/2020NAFLD Prof. Dr. Saad S Al Ani 19 *Lyosomal acid lipase deficiency (LAL-D)
  20. 20. 8/30/2020NAFLD Prof. Dr. Saad S Al Ani 20 *Lyosomal acid lipase deficiency (LAL-D) (cont.) *Hepatic steatosis -like syndrome *Microvesicular or mixed micro- and macrovesicular steatosis NOT macrovesicular changes. Diehl AM, Day C. Cause, pathogenesis, and treatment of nonalcoholic steatohepatitis. N Engl J Med . 2017;377(21):2063–2072
  21. 21. 8/30/2020NAFLD Prof. Dr. Saad S Al Ani 21 *Lyosomal acid lipase deficiency (LAL-D) (cont.) https://www.mdpi.com/1422-0067/18/6/1134
  22. 22. 8/30/2020NAFLD Prof. Dr. Saad S Al Ani 22 *Treatment *No definitive treatment for NAFLD *Gradual weight loss is effective *Low glycemic index foods and substitution of polyunsaturated fatty acids for saturated fats
  23. 23. 8/30/2020NAFLD Prof. Dr. Saad S Al Ani 23 *Treatment (cont.) The most effective treatment for patients with NAFLD, both adults and children, is lifestyle optimization, with a focus on nutrition and exercise.
  24. 24. 8/30/2020NAFLD Prof. Dr. Saad S Al Ani 24 *Treatment (cont.) Modulating gut microbiota with: probiotics, prebiotics, and synbiotics has become an attractive, safe and well tolerated treatment strategy of obesity and NAFLD. Nobili V, Cucchiara S. The Use of Probiotics in Pediatric Nonalcoholic Fatty Liver Disease: Teachable Moment or Missed Opportunity? J Pediatr Gastroenterol Nutr. 2017;64:336–337
  25. 25. 8/30/2020NAFLD Prof. Dr. Saad S Al Ani 25 *Treatment (cont.) Unfortunately, the majority of obese children are not adherent to lifestyle modifications and hypocaloric diets Kovács E, Siani A, Konstabel K, Hadjigeorgiou C, de Bourdeaudhuij I, Eiben G, Lissner L, Gwozdz W, Reisch L, Pala V, et al. Adherence to the obesity-related lifestyle intervention targets in the IDEFICS study. Int J Obes (Lond) 2014;38 Suppl 2:S144–S151
  26. 26. 8/30/2020NAFLD Prof. Dr. Saad S Al Ani 26 *Treatment (Cont.) *Vitamin E improve balloon degeneration in children with NASH *Usage of ɯ-3 docosahexaenoeic acid improve: * Insulin sensitivity * ALT * Triglycerides * BMI * Histology in children with NAFLD
  27. 27. 8/30/2020NAFLD Prof. Dr. Saad S Al Ani 27 *Treatment (Cont.) *Usage of Cysteamine bitartrate (precursor of glutathione) (Antioxidant) reduce: * Liver enzyme levels * Serum leptin and adiponectin levels
  28. 28. 8/30/2020NAFLD Prof. Dr. Saad S Al Ani 28 *References * Nobili V, Alisi A, Newton KP, Schwimmer JB. Comparison of the Phenotype and Approach to Pediatric vs Adult Patients With Nonalcoholic Fatty Liver Disease. Gastroenterology. 2016;150:1798–1810 * Ng M, Fleming T, Robinson M, Thomson B, Graetz N, Margono C, Mullany EC, Biryukov S, Abbafati C, Abera SF, et al. Global, regional, and national prevalence of overweight and obesity in children and adults during 1980-2013: a systematic analysis for the Global Burden of Disease Study 2013. Lancet. 2014;384:766–781. * Pediatric Nonalcoholic Fatty Liver Disease: the Rise of a Lethal Disease Among Mexican American Hispanic Children.Betancourt-Garcia MM, Arguelles A, Montes J, Hernandez A, Singh M, Forse RA * http://pediatric-house-calls.djmed.net/wp-content/uploads/2013/09/graphic-fatty-liver.jpg * Della Corte C, Mazzotta AR, Nobili V. Fatty liver disease and obesity in youth. Curr Open Endocrinol Obes . 2016;23(1):66–71 * Yan Y, Hou D, Zhao X, et al. Childhood adiposity and nonalcoholic fatty liver disease in adulthood. Pediatrics . 2017;139(4):e20162738 * Diehl AM, Day C. Cause, pathogenesis, and treatment of nonalcoholic steatohepatitis. N Engl J Med . 2017;377(21):2063–2072 * Schwimmer JB. Clinical advances in pediatric nonalcoholic fatty liver disease. Hepatology . 2016;63(5):1718–1725
  29. 29. 8/30/2020NAFLD Prof. Dr. Saad S Al Ani 29 *References (Cont.) * Carbone LJ, Angus PW, Yeomans ND. Incretin-based therapies for the treatment of non-alcoholic fatty liver disease: a systematic review and meta-analysis. J Gastroenterol Hepatol . 2016;31(1):23–31 [PMID] 26111358 * Nobili V, Cucchiara S. The Use of Probiotics in Pediatric Nonalcoholic Fatty Liver Disease: Teachable Moment or Missed Opportunity? J Pediatr Gastroenterol Nutr. 2017;64:336–337 * Kovács E, Siani A, Konstabel K, Hadjigeorgiou C, de Bourdeaudhuij I, Eiben G, Lissner L, Gwozdz W, Reisch L, Pala V, et al. Adherence to the obesity-related lifestyle intervention targets in the IDEFICS study. Int J Obes (Lond) 2014;38 Suppl 2:S144– S151 * Obes Surg. 2017 Jan; 27(1):236-244Della Corte C, Mazzotta AR, Nobili V . Fatty liver disease and obesity in youth. curr Open Endocrinol Obes.2016;23(1):66-71 * Himes RW, Barlow SE, Bove K ,et al. Lysosomal acid lipase deficiency unmasked in two children with nonalcoholic fatty liver disease. Pediatrics. 2016;138(4):e20160214 * Kohli R ,Sunduram S , Mouzaki M , et al . Pediatric nonalcoholic fatty liver disease: a report from the expert committee on nonalcoholic fatty liver disease (ECON). J Pediatr. 2016;172:9-13 * Yan Y ,Hou D ,Zhao X ,et al. Childhood adiposity and nonalcoholic fatty liver disease in adulthood . Pediatrics. 2017;139(4):e20162738 * Abdou RM, Zhu L, Baker RD, et al. Gut Microbiota of nonalcoholic fatty liver disease. Dig Dis Sci . 2016;61(5):1268–1281 .

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