Histological abnormalities in children with nonalcoholic fatty liver disease and normal or mildly elevated alanine aminotransferase levels

Jean Molleston, Jeffrey B. Schwimmer, Katherine P. Yates, Karen F. Murray, Oscar Cummings, Joel E. Lavine, Elizabeth M. Brunt, Ann O. Scheimann, Aynur Unalp-Arida

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Abstract

Objective To investigate the histological spectrum of nonalcoholic fatty liver disease (NAFLD) in children with normal, mildly elevated (26-50 U/L boys, 23-44 U/L girls), or elevated (>50 U/L in boys, >44 U/L in girls) serum alanine aminotransferase (ALT) levels. Study design The Nonalcoholic Steatohepatitis Clinical Research Network enrolls children aged 5-18 years with NAFLD. We analyzed baseline clinical and histological data from 91 children with suspected NAFLD and normal or mildly elevated ALT and liver biopsy analysis within 180 days of ALT measurement, and compared them with data from 392 children with elevated ALT. Results Seventeen of the 91 children with suspected NAFLD (19%) had a normal ALT level, and 74 (81%) had a mildly elevated ALT level. Overall, 45% of the biopsy specimens analyzed had steatosis ≥33%, 22% had grade ≥2 lobular inflammation, 81% had portal inflammation, 29% had ballooned hepatocytes, 35% had "suspicious/borderline" steatohepatitis, 8% had definite nonalcoholic steatohepatitis, 34% had an NAFLD activity score ≥4, and 46% had fibrosis (38% mild/moderate and 8% bridging/cirrhosis). Marked steatosis (50% vs 24%) and fibrosis (54% vs 12%) were significantly more common in the patients with mildly elevated ALT compared with those with normal ALT, with no difference in ballooning, inflammation, or NAFLD activity score ≥4 between the 2 groups. Fibrosis stage 3/4 was seen in none of the children with normal ALT, in 9% of those with mildly elevated ALT, and in 15% of those with elevated ALT. Conclusion Liver biopsy specimens from children with NAFLD with normal or mildly elevated ALT levels show significant histological abnormalities, including advanced fibrosis in children with mildly elevated ALT. Thus, measurement of ALT may underestimate liver injury in NAFLD. The use of appropriate ALT cutoff levels can help identify children at risk for more severe disease.

Original languageEnglish
JournalJournal of Pediatrics
Volume164
Issue number4
DOIs
StatePublished - 2014

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Alanine Transaminase
Fibrosis
Non-alcoholic Fatty Liver Disease
Inflammation
Biopsy
Liver
Fatty Liver
Hepatocytes

ASJC Scopus subject areas

  • Pediatrics, Perinatology, and Child Health

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Histological abnormalities in children with nonalcoholic fatty liver disease and normal or mildly elevated alanine aminotransferase levels. / Molleston, Jean; Schwimmer, Jeffrey B.; Yates, Katherine P.; Murray, Karen F.; Cummings, Oscar; Lavine, Joel E.; Brunt, Elizabeth M.; Scheimann, Ann O.; Unalp-Arida, Aynur.

In: Journal of Pediatrics, Vol. 164, No. 4, 2014.

Research output: Contribution to journalArticle

Molleston, Jean ; Schwimmer, Jeffrey B. ; Yates, Katherine P. ; Murray, Karen F. ; Cummings, Oscar ; Lavine, Joel E. ; Brunt, Elizabeth M. ; Scheimann, Ann O. ; Unalp-Arida, Aynur. / Histological abnormalities in children with nonalcoholic fatty liver disease and normal or mildly elevated alanine aminotransferase levels. In: Journal of Pediatrics. 2014 ; Vol. 164, No. 4.
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abstract = "Objective To investigate the histological spectrum of nonalcoholic fatty liver disease (NAFLD) in children with normal, mildly elevated (26-50 U/L boys, 23-44 U/L girls), or elevated (>50 U/L in boys, >44 U/L in girls) serum alanine aminotransferase (ALT) levels. Study design The Nonalcoholic Steatohepatitis Clinical Research Network enrolls children aged 5-18 years with NAFLD. We analyzed baseline clinical and histological data from 91 children with suspected NAFLD and normal or mildly elevated ALT and liver biopsy analysis within 180 days of ALT measurement, and compared them with data from 392 children with elevated ALT. Results Seventeen of the 91 children with suspected NAFLD (19{\%}) had a normal ALT level, and 74 (81{\%}) had a mildly elevated ALT level. Overall, 45{\%} of the biopsy specimens analyzed had steatosis ≥33{\%}, 22{\%} had grade ≥2 lobular inflammation, 81{\%} had portal inflammation, 29{\%} had ballooned hepatocytes, 35{\%} had {"}suspicious/borderline{"} steatohepatitis, 8{\%} had definite nonalcoholic steatohepatitis, 34{\%} had an NAFLD activity score ≥4, and 46{\%} had fibrosis (38{\%} mild/moderate and 8{\%} bridging/cirrhosis). Marked steatosis (50{\%} vs 24{\%}) and fibrosis (54{\%} vs 12{\%}) were significantly more common in the patients with mildly elevated ALT compared with those with normal ALT, with no difference in ballooning, inflammation, or NAFLD activity score ≥4 between the 2 groups. Fibrosis stage 3/4 was seen in none of the children with normal ALT, in 9{\%} of those with mildly elevated ALT, and in 15{\%} of those with elevated ALT. Conclusion Liver biopsy specimens from children with NAFLD with normal or mildly elevated ALT levels show significant histological abnormalities, including advanced fibrosis in children with mildly elevated ALT. Thus, measurement of ALT may underestimate liver injury in NAFLD. The use of appropriate ALT cutoff levels can help identify children at risk for more severe disease.",
author = "Jean Molleston and Schwimmer, {Jeffrey B.} and Yates, {Katherine P.} and Murray, {Karen F.} and Oscar Cummings and Lavine, {Joel E.} and Brunt, {Elizabeth M.} and Scheimann, {Ann O.} and Aynur Unalp-Arida",
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T1 - Histological abnormalities in children with nonalcoholic fatty liver disease and normal or mildly elevated alanine aminotransferase levels

AU - Molleston, Jean

AU - Schwimmer, Jeffrey B.

AU - Yates, Katherine P.

AU - Murray, Karen F.

AU - Cummings, Oscar

AU - Lavine, Joel E.

AU - Brunt, Elizabeth M.

AU - Scheimann, Ann O.

AU - Unalp-Arida, Aynur

PY - 2014

Y1 - 2014

N2 - Objective To investigate the histological spectrum of nonalcoholic fatty liver disease (NAFLD) in children with normal, mildly elevated (26-50 U/L boys, 23-44 U/L girls), or elevated (>50 U/L in boys, >44 U/L in girls) serum alanine aminotransferase (ALT) levels. Study design The Nonalcoholic Steatohepatitis Clinical Research Network enrolls children aged 5-18 years with NAFLD. We analyzed baseline clinical and histological data from 91 children with suspected NAFLD and normal or mildly elevated ALT and liver biopsy analysis within 180 days of ALT measurement, and compared them with data from 392 children with elevated ALT. Results Seventeen of the 91 children with suspected NAFLD (19%) had a normal ALT level, and 74 (81%) had a mildly elevated ALT level. Overall, 45% of the biopsy specimens analyzed had steatosis ≥33%, 22% had grade ≥2 lobular inflammation, 81% had portal inflammation, 29% had ballooned hepatocytes, 35% had "suspicious/borderline" steatohepatitis, 8% had definite nonalcoholic steatohepatitis, 34% had an NAFLD activity score ≥4, and 46% had fibrosis (38% mild/moderate and 8% bridging/cirrhosis). Marked steatosis (50% vs 24%) and fibrosis (54% vs 12%) were significantly more common in the patients with mildly elevated ALT compared with those with normal ALT, with no difference in ballooning, inflammation, or NAFLD activity score ≥4 between the 2 groups. Fibrosis stage 3/4 was seen in none of the children with normal ALT, in 9% of those with mildly elevated ALT, and in 15% of those with elevated ALT. Conclusion Liver biopsy specimens from children with NAFLD with normal or mildly elevated ALT levels show significant histological abnormalities, including advanced fibrosis in children with mildly elevated ALT. Thus, measurement of ALT may underestimate liver injury in NAFLD. The use of appropriate ALT cutoff levels can help identify children at risk for more severe disease.

AB - Objective To investigate the histological spectrum of nonalcoholic fatty liver disease (NAFLD) in children with normal, mildly elevated (26-50 U/L boys, 23-44 U/L girls), or elevated (>50 U/L in boys, >44 U/L in girls) serum alanine aminotransferase (ALT) levels. Study design The Nonalcoholic Steatohepatitis Clinical Research Network enrolls children aged 5-18 years with NAFLD. We analyzed baseline clinical and histological data from 91 children with suspected NAFLD and normal or mildly elevated ALT and liver biopsy analysis within 180 days of ALT measurement, and compared them with data from 392 children with elevated ALT. Results Seventeen of the 91 children with suspected NAFLD (19%) had a normal ALT level, and 74 (81%) had a mildly elevated ALT level. Overall, 45% of the biopsy specimens analyzed had steatosis ≥33%, 22% had grade ≥2 lobular inflammation, 81% had portal inflammation, 29% had ballooned hepatocytes, 35% had "suspicious/borderline" steatohepatitis, 8% had definite nonalcoholic steatohepatitis, 34% had an NAFLD activity score ≥4, and 46% had fibrosis (38% mild/moderate and 8% bridging/cirrhosis). Marked steatosis (50% vs 24%) and fibrosis (54% vs 12%) were significantly more common in the patients with mildly elevated ALT compared with those with normal ALT, with no difference in ballooning, inflammation, or NAFLD activity score ≥4 between the 2 groups. Fibrosis stage 3/4 was seen in none of the children with normal ALT, in 9% of those with mildly elevated ALT, and in 15% of those with elevated ALT. Conclusion Liver biopsy specimens from children with NAFLD with normal or mildly elevated ALT levels show significant histological abnormalities, including advanced fibrosis in children with mildly elevated ALT. Thus, measurement of ALT may underestimate liver injury in NAFLD. The use of appropriate ALT cutoff levels can help identify children at risk for more severe disease.

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