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Association of Histologic Disease Activity With Progression of Nonalcoholic Fatty Liver Disease
Open accessAbstract
Importance: The histologic evolution of the full spectrum of nonalcoholic fatty liver disease (NAFLD) and factors associated with progression or regression remain to be definitively established. Objective: To evaluate the histologic evolution of NAFLD and the factors associated with changes in disease severity over time. Design, Setting, and Participants: A prospective cohort substudy from the Nonalcoholic Steatohepatitis Clinical Research Network (NASH CRN) NAFLD Database study, a noninterventional registry, was performed at 8 university medical research centers. Masked assessment of liver histologic specimens was performed, using a prespecified protocol to score individual biopsies. Participants included 446 adults with NAFLD enrolled in the NASH CRN Database studies between October 27, 2004, and September 13, 2013, who underwent 2 liver biopsies 1 or more year apart. Data analysis was performed from October 2016 to October 2018. Main Outcomes and Measures: Progression and regression of fibrosis stage, using clinical, laboratory, and histologic findings, including the NAFLD activity score (NAS) (sum of scores for steatosis, lobular inflammation, and ballooning; range, 0-8, with 8 indicating more severe disease). Results: A total of 446 adults (mean [SD] age, 47 [11] years; 294 [65.9%] women) with NAFLD (NAFL, 86 [19.3%]), borderline NASH (84 [18.8%]), and definite NASH (276 [61.9%]) were studied. Over a mean (SD) interval of 4.9 (2.8) years between biopsies, NAFL resolved in 11 patients (12.8%) and progressed to steatohepatitis in 36 patients (41.9%). Steatohepatitis resolved in 24 (28.6%) of the patients with borderline NASH and 61 (22.1%) of those with definite NASH. Fibrosis progression or regression by at least 1 stage occurred in 132 (30%) and 151 [34%] participants, respectively. Metabolic syndrome (20 [95%] vs 108 [72%]; P = .03), baseline NAS (mean [SD], 5.0 [1.4] vs 4.3 [1.6]; P = .005), and smaller reduction in NAS (-0.2 [2] vs -0.9 [2]; P < .001) were associated with progression to advanced (stage 3-4) fibrosis vs those without progression to stage 3 to 4 fibrosis. Fibrosis regression was associated with lower baseline insulin level (20 vs 33 μU/mL; P = .02) and decrease in all NAS components (steatosis grade -0.8 [0.1] vs -0.3 [0.9]; P < .001; lobular inflammation -0.5 [0.8] vs -0.2 [0.9]; P < .001; ballooning -0.7 [1.1] vs -0.1 [0.9]; P < .001). Only baseline aspartate aminotransferase (AST) levels were associated with fibrosis regression vs no change and progression vs no change on multivariable regression: baseline AST (regression: conditional odds ratio [cOR], 0.6 per 10 U/L AST; 95% CI, 0.4-0.7; P < .001; progression: cOR, 1.3; 95% CI, 1.1-1.5; P = .002). Changes in the AST level, alanine aminotransferase (ALT) level, and NAS were also associated with fibrosis regression and progression (ΔAST level: regression, cOR, 0.9; 95% CI, 0.6-1.2; P = .47; progression, cOR, 1.3; 95% CI, 1.0-1.6; P = .02; ΔALT level: regression, cOR, 0.7 per 10 U/L AST; 95% CI, 0.5-0.9; P = .002; progression, cOR, 1.0 per 10 U/L AST; 95% CI, 0.9-1.2; P = .93; ΔNAS: regression, cOR, 0.7; 95% CI, 0.6-0.9; P = .001; progression, cOR, 1.3; 95% CI, 1.1-1.5; P = .01). Conclusions and Relevance: Improvement or worsening of disease activity may be associated with fibrosis regression or progression, respectively, in NAFLD.
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“In a natural history cohort of 445 individuals with 4.9 years mean follow-up between paired liver biopsies from the NASH CRN, improvement in the NAS over time was associated with fi brosis regression, and worsening of the NAS was associated with fi brosis progression. 260”
From EASL-EASD-EASO Clinical Practice Guidelines on the management of metabolic dysfunction-associated steatotic liver disease (MASLD). (2024) · cites this paper as [260]
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“Several studies have shown that changes in histologically assessed activity are linked with changes in fi brosis over time.”
From EASL-EASD-EASO Clinical Practice Guidelines on the management of metabolic dysfunction-associated steatotic liver disease (MASLD). (2024) · cites this paper as [260]
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“In a natural history cohort of 445 individuals with 4.9 years mean follow-up between paired liver biopsies from the NASH CRN, improvement in the NAS over time was associated with fi brosis regression, and worsening of the NAS was associated with fi brosis progression. 260”
From EASL-EASD-EASO Clinical Practice Guidelines on the management of metabolic dysfunction-associated steatotic liver disease (MASLD). (2024) · cites this paper as [260]
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Metadata
- Authors
- Kleiner, D. E., Brunt, E. M., Wilson, L. A., Behling, C., Guy, C., Contos, M., Cummings, O., Yeh, M., Gill, R., Chalasani, N., Neuschwander-Tetri, B. A., Diehl, A. M., Dasarathy, S., Terrault, N., Kowdley, K., Loomba, R., Belt, P., Tonascia, J., Lavine, J. E., Sanyal, A. J., & for the Nonalcoholic Steatohepatitis Clinical Research Network
- Affiliations
- National Institutes of Health (US)
- Washington University in St. Louis (US)
- Johns Hopkins University (US)
- University of California San Diego (US)
- Duke University (US)
- Virginia Commonwealth University (US)
- Indiana University School of Medicine (US)
- University of Washington (US)
- University of California, San Francisco (US)
- Indiana University Indianapolis (US)
- Division of Gastroenterology, Saint Louis University School of Medicine, St Louis, Missouri
- Cleveland Clinic (US)
- University of Southern California (US)
- Swedish Medical Center (US)
- Columbia University Irving Medical Center (US)
- Corresponding author
- Kleiner, David E.
- Sanyal, Arun J.
- ORCID
- Venue
- JAMA Network Open
- Publisher
- American Medical Association (AMA)
- Published
- 2019-10-04
- Volume
- 2
- Issue
- 10
- Pages
- e1912565
- ISSN
- 2574-3805 (ISSN-L)
- PMC
- PMC6784786
- OpenAlex
- W2977362851
- Cited by
- 372
- References
- 28
- Citations by year
- 2026: 32 · 2025: 53 · 2024: 48 · 2023: 66 · 2022: 62 · 2021: 65 · 2020: 44 · 2019: 2
- FWCI
- 32.92
- Type
- journal article
- Language
- en
- Open access
- gold
- doi.org
- Licence
- cc-by
- Locations
- JAMA Network Open (publishedVersion, cc-by)
- Europe PMC (PubMed Central) (publishedVersion, cc-by)
- PubMed Central (publishedVersion, cc-by)
- PubMed (publishedVersion)
- Digital Commons@Becker (Washington University School of Medicine) (submittedVersion, cc-by)
- IUScholarWorks (Indiana University) (submittedVersion, cc-by)
- Purdue University Indianapolis (Indiana University) (submittedVersion, cc-by)
- Funders
- National Institutes of Health (UL1TR000100, UL1TR000423, UL1TR000436, UL1TR000058, UL1TR000004, UL1TR000448, UL1TR000006, UL1TR000439, UL1TR002548, UL1TR001442, UL1TR002345, UL1TR002319)
- National Institute of Diabetes and Digestive and Kidney Diseases (U01DK061730, U01DK061731, U01DK061713, U24DK061730, U01DK061728, U01DK061737, U01DK061732, U01DK061734, U01DK061718, U01DK061738)
- National Center for Advancing Translational Sciences
- Topics
- Health Sciences › Medicine › Hepatology › Liver Disease Diagnosis and Treatment
- Health Sciences › Medicine › Hepatology › Liver Diseases and Immunity
- Health Sciences › Medicine › Hepatology › Liver physiology and pathology
- Keywords
- non-alcoholic fatty liver disease, nonalcoholic steatohepatitis, disease progression, fibrosis regression, NAFLD activity score, metabolic syndrome, steatosis, lobular inflammation, ballooning, liver biopsy
- MeSH terms
- Academic Medical Centers, Adult, Aspartate Aminotransferases, Female, Humans, Liver, Liver Cirrhosis, Male, Middle Aged, Risk Factors, United States, Cohort Studies, Weight Gain, Disease Progression, Non-alcoholic Fatty Liver Disease
About these checks
Registry, retraction, Cites and statistics results are computed, not judged, with one exception: a printed reference that no index lists is read once by a model before it counts as a citation error. Claims are extracted by a model and kept only when their quote appears verbatim in the text; each cited source is then checked, with a model’s help, for whether it says what the claim relies on. Those verdicts can be wrong — read the claim’s quote and the cited source before relying on one.
Statistics and arithmetic are recomputed, not judged.
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