Nonalcoholic fatty liver disease in Patients of Primary Hypothyroidism

1. Nonalcoholic fatty liver disease in Patients of Primary Hypothyroidism Dr MadhukarMittalMD, DM Asst. Professor Endocrine Unit, Department of Medicine King George Medical University (earlier CSMMU) Lucknow, India

2. Background • Several endocrine disorders are known to have increased risk for Nonalcoholic fatty liver diseae (NAFLD) • Diabetes mellitus • Hypothyroidism • Adrenal insufficiency • GH deficiency • PCOS

3. NAFLD spectrum Simple steatosis Inflammatory steatohepatitis (NASH) Fibro-fatty Liver (Increasing levels of fibrosis) Cirrhosis

4. NAFLD Prevalence • NAFLD • 20% and 30% in Western adults1,2 • 90% in the morbidly obese3 • NASH (the more advanced form of NAFLD) • 2–3% in the general population4 • 16 and 37% in the morbidly obese3 1Browning JD et al. Prevalence of hepatic steatosis in an urban population in the United States: impact of ethnicity. Hepatology 2004;40:1387 2Bedogni G et al. Prevalence of and risk factors for nonalcoholic fatty liver disease: the Dionysos nutrition and liver study. Hepatology 2005;42:44 3Machado M et al. Hepatic histology in obese patients undergoing bariatric surgery. J Hepatol 2006;45:600–6 4Neuschwander-Tetri BA et al. Nonalcoholic steatohepatitis: summary of an AASLD Single Topic Conference. Hepatology 2003;37:1202

5. Aims and Objectives Study to see for prevalence of NAFLD in patients of primary hypothyroidism To evaluate metabolic parameters in this group of patients with NAFLD

6. Material and Methods • Consecutive primary hypothyroid patients • Tested for antibodies against thyroid peroxidase (TPO) and thyroglobulin (TG) • Insulin resistance assessed • Fasting insulin • Homeostasis model assessment of insulin resistance (HOMA-IR) • Quantitative insulin-sensitivity check index (QUICKI)

7. USG grading USG abdomen done by two radiologists to grade fatty liver Jain KA et al. Spectrum of CT and sonographic appearance of fatty infiltration of the liver. Clin Imaging 1993;17:162 Saadeh S et al. The utility of radiological imaging in nonalcoholic fatty liver disease. Gastroenterology 2002; 123: 745 Tchelepi H et al. Sonography of diffuse liver disease. J Ultrasound Med 2002; 21: 1023 Zwiebel WJ. Sonographic diagnosis of diffuse liver disease. Semin Ultrasound CT MR 1995;16:8

8. NAFLD diagnosis • NAFLD defined as • USG score >2 • Fatty liver not resulting from • Excessive alcohol consumption (>20 grams/day) • Drugs/Toxins (tamoxifen, methotrexate, amiodarone etc) • Infectious diseases (viral hepatitis etc) • Any other identifiable exogenous causes (Wilson disease, Hemochromatosis, α-1 antitrypsin deficiency etc)

9. Statistical Analysis • Data presented as mean + SD, median (interquartile range) or N (%) • Distribution of continuous data tested for normality • Kolmogorov- Smirnov test • Comparing between groups for continuous variable • Student T test • Mann Whitney test for non-uniformly distributed data • Comparing categorical data • Chi square test or Fisher exact test • A two tailed p value <0.05 regarded as significant • Statistical software SPSS15.0 (SPSS, Chicago, IL)

10. Results

11. Baseline Characteristics

12. Comaparison of thyroid antibody postive vs. antibody negative patients

13. NAFLD characteristics

14. NAFLD positive vs. NAFLD negative patients

15. Discussion

16. NAFLD Non-alcoholic fatty liver disease affects all ethnic groups Prevalence higher in Hispanic and European Americans compared with African-Americans

17. NAFLD prevalence in India NAFLD was seen in around half of hypothyroid patients

18. Chung GE et al. 2324 cases of hypothyroidism (overt and subclinical) NAFLD based on USG 62% female NAFLD prevalence 30.2% Non-alcoholic fatty liver disease across the spectrum of hypothyroidism. J Hepatol. 2012 Jul;57(1):150-6

19. Thyroid antibody positivity Thyroid antibody positivity correlated with higher markers of insulin resistance Low normal FT4 levels were significantly associated with increased insulin resistance Roos A et al. J ClinEndocrinolMetab 2007;92(2):491

20. NAFLD in hypothyroidism and metabolic characteristics Patients who had NAFLD had higher systolic blood pressure and deranged metabolic parameters (higher BMI, FBS, PPBS, VLDL and low HDL)

21. Health ABC study. Waring CA et al. ClinEndocrinol 2012;76(6):911 2119 patients 684 initially identified with metabolic syndrome Higher TSH levels and subclinical hypothyroidism with TSH>10 mIU/L significantly associated with prevalent metabolic syndrome Each unit increase in TSH associated with 3% increase in odds of prevalent metabolic syndrome Thyroid function and prevalent and incident metabolic syndrome in older adults: the health, ageing and body composition (Health ABC) study. Warin CA et al. ClinEndocrinol 2012;76(6):911

22. Conclusion NAFLD seen in nearly half of primary hypothyroid patients Insulin resistance higher in thyroid antibody positive patients NAFLD associated with increased clustering of parameters of metabolic syndrome

23. Limitations • Histopathology (Liver Biopsy) not done • USG cannot differentiate between Simple Steatosis and NASH • Larger sample size needed

24. Future Course • Ongoing study • Currently 142 patients included • Noninvasive markers for liver cirrhosis • AST to platelet ratio index (APRI) • AST/ALT ratio (AAR) • BARD score

25. Acknowledgement Dr Neha Jain Dr AnitParihar Dr Vivek Kumar Dr Ravi Misra Dr AK Vaish

26. King George Medical University, Lucknow Thank You

29. NASH was first coined by Ludwig et al. in 1980 the prevalence of NAFLD has risen rapidly in parallel with the dramatic rise in population levels of obesity and diabetes, resulting in NAFLD now representing the most common cause of liver disease in the Western world