Cytokeratin-18 and hyaluronic acid levels predict liver fibrosis in children with non-alcoholic fatty liver disease
Objectives: There is a need to replace liver biopsy with non-invasive markers that predict the degree of liver fibrosis in fatty liver disease related to obesity. Therefore, we studied four potential serum markers of liver fibrosis and compared them with histopathological findings in liver biopsy in children with non-alcoholic fatty liver disease (NAFLD). Methods: We determined fasting serum level of hyaluronic acid (HA), laminin, YKL-40 and cytokeratin-18 M30 in 52 children (age range 4-19, mean 12 years, 80 % of them were overweight or obese) with biopsy-verified NAFLD. Viral hepatitis, autoimmune and metabolic liver diseases (Wilson's disease, alpha-1-antitrypsin deficiency, cystic fibrosis) were excluded. Fibrosis stage was assessed in a blinded fashion by one pathologist according to Kleiner. Receiver operating characteristics (ROC) analysis was used to calculate the power of the assays to detect liver fibrosis (AccuROC, Canada). Results: Liver fibrosis was diagnosed in 19 children (37 %). The levels of HA and CK18M30 were significantly higher in children with fibrosis compared to children without fibrosis (p=0.04 and 0.05 respectively). The ability of serum HA (cut-off 19.1 ng/ml, Se=84 %, Sp=55 %, PPV=52 %, NPV=86 %) and CK18M30 (cut-off 210 u/l, Se=79 %, Sp=60 %, PPV=56 %, NPV=82 %) to differentiate children with fibrosis from those without fibrosis was significant (AUC=0.672 and 0.666, respectively). The combination of both markers was superior (AUC=0.73, p=0.002). Laminin and YKL-40 levels did not allow a useful prediction. Conclusions: Cytokeratin-18 and hyaluronic acid are suitable serum markers predicting liver fibrosis in children with NAFLD. Studying these markers may identify patients at risk of disease progression.
- Afdhal NH (2004) Biopsy or biomarkers: is there a gold standard for diagnosis of liver fibrosis? Clin Chem 50: 1299-1300.
- Carter-Kent C, Yerian LM, Brunt EM, Angulo P, Kohli R, Ling SC et al (2009) Nonalcoholic steatohepatitis in children: a multicenter clinicopathological study. Hepatology 50: 1113-1120.
- Civera M, Urios A, Garcia-Torres ML, Ortega J, Martinez-Valls J, Cassinello N et al. (2010) Relationship between insulin resistance, inflammation and liver cell apoptosis in patients with severe obesity. Diabetes Metab Res Rev 26: 187-192.
- Diab DL, Yerian L, Schauer P, Kashyap SR, Lopez R, Hazen SL et al. (2008) Cytokeratin 18 fragment levels as a noninvasive biomarker for nonalcoholic steatohepatitis in bariatric surgery patients. Clin Gastroenterol Hepatol 6: 1249-1254.
- Feldstein AE, Charatcharoenwitthaya P, Treeprasertsuk S, Benson JT, Enders FB, Angulo P (2009) The natural history of nonalcoholic fatty liver disease in children: a follow-up study for up to 20-years. Gut 58: 1538-1544.
- Feldstein AE, Wieckowska A, Lopez AR, Liu YC, Zein NN, McCullough AJ (2009) Cytokeratin-18 fragment levels as noninvasive biomarkers for nonalcoholic steatohepatitis: a multicenter validation study. Hepatology 50: 1072-1078.
- Fitzpatrick E, Mitry RR, Quaglia A, Hussain MJ, DeBruyne R, Dhawan A (2010) Serum levels of CK18 M30 and leptin are useful predictors of steatohepatitis and fibrosis in pediatric NAFLD. J Pediatr Gastroenterol Nutr 51: 500-506.
- Johansen JS, Hvolris J, Hansen M, Backer V, Lorenzen I, Price PA (1996) Serum YKL-40 levels in healthy children and adults. Comparison with serum and synovial fluid levels of YKL-40 in patients with osteoarthritis of trauma of the knee joint. Br J Rheumatol 35: 553-559.
- Kleiner DE, Brunt EM, Van Natta M, Behling C, Contos MJ, Cummings OW et al. (2005) Design and validation of a histological scoring system for nonalcoholic fatty liver disease. Hepatology 41: 1313-1321.
- Lavine JE, Schwimmer JB (2004) Nonalcoholic fatty liver disease in the pediatric population. Clin Liver Dis 8: 549-558.
- Lebensztejn DM, Kaczmarski M, Sobaniec-Lotowska M, Bauer M, Voelker M, Schuppan D (2004) Serum laminin-2 and hyaluronan predict severe liver fibrosis in children with chronic hepatitis B. Hepatology 39: 868-869.
- Lebensztejn DM, Skiba E, Sobaniec-Lotowska M, Kaczmarski M (2007) Serum hyaluronan and laminin level in children with chronic hepatitis B during long term lamivudine treatment. Hepatogastroenterology 54: 834-838.
- Lebensztejn DM, Sobaniec-Lotowska M, Bauer M, Kaczmarski M, Voelker M, Schuppan D (2005) Serum fibrosis markers as predictors of an antifibrotic effect of interferon alfa in children with chronic hepatitis B. Eur J Gastroenterol Hepatol 17: 843-848.
- Malik R, Chang M, Bhaskar K, Nasser I, Curry M, Schuppan D et al (2009) The clinical utility of biomarkers and the nonalcoholic steatohepatitis CRN liver biopsy scoring system in patients with nonalcoholic fatty liver disease. J Gastroenterol Hepatol 24: 564-568.
- Matteoni CA, Younossi ZM, Gramlich T, Boparai N, Liu YC, McCullough AJ (1999) Nonalcoholic fatty liver disease: a spectrum of clinical and pathological severity. Gastroenterology 116: 1413-1419.
- Matthews DR, Hosker JP, Rudenski AS, Naylor BA, Treacher DF, Turner RC (1985) Homeostasis model assessment: insulin resistance and beta-cell function from fasting plasma glucose and insulin concentration in man. Diabetologia 28: 412-419.
- Nobili V, Alisi A, Torre G, De Vito R, Pietrobattista A, Morino G et al (2010) Hyaluronic acid predicts hepatic fibrosis in children with nonalcoholic fatty liver disease. Transl Res 156: 229-234.
- Patton HM, Sirlin C, Behling C, Middleton M, Schwimmer JB, Lavine JE (2006) Pediatric nonalcoholic fatty liver disease: a critical appraisal of current data and implications for future research. J Pediatr Gastroenterol Nutr 43: 413-427.
- Poynard T, Munteanu M, Imbert-Bismut F, Charlotte F, Thabut D, Le Calvez S et al. (2004) Prospective analysis of discordant results between biochemical markers and biopsy in patients with chronic hepatitis C. Clin Chem 50: 1344-1355.
- Ratziu V, Charlotte F, Heurtier A, Gombert S, Giral P, Bruckert E et al. (2005) Sampling variability of liver biopsy in nonalcoholic fatty liver disease. Gastroenterology 128: 1898-1906.
- Schwimmer JB, Deutsch R, Kahen T, Lavine JE, Stanley C, Behling C (2006) Prevalence of fatty liver in children and adolescents. Pediatrics 118: 1388-1393.
- Suzuki A, Angulo P, Lymp J, Li D, Satomura S, Lindor K (2005) Hyaluronic acid, an accurate serum marker for severe hepatic fibrosis in patients with non-alcoholic fatty liver disease. Liver Int 25: 779-786.
- Trivedi B, Cheeseman P, Mowat AP (1993) Serum hyaluronic acid in health infants and children and its value as a marker of progressive hepatobiliary disease starting in infancy. Clin Chim Acta 215: 29-39.
- Valva P, De Matteo E, Galoppo M, Pedreira A, Giacove G, Lezama C et al. (2008) Apoptosis markers in liver biopsy of nonalcoholic steatohepatitis in pediatric patients. Hum Pathol 39: 1816-1822.
- Wieckowska A, Zein NN, Yerian LM, Lopez AR, McCullough AJ, Feldstein AE (2006) In vivo assessment of liver cell apoptosis as a novel biomarker of disease severity in nonalcoholic fatty liver disease. Hepatology 44: 27-33.