Efficacy of glutathione for the treatment of nonalcoholic fatty liver disease: an open-label, single-arm, multicenter, pilot study

Background: Glutathione plays crucial roles in the detoxification and antioxidant systems of cells and has been used to treat acute poisoning and chronic liver diseases by intravenous injection. This is a first study examining the therapeutic effects of oral administration of glutathione in patients with nonalcoholic fatty liver disease (NAFLD). Methods: The study was an open label, single arm, multicenter, pilot trial. Thirty-four NAFLD patients diagnosed using ultrasonography were prospectively evaluated. All patients first underwent intervention to improve their lifestyle habits (diet and exercise) for 3 months, followed by treatment with glutathione (300 mg/day) for 4 months. We evaluated their clinical parameters before and after glutathione treatment. We also quantified liver fat and fibrosis using vibration-controlled transient elastography. The primary outcome of the study was the change in alanine aminotransferase (ALT) levels. Results: Twenty-nine patients finished the protocol. ALT levels significantly decreased following treatment with glutathione for 4 months. In addition, triglycerides, non-esterified fatty acids, and ferritin levels also decreased with glutathione treatment. Following dichotomization of ALT responders based on a median 12.9% decrease from baseline, we found that ALT responders were younger in age and did not have severe diabetes compared with ALT non-responders. The controlled attenuation parameter also decreased in ALT responders. Conclusions: This pilot study demonstrates the potential therapeutic effects of oral administration of glutathione in practical dose for patients with NAFLD. Large-scale clinical trials are needed to verify its efficacy. Trial registration: UMIN000011118 (date of registration: July 4, 2013)

Risk estimation model for nonalcoholic fatty liver disease in the Japanese using multiple genetic markers

<div><p>The genetic factors affecting the natural history of nonalcoholic fatty liver disease (NAFLD), including the development of nonalcoholic steatohepatitis (NASH) and NASH-derived hepatocellular carcinoma (NASH-HCC), are still unknown. In the current study, we sought to identify genetic factors related to the development of NAFLD, NASH, and NASH-HCC, and to establish risk-estimation models for them. For these purposes, 936 histologically proven NAFLD patients were recruited, and genome-wide association (GWA) studies were conducted for 902, including 476 NASH and 58 NASH-HCC patients, against 7,672 general-population controls. Risk estimations for NAFLD and NASH were then performed using the SNPs identified as having significant associations in the GWA studies. We found that rs2896019 in <i>PNPLA3</i> [<i>p</i> = 2.3x10^-31, OR (95%CI) = 1.85 (1.67–2.05)], rs1260326 in <i>GCKR</i> [<i>p</i> = 9.6x10^-10, OR (95%CI) = 1.38(1.25–1.53)], and rs4808199 in <i>GATAD2A</i> [<i>p</i> = 2.3x10^-8, OR (95%CI) = 1.37 (1.23–1.53)] were significantly associated with NAFLD. Notably, the number of risk alleles in <i>PNPLA3</i> and <i>GATAD2A</i> was much higher in Matteoni type 4 (NASH) patients than in type 1, type 2, and type 3 NAFLD patients. In addition, we newly identified rs17007417 in <i>DYSF</i> [<i>p</i> = 5.2x10^-7, OR (95%CI) = 2.74 (1.84–4.06)] as a SNP associated with NASH-HCC. Rs641738 in <i>TMC4</i>, which showed association with NAFLD in patients of European descent, was not replicated in our study (<i>p</i> = 0.73), although the complicated LD pattern in the region suggests the necessity for further investigation. The genetic variants of <i>PNPLA3</i>, <i>GCKR</i>, and <i>GATAD2A</i> were then used to estimate the risk for NAFLD. The obtained Polygenic Risk Scores showed that the risk for NAFLD increased with the accumulation of risk alleles [AUC (95%CI) = 0.65 (0.63–0.67)]. Conclusions: We demonstrated that NASH is genetically and clinically different from the other NAFLD subgroups. We also established risk-estimation models for NAFLD and NASH using multiple genetic markers. These models can be used to improve the accuracy of NAFLD diagnosis and to guide treatment decisions for patients.</p></div

Histogram of the odds ratios for genotype distributions between different subgroups.

<p>Each box denotes the odds ratio (OR) comparing the control or patient subgroups shown on the horizontal axes. The <i>p</i>-values, ORs, and 95% confidence intervals are shown in the <a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0185490#pone.0185490.s007" target="_blank">S6 Table</a>.</p

Risk estimation according to Polygenic Risk Scores for NAFLD patients compared with controls.

<p>The dot and bar denote the odds ratio (OR) and its 95% confidence interval in each quintile compared to the 1st quintile using rs2896019 in <i>PNPLA3</i>, rs1260326 in <i>GCKR</i>, and rs4808199 in <i>GATAD2A</i> (A), and the receiver operating characteristic (ROC) curve from the model (red line), and the ROC curves including previously reported SNPs (green dashed line) or candidate SNPs (p<1x10^-4) identified in our GWA study (black dashed line) (B) are shown.</p

Regional Manhattan plots around the SNP markers showing genome-wide significance in the GWA studies.

<p><i>P</i>-values, gene organization, and linkage disequilibrium (LD) plots according to the chromosomal position of the three significantly genome-wide associated regions for NAFLD (A-C) and the one region for NASH-HCC (D). Each figure spans 200 kb (A, B, and D) or 300 kb (C) in both the 5’ and 3’ directions from the SNP with the strongest association (shown with a red arrow) in the GWA studies. <i>P</i>-values are plotted for both genotyped and imputed SNPs in the upper panels, and previously reported SNPs with genome-wide significance are indicated by green arrows. The colors of the circles representing <i>p</i>-values correspond to the strength of LD (r2) from the most significant SNP in the GWA studies. The brightness of the red color in the LD plots in the lower panels also corresponds to the strength of LD.</p

SNP markers showing significant association in the GWA studies.

<p>SNP markers showing significant association in the GWA studies.</p

Clinical characteristics of the patient populations according to histological classification and the control population enrolled in the study.

<p>Clinical characteristics of the patient populations according to histological classification and the control population enrolled in the study.</p

Manhattan plots of the GWA data.

<p>The <i>p</i>-values for genotyped SNPs from the GWA study for all NAFLD patients (A) and for NASH-HCC patients (B) compared to controls are plotted along each chromosome in −log₁₀ scale. Horizontal line indicates the Bonferroni significance threshold (<i>p</i> = 5.3×10⁻⁷).</p