Vitamin E and changes in serum alanine aminotransferase levels in patients with non-alcoholic steatohepatitis

Abstract

Background: Non-alcoholic steatohepatitis (NASH) is a common cause of serum alanine aminotransferase (ALT) elevations and chronic liver disease, but it is unclear how well ALT elevations reflect the liver injury.

Aim: To assess how well changes in ALT elevations reflect improvements in liver histology in response to vitamin E therapy.

Methods: The vitamin E and placebo arms of the Pioglitazone vs. Vitamin E vs. Placebo in Non-alcoholic Steatohepatitis (PIVENS) trial were reassessed for associations among changes in ALT levels, body weight and liver histology. An ALT response was defined as a decrease to ≤40 U/L and by ≥30% of baseline. Liver biopsies taken before and after treatment were scored for non-alcoholic fatty liver disease activity (NAS) and fibrosis.

Results: ALT responses were more frequent among vitamin E (48%) than placebo (16%) recipients (P < 0.001). Among vitamin E recipients, ALT responses were associated with decreases in NAS (P < 0.001), but not fibrosis scores (P = 0.34), whereas among placebo recipients, ALT responses were associated with significant decreases in both (P < 0.05). Weight loss (≥2 kg) was also associated with ALT response (P < 0.001), improvements in NAS (P < 0.001) and fibrosis (P < 0.02), but vitamin E had an added effect both with and without weight loss. Weight gain (≥2 kg) was associated with lack of ALT response and worsening NAS and fibrosis scores in patients not on vitamin E.

Conclusions: Decrease of ALT levels to normal in patients with NASH is usually associated with improved histological activity. Management should stress the value of weight loss and strongly discourage weight gain. Vitamin E can improve both ALT levels and histology with and without weight loss.

Clinical trial number: NCT00063622.

Figure 1

Mean changes in ALT levels from baseline by weeks after randomisation are shown separately for the placebo (n = 68) and vitamin E (n = 71) subjects in this reanalysis of the PIVENS trial.

Figure 2

Change in NAS and fibrosis scores between baseline and week 96 in patients receiving vitamin E or placebo by pattern of ALT response. (a) change in NAS scores. (b) changes in fibrosis scores. Patterns of ALT response are categorised into four groups: as early and sustained, a late response only, an early response only [breakthrough] and nonresponse. Each dot represents an individual patient; dots are plotted slightly above or below the line for clarity using 1% jittering; the line segments connect the means for each group.

Figure 3

Change in individual NAS and fibrosis scores between baseline and week 96 in patients receiving vitamin E or placebo by amount of weight change during therapy (a) changes in NAS. (b) changes in fibrosis scores. Each dot represents an individual patient; dots are plotted slightly above or below the line for clarity using 1% jittering; the locally weighted scatterplot smoothing (lowess) curves are present for each group.