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Polikarpova Nataliya Vladimirovna,
assistant,
Valieva Tamila Abdulazizovna, assistant, Kaleda Svetlana Petrovna, assistant, Tashkent Pediatric Medical Institute Department of GP - therapy, clinical pharmacology E-mail: [email protected]
NON-ALCOHOLIC FATTY LIVER DISEASE - SOME ASPECTS OF PREVENTION
Abstract: Non-alcoholic fatty liver disease (NAFLD) is a nosological unit that has become known in the medical community relatively recently. The first mentions of it in the specialized literature appeared in 1980, when H. Ludwig et al. the term "nonalcoholic steatohepatitis" (NASH) was first introduced (Podymova S. D., La Brecque et al., 2014). Up to 80% of obese and up to 20% normal-weight people might develop it. It is estimated that 24% of the worldwide population is affected in 2017. NAFLD is the leading cause of chronic liver disease as of 2017.
Keywords: NAFLD, NASH, NAFLD treatment, liver disease.
Currently, NAFLD is considered as one of the leading Treatment of NAFLD includes a gradual reduction in
causes of chronic liver disease in the world. This is probably body weight, a balanced diet therapy with restriction of fats
due to the fact that a patient with NAFLD often had more serious diseases - type 2 diabetes mellitus (DM-2), metabolic syndrome, etc. For a long time, hepatosteasis was not given much importance, despite the fact that doctors knew about it. It has been established that insulin resistance underlies these metabolic diseases, and their compensation does not eliminate NAFLD. Moreover, NAFLD worsens the course of the underlying disease. Therefore, interest in its study has grown substantially. A large amount of heterogeneous data has already been accumulated concerning both the theoretical basis of the NAFLD pathogenesis, as well as important clinical features of the disease course, diagnosis and treatment (Volkova N. I., Porksheyan M. I., 2017).
Clinical manifestations: visceral obesity, signs of impaired glucose metabolism, dyslipidemia, and arterial hypertension. Rarely: fatigue, aching pain or discomfort in the right hypo-chondrium. If NAFLD leads to the liver cirrhosis, symptoms of liver failure and/or portal hypertension appear: an increase of the abdomen size, edema, hemorrhagic syndrome, encephalopathy (McCullough A.J. [8]). Diagnosis of NAFLD often reveals obesity in patients.
There are no standard approaches to the treatment of NAFLD. Since NAFLD is often combined with obesity, type 2 diabetes and hyperlipidemia, it is necessary to correct these conditions, and therefore treat the metabolic syndrome (La-zebnik L. B., Zvenigorodskaya L. A., 2009). Modern guidelines on the effects on the components of metabolic syndrome emphasize that lifestyle changes are the main way to correct metabolic risk factors.
and carbohydrates, as well as physical exertion (Polunina T.E. [5]). The development of steatosis and steatohepatitis is a multimodal process, so today several treatment regimens are being investigated at once, such as the treatment with thia-zolidinediones (TZD). It is proved that the use of vitamin E at a dose of 400 mg per day can improve liver histology. The possibility pioglitazone treating of NASH patients is being considered. Currently, the properties of a new potentially highly effective drug GFT505, a double agonist of PPAR a and 5 receptors, are being studied (T. E. Polunina [5]). Ome-ga-3 polyunsaturated fatty acids are the first drugs for treating elevated triglycerides in NASH patients, but it's too early to consider them as the drugs of choice for NAFLD/NASH treating. Statins are recommended to be prescribed to correct dyslipidemia in NAFLD/NASH patients, however, data from clinical studies on the effect of statins on NAFLD are not obtained. S-adenosylmethionine is formed from methionine in the process ofATP-dependent reaction catalyzed by methi-onine-adenosyltransferase, and participates in the process of transmethylation in the body. S-adenosylmethionine is usually used in a dose of400 mg 2 times a day (Kalhan S. C., Ed-mison J., Marczewski S., et al., 2011). The antioxidant effect of S-adenosylmethionine is taken into account in the treatment of NAFLD; however, there is currently no convincing evidence of its positive effect on the biochemical and histological picture of NASH (Ivashkin V. T., [4] Prof., Ed.). The effectiveness of ursodeoxycholic acid in the NAFLD treatment, NASH in particular, has been proven. At a dose of 15-30 mg per kg of body weight daily for 24-48 weeks, ursodeoxycholic acid
NON-ALCOHOLIC FATTY LIVER DISEASE - SOME ASPECTS OF PREVENTION
has been proven to decrease serum transaminase activity (Zun Xiang, Yi-peng Chen, Rui-fen Ma., Et al. [9]). However, there is no convincing evidence of its positive effect on necroinflam-matory changes and liver fibrosis, as well as on the long-term prognosis of NAFLD patients (Ivashkin V. T., [4] Prof., Ed.). Essential phospholipids have antioxidant, anti-inflammatory effects and restore the integrity of cell membranes. The use of phospholipids for NAFLD treatment reduces liver steatosis (according to ultrasound) and the level of serum transami-nases. Depending on the ratio of linoleic and linolenic acids, essential phospholipids may have additional properties (for example, lipid-lowering) (Vyushnova E.S., Mayev I.V, Babina S.M., 2010; Myazin R.G., [6]). Convincing data on the long-term positive effect of essential phospholipids on the course of NASH are also not yet obtained at the moment (Ivashkin V T., [4] Prof., Ed.).
Treatment regimens for NAFLD patients are based on pathogenesis, therefore the most important tasks for this category of patients are:
1. Metabolic disorders correction:
• weight loss (diet and physical activity);
• increased sensitivity of cellular receptors to insulin (metformin, thiazolidinediones);
• decrease in triglycerides level (fibrates, statins);
• a decrease in the concentration of TNFa (pentoxi-fylline);
• antihypertensive therapy (angiotensin II receptor
antagonists);
2. Oxidative stress treatment:
• antioxidants and hepatoprotectors (vitamin E, silib-inin, betaine, N-acetylcysteine, ursodeoxycholic acid, a-lipoic acid);
3. Intestinal microbiocenosis restoration (eubiotics, pro-biotics, prebiotics).
Diet. A diet for obese patients implies a decrease in the overall energy value of the diet. Daily caloric content is selected individually depending on body weight, age, sex, level of physical activity using special formulas.
It has been proven that weight loss of 5-10% is accompanied by a decrease in hepatosplenomegaly, ALT, AST activity and correlates with regression of hepatic steatosis (Feldstein A. E., et al, 2006). It should be noted that rapid weight loss can lead to the development of "acute" NASH with the formation of portal fibrosis, central necrosis on the background of a significant increase in inflammatory activity due to an increase in FFA in the liver against the
peripheral lipolysis background (Hamaguchi M., Koima T., Takeda N., et al, 2005). For obese and NAFLD patients, weight loss is effective: 500 g per week for children and 1600 g per week for adults (Ratziu V., Goodman Z., Sanyal A., [3]).
In addition, all patients with NAFLD recommended:
• limiting fat intake to 25-30% of the total energy value of food; the ratio of polyunsaturated and saturated fatty acids (FA) in food is more than 1;
• reducing consumption of foods high in cholesterol (no more than 300 mg per day) - excluding byproducts (liver, kidney), caviar, egg yolk, smoked sausages, fatty meats and dairy products;
• exclusion of products prepared as a result of food processing such as frying, deep-frying, etc.;
• enrichment of food with vitamins and natural pre-biotics;
• for patients with IGT and type 2 diabetes, a diet with the exception of simple and restriction of complex carbohydrates is relevant, which contributes to achieving metabolic control.
Physical activity. A prerequisite for the treatment of NAFLD patients is physical activity. It has a positive effect on weight loss and insulin sensitivity, and this increases the flow of FFA into muscle tissue, where it oxidizes, thereby reducing insulin resistance. The degree of insulin resistance reduction, as a rule, correlates with the intensity of physical exercises, which are recommended to be carried out at least 3-4 times a week, lasting 30-40 minutes.
The work of recent years proved the fundamental possibility of drinking mineral waters to influence the course of metabolic processes in lipid and carbohydrate metabolism violation in patients of different nosological groups, including those with NAFLD associated metabolic syndrome. The possibility of differentiated use of mineral waters and an aqueous solution of bischofite depending on the stage of the disease, the severity of metabolic disorders, concomitant diseases, such as digestive pathology, type 2 diabetes and hypertension, has been demonstrated.
I. B. Zabolotnaya agrees with the opinion of V K. Frolko-va et al. on the prospects of further studies of natural factors, in particular mineral waters, with a different way of realizing their biological potential for developing indications for use in the treatment and prevention of the NAFLD pathogenesis.
Preventive measures include nutrition, daily physical activity, the exclusion of unjustified use of drugs.
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