FEATURES OF THE NONALCOHOLIC STEATOHEPATITIS AND CHRONIC KIDNEY DISEASE COURSES , PATHOGENETIC CORRECTION EFFICIENCY

The aim of the study. To establish the mechanisms of mutual burden and progression of non-alcoholic steatohepatitis (NASH) and chronic kidney disease (CKD) in patients with obesity. Material and methods. 114 patients with NASH were examined against the background of І-ІІ degree obesity, including: 52 patients with NASH (group 1) (without accompanying CKD), 62 patients with NASH with a comorbid CKD І-ІІ degree (group 2). The average age of patients was (45.8 ± 3.81) years. The control group consisted of 20 practically healthy persons (PHPs) of the corresponding age and sex. Results. The obtained data testify that under the conditions of the H2S deficit and hyperproduction of homocysteine for the comorbidity of NASH from CKD I-II degree the synthesis and resorption of collagen are activated, but the anabolism processes predominate as a result of the activation of the fibroblasts system, with a significant hyperproduction of acute phase proteins, fibronectin, a higher degree of hyperthyroidism and dyslipidemia with predominance of proatherogenic lipoprotein fractions, and a higher degree of endothelium dysfunction. Conclusions. A significant increase in the synthesis of collagen and glycoproteins (fibronectin) in patients with NASH, which was observed on the background of obesity, was established, which is accompanied by an ineffective resorption of newly formed collagen due to inhibition of collagenolysis against activation of proteinase inhibitors (α2-MG), accompanied by hyperproduction of the fibroblast growth factor, homocysteine, endothelin-1, deficiency in the liberation of hydrogen sulfide and nitrogen monoxide. UDC 616.36-003.826+616.61-036.12]-036.1-07-08


Table 2
The matrix of correlation relations between the content of the extracellular matrix components, proteolysis, collagenolysis and indicators of the functional state of the liver, the lipid profile of the blood, the functional state of the endothelium, and the content of hydrogen sulfide in the blood of patients with non-alcoholic steatohepatitis with CKD (r, p) response to various stimulators, which leads to the destruction of the architecture of the liver parenchyma, with subsequent excessive deposition of the components of the extracellular matrix (ECM), the formation of fibrous tissue, and pathological regeneration with the formation of cirrhosis (the final pathological stage of liver fibrosis) ISSN 1684-7903 https://www.bsmu.edu.ua
The aim of the study.To establish mechanisms of mutual burden and progression of non-alcoholic fatty liver disease and chronic kidney disease in patients with obesity and to increase the efficiency of complex treatment for this polymorbidity.
Material and methods.114 patients with NASH were examined against the background of obesity of І-ІІ degree, including: 52 patients with NASH (group 1) (without accompanying CKD), 62 patients with NASH with a comorbid CKD І-ІІ degree (group 2).The average age of patients was (45.8 ± 3.81) years.The control group consisted of 20 practically healthy persons (PHPs) of the corresponding age and sex.patients with NASH with CKD group 2A (30 patients) received S-adenosylmethionine (600 mg Agepta) by sublingual administration for 90 days.Patients with NASH with a comorbid flow of obesity and CKD of І-ІІ degree group 2B (32 patients), except S-adenosylmethionine (600 mg Agepta, sublingual), received meldonium (500 mg vasonate) enterally for 90 days.The examinations were carried out prior to treatment and on the 90th day of treatment.
The diagnosis of NASH was established in accordance with a unified clinical protocol approved by the Ukranian Ministry Of Health, Order No. 826 dated on November 6, 2014, in the presence of criteria for the exclusion of chronic diffuse liver disease of viral, hereditary, autoimmune or medicinal origin as causes of cytolytic, cholestatic syndromes, as well as the results of the ultrasonography survey.Diagnosis and treatment of CKD were performed according to the recommendations of the clinical guidelines of the State Institute "Institute of Nephrology, NAMS of Ukraine" (2012).Changes in the metabolism of the components of the extracellular matrix were determined by the free oxyproline content in blood (FOP) by S. S. Tetyanets (1985) and protein-bound oxyproline (PBOP) by M. S. Osadchuk (1979), hexosamines (HA) by O. G. Arkhipova (1988), seromucoid (SM), sialic acids (SC) with the help of Danish Ltd (Lviv) kits, ceruloplasmin (CP) by the method of MR.Revina (1976).The content of the matrix metalloproteinase-1 (MMP-1) and the tissue inhibitor MMP-1 (TIMMP-1), the fibroblast growth factor (FGF), was determined by the enzyme-linked immunosorbent assay (ELISA) (DRG System).The content of H2S in blood was determined by the spectrophotometric method [11].The state of proteolytic activity of blood plasma was studied by the total activity of blood serum proteinases -according to M. Kunitz (1975), the intensity of lysis of low molecular weight proteins (azo-albumin), macromolecular proteins (azocasein) and collagen (lysis of azocol) with the help of the Danish Ltd (Lviv) reagents.The state of the proteinase-inhibitor system was studied by the presence of α2-MG blood serum in the blood plasma α1-IP (Danish Ltd, Lviv).The functional state of the endothelium was studied by the content of the metabolites nitrogen monoxide (NO) (nitrites / nitrates), endothelin-1, homocysteine by the ELISA method (AXIS-SHIELD (Norway)) in the blood.
Statistical processing of the results of the research was carried out using parametric and nonparametric methods of variation statistics.The normal distribution was checked using the Shapiro-Uilka test and the method of direct visual evaluation of eigenvalues distribution histograms.Quantitative indices having a normal distribution are represented as mean (M) ± standard deviation (S).In a nonparametric distribution, the data is presented as median (Me) as position, upper (Q75) and lower quartile (Q25) as a measure of scattering.For comparisons of data that had a normal distribution pattern, parametric tests were used to estimate the Student's t-criterion, Fisher's F-criterion.To estimate the degree of dependence between variables, Pearson correlation analysis using parametric distribution and Spearman rank correlation coefficient were used.
Results of the research and their discussion.The analysis of the intensity of fibrous reactions in patients with NASH, depending on the presence of a comorbid CKD, indicates a probable increase in the content of PBOP in the blood of patients in group 1-1.6 times in comparison with PHP (p <0.05), in patients with group 2 -in 2, 0 times (p <0.05).At the same time, the index of blood in the blood of the FOP (table 1), which is the biochemical marker of collagen catabolism, in patients with NASH in group 1 was 1.2 times lower than that in PHP (p <0.05).At the same time, in group 2 patients, the FOP content in the blood exceeded the data in the PHP by 1.4 times (p <0.05), indicating an increase in collagen degradation in the background of its high synthesis.In patients of the group 2, a reliable increase in blood collagenolysis was found, the intensity of which exceeded the index in PHP by 10.7% (p <0.05), in patients of group 1 -collagenolysis was reduced by 13.1% (p <0.05) with the presence of a probable intergroup difference (p <0,05).We determined the probable increase in the content of α2-MG in the blood of patients in group 2 (2.7 versus 2.1 in patients in group 1, p <0.05).
The content of H2S in blood in patients of both groups was reduced: 1.7 times and 3.2 times, respectively (p <0.05) compared to the PHP index.Indicators of the functional state of the endothelium indicate its significant dysfunction: blood NO content was significantly reduced in patients of both groups with a significant deficit in patients of group 2: 2.5 times versus 1.8 times in group 1 (p <0.05), the content of the ET-1 in blood, on the contrary, exceeded the index in PHP by 2.2 and 2.5 times, respectively (p <0.05), indicating a significant predominance of vasoconstrictors and a deficiency of the endothelie releasing factor and contributing to hypoxia, ischemia of the liver and kidney parenchyma, and are additional factors of damage due to oxygen and energy starvation [5,7,8,11].The content of homocysteine in the blood increased significantly in patients of both groups, respec- tively, in 3,1 and 6,4 times (p <0,05), that in patients of group 2 in strong interdependence (r =0,65-0,85, p <0,05)) correlated with the parameters of hyperlipidemia: TCH, TG, CH LDL, AI (p <0.05) and endothelial dysfunction: NO (r = -0.74,p <0.05), ET-1 (r = 0.63, p <0.05), as well as with H2S content (r = -0.79,p <0.05).
The interdependence of the above mentioned changes in homeostasis indices of the components of the connective tissue extracellular matrix and the content of H2S in blood confirms the existence of established correlation relationships (table 2).The obtained data indicate that in patients with NASH, which arose on the background of obesity, a significant increase in the synthesis of collagen and glycoproteins was observed in the comorbidity with CKD, which was accompanied by an ineffective resorption of newly formed collagen due to insufficient activation of collagenolysis and proteolysis, a significant imbalance in the metabolism system of the connective tissue, which leads to progressive fibrosis of the liver and kidneys and the violation of their functions.This contributed to the violation of homeostasis H2S, confirming the data of the correlation analysis (table 2).Under the conditions of the deficit of H2S and hyperproduction of homocysteine for the comorbidity of NASH with CKD I-II degree, the synthesis and resorption of collagen are activated, but the anabolism processes are dominated by the activation of the fibroblast system, hyperproduction of the FGF, with a significant hyperproduction of the acute phase proteins, fibronectin, GA, and an increased degradation of extracellular matrix fucoglycoproteins, a higher degree of hyperthyroidism and dyslipidemia with a predominance of proatherogenic fractions of lipoproteins, an increase in AI p <0.05), the highest degree of endothelium dysfunction (NO deficiency and ET-1 deficiency (p <0.05)).The protective role of H2S in the progression of fatty liver disease is due to its antioxidant, antiapoptotic, anti-inflammatory, vasodilatory and antihypoxant effects, the ability to stimulate angiogenesis, reduce the content of proatherrogenic lipoproteins in the bloodstream and inhibit the activity of fibroblasts [2,8].
All of the above factors are likely risk factors and direct links in the pathogenesis of the progression of NASH and the CKD [2][3][4][5][6][7], which need to be influenced by adequate medication support [2].
The administration of the drug ademetionin in the complex therapy showed the effect presence of this drug on a significant correction of the revealed disorders of H2S homeostasis and components of extracellular matrix (table 3).Thus, the average index of fibrotest in patients with NASH in group 2A after treatment decreased by 1.6 times (p <0.05), in the group 2B -2.3 times (p <0.05).
The content of fibronectin in the blood decreased - Another factor that has recently been recognized as a regulator of connective tissue metabolism, which is actively opposed to organ fibrosis by the inflammatory process, is the H2S molecule [10].Under the influence of treatment with ademetionin in patients with NASH and CKD, we found a significant increase in H2S content in the blood compared with the indicator before treatment: in group 2A -2.7 times (p <0.05).In patients in group 2B, the growth was 3.1 with a normalization of the index (p <0.05), indicating a higher efficiency of the ademetionin complex with meltedon for restoring the regulatory role of H2S with the inhibition of fibrotic processes.
It is known that vasoconstriction and hypoxia are the leading factors in fibrogenesis, so it is possible that reduced NO production promotes fibrosis in the liver and kidney tissue.The use of the complex of ademetionin and meltedonium contributed to a possible restoration of the synthesis and liberation of the endothelial cells of the endothelium with the elimination of the manifestations of endothelial dysfunction: an increase of 2.4 times with the normalization of the index -compared with 1.3 times in the treatment with ademetionin alone (p <0.05).
It is known that the deficiency of H2S in a strong interdependence correlates with the excess of homocysteine, which acts vasoconstrictor effect due to the blocking of acetylcholine-dependent vessel relaxation, inhibiting the transport of arginine and inhibiting NO synthesis [6,8].Pathogenetic explanation for the data obtained may be provided by the results of a study of the homocysteine content in the blood in the dynamics of treatment with ademetioninum and meltedonium (2B) compared with baseline treatment in combination with ademetionum (2A).According to the data obtained, the increase in the content of homocysteine in the treatment of patients in the group 2A decreased to 2.3 times, and in patients in group 2B -3.9 times (p <0.05) (Table 3).At the same time, the index of ET-1 in the blood in group 2A patients after treatment decreased by 1.3 times, and in patients in group 2B -by 2.1 times (p <0.05) with normalization of the indicator (p> 0, 05) and the difference with the indicator after treatment in group 2A (p <0,05).
In our opinion, the proposed complex therapy with the inclusion of antioxidant, antihypoxant, detoxification, membrane stabilizing, active metabolic and energotonic action [2] contributed to the stabilization of the extracellular components of liver, the normalization of the collagenolysis activity and the restoration of the collagen homeostasis balance in the body of patients with obesity and CKD.Conclusions 1.In patients with NASH, which arose on the background of obesity, a significant increase in the synthesis of collagen and glycoproteins (fibronectin) was observed, which was accompanied by an ineffective resorption of newly formed collagen due to inhibition of collagenolysis (CLA) on the background of activation of proteinase inhibitors (α2-MG), accompanied by hyperproduction fibroblast growth factor, homocysteine, endothelin-1, deficiency in the liberation of hydrogen sulfide and nitrogen monoxide.Under the conditions of the comorbidity of NASH with CKD of the 1st and 2nd degrees, both collagen synthesis and resorption are activated, but the processes of anabolism prevail in spite of the compensatory activation of collagenolysis, with a significant hyperproduction of actinic-phase proteins, fibronectin, glycosaminoglycans, fibroblast growth factor and increased degradation of the extracellular matrix fucoglycoproteins and lead to progressive fibrosis of the liver and disturbance of its functions.The indicated dismetabolic manifestations of the comorbidity of NASH with CKD in a higher degree of interdependence correlate with manifestations of endothelial dysfunction (deficiency NO, hyperproduction of ET-1, homocysteine), dyslipidemia, and factors of regulation of fibrogenesis (hyperproduction of FGF and H2S deficiency).
2.Treatment using ademetionina in combination with meldonium for 3 months helped to balance the homeostasis of liver extracellular matrix components by stabilizing the membranes of hepatocytes, inhibition of the inhibitors of collagenolysis and proteolysis activity, reduce degradation of fucoglycoproteins, secretion of fibroblast growth factor and homocysteine restoring pool of hydrogen sulfide and monoxide nitrogen, which contributed a significant decrease in the index of liver fibrosis and warned the progression of comorbid diseases.