Lipid Prole in Alcoholic and Non Alcoholic Fatty Liver Patients

Background: Fatty liver disease is a common and major chronic liver disease. It has been implicated that patients have disorders of lipid metabolism and involved in the pathogenesis of fatty liver. Lipid prole plays a very important role in diagnosis of liver diseases hence it was designed to observe relationship between lipid prole and fatty liver disease (FLD) based on ultrasonography (USG). Method and methodology: This Cross-sectional and analytical study was undertaken in the Department of Internal Medicine with collaboration of Department of Radiology and Department of Biochemistry, Universal College of Medical Sciences-Teaching Hospital (UCMS-TH), Bhairahawa, Nepal from March 2019 to February 2020 in total 100 patients diagnosed with FLD by USG. Result: In 100 cases, the male to female ratio was 1.8:1. 56% of the total cases presented with alcoholic fatty liver disease (AFLD) while remaining 44% with non alcoholic fatty liver disease (NAFLD). The spectrum of lipid abnormality was observed with increased total cholesterol (TC), Low Density Lipoprotein (LDL), increased triglycerides (TG) and Very Low Density Lipoprotein (VLDL) in AFLD cases as compared to NAFLD cases. However, it has been observed that TG/HDL and Non-HDL/HDL were higher in NAFLD as compared to AFLD. There was statistical signicant difference in HDL (p-value: 0.019) between alcoholic fatty liver disease grade 1 (AFLG1) and non-alcoholic fatty liver disease grade 1 (NAFLG1). Moreover, it was observed statistical signicant difference in HDL between AFLG2 and NAFLG2 (p-value: 0.012). Conclusion: Phosphate Oxidase- Phenol Antipyrine, HCC:hepatocellular carcinoma, HDL:high density lipoprotein, LDL:low density lipoprotein, NAFLD:non alcoholic fatty liver disease, OD:odd ratio, TC:total cholesterol, TG:triglycerides, USG:Ultrasonography, VLDL:very low density lipoprotein

AFLD and NAFLD have similar pathological spectra, ranging from simple hepatic steatosis to steatohepatitis, liver cirrhosis, and hepatocellular carcinoma. Both ALD and NAFLD are frequently accompanied by extrahepatic complications, including cardiovascular disease and malignancy. The survival of patients with ALD and NAFLD depends on various disease-associated conditions. (6) Elevated LDL or TG or low HDL pattern is associated with NAFLD. (7) So the present study attempted to nd out answers of some issues such as the spectrum of fatty liver disease who had visited tertiary care hospital UCMS-TH, in the south western region of Nepal. Moreover, the association between fatty liver, hemoglobin and albumin with lipid pro le has been observed. Procedure for patients and grading of fatty liver in USG:

Methods
The patients were mostly examined with real-time sonography, after 6-8 hours of fasting period. Mostly supine and right anterior oblique views were obtained. Sagittal, transverse, coronal, and subcostal oblique views were also performed using both a standard abdominal transducer and a higher frequency transducer. In few cases intercostal views were also needed.
Mild (Grade 1)-Minimal diffuse increase in hepatic echogenicity with normal visualization of diaphragm and intrahepatic vessel borders.
Moderate (Grade 2)-Moderate diffuse increase in hepatic echogenicity with slightly impaired visualization of intrahepatic vessels walls and diaphragm. Severe (Grade 3)-Marked increase in echogenicity with poor penetration of posterior segment of right lobe of liver and poor or no visualization of hepatic vessels and diaphragm.
The Patients with other causes of liver disease like viral or alcoholic hepatitis, on drugs therapy or any chemotherapy and patient's age less than 1 year and > 80 years were excluded from this study.
Test Procedure: Serum was separated from the blood sample of the patients diagnosed with fatty liver based on USG and the tests were carried out. In case of delay, the samples were stored in a refrigerator at 4C for 2 days at maximum. Within two days, laboratory investigations were performed. A lipid pro le test was done which included TG by Glycerol Phosphate Oxidase-Phenol Antipyrine (GPO/PAP method), TC and HDL by Cholesterol Oxidase-Phenol Antipyrine (CHOD-PAP), and calculated LDL by Friedwald's equation. The other tests carried out were total protein by Biuret method, Albumin by Bromo Cresol Green (BCG) dye binding method. The biochemical tests were carried out on fully automated analyzer, Human XL-600 (Germany), and hemoglobin was obtained from hematology analyzer 5 parts (Beckman coulter, DxH 520).

Data Analysis:
All the data from cases were fed in Microsoft o ce 2007 (MS Excel) and then analyzed by Statistical Package for Social Service (SPSS) for window version; (SPSS 22, Inc., Chicago, IL). All the data were expressed in terms of percentage frequency, median and compared by non-parametric test viz a viz Chi-Square test, Kruskal Wallis-H test, Man Whitney U test, and Spearman's rho correlation etc. P-value < 0.05 was considered to be statistically signi cant.  Table 1 shows that the median age of the studied subjects was 45 years with interquartile range (IQR) of 20-80 maximum of the patients were between 20-40 years followed by 41-60 years and least were more than 60 years. There was no statistical signi cance in age distribution in FLDG1 and FLDG2 (p-value: 0.8). Male is to female ratio is 1.8:1 with no statistical signi cance (p-value: 0.063).  There was statistical signi cant difference in HDL (p-value: 0.019) between AFLDG1 and NAFLDG1, HDL between AFLDG2 and NAFLDG2 (p-value: 0.012). However, Non-HDL is to HDL ratio and TG is to HDL ratio were increased in NAFLD as compared to AFLD.  Table 4 shows that the association of Lipid pro le was non-signi cant with hemoglobin status and albumin status with TC, HDL, LDL and TG p-value (0.66, 0.62, 0.61 and 0.33) and p-value (0.7, 0.07, 0.83 and 0.5) respectively.

Discussion
AFLD represents a broad range of histological changes ranging from simple steatosis to heavier forms of liver injury, including alcoholic hepatitis (AH), cirrhosis, or the parallel development of hepatocellular carcinoma (HCC). (8) NAFLD is emerging as the most common chronic liver condition in the Western world. It is associated with insulin resistance and frequently occurs with features of the metabolic syndrome.
Paik YH et al included a total of 186 patients in their study, out of that 106 cases were NAFLD and 80 were AFLD. There was no signi cant difference between the NAFLD and ALFD groups (p = 0.635) (9). In our study, we studied a total of 100 patients which included 44 with NAFLD and 56 with AFLD and similar to their study there was no signi cant difference between the NAFLD and AFLD groups (p-value = 0.8).
Mahaling DU et al, in their study out of 70 cases which were diagnosed as NAFLD on USG, NAFLDG1 cases were 47.15%, NAFLDG2 were 42.85% and NAFLDG3 were 10%. The mean age of the patients was found to be 49.14 years. Male to female ratio was 3:4. Serum TG, TC, LDL and VLDL levels were raised in 67.14%, 45.71% 34.28%, 25.71% of cases respectively. Low serum HDL levels were seen in 62.85% of patients. Their study has shown increasing grades of NAFLD were signi cantly associated with increasing values of TC. (4) In our study, NAFLDG3 and AFLDG3 cases were not present. The male to female ratio was 1.8:1. The median age of the patients was found to be 45.90 years which is similar to their study. TC, TG and VLDL and LDL were raised in 29%, 64% and 15% of the cases respectively. Some variables of the lipid pro le showed a signi cant elevation of TG (85%) (p < 0.05) and signi cant raised TC levels (82.5%). (p < 0.01) (10) Similar to their study, Low serum HDL levels were seen in 61% of the cases. The signi cant association was only observed in median HDL level between AFLDG1 and NFLDG1 (p-value: 0.019) and AFLDG2 and NAFLDG2 (p-value: 0.012). Unlike their study, no signi cant association was seen between other lipid pro les except HDL with fatty liver disease.
Pradhan B et al in their study which included a total of 1,500 patients, they found that 447 patients had AFLD. Chronic liver disease (CLD) was detected in 144 patients (9.6%). On multivariate analysis, they found the following variables to be signi cantly associated with CLD: male sex (odds ratio [OR]: 1.81; 95% con dence interval [CI]: 1.12-2.94; P = 0.02) (11). Similar to the study male predominance was found in our study as well.

Conclusion
Constellations of dyslipidemia pattern and frequency of fatty liver disease in alcoholic and nonalcoholic patients may become cumbersome and can be indicated for cardiovascular diseases.