Hello, everyone. My name is Manal Abdel-Malik, and I have the absolute pleasure of giving this Nafl debrief. I'm a professor of medicine and director of our non-alcoholic fatty liver disease clinical research program here in the Division of Gastroenterology at Duke University. My interests are in the risk factors of Nafl acquisition and progression, diagnostic and prognostic biomarkers, the translation of bench-to-clinic, and heavily invested in the clinical trials landscape of NASH. I come to you tonight live or wherever you may be around the world, so any bleeps or bloopers are completely my own. This is not pre-recorded. Here are my disclosures. As I was reflecting on the 2021 AASLD, I sat back and felt like I was looking upon the stars, especially as it related to covering a topic like the Nafl debrief. And in reflecting on the past year and a half to two years of everything the field of medicine as well as the field of liver disease has seen, nothing stood stronger in my mind as the brightness of the human spirit and what all of you should be incredibly proud of, of having brought to this year's AASLD. And in reviewing this year's coverage on Nafl, we had an entire postgraduate course, which managed the epidemic of Nafl and alcohol liver disease, the Hans Popper lecture on single cell genomics and approaches to decoding human liver disease, not to mention the number of SIGs that were conducted, not only the Nafl SIG, but the fibrosis SIG on multidisciplinary perspectives on developing new therapeutics for NASH fibrosis, the multiple parallel sessions on diagnostics and biomarkers and therapeutics and predicting outcomes. Many Meet the Professor sessions, 23 late breaker abstracts, 36 oral abstracts, 44 posters of distinction and almost 475 posters that were presented strictly on Nafl and NASH. And so we are all kind of in the gutter and I use that to condone the COVID-19 pandemic because I'm very sorry we couldn't be together in person this year, but some of us have been looking at the stars and the work that was presented this year really reflects that. I was incredibly challenged in, as a good friend said, tackling this colossal task of giving the Nafl debrief. And I must say, it's all started with me putting up my hands with a volume of abstracts and turning to my 13-year-old daughter and my 15-year-old son, Jeremy, and saying, have at it. I want you to highlight every abstract in the abstract book that has the word Nafl to NASH. So they bypassed their vocabulary lessons and got completely immersed in medical terminology in an earnest effort to help their mom out. I talked with many of my colleagues about what was the best of Nafl at this year's symposium. And I went to it. Here you see on the right, Dr. Yolanda Karakalou, who is my clinical research postdoc. And over the past week and a half, two weeks, as the abstracts were feeding in, we went at it separately. We had many email exchanges. I reached out to many of you who were so graceful to share your presentations, talk to me about your science. And it was an absolute privilege to collaborate with all of you in putting this talk together. So to start off, the NASH landscape in one picture, many of you have seen the slide. It is enriched with many, many compounds that are currently in various phases of clinical research from phase one all the way to late phase clinical trials, many of the metabolic space, some in the anti-inflammatory and anti-fibrotic space. And I give this slide as a depiction of the very robust landscape of data with regards to new therapeutics that are emerging. And while this is not complete, it does cover the highlights as to what was presented at this year's meeting with the Alpine 2-3 study, readouts from the FALCON 1 and 2 trial, the TANDEM trial, and many other phase 2a and early phase 2b data, not to mention the volume of work that was ancillary analyses from ongoing studies, baseline data, or data that pertain to non-invasive endpoints. And in reflecting on what to present, I was really quite torn. And I decided, rightfully or wrongfully, that I needed to give due diligence to those studies that have been ongoing for the past two to two and a half years, for which the most patients were invested, for which sample size were optimal, for which the clinical outcomes are robust, and for which the outcome of the clinical trial that was conducted has significant bearing on the further development of those compounds. And so with that being said, I'd like to lead in with the presentation that was rendered by Dr. Stephen Harrison as a oral abstract on the top line results of the Alpine 2 study. This was a randomized, double-blind, placebo-controlled, multi-center, phase 2b trial of three doses of FGF19. It's an analog called aldefermin on liver histology in patients with biopsy-proven NASH with fibrosis stage 2 to 3. And the overall objective of the study was to evaluate FGF19 analog on liver histology. There were 171 patients who were randomized in a 1 to 1 to 1 to 1 ratio to receive placebo versus aldefermin at a dose of 0.3 milligrams, 1 milligram, or 3 milligrams. And the key inclusion criteria for this trial was biopsy-proven NASH with a NASH score of greater than 4 and the presence of stage 2 or 3 fibrosis with an absolute liver fat content on MRI PDFF of at least equal to or greater than 8%. The primary endpoint for the study was a dose response in fibrosis improvement of at least one fibrosis stage by the NASH CRN criteria with no worsening of fibrosis. And as you can see here, aldefermin did not demonstrate a dose-dependent response in fibrosis improvement without worsening of NASH. There was a signal toward resolution of NASH without worsening of fibrosis, and this was significant particularly at the 3 milligram dosing arm. And there was evidence of fibrosis improvement by at least one point stage and resolution of NASH also at the 3 milligram treatment arm. An improvement in the NASH score by two points without worsening of fibrosis was noted. However, the study did fail to reach its primary endpoint of fibrosis improvement. It was safe and well-tolerated, and to our surprise, however, and potentially our disappointment, there was a very robust dose-dependent reduction, not only in fat contents, but in the non-invasive markers of liver injury, including AST, ALT, and the fibrosis markers of Pro-C3 and ALF. And one can ask, well, why did this study potentially not meet its primary endpoint? Well, more importantly, it was not due to the absence of target engagement because dose-dependent responses in C4 and bile acids were noted, but aldefermin will not be proceeding further in clinical development for non-cirrhotic NASH. It is, however, still enrolling its Alpine 4 study for cirrhosis. Now, what about pegbelfermin in patients with NASH and stage 3 fibrosis? These are readouts from the FALCON1 trial. The objective of this study was to evaluate the efficacy and safety of pegbelfermin, which is a pegylated FGF21 analog in patients with NASH and stage 3 or bridging hepatic fibrosis. Here you can see the study design on the right upper hand side of your graph of the slide. The study was a 48-week trial, but a liver biopsy was done at 24 weeks, and patients were randomized equally across the treatment arms of placebo, 10, 20, or 40 milligrams subcutaneously once weekly of pegbelfermin. This was a phase 2b study performed here in the United States and in Japan that enrolled 197 patients with biopsy-proven NASH and stage 3 fibrosis, and the primary endpoint of the study was at least one point improvement in fibrosis without worsening of NASH. And as you can see here in the graphs, the primary endpoint of one point improvement in fibrosis without worsening of NASH or NASH improvement without worsening of fibrosis was not met. In fact, there was no evidence of a dose-dependent response to pegbelfermin. However, there was at least a 30% relative reduction in quantitative liver fat measured by MR-PDFF that was notable in the highest dose of pegbelfermin, and actually in each of the doses compared to placebo, and this was noted both at 24 weeks and at 48 weeks. And the 15% relative reduction in liver stiffness was also noted at the highest dose of pegbelfermin compared to placebo, both at 24 and at 48 weeks. Pegbelfermin was generally safe and well-tolerated. The primary outcome of fibrosis improvement was not met, and again, this program will not be proceeding forward for further development in NASH. There was numerically higher rates of fibrosis improvement without NASH worsening or NASH improvement without fibrosis worsening at 24 weeks compared to placebo, and pegbelfermin did improve the non-invasive measures of steatosis by MR-PDFF, liver biochemistry, as well as liver stiffness. And just as a correlate to this, there was a poster presented as well on the FALCON2 study, the sister study of the FALCON1 study, and this study specifically was for patients with NASH and well-compensated cirrhosis. Again, a very comparable study design. However, the primary endpoint of liver biopsy was done at 48 weeks. Patients were randomized equally across the treatment arms of placebo, 10, 20, or 40 milligrams of pegbelfermin. Again, comparable sites in the U.S. and in Japan, and the primary endpoint being at least a one-point improvement in fibrosis. And as we saw with the FALCON1 study, again, there was, excuse me, safety, and it was well-tolerated. Primary endpoint was not met, although there was suggestions of improvement in steatosis, inflammation, and fibrosis by non-invasive markers, but certainly the primary endpoint was not met based on the histologic endpoint. The last study I'd like to highlight for you is, and in fact, one of the first, maybe the first study evaluating combination therapy for the treatment of NASH, specifically the safety and efficacy of tropifexar plus senacriviroc in adult patients with fibrotic NASH. This was a 48-week study readout, and the primary objective of this trial, when designed, was really an assessment of safety and potential efficacy. 200 patients were randomized in a one-to-one-to-one-to-one to receive tropifexar by itself, 50 patients, senacriviroc at a dose of 150 milligrams, or the combination of tropifexar with senacriviroc, either at the higher dose of tropifexar, 140 milligrams, or 90 milligrams. For 48 weeks, the inclusion criteria was biopsy-proven NASH, with a NASH score of at least 4, and stage 2 and 3 fibrosis, as I mentioned, the primary endpoint was safety and tolerability, and the secondary endpoint was at least a one-point fibrosis improvement or NASH resolution. There were no baseline differences across the treatment groups, but the study ran alongside the COVID pandemic, and because of that, needed to be extended for 4 weeks in 25 patients and up to 8 weeks in 12 patients across the treatment arms. And on the right-hand panel here, you can see the lack of steatohepatitis resolution, readings of liver biopsy, excuse me, and as well as fibrosis, the lack of fibrosis improvement by greater than or equal to one point, and so again, the combination of tropifexar, Senator Sivaroff was safe and well-tolerated. Paritis was a common treatment emerging adverse event and failed to reach its primary endpoint. Now, what about the current treatment of NAFLD and NASH? You know, we've come to recognize that we have a lot of patients, and as clinicians, we are left challenged with what to do for our patients, what lifestyle interventions to request, and which therapies that we can potentially repurpose in our standard of care. So when medical treatment fails, we currently refer for bariatric surgery or consider for clinical trials, but there was a very interesting study evaluating the intensive lifestyle management and its effect on improving steatosis and fibrosis in children with metabolic-associated fatty liver disease. The aim of the study was to assess the effect of weight loss on the severity of children, obese children and adolescents. There were 167 patients admitted with severe obesity and NAFLD assessed by ultrasound or VCTE at the Zephyr Vennium who were enrolled between July 2019 and January 2021. They had measures at baseline, 6 and 12 months. There was a correlation between ultrasound and the CAP score, and there was marked improvement in the AST and ALT at 6 and 12 months, irrespective of whether patients had an assessment of mild hepatic fibrosis or more advanced hepatic fibrosis. And as you can see here, the effective weight loss markedly improved the severity of hepatic steatosis by ultrasound, as well as capture attenuation parameter. And more interestingly, fibrosis severity is measured by transient elastography, markedly decreased from baseline to 12 months. And if you look at those patients that had at least significant hepatic fibrosis stage two or higher, again, complete resolution of fibrosis, and even those that had more advanced hepatic fibrosis, a significant downgrading of fibrosis severity in 12-month interval. So this speaks to the fact that we must integrate lifestyle interventions into our clinical practice. But sometimes I'm at a loss as to what type of diet to recommend. And Dr. Martin presented a beautiful oral presentation on the low hypocaloric Mediterranean diet versus a standard diet in patients with biopsy-proven NAFLD. The primary aim was to evaluate the effect of these two short-term dietary interventions. And as you could see here, patients were randomized. This is a multicenter trial, three months of dietary intervention, 66 obese patients with a VMI of greater than 30 kilograms per meter squared, with or without diabetic control in the past six months prior to inclusion. And they had NAFLD biopsy proven no later than six months prior to inclusion. They were randomized. And as you could see here, the liver steatosis, they were pretty balanced at baseline for their baseline characteristics, but both the low-fat diet as well as the Mediterranean diet decreased liver stiffness. It also comparably decreased hepatic steatosis biomarkers as well as the hepatic steatosis index, also comparably resolved NASH and comparably regressed fibrosis. So weight loss improves the surrogate biomarkers of NAFLD and NASH with no difference between the Mediterranean diet and the low-fat diet on NASH resolution or the metabolic features such as cholesterol or apri score. And so the bottom line is we really need to strive to achieve weight loss with higher magnitudes of weight loss rendering improvement on NASH and fibrosis. Another study by Dr. Ranini really evaluated the treatment of statins and its association on preservation of liver function in advanced chronic liver disease. And this was the results of the SHUNT-V study. And the aim of this study was to evaluate the impact of NASH, diabetes and drug therapy on hepatic function and portosystemic shunting in subjects with chronic liver disease who are enrolled into the SHUNT-V study. And the subjects that were enrolled had compensated cirrhosis or F3 fibrosis with a lower platelet count at a threshold of 175 or child's B cirrhosis who were without refractory ascites, hepatic encephalopathy or bleeding. And this study was done using the HEPQANT test which is a 90 minute colate clearance test. They get a dual colate clearance, both IV and oral and can measure the disease severity index which is a surrogate for hepatic function as well as shunting in these curves. And a lower shunt denotes lower portosystemic shunting. And interestingly, the patients with NASH have lower disease severity indexes compared to those that didn't have NASH and have less shunting compared to non-NASH patients. When they drilled down a little bit more into the cohort and compared diabetics to non-diabetics, the diabetics had lower disease severity indexes and lower shunting scores. Now this seems contra-intuitive because patients with diabetes are typically at higher risk for fibrosis progression but then they evaluated the drugs and the medications that patients with diabetes are typically on. And interestingly, statins and metformin not only decreased, had an impact on hepatic shunting but on the disease severity index and the combination effect of statins and metformin what demonstrated a 20% less portal systemic shunting and a 20% better function based on the lower disease severity index. And they concluded that the use of statins plus metformin was independently associated with preserved hepatic function and reduced shunting. So this underscores our need to really consider optimizing the use of available therapies for our patients because according to this study, we can make potential effects both not only on function but on portal hypertension. We also saw at this meeting some data about the genetic contributions to NAFLD and disease prognostication. And we know that genetics clearly plays a role in not only the acquisition of NAFLD and NASH but also disease progression and its associated outcomes. And one of the studies that was presented by Dr. Chen and Dr. Anna May's deals lab really was aimed to define the effects of hedgehog signaling disruption in adult hepatocytes and to determine the relevance of hedgehog in preclinical models, but apply that to human NAFLD. And they deconvoluted bulk RNA sequencing data both in the animals as well as from 294 liver biopsies of patients with non-alcoholic, biopsy-proven non-alcoholic fatty liver disease and 68 controls using single cell RNA sequencing. These mice were identified as non-alcoholic either controls or given something to knock down smoothen their single cell signature, RNA signature was noted. And the signature in the mice by depleting or deleting smoothen in hepatocytes typically causes hepatic accumulation of triglycerides and cholesterol and induces a metabolically stressed phenotype with systemic insulin resistance in as short as a week. And by applying this signature from these animals and RNA-seq to patients with human NAFLD and NASH, they demonstrated that the smoothen signature was also depleted in human NAFLD in an incremental manner across the spectrum of disease compared to control subjects. So in humans, the high smoothen activity hepatocyte signature was significantly depleted in NAFLD cohorts. And this suggests that the low hedgehog activity does also accumulate in patients with NAFLD and NASH and can really inform both diagnostics and therapeutics. We saw also a GWAS study on chronic ALT based from the Million Veterans Program with histologic and radiologic validation. And this study really expanded our insights on NAFLD genetics using non-invasive phenotypes with patients who have chronic elevation of ALT. And this was a trans ancestry and ancestry-specific GWAS analysis. You could see over 90,000 cases with chronic ALT elevation, 128,000 controls with normal ALT. They used an external validation cohort of patients with biopsy-proven NAFLD and NASH. And what they shared with us was a 77 trans ancestry SNP that was associated with C-ALT and genome-wide significance. Many of the SNPs we are already familiar with such as PNPLA3 and TMS6SF2, but they also demonstrated that many of the SNPs are pleiotrophic with metabolic and inflammatory traits in the triangulation approach based on chronic elevation of ALT with histologic and radiologic validation really can expand our understanding about genetic susceptibility for NAFLD and NASH and maybe help us with new therapeutics. Certainly part outcomes achieved by histology are fraught with challenges. They're fraught with sampling variability. They're fraught with intra-observer variability. They're fraught with the categorical and ordinal scale by which we use to interpret it. And what we did see at this meeting is it's brought us one step closer to the utilization of non-invasive markers to really predict an outcome independent potentially of histology such that we can achieve field function and survive metrics that are so important for FDA drug approval. One of those studies was presented by Dr. Tamika, which is a longitudinal association of MRE and liver-related outcomes as well as cardiovascular outcomes. They utilized a retrospective cohort of 248 patients who underwent MRE and standard of care and followed them out. And what they demonstrated is that serial increases, serial increases in MRE by as little as one kilopascal can be associated with a increased odds, 37% increased odds of hepatocellular carcinoma as well as hepatic decompensation. And that HCC and decompensation risks increases as MRE increases. And this also correlated with cardiovascular risk that peaked at five to 5.5 kilopascals but gradually dropped as liver disease severity increased. We also saw a very nice oral abstract from the group at UCSD that also demonstrated that liver stiffness on MRE is associated with liver-related outcomes. And they utilized 453 patients for a follow-up with follow-up on 97 patients. They looked at MRE alone and MR with FIT4 in combination, both unadjusted and adjusted for age and sex and demonstrated an increased odds, significantly increased odds of MRE being able to predict particularly at thresholds above 3.63 and particularly above five kilopascals liver-related outcomes over what can be done with FIT4 and afl-fibrosis-4 potentially MALT-score. The three-year risk of a composite outcome increased as liver stiffness increased by MRE. And when the negative MFIB index had a 98% negative predictive value for liver-related outcomes or deaths. So this was significant. And finally, we saw data from the NIMBL consortia which was a comparative assessment of performance of five blood-based biomarkers with the intention of looking at Yodan cutoffs using the U.S. multicenter NASH CRN data. They hypothesized that the AROC curve of greater than 0.7 and superior to the unit line and that these markers could perform more superiorly and that it would be superior to ALT in the diagnosis of NASH. The tests were run using different aliquots. The aliquots were within 90 days of a liver biopsy with good custody of the samples and the data. The multiple biomarkers met the criteria for success in the diagnosis of NASH, high NASH, NASH with significant or advanced hepatic fibrosis as well as the diagnosis of the at-risk patient with NASH. And here you can see on the right-hand panel the performance of these biomarkers. And so this data from the stage one NIMBL consortia provided robust sensitivity and specificity metrics that will subsequently inform stage two of the NIMBL consortia such that we could potentially have strong biomarkers to be assessed in prospective longitudinal studies. I'll end this year's NAFL debrief on a comment because we can't finish 2021 with some comment about disparities. There were two abstracts of distinction, one from Dr. Mechelberg on the impact of race on NAFL outcomes in the U.S. clinical practice. This abstract explored the impact of race on outcomes of NAFL utilized a proprietary national EMR database from academic hospital and community-based centers of 30 million individuals with an ICD diagnosis of NAFL NASH where the at-risk cohort of patients older age, older than 50, elevated ALT or diabetes. There were 81,000 patients who met the inclusion criteria of NAFL or NASH and they followed them for a little over 34 months. And interestingly here, you could see that African-Americans were protected from NAFL. Yeah, they were at increased risk for cirrhosis and hepatic decompensation and not at increased risk despite those outcomes for liver transplantation. Hispanics were at increased risk for NAFL compared to whites. And whether this is due to access to or trust in the health system, socioeconomic status or the under diagnosis of NAFL and NASH and how these confounders contribute to these outcomes is unknown or alternatively, it could be genetic polymorphisms that promote NAFL than NASH in different ethnic groups but we certainly need a lot more research in the area of disparities such that we can narrow this gap here in the lower hand corner. You could see a lower risk of NAFL than NASH but yet higher risk of cirrhosis and heat decompensation and a lower probability of receiving liver transplantation. And likewise, racial minority individuals at risk for NAFL and fibrosis in primary care and endocrinology clinics were less likely to receive an abdominal imaging or referral to a subspecialist compared to individuals from larger academic medical centers. And this abstract also a poster of distinction was a retrospective review of primary care clinics from the University of Alabama that demonstrated that patients who had indeterminate or advanced hepatic fibrosis, they use the NAFL fibrosis score to stratify patients that there was a disparity in the referral pattern even for patients to not only get abdominal imaging but to get to a hepatologist and particularly in those patients who had high NAFL fibrosis scores while they tended to get abdominal imaging there was still discordance in patients being referred to a subspecialty clinic. So whites were more likely to receive abdominal imaging and a hepatology referral compared to individuals of racial minorities. Even in those groups that had indeterminate or advanced hepatic fibrosis by non-invasive measures and that the overall referral is low and a system-wide approaches to enhance care and reduce disparities is necessary. And with that, I thank you all for your attention. I wanna call a shout out to Dr. Yolanda Carofalo who is incredibly pivotal in helping me put together this presentation for you. I thank my colleagues, my collaborators, all the investigators, the sponsors, the federal and private who allowed for such work to propel itself forward. And of course our patients and their families by which whom all science and liver disease would not be possible without them. Thank you.

Non-Alcoholic Fatty Liver Disease

NAFLD

AASLD Symposium

FGF19 analogs

pegbelfermin

NASH

lifestyle interventions