A. BACKGROUND Accumulation of fat in the liver due to non-alcoholic causes (NAFLD) is associated with hepatic insulin resistance, which impairs the ability of insulin to inhibit the production of glucose and VLDL . This leads to increases in serum glucose, insulin and triglyceride concentrations as well as hyperinsulinemia. Recent epidemiologic studies have shown that a major reason for the metabolic syndrome as well as the accompanying increased risk of cardiovascular disease and type 2 diabetes is overconsumption of simple sugars. The investigators have recently shown that overeating simple sugars (1000 extra calories/day, "CANDY" diet) increases liver fat content by 30% within 3 weeks (4), and recapitulates features of the metabolic syndrome such as hypertriglyceridemia and a low HDL cholesterol concentration. The fatty acids in intrahepatocellular triglycerides may originate from peripheral lipolysis, de novo lipogenesis, uptake of chylomicron remnants by the liver and from hepatic uptake of fatty acids released during intravascular hydrolysis of triglyceride-rich lipoproteins (the spillover pathway). A classic study using stable isotope methodology by the group of Elisabeth Parks showed that in subjects with NAFLD, the excess intrahepatocellular triglycerides originate from peripheral lipolysis and de novo lipogenesis. It is well-established that ingestion of a high carbohydrate as compared to high fat diet stimulates de novo lipogenesis in humans. Meta-analyses comparing isocaloric high fat and high carbohydrate diets have shown that high carbohydrate but not high fat diets increase increase serum triglycerides and lower HDL cholesterol. Since hypertriglyceridemia results from overproduction of VLDL from the liver, these data suggest the composition of the diet influences hepatic lipid metabolism. Whether this is because overfeeding fat leads to preferential deposition of fat in adipose tissue while high carbohydrate diets induce a relative greater increase in liver fat is unknown. There are no previous studies comparing effects of chronic overfeeding of fat as compared to carbohydrate on liver fat or and the sources of intrahepatic fatty acids. A common polymorphism in PNPLA3 at rs738409 (adiponutrin) gene is associated with a markedly increase liver fat content. This finding has been replicated in at least 20 studies across the world. The investigators have shown that PNPLA3 is regulated by the carbohydrate response element binding protein 1. Mice overexpressing the human I148M PNPLA3 variant in the liver exhibit an increase in liver triglycerides and cholesteryl esters on a high sucrose but not high fat diet. These data suggest that overfeeding a high carbohydrate as compared to a high fat diet may increase liver fat more in subjects carrying the I148M allele than in non-carriers. B. HYPOTHESIS The investigators hypothesize that overfeeding a high fat as compared to an isocaloric high carbohydrate diet influences the source of intrahepatocellular triglycerides. During a high fat diet, relatively more of intrahepatocellular triglycerides originate from peripheral lipolysis and less from DNL than during a high carbohydrate diet in the face of a similar increase in liver fat. It is also possible given the lack of previous overfeeding data comparing 2 different overfeeding diets that the high fat diet induces a smaller increase in liver fat than a high carbohydrate diet even in the face of an identical increase in caloric intake because a greater fraction of ingested fat is channeled to adipose tissue than the liver. The investigators also hypothesize that liver fat may increase more in carriers than non-carriers of the I148M variant in PNPLA3 during a high carbohydrate than a high fat diet. C. SPECIFIC AIMS The investigators wish to randomize, using the method of minimization (considers baseline age, BMI, gender, liver fat, PNPLA3 genotype) 40 non-diabetic subjects with NAFLD as determined by the non-invasive score developed in our laboratory or previous knowledge of liver fat content based on MRS to overeat either a high carbohydrate or high fat diet (1000 extra calories per day) for 3 weeks. Before and after the overfeeding diets, will measure liver fat content by 1H-MRS and the rate of adipose tissue lipolysis using doubly labeled water (DDW) and [1,1,2,3,3-2H5] glycerol as described in detail below. The investigators also wish to characterize glucose, insulin, fatty acid and triacylglyceride profiles before and while on the experimental diet. An adipose tissue biopsy is taken to determine whether expression of genes involved in lipogenesis or lipolysis, or those involved in adipose tissue inflammation change in response to overfeeding, and for measurement of LPL activity. After overfeeding, both groups will undergo weight loss to restore normal weight as described in our recent study. The metabolic study is repeated after weight loss.

NCT02133144

Conditions

1. NAFLD

Interventions

1. Behavioral: overeating fat
2. Behavioral: overeating carbohydrate

MeSH:Inflammation Weight Loss

HPO:Decreased body weight Weight loss

The investigators have shown that PNPLA3 is regulated by the carbohydrate response element binding protein 1. Mice overexpressing the human I148M PNPLA3 variant in the liver exhibit an increase in liver triglycerides and cholesteryl esters on a high sucrose but not high fat diet. --- I148M ---

These data suggest that overfeeding a high carbohydrate as compared to a high fat diet may increase liver fat more in subjects carrying the I148M allele than in non-carriers. --- I148M ---

The investigators also hypothesize that liver fat may increase more in carriers than non-carriers of the I148M variant in PNPLA3 during a high carbohydrate than a high fat diet. --- I148M ---

This project, "A double-blind placebo-controlled randomized clinical trial assessing the efficacy of metformin for hepatic fat in adolescents and young adults with polycystic ovary syndrome", proposes exploring the use of novel and noninvasive methodologies in an at-risk adolescent and young adult population with polycystic ovary syndrome (PCOS) who may gain long-term health benefits from early detection and treatment of non-alcoholic fatty liver disease (NAFLD). PCOS is a common condition that frequently presents in adolescence and young adulthood and is defined by elevated androgens (male hormones) in the blood leading to 1. hirsutism and acne and 2. menstrual abnormalities or amenorrhea. Affected individuals are at increased risk of developing insulin resistance (a precursor of diabetes), NAFLD and lipid (cholesterol) abnormalities.These features are all associated with the metabolic syndrome, a rising major public health concern. Recently, an association between PCOS and NAFLD has been noted but has only been superficially studied in the adolescent and young adult population. The susceptibility of certain PCOS patients to developing NAFLD is theorized to be due to having underlying insulin resistance, elevated androgen levels, and a genetic predisposition. Metformin is an insulin sensitizing medication widely used to treat type 2 diabetes mellitus that may have beneficial effects on insulin resistance-related conditions including PCOS and NAFLD. Although widely used in PCOS, its effect on NAFLD in this group has not been previously studied. The primary aims of this proposal are: 1) To determine whether PCOS with liver fat >/=4.8% treated with metformin for six months will have a decline in percentage liver fat compared to a placebo group. 2) To measure the association of the PNPLA3 I148M allele with NAFLD in PCOS at baseline (n=40). 2b) To measure the association of percentage liver fat with biomarkers of NAFLD, dyslipidemia, insulin resistance and body composition at baseline (n=40) and after a placebo-controlled intervention with metformin in PCOS with liver fat >4.8% (n=20). The goal of this research proposal is to explore the use of novel and noninvasive technologies in a young and at risk population. Dr. Sopher hopes to use the results of this research to lay the groundwork for the prevention and treatment of NAFLD and other metabolic disorders in adolescents and young adults with PCOS and to prevent lifelong morbidity associated with PCOS.

NCT02500147

Conditions

1. Polycystic Ovary Syndrome
2. Non-Alcoholic Fatty Liver Disease
3. Metabolic Syndrome

Interventions

1. Drug: Metformin
2. Drug: Placebo

MeSH:Polycystic Ovary Syndrome Liver Diseases Fatty Liver Non-alcoholic Fatty Liver Disease Metab Metabolic Syndrome Syndrome

HPO:Abnormality of the liver Decreased liver function Elevated hepatic transaminase Hepatic steatosis Polycystic ovaries

2) To measure the association of the PNPLA3 I148M allele with NAFLD in PCOS at baseline (n=40). --- I148M ---

The proportion of PCOS subjects with the high risk I148M PNPLA3 allele in the PCOS groups with elevated and normal liver fat will be compared using a chi-squared or Fisher's Exact test.. --- I148M ---

Other IR indices that will be evaluated are whole body insulin sensitivity (WBIS) and insulin area under the curve; 6) Genetic evaluation: A blood sample for the PNPLA3 I148M allele (baseline only). --- I148M ---

The aims of the study are: 1. To investigate if carriers of apolipoprotein (apo) CIII loss-of-function (LOF) mutations produce less apo-CIII that results in reduction of large very low-density lipoprotein (VLDL) particle secretion as compared to non-carriers of these variants and compare the results with carriers of apo-CIII gain-of-function (GOF) to elucidate the role of apo-CIII in hepatic lipid metabolism. 2. To study if carriers of the TM6SF2 E167K and PNLPLA3 I148M mutations produce less large VLDL particles to transport fat out of the liver as compared to non-carriers. 3. To test whether the specific mutations in the apo-CIII, TM6SF2 and PNLPLA3 genes are reflected in changes of liver de novo lipogenesis (DNL), liver fat, Homeostatic Model Assessment for Insulin Resistance (HOMA-IR), plasma lipid and apolipoprotein kinetics and fasting concentrations in carriers of the TM6SF2 E167K and PNLPLA3 I148M mutations as compared to non-carriers. 4. To study the effects of APOE, angiopoietin (ANGPTL3 and ANGPTL8) or endothelial lipase (LIPG) genotypes on liver fat metabolism, lipid and apolipoprotein metabolism and lipid phenotypes.

NCT04209816

Conditions

1. Non-alcoholic Fatty Liver
2. Atherogenic Dyslipidemia
3. Insulin Resistance

Interventions

1. Diagnostic Test: Lipoprotein kinetics

MeSH:Fatty Liver Non-alcoholic Fatty Liver Disease Insulin Resistance Dyslipidemias

HPO:Abnormal circulating lipid concentration Hepatic steatosis Insulin resistance

2. To study if carriers of the TM6SF2 E167K and PNLPLA3 I148M mutations produce less large VLDL particles to transport fat out of the liver as compared to non-carriers. --- E167K --- --- I148M ---

3. To test whether the specific mutations in the apo-CIII, TM6SF2 and PNLPLA3 genes are reflected in changes of liver de novo lipogenesis (DNL), liver fat, Homeostatic Model Assessment for Insulin Resistance (HOMA-IR), plasma lipid and apolipoprotein kinetics and fasting concentrations in carriers of the TM6SF2 E167K and PNLPLA3 I148M mutations as compared to non-carriers. --- E167K --- --- I148M ---

Inclusion Criteria: - persons who have provided written consent - apo-CIII loss-of-function mutation (heterozygous) or apo-CIII gain-of-function mutations (heterozygous) or TM6SF2 E167K mutation (homozygous) or PNLPLA3 I148M or apoE or LIPG or ANGPTL3 or ANGPTL8 LOF and GOF variants. --- E167K --- --- I148M ---

m² at inclusion Exclusion Criteria: - Patients with Type 1 and 2 diabetes, BMI > 40 kg/m2, - ApoE2/2 phenotype, thyrotropin concentration outside normal range, - Lipid-lowering drugs - Blood pressure >160 mmHg systolic and/or > 105 diastolic mmHg - Liver failure or abnormal liver function tests >3 x upper limit of normal - Intestinal disease - Pregnancy, breastfeeding - Patients with volume depletion Inclusion Criteria: - persons who have provided written consent - apo-CIII loss-of-function mutation (heterozygous) or apo-CIII gain-of-function mutations (heterozygous) or TM6SF2 E167K mutation (homozygous) or PNLPLA3 I148M or apoE or LIPG or ANGPTL3 or ANGPTL8 LOF and GOF variants. --- E167K --- --- I148M ---

This short-term, randomized, placebo-controlled, investigator-initiated trial aims to establish metabolic improvements in NAFLD subjects by dietary supplementation with cofactors N-acetylcysteine, L-carnitine tartrate, nicotinamide riboside and serine. Concomitant use of pivotal metabolic cofactors via simultaneous dietary supplementation will stimulate three different pathways to enhance hepatic β-oxidation and this study's hypothesis is that this will result in decreased amount of fat in the liver.

NCT04330326

Conditions

1. Non-alcoholic Fatty Liver Disease (NAFLD)

Interventions

1. Drug: Metabolic Cofactor Supplementation
2. Drug: Sorbitol

MeSH:Liver Diseases Fatty Liver Non-alcoholic Fatty Liver Disease

HPO:Abnormality of the liver Decreased liver function Elevated hepatic transaminase Hepatic steatosis

heart failure, documented coronary artery disease, valvular heart disease) - Patients with active bronchial asthma - Patients with phenylketonuria (contraindicated for NAC) - Patients with histamine intolerance - Clinically significant TSH level outside the normal range (0.04-6 mU/L) - Known allergy for substances used in the study - Concomitant medication use: 1. Lipid-lowering drugs within 3 months 2. Oral antidiabetics given for insulin resistance of obesity (metformin, liraglutide etc.) within 3 months 3. Thiazide diuretics with a dose >25 mg/d 4. Postmenopausal estrogen therapy 5. Any medication acting on nuclear hormone receptors or inducing Cytochromes P450 (CYPs) 6. Self-administration of dietary supplements such as any vitamins, omega-3 products, or plant stanol/sterol products within 1 month 7. Treatment with medications known to cause fatty liver disease such as atypical neuroleptics, tetracycline, methotrexate or tamoxifen 8. Use of an antimicrobial agent in the 4 weeks preceding randomization - Active smokers consuming >10 cigarettes/day - Alcohol consumption over 192 grams for men and 128 grams for women per week - Patients considered as inappropriate for this study for any reason (patients unable to undergo MRI study, noncompliance etc.) - Subjects with Patatin-like phospholipase domain-containing protein 3( PNPLA3) I148M (homozygous for I148M) - Women who are pregnant, are planning pregnancy, or who are breast-feeding - Women of childbearing potential not protected by effective birth control method - Active participation in another clinical study Inclusion Criteria: - Men and women (18-70 years old) - Body mass index >27kg/m2 - Triglyceride levels ≤354 mg/dl and LDL chol ≤175 mg/dl - No history of medication use for hepatic steatosis - Increased liver fat (>5.5%) --- I148M ---

heart failure, documented coronary artery disease, valvular heart disease) - Patients with active bronchial asthma - Patients with phenylketonuria (contraindicated for NAC) - Patients with histamine intolerance - Clinically significant TSH level outside the normal range (0.04-6 mU/L) - Known allergy for substances used in the study - Concomitant medication use: 1. Lipid-lowering drugs within 3 months 2. Oral antidiabetics given for insulin resistance of obesity (metformin, liraglutide etc.) within 3 months 3. Thiazide diuretics with a dose >25 mg/d 4. Postmenopausal estrogen therapy 5. Any medication acting on nuclear hormone receptors or inducing Cytochromes P450 (CYPs) 6. Self-administration of dietary supplements such as any vitamins, omega-3 products, or plant stanol/sterol products within 1 month 7. Treatment with medications known to cause fatty liver disease such as atypical neuroleptics, tetracycline, methotrexate or tamoxifen 8. Use of an antimicrobial agent in the 4 weeks preceding randomization - Active smokers consuming >10 cigarettes/day - Alcohol consumption over 192 grams for men and 128 grams for women per week - Patients considered as inappropriate for this study for any reason (patients unable to undergo MRI study, noncompliance etc.) - Subjects with Patatin-like phospholipase domain-containing protein 3( PNPLA3) I148M (homozygous for I148M) - Women who are pregnant, are planning pregnancy, or who are breast-feeding - Women of childbearing potential not protected by effective birth control method - Active participation in another clinical study Inclusion Criteria: - Men and women (18-70 years old) - Body mass index >27kg/m2 - Triglyceride levels ≤354 mg/dl and LDL chol ≤175 mg/dl - No history of medication use for hepatic steatosis - Increased liver fat (>5.5%) --- I148M --- --- I148M ---

heart failure, documented coronary artery disease, valvular heart disease) - Patients with active bronchial asthma - Patients with phenylketonuria (contraindicated for NAC) - Patients with histamine intolerance - Clinically significant TSH level outside the normal range (0.04-6 mU/L) - Known allergy for substances used in the study - Concomitant medication use: 1. Lipid-lowering drugs within 3 months 2. Oral antidiabetics given for insulin resistance of obesity (metformin, liraglutide etc.) within 3 months 3. Thiazide diuretics with a dose >25 mg/d 4. Postmenopausal estrogen therapy 5. Any medication acting on nuclear hormone receptors or inducing Cytochromes P450 (CYPs) 6. Self-administration of dietary supplements such as any vitamins, omega-3 products, or plant stanol/sterol products within 1 month 7. Treatment with medications known to cause fatty liver disease such as atypical neuroleptics, tetracycline, methotrexate or tamoxifen 8. Use of an antimicrobial agent in the 4 weeks preceding randomization - Active smokers consuming >10 cigarettes/day - Alcohol consumption over 192 grams for men and 128 grams for women per week - Patients considered as inappropriate for this study for any reason (patients unable to undergo MRI study, noncompliance etc.) - Subjects with Patatin-like phospholipase domain-containing protein 3( PNPLA3) I148M (homozygous for I148M) - Women who are pregnant, are planning pregnancy, or who are breast-feeding - Women of childbearing potential not protected by effective birth control method - Active participation in another clinical study Non-alcoholic Fatty Liver Disease (NAFLD) Liver Diseases Fatty Liver Non-alcoholic Fatty Liver Disease In this study, investigators aim to lower liver fat content in obese patients with NAFLD by increasing the hepatic levels of pivotal metabolic cofactors via simultaneous dietary supplementation of serine, L-carnitine, N-acetylcysteine (NAC) and nicotinamide riboside (NR). --- I148M ---

heart failure, documented coronary artery disease, valvular heart disease) - Patients with active bronchial asthma - Patients with phenylketonuria (contraindicated for NAC) - Patients with histamine intolerance - Clinically significant TSH level outside the normal range (0.04-6 mU/L) - Known allergy for substances used in the study - Concomitant medication use: 1. Lipid-lowering drugs within 3 months 2. Oral antidiabetics given for insulin resistance of obesity (metformin, liraglutide etc.) within 3 months 3. Thiazide diuretics with a dose >25 mg/d 4. Postmenopausal estrogen therapy 5. Any medication acting on nuclear hormone receptors or inducing Cytochromes P450 (CYPs) 6. Self-administration of dietary supplements such as any vitamins, omega-3 products, or plant stanol/sterol products within 1 month 7. Treatment with medications known to cause fatty liver disease such as atypical neuroleptics, tetracycline, methotrexate or tamoxifen 8. Use of an antimicrobial agent in the 4 weeks preceding randomization - Active smokers consuming >10 cigarettes/day - Alcohol consumption over 192 grams for men and 128 grams for women per week - Patients considered as inappropriate for this study for any reason (patients unable to undergo MRI study, noncompliance etc.) - Subjects with Patatin-like phospholipase domain-containing protein 3( PNPLA3) I148M (homozygous for I148M) - Women who are pregnant, are planning pregnancy, or who are breast-feeding - Women of childbearing potential not protected by effective birth control method - Active participation in another clinical study Non-alcoholic Fatty Liver Disease (NAFLD) Liver Diseases Fatty Liver Non-alcoholic Fatty Liver Disease In this study, investigators aim to lower liver fat content in obese patients with NAFLD by increasing the hepatic levels of pivotal metabolic cofactors via simultaneous dietary supplementation of serine, L-carnitine, N-acetylcysteine (NAC) and nicotinamide riboside (NR). --- I148M --- --- I148M ---

This study is intended to investigate the safety and tolerability, pharmacokinetics (PK) and pharmacodynamics (PD) of AZD2693, following subcutaneous (SC) administration of multiple ascending doses in patients with Non-alcoholic Steatohepatitis (NASH) with fibrosis Stage 1 to 3 and homozygous for the PNPLA3 148M risk allele.

NCT04483947

Conditions

1. Non-alcoholic Steatohepatitis (NASH)

Interventions

1. Drug: AZD2693
2. Other: Placebo

MeSH:Fatty Liver Non-alcoholic Fatty Liver Disease

HPO:Hepatic steatosis

- Provision of signed, written, and dated informed consent for mandatory Genetic PNPLA3 I148M determination genetic/biomarker, for inclusion or exclusion in the clinical trial. --- I148M ---

- Mandatory PNPLA3 Genetic Biomarker and Companion Diagnostic Development Sample: - The participant will be excluded from the study if consent for the PNPLA I148M Genetic Biomarker Samples is not given. --- I148M ---

- The mandatory consent will include assessment of PNPLA3 I148M status as well as additional genotyping of gene variants associated with PNPLA3 expression. --- I148M ---