September 8, 2008

Liver Disease Latest Risk for Overweight Children — Experts Warn More May Need Transplants As Adults

By Linda A Johnson

TRENTON, N.J. - In a new and disturbing twist on the obesity epidemic, some overweight teenagers have severe liver damage caused by too much body fat, and a handful have needed liver transplants.

Many more may need a new liver by their 30s or 40s, say experts warning that pediatricians need to be more vigilant. The condition, which can lead to cirrhosis and liver failure or liver cancer, is being seen in kids in the United States, Europe, Australia and even some developing countries, according to a surge of recent medical studies and doctors interviewed by The Associated Press.

The American Liver Foundation and other experts estimate 2 percent to 5 percent of American children over age 5, nearly all of them obese or overweight, have the condition, called nonalcoholic fatty liver disease.

"It's clearly the most common cause of liver disease" said Dr. Ronald Sokol, head of public policy at the liver foundation and a liver specialist at Children's Hospital and University of Colorado Denver.

Some experts think as many as 10 percent of all children and half of those who are obese may suffer from it, but note that few are given the simple blood test that can signal its presence. A biopsy is the only sure way to diagnose this disease.

As fat builds up, the liver can become inflamed and then scarred over time, leading to cirrhosis, a serious condition, which in years past was mostly caused by hepatitis or drinking too much alcohol. Liver failure or liver cancer can follow, but if cirrhosis has not yet developed, fatty liver disease can be reversed through weight loss.

The disease is most common in overweight children with belly fat and certain warning signs, such as diabetes or cholesterol or heart problems. However, it has been seen in a few children of normal weight.

Genetics, diet and exercise level all play a role. It is most prevalent among Hispanics, relatively rare among African-Americans, and more common among boys than girls.

"There are people in their 30s or early 40s that will require a liver transplant" from developing the condition as a kid, predicts Dr. Jos Derdoy, head of liver transplants at Cardinal Glennon Children's Medical Center in St. Louis. He has treated a 15-year- old, 530-pound boy and others with the condition.

Experts blame obesity, with about two-thirds of all Americans overweight. With fatty liver disease becoming more common in adults, many experts predict it will become the top cause of liver transplants by 2020.

"There aren't enough livers to go around," says Dr. Philip Rosenthal of the University of California-San Francisco Children's Hospital.

His patient, Irving Shaffino, a 15-year-old Mexican-American who lives outside Lubbock, Texas, was lucky to get a transplant a year ago. He was in end-stage cirrhosis and, at 5-feet-4 1/2 , weighed 180 pounds.

Sadly, however, Irving has made little progress in losing weight. Although he has grown an inch and a half since his operation, his weight was up to 219 at the start of August.

Specialists say many kids diagnosed with fatty liver disease come to subsequent checkups heavier, and at best, just one in four loses significant weight, the only treatment known to stop and even reverse the disease.

"My patients that are successful, the whole family has bought in," increasing exercise and changing diet, said Dr. Stephanie Abrams, a liver and obesity specialist at Texas Children's Hospital. "The problem is that we aren't changing society in favor of becoming lean."

The scope of the disease has only been realized in recent years. Just a handful of cases were reported in medical journals in the 1980s.

Only three liver transplants on American children with nonalcoholic fatty liver disease were recorded from 1990 through 2002; two were done last year.

"It really has been only in the last two or three years that this has become more commonplace," said Dr. Ann Scheimann, a pediatric gastroenterologist at Johns Hopkins Children's Center.

Like heart disease, liver disease is silent. Kids may feel fine for years. Any early symptoms, like fatigue and loss of appetite, are vague and usually eclipsed by more conspicuous problems, from diabetes to high blood pressure.

"The majority of children with this still go undiagnosed," said Dr. Jeffrey Schwimmer, head of the Fatty Liver Clinic at Rady Children's Hospital in San Diego.

Experts say the best way to combat the problem is to intervene early, while it can still be reversed, with a medical team working with the whole family, including liver and hormone specialists, a dietitian and counselors.

This spring, the American Academy of Pediatrics recommended doctors do a blood test of liver enzymes every two years on obese children and overweight ones with high blood pressure or cholesterol or family history of heart disease.

Within the last several months, there's been an explosion of research published on it and the role genes may play.

Surprisingly, some research comes from countries not known for high obesity rates: China, India and Iran. More reports come from Australia, England, Greece, Ireland, Israel, Italy and Japan. Doctors say globalization has given even poor countries fast food chains and sedentary pastimes: TV, Internet, video games.

Scientists now are seeking the best ways to treat it.

A small study in Rome showed weight loss helped. The U.S. government is testing the diabetes drug metformin and vitamin E and is funding about 20 other studies, including one that aims to determine how the disease progresses and who is most likely to develop cirrhosis or liver failure.


Nonalcoholic fatty liver disease

Warning signs

Nonalcoholic fatty liver disease often has no early symptoms in children or adults, but a fat belly is one signal. And diabetes, high cholesterol, high triglycerides or heart problems often accompany the disease.


As fatty liver disease worsens, these symptoms can appear:

Chronic fatigue or weakness.

Abdominal discomfort, such as cramping or nausea.

Confusion or difficulty thinking.

Bruising or bleeding easily, including nosebleeds.

Reduced appetite and weight loss.

Concerned parents can request a blood test for liver enzyme levels. Also, a doctor can check the abdomen to see if the liver is enlarged or order a scan or ultrasound.

Those tests can miss problems, however. The most reliable one is a biopsy, in which a small amount of tissue is removed from the liver and studied under a microscope.

To stop or prevent fatty liver disease, patients should:

Exercise and eat a balanced diet to lose weight slowly but steadily.

Control diabetes and cholesterol with medication and diet.

Get vaccinated against hepatitis to prevent further injury to the liver.

Avoid alcohol, drugs and supplements that can damage the liver.

Have a liver specialist oversee your care.

Avoid raw oysters and shellfish, which can harbor bacteria very dangerous to people with advanced liver disease.

Sources: American Liver Foundation, Indiana University School of Medicine, AP interviews.


Originally published by Linda A. Johnson Associated Press .

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