Novel Method for Measuring Hepatic Collagen Turnover Rate in Nonalcoholic Fatty Liver Disease (NAFLD): Comparison of Blood and Liver Biopsy Biomarkers of Fibrogenesis

Background and Objectives Excess collagen synthesis in the liver plays a causal role in progression from nonalcoholic fatty liver (NAFL) to nonalcoholic steatohepatitis (NASH). Markers that identify a patient's risk for progression, characterize disease activity and provide early assessment of treatment efficacy are needed. In particular, the availability of a non‐invasive metric of the rates of liver collagen synthesis (fibrogenesis) and turnover (fibrolysis) would be extremely valuable. We evaluated novel clinical biomarkers that directly quantify hepatic fibrogenesis rate in well‐characterized patients with biopsy‐proven NAFLD. Methods Patients with suspected NAFLD and a clinical indication for liver biopsy received the stable, non‐radioactive tracer heavy water ( 2 H 2 O, 50 ml, 2–3 times daily) by mouth for 20–35 days prior to biopsy. A plasma sample was collected weekly. Collagen fractional synthesis rate (FSR) from liver biopsy tissue and FSR of lumican (a proteoglycan involved in collagen fibril assembly that exhibits increased synthesis when collagen synthesis is increased) from plasma were measured by 2 H incorporation, using tandem mass spectrometry (LC‐MS/MS). Magnetic resonance elastography (MRE) measurements of liver stiffness were obtained within 2 weeks of biopsy. Results FSR of hepatic type I collagen (Col1a1) was significantly elevated in NASH relative to NAFL (0.97% vs 0.43 %/day, p=0.03). Liver Col1a1 FSR also significantly correlated with fibrosis severity by histological score (r= 0.63), with liver stiffness by MRE (r=0.65), and with HbA1c levels (r=0.47). FSRs of fibrillar hepatic collagen subtypes (I and III) were highly correlated (r= 0.94). FSR of circulating plasma lumican correlated strongly with liver collagen FSR (r=0.69) and with liver stiffness (r=0.71). Conclusion We conclude that hepatic collagen synthesis rates increase with fibrosis severity in NAFLD patients, indicating not only markedly increased absolute rates of collagen synthesis with disease progression but also suggesting that hepatic scar is dynamic even in advanced disease and may therefore be potentially reversible. Importantly, plasma lumican FSR correlates closely with liver collagen FSR and with liver stiffness. Moreover, established clinical risk factors for disease progression (NASH diagnosis, histologic fibrosis score, diabetes) were associated with higher collagen FSR. Non‐invasive kinetic measurements of fibrogenesis, such as plasma lumican FSR, may be helpful as markers of risk for disease progression and as early read outs of treatment response in anti‐fibrotic trials in NASH. Prospective studies are required to establish the predictive power of fibrogenesis rates for disease progression or reversal. Support or Funding Information KineMed, Inc.