Non-Alcoholic Fatty Liver Disease in Children with Acute Lymphoblastic Leukemia
Authors: Asaad Farag Kerolos Boshra , Makkeyah Sara Mostafa Mohammad , Essam Ibrahim Haya , Ismail Eman Abdel Rahman , Ashraf Okba Ahmed , El-Sayed Manal Hamdy 
Published: November 2024

Abstract

Background
Non-alcoholic fatty liver disease (NAFLD) is increasingly recognized as a major health concern and is predicted to become the leading cause of end-stage liver disease in the coming decades. Few studies examined the frequency of NAFLD in childhood acute lymphoblastic leukemia (ALL).

Aim
To assess the prevalence of NAFLD in children with ALL at various phases of treatment. The study also investigates the impact of different treatment regimens and other risk factors on NAFLD development in this population.

Methods
This cross-sectional study with prospective follow up for the newly diagnosed group of patients included 60 children with ALL recruited from the Pediatric Oncology Unit at Ain Shams University Children’s Hospital. We collected data including sociodemographic data, age at diagnosis of ALL, diagnosis and risk stratification, treatment regimens, as well as 24-hour dietary recall. All patients were assessed for anthropometric measurements, body composition analysis, abdominal examination, laboratory investigations including liver function tests and lipid profile in addition to abdominal ultrasound.

Results
The mean age of the studied patients was 8.9 years. Among all studied groups, 56% of the post- induction group, 10% of patients during the maintenance phase and 25% post-completion of therapy had NAFLD. Regarding protocol of therapy in all patients who received chemotherapy, (100%) of patients who had received total XV-HR as a protocol of therapy had NAFLD with p-value = 0.023, on the other hand there was no difference found between patients with and without NAFLDregarding total XV-LR and total XV-SR protocols with p value 0.436 and 0.933 respectively. Among all studied groups, patients with NAFLD had higher median energy level (3272 kcal/d in NAFLD vs 1834 kcal/d in non-NAFLD, p = 0.021), higher median fat intake (87 g/d for NAFLD vs 49 g/d for non-NAFLD, p = 0.046), higher median carbohydrate intake (486 g/d for NAFLD vs 274 g/d for non NAFLD, p = 0.016) and higher median fructose containing beverages (2 per month for NAFLD group versus 0 per month for non-NAFLD group p = 0.041). Additionally, NAFLD group showed higher median triceps skin fold thickness z-score of 0.09 vs -0.51 in non-NAFLD group, p = 0.002. However, there was no difference between patients with and without NAFLD in all studied patients regarding body composition parameters. Higher percentage (42.9%) of patients who had high LDL level (mg/dl) had been found in NAFLD group versus (10.9%) in non NAFLD, p = 0.022, while there was no difference found between patients with and without NAFLD in all studied patients regarding LDL serum levels. Body fat percentage positively correlated with serum LDL- cholesterol during ALL treatment with (r = 0.508, and p = 0.044). There was no difference found between patients with and without NAFLD in all treatment phases regarding median ALT (21, 18 IU/L in non-NAFLD and NAFLD group respectively), p = 0.588, median AST serum level (28, 30 IU/L in non-NAFLD and NAFLD group respectively), p = 0.612.

Conclusion
NAFLD is a relatively common finding in childhood ALL especially in the post-induction phase. ALL patients treated with total XV-HR protocol of therapy more frequently developed NAFLD than patients on total XV-LR and total XV-SR protocols. NAFLD patients had significantly higher dietary intake compared to non NAFLD patients. There was a positive correlation between body fat percentage and serum levels of LDL in children during ALL treatment.