Quantifying Hepatic Mitochondrial Fluxes in Humans

Study Overview
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Brief Summary
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In this study the investigators will quantitate hepatic mitochondrial fluxes in T2D patients with NAFL and NASH before and after 16-weeks treatment with the insulin sensitizer pioglitazone

Detailed Description
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The study team will examine hepatic mitochondrial TCA flux and pyruvate cycling (oral [U-13C]-propionate), hepatic gluconeogenesis (oral 2H2O), and hepatic insulin sensitivity (intravenous [3,4-13C2]-glucose with euglycemic insulin clamp) before and after 16 weeks treatment with the FDA approved insulin sensitizer pioglitazone. These studies will be performed in (i) type 2 diabetic subjects with NAFL but without evidence of fibrosis, and (ii) type 2 diabetic patients with NASH. Liver biopsies will be obtained before and after treatment for the diagnosis of NAFL/NASH and for molecular analyses.

Official Title
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Quantitation of Hepatic Mitochondrial Fluxes in Humans With Nonalcoholic Fatty Liver Disease (NAFLD)

Conditions
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Non-Alcoholic Fatty Liver Disease, Type 2 Diabetes, Mitochondrial Metabolism Disorders

Intervention / Treatment
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* Drug: Pioglitazone
* Other: Placebo


Participation Criteria
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Eligibility Criteria
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T2D with NAFL Inclusion Criteria: Confirmed T2D based on OGTT (2 h glucose ≥200 mg/dl). Treated with diet, metformin, and/or sulfonylurea and in good general health determined by medical history, physical exam, and routine blood chemistries; age = 18-80 years; BMI = 25-40 kg/m2; HbA1c = 7-10%; stable body weight (±4 pounds) over the preceding 3-months; not taking any medication known to affect glucose metabolism other than antidiabetic medications. Evidence of moderate/severe fatty liver (steatosis; grade S2/S3 on FibroScan corresponding to ≥10% fat on MRI-PDFF) and no/minimal hepatic fibrosis (grade F0/F1 on FibroScan). Exclusion Criteria: Alcohol consumption >14 units/week for women and >21 units/week for men. Cirrhosis (fibrosis stage 4). Type 1 diabetes and/or GAD positive subjects. Subjects not drug naive or have been on metformin more than 3 months. Presence of proliferative retinopathy. Urine albumin excretion > 300 mg/day. Evidence of other forms of chronic liver disease, including alcoholic liver disease, hepatitis B and C, primary biliary cholangitis, suspected/proven liver cancer and any other liver disease other than NAFLD. History of NY Class III-IV heart failure T2D with NASH Inclusion Criteria: Confirmed T2D based on OGTT (2 h glucose ≥200 mg/dl). Treated with diet, metformin, and/or sulfonylurea and in good general health determined by medical history, physical exam, and routine blood chemistries; age = 18-80 years; BMI = 25-40 kg/m2; HbA1c = 7-10%; stable body weight (±4 pounds) over the preceding 3-months; not taking any medication known to affect glucose metabolism other than antidiabetic medications. Evidence of moderate/severe fatty liver (steatosis; grade S2/S3 on FibroScan corresponding to ≥10% liver fat on MRI-PDFF) and moderate/severe hepatic fibrosis (grade F2/F3 on FibroScan). Exclusion Criteria: Alcohol consumption >14 units/week for women and >21 units/week for men. Cirrhosis (fibrosis stage 4). Type 1 diabetes and/or GAD positive subjects. Subjects not drug naive or have been on metformin more than 3 months. Presence of proliferative retinopathy. Urine albumin excretion > 300 mg/day. Evidence of other forms of chronic liver disease, including alcoholic liver disease, hepatitis B and C, primary biliary cholangitis, suspected/proven liver cancer and any other liver disease other than NAFLD. History of NY Class III-IV heart failure

Ages Eligible for Study
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Minimum Age: 18 Years
Maximum Age: 80 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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No

Study Plan
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How is the study designed?
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Design Details

Primary Purpose: Basic Science
Allocation: Randomized
Intervention Model: Parallel Assignment
Interventional Model Description: Patients with T2D and NAFL or NASH will be randomly assigned to receive placebo or pioglitazone treatment groups.
Masking: Single


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Experimental: NAFL TZD<br>T2D with non-alcoholic fatty liver (NAFL), treated with pioglitazone | Drug: Pioglitazone<br>* An insulin sensitizer and anti-diabetic agent. Participants will be started on 15 mg/day, increased to 30 mg/day at week 2 and then to 45 mg/day at week 4.<br>* Other names: Actos;|
| Placebo Comparator: NAFL Placebo<br>T2D with non-alcoholic fatty liver (NAFL), treated with placebo | Other: Placebo<br>* Placebo for pioglitazone<br>|
| Experimental: NASH TZD<br>T2D with non-alcoholic steatohepatitis (NASH), treated with pioglitazone | Drug: Pioglitazone<br>* An insulin sensitizer and anti-diabetic agent. Participants will be started on 15 mg/day, increased to 30 mg/day at week 2 and then to 45 mg/day at week 4.<br>* Other names: Actos;|
| Placebo Comparator: NASH Placebo<br>T2D with non-alcoholic steatohepatitis (NASH), treated with placebo | Other: Placebo<br>* Placebo for pioglitazone<br>|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Effect of pioglitazone on hepatic mitochondrial TCA cycle fluxes | Quantitated using a combine stable isotope approach before and after treatment with pioglitazone | Baseline, week 16 | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Mean absolute change from baseline in liver fat content by magnetic resonance Imaging - Proton Density Fat Fraction (MRI-PDFF) | Mean absolute change from baseline in liver fat content by MRI-PDFF | Baseline, Week 16 | 
| Mean change from baseline in body weight | Mean change from baseline in body weight | Baseline, Week 16 | 
| Mean change from baseline in body composition | Mean change from baseline in lean and fat mass measured by DEXA | Baseline, Week 16 | 
| Quantitate the effect of pioglitazone on liver histology by improvement of fibrosis | Percentage of Participants with ≥1 Point Decrease in Fibrosis Stage with No Worsening of NASH on Liver Histology | Week 16 | 
| Quantitate the effect of pioglitazone on NAFLD Activity Score (NAS) | Percentage of Participants that Achieve a ≥2 Point Decrease in NAS on Liver Histology, with ≥1 Point Reduction in at Least 2 NAS Components | Week 16 | 
| Examine the effect of pioglitazone on non-invasive markers of NAFLD | Mean change from baseline in Fibrosis-4 (FIB-4), transient elastography (Fibroscan®), NAFLD fibrosis score (NFS), alanine transaminase (ALT) and aspartate transaminase (AST) | Baseline, Week 16 | 
| Effect of pioglitazone on the hepatic lipidome | Lipidomics will be carried out using mass-spectrometry methods | Baseline, Week 16 | 
| Effect of pioglitazone on hepatic gene regulatory networks | Multimodal RNA-Seq and ATAC-Seq will be used to examine gene regulatory networks in liver samples | Baseline, Week 16 | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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Diet, NAFLD, Exercise