The liver performs many essential functions including detoxification, protein synthesis, production of biochemicals for digestion, storing glycogen, and decomposing red blood cells. Liver disease can result from alcohol use, viruses, autoimmune conditions, genetic disorders, or non-alcoholic fatty liver disease (NAFLD). NAFLD occurs when excess fat accumulates in the liver and is increasing worldwide due to the rise in obesity and metabolic syndrome. Poor diet and lifestyle factors contribute to NAFLD progression. Choline plays an important role in liver health by supporting phospholipid membranes, lipoprotein synthesis, and methylation reactions, and higher intakes may be needed to prevent NAFLD.

2. Liver, what do you know?
• Food
– Liver
– Foie gras
• Alcohol use

3. Liver anatomy
• 1,5 kg
• Supplied by blood from
– Hepatic artery
– Portal system (gut, pancreas, spleen)
• Liver sinusoids => central vene
• Bile duct

4. Liver function
• Detoxification of various metabolites
– Reduction, oxidation, conjugation, excretion
– Drugs, alcohol
• Protein synthesis
• Production of biochemicals necessary for digestion
• Bile
• Numerous functions in the human body
• Glycogen storage
• Decompensation of red blood cells
• Hormone production

5. Liver function
• Detoxification of various metabolites
– Reduction, oxidation, conjugation, excretion
– Drugs, alcohol
• Protein synthesis
• Production of biochemicals necessary for digestion
• Bile
• Numerous functions in the human body
• Glycogen storage
• Decompensation of red blood cells
• Hormone production

6. Liver disease
• Alcohol
• Steatosis (NASH/NAFLD)
• Chronic Hepatitis (B/C)
• Auto-immune hepatitis
• Primairy Biliair Cholangitis (PBC)
• Primairy Sclerosing Cholangitis (PSC)
• Metabolic diseases
• Hemochromatose
• M. Wilson
• Alfa-1-antitrypsine deficiëncy
• Drugs
• Infections
• Cryptogenic

7. Liver fibrosis -> cirrhosis

8. Complications livercirrhosis
• Portal hypertension
– Oesofageal varices
– Splenomegaly en hypersplenism
– Ascites en Spontaneous Bacterial peritonitis (SBP)
– Hepatorenal Syndrome
– Hepatic encefalopathy
• Liver failure
– Clotting problems
– Hypoalbuminaemia
• Hepatocellulair carcinoma

9. End stage

10. NAFLD / NASH
• 2016 worldwide more obesity than malnutrition
– 500.000.000
• 2016 more deaths related to obesity than malnutrition
• 15% world population obese
• 40% world population overweight
• NAFLD 17-46% of adults in western population
• Steatosis No1 indication for liver transplantation (US)
USA
Steatosis No1 indication for
liver transplantation

11. NAFLD / NASH
• WHO: 2016 worldwide more obesity than malnutrition
– 500.000.000
• 2016 more deaths related to obesity than malnutrition
• 15% world population obese (BMI >30)
• 40% world population overweight (25< BMI<30)
• NAFLD 17-46% of adults in western population
– NAFL & NASH
• NASH 3 -5% prevalence

12. Dimension of the problem
General population
NAFLD
20-40%
NASH
2-5%
Obesity
NAFLD
NASH
15-55%
DM type 2
NAFLD
NASH
20-80%
DM: >380 million
>550 in 2030
1 billion

13. NAFLD / NASH
• Characterised by
– Excessive hepatic fat accumulation
– Associated with insulin resistance
• Definition:
– Steatosis in 5% of hepatocytes (histology or proton magnetic
resonance spectroscopy 1H-MRS or MRI)
• Exclusion:
– Alcohol daily >30g(♂) and >20g (♀)

14. Risk factors
• Obesity
• Hypertension
• Dyslipidemia
• Type 2 diabetes
• Metabolic syndrome

15. Pathophysiology

16. NAFLD / NASH
Pathogenesis
• High-calorie diet
• Excess (saturated) fats
• Refined carbohydrates
• Sugar-sweetened beverages
• High fructose intake
• Western diet
• Genetic factors?
Weight gain
Obesity
NAFLD

17. Identification
• Identify risk factors of NAFLD
• Imaging
– US, (MRI)
• Markers of inflammation
– ALAT
• Markers of fibrosis
– NFS, FIB-4, ELF, Fibrotest
• Transient elastography - liverbiopsy

18. Diagnostic flow chart

19. Treatment
• Liver transplantation ($600.000)

20. Treatment
• Bariatric surgery
– ($ 6.000 - 30.000)

21. Treatment
Diet and lifestyle changes
• Small amounts of weight loss!
– reduce liver fat and improve hepatic IR
• 7% histological improvement
• Progressive increase in exercise

22. Treatment
• Insulin sensitizers
– Metformine
– Pioglitazone
– Rosiglitazone
– Incretin mimetics
• Antioxidants, cytoprotective and lipid lowering agents
– Vit E (800IU/day)
– UDCA
– Obeticholic acid
– N-3 polyunsaturated fatty acids (PUFA)
• Iron depletion

23. Treatment
Experimental therapies
• Anti-inflammatory
• Antifibrotic agents
• Insulin sensitizing
• Fatty acid/ bile acid conjugates
• Choline (Vitacholine)

24. Future perspective
• Fighting steatosis
• Lifestyle changes
• Drugs
• Supplements

26. Choline, an essential nutrient for humans
• Required to make essential membrane phospholipids.
• Precursor for biosynthesis of neurotransmitter acetylcholine
• Source of labile methyl groups.
• Choline NOT considered a vitamin (body synthesizes small amounts) still considered an
essential nutrient in humans because choline MUST be consumed to maintain health.
• Design:
– Healthy male volunteers fed choline-free diet with 500 mg/day choline X1wk.
– Randomized into 2 groups, with choline (control) & without (deficient) for 3wk.
– Final wk – all received choline.
• Results:
– choline-deficient group, plasma choline and phosphatidylcholine concentrations 30%; plasma and RBC
phosphatidylcholine  15%; no such changes occurred in the control group.
– In choline-deficient group, serum alanine aminotransferase activity 
• Observations support conclusion and choline is an essential nutrient for humans when
excess methionine and folate are not available in the diet.
Zeisel S.H., et al; FASEB J. 1991 Apr;5(7):2093-8.

27. 1. Phosphorylated down cytidine diphosphate-choline (CDP-choline) pathway to
produce phosphatidylcholine (PC) for cell membranes and circulating lipoproteins.
or
2. Oxidized to betaine, as a source of methyl groups for the synthesis of methionine &
S-adenosyl-methionine (SAM), principal methylating agent in mammalian cells.
and
3. Generate PC via the phosphatidylethanolamine N-methyltransferase (PEMT)
pathway, & catalyzes SAM-dependent sequential trimethylation of phosphatidyl
ethanolamine.
Yan, J., et al; Am J Clin Nutr December 2013 vol. 98 no. 6 1459-1467
Choline Metabolic Pathways

28. Betaine (Trimethyl
glycine)
Choline
Glycine
MethionineHomocysteine
Methyl
glycine
S-Adenyl Methionine
Methyl
tetrahydrofolate
Folate
DNA
RNA
Protein
Lipid
Choline Oxidation Pathway

29. What Pregnancy can teach us about Choline
• Large amounts of PC needed for cellular division,
tissue expansion, and lipoprotein synthesis.
• 12-wk feeding study examining impact of pregnancy
on biomarkers of choline metabolism
– 26 healthy, third-trimester, singleton pregnant women
– 21 non-pregnant women
– 2 choline intake levels (380mg from diet) and
• 100mg & 550mg (Balchem Vitacholine).
– All participants also took a multivitamin
• 600ug folate, 2.6ug B12, 1.9mg B6
• 200mg DHA (Neuromins, Natures Way).
Yan, J., et al; Am J Clin Nutr December 2013 vol. 98 no. 6 1459-1467

30. PC-DHA
480mg
linoleic (18:2n−6)
oleic (18:1n−9)
Yan J, et al; Am J Clin Nutr December 2013 vol. 98 no. 6 1459-1467
DHA (22:6n−3)
ARA (20:4n−6)

31. PC-DHA
VLDL
DHA
PC-DHA
cytidine diphosphate
930mg
PEMT Yan J, et al; Am J Clin Nutr December 2013 vol. 98 no. 6 1459-1467
40% Genetic Polymorphism in PEMT
gene – unresponsive to estrogen

32. Betaine
CholineGlycine
MethionineHomocysteine
Methyl glycine
S-Adenyl Methionine
SAM
Methyl tetra
hydrofolate
Folate
Methyl
Cobalamin
Vitamin B12
DNA
RNA
Protein
Lipid
X
X
B12 Deficiency & Choline Steal
Tetra hydrofolate
X
X
CH3- B12 B12X39% US pop subclinical
deficiency

33. Corbin KD & Zeisel SH. Curr Opin Gastroenterol. 2012 Mar; 28(2): 159–165.
http://www.histology.leeds.ac.uk/cell/plasma_membrane.php

34. Maintaining the Balance
34
Membrane Integrity
Phosphatidylcholine Packaging of
Triglyceride rich VLDL
VLDL
Choline
Gene Silencing & Activation
Protein Synthesis
Lipid Synthesis
Methylation
Cystein

35. Imbalance = Choline Steal
35
Leaky Membrane
Triglyceride Trapping  Fatty Liver  Cirrhosis  Liver Cancer
VLDL
Liver Enzymes
Stealing Choline from membranes
 Liver Enzymes
Insulin Resistance
Metabolic Syndrome
Deficiency in
USA
0.5%
39%
Methylation
Survival Mode
Robs Peter (liver) to Pay Paul (methylation)
Gene Silencing & Activation
Protein Synthesis
Lipid Synthesis
Muscle
Enzymes
 Muscle Enzymes
Gene

36. • Choline intake exceeding current recommendations may be needed to support both PC
production via CDP-choline pathway and choline-mediated one-carbon metabolism.
• The competing demands for choline by the phosphorylation or oxidative pathways and
the critical importance of this compound in a variety of key metabolic functions make the
necessity for ensuring at least recommended intakes of choline, and preferably more.

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