SFAH: Effect of Saturated Fat (Desi Ghee) on Gut-Liver Axis in Alcoholic Hepatitis

Sponsor

Institute of Liver and Biliary Sciences, India (Other)

Overall Status

Completed

CT.gov ID

NCT04084522

Collaborator

(none)

Enrollment

Location

Arms

Actual Duration (Months)

2.1

Patients Per Site Per Month

Study Details

Study Description

Brief Summary

The pathogenesis of the alcoholic liver disease (ALD) is a complex interplay of various etiopathological factors other than direct alcohol toxicity. These factors include inflammation & oxidative stress, dysbiosis, intestinal hyperpermeability, and endotoxemia. Dietary fats not only improve nutritional status in ALD but specific properties of saturated fats (SF) have the potential to favourably modulate these causative factors. This project has two parts, in the animal study 10 groups of murine model of alcoholic hepatitis (AH) would be given SF in the form of Desi Ghee and in the human study patients with AH would be randomized into two groups, one with SF ( Desi Ghee) and the other with usual unsaturated fat (cooking oil). In all effect of SF on gut microbiota, hepatic steatosis, TLR-4 expression, serum adiponectin, endotoxin levels, intestinal tight junction proteins and inflammatory markers in murine models of AH, along with hepatic morbidity & lipid profile, in patients with ALD would be studied.

Condition or Disease	Intervention/Treatment	Phase
Alcoholic Hepatitis	Dietary Supplement: Saturated Fat- Desi Ghee (Clarified Butter) Dietary Supplement: Soyabean Oil	N/A

Detailed Description

Alcohol is one of the predominant causes of liver diseases and liver-related deaths worldwide. 10% of heavy drinkers consuming more than 30g /day of alcohol for 5 years develop alcoholic liver disease (ALD). The liver acts as a major organ in alcohol metabolism. Alcohol is metabolized to acetaldehyde, the key toxin in alcohol mediated liver injury which gets converted to reactive oxygen species (ROS) through oxidative pathway thus leading to hepatocyte injury. Several experimental and human studies have shown that alcohol also causes intestinal bacterial overgrowth, intestinal mucosal damage and enhances intestinal permeability, leading to translocation of bacteria and their by-products (like LPS) in the portal circulation. Bacteria further stimulate the production of ROS and pro-inflammatory cytokines like TNF-alpha, IL-6, & chemokines, thus further damaging the liver. Alcohol intake not only causes bacterial overgrowth but also brings a qualitative change in the type of bacteria. The number of gram-negative bacteria like Enterobacteriaceae / Proteobacteria - E.Coli, Firmicutes -Enterococcocus, Bacteriodetes- Fusobacteria and Staphylococaceae -Staphylococcus increase whereas the number of gram-positive bacteria viz. Firmicutes -Lactobacillus, Ruminococcaceae, Lachnospiraceae; Actinobacteria -Bifidobacterium decrease. This change is termed dysbiosis. Thus alcohol-related liver injury is potentiated by alcohol-induced gut barrier dysfunction and ensuing cascade of events, involving dysbiosis. Studies suggest that probiotic administration decreased alcohol-induced dysbiosis, TNF- alpha & IL-6 levels, and improves gut leakiness & liver inflammation. Probiotics also restore the level of lactobacilli thus creating more acidic environment, lowering the intestinal pH & stabilizing mucosal barrier, thereby preventing microbial translocation & blocking TLR-4 signaling cascade and attenuating liver injury. Hence there is evidence that suggests to targeting dysbiosis improves alcohol-related liver disease. Studies have also shown that lactobacilli use saturated fat (SF) for its growth and supplementing SF improves gut lactobacilli levels and subsequently decreases the progression of ALD. Low levels of microbial long-chain saturated fat caused due to alcohol compromise the growth of lactobacillus and hence disrupt gut barrier integrity. A large multicentre epidemiologic study in chronic alcoholics with comparable per capita alcohol intake has shown that intake of saturated fat is associated with lower mortality rates as compared to unsaturated fats (USF) Diet rich in SF has been found to prevent ethanol-induced changes viz. an increase in proteobacteria & liver steatosis, which were actually increased with the consumption of USF. Yet another study reported that the SF diet improved intestinal tight junction expression and alleviated intestinal inflammation caused due to ethanol intake. Supplementation of long-chain fatty SF to ethanol injured mice with increased intestinal permeability restored metabolic homeostasis with decreased intestinal bad bacteria levels where supposedly saturated fat serves as a vitamin B substitute and promotes the growth of lactobacilli species which ameliorates alcoholic liver injury.

Alcohol induced disruption in the intestinal tight junction protein levels, endotoxemia and hepatic LPS signaling were found to be alleviated by SF in the form of medium chain triglycerides. Dietary SF (e.g., palm oil or MCT oil) reversed the established experimental ALD in rats, and improved liver histological changes despite continued intragastric ethanol administration.

Hence the supplementation of SF in ALD is a logical manoeuvre within the nutritional therapy of this disease, as almost 90% of these patients are malnourished primarily due to a reduced diet intake. Fats are concentrated source of energy which makes the food palatable, hence making the attainment of higher calorie (35-40 kcal/kg body weight/day) target possible. With this background use of SF in ALD is a promising modality in the medical armamentarium, given the fact that nutrition remains the cornerstone of the overall therapy.

Study Design

Study Type:

Interventional

Actual Enrollment :

60 participants

Allocation:

Randomized

Intervention Model:

Parallel Assignment

Masking:

None (Open Label)

Masking Description:

As it is a nutritional intervention masking of the either of participants or investigator or other investigator is not possible

Primary Purpose:

Treatment

Official Title:

Effect of Saturated Fat (Desi Ghee) on Gut-Liver Axis in Alcoholic Hepatitis

Actual Study Start Date :

Oct 1, 2019

Actual Primary Completion Date :

Jan 31, 2022

Actual Study Completion Date :

Jan 31, 2022

Arms and Interventions

Arm	Intervention/Treatment
Placebo Comparator: Standard Treatment Group In addition to standard pharmacological treatment, this group would receive a diet comprising of 35-40 kcal. The total distribution of the calories would be as 55-60% from carbohydrates, 20% from protein and 30% from fat, a fixed amount of 50g of oil would be given and the remaining amount of fat would be met by the invisible dietary fat. The source of visible dietary fat would be refined soyabean oil. This group would not receive any fat in the form of Desi ghee or butter or any nutritional supplement other than the prescribed diet. The diet would be explained to the patient by individual diet charts.	Dietary Supplement: Soyabean Oil Soyabean Oil consists of around 84% of unsaturated fat and is the most widely used source of unsaturated fat used in the area.
Active Comparator: Intervention Arm In addition to standard pharmacological treatment, this group would receive a diet comprising of 35-40kcal and 1.2-1.5gm protein per kg ideal body weight per day. The total distribution of the calories would be as 55-60% from carbohydrates, 20% from protein and 30-35% from fat, a fixed amount of 50g of ghee would be given in 3 divided doses of 30 ml to be taken raw, 20 ml to be used for cooking and the remaining amount of fat would be met by the invisible dietary fat. The source of visible fat would be exclusively Desi ghee. This group would not receive any fat in the form of butter or any other oil or any other nutritional supplement other than the prescribed diet. The diet would be explained to the patient by individual diet charts.	Dietary Supplement: Saturated Fat- Desi Ghee (Clarified Butter) Desi Ghee which is also known as clarified butter contains around 70% of saturated fat. in India it is one of the important culinary items which promotes longevity and protects against various diseases, attributing numerous health benefits. Ghee consumption has also significant hypolipidemic and hypocholesterolemic effects.

Arm

Intervention/Treatment

Placebo Comparator: Standard Treatment Group

In addition to standard pharmacological treatment, this group would receive a diet comprising of 35-40 kcal. The total distribution of the calories would be as 55-60% from carbohydrates, 20% from protein and 30% from fat, a fixed amount of 50g of oil would be given and the remaining amount of fat would be met by the invisible dietary fat. The source of visible dietary fat would be refined soyabean oil. This group would not receive any fat in the form of Desi ghee or butter or any nutritional supplement other than the prescribed diet. The diet would be explained to the patient by individual diet charts.

Dietary Supplement: Soyabean Oil

Soyabean Oil consists of around 84% of unsaturated fat and is the most widely used source of unsaturated fat used in the area.

Active Comparator: Intervention Arm

In addition to standard pharmacological treatment, this group would receive a diet comprising of 35-40kcal and 1.2-1.5gm protein per kg ideal body weight per day. The total distribution of the calories would be as 55-60% from carbohydrates, 20% from protein and 30-35% from fat, a fixed amount of 50g of ghee would be given in 3 divided doses of 30 ml to be taken raw, 20 ml to be used for cooking and the remaining amount of fat would be met by the invisible dietary fat. The source of visible fat would be exclusively Desi ghee. This group would not receive any fat in the form of butter or any other oil or any other nutritional supplement other than the prescribed diet. The diet would be explained to the patient by individual diet charts.

Dietary Supplement: Saturated Fat- Desi Ghee (Clarified Butter)

Desi Ghee which is also known as clarified butter contains around 70% of saturated fat. in India it is one of the important culinary items which promotes longevity and protects against various diseases, attributing numerous health benefits. Ghee consumption has also significant hypolipidemic and hypocholesterolemic effects.

Outcome Measures

Primary Outcome Measures

To determine the improvement in cirrhosis dysbiosis ratio (CDR) associated with saturated fat in patients with severe alcoholic hepatitis. [2 months]
The stool sample of the patients would be processed by 16s ribosomal RNA Gene sequencing to observe the diversity, abundance an evenness of the microbial community and thereafter Cirrhosis dysbiosis ratio (CDR) would be calculated at the starting and the end of the study i.e at baseline and at the end of two months.

Secondary Outcome Measures

To study the serum endotoxin (lipoploysacchride) levels in patients with severe alcoholic hepatitis [2 months]
The collected blood sample would be assessed for endotoxin levels by using Toxin Sensor TM Chromogenic LAL Endotoxin Assay Kit

Other Outcome Measures

To study the serum pro- inflammatory marker, TNF-alpha in patients with severe alcoholic hepatitis [2 months]
The collected blood sample would be assessed for TNF- alpha levels by using Quantikine ELISA kit
To study the serum pro- inflammatory marker, IL-6 in patients with severe alcoholic hepatitis [2 months]
The collected blood sample would be assessed for IL-6 levels by using Quantikine ELISA kit
To study the serum pro- inflammatory marker, NF-kB in patients with severe alcoholic hepatitis [2 months]
The collected blood sample would be assessed for NF-kB levels by using Quantikine ELISA kit
To study the serum anti- inflammatory marker,adiponectin in patients with severe alcoholic hepatitis [2 months]
The collected blood sample would be assessed for adiponectin levels by using Quantikine ELISA kit
To study the serum anti- inflammatory marker, IL-10 in patients with severe alcoholic hepatitis [2 months]
The collected blood sample would be assessed for IL-10 levels by using Quantikine ELISA kit
To observe the expression of gut microbiome specific genes in patients with severe alcoholic hepatitis [2 months]
The stool sample collected would be assessed for Fab genes (G and F) expression using 16s ribosomal gene sequencing.
To observe Clinical benefit in patients of severe alcoholic hepatitis [2 months]
Clinical benefit in terms of resolution of signs & symptoms to be observed.
To observe Clinical benefit in patients of severe alcoholic hepatitis [2 months]
Clinical benefit in terms of improvement in Bilirubin levels to be observed
To observe Clinical benefit in patients of severe alcoholic hepatitis [2 months]
Clinical benefit in terms of reduction of AST & ALT levels to be observed
To observe Clinical benefit in patients of severe alcoholic hepatitis [2 months]
Clinical benefit in terms of reduction Maddrey Score to be observed
To observe the Nutritional status in patients with Severe Alcoholic hepatitis [2 months]
Body composition analysis by BIA (Bioelectrical impedance analysis) for nutritional screening of the patients

Eligibility Criteria

Criteria

Ages Eligible for Study:

18 Years to 60 Years

Sexes Eligible for Study:

All

Accepts Healthy Volunteers:

Inclusion Criteria:

All patients with Severe Alcoholic Hepatitis

Aged between 18-60 years
Having Maddrey Score of >32
Last Intake of alcohol from 1 day to 60days
Patients who agree for complete alcohol abstinence from the day of enrollment

Exclusion Criteria:

Patients with-

Maddrey Score of <32 and >100
Comorbidities- Diabetes, Hypertension, Coronary Artery Disease, Chronic Kidney Disease, Hypothyroid
Continuing Alcohol intake- Non-compliant patients
Constipation
On Laxatives until 1 month prior to study
On probiotics until 1 month prior to study