A prospective study to identify clinically relevant biomarkers for early detection of progression analysis of NAFLD to NASH

Study Number: SLS-NASH-01

Study Title:  A prospective study to identify clinically relevant biomarkers for early detection of progression analysis of NAFLD to NASH

Study Sponsor: Strand Life Sciences Private Limited.

Study Type: Observational, Non-interventional, Multi-centric

Study Sites: up to 3

Total Number of Subjects: 1000

Study Arms:

Arm 1: Patients who are clinically confirmed with NAFLD with significant Fibrosis (LSM ≥8.2)

Arm 2: Subjects who are confirmed as NAFLD without significant fibrosis (LSM <8.2)

Rationale Non-alcoholic fatty liver disease (NAFLD) is the most common cause of chronic liver disease affecting up to 25% of the world’s population. In India, the prevalence of NAFLD in the general population varies from 9 to 53% with geographical and rural–urban differences in the prevalence (De A et al 2021). Non-alcoholic steatohepatitis (NASH), its progressive form, is rapidly becoming the leading cause of end-stage liver disease and liver transplantation. NASH is still an underrecognized disease, as a large majority of noncirrhotic NAFLD and NASH patients remain asymptomatic. The prevalence is reported to be higher in high-risk groups like those with metabolic syndrome (MetS) and its individual components (Goyal A et al 2020). In a multicentric study conducted in 101 Indian cities, the prevalence of NAFLD among patients with type 2 diabetes mellitus (T2DM) was reported to be 56.5% (Kalra S et al 2013). The diagnosis of fatty liver is usually made based on an incidental finding on ultrasound, MRI or CT and elevated liver enzymes. Currently, there are no standard screening guidelines or therapy available for NAFLD and NASH in India and globally. A liver biopsy, an invasive procedure, is the only test to prove a diagnosis of NASH. Non-invasive biomarkers such as APRI, FIB-4 and NFS are widely used to screen the NAFLD. Although, these biomarkers can be leveraged to reduce the high percentage of screen failures due to liver biopsy. Therefore identification of diagnostic biomarkers at an early stage is of great importance.

Genome wide association studies (GWAS) have enabled the association of genetic polymorphisms with disease state or treatment response. Recent advances in sequencing the human genome have transformed methods of identifying genetic susceptibility for complex, multifactorial diseases. Only recently have researchers started harnessing NGS technology to identify genetic susceptibility for complex diseases. Using various genotyping approaches such as whole exome sequencing studies, it is now possible to sequence protein coding regions of the genome and identify genetic susceptibility for complex diseases in an unbiased way. Genome-wide association studies have identified susceptibility loci for NAFLD, which includes variants in PNPLA3, TM6SF2, SAMM50, PARVB genes. Understanding genetic susceptibility will  aid in identification of early detection biomarkers and potential drug targets for better management of the disease. In this study, we aim to explore the genetic basis of disease risk and progression for NASH.

ObjectivesPrimary Objective

• To carry out genomic profiling of NAFLD with significant Fibrosis (LSM ≥8.2)  to identify disease specific biomarkers

Secondary Objective

• To identify genetic variants which may be protective of NAFLD with significant Fibrosis or influence rate of progression
• To discover genotype-phenotype correlations between NAFLD with significant Fibrosis  across a spectrum of disease staging including nonalcoholic fatty liver (NAFL), nonalcoholic steatohepatitis (NASH), NASH-cirrhosis

Study designThis is a multi-centric, non-interventional, observational study aimed to identify clinically relevant biomarkers for early detection of NAFLD with significant Fibrosis  and the progression analysis of NAFLD to NASH.

This study aims to operate with two major study cohorts. Cohort 1  -  ‘NAFLD  affected’ patients diagnosed with clinically proven NAFLD with significant fibrosis (LSM ≥8.2) . Blood will be collected at one at the Baseline / screening/enrolment visit to understand the Genomics/proteomic/metabolomic profile .

Cohort 2 will consist of a ‘control cohort’ and will include patients who are confirmed  NAFLD without significant fibrosis (LSM <8.2). Blood will be collected at the screening/enrollment stage. Subjects with LSM <8.2 will be followed up for next two years to document their clinical prognosis. This is critical for subjects who may be harboring the same variant as those with LSM >8.2 and yet did not clinically progress at recruitment. The primary goal of this study is to identify reliable molecular markers that will aid in the diagnosis of NAFLD with significant Fibrosis  and enable identification of potential drug targets.

Liver stiffness is generally measured as:

Sl. No

Stages

LSM score

|1

Significant fibrosis (F2) unlikely

<6.0 kPa

|2

NAFLD-Significant fibrosis (≥F2)

≥8.2 kPa

|3

NAFLD-Advanced fibrosis (≥F3)

≥9.7 kPa

|4

NAFLD-Cirrhosis (F4)

≥13.6 kPa

Table: Liver Stiffness Measurement (LSM) Cut-Offs on Vibration Controlled Transient Elastography (Fibroscan) (Duseja A et al 2022).