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Lviv clinical bulletin 2018, 3(23): 8-23

https://doi.org/10.25040/lkv2018.03.008

Clinical-pathagenetic, Age, Gender, Genetic Aspects of Non-alcoholic Fatty Liver Disease and Nonviral Chronic Hepatitis Without, and also with Comorbid Hypothyroidism; Improving of Their Treatment

V. Prysyazhnyuk, O. Voloshyn

Higher State Educational Establishment of Ukraine “Bukovinian State Medical University”

Introduction. Non-alcoholic fatty liver disease (NAFLD) is the most common ailment among all liver lesions [12, 13, 53], which occurs in 20.0-30.0 % of the adult population of Western Europe and North America and 5.0-18.0 % inhabitants of Asia [64]. This is due to an increase in the number of people with obesity, dyslipidemia, an increase in the incidence of type 2 diabetes and metabolic syndrome [1, 16, 18, 52]. The conditions that can be associated with NAFLD are also actively discussed, among which hypothyroidism plays an important role [56], the incidence of which has recently increased [9, 15, 19, 35]. According to research results, hypothyroidism even in the subclinical form increases the risk of NAFLD [8, 51]. Some scientists point out the link between the concentration of thyrotropic hormone (TTG) in the blood and the NAFLD severity [41]. F. Yan et al. have shown that the increase in TSH concentration leads to an increase in the content of triacylglycerols in the liver [70]. At the same time, the content of free thyroxine (T4) in the blood inversely correlates with the severity of liver steatosis [42].

During recent decades, chronic hepatitis (CH) has become widespread in Ukraine and in the world (13, 32). An abusive use of alcoholic beverages is evolved among the etiologic factors of CH [5, 30]. An important role in the pathogenesis of CH also belongs to the influence of household and industrial toxins [20, 57].

It is known, that cytokines and adipokines play an important role in the processes of inflammation, adipogenesis and fibrogenesis of hepatic tissue [44, 59]. However, the participation of some of them in these processes requires further study.

Age and gender peculiarities of the development and increase of the severity of NAFLD and CH were investigated by E. Ya. Sklyarov et al. [11], C. D. Williams et al. [68], M. Bertolotti et al. [25]. In particular, M. Bertolotti et al. noted that NAFLD in elderly people more often as compared to young people leads to the occurrence of steatogenic liver cirrhosis, hepatocellular carcinoma and extrahepatic manifestations of the disease [25]. C. D. Williams et al. indicate that male gender in those patients is associated with a higher aminotransferases activity, more frequent occurrence of liver fibrosis and higher rates of lethality [68]. Other researchers note the higher sensitivity of women to ethanol hepatotoxicity, which results in faster liver damage provided the use of lower doses of alcohol in comparison with men [20].

Genes are noteworthy among the factors that can affect the onset and increase in the severity of NAFLD and HC [50, 62, 69]. The genes encoding the synthesis of glutathione-S-transferase (GST) are among the major contributors to the pathogenesis of various chronic diffuse liver diseases (CDLD) [40, 65]. Other genes that affect adiposity and fibrogenesis are the genes coding the synthesis of peroxisome proliferator-activated receptors (PPARs) [67, 71], which play a key role in the synthesis, deposition, and transport of lipids and can affect the NAFLD onset and natural history [36].

The investigation of new methods of complex treatment for NAFLD and CH patients that would not only effectively reduce the clinical and laboratory manifestations of the disease, but also pathogenetically affect the mechanisms of their occurrence and natural history are actual questions of modern internal medicine.

The aim of the study is to improve the diagnostics and efficacy of treatment of non-alcoholic fatty liver disease and chronic non-viral hepatitis patients, taking into account clinical and pathogenic, age, gender, genetic factors and the presence of hypothyroidism.

Materials and methods of research. The basis of clinical study was prospective monitoring of 311 patients with CDLD, 188 among them were NAFLD patients (including 44 who in addition to the liver disease were diagnosed with hypothyroidism) and 123 patients with non-viral CH. Among the examined NAFLD patients, 102 (54.3 %) were men, 86 (45.7 %) – women, among CH patients men prevailed – 91 (74.0 %), women were 32 (26.0 %). Age of patients – from 21 to 79 years. The average age of NAFLD patients was 53.6 ± 12.34 years, CH patients – 50.2 ± 13.70 years. The control group included 45 practically healthy persons, representative of the age and gender to the examined patients.

Overweight and obesity of the alimentary origin of the I-III stages were the etiologic factor of NAFLD in the examined patients, in 24 (12.8 %) patients NAFLD was associated with type 2 diabetes.

The etiologic factor of CH in 111 (90.3 %) of the examined patients was prolonged abuse of alcoholic beverages, along with periodic, clinically determined influence of household and industrial toxic agents (lacquers, pesticides, organic solvents, gasoline, etc.). In 12 (9.7 %) patients CH was the result of prolonged contact with hepatotoxic professional factors.

NAFLD diagnosis was verified in accordance with the Order of the Ministry of Health of Ukraine No. 826 dated 06.11.2014, and an adapted clinical guideline based on the evidence of “Non-alcoholic Fatty Liver Disease” [6] and EASL-EASD-EASO Clinical Practice Guidelines for the management of non-alcoholic fatty liver disease [56].

Diagnosis of CH was made in accordance with the Order of the Ministry of Health of Ukraine No. 826 dated 06.11.2014 “On Approval and Implementation of Medical-Technological Documents for the Standardization of Medical Assistance in Chronic Non-Infectious Hepatitis” [6] and Order of the Ministry of Health of Ukraine No. 1051 dated 28.12.2009 “On Provision of Medical Aid for patients of gastroenterological profile “[7].

Hypothyrosis diagnose was verified according to clinical recommendations for the diagnosis of hypothyroidism of the European thyroid association [26], the American Association of Clinical Endocrinology and the American Thyroid Association [34]. Degree of severity and compensation of hypothyroidism were determined on the basis of clinical manifestations and indicators of the thyroid profile: concentrations of TTG and free T4 and triiodothyronine (T3) in the blood: in 20 patients hypothyroidism was found in the subclinical, and in 24 patients – in the manifestation form.

The inclusion criterion of patients in the study was a verified diagnosis of NAFLD and confirmed diagnosis of CH of toxic-alcoholic etiology.

The exclusion criteria of patients from the study were viral and autoimmune CDLD, decompensated cardiovascular diseases, systemic diseases, concomitant diseases in the active phase or stage of decompensation; pregnancy and breastfeeding, patients who did not give informed consent to participate in the study.

The classification of the World Congress of Gastroenterology (Los Angeles, 1994, supplemented by Desmet V. et al., 1995) [28], with refinements of the ICD of the 10th revision were used in the investigation. The CH activity degree was determined based on the alanine aminotransferase (ALT) activity in the blood. 96 patients (78.0%) were examined low, 27 patients (22.0%) – moderate activity of CH.

All examined patients performed a complex clinical-laboratory and instrumental diagnostic methods: general examination, palpation, percussion and auscultation, pulse measurement and blood pressure, determination of anthropometric data with the calculation of body mass index.

Biochemical blood tests and lipidogram indices were performed on a biochemical analyzer Accent-200 (Cormay S.A., Poland). The spectrum of biochemical blood count indicators included: glucose, total bilirubin and its fractions, uric acid, total protein and albumin, urea and creatinine, activity of enzymes (aspartate aminotransferase (AST), ALT, total lactate dehydrogenase (LDH (total)), alkaline phosphatase (AP), gamma-glutamyltranspeptidase (GGTP)). The lipid spectrum study envisaged the determination of the content of total cholesterol, triacylglycerols, high-density lipoprotein cholesterol (HDL), low density lipoprotein (LDL), and very low density lipoprotein (VLDL), and an atherogenic index.

Hepatic steatosis index (HSI) was determined on the basis of clinical and biochemical studies and anthropometric indices for NAFLD patients, NAFLD liver fat score was found out taking into account the content of insulin in the blood.

The study of thyroid profile included the study of TTG and free T4 and T3 in blood plasma, as well as the determination of the concentration of antibodies to tyroglobulin and thyroid peroxidase in the blood with the help of the Sunrise immune enzyme analyzer (Texan, Austria).

To exclude the viral etiology of the disease, all examined patients were tested for possible infection with hepatitis B and C. Virus hepatitis B and C were detected in the blood at ICycler iQ amplifier (Bio-Rad Laboratories, USA) with fluorescence detection in real time for polymerase chain reaction (PCR).

The activity of free radical oxidation processes was determined by spectrophotometric method in the content of reaction products of thiobarbituric acid (TBA-reactive products) in the blood. The activity of the antioxidant system was evaluated by measuring the concentration of reduced glutathione by the method of O.V. Travina [14], as well as by determining the activity of catalase [KF 1.11.1.6] by the method of M.A. Korolyuk et al. [4], glutathione-S-transferase [KF 2.5.1.18] by the method of H.W. Habig et al. [37] and glutathione peroxidase [KF 1.11.1.9] by the method of I.V. Gerush, N.P. Grygoryeva, I.F. Meschyshen [3].

The genomic polymorphism was studied at the State Institution “Reference Center for Molecular Diagnostics of the Ministry of Health of Ukraine” (Kyiv). Polymorphic variants of genes PPARγ (Pro12Ala) (rs 1801282) and GSTP1 (A313G) (rs 1695) were determined according to modified protocols with oligonucleotide primers using the PCR method and the subsequent analysis of polymorphism of the length of the restriction fragment. The GSTT1 and GSTM1 deletion polymorphisms were determined according to the oligonucleotide primer protocol by the allelic-specific PCR method. The investigated genome sites were amplified using specific primers (Metabion, Germany).

The tumor necrosis factor-α (TNF-α), interleukin-10 (IL-10) and transforming growth factor-β1 (TGF-β1) (Bender MedSystems GmbH, Austria), atrial natriuretic propeptide (proANP) (1-98) (Biomedica, Austria), leptin (Diagnostics Biochem Canada Inc., Canada), adiponectin (BioVendor – Laboratorni medicina, Czech Republic), insulin (Monobind Inc., USA) in blood plasma were determined using the Statfax 303 / Plus immunoassay analyzer (Awareness Technology Inc., USA) according to manufacturer’s instructions.

The insulin resistance index HOMA IR and the J. F. Caro index were calculated to determine insulin resistance.

Ultrasound examination of the organs of the abdominal cavity was performed using Sonix SP (Ultrasonix, Canada) and En Visor HD (Phillips Ultrasound System, USA) with liver, gall bladder, pancreas, spleen parameters, vascular sizes (v. portae, v. lienalis) investigation in accordance with the standard protocol for ultrasound examination.

To determine the nature and degree of the liver damage, acoustic radiation force impulse elastroraphy of the liver (ARFI – VTQ) was performed on the Acuson S2000 diagnostic system (Siemens Medical Solutions, USA) with a convection-shaped sensor at a frequency of 2.0-5.0 MHz at a depth of 30.0-50.0 mm from the capsule and at least 10.0 mm from the main vessels. On the basis of measurements, the average speed of the shear wave was determined, which characterized the stiffness of the liver parenchyma.

The ultrasound examination of the thyroid gland was carried out with the help of the apparatus UDS-6 (LLC “Emanis”, Ukraine) in accordance with the recommendations of the American Association of Clinical Endocrinologists, the Association of Endocrinologists and the European Association of Thyroid Glands.

Echocardiographic study was performed using ultrasound diagnostic system En Visor HDC (Phillips Ultrasound System, USA) with the definition of structural and functional parameters by the method of M. N. Asmi, M. J. Walsh [22]. The left ventricular myocardial mass was determined by the formula R. Devereux and N. Reichek in the modification of the American Society of Echocardiography, the type of remodeling of the left ventricle, according to the classification by A. Ganau et al., proposed by the ESH / ESC Committee on Diagnosis and Prevention of Arterial Hypertension [31, 33].

NAFLD patients were treated in accordance with the Order of the Ministry of Health of Ukraine No. 826 dated 06.11.2014 and adaptive clinical guidelines based on the evidence of “Non-alcoholic Fatty Liver Disease” [6] and EASL-EASD-EASO Clinical Practice Guidelines for the management of non-alcoholic fatty liver disease [56], which included: modification of lifestyle and diet, gradual decrease in body weight, metformin (in the presence of type 2 diabetes mellitus), omega-3 fatty acids.

CH patients were treated in accordance with the Order of the Ministry of Health of Ukraine No. 826 from 06.11.2014 “On approval and implementation of medical-technological documents on the standardization of medical care in chronic non-infectious hepatitis” [6] and the Order of the Ministry of Health of Ukraine No. 1051 from 28.12.2009 “On the provision of medical Assistance to patients with gastroenterological profile “[7]: hepatoprotectors (s-adenosylmethionine, essentiale), detoxification agents (reosorbilact, 5.0% glucose solution), metabolic drugs (meldonium or riboxin), multivitamins.

Hypothyroidism was treated in accordance with the Recommendations for the Treatment of Hypothyroidism of the American Thyroid Association [43], using substitution hormonal therapy with adequate doses of levothyroxine.

The first main group included 41 NAFLD patients who in addition to the main treatment were prescribed quercetin tablets 40.0 mg (1 tablet) three times daily for 30 minutes prior to meals for 14-16 days and continued their use at the outpatient stage until 2 months.

The second main group was formed by 25 CH patients, who in addition to the main treatment were prescribed quercetin tablets 40.0 mg (1 tablet) three times a day for 30 minutes before meals for 14-16 days and who then use it in outpatient stage up to 2 months.

The third main group included 30 NAFLD patients, who received L-carnitine 2.0 g (10.0 ml) once daily intravenously, for an intravenous injection for 14 days in addition to the main treatment.

The fourth main group was formed by 30 CH patients, who received L-carnitine 2.0 g (10.0 ml) once daily intravenously, for an intravenous injection for 14 days in addition to the main treatment.

Comparison group for the first and third main groups included 30 NAFLD patients who received basic treatment. Comparison group to the second and fourth main groups was formed by 30 patients with non-viral CH who were prescribed only main treatment. The effectiveness of treatment was evaluated on the 14th-16th day. Long-term treatment results were monitored after 6 and 12 months by conducting a questionnaire and an objective examination of the patients.

The statistical analysis of the data was carried out using the computer program PAST Version 2.17 (Copyright Hammer, 1999-2017) [38]. To determine the statistical differences between the two independent groups, Student’s t-criterion for independent groups was used in the case of normal data distribution; for the nonparametric data H. B. Mann – D. R. Whitney criterion was used. To compare three groups and more, the criterion of W.H. Kruskal – W.A. Wallis was used.

The reliability of changes in indicators in the dynamics of treatment for normal distribution in the samples was determined on the basis of the twin criterion of Student, in the case of a difference from normal – according to the criterion of F. Wilcoxon. The correlation analysis for the normal data distribution was performed by K. Pearson’s method, in case of data distribution different from the normal – by C. Spirman method. The statistical analysis of remote treatment results was carried out using the method of odds ratio calculating. To test the statistical hypothesis about the equality of odds ratio to a one (ω = 1) the criterion χ2 of K. Pearson was used.

The genotype distribution in the population to G. H. Hardy – W. Weinberg equilibrium was determined; the comparison of the genes alleles frequencies was performed with an index of freedom degree 1 df, frequencies of the genotypes between the studied groups and controls with a degree of freedom 2 df. To compare the distribution of the alleles of the studied polymorphisms of the genes in the examined patients and practically healthy individuals the criterion χ2 by K. Pearson and R. A. Fisher’s criterion were used. The model of inheritance was determined using the information criterion of H. Akayke. The probability of error was considered to be less than 5.0% (p <0.05).

Results of the research and their discussion. NAFLD patients have age-related increase of glucose and urea levels, LDH (total) and AP activity in blood. There was significant age-related increase in total blood cholesterol, triacylglycerols and LDL cholesterol. Elderly patients had a higher TNF-α content in the blood by 62.8 % (p = 0.045) and in 2.06 times (p = 0.01) as compared to young and middle-aged patients, indicating an increase in the activity of inflammation processes [24, 27]. Negative correlation of mean strength between IL-10 in blood and AST activity (r = -0.57, p = 0.03), ALT (r = -0.61, p = 0.02) and GGTP (r = -0.61, p = 0.03) was detected in middle-aged patients.

The concentration of proANP in the blood increased in 3,09 times (p = 0,02) and 2,05 times (p = 0,02) in elderly patients in comparison with the corresponding indicators in young and middle-aged patients, which may indicate the occurrence of latent heart failure [61]. Strong direct correlation between the concentration of proANP in blood and total bilirubin content (r = 0.95, p = 0.05), GGTP activity (r = 0.95, p = 0.05) was investigated in young patients. ProANP concentration was inversely correlated with albumin in the blood (r = -0.81, p = 0.03) in middle-aged patients. There was a strong direct correlation between the concentration of proANP in blood and GGTP activity (r = 0.93, p = 0.008) in elderly patients, as well as in young patients. Strong reverse correlation between adiponectin content and LDH activity (total) (r = -0.81, p <0.05), GTTP (r = -0.93, p = 0.008) and triacylglycerols content (r = -0.95, p <0.001) was examined in the blood in young patients. Also, the inverse correlation of mean strength between adiponectin content in the blood and GGTP activity (r = -0.61, p = 0.03), triacylglycerol content (r = -0.56, p = 0.047) was proved in middle-aged patients. Direct correlation between the amount of leptin in the blood and AST activity (r = 0.49, p = 0.045) was noted in patients of middle age.

NAFLD patients were evaluated with HSI index. For patients of young age the average index value was 43.6 ± 1.01, for middle-aged – 42.7 ± 0.87, and for elderly – 41.8 ± 0.80. The value of HSI in practically healthy individuals of different age groups was 6.5 ± 0.88, 7.8 ± 0.46, 7.6 ± 0.52, respectively, and were significantly lower (p <0.001) than those obtained in NAFLD patients. As it is known, HSI values over 36.0 allow verifying NAFLD with specificity of 92.4%, and less than 30.0 – to exclude NAFLD with sensitivity of 93.1% [47].

The NAFLD liver fat score was also determined. At the index value – 0,640 NAFLD is prognosed with a sensitivity of 84.0% and a specificity of 69.0%; with the index of 1,413, the sensitivity of the test increases to 95.0%, and at a value of 1.257 the specificity reaches 94.0% [46]. In young patients NAFLD liver fat score was 5.1 ± 1.54 on average, 4.4 ± 1.67 in middle-aged patients, and 4.2 ± 0.87 in the elderly. In practically healthy individuals, the value of the index reached – 1.8 ± 0.48, – 1.9 ± 0.69 and – 1.9 ± 0.34 respectively, and were significantly lower (p = 0.02 – <0.001) as compared to NAFLD patients. The obtained results of both of the studied indices did not have reliable age differences and confirmed NAFLD in patients of all age groups.

In the context of the results of biochemical studies, it was important to compare them with the parameters of ultrasonographic screening of the liver. In patients who underwent ultrasound examination of the liver, the classical changes that are typical for NAFLD were diagnosed: hepatomegaly, diffuse hyperechogenicity of liver parenchyma and heterogeneity of its structure, fuzzy vascular pattern and distal attenuation of echosignal. In patients of all age group vertical size of the liver was greater in comparison with practically healthy individuals of the corresponding age. However, age differences of these ultrasonographic parameters were not observed. To clarify the nature of pathological changes in the liver, acoustic radiation force impulse elastroraphy of the liver was performed. NAFLD patients determined the status of the hepatic parenchyma, which corresponded to stages from F0 to F2 (in some patients of middle and old age), which made it possible to exclude the presence of steatogenic liver cirrhosis.

In the middle-aged and elderly patients larger leasing sizes of left atrium are noted by 5.1 % (p = 0.04) and 5.3% (p = 0.03), right ventricle – by 11.5 % (p <0.001) and 13.3 % (p <0.001), thickness of the posterior wall of the left ventricle in the diastole by 7.1 % (p = 0.04) and 16.1 % (p <0.001), and in the elderly patients thickness of the interventricular septum in diastole – by 9.7 % (p = 0.006) as compared to patients of young age. The ejection fraction reduced by 5.9 % (p = 0.04) and 4.6 % (p = 0.04) in patients of the middle and old age as compared to younger ones. In the examined elderly patients greater left ventricular myocardial mass was found to be increased by 20.7 % (p = 0.01) and its index – by 30.8 % (p <0.001) as compared to parameters in young patients. According to the evaluated echocardiographic changes the formation of the concentric remodeling and eccentric hypertrophy of the left ventricle myocardium was detected in patients of young and middle age, appearance of its concentric hypertrophy was noted in elderly patients.

Higher content of albumin on average by 1.6 g / l (p = 0.04), total protein – by 1.7 g / l (p = 0.02) and creatinine – by 13.2 % (p <0.001) were recorded in male NAFLD patients as compared to women. AST and ALT activity were higher by 44.3 % (p <0.001) and 56.1 % (p = 0.001), and also GGTP – more than twice (p <0.001) in blood in men as compared to women. The obtained results confirm the data of other authors who showed that male gender in NAFLD patients is associated with higher aminotransferase activity [68].

Men with NAFLD recorded a lower content of total cholesterol in the blood by 10.1 % (p = 0.03), LDL cholesterol – at 13.5 % (p = 0.04) and HDL cholesterol – by 16.9 % (p <0.001) in comparison with women. In women with NAFLD the content of leptin in the blood by 53.0 % (p = 0.04) prevailed such parameter in males. Men reported to have bigger vertical dimension of the right lobe of the liver on average by 5.7 mm (p = 0.03) than women. This evidence that NAFLD in men is associated with higher activity of cytolytic and intoxication syndromes, which are accompanied with more pronounced hepatomegaly.

The conducted investigation have showed increased content of the glucose, decreased LDH activity and the albumin content in CH patients of middle and old age as compared to the corresponding indices of CH patients of young age. In the elderly patients higher urea, createnine levels and AP activity were noted as compared to young patients. Lower content of HDL cholesterol were observed in patients of middle and old age, and higher content of LDL cholesterol was noted in elderly as compared to young patients. Changes in the lipid profile resulted in a significantly higher atherogenic index in the elderly patients. They also had a higher TNF-α content by 79.0 % (p = 0.03) in the blood as compared to young patients. An inverse correlation of mean strength between proinflamatory cytokine and albumin (r = -0.55, p = 0.01) and direct correlation with LDH (total) (r = 0,49, p = 0.03) and AP activity (r = 0.59, p = 0.008) were investigated in the middle age patients. A direct correlation between the TNF-α concentration in the blood and AST activity (r = 0.63, p = 0.05) was established in the examined patients of old age. There were a reverse correlation of the mean strength between of IL-10 content in the blood and GGTP activity (r = -0.66, p = 0.04), as well as the direct correlation between the concentration of TGF-β1 in the blood and urea (r = 0.72, p = 0.01) and creatinine content (r = 0.69, p = 0.02) in patients of young age.

It was considered appropriate to study the concentration of proANP in the blood in the aspect of early diagnostics of the heart injury in CH patients. The growth of this indicator with age was characteristic for the examined patients: in elderly patients it was by 75.9% (p = 0.02) higher as compared to young patients. In young patients, the proANP content in the blood was positively correlated with the AST activity (r = 0.95, p = 0.01). The revealed correlation between the content of cytokines and adipokines and the biochemical markers of cytolytic, cholestatic, intoxication syndromes, lipid profile indicate their important role in the pathogenesis of NAFLD and CH.

Elderly patients were diagnosed with larger sizes of both the right and left lobes of the liver as compared to young patients. According to the results of the liver elastography, it was determined that the liver parenchyma corresponded to the stages F0-F2, indicating the absence of liver cirrhosis among CH patients.

With increase of age they observed changes in echocardiographic parameters of the heart: enlargement of the size of the left atrium, right ventricle, end diastolic and systolic size, thickness of the posterior wall of the left ventricle in the diastole, thickness of the interventricular septum in diastole. In middle-aged patients, ejection fraction was by 5.2 % (p = 0.04), and the elderly was by 9.8 % (p = 0.03) lower in comparison with CH patients of young age. Patients with CH of the middle and old age were examined with increased left ventricle myocardium mass by 14.3 % (p <0.05) and 17.7% (p <0.05) and left ventricle myocardium mass index by 17.6 % (p = 0.03) and 18.9 % (p = 0.02). The geometry of the left ventricle has changed. This was manifested by the increase in the incidence of eccentric and concentric left ventricular hypertrophy in patients of older age-groups, indicating a latent formation of heart injury, probably due to liver damage, and toxic effects [54, 66], which was one of the reasons of CH development.

A higher creatinine in the blood was recorded in male patients, at 18.0 % (p <0.001) as compared to women. At the same time, for female CH patients, LDH (total) activity and GGTP in the blood was found to be by 11.8 % (p = 0.04) and by 50.2 % (p = 0.03) higher respectively. Men with CH had a higher content of triacylglycerols by 33.6 % (p = 0.02) and a lower content of HDL cholesterol by 24.5 % (p = 0.01) in blood as compared to lipid profiles in women. Men had 2.4 times higher (p = 0.046) TNF-α level in the blood. Gender differences in ultrasonographic sizes of the liver in CH patients have not been determined.

In order to investigate the possible association of genetic factors with the peculiarities of the natural history of NAFLD and CH the A313G polymorphism of the GSTP1 gene, the deletion polymorphism of the GSTT1 and GSTM1 genes and Pro12Ala polymorphisms of PPAR gene were chosen for the study as they determinant of expression of factors that are actively involved in the pathogenesis of these CDLD. Due to the fact that analyzed parameters in control group did not differ significantly between the carriers of the genotypes of the studied polymorphisms of abovementioned genes, it was considered appropriate to use the average values of the obtained parameters as referential. G-allele of GSTP1 (A313G) gene in NAFLD patients is more widely found (χ2 = 5.69, p = 0.017) as compared to practically healthy individuals. This results are in agreement with the results of M. Hashemi et al., who showed that G-allele of GSTP1 gene is associated with a higher risk of NAFLD in the Iranian population [39]. G-alleles carriers of GSTP1 (A313G) gene recorded higher ALT activity as compared to patients with AA-genotype of the mentioned gene. In particular, in patients with AG-genotype it was higher by 65.5% (p = 0.01), and in patients with the GG-genotype – by 42.3 % (p = 0.04) in comparison with homozygous carriers of A-alelle (Fig. 1).

Fig. 1. The alanine aminotransferase activity in blood depending on polymorphous variants of A313G polymorphism of GSTP1 gene in non-alcoholic fatty liver disease patients.

Notes: p1 – the reliability of differences as compared to the indicators in practically healthy individuals; p2 – the reliability of differences as compared to the indicators in NAFLD patients with AA-genotype.

AG-genotype carriers of A313G GSTP1 gene polymorphism NAFLD patients was found to have higher glutathione-S-transferase activity by 13.3% (p = 0.047) as compared to patients with AA-genotype. NAFLD patients homozygous G-alleles had a higher content of IL-10 in the blood as compared to patients with AA- and AG-genotypes by 14.6% (p = 0.04) and 61.8% (p = 0,02). ProANP blood concentration was 2.71 times (p = 0.02) and 2.36 times (p = 0.04) higher, leptin concentration was increased by 76.0% (p = 0.02) and 59.4% (p = 0.045) and adiponectin content in the blood was lower by 70.8% (p = 0.002) and in 2.16 times (p = 0.004) in patients with AG- and GG-genotypes as compared to the corresponding indices in patients with AA-genotype (Table 1), which is an unfavorable factor taking into the consideration conclusions of G. Li et al., in which the decreased level of adiponectin is associated with an increase in the severity of steatohepatitis [48]. In general, this indicates the formation of adipokine imbalance in the examined patients, which is characteristic for NAFLD patients [16, 60].

Table 1

The content of cytokines and adipokins in the blood of nonalcoholic fatty liver disease patients depending on the A313G polymorphism of the GSTP1 gene

Notes: p1 – the reliability of differences as compared to the indicators in practically healthy individuals; p2 – the reliability of differences as compared to the indicators in NAFLD patients with AA-genotype; p3 – the reliability of differences as compared to the indicators in NAFLD patients with AG-genotype.

No significant differences in the indicators reflecting the main functions of the liver and the markers of its damage in the patients carrying the various variants of the deletion polymorphism of the GSTT1 and GSTM1 genes were found. The deletion polymorphism of GSTT1 and GSTM1 genes in these patients was associated with higher free radical activity, which led to the depletion of enzyme and non-enzyme antioxidant systems of protection and was manifested in reduced catalase activity by 11,3 % (p = 0,04) and 12.8 % (p = 0.04), glutathione-S-transferase by 15.7 % (p = 0.04) and 19.2 % (p = 0.04), restored glutathione content by 27.0 % (p <0.001) and 14.5 % (p = 0.04) in the blood, and in patients with the null-genotype of GSTM1 gene, also increased glutathione peroxidase activity by 11.5 % (p = 0.03) and increased TBA-reactive products concentration at 8,3 % (p = 0.04). Patients with null genotype of GSTT1 indicated a twofold (p = 0.01) higher TNF-α level in the blood as compared to patients with normal GSTT1 genotype. Leptin content in the blood was greater by 37.1 % (p = 0.04) in patients with null-genotype GSTM1 in comparison with patients with the normal genotype GSTM1. Patients with AG- and GG-genotypes of GSTP1 have a larger vertical diameter of the liver by the middle clavicle line at 7.0 mm (p = 0.03) and 6.6 mm (p = 0.046) respectively, as compared to homozygous carriers of A-allele of GSTP1 gene. The larger size of the right lobe of the liver was recorded at 5.5 mm (p = 0.04) and 6.2 mm (p = 0.04) in patients with deletion polymorphism of the GSTT1 and GSTM1 genes as compared to patients with normal genotype of GSTT1 and GSTM1 genes.

The distribution of genotypes of the Pro12Ala polymorphism of the PPARγ gene was not significantly different in NAFLD patients and practically healthy individuals, confirming the results of meta-analysis conducted by A. Sahebkar, which also did not detect the relationship between carrier of various PPAR-γ (Pro12Ala) genomic variants and the incidence of NAFLD [63]. NAFLD patients Ala-allele of PPAR-γ (Pro12Ala) gene carriers determined higher AST activity at 29.1 % (p = 0.04), ALT – by 45.2 % (p = 0.03) as compared to patients with Pro / Pro-genotype.

Patients Ala-allele carriers recorded decreased concentration of reduced glutathione in the blood by 15.9 % (p = 0.04) as compared to patients with Pro / Pro-genotype. Patients with NAFLD Ala-carriers showed a higher content of leptin in the blood by 45.6 % (p = 0.04) and proANP 2.43 times (p = 0.009) in comparison with patients with Pro / Pro-genotype (Table 2). Pointed increase in the leptin content in patients with Pro / Ala and Ala / Ala genotypes of PPAR-γ gene may be associated with a tendency to increase of the TNF-α content in the blood in patients in this group that may stimulate the production of leptin [58] and, probably, indicates the appearance of syndrome of leptin resistance [21].

Table 2

Cytokine and adipokine profiles depending on the Pro12Ala polymorphism of the PPAR-γ gene in nonalcoholic fatty liver disease patients

Notes: p1 – the reliability of differences as compared to the indicators in practically healthy individuals; p2 – the reliability of differences as compared to the indicators in NAFLD patients with Pro/Pro-genotype.

The study of genes polymorphism in CH patients showed that G-allele of GSTP1 was associated with a higher ALT activity in blood by 44.0 % (p = 0.046) as compared to patients with AA-genotype (Fig. 2).

Fig. 2. The alanine aminotransferase activity in the blood, depending on the polymorphous variants of A313G polymorphism of GSTP1 gene in patients with chronic hepatitis.

Notes: p1 – the reliability of differences as compared to the indicators in practically healthy individuals; p2 – the reliability of differences as compared to the indicators in CH patients with AA-genotype.

GSTP1 G-allele carriers had a lower content of reduced glutathione by 16.2% (p = 0.04) as compared to patients with AA-genotype. The GSTM1 gene deletion polymorphism in CH patients is associated with a lower catalase activity by 15.5 % (p = 0.03) and higher content of TBA-reactive products by 10.8 % (p = 0.03) in comparison with patients with normal genotype. Patients with the null-genotype of GSTT1 gene recorded a 2.24-fold higher (p = 0.03) content of IL-10 in the blood as compared to patients with normal genotype of this gene. Statistically significant differences in the ultrasonographic sizes of the liver in CH patients carriers of different allelic variants of the A313G polymorphism of the GSTP1 gene and the deletion polymorphism of GSTT1 and GSTM1 genes were not detected.

Patients with CH Ala-allele carriers of the PPAR-γ (Pro12Ala) gene indicated higher activity of glutathione peroxidase by 18.3 % (p = 0.02) and higher level of IL-10 in the blood in 2.07 times (p = 0.04) as compared to patients with Pro / Pro genotype indicating the tension of protective antioxidant systems and the anti-inflammatory substances of the cytokine profile in patients with the Ala-allele of PPAR-γ gene Pro12Ala polymorphism.

Consequently, as a result of the studies, it was found that only G-allele GSTP1 (A313G) gene from the selected polymorphisms of candidate genes is more frequently occurring in NAFLD patients as compared to practically healthy people. There was no significant difference between the frequency of allelic variants of the GSTP1 (A313G) and PPAR-γ (Pro12Ala) genes and deletion polymorphism of GSTM1 and GSTT1 genes in CH patients and practically healthy individuals. At the same time, associative connections were found between the allelic variant of a particular genome and the activity of markers of the cytolytic syndrome, indications of cytokine and adipokine profiles, indicating the participation of these genes in the pathogenesis of NAFLD and CH.

It should be noted that in addition to the well-known etiologic causes of NAFLD, other factors that may be associated with this disease are discussed. Among them, an important place relates to hypothyroidism, which, according to a number of scientists, even in the subclinical form increases the risk of this disease [8, 51].

In patients with NAFLD and subclinical and manifested hypothyroidism, clinical manifestations of liver disease were deepened, torpid course was determined, higher LDH (total) activity and a higher content of total cholesterol and LDL cholesterol in blood were observed (Table 3).

Table 3

Lipid profile in nonalcoholic fatty liver disease patients, depending on the form of hypothyroidism

Notes: p1 – the reliability of differences as compared to the indicators in practically healthy individuals; p2 – the reliability of differences as compared to the indicators in NAFLD patients with normal function of thyroid gland.

NAFLD patients and manifested hypothyroidism also determined higher AP activity and lower catalase activity in blood as compared to NAFLD patients with normal thyroid function. The content of TBA-reactive products was higher in NAFLD patients, both with subclinical and manifested hypothyroidism as compared to NAFLD patients and normal thyroid activity.

Patients with subclinical and manifested hypothyroidism have a higher content of leptin in the blood by 35.7 % (p = 0.04) and 72.1 % (p = 0.009), and those with NAFLD combined with manifested hypothyroidism – also in 2,1 times (p = 0.004) lower adiponectin as compared to patients without hypothyroidism. In NAFLD patients insulin resistance syndrome has been diagnosed, which, according to other researchers, is typical for this disease [17, 45]. The HOMA IR index was 4.17 times higher (p <0.001), while the index J. F. Caro was by 44.4 % (p = 0.04) lower in comparison with practically healthy individuals. In patients with a comorbid combination of NAFLD and hypothyroidism, the severity of the syndrome of insulin resistance aggravated. In particular, the J. F. Caro index was 4.15 times (p <0.001) and 3.38 times (p <0.001) lower in patients with concomitant subclinical and manifested hypothyrosis in comparison with patients without hypothyroidism (Fig. 3).

Fig. 3. Index of J. F. Caro in non-alcoholic fatty liver disease patients, non-alcoholic fatty liver disease and hypothyroidism patients and practically healthy persons.

Notes: p1 – the reliability of differences as compared to the indicators in practically healthy individuals; p2 – the reliability of differences as compared to the indicators in NAFLD patients with normal function of thyroid gland.

At the same time, HOMA IR index was by 67.7% (p = 0.04) higher in NAFLD patients with manifested hypothyroidism as compared to patients with normal thyroid activity (Fig. 4).

Fig. 4. HOMA IR index in non-alcoholic fatty liver disease patients, non-alcoholic fatty liver disease and hypothyroidism patients and practically healthy persons.

Notes: p1 – the reliability of differences as compared to the indicators in practically healthy individuals; p2 – the reliability of differences as compared to the indicators in NAFLD patients with normal function of thyroid gland.

Larger vertical diameter of the liver was observed in the middle clavicle line at average by 9.1 mm (p = 0.004) in NAFLD patients and manifested hypothyroidism as compared to NAFLD patients with unchanged thyroid gland function and by 8.6 mm (p = 0.04) in comparison with NAFLD patients with subclinical hypothyroidism.

Consequently, the investigation of the features of the NAFLD under the conditions of hypothyroidism has shown the torpidity of the NAFLD clinical course, which is combined with higher activity of markers of cholestasis, proatherogenic changes of the lipid profile, adipokine imbalance and deepening of the insulin resistance syndrome.

The search for new methods of complex treatment for patients with NAFLD and CH that would not only effectively reduce the clinical and laboratory manifestations of the disease, but also pathogenetically affect the mechanisms of their occurrence is the urgent task of modern internal medicine. L-carnitine and quercetin medications which, in addition to the basic treatment, were prescribed to the examined patients were used to solve this task.

NAFLD patients showed a positive effect of the L-carnitine systemic use on functional liver parameters, namely: decreased AST activity in the blood by 51.5 % (p = 0.03) and ALT – by 50.9 % (p = 0.046), LDH (total) – by 16.2 % (p = 0.03), GGTP – by 55.8 (p = 0.04). Such a conclusion was reached by M. Malaguarnera et al., who proved that the appointment of carnitine to non-alcoholic steatohepatitis patients contributes to a decrease in the ALT, AST, GGTP activities, the reduction of total cholesterol, HDL cholesterol and LDL cholesterol, triacylglycerols, C-reactive protein and TNF-α in the blood [55] A multi-center clinical trial CORONA demonstrated clinical and laboratory improvement in NAFLD in patients who were administered carnitine orotate, which was manifested in lowering of ALT activity in the blood and improving the index of attenuation of the liver parenchyma by the results of computer tomographic study [23]. Decrease in glucose content in the blood on average by 0.4 mmol / l (p = 0.03) was also noted in the examined patients indicating a beneficial effect of L-carnitine on carbohydrate metabolism. Such biochemical changes in blood in patients treated with the additional L-carnitine administration were associated with more intensive restoration of antioxidant systems, in particular, an increase in reduced glutathione content by 15.5 % (p = 0.02), an increase in the catalase activity – by 17.2 % (p = 0.04) and a decrease in the TBA-reactive products content by 21.1 % (p = 0.04) in the blood. The decrease in TNF-α content by 39.8 % (p = 0.04) was detected in these patients, indicating decrease in the intensity of inflammation and decrease in the of leptin content by 44.1 % (p = 0.02) with a simultaneous increase in 2,03 times (p = 0.03) of the adiponectin content in the blood, indicating the ability of L-carnitine to adjust the adipokine balance. The above mentioned was combined with faster regression of manifestations of dyspepsia and astenovegetative syndromes.

CH patients were studied with positive effect of L-carnitine on functional liver parameters, which was manifested in a decrease in the activity of AST at 68.2% (p = 0.01) and ALT – at 96.3 % (p = 0.02), GGTP – by 50,7 % (p = 0,008), intensified restoration of antioxidant systems, in particular increased restored glutathione content by 17,5 % (p = 0,003), increased catalase activity by 8,0 % (p = 0,046) and decreased TBA-reactive products content – by 17.1 % (p = 0.003) in the blood. Decreased content of IL-10 in the blood – by 72.5 % (p = 0.04), TNF-α – by 59.4 % (p = 0.02) were determined in these patients, which confirms the tendency to normalization of pro- and anti-inflammatory portions of the cytokine profile. The indicated changes in biochemical parameters, parameters of pro- and antioxidant systems, the cytokine spectrum were combined with a faster regress of clinical symptoms in CH patients who, in addition to the main treatment, received L-carnitine, as opposed to the patients of comparison group.

However, for full correction of clinical manifestations of the disease, biochemical parameters, antioxidant systems and changes in the cytokine profile two-week administration of L-carnitine in patients with NAFLD and CH was still not enough, which suggests the expediency of repeated courses of its use at the outpatient-polyclinic stage.

After analyzing the remote results of the treatment, a significant reduction in the risk of recurring admission for the physician care during 6 and 12 months after treatment in 5.04 times (OR = 5.04, 95% CI 1.12-22.61) and 3.31 times (OR = 3.31, 95% CI 1.09 – 10.11) respectively was typical for NAFLD patients, who in addition to standard treatment were prescribed L-carnitine. The risk of re-hospitalization in the next 6 months after treatment reduced at 4.07 times (OR = 4.07 95% CI 1.28-13.00) in CH patients who additionally received L-carnitine. In this case, there was a longer compensation of liver disease, less severe complaints of heaviness in the right hypochondrium, nausea and general weakness during repeated administration.

The activity of AST decreased by 37.2 % (p = 0.03) and ALT – by 50.4 % (p = 0.01), GGTP – by 89,9 % (p = 0.007), the content of total cholesterol decreased by 16.7 % (p = 0.03) and triacylglycerols – by 33.3 % (p = 0.002) in the blood in NAFLD patients, in case of additional quercetin intake, during the two weeks of treatment. Such a decrease in the total cholesterol and triacylglycerol contents in the blood of patients with additional use of quercetin confirmed its hypocholesterolemic and anti-atherogenic properties, as indicated by other scientists [10, 29]. In particular, S. Egert et al. investigated that administration of quercetin at a dose of 150.0 mg / day contributed to decrease in the content of atherogenic LDL in the blood in patients with excess body weight and obesity with metabolic syndrome [29].

An increase in the content of restored glutathione in the blood was noted by 36.1 % (p = 0.04), catalase activity increased by 32.7 % (p = 0.03), concentration of TBA-reactive products decreased by 27.3 % (p = 0.01), TNF-α – by 39.8 % (p = 0.03) and proANP – 2.07 times (p = 0.04), which confirms anti-inflammatory and cardioprotective properties of quercetin indicated by other scientists and substantiates the feasibility of its use as a multi-action agent in NAFLF patients. However, an inadequate correction during two weeks of treatment of the indicators studied notes the need to continue the use of quercetin in the outpatient-polyclinic stage. Taking this into consideration, we continued treatment course for up to 6 weeks for young patients and up to 8 weeks for patients of middle and old age.

During two weeks of treatment in CH patients who consumed quercetin in addition to standard treatment, ALT activity in the blood decreased by 43.7 % (p = 0.02), AST – by 27.8 % (p = 0.03), LDH (total) – by 16,9 % (p = 0,02), AP – by 30,9 % (p = 0,03), GGTP – by 55,0 % (p = 0,009). The use of quercetin had a positive effect on lipid profile, in particular, total cholesterol in the blood decreased by 10.4% (p = 0.03). CH patients who were prescribed quercetin in addition to standard treatment fixed an increase in restored glutathione content by 31.3 % (p = 0.01), catalase activity increased by 15.6 % (p = 0.04), TBA-reactive products content in the blood decreased by 21.7 % (p = 0.02). This confirms the antioxidant properties of the medication, which were also reported by other scientists [2, 49]. The administration of quercetin contributed to decreased content of proinflammatory cytokine TNF-α in the blood by 61.9 % (p = 0.02) and marker of early injury of the cardiovascular system proANP at 53.8 % (p = 0.04). However, for complete correction of clinical manifestations of the disease, biochemical changes, antioxidant status and cytokine profile two-week appointment of quercetin was not enough. This required longer compliance with the chosen treatment regimen before the onset of persistent remission at the polyclinic and outpatient stages, this is why the treatment course was continued up to 6 weeks in young patients and up to 8 weeks in patients of middle and old age.

Remote monitoring of the results of this treatment has shown that NAFLD patients who additionally used quercetin were characterised by reduction in the risk of recurrence of medical treatment in the following 6 and 12 months after treatment in 3.68 times (OR = 3.68, 95% CI 1,06-12.73) and 3.01 times (OR = 3.01, 95% CI 1.09-8.26) respectively. In CH patients, who were additionally prescribed this drug, the risk of re-hospitalization for half a year after treatment was reduced by 3.28 times as compared to patients in the group comparison (OR = 3.28 95% CI 1.01-10.62). In NAFLD patients and CH patients the above mentioned combined with a longer period of compensation for liver diseases and decreased intensity of their clinical manifestations.

Conclusions. 1. Non-alcoholic fatty liver disease in middle-aged and elderly patients is characterised by higher content of glucose, increased alkaline phosphatase activity and proatherogenic changes in the lipid profile of the blood as compared to young patients. Old patients showed higher tumor necrosis factor-α content by 62.6 % (p = 0.045) and in 2.1 times (p = 0.01) in the blood, higher atrial natriuretic propeptide concentration in 3.1 times (p = 0.02) and 2.1 times (p = 0.02) in comparison with young and middle-aged patients. Higher activity of cytolysis and metabolic intoxication are characteristic for males with non-alcoholic fatty liver disease, however, less pronounced changes in lipid and adipokin profiles as compared to women.

2. Decreased albumin content and higher total lactate dehydrogenase activity were noted in chronic hepatitis patients of middle and old age, and in old ones also increased alkaline phosphatase activity in the blood as compared to young patients. Dyslipidemia with decreased high-density lipoproteins cholesterol content is diagnosed in patients of elder groups and increased low-density lipoprotein cholesterol content in the blood, increased atherogenic index by 66.5 % (p = 0.009) in old patients as compared to young patients. Higher content of tumor necrosis factor-α by 79.0 % (p = 0.03) and atrial natriuretic propeptide by 75.9 % (p = 0.02) are inherent for chronic hepatitis patients of old age in comparison with patients of young age. The gender features of chronic hepatitis have been determined: in particular, women have higher indicators of intoxication syndrome, and men more unfavorable changes of lipid and cytokine profiles.

3. It has been shown that patients with non-alcoholic fatty liver disease have significantly higher frequency of G-allele of glutathione-S-transferase P1 gene (A313G) as compared to practically healthy persons (χ2 = 5.69, p = 0.017). Its carrier is combined with a higher activity of alanine aminotransferase and greater atrial natriuretic propeptide and leptin contents and lower adiponectin concentration in the blood, and in homozygous carriers G-allele – also with higher interleukin 10 content in the blood as compared to the corresponding indicators in patients with AA-genotype. Patients with deletion genotype of gluatatus-S-transferase T1 gene were enrolled twice (p = 0.01) higher content of tumor necrosis factor-α, and patients with null genotype of glutathione-S-transferase M1 gene by 37.1 % (p = 0.04) higher leptin content in the blood as compared to patients with normal genotypes of these genes. The Ala-allele of the peroxisome proliferator-activated receptors-γ gene in patients with non-alcoholic fatty liver disease is associated with higher activity of markers of the cytolytic syndrome, with higher content of leptin in the blood by 45.6 % (p = 0.04) and atrial natriuretic propeptide 2,4 times (p = 0.009) as compared to patients with Pro / Pro-genotype.

4. Different rates of cytolytic syndrome were recorded depending on the polymorphism of the gluatatus-S-transferase P1 gene in chronic hepatitis patients: in particular, G-alleles are associated with a higher alanine aminotransferase activity in the blood by 44.0% (p = 0.046) as compared to patients with AA-genotype. The interleukin 10 content in the blood is greater in 2.2 times (p = 0.03) in patients with the deletion genotype of glutathione-S-transferase T1 and in 2.1 times (p = 0.04) in carriers of the Ala-allele of the peroxisome proliferator-activated receptors-γ as compared to patients with normal genotype and Pro / Pro genotype of these genes, respectively.

5. The higher total lactate dehydrogenase activity, increased total cholesterol and cholesterol of low density lipoproteins contents and higher alkaline phosphatase activity in the blood were detected in non-alcoholic fatty liver disease patients with subclinical and manifested hypothyroidism as compared to patients with normal thyroid function. Higher leptin content by 35.7 % (p = 0.04) and 72.1 % (p = 0.009) respectively is inherent for patients with subclinical and manifested hypothyroidism, and decreased in 2.1 times (p = 0.004) adiponectin content in blood is typical for patients with combination of non-alcoholic fatty liver disease with manifested hypothyroidism as compared to patients without hypothyroidism. Non-alcoholic fatty liver disease is accompanied by an insulin resistance syndrome with an increase in the index of insulin resistance HOMA IR in 4.17 times (p <0.001) and decrease in the J. F. Caro index by 44.4 % (p = 0.04) as compared to practically healthy persons. The above mentioned changes are aggravated in the presence of concomitant subclinical and manifested hypothyroidism, in particular, the J.F. Caro index decreases in 4.15 times (p <0.001) and 3.38 times (p <0.001) respectively, and in patients with concomitant manifested hypothyroidism, the HOMA index IR increases by 67.7 % (p = 0.04) as compared to those in patients without hypothyroidism.

6. The administration of L-carnitine in non-alcoholic fatty liver disease patients and chronic hepatitis patients positively affects the functional parameters of the liver, which are manifested in lowering the activity of aspartate and alanine aminotransferase, γ-glutamyltranspeptidase in the blood. Additional L-carnitine appointment in non-alcoholic fatty liver disease patients reduces the content of tumor necrosis factor-α in the blood by 39.8 % (p = 0.04), which indicates decrease in the intensity of inflammation processes, as well as decrease in the leptin concentration by 44.1 % (p = 0.02) with the simultaneous increase in the adiponectin content twice as much (p = 0.03), indicating a tendency to the adipokin profile normalization. For additional use of L-carnitine in chronic hepatitis patients the concentration of tumor necrosis factor-α in the blood decreases by 59.4 % (p = 0.02), interleukin 10 – by 72.5 % (p = 0.04), which can be considered as proof of the tendency to normalize the pro- and anti-inflammatory components of the cytokine profile. Additional application of L-carnitine to basic treatment reduces the risk of repeated application for medical assistance during next year for non-alcoholic fatty liver disease patients and for 6 months for chronic hepatitis patients, longer period of compensation for diseases, reduction of their symptoms in case of need of repeated treatment.

7. The additional appointment of quercetin to the main treatment of patients with non-alcoholic fatty liver disease and those with chronic hepatitis contributes to more effective correction of indicators that reflect the processes of cytolysis, cholestasis and lipid spectrum. The content of tumor necrosis factor-α in the blood also decreased by 39.8 % (p = 0.03) and the concentration of atrial natriuretic propeptide – 2.1 times (p = 0.04) in non-alcoholic fatty liver disease patients The content of tumor necrosis factor-α in the blood decreased by 61.9 % (p = 0.02) and the concentration of atrial natriuretic propeptide – by 53.8 % (p = 0.04) in chronic hepatitis patients, for the additional use of quercetin. The risk of repeated admission for medical assistance in the next 12 and 6 months after treatment is reduced for the additional use of quercetin in non-alcoholic fatty liver disease patients and chronic hepatitis patients accordingly, which is combined with a longer period of compensation for liver disease and decrease in their clinical manifestations.

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