The Sleep, Liver Evaluation and Effective Pressure Study

Nonalcoholic fatty liver disease (NAFLD) is a common disease with a well-established link to
obesity and is increasingly prevalent with the concurrent rise in obesity. NAFLD
constitutes a disease spectrum from steatosis to cirrhosis and is associated with
significant morbidity and mortality. The pathogenesis of NAFLD, especially disease
progression, is not well understood. Obesity and insulin resistance play a role as 'a first
hit' leading to liver steatosis, but the mechanisms for a 'second hit' triggering
progression to steatohepatitis are not known. Based on our Preliminary Data, we propose a
novel hypothesis that chronic intermittent hypoxia (CIH) in patients with obstructive sleep
apnea (OSA) constitutes a 'second hit' causing progression of NAFLD from steatosis to
nonalcoholic steatohepatitis (NASH), a progressive fibrotic disease, in which cirrhosis and
liver-related death occur in up to 20% and 12% patients, respectively.

Obstructive sleep apnea (OSA) is characterized by recurrent collapse of the upper airway
during sleep, leading to CIH. OSA is a common disease, present in 2% of women and 4% of men
in the general US population, but with an increased prevalence of 30-60% in obese
populations. Furthermore, CIH has been associated with multiple metabolic complications of
OSA independent of obesity, including insulin resistance, dyslipidemia, and atherosclerosis.
Previous work in rodent models has demonstrated that intermittent hypoxia (IH) increases:
(1) insulin resistance; (2) hepatic steatosis; (3) hepatic levels of SREBP-1 and SCD-1; and
(4) hepatic oxidative stress and inflammation Thus, CIH in OSA may contribute to hepatic
steatosis, and convert hepatic steatosis to steatohepatitis. To address this hypothesis, we
will establish the impact of OSA on NASH in a susceptible cohort of obese human subjects in
whom definitive intraoperative liver biopsy will be available to diagnose and stage NAFLD.

Recent evidence in patients with obstructive sleep apnea (OSA) indicates that OSA is
associated with NASH. Nevertheless, the prevalence of OSA in patients with biopsy-confirmed
NAFLD is unknown and the effect of OSA treatment with CPAP on NASH has never been studied.
Our main hypothesis is that the severity of nocturnal intermittent hypoxemia of obstructive
sleep apnea (OSA) will be associated with the severity of NAFLD. We will examine NAFLD
severity in patients with and without obstructive sleep apnea and examine the effect of CPAP
on NAFLD progression in patients with obstructive sleep apnea.

The overall goal is to determine whether OSA is associated with NAFLD and whether CPAP
mitigates NAFLD progression. Our primary hypothesis is that the severity of nocturnal
intermittent hypoxemia of obstructive sleep apnea (OSA) will be associated with the severity
of NAFLD.

- In Specific Aim #1, we will examine NAFLD severity in patients with and without
obstructive sleep apnea. We hypothesize that the severity of NAFLD and the presence of
NASH will be associated with the presence and severity of OSA.

- In Specific Aim #2, we will examine the effect of CPAP on NAFLD progression in patients
with obstructive sleep apnea. We hypothesize that CPAP will decrease markers of hepatic
inflammation (serum aminotransferases) in patients with NAFLD, who have moderate or
severe OSA. To address this hypothesis, we will enroll patients from the JHMI
Hepatology clinic with the diagnosis of NAFLD, who have elevated serum
aminotransferases, NAFLD on liver biopsy, and moderate to severe OSA. The effect of
CPAP on markers of liver inflammation and serum aminotransferases will be determined,
and related to CPAP adherence.

Inclusion Criteria:

1. Age ≥ 21

2. Recent (≤ 12 months) liver biopsy

3. Elevated levels of alanine aminotransferase (ALT) > 40, aspartate aminotransferase
(AST) > 37, and alkaline phosphatase (ALKP) > 120

- No other cause of liver disease other than NAFLD (as assessed by patient and
physician surveys detailed below)

Exclusion Criteria:

Both patients and doctors will be asked to identify potential exclusionary conditions
including:

1. Patients with sickle cell anemia, hemoglobinopathies and other hemolytic anemias

2. Known clinical hypersensitivity or a history of asthma or allergic respiratory
disorders

3. Advanced renal failure (currently requiring dialysis or with a Glomerular Filtration
rate < 30cc/min)

4. Pregnancy

5. History of CPAP treatment for OSA

6. Recent weight loss ≥ 10%

7. Current alcohol use > 20 g/day in women and > 30 g/day in men, or prior use for ≥ 3
consecutive months during the previous 5 years as assessed with the Lifetime Drinking
History Questionnaire Viral hepatitis A, B and C

8. Autoimmune hepatitis

9. Hemochromatosis

10. Wilson's disease

11. Alpha-1-antitrypsin deficiency

12. Primary sclerosing cholangitis

13. Cirrhosis of any etiology

14. History of HIV infection and/or HAART therapy

15. Evidence of drug-induced liver injury

16. Use of vitamin E and pioglitazone or another glitazone or metformin

17. Use of systemic steroids for > 10 days during prior 6 months

18. Unstable cardiovascular disease (decompensated CHF, myocardial infarction or
revascularization procedures, unstable arrhythmias)

19. Uncontrolled hypertension with BP > 160/100

20. Daytime hypoxemia with SaO2<90%

21. Supplemental oxygen use

22. Presence of any contraindication to MR examinations (see MRI Safety Screening Sheet)

23. History of Metal in the Skull/Eyes

24. Unable to have an MRI Scan

25. Allergy or hypersensitivity reactions to gadolinium or any other ingredients,
including benzyl alcohol

26. Severe daytime hypersomnolence as defined by an Epworth Sleepiness Score of greater
than 16.

27. Severe sleep apnea as characterized by an apnea-hypopnea index of greater than 80
episodes/hour or an average low SaO2 during sleep disordered breathing episodes below
80%.

Exclusions based on etiology of hepatitis will be assessed by querying both the hepatology
list and patient about the above mentioned disorders (#7-15).