Fecal Microbiota Transplantation (FMT) in Nonalcoholic Steatohepatitis(NASH). A Pilot Study

Nonalcoholic Steatohepatitis (NASH), a severe form of fatty liver disease, is highly
prevalent and can lead to cirrhosis, liver failure and hepatocellular carcinoma. It is
strongly associated with obesity and the metabolic syndrome. The impact of the gut microbiota
on obesity and the metabolic syndrome is potentially large and increasing evidence suggests
that dysbiosis might contribute to the development of NASH. There is a fundamental gap in
understanding how alterations in the intestinal microbiota lead to a wide range of metabolic
syndrome associated conditions including fatty liver disease in humans. The long-term goal of
this project is to better understand the mechanisms linking intestinal dysbiosis and
extra-intestinal clinical phenotypes, in particular obesity and NAFLD. Compositional shifts
in gut bacteria from antibiotic use can perpetuate diseases such as Clostridum difficile
infection, and manipulation of the microbiota through stool transplant from healthy donors
can be used to cure disease. The objective of this application is to determine whether
restoration of beneficial gut microbiota via fecal microbiota transplantation using stool
from lean donors (FMT-L) improves NASH. The central hypothesis for this project is that
transfer of gut microbiota from lean donors will result in reduced hepatic steatosis, and
improved histological and biochemical features of NASH, all of which will correlate with
observed changes in the small bowel and distal gut microbiome. This hypothesis will be tested
by pursuing 3 specific aims: 1) determine the effect of FMT-L in patients with NASH on
hepatic steatosis and markers of NASH; 2) perform microbiome analyses on pre- and post-FMT-L
small bowel & stool samples; and 3) investigate mechanistic correlates linking dysbiosis with
histologic changes in NASH after FMT-L. The study will be a pilot open labeled trial
examining the effect of FMT-L in patients with biopsy proven NASH. The primary outcome
measure will be a change in MRI-determined hepatic fat fraction,12 weeks after
transplantation. Differences in the microbiota after FMT-L in the small bowel and distal gut,
including the durability of microbiota changes, will be examined using advanced metagenomic
techniques. Clinical and laboratory features of the metabolic syndrome and obesity as well as
hepatic and systemic inflammatory markers will be examined for mechanistic correlates linking
dysbiosis with histologic changes in the liver. In addition to understanding how the gut
microbiota affects fatty liver disease progression, study findings will provide a framework
for future microbiome research on metabolic syndrome related diseases such as diabetes,
obesity, and other inflammatory disorders. An increased understanding of how the human gut
microbiota is altered in metabolic disease may open a new avenue of therapeutics based on
manipulation of gut bacteria.

Inclusion Criteria:

1) >18 years of age 2) histologic evidence of definite or probable NASH based upon a liver
biopsy obtained <90 days prior to enrollment and a NAFLD activity score (NAS) ≥4 with ≥1 in
each component of the NAS score (steatosis, scored 0-3, ballooning degeneration, 0-2, and
lobular inflammation, 0-3).

Exclusion Criteria:

1. current or history of significant alcohol consumption for a period of more than 3
consecutive months within 1 year prior to screening (significant alcohol consumption
is defined as more than 20 g/day in females and more than 30 g/day in males, on
average)

2. Another form of liver disease

3. Recent antibiotic use within 3 months or need for chronic antibiotic therapy

4. Use of drugs historically associated with NAFLD or drugs known to improve NASH
histology such as vitamin E> 400 IU/day or pioglitazone

5. Prior or planned (during the study period) bariatric surgery

6. Uncontrolled diabetes defined as HbA1c 9.5% or higher within 60 days prior to
enrollment

7. Presence of cirrhosis on liver biopsy

8. Clinical evidence of hepatic decompensation

9. Inability to safely obtain a liver biopsy or perform an upper endoscopy

10. Human Immunodeficiency Virus (HIV) infection

11. Active, serious medical disease with likely life expectancy less than 5 years

12. Active substance abuse including inhaled or injection drugs in the year prior to
screening

13. pregnancy, planned pregnancy, potential for pregnancy and unwillingness to use
effective birth control during the trial, breast feeding

14. Participation in an IND trial in the 30 days before randomization

15. Any other condition which, in the opinion of the investigator, would impede compliance
or hinder completion of the study

16. History of severe (anaphylactic) food allergy

17. History of inflammatory bowel disease

18. History of gastroparesis or altered gastric motility -