Periodic Reporting for period 6 - LITMUS (Liver Investigation: Testing Marker Utility in Steatohepatitis)
Reporting period: 2022-11-01 to 2024-02-29
MASLD (formerly called NAFLD) is a common condition, strongly associated with the Metabolic Syndrome (obesity, type 2 diabetes mellitus and dyslipidaemia) and characterised by substantial inter-patient variability in severity and rate of progression. An important paradox exists: a significant proportion of the population have MASLD but only a minority progress to advanced liver disease or morbidity/mortality.
The transition from MASL to MASH and the stage of fibrosis are important discriminators between a relatively benign prognosis and an increased risk of morbidity/mortality. Liver biopsy remains the established but imperfect ‘gold standard’ investigation, being invasive, resource intensive, prone to sampling error and carrying a small but significant risk of complications. Such invasive tests are not practical outside specialist practice and are particularly unsuitable with such a large ‘at risk’ population. A lack of tractable non-invasive biomarkers has impeded the diagnosis, risk stratification and monitoring of patients. It has also hampered drug development and the conduct of clinical trials, which still depend on histological effect as an endpoint. The overarching aim of LITMUS was to develop, robustly validate and advance towards regulatory qualification biomarkers that diagnose, risk stratify and/or monitor MASLD/MASH progression and fibrosis stage. Success will help target care to those at greatest risk, and ultimately facilitate drug development and novel treatments.
The LITMUS project delivered a step-change in our understanding of biomarkers for MASLD/MASH and realised the following objectives:
1. Expanded the ‘European NAFLD Registry’ through prospective recruitment of well-characterised cases so that it is now the largest international cohort of patients with histologically characterised MASLD/MASH under longitudinal follow-up.
2. Established a robust technological and methodological platform for the definitive validation of candidate biomarkers. Thus, LITMUS has built an impartial, technology-unbiased platform for biomarker discovery, assessment and validation across the MASLD spectrum and all three FDA BEST biomarker domains (diagnostic, prognostic and
monitoring), with a clear line of sight to regulatory qualification.
3. LITMUS has identified and defined the most accurate and tractable biomarkers relevant to MASLD, publishing a series of seminal papers on biomarker performance and advancing the discovery of new biomarkers.
4. The biomarker validation work conducted by LITMUS is of the requisite standard to support regulatory qualification of biomarkers and has underpinned a number of regulatory submissions to agencies in Europe and USA.
5. LITMUS has also addressed the pre-clinical drug development space, building consensus on the phenotypic validity of preclinical models of MASLD/MASH and back-translating biomarkers for validation in these models so that they may be used in pre-clinical drug development.
The transition from MASL to MASH and the stage of fibrosis are important discriminators between a relatively benign prognosis and an increased risk of morbidity/mortality. Liver biopsy remains the established but imperfect ‘gold standard’ investigation, being invasive, resource intensive, prone to sampling error and carrying a small but significant risk of complications. Such invasive tests are not practical outside specialist practice and are particularly unsuitable with such a large ‘at risk’ population. A lack of tractable non-invasive biomarkers has impeded the diagnosis, risk stratification and monitoring of patients. It has also hampered drug development and the conduct of clinical trials, which still depend on histological effect as an endpoint. The overarching aim of LITMUS was to develop, robustly validate and advance towards regulatory qualification biomarkers that diagnose, risk stratify and/or monitor MASLD/MASH progression and fibrosis stage. Success will help target care to those at greatest risk, and ultimately facilitate drug development and novel treatments.
The LITMUS project delivered a step-change in our understanding of biomarkers for MASLD/MASH and realised the following objectives:
1. Expanded the ‘European NAFLD Registry’ through prospective recruitment of well-characterised cases so that it is now the largest international cohort of patients with histologically characterised MASLD/MASH under longitudinal follow-up.
2. Established a robust technological and methodological platform for the definitive validation of candidate biomarkers. Thus, LITMUS has built an impartial, technology-unbiased platform for biomarker discovery, assessment and validation across the MASLD spectrum and all three FDA BEST biomarker domains (diagnostic, prognostic and
monitoring), with a clear line of sight to regulatory qualification.
3. LITMUS has identified and defined the most accurate and tractable biomarkers relevant to MASLD, publishing a series of seminal papers on biomarker performance and advancing the discovery of new biomarkers.
4. The biomarker validation work conducted by LITMUS is of the requisite standard to support regulatory qualification of biomarkers and has underpinned a number of regulatory submissions to agencies in Europe and USA.
5. LITMUS has also addressed the pre-clinical drug development space, building consensus on the phenotypic validity of preclinical models of MASLD/MASH and back-translating biomarkers for validation in these models so that they may be used in pre-clinical drug development.
WP2 completed the statistical analysis of the performance of markers for the diagnostic and diagnostic screening context of use. The analysis focused on the diagnostic accuracy in detecting fibrotic NASH for clinical trial recruitment.
WP3 highlights include: (i) Establishing the largest international cohort of histologically characterised NAFLD patients: the “European NAFLD Registry”, including the Metacohort (1a) and LITMUS Study cohort (1b), with biological samples held at a central biobank from longitudinal followup of participants; (ii) Creation of an Atlas of digital images for the harmonisation of NAFLD histological evaluation and future AI-based analysis; (iii) Central histological interpretation and scoring of liver biopsies progressing well; (iv) Further development of the NASH-CHECK PROM to cover NASH F1-3 and F4 patients completed.
In WP4, a range of blood-based biomarkers have been tested at the central labs for both 1a and 1b cases, with data passed to WP2 for analysis. Biomarker discovery activities have identified a range of promising novel markers including miRNA miR193a, GDF15 and TSP-2 . A series of comprehensive research papers and reviews have been published, including Transcriptomics, Lipidomics/Metabolomics, and other biomarker platforms. Further papers on proteomics using the Somascan platform have been submitted for publication.
In WP5, imaging data acquisition has been completed in 10 countries. All MR data have been analysed and the results have been entered into the European NAFLD Registry and provided to WP2 for the statistical analysis.
WP6 has completed the in vivo studies of the prioritised preclinical models and generated NGS data. Publication of the results is underway.
In WP7, 3 biomarkers have been selected based on all of the LITMUS work (PRO-C3, the ADAPT score and Fast) for inclusion in a Qualification Plan for diagnostic enrichment which was prepared and submitted to the FDA. This document describes how biomarkers in the LITMUS consortium can and should be qualified. In addition, the NASH-CHECK PRO was submitted to EMA for full Qualification Advice.
WP8 has collected ethical approvals for the prospective patient recruitment as these became available in the various different countries.
WP3 highlights include: (i) Establishing the largest international cohort of histologically characterised NAFLD patients: the “European NAFLD Registry”, including the Metacohort (1a) and LITMUS Study cohort (1b), with biological samples held at a central biobank from longitudinal followup of participants; (ii) Creation of an Atlas of digital images for the harmonisation of NAFLD histological evaluation and future AI-based analysis; (iii) Central histological interpretation and scoring of liver biopsies progressing well; (iv) Further development of the NASH-CHECK PROM to cover NASH F1-3 and F4 patients completed.
In WP4, a range of blood-based biomarkers have been tested at the central labs for both 1a and 1b cases, with data passed to WP2 for analysis. Biomarker discovery activities have identified a range of promising novel markers including miRNA miR193a, GDF15 and TSP-2 . A series of comprehensive research papers and reviews have been published, including Transcriptomics, Lipidomics/Metabolomics, and other biomarker platforms. Further papers on proteomics using the Somascan platform have been submitted for publication.
In WP5, imaging data acquisition has been completed in 10 countries. All MR data have been analysed and the results have been entered into the European NAFLD Registry and provided to WP2 for the statistical analysis.
WP6 has completed the in vivo studies of the prioritised preclinical models and generated NGS data. Publication of the results is underway.
In WP7, 3 biomarkers have been selected based on all of the LITMUS work (PRO-C3, the ADAPT score and Fast) for inclusion in a Qualification Plan for diagnostic enrichment which was prepared and submitted to the FDA. This document describes how biomarkers in the LITMUS consortium can and should be qualified. In addition, the NASH-CHECK PRO was submitted to EMA for full Qualification Advice.
WP8 has collected ethical approvals for the prospective patient recruitment as these became available in the various different countries.
The 6th period has been focused on participant follow-up, analysing the performance of various wet and imaging biomarkers in the LITMUS Study cohort. We have already achieved the following important advances:
1. European NAFLD Registry/Biobank - the largest international registry of histologically characterised NAFLD patients under longitudinal follow-up with over 9,000 cases (https://doi.org/10.1016/j.cct.2020.106175(opens in new window))
2. LITMUS Demonstrator: Analysis of biomarker performance.
3. LITMUS Accelerator: Transcriptomics (https://doi.org/10.1126/scitranslmed.aba4448(opens in new window)) lipidomics and proteomics (SOMAScan) to identify promising novel circulating biomarkers.
4. Meta-analyses of diagnostic accuracy studies which will provide insight on the different cut-off values of the biomarkers for detecting different target conditions in NAFLD
5. Established the proof-of-principle that NMR-based metabolomics can be used to find non-invasive metabolic biomarkers to measure NASH onset and progression
6. Atlas of histological images available online for educational purposes, including training of general pathologists in diagnosing and grading/staging NAFLD in liver biopsies (https://tinyurl.com/msmt6re7(opens in new window))
7. Comparative biology assessment and ranking of animal models of NASH for fidelity to human disease and initiation of in vivo validation studies
8. Validated a number of biomarkers that diagnose, risk stratify and/or monitor NAFLD/NASH progression and fibrosis stage
9. Submission to FDA of a Qualification Plan for the diagnostic enrichment context of use including 3 selected biomarkers
Twitter: @LITMUS_IMI
1. European NAFLD Registry/Biobank - the largest international registry of histologically characterised NAFLD patients under longitudinal follow-up with over 9,000 cases (https://doi.org/10.1016/j.cct.2020.106175(opens in new window))
2. LITMUS Demonstrator: Analysis of biomarker performance.
3. LITMUS Accelerator: Transcriptomics (https://doi.org/10.1126/scitranslmed.aba4448(opens in new window)) lipidomics and proteomics (SOMAScan) to identify promising novel circulating biomarkers.
4. Meta-analyses of diagnostic accuracy studies which will provide insight on the different cut-off values of the biomarkers for detecting different target conditions in NAFLD
5. Established the proof-of-principle that NMR-based metabolomics can be used to find non-invasive metabolic biomarkers to measure NASH onset and progression
6. Atlas of histological images available online for educational purposes, including training of general pathologists in diagnosing and grading/staging NAFLD in liver biopsies (https://tinyurl.com/msmt6re7(opens in new window))
7. Comparative biology assessment and ranking of animal models of NASH for fidelity to human disease and initiation of in vivo validation studies
8. Validated a number of biomarkers that diagnose, risk stratify and/or monitor NAFLD/NASH progression and fibrosis stage
9. Submission to FDA of a Qualification Plan for the diagnostic enrichment context of use including 3 selected biomarkers
Twitter: @LITMUS_IMI