Periodic Reporting for period 5 - LITMUS (Liver Investigation: Testing Marker Utility in Steatohepatitis)
Período documentado: 2021-11-01 hasta 2022-10-31
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 NAFLD but only a minority progress to advanced liver disease or morbidity/mortality.
The transition from NAFL to NASH 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 is to develop, robustly validate and advance towards regulatory qualification biomarkers that diagnose, risk stratify and/or monitor NAFLD/NASH progression and fibrosis stage. Success will help target care to those at greatest risk, and ultimately facilitate drug development and novel treatments.
The specific objectives of LITMUS are to:
1. leverage existing cross-sectional and longitudinal patient cohorts and bioresources into a single unified resource for biomarker validation. The infrastructure of the existing ‘European NAFLD Registry’ and additional large patient cohorts will be employed and expanded to fulfil this aim (Phase 1a). LITMUS has links with international cohorts to form the core of a nascent ‘Global NAFLD Registry’.
2. expand our clinical network of European centres and accelerate the prospective recruitment of patients with histologically characterised NAFLD to further validate candidate biomarkers. Prospective recruitment and longitudinal follow-up collecting a predefined dataset and standardised sample set (Phase 1b).
3. establish a robust technological and methodological platform and use it for the definitive validation of candidate biomarkers. LITMUS offers an impartial, technology-unbiased platform for biomarker discovery, assessment and validation across the NAFLD spectrum and all three FDA BEST biomarker domains (diagnostic, prognostic and monitoring), with a clear line of sight to regulatory qualification.
4. identify and define the most accurate and tractable biomarkers relevant to NAFLD. LITMUS will provide validation data of the requisite standard to support regulatory qualification of biomarkers for trial use against both histological/biochemical indices and clinically relevant long-term outcome measures.
5. develop consensus and qualify preclinical models of NAFLD/NASH and then back-translate biomarkers for validation in these models so that they may be used in pre-clinical drug development.
The transition from NAFL to NASH 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 is to develop, robustly validate and advance towards regulatory qualification biomarkers that diagnose, risk stratify and/or monitor NAFLD/NASH progression and fibrosis stage. Success will help target care to those at greatest risk, and ultimately facilitate drug development and novel treatments.
The specific objectives of LITMUS are to:
1. leverage existing cross-sectional and longitudinal patient cohorts and bioresources into a single unified resource for biomarker validation. The infrastructure of the existing ‘European NAFLD Registry’ and additional large patient cohorts will be employed and expanded to fulfil this aim (Phase 1a). LITMUS has links with international cohorts to form the core of a nascent ‘Global NAFLD Registry’.
2. expand our clinical network of European centres and accelerate the prospective recruitment of patients with histologically characterised NAFLD to further validate candidate biomarkers. Prospective recruitment and longitudinal follow-up collecting a predefined dataset and standardised sample set (Phase 1b).
3. establish a robust technological and methodological platform and use it for the definitive validation of candidate biomarkers. LITMUS offers an impartial, technology-unbiased platform for biomarker discovery, assessment and validation across the NAFLD spectrum and all three FDA BEST biomarker domains (diagnostic, prognostic and monitoring), with a clear line of sight to regulatory qualification.
4. identify and define the most accurate and tractable biomarkers relevant to NAFLD. LITMUS will provide validation data of the requisite standard to support regulatory qualification of biomarkers for trial use against both histological/biochemical indices and clinically relevant long-term outcome measures.
5. develop consensus and qualify preclinical models of NAFLD/NASH and then back-translate biomarkers for validation in these models so that they may be used in pre-clinical drug development.
WP2 continued 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 performed in 10 countries. The study design was modified to mitigate the effects of slow recruitment due to COVID-19 and broaden the range of data captured to include vendor-specific PDFF. We have conducted comprehensive individual patient data metaanalyses and systematic reviews of diagnostic accuracy of imaging biomarkers.
WP6 has collected phenotype and RNA sequencing data on numerous pre-clinical models and conducted a comparative analysis with LITMUS’ human data and omics technology datasets to develop a ‘Human Proximity Score’ to assess fidelity of pre-clinical NAFLD models. This has been used to prioritise models for further ongoing in vivo studies in LITMUS and guide pre-clinical drug development strategies by pharma partners.
In WP7, two Letters of Intent were accepted by the FDA (covering Diagnostic Screening and Prognostic Enrichment), qualification advice has also been successfully received from the EMA. Despite the impacts of COVID19 on travel, dissemination activities have continued to increase in P5, with multiple publications in peer reviewed journals and participating in virtual conferences.
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 performed in 10 countries. The study design was modified to mitigate the effects of slow recruitment due to COVID-19 and broaden the range of data captured to include vendor-specific PDFF. We have conducted comprehensive individual patient data metaanalyses and systematic reviews of diagnostic accuracy of imaging biomarkers.
WP6 has collected phenotype and RNA sequencing data on numerous pre-clinical models and conducted a comparative analysis with LITMUS’ human data and omics technology datasets to develop a ‘Human Proximity Score’ to assess fidelity of pre-clinical NAFLD models. This has been used to prioritise models for further ongoing in vivo studies in LITMUS and guide pre-clinical drug development strategies by pharma partners.
In WP7, two Letters of Intent were accepted by the FDA (covering Diagnostic Screening and Prognostic Enrichment), qualification advice has also been successfully received from the EMA. Despite the impacts of COVID19 on travel, dissemination activities have continued to increase in P5, with multiple publications in peer reviewed journals and participating in virtual conferences.
WP8 has collected ethical approvals for the prospective patient recruitment as these became available in the various different countries.
The 5th period has been focused on prospective recruitment and participant followup, analysing the performance of various wet and imaging biomarkers, both in the literature and in our own cohorts. 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 (https://doi.org/10.1016/j.cct.2020.106175)
2. LITMUS Demonstrator: Analysis of biomarker performance.
3. LITMUS Accelerator: Transcriptomics (https://doi.org/10.1126/scitranslmed.aba4448) 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)
7. Comparative biology assessment and ranking of animal models of NASH for fidelity to human disease and initiation of in vivo validation studies
By the end of the project, we expect to have validated a number of biomarkers that diagnose, risk stratify and/or monitor NAFLD/NASH progression and fibrosis stage.
Twitter: @LITMUS_IMI
1. European NAFLD Registry/Biobank - the largest international registry of histologically characterised NAFLD patients under longitudinal follow-up (https://doi.org/10.1016/j.cct.2020.106175)
2. LITMUS Demonstrator: Analysis of biomarker performance.
3. LITMUS Accelerator: Transcriptomics (https://doi.org/10.1126/scitranslmed.aba4448) 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)
7. Comparative biology assessment and ranking of animal models of NASH for fidelity to human disease and initiation of in vivo validation studies
By the end of the project, we expect to have validated a number of biomarkers that diagnose, risk stratify and/or monitor NAFLD/NASH progression and fibrosis stage.
Twitter: @LITMUS_IMI