title: Outcome of phlebotomy for treating nonalcoholic fatty liver disease: A systematic review and meta-analysis.
abstract: OBJECTIVE
  No medications have been approved for managing nonalcoholic fatty liver disease (NAFLD). Lifestyle intervention is the mainstay for its treatment. Hyperferritinemia, which appears to be associated with the severity of liver injury and insulin resistance, is frequently observed in patients with NAFLD.
  
  
  METHODS
  We conducted a systematic review and meta-analysis of the outcomes of four interventional trials regarding the effect of phlebotomy in patients with NAFLD versus the outcomes of NAFLD patients who did not undergo phlebotomy. Primary outcome was the pooled mean difference (MD) of the homeostasis model assessment of insulin resistance (HOMA-IR). The secondary outcomes were the changes in liver enzymes and the lipid profile.
  
  
  RESULTS
  Four interventional studies involving 438 participants were included in the meta-analysis. HOMA-IR was lower in patients who underwent phlebotomy, with an MD of 0.84 [95% confidence interval (CI) 0.01 to 1.67, I2 = 72%]. Phlebotomy also significantly reduced the alanine aminotransferase (MD = 10.05, 95% CI 7.19-12.92, I2 = 34%) and triglyceride (MD = 9.89, 95% CI 4.96-14.83, I2 = 22%) levels and increased the high-density cholesterol level (MD = 3.48, 95% CI 2.03-4.92, I2 = 18%).
  
  
  CONCLUSIONS
  Phlebotomy decreased insulin resistance and liver transaminase levels in patients with NAFLD. In addition, it improved their lipid profile.
authors.affiliation: Department of Internal Medicine, University of Hawaii, Honolulu, HI, USA; Department of Internal Medicine, King Chulalongkorn Memorial Hospital, Bangkok, Thailand.
authors.forename: Veeravich
authors.initials: V
authors.lastname: Jaruvongvanich
authors.affiliation: Department of Internal Medicine, University of Hawaii, Honolulu, HI, USA.
authors.forename: Tanawan
authors.initials: T
authors.lastname: Riangwiwat
authors.affiliation: Department of Internal Medicine, Bassett Medical Center and Columbia University College of Physicians and Surgeons, Cooperstown, NY, USA; Department of Preventive and Social Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand.
authors.forename: Anawin
authors.initials: A
authors.lastname: Sanguankeo
authors.affiliation: Department of Internal Medicine, Bassett Medical Center and Columbia University College of Physicians and Surgeons, Cooperstown, NY, USA; Department of Preventive and Social Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand.
authors.forename: Sikarin
authors.initials: S
authors.lastname: Upala
mesh_terms: D005260:Female; D005293:Ferritins / Q000032:analysis / Q000097:blood; D006801:Humans; D007333:Insulin Resistance; D008099:Liver / Q000201:enzymology*; D008297:Male; D008875:Middle Aged; D065626:Non-alcoholic Fatty Liver Disease / Q000000981:diagnostic imaging / Q000628:therapy*; D064887:Observational Studies as Topic; D018962:Phlebotomy / Q000379:methods*; D016032:Randomized Controlled Trials as Topic; D000637:Transaminases / Q000378:metabolism*; D014463:Ultrasonography
chemical_list: D005293:Ferritins; D000637:Transaminases