NAFLD and increased risk of cardiovascular disease: clinical associations, pathophysiological mechanisms and pharmacological implications

Inflammatory and metabolic markers mediate the association of hepatic steatosis and fibrosis with 10-year ASCVD risk

BACKGROUND AND AIMS

Liver steatosis and fibrosis increase the predicted 10-year atherosclerotic cardiovascular disease (ASCVD) risk, though the roles of chronic inflammation and metabolic dysregulation remain unclear. This cross-sectional study quantitatively assesses this association and evaluates the mediating effects of metabolic dysregulation and chronic inflammation.

METHODS

In this study, we enrolled 6110 adults from ten communities in Canton, China. Hepatic steatosis and fibrosis were assessed using vibration-controlled transient elastography (VCTE) through controlled attenuation parameter (CAP) and liver stiffness measurement (LSM), while predicted 10-year ASCVD risk was calculated using the China-PAR project model. Associations between CAP/LSM values and predicted 10-year ASCVD risk were analyzed. Mediation analysis quantified the effects of high-sensitivity C-reactive protein (hs-CRP), homeostasis model assessment of insulin resistance (HOMA-IR), remnant cholesterol (RC), and non-high-density lipoprotein cholesterol (non-HDL-C). The main statistical methods used included logistic regression, restricted cubic splines (RCS) analysis, interaction calculations, and mediation analysis to examine the relationships and mediators.

RESULTS

The study population had a mean age of 50.1 years (SD = 9.7), with 3927 females (64.3%) and 2183 males (35.7%). Additionally, 808 participants (13.2%) had type 2 diabetes, and 1911 participants (31.3%) had hypertension. Compared to the first CAP quartile (Q1), higher CAP quartiles showed increased odds ratios (OR) for predicted moderate to high 10-year ASCVD risk: 1.14 (0.89, 1.45), 1.37 (1.08, 1.73), and 2.44 (1.93, 3.10). Mediation analysis showed hs-CRP and HOMA-IR mediated CAP's link to ASCVD risk, with mediation proportions of 15.40% and 27.37%. RC and non-HDL-C mediated this association at 7.12% and 6.26%. Among patients with hepatic steatosis (CAP ≥ 248 dB/m), LSM Q4 participants had a significantly higher predicted 10-year ASCVD risk than those in LSM Q1 (OR 2.22, [1.52, 3.25]), with hs-CRP and HOMA-IR mediating 2.62% and 13.75%, respectively.

CONCLUSION

Liver steatosis and fibrosis were associated with the increased predicted ASCVD risk, with mediation effects from hs-CRP, HOMA-IR, RC, and non-HDL-C.

Quercetin alleviates metabolic-associated fatty liver disease by tuning hepatic lipid metabolism, oxidative stress and inflammation

The natural flavonoid quercetin, which exhibits a range of biological activities, has been implicated in liver disease resistance in recent research. In vivo study attesting to quercetin's protective effect against metabolic-associated fatty liver disease (MAFLD) is inadequate, however. Here, our investigation explored the potential benefits of quercetin in preventing MAFLD in C57BL/6 mice fed a high-fat diet (HFD). The results revealed that quercetin ameliorated the aberrant enhancement of body and liver weight. The hepatic histological anomalie induced by MAFLD were also mitigated by quercetin. HFD-induced imbalance in serum LDL, HDL, AST, ALT, TG, and LDH was mitigated by quercetin. Mechanically, we found that quercetin improved lipid metabolism by reducing lipogenesis proteins including ACC, FASN, and SREBP-1c and enhancing β-oxidation proteins including PPARα and CPT1A. In vitro study demonstrated that quercetin regulated hepatic lipid metabolism by targeting SREBP-1c and PPARα. Additionally, quercetin enhanced the antioxidant capacity in HFD-treated mice by downregulating Nrf2 and HO-1 expressions and upregulating SOD and GPX1 expressions. The hyper-activation of inflammation was also restored by quercetin via eliminating the phosphorylation of IκBα and NF-κB p65. Collectively, our observations highlight that quercetin exerts hepatoprotective properties in MAFLD mice by regulating hepatic lipid metabolism, oxidative stress and inflammatory response.

Impact of cardiometabolic risk factors for metabolic dysfunction-associated steatotic liver disease on mortality

BACKGROUND AND AIMS

Metabolic dysfunction-associated steatotic liver disease (MASLD) is a potential independent risk factor for cardiovascular disease (CVD)-associated and all-cause mortalities as they share common risk factors. We investigated the association between cardiometabolic risk factors for MASLD and CVD-associated and all-cause mortality risks in middle-aged and older Korean adults.

METHODS AND RESULTS

We used data from the Korean Genome and Epidemiology Study, a population-based prospective cohort study. Five cardiometabolic risk factors were assessed. MASLD was defined as liver steatosis with a fatty liver index (FLI) ≥60 and at least one cardiometabolic risk factor. The non-MASLD group included individuals with a FLI <60 or FLI ≥60 without cardiometabolic risk factors. The primary outcomes were CVD-associated and all-cause mortalities. Cox proportional hazard models were used to evaluate the association between cardiometabolic risk factors for MASLD and mortalities, adjusting for covariates. Multivariable Cox regression analysis revealed that the MASLD group had increased CVD-associated and all-cause mortality risks compared to the non-MASLD group. The presence of three or more and one or more cardiometabolic risk factors significantly increased the CVD-associated and all-cause mortality rate, respectively. The combination of hypertriglyceridemia, low high-density lipoprotein cholesterol (HDL-C), and high glucose concentrations significantly increased both CVD-associated (hazard ratio [HR] 3.64; 95 % confidence interval [CI] 1.44-9.22; p = 0.006) and all-cause (HR 4.57; 95 % CI: 1.74-12.05; p = 0.002) mortality risks.

CONCLUSION

Cardiometabolic risk factors for MASLD are strongly associated with higher CVD-associated and all-cause mortality risks, highlighting the need to manage hypertriglyceridemia, low HDL-C, and high glucose concentrations.

Fu brick tea supplementation ameliorates non-alcoholic fatty liver disease and associated endotoxemia via maintaining intestinal homeostasis and remodeling hepatic immune microenvironment

Non-alcoholic fatty liver disease (NAFLD) is a prevalent disorder of excessive fat accumulation and inflammation in the liver that currently lacks effective therapeutic interventions. Fu brick tea (FBT) has been shown to ameliorate liver damage and modulate gut microbiota dysbiosis in NAFLD, but the potential mechanisms have not been comprehensively elucidated, especailly whether its hepatoprotective effects are determined to depend on the homeostasis of gut microbiota, intestinal barrier function and hepatic immune microenvironment. In this study, our results further demonstrated that FBT not only alleviated NAFLD symptoms and related endotoxemia in high-fat diet (HFD)-fed rats, but also attenuated intestinal barrier dysfunction and associated inflammation, also confirmed in Caco-2 cell experiment. Meanwhile, FBT intervention significantly relieved HFD-induced gut microbiota dysbiosis, characterized by increased diversity and composition, particularly facilitating beneficial microbes, including short chain fatty acids (SCFAs) and bile acids producers, such as Blautia and Fusicatenibacter, and inhibiting Gram-negative bacteria, such as Prevotella_9 and Phascolarctobacterium. Also, the gut microbiota-dependent hepatoprotective effects of FBT were verified by fecal microbiota transplantation (FMT) experiment. Thus, the beneficial moulation of gut microbiota altered by FBT in levels of SCFAs, bile acids and lipopolysaccharides, intestinal barrier function and TLR4/NF-κB pathway contributed to alleviate liver steatosis and inflammation. Additionally, the hepatoprotective effects of FBT was further demonstrated by suppressing Kupffer cell activation and regulating lipid metabolism using an ex vivo model of liver organoid. Therefore, FBT supplementation can maintain intenstinal homeostasis and remodel hepatic immune microenvironment to prevent NAFLD and associated endotoxemia.

Impact of triglyceride glucose - Body mass index on depression risk in Chinese middle-aged and elderly adults: Evidence from a large-scale study

BACKGROUND

Current literature lacks evidence to characterize the relationship between the triglyceride glucose - body mass index (TyG-BMI) and depression. Therefore, this study aimed to elucidate the potential association between TyG-BMI and depression risk in a Chinese middle-aged and elderly population.

METHODS

The study utilized data from the China Health and Retirement Longitudinal Study (CHARLS) conducted in 2011, which included 17,708 participants. We used multifactorial logistic regression modeling to investigate the relationship between TyG-BMI and depression in Chinese adults, using smoothed curve fitting to assess the nonlinear relationship between them. In addition, we performed sensitivity and subgroup analyses to verify the robustness of the results.

RESULTS

A total of 9328 participants were included in our study, After adjusting for all potential covariates, participants with higher levels of TyG-BMI had a lower risk of depression compared to Q1, the adjusted OR (95 % CI) values were Q2 (OR: 0.84, 95 % CI: 0.74-0.96, p = 0.009), Q3 (OR: 0.75, 95 % CI: 0.65-0.86, p < 0.001), and Q4 (OR: 0.67, 95 % CI: 0.57-0.79, p < 0.001). The association between TyG-BMI and depression exhibited an L-shaped curve (nonlinear, p = 0.004). When TyG-BMI <200, Increased TyG-BMI was associated with a significantly lower risk of depression (OR = 0.87 [95 %CI:0.82-0.93], p < 0.001). However, there was no association between TyG-BMI and depression when TyG-BMI ≥200 (OR = 0.96 [95 %CI:0.91-1.02], p = 0.22).

CONCLUSION

The connection between TyG-BMI and depression in Chinese adults is L-shaped, with an inflection point around 200.

Estimating the clinical and healthcare burden of metabolic dysfunction-associated steatohepatitis in England: a retrospective cohort study using routinely collected healthcare data from 2011 to 2020

OBJECTIVE

To characterise patients with metabolic dysfunction-associated steatohepatitis (MASH) in England and to estimate its associated healthcare resource use (HCRU) and costs, both overall and by progression status and comorbidities.

DESIGN

This was a retrospective observational study of adults with a MASH-coded primary and/or secondary care recorded diagnosis in England (2011-2020). The analysis used data from the Clinical Practice Research Datalink linked to the Hospital Episode Statistics and death registrations. Annualised all-cause and MASH-related (ie, coded as MASH, end-stage liver disease or major adverse cardiovascular event) HCRU and costs were calculated for patients with incident MASH. Subgroup analyses were conducted for patients with type 2 diabetes, overweight/obesity, cardiovascular disease or progression to cirrhosis. Comparative cost analysis was conducted between those with progressed MASH and those who did not progress.

RESULTS

A total of 2696 patients were included (mean follow-up: 4 years). Incidence of MASH was estimated at 4.7 per 100 000 person-years overall and increased among patients with key comorbidities. Patients who had type 2 diabetes had greater HCRU and costs than those who did not (eg, mean 1.8 vs 1.0 all-cause inpatient admissions and £2227 vs £1151 all-cause inpatient costs per-patient per-year). Some patients with MASH progressed to compensated (8.6%) or decompensated cirrhosis (6.5%) during the study. HCRU and costs were substantially higher among patients who progressed than among those who did not (eg, mean 2.4 vs 1.1 all-cause inpatient admissions and £3620 vs £1290 all-cause inpatient costs per-patient per-year).

CONCLUSION

HCRU and costs associated with MASH are higher among patients who have cardiometabolic comorbidities or who progress to advanced disease stages. Therefore, efforts to detect cases early and prevent disease progression could reduce healthcare burden.

Nephrological, Pulmonary, and Dermatological Complications in the Context of MAFLD/NAFLD: A Narrative Review

Background: The most common cause of chronic liver disease is now known to be non-alcoholic fatty liver disease (NAFLD), recently redefined as metabolic-associated fatty liver disease (MAFLD). This review aims to synthesize current evidence on the pathophysiology and clinical implications of nephrological, pulmonary, and dermatological manifestations among NAFLD/MAFLD patients. In order to find safe and efficient treatments, NAFLD/MAFLD has emerged as a primary concern for hepatologists worldwide. Methods: We conducted a comprehensive review of the literature from major databases, focusing on studies that evaluated the extrahepatic manifestations of NAFLD/MAFLD. Emphasis was placed on identifying pathophysiological mechanisms and assessing their clinical impact on renal, pulmonary, and dermatological systems. Results: Recent developments in the management of chronic viral hepatitis have lowered the mortality rate associated with chronic liver disease. However, the prevalence of NAFLD/MAFLD continues to rise, making chronic liver disease a significant health concern for the future. An increasing percentage of patients on liver transplant waiting lists now have cirrhosis and hepatocellular carcinoma due to non-alcoholic liver disease. Furthermore, the incidence and prevalence of chronic kidney disease have surged, linking NAFLD/MAFLD to higher morbidity, mortality, and healthcare costs. Conclusions: NAFLD/MAFLD is underdiagnosed and underappreciated, yet its incidence is rapidly increasing, raising concerns about a potential global epidemic. Given its multisystemic impact-extending to renal, pulmonary, and dermatological complications-it is crucial to develop interdisciplinary strategies for early detection and effective management of the disease.

Hidden in the Fat: Unpacking the Metabolic Tango Between Metabolic Dysfunction-Associated Steatotic Liver Disease and Metabolic Syndrome

Metabolic syndrome (MetS) and metabolic dysfunction-associated steatotic liver disease (MASLD) are closely related, with rapidly increasing prevalence globally, driving significant public health concerns. Both conditions share common pathophysiological mechanisms such as insulin resistance (IR), adipose tissue dysfunction, oxidative stress, and gut microbiota dysbiosis, which contribute to their co-occurrence and progression. While the clinical implications of this overlap, including increased cardiovascular, renal, and hepatic risk, are well recognized, current diagnostic and therapeutic approaches remain insufficient due to the clinical and individuals' heterogeneity and complexity of these diseases. This review aims to provide an in-depth exploration of the molecular mechanisms linking MetS and MASLD, identify critical gaps in our understanding, and highlight existing challenges in early detection and treatment. Despite advancements in biomarkers and therapeutic interventions, the need for a comprehensive, integrated approach remains. The review also discusses emerging therapies targeting specific pathways, the potential of precision medicine, and the growing role of artificial intelligence in enhancing research and clinical management. Future research is urgently needed to combine multi-omics data, precision medicine, and novel biomarkers to better understand the complex interactions between MetS and MASLD. Collaborative, multidisciplinary efforts are essential to develop more effective diagnostic tools and therapies to address these diseases on a global scale.

Incremental predictive value of liver fat fraction based on spectral detector CT for major adverse cardiovascular events in T2DM patients with suspected coronary artery disease

BACKGROUND

The purpose of this study was to explore the incremental predictive value of liver fat fraction (LFF) in forecasting major adverse cardiovascular events (MACE) among patients with type 2 diabetes mellitus (T2DM).

METHODS

We prospectively enrolled 265 patients with T2DM who presented to our hospital with symptoms of chest distress and pain suggestive of coronary artery disease (CAD) between August 2021 and August 2022. All participants underwent both coronary computed tomography angiography (CCTA) and upper abdominal dual-layer spectral detector computed tomography (SDCT) examinations within a 7-day interval. Detailed clinical data, CCTA imaging features, and LFF determined by SDCT multi-material decomposition algorithm were meticulously recorded. MACE was defined as the occurrence of cardiac death, acute coronary syndrome (ACS), late-phase coronary revascularization procedures, and hospital admissions due to heart failure.

RESULTS

Among 265 patients (41% male), 51 cases of MACE were documented during a median follow-up of 30 months. The LFF in T2DM patients who experienced MACE was notably higher compared to those without MACE (p < 0.001). The LFF was divided into tertiles using the cutoffs of 4.10 and 8.30. Kaplan-Meier analysis indicated that patients with higher LFF were more likely to develop MACE, regardless of different subgroups in framingham risk score (FRS) or coronary artery calcium score (CACS). The multivariate Cox regression results indicated that, compared with patients in the lowest tertile, those in the second tertile (hazard ratio [HR] = 3.161, 95% confidence interval [CI] 1.163-8.593, P = 0.024) and third tertile (HR = 4.372, 95% CI 1.591-12.014, P = 0.004) had a significantly higher risk of MACE in patients with T2DM. Even after adjusting for early revascularization, both LFF tertile and CACS remained independently associated with MACE. Moreover, compared with the traditional FRS model, the model that included LFF, CACS, and FRS showed stable clinical net benefit and demonstrated better predictive performance, with a C-index of 0.725, a net reclassification improvement (NRI) of 0.397 (95% CI 0.187-0.528, P < 0.01), and an integrated discrimination improvement (IDI) of 0.100 (95% CI 0.043-0.190, P < 0.01).

CONCLUSIONS

The elevated LFF emerged as an independent prognostic factor for MACE in patients with T2DM. Incorporating LFF with FRS and CACS provided incremental predictive power for MACE in patients with T2DM.

RESEARCH INSIGHTS

WHAT IS CURRENTLY KNOWN ABOUT THIS TOPIC?: T2DM is associated with increased MACE rates, underscoring the need for improved risk prediction. CACS is a well-established tool for MACE risk assessment but may not capture all risk factors. Hepatic steatosis is a common comorbidity in metabolic syndrome and T2DM. WHAT IS THE KEY RESEARCH QUESTION?: Does the incorporation of LFF derived from SDCT into existing risk prediction models enhance the accuracy of MACE forecasting in patients with T2DM? WHAT IS NEW?: SDCT-LFF measurement introduces a more accurate method for assessing hepatic steatosis. LFF as an independent predictor of MACE in T2DM patients is a novel finding. The study presents LFF as an additional tool for risk stratification, complementing FRS and CACS. HOW MIGHT THIS STUDY INFLUENCE CLINICAL PRACTICE?: Study findings may guide personalized prevention for T2DM patients at higher MACE risk.

In the Era of Cardiovascular-Kidney-Metabolic Syndrome in Cardio-Oncology: From Pathogenesis to Prevention and Therapy

Cardiovascular-kidney-metabolic (CKM) syndrome represents a complex interplay between cardiovascular disease (CVD), chronic kidney disease (CKD), and metabolic disorders, significantly impacting cancer patients. The presence of CKM syndrome in cancer patients not only worsens their prognosis but also increases the risk of major adverse cardiovascular events (MACE), reduces quality of life (QoL), and affects overall survival (OS). Furthermore, several anticancer therapies, including anthracyclines, tyrosine kinase inhibitors, immune checkpoint inhibitors, and hormonal treatments, can exacerbate CKM syndrome by inducing cardiotoxicity, nephrotoxicity, and metabolic dysregulation. This review explores the pathophysiology of CKM syndrome in cancer patients and highlights emerging therapeutic strategies to mitigate its impact. We discuss the role of novel pharmacological interventions, including sodium-glucose cotransporter-2 inhibitors (SGLT2i), proprotein convertase subtilisin/kexin type 9 inhibitors (PCSK9i), and soluble guanylate cyclase (sGC) activators, as well as dietary and lifestyle interventions. Optimizing the management of CKM syndrome in cancer patients is crucial to improving OS, enhancing QoL, and reducing MACE. By integrating cardiometabolic therapies into oncologic care, we can create a more comprehensive treatment approach that reduces the burden of cardiovascular and renal complications in this vulnerable population. Further research is needed to establish personalized strategies for CKM syndrome prevention and treatment in cancer patients.

Urinary metal levels and their association with Parkinson's disease risk: insights from NHANES 2013-2020

Background

Parkinson's disease (PD) poses a significant public health challenge worldwide, with both genetic predispositions and behavioral factors contributing to its onset and progression. While the precise mechanisms underlying PD remain uncertain, environmental influences are increasingly acknowledged as critical risk factors. This research focused on investigating the relationship between urinary metal levels and the likelihood of developing PD.

Methods

Using data from the National Health and Nutrition Examination Survey (NHANES), urinary levels of nine metals-barium (Ba), cadmium (Cd), cobalt (Co), cesium (Cs), molybdenum (Mo), lead (Pb), antimony (Sb), thallium (Tl), and uranium (Tu)-were measured in a cohort of 3,148 US adults. To examine their association with Parkinson's disease (PD) risk, multivariate logistic regression, weighted quantile sum (WQS) regression, and quantile regression were employed to evaluate both single and combined metal exposures. Additionally, Bayesian kernel machine regression (BKMR) was utilized to explore the joint effects of these metals, allowing for the assessment of potential nonlinear and non-additive interactions (using the "BKMR" package). Smooth curve fitting was further applied to visualize the nonlinear relationships between urinary metal concentrations and PD risk.

Results

In the single-exposure model, Mo, Tu and Cd were positively correlated with the risk of PD, with odds ratios (OR) ranging from 4.61 to 5.46 (all p < 0.05). Mixed-exposure analyses showed a consistent association (OR 1.48, 95% CI 1.06 to 2.06). The metals with the highest weight in the WQS model were Mo (56.79%), Co (34.20%), Ba (3.33%), and Tu (3.27%). In addition, BKMR model analysis showed that most single and mixed metals were positively associated with PD risk. Taken together, the results suggest that metal concentrations can increase the prevalence of PD.

Conclusion

In conclusion, this cross-sectional analysis of NHANES data indicates that higher urinary concentrations of metals including Mo, Cd, and Tu are associated with increased odds of PD among US adults. Mixed exposures to several metals may jointly elevate PD risk in a dose-dependent manner.

A Mendelian randomization study reveals a causal association between NASH and the risk of atrial fibrillation

Background

Epidemiological evidence suggests that non-alcoholic fatty liver disease (NAFLD) may increase the risk of atrial fibrillation (AF). However, the findings are inconsistent, and the causality remains to be established.

Methods

We conducted two-step, two-sample Mendelian randomization (MR) analysis to assess the association between genetically predicted NAFLD (i.e. chronically elevated serum alanine aminotransferase levels [cALT], imaging-based and biopsy-confirmed NAFLD) and AF. Subsequently, we further performed Mendelian randomization to investigate the causal relationship between non-alcoholic steatohepatitis (NASH), a subtype of NAFLD, and AF. The inverse variance weighted (IVW) method was used as the primary approach to reveal the potential causation between the exposure and outcome.

Results

There was no significant causal association between NAFLD diagnosed based on cALT, confirmed by imaging, or verified by biopsy, and an increased risk of atrial fibrillation. Furthermore, the results of the IVW method revealed a positive causal effect of NASH on AF (OR=1.113, 95% CI=1.025-1.209, P = 0.011). In the reverse analysis, however, no evidence supported a significant genetic association between AF and NASH (OR=0.974, 95% CI=0.934-1.016, P = 0.214).

Conclusion

A causal relationship existed between NASH and the risk of AF. However, no significant genetic association has been observed between NAFLD and AF risk. This suggests that managing the progression of NAFLD may hold potential value in preventing the onset of AF.

Relationship between albumin-corrected anion gap and non-alcoholic fatty liver disease: a cross-sectional analysis of NHANES 2017-2018

Objectives

The objective of this study was to examine the correlation between the albumin-corrected anion gap (ACAG) and non-alcoholic fatty liver disease (NAFLD) using data from the National Health and Nutrition Examination Survey (NHANES) 2017-2018.

Methods

A cross-sectional analysis was conducted, comprising 4,379 participants, who were stratified into two groups: those with NAFLD and those without NAFLD. The baseline characteristics were compared using the most appropriate statistical tests. The relationship between ACAG levels and NAFLD was assessed using generalized linear models, with adjustments made for potential confounding factors. The analysis of threshold effects was conducted using piecewise regression. Furthermore, the relationship between ACAG and NAFLD was investigated in different age groups.

Results

The mean age of participants with non-alcoholic fatty liver disease (NAFLD) was significantly higher than that of non-NAFLD participants (48.88 vs. 43.46 years, p < 0.001). The presence of NAFLD was associated with higher levels of ACAG (18.80 ± 0.24 vs. 18.10 ± 0.19, p < 0.001). In fully adjusted models, each 1-unit increase in ACAG was associated with a significantly increased risk of NAFLD in participants under 60 years old (β: 0.87, 95% CI: 0.05, 1.69, p < 0.05). In younger participants, elevated NAFLD risk was observed in those with higher ACAG quartiles (P for trend <0.05). In contrast, no significant associations were identified in participants aged 60 years and older (P for trend >0.05), suggesting the presence of age-specific differences in the relationship between ACAG and NAFLD.

Conclusion

The impact of ACAG on NAFLD is significantly correlated, especially in the age group, where elevated levels of ACAG are associated with increased risk of NAFLD in young people. ACAG may be a potential and reliable biomarker for predicting NAFLD risk in clinical assessment, but its implementation should consider the patient's age factor.

Association between cardiovascular health and markers of liver function: a cross-sectional study from NHANES 2005-2018

Background

Cardiovascular health (CVH) has been associated with various systemic diseases. However, the relationship between CVH, as measured by Life's Essential 8 (LE8), and liver function markers in the general population remains poorly understood.

Methods

This study analyzed data from 21,156 participants (aged ≥ 20) from the NHANES 2005-2018 to investigate the associations between CVH and liver function markers [alanine aminotransferase (ALT), aspartate aminotransferase (AST), gamma-glutamyl transferase (GGT), alkaline phosphatase (ALP), albumin and AST/ALT ratio]. Linear regression models were used, along with a restricted cubic spline (RCS) to assess dose-response. Weighted quantile sum (WQS) regression and quantile g-computation (QGC) analyses were employed to evaluate the association between CVH and liver function markers.

Results

Linear regression analysis showed that each 1-point increase in CVH score was significantly associated with decreased levels of liver enzymes [ALT: -0.200 U/L (95% CI: -0.223, -0.176), AST: -0.043 U/L (-0.062, -0.024), GGT: -0.453 U/L (-0.509, -0.397), ALP: -0.310 U/L (-0.340, -0.281)] and increased levels of albumin [0.040 g/dL (0.036, 0.045)] and AST/ALT ratio [0.0056 (0.0051, 0.0061)]. Notably, CVH score demonstrated non-linear dose-response relationships with ALT, ALP, and AST/ALT ratio. Age significantly modified these associations, while nicotine exposure, BMI, and blood lipids were identified as primary contributors through WQS and QGC analyses. E-value analysis suggested robustness to unmeasured confounding.

Conclusion

This study demonstrates robust associations between CVH and liver function markers in United States adults, with nicotine exposure, BMI, and blood lipids identified as significant contributors. These findings suggest that maintaining optimal cardiovascular health may have beneficial effects on liver function, highlighting potential targets for integrated prevention strategies.

Clinical Insights into Non-Alcoholic Fatty Liver Disease and the Therapeutic Potential of Flavonoids: An Update

Non-alcoholic fatty liver disease (NAFLD) is considered a significant global health issue related to serious metabolic disorders. However, effective pharmacological treatments are still limited. Flavonoids, a wide group of polyphenol substances, exert anti-inflammatory and lipid-lowering effects in preclinical data. Thus, implementing these research findings in clinical practice could significantly help manage NAFLD and its consequences. This narrative review assesses the therapeutic potential of flavonoids in managing NAFLD. The research collected randomized controlled trials (RCTs) and meta-analyses of RCTs from the past five years concerning the impact of flavonoids on NAFLD. A total of 20 studies were selected according to predetermined inclusion criteria, comprising thirteen randomized controlled trials (RCTs) and seven meta-analyses. The research underscores the beneficial effects of flavonoids in the management of NAFLD through the enhancement of lipid metabolism, the reduction in hepatic steatosis, and the provision of anti-inflammatory actions. Clinical trials demonstrate that interventions rich in flavonoids, including quercetin, epigallocatechin gallate, naringenin, and isoflavones, substantially reduce liver fat content and enhance liver enzyme profiles, with certain compounds exhibiting superior efficacy in particular subgroups, such as older adults and females. Nonetheless, whereas these therapies significantly diminish hepatic steatosis, their effect on fibrosis is constrained. To sum up, flavonoids exhibit significant potential as supplementary treatments for NAFLD by enhancing liver function, lipid metabolism, and inflammation. Additional extensive controlled clinical trials are necessary to create uniform treatment methods and ascertain their long-term therapeutic advantages.

Global burden and future trends of metabolic dysfunction-associated Steatotic liver disease: 1990-2021 to 2045

INTRODUCTION AND OBJECTIVES

Metabolic dysfunction-associated steatotic liver disease (MASLD), formerly non-alcoholic fatty liver disease, is a growing global health challenge. This study examines the global burden of MASLD from 1990 to 2021 and projects data for 2045.

MATERIALS AND METHODS

Using data from the Global Burden of Disease (GBD) Study 2021, the study analyzed MASLD across 204 countries from 1990 to 2021, focusing on prevalence, incidence, deaths, and disability-adjusted life years (DALYs). Linear and Joinpoint regression assessed trends, an age-period-cohort model evaluated health outcomes, and a Bayesian model forecasted future cases.

RESULTS

In 2021, approximately 1.27 billion people globally had MASLD, with a higher prevalence in males (51.41 %). There were 48.35 million new cases, primarily in males (52.24 %). The age-standardized prevalence rate (ASPR) increased from 12,085.09 in 1990 to 15,018.07 per 100,000 in 2021 (AAPC 0.71). The age-standardized incidence rate (ASIR) rose from 475.54 to 593.28 per 100,000 (AAPC 0.71). MASLD caused 138,328 deaths, with females experiencing higher mortality (52.18 %). East Asia, South Asia, and North Africa/Middle East had the highest prevalence and incidence rates, while Western Europe showed the fastest growth. By 2045, ASIR is projected to reach 928.10 per 100,000, resulting in 667.58 million new cases, predominantly affecting males.

CONCLUSIONS

MASLD poses a significant burden with notable gender and regional disparities. The projected increase by 2045 underscores the need for urgent public health interventions and targeted strategies to mitigate this growing epidemic.

Cardiovascular disease and metabolic dysfunction-associated steatotic liver disease: pathophysiology and diagnostic aspects

Metabolic dysfunction-associated steatotic liver disease (MASLD) can be interpreted as the hepatic expression of metabolic syndrome, which is estimated to affect 30% of the adult population. Obesity, dyslipidaemia, arterial hypertension, and T2DM are considered significant risk factors of MASLD. The relationship is two-way with MASLD found in up to 75% of patients with T2DM. Importantly, MASLD is associated with increased risk of cardiovascular diseases (CVD) such as arrhythmia, atherosclerotic heart disease, heart failure, and CVD-associated mortality. In addition, MASLD patients present with a high prevalence of major adverse cardiac events, which calls for systematic surveillance of CVD in MASLD. This review focuses on the pathophysiology behind development of CVD in MASLD, the types of cardiovascular complications, morbidity and survival, and suggestions for evaluation of patients with MASLD.

LTSI Consensus Guidelines: Preoperative Cardiac Evaluation in Adult Liver Transplant Recipients

Cardiovascular disease (CVD) is the leading cause of morbidity and mortality among LT candidates and accounts for up to 40% of the overall mortality within one month. It is influenced by traditional and nontraditional risk factors related to end-stage liver disease. A large proportion of CLD patients have underlying cardiovascular disease (CVD) especially if the etiology is metabolic associated steatohepatitis. Despite the large number of liver transplantations being conducted in India, there is a lack of an evidence-based guidelines for screening of CVD in this patient population. This consensus statement from Liver Transplant Society of India (LTSI) is the first attempt for developing an evidence-based document on preoperative cardiac evaluation from India. A task force consisting of transplant-anesthesiologists, transplant hepatologists, liver transplant surgeon and cardiologists from high volume centres was formed which reviewed the existing evidence and literature and formulated graded recommendations. The document focuses on identification of underlying cardiac pathologies, risk stratification and optimisation of modifiable cardiac diseases. Implementation of best practices and optimal strategies should be encouraged to improve cardiovascular outcomes in these populations.

MAFLD as a predictor of adverse cardiovascular events among CHD patients with LDL-C<1.8 mmol/L

BACKGROUND AND AIMS

Patients receiving statin therapy still suffer from adverse cardiovascular events. Metabolic (dysfunction)-associated fatty liver disease (MAFLD) is a newly proposed concept that shares common metabolic risk factors with cardiovascular disease. This study aimed to investigate the association between MAFLD and adverse cardiovascular outcomes in coronary heart disease (CHD) patients with LDL-C<1.8 mmol/L.

METHODS AND RESULTS

CHD patients with LDL-C<1.8 mmol/L were divided into MAFLD and non-MAFLD groups. Propensity score matching (PSM) was used to control for baseline differences between the two groups. The primary endpoint was major adverse cardiac and cerebrovascular events (MACCEs). All MAFLD patients were further stratified into two groups with and without advanced liver fibrosis, according to the Fibrosis-4 (FIB-4) index cutoffs, and the associations between advanced liver fibrosis status and cardiovascular outcomes were analyzed. After PSM, 800 MAFLD and 800 non-MAFLD patients with LDL-C<1.8 mmol/L were analyzed. MAFLD patients exhibited a significantly greater cumulative incidence and risk of MACCEs than non-MAFLD patients (9.6 % versus 6.6 %, p < 0.05; HR 1.48, 95 % CI 1.04-2.1, p < 0.05). Among MAFLD patients with LDL-C<1.8 mmol/L, advanced liver fibrosis staged by the FIB-4 index was associated with an elevated risk for MACCEs (HR 2.91, 95 % CI 1.17-7.19, p < 0.05), all-cause mortality, myocardial infarction (MI) and stent thrombosis.

CONCLUSION

MAFLD was an independent risk factor for adverse cardiovascular outcomes in CHD patients with LDL-C<1.8 mmol/L. Additionally, advanced liver fibrosis predicts increased risks for adverse cardiovascular events among MAFLD patients. These findings suggest that MAFLD and liver fibrosis screening and management contribute to the residual cardiovascular risk of CHD patients.

Global burden of MAFLD, MAFLD related cirrhosis and MASH related liver cancer from 1990 to 2021

Metabolic dysfunction-associated fatty liver disease (MAFLD) is the most prevalent chronic liver disease globally, driven by rising obesity, metabolic syndrome (MetS), and type 2 diabetes mellitus (T2DM). This study evaluates the global, regional, and national burden of MAFLD-related diseases from 1990 to 2021 and projects future trends. Data were sourced from the Global Burden of Disease (GBD) 2021 database, including estimates for the incidence, prevalence, mortality, and disability-adjusted life years (DALYs) associated with MAFLD, MAFLD-related cirrhosis, and MASH-related liver cancer. Countries were classified into 21 regions and five socio-demographic index (SDI) quintiles to analyze health disparities. Decomposition analyses assessed the contributions of population growth, aging, and epidemiological shifts. Future trends were modeled using the Bayesian Age-Period-Cohort (BAPC) framework. In 2021, approximately 1.27 billion MAFLD cases were reported globally, with an age-standardized prevalence rate (ASPR) of 15,018 per 100,000. The highest incidence occurred in South and East Asia. Mortality reached 138,328 cases for MAFLD and 97,403 for MAFLD-related cirrhosis. Decomposition analyses highlighted population growth and aging as key drivers. BAPC projections indicate a continued rise in MAFLD burden, particularly in low- and middle-income countries. This study underscores the increasing global burden of MAFLD and its complications. Targeted public health interventions focusing on prevention and early management are urgently needed to mitigate future impacts.

Effects of Semaglutide on Muscle Structure and Function in the SLIM LIVER Study

BACKGROUND

Semaglutide is highly effective for decreasing weight. Concomitant loss of muscle mass often accompanies weight loss and may have consequences on muscle function.

METHODS

This is a secondary analysis from the SLIM LIVER (Advancing Clinical Therapeutics Globally for HIV/AIDS and Other Infections, ACTG A5371) study, a single-arm study of semaglutide in people with human immunodeficiency virus (HIV, PWH) with metabolic dysfunction-associated steatotic liver diseases (MASLD). Participants received subcutaneous semaglutide for 24 weeks (titrated to 1 mg/week by week 4). Psoas volume and fat fraction were assessed from liver magnetic resonance imaging, and physical function was assessed by 10-time chair rise test and 4 m gait speed. Mean change from baseline to week 24 was estimated with linear regression modeling.

RESULTS

Fifty-one PWH were enrolled (muscle measures n = 46). The mean age was 50 years (standard deviation, 11), body mass index was 35.5 kg/m2 (5.6), 43% were women, 33% Black, and 39% Hispanic/Latino. Psoas muscle volume decreased by 9.3% (95% confidence interval [CI]: -13.4 to -5.2; P < .001) over 24 weeks, but psoas muscle fat did not significantly change (-0.42%; 95% CI: -1.00 to .17; P = .16). Chair rise and gait speed showed nonsignificant improvements of 1.27 seconds (95% CI: -2.7 to .10) and 0.05 m/sec (95% CI: -.01 to .10), respectively (both P > .07). The prevalence of slow gait speed (<1 m/sec) decreased from 63% to 46% (P = .029).

CONCLUSIONS

In PWH receiving semaglutide for MASLD, despite decreased psoas muscle volume, there was no significant change in physical function, suggesting function was maintained despite significant loss of muscle.

CLINICAL TRIALS REGISTRATION

NCT04216589.

Cardiovascular Manifestations of Patients with Non-Alcoholic Fatty Liver Disease

Background: Non-alcoholic fatty liver disease (NAFLD), more recently redefined as metabolic-associated fatty liver disease (MAFLD), is now recognized as the most prevalent cause of chronic liver disease. Its strong association with cardiovascular disease (CVD) underscores its emerging role in global morbidity and mortality. Objective: This review critically examines the pathophysiological mechanisms that link NAFLD/MAFLD with CVD. It focuses on shared metabolic disturbances, inflammatory pathways, and alterations in the gut microbiota that contribute to hepatic and cardiovascular pathology. Review and Gaps: Current evidence highlights insulin resistance, dyslipidemia, systemic inflammation, and gut dysbiosis as pivotal factors connecting NAFLD/MAFLD to CVD. Despite these insights, inconsistencies in diagnostic criteria and a lack of validated non-invasive biomarkers hinder a clear understanding of the causal relationship between liver and cardiovascular diseases. Conclusions: Addressing these knowledge gaps through standardized diagnostic protocols and large-scale longitudinal studies is essential. Improved biomarker validation and clearer delineation of the underlying mechanisms will improve cardiovascular risk stratification and enable more personalized therapeutic strategies for patients with NAFLD/MAFLD.

Gastrointestinal adverse events associated with GLP-1 receptor agonists in metabolic dysfunction-associated steatotic liver disease (MASLD): a systematic review and meta-analysis

Background

Metabolic dysfunction-associated steatotic liver disease, a prevalent chronic liver condition, can cause severe complications like hepatitis, cirrhosis, and hepatocellular carcinoma. In recent years, glucagon-like peptide-1 receptor agonists (GLP - 1RA) have shown unique therapeutic advantages and may become a preferred treatment for it. This meta-analysis aims to systematically examine GLP-1RA associated adverse events, providing a basis for guiding patient clinical management.

Methods

We conducted a search for randomized controlled trials (RCTs) investigating the therapeutic effects of GLP-1RA in the treatment of metabolic dysfunction-associated steatotic liver disease across four databases: PubMed, Embase, Web of Science, and Cochrane Library. The search period extended from the inception of each database until December 2023. Information pertaining to various adverse events was collected as outcome measures. Statistical analysis of the results and assessment of bias risk were conducted utilizing Review Manager (version 5.4.1) software.

Results

An analysis of 10 studies encompassing 960 participants revealed a significantly higher overall incidence of adverse events in the GLP-1RA group compared to the control group (OR: 2.40 [1.10, 5.26], P = 0.03). Subgroup analysis based on treatment duration demonstrated a higher rate of adverse events in the GLP-1RA group during follow-ups of less than 30 weeks (P = 0.0005, OR: 3.58 [1.75, 7.32]), but no statistical difference was observed between the two groups in follow-ups exceeding 30 weeks. There was no statistically significant difference between the two groups in adverse events leading to discontinuation (P = 0.29, OR: 1.47 [0.72, 2.98]). However, a notable difference was observed in gastrointestinal adverse events (P < 0.00001, OR: 4.83 [3.36, 6.95]).

Conclusion

GLP-1RA exhibits an overall higher incidence of adverse events in the treatment of metabolic dysfunction-associated steatotic liver disease, particularly in the gastrointestinal domain. Short-term use of GLP-1RA may be associated with a greater occurrence of adverse events, underscoring the importance of educating patients on preventive measures and establishing tolerance. However, there was no statistically significant difference between the two groups in severe adverse events and adverse events leading to discontinuation, confirming the safety profile of GLP-1RA application.

Feasibility of Serum Galectin-1 as a Diagnostic Biomarker for Metabolic Dysfunction-Associated Steatotic Liver Disease: A Study on a Segment of the Chinese Population Using Convenience Sampling

Background/Objectives: Metabolic Dysfunction-Associated Steatotic Liver Disease (MASLD) is commonly considered as a hepatic manifestation of metabolic syndrome, posing considerable public health and economic challenges due to its high prevalence. This study investigates the diagnostic potential of serum galectin-1 levels in MASLD patients. Methods: A total of 128 participants were analyzed for this study, comprising 68 healthy controls and 60 MASLD patients. The hepatic steatosis index (HSI) and fatty liver index (FLI) were calculated to evaluate the liver steatosis. Serum galectin-1 levels were measured using an enzyme-linked immunosorbent assay. We additionally conducted a comparative analysis of galectin-1 mRNA and protein expression levels in the liver tissue between the mouse models of MASLD, including ob/ob mice (n = 6), high-fat diet-fed C57 mice (n = 6), and the control group (n = 6). Results: Average serum galectin-1 levels significantly differed between groups, with lower values in the controls (p < 0.01). The frequency of MASLD increased with higher quartiles of galectin-1 levels (p < 0.01). The correlation analysis showed a positive relationship between serum galectin-1 and both HSI and FLI (p < 0.01). The multivariate logistic regression indicated that elevated galectin-1 was associated with an increased risk of MASLD (p < 0.01), yielding an area under the receiver operating characteristic curve for predicting MASLD at 0.745 (95% CI: 0.662-0.829). Hepatic galectin-1 levels were also elevated in the MASLD mouse model at both transcript and protein levels (p < 0.01). Conclusions: Serum galectin-1 can be used as a potential biomarker to help diagnose MASLD.

Impact of shear wave elastography and attenuation imaging for predicting life-threatening event in patients with metabolic dysfunction-associated steatotic liver disease

We aimed to elucidate the value of ultrasound-based biomarkers for predicting the major life-threatening events in metabolic dysfunction-associated steatotic liver disease (MASLD). We established a prospective cohort of 279 patients who underwent two-dimensional shear wave elastography (2D-SWE), ultrasound-guided attenuation parameter (UGAP). An area under the curve analysis was performed to determine the cutoff values of liver stiffness measurements (LSM) by 2D-SWE and attenuation coefficient (AC) by UGAP for a moderate fibrosis and a moderate steatosis. We then classified the cohort into Groups A (low LSM and low AC), B (low LSM and high AC), C (high LSM and high AC), and D (high LSM and low AC). We compared the incidence of events between the groups, and estimated the hazard ratios (HRs) with 95% confidence intervals (CIs). The LSM and AC cut off values were 8.37 kPa and 0.62 dB/cm/MHz, respectively. The cumulative incidence rate in Groups A, B, C, and D were 11.2%, 12.2%, 29.5%, and 31.0%/5years, respectively (p < 0.05). LSM (HRs = 1.20, 95%CIs: 1.09-1.32, p < 0.01), and AC (HRs = 1.62, 95%CIs: 1.04-2.51, p = 0.03) were associated with life-threatening events. A combination of 2D-SWE and UGAP may help identify patients with MASLD at high risk for subsequent life-threatening events.

Dietary and lifestyle indices for hyperinsulinemia and odds of MAFLD in overweight and obese children and adolescents

Lifestyle and dietary intake play a pivotal role in development of metabolic dysfunction-associated fatty liver disease(MAFLD). We performed this cross-sectional study to evaluate the association between lifestyle and dietary insulinemic potential and odds of MAFLD in overweight and obese children and adolescents. The insulinemic potential of the diet and lifestyle was assessed by computing the scores of the empirical dietary index for hyperinsulinemia(EDIH), the empirical lifestyle index for hyperinsulinemia(ELIH), the empirical dietary index for insulin resistance(EDIR), and the empirical lifestyle index for insulin resistance(ELIR). MAFLD was diagnosed according to the consensus definitions. Odds ratios (ORs) and 95% confidence intervals (CIs) were calculated by logistic regression. A total of 334 (49.1% boys) with mean ± SD age and BMI-for-age-Z-score of 9.3 ± 1.8 and 2.55 ± 0.69, respectively, were enrolled. After adjusting for all potential confounders, participants in the highest quartile of ELIH score had greater odds of developing MAFLD (OR:3.50;95%CI:1.49-8.22) compared with those in the lowest quartile. This association remained significant among boys and pubertal ones. However, no significant association between EDIH, EDIR, or ELIR and odds of MAFLD was found. Our study suggests that the collective insulinemic potential of dietary intake, BMI, and physical activity is associated with increased odds of MAFLD.

Nonlinear associations of the hs-CRP/HDL-C index with metabolic dysfunction-associated steatotic liver disease and advanced liver fibrosis in US adults: insights from NHANES 2017-2018

Metabolic dysfunction-associated steatotic liver disease (MASLD) is a globally widespread chronic liver condition that may progress to severe liver diseases, including advanced liver fibrosis. The high-sensitivity C-reactive protein-to-high-density lipoprotein cholesterol (hs-CRP/HDL-C) index may be a potential indicator for MASLD and advanced liver fibrosis, given its relevance to inflammation and plasma lipids. In this study, the hs-CRP/HDL-C index was investigated in relation to prevalent MASLD and advanced liver fibrosis. The study analyzed secondary data from the National Health and Nutrition Examination Survey (NHANES) 2017-2018 database. The hs-CRP/HDL-C index was calculated by the quotient of hs-CRP and HDL-C. Multiple logistic regression models, Cochran-Armitage trend tests, smooth curve fitting, threshold effect analyses, and stratified analyses were used to evaluate whether the hs-CRP/HDL-C index associated with MASLD and advanced liver fibrosis. The study cohort comprised 3684 participants, of whom 1268 (34.42%) were diagnosed with MASLD and 156 (12.28%) with advanced liver fibrosis. Logistic analyses adjusted for covariates revealed positive associations of the hs-CRP/HDL-C index with MASLD and advanced liver fibrosis, consistent across all subgroups. Smooth curve fitting and threshold effect analyses revealed nonlinear relationships of hs-CRP/HDL-C index with MASLD and advanced liver fibrosis, with inflection points at 0.8 for MASLD and 1.2 for advanced liver fibrosis. Additionally, significant interactions were observed between MASLD and covariates such as gender, smoking status, chronic kidney disease (CKD), and cancer. Similarly, the hs-CRP/HDL-C index exhibited positive correlations with advanced liver fibrosis across diverse subgroups, with notable interactions related to cancer. MASLD and advanced liver fibrosis were associated with hs-CRP/HDL-C index, indicating its potential utility as a clinical marker for these conditions.

Exploring the mechanisms of Shugan-Jieyu-Jianpi formula against irritable bowel syndrome combined with non-alcoholic fatty liver disease by network pharmacology and experimental validation

The study was aimed to investigate the clinical effect and mechanism of Shugan-Jieyu-Jianpi (SGJYJP) formula for the treatment of irritable bowel syndrome (IBS) combined with non-alcoholic fatty liver disease (NAFLD). The clinical efficacy of SGJYJP was evaluated in 54 patients with IBS-NAFLD. The potential molecular mechanism of SGJYJP formula was investigated by network pharmacology. Animal models were constructed to explore the related mechanism. From clinical studies, the total effective rate of patients in SGJYJP group was significantly higher than that in pinaverium group. The protein expression of TGFB1 was declined in IBS-NAFLD rats, together with the increased expression of PTGS2 and TNF, which was abolished by SGJYJP treatment. SGJYJP significantly reduced the expression of TNF signalling related molecules of TRAF2, caspase-8, and elevated the expression of Bcl-xl in IBS-NAFLD animal models. SGJYJP may exert therapeutic effect on IBS-NAFLD by targeting PTGS2, TGFB1, and TNF genes and TNF signalling.

Associations between MASLD, atrial fibrillation, cardiovascular events, mortality and aspirin use in older adults

The impact of metabolic dysfunction-associated steatotic liver disease (MASLD), the preferred nomenclature for NAFLD, on cardiovascular health and mortality among older adults is uncertain. As such, we aimed to identify whether MASLD increases the risk of Major Adverse Cardiovascular Events (MACE) (a composite of fatal coronary heart disease [excluding heart failure], nonfatal myocardial infarction, or fatal or nonfatal ischemic stroke), Atrial Fibrillation (AF), or all-cause mortality in older adults, and whether aspirin attenuates these risks in individuals with MASLD. This is a non-prespecified post-hoc analysis of the ASPREE (ASPirin in Reducing Events in the Elderly) randomized trial. Participants were community dwelling well adults aged ≥ 70 years without a history of atherosclerotic cardiovascular disease or AF. Fatty Liver Index (FLI) was used to identify MASLD at baseline. FLI is a composite of anthropometric and biochemical markers used in epidemiologic studies to rule in and rule out hepatic steatosis. MACE and cause of death were adjudicated by clinical experts; AF was assessed by previously defined algorithm in ASPREE. 9,097 participants were stratified into groups according to FLI. In univariate analysis, prevalent MASLD (FLI ≥ 60 with evidence of metabolic dysfunction; n = 2,998 [33.0%]) was associated with an increased risk of MACE (HR 1.47 [95% CI 1.22-1.78]) and AF (HR 1.50 [95% CI 1.19-1.88] but not all-cause mortality (HR 1.04 [95% CI 0.91-1.19]). After adjusting for cardiovascular disease risk factors, only the association between MASLD and AF remained significant (HR 1.46 [95% CI 1.11-1.93]). Aspirin did not reduce the risk of MACE, death, or AF in the MASLD group. MASLD was associated with an increased hazard of incident AF, but not of MACE or all-cause mortality, in community dwelling older adults. Primary prevention with aspirin does not ameliorate these risks in older adults with MASLD.

FIB-4 Index and Liver Stiffness Measurement are Potential Predictors of Atherosclerosis in Metabolic Dysfunction-Associated Steatotic Liver Disease

AIMS

Cardiovascular disease (CVD) is a common cause of death in patients with metabolic dysfunction-associated steatotic liver disease (MASLD). Therefore, CVD surveillance is important, but it is not well established. We evaluated the association between liver fibrosis, carotid artery atherosclerosis, and coronary artery stenosis in patients with MASLD.

METHODS

Overall, 153 patients with MASLD who underwent carotid artery ultrasound were enrolled. Maximum intima-media thickness including plaques (Max-IMT) was measured by ultrasound. To predict liver fibrosis, liver stiffness was measured by vibration-controlled transient elastography and the fibrosis 4 (FIB-4) index was calculated. Coronary computed tomography angiography was performed to detect coronary artery stenosis based on a Max-IMT of ≥ 1.1 mm.

RESULTS

The median Max-IMT was 1.3 mm, and 63 patients (41.2%) had a Max-IMT of ≥ 1.5 mm. FIB-4 index and liver stiffness was significantly correlated with Max-IMT, respectively (ρ=0.356, p＜0.001, ρ=0.25, p=0.002). Liver stiffness was significantly associated with a Max-IMT of ≥1.5 mm, independent of age. Individuals with higher FIB-4 index had moderate or severe coronary artery stenosis more frequently. Individuals with higher LSM level also had moderate or severe coronary artery stenosis more frequently, especially severe stenosis.

CONCLUSIONS

Liver fibrosis parameters were associated with carotid artery atherosclerosis and coronary artery stenosis. Evaluation of liver fibrosis may be useful to identify significant atherosclerosis and coronary artery stenosis in patients with MASLD.

Oxidised Apolipoprotein Peptidome Characterises Metabolic Dysfunction-Associated Steatotic Liver Disease

BACKGROUND

Metabolic Dysfunction-Associated Steatotic Liver Disease (MASLD) encompasses a spectrum of histological conditions ranging from simple steatosis to fibrosing steatohepatitis, and is a risk factor for cardiovascular diseases (CVD). While oxidised apolipoproteins A and B have been linked to obesity and CVD, the association between other oxidised apolipoproteins and MASLD is yet to be established. To fill this gap, we characterised the circulating serum peptidome of patients with MASLD.

METHODS

We studied the serum of 87 biopsy-confirmed MASLD patients and 20 age- and sex-matched control (CTRL) subjects. We first employed an untargeted LC-MS/MS peptidomics approach (9 CTRL, 32 MASLD) to identify key hits differentially modulated, and subsequently validated the most relevant findings through targeted peptidomics in an enlarged study population (87 MASLD and 20 CTRL).

RESULTS

Untargeted serum peptidomics identified several oxidised apolipoprotein peptide fragments, including ApoE and ApoC-III, significantly upregulated in MASLD compared to CTRL. Specifically focusing on the oxidative status of intact ApoC-III, studied through its major glycoforms (ApoC-III0, ApoC-IIIi and ApoC-IIIii), we observed a marked reduction in non-oxidised forms of these circulating peptides alongside substantially increased levels of their oxidised proteoforms in MASLD versus controls (but not within the disease stages). Oxidised ApoE and ApoC-III peptide fragments were also significantly correlated with obesity, insulin resistance, dyslipidaemia and transaminases, suggesting a potential link between circulating apolipoprotein oxidation and systemic/hepatic metabolic dysfunction.

CONCLUSION

Our data reveals a previously unreported oxidised apolipoprotein profile associated with MASLD. The functional and clinical implications of these findings warrant further mechanistic investigation.

Smad4 deficiency in hepatocytes attenuates NAFLD progression via inhibition of lipogenesis and macrophage polarization

Nonalcoholic fatty liver disease (NAFLD), a major cause of chronic liver disorders, has become a serious public health issue. Although the Smad4 signaling pathway has been implicated in the progression of NAFLD, the specific role of Smad4 in hepatocytes in NAFLD pathogenesis remains unclear. Hepatocyte-specific knockout Smad4 mice (AlbSmad4-/-) were first constructed using the Cre-Loxp recombinant system to establish a high-fat diet induced NAFLD model. The role of Smad4 in the occurrence and development of NAFLD was determined by monitoring the body weight of mice, detecting triglycerides and free fatty acids in serum and liver tissue homogenates, staining the tissue sections to observe the accumulation of liver fat, and RT-qPCR detecting the expression of genes related to lipogenesis, fatty acid intake, and fatty acid β oxidation. The molecular mechanism of Smad4 in hepatocytes affecting NAFLD was therefore investigated through combining in vitro and in vivo experiments. Smad4 deficiency in hepatocytes mitigated NAFLD progression and decreased inflammatory cell infiltration. Moreover, Smad4 deficiency inhibited CXCL1 secretion by suppressing the activation of the ASK1/P38/JNK signaling pathway. Furthermore, targeting CXCL1 using CXCR2 inhibitors diminished hepatocyte lipogenesis and inhibited the polarization of M1-type macrophages. Collectively, these results suggested that Smad4 plays a vital role in exacerbating NAFLD and may be a promising candidate for anti-NAFLD therapy.

Systematic pharmacology and experimental validation to elucidate the inflammation-associated mechanism of Huanglian Wendan (HLWD) decoction in the treatment of MAFLD associated with atherosclerosis

ETHNOPHARMACOLOGICAL RELEVANCE

Metabolic-associated fatty liver disease (MAFLD) and atherosclerosis are very common disorders that frequently coexist. The therapeutic efficacy of Huanglian Wendan (HLWD) decoction, a traditional Chinese medicine (TCM) prescription, is satisfactory in treating MAFLD associated with atherosclerosis. However, the underlying mechanisms through which HLWD exerts its effects need to be elucidated. Given the complex composition of HLWD and its multiple therapeutic targets, pharmacological investigation is challenging.

AIM OF THIS STUDY

This study aimed to identify the effective compounds in HLWD and elucidate the mechanisms involved in its therapeutic effect on MAFLD associated with atherosclerosis.

MATERIALS AND METHODS

We used a systematic pharmacology method to identify effective compounds present in HLWD and determine the mechanism by which it affects MAFLD associated with atherosclerosis. The effective components of HLWD were identified through ultrahigh-performance liquid chromatography-q exactive-orbitrap high resolution mass spectrometry (UHPLC-Q-Orbitrap HRMS). Next, a comprehensive in silico method was used to predict potential related targets and disease targets for these compounds to establish corresponding pathways. The accuracy of our assumed systemic pharmacology results was determined by conducting follow-up experiments.

RESULTS

By conducting UHPLC-Q-Orbitrap HRMS combined with network analysis, we identified 18 potentially active components of HLWD and assessed the inflammatory regulatory mechanism by which it affects MAFLD associated with atherosclerosis on the basis of 52 key targets. We used a high-fat, high-cholesterol (HFHC)-induced mice model of MAFLD associated with atherosclerosis to confirm our results. We found that administering HLWD significantly improved the appearance of their liver and reduced their body weight, liver weight, blood lipids, hepatic damage, and hepatic pathology. HLWD also decreased atherosclerotic lesion areas, foam cells, and inflammatory cells in the aorta. HLWD showed anti-inflammatory effects, suppressed M1 polarization, and promoted M2 polarization in the liver and aorta. HLWD might also regulate peroxisome proliferator-activated receptor-γ (PPARγ)/nuclear factor kappa-B (NF-κB) signaling to influence macrophage polarization and inflammation.

CONCLUSIONS

Our results showed that HLWD protected against HFHC diet-induced MAFLD associated with atherosclerosis by regulating PPARγ/NF-κB signaling, thus adjusting macrophage polarization and inflammation. Additionally, pharmacochemistry research, network pharmacology analysis, and experimental verification can be combined to form a comprehensive model used in studies on TCM.

Comprehensive profiling of serum microRNAs in normal and non-alcoholic fatty liver disease (NAFLD) patients

Pediatric non-alcoholic fatty liver disease (NAFLD) is emerging as a worldwide health concern with the potential to advance to cirrhosis and liver cancer. NAFLD can also directly contribute to heart problems through inflammation and insulin resistance, even in individuals without other risk factors. The pathological mechanisms of NAFLD are linked to functional differences of miRNAs in different biological environments. The miRNA in serum exosomes may reflect the pathological state of the liver and changes in systemic metabolism, while the miRNA in serum may be associated with physiological processes other than the liver. Pediatric non-alcoholic fatty liver disease (NAFLD) is emerging as a worldwide health concern with the potential to advance to cirrhosis and liver cancer. NAFLD can also directly contribute to heart problems through inflammation and insulin resistance, even in individuals without other risk factors. The pathological mechanisms of NAFLD are linked to functional differences of miRNAs in different biological environments. The miRNA in serum exosomes may reflect the pathological state of the liver and changes in systemic metabolism, while the miRNA in serum may be associated with physiological processes other than the liver. Pediatric non-alcoholic fatty liver disease (NAFLD) is emerging as a worldwide health concern with the potential to advance to cirrhosis and liver cancer. NAFLD can also directly contribute to heart problems through inflammation and insulin resistance, even in individuals without other risk factors. The pathological mechanisms of NAFLD are linked to functional differences of miRNAs in different biological environments. The miRNA in serum exosomes may reflect the pathological state of the liver and changes in systemic metabolism, while the miRNA in serum may be associated with physiological processes other than the liver. Our study identified 36 miRNAs with differential expression in the serum of NAFLD patients compared to the control group, including 21 miRNAs with significantly increased expression and 15 with decreased expression. Consistent with our previously reported data on serum-derived exosomal miRNA profiling, this study also observed a notable upregulation of serum miR-122-5p levels in NAFLD patients. PCR validation confirmed the differential expression of miR-122-5p identified through RNA sequencing. Functional analysis using GO and KEGG pathways revealed a diverse range of biological roles associated with these differentially expressed miRNAs. Notably, NAFLD significantly impacts heart health, with miR-122-5p playing a key role in regulating cardiovascular function. Furthermore, activation of the miR-122/Sirt-6/ACE2 axis may contribute to myocardial necrosis, highlighting its potential role in NAFLD-associated cardiovascular risks. Our study suggests that miR-122 plays a key role in the progression of NAFLD and its associated metabolic disturbances, which can increase the risk of cardiovascular disease. Targeting miR-122 may offer potential therapeutic benefits for improving both liver and heart health in individuals with NAFLD.

An insight on the additive impact of type 2 diabetes mellitus and nonalcoholic fatty liver disease on cardiovascular consequences

BACKGROUND

Nonalcoholic fatty liver disease (NAFLD) and type 2 diabetes mellitus (T2DM) are associated with a multifactorial complicated aetiology that is often coexisting and has a strong and distinct connection with cardiovascular diseases (CVDs). In order to accomplish effective and appropriate therapeutic strategies, a deeper understanding of the bidirectional interaction between NAFLD patients, NAFLD patients with T2DM, and NAFLD patients with CVDs is required to control the concomitant rise in prevalence of these conditions worldwide. This article also aims to shed light on the epidemiology and mechanisms behind the relationship between T2DM, NAFLD and the related cardiovascular consequences.

METHOD

Literature was collected from PubMed, Medline, Embase, Web of Science and Google scholar from inception to June, 2024. For surveying literature different combinations and formats of terms including NAFLD, NASH, T2DM and CVDs were used.

RESULTS

In the recent decade, clinical and epidemiological studies have been conducted and provide strong evidence that NAFLD is closely linked with CVD progression along with associated morbidity and mortality in both patients with and without T2DM. Several mechanistic approaches contribute to cardiovascular consequences and abnormalities in cardiac biomarkers in T2DM and NAFLD patients, including adipose tissue malfunction, mitochondrial dysfunction, the microbiota, genetic and epigenetic alterations contributing to insulin resistance, glucotoxicity and lipotoxicity.

CONCLUSION

The study reveals a complex interplay between diabetes, hepatic and cardiovascular complications, leading to significant morbidity and mortality in diabetic and NAFLD patients. This pandemic necessitates further research to identify mitigating variables and develop effective treatment approaches.

Association between SPISE and NAFLD in patients with type 2 diabetes

Aims

Non-alcoholic fatty liver disease (NAFLD) is closely related to type 2 diabetes (T2D), with reduced insulin sensitivity being a key factor in their disrupted metabolic processes. The single point insulin sensitivity estimator (SPISE) is a novel index. This study aims to explore the association between SPISE and NAFLD in T2D population.

Methods

This study included a total of 2,459 patients with T2D. SPISE was calculated based on high density lipoprotein-cholesterol (HDL-c), triglycerides (TG), and body mass index (BMI). Participants were categorized into NAFLD and non-NAFLD groups based on the results of ultrasonographic diagnosis. The relationship between SPISE and NAFLD was analyzed separately for each gender.

Results

The overall prevalence of NAFLD is 38.5%. In females and males, the SPISE was significantly reduced in the NAFLD group compared to the non-NAFLD group (both P < 0.05). The prevalence of NAFLD showed a significant reduction across quartiles of the SPISE in both genders (both P < 0.05).Additionally, univariate correlation analysis showed a negative correlation between SPISE and NAFLD (both P < 0.05). In multivariate regression analysis, a reduced SPISE was identified as an independent risk factor for NAFLD (odds ratios of 0.572 and 0.737, 95% CI of 0.477-0.687 and 0.587-0.926, respectively).Moreover, the area under the receiver operating characteristic (ROC) curve for SPISE was 0.209 in females and 0.268 in males (95% CI of 0.175-0.244 and 0.216-0.320, respectively). These results are more meaningful than those of other variables.

Conclusion

SPISE is significantly reduced in NAFLD patients with T2D. Compared to other indicators, SPISE demonstrates superior predictive value in diagnosing NAFLD, and it is independent of gender.

Cardiovascular Risk Reduction in Metabolic Dysfunction-Associated Steatotic Liver Disease and Metabolic Dysfunction-Associated Steatohepatitis

PURPOSE OF REVIEW

Metabolic dysfunction-associated steatotic liver disease (MASLD) is the most common chronic liver disease, characterized by hepatic steatosis with at least one cardiometabolic risk factor. Patients with MASLD are at increased risk for the occurrence of cardiovascular events. Within this review article, we aimed to provide an update on the pathophysiology of MASLD, its interplay with cardiovascular disease, and current treatment strategies.

RECENT FINDINGS

Given their high burden of cardiovascular comorbidities, patients with MASLD or MASH should undergo regular cardiovascular risk assessment using established risk models. In the absence of liver-specific therapies, therapeutic strategies should focus on improving cardiometabolic risk factors. Patients require a multimodal and multi-stakeholder treatment approach, including optimization of lifestyle, dysglycemia, obesity, and dyslipidemia. Statin treatment represents a safe and effective but often underused therapy in the management of at-risk patients with MASLD and MASH. Novel promising approaches include the use of GLP-1 receptor agonists, especially in, but not limited to, patients with cardiovascular disease and obesity. Patients with MASLD and MASH are at high cardiovascular risk requiring a multi-modal therapeutic approach including regular cardiovascular risk assessment, as well as lifestyle and pharmacological interventions. Statin therapy represents an inexpensive, safe and effective therapy across the spectrum of non-alcohol related steatotic liver diseases without major safety concerns. More prospective, randomized trials in patients with MASLD and MASH are needed.

Association Between Sociodemographic Variables, Healthy Habits, and Stress with Risk Scales for Liver Disease Associated with Metabolic Dysfunction

Metabolic dysfunction-associated fatty liver disease (MAFLD) is the most common cause of chronic liver disease worldwide, with a multifactorial etiology. This study aims to evaluate the associations between various sociodemographic variables, healthy habits, and stress with risk scale values for MAFLD.

MATERIALS AND METHODS

A descriptive, cross-sectional study was conducted on 16,708 Spanish workers to assess how sociodemographic variables (age, gender, and socioeconomic status), healthy habits (smoking, Mediterranean diet adherence, and physical activity), and stress correlate with values from three MAFLD risk scales: fatty liver index (FLI), hepatic steatosis index (HSI), and lipid accumulation product (LAP).

RESULTS

All analyzed variables were associated with the values of the three MAFLD risk scales. Among them, the variables showing the strongest associations (represented by odds ratio values) were age and physical activity.

CONCLUSIONS

The profile of an individual at higher risk of elevated MAFLD risk scale values is a male, aged 50 or older, belonging to lower socioeconomic levels (manual laborers), a smoker, sedentary, with low adherence to the Mediterranean diet, and with high stress scale scores.

Association between neutrophil-to-high-density lipoprotein cholesterol ratio and non-alcoholic fatty liver disease or metabolic dysfunction-associated steatotic liver disease: evidence from NHANES 2017-2020

Background

Non-alcoholic fatty liver disease (NAFLD) or metabolic dysfunction-associated steatotic liver disease (MASLD) is closely associated with chronic inflammation and lipid metabolism disorders. The neutrophil-to-high-density lipoprotein cholesterol ratio (NHR) is an integrative marker reflecting inflammatory responses and lipid metabolism disorders and is associated with various diseases. This cross-sectional study aimed to determine the association between NHR and NAFLD, MASLD, and liver fibrosis.

Methods

Data for this study were obtained from the 2017-2020 National Health and Nutrition Examination Survey (NHANES), we employed weighted multiple regression and restricted cubic spline (RCS) analysis to assess the relationship between NHR and NAFLD, MASLD, and liver fibrosis. Additionally, we performed stratified analyses based on gender, age, body mass index, diabetes, hypertension, smoking status, and history of cardiovascular disease to evaluate the consistency of these associations across different subgroups.

Results

A total of 6,526 participants were included in the study. 2,839 (weighted 44.1%) participants were diagnosed with NAFLD and 2,813 (weighted 43.7%) participants were diagnosed with MASLD. After adjusting for confounders, NHR was positively associated with the risk of NAFLD/MASLD, and the correlation was particularly significant in the subgroups of females, those without hypertension, and those without diabetes (p < 0.05). By the NHR quartile, the risk of NAFLD/MASLD increased progressively with higher NHR levels (P for trend <0.001). In addition, RCS analysis showed a nonlinear association between NHR and NAFLD/MASLD and liver fibrosis (P-non-linear <0.05).

Conclusion

NHR may serve as a potential marker for NAFLD/MASLD and liver fibrosis, and lowering NHR levels could help reduce the incidence of these conditions.

Exploring the molecular mechanisms of tirzepatide in alleviating metabolic dysfunction-associated fatty liver in mice through integration of metabolomics, lipidomics, and proteomics

Clinical studies have suggested that tirzepatide may also possess hepatoprotective effects; however, the molecular mechanisms underlying this association remain unclear. In our study, we performed biochemical analyses of serum and histopathological examinations of liver tissue in mice. To preliminarily explore the molecular mechanisms of tirzepatide on metabolic dysfunction-associated fatty liver disease (MAFLD), liquid chromatography-mass spectrometry (LC-MS) was employed for comprehensive metabolomic, lipidomic, and proteomic analyses in MAFLD mice fed a high-fat diet (HFD). The results demonstrated that tirzepatide significantly reduced serum levels of alanine transaminase (ALT) and aspartate transaminase (AST), as well as hepatic triglycerides (TG) and total cholesterol (TC), indicating its efficacy in treating MAFLD. Further findings revealed that tirzepatide reduced fatty acid uptake by downregulating Cd36 and Fabp2/4, as well as enhance the mitochondrial-lysosomal function by upregulating Lamp1/2. In addition, tirzepatide promoted cholesterol efflux and reduced cholesterol reabsorption by upregulating the expression of Hnf4a, Abcg5, and Abcg8. These results suggest that tirzepatide exerts its therapeutic effects on MAFLD by reducing fatty acid uptake, promoting cholesterol excretion, and enhancing mitochondrial-lysosomal function, providing a theoretical basis for a comprehensive understanding of tirzepatide.

The Triad of Risk: Linking MASLD, Cardiovascular Disease and Type 2 Diabetes; From Pathophysiology to Treatment

Metabolic dysfunction-associated steatotic liver disease (MASLD) is an emerging global health concern, and it is not only the keystone precursor of eventual liver-related morbidity, but it also places patients at considerably higher cardiovascular risk, which is still a leading cause of death in these patients. The most important common underlying pathophysiological mechanisms in these diseases are primarily related to insulin resistance, chronic inflammation and oxidative stress. The presence of MASLD with cardiovascular disease (CVD) and type 2 diabetes mellitus (T2DM) elevates the risk for poor outcomes, thus this review highlights a method to the therapeutic approaches. Given the intertwined nature of MASLD, T2DM, and CVD, there is an urgent need for therapeutic strategies that address all three conditions. Although lifestyle changes are important as treatment, medication plays a crucial role in managing hyperglycemia, enhancing liver function and lowering cardiovascular risk. The onset and progression of MASLD should be addressed through a multifaceted therapeutic approach, targeting inflammatory, immune, metabolic, oxidative stress, hormonal and gutaxis pathways, alongside the treatment strategies for T2DM. In this review, we discuss the effects of antidiabetic drugs with an impact on both liver outcomes and cardiovascular risk in patients affected by MASLD, T2DM and CDV.

Efficacy of intermittent fasting on improving liver function in individuals with metabolic disorders: a systematic review and meta-analysis

BACKGROUND

Intermittent fasting (IF) can be an effective dietary therapy for weight loss and improving cardiometabolic health. However, there is scant evidence regarding the role of IF on indicators of liver function, particularly in adults with metabolic disorders. Therefore, we performed a systematic review and meta-analysis to investigate the effects of IF on liver function in adults with metabolic disorders.

METHODS

Three primary electronic databases including PubMed, Web of Science, and Scopus, were searched from inception to September 2024 to identify original studies that used IF interventions with or without control groups in adults with metabolic disorders. Inclusion criteria were (1) studies of human participants with metabolic diseases, (2) interventions that evaluated the effects of IF, (3) with or without a control group, and (4) measured liver fat, liver steatosis, liver fibrosis, or liver enzymes, including alanine aminotransferase (ALT) and aspartate aminotransferase (AST) as primary outcomes. Standardized mean differences (SMD) and 95% confidence intervals were calculated using random effects models. Heterogeneity was assessed using the Cochran's Q statistic and I-squared statistic (I2). Publication bias was assessed using the visual inspection of funnel plots and Egger's tests. The risk of bias was assessed using the PEDro scale and the NIH quality assessment tool.

RESULTS

A total 21 studies involving 1,226 participants with metabolic disorders were included in the meta-analysis. Overall, IF effectively decreased liver fat with a large effect size [SMD: -1.22 (95% CI: -1.63 to -0.80), p = 0.001], liver steatosis with a medium effect size [SMD: -0.73 (95% CI: -1.12 to -0.35), p = 0.001], ALT with a small effect size [SMD: -0.44 (95% CI: -0.58 to -0.30), p = 0.001], and AST with a small effect size [SMD: -0.30 (95% CI: -0.49 to -0.11), p = 0.001], but not liver fibrosis [SMD: -0.28 (95% CI: -0.59 to 0.02), p = 0.07]. Subgroup analyses showed that IF decreased liver fat and ALT significantly, independent of IF mode, participant age, health status, weight status, and intervention duration. IF significantly decreased liver fibrosis in those with obesity; and decreased AST following 5:2 diets, in middle-aged adults, adults with obesity, and regardless of health status or intervention duration.

CONCLUSIONS

IF seems to be an effective dietary therapy for improving liver function in adults with metabolic disorders, and many of liver function-related benefits occur regardless of IF mode, intervention duration, or participant health status.

LIMITATIONS

Significant heterogeneity, small numbers of studies and inclusion of non-randomized trials or single-group pre-post trials were the main limitation of our meta-analysis. Further randomized clinical trials are needed to elucidate the effects of IF on liver function in adults with metabolic disorders.

Metabolic Dysfunction-associated Steatotic Liver Disease Increases the Risk of Primary Open-Angle Glaucoma

PURPOSE

Liver disease is associated with a range of extrahepatic complications, which have recently been expanded to include ophthalmic conditions. However, evidence is lacking regarding its impact on primary open-angle glaucoma (POAG). This study aimed to investigate whether major liver diseases, including metabolic dysfunction-associated steatotic liver disease (MASLD), alcoholic liver disease (ALD), viral hepatitis, and liver fibrosis and cirrhosis, were associated with POAG.

DESIGN

A prospective study based on the UK Biobank cohort with a 2-sample Mendelian randomization (MR) analysis for inferring causality.

PARTICIPANTS

A total of 332 345 UK Biobank participants free of glaucoma recruited between 2006 and 2010.

METHODS

The exposures of interest were severe liver diseases defined as hospital admission, including MASLD, ALD, viral hepatitis, and liver fibrosis and cirrhosis. The Cox proportional hazard models were used with each liver disease treated as a time-varying exposure. The MR analysis was further conducted based on the genome-wide association studies of a histologically characterized cohort for MASLD (n = 19 264) and the International Glaucoma Genetics Consortium cohort for POAG (n = 216 257).

MAIN OUTCOME MEASURES

The risk of POAG estimated by hazard ratio (HR) and 95% confidence interval (CI) in observational analysis and odds ratio (OR) and 95% CI in MR analysis.

RESULTS

Severe MASLD was associated with a 45% increased risk of POAG (HR, 1.45; 95% CI, 1.12-1.87; P = 0.005), whereas no association was identified between ALD, viral hepatitis, or liver fibrosis and cirrhosis and incident POAG. Subgroup analysis showed that the risk of POAG in relation to MASLD was higher in individuals having more physical activity (HR, 1.53; 95% CI, 1.04-2.25 vs. HR, 1.39; 95% CI, 0.99-1.95, P for interaction = 0.033). Mendelian randomization analysis provided evidence that MASLD was causally associated with a greater risk of POAG (inverse-variance weighted model: OR, 1.035; 95% CI, 1.010-1.061; P = 0.005).

CONCLUSIONS

Severe MASLD was longitudinally associated with an increased risk of incident POAG, with MR analyses suggesting a potential causal link. These findings suggest that a POAG examination should be considered in the holistic management of MASLD and further underscore the impact of the liver on eye health.

FINANCIAL DISCLOSURE(S)

The authors have no proprietary or commercial interest in any materials discussed in this article.

A New Hope for the Patients of Non-Alcoholic Steatohepatitis: FDA Gives Green Signal for Resmetirom Use

Background and Aims

Non-Alcoholic Steatohepatitis (NASH), a severe form of Non-Alcoholic Fatty Liver Disease (NAFLD), is characterized by inflammation and fibrosis in the liver, often progressing to cirrhosis and hepatocellular carcinoma. Despite its rising prevalence and significant disease burden, effective pharmacological treatments have been limited to lifestyle modifications and surgical interventions. Recently, resmetirom, a thyroid hormone receptor-β agonist, received FDA approval for treating NASH, offering new hope to patients. This review explores the current understanding of NASH and the role of resmetirom as a breakthrough therapeutic option.

Methods

This study is a comprehensive literature review analyzing peer-reviewed articles, clinical trial data, and public health reports. No original analyses were conducted, and no statistical software was utilized in this review.

Results

Resmetirom demonstrated efficacy in resolving NASH without fibrosis progression and improving fibrosis scores in patients with biopsy-confirmed NASH. In a randomized Phase 3 trial, significant histological improvements were observed in 25.9% and 29.9% of patients receiving 80 and 100 mg doses, respectively, compared to 9.7% in the placebo group. Similar trends were noted in fibrosis improvement, with 24.2% and 25.9% of patients showing ≥ 1 stage improvement compared to 14.2% in the placebo group. Adverse effects, including nausea and diarrhea, were reported more frequently in the treatment groups, but the rates of serious adverse events were comparable across groups.

Conclusion

The approval of resmetirom marks a significant advancement in the treatment of NASH, addressing the limitations of lifestyle-based interventions. As the obesity epidemic drives the increasing prevalence of NASH, resmetirom provides a promising therapeutic option, paving the way for improved patient outcomes and future research.

A Pragmatic Management Approach for Metabolic Dysfunction-Associated Steatosis and Steatohepatitis

Obesity and associated insulin resistance induce a chronic metaboinflammatory state that lead to injury and dysfunction of multiple organs resulting in a cluster of noncommunicable diseases such as type 2 diabetes mellitus, hypertension, cardiovascular disease, chronic kidney disease, and metabolic dysfunction-associated steatotic liver disease (MASLD). Metabolic dysfunction-associated steatohepatitis (MASH) is a histologically active form of MASLD and characterized by greater injury and inflammation and progresses to cirrhosis with greater certainty than steatosis alone. The progression to cirrhosis is characterized by increasing fibrosis. The goal of treatment of MASLD/MASH was to improve the metaboinflammatory state i.e., the root cause of the liver disease and to prevent fibrosis progression to cirrhosis whereas in those who already have cirrhosis need additional care to prevent portal hypertension-related outcomes. Fibrosis regression is thus a key objective of treatment. The recent approval of resmetirom for MASH with fibrosis and the use of glucagon-like peptide-1 receptor agonists for obesity and type 2 diabetes has increased awareness of these NCDs and resulted in the growing demand for liver assessment and care in obese individuals. Patients with MASLD also have multiple metabolic comorbidities which represent competing threats to life, and the care of the patient requires both assessment of the totality of the risk and a more holistic approach integrating the care of all of the threats to life. Here, we provide a pragmatic and easily implementable risk-based approach to the evaluation and management of MASLD.

Retinopathy in Metabolic Dysfunction-Associated Steatotic Liver Disease

Metabolic dysfunction-associated steatotic liver disease (MASLD) is a multisystemic disease, i.e., influencing various organ systems beyond the liver and, thus, contributing to comorbidities. Characterized by excessive fat accumulation in the hepatocytes, MASLD is frequently linked to metabolic syndrome components, such as obesity, insulin resistance, dyslipidemia, and hypertension. Therefore, exploring the intricate connection between MASLD and other organ systems, including the eyes, seems to be essential. In this context, retinopathy has been investigated for its potential association with MASLD, since both conditions share common pathogenetic pathways. Chronic low-grade inflammation, oxidative stress, insulin resistance, and endothelial dysfunction are only some of those mechanisms contributing to disease progression and, possibly, determining the bidirectional interplay between the liver and retinal pathology. This narrative review aims to summarize data concerning the multisystemicity of MASLD, primarily focusing on its potential association with the eyes and, particularly, retinopathy. Identifying this possible association may emphasize the need for early screening and integrated management approaches that address the liver and eyes as interconnected components within the framework of a systemic disease. Further research is necessary to delineate the precise mechanisms and develop targeted interventions to mitigate the bidirectional impact between the liver and eyes, aiming to reduce the overall burden of disease and improve patient outcomes.

Development of a Polygenic Risk Score for Metabolic Dysfunction-Associated Steatotic Liver Disease Prediction in UK Biobank

BACKGROUND

Metabolic dysfunction-associated steatotic liver disease (MASLD) is the leading cause of liver-related morbidity and mortality. Although the invasive liver biopsy remains the golden standard for MASLD diagnosis, Magnetic Resonance Imaging-derived Proton Density Fat Fraction (MRI-PDFF) is an accurate, non-invasive method for the assessment of treatment response. This study aimed at developing a Polygenic Risk Score (PRS) to improve MRI-PDFF prediction using UK Biobank data to assess an individual's genetic liability to MASLD.

METHODS

We iteratively sequestered 10% of MRI-PDFF samples as a validation set and split the rest of each dataset into base and target partitions, containing GWAS summary statistics and raw genotype data, respectively. PRSice2 was deployed to derive PRS candidates. Based on the frequency of SNP appearances along the PRS candidates, we generated different SNP sets according to variable frequency cutoffs. By applying the PRSs to the validation set, we identified the optimal SNP set, which was then applied to a Greek nonalcoholic fatty liver disease (NAFLD) study.

RESULTS

Data from 3553 UK Biobank participants yielded 49 different SNP sets. After calculating the PRS on the validation set for every SNP set, an optimal PRS with 75 SNPs was selected (incremental R2 = 0.025, p-value = 0.00145). Interestingly, 43 SNPs were successfully mapped to MASLD-related known genes. The selected PRS could predict traits, like LDL cholesterol and diastolic blood pressure in the UK Biobank, as also disease outcome in the Greek NAFLD study.

CONCLUSIONS

Our findings provide strong evidence that PRS is a powerful prediction model for MASLD, while it can also be applied on populations of different ethnicity.

Structure-based identification of HNF4α agonists: Rosmarinic acid as a promising candidate for NAFLD treatment

The prevention and treatment of metabolic disorders, such as non-alcoholic fatty liver disease (NAFLD), have emerged as critical global health challenges. Current lipid-lowering pharmacotherapies are associated with side effects, including hepatotoxicity, rhabdomyolysis, and decreased erythrocyte counts, underscoring the urgent need for safer therapeutic alternatives. Hepatocyte nuclear factor 4α (HNF4α) has been identified as a pivotal regulator of lipid metabolism, making it an attractive target for drug development. In this study, we investigated the structural characteristics and binding interactions of four HNF4α agonists: Alverine, Benfluorex, N-trans caffeoyltyramine (NCT), and N-trans feruloyltyramine (NFT). Our results indicate that the conjugated structure formed by the amide bond and the aromatic ring in NCT and NFT enhances electron density, potentially contributing to their increased specificity for HNF4α relative to Alverine and Benfluorex. Additionally, electrostatic interactions between the aromatic moieties of the compounds and HNF4α residues were found to play a crucial role in ligand binding. Leveraging these insights, we performed a high-throughput virtual screening of 2131 natural compounds, using the binding modes of NCT and NFT as reference templates. Rosmarinic acid emerged as a promising HNF4α agonist, exhibiting a high consensus score and favorable binding affinity. Subsequent biological assays demonstrated that rosmarinic acid significantly inhibited HepG2 cell proliferation which related to the enhancement of autophagy. After the knockdown of P2 isoform of HNF4α, HepG2 was more sensitive to the administration of NCT and rosmarinic acid. Furthermore, the proliferation of DLD-1 cell, which only expresses the P2 isoform of HNF4α, was not significantly inhibited by the administration of NCT and rosmarinic acid. Collectively, these findings suggest that rosmarinic acid is a promising HNF4α agonist which is more effective to activate the P1 isoform of HNF4α and holds potential as an effective treatment for NAFLD, providing a foundation for the development of novel lipid-lowering drugs with enhanced efficacy and reduced side effect.

Data Availability

Data will be made available on request.

Association between the lymphocyte-to-high-density lipoprotein ratio and metabolic dysfunction-associated steatotic liver disease among US adults: a cross-sectional study from NHANES 2017 to 2020

BACKGROUND

Metabolic dysfunction-associated steatotic liver disease (MASLD) is a liver disease that is strongly associated with chronic low-grade inflammation. Stage 3 of MASLD is characterized by excessive formation of connective tissues, commonly referred to as liver fibrosis. Although numerous inflammatory markers have been identified and extensively studied, including the tumor necrosis factor-α and interleukin-6 have been studied [Byrne CD, Targher G. NAFLD: a multisystem disease. J Hepatol. 2015;62(1 Suppl):S47-64], the lymphocyte-to-high-density lipoprotein ratio (LHR) as a new biomarker that has not been sufficiently studied. This study aims to investigate the relationship between LHR levels and MASLD, determine its potential as a predictive marker for steatosis and fibrosis stages.

METHODS

This was a population-based study using data from 15,560 participants in the 2017-2020 National Health and Nutrition Examination Survey (NHANES) database. The study aimed to explore the relationship between LHR and MASLD. The disease progression was tracked by continuously measuring CAP and liver stiffness measurements. Participants who exhibited a median Controlled Attenuation Parameter (CAP) of 248 dB/m or higher were deemed to have hepatic steatosis. The LHR was calculated by dividing the lymphocyte count by the high-density lipoprotein cholesterol (HDL-C) level. Multivariate linear regression models were employed to explore the linear association between LHR and MASLD. Fitted smoothing curves and threshold effect analysis were employed to display nonlinear relationships. A two-part linear regression model was employed to estimate threshold effects. Subgroup analyses were conducted to determine the consistency of this association across various demographic groups.

RESULTS

A total of 6,950 adults aged 18 years and older were enrolled in the study, with an average age of 48.15 ± 17.10 years (49.14% male, 50.86% female). The adjusted multiple logistic regression analysis revealed a significant positive correlation between LHR and MASLD (OR: 1.64, 95% CI: 1.40-1.92). Using the complex two-piece linear regression model, we observed an inverted L-shaped association between LHR and CAP, suggesting a critical inflection point at -2.58. Subgroup analyses indicated a pronounced association of the LHR index with obese individuals (OR: 1.96, 95% CI: 1.66-2.32) and females (OR: 1.76, 95% CI: 1.25-2.46). There was no significant association between LHR and clinically significant fibrosis.

CONCLUSION

The LHR index is positively correlated with MASLD among US adults. Therefore, LHR may be a robust marker for early screening, diagnosis, and monitoring of treatment efficacy in clinical practice.

Diverting hepatic lipid fluxes with lifestyles revision and pharmacological interventions as a strategy to tackle steatotic liver disease (SLD) and hepatocellular carcinoma (HCC)

Steatotic liver disease (SLD) and Hepatocellular Carcinoma (HCC) are characterised by a substantial rewiring of lipid fluxes caused by systemic metabolic unbalances and/or disrupted intracellular metabolic pathways. SLD is a direct consequence of the interaction between genetic predisposition and a chronic positive energy balance affecting whole-body energy homeostasis and the function of metabolically-competent organs. In this review, we discuss how the impairment of the cross-talk between peripheral organs and the liver stalls glucose and lipid metabolism, leading to unbalances in hepatic lipid fluxes that promote hepatic fat accumulation. We also describe how prolonged metabolic stress builds up toxic lipid species in the liver, and how lipotoxicity and metabolic disturbances drive disease progression by promoting a chronic activation of wound healing, leading to fibrosis and HCC. Last, we provide a critical overview of current state of the art (pre-clinical and clinical evidence) regarding mechanisms of action and therapeutic efficacy of candidate SLD treatment options, and their potential to interfere with SLD/HCC pathophysiology by diverting lipids away from the liver therefore improving metabolic health.