Risk of chronic kidney disease in patients with non-alcoholic fatty liver disease: is there a link?

Higher NAFLD fibrosis score is associated with impaired eGFR

BACKGROUND/PURPOSE

Chronic kidney disease (CKD) has become a worldwide health problem, leading to high morbidity and mortality, and non-alcoholic fatty liver disease (NAFLD) is considered a risk factor for CKD. The aim of this study was to explore the relationship between NAFLD fibrosis score (NFS) and the estimated glomerular filtration rate (eGFR), and identify possible risk factors related to the NFS among Taiwanese subjects.

METHODS

Subjects were enrolled from the database of the Department of Preventive Medicine of Kaohsiung Municipal Hsiao-Kang Hospital. The eGFR was calculated according to the Taiwanese Modification of Diet in Renal Disease (TMDRD) equation, and the NFS was employed to evaluate the fibrotic level.

RESULTS

In total, 11,376 subjects were enrolled in this study, with a mean age of 52.0 ± 6.81 years, including 4529 (39.8%) males. A fasting sugar level ≥100 mg/dL (OR = 1.70, 95% CI = 1.52-1.87) and an abnormal waist circumference (OR = 1.81, 95% CI = 1.65-1.99) were significant factors associated with NFS (p < 0.05). Trends of a decreasing TMDRD score and an increasing NFS with increasing age were noted (p < 0.05). The NFS was significantly negatively correlated with the TMDRD score (standard coefficients: -0.067, p < 0.001).

CONCLUSION

A higher NFS is associated with an impaired eGFR in Taiwanese subjects. Controlling risk factors, especially fasting sugar level and waist circumference, may be useful in preventing NFS deterioration, which is negatively correlated with the eGFR.

Association of nonalcoholic fatty liver and chronic kidney disease: An analysis of 37,825 cases from health checkup center in Taiwan

OBJECTIVE

Nonalcoholic fatty liver (NAFLD) and chronic kidney disease (CKD) share common pathogenic mechanisms and risk factors. The relationship between in NAFLD and CKD remains controversial. We aim to assess the association between NAFLD and CKD.

MATERIALS AND METHODS

A cross-sectional study was based on individuals who received physical checkups at the Taipei Tzu Chi Hospital from September 5, 2005, to December 31, 2016. Demographic and clinical characteristics of the study population were collected. NAFLD was defined by abdominal ultrasonography and excluded other liver disease. CKD was defined as estimated glomerular filtration rate ≤60 mL/min/1.73 m2 or the presence of proteinuria. The association between NAFLD and CKD was then analyzed using SAS software by using the multivariable logistic model. A higher prevalence of CKD was shown in individuals with NAFLD compared to those without NAFLD.

RESULTS

In univariate analysis, individuals with mild NAFLD and moderate-to-severe NAFLD were both significantly associated with CKD (odds ratio [OR], 1.23; 95% confidence interval [CI], 1.13-1.33; OR, 1.66; CI, 1.49-1.85) when compared to individuals without NAFLD. After multivariate adjustment, individuals with moderate-to-severe NAFLD were still significantly more likely to have CKD (OR, 1.17, 95% CI, 1.03-1.33).

CONCLUSIONS

Our finding showed that the presence and severity of NAFLD was positively associated with CKD in unadjusted and adjusted analysis. Further follow-up studies may be needed to validate these associations.

Impact of Chronic Kidney Disease on Outcomes in Cirrhosis

We hypothesize that the prevalence of chronic kidney disease (CKD) among patients with cirrhosis has increased due to the increased prevalence of CKD-associated comorbidities, such as diabetes. We aimed to assess the characteristics of hospitalized patients with cirrhosis with CKD and its impact on renal and patient outcomes. The North American Consortium for the Study of End-Stage Liver Disease (NACSELD) prospectively enrolled nonelectively admitted patients with cirrhosis and collected data on demographics, laboratory results, in-hospital clinical course, and postdischarge 3-month outcomes. CKD positive (CKD+) patients, defined as having an estimated glomerular filtration rate (eGFR; Modification of Diet in Renal Disease-4 variable formula) of ≤60 mL/minute for >3 months, were compared with chronic kidney disease negative (CKD-) patients for development of organ failures, hospital course, and survival. There were 1099 CKD+ patients (46.8% of 2346 enrolled patients) who had significantly higher serum creatinine (2.21 ± 1.33 versus 0.83 ± 0.21 mg/dL in the CKD- group) on admission, higher prevalence of nonalcoholic steatohepatitis cirrhosis etiology, diabetes, refractory ascites, and hospital admissions in the previous 6 months compared with the CKD- group (all P < 0.001). Propensity matching (n = 922 in each group) by Child-Pugh scores (9.78 ± 2.05 versus 9.74 ± 2.04, P = 0.70) showed that CKD+ patients had significantly higher rates of superimposed acute kidney injury (AKI; 68% versus 21%; P < 0.001) and eventual need for dialysis (11% versus 2%; P < 0.001) than CKD- patients. CKD+ patients also had more cases of acute-on-chronic liver failure as defined by the NACSELD group, which was associated with reduced 30- and 90-day overall survival (P < 0.001 for both). A 10 mL/minute drop in eGFR was associated with a 13.1% increase in the risk of 30-day mortality. In conclusion, patients with CKD should be treated as a high-risk group among hospitalized patients with cirrhosis due to their poor survival, and they should be monitored carefully for the development of superimposed AKI.

Nonalcoholic fatty liver disease alters microcystin-LR toxicokinetics and acute toxicity

Microcystin-LR (MCLR) is a cyanotoxin produced by blue-green algae that causes liver and kidney toxicities. MCLR toxicity is dependent on cellular uptake through the organic anion transporting polypeptide (OATP) transporters. Nonalcoholic fatty liver disease (NAFLD) progresses through multiple stages, alters expression of hepatic OATPs, and is associated with chronic kidney disease. The purpose of this study was to determine whether NAFLD increases systemic exposure to MCLR and influences acute liver and kidney toxicities. Rats were fed a control diet or two dietary models of NAFLD; methionine and choline deficient (MCD) or high fat/high cholesterol (HFHC). Two studies were performed in these groups: 1) a single dose intravenous toxicokinetic study (20 μg/kg), and 2) a single dose intraperitoneal toxicity study (60 μg/kg). Compared to control rats, plasma MCLR area under the concentration-time curve (AUC) in MCD rats doubled, whereas biliary clearance (Clbil) was unchanged; in contrast, plasma AUC in HFHC rats was unchanged, whereas Clbil approximately doubled. Less MCLR bound to PP2A was observed in the liver of MCD rats. This shift in exposure decreased the severity of liver pathology only in the MCD rats after a single toxic dose of MCLR (60 μg/kg). In contrast, the single toxic dose of MCLR increased hepatic inflammation, plasma cholesterol, proteinuria, and urinary KIM1 in HFHC rats more than MCLR exposed control rats. In conclusion, rodent models of NAFLD alter MCLR toxicokinetics and acute toxicity and may have implications for liver and kidney pathologies in NAFLD patients.

Chronic kidney disease is independently associated with increased mortality in patients with nonalcoholic fatty liver disease

BACKGROUND & AIMS

Nonalcoholic fatty liver disease and chronic kidney disease share similar pathophysiologic features. Our aim was to assess the association between different stages of chronic kidney disease and mortality in patients with nonalcoholic fatty liver disease.

METHODS

Third National Health and Nutrition Examination Survey-linked mortality files were utilized. Nonalcoholic fatty liver disease was diagnosed by hepatic ultrasound and chronic kidney disease was defined according to the Kidney Disease Improving Global outcomes guideline. Multivariable Cox proportional hazard model was used to assess the effect of chronic kidney disease on overall and cardiovascular mortality.

RESULTS

Total cohort included 11 695 adult participants; mean age 43.3 years, 48.4% male, 76.4% white, 18.6% had nonalcoholic fatty liver disease and 9.3% had chronic kidney disease. 5.6% had diabetes, 21.3% had hypertension, 4.3% had cardiovascular disease. Compared to subjects without chronic kidney disease or nonalcoholic fatty liver disease, nonalcoholic fatty liver disease patients with chronic kidney disease were more likely to be older, had less income, and higher prevalence of comorbidities (all P < 0.001). Prevalence of chronic kidney disease among nonalcoholic fatty liver disease cohort was 11.31%. Compared to non-nonalcoholic fatty liver disease group, patients with nonalcoholic fatty liver disease had higher rates of stage 1, 2 and 3a chronic kidney disease, but similar rates for stage 3b, 4 and 5. Mortality rate was 18.5% in 17 years. Among nonalcoholic fatty liver disease cohort, the presence of chronic kidney disease stages 2-3a (HR = 2.31, 95% CI: 1.70-3.15) and stages 3b-5 (HR = 4.83, 95% CI: 2.40-9.71) were independently associated with increased overall mortality.

CONCLUSIONS

Among patients with nonalcoholic fatty liver disease, moderate to advanced stages of chronic kidney disease are associated with overall mortality. Identification of chronic kidney disease in nonalcoholic fatty liver disease has important prognostic implications.

Lipidomic analysis reveals the efficiency of Eclipta prostrata on diet-induced nonalcoholic fatty liver disease in rats

Non-alcoholic fatty liver disease is a leading cause of chronic liver disease in western countries. The current study aimed to detect and evaluate lipidomic biomarkers for early detection of NAFLD as well as the potential efficiency of methanolic extract of Eclipta prostrata (E. prostrata) on disease management. In this study, Phytochemical screening of E. prostrata methanolic extract was performed using HPLC. NAFLD was induced in albino rats using a high-fat diet together with cholesterol and cholic acid. Comprehensive lipidomic analyses on sera from rats bearing NAFLD as well as normal healthy animals were carried out based on GCMS and multivariate data analysis. The results showed that high doses (300&200 mg/kg.BW) of E. prostrata extract exhibited significant improvement in liver enzymes (ALT & AST) and lipid profile [total cholesterol (TC), triacylglycerides (TAGs), high-density lipoprotein cholesterol (HDL-C) and low-density lipoprotein-cholesterol (LDL-C)] in rats bearing NAFLD. Glycerol, linoleic acid, arachidonic acid and cholest-5-en-3-ol (3β) acetate were detected as lipidomic biomarkers for early detection of NAFLD in rats' sera. Furthermore, E. prostrata extract showed a significant amelioration in the levels of these metabolic biomarkers in both protective and treated groups. These finding devoutly recommend using of lipidomic biomarkers for early detection of NAFLD and E. prostrata could be used as a protective agent as well as ameliorate this disease through its probable action on the fore-mentioned metabolites.

Frequency of incidental fatty liver on ultrasound and its association with diabetes mellitus and hypertension

Objective:

To see the frequency of incidental fatty liver on ultrasound and its association with diabetes mellitus and hypertension.

Methods:

A cross sectional study was conducted from January 2016 to June 2016 in the department of Surgery and Radiology at Hamdard University Hospital. Patients of both genders and all ages were selected by non purposive convenience sampling. Critically ill, trauma cases and all those patients who had a history of chronic liver disease, alcohol intake and expected pregnancy were excluded. Blood pressure and random blood sugar were recorded.

Results:

Six hundred patients were included in the study with mean age of 44.65±18.8 years. 240 patients (40%) had incidental finding of fatty liver on ultrasound. Out of 240 with fatty liver patients 117 were males (48.8%) and 123 were females (51.3%). Total 141 patients were diagnosed with hypertension, out of which 81(57.44%, p< 0.001) had fatty liver on ultrasound. Diabetes mellitus was diagnosed in 84 patients, in which 57 patients (67.8%, p<0.001) had fatty liver.

Conclusion:

Fatty liver is a frequently found incidental finding on ultrasound. There is a significant association of fatty liver with diabetes mellitus and hypertension.

Refining the Role of Simultaneous Liver Kidney Transplantation

Adoption of the model for end-stage liver disease score by Organ Procurement and Transplant Network (OPTN) deceased donor liver allocation policy in 2002 has led to an increase in the number of simultaneous liver kidney (SLK) transplantation. Since kidney function recovery following liver transplantation is difficult to predict, allocation of the kidney for SLK transplantation thus far has not been based on much rationale and evidence. Lack of OPTN policy towards SLK organ allocation has resulted in great variations among transplant centers regarding SLK transplantation. Increasing use of kidneys towards SLK transplantation diverts deceased donor kidneys away from candidates awaiting kidney-alone transplantation. Recently OPTN/United Network of Organ Sharing has implemented medical eligibility criteria for adult SLK transplantation which also includes a concept of safety net. Implementation of the new policy is a move in a positive direction, providing consistency in our practice and evidence-based guidelines in selecting candidates for SLK transplantation. This policy needs to be monitored prospectively and modified based on new data that will emerge over time. This review outlines the literature on SLK transplantation and efforts towards developing rational policy on SLK organ allocation.

Renal dysfunction in patients with nonalcoholic fatty liver disease and risk factors

AIM

To assess the renal function in patients with nonalcoholic fatty liver disease (NAFLD) and to identify the risk factors for renal dysfunction.

METHODS

A total of 856 volunteers who underwent health examination were initially enrolled in this study to identify those with NAFLD. The biochemical indexes of patients with NAFLD and healthy volunteers were statistically analyzed, and the renal function with estimated glomerular filtration rate was calculated. In addition, the risk factors for renal damage were identified.

RESULTS

A total of 253 patients with NAFLD were identified, and the remaining 603 cases were used as a control group. There was no significant difference in serum BUN between the two groups (t = 1.678, P = 0.062), while other biochemical indexes differed significantly (P < 0.05). The prevalence of renal function impairment was higher in individuals with NAFLD compared to those without (28.8% vs 17.5%, P < 0.0001). Logistic regression analysis showed that NAFLD was associated with renal function impairment, even after adjustment for demographics and components of metabolic syndrome (OR = 2.85, 95%CI: 1.93-4.21, P = 0.000).

CONCLUSION

The biochemical indexes of NAFLD patients are significantly abnormal, and renal function impairment is associated with NAFLD. Patients with NAFLD should be regularly assessed for renal function to avoid progressing into chronic kidney disease and increasing the medical burden.

High circulatory leptin mediated NOX-2-peroxynitrite-miR21 axis activate mesangial cells and promotes renal inflammatory pathology in nonalcoholic fatty liver disease

High circulatory insulin and leptin followed by underlying inflammation are often ascribed to the ectopic manifestations in non-alcoholic fatty liver disease (NAFLD) but the exact molecular pathways remain unclear. We have shown previously that CYP2E1-mediated oxidative stress and circulating leptin in NAFLD is associated with renal disease severity. Extending the studies, we hypothesized that high circulatory leptin in NAFLD causes renal mesangial cell activation and tubular inflammation via a NOX2 dependent pathway that upregulates proinflammatory miR21. High-fat diet (60% kcal) was used to induce fatty liver phenotype with parallel insulin and leptin resistance. The kidneys were probed for mesangial cell activation and tubular inflammation that showed accelerated NASH phenotype and oxidative stress in the liver. Results showed that NAFLD kidneys had significant increases in α-SMA, a marker of mesangial cell activation, miR21 levels, tyrosine nitration and renal inflammation while they were significantly decreased in leptin and p47 phox knockout mice. Micro RNA21 knockout mice showed decreased tubular immunotoxicity and proinflammatory mediator release. Mechanistically, use of NOX2 siRNA or apocynin,phenyl boronic acid (FBA), DMPO or miR21 antagomir inhibited leptin primed-miR21-mediated mesangial cell activation in vitro suggesting a direct role of leptin-mediated NOX-2 in miR21-mediated mesangial cell activation. Finally, JAK-STAT inhibitor completely abrogated the mesangial cell activation in leptin-primed cells suggesting that leptin signaling in the mesangial cells depended on the JAK-STAT pathway. Taken together the study reports a novel mechanistic pathway of leptin-mediated renal inflammation that is dependent on NOX-2-miR21 axis in ectopic manifestations underlying NAFLD-induced co-morbidities.

Factors predicting non-alcoholic steatohepatitis (NASH) and advanced fibrosis in patients with non-alcoholic fatty liver disease (NAFLD)

Introduction To determine the factors predicting non-alcoholic steatohepatitis (NASH) and advanced fibrosis in patients with non-alcoholic fatty liver disease (NAFLD). Methodology All patients aged >18 years and having a fatty liver on abdominal ultrasound (US), presenting from January 2011 to January 2017, were included. A liver biopsy was performed on all the patients. Results Of 96 patients undergoing liver biopsy for non-alcoholic fatty liver disease (NAFLD), 76 (79.2%) were men. On liver US, diffuse fatty liver (DFL) was noted in 68 (70.8%) patients. Liver biopsy showed non-alcoholic steatohepatitis (NASH) in 78 (81.3%) patients. Factors associated with NASH were male gender, body mass index (BMI) > 27 kg/m2, DFL and raised alanine aminotransferase (ALT). A GULAB score (based on gender, US liver findings, lipid (fasting) levels, ALT level and BMI) of ≥5 predicted NASH with 82.05% sensitivity. Factors associated with advanced fibrosis in NAFLD were age >40 years, diabetes mellitus, AST/ALT ratio > 1 and raised GGT. Conclusion NASH is common in patients with male gender, high BMI, DFL on liver US, raised ALT and GULAB score ≥5.

Nonalcoholic fatty liver disease accelerates kidney function decline in patients with chronic kidney disease: a cohort study

This study aimed to investigate the association of nonalcoholic fatty liver disease (NAFLD) and its severity with the decline in kidney function in patients with chronic kidney disease (CKD). We conducted a cohort study of 1,525 CKD patients who underwent repeated health check-up examinations from January 2003 through December 2013. NAFLD was diagnosed by ultrasonography and its severity was assessed by the NAFLD fibrosis score. At baseline, the prevalence of NAFLD was 40.9%, and the mean estimated glomerular filtration rate (eGFR) was 59.1 ml/min/1.73 m2. The average follow-up was 6.5 years. The age- and sex-adjusted decline in eGFR was greater in patients with NAFLD (-0.79% per year, 95% CI -1.31%, -0.27%) compared to those without it (0.30%, 95% CI -0.14%, 0.76%; p = 0.002). In multivariable adjusted models, the average difference in annual percent change in decline in eGFR comparing patients with NAFLD to those without NAFLD was -1.06% (-1.73%, -0.38%; p = 0.002). The decline in eGFR associated with NAFLD was greater in patients with higher NAFLD fibrosis score, in those with proteinuria or with low eGFR at baseline ( <45 ml/min/1.73 m2), and in those who were smokers and hypertensive. Therefore, NAFLD is independently associated with CKD progression.

The Utility of Noninvasive Scores in Assessing the Prevalence of Nonalcoholic Fatty Liver Disease and Advanced Fibrosis in Type 2 Diabetic Patients

GOALS

The aim of our study is to assess the prevalence of nonalcoholic fatty liver disease (NAFLD) and advanced hepatic fibrosis in patients with type 2 diabetes mellitus (T2DM) using simple noninvasive scores.

BACKGROUND

In individuals with T2DM, there is a very high prevalence of NAFLD. Moreover, T2DM is a risk factor for advanced disease in NAFLD patients.

STUDY

Using International Classification of Diseases, Ninth Revision codes all patients with the diagnosis of T2DM were reviewed and a retrospective chart analysis was performed on 169,910 patients between the ages of 18 to 80. To predict the prevalence of NAFLD, we calculated the hepatic steatosis index. To estimate the prevalence of advanced fibrosis, NAFLD fibrosis score (NFS), fibrosis-4 index, aspartate aminotransferase (AST) to platelet ratio index (APRI), and AST/alanine aminotransferase (ALT) ratio were calculated.

RESULTS

Of the 121,513 patients included in the analysis, 89.4% were above normal weight limit. NAFLD based on Hepatic Steatosis Index>36 was present in 87.9% of patients. Advanced fibrosis was present in 35.4% based on NFS>0.676, 8.4% based on fibrosis-4>2.67, 1.9% based on APRI>1.5, and 16.9% based on AST/ALT>1.4% indicating advanced fibrosis and high risk of developing cirrhosis related to NAFLD.

CONCLUSIONS

In this large cohort of patients with T2DM, we detected high prevalence of hepatic steatosis and advanced fibrosis using noninvasive scores. These scores are easy and nonexpensive tools to screen for NAFLD and advanced fibrosis, although the significant variability of the percentage of patients with advanced fibrosis using these scores indicates the need for further validation in diabetic populations.

Nonalcoholic Fatty Liver Disease/Nonalcoholic Steatohepatitis in Liver Transplantation

The number of transplants caused by nonalcoholic fatty liver disease/nonalcoholic steatohepatitis (NASH) has been progressively increasing and this is expected to become the most common indication for liver transplant in the United States. Patients with NASH show many features of the metabolic syndrome and, as a result, are at higher risk for postoperative cardiovascular morbidity and mortality. Despite this, patients with NASH have long-term graft and patient survival rates comparable with other causes of chronic liver disease. Posttransplant metabolic syndrome is a common occurrence that increases the risk of steatosis in the graft liver.

Hypertension, diabetes, atherosclerosis and NASH: Cause or consequence?

Non-alcoholic fatty liver disease (NAFLD) has become one of the most common forms of chronic liver disease worldwide and its prevalence is expected to continue rising. NAFLD has traditionally been considered a consequence of metabolic syndrome (MetS). However, the link between NAFLD and MetS components, especially type 2 diabetes mellitus (T2DM), hypertension (HTN), and cardiovascular disease (CVD) is more complex than previously thought. Indeed, the adverse effects of NAFLD extend far beyond the liver, with a large body of clinical evidence now suggesting that NAFLD may precede and/or promote the development of T2DM, HTN and atherosclerosis/CVD. The risk of developing these cardiometabolic diseases parallels the underlying severity of NAFLD. Accumulating evidence suggests that the presence and severity of NAFLD is associated with an increased risk of incident T2DM and HTN. Moreover, long-term prospective studies indicate that the presence and severity of NAFLD independently predicts fatal and nonfatal CVD events. In this review, we critically discuss the rapidly expanding body of clinical evidence that supports the existence of a bi-directional relationship between NAFLD and various components of MetS, particularly T2DM and HTN, as well as the current knowledge regarding a strong association between NAFLD and CVD morbidity and mortality. Finally, we discuss the most updated putative biological mechanisms through which NAFLD may contribute to the development of HTN, T2DM and CVD.

Implication of Nonalcoholic Fatty Liver Disease, Metabolic Syndrome, and Subclinical Inflammation on Mild Renal Insufficiency

BACKGROUND

Limited information exists about the impact of nonalcoholic fatty liver disease (NAFLD) on mild renal insufficiency. We compared the relative influence of NAFLD, metabolic syndrome (MetS), and subclinical inflammation, alone or in combination, on mild renal insufficiency.

METHODS

This study included 1174 Korean adults. NAFLD was diagnosed using ultrasonography. Mild renal insufficiency was defined as an estimated glomerular filtration rate (eGFR) ≥ 60 and <90 mL/min/1.73 m².

RESULTS

In partial correlation analysis, several components of MetS and liver aminotransferase levels, but not high-sensitivity C-reactive protein (hsCRP), were associated with eGFR. Multivariate logistic regression analysis demonstrated the independent association of NAFLD (P = 0.034) and MetS (P = 0.018) with mild renal insufficiency, but not elevated hsCRP (P = 0.885). Furthermore, NAFLD without the MetS group (odds ratio (95% confidence interval) = 1.56 (1.05-2.34)) or MetS without the NAFLD group (1.82 (1.11-3.00)) was associated with mild renal insufficiency after adjusting for confounding variables. However, individuals with high hsCRP showed no relationship with mild renal insufficiency, irrespective of the existence of NAFLD.

CONCLUSIONS

This study demonstrated that NAFLD and MetS are independently associated with mild renal insufficiency, whereas subclinical inflammation did not affect the risk for mild renal insufficiency in Korean adults.

Trend over time in hepatic fibrosis score in a cohort of type 2 diabetes patients

AIMS

The prevalence and progression of hepatic fibrosis and its correlated factors in type 2 diabetes (T2DM) are poorly known. We aimed to define the percentage of T2DM patients who progress to fibrosis and the factors associated with disease progression.

METHODS

Data from the electronic health records of 1527 patients with diagnosed T2DM and nonalcoholic fatty liver disease (NAFLD), as diagnosed by the Fatty Liver Index, were extracted from the AMD Annals database, which collects data from the Italian network of diabetes clinics. For the main analysis, we evaluated variables associated with Fibrosis 4 [FIB-4] score at baseline and at 3-year follow-up to determine their role in predicting FIB-4 at 3 years and the risk of hepatic fibrosis in T2DM.

RESULTS

High-risk of advanced fibrosis was detected in 13.1% of patients at baseline and in 18.1% at 3 years, LDL cholesterol, and body-mass index, correlated negatively with baseline FIB-4 scores, whereas gamma glutamil transerasi correlated positively . The FIB-4 score at 3 years was associated with lower values of baseline renal function, LDL, and BMI; however, the baseline FIB-4 score was the strongest predictor for the FIB-4 score at 3 years.

CONCLUSIONS

The prevalence of and progression to hepatic fibrosis within 3 years in patients with T2DM is not negligible. Patients with a higher likelihood of liver scarring differ from those with hepatic steatosis. Differently from NAFLD, the FIB-4 score is inversely correlated with insulin resistance and appears to increase independent of classic metabolic factors.

The fatty liver index as a predictor of incident chronic kidney disease in a 10-year prospective cohort study

Background

Although non-alcoholic fatty liver disease (NAFLD) is considered to be associated with chronic kidney disease (CKD), long-term follow up data is lacking. We investigated whether NAFLD, as determined by the fatty liver index (FLI), could predict incident CKD in 10-year prospective cohort study. We also assessed the clinical utility of FLI to predict the development of CKD.

Methods

6,238 adults aged 40 to 69 years without baseline CKD from the Ansan—Ansung cohort were examined. Patients were classified according to FLI as follows: FLI<30, no NAFLD; FLI≥60, NAFLD; and 30≤ FLI<60, intermediate. Incident CKD was defined as estimated glomerular filtration rate (eGFR) <60 ml/min per 1.73 m². The clinical utility of FLI in predicting incident CKD was estimated via area under the receiver-operating characteristic curve (AUC), net reclassification improvement (NRI), and integrated discrimination improvement (IDI) analyses.

Results

During an average of 10 years of follow-up, 724 subjects (15.21%) developed CKD. The adjusted hazard ratio [95% confidence interval (CI)] for incident CKD increased in a graded manner with FLI increased (<30 vs. 30–59 vs. ≥60 = 1 vs. 1.17 [0.997–1.375] vs. 1.459 [1.189–1.791], respectively, P for trend = 0.0012). Incorporation of FLI into traditional risk factors of CKD significantly increased prediction of incident CKD based on NRI (17%; 95% CI, 8.9–25%; P-value <0.001) and IDI (0.002; 95% CI, 0.0046–0.0143; P-value = 0.046).

Conclusions

FLI, a surrogate marker of NAFLD, was an independent risk factor for incident CKD. FLI provides meaningful incremental risk reclassification beyond that of conventional risk factors of CKD.

Acute Kidney Injury in Cirrhosis: Baseline Serum Creatinine Predicts Patient Outcomes

OBJECTIVES

The International Ascites Club (IAC) recently defined Stage 1 acute kidney injury (AKI) for cirrhosis as an acute increase in serum creatinine (SCr) by ≥0.3 mg/dl or by ≥50% in <48 h from a stable value within 3 months. The baseline SCr may influence AKI risk and patient outcomes. The objective of this study is to determine in cirrhosis whether the baseline SCr has any effect on the in-hospital AKI course and patient survival.

METHODS

North American Consortium for the Study of End-Stage Liver Disease is a consortium of tertiary-care hepatology centers prospectively enroling non-elective cirrhotic inpatients. Patients with different baseline SCr levels (≤0.5, 0.51-1.0, 1.01-1.5, >1.5 mg/dl) were evaluated for the development of AKI, and compared for AKI outcomes and 30-day survival.

RESULTS

653 hospitalized cirrhotics (56.7±10years, 64% men, 30% with infection) were included. The incidence of AKI was 47% of enrolled patients. Patients with higher baseline SCr were more likely to develop AKI, with significantly higher delta and peak SCr (P<0.001) than the other groups, more likely to have a progressive AKI course (P<0.0001), associated with a significantly reduced 30-day survival (P<0.0001). Multivariate logistic regression showed that the delta SCr during an AKI episode to be the strongest factor impacting AKI outcomes and survival (P<0.001), with a delta SCr of 0.70 mg/dl having a 68% sensitivity and 80% specificity for predicting 30-day mortality.

CONCLUSIONS

Admitted cirrhotic patients with higher baseline SCr are at higher risk for in-hospital development of AKI, and more likely to have AKI progression with reduced survival. Therefore, such patients should be closely monitored and treated promptly for their AKI.

Non-alcoholic fatty liver disease and its relationship with cardiovascular disease and other extrahepatic diseases

Key physiological functions of the liver, including glucose and lipid metabolism, become disturbed in the setting of non-alcoholic fatty liver disease (NAFLD) and may be associated with a systemic inflammatory 'milieu' initiated in part by liver-secreted cytokines and molecules. Consequently, the pathophysiological effects of NAFLD extend beyond the liver with a large body of clinical evidence demonstrating NAFLD to be independently associated with both prevalent and incident cardiovascular disease (CVD), chronic kidney disease (CKD) and type 2 diabetes mellitus (T2DM). The magnitude of risk of developing these extrahepatic diseases parallels the underlying severity of NAFLD, such that patients with non-alcoholic steatohepatitis (NASH) appear to be at greater risk of incident CVD, CKD and T2DM than those with simple steatosis. Other modifiers of risk may include genetic variants (eg, patatin-like phospholipase domain-containing 3 and trans-membrane 6 superfamily member 2 polymorphisms), visceral adipose tissue accumulation, dietary intake and the gut microbiome. Emerging data also suggest that NAFLD may be a risk factor for colonic neoplasia and reduced bone mineral density, especially among men. Importantly, improvement/resolution of NAFLD is associated with a reduced incidence of T2DM and improved kidney function, adding weight to causality and suggesting liver focused treatments may reduce risk of extrahepatic complications. Awareness of these associations is important for the clinicians such that CVD risk factor management, screening for T2DM and CKD are part of the routine management of patients with NAFLD.

Prevalence of Non Alcoholic Fatty Liver Disease and its Association with Diabetic Nephropathy in Patients with Type 2 Diabetes Mellitus

INTRODUCTION

Non Alcoholic Fatty Liver Disease (NAFLD) and Type 2 Diabetes Mellitus (T2DM) are two common problems affecting global health as these two conditions can influence each other. There is very little information about the possible association between NAFLD and diabetic microvascular complications such as diabetic nephropathy.

AIM

The aim of this study was to evaluate the prevalence of NAFLD in patients with T2DM and to investigate the association between NAFLD and diabetic nephropathy in these patients.

MATERIALS AND METHODS

This cross-sectional study was conducted on 255 patients with T2DM, with minimum age being 30 years. Hepatic ultrasonography using a 3.5 MHz probe was performed in all subjects. Fatty liver based on standard criteria was diagnosed with liver brightness, contrast between the echogenicity of the liver, kidneys and the blood vessels fading rate. Screening for microalbuminuria was performed by the preferred method, measurement of the Urine Albumin-To-Creatinine (UACR) ratio in a random spot collection.

RESULTS

In this study, 255 patients with T2DM were enrolled of which 173 (68%) were females and 82 (32%) were males. Of these 221 subjects (86.66%) had NAFLD. Diabetic nephropathy was observed among 33% of individuals, microalbuminuria among 32% and macroalbuminuria in 10% of all individuals. Duration of diabetes, Body Mass Index (BMI), hypertriglyceridemia, and HbA1c were significantly associated with incidence of NAFLD. Also, duration of diabetes and HbA1c were significantly associated with diabetic nephropathy in patients with T2DM.

CONCLUSION

NAFLD in patients with T2DM is extremely common. NAFLD is not considered as a risk factor for diabetic nephropathy. To better understand the pathogenesis of NAFLD and its causal relationship with complications of diabetes such as diabetic nephropathy, prospective studies and long term follow up are needed.

Changes in drug transport and metabolism and their clinical implications in non-alcoholic fatty liver disease

INTRODUCTION

The incidence of non-alcoholic fatty liver disease (NAFLD) is rising, especially in Western countries. Drug treatment in patients with NAFLD is common since it is linked to other conditions like diabetes, obesity, and cardiovascular disease. Consequently, changes in drug metabolism may have serious clinical implications. Areas covered: A literature search for studies in animal models or patients with obesity, fatty liver, non-alcoholic steatohepatitis (NASH) or NASH cirrhosis published before November 2016 was performed. After discussing epidemiology and animal models for NAFLD, we summarized both basic as well as clinical studies investigating changes in drug transport and metabolism in NAFLD. Important drug groups were assessed separately with emphasis on clinical implications for drug treatment in patients with NAFLD. Expert opinion: Given the frequency of NAFLD even today, a high degree of drug treatment in NAFLD patients appears safe and well-tolerated despite considerable changes in hepatic uptake, distribution, metabolism and transport of drugs in these patients. NASH causes changes in biliary excretion, systemic concentrations, and renal handling of drugs leading to alterations in drug efficacy or toxicity under specific circumstances. Future clinical drug studies should focus on this special patient population in order to avoid serious adverse events in NAFLD patients.

Improvement in liver histology due to lifestyle modification is independently associated with improved kidney function in patients with non-alcoholic steatohepatitis

BACKGROUND

Several recent studies have shown a strong association between non-alcoholic steatohepatitis (NASH) and chronic kidney disease.

AIM

To examine the relationship between changes in liver histology and renal function in patients with NASH.

METHODS

The present analysis represents a post hoc analysis of a recently published trial that included 261 patients with NASH who were treated with lifestyle modifications during 52 weeks. Kidney function was evaluated through Chronic Kidney Disease Epidemiology Collaboration estimated glomerular filtration rates (eGFR, mL/min/1.73 m² ) overtime. We explored correlations between the kidney function and improvement in histological outcomes at 52 weeks.

RESULTS

Interestingly, a one-stage reduction in fibrosis (r = 0.20, P < 0.01) and resolution of NASH (r = 0.17, P < 0.01) were significantly correlated with an improvement in the kidney function. The eGFR values significantly increased in patients with fibrosis improvement (+7.6 ± 6.5 mL/min/1.73 m² ), compared to those without fibrosis improvement (-1.98 ± 6.4 mL/min/1.73 m² ) (P < 0.01) at end of treatment (EOT). Likewise, NASH resolution was associated with an increase in eGFR compared with patients without NASH resolution (2.32 ± 7.8 mL/min/1.73 m² vs. -1.04 ± 5.9 mL/min/1.73 m² , P = 0.04) at EOT. After controlling for the confounders, the association between fibrosis improvement, NASH resolution and eGFR change remained significant (P < 0.05 for both).

CONCLUSIONS

Improvement in liver histology due to lifestyle modification is independently associated with improved kidney function in NASH. As new drugs for NASH emerge, studies should address whether improvement in histology in response to pharmacotherapies yield the same improvement in kidney function as weight loss.

Association between gamma-glutamyltransferase and albuminuria in nondiabetic adults with normal renal function

BACKGROUND

Serum gamma-glutamyltransferase (GGT) has been associated with albuminuria in diabetes patients, but it has not been investigated in the general population. We aimed to investigate the association between serum GGT and albuminuria in the nondiabetic Korean population with normal kidney function.

METHODS

Study participants (3948; 1549 men and 2399 women) with an estimated glomerular filtration rate ≥60 mL/min/1.73 m² were analyzed from the fifth Korean National Health and Nutrition Examination Survey (2011). Albuminuria was defined as an albumin-creatinine ratio >30 mg/g. Serum GGT was analyzed by dividing into quartiles. Multiple logistic models were used to analyze the associations between GGT and albuminuria.

RESULTS

The prevalence of albuminuria was 5.1% and increased linearly according to increasing GGT quartiles (P for trend = 0.005). A linear regression analysis revealed that GGT was positively related with albuminuria (P = 0.008). After adjusting for confounding factors, the odds ratio for albuminuria was 1.80 (95% CI 1.079-3.010, P for trend = 0.029) for the highest quartile group compared with those observed in the lowest quartile of GGT. In addition, this independent relationship did not change when the cut-off value of GGT (30 IU/L) was applied to this analysis. Compared with GGT value ≤30 IU/L, the adjusted odds ratio of albuminuria in participants with GGT >30 IU/L was 1.96 (95% CI 1.319-2.906, P < 0.001).

CONCLUSION

Higher serum GGT levels within the reference range were significantly associated with albuminuria in nondiabetic Koreans with preserved kidney function, independently of traditional cardio-renal risk factors.

Bile Acid Nuclear Receptor Farnesoid X Receptor: Therapeutic Target for Nonalcoholic Fatty Liver Disease

Nonalcoholic fatty liver disease (NAFLD) is one of the causes of fatty liver, occurring when fat is accumulated in the liver without alcohol consumption. NAFLD is the most common liver disorder in advanced countries. NAFLD is a spectrum of pathology involving hepatic steatosis with/without inflammation and nonalcoholic steatohepatitis with accumulation of hepatocyte damage and hepatic fibrosis. Recent studies have revealed that NAFLD results in the progression of cryptogenic cirrhosis that leads to hepatocarcinoma and cardiovascular diseases such as heart failure. The main causes of NAFLD have not been revealed yet, metabolic syndromes including obesity and insulin resistance are widely accepted for the critical risk factors for the pathogenesis of NAFLD. Nuclear receptors (NRs) are transcriptional factors that sense environmental or hormonal signals and regulate expression of genes, involved in cellular growth, development, and metabolism. Several NRs have been reported to regulate genes involved in energy and xenobiotic metabolism and inflammation. Among various NRs, farnesoid X receptor (FXR) is abundantly expressed in the liver and a key regulator to control various metabolic processes in the liver. Recent studies have shown that NAFLD is associated with inappropriate function of FXR. The impact of FXR transcriptional activity in NAFLD is likely to be potential therapeutic strategy, but still requires to elucidate underlying potent therapeutic mechanisms of FXR for the treatment of NAFLD. This article will focus the physiological roles of FXR and establish the correlation between FXR transcriptional activity and the pathogenesis of NAFLD.

Nonalcoholic fatty liver disease - A multisystem disease?

Non-alcoholic fatty liver disease (NAFLD) is one of the most common comorbidities associated with overweight and metabolic syndrome (MetS). Importantly, NAFLD is one of its most dangerous complications because it can lead to severe liver pathologies, including fibrosis, cirrhosis and hepatic cellular carcinoma. Given the increasing worldwide prevalence of obesity, NAFLD has become the most common cause of chronic liver disease and therefore is a major global health problem. Currently, NAFLD is predominantly regarded as a hepatic manifestation of MetS. However, accumulating evidence indicates that the effects of NAFLD extend beyond the liver and are negatively associated with a range of chronic diseases, most notably cardiovascular disease (CVD), diabetes mellitus type 2 (T2DM) and chronic kidney disease (CKD). It is becoming increasingly clear that these diseases are the result of the same underlying pathophysiological processes associated with MetS, such as insulin resistance, chronic systemic inflammation and dyslipidemia. As a result, they have been shown to be independent reciprocal risk factors. In addition, recent data have shown that NAFLD actively contributes to aggravation of the pathophysiology of CVD, T2DM, and CKD, as well as several other pathologies. Thus, NAFLD is a direct cause of many chronic diseases associated with MetS, and better detection and treatment of fatty liver disease is therefore urgently needed. As non-invasive screening methods for liver disease become increasingly available, detection and treatment of NAFLD in patients with MetS should therefore be considered by both (sub-) specialists and primary care physicians.

Acute kidney injury and post-reperfusion syndrome in liver transplantation

In the past decades liver transplantation (LT) has become the treatment of choice for patients with end stage liver disease (ESLD). The chronic shortage of cadaveric organs for transplantation led to the utilization of a greater number of marginal donors such as older donors or donors after circulatory death (DCD). The improved survival of transplanted patients has increased the frequency of long-term complications, in particular chronic kidney disease (CKD). Acute kidney injury (AKI) post-LT has been recently recognized as an important risk factor for the occurrence of de novo CKD in the long-term outcome. The onset of AKI post-LT is multifactorial, with pre-LT risk factors involved, including higher Model for End-stage Liver Disease score, more sever ESLD and pre-existing renal dysfunction, either with intra-operative conditions, in particular ischaemia reperfusion injury responsible for post-reperfusion syndrome (PRS) that can influence recipient’s morbidity and mortality. Post-reperfusion syndrome-induced AKI is an important complication post-LT that characterizes kidney involvement caused by PRS with mechanisms not clearly understood and implication on graft and patient survival. Since pre-LT risk factors may influence intra-operative events responsible for PRS-induced AKI, we aim to consider all the relevant aspects involved in PRS-induced AKI in the setting of LT and to identify all studies that better clarified the specific mechanisms linking PRS and AKI. A PubMed search was conducted using the terms liver transplantation AND acute kidney injury; liver transplantation AND post-reperfusion syndrome; acute kidney injury AND post-reperfusion syndrome; acute kidney injury AND DCD AND liver transplantation. Five hundred seventy four articles were retrieved on PubMed search. Results were limited to title/abstract of English-language articles published between 2000 and 2015. Twenty-three studies were identified that specifically evaluated incidence, risk factors and outcome for patients developing PRS-induced AKI in liver transplantation. In order to identify intra-operative risk factors/mechanisms specifically involved in PRS-induced AKI, avoiding confounding factors, we have limited our study to “acute kidney injury AND DCD AND liver transplantation”. Accordingly, three out of five studies were selected for our purpose.

Nonalcoholic fatty liver disease is associated with low-grade albuminuria in Chinese adults (change not displayed)

BACKGROUND

Nonalcoholic fatty liver disease (NAFLD) was associated with higher risk of cardiovascular disease (CVD). Low-grade albuminuria was recognized as an early indicator of CVD. Epidemiological studies investigating the association between NAFLD and low-grade albuminuria were limited.

AIM

To determine whether NAFLD is independently associated with the presence of low-grade albuminuria in Chinese adults.

DESIGN

A cross-sectional community-based population study was performed in 8270 Chinese adults aged 40 years or older.

METHODS

A first-voided early morning spot urine sample was obtained for urinary albumin and creatinine measurements. The highest quartile of urinary albumin-to-creatinine ratio was defined as low-grade albuminuria, after excluding the participants with micro- or macroalbuminuria. NAFLD was diagnosed by using ultrasonography findings after the exclusion of alcohol abuse and other liver diseases.

RESULTS

The prevalence of low-grade albuminuria was significantly higher in participants with NAFLD than in those without NAFLD (33.6% vs. 21.3% in men and 30.4% vs. 22.8% in women, respectively). Multivariate-adjusted logistic regression analysis revealed that NAFLD was significantly associated with increased odds ratio of low-grade albuminuria in men (odds ratio, 1.47; 95% CI, 1.16-1.87) after adjusting for multiple confounders. The significant association was not detected in women.

CONCLUSIONS

NAFLD was significantly associated with an increased risk of present low-grade albuminuria in middle-aged and elderly Chinese men.

Assessment of Vitamin D status in a group of Egyptian children with non alcoholic fatty liver disease (multicenter study)

BACKGROUND

Nonalcoholic fatty liver disease (NAFLD) is one of the health problems with great burden on the liver that may end with liver cirrhosis and hepatocellular carcinoma. The aim of this work was to assess serum vitamin D level in nonalcoholic fatty liver disease children.

METHODS

This cross sectional case control study involved 47 patients with nonalcoholic fatty liver disease selected while recruiting the pediatric hepatology clinics. Their ages ranged from 5-15 years and were compared with 23 healthy age and sex matched children. All involved patients were subjected to careful history taking, clinical examination and for patients and control, anthropometric measures for body mass index (BMI) calculation (plotted on WHO percentile growth charts), aspartate aminotransferase (AST), alanine aminotransferase (ALT), alkaline phosphatase (ALP), gamma glutamyl transferase (GGT), bilirubin (total and direct), serum albumin, creatinine, triglycerides, cholesterol, high density lipoprotein (HDL),low density lipoprotein (LDL), fasting blood glucose and fasting insulin (for calculation of insulin resistance), C reactive protein and serum vitamin D all were assayed. NAFLD was detected by ultrasonography and graded as absent, mild, moderate and severe.

RESULTS

Ninety-three percent of NAFLD patients were obese. Significant differences were found between patients and control regarding AST, ALT, ALP, GGT, total and direct bilirubin, serum albumin, creatinine, triglycerides, cholesterol, HDL, fasting blood glucose, fasting insulin, the homeostatic model assessment for insulin resistance (HOMA-IR) and serum vitamin D levels. Significant negative correlation was found between serum vitamin D level and grades of steatosis.

CONCLUSIONS

Serum vitamin D level decreases in children with NAFLD. This low serum vitamin D level is associated with higher stages of steatosis but not with BMI.

Non-alcoholic fatty liver disease and liver transplantation

Cirrhosis secondary to non-alcoholic steatohepatitis (NASH) is a common indication for liver transplant. In comparison to other cirrhotic patients, patients with NASH cirrhosis are more likely to be older and have the metabolic syndrome. Pre-transplant, patients require careful evaluation of cardiovascular risk. As the incidence of non-alcoholic fatty liver disease (NAFLD) is rising, a greater proportion of donor grafts have steatosis greater than 30%, which is associated with poor outcomes. Grafts with steatosis greater than 60% are unsuitable for transplant. Overall, post-transplant survival outcomes for patients with NASH cirrhosis are similar to those with cirrhosis without NASH. However, NASH cirrhosis is associated with a higher 30-day mortality, predominantly from an increase in cardiovascular events and infections. Following liver transplant, there is a significant risk of NASH recurrence, although this seldom results in allograft loss. Furthermore, a significant number of patients who had a liver transplant for other reasons develop NASH de novo. When patients with NASH cirrhosis are considered for transplant, one of the major challenges lies in identifying which patients are too high risk for surgery. This review aims to provide information to aid this decision making process, and to provide guidance on the peri-operative care strategies that can modify risk.

Extrahepatic Manifestations of Nonalcoholic Fatty Liver Disease

Nonalcoholic fatty liver disease (NAFLD) is the most common cause of chronic liver disease worldwide with an increased prevalence of metabolic, macro- and microvascular complications. The primary causes of mortality in NAFLD are cardiovascular disease (CVD), malignancy and liver disease. NAFLD is a multisystem disease that affects a variety of extra-hepatic organ systems. The main focus of this review is to summarize the reported extra-hepatic associations, which include CVD, chronic kidney disease, obstructive sleep apnea, osteoporosis, psoriasis, colorectal cancer, iron overload and various endocrinopathies (e.g. type 2 diabetes mellitus, thyroid dysfunction, and polycystic ovarian syndrome). Due to the systemic manifestations of NAFLD patients require a multidisciplinary assessment and may benefit from more rigorous surveillance and early treatment interventions to decrease mortality related to malignancy or cardiometabolic diseases.

Acute kidney injury following liver transplantation: a systematic review of published predictive models

Acute kidney injury is a frequent postoperative complication amongst liver transplant recipients and is associated with increased morbidity and mortality. This systematic review analysed the existing predictive models, in order to solidify current understanding. Articles were selected for inclusion if they described the primary development of a clinical prediction model (either an algorithm or risk score) to predict AKI post liver transplantation. The database search yielded a total of seven studies describing the primary development of a prediction model or risk score for the development of AKI following liver transplantation. The models span thirteen years of clinical research and highlight a gradual change in the definitions of AKI, emphasising the need to employ standardised definitions for subsequent studies. Collectively, the models identify a diverse range of predictive factors with several common trends. They emphasise the impact of preoperative renal dysfunction, liver disease severity and aetiology, metabolic risk factors as well as intraoperative variables including measures of haemodynamic instability and graft quality. Although several of the models address postoperative parameters, their utility in predictive modelling seems to be of questionable relevance. The common risk factors identified within this systematic review provide a minimum list of variables, which future studies should address. Research in this area would benefit from prospective, multi-site studies with larger cohorts as well as the subsequent internal and external validation of predictive models. Ultimately, the ability to identify patients at high risk of post-transplant AKI may enable early intervention and perhaps prevention.

The Burden of NAFLD and Its Characteristics in a Nationwide Population with Type 2 Diabetes

OBJECTIVE

We studied the prevalence of nonalcoholic fatty liver disease (NAFLD) and its clinical correlates in a population of patients with type 2 diabetes mellitus (T2DM).

METHODS

Clinical data of 94,577 T2DM patients were retrieved from 160 diabetes clinics in Italy in a standardized format and centrally analyzed anonymously. After exclusion of 5967 cases (high or uncertain alcohol intake), in 38,880 the Fatty Liver Index (FLI) was used as a proxy for the diagnosis of NAFLD. Factors associated with FLI assessed NAFLD (FLI-NAFLD) were evaluated through multivariate analysis.

RESULTS

FLI-NAFLD was present in 59.6% of patients. Compared to non-NAFLD, FLI-NAFLD was associated with impairment in renal function, higher albumin excretion, HbA1c and blood pressure, lower HDL cholesterol, and poorer quality of care. ALT was within normal limits in 73.6% of FLI-NAFLD patients (45.6% if the updated reference values were used). The prevalence of FLI-NAFLD did not differ if the whole sample (94,577 cases) was examined, irrespective of alcohol intake.

CONCLUSIONS

FLI-NAFLD was present in the majority of T2DM patients of our sample and metabolic derangement, not alcohol consumption, was mainly associated with the disease. FLI-NAFLD patients have a worse metabolic profile. ALT levels are not predictive of NAFLD.

Fatty liver disease: Disparate predictive ability for cardiometabolic risk and all-cause mortality

AIM: To assess the association of a surrogate of fatty liver disease (FLD) with incident type-2 diabetes, coronary heart disease, and all-cause mortality.

METHODS: In a prospective population-based study on 1822 middle-aged adults, stratified to gender, we used an algorithm of fatty liver index (FLI) to identify associations with outcomes. An index ≥ 60 indicated the presence of FLD. In Cox regression models, adjusted for age, smoking status, high-density lipoprotein cholesterol, and systolic blood pressure, we assessed the predictive value of FLI for incident diabetes, coronary heart disease (CHD), and all-cause mortality.

RESULTS: At a mean 8 year follow-up, 218 and 285 incident cases of diabetes and CHD, respectively, and 193 deaths were recorded. FLD was significantly associated in each gender with blood pressure, total cholesterol, apolipoprotein B, uric acid, and C-reactive protein; weakly with fasting glucose; and inversely with high-density lipoprotein-cholesterol and sex hormone-binding globulin. In adjusted Cox models, FLD was (with a 5-fold HR) the major determinant of diabetes development. Analyses further disclosed significant independent prediction of CHD by FLD in combined gender [hazard ratio (HR) = 1.72, 95% confidence interval (CI): 1.17-2.53] and men (HR = 2.35, 95%CI: 1.25-4.43). Similarly-adjusted models for all-cause mortality proved, however, not to confer risk, except for a tendency in prediabetics and diabetic women.

CONCLUSION: A surrogate of FLD conferred significant high risk of diabetes and coronary heart disease, independent of some metabolic syndrome traits. All-cause mortality was not associated with FLD, except likely in the prediabetic state. Such a FLI may reliably be used in epidemiologic studies.

Prognostic effect of high-flux hemodialysis in patients with chronic kidney disease

We investigated the prognostic effects of high-flux hemodialysis (HFHD) and low-flux hemodialysis (LFHD) in patients with chronic kidney disease (CKD). Both an electronic and a manual search were performed based on our rigorous inclusion and exclusion criteria to retrieve high-quality, relevant clinical studies from various scientific literature databases. Comprehensive meta-analysis 2.0 (CMA 2.0) was used for the quantitative analysis. We initially retrieved 227 studies from the database search. Following a multi-step screening process, eight high-quality studies were selected for our meta-analysis. These eight studies included 4967 patients with CKD (2416 patients in the HFHD group, 2551 patients in the LFHD group). The results of our meta-analysis showed that the all-cause death rate in the HFHD group was significantly lower than that in the LFHD group (OR=0.704, 95%CI=0.533-0.929, P=0.013). Additionally, the cardiovascular death rate in the HFHD group was significantly lower than that in the LFHD group (OR=0.731, 95%CI=0.616-0.866, P<0.001). The results of this meta-analysis clearly showed that HFHD decreases all-cause death and cardiovascular death rates in patients with CKD and that HFHD can therefore be implemented as one of the first therapy choices for CKD.

Change in fatty liver status and 5-year risk of incident metabolic syndrome: a retrospective cohort study

INTRODUCTION

Fatty liver is associated with metabolic syndrome (MetS) but it may also occur without MetS. Whether resolution of fatty liver in the general population affects risk of MetS is unknown. Our aim was to determine whether a change in fatty liver status (either the development of new fatty liver or the resolution of existing fatty liver) would modify the risk of de novo MetS.

METHODS

Two thousand eighty-nine people without hypertension, diabetes, and MetS were examined at baseline and at 5-year follow-up using a retrospective cohort study design. Fatty liver status was assessed at baseline and at follow-up by ultrasonography. Adjusted hazard ratios (aHR) and 95 % confidence intervals (CIs) for de novo MetS at follow-up were calculated controlling for the potential confounders, compared to the reference group (people who never had fatty liver at baseline and follow-up).

RESULTS

During follow-up, fatty liver developed in 251 people and fatty liver resolved in 112 people. After the adjustment for multiple confounders, persisting fatty liver and incident fatty liver development were associated with de novo MetS, with aHR of 2.60 (95 % CIs [1.61,4.20]) and 3.31 (95 % CIs [1.99,5.51]), respectively. Risk of new MetS in resolved fatty liver group was attenuated with insignificant aHR of 1.29 accompanying 95 % CIs of 0.60 and 2.80.

DISCUSSION

Development or maintenance of fatty liver is positively associated with occurrence of new MetS. Resolution of fatty liver status has similar risk of de novo MetS with those who never had fatty liver. Therefore, cautious management is needed with those with fatty liver.

NKT cell modulates NAFLD potentiation of metabolic oxidative stress-induced mesangial cell activation and proximal tubular toxicity

Obesity and nonalcoholic fatty liver disease (NAFLD) are associated with the development and progression of chronic kidney disease. We recently showed that NAFLD induces liver-specific cytochrome P-450 (CYP)2E1-mediated metabolic oxidative stress after administration of the CYP2E1 substrate bromodichloromethane (BDCM) (Seth RK, Das S, Kumar A, Chanda A, Kadiiska MB, Michelotti G, Manautou J, Diehl AM, Chatterjee S. Toxicol Appl Pharmacol 274: 42-54, 2014; Seth RK, Kumar A, Das S, Kadiiska MB, Michelotti G, Diehl AM, Chatterjee S. Toxicol Sci 134:291-303, 2013). The present study examined the effects of CYP2E1-mediated oxidative stress in NAFLD leading to kidney toxicity. Mice were fed a high-fat diet for 12 wk to induce NAFLD. NAFLD mice were exposed to BDCM, a CYP2E1 substrate, for 4 wk. NAFLD + BDCM increased CYP2E1-mediated lipid peroxidation in proximal tubular cells compared with mice with NAFLD alone or BDCM-treated lean mice, thus ruling out the exclusive role of BDCM. Lipid peroxidation increased IL-1β, TNF-α, and interferon-γ. In parallel, mesangial cell activation was observed by increased α-smooth muscle actin and transforming growth factor-β, which was blocked by the CYP2E1 inhibitor diallyl sulphide both in vivo and in vitro. Mice lacking natural killer T cells (CD1d knockout mice) showed elevated (>4-fold) proinflammatory mediator release, increased Toll-like receptor (TLR)4 and PDGF2 mRNA, and mesangial cell activation in the kidney. Finally, NAFLD CD1D knockout mice treated with BDCM exhibited increased high mobility group box 1 and Fas ligand levels and TUNEL-positive nuclei, indicating that higher cell death was attenuated in TLR4 knockout mice. Tubular cells showed increased cell death and cytokine release when incubated with activated mesangial cells. In summary, an underlying condition of progressive NAFLD causes renal immunotoxicity and aberrant glomerular function possibly through high mobility group box 1-dependent TLR4 signaling and mesangial cell activation, which, in turn, is modulated by intrinsic CD1D-dependent natural killer T cells.

Mechanism of Altered Metformin Distribution in Nonalcoholic Steatohepatitis

Metformin is an antihyperglycemic drug that is widely prescribed for type 2 diabetes mellitus and is currently being investigated for the treatment of nonalcoholic steatohepatitis (NASH). NASH is known to alter hepatic membrane transporter expression and drug disposition similarly in humans and rodent models of NASH. Metformin is almost exclusively eliminated through the kidney primarily through active secretion mediated by Oct1, Oct2, and Mate1. The purpose of this study was to determine how NASH affects kidney transporter expression and metformin pharmacokinetics. A single oral dose of [(14)C]metformin was administered to C57BL/6J (wild type [WT]) and diabetic ob/ob mice fed either a control diet or a methionine- and choline-deficient (MCD) diet. Metformin plasma concentrations were slightly increased in the WT/MCD and ob/control groups, whereas plasma concentrations were 4.8-fold higher in ob/MCD mice compared with WT/control. The MCD diet significantly increased plasma half-life and mean residence time and correspondingly decreased oral clearance in both genotypes. These changes in disposition were caused by ob/ob- and MCD diet-specific decreases in the kidney mRNA expression of Oct2 and Mate1, whereas Oct1 mRNA expression was only decreased in ob/MCD mice. These results indicate that the diabetic ob/ob genotype and the MCD disease model alter kidney transporter expression and alter the pharmacokinetics of metformin, potentially increasing the risk of drug toxicity.

Intrahepatic triglyceride content is independently associated with chronic kidney disease in obese adults: A cross-sectional study

BACKGROUND

Non-alcoholic fatty liver disease (NAFLD) and chronic kidney disease (CKD) are associated with some common critical cardio-metabolic risk factors. The aim of this study was to explore the association between intrahepatic triglyceride (IHTG) content and CKD in obese subjects.

METHODS

A total of 1068 obese participants received anthropometric, biochemical measurements and hepatic ultrasonography. Of those, 485 participants received magnetic resonance spectroscopy ((1)H-MRS) for the determination of IHTG content. CKD was defined as a urinary albumin:creatinine ratio (UACR)≥30 mg/g and/or estimated glomerular filtration rate (eGFR)<60 mL/min per 1.73 m(2).

RESULTS

The prevalence of CKD was significantly higher in NAFLD subjects compared to subjects without NAFLD, while the prevalence of CKD was gradually increased as the IHTG content increased by quartiles (P for trend<0.001). After adjustment for multivariate metabolic factors, the risk of abnormal albuminuria and CKD was increased by 68% [OR (95% CI): 1.68 (1.21-2.33), P<0.01] and 54% [OR (95% CI): 1.54 (1.14-2.07), P<0.01] respectively per one standard deviation (SD) increase in IHTG content. The association between IHTG content and CKD was not changed by conventional risk factors, including age, BMI and hypertension (all P<0.05).

CONCLUSION

IHTG content is independently associated with CKD in obese adults.

Effect of Non-Alcoholic Fatty Liver Disease on Estimated Glomerular Filtration Rate Could Be Dependent on Age

There is a gap between the association of non-alcoholic fatty liver disease (NAFLD) and renal function in an apparently healthy population. This study aims to assess whether NAFLD is associated with estimated glomerular filtration rate (eGFR) levels and to understand early changes of eGFR in NAFLD. A cross-sectional study was performed among apparently healthy persons who underwent general health screening including laboratory assessments and hepatic ultrasonography from January 2013 to December 2013 at the First Affiliated Hospital of Zhejiang University, College of Medicine, China. This study included 1,193 subjects with a mean age of 48 years. Prevalence of NAFLD was 31.3%. Mean eGFR was significantly lower in NAFLD than in controls (107 ± 19 mL/min/1.73 m(2) vs. 113 ± 23 mL/min/1.73 m(2), P<0.001). Correlation analysis between eGFR and NAFLD related risk factors revealed an inverse correlation between eGFR levels and some NAFLD risk factors (all P<0.01). All subjects were classified into five phases according to age. Average eGFR levels of NAFLD were lower than controls in three phases for subjects with ≤ 50 years of age (all P<0.05), while there were no significant differences on average eGFR levels between NAFLD and controls in two phases for subjects with >50 years of age (Both P>0.05). The eGFR level is significantly associated with NAFLD and its risk factors in an apparently healthy population. Effects of NAFLD on eGFR could be dependent on age.

Cardiovascular risk across the histological spectrum and the clinical manifestations of non-alcoholic fatty liver disease: An update

Non-alcoholic fatty liver disease (NAFLD) is considered to be an independent cardiovascular disease (CVD) risk factor. However, simple steatosis has a benign clinical course without excess mortality. In contrast, the advanced form of NAFLD, non-alcoholic steatohepatitis (NASH) with liver fibrosis increases mortality by approximately 70%, due to an increase in CVD mortality by approximately 300%. Chronic kidney disease (CKD) may be caused by NAFLD/NASH and it substantially increases CVD risk, especially in the presence of type 2 diabetes mellitus. Moreover, CKD may trigger NAFLD/NASH deterioration in a vicious cycle. NAFLD/NASH is also related to increased arterial stiffness (AS), an independent CVD risk factor that further raises CVD risk. Diagnosis of advanced liver fibrosis (mainly by simple non-invasive tests), CKD, and increased AS should be made early in the course of NAFLD and treated appropriately. Lifestyle measures and statin treatment may help resolve NAFLD/NASH and beneficially affect the CVD risk factors mentioned above.

Nonalcoholic fatty liver disease and the renin-angiotensin system blockers in the patients with chronic kidney disease

BACKGROUND

Recent data suggest that the renin-angiotensin-aldosteron system (RAAS) may be of importance in the pathogenesis of nonalcoholic fatty liver disease (NAFLD). We were interested to investigate whether the therapy with RAAS blockers in patients with different stages of chronic kidney disease (CKD) has any effect on steatosis and fibrosis grade; NAFLD documented by transient elastography (TE) (Fibroscan(®)-CAP).

METHODS

Of 191 patients with various stages of CKD there were 61 patients with CKD grade III and IV, 62 patients with end-stage renal disease treated with chronic hemodialysis and 68 renal transplant recipients. Liver stiffness was selected as the parameter to quantify liver fibrosis. Furthermore, the Controlled Attenuation Parameter (CAP) was used to detect and quantify liver steatosis with the help of TE.

RESULTS

CKD patients (p = 0.005) and CKD-NAFLD patients (p = 0.0005) with angiotensin-converting enzyme inhibitors (ACE-I) or angiotensin receptor blockers (ARBs) had statistically significant lower degree of liver stiffness in comparison to those without these medications (p = 0.005). Also, we were interested to explore is there any difference in fibrosis and steatosis grade due to use of ACE-I or ARBs. We did not find statistically significant differences between those two subgroups of patients with respect to liver steatosis/fibrosis.

CONCLUSION

Based on our results, RAAS blockers could be an attractive option for the management of NAFLD. We believe that TE provides the opportunity of noninvasive screening of NAFLD in CKD patients. In further prospective analysis, we believe that by using TE as noninvasive method we could investigate are ACE-I/ARBs really effective medications for the treatment of NAFLD in CKD patients.

NAFLD: a multisystem disease

Non-alcoholic fatty liver disease (NAFLD) is the most common cause of chronic liver disease in Western countries that is predicted to become also the most frequent indication for liver transplantation by 2030. Over the last decade, it has been shown that the clinical burden of NAFLD is not only confined to liver-related morbidity and mortality, but there is now growing evidence that NAFLD is a multisystem disease, affecting extra-hepatic organs and regulatory pathways. For example, NAFLD increases risk of type 2 diabetes mellitus (T2DM), cardiovascular (CVD) and cardiac diseases, and chronic kidney disease (CKD). Although the primary liver pathology in NAFLD affects hepatic structure and function to cause morbidity and mortality from cirrhosis, liver failure and hepatocellular carcinoma, the majority of deaths among NAFLD patients are attributable to CVD. This narrative review focuses on the rapidly expanding body of clinical evidence that supports the concept of NAFLD as a multisystem disease. The review discusses the factors involved in the progression of liver disease in NAFLD and the factors linking NAFLD with other extra-hepatic chronic diseases, such as T2DM, CVD, cardiac diseases and CKD. The review will not discuss NAFLD treatments as these are discussed elsewhere in this issue of the Journal. For this review, PubMed was searched for articles using the keywords "non-alcoholic fatty liver disease" or "fatty liver" combined with "diabetes", "cardiovascular (or cardiac) disease", "cardiovascular mortality" or "chronic kidney disease" between 1990 and 2014. Articles published in languages other than English were excluded.

Comorbidities and Metabolic Derangement of NAFLD

Nonalcoholic fatty liver disease (NAFLD) is an increasingly common cause of chronic liver disease worldwide and is becoming a major public health problem. NAFLD has been recognized as a hepatic manifestation of metabolic syndrome linked with insulin resistance. Growing evidence supports that NAFLD is associated with systemic diseases such as cardiovascular disease (CVD), chronic kidney disease (CKD), type 2 diabetes, obesity, and metabolic syndrome. The majority of deaths in patients with NAFLD come from cardiovascular disease. These findings are strongly attributed to nonalcoholic steatohepatitis (NASH) rather than simple steatosis. NAFLD should be considered not only a liver specific disease but also an early mediator of systemic disease. The underlying mechanisms and pathogenesis of NAFLD with regard to other medical disorders are not yet fully understood. Further investigation is needed for future therapeutic strategies for NAFLD. This review focuses on the relationship between NAFLD and various comorbid diseases and metabolic derangement.

Nonalcoholic steatohepatitis in precision medicine: Unraveling the factors that contribute to individual variability

There are numerous factors in individual variability that make the development and implementation of precision medicine a challenge in the clinic. One of the main goals of precision medicine is to identify the correct dose for each individual in order to maximize therapeutic effect and minimize the occurrence of adverse drug reactions. Many promising advances have been made in identifying and understanding how factors such as genetic polymorphisms can influence drug pharmacokinetics (PK) and contribute to variable drug response (VDR), but it is clear that there remain many unidentified variables. Underlying liver diseases such as nonalcoholic steatohepatitis (NASH) alter absorption, distribution, metabolism, and excretion (ADME) processes and must be considered in the implementation of precision medicine. There is still a profound need for clinical investigation into how NASH-associated changes in ADME mediators, such as metabolism enzymes and transporters, affect the pharmacokinetics of individual drugs known to rely on these pathways for elimination. This review summarizes the key PK factors in individual variability and VDR and highlights NASH as an essential underlying factor that must be considered as the development of precision medicine advances. A multifactorial approach to precision medicine that considers the combination of two or more risk factors (e.g. genetics and NASH) will be required in our effort to provide a new era of benefit for patients.

Liver steatosis and the risk of albuminuria: the multi-ethnic study of atherosclerosis

OBJECTIVE

To measure association between hepatic fat and albuminuria (an early marker of renal injury) in individuals without diabetes or hypertension.

METHODS

2,281 individuals in the Multi-Ethnic Study of Atherosclerosis without diabetes or hypertension, renal disease, or excess alcohol consumption underwent computed tomography (CT) for assessment of liver attenuation (marker of hepatic lipid content) and urinalysis (for albuminuria) at initial study visit, with assessment of incident and prevalent albuminuria by logistic regression in follow-up.

RESULTS

After adjustment for age, gender, race, smoking, blood pressure, insulin resistance, and body mass index, individuals with less liver fat (higher liver CT attenuation) had a lower probability of having albuminuria at Exam 1 (OR per 10 unit increase in attenuation 0.77, 95 % CI 0.61-0.97, P = 0.02). At median 9.3 years follow-up, albuminuria was identified in 129 individuals were (5.8 %). In fully adjusted models (with age, smoking, body mass index, blood pressure, diabetes and hypertension as time-dependent covariates), lower liver attenuation (greater liver fat) was associated with higher risk of incident albuminuria (OR 0.79, 95 % CI 0.66-0.94, P = 0.008).

CONCLUSIONS

Hepatic attenuation is associated with prevalent and incident albuminuria, an early, potent risk factor for renal risk in a population not clearly at risk for future renal failure.

Acute kidney injury following orthotopic liver transplantation: incidence, risk factors, and effects on patient and graft outcomes

BACKGROUND

Liver transplant recipients frequently develop acute kidney injury (AKI), but the predisposing factors and long-term consequences of AKI are not well understood. The aims of this study were to identify predisposing factors for early post-transplant AKI and the impact of AKI on patient and graft survival and to construct a model to predict AKI using clinical variables.

METHODS

In this 5-year retrospective study, we analysed clinical and laboratory data from 424 liver transplant recipients from our centre.

RESULTS

By 72 h post-transplant, 221 patients (52%) had developed AKI [according to the Kidney Disease Improving Global Outcomes (KDIGO) criteria]. Predisposing factors for development of AKI were female sex, weight (>100 kg), severity of liver disease (Child-Pugh score), pre-existing diabetes mellitus, number of units of blood or fresh frozen plasma transfused during surgery, and non-alcoholic steatohepatitis as the aetiology of end-stage liver disease (P≤0.05). Notably, preoperative serum creatinine (SCr) was not a significant predisposing factor. After fitting a forward stepwise regression model, female sex, weight >100 kg, high Child-Pugh score, and diabetes remained significantly associated with the development of AKI within 72 h (P≤0.05). The area under the receiver operator characteristic curve for the final model was 0.71. The incidence of new chronic kidney disease and requirement for dialysis at 3 months and 1 yr post-transplant were significantly higher among patients who developed AKI.

CONCLUSIONS

Development of AKI within the first 72 h after transplant impacted short-term and long-term graft survival.