The global epidemiology of NAFLD and NASH in patients with type 2 diabetes: A systematic review and meta-analysis

The effect of SGLT2 inhibitors on hepatic steatosis detected by MRI-PDFF in patients with type 2 Diabetes mellitus and metabolic-associated steatotic liver disease

Sodium-glucose co-transporter type-2 (SGLT2) inhibitors have been identified to have a crucial hepatoprotective role in patients with type 2 diabetes (T2DM) and metabolic-associated steatotic liver disease (MASLD). Thus, we aimed to assess the effect of SGLT2 inhibitors on hepatic steatosis in patients with T2DM and MASLD added to the standard of care (SOC) treatment. Our study was a single-arm clinical trial with trial no ISRCTN85961860. Thirty T2DM patients with MASLD were recruited from the outpatient endocrinology and diabetes clinic of the Internal Medicine Department at Kasr Al-Aini Hospital, Cairo University, Egypt. Our Patients received Empagliflozin 10 mg daily which was added to SOC treatment and followed up for 24 weeks. Magnetic resonance imaging proton density fat fraction (MRI-PDFF) was done at baseline and after 24 weeks to assess the percentage change in hepatic fat mass. Also changes in Fib-4 and NAFLD fibrosis scores were calculated. Our study showed a statistically significant decrease in the mean MRI-PDFF measurement of hepatic steatosis after 24 weeks of adding empagliflozin to SOC treatment (13.297 ± 7.15) compared to the mean at baseline (15.288 ± 8.72), P = 0.006 with overall percentage decrease about 13.16% of liver steatosis. There were significant decreases in BMI, fasting blood glucose, and Alanine transaminase, (P < 0.001, 0.03, 0.01) respectively. There were no significant differences in Fib-4 or NAFLD fibrosis scores. Adding empagliflozin 10 mg to the standard treatment in patients with diabetes and MASLD could reduce hepatic fat mass significantly after 24 weeks of treatment. Thus, adding SGLT2 inhibitors to the clinical practice guidelines could be a therapeutic agent for patients with MASLD and T2DM.

Association of occupational noise exposure and shift work with non-alcoholic fatty liver disease: a cross-sectional study of male workers in the Chinese automobile manufacturing industry

OBJECTIVE

This study aimed to determine the relationship between occupational noise, shift work and non-alcoholic fatty liver disease (NAFLD) in male workers in the automobile manufacturing industry.

DESIGN

Cross-sectional study.

SETTING

This study was carried out at the Guangzhou Twelfth People's Hospital using data from April to September 2022.

PARTICIPANTS

A total of 4672 eligible participants were included in the study.

PRIMARY AND SECONDARY OUTCOME MEASURES

Diagnosis of NAFLD was made using ultrasound. Noise was detected according to the Measurement of Physical Factors in the Workplace-Part 8: Noise. Environmental noise intensity was assessed using an EDGE personal noise dosimeter manufactured by CASELLA (UK). The working status of workers was investigated by questionnaire.

RESULTS

The OR of NAFLD was 1.39 (1.03, 1.88) in the cumulative noise exposure (CNE)≥95 group compared with CNE<85 group. Improved risk of NAFLD in workers with shift work compared with those without shift work (OR=1.35, 95% CI: 1.09, 1.68). As stratified analyses showed, the ORs of NAFLD prevalence related to occupational noise and shift work exposure appear to be increased in young workers. When both shift work and noise exposure work are present simultaneously, the synergy index between them was 0.47 (95% CI: 0.25, 0.89). Combined effects analysis revealed that the OR of NAFLD was 2.02 (95% CI: 1.34, 2.99) in CNE≥95 and cumulative length of night shifts work>2920 hours.

CONCLUSION

Occupational noise exposure may be an independent risk factor for NAFLD. It may synergistically affect disease when combined with night shift work, particularly among younger workers. These findings underscore the importance for companies to prioritise the management and training of younger workers, along with targeted occupational health education initiatives, as crucial measures for reducing the incidence of NAFLD.

Screening to identify people with type 2 diabetes at risk of liver cancer in primary care: a randomised controlled trial protocol

INTRODUCTION

Hepatocellular carcinoma (HCC) is expected to become the third most common cause of cancer death worldwide by 2030. The increase in HCC is in large part due to the rising prevalence of risk factors such as type 2 diabetes mellitus (T2DM). Up to 1 in 20 people living with T2DM have liver cirrhosis, and they have a 1% to 2% incidence of HCC per year. Patients with cirrhosis enter surveillance for HCC to identify early-stage, curable tumours. A diagnosis of T2DM does not mandate testing to identify patients with cirrhosis, with testing restricted to those with additional risks. There has never been a trial and nested cost-effectiveness evaluation comparing screening all patients with T2DM for cirrhosis against usual care.

METHODS AND ANALYSIS

The study will use a multi-centre, unblinded individual randomised controlled trial design. The aim will be to determine the effectiveness and cost-effectiveness of screening all adults with T2DM to identify those at high risk of HCC. The recruitment strategy has been supported by patient and public involvement (PPI). Participants will be identified via an automated search of primary care records and invited to participate via text. 320 participants will be randomised for screening. The screening will include measurement of bio-markers for liver fibrosis (ELF and Fib-4) and vibration-controlled transient elastography. Another 320 participants will be randomised to standard care. Demographic and medical history data will be collected at baseline from all participants. Outcome data will be collected remotely from healthcare records. The primary outcome is the proportion of participants in each arm who are referred to HCC surveillance following testing for liver disease within 12 months of randomisation. The results will be used to calculate the incremental cost-effectiveness ratio of screening via a Markov model.

ETHICS AND DISSEMINATION

The results of this study will be presented directly to National Health Service England. Additional dissemination via conference proceedings and publication will be supported by our PPI team. Ethical approval was granted by the West of Scotland Research Ethics Service on 2 August 2023, REC reference 23/WS/0102.

TRIAL REGISTRATION NUMBER

ISRCTN17017677.

Reversed role of CD36 deficiency in high-fat diet or methionine/choline-deficient diet-induced hepatic steatosis and steatohepatitis

Introduction

Cluster of differentiation 36 (CD36) is highly expressed in the liver of patients with metabolic dysfunction-associated fatty liver disease (MAFLD) or metabolic dysfunction-associated steatohepatitis (MASH). However, the precise role of CD36 in MAFLD/MASH is controversial. In the current study, we aimed to uncover the role of CD36 in the early stage of MAFLD/MASH induced by high-fat diet (HFD) and methionine/choline-deficient (MCD) diet.

Methods

CD36-/- mice and littermate control mice were fed a normal food diet (NCD); HFD or MCD diet for 6 weeks.

Results

We determined that CD36 deficiency attenuated HFD-induced hepatic steatosis while exacerbating MCD diet-induced steatohepatitis. Mechanistically, CD36 deficiency reduced HFD-induced expression of fatty acid synthase (FASN), sterol regulatory element binding protein 1c (SREBP1c), and acetyl-CoA carboxylase alpha (ACC1), thereby inhibiting de novo fatty acid synthesis. The expression of superoxide dismutase and genes involving fatty acid oxidation was inhibited by MCD diet. CD36 deficiency reduced expression of genes involving fatty acid oxidation, while MCD diet had no effect on these genes expression in CD36-/- mice. Meanwhile, MCD diet-reduced superoxide dismutase expression was further inhibited by CD36 deficiency. Thus, MCD-induced liver ROS and inflammation were further enhanced by CD36 deficiency. By liver lipidomic analysis, we found that the levels of triglyceride (TG), diacylglycerols (DG), acylcarnitine (AcCA), ceramide (Cer) and LPC were increased, while phosphatidylcholine/phosphatidylethanolamine (PC/PE) were decreased in MCD diet-treated CD36-/- mice compared with MCD diet-treated wild type mice. Indeed, the expression of serine palmitoyltransferase 2 (SPTLC2), the key rate-limiting enzyme of ceramide synthesis, was higher in CD36-/- mice.

Discussion

CD36 deficiency improves HFD-induced MAFLD by inhibiting fatty acid synthesis, while accelerating MCD diet-induced MASH via promoting Cer, LPC, TG and DG accumulation to accelerate liver inflammation. The complex role of CD36 in MAFLD/MASH needs more investigation to discover the precise and effective strategy when targeting CD36.

Non-alcoholic fatty liver disease is associated with structural covariance network reconfiguration in cognitively unimpaired adults with type 2 diabetes

Type 2 diabetes (T2D) is often accompanied by non-alcoholic fatty liver disease (NAFLD), both of which are related to brain damage and cognitive impairment. However, cortical structural alteration and its relationship with metabolism and cognition in T2D with NAFLD (T2NAFLD) and without NAFLD (T2noNAFLD) remain unclear. The brain MRI scans, clinical measures and neuropsychological test were evaluated in 50 normal controls (NC), 73 T2noNAFLD, and 58 T2NAFLD. The cortical thickness and graph theory properties of structural covariance network was calculated. Statistical analyses included one-way analysis of covariance with post hoc, partial correlation and mediation analysis. The nonparametric permutation test was performed to evaluate differences in topological properties of structural covariance network. We found T2NAFLD group had worse glucose and lipid profiles, more obesity and more severe insulin resistance, and poorer working memory compared to T2noNAFLD and NC. T2D patients demonstrated increase in cortical thickness compared to NC, but no difference between the two T2D groups. The structural covariance network integration decreased in T2D patients, with T2NAFLD exhibiting more obvious network reconfiguration at node level. Cortical thickness mediated the relationship between post-prandial glucose, waist-hip ratio, and working memory. The findings suggest that cortical thickening may be a compensatory response to reduced network integration, with NAFLD exacerbating regional structural network changes in T2D. This research advances our understanding of how these metabolic comorbidities contribute to cognitive decline, potentially guiding future therapeutic strategies for T2D patients with and without NAFLD.

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.

Berberine Ursodeoxycholate for the Treatment of Type 2 Diabetes: A Randomized Clinical Trial

Importance

Few of the available therapies for type 2 diabetes (T2D) comprehensively address disease burden beyond glycemic control. Examining whether berberine ursodeoxycholate (HTD1801), a first-in-class gut-liver anti-inflammatory metabolic modulator, has the potential to treat the core aspects of metabolic disease is important.

Objective

To assess the safety and efficacy of HTD1801 in patients with T2D that is inadequately controlled with diet and exercise.

Design, Setting, and Participants

This phase 2 double-blind, placebo-controlled, 12-week randomized clinical trial, conducted in China between March 2022 and January 2023, included patients with T2D who underwent 8 or more weeks of diet and exercise, had a hemoglobin A1c (HbA1c) level of 7.0% to 10.5%, and had a fasting plasma glucose (FPG) level less than 250.5 mg/dL.

Interventions

Patients were randomized 1:1:1 to placebo (n = 38), HTD1801 500 mg twice daily (n = 37), and HTD1801 1000 mg twice daily (n = 38).

Main Outcomes and Measures

The primary end point was the HbA1c level change from baseline to week 12. Secondary end points included glycemic, hepatic, and cardiometabolic parameters. The primary end point was analyzed using a mixed-effects model for repeated measures, with the HbA1c level change from baseline as the dependent variable. Treatment group, measurement time point, and interaction between treatment group and measurement time point were independent variables.

Results

The study included 113 patients with T2D (mean [SD] age, 54.3 [10.6] years; 72 male [63.7%]) who were randomized. Among these patients, the mean (SD) HbA1c level was 8.2% (0.8%); body mass index, 25.5 (3.7), calculated as weight in kilograms divided by height in meters squared; and FPG level, 160.7 (38.3) mg/dL. Baseline disease severity was balanced across treatment groups. The primary end point was achieved with significant dose-dependent reductions in the HbA1c level in both HTD1801 groups compared with the placebo group. The least-squares mean difference in the HbA1c level at week 12 was -0.4% (95% CI, -0.79% to -0.03%; P = .04) for the 500-mg group and -0.7% (95% CI, -1.10% to -0.35%; P < .001) for the 1000-mg group compared with the placebo group. HbA1c level reductions were paralleled with mean (SD) improvements in the FPG level in both the 500-mg group (-13.0 [38.2] mg/dL) and the 1000-mg group (-18.4 [21.8] mg/dL) groups. Reductions were observed in lipids and markers of liver injury in the 1000-mg group. HTD1801 was safe and well tolerated, with 110 patients (97.3%) completing the study. Treatment-emergent adverse events, generally mild, occurred in 59 patients (52.2%) overall. One patient (in the 500-mg group) experienced a serious adverse event of retinal hemorrhage, which was unlikely related to treatment. No patients discontinued due to an adverse event.

Conclusions and Relevance

In this placebo-controlled randomized clinical trial, treatment with HTD1801 resulted in significant reductions in the HbA1c level and improvements in key cardiometabolic and liver parameters. HTD1801 was safe and well tolerated. These findings are being confirmed in ongoing phase 3 studies. The effects demonstrated by HTD1801 support an oral treatment option for T2D and its comorbidities.

Trial Registration

ClinicalTrials.gov Identifier: NCT06411275.

The acetylation of Ganoderma applanatum polysaccharides on ameliorating T2DM-induced hepatic and colonic injuries by modulating the Nrf2/keap1-TLR4/NFκB-Bax/Bcl-2 pathways

It was imperative to discover and utilize high-efficiency, non-toxic substances for the prevention and management of type 2 diabetes mellitus (T2DM) and its associated complications, given the escalating prevalence and significant global health burden. In the present study, the acetylated Ganoderma applanatum polysaccharide (A-GAP) was successfully obtained and characterized, demonstrating excellent efficacy in ameliorating organ damage induced by T2DM through targeted modulation of the gut-liver axis. The physiological and molecular biological findings indicated that A-GAP may modulate the Nrf2/Keap1-TLR4/NFκB-Bax/Bcl-2 signaling pathway network, thereby mitigating oxidative stress and the subsequent inflammatory response, ultimately alleviating the inhibitory effects of IRS and insulin resistance. Besides, the regulatory impact of A-GAP on the gut-liver axis had been confirmed by its ability to maintain intestinal barrier integrity and increase levels of intestinal tight junction proteins, effectively preventing endotoxin translocation to the liver. This discovery highlighted the potential of A-GAP as a promising option for functional or nutritional foods and pharmaceuticals in managing T2DM and its complications, showcasing the significance of acetylation in enhancing the bioactivities of natural substances.

The use of simple tests to predict biopsy-proven steatohepatitis in people with type 2 diabetes

BACKGROUND/AIMS

Metabolic-associated steatotic liver disease (MASLD) has become the most common chronic liver disease, especially in people with type 2 diabetes mellitus (T2DM). Liver biopsy remains the gold standard method for diagnosis of MASLD subtypes, but prevalences may be under or overestimated when biopsy is performed with selection bias. The aims of this study were to define prevalence of MASLD subtypes by liver biopsy in T2DM participants not selected by abnormal exams, determine variables associated with metabolic-associated steatohepatitis (MASH), and analyze performance of aminotransferases and abdominal ultrasound in diagnosis.

METHODS

T2DM participants from 18 to 70 years were considered for enrollment. Of the 396 participants, 85 were included and submitted to clinical, laboratory examinations, and ultrasound. Eighty-three performed liver biopsy evaluated by two independent pathologists. Factors independently associated to MASH and significant fibrosis were assessed by hierarchical multivariate logistic regression.

RESULTS

Prevalence of MASLD was 92% (50% simple steatosis, 42% MASH) and kappa = 0.78. Steatosis was mild in 76% of participants with simple steatosis and severe in 65% of MASH (P < 0.001). Presence of MASH or fibrosis was associated with BMI and alanine aminotransferase (ALT) [threshold of 33.5 mg/dl in predicting MASH (area under the curve = 0.82, P = 0.001)].

CONCLUSION

Prevalence of MASLD by liver biopsy in T2DM regardless of ultrasound or ALT elevation is almost 100%, with 42% of MASH. MASH was associated to severe steatosis on histology. BMI and ALT were independently associated with MASH and ALT close to the upper limit of normal gave the best cutoff point for MASH detection.

RNA-seq analysis reveals transcriptome changes in livers from Efcab4b knockout mice

EFCAB4B is an evolutionarily conserved protein that encodes for the Rab GTPase Rab46, and the CRAC channel modulator, CRACR2A. Previous genome wide association studies have demonstrated the association of EFCAB4B variants in the progression of non-alcoholic fatty liver disease (NAFLD). In this study we show that mice with global depletion of Efcab4b -/- have significantly larger livers than their wild-type (WT) counterparts. We performed RNA-sequencing (RNA-seq) analysis of liver tissues to investigate differential global gene expression among Efcab4b -/- and WT mice. Of the 69 differentially expressed genes (DEGs), analyses of biological processes found significant enrichment in liver and bile development, with 6 genes (Pck1, Aacs, Onecut1, E2f8, Xbp1, and Hes1) involved in both processes. Specific consideration of possible roles of DEGs or their products in NAFLD progression to (NASH) and hepatocarcinoma (HCC), demonstrated DEGs in the livers of Efcab4b -/- mice had roles in molecular pathways including lipid metabolism, inflammation, ER stress and fibrosis. The results in this study provide additional insights into molecular mechanisms responsible for increasing susceptibility of liver injuries associated with EFCAB4B.

Comparison of SPISE and METS-IR and Other Markers to Predict Insulin Resistance and Elevated Liver Transaminases in Children and Adolescents

BACKGRUOUND

Studies on predictive markers of insulin resistance (IR) and elevated liver transaminases in children and adolescents are limited. We evaluated the predictive capabilities of the single-point insulin sensitivity estimator (SPISE) index, metabolic score for insulin resistance (METS-IR), homeostasis model assessment of insulin resistance (HOMA-IR), the triglyceride (TG)/ high-density lipoprotein cholesterol (HDL-C) ratio, and the triglyceride-glucose index (TyG) for IR and alanine aminotransferase (ALT) elevation in this population.

METHODS

Data from 1,593 participants aged 10 to 18 years were analyzed using a nationwide survey. Logistic regression analysis was performed with IR and ALT elevation as dependent variables. Receiver operating characteristic (ROC) curves were generated to assess predictive capability. Proportions of IR and ALT elevation were compared after dividing participants based on parameter cutoff points.

RESULTS

All parameters were significantly associated with IR and ALT elevation, even after adjusting for age and sex, and predicted IR and ALT elevation in ROC curves (all P<0.001). The areas under the ROC curve of SPISE and METS-IR were higher than those of TyG and TG/HDL-C for predicting IR and were higher than those of HOMA-IR, TyG, and TG/HDL-C for predicting ALT elevation. The proportions of individuals with IR and ALT elevation were higher among those with METS-IR, TyG, and TG/ HDL-C values higher than the cutoff points, whereas they were lower among those with SPISE higher than the cutoff point.

CONCLUSION

SPISE and METS-IR are superior to TG/HDL-C and TyG in predicting IR and ALT elevation. Thus, this study identified valuable predictive markers for young individuals.

Impact of PNPLA3 I148M on Clinical Outcomes in Patients With MASLD

BACKGROUND AND AIMS

Metabolic dysfunction-associated steatotic liver disease (MASLD) is a heterogenous clinical and histopathological entity, where multiple metabolic co-factors are intertwined with high interindividual variability. The impact and severity of each factor (including obesity and type 2 diabetes) define a systemic dysmetabolism that can lead to either advanced liver disease and its complication (including hepatocellular carcinoma and clinical events related to portal hypertension) or extrahepatic events: incident cardiovascular disease, chronic kidney disease and extrahepatic cancers. The balance between environmental factors and genetic susceptibility has unique implications in MASLD: the intermittent injury of metabolic co-factors, their fluctuation over time and their specific management, are counterbalanced by the presence of gene variants that can significantly impact the disease at multiple levels. The I148M variant in the PNPLA3 gene is the most investigated genetic susceptibility that induces a more severe steatohepatitis, enhanced fibrogenesis and can shape the incidence of long-term clinical events regardless of, or worsened by, other metabolic risk factors.

METHODS AND RESULTS

In this review, we will summarise the updated evidence on the natural history of MASLD accounting for classical metabolic risk factors, the role of PNPLA3 in clinical sub-phenotyping (e.g., 'lean MASLD'), impact on disease severity and fibrosis progression, as well as its role for prognostication, alone or in combination with non-invasive tools into polygenic risk scores.

The fibrosis investigating navigator in diabetes (FIND): A tool to predict liver fibrosis risk in subjects with diabetes

BACKGROUND

Type 2 diabetes increases the risk of cirrhosis and liver cancer. Noninvasive and early assessment of liver fibrosis is essential. We aimed to develop a score to aid in the initial assessment of liver fibrosis in the diabetic population.

METHODS

A fibrosis investigating navigator in diabetes (FIND) score was developed and validated in the NHANES dataset (2017-2020). Fibrosis was defined as a liver stiffness measurement (LSM) ≥8.0 kPa. The diagnostic accuracies of FIB-4, NFS, LiverRisk, steatosis-associated fibrosis estimator (SAFE) and metabolic dysfunction-associated fibrosis (MAF-5) were compared. FIND was also externally validated in various liver diseases via biopsy as a reference in an Asian centre between 2016 and 2020. Finally, we examined the prognostic implications of the FIND index utilizing data from the UK Biobank cohort (2006-2010).

RESULTS

The FIND score model yielded an AUROC of 0.781 for the prediction of an LSM ≥8 kPa in the validation set, which was consistently greater than that of other available models (all p < 0.05). In the whole NHANES dataset, the 85% sensitivity cut-off of 0.16 corresponded to a NPV of 91.9%, whereas the 85% specificity cut-off of 0.31 corresponded to a PPV of 50.6%. FIND displayed overall accuracies similar to those of the other models in staging fibrosis stages, with biopsy used as a reference. In the UK Biobank cohort, FIND >0.31 was associated with an increased risk of all-cause and liver-related mortality in the diabetic population in adjusted models (HR, 1.75; 95% CI, 1.62-1.89; HR, 23.59; 95% CI, 13.67-40.69).

CONCLUSIONS

In diabetes patients, the novel FIND score performs well in identifying subjects at risk of liver fibrosis and predicting all-cause and liver-related mortality.

Activation of SIRT1 by SRT1720 alleviates dyslipidemia, improves insulin sensitivity and exhibits liver-protective effects in diabetic rats on a high-fat diet: New insights into the SIRT1/Nrf2/NFκB signaling pathway

Insulin resistance and diabetes are associated with non-alcoholic fatty liver disease (NAFLD) and non-alcoholic steatohepatitis (NASH) conditions, which are distinguished by metabolic dysfunction, oxidative stress and inflammation. Sirtuin 1 (SIRT1), a NAD+-dependent deacetylase, is fundamental in regulating metabolic pathways, reducing inflammation, and improving antioxidant defenses. This is the first study to investigate the effects of SRT1720, a SIRT1 activator, in diabetic rats on a high-fat diet. SRT1720 significantly lowered fasting blood glucose and insulin levels and enhanced glucose tolerance and HOMA-IR and QUICKI scores, indicating increased insulin sensitivity. The treatment also reduced total cholesterol, triglycerides, and LDL levels, showing amelioration of dyslipidemia. Moreover, SRT1720 lowered markers of liver fibrosis, including TGF-β, TIMP-1, Col1a1, and hydroxyproline, and decreased inflammation by reducing NFκB activity and pro-inflammatory cytokines (TNF-α and IL-6). Furthermore, SRT1720 augmented Nrf2 activity and HO-1 levels. Consequently, the SRT1720's protective role improved liver function and histology and prolonged rats' survival. These functions were suppressed by the co-administration of the SIRT1 inhibitor EX527, confirming that the beneficial effects of SRT1720 are SIRT1-dependent. Correlation analyses uncovered that increased SIRT1 activity was strongly associated with decreased oxidative stress, inflammation, insulin resistance, and fibrosis markers. To conclude, our results find that SRT1720 represents a promising therapeutic strategy for managing Type 2 diabetes in NAFLD or NASH patients possibly through the modulation of the SIRT1/Nrf2/NFκB signaling pathwa. SRT1720 could potentially halt or reverse the progression of these conditions and associated complications and merits further investigations.

Pharmacological treatment for metabolic dysfunction-associated steatotic liver disease and related disorders: Current and emerging therapeutic options

Metabolic dysfunction-associated steatotic liver disease (MASLD; formerly known as nonalcoholic fatty liver disease) is a chronic liver disease affecting over a billion individuals worldwide. MASLD can gradually develop into more severe liver pathologies, including metabolic dysfunction-associated steatohepatitis (MASH), cirrhosis, and liver malignancy. Notably, although being a global health problem, there are very limited therapeutic options against MASLD and its related diseases. While a thyroid hormone receptor agonist (resmetirom) is recently approved for MASH treatment, other efforts to control these diseases remain unsatisfactory. Given the projected rise in MASLD and MASH incidence, it is urgent to develop novel and effective therapeutic strategies against these prevalent liver diseases. In this article, the pathogenic mechanisms of MASLD and MASH, including insulin resistance, dysregulated nuclear receptor signaling, and genetic risk factors (eg, patatin-like phospholipase domain-containing 3 and hydroxysteroid 17-β dehydrogenase-13), are introduced. Various therapeutic interventions against MASH are then explored, including approved medication (resmetirom), drugs that are currently in clinical trials (eg, glucagon-like peptide 1 receptor agonist, fibroblast growth factor 21 analog, and PPAR agonist), and those failed in previous trials (eg, obeticholic acid and stearoyl-CoA desaturase 1 antagonist). Moreover, given that the role of gut microbes in MASLD is increasingly acknowledged, alterations in the gut microbiota and microbial mechanisms in MASLD development are elucidated. Therapeutic approaches that target the gut microbiota (eg, dietary intervention and probiotics) against MASLD and related diseases are further explored. With better understanding of the multifaceted pathogenic mechanisms, the development of innovative therapeutics that target the root causes of MASLD and MASH is greatly facilitated. The possibility of alleviating MASH and achieving better patient outcomes is within reach. SIGNIFICANCE STATEMENT: Metabolic dysfunction-associated steatotic liver disease (MASLD) is the most common chronic liver disease worldwide, and it can progress to more severe pathologies, including steatohepatitis, cirrhosis, and liver cancer. Better understanding of the pathogenic mechanisms of these diseases has facilitated the development of innovative therapeutic strategies. Moreover, increasing evidence has illustrated the crucial role of gut microbiota in the pathogenesis of MASLD and related diseases. It may be clinically feasible to target gut microbes to alleviate MASLD in the future.

Global Epidemiological Impact of PNPLA3 I148M on Liver Disease

The prevalence of metabolic dysfunction-associated steatotic liver disease (MASLD) has increased exponentially over the past three decades, in parallel with the global rise in obesity and type 2 diabetes. It is currently the most common cause of liver-related morbidity and mortality. Although obesity has been identified as a key factor in the increased prevalence of MASLD, individual differences in susceptibility are significantly influenced by genetic factors. PNPLA3 I148M (rs738409 C>G) is the variant with the greatest impact on the risk of developing progressive MASLD and likely other forms of steatotic liver disease. This variant is prevalent across the globe, with the risk allele (G) frequency exhibiting considerable variation. Here, we review the contribution of PNPLA3 I148M to global burden and regional differences in MASLD prevalence, focusing on recent evidence emerging from population-based sequencing studies and prevalence assessments. We calculated the population attributable fraction (PAF) as a means of quantifying the impact of the variant on MASLD. Furthermore, we employ quantitative trait locus (QTL) analysis to ascertain the associations between rs738409 and a range of phenotypic traits. This analysis suggests that these QTLs may underpin pleiotropic effects on extrahepatic traits. Finally, we outline potential avenues for further research and identify key areas for investigation in future studies.

Iron overload is closely associated with metabolic dysfunction-associated fatty liver disease in type 2 diabetes

OBJECTIVE

The relationship between iron metabolism disturbances and metabolic dysfunction-associated fatty liver disease (MAFLD) remains controversial. This study aimed to investigate the association of iron overload with MAFLD in patients with type 2 diabetes mellitus (T2DM).

METHODS

This study included 155 Chinese inpatients with T2DM. MAFLD was diagnosed and grouped using magnetic resonance imaging (MRI). MRI biomarkers such as proton density fat fraction and iron accumulation (R 2 * ) were measured. Their clinical characteristics were compared, and the association of iron metabolism markers with MAFLD in patients with T2DM was analyzed.

RESULTS

Iron metabolism markers, including MRI-R 2 * , ferritin, serum iron, hepcidin, and total iron-binding capacity, were overloaded in groups with MAFLD (p < 0.001 for trend). They were positively correlated with MAFLD and reflected the severity of MAFLD. The five markers of logistic regression analysis revealed an increased MAFLD risk (p < 0.001 for trend). The areas under the curve of five markers all exceeded 0.5, indicating certain predictive values for MAFLD.

CONCLUSIONS

MAFLD is associated with significant iron overload in Chinese patients with T2DM. Serum iron, ferritin, total iron-binding capacity, hepcidin, andR 2 * value are essential iron metabolism markers to evaluate and predict the progression of MAFLD in patients with T2DM.

Clinical Relevancies of Sarcopenic Obesity in Patients with Metabolic Dysfunction-Associated Fatty Liver Disease (MASLD)

AIM

Sarcopenic obesity (SO) is associated with adverse outcomes in diseased patients. This study aimed to examine the prevalence and risks associated with SO, with a focus on the impact of SO on cardiovascular risk in patients with MASLD.

MATERIALS AND METHODS

In this cross-sectional study, patients with MASLD were prospectively enrolled. Through dual-energy X-ray absorptiometry (DXA) scans, their body compositions were analyzed to identify who had SO and osteopenia/osteoporosis. The primary aim is to investigate risks associated with SO, followed by analyzing the association between SO and cardiovascular disease (CVD).

RESULTS

Two hundred and twenty-three patients with MASLD were enrolled. The prevalence of SO was 47.1%, respectively. Patients coexisted with MASLD and SO had increased visceral adipose tissue (VAT), higher fatty liver index (FLI) and fibrosis 4 (FIB-4) score. Regression analysis revealed higher FLI and FIB-4 score, as well as history of hypertension, were risks associated with SO. The 10-year atherosclerotic cardiovascular disease (ASCVD) risk score was higher in patients coexisted with MASLD and SO compared to those without (10.1% vs. 7.3%, p = 0.006). Regression analysis showed that increased VAT and FIB-4 score were associated with raised risk of ASCVD.

CONCLUSION

Prevalence of SO in MASLD patients is considerable. The presence of SO also linked to higher risk of ASCVD. Therefore, the recognition of SO in patients with MASLD is important in clinical care.

Global burden and risk factors of MASLD: trends from 1990 to 2021 and predictions to 2030

The prevalence of metabolic dysfunction-associated steatotic liver disease (MASLD) is increasing globally, posing a major public health issue. This study analyzes the global, regional, and national burden of MASLD and its risk factors from 1990 to 2021, with projections to 2030. We obtained data on MASLD prevalence, deaths, and disability-adjusted life years (DALYs) from the Global Burden of Disease 2021 for 204 countries. Counts and rates per 100,000 population were calculated, and trends to 2030 were predicted using the Bayesian Age-Period-Cohort model. In 2021, there were 1,267.9 million MASLD cases globally, with 138.3 thousand deaths and 3667.3 thousand DALYs. The global age-standardized prevalence, death, and DALY rates were 15,018.1, 1.6, and 42.4 per 100,000 population, increasing by 24.3%, 5.5%, and 5.5% since 1990. North Africa and the Middle East had the highest prevalence, while Andean and Central Latin America had the highest death and DALY rates. Men aged 15-69 and 90-94 had higher DALY rates, while women aged 70-89 and 95+ had higher rates. A reversed V-shaped association was found between the sociodemographic index and DALY rate. High fasting plasma glucose (5.9%) and smoking (2.4%) were major risk factors. Public health efforts should prioritize early detection and management of MASLD in younger populations and develop targeted strategies for older adults, especially women, to reduce the disease burden. Effective policies to address high fasting plasma glucose and smoking can mitigate MASLD's impact.

Detecting severe coronary artery stenosis in T2DM patients with NAFLD using cardiac fat radiomics-based machine learning

To analyze radiomics features of cardiac adipose tissue in individuals with type 2 diabetes (T2DM) and non-alcoholic fatty liver disease (NAFLD), integrating relevant clinical indicators, and employing machine learning techniques to construct a precise model for detecting severe coronary artery stenosis. A retrospective analysis of 710 T2DM patients with NAFLD was conducted at First People's Hospital of Wenling. The study population was randomly divided into a training set (n = 497) and a validation set (n = 213). Radiomics features from cardiac fat CT images, including epicardial adipose tissue (EAT) and paracardial adipose tissue (PAT), were extracted for all patients. The semi-automated segmentation and extraction of shape, first-order statistics, texture, and wavelet were performed using specialized software. Simultaneously, clinical characteristics were collected. Following feature selection, four machine learning algorithms were utilized to develop radiomics, clinical, and combined radiomics-clinical models. The detection performance of these models was subsequently evaluated in both the training and validation cohorts. Additionally, Shapley Additive exPlanations (SHAP) values were calculated to quantify the importance of features. A total of 10 radiomics features for EAT and PAT were extracted from CT images after feature selection. The clinical model obtained an area under the curve (AUC) of 0.747 with the support vector machine (SVM), while the radiomics model reached an AUC of 0.838 with the extreme gradient boosting (XGBoost) algorithm. In comparison, the radiomics-clinical model using XGBoost demonstrated superior detection capability, achieving an AUC of 0.883 in the training set and maintaining high performance in the validation set, with the highest F1 score, accuracy, and precision. SHAP analysis revealed the importance of radiomics features from EAT and PAT, as well as clinical factors such as diabetes duration, global longitudinal strain (GLS), and low-density lipoprotein cholesterol (LDL-C), in detecting severe coronary artery stenosis. This study confirms that the integrated application of cardiac fat radiomics features and clinical data using machine learning models, particularly the XGBoost algorithm, facilitates the detection of severe coronary artery stenosis in T2DM patients with NAFLD. SHAP analysis further elucidates the contribution of key variables in the model, providing crucial foundations for personalized treatment decision-making.

The association between non-high-density lipoprotein cholesterol to high-density lipoprotein cholesterol ratio and hepatic steatosis and liver fibrosis among US adults based on NHANES

Recently, the non-high-density to high-density lipoprotein cholesterol ratio (NHHR) has gained growing attention as an indicator for predicting diseases associated with lipid metabolism. Hepatic steatosis and fibrosis are tightly associated lipid metabolism. Our study aims to analyze the correlations among NHHR, hepatic steatosis, and fibrosis. This study analysed data from 14,578 adults in the US National Health and Nutrition Examination Survey (2005-2018). The degree of hepatic steatosis was measured through the Fatty Liver Index (FLI), while liver fibrosis severity was evaluated with the Fibrosis-4 (FIB-4) index. Multivariate linear regression assessed the association between NHHR and the FLI and FIB-4 score. Smooth curve describing the relationship between NHHR and FLI or FIB-4. Additionally, a two-part linear regression model adopted in order to more accurately account for the nonlinear relationship, with threshold effects estimated through its two components. To confirm the robustness of the findings, interaction tests and subgroup analyses were conducted. The multivariate logistic regression analysis demonstrated a significantly positive correlation of lnNHHR with FLI across all three models. In Model 3, the association was (β = 11.14, 95%CI:10.38,11.90). Curve fitting indicated a nonlinear relationship. The positive correlation between lnNHHR and FLI persists across gender, BMI, and physical activity groups. Nevertheless, a notable negative correlation between lnNHHR and FIB-4 was observed in all three models. In Model 3, the relationship between lnNHHR and FIB-4 was as follows: (β = -0.20; 95% CI: -0.22, -0.17). Curve fitting revealed a V-shaped relationship, with threshold effect analysis identifying a breakpoint at 1.51. Above this threshold, the relationship was found to be statistically insignificant (p-value = 0.424). Receiver operating characteristic (ROC) curve analysis demonstrated that NHHR exhibited better predictive performance for MASLD compared to non-HDL-C, HDL-C, and LDL-C/HDL-C. The current study's findings suggest that elevated levels of NHHR correlate with a greater risk of hepatic steatosis among adults in the U.S. Our findings imply that NHHR may be a valuable tool in improving MASLD prevention strategies in the general population.

Isoschaftoside in Fig Leaf Tea Alleviates Nonalcoholic Fatty Liver Disease in Mice via the Regulation of Macrophage Polarity

BACKGROUND

Nonalcoholic fatty liver disease (NAFLD) is a subset of fatty liver disease that is not caused by alcohol or viruses, and its increasing incidence presents a major global health concern. As few pharmacotherapies are available for NAFLD, lifestyle modifications, including diet and exercise, serve as the foundation for treatment. Therefore, NAFLD prevention is more important than cure, emphasizing the need for drugs with excellent safety and long-term efficacy. Fig leaf tea contains rutin and isoschaftoside (ISS), which may possess anti-inflammatory properties. Therefore, the aim of this murine-model-based study was to investigate the potential benefits of fig leaf tea in alleviating NAFLD and to determine the underlying mechanism by gene expression analysis.

RESULTS

We found that in mice with NAFLD induced by a high-fat diet, the administration of high concentration fig leaf tea or 50 µM ISS significantly ameliorated lobule inflammation. In contrast, low concentration fig leaf tea containing 75 µM ISS did not improve inflammation. The balance between the NAFLD-promoting component of fig leaf tea and the inhibitory effect of ISS was thought to be affected. Gene expression analysis of the liver showed that high concentration fig leaf tea or ISS significantly suppressed the expression of M1 macrophage markers such as CD antigens, toll-like receptors (TLR), chemokines, and cytokines. Further, ISS suppressed the amount of TNF-α released during the M1 polarization of macrophage cells upon lipopolysaccharide (LPS) stimulation.

CONCLUSIONS

Overall, these results suggest that controlling macrophage polarization may improve NAFLD. Furthermore, these findings highlight the potential clinical applicability of ISS.

Insights Into Non-Alcoholic Fatty Liver Disease and Diabetes Mellitus in Somalia: Prevalence and Risk Factors

Introduction

NAFLD is a rapidly expanding global health issue that is distinguished by the accumulation of hepatic fat that is not associated with alcohol consumption. Parallel to the increase in obesity and type 2 diabetes mellitus (T2DM), its prevalence is also increasing. Amidst a backdrop of limited epidemiological data, Somalia, which is undergoing urbanization and dietary adjustments, is contending with escalating rates of NAFLD. Our study aims to addresses critical voids in local epidemiological data regarding this subject in Somalia.

Methods and Materials

The objective of this retrospective study was to evaluate the prevalence of NAFLD and concomitant risk factors among T2DM patients at the Mogadishu Somalia Turkish Training and Research Hospital. A total of 832 patients diagnosed with T2DM between May 2023 and March 2024 were used to analyze the data. Various variables, such as age, sex, diabetic medications, hypertension, insulin resistance, hyperlipidemia, and NAFLD grade, were obtained from electronic medical records. Statistical analyses were conducted to investigate the associations and predictors of NAFLD using descriptive analysis, logistic regression, and multiple regression.

Results

The study cohort was predominately female (57%), with a mean age of 53.48 years. The most prevalent grades of NAFLD were grade 1 and grade 2, with NAFLD being identified in 53.8% of patients. NAFLD displayed a robust correlation with insulin resistance (OR: 52.04), with hypertension (OR: 20.091) and hyperlipidemia (OR: 2.528) following shortly thereafter. These factors collectively account for 57% of the variance in NAFLD, as indicated by multiple regression analysis (R2 = 0.57, F (6,823) = 184.302, p < 0.001).

Conclusion

This investigation emphasizes the presence of a high prevalence of NAFLD among T2DM patients in Mogadishu, Somalia, 53.8% which is substantially influenced by hypertension, insulin resistance, and hyperlipidemia. In this region, the necessity of targeted healthcare strategies to mitigate metabolic liver diseases is underscored by the results.

The lack of apoA-I in apoE-KO mice affects the liver transcriptome

BACKGROUND AND AIMS

Liver is the major organ involved in apoA-I synthesis and HDL-C turnover, but the impact of apoA-I/HDL on hepatic transcriptome has never been investigated before. In the present study, a transcriptomic analysis by high-throughput RNA-seq was conducted in the liver of atherosclerosis-prone mice, with the aim of identifying new genes/pathways modulated by apoA-I/HDL with a potential effect on atherosclerosis development.

METHODS AND RESULTS

Eight-week-old apoE knockout (apoEKO) mice lacking apoA-I/HDL (DKO) and with physiological levels of apoA-I/HDL (DKO/hA-I) were fed either a standard rodent diet (SRD) or a Western diet (WD) for 22 weeks. After both dietary treatments, DKO mice were characterized by lower cholesterol levels, but increased atherosclerosis development, compared to DKO/hA-I mice. The liver transcriptome of DKO and DKO/hA-I mice fed SRD diverged in a relatively small number of genes, suggestive of a greater activation of the PPAR signaling pathway and the retinoid metabolism pathway in DKO/hA-I mice. Following WD, transcriptomic analysis highlighted in both genotypes an upregulated expression of immune/inflammatory genes and a reduced activation of the retinoid metabolism. The evaluation of the hepatic response of the two genotypes to the dietary switch from SRD to WD revealed strong divergences in genes involved in metabolic pathways only in the presence of apoA-I/HDL, with reduced endogenous sterol biosynthesis and glutathione metabolism, together with increased glucose metabolism.

CONCLUSION

The presence or absence of apoA-I expression differently alters hepatic pathways involved not only in cholesterol metabolism, but also in those of glutathione and glucose metabolism.

Global, regional, and national burden of liver cancer due to non-alcoholic steatohepatitis and non-alcoholic fatty liver disease, 1990-2021: a multi-model trend analysis and forecasting study

BACKGROUND

Non-alcoholic fatty liver disease (NAFLD) and its advanced form, non-alcoholic steatohepatitis (NASH), significantly contribute to the increasing incidence of liver cancer due to NASH (NALC), emphasizing the urgent need to address the associated global health burden.

METHODS

Using the Global Burden of Disease 2021 dataset, we analyzed the incidence, mortality, and disability-adjusted life year (DALY) rates of NALC and NAFLD from 1990 to 2021 across 204 countries. The Joinpoint model, age-period-cohort modeling, decomposition analysis, and frontier analysis were used to assess trends, identify contributing factors, and evaluate health inequities. Projections for future incidence were made using Nordpred and Bayesian age-period-cohort models.

RESULTS

The global incidence and mortality rates of NALC have increased significantly. Incidence rose from 14,413.92 cases (95% CI 11,470.95-17,854.24) in 1990 to 42,291.37 (95% CI 34,032.64-51,129.45) in 2021. This trend was particularly evident in low-middle SDI countries, while high SDI countries exhibited declining mortality rates despite rising incidence. Population growth was a primary driver of the increased burden in most regions. Projections suggest that NALC incidence may reach 43,525.53 (95% CI 14,169.28-72,881.77) by 2039, particularly among the elderly, highlighting the serious future risks associated with NALC globally.

CONCLUSION

The findings highlight the growing global burden of NALC driven by NAFLD, especially in low- to middle-income regions. Targeted interventions, alongside a deeper understanding and better resource allocation, are essential to mitigate the rising incidence and address the health disparities associated with this expanding public health challenge.

Ethnic differences in metabolic and histologic features among White, Hispanic, Black and Asian patients with metabolic-associated Steatotic liver disease: A network meta-analysis

INTRODUCTION AND OBJECTIVES

Current evidence on the impact of ethnic disparities on metabolic-associated steatotic liver disease (MASLD) is limited to individual studies with small sample sizes from specific regions. This network meta-analysis aimed to assess variations in metabolism and histological characteristics of MASLD among four ethnicities.

MATERIALS AND METHODS

Observational studies on MASLD involving at least two ethnic groups (White, Black, Asian, and Hispanic) were identified from PubMed, Embase, and Web of Science databases up to May 7th, 2024, for inclusion in this study. The results were reported as unstandardized mean differences (MDs) and odds ratios (ORs) with 95% confidence intervals (CIs).

RESULTS

A total of twenty-seven articles involving 14,440 non-Hispanic Whites, 4,927 non-Hispanic Blacks, 5,254 Asians, and 8,344 Hispanic MASLD patients were included in this study. The prevalence of type 2 diabetes mellitus of all ethnic groups combined was 33%, without significant difference among the four ethnicities. Asians showed higher levels of total cholesterol compared to the other groups, while Blacks had the lowest levels of alanine aminotransferase. Among biopsy-proven MASLD patients, Blacks individuals had a lower risk of significant fibrosis compared to Whites (OR=0.63, 95% CI: 0.45 to 0.87), as well as lower risks of liver inflammation (OR=0.53, 95% CI: 0.29 to 0.95) and nonalcoholic steatohepatitis (NASH) (OR=0.53, 95% CI: 0.29 to 0.95) compared to Hispanics.

CONCLUSIONS

Asians MASLD patients had higher risk of suffering from abnormal lipid metabolism while Black MASLD patients presented milder liver histologic features than both Whites and Hispanics individuals.

Caffeine intake associated with a lower risk of liver fibrosis in different glucose status

BACKGROUND AND AIMS

To investigate the prevalence of liver fibrosis, and the association between caffeine intake and fibrosis in populations with different glucose metabolism status.

METHODS

This was a cross-sectional study based on the National Health and Nutrition Examination Survey (2005-March 2020). Of the 39,221 adult individuals with no necessary laboratory results missing, a total of 23,711 eligible individuals were included in the study. Individuals were divided into T2DM, prediabetes, and diabetes-free groups. Fibrosis-4 index was calculated to evaluate the risk of liver fibrosis. Caffeine intake was obtained through a 24-hour dietary recall.

RESULTS

The mean ± SE age of prediabetes group was 53 ± 0·4 years, and in type 2 diabetes mellitus group, the individuals have a mean ± SE age of 62 ± 0·3 years. The participants with type 2 diabetes mellitus had significantly higher risk of liver fibrosis than those with prediabetes or normal glucose tolerance (5·9% vs. 3·2% vs. 2·5%, P < 0·001). Compared to individuals with daily caffeine intake < 78 mg, individuals with daily caffeine intake ≥ 78 mg had significantly lower risk of liver fibrosis in all subgroups (odds ratio: diabetes-free group: 0·698[0·577-0·846]; prediabetes group: 0·553[0·397-0·769]; type 2 diabetes mellitus group: 0·720[0·556-0·933]; all P < 0·05).

CONCLUSIONS

Prevalence of liver fibrosis is high in patients with type 2 diabetes mellitus and prediabetes. It is indicated that individuals with prediabetes should also be screened for fibrosis. Caffeine intake ≥ 78 mg per day is associated with a lower risk of liver fibrosis.

Comparison Between the Impact of Diabetes Mellitus on Liver Diseases and Vice Versa Among Saudi and Egyptian Patients

Background: The risk of dying from chronic liver diseases (CLDs) is two to three times higher for patients with diabetes (DM). Nonalcoholic fatty liver disease (NAFLD) is the primary cause of this increased risk, which has an etiology unrelated to alcohol or viruses. Previous research reported that diabetes and CLD are related, since they influence each other. Aim: Estimation of the impact of diabetes (DM) on liver diseases (LD), and of the impact of liver diseases on DM among Egyptian and Saudi patients. It is a descriptive and prospective analytical study design. The investigation was carried out in Saudi Arabia and Egypt at gastroenterology outpatient clinics. Methods: Prospective data were collected through face-to-face patient interviews during clinic visits between June 2021 and June 2023. The interviews covered the patients' basic characteristics and information on DM and LD. Certain laboratory tests were conducted on these patients, such as liver function, glucose level, lipid profile, INR, and prothrombin time. Results: The total of 2748 participants in this study included 1242 diabetic patients of both genders from Saudi Arabia and 1506 from Egypt. Most Saudis had between 10 and 20 years' duration of DM (35.5%), with HbA1c (7-10%) values of 47.8%, while the Egyptian patients had >20 years' duration of DM (39.8%), with HbA1c (7-10%) values of 49.8%. Regarding the impact of DM on the development of liver diseases, about 35.5% (Saudis) vs. 23.5% (Egyptians) had liver diseases due to DM, a significant difference (p-value = 0.011). Liver enzymes were increased in many of the Egyptian and Saudi patients (41.4% vs. 33%), while the presence of fatty liver (28.2% vs. 35.7%) and hepatocellular carcinoma (13.7% vs. 6.1%) were also significantly different (p-value = 0.047). While the impact of liver diseases on DM was observed more among Egyptian (59%) than among Saudi (46.4%) patients because of liver cirrhosis (HCV or HBV), known to be a reason for diabetes in Egyptians (27.9%) vs. Saudis (8.0%), a higher incidence of fatty liver leading to DM was observed in Saudis than in Egyptians (15.9% vs. 11.6%) (p-value = 0.000. Obesity was more prevalent among Saudi patients (63.8%) than among Egyptian patients (48.6%) (p-value = 0.019). Fewer Egyptians (about 65%) suffered from dyslipidemia than Saudis (about 80%). Higher INR and longer prothrombin times were observed in Egyptians (29.9% and 29.1%, respectively) than in Saudis (20.3% and 18.8%, respectively), with a significant difference between the two nations (p-value < 0.050). Conclusions: We may conclude that diabetes in most patients has a negative impact on the development of liver diseases (particularly fatty liver in Saudi patients). In addition, most liver diseases (liver cirrhosis) have a negative influence on the development of DM (more so in Egyptian patients). There is a link between DM and liver disease. In particular, liver cirrhosis and diabetes were found to influence each other. Therefore, correct medication, adherence to treatment, lifestyle modifications, successful cirrhosis control (in patients with liver diseases), and diabetic control (in diabetic patients) could lead to effective management of both diseases. The negative fallouts in the two cases were prompted by obesity, morbid eating, and poor quality of life.

A phase IIb randomised-controlled trial of the FFAR1/FFAR4 agonist icosabutate in MASH

BACKGROUND & AIMS

Via regulation of glycaemic control and inflammation, free fatty receptor (FFAR)1 and 4 are potential targets for the treatment of metabolic dysfunction-associated steatohepatitis (MASH). In this study, we tested the efficacy and safety of icosabutate, a FFAR1/FFAR4 agonist, in patients with MASH.

METHODS

We performed a phase IIb, multicentre, 52-week, randomised, placebo-controlled trial (ICONA) testing the efficacy of icosabutate in patients with MASH and F1-F3 (mild to severe) fibrosis. Patients were randomised 1:1:1 to receive once-daily, oral icosabutate 300 mg, 600 mg or placebo for 52 weeks. The primary efficacy endpoint was the proportion of patients with MASH resolution with no worsening of fibrosis in the 600 mg arm.

RESULTS

The primary population for efficacy analysis comprised 187 patients (placebo [n = 62], 300 mg icosabutate [n = 58] or 600 mg icosabutate [n = 67]). The percentage of patients with MASH resolution favoured the icosabutate 600 mg arm without reaching statistical significance (23.9% vs. 14.5%; odds ratio 2.01; 95% CI 0.8-5.08; p = 0.13). A higher percentage of patients treated with icosabutate achieved a ≥1-stage improvement in fibrosis, with a response rate of 29.3% in the 300 mg arm (odds ratio 2.89; 95% CI 1.09-7.70) and 23.9% in the 600 mg arm (odds ratio 2.4; 95% CI 0.90-6.37) vs. 11.3% in the placebo arm. An improvement in fibrosis was observed using AI-assisted digital pathology. Marked decreases in biomarkers of liver damage were observed. Icosabutate was generally safe and well tolerated, with mild to moderate treatment-emergent adverse events and no reports of drug-induced liver injury.

CONCLUSION

Although the primary endpoint was not met, treatment with icosabutate was associated with encouraging fibrosis (as measured by both conventional and AI-assisted digital pathology) and non-invasive biomarker data, supporting further development in patients with MASH.

CLINICALTRIALS

GOV IDENTIFIER

NCT04052516.

IMPACT AND IMPLICATIONS

With expression on multiple cell types regulating both glycaemic control and liver inflammation, targeting free fatty acid receptors (FFAR)1 and 4 could offer an attractive approach for the treatment of both fibrosing metabolic dysfunction-assoicated steatohepatitis (MASH) and its comorbidities. Although treatment of patients with MASH and F1-F3 fibrosis with oral icosabutate (a FFAR1/FFAR4 agonist) did not meet the pre-defined primary endpoint (MASH resolution without worsening of fibrosis), the overall dataset (including AI-assisted digital pathology) suggest an improvement in fibrosis in treated patients. Improvements in multiple biomarkers of liver damage, inflammation and glycaemic control were observed in response to therapy. Icosabutate was generally safe and well tolerated, and the overall data support further testing of icosabutate in patients with MASH, in particular those with more advanced disease (F2-F3 fibrosis) and type 2 diabetes.

Dissecting the shared genetic architecture between nonalcoholic fatty liver disease and type 2 diabetes

Observational studies have reported a bidirectional correlation between nonalcoholic fatty liver disease (NAFLD) and type 2 diabetes (T2D), but the shared genetic basis between the two conditions remains unclear. Using genome-wide association study (GWAS) summary data from European-ancestry populations, we examined the cross-trait genetic correlation and identified genomic overlaps and shared risk loci. We employed a latent causal variable model and Mendelian randomization (MR) analysis to infer causal relationships. Colocalization analysis and conditional/conjunctional false discovery rate (condFDR/conjFDR) were used to identify genomic overlaps and shared risk loci. Two-step MR analysis was utilized to identify potential mediators. We observed a strong positive genomic correlation between NAFLD and T2D (rg = 0.652, P = 5.67 × 10-6) and identified tissue-specific transcriptomic correlations in the pancreas, liver, skeletal muscle, subcutaneous adipose, and blood. Genetic enrichment was observed in NAFLD conditional on associations with T2D and vice versa, indicating significant polygenic overlaps. We found robust evidence for the causal effect of NAFLD on T2D, particularly insulin-related T2D, rather than vice versa. Colocalization analysis identified shared genomic regions between NAFLD and T2D, including GCKR, FTO, MAU2-TM6SF2, and PNPLA3-SAMM50. High-density lipoprotein cholesterol and insulin were partly mediated the association between NAFLD and T2D. These findings unveil a close genetic link between NAFLD and T2D, shedding light on the biological mechanisms connecting NAFLD progression to T2D.

Pre-diabetes and cardiovascular risk factors in NAFLD patients: a retrospective comparative analysis

Objectives

Insulin resistance plays a critical role in the pathophysiology of diabetes mellitus and non-alcoholic fatty liver disease (NAFLD). Moreover, insulin resistance has a central role in atherogensis as the major leading cause of cardiovascular disease (CVD). The aim of the present study was to assess the frequency of pre-diabetes and evaluate the cardiometabolic risk factors among NAFLD patients, comparing those with pre-diabetes to those with normal glucose tolerance.

Methods

In the current retrospective case-control study, the data of 1031 NAFLD patients was retrieved. Based on blood glucose levels, 337 diabetics, 340 pre-diabetes, and, 354 normal glucose patients were diagnosed. After excluding diabetic NAFLD patients, 694 individuals were divided into two groups: normal glucose and pre-diabetes. Various variables, such as age, anthropometric measurements, hypertension, systolic and diastolic blood pressure, and lipid profiles, were extracted from patient files. Statistical analysis was conducted to assess cardiovascular risk factors in NAFLD patients.

Results

Higher age, female gender, higher BMI, triglyceride, waist and hip circumference and waist-to-hip ratio were found in pre-diabetic NAFLD individuals compared with normoglycemic ones (P-value<0.05). Multivariable age-, sex-, BMI- and smoking- adjusted logistic regression showed a predicting role of pre-diabetes and NAFLD concurrence with metabolic syndrome (P-value<0.001, OR:4.31, 95% CI: 2.95- 6.29), but not CVD (P-value=0.353, OR:1.37, 95% CI: 0.71- 2.61).

Conclusion

In this study, nearly one-third of NAFLD patients had pre-diabetes. The mean value of age, BMI, TG, waist and Hip circumference was significantly higher in pre-diabetic patients. The concurrence of pre-diabetes and NAFLD was a predicting factor for metabolic syndrome, but not CVD events.

Dual GIP and GLP-1 receptor agonist tirzepatide alleviates hepatic steatosis and modulates gut microbiota and bile acid metabolism in diabetic mice

Tirzepatide is a dual agonist of glucose-dependent insulinotropic polypeptide (GIP) and glucagon-like peptide-1 (GLP-1) receptors and is a promising therapeutic option for type 2 diabetes mellitus (T2DM). Nevertheless, its effect and underlying mechanism on hepatic steatosis remain ambiguous. Herein, we explored the impact of tirzepatide on improving hepatic steatosis in diabetic mice, with a particular focus on the gut microbiota and bile acids (BAs) using animal models. The tirzepatide effectively reduced body weight, improved insulin resistance, decreased serum and hepatic lipid levels, and mitigated liver injury. Compared to semaglutide, tirzepatide exhibited superior efficacy in reducing hepatic lipid accumulation. 16S rRNA gene sequencing and targeted metabolomics of BAs revealed that tirzepatide ameliorated gut microbiota dysbiosis and BAs metabolism in diabetic mice. Notably, tirzepatide observably increased the abundance of beneficial genera such as Akkermansia, elevated the ratio of farnesoid X receptor (FXR) antagonists (glycoursodeoxycholic acid: GUDCA, β-muricholic acid: β-MCA, hyodeoxycholic acid: HDCA, ursodeoxycholic acid: UDCA) to natural agonists (cholic acid: CA, lithocholic acid: LCA, chenodeoxycholic acid: CDCA, glycocholic acid: GCA, taurodeoxycholic acid: TDCA), and reduced FXR expression in intestinal tissues. In conclusion, tirzepatide attenuated hepatic steatosis in diabetic mice and regulated the gut microbiota and BAs metabolism, which may help to provide a novel therapeutic approach and therapeutic target for metabolic dysfunction-associated steatotic liver disease (MASLD).

Hepatic Steatosis Aggravates Vascular Calcification via Extracellular Vesicle-Mediated Osteochondrogenic Switch of Vascular Smooth Muscle Cells

The global incidence of metabolic dysfunction-associated fatty liver disease (MAFLD) has risen sharply. This condition is strongly associated with the risk of cardiovascular disease (CVD), but how MAFLD affects the development and progression of CVD, particularly concerning vascular calcification, remains unclear. Herein, extracellular vesicles (EVs) are identified from steatotic hepatocytes as a trigger that accelerated the progression of both vascular intimal and medial calcification. Steatotic hepatocytes are found to release more EVs, which are able to reach the vascular tissue, be taken up by vascular smooth muscle cells (VSMCs), and promote their osteogenic differentiation. Within these toxic vesicles, a protein cargo is identified called lectin galactoside-binding soluble 3 binding protein (Lgals3bp) that acted as a potent inducer of osteochondrogenic transformation in VSMCs. Both the inhibition of EV release and the liver-specific knockdown of Lgals3bp profoundly attenuated vascular calcification. This work partially explains the reason for the high incidence of vascular calcification in MAFLD and unveils a novel mechanism that may be used to prevent or treat cardiovascular complications in patients with MAFLD.

MASH as an emerging cause of hepatocellular carcinoma: current knowledge and future perspectives

Hepatocellular carcinoma is one of the deadliest and fastest-growing cancers. Among HCC etiologies, metabolic dysfunction-associated fatty liver disease (MAFLD) has served as a major HCC driver due to its great potential for increasing cirrhosis. The obesogenic environment fosters a positive energy balance and results in a continuous rise of obesity and metabolic syndrome. However, it is difficult to understand how metabolic complications lead to the poor prognosis of liver diseases and which molecular mechanisms are underpinning MAFLD-driven HCC development. Thus, suitable preclinical models that recapitulate human etiologies are essentially required. Numerous preclinical models have been created but not many mimicked anthropometric measures and the course of disease progression shown in the patients. Here we review the literature on adipose tissues, liver-related HCC etiologies and recently discovered genetic mutation signatures found in MAFLD-driven HCC patients. We also critically review current rodent models suggested for MAFLD-driven HCC study.

Predictors of liver fibrosis progression in cohort of type 2 diabetes mellitus patients with MASLD

AIM

To investigate predictors of liver fibrosis progression in patients with type 2 diabetes mellitus (T2DM) over a minimum follow-up duration of three years.

METHODS

Two hundred and thirty-three patients completed the follow-up period and their clinical, laboratory and liver FibroScan data are reported. Patients were categorized into progressors 42 (18.0 %) and non-progressors 191 (82.0 %) based on liver fibrosis progression. Factors influencing fibrosis progression were identified by comparing these groups.

RESULTS

Progressors showed significantly increased aspartate aminotransferase (AST) (p = 0.010), increased alkaline phosphatase (ALP) (p = 0.001) and decreased platelet count (p = 0.002). Non-progressors exhibited significant decreases in diastolic blood pressure (DBP) (p = 0.050), body mass index (BMI) (p < 0.001), waist circumference (p < 0.001), gamma-glutamyl transferase (GGT) (p < 0.001), albumin (p < 0.001), alanine aminotransferase (ALT) (p = 0.022), glycosylated haemoglobin (HbA1c) (p = 0.002) and fasting blood sugar (FBS) (p = 0.030) with increase in HDL-cholesterol (p < 0.001), creatinine (p < 0.001), bilirubin (p < 0.001), and ALP (p = 0.007). Baseline parameters predictive of liver fibrosis progression included elevated AST and reduced platelet count. Delta changes from baseline to follow-up revealed that increases in ALP, BMI, waist circumference, and reduction in platelet count were correlated with fibrosis progression. Use of GLP-1 receptor agonist was associated with reduced progression.

CONCLUSION

In conclusion, increase in ALP and waist circumference and reduction in platelet count are predictive of liver fibrosis progression in patients with T2DM. GLP-1 receptor agonists use seems to have a promising protective effect against liver fibrosis progression.

CLINICALTRIALS

govID:NCT05697991.

Targeting PYK2 with heterobifunctional T6BP helps mitigate MASLD and MASH-HCC progression

BACKGROUND & AIMS

The mechanisms underlying the regulation of hepatocyte non-receptor tyrosine kinases in metabolic dysfunction-associated steatohepatitis (MASH) remain largely unclear.

METHODS

Hepatocyte-specific overexpression or deletion and anti-protein tyrosine kinase 2 beta (PYK2) or anti-TRAF6-binding protein (T6BP) crosslinking were utilized to study fatty liver protection by T6BP. A P-PTC (peptide-proteolysis targeting chimera) degrades PYK2 to block MASH progression.

RESULTS

We found that T6BP is a novel and critical suppressor of PYK2 that reduces hepatic lipid accumulation, pro-inflammatory factor release, and pro-fibrosis production. Mechanistic evidence suggests that T6BP directly targets PYK2 and prevents its N-terminal FERM domain-triggered dimerization, disrupting downstream PYK2-JNK signaling hyperactivation. Additionally, T6BP favorably recruits CBL, a particular E3 ubiquitin ligase targeting PYK2, to form a complex and degrade PYK2. T6BP (F1), a core fragment of T6BP, directly blocks N-terminal FERM domain-associated dimerization of PYK2, followed by T6BP-recruiting CBL-mediated PYK2 degradation in a typical T6BP-dependent manner when the tiny fragment is specifically expressed using thyroxine binding globulin (TBG) vectors. This inhibits the progression of MASH, MASH-related hepatocellular carcinoma, and metabolic syndrome in dietary rodent models. We devised, and validated in animal models, the first-ever P-PTC based on the core segment of T6BP, as a ligand for the targeted recruitment of CBL, that could be used to target metabolic disorders like MASH.

CONCLUSIONS

Our study uncovered a previously unknown mechanism, with T6BP identified as a key suppressor of steatosis. This, alongside the discovery of crucial T6BP-based fragments that interrupt PYK2 dimerization hold much promise for the treatment of MASH.

IMPACT AND IMPLICATIONS

Excessive high-energy diet ingestion is critical in driving steatohepatitis via regulation of hepatocyte non-receptor tyrosine kinases. The mechanisms underlying the regulation of hepatocyte PYK2 in metabolic dysfunction-associated steatohepatitis remain largely unclear. Here, we found that T6BP as a critical fatty liver eliminator could be used for the development of promising therapeutic options. Additionally, vital T6BP-based pharmacon fragments that impede PYK2 dimerization have been found, offering new and effective treatments for advanced fatty liver symptoms and complications.

Delicate and thin fibrous septa indicate a regression tendency in metabolic dysfunction-associated steatohepatitis patients with advanced fibrosis

BACKGROUND AND AIMS

Metabolic dysfunction-associated steatohepatitis (MASH)-related fibrosis is reversible. However, the dynamic morphology change in fibrosis regression remains unclear. We aim to explore the morphological characteristics of fibrosis regression in advanced MASH patients.

METHODS

Clinical and histological data of 79 biopsy-proved MASH patients with advanced fibrosis (F3-F4) were reviewed. The second harmonic generation/two-photon excitation fluorescence (SHG/TPEF) image technology was used to quantitatively identify the R (regressive) septa from P (progressive) septa and PS (perisinusoidal) fibrosis. Non-invasive tests were used to compare the fibrosis level with and without R septa groups. Transcriptomics was used to explore hub genes and the underlying mechanism of the formation of R septa.

RESULTS

The R septa were different from the P septa and PS fibrosis in detail collagen quantitation identified by SHG/TPEF technology. The R septa were found in MASH fibrosis-regressed patients, which met the definition of the "Beijing classification". Therefore, patients were divided into two groups according to septa morphology: with R septa (n = 10, 12.7%), and without R septa (n = 69, 87.3%). Patients with R septa had lower values in most non-invasive tests, especially for liver stiffness assessed by TE (12.3 vs. 19.4 kPa, p = 0.010) and FAST (FibroScan®-AST) score (0.43 vs. 0.70, p = 0.003). Transcriptomics analysis showed that the expressions of five hub fibrogenic genes, including Col3A1, BGN, Col4A1, THBS2, and Col4A2 in the R septa group, were significantly lower.

CONCLUSIONS

The R septa can be differentiated from the P septa and PS fibrosis by quantitative assessment of SHG/TPEF, and it represents a tendency of fibrosis regression in MASH patients.

TRIAL REGISTRATION

NCT03386890, 29/12/2017.

Association Between Active DNA Demethylation and Liver Fibrosis in Individuals with Metabolic-Associated Steatotic Liver Disease (MASLD)

Metabolic-associated steatotic liver disease (MASLD) represents the most common chronic hepatopathy worldwide and an independent risk factor for cardiovascular disease and mortality, particularly when liver fibrosis occurs. Epigenetic alterations, such as DNA methylation, may influence MASLD susceptibility and progression; yet mechanisms underlying this process are limited. This study aimed to investigate whether active DNA demethylation in peripheral blood mononuclear cells (PBMCs) from individuals with MASLD, alongside the methylation and mRNA levels of inflammation- and fibrosis-related candidate genes, is associated with liver fibrosis. For this study, global demethylation intermediates (5-hydroxymethylcytosine [5hmC], 5-formylcytosine [5fC]) were quantified in PBMCs from 89 individuals with/without MASLD using ELISA. Site-specific DNA methylation of SOCS3, SREBF1, and TXNIP was analyzed by mass spectrometry-based bisulfite sequencing; mRNA expression was assessed via RT-PCR. Individuals with MASLD and moderate-to-high fibrosis risk (estimated by the fibrosis non-alcoholic steatohepatitis (NASH) index, FNI) progressively exhibited greater global 5hmC and 5fC levels. Higher FNI was associated with reduced methylation of the SOCS3 gene and increased mRNA expression of the SOCS3, TXNIP, IL-6, and MCP-1 genes. In conclusion, elevated fibrosis risk in MASLD is associated with active global DNA demethylation, as well as differential methylation and expression patterns of genes, which are key regulators of inflammation and fibrosis. These epigenetic alterations in PBMCs may mirror DNA methylation changes in the liver, which may potentially contribute to liver fibrogenesis and represent novel biomarkers for MASLD progression toward fibrosis.

Moving diagnosis of liver fibrosis into the community

Chronic liver disease (CLD) is a leading cause of death worldwide, with alcohol consumption and metabolic risk factors accounting for the majority of cases of CLD in many developed countries. Currently, specific strategies for the early diagnosis of CLD are lacking and consequently most cases are diagnosed at an advanced stage, which is associated with negative consequences for disease management and prognosis. Screening for CLD is based on either detection of chronic viral hepatitis B and C, or detection of liver fibrosis in patients with steatotic liver disease related to alcohol or metabolic dysfunction. Non-invasive tools, including serological and imaging-based tests, can be used to detect liver fibrosis. Clinical practice guidelines recommend screening for liver fibrosis using algorithms that combine different non-invasive tests, with widely available but low accuracy tests, such as FIB-4, recommended as a first screening step in the primary care setting, and other tests with lower availability but higher accuracy, such as transient elastography or the enhanced liver fibrosis test, recommended as a second step. There are different pathways for early detection of patients with CLD from primary to specialised care, with primary care providers being key for early detection, management and referral of patients. In addition, interventions targeting metabolic risk factors and alcohol consumption should be carried out in collaboration between specialists and primary care. In this review, we describe liver fibrosis from the community perspective, highlighting gaps in knowledge on how to define the optimal combination of tests, target population, the ideal pathway of care for CLD, and how to increase implementation of programmes for early diagnosis of liver diseases in clinical practice.

Prevalence of advanced hepatic fibrosis and individualization of associated risk factors by Bayesian analysis in MASLD patients in French cardio-metabolic health networks

The aim of this study was to determine the prevalence of advanced hepatic fibrosis and to individualize using Bayesian analysis its associated risk factors in patients with metabolic dysfunction-associated steatotic liver disease (MASLD) being cared for in three Alsatian cardio-metabolic health networks in the North East of France. Overall, 712 patients aged ≥18 years with a female predominance were included into a prospective, cross-sectional, and observational study. Advanced fibrosis and severe steatosis were evaluated using transient elastography (FibroScan®). The proportion of MASLD patients was 80% and 84% in women and men (difference -4.2% [-10.0; 1.9]), respectively. Advanced fibrosis was observed in 11% of patients, being more common in men (16.9%) than women (7.5%) (difference 9.4 [4.3-15.0]). Severe steatosis was also more common in men (74.9%) than women (63.4%) (difference 11.4 [4.2-18.2]). Only three of the tested variables were likely associated with advanced fibrosis: gender (OR: 1.78 [1.17-2.68]; Pr [OR >1] = 1), T2DM (OR: 1.54 [1-2.37]; Pr [OR >1] = 0.97) and hypertriglyceridemia (OR: 1.49 [0.97-2.27]; Pr (OR >1) = 0.97). In conclusion, this study confirmed the usefulness of assessing hepatic fibrosis in patients with metabolic dysfunction. Therefore, access to FibroScan® should be facilitated in all cardio-metabolic health networks.

Global, regional, and national burden of NAFLD in youths and young adults aged 15-39 years, 1990-2021, its attributable risk factors, and projections to 2035: a systematic analysis of the Global Burden of Disease Study 2021

Non-alcoholic fatty liver disease (NAFLD) is a significant health burden in youths and young adults, and the trend toward younger onset of NAFLD is alarming. Utilizing data from the Global Burden of Disease (GBD) 2021 study, this study assessed the burden and trends of NAFLD in youths and young adults aged 15-39 from 1990 to 2021 and extracted data from this study on the incidence, prevalence, death, and disability-adjusted life-years (DALYs) rates of NAFLD. We evaluated the global temporal trend of NAFLD from 1990 to 2021 with estimated annual percentage change (EAPC) and age-standardized rate (ASR). The Bayesian age-period-cohort (BAPC) model was used to predict future trends of the NAFLD burden to 2035. We found that the global burden of NAFLD in youths and young adults has risen steadily from 1990 to 2021, and projects to increase to 2035, which places enormous pressure on society. To alleviate this burden, implementing measures targeting risk factors such as glycemic control and smoking cessation is necessary.

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.

Efficacy of fish oil supplementation on metabolic dysfunction-associated steatotic liver disease: a meta-analysis

Objective

Globally, the occurrence of Metabolic dysfunction-associated steatotic liver disease (MASLD) is on a steady rise. Fish oil has anti-inflammatory effects and can improve lipid metabolism. The article aims to assess the impact of fish oil supplementation on MASLD.

Methods

We conducted a systematic search of Cochrane, Embase, PubMed, and Web of Science up to September 31, 2024, for randomized control trials (RCTs). The risk of bias of the included RCTs was evaluated using the Cochrane Collaboration's tool. Outcomes measured were aspects of liver injury, lipid profile, insulin resistance, anthropometric measurements, and more.

Results

Seven randomized controlled trials (RCTs) involving 439 participants were incorporated into the analysis. In general, the risk of bias in these RCTs was either low or not clearly defined. Pooled analysis showed that triglycerides [TG, pooled standard mean difference (SMD): -0.40 (95% CI: -0.58 to -0.21)], aspartate transaminase [AST, SMD: -0.29 (95% CI: -0.48 to -0.10)], HOMA-IR [SMD: -2.06 (95% CI: -3.36 to -0.49)] and waist circumference [Waist-C, SMD: -0.31 (95% CI: -0.54 to -0.08)] were significantly improved. But showed no significant benefits on alanine transaminase [ALT, SMD: -0.15 (95% CI: -0.45 to 0.15)], gamma-glutamyl transpeptidase [GGT, SMD: -0.07 (95% CI: -0.26 to 0.12)], body mass index [BMI, SMD: 0.16 (95% CI: -0.34 to 0.02)], high-density lipoprotein cholesterol [HDL, SMD: 0.02 (95% CI: -0.18 to 0.22)], low-density lipoprotein cholesterol [LDL, SMD: -0.01 (95% CI: -0.20 to 0.18)], Total Cholesterol [TC, SMD: -0.34 (95% CI: -0.70 to 0.01)] and so on.

Conclusion

The current evidence supports the fish oil supplementation in improving MASLD. Fish oil supplementation may also regulate blood lipids and improve glucose metabolism disorders.

Systematic review registration

https://www.crd.york.ac.uk/PROSPERO/#myprospero, identifier CRD42024513246.

Identification of retinol dehydrogenase 10 as a shared biomarker for metabolic dysfunction-associated steatotic liver disease and type 2 diabetes mellitus

Background

Metabolic dysfunction-associated steatotic liver disease (MASLD) is an independent risk factor for type 2 diabetes mellitus (T2DM), and its early identification and intervention offer opportunities for reversing diabetes mellitus.

Methods

In this study, we identified biomarkers for the MASLD dataset (GSE33814, GSE48452) and the T2DM dataset (GSE76895 and GSE89120) by bioinformatics analysis. Next, we constructed weighted gene co-expression network (WGCNA) for disease module analysis to screen out shared genes strongly associated with diseases. We also analyzed the enriched pathways of shared genes using Gene Ontology (GO) and Kyoto Encyclopedia of Genes and Genomes (KEGG) pathways. Next, hub gene validation was performed using the least absolute shrinkage and selection operator (LASSO) and receiver operating characteristic (ROC) curves. Finally, we used RT-qPCR, immunofluorescence, Western blotting and Elisa to validate hub gene expression in MASLD and T2DM mouse models.

Results

This analysis identified 20 genes shared by MASLD and T2DM that were enriched in the bile secretion, phototransduction, cancer, carbohydrate digestion and absorption, cholesterol/glycerol metabolism, and retinol metabolism. The LASSO algorithm and ROC curve identified Retinol Dehydrogenase 10 (RDH10) as the best diagnostic gene for MASLD and T2DM. Immunofluorescence and Western blot showed that RDH10 expression was reduced in the liver and pancreatic islets of MASLD and T2DM model mice. Similarly, serum levels of RDH10 were significantly lower in MASLD and T2DM model mice and humans than in controls.

Conclusion

Our study suggests that RDH10 is a common diagnostic marker for MASLD and T2DM and provides new research directions for the prevention and treatment of MASLD and T2DM.

Noninvasive Assessment of the Severity of Liver Fibrosis in MASLD Patients with Long-Standing Type 2 Diabetes

BACKGROUND

Type 2 diabetes mellitus (T2DM) and metabolic dysfunction-associated steatotic liver disease (MASLD), which have a reciprocal relationship compounded by obesity, are highly prevalent in the Middle East affecting morbidity, mortality, and healthcare costs.

OBJECTIVE

This study aimed to assess the severity of MASLD and liver fibrosis among adult Emirati patients with long-standing T2DM.

DESIGN AND PARTICIPANTS

This cross-sectional study used noninvasive methods to assess the severity of MASLD and fibrosis progression in an adult cohort of Emirati patients (N = 546) with a mean T2DM duration of 16 years.

MAIN MEASURES

Fatty liver infiltration was assessed by hepatic steatosis index (HSI), while fibrosis was assessed by the fibrosis-4 (FIB-4) index and aspartate aminotransferase/platelet ratio index (APRI). Of those, 108 patients were randomly subjected to ultrasound-based FibroScan® to assess controlled attenuation parameter (CAP) and liver stiffness measurement (LSM).

KEY RESULTS

All patients had fatty liver with ~ 83% being categorized as having severe steatosis. Serum-based fibrosis biomarker panels detected significant liver fibrosis in ~ 2.5% of these patients. The APRI appeared to be more restrictive in detecting moderate fibrosis (1.5%) than the FIB-4 index (25.5%). CAP significantly correlated with the LSM, indicating that the two methods contributed to the same underlying pathophysiology. Liver steatosis was more severe in female patients, who were older and had a higher body mass index (BMI) than those with moderate or no significant fibrosis. They also had higher serum liver enzymes and were more likely to have age-related changes in kidney function. Interestingly, severity of both steatosis and fibrosis remained unaffected by age and duration of T2D except for fibrosis severity detected by FibroScan®.

CONCLUSIONS

This study highlights the critical need for routine screening of MASLD among Emirati patients with long-standing T2DM, given the high point prevalence of severe steatosis (~ 83%), predominantly among women in this population.

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.

Development and validation of machine learning models for MASLD: based on multiple potential screening indicators

Background

Multifaceted factors play a crucial role in the prevention and treatment of metabolic dysfunction-associated steatotic liver disease (MASLD). This study aimed to utilize multifaceted indicators to construct MASLD risk prediction machine learning models and explore the core factors within these models.

Methods

MASLD risk prediction models were constructed based on seven machine learning algorithms using all variables, insulin-related variables, demographic characteristics variables, and other indicators, respectively. Subsequently, the partial dependence plot(PDP) method and SHapley Additive exPlanations (SHAP) were utilized to explain the roles of important variables in the model to filter out the optimal indicators for constructing the MASLD risk model.

Results

Ranking the feature importance of the Random Forest (RF) model and eXtreme Gradient Boosting (XGBoost) model constructed using all variables found that both homeostasis model assessment of insulin resistance (HOMA-IR) and triglyceride glucose-waist circumference (TyG-WC) were the first and second most important variables. The MASLD risk prediction model constructed using the variables with top 10 importance was superior to the previous model. The PDP and SHAP methods were further utilized to screen the best indicators (including HOMA-IR, TyG-WC, age, aspartate aminotransferase (AST), and ethnicity) for constructing the model, and the mean area under the curve value of the models was 0.960.

Conclusions

HOMA-IR and TyG-WC are core factors in predicting MASLD risk. Ultimately, our study constructed the optimal MASLD risk prediction model using HOMA-IR, TyG-WC, age, AST, and ethnicity.

Value of triglyceride glucose-body mass index in predicting nonalcoholic fatty liver disease in individuals with type 2 diabetes mellitus

Background

There is limited data on the association between TyG-BMI and NAFLD in patients with Type 2 Diabetes Mellitus (T2DM). The magnitude of risk prediction and predictive efficacy of TyG-BMI for T2DM with NAFLD remains unclear.

Objective

To examine the association of TyG-BMI with NAFLD in T2DM patients and assess the effectiveness of screening using the TyG-BMI index.

Methods

We conducted a retrospective analysis of clinical data from 602 T2DM patients at an enterprise health lodge from September 2021 to November 2022. Patients were categorized into two groups: T2DM alone (n=250) and T2DM with NAFLD (n=352). The Mann-Whitney U test was used for comparing non-normally distributed continuous data between groups, while the Chi-square test was used for categorical data. Logistic regression analysis was performed to evaluate the effect of BMI, TyG index, and TyG-BMI index on NAFLD. The ROC curve was used to assess the predictive efficacy of the TyG-BMI index for NAFLD in T2DM patients.

Results

BMI predicted the development of NAFLD in T2DM patients with an area under the receiver operating characteristic (ROC) curve of 0.792 (95% CI 0.757-0.828), and the optimal cutoff value was 25.22, with 72.2% sensitivity and 71.6% specificity; The area under the receiver operating characteristic (ROC) curve of the TyG index to predict the development of NAFLD in patients with T2DM was 0.755 (95% CI 0.716-0.794), and the optimal cutoff value was 8. 945, with a sensitivity of 80.1% and a specificity of 59.2%; The area under the receiver operating characteristic (ROC) curve of TyG-BMI index to predict the development of NAFLD in T2DM patients was 0.852, (95% CI 0.822-0.882), and the optimal cutoff value was 227.385, with a sensitivity and specificity of 80.1% and 59.2%, respectively.

Conclusions

The TyG-BMI index is a significant predictor of comorbid NAFLD in T2DM patients and provides better screening performance than BMI alone. The TyG-BMI index shows promise as an early screening tool for NAFLD in T2DM patients.