External validation of the fatty liver index and lipid accumulation product indices, using 1H-magnetic resonance spectroscopy, to identify hepatic steatosis in healthy controls and obese, insulin-resistant individuals

Relationship Between Fatty Acid Binding Protein 4 and Liver Fat in Individuals at Increased Cardiometabolic Risk

Background: Liver steatosis is considered the onset of the non-alcoholic fatty liver disease (NAFLD), a major public health challenge. Nevertheless, NAFLD detection and diagnosis remain a difficult task. Fatty acid binding protein 4 (FABP4) has been proposed as potential biomarker for the ectopic fat accumulation in non-adipose tissues, although its role reflecting liver steatosis in metabolic patients is not fully explored. The aim of this study was to assess the relationship between FABP4 and the fatty liver index (FLI) in metabolic patients and to evaluate its potential role in the fatty liver disease.

Methods: A cross-sectional study involving 389 participants at increased cardiometabolic risk was performed. FLI was calculated in order to assess liver fatty disease and a FLI ≥ 60 was considered to define liver steatosis. The serum FABP4 levels were assessed by using a sandwich enzyme-linked immunosorbent assay. Multivariable regression models were used to examine the associations of FABP4 with fatty liver after adjusting for demographic and clinical characteristics.

Results: Both, FLI and serum FABP4 levels were upregulated in diabetic, obese, and metabolic syndrome patients. Serum FABP4 levels were higher in individuals with liver steatosis. Serum FABP4 were robustly associated with FLI in metabolic patients in both linear and logistic regression analyses.

Conclusion: Our findings show that the serum FABP4 is associated to liver steatosis in metabolic patients.

Non-alcoholic fatty liver disease: a multidisciplinary clinical practice approach—the institutional adaptation to existing Clinical Practice Guidelines

Abstract

Non-alcoholic fatty liver disease (NAFLD) is among the most frequently encountered chronic liver diseases in everyday clinical practice. It is considered the hepatic manifestation of metabolic syndrome. Today, liver biopsy is still the gold standard for NAFLD confirmation and assessing NAFLD's possible progression to non-alcoholic steatohepatitis, fibrosis, cirrhosis, and hepatocellular carcinoma. Because of the high prevalence of NAFLD and potential associated risks of invasive diagnostic procedures, it is of great interest to recruit the patients for liver biopsy. However, as the presence of liver fibrosis determines the further clinical course, liver biopsy is expectedly reserved for those with increased fibrosis risk. The quality of liver biopsy recruitment and patient monitoring could be significantly improved by using non-invasive tools to assess liver fibrosis presence and interactive collaboration between general practitioners, gastroenterologists, and endocrinologists. As a result, the quality of liver biopsy recruitment and patients monitoring could be significantly improved. Here, we proposed clinical practice guidelines that could be implemented for everyday clinical practice in NAFLD patients.

Fatty liver index predicts incident risk of prediabetes, type 2 diabetes and non-alcoholic fatty liver disease (NAFLD)

AIMS

To investigate the association between overweight/obesity and fatty liver index (FLI) on the odds of incident prediabetes/type 2 diabetes and non-alcoholic fatty liver disease (NAFLD) in 2020 participants after 10 years follow up.

METHODS

At baseline (in 2001) 2020 participants, males and females, aged 24-39 years, were stratified according to body mass index (BMI), normal weight (<25 kg/m2), overweight (≥25-<30 kg/m2), or obese (≥30 kg/m2) and FLI (as high FLI ≥60 or low FLI <60). We examined the incidence of prediabetes/type 2 diabetes and NAFLD (ultrasound assessed) over 10 years to 2011 to determine the relative impact of FLI and BMI.

RESULTS

514 and 52 individuals developed prediabetes and type 2 diabetes during follow-up. Such individuals were older, with higher BMI, serum glucose, insulin, alanine aminotransferase (ALT) and triglyceride (TG) concentrations than those who did not develop prediabetes or type 2 diabetes (n = 1454). The additional presence of high FLI significantly increased the risk of developing prediabetes and type 2 diabetes above the risk of being overweight/obese. Compared with normal weight, low FLI participants, the odds of prediabetes were ∼2-fold higher and the odds of type 2 diabetes were 9-10-fold higher respectively in the overweight/obese, high FLI group. No difference was observed between normal weight, low FLI and overweight/obese and low FLI groups.

CONCLUSIONS

An increased FLI significantly increases the odds of incident prediabetes, type 2 diabetes and NAFLD in individuals with overweight/obese highlighting the contributory role of liver fat accumulation in the pathophysiology of prediabetes/type 2 diabetes.Key messagesObesity is a risk factor for non-alcoholic fatty liver disease (NAFLD), prediabetes and type 2 diabetes.Additionally, NAFLD is more prevalent in people with prediabetes and type 2 diabetes when compared to age- and BMI-matched individuals.The presence of a raised fatty liver index (FLI) confers a significantly increased risk of developing prediabetes, type 2 diabetes and NAFLD above that conferred by being overweight/obese.The degree of elevation of FLI can risk stratify for incident prediabetes and type 2 diabetes in people with obesity.

Non-invasive diagnosis of non-alcoholic fatty liver disease using an algorithm combining clinical indexes and ultrasonographic measures

INTRODUCTION AND OBJECTIVE

Non-Alcoholic Fatty Liver Disease (NAFLD) is a metabolic liver disease related to insulin resistance, which requires invasive methods for diagnosis. The aim of this study was to analyze whether the use of an algorithm involving both clinical indices and hepatic ultrasound measurements improves the accuracy for the non-invasive diagnosis of NAFLD.

PATIENTS AND METHODS

Cross-sectional study with patients undergoing elective cholecystectomy. We collected anthropometric, metabolic, liver biopsy, and liver ultrasonography data. We calculated unpaired t-test and Pearson's coefficient, and areas under the receiver-operating characteristic curves (AUROC) for the Fatty Liver Index (FLI), Lipid Accumulation Product (LAP) indexes, right liver index diameter, and for predictive models constructed with discriminant analysis.

RESULTS

One hundred patients in groups with and without NAFLD. FLI, LAP, right and caudate liver lobe diameters, and congestion index were higher in NAFLD group (p = 0.011, p = 0.011, p = 0.001, p = 0.027, p = 0.009). The right liver lobe diameter had the highest AUROC. Predictive models that combined sensitivity and specificity for the clinical indexes and liver ultrasound had an AUROC over 0.7.

CONCLUSION

The ultrasonography measure of right liver lobe diameter by itself can reliably identify patients with NAFLD with a good sensitivity and specificity, however, this can be improved by adding the LAP mathematical index in our population.

Anthropometric clinical indicators of visceral adiposity as predictors of nonalcoholic fatty liver disease

OBJECTIVE

This study aims to evaluate the role of anthropometric clinical indicators of visceral adiposity as predictors of NAFLD, identifying the cutoff points based on gender.

METHODS

This was a cross-sectional study conducted in patients with or without NAFLD. Waist circumference (WC), body mass index (BMI), waist-to-height ratio (WHtR), Conicity Index (C Index), and lipid accumulation product (LAP) were evaluated.

RESULTS

A total of 107 individuals were evaluated, of which 46.7% were diagnosed with NAFLD. Individuals with NAFLD presented higher values of WC, BMI, C Index, LAP, and WHtR when compared with those without NAFLD (p<0.05). For the total sample, the indicators WC, BMI, WHtR, LAP, and C Index had an area under the receiver operator characteristic curve (AUC) above 0.87, with no difference in the prediction of NAFLD in both sexes. WHtR (AUC=0.934) was the indicator of visceral adiposity with the best discriminatory power for NAFLD, followed by LAP (0.919), WC (0.912), C Index (0.907), and BMI (0.877).

CONCLUSIONS

The anthropometric clinical indicators of visceral adiposity showed high performance, especially the WHtR indicator, as NAFLD predictors.

Predicting Non-Alcoholic Fatty Liver Disease for Adults Using Practical Clinical Measures: Evidence from the Multi-ethnic Study of Atherosclerosis

BACKGROUND

Many adults have risk factors for non-alcoholic fatty liver disease (NAFLD). Screening all adults with risk factors for NAFLD using imaging is not feasible.

OBJECTIVE

To develop a practical scoring tool for predicting NAFLD using participant demographics, medical history, anthropometrics, and lab values.

DESIGN

Cross-sectional.

PARTICIPANTS

Data came from 6194 white, African American, Hispanic, and Chinese American participants from the Multi-Ethnic Study of Atherosclerosis cohort, ages 45-85 years.

MAIN MEASURES

NAFLD was identified by liver computed tomography (≤ 40 Hounsfield units indicating > 30% hepatic steatosis) and data on 14 predictors was assessed for predicting NAFLD. Random forest variable importance was used to identify the minimum subset of variables required to achieve the highest predictive power. This subset was used to derive (n = 4132) and validate (n = 2063) a logistic regression-based score (NAFLD-MESA Index). A second NAFLD-Clinical Index excluding laboratory predictors was also developed.

KEY RESULTS

NAFLD prevalence was 6.2%. The model included eight predictors: age, sex, race/ethnicity, type 2 diabetes, smoking history, body mass index, gamma-glutamyltransferase (GGT), and triglycerides (TG). The NAFLD-Clinical Index model excluded GGT and TG. In the NAFLD-MESA model, the derivation set achieved an AUCNAFLD-MESA = 0.83 (95% CI, 0.81 to 0.86), and the validation set an AUCNAFLD-MESA = 0.80 (0.77 to 0.84). The NAFLD-Clinical Index model was AUCClinical = 0.78 [0.75 to 0.81] in the derivation set and AUCClinical = 0.76 [0.72 to 0.80] in the validation set (pBonferroni-adjusted < 0.01).

CONCLUSIONS

The two models are simple but highly predictive tools that can aid clinicians to identify individuals at high NAFLD risk who could benefit from imaging.

EASL Clinical Practice Guidelines on non-invasive tests for evaluation of liver disease severity and prognosis - 2021 update

Non-invasive tests are increasingly being used to improve the diagnosis and prognostication of chronic liver diseases across aetiologies. Herein, we provide the latest update to the EASL Clinical Practice Guidelines on the use of non-invasive tests for the evaluation of liver disease severity and prognosis, focusing on the topics for which relevant evidence has been published in the last 5 years.

Metabolic-associated Fatty Liver Disease as Assessed by the Fatty Liver Index Among Migrant and Non-migrant Ghanaian Populations

BACKGROUND AND AIMS

Metabolic-associated fatty liver disease (MAFLD) is driven by high caloric intake and sedentary lifestyle. Migration towards high income countries may induce these driving factors; yet, the influence of such on the prevalence of MAFLD is clearly understudied. Here, we investigated the Fatty Liver Index (FLI), a proxy of steatosis in MAFLD, after migration of Ghanaian subjects.

METHODS

Cross-sectional data of 5282 rural, urban and migrant participants from the Research on Obesity and Diabetes among African Migrants (also known as RODAM) study were analyzed with logistic regression for geographical differences in FLI and associations with type 2 diabetes mellitus (T2DM), waist-to-hip ratio, and 10-year predicted risk of atherosclerotic cardiovascular disease (ASCVD).

RESULTS

Both FLI and the proportion with an FLI indicative of MAFLD steatosis (FLI ≥60) were higher in migrants compared with non-migrants. Prevalence of elevated FLI (FLI ≥60) in non-migrant males was 4.2% compared to 28.9% in migrants. For females, a similar gradient was observed, from 13.6% to 36.6% respectively. Compared to rural residents, the odds for a FLI ≥60 were higher in migrants living in urban Europe (odds ratio [OR] 9.02, 95% confidence interval [CI]: 5.02-16.20 for men, and 4.00, 95% CI: 3.00-5.34 for women). Compared to controls, the ORs for FLI ≥60 were 2.43 (95% CI: 1.73-3.41) for male T2DM cases and 2.02 (95% CI: 1.52-2.69) for female T2DM cases. One-unit higher FLI was associated with an elevated (≥7.5%) 10-year ASCVD risk (OR: 1.051, 95% CI: 1.041-1.062 for men, and 1.020, 95% CI: 1.015-1.026 for women).

CONCLUSIONS

FLI as a proxy for MAFLD increased stepwise in Ghanaians from rural areas, through urban areas, to Europe. Our results clearly warrant awareness for MAFLD in migrant population as well as confirmation with imaging modalities.

Diagnostic significance of clinical and laboratory indices in predicting non-alcoholic fatty liver disease during screening studies

Aim. To study the significance of clinical and laboratory non-invasive indexes along with the insulin resistance index when carrying out diagnostic assessment of non-alcoholic fatty liver disease (NAFLD) during screening examinations. Materials and methods. The study involved 348 employees working at oil-production enterprises. An ultrasound scanning of the liver was carried out to assess the criteria of NAFLD. The following indexes were calculated: fatty liver index (FLI), hepatic steatosis index (HSI), lipid accumulation products (LAP), and homeostasis model assessment of insulin resistance (HOMA1-IR). The prognostic significance of these indexes in relation to the probability of NAFLD diagnosis based on ultrasound data was studied using single-factor and multi-factor logistic regression models followed by ROC-analysis. Results. The FLI, HSI, and HOMA1-IR indexes in single-factor logistic regression models showed a high statistical significance when carrying out diagnostic assessment the NAFLD with good model calibration capability. The percentage of correct binary classification regards the presence/absence of NAFLD amounted to 82.4% for FLI, 79.7% for HSI, and 72.7% for HOMA1-IR (p0.001). According to the ROC-analysis, the area under the curve (AUC) by the NAFLD diagnostic assessment was 0.917 (95% CI 0.8890.945); 0.880 (95% CI 0.8460.915) and 0.849 (95% CI 0.7640.934), respectively. The multi-factor logistic regression model with the inclusion of FLI and HOMA1-IR 72.7% enabled us to achieve the correct binary classification in terms of NAFLD in 84.2% of cases. When it comes to the ROC-analysis, considering the probabilities predicted in the multi-factor logistic model as the test variable and NAFLD in ultrasound examination as the state variable, it was possible to set the value of AUC 0.933 (95% CI 0.8820.985). Conclusion. The studied clinical and laboratory indexes (FLI, HSI, HOMA1-IR) have a high diagnostic significance regarding NAFLD diagnosed using ultrasonographic criteria. The application of the proposed two-factor logistics model makes it possible to predict the presence of NAFLD when examining a large number of patients, without involving additional ultrasound diagnostics specialists in order to use medical resources rationally.

Circulating Glycerolipids, Fatty Liver Index, and Incidence of Type 2 Diabetes: A Prospective Study Among Chinese

CONTEXT

Few lipidomic studies have specifically investigated the association of circulating glycerolipids and type 2 diabetes (T2D) risk, especially among Asian populations. It remains unknown whether or to what degree fatty liver could explain the associations between glycerolipids and T2D.

OBJECTIVE

We aimed to assess associations between plasma glycerolipids and incident T2D and to explore a potential role of liver fat accumulation in the associations.

METHODS

This was a prospective cohort study with 6 years of follow-up. The study population included 1781 Chinese participants aged 50 to 70 years. The main outcome measure was incident T2D.

RESULTS

At the 6-year resurvey, 463 participants had developed T2D. At the false discovery rate (FDR) of 5%, 43 of 104 glycerolipids were significantly associated with incident T2D risk after multivariate adjustment for conventional risk factors. After further controlling for glycated hemoglobin (HbA1c), 9 of the 43 glycerolipids remained significant, including 2 diacylglycerols (DAGs) (16:1/20:4, 18:2/20:5) and 7 triacylglycerols (TAGs) (46:1, 48:0, 48:1, 50:0, 50:1, 50:2, and 52:2), with relative risks (RRs) (95% CIs) ranging from 1.16 (1.05-1.27) to 1.23 (1.11-1.36) per SD increment of glycerolipids. However, additional adjustment for fatty liver index largely attenuated these findings (RR [95% CI] 0.88 [0.81 to 0.95] to 1.10 [1.01 to 1.21]). Mediation analyses suggested that the fatty liver index explained 12% to 28% of the glycerolipids-T2D associations (all P < 0.01).

CONCLUSION

Higher plasma levels of DAGs and TAGs were associated with increased incident T2D risk in this Chinese population, which might be partially explained by liver fat accumulation.

Lean NAFLD: an underrecognized and challenging disorder in medicine

Classically, Non-Alcoholic Fatty Liver Disease (NAFLD) has been thought to be driven by excessive weight gain and obesity. The overall greater awareness of this disorder has led to its recognition in patients with normal body mass index (BMI). Ongoing research has helped to better understand potential causes of Lean NAFLD, the risks for more advanced disease, and potential therapies. Here we review the recent literature on prevalence, risk factors, severity of disease, and potential therapeutic interventions.

Fatty Liver Index and Development of Cardiovascular Disease: Findings from the UK Biobank

BACKGROUND

Nonalcoholic fatty liver disease is common and is associated with rising morbidity and mortality in the UK. Cardiovascular disease is the main cause of death in people with nonalcoholic fatty liver disease.

AIMS

To determine the association between baseline cardiovascular risk factors with fatty liver index, and to investigate the association between fatty liver index and the incidence of cardiovascular disease in the UK.

METHODS

This study is a population-based retrospective cohort study using the UK Biobank database.

RESULTS

The mean fatty liver index in the study cohort was 44.9, and 33.7% met the criteria for nonalcoholic fatty liver disease. Fatty liver index was significantly associated with a wide range of cardiovascular risk factors at baseline. During a mean follow-up of 7.86 years, the combined incidence of cardiovascular disease was 6.92 per 1000-person years at risk. We found significant association between fatty liver index and incident cardiovascular disease in the fully adjusted model. We found significant association between fatty liver index and incident cardiovascular disease in subgroups stratified by BMI as well as subgroups with fatty liver index < 30, < 60, and ≥ 60.

CONCLUSIONS

Fatty liver index not only predicts NAFLD diagnosis, but also indicates baseline and future development of cardiovascular disease on long-term follow-up across weight categories and fatty liver index spectrum. These findings can inform clinicians and other stakeholders on cardiovascular disease management and preventive efforts. Patients with high fatty liver index should be counseled on the increased future risk of developing cardiovascular disease.

Association between non-alcoholic fatty liver disease and the risk of biliary tract cancers: A South Korean nationwide cohort study

AIMS

The association between non-alcoholic fatty liver disease (NAFLD) and cholangiocarcinoma has been previously reported only in case-control studies. Therefore, we conducted this nationwide cohort study to evaluate the longitudinal association between NAFLD and the risk of biliary tract cancer (BTC), including cholangiocarcinoma and gallbladder cancer.

METHODS

We included 8,120,674 adults who underwent national health screening in 2009 based on the Korean National Health Insurance Service data. NAFLD was determined using the fatty liver index: ≥60, NAFLD; 30-59, intermediate score; <30, no NAFLD. The exclusion criteria were baseline clinical liver disease, heavy alcohol consumption and cancer. Participants were followed up until December 2017 for the development of BTC. Cox proportional hazards regression models were performed.

RESULTS

During the median follow-up period of 7.2 years, 13,043 patients were with newly diagnosed BTC. NAFLD was associated with an increased risk of BTC (adjusted hazard ratio [aHR], 1.28; 95% CI, 1.20-1.37) compared with no NAFLD. The aHRs for the association of cholangiocarcinoma and gallbladder cancer with NAFLD were 1.33 (95% CI, 1.23-1.43) and 1.14 (95% CI, 1.003-1.29), respectively. Overall, the aHR for BTC tended to increase with the increasing fatty liver index (P for trend < 0.001). Concomitant NAFLD and diabetes were associated with an increased risk of BTC by 47% (aHR, 1.47; 95% CI, 1.35-1.60).

CONCLUSION

In this nationwide cohort study, NAFLD was associated with an increased risk of cholangiocarcinoma and gallbladder cancer. This finding suggests that NAFLD is a potentially modifiable risk factor for BTC.

The Repeatedly Elevated Fatty Liver Index Is Associated With Increased Mortality: A Population-Based Cohort Study

Aims

Non-alcoholic fatty liver disease (NAFLD) has a dynamic disease course, therefore repeated measurements of NAFLD status could have benefits rather than single one. The aim of this study was to investigate the effects of persistent NAFLD on the incidence of myocardial infarction (MI) and stroke and all-cause mortality by using repeated measurement of fatty liver index (FLI).

Methods

About 3 million subjects who had undergone the health screening four times from 2009 until 2013 were included. NAFLD was defined as an FLI ≥60. FLI points were defined as the number of times participants meeting the criteria of NAFLD (0-4). Outcomes included all-cause mortality, MI, and stroke.

Results

The higher the FLI points, the higher the risk of all-cause mortality, MI, and stroke (P for trend <0.001, all). Subjects with four FLI points had a higher risk of all-cause mortality (aHR, 1.86; 95% CI, 1.75-1.98; P < 0.001), incidence of MI (aHR, 1.3; 95% CI, 1.21-1.40; P < 0.001), and stroke (aHR, 1.27; 95% CI, 1.19-1.37; P < 0.001) after adjustment for age, sex, smoking, alcohol consumption, income, hypertension, dyslipidemia, diabetes, body mass index, and physical activity. When the 1st and the last FLI were compared, the "incident NAFLD" group had a higher risk for death compared to the "no NAFLD" group (aHR, 1.46; 95% CI, 1.37-1.55), and the "regression of NAFLD" group had a decreased risk for death compared to the "persistent NAFLD" group (aHR, 0.83; 95% CI, 0.77-0.89).

Conclusion

Repeated evaluations of NAFLD status based on FLI measurements could help physicians identify higher-risk groups in terms of mortality, MI, and stroke. The association between FLI worsening or improvement and outcomes also suggests clinical benefits of the prevention and treatment of NAFLD.

Fatty liver index and left ventricular mass: prospective associations from two independent cohorts

OBJECTIVES

Heart disease is the most common cause of death in patients with nonalcoholic fatty liver disease (NAFLD). Emerging data have shown that NAFLD may affect subclinical myocardial remodeling, mainly left ventricular hypertrophy; however, evidence from the prospective studies is still lacking.

METHODS

Prospective analyses were performed to investigate the association of fatty liver index (FLI) with left ventricular mass (LVM) among 1962 participants from the Bogalusa Heart Study (BHS, 1995-2010) and 1547 participants from the Cardiovascular Risk in Young Finns Study (YFS, 2001-2011) free of cardiovascular diseases (CVD) at baseline. LVM was assessed by two-dimensional guided M-mode echocardiography and indexed (LVMI) to body height (m2.7). Multivariable regression models were applied after adjustment for traditional CVD risk factors.

RESULTS

In both cohorts, we observed significant and positive associations between FLI and LVM (BHS: β=0.59, P < 0.001; YFS: β=0.41, P < 0.001) and LVMI (BHS: β=0.14, P < 0.001; YFS: β=0.09, P < 0.001). In addition, we found that the relationship between FLI and LVMI was stronger in women than men (BHS: P-interaction = 0.01; YFS: P-interaction < 0.01); and the relationship between FLI and LVM/LVMI was stronger in black than white individuals (LVM: P-interaction = 0.02; LVMI: P-interaction = 0.04). Moreover, we found that the associations of FLI with LVM and LVMI were attenuated by high physical activity, especially in BHS (P-interaction = 0.02).

CONCLUSION

Our findings from two independent prospective cohorts indicate that FLI is positively associated with LVM/LVMI, independent of traditional cardiovascular risk factors. Such relationships are more pronounced among women and black individuals and are attenuated by high physical activity.

Effects of fructose restriction on liver steatosis (FRUITLESS); a double-blind randomized controlled trial

BACKGROUND

There is an ongoing debate on whether fructose plays a role in the development of nonalcoholic fatty liver disease.

OBJECTIVES

The aim of this study was to investigate the effects of fructose restriction on intrahepatic lipid (IHL) content in a double-blind randomized controlled trial using an isocaloric comparator.

METHODS

Between March 2017 and October 2019, 44 adult overweight individuals with a fatty liver index ≥ 60 consumed a 6-wk fructose-restricted diet (<7.5 g/meal and <10 g/d) and were randomly assigned to supplementation with sachets of glucose (= intervention group) or fructose (= control group) 3 times daily. Participants and assessors were blinded to the allocation. IHL content, assessed by proton magnetic resonance spectroscopy, was the primary outcome and glucose tolerance and serum lipids were the secondary outcomes. All measurements were conducted in Maastricht University Medical Center.

RESULTS

Thirty-seven participants completed the study protocol. After 6 wk of fructose restriction, dietary fructose intake and urinary fructose excretion were significantly lower in the intervention group (difference: -57.0 g/d; 95% CI: -77.9, -39.5 g/d; and -38.8 μmol/d; 95% CI: -91.2, -10.7 μmol/d, respectively). Although IHL content decreased in both the intervention and control groups (P < 0.001 and P = 0.003, respectively), the change in IHL content was more pronounced in the intervention group (difference: -0.7% point, 95% CI: -2.0, -0.03% point). The changes in glucose tolerance and serum lipids were not significantly different between groups.

CONCLUSIONS

Six weeks of fructose restriction per se led to a small, but statistically significant, decrease in IHL content in comparison with an isocaloric control group.This trial was registered at clinicaltrials.gov as NCT03067428.

Evaluation of different b-values in DWI and 1H MRS for pancreatic cancer and pancreatitis: a rabbit model

Pancreatic cancer is a common malignant tumor with high incidence of metastasis. Currently, there is no absolute standard for the choice of b-value for diffusion-weighted imaging (DWI) for pancreatic cancer. The b-value is rarely reported in animal model study, especially in pancreatic cancer/mass pancreatitis rabbit models. The authors’ aim was to determine the different b-values to differentiate the diagnosis of pancreatic cancer and mass pancreatitis in rabbit models using DWI. When comparing the effect of different b-values in diagnostic process, the pathological results could be regarded as the gold standard. In this research, 30 healthy New Zealand rabbits were selected and divided into three groups by random number table method: group 1 (pancreatic cancer), group 2 (mass pancreatitis) and the control group (healthy). After DWI (three different b-values 333, 667, 1000 s/mm², respectively) and MRI examination, the model rabbits were then killed. Afterward, the tumor mass was removed for biopsy, and occupation anatomy and tumor histopathology were examined. Fat-suppressing sequences of T₂WI, DWI, ADC, difference of ADC (DADC), and MRS were used. The present study determined that the effective differential diagnosis of pancreatic cancer and pancreatitis was determined at low b-values (333 s/mm²) when performed DWI inspection in rabbit models.

Comparative Assessment and External Validation of Hepatic Steatosis Formulae in a Community-Based Setting

Several hepatic steatosis formulae have been validated in various cohorts using ultrasonography. However, none of these studies has been validated in a community-based setting using the gold standard method. Thus, the aim of this study was to externally validate hepatic steatosis formulae in community-based settings using magnetic resonance imaging (MRI). A total of 1301 community-based health checkup subjects who underwent liver fat quantification with MRI were enrolled in this study. Diagnostic performance was assessed using the area under the receiver operating characteristic curve (AUROC). Non-alcoholic fatty liver disease (NAFLD) liver fat score showed the highest diagnostic performance with an AUROC of 0.72, followed by Framingham steatosis index (0.70), hepatic steatosis index (HSI, 0.69), ZJU index (0.69), and fatty liver index (FLI, 0.68). There were considerable gray zones in three fatty liver prediction models using two cutoffs (FLI, 28.9%; HSI, 48.9%; and ZJU index, 53.6%). The diagnostic performance of NAFLD liver fat score for detecting steatosis was comparable to that of ultrasonography. The diagnostic agreement was 72.7% between NAFLD liver fat score and 70.9% between ultrasound and MRI. In conclusion, the NAFLD liver fat score showed the best diagnostic performance for detecting hepatic steatosis. Its diagnostic performance was comparable to that of ultrasonography in a community-based setting.

Ethnic influence on nonalcoholic fatty liver disease prevalence and lack of disease awareness in the United States, 2011-2016

BACKGROUND

Nonalcoholic fatty liver disease (NAFLD) is a rising global disease associated with clinical and economic burdens.

OBJECTIVES

We aimed to quantify NAFLD prevalence and awareness to provide stakeholders necessary information to combat NAFLD burden.

METHODS

This study utilizes data from the National Health and Nutrition Examination Survey 2011-2016 and included 4538 adult participants who did not have heavy drinking or viral hepatitis history. The US fatty liver index defined NAFLD and NAFLD fibrosis score defined fibrosis. NAFLD awareness was captured by questionnaire.

RESULTS

Amongst the study population of 4538 persons, NAFLD prevalence was 32.5%, lowest in non-Hispanic Blacks (18.0%) and Asians (18.1%), highest amongst Mexican Americans (48.4%). Within the NAFLD group, advanced fibrosis was highest in non-Hispanic Blacks (28.5%) and lowest amongst non-Hispanic Asians (2.7%). Of the 1473 (97.5%) NAFLD participants who answered NAFLD awareness question, 90% visited a healthcare centre at least once in the past year, but only 5.1% were aware of having NAFLD. On weighted population estimates, 77.33 million persons had NAFLD, 17.63 million had advanced fibrosis, and 73.39 million NAFLD participants were not aware of having NAFLD.

CONCLUSIONS

Of 77.33 million people in the United States have NAFLD with 17.63 million having advanced fibrosis, with lowest prevalence in non-Hispanic Asians and highest in Mexican Americans. A conundrum exists amongst non-Hispanic Blacks who have low NAFLD prevalence but highest prevalence of advanced fibrosis. Awareness of NAFLD was low across all ethnicities. Effort is needed to improve disease awareness whilst addressing NAFLD clinical burden across ethnicities.

Light-to-Moderate Alcohol Consumption Is Associated With Increased Risk of Type 2 Diabetes in Individuals With Nonalcoholic Fatty Liver Disease: A Nine-Year Cohort Study

OBJECTIVE

This study explored the association between light-to-moderate alcohol consumption (LMAC) and risk of type 2 diabetes mellitus (T2DM) in individuals with nonalcoholic fatty liver disease (NAFLD).

METHODS

A 9-year cohort study was performed among Chinese men who underwent their annual health checkups between 2009 and 2018. NAFLD was diagnosed based on abdominal ultrasound with exclusion of excess alcohol intake and other causes of liver disease. Logistic regression and Cox proportional regression analyses were applied to identify the risk of prevalent and incident T2DM.

RESULTS

Of the 7,079 participants enrolled, 243 had T2DM at baseline and 630 developed T2DM during the 45,456 person-years follow-up. Both at the baseline and by the end of the follow-up, LMAC was associated with a decreased risk of prevalent T2DM in NAFLD-free participants but with a significantly increased risk in patients with NAFLD. LMAC was also associated with a decreased risk of incident T2DM in NAFLD-free participants. The adjusted hazard ratios (95% confidence interval) of incident T2DM were 0.224 (0.115-0.437) and 0.464 (0.303-0.710) for NAFLD-free light drinkers and NAFLD-free moderate drinkers, respectively. Nondrinking, light-drinking, and moderate-drinking patients with NAFLD all showed significantly increased risks of incident T2DM. Compared with NAFLD-free nondrinkers, the adjusted hazard ratios (95% confidence interval) of incident T2DM were 1.672 (1.336-2.092), 2.642 (1.958-3.565), and 2.687 (2.106-3.427) for nondrinking, light-drinking, and moderate-drinking patients with NAFLD, respectively.

DISCUSSION

LMAC decreased the risks of prevalent and incident T2DM in NAFLD-free participants. LMAC, however, was associated with an increased risk of T2DM in patients with NAFLD (ClinicalTrials.gov number: NCT03847116).

Utility of Liver Function Tests and Fatty Liver Index to Categorize Metabolic Phenotypes in a Mediterranean Population

The aim of this study was to analyze the utility of liver function tests (LFT) and fatty liver index (FLI), a surrogate marker of non-alcoholic fatty liver disease, in the categorization of metabolic phenotypes in a Mediterranean population. A cross-sectional study was performed on a random representative sample of 2233 adults assigned to a health center in Málaga, Spain. The metabolic phenotypes were determined based on body mass index (BMI) categorization and the presence or absence of two or more cardiometabolic abnormalities (high blood pressure, low high-density lipoprotein (HDL) cholesterol, hypertriglyceridemia, pre-diabetes) or type 2 diabetes. No difference was observed between metabolically healthy and metabolically abnormal phenotypes on LFT. The mean FLI of the population was 41.1 ± 28.6. FLI was significantly higher (p < 0.001) in the metabolically abnormal phenotypes in all BMI categories. The proportion of individuals with pathological FLI (≥60) was significantly higher in the metabolically abnormal overweight and obese phenotypes (p < 0.001). On a multivariate model adjusted for sex, age, and waist circumference, a significant correlation was found between pathological FLI and metabolically abnormal phenotypes in the overweight and obese BMI categories. Area under the curve (AUC) of FLI as a biomarker was 0.76, 0.74, and 0.72 for the metabolically abnormal normal-weight, overweight, and obese groups, respectively. Liver biochemistry is poorly correlated with metabolic phenotypes. Conversely, a good correlation between FLI, as a marker of non-alcoholic fatty liver disease (NAFLD), and metabolically abnormal phenotypes in all BMI ranges was found. Our study suggests that FLI may be a useful marker for characterizing metabolically abnormal phenotypes in individuals who are overweight or obese.

Which Metabolic Index is Appropriate for Predicting Non-alcoholic Steatohepatitis?

BACKGROUND There are controversial ideas about the application of metabolic indices for the prediction of nonalcoholic steatohepatitis (NASH). In this study, we evaluated some novel metabolic indices for the screening of NASH. METHODS This prospective case-control study was performed in a gastroenterology outpatient clinic. Consecutively selected patients with persistently elevated aminotransferase levels and evidence of fatty liver in ultrasonography were enrolled. Those with other etiologies of aminotransferase elevation were excluded. The remaining was presumed to have NASH. The control group consisted of age and sex-matched subjects with normal liver function tests and liver ultrasound examinations. RESULTS Finally, 94 patients with steatohepatitis and 106 controls were included in the project. The mean liver fat content (LFC), aspartate aminotransferase, and alanine aminotransferase levels were significantly lower in the control group than in the NASH group. LFC was independently associated with the presence of NASH in logistic regression analysis. LFC had a good area under the curve for the prediction of NASH in ROC (receiver operating characteristic curve) analysis. CONCLUSION LFC seems to be a reliable metabolic index for the detection of patients with NASH.

Elevated Fatty Liver Index as a Risk Factor for All-Cause Mortality in Human Immunodeficiency Virus-Hepatitis C Virus-Coinfected Patients (ANRS CO13 HEPAVIH Cohort Study)

BACKGROUND AND AIMS

Human immunodeficiency virus (HIV)-hepatitis C virus (HCV)-coinfected patients are at high risk of metabolic complications and liver-related events, which are both associated with hepatic steatosis and its progressive form, nonalcoholic steatohepatitis, a known risk factor for mortality. The fatty liver index (FLI), a noninvasive steatosis biomarker, has recently drawn attention for its clinical prognostic value, although its capacity to predict mortality risk in HIV-HCV-coinfected patients has never been investigated. Using a Cox proportional hazards model for mortality from all causes, with data from the French National Agency for Research on Aids and Viral Hepatitis CO13 HEPAVIH cohort (983 patients, 4,432 visits), we tested whether elevated FLI (≥60) was associated with all-cause mortality.

APPROACH AND RESULTS

After multiple adjustment, individuals with FLI ≥ 60 had almost double the risk of all-cause mortality (adjusted hazard ratio [95% confidence interval], 1.91 [1.17-3.12], P = 0.009), independently of the following factors: HCV cure (0.21 [0.07-0.61], P = 0.004), advanced fibrosis (1.77 [1.00-3.14], P = 0.05), history of hepatocellular carcinoma and/or liver transplantation (7.74 [3.82-15.69], P < 10^-3 ), history of indirect clinical signs of cirrhosis (2.80 [1.22-6.41], P = 0.015), and HIV Centers for Disease Control and Prevention clinical stage C (2.88 [1.74-4.79], P < 10^-3 ).

CONCLUSIONS

An elevated FLI (≥60) is a risk factor for all-cause mortality in HIV-HCV-coinfected patients independently of liver fibrosis and HCV cure. In the present era of nearly 100% HCV cure rates thanks to direct-acting antivirals, these findings encourage the more systematic use of noninvasive steatosis biomarkers to help identify coinfected patients with higher mortality risk.

Association between Fatty Liver Index and Periodontitis: the Korea National Health and Nutrition Examination Survey

It has been suggested that periodontitis is associated with metabolic abnormalities including non-alcoholic fatty liver disease (NAFLD). The fatty liver index (FLI) is a non-invasive surrogate marker and predictor of NAFLD. We aimed to determine whether FLI itself would be associated with periodontitis through a secondary analysis of previously reported nationally representative probability sample data of the Korean population. FLI was calculated from a previously developed algorithm which combines measures of body mass index (BMI), waist circumference, triglyceride, and gamma-glutamyl transferase (GGT). Periodontitis was diagnosed based on the Community Periodontal Index (CPI) developed by the World Health Organization. Of 4,272 participants, 26.1% were diagnosed with periodontitis. Higher FLI was associated with a higher prevalence of periodontitis (Odds ratio (OR) _{highest vs. lowest quartile of FLI},1.63; 95% confidence interval (CI), 1.23–2.16; P = 0.001 for trend) adjusting for confounding factors. In the highest FLI quartile, prevalence of periodontitis was higher in individuals with diabetes (OR _{highest vs. lowest quartile of FLI}, 2.89; 95% CI, 1.01–8.27 for diabetic subgroup; OR _{highest vs. lowest quartile of FLI}, 1.45; 95% CI, 1.07–1.96 for non-diabetic subgroup). In summary, FLI was associated with prevalent periodontitis.

Irisin and markers of metabolic derangement in non-diabetic Caucasian subjects with stage I-II obesity during early aging

Irisin concentrations are decreased in subjects with overt diabetes and upregulated in those with obesity or impaired fasting glucose. However, gender-balanced data in older populations, in whom risk factors commonly culminate in overt cardiovascular disease, are scarce. We assessed in non-diabetic Caucasian subjects with stage I-II obesity in the early aging range (50 to 70 years), the relationship between irisin, body composition and markers of metabolic derangement by gender. In 60 (31 women, 29 men) non-diabetics with a body mass index ≥30 - ≤40 kg/m², we measured anthropometrics and body composition (Air Displacement Plethysmography). We assayed lipid and glucose profile by routine methods, plasma irisin by ELISA and measured insulin resistance by the HOMA index. Irisin levels were higher in women than in men (161 [105–198]) vs 83 [33–115] ng/ml, P<0.001), and correlated directly with HOMA index in both (rho 0.735, P<0.001 M, rho 0.452, P = 0.011 F). Sex differences were maintained across insulin resistance severity stages. In men, irisin concentrations correlated directly with body mass index (rho 0.755, P<0.001), waist circumference (rho 0.623, P<0.001), fat mass index (rho 0.762, P<0.001), glucose (rho 0.408, P = 0.028), the fatty liver index (rho 0.705, P<0.001) and FINDRISC score (rho 0.536, P = 0.003). Among non-diabetic Caucasian subjects with obesity in the early stages of aging, irisin levels reflect the amount of body fat and insulin resistance severity, independently of between-gender differences in the adipomyokine concentrations and are associated with markers of visceral adiposity in men but not in women.

Enhanced GIP Secretion in Obesity Is Associated with Biochemical Alteration and miRNA Contribution to the Development of Liver Steatosis

Nutrient excess enhances glucose-dependent insulinotropic polypeptide (GIP) secretion, which may in turn contribute to the development of liver steatosis. We hypothesized that elevated GIP levels in obesity may affect markers of liver injury through microRNAs. The study involved 128 subjects (body mass index (BMI) 25–40). Fasting and postprandial GIP, glucose, insulin, and lipids, as well as fasting alanine aminotransferase (ALT), γ-glutamyltransferase (GGT), cytokeratin-18, fibroblast growth factor (FGF)-19, and FGF-21 were determined. TaqMan low density array was used for quantitative analysis of blood microRNAs. Fasting GIP was associated with ALT [β = 0.16 (confidence interval (CI): 0.01–0.32)], triglycerides [β = 0.21 (95% CI: 0.06–0.36], and FGF-21 [β = 0.20 (95%CI: 0.03–0.37)]; and postprandial GIP with GGT [β = 0.17 (95%CI: 0.03–0.32)]. The odds ratio for elevated fatty liver index (>73%) was 2.42 (95%CI: 1.02–5.72) for high GIP versus low GIP patients. The miRNAs profile related to a high GIP plasma level included upregulated miR-136-5p, miR-320a, miR-483-5p, miR-520d-5p, miR-520b, miR-30e-3p, and miR-571. Analysis of the interactions of these microRNAs with gene expression pathways suggests their potential contribution to the regulation of the activity of genes associated with insulin resistance, fatty acids metabolism, and adipocytokines signaling. Exaggerated fasting and postprandial secretion of GIP in obesity are associated with elevated liver damage markers as well as FGF-21 plasma levels. Differentially expressed microRNAs suggest additional, epigenetic factors contributing to the gut–liver cross-talk.

Altilix® Supplement Containing Chlorogenic Acid and Luteolin Improved Hepatic and Cardiometabolic Parameters in Subjects with Metabolic Syndrome: A 6 Month Randomized, Double-Blind, Placebo-Controlled Study

The objective was to evaluate the effects of 6 months of supplementation with Altilix^®, containing chlorogenic acid and its derivatives, and luteolin and its derivatives, on cardiovascular risk and hepatic markers in subjects with metabolic syndrome (MetS). A randomized, double-blind, placebo-controlled study was performed in 100 subjects with MetS with a follow-up period of 6 months; 50 subjects were randomized to Altilix^® (26 men and 24 women, mean age 63 ± 8 years) and the other 50 to placebo (28 men and 22 women, mean age 63 ± 11 years). Anthropometric, cardiometabolic, and hepatic parameters were assessed at baseline and at the end of follow-up. Carotid intima-media thickness and endothelial function were assessed by doppler ultrasound and by flow-mediated dilation of the brachial artery, respectively. The presence and degree of non-alcoholic fatty liver disease (NAFLD) was assessed by the fatty liver index (FLI), and subjects were divided into three subgroups: (1) without NAFLD; (2) with borderline NAFLD; and (3) with NAFLD. After 6 months of Altilix^® supplementation, we found a significant improvement vs. placebo in most of the evaluated parameters, including body weight (−2.40% (95% CI −3.79, −1.01); p < 0.001), waist circumference (−2.76% (95% CI −4.55, −0.96); p = 0.003), HbA1c (−0.95% (95% CI −1.22, −0.67); p < 0.001), plasma lipids, FLI (−21.83% (95% CI −27.39, −16.27); p < 0.001), hepatic transaminases, flow-mediated dilation (10.56% (95% CI 5.00, 16.12); p < 0.001), and carotid intima-media thickness (−39.48% (95% CI −47.98, −30.97); p < 0.001). Further, the improvement in cardiometabolic variables was independent of the degree of hepatic steatosis. Altilix^® supplementation improved hepatic and cardio-metabolic parameters in MetS subjects. Altilix^® supplementation was a beneficial approach in the management of hepatic and cardiometabolic alterations in MetS subjects.

Metabolomics: a search for biomarkers of visceral fat and liver fat content

INTODUCTION

Excess visceral and liver fat are known risk factors for cardiometabolic disorders. Metabolomics might allow for easier quantification of these ectopic fat depots, instead of using invasive and costly tools such as MRI or approximations such as waist circumference.

OBJECTIVE

We explored the potential use of plasma metabolites as biomarkers of visceral adipose tissue (VAT) and hepatic triglyceride content (HTGC).

METHODS

We performed a cross-sectional analysis of a subset of the Netherlands Epidemiology of Obesity study. Plasma metabolite profiles were determined using the Biocrates AbsoluteIDQ p150 kit in 176 individuals with normal fasting plasma glucose. VAT was assessed with magnetic resonance imaging and HTGC with proton-MR spectroscopy. We used linear regression to investigate the associations of 190 metabolite variables with VAT and HTGC.

RESULTS

After adjustment for age, sex, total body fat, currently used approximations of visceral and liver fat, and multiple testing, three metabolite ratios were associated with VAT. The strongest association was the lysophosphatidylcholines to total phosphatidylcholines (PCs) ratio [- 14.1 (95% CI - 21.7; - 6.6) cm² VAT per SD of metabolite concentration]. Four individual metabolites were associated with HTGC, especially the diacyl PCs of which C32:1 was the strongest at a 1.31 (95% CI 1.14; 1.51) fold increased HTGC per SD of metabolite concentration.

CONCLUSION

Metabolomics may be a useful tool to identify biomarkers of visceral fat and liver fat content that have added diagnostic value over current approximations. Replication studies are required to validate the diagnostic value of these metabolites.

Overview of the Pathogenesis, Genetic, and Non-Invasive Clinical, Biochemical, and Scoring Methods in the Assessment of NAFLD

Nonalcoholic fatty liver disease (NAFLD) is the most prevalent chronic liver disease worldwide. It represents a range of disorders, including simple steatosis, nonalcoholic steatohepatitis (NASH), and liver cirrhosis, and its prevalence continues to rise. In some cases, hepatocellular carcinoma (HCC) may develop. The develop;ment of non-invasive diagnostic and screening tools is needed, in order to reduce the frequency of liver biopsies. The most promising methods are those able to exclude advanced fibrosis and quantify steatosis. In this study, new perspective markers for inflammation, oxidative stress, apoptosis, and fibrogenesis; emerging scoring models for detecting hepatic steatosis and fibrosis; and new genetic, epigenetic, and multiomic studies are discussed. As isolated biochemical parameters are not specific or sensitive enough to predict the presence of NASH and fibrosis, there is a tendency to use various markers and combine them into mathematical algorithms. Several predictive models and scoring systems have been developed. Current data suggests that panels of markers (NAFLD fibrosis score, Fib-4 score, BARD score, and others) are useful diagnostic modalities to minimize the number of liver biopsies. The review unveils pathophysiological aspects related to new trends in current non-invasive biochemical, genetic, and scoring methods, and provides insight into their diagnostic accuracies and suitability in clinical practice.

Associations of visceral fat thickness and anthropometric measurements with non-alcoholic fatty liver disease development in male patients mono-infected with human immunodeficiency virus

BACKGROUND

Non-alcoholic fatty liver disease (NAFLD) represents the most common form of chronic liver disease in mono-infected (without concomitant hepatitis B and/or C virus infection) people living with human immunodeficiency virus (HIV). The proper and on time identification of at-risk HIV-positive individuals would be relevant in order to reduce the rate of progression from NAFLD into non-alcoholic steatohepatitis (NASH), cirrhosis and hepatocellular carcinoma.

OBJECTIVES

The aim of this study was to explore visceral fat thickness (VFT) and anthropometric measurements associated with the development of NAFLD in patients mono-infected with HIV and on long-standing combination antiretroviral therapy (cART).

METHOD

Eighty-eight (n = 88) HIV-positive male patients, average age 39.94 ± 9.91 years, and stable on cART, were included in this prospective study. VFT was measured using ultrasonography. Anthropometric measurements included body mass index (BMI), waist-to-hip ratio (W/H), waist-to-height ratio (WHtR), waist and hip circumference (WC, HC). Differences between variables were determined using the chi-square test. The receiver operating characteristic (ROC) curve and the Youden index were used to determine optimal cut-off values of VFT and hepatic steatosis. The area under the curve (AUC), 95% confidence intervals, sensitivity and specificity are reported for the complete sample. Significance was set at p < 0.05.

RESULTS

Patients with steatosis had significantly higher values of BMI, HC, WC, W/H and WHtR. The VFT was higher in patients with steatosis (p < 0.001). Specifically, VFT values above 31.98 mm and age > 38.5 years correlated with steatosis in HIV-positive patients, namely sensitivity 89%, specificity 72%, AUC 0.84 (95% CI, 0.76-0.93, p < 0.001), with the highest Youden index = 0.61. The sensitivity of the age determinant above this cut-off point was 84%, specificity 73% and AUC 0.83 (95% CI, 0.75-0.92, p < 0.001), with the highest Youden index of 0.57.

CONCLUSION

In the absence of more advanced radiographic and histological tools, simple anthropometric measurements and VFT could assist in the early identification of persons at risk of hepatic steatosis in low- and middle-income regions.

Copeptin relates to a fatty liver and measures of obesity in a South African population with mixed ethnicities

PURPOSE

Elevated copeptin, a vasopressin marker, is linked to metabolic disease, and obese rats with low-vasopressin concentration had a decreased risk of liver steatosis. We here investigated the association between copeptin and nonalcoholic fatty liver disease (NAFLD) and possible differences in copeptin concentration between ethnicities.

METHODS

In this cross-sectional study of 361 South Africans (n = 172 African black, 189 = Caucasian) with a mean age of 45 years and 45% men, plasma copeptin was measured and associated with NAFLD according to a validated fatty liver index accounting for measures of BMI, waist, triglycerides, and gamma-glutamyltransferase.

RESULTS

There was no significant difference in copeptin concentrations between ethnicities after age and gender adjustment (p = 0.24). Increasing copeptin tertile levels were significantly associated with obesity, overweight, and abdominal obesity, respectively, after multivariate adjustment for age, gender, ethnicity, and high HOMA-IR (p = 0.02 for all). Individuals in the second and third copeptin tertile had an increased odds (95% CI) of NAFLD of 1.77 (1.04-3.02) and 2.97 (1.74-5.06), respectively, compared to the bottom tertile (p < 0.001). The association between increasing copeptin tertile and NAFLD remained significant after adjustment for age, gender, ethnicity, high HOMA-IR, self-reported current alcohol intake, and statin treatment (p = 0.01).

CONCLUSIONS

Elevated plasma copeptin is independently associated with NAFLD in a population with mixed ethnicities, pointing at the pharmacologically modifiable vasopressin system as a new mechanism behind NAFLD.

Associations Between Body Fat, Muscle Mass, and Nonalcoholic Fatty Liver Disease: A Population-Based Study

Nonalcoholic fatty liver disease (NAFLD) is one of the most common forms of liver disease worldwide and has emerged as a significant public health concern in China. A better understanding of the etiology of NAFLD can inform effective management strategies for this disease. We examined factors associated with NAFLD in two districts of Hangzhou, China, focusing on the relationship of regional body fat distribution, muscle mass, and NAFLD. We used baseline data to carry out a cross‐sectional analysis among 3,589 participants from the Wellness Living Laboratory (WELL) China study, a longitudinal population‐based study that aims to investigate and promote well‐being among the Chinese population. NAFLD was defined using the widely validated fatty liver index (FLI). Multivariate logistic regressions were performed to assess independent associations between NAFLD and metabolic risk factors (e.g., insulin resistance) and dual x‐ray absorptiometry (DXA)‐derived measures (e.g., android fat ratio [AFR] and skeletal muscle index [SMI]). Of the 3,589 participants, 476 (13.3%) were classified as having FLI‐defined NAFLD (FLI ≥60). Among those, 58.0% were men. According to our analysis, AFR (odds ratio [OR], 10.0; 95% confidence interval [CI], 5.8‐18.5), insulin resistance (OR, 4.0; 95% CI, 3.0‐5.3), high alanine aminotransferase levels (OR, 7.6; 95% CI, 5.8‐10.0), smoking (OR, 2.0; 95% CI, 1.4‐3.0), and male sex (OR, 2.9; 95% CI, 2.0‐4.2) were positively associated with NAFLD risk, while SMI (OR, 0.1; 95% CI, 0.07‐0.13) was inversely associated with NAFLD risk. Conclusion: In addition to known metabolic risk factors, DXA‐derived AFR and SMI may provide additional insights to the understanding of NAFLD. Interventions that aim to decrease AFR and increase SMI may be important to reduce the burden of NAFLD in this population.

Bile Acid and Fibroblast Growth Factor 19 Regulation in Obese Diabetics, and Non-Alcoholic Fatty Liver Disease after Sleeve Gastrectomy

Background: Sleeve gastrectomy (SG) is an effective treatment for obesity and type 2 diabetes mellitus (T2DM), and non-alcoholic fatty liver disease (NAFLD); however, the mechanism is not completely understood. Bile acids and fibroblast growth factors (FGFs) are involved in the regulation of energy metabolism. Methods: We investigated the roles of total bile acid and FGF 19 in T2DM remission and NAFLD improvement in obese subjects undergoing SG. A total of 18 patients with obesity and T2DM undergoing laparoscopic SG were enrolled in this study. Serial plasma total bile acid and FGF 19 levels were measured, while the fatty liver index was calculated before and after surgery. Results: The FGF 19 level significantly increased, and the total bile acid level and fatty liver index decreased 1 year after surgery. The complete T2DM remission rate was 66.7% one year after surgery; the complete remitters had significantly lower FGF 19 levels and higher insulin levels than the non-complete remitters. The complete remitters also had significantly decreased total bile acid levels and increased FGF 19 levels 1 year after surgery compared with those before surgery. The fatty improvers had significantly decreased total bile acid levels and increased FGF 19 levels 1 year after surgery compared with those before surgery. Conclusion: The total bile acids level and fatty liver index decreased, and the FGF 19 levels increased 1 year after SG. Both T2DM complete remitters and NAFLD improvers showed significantly decreased total bile acid levels and increased FGF 19 levels 1 year after SG. Plasma total bile acids and FGF 19 might have roles in T2DM remission and NAFLD improvement. Low preoperative FGF 19 levels might be a predictor for NAFLD improvement after SG.

Physical Activity, Fatty Liver, and Glucose Metabolism Over the Life Course: The Lifelines Cohort

OBJECTIVES

We examined the dose-dependent association of habitual moderate-to-vigorous physical activity (MVPA) with the biochemical markers for nonalcoholic fatty liver disease (NAFLD) and whether this association changes with age and degree of impaired glucose metabolism. We also investigated whether the associations depend on the domain of MVPA.

METHODS

In this study, using data from the population-based Lifelines cohort (N = 42,661), MVPA was self-reported on the short questionnaire to assess health-enhancing physical activity. NAFLD was defined as a fatty liver index value of >60, based on body mass index, waist circumference, plasma triglycerides, and gamma-glutamyltransferase. Glucose metabolism was defined as normal (NGM), impaired (IGM), and type 2 diabetes mellitus (T2DM). Exclusion criteria were previously diagnosed hepatitis or cirrhosis and excessive alcohol use. All analyses were adjusted for age, sex, and education.

RESULTS

Higher MVPA was dose dependently associated with a lower risk of having NAFLD: compared with "No MVPA," the odds ratios (ORs) (95% confidence intervals) for MVPA quintiles were 0.78 (0.71-0.86), 0.64 (0.58-0.70), 0.53 (0.48-0.59), 0.51 (0.46-0.56), and 0.45 (0.41-0.50) for the highest level of MVPA. The association between MVPA and NAFLD was stronger for more impaired glucose status (ORNGM = 0.49 (0.42-0.57), ORIGM = 0.46 (0.40-0.54), ORT2DM = 0.42 (0.27-0.66)) and for older age (OR20-40 years = 0.51 (0.42-0.62), OR60-80 years = 0.37 (0.29-0.48)) with the highest level of MVPA, relative to No MVPA. No favorable association was observed for occupational MVPA. With regard to MVPA and fibrosis, associations with fibrosis markers showed contradictory results.

CONCLUSIONS

Higher MVPA levels are dose dependently associated with a lower NAFLD risk. This association is stronger in people with diabetes and older adults.

A gathering storm: HIV infection and nonalcoholic fatty liver disease in low and middle-income countries

: Despite the decreasing total incidence of liver-related deaths, liver disease remains one of the major non-AIDS causes of morbidity and mortality amongst people living with HIV, and a significant proportion of liver disease in these individuals can be attributed to nonalcoholic fatty liver disease (NAFLD). NAFLD in HIV infection is a growing problem in view of increasing life expectancy associated with the use of effective antiretroviral therapy (ART), wider uptake of ART and increasing rates of obesity in many Asian as well as western countries. The problem may be more pronounced in developing countries where there are limited resources available for mass screening and diagnosis of NAFLD. There is a small but growing body of literature examining NAFLD in the setting of HIV, with data from low and middle-income countries (LMICs) particularly lacking. Here, we review the cohort data on NAFLD in HIV, and discuss the risk factors, pathogenesis of hepatic steatosis, NAFLD and nonalcoholic steatohepatitis (NASH), diagnostic approaches and therapeutic options available for NAFLD in the setting of HIV, and the specific challenges of NAFLD in HIV for LMICs.

Association of fatty liver disease with mortality outcomes in an Eastern Finland male cohort

Objective

Fatty liver disease (FLD) has been associated with extrahepatic morbidity outcomes. However, reports on the association of FLD, assessed using fatty liver index (FLI), with mortality outcomes have been inconsistent. Our objective was to examine the effect of metabolic factors (blood pressure, insulin, fasting glucose, lipoproteins) on the associations of FLI with mortality outcomes among middle-aged men.

Study design

Prospective cohort study.

Methods

Our subjects were 1893 men at baseline from 1984 to 1989 in the Kuopio Ischaemic Heart Disease Risk Factor Study cohort. Multivariable Cox regression models were used to analyse the association of baseline FLI, with the HRs for all-cause, disease, cardiovascular, non-cardiovascular and cancer mortality outcomes.

Results

The mean FLI in the FLI categories were 16.2 in the low and reference category (FLI<30), 43.4 in the intermediate FLI category (FLI=30–<60) and 77.5 in the high FLI (FLD) category (FLI≥60). Over an average follow-up of 20 years, 848 disease deaths were recorded through Finnish national cause of death register. In models adjusted for constitutional, lifestyle and inflammatory factors, for the high (FLI≥60) vs low (FLI<30) FLI category, the HRs (95% CI) for mortality outcomes were 1.50 (1.26–1.78) for all-cause mortality; 1.56 (1.31–2.86) for disease mortality; 1.51 (1.18–1.94) for cardiovascular disease (CVD) mortality; 1.42 (1.12–1.80) for non-CVD mortality and 1.45 (1.02–2.07) for cancer mortality. With further adjustment for metabolic factors, the HRs were 1.25 (1.01–1.53) for all-cause mortality; 1.26 (1.02–1.56) for disease mortality; 1.06 (0.78–1.43) for CVD mortality; 1.46 (1.09–1.94) for non-CVD mortality and 1.49 (0.97–2.29) for cancer mortality.

Conclusion

High FLI (FLD) is associated with increased risks of mortality outcomes. The FLI-CVD mortality association can be largely explained by metabolic factors. Persons with FLD should be monitored for metabolic deterioration and extrahepatic morbidity to improve their prognoses.

Oxidative Stress and Non-Alcoholic Fatty Liver Disease: Effects of Omega-3 Fatty Acid Supplementation

Aging is a complex phenomenon characterized by the progressive loss of tissue and organ function. The oxidative-stress theory of aging postulates that age-associated functional losses are due to the accumulation of ROS-induced damage. Liver function impairment and non-alcoholic fatty liver disease (NAFLD) are common among the elderly. NAFLD can progress to non-alcoholic steatohepatitis (NASH) and evolve to hepatic cirrhosis or hepatic carcinoma. Oxidative stress, lipotoxicity, and inflammation play a key role in the progression of NAFLD. A growing body of evidence supports the therapeutic potential of omega-3 polyunsaturated fatty acids (n-3 PUFA), mainly docosahaexenoic (DHA) and eicosapentaenoic acid (EPA), on metabolic diseases based on their antioxidant and anti-inflammatory properties. Here, we performed a systematic review of clinical trials analyzing the efficacy of n-3 PUFA on both systemic oxidative stress and on NAFLD/NASH features in adults. As a matter of fact, it remains controversial whether n-3 PUFA are effective to counteract oxidative stress. On the other hand, data suggest that n-3 PUFA supplementation may be effective in the early stages of NAFLD, but not in patients with more severe NAFLD or NASH. Future perspectives and relevant aspects that should be considered when planning new randomized controlled trials are also discussed.

Noninvasive Assessment of Liver Disease in Patients With Nonalcoholic Fatty Liver Disease

Nonalcoholic fatty liver disease (NAFLD) is estimated to afflict approximately 1 billion individuals worldwide. In a subset of NAFLD patients, who have the progressive form of NAFLD termed nonalcoholic steatohepatitis (NASH), it can progress to advanced fibrosis, cirrhosis, hepatocellular carcinoma, and liver-related morbidity and mortality. NASH is typically characterized by a specific pattern on liver histology, including steatosis, lobular inflammation, and ballooning with or without peri-sinusoidal fibrosis. Thus, key issues in NAFLD patients are the differentiation of NASH from simple steatosis and identification of advanced hepatic fibrosis. Until now, liver biopsy has been the gold standard for identifying these 2 critical end points, but has well-known limitations, including invasiveness; rare but potentially life-threatening complications; poor acceptability; sampling variability; and cost. Furthermore, due to the epidemic proportion of individuals with NAFLD worldwide, liver biopsy evaluation is impractical, and noninvasive assessment for the diagnosis of NASH and fibrosis is needed. Although much of the work remains to be done in establishing cost-effective strategies for screening for NASH, advanced fibrosis, and cirrhosis, in this review, we summarize the current state of the noninvasive assessment of liver disease in NAFLD, and we provide an expert synthesis of how these noninvasive tools could be utilized in clinical practice. Finally, we also list the key areas of research priorities in this area to move forward clinical practice.

Dietary Sources of Fructose and Its Association with Fatty Liver in Mexican Young Adults

Fructose intake has been associated with non-alcoholic fatty liver disease (NAFLD). The objective of this study was to assess the consumption of dietary fructose according to: 1) classification of hepatic steatosis by two indexes and 2) diagnosis of NAFLD by MRI. We conducted a cross-sectional analysis among 100 young adults from Mexico City. The Hepatic Steatosis Index (HSI) and the Fatty Liver Index (FLI) were estimated using Body Mass Index (BMI), waist circumference, and fasting concentrations of glucose, triglycerides, and hepatic enzymes (ALT, AST, GGT). A semi-quantitative food frequency questionnaire was administered to obtain dietary sources of fructose. We estimated the concordance between the hepatic indices and NAFLD and the correlation between the index scores and the percentage of liver fat. Eighteen percent presented NAFLD; 44% and 46% were classified with hepatic steatosis according to HSI and FLI, respectively. We compared dietary intake of fructose by each outcome: HSI, FLI, and NAFLD. Sugar-sweetened beverages (SSB) and juices were consumed significantly more by those with steatosis by FLI and NAFLD suggesting that SSB intake is linked to metabolic alterations that predict the risk of having NAFLD at a young age.

Beneficial effects of SGLT2 inhibitors on fatty liver in type 2 diabetes: A common comorbidity associated with severe complications

Patients with type 2 diabetes mellitus (T2DM) are exposed to non-alcoholic fatty liver disease (NAFLD), a comorbidity associated with cardiovascular disease and chronic kidney disease, and which may progress to non-alcoholic steatohepatitis (NASH), fibrosis and cirrhosis. Sodium-glucose cotransporter type-2 (SGLT2) inhibitors are glucose-lowering agents that improve glucose control while promoting weight loss and lowering serum uric acid levels. These agents may exert cardiovascular and renal protection in T2DM patients with established cardiovascular disease. Recent findings from both randomized controlled trials and open-label studies have also shown that SGLT2 inhibitors are able to reduce fatty liver content, as assessed by different imaging techniques, and improve biological markers of NAFLD, especially serum liver enzymes, in patients with T2DM. In addition, there are emerging data to suggest a mechanism beyond the reduction of hyperglycaemia and body weight, and a potential role for the decrease in low-grade inflammation and oxidative stress associated with SGLT2 inhibitor therapy. This positive effect of SGLT2 inhibitors on NAFLD complements their already well-known effects on cardiovascular and chronic kidney diseases.

Hepatic Fat Content and Liver Enzymes Are Associated with Circulating Free and Protein-Bound Advanced Glycation End Products, Which Are Associated with Low-Grade Inflammation: The CODAM Study

Advanced glycation end products (AGEs) accumulate in fatty livers and may contribute to low-grade inflammation (LGI), potentially via their receptor, RAGE. It is unknown if the AGE accumulation in fatty livers results in elevated circulating AGEs. In a cohort study, we investigated the association of liver fat and hepatocellular damage with circulating AGEs and soluble RAGE (sRAGE) and subsequently the association of circulating AGEs and sRAGE with LGI. Cross-sectional associations of liver fat percentage (eLF%; ln-transformed) and liver enzymes (LE score; standardized) with circulating AGEs (free CML, CEL, and MG-H1 in nM and protein-bound CML, CEL, and pentosidine in nmol/mmol lysine; ln-transformed) and sRAGE (pg/ml, ln-transformed) and additionally of AGEs and sRAGE with LGI (standardized) were determined by multiple linear regression. eLF% was positively associated with circulating free CEL (β = 0.090; 95% CI 0.041; 0.139) but inversely with protein-bound CML (β = -0.071; 95% CI -0.108; -0.034). Similarly, the LE score was positively associated with free CML (β = 0.044; 95% CI 0.012; 0.076) and CEL (β = 0.040; 95% CI 0.009; 0.072) but inversely with protein-bound CML (β = -0.037; 95% CI -0.060; -0.013). Free CML (β = 0.297; 95% CI 0.049; 0.545) was positively associated with LGI, while protein-bound CML (β = -0.547; 95% CI -0.888; -0.207) was inversely associated, although this association was absent after adjustment for BMI. eLF% and LE score were not associated with sRAGE and sRAGE not with LGI after adjustment for BMI. Liver fat and enzymes were positively associated with circulating free AGEs, which were associated with LGI. In contrast, inverse relations were observed of liver fat and enzymes with circulating protein-bound AGEs and of protein-bound AGEs with LGI. These data suggest that hepatic steatosis and inflammation affect the formation and degradation of hepatic protein-bound AGEs resulting in elevated circulating free AGE levels. These alterations in AGE levels might influence LGI, but this is likely independent of RAGE.

Ultrasound/Elastography techniques, lipidomic and blood markers compared to Magnetic Resonance Imaging in non-alcoholic fatty liver disease adults

INTRODUCTION

Non-alcoholic fatty liver disease (NAFLD) may progress to steatohepatitis, cirrhosis and complicated hepatocellular carcinoma with defined differential symptoms and manifestations.

OBJECTIVE

To evaluate the fatty liver status by several validated approaches and to compare imaging techniques, lipidomic and routine blood markers with magnetic resonance imaging in adults subjects with non-alcoholic fatty liver disease.

MATERIALS AND METHODS

A total of 127 overweight/obese with NAFLD, were parallelly assessed by Magnetic Resonance Imaging (MRI), ultrasonography, transient elastography and a validated metabolomic designed test to diagnose NAFLD in this cross-sectional study. Body composition (DXA), hepatic related biochemical measurements as well as the Fatty Liver Index (FLI) were evaluated. This study was registered as FLiO: Fatty Liver in Obesity study; NCT03183193.

RESULTS

The subjects with more severe liver disease were found to have worse metabolic parameters. Positive associations between MRI with inflammatory and insulin biomarkers were found. A linear regression model including ALT, RBP4 and HOMA-IR was able to explain 40.9% of the variability in fat content by MRI. In ROC analyses a combination panel formed of ALT, HOMA-IR and RBP4 followed by ultrasonography, ALT and metabolomic test showed the major predictive ability (77.3%, 74.6%, 74.3% and 71.1%, respectively) for liver fat content.

CONCLUSIONS

A panel combination including routine blood markers linked to insulin resistance showed highest associations with MRI considered as a gold standard for determining liver fat content. This combination of tests can facilitate the diagnosis of early stages of non-alcoholic liver disease thereby avoiding other invasive and expensive methods.

Lipid accumulation product in relation to 10-year cardiovascular disease incidence in Caucasian adults: The ATTICA study

BACKGROUND AND AIMS

The lipid accumulation product (LAP) is an index describing lipid over-accumulation based on waist circumference (WC) and fasting triglycerides, and can outperform the body mass index (BMI) in recognizing cardiovascular disease (CVD) risk. We aimed to explore the association of LAP with long-term CVD risk and compare its CVD-predictive value against common anthropometric indices/ratios of obesity.

METHODS

ATTICA is a prospective, population-based cohort that recruited 3042 adults without pre-existing CVD from the Greek general population (age 18-89 years; 1514 men). The 10-year study follow-up (2011-2012) captured the fatal/non-fatal CVD incidence in 2020 participants (50% men). Baseline LAP (cm·mmol/L) was calculated and analyzed in relation to the 10-year CVD incidence.

RESULTS

In total, 317 CVD cases (15.7%) were documented during the follow-up. Baseline LAP showed a significant positive association with the 10-year CVD incidence, even after adjusting for hypertension, diabetes, hypercholesterolemia, smoking, physical activity, Mediterranean diet adherence, and key pro-inflammatory biomarkers (Hazard Ratios per 10 cm·mmol/L of LAP ranging from 1.1 to 1.21, p = 0.04). Moreover, LAP predicted the 10-year CVD study incidence better than common obesity indices (BMI, WC, waist-to-hip, waist-to-height ratio).

CONCLUSIONS

These findings support a positive association between LAP and long-term CVD incidence in CVD-free Caucasian adults from the general population.

The Comparison of Simple Anthropometric and Biochemical Parameters for Predicting Liver Steatosis in Obese Balinese Young Women

BACKGROUND:

The prevalence of non-alcoholic fatty liver disease (NAFLD) is increasing globally. Early identification of liver steatosis (LS) status is critical to prevent the development of NAFLD into non-alcoholic steatohepatitis (NASH) fibrosis.

AIM:

This study aimed at exploring the validity of simple anthropometric and biochemical parameters to predict LS in young obese women.

MATERIALS AND METHODS:

This is a cross-sectional study involving 132 young obese women. We collected the data of measured waist circumference (WC), body mass index (BMI), serum triglyceride (TG), and gamma-glutamyltransferase (GGT). The lipid accumulation product (LAP) was designed from TG and WC variables. Fatty liver index (FLI) was calculated from TG, BMI, WC, and GGT variables. LS status was measured using ultrasonography assay. Statistical significance was set at p < 0.05.

RESULTS:

A positive correlation was found between BMI, WC, TG, GGT, LAP, FLI, and LS (p = 0.001). We found that BMI is a better predictor for LS to WC. Our multiple linear regression analysis revealed that BMI, GGT, and TG could predict 41.4% of LS. The validity (specificity, sensitivity, and odds ratio) of simple body fat parameters in predicting LS were as follows: BMI ≥ 30 kg/m² (69.6%, 74.4%, and 6.21), WC ≥ 90 cm (67.4%, 70.0%, and 4.28), TG ≥ 100 mg/dL (70.6%, 70.0%, and 5.62) and GGT ≥ 20 μg/L (69.6%, 77.5%, and 7.87), as well as LAP ≥ 30 (82.6%, 70.0%, and 11.1), and FLI ≥ 2.5 (79.3%, 72.5%, and 10.1), significantly.

CONCLUSION:

Simple anthropometric and biochemical parameters (BMI, WC, and TG, GGT), are appropriately predicting LS as well as LAP, and FLI among obese Balinese young women.

Anthropometric indicators of visceral adiposity as predictors of non-alcoholic fatty liver disease: A review

The objective was to critically analyze studies that evaluated the predictive capacity of indicators of visceral adiposity in non-alcoholic fatty liver disease (NAFLD). The bibliographic research was carried out using the electronic database PubMed, LILACS and SciELO, references of selected articles. Although we found few studies, they have already used several indicators of visceral adiposity as waist circumference, waist-to-hip ratio, waist-to-height ratio, Lipid accumulation product, Body Shape Index, Body Roundness Index and most them were good predictors of NAFLD. Thus, the anthropometric indicators may contribute for the diagnosis of NAFLD in a simple, low-cost and non-invasive way, allowing early therapeutic measures to prevent the evolution to non-alcoholic steatohepatitis.

Increased Serum Uric Acid over five years is a Risk Factor for Developing Fatty Liver

The prevalence of fatty liver disease (FLD) is increasing. To clarify risk factors for developing FLD, we analyzed a database from healthy Japanese adults who had annual medical check-ups in 2004 and reexamined in 2009. We used the fatty liver index (FLI) to classify participants as FLD (FLI ≥60), borderline FLD (30≤ FLI <60), and normal liver (FLI <30). Subjects with hepatitis B or C virus infection and subjects with FLD at the baseline were excluded. The cumulative incidence of FLD from normal liver and from borderline FLD over five years were 0.65% (52/8,025) and 12.9% (244/1,888), respectively. After multiple adjustments, higher serum uric acid (SUA) (OR:1.92; 95% CI:1.40–2.63) and increased SUA change (OR:3.734; 95% CI:2.57–5.42) became risk factors for developing FLD from normal liver, as well as younger age and higher body mass index. The risk factors for developing FLD from borderline FLD were similar. Not only higher baseline SUA but also increased SUA change became independent risks for developing FLD.