Changing epidemiology, global trends and implications for outcomes of NAFLD

Similar weight loss with semaglutide regardless of diabetes and cardiometabolic risk parameters in individuals with metabolic dysfunction-associated steatotic liver disease: Post hoc analysis of three randomised controlled trials

AIMS

Weight loss mediated by glucagon-like peptide-1 (GLP-1) analogues is lower in patients with type 2 diabetes versus those without. Type 2 diabetes and obesity are risk factors for metabolic dysfunction-associated steatotic liver disease (MASLD) and associated steatohepatitis (MASH). We evaluated weight changes in adults with MASLD/MASH with or without type 2 diabetes receiving the GLP-1 analogue semaglutide.

MATERIALS AND METHODS

This was a post hoc analysis of data from three 48-72-week randomised trials investigating the effect of semaglutide versus placebo in adults with MASLD (NCT03357380) or biopsy-confirmed MASH (NCT02970942 and NCT03987451). Pooled data for semaglutide (0.4 mg once daily and 2.4 mg once weekly [n = 163]) and placebo (n = 137) were analysed at 1 year. Weight changes were analysed by type 2 diabetes status (type 2 diabetes [n = 209], pre-type 2 diabetes [n = 51] and no diabetes [n = 40]) and by other cardiometabolic risk parameters using analysis of covariance and Spearman's rank correlations.

RESULTS

The overall mean weight change was -11.1 kg (-11.7%) and -0.7 kg (-0.6%) with semaglutide and placebo, respectively. While numerically higher for people without type 2 diabetes, estimated treatment differences with semaglutide versus placebo were similar overall for people with type 2 diabetes (-10.2 kg; -10.8%), pre-type 2 diabetes (-9.8 kg; -10.2%) and no diabetes (-11.6 kg; -13.1%). Differences between groups were not statistically significant (p > 0.50 for all). Baseline fasting plasma glucose, glycated haemoglobin, insulin levels, insulin resistance and lipids did not correlate with weight change.

CONCLUSIONS

People with MASLD/MASH had similar semaglutide-mediated weight loss regardless of type 2 diabetes status and other cardiometabolic risk parameters.

Integrated HPLC, pharmacodynamics, and immunoprofiling to explore active components and mechanism of Zhi Bai Heye Fang on glycolipid metabolic disorders in mice

Zhi Bai Heye Fang (AR-PCC-NF) exerts a positive effect on glycolipid metabolic disorders in the clinical setting; however, its efficacy components and mechanisms of action remain unclear. Glycolipid metabolic disorders in mice were used to evaluate the therapeutic effects of AR-PCC-NF and its individual components, and the chemical components of AR-PCC-NF were detected by HPLC. An insulin-resistant cell model was then treated with 12 biological components in vitro, and seven candidate active components were administered to mice with glycolipid metabolic disorders to investigate the efficacy and mechanism of AR-PCC-NF. AR-PCC-NF improved glucolipid metabolism more effectively than did the individual components. The protein expression of INSR and GLUT4 was elevated, and FOXO1 expression and impaired mitochondrial debris in the liver were reduced by AR-PCC-NF. Furthermore, neomangiferin, chlorogenic acid, isomangiferin, 2-hydroxy-1-methoxyaporphine, hyperoside, nuciferine, and berberine improved glucose consumption or T-CHO in vitro. Interestingly, in vivo, neomangiferin, chlorogenic acid, isomangiferin, 2-hydroxy-1-methoxyaporphine, hyperoside, nuciferine, and berberine partially improved abnormal glucolipid metabolism in mice when used separately, but the effects were equivalent to those of AR-PCC-NF when the seven active components were used in combination. Moreover, AR-PCC-NF and its efficacy components upregulated the protein expression of p-AMPK/AMPK and PGC-1α, decreased the levels PPARα, and reduced mitochondrial debris in the liver. In conclusion, neomangiferin, chlorogenic acid, isomangiferin, 2-hydroxy-1-methoxyaporphine, hyperoside, nuciferine, and berberine are the main active components of AR-PCC-NF in the treatment of glycolipid metabolic diseases, and the mechanism is related to the regulation of the AMPK/PGC-1α.

Loss of mitochondrial amidoxime-reducing component 1 (mARC1) prevents disease progression by reducing fibrosis in multiple mouse models of chronic liver disease

BACKGROUND

Metabolic dysfunction-associated steatotic liver disease is a prevalent disease that affects nearly one-third of the global population. Recent genome-wide association studies revealed that a common missense variant in the gene encoding mitochondrial amidoxime reducing component 1 (mARC1) is associated with protection from metabolic dysfunction-associated steatotic liver disease, all-cause cirrhosis, and liver-related mortality suggesting a role for mARC1 in liver pathophysiology; however, little is known about its function in the liver. In this study, we aimed to evaluate the impact of mARC1 hepatoprotective variants on protein function, the effect of loss of mARC1 on cellular lipotoxic stress response, and the effect of global or hepatocyte-specific loss of mARC1 in various mouse models of metabolic dysfunction-associated steatohepatitis and liver fibrosis.

METHODS AND RESULTS

Expression and characterization of mARC1 hepatoprotective variants in cells and mouse liver revealed that the mARC1 p.A165T exhibited lower protein levels but maintained its mitochondrial localization. In cells, the knockdown of mARC1 improved cellular bioenergetics and decreased mitochondrial superoxide production in response to lipotoxic stress. Global genetic deletion and hepatocyte-specific knockdown of mARC1 in mice significantly reduced liver steatosis and fibrosis in multiple mouse models of metabolic dysfunction-associated steatohepatitis and liver fibrosis. Furthermore, RNA-seq analysis revealed that the pathways involved in extracellular matrix remodeling and collagen formation were downregulated in the liver, and the plasma lipidome was significantly altered in response to the loss of mARC1 in mice.

CONCLUSIONS

Overall, we have demonstrated that loss of mARC1 alters hepatocyte response to lipotoxic stress and protects mice from diet-induced MASH and liver fibrosis consistent with findings from human genetics.

Epidemiology of metabolic dysfunction-associated steatotic liver disease

As the rates of obesity and type 2 diabetes (T2D) continue to increase globally, so does the prevalence of metabolic dysfunction-associated steatotic liver disease (MASLD). Currently, 38% of all adults and 7-14% of children and adolescents have MASLD. By 2040, the MASLD prevalence rate for adults is projected to increase to more than 55%. Although MASLD does not always develop into progressive liver disease, it has become the top indication for liver transplant in the United States for women and those with hepatocellular carcinoma (HCC). Nonetheless, the most common cause of mortality among patients with MASLD remains cardiovascular disease. In addition to liver outcomes (cirrhosis and HCC), MASLD is associated with an increased risk of developing de novo T2D, chronic kidney disease, sarcopenia, and extrahepatic cancers. Furthermore, MASLD is associated with decreased health-related quality of life, decreased work productivity, fatigue, increased healthcare resource utilization, and a substantial economic burden. Similar to other metabolic diseases, lifestyle interventions such as a heathy diet and increased physical activity remain the cornerstone of managing these patients. Although several obesity and T2D drugs are available to treat co-morbid disease, resmetirom is the only MASH-targeted medication for patients with stage 2-3 fibrosis that has approved by the Food and Drug Administration for use in the United States. This review discusses MASLD epidemiology and its related risk factors and outcomes and demonstrates that without further global initiatives, MASLD incidence could continue to increase.

The Epidemiology of Ascites in a Multi-Ethnic Asian Population

Introduction

Ascites is a common condition seen by clinicians in secondary care. Data on the epidemiology of ascites in Asians is lacking.

Methodology

A retrospective case record review was performed in this large, referral institution between January 2016 and December 2019. Clinical and epidemiological data of adult (age > 18 years) patients with ascites, identified from the Radiology database, were obtained from this institutions' electronic medical records.

Results

A total of 838 patients (median age 59.77 ± 14.46 years, 56% males, ethnicity: Chinese 41.9%, Malay 34.8%, Indian 22.7%) were included in the study. Malignancy (28.9%) and liver cirrhosis (27.9%) were the most common etiology of ascites. Most of the malignant etiology of ascites were due to female-related (breast and ovarian) and gastrointestinal (colon, liver, pancreatic, bile duct) cancer. Liver cirrhosis-related ascites was mostly due to metabolic-associated fatty liver disease (MASLD, 35.5%) and hepatitis B infection (20.5%). An increased age (> 40 years) was associated with all causes of ascites. The etiology of ascites varied with ethnicity as follows: the most common cause of ascites was malignancy (37.6%) among ethnic Chinese, heart failure (20.5%) in ethnic Malays and chronic liver disease (43.7%) in ethnic Indians.

Conclusion

Malignancy and liver cirrhosis are the leading cause of ascites in a multi-ethnic Asian population. Demographic factors, particularly ethnicity, have a strong influence on the etiology of ascites.

Adipokine/hepatokines profiling of fatty liver in adolescents and young adults: cross-sectional and prospective analyses of the BCAMS study

OBJECTIVE

The underlying connections between obesity and non-alcoholic fatty liver disease (NAFLD) are not fully understood. One potential link might be the imbalanced adipokines and hepatokines. We aimed to explore the associations between specific adipokines/hepatokines and NAFLD in Chinese youth and to determine how these biomarkers mediate the obesity-NAFLD relationship.

METHODS

We analyzed data from the 10-year follow-up visit of the Beijing Children and Adolescents Metabolic Syndrome (BCAMS) study (n = 509; mean age = 20.2 years) for a comprehensive metabolic risk assessment, including liver ultrasound and plasma measurements of adiponectin, leptin, fibroblast growth factor 21 (FGF21), retinol-binding protein 4 (RBP4), and angiopoietin-like protein 8 (ANGPTL8). Longitudinal analysis was performed on a subgroup (n = 307), with complete baseline (mean age = 12.2 years) and follow-up data. Mediation models assessed how obesity at baseline and follow-up influence NAFLD through these biomarkers.

RESULTS

Participants with NAFLD exhibited a high prevalence of central obesity (90.9%). Both cross-sectional and prospective analyses identified increased RBP4, FGF21, leptin, and decreased adiponectin levels as significant predictors of NAFLD. More adipokine/hepatokine abnormalities were linked to higher NAFLD risk. Furthermore, ratios reflecting adipokine/hepatokine imbalances, including leptin/adiponectin, FGF21/adiponectin, and RBP4/adiponectin, demonstrated stepwise changes correlating with NAFLD severity (all p < 0.05). Mediation analysis indicated that these four adipokines/hepatokines accounted for approximately 72.4% of the central obesity-NAFLD relationship and 80.1% in the subgroup analysis using baseline childhood data.

CONCLUSIONS

Dysregulated adipokines/hepatokines may explain the onset or progression of obesity-related NAFLD in youths. Higher RBP4, FGF21 and leptin, alongside lower adiponectin, could serve as early biomarkers for NAFLD.

Exploring the role of curcumin in mitigating oxidative stress to alleviate lipid metabolism disorders

Lipid metabolism plays a crucial role in maintaining homeostasis and overall health, as lipids are essential molecules involved in bioenergetic processes. An increasing body of research indicates that disorders of lipid metabolism can contribute to the development and progression of various diseases, including hyperlipidemia, obesity, non-alcoholic fatty liver disease (NAFLD), diabetes mellitus, atherosclerosis, and cancer, potentially leading to poor prognoses. The activation of the oxidative stress pathway disrupts lipid metabolism and induces cellular stress, significantly contributing to metabolic disorders. A well-documented crosstalk and interconnection between these metabolic disorders exists. Consequently, researchers have sought to identify antioxidant-rich substances in readily accessible everyday foods for potential use as complementary therapies. Curcumin, known for its anti-inflammatory and antioxidant properties, has been shown to enhance cellular antioxidant activity, mitigate oxidative stress, and alleviate lipid metabolism disorders by reducing reactive oxygen species (ROS) accumulation. These effects include decreasing fat deposition, increasing fatty acid uptake, and improving insulin sensitivity. A review of the existing literature reveals numerous studies emphasizing the role of curcumin in the prevention and management of metabolic diseases. Curcumin influences metabolic disorders through multiple mechanisms of action, with the oxidative stress pathway playing a central role in various lipid metabolism disorders. Thus, we aimed to elucidate the role of curcumin in various metabolic disorders through a unified mechanism of action, offering new insights into the prevention and treatment of metabolic diseases. Firstly, this article provides a brief overview of the basic pathophysiological processes of oxidative stress and lipid metabolism, as well as the role of oxidative stress in the pathogenesis of lipid metabolism disorders. Notably, the article reviews the role of curcumin in mitigating oxidative stress and in preventing and treating diseases associated with lipid metabolism disorders, including hyperlipidemia, non-alcoholic fatty liver disease (NAFLD), atherosclerosis, obesity, and diabetes, thereby highlighting the therapeutic potential of curcumin in lipid metabolism-related diseases.

AAV capsid prioritization in normal and steatotic human livers maintained by machine perfusion

Therapeutic efficacy and safety of adeno-associated virus (AAV) liver gene therapy depend on capsid choice. To predict AAV capsid performance under near-clinical conditions, we established side-by-side comparison at single-cell resolution in human livers maintained by normothermic machine perfusion. AAV-LK03 transduced hepatocytes much more efficiently and specifically than AAV5, AAV8 and AAV6, which are most commonly used clinically, and AAV-NP59, which is better at transducing human hepatocytes engrafted in immune-deficient mice. AAV-LK03 preferentially transduced periportal hepatocytes in normal liver, whereas AAV5 targeted pericentral hepatocytes in steatotic liver. AAV5 and AAV8 transduced liver sinusoidal endothelial cells as efficiently as hepatocytes. AAV capsid and steatosis influenced vector episome formation, which determines gene therapy durability, with AAV5 delaying concatemerization. Our findings inform capsid choice in clinical AAV liver gene therapy, including consideration of disease-relevant hepatocyte zonation and effects of steatosis, and facilitate the development of AAV capsids that transduce hepatocytes or other therapeutically relevant cell types in the human liver with maximum efficiency and specificity.

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.

Prognostic performance of the two-step clinical care pathway in metabolic dysfunction-associated steatotic liver disease

BACKGROUND & AIMS

Current guidelines recommend a two-step approach for risk stratification in patients with metabolic dysfunction-associated steatotic liver disease (MASLD) involving Fibrosis-4 index (FIB-4) followed by liver stiffness measurement (LSM) by vibration-controlled transient elastography (VCTE) or similar second-line tests. This study aimed to examine the prognostic performance of this approach.

METHODS

The VCTE-Prognosis study was a longitudinal study of patients with MASLD who had undergone VCTE examinations at 16 centres from the US, Europe and Asia with subsequent follow-up for clinical events. The primary endpoint was incident liver-related events (LREs), defined as hepatic decompensation and/or hepatocellular carcinoma.

RESULTS

Of 12,950 patients (mean age 52 years, 41% female, 12.1% LSM >12 kPa), baseline FIB-4, at cut-offs of 1.3 (or 2.0 for age ≥65) and 2.67, classified 66.3% as low-risk and 9.8% as high-risk, leaving 23.9% in the intermediate-risk zone. After classifying intermediate FIB-4 patients as low-risk if LSM was <8.0 kPa and high-risk if LSM was >12.0 kPa, 81.5%, 4.6%, and 13.9% of the full cohort were classified as low-, intermediate-, and high-risk, respectively. At a median (IQR) follow-up of 47 (23-72) months, 248 (1.9%) patients developed LREs. The 5-year cumulative incidence of LREs was 0.5%, 1.0% and 10.8% in the low-, intermediate- and high-risk groups, respectively. Replacing LSM with Agile 3+, Agile 4, and FAST did not reduce the intermediate-risk zone or improve event prediction. Classifying intermediate FIB-4 patients by LSM <10 kPa (low-risk) and >15 kPa (high-risk) reduced the intermediate-risk zone while maintaining predictive performance.

CONCLUSIONS

The non-invasive two-step approach of FIB-4 followed by LSM is effective in classifying patients at different risks of LREs.

IMPACT AND IMPLICATIONS

Metabolic dysfunction-associated steatotic liver disease (MASLD) is emerging as one of the leading causes of cirrhosis and hepatocellular carcinoma worldwide, but only a minority of patients will develop these complications. Therefore, it is necessary to use non-invasive tests instead of liver biopsy for risk stratification. Additionally, as most patients with MASLD are seen in primary care instead of specialist settings, cost and availability of the tests should be taken into consideration. In this multicentre study, the use of the Fibrosis-4 index followed by liver stiffness measurement by vibration-controlled transient elastography effectively identified patients who would later develop liver-related events. The results support current recommendations by various regional guidelines on a clinical care pathway based on non-invasive tests to diagnose advanced liver fibrosis.

Non-canonical Wnt signaling pathway activated NFATC3 promotes GDF15 expression in MASH: prospective analyses of UK biobank proteomic data

BACKGROUND

Our previous research demonstrated that growth differentiation factor 15 (GDF15) exhibited superior predictive capability for metabolic dysfunction-associated steatohepatitis (MASH) development with an AUC of 0.86 at 10 years before disease diagnosis. However, the specific pathways and molecular mechanisms associated with GDF15 expression during MASH development remain to be fully investigated in humans.

METHODS

A nested case-control study comprising a MASH group of 78 individuals and three age- and sex-matched control groups (156 metabolic dysfunction-associated steatosis, 78 viral hepatitis, and 156 normal liver controls) was conducted. The baseline levels of GDF15-related transcription factors and upstream signaling pathways associated with the identified transcription factors were analysed prospectively.

RESULTS

The significantly higher level of nuclear factor of activated T cells 3 (NFATC3), a transcription factor for GDF15, was identified in the circulation in MASH patients compared to controls. Expression of the non-canonical Wnt signaling pathway that is upstream of NFATC3, and its related proteins CTHRC1, FRZB, SFRP1, and SFRP4, were highest in the MASH group, suggesting a non-canonical Wnt signaling/NFATC3/GDF-15 cascade in MASH disease pathogenesis. A predictive model for MASH development based on four biomarkers (CTHRC1, FRZB, NFATC3, and GDF15) showed an AUC of 0.90 at 10 years. A protein-clinical model that included these four circulating proteins and BMI yielded an AUC of 0.93 at 10 years.

CONCLUSIONS

Non-canonical Wnt signaling pathway may activate NFATC3 to promote GDF15 expression in MASH disease pathogenesis. These molecular mechanisms provide novel insights for developing targeted therapies that could modulate the non-canonical Wnt/NFATC3/GDF15 cascade to prevent/treat MASH.

Construction of a Compound Model to Enhance the Accuracy of Hepatic Fat Fraction Estimation with Quantitative Ultrasound

Background: we evaluated regression models based on quantitative ultrasound (QUS) parameters and compared them with a vendor-provided method for calculating the ultrasound fat fraction (USFF) in metabolic dysfunction-associated steatotic liver disease (MASLD). Methods: We measured the attenuation coefficient (AC) and the backscatter-distribution coefficient (BSC-D) and determined the USFF during a liver ultrasound and calculated the magnetic resonance imaging proton-density fat fraction (MRI-PDFF) and steatosis grade (S0-S4) in a combined retrospective-prospective cohort. We trained multiple models using single or various QUS parameters as independent variables to forecast MRI-PDFF. Linear and nonlinear models were trained during five-time repeated three-fold cross-validation in a retrospectively collected dataset of 60 MASLD cases. We calculated the models' Pearson correlation (r) and the intraclass correlation coefficient (ICC) in a prospectively collected test set of 57 MASLD cases. Results: The linear multivariable model (r = 0.602, ICC = 0.529) and USFF (r = 0.576, ICC = 0.54) were more reliable in S0- and S1-grade steatosis than the nonlinear multivariable model (r = 0.492, ICC = 0.461). In S2 and S3 grades, the nonlinear multivariable (r = 0.377, ICC = 0.32) and AC-only (r = 0.375, ICC = 0.313) models' approximated correlation and agreement surpassed that of the multivariable linear model (r = 0.394, ICC = 0.265). We searched a QUS parameter grid to find the optimal thresholds (AC ≥ 0.84 dB/cm/MHz, BSC-D ≥ 105), above which switching from a linear (r = 0.752, ICC = 0.715) to a nonlinear multivariable (r = 0.719, ICC = 0.641) model could improve the overall fit (r = 0.775, ICC = 0.718). Conclusions: The USFF and linear multivariable models are robust in diagnosing low-grade steatosis. Switching to a nonlinear model could enhance the fit to MRI-PDFF in advanced steatosis.

Correlation between metabolic dysfunction-associated steatotic liver disease and subclinical coronary atherosclerosis in eastern China

BACKGROUND

Metabolic dysfunction-associated steatotic liver disease (MASLD) is characterized by the presence of at least one cardiovascular disease (CVD) risk factor, underscoring its potential to elevate CVD risk in affected individuals. However, evidence linking MASLD to subclinical coronary atherosclerosis remains scarce, and further investigations are necessary to elucidate the independent role of varying MASLD severities as a CVD risk factor.

METHODS

This study analyzed 7,507 participants aged ≥ 40 who underwent comprehensive health evaluations at the Shanghai Health and Medical Center. Logistic regression analysis was utilized to explore the relationship between MASLD severity and the presence of coronary artery calcification (CAC). Correlation analysis was performed to assess the association between MASLD severity and CAC staging.

RESULTS

After adjusting for established CVD risk factors, MASLD showed a significant association with CAC, which intensified with increasing MASLD severity. Among individuals with hypertension, MASLD was markedly correlated with CAC. In contrast, in non-hypertensive participants, only moderate and severe MASLD were significantly associated with CAC, while mild MASLD demonstrated no notable link, even after adjustment for CVD risk factors. Moreover, correlation analysis revealed a positive association between MASLD severity and CAC staging, indicating that higher MASLD severity aligned with more advanced CAC stages.

CONCLUSION

This study highlighted that MASLD severity was independently associated with subclinical atherosclerosis, irrespective of traditional CVD risk factors, in an urban eastern Chinese population without a prior history of coronary atherosclerosis. The strongest associations were observed in individuals with severe MASLD, emphasizing the importance of assessing MASLD severity in CVD risk stratification.

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

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

Practical Approaches to Managing Dyslipidemia in Patients With Metabolic Dysfunction-Associated Steatotic Liver Disease

Dyslipidemia is a major risk factor for cardiovascular disease, and its impact may be exacerbated when accompanied by metabolic dysfunction-associated steatotic liver disease (MASLD). The simultaneous management of these conditions poses multiple challenges for healthcare providers. Insulin resistance has been implicated in the pathogenesis of both dyslipidemia and MASLD, necessitating a holistic approach to managing dyslipidemia, glucose levels, body weight, and MASLD. This review explores the intricate pathophysiological relationship between MASLD and dyslipidemia. It also examines current guidance regarding the use of lipid-lowering agents (including statins, ezetimibe, fibrates, omega-3 polyunsaturated fatty acids, and proprotein convertase subtilisin/kexin type 9 inhibitors) as well as glucose-lowering medications (such as pioglitazone, glucagon-like peptide-1 receptor agonists, and sodium-glucose cotransporter 2 inhibitors) in patients with MASLD, with or without metabolic dysfunction-associated steatohepatitis (MASH), and dyslipidemia. Additionally, the review addresses the potential of emerging drugs to concurrently target both MASLD/MASH and dyslipidemia. Our hope is that a deeper understanding of the mechanisms underlying MASLD and dyslipidemia may assist clinicians in the management of these complex cases.

Association between menopause, body composition, and nonalcoholic fatty liver disease: A prospective cohort in northern China

BACKGROUND

The association between menopause, changes in body composition, and nonalcoholic fatty liver disease is not clear, and there is a lack of weight management strategies for perimenopausal women from the perspective of preventing nonalcoholic fatty liver disease.

METHODS

A total of 1316 postmenopausal and 3049 premenopausal women in the Kailuan cohort in China between 2006 and 2017 were enrolled and followed up till 2021. Cox regression models, including the causal mediation analyses, were used to estimate the association between menopause and nonalcoholic fatty liver disease and the potential mediation effect of changes in body composition. We also explored the impact of weight changes on the correlation between menopause and nonalcoholic fatty liver disease.

RESULTS

Women who experienced menopause had a higher risk of nonalcoholic fatty liver disease than premenopausal women (9-year cumulative incidence: 56.87 % vs. 48.80 %, adjusted hazard ratio = 1.219, 95 % confidence interval: 1.088-1.365). The nine-year cumulative incidence of nonalcoholic fatty liver disease was higher among overweight/obese postmenopausal women (67.24 % vs. 45.74 %, P < 0.001) and those with abdominal obesity (63.36 % vs. 49.69 %, P < 0.001); however, the hazard ratio of menopause for nonalcoholic fatty liver disease was more evident in women with a body mass index under 23.0 kg/m2 (hazard ratio = 1.434, 95 % confidence interval: 1.168-1.759) and those with normal waist circumference (hazard ratio = 1.362, 95 % confidence interval: 1.129-1.643), which could partially be explained by the visceral fat index (7.09 % and 7.35 % mediation, respectively). Weight loss of 3 % or more or reduction in waist circumference by 5 % or more was associated with a 31.1 % reduction (95 % confidence interval, 20.8 %-40.0 %) or a 14.2 % reduction (95 % confidence interval, 1.1 %-25.6 %) in the risk of nonalcoholic fatty liver disease among the premenopausal women. For postmenopausal women, weight gain of 3 % or more was associated with an increased risk of nonalcoholic fatty liver disease, especially in individuals with a body mass index under 23.0 kg/m2.

CONCLUSION

Menopause was associated with a higher risk of nonalcoholic fatty liver disease, partially by increasing visceral fat. Controlling weight in perimenopausal women may reduce the risk.

Comparison Between Attenuation Measurement and the Controlled Attenuation Parameter for the Assessment of Hepatic Steatosis Based on MRI Images

BACKGROUND AND AIMS

This study prospectively compared the diagnostic accuracies of the improved Attenuation Measurement (iATT) algorithm and the Controlled Attenuation Parameter (CAP) and assessed the interchangeability of iATT with magnetic resonance imaging-derived proton density fat fraction (MRI-derived PDFF).

METHODS

Patients with chronic liver disease were prospectively enrolled and underwent iATT, CAP and MRI-derived PDFF measurements for hepatic steatosis evaluation. According to MRI-derived PDFF values, steatosis grades were categorised as steatosis (S)0 (< 5.2%), S1 (≥ 5.2%, < 11.3%), S2 (≥ 11.3%, < 17.1%) and S3 (≥ 17.1%). Correlation coefficients (CCs) were determined, diagnostic performances were compared by the area under the receiver operating characteristic curve (AUROC) and agreement was evaluated using the calculated percentage error (PE) and expected limit of agreement (LOA).

RESULTS

A total of 414 patients (median age 64 years, 203 females) were evaluated. The CC between iATT and MRI-derived PDFF was 0.727 (95% confidence interval [CI] 0.678-0.770), which was higher than that between CAP and MRI-derived PDFF at 0.615 (95% CI 0.551-0.672) (p < 0.001). The AUROCs of iATT for ≥ S1, ≥ S2 and ≥ S3 were 0.901 (95% CI 0.870-0.931), 0.878 (95% CI 0.846-0.910) and 0.839 (95% CI 0.794-0.883), respectively. The diagnostic performances of iATT for ≥ S1 and ≥ S2 showed significantly higher AUROCs than those of CAP (p < 0.001, p = 0.036, respectively). The calculated PE and the expected LOA for CAP and iATT were 38.94% and 22.66% and 32.94% and 30.03%, respectively.

CONCLUSIONS

iATT was superior to CAP and comparable to MRI-derived PDFF in assessing hepatic steatosis.

TRIAL REGISTRATION

This study was registered in the University Hospital Medical Information Network (UMIN) Clinical Trials Registry (UMIN000047411).

Advanced Liver Fibrosis Predicts Liver Outcomes in Biopsy-proven Metabolic Dysfunction-associated Steatotic Liver Disease: A U.S.-based Single-center Retrospective Cohort Study

BACKGROUND AND AIMS

Data regarding risk factors and long-term outcomes of U.S. patients with biopsy-proven metabolic dysfunction-associated steatotic liver disease (MASLD) are limited. This study aimed to investigate the role of clinical and histologic risk factors on long-term outcomes in patients with MASLD.

METHODS

A retrospective cohort study of 451 adults with biopsy-proven MASLD was conducted at a U.S. academic hospital from 2012 to 2020. An experienced pathologist evaluated the index liver biopsy. Patients with a prior liver transplant or alternative etiologies of chronic liver disease were excluded. The duration of the risk exposure was determined from the date of the index liver biopsy to an outcome event or the last follow-up examination. Outcome events of interest included incident liver-related events, liver decompensation, and all-cause mortality.

RESULTS

In the final cohort of 406 patients followed for a median of 3.7 years (interquartile range: 4.8 years), 35 patients died, 41 developed hepatic decompensation, and 70 experienced a liver-related event. Among histologic risk factors, stage 3 (adjusted Hazard ratio (aHR) 2.68, 95% confidence interval (CI) 1.18-6.11) and stage 4 (aHR 6.96, 95% CI 3.55-13.64) fibrosis were associated with incident liver-related events compared to stage 0-1 fibrosis. Stage 4 (aHR 8.46, 95% CI 3.26-21.99) fibrosis alone was associated with incident liver decompensation events compared to stage 0-1 fibrosis. Among clinical risk factors, hypertension (aHR 2.58, 95% CI 1.05-6.34) was associated with incident liver decompensation.

CONCLUSIONS

In a U.S. single-center cohort of patients with biopsy-proven MASLD, advanced fibrosis was the primary risk factor for incident liver decompensation and liver-related events.

Investigation of Active Components of Meconopsis integrifolia (Maxim.) Franch in Mitigating Non-Alcoholic Fatty Liver Disease

Nonalcoholic fatty liver disease (NAFLD) has rapidly emerged as the most prevalent chronic liver disease globally, representing a significant and escalating public health challenge. Meconopsis integrifolia (Maxim.) Franch, a traditional Tibetan medicinal herb used for treating hepatitis, remains largely unexplored regarding its therapeutic potential and active components in combating NAFLD. This study first evaluated the in vitro lipid accumulation inhibitory activity of different extraction fractions of M. integrifolia using a HepG2 cell steatosis model. The ethyl acetate fraction was found to significantly reduce triglyceride (TG) and low-density lipoprotein (LDL) levels, inhibit lipid droplet deposition in HepG2 cells, and promote lipid metabolism balance through modulation of the AMPK/SREPB-1c/PPAR-α signaling pathway. Further analysis utilizing chromatographic techniques and nuclear magnetic resonance spectroscopy (NMR) led to the isolation of 13 compounds from the active ethyl acetate fraction. Notably, compounds 6, 9, 10, 11, 12, and 13 were identified for the first time from this Tibetan herb. In vitro activity assays and molecular docking analyses further confirmed that the compounds Luteolin (1), Quercetin 3-O-[2‴, 6‴-O-diacetyl-β-d-glucopyranosyl-(1→6)-β-d-glucopyranoside] (6), and Quercetin 3-O-[2‴-O-acetyl-β-d-glucopyranosyl-(1→6)-β-d-glucopyranoside] (8) are potential key components responsible for the NAFLD-ameliorating effects of M. integrifolia. This study highlights the therapeutic potential of M. integrifolia in treating NAFLD and provides a foundation for its further development and application, underscoring its significance in the advanced utilization of traditional Tibetan medicine.

Relationship of Interleukin 6 with Hepatic Steatosis and Liver Fibrosis in Rheumatoid Arthritis at a Rheumatology Care Center in Cartagena, Colombia

BACKGROUND/OBJECTIVES

This study aimed to investigate the association of IL-6 with steatotic liver disease (SLD) and liver fibrosis (LF) in rheumatoid arthritis (RA) patients at a rheumatology center in Cartagena de Indias, Colombia.

METHODS

This was a cross-sectional study that included RA and non-RA cases. The level of cellular expression of interleukin 6 (IL-6) was evaluated by flow cytometry in peripheral blood leukocytes, and the presence of SLD and LF was detected by elastosonography. The main outcome was to establish the association between the levels of cellular expression of IL-6 and the development of SLD and LF.

RESULTS

This study included 47 cases of RA and 34 cases on-RA, with a mean age of 54 and 55 years, respectively. The frequency of SLD was 55.3% in RA and 38.2% in non-RA. The frequency of LF was 12.8% in RA and 14.7% in non-RA, with no statistical difference. The levels of cellular expression of IL-6 were significantly higher in RA compared to non-RA. Cellular expression of IL-6 was associated with the presence of SLD (54% vs. 30.3%; p = 0.002). This association was not maintained in RA cases (49.5% vs. 47.6%; p = 0.571). No association was found between cellular expression of IL-6 and LF in the total population (43.8% vs. 42.7%; p = 0.813) nor in RA cases (59.41% vs. 48.3%; p = 0.526).

CONCLUSIONS

IL-6 levels were related to SLD in the evaluated sample, and RA was not a risk factor for SLD or LF. The prognostic role of IL-6 for SLD in patients with RA requires further studies.

Statins decrease the risk of hepatocellular carcinoma in metabolic dysfunction-associated steatotic liver disease: A systematic review and meta-analysis

BACKGROUND

Metabolic dysfunction-associated steatotic liver disease (MASLD) is a leading cause of chronic liver disease with a significant risk of developing hepatocellular carcinoma (HCC). Recent clinical evidence indicates the potential benefits of statins in cancer chemoprevention and therapeutics. However, it is still unclear if these drugs can lower the specific risk of HCC among patients with MASLD.

AIM

To investigate the impact of statin use on the risk of HCC development in patients with MASLD.

METHODS

A systematic review and meta-analysis of all the studies was performed that measured the effect of statin use on HCC occurrence in patients with MASLD. The difference in HCC risk between statin users and non-users was calculated among MASLD patients. We also evaluated the risk difference between lipophilic versus hydrophilic statins and the effect of cumulative dose on HCC risk reduction.

RESULTS

A total of four studies consisting of 291684 patients were included. MASLD patients on statin therapy had a 60% lower pooled risk of developing HCC compared to the non-statin group [relative risk (RR) = 0.40, 95%CI: 0.31-0.53, I 2 = 16.5%]. Patients taking lipophilic statins had a reduced risk of HCC (RR = 0.42, 95%CI: 0.28-0.64), whereas those on hydrophilic statins had not shown the risk reduction (RR = 0.57, 95%CI: 0.27-1.20). The higher (> 600) cumulative defined daily doses (cDDD) had a 70% reduced risk of HCC (RR = 0.30, 95%CI: 0.21-0.43). There was a 29% (RR = 0.71, 95%CI: 0.55-0.91) and 43% (RR = 0.57, 95%CI: 0.40-0.82) decreased risk in patients receiving 300-599 cDDD and 30-299 cDDD, respectively.

CONCLUSION

Statin use lowers the risk of HCC in patients with MASLD. The higher cDDD and lipophilicity of statins correlate with the HCC risk reduction.

Mechanisms and therapeutic targets of mitochondria in the progression of metabolic dysfunction-associated steatotic liver disease

Metabolic Dysfunction-Associated Steatotic Liver Disease (MASLD) includes liver disease processes from simple fatty liver to nonalcoholic steatohepatitis, which may progress to liver fibrosis, cirrhosis, and even hepatocellular carcinoma (HCC). As the incidence of HCC derived from viral hepatitis decreases, MASLD has emerged as a significant health threat, driven by lifestyle changes and rising obesity rates among patients. The pathogenesis of MASLD is complex, involving factors such as insulin resistance, gut microbiota imbalance, and genetic and epigenetic factors. In recent years, the role of mitochondrial dysfunction in MASLD has gained significant attention, involving β-oxidation imbalance, oxidative stress increase, mitophagy defects, and mitochondrial DNA (mtDNA) mutations. This article reviews the pathophysiological mechanisms of mitochondrial dysfunction in MASLD, diagnostic methods, and potential therapeutic strategies. By synthesizing current research findings, the review aims to highlight the critical role of mitochondrial dysfunction as a target for future diagnostic and therapeutic interventions. This focus could pave the way for innovative clinical strategies, ultimately improving treatment options and patient prognosis in MASLD.

Prevalence and characteristics of liver steatosis and fibrosis in type 2 diabetes mellitus (T2DM) patients: a cross-sectional study in populations of eastern China

OBJECTIVES

To describe the prevalence, clinical characteristics and risk factors of liver steatosis and fibrosis in type 2 diabetes mellitus (T2DM) patients in eastern China.

DESIGN

A cross-sectional, multicentre study based on an ongoing cohort study.

SETTING

16 clinics in eastern China, including primary clinics to tertiary hospitals.

PARTICIPANTS

1816 patients with T2DM diagnosis who met the inclusion criteria were recruited into the study.

INTERVENTION

Participants underwent elastography examination.

MAIN OUTCOME MEASURES

Descriptive analysis was performed to calculate the prevalence and characteristics of liver steatosis and fibrosis. The correlated factors were analysed using single- and multivariate logistic regression analysis.

RESULTS

The prevalence of liver steatosis in T2DM patients is 69.7%, with 46% moderate to severe steatosis. 34.6% and 6.7% of the patients were detected with liver fibrosis and cirrhosis. Steatosis patients were younger, had higher body mass index (BMI), higher levels of insulin resistance and more severe lipid metabolism disorders. Similar trends of differences were observed in patients with fibrosis. Female gender (OR=0.574, 95% CI 0.381 to 0.865), BMI (OR=1.491, 95% CI 1.375 to 1.616), disease duration, inflammation and serum lipid profile markers were risk factors of steatosis, while BMI (OR=1.204, 95% CI 1.137 to 1.275) and female gender (OR=0.672, 95% CI 0.470 to 0.961) were still the most significant predictors of liver fibrosis.

CONCLUSIONS

The prevalence of liver steatosis and fibrosis were high in patients with T2DM. Liver steatosis and fibrosis in these patients appeared to be more associated with lipid metabolism disorders and insulin resistance rather than glucose levels.

TRIAL REGISTRATION NUMBER

Clinical trial: NCT05597709.

Exploring the Role of Peroxisome Proliferator-Activated Receptors and Endothelial Dysfunction in Metabolic Dysfunction-Associated Steatotic Liver Disease

The endothelium is a well known regulator of vascular homeostasis. Several factors can influence the balance of the bioavailability of active substances. This imbalance can lead to inflammation and, consequently, endothelial dysfunction, which is an underlying pathology in cardiovascular disease that commonly coexists with metabolic and chronic diseases such as metabolic dysfunction-associated steatotic liver disease (MASLD). In MASLD, a reduction in nitric oxide availability is observed, and as a result, hepatic stellate cells and liver sinusoidal endothelial cells are activated. Considering the extensive research dedicated to finding several targets with diagnostic and therapeutic effects, nuclear hormone receptors such as peroxisome proliferator-activated receptors have been highlighted as being highly influential in the gut-liver-adipose axis and are considered potential regulators of metabolism and inflammation in several pathologies. Currently, PPAR agonists are widely explored in clinical trials and experimental studies. Agents such as lanifibranor, elafibranor, daidzein, and Icariin have shown promise in improving the metabolic, hepatic, and cardiovascular health of patients with MASLD. This review aims to provide a comprehensive overview of the role of peroxisome proliferator-activated receptors in endothelial dysfunction and MASLD, exploring their mechanisms in disease progression and potential pharmacological targeting.

Molecular Mechanisms of Fibrosis in Cholestatic Liver Diseases and Regenerative Medicine-Based Therapies

The aim of this review is to explore the potential of new regenerative medicine approaches in the treatment of cholestatic liver fibrosis. Cholestatic liver diseases, such as primary biliary cholangitis (PBC), primary sclerosing cholangitis (PSC), and biliary atresia (BA), due to the accumulation of bile, often progress to liver fibrosis, cirrhosis, and liver failure. When the disease becomes severe enough to require liver transplantation. Deeply understanding the disease's progression and fibrosis formation is crucial for better diagnosis and treatment. Current liver fibrosis treatments mainly target the root causes and no direct treatment method in fibrosis itself. Recent advances in regenerative medicine offer a potential approach that may help find the ways to target fibrosis directly, offering hope for improved outcomes. We also summarize, analyze, and discuss the current state and benefits of regenerative medicine therapies such as mesenchymal stem cell (MSC) therapy, induced pluripotent stem cells (iPSCs), and organoid technology, which may help the treatment of cholestatic liver diseases. Focusing on the latest research may reveal new targets and enhance therapeutic efficacy, potentially leading to more effective management and even curative strategies for cholestatic liver diseases.

Lactobacillus sp. for the Attenuation of Metabolic Dysfunction-Associated Steatotic Liver Disease in Mice

Probiotics are studied for their therapeutic potential in the treatment of several diseases, including metabolic dysfunction-associated steatotic liver disease (MASLD). Part of the significant progress made in understanding the pathogenesis of steatosis has come from identifying the complex interplay between the gut microbiome and liver function. Recently, probiotics have shown beneficial effects for the treatment and prevention of steatosis and MASLD in rodent models and in clinical trials. Numerous studies have demonstrated the promising potential of lactic acid bacteria, especially the genus Lactobacillus. Lactobacillus is a prominent bile acid hydrolase bacterium that is involved in the biotransformation of bile acids. This genus' modulation of the gut microbiota also contributes to overall gut health; it controls gut microbial overgrowth, shapes the intestinal bile acid pool, and alleviates inflammation. This narrative review offers a comprehensive summary of the potential of Lactobacillus in the gut-liver axis to attenuate steatosis and MASLD. It also highlights the roles of Lactobacillus in hepatic lipid metabolism, insulin resistance, inflammation and fibrosis, and bile acid synthesis in attenuating MASLD.

Predictors of Significant Fibrosis Among People Living with HIV with Metabolic Dysfunction- Associated Steatotic Liver Disease

Objective: Metabolic dysfunction-associated steatotic liver disease (MASLD) is highly prevalent among people living with HIV (PLWH) due to comorbidities and factors related to HIV infection. This study aimed to identify clinical predictors of significant fibrosis among PLWH with MASLD. Materials and Methods: A retrospective cohort study was conducted with PLWH having CD4 counts ≥200, enrolled between April and October 2023 at two tertiary hospitals. The primary outcome was identifying the clinical predictors of significant fibrosis (F≥2) defined by TE≥8 kPa. Secondary outcomes included MASLD prevalenceand characteristics. Results: Among 96 PLWH, 52 (54.2%) had MASLD. The mean age was 49.7±8.0 years, 63.5% were male, and the mean BMI was 25.8±4.1 kg/m². Obesity, diabetes, and dyslipidemia were present in 17.3%, 19.2%, and 46.2% of participants, respectively. The mean CAP and TE were 285±36 dB/m and 8.7±7.8 kPa, respectively. Significantfibrosis was present in 24 patients (46.2%). Fibrosis scoring systems (FIB-4, APRI, NFS) demonstrated good accuracy (AUROCs: 0.84, 0.85, 0.76, respectively). Multivariate analysis identified predictors of significant fibrosis: higher BMI (aOR 1.24, p=0.042), dyslipidemia (aOR 3.96, p=0.038), and higher AST (aOR 1.19, p=0.011). The AGA pathway using two steps (FIB-4 and TE) improved reclassification of significant fibrosis risk, reducing the number of individuals at indeterminate risk, 12 out of 52 in the first step to 7 out of 52 in the second step. Conclusion: MASLD is highly prevalent in PLWH, with about half experiencing significant fibrosis. Predictors of significant fibrosis include dyslipidemia, higher BMI, and elevated AST levels. Fibrosis scoring systems accurately predict significant fibrosis.

Relation of 91 Circulating Inflammatory Proteins to Nonalcoholic Fatty Liver Disease: A Two-Sample Mendelian Randomisation Study

Increasingly, emerging research evidence has demonstrated that nonalcoholic fatty liver disease (NAFLD) is a disease closely associated with systemic inflammation. However, the specific upstream inflammatory factors engaged in the pathogenesis of NAFLD remain unclear. Our study aimed to identify the inflammatory regulators causally associated with NAFLD pathogenesis through Mendelian randomisation. A two-sample Mendelian randomisation method was applied to analyse the causal association between 91 circulating inflammatory proteins and NAFLD. Data on circulating inflammatory proteins were derived from samples of European ancestry (14,824 samples) and NAFLD data were obtained from the FinnGen consortium (2025 cases and 284,826 controls). Instrumental variables were selected from the genetic variance and F-statistics were calculated to avoid bias. We adopted the random-effects inverse variance weighting (IVW) method as our primary analytical approach. Supplementary analyses were also implemented, including weighted median, MR-Egger and weighted mode. Moreover, we conducted pleiotropy and heterogeneity analyses to validate the accuracy of the findings. The application of Mendelian randomisation analysis identified four inflammatory factors that might be causally associated with NAFLD at the genetic level. Elevated levels of eotaxin (or = 1.27, 95% CI: 1.05-1.53, p = 0.014), osteoprotegerin (OPG) (or = 1.29, 1.03-1.60, p = 0.023) and TNFRSF9 (or = 1.32, 95% CI: 1.06-1.64, p = 0.014) may be causally related to an increasing risk of NAFLD. Conversely, heightened leukaemia inhibitory factor (LIF) levels (or = 0.63, 0.44-0.92, p = 0.016) were linked to a lower risk of NAFLD onset. There was no causal relationship between levels of other circulating inflammatory proteins and NAFLD. Our analysis uncovered four upstream inflammatory factors genetically associated with the pathogenesis of NAFLD. These results highlight the potential involvement of inflammation in NAFLD, which provides partial insights for further research in this field in the future.

MetALD: Does it require a different therapeutic option?

New guidelines for the definitions of steatotic liver disease have named the entity of metabolic dysfunction and alcohol-associated liver disease (MetALD) as an overlap condition of metabolic dysfunction-associated steatotic liver disease (MASLD) and alcohol-associated liver disease. There is a broad range of therapeutics in all stages of development for MASLD, but these therapeutics, in general, have not been studied in patients with significant ongoing alcohol use. In this review, we discuss the current understanding of the endogenous and exogenous risks for MASLD and MetALD. Rational strategies for therapeutic intervention in MetALD include biopsychosocial interventions, alcohol use cessation strategies, including the use of medications for alcohol use disorder, and judicious use of therapeutics for steatotic liver disease. Therapeutics with promise for MetALD include incretin-based therapies, FGF21 agonists, thyroid hormone receptor beta agonists, sodium-glucose co-transporter 2 inhibitors, and agents to modify de novo lipogenesis. Currently, glucagon-like peptide 1 receptor agonists and peroxisome proliferator-activated receptor γ agonists have the largest body of literature supporting their use in MASLD, and there is a paucity of agents in trials for alcohol-associated liver disease. From existing studies, it is not clear if unique therapeutics or a combinatorial approach are needed for MetALD. Further elucidation of the safety and benefits of MASLD-related therapies is of paramount importance for advancing therapeutics for MetALD in carefully designed inclusive clinical trials.

Diagnostics and omics technologies for the detection and prediction of metabolic dysfunction-associated steatotic liver disease-related malignancies

The prevalence of metabolic dysfunction-associated steatotic liver disease (MASLD) continues to rise, making it the leading etiology of chronic liver diseases and a prime cause of liver-related mortality. MASLD can progress into steatohepatitis (termed MASH), fibrosis, cirrhosis, and ultimately cancer. MASLD is associated with increased risks of hepatocellular carcinoma (HCC) and also extrahepatic malignancies, which can develop in both cirrhotic and non-cirrhotic patients, emphasizing the importance of identifying patients with MASLD at risk of developing MASLD-associated malignancies. However, the optimal screening, diagnostic, and risk stratification strategies for patients with MASLD at risk of cancer are still under debate. Individuals with MASH-associated cirrhosis are recommended to undergo surveillance for HCC (e.g. by ultrasound and biomarkers) every six months. No specific screening approaches for MASLD-related malignancies in non-cirrhotic cases are established to date. The rapidly developing omics technologies, including genetics, metabolomics, and proteomics, show great potential for discovering non-invasive markers to fulfill this unmet need. This review provides an overview on the incidence and mortality of MASLD-associated malignancies, current strategies for HCC screening, surveillance and diagnosis in patients with MASLD, and the evolving role of omics technologies in the discovery of non-invasive markers for the prediction and risk stratification of MASLD-associated HCC.

PDCD4 deficiency in hepatocytes exacerbates nonalcoholic steatohepatitis through enhanced MHC class II transactivator expression

Nonalcoholic steatohepatitis (NASH) is a primary cause of liver cirrhosis and hepatocellular carcinoma, presenting a significant and unmet medical challenge. The necessity to investigate the molecular mechanisms underlying NASH is highlighted by the observed decrease in programmed cell death 4 (PDCD4) expression in NASH patients, suggesting that PDCD4 may play a protective role in maintaining liver health. In this study, we identify PDCD4 as a natural inhibitor of NASH development in mice. The absence of PDCD4 leads to the spontaneous progression of NASH. Notably, PDCD4-deficient hepatocytes display elevated major histocompatibility complex class II (MHCII) expression due to CIITA activation, indicating that PCDC4 prevents the abnormal transformation of hepatocytes into antigen-presenting cells (APCs). Cell co-culture experiments reveal that hepatocytes lacking PDCD4, which resemble APCs, can directly activate CD4+ T cells by presenting multiple peptides, resulting in the release of inflammatory factors. Additionally, both cellular and animal studies show that CIITA promotes lipid accumulation in hepatocytes and exacerbates NASH progression. In summary, our findings reveal a novel role of PDCD4 in regulating CIITA and MHCII expression during NASH development, offering new therapeutic approaches for NASH treatment.

Assessment of Non-alcoholic Fatty Liver Disease and Level of Risk of Fibrosis in Diabetic and Non-diabetic Individuals

Background and aim Non-alcoholic fatty liver disease (NAFLD), now known as metabolic dysfunction-associated steatotic liver disease (MASLD), is more common in people with type-2 diabetes mellitus (T2DM) than in people without diabetes mellitus (non-DM). This disease can lead to cirrhosis or hepatic cancer. There is limited data on NAFLD prevalence and the level of risk of fibrosis in Bangladeshi individuals. This study aimed to assess NAFLD prevalence and compare the proportion of NAFLD and the level of risk of fibrosis between T2DM and non-DM Bangladeshi individuals. Methods A cross-sectional analytical study was conducted for six months in 2024 in the outpatient section of the Department of Medicine at Holy Family Red Crescent Medical College, Dhaka, Bangladesh. Among the patients seeking outpatient care, a total of 179 male and non-pregnant female participants aged 18 years and older were selected using a purposive sampling technique. Individuals with a history of alcohol use, diagnosed cases of chronic liver diseases, prior use of hepatotoxic drugs, and primary biliary cholangitis were excluded from the study. Detailed demographic characteristics, comorbidities, family history of diabetes and liver disease, physical measurements, and biochemical tests were done. Ultrasonography (USG) of the hepatobiliary system was employed to ascertain the existence of NAFLD. The presence or absence of T2DM was evaluated through prior medical documents, corroborated by laboratory analyses of random blood glucose (RBS) and glycosylated hemoglobin (HbA1c) levels. The Fibrosis-4 (FIB-4) index score was utilized to evaluate the risk of liver fibrosis. Results The mean age of the participants was 49.11±12.25 years and 107 (59.8%) of participants were female. Almost two-thirds of the participants were suffering from T2DM. About 17 (9.5%) of the study participants were suffering from NAFLD, which was much higher among T2DM (15 (12.5%)) than non-DM individuals (two (3.3%)). T2DM and family history of liver disease were found to significantly increase the risk of suffering from NAFLD by 5.247 times (95% CI: 1.081-25.468) and 4.202 times (95% CI: 1.249-14.135), respectively. About one (6.7%) of T2DM individuals with NAFLD were at high risk for fibrosis. Conclusion Almost one in 10 people had NAFLD, and it was way more common among those with T2DM, who also exhibit a higher risk of hepatic fibrosis. Moreover, T2DM and a family history of liver disease can independently increase the risk of NAFLD.

Forty years of successful national research collaboration in liver disease - the Swedish experience

AIM

Sweden has historically provided a fruitful arena for research in clinical medicine. We here share 40 years of experience of collaboration in the Swedish hepatology research group (SWEHEP) (https://www.swehep.se).

METHODS

We describe the way the Swedish hepatology pioneers started the group and how the network continuously developed over the years. Successful projects such as thorough studies of natural history and various clinical aspects of autoimmune hepatitis, primary biliary cholangitis, primary sclerosing cholangitis, and steatosis are described.

RESULTS

Over the years, more than 80 publications have been published by the group. A summary of new and ongoing research programs includes the randomized placebo-controlled trial of simvastatin in PSC (PiSCATIN), the prospective BIGMAP (Biochemical and genetic markers for the assessment and prognostication of liver cirrhosis) initiative in patients with liver cirrhosis, and the DETECT-HCC, a prospective multicenter cohort study comparing abbreviated MRI and ultrasound for surveillance of hepatocellular carcinoma every six months over two years. The group philosophy, success factors for the longstanding collaboration as well as experience of failures are shared.

CONCLUSION

The success of hepatology research in Sweden is based on longstanding collaboration over generations of hepatologists, where everyone contributes, regular research meetings, mutual trust, and perseverance.

Association of healthy lifestyles with risk of all-cause and cause-specific mortality among individuals with metabolic dysfunction-associated steatotic liver disease: results from the DFTJ cohort

AIM

To examine the associations of healthy lifestyles with risk of all-cause and cause-specific mortality among adults with metabolic dysfunction-associated steatotic liver disease (MASLD), and whether the association was mediated by systemic immune-inflammatory biomarkers (SIIBs).

METHODS

The study included 10,347 subjects with MASLD, who were enrolled in the Dongfeng-Tongji cohort study. The healthy lifestyles referred to non-smoking, being physically active (≥7.5 metabolic equivalents-hours/week), low-risk alcohol consumption (1-14 g/day for women and 1-28 g/day for men), and optimal sleep duration (≥6 to ≤8 h/day). Cox proportional hazard models were used to examine the relationship between each lifestyle and SIIBs with the risk of all-cause and cause-specific mortality. A mediation analysis was conducted to investigate the role of SIIBs on the association between healthy lifestyles and mortality.

RESULTS

There were 418 MASLD subjects dead till the follow-up of 2018, including 259 deaths from cardiovascular disease (CVD). Compared to MASLD participants with 0-1 healthy lifestyle score (HLS), those with 3-4 HLS had the lowest risk of all-cause mortality [hazard ratio (HR), 0.46; 95% CI, (0.36-0.60)], and CVD mortality [HR (95%CI), 0.41 (0.29-0.58)]. Mediation analyses indicated that SIIBs mediated the association between healthy lifestyles and mortality, with proportions ranging from 2.5% to 6.1%.

CONCLUSIONS

These findings suggest that adherence to healthy lifestyles can significantly reduce mortality for MASLD patients, and the decreased SIIBs may partially explain the protection mechanism of healthy lifestyles.

Metabolic Dysfunction-Associated Steatotic Liver Disease in Chronic Hepatitis C Virus Infection: From Basics to Clinical and Nutritional Management

Metabolic dysfunction-associated steatotic liver disease (MASLD) is closely associated with obesity and other cardiometabolic risk factors. MASLD has rapidly become the most common cause of liver disease worldwide, currently affecting 38% of the global population. Excess weight causes chronic inflammation and the activation of different pathways involved in liver damage. MASLD can progress from simple steatosis to steatohepatitis, giving way to its inflammatory component, metabolic dysfunction-associated steatohepatitis (MASH), previously recognized as non-alcoholic steatosis hepatitis (NASH). Chronic hepatitis C virus (HCV) infection remains a significant challenge to liver health as it triggers hepatic inflammation, metabolic disruption, and hepatic steatosis. The convergence of MASLD and chronic HCV infection can significantly alter the course of liver disease and accelerate the progression to severe liver damage. Currently, HCV treatment has a high cure rate. However, in patients who achieve a sustained virological response after treatment with direct-acting antivirals, weight gain, and excessive calorie intake may contribute to increased liver steatosis and a higher risk of liver disease progression. Therefore, the effective clinical and nutritional management of HCV patients, both before and after viral eradication, is crucial to reducing the risk of death from hepatocellular carcinoma. Understanding the complex interactions between MASLD and HCV infection is crucial for managing these patients appropriately. Herein, host and viral mechanisms inducing liver damage during the coexistence of MASLD and HCV infection are described, and their therapeutic and dietary management are discussed.

Prospective appraisal of clinical diagnostic algorithms for hepatocellular carcinoma surveillance in Chinese patients with chronic hepatitis B infection

Hepatocellular carcinoma (HCC) is often detected at advanced stages among patients with hepatitis B virus (HBV), underscoring the urgency for more precise surveillance tests. Here, we compare the clinical performance of the novel - GAAD (gender [biological sex], age, alpha-fetoprotein [AFP], protein-induced by vitamin K absence-II [PIVKA-II]) and GALAD (gender [biological sex], age, AFP, Lens-culinaris AFP [AFP-L3]), PIVKA-II) algorithms to assess the utility of AFP-L3 for distinguishing HCC from benign chronic liver disease (CLD) in Chinese patients with predominantly chronic HBV infection. Eligible adults were enrolled, and biomarkers were measured using Elecsys (Cobas) or µTASWAKO assays. In total, 411 participants provided serum samples (HCC, n = 176 [early-stage, n = 110]; CLD, n = 136; specificity n = 101). HBV was the underlying disease etiology for most participants (HCC, 95%; benign CLD, 72%). For GAAD (Cobas), GALAD (Cobas), and GALAD (µTASWAKO), AUCs were 93.1% (95% CI: 90.0-96.2), 93.2% (90.0-96.3), and 92.7% (88.4-96.9) for early-stage, and 95.6% (93.6-97.6), 95.6% (93.6-97.7), and 95.8% (93.2-98.3) for all-stage HCC, versus CLD, respectively. Interestingly, both GAAD and GALAD algorithms demonstrated comparable diagnostic performance regardless of disease etiology (HBV vs. non-HBV), presence of cirrhosis, geographic region, and within pan-tumor specificity panels (p < 0.001), indicating AFP-L3 may have a negligible role in HCC surveillance.

Association between serum antibodies to oral microorganisms and nonalcoholic fatty liver disease in adults

BACKGROUND

Alterations in the bacteria, such as the periodontal bacteria, might be considered potential risk factors for nonalcoholic fatty liver disease (NAFLD). Most studies analyzing this association have focused mainly on a specific periodontal bacteria (Porphyromonas gingivalis) and have involved relatively small study populations (tens or hundreds of individuals). To address this gap, a sizable, nationally representative adult population was utilized to investigate the association between the incidence of NAFLD and high serum IgG antibodies for 19 periodontal bacteria.

METHODS

To explore this association, data from the Third National Health and Nutrition Examination Survey (NHANES III)-which provides a cross-sectional representation of the noninstitutionalized U.S. population, encompassing 33,994 individuals-were analyzed. Participants aged 40 years and above with data on NAFLD-determined by the gold standard of ultrasound examination (USON)-as well as comprehensive records of serum IgG antibodies against periodontal bacteria, were included, resulting in a final analysis subset of 6,330 individuals.

RESULTS

Using a cluster analysis based on the Socransky classification scheme for oral microorganisms, antibody titers for the 19 bacteria were grouped into four clusters-Red-Green, Orange-Blue, Yellow-Orange, and Orange-Red. When these clusters, as well as individual antibody relationships with NAFLD, were examined, the adjusted odds ratios (ORs) ranged from 0.958 [95% confidence interval (CI): 0.916, 1.003] to 1.021 [95% CI: 0.987, 1.055]. This indicated that no statistically significant associations were found (P > 0.05), underscoring the absence of a meaningful link.

CONCLUSIONS

In summary, it was discovered that there is currently no evidence to correlate serum antibodies to periodontal pathogens with NAFLD in the nationally representative NHANES III.

CLINICAL TRIAL NUMBER

Not applicable.

Multiple Machine Learning Identifies Key Gene PHLDA1 Suppressing NAFLD Progression

Non-alcoholic fatty liver disease (NAFLD) poses a serious global health threat, with its progression mechanisms not yet fully understood. While several molecular markers for NAFLD have been developed in recent years, a lack of robust evidence hampers their clinical application. Therefore, identifying novel and potent biomarkers would directly aid in the prediction, prevention, and personalized treatment of NAFLD. We downloaded NAFLD-related datasets from the Gene Expression Omnibus (GEO). Differential expression analysis and functional analysis were initially conducted. Subsequently, Weighted Gene Co-expression Network Analysis (WGCNA) and multiple machine learning strategies were employed to screen and identify key genes, and the diagnostic value was assessed using Receiver Operating Characteristic (ROC) analysis. We then explored the relationship between genes and immune cells using transcriptome data and single-cell RNA sequencing (scRNA-seq) data. Finally, we validated our findings in cell and mouse NAFLD models. We obtained 23 overlapping differentially expressed genes (DEGs) across three NAFLD datasets. Enrichment analysis revealed that DEGs were associated with Apoptosis, Parathyroid hormone synthesis, secretion and action, Colorectal cancer, p53 signaling pathway, and Biosynthesis of unsaturated fatty acids. After employing machine learning strategies, we identified one gene, pleckstrin homology like domain family A member 1 (PHLDA1), downregulated in NAFLD and showing high diagnostic accuracy. CIBERSORT analysis revealed significant associations of PHLDA1 with various immune cells. Single-cell data analysis demonstrated downregulation of PHLDA1 in NAFLD, with PHLDA1 exhibiting a significant negative correlation with macrophages. Furthermore, we found PHLDA1 to be downregulated in an in vitro hepatic steatosis cell model, and overexpression of PHLDA1 significantly reduced lipid accumulation, as well as the expression of key molecules involved in hepatic lipogenesis and fatty acid uptake, such as FASN, SCD-1, and CD36. Additionally, gene set enrichment analysis (GSEA) pathway enrichment analysis suggested that PHLDA1 may influence NAFLD progression through pathways such as Cytokine Cytokine Receptor Interaction, Ecm Receptor Interaction, Parkinson's Disease, and Ribosome pathways. Our conclusions were further validated in a mouse model of NAFLD. Our study reveals that PHLDA1 inhibits the progression of NAFLD, as overexpression of PHLDA1 significantly reduces lipid accumulation in cells and markedly decreases the expression of key molecules involved in liver lipogenesis and fatty acid uptake. Therefore, PHLDA1 may emerge as a novel potential target for future prediction, diagnosis, and targeted prevention of NAFLD.

Modern aspects of therapy of metabolic associated liver disease in patients with type 2 diabetes mellitus

Metabolic associated fatty liver disease (MAFLD) is currently the most common liver disease. The main risk factors for its development are poor nutrition, sedentary lifestyle and obesity. MAFLD is associated with various cardiometabolic conditions – lipid metabolism disorders, cardiovascular pathology and carbohydrate metabolism disorders. The association of MAFLD and type 2 diabetes mellitus (DM) is common among patients, since these diseases have a common pathogenesis link – insulin resistance. The combination of these diseases has a mutual negative effect on each other and increases the risks of cardiovascular diseases, hospitalizations, as well as the risks of liver fibrosis progression. Therefore, the detection of MAFLD and its treatment in type 2 DM are extremely important to improve the patient’s prognosis. Diagnostics of MAFLD includes laboratory and instrumental research methods. The “gold standard” of diagnostics is considered to be liver biopsy, but due to the fact that this method is invasive, it is rarely used and only for differential diagnostics of MAFLD with other liver pathologies. The most accessible instrumental method for detecting liver steatosis is ultrasound. Treatment of MAFLD primarily involves lifestyle changes (rational nutrition with limitation of simple carbohydrates and animal fats, adequate physical activity) and weight loss. Also, hypoglycemic drugs used to treat type 2 diabetes (metformin, pioglitazone, glucagon-like peptide-1 agonists) can have a certain positive effect on MAFLD. Essential phospholipids, which have membrane-stabilizing, antioxidant and antifibrotic effects, are also an important component of MAFLD treatment. A number of domestic and foreign studies have shown the high efficiency of Essential Phospholipids both in relation to biochemical parameters in patients with a combination of type 2 diabetes and MAFLD, and in relation to ultrasound signs, improving the function and structure of the liver in MAFLD, as well as slowing the progression of liver fibrosis.

β-Klotho as novel therapeutic target in Metabolic Dysfunction-Associated Steatotic Liver Disease (MASLD): A narrative review

Metabolic Dysfunction-Associated Steatotic Liver Disease (MASLD) represents the most frequent cause of hepatic disorder, and its progressive form defined as Metabolic Dysfunction-Associated Steatohepatitis (MASH) contributes to the development of fibrosis/cirrhosis and hepatocellular carcinoma (HCC). Today effective therapeutic strategies addressing MASH-related comorbidities, inflammation, and fibrosis are needed. The fibroblast growth factor (FGF) 19 and 21 and their fibroblast growth factor receptor/β-Klotho (KLB) complexes have recently emerged as promising druggable targets for MASLD. However, less is known regarding the causative association between KLB activity and advanced stages of liver disease. In the present narrative review, we aimed to provide an up-to-date picture of the role of the KLB co-receptor in MASLD development and progression. We performed a detailed analysis of recently published preclinical and clinical data to decipher the molecular mechanisms underlying KLB function and to correlate the presence of inherited or acquired KLB aberrancies with the predisposition towards MASLD. Moreover, we described ongoing clinical trials evaluating the therapeutic approaches targeting FGF19-21/FGFR/KLB in patients with MASLD and discussed the challenges related to their use. We furtherly described that KLB exhibits protective effects against metabolic disorders by acting in an FGF-dependent and independent manner thus triggering the hypothesis that KLB soluble forms may play a critical role in preserving liver health. Therefore, targeting KLB may provide promising strategies for treating MASLD, as supported by experimental evidence and ongoing clinical trials.

Liver Cancer Etiology: Old Issues and New Perspectives

PURPOSE OF REVIEW

This review aims to synthesize the old issues and current understandings of the etiology of liver cancer, focusing on the diverse causative factors influenced by geographical, socioeconomic, and lifestyle variations across different regions.

RECENT FINDINGS

We highlight significant geographic disparities in liver cancer risk factors. While hepatitis B and C viruses, aflatoxin exposure, and alcohol consumption remain globally established contributors; metabolic dysfunction-associated steatotic liver disease and metabolic syndromes are increasingly prominent in the West. Chronic HBV and aflatoxin continue to dominate as risk factors in Asia and Africa. Dietary factors, metabolic diseases like diabetes and obesity, genetic predispositions, environmental risk factors and lifestyle choices such as smoking and alcohol use play substantial roles in specific populations. Protective factors like coffee and tea consumption, along with aspirin use, vegetables and fruits have shown potential in reducing HCC risk, although findings vary by population and dietary habits. Liver cancer etiology is influenced by various factors that differ by region. Established risk factors include hepatitis B and C, aflatoxin, and alcohol. Emerging risks, such as metabolic dysfunction-associated steatotic liver disease, are more prevalent in Western countries, while aflatoxin and HBV remains significant in Asia and Africa. Diet, metabolic conditions like diabetes and obesity, genetic predispositions, and lifestyle choices also play crucial roles. Coffee, tea, aspirin, vegetables, and fruits may reduce HCC risk, but effectiveness varies. Future research should integrate epidemiology, genetics, and nutrition, with global cooperation and data sharing essential for effective cancer control strategies.

Transforming steatotic liver disease management: The emerging role of GLP-1 receptor agonists

Chronic liver disease is a major cause of mortality, with approximately 2 million deaths worldwide each year, and it poses a significant economic burden. The most common cause of chronic liver disease in the United States and Europe is steatotic liver disease (SLD), which includes metabolic dysfunction-associated SLD, metabolic dysfunction and alcohol-associated SLD, and alcohol-associated liver disease (ALD). Effective treatment of these conditions is essential to reduce the liver disease burden, with promising approaches including treating cardiometabolic risk factors and excessive alcohol intake. Glucagon-like peptide 1 receptor agonists, both as monotherapy and in combination with other drugs, are gaining attention for their beneficial impact on cardiometabolic risk factors and excessive alcohol intake. In this review, we examine the molecular and clinical effects of glucagon-like peptide 1 receptor agonists, focusing on their direct hepatic steatohepatitis and liver fibrosis but also the indirect influence on cardiometabolic risk factors and excessive alcohol intake as key features of SLD. We also explore the future implications of glucagon-like peptide 1 receptor agonists for treating metabolic dysfunction-associated SLD, metabolic dysfunction and alcohol-associated SLD, alcohol-associated liver disease, and the potential challenges.

[Steatosis]

Steatosis is defined by hepatocyte accumulation of lipids. Different types of steatosis are described (macro-, medio- and microvacuolar). Macrovacuolar steatosis is a common lesion, mainly observed during metabolic syndrome and excessive alcohol consumption. Steatohepatitis combines steatosis, the presence of ballooned hepatocytes and lobular inflammatory foci. Liver fibrosis is the main consequence of steatohepatitis. Liver biopsy is the gold standard diagnostic test.

Metabolic dysfunction-associated steatotic liver disease and extrahepatic gastrointestinal cancers

Metabolic dysfunction-associated steatotic liver disease (MASLD) poses a significant and ever-increasing health and economic burden worldwide. Substantial epidemiological evidence shows that MASLD is a multisystem disease that is associated not only with liver-related complications but is also associated with an increased risk of developing cardiometabolic comorbidities and extrahepatic cancers (principally gastrointestinal [GI] cancers). GI cancers account for a quarter of the global cancer incidence and a third of cancer-related deaths. In this narrative review, we provide an overview of the literature on (a) the epidemiological data on the risk of non-liver GI cancers in MASLD, (b) the putative mechanisms by which MASLD (and factors linked with MASLD) may increase this risk, and (c) the possible pharmacotherapies beneficially affecting both MASLD and extrahepatic GI cancer risk. There are multiple potential pathophysiological mechanisms by which MASLD may increase extrahepatic GI cancer risk. Although further studies are needed, the current evidence supports a possible extrahepatic carcinogenic role for MASLD, regardless of obesity and diabetes status, thus highlighting the potential role of tailoring cancer screening for individuals with MASLD. Although there are conflicting data in the literature, aspirin, statins and metformin appear to exert some chemo-preventive effects against GI cancer.

Gut microbes, diet, and genetics as drivers of metabolic liver disease: a narrative review outlining implications for precision medicine

Metabolic dysfunction-associated steatotic liver disease (MASLD) is rapidly increasing in prevalence, impacting over a third of the global population. The advanced form of MASLD, Metabolic dysfunction-associated steatohepatitis (MASH), is on track to become the number one indication for liver transplant. FDA-approved pharmacological agents are limited for MASH, despite over 400 ongoing clinical trials, with only a single drug (resmetirom) currently on the market. This is likely due to the heterogeneous nature of disease pathophysiology, which involves interactions between highly individualized genetic and environmental factors. To apply precision medicine approaches that overcome interpersonal variability, in-depth insights into interactions between genetics, nutrition, and the gut microbiome are needed, given that each have emerged as dynamic contributors to MASLD and MASH pathogenesis. Here, we discuss the associations and molecular underpinnings of several of these factors individually and outline their interactions in the context of both patient-based studies and preclinical animal model systems. Finally, we highlight gaps in knowledge that will require further investigation to aid in successfully implementing precision medicine to prevent and alleviate MASLD and MASH.