Increased overall mortality and liver-related mortality in non-alcoholic fatty liver disease

Low psoas muscle index associates with long-term mortality in cirrhosis: construction of a nomogram

BACKGROUND

To develop a nomogram incorporating indicator of muscle waste to prognosticate long-term mortality in liver cirrhosis (LC), and identify the prognostic impact of psoas muscle index (PMI).

METHODS

A total of 251 LC patients who underwent computed tomography were included in this study. Multiple Cox regression was performed, and sex-specific nomogram models incorporating PMI were developed. The utility of the proposed models were evaluated by Harrell's concordance index (C-index), calibration curve and decision curve analysis. X-tile was used to determine optimal cutpoint for stratifying subjects with distinct outcomes. Subgroup analysis was implemented in terms of age and MELD score. The correlation between PMI and gait speed was also evaluated.

RESULTS

On multiple analysis, independent predictors for 3-year all-cause mortality were age, BMI, PMI and MELD for males, and age, PMI and MELD for females. Both nomogram models gave rise to moderately strong discrimination, with a C-index of 0.792 (95% CI: 0.723-0.861) in males and 0.715 (95% CI: 0.637-0.793) in females, respectively. The calibration curve implied predicted survival corresponding optimally with the actual outcomes. The proposed models were feasible in clinical settings based on decision curve analysis. On subgroup analysis, PMI might confer valid predictive value on LC patients with MELD <15. Moreover, a definitely positive correlation between PMI and gait speed was revealed.

CONCLUSIONS

Our proposed nomogram embedding PMI rendered an individualized predictive tool for long-term mortality in LC. The diminishing value of PMI is likely indicative of muscle dysfunction.

Oral gallic acid improve liver steatosis and metabolism modulating hepatic lipogenic markers in obese mice

INTRODUCTION

Gallic acid (GA) is a natural endogenous polyphenol found in a variety of fruits, vegetables and wines, with beneficial effects on the energetic homeostasis.

AIM

The present study aimed to investigate oral gallic acid effects on liver steatosis and hepatic lipogenesis markers in obese mice evaluating new possible molecular related mechanisms.

METHODS

Twenty-four Swiss male mice were divided into four groups and fed for 60 days with standard diet (ST), standard diet plus gallic acid (ST + GA), high-fat diet (HFD), and high-fat diet plus gallic acid (HFD + GA). We evaluated the relationship between body weight, food intake and serum levels of total cholesterol, triglycerides, insulin, aspartate and alanine transaminases. Liver histology was analyzed by hematoxylin and eosin staining. These results were accompanied by bioinformatics analyses. The acetyl-CoA carboxylase (ACC), sterol regulatory element binding protein-1 (SREBP-1) and fatty acid synthase (FAS) expression was assessed by quantitative real-time reverse transcriptase PCR (qRT-PCR).

RESULTS

The main findings of the present study showed that GA reduced liver steatosis, body weight and plasma insulin levels. Analyzes of hepatic steatosis related genes expression showed that ACC and FAS mRNA were significantly suppressed in liver of HFD + GA mice. These data was corroborated by bioinformatics analysis.

CONCLUSION

These data suggest an important clinical application of GA in the prevention and treatment of liver diseases.

Longitudinal Association of Non-Alcoholic Fatty Liver Disease With Changes in Myocardial Structure and Function: The CARDIA Study

Background

Non‐alcoholic fatty liver disease (NAFLD) is associated with high cardiovascular morbidity/mortality, including heart failure. Abnormalities in left ventricular (LV) structure/function are associated with heart failure risk.

Methods and Results

Participants from the population‐based CARDIA (Coronary Artery Risk Development in Young Adults) study year 25 exam (2010–2011, aged 43–55 years, 61% women, 48% black) with computed tomography measured liver fat and comprehensive echocardiography were included. Echocardiography was repeated at year 30 follow‐up (aged 47–62 years, N=1827). NAFLD was defined as liver attenuation ≤40 HU after exclusions. LV geometry was classified into normal and abnormal by integrating relative wall thickness and LV mass index. Diastolic function was defined using Doppler and tissue Doppler imaging. Systolic function was assessed with myocardial strain measured by speckle tracking. NAFLD prevalence was 8.7% (n=159). NAFLD participants had higher LV mass, relative wall thickness, incident LV hypertrophy and abnormal LV geometry versus non‐NAFLD (P<0.02). NAFLD participants had impaired LV relaxation (E/A ratio 1.1 versus 1.2), higher LV filling pressures (E/e′ ratio 7.9 versus 7.2), worse longitudinal strain (−13.9% versus −15.3%), and lower LV ejection fraction (58.9% versus 60.2%, P<0.01). In multivariable analyses adjusted for heart failure risk factors, NAFLD was independently associated with incident LV hypertrophy (odds ratio: 1.9, 95% CI: 1.1–3.4), abnormal LV geometry (odds ratio: 1.9, 1.1–3.3) and greater change in strain (odds ratio: 2.2, 1.1–4.7). Adjustment for body mass index attenuated associations to non‐significance.

Conclusions

NAFLD is associated with subclinical changes over time in LV structure/function and obesity explains much of the association. Presence of obesity in mid‐life may identify an important at‐risk population in whom to focus preventive heart failure strategies.

Non-alcoholic fatty liver disease and cardiovascular disease: assessing the evidence for causality

Non-alcoholic fatty liver disease (NAFLD) is highly prevalent among individuals with type 2 diabetes. Although epidemiological studies have shown that NAFLD is associated with cardiovascular disease (CVD), it remains unknown whether NAFLD is an active contributor or an innocent bystander. Plasma lipids, low-grade inflammation, impaired fibrinolysis and hepatokines are potential mediators of the relationship between NAFLD and CVD. The Mendelian randomisation approach can help to make causal inferences. Studies that used common variants in PNPLA3, TM6SF2 and GCKR as instruments to investigate the relationship between NAFLD and coronary artery disease (CAD) have reported contrasting results. Variants in PNPLA3 and TM6SF2 were found to protect against CAD, whereas variants in GCKR were positively associated with CAD. Since all three genes have been associated with non-alcoholic steatohepatitis, the second stage of NAFLD, the question of whether low-grade inflammation is an important mediator of the relationship between NAFLD and CAD arises. In contrast, the differential effects of these genes on plasma lipids (i.e. lipid-lowering for PNPLA3 and TM6SF2, and lipid-raising for GCKR) strongly suggest that plasma lipids account for their differential effects on CAD risk. This concept has recently been confirmed in an extended set of 12 NAFLD susceptibility genes. From these studies it appears that plasma lipids are an important mediator between NAFLD and CVD risk. These findings have important clinical implications, particularly for the design of anti-NAFLD drugs that also affect lipid metabolism.

Impact of sleeve gastrectomy and dietary change on metabolic and hepatic function in an obesity rat model - Experimental research

PURPOSE

Sleeve gastrectomy (SG) is an effective procedure to treat morbid obesity. SG induces remission of type 2 diabetes and metabolic syndrome and improves non-alcoholic fatty liver disease (NAFLD). However, it is imperative to clarify the extent to which these beneficial effects may be attributed to SG among other concomitant changes including postoperative diet. The current study addresses this question in a rodent model of obesity by subjecting it to SG, normal diet, or a combination of the two.

METHODS

Male Wistar-rats were fed with either high fat diet (HF, n = 32) or received chow diet (CD, n = 8). After 15 weeks, the HF-fed rats underwent either SG or sham operation, following which they were randomised to either continue HF or switched to CD for another 6 weeks. Body weight, fasting blood glucose level, blood pressure, and adipokine expression (leptin, adiponectin, MCP-1) in the adipose tissue along with triglycerides level in the blood serum were assessed to evaluate metabolic function. Hepatic function was assessed by histological evaluation of liver fibrosis (Hydroxyproline, Sirius Red) and reverse transcription polymerase chain reaction (RT-PCR) of the inflammation marker monocyte chemoattractant protein-1 (MCP-1).

RESULTS

Postoperative dietary change improved adipose tissue inflammation and arterial blood pressure regardless of the surgical intervention, while SG improved hyperglycaemia, blood triglyceride levels and, regardless of the postoperative diet, hepatic inflammation and fibrosis. However, combined administration of SG with post-operative normal diet was the most effective with regard to reducing the body weight.

CONCLUSION

HF for 15 weeks induced obesity with metabolic syndrome and NAFLD in rats. SG and dietary intervention improved metabolic state and NAFLD; however, their combination was significantly more effective.

Long-term Liver-related Outcomes of Patients With Chronic Liver Diseases in Australia

BACKGROUND & AIMS

Chronic liver disease is a major health burden that produces significant liver-related morbidity and mortality. We aimed to evaluate liver-related outcomes of patients with different causes of chronic liver disease in Australia.

METHODS

We collected data from 10,933 patients with chronic liver disease assessed by Hepascore (a serum fibrosis model) in Western Australia from 2004 through 2015. We obtained records of liver-related death, transplantation, decompensation, and hepatocellular carcinoma from WA Data Linkage Unit databases. Competing risk analysis was used to calculate the cumulative risk of each clinical endpoint, and risks for clinical endpoints were compared among all causes of chronic liver disease.

RESULTS

In our final cohort for analysis, 5566 patients had hepatitis C virus (HCV) infection, 1989 had HBV infection, 119 were infected with HBV and HCV, 955 had alcohol-associated liver disease, 1597 had non-alcoholic fatty liver disease (NAFLD), 123 had alcohol-associated liver disease and metabolic risk factors, 561 had autoimmune liver disease without overlap syndrome, and 23 autoimmune overlap syndrome. Significant differences among chronic liver diseases were observed in risk of all-cause death (P < .001), liver-related death (P < .001), liver transplantation (P < .001), and decompensation (P < .001) but not hepatocellular carcinoma (P=.095). Patients with alcohol-associated liver disease had the highest 5-year cumulative risk of liver-related death (17.1%) and the second-highest 5-year cumulative risk of decompensation (29.2%). Multivariate analysis found patients with alcohol-associated liver disease had significantly higher risks of liver-related death and decompensation than patients with HCV infection with hazard ratios (HRs) of 2.39 (95% CI, 1.88-3.03) and 3.42 (95% CI, 2.74-4.27), respectively. Patients with NAFLD had a significantly lower risk of liver related death and decompensation than patients with HCV infection, with HRs of 0.67 (95% CI, 0.48-0.95) and 0.70 (95% CI, 0.52-0.94) respectively.

CONCLUSIONS

In an analysis of patients in Western Australia, we found patients with alcohol-associated liver disease to have significantly higher risk of decompensation and liver-related death than patients with HCV infection, whereas patients with NAFLD have significantly lower risks of either outcome.

Nonalcoholic Fatty Liver Disease and the Heart: JACC State-of-the-Art Review

Nonalcoholic fatty liver disease (NAFLD) and cardiovascular disease (CVD) are both manifestations of end-organ damage of the metabolic syndrome. Through multiple pathophysiological mechanisms, CVD and NAFLD are associated with each other. Systemic inflammation, endothelial dysfunction, hepatic insulin resistance, oxidative stress, and altered lipid metabolism are some of the mechanisms by which NAFLD increases the risk of CVD. Patients with NAFLD develop increased atherosclerosis, cardiomyopathy, and arrhythmia, which clinically result in cardiovascular morbidity and mortality. Defining the mechanisms linking these 2 diseases offers the opportunity to further develop targeted therapies. The aim of this comprehensive review is to examine the association between CVD and NAFLD and discuss the overlapping management approaches.

Liver parameters as part of a non-invasive model for prediction of all-cause mortality after myocardial infarction

INTRODUCTION

Liver parameters are associated with cardiovascular disease risk and severity of stenosis. It is unclear whether liver parameters could predict the long-term outcome of patients after acute myocardial infarction (AMI). We performed an unbiased analysis of the predictive value of serum parameters for long-term prognosis after AMI.

MATERIAL AND METHODS

In a retrospective, observational, single-center, cohort study, 569 patients after AMI were enrolled and followed up until 6 years for major adverse cardiovascular events, including cardiac death. Patients were classified into non-survivors (n = 156) and survivors (n = 413). Demographic and laboratory data were analyzed using ensemble feature selection (EFS) and logistic regression. Correlations were performed for serum parameters.

RESULTS

Age (73; 64; p < 0.01), alanine aminotransferase (ALT; 93 U/l; 40 U/l; p < 0.01), aspartate aminotransferase (AST; 162 U/l; 66 U/l; p < 0.01), C-reactive protein (CRP; 4.7 U/l; 1.6 U/l; p < 0.01), creatinine (1.6; 1.3; p < 0.01), γ-glutamyltransferase (GGT; 71 U/l; 46 U/l; p < 0.01), urea (29.5; 20.5; p < 0.01), estimated glomerular filtration rate (eGFR; 49.6; 61.4; p < 0.01), troponin (13.3; 7.6; p < 0.01), myoglobin (639; 302; p < 0.01), and cardiovascular risk factors (hypercholesterolemia p < 0.02, family history p < 0.01, and smoking p < 0.01) differed significantly between non-survivors and survivors. Age, AST, CRP, eGFR, myoglobin, sodium, urea, creatinine, and troponin correlated significantly with death (r = -0.29; 0.14; 0.31; -0.27; 0.20; -0.13; 0.33; 0.24; 0.12). A prediction model was built including age, CRP, eGFR, myoglobin, and urea, achieving an AUROC of 77.6% to predict long-term survival after AMI.

CONCLUSIONS

Non-invasive parameters, including liver and renal markers, can predict long-term outcome of patients after AMI.

The impact of modifiable risk factors on the long-term outcomes of non-alcoholic fatty liver disease

BACKGROUND

Cardiovascular (CV) disease is the leading cause of mortality in patients with non-alcoholic fatty liver disease (NAFLD). The American Heart Association (AHA) developed 7 CV health metrics (poor, intermediate and ideal health) to improve CV health.

AIM

To assess population-attributable fractions (PAFs) of CV health metrics to all-cause and CV mortality among NAFLD patients METHODS: We included adult participants from National Health and Nutrition Examination Survey (NHANES 1988-1994) with clinical and mortality data. NAFLD was defined as the presence of hepatic steatosis on ultrasonography in the absence of other chronic liver diseases and excessive alcohol use.

RESULTS

A total of 4040 adults with NAFLD and 7515 without were included. NAFLD had fewer ideal health metrics than non-NAFLD (age-standardised prevalence: 20% vs 10% for ≤1 ideal health metric; 5.1% vs 8.7% for ≥6, all P < .001). Following median follow-up of 19.2 years (IQR: 17.5-21.0 years), 1,136 NAFLD subjects (327 CV deaths) and 1600 non-NAFLD subjects (447 CV deaths) died. Increased number of ideal health metrics (all trend P < .0001) correlated with lower risk for all-cause and CV mortality. If all NAFLD subjects achieved 7 ideal health metrics, 66% of all-cause deaths and 83% of CV deaths were preventable. Among NAFLD subjects, lack of glycaemic control (adjusted PAF = 28.3% all-cause; 38.1% CV) and hypertension (adjusted PAF of 23% all-cause; 52.8% CV) were the largest mortality contributors. Ideal physical activity level obtainment provided an adjusted PAF = 13.9% all-cause and 13.8% CV mortality.

CONCLUSIONS

Attainment of ideal CV health metrics provides protection against all-cause and CV deaths in NAFLD.

Association between advanced fibrosis in fatty liver disease and overall mortality based on body fat distribution

BACKGROUND

Studies on association between fatty liver disease and overall mortality have yielded conflicting results. We evaluated the impact of fatty liver disease and advanced fibrosis on overall morality with a focus on body size and abdominal fat distribution measured by computed tomography.

METHODS

We performed a prospective cohort study including 34 080 subjects (mean age, 51.4 years; 58.6% men) who underwent abdominal ultrasonography and fat computed tomography, from 2007 to 2015. Fatty liver was diagnosed by ultrasonography, and advanced fibrosis was defined as high probability of advanced fibrosis based on three noninvasive methods, aspartate aminotransferase-to-platelet ratio index, non-alcoholic fatty liver disease fibrosis score, and fibrosis-4 score. Body size was categorized by body mass index into obese (≥ 25 kg/m2 ) or nonobese (< 25 kg/m2 ). Multivariate proportional Cox hazard regression analyses were performed.

RESULTS

The prevalence of fatty liver disease was 37.5%, while the prevalence of advanced fibrosis in fatty liver disease was 1.8%. During a median follow-up of 87 months (interquartile range, 62-110), 296 deaths occurred. Fatty liver disease was not associated with higher overall mortality (multivariate-adjusted hazard ratio [HR] 1.02, 95% confidence interval [CI] 0.77-1.34), while increased subcutaneous adiposity was associated with decreased mortality (HR 0.72, 95% CI 0.60-0.88). Advanced fibrosis resulted in a 3.5-fold increase in overall mortality (adjusted HR 3.52, 95% CI 1.86-6.65), which was more pronounced in the nonobese.

CONCLUSIONS

While fatty liver disease did not impact overall mortality, subcutaneous adiposity was associated with reduced overall mortality. Advanced fibrosis was an independent predictor of increase in overall mortality.

Extra-Hepatic Manifestations of Nonalcoholic Fatty Liver Disease: A Review

Nonalcoholic fatty liver disease (NAFLD) is now the leading cause of chronic liver disease worldwide with a strong association with metabolic syndrome. NAFLD is truly a systemic disease and is associated with a plethora of extra-hepatic manifestations or comorbidities. These are either related to secondary effects of associated obesity or from pathophysiological effects of insulin resistance in NAFLD. Three most common causes of increased morbidity and mortality associated with NAFLD are cardiovascular disease, liver disease, and cancer. In this narrative review, we will discuss comprehensively on cardiovascular disease, type 2 diabetes mellitus, and chronic kidney disease and will also highlight on malignancy especially colorectal cancer, pulmonary disorders including obstructive sleep apnea, endocrine disorders such as hypothyroidism and polycystic ovarian syndrome, dermatological disorders especially psoriasis, and hematological associations including iron overload and susceptibility to thrombosis. In addition to focusing on pathogenesis of these extrahepatic manifestations, we will highlight their clinical implications for physicians in routine clinical practice. Further, there remains an unmet need for safe and effective therapies and examining their benefits on these extra-hepatic manifestations among patients with NAFLD.

Nonalcoholic Fatty Liver Disease in Adults: Current Concepts in Etiology, Outcomes, and Management

Nonalcoholic fatty liver disease (NAFLD) is a spectrum of disease, extending from simple steatosis to inflammation and fibrosis with a significant risk for the development of cirrhosis. It is highly prevalent and is associated with significant adverse outcomes both through liver-specific morbidity and mortality but, perhaps more important, through adverse cardiovascular and metabolic outcomes. It is closely associated with type 2 diabetes and obesity, and both of these conditions drive progressive disease toward the more advanced stages. The mechanisms that govern hepatic lipid accumulation and the predisposition to inflammation and fibrosis are still not fully understood but reflect a complex interplay between metabolic target tissues including adipose and skeletal muscle, and immune and inflammatory cells. The ability to make an accurate assessment of disease stage (that relates to clinical outcome) can also be challenging. While liver biopsy is still regarded as the gold-standard investigative tool, there is an extensive literature on the search for novel noninvasive biomarkers and imaging modalities that aim to accurately reflect the stage of underlying disease. Finally, although no therapies are currently licensed for the treatment of NAFLD, there are interventions that appear to have proven efficacy in randomized controlled trials as well as an extensive emerging therapeutic landscape of new agents that target many of the fundamental pathophysiological processes that drive NAFLD. It is highly likely that over the next few years, new treatments with a specific license for the treatment of NAFLD will become available.

Higher NAFLD fibrosis score is associated with impaired eGFR

BACKGROUND/PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Metabolic syndrome, but not non-alcoholic fatty liver disease, increases 10-year mortality: A prospective, community-cohort study

BACKGROUND

Data on outcomes of non-alcoholic fatty liver disease (NAFLD) from South Asia are lacking. We compared mortality, among those with- and without-NAFLD, after 10-years follow-up among urban, adult Sri Lankans.

METHOD

Participants (aged 35-64 years), selected by age-stratified random sampling, were screened by structured-interview in 2007. Anthropometric measurements, liver ultrasonography and biochemical/serological tests were done. NAFLD was diagnosed on ultrasound criteria, safe-alcohol consumption (Asian-standards) and absence of hepatitis B/C. Subjects without NAFLD were those without any ultrasound criteria of fatty liver, safe-alcohol consumption and absence of hepatitis B/C. The cohort was re-evaluated to assess mortality in 2017. Participants or their households were contacted by telephone/post, and deaths confirmed by home-visits and death certificate review. Cox-regression was used to determine predictors of all-cause mortality (ACM) and cardiovascular mortality (CVM) in those with- and without-NAFLD.

RESULTS

2724 (91.2%) of 2985 original participants were contacted (851-with NAFLD and 1072-without NAFLD). Overall there were 169 (6.2%) deaths [41-deaths among NAFLD (17-cardiovascular; 9-cancer-related; 4-liver-specific; 11-other) and 79-deaths among no-NAFLD (28-cardiovascular; 17-cancer-related; 1-liver-specific; 33-other)]. Metabolic syndrome (MetS), low-education level, higher age and male-gender independently predicted ACM. MetS, increasing age and male-gender independently predicted CVM. NAFLD did not predict either ACM or CVM. In those with NAFLD, MetS and age >55-years were independently associated with ACM, while MetS and male-gender were associated with CVM.

CONCLUSION

In this community-based study, increasing age, male-gender and MetS, but not NAFLD, predicted 10-year ACM and CVM. Among those with NAFLD, only those metabolically abnormal were at a higher risk for mortality.

Bariatric Surgery in Cirrhotic Patients: Is It Safe?

Introduction

Ten percent of cirrhotic patients are known to have a high risk of postoperative complications. Ninety percent of bariatric patients suffer from non-alcoholic fatty liver disease (NAFLD), and 50% of them may develop non-alcoholic steatohepatitis (NASH) which can progress to cirrhosis. The aim of this study was to assess whether the presence of cirrhosis at the time of bariatric surgery is associated with an increased rate and severity of short- and long-term cirrhotic complications.

Methods

A cohort of 110 bariatric patients, between May 2003 and February 2018, who had undergone liver biopsy at the time of bariatric surgery were reassessed for histological outcome and divided into two groups based on the presence (C, n = 26) or absence (NC, n = 84) of cirrhosis. The NC group consisted of NASH (n = 49), NAFLD (n = 24) and non-NAFLD (n = 11) liver histology. Medical notes were retrospectively assessed for patient characteristics, development of 30-day postoperative complications, severity of complications (Clavien-Dindo (CD) classification) and length of stay. The C group was further assessed for long-term cirrhosis-related outcomes.

Results

The C group was older (52 years vs 43 years) and had lower BMI (46 kg/m2 vs 52 kg/m2) and weight (126 kg vs 145 kg) compared to the NC group (p < 0.05). The C group had significantly higher overall complication rate (10/26 vs 14/84, p < 0.05) and severity of complications (CD class ≥ III, 12% vs 7%, p < 0.05) when compared to the NC group. The length of stay was similar between the two groups (5 days vs 4 days). The C group had significant improvement in model end-stage liver disease scores (7 vs 6, p < 0.01) with median follow-up of 4.5 years (range 2–11 years). There were no long-term cirrhosis-related complications or mortality in our studied cohort (0/26).

Conclusion

Bariatric surgery in cirrhotic patients has a higher risk of immediate postoperative complications. Long-term cirrhosis-related complications or mortality was not increased in this small cohort. Preoperative identification of liver cirrhosis may be useful for risk stratification, optimisation and informed consent. Bariatric surgery in well-compensated cirrhotic patients may be used as an aid to improve long-term outcome.

Evolution of NAFLD and Its Management

The global prevalence of nonalcoholic fatty liver disease (NAFLD) is estimated to be 25% and continues to rise worldwide in the setting of the obesity epidemic. This increase is especially concerning because NAFLD is often a progressive disease that can be associated with significant complications such as liver cirrhosis, hepatocellular carcinoma, and an increase in liver-related and overall mortality. Because of the devastating complications and comorbidities, NAFLD is a very costly disease for the healthcare system, with estimated annual direct medical costs exceeding $100 billion in the United States alone. Given this progressive course, it is imperative to make the diagnosis in patients with risk factors (metabolic syndrome, weight gain, and insulin resistance/diabetes). Once the diagnosis is made, the focus should shift to treatment and monitoring for the development of associated complications. Given that currently no pharmaceutical intervention is approved for the treatment of NAFLD, focus shifts instead to mitigation of risk factors through avoidance of foods that are rich in red meat, trans fats, refined carbohydrates, and high-fructose corn syrup; are low fiber; and have high energy density. The landmark of treatment, however, continues to be weight loss and improvement of insulin resistance, often through a multimodality approach. The current manuscript reviews the clinical phenotypes of NAFLD, its risk factors, and pathogenesis, as well as treatment options including lifestyle modifications and dietary interventions, medical therapies, endoscopic bariatric interventions, and bariatric surgery.

Weight loss interventions for Hispanic women in the USA: a protocol for a systematic review

BACKGROUND

In the U.S., Hispanic women experience a disproportionate rate of obesity and obesity-related chronic diseases. At the same time, Hispanic women remain considerably underrepresented in behavioral weight loss interventions. The purpose of this review is to systematically evaluate the evidence related to the effectiveness of weight loss interventions among Hispanic women in the U.S. This review will identify elements of successful weight loss interventions as well as areas for future research.

METHODS/DESIGN

The following databases will be searched to identify all relevant articles (from inception onwards): PubMed, Embase, Scopus, Web of Science (Science Citation Index and Social Sciences Citation Index), PsycINFO, CINAHL, Chicano Database, SPORTDiscus, CAB Abstracts, and Google Scholar. We will include randomized controlled trials and quasi-experimental studies of adult women (> 18 years) from Hispanic/Latino background living in the United States. Eligible interventions will target weight-related behaviors (including diet, physical activity, behavior modification and/or their combinations). The review's primary outcome will be weight change (expressed as change in lbs/kg or body mass index (BMI) (kg/m2)). Three reviewers will independently screen and select data and two will extract data. The methodological quality (or risk of bias) of individual studies will be appraised using the Effective Public Health Practice Project Quality Assessment Tool. A narrative synthesis will describe quality and content of the evidence.

DISCUSSION

The aim of this systematic review is to critically examine existing weight loss interventions for Hispanic women in the U.S. and provide quality evidence for the effectiveness of these interventions on weight loss. Further, this review seeks to identify characteristics of effective interventions and suggest future directions for research efforts targeting weight loss in this population. This review will inform the development of future weight loss interventions for this population.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42019119094.

NAFLD and Atherosclerosis: Two Sides of the Same Dysmetabolic Coin?

The prevalence of non-alcoholic fatty liver disease (NAFLD) is strongly increasing and may put patients at increased risk for atherosclerotic cardiovascular disease (asCVD). Both disease phenotypes often co-occur, in the case of obesity, insulin resistance, diabetes mellitus type 2, and the metabolic syndrome. We explore the pathogenesis of NAFLD, the epidemiology of asCVD in NAFLD patients, shared drivers of both phenotypes, and factors caused by NAFLD that contribute to asCVD. Genetic studies support that NAFLD may drive asCVD through mixed hyperlipidemia. Next, we discuss the prospects of lifestyle improvement and pharmacological treatment of NAFLD for asCVD risk reduction. Finally, we point out that earlier identification of patients with NAFLD should be pursued by increasing awareness of the association of these two phenotypes and collaboration between the involved physicians.

Low Awareness of Nonalcoholic Fatty Liver Disease in a Population-Based Cohort Sample: the CARDIA Study

BACKGROUND

Nonalcoholic fatty liver disease (NAFLD) is the most common chronic liver disease in the United States, yet little is known about NAFLD awareness in individuals with incidental fatty liver on imaging.

OBJECTIVE

To assess the level of awareness of imaging-defined NAFLD among individuals with and without metabolic risk factors.

DESIGN

Cross-sectional analysis within a prospective longitudinal population-based cohort study conducted in four U.S. cities.

PARTICIPANTS

Adults age 43 to 55 years enrolled in the Coronary Artery Risk Development in Young Adults (CARDIA) Study who underwent computed tomography and a personal health questionnaire at the year 25 exam (2010-2011, n = 2788).

MAIN MEASURES

NAFLD was defined as liver attenuation ≤ 51 Hounsfield units after exclusion of other causes of liver fat. Participants were considered "NAFLD aware" if they reported being told previously by a doctor or nurse that they had "fatty liver."

KEY RESULTS

NAFLD prevalence was 23.9%. Only 16 of 667 (2.4%) participants with CT-defined NAFLD were aware of a NAFLD diagnosis. NAFLD aware participants were more likely to be white (81.3% vs. 53.5%, p = 0.03) and have the metabolic syndrome (87.5% vs. 59.3%, p = 0.02) and/or hypertension (75.0% vs. 50.2%, p = 0.05). In multivariable analyses adjusted for demographics, metabolic syndrome and hypertension remained predictive of NAFLD awareness.

CONCLUSION

There is low awareness of NAFLD among individuals with hepatic steatosis on imaging, even among those with metabolic risk factors. These findings highlight an opportunity to raise public and practitioner awareness of NAFLD with the goal of increasing diagnosis and implementing early treatment strategies.

Leptin/adiponectin ratio correlates with hepatic steatosis but not arterial stiffness in nonalcoholic fatty liver disease in Japanese population

BACKGROUND AND AIMS

Cardiovascular disease (CVD) is a leading cause of mortality in nonalcoholic fatty liver disease (NAFLD). The aim of this study was to investigate the relationship of leptin-to-adiponectin (L/A) ratio with hepatic steatosis and arterial stiffness in NAFLD.

METHODS

The subjects were 871 Japanese adults who participated in a health survey. Dietary intake, body composition, lipid profile, serum interleukin-6 (IL-6), leptin, and adiponectin were analyzed. NAFLD was defined as fatty liver on ultrasonography in the absence of other causes of steatosis. Arterial stiffness was evaluated by the brachial-ankle pulse wave velocity (baPWV).

RESULTS

The subjects with NAFLD had a greater body mass index (BMI) and body fat percentage (BFP); a higher intake of daily energy (kcal) and carbohydrates; and a higher prevalence of hypertension, diabetes, and hyperlipidemia. The subjects with NAFLD had higher serum leptin and lower serum adiponectin concentrations and a higher L/A ratio than subjects without NAFLD. The L/A ratio increased with increasing severity of steatosis. The L/A ratio showed positive correlations with BMI and BFP, and a negative correlation with age. Women had higher L/A ratio and BFP levels than men regardless of the presence or absence of NAFLD. There was a weak positive correlation between baPWV and severity of steatosis. BaPWV was strongly correlated with age, while no relation was found between baPWV and L/A ratio. IL-6 level was correlated with baPVW and age, while the correlation between Il and 6 level and L/A ratio was very weak. The L/A ratio was correlated with triglycerides and the ratio of total cholesterol to high-density lipoprotein-cholesterol.

CONCLUSION

L/A ratio and arterial stiffness were associated with the severity of steatosis, whereas there was no correlation between L/A ratio and arterial stiffness in NAFLD. These findings suggest that not only leptin and adiponectin but also other factors might be involved in the pathogenesis for atherosclerosis in NAFLD.

Risk factors for cardiovascular disease in patients with non-alcoholic fatty liver disease with polymorbidity

Aim.To study the associations of the frequency and values of parameters of the main risk factors (RF) of cardiovascular diseases (CVD) and the degree of transnosological polymorbidity (PM) in patients with nonalcoholic fatty liver disease (NAFLD).

Material and methods. The analysis of 3667 medical records (men, women) treated in the clinic of Research Institute of Experimental and Clinical Medicine (Novosibirsk) was carried out. Index of polymorbidity was evaluated by the number of nosological forms in accordance with the International Classification of Diseases, 10th revision (ICD-10). The following risk factors were assessed according to clinical and laboratory tests: arterial hypertension, dyslipidemia, hyperglycemia, obesity.

Results.Both among men and women with increasing index of PM there was identified growth of the parameters that determine the main RF: systolic BP, diastolic BP, obesity (both in men and women), atherogenicity index (in women), glucose concentration in the blood serum (in women). Frequency of AH occurrence in persons with a high degree of PM among men was 49%, and among women — 69% higher, compared with persons with a low degree of PM. Among men, there was an increase in the incidence of AH (by 9%) and obesity (by 9%) in individuals with a high degree of PM, compared with individuals with an average degree of PM. Among women, there was an increase in the incidence of AH (by 15%), obesity (by 9%), hyperglycemia (by 11%) in persons with a high degree of PM, compared with individuals with an average degree of PM.

Conclusion.There was established the role of risk factors for cardiovascular diseases, arterial hypertension mainly, in the development of polymorbidity in patients with NAFLD. The findings indicate the need for personified prevention and treatment of such patients with mandatory identification and correction of modifiable CVD RF.

Non-alcoholic fatty liver disease and risk of incident acute myocardial infarction and stroke: findings from matched cohort study of 18 million European adults

OBJECTIVE

To estimate the risk of acute myocardial infarction (AMI) or stroke in adults with non-alcoholic fatty liver disease (NAFLD) or non-alcoholic steatohepatitis (NASH).

DESIGN

Matched cohort study.

SETTING

Population based, electronic primary healthcare databases before 31 December 2015 from four European countries: Italy (n=1 542 672), Netherlands (n=2 225 925), Spain (n=5 488 397), and UK (n=12 695 046).

PARTICIPANTS

120 795 adults with a recorded diagnosis of NAFLD or NASH and no other liver diseases, matched at time of NAFLD diagnosis (index date) by age, sex, practice site, and visit, recorded at six months before or after the date of diagnosis, with up to 100 patients without NAFLD or NASH in the same database.

MAIN OUTCOME MEASURES

Primary outcome was incident fatal or non-fatal AMI and ischaemic or unspecified stroke. Hazard ratios were estimated using Cox models and pooled across databases by random effect meta-analyses.

RESULTS

120 795 patients with recorded NAFLD or NASH diagnoses were identified with mean follow-up 2.1-5.5 years. After adjustment for age and smoking the pooled hazard ratio for AMI was 1.17 (95% confidence interval 1.05 to 1.30; 1035 events in participants with NAFLD or NASH, 67 823 in matched controls). In a group with more complete data on risk factors (86 098 NAFLD and 4 664 988 matched controls), the hazard ratio for AMI after adjustment for systolic blood pressure, type 2 diabetes, total cholesterol level, statin use, and hypertension was 1.01 (0.91 to 1.12; 747 events in participants with NAFLD or NASH, 37 462 in matched controls). After adjustment for age and smoking status the pooled hazard ratio for stroke was 1.18 (1.11 to 1.24; 2187 events in participants with NAFLD or NASH, 134 001 in matched controls). In the group with more complete data on risk factors, the hazard ratio for stroke was 1.04 (0.99 to 1.09; 1666 events in participants with NAFLD, 83 882 in matched controls) after further adjustment for type 2 diabetes, systolic blood pressure, total cholesterol level, statin use, and hypertension.

CONCLUSIONS

The diagnosis of NAFLD in current routine care of 17.7 million patient appears not to be associated with AMI or stroke risk after adjustment for established cardiovascular risk factors. Cardiovascular risk assessment in adults with a diagnosis of NAFLD is important but should be done in the same way as for the general population.

Cholecystectomy versus central obesity or insulin resistance in relation to the risk of nonalcoholic fatty liver disease: the third US National Health and Nutrition Examination Survey

BACKGROUND

Cholecystectomy, central obesity, and insulin resistance (IR) are established risk factors for nonalcoholic fatty liver disease (NAFLD). We aimed to examine the relative contributions and combined association of cholecystectomy and central obesity/IR with NAFLD risk.

METHODS

We conducted a cross-sectional analysis of data from the third National Health and Nutrition Examination Survey (NHANES III), in which ultrasonography was performed. Odds ratios (ORs) and 95% confidence intervals for NAFLD were estimated using logistic regression.

RESULTS

Cholecystectomy associated with a higher prevalence of NAFLD compared with gallstones among both centrally obese and non-centrally-obese subjects. Gallstones associated with a higher prevalence of NAFLD only in the presence of central obesity. In centrally obese participants, the OR increased from 2.67 (2.15-3.32) for participants without gallstone disease to 6.73 (4.40-10.29) for participants with cholecystectomy. In participants with cholecystectomy, the OR increased from 2.57 (1.35-4.89) for participants without central obesity to 6.73 (4.40-10.29) for centrally obese counterparts. We observed a modest increase in the risk of NAFLD with cholecystectomy compared with a large increase in the risk with IR or metabolic syndrome.

CONCLUSION

The magnitude of the NAFLD risk contributed by cholecystectomy was similar to central obesity in combined analyses. The magnitude of the association with IR or metabolic syndrome was greater than with cholecystectomy.

Reduced lysosomal acid lipase activity: A new marker of liver disease severity across the clinical continuum of non-alcoholic fatty liver disease?

Lysosomal acid lipase (LAL) plays a key role in intracellular lipid metabolism. Reduced LAL activity promotes increased multi-organ lysosomal cholesterol ester storage, as observed in two recessive autosomal genetic diseases, Wolman disease and Cholesterol ester storage disease. Severe liver steatosis and accelerated liver fibrosis are common features in patients with genetic LAL deficiency. By contrast, few reliable data are available on the modulation of LAL activity in vivo and on the epigenetic and metabolic factors capable of regulating its activity in subjects without homozygous mutations of the Lipase A gene. In the last few years, a less severe and non-genetic reduction of LAL activity was reported in children and adults with non-alcoholic fatty liver disease (NAFLD), suggesting a possible role of LAL reduction in the pathogenesis and progression of the disease. Patients with NAFLD show a significant, progressive reduction of LAL activity from simple steatosis to non-alcoholic steatohepatitis and cryptogenic cirrhosis. Among cirrhosis of different etiologies, those with cryptogenic cirrhosis show the most significant reductions of LAL activity. These findings suggest that the modulation of LAL activity may become a possible new therapeutic target for patients with more advanced forms of NAFLD. Moreover, the measurement of LAL activity may represent a possible new marker of disease severity in this clinical setting.

Consumption of a Leuconostoc holzapfelii-enriched synbiotic beverage alters the composition of the microbiota and microbial extracellular vesicles

Synbiotics, the combination of probiotics and prebiotics, are known to confer health benefits via intestinal microbiota modulation. However, significant intestinal microbiota alterations can be difficult to determine in intervention studies based on solely bacterial stool metagenomic analysis. Intestinal microbiota constituents secrete 20-200-nm-sized extracellular vesicles (EVs) containing microbial DNA, proteins, and lipids that are distributed throughout the body, providing an alternative target for microbiota metagenomic analysis. Here, we determined the impact of a synbiotic beverage enriched with the kimchi-derived bacterium Leuconostoc holzapfelii (L. holzapfelii) on the intestinal microbiota and local and circulatory microbiota-derived EV composition of healthy Korean adults. We isolated microbial DNA from stool bacteria, stool EVs, and urinary EVs and conducted next-generation sequencing of the 16S rDNA V3-V4 regions before and after synbiotic consumption. The species diversity of circulating urinary EVs was significantly increased after synbiotic consumption, while stool bacterial and EV diversity remained unchanged. Furthermore, we found that while a single genus was decreased among the stool bacteria constituents, stool EVs and urinary EVs showed significant alterations in four and eight genera, respectively. Blood chemistry assays revealed that synbiotic consumption significantly lowered aspartate aminotransferase (AST) serum levels, particularly in subjects with starting levels above the normal range (>40 UI/L). In conclusion, the L. holzapfelii-enriched synbiotic beverage greatly altered serum AST levels and microbial EV composition in urine and stool, while only minor changes were observed in the gut microbiota composition. Based on these findings, we suggest the potential use of microbiota-derived EVs as surrogate markers in future predictive diagnosis studies.

Nonalcoholic fatty liver disease and mortality from all causes, cardiovascular disease, and cancer: a meta-analysis

Whether nonalcoholic fatty liver disease (NAFLD) is associated with an increased risk of mortality remains controversial. The present study aimed to clarify this issue. A systematic search of PubMed and Embase was conducted through October 2018. Studies providing risk estimates of NAFLD and mortality were included. A random-effects model was employed to calculate summary risk estimates. Subgroup analyses were performed to identify potential effect modifiers. Fourteen studies, involving 498501 subjects and 24234 deaths, were included. Patients with NAFLD were found to be at an elevated risk of all-cause mortality compared with those without [hazard ratio (HR) = 1.34; 95% confidence interval (CI) 1.17-1.54)]. The significantly positive association between NAFLD and all-cause mortality could not be modified by age, sex, follow-up duration, and adjustment for body mass index, diabetes, smoking or hypertension (all Pinteraction > 0.05), and remained in sensitivity analyses. No significant associations of NAFLD with CVD (HR = 1.13; 95% CI 0.92-1.38) and cancer (HR = 1.05; 95% CI 0.89-1.25) mortality were found. In conclusion, NAFLD is a predictor of increased all-cause mortality but not CVD and cancer mortality. These findings have important implications for decision making in public health and clinical practice, and highlight the urgency of developing effective treatments for NAFLD.

Nonalcoholic Fatty Liver Disease and Renal Function Impairment: A Cross-Sectional Population-Based Study on Its Relationship From 1999 to 2016

There is growing evidence that links nonalcoholic fatty liver disease (NAFLD) with impairment of renal function. As such, we aimed to demonstrate the trend of NAFLD, NAFLD with renal insufficiency (RI), disease awareness, and mortality over time. Patient data were extracted from the National Health and Nutrition Examination Survey (NHANES) 1999-2016. A total of 14,255 adult study participants without competing liver disease or heavy drinking and with complete laboratory data were included. NAFLD was defined using the U.S. Fatty Liver Index (USFLI) and RI was defined using the Chronic Kidney Disease Epidemiology Collaboration equation and urine albumin:creatinine ratio. Death data were obtained from the National Death Index (up to December 31, 2015). Prevalence of NAFLD in participants was 31.2% (95% confidence interval [CI], 30.01-32.46); of these participants, 22.05% (95% CI, 20.34-23.85) had RI. From 1999 to 2016, prevalence of both NAFLD without RI (P = 0.048) and NAFLD-RI (P = 0.006) increased significantly. Among those with NAFLD-RI, awareness of kidney disease was 8.56% (95% CI, 6.69-10.89), while awareness of liver disease among all NAFLD was 4.49% (95% CI, 3.17-6.33). Among those with NAFLD, mortality incidence per 1,000 person years was highest among those with severe RI in all-cause mortality (104.4; 95% CI, 83.65-130.39) and other residual causes of mortality (mean, 50.88; 95% CI, 37.02-69.93). Conclusion: Prevalence of NAFLD and NAFLD-RI has increased over the past 2 decades in the United States. Low kidney disease and liver disease awareness are major public health issues as those with NAFLD-RI have significantly higher mortality than those with only NAFLD.

Fatty liver and mortality: a cohort population study in South Italy

OBJECTIVE

Alcoholic fatty liver (AFLD) and non-alcoholic fatty liver (NAFLD) are two common conditions. However, if they can increase the risk of death is poorly explored. We therefore aimed to investigate the potential association between the presence and severity of liver steatosis and mortality in a large sample of older people.

DESIGN

Prospective.

SETTING

Community.

PARTICIPANTS

Women and men randomly sampled from the electoral rolls of the population of Castellana Grotte, a town in Southern Italy (Apulia region) between 2005 and 2006. Among 1942 initially contacted, 1708 (=87.9%) participated to the baseline survey (Multicentrica Colelitiasi III (MICOL III)). This specific study included 1445 older participants (mean age=65.2 years, females=44.2%).

EXPOSURE

NAFLD or AFLD.

PRIMARY AND SECONDARY OUTCOMES

Mortality (all-cause and specific-cause).

RESULTS

After a median of 12 years, 312 participants (=21.6%) died. After adjusting for nine potential confounders, the presence of steatosis was not associated with any increased risk of death in both NAFLD and AFLD. The severity of liver steatosis was not associated with any increased risk of mortality in NAFLD, while in AFLD, the presence of moderate steatosis significantly increased the risk of overall (HR=2.16; 95% CI 1.19 to 3.91) and cancer-specific (HR=3.54; 95% CI 1.16 to 10.87) death.

CONCLUSIONS

Liver steatosis is not associated with any increased risk of death in NAFLD, while moderate steatosis could be a risk factor for mortality (particularly due to cancer) in people affected by AFLD.

The association between liver fat and systemic calcified atherosclerosis

BACKGROUND

The association of nonalcoholic fatty liver disease (NAFLD) with systemic calcified atherosclerosis, other than the coronary arteries, has not been clearly elucidated. We investigated the association between NAFLD and calcification in eight different vascular beds.

METHODS

In a community-based cohort with computed tomography scans for carotid artery, coronary artery, thoracic aorta, abdominal aorta, iliac artery, renal artery, celiac trunk, and superior mesenteric artery, the association between NAFLD and arterial calcification was evaluated with adjustment for age, sex, hypertension, dyslipidemia, diabetes, obesity, current smoking status, and family history of heart disease in the first-degree relatives.

RESULTS

In age- and sex-adjusted models, NAFLD was significantly associated with calcification in the coronary artery, carotid artery, thoracic aorta, celiac trunk, and superior mesenteric artery vascular beds (P < .05). However, adjustment for the traditional chronic venous disease risk factors attenuated the associations, except in the case of the thoracic aorta (odds ratio [OR], 1.38; 95% confidence interval [CI], 1.09-1.78) and celiac trunk (OR, 2.05; 95% CI, 1.16-3.65). In addition, NAFLD was independently associated with multiarterial calcification (four or more [OR, 1.33; 95% CI, 1.01-1.74], five or more [OR, 1.46; 95% CI, 1.09-1.97], and six or more [OR, 1.58; 95% CI, 1.09-2.30] of eight evaluated arterial segments).

CONCLUSIONS

The association between NAFLD and arterial calcification is mainly mediated by conventional risk factors. The independent association between NAFLD and calcification in the thoracic aorta and celiac trunk as well as in a larger number of vascular beds needs confirmation in future prospective studies in diverse populations.

Interaction of volatile organic compounds and underlying liver disease: a new paradigm for risk

Occupational and environmental exposures to industrial chemicals are known to cause hepatotoxicity and liver injury, in humans and in animal models. Historically, research has focused on severe acute liver injury (e.g. fulminant liver failure) or endstage diseases (e.g. cirrhosis and HCC). However, it has become recently recognized that toxicants can cause more subtle changes to the liver. For example, toxicant-associated steatohepatitis, characterized by hepatic steatosis, and inflammation, was recently recognized in an occupational cohort exposed to vinyl chloride. At high occupational levels, toxicants are sufficient to cause liver damage and disease even in healthy subjects with no comorbidities for liver injury. However, it is still largely unknown how exposure to toxicants initiate and possibly more importantly exacerbate liver disease, when combined with other factors, such as underlying non-alcoholic fatty liver disease caused by poor diet and/or obesity. With better understanding of the mechanism(s) and risk factors that mediate the initiation and progression of toxicant-induced liver disease, rational targeted therapy can be developed to better predict risk, as well as to treat or prevent this disease. The purpose of this review is to summarize established and proposed mechanisms of volatile organic compound-induced liver injury and to highlight key signaling events known or hypothesized to mediate these effects.

Cohort profile: the Trivandrum non-alcoholic fatty liver disease (NAFLD) cohort

PURPOSE

The Trivandrum non-alcoholic fatty liver disease (NAFLD) cohort is a population-based study designed to examine the interaction between genetic and lifestyle factors and their association with increased risk of NAFLD within the Indian population.

PARTICIPANTS

Between 2013 and 2016, a total of 2222 participants were recruited to this cohort through multistage cluster sampling across the whole population of Trivandrum-a district within the state of Kerala, South India. Data were collected from all inhabitants of randomly selected households over the age of 25.

FINDINGS TO DATE

Full baseline clinical and pathological data were collected from 2158 participants. This included detailed demographic profiles, anthropometric measures and lifestyle data (food frequency, physical activity and anxiety and depression questionnaires). Biochemical profile and ultrasound assessment of the liver were performed and whole blood aliquots were collected for DNA analysis.The NAFLD prevalence within this population was 49.8% which is significantly higher than the global pooled prevalence of 25%. This highlights the importance of robust, prospective studies like this to enable collection of longitudinal data on risk factors, disease progression and to facilitate future interventional studies.

FUTURE PLANS

The complete analysis of data collected from this cohort will give valuable insights into the interaction of the phenotypic and genotypic profiles that result in such a dramatic increased risk of NAFLD within the Indian population. The cohort will also form the basis of future lifestyle interventional studies, aimed at improving liver and metabolic health.

Nonalcoholic Fatty Liver Disease: Identification and Management of High-Risk Patients

Nonalcoholic fatty liver disease (NAFLD) is an increasingly dominant cause of liver disease worldwide. The progressive subtype, nonalcoholic steatohepatitis, is a leading indication for liver transplantation and a noteworthy cause of hepatocellular carcinoma. The overall prevalence of NAFLD is on the rise, and even more concerning data modeling predicts that an increasing percentage of those with NAFLD will develop advanced disease. This increased volume of patients with advanced liver disease will impose a significant health care burden in terms of resources and cost. Thus, the identification of patients with established fibrosis or at high risk of developing advanced liver disease is critical to effectively intervene and prevent overall and liver-related morbidity and mortality. Herein, we provide a framework to consider for the identification of patients with NAFLD at high risk of nonalcoholic steatohepatitis with advanced fibrosis and provide a critical assessment of currently accessible diagnostic and treatment modalities.

Liver steatosis is a strong predictor of mortality and cancer in chronic hepatitis B regardless of viral load

Liver steatosis may occur concomitantly in patients with chronic hepatitis B infection (CHB) and is implicated in increased morbidity and mortality. Hepatitis B virus (HBV) viral load is a marker for disease progression and long-term outcomes in CHB. We investigated the association between liver steatosis and HBV viral load and their individual effects on all-cause mortality and the development of cancer in patients with CHB and liver steatosis.

Methods

This retrospective study included 524 treatment-naïve patients with CHB, with a mean follow-up of 6 years. Liver biopsy was available for 170 patients and liver steatosis was validated by at least 3 ultrasonographic examinations.

Results

A total of 241/524 (46%) patients with CHB had liver steatosis, with a strong correlation between the degree of liver steatosis as assessed by ultrasonography or by liver biopsy (r = 0.9, p < 0.001). Although liver steatosis was not significantly associated with advanced fibrosis, a multivariate analysis showed that liver steatosis was associated with a 4-fold increased risk of all-cause mortality and cancer (hazard ratio 4.35; 95% CI 1.69–8.99; p < 0.001), irrespective of other major metabolic factors. However, baseline HBV viral load was not significantly associated with this composite outcome (hazard ratio 1.65; p = 0.29). In addition, liver steatosis was inversely associated with HBV viral load.

Conclusion

Patients with CHB and liver steatosis have an increased risk of all-cause mortality and cancer development compared to patients with CHB without liver steatosis, regardless of their baseline HBV viral load. Although tending to have a lower baseline viral load, patients with CHB and liver steatosis should be closely monitored irrespective of viral load.

Lay summary

Patients with chronic hepatitis B infection (CHB) may have liver steatosis at the same time. Here we show that in patients with CHB, liver steatosis is significantly associated with all-cause mortality and cancer, irrespective of other major metabolic factors, and the effect of liver steatosis on mortality and cancer is stronger than the effect of hepatitis B viral load on these outcomes. Thus, patients with CHB and liver steatosis should be closely monitored, irrespective of their viral load.

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HBV viral load is an important predictor of adverse outcomes in patients with chronic HBV (CHB).

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Liver steatosis may co-occur with CHB but its effect on all-cause mortality and cancer has not been determined.

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Liver steatosis is significantly associated with all-cause mortality and cancer in patients with CHB.

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The effect of liver steatosis on mortality and cancer is stronger than the effect of HBV viral load.

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Patients with CHB and liver steatosis should be closely monitored, irrespective of their viral load.

The Epidemiology, Risk Profiling and Diagnostic Challenges of Nonalcoholic Fatty Liver Disease

Nonalcoholic fatty liver disease (NAFLD) encompasses a wide spectrum of liver damage from the more prevalent (75%⁻80%) and nonprogressive nonalcoholic fatty liver (NAFL) category to its less common and more ominous subset, nonalcoholic steatohepatitis (NASH). NAFLD is now the most common cause of chronic liver disease in the developed world and is a leading indication for liver transplantation in United States (US). The global prevalence of NAFLD is estimated to be 25%, with the lowest prevalence in Africa (13.5%) and highest in the Middle East (31.8%) and South America (30.4%). The increasing incidence of NAFLD has been associated with the global obesity epidemic and manifestation of metabolic complications, including hypertension, diabetes, and dyslipidemia. The rapidly rising healthcare and economic burdens of NAFLD warrant institution of preventative and treatment measures in the high-risk sub-populations in an effort to reduce the morbidity and mortality associated with NAFLD. Genetic, demographic, clinical, and environmental factors may play a role in the pathogenesis of NAFLD. While NAFLD has been linked with various genetic variants, including PNPLA-3, TM6SF2, and FDFT1, environmental factors may predispose individuals to NAFLD as well. NAFLD is more common in older age groups and in men. With regards to ethnicity, in the US, Hispanics have the highest prevalence of NAFLD, followed by Caucasians and then African-Americans. NAFLD is frequently associated with the components of metabolic syndrome, such as type 2 diabetes mellitus (T2DM), obesity, hypertension, and dyslipidemia. Several studies have shown that the adoption of a healthy lifestyle, weight loss, and pro-active management of individual components of metabolic syndrome can help to prevent, retard or reverse NAFLD-related liver damage. Independently, NAFLD increases the risk of premature cardiovascular disease and associated mortality. For this reason, a case can be made for screening of NAFLD to facilitate early diagnosis and to prevent the hepatic and extra-hepatic complications in high risk sub-populations with morbid obesity, diabetes, and other metabolic risk factors.

Nonalcoholic Steatohepatitis Is the Fastest Growing Cause of Hepatocellular Carcinoma in Liver Transplant Candidates

BACKGROUND & AIMS

Although hepatitis B and C have been the main drivers of hepatocellular carcinoma (HCC), nonalcoholic steatohepatitis (NASH) has recently become an important cause of HCC. The aim of this study was to assess the causes of HCC among liver transplant (LT) candidates in the United States.

METHODS

The Scientific Registry of Transplant Recipients (2002-2016) was used to estimate the trends in prevalence of HCC in LT candidates with the most common types of chronic liver disease: alcoholic liver disease (ALD), chronic hepatitis B (CHB), chronic hepatitis C, and NASH.

RESULTS

158,347 adult LT candidates were included. Of these, 26,121 (16.5%) had HCC; this proportion increased from 6.4% (2002) to 23.0% (2016) (trend P < .0001). Over the study period, CHC remained the most common etiology for HCC (65%). The proportions of HCC accounted for by CHC and ALD remained stable (both trend P > .10), the proportion of CHB decreased 3.1-fold (P < .0001), while the proportion of NASH in HCC increased 7.7-fold (from 2.1% to 16.2%; P < .0001). Furthermore, since 2002, the prevalence of HCC in LT candidates with NASH increased 11.8-fold, while this rate increased 6.0-fold in CHB, 3.4-fold in ALD, and 2.3-fold in CHC (all P < .0001); the increasing trend in NASH was steeper than that for any other etiology (P < .0001 in a trend regression model). The proportion of LT candidates with HCC who ultimately received a transplant or died while waiting did not differ between etiologies (P > .05).

CONCLUSIONS

Nonalcoholic steatohepatitis is the most rapidly growing cause of HCC among US patients listed for liver transplantation.

Non-alcoholic fatty liver disease: Prevalence and all-cause mortality according to sedentary behaviour and cardiorespiratory fitness. The HUNT Study

PURPOSE

Sedentary behaviour (SB) and low physical activity (PA) are independently associated with non-alcoholic fatty liver disease (NAFLD). Compared to PA, high cardiorespiratory fitness (CRF) has been associated with a higher protection against all-cause mortality and a number of specific diseases. However, this relationship has not been investigated in NAFLD. This study examined the roles of SB and CRF on: i) the likelihood of having NAFLD in the general population, and ii) the risk of mortality over 9 years within individuals having NAFLD.

METHODS

A cross-sectional analysis of 15,781 adults (52% female; age range 19-95 years) was conducted. Self-reported SB was divided into tertiles. CRF was estimated using validated non-exercise models, and the presence of NAFLD from the Fatty Liver Index. Adjusted Odds Ratios and 95% Confidence Intervals for NAFLD were estimated using logistic regression analyses. Hazard Ratios for all-cause mortality were estimated using Cox proportional hazard regression in individuals with NAFLD.

RESULTS

For each additional 1 h/d of SB, the likelihood of having NAFLD was significantly increased by 4% (CI, 3-6%). In combined analyses, compared with the reference group [high CRF and low (≤4 h/d) SB], individuals with low CRF had a markedly higher likelihood of having NAFLD (OR, 16.9; CI 12.9-22.3), even if they had SB ≤ 4 h/d. High CRF attenuated the negative role of SB up to 7 h/d on NAFLD. Over 9.4 ± 1.3 years of follow-up, individuals with NAFLD and low CRF had the risk of mortality increased by 52% (CI, 10-106%) compared to those with high CRF, regardless of SB or meeting PA guidelines.

CONCLUSIONS

Low CRF increases the risk of premature death in individuals with NAFLD, and is strongly associated with higher likelihood of having NAFLD, outweighing the influence of SB.

Non-alcoholic fatty liver disease presence and severity are associated with aortic stiffness beyond abdominal obesity: The ELSA-Brasil

BACKGROUND AND AIMS

It is uncertain whether non-alcoholic fatty liver disease (NAFLD) is associated with aortic stiffness in a racial/ethnically diverse and admixed society. We addressed whether NAFLD presence and severity were associated with carotid-femoral pulse wave velocity (cf-PWV) in individuals free of cardiovascular disease.

METHODS

In 7196 individuals free of cardiovascular disease at the baseline Brazilian longitudinal study of adult health, we classified NAFLD presence and severity (mild, moderate and severe) by ultrasound hepatic attenuation. We measured cf-PWV using a non-invasive validated device (Complior SP, Artech Medicale France). We compared cf-PWV of NAFLD individuals to those without by analysis of covariance adjusted for demographics, life style, waist circumference, and arterial pressure. We also analyzed the cf-PWV trend from no-NAFLD to severe NAFLD.

RESULTS

In unadjusted analysis, from no-NAFLD to severe NAFLD, there were slightly older individuals, lower frequency of smokers, more prevalent diabetes and hypertension. In adjusted analysis, there was slightly higher cf-PWV (m/s) (95%CI) in NAFLD vs. no-NAFLD, respectively 9.32 (9.22, 9.41) and 9.24 (9.15, 9.33) (p = 0.037). Across NAFLD severity spectrum, adjusted cf-PWV increased from 9.24 (9.15, 9.33) in no-NAFLD to 9.69 (9.46, 9.93) in severe NAFLD (p for trend association = 0.001). In sensitivity analysis, diabetes adjustment nullified the association of binary NAFLD with cf-PWV, but not that of increasingly severe NAFLD.

CONCLUSIONS

In racial/ethnically diverse individuals free of cardiovascular disease, NAFLD is associated with aortic stiffness beyond abdominal obesity. The specific NAFLD impact on CVD worldwide is potentially relevant.

Relationship Between Nonalcoholic Fatty Liver Disease Susceptibility Genes and Coronary Artery Disease

Coronary artery disease (CAD) is the principal cause of death in patients with nonalcoholic fatty liver disease (NAFLD). The aim of the present study was to investigate whether NAFLD is causally involved in the pathogenesis of CAD. For this, previously reported NAFLD susceptibility genes were clustered and tested for an association with CAD in the Coronary Artery Disease Genome‐Wide Replication and Meta‐Analysis plus the Coronary Artery Disease Genetics (CARDIoGRAMplusC4D) Consortium data set. The role of plasma lipids as a potential mediator was explored by using data from the Global Lipids Genetics Consortium. Statistical analyses revealed that the combination of 12 NAFLD genes was not associated with CAD in 60,801 CAD cases and 123,504 controls (odds ratio [OR] per NAFLD risk allele, 1.0; 95% confidence interval [CI], 0.99‐1.00). In a subsequent sensitivity analysis, a positive relationship was observed after exclusion of gene variants that are implicated in NAFLD through impaired very low‐density lipoprotein secretion (i.e., microsomal triglyceride transfer protein [MTTP], patatin‐like phospholipase domain containing 3 [PNPLA3], phosphatidylethanolamine N‐methyltransferase [PEMT], and transmembrane 6 superfamily member 2 [TM6SF2]) (OR, 1.01; 95% CI, 1.00‐1.02). Clustering of the excluded genes showed a significant negative relationship with CAD (OR, 0.97; 95% CI, 0.96‐0.99). A substantial proportion of the observed heterogeneity between the individual NAFLD genes in relation to CAD could be explained by plasma lipids, as reflected by a strong relationship between plasma lipids and CAD risk conferred by the NAFLD susceptibility genes (r = 0.76; P = 0.004 for low‐density lipoprotein cholesterol). Conclusion: NAFLD susceptibility genes do not cause CAD per se. The relationship between these genes and CAD appears to depend to a large extent on plasma lipids. These observations strongly suggest taking plasma lipids into account when designing a new drug to target NAFLD.

Impact of Non-Alcoholic Fatty Liver Disease on Cardiovascular Outcomes in Patients With Stable Coronary Artery Disease: A Matched Case-Control Study

INTRODUCTION

Whether non-alcoholic fatty liver disease (NAFLD) is associated with cardiovascular risk has still been controversial. The reasons for this disparity may be associated with subject selection, events definition, diagnostic criteria of NAFLD, or research methods. The aim of this study was to determine the relationship of NAFLD to cardiovascular disease (CVD) outcomes in patients with stable, new-onset coronary artery disease (CAD).

METHODS

A matched case-control study based on the cohort with stable, new-onset CAD was implemented in 162 cases (patients who developed all-cause death, non-fatal myocardial infarction and stroke during an average of 11,484 patient-years of follow-up) and 162 controls without cardiovascular events matched with the same sex, the age difference ≤3 years old, and the admission date within 3 months. Abdominal ultrasonography and coronary angiography were performed at admission. COX proportional hazard models and conditional logistic regression analysis were used to assess the effect of NAFLD on CVD outcomes.

RESULTS

NAFLD was more common in the event group than in the control group (P = 0.012). Kaplan-Meier analysis showed a significant association between NAFLD and CVD outcomes (P = 0.007). Moreover, Cox regression (hazard ratios 1.56; 95% confidence interval, 1.04-2.34, P = 0.031) and conditional logistic regression (odds ratio 2.72, 95% confidence interval, 1.16-6.39, P = 0.022) analyses further demonstrated that NAFLD was an independent risk factor for CVD outcomes.

CONCLUSIONS

NAFLD is indeed an independent predictor of CVD outcomes in patients with stable, new-onset CAD. Further randomized controlled trials may be needed to confirm our findings.

Web-Based Exercise as an Effective Complementary Treatment for Patients With Nonalcoholic Fatty Liver Disease: Intervention Study

Background

Physical inactivity is a major risk factor for nonalcoholic fatty liver disease (NAFLD). Exercise-based prevention interventions for improving cardiorespiratory fitness are a recommended complementary treatment for NAFLD. Achievement of minimally effective physical activity to improve cardiorespiratory fitness among patients typically involves high personal and financial expenses in face-to-face settings. We designed an eHealth approach for patients with NAFLD to improve the cardiorespiratory fitness and report the first results of the HELP (Hepatic Inflammation and Physical Performance in Patients With NASH [nonalcoholic steatohepatitis]) study.

Objective

We aimed to assess the effectiveness of an 8-week, tailored, Web-based exercise intervention for cardiorespiratory fitness improvement, expressed as peak oxygen uptake (peak volume of oxygen [VO_2peak]), in patients with histologically confirmed NAFLD.

Methods

In a 24-month period, 44 patients were enrolled into an 8-week, prospective, single-arm study with 12 weeks of follow-up. After a medical examination and performance diagnostics, a sports therapist introduced the patients to a Web-based platform for individualized training support. Regular individual patient feedback was provided to systematically adapt the weekly exercise schedule, which allowed us to monitor and ensure patient adherence to strength and endurance training and optimize the step-wise progressive exercise load. Exercise progression was based on an a priori algorithm that considered the subjective rate for both perceived exhaustion and general physical discomfort. The VO_2peak was assessed at baseline and at the end of the study by spiroergometry.

Results

A total of 43 patients completed the intervention with no adverse events. The VO_2peak increased significantly by 2.4 mL/kg/min (8.8%; 95% confidence interval [CI]: 1.48-3.27; P<.001) accompanied by a reduction of 1.0 kg in a body weight (95% CI: 0.33-1.58; P=.004) and 1.3 kg in body fat mass (95% CI: 0.27-2.27; P=.01). In an exploratory analysis, step-wise logistic regression analysis revealed low body fat and VO_2peak at baseline and the total minutes of endurance training during the intervention as main contributors to a positive change in VO_2peak. Our predictive model indicated that the average patient with NAFLD needed 223 min for stabilization of VO_2peak and 628 min for average improvement in VO_2peak. However, in patients with a VO_2peak approximately 20% higher than the average VO_2peak, 628 min were only sufficient to stabilize the VO_2peak and >40% reduction in the average fat mass would be required to achieve an average outcome.

Conclusions

This is the first study to show that patients with NAFLD can be effectively supported by a Web-based approach, which can increase the VO_2peak to a similar extent as face-to-face interventions. Patients with low body fat and low VO_2peak benefited the most from our intervention. In terms of future treatment strategies, NAFLD patients with high body fat may particularly benefit from body-fat reduction through a strict nutritional intervention, subsequently enabling a more effective exercise intervention.

Trial Registration

ClinicalTrials.gov NCT02526732; https://clinicaltrials.gov/ct2/show/NCT02526732 (Archived by WebCite at http://www.webcitation.org/74pXhXXfq)

International Registered Report Identifier (IRRID)

RR2-10.2196/resprot.8607

The changing epidemiology of liver diseases in the Asia-Pacific region

This Review presents current epidemiological trends of the most common liver diseases in Asia-Pacific countries. Hepatitis B virus (HBV) remains the primary cause of cirrhosis; despite declining prevalence in most Asian nations, this virus still poses a severe threat in some territories and regions. Mortality resulting from HBV infection is declining as a result of preventive measures and antiviral treatments. The epidemiological transition of hepatitis C virus (HCV) infection has varied in the region in the past few decades, but the medical burden of infection and the prevalence of its related cancers are increasing. The lack of licensed HCV vaccines highlights the need for novel treatment strategies. The prevalence of nonalcoholic fatty liver disease (NAFLD) has risen in the past decade, mostly owing to increasingly urbanized lifestyles and dietary changes. Alternative herbal medicine and dietary supplements are major causes of drug-induced liver injury (DILI) in some countries. Complications arising from these chronic liver diseases, including cirrhosis and liver cancer, are therefore emerging threats in the Asia-Pacific region. Key strategies to control these liver diseases include monitoring of at-risk populations, implementation of national guidelines and increasing public and physician awareness, in concert with improving access to health care.

Hepatic Gene Expression Profiles Differentiate Steatotic and Non-steatotic Grafts in Liver Transplant Recipients

Background: Liver transplantation leads to non-alcoholic fatty liver disease or non-alcoholic steatohepatitis in up to 40% of graft recipients. The aim of our study was to assess transcriptomic profiles of liver grafts and to contrast the hepatic gene expression between the patients after transplantation with vs. without graft steatosis. Methods: Total RNA was isolated from liver graft biopsies of 91 recipients. Clinical characteristics were compared between steatotic (n = 48) and control (n = 43) samples. Their transcriptomic profiles were assessed using Affymetrix HuGene 2.1 ST Array Strips processed in Affymetrix GeneAtlas. Data were analyzed using Partek Genomics Suite 6.6 and Ingenuity Pathway Analysis. Results: The individuals with hepatic steatosis showed higher indices of obesity including weight, waist circumference or BMI but the two groups were comparable in measures of insulin sensitivity and cholesterol concentrations. We have identified 747 transcripts (326 upregulated and 421 downregulated in steatotic samples compared to controls) significantly differentially expressed between grafts with vs. those without steatosis. Among the most downregulated genes in steatotic samples were P4HA1, IGF1, or fetuin B while the most upregulated were PLIN1 and ME1. Most influential upstream regulators included HNF1A, RXRA, and FXR. The metabolic pathways dysregulated in steatotic liver grafts comprised blood coagulation, bile acid synthesis and transport, cell redox homeostasis, lipid and cholesterol metabolism, epithelial adherence junction signaling, amino acid metabolism, AMPK and glucagon signaling, transmethylation reactions, and inflammation-related pathways. The derived mechanistic network underlying major transcriptome differences between steatotic samples and controls featured PPARA and SERPINE1 as main nodes. Conclusions: While there is a certain overlap between the results of the current study and published transcriptomic profiles of non-transplanted livers with steatosis, we have identified discrete characteristics of the non-alcoholic fatty liver disease in liver grafts potentially utilizable for the establishment of predictive signature.

Blond and blood juice supplementation in high fat diet fed mice: effect on antioxidant status and DDAH/ADMA pathway

Non-alcoholic fatty liver disease (NAFLD) is the most common liver disease spread throughout the world. The most frequent causes of death in NAFLD patients are due both to liver and cardiovascular damage. Several pathways, including the dimethylarginine dimethylaminohydrolase (DDAH)/asymmetric dimethylarginine (ADMA) pathway, are involved in the pathogenesis of NAFLD. It has been reported that ADMA plasmatic levels are increased in patients with hepatic dysfunction such as NAFLD. Although many studies demonstrated that some foods are effective in the treatment of NAFLD, few studies have evaluated their effects with respect to the prevention of the disease. It has been reported that sweet orange juice (OJ) consumption may be associated with potential health benefits. However, some varieties of sweet orange are more effective than others. The aim of the present paper was to investigate the effect of blond and blood sweet orange juice in prevention of NAFLD by evaluating its ability to improve liver steatosis in mice with diet-induced obesity, reducing oxidative stress and affecting the DDAH/ADMA pathway. Results obtained in our experimental conditions evidenced that blood orange juice rather than blond orange juice was more effective. Blood orange juice or blond orange juice enriched in anthocyanins may represent a promising dietary option for the prevention of fatty liver disease.

Non-alcoholic fatty liver disease (NAFLD) is the most common liver disease spread throughout the world.

Low Urine pH Is Associated with Non-alcoholic Fatty Liver Disease: A Community-based Cross-sectional Study

Objective Low urine pH is associated with several metabolic diseases, such as dyslipidemia, diabetes, and metabolic syndrome. However, the association between low urine pH and non-alcoholic fatty liver disease (NAFLD) remains unknown. Therefore, we conducted a community-based cross-sectional study to investigate this association. Methods Between April 2013 and March 2014, the records of 4,945 Japanese subjects who had undergone annual health checkups were reviewed to identify subjects who met the diagnostic criteria for NAFLD. Patients Based on urine pH, the participants were classified into four groups; a low urine pH was defined as ≤5.5. Of the 3,411 subjects who qualified for enrollment, 1,028 met the diagnostic criteria for NAFLD. Results The prevalence of NAFLD was significantly increased with decreasing urine pH in both men and women (p<0.01 and p=0.02, respectively). A multivariate analysis, including adjustments for age, metabolic markers, and the renal function, showed a significant association between low urine pH and NAFLD in men and women (odds ratio, 1.37; 95% confidence interval, 1.01-1.85, p=0.04 and odds ratio, 1.73; 95% confidence interval, 1.15-2.62, p<0.01, respectively). Conclusion Our study indicates that NAFLD is associated with a low urine pH in both sexes, findings that might help clinicians identify patients at high risk for NAFLD.

Non-alcoholic fatty liver disease: Relationship with cardiovascular risk markers and clinical endpoints

Non-alcoholic fatty liver disease (NAFLD) is a common diagnosis and is increasing in prevalence worldwide. NAFLD is usually asymptomatic at presentation; progression of the disease is unpredictable, leading to the development of a variety of techniques for screening, diagnosis and risk stratification. Clinical methods in current use include serum biomarker panels, hepatic ultrasound, magnetic resonance imaging, and liver biopsy. NAFLD is strongly associated with the metabolic syndrome, and the most common cause of death for people with the condition is cardiovascular disease. Whether NAFLD is an independent cardiovascular risk factor needs exploration. NAFLD has been associated with surrogate markers of cardiovascular disease such as carotid intima-media thickness, the presence of carotid plaque, brachial artery vasodilatory responsiveness and CT coronary artery calcification score. There is no effective medical treatment for NAFLD and evidence is lacking regarding the efficacy of interventions in mitigating cardiovascular risk. Health care professionals managing patients with NAFLD should tackle the issue with early identification of risk factors and aggressive modification. Current management strategies therefore comprise lifestyle change, with close attention to known cardiovascular risk factors.