Non-alcoholic fatty liver disease and risk of incident cardiovascular disease: A meta-analysis

Comparative associations of MASLD and MAFLD with the presence and severity of coronary artery calcification

We aimed to compare the associations of metabolic dysfunction-associated steatotic liver disease (MASLD) and metabolic dysfunction-associated fatty liver disease (MAFLD) with coronary artery calcification (CAC). Patients who simultaneously underwent ultrasonography to diagnose hepatic steatosis and cardiac computed tomography to detect CAC were included. The presence and severity of CAC were defined with CAC-score thresholds of >0 and > 300, respectively, and patients were divided into the following groups: no MASLD or MAFLD (reference), MASLD-only, MAFLD-only, and overlapping groups. Overall, 1,060/2,773 (38.2%) patients had CAC, of which 196 (18.5%) had severe CAC. The MASLD and MAFLD prevalence rates were 32.6% and 45.2%, respectively, with an overlap of 30.7%. In an ASCVD risk score-adjusted model, both MASLD (adjusted odd ratios [aOR], 1.21; 95% confidence interval [CI], 1.02-1.44; p = 0.033) and MAFLD (aOR, 1.20; 95% CI, 1.01-1.42, p = 0.034) were associated with CAC, whereas only MASLD (aOR, 1.38; 95% CI, 1.01-1.89, p = 0.041) was associated with severe CAC. Compared to the reference group, the overlapping group showed an association with CAC (aOR, 1.22; 95% CI, 1.01-1.47; p = 0.038); however, the MASLD and MAFLD subgroups did not differ in their association with CAC. MASLD may predict a higher risk of ASCVD more effectively than MAFLD.

The evil relationship between liver fibrosis and cardiovascular disease in metabolic dysfunction-associated fatty liver disease (MAFLD): Looking for the culprit

Metabolic dysfunction-associated fatty liver disease (MAFLD), the hepatic component of the metabolic syndrome caused by insulin resistance, is a major public health problem, affecting about the 25 % of the general population in Western countries. Morbidity and mortality of MAFLD patients is increased primarily due to cardiovascular disease (CVD). Liver fibrosis, the byproduct of hepatic repair, is the main determinant of MAFLD progression and the strongest predictor for overall mortality. Since the mechanistic relationship between MAFLD, fibrosis, insulin resistance and the cardiometabolic risk is far to be clear, deciphering the functional link of hepatic fibrogenesis with genetic factors and hypercoagulability in MAFLD-associated CVD may hold translational potential for risk profiling and innovative therapeutic targeting.

Metabolic-dysfunction associated steatotic liver disease-related diseases, cognition and dementia: A two-sample mendelian randomization study

BACKGROUND

The results of current studies on metabolic-dysfunction associated steatotic liver disease (MASLD)-related diseases, cognition and dementia are inconsistent. This study aimed to elucidate the effects of MASLD-related diseases on cognition and dementia.

METHODS

By using single-nucleotide polymorphisms (SNPs) associated with different traits of NAFLD (chronically elevated serum alanine aminotransferase levels [cALT], imaging-accessed and biopsy-proven NAFLD), metabolic dysfunction-associated steatohepatitis, and liver fibrosis and cirrhosis, we employed three methods of mendelian randomization (MR) analysis (inverse-variance weighted [IVW], weighted median, and MR-Egger) to determine the causal relationships between MASLD-related diseases and cognition and dementia. We used Cochran's Q test to examine the heterogeneity, and MR-PRESSO was used to identify outliers (NbDistribution = 10000). The horizontal pleiotropy was evaluated using the MR-Egger intercept test. A leave-one-out analysis was used to assess the impact of individual SNP on the overall MR results. We also repeated the MR analysis after excluding SNPs associated with confounding factors.

RESULTS

The results of MR analysis suggested positive causal associations between MASLD confirmed by liver biopsy (p of IVW = 0.020, OR = 1.660, 95%CI = 1.082-2.546) and liver fibrosis and cirrhosis (p of IVW = 0.009, OR = 1.849, 95%CI = 1.169-2.922) with vascular dementia (VD). However, there was no evidence of a causal link between MASLD-related diseases and cognitive performance and other types of dementia (any dementia, Alzheimer's disease, dementia with lewy bodies, and frontotemporal dementia). Sensitivity tests supported the robustness of the results.

CONCLUSIONS

This two-sample MR analysis suggests that genetically predicted MASLD and liver fibrosis and cirrhosis may increase the VD risk. Nonetheless, the causal effects of NAFLD-related diseases on VD need more in-depth research.

Predicting major adverse cardiovascular events after orthotopic liver transplantation using a supervised machine learning model: A cohort study

BACKGROUND

Liver transplant (LT) patients have become older and sicker. The rate of post-LT major adverse cardiovascular events (MACE) has increased, and this in turn raises 30-d post-LT mortality. Noninvasive cardiac stress testing loses accuracy when applied to pre-LT cirrhotic patients.

AIM

To assess the feasibility and accuracy of a machine learning model used to predict post-LT MACE in a regional cohort.

METHODS

This retrospective cohort study involved 575 LT patients from a Southern Brazilian academic center. We developed a predictive model for post-LT MACE (defined as a composite outcome of stroke, new-onset heart failure, severe arrhythmia, and myocardial infarction) using the extreme gradient boosting (XGBoost) machine learning model. We addressed missing data (below 20%) for relevant variables using the k-nearest neighbor imputation method, calculating the mean from the ten nearest neighbors for each case. The modeling dataset included 83 features, encompassing patient and laboratory data, cirrhosis complications, and pre-LT cardiac assessments. Model performance was assessed using the area under the receiver operating characteristic curve (AUROC). We also employed Shapley additive explanations (SHAP) to interpret feature impacts. The dataset was split into training (75%) and testing (25%) sets. Calibration was evaluated using the Brier score. We followed Transparent Reporting of a Multivariable Prediction Model for Individual Prognosis or Diagnosis guidelines for reporting. Scikit-learn and SHAP in Python 3 were used for all analyses. The supplementary material includes code for model development and a user-friendly online MACE prediction calculator.

RESULTS

Of the 537 included patients, 23 (4.46%) developed in-hospital MACE, with a mean age at transplantation of 52.9 years. The majority, 66.1%, were male. The XGBoost model achieved an impressive AUROC of 0.89 during the training stage. This model exhibited accuracy, precision, recall, and F1-score values of 0.84, 0.85, 0.80, and 0.79, respectively. Calibration, as assessed by the Brier score, indicated excellent model calibration with a score of 0.07. Furthermore, SHAP values highlighted the significance of certain variables in predicting postoperative MACE, with negative noninvasive cardiac stress testing, use of nonselective beta-blockers, direct bilirubin levels, blood type O, and dynamic alterations on myocardial perfusion scintigraphy being the most influential factors at the cohort-wide level. These results highlight the predictive capability of our XGBoost model in assessing the risk of post-LT MACE, making it a valuable tool for clinical practice.

CONCLUSION

Our study successfully assessed the feasibility and accuracy of the XGBoost machine learning model in predicting post-LT MACE, using both cardiovascular and hepatic variables. The model demonstrated impressive performance, aligning with literature findings, and exhibited excellent calibration. Notably, our cautious approach to prevent overfitting and data leakage suggests the stability of results when applied to prospective data, reinforcing the model's value as a reliable tool for predicting post-LT MACE in clinical practice.

Metabolic Dysfunction Associated Liver Disease in Patients Undergoing Coronary Computed Tomography Angiography

In this single-center cross-sectional study on patients undergoing coronary computed tomography angiography (CCTA), we assessed the prognostic significance of metabolic dysfunction associated steatotic liver disease (MASLD), metabolic syndrome (MetS), and CCTA-derived parameters for predicting major adverse cardiovascular events (MACE). Over a mean follow-up of 26.9 months, 2038 patients were analyzed, with 361 (17.7%) experiencing MACE. MASLD was associated with a higher MACE incidence (25.90% vs. 14.71% without MASLD, p < 0.001). Cox regression revealed significant associations between MASLD, coronary calcium score (CCS), number of plaques (NoP), epicardial fat volume (EFV), and MACE, with hazard ratios of 1.843, 1.001, 1.097, and 1.035, respectively (p < 0.001 for all). A composite risk score integrating CCS, NoP, EFV, and MASLD demonstrated superior predictive value for MACE (AUC = 0.948) compared to individual variables (p < 0.0001 for all). In conclusion, MASLD is linked to an elevated risk of MACE, and a comprehensive risk-scoring system incorporating imaging and clinical factors enhances MACE prediction accuracy.

Evolving role of semaglutide in NAFLD: in combination, weekly and oral administration

Non alcoholic fatty disease (NAFLD) is the most common chronic liver disease that is managed in the liver departments. It seems that the prevalence of the disease is rising worldwide and as it has the same pathogenetic pathways with metabolic syndrome, treatments that target components of the metabolic syndrome seem promising for the therapy of NAFLD as well. In this review we discuss the evolving role of semaglutide, which is a glucagon-like peptide-1 receptor agonist (GLP-1 RA) that has been already approved for the treatment of type II diabetes mellitus (T2DM) and obesity.

Effect of Low-Dose Alcohol Consumption on Chronic Liver Disease

Although alcohol is one of the most important etiologic agents in the development of chronic liver disease worldwide, also recognized as a promoter of carcinogenesis, several studies have shown a beneficial effect of moderate consumption in terms of reduced cardiovascular morbidity and mortality. Whether this benefit is also present in patients with liver disease due to other causes (viral, metabolic, and others) is still debated. Although there is no clear evidence emerging from guidelines and scientific literature, total abstention from drinking is usually prescribed in clinical practice. In this review, we highlight the results of the most recent evidence on this controversial topic, in order to understand the effect of mild alcohol use in this category of individuals. The quantification of alcohol intake, the composition of the tested populations, and the discrepancy between different works in relation to the outcomes represent important limitations emerging from the scientific literature. In patients with NAFLD, a beneficial effect is demonstrated only in a few works. Even if there is limited evidence in patients affected by chronic viral hepatitis, a clear deleterious effect of drinking in determining disease progression in a dose-dependent manner emerges. Poor data are available about more uncommon pathologies such as hemochromatosis. Overall, based on available data, it is not possible to establish a safe threshold for alcohol intake in patients with liver disease.

Effects of plant natural products on metabolic-associated fatty liver disease and the underlying mechanisms: a narrative review with a focus on the modulation of the gut microbiota

Metabolic-associated fatty liver disease (MAFLD) is a chronic liver disease characterized by the excessive accumulation of fat in hepatocytes. However, due to the complex pathogenesis of MAFLD, there are no officially approved drugs for treatment. Therefore, there is an urgent need to find safe and effective anti-MAFLD drugs. Recently, the relationship between the gut microbiota and MAFLD has been widely recognized, and treating MAFLD by regulating the gut microbiota may be a new therapeutic strategy. Natural products, especially plant natural products, have attracted much attention in the treatment of MAFLD due to their multiple targets and pathways and few side effects. Moreover, the structure and function of the gut microbiota can be influenced by exposure to plant natural products. However, the effects of plant natural products on MAFLD through targeting of the gut microbiota and the underlying mechanisms are poorly understood. Based on the above information and to address the potential therapeutic role of plant natural products in MAFLD, we systematically summarize the effects and mechanisms of action of plant natural products in the prevention and treatment of MAFLD through targeting of the gut microbiota. This narrative review provides feasible ideas for further exploration of safer and more effective natural drugs for the prevention and treatment of MAFLD.

Association of non-alcoholic fatty liver disease with cardiovascular disease and all cause death in patients with type 2 diabetes mellitus: nationwide population based study

OBJECTIVE

To investigate the risk of non-alcoholic fatty liver disease (NAFLD) for cardiovascular disease and all cause death in patients with type 2 diabetes mellitus (T2DM).

DESIGN

Nationwide population based study.

SETTING

Longitudinal cohort study in Korea.

PARTICIPANTS

7 796 763 participants in the National Health Screening Programme in 2009 were divided into three groups based on NAFLD status: no NAFLD (fatty liver index<30); grade 1 NAFLD (30≤fatty liver index<60); and grade 2 NAFLD (fatty liver index≥60). Median follow-up was 8.13 years.

MAIN OUTCOME MEASURES

The primary outcome was incident cardiovascular disease (myocardial infarction, ischaemic stroke) or all cause death.

RESULTS

Of 7 796 763 participants, 6.49% (n=505 763) had T2DM. More patients with T2DM had grade 1 NAFLD (34.06%) and grade 2 NAFLD (26.73%) than those without T2DM (grade 1 NAFLD: 21.20%; grade 2 NAFLD: 10.02%). The incidence rate (per 1000 person years) of cardiovascular disease and all cause death increased in the order of no NAFLD, grade 1 NAFLD, and grade 2 NAFLD, and the incidence rates in patients with T2DM were higher than those in patients without T2DM. The five year absolute risk for cardiovascular disease and all cause death increased in the order of no NAFLD, grade 1 NAFLD, and grade 2 NAFLD in patients without and with T2DM (no NAFLD, without T2DM: 1.03, 95% confidence interval 1.02 to 1.04, and 1.25, 1.24 to 1.26, respectively; grade 1 NAFLD, without T2DM: 1.23, 1.22 to 1.25, and 1.50, 1.48 to 1.51, respectively; grade 2 NAFLD, without T2DM: 1.42, 1.40 to 1.45, and 2.09, 2.06 to 2.12, respectively; no NAFLD, with T2DM: 3.34, 3.27 to 3.41, and 3.68, 3.61 to 3.74, respectively; grade 1 NAFLD, with T2DM: 3.94, 3.87 to 4.02, and 4.25, 4.18 to 4.33, respectively; grade 2 NAFLD, with T2DM: 4.66, 4.54 to 4.78, and 5.91, 5.78 to 6.05, respectively). Patients with T2DM and without NAFLD had a higher five year absolute risk for cardiovascular disease and all cause death than those without T2DM and with grade 2 NAFLD. Risk differences for cardiovascular disease and all cause death between no NAFLD and grade 1 or grade 2 NAFLD were higher in patients with T2DM than in those without T2DM.

CONCLUSIONS

NAFLD in patients with T2DM seems to be associated with a higher risk of cardiovascular disease and all cause death, even in patients with mild NAFLD. Risk differences for cardiovascular disease and all cause death between the no NAFLD group and the grade 1 or grade 2 NAFLD groups were higher in patients with T2DM than in those without T2DM.

Effect of repeatedly applied cold water immersion on subclinical atherosclerosis, inflammation, fat accumulation and lipid profile parameters of volunteers

Significant acute cardiovascular, metabolic, and endocrine changes have been traced to short-lasting cold water immersion (CWI); however, the long-term impact of recurrent CWI on atherogenesis, lipid parameters, and fat distribution has not yet been studied. The goal of this study was to investigate the alleged protective effect. A total of 35 healthy volunteers were monitored for a period of 5 months during which the CWI was performed under standardized conditions (three times per week for 7-10 min, without neoprene equipment). Volunteers with measured weight or muscle mass increases of more than 5% were ineligible. An analogous control group (N = 30) was included. At the onset and completion of the study, blood samples were obtained, and clinical assessments took place. PCSK9 and hsCRP levels were measured together with other lipid-related and non-lipid-related indicators. Carotid intima-media thickness test (cIMT) and echo-tracking for the identification of arterial stiffness (PWV, AI, and β) were used to identify early vascular alterations. Hepatorenal index (HRI) calculations served to quantify liver steatosis, while changes in subcutaneous and visceral fat thickness were used to quantify fat distribution. The given protocol was successfully completed by 28 volunteers. Long-term repeated CWI resulted in a significant decline in cIMT (p = 0.0001), AI (p = 0.0002), Beta (p = 0.0001), and PWV (p = 0.0001). PCSK9 (p = 0.01) and hsCRP (p = 0.01) showed a significant decrease when compared to initial values. In comparison to the starting values, liver fat accumulation decreased by 11% on average (HRI p = 0.001). LDL, TC, TG, and VLDL levels all significantly decreased as well. We suggest that repeated CWI may have beneficial impact on lipid, non-lipid, and lipid-related indices, as well as atherogenesis and liver fat storage.

Limitations of Noninvasive Tests-Based Population-Level Risk Stratification Strategy for Nonalcoholic Fatty Liver Disease

BACKGROUND

Nonalcoholic fatty liver disease (NAFLD) and nonalcoholic steatohepatitis (NASH) are highly prevalent but underdiagnosed.

AIMS

We used an electronic health record data network to test a population-level risk stratification strategy using noninvasive tests (NITs) of liver fibrosis.

METHODS

Data were obtained from PCORnet® sites in the East, Midwest, Southwest, and Southeast United States from patients aged [Formula: see text] 18 with or without ICD-10-CM diagnosis codes for NAFLD, NASH, and NASH-cirrhosis between 9/1/2017 and 8/31/2020. Average and standard deviations (SD) for Fibrosis-4 index (FIB-4), NAFLD fibrosis score (NFS), and Hepatic Steatosis Index (HSI) were estimated by site for each patient cohort. Sample-wide estimates were calculated as weighted averages across study sites.

RESULTS

Of 11,875,959 patients, 0.8% and 0.1% were coded with NAFLD and NASH, respectively. NAFLD diagnosis rates in White, Black, and Hispanic patients were 0.93%, 0.50%, and 1.25%, respectively, and for NASH 0.19%, 0.04%, and 0.16%, respectively. Among undiagnosed patients, insufficient EHR data for estimating NITs ranged from 68% (FIB-4) to 76% (NFS). Predicted prevalence of NAFLD by HSI was 60%, with estimated prevalence of advanced fibrosis of 13% by NFS and 7% by FIB-4. Approximately, 15% and 23% of patients were classified in the intermediate range by FIB-4 and NFS, respectively. Among NAFLD-cirrhosis patients, a third had FIB-4 scores in the low or intermediate range.

CONCLUSIONS

We identified several potential barriers to a population-level NIT-based screening strategy. HSI-based NAFLD screening appears unrealistic. Further research is needed to define merits of NFS- versus FIB-4-based strategies, which may identify different high-risk groups.

Liver fibrosis in NAFLD/NASH: from pathophysiology towards diagnostic and therapeutic strategies

Liver fibrosis, as an excess deposition of extracellular matrix (ECM) components, results from chronic liver injury as well as persistent activation of inflammatory response and of fibrogenesis. Liver fibrosis is a major determinant for chronic liver disease (CLD) progression and in the last two decades our understanding on the major molecular and cellular mechanisms underlying the fibrogenic progression of CLD has dramatically improved, boosting pre-clinical studies and clinical trials designed to find novel therapeutic approaches. From these studies several critical concepts have emerged, starting to reveal the complexity of the pro-fibrotic microenvironment which involves very complex, dynamic and interrelated interactions between different hepatic and extrahepatic cell populations. This review will offer first a recapitulation of established and novel pathophysiological basic principles and concepts by intentionally focus the attention on NAFLD/NASH, a metabolic-related form of CLD with a high impact on the general population and emerging as a leading cause of CLD worldwide. NAFLD/NASH-related pro-inflammatory and profibrogenic mechanisms will be analysed as well as novel information on cells, mediators and signalling pathways which have taken advantage from novel methodological approaches and techniques (single cell genomics, imaging mass cytometry, novel in vitro two- and three-dimensional models, etc.). We will next offer an overview on recent advancement in diagnostic and prognostic tools, including serum biomarkers and polygenic scores, to support the analysis of liver biopsies. Finally, this review will provide an analysis of current and emerging therapies for the treatment of NAFLD/NASH patients.

Association between dietary vitamin A intake from different sources and non-alcoholic fatty liver disease among adults

Non-alcoholic fatty liver disease (NAFLD) has become an urgent public health issue with high global prevalence, but data on NAFLD are inconsistent. The association of total dietary vitamin A intake with the NAFLD risk was not well documented in previous studies. To explore the relationship between dietary vitamin A intake from different sources and NAFLD risk among American adults. Data were collected from the National Health and Nutrition Examination Survey (NHANES) from 2007 to 2014. Logistic regression and restricted cubic spline models were used to estimate the relationship between total dietary vitamin A intake and NAFLD risk. 6,613 adult participants were included. After adjusting potential confounders, the odds ratios (ORs) with 95% confidence intervals (CIs) of NAFLD for the highest quartile intake of total vitamin A, preformed vitamin A, provitamin A carotenoids were respectively 0.86 (0.69-1.06), 0.97 (0.74-1.28), and 0.78 (0.61-0.99), compared to the lowest quartile. Stratifying gender and age, provitamin A carotenoids intake was inversely associated with NAFLD risk in females and participants aged < 45 years. Dose-response analysis indicated a linear negative relationship between provitamin A carotenoids intake and NAFLD risk. Provitamin A carotenoids intake was inversely associated with NAFLD, especially in women and those aged < 45 years among adult American.

2024 UPDATE: the Brazilian Diabetes Society position on the management of metabolic dysfunction-associated steatotic liver disease (MASLD) in people with prediabetes or type 2 diabetes

BACKGROUND

Metabolic dysfunction-associated steatotic liver disease (MASLD) is the most common liver disease affecting 30% of the world's population and is often associated with metabolic disorders such as metabolic syndrome, type 2 diabetes (T2D), and cardiovascular disease. This review is an update of the Brazilian Diabetes Society (Sociedade Brasileira de Diabetes [SBD]) evidence-based guideline for the management of MASLD in clinical practice.

METHODS

The methodology was published previously and was defined by the internal institutional steering committee. The SBD Metabolic Syndrome and Prediabetes Department drafted the manuscript, selecting key clinical questions for a narrative review using MEDLINE via PubMed with the MeSH terms [diabetes] and [fatty liver]. The best available evidence was reviewed, including randomized clinical trials (RCTs), meta-analyses, and high-quality observational studies related to MASLD.

RESULTS AND CONCLUSIONS

The SBD Metabolic Syndrome and Prediabetes Department formulated 9 recommendations for the management of MASLD in people with prediabetes or T2D. Screening for the risk of advanced fibrosis associated with MASLD is recommended in all adults with prediabetes or T2D. Lifestyle modification (LSM) focusing on a reduction in body weight of at least 5% is recommended as the first choice for these patients. In situations where LSMs are insufficient to achieve weight loss, the use of anti-obesity medications is recommended for those with a body mass index (BMI) ≥ 27 kg/m2. Pioglitazone and glucagon-like peptide-1 receptor agonists (GLP-1RA) monotherapy are the first-line pharmacological treatments for steatohepatitis in people with T2D, and sodium-glucose cotransporter-2 (SGLT2) inhibitors may be considered in this context. The combination of these agents may be considered in the treatment of steatohepatitis and/or fibrosis, and bariatric surgery should be considered in patients with a BMI ≥ 35 kg/m2, in which the combination of LSM and pharmacotherapy has not been shown to be effective in improving MASLD.

Loneliness and Social Isolation with Risk of Incident Non-alcoholic Fatty Liver Disease, UK Biobank 2006 to 2022

Background: Although loneliness and social isolation are proposed as important risk factors for metabolic diseases, their associations with the risk of non-alcoholic fatty liver disease (NAFLD) have not been elucidated. The aims of this study were to determine whether loneliness and social isolation are independently associated with the risk of NAFLD and to explore potential mediators for the observed associations. Methods: In this large prospective cohort analysis with 405,073 participants of the UK Biobank, the status of loneliness and social isolation was assessed through self-administrated questionnaires at study recruitment. The primary endpoint of interest was incident NAFLD. Multivariable-adjusted Cox proportional hazard regression models were used to calculate hazard ratios (HRs) and 95% confidence intervals for the associations between loneliness, social isolation, and risk of NAFLD. Results: During a median follow-up of 13.6 years, there were 5,570 cases of NAFLD identified. In the multivariable-adjusted model, loneliness and social isolation were both statistically significantly associated with an increased risk of NAFLD (HR = 1.22 and 1.13, respectively). No significant multiplicative or additive interaction was found between loneliness and social isolation on the risk of NAFLD. The mediation analysis estimated that 30.4%, 16.2%, 5.3%, 4.1%, 10.5%, and 33.2% of the loneliness-NAFLD association was mediated by unhealthy lifestyle score, obesity, current smoking, irregular physical activity, suboptimal sleep duration, and depression, respectively. On the other hand, 25.6%, 10.1%, 15.5%, 10.1%, 8.1%, 11.6%, 9.6%, 4.8%, and 3.0% of the social isolation-NAFLD association was mediated by unhealthy lifestyle score, obesity, current smoking, irregular physical activity, suboptimal sleep duration, depression, C-reactive protein, count of white blood cells, and count of neutrophils, respectively. Conclusions: Our study demonstrated that loneliness and social isolation were associated with an elevated risk of NAFLD, independent of other important risk factors. These associations were partially mediated by lifestyle, depression, and inflammatory factors. Our findings substantiate the importance of loneliness and social isolation in the development of NAFLD.

Cardiovascular outcomes post bariatric surgery in patients with metabolic dysfunction-associated steatotic liver disease - A systematic review and meta-analysis

BACKGROUND

Metabolic dysfunction-associated steatotic liver disease (MASLD), previously known as non-alcoholic fatty liver disease (NAFLD), is linked with an increased risk of adverse cardiovascular events. Studies have suggested an association between the reduction of incident cardiovascular events in patients with MASLD after bariatric surgery. This systematic review and meta-analysis were performed to assess the influence of bariatric surgery on cardiovascular outcomes in patients with diagnosed MASLD by identifying all available cohort studies and pooling their data.

METHODS

PubMed and Google Scholar databases were searched till July 2023 for published studies that assessed the effect of bariatric surgery on cardiovascular outcomes in MASLD patients. Using a random effects model, hazard ratios (HRs) with 95 % confidence intervals (CIs) were pooled.

RESULTS

The systematic review identified three cohort studies. The analysis of 240,516 MASLD patients found a significantly reduced incidence of cardiovascular events. (HR 0.51; 95 % CI 0.48 to 0.54, P value <0.00001).

CONCLUSION

Bariatric surgery in MASLD patients significantly reduced the incidence of cardiovascular events, suggesting that bariatric surgery is an effective therapeutic tool among MASLD patients compared to non-surgical interventions.

Fatty Liver Index as a proxy for non-alcoholic fatty liver disease and the risk of stroke and coronary heart disease: The Suita Study

BACKGROUND

Non-alcoholic fatty liver disease (NAFLD) is the most common chronic liver disease in developed countries, but its role in predicting cardiovascular disease (CVD) needs further investigation. Herein, we studied the association between NAFLD and the risk of CVD, stroke, and coronary heart disease (CHD) among Japanese people.

METHODS

This prospective cohort study analyzed data from 2,517 men and 3,958 women, aged 30-84 years, who were registered in the Suita Study. NAFLD was defined as Fatty Liver Index (FLI) ≥ 60. Cox proportional hazard models were applied to calculate the hazard ratios (HRs) and 95% confidence intervals (95% CIs) of incident CVD, stroke, and CHD events by baseline FLI. The results were adjusted for age, smoking, alcohol consumption, hypertension, diabetes, lipid profile, chronic kidney disease, and cardiac murmur or valvular diseases.

RESULTS

Within 16.6 years of median follow-up, 590 participants developed CVD (346 stroke events and 244 CHD events). Women with NAFLD (FLI ≥ 60) showed a higher risk of CVD and stroke: HRs (95% CIs) = 1.69 (1.16, 2.46) and 2.06 (1.31, 3.24), respectively. Besides, women in the fourth and fifth (highest) FLI quintiles showed a higher risk of CVD and stroke than those in the third (middle) quintile: HRs (95% CIs) = 1.60 (1.08, 2.36) and 1.67 (1.13, 2.45) for CVD and 1.73 (1.07, 2.79) and 1.90 (1.18, 3.05) for stroke, respectively. No corresponding associations were detected in men. NAFLD was not associated with CHD risk in either sex.

CONCLUSIONS

NAFLD, diagnosed by FLI, was associated with a higher risk of CVD and stroke in Japanese women. From a preventive perspective, women with NAFLD should be targeted for CVD screenings and interventions.

Metabolic dysfunction-associated steatotic liver disease in older adults is associated with frailty and social disadvantage

BACKGROUND & AIMS

The burden of metabolic dysfunction-associated steatotic liver disease (MASLD) is growing rapidly, as is the number of older adults globally. However, relatively few studies have been performed evaluating the prevalence and risk factors for MASLD in older adults. As such, we aimed to identify the prevalence of MASLD in older adults, as well as sociodemographic, clinical, functional and biochemical associations.

METHODS

The study population included older adults without a history of cardiovascular disease, dementia or independence-limiting functional impairment who had participated in the ASPirin in Reducing Events in the Elderly (ASPREE) randomised trial. MASLD was defined using the Fatty Liver Index (FLI). Associations were identified using Poisson regression with robust variance for FLI ≥ 60 vs FLI < 30.

RESULTS

9097 Australian participants aged ≥70 years had complete biochemical and anthropometric data to identify MASLD. The study population had a mean age of 75.1 ± 4.3 years and was 45.0% male. Almost one-third (33.0%) had prevalent MASLD, and the prevalence decreased with increasing age (adjusted RR [aRR] 0.96, 95% CI: 0.96-0.97). MASLD was also negatively associated with social advantage (aRR 0.94, 95% CI: 0.90-0.99) and exercise tolerance and was positively associated with diabetes mellitus (aRR: 1.22, 95% CI: 1.16-1.29), hypertension (aRR: 1.31, 95% CI: 1.22-1.41), male sex (aRR: 1.66, 95% CI: 1.57-1.74), pre-frailty (aRR: 1.99, 95% CI: 1.82-2.12) and frailty (aRR: 2.36, 95% CI: 2.16-2.56). MASLD and nonalcoholic fatty liver disease (NAFLD) results were 100% concordant.

CONCLUSION

This study in a large cohort of relatively healthy community-dwelling older adults shows that MASLD is common, decreases with age and is associated with poorer metabolic health, social disadvantage and frailty.

The Independent Association of Non-alcoholic Fatty Liver Disease With Incident Cardiovascular Disease: A GRADE Evaluation of the Evidence Through a Systematic Review and Meta-analysis

Background

We conducted a systematic review and meta-analysis to study the association between non-alcoholic fatty liver disease (NAFLD) and incident cardiovascular disease (CVD).

Methods

We searched Medline, Embase, Cochrane database and TRIP database. Random-effects model meta-analyses were used to obtain pooled effect sizes and 95% confidence intervals. The certainty in evidence was rated using the GRADE tool.

Results

Altogether 36 studies including a total of 7,068,007 participants were included in the systematic review and meta-analysis. Pooled data from 19 cohort studies demonstrated a significant increase in the risk of non-fatal CVD events in patients with NAFLD (HR 1.57, 95% CI 1.33-1.85, I2 = 95%). Pooled data from eight studies showed a significant increase in fatal CVD (HR 1.40, 95% CI 1.24-1.57, I2 =27%), and eight cohort studies suggested a significant increase in combined non-fatal and fatal CVD (HR 1.41, 95% CI 1.13-1.76, I2 =80%). Meta-analysis of studies reporting adjusted estimates in NAFLD patients with fibrosis revealed a significant increase in CVD events with acceptable level of heterogeneity (HR 1.64, 95% CI 1.25-2.16, I2 = 31%). The anticipated absolute increase in the risk of combined fatal and non-fatal CVD was estimated to be 29 more per thousand with NAFLD; that of fatal CVD events 16 more per thousand and that of non-fatal CVD events 19 more per thousand with NAFLD. The GRADE rating ranged from very low to low for overall and subgroup analyses.

Conclusion

The present systematic review suggests that NAFLD increases the risk of incident CVD. Cohort studies with the ability to analyze subgroup effects based on severity, along with randomized controlled trials that provide experimental evidence demonstrating a decrease in cardiovascular disease events through the treatment of non-alcoholic fatty liver disease, are necessary to validate and reinforce these findings.

Association between liver fibrosis and stroke recurrence in young patients with ischemic stroke

BACKGROUND AND AIM

Stroke incidence rates are rising among young adults. Liver fibrosis has recently been recognized as a risk factor for cardiovascular events and stroke in the general population. It remains unclear whether liver fibrosis influences the prognosis of stroke. We aimed to evaluate the association between liver fibrosis and stroke recurrence in young stroke patients.

METHODS AND RESULTS

Young adults with first-ever ischemic stroke were enrolled from a prospective stroke registry and were followed up for stroke recurrence. Liver fibrosis was evaluated by Fibrosis-4 (FIB-4) score and was stratified into three categories. Cox regression analysis was performed to assess the relationship between liver fibrosis and stroke recurrence. Over a median follow-up of 3.1 (1.7-4.6) years, 72 (11.6%) recurrent strokes occurred among 621 patients. According to the FIB-4 score, 73 (11.7%) patients had indeterminate fibrosis, while 11 (1.8%) had advanced fibrosis. Univariate Cox analysis revealed that patients with a high FIB-4 score were more likely to experience stroke recurrence than those with a low FIB-4 score (hazard ratio 3.748, 95% confidence interval 1.359-10.332, P = 0.011). After adjusting for potential confounders in the multivariate analysis, FIB-4 score remained an independent risk factor.

CONCLUSIONS

Young stroke patients with advanced liver fibrosis were at a greater risk of stroke recurrence. Evaluating liver fibrosis may provide valuable information for stroke risk stratification, and the FIB-4 score could serve as a useful tool.

Prospective cohort study of Helicobacter pylori infection on the risk of nonalcoholic fatty liver disease

To investigate the epidemiological connection between nonalcoholic fatty liver disease (NAFLD) and Helicobacter pylori ( H. pylori). 6,478 retired and active workers, aged 22-69 years, were included in the study. Their baseline measures of height, weight, waist measurement, body mass index, blood pressure, fasting blood sugar, plasma lipid, liver function index, glycosylated hemoglobin, abdominal ultrasonography, and findings from the line “13 C urea breath test” H. pylori test were analyzed, and follow-up with consistent baseline methods and criteria was performed annually. Over a 4-year period, the prevalence of NAFLD increased by 16.9%, with 612 (18.7%) of those who tested positive for H. pylori developing NAFLD, whereas 484 (15.1%) of those who did not test positive for H. pylori were later diagnosed with new NAFLD ( χ2 = 14.862, P < 0.05). One of the risk factors identified in the univariable Cox regression model for NAFLD was H. pylori (Hazard Ratio = 1.297; 95.0% confidence interval (CI) 1.150,1.485, P < 0.000); however, H. pylori continued to be an independent factor affecting the risk of NAFLD even after accounting for gender, age, and aspects of the metabolic syndrome (Hazard Ratio = 1.240; 95.0% CI 1.077,1.429, P = 0.003). The growth of NAFLD may be correlated with H. pylori infection.

What Does Sarcopenia Have to Do with Nonalcoholic Fatty Liver Disease?

Nonalcoholic fatty liver disease (NAFLD) is one of the most common causes of chronic liver disease. As the second stage of developing steatosis, nonalcoholic hepatitis (NASH) carries the risk of fibrosis, cirrhosis, and hepatocellular carcinoma. Sarcopenia is defined as a condition characterized by a decrease in muscle mass and functional decline. Both NAFLD and sarcopenia are global problems. The pathophysiological mechanisms that link the two entities of the disease are insulin resistance, inflammation, nutritional deficiencies, impairment of myostatin and adiponectin, or physical inactivity. Furthermore, disorders of the gut-liver axis appear to induce the process of developing NAFLD and sarcopenia. The correlations between NAFLD and sarcopenia appear to be bidirectional, so the main objective of the review was to determine the cause-and-effect relationship between the two diseases.

Metabolic dysfunction-associated steatotic liver disease and the heart

The prevalence and severity of metabolic dysfunction-associated steatotic liver disease (MASLD) are increasing. Physicians who treat patients with MASLD may acknowledge the strong coincidence with cardiometabolic disease, including atherosclerotic cardiovascular disease (asCVD). This raises questions on co-occurrence, causality, and the need for screening and multidisciplinary care for MASLD in patients with asCVD, and vice versa. Here, we review the interrelations of MASLD and heart disease and formulate answers to these matters. Epidemiological studies scoring proxies for atherosclerosis and actual cardiovascular events indicate increased atherosclerosis in patients with MASLD, yet no increased risk of asCVD mortality. MASLD and asCVD share common drivers: obesity, insulin resistance and type 2 diabetes mellitus (T2DM), smoking, hypertension, and sleep apnea syndrome. In addition, Mendelian randomization studies support that MASLD may cause atherosclerosis through mixed hyperlipidemia, while such evidence is lacking for liver-derived procoagulant factors. In the more advanced fibrotic stages, MASLD may contribute to heart failure with preserved ejection fraction by reduced filling of the right ventricle, which may induce fatigue upon exertion, often mentioned by patients with MASLD. Some evidence points to an association between MASLD and cardiac arrhythmias. Regarding treatment and given the strong co-occurrence of MASLD and asCVD, pharmacotherapy in development for advanced stages of MASLD would ideally also reduce cardiovascular events, as has been demonstrated for T2DM treatments. Given the common drivers, potential causal factors and especially given the increased rate of cardiovascular events, comprehensive cardiometabolic risk management is warranted in patients with MASLD, preferably in a multidisciplinary approach.

Causal effects of non-alcoholic fatty liver disease on osteoporosis: a Mendelian randomization study

Background

Osteoporosis (OP) is a systemic skeletal disease characterized by compromised bone strength leading to an increased risk of fracture. There is an ongoing debate on whether non-alcoholic fatty liver disease (NAFLD) is an active contributor or an innocent bystander in the pathogenesis of OP. The aim of this study was to assess the causal association between NAFLD and OP.

Methods

We performed two-sample Mendelian randomization (MR) analyses to investigate the causal association between genetically predicted NAFLD [i.e., imaging-based liver fat content (LFC), chronically elevated serum alanine aminotransferase (cALT) and biopsy-confirmed NAFLD] and risk of OP. The inverse variant weighted method was performed as main analysis to obtain the causal estimates.

Results

Imaging-based LFC and biopsy-confirmed NAFLD demonstrated a suggestive causal association with OP ([odds ratio (OR): 1.003, 95% CI: 1.001-1.004, P < 0.001; OR: 1.001, 95% CI: 1.000-1.002, P = 0.031]). The association between cALT and OP showed a similar direction, but was not statistically significant (OR: 1.001, 95% CI: 1.000-1.002, P = 0.079). Repeated analyses after exclusion of genes associated with confounding factors showed consistent results. Sensitivity analysis indicated low heterogeneity, high reliability and low pleiotropy of the causal estimates.

Conclusion

The two-sample MR analyses suggest a causal association between genetically predicted NAFLD and OP.

Associations of Unhealthy Lifestyle and Nonalcoholic Fatty Liver Disease With Cardiovascular Healthy Outcomes

BACKGROUND

The role of nonalcoholic fatty liver disease (NAFLD) as a mediator in the association between various unhealthy lifestyles and major adverse cardiovascular events and all-cause death remains unclear.

METHODS AND RESULTS

This study used data from the UK Biobank, with follow-up until the end of 2021. It involved the calculation of unweighted and weighted lifestyle scores using the Cox model to classify participants on the basis of these scores. Additionally, the research assessed the mediation effect proportion of NAFLD using the difference method and examined the interaction and joint effects of lifestyle and NAFLD on health outcomes. Among the 134 616 enrolled participants, 4024 had records of major adverse cardiovascular events, while among the 130 144 participants included in the analysis of all-cause death, 6697 deaths occurred. The proportions of the association between overall lifestyle and major adverse cardiovascular events mediated by NAFLD were 19.4% and 21.7% (95% CI, 16.2-22.6 and 17.8-25.7) for scores 1 and 2, respectively, and those for all-cause death were 14.1% and 10.1% (95% CI, 11.3-17.1 and 7.9-12.2). After fully adjusting for traditional cardiovascular risk factors, the mediating effects declined across both outcomes. The associations between overall lifestyle and outcomes were stronger among those of the non-NAFLD group, and significant interactions were observed between overall lifestyle and NAFLD status. The joint analysis revealed that patients with NAFLD with unhealthy lifestyle had the highest risk of major adverse cardiovascular events and all-cause death.

CONCLUSIONS

Improving lifestyle and addressing metabolic risk factors are essential for cardiovascular risk management in patients with NAFLD.

Detection of Moderate Hepatic Steatosis on Portal Venous Phase Contrast-Enhanced CT: Evaluation Using an Automated Artificial Intelligence Tool

BACKGROUND. Precontrast CT is an established means of evaluating for hepatic steatosis; postcontrast CT has historically been limited for this purpose. OBJECTIVE. The purpose of this study was to evaluate the diagnostic performance of portal venous phase postcontrast CT in detecting at least moderate hepatic steatosis using liver and spleen attenuation measurements determined by an automated artificial intelligence (AI) tool. METHODS. This retrospective study included 2917 patients (1381 men, 1536 women; mean age, 56.8 years) who underwent a CT examination that included at least two series through the liver. Examinations were obtained from an AI vendor's data lake of data from 24 centers in one U.S. health care network and 29 centers in one Israeli health care network. An automated deep learning tool extracted liver and spleen attenuation measurements. The reference for at least moderate steatosis was precontrast liver attenuation of less than 40 HU (i.e., estimated liver fat > 15%). A radiologist manually reviewed examinations with outlier AI results to confirm portal venous timing and identify issues impacting attenuation measurements. RESULTS. After outlier review, analysis included 2777 patients with portal venous phase images. Prevalence of at least moderate steatosis was 13.9% (387/2777). Patients without and with at least moderate steatosis, respectively, had mean postcontrast liver attenuation of 104.5 ± 18.1 (SD) HU and 67.1 ± 18.6 HU (p < .001); a mean difference in postcontrast attenuation between the liver and the spleen (hereafter, postcontrast liver-spleen attenuation difference) of -7.6 ± 16.4 (SD) HU and -31.8 ± 20.3 HU (p < .001); and mean liver enhancement of 49.3 ± 15.9 (SD) HU versus 38.6 ± 13.6 HU (p < .001). Diagnostic performance for the detection of at least moderate steatosis was higher for postcontrast liver attenuation (AUC = 0.938) than for the postcontrast liver-spleen attenuation difference (AUC = 0.832) (p < .001). For detection of at least moderate steatosis, postcontrast liver attenuation had sensitivity and specificity of 77.8% and 93.2%, respectively, at less than 80 HU and 90.5% and 78.4%, respectively, at less than 90 HU; the postcontrast liver-spleen attenuation difference had sensitivity and specificity of 71.4% and 79.3%, respectively, at less than -20 HU and 87.0% and 62.1%, respectively, at less than -10 HU. CONCLUSION. Postcontrast liver attenuation outperformed the postcontrast liver-spleen attenuation difference for detecting at least moderate steatosis in a heterogeneous patient sample, as evaluated using an automated AI tool. Splenic attenuation likely is not needed to assess for at least moderate steatosis on postcontrast images. CLINICAL IMPACT. The technique could promote early detection of clinically significant nonalcoholic fatty liver disease through individualized or large-scale opportunistic evaluation.

Chronic liver disease is not associated with statin prescription in a primary care cohort

Statins have historically been underutilized in patients with chronic liver disease (CLD). We sought to investigate the association between CLD and statin prescription in a primary care setting. Our retrospective cohort study identified primary care patients with a low-density lipoprotein value and more than one office visit from 2012 through 2018. Indication for statin therapy was determined using the Third Adult Treatment Panel criteria prior to November 2016 and the American College of Cardiology and American Heart Association guidelines thereafter. Indication for statin prescription and statin therapy by year was determined. Patients with CLD were identified using ICD-9/10 diagnosis codes. In total, 2119 individuals with an indication for statin therapy were identified. Of these individuals, 354 (16.7%) had CLD. Alcoholic and nonalcoholic fatty liver disease comprised 44.9% and 28.5% of the CLD population, respectively; 27.7% had cirrhosis. There was no difference in the prevalence of statin prescriptions when comparing patients with a CLD diagnosis to those without one (57.9 vs 59.9%, p = 0.48). A diagnosis of CLD was also not significantly associated with statin prescription when adjusting for other covariates (odds ratio (OR) 1.02; 95% confidence interval (CI) 0.78-1.33). An alanine aminotransferase level greater than 45 U/L significantly reduced the odds of a statin prescription (OR 0.62; 95% CI 0.44-0.87). Overall, the presence of a CLD diagnosis was not associated with attenuated statin utilization compared to those without a CLD diagnosis. Nevertheless, adherence to guideline indicated statin therapy remains suboptimal and efforts to increase statin utilization in this high-risk population remain prudent.

Activation of GPBAR1 attenuates vascular inflammation and atherosclerosis in a mouse model of NAFLD-related cardiovascular disease

While patients with nonalcoholic fatty liver disease (NAFLD) are at increased risk to develop clinically meaningful cardiovascular diseases (CVD), there are no approved drug designed to target the liver and CVD component of NAFLD. GPBAR1, also known as TGR5, is a G protein coupled receptor for secondary bile acids. In this study we have investigated the effect of GPBAR1 activation by BAR501, a selective GPBAR1 agonist, in Apolipoprotein E deficient (ApoE-/-) mice fed a high fat diet and fructose (Western diet), a validated model of NAFLD-associated atherosclerosis. Using aortic samples from patients who underwent surgery for abdominal aneurism, and ex vivo experiments with endothelial cells and human macrophages, we were able to co-localize the expression of GPBAR1 in CD14+ and PECAM1+ cells. Similar findings were observed in the aortic plaques from ApoE-/- mice. Treating ApoE-/- mice with BAR501, 30 mg/kg for 14 weeks, attenuated the body weight gain while ameliorated the insulin sensitivity by increasing the plasma concentrations of GLP-1 and FGF15. Activation of GPBAR1 reduced the aorta thickness and severity of atherosclerotic lesions and decreased the amount of plaques macrophages. Treating ApoE-/- mice reshaped the aortic transcriptome promoting the expression of anti-inflammatory genes, including IL-10, as also confirmed by tSNE analysis of spleen-derived macrophages. Feeding ApoE-/- mice with BAR501 redirected the bile acid synthesis and the composition of the intestinal microbiota. In conclusion, GPBAR1 agonism attenuates systemic inflammation and improve metabolic profile in a genetic/dietetic model of atherosclerosis. BAR501 might be of utility in the treatment for NAFLD-related CVD.

How non-alcoholic fatty liver disease and cirrhosis affect the heart

Liver diseases affect the heart and the vascular system. Cardiovascular complications appear to be a leading cause of death in patients with non-alcoholic fatty liver disease (NAFLD) and cirrhosis. The predominant histological changes in the liver range from steatosis to fibrosis to cirrhosis, which can each affect the cardiovascular system differently. Patients with cirrhotic cardiomyopathy (CCM) and NAFLD are at increased risk of impaired systolic and diastolic dysfunction and for suffering major cardiovascular events. However, the pathophysiological mechanisms behind these risks differ depending on the nature of the liver disease. Accurate assessment of symptoms by contemporary diagnostic modalities is essential for identifying patients at risk, for evaluating candidates for treatment, and prior to any invasive procedures. This review explores current perspectives within this field.

NAFLD and type 2 diabetes: A practical guide for the joint management

Non-alcoholic fatty liver disease (NAFLD) is becoming a major cause of liver disease-related morbidity, as well as mortality. Importantly, NAFLD is considered a mediator of systemic diseases including cardiovascular disease. Its prevalence is expected to increase, mainly due to its close association with obesity and type 2 diabetes mellitus (T2D). In addition, T2D and NAFLD share common pathophysiological mechanisms, and one can lead to or worsen the other. Therefore, a close collaboration between primary care physician, endocrinologists and hepatologists is essential to optimize the management of patients with NAFLD and T2D. Here, we summarize relevant aspects about NAFLD and T2D that all clinician managing these patients should know as well as current therapeutic options for the treatment of T2D associated with NAFLD.

Lack of association between nonalcoholic fatty liver disease and intracerebral hemorrhage: A community-based cohort study

BACKGROUND

The association between nonalcoholic fatty liver disease (NAFLD) and intracerebral hemorrhage (ICH) remains unclear. This study aimed to investigate whether NAFLD and its severity predict incident ICH.

METHODS

Participants free of other liver diseases, prior stroke, myocardial infarction, cancer, or alcohol abuse in the Kailuan cohort were enrolled in this study. Abdominal ultrasonography was used to diagnose NAFLD and assess its severity. Participants were stratified into different groups including nonfatty liver, mild, moderate and severe NAFLD. Multivariable Cox proportional hazards regression models were used to evaluate the hazard ratios (HRs) and 95% CIs of ICH events in the 11-year follow-up.

RESULTS

A total of 77,461 participants were enrolled in our study. Among them, NAFLD was diagnosed in 23,890 (30.83 %) participants, including 15,581 (20.11 %) with mild NAFLD, 6839 (8.83 %) with moderate NAFLD and 1470 (1.90 %) with severe NAFLD. We documented 692 ICH events during 848,579 person years of follow-up. Patients with more severe NAFLD tended to be older, had higher levels of BMI, higher proportions of hypertension, diabetes and other known risk factors for cerebrovascular disease. However, there was no significant associations between NAFLD, its severity and incident ICH events. Relative to nonfatty liver participants, the HRs for participants with mild NAFLD, moderate and severe NAFLD were 0.98 (95 % CI, 0.80 to 1.20), 1.19 (95 % CI, 0.92 to 1.54) and 1.29 (95 % CI, 0.81 to 2.06), respectively.

CONCLUSIONS

NAFLD and its severity did not appear to be significantly associated with ICH after adjustment for potential risk factors.

Impact of fibrosis on liver-related event incidence in nonalcoholic fatty liver disease: A multicenter observational study

AIM

There are few reports on the prognosis of liver-related events in Japanese patients with nonalcoholic fatty liver disease (NAFLD). We undertook an observational study to compare the prognosis between fibrotic and nonfibrotic groups in Japanese NAFLD patients.

METHODS

Prognosis in 393 NAFLD patients who underwent liver biopsy between April 2013 and April 2015 at multiple centers were investigated. The time to onset of liver-related events, cardiovascular events, development of extrahepatic cancers, and death were compared between the pathologically fibrotic nonalcoholic steatohepatitis (NASH) group and nonalcoholic fatty liver (NAFL) + nonfibrotic NASH group. A similar analysis was carried out based on the fibrotic classification diagnosed using four noninvasive fibrosis prediction models.

RESULTS

The mean age and body mass index at the time of liver biopsy was 55.7 years old and 28.04 kg/m2 , respectively The cumulative incidence of liver-related events at 1080 days after liver biopsy was 5.79% in the pathologically fibrotic NASH group and 0% in the NAFL + nonfibrotic NASH group, with a significant difference (p = 0.0334). The cumulative incidence of liver-related events was significantly higher in the positive group for the prediction model than in the negative group in all four models (all p values were <0.0001). There was no significant difference between the pathologically fibrotic NASH group and NAFL + nonfibrotic NASH group in terms of cumulative incidence of cardiovascular events, development of extrahepatic cancers, and death.

CONCLUSIONS

The incidence of liver-related events was significantly higher in the fibrotic NASH group than that of the NAFL + nonfibrotic NASH group in Japanese NAFLD patients.

Effect of Policaptil Gel Retard on Liver Fat Content and Fibrosis in Adults with Metabolic Syndrome and Type 2 Diabetes: A Non-invasive Approach to MAFLD

INTRODUCTION

Non-alcoholic fatty liver disease (NAFLD) is part of a disease spectrum ranging from steatosis to steatohepatitis (NASH), fibrosis, and cirrhosis, and when associated with metabolic syndrome (MS), and overt diabetes is defined as metabolic NAFLD (MAFLD). Some easily available, inexpensive biomarkers have been validated based on common anthropometric and laboratory parameters, including the Fatty Liver Index (FLI), the Fibrosis (FIB)-4 Score (FIB-4), and the NAFLD Fibrosis Score (NFS). In people with overweight/obesity, MS, and diabetes, the pathogenesis of fatty liver involves parameters known to be positively affected by Policaptil Gel Retard (PGR), a phytocomplex already successfully used in adolescents and adults with MS and type 2 diabetes mellitus (T2DM). This study's primary outcome was to assess PGR's ability to improve indirect validated signs of liver steatosis and fibrosis, i.e., FLI, FIB-4, and NFS Scores; as the secondary outcome, we aimed to confirm PGR's positive effects on anthropometric parameters and lipid levels and to assess any eventually occurring cytolysis liver marker changes in patients with MS/T2DM and MAFLD/NASH.

METHODS

In this spontaneous, longitudinal, single-blind, randomized clinical study, 245 outpatients with MS/T2DM were enrolled and randomized to PGR or placebo for 24 weeks. All underwent a low-calorie diet (20-25% less than the calories required to maintain current weight) and were encouraged to intensify physical activity. Fat distribution, liver fat content/fibrosis, and biochemical parameters were evaluated at baseline and after 24 weeks.

RESULTS

Our data show for the first time in adults with MAFLD that, when added to lifestyle changes including a hypocaloric diet and intensified physical activity, PGR improves lipid and glucose metabolism-related parameters, including insulin-resistance, and significantly reduces not only visceral fat but also liver fat content and related liver fibrosis severity. The prevalence of subjects with severe steatosis (FLI > 60) significantly decreased from 95.08 to 47.53% (p < 0.001) only in the treatment group, which also displayed a significantly decreased prevalence of medium-severe cases (F3-F4) from 83.62% to 52.35% (p < 0.001) and a markedly increased prevalence of low degree cases (F0-F1) from 9.01 to 42.15% (p < 0.001).

CONCLUSIONS

The effect of PGR is related to a reduction in the post-meal blood glucose and insulin peaks. As glucose absorption (GA) directly regulates pancreatic insulin release, the attenuated insulin response is likely due to delayed GA with decreased body weight, visceral fat, and cardiovascular risk. Also, an effect on the intestinal microbiota, already documented in the animal model, cannot be excluded, especially considering the reported PGR-related shift from the Firmicutes, notoriously responsible for increased lipid gut absorption, to the Bacteroides phylum.

[Non-alcoholic fatty liver disease: aspects of management of a comorbid patient. A review]

Against the background of the rapid increase in the prevalence of obesity worldwide, the frequency of the development of metabolic disorders associated with it is increasing. Non-alcoholic fatty liver disease (NAFLD) is recognized as the main hepatic manifestation of metabolic syndrome. Currently, NAFLD affects about 25-30% of the world's population and, in most cases, is associated with obesity and type 2 diabetes, as well as with increased cardiovascular risk. Diagnosis of NAFLD includes laboratory and instrumental research methods, various non-invasive tests, and the "gold standard" for confirming the diagnosis is a liver biopsy. Due to the greater availability and sufficient information content, ultrasound methods of research come to the fore in the examination of patients at risk. Lifestyle modification remains the cornerstone in the management of such patients, however, given the complex pathogenesis of the disease, treatment of NAFLD may include several therapeutic strategies. In the treatment of comorbid patients, some groups of hypoglycemic drugs are used, including ar-GLP-1, i-NGL-2, pioglitazone, lipid-lowering drugs, drugs for the treatment of obesity. The so-called hepatoprotectors, including essential phospholipids (EFL), have demonstrated their effectiveness in reducing liver damage due to antioxidant, antifibrotic, and lipid-regulating effects. According to a number of studies, EFL helps to reduce the severity of steatosis, improving both objective and subjective manifestations of hepatic dysfunction. In this connection, the guidelines of various countries include EFL group drugs in the protocol of treatment of patients with NAFLD both in monotherapy and in combination with other drugs.

Relationship of cardiac remodeling and perfusion alteration with hepatic lipid metabolism in a prediabetic high fat high sucrose diet female rat model

BACKGROUND AND AIMS

Cardiovascular disease (CVD) is known to be linked with metabolic associated fatty liver disease and type 2 diabetes, but few studies assessed this relationship in prediabetes, especially among women, who are at greater risk of CVD. We aimed to evaluate cardiac alterations and its relationship with hepatic lipid metabolism in prediabetic female rats submitted to high-fat-high-sucrose diet (HFS).

METHODS AND RESULTS

Wistar female rats were divided into 2 groups fed for 5 months with standard or HFS diet. We analyzed cardiac morphology, function, perfusion and fibrosis by Magnetic Resonance Imaging. Hepatic lipid contents along with inflammation and lipid metabolism gene expression were assessed. Five months of HFS diet induced glucose intolerance (p < 0.05), cardiac remodeling characterized by increased left-ventricular volume, wall thickness and mass (p < 0.05). No significant differences were found in left-ventricular ejection fraction and cardiac fibrosis but increased myocardial perfusion (p < 0.01) and reduced cardiac index (p < 0.05) were shown. HFS diet induced hepatic lipid accumulation with increased total lipid mass (p < 0.001) and triglyceride contents (p < 0.05), but also increased mitochondrial (CPT1a, MCAD; (p < 0.001; p < 0.05) and peroxisomal (ACO, LCAD; (p < 0.05; p < 0.001) β-oxidation gene expression. Myocardial wall thickness and perfusion were correlated with hepatic β-oxidation genes expression. Furthermore, myocardial perfusion was also correlated with hepatic lipid content and glucose intolerance.

CONCLUSION

This study brings new insights on the relationship between cardiac sub-clinical alterations and hepatic metabolism in female prediabetic rats. Further studies are warranted to explore its involvement in the higher CVD risk observed among prediabetic women.

Non-alcoholic fatty liver disease and the risk of malignant tumors

The prevalence of non-alcoholic fatty liver disease  (NAFLD) and metabolic  associated liver disease  (MAFLD) is growing world-wide. A new terminology  (MAFLD) allows us not only to focus on the “metabolic” genesis  of this pathology, but also to take into account  other  factors  affecting  damage  to hepatocytes, such as alcohol  consumption in low doses, viral and toxic hepatitis. Currently, obesity is a pathology, that is growing with MAFLD and causes  of various non-communicable diseases. Most deaths in patients with  NAFLD/MAFLD  are  caused,  firstly, by adverse  cardiovascular  events,  secondly, by malignant tumors  of both the digestive  organs  (liver, intestine, esophagus, stomach  and pancreas)  and other  localizations (kidney cancer  in men, breast cancer  in women) and, thirdly, by development of hepatic  complications (cirrhosis, hepatocellular carcinoma  – HCC). Because of the  pandemic  growth  of MAFLD and its association with cardiovascular  diseases  and obesity, the  question about  properly clinical management of patients suffered from comorbid pathology to reduce the risks of deaths  is timely and very relevant. This review has been prepared to systematize the available  literature dates  about association of NAFLD/MAFLD with the malignant tumors. A literature searches were  conducted,  modern  epidemiological dates  about  the  prevalence of NAFLD/MAFLD  in the population and their complicated forms were presented. The risk of HCC formation  both with and without  cirrhosis in NAFLD was assessed.  It was found that  the severity of liver fibrosis can be useful predictor  of the future risk of not only the adverse cardiovascular  events,  but  also  the  malignant tumors  in patients with  NAFLD/MAFLD. Possible  targets  for treatment were discussed,  the  impact  on which is useful  for the  treatment and prevention of progressive  forms of the  disease.  One of the possible  therapeutic molecules is essential phospholipids, which are  currently  included  in the  consent  documents for the managment of patients with NAFLD.

Metabolic dysfunction-associated steatotic liver disease increases the risk of incident cardiovascular disease: a nationwide cohort study

Background

The various subcategories under the overarching term of steatotic liver disease (SLD) have been recently proposed by the nomenclature consensus group and endorsed by international academic liver societies. Our aim was to investigate the association between each subtype of SLD and incident cardiovascular disease (CVD) in a nationwide Korean cohort.

Methods

From a nationwide health screening database from Korea, 351,068 individuals aged 47-86 years between January 1, 2009 and December 31, 2010 were included and followed until December 31, 2019 for a median of 9.0 years. Individuals were categorised into no SLD, metabolic dysfunction-associated steatotic liver disease (MASLD), MASLD with increased alcohol intake (MetALD), and alcohol-related liver disease (ALD). Hepatic steatosis was defined as fatty liver index ≥60. The primary outcome was a composite CVD, which includes non-fatal and fatal myocardial infarction and stroke. The subdistribution hazard ratio (SHR) was calculated using the Fine-Gray model with treating non-CVD-related death as a competing risk.

Findings

There were 199,817 male (56.9%) and 151,251 female (43.1%) with a median age of 55 years (interquartile range, 50-61). The prevalence of no SLD, MASLD, MetALD, and ALD was 44.3%, 47.2%, 6.4%, and 2.1%, respectively; and the incidence rate of CVD in each subcategory was 6.2, 8.5, 8.5, and 9.6 per 1000 person-years, respectively. MASLD (SHR, 1.19; 95% confidence interval [CI], 1.15-1.24), MetALD (SHR, 1.28; 95% CI, 1.20-1.36), and ALD (SHR, 1.29; 95% CI, 1.18-1.41) increased the risk of CVD compared to no SLD, which increment was in consecutive order (Ptrend < 0.001).

Interpretation

Individuals with MASLD, MetALD, or ALD are at an increased risk of developing incident CVD. Higher risk of CVD observed in MetALD compared to MASLD suggests the additive impact of alcohol consumption in conjunction with cardiometabolic risk factors on CVD development. These findings support and validate the utility of the new consensus criteria for SLD in predicting CVD.

Funding

The National Research Foundation of Korea and the Korea Centers for Disease Control and Prevention.

Prognostic value of coronary artery calcium score for the prediction of atherosclerotic cardiovascular disease in participants with suspected nonalcoholic hepatic steatosis: Results from the multi-ethnic study of atherosclerosis

BACKGROUND

Nonalcoholic fatty liver disease (NAFLD) is associated with an increased risk of atherosclerotic cardiovascular disease (ASCVD) events; thus, a diagnostic approach to help identify NAFLD patients at high risk is needed. In this study, we hypothesized that coronary artery calcium (CAC) screening could help stratify the risk of ASCVD events in participants with suspected nonalcoholic hepatic steatosis.

METHODS

A total of 713 participants with suspected nonalcoholic hepatic steatosis without previous cardiovascular events from the Multi-Ethnic Study of Atherosclerosis (MESA) were followed for the occurrence of incident ASCVD. Nonalcoholic hepatic steatosis was defined using nonenhanced computed tomography and liver/spleen attenuation ratio <1. Cox proportional hazards regression models were used to estimate hazard ratios (HR). C-statistics and areas under the time-dependent receiver operating characteristic curves (tAUC) were used to compare incremental contributions of CAC score when added to the clinical risk factors.

RESULTS

In multivariable analyses, CAC score was found to be independently associated with incident ASCVD (HR = 1.33, 95% CI = 1.22-1.44, P < .001). The addition of CAC score to clinical risk factors increased the C-statistic from 0.677 to 0.739 (P < .001) and tAUC at 10 years from 0.668 to 0.771, respectively. In subgroup analyses, the incremental prognostic value of CAC score was more significant in participants with low/borderline- (<7.5%) and intermediate- (7.5%-20%) 10-year ASCVD risk scores.

CONCLUSIONS

The inclusion of CAC score in global risk assessment was found to significantly improve the classification of incident ASCVD events in participants with suspected nonalcoholic hepatic steatosis, indicating a potential role for CAC screening in risk assessment.

The chronic consumption of dietary fructose promotes the gut Clostridium species imbalance and bile acid alterations in developing nonalcoholic fatty liver disease

Excessive fructose intake is associated with the rising prevalence of nonalcoholic fatty liver disease (NAFLD). The gut microbiome (GM) and bile acids (BAs) are involved in the pathogenesis of NAFLD, but the impact of fructose on their cross-talk is unclear. In this study, adult male C57BL/6J mice were fed a normal diet with tap water (ND) or with 4% fructose in the drinking water (Fru), 60% high-fat diet with tap water (HF) or with 4% fructose solution (HFF) for 12 weeks. Targeted BA analysis was performed in five anatomical sites including the liver, ileum contents, portal serum, cecum contents, and feces. Metagenomic sequencing was performed to explore gut dysbiosis. Within 12 weeks, the 4% fructose diet could initially stimulate gut dysbiosis and BA upregulation in the ileum, portal serum, and cecum when the intestinal and hepatic transport system remained stable without hepatic lipid accumulation. However, the chronic consumption of fructose promoted HF-induced NAFLD, with significantly increased body weight, impaired glucose tolerance, and advanced liver steatosis. BA transporters were inhibited in HFF, causing the block of internal BA circulation and increased BA secretion via cecum contents and feces. Notably, lithocholic acid (LCA) and its taurine conjugates were elevated within the enterohepatic circulation. Meanwhile, the Clostridium species were significantly altered in both Fru and HFF groups and were closely associated with fructose and BA metabolism. In summary, excessive fructose caused gut dysbiosis and BA alterations, promoting HF-induced NAFLD. The crosstalk between Clostridium sp. and LCA species were potential targets in fructose-mediated NAFLD.

The prothrombotic tendency of metabolic-associated fatty liver disease

Our understanding of the function of the liver has evolved over the centuries. Early theories proposing that the liver could be used to divine the future have been superseded by our current knowledge of the importance of the liver in processes such as digestion and detoxification. Similarly, although liver disease was previously associated with only an increased risk of bleeding, there is now a substantial body of evidence demonstrating an increased thrombotic potential in patients with this disease. Metabolic-associated fatty liver disease (MAFLD) is increasing in frequency and is likely to overtake alcoholic liver disease as the primary indication for liver transplant in the future. In this review, we discuss the evidence linking liver disease, and MAFLD in particular, with arterial and venous thromboembolic disease. We review the safety and efficacy of anticoagulation in advanced liver disease and consider whether antithrombotic agents could slow or halt the progression of fibrosis in MAFLD.

The causal associations of non-alcoholic fatty liver disease with blood pressure and the mediating effects of cardiometabolic risk factors: A Mendelian randomization study

BACKGROUND AND AIMS

Non-alcoholic fatty liver disease (NAFLD) is prevalent in hypertensive people, but the causal effect remains unclear. We employed Mendelian randomization (MR) approach to assess the causality between NAFLD and different blood pressure (BP) parameters.

METHOD AND RESULTS

Instrumental variables for genetically predicted NAFLD, including chronically elevated serum alanine aminotransferase levels (cALT) and imaging and biopsy-confirmed NAFLD, were obtained from a genome-wide association study (N = 164,197). Multiple MR methods were implemented, including Inverse variance weighted, MR-Egger, Maximum likelihood, Weighted median, Simple median, Penalised weighted median, MR-RAPS, and cML-MA. Outliers were detected using MR-PRESSO, and pleiotropy was assessed using MR-Egger intercept and Phenoscanner. Heterogeneity was quantified using Cochran's Q and Rucker's Q' tests. Potential shared risk factors were analyzed to reveal the mediating effect. A higher genetic predisposition to cALT was causally associated with an increased risk of elevated BP levels, resulting in 0.65 mmHg (95% CI, 0.42-0.87), 0.38 mmHg (95% CI, 0.25-0.50) and 0.33 mmHg (95% CI, 0.22-0.44) higher for systolic BP, diastolic BP and pulse pressure, respectively. When more stringent criteria were used, imaging and biopsy-confirmed NAFLD showed a 1.12 mmHg (95% CI, 0.94-1.30) increase in SBP and a 0.55 mmHg (95% CI, 0.39-0.70) increase in DBP. Risk factor and mediation analyses suggested type 2 diabetes and fasting insulin levels might mediate the causal relationship between NAFLD and BP.

CONCLUSION

The two-sample MR analyses showed robust causal effects of genetically predicted NAFLD on 3 different BP indices. The shared genetic profile between NAFLD and BP may suggest important therapeutic targets and early interventions for cardiometabolic risk factors.

Fibrosis-4 index is closely associated with clinical outcomes in acute cardioembolic stroke patients with nonvalvular atrial fibrillation

Liver cirrhosis is a confirmed risk factor for poor prognosis of stroke; however, the contribution of clinically inapparent liver fibrosis to cardioembolic stroke (CES) and its outcomes are poorly understood. This study aimed to investigate the associations between liver fibrosis-measured by the Fibrosis-4 (FIB-4) score-and stroke severity and short-term clinical outcomes of patients with acute CES due to nonvalvular atrial fibrillation (NVAF). A total of 522 patients were followed for a median of 90 days. We calculated the FIB-4 score and defined liver fibrosis as follows: likely advanced fibrosis (FIB-4 > 3.25), indeterminate advanced fibrosis (FIB-4, 1.45-3.25), and unlikely advanced fibrosis (FIB-4 < 1.45). Logistic regression analysis and Cox regression analysis were used to investigate the relations between the FIB-4 score and stroke severity, major disability at discharge, and all-cause mortality. Among these 522 acute CES patients with NVAF, the mean FIB-4 score (2.28) on admission reflected intermediate fibrosis, whereas liver enzymes were largely normal. In multivariate regression analysis, patients with advanced liver fibrosis were more likely to have a higher risk of severe stroke (OR = 2.21, 95% CI 1.04-3.54), major disability at discharge (OR = 4.59, 95% CI 1.88-11.18), and all-cause mortality (HR = 1.25, 95% CI 1.10-1.56) than their counterparts. Regarding sex, these associations were stronger in males but not significant in females. In patients with acute CES due to NVAF, advanced liver fibrosis is associated with severe stroke, major disability, and all-cause death. Our findings indicate that early screening and management of liver fibrosis may decrease stroke severity and risk of death in patients with NVAF, especially for male patients. Consequently, FIB-4 > 3.25 of male patients should receive ultrasound elastography to further determine the degree of liver fibrosis.

NAFLD: An Emerging Causal Factor for Cardiovascular Disease

Nonalcoholic fatty liver disease (NAFLD) is the most prevalent chronic liver disease worldwide that poses a significant threat to human health. Cardiovascular disease (CVD) is the leading cause of mortality in NAFLD patients. NAFLD and CVD share risk factors such as obesity, insulin resistance, and type 2 diabetes. However, whether NAFLD is a causal risk factor for CVD remains a matter of debate. This review summarizes the evidence from prospective clinical and Mendelian randomization studies that underscore the potential causal relationship between NAFLD and CVD. The mechanisms of NAFLD contributing to the development of CVD and the necessity of addressing CVD risk while managing NAFLD in clinical practice are also discussed.

Causal effects of nonalcoholic fatty liver disease on cerebral cortical structure: a Mendelian randomization analysis

Background

Previous studies have highlighted changes in the cerebral cortical structure and cognitive function among nonalcoholic fatty liver disease (NAFLD) patients. However, the impact of NAFLD on cerebral cortical structure and specific affected brain regions remains unclear. Therefore, we aimed to explore the potential causal relationship between NAFLD and cerebral cortical structure.

Methods

We conducted a Mendelian randomization (MR) study using genetic predictors of alanine aminotransferase (ALT), NAFLD, and percent liver fat (PLF) and combined them with genome-wide association study (GWAS) summary statistics from the ENIGMA Consortium. Several methods were used to assess the effect of NAFLD on full cortex and specific brain regions, along with sensitivity analyses.

Results

At the global level, PLF nominally decreased SA of full cortex; at the functional level, ALT presented a nominal association with reduced SA of parahippocampal gyrus, TH of pars opercularis, TH of pars orbitalis, and TH of pericalcarine cortex. Besides, NAFLD presented a nominal association with reduced SA of parahippocampal gyrus, TH of pars opercularis, TH of pars triangularis and TH of pericalcarine cortex, but increased TH of entorhinal cortex, lateral orbitofrontal cortex and temporal pole. Furthermore, PLF presented a nominal association with reduced SA of parahippocampal gyrus, TH of pars opercularis, TH of cuneus and lingual gyrus, but increased TH of entorhinal cortex.

Conclusion

NAFLD is suggestively associated with atrophy in specific functional regions of the human brain.

Serum uric acid level in chronic liver disease and its correlation with Child-Pugh score in a tertiary care hospital from South India

Background

Chronic liver disease (CLD) is one of the important causes of morbidity and mortality in our country, and since the damage to the liver is irreversible, we have to look for many severity markers or predictors for the prognosis of the patient. In this study, we have tried to correlate the level of serum uric acid (UA) with the severity of CLD presented as a Child-Pugh score.

Methods

A cross-sectional observational study was conducted at Vijayanagar Institute of Medical Science (VIMS), Ballari, Karnataka, from October 2015 to June 2017 in the Department of General Medicine. Fifty patients diagnosed with CLD, aged between 18 and 65 years, of either gender, were enrolled in the study. Serum UA levels were measured, and liver function and coagulation parameters were assessed. A statistical analysis was performed to evaluate the association between serum UA levels, liver function test, and coagulation parameters.

Results

In our study, the mean serum UA level was 6.52 mg/dl and was raised in patients with CLD in correlation to its severity. Alcoholic liver disease (ALD) was the most common etiology for CLD (80%) followed by hepatitis B (Hep B) virus infection (12%) and hepatitis C (Hep C) virus infection (6%). Serum UA levels increased as the Child-Turcotte-Pugh (CTP) score increased. The mean UA level in CTP class C was 8.29 mg/dl. Various parameters such as serum aspartate aminotransferase (AST), alanine transaminase (ALT), alkaline phosphatase, total bilirubin, international normalized ratio (INR), calcium, and albumin were significantly associated with serum UA levels in CLD patients.

Conclusion

The correlation between rising blood UA levels and the Child-Pugh score shows that UA estimate may be a valid and affordable indicator for assessing the extent of liver cirrhosis in CLD.