NAFLD and increased risk of cardiovascular disease: clinical associations, pathophysiological mechanisms and pharmacological implications

Associations between life's essential 8 and non-alcoholic fatty liver disease among US adults

BACKGROUND

Nonalcoholic fatty liver disease (NAFLD) is closely associated with Cardiovascular disease (CVD). We aim to examine the association of Life's Essential 8 (LE8), the recently updated measurement of cardiovascular health (CVH), with the presence of NAFLD among US adults.

METHODS

This population-based cross-sectional study used data from the National Health and Nutrition Examination Survey in 2017-2018 and included adults 20 years or older. LE8 score (range 0-100) was measured according to American Heart Association definitions and was categorized into low (0-49), moderate (50-79), and high (80-100) CVH. NAFLD was determined by transient elastography measured hepatic steatosis in the absence of other liver diseases and excess alcohol use. Multivariable logistic and restricted cubic spline models were used to assess the associations.

RESULTS

Among 3588 participants included (weighted mean age, 48.0 years; 95% confidence interval [CI] 46.4-49.7 years), 1839 were female (weighted percentage, 51.6%; 95% CI 49.0-54.2%) and 1483 were determined to have NAFLD (weighted percentage, 36.5%; 95% CI 33.3-39.7%). The weighted mean LE8 score of the study population was 67.9 (95% CI 66.6-69.2). After the adjustment of potential confounders, higher LE8 scores were associated with reduced odds of NAFLD (odds ratio [OR] for per 10 score increase, 0.67; 95% CI 0.59-0.76) and a nonlinear dose-response relationship was observed. Similar patterns were also identified in the association of health behavior and health factor scores with NAFLD. The inversed association of LE8 score and NAFLD was significantly stronger among younger, Asian, and participants with higher education and income level.

CONCLUSIONS

LE8 and its subscales scores were negatively associated with the presence of NAFLD in non-linear fashions. Promoting adherence to optimal CVH levels may be beneficial to reduce the burden of NAFLD as well as CVD.

Effects of Shenxiang Suhe Pill on coronary heart disease complicated with nonalcoholic fatty liver disease: A case-control study

OBJECTIVE

To observe the clinical effect of Shenxiang Suhe Pill in the treatment of coronary heart disease (CHD) patients with nonalcoholic fatty liver disease (NAFLD).

METHODS

56 CHD patients with NAFLD were randomly divided into an experimental group and control group. The control group was treated by conventional western medicines, while the experimental group was given Shenxiang Suhe Pill in addition to the treatment of the control group. Both groups were treated for 12 weeks. Before treatment and after 12 weeks of treatment, the clinical efficacy indices of the 2 groups were evaluated, including transient elastic B-ultrasound (Fibroscan), controlled attenuation parameter (CAP), alanine aminotransferase (ALT), aspartate aminotransferase (AST), low density lipoprotein cholesterol, high density lipoprotein cholesterol, triglyceride (TG), total cholesterol, high sensitivity-reactive protein (hs-CRP) and lactate dehydrogenase (LDH).

RESULTS

Compared with the control group, the CAP value of the experimental group decreased more significantly, and the severity classification of NAFLD was also significantly improved (P < .05). LDH and hs-CRP in the experimental group decreased after treatment (P < .05). TG and high density lipoprotein cholesterol indicators improved more in the experimental group than in the control group (P < .05). ALT and AST in neither group showed significant change (P > .05).

CONCLUSION

Shenxiang Suhe Pills has a significant overall curative effect in the treatment of patients with CHD complicated with NAFLD. It can reduce liver lipid deposition, reduce the severity of NAFLD, and has lipid-lowering and anti -inflammatory effects.

Metabolic dysfunction-associated fatty liver disease and implications for cardiovascular risk and disease prevention

The newly proposed term "metabolic dysfunction-associated fatty liver disease" (MAFLD) is replacing the old term "non-alcoholic fatty liver disease" (NAFLD) in many global regions, because it better reflects the pathophysiology and cardiometabolic implications of this common liver disease. The proposed change in terminology from NAFLD to MAFLD is not simply a single-letter change in an acronym, since MAFLD is defined by a set of specific and positive diagnostic criteria. In particular, the MAFLD definition specifically incorporates within the classification recognized cardiovascular risk factors. Although convincing evidence supports a significant association between both NAFLD and MAFLD, with increased risk of CVD morbidity and mortality, neither NAFLD nor MAFLD have received sufficient attention from the Cardiology community. In fact, there is a paucity of scientific guidelines focusing on this common and burdensome liver disease from cardiovascular professional societies. This Perspective article discusses the rationale and clinical relevance for Cardiologists of the newly proposed MAFLD definition.

Treatment with phosphatidylcholine of patients with nonalcoholic fatty liver disease: a prospective pilot study

BACKGROUND

Nonalcoholic fatty liver disease (NAFLD) is characterized by a complex clinical picture that includes nonalcoholic steatohepatitis and cirrhosis. In the last decades, several studies have shown that NAFLD increases the risk of cardiovascular diseases. In a prospective pilot study, the benefit of treatment with phosphatidylcholine in NAFLD patients has been assessed.

METHODS

Thirty patients with NAFLD were enrolled. All received treatment with phosphatidylcholine (Essentiale® Forte N; Sanofi, Paris, France) 300 mg capsules, administered 2 at time orally, 3 times a day with meals for three months. The clinical and laboratory parameters before and after treatment were compared.

RESULTS

After the administration of Essentiale® Forte N (Sanofi) the level of alanine aminotransferase (ALT) decreased by 59.6% (P<0.05) and that of aspartate transaminase (AST) decreased by 75.4% (P<0.05). Moreover, after treatment, an increase in antioxidant enzymes superoxide dismutase by 48% (P<0.05) and glutathione peroxidase by 48.1% (P<0.05) was observed.

CONCLUSIONS

The results of the study indicate that treatment with Essentiale® Forte N (Sanofi) for 3 months was associated with a significant decrease in transaminase levels, in the activity of lipid peroxidation markers and with an increase in the level of antioxidant enzymes.

Detangling the interrelations between MAFLD, insulin resistance, and key hormones

Metabolic dysfunction-associated fatty liver disease (MAFLD) has increasingly become a significant and highly prevalent cause of chronic liver disease, displaying a wide array of risk factors and pathophysiologic mechanisms of which only a few have so far been clearly elucidated. A bidirectional interaction between hormonal discrepancies and metabolic-related disorders, including obesity, type 2 diabetes mellitus (T2DM), and polycystic ovarian syndrome (PCOS) has been described. Since the change in nomenclature from non-alcoholic fatty liver disease (NAFLD) to MAFLD is based on the clear impact of metabolic elements on the disease, the reciprocal interactions of hormones such as insulin, adipokines (leptin and adiponectin), and estrogens have strongly pointed to the intrinsic links that lead to the heterogeneous epidemiology, clinical presentations, and risk factors involved in MAFLD in different populations. The objective of this work is twofold. Firstly, there is a brief discussion regarding the change in nomenclature as well as epidemiology, risk factors, and pathophysiologic mechanisms other than hormonal effects, which include nutrition and the gut microbiome, as well as genetic and epigenetic influences. Secondly, we review the basis of the most important hormonal factors involved in the development and progression of MAFLD that act both independently and in an interrelated manner.

Predictors of renal recovery in recipients of liver transplant alone who met 2017 simultaneous liver-kidney transplant criteria

BACKGROUND

Severe renal dysfunction is common among liver transplant (LT) candidates and often prompts simultaneous liver-kidney transplantation (SLKT) consideration. In view of 2017 United Network of Organ Sharing (UNOS) criteria for SLKT, we investigated the likelihood and predictors of renal recovery among patients who met the aforementioned criteria yet received liver transplant alone (LTA).

METHODS

We retrospectively analyzed relative renal recovery (RRR; increase in eGFR to >30 ml/min) in adult LTA recipients between 1/2009 and 1/2019.

RESULTS

Of 1165 LT recipients, 54 met 2017 UNOS criteria, with 37 receiving LTA. RRR occurred in 84% of LTA recipients, none of whom had pre-LT eGFR <20 ml/min. Sustained RRR (>180 days) occurred in 43% of patients. While prolonged pre-LT severe renal impairment (eGFR <30 ml/min) predicted failure to have sustained RRR (HR .19 per 90-day, CI .04-.87, p < .005), having an eGFR measurement of >30 ml/min within 90 days pre-LT (HR 5.52, CI 1.23-24.79, p .01) associated with achieving sustained RRR. Sustained RRR was protective against the composite outcome of renal replacement therapy, kidney transplant, and death (HR .21, p .01).

CONCLUSION

LT candidates who meet 2017 UNOS criteria for SLKT yet undergo LTA can still have relative renal recovery post-LT, exceeding 80% on short-term follow-up and 40% on long-term follow-up. eGFR trends within 90 days pre-LT can predict sustained renal recovery, which appears protective of adverse outcomes. These recovery rates advocate for applying the more restrictive criteria for SLKT outlined in this article and increasing utilization of the safety net (SN) policy for those who do not meet the proposed criteria.

Current insights in molecular characterization of non-alcoholic fatty liver disease and treatment

There is a continuously rising incidence of non-alcoholic fatty liver disease (NAFLD) around the world, which parallels the increasing incidence of metabolic diseases. NAFLD is a range of liver conditions that contains simple non-alcoholic fatty liver and advanced non-alcoholic steatohepatitis. In serious cases, NAFLD may develop into cirrhosis or even liver cancer. NAFLD has an intense relationship with metabolic syndrome, type 2 diabetes mellitus. It is known that gut microbiota, and functional molecules such as adenosine monophosphate-activated protein kinase JNK, and peroxisome proliferator-activated receptors (PPARs) in progressing and treating NAFLD. Traditionally, the conventional and effective therapeutic strategy is lifestyle intervention. Nowadays, new medicines targeting specific molecules, such as farnesoid X receptor, PPARs, and GLP-1 receptor, have been discovered and shown beneficial effects on patients with NAFLD. In this article, we focus on the molecular mechanisms and therapeutic approaches to NAFLD.

Ornithine Aspartate and Vitamin-E Combination Has Beneficial Effects on Cardiovascular Risk Factors in an Animal Model of Nonalcoholic Fatty Liver Disease in Rats

Cardiovascular (CV) disease is the main cause of death in nonalcoholic fatty liver disease (NAFLD), a clinical condition without any approved pharmacological therapy. Thus, we investigated the effects of ornithine aspartate (LOLA) and/or Vitamin E (VitE) on CV parameters in a steatohepatitis experimental model. Adult Sprague Dawley rats were randomly assigned (10 animals each) and treated from 16 to 28 weeks with gavage as follows: controls (standard diet plus distilled water (DW)), NAFLD (high-fat choline-deficient diet (HFCD) plus DW), NAFLD+LOLA (HFCD plus LOLA (200 mg/kg/day)), NAFLD+VitE (HFCD plus VitE (150 mg twice a week)) or NAFLD+LOLA+VitE in the same doses. Atherogenic ratios were higher in NAFLD when compared with NAFLD+LOLA+VitE and controls (p < 0.05). Serum concentration of IL-1β, IL-6, TNF-α, MCP-1, e-selectin, ICAM-1, and PAI-1 were not different in intervention groups and controls (p > 0.05). NAFLD+LOLA decreased miR-122, miR-33a, and miR-186 (p < 0.05, for all) in relation to NAFLD. NAFLD+LOLA+VitE decreased miR-122, miR-33a and miR-186, and increased miR-126 (p < 0.05, for all) in comparison to NAFLD and NAFLD+VitE. NAFLD+LOLA and NAFLD+LOLA+VitE prevented liver collagen deposition (p = 0.006) in comparison to NAFLD. Normal cardiac fibers (size and shape) were lower in NAFLD in relation to the others; and the inverse was reported for the percentage of regular hypertrophic cardiomyocytes. NAFLD+LOLA+VitE promoted a significant improvement in atherogenic dyslipidemia, liver fibrosis, and paracrine signaling of lipid metabolism and endothelial dysfunction. This association should be further explored in the treatment of NAFLD-associated CV risk factors.

Comprehensive Review of Cardiovascular Disease Risk in Nonalcoholic Fatty Liver Disease

Nonalcoholic Fatty Liver Disease (NAFLD) is a growing global phenomenon, and its damaging effects in terms of cardiovascular disease (CVD) risk are becoming more apparent. NAFLD is estimated to affect around one quarter of the world population and is often comorbid with other metabolic disorders including diabetes mellitus, hypertension, coronary artery disease, and metabolic syndrome. In this review, we examine the current evidence describing the many ways that NAFLD itself increases CVD risk. We also discuss the emerging and complex biochemical relationship between NAFLD and its common comorbid conditions, and how they coalesce to increase CVD risk. With NAFLD's rising prevalence and deleterious effects on the cardiovascular system, a complete understanding of the disease must be undertaken, as well as effective strategies to prevent and treat its common comorbid conditions.

Risk factors for cardiovascular disease in patients with metabolic-associated fatty liver disease: a machine learning approach

BACKGROUND

Nonalcoholic fatty liver disease is associated with an increased cardiovascular disease (CVD) risk, although the exact mechanism(s) are less clear. Moreover, the relationship between newly redefined metabolic-associated fatty liver disease (MAFLD) and CVD risk has been poorly investigated. Data-driven machine learning (ML) techniques may be beneficial in discovering the most important risk factors for CVD in patients with MAFLD.

METHODS

In this observational study, the patients with MAFLD underwent subclinical atherosclerosis assessment and blood biochemical analysis. Patients were split into two groups based on the presence of CVD (defined as at least one of the following: coronary artery disease; myocardial infarction; coronary bypass grafting; stroke; carotid stenosis; lower extremities artery stenosis). The ML techniques were utilized to construct a model which could identify individuals with the highest risk of CVD. We exploited the multiple logistic regression classifier operating on the most discriminative patient's parameters selected by univariate feature ranking or extracted using principal component analysis (PCA). Receiver operating characteristic (ROC) curves and area under the ROC curve (AUC) were calculated for the investigated classifiers, and the optimal cut-point values were extracted from the ROC curves using the Youden index, the closest to (0, 1) criteria and the Index of Union methods.

RESULTS

In 191 patients with MAFLD (mean age: 58, SD: 12 years; 46% female), there were 47 (25%) patients who had the history of CVD. The most important clinical variables included hypercholesterolemia, the plaque scores, and duration of diabetes. The five, ten and fifteen most discriminative parameters extracted using univariate feature ranking and utilized to fit the ML models resulted in AUC of 0.84 (95% confidence interval [CI]: 0.77-0.90, p < 0.0001), 0.86 (95% CI 0.80-0.91, p < 0.0001) and 0.87 (95% CI 0.82-0.92, p < 0.0001), whereas the classifier fitted over 10 principal components extracted using PCA followed by the parallel analysis obtained AUC of 0.86 (95% CI 0.81-0.91, p < 0.0001). The best model operating on 5 most discriminative features correctly identified 114/144 (79.17%) low-risk and 40/47 (85.11%) high-risk patients.

CONCLUSION

A ML approach demonstrated high performance in identifying MAFLD patients with prevalent CVD based on the easy-to-obtain patient parameters.

Non-coding RNAs: The link between maternal malnutrition and offspring metabolism

Early life nutrition is associated with the development and metabolism in later life, which is known as the Developmental Origin of Health and Diseases (DOHaD). Epigenetics have been proposed as an important explanation for this link between early life malnutrition and long-term diseases. Non-coding RNAs (ncRNAs) may play a role in this epigenetic programming. The expression of ncRNAs (such as long non-coding RNA H19, microRNA-122, and circular RNA-SETD2) was significantly altered in specific tissues of offspring exposed to maternal malnutrition. Changes in these downstream targets of ncRNAs lead to abnormal development and metabolism. This review aims to summarize the existing knowledge on ncRNAs linking the maternal nutrition condition and offspring metabolic diseases, such as obesity, type 2 diabetes (T2D) and non-alcoholic fatty liver disease (NAFLD).

Liver transplantation for NAFLD cirrhosis: Age and recent coronary angioplasty are major determinants of survival

BACKGROUND AND AIMS

Liver transplantation (LT) is the treatment of end-stage non-alcoholic liver disease (NAFLD), that is decompensated cirrhosis and/or complicated by hepatocellular carcinoma (HCC). Few data on long-term outcome are available. The aim of this study was to evaluate overall patient and graft survivals and associated predictive factors.

METHOD

This retrospective multicentre study included adult transplant patients for NAFLD cirrhosis between 2000 and 2019 in participating French-speaking centres.

RESULTS

A total of 361 patients (69.8% of male) were included in 20 centres. The median age at LT was 62.3 years [57.4-65.9] and the median MELD score was 13.9 [9.1-21.3]; 51.8% of patients had HCC on liver explant. Between 2004 and 2018, the number of LT for NAFLD cirrhosis increased by 720%. A quarter of the patients had cardiovascular history before LT. Median follow-up after LT was 39.1 months [15.8-72.3]. Patient survival at 1, 5 and 10 years after LT was 89.3%, 79.8% and 68.1% respectively. The main causes of death were sepsis (37.5%), malignancies (29.2%) and cardiovascular events (22.2%). In multivariate analysis, three risk factors for overall mortality after LT were recipient pre-LT BMI < 32 kg/m² at LT time (OR: 2.272; p = .012), pre-LT angioplasty during CV check-up (OR: 2.916; p = .016), a combined donor and recipient age over 135 years (OR: 2.020; 95%CI: p = .035).

CONCLUSION

Survival after LT for NAFLD cirrhosis is good at 5 years. Donor and recipient age, and cardiovascular history, are major prognostic factors to consider.

Sarcopenia, healthy living, and mortality in patients with chronic liver diseases

Chronic liver diseases (CLDs) are associated with increased morbidity and mortality. Sarcopenia is an important complication of CLD that can be impacted by several modifiable risk factors. Our aim was to assess the associations between healthy living, sarcopenia, and long-term outcomes among patients with CLD. We used the Third National Health and Nutrition Examination Survey data with National Death Index-linked mortality files. We used the American Heart Association's Life's Simple 7 (LS7) metrics as surrogates of healthy living. The study included 12,032 subjects (34.9% CLDs [0.5% hepatitis B virus (HBV), 1.8% hepatitis C virus (HCV), 5.7% alcohol-associated liver disease (ALD), 26.9% nonalcoholic fatty liver disease (NAFLD)] and 65.1% controls). Prevalence of sarcopenia was higher among NAFLD than other CLDs and the controls (40.7% in NAFLD, 27.2% in ALD, 22.4% in HCV, 16.8% in HBV, and 18.5% in controls; p < 0.001). Among NAFLD and ALD, patients with sarcopenia were less likely to meet ideal LS7 metrics than those without sarcopenia. During 27 years of follow-up, among 4 patients with CLDs and the controls, all-cause cumulative mortality was highest among patients with HCV (35.2%), followed by ALD (34.7%) and NAFLD (29.6%). The presence of sarcopenia was associated with higher risk of all-cause mortality only among subjects with NAFLD (hazard ratio [HR] 1.24; 95% confidence interval [CI] 1.01-1.54; p = 0.04). Among subjects with NAFLD, presence of sarcopenia was associated with higher risk of cardiovascular-specific (HR 2.28 [1.71-3.05; p < 0.01]), cancer-specific (HR 1.90 [1.37-2.65]; p < 0.01), diabetes-specific (HR 6.42 [2.87-14.36]; p < 0.01), and liver-specific mortality (HR 2.49 [1.08-5.76]; p = 0.04). The multivariable model showed that component of LS7 metrics that provided the strongest protection against sarcopenia were ideal body mass index, ideal blood pressure, ideal physical activity, and ideal glycemic control among subjects with NAFLD subjects. Conclusions: Among subjects with NAFLD, sarcopenia is associated with a higher risk of all-cause mortality and liver mortality. Attainment of ideal LS7 metrics provides protection against sarcopenia in NAFLD.

Fatty liver disease reverses the obesity paradox in chronic kidney disease stages 3-5: A follow-up study of NHANES III

High body mass index (BMI) has been associated with better survival in patients with end-stage kidney disease. Individuals with fatty liver disease (FLD) have a higher risk of chronic kidney disease. It remains unclear whether the survival benefit of high BMI in patients with chronic kidney disease is present when there is concomitant FLD. This study used the data set from the Third American National Health and Nutrition Examination Survey and the corresponding survival data. The Cox proportional hazards model was used to evaluate the effect of BMI on mortality. A total of 12,445 participants were included. The prevalence of FLD was 39.8%. The median follow-up time (with interquartile range) was 22.8 (20.8-24.8) years. During this period, 3749 (30.1%, 14.4 of 1000 person-year) deaths were observed. Among these, 1169 (31.2%) died within the first 10 years. The Cox regression analysis showed that the BMI level was not associated with 25-year mortality in patients with decreased glomerular filtration rate (GFR < 60 ml/min/1.73 m2 ), but 10-year mortality was significantly lower in patients with BMI ≥ 25 kg/m2 than in those with BMI < 25 kg/m2 (p = 0.049). Multivariate analysis showed BMI ≥ 25 kg/m2 was an independent protective factor for 10-year mortality (hazard ratio [HR] 0.691, 95% confidence interval [CI] 0.559-0.856; p = 0.001). This protective effect of higher BMI was lost in patients with FLD (HR 0.884, 95% CI 0.585-1.335; p = 0.557) but persisted in the non-FLD group (HR 0.625, 95% CI 0.479-0.816; p = 0.001). The survival benefit of overweight/obesity for patients with decreased GFR, which was attenuated by the presence of FLD, only existed in the first decade.

Risk of cardiovascular disease and loss in life expectancy in NAFLD

BACKGROUND AND AIMS

Conflicting evidence exists on cardiovascular disease (CVD) risk in patients with NAFLD, and data are lacking on whether NAFLD increases mortality after a CVD event. Moreover, life expectancy in NAFLD has not been studied. We therefore examined CVD risk and life expectancy in patients with NAFLD compared with the general population.

APPROACH AND RESULTS

In this nationwide population-based cohort, all patients with NAFLD diagnosis and without baseline CVD (ascertaining from the Swedish National Patient Register from 1987 to 2016, n = 10,023) were matched 10:1 on age, sex, and municipality to individuals from the general population (controls, n = 96,313). CVD diagnosis and mortality were derived from national registers. Multistate models and flexible parametric survival models were used to estimate adjusted hazard ratios (aHRs) for CVD risk and loss in life expectancy due to NAFLD. We identified 1037 (10.3%) CVD events in patients with NAFLD and 4041 (4.2%) in controls. CVD risk was 2.6-fold higher in NAFLD compared with controls (aHR = 2.61, 95% CI = 2.36-2.88) and was strongest for nonfatal CVD (aHR = 3.71, 95% CI = 3.29-4.17). After a nonfatal CVD event, the risk for all-cause mortality was similar between patients with NAFLD and controls (aHR = 0.89, 95% CI = 0.64-1.25). Life expectancy in patients with NAFLD was, on average, 2.8 years lower than controls, with the highest loss of life-years when NAFLD was diagnosed in middle age (40-60 years).

CONCLUSIONS

NAFLD was associated with a higher risk of nonfatal CVD but did not affect post-CVD mortality risk. Patients diagnosed with NAFLD have a lower life expectancy than the general population.

Antifibrotic effect and long-term outcome of SGLT2 inhibitors in patients with NAFLD complicated by diabetes mellitus

The aim of this retrospective multicenter study was to clarify the antifibrotic effect and long-term outcome of sodium glucose cotransporter 2 inhibitors (SGLT2-Is) in patients with nonalcoholic fatty liver disease (NAFLD) complicated by type 2 diabetes mellitus (T2DM). Of the 1262 consecutive patients with T2DM who recently received SGLT2-Is, 202 patients with NAFLD had been receiving SGLT2-Is for more than 48 weeks and were subjected to this analysis. Furthermore, 109 patients who had been on SGLT2-I therapy for more than 3 years at the time of analysis were assessed for the long-term effects of SGLT2-Is. Significant decreases in body weight, liver transaminases, plasma glucose, hemoglobin A1c, and Fibrosis-4 (FIB-4) index were found at week 48. Overall, the median value of FIB-4 index decreased from 1.42 at baseline to 1.25 at week 48 (p < 0.001). In the low-risk group (FIB-4 index < 1.3), there was no significant change in the FIB-4 index. In the intermediate-risk (≥1.3 and <2.67) and high-risk (≥2.67) groups, the median levels significantly decreased from 1.77 and 3.33 at baseline to 1.58 and 2.75 at week 48, respectively (p < 0.001 for both). Improvements in body weight, glucose control, liver transaminases, and FIB-4 index were found at 3 years of SGLT2-I treatment. In the intermediate-risk and high-risk groups (≥1.3 FIB-4 index), the FIB-4 index maintained a significant reduction from baseline throughout the 3 years of treatment. Conclusion: This study showed that SGLT2-Is offered a favorable effect on improvement in FIB-4 index as a surrogate marker of liver fibrosis in patient with NAFLD complicated by T2DM, especially those with intermediate and high risks of advanced fibrosis, and this antifibrotic effect is sustained for the long term.

Efficacy of aerobic and resistance exercises in improving visceral adipose in patients with non-alcoholic fatty liver: a meta-analysis of randomized controlled trials

BACKGROUND

Non-alcoholic fatty liver disease (NAFLD) is a common chronic disease that can cause liver deterioration if insufficiently diagnosed and untreated. The verification of whether exercise interventions improve liver enzymes and lipid and glucose parameters is scant.

AIM

We conducted this systematic review and meta-analysis to examine the efficacy of aerobic and resistance exercise interventions in patients with NAFLD.

METHODS

We searched the related studies in the PubMed, Embase, Cochrane Library, and Web of Science databases. We screened 1129 articles published before September 1, 2021, based on the inclusion and exclusion standards, after which 17 articles with a total of 1168 participants were finally included. The indices of liver enzymes and lipid and glucose metabolism were gathered and examined by Stata SE.

RESULTS

The outcomes suggested that aerobic and resistance exercise can markedly improve the parameters of liver enzymes, blood lipids, and glucose, and especially visceral adipose tissue (weighted mean different [WMD] = -8.3 at 95% CI [-11.59 to -5.00], p < 0.0001), in patients with NAFLD.

CONCLUSION

This study demonstrated that aerobic and resistance exercises positively affect NAFLD treatment. To further quantify the effects on patients with NAFLD, a more specific and uniform exercise program should be proposed.

Advances and Emerging Therapies in the Treatment of Non-alcoholic Steatohepatitis

Non-alcoholic steatohepatitis (NASH) now represents one of the most prevalent forms of cirrhosis and hepatocellular carcinoma. A number of treatment agents have undergone assessment in humans following promising results in animal models. Currently, about 50 therapeutic agents are in various stages of development. Recently, however, there have been a number of exciting and positive developments in this landscape, although there are inherent challenges ahead. In this article, we review the aetiological and pathological basis of NASH progression and describe putative targets for current therapies. We also discuss some of the likely future directions and difficulties around this complex and challenging disease paradigm.

Update on genetics and epigenetics in metabolic associated fatty liver disease

Nonalcoholic fatty liver disease (NAFLD) is becoming the most frequent chronic liver disease worldwide. Metabolic (dysfunction) associated fatty liver disease (MAFLD) is suggested to replace the nomenclature of NAFLD. For individuals with metabolic dysfunction, multiple NAFLD-related factors also contribute to the development and progression of MAFLD including genetics and epigenetics. The application of genome-wide association study (GWAS) and exome-wide association study (EWAS) uncovers single-nucleotide polymorphisms (SNPs) in MAFLD. In addition to the classic SNPs in PNPLA3, TM6SF2, and GCKR, some new SNPs have been found recently to contribute to the pathogenesis of liver steatosis. Epigenetic factors involving DNA methylation, histone modifications, non-coding RNAs regulations, and RNA methylation also play a critical role in MAFLD. DNA methylation is the most reported epigenetic modification. Developing a non-invasion biomarker to distinguish metabolic steatohepatitis (MASH) or liver fibrosis is ongoing. In this review, we summarized and discussed the latest progress in genetic and epigenetic factors of NAFLD/MAFLD, in order to provide potential clues for MAFLD treatment.

Association between triglyceride-glucose index and nonalcoholic fatty liver disease in type 2 diabetes mellitus

BACKGROUND

Lipid and glucose metabolism abnormalities are associated with nonalcoholic fatty liver disease (NAFLD). The triglyceride-glucose (TyG) index is a recently developed indicator that can identify individuals at risk for NAFLD. However, the applicability of the TyG index for identifying NAFLD in patients with type 2 diabetes mellitus (T2DM) is unclear. The aim of this study was to investigate the ability of the TyG index to identify individuals at risk for NAFLD in the T2DM population.

METHODS

A total of 2280 participants with T2DM were recruited in this cross-sectional study. The TyG index was calculated, and NAFLD was diagnosed by ultrasonography. Binary logistic regression models were used to evaluate the association of the TyG index, glycemic parameters and lipid parameters with NAFLD.

RESULTS

Logistic regression analysis showed that the TyG index was significantly associated with NAFLD in subjects with T2DM, the odds ratio (OR) were 3.27 (95% confidence interval [CI], 2.03-5.27; P < 0.001) for NAFLD in the highest TyG quartile after adjustment for known confounders. In stratified analysis, an elevated TyG index were more remarkably associated with NAFLD in younger patients (< 65 years; OR, 2.35; 95% CI, 1.83-3.02; P < 0.001), females (OR, 2.69; 95% CI, 1.67-4.32; P < 0.001), patients with BMI < 25 kg/m² (OR, 2.80; 95% CI, 2.01-3.91; P < 0.0001), and with lower high-density lipoprotein cholesterol (< 1 mmol/L; OR, 2.76; 95% CI, 1.98-3.83; P < 0.001).

CONCLUSION

The TyG index is significantly associated with NAFLD and shows superior ability for identify NAFLD risk compared with other lipid and glycemic parameters in T2DM.

Fatty Liver Is an Independent Risk Factor for Elevated Intraocular Pressure

Elevated intraocular pressure (EIOP) is a major risk factor for glaucoma. Both EIOP and fatty liver share metabolic risk factors, which implies a possible link between EIOP and fatty liver. We aimed to determine the association of fatty liver with EIOP and estimate the effect of fatty liver on EIOP directly and indirectly through insulin resistance. Data from 16,240 adults who underwent health examinations at a single center were analyzed. Multiple logistic regression analyses revealed that fully adjusted odds ratio (OR) and 95% confidence interval (CI) for EIOP in the fatty liver group compared to the non-fatty liver group were 1.36 and 1.08-1.71. Alcoholic liver disease was associated with EIOP in subgroup analysis (OR = 1.80, 95% CI: 1.27-2.56). There was a linear dose-response relationship between EIOP and the severity of fatty liver. Mediation analysis revealed that the total effect of fatty liver on intraocular pressure was 0.90 (0.81-0.99), with a direct effect of 0.81 (0.71-0.90) and an indirect effect of 0.09 (0.06-0.11) through insulin resistance. Fatty liver is independently associated with EIOP. It primarily has a direct effect on intraocular pressure. This suggests that evaluation of EIOP should be considered in patients with fatty liver.

Emerging trends and hotspots in the links between the gut microbiota and MAFLD from 2002 to 2021: A bibliometric analysis

BACKGROUND

The prevalence of metabolic associated fatty liver disease (MAFLD) presented a booming growth over recent years in the whole world. MAFLD was associated with a higher risk of end-stage liver disease, hepatocellular carcinoma and liver transplantation. Accumulating evidence indicated that gut microbiota and MAFLD were interrelated and interacted with each other. However, to the knowledge of the authors, no bibliometric quantitative analysis has been carried out to evaluate the links between the gut microbiota and MAFLD. This study aimed to use bibliometric analysis to evaluate current publication trends and hotspots in the links between the gut microbiota and MAFLD, in order to advance research in this field.

METHODS

The articles regarding the links between gut microbiota and MAFLD from 2002 to 2021 were identified from the Science Citation Index-Expanded of Web of Science Core Collection. CiteSpace software, Vosviewer, the R package "bibliometrix" and the Online Analysis Platform of Literature Metrology were used to analyze current publication trends and hotspots in this field.

RESULTS

A total of 707 articles were retrieved regarding the links between gut microbiota and MAFLD from 2002 to 2021. The USA occupied the leading role until 2015 and the dominance of China started in 2016. The USA was the most frequently involved country in international cooperation. Shanghai Jiao Tong University was the most productive institution. Ina Bergheim was the most productive author, publishing 14 articles. The co-citation keywords cluster label displayed ten main clusters: probiotics, bile acid, immune function, adolescents, nutritional genomics, high fat diet, systems biology, lipopolysaccharides, phosphatidylcholine, and oxidative stress. Keyword bursts analysis indicated that diet induced obesity, metabolic syndrome, ppar alpha, and lactobacillus were the research hotspots with high strength.

CONCLUSION

The number of publications covering the links of gut microbiota and MAFLD increased dramatically in the past decade and especially became exponential growth in the last 3 years. Probiotics and bile acid will be the research direction of great importance in the etiology and novel treatment for MAFLD. This study provided systematic information and instructive assistance for future research work, that helped to discover the mechanisms and new treatments of MAFLD.

RNA binding protein HuR protects against NAFLD by suppressing long noncoding RNA H19 expression

BACKGROUND

NAFLD has become the most common chronic liver disease worldwide. Human antigen R (HuR), an RNA-binding protein, is an important post-transcriptional regulator. HuR has been reported as a key player in regulating lipid homeostasis in the liver and adipose tissues by using tissue-specific HuR knockout mice. However, the underlying mechanism by which hepatocyte-specific HuR regulates hepatic lipid metabolism under metabolic stress remains unclear and is the focus of this study.

METHODS

Hepatocyte-specific HuR deficient mice (HuRhKO) and age-/gender-matched control mice, as well as long-noncoding RNA H19 knockout mice (H19-/-), were fed a Western Diet plus sugar water (WDSW). Hepatic lipid accumulation, inflammation and fibrosis were examined by histology, RNA transcriptome analysis, qRT-PCR, and Western blot analysis. Bile acid composition was measured using LC-MS/MS.

RESULTS

Hepatocyte-specific deletion of HuR not only significantly increased hepatic lipid accumulation by modulating fatty acid synthesis and metabolism but also markedly induced inflammation by increasing immune cell infiltration and neutrophil activation under metabolic stress. In addition, hepatic deficiency of HuR disrupted bile acid homeostasis and enhanced liver fibrosis. Mechanistically, HuR is a repressor of H19 expression. Analysis of a recently published dataset (GSE143358) identified H19 as the top-upregulated gene in liver-specific HuR knockout mice. Similarly, hepatocyte-specific deficiency of HuR dramatically induced the expression of H19 and sphingosine-1 phosphate receptor 2 (S1PR2), but reduced the expression of sphingosine kinase 2 (SphK2). WDSW-induced hepatic lipid accumulation was alleviated in H19-/- mice. Furthermore, the downregulation of H19 alleviated WDSW-induced NAFLD in HuRhKO mice.

CONCLUSIONS

HuR not only functions as an RNA binding protein to modulate post-transcriptional gene expression but also regulates H19 promoter activity. Hepatic HuR is an important regulator of hepatic lipid metabolism via modulating H19 expression.

Association of Bariatric Surgery With Cardiovascular Outcomes in Adults With Severe Obesity and Nonalcoholic Fatty Liver Disease

Importance

There are no approved treatments for nonalcoholic fatty liver disease (NAFLD) despite its association with obesity and increased risk of cardiovascular disease (CVD).

Objective

To examine the association between bariatric surgery and CVD risk in individuals with severe obesity and NAFLD.

Design, Setting, and Participants

This large, population-based retrospective cohort study obtained data from the MarketScan Commercial Claims and Encounters database from January 1, 2007, to December 31, 2017. Participants included insured adults aged 18 to 64 years with NAFLD and severe obesity (body mass index ≥40) without a history of bariatric surgery or CVD before NAFLD diagnosis. Baseline characteristics were balanced between individuals who underwent surgery (surgical group) and those who did not (nonsurgical group) using inverse probability of treatment weighting. Data were analyzed from March 2020 to April 2021.

Exposures

Bariatric surgery (Roux-en-Y gastric bypass, sleeve gastrectomy, and other bariatric procedures) vs nonsurgical care.

Main Outcomes and Measures

The main outcome was the incidence of cardiovascular events (primary or secondary composite CVD outcomes). The primary composite outcome included myocardial infarction, heart failure, or ischemic stroke, and the secondary composite outcome included secondary ischemic heart events, transient ischemic attack, secondary cerebrovascular events, arterial embolism and thrombosis, or atherosclerosis. Cox proportional hazards regression models with inverse probability treatment weighting were used to examine the associations between bariatric surgery, modeled as time varying, and all outcomes.

Results

The study included 86 964 adults (mean [SD] age, 44.3 [10.9] years; 59 773 women [68.7%]). Of these individuals, 30 300 (34.8%) underwent bariatric surgery and 56 664 (65.2%) received nonsurgical care. All baseline covariates were balanced after applying inverse probability treatment weighting. In the surgical group, 1568 individuals experienced incident cardiovascular events compared with 7215 individuals in the nonsurgical group (incidence rate difference, 4.8 [95% CI, 4.5-5.0] per 100 person-years). At the end of the study, bariatric surgery was associated with a 49% lower risk of CVD (adjusted hazard ratio [aHR], 0.51; 95% CI, 0.48-0.54) compared with nonsurgical care. The risk of primary composite CVD outcomes was reduced by 47% (aHR, 0.53 [95% CI, 0.48-0.59), and the risk of secondary composite CVD outcomes decreased by 50% (aHR, 0.50; 95% CI, 0.46-0.53) in individuals with vs without surgery.

Conclusions and Relevance

Results of this study suggest that, compared with nonsurgical care, bariatric surgery was associated with significant reduction in CVD risk in individuals with severe obesity and NAFLD.

Hepatic T1-Time Predicts Cardiovascular Risk in All-Comers Referred for Cardiovascular Magnetic Resonance: A Post-Hoc Analysis

BACKGROUND

Liver damage is frequently observed in patients with cardiovascular disease but infrequently quantified. We hypothesized that in patients with cardiovascular disease undergoing cardiac magnetic resonance, liver T1-times indicate liver damage and are associated with cardiovascular outcome.

METHODS

We measured hepatic T1-times, displayed on standard cardiac T1-maps, in an all-comer cardiac magnetic resonance-cohort. At the time of cardiac magnetic resonance, we assessed validated general liver fibrosis scores. Kaplan-Meier estimates and Cox-regression models were used to investigate the association between hepatic T1-times and a composite endpoint of non-fatal myocardial infarction, heart failure hospitalization, and death.

RESULTS

One thousand seventy-five participants (58±18 year old, 47% female) were included (972 patients, 50 controls, 53 participants with transient elastography). Hepatic T1-times were 590±89 ms in patients and 574±45 ms in controls (P=0.052). They were significantly correlated with cardiac size and function, presence of atrial fibrillation, NT-pro-BNP levels, and gamma-glutamyl-transferase levels (P<0.001 for all). During follow-up (58±31 months), a total of 280 (29%) events occurred. On Cox-regression, high hepatic T1-times yielded a significantly higher risk for events (adjusted hazard ratio, 1.66 [95% CI, 1.45-1.89] per 100 ms increase; P<0.001), even when adjusted for age, sex, left and right ventricular ejection fraction, NT-proBNP (N-terminal prohormone of brain natriuretic peptide), and myocardial T1-time. On receiver operating characteristic analysis and restricted cubic splines, we found that a hepatic T1-time exceeding 610 ms was associated with excessive risk.

CONCLUSIONS

Hepatic T1-times on standard cardiac magnetic resonance scans were significantly associated with cardiac size and function, comorbidities, natriuretic peptides, and independently predicted cardiovascular mortality and morbidity. A hepatic T1-time >610 ms seems to indicate excessive risk.

REGISTRATION

URL: https://www.

CLINICALTRIALS

gov; Unique identifier: NCT04220450.

Aspartate aminotransferase to alanine aminotransferase ratio and clinical outcomes after acute ischemic stroke: the CNSR-III registry

Elevated aspartate aminotransferase-to-alanine aminotransferase ratio (AAR) has been associated with cardiovascular diseases and mortality. The clinical significance of AAR in the prognosis of stroke has yet to be established. We aimed to investigate the associations between AAR levels and clinical outcomes in acute ischemic stroke (AIS) or transient ischemic attack (TIA). Patients with AIS or TIA in the Third China National Stroke Registry (CNSR-III) were divided into four groups by quartiles of AAR, and two groups according to AAR < 1 and AAR ≥ 1. Multivariable Cox regression for all-cause mortality and logistic regression for poor functional outcome (modified Rankin Scale, mRS 3-6/2-6) were adopted to explore the associations between AAR and clinical outcomes at 3 months and 1 year. Among 10,877 included patients, the median AAR was 1.06 (interquartile range [IQR], 0.82 to 1.36). In the multivariable-adjusted model, patients in the fourth AAR quartile had higher risk of all-cause mortality within 3 months and 1 year (hazard ratio [HR] 2.08, 95% confidence interval [CI] 1.25 to 3.47; HR 2.26, 95% CI 1.55 to 3.27), and mRS 3-6/2-6 at 1 year (odds ratio [OR] 1.29, 95% CI 1.07 to 1.55; OR 1.20, 95% CI 1.02 to 1.42), compared with those in the first quartile. Similar associations were also observed when AAR ≥ 1 compared with AAR < 1. Elevated AAR was associated with higher risk of all-cause mortality and poor functional outcome after AIS or TIA, and should be carefully assessed after admission.

Impact of liver fibrosis score on the incidence of stroke: A cohort study

PURPOSE

The purpose was to explore the value of liver fibrosis scores (fibrosis-4, BAAT score and BARD score) for incidence risk of stroke in a cohort study.

METHODS

A total of 9088 participants without stroke history enrolled the follow-up. Three liver fibrosis scores (LFSs) including FIB-4, BARD score and BAAT score were adopted. The end point was stroke. Cox regression analysis was used to calculate hazard ratios and 95% confidence interval. Kaplan-Meier curve was used to show the probability of stoke in different levels of LFSs. Subgroup analysis showed the association between LFSs and stroke under different stratification. Restricted cubic spline could further explore whether there is a linear relationship between LFSs and stroke. Finally, we used C-statistics, Net Reclassification Index (NRI) and Integrated Discrimination Improvement (IDI) to assess the discriminatory power of each LFS for stroke.

RESULTS

During a median follow-up time of 4.66 years, 272 participants had a stroke. Through the baseline characteristics, we observed that the stroke incidence population tends to be male and older. It was shown by Kaplan-Meier that three LFSs were associated with stroke and high levels of LFSs significantly increase the probability of stroke. In the univariate Cox regression analysis, the HR of stroke risk was 6.04 (4.14-8.18) in FIB-4, 2.10 (1.45-3.04) in BAAT score and 1.81 (1.38-2.38) in BARD score by comparing the high level with the low level at each LFSs. The adjusted HRs for three LFSs were 2.05 (1.33-3.15) in FIB-4, 1.61 (1.10-2.35) in BAAT score and 1.54 (1.17-2.04) in BARD score by comparing the high group with low group. We found that multivariable-adjusted HRs of three LFSs still increased for stroke when stratified by various factors in subgroup analysis. Moreover, after adding LFSs to original risk prediction model which consist of age, sex, drinking, smoking, hypertension, diabetes, low-density lipoprotein cholesterol, total cholesterol and triglycerides, we found that new models have higher C-statistics of stroke. Furthermore, we calculated Net Reclassification Index (NRI) and Integrated Discrimination Improvement (IDI) to show the ability of LFSs to predict stroke.

CONCLUSIONS

Our study showed that three LFSs were associated with stroke amongst middle-aged populations in rural areas of Northeast China. Furthermore, it suggests that LFSs can be used as a risk stratification tool to predict stroke.

A poor perspective of self weight significantly increases adverse outcomes in non-alcoholic fatty liver disease (NAFLD)

Background

Non-alcoholic fatty liver disease (NAFLD) is prevalent amongst overweight and obese individuals, and weight loss remains the main mode of treatment for NAFLD patients. Weight perception plays a key role in the efficacy of such treatment. The current study aims to investigate the prevalence, associating factors and implications of poor weight perception amongst such individuals.

Methods

An analysis was done on data collected from NHANES between 1999 and 2018. Comparison was made between NAFLD individuals with and without poor weight perception in terms of prevalence, associated characteristics, and clinical outcomes. Multivariate analysis was used to compare effect size of adverse events associated with NAFLD individuals with poor weight perception.

Results

Of the 12,170 NAFLD patients, 19.2% (CI: 18.5 to 19.9%) had poor weight perception. Poor weight perception was significantly associated with lower education levels, reduced levels of exercise and unhealthier lipid profiles. There was an increased risk in all-cause mortality (HR: 1.18, CI: 1.00 to 1.38, p = 0.047), cardiovascular disease mortality (SHR: 1.33, CI: 1.03 to 1.71, p = 0.026), major adverse cardiovascular events (OR: 1.21 CI: 1.10 to 1.32, p < 0.001), and advanced fibrosis (OR: 1.30, CI: 1.03 to 1.64, p = 0.025) for individuals with poor weight perception.

Conclusion

This study highlights the positive association between appropriate weight perception and better outcomes in individuals with NAFLD. Poor weight perception increased the risk of adverse events and decreased inclination toward seeking weight loss treatment. Greater emphasis should be placed on dealing with weight perception in individuals with NAFLD for better treatment outcomes.

Relationship between nonalcoholic fatty liver disease and coronary plaque stability and risk factors for composite cardiovascular adverse events

BACKGROUND

Cardiovascular disease is a major disease threatening human life and health. In recent years, the relationship between cardiovascular disease and non-alcoholic fatty liver disease has become a research hotspot. Non-alcoholic fatty liver disease is closely related to the severity of coronary heart disease, which can be used for preliminary assessment of the risk of cardiovascular events in coronary heart disease.

AIM

To explore the relationship between non-alcoholic fatty liver disease (NAFLD) and coronary plaque stability and the multivariate analysis of prognosis.

METHODS

A total of 320 patients who underwent coronary CT angiography at our hospital from January 2019 to January 2021 were selected and divided into an NAFLD group (n = 91) and a non-NAFLD group (n = 229) according to the presence or absence of NAFLD. The general data and coronary plaque presence (plaque presence rate and plaque number) were compared between the two groups, and coronary plaque stability (soft plaque, mixed plaque, and hard plaque) in NAFLD patients with different degrees of fatty liver degeneration were compared. Spearman correlation was used to analyze the correlation between the degree of fatty liver degeneration and coronary plaque stability and Gensini score. All patients were followed for 12 mo, and composite cardiovascular adverse events (coronary revascularization, myocardial infarction, all-cause death, and cardiac death) were counted. The clinical data of patients with different prognoses were compared, and the prognostic factors were analyzed by multivariate Logistic regression.

RESULTS

The proportion of patients with coronary plaques (76.92%) and the proportion of patients with ≥ 2 coronary plaques (12.09%) in the NAFLD group were significantly higher than those in the non-NAFLD group (58.08% and 4.37%, respectively, P < 0.05). Patients with severe fatty liver degeneration had the highest proportion of soft plaques and Gensini score followed by those with moderate and mild fatty liver degeneration (P < 0.05); the degree of fatty liver degeneration in the NAFLD group was positively correlated with coronary plaque stability and Gensini score (P < 0.05). Body mass index, proportion of patients with diabetes, TG level, proportion of patients with NAFLD, and proportion of soft plaques in patients with composite adverse cardiovascular events were higher than those in patients without (P < 0.05). BMI, diabetes, TG level, NAFLD, and soft plaque were independent risk factors for compound cardiovascular adverse events (P < 0.05).

CONCLUSION

NAFLD is closely related to the stability of coronary plaque and the degree of coronary stenosis in CVD patients, and both NAFLD and coronary plaque instability are prognostic risk factors for composite cardiovascular adverse events.

Nonalcoholic fatty liver disease in inflammatory arthritis: Relationship with cardiovascular risk

Liver disease is one of the most important causes of morbidity and mortality worldwide whose prevalence is dramatically increasing. The first sign of hepatic damage is inflammation which could be accompanied by the accumulation of fat called non-alcoholic fatty liver disease (NAFLD), causing damage in the hepatocytes. This stage can progress to fibrosis where the accumulation of fibrotic tissue replaces healthy tissue reducing liver function. The next stage is cirrhosis, a late phase of fibrosis where a high percentage of liver tissue has been replaced by fibrotic tissue and liver functionality is substantially impaired. There is a close interplay of cardiovascular disease (CVD) and hepatic alterations, where different mechanisms mediating this relation between the liver and systemic vasculature have been described. In chronic inflammatory diseases such as rheumatoid arthritis (RA) and psoriatic arthritis (PsA), in which the CVD risk is high, hepatic alterations seem to be more prevalent compared to the general population and other rheumatic disorders. The pathogenic mechanisms involved in the development of this comorbidity are still unraveled, although chronic inflammation, autoimmunity, treatments, and metabolic deregulation seem to have an important role. In this review, we will discuss the involvement of liver disease in the cardiovascular risk associated with inflammatory arthritis, the pathogenic mechanisms, and the recognized factors involved. Likewise, monitoring of the liver disease risk in routine clinical practice through both, classical and novel techniques and indexes will be exposed. Finally, we will examine the latest controversies that have been raised about the effects of the current therapies used to control the inflammation in RA and PsA, in the liver damage of those patients, such as methotrexate, leflunomide or biologics.

Worldwide long-term trends in the incidence of nonalcoholic fatty liver disease during 1990-2019: A joinpoint and age-period-cohort analysis

BACKGROUND

Non-alcoholic fatty liver disease (NAFLD) was previously a neglected disease that is now becoming a worldwide pandemic. A better understanding of its incidence and long-term trends will help to increase public awareness of the disease and the development of future prevention strategies.

METHODS

The incidence rates of NAFLD during 1990-2019 were collected from the Global Burden of Disease Study 2019 database according to the following parameters: sex, age, socio-demographic index, and geographical region. Estimated annual percentage changes and joinpoint models were used to assess the long-term trend of NAFLD, and an age-period-cohort model was used to assess the extents of the age, period, and cohort effects.

RESULTS

Adult males, postmenopausal females, Latin American populations, and people in developing countries had a high risk of developing NAFLD. The joinpoint model indicated a new trend of increasing NAFLD incidence in 2005. Age was a risk factor affecting NAFLD incidence, with this effect increasing in more-recent periods. Younger birth cohorts had lower risks of NAFLD.

CONCLUSIONS

Recent prevention measures for NAFLD have achieved good initial results. However, it remains a high priority to increase the public awareness of this condition, develop its diagnostic criteria, identify cost-effective screening methods, and seek policy support to act against NAFLD, which will be a major public health problem in the future.

Non-alcoholic fatty liver disease and incident major adverse cardiovascular events: results from a nationwide histology cohort

OBJECTIVE

Some data suggest a positive association between non-alcoholic fatty liver disease (NAFLD) and incident major adverse cardiovascular events (MACEs). However, data are lacking from large cohorts with liver histology, which remains the gold standard for staging NAFLD severity.

DESIGN

This population-based cohort included all Swedish adults with histologically confirmed NAFLD and without cardiovascular disease (CVD) at baseline (1966-2016, n=10 422). NAFLD was defined from prospectively recorded histopathology and categorised as simple steatosis, non-fibrotic steatohepatitis, non-cirrhotic fibrosis and cirrhosis. Patients with NAFLD were matched to ≤5 population controls without NAFLD or CVD, by age, sex, calendar year and county (n=46 517). Using Cox proportional hazards modelling, we calculated multivariable adjusted HRs (aHRs) and 95% CIs for MACE outcomes (ie, ischaemic heart disease (IHD), stroke, congestive heart failure (CHF) or cardiovascular (CV) mortality).

RESULTS

Over a median of 13.6 years, incident MACE was confirmed in 2850 patients with NAFLD and 10 648 controls. Patients with NAFLD had higher incidence of MACE than controls (24.3 vs 16.0/1000 person-years (PY); difference=8.3/1000 PY; aHR 1.63, 95% CI 1.56 to 1.70), including higher rates of IHD (difference=4.2/1000 PY; aHR 1.64, 95% CI 1.54 to 1.75), CHF (difference=3.3/1000 PY; aHR 1.75, 95% CI 1.63 to 1.87), stroke (difference=2.4/1000 PY; aHR 1.58, 95% CI 1.46 to 1.71) and CV mortality (difference=1.2/1000 PY; aHR 1.37, 95% CI 1.27 to 1.48). Rates of incident MACE increased progressively with worsening NAFLD severity (ptrend=0.02), with the highest incidence observed with cirrhosis (difference vs controls=27.2/1000 PY; aHR 2.15, 95% CI 1.77 to 2.61).

CONCLUSION

Compared with matched population controls, patients with biopsy-proven NAFLD had significantly higher incidence of MACE, including IHD, stroke, CHF and CV mortality. Excess risk was evident across all stages of NAFLD and increased with worsening disease severity.

A Meta-Analysis of Sleep Disorders and Nonalcoholic Fatty Liver Disease: Potential Causality and Symptom Management

Nonalcoholic fatty liver disease is a type of metabolic disease, and recent research indicates that it may be associated with sleep disorders. We conducted a meta-analysis of current studies to estimate the associations between nonalcoholic fatty liver disease and sleep situation, including sleep duration, daytime sleepiness, and sleep disorder. This study follows the checklist of the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA). Articles in the recent 10 years were searched from five databases. Eighteen articles, which met the eligibility criteria, were included in this meta-analysis. The results show that patients with nonalcoholic fatty liver disease have a shorter sleep duration and higher Epworth Sleepiness Scale score. Patients with short sleep duration (≤6 hours per night) or with obstructive sleep apnea have a higher risk of nonalcoholic fatty liver disease. In conclusion, there is a significant association between nonalcoholic fatty liver disease and sleep disorders in the included studies. In addition, patients with nonalcoholic fatty liver disease may have more severe daytime sleepiness and shorter sleep duration. More attention should be paid to the sleep situation of nonalcoholic fatty liver disease patients to potentially slow the disease progression.

Implications of the heterogeneity between guideline recommendations for the use of low dose aspirin in primary prevention of cardiovascular disease

The most recent primary cardiovascular disease (CVD) prevention clinical guidelines used in Europe, Italy, the USA, China, and South Korea differ in aspects of their approach to CVD risk assessment and reduction. Low dose aspirin use is recommended in certain high-risk patients by most but not all the countries. Assessment of traditional risk factors and which prediction models are commonly used differ between countries. The assessments and tools may not, however, identify all patients at high risk but without manifest CVD. The use of coronary artery calcium (CAC) score to guide decisions regarding primary prevention aspirin therapy is recommended only by the US primary prevention guidelines and the 2021 European Society of Cardiology guidelines. A more consistent and comprehensive global approach to CVD risk estimation in individual patients could help to personalize primary CVD prevention. Wider detection of subclinical atherosclerosis, together with structured assessment and effective mitigation of bleeding risk, may appropriately target patients likely to gain net benefit from low dose aspirin therapy.

Recent advances in lean NAFLD

As the predominant type of chronic liver disease, the growing prevalence of nonalcoholic fatty liver disease (NAFLD) has become a concern worldwide. Although obesity plays the most pivotal role in NAFLD, approximately 10-20% of individuals with NAFLD who are not overweight or obese (BMI < 25 kg/m2, or BMI < 23 kg/m2 in Asians) have "lean NAFLD." Lean individuals with NAFLD have a lower prevalence of diabetes, hypertension, hypertriglyceridemia, central obesity, and metabolic syndrome than nonlean individuals with NAFLD, but higher fibrosis scores and rates of cardiovascular morbidity and all-cause mortality in advanced stages. The pathophysiological mechanisms of lean NAFLD remain poorly understood. Studies have shown that lean NAFLD is more correlated with factors such as environmental, genetic susceptibility, and epigenetic regulation. This review will examine the way in which the research progress and characteristic of lean NAFLD, and explore the function of epigenetic modification to provide the basis for the clinical treatment and diagnosis of lean NAFLD.

Nonalcoholic Fatty Liver Disease: Review of Management for Primary Care Providers

Nonalcoholic fatty liver disease (NAFLD) is one of the most common causes of chronic liver disease in the United States and worldwide. The progressive form of NAFLD, nonalcoholic steatohepatitis (NASH), is a leading indication for liver transplant. Comorbidities associated with NAFLD development and NASH include type 2 diabetes, obesity, metabolic syndrome, and dyslipidemia. Extrahepatic morbidity and mortality are considerable as NAFLD is associated with an increased risk of cardiovascular disease and chronic kidney disease. Once NAFLD is diagnosed, the presence of liver fibrosis is the central determinant of hepatic prognosis. Severe liver fibrosis requires aggressive clinical management. No pharmacologic agents have regulatory approval in the United States for the treatment of NAFLD or NASH. Management is centered on efforts to reduce underlying obesity (lifestyle, medications, surgical or endoscopic interventions) and metabolic derangements (prediabetes, type 2 diabetes, hypertension, hyperlipidemia, and others). Current pharmacologic therapy for NAFLD is limited mainly to the use of vitamin E and pioglitazone, although other agents are being investigated in clinical trials. Cardiovascular and metabolic risk factors must also be assessed and managed. Here, NAFLD evaluation, diagnosis, and management are considered in the primary care setting and endocrinology clinics.

Psoriasis and Cardiometabolic Diseases: Shared Genetic and Molecular Pathways

A convincing deal of evidence supports the fact that severe psoriasis is associated with cardiovascular diseases. However, the precise underlying mechanisms linking psoriasis and cardiovascular diseases are not well defined. Psoriasis shares common pathophysiologic mechanisms with atherosclerosis and cardiovascular (CV) risk factors. In particular, polymorphism in the IL-23R and IL-23 genes, as well as other genes involved in lipid and fatty-acid metabolism, renin-angiotensin system and endothelial function, have been described in patients with psoriasis and with cardiovascular risk factors. Moreover, systemic inflammation in patients with psoriasis, including elevated serum proinflammatory cytokines (e.g., TNF-α, IL-17, and IL-23) may contribute to an increased risk of atherosclerosis, hypertension, alteration of serum lipid composition, and insulin resistance. The nonlinear and intricate interplay among various factors, impacting the molecular pathways in different cell types, probably contributes to the development of psoriasis and cardiovascular disease (CVD). Future research should, therefore, aim to fully unravel shared and differential molecular pathways underpinning the association between psoriasis and CVD.

Endothelial Cell Dysfunction and Nonalcoholic Fatty Liver Disease (NAFLD): A Concise Review

Nonalcoholic fatty liver disease (NAFLD) is one of the most common liver diseases worldwide. It is strongly associated with obesity, type 2 diabetes (T2DM), and other metabolic syndrome features. Reflecting the underlying pathogenesis and the cardiometabolic disorders associated with NAFLD, the term metabolic (dysfunction)-associated fatty liver disease (MAFLD) has recently been proposed. Indeed, over the past few years, growing evidence supports a strong correlation between NAFLD and increased cardiovascular disease (CVD) risk, independent of the presence of diabetes, hypertension, and obesity. This implies that NAFLD may also be directly involved in the pathogenesis of CVD. Notably, liver sinusoidal endothelial cell (LSEC) dysfunction appears to be implicated in the progression of NAFLD via numerous mechanisms, including the regulation of the inflammatory process, hepatic stellate activation, augmented vascular resistance, and the distortion of microcirculation, resulting in the progression of NAFLD. Vice versa, the liver secretes inflammatory molecules that are considered pro-atherogenic and may contribute to vascular endothelial dysfunction, resulting in atherosclerosis and CVD. In this review, we provide current evidence supporting the role of endothelial cell dysfunction in the pathogenesis of NAFLD and NAFLD-associated atherosclerosis. Endothelial cells could thus represent a "golden target" for the development of new treatment strategies for NAFLD and its comorbid CVD.

Untargeted metabolomics reveals the role of AQP9 in nonalcoholic fatty liver disease in a mice model

Previous studies have shown that AQP9 plays an important role in energy metabolism in nonalcoholic fatty liver disease (NAFLD). Recently, metabolomic analyses were used to determine the slight changes in metabolic profiles and helped to understand the disease progression, therapeutic intervention of NAFLD. A mouse model of NAFLD was established with a high-fat diet (HFD), and Aqp9 knockout mice were constructed. Untargeted metabolomics techniques were used to evaluate the potential mechanism of the effect of AQP9 in NAFLD. The results indicated that AQP9 plays a regulatory role in the occurrence of NAFLD. Moreover, a total of 220 candidate biomarkers were screened and identified. Cluster analysis and enrichment analysis of differential metabolites indicated that fatty acid biosynthesis was mainly disturbed when compared against the control group, which was mitigated by knockout of Aqp9. These results show that untargeted metabolomics help to understand the effects of AQP9 in NAFLD.

New Insights into Non-Alcoholic Fatty Liver Disease and Coronary Artery Disease: The Liver-Heart Axis

Non-alcoholic fatty liver disease (NAFLD) represents the hepatic expression of the metabolic syndrome and is the most prevalent liver disease. NAFLD is associated with liver-related and extrahepatic morbi-mortality. Among extrahepatic complications, cardiovascular disease (CVD) is the primary cause of mortality in patients with NAFLD. The most frequent clinical expression of CVD is the coronary artery disease (CAD). Epidemiological data support a link between CAD and NAFLD, underlain by pathogenic factors, such as the exacerbation of insulin resistance, genetic phenotype, oxidative stress, atherogenic dyslipidemia, pro-inflammatory mediators, and gut microbiota. A thorough assessment of cardiovascular risk and identification of all forms of CVD, especially CAD, are needed in all patients with NAFLD regardless of their metabolic status. Therefore, this narrative review aims to examine the available data on CAD seen in patients with NAFLD, to outline the main directions undertaken by the CVD risk assessment and the multiple putative underlying mechanisms implicated in the relationship between CAD and NAFLD, and to raise awareness about this underestimated association between two major, frequent and severe diseases.

Elastographic parameters of liver steatosis and fibrosis predict independently the risk of incident chronic kidney disease and acute myocardial infarction in patients with type 2 diabetes mellitus

AIMS

The aim of this prospective study was to examine the relationship between controlled attenuation parameter (CAP) and liver stiffness measurements (LSM) with the risk of developing a composite endpoint inclusive of incident acute myocardial infarction (AMI), cerebrovascular insult (CVI) or chronic kidney disease (CKD) in people with type 2 diabetes mellitus (T2DM).

METHODS

This study included 238 T2DM outpatients without chronic liver diseases.

RESULTS

The patient population was followed for a median period of 7.6 years. Kaplan-Meier survival analyses showed that there was a higher proportion of patients who developed the aforementioned composite outcome (P < 0.001 by the log-rank test), as well as CKD (P < 0.001) or AMI alone (P = 0.014) among those with elevated CAP values (≥238 dB/m) at baseline. Similarly, Kaplan-Meier survival analyses showed that there was a higher proportion of patients who developed the composite outcome (P < 0.001), as well as CKD (P < 0.001), or AMI alone (P < 0.001) among those with elevated LSM values (≥7.0/6.2 kPa). In multivariable regression analyses, the presence of elevated CAP (adjusted-hazard ratio 2.34, 95% CI 1.32-4.15) and elevated LSM (adjusted-hazard ratio 2.84, 95% CI 1.92-4.21), independently of each other, were associated with a higher risk of developing the composite outcome, as well as incident AMI or CKD alone after adjusting for traditional cardiovascular risk factors and diabetes-related variables.

CONCLUSIONS

Our study shows that the elastographic parameters of liver steatosis and fibrosis independently predict the long-term risk of developing chronic vascular complications in T2DM patients.

Changing clinical management of NAFLD in Asia

Non-alcoholic fatty liver disease (NAFLD) has become the leading cause of chronic liver disease, affecting approximately 25% of the world's population. Recently, because of the sedentary lifestyle and overnutrition resulting from urbanisation, the burden of NAFLD has rapidly increased in many Asian countries. Currently, the prevalence of NAFLD in Asia is approximately 30%, as is the case in many Western countries. In Asia, the prevalence and presentation of NAFLD vary widely across regions because of the substantial diversity in race, socioeconomic status and living environment. Furthermore, the dual aetiology of fatty liver, particularly with viral hepatitis in Asia, makes it complex and challenging to manage. Because Asians are likely to have central adiposity and insulin resistance, approximately 7%-20% of non-obese Asians with body mass indexes of less than 25 kg/m² are estimated to have NAFLD. Accumulating evidence indicates that NAFLD is associated with various extrahepatic comorbidities such as cardiovascular disease, chronic kidney disease, malignancy, in addition to liver-specific complications. Therefore, NAFLD should be managed as a multisystem disease in conjunction with metabolic syndrome. Lifestyle modification remains the basis of NAFLD management, but few patients can achieve adequate weight loss and maintain it long term. While various pharmacological agents are in phase 3 trials for steatohepatitis, Asian patients are underrepresented in most trials. This article reviews the epidemiological trends, clinical features, optimal assessment and current management practices for NAFLD in Asia.

Gut microbiome is associated with metabolic syndrome accompanied by elevated gamma-glutamyl transpeptidase in men

It is predicted that by 2035, metabolic syndrome (MS) will be found in nearly more than half of our adult population, seriously affecting the health of our body. MS is usually accompanied by the occurrence of abnormal liver enzymes, such as elevated gamma-glutamyl transpeptidase (GGT). More and more studies have shown that the gut microbiota is involved in MS; however, the correlation between gut microbiota and MS with elevated GGT has not been studied comprehensively. Especially, there are few reports about its role in the physical examination of the population of men with MS and elevated GGT. By using the whole-genome shotgun sequencing technology, we conducted a genome-wide association study of the gut microbiome in 66 participants diagnosed as having MS accompanied by high levels of GGT (case group) and 66 participants with only MS and normal GGT level (control group). We found that the number of gut microbial species was reduced in participants in the case group compared to that of the control group. The overall microbial composition between the two groups is of significant difference. The gut microbiota in the case group is characterized by increased levels of "harmful bacteria" such as Megamonas hypermegale, Megamonas funiformis, Megamonas unclassified, Klebsiella pneumoniae, and Fusobacterium mortiferum and decreased levels of "beneficial bacteria" such as Faecalibacterium prausnitzii, Eubacterium eligens, Bifidobacterium longum, Bifidobacterium pseudocatenulatum, Bacteroides dorei, and Alistipes putredinis. Moreover, the pathways of POLYAMSYN-PWY, ARG+POLYAMINE-SYN, PWY-6305, and GOLPDLCAT-PWY were also increased in the case group, which may play a role in the elevation of GGT by producing amine, polyamine, putrescine, and endogenous alcohol. Taken together, there are apparent changes in the composition of the gut microbiome in men with MS and abnormal GGT levels, and it is high time to discover specific gut microbiome as a potential therapeutic target in that population. More in-depth studies of relevant mechanism could offer some new methods for the treatment of MS with elevated GGT.

Therapeutic effects of isosteviol sodium on non-alcoholic fatty liver disease by regulating autophagy via Sirt1/AMPK pathway

Isosteviol sodium (STVNa) is a beyerane diterpene synthesized via acid hydrolysis of stevioside, which can improve glucose and lipid metabolism in animals with diabetes. However, it remains unknown whether STVNa can exhibit a therapeutic effect on nonalcoholic fatty liver disease (NAFLD) and its underlying mechanism. We hypothesize that autophagic initiation may play a key role in mediating the development of NAFLD. Herein, we assessed the effects of STVNa on NAFLD and its underlying mechanisms. The results demonstrated that STVNa treatment effectively ameliorated NAFLD in rats fed high-fat diet (HFD). Moreover, STVNa decreased the expression of inflammation-related genes and maintained a balance of pro-inflammatory cytokines in NAFLD rats. STVNa also reduced lipid accumulation in free fatty acid (FFA)-exposed LO2 cells. In addition, STVNa attenuated hepatic oxidative stress and fibrosis in NAFLD rats. Furthermore, STVNa enhanced autophagy and activated Sirtuin 1/adenosine monophosphate-activated protein kinase (Sirt1/AMPK) pathway both in vivo and in vitro, thus attenuating intracellular lipid accumulation. In summary, STVNa could improve lipid metabolism in NAFLD by initiating autophagy via Sirt1/AMPK pathway. Therefore, STVNa may be an alternative therapeutic agent for treatment of NAFLD.

Non-alcoholic fatty liver disease and risk of new-onset heart failure: an updated meta-analysis of about 11 million individuals

OBJECTIVE

Recent studies reported an association between non-alcoholic fatty liver disease (NAFLD) and increased risk of new-onset heart failure (HF). However, the magnitude of the risk and whether this risk changes with severity of liver disease remains uncertain. We performed a meta-analysis of observational studies to quantify the magnitude of the association between NAFLD and risk of new-onset HF.

DESIGN

We systematically searched Scopus, Web of Science and PubMed from database inception to March 2022 to identify eligible observational studies, in which NAFLD was diagnosed by serum biomarkers/scores, International Classification of Diseases (ICD) codes, imaging techniques or liver histology. The primary outcome was new-onset HF, as assessed mainly by ICD codes. Data from selected studies were extracted, and meta-analysis was performed using random-effects models to obtain summary hazard ratios (HRs) with 95% CIs.

RESULTS

We identified 11 longitudinal cohort studies with aggregate data on 11 242 231 middle-aged individuals from different countries and 97 716 cases of incident HF over a median of 10 years. NAFLD was associated with a moderately higher risk of new-onset HF (pooled random-effects hazard ratio 1.50, 95% CI 1.34 to 1.67, p<0.0001; I 2=94.8%). This risk was independent of age, sex, ethnicity, adiposity measures, diabetes, hypertension and other common cardiovascular risk factors. Sensitivity analyses did not change these results. The funnel plot did not show any significant publication bias.

CONCLUSION

NAFLD is associated with a 1.5-fold higher long-term risk of new-onset HF, regardless of the presence of diabetes, hypertension and other common cardiovascular risk factors. However, the observational design of the studies does not allow for proving causality.

Semaglutide might be a key for breaking the vicious cycle of metabolically associated fatty liver disease spectrum?

Metabolically associated fatty liver disease (MAFLD) is a liver manifestation of metabolic syndrome potentially related to unfavorable hepatic and extrahepatic outcomes and progression to cirrhosis. Up to date, there are no approved pharmacotherapies for the treatment of MAFLD, so management focused on lifestyle interventions to encourage weight loss, and treatment of coexisting conditions is the only available option. Unfortunately, the aforementioned is often not potent enough to offer reversal or slow down hepatic inflammation and fibrosis. Glucagon-like peptide-1 receptor agonists have a favorable effect on glycemic management and weight loss of patients with type 2 diabetes mellitus and recently published data suggest their potential in MAFLD treatment. In addition, some of the agents have proven cardiovascular and renal benefits in dedicated cardiovascular outcome trials, making them an interesting therapeutic option. In this opinion review, we discuss the role of semaglutide in MAFLD.

Advance of Serum Biomarkers and Combined Diagnostic Panels in Nonalcoholic Fatty Liver Disease

Nonalcoholic fatty liver disease (NAFLD) affects approximately 25-30% population worldwide, which progresses from simple steatosis to nonalcoholic steatohepatitis (NASH), fibrosis, cirrhosis, and hepatocellular carcinoma, and has complications such as cardiovascular events. Liver biopsy is still the gold standard for the diagnosis of NAFLD, with some limitations, such as invasive, sampling deviation, and empirical judgment. Therefore, it is urgent to develop noninvasive diagnostic biomarkers. Currently, a large number of NAFLD-related serum biomarkers have been identified, including apoptosis, inflammation, fibrosis, adipokines, hepatokines, and omics biomarkers, which could effectively diagnose NASH and exclude patients with progressive fibrosis. We summarized serum biomarkers and combined diagnostic panels of NAFLD, to provide some guidance for the noninvasive diagnosis and further clinical studies.

Remnant Cholesterol Predicts Long-term Mortality of Patients With Metabolic Dysfunction-associated Fatty Liver Disease

CONTEXT

Elevated serum remnant cholesterol independently predicts risks of cardiovascular diseases. However, the association between remnant cholesterol and metabolic dysfunction-associated fatty liver disease (MAFLD) remains unclear.

OBJECTIVE

This study aimed to explore the association of remnant cholesterol with MAFLD and its long-term mortality.

METHODS

We extracted data from the NHANES III, 1988 to1994 and the linked mortality data until December 31, 2015. The association between remnant cholesterol and MAFLD was analyzed by multivariable logistic regression. Cox proportional hazards regression was performed to assess whether elevated remnant cholesterol increased all-cause and cause-specific mortalities in MAFLD patients.

RESULTS

At baseline, 28.6% (1474/5156) of participants had MAFLD. In multivariable logistic regression, the fourth quartile of remnant cholesterol was associated with an increased risk of MAFLD compared with the first quartile (odds ratio [OR]: 1.714; 95% CI, 1.586-1.971; P < .001). In participants with normal levels of triglycerides, low-density lipoprotein and high-density lipoprotein cholesterol, the relationship between remnant cholesterol and MAFLD risk remained significant (OR: 1.346; 95% CI, 1.248-1.761; P < .001). During a median follow-up of 307 months, MAFLD patients with serum remnant cholesterol in the fourth quartile were associated with a higher risk of all-cause mortality (hazard ratio [HR]: 2.183; 95% CI, 1.825-2.407; P < .001), as well as a higher risk of cardiovascular mortality (HR: 2.346; 95% CI, 2.046-2.885; P < .001) and cancer-related mortality (HR: 2.366; 95% CI, 1.864-2.932; P < .001) compared with MAFLD patients in the first quartile.

CONCLUSION

Remnant cholesterol was independently associated with the risk of MAFLD and predicted all-cause, cardiovascular, and cancer-related mortalities in MAFLD patients.