Sarcopenia is associated with significant liver fibrosis independently of obesity and insulin resistance in nonalcoholic fatty liver disease: Nationwide surveys (KNHANES 2008-2011)

Impact of physical activities in metabolic dysfunction associated steatotic liver disease, sarcopenia, and cardiovascular disease

BACKGROUND AND AIMS

There are no comprehensive studies that investigated differential effects of physical activity (PA) types on metabolic dysfunction associated steatotic liver disease (MASLD) and their associations with sarcopenia and cardiovascular disease.

METHODS

A cross-sectional analysis using data from 66,021 participants from the Korean National Health and Nutrition Examination Surveys 2007-2020. Aerobic PA (A-PA) was defined as ≥ moderate-intensity 150 min/week or high-intensity 75 min/week; Muscle strengthening PA (MS-PA) was defined as ≥ 2 days/week of muscle strength training. Multicomponent PA included A-PA and MS-PA. The atherosclerotic cardiovascular disease (ASCVD) risk was determined by the pooled ASCVD risk score.

RESULTS

The prevalence of MASLD was lower in all PA groups compared to physically inactive individuals. Among individuals with MASLD, multicomponent PA was associated with a lower ASCVD risk, compared with other groups (OR = 0.74, 95 % CI = 0.73-0.75 for A-PA; OR = 0.70, 95 % CI = 0.68-0.64 for MS-PA; OR = 0.62, 95 % CI = 0.61-0.64 for multicomponent PA). Sarcopenia risk was decreased among physically active individuals with MASLD (OR = 0.77, 95 % CI, 0.76-0.77 for A-PA; OR = 0.97, 95 % CI = 0.96-0.98 for MS-PA; OR = 0.57, 95 % CI = 0.57-0.58 for multicomponent PA).

CONCLUSIONS

Regardless of types of exercise, physically active individuals had lower risks of MASLD, sarcopenia, and ASCVD.

Metabolic dysfunction-associated steatotic liver disease: A story of muscle and mass

Skeletal muscle alterations (SMA) are increasingly recognized as both contributors and consequences of metabolic dysfunction-associated steatotic liver disease (MASLD), affecting disease progression and outcomes. Sarcopenia is common in patients with MASLD, with a prevalence ranging from 20% to 40% depending on the population and diagnostic criteria used. In advanced stages, such as metabolic dysfunction-associated steatohepatitis and fibrosis, its prevalence is even higher. Sarcopenia exacerbates insulin resistance, systemic inflammation, and oxidative stress, all of which worsen MASLD. It is an independent risk factor for fibrosis progression and poor outcomes including mortality. Myosteatosis refers to the abnormal accumulation of fat within muscle tissue, leading to decreased muscle quality. Myosteatosis is prevalent (> 30%) in patients with MASLD, especially those with obesity or type 2 diabetes, although this can vary with the imaging techniques used. It reduces muscle strength and metabolic efficiency, further contributing to insulin resistance and is usually associated with advanced liver disease, cardiovascular complications, and lower levels of physical activity. Altered muscle metabolism, which includes mitochondrial dysfunction and impaired amino acid metabolism, has been reported in metabolic syndromes, including MASLD, although its actual prevalence is unknown. Altered muscle metabolism limits glucose uptake and oxidation, worsening hyperglycemia and lipotoxicity. Reduced muscle perfusion and oxygenation due to endothelial dysfunction and systemic metabolic alterations are common in MASLD associated with comorbidities, such as obesity, hypertension, and atherosclerosis. It decreases the muscle capacity for aerobic metabolism, leading to fatigue and reduced physical activity in patients with MASLD, aggravating metabolic dysfunction. Various SMA in MASLD worsen insulin resistance and hepatic fat accumulation, may accelerate progression to fibrosis and cirrhosis, and increase the risk of cardiovascular disease and mortality. Management strategies for SMA include resistance training, aerobic exercise, and nutritional support (e.g., high-protein diets, vitamin D, and omega-3 fatty acids), which are essential for mitigating skeletal muscle loss and improving outcomes. However, pharmacological agents that target the muscle and liver (such as glucagon-like peptide-1 receptor agonists) show promise but have not yet been approved for the treatment of MASLD.

Unraveling the Metabolic Pathways Between Metabolic-Associated Fatty Liver Disease (MAFLD) and Sarcopenia

Metabolic-Associated Fatty Liver Disease (MAFLD) is a public health concern that is constantly expanding, with a fast-growing prevalence, and it affects about a quarter of the world's population. This condition is a significant risk factor for cardiovascular, hepatic, and oncologic diseases, such as hypertension, hepatoma, and atherosclerosis. Sarcopenia was long considered to be an aging-related syndrome, but today, it is acknowledged to be secondarily related to chronic diseases such as metabolic syndrome, cardiovascular conditions, and liver diseases, among other comorbidities associated with insulin resistance and chronic inflammation, besides inactivity and poor nutrition. The physiopathology involving MAFLD and sarcopenia has still not been solved. Inflammation, oxidative stress, mitochondrial dysfunction, and insulin resistance seem to be some of the keys to this relationship since this hormone target is mainly the skeletal muscle. This review aimed to comprehensively discuss the main metabolic and physiological pathways involved in these conditions. MAFLD and sarcopenia are interconnected by a complex network of pathophysiological mechanisms, such as insulin resistance, skeletal muscle tissue production capacity, chronic inflammatory state, oxidative stress, and mitochondrial dysfunction, which are the main contributors to this relationship. In addition, in a clinical analysis, patients with sarcopenia and MAFLD manifest more severe hepatitis fibrosis when compared to patients with only MAFLD. These patients, with both disorders, also present clinical improvement in their MAFLD when treated for sarcopenia, reinforcing the association between them. Lifestyle changes accompanied by non-pharmacological interventions, such as dietary therapy and increased physical activity, undoubtedly improve this scenario.

The Molecular Pathogenesis of Sarcopenia/Frailty in Cirrhosis

Cirrhosis is an important cause of morbidity and death in patients with chronic liver disease. It can be divided into compensatory and decompensated stages. During the decompensation period, complications such as esophageal and gastric varices hemorrhage, hepatic encephalopathy, infection, and hepatorenal syndrome are often incurred, which has a high mortality rate and leverages huge economic burden on society, healthcare resources, and individuals. Sarcopenia and frailty are common in patients with cirrhosis. The pathogenesis of sarcopenia and frailty in the context of cirrhosis is complicated and multifactorial, including overwhelming systemic inflammation, imbalance of muscle protein metabolism, malnutrition, endocrine and metabolic dysfunctions, intestinal microecological disorders, lack of physical exercise, and other aspects. Notably, accumulating evidence implicates that many patients experience sarcopenia/frailty even before the onset of liver cirrhosis. In this regard, the magnitude of liver fibrosis is closely linked to the progression of sarcopenia with reciprocal impact. In conclusion, this review article will shed light on the pathogenesis of cirrhosis complicated with sarcopenia/frailty, aimed at facilitating early diagnosis and effective management.

Type 2 Diabetes Mellitus Is a Risk Factor for Skeletal Muscle Loss in the Course of Dietary Treatment for Patients with Metabolic Dysfunction-associated Steatotic Liver Disease

Objective This study assessed the impact of dietary therapy and reduced body weight on the loss of skeletal muscle in patients with metabolic dysfunction-associated steatotic liver disease (MASLD). Methods This was a single-center retrospective observational study. We enrolled 129 patients with MASLD who had undergone dietary therapy at our facility. We assessed skeletal muscle mass using a bioelectrical impedance analysis at the start of dietary treatment and 12 months after the first assessment. Variables related to muscle reduction were analyzed using a logistic regression model. Results One hundred and eighteen cases were analyzed, excluding those with missing data. In the muscle reduction group, there were more subjects with body weight reduction than in the control group (68% and 40%, respectively, p=0.002), and their body mass index (BMI) was decreased (-0.7 kg/m2 and +0.3 kg/m2, respectively, p=0.0003). There was a significant correlation between the changes in the BMI and muscle mass (R=0.48, p<0.0001). We standardized muscle mass change by dividing it by weight change to analyze the severe decrease in muscle mass compared to weight change. A logistic regression analysis revealed that type 2 diabetes mellitus (T2DM) was an independent variable related to severe skeletal muscle loss (odds ratio, 2.69; 95% CI: 1.13-6.42, p=0.03). Conclusion Weight loss is associated with skeletal muscle loss during dietary treatment for MASLD. T2DM is a risk factor for severe skeletal muscle loss.

Clinical Relevancies of Sarcopenic Obesity in Patients with Metabolic Dysfunction-Associated Fatty Liver Disease (MASLD)

AIM

Sarcopenic obesity (SO) is associated with adverse outcomes in diseased patients. This study aimed to examine the prevalence and risks associated with SO, with a focus on the impact of SO on cardiovascular risk in patients with MASLD.

MATERIALS AND METHODS

In this cross-sectional study, patients with MASLD were prospectively enrolled. Through dual-energy X-ray absorptiometry (DXA) scans, their body compositions were analyzed to identify who had SO and osteopenia/osteoporosis. The primary aim is to investigate risks associated with SO, followed by analyzing the association between SO and cardiovascular disease (CVD).

RESULTS

Two hundred and twenty-three patients with MASLD were enrolled. The prevalence of SO was 47.1%, respectively. Patients coexisted with MASLD and SO had increased visceral adipose tissue (VAT), higher fatty liver index (FLI) and fibrosis 4 (FIB-4) score. Regression analysis revealed higher FLI and FIB-4 score, as well as history of hypertension, were risks associated with SO. The 10-year atherosclerotic cardiovascular disease (ASCVD) risk score was higher in patients coexisted with MASLD and SO compared to those without (10.1% vs. 7.3%, p = 0.006). Regression analysis showed that increased VAT and FIB-4 score were associated with raised risk of ASCVD.

CONCLUSION

Prevalence of SO in MASLD patients is considerable. The presence of SO also linked to higher risk of ASCVD. Therefore, the recognition of SO in patients with MASLD is important in clinical care.

Assessment of skeletal muscle alterations and circulating myokines in metabolic dysfunction-associated steatotic liver disease: A cross-sectional study

BACKGROUND

Skeletal muscle alterations (SMAs) are being increasingly recognized in patients with metabolic dysfunction-associated steatotic liver disease (MASLD) and appear to be associated with deleterious outcomes in these patients. However, their actual prevalence and pathophysiology remain to be elucidated.

AIM

To determine the prevalence of SMAs and to assess the significance of circulating myokines as biomarkers in patients with MASLD.

METHODS

Skeletal muscle strength and muscle mass were measured in a cross-sectional study in a cohort of 62 patients fulfilling MASLD criteria, recruited from the outpatient clinics of a tertiary level hospital. The degree of fibrosis and liver steatosis was studied using abdominal ultrasound and transitional elastography. Anthropometric and metabolic characteristics as well as serum levels of different myokines were also determined in the MASLD cohort. Statistical analysis was performed comparing results according to liver fibrosis and steatosis.

RESULTS

No significant differences were found in both skeletal muscle strength and skeletal muscle mass in patients with MASLD between different stages of liver fibrosis. Interestingly, serum levels of fibroblast growth factor-21 (FGF21) were significantly higher in patients with MASLD with advanced hepatic fibrosis (F3-F4) than in those with lower fibrosis stages (F0-F2) (197.49 ± 198.27 pg/mL vs 95.62 ± 83.67 pg/mL; P = 0.049). In addition, patients with MASLD with severe hepatosteatosis (S3) exhibited significantly higher serum levels of irisin (1116.87 ± 1161.86 pg/mL) than those with lower grades (S1-S2) (385.21 ± 375.98 pg/mL; P = 0.001).

CONCLUSION

SMAs were uncommon in the patients with MASLD studied. Higher serum levels of irisin and FGF21 were detected in patients with advanced liver steatosis and fibrosis, respectively, with potential implications as biomarkers.

Impact of segmental body composition on metabolic dysfunction-associated fatty liver disease in Chinese children

Purpose

This study aimed to assess the relationship between regional body composition and metabolic dysfunction-associated fatty liver disease (MAFLD) in Chinese children.

Methods

In this study, 1399 children aged 7-14 years were included. Liver steatosis was assessed using the controlled attenuation parameter (CAP) measured through Fibroscan. MAFLD is defined as the presence of liver steatosis along with either overweight/obesity, prediabetes/diabetes, or at least two metabolic index abnormalities. Regression analyses were applied to assess the relationship between regional body composition and MAFLD in children. Subgroup analyses were performed based on sex and weight.

Results

The participants had a mean age of 9 years, with 52.11% being boys. Among them, 134 (9.57%) were diagnosed with MAFLD, and 17 (1.22%) had severe fatty liver disease. We found an inverse correlation between the muscle percentage in each region and MAFLD, with the extremities demonstrating the most significant negative correlation (OR: 0.732; 95% CI: 0.634-0.844). Conversely, regional fat was positively associated with MAFLD, with the strongest correlation found in the upper limbs (OR: 3.104; 95% CI: 2.023-4.764). Subgroup analyses showed similar results.

Conclusion

The decrease in regional muscle percentage, particularly in the limbs, along with the increase in regional fat percentage, especially in the upper limbs, is associated with a higher probability of developing MAFLD in prepubertal children. Additional prospective studies are needed to strengthen and validate these findings.

Impact of steatotic liver disease subtypes, sarcopenia, and fibrosis on all-cause and cause-specific mortality: a 15.7-year cohort study

BACKGROUND

Steatotic liver disease (SLD) was a newly proposed disease category derived from metabolic dysfunction-associated fatty liver disease (MAFLD). MAFLD and sarcopenia were independent risk factors for mortality. We aimed to evaluate the impacts of SLD subtypes, MAFLD, and sarcopenia on mortality.

METHODS

A total of 6543 subjects were identified from the National Health and Nutrition Examination Survey 1999-2006 with the latest Linked Mortality file. Hepatic steatosis, advanced fibrosis, and sarcopenia were determined by the laboratory- and anthropometry- based fatty liver index and fibrosis-4 index, and dual-energy X-ray absorptiometry-based appendicular skeletal muscle mass index, respectively. Associations of SLD subtypes, MAFLD, and sarcopenia with mortality were estimated using the weighted Cox proportional hazards model.

RESULTS

During a mean follow-up time of 15.7 years, 1567 (16.7%) deaths occurred including 494 (4.9%) deaths from cardiovascular diseases and 372 (4.1%) from cancer. The all-cause mortality rates of MAFLD, metabolic dysfunction-associated steatotic liver disease (MASLD), metabolic dysfunction and alcohol-associated liver disease (MetALD), other aetiology SLD, MASLD without sarcopenia, and MASLD with sarcopenia were 21.0%, 19.8%, 30.2%, 30.9%, 19.2%, and 75.5%, respectively. MAFLD increased the risk of all-cause mortality (hazard ratio [HR] 1.26, 95% confidence interval [CI] 1.00-1.59). MASLD predicted all-cause mortality (HR 1.17, 95% CI 1.03-1.33) but this prediction became insignificant after adjustment for metabolic risks. In contrast, MetALD and other aetiology SLD were significantly associated with all-cause mortality (HR 1.83, 95% CI 1.21-2.76; HR 2.50, 95% CI 1.82-3.44, respectively), predominantly associated with cancer-specific mortality (HR 2.42, 95% CI 1.23-4.74; HR 2.49, 95% CI 1.05-5.90, respectively). MASLD with sarcopenia increased the risk of all-cause mortality by almost twice (HR 2.19, 95% CI 1.37-3.49) and further coexisting advanced fibrosis additively increased mortality (HR 3.41, 95% CI 1.92-6.05).

CONCLUSION

SLD definition identified a more homogeneous group with metabolically hepatic steatosis at higher risks of mortality. MASLD or MASLD-related advanced fibrosis and sarcopenia additively increased mortality.

A Novel Point-of-Care Prediction Model for Steatotic Liver Disease: Expected Role of Mass Screening in the Global Obesity Crisis

Background/Aims

The incidence of steatotic liver disease (SLD) is increasing across all age groups as the incidence of obesity increases worldwide. The existing noninvasive prediction models for SLD require laboratory tests or imaging and perform poorly in the early diagnosis of infrequently screened populations such as young adults and individuals with healthcare disparities. We developed a machine learning-based point-of-care prediction model for SLD that is readily available to the broader population with the aim of facilitating early detection and timely intervention and ultimately reducing the burden of SLD.

Methods

We retrospectively analyzed the clinical data of 28,506 adults who had routine health check-ups in South Korea from January to December 2022. A total of 229,162 individuals were included in the external validation study. Data were analyzed and predictions were made using a logistic regression model with machine learning algorithms.

Results

A total of 20,094 individuals were categorized into SLD and non-SLD groups on the basis of the presence of fatty liver disease. We developed three prediction models: SLD model 1, which included age and body mass index (BMI); SLD model 2, which included BMI and body fat per muscle mass; and SLD model 3, which included BMI and visceral fat per muscle mass. In the derivation cohort, the area under the receiver operating characteristic curve (AUROC) was 0.817 for model 1, 0.821 for model 2, and 0.820 for model 3. In the internal validation cohort, 86.9% of individuals were correctly classified by the SLD models. The external validation study revealed an AUROC above 0.84 for all the models.

Conclusions

As our three novel SLD prediction models are cost-effective, noninvasive, and accessible, they could serve as validated clinical tools for mass screening of SLD.

Emerging Roles of High-mobility Group Box-1 in Liver Disease

High-mobility group box-1 (HMGB1) is an architectural chromosomal protein with various roles depending on its cellular localization. Extracellular HMGB1 functions as a prototypical damage-associated molecular pattern that triggers inflammation and adaptive immune responses, mediated by specific cell surface receptors, including receptors for advanced glycation end products and toll-like receptors. Post-translational modifications of HMGB1 significantly impact various cellular processes that contribute to the pathogenesis of liver diseases. Recent studies have highlighted the close relationship between HMGB1 and the pathogenesis of acute liver injuries, including acetaminophen-induced liver injury, hepatic ischemia-reperfusion injury, and acute liver failure. In chronic liver diseases, HMGB1 plays a role in nonalcoholic fatty liver disease, alcohol-associated liver disease, liver fibrosis, and hepatocellular carcinoma. Targeting HMGB1 as a therapeutic approach, either by inhibiting its release or blocking its extracellular function, is a promising strategy for treating liver diseases. This review aimed to summarize the available evidence on HMGB1's role in liver disease, focusing on its multifaceted signaling pathways, impact on disease progression, and the translation of these findings into clinical interventions.

Incidence of metabolic dysfunction-associated steatotic liver disease and advanced fibrosis and impact of overweight/obesity in elderly population: a nationwide cohort study

BACKGROUND AND AIM

The prevalence of metabolic dysfunction-associated steatotic liver disease (MASLD) is increasing worldwide, coinciding with aging population. However, limited studies have evaluated its incidence and progression to advanced fibrosis in the elderly population. Therefore, our study aimed to investigate the incidence of MASLD and advanced fibrosis in this age group.

METHODS

We included 878 686 individuals aged ≥60 years from the Korea National Health Insurance Service-Senior cohort. After excluding participants with preexisting MASLD, 329 388 individuals were finally analyzed. Participants were categorized into four groups based on the presence of overweight/obesity and additional risk factors (aRF) included in the cardiometabolic diagnostic criteria of MASLD.

RESULTS

The overall incidence of MASLD was 1.94 per 100 person-years, and the incidence of advanced fibrosis in MASLD patients was 1.78 per 100 person-years. MASLD development was significantly higher in overweight/obese patients (2.65 per 100 person-years) compared to lean patients (1.09 per 100 person-years), and this trend persisted after stratification by the presence of aRF. Similarly, the incidence of advanced fibrosis among MASLD patients was higher in overweight/obese individuals (2.06 per 100 person-years) compared to lean counterparts (0.87 per 100 person-years), irrespective of aRF.

CONCLUSIONS

The lower incidence of MASLD in the elderly population compared to the general population underscores the importance of identifying age-specific risk factors. Overweight/obesity emerged as a robust predictor of MASLD development and advanced fibrosis. Additionally, the presence of additional cardiometabolic risk factors further increased the risk of incident MASLD and advanced fibrosis among the elderly.

Association of muscle mass, grip strength and fat-to-muscle ratio and metabolic dysfunction-associated steatotic liver disease in a middle-to-elderly aged population

OBJECTIVE

The association of appendicular skeletal muscle mass (ASM), grip strength and fat-to-muscle ratio (FMR) and the progression of metabolic dysfunction-associated steatotic liver disease (MASLD) are not well known.

MATERIALS AND METHODS

This study included participants older than 40 years who underwent bioelectrical impedance assessment in Prevalence of Metabolic Diseases and Risk Factors in Shunde (SPEED-Shunde). We measured grip strength with an electronic grip strength metre. ASM and grip strength were adjusted by dividing body mass index (BMI). FMR was calculated as total fat mass to total muscle mass. Liver steatosis and liver fibrosis were evaluated by vibration-controlled transient elastography. Multifactorial logistic regression was used to analyse the relationship between ASM, grip strength, FMR, and MASLD or MASLD-associated liver fibrosis. We performed subgroup analyses according to sex, age and BMI. Interaction tests and linear trend tests were also conducted.

RESULTS

This study included a total of 3277 participants. FMR was positively associated with MASLD (OR: 1.89, 95% CI: 1.66-2.15) and MASLD-associated liver fibrosis (OR: 1.70, 95% CI: 1.22-2.37). While ASM/BMI (OR: 0.59, 95% CI: 0.52-0.67) or grip strength/BMI (OR: 0.72, 95% CI: 0.66-0.78) were negatively associated with MASLD. Interactions were observed between ASM/BMI and age, grip strength and sex in MASLD, as well as FMR and MASLD-associated liver fibrosis.

CONCLUSION

In a middle-to-elderly aged population, FMR was positively associated with the risk of MASLD and MASLD-associated liver fibrosis, and muscle mass and grip strength were negatively associated with MASLD, rather than MASLD-associated liver fibrosis.

Metabolic and hepatic phenotypes in sarcopenic obesity and impact of bariatric surgery

BACKGROUND & AIMS

Sarcopenic obesity (SO) is associated with cardiometabolic disorders and steatotic liver disease and carries major health risks. We assessed the hepatic and metabolic clinical phenotype associated with SO in patients with obesity undergoing bariatric surgery (BS). We also evaluated whether weight-loss and metabolic improvement post-surgery differ between patients with and without SO.

METHODS

972 consecutive patients from a single-center BS cohort who underwent whole-body dual-energy X-ray absorptiometry (DXA) and peri-operative liver biopsy were included. SO was diagnosed using the AIM-SO score, an AI-assisted unbiased clustering algorithm based on body composition. One-year post-surgery, 862 patients were reassessed for AIM-SO score changes.

RESULTS

Pre-operatively, 207 (21.3 %) patients were diagnosed with SO. These patients had significantly higher prevalence of type-2 diabetes (T2D), arterial hypertension and obstructive sleep apnea (OSA) compared to patients without SO (all p ≤ 0.003). Patients with SO had more severe liver damage: higher grades of moderate/advanced steatosis (64.2 % vs. 47.3 %), steatohepatitis (44.4 % vs. 32.3 %) and advanced fibrosis (12.1 % vs. 6.0 %) (all p ≤ 0.01). One-year post-BS, 58.5 % of patients had remission of SO. Patients with persistent SO exhibited less weight-loss than those with SO remission (-23.8 kg vs. -29.1 kg, p < 0.001) and had lower rates of remission for T2D (41.9 % vs. 69.8 %), arterial hypertension (20.8 % vs. 45.3 %), and metabolic syndrome (47.6 % vs. 75.0 %) (all p ≤ 0.009).

CONCLUSION

The DXA-based AIM-SO score identifies patients with SO who are at greater risk of hepatic and cardiometabolic comorbidities, and predicts less favorable weight-loss and metabolic improvements post-BS.

Relationship between sarcopenia and metabolic dysfunction-associated steatotic liver disease (MASLD): A systematic review and meta-analysis

INTRODUCTION AND OBJECTIVES

Metabolic dysfunction-associated steatotic liver disease (MASLD) formerly known as Nonalcoholic fatty liver disease (NAFLD) is a common chronic disease. Identifying MASLD risk factors could help early intervention and reduce the burden of the disease. Previous studies investigated the association between sarcopenia and NAFLD. Several trials were published after the last meta-analysis with indecisive results. This is an updated meta-analysis which aims to assess the association between sarcopenia, MASLD, and MASLD-related fibrosis.

MATERIALS AND METHODS

Relevant trials published on PubMed, Web of Science, Scopus, and Cochrane Library databases until October 2022 were included. We included studies in which skeletal mass index (SMI) or sarcopenia was compared between patients with and without NAFLD now MASLD. Also, studies comparing fibrosis between MASLD patients with and without sarcopenia were included. Data were pooled as odds ratios (ORs) and 95 % confidence intervals (CIs) using Review Manager Software.

RESULTS

A total of 25 studies were included. The incidence of sarcopenia was significantly higher in MASLD than controls (OR, 1.25; 95 % CI, 1.08-1.44; P = 0.003). SMI odds showed no significant difference between MASLD patients and controls (OR, 1.02; 95 % CI, 0.91-1.15; P = 0.7). MASLD patients with sarcopenia had higher odds of fibrosis than MASLD patients without sarcopenia (OR, 1.49; 95 % CI, 1.03-2.14; P = 0.03).

CONCLUSIONS

Sarcopenia increased MASLD's probability and was associated with a higher probability of liver fibrosis in MASLD patients. However, SMI had no predictive value of MASLD occurrence.

Clinical validation of the suppressive impact of letrozole on liver fibrosis in patients with breast cancer undergoing continuous letrozole administration: A retrospective study

Treatment strategies for preventing liver fibrosis have not yet been established. Letrozole, widely used for breast cancer, has recently been reported to suppress liver fibrosis in murine models. Therefore, we aimed to validate the suppressive effects of letrozole on liver fibrosis in the clinical setting. From 2006 to 2020, 23 consecutive patients who received continuous letrozole treatment for 24 months or more and had a liver fibrosis marker FIB-4 index of ≥ 2.30, were included. Forty-three patients who underwent anastrozole treatment for 24 months or more and had a liver fibrosis marker FIB-4 index of ≥ 2.30, were also included as controls. The Fisher exact, chi-square, unpaired Student t, and paired Student t test were used to analyze the data. The patient characteristics were similar between the letrozole- and anastrozole-treated patient groups. Among the letrozole-treated patients, the mean FIB-4 index tended to decline during letrozole treatment; a significant decrease was observed at 18 and 24 months compared with the baseline values (p = 0.044 and p = 0.013). In addition, the mean aspartate aminotransferase-to-platelet ratio index (APRI) decreased during letrozole treatment; the values at 18 and 24 months were significantly lower than those at baseline (p = 0.024 and p = 0.026). In contrast, among anastrozole-treated patients, the mean FIB-4 index and APRI did not change during anastrozole treatment. When changes in the FIB-4 index were further examined in a limited number of patients with a FIB-4 index ≥ 2.67, a significant reduction in the FIB-4 index at 24 months compared with baseline was also observed in letrozole-treated patients (p = 0.023), but not in anastrozole-treated patients. In conclusion, our findings support a possible suppressive effect of letrozole on liver fibrosis in the clinical setting. Further studies are required to better understand the pharmacological effects of letrozole.

Clinical Characteristics of Sarcopenia in Nonalcoholic Fatty Liver Disease: A Systemic Scoping Review

INTRODUCTION

This systematic scoping review aimed to synthesize existing research findings on the clinical manifestations in patients with nonalcoholic fatty liver disease (NAFLD) and sarcopenia.

METHODS

Adhering to scoping review guidelines, we comprehensively searched five databases for literature on sarcopenia's clinical manifestations in NAFLD patients from December 2013 to December 2023, meticulously compiling and synthesizing the findings.

RESULTS

A total of 312 articles were identified, with 9 studies included in the final review. Of these, 90% were cross-sectional investigations, with 70% from Asian cohorts. Comparative analysis between patients solely afflicted with NAFLD and those additionally experiencing sarcopenia revealed discernible trends. Individuals with both conditions tended to be older, have a higher body mass index, and show a higher prevalence among females, underscoring the influence of unhealthy lifestyles and obesity. Furthermore, comorbidities like metabolic syndrome, hypertension, and diabetes have been implicated in sarcopenia manifestation among NAFLD patients. Nonetheless, the lack of standardized diagnostic criteria and patterns poses an ongoing clinical challenge for this subgroup.

CONCLUSIONS

Our review highlights distinct clinical characteristics evident in NAFLD patients with sarcopenia. However, comprehensive investigations remain scarce, impeding accurate early detection and intervention. Future research should prioritize bridging these gaps and fostering enhanced clinical management strategies.

Development and external validation of a machine-learning based model to predict pre-sarcopenia in MASLD population: Results from NHANES 2017-2018

INTRODUCTION AND OBJECTIVES

With rising prevalence of pre-sarcopenia in metabolic dysfunction-associated steatotic liver disease (MASLD), this study aimed to develop and validate machine learning-based model to identify pre-sarcopenia in MASLD population.

MATERIALS AND METHODS

A total of 571 MASLD subjects were screened from the National Health and Nutrition Examination Survey 2017-2018. This cohort was randomly divided into training set and internal testing set with a ratio of 7:3. Sixty-six MASLD subjects were collected from our institution as external validation set. Four binary classifiers, including Random Forest (RF), support vector machine, and extreme gradient boosting and logistic regression, were fitted to identify pre-sarcopenia. The best-performing model was further validated in external validation set. Model performance was assessed in terms of discrimination and calibration. Shapley Additive explanations were used for model interpretability.

RESULTS

The pre-sarcopenia rate was 17.51 % and 15.16 % in NHANES cohort and external validation set, respectively. RF outperformed other models with area under receiver operating characteristic curve (AUROC) of 0.819 (95 %CI: 0.749, 0.889). When six top-ranking features were retained as per variable importance, including weight-adjusted waist, sex, race, creatinine, education and alkaline phosphatase, a final RF model reached an AUROC being 0.824 (0.737, 0.910) and 0.732 (95 %CI: 0.529, 0.936) in internal and external validation sets, respectively. The model robustness was proved in sensitivity analysis. The calibration curve and decision curve analysis confirmed a good calibration capacity and good clinical usage.

CONCLUSIONS

This study proposed a user-friendly model using explainable machine learning algorithm to predict pre-sarcopenia in MASLD population. A web-based tool was provided to screening pre-sarcopenia in community and hospitalization settings.

Does Breast Feeding Protect Mothers From Obesity?

BACKGROUND

Hepatosteatosis, which we frequently observe today with change in lifestyle, is often unnoticed, but preventable and reversible; if not prevented, it can lead to serious comorbidities. There is contradicting evidence in the literature; we believe that breastfeeding has a protective effect on hepatosteatosis. In this cross-sectional study we conducted, we aimed to examine the relationship between breastfeeding duration, metabolic parameters and fatty liver.

METHODS

We examined the data of 135 patients aged 20-40 years who have had at least one pregnancy and were admitted to our polyclinic. Forty-five healthcare staff who never breastfed were included in the control group. Measurements of height and weight were taken, and number of children and total breastfeeding time were questioned. Blood values were measured to calculate insulin resistance, non-alcoholic fatty liver disease (NAFLD) fibrosis score and Fibrosis-4 (FIB-4) score.

RESULTS

Consequently, there was no significant correlation between total breastfeeding time and body mass index (BMI), NAFLD fibrosis score, Homeostatic Model Assessment for Insulin Resistance (HOMA-IR) value and hemoglobin A1C (HbA1C). When two groups were formed as patients breastfeeding for less than six months and patients breastfeeding for more than six months, a significant difference in BMI was observed between these two groups (p: 0.02). There was a significant relationship between BMI and NAFLD (p: 0.00) and HOMA-IR (p: 0.00). It was observed that there was a significant difference between BMI FIB-4 and NAFLD fibrosis scores of the control group and breastfed group.

CONCLUSIONS

Lactation should be maintained for at least six months for maternal health together with the baby's health, and more comprehensive studies should be conducted for long-term data.

Low muscle quality index is associated with increased risk of advanced fibrosis in adult patients with nonalcoholic fatty liver disease: NHANES 2011-2014

Muscle quality index (MQI) is a novel indicator reflecting the quality of skeletal muscles. The association between MQI and the development of advanced fibrosis in patients with nonalcoholic fatty liver disease (NAFLD) is unknown. We investigated the association of low MQI with advanced fibrosis among adults with NAFLD using a nationally representative sample of the US population. Adults with NAFLD who participated in the National Health and Nutrition Examination Survey (NHANES) 2011-2014 were included. Sex-specific standard was used to define low and extremely low MQI. Univariate and multivariate logistic regressions were used to assess the association between MQI level and advanced fibrosis. In the study, 3758 participants with NAFLD were included. The prevalence of low and extremely low MQI was 11.7% (95% CI 10.4-13.0%) and 2.2% (95% CI 1.6-2.8%), respectively. Among these participants, 96 were assessed to have advanced fibrosis. Individuals with low [(odds ratio (OR) 2.45, 95% confidence interval (CI) 1.22-4.91)] and extremely low MQI (OR 10.48, 95% CI 3.20-34.27) were associated with advanced fibrosis in multivariable analysis. A linear trend relationship was also observed between MQI level and the risk of advanced fibrosis (Ptrend = 0.001). Subgroup and sensitivity analyses yielded similar results to the main analyses. Decreased MQI is highly prevalent, and is associated with an increased risk of advanced fibrosis in adult US population with NAFLD.

Association of remnant cholesterol with sarcopenia in Korean adults: a nationwide population-based study using data from the KNHANES

Background

Mounting evidence indicates the importance of the interplay between skeletal muscles and lipid metabolism. Remnant cholesterol (remnant-C) is considered one of the principal residual risk factors for cardiovascular disease and metabolic disorders; however, there are limited studies on the impact of remnant-C on sarcopenia.

Methods

Data from the Korea National Health and Nutrition Examination Surveys (KNHANES) between 2008 and 2011 were used in this nationwide population-based study. In total, 17,408 participants were enrolled in this study. The subjects were categorized into four groups according to the quartile of remnant-C values. We conducted multivariable logistic regression analysis to evaluate the association between remnant-C and muscle mass measured using dual-energy X-ray absorptiometry.

Results

A total of 1,791 participants (10.3%) presented low muscle mass, and there was a sequential increase in the percentage of low muscle mass across remnant-C quartiles (Q1, 5.2%; Q2, 8.7%; Q3, 11.5%; Q4, 15.7%). In the full adjusted model, those in the highest remnant-C quartile group showed significantly increased odds ratio (OR) for low muscle mass compared with those in the lowest remnant-C group after adjusting for various confounding factors (OR = 1.33, 95% confidence interval (CI) = 1.06-1.68, P <0.05). A wide range of subgroups and sensitivity analyses showed consistent results, supporting the robustness of our findings.

Conclusions

Increased remnant-C value was associated with a high risk of low muscle mass in the Korean population. Remnant-C may be a novel marker for the prediction and management of sarcopenia in aging societies.

Shining a spotlight on sarcopenia and myosteatosis in liver disease and liver transplantation: Potentially modifiable risk factors with major clinical impact

Muscle-wasting and disease-related malnutrition are highly prevalent in patients with chronic liver diseases (CLD) as well as in liver transplant (LT) candidates. Alterations of body composition (BC) such as sarcopenia, myosteatosis and sarcopenic obesity and associated clinical frailty were tied to inferior clinical outcomes including hospital admissions, length of stay, complications, mortality and healthcare costs in various patient cohorts and clinical scenarios. In contrast to other inherent detrimental individual characteristics often observed in these complex patients, such as comorbidities or genetic risk, alterations of the skeletal muscle and malnutrition are considered as potentially modifiable risk factors with a major clinical impact. Even so, there is only limited high-level evidence to show how these pathologies should be addressed in the clinical setting. This review discusses the current state-of-the-art on the role of BC assessment in clinical outcomes in the setting of CLD and LT focusing mainly on sarcopenia and myosteatosis. We focus on the disease-related pathophysiology of BC alterations. Based on these, we address potential therapeutic interventions including nutritional regimens, physical activity, hormone and targeted therapies. In addition to summarizing existing knowledge, this review highlights novel trends, and future perspectives and identifies persisting challenges in addressing BC pathologies in a holistic way, aiming to improve outcomes and quality of life of patients with CLD awaiting or undergoing LT.

The effects of exposure to and timing of a choline-deficient diet during pregnancy and early postnatal life on the skeletal muscle transcriptome of the offspring

BACKGROUND & AIMS

Nonalcoholic fatty liver disease (NAFLD) is related to muscle loss, but the precise mechanism underlying this association remains unclear. The aim of the present study was thus to determine the influence of maternal fatty liver and dietary choline deficiency during pregnancy and/or lactation periods on the skeletal muscle gene expression profile among 24-day-old male rat offspring.

METHODS

Histological examination of skeletal muscle tissue specimens obtained from offspring of dams suffering from fatty liver, provided with proper choline intake during pregnancy and lactation (NN), fed a choline-deficient diet during both periods (DD), deprived of choline only during pregnancy (DN), or only during lactation (ND), was performed. The global transcriptome pattern was assessed using a microarray approach (Affymetrix® Rat Gene 2.1 ST Array Strip). The relative expression of selected genes was validated by real-time PCR (qPCR).

RESULTS

Morphological differences in fat accumulation in skeletal muscle related to choline supply were observed. The global gene expression profile was consistent with abnormal morphological changes. Mettl21c gene was overexpressed in all choline-deficient groups compared to the NN group, while two genes, Cdkn1a and S100a4, were downregulated. Processes of protein biosynthesis were upregulated, and processes related to cell proliferation and lipid metabolism were inhibited in DD, DN, and ND groups compared to the NN group.

CONCLUSIONS

Prenatal and early postnatal exposure to fatty liver and dietary choline deficiency leads to changes in the transcriptome profile in skeletal muscle of 24-day old male rat offspring and is associated with muscle damage, but the mechanism of it seems to be different at different developmental stages of life. Adequate choline intake during pregnancy and lactation can prevent severe muscle disturbance in the progeny of females suffering from fatty liver.

Sex difference in skeletal muscle mass in relation to metabolic dysfunction-associated steatotic liver disease: a propensity score matching study

BACKGROUND

While low muscle mass is considered a risk factor for metabolic dysfunction-associated steatotic liver disease (MASLD), whether the relationship is independent of fat mass remains unclear.

OBJECTIVES

This study aims to clarify the association between the sex-specific height-adjusted low skeletal muscle mass index (LSMI) and MASLD.

METHODS

Data from the 2008-2010 Korean National Health and Nutrition Examination Survey were analyzed. LSMI was defined using the 2019 Asian Working Group for Sarcopenia. The non-alcoholic fatty liver disease-liver fat score was used to assess MASLD. Gender-specific 1:1 propensity score matching (PSM) was performed to mitigate the confounding effects of anthropometric variables and lifestyles. Conditional logistic analysis was used on the dataset after PSM to estimate the odds ratio (OR) with a 95% confidence interval (CI).

RESULTS

After PSM, the prevalence of MASLD was significantly higher in men with LSMI than in those without LSMI (37.4% vs. 29.6%). No significant difference was observed in the prevalence of MASLD between groups after PSM in women (20.4% vs. 20.3%). Conditional logistic analysis revealed that the odds of having MASLD were significantly higher in men with LSMI compared to those without LSMI (OR = 1.38, 95% CI: 1.09-1.75), while no significant association was found in women with LSMI (OR = 1.10, 95% CI: 0.87-1.40).

CONCLUSION

Height-adjusted LSMI is an independent factor associated with MASLD in the condition of the same level of fat mass in men. Further prospective studies in diverse populations are needed to confirm our findings.

Association between the skeletal muscle mass to visceral fat area ratio and metabolic dysfunction-associated fatty liver disease: A cross-sectional study of NHANES 2017-2018

BACKGROUND AND AIMS

Previous studies have shown that sarcopenic obesity (SO) was associated with nonalcoholic fatty liver disease (NAFLD). However, research is limited in the context of the NAFLD renamed as metabolic dysfunction-associated steatotic liver disease (MASLD) defined by updated diagnostic criteria. The aim of this study was to use the index skeletal muscle mass to visceral fat area ratio (SVR) to describe SO in a large and representative US population (National Health and Nutrition Examination Survey 2017-2018) of adults and investigate their association with MASLD.

METHODS

A total of 2087 individuals were included in the analysis. SVR was calculated according to the measurement of dual-energy x-ray absorptiometry and MASLD was diagnosed with controlled attenuation parameter scores and cardiometabolic risk factors. SVR was divided into tertiles. Logistic regression adjusted for confounders was used to evaluate the association between SVR and MASLD. Several sensitivity analyses were performed to test the robustness of our findings.

RESULTS

In a multivariate logistic regression analysis, a significant association between SVR and MASLD was shown (odds ratio [OR]: 3.11, 95% confidence interval [CI]: 1.31-7.39, p = .010 for middle levels of SVR; OR: 3.82, 95% CI: 1.45-10.08, p = .007 for lowest levels of SVR). The sensitivity analyses confirmed that the association was robust.

CONCLUSION

Our findings imply that decreased SVR is linked to MASLD.

Prevalence and outcome of sarcopenia in non-alcoholic fatty liver disease

BACKGROUND

Nonalcoholic fatty liver disease (NAFLD) includes a spectrum of conditions, progressing from mild steatosis to advanced fibrosis. Sarcopenia, characterized by decreased muscle strength and mass, shares common pathophysiological traits with NAFLD. An association exists between sarcopenia and increased NAFLD prevalence. However, data on the prevalence of sarcopenia in NAFLD and its impact on the outcomes of NAFLD remain inconsistent.

AIM

To analyze the prevalence and outcomes of sarcopenia in patients with NAFLD.

METHODS

We conducted a comprehensive search for relevant studies in MEDLINE, Embase, and Scopus from their inception to June 2023. We included studies that focused on patients with NAFLD, reported the prevalence of sarcopenia as the primary outcome, and examined secondary outcomes, such as liver fibrosis and other adverse events. We also used the Newcastle-Ottawa scale for quality assessment.

RESULTS

Of the 29 studies included, the prevalence of sarcopenia in NAFLD varied widely (1.6% to 63.0%), with 20 studies reporting a prevalence of more than 10.0%. Substantial heterogeneity was noted in the measurement modalities for sarcopenia. Sarcopenia was associated with a higher risk of advanced fibrosis (odd ratio: 1.97, 95% confidence interval: 1.44-2.70). Increased odds were consistently observed in fibrosis assessment through biopsy, NAFLD fibrosis score/body mass index, aspartate aminotransferase to alanine aminotransferase ratio, diabetes (BARD) score, and transient elastography, whereas the fibrosis-4 score showed no such association. Sarcopenia in NAFLD was associated with a higher risk of steatohepatitis, insulin resistance, cardiovascular risks, and mortality.

CONCLUSION

This systematic review highlights the critical need for standardized diagnostic criteria and measurement methods for sarcopenia in NAFLD patients. The variability in study designs and assessment methods for sarcopenia and liver fibrosis may account for the inconsistent findings. This review demonstrates the multidimensional impact of sarcopenia on NAFLD, indicating its importance beyond liver-related events to include cardiovascular risks, mortality, and metabolic complications.

Relationship between sarcopenia and fatty liver in middle-aged and elderly patients with type 2 diabetes mellitus

OBJECTIVE

In this study, we investigated the relationship between sarcopenia and fatty liver in middle-aged and elderly patients diagnosed with type 2 diabetes mellitus (T2DM) to provide a theoretical foundation for the prevention and treatment of sarcopenia.

METHODS

A total of 282 patients diagnosed with T2DM aged 50 and older and were admitted to the Endocrinology Department of Xin Medical University First Affiliated Hospital between December 2021 and February 2023, were selected. Body mass index (BMI), and limb and trunk muscle mass of the patients were measured, and data were collected. Patients were grouped based on the sarcopenia diagnostic criteria. All study participants underwent the same physical examinations and laboratory tests. The relationship between the onset of sarcopenia and fatty liver in middle-aged and elderly patients diagnosed with T2DM was then investigated using statistical analysis.

RESULTS

Comparing the sarcopenia group to the non-sarcopenia group revealed statistically significant variations in gender, BMI, fatty liver prevalence rate, uric acid (UA), alanine aminotransferase (ALT), blood glucose, blood lipid associated indicators, and limb skeletal muscle content. There were, however, no statistically significant differences in age, disease duration, hypertension, smoking, or alcohol intake. There was a positive correlation between BMI, UA, fasting c-peptide, and Appendicular Skeletal Muscle Index (ASMI). Higher levels of BMI, ASMI, and UA were identified as protective variables against sarcopenia by multifactorial logistic regression analysis.

CONCLUSION

Higher levels of BMI, ASMI, and UA can greatly reduce skeletal muscle atrophy in patients with T2DM. Patients with a fatty liver may be less vulnerable to sarcopenia. There is little evidence, however, that a fatty liver works as a preventive factor against sarcopenia.

Increased visceral fat area to skeletal muscle mass ratio is positively associated with the risk of metabolic dysfunction-associated steatotic liver disease in a Chinese population

BACKGROUND

The diagnosis and comprehension of nonalcoholic fatty liver disease (NAFLD), recently redefined as metabolic dysfunction-associated steatotic liver disease (MASLD) are gaining a better understanding. In this study, we examined the association between visceral fat area and skeletal muscle mass ratio (VSR) and the prevalence of MASLD in a Chinese population.

METHODS

A cross-sectional study was conducted involving 10,916 individuals who underwent bioelectrical impedance analysis, along with anthropometric and biochemical measurements, from January 2022 to June 2023. According to the VSR distribution, sex-specific quartiles of VSR within the study population were defined. Linear trend tests were performed for the categorized VSR variables. Logistic regression models were performed to estimate the odds ratio and 95% confidence intervals between VSR distribution and MASLD prevalence stratified by sex.

RESULTS

The prevalence of MASLD was 37.94% in the overall population (56.34% male), and it gradually increased with higher VSR levels in both genders (P < 0.001). Logistic regression analysis demonstrated a significant association between VSR and MASLD prevalence after adjusting for confounders. The odds ratio (95% confidence interval) for MASLD, comparing the lowest to the highest VSR quartile, was 3.159 (2.671, 3.736) for men and 2.230 (1.764, 2.819) for women (all P < 0.001). Restricted cubic splines also indicated significant non-linear relationships between VSR and MASLD prevalence.

CONCLUSIONS

VSR is positively associated with the prevalence of MASLD in this Chinese population, with a notably higher risk for men as VSR increases compared to women.

Approaching the Sarcopenic Patient with Nonalcoholic Steatohepatitis-related Cirrhosis

Sarcopenia is a well-known complication of chronic liver disease (CLD), and it is almost always observed in patients with cirrhosis, at least in those with decompensated disease. Since nonalcoholic fatty liver disease (NAFLD), recently renamed metabolic dysfunction-associated steatotic liver disease (MASLD), is becoming the leading cause of end-stage liver disease, a new scenario characterized by the frequent coexistence of NAFLD, obesity, and sarcopenia is emerging. Although it is not yet resolved whether the bidirectional relationship between sarcopenia and NAFLD subtends causal determinants, it is clear that the interaction of these two conditions is associated with an increased risk of poor outcomes. Notably, during the course of CLD, deregulation of the liver-muscle-adipose tissue axis has been described. Unfortunately, owing to the lack of properly designed studies, specific therapeutic guidelines for patients with sarcopenia in the context of NAFLD-related CLD have not yet been defined. Strategies aimed to induce the loss of fat mass together with the maintenance of lean body mass seem most appropriate. This can be achieved by properly designed diets integrated with specific nutritional supplementations and accompanied by adequate physical exercise. Future studies aiming to add to the knowledge of the correct assessment and approach to sarcopenia in the context of NAFLD-related CLD are eagerly awaited.

Mortality in metabolic dysfunction-associated steatotic liver disease: A nationwide population-based cohort study

BACKGROUND

A new fatty liver disease nomenclature, steatotic liver disease (SLD) has been proposed; however, there are no data on clinical outcomes. We investigated the impact of SLD with metabolic dysfunction (MD; SLD-MD) on all-cause mortality.

METHODS

We evaluated nationally representative participants aged ≥19 years using data from the Korea National Health and Nutrition Examination Survey 2007-2015 and their linked death data through 2019. The presence of fatty liver disease was assessed by liver fat score, fatty liver index and significant liver fibrosis was evaluated by the Fibrosis-4 Index, and fibrosis score. SLD-MD was categorized into three groups: metabolic dysfunction-associated steatotic liver disease (MASLD); metabolic alcoholic liver disease (MetALD); and SLD with other combination etiologies.

RESULTS

Among 26734 individuals (11561 men and 15173 women, mean age 48.8 years), 1833 (6.9 %) died during a mean follow-up period of 110.6 ± 33.9 months. Mortality risk was significantly higher in individuals with SLD-MD (hazard ratio [HR] = 1.35) than in those without (P < 0.001). Among the three groups, MASLD (HR = 1.32) and SLD with other combination etiologies (HR = 2.06) independently increased mortality risk (all P < 0.001). When individuals with SLD-MD had significant liver fibrosis or diabetes, mortality risk increased further (HR = 1.68 and 1.85, respectively; all P < 0.001). SLD-MD with both significant liver fibrosis and diabetes showed the highest mortality risk (HR = 2.29, P < 0.001). When applied fatty liver index and fibrosis score, similar results were observed.

CONCLUSIONS

SLD-MD is associated with a higher mortality risk. When SLD-MD was combined with significant liver fibrosis or diabetes, the mortality risk became much higher. Treatment strategies to reduce fibrotic burden and improve glycemic control in individuals with MASLD are needed.

NAFLD Fibrosis Progression and Type 2 Diabetes: The Hepatic-Metabolic Interplay

The bidirectional relationship between type 2 diabetes and (non-alcoholic fatty liver disease) NAFLD is indicated by the higher prevalence and worse disease course of one condition in the presence of the other, but also by apparent beneficial effects observed in one, when the other is improved. This is partly explained by their belonging to a multisystemic disease that includes components of the metabolic syndrome and shared pathogenetic mechanisms. Throughout the progression of NAFLD to more advanced stages, complex systemic and local metabolic derangements are involved. During fibrogenesis, a significant metabolic reprogramming occurs in the hepatic stellate cells, hepatocytes, and immune cells, engaging carbohydrate and lipid pathways to support the high-energy-requiring processes. The natural history of NAFLD evolves in a variable and dynamic manner, probably due to the interaction of a variable number of modifiable (diet, physical exercise, microbiota composition, etc.) and non-modifiable (genetics, age, ethnicity, etc.) risk factors that may intervene concomitantly, or subsequently/intermittently in time. This may influence the risk (and rate) of fibrosis progression/regression. The recognition and control of the factors that determine a rapid progression of fibrosis (or its regression) are critical, as the fibrosis stages are associated with the risk of liver-related and all-cause mortality.

Blockade of angiotensin II modulates insulin-like growth factor 1-mediated skeletal muscle homeostasis in experimental steatohepatitis

Sarcopenia is associated with mortality in patients with nonalcoholic steatohepatitis (NASH). Angiotensin II receptor blocker (ARB) has been suggested to prevent sarcopenia, but reports on its effect on NASH-derived skeletal muscle atrophy in conjunction with insulin-like growth factor 1 (IGF-1)-mediated muscle homeostasis are few. Our aim was to examine the combined effect of the ARB losartan and IGF-1 replacement on skeletal muscle atrophy in a methionine-choline deficient (MCD) diet-fed murine steatohepatitis model. The MCD-fed mice developed steatohepatitis and skeletal muscle atrophy, as indicated by the reduction of psoas muscle mass and attenuation of forelimb and hindlimb grip strength. Significantly suppressed steatohepatitis and skeletal muscle atrophy was observed after single treatment with ARB or IGF-1, and these effects were augmented after combination treatment. Treatment with ARB and IGF-1 effectively inhibited ubiquitin proteasome-mediated protein degradation by reducing forkhead box protein O1 (FOXO1) and FOXO3a transcriptional activity in the skeletal muscle. Combined ARB and IGF-1 decreased the intramuscular expression of proinflammatory cytokines (i.e., TNFα, IL6, and IL1β) and increased the Trolox equivalent antioxidant capacity and antioxidant enzymes (CAT, GPX1, SOD2, and CYTB). This antioxidant effect was based on downregulation of NADPH oxidase (NOX) 2, normalization of mitochondrial biogenesis and dynamics. Moreover, ARB increased the hepatic and plasma IGF-1 levels and improved steatohepatitis, leading to enhanced skeletal muscle protein synthesis mediated by IGF-1/ AKT/ mechanistic target of rapamycin signaling. Collectively, combined ARB and IGF-1 replacement could be a promising new therapeutic target for NASH-derived skeletal muscle wasting.

Effects of nonalcoholic fatty liver disease on sarcopenia: evidence from genetic methods

With the aging of the population, sarcopenia has become more common. Studies have shown a broad association between liver disease and sarcopenia. However, this link remains unclear. Our study explored the link between NAFLD and sarcopenia and predicting the pathogenesis. To begin, we investigated the causal relationship and genetic correlation between them using MR and LDSC. Second, each GWAS was annotated by MAGMA. The annotated genes were analyzed for pleiotropy using the PLACO approach. Finally, functional analysis was conducted on the identified pleiotropic genes. We observed a significant genetic correlation between NAFLD and sarcopenia. Subsequently, we conducted gene-level pleiotropy analysis using PLACO and identified a total of 153 genes with pleiotropic effects. Functional analysis revealed enrichment of these genes in various tissues, including pancreas, liver, heart, blood, brain, and muscle, with involvement in cellular regulation, intracellular function, and antigen response. Moreover, our MR analysis provided evidence of a causal relationship between NAFLD and sarcopenia. Our study has discovered the genetic and causal relationships between NAFLD and sarcopenia, providing further insights into their pathophysiological mechanisms. The identification of pleiotropic genes also offers potential targets for future drug therapies aimed at controlling or treating NAFLD and sarcopenia.

Lower creatinine to cystatin C ratio is associated with an increased risk of MASLD: A cross-sectional and prospective study of 368,634 UK Biobank participants

OBJECTIVE

Metabolic dysfunction-associated steatotic liver disease (MASLD) affects many populations, and screening out the high-risk populations at an early stage is a challenge. As a sarcopenia index, the relationship between creatinine to cystatin C ratio (CCR) and MASLD remains unclear. This cross-sectional, prospective study aimed to explore the relationship between CCR and MASLD. Design Firstly, explored the correlation between CCR and MASLD in cross-sectional analyses. Then excluded the population with baseeline diagnosis of MASLD and analyzed the association with baseline CCR levels and the onset of MASLD in the population with available follow-up data. Univariate and multivariate logistic regression analyses were used to calculate odds ratios (ORs) to evaluate the association between CCR levels and MASLD.

PATIENTS AND MEASUREMENTS

This study included 368,634 participants from the UK Biobank for cross-sectional and prospective analyses. The demographic characteristics and laboratory measurements of all participants were obtained from the UK Biobank. MASLD was diagnosed according to the multi-society consensus nomenclature. Hepatic steatosis was defined as FLI  ≥60.

RESULTS

We grouped the study participants according to CCR tertiles. In cross-sectional analyses, participants in CCR tertile 1 had the highest MASLD risk (OR: 1.070, 95% CI: 1.053-1.088, p < .001). And the similar association was observed in the prospective analyses (CCR tertile 1 OR: 1.340, 95% CI: 1.077-1.660, p = .009; CCR tertile 2 OR: 1.217, 95% CI: 1.021-1.450, p = .029, respectively). After stratification by gender, the significant association between CCR and the onset of MASLD was only observed in males (CCR tertile 1 OR: 1.639, 95% CI: 1.160-2.317, p = .005; CCR tertile 2 OR: 1.322, 95% CI: 1.073-1.628, p = .005, respectively).

CONCLUSION

Our results indicated that lower CCR was significantly associated with higher risk of MASLD, based on which predictive models can be developed to screen populations at high risk of developing MASLD.

Pathophysiological-Based Nutritional Interventions in Cirrhotic Patients with Sarcopenic Obesity: A State-of-the-Art Narrative Review

In recent decades, following the spread of obesity, metabolic dysfunction has come to represent the leading cause of liver disease. The classical clinical presentation of the cirrhotic patient has, therefore, greatly changed, with a dramatic increase in subjects who appear overweight or obese. Due to an obesogenic lifestyle (lack of physical activity and overall malnutrition, with an excess of caloric intake together with a deficit of proteins and micronutrients), these patients frequently develop a complex clinical condition defined as sarcopenic obesity (SO). The interplay between cirrhosis and SO lies in the sharing of multiple pathogenetic mechanisms, including malnutrition/malabsorption, chronic inflammation, hyperammonemia and insulin resistance. The presence of SO worsens the outcome of cirrhotic patients, affecting overall morbidity and mortality. International nutrition and liver diseases societies strongly agree on recommending the use of food as an integral part of the healing process in the comprehensive management of these patients, including a reduction in caloric intake, protein and micronutrient supplementation and sodium restriction. Based on the pathophysiological paths shared by cirrhosis and SO, this narrative review aims to highlight the nutritional interventions currently advocated by international guidelines, as well as to provide hints on the possible role of micronutrients and nutraceuticals in the treatment of this multifaceted clinical condition.

Association between cataract and fatty liver diseases from a nationwide cross-sectional study in South Korea

This study examined the link between fatty liver disease (FLD) and cataracts, as previous research has suggested that FLD may contribute to metabolic syndrome, systemic inflammation, and potentially cataracts. We studied a nationwide cross-sectional cohort of the Fifth Korean National Health and Nutrition Examination Survey 2010-2011. FLD was defined as nonalcoholic FLD (NAFLD) and metabolic dysfunction-associated FLD (MAFLD). Multinomial logistic regression was utilized to investigate the relationship between cataracts and FLD after adjustment for potential confounders. Participants with cataracts had higher liver fibrosis scores, including the NAFLD fibrosis score (NFS; P < 0.001), fibrosis-4 index (FIB4; P < 0.001), and fatty liver index (FLI; P = 0.001). NAFLD was not associated with a higher odds ratio (OR) for cataracts in the fully adjusted model (OR = 1.23, P = 0.058). MAFLD was significantly associated with a higher OR (OR = 1.34, P = 0.006). After adjusting for all factors, the severity of FLD was linked to an increased risk of cataracts, with significant linear trends (P values for linear trends of NFS, FIB4, and FLI < 0.05). After adjusting for well-known cataract risk factors, MAFLD was significantly associated with cataracts. Our analysis suggests that FLD may serve as an independent risk factor for cataracts.

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.

Restoring skeletal muscle mass as an independent determinant of liver fat deposition improvement in MAFLD

AIMS

Cross-sectional studies have demonstrated the association of skeletal muscle mass with metabolic-associated fatty liver disease (MAFLD), while longitudinal data are scarce. We aimed to explore the impact of changes in relative skeletal muscle mass on the MAFLD treatment response.

METHODS

MAFLD patients undergoing magnetic resonance imaging-based proton density fat fraction for liver fat content (LFC) assessments and bioelectrical impedance analysis before and after treatment (orlistat, meal replacement, lifestyle modifications) were enrolled. Appendicular muscle mass (ASM) was adjusted by weight (ASM/W).

RESULTS

Overall, 256 participants were recruited and divided into two groups: with an ASM/W increase (n=166) and without an ASM/W increase (n=90). There was a great reduction in LFC in the group with an ASM/W increase (16.9% versus 8.2%, P < 0.001). However, the change in LFC in the group without an ASM/W increase showed no significant difference (12.5% versus 15.0%, P > 0.05). △ASM/W Follow-up-Baseline [odds ratio (OR)=1.48, 95% confidence interval (CI) 1.05-2.07, P = 0.024] and △total fat mass (OR=1.45, 95% CI 1.12-1.87, P = 0.004) were independent predictors for steatosis improvement (relative reduction of LFC ≥ 30%). The subgroup analysis showed that, despite without weight loss, decrease in HOMA-IR (OR=6.21, 95% CI 1.28-30.13, P=0.023), △total fat mass Baseline -Follow-up (OR=3.48, 95% CI 1.95-6.21, P <0.001 and △ASM/W Follow-up-Baseline (OR=2.13, 95% CI 1.12-4.05, P=0.022) independently predicted steatosis improvement.

CONCLUSIONS

ASM/W increase and loss of total fat mass benefit the resolution of liver steatosis, independent of weight loss for MAFLD.

Evaluation of muscle strength and quality in North African patients with chronic hepatitis B: A pilot case control study

Early detection of alteration of muscle strength, quantity, and quality, and sarcopenia is useful in non-cirrhotic chronic hepatitis B (NC-CHB) patients. Studies, which explored the handgrip strength (HGS) are scarce with questionable results, and no previous case-control study explored the presence of sarcopenia.The aim of this study was to assess the muscle strength [i.e.; HGS absolute (HGS_A), HGS_A/body mass index (BMI)], muscle quantity [i.e.; appendicular skeletal muscle (ASM), ASM/height², ASM/total body weight (TBW), ASM/BMI], and muscle quality [i.e.; HGS_A/total muscle mass (TMM), HGS_A/ASM] of NC-CHB patients.This was a case-control study. Cases (n = 26) were untreated NC-CHB patients, and controls (n = 28) were 'apparently' healthy participants. Muscle mass was estimated via the TMM (kg) and ASM (kg). Muscle strength was evaluated via the HGS data [i.e.; HGS_A (kg), HGS_A/BMI (m²)]. Six variants of HGS_A were determined: highest values for the dominant and non-dominant hands, highest value between the two hands, averages of the three measurements for the two hands, and the average of the highest values of the two hands. Muscle quantity was expressed in three relative variants (ASM/height², ASM/TBW, and ASM/BMI). Muscle quality was evaluated via relative HGS data adjusted by muscle mass (i.e.; HGS_A/TMM, HGS_A/ASM). Probable and confirmed sarcopenia were retained in front of low muscle strength, and low muscle strength and muscle quantity or quality, respectively.There were no significant differences between controls and NC-CHB patients in values of muscle i) Strength whatever the HGS' mode of expression (e.g.; HGS_A/BMI: 1.59 ± 0.54 vs. 1.53 ± 0.54 m², p = 0.622, respectively), ii) Quantity (e.g.; ASM/BMI: 0.79 ± 0.24 vs. 0.77 ± 0.23 m², p = 0.883), and iii) Quality (e.g.; HGS_A/ASM: 2.00 ± 0.25 vs. 2.01 ± 0.41, p = 0.952, respectively). One NC-CHB participant had a confirmed sarcopenia.To conclude, both controls and NC-CHB patients had similar HGS values. Only one NC-CHB patient had a confirmed sarcopenia.

Association of fat-to-muscle ratio with non-alcoholic fatty liver disease: a single-centre retrospective study

OBJECTIVES

Sarcopenia is a known risk factor for non-alcoholic fatty liver disease (NAFLD). Studies evaluating the association between the fat-to-muscle ratio (FMR) and NAFLD are limited. Therefore, the aim of our study was to investigate the association between FMR and NAFLD.

DESIGN

A retrospective study was conducted on individuals who underwent health examination at Wuhan Union Hospital between January 2020 and November 2021. Clinical data were collected from electronic medical records.

SETTING

Wuhan Union Hospital, Wuhan, China.

PARTICIPANTS

1592 participants aged ≥40 years who underwent body composition analysis and liver ultrasonography were retrospectively reviewed.

OUTCOME MEASURES

Liver ultrasonography was used to assess liver steatosis, and the fibrosis-4 index was used to calculate the risk scores for liver fibrosis. The 10-year atherosclerotic cardiovascular disease (ASCVD) risk prediction model was used to calculate ASCVD risk scores.

RESULTS

The FMR was significantly higher in individuals with NAFLD than in those without NAFLD (p<0.001). The prevalence of NAFLD gradually increased from FMR tertile 1 (reference) to tertile 2 (OR=1.49, 95% CI 1.13 to 1.97) and tertile 3 (OR=2.85, 95% CI 2.08 to 3.90). In addition, patients with NAFLD in FMR tertile 3 had a significantly higher risk of liver fibrosis (OR=4.48, 95% CI 2.12 to 9.50) and ASCVD (OR=4.63, 95% CI 2.62 to 8.19) than those in FMR tertile 1 after adjustment for multiple confounders.

CONCLUSION

In this study, we found a significant association between FMR and NAFLD. A higher FMR indicates a higher risk of NAFLD in the study population and a higher risk of liver fibrosis and ASCVD in NAFLD patients.

Impact of skeletal muscle mass evaluating methods on severity of metabolic associated fatty liver disease in non-elderly adults

The study aimed to explore the relationships of skeletal muscle mass with disease severity in metabolic-associated fatty liver disease (MAFLD) patients with different methods. Consecutive subjects undergoing bioelectrical impedance analysis were included. The steatosis grade and liver fibrosis were evaluated by MRI-derived proton density fat fraction and two-dimensional shear wave elastography. The appendicular skeletal muscle mass (ASM) was adjusted by height2 (ASM/H2), weight (ASM/W) and BMI (ASM/BMI). Overall, 2223 subjects (50·5 %, MAFLD; 46·9 %, male) were included, with the mean age 37·4 ± 10·6 years. In multivariate logistic regression analysis, the subjects with the lowest quartile (Q1) of ASM/W or ASM/BMI had higher risk ratios for MAFLD (OR (95 % CI) in male: 2·57 (1·35, 4·89), 2·11(1·22, 3·64); in female: 4·85 (2·33, 10·01), 4·81 (2·52, 9·16), all P < 0·05, all for Q1 v. Q4). The MAFLD patients with lower quartiles of ASM/W had the higher risk OR for insulin resistance (IR), both in male and female (2·14 (1·16, 3·97), 4·26 (1·29, 14·02) for Q4 v. Q1, both P < 0·05). While the significant OR were not observed when ASM/H2 and ASM/BMI were used. There were significant dose-dependent associations between decreased ASM/W as well as ASM/BMI and moderate-severe steatosis (2·85(1·54, 5·29), 1·90(1·09, 3·31), both P < 0·05) in male MAFLD patients. In conclusion, ASM/W is superior to ASM/H2 and ASM/BMI in predicting the degree of MAFLD. A lower ASM/W is associated with IR and moderate-severe steatosis in non-elderly male MAFLD.

A novel imaging index for predicting adverse progression in acute-on-chronic liver failure related to hepatitis B virus: the low erector spine index

BACKGROUND

It is widely known that muscle mass influences the outcomes of many chronic diseases. Erector spine mass is a convenient parameter obtained from routine abdominal computed tomography (CT). The clinical application value of erector spine mass, and whether erector spine mass could predict the outcome of disease has not been studied.

AIM

To evaluate the role of the erector spine index (ESI) calculated based on abdominal CT imaging in the progression of acute-on-chronic liver failure related to the hepatitis B virus (HBV-ACLF).

METHODS

We performed a retrospective study of 118 HBV-ACLF patients and calculated the ESI (the total erector spine area normalized for height2 in meters) for each patient through abdominal CT. The findings were analyzed regarding the progression of HBV-ACLF and the ESI at baseline, including mortality and the development of complications.

RESULTS

The ESI level was associated with mortality and the development of complications. During the 90-day follow-up period, patients with a low ESI (<12.05 cm2/m2) had higher mortality than those with a high ESI (≥ 12.05 cm2/m2) (51.7% vs. 26.7%), and the cumulative survival rates were 71.0%±4.6 and 85.8%±3.9, respectively (log-rank P = 0.003). The hazard ratios (HRs) calculated using univariable and multivariable analyses were 2.23(95% confidence interval (CI): 1.25-4.21, P = 0.005) and 2.52 (95% CI: 1.34-9.24, P = 0.011), respectively. Patients with a low ESI (<12.05 cm2/m2) had higher incidences of kidney dysfunction (43.5% vs. 23.2%, P = 0.029; log-rank P = 0.017) and hepatic encephalopathy (39.6% vs. 14.0%, P = 0.003; log-rank P = 0.010) than those with a high ESI. A low ESI was an independent risk factor for kidney dysfunction (adjusted HR = 1.36, 95% CI: 1.05-2.93, P = 0.043) and the development of hepatic encephalopathy (adjusted HR = 2.26; 95% CI: 2.05-3.13, P = 0.036). In addition, the presence of hepatic encephalopathy (the odds ratio (OR) = 2.26, 95% CI: 2.05-3.18, P = 0.006), spontaneous bacterial peritonitis (OR = 3.95, 95% CI: 1.01-5.46, P = 0.037), and kidney dysfunction (OR = 4.47, 95% CI: 1.02-9.64, P = 0.032) was independently associated with a low ESI in patients.

CONCLUSION

A low ESI is an independent risk factor for mortality in patients with HBV-ACLF, as well as the development of kidney dysfunction and hepatic encephalopathy.

A bibliometric analysis and visualization of nonalcoholic fatty liver disease from 2012 to 2021

As a common chronic liver disease, nonalcoholic fatty liver disease (NAFLD) has attracted increasing attention in the past decade. Nevertheless, there are few bibliometric analyses that systematically study this field as a whole. This paper explores the latest research progress and future research trends of NAFLD through the method of bibliometric analysis. The articles related to NAFLD, published from 2012 to 2021 in the Web of Science Core Collections, were searched on February 21, 2022, using relevant keywords. Two different scientometrics software tools were used to conduct the knowledge maps of NAFLD research field. A total of 7975 articles on NAFLD research were included. From 2012 to 2021, the publications related to NAFLD increased by year. China ranked on the top of the list with 2043 publications, and the University of California System emerged as the premier institution in this field. PLOs One, Journal of Hepatology and Scientific Reports became the prolific journals in this research field. Co-cited reference analysis revealed the landmark literature in this research field. In terms of potential hotspots, the burst keywords analysis revealed that liver fibrosis stage, sarcopenia, and autophagy will become the focus of future NAFLD research. The annual output of the global publications in the field of NAFLD research showed a strong upward trend. Research in the field of NAFLD in China and America is more mature than in other countries. Classic literature lays the foundation for research, and multi-field studies provide the new development directions. And besides, fibrosis stage, sarcopenia and autophagy research are the hot spots and frontiers of this field.

Association of Visceral Fat Obesity, Sarcopenia, and Myosteatosis with Non-Alcoholic Fatty Liver Disease without Obesity

BACKGROUND/AIMS

To investigate whether non-alcoholic fatty liver disease (NAFLD) in individuals without generalized obesity is associated with visceral fat obesity (VFO), sarcopenia, and/or myosteatosis.

METHODS

This cross-sectional analysis included 14,400 individuals (7,470 men) who underwent abdominal computed tomography scans during routine health examinations. The total abdominal muscle area (TAMA) and skeletal muscle area (SMA) at the 3rd lumbar vertebral level were measured. The SMA was divided into the normal attenuation muscle area (NAMA) and low attenuation muscle area, and the NAMA/TAMA index was calculated. VFO was defined by visceral to subcutaneous fat ratio, sarcopenia by body mass index-adjusted SMA, and myosteatosis by the NAMA/TAMA index. NAFLD was diagnosed with ultrasonography.

RESULTS

Of the 14,400 individuals, 4,748 (33.0%) had NAFLD, and the prevalence of NAFLD among non-obese individuals was 21.4%. In regression analysis, both sarcopenia (men: odds ratio [OR] 1.41, 95% confidence interval [CI] 1.19-1.67, P<0.001; women: OR=1.59, 95% CI 1.40-1.90, P<0.001) and myosteatosis (men: OR=1.24, 95% CI 1.02-1.50, P=0,028; women: OR=1.23, 95% CI 1.04-1.46, P=0.017) were significantly associated with non-obese NAFLD after considering for VFO and other various risk factors, whereas VFO (men: OR=3.97, 95% CI 3.43-4.59 [adjusted for sarcopenia], OR 3.98, 95% CI 3.44-4.60 [adjusted for myosteatosis]; women: OR=5.42, 95% CI 4.53-6.42 [adjusted for sarcopenia], OR=5.33, 95% CI 4.51-6.31 [adjusted for myosteatosis]; all P<0.001) was strongly associated with non-obese NAFLD after adjustment with various known risk factors.

CONCLUSION

In addition to VFO, sarcopenia and/or myosteatosis were significantly associated with non-obese NAFLD.

Metabolic Dysfunction-Associated Steatotic Liver Disease and Metabolic Dysfunction-Associated Steatohepatitis: The Patient and Physician Perspective

Diagnosing and managing metabolic dysfunction-associated steatotic liver disease (MASLD) remains a major challenge in primary care due to lack of agreement on diagnostic tools, difficulty in identifying symptoms and determining their cause, absence of approved pharmacological treatments, and limited awareness of the disease. However, prompt diagnosis and management are critical to preventing MASLD from progressing to more severe forms of liver disease. This highlights the need to raise awareness and improve understanding of MASLD among both patients and physicians. The patient perspective is invaluable to advancing our knowledge of this disease and how to manage it, as their perspectives have led to the growing recognition that patients experience subtle symptoms and that patient-reported outcomes should be incorporated into drug development. This review and expert opinion examine MASLD and metabolic dysfunction-associated steatohepatitis from the patient and physician perspective from pre-diagnosis to diagnosis and early care, through to progression to advanced liver damage. Specifically, the paper dives into the issues patients and physicians experience, and, in turn, what is required to improve diagnosis and management, including tips and tools to empower patients and physicians dealing with MASLD.

Association between Alcohol Consumption and Metabolic Dysfunction-Associated Steatotic Liver Disease Based on Alcohol Flushing Response in Men: The Korea National Health and Nutrition Examination Survey 2019-2021

Metabolic dysfunction-associated steatotic liver disease (MASLD) is distinguished by the buildup of excessive liver fat unrelated to alcohol consumption. However, the role of alcohol consumption on disease progression is debatable. Recently, alcohol flushing syndrome in Asian populations has gained interest, and its role in the risk of developing MASLD is unknown. Therefore, in this cross-sectional study, we investigated the association between alcohol consumption and MASLD in Korean men, considering their alcohol flushing response and utilizing the lipid accumulation product (LAP) score. Data from the Korean National Health and Nutrition Examination Survey (2019-2021) were analyzed. Participants were categorized into non-or-infrequent drinkers and light-to-heavy drinkers and further sub-classified based on alcohol flushing response as non-flushers and flushers. Multivariate logistic regression analysis showed a significant association between alcohol consumption and MASLD risk in both non-flushers (aHR 1.90, 95% CI 1.51-2.40, p < 0.001) and flushers (aHR 2.35, 95% CI 1.94-2.84, p < 0.001) after adjusting for potential confounding factors such as age, exercise, smoking, body mass index, systolic blood pressure, total cholesterol, and fasting plasma glucose. There was a significant interaction between alcohol consumption and alcohol flushing response for MASLD risk (p for interaction < 0.001). These findings emphasize the importance of alcohol flushing as a potential indicator of MASLD risk in Korean men and highlight the need for further research to understand the underlying mechanisms and develop targeted preventive strategies.

Lean nonalcoholic fatty liver disease: Age-dependent differences in pathology, prognosis, and liver-related events

AIM

This study aimed to evaluate the age-specific characteristics, prognosis, and complications of patients with lean nonalcoholic fatty liver disease (NAFLD).

METHODS

Background factors (age, sex, diabetes, dyslipidemia, hypertension, and PNPLA3 gene polymorphism), blood test results, liver histology findings, muscle mass, and grip strength were investigated in 782 patients with NAFLD who underwent liver biopsy. Prognosis and complications were compared among 549 patients with nonlean or lean NAFLD who were followed up for 6.5 years. Additionally, background factors, blood test results, liver histology findings, prognosis, and complications were compared according to age (≥60 years vs. <60 years) in patients with lean NAFLD.

RESULTS

Lean NAFLD patients showed lower aspartate aminotransferase, alanine aminotransferase, homeostasis model assessment-insulin resistance, high-sensitivity C-reactive protein, ferritin, and leptin but higher adiponectin and hemoglobin A1c (HbA1c) levels than patients with nonlean NAFLD. Furthermore, lean NAFLD patients showed less liver fibrosis, inflammation, steatosis, and ballooning. Among lean NAFLD patients, those aged 60 years and older were more frequently female, showed higher rates of hypertension, diabetes, and dyslipidemia, had higher HbA1c and type IV collagen 7S levels, lower platelet count, higher liver fibrosis and inflammation grades, and lower muscle mass and grip strength. Lean NAFLD was associated with a worse prognosis in patients aged 60 years and over than in those younger than 60 years of age and with a higher incidence of liver-related disease, cerebrocardiovascular events, and nonliver cancer.

CONCLUSIONS

Age is an important consideration in patients with lean NAFLD. Compared with nonlean NAFLD, lean NAFLD was associated with a worse prognosis and higher risk of complications in patients aged 60 years and older.

MAFLD might be better in identifying subjects with sarcopenia or cardiovascular risk than NAFLD: A nationwide study

BACKGROUND AND AIM

Clinical features of non-alcoholic fatty liver disease (NAFLD), but not fulfilling the diagnostic criteria of metabolic dysfunction-associated fatty liver disease (MAFLD), remain unclear. We investigated the risk of sarcopenia and cardiovascular disease (CVD) in MAFLD and non-metabolic risk (MR) NAFLD.

METHODS

Subjects were selected from the Korean National Health and Nutrition Examination Surveys 2008-2011. Liver steatosis was assessed using fatty liver index. Significant liver fibrosis was defined using fibrosis-4 index, categorized by age cut-offs. Sarcopenia was defined as the lowest quintile sarcopenia index. Atherosclerotic CVD (ASCVD) risk score > 10% was defined as high probability.

RESULTS

A total of 7248 subjects had fatty liver (137 with non-MR NAFLD, 1752 with MAFLD/non-NAFLD, and 5359 with overlapping MAFLD and NAFLD). In non-MR NAFLD group 28 (20.4%) had significant fibrosis. The risk of sarcopenia (adjusted odds ratio [aOR] = 2.71, 95% confidence index [CI] = 1.27-5.78) and high probability of ASCVD (aOR = 2.79, 95% CI = 1.23-6.35) was significantly higher in MAFLD/non-NAFLD group than in non-MR NAFLD group (all P < 0.05). The risk of sarcopenia and high probability of ASCVD was similar between subjects with and without significant fibrosis in non-MR NAFLD group (all P > 0.05). However, the risk was significantly higher in MAFLD group than in non-MR NAFLD group (aOR = 3.38 for sarcopenia and 3.73 for ASCVD; all P < 0.05).

CONCLUSIONS

The risks of sarcopenia and CVD were significantly higher in MAFLD group but did not differ according to fibrotic burden in non-MR NAFLD group. The MAFLD criteria might be better for identifying high-risk fatty liver disease than the NAFLD criteria.