Hepatic Fibrosis Associates With Multiple Cardiometabolic Disease Risk Factors: The Framingham Heart Study

Liver Fibrosis Marker FIB-4 Is Associated With Hepatic and Extrahepatic Malignancy Risk in a Population-Based Cohort Study

BACKGROUND AND AIMS

An association between Metabolic Dysfunction-Associated Steatotic Liver Disease (MASLD) and the development of extrahepatic malignancies has been demonstrated. However, the association of fibrosis with extrahepatic cancer is unclear. Our study aimed to test the long-term association between liver fibrosis marker and the incidence of hepatic and extrahepatic malignancies.

METHODS

A retrospective cohort study of a nationally representative sample, following 763 752 adult Clalit health services members without pre-existing liver-related diagnoses or malignancies for 14.67 years. The adjusted association between baseline liver Fibrosis-4 score (FIB-4; FIB-4 ≥ 2.67 indicated presumed advanced fibrosis), assessed from routine laboratory measurements, and incident cancer was assessed through multivariable Cox regression models.

RESULTS

The study included 763 752 people (mean age 54.3 ± 8.2 years, 43.9% males). Presumed advanced fibrosis was associated with a 16% greater risk for malignancy compared to the risk of those with no fibrosis (hazard ratio (HR) = 1.16; 95% CI, 1.10-1.22), adjusting for age, sex, ethnicity, socioeconomic status, peripherality index, baseline smoking, and obesity. The association of advanced fibrosis with malignancy was stronger when the age-specific FIB-4 cutoff was applied (HR = 1.40; 1.34-1.46) and in a subsample of subjects with MASLD diagnosis at baseline (HR = 1.43; 1.12-1.83). The association remained robust across sex, age, and ethnic groups. Both inconclusive fibrosis and fibrosis were strongly associated with malignancy of the liver or bile ducts [(HR = 1.41; 1.21-1.66) and (HR = 5.66; 4.19-7.64), respectively].

CONCLUSIONS

Liver fibrosis score is independently associated with malignancy occurrence and certain types of malignancies, and may serve as an indicator of high-risk cancer in the general population.

Decoding the Liver-Heart Axis in Cardiometabolic Diseases

The liver and heart are closely interconnected organs, and their bidirectional interaction plays a central role in cardiometabolic disease. In this review, we summarize current evidence linking liver dysfunction-particularly metabolic dysfunction-associated steatotic liver disease, alcohol-associated liver disease, and cirrhosis-with an increased risk of heart failure and other cardiovascular diseases. We discuss how these liver conditions contribute to cardiac remodeling, systemic inflammation, and hemodynamic stress and how cardiac dysfunction in turn impairs liver perfusion and promotes hepatic injury. Particular attention is given to the molecular mediators of liver-heart communication, including hepatokines and cardiokines, as well as the emerging role of advanced research methodologies, including omics integration, proximity labeling, and organ-on-chip platforms, that are redefining our understanding of interorgan cross talk. By integrating mechanistic insights with translational tools, this review aims to support the development of multiorgan therapeutic strategies for cardiometabolic disease.

Liver fibrosis associated with more severe motor deficits in early Parkinson's disease

OBJECTIVE

To determine the impact of hepatic dysfunction on the motor manifestations of Parkinson's disease.

METHODS

We conducted a retrospective cohort study using data from the Parkinson's Progression Markers Initiative. Liver fibrosis was defined using the Fibrosis-4 score. Our primary outcome was the association of baseline Fibrosis-4 score with the Movement Disorders Society - Unified Parkinson's Disease Rating Scale (MDS-UPDRS) part III score. Additional outcomes were MDS-UPDRS part II, MDS-UPDRS part IV, Hoehn and Yahr stage, and levodopa equivalent daily dose. We used linear regression models to evaluate associations at baseline and 5 years after enrollment. We used linear mixed models to evaluate the association of liver fibrosis with the progression of motor dysfunction. Models were adjusted for demographics, comorbidities, alcohol use, time since Parkinson's disease diagnosis, levodopa equivalent daily dose, and genetic predisposition.

RESULTS

We included 360 people with Parkinson's disease with a mean age of 61.8 years (standard deviation 9.7) and 41.1 % women. There was a significant association between liver fibrosis and baseline MDS-UPDRS part III score (β=2.3, 95 % CI: 0.2, 4.5). Liver fibrosis was also correlated with higher interhemispheric signal asymmetry on DAT-SPECT scans in the anterior putamen (p < 0.05 by Wilcoxon rank sum test). There was no correlation with Fibrosis-4 score and any other motor assessment at baseline or after 5 years. Patients with elevated Fibrosis-4 scores had a slower rate of progression in MDS-UPDRS part III scores.

CONCLUSION

In people with Parkinson's disease, the presence of comorbid liver fibrosis was associated with more severe motor dysfunction early, but not later, within their disease course.

Targeting Liver Fibrosis with Nanoparticle Technology: The Dual-Drug Strategy for Hepatic Stellate Cell Activation Inhibition

Hepatic stellate cells (HSCs) are pivotal in the pathogenesis and progression of liver fibrosis. Their activation is characterized by increased expression of integrin receptor αvβ3 and elevated intracellular oxidative stress, leading to extracellular matrix deposition. To address these challenges, we developed a nanotechnology-driven drug delivery system for the targeted transport of curcumin (CUR) and dihydromyricetin (DHM), two potential antifibrotic drugs with anti-inflammatory and antioxidant properties, into activated HSCs. Our results demonstrated that intravenously administered cyclo-RGD peptide (cRGDfk)-modified drug-loaded nanoparticles (NPs) effectively targeted fibrotic liver tissues, particularly activated HSCs. These drug-loaded NPs inhibited HSC activation and migration, induced apoptosis in activated HSCs, and downregulated α-SMA expression. In a carbon tetrachloride (CCl4)-induced liver fibrosis model, the NPs exhibited significant antifibrotic effects and reduced the number of Ly6Chi monocyte-derived macrophages in the liver. These findings suggest that cRGDfk-modified NPs carrying CUR and DHM have potential clinical applications in liver fibrosis therapy.

Association of MPO levels with cardiometabolic disease stratified by atherosclerotic cardiovascular risk and intensity of therapy in a workforce population

Cardiometabolic risk increases cardiovascular (CVD), chronic kidney (CKD) and non-alcoholic fatty liver (NAFLD) disease risk. High myeloperoxidase (MPO) levels identify individuals at risk for CVD. We whether elevation of MPO associated with kidney and liver disease risk in subgroups stratified by ASCVD risk and intensity of therapy. Adjusted logistic models assessed the associations of MPO with markers of kidney disease (estimated glomerular filtration rate) and liver fibrosis (NAFLD score > 0.676 or Fibrosis-4 [FIB-4] score > 2.67) across ASCVD risk (low < 7.5%; intermediate 7.5% to < 20%; high ≥ 20%). This retrospective study comprised 20,772 participants in an employer-sponsored health assessment. High MPO associated with impaired kidney function with low (OR 2.2, 95% CI 1.6-3.7) and intermediate (OR 2.0, 95% CI 1.3-3.5) ASCVD risk, and with high FIB-4 or NAFLD scores in low (OR 2.4, 95% CI 1.2-4.7), intermediate (OR 3.1, 95% CI 2.0-6.0), and high (OR 3.8, 95% CI 2.9-7.4) ASCVD risk groups. High MPO was associated with markers of CKD and liver fibrosis in low to intermediate ASCVD risk and treated groups. These findings demonstrate the commonality of cardiometabolic biomarkers across multiple organs.   Prospective studies are warranted to assess whether high MPO levels identify persons at risk for CKD and liver fibrosis who may benefit from preventive strategies.

The cross-sectional association between ultra-processed food intake and metabolic dysfunction-associated steatotic liver disease

BACKGROUND AND AIMS

The prevalence of Metabolic Dysfunction-Associated Steatotic Liver Disease has increased in parallel with a rise in consumption of ultra-processed foods (UPF), but little is known about their association.

METHODS

We cross-sectionally examined associations of UPF with hepatic steatosis and fibrosis in 2458 (mean age 54 years; 55.9 % women) community-dwelling adults who completed vibration-controlled transient elastography and a food frequency questionnaire. Dietary intake was categorized into levels of food processing via the NOVA system. We used multivariable-adjusted logistic regression models to evaluate the association of energy-adjusted UPF intake (per 1-SD unit and by quintile) with clinical hepatic steatosis (Controlled Attenuation Parameter [CAP]≥ 290 dB/m) and fibrosis (Liver Stiffness Measurement [LSM] ≥ 8.2 kPa) and tested for linear trends of UPF intake with CAP and LSM. We adjusted for age, sex, smoking, alcohol intake, physical activity, and intake of minimally processed foods. Additional models adjusted for diet quality index or body mass index (BMI).

RESULTS

Higher intake of UPF was directly associated with higher odds of hepatic steatosis (Odds Ratio 1.33 [95 % Confidence Interval 1.21, 1.46] per standard deviation increase). UPF intake and CAP had a dose-response relation (Ptrend <0.001). There were 2.50 times higher odds of hepatic steatosis (Confidence Interval 1.81, 3.45) with a 19.49 (standard error: 3.73) unit increase in CAP (P < 0.001) when comparing quintile 5 to quintile 1 of UPF consumption. Higher UPF was not significantly associated with hepatic fibrosis. Adjustment for BMI attenuated the strength of all UPF-hepatic associations.

CONCLUSIONS

UPF consumption was positively associated with hepatic steatosis. Longitudinal studies are needed to assess whether lowering consumption of UPF can decrease odds of hepatic fibrosis.

Association between the NHHR and hepatic steatosis and liver fibrosis: a population-based study

Non-alcoholic fatty liver disease (NAFLD) is strongly associated with dyslipidemia, and the non-high-density lipoprotein cholesterol to high-density lipoprotein cholesterol ratio (NHHR) is a more comprehensive indicator of lipids. This study aimed to investigate the association between NHHR and hepatic steatosis and liver fibrosis. The 2017-2020 national health and nutrition examination survey (NHANES) dataset was used for the cross-sectional survey. NHHR was calculated by lipid profiling, and the controlled attenuation parameter (CAP) and liver stiffness measurement (LSM) were determined by vibration-controlled transient elastography (VCTE). Multiple linear regression models were used to test the linear association between NHHR and hepatic steatosis and liver fibrosis. Fitted smoothing curves and threshold effect analysis were used to describe the nonlinear relationships. This population-based study included 6575 adults (≥ 18 years). After adjusting for covariates, we found a U-shaped association between NHHR and hepatic steatosis, with a breakpoint of 1.26. There was a negative association on the left side of the breakpoint (OR [95% CI] - 24.31 [- 43.92, - 4.70]) and a positive association on the right side of the breakpoint (OR [95% CI] 3.82 [2.05, 5.59]). There was no significant association between NHHR and liver fibrosis. In addition, subgroup analyses and interaction tests showed stable results. In summary, NHHR has a U-shaped association with hepatic steatosis and no significant association with liver fibrosis. Keeping NHHR below 1.26 may be an effective option to reduce the risk of hepatic steatosis. NHHR is a more efficient and cost-effective marker for NAFLD surveillance that can be utilized in future clinical practice.

Eggs, Dietary Choline, and Nonalcoholic Fatty Liver Disease in the Framingham Heart Study

BACKGROUND

Eggs are rich in bioactive compounds, including choline and carotenoids that may benefit cardiometabolic outcomes. However, little is known about their relationship with nonalcoholic fatty liver disease (NAFLD).

OBJECTIVES

We investigated the association between intakes of eggs and selected egg-rich nutrients (choline, lutein, and zeaxanthin) and NAFLD risk and changes in liver fat over ∼6 y of follow-up in the Framingham Offspring and Third Generation cohorts.

METHODS

On 2 separate occasions (2002-2005 and 2008-2011), liver fat was assessed using a computed tomography scan to estimate the average liver fat attenuation relative to a control phantom to create the liver phantom ratio (LPR). In 2008-2011, cases of incident NAFLD were identified as an LPR ≤0.33 in the absence of heavy alcohol use, after excluding prevalent NAFLD (LPR ≤0.33) in 2002-2005. Food frequency questionnaires were used to estimate egg intakes (classified as <1, 1, and ≥2 per week), dietary choline (adjusted for body weight using the residual method), and the combined intakes of lutein and zeaxanthin. Multivariable modified Poisson regression and general linear models were used to compute incident risk ratios (RR) of NAFLD and adjusted mean annualized liver fat change.

RESULTS

NAFLD cumulative incidence was 19% among a total of 1414 participants. We observed no associations between egg intake or the combined intakes of lutein and zeaxanthin with an incident NAFLD risk or liver fat change. Other diet and cardiometabolic risk factors did not modify the association between egg intake and NAFLD risk. However, dietary choline intakes were inversely associated with NAFLD risk (RR for tertile 3 compared with tertile 1: 0.69, 95% CI: 0.51, 0.94).

CONCLUSIONS

Although egg intake was not directly associated with NAFLD risk, eggs are a major source of dietary choline, which was strongly inversely associated with NAFLD risk in this community-based cohort.

Association between elevated fibrosis-4 index of liver fibrosis and risk of hemorrhagic stroke

BACKGROUND

Cirrhosis is associated with an increased risk of hemorrhagic stroke. Liver fibrosis, typically a silent condition, is antecedent to cirrhosis. The objective of this study was to test the hypothesis that elevated Fibrosis-4 (FIB-4) index, indicating a high probability of liver fibrosis, is associated with an increased risk of hemorrhagic stroke.

METHODS

We performed a cohort analysis of the prospective United Kingdom Biobank cohort study. Participants 40-69 years old were enrolled between 2007 and 2010 and had available follow-up data until March 1, 2018. We excluded participants with prevalent hemorrhagic stroke or thrombocytopenia. High probability of liver fibrosis was defined as having a value >2.67 of the validated FIB-4 index. The primary outcome was hemorrhagic stroke (intracerebral or subarachnoid hemorrhage), defined based on hospitalization and death registry data. Secondary outcomes were intracerebral and subarachnoid hemorrhage, separately. We used Cox proportional hazards models to evaluate the association of FIB-4 index >2.67 with hemorrhagic stroke while adjusting for potential confounders including hypertension, alcohol use, and antithrombotic use.

RESULTS

Among 452,994 participants (mean age, 57 years; 54% women), approximately 2% had FIB-4 index >2.67, and 1241 developed hemorrhagic stroke. In adjusted models, FIB-4 index >2.67 was associated with an increased risk of hemorrhagic stroke (HR, 2.0; 95% CI, 1.6-2.6). Results were similar for intracerebral hemorrhage (HR, 2.0; 95% CI, 1.5-2.7) and subarachnoid hemorrhage (HR, 2.2; 95% CI, 1.5-3.5) individually.

CONCLUSIONS

Elevated FIB-4 index was associated with an increased risk of hemorrhagic stroke.

Association Between Liver Fibrosis and Risk of Incident Stroke and Mortality: A Large Prospective Cohort Study

BACKGROUND

There is a well-established relationship between liver conditions and cardiovascular diseases. However, uncertainty persists regarding the contribution of liver fibrosis to major stroke types including ischemic stroke, intracerebral hemorrhage, and subarachnoid hemorrhage at the population level.

METHODS

In this large prospective cohort study, participants without previous stroke or coronary heart disease at baseline from the UK Biobank were included. We identified participants at high probability of advanced liver fibrosis using the Fibrosis-4 index >2.67 or aspartate aminotransferase to platelet ratio index ≥1.0. Multivariable Cox proportional hazard regression analyses were conducted to estimate hazard ratios (HRs) for liver fibrosis with the incidence of major stroke types, stroke-related death, and all-cause death.

RESULTS

Among 379 953 participants (mean age, 56.2 [SD, 8.1] years; 44.6% men), 7396 (1.9%) had a Fibrosis-4 index >2.67 at baseline. During a median follow-up of 12.75 (interquartile range, 12.03-13.48) years, 7143 (1.9%) incident stroke cases were documented. Advanced liver fibrosis assessed by the Fibrosis-4 index was associated with an increased risk of ischemic stroke (HR, 1.94 [95% CI, 1.70-2.22]), intracerebral hemorrhage (HR, 2.14 [95% CI, 1.63-2.81]), subarachnoid hemorrhage (HR, 1.90 [95% CI, 1.27-2.84), stroke-related death (HR, 2.20 [95% CI, 1.73-2.80]), and all-cause death (HR, 2.59 [95% CI, 2.46-2.73]). Using the aspartate aminotransferase to platelet ratio index as an alternative score, liver fibrosis was correlated with magnified risk of intracerebral hemorrhage (HR, 3.76 [95% CI, 2.38-5.93]) and subarachnoid hemorrhage (HR, 3.05 [95% CI, 1.51-6.13]) compared with ischemic stroke (HR, 1.58 [95% CI, 1.17-2.14]). Restricted cubic spline analysis showed nonlinear associations of the Fibrosis-4 index and aspartate aminotransferase to platelet ratio index with stroke incidence and all-cause death.

CONCLUSIONS

Liver fibrosis is associated with increased risk of incident stroke and death among people without previous stroke or cardiovascular events, with particularly greater risk of intracerebral hemorrhage and subarachnoid hemorrhage. Noninvasive indices of liver fibrosis may serve as an easily accessible marker to detect individuals facing elevated risk of stroke and death in the primary prevention settings.

Alcohol-associated liver disease: Natural history, management and novel targeted therapies

Alcohol consumption is a leading cause of preventable morbidity and mortality worldwide and the primary cause of advanced liver disease. Alcohol use disorder is a chronic, frequently relapsing condition characterized by persistent alcohol consumption despite its negative consequences. Alcohol-associated liver disease (ALD) encompasses a series of stages, from fatty liver (steatosis) to inflammation (steatohepatitis), fibrosis, and, ultimately, liver cirrhosis and its complications. The development of ALD is complex, involving both genetic and environmental factors, yet the exact mechanisms at play remain unclear. Alcohol-associated hepatitis (AH), a severe form of ALD, presents with sudden jaundice and liver failure. Currently, there are no approved targeted therapies able to interfere in the pathogenesis of ALD to stop the progression of the disease, making alcohol abstinence the most effective way to improve prognosis across all stages of ALD. For patients with advanced ALD who do not respond to medical therapy, liver transplantation is the only option that can improve prognosis. Recently, AH has become an early indication for liver transplantation in non-responders to medical treatment, showing promising results in carefully selected patients. This review provides an update on the epidemiology, natural history, pathogenesis, and current treatments for ALD. A deeper insight into novel targeted therapies investigated for AH focusing on new pathophysiologically-based agents is also discussed, including anti-inflammatory and antioxidative stress drugs, gut-liver axis modulators, and hepatocyte regenerative molecules.

Impact of non-alcoholic fatty liver disease and liver fibrosis on outcomes of acute ischemic stroke: A systematic review and meta-analysis

Objective

We reviewed the evidence on the impact of non-alcoholic fatty liver disease (NAFLD) and liver fibrosis on mortality, functional dependence, and recurrence after acute ischemic stroke (AIS).

Methods

This PROSPERO registered review searched PubMed, Embase, CENTRAL, and Web of Science databases from inception of databases to 30th July 2023 for studies comparing outcomes of AIS based on the presence of NAFLD and liver fibrosis. Adjusted data on mortality, functional dependence and risk of recurrent AIS was pooled to obtain odds ratio (OR) with 95% confidence intervals (CI) in a random-effects model.

Results

Ten studies were included. Descriptive analysis showed conflicting effects of NAFLD on AIS outcomes with some studies showing better functional outcomes with the presence of NAFLD. Meta-analysis showed that the presence of liver fibrosis was associated with a significantly increased risk of mortality (OR: 2.22 95% CI: 1.02-4.86 I2=92%) and functional dependence (OR: 1.89 95% CI: 1.27-2.82 I2=53%) as compared to no fibrosis. Meta-analysis found that liver fibrosis did not increase the risk of recurrent AIS (OR: 1.32 95% CI: 0.74-2.37 I2=74%).

Conclusion

Scant evidence exists for the effect of NAFLD and liver fibrosis on AIS outcomes. A paradoxical effect of NAFLD on functional outcomes has been noted which needs confirmation by future studies. Liver fibrosis was found to increase the risk of mortality and functional dependence in AIS.

Hepatic Steatosis and Fibrosis, Cardiorespiratory Fitness, and Metabolic Mediators in the Community

BACKGROUND AND AIMS

Individuals with steatotic liver disease (SLD) are at high cardiovascular disease (CVD) risk, but approaches to characterise and mitigate this risk are limited. By investigating relations, and shared metabolic pathways, of hepatic steatosis/fibrosis and cardiorespiratory fitness (CRF), we sought to identify new avenues for CVD risk reduction in SLD.

METHODS

In Framingham Heart Study (FHS) participants (N = 2722, age 54 ± 9 years, 53% women), vibration-controlled transient elastography (VCTE) was performed between 2016-2019 to assess hepatic steatosis (continuous attenuation parameter [CAP]) and fibrosis (liver fibrosis measure [LSM]). Concurrently, participants underwent maximum effort cardiopulmonary exercise testing (CPET), and metabolomic profiling (201 circulating metabolites) was performed in a subsample (N = 1268).

RESULTS

Mean BMI was 28.0 ± 5.3, 27% had hepatic steatosis, 7.6% had fibrosis, and peak oxygen uptake (VO2) was 26.2 ± 6.8 mL/kg/min in men and 20.7 ± 6.0 mL/kg/min in women (95% predicted overall). In linear models adjusted for cardiometabolic risk factors, greater CAP and LSM were associated with lower peak VO2 (p ≤ 0.002 for all), and the CAP association remained significant after BMI adjustment (p < 0.0001). We observed shared metabolic architecture of CAP, LSM, and peak VO2, with metabolites mediating up to 35% (for CAP) and 74% (for LSM) of the association with peak VO2. Metabolite mediators included amino acids and derivatives implicated in cardiometabolic risk and both protective and deleterious lipid species.

CONCLUSIONS

Hepatic steatosis and fibrosis are associated with CRF impairment in the community, and these relations are partly mediated by pathways of altered lipid metabolism and general cardiometabolic risk.

Morbidity and Mortality Risk Among People With Human Immunodeficiency Virus and Central or Visceral Adiposity: A Targeted Literature Review

BACKGROUND

Given the known relationship between human immunodeficiency virus (HIV), antiretroviral therapies, and excess visceral adipose tissue (VAT), this review sought to characterize risk of negative health outcomes associated with excess VAT and increased waist circumference (WC) in people with HIV (PWH).

METHODS

Comprehensive targeted literature searches were conducted in Medline/Embase (27 June 2022), identifying peer-reviewed articles and conference abstracts reporting on cohorts of PWH. Screening was guided by PECOS (Population, Exposure, Comparator, Outcomes, Study design) criteria. From the included studies, outcomes of interest including mortality and morbidity risk by VAT area and WC were extracted, overall, and by sex, race/ethnicity, and duration of HIV. Relationships between outcome and exposure variables were summarized.

RESULTS

Thirty-five studies were included (sample size range: 31-1748 PWH). Twenty-five studies characterized the relationship between increased WC and negative health outcomes-cardiovascular disease (CVD), arteriosclerosis, hypertension, diabetes, hepatic fat and fibrosis, and cognitive impairment-among PWH. Fifteen studies reported on increased VAT and negative health outcomes: all-cause mortality, CVD, atherosclerosis, hepatic fat, and fibrosis. Importantly, there was a 2.1-times higher odds of 5-year all-cause mortality among PWH with the highest amount of VAT in the only study identified reporting on mortality. Among the studies characterizing the relationship between morbidity and VAT, for example, 1 found that, for each 10-cm2 increase in VAT, the risk of prevalent CVD increased by 1.05 (95% CI: 1.0-1.1) times.

CONCLUSIONS

WC may be a useful and cost-effective surrogate for visceral adiposity, which is an important marker of morbidity and mortality among PWH.

The Bidirectional Relationship Between Type 2 Diabetes and Metabolic Dysfunction-Associated Steatotic Liver Disease: A Retrospective Cohort Study

Introduction Type 2 diabetes (T2D) and metabolic dysfunction-associated steatotic liver disease (MASLD) have shared pathophysiology. We aim to explore associations between these diseases and the impact of T2D therapies on MASLD-related outcomes in a real-world population. Methods A retrospective cohort study included 153 patients with biopsy-proven MASLD. Health records were reviewed for biochemical or radiological changes over follow-up and compared by T2D status. The rate of incident T2D was determined, and in those with T2D, the changes over follow-up were compared by prescribed treatment. The statistical significance of changes over follow-up was evaluated by Student's t-test, and logistic regression was undertaken to determine the impact of variables on T2D development. Results One hundred and fifty-three patients were included with a mean follow-up of 48.0±22.0 months. Patients with T2D (n=73) were older than patients without T2D (n=80; 56.3 vs 51.9 years, p<0.05). Patients with T2D had a greater stage of hepatic fibrosis (2.6 vs 1.7, p<0.001). Nine (12.3%) patients with T2D and four (5.0%) without T2D died during follow-up (p=0.10). Patients without T2D had greater glycosylated haemoglobin (HbA1c) over follow-up (3.0 mmol/mol, p<0.01), and 21 (26.3%) developed T2D. Patients with T2D treated with sodium-glucose transporter-2 inhibitors (SGLT-2i) and/or glucagon-like peptide-1 receptor analogues (GLP-1RA) had a reduction in FibroScan®-controlled attenuation parameter (-33.7dB/m, p<0.001) but not liver stiffness measure. There were no significant FibroScan® changes in those receiving other treatments. Conclusions Patients with T2D had greater hepatic fibrosis, and one in four patients with MASLD developed T2D over four years. Treatment with SGLT-2i and/or GLP-1RA in patients with T2D is associated with improved measures of steatosis but not fibrosis.

Liver fibrosis as a barometer of systemic health by gauging the risk of extrahepatic disease

This review article proposes the theory that liver fibrosis, the abnormal accumulation of excessive extracellular matrix, is not just an indicator of liver disease but also a negative reflection of overall systemic health. Liver fibrosis poses a heavy financial burden on healthcare systems worldwide and can develop due to chronic liver disease from various causes, often due to sustained inflammation. Liver fibrosis may not generate symptoms and become apparent only when it reaches the stage of cirrhosis and is associated with clinically significant portal hypertension and leads to decompensation events or promotes the development of hepatocellular carcinoma. While chronic viral hepatitis and excessive alcohol consumption were once the primary causes of chronic liver disease featuring fibrosis, this role is now increasingly taken over by metabolic dysfunction-associated steatotic liver disease (MASLD). In MASLD, endothelial dysfunction is an essential component in pathogenesis, promoting the development of liver fibrosis, but it is also present in endothelial cells of other organs such as the heart, lungs, and kidneys. Accordingly, liver fibrosis is a significant predictor of liver-related outcomes, as well as all-cause mortality, cardiovascular risk, and extrahepatic cancer. Physicians should be aware that individuals seeking medical attention for reasons unrelated to liver health may also have advanced fibrosis. Early identification of these at-risk individuals can lead to a more comprehensive assessment and the use of various treatment options, both approved and investigational, to slow or reverse the progression of liver fibrosis.

Natural history and progression of metabolic dysfunction-associated steatotic liver disease

The natural history of metabolic dysfunction-associated steatotic liver disease (MASLD), previously referred to as non-alcoholic fatty liver disease (NAFLD), is complex and long. A minority of patients develop inflammation and risk progressive fibrosis that can result in cirrhosis. Progression to cirrhosis occurs in 3-5% of patients and often takes more than 20 years. This narrative review presents an update on the natural history of MASLD, discussing studies and risk estimates for progression to severe outcomes, such as decompensated cirrhosis or hepatocellular carcinoma. We highlight the dynamic progression of liver damage, how to identify patients whose disease progresses over time, and how risk factors might be mitigated to reduce the risk for disease progression.

Mediating effect of diabetes on the relationship between nonalcoholic fatty liver disease and atherosclerotic cardiovascular disease: a prospective cohort study

OBJECTIVE

This study explored the mediating effect of diabetes on the relationship between nonalcoholic fatty liver disease (NAFLD) and atherosclerotic cardiovascular disease (ASCVD).

METHODS

In this prospective community cohort study, 82 975 participants were enrolled, with the primary outcome being the incidence of new-onset ASCVD. Using the Cox proportional hazards model, the hazard ratio (HR) and 95% confidence interval (CI) for ASCVD occurrence were computed between NAFLD and non-NAFLD groups. The correlation between NAFLD and diabetes was assessed using a binary logistic regression model, and that between NAFLD, diabetes and ASCVD using a mediation model.

RESULTS

During follow-up, 9471 ASCVD cases were observed. Compared with individuals without NAFLD, those with NAFLD showed an increased ASCVD risk (HR: 1.424; 95% CI: 1.363-1.488; P < 0.001). Stratifying NAFLD based on metabolic subphenotypes revealed a higher ASCVD risk in the NAFLD combined with diabetes subgroup than in the non-NAFLD subgroup (HR: 1.960; 95% CI: 1.817-2.115; P < 0.001). NAFLD was positively associated with baseline diabetes (odds ratio: 2.983; 95% CI: 2.813-3.163; P < 0.001). Furthermore, NAFLD severity was positively correlated with diabetes risk. Mediation analysis indicated that diabetes partially mediated the effect of NAFLD on ASCVD incidence, accounting for 20.33% of the total effect.

CONCLUSION

NAFLD is an independent predictor of increased ASCVD risk, which may be slightly mediated by diabetes in patients with NAFLD. Evaluating NAFLD and diabetes may be crucial in the early screening and prevention of ASCVD.

Association Between Nonalcoholic Fatty Liver Disease and the Risk of Cardiovascular Disease in the Middle-Age and Elderly Population of Northern China: A Cross-Sectional Study

Background

Nonalcoholic fatty liver disease (NAFLD) has become a major global health burden, which increases the risk of extra-hepatic complications such as type 2 diabetes mellitus (T2DM), dyslipidemia, metabolic syndrome (MetS), and cardiovascular disease (CVD). However, NAFLD remains underappreciated and underdiagnosed. Our study aimed to explore the prevalence of NAFLD and the association between NAFLD and CVD events among adults aged 40 and older in Northern China.

Methods

This study was conducted in the Shijingshan district of Beijing, China from November 2011 to August 2012. A total of 18891 subjects were recruited in the study. The information including demographical information, lifestyle, previous history of diabetes, hypertension, dyslipidemia, CVD, and liver disease were gathered. Data on physical examination, blood lipid profile, fasting blood glucose, and 2-hour blood glucose were recorded. Determination of MetS was according to T2DM guideline of Chinese Diabetes Society (2020 edition). The association between CVD and NAFLD was evaluated by multivariate logistic regression.

Results

The prevalence of NAFLD was 15.2%. After adjustment for age, smoking status, alcohol intake, WC, hypertension, dyslipidemia and hyperglycemia, the odds ratios (ORs) of CVD in men were 1.622 (95%CI: 1.345-1.957) and 1.990 (95%CI: 1.709-2.316) in women with NAFLD, compared with the subjects without NAFLD.

Conclusions

NAFLD is independently associated with increased risk of CVD development.

The association between liver fibrosis score and incident dementia: A nationwide retrospective cohort study

BACKGROUND

We assessed the relationship of liver fibrosis score with incident dementia in a large, national sample.

METHODS

For this retrospective cohort study, data of dementia-free individuals aged 40-69 years were derived from electronic records of the largest healthcare provider in Israel. The association between liver fibrosis score (FIB-4), assessed from routine laboratory measurements, and incident dementia was explored through multivariate cox regression models.

RESULTS

Of the total sample (N = 826,578, mean age 55 ± 8 years at baseline), 636,967 (77%) had no fibrosis, 180,114 (21.8%) had inconclusive fibrosis status and 9497 (1.2%) had high risk for advanced fibrosis. Over a median follow-up of 17 years, 41,089 dementia cases were recorded. Inconclusive liver fibrosis and advanced fibrosis were associated with increased dementia risk (HR = 1.09, 95%CI: 1.07-1.11 and HR = 1.18, 95%CI: 1.10-1.27, respectively). This association remained robust through seven sensitivity analyses.

CONCLUSIONS

Liver fibrosis assessed through a serum-based algorithm may serve as a risk factor for dementia in the general population.

HIGHLIGHTS

Liver fibrosis may predict dementia diagnosis in the general population. Inconclusive liver fibrosis was associated with 9% increased dementia risk. Advanced liver fibrosis was associated with 18% increased dementia risk. Findings remained robust in sensitivity analyses and after adjustments.

Metagenomic comparison of intestinal microbiota between normal and liver fibrotic rhesus macaques (Macaca mulatta)

Liver fibrosis is an important pathological process in chronic liver disease and cirrhosis. Recent studies have found a close association between intestinal microbiota and the development of liver fibrosis. To determine whether there are differences in the intestinal microbiota between rhesus macaques with liver fibrosis (MG) and normal rhesus macaques (MN), fecal samples were collected from 8 male MG and 12 male MN. The biological composition of the intestinal microbiota was then detected using 16S rRNA gene sequencing. The results revealed statistically significant differences in ASVs and Chao1 in the alpha-diversity and the beta-diversity of intestinal microbiota between MG and MN. Both groups shared Prevotella and Lactobacillus as common dominant microbiota. However, beneficial bacteria such as Lactobacillus were significantly less abundant in MG (P = 0.02). Predictive functional analysis using PICRUSt2 gene prediction revealed that MG exhibited a higher relative abundance of functions related to substance transport and metabolic pathways. This study may provide insight into further exploration of the mechanisms by which intestinal microbiota affect liver fibrosis and its potential future use in treating liver fibrosis.

Prevalence of Metabolic Dysfunction-associated Steatotic Liver Disease (MASLD) in Persons with Obesity and Type 2 Diabetes Mellitus: A Cross-sectional Study

Background

Metabolic dysfunction-associated steatotic liver disease (MASLD) is an important entity in patients with type-2 diabetes (T2D). Exploring the prevalence and related factors of MASLD is vital toward developing effective methods of diagnosis and treatment. The objective of this study was to determine the prevalence of MASLD in persons with obesity and T2D.

Materials and methods

This cross-sectional study was conducted at a private healthcare facility (Medicell Clinics) in Karachi, Pakistan, reviewing records from January to December 2022. Persons of either gender aged 18 or above with a diagnosis of T2D and/or obesity were analyzed.

Results

Of a total of 646 persons, 430 (66.6%) were females. The mean age was 48.58 ± 13.88 years, ranging between 18 and 85 years. T2D was noted in 351 (54.3%) patients, while obesity was observed in 593 (91.8%) persons, 396 (61.3%) had MASLD. Persons having MASLD had significantly higher body mass index (31.16 ± 5.13 vs 28.14 ± 4.76 kg/m2, p < 0.001). Likewise, obesity was significantly associated with MASLD (94.9 vs 86.8%, p < 0.001). The odds ratios (OR) and 95% confidence intervals (CIs) are reported in multivariate logistic regression table. Persons with T2DM (OR = 1.519, p = 0.009), and obesity (OR = 2.651, p = 0.001) showed significantly increased odds of having MASLD. The analysis revealed that individuals in the age-group of 18-40 (OR = 1.627, p = 0.014) had increased odds of having MASLD.

Conclusion

The prevalence of MASLD was very high in persons with T2D, and obesity. Type-2 diabetes with or without obesity, or the other way around, significantly increases the risk of MASLD. Therefore, these persons should be screened for MASLD to improve clinical outcomes in the affected people.

How to cite this article

Latif S, Ahsan T. Prevalence of Metabolic Dysfunction-associated Steatotic Liver Disease (MASLD) in Persons with Obesity and Type 2 Diabetes Mellitus: A Cross-sectional Study. Euroasian J Hepato-Gastroenterol 2024;14(2):129-133.

Prevalence and Predictors for Lean Fatty Liver Disease in General Population Attending a COVID-19 Vaccination Center in a Tertiary Care Hospital in India

Background

There is an international consensus among experts advocating for the classification of fatty liver disease as a metabolic condition. However, some authors have raised concerns that this metabolic-centric framing may result in the underdiagnosis of metabolicdysfunction-associated steatotic liver disease (MASLD) in lean individuals. The present study was carried out with the objective of describing metabolic characteristics in MASLD and the prevalence of lean MASLD in the general population.

Methods

We carried out a hospital-based cross-sectional study. A pre-tested proforma was used to collect data on socio-demographic factors, lifestyle factors, and medical history. Transient elastography and blood investigations were carried out in all patients. The identification of independent predictors for MASLD and liver fibrosis was carried out using multivariable logistic regression. A test of interaction was conducted for studying effect modification in the association of diabetes and MASLD by subgroups of body mass index (BMI).

Results

A total of 1,243 participants were interviewed and screened for MASLD. The overall prevalence of MASLD was 43.7% (n = 543), with the prevalence of lean MASLD being 4.3% (n = 53). The prevalence of MASLD in lean vs non-lean subjects differed (21.3 vs 66.7%, p < 0.001). Of the total MASLD cases, lean MASLD constituted 9.7% of cases. The association of diabetes and MASLD did not differ in subgroups by BMI. The test for interaction to detect effect modification was not statistically significant (p = 0.673).

Conclusion

The results support laying emphasis on metabolic dysfunction as a key criterion when defining fatty liver disease. The findings emphasize the shared metabolic underpinnings between lean and non-lean MASLD and advocate for inclusive approaches in diagnosis, management, and public health initiatives.

How to cite this article

Prasad M, Bhardwaj N, Gupta E, et al. Prevalence and Predictors for Lean Fatty Liver Disease in General Population Attending a COVID-19 Vaccination Center in a Tertiary Care Hospital in India. Euroasian J Hepato-Gastroenterol 2024;14(2):145-150.

Association of Aortic Stiffness and Pressure Pulsatility With Noninvasive Estimates of Hepatic Steatosis and Fibrosis: The Framingham Heart Study

BACKGROUND

Arterial stiffening may contribute to the pathogenesis of metabolic dysfunction-associated steatotic liver disease. We aimed to assess relations of vascular hemodynamic measures with measures of hepatic steatosis and fibrosis in the community.

METHODS

Our sample was drawn from the Framingham Offspring, New Offspring Spouse, Third Generation, Omni-1, and Omni-2 cohorts (N=3875; mean age, 56 years; 54% women). We used vibration-controlled transient elastography to assess controlled attenuation parameter and liver stiffness measurements as measures of liver steatosis and liver fibrosis, respectively. We assessed noninvasive vascular hemodynamics using arterial tonometry. We assessed cross-sectional relations of vascular hemodynamic measures with continuous and dichotomous measures of hepatic steatosis and fibrosis using multivariable linear and logistic regression.

RESULTS

In multivariable models adjusting for cardiometabolic risk factors, higher carotid-femoral pulse wave velocity (estimated β per SD, 0.05 [95% CI, 0.01-0.09]; P=0.003), but not forward pressure wave amplitude and central pulse pressure, was associated with more liver steatosis (higher controlled attenuation parameter). Additionally, higher carotid-femoral pulse wave velocity (β=0.11 [95% CI, 0.07-0.15]; P<0.001), forward pressure wave amplitude (β=0.05 [95% CI, 0.01-0.09]; P=0.01), and central pulse pressure (β=0.05 [95% CI, 0.01-0.09]; P=0.01) were associated with more hepatic fibrosis (higher liver stiffness measurement). Associations were more prominent among men and among participants with obesity, diabetes, and metabolic syndrome (interaction P values, <0.001-0.04). Higher carotid-femoral pulse wave velocity, but not forward pressure wave amplitude and central pulse pressure, was associated with higher odds of hepatic steatosis (odds ratio, 1.16 [95% CI, 1.02-1.31]; P=0.02) and fibrosis (odds ratio, 1.40 [95% CI, 1.19-1.64]; P<0.001).

CONCLUSIONS

Elevated aortic stiffness and pressure pulsatility may contribute to hepatic steatosis and fibrosis.

Coronary artery disease as a risk factor for metabolic dysfunction-associated steatotic liver disease and liver fibrosis

INTRODUCTION AND OBJECTIVES

Patients with metabolic dysfunction-associated steatotic liver disease (MASLD) are at an increased cardiovascular risk. On the contrary, non-alcoholic fatty liver disease (NAFLD) is highly prevalent in patients with coronary heart disease (CHD). However, it is not known whether patients with significant CHD show a higher frequency of liver fibrosis. This study aimed to determine the frequency of MASLD and liver fibrosis in patients with CHD and to assess whether coronary stenosis is significantly associated with MASLD and fibrosis.

PATIENTS AND METHODS

This observational and analytical study included adult patients without any known liver disease who underwent coronary angiography for suspected coronary artery disease (Jul 2021-Jul 2022). The presence of significant CHD (> 50% stenosis of at least one coronary artery) was determined. Liver elastography (FibroScan®) was performed up to 6 months after the coronary angiographic study to determine liver fibrosis, a measurement of liver stiffness (> 6.5 Kpa). Fisher's test, Mann-Whitney U test, and logistic regression models were used (p < 0.05).

RESULTS

The study included 113 patients (76% men, average age: 63 years [standard deviation: 9.9]), of which 72% presented with significant CHD. The prevalence rate of MASLD was 52%. Liver fibrosis was present in 12% of the patients and all patients in the significant CHD group (p = 0.007). An increase in the number of vessels with significant CHD increased the probability of liver fibrosis (odds ratio, 1.79; 95% confidence interval, 1.06-3.04; p = 0.029).

CONCLUSIONS

MASLD is highly prevalent in patients with significant CHD but without known liver damage. These data suggest that MASLD and liver fibrosis should be investigated in patients with CHD. The presence of confounding variables, especially the presence of type 2 diabetes mellitus, should be evaluated in further studies.

Screening for liver fibrosis: lessons from colorectal and lung cancer screening

Many countries have incorporated population screening programmes for cancer, such as colorectal and lung cancer, into their health-care systems. Cirrhosis is more prevalent than colorectal cancer and has a comparable age-standardized mortality rate to lung cancer. Despite this fact, there are no screening programmes in place for early detection of liver fibrosis, the precursor of cirrhosis. In this Perspective, we use insights from colorectal and lung cancer screening to explore the benefits, challenges, implementation strategies and pathways for future liver fibrosis screening initiatives. Several non-invasive methods and referral pathways for early identification of liver fibrosis exist, but in addition to accurate detection, screening programmes must also be cost-effective and demonstrate benefit through a reduction in liver-related mortality. Randomized controlled trials are needed to confirm this. Future randomized screening trials should evaluate not only the screening tests, but also interventions used to halt disease progression in individuals identified through screening.

Lifestyle factors modified the mediation role of liver fibrosis in the association between occupational physical activity and blood pressure

Objectives

The study aimed to estimate the role of liver fibrosis in the association between occupational physical activity (OPA) and blood pressure (BP), which is modified by lifestyle factors.

Methods

The questionnaire survey and physical examination were completed among 992 construction workers in Wuhan, China. Associations between OPA or lifestyle factors and liver fibrosis indices and blood pressure were assessed using generalized additive models. The mediation analysis was used to evaluate the role of liver fibrosis in the association between OPA and lifestyle factors and BP.

Results

Moderate/high OPA group workers had an increased risk of liver fibrosis [odds ratio (OR) = 1.69, 95% confidence intervals (CI): 1.16-2.47, P < 0.05] compared with low OPA group workers. Smoking or drinking alcohol was related to liver fibrosis (aspartate aminotransferase to platelet ratio index: OR = 2.22, 95% CI: 1.07-4.62 or OR = 2.04, 95% CI: 1.00-4.15; P < 0.05). Compared with non-drinkers, drinkers were related to a 2.35-mmHg increase in systolic blood pressure (95% CI: 0.09-4.61), and a 1.60-mmHg increase in diastolic blood pressure (95% CI: 0.08-3.13; P < 0.05). We found a significant pathway, "OPA → liver fibrosis → blood pressure elevation," and lifestyle factors played a regulatory role in the pathway.

Conclusion

OPA or lifestyle factors were associated with liver fibrosis indices or BP in construction workers. Furthermore, the association between OPA and BP may be partially mediated by liver fibrosis; lifestyle factors strengthen the relationship between OPA and BP and the mediation role of liver fibrosis in the relationship.

Risk of incident cardiovascular disease among patients with gastrointestinal disorder: a prospective cohort study of 330 751 individuals

BACKGROUND AND AIMS

The associations between gastrointestinal diseases (GIs) and cardiovascular disease (CVD) were unclear. We conducted a prospective cohort study to explore their associations.

METHODS

This study included 330 751 individuals without baseline CVD from the UK Biobank cohort. Individuals with and without GIs were followed up until the ascertainment of incident CVDs, including coronary heart disease (CHD), cerebrovascular disease (CeVD), heart failure (HF), and peripheral artery disease (PAD). The diagnosis of diseases was confirmed with combination of the nationwide inpatient data, primary care data, and cancer registries. A multivariable Cox proportional hazard regression model was used to estimate the associations between GIs and the risk of incident CVD.

RESULTS

During a median follow-up of 11.8 years, 31 605 incident CVD cases were diagnosed. Individuals with GIs had an elevated risk of CVD (hazard ratio 1.37; 95% confidence interval 1.34-1.41, P < 0.001). Eleven out of 15 GIs were associated with an increased risk of CVD after Bonferroni-correction, including cirrhosis, non-alcoholic fatty liver disease, gastritis and duodenitis, irritable bowel syndrome, Barrett's esophagus, gastroesophageal reflux disease, peptic ulcer, celiac disease, diverticulum, appendicitis, and biliary disease. The associations were stronger among women, individuals aged ≤60 years, and those with body mass index ≥25 kg/m2.

CONCLUSIONS

This large-scale prospective cohort study revealed the associations of GIs with an increased risk of incident CVD, in particular CHD and PAD. These findings support the reinforced secondary CVD prevention among patients with gastrointestinal disorders.

Association between hepatic steatosis and fibrosis and arthritis among US adults: A population-based study

BACKGROUND

Lipid metabolism factors may play a role in the development of arthritis and hepatic steatosis and fibrosis. The aim of this study was to explore the potential association between arthritis and hepatic steatosis and liver fibrosis.

MATERIALS AND METHODS

The nationally representative sample from the National Health and Nutrition Examination Survey was analyzed, with data on arthritis diagnosis, subtype, and liver status obtained. Liver status was assessed using transient elastography. Hepatic steatosis was defined as a Controlled Attenuation Parameter (CAP) score ≥263 dB/m, and liver fibrosis status was defined as F0‒F4. Logistic regression models and subgroup analyses stratified by sex were used to evaluate the associations. Smooth curve fitting was used to describe the associations.

RESULTS

The present study of 6,840 adults aged 20 years or older found a significant positive correlation between arthritis and CAP in multivariate logistic regression analysis (β = 0.003, 95 % CI 0.001 to 0.0041, p < 0.001). Participants with arthritis had a higher risk of hepatic steatosis (OR = 1.248, 95 % CI 1.036 to 1.504, p = 0.020), particularly those with osteoarthritis or degenerative arthritis, but not rheumatoid arthritis (p = 0.847). The positive correlation was maintained in females (β = 0.004, 95 % CI 0.002 to 0.006, p < 0.001), but not in males. There was no significant relationship between arthritis and liver fibrosis (p = 0.508).

CONCLUSION

This study indicates that there is a positive correlation between arthritis and hepatic steatosis, particularly in females. Nonetheless, there is no significant relationship between arthritis and the risk of liver fibrosis.

Evaluation of MASLD Fibrosis, FIB-4 and APRI Score in MASLD Combined with T2DM and MACCEs Receiving SGLT2 Inhibitors Treatment

Purpose

This study aims to investigate the relationship between Sodium Glucose Co-transporter-2 inhibitors (SGLT2i) treatment and fibrosis in patients with Metabolic dysfunction-associated steatotic liver disease (MASLD) combined with Type 2 Diabetes Mellitus (T2DM) and Major Adverse Cardiovascular and Cerebrovascular Events (MACCEs).

Methods

A case-control study was conducted, involving 280 patients with MASLD combined with T2DM treated at the First Affiliated Hospital of Xinjiang Medical University from January 2014 to October 2023. Among these patients, 135 received SGLT2i treatment. The association between the Fibrosis-4 (FIB-4) index and the occurrence of MACCEs, as well as the association between the Aspartate Aminotransferase-to-Platelet Ratio Index (APRI) scores and MACCEs, were evaluated.

Results

The FIB-4 index and APRI scores were significantly lower in the SGLT2i treatment group compared to the non-SGLT2i group (1.59 vs 1.25, P<0.001). SGLT2i treatment tended to reduce the occurrence of MACCEs compared to non-SGLT2i treatment (45.5% vs 38.5%, P=0.28). All patients who developed MACCEs in the non-SGLT2i treatment group had higher FIB-4 index (1.83 vs 1.35, P=0.003). Additionally, after SGLT2i treatment for a median duration of 22 months, patients showed significant reductions in blood glucose, APRI, and FIB-4 index.

Conclusion

SGLT2i treatment significantly reduces the occurrence of MACCEs and liver fibrosis in patients with MASLD combined with T2DM. The FIB-4 index may serve as a potential surrogate marker for predicting the occurrence of MACCEs.

Metabolic dysfunction-associated steatotic liver disease-related hepatic fibrosis increases risk of insulin resistance, type 2 diabetes, and chronic kidney disease

Metabolic dysfunction-associated steatotic liver disease (MASLD) (previously called nonalcoholic fatty liver disease, NAFLD) is associated with cardiometabolic risk factors and chronic kidney disease (CKD). However, evidence is lacking regarding whether the severity of fibrosis is affected by these risk factors and diseases and to what degree. We aimed to determine the correlation between these factors and vibration-controlled transient elastography-determined liver stiffness measurements (LSMs) and controlled attenuation parameter (CAP) values in a sample of the US population. Data from the 2017-2018 cycle of the National Health and Nutrition Examination Survey were pooled. The association between LSM and cardiometabolic risk factors and CKD was assessed using generalized linear or logistic regression analyses. In multivariate regression analyses, CAP and BMI were adjusted as confounders. Of 3647 participants, 2079 (57.1%) had NAFLD/MASLD [weighted prevalence 54.8%; 95% confidence interval (CI) 51.8-57.9%]; the weighted prevalence of significant fibrosis (LSM ≥ 7.9 kPa) was 9.7% (95% CI 8.2-11.3%). Log LSM was associated with higher levels of homeostatic model assessment of insulin resistance ( β  = 2.19; P  = 0.017), hepatic steatosis (CAP > 248 dB/m) [odds ratio (OR) 3.66; 95% CI 2.22-6.02], type 2 diabetes (OR 2.69; 95% CI 1.72-4.20), and CKD (OR 1.70; 95% CI 1.24-2.34). These correlations did not change notably after adjustments were made for waist circumference, CAP, and BMI. LSM and CAP, although influenced by waist circumference and BMI, are good indicators of hepatic fibrosis and steatosis. LSM is associated with insulin resistance, diabetes, and CKD independent of hepatic steatosis and obesity.

Liver fibrosis, NT-ProBNP and mortality in patients with MASLD: A population-based cohort study

BACKGROUND & AIM

Liver fibrosis is the strongest predictor of liver-related mortality in many chronic liver diseases. NT-ProBNP is independently associated with cardiovascular mortality in general population settings. Here, we evaluate the relative contribution of non-invasively identified liver fibrosis and NT-ProBNP on all-cause and cardiovascular mortality in patients with metabolic (dysfunction)-associated steatotic liver disease (MASLD).

METHODS AND RESULTS

Serum NT-ProBNP levels were measured in 4229 patients with MASLD from the general population without a known history of heart failure that participated in the 1999-2004 cycles of the National Health and Nutrition Examination Survey. Presence of liver fibrosis was estimated using the Fibrosis-4 index (FIB-4). We applied Cox proportional hazard models adjusted for cardiovascular risk factors to evaluate the association between NT-ProBNP and FIB-4 levels and all-cause and cardiovascular mortality through December 2019. Mortality was lower for participants with normal levels of both biomarkers, intermediate if a single biomarker was elevated and highest when both were above the chosen threshold. In the multivariable-adjusted models, both elevated FIB-4 (≥2.67) and elevated NT-ProBNP levels (≥125 pg/ml) were independently associated with higher risks of all-cause mortality (HR 2.2, 95 % CI 1.5-3.2 and HR 1.6, 95 % CI 1.4-2.0, respectively) and cardiovascular mortality (HR 2.1, 95 % CI 1.2-3.7 and HR 2.1, 95 % CI 1.5-2.9, respectively). The associations remained consistent in subgroup analyses based on sex, obesity and age.

CONCLUSIONS

Both FIB-4 and NT-ProBNP are independently associated with higher mortality in patients with MASLD. Their combined use might prove useful to risk-stratify patients in clinical practice.

Liver stiffness as a cornerstone in heart disease risk assessment

Metabolic dysfunction-associated steatotic liver disease (MASLD) typically presents with hepatic fibrosis in advanced disease, resulting in increased liver stiffness. A subset of patients further develops liver cirrhosis and hepatocellular carcinoma. Cardiovascular disease is a common comorbidity in patients with MASLD and its prevalence is increasing in parallel. Recent evidence suggests that especially liver stiffness, whether or not existing against a background of MASLD, is associated with heart diseases. We conducted a narrative review on the role of liver stiffness in the prediction of highly prevalent heart diseases including heart failure, cardiac arrhythmias (in particular atrial fibrillation), coronary heart disease, and aortic valve sclerosis. Research papers were retrieved from major scientific databases (PubMed, Web of Science) until September 2023 using 'liver stiffness' and 'liver fibrosis' as keywords along with the latter cardiac conditions. Increased liver stiffness, determined by vibration-controlled transient elastography or hepatic fibrosis as predicted by biomarker panels, are associated with a variety of cardiovascular diseases, including heart failure, atrial fibrillation, and coronary heart disease. Elevated liver stiffness in patients with metabolic liver disease should lead to considerations of cardiac workup including N-terminal pro-B-type natriuretic peptide/B-type natriuretic peptide determination, electrocardiography, and coronary computed tomography angiography. In addition, patients with MASLD would benefit from heart disease case-finding strategies in which liver stiffness measurements can play a key role. In conclusion, increased liver stiffness should be a trigger to consider a cardiac workup in metabolically compromised patients.

Association of liver fibrosis with cognitive decline in Parkinson's disease

BACKGROUND

Cognitive decline is a common but variable non-motor manifestation of Parkinson's disease. Chronic liver disease contributes to dementia, but its impact on cognitive performance in Parkinson's disease is unknown. We assessed the effect of liver fibrosis on cognition in Parkinson's disease.

METHODS

We conducted a retrospective cohort study using data from the Parkinson's Progression Markers Initiative. Our exposure was liver fibrosis at baseline, based on the validated Fibrosis-4 score. Our primary outcome was the Montreal Cognitive Assessment, and additional outcome measures were the Symbol Digit Modalities Test, the Benton Judgement of Line Orientation, the Letter-Number Sequencing Test, and the Modified Semantic Fluency Test. We used linear regression models to assess the relationship between liver fibrosis and scores on cognitive assessments at baseline and linear mixed models to evaluate the association between baseline Fibrosis-4 score with changes in each cognitive test over five years. Models were adjusted for demographics, comorbidities, and alcohol use.

RESULTS

We included 409 participants (mean age 61, 40 % women). There was no significant association between liver fibrosis and baseline performance on any of the cognitive assessments in adjusted models. However, over the subsequent five year period, liver fibrosis was associated with more rapid decline in scores on the Montreal Cognitive Assessment (interaction coefficient, -0.07; 95 % CI, -0.12, -0.02), the Symbol Digit Modalities Test, the Benton Judgement of Line Orientation, and the Modified Semantic Fluency Test.

CONCLUSION

In people with Parkinson's disease, the presence of comorbid liver fibrosis was associated with more rapid decline across multiple cognitive domains.

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

Background

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

Methods

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

Results

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

Conclusion

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

Keeping an eye on the nutrition: The importance of nutrition management on cardiometabolic risk factors in cirrhotic patients

Chronic liver diseases, especially cirrhosis, are associated with significant morbidity and mortality. Besides predisposing to chronic liver disease per se, diabetes, hypertension, and dyslipidemia worsen the prognosis of patients with cirrhosis induced by other causes. There is no standard of care in the management of these factors in patients with cirrhosis. Also, in particular, it is not known whether nutritional interventions in the modification of cardiometabolic factors can improve the course of cirrhosis or not. This narrative review aimed to investigate the clinical significance of diabetes, hypertension, and dyslipidemia and appropriate nutritional interventions in cirrhotic patients. A comprehensive literature search of the published data was performed in regard to the association of cirrhosis with cardiometabolic factors and the management of cirrhosis and its complications. There is limited evidence on the association of cirrhosis with cardiometabolic risk factors. Cirrhotic cardiometabolic abnormalities are associated with an increased risk of complications, such that the coexistence of diabetes, hypertension, and dyslipidemia increases the risk of clinical decompensation in cirrhosis. Dietary management of cirrhotic patients with risk factors such as diabetes, hypertension, or dyslipidemia does not seem to be considerably different from non-cirrhotic patients.

Racial and ethnic differences and the role of unfavorable social determinants of health across steatotic liver disease subtypes in the United States

BACKGROUND

The global liver community established a more precise criteria to characterize steatotic liver disease (SLD), specifically metabolic dysfunction-associated steatotic liver disease (MASLD) and metabolic dysfunction-associated and alcohol-associated liver disease (MetALD). We aimed to estimate the burden of SLD subtypes and unfavorable social determinants of health (SDOH) in US adults and whether clinical and social factors drive disparities across racial/ethnic subgroups.

METHODS

We evaluated 4263 persons aged 20 years or older from the National Health and Nutrition Examination Survey 2017-2018. We estimated the weighted age-adjusted prevalence and severity of SLD, examined the prevalence of SDOH across SLD subtypes, and performed stepwise regression analysis to evaluate associations between race/ethnicity and SLD, accounting for metabolic risks, alcohol use, and SDOH.

RESULTS

Hispanic adults had the highest prevalence of MASLD (22.3%), MASLD-predominant MetALD (10.3%), alcohol-associated liver disease (ALD)-predominant MetALD (5.6%), and ALD (5.4%). Hispanic adults with MASLD had the highest prevalence of high-risk metabolic dysfunction-associated steatohepatitis (18.0%) and advanced fibrosis (21.1%), whereas non-Hispanic (NH) White adults with MetALD had the highest prevalence of high-risk metabolic dysfunction-associated steatohepatitis (19.3%), advanced fibrosis (19.5%), and cirrhosis (8.1%). Adults with ALD-predominant MetALD and ALD had an increased burden of unfavorable SDOH than those with MASLD, particularly food insecurity, limited health care access, and single living. In stepwise regression, the odds of SLD in Hispanic adults decreased after adjusting for metabolic risks (OR 1.40, 95% CI, 1.06-1.84) and alcohol use (OR 1.36, 95% CI, 1.01-1.82). Differences did not persist after adjusting for cumulative SDOH and nativity status (OR 1.22, 95% CI, 0.89-1.68).

CONCLUSIONS

We found substantial disparities in the burden of unfavorable SDOH across SLD subtypes, particularly among those with ALD-predominant MetALD and ALD. Population-based approaches targeting SDOH may mitigate racial/ethnic differences among US adults with SLD.

Early-stage non-alcoholic fatty liver disease in relation to atherosclerosis and inflammation

BACKGROUND AND AIMS

Non-alcoholic fatty liver disease (NAFLD) is a multisystem disease closely linked to cardiovascular disease (CVD). This study aims to investigate the connection between early-stage NAFLD and atherosclerosis, as well as the correlation between liver fibrosis and coronary heart disease while exploring underlying inflammatory mechanisms.

METHODS

In this retrospective study, the authors analyzed data from 607 patients who underwent both coronary computed tomography angiography (CCTA) and abdominal ultrasonography (US). Logistic regression was utilized to examine the association between NAFLD and atherosclerosis, while mediation analysis was conducted to explore whether inflammatory markers mediate the link between liver fibrosis and coronary artery disease.

RESULTS

Among the 607 patients included, 237 (39.0 %) were diagnosed with NAFLD through ultrasonography. After adjusting for traditional cardiovascular risk factors, ALT, and AST, NAFLD demonstrated a significant correlation with carotid intimal thickening (1.58, 95 % CI 1.04‒2.40; p = 0.034) and non-calcified plaque (1.56, 95 % CI 1.03‒2.37; p = 0.038). Additionally, fibrosis predictive markers, including FIB-4 > 1.3 (1.06, 95 % CI 2.30‒5.00; p = 0.035) and APRI (6.26, 95 % CI 1.03‒37.05; p = 0.046), independently correlated with coronary heart disease after adjusting for cardiovascular risk factors. Conversely, among systemic inflammatory markers, only the neutrophil-to-lymphocyte ratio (NLR) and systemic inflammatory response index (SIRI) are independently associated with coronary heart disease. ROC curve analysis indicated that combining predictive fibrosis markers or inflammatory markers with traditional cardiovascular risk factors enhanced the predictive accuracy for coronary heart disease. Mediation analysis revealed that NLR fully mediated the effect of liver fibrosis on coronary heart disease.

CONCLUSION

NAFLD is associated with carotid intimal thickening and non-calcified plaque, suggesting an increased cardiovascular risk. Furthermore, liver fibrosis independently increases the risk of coronary heart disease in the early-stage NAFLD population, and inflammation may play a fully mediating role in the effect of liver fibrosis on coronary heart disease. Early intervention is crucial for NAFLD patients to mitigate future major adverse cardiovascular events.

Practical Aspects of Clinical Manifestations, Pathogenesis and Therapy of Alcoholic Liver Disease and Non-alcoholic Fatty Liver Disease: Expert Opinion

Aim:to present the results of an expert discussion of modern aspects of the clinical manifestations, pathogenesis and treatment of alcoholic liver disease (ALD) and non-alcoholic fatty liver disease (NAFLD).

Key points.ALD and NAFLD are characterized by high prevalence and have a significant impact on public health. For the diagnosis of liver pathology, it is important to determine the stage of fibrosis and the severity of the exacerbation of the disease. In the treatment of ALD, it is recommended to achieve abstinence, proper nutrition, the appointment of B vitamins, drugs with cytoprotective activity. In severe hepatitis, corticosteroids may be prescribed. In the treatment of NAFLD, diet and lifestyle modification, weight loss, the use of insulin sensitizers, vitamin E, statins (in the presence of hyperlipidemia) and drugs with metabolic activity are effective.

Currently, a point of view is being actively expressed about the synergism of the action of alcohol and the metabolic syndrome on the development of fibrosis, cirrhosis, and hepatocellular carcinoma. The current international consensus recommends a change in the nomenclature of NAFLD and ALD and proposes the terms “metabolically associated steatotic liver disease” and “metabolically associated alcoholic liver disease”.

Conclusion.The closeness of the clinical manifestations and pathogenesis of NAFLD and ALD justifies attention to drugs with metabolic activity, which are recommended by the Russian Gastroenterological Association and Russian Scientific Liver Society for the treatment of these diseases. The experts support the suggestion to quantify alcohol consumption in patients with NAFLD in order to change the management of patients, if necessary.

Nonheavy Alcohol Use Associates With Liver Fibrosis and Nonalcoholic Steatohepatitis in the Framingham Heart Study

BACKGROUND AND AIMS

While heavy alcohol use consistently associates with liver disease, the effects of nonheavy alcohol consumption are less understood. We aimed to investigate the relationship between nonheavy alcohol use and chronic liver disease.

METHODS

This cross-sectional study included 2629 current drinkers in the Framingham Heart Study who completed alcohol use questionnaires and transient elastography. We defined fibrosis as liver stiffness measurement (LSM) ≥8.2 kPa. We defined at-risk nonalcoholic steatohepatitis (NASH) as FibroScan-aspartate aminotransferase (FAST) score >0.35 (90% sensitivity) or ≥0.67 (90% specificity). We performed logistic regression to investigate associations of alcohol use measures with fibrosis and NASH, adjusting for sociodemographic and metabolic factors. Subgroup analysis excluded heavy drinkers (>14 drinks per week for women or >21 for men).

RESULTS

In this sample (mean age 54.4 ± 8.9 years, 53.3% women), mean LSM was 5.6 ± 3.4 kPa, 8.2% had fibrosis, 1.9% had NASH by FAST ≥0.67, and 12.4% had NASH by FAST >0.35. Participants drank 6.2 ± 7.4 drinks per week. Total drinks per week and frequency of drinking associated with increased odds of fibrosis (adjusted odds ratio [aOR], 1.18; 95% confidence interval [CI], 1.04-1.33; and aOR, 1.08; 95% CI, 1.01-1.16, respectively). Risky weekly drinking, present in 17.4%, also associated with fibrosis (aOR, 1.49; 95% CI, 1.03-2.14). After excluding 158 heavy drinkers, total drinks per week remained associated with fibrosis (aOR, 1.16; 95% CI, 1.001-1.35). Multiple alcohol use measures positively associated with FAST >0.35.

CONCLUSIONS

In this community cohort, we demonstrate that nonheavy alcohol use associates with fibrosis and NASH, after adjustment for metabolic factors. Longitudinal studies are needed to determine the benefits of moderating alcohol use to reduce liver-related morbidity and mortality.

Increased risk of cardiometabolic disease in normal-weight individuals with non-alcoholic fatty liver disease

BACKGROUND

Non-alcoholic fatty liver disease (NAFLD) is strongly associated with obesity, but there is increasing evidence that not all individuals who are overweight/obese also develop NAFLD. Currently, it is unclear whether normal-weight (Nw) individuals with NAFLD have a higher risk of cardiometabolic disease risk compared with individual sub-groups (Nw and Obesity [Ob]) of non-NAFLD.

AIMS

This study aimed to compare the cardiometabolic profiles, cardiovascular disease, and diabetes between Nw vs. Ob with non-NAFLD vs. NAFLD.

METHODS

This study utilized the Korea National Health and Nutrition Examination Surveys collected from 2019 to 2021. Individuals were stratified into Nw vs. Ob categories and further divided into non-NAFLD and NAFLD groups based on the hepatic steatosis index and liver fat score (N = 6615).

RESULTS

The prevalence of non-NAFLD Nw, non-NAFLD Ob, NAFLD Nw, and NAFLD Ob groups was 36%, 20%, 7%, and 37%, respectively. NAFLD Nw vs. non-NAFLD Ob manifests deteriorated cardiometabolic disease risk profiles and surrogate markers of insulin resistance despite having higher weight, waist circumference, and BMI. In addition, compared to non-NAFLD Nw, individuals with NAFLD Nw had a significantly higher risk of CVDs (738%, p < .001) and diabetes (408%, p < .001), with no difference between NAFLD Nw and NAFLD Ob groups.

CONCLUSIONS

Cardiometabolic disease risk is more closely related to NAFLD developments than adiposity status. Therefore, not all overweight/obese individuals have a higher cardiometabolic disease risk, and NAFLD in Nw is an aggressive disease that is associated with cardiometabolic disease risk compared with Ob individuals without NAFLD.

Synergistic association of long-term ozone exposure and solid fuel use with biomarkers of advanced fibrosis

This study aims to explore the association of combined exposure to cooking fuel type and ambient ozone (O3) levels with hepatic fibrosis indices among rural adults. A total of 21,010 participants were derived from the Henan Rural Cohort. Information regarding cooking fuel type was collected through a questionnaire, and the concentration of ground-level O3 for each subject was obtained from the Tracking Air Pollution in China (TAP) dataset. A generalized linear model was used to examine the independent association of cooking fuel type or O3 exposure with hepatic fibrosis indices (FIB-4, APRI, and AST/ALT), and their possible interactions with advanced fibrosis were conducted. Compared to clean fuel users, solid fuel users had increased the risk of advanced fibrosis, the adjusted odds ratio (OR) of its assessment by FIB-4 1.240 (1.151, 1.336), by APRI 1.298 (1.185, 1.422), and by AST/ALT 1.135 (1.049, 1.227), respectively. Compared to low O3 exposure, the adjusted ORs of advanced fibrosis assessed by FIB-4, APRI, and AST/ALT in women with high O3 exposure were correspondingly 1.219 (1.138, 1.305), 1.110 (1.017, 1.212), and 0.883 (0.822, 0.949). The adjusted ORs of advanced fibrosis assessed by FIB-4, APRI, and AST/ALT for solid fuel users with high O3 exposure relative to clean fuel users with low O3 exposure in women were 1.557 (1.381, 1.755), 1.427 (1.237, 1.644), and 0.979 (0.863, 1.108), respectively. Significant additive effect of O3 exposure and solid fuel use on FIB-4-defined advanced fibrosis was observed in women, which was quantified by RERI (0.265, 95%CI: 0.052, 0.477), AP (0.170 95%CI: 0.045, 0.295), and SI (1.906, 95%CI: 1.058, 3.432). Solid fuel users with high O3 exposure were significantly associated with elevated hepatic fibrosis indices among rural women, suggesting that poor air quality may induce hepatocellular injury, and women might be more vulnerable to air pollution. The findings indicate that using cleaner fuels in cooking is an effective measure to maintain sustainable development of the environment and gain beneficial effect on human health. Clinical trial registration: The Henan Rural Cohort Study has been registered at the Chinese Clinical Trial Register (registration number: ChiCTR-OOC-15006699). Date of registration: 06 July 2015. http://www.chictr.org.cn/showproj.aspx?proj=11375.

[Elevated liver values caused by nonalcoholic steatohepatitis (NASH)]

Non-alcoholic steatohepatitis (NASH) is the progressive entity of non-alcoholic fatty liver disease (NAFLD) and characterised by increased inflammatory activity, potentially resulting in liver fibrosis and ultimately cirrhosis. NASH activity and hepatic fibrosis are the prognosis determinating risk factors - rational stepwise diagnostic approaches are urgently needed as therapeutic options beyond lifestyle modifications are limited.

Longitudinal association between overweight years, polygenic risk and NAFLD, significant fibrosis and cirrhosis

BACKGROUND

Adiposity amplifies the genetic risk of non-alcoholic fatty liver disease (NAFLD).

AIM

We evaluated the association between overweight-years, a cumulative exposure based on the product of the duration and severity of excess body weight (body mass index (BMI) ≥ 25 kg/m2 ), and genetic risk on liver fat and fibrosis.

METHODS

This is a longitudinal analysis derived from a prospective cohort of adults in the Framingham Heart Study who underwent genotyping and vibration-controlled-transient-elastography with controlled attenuation parameter. Univariable and multivariable linear and logistic regression analyses were used to assess the association between overweight-years and liver fat and fibrosis. The association between genetic variants of liver fat (PNPLA3, TM6SF2, GCKR) and fibrosis (PNPLA3, TM6SF2, HSD17B13) was also assessed using a polygenic risk score.

RESULTS

Our sample included 2478 participants (54% women) with mean age and BMI of 40 (±8.5) years and 26.5(±5.1) kg/m2 , respectively. The mean follow-up was 14(±0.9) years, and each participant underwent three study visits. The prevalence of NAFLD was 28.3% (n = 700), and 207 (8.4%) had clinically significant fibrosis. In age-, sex- and diabetes-adjusted multivariable analyses, overweight-years (per SD) had a strong association with NAFLD (aOR 3.53 [95% CI: 3.10-4.02], p < 0.001), clinically significant fibrosis (aOR 1.60 [95% CI: 1.40-1.84], p < 0.001) and cirrhosis (aOR 1.81 [95% CI: 1.38-2.37], p < 0.001). High-polygenic risk was significantly associated with liver fat and clinically significant fibrosis (p < 0.05).

CONCLUSION

Overweight-years is strongly associated with NAFLD and clinically significant fibrosis and combined with polygenic risk may assist in defining the trajectory of NAFLD.

A Healthy Diet is Associated with a Lower Risk of Hepatic Fibrosis

BACKGROUND

Higher diet quality is associated with a lower risk of NAFLD.

OBJECTIVES

We examined the relationship between diet quality and hepatic fibrosis.

METHODS

We analyzed cross-sectional associations between 3 a priori diet quality scores-the Dietary Approaches to Stop Hypertension (DASH) score, the Alternative Healthy Eating Index (AHEI), and a modified Mediterranean-style Diet Score (MDS)-and hepatic fat [controlled attenuation parameter (CAP)] and fibrosis [liver stiffness measurement (LSM)] measured by vibration-controlled transient elastography (VCTE) in 2532 Framingham Heart Study (FHS) participants and 3295 participants of the National Health and Nutrition Examination Survey (NHANES).

RESULTS

Higher diet quality scores were associated with lower LSM in both FHS and NHANES after adjustment for demographic and lifestyle factors. Additional adjustment for CAP or BMI attenuated the observed associations. Association strength was similar across all 3 diet quality scores. Fixed-effect meta-analysis demonstrated that, under CAP-adjusted models, the LSM decreases associated with 1-SD increase of the DASH, AHEI, and MDS scores were 2% (95% CI: 0.7%, 3.3%; P = 0.002), 2% (95% CI: 0.7%, 3.3%; P = 0.003), and 1.7% (95% CI: 0.7%, 2.6%; P = 0.001), respectively, whereas in the meta-analysis of BMI-adjusted models, LSM reductions associated with 1-SD increase of the DASH, AHEI, and MDS scores were 2.2% (95% CI: -0.1%, 2.2%; P = 0.07), 1.5% (95% CI: 0.3%, 2.7%; P = 0.02), and 0.9 (95% CI: -0.1%, 1.9%; P = 0.07), respectively.

CONCLUSIONS

We demonstrated associations of higher diet quality with favorable hepatic fat and fibrosis measures. Our data suggest that a healthy diet may reduce the likelihood of obesity and hepatic steatosis as well as the progression of steatosis to fibrosis.

Association of liver fibrosis with cognitive test performance and brain imaging parameters in the UK Biobank study

INTRODUCTION

We hypothesized that liver fibrosis is associated with worse cognitive performance and corresponding brain imaging changes.

METHODS

We examined the association of liver fibrosis with cognition and brain imaging parameters in the UK Biobank study. Liver fibrosis was assessed using the Fibrosis-4 (FIB-4) score. The primary cognitive outcome was the digit symbol substitution test (DSST); secondary outcomes were additional executive function/processing speed and memory tests. Imaging outcomes were hippocampal, total brain, and white matter hyperintensity (WMH) volumes.

RESULTS

We included 105,313 participants with cognitive test data, and 41,982 with magnetic resonance imaging (MRI). In adjusted models, liver fibrosis was associated with worse performance on the DSST and tests of executive function but not memory. Liver fibrosis was associated with lower hippocampal and total brain volumes, without compelling association with WMH volume.

DISCUSSION

Liver fibrosis is associated with worse performance on select cognitive tests and lower hippocampal and total brain volumes.

HIGHLIGHTS

It is increasingly recognized that chronic liver conditions impact brain health. We performed an analysis of data from the UK Biobank prospective cohort study. Liver fibrosis was associated with worse performance on executive function tests. Liver fibrosis was not associated with memory impairment. Liver fibrosis was associated with lower hippocampal and total brain volumes.

Liver fat is superior to visceral and pancreatic fat as a risk biomarker of impaired glucose regulation in overweight/obese subjects

AIM

To investigate the distribution of abdominal fat, particularly ectopic fat accumulation, in relation to glucose metabolism in overweight/obese patients.

MATERIALS AND METHODS

This study included 257 overweight/obese subjects with body mass index ≥23 kg/m² . All the subjects underwent an oral glucose tolerance test. Magnetic resonance imaging-proton density fat fraction was used to measure fat accumulation in the liver, pancreas and abdomen. Impaired glucose regulation (IGR) was defined as the presence of prediabetes or diabetes.

RESULTS

Liver fat content (LFC) and visceral adipose tissue (VAT) were higher in overweight/obese subjects with diabetes than in those with normal glucose tolerance (NGT). No significant differences were observed in the pancreas fat content and subcutaneous fat area between subjects with NGT and IGR. LFC was an independent risk factor of IGR (odds ratio = 1.824 per standard deviation unit, 95% CI 1.242-2.679, p = .002). Compared with the lowest tertile of LFC, the multivariate-adjusted odds ratio for the prevalence of IGR in the highest tertile was 2.842 (95% CI 1.205-6.704). However, no association was observed between the VAT per standard deviation increment and tertiles after adjusting for multiple factors. For discordant visceral and liver fat phenotypes, the high LFC-low VAT and high LFC-high VAT groups had a higher prevalence of IGR than the low LFC-low VAT group. However, there was no difference in the prevalence of IGR between the low LFC-low VAT and low LFC-high VAT groups.

CONCLUSION

Compared with visceral and pancreatic fat content, LFC is a superior risk biomarker for IGR in overweight/obese subjects.

The associations between modifiable risk factors and nonalcoholic fatty liver disease: A comprehensive Mendelian randomization study

BACKGROUND AND AIMS

Early identification of modifiable risk factors is essential for the prevention of nonalcoholic fatty liver disease (NAFLD). We aimed to systematically explore the relationships between genetically predicted modifiable risk factors and NAFLD.

APPROACH AND RESULTS

We applied univariable and multivariable Mendelian randomization analyses to explore the relationships between 35 modifiable risk factors and NAFLD. We also evaluated the combined results in three independent large genome-wide association studies. Genetically predicted alcohol frequency, elevated serum levels of liver enzymes, triglycerides, C-reactive protein, and obesity traits, including body mass index, waist circumference, and body fat mass, were associated with increased risks of NAFLD (all with p  < 0.05). Poor physical condition had a suggestive increased risk for NAFLD (odds ratio [OR] = 2.63, p  = 0.042). Genetically instrumented type 2 diabetes (T2DM), hypothyroidism, and hypertension all increased the risk for NAFLD, and the ORs (95% confidence interval) were 1.508 (1.20-1.90), 13.08 (1.53-111.65), and 3.11 (1.33-7.31) for a 1-U increase in log-transformed odds, respectively. The positive associations of T2DM and hypertension with NAFLD remained significant in multivariable analyses. The combined results from the discovery and two replication datasets further confirmed that alcohol frequency, elevated serum liver enzymes, poor physical condition, obesity traits, T2DM, and hypertension significantly increase the risk of NAFLD, whereas higher education and high-density lipoprotein cholesterol (HDL-cholesterol) could lower NAFLD risk.

CONCLUSIONS

Genetically predicted alcohol frequency, elevated serum liver enzymes, poor physical condition, obesity traits, T2DM, and hypertension were associated with an increased risk of NAFLD, whereas higher education and HDL-cholesterol were associated with a decreased risk of NAFLD.

The Past, Present, and Future of Noninvasive Test in Chronic Liver Diseases

Chronic liver disease is a major global health threat and is the 11th leading cause of death globally. A liver biopsy is frequently required in assessing the degree of steatosis and fibrosis, information that is important in diagnosis, management, and prognostication. However, liver biopsies have limitations and carry a considerable risk, leading to the development of various modalities of noninvasive testing tools. These tools have been developed in recent years and have improved markedly in diagnostic accuracy. Moving forward, they may change the practice of hepatology.