The ZJU index is a powerful index for identifying NAFLD in the general Chinese population

Association between the ZJU index and risk of new-onset non-alcoholic fatty liver disease in non-obese participants: a Chinese longitudinal prospective cohort study

Background

Non-alcoholic fatty liver disease (NAFLD) is increasingly observed in non-obese individuals. The ZJU (Zhejiang University) index has been established as a new and efficient tool for detecting NAFLD, but the relationship between the ZJU index and NAFLD within non-obese individuals still remains unclear.

Methods

A post-hoc evaluation was undertaken using data from a health assessment database by the Wenzhou Medical Center. The participants were divided into four groups based on the quartile of the ZJU Index. Cox proportional hazards regression, Kaplan-Meier analysis and tests for linear trends were used to evaluate the relationship between the ZJU index and NAFLD incidence. Subgroup analysis was conducted to test the consistency of the correlation between ZJU and NAFLD in subsgroups. Receiver operative characteristic (ROC) curve analysis was performed to evaluate the predictive performance of the ZJU index, compared with the Atherogenic index of plasma (AIP) and Remnant lipoprotein cholesterol (RLP-C) index.

Results

A total of 12,127 were included in this study, and 2,147 participants (17.7%) developed NAFLD in 5 years follow-up. Participants in higher ZJU quartiles tended to be female and have higher liver enzymes (including ALP, GGT, ALT, AST), GLU, TC, TG, LDL and higher NAFLD risk. Hazard Ratios (HR) and 95% confidence intervals (CI) for new-onset NAFLD in Q2, Q3, and Q4 were 3.67(2.43 to 5.55), 9.82(6.67 to 14.45), and 21.67(14.82 to 31.69) respectively in the fully adjusted model 3. With increased ZJU index, the cumulative new-onset NAFLD gradually increased. Significant linear associations were observed between the ZJU index and new-onset NAFLD (p for trend all<0.001). In the subgroup analysis, we noted a significant interaction in sex, with HRs of 3.27 (2.81, 3.80) in female and 2.41 (2.21, 2.63) in male (P for interaction<0.01). The ZJU index outperformed other indices with an area under the curve (AUC) of 0.823, followed by AIP (AUC=0.747) and RLP-C (AUC=0.668).

Conclusion

The ZJU index emerges as a promising tool for predicting NAFLD risk in non-obese individuals, outperforming other existing parameters including AIP and RLP-C. This could potentially aid in early detection and intervention in this specific demographic.

Diagnostic value of FibroTouch in identifying hepatic steatosis in NAFLD with MRI-PDFF as the reference standard

OBJECTIVE

To estimate the performance of the FibroTouch-based ultrasound attenuation parameter (UAP) for assessing hepatic steatosis in nonalcoholic fatty liver disease (NAFLD), with magnetic resonance imaging proton density fat fraction (MRI-PDFF) as the reference standard.

METHODS

This prospective, cross-sectional study included 275 individuals in the training group and 110 individuals in the validation group, all of whom completed a standardized research visit, laboratory tests, MRI-PDFF, and UAP measurements over 1 month. Pearson correlation coefficient and Bland-Altman analysis were used to assess the agreement between UAP and MRI-PDFF for the detection of hepatic steatosis. The diagnostic value of UAP was evaluated by the area under the receiver operating characteristic (ROC) curve (AUROC). Confounding factors to UAP performance were identified by ROC curves and regression analyses.

RESULTS

The AUROC of UAP for detecting MRI-PDFF at ≥5%, ≥10%, and ≥20% were 0.95 (95% confidence interval [CI] 0.92-0.97), 0.86 (95% CI 0.81-0.90), and 0.90 (95% CI 0.86-0.93), respectively, and their optimal thresholds were 259, 274, and 295 dB/m, respectively. The UAP measurements had higher diagnostic accuracy in participants with lower waist circumference (≤90 cm for men and ≤80 cm for women) compared to those with higher waist circumference (AUROC values: 0.97 vs 0.84, P < 0.05). Bland-Altman analysis showed good agreement between UAP and MRI-PDFF (bias 0.00021). According to established regression analyses, hepatic steatosis could be accurately diagnosed using UAP estimation.

CONCLUSIONS

FibroTouch-UAP has a high diagnostic potential for hepatic steatosis in NAFLD patients and helps clinical assessment and monitoring.

Liver Fat Scores for Noninvasive Diagnosis and Monitoring of Nonalcoholic Fatty Liver Disease in Epidemiological and Clinical Studies

Nonalcoholic fatty liver disease (NAFLD) is strongly associated with the metabolic syndrome and type 2 diabetes and independently contributes to long-term complications. Being often asymptomatic but reversible, it would require population-wide screening, but direct diagnostics are either too invasive (liver biopsy), costly (MRI) or depending on the examiner's expertise (ultrasonography). Hepatosteatosis is usually accommodated by features of the metabolic syndrome (e.g. obesity, disturbances in triglyceride and glucose metabolism), and signs of hepatocellular damage, all of which are reflected by biomarkers, which poorly predict NAFLD as single item, but provide a cheap diagnostic alternative when integrated into composite liver fat indices. Fatty liver index, NAFLD LFS, and hepatic steatosis index are common and accurate indices for NAFLD prediction, but show limited accuracy for liver fat quantification. Other indices are rarely used. Hepatic fibrosis scores are commonly used in clinical practice, but their mandatory reflection of fibrotic reorganization, hepatic injury or systemic sequelae reduces sensitivity for the diagnosis of simple steatosis. Diet-induced liver fat changes are poorly reflected by liver fat indices, depending on the intervention and its specific impact of weight loss on NAFLD. This limited validity in longitudinal settings stimulates research for new equations. Adipokines, hepatokines, markers of cellular integrity, genetic variants but also simple and inexpensive routine parameters might be potential components. Currently, liver fat indices lack precision for NAFLD prediction or monitoring in individual patients, but in large cohorts they may substitute nonexistent imaging data and serve as a compound biomarker of metabolic syndrome and its cardiometabolic sequelae.

Comparison of the diagnostic performance of twelve noninvasive scores of metabolic dysfunction-associated fatty liver disease

BACKGROUND

The absence of distinct symptoms in the majority of individuals with metabolic dysfunction-associated fatty liver disease (MAFLD) poses challenges in identifying those at high risk, so we need simple, efficient and cost-effective noninvasive scores to aid healthcare professionals in patient identification. While most noninvasive scores were developed for the diagnosis of nonalcoholic fatty liver disease (NAFLD), consequently, the objective of this study was to systematically assess the diagnostic ability of 12 noninvasive scores (METS-IR/TyG/TyG-WC/TyG-BMI/TyG-WtHR/VAI/HSI/FLI/ZJU/FSI/K-NAFLD) for MAFLD.

METHODS

The study recruited eligible participants from two sources: the National Health and Nutrition Examination Survey (NHANES) 2017-2020.3 cycle and the database of the West China Hospital Health Management Center. The performance of the model was assessed using various metrics, including area under the receiver operating characteristic curve (AUC), net reclassification index (NRI), integrated discrimination improvement (IDI), decision curve analysis (DCA), and subgroup analysis.

RESULTS

A total of 7398 participants from the NHANES cohort and 4880 patients from the Western China cohort were included. TyG-WC had the best predictive power for MAFLD risk in the NHANES cohort (AUC 0.863, 95% CI 0.855-0.871), while TyG-BMI had the best predictive ability in the Western China cohort (AUC 0.903, 95% CI 0.895-0.911), outperforming other models, and in terms of IDI, NRI, DCA, and subgroup analysis combined, TyG-WC remained superior in the NAHANES cohort and TyG-BMI in the Western China cohort.

CONCLUSIONS

TyG-BMI demonstrated satisfactory diagnostic efficacy in identifying individuals at a heightened risk of MAFLD in Western China. Conversely, TyG-WC exhibited the best diagnostic performance for MAFLD risk recognition in the United States population. These findings suggest the necessity of selecting the most suitable predictive models based on regional and ethnic variations.

Nonalcoholic fatty liver disease (NAFLD) detection and deep learning in a Chinese community-based population

OBJECTIVES

We aimed to develop and validate a deep learning system (DLS) by using an auxiliary section that extracts and outputs specific ultrasound diagnostic features to improve the explainable, clinical relevant utility of using DLS for detecting NAFLD.

METHODS

In a community-based study of 4144 participants with abdominal ultrasound scan in Hangzhou, China, we sampled 928 (617 [66.5%] females, mean age: 56 years ± 13 [standard deviation]) participants (2 images per participant) to develop and validate DLS, a two-section neural network (2S-NNet). Radiologists' consensus diagnosis classified hepatic steatosis as none steatosis, mild, moderate, and severe. We also explored the NAFLD detection performance of six one-section neural network models and five fatty liver indices on our data set. We further evaluated the influence of participants' characteristics on the correctness of 2S-NNet by logistic regression.

RESULTS

Area under the curve (AUROC) of 2S-NNet for hepatic steatosis was 0.90 for ≥ mild, 0.85 for ≥ moderate, and 0.93 for severe steatosis, and was 0.90 for NAFLD presence, 0.84 for moderate to severe NAFLD, and 0.93 for severe NAFLD. The AUROC of NAFLD severity was 0.88 for 2S-NNet, and 0.79-0.86 for one-section models. The AUROC of NAFLD presence was 0.90 for 2S-NNet, and 0.54-0.82 for fatty liver indices. Age, sex, body mass index, diabetes, fibrosis-4 index, android fat ratio, and skeletal muscle via dual-energy X-ray absorptiometry had no significant impact on the correctness of 2S-NNet (p > 0.05).

CONCLUSIONS

By using two-section design, 2S-NNet had improved the performance for detecting NAFLD with more explainable, clinical relevant utility than using one-section design.

KEY POINTS

• Based on the consensus review derived from radiologists, our DLS (2S-NNet) had an AUROC of 0.88 by using two-section design and yielded better performance for detecting NAFLD than using one-section design with more explainable, clinical relevant utility. • The 2S-NNet outperformed five fatty liver indices with the highest AUROCs (0.84-0.93 vs. 0.54-0.82) for different NAFLD severity screening, indicating screening utility of deep learning-based radiology may perform better than blood biomarker panels in epidemiology. • The correctness of 2S-NNet was not significantly influenced by individual's characteristics, including age, sex, body mass index, diabetes, fibrosis-4 index, android fat ratio, and skeletal muscle via dual-energy X-ray absorptiometry.

Genetic Variations of AKT1 are Associated with Risk Screening for Non-Alcoholic Fatty Liver Disease

Purpose

Protein kinase B (PKB/AKT) has shown a high profile in the research of metabolic diseases. This research sought to determine whether the AKT1 gene's single nucleotide polymorphisms (SNPs) and the risk of developing non-alcoholic fatty liver disease (NAFLD) were related.

Patients and Methods

Recruited in this case-control study were 2693 subjects, including 815 with NAFLD and 1878 without NAFLD. Three SNPs of AKT1 (rs2494732, rs2494752 and rs1130233) were genotyped. To examine the correlation between SNPs and NAFLD susceptibility, logistic regression was performed.

Results

After adjusting for sex, age, triglyceride and glucose, AKT1 rs2494732-C (all P < 0.05 in co-dominant model, dominant model and additive model) and rs2494752-G (P < 0.05 in co-dominant model) were linked to a lower risk of NAFLD. The combined effect of both SNPs on NAFLD risk was statistically significant, showing a dose dependence (P_trend = 0.010). Sex, body mass index, hypertension, hyperglycemia, hypertriglyceridemia, high-density lipoprotein-cholesterol, alanine aminotransferase, and beneficial alleles were all significant predictors of NAFLD risk (all P < 0.05). The prediction model achieved good discrimination, with an area under the receiver operating characteristic curve of 0.779. The Hosmer-Lemeshow test suggested an inadequate calibration of the model (χ² = 21.073, P = 0.007).

Conclusion

AKT1 rs2494732 and rs2494752 may be related to Chinese NAFLD susceptibility. The prediction model combining both SNPs with clinical factors displays a strong ability to discriminate NAFLD patients. Both SNPs may be exploited to design new models for early screening of NAFLD high-risk population.

Development and validation of a nomogram for predicting metabolic-associated fatty liver disease in the Chinese physical examination population

AIM

We aim to develop and validate a nomogram including readily available clinical and laboratory indicators to predict the risk of metabolic-associated fatty liver disease (MAFLD) in the Chinese physical examination population.

METHODS

The annual physical examination data of Chinese adults from 2016 to 2020 were retrospectively analyzed. We extracted the clinical data of 138 664 subjects and randomized participants to the development and validation groups (7:3). Significant predictors associated with MAFLD were identified by using univariate and random forest analyses, and a nomogram was constructed to predict the risk of MAFLD based on a Lasso logistic model. Receiver operating characteristic curve analysis, calibration curves, and decision curve analysis were used to verify the discrimination, calibration, and clinical practicability of the nomogram, respectively.

RESULTS

Ten variables were selected to establish the nomogram for predicting MAFLD risk: sex, age, waist circumference (WC), uric acid (UA), body mass index (BMI), waist-to-hip ratio (WHR), systolic blood pressure (SBP), fasting plasma glucose (FPG), triglycerides (TG), and alanine aminotransferase (ALT). The nomogram built on the nonoverfitting multivariable model showed good prediction of discrimination (AUC 0.914, 95% CI: 0.911-0.917), calibration, and clinical utility.

CONCLUSIONS

This nomogram can be used as a quick screening tool to assess MAFLD risk and identify individuals at high risk of MAFLD, thus contributing to the improved management of MAFLD.

Assessing the clinical utility of major indices for nonalcoholic fatty liver disease in East Asian populations

Nonalcoholic fatty liver disease (NAFLD) is currently the most common form of chronic liver disease. The growing prevalence of NAFLD is strongly associated with the high incidence of metabolic syndrome. NAFLD affects as much as 19% of the US population with a disproportionate impact on minority racial groups such as Asian Americans. If not promptly managed, NAFLD may progress to more feared complications. Liver indices for NAFLD screening have been proposed but were often developed using study populations with different anthropometrics than patients of East Asian descent. This review compares the accuracy of five indices for NAFLD screening in Asian cohorts. The Fatty Liver Index performed well in multiple large-scale community studies, although other indices may be more suited for specific patient cohorts. This is important, as the utilization of liver indices could accelerate screening for NAFLD for early management and to reduce liver disease-related health disparities among Asian Americans.

Development and Validation of a Nomogram for Prediction of the Risk of MAFLD in an Overweight and Obese Population

BACKGROUND AND AIMS

Metabolic associated fatty liver disease (MAFLD) is a serious condition, and a simple method is needed for practitioners to identify patients with the disease and have a high risk of disease progression.

METHODS

We developed and validated a nomogram for fatty liver disease and reclassified the risk factors for MAFLD. The development cohort had 335 patients who received bioelectrical impedance analysis and liver ultrasound attenuation measurements at Shenzhen People's Hospital between September 2020 and June 2021. The validation cohort had 200 patients from other hospitals who received the same evaluation. A random forest procedure and binary logistic analysis were used to screen for risk factors, establish a fatty liver disease predictive model, and forecast the risk of MAFLD. The performance of the nomogram was evaluated by measurement of discrimination, calibration, and clinical usefulness.

RESULTS

The nomogram provided good predictions in a model that included body mass index (BMI) and waist circumference. The areas under the curve of the nomogram were 0.793 in the development cohort and 0.774 in the validation cohort. The nomogram performed well for calibration, category-free net reclassification improvement, and integrated discrimination improvement. Decision curve analysis indicated the nomogram performed better than BMI for predicting net outcome.

CONCLUSIONS

The nomogram was an effective screening tool for fatty liver disease, and for those overweight individuals, may help physicians make appropriate decisions regarding treatment of MAFLD.

2019 Global NAFLD Prevalence: A Systematic Review and Meta-analysis

BACKGROUND & AIMS

The increasing rates of obesity and type 2 diabetes mellitus may lead to increased prevalence of nonalcoholic fatty liver disease (NAFLD). We aimed to determine the current and recent trends on the global and regional prevalence of NAFLD.

METHODS

Systematic search from inception to March 26, 2020 was performed without language restrictions. Two authors independently performed screening and data extraction. We performed meta-regression to determine trends in NAFLD prevalence.

RESULTS

We identified 17,244 articles from literature search and included 245 eligible studies involving 5,399,254 individuals. The pooled global prevalence of NAFLD was 29.8% (95% confidence interval [CI], 28.6%-31.1%); of these, 82.5% of included articles used ultrasound to diagnose NAFLD, with prevalence of 30.6% (95% CI, 29.2%-32.0%). South America (3 studies, 5716 individuals) and North America (4 studies, 18,236 individuals) had the highest NAFLD prevalence at 35.7% (95% CI, 34.0%-37.5%) and 35.3% (95% CI, 25.4%-45.9%), respectively. From 1991 to 2019, trend analysis showed NAFLD increased from 21.9% to 37.3% (yearly increase of 0.7%, P < .0001), with South America showing the most rapid change of 2.7% per year, followed by Europe at 1.1%.

CONCLUSIONS

Despite regional variation, the global prevalence of NAFLD is increasing overall. Policy makers must work toward reversing the current trends by increasing awareness of NAFLD and promoting healthy lifestyle environments.

External validation and comparison of simple tools to screen for nonalcoholic fatty liver disease in Chinese community population

BACKGROUND

Various noninvasive tools based on anthropometric indicators, blood lipids, and liver enzymes, etc. have been developed to screen for nonalcoholic fatty liver disease (NAFLD), with different diagnostic performance and cutoff values among studies. We aimed to validate and compare eight NAFLD-related models developed by simple indicators and to define their cutoff values in Chinese community population.

METHODS

A cross-sectional study was conducted in a health examination cohort of 3259 people. NAFLD was diagnosed by ultrasonography. General, anthropometric and biochemical data were collected. Fatty liver index (FLI), fatty liver disease index (FLD), Zhejiang University index (ZJU), lipid accumulation product (LAP), regression formula of controlled attenuation parameter (CAP), waist-to-height ratio (WHtR), triglyceride and glucose index (TyG), and visceral adiposity index (VAI) were calculated. The accuracy and cutoff points to detect NAFLD were evaluated by area under the receiver operator characteristic curve and the maximum Youden index analysis, respectively. A head-to-head comparison between these models and Decision Curve Analysis (DCA) was conducted.

RESULTS

In eight noninvasive diagnostic models of NAFLD, AUCs of FLI and FLD for NAFLD were higher than those of other models in the whole (0.852 and 0.852), male (0.826 and 0.824), and female (0.897 and 0.888) population, respectively. DCA showed that FLI, FLD, and ZJU have higher net benefit to screen for NAFLD compared to other models.

CONCLUSIONS

FLI and FLD could be the most accurate and applicable of eight models for the noninvasive diagnosis of NAFLD in both male and female groups.

Comparison of the Diagnostic Performance of Steatosis Indices for Discrimination of CT-Diagnosed Metabolic Dysfunction-Associated Fatty Liver Disease

Non-alcoholic fatty liver disease (NAFLD) was redefined as metabolic dysfunction-associated fatty liver disease (MAFLD) in 2020. Due to this, further validation of the non-invasive tests used in NAFLD diagnosis is required for MAFLD. There are five known steatosis indices for computed tomography (CT)-diagnosed MAFLD. These indices include the fatty liver index (FLI), the hepatic steatosis index (HSI), the lipid accumulation product (LAP), the visceral adiposity index (VAI), and the Zhejiang University index (ZJU). We aimed to analyze the diagnostic abilities of these five widely known steatosis indices for CT-diagnosed MAFLD. From March 2012 to October 2019, we retrospectively analyzed the clinical information and images of 1300 adults aged ≥19 years who underwent CT scans at our institution. To compare differences, the Chi-square test and independent t-test were used for categorical and continuous variables, respectively. The area under the receiver operating characteristic (AUROC) curve was used to validate the diagnostic accuracy of MAFLD. Of the five indices, FLI was the best at predicting MAFLD, with the highest AUROC (0.791). The sensitivity and specificity of FLI for diagnosing MAFLD were both 70.9%. The optimal cut-off value was 29.9. FLI is a useful surrogate index for screening MAFLD in clinical practice.

Diagnostic accuracy of the visceral adiposity index in patients with metabolic-associated fatty liver disease: a meta-analysis

Background

Conflicting results on the prognostic value of the visceral adiposity index (VAI) in patients with metabolic-associated fatty liver disease (MAFLD) have been reported. This study aimed to assess the diagnostic value of the VAI in MAFLD patients.

Methods

The Cochrane Library, PubMed, Embase, and other databases were searched to collect all documents that met the inclusion criteria from the establishment of the database to September 2021. The methodological quality of the included studies was assessed using the Newcastle–Ottawa Scale. The heterogeneity among the studies was analysed by the Cochran Q test and I² test, and the appropriate model was selected according to the heterogeneity results. The diagnostic efficacy of the VAI was evaluated by sensitivity, specificity, and area under the curve, and a Fagan diagram was generated to evaluate the diagnostic ability of the VAI.

Results

A total of 9 studies were included. The overall quality of the included studies was good. Meta-analysis showed that the combined sensitivity of the VAI for the diagnosis of MAFLD was 0.70 [95% CI (0.69–0.71)], the combined specificity was 0.67 [95% CI (0.67–0.68)], the combined positive likelihood ratio was 2.08 [95% CI (1.87–2.31)], the combined negative likelihood ratio was 0.39 [95% CI (0.34–0.44)], and the combined diagnostic odds ratio was 5.81 [95% CI (4.73–7.14)]. The corresponding area under the curve was 0.79 [95% CI (0.75–0.82)]. Meta-regression analysis showed that the diagnostic method was a potential source of heterogeneity (P < 0.05). The Fagan diagram showed that the precision of MAFLD diagnosis was 70% when the pretest probability was set to 50% and then supplemented by the VAI.

Conclusions

The VAI is an independent predictor in the diagnosis of MAFLD and may be helpful in the detection of MAFLD. A VAI > 2.33 suggests that patients have a high probability of having MAFLD.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12944-022-01636-8.

The Visceral Adiposity Index in Non-Alcoholic Fatty Liver Disease and Liver Fibrosis-Systematic Review and Meta-Analysis

(1) Background: In order to avoid a liver biopsy in non-alcoholic fatty liver disease (NAFLD), several noninvasive biomarkers have been studied lately. Therefore, we aimed to evaluate the visceral adiposity index (VAI) in NAFLD and liver fibrosis, in addition to its accuracy in predicting NAFLD and NASH. (2) Methods: We searched PubMed, Embase, Scopus, and Cochrane Library, identifying observational studies assessing the VAI in NAFLD and liver fibrosis. QUADAS-2 was used to evaluate the quality of included studies. The principal summary outcomes were mean difference (MD) and area under the curve (AUC). (3) Results: A total of 24 studies were included in our review. VAI levels were significantly increased in NAFLD (biopsy-proven and ultrasound-diagnosed), simple steatosis vs. controls, and severe steatosis vs. simple steatosis. However, no significant MD was found according to sex, liver fibrosis severity, simple vs. moderate and moderate vs. severe steatosis, pediatric NAFLD, and NASH patients. The VAI predicted NAFLD (AUC 0.767) and NASH (AUC 0.732). (4) Conclusions: The VAI has a predictive value in diagnosing NAFLD and NASH, with significantly increased values in adult NAFLD patients, simple steatosis compared to controls, and severe steatosis compared to simple steatosis.

The performance of noninvasive indexes of adults in identification of nonalcoholic fatty liver disease in children

BACKGROUND

The aim of this study is to evaluate the performance of three existing prediction scores which are applicable to adults for identifying nonalcoholic fatty liver disease (NAFLD) in Chinese children.

METHODS

We used data from routine check-up based medical records of 1845 children to validate the performance of three existing scoring systems including the hepatic steatosis index (HSI), Zhejiang University index (ZJU index), and triglyceride-glucose index (TyG index) in detection of NAFLD in children. Propensity score matching was applied to adjust for potential confounding effects in both training and validation cohorts. The area under the curve (AUC) of the receiver operating characteristic curve analysis was utilized to assess the performance of the three scoring systems.

RESULTS

Children with NAFLD had higher scores of HSI, ZJU index, and TyG index when compared with the control group (children without NAFLD). Elevated HSI, ZJU index, and TyG index scores were significantly associated with the presence of pediatric NAFLD since adjusted odds ratio and 95% CI with per interquartile range elevation of the HSI, ZJU index, and TyG index were 32.81 (20.48, 52.55), 26.31 (16.97, 40.79), and 1.83 (1.57, 2.13), respectively. In terms of discrimination of NAFLD in children, the AUC of the HSI, ZJU index, and TyG index depending on the validation cohort were 0.964, 0.960, and 0.769, respectively.

CONCLUSIONS

The HSI and ZJU index could be appropriate noninvasive biomarkers in distinguishing NAFLD in children from their controls with satisfied accuracy, which would emphasize the clinical and public health policy relevance of pediatric NAFLD. Our findings need to be confirmed by additional longitudinal studies.

Dose-response association of the ZJU index and fatty liver disease risk: A large cohort in China

AIM

The aim of this study is to investigate the sex-specific association between the ZJU index and risk of fatty liver disease in a large Chinese cohort.

METHODS

A total of 28 729 adults without fatty liver disease at baseline and who completed at least one follow-up of annual examinations between 2009 and 2016 were included in this study. The Cox proportional hazards model was used to estimate hazard ratios (HRs) and 95% confidence intervals (CI) for fatty liver disease risk associated with the ZJU index.

RESULTS

During a median follow-up of 3.01 years, 7373 developed fatty liver disease. There were significant associations between the ZJU index and fatty liver disease for women and men with increasing HRs as the quartiles increase across Q2-Q4, corresponding HRs (95% CIs) in M3 were 2.28 (1.98-2.64), 3.52 (3.07-4.04), and 4.87 (4.24-5.59) for women and 2.44 (2.17-2.75), 4.18 (3.73-4.68), and 6.23 (5.56-6.98) for men. The association between the ZJU index and fatty liver disease risk remained significant in all the subgroups except that of T2DM and abdominal obesity subgroups for men. However, the association became nonsignificant when comparing Q3 and Q2 of the ZJU index with reference in the subgroups of T2DM for men, and nonsignificant when comparing Q3 of the ZJU index with reference in the subgroups of participants with T2DM and abdominal obesity for women.

CONCLUSION

The ZJU index was significantly associated with the risk of fatty liver disease in Chinese population. It will be better to keep body mass index, alanine aminotransferase, aspartate aminotransferase, triglyceride, and fasting plasma glucose at a normal level for preventing fatty liver disease.

Association of nonalcoholic fatty liver disease with serum vitamin D levels in combination of physical fitness in korean older adults

The prevalence of non-alcoholic fatty liver disease (NAFLD) tends to increase with age, but little is known regarding relations between the risk of NAFLD in older adults and serum vitamin D (25-hydroxyvitamin D) and physical fitness levels. The aim of this study was to investigate the relationship between NAFLD risk and serum vitamin D levels combined with physical fitness in elderly adults using a non-invasive diagnostic approach. We enrolled 533 Korean older adults (80.8 % women), aged 65 years or older in this cross-sectional study. NAFLD in absence of another cause of liver disease was defined according to the ZJU and NAFLD liver fat (LFS) score. Physical fitness was assessed using a senior fitness test protocol. Logistic regression analysis was used to estimate odds ratios (ORs) and 95 % confidence intervals (CIs) of NAFLD for different combinations of serum vitamin D and physical fitness levels. According to the ZJU (OR: 3.073, CI: 1.285-7.350, p = 0.012) and LFS (OR = 2.443, CI = 1.071-5.572, p = 0.034), individuals with serum vitamin D < 30 ng/ml and poor physical fitness had a significantly higher risk of NAFLD than individuals with serum vitamin D ≥ 30 ng/ml and high fitness (reference, OR = 1), even after adjustments for age, sex, smoking, alcohol consumption and physical inactivity. However, there was no significant association after adjustment for additional metabolic diseases. Our findings suggest that the maintenance of appropriate levels of serum vitamin D and/or high physical fitness and the monitoring metabolic diseases can help reduce the risk of NAFLD in older adults.

The ZJU index is a powerful surrogate marker for NAFLD in severely obese North American women

Introduction

Non-alcoholic fatty liver disease (NAFLD) is the most common chronic liver disease in the western world and is highly associated with multiple cardiometabolic complications. The Zhejiang University (ZJU) index was first developed to predict NAFLD in Chinese populations, where it was shown to have better predictive value than other currently used indices. The aims of the present study were to 1) determine the diagnostic accuracy of ZJU index in identifying NAFLD in a well-phenotyped cohort of obese middle-aged American women and 2) compare its performance with other non-invasive indices for NAFLD identification.

Methods

To achieve this goal, we performed a retrospective analysis of a prospectively-collected cohort of participants enrolled in a weight loss trial for severe obesity (RENEW, clinicaltrials.gov identifier: NCT00712127). One hundred and seven women between the age of 30 and 55 with obesity class II (BMI 35–39.9 kg/m²) or class III (BMI ≥ 40 kg/m²) were recruited for analyses. Hepatic steatosis was measured using liver/spleen attenuation ratio (L/S ratio) from unenhanced abdominal computed tomography. Beside ZJU index, hepatic steatosis index (HSI), lipid accumulation production index (LAPI), and visceral adiposity index (VAI) were also determined and to compare their performance in predicting NAFLD.

Results

Of 107 obese women in the study, 40 (37.4%) met imaging criteria for NAFLD using cut-off value of L/S ratio < 1.1. The ZJU index was positively correlated with HIS, LAPI, but not VAI. The area under the curve was highest for the ZJU index (AUC = 0.742, 95% CI:0.647–0.837), followed by HSI (AUC = 0.728, 95% CI:0.631–0.825), LAPI (AUC = 0.682, CI:0.583–0.781), and VAI (AUC = 0.621, 95% CI:0.518–0.725), respectively, using the Youden method.

Conclusion

The ZJU index is a powerful surrogate marker for NAFLD in severely obese western females and its predictive value was better than that of other commonly used indices for predicting NAFLD. Our study is the first to suggest that the ZJU index could be a promising model for use in western as well as Chinese populations.

Risk factors for non-alcoholic fatty liver disease-associated hepatic fibrosis in type 2 diabetes patients

AIMS

In patients with type 2 diabetes, non-alcoholic fatty liver disease (NAFLD) and liver fibrosis is frequent and presumably associated with increased cardiovascular disease risk and mortality. The objective was to investigate risk factors associated with hepatic fibrosis in patients with type 2 diabetes and NAFLD to provide a basis for the prevention and treatment.

METHODS

Liver stiffness measurements (LSM) expressed in kilopascals (kPa) and controlled attenuation parameter (CAP) expressed in dB/m were diagnosed by transient elastography. Hepatic steatosis and significant fibrosis were defined as having a CAP score ≥ 260 dB/m and an LSM score ≥ 8 kPa, respectively. Associations between fibrosis categories with anthropometric and metabolic variables were determined; then, variables with statistical significance in the univariate analysis were included in multivariate model.

RESULTS

A total of 108 participant with type 2 diabetes and NAFLD (mean age: 44.69 ± 5.57 years; mean duration of diabetes 4.68 ± 4.24 years) were recruited. In these patients, body mass index, obesity, fat mass, waist circumferences, resting energy expenditure, CAP score, fasting insulin, C-peptide, HbA1C, hs-CRP as well as liver enzymes and systolic blood pressure and diastolic blood pressure were positively associated with fibrosis (all p < 0.05). Using multivariate logistic regression, serum aspartate aminotransferase (OR 1.12; 95% CI 1.06-1.19), waist circumferences (odds ratio [OR] 1.15; 95% CI 1.05-1.25) and C-peptide (OR 3.81; 95% CI 1.5-9.7) remained as independently associated with liver fibrosis.

CONCLUSION

For participants with type 2 diabetes with coexisting NAFLD, stratification by independent risk factors for fibrosis could have important prognostic value.

Risk for the development of non-alcoholic fatty liver disease: A prospective study

BACKGROUND AND AIM

Non-invasive assessment was widely used to identify the risk of non-alcoholic fatty liver disease (NAFLD) among individuals with increased metabolic risks. This study aimed to investigate the prospective relationship between ZJU index and the development of NAFLD in a Chinese population.

METHODS

A cohort of 6310 initially NAFLD-free participants was enrolled in this prospective study. Abdominal ultrasound was used to diagnosis NAFLD. NAFLD incidence was calculated among participants with different baseline ZJU index quintiles. Cox proportional hazards regression analyses were conducted to calculate the risks for incident NAFLD.

RESULTS

During 37 705 person-year follow-ups, 1071 incident NAFLD cases were identified. The baseline ZJU index was linear and positively correlated with NAFLD incidence. The incidence was 5.53, 11.75, 23.77, 43.28, and 85.60 cases per 1000 person-year follow-up for participants with baseline ZJU index in quintiles 1-5, respectively. Compared with participants with baseline ZJU index in quintile 1, the hazard ratios (95% confidence interval) for incident NAFLD were 2.092 (1.458-3.002), 4.094 (2.942-5.698), 7.095 (5.167-9.742), and 13.191 (9.684-17.968) for participants with baseline ZJU index in quintiles 2-5, respectively. Further analysis found that the changes of ZJU index during follow-up was also independently associated with risk for incident NAFLD.

CONCLUSIONS

Baseline ZJU index and absolute ZJU index changes independently predicts the risk for incident NAFLD in Chinese population.

Validation of simple indexes for nonalcoholic fatty liver disease in western China: a retrospective cross-sectional study

Various noninvasive algorithms have been developed for predicting the presence of nonalcoholic fatty liver disease (NAFLD). The evaluation of the indexes' diagnostic performance has been reported in Europe and Asia over the past decade; however, external validation of them in China is rare. This study was aimed to evaluate various indexes for NAFLD in western China. It was a retrospective cross-sectional study, using data from a large-scale health check-up project at Sichuan provincial hospital. Receiver operating characteristic (ROC) curves of eight indexes, including the fatty liver index (FLI), the hepatic steatosis index, lipid accumulation product and etc., were developed to predict ultrasonographic NAFLD. There were 13,122 subjects in this study (2,692 NAFLD patients and 10,430 non-NAFLD participants). The area under ROC curve of FLI for predicting NAFLD was 0.880 (95% confidence interval, 0.874-0.886), which was significantly higher than other seven indexes. Accuracy, sensitivity and specificity of FLI for NAFLD were good (cut-off value = 30, 0.782, 0.832, 0.770 and cut-off value = 60, 0.838, 0.443, 0.940, respectively). Furthermore, FLI also presented advantages in expenditure and accessibility, compared with other indexes. It supports FLI as an easily accessible index for physicians and a reliable predictor for NAFLD screening in western China.