Metabolic Syndrome, Nonalcoholic Fatty Liver Disease, and Chronic Hepatitis B: A Narrative Review

Mediational role of metabolic syndrome between physical activity, sedentary behavior and non-alcoholic fatty liver disease: a cross-sectional study

BACKGROUND

Physical activity (PA), sedentary behavior (SB), metabolic syndrome (MetS), and non-alcoholic fatty liver disease (NAFLD) have been linked in previous studies. Nevertheless, it is unclear whether MetS has a mediating influence on the relationships among physical activity, sedentary behavior, and non-alcoholic fatty liver disease. This study aims to assess the connections between physical activity, sedentary behavior, and non-alcoholic fatty liver disease and to explore the extent to which metabolic syndrome acts as a mediator in this association.

METHODS

A total of 3351 adults from the National Health and Nutrition Examination Survey (NHANES) from 2017 to 2018 were included in our study. Physical activity and sedentary behavior were categorized as work activity (WA), recreational activity (RA), walking/bicycling (for commuting) and sedentary behavior to investigate the association with metabolic syndrome and non-alcoholic fatty liver disease. Besides, mediation analysis was utilized to determine the extent to which metabolic syndrome mediates the relationships among inadequate physical activity, prolonged sedentary behavior, and non-alcoholic fatty liver disease.

RESULTS

Regression analysis revealed that a reduced risk of developing NAFLD was associated with sufficient recreational activity (OR = 0.61, 95% CI: 0.44-0.83, P = 0.004), while an increased risk of MetS was observed in sedentary behavior group (OR = 1.28, 95% CI: 1.00-1.64, P < 0.05). In addition, strong associations were detected between MetS and NAFLD. Mediation analysis indicated that metabolic syndrome accounts for 17.9% of the influence that recreational activity has on the risk of NAFLD. Subgroup analysis indicated sex differences in these associations. Specifically, recreational activity may not significantly influence the risk of developing NAFLD in females, and the mediating role of MetS was no longer significant in both sex-specific subgroups.

CONCLUSION

In the general adult population, metabolic syndrome may account for nearly 18% of the association between insufficient recreational activity and non-alcoholic fatty liver disease.

Risk Stratification of Metabolic Risk Factors and Statin Use Associated With Liver and Nonliver Outcomes in Chronic Hepatitis B

BACKGROUND

We investigated the association of metabolic risk factors (MRFs) and statin use with liver and nonliver outcomes in a nationwide cohort of patients with chronic hepatitis B (CHB) in the United States.

METHODS

We conducted a retrospective cohort study of adult patients with CHB using the MarketScan Databases (January 2007-December 2021). Incidence of liver and nonliver outcomes (cardiovascular disease, chronic kidney disease, and extrahepatic cancer) was analyzed. MRFs included diabetes mellitus (DM), hypertension, hyperlipidemia, and obesity.

RESULTS

The study included 52 277 patients with CHB, and 1:1 propensity score matching yielded 16 696 pairs of matched patients with and without MRFs for analysis. When compared with those without MRFs, patients with DM and all 3 other MRFs had the highest adjusted hazard ratio (95% CI) for any liver outcome at 2.08 (1.22-3.52), followed by 12.98 (7.73-21.80) for cardiovascular disease, 9.25 (5.46-15.66) for chronic kidney disease, and 2.01 (1.00-4.04) for extrahepatic cancer. Increased metabolic burden was associated with liver and nonliver outcomes except for comparison between patients without MRFs and those with MRFs but no DM (P > .2 for all liver outcomes). Among lower metabolic burden (≤2 MRFs), statin use was associated with a 15% lower risk of any liver outcomes, 35% reduced risk of HCC, and 15% lower risk of cirrhosis but not among those with higher metabolic burden (≥3 MRFs).

CONCLUSIONS

Higher metabolic burden was associated with a greater risk for liver and nonliver complications in patients with CHB, with DM having the highest impact among other MRFs. Statin use was associated with a reduced risk of liver outcomes among lower metabolic burden.

The Asian Pacific association for the study of the liver clinical practice guidelines for the diagnosis and management of metabolic dysfunction-associated fatty liver disease

Metabolic dysfunction-associated fatty liver disease (MAFLD) affects over one-fourth of the global adult population and is the leading cause of liver disease worldwide. To address this, the Asian Pacific Association for the Study of the Liver (APASL) has created clinical practice guidelines focused on MAFLD. The guidelines cover various aspects of the disease, such as its epidemiology, diagnosis, screening, assessment, and treatment. The guidelines aim to advance clinical practice, knowledge, and research on MAFLD, particularly in special groups. The guidelines are designed to advance clinical practice, to provide evidence-based recommendations to assist healthcare stakeholders in decision-making and to improve patient care and disease awareness. The guidelines take into account the burden of clinical management for the healthcare sector.

Attenuation imaging: Diagnostic differences in hepatic steatosis for chronic hepatitis B vs metabolic dysfunction-associated steatotic liver disease patients

BACKGROUND

Hepatic steatosis, characterized by fat accumulation in hepatocytes, can result from metabolic dysfunction-associated steatotic liver disease (MASLD), infections, alcoholism, chemotherapy, and toxins. MASLD is diagnosed via imaging or biopsy with metabolic criteria and may progress to metabolic dysfunction-associated steatohepatitis, potentially leading to fibrosis, cirrhosis, or cancer. The coexistence of hepatic steatosis with chronic hepatitis B (CHB) is mainly related to metabolic factors and increases mortality and cancer risks. As a noninvasive method, attenuation imaging (ATI) shows promise in quantifying liver fat, demonstrating strong correlation with liver biopsy.

AIM

To investigate the disparity of ATI for assessing biopsy-based hepatic steatosis in CHB patients and MASLD patients.

METHODS

The study enrolled 249 patients who underwent both ATI and liver biopsy, including 78 with CHB and 171 with MASLD. Hepatic steatosis was classified into grades S0 to S3 according to the proportion of fat cells present. Liver fibrosis was staged from 0 to 4 according to the meta-analysis of histological data in viral hepatitis scoring system. The diagnostic performance of attenuation coefficient (AC) values across different groups was compared for each grade of steatosis. Factors associated with the AC values were determined through linear regression analysis. A multivariate logistic regression model was established to predict ≥ S2 within the MASLD group.

RESULTS

In both the CHB and the MASLD groups, AC values increased significantly with higher steatosis grade (P < 0.001). In the CHB group, the areas under the curve (AUCs) of AC for predicting steatosis grades ≥ S1, ≥ S2 and S3 were 0.918, 0.960 and 0.987, respectively. In contrast, the MASLD group showed AUCs of 0.836, 0.774, and 0.688 for the same steatosis grades. The diagnostic performance of AC for detecting ≥ S2 and S3 indicated significant differences between the two groups (both P < 0.001). Multivariate linear regression analysis identified body mass index, triglycerides, and steatosis grade as significant factors for AC. When the steatosis grade is ≥ S2, it can progress to more serious liver conditions. A clinical model integrating blood biochemical parameters and AC was developed in the MASLD group to enhance the prediction of ≥ S2, achieving an AUC of 0.848.

CONCLUSION

The AC could effectively discriminate the degree of steatosis in both the CHB and MASLD groups. In the MASLD group, when combined with blood biochemical parameters, AC exhibited better predictive ability for moderate to severe steatosis.

Impact of Metabolic Dysfunction-Associated Fatty/Steatotic Liver Disease on Hepatocellular Carcinoma Incidence and Long-Term Prognosis Post-Liver Resection: A Systematic Review and Meta-Analysis

BACKGROUND

This study investigates the influence of metabolic dysfunction-associated fatty liver disease (MAFLD)/metabolic dysfunction-associated steatotic liver disease (MASLD) on the incidence of hepatocellular carcinoma (HCC) among general population and patients with chronic hepatitis B (CHB). It also explores its implications for the long-term prognosis of HCC patients following hepatic resection.

METHODS

Relevant studies were selected based on predefined inclusion and exclusion criteria, including adherence to diagnostic criteria for MAFLD/MASLD and reporting hazard ratios (HRs) using Cox proportional hazards models. The meta-analysis utilized R statistical software (version 4.3.0) with random-effects models to calculate pooled HRs. Sensitivity analyses were performed to ensure the robustness of results.

RESULTS

Our analysis included 19 studies, among which 12 studies focused on the cumulative incidence of HCC in the general population (979,213 individuals; 294,984 with MAFLD/MASLD and 684,229 without). MAFLD/MASLD significantly increased the cumulative incidence of HCC in the general population (HR = 1.82; 95% CI, 1.34-2.48). In CHB patients (316,445 participants; 108,183 with MAFLD/MASLD and 208,262 without), the cumulative incidence of HCC was also higher in the MAFLD/MASLD group (HR = 1.36; 95% CI, 1.32-1.40). For 7383 postoperative HCC patients (2192 with MAFLD/MASLD and 5191 without), MAFLD/MASLD did not significantly affect overall survival (OS) (HR = 0.93; 95% CI, 0.69-1.26) or recurrence-free survival (RFS) (HR = 0.98; 95% CI, 0.86-1.13).

CONCLUSION

In conclusion, MAFLD/MASLD can significantly increase the incidence of HCC in both the general population and CHB patients. However, it does not significantly influence long-term prognosis after hepatic resection, suggesting that other factors may have a greater role in determining postoperative outcomes. This highlights the need for tailored management strategies for MAFLD/MASLD patients undergoing HCC resection.

Diagnostic accuracy of FibroScan-AST (FAST) score, non-alcoholic fatty liver fibrosis score (NFS), FibroScan, and liver fibrosis index (FIB-4) for identifying fibrotic non-alcoholic steatohepatitis in patients with chronic hepatitis B with metabolic dysfunction-associated fatty liver disease

OBJECTIVE

To evaluate the diagnostic value of the FibroScan-AST (FAST) score, non-alcoholic fatty liver fibrosis score (NFS), FibroScan, and liver fibrosis index (FIB-4) for identifying fibrotic non-alcoholic steatohepatitis (NASH) in patients with chronic hepatitis B (CHB) with metabolic dysfunction-associated fatty liver disease (MAFLD).

METHODS

All patients with CHB and MAFLD who underwent liver biopsy at the Zhenjiang Third Hospital affiliated with Jiangsu University between August 2010 and December 2022 were included in the analysis. The diagnostic accuracy of FAST, NFS, FibroScan, and FIB-4 for diagnosing NASH and liver fibrosis were evaluated based on the area under the receiver-operating characteristic curve (AUC).

RESULTS

A total of 156 patients with CHB combined with MAFLD were included, including 69 with NASH and fibrosis stage 2 or higher (NASH+F ≥ 2), and 16 with NASH and cirrhosis (NASH+F4). The AUC of FAST, NFS, liver stiffness measurement (LSM), and FIB-4 for diagnosing NASH+F ≥ 2 was 0.739 (p < 0.001), 0.643 (p = 0.006), 0.754 (p < 0.001), and 0.665 (p = 0.003), respectively. The specificity of FAST, NFS, LSM, and FIB-4 was 67%, 51.8%, 78.6% and 76.8%, respectively, and the sensitivity was 75%, 78.6%, 67.9%, and 53.6%, respectively. No significant differences were found between groups. The AUC of FAST, NFS, LSM, and FIB-4 for diagnosing NASH+F4 was 0.650 (p = 0.038), 0.725 (p = 0.001), 0.851 (p < 0.001), and 0.560 (p = 0.533), respectively. The specificity of the FAST, NFS, LSM, and FIB-4 was 55.9%, 50.0%, 71.6%, and 75.5%, respectively and the sensitivity was 80.0%, 100%, 100%, and 50.0%, respectively. The differences between AUCs of FIB-4 and FAST compared with LSM were 0.291 and 0.201, respectively (p < 0.05).

CONCLUSION

In patients with CHB combined with MAFLD, FAST did not have better accuracy than NFS and FIB-4 for predicting fibrotic NASH, whereas LSM had better accuracy than FAST and FIB-4.

Antiviral therapy response in patients with chronic hepatitis B and fatty liver: A systematic review and meta-analysis

The impact of concurrent fatty liver (FL) on response to antiviral therapy in chronic hepatitis B (CHB) patients has not been well characterized. We aimed to systematically review and analyse antiviral treatment response in CHB patients with and without FL. We searched PubMed, Embase, Web of Science and the Cochrane Library databases from inception to 31 May 2023 for relevant studies. Biochemical response (BR), complete viral suppression (CVS) and hepatitis B e antigen (HBeAg) seroconversion in CHB patients with FL (CHB-FL) and without FL (non-FL CHB) were compared. In an initial pool of 2101 citations, a total of 10 studies involving 2108 patients were included. After 12 weeks of treatment, CHB-FL patients as compared with non-FL CHB patients had lower BR rate (48.37% [108/227] vs. 72.98% [126/174], p = .04) but similar trend for CVS (36.86% [80/227] vs. 68.81% [114/174], p = .05) and similar rates of HBeAg seroconversion (6.59% [7/103] vs. 7.40% [7/110], p = .89). However, at week 48, there were no statistically significant differences between CHB-FL and non-FL CHB patients in any of the outcomes, including BR (60.03% [213/471] vs. 69.37% [314/717], p = .67), CVS (65.63% [459/746] vs. 73.81% [743/1132], p = .27) and HBeAg seroconversion (10.01% [30/275] vs. 14.06% [65/453], p = .58) with similar findings for week 96. BR rate was lower in CHB-FL patients after 12 weeks of antiviral treatment. However, after a longer follow-up of either 48 or 96 weeks, no statistically significant differences were observed in BR, CVS or HBeAg seroconversion rates between CHB patients with and without FL.

Interferon-α could induce liver steatosis to promote HBsAg loss by increasing triglyceride level

Background

The correlation between metabolic syndrome (MetS) and hepatitis B surface antigen (HBsAg) loss remains to be further elucidated, particularly in patients receiving pegylated interferon-α (PEG-IFN) treatment.

Methods

758 patients with low HBsAg quantification who had received nucleos(t)ide analog (NUC) therapy for at least one year and subsequently switched to or add on PEG-IFN therapy over an unfixed course were enrolled. 412 patients were obtained with baseline data matched. A total of 206 patients achieved HBsAg loss (cured group) within 48 weeks. Demographic and biochemical data associated with MetS were gathered for analysis. HepG2.2.15 cell line was used in vitro experiments to validate the efficacy of interferon-α (IFN-α).

Results

The proportion of patients with diabetes or hypertension in the uncured group was significantly higher than in the cured group. The levels of fasting blood glucose (FBG) and glycated albumin remained elevated in the uncured group over the 48 weeks. In contrast, the levels of blood lipids and uric acid remained higher in the cured group within 48 weeks. Triglycerides levels and liver steatosis of all patients increased after PEG-IFN therapy. Baseline elevated uric acid levels and hepatic steatosis may be beneficial for HBsAg loss. IFN-α could induce hepatic steatosis and indirectly promote HBsAg loss by increasing triglyceride level through upregulation of acyl-CoA synthetase long-chain family member 1(ACSL1).

Conclusions

IFN-α could induce liver steatosis to promote HBsAg loss by increasing triglyceride level through upregulation of ACSL1. Comorbid diabetes may be detrimental to obtaining HBsAg loss with PEG-IFN therapy in CHB patients.

Serum ApoB/ApoA1 ratio in patients with CHB and the occurrence of HBV related cirrhosis and HBV related hepatocellular carcinoma

Clinical research has suggested that chronic HBV infection exerts a certain effect on the occurrence of cardiovascular disease by regulating cholesterol metabolism in liver cells. High serum apolipoprotein B/apolipoprotein A1 (ApoB/ApoA1) ratio plays a certain role in the above regulation, and it serves as a risk factor for cardiovascular disease. However, whether the ApoB/ApoA1 ratio is correlated with chronic HBV infection and its disease progression remains unclear. In accordance with the inclusion and exclusion criteria, all 378 participants administrated at Renmin Hospital of Wuhan University from March 2021 to March 2022, fell into Healthy Control (HC) group (50 participants), Hepatocellular carcinoma (HCC) group (107 patients), liver cirrhosis (LC) group (64 patients), chronic hepatitis B (CHB) group (62 patients), chronic hepatitis C (CHC) group (46 patients) and Hepatitis E Virus (HEV) group (49 patients). Serum ApoA1 and ApoB concentrations were measured at admission, and the ApoB/ApoA1 ratio was determined. The levels of laboratory parameters in the respective group were compared and ApoB/ApoA1 ratios in HCC patients and LC patients with different severity were further analyzed. ROC curves were plotted to analyze the early diagnostic ability of ApoB/ApoA1 ratio for HBV-associated HCC. Logistic regression and restricted cubic spline analysis were used to explore the correlation between ApoB/ApoA1 ratio and LC and HCC risk. A comparison was drawn in terms of ApoB/ApoA1 ratio between the groups, and the result was expressed in descending sequence: HEV group > CHB group > LC group > HCC group > CHC group > HC group, early-stage HCC < middle-stage HCC < advanced-stage HCC, Class A LC < Class B LC < Class C LC. Serum ApoB/ApoA1 ratio combined diagnosis with AFP exhibited the capability of increasing the detection efficacy and specificity of AFP for HCC and AFP-negative HCC. The incidence of LC and HCC in the respective logistic regression model showed a negative correlation with the serum ApoB/ApoA1 ratio in CHB patients (P < 0.05). After all confounding factors covered in this study were regulated, the result of the restricted cubic spline analysis suggested that in a certain range, serum ApoB/ApoA1 ratio showed an inverse correlation with the prevalence of LC or HCC in CHB patients. Serum ApoB/ApoA1 ratio in CHB patients may be conducive to identifying high-risk patients for HCC or LC, such that LC and HCC can be early diagnosed and treated.