Metabolic dysfunction: The silenced connection with fatty liver disease

Synergistic impact of serum uric acid and ferritin on MAFLD risk: A comprehensive cohort analysis

The characterization of Metabolic Dysfunction-Associated Fatty Liver Disease (MAFLD) underscores metabolic anomalies as critical in fatty liver disease progression. Serum uric acid is increasingly recognized as a determinant for fatty liver diseases due to its association with metabolic disorders. Ferritin, in parallel, serves as an inflammatory marker closely tied to metabolic syndrome and insulin resistance. Our study explores the combined influence of serum uric acid and ferritin on MAFLD prevalence. We conducted a retrospective cohort analysis at Samsung Changwon Hospital's Health Screening Center (2011-2018), encompassing 7,818 individuals post-exclusion criteria. Participants were stratified into gender-specific quartiles based on serum uric acid and ferritin levels. Utilizing multivariable Cox proportional hazard models alongside Kaplan-Meier analysis, we assessed the incidence of MAFLD and its relationship with these serum biomarkers, also performing subgroup assessments by gender, age, and BMI. Over 41,819 person-years with an average observation period of 5.35 ± 2.06 years, 1,073 incident cases of MAFLD were recorded. The risk of MAFLD was notably higher within the upper quartiles of serum uric acid (HR: 2.17, 95% CI: 1.70-2.78). Each increment in natural logarithmic serum uric acid level correlated with an increased risk (HR: 3.65, 95% CI: 2.32-5.74). Serum ferritin also indicated an enhanced risk, albeit less pronounced. The simultaneous presence of elevated levels of both uric acid and ferritin correlated with the highest MAFLD risk (HR: 3.89, 95% CI: 2.41-6.28). Our findings affirm that high serum uric acid levels significantly escalate the risk of MAFLD, with serum ferritin levels contributing to a lesser yet substantial degree. The concurrent elevation of both biomarkers magnifies MAFLD risk, reinforcing the need for their combined assessment in MAFLD risk evaluation.

Evaluating the RESET care program: Advancing towards scalable and effective healthcare solutions for metabolic dysfunction-associated liver disease

In this article, we discuss the recently published article by Soni et al. This study explores the effectiveness of a comprehensive digital health program, RESET care, which integrates personalized dietary plans, structured exercise, and cognitive behavioral therapy delivered through a mobile app equipped with Internet of Things devices such as body composition analyzers and smartwatches. Metabolic dysfunction-associated liver disease (MASLD), a global health burden affecting approximately 25% of the population, demands sustainable lifestyle modifications as its primary management strategy. The study reports that 100% of participants in the comprehensive intervention group (diet + exercise + cognitive behavioral therapy) achieved a weight reduction ≥ 7% (6.99 ± 2.98 kg, 7.00% ± 3.39%; P = 0.002), a clinically significant threshold for MASLD improvement. In addition, participants showed a mean weight reduction of 6.99 kg (101.10 ± 17.85 vs 94.11 ± 17.38, P < 0.001) and a body mass index reduction of 2.18 kg/m² (32.90 ± 3.02 vs 30.72 ± 3.41, P < 0.001). These results underscore the potential of digital health platforms to provide scalable, evidence-based solutions for the treatment of MASLD. While these results highlight the potential of digital platforms in the scalable and personalized management of MASLD, the small study sample size and short duration of follow-up limit the generalizability of the results. Future large-scale, long-term trials are needed to confirm sustained benefits, cost-effectiveness, and broader applicability. This letter contextualizes the study within the evolving landscape of MASLD management and emphasizes the clinical implications of integrating digital technologies into standard care.

Inter- and Intraobserver variability of attenuation coefficient measurement in innovative ultrasound diagnosis of metabolic dysfunction-associated steatotic liver disease: a cross-sectional study

Introduction

Evaluation of the ultrasound attenuation coefficient is widely used in the diagnosis of steatotic liver disease (SLD). US steatometry with real-time attenuation coefficient measurement (ACM) is an imaging tool that can replace and surpass the B-mode and improve the noninvasive diagnosis of SLD.

Aim

To evaluate the intra- and interobserver variability of ACM for the assessment of SLD.

Materials and methods

A single-center cross-sectional study was conducted at the Kyiv City Clinical Endocrinology Center. We examined 52 patients (25 men and 27 women) with a mean age of 53.2 ± 4.73 years. B-mode and ACM were performed on a Soneus P7 US system (Ultrasign, Ukraine). Examinations were performed by 2 radiologists with 28 (expert 1) and 17 (expert 2) years of experience and 4 general practitioners (GPs) without US experience (nonexperts 1-4). The training of 4 GPs on mastering the ACM was only 60 min due to US steatophantom. Each doctor performed 5 measurements of the ACM for each patient. The inter- and intraobserver variability of the results was determined by using an intraclass correlation coefficient (ICC) with a 95% confidence interval (95% CI).

Results

The overall intraobserver variability after 5 days of examination was as follows: for expert 1-0.958 (95% CI 0.938-0.974); for expert 2-0.936 (95% CI 0.905-0.980); nonexpert 1-0.891 (95% CI 0.843-0.929); nonexpert 2-0.915 (95% CI 0.876-0.945); nonexpert 3-0.927 (95% CI 0.893-0.953); nonexpert 4-0.880 (95% CI 0.827-0.927). Interobserver variability at the final timepoint (day 5) was as follows: between experts 1 and 2, 0.942 (95% CI 0.898-0.967); between nonexperts 1-4 overall, 0.871 (95% CI 0.800-0.921); and overall, 0.922 (95% CI 0.883-0.951).

Conclusion

Real-time US steatometry with ACM measurement is an informative, simple method with excellent intra- and interobserver variability and a reproducible method for population assessment for the early diagnosis and staging of SLD. The simplicity of ACM technology allows general practitioners to master the technique within 60 min. ACM measurements can be effectively employed by general practitioners (GPs) for population screening, enabling timely identification and management of MASLD.

Cardiovascular disease and metabolic dysfunction-associated steatotic liver disease: pathophysiology and diagnostic aspects

Metabolic dysfunction-associated steatotic liver disease (MASLD) can be interpreted as the hepatic expression of metabolic syndrome, which is estimated to affect 30% of the adult population. Obesity, dyslipidaemia, arterial hypertension, and T2DM are considered significant risk factors of MASLD. The relationship is two-way with MASLD found in up to 75% of patients with T2DM. Importantly, MASLD is associated with increased risk of cardiovascular diseases (CVD) such as arrhythmia, atherosclerotic heart disease, heart failure, and CVD-associated mortality. In addition, MASLD patients present with a high prevalence of major adverse cardiac events, which calls for systematic surveillance of CVD in MASLD. This review focuses on the pathophysiology behind development of CVD in MASLD, the types of cardiovascular complications, morbidity and survival, and suggestions for evaluation of patients with MASLD.

Golgi protein 73: charting new territories in diagnosing significant fibrosis in MASLD: a prospective cross-sectional study

Objectives

To explore the correlation between serum Golgi protein 73 (GP73) levels and the degree of fibrosis in Metabolic dysfunction associated steatotic liver disease (MASLD); to establish a non-invasive diagnostic algorithm based on serum GP73 and liver elasticity.

Methods

This is a prospective cross-sectional study, including 228 patients diagnosed with MASLD from May 2018 to January 2024 at two tertiary hospitals. Clinical data and hepatic pathological features and the correlation between serum GP73 and liver fibrosis were assessed. A new algorithm was conducted after logistic regression. Receiver Operating Characteristic (ROC) curve was used to compare its diagnostic performance with traditional models.

Results

Significant fibrosis was diagnosed in 37.2% (85/228) patients. Serum GP73 levels were markedly higher in patients with significant fibrosis than in those without (128 ng/mL v.s 46 ng/mL, p< 0.001). Serum GP73 levels independently predicted significant liver fibrosis (adjusted odds ratio, aOR 1.028, p< 0.001). A new algorithm based on GP73 was developed with a higher area under ROC (AUC) of 0.840 than that of Fibrosis index-4 (p< 0.001).

Conclusions

Serum GP73 is an independent risk factor for significant liver fibrosis in MASLD, and the GFA (GP73-Fibroscan-Age) model has good diagnostic efficacy for significant liver fibrosis.

Nicotinamide Adenine Dinucleotide Phosphate Oxidases and Metabolic Dysfunction-Associated Steatotic Liver Disease

Metabolic dysfunction-associated steatotic liver disease (MASLD) is characterized by lipid accumulation in the liver due to an excess in their supplies or an impairment in their management. While some patients remain stable for years, a proportion of them progress up to steatohepatitis (MASH). MASLD links with systemic pathways being associated with metabolic and non-metabolic diseases. Although liver lipid accumulation represents the first hit for MASLD, the pathophysiology of its development and progression to MASH remains not completely understood. Oxidative stress has received particular attention in recent years, as most of the oxidative process occurs in the liver, which is also the target of oxidative stress-induced damage. Growing evidence linked the activity of nicotinamide adenine dinucleotide phosphate (NADPH) oxidases (NOX) to the increased liver production of reactive oxygen species up to liver damage and fibrosis. NOX acts both in hepatocytes and in non-parenchymal hepatic cells, contributing to hepatocyte lipotoxicity, impaired hepatic microcirculation, hepatic stellate, and mesenchymal stem cells activation and proliferation. This review aims to summarize the current knowledge on the involvement of oxidative stress in the MASLD-MASH transition, focusing on the role of NOX isoforms, and to suggest targeting NOX as a therapeutic approach in MASLD.

Revolutionizing the understanding of liver disease: Metabolism, function and future

The intersection between metabolic-associated steatotic liver disease (MASLD) and chronic hepatitis B virus (HBV) infection is an emerging area of research with significant implications for public health and clinical practice. Wang et al's study highlights the complexities of managing patients with concurrent MASLD and HBV. The findings revealed that patients with concurrent MASLD-HBV exhibited more severe liver inflammation and fibrosis, whereas those with HBV alone presented a better lipid profile. The growing recognition of metabolic dysfunction in liver disease, reflected in the shift from nonalcoholic liver disease to MASLD, demands updates to clinical guidelines, particularly for patients with dual etiologies. Understanding the biological interactions between MASLD and HBV could lead to novel therapeutic approaches, emphasizing the need for personalized treatment strategies. The coexistence of MASLD and HBV presents therapeutic challenges, particularly in managing advanced fibrosis and cirrhosis, which are more likely in these patients. The aim of this editorial is to analyze the interaction between MASLD and HBV, highlight the pathophysiological mechanisms that exacerbate liver disease when both conditions coexist, and discuss the clinical implications of the findings of Wang et al.

Protein restriction associated with high fat induces metabolic dysregulation without obesity in juvenile mice

Dysregulation of energy metabolism, including hyperglycemia, insulin resistance and fatty liver have been reported in a substantial proportion of lean children. However, non-obese murine models recapitulating these features are lacking to study the mechanisms underlying the development of metabolic dysregulations in lean children. Here, we develop a model of diet-induced metabolic dysfunction without obesity in juvenile mice by feeding male and female mice a diet reflecting Western nutritional intake combined with protein restriction (mWD) during 5 weeks after weaning. mWD-fed mice (35% fat, 8% protein) do not exhibit significant weight gain and have moderate increase in adiposity compared to control mice (16% fat, 20% protein). After 3 weeks of mWD, juvenile mice have impaired glucose metabolism including hyperglycemia, insulin resistance and glucose intolerance. mWD also triggers hepatic metabolism alterations, as shown by the development of simple liver steatosis. Both male and female mice fed with mWD displayed metabolic dysregulation, which a probiotic treatment with Lactiplantibacillus plantarum WJL failed to improve. Overall, mWD-fed mice appear to be a good preclinical model to study the development of diet-induced metabolic dysfunction without obesity in juveniles.

Metabolic dysfunction associated fatty liver disease in healthy weight individuals

Metabolic dysfunction associated fatty liver disease (MAFLD) is an increasing public health problem, affecting one third of the global population. Contrary to conventional wisdom, MAFLD is not exclusive to obese or overweight individuals. Epidemiological studies have revealed a remarkable prevalence among healthy weight individuals, leading investigations into the genetic, lifestyle, and dietary factors that contribute to the development of MAFLD in this population. This shift in perspective requires reconsideration of preventive strategies, diagnostic criteria and therapeutic approaches tailored to address the unique characteristics of MAFLD healthy weight individuals. It also underscores the importance of widespread awareness and education, within the medical community and among the general population, to promote a more inclusive understanding of liver metabolic disorders. With this review, we aim to provide a comprehensive exploration of MAFLD in healthy weight individuals, encompassing epidemiological, pathophysiological, and clinical aspects.

Prebiotic Treatment in Patients with Nonalcoholic Fatty Liver Disease (NAFLD)-A Randomized Pilot Trial

Several studies show that gut microbiotas in patients with nonalcoholic fatty liver disease (NAFLD) differ from those in a healthy population, suggesting that this alteration plays a role in NAFLD pathogenesis. We investigated whether prebiotic administration affects liver fat content and/or liver-related and metabolic parameters. Patients with NAFLD and metabolic syndrome (age: 50 ± 11; 79% men) were randomized to receive either 16 g/day of prebiotic (ITFs-inulin-type fructans) (n = 8) or placebo (maltodextrin) (n = 11) for 12 weeks. Patients were instructed to maintain a stable weight throughout the study. Liver fat content (measured by H1MRS), fecal microbiota, and metabolic, inflammatory, and liver parameters were determined before and after intervention. Fecal samples from patients who received the prebiotic had an increased content of Bifidobacterium (p = 0.025), which was not observed with the placebo. However, the baseline and end-of-study liver fat contents did not change significantly in the prebiotic and placebo groups, neither did the liver function tests' metabolic and inflammatory mediators, including fibroblast growth factor-19 and lipopolysaccharide-binding protein. Body weight remained stable in both groups. These findings suggest that prebiotic treatment without weight reduction is insufficient to improve NAFLD.

Effect of Gracilaria vermiculophylla Macroalga on Non-Alcoholic Fatty Liver Disease in Obese Rats

Marine algae are valuable sources of bioactive compounds that have the potential to be used in the management of various pathologies. Despite the increasing prevalence of NAFLD, the absence of an approved effective pharmacological treatment with demonstrable effectiveness persists. In this context, the aim of the present study is to assess the effect of Gracilaria vermiculophylla red seaweed dietary supplementation on hepatic lipid accumulation, as well as on oxidative stress, inflammation and fibrosis- related markers on obese fa/fa Zucker rats fed with a standard diet, supplemented or not with 2.5% or 5% dehydrated Gracilaria vermiculophylla. After a six-week supplementation with the macroalga, no significant reduction in hepatic total lipid content or hepatic triglyceride content was observed. However, both doses were able to diminish hepatic NEFA concentration by reducing de novo lipogenesis and increasing mitochondrial biogenesis. Moreover, supplementation with the dose of 2.5% improved some oxidative stress and inflammation-related markers. Supplementation with the dose of 5% did not exert these clear beneficial effects. Thus, this study demonstrates that while Gracilaria vermiculophylla may not mitigate hepatic steatosis, it could exert protective effects on the liver by reducing NEFA content and enhancing oxidative stress and inflammation parameters.

Impact of microplastics and nanoplastics on liver health: Current understanding and future research directions

With continuous population and economic growth in the 21st century, plastic pollution is a major global issue. However, the health concern of microplastics/ nanoplastics (MPs/NPs) decomposed from plastic wastes has drawn public attention only in the recent decade. This article summarizes recent works dedicated to understanding the impact of MPs/NPs on the liver-the largest digestive organ, which is one of the primary routes that MPs/NPs enter human bodies. The interrelated mechanisms including oxidative stress, hepatocyte energy re-distribution, cell death and autophagy, as well as immune responses and inflammation, were also featured. In addition, the disturbance of microbiome and gut-liver axis, and the association with clinical diseases such as metabolic dysfunction-associated fatty liver disease, steatohepatitis, liver fibrosis, and cirrhosis were briefly discussed. Finally, we discussed potential directions in regard to this trending topic, highlighted current challenges in research, and proposed possible solutions.

Administration of silymarin in NAFLD/NASH: A systematic review and meta-analysis

INTRODUCTION AND OBJECTIVES

Nonalcoholic fatty liver disease (NAFLD) is a chronic liver disease with a high prevalence worldwide and poses serious harm to human health. There is growing evidence suggesting that the administration of specific supplements or nutrients may slow NAFLD progression. Silymarin is a hepatoprotective extract of milk thistle, but its efficacy in NAFLD remains unclear.

MATERIALS AND METHODS

Relevant studies were searched in PubMed, Embase, the Cochrane Library, Web of Science, clinicaltrails.gov, and China National Knowledge Infrastructure and were screened according to the eligibility criteria. Data were analyzed using Revman 5.3. Continuous values and dichotomous values were pooled using the standard mean difference (SMD) and odds ratio (OR). Heterogeneity was evaluated using the Cochran's Q test (I2 statistic). A P<0.05 was considered statistically significant.

RESULTS

A total of 26 randomized controlled trials involving 2,375 patients were included in this study. Administration of silymarin significantly reduced the levels of TC (SMD[95%CI]=-0.85[-1.23, -0.47]), TG (SMD[95%CI]=-0.62[-1.14, -0.10]), LDL-C (SMD[95%CI]=-0.81[-1.31, -0.31]), FI (SMD[95%CI]=-0.59[-0.91, -0.28]) and HOMA-IR (SMD[95%CI]=-0.37[-0.77, 0.04]), and increased the level of HDL-C (SMD[95%CI]=0.46[0.03, 0.89]). In addition, silymarin attenuated liver injury as indicated by the decreased levels of ALT (SMD[95%CI]=-12.39[-19.69, -5.08]) and AST (SMD[95% CI]=-10.97[-15.51, -6.43]). The levels of fatty liver index (SMD[95%CI]=-6.64[-10.59, -2.69]) and fatty liver score (SMD[95%CI]=-0.51[-0.69, -0.33]) were also decreased. Liver histology of the intervention group revealed significantly improved hepatic steatosis (OR[95%CI]=3.25[1.80, 5.87]).

CONCLUSIONS

Silymarin can regulate energy metabolism, attenuate liver damage, and improve liver histology in NAFLD patients. However, the effects of silymarin will need to be confirmed by further research.

Breaking new ground: MASLD vs. MAFLD-which holds the key for risk stratification?

BACKGROUND

The classification and nomenclature of non-alcoholic fatty liver disease (NAFLD) has been the subject of ongoing debate in the medical community. Through the introduction of metabolic dysfunction-associated fatty liver disease (MAFLD) and the later release of metabolic dysfunction-associated steatotic liver disease (MASLD), the limitations associated with NAFLD are intended to be addressed. Both terminologies incorporate the metabolic component of the disease by providing diagnostic criteria that relies on the presence of underlying metabolic risk factors.

MATERIALS AND METHODS

An epidemiologic cross-sectional study of individuals who had undergone abdominal ultrasound and vibration-controlled transient elastography (VCTE) as part of a routine check was performed. We evaluated clinical, anthropometric, and biochemical variables to determine the metabolic profile of each subject.

RESULTS

The study included a total of 500 participants, 56.8% (n = 284) males and 43.2% (n = 216) females, with a mean age of 49 ± 10 years. 59.4% (n = 297) were diagnosed with MAFLD and MASLD, 10.2% (n = 51) were diagnosed only with MASLD and 30.4% (n = 152) were not diagnosed with either MAFLD or MASLD. The differences in prevalence were mainly based on the detection of individuals with a BMI < 25 kg/m2, where MASLD captures the largest number (p < 0.001).

CONCLUSIONS

Although MASLD has a higher capture of lean patients compared to MAFLD, patients with MAFLD and MASLD have a worse metabolic profile than those with only MASLD. Our results provide evidence that MAFLD better identifies patients likely to have a higher risk of liver fibrosis and of disease progression.

Dysmetabolic comorbidities and non-alcoholic fatty liver disease: a stairway to metabolic dysfunction-associated steatotic liver disease

Non-alcoholic fatty liver disease (NAFLD) is the most common cause of chronic liver disease. This term does not describe the pathogenetic mechanisms and complications associated with NAFLD. The new definition, Metabolic Dysfunction-associated Steatotic Liver disease (MASLD), emphasizes the relationship between NAFLD and cardiometabolic comorbidities. Cardiovascular disease features, such as arterial hypertension and atherosclerosis, are frequently associated with patients with MASLD. Furthermore, these patients have a high risk of developing neoplastic diseases, primarily hepatocellular carcinoma, but also extrahepatic tumors, such as esophageal, gastric, and pancreatic cancers. Moreover, several studies showed the correlation between MASLD and endocrine disease. The imbalance of the gut microbiota, systemic inflammation, obesity, and insulin resistance play a key role in the development of these complications. This narrative review aims to clarify the evolution from NAFLD to the new nomenclature MASLD and evaluate its complications.

Prevalence of Non-Alcoholic Fatty Liver Disease in Adult Individuals with Moderate-to-Severe Atopic Dermatitis

BACKGROUND

There are no published studies on the prevalence of non-alcoholic fatty liver disease (NAFLD) in patients with atopic dermatitis (AD).

OBJECTIVES

To estimate the prevalence of NAFLD (assessed via liver ultrasonography) in adults with moderate-to-severe AD.

METHODS

We performed a retrospective, cross-sectional, observational study including adult patients affected by moderate-to-severe AD, moderate-to-severe chronic plaque psoriasis, or a previous diagnosis of thin melanoma in situ (considered as the control group) who attended the Verona University Hospital between January 2022 and April 2023. Fatty liver was assessed via liver ultrasonography.

RESULTS

A total of 144 adults with AD, 466 with chronic plaque psoriasis, and 99 with thin melanoma were included. The prevalence rates of ultrasound-detected NAFLD among patients with in situ melanoma, those with moderate-to-severe AD, and those with moderate-to-severe chronic plaque psoriasis were 23.2% (23 out of 99), 24.1% (36 out of 144), and 49.8% (228 out of 466), respectively (p < 0.01). Logistic regression analysis revealed that being of male sex, a higher age, a higher body mass index, and psoriasis were independently associated with NAFLD, whereas AD was not.

CONCLUSIONS

Our findings show that the prevalence of ultrasound-detected NAFLD in patients with moderate-to-severe AD was comparable to that of patients with a previous diagnosis of in situ melanoma. It is plausible to hypothesize that the Th2-type inflammation typically characterizing AD is not a risk factor for NAFLD. Patients with moderate-to-severe psoriasis, but not those with AD, should be screened for NAFLD and other metabolic comorbidities.