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Eslam M, Fan JG, Yu ML, Wong VWS, Cua IH, Liu CJ, Tanwandee T, Gani R, Seto WK, Alam S, Young DY, Hamid S, Zheng MH, Kawaguchi T, Chan WK, Payawal D, Tan SS, Goh GBB, Strasser SI, Viet HD, Kao JH, Kim W, Kim SU, Keating SE, Yilmaz Y, Kamani L, Wang CC, Fouad Y, Abbas Z, Treeprasertsuk S, Thanapirom K, Al Mahtab M, Lkhagvaa U, Baatarkhuu O, Choudhury AK, Stedman CAM, Chowdhury A, Dokmeci AK, Wang FS, Lin HC, Huang JF, Howell J, Jia J, Alboraie M, Roberts SK, Yoneda M, Ghazinian H, Mirijanyan A, Nan Y, Lesmana CRA, Adams LA, Shiha G, Kumar M, Örmeci N, Wei L, Lau G, Omata M, Sarin SK, George J. 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. Hepatol Int 2025; 19:261-301. [PMID: 40016576 DOI: 10.1007/s12072-024-10774-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2024] [Accepted: 12/28/2024] [Indexed: 03/01/2025]
Abstract
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.
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Affiliation(s)
- Mohammed Eslam
- Storr Liver Centre, Westmead Institute for Medical Research, Westmead Hospital and University of Sydney, Westmead, NSW, 2145, Australia.
| | - Jian-Gao Fan
- Center for Fatty Liver, Department of Gastroenterology, Shanghai Key Lab of Pediatric Gastroenterology and Nutrition, Xin Hua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Ming-Lung Yu
- Hepatobiliary Division, Department of Internal MedicineCollege of Medicine and Center for Liquid Biopsy and Cohort ResearchFaculty of Internal Medicine and Hepatitis Research Center, School of Medicine, College of MedicineSchool of Medicine and Doctoral Program of Clinical and Experimental Medicine, College of Medicine and Center of Excellence for Metabolic Associated Fatty Liver Disease, Kaohsiung Medical University, National Sun Yat-Sen University, Kaohsiung, Taiwan
| | - Vincent Wai-Sun Wong
- Medical Data Analytics Centre, Department of Medicine and Therapeutics, State Key Laboratory of Digestive Disease, Institute of Digestive Disease, Chinese University of Hong Kong, Hong Kong, China
| | - Ian Homer Cua
- Institute of Digestive and Liver Diseases, St. Luke's Medical Center, Global City, Philippines
| | - Chun-Jen Liu
- Division of Gastroenterology and Hepatology, Department of Internal MedicineHepatitis Research CenterGraduate Institute of Clinical Medicine, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan
| | - Tawesak Tanwandee
- Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Rino Gani
- Department of Internal Medicine, Hepatobiliary Division, Dr. Cipto Mangunkusumo National General Hospital, Universitas Indonesia, Pangeran Diponegoro Road No. 71St, Central Jakarta, 10430, Indonesia
| | - Wai-Kay Seto
- Department of Medicine, School of Clinical Medicine, State Key Laboratory of Liver Research, The University of Hong Kong, Hong Kong, China
- Department of Medicine, The University of Hong Kong-Shenzhen Hospital, Shenzhen, China
| | - Shahinul Alam
- Department of Hepatology, Bangabandhu Sheikh Mujib Medical University, Shahbag, Dhaka, Bangladesh
| | - Dan Yock Young
- Department of Medicine, Yong Loo Lin School of Medicine, National University Singapore, Singapore, Singapore
| | - Saeed Hamid
- Department of Medicine, Aga Khan University, Karachi, Pakistan
| | - Ming-Hua Zheng
- MAFLD Research Center, Department of Hepatology, The First Affiliated Hospital of Wenzhou Medical University, Key Laboratory of Diagnosis and Treatment for The Development of Chronic Liver Disease in Zhejiang Province, Wenzhou, China
| | - Takumi Kawaguchi
- Division of Gastroenterology, Department of Medicine, Kurume University School of Medicine, Kurume, Japan
| | - Wah-Kheong Chan
- Gastroenterology and Hepatology Unit, Department of Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Diana Payawal
- Department of Medicine, Cardinal Santos Medical Center, Mandaluyong, Philippines
| | - Soek-Siam Tan
- Department of Hepatology, Selayang Hospital, Batu Caves, Malaysia
| | - George Boon-Bee Goh
- Department of Gastroenterology and Hepatology, Singapore General Hospital, Singapore, Singapore
- Medicine Academic Clinical Program, Duke-NUS Medical School, Singapore, Singapore
| | - Simone I Strasser
- AW Morrow Gastroenterology and Liver Centre, Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | - Hang Dao Viet
- Internal Medicine Faculty, Hanoi Medical University, Hanoi, Vietnam
| | - Jia-Horng Kao
- Graduate Institute of Clinical MedicineDepartment of Internal MedicineHepatitis Research CenterDepartment of Medical Research, National Taiwan University College of Medicine, National Taiwan University, National Taiwan University Hospital, 1 Chang-Te Street, 10002, Taipei, Taiwan
| | - Won Kim
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Seoul National University College of Medicine, Seoul Metropolitan Government Boramae Medical Center, Seoul, Republic of Korea
| | - Seung Up Kim
- Department of Internal Medicine, Yonsei University College of Medicine, Severance Hospital, 50-1, Yonsei-Ro, Seodaemun-Gu, Seoul, 03722, Republic of Korea
| | - Shelley E Keating
- School of Human Movement and Nutrition Sciences, The University of Queensland, Brisbane, QLD, 4072, Australia
| | - Yusuf Yilmaz
- Department of Gastroenterology, School of Medicine, Recep Tayyip Erdoğan University, Rize, Turkey
| | | | - Chia-Chi Wang
- Buddhist Tzu Chi Medical Foundation and School of Medicine, Taipei Tzu Chi Hospital, Tzu Chi University, Taipei, Taiwan
| | - Yasser Fouad
- Department of Gastroenterology, Hepatology and Endemic Medicine, Faculty of Medicine, Minia University, Cairo, Egypt
| | - Zaigham Abbas
- Department of Hepatogastroenterology, Dr.Ziauddin University Hospital, Clifton, Karachi, Pakistan
| | | | | | - Mamun Al Mahtab
- Department of Hepatology, Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh
| | - Undram Lkhagvaa
- Department of Health Policy, School of Public Health, Mongolian National University of Medical Sciences, Ulaanbaatar, Mongolia
| | - Oidov Baatarkhuu
- Department of Infectious Diseases, School of Medicine, Mongolian National University of Medical Sciences, Ulaanbaatar, Mongolia
| | - Ashok Kumar Choudhury
- Department of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, 110070, India
| | | | - Abhijit Chowdhury
- Department of Hepatology, School of Digestive and Liver Diseases, Institute of Post Graduate Medical Education and Research, Kolkata, India
| | - A Kadir Dokmeci
- Department of Medicine, Ankara University School of Medicine, Ankara, Turkey
| | - Fu-Sheng Wang
- Senior Department of Infectious Diseases, The Fifth Medical Center of Chinese PLA General Hospital, National Clinical Research Center for Infectious Diseases, Chinese PLA Medical School, Chinese PLA General Hospital, Beijing, 100039, China
| | - Han-Chieh Lin
- Division of Gastroenterology and Hepatology, Department of Medicine, Institute of Clinical Medicine, School of Medicine, Taipei Veterans General Hospital, National Yang-Ming Chiao Tung University, No. 201, Section 2, Shipai RdNo. 155, Section 2, Linong St, Beitou District, Taipei City, 112, Taiwan
| | - Jee-Fu Huang
- Hepatobiliary Division, Department of Internal MedicineCollege of Medicine and Center for Liquid Biopsy and Cohort ResearchFaculty of Internal Medicine and Hepatitis Research Center, School of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Jess Howell
- Burnet Institute, Melbourne, VIC, 3004, Australia
- Department of Epidemiology and Preventive Medicine, Monash University, Clayton, VIC, 3008, Australia
- Department of Medicine, The University of Melbourne, Parkville, VIC, 3050, Australia
- Department of Gastroenterology, St Vincent's Hospital Melbourne, Melbourne, VIC, 3165, Australia
| | - Jidong Jia
- Liver Research Center, Beijing Key Laboratory of Translational Medicine On Liver Cirrhosis, Beijing Friendship Hospital, Capital Medical University, National Clinical Research Center of Digestive Diseases, Beijing, China
| | - Mohamed Alboraie
- Department of Internal Medicine, Al-Azhar University, Cairo, 11884, Egypt
| | - Stuart K Roberts
- Department of Gastroenterology and Hepatology, Central Clinical School, The Alfred, Monash University, Melbourne, Australia
| | - Masato Yoneda
- Department of Gastroenterology and Hepatology, Yokohama City University Graduate School of Medicine, Yokohama, 236-0004, Japan
| | - Hasmik Ghazinian
- Gastroenterology and Hepatology Department, Yerevan Medical Scientific Center, Yerevan, Armenia
| | - Aram Mirijanyan
- Gastroenterology and Hepatology Department, Yerevan Medical Scientific Center, Yerevan, Armenia
| | - Yuemin Nan
- Department of Traditional and Western Medical Hepatology, Third Hospital of Hebei Medical University, Shijiazhuang, China
| | | | - Leon A Adams
- Medical School, Faculty of Medicine and Health Sciences, The University of Western Australia, Nedlands, WA, Australia
| | - Gamal Shiha
- Hepatology and Gastroenterology Unit, Internal Medicine Department, Faculty of Medicine, Mansoura University, Egyptian Liver Research Institute and Hospital (ELRIAH), Sherbin, El Mansoura, Egypt
| | - Manoj Kumar
- Department of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Necati Örmeci
- Department of Gastroenterohepatology, Istanbul Health and Technology University, Istanbul, Turkey
| | - Lai Wei
- Hepatopancreatobiliary Center, Beijing Tsinghua Changgung Hospital, Tsinghua University, Beijing, China
| | - George Lau
- Humanity and Health Medical Group, Humanity and Health Clinical Trial Center, Hong Kong SAR, China
- The Fifth Medical Center of Chinese, PLA General Hospital, Beijing, 100039, China
| | - Masao Omata
- Department of Gastroenterology, Yamanashi Central Hospital, Yamanashi, Japan
- University of Tokyo, Tokyo, Japan
| | - Shiv K Sarin
- Department of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, India.
| | - Jacob George
- Storr Liver Centre, Westmead Institute for Medical Research, Westmead Hospital and University of Sydney, Westmead, NSW, 2145, Australia
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Park Y, Ko KS, Rhee BD. Non-Alcoholic Fatty Liver Disease (NAFLD) Management in the Community. Int J Mol Sci 2025; 26:2758. [PMID: 40141404 PMCID: PMC11943420 DOI: 10.3390/ijms26062758] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2025] [Revised: 03/10/2025] [Accepted: 03/17/2025] [Indexed: 03/28/2025] Open
Abstract
Non-alcoholic fatty liver disease (NAFLD) has frequently been associated with obesity, type 2 diabetes (T2D), and dyslipidemia, all of which are shared by increased insulin resistance. It has become the most common liver disorder in Korea as well as in developed countries and is therefore associated with an increased health burden of morbidity and mortality. It has an association with T2D, and T2D increases the risk of cirrhosis and related complications. NAFLD encompasses a disease continuum from simple steatosis to non-alcoholic steatohepatitis which is characterized by faster fibrosis progression. Although its liver-related complication is estimated to be, at most, 10%, it will be a leading cause of cirrhosis and hepatocellular carcinoma soon in Korea. Although the main causes of death in people with NAFLD are cardiovascular disease and extra-hepatic malignancy, advanced liver fibrosis is a key prognostic marker for liver-related outcomes and can be assessed with combinations of non-invasive tests in the community. A number of components of metabolic syndrome involved could be another important prognostic information of NAFLD assessed easily in the routine care of the community. There is a few approved therapies for NAFLD, although several drugs, including antioxidants, attract practitioners' attention. Because of the modest effect of the present therapeutics, let alone complex pathophysiology and substantial heterogeneity of disease phenotypes, combination treatment is a viable option for many patients with NAFLD in the Korean community. Comprehensive approach taking healthy lifestyle and weight reduction into account remain a mainstay to the prevention and treatment of NAFLD.
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Affiliation(s)
- Yongsoo Park
- Department of Internal Medicine, Sanggye Paik Hospital, College of Medicine, Inje University, 1342 Dongil-ro, Nowon-gu, Seoul 01757, Republic of Korea; (K.S.K.); (B.D.R.)
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Chianelli M, Armellini M, Carpentieri M, Coccaro C, Cuttica CM, Fusco A, Marucci S, Nelva A, Nizzoli M, Ponziani MC, Sciaraffia M, Tassone F, Busetto L. Obesity in Prediabetic Patients: Management of Metabolic Complications and Strategies for Prevention of Overt Diabetes. Endocr Metab Immune Disord Drug Targets 2025; 25:8-36. [PMID: 38778593 PMCID: PMC11826913 DOI: 10.2174/0118715303282327240507184902] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2024] [Revised: 04/02/2024] [Accepted: 04/11/2024] [Indexed: 05/25/2024]
Abstract
Obesity and prediabetes affect a substantial part of the general population, but are largely underdiagnosed, underestimated, and undertreated. Prediabetes differs from diabetes only in the degree of hyperglycaemia consequent to the progressive decline in residual beta-cell function. Both prediabetes and diabetes occur as a consequence of insulin resistance that starts several years before the clinical onset of overt diabetes. Macrovascular complications in patients with diabetes are mainly caused by insulin resistance. This is why in prediabetes, the overall cardiovascular risk is, by all means, similar to that in patients with diabetes. It is important, therefore, to identify prediabetes and treat patients not only to prevent or delay the onset of diabetes, but to reduce the cardiovascular risk associated with prediabetes. This review provides an overview of the pathophysiology of prediabetes in patients with obesity and the progression toward overt diabetes. We have reviewed nutritional and pharmacological approaches to the management of obesity and reduced glucose tolerance, and the treatment of the major comorbidities in these patients, including hypertension, dyslipidaemia, and Metabolic dysfunction-associated Steatotic Liver Disease (MASLD), has also been reviewed. In patients with obesity and prediabetes, the nutritional approach is similar to that adopted for patients with obesity and diabetes; treatments of dyslipidaemia and hypertension also have the same targets compared to patients with diabetes. MASLD is a critical issue in these patients; in the prediabetic state, MASLD rarely progresses into fibrosis. This highlights the importance of the early recognition of this pathological condition before patients become diabetic when the risk of fibrosis is much higher. It is necessary to raise awareness of the clinical relevance of this pathological condition in order to prompt early intervention before complications occur. The single most important therapeutic goal is weight loss, which must be early and persistent.
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Affiliation(s)
- Marco Chianelli
- Unit of Endocrinology and Metabolism, Regina Apostolorum Hospital, Albano, Rome, Italy
| | - Marina Armellini
- Endocrinology and Metabolism Unit, University-Hospital S. Maria della Misericordia, Udine, Italy
| | - Maria Carpentieri
- Endocrinology and Metabolism Unit, University-Hospital S. Maria della Misericordia, Udine, Italy
| | - Carmela Coccaro
- Department of Civil Disability, Istituto Nazionale della Previdenza Sociale, Rome, Italy
| | | | - Alessandra Fusco
- Diabetology Center Villaricca, Azienza Sanitaria 2 Naples, Naples, Italy
| | - Simonetta Marucci
- Scienza dell'Alimentazione e Nutrizione Umana, University Campus Biomedico, Rome, Italy
| | - Anna Nelva
- Unit of Endocrinology and Diabetology, Ospedale degli Infermi, Ponderano, Italy
| | - Maurizio Nizzoli
- Unit of Endocrinology and Metabolism G.B. Morgagni Hospital, Forlì, Italy
| | | | | | - Francesco Tassone
- Department of Endocrinology, Diabetes & Metabolism, Santa Croce e Carle Hospital, Cuneo, Italy
| | - Luca Busetto
- Department of Medicine, University of Padova, Padova, Italy
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Zhang X, Kam LY, Barnett SD, Henry L, Cheung R, Nguyen MH. Disease Progression for Histologic Diagnosis of Metabolic Dysfunction-Associated Steatotic Liver Disease in the Real-World: A Nationwide US Study. Dig Dis 2024; 43:36-45. [PMID: 39401491 PMCID: PMC11817862 DOI: 10.1159/000541945] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2024] [Accepted: 10/06/2024] [Indexed: 11/12/2024]
Abstract
INTRODUCTION We compared clinical characteristics and outcomes in real-world metabolic dysfunction-associated steatotic liver disease (MASLD) patients with or without liver biopsy using a nationwide cohort in United States (USA) to fill in gaps in selection of biopsy patients. METHODS We conducted a retrospective cohort study of adult MASLD patients using Marketscan® Databases (1/2007-12/2021). Patients were categorized into those with or without liver biopsy during follow-up. RESULTS We analyzed 540,326 MASLD patients: 23,732 with and 516,594 without biopsy. Only 4% of MASLD patients received liver biopsy and biopsy rate decreased in the last 5 years (9.4%-3.6%). After 1:5 propensity score matching on baseline characteristics including age, sex, and comorbidities, a total of 23,731 patients with biopsy and 118,396 matched patients without biopsy were analyzed. The incidence per 1,000 person-years for hepatocellular carcinoma (HCC) was 0.22 versus 2.18, cirrhosis 29.75 versus 90.44, and hepatic decompensation 15.84 versus 28.25 compared patients with and without biopsy. In multivariable analysis, patients with biopsy had more than 9 times higher risk of developing HCC, 3 times higher risk of cirrhosis, and 78% higher risk of hepatic decompensation. In subgroup analysis, the association remained consistent when stratified by age (<50 and ≥50), sex, and diabetes mellitus. Predictors of having biopsy included age, metabolic diseases, and living in North central or Northeast of USA. CONCLUSION These data can inform clinical patient management that biopsy patients likely represent a selected group at higher risk for disease progression, especially in clinical trials for MASLD therapies. INTRODUCTION We compared clinical characteristics and outcomes in real-world metabolic dysfunction-associated steatotic liver disease (MASLD) patients with or without liver biopsy using a nationwide cohort in United States (USA) to fill in gaps in selection of biopsy patients. METHODS We conducted a retrospective cohort study of adult MASLD patients using Marketscan® Databases (1/2007-12/2021). Patients were categorized into those with or without liver biopsy during follow-up. RESULTS We analyzed 540,326 MASLD patients: 23,732 with and 516,594 without biopsy. Only 4% of MASLD patients received liver biopsy and biopsy rate decreased in the last 5 years (9.4%-3.6%). After 1:5 propensity score matching on baseline characteristics including age, sex, and comorbidities, a total of 23,731 patients with biopsy and 118,396 matched patients without biopsy were analyzed. The incidence per 1,000 person-years for hepatocellular carcinoma (HCC) was 0.22 versus 2.18, cirrhosis 29.75 versus 90.44, and hepatic decompensation 15.84 versus 28.25 compared patients with and without biopsy. In multivariable analysis, patients with biopsy had more than 9 times higher risk of developing HCC, 3 times higher risk of cirrhosis, and 78% higher risk of hepatic decompensation. In subgroup analysis, the association remained consistent when stratified by age (<50 and ≥50), sex, and diabetes mellitus. Predictors of having biopsy included age, metabolic diseases, and living in North central or Northeast of USA. CONCLUSION These data can inform clinical patient management that biopsy patients likely represent a selected group at higher risk for disease progression, especially in clinical trials for MASLD therapies.
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Affiliation(s)
- Xinrong Zhang
- Division of Gastroenterology and Hepatology, School of Medicine, Stanford University Medical Center, Palo Alto, CA, USA
| | - Leslie Yeeman Kam
- Division of Gastroenterology and Hepatology, School of Medicine, Stanford University Medical Center, Palo Alto, CA, USA
| | - Scott D. Barnett
- Division of Gastroenterology and Hepatology, School of Medicine, Stanford University Medical Center, Palo Alto, CA, USA
| | - Linda Henry
- Division of Gastroenterology and Hepatology, School of Medicine, Stanford University Medical Center, Palo Alto, CA, USA
| | - Ramsey Cheung
- Division of Gastroenterology and Hepatology, School of Medicine, Stanford University Medical Center, Palo Alto, CA, USA
- Veterans Affairs Palo Alto Health Care System, Palo Alto, CA, USA
| | - Mindie H. Nguyen
- Division of Gastroenterology and Hepatology, School of Medicine, Stanford University Medical Center, Palo Alto, CA, USA
- Department of Epidemiology and Population Health, Stanford University, Palo Alto, CA, USA
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Ogawa Y, Tomeno W, Imamura Y, Baba M, Ueno T, Kobayashi T, Iwaki M, Nogami A, Kessoku T, Honda Y, Notsumata K, Fujikawa H, Kaai M, Imajo K, Kawanaka M, Hyogo H, Hisatomi M, Takeuchi M, Hakamada T, Honda T, Tatsuta M, Morishita A, Mikami S, Furuya K, Manabe N, Kamada T, Kawaguchi T, Yoneda M, Saito S, Nakajima A. Distribution of Fibrosis-4 index and vibration-controlled transient elastography-derived liver stiffness measurement for patients with metabolic dysfunction-associated steatotic liver disease in health check-up. Hepatol Res 2024. [PMID: 39364641 DOI: 10.1111/hepr.14117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2024] [Revised: 09/04/2024] [Accepted: 09/08/2024] [Indexed: 10/05/2024]
Abstract
AIMS The multisociety consensus nomenclature has introduced steatotic liver disease (SLD) with diverse subclassifications, which are metabolic dysfunction-associated steatotic liver disease (MASLD), metabolic dysfunction and alcohol-associated steatotic liver disease (MetALD), alcohol-associated liver disease (ALD), specific etiology, and cryptogenic. We investigated their prevalence, as per the new definition, in individuals undergoing health check-ups. Additionally, we analyzed the distribution of Fibrosis-4 (FIB-4) index and vibration-controlled transient elastography (VCTE)-derived liver stiffness measurement (LSM) for MASLD. METHODS In this cross-sectional study, 6530 subjects undergoing a health check-up in Japan were included. Conventional B-mode ultrasound was carried out on all 6530 subjects, and those with MASLD underwent VCTE. RESULTS The prevalence of SLD was 39.5%, comprising MASLD 28.7%, MetALD 8.6%, ALD 1.2%, specific etiology SLD 0.3%, and cryptogenic SLD 0.7%. Subjects with VCTE-derived LSM ≥8 kPa constituted 2.1% of MASLD. FIB-4 ≥1.3 showed that the sensitivity, specificity, positive predictive value (PPV), and negative predictive value for diagnosing VCTE-derived LSM ≥8 kPa were 60.6%, 77.0%, 5.3%, and 98.9%, respectively. The referral rate to specialists was 23.8% using FIB-4 ≥1.30. "FIB-4 ≥1.3 in subjects <65 years and FIB-4 ≥2.0 in subjects ≥65 years" showed higher PPV (6.7%) and lower referral rate (17.1%) compared with FIB-4 ≥1.3, but the sensitivity (54.5%) did not show adequate diagnostic capability as a noninvasive test for diagnosing VCTE-derived LSM ≥8 kPa. CONCLUSIONS Acknowledging the selection bias in hepatology centers, we undertook this prospective health check-up study. Although the FIB-4 index proves to be a convenient marker, it might not perform well as a primary screening tool for liver fibrosis in the general population (UMIN Clinical Trials Registry No. UMIN000035188).
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Affiliation(s)
- Yuji Ogawa
- Department of Gastroenterology, NHO Yokohama Medical Center, Yokohama, Japan
| | - Wataru Tomeno
- Department of Gastroenterology, International University of Health and Welfare Atami Hospital, Atami, Japan
| | - Yasushi Imamura
- Department of Hepatology, Kagoshima Kouseiren Hospital, Kagoshima, Japan
| | - Masaru Baba
- Department of Gastroenterology and Hepatology, JCHO Hokkaido Hospital, Sapporo, Japan
| | - Takato Ueno
- Division of Research Center for Innovative Cancer Therapy, Kurume University, Kurume, Japan
| | - Takashi Kobayashi
- Department of Gastroenterology and Hepatology, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Michihiro Iwaki
- Department of Gastroenterology and Hepatology, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Asako Nogami
- Department of Gastroenterology and Hepatology, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Takaomi Kessoku
- Department of Palliative Care, International University of Health and Welfare Narita Hospital, Narita, Japan
- Department of Internal Medicine, Kanagawa Dental University Yokohama Clinic, Yokohama, Japan
| | - Yasushi Honda
- Department of Gastroenterology and Hepatology, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Kazuo Notsumata
- Department of Gastroenterology, Fukui-ken Saiseikai Hospital, Fukui, Japan
| | - Hirotoshi Fujikawa
- Department of Gastroenterology, JCHO Yokohama Chuo Hospital, Yokohama, Japan
| | - Megumi Kaai
- Department of Gastroenterology, Shin-yurigaoka General Hospital, Kawasaki, Japan
| | - Kento Imajo
- Department of Gastroenterology and Hepatology, Yokohama City University Graduate School of Medicine, Yokohama, Japan
- Department of Gastroenterology, Shin-yurigaoka General Hospital, Kawasaki, Japan
| | - Miwa Kawanaka
- Department of General Internal Medicine 2, Kawasaki Medical School General Medical Center, Okayama, Japan
| | - Hideyuki Hyogo
- Department of Internal Medicine, Hyogo Life Care Clinic Hiroshima, Hiroshima, Japan
| | - Mitsurou Hisatomi
- Department of Gastroenterology, Tsushima City Hospital, Tsushima, Japan
| | - Mamiko Takeuchi
- Department of Gastroenterology, Anjo Kosei Hospital, Anjo, Japan
| | - Taku Hakamada
- Department of Gastroenterology, Shin-yurigaoka General Hospital, Kawasaki, Japan
| | - Takashi Honda
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Miwa Tatsuta
- Department of Gastroenterology, KKR Takamatsu Hospital, Takamatsu, Japan
| | - Asahiro Morishita
- Department of Gastroenterology and Neurology, Faculty of Medicine, Kagawa University, Kita-gun, Japan
| | - Shigeru Mikami
- Department of Internal Medicine, Division of Gastroenterology, Kikkoman General Hospital, Noda, Japan
| | - Ken Furuya
- Department of Gastroenterology and Hepatology, JCHO Hokkaido Hospital, Sapporo, Japan
| | - Noriaki Manabe
- Department of Clinical Pathology and Laboratory Medicine, Kawasaki Medical School General Medical Center, Okayama, Japan
| | - Tomoari Kamada
- Department of Health Care Medicine, Kawasaki Medical School General Medical Center, Okayama, Japan
| | - Takumi Kawaguchi
- Division of Gastroenterology, Department of Medicine, Kurume University School of Medicine, Kurume, Japan
| | - Masato Yoneda
- Department of Gastroenterology and Hepatology, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Satoru Saito
- Department of Gastroenterology and Hepatology, Yokohama City University Graduate School of Medicine, Yokohama, Japan
- Department of Gastroenterology, Sanno Hospital, Tokyo, Japan
| | - Atsushi Nakajima
- Department of Gastroenterology and Hepatology, Yokohama City University Graduate School of Medicine, Yokohama, Japan
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De Vito F, Suraci E, Marasco R, Luzza F, Andreozzi F, Sesti G, Fiorentino TV. Association between higher duodenal levels of the fructose carrier glucose transporter-5 and nonalcoholic fatty liver disease and liver fibrosis. J Intern Med 2024; 295:171-180. [PMID: 37797237 DOI: 10.1111/joim.13729] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/07/2023]
Abstract
BACKGROUND An increased dietary fructose intake has been shown to exert several detrimental metabolic effects and contribute to the pathogenesis of nonalcoholic fatty liver disease (NAFLD). An augmented intestinal abundance of the fructose carriers glucose transporter-5 (GLUT-5) and glucose transporter-2 (GLUT-2) has been found in subjects with obesity and type 2 diabetes. Herein, we investigated whether elevated intestinal levels of GLUT-5 and GLUT-2, resulting in a higher dietary fructose uptake, are associated with NAFLD and its severity. METHODS GLUT-5 and GLUT-2 protein levels were assessed on duodenal mucosa biopsies of 31 subjects divided into 2 groups based on ultrasound-defined NAFLD presence who underwent an upper gastrointestinal endoscopy. RESULTS Individuals with NAFLD exhibited increased duodenal GLUT-5 protein levels in comparison to those without NAFLD, independently of demographic and anthropometric confounders. Conversely, no difference in duodenal GLUT-2 abundance was observed amongst the two groups. Univariate correlation analyses showed that GLUT-5 protein levels were positively related with body mass index, waist circumference, fasting and 2 h post-load insulin concentrations, and insulin resistance (IR) degree estimated by homeostatic model assessment of IR (r = 0.44; p = 0.02) and liver IR (r = 0.46; p = 0.03) indexes. Furthermore, a positive relationship was observed between duodenal GLUT-5 abundance and serum uric acid concentrations (r = 0.40; p = 0.05), a product of fructose metabolism implicated in NAFLD progression. Importantly, duodenal levels of GLUT-5 were positively associated with liver fibrosis risk estimated by NAFLD fibrosis score. CONCLUSION Increased duodenal GLUT-5 levels are associated with NAFLD and liver fibrosis. Inhibition of intestinal GLUT-5-mediated fructose uptake may represent a strategy for prevention and treatment of NAFLD.
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Affiliation(s)
- Francesca De Vito
- Department of Medical and Surgical Sciences, University Magna Graecia of Catanzaro, Catanzaro, Italy
| | - Evelina Suraci
- Department of Health Sciences, University Magna Graecia of Catanzaro, Catanzaro, Italy
| | - Raffaella Marasco
- Department of Health Sciences, University Magna Graecia of Catanzaro, Catanzaro, Italy
| | - Francesco Luzza
- Department of Health Sciences, University Magna Graecia of Catanzaro, Catanzaro, Italy
| | - Francesco Andreozzi
- Department of Medical and Surgical Sciences, University Magna Graecia of Catanzaro, Catanzaro, Italy
| | - Giorgio Sesti
- Department of Clinical and Molecular Medicine, University of Rome-Sapienza, Rome, Italy
| | - Teresa Vanessa Fiorentino
- Department of Medical and Surgical Sciences, University Magna Graecia of Catanzaro, Catanzaro, Italy
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Bech KT, Lindvig KP, Thiele M, Castera L. Algorithms for Early Detection of Silent Liver Fibrosis in the Primary Care Setting. Semin Liver Dis 2024; 44:23-34. [PMID: 38262447 DOI: 10.1055/s-0043-1778127] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2024]
Abstract
More than one-third of the adult world population has steatotic liver disease (SLD), with a few percent of individuals developing cirrhosis after decades of silent liver fibrosis accumulation. Lack of systematic early detection causes most patients to be diagnosed late, after decompensation, when treatment has limited effect and survival is poor. Unfortunately, no isolated screening test in primary care can sufficiently predict advanced fibrosis from SLD. Recent efforts, therefore, combine several parameters into screening algorithms, to increase diagnostic accuracy. Besides patient selection, for example, by specific characteristics, algorithms include nonpatented or patented blood tests and liver stiffness measurements using elastography-based techniques. Algorithms can be composed as a set of sequential tests, as recommended by most guidelines on primary care pathways. Future use of algorithms that are easy to interpret, cheap, and semiautomatic will improve the management of patients with SLD, to the benefit of global health care systems.
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Affiliation(s)
- Katrine Tholstrup Bech
- Department of Gastroenterology and Hepatology, Odense University Hospital, Odense C, Denmark
- Institute of Clinical Research, University of Southern Denmark, Odense C, Denmark
| | - Katrine Prier Lindvig
- Department of Gastroenterology and Hepatology, Odense University Hospital, Odense C, Denmark
- Institute of Clinical Research, University of Southern Denmark, Odense C, Denmark
| | - Maja Thiele
- Department of Gastroenterology and Hepatology, Odense University Hospital, Odense C, Denmark
- Institute of Clinical Research, University of Southern Denmark, Odense C, Denmark
| | - Laurent Castera
- Service d'Hépatologie, Assistance Publique-Hôpitaux de Paris (APHP), Hôpital Beaujon, Clichy, France
- Faculté de Médecine, Université Paris Cité, UMR1149 (CRI), INSERM, Paris, France
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8
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Parola M, Pinzani M. Liver fibrosis in NAFLD/NASH: from pathophysiology towards diagnostic and therapeutic strategies. Mol Aspects Med 2024; 95:101231. [PMID: 38056058 DOI: 10.1016/j.mam.2023.101231] [Citation(s) in RCA: 57] [Impact Index Per Article: 57.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2023] [Revised: 11/13/2023] [Accepted: 11/20/2023] [Indexed: 12/08/2023]
Abstract
Liver fibrosis, as an excess deposition of extracellular matrix (ECM) components, results from chronic liver injury as well as persistent activation of inflammatory response and of fibrogenesis. Liver fibrosis is a major determinant for chronic liver disease (CLD) progression and in the last two decades our understanding on the major molecular and cellular mechanisms underlying the fibrogenic progression of CLD has dramatically improved, boosting pre-clinical studies and clinical trials designed to find novel therapeutic approaches. From these studies several critical concepts have emerged, starting to reveal the complexity of the pro-fibrotic microenvironment which involves very complex, dynamic and interrelated interactions between different hepatic and extrahepatic cell populations. This review will offer first a recapitulation of established and novel pathophysiological basic principles and concepts by intentionally focus the attention on NAFLD/NASH, a metabolic-related form of CLD with a high impact on the general population and emerging as a leading cause of CLD worldwide. NAFLD/NASH-related pro-inflammatory and profibrogenic mechanisms will be analysed as well as novel information on cells, mediators and signalling pathways which have taken advantage from novel methodological approaches and techniques (single cell genomics, imaging mass cytometry, novel in vitro two- and three-dimensional models, etc.). We will next offer an overview on recent advancement in diagnostic and prognostic tools, including serum biomarkers and polygenic scores, to support the analysis of liver biopsies. Finally, this review will provide an analysis of current and emerging therapies for the treatment of NAFLD/NASH patients.
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Affiliation(s)
- Maurizio Parola
- Dept. Clinical and Biological Sciences, Unit of Experimental Medicine and Clinical Pathology, University of Torino, Corso Raffaello 30, 10125, Torino, Italy.
| | - Massimo Pinzani
- UCL Institute for Liver and Digestive Health, Division of Medicine - Royal Free Hospital, London, NW32PF, United Kingdom.
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Bhayani PD, Parameswaran SA, Palaniswamy KR, Piramanayagam P, Murugan N. Is Aspartate Aminotransferase to Platelet Ratio Index a Better Noninvasive Score for Predicting Advanced Fibrosis in Nonalcoholic Fatty Liver Disease Patients? Euroasian J Hepatogastroenterol 2024; 14:35-39. [PMID: 39022213 PMCID: PMC11249902 DOI: 10.5005/jp-journals-10018-1425] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2024] [Accepted: 03/07/2024] [Indexed: 07/20/2024] Open
Abstract
Background In the 21st century, nonalcoholic fatty liver disease (NAFLD) is the most prevalent liver disorder. The prevalence of NAFLD within the general population in India ranges from 9 to 53%. The gold standard for assessing the severity of liver fibrosis is liver biopsy. However, due to various difficulties involved with liver biopsy, it is imperative to identify different non-invasive tools that can replace liver biopsy. Methodology A prospective observational study of 130 patients meeting the inclusion criteria for NAFLD was done for a period of 18 months. We aimed to compare the performance characteristics of different noninvasive scores [fibrosis-4 (FIB-4) score, nonalcoholic fatty liver disease fibrosis score (NFS), and aspartate aminotransferase to platelet ratio index (APRI)] in predicting advanced fibrosis as assessed by FibroScan. Results In the study, 76.9% of patients were male. Advanced fibrosis was seen in 12.3% of the patients. Majority of the patients with advanced fibrosis had metabolic syndrome. Based on the area under the receiver operating characteristic curve (AUROC), the new cut-off for ruling out advanced fibrosis for FIB-4, NFS, and APRI were 1.18, -0.9, and 0.65, respectively, and APRI had the best AUROC (0.768). Conclusion Abnormal glycemic status and metabolic syndrome were risk factors for advanced fibrosis. The newly derived cut-offs for the FIB-4 score, NFS score, and APRI score had a better Negative predictive value compared to the original cut-offs. How to cite this article Bhayani PD, Parameswaran SA, Palaniswamy KR, et al. Is Aspartate Aminotransferase to Platelet Ratio Index a Better Noninvasive Score for Predicting Advanced Fibrosis in Nonalcoholic Fatty Liver Disease Patients? Euroasian J Hepato-Gastroenterol 2024;14(1):35-39.
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Affiliation(s)
- Priyansh D Bhayani
- Department of Medical Gastroenterology, Apollo Hospitals, Chennai, Tamil Nadu, India
| | | | | | | | - Natarajan Murugan
- Department of Hepatology, Apollo Hospitals, Chennai, Tamil Nadu, India
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10
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Cheung JTK, Zhang X, Wong GLH, Yip TCF, Lin H, Li G, Leung HHW, Lai JCT, Mahadeva S, Nik Mustapha NR, Wang XD, Liu WY, Wong VWS, Chan WK, Zheng MH. MAFLD fibrosis score: Using routine measures to identify advanced fibrosis in metabolic-associated fatty liver disease. Aliment Pharmacol Ther 2023; 58:1194-1204. [PMID: 37724633 DOI: 10.1111/apt.17722] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Revised: 08/06/2023] [Accepted: 09/07/2023] [Indexed: 09/21/2023]
Abstract
BACKGROUND Early screening may prevent fibrosis progression in metabolic-associated fatty liver disease (MAFLD). AIMS We developed and validated MAFLD fibrosis score (MFS) for identifying advanced fibrosis (≥F3) among MAFLD patients. METHODS This cross-sectional, multicentre study consecutively recruited MAFLD patients receiving tertiary care (Malaysia as training cohort [n = 276] and Hong Kong and Wenzhou as validation cohort [n = 431]). Patients completed liver biopsy, vibration-controlled transient elastography (VCTE), and clinical and laboratory assessment within 1 week. We used machine learning to select 'highly important' predictors of advanced fibrosis, followed by backward stepwise regression to construct MFS formula. RESULTS MFS was composed of seven variables: age, body mass index, international normalised ratio, aspartate aminotransferase, gamma-glutamyl transpeptidase, platelet count, and history of type 2 diabetes. MFS demonstrated an area under the receiver-operating characteristic curve of 0.848 [95% CI 0.800-898] and 0.823 [0.760-0.886] in training and validation cohorts, significantly higher than aminotransferase-to-platelet ratio index (0.684 [0.603-0.765], 0.663 [0.588-0.738]), Fibrosis-4 index (0.793 [0.735-0.854], 0.737 [0.660-0.814]), and non-alcoholic fatty liver disease fibrosis score (0.785 [0.731-0.844], 0.750 [0.674-0.827]) (DeLong's test p < 0.05). MFS could include 92.3% of patients using dual cut-offs of 14 and 15, with a correct prediction rate of 90.4%, resulting in a larger number of patients with correct diagnosis compared to other scores. A two-step MFS-VCTE screening algorithm demonstrated positive and negative predictive values and overall diagnostic accuracy of 93.4%, 89.5%, and 93.2%, respectively, with only 4.0% of patients classified into grey zone. CONCLUSION MFS outperforms conventional non-invasive scores in predicting advanced fibrosis, contributing to screening in MAFLD patients.
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Affiliation(s)
- Johnny T K Cheung
- Medical Data Analytics Centre, Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong, China
| | - Xinrong Zhang
- Medical Data Analytics Centre, Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong, China
- State Key Laboratory of Digestive Disease, Institute of Digestive Disease, The Chinese University of Hong Kong, Hong Kong, China
| | - Grace Lai-Hung Wong
- Medical Data Analytics Centre, Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong, China
- State Key Laboratory of Digestive Disease, Institute of Digestive Disease, The Chinese University of Hong Kong, Hong Kong, China
| | - Terry Cheuk-Fung Yip
- Medical Data Analytics Centre, Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong, China
- State Key Laboratory of Digestive Disease, Institute of Digestive Disease, The Chinese University of Hong Kong, Hong Kong, China
| | - Huapeng Lin
- Medical Data Analytics Centre, Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong, China
- State Key Laboratory of Digestive Disease, Institute of Digestive Disease, The Chinese University of Hong Kong, Hong Kong, China
| | - Guanlin Li
- Medical Data Analytics Centre, Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong, China
- State Key Laboratory of Digestive Disease, Institute of Digestive Disease, The Chinese University of Hong Kong, Hong Kong, China
| | - Howard Ho-Wai Leung
- Department of Anatomical and Cellular Pathology, The Chinese University of Hong Kong, Hong Kong, China
| | - Jimmy Che-To Lai
- Medical Data Analytics Centre, Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong, China
- State Key Laboratory of Digestive Disease, Institute of Digestive Disease, The Chinese University of Hong Kong, Hong Kong, China
| | - Sanjiv Mahadeva
- Gastroenterology and Hepatology Unit, Department of Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | | | - Xiao-Dong Wang
- Key Laboratory of Diagnosis and Treatment for the Development of Chronic Liver Disease in Zhejiang Province, Wenzhou, China
| | - Wen-Yue Liu
- Department of Endocrinology, the First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Vincent Wai-Sun Wong
- Medical Data Analytics Centre, Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong, China
- State Key Laboratory of Digestive Disease, Institute of Digestive Disease, The Chinese University of Hong Kong, Hong Kong, China
| | - Wah-Kheong Chan
- Gastroenterology and Hepatology Unit, Department of Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Ming-Hua Zheng
- Key Laboratory of Diagnosis and Treatment for the Development of Chronic Liver Disease in Zhejiang Province, Wenzhou, China
- MAFLD Research Centre, Department of Hepatology, the First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
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11
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Arora U, Goyal RM, Teh KKJ, Pei Y, Goh GBB, Lin S, Kumar R, Biswas S, Vaishnav M, Swaroop S, Pathak P, Sheikh S, Bharadiya V, Elhence A, Gamanagatti S, Yadav R, Das P, Aggarwal S, Choudhary N, Anirvan P, Singh SP, De A, Duseja A, Shalimar. Poor Performance of Non-invasive Tests for Advanced Fibrosis in Nonalcoholic Fatty Liver Disease: A Multicentric Asian Study. Dig Dis Sci 2023; 68:4485-4498. [PMID: 37733130 DOI: 10.1007/s10620-023-08085-y] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2022] [Accepted: 07/31/2023] [Indexed: 09/22/2023]
Abstract
BACKGROUND Non-invasive tests (NITs) are useful to assess advanced fibrosis (AF) in nonalcoholic fatty liver disease (NAFLD). Data from Asian countries suggest that these tests have poor performance. We aimed to assess diagnostic accuracy of established thresholds of biomarker-based NITs and Transient Elastography (TE) in identifying AF and evaluated the utility of a two-step test approach. METHODS Biopsy-proven 641 NAFLD patients (55.2% males, median age 42 years) were included from three different centers of Asia. AF (≥ F3) was identified as per histological staging (24.8%). RESULTS TE had the highest area under the receiver operating characteristic curve (AUROC) 0.82 (0.79-0.86), and all other biomarker-based NITs had low AUROC (< 0.7). NITs performed poorly at established thresholds. The combination of NITs utilizing liver stiffness measurement (LSM) and biomarkers, Agile 3+ and FAST, demonstrated acceptable diagnostic accuracy (AUROC 0.82 and 0.78, respectively), but none were superior to LSM alone. LSM measured using appropriate M and XL probes remained accurate regardless of body mass index (BMI); NFS and APRI scores were less accurate at higher BMI ranges. A two-step approach using NFS rule-out criteria (< - 2.97 to rule out) followed by LSM (< 7.3 kPa to rule out and ≥ 12.7 kPa to rule in) correctly classified 62.4% of patients, with only 10.2% of patients incorrectly classified. CONCLUSION NITs have not been validated to identify AF in the Asian NAFLD population, and internationally accepted thresholds yield high false-negative rates. LSM and LSM-based combination tests remain the most accurate.
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Affiliation(s)
- Umang Arora
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, Delhi, 110029, India
| | - Ritik M Goyal
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, Delhi, 110029, India
| | - Kevin K J Teh
- Department of Gastroenterology and Hepatology, Singapore General Hospital, Singapore, Singapore
| | - Yiying Pei
- Department of Gastroenterology and Hepatology, Singapore General Hospital, Singapore, Singapore
| | - George B B Goh
- Department of Gastroenterology and Hepatology, Singapore General Hospital, Singapore, Singapore
| | - Su Lin
- Department of Liver Research Center, The First Affiliated Hospital of Fujian Medical University, Fuzhou, Fujian, China
| | - Rahul Kumar
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore, Singapore
- Medicine Academic Clinical Programme, SingHealthDuke-NUS Academic Medical Centre, Singapore, Singapore
| | - Sagnik Biswas
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, Delhi, 110029, India
| | - Manas Vaishnav
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, Delhi, 110029, India
| | - Shekhar Swaroop
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, Delhi, 110029, India
| | - Piyush Pathak
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, Delhi, 110029, India
| | - Sabreena Sheikh
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, Delhi, 110029, India
| | - Vishwesh Bharadiya
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, Delhi, 110029, India
| | - Anshuman Elhence
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, Delhi, 110029, India
| | | | - Rajni Yadav
- Department of Pathology, All India Institute of Medical Sciences, Delhi, India
| | - Prasenjit Das
- Department of Pathology, All India Institute of Medical Sciences, Delhi, India
| | - Sandeep Aggarwal
- Department of Surgical Disciplines, All India Institute of Medical Sciences, Delhi, India
| | | | - Prajna Anirvan
- Srirama Chandra Bhanja Medical College and Hospital, Cuttack, Orissa, India
| | - Shivaram P Singh
- Srirama Chandra Bhanja Medical College and Hospital, Cuttack, Orissa, India
| | - Arka De
- Department of Hepatology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Ajay Duseja
- Department of Hepatology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Shalimar
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, Delhi, 110029, India.
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12
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Zhang X, Yip TCF, Wong GLH, Leow WX, Liang LY, Lim LL, Li G, Ibrahim L, Lin H, Lai JCT, Chim AML, Chan HLY, Kong APS, Chan WK, Wong VWS. Clinical care pathway to detect advanced liver disease in patients with type 2 diabetes through automated fibrosis score calculation and electronic reminder messages: a randomised controlled trial. Gut 2023; 72:2364-2371. [PMID: 37549979 PMCID: PMC10715546 DOI: 10.1136/gutjnl-2023-330269] [Citation(s) in RCA: 22] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2023] [Accepted: 07/30/2023] [Indexed: 08/09/2023]
Abstract
OBJECTIVE We aimed to test the hypothesis that automated fibrosis score calculation and electronic reminder messages could increase the detection of advanced liver disease in patients with type 2 diabetes. DESIGN In this pragmatic randomised controlled trial at five general medical or diabetes clinics in Hong Kong and Malaysia, we randomly assigned patients in a 1:1 ratio to the intervention group with Fibrosis-4 index and aspartate aminotransferase-to-platelet ratio index automatically calculated based on routine blood tests, followed by electronic reminder messages to alert clinicians of abnormal results, or the control group with usual care. The primary outcome was the proportion of patients with increased fibrosis scores who received appropriate care (referred for hepatology care or specific fibrosis assessment) within 1 year. RESULTS Between May 2020 and Oct 2021, 1379 patients were screened, of whom 533 and 528 were assigned to the intervention and control groups, respectively. A total of 55 out of 165 (33.3%) patients with increased fibrosis scores in the intervention group received appropriate care, compared with 4 of 131 (3.1%) patients in the control group (difference 30.2% (95% CI 22.4% to 38%); p<0.001). Overall, 11 out of 533 (2.1%) patients in the intervention group and 1 out of 528 (0.2%) patients in the control group were confirmed to have advanced liver disease (difference 1.9% (95% CI 0.61% to 3.5%); p=0.006). CONCLUSION Automated fibrosis score calculation and electronic reminders can increase referral of patients with type 2 diabetes and abnormal fibrosis scores at non-hepatology settings. TRIAL REGISTRATION NUMBER NCT04241575.
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Affiliation(s)
- Xinrong Zhang
- Medical Data Analytics Centre, The Chinese University of Hong Kong, Hong Kong, People's Republic of China
- State Key Laboratory of Digestive Disease, Institute of Digestive Disease, The Chinese University of Hong Kong, Hong Kong, People's Republic of China
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong, People's Republic of China
| | - Terry Cheuk-Fung Yip
- Medical Data Analytics Centre, The Chinese University of Hong Kong, Hong Kong, People's Republic of China
- State Key Laboratory of Digestive Disease, Institute of Digestive Disease, The Chinese University of Hong Kong, Hong Kong, People's Republic of China
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong, People's Republic of China
| | - Grace Lai-Hung Wong
- Medical Data Analytics Centre, The Chinese University of Hong Kong, Hong Kong, People's Republic of China
- State Key Laboratory of Digestive Disease, Institute of Digestive Disease, The Chinese University of Hong Kong, Hong Kong, People's Republic of China
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong, People's Republic of China
| | - Wei-Xuan Leow
- Gastroenterology and Hepatology Unit, Department of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Lilian Yan Liang
- Medical Data Analytics Centre, The Chinese University of Hong Kong, Hong Kong, People's Republic of China
- State Key Laboratory of Digestive Disease, Institute of Digestive Disease, The Chinese University of Hong Kong, Hong Kong, People's Republic of China
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong, People's Republic of China
| | - Lee-Ling Lim
- Endocrine Unit, Department of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Guanlin Li
- Medical Data Analytics Centre, The Chinese University of Hong Kong, Hong Kong, People's Republic of China
- State Key Laboratory of Digestive Disease, Institute of Digestive Disease, The Chinese University of Hong Kong, Hong Kong, People's Republic of China
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong, People's Republic of China
| | - Luqman Ibrahim
- Endocrine Unit, Department of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Huapeng Lin
- Medical Data Analytics Centre, The Chinese University of Hong Kong, Hong Kong, People's Republic of China
- State Key Laboratory of Digestive Disease, Institute of Digestive Disease, The Chinese University of Hong Kong, Hong Kong, People's Republic of China
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong, People's Republic of China
| | - Jimmy Che To Lai
- Medical Data Analytics Centre, The Chinese University of Hong Kong, Hong Kong, People's Republic of China
- State Key Laboratory of Digestive Disease, Institute of Digestive Disease, The Chinese University of Hong Kong, Hong Kong, People's Republic of China
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong, People's Republic of China
| | - Angel Mei-Ling Chim
- Medical Data Analytics Centre, The Chinese University of Hong Kong, Hong Kong, People's Republic of China
- State Key Laboratory of Digestive Disease, Institute of Digestive Disease, The Chinese University of Hong Kong, Hong Kong, People's Republic of China
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong, People's Republic of China
| | - Henry Lik Yuen Chan
- Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, People's Republic of China
- Union Hospital, Hong Kong, People's Republic of China
| | - Alice Pik-Shan Kong
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong, People's Republic of China
| | - Wah Kheong Chan
- Gastroenterology and Hepatology Unit, Department of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Vincent Wai-Sun Wong
- Medical Data Analytics Centre, The Chinese University of Hong Kong, Hong Kong, People's Republic of China
- State Key Laboratory of Digestive Disease, Institute of Digestive Disease, The Chinese University of Hong Kong, Hong Kong, People's Republic of China
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong, People's Republic of China
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13
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Miranda WR, Kamath PS, Jain CC, Connolly HC, Egbe AC. Liver Fibrosis Scores Are Associated With Resting and Exercise Fontan and Pulmonary Artery Wedge Pressures: Insights Into FALD. Can J Cardiol 2023; 39:1349-1357. [PMID: 37150355 DOI: 10.1016/j.cjca.2023.04.024] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2023] [Revised: 04/03/2023] [Accepted: 04/27/2023] [Indexed: 05/09/2023] Open
Abstract
BACKGROUND Alterations in liver perfusion and venous hypertension have been implicated in the pathophysiology of Fontan-associated liver disease (FALD). However, the correlation between exercise hemodynamics and markers of FALD have not been studied. METHODS We performed a retrospective review of 32 consecutive adults undergoing exercise catheterisation at the Mayo Clinic, Minnesota. Invasive hemodynamics were correlated with aspartate transaminase to platelet ratio index (APRI) and the Fibrosis-4 (Fib-4) score, well validated surrogates of liver fibrosis. RESULTS The mean age was 30.9 ± 7 years. The mean APRI was 0.5 ± 0.2 and the mean Fib-4 score 1.3 ± 0.8. Fib-4 scores correlated with spleen size on abdominal imaging (r = 0.40; P = 0.03). Resting Fontan pressure was 13.9 ± 3.9 mm Hg and pulmonary artery wedge pressure (PAWP) 10.0 ± 3.5 mm Hg. At peak exercise (69.4 ± 23.2 W), Fontan pressures increased to 26.5 ± 6.2 mm Hg and PAWP to 22.4 ± 7.1 mm Hg. APRI and Fib-4 score were directly related to Fontan pressure and PAWP at rest and during exercise, and inversely related to exercise arterial O2 saturation. Fib-4 inversely correlated with O2 delivery indices. Similarly, when categorising patients according to high APRI (> 0.5 vs ≤ 0.5) or Fib-4 score (≥ 1.45 vs < 1.45) according to previously proposed cutoffs for diagnosis of liver fibrosis, those with elevated scores had higher resting and exercise Fontan and PAWP pressure with lower O2 arterial saturation. CONCLUSIONS APRI and Fib-4 score correlated with resting and exercise Fontan pressure and PAWP. In addition, Fib-4 scores were inversely related to O2 delivery indices. These findings support a role played by hepatic venous hypertension and reduced O2 supply in patients with FALD.
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Affiliation(s)
- William R Miranda
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA.
| | - Patrick S Kamath
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - C Charles Jain
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Heidi C Connolly
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Alexander C Egbe
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
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Armandi A, Michel M, Gjini K, Emrich T, Bugianesi E, Schattenberg JM. Emerging concepts in the detection of liver fibrosis in non-alcoholic fatty liver disease. Expert Rev Mol Diagn 2023; 23:771-782. [PMID: 37505901 DOI: 10.1080/14737159.2023.2242779] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Revised: 06/24/2023] [Accepted: 07/27/2023] [Indexed: 07/30/2023]
Abstract
INTRODUCTION The non-invasive identification of liver fibrosis related to Non-Alcoholic Fatty Liver Disease is crucial for risk-stratification of patients. Currently, the reference standard to stage hepatic fibrosis relies on liver biopsy, but multiple approaches are developed to allow for non-invasive diagnosis and risk stratification. Non-invasive tests, including blood-based scores and vibration-controlled transient elastography, have been widely validated and represent a good surrogate for risk stratification according to recent European and American guidelines. AREAS COVERED Novel approaches are based on 'liquid' biomarkers of liver fibrogenesis, including collagen-derived markers (PRO-C3 or PRO-C6), or 'multi-omics' technologies (e.g. proteomic-based molecules or miRNA testing), bearing the advantage of tailoring the intrahepatic disease activity. Alternative approaches are based on 'dry' biomarkers, including magnetic resonance-based tools (including proton density fat fraction, magnetic resonance elastography, or corrected T1), which reach similar accuracy of liver histology and will potentially help identify the best candidates for pharmacological treatment of fibrosing non-alcoholic steatohepatitis. EXPERT OPINION In the near future, the sequential use of non-invasive tests, as well as the complimentary use of liquid and dry biomarkers according to the clinical need (diagnosis, risk stratification, and prognosis, or treatment response) will guide and improve the management of this liver disease.
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Affiliation(s)
- Angelo Armandi
- Division of Gastroenterology and Hepatology, Department of Medical Sciences, University of Turin, Corso Dogliotti 14, 10126 Turin, Italy
- Metabolic Liver Research Program, I. Department of Medicine, University Medical Centre Mainz, Langenbeckstrasse 1, 55131 Mainz, Germany
| | - Maurice Michel
- Metabolic Liver Research Program, I. Department of Medicine, University Medical Centre Mainz, Langenbeckstrasse 1, 55131 Mainz, Germany
- I. Department of Medicine, University Medical Centre Mainz, Langenbeckstrasse 1, 55131 Mainz, Germany
| | - Kamela Gjini
- Division of Gastroenterology and Hepatology, Department of Medical Sciences, University of Turin, Corso Dogliotti 14, 10126 Turin, Italy
| | - Tilman Emrich
- Department of Radiology, University Medical Centre Mainz, Langenbeckstrasse 1, 55131 Mainz, Germany
| | - Elisabetta Bugianesi
- Division of Gastroenterology and Hepatology, Department of Medical Sciences, University of Turin, Corso Dogliotti 14, 10126 Turin, Italy
| | - Jorn M Schattenberg
- Metabolic Liver Research Program, I. Department of Medicine, University Medical Centre Mainz, Langenbeckstrasse 1, 55131 Mainz, Germany
- I. Department of Medicine, University Medical Centre Mainz, Langenbeckstrasse 1, 55131 Mainz, Germany
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15
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Sanyal AJ, Castera L, Wong VWS. Noninvasive Assessment of Liver Fibrosis in NAFLD. Clin Gastroenterol Hepatol 2023; 21:2026-2039. [PMID: 37062495 DOI: 10.1016/j.cgh.2023.03.042] [Citation(s) in RCA: 65] [Impact Index Per Article: 32.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2023] [Revised: 03/06/2023] [Accepted: 03/24/2023] [Indexed: 04/18/2023]
Abstract
Nonalcoholic fatty liver disease (NAFLD) has emerged as a leading cause of liver-related morbidity and mortality worldwide, afflicting approximately a billion individuals. NAFLD is a slowly progressive disease that may evolve in a subset of patients toward cirrhosis, hepatocellular carcinoma, and end-stage liver disease. Liver fibrosis severity is the strongest predictor of clinical outcomes. The emergence of effective therapeutics on the horizon highlights the need to identify among patients with NAFLD, those with severe fibrosis or cirrhosis, who are the most at risk of developing complications and target them for therapy. Liver biopsy has been the reference standard for this purpose. However, it is not suitable for large-scale population evaluation, given its well-known limitations (invasiveness, rare but severe complications, and sampling variability). Thus, there have been major efforts to develop simple noninvasive tools that can be used in routine clinical settings and in drug development. Noninvasive approaches are based on the quantification of biomarkers in serum samples or on the measurement of liver stiffness, using either ultrasound- or magnetic resonance-based elastography techniques. This review provides a roadmap for future development and integration of noninvasive tools in clinical practice and in drug development in NAFLD. We discuss herein the principles for their development and validation, their use in clinical practice, including for diagnosis of NAFLD, risk stratification in primary care and hepatology settings, prediction of long-term liver-related and non-liver-related outcomes, monitoring of fibrosis progression and regression, and response to future treatment.
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Affiliation(s)
- Arun J Sanyal
- Division of Gastroenterology, Hepatology and Nutrition, Department of Internal Medicine, Virginia Commonwealth University School of Medicine, Richmond, Virginia.
| | - Laurent Castera
- UMR1149 (Center of Research on Inflammation), French Institute of Health and Medical Research, Université Paris Cité, Paris, France; Service d'Hépatologie, Hôpital Beaujon, Assistance Publique-Hôpitaux de Paris, Clichy, France.
| | - Vincent Wai-Sun Wong
- State Key Laboratory of Digestive Disease, Institute of Digestive Disease, The Chinese University of Hong Kong, Hong Kong, China; Medical Data Analytics Centre, Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong, China.
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16
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Schreiner AD, Sattar N. Identifying Patients with Nonalcoholic Fatty Liver Disease in Primary Care: How and for What Benefit? J Clin Med 2023; 12:4001. [PMID: 37373694 DOI: 10.3390/jcm12124001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Revised: 05/31/2023] [Accepted: 06/01/2023] [Indexed: 06/29/2023] Open
Abstract
Despite its increasing prevalence, nonalcoholic fatty liver disease (NAFLD) remains under-diagnosed in primary care. Timely diagnosis is critical, as NAFLD can progress to nonalcoholic steatohepatitis, fibrosis, cirrhosis, hepatocellular carcinoma, and death; furthermore, NAFLD is also a risk factor linked to cardiometabolic outcomes. Identifying patients with NAFLD, and particularly those at risk of advanced fibrosis, is important so that healthcare practitioners can optimize care delivery in an effort to prevent disease progression. This review debates the practical issues that primary care physicians encounter when managing NAFLD, using a patient case study to illustrate the challenges and decisions that physicians face. It explores the pros and cons of different diagnostic strategies and tools that physicians can adopt in primary care settings, depending on how NAFLD presents and progresses. We discuss the importance of prescribing lifestyle changes to achieve weight loss and mitigate disease progression. A diagnostic and management flow chart is provided, showing the key points of assessment for primary care physicians. The advantages and disadvantages of advanced fibrosis risk assessments in primary care settings and the factors that influence patient referral to a hepatologist are also reviewed.
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Affiliation(s)
- Andrew D Schreiner
- Department of Medicine, Medical University of South Carolina, 171 Ashley Ave, Charleston, SC 29425, USA
| | - Naveed Sattar
- Institute of Cardiovascular & Medical Sciences, University of Glasgow, 126 University Place, Glasgow G12 8TA, UK
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Abstract
Nonalcoholic fatty liver disease (NAFLD) is strongly associated with obesity but around 10% to 20% of patients with NAFLD have normal body mass index, a condition referred to as lean or nonobese NAFLD. Although lean patients more often have milder liver disease, a proportion may nonetheless develop steatohepatitis and advanced liver fibrosis. Both genetic and environmental factors contribute to the development of NAFLD. Noninvasive tests have similarly good accuracy as initial assessments for lean NAFLD. Future studies should determine the most appropriate treatment in this special population.
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Affiliation(s)
- Ajay Duseja
- Department of Hepatology, Post Graduate Institute of Medical Education and Research, Chandigarh, India.
| | - Arka De
- Department of Hepatology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Vincent Wong
- Department of Medicine and Therapeutics, Medical Data Analytics Center, The Chinese University of Hong Kong, Hong Kong; State Key Laboratory of Digestive Disease, Institute of Digestive Disease, The Chinese University of Hong Kong, Hong Kong
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18
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Yip TCF, Vilar-Gomez E, Petta S, Yilmaz Y, Wong GLH, Adams LA, de Lédinghen V, Sookoian S, Wong VWS. Geographical similarity and differences in the burden and genetic predisposition of NAFLD. Hepatology 2023; 77:1404-1427. [PMID: 36062393 DOI: 10.1002/hep.32774] [Citation(s) in RCA: 69] [Impact Index Per Article: 34.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2022] [Revised: 08/28/2022] [Accepted: 09/01/2022] [Indexed: 12/13/2022]
Abstract
NAFLD has become a major public health problem for more than 2 decades with a growing prevalence in parallel with the epidemic of obesity and type 2 diabetes (T2D). The disease burden of NAFLD differs across geographical regions and ethnicities. Variations in prevalence of metabolic diseases, extent of urban-rural divide, dietary habits, lifestyles, and the prevalence of NAFLD risk and protective alleles can contribute to such differences. The rise in NAFLD has led to a remarkable increase in the number of cases of cirrhosis, hepatocellular carcinoma, hepatic decompensation, and liver-related mortality related to NAFLD. Moreover, NAFLD is associated with multiple extrahepatic manifestations. Most of them are risk factors for the progression of liver fibrosis and thus worsen the prognosis of NAFLD. All these comorbidities and complications affect the quality of life in subjects with NAFLD. Given the huge and growing size of the population with NAFLD, it is expected that patients, healthcare systems, and the economy will suffer from the ongoing burden related to NAFLD. In this review, we examine the disease burden of NAFLD across geographical areas and ethnicities, together with the distribution of some well-known genetic variants for NAFLD. We also describe some special populations including patients with T2D, lean patients, the pediatric population, and patients with concomitant liver diseases. We discuss extrahepatic outcomes, patient-reported outcomes, and economic burden related to NAFLD.
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Affiliation(s)
- Terry Cheuk-Fung Yip
- Medical Data Analytics Center, Department of Medicine and Therapeutics , The Chinese University of Hong Kong , Hong Kong
- State Key Laboratory of Digestive Disease , The Chinese University of Hong Kong , Hong Kong
| | - Eduardo Vilar-Gomez
- Division of Gastroenterology and Hepatology, Department of Medicine , Indiana University School of Medicine , Indianapolis , Indiana , USA
| | - Salvatore Petta
- Section of Gastroenterology and Hepatology, Dipartimento Di Promozione Della Salute, Materno Infantile, Medicina Interna e Specialistica Di Eccellenza (PROMISE) , University of Palermo , Palermo , Italy
| | - Yusuf Yilmaz
- Department of Gastroenterology, School of Medicine , Recep Tayyip Erdogan University , Rize , Turkey
- Liver Research Unit , Institute of Gastroenterology , Marmara University , Istanbul , Turkey
| | - Grace Lai-Hung Wong
- Medical Data Analytics Center, Department of Medicine and Therapeutics , The Chinese University of Hong Kong , Hong Kong
- State Key Laboratory of Digestive Disease , The Chinese University of Hong Kong , Hong Kong
| | - Leon A Adams
- Department of Hepatology , Sir Charles Gairdner Hospital , Perth , Australia
- Medical School , University of Western Australia , Perth , Australia
| | - Victor de Lédinghen
- Hepatology Unit , Hôpital Haut Lévêque, Bordeaux University Hospital , Bordeaux , France
- INSERM U1312 , Bordeaux University , Bordeaux , France
| | - Silvia Sookoian
- School of Medicine, Institute of Medical Research A Lanari , University of Buenos Aires , Ciudad Autónoma de Buenos Aires , Argentina
- Department of Clinical and Molecular Hepatology, Institute of Medical Research (IDIM) , National Scientific and Technical Research Council (CONICET), University of Buenos Aires , Ciudad Autónoma de Buenos Aires , Argentina
| | - Vincent Wai-Sun Wong
- Medical Data Analytics Center, Department of Medicine and Therapeutics , The Chinese University of Hong Kong , Hong Kong
- State Key Laboratory of Digestive Disease , The Chinese University of Hong Kong , Hong Kong
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19
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Lim GEH, Tang A, Ng CH, Chin YH, Lim WH, Tan DJH, Yong JN, Xiao J, Lee CWM, Chan M, Chew NW, Xuan Tan EX, Siddiqui MS, Huang D, Noureddin M, Sanyal AJ, Muthiah MD. An Observational Data Meta-analysis on the Differences in Prevalence and Risk Factors Between MAFLD vs NAFLD. Clin Gastroenterol Hepatol 2023; 21:619-629.e7. [PMID: 34871813 DOI: 10.1016/j.cgh.2021.11.038] [Citation(s) in RCA: 138] [Impact Index Per Article: 69.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Revised: 11/12/2021] [Accepted: 11/16/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS The shift to redefine nonalcoholic fatty liver disease (NAFLD) as metabolic associated fatty liver disease (MAFLD) can profoundly affect patient care, health care professionals, and progress within the field. To date, there remains no consensus on the characterization of NAFLD vs MAFLD. Thus, this study sought to compare the differences between the natural history of NAFLD and MAFLD. METHODS Medline and Embase databases were searched to include articles on prevalence, risk factors, or outcomes of patients with MAFLD or NAFLD. Meta-analysis of proportions was conducted using the generalized linear mix model. Risk factors and outcomes were evaluated in conventional pairwise meta-analysis. RESULTS Twenty-two articles involving 379,801 patients were included. Pooled prevalence of MAFLD was 39.22% (95% confidence interval [CI], 30.96%-48.15%) with the highest prevalence in Europe and Asia, followed by North America. The current MAFLD Definition only accounted for 81.59% (95% CI, 66.51%-90.82%) of NAFLD diagnoses. Patients had increased odds of being diagnosed with MAFLD compared with NAFLD (odds ratio, 1.37; 95% CI, 1.16-1.63; P < .001). Imaging modality resulted in a significantly higher odds of being diagnosed with MAFLD compared with NAFLD, but not biopsy. MAFLD was significantly associated with males, higher body mass index, hypertension, diabetes, lipids, transaminitis, and greater fibrosis scores compared with NAFLD. CONCLUSIONS There were stark differences in the prevalence and risk factors between MAFLD and NAFLD. However, in the use of the MAFLD Definition, a greater emphasis on the management of concomitant metabolic diseases and a collaborative effort is required to explore the complex pathophysiologic mechanisms underlying the disease.
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Affiliation(s)
- Grace En Hui Lim
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore
| | - Ansel Tang
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Cheng Han Ng
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Yip Han Chin
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Wen Hui Lim
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Darren Jun Hao Tan
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Jie Ning Yong
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Jieling Xiao
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Chloe Wen-Min Lee
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Mark Chan
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore; Department of Cardiology, National University Heart Centre, National University Hospital, Singapore
| | - Nicholas Ws Chew
- Department of Cardiology, National University Heart Centre, National University Hospital, Singapore
| | - Eunice Xiang Xuan Tan
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore; Division of Gastroenterology and Hepatology, Department of Medicine, National University Hospital, Singapore; National University Centre for Organ Transplantation, National University Health System, Singapore
| | - Mohammad Shadab Siddiqui
- Division of Gastroenterology, Hepatology and Nutrition, Department of Internal Medicine, Virginia Commonwealth University, Richmond, Virginia
| | - Daniel Huang
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore; Division of Gastroenterology and Hepatology, Department of Medicine, National University Hospital, Singapore; National University Centre for Organ Transplantation, National University Health System, Singapore
| | - Mazen Noureddin
- Cedars-Sinai Fatty Liver Program, Division of Digestive and Liver Diseases, Department of Medicine, Comprehensive Transplant Center, Cedars-Sinai Medical Center, Los Angeles, California
| | - Arun J Sanyal
- Division of Gastroenterology, Hepatology and Nutrition, Department of Internal Medicine, Virginia Commonwealth University, Richmond, Virginia
| | - Mark D Muthiah
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore; Division of Gastroenterology and Hepatology, Department of Medicine, National University Hospital, Singapore; National University Centre for Organ Transplantation, National University Health System, Singapore.
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20
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Jacobson IM, Wong VWS, Castera L, Anstee QM, Noureddin M, Cusi K, Harrison SA, Bugianesi E, Younossi ZM. Expert Panel Consensus on Clinical Assertion Statements Describing Noninvasive Tools for Diagnosing Nonalcoholic Steatohepatitis. J Clin Gastroenterol 2023; 57:253-264. [PMID: 36251413 PMCID: PMC9911115 DOI: 10.1097/mcg.0000000000001780] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
GOALS AND BACKGROUND A panel of 9 experts in nonalcoholic steatohepatitis gathered to assess multiple components of the diagnostic process. MATERIALS AND METHODS The Clinical Assertion Statements covered screening of patients with type 2 diabetes for high-risk nonalcoholic fatty liver disease, which-if any-noninvasive tests could determine whether to delay or defer biopsy, whether primary care providers and endocrinologists should routinely calculate Fibrosis-4 (FIB-4) scores in patients with nonalcoholic fatty liver disease or those at risk for it, optimal noninvasive tests to stage fibrosis, the need to consider fibrosis in patients with normal transaminase levels, periodic monitoring for progressive fibrosis, whether patients should undergo biopsy before pharmacotherapy, and the clinical utility of genetic testing. RESULTS AND CONCLUSIONS Evidence was presented to support or refute each Clinical Assertion Statement; the panel voted on the nature of the evidence, level of support, and level of agreement with each Statement. Panel level of agreement and rationale of each Clinical Assertion Statement are reported here.
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Affiliation(s)
- Ira M. Jacobson
- Department of Medicine and Therapeutics, NYU Langone Health, New York, NY
| | - Vincent Wai-Sun Wong
- Department of Medicine and Therapeutics
- State Key Laboratory of Digestive Disease, The Chinese University of Hong Kong, Hong Kong, Hong Kong
| | - Laurent Castera
- Department of Hepatology, Hôpital Beaujon (Beaujon Hospital), Assistance Publique-Hôpitaux de Paris, Clichy
- Department of Hepatology, University of Paris, Paris, France
| | - Quentin M. Anstee
- Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University
- Newcastle NIHR Biomedical Research Centre, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne
| | - Mazen Noureddin
- Fatty Liver Program, Karsh Division of Gastroenterology and Hepatology, Cedars Sinai Medical Center, Los Angeles, CA
| | - Kenneth Cusi
- Division of Endocrinology, Diabetes and Metabolism, University of Florida
- Malcom Randall VAMC, Gainesville, FL
| | | | - Elisabetta Bugianesi
- Department of Medical Sciences, Division of Gastroenterology, University of Torino, Torino, Italy
| | - Zobair M. Younossi
- Inova Medicine, Inova Health System
- Department of Medicine, Center for Liver Diseases, Inova Fairfax Medical Campus, Falls Church, VA
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21
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Zhang X, Wong GLH, Yip TCF, Cheung JTK, Tse YK, Hui VWK, Lin H, Lai JCT, Chan HLY, Kong APS, Wong VWS. Risk of liver-related events by age and diabetes duration in patients with diabetes and nonalcoholic fatty liver disease. Hepatology 2022; 76:1409-1422. [PMID: 35334125 DOI: 10.1002/hep.32476] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Revised: 03/08/2022] [Accepted: 03/23/2022] [Indexed: 12/24/2022]
Abstract
BACKGROUND AND AIMS Several guidelines recommend screening for NAFLD in patients with type 2 diabetes (T2D). We aimed to determine if there is a threshold of age and duration of T2D for liver-related event development to guide screening strategies. APPROACH AND RESULTS We conducted a territory-wide retrospective cohort study of adult patients with NAFLD and T2D diagnosed between 2000 and 2014 in Hong Kong to allow for at least 5 years of follow-up. The primary endpoint was liver-related events, defined as a composite of HCC and cirrhotic complications. This study included 7028 patients with NAFLD with T2D (mean age, 56.1 ± 13.3 years; 3363 male [47.9%]). During a follow-up of 77,308 person-years, there was a threshold effect with 1.1%, 4.9%, and 94.0% of patients developing liver-related events at the age of <40, 40-50, and ≥50 years, respectively. Similarly, 3.1%, 5.1%, and 91.8% of patients developed cirrhosis at the age of <40, 40-50, and ≥50 years, respectively. In contrast, liver-related events increased linearly with diabetes duration, with no difference in the annual incidence rate between the first 10 years of T2D diagnosis and subsequent years (0.06% vs. 0.10%; p = 0.136). On multivariable analysis, baseline age ≥50 years (adjusted HR [aHR] 2.01) and cirrhosis (aHR 3.12) were the strongest risk factors associated with liver-related events. Substitution of cirrhosis with the aspartate aminotransferase-to-platelet ratio index or the Fibrosis-4 index yielded similar results. CONCLUSIONS Age rather than duration of T2D predicts liver-related events in patients with NAFLD and T2D. It is reasonable to screen patients with NAFLD and T2D for advanced liver disease starting at 50 years of age.
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Affiliation(s)
- Xinrong Zhang
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong SAR, China
- Medical Data Analytic Centre, The Chinese University of Hong Kong, Hong Kong SAR, China
- Institute of Digestive Disease, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Grace Lai-Hung Wong
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong SAR, China
- Medical Data Analytic Centre, The Chinese University of Hong Kong, Hong Kong SAR, China
- Institute of Digestive Disease, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Terry Cheuk-Fung Yip
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong SAR, China
- Medical Data Analytic Centre, The Chinese University of Hong Kong, Hong Kong SAR, China
- Institute of Digestive Disease, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Johnny T K Cheung
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Yee-Kit Tse
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong SAR, China
- Medical Data Analytic Centre, The Chinese University of Hong Kong, Hong Kong SAR, China
- Institute of Digestive Disease, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Vicki Wing-Ki Hui
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong SAR, China
- Medical Data Analytic Centre, The Chinese University of Hong Kong, Hong Kong SAR, China
- Institute of Digestive Disease, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Huapeng Lin
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong SAR, China
- Medical Data Analytic Centre, The Chinese University of Hong Kong, Hong Kong SAR, China
- Institute of Digestive Disease, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Jimmy Che-To Lai
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong SAR, China
- Medical Data Analytic Centre, The Chinese University of Hong Kong, Hong Kong SAR, China
- Institute of Digestive Disease, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Henry Lik-Yuen Chan
- Medical Data Analytic Centre, The Chinese University of Hong Kong, Hong Kong SAR, China
- Union Hospital, Hong Kong SAR, China
| | - Alice Pik-Shan Kong
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Vincent Wai-Sun Wong
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong SAR, China
- Medical Data Analytic Centre, The Chinese University of Hong Kong, Hong Kong SAR, China
- Institute of Digestive Disease, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong SAR, China
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22
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Wong VWS, Zelber-Sagi S, Cusi K, Carrieri P, Wright E, Crespo J, Lazarus JV. Management of NAFLD in primary care settings. Liver Int 2022; 42:2377-2389. [PMID: 35986897 DOI: 10.1111/liv.15404] [Citation(s) in RCA: 46] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2022] [Revised: 07/23/2022] [Accepted: 08/10/2022] [Indexed: 02/13/2023]
Abstract
Non-alcoholic fatty liver disease (NAFLD) affects at least 25% of the general population and is an increasingly important cause of cirrhosis and hepatocellular carcinoma. Although it is the research focus of the hepatology field, it is clear that primary care physicians are seeing the majority of NAFLD patients and are in a pivotal position to provide quality care. In this article, we review the role of primary care in the management of NAFLD. NAFLD is common in patients with diabetes, obesity and other metabolic risk factors. Abdominal ultrasonography is the most commonly used method to diagnose fatty liver. Simple fibrosis scores have high negative predictive values in excluding advanced liver fibrosis and future liver-related events and can be used in primary care as initial evaluation. An abnormal result should be followed by subsequent workup or specialist referral. Primary care is the ideal setting to institute multidisciplinary care, especially the involvement of dietitians and physical activity trainers in lifestyle intervention, as well as initiating the discussion of bariatric surgery in patients with severe obesity. Although specific drug treatment for steatohepatitis would require a more precise diagnosis, metabolic drugs that improve both steatohepatitis and cardiovascular outcomes (e.g. glucagon-like peptide-1 receptor agonists) may be considered in patients with NAFLD.
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Affiliation(s)
- Vincent W S Wong
- Medical Data Analytics Centre, Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong, China
| | | | - Kenneth Cusi
- Division of Endocrinology, Diabetes and Metabolism, University of Florida, Gainesville, Florida, USA
| | - Patrizia Carrieri
- Aix Marseille Univ, Inserm, IRD, SESSTIM, Sciences Economiques & Sociales de la Santé & Traitement de l'Information Médicale, ISSPAM, Marseille, France
| | - Eugene Wright
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - Javier Crespo
- Department of Gastroenterology and Hepatology, Marqués de Valdecilla University Hospital, Valdecilla Biomedical Research Institute (IDIVAL), Santander, University of Cantabria, Santander, Cantabria, Spain
| | - Jeffrey V Lazarus
- Barcelona Institute for Global Health (ISGlobal), Hospital Clínic, University of Barcelona, Barcelona, Spain.,Faculty of Medicine, University of Barcelona, Barcelona, Spain
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23
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Coste P, Llop E, Perelló C, Hernández M, López M, Abad J, Ferre C, Martínez JL, Fernández N, Calleja JL. Comparison of non-invasive fibrosis scores to predict increased liver stiffness in the general population with unknown liver disease: Searching for the primary physician's best friend. Dig Liver Dis 2022; 54:1209-1214. [PMID: 35428580 DOI: 10.1016/j.dld.2022.03.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2021] [Revised: 03/20/2022] [Accepted: 03/21/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND Serum-based scores (SBS) appear to be a high applicability strategy for assessment of liver fibrosis in primary care. Aim of the study was to evaluate their performance to detect ≥F2 in a general population and to design a highly-applicable strategy for screening. METHODS prospective population-based cohort study in randomly identified subjects, aged 40-70y. Medical history, blood tests and elastography were obtained, ≥F2 was determined by using LSM cutoff ≥9.2/7.8 kPa for M/XL probe and SBS diagnostic accuracies were evaluated. RESULTS 986 patients were analyzed. LSM prevalence estimate suggestive of ≥F2 was 1.9% and Metabolic Sindrome (MS) (OR 3.4, 1.3-9.0;p = 0.01), was the only factor independently associated with ≥F2, with increasing prevalence according to the number of criteria (0 criterion:0%,1:0.3%,2:2.8%,3:2.4%,4:6.9%,5:14.3%;p<0.001). FLI and NFS were the two best-performing tests in the cross-sectional study, with AUROCs for ≥F2 of 0.89 (95%CI,0.84- 0.95) and 0.82 (95%CI,0.74-0.90), respectively. Predefined cutoff for FLI≥60 (Sn89.5%, Sp72.1%, NPV99.9%) and NFS≥-1.455 (Sn83.3%, Sp68%, NPV99.6%) showed adequate diagnostic accuracy. Based on these findings, a 3- step algorithm strategy to detect liver fibrosis in the community setting is proposed (Sn84.2%, Sp75.2%, NVP99.6%). CONCLUSIONS A staged risk-stratification model improves the detection of ≥F2 in the community setting, while reducing unnecessary referrals.
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Affiliation(s)
- Pablo Coste
- Servicio de Gastroenterología y Hepatología, Hospital Universitario Puerta de Hierro, Instituto de Investigación Puerta de Hierro, Universidad Autónoma de Madrid, Majadahonda, Madrid, España
| | - Elba Llop
- Servicio de Gastroenterología y Hepatología, Hospital Universitario Puerta de Hierro, Instituto de Investigación Puerta de Hierro, Universidad Autónoma de Madrid, Majadahonda, Madrid, España
| | - Cristie Perelló
- Servicio de Gastroenterología y Hepatología, Hospital Universitario Puerta de Hierro, Instituto de Investigación Puerta de Hierro, Universidad Autónoma de Madrid, Majadahonda, Madrid, España
| | - Marta Hernández
- Servicio de Gastroenterología y Hepatología, Hospital Universitario Puerta de Hierro, Instituto de Investigación Puerta de Hierro, Universidad Autónoma de Madrid, Majadahonda, Madrid, España
| | - Marta López
- Servicio de Gastroenterología y Hepatología, Hospital Universitario Puerta de Hierro, Instituto de Investigación Puerta de Hierro, Universidad Autónoma de Madrid, Majadahonda, Madrid, España
| | - Javier Abad
- Servicio de Gastroenterología y Hepatología, Hospital Universitario Puerta de Hierro, Instituto de Investigación Puerta de Hierro, Universidad Autónoma de Madrid, Majadahonda, Madrid, España
| | - Carlos Ferre
- Servicio de Gastroenterología y Hepatología, Hospital Universitario Puerta de Hierro, Instituto de Investigación Puerta de Hierro, Universidad Autónoma de Madrid, Majadahonda, Madrid, España
| | - José Luis Martínez
- Servicio de Gastroenterología y Hepatología, Hospital Universitario Puerta de Hierro, Instituto de Investigación Puerta de Hierro, Universidad Autónoma de Madrid, Majadahonda, Madrid, España
| | - Natalia Fernández
- Servicio de Gastroenterología y Hepatología, Hospital Universitario Puerta de Hierro, Instituto de Investigación Puerta de Hierro, Universidad Autónoma de Madrid, Majadahonda, Madrid, España
| | - José Luis Calleja
- Servicio de Gastroenterología y Hepatología, Hospital Universitario Puerta de Hierro, Instituto de Investigación Puerta de Hierro, Universidad Autónoma de Madrid, Majadahonda, Madrid, España.
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Thévenot T, Vendeville S, Weil D, Akkouche L, Calame P, Canivet CM, Vanlemmens C, Richou C, Cervoni JP, Seronde MF, Di Martino V, Boursier J. Systematic screening for advanced liver fibrosis in patients with coronary artery disease: The CORONASH study. PLoS One 2022; 17:e0266965. [PMID: 35617294 PMCID: PMC9135299 DOI: 10.1371/journal.pone.0266965] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2021] [Accepted: 03/31/2022] [Indexed: 12/14/2022] Open
Abstract
Although coronary artery disease (CAD) and advanced liver fibrosis (AdLF) are commonly associated in patients with non-alcoholic fatty liver disease (NAFLD), the prevalence of AdLF and the diagnostic performance of non-invasive fibrosis tests (NITs) in CAD patients remains unknown. We aimed to prospectively screen for AdLF in patients with documented CAD using NITs and Fibroscan. High and intermediate zones of NITs were combined to define AdLF. AdLF was suspected whenever APRI ≥ 0.5, Forns index ≥ 4.2, NAFLD fibrosis score (NFS) ≥ -1.455/0.12 for age </≥ 65 yrs), Fib4 (≥ 1.30/2.0 for age </≥ 65 yrs) and eLIFT≥ 8. A presumed AdLF assessed by Fibroscan ≥ 8 kPa was the primary outcome measure. Results were given on the basis of intent-to-diagnose liver stiffness ≥ 8 kPa. Among 189 patients (age 60±7years), 10 (5.3%) had a Fibroscan ≥ 8 kPa, of whom 5 underwent liver biopsy (F3/F4: n = 3; no fibrosis: n = 2). AdLF was suspected in 31% of cases using eLIFT (specificity, Sp 70%), 85% with Forns (Sp 16%), 38% with NFS (Sp 63%), 25% with Fib4 (Sp 74%), and 10% with APRI (Sp 91%). In 149 patients “at-risk” of NAFLD (i.e., elevated ALT or diabetes or hypertriglyceridemia or BMI ≥25 kg/m2), AdLF ranged between 10% (APRI) to 84% (Forns). In this subgroup, the most efficient NITs to predict Fibroscan ≥ 8 kPa were eLIFT (Se 60%, Sp 70%) and NFS (Se 70%, Sp 60%). Finally, in CAD patients with risk factors for NAFLD, NFS or the more user-friendly eLIFT are the most attractive first-line biochemical NITs to discriminate good candidates for Fibroscan.
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Affiliation(s)
- Thierry Thévenot
- Department of Hepatology, University Hospital Jean Minjoz, Besançon, France
- * E-mail:
| | - Sophie Vendeville
- Department of Hepatology, University Hospital Jean Minjoz, Besançon, France
| | - Delphine Weil
- Department of Hepatology, University Hospital Jean Minjoz, Besançon, France
| | - Linda Akkouche
- Department of Cardiology, University Hospital Jean Minjoz, Besançon, France
| | - Paul Calame
- Department of Radiology, University Hospital Jean Minjoz, Besançon, France
| | - Clémence M. Canivet
- Hepato-Gastroenterology Department, Angers University Hospital, Angers, France
| | - Claire Vanlemmens
- Department of Hepatology, University Hospital Jean Minjoz, Besançon, France
| | - Carine Richou
- Department of Hepatology, University Hospital Jean Minjoz, Besançon, France
| | - Jean-Paul Cervoni
- Department of Hepatology, University Hospital Jean Minjoz, Besançon, France
| | | | - Vincent Di Martino
- Department of Hepatology, University Hospital Jean Minjoz, Besançon, France
| | - Jérôme Boursier
- Hepato-Gastroenterology Department, Angers University Hospital, Angers, France
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Prasoppokakorn T, Chan WK, Wong VWS, Pitisuttithum P, Mahadeva S, Nik Mustapha NR, Wong GLH, Leung HHW, Sripongpun P, Treeprasertsuk S. Validation model of fibrosis-8 index score to predict significant fibrosis among patients with nonalcoholic fatty liver disease. World J Gastroenterol 2022; 28:1563-1573. [PMID: 35582126 PMCID: PMC9048465 DOI: 10.3748/wjg.v28.i15.1563] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2021] [Revised: 11/25/2021] [Accepted: 03/15/2022] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Identifying hepatic fibrosis is crucial for nonalcoholic fatty liver disease (NAFLD) management. The fibrosis-8 (FIB-8) score, recently developed by incorporating four additional variables into the fibrosis-4 (FIB-4) score, showed better performance in predicting significant fibrosis in NAFLD. AIM To validate the FIB-8 score in a biopsy-proven NAFLD cohort and compare the diagnostic performance of the FIB-8 and FIB-4 scores and NAFLD fibrosis score (NFS) for predicting significant fibrosis. METHODS We collected the data of biopsy-proven NAFLD patients from three Asian centers in three countries. All the patients with available variables for the FIB-4 score (age, platelet count, and aspartate and alanine aminotransferase levels) and FIB-8 score (the FIB-4 variables plus 4 additional parameters: The body mass index (BMI), albumin to globulin ratio, gamma-glutamyl transferase level, and presence of diabetes mellitus) were included. The fibrosis stage was scored using nonalcoholic steatohepatitis CRN criteria, and significant fibrosis was defined as at least fibrosis stage 2. RESULTS A total of 511 patients with biopsy-proven NAFLD and complete data were included for validation. Of these 511 patients, 271 (53.0%) were female, with a median age of 51 (interquartile range: 41, 58) years. The median BMI was 29 (26.3, 32.6) kg/m2, and 268 (52.4%) had diabetes. Among the 511 NAFLD patients, 157 (30.7%) had significant fibrosis (≥ F2). The areas under the receiver operating characteristic curves of the FIB-8 and FIB-4 scores and NFS for predicting significant fibrosis were 0.774, 0.743, and 0.680, respectively. The FIB-8 score demonstrated significantly better performance for predicting significant fibrosis than the NFS (P = 0.001) and was also clinically superior to FIB-4, although statistical significance was not reached (P = 0.073). The low cutoff point of the FIB-8 score for predicting significant fibrosis of 0.88 showed 92.36% sensitivity, and the high cutoff point of the FIB-8 score for predicting significant fibrosis of 1.77 showed 67.51% specificity. CONCLUSION We demonstrated that the FIB-8 score had significantly better performance for predicting significant fibrosis in NAFLD patients than the NFS, as well as clinically superior performance vs the FIB-4 score in an Asian population. A novel simple fibrosis score comprising commonly accessible basic laboratories may be beneficial to use for an initial assessment in primary care units, excluding patients with significant liver fibrosis and aiding in patient selection for further hepatologist referral.
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Affiliation(s)
- Thaninee Prasoppokakorn
- Department of Medicine, Division of Gastroenterology, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok 10330, Thailand
| | - Wah-Kheong Chan
- Department of Medicine, Division of Gastroenterology, Division of Gastroenterology and Hepatology Unit, Faculty of Medicine, University of Malaya, Kuala Lumpur 50603, Malaysia
| | - Vincent Wai-Sun Wong
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong, China
| | - Panyavee Pitisuttithum
- Department of Medicine, Division of General Internal Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok 10330, Thailand
| | - Sanjiv Mahadeva
- Department of Medicine, Division of Gastroenterology, Division of Gastroenterology and Hepatology Unit, Faculty of Medicine, University of Malaya, Kuala Lumpur 50603, Malaysia
| | | | - Grace Lai-Hung Wong
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong, China
| | - Howard Ho-Wai Leung
- Department of Anatomical and Cellular Pathology, The Chinese University of Hong Kong, Hong Kong, China
| | - Pimsiri Sripongpun
- Department of Internal Medicine, Prince of Songkla University, Hat Yai 90110, Thailand
- Department of Medicine, Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Palo Alto, CA 94305, United States
| | - Sombat Treeprasertsuk
- Department of Medicine, Division of Gastroenterology, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok 10330, Thailand
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Milluzzo A, Manuella L, Cannata E, Russo G, La Vignera S, Purrello F, Di Cataldo A, Sciacca L. Influence of Body Mass Index, Cancer Type and Treatment on Long-Term Metabolic and Liver Outcomes in Childhood Cancer Survivors. J Clin Med 2022; 11:878. [PMID: 35160329 PMCID: PMC8836510 DOI: 10.3390/jcm11030878] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2021] [Revised: 02/04/2022] [Accepted: 02/05/2022] [Indexed: 11/25/2022] Open
Abstract
In the last decade, the survival of subjects affected by cancer in childhood has significantly improved. The increased lifespan of childhood cancer survivors (CCS) led to a greater risk for long-term, therapy-related morbidity. To identify the clinical predictors of metabolic adverse outcomes in CCS (average off-therapy period: 12 years), we recruited 126 survivors of different childhood cancers (86.5% hematological cancers) who received at least anticancer chemotherapy, consecutively approached during their annual oncohematological outpatient visit. At examination, anthropometric measures and cancer-related history were collected. Moreover, a fasting venous sample was carried out for measuring fasting plasma glucose and insulin, glycated hemoglobin, lipid panel, and transaminases. We calculated the indexes of insulin resistance (HOMA-IR, McAuley, and QUICKI) and secretion (HOMA-β), liver steatosis (Hepatic Steatosis Index) and fibrosis (FIB-4 and NAFLD fibrosis score), and visceral fat dysfunction (Visceral Adiposity Index). More than one-third of the subjects (37.3%) did not have normal weight, with 11.1% of them affected by obesity. At recruitment, obese subjects were at significantly higher risk for impaired fasting glucose, metabolic syndrome, visceral adipose dysfunction, and liver steatosis/fibrosis. Subjects who received bone marrow transplantation were prone to insulin resistance, while survivors of lymphoma presented a visceral adipose dysfunction These results suggest a carefully metabolic monitoring of CCS, particularly in subgroups at higher risk, to early detect these conditions, promptly begin therapeutic interventions, and mitigate the dysmetabolic-related health burden.
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Affiliation(s)
- Agostino Milluzzo
- Department of Clinical and Experimental Medicine, Endocrinology, University of Catania Medical School, 95122 Catania, Italy; (A.M.); (L.M.)
- Department of Medical and Surgical Sciences and Advanced Technologies “GF Ingrassia”, University of Catania, 95122 Catania, Italy
| | - Lucia Manuella
- Department of Clinical and Experimental Medicine, Endocrinology, University of Catania Medical School, 95122 Catania, Italy; (A.M.); (L.M.)
| | - Emanuela Cannata
- Department of Clinical and Experimental Medicine, Paediatric Oncohematology Unit, University of Catania Medical School, 95122 Catania, Italy; (E.C.); (G.R.); (A.D.C.)
| | - Giovanna Russo
- Department of Clinical and Experimental Medicine, Paediatric Oncohematology Unit, University of Catania Medical School, 95122 Catania, Italy; (E.C.); (G.R.); (A.D.C.)
| | - Sandro La Vignera
- Department of Clinical and Experimental Medicine, University of Catania, Policlinico “G. Rodolico”, 95123 Catania, Italy;
| | - Francesco Purrello
- Department of Clinical and Experimental Medicine, Internal Medicine, Garibaldi-Nesima Hospital, University of Catania, 95123 Catania, Italy;
| | - Andrea Di Cataldo
- Department of Clinical and Experimental Medicine, Paediatric Oncohematology Unit, University of Catania Medical School, 95122 Catania, Italy; (E.C.); (G.R.); (A.D.C.)
| | - Laura Sciacca
- Department of Clinical and Experimental Medicine, Endocrinology, University of Catania Medical School, 95122 Catania, Italy; (A.M.); (L.M.)
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Li G, Zhang X, Lin H, Liang LY, Wong GLH, Wong VWS. Non-invasive tests of non-alcoholic fatty liver disease. Chin Med J (Engl) 2022; 135:532-546. [PMID: 35089884 PMCID: PMC8920457 DOI: 10.1097/cm9.0000000000002027] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2021] [Indexed: 11/26/2022] Open
Abstract
ABSTRACT For the detection of steatosis, quantitative ultrasound imaging techniques have achieved great progress in past years. Magnetic resonance imaging proton density fat fraction is currently the most accurate test to detect hepatic steatosis. Some blood biomarkers correlate with non-alcoholic steatohepatitis, but the accuracy is modest. Regarding liver fibrosis, liver stiffness measurement by transient elastography (TE) has high accuracy and is widely used across the world. Magnetic resonance elastography is marginally better than TE but is limited by its cost and availability. Several blood biomarkers of fibrosis have been used in clinical trials and hold promise for selecting patients for treatment and monitoring treatment response. This article reviews new developments in the non-invasive assessment of non-alcoholic fatty liver disease (NAFLD). Accumulating evidence suggests that various non-invasive tests can be used to diagnose NAFLD, assess its severity, and predict the prognosis. Further studies are needed to determine the role of the tests as monitoring tools. We cannot overemphasize the importance of context in selecting appropriate tests.
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Affiliation(s)
- Guanlin Li
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong, China
- State Key Laboratory of Digestive Disease, The Chinese University of Hong Kong, Hong Kong, China
- Medical Data Analytics Centre, The Chinese University of Hong Kong, Hong Kong, China
| | - Xinrong Zhang
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong, China
- State Key Laboratory of Digestive Disease, The Chinese University of Hong Kong, Hong Kong, China
- Medical Data Analytics Centre, The Chinese University of Hong Kong, Hong Kong, China
| | - Huapeng Lin
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong, China
- State Key Laboratory of Digestive Disease, The Chinese University of Hong Kong, Hong Kong, China
- Medical Data Analytics Centre, The Chinese University of Hong Kong, Hong Kong, China
| | - Lilian Yan Liang
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong, China
- State Key Laboratory of Digestive Disease, The Chinese University of Hong Kong, Hong Kong, China
- Medical Data Analytics Centre, The Chinese University of Hong Kong, Hong Kong, China
| | - Grace Lai-Hung Wong
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong, China
- State Key Laboratory of Digestive Disease, The Chinese University of Hong Kong, Hong Kong, China
- Medical Data Analytics Centre, The Chinese University of Hong Kong, Hong Kong, China
| | - Vincent Wai-Sun Wong
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong, China
- State Key Laboratory of Digestive Disease, The Chinese University of Hong Kong, Hong Kong, China
- Medical Data Analytics Centre, The Chinese University of Hong Kong, Hong Kong, China
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28
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Fujii H, Enomoto M, Fukumoto S, Kimura T, Nadatani Y, Takashima S, Hagihara A, Uchida‐Kobayashi S, Tamori A, Nishimoto N, Kawada N. Validation of a two-step approach combining serum biomarkers and liver stiffness measurement to predict advanced fibrosis. JGH Open 2021; 5:801-808. [PMID: 34263075 PMCID: PMC8264241 DOI: 10.1002/jgh3.12590] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Revised: 05/17/2021] [Accepted: 05/30/2021] [Indexed: 11/18/2022]
Abstract
BACKGROUND AND AIM The Gut and Obesity in Asia Workgroup recently reported that a two-step approach using fibrosis scores followed by liver stiffness measurement (LSM) could accurately detect patients with non-alcoholic fatty liver disease (NAFLD) having advanced fibrosis in low-risk fibrosis populations. This study aimed to validate the utility of this approach using a Japanese health checkup registry. METHODS This cross-sectional study included subjects who underwent a health checkup from 2014 to 2019. Using estimated fibrosis stage measured by LSM as a standard, we calculated the percentage of misclassification from assessments made based on fibrosis scores (NAFLD fibrosis score [NFS] or Fibrosis-4 score [FIB-4]) and LSM, alone or in combination. RESULTS Of 630 subjects with NAFLD, 4 (0.8%) had advanced fibrosis. In the first-step evaluation, only 21.4-38.0% of subjects needed further testing. This approach was associated with a high specificity of approximately 100% and a negative predictive value of 99.7%. The percentage of misclassification based on NFS or FIB-4 values followed by LSM in all subjects and using LSM after NFS or FIB-4 determination only in subjects with indeterminate/high NFS or FIB-4 values (two-step approach) was 0% and 0.3% and 0.16% and 0.3%, respectively. In addition, very few false negatives occurred for both NFS and FIB-4. CONCLUSION The two-step approach helps to identify the subjects with NAFLD who have advanced fibrosis during a routine health checkup and is associated with only a few false negatives.
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Affiliation(s)
- Hideki Fujii
- Department of Premier Preventive MedicineGraduate School of Medicine, Osaka City UniversityOsakaJapan
| | - Masaru Enomoto
- Department of HepatologyGraduate School of Medicine, Osaka City UniversityOsakaJapan
| | - Shinya Fukumoto
- Department of Premier Preventive MedicineGraduate School of Medicine, Osaka City UniversityOsakaJapan
| | - Tatsuo Kimura
- Department of Premier Preventive MedicineGraduate School of Medicine, Osaka City UniversityOsakaJapan
| | - Yuji Nadatani
- Department of Premier Preventive MedicineGraduate School of Medicine, Osaka City UniversityOsakaJapan
| | - Shingo Takashima
- Department of Premier Preventive MedicineGraduate School of Medicine, Osaka City UniversityOsakaJapan
| | - Atsushi Hagihara
- Department of HepatologyGraduate School of Medicine, Osaka City UniversityOsakaJapan
| | | | - Akihiro Tamori
- Department of HepatologyGraduate School of Medicine, Osaka City UniversityOsakaJapan
| | - Naoki Nishimoto
- Division of Data Management, Division of BiostatisticsClinical Research and Medical Innovation Center, Hokkaido University HospitalSapporoJapan
| | - Norifumi Kawada
- Department of HepatologyGraduate School of Medicine, Osaka City UniversityOsakaJapan
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Powell EE, Wong VWS, Rinella M. Non-alcoholic fatty liver disease. Lancet 2021; 397:2212-2224. [PMID: 33894145 DOI: 10.1016/s0140-6736(20)32511-3] [Citation(s) in RCA: 1598] [Impact Index Per Article: 399.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Revised: 11/04/2020] [Accepted: 11/13/2020] [Indexed: 02/07/2023]
Abstract
Non-alcoholic fatty liver disease (NAFLD) has a global prevalence of 25% and is a leading cause of cirrhosis and hepatocellular carcinoma. NAFLD encompasses a disease continuum from steatosis with or without mild inflammation (non-alcoholic fatty liver), to non-alcoholic steatohepatitis (NASH), which is characterised by necroinflammation and faster fibrosis progression than non-alcoholic fatty liver. NAFLD has a bidirectional association with components of the metabolic syndrome, and type 2 diabetes increases the risk of cirrhosis and related complications. Although the leading causes of death in people with NAFLD are cardiovascular disease and extrahepatic malignancy, advanced liver fibrosis is a key prognostic marker for liver-related outcomes and overall mortality, and can be assessed with combinations of non-invasive tests. Patients with cirrhosis should be screened for hepatocellular carcinoma and oesophageal varices. There is currently no approved therapy for NAFLD, although several drugs are in advanced stages of development. Because of the complex pathophysiology and substantial heterogeneity of disease phenotypes, combination treatment is likely to be required for many patients with NAFLD. Healthy lifestyle and weight reduction remain crucial to the prevention and treatment of NAFLD.
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Affiliation(s)
- Elizabeth E Powell
- Centre for Liver Disease Research, Faculty of Medicine, University of Queensland, Translational Research Institute, Brisbane, QLD, Australia; Department of Gastroenterology and Hepatology, Princess Alexandra Hospital, Brisbane, QLD, Australia.
| | - Vincent Wai-Sun Wong
- Department of Medicine and Therapeutics, Chinese University of Hong Kong, Hong Kong Special Administrative Region, China; State Key Laboratory of Digestive Disease, Chinese University of Hong Kong, Hong Kong Special Administrative Region, China
| | - Mary Rinella
- Northwestern University, Feinberg School of Medicine, Chicago, IL, USA
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30
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Shang Y, Nasr P, Ekstedt M, Widman L, Stål P, Hultcrantz R, Kechagias S, Hagström H. Non-alcoholic fatty liver disease does not increase dementia risk although histology data might improve risk prediction. JHEP Rep 2020; 3:100218. [PMID: 33554097 PMCID: PMC7847958 DOI: 10.1016/j.jhepr.2020.100218] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2020] [Revised: 11/04/2020] [Accepted: 11/17/2020] [Indexed: 12/17/2022] Open
Abstract
Background & Aims Non-alcoholic fatty liver disease (NAFLD) is common in the general population, but its association with dementia is unclear. We aimed to assess the risk of dementia related to NAFLD, and to determine whether histological parameters could improve the predictive capacity of a conventional risk model for dementia in patients with biopsy-proven NAFLD. Methods A retrospective matched cohort study of 656 NAFLD patients underwent liver biopsy at 2 hospitals between 1971 and 2009. Up to 10 individuals (controls) from the general population (n = 6,436) were matched for age, sex, and municipality to each patient. Dementia was ascertained from National registers until 2014. Using Cox regression, we estimated hazard ratios for dementia with 95% confidence intervals. In the biopsy cohort, the discriminative power of adding histological markers to a conventional risk model was assessed by Harrell’s C-index and compared with a likelihood-ratio test. Results During a mean follow-up of 19.7 ± 8.7 years, 3.3% of the NAFLD patients and 4.9% of the controls developed dementia (p = 0.07). Overall, NAFLD was not significantly associated with incident dementia. In the biopsy cohort, the model of conventional risk factors (age, sex, hypertension, and cardiovascular diseases) had a C-index of 0.912 to predict incident dementia. Adding individual histological parameters significantly increased the prediction of dementia, with the most pronounced improvement for fibrosis stage (C-index = 0.938, p <0.05). Conclusions Although NAFLD was not associated with the risk of dementia, we found that adding histological markers to a conventional risk model for dementia enhanced the predictive capacity, indicating a shared metabolic origin. Lay summary Both non-alcoholic fatty liver disease (NAFLD) and dementia are increasing in prevalence because of a more sedentary lifestyle, increased prevalence of obesity and population ageing. However, the link between these 2 diseases is not well studied. We investigated the association between NAFLD and the risk of dementia and found no association. However, liver histology parameters, especially fibrosis, could significantly improve the prediction of dementia risk. The link between NAFLD and dementia is unclear. We assessed the association between biopsy-proven NAFLD and dementia. NAFLD is not associated with an increased risk of dementia. Adding histological markers to a conventional risk model for dementia enhanced its predictive capacity.
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Affiliation(s)
- Ying Shang
- Department of Neurobiology, Care Sciences and Society (NVS), Karolinska Institutet, Stockholm, Sweden
| | - Patrik Nasr
- Department of Gastroenterology and Hepatology, Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
| | - Mattias Ekstedt
- Department of Gastroenterology and Hepatology, Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
| | - Linnea Widman
- Division of Biostatistics, Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Per Stål
- Division of Hepatology, Department of Upper GI, Karolinska University Hospital, Stockholm, Sweden.,Department of Medicine, Huddinge, Karolinska Institutet, Stockholm, Sweden
| | - Rolf Hultcrantz
- Division of Hepatology, Department of Upper GI, Karolinska University Hospital, Stockholm, Sweden.,Department of Medicine, Huddinge, Karolinska Institutet, Stockholm, Sweden
| | - Stergios Kechagias
- Department of Gastroenterology and Hepatology, Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
| | - Hannes Hagström
- Division of Hepatology, Department of Upper GI, Karolinska University Hospital, Stockholm, Sweden.,Department of Medicine, Huddinge, Karolinska Institutet, Stockholm, Sweden.,Clinical Epidemiology Unit, Department of Medicine, Stockholm, Karolinska Institutet, Stockholm, Sweden
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Fu C, Wai JW, Nik Mustapha NR, Irles M, Wong GLH, Mahadeva S, Shili S, Chan AWH, Merrouche W, Chan HLY, Foucher J, Le Bail B, Wong VWS, Chan WK, de Lédinghen V. Performance of Simple Fibrosis Scores in Nonobese Patients With Nonalcoholic Fatty Liver Disease. Clin Gastroenterol Hepatol 2020; 18:2843-2845.e2. [PMID: 31574313 DOI: 10.1016/j.cgh.2019.09.027] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2019] [Revised: 09/12/2019] [Accepted: 09/20/2019] [Indexed: 02/07/2023]
Abstract
Because only a minority of patients with nonalcoholic fatty liver disease (NAFLD) have advanced fibrosis and would eventually develop liver-related complications, current guidelines recommend initial assessment with noninvasive tests of fibrosis.1-3 Most previous studies focused on overweight and obese patients. Despite a strong association between obesity and NAFLD, 3%-30% of people with relatively normal body mass index (BMI) may still have NAFLD.4,5 Hence, this study aims to evaluate the performance of the common noninvasive tests in non-obese (BMI <25 kg/m2) and obese (BMI ≥25 kg/m2) NAFLD patients.
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Affiliation(s)
- Charmaine Fu
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong
| | - Janae Wentong Wai
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong
| | | | - Marie Irles
- Centre d'Investigation de la Fibrose Hépatique, Bordeaux University Hospital, Pessac, France
| | - Grace Lai-Hung Wong
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong; State Key Laboratory of Digestive Disease, The Chinese University of Hong Kong, Hong Kong
| | - Sanjiv Mahadeva
- Department of Medicine, Gastroenterology and Hepatology Unit, University of Malaya, Kuala Lumpur, Malaysia
| | - Sarah Shili
- Centre d'Investigation de la Fibrose Hépatique, Bordeaux University Hospital, Pessac, France
| | - Anthony Wing-Hung Chan
- Department of Anatomical and Cellular Pathology, The Chinese University of Hong Kong, Hong Kong
| | - Wassil Merrouche
- Centre d'Investigation de la Fibrose Hépatique, Bordeaux University Hospital, Pessac, France
| | - Henry Lik-Yuen Chan
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong; State Key Laboratory of Digestive Disease, The Chinese University of Hong Kong, Hong Kong
| | - Juliette Foucher
- Centre d'Investigation de la Fibrose Hépatique, Bordeaux University Hospital, Pessac, France
| | - Brigitte Le Bail
- Pathology Unit, Hôpital Pellegrin, Bordeaux University Hospital, Pessac, France; INSERM U1053, Bordeaux University, Bordeaux, France
| | - Vincent Wai-Sun Wong
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong; State Key Laboratory of Digestive Disease, The Chinese University of Hong Kong, Hong Kong
| | - Wah Kheong Chan
- Department of Medicine, Gastroenterology and Hepatology Unit, University of Malaya, Kuala Lumpur, Malaysia.
| | - Victor de Lédinghen
- Centre d'Investigation de la Fibrose Hépatique, Bordeaux University Hospital, Pessac, France; INSERM U1053, Bordeaux University, Bordeaux, France.
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Blank V, Petroff D, Beer S, Böhlig A, Heni M, Berg T, Bausback Y, Dietrich A, Tönjes A, Hollenbach M, Blüher M, Keim V, Wiegand J, Karlas T. Current NAFLD guidelines for risk stratification in diabetic patients have poor diagnostic discrimination. Sci Rep 2020; 10:18345. [PMID: 33110165 PMCID: PMC7591877 DOI: 10.1038/s41598-020-75227-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2020] [Accepted: 10/12/2020] [Indexed: 12/13/2022] Open
Abstract
Patients with type 2 diabetes (T2D) are at risk for non-alcoholic fatty liver disease (NAFLD) and associated complications. This study evaluated the performance of international (EASL-EASD-EASO) and national (DGVS) guidelines for NAFLD risk stratification. Patients with T2D prospectively underwent ultrasound, liver stiffness measurement (LSM) and serum-based fibrosis markers. Guideline-based risk classification and referral rates for different screening approaches were compared and the diagnostic properties of simplified algorithms, genetic markers and a new NASH surrogate (FAST score) were evaluated. NAFLD risk was present in 184 of 204 screened patients (age 64.2 ± 10.7 years; BMI 32.6 ± 7.6 kg/m2). EASL-EASD-EASO recommended specialist referral for 60-77% depending on the fibrosis score used, only 6% were classified as low risk. The DGVS algorithm required LSM for 76%; 25% were referred for specialised care. The sensitivities of the diagnostic pathways were 47-96%. A simplified referral strategy revealed a sensitivity/specificity of 46/88% for fibrosis risk. Application of the FAST score reduced the referral rate to 35%. This study (a) underlines the high prevalence of fibrosis risk in T2D, (b) demonstrates very high referral rates for in-depth hepatological work-up, and (c) indicates that simpler referral algorithms may produce comparably good results and could facilitate NAFLD screening.
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Affiliation(s)
- Valentin Blank
- Division of Gastroenterology, Department of Medicine II, Leipzig University Medical Center, Liebigstraße 20, 04103, Leipzig, Germany
- Integrated Research and Treatment Center (IFB) AdiposityDiseases, University of Leipzig, Philipp-Rosenthal-Str. 27, 04103, Leipzig, Germany
| | - David Petroff
- Integrated Research and Treatment Center (IFB) AdiposityDiseases, University of Leipzig, Philipp-Rosenthal-Str. 27, 04103, Leipzig, Germany
- Clinical Trial Centre Leipzig, University of Leipzig, Härtelstraße 16/18, 04107, Leipzig, Germany
| | - Sebastian Beer
- Division of Gastroenterology, Department of Medicine II, Leipzig University Medical Center, Liebigstraße 20, 04103, Leipzig, Germany
| | - Albrecht Böhlig
- Division of Hepatology, Department of Medicine II, Leipzig University Medical Center, Liebigstraße 20, 04103, Leipzig, Germany
| | - Maria Heni
- Division of Gastroenterology, Department of Medicine II, Leipzig University Medical Center, Liebigstraße 20, 04103, Leipzig, Germany
| | - Thomas Berg
- Division of Hepatology, Department of Medicine II, Leipzig University Medical Center, Liebigstraße 20, 04103, Leipzig, Germany
| | - Yvonne Bausback
- Division of Angiology, Leipzig University Medical Center, Liebigstraße 20, 04103, Leipzig, Germany
| | - Arne Dietrich
- Integrated Research and Treatment Center (IFB) AdiposityDiseases, University of Leipzig, Philipp-Rosenthal-Str. 27, 04103, Leipzig, Germany
- Division of Visceral, Transplantation, Thorax and Vascular Surgery, Section of Bariatric Surgery, Leipzig University Medical Center, Liebigstraße 20, 04103, Leipzig, Germany
| | - Anke Tönjes
- Division of Endocrinology and Nephrology, Leipzig University Medical Center, Liebigstraße 20, 04103, Leipzig, Germany
| | - Marcus Hollenbach
- Division of Gastroenterology, Department of Medicine II, Leipzig University Medical Center, Liebigstraße 20, 04103, Leipzig, Germany
| | - Matthias Blüher
- Integrated Research and Treatment Center (IFB) AdiposityDiseases, University of Leipzig, Philipp-Rosenthal-Str. 27, 04103, Leipzig, Germany
- Division of Endocrinology and Nephrology, Leipzig University Medical Center, Liebigstraße 20, 04103, Leipzig, Germany
| | - Volker Keim
- Division of Gastroenterology, Department of Medicine II, Leipzig University Medical Center, Liebigstraße 20, 04103, Leipzig, Germany
| | - Johannes Wiegand
- Division of Hepatology, Department of Medicine II, Leipzig University Medical Center, Liebigstraße 20, 04103, Leipzig, Germany
| | - Thomas Karlas
- Division of Gastroenterology, Department of Medicine II, Leipzig University Medical Center, Liebigstraße 20, 04103, Leipzig, Germany.
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Anugwom C, Ashraf A, Debes JD. Virus-mediated thrombocytopenia in Hepatitis C infection: The impact on fibrosis scores. Dig Liver Dis 2020; 52:797-798. [PMID: 32446728 DOI: 10.1016/j.dld.2020.04.027] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2020] [Revised: 04/06/2020] [Accepted: 04/21/2020] [Indexed: 12/11/2022]
Affiliation(s)
- Chimaobi Anugwom
- Department of Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Ashhab Ashraf
- Division of Gastroenterology and Hepatology, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Jose D Debes
- Department of Medicine, University of Minnesota, Minneapolis, MN, USA; Hennepin Healthcare, Minneapolis, MN, USA.
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Shaheen AA, Riazi K, Medellin A, Bhayana D, Kaplan GG, Jiang J, Park R, Schaufert W, Burak KW, Sargious M, Swain MG. Risk stratification of patients with nonalcoholic fatty liver disease using a case identification pathway in primary care: a cross-sectional study. CMAJ Open 2020; 8:E370-E376. [PMID: 32414883 PMCID: PMC7239637 DOI: 10.9778/cmajo.20200009] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Identification of patients with nonalcoholic fatty liver disease (NAFLD) with advanced liver fibrosis in primary care remains an unmet need. Our primary objective was to implement a pathway driven by shear wave elastography (SWE) to facilitate risk stratification of patients with NAFLD within primary care and evaluate whether SWE assessment can reduce referrals of patients with NAFLD at low risk for fibrosis to hepatology. METHODS A multidisciplinary NAFLD clinical care pathway was codeveloped by hepatologists, radiologists and primary care physicians in Calgary to provide access to SWE-based screening of patients with NAFLD risk factors in primary care. The study outcome measures were estimated NAFLD-related referrals to the hepatology service in Calgary after implementation of the NAFLD pathway and characteristics of patients with NAFLD at risk for advanced fibrosis. The NAFLD pathway was implemented in January 2018 and was made available to all primary care physicians in the Calgary Health Zone. Patients with NAFLD who had liver stiffness (SWE value ≥ 8.0 kPa) or an inconclusive assessment were referred to hepatology. A serum liver fibrosis score was also measured with the fibrosis-4 (FIB-4) index, and performance of an FIB-4 index score of 1.30 or greater to risk stratify patients with NAFLD was evaluated. Demographic, clinical and laboratory characteristics of study groups were compared. RESULTS Between March and October 2018, 2084 patients with suspected NAFLD were evaluated. Nonalcoholic fatty liver disease was confirmed by ultrasonography in 1958 (94.1%). A majority of the cohort had elevated liver enzyme values (1028 [52.5%]) and obesity (body mass index ≥ 30) (1063/1764 [60.3%]). Most patients with NAFLD (1791 [91.5%]) had an SWE value less than 8.0 kPa and were not referred to hepatology. Sixty-seven patients (3.4%) had an SWE value of 8.0 kPa or more, and 100 (5.1%) had an inconclusive SWE; these patients were referred to hepatology. Using an FIB-4 index score cut-off of 1.30 would have led to hepatology referral of 396/1251 patients (31.6%). INTERPRETATION Implementation of a primary care-accessible SWE pathway for patients with NAFLD facilitated fibrosis risk stratification and greatly reduced hepatology referrals. Using the FIB-4 index score alone would led to higher rates of referral of patients with NAFLD.
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Affiliation(s)
- Abdel Aziz Shaheen
- Division of Gastroenterology and Hepatology (Shaheen, Riazi, Kaplan, Burak, Swain), Department of Medicine, University of Calgary; EFW Radiology group (Medellin, Bhayana, Park); Alberta Health Services (Jiang, Schaufert); Community Primary Care, Alberta Health Services (Sargious), Calgary, Alta.
| | - Kiarash Riazi
- Division of Gastroenterology and Hepatology (Shaheen, Riazi, Kaplan, Burak, Swain), Department of Medicine, University of Calgary; EFW Radiology group (Medellin, Bhayana, Park); Alberta Health Services (Jiang, Schaufert); Community Primary Care, Alberta Health Services (Sargious), Calgary, Alta
| | - Alexandra Medellin
- Division of Gastroenterology and Hepatology (Shaheen, Riazi, Kaplan, Burak, Swain), Department of Medicine, University of Calgary; EFW Radiology group (Medellin, Bhayana, Park); Alberta Health Services (Jiang, Schaufert); Community Primary Care, Alberta Health Services (Sargious), Calgary, Alta
| | - Deepak Bhayana
- Division of Gastroenterology and Hepatology (Shaheen, Riazi, Kaplan, Burak, Swain), Department of Medicine, University of Calgary; EFW Radiology group (Medellin, Bhayana, Park); Alberta Health Services (Jiang, Schaufert); Community Primary Care, Alberta Health Services (Sargious), Calgary, Alta
| | - Gilaad G Kaplan
- Division of Gastroenterology and Hepatology (Shaheen, Riazi, Kaplan, Burak, Swain), Department of Medicine, University of Calgary; EFW Radiology group (Medellin, Bhayana, Park); Alberta Health Services (Jiang, Schaufert); Community Primary Care, Alberta Health Services (Sargious), Calgary, Alta
| | - Jason Jiang
- Division of Gastroenterology and Hepatology (Shaheen, Riazi, Kaplan, Burak, Swain), Department of Medicine, University of Calgary; EFW Radiology group (Medellin, Bhayana, Park); Alberta Health Services (Jiang, Schaufert); Community Primary Care, Alberta Health Services (Sargious), Calgary, Alta
| | - Roy Park
- Division of Gastroenterology and Hepatology (Shaheen, Riazi, Kaplan, Burak, Swain), Department of Medicine, University of Calgary; EFW Radiology group (Medellin, Bhayana, Park); Alberta Health Services (Jiang, Schaufert); Community Primary Care, Alberta Health Services (Sargious), Calgary, Alta
| | - Wendy Schaufert
- Division of Gastroenterology and Hepatology (Shaheen, Riazi, Kaplan, Burak, Swain), Department of Medicine, University of Calgary; EFW Radiology group (Medellin, Bhayana, Park); Alberta Health Services (Jiang, Schaufert); Community Primary Care, Alberta Health Services (Sargious), Calgary, Alta
| | - Kelly W Burak
- Division of Gastroenterology and Hepatology (Shaheen, Riazi, Kaplan, Burak, Swain), Department of Medicine, University of Calgary; EFW Radiology group (Medellin, Bhayana, Park); Alberta Health Services (Jiang, Schaufert); Community Primary Care, Alberta Health Services (Sargious), Calgary, Alta
| | - Monica Sargious
- Division of Gastroenterology and Hepatology (Shaheen, Riazi, Kaplan, Burak, Swain), Department of Medicine, University of Calgary; EFW Radiology group (Medellin, Bhayana, Park); Alberta Health Services (Jiang, Schaufert); Community Primary Care, Alberta Health Services (Sargious), Calgary, Alta
| | - Mark G Swain
- Division of Gastroenterology and Hepatology (Shaheen, Riazi, Kaplan, Burak, Swain), Department of Medicine, University of Calgary; EFW Radiology group (Medellin, Bhayana, Park); Alberta Health Services (Jiang, Schaufert); Community Primary Care, Alberta Health Services (Sargious), Calgary, Alta
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Jun DW, Nguyen MH. Editorial: choosing an appropriate risk stratification tool for nonalcoholic fatty liver disease-one size does not fit all. Authors' reply. Aliment Pharmacol Ther 2020; 51:662-663. [PMID: 32100348 DOI: 10.1111/apt.15651] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/09/2022]
Affiliation(s)
- Dae Won Jun
- Department of Internal Medicine, Hanyang University College of Medicine, Seoul, Korea
| | - Mindie H Nguyen
- Division of Gastroenterology and Hepatology, Stanford University Medical Center, Palo Alto, CA, USA
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Shaheen AA, Swain MG. Editorial: choosing an appropriate risk stratification tool for nonalcoholic fatty liver disease-one size does not fit all. Aliment Pharmacol Ther 2020; 51:661-662. [PMID: 32100347 DOI: 10.1111/apt.15640] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Affiliation(s)
- Abdel-Aziz Shaheen
- Calgary Liver Unit, Division of Gastroenterology and Hepatology, Department of Medicine, University of Calgary, Calgary, AB, Canada
| | - Mark G Swain
- Calgary Liver Unit, Division of Gastroenterology and Hepatology, Department of Medicine, University of Calgary, Calgary, AB, Canada
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Castera L. Non-invasive tests for liver fibrosis in NAFLD: Creating pathways between primary healthcare and liver clinics. Liver Int 2020; 40 Suppl 1:77-81. [PMID: 32077617 DOI: 10.1111/liv.14347] [Citation(s) in RCA: 56] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/25/2019] [Accepted: 12/26/2019] [Indexed: 12/12/2022]
Abstract
Despite affecting around one-fourth of the general population worldwide, non-alcoholic fatty liver disease (NAFLD) remains a largely under-recognized disease in primary healthcare, with not more than 10% of patients diagnosed with NAFLD referred to specialists. The main challenge in clinical practice is the identification of those with advanced liver fibrosis or cirrhosis, as they are at the greatest risk of developing complications. Liver biopsy appears to be an unrealistic and unsuitable option because of the large number of high-risk patients and the well-known limitations of this technique. This has favoured the development of non-invasive tests, which have been an area of intensive research in the past decade. Transient elastography, FIB-4 and the NAFLD fibrosis score are the most extensively used and best validated tests, with summary AUROC values for detecting advanced fibrosis in NAFLD patients of 0.88, 0.84 and 0.84 respectively. Although much work remains to be done to establish cost-effective strategies for the screening for advanced fibrosis, the sequential use of non-invasive tests (serum biomarkers, then measurement of liver stiffness using transient elastography) appears to be the most promising strategy. The next step is to establish effective pathways in primary healthcare and/or diabetes clinics where most NAFLD patients are seen, to identify those who need to be referred to liver clinics for further assessment.
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Affiliation(s)
- Laurent Castera
- Department of Hepatology, Hôpital Beaujon, Assistance Publique-Hôpitaux de Paris, INSERM, UMR 1149-CRI, Université de Paris, Clichy, France
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Wai JW, Fu C, Wong VWS. Confounding factors of non-invasive tests for nonalcoholic fatty liver disease. J Gastroenterol 2020; 55:731-741. [PMID: 32451628 PMCID: PMC7376510 DOI: 10.1007/s00535-020-01686-8] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2020] [Accepted: 03/27/2020] [Indexed: 02/07/2023]
Abstract
Nonalcoholic fatty liver disease (NAFLD) affects at least 25% of the general adult population worldwide. Because only a fraction of the patients would develop liver-related complications, it is preferable to perform non-invasive tests as the initial assessment. This review summarizes the known and potential confounding factors that affect the performance of non-invasive tests of hepatic steatosis and fibrosis in patients with NAFLD. Clinicians may apply the knowledge and exercise caution in selecting investigations and interpreting test results when confounding factors are present.
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Affiliation(s)
- Janae Wentong Wai
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, 9/F, Prince of Wales Hospital, 30-32 Ngan Shing Street, Hong Kong, China
| | - Charmaine Fu
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, 9/F, Prince of Wales Hospital, 30-32 Ngan Shing Street, Hong Kong, China
| | - Vincent Wai-Sun Wong
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, 9/F, Prince of Wales Hospital, 30-32 Ngan Shing Street, Hong Kong, China ,State Key Laboratory of Digestive Disease, The Chinese University of Hong Kong, Hong Kong, China
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Daily Aspirin Use Associated With Reduced Risk For Fibrosis Progression In Patients With Nonalcoholic Fatty Liver Disease. Clin Gastroenterol Hepatol 2019; 17:2776-2784.e4. [PMID: 31077838 PMCID: PMC6842070 DOI: 10.1016/j.cgh.2019.04.061] [Citation(s) in RCA: 115] [Impact Index Per Article: 19.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2019] [Revised: 04/09/2019] [Accepted: 04/26/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS There are few data from prospective studies on the effects of aspirin on fibrosis in patients with nonalcoholic fatty liver disease (NAFLD). METHODS We performed a prospective cohort study of 361 adults with biopsy-confirmed NAFLD, from 2006 through 2015, examined every 3-12 months for incident advanced fibrosis defined using serial measurements of validated indices (the Fibrosis-4, NAFLD fibrosis score, and aspartate aminotransferase to platelet ratio indices). Histologic analyses of liver biopsies collected at baseline were performed by a blinded pathologist. Information collected at baseline and at each examination included frequency and duration of aspirin and nonsteroidal anti-inflammatory drug (NSAID) use. Using multivariable-adjusted logistic regression, we estimated the association of aspirin use with prevalent steatohepatitis (NASH) and fibrosis. Using multivariable-adjusted Cox proportional hazards modeling, we estimated the association between aspirin use and risk for fibrosis progression. RESULTS At enrollment, 151 subjects used aspirin daily. Compared with non-regular use, daily aspirin use was associated with significantly lower odds of NASH (adjusted odds ratio, 0.68; 95% CI, 0.37-0.89) and fibrosis (adjusted odds ratio, 0.54; 95% CI, 0.31-0.82). Among individuals with baseline F0-F2 fibrosis (n = 317), 86 developed advanced fibrosis over 3692 person-years. Daily aspirin users had significantly lower risk for developing incident advanced fibrosis vs non-regular users (adjusted hazard ratio [aHR], 0.63; 95% CI, 0.43-0.85). This relationship appeared to be duration dependent (adjusted P trend=.026), with the greatest benefit found with at least 4 years or more of aspirin use (aHR, 0.50; 95% CI, 0.35-0.73). Conversely, use of nonaspirin NSAIDs was not associated with risk for advanced fibrosis (aHR, 0.93; 95% CI, 0.81-1.05). CONCLUSIONS In a prospective study of patients with biopsy-proven NAFLD, daily aspirin use was associated with less severe histologic features of NAFLD and NASH, and lower risk for progression to advanced fibrosis with time.
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Morrison M, Hughes HY, Naggie S, Syn WK. Nonalcoholic Fatty Liver Disease Among Individuals with HIV Mono-infection: A Growing Concern? Dig Dis Sci 2019; 64:3394-3401. [PMID: 31643035 DOI: 10.1007/s10620-019-05861-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2019] [Accepted: 09/24/2019] [Indexed: 12/11/2022]
Abstract
PURPOSE OF REVIEW Liver disease is a leading cause of non-AIDS-related death in the HIV population since the introduction of highly active antiretroviral treatment (HAART). Recent studies suggest that patients with HIV are at high risk for nonalcoholic fatty liver disease (NAFLD) and progressive liver fibrosis. Evidence for the prevalence, risk factors, and diagnostic methodologies of NAFLD in patients with HIV mono-infection is summarized here. RECENT FINDINGS Although limited, published studies suggest that the prevalence of NAFLD is higher (30-50%) and progresses at an increased rate in patients with HIV compared to the general population. Identifying those at risk for significant liver fibrosis is critical, preferably with non-invasive screening tests. While there is a paucity of evidence in this population, transient elastography (TE) appears to provide a sensitive, non-invasive screening modality. Identifying NAFLD early will allow for dietary and lifestyle interventions, as well as future drug therapies to decrease the risk of progressive liver fibrosis and cirrhosis in the high-risk HIV population. Clinicians should be aware of this risk and consider using TE for NAFLD diagnosis and surveillance.
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Affiliation(s)
- Margaret Morrison
- Division of General Internal Medicine, Medical University of South Carolina, Charleston, SC, USA
| | - Heather Y Hughes
- Section of Infectious Diseases, Department of Medicine, Ralph H. Johnson VAMC, Charleston, SC, USA
- Divison of Infectious Diseases, Department of Medicine, Medical University of South Carolina, Charleston, SC, USA
| | - Susanna Naggie
- Division of Infectious Diseases, Department of Medicine, Duke University School of Medicine, Durham, NC, USA
- Division of Infectious Diseases, Department of Medicine, Durham VAMC, Durham, NC, USA
| | - Wing-Kin Syn
- Section of Gastroenterology and Hepatology, Ralph H. Johnson VAMC, Charleston, SC, USA.
- Division of Gastroenterology and Hepatology, Department of Medicine, Medical University of South Carolina, Charleston, SC, USA.
- Department of Physiology, Faculty of Medicine and Nursing, University of Basque Country UPV/EHU, Leioa, Spain.
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Weinstein G, Davis-Plourde K, Himali JJ, Zelber-Sagi S, Beiser AS, Seshadri S. Non-alcoholic fatty liver disease, liver fibrosis score and cognitive function in middle-aged adults: The Framingham Study. Liver Int 2019; 39:1713-1721. [PMID: 31155826 PMCID: PMC6736704 DOI: 10.1111/liv.14161] [Citation(s) in RCA: 75] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2019] [Revised: 05/05/2019] [Accepted: 05/26/2019] [Indexed: 02/06/2023]
Abstract
BACKGROUND Non-alcoholic fatty liver disease (NAFLD) is common and has been recently related to brain health. We aimed to assess the relationships of NAFLD and its severity, using the NAFLD fibrosis score (NFS), with cognitive performance. METHODS Framingham study Offspring and 3rd generation participants were included if they attended exams 9 (2002-2008) and 2 (2008-2011), respectively, were free of dementia and stroke, and did not have excessive alcohol intake. Between 2008 and 2011, participants underwent Multi-detector computed tomography scans of the abdomen to determine NAFLD diagnosis and the NFS was used to categorize the severity of fibrosis. Cross-sectional relationships of NAFLD and the NFS with cognitive testing of memory, abstract reasoning, visual perception, attention and executive function were assessed, while adjusting for multiple cardiometabolic variables including visceral adipose tissue, diabetes and insulin resistance. RESULTS Of the 1287 participants (mean age = 61±12 years, 48% men), 378 (29%) had NAFLD. The presence of NAFLD was not associated with cognitive function. However, among those with NAFLD (mean age = 61±12 years; 58% men), high compared to low risk of advanced fibrosis was associated with poorer performance on similarities (β = -2.22 ± 0.83; P = 0.009) and trail-making B minus A (β = -0.11 ± 0.05; P = 0.028), independently of potential confounders. CONCLUSIONS Participants with high risk of advanced fibrosis may have poorer cognitive function compared to those with low risk, particularly in executive function and abstract reasoning. Future findings are necessary to evaluate the value of the NFS as a biomarker that predicts cognitive impairment and dementia and to explore the role of hepatic fibrosis in brain health.
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Affiliation(s)
- Galit Weinstein
- School of Public Health, University of Haifa, 3498838 Haifa, Israel
| | - Kendra Davis-Plourde
- Department of Biostatistics, Boston University School of Public Health, Boston, MA, USA
- The Framingham Study, Framingham, MA, USA
| | - Jayandra J Himali
- Department of Biostatistics, Boston University School of Public Health, Boston, MA, USA
- The Framingham Study, Framingham, MA, USA
- Department of Neurology, Boston University School of Medicine, Boston, MA
| | - Shira Zelber-Sagi
- School of Public Health, University of Haifa, 3498838 Haifa, Israel
- Liver Unit, Department of Gastroenterology, Tel-Aviv Medical Center, 6423906 Tel-Aviv, Israel
| | - Alexa S. Beiser
- Department of Biostatistics, Boston University School of Public Health, Boston, MA, USA
- The Framingham Study, Framingham, MA, USA
- Department of Neurology, Boston University School of Medicine, Boston, MA
| | - Sudha Seshadri
- The Framingham Study, Framingham, MA, USA
- Department of Neurology, Boston University School of Medicine, Boston, MA
- Glenn Biggs Institute for Alzheimer’s and Neurodegenerative Diseases, University of Texas Health Sciences Center, San Antonio, TX, USA
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Loomba R, Jain A, Diehl AM, Guy CD, Portenier D, Sudan R, Singh S, Faulkner C, Richards L, Hester KD, Okada L, Li XJ, Mimms L, Abdelmalek MF. Validation of Serum Test for Advanced Liver Fibrosis in Patients With Nonalcoholic Steatohepatitis. Clin Gastroenterol Hepatol 2019; 17:1867-1876.e3. [PMID: 30448594 DOI: 10.1016/j.cgh.2018.11.004] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2018] [Revised: 10/11/2018] [Accepted: 11/02/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS We analyzed markers of fibrosis in serum samples from patients with nonalcoholic fatty liver disease (NAFLD), assessed by liver biopsy. We used serum levels of markers to develop an algorithm to discriminate patients with advanced fibrosis from those with mild or moderate fibrosis and validated its performance in 2 independent cohorts of patients with NAFLD. METHODS We performed a retrospective analysis of serum samples from 396 patients with NAFLD and different stages of fibrosis (F0-F4), collected from 2007 through 2017 on the day of liver biopsy (training cohort 1). We measured serum concentrations of alpha-2 macroglobulin (A2M), hyaluronic acid (HA), and TIMP metallopeptidase inhibitor 1 (TIMP1), and used measurements to develop an algorithm that could discriminate patients with NAFLD with advanced fibrosis (F3-F4; 24.1% of cohort) from those with mild or moderate fibrosis (F0-F2; 79.5% of cohort). We validated the algorithm using serum samples collected from a separate 396 patients from the same time period and location (validation cohort 1), as well as 244 patients with NAFLD evaluated at a separate location, from 2011 through 2017, within a median of 11 days of liver biopsy (cohort 2). RESULTS The algorithm identified patients with advanced fibrosis vs mild or moderate fibrosis in training cohort 1 with an area under the receiver operating characteristic (AUROC) curve of 0.867 (95% CI, 0.827-0.907), 84.8% sensitivity (95% CI, 75.5%-91.0%), and 72.3% specificity (95% CI, 66.9%-77.3%), at a cutoff score of 17. The AUROC for the combined validation cohorts 1 and 2 (n=640) was 0.856 (95% CI, 0.820-0.892), identifying patients with 79.7% sensitivity (95% CI, 71.9%-86.2%) and 75.7% specificity (95% CI, 71.8%-79.4%) at the predetermined cutoff score of 17. The algorithm had negative predictive values that ranged from 92.5% to 94.7% in the validation cohorts; it correctly classified 90.0% of F0 samples, 75.0% of F1 samples, 77.4% of F3 samples, and 94.4% of F4 samples. CONCLUSION We developed an algorithm that identifies patients with advanced fibrosis from those with mild to moderate fibrosis in patients with NAFLD with an AUROC value of approximately 0.86, based on levels of serum biomarkers. We validated the findings in 2 separate sets of patients with biopsy-proven NAFLD. The algorithm can be used non-invasively to determine risk of advanced fibrosis in patients with NAFLD.
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Affiliation(s)
- Rohit Loomba
- Division of Gastroenterology, University of California, San Diego, San Diego, California.
| | - Anjali Jain
- Prometheus Laboratories Inc., San Diego, California
| | - Anna Mae Diehl
- Department of Gastroenterology, Duke University, Durham, North Carolina
| | - Cynthia D Guy
- Department of Pathology, Duke University, Durham, North Carolina
| | - Dana Portenier
- Department of Weight Loss and Metabolic Surgery, Duke University, Durham, North Carolina
| | - Ranjan Sudan
- Department of Weight Loss and Metabolic Surgery, Duke University, Durham, North Carolina
| | - Seema Singh
- Division of Gastroenterology, University of California, San Diego, San Diego, California
| | - Claire Faulkner
- Division of Gastroenterology, University of California, San Diego, San Diego, California
| | - Lisa Richards
- Division of Gastroenterology, University of California, San Diego, San Diego, California
| | | | - Lauren Okada
- Prometheus Laboratories Inc., San Diego, California
| | - Xiao-Jun Li
- Prometheus Laboratories Inc., San Diego, California
| | - Larry Mimms
- Prometheus Laboratories Inc., San Diego, California
| | - Manal F Abdelmalek
- Department of Gastroenterology, Duke University, Durham, North Carolina.
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Chow JCL, Wong GLH, Chan AWH, Shu SST, Chan CKM, Leung JKY, Choi PCL, Chim AML, Chan HLY, Wong VWS. Repeating measurements by transient elastography in non-alcoholic fatty liver disease patients with high liver stiffness. J Gastroenterol Hepatol 2019; 34:241-248. [PMID: 29890010 DOI: 10.1111/jgh.14311] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2018] [Revised: 05/29/2018] [Accepted: 06/01/2018] [Indexed: 12/15/2022]
Abstract
BACKGROUND AND AIM The Baveno VI Consensus recommends repeating examination in patients with high liver stiffness measurement (LSM) by transient elastography to reduce false-positive diagnosis of advanced liver disease. We tested whether repeating transient elastography can increase the overall diagnostic accuracy. METHODS Ninety-seven patients with non-alcoholic fatty liver disease who underwent two FibroScan examinations within 6 months prior to liver biopsy were evaluated. An LSM cut-off of 7.9 kPa was used to exclude F3-4 fibrosis. RESULTS Seventy-eight patients had high LSM at baseline, among whom 27 had low LSM on repeated testing; only four had F3 and none had cirrhosis. In contrast, 31 of 51 patients with high LSM at both examinations had F3-4. Nineteen patients had low LSM at baseline; none of them had F3-4 regardless of the second LSM results. If we took LSM <7.9 kPa at either examination as sufficient to exclude F3-4, the negative predictive value remained high at 91%. The positive predictive value for F3-4 increased from 45% in patients with high LSM at baseline to 61% in those with high LSM at both examinations. Sensitivity analysis using different cut-offs yielded similar results, with 76% of patients with LSM >12 kPa at both examinations having F3-4. CONCLUSIONS Transient elastography is a highly sensitive screening test to exclude F3-4 fibrosis in non-alcoholic fatty liver disease patients. One-third of patients with high LSM may have normal results on repeated examination. By repeating examination in cases with high LSM, one may spare patients from unnecessary liver biopsy.
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Affiliation(s)
- Jeremy Chak-Lun Chow
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Shatin, Hong Kong
| | - Grace Lai-Hung Wong
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Shatin, Hong Kong.,State Key laboratory of Digestive Disease, The Chinese University of Hong Kong, Shatin, Hong Kong
| | - Anthony Wing-Hung Chan
- Department of Anatomical and Cellular Pathology, The Chinese University of Hong Kong, Shatin, Hong Kong
| | - Sally She-Ting Shu
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Shatin, Hong Kong.,State Key laboratory of Digestive Disease, The Chinese University of Hong Kong, Shatin, Hong Kong
| | - Carmen Ka-Man Chan
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Shatin, Hong Kong.,State Key laboratory of Digestive Disease, The Chinese University of Hong Kong, Shatin, Hong Kong
| | - Julie Ka-Yu Leung
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Shatin, Hong Kong.,State Key laboratory of Digestive Disease, The Chinese University of Hong Kong, Shatin, Hong Kong
| | - Paul Cheung-Lung Choi
- Department of Anatomical and Cellular Pathology, The Chinese University of Hong Kong, Shatin, Hong Kong
| | - Angel Mei-Ling Chim
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Shatin, Hong Kong.,State Key laboratory of Digestive Disease, The Chinese University of Hong Kong, Shatin, Hong Kong
| | - Henry Lik-Yuen Chan
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Shatin, Hong Kong.,State Key laboratory of Digestive Disease, The Chinese University of Hong Kong, Shatin, Hong Kong
| | - Vincent Wai-Sun Wong
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Shatin, Hong Kong.,State Key laboratory of Digestive Disease, The Chinese University of Hong Kong, Shatin, Hong Kong
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Speculation of the Time-Dependent Change of FIB4 Index in Patients with Nonalcoholic Fatty Liver Disease: A Retrospective Study. Can J Gastroenterol Hepatol 2018; 2018:5323061. [PMID: 29721486 PMCID: PMC5867539 DOI: 10.1155/2018/5323061] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2017] [Accepted: 01/22/2018] [Indexed: 02/06/2023] Open
Abstract
AIM To speculate on the time-dependent change of FIB4 index in patients with nonalcoholic fatty liver disease (NAFLD) and its increase-decrease rate per year, simply and accurately. METHODS In all 23 patients with NAFLD with the value of FIB4 index over 1.30 at the peak, the period from the first to each examination date was calculated and this period (years) was regarded as x. Next, the mean value of FIB4 index during the past year to each examination date was regarded as y. In every y, the minimum and the maximum y value were found out. Between x corresponding to this minimum y and x corresponding to this maximum y, the correlation between x and y was analyzed as the main subject. Then, the slope of each correlation was investigated, because it should indicate increase-decrease rate per year. RESULTS In all 23 patients, the correlations as the main subject were recognized and the mean absolute value of correlation coefficient (r) was 0.91 ± 0.08. As for the slope, the mean absolute value was 0.1371 ± 0.1147 (/year). CONCLUSION Simply and accurately, the time-dependent change of FIB4 index and its increase-decrease rate per year could be approximately speculated.
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Hernaez R, Thrift AP. High Negative Predictive Value, Low Prevalence, and Spectrum Effect: Caution in the Interpretation. Clin Gastroenterol Hepatol 2017; 15:1355-1358. [PMID: 28501535 DOI: 10.1016/j.cgh.2017.05.002] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2017] [Revised: 05/04/2017] [Accepted: 05/05/2017] [Indexed: 02/07/2023]
Affiliation(s)
- Ruben Hernaez
- Section of Gastroenterology and Hepatology, Department of Medicine, Baylor College of Medicine and Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas; Center for Innovations in Quality, Effectiveness and Safety (IQuESt), Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas
| | - Aaron P Thrift
- Section of Gastroenterology and Hepatology, Department of Medicine, Baylor College of Medicine and Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas; Dan L. Duncan Comprehensive Cancer Center, Baylor College of Medicine, Houston, Texas
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