Differential Clinical Characteristics and Mortality Outcomes in Persons With NAFLD and/or MAFLD

Prevalence of MAFLD in the U.S. based on NHANES 2009-2018: differences in demographic characteristics, physical indices and lifestyle conditions

BACKGROUND

The incidence of metabolic dysfunction-associated fatty liver disease (MAFLD) is high among U.S. adults, but studies on its occurrence in different ethnic and age groups are limited. The aim of the present study was to assess MAFLD occurrence among the U.S. adults by considering demographic characteristics, physical indices, and lifestyle conditions.

METHODS

This study utilized the National Health and Nutrition Examination Survey (NHANES) data 2009-2018 from 23,546 participants aged ≥ 20 years. Variables such as age, sex, race, body mass index (BMI), waist circumference (WC), blood pressure, sedentary behavior, sleep, and depression were analyzed.

RESULTS

Among 9933 participants, 3562 had MAFLD (34.1%), with notably higher percentages of Mexican-Americans (54.1%) and lower percentages of blacks (20.5%). The incidence of MAFLD was significantly greater (P < 0.001) in males (39%) than in females (29.2%), which was particularly evident within the 36-40 years age group. The MAFLD incidence exhibited an age-dependent pattern, initially increasing and subsequently declining (except for whites). Compared to white MAFLD patients, black MAFLD patients exhibited greater BMI, WC, systolic blood pressure (SBP), and diastolic blood pressure (DBP) values, whereas values for these measures were lower among Mexican-American patients. Logistic regression analysis adjusting for age and sex revealed that depression was more common among MAFLD patients (P < 0.001), except for severe depression (P > 0.05). Notably, the MAFLD incidence was not significantly associated with sedentary behavior or sleep duration.

CONCLUSIONS

The MAFLD incidence varies across different racial, age, and sex groups, and targeted interventions are essential for reducing the burden of MAFLD. However, further research is necessary to explore the correlations among MAFLD incidence, sleep patterns, and an inactive lifestyle.

Genetic variants associated with metabolic dysfunction-associated fatty liver diseases in a Korean population

BACKGROUND

Susceptibility to metabolic dysfunction-associated fatty liver diseases (MAFLD) shows a large inter-ethnic variability. Currently, large-scale genome-wide association studies (GWAS) on MAFLD in a Korean population are limited. This study aimed to investigate genes underlying MAFLD in a Korean population.

METHODS

A total of 13,457 Korean adults (4061 cases and 9396 controls) who underwent abdominal ultrasonography, biochemical testing, and genetic studies at a comprehensive health promotion center from 2019 to 2023 were included. Genome-wide genotyping was conducted using Infinium Asian Screening Array and an iSCAN system (Illumina, San Diego, CA, USA). Gene-based approach was conducted with Multi-Marker Analysis for Genomic Annotation (MAGMA) and Functional Mapping and Annotation (FUMA). Expression quantitative trait loci (eQTLs) mapping was done using GTEx v8 data.

RESULTS

The 22q13.3, 19p13.11, and 2p23.3 loci were associated with MAFLD after adjusting for age, sex, and body mass index (p < 5 × 10-8). Of these, 154 (89%) variants were identified as eQTLs (FDR < 0.05). Gene-based approach showed that PNPLA3, SAMM50, and PARVB were significantly associated with MAFLD (Bonferroni-corrected p < 2.99 × 10-6), followed by PDLIM4, GCKR, APOB, GPAM, HMGA1, C5orf56, and APOC1.

CONCLUSIONS

This is the largest-scale GWAS of MAFLD in a Korean adult population. Genotyping PARVB as well as PNPLA3 might help us identify individuals with the highest risk of MAFLD in Korean adults. These findings would contribute to our understanding of genetic pathogenesis of MAFLD in the Korean population.

Rethinking carnitine palmitoyltransferase II and liver stem cells in metabolic dysfunction-associated fatty liver disease-related hepatocellular carcinoma

This article discusses a recent study by Wang et al that sheds light on the metabolic and immunological mechanisms driving the progression of metabolic dysfunction-associated fatty liver disease (MAFLD) to hepatocellular carcinoma (HCC). The study highlights the role of mitochondrial carnitine palmitoyltransferase II (CPT II) inactivity, which activates liver cancer stem cells marked by cluster of differentiation 44 (CD44) and CD24 expression, promoting HCC development. Using dynamic mouse models and clinical samples, Wang et al identified CPT II downregulation, mitochondrial membrane potential alterations, and reduced intrahepatic CD4+ T cell as key drivers of disease progression. The findings link these changes to steroid biosynthesis and p53 signaling, contributing to T-cell dysfunction and immunosuppression. This article emphasizes the relevance of these results in understanding MAFLD pathogenesis and discusses potential therapeutic strategies targeting CPT II activity, mitochondrial function, and immune surveillance to prevent or mitigate HCC development in advanced MAFLD.

MAFLD but not MASLD increases risk of all-cause mortality in regional Australia, with components of metabolic syndrome exacerbating factors: 20 year longitudinal, cohort study

BACKGROUND AND AIMS

Controversy remains whether the mortality risk in people with fatty liver disease (FLD) including metabolic-(dysfunction) associated steatotic liver disease (MASLD) and metabolic-(dysfunction) associated fatty liver disease (MAFLD) is higher than observed in those without FLD. We aimed to determine the mortality rate and mortality rate ratio (MRR) for these FLDs.

METHODS

The study population was a randomly selected cohort of community-dwelling adults in regional Victoria, Australia between 2001 and 2003 with sufficient data evaluable for Fatty Liver Index and determination on alcohol consumption. MASLD and MAFLD were diagnosed by established criteria. The primary outcome was overall mortality and main secondary outcome was major adverse liver outcomes (MALO) (i.e., decompensated liver disease, primary liver cancer and liver-related death). Non-fatal and fatal outcomes were captured via data linkage to hospital admission, cancer registry, and death registries. MRR was calculated with non-FLD participants as the comparator.

RESULTS

1444 (99.3%) and 1324 (91.1%) individuals from a total of 1454 were included in the final MAFLD and MASLD analyses. The median follow-up was 19.7 years (IQR 19.1-20.1) and there were 298 deaths. The MRR for MAFLD and MASLD was 1.39 (95% CI 1.10-1.76) and 1.25 (95% CI 0.96-1.61), respectively. MAFLD persisted as a risk factor for all-cause death on multivariable models correcting for lifestyle and socioeconomic variables, but not when adjusted for metabolic risk factors. MALOs were increased in MAFLD [incidence rate ratio (IRR) 3.03, 95% CI 1.22-8.18] and MASLD (IRR 2.80, 95% CI 1.05-7.90). Metabolic risk factors increased the risk of overall mortality and MALO, and cancer (34.3-34.6%) and cardiovascular disease (30.1-33.7%) were the most common cause of death in FLD.

CONCLUSION

In this population-based longitudinal study, MAFLD but not MASLD increases the risk of overall mortality, with metabolic syndrome components key risk factors increasing risk of death.

The role of the advanced lung cancer inflammation index (ALI) in the risk of liver fibrosis and mortality among US adult MAFLD patients: a cross-sectional study of NHANES 1999-2018

BACKGROUND

Metabolic dysfunction-associated fatty liver disease (MAFLD) is a prevalent chronic liver disease globally, with inflammation and nutrition playing key roles in its progression. The Advanced Lung Cancer Inflammation Index (ALI) is a novel biomarker reflecting nutritional and inflammatory status. This study aims to explore the association between ALI and the risk of liver fibrosis and prognosis in MAFLD patients.

METHODS

This cross-sectional study analyzed NHANES data from the 1999-2018 on adult participants in the US. Weighted logistic regression assessed the association between ALI and liver fibrosis risk. Mortality outcomes, including all-cause, cardiovascular disease (CVD), and cancer mortality, analyzed using weighted Kaplan-Meier and Cox proportional hazards models. Restricted cubic splines (RCS) and threshold effect analyses were uesd to explore non-linear relationships. Receiver operating characteristic (ROC) curve evaluated the prognostic value of ALI, and stratified analyses examined subgroup differences.

RESULTS

A total of 6,858 MAFLD patients (mean age 51.38 ± 17.22 years, 54% male) were included. A non-linear relationship was found between ALI and liver fibrosis risk, with a threshold at 5.68, beyond which the risk increased significantly (OR = 2.35, 95% CI: 1.89-2.95). Stronger associations were observed in subgroups with central obesity and prediabetes (P for interaction < 0.05). ALI was inversely associated with all-cause mortality (HR = 0.64, 95% CI: 0.56-0.72) and CVD mortality (HR = 0.57, 95% CI: 0.46-0.65), but not cancer mortality. RCS analysis showed an L-shaped non-linear relationship with all-cause mortality (threshold at 5.36) and a linear relationship with CVD mortality. Low HDL cholesterol and excessive alcohol consumption influenced the association between ALI and all-cause mortality (P for interaction < 0.05). ALI demonstrated the highest predictive accuracy for CVD mortality.

CONCLUSION

ALI is associated with an increased risk of liver fibrosis and reduced all-cause and CVD mortality, highlighting its potential value in assessing MAFLD prognosis, particularly CVD-related mortality.

Global prevalence, metabolic characteristics, and outcomes of lean-MAFLD: a systematic review and meta-analysis

BACKGROUND

Metabolic Dysfunction-Associated Fatty Liver disease (MAFLD) among lean individuals is increasingly recognized. We aimed to compare the prevalence, metabolic characteristics, and outcomes of lean vs overweight/obese-MAFLD patients.

METHODS

Databases of Embase, Medline, and Web of Science were searched from inception till October 2023. Only cohorts adhering to the lean-MAFLD criteria as defined by the international consensus statement were included.

RESULTS

In the pooled analysis of 10,013,382 individuals, the prevalence of lean-MAFLD in the general population was 1.94% (95% CI 1.10-3.39%, I2 = 98.7%). Lean and overweight/obese-MAFLD patients had similar metabolic characteristics for blood pressure, LDL, TG, blood glucose, and HbA1c. There was an increased incidence rate and likelihood for liver-related mortality for lean-MAFLD vs overweight/obese-MAFLD [1.33 per 1000 patient-years (95% CI 1.28-1.39) vs 0.76 (95% CI 0.25-2.28), (OR 3.56 (95% CI 3.45-3.67), p < 0.01). There were similar incidence rates and odds ratios between lean vs overweight/obese-MAFLD for: (1) all-cause mortality [10.08 per 1000 patient-years (95% CI 9.93-10.23) vs 8.94 per 1000 patient-years (95% CI 4.08-19.57), (OR 1.92 (95% CI 0.01-220.57), p = 0.33)]; (2) cardiovascular-related mortality [2.53 per 1000 patient-years (95% CI 0.65-9.96) vs 2.07 per 1000 patient-years (95% CI 0.80-5.39), (OR 1.91 (95% CI 0.02-142.76), p = 0.58)]; and (3) cancer-related mortality [3.42 per 1000 patient-years (95% CI 3.33-3.51) vs 3.15 per 1000 patient-years (95% CI 1.21-8.19), (OR 1.99 (95% CI 0.29-13.52), p = 0.13).

CONCLUSION

Lean-MAFLD patients have an equivalent metabolic burden compared to overweight/obese-MAFLD patients and thus a similar incidence rate of major extrahepatic complications. However, they have an increased risk of liver-related mortality.

Mortality risk associated with MASLD, MASLD type and different cardiometabolic risk factors in IBD patients: A long-term prospective cohort study

PURPOSE

To examine the mortality risk associated with metabolic dysfunction-associated steatotic liver disease (MASLD), MASLD type, lean/non-lean MASLD and different cardiometabolic risk factors (CMRFs) in patients with inflammatory bowel disease (IBD) based on a long-term prospective cohort.

METHODS

Prevalent IBD patients at baseline who were free of alcoholic liver disease, cancer and hepatitis B/C virus seropositive were included (N=4622). MASLD, MASLD type [pure MASLD, MASLD with increased alcohol intake (MetALD)], lean/non-lean MASLD and CMRFs at baseline were defined according to the latest criteria proposed by AASLD and EASL. Primary outcome was all-cause mortality. Cox proportional hazard model was used to examine the association.

RESULTS

Overall, 1,763 (38.1%) were diagnosed with MASLD. During a median of 13.3-year follow-up, 451 all-cause deaths were identified. Compared with IBD-only patients, those with MASLD had a 58% excess risk of mortality (HR=1.58, 95%CI:1.07-2.32). Furthermore, as number of CMRFs increased in MASLD patients, mortality risk was significantly increased (Ptrend=0.005), with a 85% and 83% higher risk in MASLD with 3 CMRFs (HR=1.85, 95%CI:1.20-2.85) and ≥4 CMRFs (HR=1.83, 95%CI:1.16-2.89) versus IBD-only patients. Specifically, similar elevated mortality risk was observed in either pure MASLD (HR= 1.62, 95%CI:1.09-2.43) or MetALD (HR=2.03, 95%CI:1.24-3.32). Moreover, the excess mortality risk was both indicated in lean (HR=3.14, 95%CI:1.57-6.29) and non-lean MASLD (HR=1.67, 95%CI:1.12-2.48).

CONCLUSIONS

MASLD, either pure MASLD or MetALD, as well as lean/non-lean MASLD, is associated with increased mortality risk in IBD patients, with greater risk as number of cardiometabolic risk factors increased and evidently higher risk in lean MASLD patients.

Metabolic dysfunction-associated fatty liver disease indicates more hepatic fibrosis than nonalcoholic fatty liver disease

The term metabolic dysfunction-associated fatty liver disease (MAFLD) has been proposed based on a redefinition of the nonalcoholic fatty liver disease (NAFLD) criteria. Our study aimed to address the knowledge gap by comparing the diagnostic accuracy of MAFLD and NAFLD criteria in identifying significant fibrosis among patients with hepatic steatosis. A cross-sectional study was conducted on 2626 patients with hepatic steatosis treated at Beijing Ditan Hospital between January 2009 and December 2022. Patients with viral hepatitis were excluded. Significant fibrosis was defined as a Meta-analysis of Histological Data in Viral Hepatitis (METAVIR) score F ≥ 2. MAFLD and NAFLD were diagnosed in 478 and 428 patients, respectively. Clinicopathological characteristics were compared between the MAFLD+ NAFLD- group (patients who met the criteria for MAFLD but not NAFLD) and MAFLD- NAFLD+ group (patients who met the criteria for NAFLD but not MAFLD). A total of 743 patients with histologically verified hepatic steatosis were analyzed. The MAFLD+ NAFLD- group comprised 163 (21.9%) and the MAFLD- NAFLD+ group comprised 113 (15.2%) patients. Patients in the MAFLD+ NAFLD- group were older and more likely to be male and had higher body mass index and liver stiffness levels than those in the MAFLD- NAFLD+ group. The prevalence of significant fibrosis was higher in the MAFLD+ NAFLD- group than in the MAFLD- NAFLD+ group (43.6% vs 15.9%, P < .001). The MAFLD criteria may be a better indicator of fibrosis than the NAFLD criteria. Fibrosis in patients with MAFLD can be determined by metabolic disorders, not excessive alcohol consumption.

Advances in research on metabolic dysfunction-associated steatotic liver disease

The global increase in obesity-related metabolic disorders has led to metabolic dysfunction-associated steatotic liver disease (MASLD) emerging as one of the most prevalent chronic liver disease worldwide. Despite growing concerns, the exact pathogenesis of MASLD remains unclear and no definitive treatments have been made available. Consequently, the need for comprehensive research on MASLD is more critical than ever. Gaining insight into the mechanisms of the disease can lay the groundwork for identifying new therapeutic targets and can facilitate the development of diagnostic tools that enable the early detection and intervention of MASLD. Research has discovered a multifactorial etiology for MASLD, suggesting that potential therapeutic strategies should be considered from a variety of perspectives. This review delves into the pathogenesis of MASLD, current diagnostic approaches, potential therapeutic targets, the status of clinical trials for emerging drugs, and the most promising treatment methods available today. With a focus on therapeutic targets, the aim is to offer fresh insights and guide for future research in the treatment of MASLD.

Prognostic and predictive effects of new steatotic liver disease nomenclatures: a large population-based study

We aimed to compare the association of metabolic dysfunction-associated fatty liver disease (MAFLD), metabolic dysfunction-associated steatotic liver disease (MASLD), alcohol-related liver disease (ALD), metabolic dysfunction and ALD (MetALD), and MASLD with viral hepatitis (MASLD-Viral) with risks of cirrhosis, liver cancer, and mortality. The data of 464,556 adults from the UK Biobank (UKB), 13,526 adults from the National Health and Nutrition Examination Survey (NHANES), and 2554 adults from BeijngFH Health Cohort Study (FHCS) were included. Adjusted hazard ratios (aHR) and odds ratios were calculated using Cox and Logistic regression models, respectively. Compared with non-SLD, the risk of liver cancer increased from MetALD (aHR 1.70 [95% CI 1.37, 2.09]), MASLD (1.91 [1.66, 2.21]), MAFLD (2.01 [1.76, 2.29]), ALD (3.16 [2.54, 3.93]), to MASLD-Viral (22.0 [10.8, 44.4]) in a stepwise manner in the UKB; the risk of all-cause mortality increased from MetALD, MASLD, MAFLD, ALD, to MASLD-Viral in the NHANES. The odds ratio of liver fibrosis increased from MASLD, MAFLD, to MASLD-Viral in the FHCS. In patients with diabetes, metformin plus other drugs were associated with higher risks of cirrhosis, liver cancer, and all-cause mortality in MASLD or MAFLD. Prevention rather than antiglycemic treatment is important for patients with diabetic MASLD or MAFLD.

Elevated concurrent carotid atherosclerosis rates in patients with metabolic dysfunction-associated fatty liver disease (MAFLD) compared to non-alcoholic fatty liver disease (NAFLD): A cross-sectional observational study

BACKGROUND AND AIM

Non-alcoholic fatty liver disease (NAFLD) has been recognized as an independent risk factor for atherosclerotic cardiovascular disease. Recently, there has been a shift towards diagnosing metabolic dysfunction-associated fatty liver disease (MAFLD), offering simplified criteria and improved risk assessment. However, the association between MAFLD and carotid atherosclerosis remains poorly understood.

METHODS AND RESULTS

The study analyzed the association of concurrent carotid atherosclerosis between NAFLD and MAFLD patients with a retrospective cohort design. The study enrolled participants who underwent abdominal and carotid artery ultrasounds from a medical center in Taiwan. NAFLD and MAFLD were diagnosed based on imaging and specific criteria. Associations between NAFLD, MAFLD, and carotid atherosclerosis were analyzed using logistic regression. Among 11,194 participants, 57.1 % were diagnosed with fatty liver disease, among which the NAFLD-MAFLD group comprised 4689 individuals, with 900 in the NAFLD-only group and 669 in the MAFLD-only group. Significant demographic and clinical differences were observed between groups. Logistic regression showed that the MAFLD-NAFLD group and MAFLD-only group had significantly higher odds of concomitant carotid atherosclerosis. Among MAFLD patients, 65.5 % had concurrent carotid arteriosclerosis with an odds ratio of 2.35 compared to non-MAFLD patients. The odds ratios for variables in MAFLD patients, such as diabetes mellitus, Fibrosis-4(FIB-4), number of FIB-4 > 1.3, and number of NAFLD fibrosis score > -1.455 were all greater than 2.

CONCLUSIONS

MAFLD is associated with a higher prevalence of carotid atherosclerosis, compared to NAFLD. This suggests that MAFLD may serve as a significant risk factor for cardiovascular complications.

Convolutional neural network classification of ultrasound parametric images based on echo-envelope statistics for the quantitative diagnosis of liver steatosis

PURPOSE

Early detection and quantitative evaluation of liver steatosis are crucial. Therefore, this study investigated a method for classifying ultrasound images to fatty liver grades based on echo-envelope statistics (ES) and convolutional neural network (CNN) analyses.

METHODS

Three fatty liver grades, i.e., normal, mild, and moderate-to-severe, were defined using the thresholds of the magnetic resonance imaging-derived proton density fat fraction (MRI-PDFF). There were 10 cases of each grade, totaling 30 cases. To visualize the texture information affected by the deposition of fat droplets within the liver, the maps of first- and fourth-order moments and the heat maps formed from both moments were employed as parametric images derived from the ES. Several dozen to hundreds of regions of interest (ROIs) were extracted from the liver region in each parametric image. A total of 7680 ROIs were utilized for the transfer learning of a pretrained VGG-16 and classified using the transfer-learned VGG-16.

RESULTS

The classification accuracies of the ROIs in all types of the parametric images were approximately 46%. The fatty liver grade for each case was determined by hard voting on the classified ROIs within the case. In the case of the fourth-order moment maps, the classification accuracy of the cases through hard voting mostly increased to approximately 63%.

CONCLUSIONS

The formation of parametric images derived from the ES and the CNN classification of the parametric images were proposed for the quantitative diagnosis of liver steatosis. In more than 60% of the cases, the fatty liver grade could be estimated solely using ultrasound images.

Association between bowel movement frequency, stool consistency and MAFLD and advanced fibrosis in US adults: a cross-sectional study of NHANES 2005-2010

BACKGROUND

Although previous studies have established associations between specific gut microbiota (GM) and metabolic dysfunction-associated fatty liver disease (MAFLD), research examining the relationship between functional gastrointestinal symptoms and MAFLD, including advanced fibrosis, remains limited. This study aims to investigate the association between stool consistency, bowel movement frequency (BMF), and the occurrence of MAFLD and advanced fibrosis in U.S. adults.

METHODS

This population-based study included 9,928 adults from the 2005-2010 National Health and Nutrition Examination Survey (NHANES), with a mean age of 47.19 ± 16.65 years, comprising 47.7% males and 52.3% females. Weighted logistic regression was used to assess the association between stool consistency, BMF, and MAFLD or advanced fibrosis. A linear trend was assessed by treating BMF categories as continuous variables with ordinal values. The dose-response relationship between BMF and MAFLD was analyzed using restricted cubic splines (RCS) regression. Sensitivity and subgroup analyses were performed to confirm the robustness of the findings.

RESULTS

In the RCS regression, no significant nonlinear relationship was observed between BMF and the risk of MAFLD (p-overall < 0.0001; p-nonlinear = 0.0663). The multivariable-adjusted odds ratios (ORs) and 95% confidence intervals (CIs) for MAFLD were 0.82 (95% CI 0.69-0.98), 1.31 (95% CI 1.16-1.46), and 1.50 (95% CI 1.14-1.99) for participants with 3-6 BMs/week, 1-2 BMs/day, and > 2 BMs/day, respectively, compared to those with once/day (p-trend < 0.001). For stool consistency, hard stools were associated with a decreased risk of MAFLD (OR 0.77; 95% CI 0.62-0.95), whereas loose stools increased the risk (OR 1.37; 95% CI 1.05-1.80), relative to normal stools. A significant interaction between BMF and age was observed. No significant associations were found between stool consistency or BMF and advanced liver fibrosis. Sensitivity analyses confirmed the robustness of these findings.

CONCLUSIONS

This cross-sectional study demonstrates that a BMF of 3-6 BMs/week and hard stools are associated with a reduced risk of MAFLD, whereas a BMF of more than once/day and loose stools are linked to an increased risk of MAFLD. Moreover, no significant associations were observed between stool consistency, BMF, and advanced fibrosis among individuals diagnosed with MAFLD.

CLINICAL TRIAL NUMBER

Not applicable.

Life's essential 8 and mortality in US adults with metabolic dysfunction-associated steatotic liver disease

BACKGROUND

Metabolic dysfunction-associated steatotic liver disease (MASLD) is linked to increased all-cause mortality due to metabolic dysfunctions like obesity, diabetes, and cardiovascular diseases. This study examines the association between Life's Essential 8 (LE8) scores and both all-cause and cardiovascular disease (CVD) mortality in MASLD participants.

METHODS

Data from 5,916 MASLD participants in the NHANES (2005-2018) were analyzed. Associations between LE8 scores and all-cause and CVD mortality were assessed using Cox proportional hazards models, with follow-up until December 31, 2019. Dose-response relationships and survival differences were evaluated using Kaplan-Meier survival curves and Restricted Cubic Spline models.

RESULTS

Over a median follow-up of 7.6 years, moderate and high LE8 scores were associated with 33% (HR: 0.67; 95% CI: 0.56-0.79) and 47% (HR: 0.53; 95% CI: 0.33-0.84) lower risk of all-cause mortality, respectively, compared to low scores. For CVD mortality, the adjusted HRs were 0.56 (95% CI: 0.41-0.78) and 0.35 (95% CI: 0.12-1.0). Higher LE8 scores were significantly associated with reduced cumulative incidence of all-cause and CVD mortality (log-rank P < 0.001). A 10-point increase in health behavior scores, particularly in diet, physical activity, and nicotine exposure, was linked to an 11% reduction in all-cause mortality risk and an 11% reduction in CVD mortality risk. Among health factors, only blood glucose showed a significant association with CVD mortality.

CONCLUSION

Higher LE8 scores in MASLD patients are associated with lower mortality risk, suggesting the potential value of promoting cardiovascular health in this population. Further research is needed to confirm these associations.

Prevalence and Prognostic Significance of Malnutrition in Patients with Non-Alcoholic Fatty Liver Disease (NAFLD)

BACKGROUND

Non-alcoholic fatty liver disease (NAFLD) has become the primary cause of chronic liver disease. Although malnutrition is a common late-stage clinical consequence during the course of organ dysfunction and death in critical patients, it has not received sufficient attention in the context of NAFLD. The aim of this study was to explore the prevalence and prognostic significance of malnutrition in patients with NAFLD using three simple tools for nutrition assessment.

METHODS

Participants (n = 3908) in the National Health and Nutrition Examination Survey (NHANES) database were divided into NAFLD (n = 1737) and non-NAFLD (n = 2171) groups. The controlling nutritional status (CONUT) score, prognostic nutrition index (PNI), and nutrition risk index (NRI) were applied to investigate the association between malnutrition and mortality among NAFLD patients.

RESULTS

The median age of participants was 54.0 years, with females accounting for 52.2% of the study cohort. A majority of elderly male participants had NAFLD, and up to 18% of NAFLD patients suffered from malnutrition. During the average period of follow-up (24.4 ± 7.2 months), 36 all-cause deaths occurred in the NAFLD group. Multivariate analysis revealed that malnutrition was associated with significantly higher mortality compared with normal nutrition. The adjusted hazard ratio (HR) for PNI was 4.44 (95% CI: 2.07-9.53, p < 0.001), and for NRI it was 6.98 (95% CI: 1.47-33.11, p = 0.014). The CONUT score also showed a trend for association with higher mortality.

CONCLUSION

Malnutrition is a common comorbidity in NAFLD patients and is closely associated with poor prognosis and higher mortality. The three nutrition assessment tools employed in this study could be used to improve the predictive ability of nutritional status for mortality among NAFLD patients.

Associations of serum folate and vitamin B12 levels with all-cause mortality among patients with metabolic dysfunction associated steatotic liver disease: a prospective cohort study

Introduction

Serum folate and vitamin B12 levels correlate with the prevalence of fatty liver disease, but it is not clear how they affect mortality. Therefore, this study aimed to investigate the association of serum folate and vitamin B12 concentrations with all-cause mortality in individuals with metabolic dysfunction-associated steatotic liver disease (MASLD).

Methods

MASLD subjects were from the Third National Health and Nutrition Examination Survey (NHANES III) in the United States, and mortality follow-up data were obtained by linkage to death records from the National Death Index. Multivariable Cox proportional regression models and restricted cubic spline (RCS) models were used to evaluate the association of serum folate/vitamin B12 with all-cause mortality in the MASLD population.

Results

3,636 and 2,125 MASLD individuals were included in the analyses related to serum folate and vitamin B12, respectively. During a follow-up period of more than 20 years, the RCS models demonstrated significant nonlinear associations of both serum folate (P <0.001) and vitamin B12 (P =0.016) with all-cause mortality in MASLD. When their serum concentrations were below the median level, the risk of all-cause mortality decreased with increasing concentration, reaching a lowest risk around the median level, and then leveled off. In the multivariable cox regression model, for vitamin B12, the risk of all-cause mortality was reduced by 42% and 28% in the third and fourth quartile groups, respectively, compared with the lowest quartile group (hazard ratio [HR]=0.58, 95% CI: 0.39-0.86, P =0.008; HR =0.72, 95% CI: 0.54-0.96, P=0.026, respectively). For folate, the risk of all-cause mortality was reduced by 28% in the third quartile compared with the lowest quartile (HR =0.72, 95% CI: 0.57-0.91, P =0.005).

Conclusion

This longitudinal cohort study suggests that low serum folate and vitamin B12 levels in patients with MASLD are significantly associated with an elevated risk of all-cause mortality.

The role of dietary modification in the prevention and management of metabolic dysfunction-associated fatty liver disease: An international multidisciplinary expert consensus

Metabolic dysfunction-associated fatty liver disease (MAFLD) or metabolic dysfunction-associated steatotic liver disease (MASLD), has become the leading cause of chronic liver disease worldwide. Optimal dietary intervention strategies for MAFLD are not standardized. This study aimed to achieve consensus on prevention of MAFLD through dietary modification. A multidisciplinary panel of 55 international experts, including specialists in hepatology, gastroenterology, dietetics, endocrinology and other medical specialties from six continents collaborated in a Delphi-based consensus development process. The consensus statements covered aspects ranging from epidemiology to mechanisms, management, and dietary recommendations for MAFLD. The recommended dietary strategies emphasize adherence to a balanced diet with controlled energy intake and personalized nutritional interventions, such as calorie restriction, high-protein, or low-carbohydrate diets. Specific dietary advice encouraged increasing the consumption of whole grains, plant-based proteins, fish, seafood, low-fat or fat-free dairy products, liquid plant oils, and deeply colored fruits and vegetables. Concurrently, it advised reducing the intake of red and processed meats, saturated and trans fats, ultra-processed foods, added sugars, and alcohol. Additionally, maintaining the Mediterranean or DASH diet, minimizing sedentary behavior, and engaging in regular physical activity are recommended. These consensus statements lay the foundation for customized dietary guidelines and proposing avenues for further research on nutrition and MAFLD.

Non-invasive prediction nomogram for predicting significant fibrosis in patients with metabolic-associated fatty liver disease: a cross-sectional study

BACKGROUND AND AIM

This study aims to validate the efficacy of the conventional non-invasive score in predicting significant fibrosis in metabolic-associated fatty liver disease (MAFLD) and to develop a non-invasive prediction model for MAFLD.

METHODS

This cross-sectional study was conducted among 7701 participants with MAFLD from August 2018 to December 2023. All participants were divided into a training cohort and a validation cohort. The study compared different subgroups' demographic, anthropometric, and laboratory examination indicators and conducted logistic regression analysis to assess the correlation between independent variables and liver fibrosis. Nomograms were created using the logistic regression model. The predictive values of noninvasive models and nomograms were evaluated using receiver operating characteristic (ROC) curve analysis and decision curve analysis (DCA).

RESULTS

Four nomograms were developed for the quantitative analysis of significant liver fibrosis risk based on the multivariate logistic regression analysis results. The nomogram's area under ROC curves (AUC) was 0.710, 0.714, 0.748, and 0.715 in overall MAFLD, OW-MAFLD, Lean-MAFLD, and T2DM-MAFLD, respectively. The nomogram had a higher AUC in all MAFLD participants and OW-MAFLD than the other non-invasive scores. The DCA curve showed that the net benefit of each nomogram was higher than that of APRI and FIB-4. In the validation cohort, the AUCs of the nomograms were 0.722, 0.750, 0.719, and 0.705, respectively.

CONCLUSION

APRI, FIB-4, and NFS performed poorly predicting significant fibrosis in patients with MAFLD. The new model demonstrated improved diagnostic accuracy and clinical applicability in identifying significant fibrosis in MAFLD.

Metabolic (dysfunction)-associated fatty liver disease metrics and contributions to liver research

BACKGROUND

The international consensus to revise non-alcoholic fatty liver disease to metabolic (dysfunction)-associated fatty liver disease (MAFLD) in 2020 attracted significant attention. The impact of the MAFLD definition on the research community has not been objectively assessed. We conducted an analysis of systematically collected literature on MAFLD to understand its research impact.

METHODS

From PubMed, Web of Science, and Scopus, the literature adopting MAFLD, written in English, and published from 2020 to 10 October 2023 was collected. The publication metrics, including publication counts, publishing journals, author countries, author keywords, and citation information, were analyzed to evaluate the research impact and key topics on MAFLD.

RESULTS

1469 MAFLD-related papers were published in 434 journals with a steady increase in the number. The intense publishing and citations activity on MAFLD indicates the large impact of the redefinition. Topic assessment with keyword and citation analysis revealed a transition from the proposal and discussion of the redefinition to clinical characterization of MAFLD with a focus on metabolic dysfunction. Moreover, the diagnostic criteria for MAFLD showed better performance in predicting hepatic and extrahepatic outcomes compared to NAFLD. The publications were from 99 countries with evidence of strong regional and global collaboration. Multiple international societies and stakeholders have endorsed MAFLD for its utility in clinical practice, improving patient management and promoting multidisciplinary care, while alleviating stigma.

CONCLUSION

This survey provides a quantitative measure of the considerable international impact and contributions of the MAFLD definition towards liver research and as part of the spectrum of cardiometabolic disorders.

Hepatocardial relationships in non-alcoholic fatty liver disease: issues of epidemiology, diagnosis, prognosis

World statistics indicate a steady increase in the prevalence of non-alcoholic fatty liver disease, which correlates with the pandemics of obesity and diabetes, which are quite common in Russia. The commonality of cardiometabolic risk factors, the high global prevalence of non-alcoholic fatty liver disease and atherosclerotic cardiovascular diseases generates the interest of researchers in studying hepatocardial relationships. Currently, non-alcoholic fatty liver disease is positioned as a hepatic manifestation of a multisystem disorder, heterogeneous in underlying causes, manifestations, course and outcomes. The purpose of this review was to analyze hepatocardial relationships based on publications. 76 sources on the epidemiology of non-alcoholic fatty liver disease, published from 2011–2023 in journals indexed in Pubmed and eLibrary, were analyzed. Age and gender aspects of the development of non-alcoholic fatty liver disease were considered. The pathogenetic mechanisms of hepatocardial relationships, which were closely related to systemic inflammation, insulin resistance, metabolic syndrome and its components, were highlighted. The criteria and methods for diagnosing non-alcoholic fatty liver disease and metabolic-associated liver disease were outlined. Recent studies demonstrated the presence of hepatocardial connections, characterized by an increased risk of developing atherosclerosis, cardiomyopathy and rhythm disturbances, changes in the structural and functional parameters and geometry of the heart, as well as diastolic dysfunction, which may precede and/or contribute to the development of chronic heart failure in patients with non-alcoholic fatty liver disease. The article presents data on non-alcoholic fatty liver disease as a new factor associated with the development of adverse cardiovascular events to a greater extent than the outcome of liver diseases themselves, which confirms the need for primary and secondary prevention of cardiovascular diseases in this cohort of patients.

Long-term Risks of Cirrhosis and Hepatocellular Carcinoma Across Steatotic Liver Disease Subtypes

INTRODUCTION

The prospective study aimed to investigate the long-term associated risks of cirrhosis and hepatocellular carcinoma (HCC) across various subtypes of steatotic liver disease (SLD).

METHODS

We enrolled 332,175 adults who participated in a health screening program between 1997 and 2013. Participants were categorized into various subtypes, including metabolic dysfunction-associated SLD (MASLD), MASLD with excessive alcohol consumption (MetALD), and alcohol-related liver disease (ALD), based on ultrasonography findings, alcohol consumption patterns, and cardiometabolic risk factors. We used computerized data linkage with nationwide registries from 1997 to 2019 to ascertain the incidence of cirrhosis and HCC.

RESULTS

After a median follow-up of 16 years, 4,458 cases of cirrhosis and 1,392 cases of HCC occurred in the entire cohort, resulting in an incidence rate of 86.1 and 26.8 per 100,000 person-years, respectively. The ALD group exhibited the highest incidence rate for cirrhosis and HCC, followed by MetALD, MASLD, and non-SLD groups. The multivariate adjusted hazard ratios for HCC were 1.92 (95% confidence interval [CI] 1.51-2.44), 2.91 (95% CI 2.11-4.03), and 2.59 (95% CI 1.93-3.48) for MASLD, MetALD, and ALD, respectively, when compared with non-SLD without cardiometabolic risk factors. The pattern of the associated risk of cirrhosis was similar to that of HCC (all P value <0.001). The associated risk of cirrhosis for ALD increased to 4.74 (95% CI 4.08-5.52) when using non-SLD without cardiometabolic risk factors as a reference.

DISCUSSION

This study highlights elevated risks of cirrhosis and HCC across various subtypes of SLD compared with non-SLD, emphasizing the importance of behavioral modifications for early prevention.

Metabolic Dysfunction-Associated Steatotic Liver Disease in Type 2 Diabetes Mellitus: A Review and Position Statement of the Fatty Liver Research Group of the Korean Diabetes Association

Since the role of the liver in metabolic dysfunction, including type 2 diabetes mellitus, was demonstrated, studies on non-alcoholic fatty liver disease (NAFLD) and metabolic dysfunction-associated fatty liver disease (MAFLD) have shown associations between fatty liver disease and other metabolic diseases. Unlike the exclusionary diagnostic criteria of NAFLD, MAFLD diagnosis is based on the presence of metabolic dysregulation in fatty liver disease. Renaming NAFLD as MAFLD also introduced simpler diagnostic criteria. In 2023, a new nomenclature, steatotic liver disease (SLD), was proposed. Similar to MAFLD, SLD diagnosis is based on the presence of hepatic steatosis with at least one cardiometabolic dysfunction. SLD is categorized into metabolic dysfunction-associated steatotic liver disease (MASLD), metabolic dysfunction and alcohol-related/-associated liver disease, alcoholrelated liver disease, specific etiology SLD, and cryptogenic SLD. The term MASLD has been adopted by a number of leading national and international societies due to its concise diagnostic criteria, exclusion of other concomitant liver diseases, and lack of stigmatizing terms. This article reviews the diagnostic criteria, clinical relevance, and differences among NAFLD, MAFLD, and MASLD from a diabetologist's perspective and provides a rationale for adopting SLD/MASLD in the Fatty Liver Research Group of the Korean Diabetes Association.

Association of plain water intake with risk of all-cause and cause-specific mortality in individuals with non-alcoholic fatty liver disease or metabolic dysfunction-associated steatotic liver disease

Non-alcoholic fatty liver disease (NAFLD) or metabolic dysfunction-associated steatotic liver disease (MASLD)-related mortality have increased dramatically in past decades. Our study aims to investigate the association between plain water and this prevalent metabolic disease, as water plays a crucial role in regulating metabolic processes. A total of 3,543/3,428 individuals with NAFLD/MASLD were included in this study from National Health and Nutrition Examination Survey (NHANES). Daily plain water intake was recorded, and mortality status was tracked until December 31, 2019. Multivariate Cox regression models and restricted cubic spline (RCS) regression models were used to assess the association between plain water intake and long-term all-cause as well as cause-specific mortality among participants with NAFLD/MASLD. Furthermore, we investigated the relationship between substituting other beverages with plain water intake and the risk of mortality. The multivariate Cox regression analyses revealed a significant association between higher plain water intake and lower all-cause mortality, cerebrovascular diseases mortality, and cancer mortality in both NAFLD or MASLD patients. Dose-response analyses revealed a non-linear trend between plain water intake and mortality among NAFLD/MASLD patients. Additionally, replacing sugar or artificial beverages with plain water was linked to reduced all-cause mortality, cerebrovascular diseases mortality, and cancer mortality in patients with NAFLD/MASLD. Higher plain water intake is independently linked to lower risk of all-cause, cerebrovascular diseases mortality, and cancer mortality in NAFLD/MASLD patients. Increasing plain water intake may be an effective way for these patients to reduce their risk of mortality.

Risk of Hepatocellular Carcinoma by Steatotic Liver Disease and Its Newly Proposed Subclassification

Introduction

Steatotic liver disease (SLD) is a new overarching term proposed to replace nonalcoholic fatty liver disease and metabolic dysfunction-associated fatty liver disease. Subclassification includes metabolic dysfunction-associated SLD (MASLD), MASLD with increased alcohol intake (MetALD), and cryptogenic SLD. This study aimed to investigate whether SLD and its subclassification could stratify hepatocellular carcinoma (HCC) risk.

Methods

A cohort of 85,119 adults without viral hepatitis or heavy alcohol intake was analyzed for the risk of HCC according to SLD and its subclassification. The fibrosis-4 (FIB-4) index was used to estimate the degree of liver fibrosis.

Results

During a median follow-up of 11.9 years, HCC was diagnosed in 123 individuals. The incidence rate of HCC per 1,000 person-years was higher in individuals with SLD than in those without SLD (0.197 vs. 0.071, p < 0.001), with an adjusted hazard ratio of 2.02 (95% confidence interval: 1.40-2.92). The HCC incidence rate per 1,000 person-years was 0, 0.180, and 0.648 for cryptogenic SLD, MASLD, and MetALD, respectively. When participants with SLD was further stratified by the FIB-4 index, the HCC incidence rate per 1,000 person-years was 0.074 for SLD with FIB-4 < 1.3 and 0.673 for SLD with FIB-4 ≥ 1.3. Of note, HCC risk was substantially high (HCC incidence rate: 1.847 per 1,000 person-years) for MetALD with FIB-4 ≥ 1.3.

Conclusions

HCC risk was different by SLD and its subclassification. The utilization of SLD and its subclassification can aid in stratifying HCC risk and facilitate the identification of individuals requiring interventions to mitigate the risk of HCC.

Lifestyle intervention for metabolic dysfunction-associated fatty liver disease: a 24-h integrated behavior perspective

INTRODUCTION

The prevalence, health and socioeconomic burden of metabolic dysfunction-associated fatty liver disease (MAFLD) is growing, increasing the need for novel evidence-based lifestyle approaches. Lifestyle is the cornerstone for MAFLD management and co-existing cardiometabolic dysfunction. The aim of this review was to evaluate the evidence for lifestyle management of MAFLD, with a specific lens on 24-hour integrated behaviour and provide practical recommendations for implementation of the evidence.

RESULTS

Weight loss ≥ 7-10% is central to lifestyle management; however, liver and cardiometabolic benefits are attainable with improved diet quality and exercise even without weight loss. Lifestyle intervention for MAFLD should consider an integrated '24-h' approach that is cognisant of diet, physical activity/exercise, sedentary behavior, smoking, alcohol intake and sleep. Dietary management emphasises energy deficit and improved diet quality, especially the Mediterranean diet, although sociocultural adaptations to meet preferences should be considered. Increasing physical activity and reducing sedentary behavior can prevent MAFLD, with strongest evidence in MAFLD supporting regular structured moderate-vigorous aerobic exercise for 150-240 min/week. Resistance training in addition to aerobic exercise should be considered and prioritised for those who are losing body mass via diet and/or pharmacological approaches and those with sarcopenia, to minimise bone and lean mass loss. Limited evidence suggests that sleep is important for MAFLD prevention. Emerging novel approaches to diet and exercise may address some of the key barriers to behaviour change (e.g. lack of time, access to resources and social support).

FUTURE DIRECTIONS

Large-scale multidisciplinary trials in people with MAFLD with long-term follow-up, that can be scaled up into mainstream healthcare, are required. Future management guidelines should consider the heterogeneity of MAFLD and specialised models of care that coordinate the health workforce to manage the increased and growing MAFLD population.

Prevalence, proportions of elevated liver enzyme levels, and long-term cardiometabolic mortality of patients with metabolic dysfunction-associated steatotic liver disease

BACKGROUND AND AIM

This study estimated the prevalence of metabolic dysfunction-associated steatotic liver disease (MASLD) according to cardiometabolic risk factors. The long-term impacts of MASLD on all-cause and cardiometabolic-specific mortality were evaluated.

METHODS

We enrolled 343 816 adults aged ≥30 years who participated in a health screening program from 1997 through 2013. MASLD was identified on the basis of abdominal ultrasonography and metabolic profiles. The participants were further categorized by liver enzyme elevation. Baseline cardiometabolic comorbidities were classified on the basis of self-reported medication use and clinical seromarkers. All-cause and cardiometabolic-specific deaths were determined through computerized data linkage with nationwide death certifications until December 31, 2020.

RESULTS

The overall prevalence of MASLD was 36.4%. Among patients with MASLD, 35.9% had abnormal liver enzyme levels. Compared with patients without MASLD, abnormal liver enzymes were positively associated with cardiometabolic comorbidities in patients with MASLD (Pfor trend < 0.001). After follow-up, patients with MASLD had a 9%-29% higher risk of all-cause, cardiovascular-related, or diabetes-related mortality. In the groups with MASLD and elevated and normal liver enzyme levels, the multivariate-adjusted hazard ratios for cardiovascular deaths were 1.14 (1.05-1.25) and 1.10 (1.03-1.17), respectively, and those for diabetes deaths were 1.42 (1.05-1.93) and 1.24 (0.98-1.57), respectively, compared with those in the non-MASLD group (Pfor trend < 0.001).

DISCUSSION

Individuals with MASLD and elevated liver enzyme levels exhibited significantly higher risks of all-cause and cardiometabolic deaths and should be monitored and given consultation on cardiometabolic modifications.

The systemic inflammation response index as a risk factor for hepatic fibrosis and long-term mortality among individuals with metabolic dysfunction-associated steatotic liver disease

BACKGROUND AND AIMS

The systemic inflammation response index (SIRI) is associated with various diseases with inflammatory components, but its relationship with the progression of hepatic fibrosis and survival outcomes in patients with metabolic dysfunction-associated steatotic liver disease (MASLD) is still unclear. This study was designed to investigate the potential associations between the SIRI and advanced hepatic fibrosis (AHF) as well as between the SIRI and long-term outcomes in individuals with MASLD.

METHODS AND RESULTS

A prospective cohort study was conducted using data gathered from the National Health and Nutrition Examination Survey (NHANES) spanning from 2005 to 2016. Weighted binary logistic regression, the Cox proportional hazards model, and time-dependent receiver operating characteristic (ROC) analyses were employed to assess the relationships among the SIRI, AHF, and mortality in patients with MASLD. Our study included a total of 5126 patients with MASLD. A higher SIRI was significantly associated with increased odds of AHF (OR 1.55, 95% CI 1.22, 1.96). According to the survival analyses, a higher SIRI was associated with greater all-cause (HR 1.19, 95% CI 1.15, 1.22) and cardiovascular mortality (HR 1.25, 95% CI 1.19, 1.32) after adjustment. The time-dependent ROC analysis indicated that the SIRI had a modest predictive value for discriminating MASLD individuals at higher versus lower mortality risk over 3-year, 5-year, and 10-year follow-up.

CONCLUSIONS

The SIRI is a promising tool for identifying MASLD individuals at risk of progressing to AHF and for predicting mortality outcomes.

METS-IR/HOMA-IR and MAFLD in U.S. adults: dose-response correlation and the effect mediated by physical activity

OBJECTIVES

Metabolic dysfunction-associated fatty liver disease (MAFLD), a globally prevalent disease, is closely linked to insulin resistance (IR). Physical activity (PA) is closely linked to both MAFLD and IR. We aim to explore the dose-response relationship between metabolic score for IR (METS-IR)/homeostasis model assessment of IR (HOMA-IR) and MAFLD, and investigate the relationship between PA, IR and MAFLD.

METHODS

Participants from the NHANES study were included in this cross-section study. Logistic regression and the receiver operating characteristic were used to assess the predictive performance of METS-IR/HOMA-IR for MAFLD. Restrictive cubic splines were performed to visualize their dose-response relationship. Decision tree analysis was used to identify high-risk populations of MAFLD. PA's mediating effect in the association between METS-IR/HOMA-IR and MAFLD was also examined.

RESULTS

Of all 1,313 participants, 693 had MAFLD (52.78%). There were a positive association between METS-IR (OR = 1.162, 95% CI = 1.126-1.199) and HOMA-IR (OR = 1.630, 95% CI = 1.431-1.856) and MAFLD risk. The AUCs of the METS-IR and HOMA-IR were 0.831 (0.809, 0.853) and 0.767 (0.741, 0.791), respectively, with significantly different predictive performance (P < 0.001). Adding METS-IR/HOMA-IR to the basic model greatly improved the statistical significance for MAFLD. Five high-risk subgroups were identified for MAFLD. PA mediated about 0.81% and 0.78% (indirect effect/total effect) in the association between METS-IR/HOMA-IR and MAFLD.

CONCLUSIONS

MAFLD risk might be predicted by METS-IR/HOMA-IR, among which METS-IR performed better. And PA mediated the association between them. More attention should be paid to the therapeutic effect of lifestyle changes on MAFLD.

HIGHLIGHTS

1. Positive associations were found between METS-IR and HOMA-IR and MAFLD risk. 2. METS-IR has better predictive performance for MAFLD risk than HOMA-IR. 3.Two high-risk subgroups were identified for MAFLD by METS-IR: individuals with METS-IR ≥ 40; Hispanic black individuals with 34 ≤ METS-IR < 40 and aged ≥ 46. 4. In the significant association between METS-IR/HOMA-IR and MAFLD, about 0.81% and 0.78% (indirect effect/total effect), respectively, were mediated by physical activity.

Metabolic dysfunction-associated fatty liver disease and heavy alcohol consumption increase mortality:A nationwide study

BACKGROUND

The effects of excessive alcohol consumption on the prognosis of metabolic dysfunction-associated fatty liver disease (MAFLD) remain unclear. We investigated all-cause and cause-specific mortality according to the amount of alcohol consumed by Asian individuals with MAFLD.

METHODS

This nationwide retrospective study included 996,508 adults aged 40-79 years who underwent health check-ups between 2009 and 2012. Participants were categorized by the alcohol consumption-non-alcohol, moderate alcohol, and heavy alcohol group (≥ 30 g/day for men, ≥ 20 g/day for women) and by the combination of the presence or absence of MAFLD. Hepatic steatosis was defined as the fatty liver index ≥ 30. Cox analyses were used to analyze the association between alcohol consumption and MAFLD and all-cause and cause-specific mortality.

RESULTS

MAFLD significantly increased all-cause, liver-, and cancer-related mortality. Individuals with both MAFLD and heavy alcohol consumption expressed the highest mortality risk in liver-related mortality compared to non-MAFLD and non-alcohol group (adjusted hazard ratio (HR), 9.8; 95% confidence interval (CI), 8.20-12.29). Regardless of MAFLD, heavy alcohol consumption increased the risk of liver- and cancer-related mortality.

CONCLUSIONS

MAFLD and heavy alcohol consumption increased all-cause, liver-, and cancer-related mortality. Heavy alcohol consumption and MAFLD synergistically increase liver-related mortality.

Identifying the most critical behavioral lifestyles associated with MAFLD: evidence from the NHANES 2017-2020

Background & aims

Accumulating studies have demonstrated associations between single lifestyle exposures and metabolic dysfunction-associated fatty liver disease (MAFLD). However, the joint effects of lifestyle exposures remain unclear, hindering the development of targeted prevention and control strategies. We aimed to investigate the joint associations between lifestyle exposomes and MAFLD.

Methods

This study included 5,002 participants from NHANES 2017-2020. Lifestyle exposomes, including sleep duration, metabolic equivalent of task (MET), Healthy Eating Index (HEI)-2015 score, alcohol consumption, and smoke exposure, were identified from questionnaire data. MAFLD was diagnosed by vibration-controlled transient elastography measurements and laboratory data. A logistic regression model and the weighted quantile sum method were used to evaluate the associations of single and joint lifestyle exposomes, respectively, with MAFLD. The population attributable fractions (PAFs) were calculated to assess the population benefits of different intervention strategies.

Results

Per-quartile range increases in sleep duration (OR=0.883, 95% CI: 0.826-0.944), MET (0.916, 0.871-0.963), and HEI-2015 score (0.827, 0.756-0.904) were significantly associated with MAFLD. The joint exposure of sleep duration, MET, and HEI-2015 score was associated with MAFLD (0.772, 0.688-0.865), with the highest weight (importance) for MET (0.526). PAFs revealed greater intervention benefits for sleep and the HEI-2015 when the majority of the population (>5%) had a low MAFLD risk (weak intervention targets), whereas MET was the most efficient intervention strategy when minority populations (≤5%) had a low MAFLD risk (strong intervention targets).

Conclusion

This study demonstrated significant associations between MAFLD and single and joint exposures to sleep duration, MET, and HEI-2015 and identified physical activity as the most important lifestyle factor. Further population benefit analyses may provide evidence and suggestions for population-level interventions.

Assessing the Prognostic Utility of the New Mayo Adhesive Probability Score in East Asian Populations and its Correlation with Metabolic-Associated Fatty Liver Disease

We assessed the prognostic utility of the new perinephric fat adherence risk score - Mayo Adhesive Probability (MAP), in patients of East Asian ethnicity undergoing either laparoscopic partial nephrectomy (LPN) or laparoscopic radical nephrectomy (LRN). A retrospective analysis of clinical data was carried out on 169 patients who either underwent LPN or LRN surgery. These patients were categorized into two groups, group A (0-2 points) and group B (3-4 points) using the new MAP score. The overall clinical data between these two groups was compared and potential risk factors were investigated using logistic regression analyses. The new MAP score yielded an area under the curve of 0.761 (95 % CI: 0.691-0.831), indicating its effectiveness. Group B had a significantly higher incidence of adherent perirenal fat (APF) during surgery (p<0.001) and had a greater average age (p<0.001). There was an increased prevalence of hypertension (p=0.009), type 2 diabetes mellitus (p<0.001), and MAFLD (p<0.001) in group B. Additionally, there were significant differences in posterior perinephric fat thickness (p<0.05), lateral perinephric fat thickness (p<0.001), and perinephric stranding (p<0.001) between the two groups. The new MAP score holds significance in predicting APF in people of East Asian ethnicity undergoing LPN or LRN, and there is a strong correlation between elevated MAP scores and risk factors such as MAFLD and advanced age.

Association between triglyceride-glucose related indices and mortality among individuals with non-alcoholic fatty liver disease or metabolic dysfunction-associated steatotic liver disease

BACKGROUND

The prognostic value of triglyceride-glucose (TyG) related indices in non-alcoholic fatty liver disease (NAFLD) or metabolic dysfunction-associated steatotic liver disease (MASLD) is still unclear. This study aimed to determine the associations between TyG-related indices and long-term mortality in this population.

METHODS

The data came from the National Health and Nutrition Examination Survey (NHANES III) and National Death Index (NDI). Baseline TyG, TyG combining with body mass index (TyG-BMI), and TyG combining with waist circumference (TyG-WC) indices were calculated, and mortality status was determined through 31 December 2019. Multivariate Cox and restricted cubic spline (RCS) regression models were performed to evaluate the relationship between TyG-related indices and long-term mortality among participants with NAFLD/MASLD. In addition, we examined the association between TyG-related indices and all-cause mortality within subgroups defined by age, sex, race/ethnicity, and fibrosis-4 index (FIB-4).

RESULTS

There were 10,390 participants with completed ultrasonography and laboratory data included in this study. NAFLD was diagnosed in 3672/10,390 (35.3%) participants, while MASLD in 3556/10,390 (34.2%) amongst the overall population. The multivariate Cox regression analyses showed high levels of TyG-related indices, particularly in TyG-BMI and TyG-WC indices were significantly associated with the all-cause mortality, cardiovascular mortality, and diabetes mortality in either NAFLD or MASLD. The RCS curves showed a nonlinear trend between three TyG-related indices with all-cause mortality in either NAFLD or MASLD. Subgroup analyses showed that TyG-BMI and TyG-WC indices were more suitable for predicting all-cause mortality in patients without advanced fibrosis.

CONCLUSION

Our study highlights the clinical value of TyG-related indices in predicting the survival of the NAFLD/MASLD population. TyG-BMI and TyG-WC indices would be the surrogate biomarkers for the follow-up of the population without advanced fibrosis.

Head-to-head comparison of three different US-based quantitative parameters for hepatic steatosis assessment: a prospective study

PURPOSE

To evaluate the diagnostic performance of attenuation coefficient (AC), hepato-renal index (HRI) and controlled attenuation parameter (CAP) in quantitative assessment of hepatic steatosis by employing histopathology as reference standard.

METHODS

Participants with suspected metabolic-associated fatty liver disease (MAFLD) who underwent US-based parameter examinations and liver biopsy were prospectively recruited. The distributions of US parameters across different grades of steatosis were calculated, and diagnostic performance was determined based on the areas under the receiver operating characteristic curve (AUC).

RESULTS

A total of 73 participants were included, with hepatic steatosis grades S0, S1, S2, and S3 distributed as follows: 13, 20, 27, and 13 respectively. The correlation coefficients for CAP, AC, and HRI ranged from 0.67 to 0.74. AC and HRI showed a strong correlation with steatosis grade. The AUC for CAP and AC in diagnosing steatosis ≥ S1 were significantly higher at 0.99 and 0.98 compared to HRI's value. For diagnosing steatosis ≥ S2, the AUC of CAP (AUC: 0.85) was lower than that of AC (AUC: 0.94), and HRI (AUC: 0.94). Similarly for diagnosing steatosis S3, the AUC of CAP (AUC: 0.68) was lower than that of AC (AUC: 0.88), and HRI (AUC: 0.88).

CONCLUSION

The AC and HRI values increased with the progression of hepatic steatosis grade, while CAP increased from S0 to S2 but not from S2 to S3. For mild steatosis diagnosis, CAP and AC showed superior diagnostic performance compared to HRI, while AC and HRI were more advantageous in differentiating moderate and severe steatosis.

Comparative study of MAFLD as a predictor of metabolic disease treatment for NAFLD

A novel concept of Metabolic Associated Fatty Liver Disease (MAFLD) was proposed, incorporating metabolic abnormalities such as obesity and diabetes, which are risk factors that affect the prognosis. Non-Alcoholic Fatty Liver Disease (NAFLD), entails fat accumulation in the liver without alcohol consumption and is often linked to obesity, insulin resistance, and metabolic syndrome. However, the broad nature of the disease concept has hindered prognosis accuracy. In this study, we assess the contribution of the impact of diagnostic criteria for MAFLD on metabolic disease progression compared to conventional diagnostic criteria for NAFLD. A total of 7159 patient who were presented to the health screening center in Tokai University Hospital both in 2015 and 2020 were included in the study. Fatty liver was diagnosed using abdominal ultrasonography. The diagnostic criteria for NAFLD were consistent with the global guidelines based on alcohol consumption. The diagnostic criteria for MAFLD were based on the International Consensus Panel. Medications (anti-hypertensive, diabetic, and dyslipidemia medications) were evaluated by self-administration in the submitted medical questionnaire. A total of 2500 (34.9%) participants were diagnosed with fatty liver (FL +), 1811 (72.4%) fit both NAFLD and MAFLD diagnostic criteria (overlap), 230 (9.2%) fit only the NAFLD diagnostic criteria (NAFLD group) and 404 (16.1%) fit the MAFLD diagnostic criteria (MAFLD group) at 2015. Over the next 5 years, medication rates increased in the NAFLD group for anti-hypertensive, + 17 (7.4%); diabetes, + 3 (1.3%); and dyslipidemia, + 32 (13.9%). In contrast, the only-MAFLD group showed a more significant increase with + 49 (12.1%), + 21 (5.2%), and + 49 (12.1%), for the respective medications, indicating a substantial rise in patients starting new medications. Our analysis of repeated health check-ups on participants revealed that the diagnostic criteria for MAFLD are more predictive of future treatment for metabolic disease than conventional diagnostic criteria for NAFLD.

Machine Learning Reveals Serum Glycopatterns as Potential Biomarkers for the Diagnosis of Nonalcoholic Fatty Liver Disease (NAFLD)

Nonalcoholic fatty liver disease (NAFLD) has emerged as the predominant chronic liver condition globally, and underdiagnosis is common, particularly in mild cases, attributed to the asymptomatic nature and traditional ultrasonography's limited sensitivity to detect early-stage steatosis. Consequently, patients may experience progressive liver pathology. The objective of this research is to ascertain the efficacy of serum glycan glycopatterns as a potential diagnostic biomarker, with a particular focus on the disease's early stages. We collected a total of 170 serum samples from volunteers with mild-NAFLD (Mild), severe-NAFLD (Severe), and non-NAFLD (None). Examination via lectin microarrays has uncovered pronounced disparities in serum glycopatterns identified by 19 distinct lectins. Following this, we employed four distinct machine learning algorithms to categorize the None, Mild, and Severe groups, drawing on the alterations observed in serum glycopatterns. The gradient boosting decision tree (GBDT) algorithm outperformed other models in diagnostic accuracy within the validation set, achieving an accuracy rate of 95% in differentiating the None group from the Mild group. Our research indicates that employing lectin microarrays to identify alterations in serum glycopatterns, when integrated with advanced machine learning algorithms, could constitute a promising approach for the diagnosis of NAFLD, with a special emphasis on its early detection.

Impact of metabolic phenotype and alcohol consumption on mortality risk in metabolic dysfunction-associated fatty liver disease: a population-based cohort study

Patients with metabolic dysfunction-associated fatty liver disease (MAFLD) often present with concomitant metabolic dysregulation and alcohol consumption, potentially leading to distinct clinical outcomes. We analyzed data from 8043 participants with MAFLD in the Thai National Health Examination Survey with linked mortality records. According to the MAFLD criteria, 1432 individuals (17.2%) were categorized as having the diabetes phenotype, 5894 (71.0%) as the overweight/obesity phenotype, and 978 (11.8%) as the lean metabolic phenotype. Over 71,145 person-years, 916 participants died. Using Cox proportional hazard models adjusting for physiological, lifestyle, and comorbid factors, both diabetes (adjusted hazards ratio [aHR] 1.59, 95% CI 1.18-2.13) and lean metabolic phenotypes (aHR 1.28, 95% CI 1.01-1.64) exhibited significantly higher mortality risk compared to the overweight/obesity phenotype. A J-shaped relationship was observed between daily alcohol consumption and the risk of all-cause mortality. Daily alcohol intake exceeding 50 g for women and 60 g for men increased the all-cause mortality risk among MAFLD individuals with the lean metabolic phenotype (aHR 3.39, 95% CI 1.02-11.29). Our study found that metabolic phenotype and alcohol consumption have interactive effects on the risk of all-cause mortality in patients with MAFLD, indicating that evaluating both factors is crucial for determining prognostic outcomes and management strategies.

Exposure to famine during early life and the risk of MAFLD during adulthood: evidence from the China Multi-Ethnic Cohort (CMEC) study

Background

Metabolic dysfunction-associated fatty liver disease (MAFLD) is the most common chronic liver disease, affecting nearly one-third of the global population. The relationship between early-life famine exposure and MAFLD remains unclear in the multiethnic region of less-developed southwest China.

Methods

A total of 18 558 participants who came from the baseline survey of the China Multi-Ethnic Cohort Study in Yunnan were included. Participants were divided into four groups according to birth year, including non-exposed (1962-1978 and 1939-1943), fetal exposed (1959-1961), childhood exposed (1949-1958) and adolescence exposed (1943-1949). Logistic regression analysis was used to explore the relationship between famine exposure in early life and the risk of MAFLD in adulthood.

Results

Experiencing the shock of early-life exposure to famine would affect adulthood MAFLD. Exposure to famine during fetal life and childhood increased the risk of MAFLD in adulthood, with this association being particularly pronounced in Bai populations. Moreover, famine exposure in males during fetal life raised the risk of MAFLD in adulthood.

Conclusion

We suggest that adequate nutrition in early life may be beneficial in preventing MAFLD in adulthood. The prevention of chronic liver disease should adopt a whole-life strategy by extending the prevention window beginning from fetal life.

Metabolic dysfunction-associated steatotic liver disease: Evolution of the final terminology

The medical term nonalcoholic fatty liver disease (NAFLD) was coined in 1986 for a condition that has since become the most prevalent liver disorder worldwide. In the last 3 years, the global professional community launched 2 consecutive efforts to purge NAFLD from the medical dictionary and recommended new terms based on disease pathophysiology rather than distinction from similar conditions featuring liver steatosis. A consensus by renowned clinical scholars primarily residing in the Asian-Pacific region introduced metabolic dysfunction-associated fatty liver disease (MAFLD) as a new name to replace NAFLD in 2020. In 2023, a nomenclature and classification resulting in the term metabolic dysfunction-associated steatotic liver disease (MASLD) was developed by a large expert panel under the auspices of leading liver societies from Europe and Americas. These marked and rapid shifts in nomenclature have garnered the attention of many researchers and clinicians across the globe due to the multilevel impact of a frequent and potentially progressive chronic liver disease in both adult and pediatric populations. The proposed terminologies differ in several ways but they have more in common than differences. They both capture key features of liver disease associated with cardiometabolic risk factors and with significant impact on all-cause and liver-related mortality. The framework of MASLD has incorporated many innovative aspects of MAFLD and while several conceptual disparities remain a work in progress, global efforts should focus on new insights into disease pathogenesis, outcome trajectories, prevention, and treatment. Here, some of these challenges are discussed to facilitate this process.

Association between Serum Ferritin Levels and Metabolic-associated Fatty Liver Disease in Adults: a Cross-sectional Study Based on the NHANES

OBJECTIVE

Ferritin, initially acting as an iron-storage protein, was found to be associated with metabolic diseases. Our study was designed to investigate the association between serum ferritin and metabolic-associated fatty liver disease (MAFLD) using data from the National Health and Nutrition Examination Survey (NHANES) of the United State of America.

METHODS

A cross-sectional study was conducted, enrolling a total of 2145 participants from the NHANES in the 2017-2018 cycles. Hepatic steatosis and liver fibrosis were assessed by ultrasound images and several non-invasive indexes. Multiple regression analysis was conducted to determine the associations between serum ferritin concentration and MAFLD and liver fibrosis.

RESULTS

The analysis revealed that participants with higher serum ferritin levels (Q3 and Q4 groups) had a higher prevalence of MAFLD than those with the lowest serum ferritin levels [Q3 vs. Q1: OR=2.17 (1.33, 3.53), P<0.05 in fatty liver index (FLI); Q4 vs. Q1: OR=3.13 (1.91, 5.13), P<0.05 in FLI]. Additionally, participants with the highest serum ferritin levels (Q4 group) displayed a higher prevalence of liver fibrosis [Q4 vs. Q1: OR=2.59 (1.19, 5.62), P<0.05 in liver stiffness measurement; OR=5.06 (1.12, 22.94), P<0.05 in fibrosis-4 index], with significantly increased risk observed in participants with concomitant diabetes [OR=7.45 (1.55, 35.72), P=0.012].

CONCLUSION

Our study revealed that elevated serum ferritin levels are associated with a higher prevalence of MAFLD and advanced liver fibrosis in patients. Elevated serum ferritin levels combined with diabetes are important risk factors for liver fibrosis.

The correlation between liver fibrosis and the 10-year estimated risk of cardiovascular disease in adults with metabolic-associated fatty liver disease: A cross-sectional study in Vietnam

BACKGROUND AND AIMS

Metabolic-associated fatty liver disease (MAFLD) emerged as a novel term replacing nonalcoholic fatty liver disease (NAFLD) in 2020. While most MAFLD patients are asymptomatic, long-term hepatic fat accumulation may lead to liver fibrosis and cardiovascular disease (CVD). Nevertheless, the relationship between MAFLD and cardiovascular (CV) risk factors remains unclear. This study aimed to assess the 10-year estimated CVD risk in individuals diagnosed with MAFLD.

METHODS

Between January 2022 and August 2023, this cross-sectional study enrolled 139 MAFLD patients. We employed the systematic coronary risk evaluation 2 (SCORE2) and the systematic coronary risk evaluation 2-older persons (SCORE2-OP) scoring systems to evaluate and categorize the 10-year CV risk. Liver fibrosis was assessed using biochemical parameters (FIB-4, AST/ALT, and APRI), and their correlation with CV risk was examined.

RESULTS

Most MAFLD patients were categorized as having high or very high CV risk based on the SCORE2 and SCORE2-OP. Liver fibrosis, measured by the FIB-4 score, significantly differed among the various CV risk groups. Moreover, FIB-4 correlated positively with SCORE2 and SCORE2-OP (r = 0.588, p < 0.001), indicating its substantial predictive ability for identifying individuals at very high CV risk (AUC = 0.765, 95% CI: 0.686-0.845, p < 0.001). A FIB-4 score of 1.275 demonstrated 81% sensitivity and 64% specificity in predicting very high CV risk among MAFLD patients.

CONCLUSION

Patients with MAFLD predominantly face high or very high CV risks, with elevated liver fibrosis associated with increased 10-year estimated CVD risk. The FIB-4 score exhibits promising predictive value for identifying MAFLD patients at very high risk of CV disease.

Genome-wide association study of metabolic dysfunction-associated fatty liver disease in a Korean population

Genome-wide association studies have identified several genetic variants associated with nonalcoholic fatty liver disease. To emphasize metabolic abnormalities in fatty liver, metabolic (dysfunction)-associated fatty liver disease (MAFLD) has been introduced; thus, we aimed to investigate single-nucleotide polymorphisms related to MAFLD and its subtypes. A genome-wide association study was performed to identify genetic factors related to MAFLD. We used a Korean population-based sample of 2282 subjects with MAFLD and a control group of 4669. We replicated the results in a validation sample which included 639 patients with MAFLD and 1578 controls. Additionally, we categorized participants into three groups, no MAFLD, metabolic dysfunction (MD)-MAFLD, and overweight/obese-MAFLD. After adjusting for age, sex, and principal component scores, rs738409 [risk allele G] and rs3810622 [risk allele T], located in the PNPLA3 gene, showed significant associations with MAFLD (P-values, discovery set = 1.60 × 10-15 and 4.84 × 10-10; odds ratios, 1.365 and 1.284, validation set = 1.39 × 10-4, and 7.15 × 10-4, odds ratios, 1.299 and 1.264, respectively). An additional SNP rs59148799 [risk allele G] located in the GATAD2A gene showed a significant association with MAFLD (P-values, discovery set = 2.08 × 10-8 and validation set = 0.034, odds ratios, 1.387 and 1.250). rs738409 was significantly associated with MAFLD subtypes ([overweight/obese-MAFLD; odds ratio (95% confidence interval), P-values, 1.515 (1.351-1.700), 1.43 × 10-12 and MD-MAFLD: 1.300 (1.191-1.416), 2.90 × 10-9]. There was a significant relationship between rs3810622 and overweight/obese-MAFLD and MD-MAFLD [odds ratios (95% confidence interval), P-values, 1.418 (1.258, 1.600), 1.21 × 10-8 and 1.225 (1.122, 1.340), 7.06 × 10-6, respectively]; the statistical significance remained in the validation set. PNPLA3 was significantly associated with MAFLD and MAFLD subtypes in the Korean population. These results indicate that genetic factors play an important role in the pathogenesis of MAFLD.

Metabolic dysfunction-associated fatty liver disease and nonalcoholic fatty liver disease from clinical to pathological characteristics: a multi-center cross-sectional study in real world

BACKGROUND

The evaluation of patients with fatty liver as defined by metabolic dysfunction-associated fatty liver disease (MAFLD) in the real world remains poorly researched. This study aimed to analyse the clinical and histological features of patients with MAFLD and nonalcoholic fatty liver disease (NAFLD) and to characterize each metabolic subgroup of MAFLD.

METHODS

A total of 2563 patients with fatty liver confirmed by ultrasonography and/or magnetic resonance tomography and/or liver biopsy-proven from three hospitals in China were included in the study. Patients were divided into different groups according to diagnostic criteria for MAFLD and NAFLD, and MAFLD into different subgroups.

RESULTS

There were 2337 (91.2%) patients fitting the MAFLD criteria, and 2095 (81.7%) fitting the NAFLD criteria. Compared to patients with NAFLD, those with MAFLD were more likely to be male, had more metabolic traits, higher liver enzyme levels, and noninvasive fibrosis scores. Among the patients with liver biopsy, the extent of advanced fibrosis in cases with MAFLD was significantly higher than those with NAFLD, 31.8% versus 5.2% (P < .001); there was no significant difference in advanced fibrosis between obese cases and lean individuals in MAFLD (P > .05); MAFLD complicated with diabetes had significantly higher advanced fibrosis than those without diabetes (43.3% and 17.2%, respectively; P < .001).

CONCLUSIONS

Patients with MAFLD have a higher degree of liver fibrosis than NAFLD patients. In addition, diabetic patients should be screened for fatty liver and liver fibrosis degree.

Advances in management of metabolic dysfunction-associated steatotic liver disease: from mechanisms to therapeutics

Metabolic dysfunction-associated steatotic liver disease (MASLD) is the leading cause of chronic liver disease that affects over 30% of the world's population. For decades, the heterogeneity of non-alcoholic fatty liver disease (NAFLD) has impeded our understanding of the disease mechanism and the development of effective medications. However, a recent change in the nomenclature from NAFLD to MASLD emphasizes the critical role of systemic metabolic dysfunction in the pathophysiology of this disease and therefore promotes the progress in the pharmaceutical treatment of MASLD. In this review, we focus on the mechanism underlying the abnormality of hepatic lipid metabolism in patients with MASLD, and summarize the latest progress in the therapeutic medications of MASLD that target metabolic disorders.

Prognosis of biopsy-confirmed metabolic dysfunction- associated steatotic liver disease: A sub-analysis of the CLIONE study

BACKGROUND/AIMS

Metabolic dysfunction-associated steatotic liver disease (MASLD) was recently proposed as an alternative disease concept to nonalcoholic fatty liver disease (NAFLD). We aimed to investigate the prognosis of patients with biopsy-confirmed MASLD using data from a multicenter study.

METHODS

This was a sub-analysis of the Clinical Outcome Nonalcoholic Fatty Liver Disease (CLIONE) study that included 1,398 patients with NAFLD. Liver biopsy specimens were pathologically diagnosed and histologically scored using the NASH Clinical Research Network system, the FLIP algorithm, and the SAF score. Patients who met at least one cardiometabolic criterion were diagnosed with MASLD.

RESULTS

Approximately 99% of cases (n=1,381) were classified as MASLD. Patients with no cardiometabolic risk (n=17) had a significantly lower BMI than patients with MASLD (20.9 kg/m2 vs. 28.0 kg/m2, P<0.001), in addition to significantly lower levels of inflammation, ballooning, NAFLD activity score, and fibrosis stage based on liver histology. These 17 patients had a median follow-up of 5.9 years, equivalent to 115 person-years, with no deaths, liver-related events, cardiovascular events, or extrahepatic cancers. The results showed that the prognosis for pure MASLD was similar to that for the original CLIONE cohort, with 47 deaths and one patient who underwent orthotopic liver transplantation. The leading cause of death was extrahepatic cancer (n=10), while the leading causes of liver-related death were liver failure (n=9), hepatocellular carcinoma (n=8), and cholangiocarcinoma (n=4).

CONCLUSION

Approximately 99% of NAFLD cases were considered MASLD based on the 2023 liver disease nomenclature. The NAFLD-only group, which is not encompassed by MASLD, had a relatively mild histopathologic severity and a favorable prognosis. Consequently, the prognosis of MASLD is similar to that previously reported for NAFLD.

Ultrasonographic findings of metabolic dysfunction-associated fatty liver disease: A comparative study with non-alcoholic fatty liver disease and clinical characteristics

PURPOSE

Metabolic dysfunction-associated fatty liver disease (MAFLD) is a new term proposed to replace non-alcoholic fatty liver disease (NAFLD). We analyzed the ultrasonographic findings of MAFLD and NAFLD.

METHODS

We conducted a retrospective cross-sectional study of subjects aged ≥19 years who underwent a health screening examination, including ultrasonography, (n = 17,066). Patients were separated into one of three groups; pure MAFLD (n = 5304), pure NAFLD (n = 579), and both NAFLD & MAFLD (n = 11,183). The outcomes were the degree of fatty liver disease and liver cirrhosis, defined by ultrasonography. In addition, the risk of ultrasonographic cirrhosis was assessed in the MAFLD group based on clinical characteristics.

RESULTS

The pure NAFLD group had a lower risk of severe fatty liver disease than the both NAFLD & MAFLD groups (0.9 % vs. 4.4 %, p < 0.001). Cirrhosis was not diagnosed in the NAFLD group. Cirrhosis was more common in the pure MAFLD group than in the both NAFLD & MAFLD group (0.3 % vs. 0.0 %, p < 0.001). In the MAFLD group, multivariable analysis showed that diagnosis by hepatic steatosis index (Odds ratio [OR], 12.39; 95 % confidence interval [CI], 3.40-45.19; p < 0.001) or significant alcohol intake (OR, 9.58, 95 % CI, 1.93-47.61; p = 0.006) was independently associated with risk of liver cirrhosis on ultrasonography.

CONCLUSION

Liver cirrhosis was more frequently identified on ultrasonography in patients with MAFLD than in NAFLD. MAFLD diagnosed using the hepatic steatosis index or significant alcohol intake is a risk factor for liver cirrhosis.

Natural history of metabolic dysfunction-associated steatotic liver disease

Metabolic dysfunction-associated steatotic liver disease (MASLD), which has been the term for non-alcoholic fatty liver disease (NAFLD) since June 2023, represents the most common liver disease worldwide and is a leading cause of liver-related morbidity and mortality. A thorough knowledge of the disease's natural history is required to promptly stratify patients' risks, since MASLD is a multifaceted disorder with a broad range of clinical phenotypes. The histological disease spectrum ranges from isolated hepatic steatosis, currently named as metabolic dysfunction-associated steatotic liver (MASL), to metabolic dysfunction-associated steatohepatitis (MASH) and eventually may accumulate hepatic fibrosis and develop cirrhosis and/or hepatocellular carcinoma (HCC). Several risk factors for fibrosis progression have been identified, while the disease's progression displays notable dynamism and bidirectionality. When compared to the general population, all MASLD histological stages are substantially related with greater overall mortality, and this association exhibits a disease severity-dependent pattern. Interestingly, the fibrosis stage is the most accurate predictor of mortality among MASLD patients. The mortality attributed to MASLD predominantly stems from issues linked with the liver and cardiovascular system, as well as HCC and extrahepatic cancers. In light of the disease natural course, it is crucial to prioritize the identification of at-risk patients for disease progression in order to effectively address and change modifiable risk factors, hence mitigating disease complications. Further investigation is required to define the phenotype of rapid progressors more precisely as well as to improve risk stratification for HCC in non-cirrhotic individuals.

Global incidence of adverse clinical events in non-alcoholic fatty liver disease: A systematic review and meta-analysis

BACKGROUND/AIMS

Nonalcoholic fatty liver disease (NAFLD) is associated with a multitude of adverse outcomes. We aimed to estimate the pooled incidence of NAFLD-related adverse events.

METHODS

We performed a systematic review and meta-analysis of cohort studies of adults with NAFLD to evaluate the pooled incidence of adverse events.

RESULTS

19,406 articles were screened, 409 full-text articles reviewed, and 79 eligible studies (1,377,466 persons) were included. Mean age was 51.47 years and body mass index 28.90 kg/m2. Baseline comorbidities included metabolic syndrome (41.73%), cardiovascular disease (CVD) (16.83%), cirrhosis (21.97%), and nonalcoholic steatohepatitis (NASH) (58.85%). Incidence rate per 1,000 person-years for mortality included: all-cause (14.6), CVD-related (4.53), non-liver cancer-related (4.53), and liver-related (3.10). Incidence for liver-related events included overall (24.3), fibrosis progression (49.0), cirrhosis (10.9), liver transplant (12.0), and hepatocellular carcinoma (HCC) (3.39). Incidence for non-liver events included metabolic syndrome (25.4), hypertension (25.8), dyslipidemia (26.4), diabetes (19.0), CVD (24.77), renal impairment (30.3), depression/anxiety (29.1), and non-liver cancer (10.5). Biopsy-proven NASH had higher incidence of HCC (P=0.043) compared to non-NASH. Higher rates of CVD and mortality were observed in North America and Europe, hypertension and non-liver cancer in North America, and HCC in Western Pacific/Southeast Asia (P<0.05). No significant differences were observed by sex. Time-period analyses showed decreasing rates of cardiovascular and non-liver cancer mortality and increasing rates of decompensated cirrhosis (P<0.05).

CONCLUSION

People with NAFLD have high incidence of liver and non-liver adverse clinical events, varying by NASH, geographic region, and time-period, but not sex.

Dietary inflammatory index is associated with metabolic dysfunction-associated fatty liver disease among United States adults

Background

Metabolic dysfunction-associated fatty liver disease (MAFLD) is presently the most prevalent chronic liver disorder globally that is closely linked to obesity, dyslipidemia metabolic syndrome, and type 2 diabetes mellitus (T2DM). Its pathogenesis is strongly associated with inflammation, and diet is a major factor in reducing inflammation. However, current research has focused primarily on exploring the relationship between diet and NAFLD, with less research on its link to MAFLD.

Methods

In this research, using dietary inflammatory index (DII) as a measure to assess dietary quality, we analyzed the relationship between diet and MAFLD. Data from the National Health and Nutrition Examination Survey (NHANES) 2017-2018, including 3,633 adults with complete DII and MAFLD, were used to develop cross-sectional analyses. Logistic regression analysis was adapted for investigating the relationship between DII and MAFLD development. Additionally, subgroup analysis and threshold effect analysis were carried out.

Results

A positive link between DII and MAFLD was found in the fully adjusted model (OR = 1.05; 95%CI, 1.00-1.11, p < 0.05). Subgroup analysis indicated that there was no significant dependence for the connection between DII and MAFLD except for the subgroup stratified by age. Compared with other age groups, people with MAFLD had 20% higher DII scores than non-MAFLD participants in those aged 20-41 years old (OR = 1.20; 95%CI, 1.08-1.33, p < 0.001). Furthermore, we found a U-shaped curve with an inflection point of 3.06 illustrating the non-linear connection between DII and MAFLD.

Conclusion

As a result, our research indicates that pro-inflammatory diet may increase the chance of MAFLD development, thus improved dietary patterns as a lifestyle intervention is an important strategy to decrease the incidence of MAFLD.