Nonalcoholic fatty liver disease in patients with acute ischemic stroke is associated with more severe stroke and worse outcome

Increased Hepatorenal Index Is Associated with the Risk of Developing Stroke in Patients with Nonalcoholic Fatty Liver Disease

OBJECTIVE

The aim of this study was to examine the relationship between the sonographic hepatorenal index and stroke risk in patients with nonalcoholic fatty liver disease (NAFLD).

METHODS

From December 2023 to July 2024, 72 NAFLD patients with stroke, 53 stroke-free NAFLD patients, and 54 healthy controls were enrolled in our study. The hepatorenal index was calculated as the ratio of the echo intensity of the liver to that of the renal cortex. The mean brightness values for one region of interest within the right hepatic lobe and the other size-matched region at the same depth of field within the right kidney were obtained with two-dimensional ultrasound and a 1- to 6-MHz convex array probe. Laboratory tests were performed with a Cobas 8000 automatic biochemical analyzer. Univariate and multivariate analyses were adopted to analyze the risk factors for stroke in NAFLD patients.

RESULTS

NAFLD patients had a greater hepatorenal index than healthy controls did (P < 0.05). Additionally, NAFLD patients with stroke had an even greater hepatorenal index than did those with stroke-free NAFLD (P < 0.001). Multivariate regression analysis further revealed that the hepatorenal index was independently associated with stroke risk in NAFLD patients (β = 8.897, P < 0.001) after controlling for age, body mass index, systolic blood pressure, and serum glucose, total cholesterol, alanine transaminase, and creatinine concentrations. Receiver operating characteristic curve analysis revealed a sensitivity of 62.5% and specificity of 95.3% for the hepatorenal index, with a cutoff value of 1.255 and an area under the curve of 0.80.

CONCLUSION

The increased sonographic hepatorenal index could be an independent predictor of stroke development in patients with NAFLD.

Association of liver fibrosis-4 index with functional outcomes in chinese patients with acute ischemic stroke undergoing mechanical thrombectomy

This study aimed to investigate the association between the Fibrosis-4 (FIB-4) index and functional outcomes and hemorrhagic complications in patients with large vessel occlusion acute ischemic stroke (LVO-AIS) treated with mechanical thrombectomy (MT). In this single-center retrospective cohort study, we consecutively enrolled patients with LVO-AIS who underwent MT between January 2018 and February 2024. The primary endpoint was poor functional outcome at 90 days (modified Rankin Scale score 3-6). Secondary endpoints included hemorrhagic transformation (HT) and symptomatic intracranial hemorrhage (sICH). Multivariable logistic regression models and restricted cubic spline analyses were used to evaluate the association between FIB-4 index and outcomes after adjusting for potential confounders. Among 421 patients, 254 (60.33%) had poor outcomes, 197 (46.79%) developed HT, and 76 (18.05%) experienced sICH. After adjustment for confounding factors, each unit increase in FIB-4 index was associated with a 38% higher risk of poor outcome (P = 0.013). This association showed significant nonlinearity (P-nonlinear = 0.010), with risk increasing exponentially beyond a FIB-4 threshold of 2.4. Advanced fibrosis (FIB-4 ≥ 2.67) was independently associated with poor outcomes (P = 0.024). FIB-4 index independently predicts poor functional outcomes in LVO-AIS patients. This readily available biomarker may help identify high-risk patients who could benefit from enhanced monitoring and individualized treatment strategies.

Liver Metabolism in Ischemic Stroke

Focal brain damage and neurological deficits are the direct consequences of acute ischemic stroke (AIS). In addition, cerebral ischemia causes systemic alterations across peripheral organs. Dysregulation of the autonomic and endocrine systems as well as the release of brain-derived pro-inflammatory mediators trigger a peripheral immune response and systemic inflammation. As a key metabolic organ, the liver contributes not only to post-stroke immunosuppression but also to stress-induced hyperglycemia. At the same time, increased ketogenesis and glutathione production in the liver are likely to combat inflammation and oxidative stress after AIS. The closely linked lipid metabolism could regulate both glucose and glutathione homeostasis. In addition, increased hepatic very low-density lipoprotein (VLDL) secretion may improve the availability of phospholipids, polyunsaturated fatty acids (PUFAs) and glutathione after AIS. This review provides an overview of recent findings concerning ischemic stroke and the liver and discusses the therapeutic potential of targeting the hepatic metabolism to improve patient outcome after stroke.

Effect of statin use on liver enzymes and lipid profile in patients with non-alcoholic fatty liver disease (NAFLD)

BACKGROUND

Non-alcoholic fatty liver disease (NAFLD) is an independent risk factor for cardiovascular disease (CVD). Statins are recommended for treatment of dyslipidemia to reduce the overall cardiovascular risk in patients with NAFLD. However, statin treatment was underutilized and the effect of statins on liver enzymes remained unclear in this patient population.

OBJECTIVES

This study aimed to provide real-world evidence of the safety and effect of statin use in patients with NAFLD.

METHODS

We conducted a cross-sectional survey study of adults with NAFLD using pooled data from the US NHANES database 2009-2018. NAFLD was defined by Fatty Liver Index (FLI) ≥ 60 and United States Fatty Liver Index (USFLI) ≥ 30. Multivariate regression analyses adjusted for baseline clinical and demographic characteristics were performed to compare the liver enzymes and lipid profile between statin and non-statin users.

RESULTS

The study included 2,533 adults with NAFLD, representing 22.6 million individuals in the US, with 27% receiving statin treatment between 2009 and 2018. The mean differences of liver enzymes for AST, ALT, ALP, and GGT between statin and non-statin users were -0.86 (p=0.539), -3.49 (p=0.042), -0.25 (p=0.913), and 0.57 (p=0.901), respectively. In individuals with NAFLD and dyslipidemia, total cholesterol and LDL levels were significantly lower in statin users compared to non-statin users (mean difference, -28.9; p<0.001 and -27.7; p<0.001).

CONCLUSION

The use of statins was not associated with elevated liver enzymes in patients with NAFLD. Significantly lower levels of ALT, total cholesterol, and LDL were observed in statin users compared to non-statin users.

Nonalcoholic Fatty Liver Disease as a Potential Risk Factor for Cardiovascular Disease in Patients with Type 2 Diabetes: A Prospective Cohort Study

Methods and Results

In this prospective cohort study, 1197 patients with type 2 diabetes (T2D) were divided into two groups (360 patients with NAFLD and 847 without NAFLD) and were followed for a median of 5 years for the incidence of CVD. Cox regression analysis was used to assess the association between NAFLD, liver enzyme level, aspartate aminotransferase to platelet ratio index (APRI), and the incidence risk of CVD and its subgroups (i.e., myocardial infarction, chronic heart disease, coronary artery bypass grafting, and percutaneous coronary intervention). There was a significant positive association between CVD incidence and NAFLD (HR = 1.488, 95% CI = 1.041-2.124, p value = 0.029). Although patients with NAFLD had higher levels of ALT and AST levels (p value = <0.001), there was no significant association between liver enzymes and the incidence risk of CVD when adjusted for different variables. Furthermore, NAFLD was associated with NAFLD APRI Q (2), APRI Q (3), and APRIQ (4) (1.365 (1.046-1.781), 1.623 (1.234-2.135), and 3.373 (2.509-4.536)), respectively.

Conclusion

NAFLD increased the incidence risk of CVD in T2D. However, there was no association between liver enzymes (ALT, AST, ALK-P, and GGT) and a higher incidence risk of CVD in T2D when adjusted for confounding variables.

Global epidemiology of type 2 diabetes in patients with NAFLD or MAFLD: a systematic review and meta-analysis

BACKGROUND

Non-alcoholic fatty liver disease (NAFLD) and metabolic-associated fatty liver disease (MAFLD) shares common pathophysiological mechanisms with type 2 diabetes, making them significant risk factors for type 2 diabetes. The present study aimed to assess the epidemiological feature of type 2 diabetes in patients with NAFLD or MAFLD at global levels.

METHODS

Published studies were searched for terms that included type 2 diabetes, and NAFLD or MAFLD using PubMed, EMBASE, MEDLINE, and Web of Science databases from their inception to December 2022. The pooled global and regional prevalence and incidence density of type 2 diabetes in patients with NAFLD or MAFLD were evaluated using random-effects meta-analysis. Potential sources of heterogeneity were investigated using stratified meta-analysis and meta-regression.

RESULTS

A total of 395 studies (6,878,568 participants with NAFLD; 1,172,637 participants with MAFLD) from 40 countries or areas were included in the meta-analysis. The pooled prevalence of type 2 diabetes among NAFLD or MAFLD patients was 28.3% (95% confidence interval 25.2-31.6%) and 26.2% (23.9-28.6%) globally. The incidence density of type 2 diabetes in NAFLD or MAFLD patients was 24.6 per 1000-person year (20.7 to 29.2) and 26.9 per 1000-person year (7.3 to 44.4), respectively.

CONCLUSIONS

The present study describes the global prevalence and incidence of type 2 diabetes in patients with NAFLD or MAFLD. The study findings serve as a valuable resource to assess the global clinical and economic impact of type 2 diabetes in patients with NAFLD or MAFLD.

Gut microbiota alterations are associated with functional outcomes in patients of acute ischemic stroke with non-alcoholic fatty liver disease

Introduction

Patients with acute ischemic stroke (AIS) with non-alcoholic fatty liver disease (NAFLD) frequently have poor prognosis. Many evidences suggested that the changes in gut microbiota may play an important role in the occurrence and development of AIS patients with NAFLD. The purpose of this study was to explore microbial characteristics in patients of AIS with NAFLD, and the correlation between gut microbiota and functional outcomes.

Methods

The patients of AIS were recruited and divided into NAFLD group and non-NAFLD group. The stool samples and clinical information were collected. 16 s rRNA sequencing was used to analyze the characteristics of gut microbiota. The patients of AIS with NAFLD were followed-up to evaluate the functional outcomes of disease. The adverse outcomes were determined by modified Rankin scale (mRS) scores at 3 months after stroke. The diagnostic performance of microbial marker in predicting adverse outcomes was assessed by recipient operating characteristic (ROC) curves.

Results

Our results showed that the composition of gut microbiota between non-NAFLD group and NAFLD group were different. The characteristic bacteria in the patients of AIS with NAFLD was that the relative abundance of Dorea, Dialister, Intestinibacter and Flavonifractor were decreased, while the relative abundance of Enorma was increased. Moreover, the characteristic microbiota was correlated with many clinical parameters, such as mRS scores, mean arterial pressure and fasting blood glucose level. In addition, ROC models based on the characteristic microbiota or the combination of characteristic microbiota with independent risk factors could distinguish functional dependence patients and functional independence patients in AIS with NAFLD (area under curve is 0.765 and 0.882 respectively).

Conclusion

These findings revealed the microbial characteristics in patients of AIS with NAFLD, and further demonstrated the predictive capability of characteristic microbiota for adverse outcomes in patients of AIS with NAFLD.

The prothrombotic tendency of metabolic-associated fatty liver disease

Our understanding of the function of the liver has evolved over the centuries. Early theories proposing that the liver could be used to divine the future have been superseded by our current knowledge of the importance of the liver in processes such as digestion and detoxification. Similarly, although liver disease was previously associated with only an increased risk of bleeding, there is now a substantial body of evidence demonstrating an increased thrombotic potential in patients with this disease. Metabolic-associated fatty liver disease (MAFLD) is increasing in frequency and is likely to overtake alcoholic liver disease as the primary indication for liver transplant in the future. In this review, we discuss the evidence linking liver disease, and MAFLD in particular, with arterial and venous thromboembolic disease. We review the safety and efficacy of anticoagulation in advanced liver disease and consider whether antithrombotic agents could slow or halt the progression of fibrosis in MAFLD.

Management of Stroke in Patients With Chronic Liver Disease: A Practical Review

Chronic liver disease (CLD) is a highly prevalent condition. There is burgeoning recognition that there are many people with subclinical liver disease that may nonetheless be clinically significant. CLD has a variety of systemic aberrations relevant to stroke, including thrombocytopenia, coagulopathy, elevated liver enzymes, and altered drug metabolism. There is a growing body of literature on the intersection of CLD and stroke. Despite this, there have been few efforts to synthesize these data, and stroke guidelines provide scant guidance on this topic. To fill this gap, this multidisciplinary review provides a contemporary overview of CLD for the vascular neurologist while appraising data regarding the impact of CLD on stroke risk, mechanisms, and outcomes. Finally, the review addresses acute and chronic treatment considerations for patients with stroke-ischemic and hemorrhagic-and CLD.

Application of noninvasive test (acoustic attenuation imaging and ultrasonic shear wave elastography) to grade nonalcoholic fatty liver disease: An observational study

The aim of this study was to validate the diagnostic efficacy of acoustic attenuation imaging (ATI) and ultrasonic shear wave elastography (SWE) in classifying nonalcoholic fatty liver disease (NAFLD). A total of 100 patients with NAFLD were recruited from our hospital between January 2021 and December 2022. Patient demographics and clinical data were collected, and 2-dimensional ultrasound was used to screen patients based on liver echo characteristics. Patients without liver space-occupying lesions underwent routine ultrasound examinations. Imaging or serology was used to confirm the presence of fatty liver in patients or healthy individuals. Patients with alcoholic liver disease (alcohol equivalent content < 20 g/day for women, <30 g/day for men), as well as those with lenticular degeneration, total parenteral nutrition, autoimmune liver disease, drug-induced hepatitis, and viral hepatitis, were excluded from the study. Out of the 100 included patients, 24 had normal liver, 21 had mild fatty liver, 30 had moderate fatty liver, and 25 had severe fatty liver. There were age differences between the normal group and patients with mild fatty liver, and the average body mass index (BMI) varied across the 4 groups. As the severity of the disease increased, the average BMI also increased (P < .05). The ATI scores and SWE scores differed significantly among the different groups (P < .05), with both scores showing an upward trend as the fatty liver condition worsened. Correlation analysis revealed positive correlations between ATI and SWE scores and the degree of fatty liver (P < .05), positive correlations with BMI (P < .05), and negative correlations with high-density lipoprotein cholesterol expression (P < .05). The area under the curve (AUC) for the ATI score in diagnosing different degrees of fatty liver was > 0.750, and the AUC for the SWE score was also > 0.750. The AUC for SWE score in diagnosing different degrees of fatty liver ranged from 1.01 to 4.57, while the combined AUC for ATI and SWE scores was > 0.850, with respective cutoff values of 3.62, 5.72, and 7.57 based on the maximum approximate entry index. The combination of ATI and SWE has a significant impact on the grading diagnosis of NAFLD, and its application can be extended to clinical practice.

The nonalcoholic fatty liver risk in prediction of unfavorable outcome after stroke: A nationwide registry analysis

Few researches have looked at the relationship between nonalcoholic fatty liver disease (NAFLD) at the time of admission and the long-term outcomes of patients suffering from acute ischemic stroke (AIS). We aimed to probe the relationship between NAFLD risk evaluated by NAFLD indices and long-term endpoints, along with the prognostic value of merging NAFLD indices with established risk markers for the prognosis of AIS patients. The fatty liver index (FLI) and the Hepatic steatosis index (HSI) were used to evaluate NAFLD risk in the Third China National Stroke Registry (CNSR-III), a large, prospective, national, multicenter cohort registry study. NAFLD was defined as FLI ≥35 for males and FLI ≥ 20 for females, as well as HSI>36. Death or major disability (modified Rankin Scale score ≥3) were the primary outcomes following the beginning of a stroke. On patient outcomes, the prognostic performance of two objective NAFLD parameters was evaluated. NAFLD was detected in 32.10-51.90% of AIS patients. After 1-year, 14.5% of the participants had died or suffered a severe outcome. After controlling for known risk factors, NAFLD was associated with a modest probability of adverse outcome (odds ratio,0.72[95% CI, 0.61-0.86] for FLI; odds ratio,0.68[95% CI, 0.55-0.85] for HSI). The inclusion of the two NAFLD indicators in the conventional prediction model was justified by the integrated discrimination index, continuing to increase the model's overall predictive value for long-term adverse outcomes. NAFLD risk was linked to a lower risk of long-term death or major disability in people with AIS. The predictive value of objective NAFLD after AIS was demonstrated in our study.

White matter hyperintensities burden in the frontal regions is positively correlated to the freezing of gait in Parkinson's disease

Objective

Previous studies have reported that white matter hyperintensities (WMHs) are associated with freezing of gait (FOG), but it is not clear whether their distribution areas have correlations with FOG in Parkinson's disease (PD) and the potential influencing factors about WMHs.

Methods

Two hundred and forty-six patients with PD who underwent brain MRI were included. Participants were divided into PD with FOG (n = 111) and PD without FOG (n = 135) groups. Scheltens score was used to assess the WMHs burden in the areas of deep white matter hyperintensities (DWMHs), periventricular hyperintensities (PVHs), basal ganglia hyperintensities (BGHs), and infratentorial foci of hyperintensities (ITF). Whole brain WMHs volume was evaluated by automatic segmentation. Binary logistic regression was used to evaluate relationships between WMHs and FOG. The common cerebrovascular risk factors that may affect WMHs were evaluated by mediation analysis.

Results

There were no statistical differences between PD with and without FOG groups in whole brain WMHs volume, total Scheltens score, BGHs, and ITF. Binary logistic regression showed that the total scores of DWMHs (OR = 1.094; 95% CI, 1.001, 1.195; p = 0.047), sum scores of PVHs and DWMHs (OR = 1.080; 95% CI, 1.003, 1.164; p = 0.042), especially the DWMHs in frontal (OR = 1.263; 95% CI, 1.060, 1.505 p = 0.009), and PVHs in frontal caps (OR = 2.699; 95% CI, 1.337, 5.450; p = 0.006) were associated with FOG. Age, hypertension, and serum alkaline phosphatase (ALP) are positively correlated with scores of DWMHs in frontal and PVHs in frontal caps.

Conclusion

These results indicate that WMHs distribution areas especially in the frontal of DWMHs and PVHs play a role in PD patients with FOG.

Therapeutic effects of CD133 + Exosomes on liver function after stroke in type 2 diabetic mice

Background and purpose

Non-alcoholic fatty liver disease (NAFLD) is known to adversely affect stroke recovery. However, few studies investigate how stroke elicits liver dysfunction, particularly, how stroke in type 2 diabetes mellitus (T2DM) exacerbates progression of NAFLD. In this study, we test whether exosomes harvested from human umbilical cord blood (HUCBC) derived CD133 + cells (CD133 + Exo) improves neuro-cognitive outcome as well as reduces liver dysfunction in T2DM female mice.

Methods

Female, adult non-DM and T2DM mice subjected to stroke presence or absence were considered. T2DM-stroke mice were randomly assigned to receive PBS or Exosome treatment group. CD133 + Exo (20 μg/200 μl PBS, i.v.) was administered once at 3 days after stroke. Evaluation of neurological (mNSS, adhesive removal test) and cognitive function [novel object recognition (NOR) test, odor test] was performed. Mice were sacrificed at 28 days after stroke and brain, liver, and serum were harvested.

Results

Stroke induces severe and significant short-term and long-term neurological and cognitive deficits which were worse in T2DM mice compared to non-DM mice. CD133 + Exo treatment of T2DM-stroke mice significantly improved neurological function and cognitive outcome indicated by improved discrimination index in the NOR and odor tests compared to control T2DM-stroke mice. CD133 + Exo treatment of T2DM stroke significantly increased vascular and white matter/axon remodeling in the ischemic brain compared to T2DM-stroke mice. However, there were no differences in the lesion volume between non-DM stroke, T2DM-stroke and CD133 + Exo treated T2DM-stroke mice. In T2DM mice, stroke induced earlier and higher TLR4, NLRP3, and cytokine expression (SAA, IL1β, IL6, TNFα) in the liver compared to heart and kidney, as measured by Western blot. T2DM-stroke mice exhibited worse NAFLD progression with increased liver steatosis, hepatocellular ballooning, fibrosis, serum ALT activity, and higher NAFLD Activity Score compared to T2DM mice and non-DM-stroke mice, while CD133 + Exo treatment significantly attenuated the progression of NAFLD in T2DM stroke mice.

Conclusion

Treatment of female T2DM-stroke mice with CD133 + Exo significantly reduces the progression of NAFLD/NASH and improves neurological and cognitive function compared to control T2DM-stroke mice.

Association between Metabolic Dysfunction-associated Fatty Liver Disease and Cognitive Impairment

BACKGROUND AND AIMS

Metabolic dysfunction-associated fatty liver disease (MAFLD) is a newly proposed term based on modified criteria. Although nonalcoholic fatty liver disease (NAFLD) has been well-documented as a multisystem disease, research on the correlation of MAFLD and extra-hepatic diseases is limited. This study aimed to clarify the association of MAFLD, as well as NAFLD status with cognitive function.

METHODS

A total of 5,662 participants 20-59 years of age who underwent cognitive tests and liver ultrasonography in the Third National Health and Nutrition Examination Survey were included in the analysis. Cognitive function was evaluated using three computer-administered tests, the serial digit learning test (SDLT), the simple reaction time test (SRTT) and the symbol digit substitution test (SDST).

RESULTS

Participants with MAFLD had significantly poorer performance on the SRTT [odds ratio (OR) 1.47, 95% confidence interval (CI): 1.14-1.89)]. MAFLD with moderate-severe liver steatosis was associated with higher risks of scoring low in the SDLT (OR 1.37, 95% CI: 1.04-1.82) and SRTT (OR 1.55, 95% CI: 1.19-2.02). NAFLD combined with metabolic dysfunction, instead of NAFLD without metabolic disorders, was associated an increased risk of a low SRTT score (OR 1.44, 95% CI: 1.10-1.82). MAFLD patients had a high probability of fibrosis, prediabetes, and diabetes and were also significantly associated with increased risks based on the SDST or SRTT score.

CONCLUSIONS

MAFLD was significantly associated with increased risk of cognitive impairment, especially among MAFLD patients with a high degree of liver fibrosis, moderate-severe steatosis, or hyperglycemia.

Linking Nonalcoholic Fatty Liver Disease and Brain Disease: Focusing on Bile Acid Signaling

A metabolic illness known as non-alcoholic fatty liver disease (NAFLD), affects more than one-quarter of the world's population. Bile acids (BAs), as detergents involved in lipid digestion, show an abnormal metabolism in patients with NAFLD. However, BAs can affect other organs as well, such as the brain, where it has a neuroprotective effect. According to a series of studies, brain disorders may be extrahepatic manifestations of NAFLD, such as depression, changes to the cerebrovascular system, and worsening cognitive ability. Consequently, we propose that NAFLD affects the development of brain disease, through the bile acid signaling pathway. Through direct or indirect channels, BAs can send messages to the brain. Some BAs may operate directly on the central Farnesoid X receptor (FXR) and the G protein bile acid-activated receptor 1 (GPBAR1) by overcoming the blood-brain barrier (BBB). Furthermore, glucagon-like peptide-1 (GLP-1) and the fibroblast growth factor (FGF) 19 are released from the intestine FXR and GPBAR1 receptors, upon activation, both of which send signals to the brain. Inflammatory, systemic metabolic disorders in the liver and brain are regulated by the bile acid-activated receptors FXR and GPBAR1, which are potential therapeutic targets. From a bile acid viewpoint, we examine the bile acid signaling changes in NAFLD and brain disease. We also recommend the development of dual GPBAR1/FXR ligands to reduce side effects and manage NAFLD and brain disease efficiently.

Aspartate aminotransferase to alanine aminotransferase ratio and clinical outcomes after acute ischemic stroke: the CNSR-III registry

Elevated aspartate aminotransferase-to-alanine aminotransferase ratio (AAR) has been associated with cardiovascular diseases and mortality. The clinical significance of AAR in the prognosis of stroke has yet to be established. We aimed to investigate the associations between AAR levels and clinical outcomes in acute ischemic stroke (AIS) or transient ischemic attack (TIA). Patients with AIS or TIA in the Third China National Stroke Registry (CNSR-III) were divided into four groups by quartiles of AAR, and two groups according to AAR < 1 and AAR ≥ 1. Multivariable Cox regression for all-cause mortality and logistic regression for poor functional outcome (modified Rankin Scale, mRS 3-6/2-6) were adopted to explore the associations between AAR and clinical outcomes at 3 months and 1 year. Among 10,877 included patients, the median AAR was 1.06 (interquartile range [IQR], 0.82 to 1.36). In the multivariable-adjusted model, patients in the fourth AAR quartile had higher risk of all-cause mortality within 3 months and 1 year (hazard ratio [HR] 2.08, 95% confidence interval [CI] 1.25 to 3.47; HR 2.26, 95% CI 1.55 to 3.27), and mRS 3-6/2-6 at 1 year (odds ratio [OR] 1.29, 95% CI 1.07 to 1.55; OR 1.20, 95% CI 1.02 to 1.42), compared with those in the first quartile. Similar associations were also observed when AAR ≥ 1 compared with AAR < 1. Elevated AAR was associated with higher risk of all-cause mortality and poor functional outcome after AIS or TIA, and should be carefully assessed after admission.

Hepatic Fibrosis Is a Risk Factor for Greater Severity and Worse Outcome of Acute Ischemic Stroke

Background: Nonalcoholic fatty liver disease, particularly in the presence of hepatic fibrosis, is associated with an increased risk of cardiovascular events, including ischemic stroke. However, it is unclear whether hepatic fibrosis is associated with the severity and outcome of acute ischemic stroke. Aim: To evaluate the relationship between hepatic fibrosis and the severity at admission and in-hospital outcome of acute ischemic stroke. Patients and methods: We prospectively studied all patients who were admitted to our department with acute ischemic stroke between September 2010 and February 2018 (n = 1107; 42.1% males, age 79.8 ± 7.2 years). The severity of stroke was assessed at admission with the National Institutes of Health Stroke Scale (NIHSS). Severe stroke was defined as NIHSS ≥ 21. The presence of hepatic fibrosis was evaluated with the Fibrosis-4 index (FIB-4). The outcome was assessed with dependency at discharge (modified Rankin Scale between 2 and 5) and with in-hospital mortality. Results: Patients with severe stroke had a higher FIB-4 index than patients with non-severe stroke (2.7 ± 1.7 and 2.3 ± 1.4, respectively; p < 0.05). Independent risk factors for severe IS were age (relative risk (RR) 1.064, 95% confidence interval (CI) 1.030−1.100, p < 0.001), female sex (RR 1.723, 95% CI 1.100−2.698, p = 0.012), atrial fibrillation (RR 1.869, 95% CI 1.234−2.831, p = 0.002), diastolic blood pressure (DBP) (RR 1.019, 95% CI 1.006−1.033, p = 0.001), and the FIB-4 index (RR 1.130, 95% CI 1.007−1.268, p = 0.022). At discharge, 64.2% of patients were dependent. The FIB-4 index did not differ between patients who were dependent and those who were independent at the time of discharge (2.3 ± 1.5 and 2.1 ± 1.2, respectively; p = 0.061). During hospitalization, 9.8% of patients died. Patients who died during hospitalization had a higher FIB-4 index than those who were discharged (2.9 ± 1.8 and 2.3 ± 1.4, respectively; p < 0.005). Independent risk factors for in-hospital mortality were DBP (RR 1.022, 95% CI 1.010−1.034, p < 0.001), serum glucose levels (RR 1.004, 95% CI 1.001−1.007, p = 0.007), serum triglyceride levels (RR 0.993, 95% CI 0.987−0.999, p = 0.023), NIHSS (RR 1.120, 95% CI 1.092−1.149, p < 0.001), and the FIB-4 index (RR 1.169, 95% CI 1.060−1.289, p = 0.002). Conclusions: Hepatic fibrosis, evaluated with the FIB-4 index, appears to be associated with more severe ischemic stroke and might also represent an independent risk factor for in-hospital mortality in patients admitted with acute ischemic stroke.

MCP1, CRP and Procalcitonin as Novel Diagnostic Markers in Cirrhotic Patients with Spontaneous Bacterial Peritonitis

Background & Aims:

The aim of the study was to evaluate serum c-reactive protein (CRP), ascitic procalcitonin (PCT) and monocyte chemotactic protein-1 (MCP-1) in the diagnosis of spontaneous bacterial peritonitis (SBP) in cirrhotic patients.

Methods:

A cross-sectional analytic study that included 199 patients with decompensated cirrhosis (101 with SBP and 98 without SBP). Patients were classified according to Child-Pugh criteria. Ascitic PCT and MCP-1 were measured by enzyme-linked immunosorbent assay. Serum CRP, liver and renal functions were assessed.

Results:

Three markers are significantly elevated in SBP patients than those without ascites. Using the ROC curve at AUC 0.883 and a cut-off value of >186 ng/ml, the diagnostic performance of ascitic MCP-1 level was higher than CRP (AUC 0.562) and ascitic fluid procalcitonin (AUC 0.751) in the diagnosis of SBP. The sensitivity and specificity were 86.15% and 79.59% at the cutoff of 186 ng/ml for MCP-1, 65.4 and 75.5 at ≥ 1 ng/ml for PCT, and 52.5 and 64.3, respectively for at 11.2 mg/dl CRP.

Conclusion:

Ascitic MCP-1 has a better diagnostic value with higher sensitivity and specificity in diagnosis SBP compared to CRP and procalcitonin which has higher diagnostic accuracy than CRP. Further studies with a large number will be necessary to evaluate the usefulness of these markers in diagnosis, follow-up and relation to morbidity and mortality of SBP patients.

A combined association of serum uric acid, alanine aminotransferase and waist circumference with non-alcoholic fatty liver disease: a community-based study

Background

Increasing evidence has supported that serum uric acid (SUA), alanine aminotransferase (ALT) and waist circumference (WC) are associated with the occurrence of non-alcoholic fatty liver disease (NAFLD). However, the combined role of these factors in early screening of NAFLD has not been investigated. We aimed to de lineate this role in a community-based population.

Methods

Binary logistic regression was used to explore the correlations of SUA, ALT and WC with NAFLD risk. The goodness of fit and discriminative ability of the model were evaluated by the Hosmer-Lemeshow test and area under the receiver operating characteristic curve (AUROC), respectively.

Results

Logistic regression analysis indicated that elevated SUA (adjusted odds ratio (OR) = 2.44, 95% confidence interval (CI) [1.76-3.38]), ALT (adjusted OR = 4.98, 95% CI [3.41-7.27]) and WC (adjusted OR = 3.22, 95% CI [2.01-5.16]) were facilitating factors for incident NAFLD after fully adjusted for related confounders. In addition, the risk of NAFLD followed linear trend s with increasing levels of these three indicators (all P _trend < 0.001). The risk assessment model consisting of SUA, ALT, WC and demographics showed useful discrimination by AUROC being 0.825 (95% CI [0.811-0.838]) and good performance of calibration (P = 0.561).

Conclusions

SUA, ALT and WC were all associated with NAFLD, independent of known risk factors. The simple model composed of these indicators showed good performance in the Chinese population, which may be applicable for appraisal of NAFLD risk in primary healthcare.

NAFLD as a continuous driver in the whole spectrum of vascular disease

Vascular disease is the prime determinant to cardiovascular morbidities and mortalities, which comprises the early vascular damage and subsequent cardiovascular events. Non-alcohol Fatty Liver Disease (NAFLD) is a systemic metabolic disorder that drives the progression of vascular disease through complex interactions. Although a causal relationship between NAFLD and cardiovascular disease (CVD) has not been established, a growing number of epidemiological studies have demonstrated an independent association between NAFLD and early vascular disease and subsequent cardiovascular events. In addition, mechanistic studies suggest that NAFLD initiates and accelerates vascular injury by increasing systemic inflammation and oxidative stress, impairing insulin sensitivity and lipid metabolism, and modulating epigenetics, the intestinal flora and hepatic autonomic nervous system; thus, NAFLD is a putative driving force for CVD progression. In this review, we summarize the clinical evidence supporting the association of NAFLD with subclinical vascular disease and cardiovascular events and discuss the potential mechanisms by which NAFLD promotes the progression of vascular disease.

Fatty liver and cerebrovascular disease: plausible association and possible mechanisms

PURPOSE OF REVIEW

Nonalcoholic fatty liver disease (NAFLD) is a common comorbidity and has wide ranging extrahepatic manifestations, including through cardiometabolic pathways. As such, there is growing interest in the impact of NAFLD on cerebrovascular disease and brain health more broadly. In this review, we assess recent research into understanding the association between NAFLD and brain health while highlighting potential clinical implications.

RECENT FINDINGS

Mechanistically, NAFLD is characterized by both a proinflammatory and proatherogenic state, which results in vascular inflammation and neurodegeneration, potentially leading to clinical and subclinical cerebrovascular disease. Mounting epidemiological evidence suggests an association between NAFLD and an increased risk and severity of stroke, independent of other vascular risk factors. Studies also implicate NAFLD in subclinical cerebrovascular disease, such as carotid atherosclerosis and microvascular disease. In contrast, there does not appear to be an independent association between NAFLD and cognitive impairment.

SUMMARY

The current literature supports the formulation of NAFLD as a multisystem disease that may also have implications for cerebrovascular disease and brain health. Further prospective studies are needed to better assess a temporal relationship between the two diseases, confirm these early findings, and decipher mechanistic links.

MAFLD progression contributes to altered thalamus metabolism and brain structure

Metabolic associated fatty liver disease (MAFLD), commonly known as non-alcoholic fatty liver disease, represents a continuum of events characterized by excessive hepatic fat accumulation which can progress to nonalcoholic steatohepatitis (NASH), fibrosis, cirrhosis, and in some severe cases hepatocellular carcinoma. MAFLD might be considered as a multisystem disease that affects not only the liver but involves wider implications, relating to several organs and systems, the brain included. The present study aims to investigate changes associated with MAFLD-induced alteration of thalamic metabolism in vivo. DIAMOND (Diet-induced animal model of non-alcoholic fatty liver disease) mice were fed a chow diet and tap water (NC NW) or fat Western Diet (WD SW) for up to 28 weeks. At the baseline and weeks 4, 8, 20, 28 the thalamic neurochemical profile and total cerebral brain volume were evaluated longitudinally in both diet groups using ¹H-MRS. To confirm the disease progression, at each time point, a subgroup of animals was sacrificed, the livers excised and placed in formalin. Liver histology was assessed and reviewed by an expert liver pathologist. MAFLD development significantly increases the thalamic levels of total N-acetylaspartate, total creatine, total choline, and taurine. Furthermore, in the WD SW group a reduction in total cerebral brain volume has been observed (p < 0.05 vs NC NW). Our results suggest that thalamic energy metabolism is affected by MAFLD progression. This metabolic imbalance, that is quantifiable by ¹H-MRS in vivo, might cause structural damage to brain cells and dysfunctions of neurotransmitter release.

High prevalence of non-alcoholic fatty liver disease in patients with a first episode of acute ischemic stroke. Impact on disability and death

INTRODUCTION

Non-alcoholic fatty liver disease (NAFLD) is the most common chronic liver disease, and it is associated with an increased risk of overall mortality being cardiovascular disease the most common cause of mortality. Strategies are needed to identify high risk groups for NAFLD to improve screening approaches. Moreover, there is a lack of information about the prevalence of NAFLD on patients with acute ischemic stroke (AIS) and the influence of NAFLD on the prognosis of the stroke. The aim of the study was to define the prevalence of NAFLD in patients with a first episode of AIS and the secondary aims were to evaluate the prevalence of NAFLD at different ages and its impact on the severity and prognosis of the AIS.

MATERIALS AND METHODS

Observational study including consecutive patients admitted for the first AIS from January 2005 to May 2018. Patients with harmful alcohol intake, other liver diseases and malignancies were excluded. Sociodemographic data, cardiovascular risk factors, comorbidities, and blood test at admission were reviewed. NAFLD and liver fibrosis were assessed with the serological scores Fatty Liver Index (FLI) and Fibrosis-4 respectively. NAFLD was defined by a FLI>60. Stroke severity and prognosis were evaluated with the National Institute of Health Stroke Scale and modified Rankin Scale respectively in patients aged from 40 to 79 years old.

RESULTS

We included 1601 patients, 52.4% were female and median (IQR) age of 77 (66 - 83) years. The 41% of the total cohort had a FLI>60 with different prevalence according to age in decades: in 30-39 years: 35.7%; in 40-49: 47.5%; in 50-59: 51.1%, in 60-69: 56%, in 70-79: 41.4%; in 80-89: 34.9% (p<0.001). The presence of NAFLD did not impact on the severity or the prognosis of stroke. However, patients with NAFLD were younger than those without NAFLD (74 vs. 78; p<0.001).

CONCLUSION

Presence of NAFLD did not impact on disability and death after the stroke. However, patients with a first episode of stroke showed a high prevalence of NAFLD, especially at intermediate ages, and therefore, screening for NAFLD should be advisable.

Risk factors and characteristics associated with nonalcoholic fatty liver disease in patients with ischemic colitis

BACKGROUND

Ischemic colitis (IC) was investigated to be associated with dyslipidemia and subcutaneous adipose tissue. Nonalcoholic fatty liver disease (NAFLD) is associated with ischemic diseases such as coronary heart disease, ischemic stroke. But there is a paucity of data regarding the association between NAFLD and IC. NAFLD may be associated with the treatment and prognosis of IC. We investigated risk factors and characteristics associated with NAFLD in patients with IC.

METHODS

Patients with IC (NAFLD: 34 and controls: 81) from Zhongnan Hospital were investigated retrospectively from January 2012 to December 2018. Clinical data were compared by chi-square tests or independent samples T-tests. Binary logistic regressions and Kaplan-Meier analysis were performed to evaluate risk factors and prognosis, respectively.

RESULTS

NAFLD was diagnosed in 28.19% patients with IC. In the logistic regression analysis, hypertension [odds ratio (OR) 3.523; P = 0.019], elevated alanine aminotransferase (ALT) (OR 6.278; P = 0.048), elevated triglyceride (OR 4.667; P = 0.003) and increased weight (OR 1.055; P = 0.039) were risk factors of NAFLD in patients with IC. Patients with NAFLD were more likely to require the vasodilators (P = 0.011) and get a relapse of IC (P = 0.011).

CONCLUSION

NAFLD was found in 28.19% of patients with IC. Hypertension, increased weight, elevated ALT and triglyceride are independent predictors of NAFLD in patients with IC. NAFLD in patients with IC is associated with a greater probability of requiring for the vasodilators. NAFLD in IC and period of bowel rest are risk factors for the recurrence of IC.

Utility of modified Rankin Scale for brain vascular malformations in hereditary hemorrhagic telangiectasia

Background

Approximately 10% of hereditary hemorrhagic telangiectasia (HHT) patients harbour brain vascular malformations (VMs). Intracranial hemorrhage (ICH) from brain VMs can lead to death or morbidity, while treatment options for brain VMs also have associated morbidity. The modified Rankin Scale (mRS) may provide an approach to identifying HHT-brain VM patients with poor outcomes, and their predictors. We aimed to measure the relationship between mRS score and brain VM, brain VM number, as well as other aspects of HHT, at enrollment and during prospective follow-up.

Methods

1637 HHT patients (342 with brain VMs) were recruited from 14 HHT centres of the Brain Vascular Malformation Consortium since 2010 and followed prospectively (mean = 3.4 years). We tested whether the presence of brain VM, other HHT organ involvement, and HHT mutation genotype were associated with worse mRS scores at baseline and during follow-up, using linear mixed models, adjusting for age, sex, and year of visit.

Results

Presence of brain VMs was not associated with worse mRS score at baseline and there was no significant worsening of mRS with prospective follow-up in these patients; 92% had baseline mRS of 0–2. HHT-related gastrointestinal (GI) bleeding was associated with worse mRS scores at baseline (0.37, 95% CI 0.26–0.47, p < 0.001), as were history of anemia (0.35, 95% CI 0.27–0.43, p < 0.001) and liver VMs (0.19, 95% CI 0.09–0.30, p < 0.001). Presence of pulmonary arteriovenous malformations (AVMs) was not associated with worse mRS scores at baseline. mRS score was not associated with either HHT genotype (Endoglin vs ACVRL1). Only GI bleeding was associated with a significantly worsening mRS during prospective follow-up (0.64, 95% CI 0.21–1.08, p = 0.004).

Conclusion

Most HHT-brain VM patients had good functional capacity (mRS scores 0–2) at baseline that did not change significantly over 3.4 mean years of follow-up, suggesting that mRS may not be useful for predicting or measuring outcomes in these patients. However, HHT patients with GI bleeding, anemia history or liver VMs had worse mRS scores, suggesting significant impact of these manifestations on functional capacity. Our study demonstrates the insensitivity of the mRS as an outcomes measure in HHT brain VM patients and reinforces the continued need to develop outcomes measures, and their predictors, in this group.

Non-alcoholic fatty liver disease frequency and associated factors at admission of acute stroke

Background/purpose of the study

If non-alcoholic fatty liver disease (NAFLD) frequency is very high in stroke patients, NAFLD may be a risk factor for stroke and identifying factors of NAFLD presence may lead to stroke prevention. This retrospective study aimed to investigate whether NAFLD frequency was very high and identify factors associated with NAFLD presence at acute stroke admission.

Methods

We included stroke patients aged 40 − 79 years who (1) were admitted from 2016 to 2019, within 24 h of onset; (2) underwent abdominal ultrasonography; and (3) underwent blood examination of biomarkers. We evaluated the frequency and significant factors of NAFLD presence.

Results

Among 1672 stroke patients, 676 patients met our inclusion criteria, and 267 patients (39.5%) had NAFLD. Compared to patients without NAFLD, patients with NAFLD were young; had high anthropometric values; high blood pressure; low aspartate aminotransferase/alanine aminotransferase ratio (AST/ALT) ratio; high levels of liver enzymes, serum albumin, HbA1c, and serum lipids; low-density lipoprotein; high serum level of some fatty acids; and high fatty acid% of palmitic acid (PA) and dihomo-gamma-linolenic acid (DGLA). After excluding variables with multicollinearity, independent NAFLD-presence factors were high body mass index (BMI), low AST/ALT ratio, high serum albumin level, high PA%, and high DGLA level.

Conclusions

The frequency of NAFLD was high in our patient group. Significant NAFLD-presence factors were high BMI, low AST/ALT ratio, high serum albumin level, high PA%, and high DGLA level. A further study is warranted to determine the effects of the NAFLD-presence factors on stroke onset or prevention.

Supplementary Information

The online version contains supplementary material available at 10.1007/s12072-021-10253-z.

Incorporating fatty liver disease in multidisciplinary care and novel clinical trial designs for patients with metabolic diseases

With the global epidemics of obesity and associated conditions, including type 2 diabetes, metabolic dysfunction-associated fatty liver disease, chronic kidney disease, hypertension, stroke, cardiovascular disease, osteoporosis, cancer, and cognitive changes, the prevalence of multimorbidity is rapidly increasing worldwide. In this Review, a panel of international experts from across the spectrum of metabolic diseases come together to identify the challenges and provide perspectives on building a framework for a virtual primary care-driven, patient-centred, multidisciplinary model to deliver holistic care for patients with metabolic dysfunction-associated fatty liver disease and associated metabolic diseases. We focus on clinical care and innovative trial design for metabolic dysfunction-associated fatty liver disease and associated metabolic diseases. This work represents a call to action to promote collaboration and partnerships between stakeholders for improving the lives of people with, or at risk of, metabolic dysfunction-associated fatty liver disease and associated metabolic diseases.

Relationship between Helicobacter pylori infection and nonalcoholic fatty liver disease: What should we expect from a meta-analysis?

BACKGROUND

The relationship between Helicobacter pylori (H. pylori) infection and nonalcoholic fatty liver disease (NAFLD) is a matter of debate. Although it has been studied in many observational studies, the results remain controversial. Therefore, we performed a meta-analysis to assess the association between H pylori infection and risk of NAFLD.

METHODS

We searched Pubmed, EMBASE, and Web of Science databases, from inception to September 10, 2020. Odds ratio (OR) and 95% confidence interval (CI) were pooled by random-effects model. The statistical heterogeneity among studies (I2-index), subgroup analyses, regression analyses, sensitivity analysis and the possibility of publication bias were assessed.

RESULTS

A total of seventeen studies involving 91,958 individuals were included in our meta-analysis. Meta-analysis of data from cross-sectional and case-control studies showed that H pylori infection was associated with increased risk of prevalent NAFLD (n = 15; involving 74,561 middle-aged individuals; OR1.38, 95% CI 1.23-1.55, I2 = 86.8%, P < .001). The results of meta-regression implicated that the study type and the case-control ratio impacted the total effect size. Funnel plot did not show significant publication bias. Meta-analysis of data from longitudinal studies showed that H pylori infection was also associated with increased NAFLD incidence (n = 2; involving 17397 individuals; OR 1.21, 95% CI 1.01-1.44, I2 = 6.5%, P = .301).

CONCLUSIONS

The results indicated that a positive association between H pylori infection and the risk of NAFLD. Further studies are required to strengthen the association and clarify the mechanism.

Prognostic Value of Abnormal Liver Function Tests After Mechanical Thrombectomy for Acute Ischemic Stroke

Objective: To determine the clinical significance of post-procedural abnormal liver function test (ALFT) on the functional outcomes at 90 days in acute ischemic stroke (AIS) treated with mechanical thrombectomy (MT).

Methods: In this retrospective observational study, patients with AIS undergoing MT were enrolled from the Nanjing Stroke Registry Program and the multicenter Captor trial. A favorable outcome was defined as a modified Rankin Scale score 0–2 at 90 days. Predictive models were established by multivariable logistic regression. Improved predictive value of models was assessed by continuous net reclassification improvement (NRI) and integrated discrimination improvement (IDI). In addition, multivariable logistic regression and restricted cubic spline were used to analyze dose–response correlations between the severity of ALFT and prognosis.

Results: Among 420 patients enrolled, 234 (55.7%) patients were diagnosed as post-procedural ALFT after MT. Patients with post-procedural ALFT had higher National Institute of Health Stroke Scale score on admission (median, 18 vs. 15, p < 0.001) and more pneumonia (65.4 vs. 38.2%, p < 0.001) than those without post-procedural ALFT. Post-procedural ALFT, rather than preprocedural ALFT, was independently associated with favorable outcome (adjusted odds ratio, 0.48; 95% CI 0.28–0.81; p = 0.006). The improvement of predictive model after adding post-procedural ALFT was significant [continuous NRI (value, 0.401; p < 0.001), IDI (value, 0.013; p < 0.001)]. However, the restricted cubic spline indicated no evidence of a dose–response relationship between the severity of post-procedural ALFT and prognosis.

Conclusions: In AIS patients treated by MT, post-procedural ALFT was associated with more severe stroke and served as an independent predictor of worse prognosis at 90 days.

Non-Alcoholic Fatty Liver Disease and Cardiovascular Comorbidities: Pathophysiological Links, Diagnosis, and Therapeutic Management

Non-alcoholic fatty liver disease (NAFLD) has a growing prevalence in recent years. Its association with cardiovascular disease has been intensively studied, and certain correlations have been identified. The connection between these two entities has lately aroused interest regarding therapeutic management. In order to find the best therapeutic options, a detailed understanding of the pathophysiology that links (NAFLD) to cardiovascular comorbidities is needed. This review focuses on the pathogenic mechanisms that are behind these two diseases and on the therapeutic management available at this time.

Association of non-alcoholic fatty liver disease with diabetic retinopathy in type 2 diabetic patients: A meta-analysis of observational studies

Aims/Introduction

Non‐alcoholic fatty liver disease (NAFLD) is becoming more and more prevalent in type 2 diabetes mellitus. Evidence connecting NAFLD to diabetic retinopathy (DR) is increasing, but the results vary. Thus, we undertook a meta‐analysis to explore the effect of NAFLD on diabetic retinopathy in patients with type 2 diabetes mellitus.

Materials and Methods

PubMed, Embase, Cochrane and Scopus database were searched for until September 30, 2019. Original studies analyzing the association between NAFLD and diabetic retinopathy in the type 2 diabetic population were included. This meta‐analysis was processed by RevMan 5.3 software. Subgroup analyses based on countries were carried out. The pooled odds ratios and 95% confidence intervals were used to evaluate the association between NAFLD and diabetic retinopathy incidence. The I² test was used to assess heterogeneity of studies.

Results

We retrieved 414 articles, and nine studies involving 7,170 patients were included in the final analysis. The pooled effects estimate suggested that NAFLD was not associated with the risk of diabetic retinopathy in patients with type 2 diabetes mellitus. Subgroup analysis suggested that in China, Korea and Iran, patients with type 2 diabetes mellitus with NAFLD had a decreased risk for diabetic retinopathy compared with the non‐NAFLD individuals. However, in Italy and India, patients with type 2 diabetes mellitus with NAFLD had an increased risk for diabetic retinopathy compared with the non‐NAFLD individuals. In addition, no relevance between NAFLD and diabetic retinopathy was found in America.

Conclusions

On the whole, there was no association between NAFLD and diabetic retinopathy in individuals with type 2 diabetes mellitus. However, subgroup analysis showed that a difference of country may have an influence on the result.

A Non-Invasive Prediction Model for Non-Alcoholic Fatty Liver Disease in Adults with Type 2 Diabetes Based on the Population of Northern Urumqi, China

BACKGROUND

High prevalence of non-alcoholic fatty liver disease (NAFLD) occurs in type 2 diabetes mellitus (T2DM), and about 13% of diabetic patients eventually die of liver cirrhosis or liver cancer. The purpose of our research was to develop a non-invasive predictive model of NAFLD in adults with T2DM.

PATIENTS AND METHODS

Adult patients diagnosed with T2DM during physical examination in 2018 in Urumqi were recruited, in total 40,921 cases. We chose questionnaire and physical measurement variables to build a simple, low-cost model. Variables were selected by the least absolute shrinkage and selection operator regression (LASSO). The features chosen by LASSO were used to build the nomogram prediction model of NAFLD. The receiver operating curve (ROC) and calibration were used for model validation.

RESULTS

Determinants in the nomogram included age, ethnicity, sex, exercise, smoking, dietary ratio, heart rate, systolic blood pressure (SBP), BMI, waist circumference, and atherosclerotic vascular disease (ASCVD). The area under ROC of developing group and validation group was 0.756 (95% confidence interval 0.750-0.761) and 0.755 (95% confidence interval 0.746-0.763), respectively, and the P values of the two calibration curves were 0.694 and 0.950, suggesting that the nomogram had good disease recognition ability and calibration.

CONCLUSION

A nomogram constructed with accuracy can calculate the possibility of NAFLD in adults with T2DM. If validated externally, this tool could be utilized as a non-invasive method to diagnose non-alcoholic fatty liver in adults with T2DM.

The Association between Nonalcoholic Fatty Liver Disease and Stroke: Results from the Korean Genome and Epidemiology Study (KoGES)

(1) Background: Non-alcoholic fatty liver disease (NAFLD) is associated with various cardiometabolic diseases. However, the association between NAFLD and stroke is not well known. The purpose of our study is to reveal the relationship between NAFLD and Stroke incidence. (2) Methods: Using data from a Korean prospective cohort study, we excluded participants with heavy alcohol consumption and a history of stroke; hence, 7964 adults aged 40–69 years were included in this study. According to their fatty liver index (FLI), participants were divided into three groups: <30 (n = 4550, non-NAFLD), 30–59.9 (n = 2229, intermediate), and ≥60 (n = 1185, NAFLD). The incidence of stroke according to the degree of FLI was evaluated using the Cox proportional hazard model. (3) Results: During the 12-year follow-up period, 168 strokes occurred. A graded association between NAFLD and stroke incidence was observed, i.e., 1.7% (n = 76), 2.5% (n = 56), and 3.0% (n = 36) for non-NAFLD, intermediate, and NAFLD FLI groups, respectively. After adjusting for confounding variables and compared to the risk of stroke in the non-NAFLD group, the risk of stroke in the NAFLD group was the highest (hazard ratio [HR]: 1.98, 95% confidence interval [CI]: 1.17–3.34), followed by the risk of stroke in the intermediate group (HR: 1.41, 95% CI: 0.94–2.21) (p for trend < 0.001). However, the level of aspartate aminotransferase, alanine aminotransferase, or gamma-glutamyltransferase alone did not show any significant association with stroke. (4) Conclusions: This study demonstrated that the risk of stroke incidence gradually increased with the degree of FLI. Individuals with NAFLD should be properly counseled and monitored for risk for stroke.

Serum Markers as a Predictor of Hepatic Fibrosis Compared to Fibroscan in chronic hepatitis B Infected Egyptian patients: A Cross-sectional Study

Background & Aims:

The gamma-glutamyl transpeptidase (GGT) to platelet ratio (GPR), the gamma-glutamyl transpeptidase to albumin (GAR) and S-index are novel biomarkers suggested to assess liver fibrosis. The aim of the work was to assess the correlation between GGT and other related markers as GAR and GPR among other previous documented markers and the degree of fibrosis and steatosis in chronic HBV Egyptian patients as measured by fibroscan.

Materials And Methods:

After ethical approval of the protocol, a total of 170 chronic HBV patients were recruited from tropical medicine department, Tanta University. They underwent fibroscan examination for fibrosis and steatosis measurement with concomitant testing of liver functions and complete blood picture. Proposed serum markers were calculated. The relation between these ratios with the fibrosis and steatosis measured by fibroscan were tested using Pearson rank correlation.

Results:

There was a highly significant positive correlation between gamma-glutamyl transpeptidase and platelet ratio (GPR), GAR, GGT, Fib4, APRI and fibrosis (p=<0.001, <0.001,<0.001,<0.001,0.011 and <0.001 respectively), while there was no correlation with the degree of steatosis (p=0.922,0.66,0.936,0.214,0.591 and 0.760 respectively). Also these markers were significantly higher in patients with higher grades of fibrosis (f2-4) (p= 0.007,0.013,<0.001,0.018,0.029,and 0.002 respectively), they also showed high sensitivity and low specificity in detecting higher grades of fibrosis with no statistically significant difference between the AUC of GPR and GAR (p=0.89).

Conclusion:

Noninvasive serum markers including GGT, GPR, GAR, Fib4, APRI, and S-index are positively correlated to the degree of fibrosis in CHB patients with high sensitivity and low specificity. They were good negative tests for diagnosis of significant fibrosis.

[Clinical features of the comorbid course of non-alcoholic fatty liver disease and gallstone disease]

AIM

To determine the diagnostic value of clinical features of the comorbid course of non-alcoholic fatty liver disease (NAFLD) and gallstone disease (GD) to improve the effectiveness of patient management.

MATERIALS AND METHODS

183 patients with NAFLD were included into the open comparative study. The main group was represented by patients with NAFLD and GD (n=88), of which 53 patients underwent cholecystectomy (CE). The comparison group was represented by patients with NAFLD without GD (n=95). A standard laboratory and instrumental examinations were performed, including elastometry to assess of the stage of liver fibrosis.

RESULTS

There were more women in the main group (2=8.48; p0.01). There were positive correlations between the age of patients and the duration of NAFLD with the presence of GD and CE (rs=0.135; p0.01 and rs=0.168; p0.01 respectively). Patients of the main group had the general weakness and fatigue (2=11.33, rs=0.234; p0.01 and 2=15.68, rs=0.281; p0.01 respectively), as well as a bitter taste in the mouth (2=11.66; p0.01; rs=0.147; p0.01). Coronary heart disease was diagnosed more often among people suffering from NAFLD and GD (25% vs 9.47% in patients of the comparison group, p0.01). Both of NAFLD and GD were associated with the development of type 2 diabetes (rs=0.164; p0.01). Individuals suffering from GD after CE had higher LDL and GGT values (rs=0.228; p0.01 and rs=0.298; p0.01 respectively). The number of people with advanced fibrosis were significantly higher (26.31%) in the GD group, especially among people after CE (30.18%). The stage of liver fibrosis had a positive significant relationship with CE (rs=0.366; p0.01).

CONCLUSION

Patients suffering from GD and NAFLD had a symptom of dyspepsia and general weakness. High prevalence of type 2 diabetes and сoronary heart disease, high level of LDL and GGT were found in patients with GD and after CE. CE in patients suffering from GD and NAFLD was associated with the formation of progressive stages of liver fibrosis.

Non-alcoholic fatty liver disease in inflammatory bowel disease patients

Non-alcoholic fatty liver disease is a highly prevalent medical condition, characterized by intrahepatic fat accumulation which may eventually lead to hepatic inflammation, cell death and reactive fibrosis. Obesity and metabolic disturbances constitute significant contributors to liver steatosis pathogenesis, however, there is a growing awareness that fatty liver may emerge even in normal weight or metabolically healthy individuals. In recent years, advanced imaging techniques have revealed that liver steatosis is quite common in inflammatory bowel disease patients, suggesting that intestinal inflammation and disturbances of the liver-gut axis may also play a key role in non-alcoholic fatty liver disease pathophysiology. The current review focuses on the co-occurrence of the two disorders, integrating research findings on epidemiology, clinical characteristics and common pathophysiological processes. The study of liver steatosis in inflammatory bowel disease patients may provide useful insights on the complex links between dietary fat intake, metabolic dysregulation, gut physiology and intrahepatic cellular mechanisms underlying liver inflammation and damage.

Association between non-alcoholic fatty liver and acute cerebral infarction: a protocol of systematic review and meta-analysis

BACKGROUND

This study will systematically synthesize the evidence on the potential association between non-alcoholic fatty liver (NAFL) and acute cerebral infarction (ACI).

METHODS

We will propose literature search in electronic databases (MEDLINE, EMBASE, Cochrane Library, Scopus, Web of Science, WANGFANG, and China National Knowledge Infrastructure) from the source to March 1, 2020. There are no restrictions related to the language and publication status. Two review authors will separately carry out records selection, data extraction and study quality assessment. Any divisions will be solved by discussion with consulting a third review author. We will use RevMan 5.3 software to perform data analysis.

RESULTS

The present study will afford additional insight into the investigation the association between NAFL and ACI.

CONCLUSION

The results of this study will provide helpful evidence to explore the association between NAFL and ACI.Study registration number: INPLASY202040102.

The Effect of Stem Cell Transplantation Therapy for Post Viral Chronic Liver Cell Failure on Associated Type II Diabetes Mellitus: A Pilot Study

BACKGROUND

It was observed that type II diabetes mellitus associated with chronic liver failure improved after stem cell transplantation. However, there were no adequate studies regarding this issue. The aim of this study was to evaluate the effect of stem cell transplantation on associated type II diabetes mellitus and on the liver function tests.

METHODS

This pilot study included 30 patients of post-hepatitis chronic liver failure who were classified into two groups: Group I included patients with chronic liver cell failure associated with type 2 diabetes. Group II included patients without type II diabetes. Autologous CD34+ and CD133+ stem cells were percutaneously infused into the portal vein. Responders (regarding the improvement of diabetes as well as improvement of liver condition) and non-responders were determined. Patients were followed up for one, three and six months after the intervention evaluating their three-hour glucose tolerance test, C- peptide (Fasting and postprandial), Child-Pugh score and performance score one month, three months, and six months after stem cell therapy.

RESULTS

Both synthetic and excretory functions of the liver were improved in 10 patients (66.66 %) of group I and in 12 patients (80 %) of group II. Significant improvement in the Oral Glucose Tolerance Test in the responders of both the groups was well defined from the 3rd month and this was comparable to changes in liver function tests and Child-Pugh score.

CONCLUSION

Successful stem cell therapy in chronic liver cell failure patients can improve but not cure the associating type 2 diabetes by improving insulin resistance.

Brain involvement in non-alcoholic fatty liver disease (NAFLD): A systematic review

Non-alcoholic fatty liver disease (NAFLD) is associated with high cardiovascular morbidity and mortality which usually is considered to be related to cardiac involvement, while scarce attention is addressed to brain damage. Viceversa NAFLD is associated with asymptomatic brain lesions, alterations in cerebral perfusion and activity, cognitive impairment and brain aging and with increased risk and severity of both ischemic and haemorrhagic stroke. Besides known metabolic risk factors, NAFLD is characterized by a pro inflammatory state, which contributes to atherosclerosis and microglia activation, endothelial dysfunction, pro-coagulant state and platelets activation, which in turn promote both micro and macrovascular damage eventually responsible for clinical and subclinical cerebrovascular alterations. A better knowledge of the association between NAFLD and brain alterations could lead to an improved management of risk factors underpinning both liver and cerebral disease, possibly preventing the progression of asymptomatic brain lesions to clinical cerebrovascular accidents.

Cardiovascular Risk in Non-Alcoholic Fatty Liver Disease: Mechanisms and Therapeutic Implications

New evidence suggests that non-alcoholic fatty liver disease (NAFLD) has a strong multifaceted relationship with diabetes and metabolic syndrome, and is associated with increased risk of cardiovascular events, regardless of traditional risk factors, such as hypertension, diabetes, dyslipidemia, and obesity. Given the pandemic-level rise of NAFLD—in parallel with the increasing prevalence of obesity and other components of the metabolic syndrome—and its association with poor cardiovascular outcomes, the question of how to manage NAFLD properly, in order to reduce the burden of associated incident cardiovascular events, is both timely and highly relevant. This review aims to summarize the current knowledge of the association between NAFLD and cardiovascular disease, and also to discuss possible clinical strategies for cardiovascular risk assessment, as well as the spectrum of available therapeutic strategies for the prevention and treatment of NAFLD and its downstream events.

The grade of nonalcoholic fatty liver disease is an independent risk factor for gallstone disease: An observational Study

There have been reports linking nonalcoholic fatty liver disease (NAFLD) with gallstone disease (GD) owing to shared risk factors. However, there are no reported associations between the different NAFLD grades and GD. This study aimed to determine whether NAFLD grade is an independent risk factor for GD in a Korean population.This study enrolled 7886 participants who completed a questionnaire and underwent medical examination and ultrasound scanning at the Health Promotion Center of Jeju National University Hospital in Korea, from January 2009 to December 2017. Fatty liver grading and presence of gallstones were investigated using abdominal ultrasound. Body mass index and biochemical parameters were measured, and age, sex, and metabolic syndrome status were collected from medical records. Univariate and multivariate analyses were performed to identify risk factors for GD.The estimated prevalences of NAFLD and GD were 40.6% and 4.5%, respectively. In the univariate analysis, factors associated with GD were age; NAFLD; presence of metabolic syndrome; and levels of fasting blood glucose, high-density lipoproteins, aspartate aminotransferase, and alanine aminotransferase. Multivariate logistic regression analysis revealed older age and higher NAFLD grade as independent risk factors for GD.Older age and higher grade of NAFLD were independent risk factors for GD in our cohort. There was a strong correlation between grade of NAFLD on abdominal ultrasonography and GD.

Structural changes in liver under conditions of experimental hemorrhagic stroke

The article describes the results of histological and morphometric studies of liver in Balb/c mice with hemorrhagic stroke. The hemorrhagic stroke was modeled in the animals by administering autoblood in volume of 0.1 ml in the right hemisphere, and within 5, 10 and 30 days an analysis of structural changes in the liver was performed. Progressive changes were established in terms of 5-10 days of the experiment. This consisted of changes in the sinusoidal capillaries and notable changes in the central veins of the liver lobuli. Herein, acute dilatation and erythrocytal stasis were most pronounced around the lumen of the central veins, while hepatocytes with signs of necrosis (severe cytoplasmic swelling, vacuolar dystrophic changes) were detected in the sinusoid capillaries. The results of the morphometry indicated an increase in the area of the nucleus and the cells caused by intracellular swelling, domination of euchromatin and decrease of total density of chromatin in nuclei. Partial regression of the diameter of sinusoidal capillaries and the area of hepatocytes were detected on the 30th day of the experiment. The changes in the sinusoidal capillaries of the liver lobules are assessed as secondary to stroke, as well as to changes in organ microcirculation, and are associated with dystrophic changes in the hepatocytes.

Cardio-Metabolic Disorders in Non-Alcoholic Fatty Liver Disease

With the progressive epidemics of obesity, non-alcoholic fatty liver disease (NAFLD) has become the most common cause of chronic liver disease in adults and children. The increasing prevalence and incidence of NAFLD with advanced fibrosis is concerning because patients appear to experience higher non-liver-related morbidity and mortality than the general population. Recent clinical evidence suggests that NAFLD is directly associated with an increased risk of cardio-metabolic disorders. This mini review describes briefly the current understanding of the pathogenesis of NAFLD, summarizing the link between NAFLD and cardio-metabolic complications, focusing mainly upon ischemic stroke, type 2 diabetes mellitus (DM), hypertension, chronic kidney disease (CKD) and cardiac arrhythmias. In addition, it describes briefly the current understanding of the pathogenesis of NAFLD.

Presence of diabetic retinopathy is lower in type 2 diabetic patients with non-alcoholic fatty liver disease

To analyze the association between non-alcoholic fatty liver disease (NAFLD) and the presence of diabetic retinopathy (DR) in patients with type 2 diabetes mellitus (T2DM).Total 411 T2DM patients were divided into NAFLD and control groups. NAFLD was diagnosed by ultrasound. Retinopathy was diagnosed by fundus photography. All patients were screened based on medical history, physical examinations, and laboratory measurements.The prevalence of NAFLD and DR in T2DM patients was 60.8% and 40.9%, respectively. The presence of DR was associated with diabetes duration, systolic blood pressure (SBP), glycated hemoglobin (HbA1c), and proteinuria (all P < .001) using univariate and multivariate regression analyses. The prevalence of DR was lower in patients with NAFLD than those without NAFLD (37.2% vs 46.6%, P = .065), and significantly lower in patients with moderate and severe NAFLD (30.2% vs 46.6%, P = .012; 14.3% vs 46.6%, P = .024). The presence of DR in NAFLD patients was associated with diabetes duration (P = .032) in Chi-squared analysis.NAFLD and DR were highly prevalent in T2DM patients. Diabetes duration, SBP, HbA1c, and proteinuria were risk factors for DR in T2DM patients. The presence of DR was lower in T2DM patients with NAFLD, which was mainly due to their shorter diabetes duration.

Efficacy of a non-invasive model in predicting the cardiovascular morbidity and histological severity in non-alcoholic fatty liver disease

BACKGROUND

Insulin resistance (IR) in cases of non-alcoholic fatty liver disease (NAFLD) is connected to remarkable liver cell inflammation and cardiovascular complications. Given the prevalence of NAFLD and its association with potential sequels, there is a strong need for an accurate non-invasive tool to monitor the progression of NAFLD.

METHODS

272 patients with NAFLD and cardio-metabolic risk factors were tested for HOMA-IR, mean platelet volume (MPV), neutrophil-lymphocyte ratio (NLR), uric acid, ferritin, lipid profile, liver stiffness measurement (LSM), controlled attenuation parameter (CAP) by fibroscan and carotid intima media thickness (CIMT). Liver biopsy was performed to validate the results.100 healthy controls were selected. A score was constructed and applied to a validation group (n = 61).

RESULTS

Logistic regression revealed that significant fibrosis and cardiovascular risk in NAFLD were independently associated with AST/ALT ratio (p = 0.000), GGT (p = 0.000), CIMT (p = 0.001), uric acid (p = 0.000), VLDL (p = 0.000), HOMA-IR (p = 0.000), ferritin (p = 0.000) CAP (p = 0.000), LSM (p0.000). A non-invasive model was formulated by which a value > 15 was accurate in identification of advanced fibrosis and cardiovascular risk with a sensitivity of 97.3%, specificity 97%.

CONCLUSION

The score correlated well with the results of liver biopsy and can be repeated with great flexibility to assess severity of NAFLD.

The Paradoxical Protective Effect of Liver Steatosis on Severity and Functional Outcome of Ischemic Stroke

Background: There is very limited information on the relationship between non-alcoholic fatty liver disease (NAFLD) and the severity or functional outcomes of ischemic stroke or transient ischemic stroke (TIA). We investigated the correlation between NAFLD and stroke outcomes. Methods: NAFLD was assessed in 321 patients with first-ever acute ischemic stroke or TIA, who underwent transient elastography from January 2014 to December 2014. The association of liver steatosis with stroke severity, assessed using the National Institute of Health Stroke Scale (NIHSS), was investigated using robust regression analysis. We also compared the functional outcome at 90 days according to the presence or burden of liver steatosis. Results: NAFLD was observed in 206 (64.2%) patients. Patients with NAFLD had less severe stroke (median NIHSS score 2 vs. 3, P = 0.012) and more favorable functional outcome at 90 days (85.3 vs. 70.5, P = 0.004). Patients with NAFLD were likely to have a 23.3% lower [95% confidence interval (CI), -39.2 to -3.2%, P = 0.026] NIHSS score and a 2.5-fold higher (95% CI, 1.08-5.67, P = 0.033) possibility of favorable functional outcome in multivariate analysis. Conclusions: Our study shows that a higher burden of liver steatosis seems to be associated with less severe stroke and better functional outcome after ischemic stroke or TIA.