Fatty liver is an independent predictor of early carotid atherosclerosis

The Maternal and Fetal Consequences of Metabolic Dysfunction-Associated Fatty Liver Disease and Gestational Diabetes Mellitus

Both metabolic dysfunction-associated fatty liver disease (MAFLD) and gestational diabetes mellitus (GDM) during pregnancy are emerging as an adverse synergistic relationship of growing concern. This narrative review focuses on the maternal and fetal consequences associated with women who have MAFLD and/or GDM during pregnancy, including an exploration of long-term cardiometabolic risks for postpartum maternal and childhood health. We conclude that implementation of a life course approach to management of these high-risk women remains paramount.

Positive Association Between Ultrasonographic Fatty Liver Indicator and the Severity of Coronary Artery Disease

Background: This study investigates the link between metabolic dysfunction-associated fatty liver disease (MAFLD) and coronary artery disease (CAD) using the ultrasonographic fatty liver indicator (US-FLI) to assess liver steatosis. Methods: A total of 204 patients were included, with hepatic steatosis evaluated through ultrasound characteristics, diagnosing fatty liver when US-FLI was ≥2. CAD severity was determined using the SYNTAX score (SS), categorizing 100 CAD patients into mild (SS ≤ 22) and moderate-severe (MS) (SS ≥ 23) groups. The association between US-FLI and SS in patients with MAFLD was evaluated through the multivariate logistic regression model. A receiver operating characteristic curve was applied to determine the accuracy, sensitivity, and specificity of US-FLI in predicting SS. Results: In the multivariate logistic regression analysis, US-FLI was an independent predictor of the CAD group (OR = 1.194, 95% CI: 1.008-1.414, p = 0.040) and the MS group (OR = 1.262, 95% CI: 1.025-1.553, p = 0.028). In the receiver operating characteristic curve analysis, a US-FLI value of 2 was found to be the optimal threshold point for diagnosing MS CAD patients (AUC = 0.620, 95% CI: 0.509-0.713, p = 0.039), with a sensitivity of 65.22% and a specificity of 55.56%. The diagnostic performance of MS CAD patients significantly improved when US-FLI was combined with type 2 diabetes mellitus (T2DM) (AUC = 0.732, 95% CI: 0.632-0.832, p < 0.001), with a sensitivity of 65.22% and specificity of 77.78%. Conclusions: US-FLI was independently and positively associated with CAD severity. US-FLI combined with T2DM had better diagnostic performance in patients with MS CAD.

PNPLA3 Polymorphism Is Inversely Correlated with Aortic Stiffness in Patients with Metabolic Dysfunction-Associated Steatotic Liver Disease Without Fibrosis

Metabolic dysfunction-associated steatotic liver disease (MASLD) corresponds to the condition of increased hepatic fat levels, which is the leading cause of hepatic failure and carcinoma. It is also an independent risk factor for cardiovascular disease (CVD) and mortality. MASLD can be due to obesity with insulin resistance and/or genetic predisposition, i.e., polymorphism in the patatin-like phospholipase domain-containing 3 (PNPLA3) gene. PNPLA3 polymorphism has been associated with increased hepatic fat levels, fibrosis, cirrhosis, and hepatocellular carcinoma, while its association with CVD remains to be fully understood. The aim of the current study was to examine whether the vascular phenotype of patients with MASLD differed between carriers and noncarriers of the PNPLA3 polymorphism. Adult patients with MASLD underwent clinical assessment, PNPLA3 genotyping, arterial tonometry for aortic stiffness measurement, and ultrasound examination of carotid arteries. In total, 117 patients with MASLD and no fibrosis (median hepatic stiffness was 4.71 kPa) were recruited. Carriers of the PNPLA3 polymorphism were younger and exhibited higher levels of ALT and APRI, as compared to wild-type subjects. On the other hand, carriers of the PNPLA3 polymorphism had not only a better metabolic profile (i.e., lower glucose and glycated hemoglobin) but also lower blood pressure, carotid intima-media thickness (IMT), and cardiovascular risk. In addition, PNPLA3 polymorphism was negatively correlated with aortic stiffness, which is a marker of arteriolosclerosis and vascular ageing. Our data are consistent with previous observations that in case of genetically-driven MASLD, there is an inverse association with common predictors of CVD. Our data support the view that the main contributors to CVD risk in patients with MASLD remain conventional cardiometabolic risk factors (i.e., age, glucose) that are more likely to be found in metabolic syndrome-related MASLD rather than genetically-driven MASLD, at least in the first stages of the disease.

Incremental Value of Blood-Based Markers of Liver Fibrosis in Cardiovascular Risk Stratification

CONTEXT

Nonalcoholic fatty liver disease (NAFLD) with advanced liver fibrosis is associated with cardiovascular disease (CVD).

OBJECTIVE

This work aimed to examine if markers of vascular injury mediate the link between liver fibrosis noninvasive tests (LFNITs) and CVD events, and to compare the incremental predictive value of LFNITs over established CVD risk scores.

METHODS

Consecutively recruited individuals (n = 1692) with or without clinically overt coronary artery disease (CAD) from the Athens Cardiometabolic Cohort, were analyzed. Fibrosis-4 index (FIB-4), NAFLD Fibrosis score (NFS), and BARD score were evaluated for direct and indirect associations with indices of subclinical arterial injury including carotid maximal wall thickness (maxWT) and pulse wave velocity (PWV) and with a composite of major adverse cardiovascular events (MACE) that consisted of cardiac death, acute myocardial infarction, or coronary revascularization (39-month median follow-up).

RESULTS

FIB-4 was the only LFNIT that was consistently associated with multiple markers of vascular injury, irrespective of CAD presence and after controlling for traditional risk factors, surrogates of insulin resistance, or obesity (adjusted P < .05 for all). FIB-4 was also independently associated with CAD presence (adjusted odds ratio [OR] 6.55; 3.48-12.3; P < .001). Increased FIB-4 greater than 2.67 was incrementally associated with an increased risk for MACE (OR [95% CI] 2.00 [1.12-3.55], ΔAUC [95% CI] 0.014 [0.002-0.026]). These associations were mediated by maxWT rather than PWV. Only FIB-4 (>3.25) was independently and incrementally associated with all-cause mortality (adjusted P < 0.05).

CONCLUSION

In a cardiometabolically diverse population, the incremental associations of LFNITs with CVD outcomes were mediated by atherosclerotic burden rather than arterial stiffening. FIB-4 consistently demonstrated associations with all study end points. These findings provide mechanistic insights and support the clinical applicability of FIB-4 in CVD prevention.

Cardiovascular Manifestations of Patients with Non-Alcoholic Fatty Liver Disease

Background: Non-alcoholic fatty liver disease (NAFLD), more recently redefined as metabolic-associated fatty liver disease (MAFLD), is now recognized as the most prevalent cause of chronic liver disease. Its strong association with cardiovascular disease (CVD) underscores its emerging role in global morbidity and mortality. Objective: This review critically examines the pathophysiological mechanisms that link NAFLD/MAFLD with CVD. It focuses on shared metabolic disturbances, inflammatory pathways, and alterations in the gut microbiota that contribute to hepatic and cardiovascular pathology. Review and Gaps: Current evidence highlights insulin resistance, dyslipidemia, systemic inflammation, and gut dysbiosis as pivotal factors connecting NAFLD/MAFLD to CVD. Despite these insights, inconsistencies in diagnostic criteria and a lack of validated non-invasive biomarkers hinder a clear understanding of the causal relationship between liver and cardiovascular diseases. Conclusions: Addressing these knowledge gaps through standardized diagnostic protocols and large-scale longitudinal studies is essential. Improved biomarker validation and clearer delineation of the underlying mechanisms will improve cardiovascular risk stratification and enable more personalized therapeutic strategies for patients with NAFLD/MAFLD.

Race/ethnicity-specific association between the American Heart Association's new Life's Essential 8 and stroke in US adults with nonalcoholic fatty liver disease: Evidence from NHANES 2005-2018

BACKGROUND

The Life's Essential 8 (LE8) is a recently introduced assessment of cardiovascular health (CVH) by the American Heart Association (AHA). Nonalcoholic fatty liver disease (NAFLD) is currently the most common chronic liver disease and is associated with an increased risk of stroke. We aimed to explore the association of LE8 with stroke in NAFLD using a national cross-sectional study.

METHODS

Eligible participants with NAFLD aged 20-85 years in NHANES 2005-2018 were included. LE8 was assessed according to AHA criteria and categorized into metabolic and behavioral factors. US Fatty Liver Index (USFLI) ≥ 30 and exclusion of other chronic liver diseases suggested NAFLD. Stroke was diagnosed according to self-report on standardized questionnaires.

RESULTS

After adjusting for all confounders, each point increase in LE8, LE8 metabolic factors, and LE8 behavioral factors was associated with a 4.4 %, 1.8 %, and 2.5 % reduction in stroke prevalence in NAFLD, respectively. Both moderate and high CVH assessed by LE8 and LE8 behavioral factors were associated with reduced odds of stroke compared with low CVH. Stroke prevalence declined progressively with increasing number of ideal LE8 components, with the lowest odds of stroke at 3 + ideal LE8 components for both LE8 metabolic and behavioral factors. Restricted cubic spline suggested dose-response associations. Race/ethnicity was a significant effect modifier, and this association was present only among non-Hispanic white population and other Hispanic population. FLI as a diagnostic indicator of NAFLD yielded generally consistent results.

CONCLUSIONS

Higher LE8 score, especially LE8 behavioral factors, was associated with reduced prevalence of stroke in NAFLD, especially among non-Hispanic white population and other Hispanic population. The odds of stroke declined progressively with increased ideal LE8 component number. These findings underscore the preventive value of adherence to high CVH for stroke prevention in NAFLD.

Metabolic Dysfunction-Associated Steatotic Liver Disease: Pathogenetic Links to Cardiovascular Risk

Metabolic dysfunction-associated steatotic liver disease (MASLD) is correlated with an increased cardiovascular risk, independent of other traditional risk factors. The mechanisms underlying this pathogenic link are complex yet remain incompletely elucidated. Among these, the most significant are visceral adiposity, low-grade inflammation and oxidative stress, endothelial dysfunction, prothrombotic status, insulin resistance, dyslipidemia and postprandial hyperlipemia, gut dysbiosis, and genetic mutations. Cardiovascular diseases are the leading cause of death in patients with MASLD. These patients have an increased incidence of coronary artery disease, carotid artery disease, structural and functional cardiac abnormalities, and valvulopathies, as well as arrhythmias and cardiac conduction disorders. In this review, we present the latest data on the association between MASLD and cardiovascular risk, focusing on the pathogenic mechanisms that explain the correlation between these two pathologies. Given the high rates of cardiovascular morbidity and mortality among patients with MASLD, we consider it imperative to raise awareness of the risks associated with this condition within the general population. Further research is essential to clarify the mechanisms underlying the increased cardiovascular risk linked to MASLD. This understanding may facilitate the identification of new diagnostic and prognostic biomarkers for these patients, as well as novel therapeutic targets.

Cardiovascular Risk Reduction in Metabolic Dysfunction-Associated Steatotic Liver Disease and Metabolic Dysfunction-Associated Steatohepatitis

PURPOSE OF REVIEW

Metabolic dysfunction-associated steatotic liver disease (MASLD) is the most common chronic liver disease, characterized by hepatic steatosis with at least one cardiometabolic risk factor. Patients with MASLD are at increased risk for the occurrence of cardiovascular events. Within this review article, we aimed to provide an update on the pathophysiology of MASLD, its interplay with cardiovascular disease, and current treatment strategies.

RECENT FINDINGS

Given their high burden of cardiovascular comorbidities, patients with MASLD or MASH should undergo regular cardiovascular risk assessment using established risk models. In the absence of liver-specific therapies, therapeutic strategies should focus on improving cardiometabolic risk factors. Patients require a multimodal and multi-stakeholder treatment approach, including optimization of lifestyle, dysglycemia, obesity, and dyslipidemia. Statin treatment represents a safe and effective but often underused therapy in the management of at-risk patients with MASLD and MASH. Novel promising approaches include the use of GLP-1 receptor agonists, especially in, but not limited to, patients with cardiovascular disease and obesity. Patients with MASLD and MASH are at high cardiovascular risk requiring a multi-modal therapeutic approach including regular cardiovascular risk assessment, as well as lifestyle and pharmacological interventions. Statin therapy represents an inexpensive, safe and effective therapy across the spectrum of non-alcohol related steatotic liver diseases without major safety concerns. More prospective, randomized trials in patients with MASLD and MASH are needed.

Decoding the fatty liver-hyperuricemia link in the obese and nonobese hypertensive patients: insights from a cohort study

Metabolic-dysfunction-associated fatty liver disease (MAFLD) and serum uric acid are closely related to cardiovascular and cerebrovascular diseases. However, the causal association between MAFLD and serum uric acid remains unclear. A total of 3417 patients without hyperuricemia were included in the final analysis. MAFLD was defined as fatty liver index (FLI) ≥ 30. Multivariate Cox regression analysis was used to explore the association between FLI and new-onset hyperuricemia. Restricted cubic splines and threshold saturation effect analysis were used to detect nonlinear associations. The mean age was 62.8 ± 8.3 year, and 68.5% were women. A total of 738 (21.6%) hypertensive patients developed new-onset hyperuricemia, 388 (11.4%) new-onset hyperuricemia10 and 190 (5.6%) new-onset hyperuricemia20 during the 4-year midday follow-up period. In the fully adjusted model, compared with the Q1 (FLI ≤ 8.5) group, the risk of hyperuricemia increased by 56% (HR: 1.56; 95% CI: 1.02, 2.38) in the Q4 (FLI > 39.4) group, new-onset hyperuricemia10 increased by 108% (HR: 2.08; 95% CI: 1.15, 3.78), and new-onset hyperuricemia20 increased by 156% (HR: 2.56; 95% CI: 1.11, 5.94), respectively. Saturation effects showed a nonlinear association between FLI and new-onset hyperuricemia (p for log likelihood ratio test < 0.05). Subgroup analysis and stratified analysis showed that there had a significantly higher risk of new-onset hyperuricemia in the patients with normal body mass index (< 24 kg/m2) (p for interaction: 0.018) and non-central obesity (p for interaction: 0.024). MAFLD is an independent risk factor for hyperuricemia in hypertensive patients, especially in patients with normal body mass index and non-central obesity.

Neutrophil to albumin ratio: a biomarker in non-alcoholic fatty liver disease and with liver fibrosis

Objective

Given the high prevalence of non-alcoholic fatty liver disease (NAFLD) and its potential to progress to liver fibrosis, it is crucial to identify the presence of NAFLD in patients to guide their subsequent management. However, the current availability of non-invasive biomarkers for NAFLD remains limited. Therefore, further investigation is needed to identify and develop non-invasive biomarkers for NAFLD.

Methods

A retrospective analysis was conducted on 11,883 patients admitted to the Healthcare Center, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, from January 2016 to December 2019 and divided into NAFLD and non-NAFLD groups. Anthropometric and laboratory examination data were collected. The correlations between variables and NAFLD were evaluated using the student's t-test or Mann-Whitney U test and binary logistic regression analysis. The predictive ability of these variables for NAFLD was assessed using the areas under the curves (AUCs) of receiver operating characteristics.

Results

Among the included patients, 3,872 (32.58%) were diagnosed with NAFLD, with 386 (9.97%) individuals having liver fibrosis. Patients with NAFLD exhibited a higher proportion of males, elevated body mass index (BMI), and increased likelihood of hypertension, diabetes mellitus, and atherosclerosis. Logistic regression analysis identified the neutrophil to albumin ratio (NAR) as the most promising novel inflammation biomarkers, with the highest AUC value of 0.701, a cut-off value of 0.797, sensitivity of 69.40%, and specificity of 66.00% in identifying the risk of NAFLD. Moreover, NAR demonstrated superior predictive value in identifying NAFLD patients at risk of liver fibrosis, with an AUC value of 0.795, sensitivity of 71.30%, and specificity of 73.60% when NAR reached 1.285.

Conclusion

These findings highlight that the novel inflammatory biomarker, NAR, is a convenient and easily accessible non-invasive predictor for NAFLD and NAFLD with liver fibrosis.

Metabolic dysfunction-associated fatty liver disease: current therapeutic strategies

The definition of "Metabolic Associated Fatty Liver Disease - MAFLD" has replaced the previous definition of Nonalcoholic Fatty Liver Disease (NAFLD), because cardiometabolic criteria have been added for the prevention of cardiological risk in these patients. This definition leads to an in-depth study of the bidirectional relationships between hepatic steatosis, Type 2 Diabetes Mellitus (T2DM), Cardiovascular Disease (CVD) and/or their complications. Lifestyle modification, which includes correct nutrition combined with regular physical activity, represents the therapeutic cornerstone of MAFLD. When therapy is required, there is not clear accord on how to proceed in an optimal way with nutraceutical or pharmacological therapy. Numerous studies have attempted to identify nutraceuticals with a significant benefit on metabolic alterations and which contribute to the improvement of hepatic steatosis. Several evidences are supporting the use of silymarin, berberine, curcumin, Nigella sativa, Ascophyllum nodosum, and Fucus vesiculosus, vitamin E, coenzyme Q10 and Omega-3. However, more evidence regarding the long-term efficacy and safety of these compounds are required. There is numerous evidence that highlights the use of therapies such as incretins or the use of Proprotein Convertase Subtilisin/Kexin type 9 (PCSK9) inhibitors or other similar therapies which, by assisting existing therapies for pathologies such as diabetes, hypertension, insulin resistance, have given a breakthrough in prevention and the reduction of cardiometabolic risk. This review gave an overview of the current therapeutic strategies that are expected to aid in the treatment and prevention of MAFLD.

NADPH oxidase 1 promotes hepatic steatosis in obese mice and is abrogated by augmented skeletal muscle mass

Exercise as a lifestyle modification is a frontline therapy for nonalcoholic fatty liver disease (NAFLD), but how components of exercise attenuate steatosis is unclear. To uncouple the effect of increased muscle mass from weight loss in obesity, myostatin knockout mice were bred on a lean and obese db/db background. Myostatin deletion increases gastrocnemius (Gastrocn.) mass and reduces hepatic steatosis and hepatic sterol regulatory element binding protein 1 (Srebp1) expression in obese mice, with no impact on adiposity or body weight. Interestingly, hypermuscularity reduces hepatic NADPH oxidase 1 (Nox1) expression but not NADPH oxidase 4 (Nox4) in db/db mice. To evaluate a deterministic function of Nox1 on steatosis, Nox1 knockout mice were bred on a lean and db/db background. NOX1 deletion significantly attenuates hepatic oxidant stress, steatosis, and Srebp1 programming in obese mice to parallel hypermuscularity, with no improvement in adiposity, glucose control, or hypertriglyceridemia to suggest off-target effects. Directly assessing the role of NOX1 on SREBP1, insulin (Ins)-mediated SREBP1 expression was significantly increased in either NOX1, NADPH oxidase organizer 1 (NOXO1), and NADPH oxidase activator 1 (NOXA1) or NOX5-transfected HepG2 cells versus ?-galactosidase control virus, indicating superoxide is the key mechanistic agent for the actions of NOX1 on SREBP1. Metabolic Nox1 regulators were evaluated using physiological, genetic, and diet-induced animal models that modulated upstream glucose and insulin signaling, identifying hyperinsulinemia as the key metabolic derangement explaining Nox1-induced steatosis in obesity. GEO data revealed that hepatic NOX1 predicts steatosis in obese humans with biopsy-proven NAFLD. Taken together, these data suggest that hypermuscularity attenuates Srebp1 expression in db/db mice through a NOX1-dependent mechanism.NEW & NOTEWORTHY This study documents a novel mechanism by which changes in body composition, notably increased muscle mass, protect against fatty liver disease. This mechanism involves NADPH oxidase 1 (NOX1), an enzyme that increases superoxide and increases insulin signaling, leading to increased fat accumulation in the liver. NOX1 may represent a new early target for preventing fatty liver to stave off later liver diseases such as cirrhosis or liver cancer.

The Impact of Obesity on Diabetes Onset and Neovascularization in Mouse Models of Metabolic Stress

Animal models of metabolic disorders are essential to studying pathogenic mechanisms and developing therapies for diabetes, but the induction protocols vary, and sexual dimorphism often exists. In a chronic diabetic model of diet-induced obesity (DIO) and low-dose streptozotocin (STZ)-induced hyperglycemia, blood glucose and lipid profiles were measured. The high-fat (HF) diet damaged insulin sensitivity and increased triglycerides, total cholesterol, LDL-cholesterol, HDL-cholesterol, and liver lipid deposition. STZ increased blood glucose and liver fibrosis with less effects on blood lipids or liver lipid deposition. The combination of DIO and STZ treatments led to significant liver lipid deposition and fibrosis. Female mice showed delayed body weight gain on HF diet and resisted STZ-induced hyperglycemia. However, once they developed DIO, which occurs around 26 weeks of HF diet, the female mice were prone to STZ-induced hyperglycemia. In hindlimb ischemia, male mice in the DIO-STZ group showed significantly worse neovascularization compared with DIO or STZ groups. The DIO-STZ females showed significantly worse recovery than the DIO-STZ males. Our observations suggest that DIO-STZ is a plausible model for studying metabolic and cardiovascular disorders in obesity and diabetes. Moreover, the findings in female animals stress the need to assess sexual dimorphism and investigate the underlying mechanisms that contribute to the worse vasculopathy manifestations in females in metabolic models.

Nonalcoholic Fatty Liver Disease (NAFLD) and Cardiovascular Risk: Is Imaging Helpful?

Nonalcoholic Fatty Liver Disease (NAFLD) is proving to be a globally prevalent condition. Moreover, NAFLD may be an independent risk factor associated with higher cardiovascular (CVD) morbidity and mortality. Further studies are needed to assess whether NAFLD needs to be included in the atherosclerotic risk score algorithms or whether patients with NAFLD need to be screened early on to assess their CVD risk especially since imaging such as positron emission tomography can be used to assess both NAFLD and CV disease at the same time. Therefore employing cardiovascular imaging modalities to investigate the incidence, extent, and nature of atherosclerotic lesions in NAFLD may be beneficial. Additionally, whether treating NAFLD halts the progression of CVD on imaging remains to be seen. Further research to delineate NAFLD and CVD associations, deciphering screening imaging modalities, and investigating targeted interventions could improve CVD morbidity and mortality in NAFLD.

Performance of nonalcoholic fatty liver fibrosis score in estimating atherosclerotic cardiovascular disease risk

BACKGROUND AND AIMS

It is currently unclear whether the nonalcoholic fatty liver disease (NAFLD) fibrosis score, when compared to major anthropometric indices, is useful in estimating the risk of atherosclerotic cardiovascular disease (ASCVD).

METHODS AND RESULTS

This study included 3886 adults undergoing a health checkup. An elevated risk of ASCVD was determined as a 10-year ASCVD risk ≥7.5% using Pooled Cohort Equations. NAFLD was diagnosed with abdominal ultrasonography. Receiver operating characteristic curves were used to evaluate the performance of estimating an elevated ASCVD risk. Among study participants, 521 (13.4%) had an elevated ASCVD risk and 1473 (37.9%) had NAFLD. Subjects with NAFLD had a significantly higher rate of ASCVD risk ≥7.5% (p < 0.001) compared to those without NAFLD. After adjusting for cardiometabolic risk factors, NAFLD (OR = 1.49, 95% CI: 1.10-2.00, p = 0.009) in all participants and NAFLD fibrosis score >0.676 (OR = 1.95, 95% CI: 1.30-2.92, p = 0.001) in individuals with NAFLD were significantly associated with an elevated risk of ASCVD. When compared to different anthropometric indices, NAFLD fibrosis score exhibited the largest area under the curve (AUC) in individuals with NAFLD (AUC = 0.750) in estimating an elevated ASCVD risk. Furthermore, NAFLD fibrosis score displayed the best predictive performance for identifying an elevated ASCVD risk in male participants with NAFLD (AUC = 0.737).

CONCLUSION

NAFLD was a significant risk factor for elevated ASCVD risk. NAFLD fibrosis score >0.676 was associated with increased ASCVD risk in individuals with NAFLD. Compared with anthropometric indices, NAFLD fibrosis score demonstrated the best performance in estimating elevated ASCVD risk among those with NAFLD.

Predictive Value of Fatty Liver Index for Long-Term Cardiovascular Events in Patients Receiving Liver Transplantation: The COLT Study

BACKGROUND AND AIMS

Cardiovascular disease (CVD) is the leading cause of early mortality in orthotopic liver transplantation (OLT) patients. The fatty liver index (FLI) is strongly associated with carotid and coronary atherosclerosis, as well as cardiovascular mortality, surpassing traditional risk factors. Given the lack of data on FLI as a predictor of cardiovascular events in OLT recipients, we conducted a retrospective study to examine this topic.

METHODS AND RESULTS

We performed a multicenter retrospective analysis of adult OLT recipients who had regular follow-up visits every three to six months (or more frequently if necessary) from January 1995 to December 2020. The minimum follow-up period was two years post-intervention. Anamnestic, clinical, anthropometric and laboratory data were collected, and FLI was calculated for all patients.

CLINICAL TRIAL

gov registration ID NCT05895669. A total of 110 eligible patients (median age 57 years [IQR: 50-62], 72.7% male) were followed for a median duration of 92.3 months (IQR: 45.7-172.4) post-liver transplantation. During this period, 16 patients (14.5%) experienced at least one adverse cardiovascular event (including fatal and non-fatal myocardial infarction and stroke). Receiver Operating Characteristic (ROC) analysis identified a cut-off value of 66.0725 for predicting cardiovascular events after OLT, with 86.7% sensitivity and 63.7% specificity (68% vs. 31%; p = 0.001). Kaplan-Meier analysis showed that patients with FLI > 66 had significantly reduced cardiovascular event-free survival than those with FLI ≤ 66 (log-rank: 0.0008). Furthermore, multivariable Cox regression analysis demonstrated that FLI > 66 and pre-OLT smoking were independently associated with increased cardiovascular risk.

CONCLUSIONS

Our findings suggest that FLI > 66 and pre-OLT smoking predict cardiovascular risk in adult OLT recipients.

Histone Modifications in NAFLD: Mechanisms and Potential Therapy

Nonalcoholic fatty liver disease (NAFLD) is a progressive condition that encompasses a spectrum of liver disorders, beginning with the simple steatosis, progressing to nonalcoholic steatohepatitis (NASH), and possibly leading to more severe diseases, including liver cirrhosis and hepatocellular carcinoma (HCC). In recent years, the prevalence of NAFLD has increased due to a shift towards energy-dense dietary patterns and a sedentary lifestyle. NAFLD is also strongly associated with metabolic disorders such as obesity and hyperlipidemia. The progression of NAFLD could be influenced by a variety of factors, such as diet, genetic factors, and even epigenetic factors. In contrast to genetic factors, epigenetic factors, including histone modifications, exhibit dynamic and reversible features. Therefore, the epigenetic regulation of the initiation and progression of NAFLD is one of the directions under intensive investigation in terms of pathogenic mechanisms and possible therapeutic interventions. This review aims to discuss the possible mechanisms and the crucial role of histone modifications in the framework of epigenetic regulation in NAFLD, which may provide potential therapeutic targets and a scientific basis for the treatment of NAFLD.

A proposal from the liver forum for the management of comorbidities in non-alcoholic steatohepatitis therapeutic trials

The current document has been developed by the Liver Forum who mandated the NAFLD-Associated Comorbidities Working Group - a multistakeholder group comprised of experts from academic medicine, industry and patient associations - to identify aspects of diverse comorbidities frequently associated with non-alcoholic steatohepatitis (NASH) that can interfere with the conduct of therapeutic trials and, in particular, impact efficacy and safety results. The objective of this paper is to propose guidance for the management of relevant comorbidities in both candidates and actual participants in NASH therapeutic trials. We relied on specific guidelines from scientific societies, when available, but adapted them to the particulars of NASH trials with the aim of addressing multiple interacting requirements such as maintaining patient safety, reaching holistic therapeutic objectives, minimising confounding effects on efficacy and safety of investigational agents and allowing for trial completion. We divided the field of action into: first, analysis and stabilisation of the patient's condition before inclusion in the trial and, second, management of comorbidities during trial conduct. For the former, we discussed the concept of acceptable vs. optimal control of comorbidities, defined metabolic and ponderal stability prior to randomisation and weighed the pros and cons of a run-in period. For the latter, we analysed non-hepatological comorbid conditions for changes or acute events possibly occurring during the trial, including changes in alcohol consumption, in order to detail when specific interventions are necessary and how best to manage concomitant drug intake in line with methodological constraints. These recommendations are intended to act as a guide for clinical trialists and are open to further refinement when additional data become available.

Fatty Liver Index and Its Association with 10-Year Atherosclerotic Cardiovascular Disease Risk: Insights from a Population-Based Cross-Sectional Study in China

This cross-sectional study aimed to investigate the association between non-alcoholic fatty liver disease (NAFLD) and atherosclerotic cardiovascular disease (ASCVD), a global public health concern. A total of 9044 out of 10,104 adults from Guangzhou, China, were included in the analysis. We utilized the fatty liver index (FLI), a noninvasive indicator of NAFLD, and the pooled cohort equations (PCE) based on the 2013 ACC/AHA Guideline, the China-PAR model, and the Framingham Risk Score to assess the 10-year ASCVD risk. The results demonstrated a significant association between FLI and 10-year ASCVD risk (p < 0.001). Adjusted for age, individuals with high FLI (≥60) had an odds ratio of 3.91 (95% CI 2.52-6.08) compared to those with low FLI (<30). These findings persisted after adjusting for metabolic indicators. Notably, this association was consistently observed across all three risk prediction models: the PCE model, the China-PAR model, and the Framingham Risk Score. In conclusion, our study provides evidence supporting FLI as a reliable indicator of increased 10-year ASCVD risk in Chinese NAFLD patients. FLI serves as a valuable marker for early detection of ASCVD, highlighting its potential in clinical practice for risk assessment and prevention strategies.

Cardiac dysfunction in a cohort of biopsy proven nonalcoholic steatohepatitis in comparison to nonalcoholic fatty liver

Introduction

NAFLD (non-alcoholic fatty liver disease) is increasing worldwide. Inflammation, fibrosis, and steatosis are the three components of NAFLD. Cardiac events are the most common cause of death in NAFLD. It is believed that there is an association between the inflammatory component of NAFLD and cardiac dysfunction. The gold standard for diagnosis of NAFLD is liver biopsy. Based on histology, NAFLD is categorized into two, nonalcoholic fatty liver (NAFL) and nonalcoholic steatohepatitis (NASH). As biopsy is an invasive procedure, studies comparing cardiac dysfunction in NAFL and NASH are few. The aim of our study is to compare cardiac dysfunction in patients with NAFL and NASH.

Materials and method

This is a cross-sectional study in which all patients who were biopsy proven for NAFLD without stage 4 fibrosis were included. Cardiac dysfunction in these patients was assessed by 2 D ECHO.

Results

Out of the 92 patients, 52 were males and 40 were females (53.5 vs 46.5 %). Among these patients, 48 had NAFL, whereas 48 had NASH. Among the variables analyzed for the study SGOT, SGPT, ALP, Ferritin, ANA, TSH, LVEF, LA diameter, E/e, NAS score, lobular inflammation, ballooning, and steatosis statistically correlated with cardiac diastolic dysfunction. Majority of the patients with NASH had cardiac dysfunction (32/44) while only a few patients with NAFL (4/48) had cardiac dysfunction (p value = 0.002). Among the variables that can cause diastolic dysfunction, i.e., coronary artery disease, dyslipidemia, diabetes mellitus, and hypertension, only diabetes mellitus had an independent association. By binary logistic regression, it was seen that NASH was an independent risk factor for predicting cardiac dysfunction.

Conclusion

The prevalence of cardiac dysfunction is more in NASH than NAFL in patients with NAFLD. NASH is an independent risk factor for cardiac dysfunction. There is no correlation between fibrosis and diastolic dysfunction.

The interplay between nonalcoholic fatty liver disease and atherosclerotic cardiovascular disease

Therapeutic approaches that lower circulating low-density lipoprotein (LDL)-cholesterol significantly reduced the burden of cardiovascular disease over the last decades. However, the persistent rise in the obesity epidemic is beginning to reverse this decline. Alongside obesity, the incidence of nonalcoholic fatty liver disease (NAFLD) has substantially increased in the last three decades. Currently, approximately one third of world population is affected by NAFLD. Notably, the presence of NAFLD and particularly its more severe form, nonalcoholic steatohepatitis (NASH), serves as an independent risk factor for atherosclerotic cardiovascular disease (ASCVD), thus, raising interest in the relationship between these two diseases. Importantly, ASCVD is the major cause of death in patients with NASH independent of traditional risk factors. Nevertheless, the pathophysiology linking NAFLD/NASH with ASCVD remains poorly understood. While dyslipidemia is a common risk factor underlying both diseases, therapies that lower circulating LDL-cholesterol are largely ineffective against NASH. While there are no approved pharmacological therapies for NASH, some of the most advanced drug candidates exacerbate atherogenic dyslipidemia, raising concerns regarding their adverse cardiovascular consequences. In this review, we address current gaps in our understanding of the mechanisms linking NAFLD/NASH and ASCVD, explore strategies to simultaneously model these diseases, evaluate emerging biomarkers that may be useful to diagnose the presence of both diseases, and discuss investigational approaches and ongoing clinical trials that potentially target both diseases.

MAFLD: a multisystem disease

Nonalcoholic fatty liver disease (NAFLD), affecting about 25% of general population and more than 50% of dysmetabolic patients, is an emerging cause of chronic liver disease and its complications. Recently, an international consensus of experts proposed to rename this disease as 'Metabolic dysfunction-Associated Fatty Liver Disease' (MAFLD) to focus on the bidirectional interplay between fatty liver and metabolic alterations and to stress the need of assessing fatty liver independently from alcohol consumption and other coexisting causes of liver disease. The peculiarity of NAFLD/MAFLD lies in the presence of a higher risk of not only - as expected - liver-related events but also of extrahepatic events, mostly cardiovascular and cancers. Available evidence suggests that these associations are not only the expression of sharing the same risk factors but shed light about the ability of NAFLD/MAFLD and particularly of its progressive form - nonalcoholic/metabolic dysfunction-associated steatohepatitis - to act as an independent risk factor via promotion of atherogenic dyslipidemia and a proinflammatory, profibrogenic, and procoagulant systemic environment. The present review summarizes available epidemiological and clinical evidence supporting the concept of NAFLD/MAFLD as a multisystemic disease, and highlights potential explanatory mechanisms underlying the association between NAFLD/MAFLD and extrahepatic disorders.

Shared Mechanisms between Cardiovascular Disease and NAFLD

The burden of nonalcoholic fatty liver disease (NAFLD) is rising globally. Cardiovascular disease is the leading cause of death in patients with NAFLD. Nearly half of individuals with NAFLD have coronary heart disease, and more than a third have carotid artery atherosclerosis. Individuals with NAFLD are at a substantially higher risk of fatal and nonfatal cardiovascular events. NAFLD and cardiovascular disease share multiple common disease mechanisms, such as systemic inflammation, insulin resistance, genetic risk variants, and gut microbial dysbiosis. In this review, we discuss the epidemiology of cardiovascular disease in NAFLD, and highlight common risk factors. In addition, we examine recent advances evaluating the shared disease mechanisms between NAFLD and cardiovascular disease. In conclusion, multidisciplinary collaborations are required to further our understanding of the complex relationship between NAFLD and cardiovascular disease and potentially identify therapeutic targets.

Assessment of fatty liver and its correlation with glycemic control in patients with type 2 diabetes mellitus attending Dessie Comprehensive Specialized Hospital, Northeast Ethiopia

OBJECTIVES

The purpose of conducting this study was to assess fatty liver disease and its correlation with glycemic control in type 2 diabetes mellitus patients. In addition, evaluation of associated factors and correlation analysis between the fatty liver index and hemoglobin A1C level in patients with type 2 diabetes mellitus was another aim of this study.

METHODS

A hospital-based cross-sectional study was conducted among type 2 diabetes mellitus patients attending at diabetes clinic of Dessie Comprehensive Specialized Hospital located in south Wollo, Ethiopia. It was conducted from July to August 2021. The fatty liver index was calculated to assess fatty liver disease. Simple descriptive statistics, multivariate analysis, and an independent sample t-test were utilized for statistical analysis. Multiple logistic regression analysis was used to determine the associated factors of fatty liver. The p value < 0.05 was considered as statistically significant.

RESULTS

In this study, the mean ± standard deviation values of body mass index among type 2 diabetes mellitus patients were 25.82 ± 3.64, 28.04 ± 2.43, and 22.70 ± 2.62 in both fatty and non-fatty liver cases, respectively. In this study, the prevalence of fatty liver among type 2 diabetes mellitus patients was 58.4%. There was a significant positive correlation between the level of Hemoglobin A1C or glycated hemoglobin and fatty liver index (p value = 0.008, r = 0.35). The development of fatty liver was 4.6 times more likely among patients with type 2 diabetes mellitus who had insufficient physical exercise than sufficient exercise. Patients with insulin and oral hypoglycemic drugs were 0.8 folds less likely to have a fatty liver as compared to oral hypoglycemic drug treatment.

CONCLUSION

The results of this study showed that the prevalence of non-alcoholic fatty liver disease was elevated among patients with type 2 diabetes mellitus who had higher levels of body mass index, waist circumference, triglycerides, glycated hemoglobin, and gamma-glutamyltransferase. Therefore, glycemic control, sufficient physical exercise, and insulin treatment may reduce the risk of fatty liver disease in patients with type 2 diabetes mellitus.

Immune cell-mediated features of non-alcoholic steatohepatitis

Non-alcoholic fatty liver disease (NAFLD) includes a range of hepatic manifestations, starting with liver steatosis and potentially evolving towards non-alcoholic steatohepatitis (NASH), cirrhosis or even hepatocellular carcinoma. NAFLD is a major health burden, and its incidence is increasing worldwide. Although it is primarily a disease of disturbed metabolism, NAFLD involves several immune cell-mediated inflammatory processes, particularly when reaching the stage of NASH, at which point inflammation becomes integral to the progression of the disease. The hepatic immune cell landscape is diverse at steady state and it further evolves during NASH with direct consequences for disease severity. In this Review, we discuss current concepts related to the role of immune cells in the onset and progression of NASH. A better understanding of the mechanisms by which immune cells contribute to NASH pathogenesis should aid the design of innovative drugs to target NASH, for which current therapeutic options are limited.

Low total osteocalcin levels are associated with all-cause and cardiovascular mortality among patients with type 2 diabetes: a real-world study

BACKGROUND

The association between osteocalcin and mortality has been scantly studied. We aimed to investigate the association between osteocalcin along with its trajectories and mortality based on long-term longitudinal data.

METHODS

We performed a retrospective cohort study of 9413 type 2 diabetic patients with at least three measurements of total serum osteocalcin within 3 years since their first inpatient diagnosis of type 2 diabetes. Baseline, mean values of osteocalcin levels and their trajectories were used as exposures. A multivariable-adjusted Cox proportional hazards model was used to estimate the association of osteocalcin levels and their trajectories with mortality.

RESULTS

During a mean follow-up of 5.37 years, 1638 patients died, of whom 588 were due to cardiovascular events. Multivariable-adjusted hazard ratios (HRs) across quintiles of baseline osteocalcin levels were 2.88 (95% confidence interval (CI) 2.42-3.42), 1.65 (95% CI 1.37-1.99), 1.17 (95% CI 0.96-1.42), 1.00, and 1.92 (95% CI 1.60-2.30) for all-cause mortality, and 3.52 (95% CI 2.63-4.71), 2.00 (95% CI 1.46-2.73), 1.03 (95% CI 0.72-1.47), 1.00, 1.67 (95% CI 1.21-2.31) for CVD mortality, respectively. When we used the mean values of osteocalcin as the exposure, U-shaped associations were also found. These U-shaped associations were consistent among patients of different baseline characteristics. Patients with a stable or even increasing trajectory of osteocalcin may have a lower risk of both all-cause and CVD mortality.

CONCLUSIONS

A U-shape association between baseline osteocalcin and mortality was observed among patients with type 2 diabetes. Patients with lower levels of serum osteocalcin during follow-ups had higher risks for all-cause and cardiovascular mortality.

Metabolic Dysfunction-Associated Fatty Liver Disease Is Associated with the Risk of Incident Cardiovascular Disease: A Prospective Cohort Study in Xinjiang

In 2020, a group of international experts proposed a new term ‘metabolic dysfunction-associated fatty liver disease’ (MAFLD) to replace ‘non-alcoholic fatty liver disease’. This study aimed to describe the epidemic characteristics of MAFLD, incidence of cardiovascular disease (CVD), and relationship between MAFLD and incident CVD. In 2016, 12,794 Uyghur adults from Kashgar, Xinjiang, were grouped according to the presence or absence of MAFLD. The primary outcome was the occurrence of CVD events. Fatty liver was diagnosed using ultrasound. The prevalence of MAFLD was 16.55%. After excluding patients with previous CVD, 11,444 participants were followed up for a median period of 4.7 years. During the follow-up period, the overall CVD incidence was 10.40% (1190/11,444). The incidence of CVD in the patients with MAFLD was significantly higher than that in the non-MAFLD patients (18.38% vs. 9.02%, p < 0.001; multivariable-adjusted hazard ratio = 1.37, 95% CI = 1.20−1.56). The prevalence of MAFLD was relatively low, whereas the incidence of CVD was relatively high among the Uyghur adults in rural Xinjiang. Individuals with MAFLD have a higher risk of developing CVD independent of traditional cardiovascular risk factors, obesity, type 2 diabetes mellitus (T2DM), and dyslipidaemia.

Nonalcoholic Fatty Liver Disease and Cardiovascular Risk: A Scientific Statement From the American Heart Association

Nonalcoholic fatty liver disease (NAFLD) is an increasingly common condition that is believed to affect >25% of adults worldwide. Unless specific testing is done to identify NAFLD, the condition is typically silent until advanced and potentially irreversible liver impairment occurs. For this reason, the majority of patients with NAFLD are unaware of having this serious condition. Hepatic complications from NAFLD include nonalcoholic steatohepatitis, hepatic cirrhosis, and hepatocellular carcinoma. In addition to these serious complications, NAFLD is a risk factor for atherosclerotic cardiovascular disease, which is the principal cause of death in patients with NAFLD. Accordingly, the purpose of this scientific statement is to review the underlying risk factors and pathophysiology of NAFLD, the associations with atherosclerotic cardiovascular disease, diagnostic and screening strategies, and potential interventions.

Current considerations for clinical management and care of non-alcoholic fatty liver disease: Insights from the 1st International Workshop of the Canadian NASH Network (CanNASH)

Non-alcoholic fatty liver disease (NAFLD) affects approximately 8 million Canadians. NAFLD refers to a disease spectrum ranging from bland steatosis to non-alcoholic steatohepatitis (NASH). Nearly 25% of patients with NAFLD develop NASH, which can progress to liver cirrhosis and related end-stage complications. Type 2 diabetes and obesity represent the main risk factors for the disease. The Canadian NASH Network is a national collaborative organization of health care professionals and researchers with a primary interest in enhancing understanding, care, education, and research around NAFLD, with a vision of best practices for this disease state. At the 1st International Workshop of the CanNASH network in April 2021, a joint event with the single topic conference of the Canadian Association for the Study of the Liver (CASL), clinicians, epidemiologists, basic scientists, and community members came together to share their work under the theme of NASH. This symposium also marked the initiation of collaborations between Canadian and other key opinion leaders in the field representative of international liver associations. The main objective is to develop a policy framework that outlines specific targets, suggested activities, and evidence-based best practices to guide provincial, territorial, and federal organizations in developing multidisciplinary models of care and strategies to address this epidemic.

Performance of Serum-Based Scores for Identification of Mild Hepatic Steatosis in HBV Mono-infected and HBV-HIV Co-infected Adults

BACKGROUND

There are limited data on noninvasive methods to identify hepatic steatosis in coexisting hepatitis B virus (HBV) infection.

AIMS

To evaluate the diagnostic performance of noninvasive serum-based scores to detect steatosis using two distinct chronic HBV cohorts with liver histology evaluation.

METHODS

Chronic HBV cohorts with untreated HBV mono-infection (N = 302) and with treated HBV-HIV (N = 92) were included. Liver histology was scored centrally. Four serum-based scores were calculated: hepatic steatosis index (HSI), nonalcoholic fatty liver disease Liver Fat Score (NAFLD-LFS), visceral adiposity index (VAI), and triglyceride glucose (TyG) index. Optimal cutoffs (highest sensitivity + specificity) to detect ≥ 5% HS, stratified by cohort, were evaluated.

RESULTS

HBV-HIV (vs. HBV mono-infected) patients were older (median 50 vs. 43 years), and a higher proportion were male (92% vs. 60%), were black (51% vs. 8%), had the metabolic syndrome (41% vs. 25%), and suppressed HBV DNA (< 1000 IU/mL; 82% vs. 9%). Applying optimal cutoffs, the area under the receiver operator curve for detecting ≥ 5% steatosis in HBV-only and HBV-HIV, respectively, was 0.69 and 0.61 for HSI, 0.70 and 0.76 for NAFLD-LFS, 0.68 and 0.64 for TyG, and 0.68 and 0.69 for VAI. The accuracy of optimal cutoffs ranged from 61% (NAFLD-LFS) to 67% (TyG) among HBV-only and 56% (HSI) to 76% (NAFLD-LFS) among HBV-HIV. Negative predictive values were higher than positive predictive values for all scores in both groups.

CONCLUSION

The relative utility of scores to identify steatosis in chronic HBV differs by co-infection/anti-HBV medication status. However, even with population-specific cutoffs, several common serum-based scores have only moderate utility. ClinicalTrials.gov NCT01924455.

Hypercoagulability in Patients with Non-Alcoholic Fatty Liver Disease (NAFLD): Causes and Consequences

Non-alcoholic fatty liver disease (NAFLD) is the most common chronic liver disease, and it is anticipated that it could become even more prevalent in parallel with an increase in the incidence of metabolic diseases closely related to NAFLD, such as obesity, type II diabetes, dyslipidemia, and arterial hypertension. In addition to liver impairment, NAFLD is associated with cardiovascular diseases. Fibrosis, atherosclerosis, and venous thrombosis are basically the pathogenic mechanisms behind these clinical manifestations, and all are plausibly associated with hypercoagulability that may, in turn, develop because of an imbalance of pro- vs. anticoagulants and the presence of such procoagulant molecular species as microvesicles, neutrophil extracellular traps (NETs), and inflammation. The assessment of hypercoagulability by means of thrombin generation is a global procedure that mimics the coagulation process occurring in vivo much better than any other coagulation test, and is considered to be the best candidate laboratory tool for assessing, with a single procedure, the balance of coagulation in NAFLD. In addition to defining the state of hypercoagulability, the assessment of thrombin generation could also be used to investigate, in clinical trials, the best approach (therapeutic and/or lifestyle changes) for minimizing hypercoagulability and, hence, the risk of cardiovascular diseases, progression to atherosclerosis, and liver fibrosis in patients with NAFLD.

Fatty Liver Index is Positively Associated with Arterial Stiffness in a Chinese Cohort Undergoing Health Assessment

Objective

Nonalcoholic fatty fiver disease (NAFLD) is a metabolic liver injury closely related to insulin resistance. Fatty liver index (FLI) can be used as a surrogate marker and is a validated index for NAFLD. This study aimed to explore the relationship between FLI and arterial stiffness in a Chinese population.

Methods

From December 2017 to March 2019, 402 inpatients (mean age 51.12 ± 11.95 years) were recruited for cardiovascular disease screening at Ruijin Hospital North, Shanghai. Measurement of brachial systolic, diastolic, mean, and pulse pressure was done with cuff sphygmomanometry and carotid-femoral pulse wave velocity (cfPWV) was measured (SphygmoCor) to assess arterial stiffness.

Results

Subjects were divided into three groups according to their FLI < 30, normal; 30–59, intermediate fatty liver index; ≥ 60, NAFLD. The proportion of subjects with hepatic steatosis (FLI ≥ 60), intermediate FLI (30–59), and no steatosis (FLI < 30) was 34.4%, 31.8%, and 33.8%, respectively. The male population (53.9%) had significantly higher FLI levels (p < 0.05). Subjects with FLI ≥ 60 had higher cfPWV (8.41 ± 1.77 m/s) than those with FLI < 30 (7.81 ± 1.83 m/s; p = 0.006). cfPWV was positively correlated with logFLI (r = 0.168, p = 0.001). After adjusting for age, sex, body mass index, mean arterial blood pressure, glucose, cholesterol, heart rate, and glomerular filtration rate (eGFR), FLI remained positively associated with cfPWV (β = 0.097, p = 0.024).

Conclusion

cfPWV, as a measure of arterial stiffness, is higher in the NAFLD group when compared to that in normal groups. Fatty liver index is positively associated with arterial stiffness in a Chinese population.

Links between metabolic syndrome and metabolic dysfunction-associated fatty liver disease

Metabolic dysfunction-associated fatty liver disease (MAFLD) is a chronic condition characterized by hepatic fat accumulation combined with underlying metabolic dysregulation. Having evolved from the previous term of nonalcoholic fatty liver disease (NAFLD), the term MAFLD more closely implicates the presence of overweight/obesity, type 2 diabetes, or metabolic dysregulation as essential pathogenic factors, leading to better identification of individuals with this metabolic liver disease. Low-grade inflammation, increased oxidative stress, mitochondrial dysfunction, and intestinal dysbiosis are also involved in its pathogenesis. MAFLD is not only associated with liver-related complications, but also with adverse cardiometabolic outcomes. Further studies are needed to assess whether the newly proposed definition of MAFLD is more accurate than the NAFLD in predicting the adverse liver-related and extrahepatic outcomes.

Current management of NAFLD/NASH

NAFLD is the most common cause of liver disease worldwide, and its prevalence is significantly increasing. Studies have shown that it is associated with comorbidities such as diabetes, metabolic syndrome and obesity. Early diagnosis and management are highly important and could modify the prognosis of the disease. Evaluating the possibility of multiple aetiologies and recognizing the additional causes of liver disease should be a part of the patient's initial assessment. There are no approved drug treatments as yet, so the main management strategies should involve lifestyle changes such as physical activity and dietary re-education.

Carotid Intima-media Thickness in Patients with Non-alcoholic Fatty Liver Disease Attending a Tertiary Care Center: A Descriptive Cross-sectional Study

INTRODUCTION

Non-alcoholic fatty liver disease is fatty infiltration of the liver in the absence of other causes of steatosis. It is strongly associated with central adiposity, high body mass index, insulin resistance states, hypertension, hyperlipidemia which are features of metabolic syndrome. The objective of study is to find out the carotid intima-media thickness of non alcoholic fatty liver disease patients attending a tertiary care center.

METHODS

This was a descriptive cross sectional study conducted at National Academy of Medical Sciences, Bir Hospital from July 2018 to June 2019 among 70 diagnosed cases of non alcoholic fatty liver disease based on ultrasound findings. Data collection was started after receiving ethical approval from Institutional Review Board of the Institute. Convenience sampling method was used. Data were entered using Microsoft Excel. The carotid intima-media thickness of both sides were measured by ultrasound. Statistical Package for Social Sciences version 20 was used for analysis.

RESULTS

Out of 70 cases, the mean carotid intima-media thickness was 0.7140±0.1796mm on right and 0.7161±0.1828mm on left side. Among 70 cases 45 (64.3%) were Grade II non alcoholic fatty liver disease and 25 (35.7%) were Grade I. It was 0.5720±0.1275mm and 0.7929±0.1546mm in Grade I and II non alcoholic fatty liver disease cases respectively on right side whereas it was 0.5676±0.1259mm and 0.7987±0.1557mm respectively on left side.

CONCLUSIONS

This study showed increased carotid intima-media thickness in non alcoholic fatty liver disease cases.

Carotid Intima-media Thickness in Patients with Non-alcoholic Fatty Liver Disease Attending a Tertiary Care Center: A Descriptive Cross-sectional Study

INTRODUCTION

Non-alcoholic fatty liver disease is fatty infiltration of the liver in the absence of other causes of steatosis. It is strongly associated with central adiposity, high body mass index, insulin resistance states, hypertension, hyperlipidemia which are features of metabolic syndrome. The objective of study is to find out the carotid intima-media thickness of non alcoholic fatty liver disease patients attending a tertiary care center.

METHODS

This was a descriptive cross sectional study conducted at National Academy of Medical Sciences, Bir Hospital from July 2018 to June 2019 among 70 diagnosed cases of non alcoholic fatty liver disease based on ultrasound findings. Data collection was started after receiving ethical approval from Institutional Review Board of the Institute. Convenience sampling method was used. Data were entered using Microsoft Excel. The carotid intima-media thickness of both sides were measured by ultrasound. Statistical Package for Social Sciences version 20 was used for analysis.

RESULTS

Out of 70 cases, the mean carotid intima-media thickness was 0.7140±0.1796mm on right and 0.7161±0.1828mm on left side. Among 70 cases 45 (64.3%) were Grade II non alcoholic fatty liver disease and 25 (35.7%) were Grade I. It was 0.5720±0.1275mm and 0.7929±0.1546mm in Grade I and II non alcoholic fatty liver disease cases respectively on right side whereas it was 0.5676±0.1259mm and 0.7987±0.1557mm respectively on left side.

CONCLUSIONS

This study showed increased carotid intima-media thickness in non alcoholic fatty liver disease cases.

Ursodeoxycholic acid as a means of preventing atherosclerosis, steatosis and liver fibrosis in patients with nonalcoholic fatty liver disease

BACKGROUND

Atherosclerotic cardiovascular disease (ASCVD) is the leading cause of mortality in patients with nonalcoholic fatty liver disease (NAFLD). Weight loss is a key factor for successful NAFLD and CVD therapy. Ursodeoxycholic acid (UDCA), which is one of the first-line therapeutic agents for treatment of NAFLD, is reported to have a beneficial effect on dyslipidemia and ASCVD risk because of antioxidant properties.

AIM

To evaluate the effects of 6 mo of UDCA treatment on hepatic function tests, lipid profile, hepatic steatosis and fibrosis, atherogenesis, and ASCVD risk in men and women with NAFLD, as well as to assess the impact of > 5% weight reduction on these parameters.

METHODS

An open-label, multicenter, international noncomparative trial was carried out at primary health care settings and included 174 patients with ultrasound-diagnosed NAFLD who received 15 mg/kg/d UDCA for 6 mo and were prescribed lifestyle modification with diet and exercise. The efficacy criteria were liver enzymes, lipid profile, fatty liver index (FLI), noninvasive liver fibrosis tests (nonalcoholic fatty liver disease fibrosis score and liver fibrosis index), carotid intima-media thickness (CIMT), and ASCVD risk score. To test statistical hypotheses, the Wilcoxon test, paired t-test, Fisher's exact test, and Pearson's chi-squared test were used.

RESULTS

The alanine aminotransferase (ALT) level changed by -14.1 U/L (-31.0; -5.3) from baseline to 3 mo and by -6.5 U/L (-14.0; 0.1) from 3 to 6 mo. The magnitude of ALT, aspartate transaminase, and glutamyltransferase decrease was greater during the first 3 mo of treatment compared to the subsequent 3 mo (P < 0.001, P < 0.01, P < 0.001, respectively). At 6 mo, in the total sample, we observed a statistically significant decrease in body weight and levels of FLI: 84.9 ± 10.4 vs 72.3 ± 17.6, P < 0.001, total cholesterol: 6.03 ± 1.36 vs 5.76 ± 1.21, Р < 0.001, low-density lipoprotein: 3.86 ± 1.01 vs 3.66 ± 0.91, Р < 0.001, and triglyceride: 3.18 (2.00; 4.29) vs 2.04 (1.40; 3.16), Р < 0.001. No effect on nonalcoholic fatty liver disease fibrosis score or liver fibrosis index was found. The CIMT decreased significantly in the total sample (0.985 ± 0.243 vs 0.968 ± 0.237, P = 0.013), whereas the high-density lipoprotein (Р = 0.036) and 10-year ASCVD risk (Р = 0.003) improved significantly only in women. Fifty-four patients (31%) achieved > 5% weight loss. At the end of the study, the FLI decreased significantly in patients with (88.3 ± 10.2 vs 71.4 ± 19.6, P < 0.001) and without > 5% weight loss (83.5 ± 10.3 vs 72.8 ± 16.7, P < 0.001). The changes in ALT, aspartate transaminase, glutamyltransferase, total cholesterol, and low-density lipoprotein levels were similar between the subgroups.

CONCLUSION

UDCA normalizes liver enzymes greatly within the first 3 mo of treatment, improves lipid profile and hepatic steatosis independent of weight loss, and has a positive effect on CIMT in the total sample and 10-year ASCVD risk in women after 6 mo of treatment.

Natural History of NAFLD

The epidemiology and the current burden of chronic liver disease are changing globally, with non-alcoholic fatty liver disease (NAFLD) becoming the most frequent cause of liver disease in close relationship with the global epidemics of obesity, type 2 diabetes and metabolic syndrome. The clinical phenotypes of NAFLD are very heterogeneous in relationship with multiple pathways involved in the disease progression. In the absence of a specific treatment for non-alcoholic steatohepatitis (NASH), it is important to understand the natural history of the disease, to identify and to optimize the control of factors that are involved in disease progression. In this paper we propose a critical analysis of factors that are involved in the progression of the liver damage and the occurrence of extra-hepatic complications (cardiovascular diseases, extra hepatic cancer) in patients with NAFLD. We also briefly discuss the impact of the heterogeneity of the clinical phenotype of NAFLD on the clinical practice globally and at the individual level.

Nine Markers to Predict Nonalcoholic Fatty Liver Disease for a Chinese Diabetic Population

Background: Nonalcoholic fatty liver disease (NAFLD) increases the possibility to suffer from liver or cardiovascular disease. Although hepatic biopsy is well acknowledged as the standard diagnosis, it is difficult to implement because of its intrusiveness and cost concerns. Moreover, overweight people or diabetic patients are always NAFLD-positive, but not absolute. Therefore, to distinguish whether a diabetic case has NAFLD via nonintrusive indicators is of great significance for further interventions. Objective: With 8499 diabetic patients hosted by Shanghai Sixth People’s Hospital, we try to rank the impacts of multiple routine indicators (features) on NAFLD, and further predict NAFLD within this diabetic population. Methods: We first rank dozens of related features according to their contributions in NAFLD prediction, and then we prune several trivial features to simplify the prediction. Additionally, three classification algorithms are considered and compared, e.g., C4.5, Naïve Bayes and Random Forest. Results: The experiment shows that Random Forest outperforms the rest (accuracy 85.1%, recall 90.98% and AUC 0.631). Conclusions: We find that the top nine markers together can effectively tell NAFLD out of this diabetic population. They are triglyceride (TG), low density lipoprotein (LDL), insulin (INS), hbA1C, high-density lipoprotein (HDL), fasting plasma glucose (FPG), age, total cholesterol (TC) and duration.

Diagnostic value of serological biomarkers for detection of non-alcoholic fatty liver disease (NAFLD) and/or advanced liver fibrosis in people living with HIV

OBJECTIVES

We aimed to evaluate the accuracy of serological biomarkers for non-alcoholic fatty liver disease (NAFLD) and advanced fibrosis (METAVIR-F3F4) in HIV mono-infected individuals.

METHODS

In all, 674 participants from the PROSPEC-HIV study (NCT02542020), who had blood sample tests and transient elastography (TE) performed on the same day, were eligible. Exclusion criteria were viral hepatitis co-infection (n = 90), abusive alcohol intake (n = 61), missing data (n = 47) or unreliable TE (n = 39). NAFLD was defined by controlled attenuation parameter ≥ 248 dB/m and advanced fibrosis by liver stiffness measurement ≥ 8.7 kPa with M probe or ≥ 7.2 kPa with XL probe. Biomarkers for NAFLD [Steato-ELSA, Fatty Liver Index (FLI), Hepatic Steatosis Index (HSI), NAFLD-Liver Fat Score (NAFLD-LFS)] and fibrosis [Fibrosis-4 score (FIB-4), Aspartate-to-Platelet Ratio Index (APRI) and NAFLD Fibrosis Score (NFS)] were calculated.

RESULTS

A total of 437 patients [57% female, age = 44 (interquartile range: 35-52) years, body mass index (BMI) = 26.1 (23.4-29.3) kg/m² , CD4 = 660 (427-901) cells/μL] were included. The prevalence [95% confidence interval (CI)] of NAFLD and advanced fibrosis were 38.2% (33.8-42.9) and 10.5% (8.0-13.8), respectively. The areas (95% CI) under the receiver operator curve (AUROCs) for diagnosis of NAFLD were 0.854 (0.818-0.889), 0.840 (0.804-0.877), 0.805 (0.762-0.847) and 0.793 (0.750-0.836) for Steato-ELSA, FLI, HSI and NAFLD-LFS (P < 0.001), respectively. All tests yielded satisfactory sensitivities, specificities and negative predictive values (NPVs). The AUROCs (95% CI) for diagnosis of advanced fibrosis were 0.736 (0.659-0.814), 0.700 (0.614-0.7851) and 0.795 (0.726-0.864) for FIB-4, APRI and NFS (P = 0.077), respectively. These tests yielded high specificities and negative predictive values (NPVs) > 90%.

CONCLUSION

Biomarkers for NAFLD had a good accuracy and those for fibrosis had high specificities and NPVs. These tests should be integrated to HIV care to detect NAFLD and to exclude advanced liver fibrosis.

Dose-response relationship between serum fibroblast growth factor 21 and liver fat content in non-alcoholic fatty liver disease

BACKGROUND & AIM

Although serum fibroblast growth factor 21 (FGF21) levels are associated with liver fat content in non-alcoholic liver fat disease (NAFLD), the precise nature of the association remains undetermined. Therefore, this study aimed to explore the potential dose-response relationship between FGF21 and liver fat content in NAFLD.

METHODS

For this exploratory study from a randomized trial, 220 NAFLD patients with central obesity were recruited via community-based screening and randomly assigned to either control, moderate or vigorous-moderate exercise groups for 12 months. After this exercise intervention, patients were followed-up for a further 12 months. Serum FGF21 levels were measured by ELISA. Intrahepatic triglyceride (IHTG) content was determined by proton magnetic resonance spectroscopy.

RESULTS

Of the 220 patients, 149 (67.7%) were female; mean age was 53.9 ± 7.1 years and mean BMI was 28.0 ± 2.9 kg/m² for all patients. Baseline IHGT increased gradually (P = 0.029 for trend) according to baseline serum FGF21 quartiles 1, 2, 3 and 4 (212.3, 358.9, 538.7 and 793.5 pg/mL, respectively). On grouping the distribution of serum FGF21 level changes into quartiles at month 12, the relative IHTG loss increased as serum FGF21 levels were reduced (P = 0.004 for trend). A similar trend was observed at month 24 (P = 0.006 for trend). Multivariate linear regression analysis revealed that changes in serum FGF21 levels were independently associated with changes in IHTG at both month 12 [β (SE), 0.136 (0.118); P = 0.048] and month 24 [β (SE), 0.152 (0.139); P = 0.041]. Using restricted cubic spline regression, changes in serum FGF21 were strongly and positively associated with their corresponding relative IHTG loss at both month 12 and follow-up (P_overall = 0.017, P_non-linear = 0.044 and P_overall = 0.020, P_non-linear = 0.361, respectively, for dose-response).

CONCLUSION

Serum FGF21 is strongly associated with liver fat content in a dose-response manner in centrally obese NAFLD patients. These findings support the use of serum FGF21 as a biomarker of liver fat content in NAFLD.

The pivotal role of heme Oxygenase-1 in reversing the pathophysiology and systemic complications of NAFLD

The pathogenesis and molecular pathways involved in non-alcoholic fatty liver disease (NAFLD) are reviewed, as well as what is known about mitochondrial dysfunction that leads to heart disease and the progression to steatohepatitis and hepatic fibrosis. We focused our discussion on the role of the antioxidant gene heme oxygenase-1 (HO-1) and its nuclear coactivator, peroxisome proliferator-activated receptor-gamma coactivator (PGC1-α) in the regulation of mitochondrial biogenesis and function and potential therapeutic benefit for cardiac disease, NAFLD as well as the pharmacological effect they have on the chronic inflammatory state of obesity. The result is increased mitochondrial function and the conversion of white adipocyte tissue to beige adipose tissue ("browning of white adipose tissue") that leads to an improvement in signaling pathways and overall liver function. Improved mitochondrial biogenesis and function is essential to preventing the progression of hepatic steatosis to NASH and cirrhosis as well as preventing cardiovascular complications.

Association between non-alcoholic fatty liver disease and myocardial glucose uptake measured by 18F-fluorodeoxyglucose positron emission tomography

BACKGROUND

Non-alcoholic fatty liver disease (NAFLD) has emerged as an independent risk factor for cardiovascular diseases. However, there were few studies evaluating the condition of myocardial glucose metabolism in patients with NAFLD. Therefore, the aim of this study was to investigate the association between NAFLD and myocardial glucose uptake assessed by using 18F-fluorodeoxyglucose (18F-FDG) positron emission tomography (PET) and whether or not alteration of myocardial glucose uptake could be an indicator linking to cardiac dysfunction in NAFLD individuals.

METHODS AND RESULTS

A total of 743 asymptomatic subjects (201 with NAFLD, 542 without NAFLD) were retrospectively studied. The ratio of maximum myocardium FDG uptake to the mean standardized uptake value of liver (SUVratio) was calculated to estimate myocardial glucose uptake by using 18F-FDG PET. The diagnosis of fatty liver and fatty liver grading was confirmed by unenhanced CT according to diagnostic criterion of previous studies. The myocardial geometric and functional data were obtained by echocardiogram. Myocardial glucose uptake was significantly lower in individuals with NAFLD compared with those without fatty liver (P < .001). When analysis of association trend was performed, SUVratio quartiles showed correlated inversely and strongly with liver steatosis (P < .001). NAFLD patients with lower myocardial glucose uptake were more likely to have higher proportion of increased LV filling pressure (P < .05). A significant relationship between myocardial SUVratio and E/e' ratio was presented in the trend analysis (P < .05). Moreover, multivariate regression analysis showed that myocardial glucose uptake was independently associated with NAFLD after adjusting for clinical important factors (all P < .001).

CONCLUSIONS

The presence of NAFLD in otherwise healthy subjects is closely associated with decreased myocardial glucose uptake assessing by 18F-FDG PET imaging. Furthermore, the NAFLD individuals with lower myocardial glucose uptake are more likely to have high risk of having impaired diastolic heart function.

Clinical considerations in the management of non-alcoholic steatohepatitis cirrhosis pre- and post-transplant: A multi-system challenge

Non-alcoholic steatohepatitis (NASH) is the most common chronic liver disease worldwide, and the fastest growing indication for liver transplantation in the United States. NASH is now the leading etiology for liver transplantation in women, the second leading indication for men, and the most common cause amongst recipients aged 65 years and older. Patients with end-stage liver disease related to NASH represent a unique and challenging patient population due the high incidence of associated comorbid diseases, including obesity, type 2 diabetes (T2D), and hypertension. These challenges manifest in the pre-liver transplantation period with increased waitlist times and waitlist mortality. Furthermore, these patients carry considerable risk of morbidity and mortality both before after liver transplantation, with high rates of T2D, cardiovascular disease, chronic kidney disease, poor nutrition, and disease recurrence. Successful transplantation for these patients requires identification and management of their comorbidities in the face of liver failure. Multidisciplinary evaluations include a thorough pre-transplant workup with a complete cardiac evaluation, control of diabetes, nutritional support, and even, potentially, consultation with a bariatric surgeon. This article provides a comprehensive review of the conditions and challenges facing patients with NASH cirrhosis undergoing liver transplantation and provides recommendations for evaluation and management to optimize them before liver transplantation to produce successful outcomes.

Fatty liver index and development of cardiovascular disease in Koreans without pre-existing myocardial infarction and ischemic stroke: a large population-based study

BACKGROUND

Despite the known association between non-alcoholic fatty liver disease (NAFLD) and cardiovascular disease (CVD), whether NAFLD predicts future CVD events, especially CVD mortality, remains uncertain. We evaluated the relationship between fatty liver index (FLI), a validated marker of NAFLD, and risk of major adverse cardiac events (MACEs) in a large population-based study.

METHODS

We identified 3011,588 subjects in the Korean National Health Insurance System cohort without a history of CVD who underwent health examinations from 2009 to 2011. The primary endpoint was a composite of cardiovascular deaths, non-fatal myocardial infarction (MI), and ischemic stroke. A Cox proportional hazards regression analysis was performed to assess association between the FLI and the primary endpoint.

RESULTS

During the median follow-up period of 6 years, there were 46,010 cases of MACEs (7148 cases of cardiovascular death, 16,574 of non-fatal MI, and 22,288 of ischemic stroke). There was a linear association between higher FLI values and higher incidence of the primary endpoint. In the multivariable models adjusted for factors, such as body weight and cholesterol levels, the hazard ratio for the primary endpoint comparing the highest vs. lowest quartiles of the FLI was 1.99 (95% confidence interval [CIs], 1.91-2.07). The corresponding hazard ratios (95% CIs) for cardiovascular death, non-fetal MI, and ischemic stroke were 1.98 (1.9-2.06), 2.16 (2.01-2.31), and 2.01 (1.90-2.13), respectively (p < 0.001). The results were similar when we performed stratified analyses by age, sex, use of dyslipidemia medication, obesity, diabetes, and hypertension.

CONCLUSIONS

Our findings indicate that the FLI, which is a surrogate marker of NAFLD, has prognostic value for detecting individuals at higher risk for cardiovascular events.

Combined effects of lifestyle risk factors on fatty liver index

Background

Factors of lifestyle may have a major impact on liver-related morbidity and mortality.

We examined independent and joint effects of lifestyle risk factors on fatty liver index (FLI), a biomarker of hepatic steatosis, in a population-based cross-sectional national health survey.

Methods

The study included 12,368 participants (5784 men, 6584 women) aged 25–74 years. Quantitative estimates of alcohol use, smoking, adiposity and physical activity were used to establish a total score of risk factors, with higher scores indicating an unhealthier lifestyle. FLI was calculated based on an algorithm including body mass index, waist circumference, serum gamma-glutamyltransferase and triglycerides.

Results

The occurrence of FLI ≥ 60% indicating fatty liver increased from 2.4% in men with zero risk factors to 81.9% in those with a total risk score of 7–8 (p <  0.0005 for linear trend) and in women from 0 to 73.5% (p <  0.0005). The most striking individual impacts on the likelihood for FLI above 60% were observed for physical inactivity (p <  0.0005 for both genders) and alcohol consumption (p <  0.0005 for men). Interestingly, coffee consumption was also found to increase with increasing risk factor scores (p <  0.0005 for linear trend in both genders).

Conclusions

The data indicates that unfavorable combinations of lifestyle risk factors lead to a high likelihood of hepatic steatosis. Use of FLI as a diagnostic tool may benefit the assessment of interventions aimed at maintaining a healthy lifestyle and prevention of liver-related morbidity.