Using the ELF test, FIB-4 and NAFLD fibrosis score to screen the population for liver disease

Elevated Liver Enzymes in Turner Syndrome: The Role of Low-grade Inflammation and Hormonal Imbalances

Context

Turner syndrome (TS) is a chromosomal disorder in females characterized by the partial or complete absence of 1 X chromosome. Women with TS face a higher risk of liver disease, elevated enzymes and fibrosis, potentially linked to inflammation, and hormonal imbalances, though the cause remains unclear.

Objective

This paper investigates the associations between liver parameters, inflammatory markers, and hormonal factors in women with TS compared with age-matched female controls.

Methods

We included 82 women with TS and 59 female controls. Participants underwent clinical examinations, anthropometric measurements, and fasting biochemical assessments of liver enzymes ( γ-glutamyl transferase [GGT], aspartate aminotransferase [AST], alanine aminotransferase [ALT], FIB-4), inflammatory markers (C-reactive protein [CRP], soluble CD163 [sCD163]), sex hormones, and 11-oxygenated C19 steroids. We also assessed myeloperoxidase (MPO) and neutrophil elastase gene expression levels and performed FibroScan and dual-energy X-ray absorptiometry.

Results

Women with TS had higher levels of liver enzymes (GGT, AST, ALT) and FIB-4 than controls (P < .001, all). The inflammatory markers CRP and sCD163 were both correlated with elevated liver parameters in women with TS. Hormonal variables such as 11β-hydroxytestosterone levels, were also associated with elevated liver enzymes in women with TS. The neutrophil activation marker MPO was elevated in TS and correlated with liver parameters and sCD163.

Conclusion

Women with TS have elevated liver enzymes associated with low-grade chronic inflammation and hormonal imbalances. These findings highlight the importance of regular monitoring of liver function, inflammatory markers, and hormonal levels in women with TS to enable early intervention and potentially improve clinical outcomes.

Ensuring Clinical Excellence: The Mindray SAL9000 Biochemical Immunoassay System

This study aimed to evaluate the performance and clinical laboratory adaptability of the Mindray SAL9000 biochemical immunoassay automation system, ensuring compliance with ISO 15189 standards and relevant national requirements. We conducted comprehensive performance verification tests on 21 biochemical analytes and 15 immunoassays, including precision, accuracy, linear bias, measurement range assessments, interference testing, reference range validation, inter-instrument comparison, and carryover verification. The Mindray SAL9000 demonstrated high performance across various parameters, with all analytes showing good linearity and minimal bias. While specific interfering substances affected some analytes, the system showed excellent resistance to common interferences such as hemolysis, ascorbic acid, and jaundice. The inter-instrument comparison with the BS2000M and Roche 702 indicated a good correlation, with most parameters showing biases of less than 10%, although exceptions were noted for ALT and AST. In conclusion, the Mindray SAL9000 meets clinical requirements through its high precision, excellent accuracy, and broad measurement range, making it a reliable and adaptable choice for clinical outpatient and emergency laboratories.

Disease classification, diagnostic challenges, and evolving clinical trial design in MASLD

Metabolic dysfunction-associated steatotic liver disease (MASLD) diagnosis and management have evolved rapidly alongside the increasing prevalence of obesity and related complications. Hepatology has expanded its focus beyond late-stage cirrhosis and portal hypertension to earlier, complex MASLD cases in younger patients, necessitating closer collaboration with endocrinology. The renaming of nonalcoholic fatty liver disease (NAFLD) to MASLD reflects its pathophysiology, reduces stigma, and has prompted new research directions. Noninvasive tests such as liver stiffness measurement now play a crucial role in diagnosis, reducing reliance on invasive liver biopsies. However, advanced omics technologies, despite their potential to enhance diagnostic precision and patient stratification, remain underutilized in routine clinical practice. Behavioral factors, including posttraumatic stress disorder (PTSD) and lifestyle choices, influence disease outcomes and must be integrated into patient management strategies. Primary care settings are critical for early screening to prevent progression to advanced disease, yet sizable challenges remain in implementing effective screening protocols. This Review explores these evolving aspects of MASLD diagnosis and management, emphasizing the need for improved diagnostic tools, multidisciplinary collaboration, and holistic care approaches to address existing gaps and ensure comprehensive patient care across all healthcare levels.

Targeting neutrophil extracellular traps: SERPINE1 and THBS1 as non-invasive biomarkers for early detection of liver fibrosis in metabolic dysfunction-associated Steatotic liver disease

Metabolic dysfunction - Associated Steatotic Liver Disease (MASLD), formerly known as non-alcoholic fatty liver disease (NAFLD), poses a significant clinical burden due to its high prevalence and potential progression to fibrosis. While neutrophil extracellular traps (NETs) have been implicated in MASLD progression, their specific role in fibrosis remains unclear. This study integrates transcriptomic and single-cell data using weighted gene co-expression network analysis (WGCNA), causal WGCNA (CWGCNA), single-sample gene set enrichment analysis (ssGSEA), gene set variation analysis (GSVA), and linear models for microarray data (Limma) to identify key genes driving steatosis-to-fibrosis transition. Validation in human serum, mouse liver tissue, and mouse serum confirmed that SERPINE1 and THBS1 as robust non-invasive biomarkers with strong diagnostic performance. When combined with clinical features, these markers improved fibrosis prediction accuracy in MASLD patients. Additionally, SERPINE1 appears to mediate interactions between hepatic stellate cells and neutrophils, highlighting a novel therapeutic target. Overall, our findings reveal that NETs-related genes, particularly SERPINE1 and THBS1, hold strong diagnostic value for early-stage fibrosis in MASLD. Targeting SERPINE1 in hepatic stellate cells offers a promising strategy for therapeutic intervention. This study provides a novel framework for non-invasive MASLD fibrosis prediction and lays the foundation for targeted interventions to mitigate disease progression.

Comparison of Referral Rates and Costs Using Fibrosis-4 and Enhanced Liver Fibrosis (ELF) Testing Strategies for Initial Evaluation of Metabolic Dysfunction-Associated Steatotic Liver Disease (MASLD) in a Veteran Population

BACKGROUND

Global metabolic dysfunction-associated steatotic liver disease (MASLD) prevalence is estimated at 30% and projected to reach 55.7% by 2040. In the Veterans Affairs (VA) healthcare system, an estimated 1.8 million veterans have metabolic dysfunction-associated steatohepatitis (MASH).

METHODS

Adult patients at risk for MASLD in a VA healthcare system underwent Fibrosis-4 (FIB-4) and Enhanced Liver Fibrosis (ELF®) testing. Referral rates and cost savings were compared among 6 noninvasive testing (NIT) strategies using these 2 tests independently or sequentially at various cutoffs.

RESULTS

Enrolled patients (N = 254) had a mean age of 65.3 ± 9.3 years and mean body mass index (BMI) of 31.7 ± 6, 87.4% male: 78.3% were non-Hispanic/Latino, and 96.5% had type 2 diabetes mellitus (T2DM). Among the 6 evaluated strategies, using FIB-4 followed by ELF at a 9.8 cutoff yielded the highest proportion of patients retained in primary care without need of referral to hepatology clinic (165/227; 72.7%), and was associated with the lowest costs ($407.62). Compared to the FIB-4 only strategy, FIB-4/ELF with a 9.8 cutoff strategy resulted in 26% fewer referrals and 8.47% lower costs. In the subgroup of patients with BMI >32, there were 25.17% fewer referrals and costs were 8.31% lower.

CONCLUSIONS

Our study suggests that sequential use of ELF with a 9.8 cutoff following indeterminate FIB-4 tests results in lower referral rates and lower care costs in a veteran population at risk of MASLD. Adding ELF as a sequential test after indeterminate FIB-4 might help reduce the number of referrals and overall cost of care.

Targeting Liver Fibrosis with Nanoparticle Technology: The Dual-Drug Strategy for Hepatic Stellate Cell Activation Inhibition

Hepatic stellate cells (HSCs) are pivotal in the pathogenesis and progression of liver fibrosis. Their activation is characterized by increased expression of integrin receptor αvβ3 and elevated intracellular oxidative stress, leading to extracellular matrix deposition. To address these challenges, we developed a nanotechnology-driven drug delivery system for the targeted transport of curcumin (CUR) and dihydromyricetin (DHM), two potential antifibrotic drugs with anti-inflammatory and antioxidant properties, into activated HSCs. Our results demonstrated that intravenously administered cyclo-RGD peptide (cRGDfk)-modified drug-loaded nanoparticles (NPs) effectively targeted fibrotic liver tissues, particularly activated HSCs. These drug-loaded NPs inhibited HSC activation and migration, induced apoptosis in activated HSCs, and downregulated α-SMA expression. In a carbon tetrachloride (CCl4)-induced liver fibrosis model, the NPs exhibited significant antifibrotic effects and reduced the number of Ly6Chi monocyte-derived macrophages in the liver. These findings suggest that cRGDfk-modified NPs carrying CUR and DHM have potential clinical applications in liver fibrosis therapy.

The non-high-density lipoprotein cholesterol to high-density lipoprotein cholesterol ratio as a predictor of all cause and cardiovascular mortality in United States adults with NAFLD: a prospective cohort study

BACKGROUND

The non-HDL cholesterol to HDL cholesterol ratio (NHHR) is a novel composite lipid index. However, its relationship with mortality, particularly in individuals with non-alcoholic fatty liver disease (NAFLD), remains unclear. The aim of this study was to explore the association between NHHR and both all-cause and cardiovascular mortality in adults with NAFLD in the United States.

METHODS

This study included 12,648 adult participants with NAFLD from the National Health and Nutrition Examination Survey (NHANES) database (1999-2018). Multivariate Cox proportional hazards models and restricted cubic spline (RCS) methods were employed to assess all-cause and cardiovascular mortality. Subgroup analyses were performed to verify the consistency of these associations.

RESULTS

Over a median follow-up of 99.27 months, 1,659 participants died from all causes, including 460 from cardiovascular disease. RCS analysis revealed a U-shaped relationship between NHHR and all-cause mortality, no association was found between NHHR and cardiovascular mortality. The inflection points for all-cause mortality were 2.67. Subgroup analysis showed that a stronger association between NHHR and all-cause mortality in those with diabetes(P = 0.048).

CONCLUSIONS

NHHR is associated with all-cause mortality in NAFLD patients, with distinct non-linear relationships, while it is not associated with cardiovascular mortality. NHHR monitoring may be valuable for assessing mortality risk, particularly in those with diabetes.

Non-Invasive Tests as a Replacement for Liver Biopsy in the Assessment of MASLD

Metabolic dysfunction-associated steatotic fatty liver disease (MASLD) is a worsening global health issue, affecting over one-third of the adult population and representing the leading cause of liver-related morbidity and mortality. MASLD is not only a key precursor to chronic liver disease, but also a systemic condition that leads to numerous extrahepatic complications, increasing the risk of cardiovascular diseases, chronic kidney disease, type 2 diabetes, and certain cancers. The primary reference method for assessing liver fibrosis, allowing for precise determination of its location and severity, remains liver biopsy. However, it is an invasive procedure and involves certain risks. In recent years, the importance of MASLD diagnosis using noninvasive diagnostic methods has been increasing, including serological markers, methods based on multi-omics, and imaging techniques such as liver elastography. This review presents data on the diagnosis and evaluation of this disease that may find application in future clinical practice. The focus is on presenting both currently used and newly identified noninvasive diagnostic methods that open up the prospect of gradually replacing biopsy in the diagnosis of MASLD.

Steatotic Liver Disease Classification is Dynamic, Affecting Clinical Trial Eligibility and Subclass-Specific Treatments

BACKGROUND & AIMS

Steatotic liver disease (SLD) includes the subclasses metabolic-dysfunction-associated steatotic liver disease, metabolic and alcohol-related liver disease, and alcohol-related liver disease. We investigated the robustness of the SLD diagnoses after 2 years.

METHODS

We performed a prospective cohort study among individuals from the general population and individuals at risk of SLD. Participants were classified according to the diagnostic criteria of the SLD nomenclature at baseline and after 2 years.

RESULTS

We included 1042 participants, mean age was 57 ± 10 years, 663 were male (64%) and 379 (36%) female, and 70 (7%) had advanced fibrosis. At baseline, 595 (57%) had SLD, hereof 371 (62%) met the criteria for metabolic-dysfunction-associated steatotic liver disease, 140 (24%) for metabolic and alcohol-related liver disease, and 83 (14%) for alcohol-related liver disease, and 1 (<1%) was classified as cryptogenic SLD. Median time between the baseline and follow-up visit was 25 months (interquartile range, 24-31). Overall, 399 (38%) of the 1042 participants changed SLD classification from baseline to follow-up. In the group without SLD at baseline, 25% had SLD at follow-up. In comparison, 38% with metabolic-dysfunction-associated steatotic liver disease at baseline were classified differently at follow-up, whereas 62% and 69% of participants with baseline metabolic and alcohol-related liver disease and alcohol-related liver disease were classified differently at follow-up. The primary reasons for changing classification were that individuals no longer met the criteria for having SLD or had altered their alcohol intake.

CONCLUSIONS

SLD and the subclassification hereof is highly dynamic, especially driven by changes in alcohol use and hepatic steatosis. This affects eligibility for clinical trials and clinical management of patients with SLD.

Association between fibrosis-4 index (FIB-4) and gallstones: an analysis of the NHANES 2017-2020 cross-sectional study

BACKGROUND

Gallstones are a common digestive disorder, yet the association between the fibrosis-4 index (FIB-4) and gallstone formation remains poorly understood. This study explores the link between FIB-4 levels and gallstone prevalence among US adults.

METHODS

This study was based on data from the 2017-2020 National Health and Nutrition Examination Survey (NHANES), which included 7,771 participants. The association between FIB-4 and gallstone risk was analyzed using multivariate logistic regression with restricted cubic spline (RCS) analysis to assess nonlinear correlations, and threshold effects analysis to identify inflection points. Robustness checks included subgroup analysis.

RESULTS

The weighted prevalence of gallstones in this study was 11%. Multiple logistic regression analysis showed that FIB-4 levels were significantly and positively associated with the risk of gallstones. In the fully adjusted model, each unit increase in FIB-4 as a continuous variable increased the risk of gallstones by 19% (OR = 1.19, 95% CI: 1.10, 1.29). When FIB-4 was grouped by quartiles, the risk of gallstones was increased by 60% (OR = 1.60, 95% CI: 1.25, 2.03) in the Q4 group compared to the Q1 group. RCS analysis further revealed a nonlinear positive correlation between FIB-4 and gallstones (P for nonlinear = 0.015) with an inflection point at 2.43, (P for log likelihood ratio test = 0.001). Bonferroni-corrected subgroup analyses showed that the association of FIB-4 with gallstones was statistically significant among non-Hispanic whites, those without heart failure, those without coronary heart disease, alcohol drinkers, and smokers (P < 0.00217).

CONCLUSION

In this study, we found that elevated levels of FIB-4 were significantly and positively association with the risk of gallstones, and showed a non-linear trend. FIB-4 may have a potential application in the risk assessment of gallstones.

The Asian Pacific association for the study of the liver clinical practice guidelines for the diagnosis and management of metabolic dysfunction-associated fatty liver disease

Metabolic dysfunction-associated fatty liver disease (MAFLD) affects over one-fourth of the global adult population and is the leading cause of liver disease worldwide. To address this, the Asian Pacific Association for the Study of the Liver (APASL) has created clinical practice guidelines focused on MAFLD. The guidelines cover various aspects of the disease, such as its epidemiology, diagnosis, screening, assessment, and treatment. The guidelines aim to advance clinical practice, knowledge, and research on MAFLD, particularly in special groups. The guidelines are designed to advance clinical practice, to provide evidence-based recommendations to assist healthcare stakeholders in decision-making and to improve patient care and disease awareness. The guidelines take into account the burden of clinical management for the healthcare sector.

Evidence-based criteria for identifying at-risk individuals requiring liver disease screening

BACKGROUND

Liver fibrosis screening is recommended in at-risk groups, but a clear definition of "at risk" for entry criteria is lacking. We analyzed different combinations of established risk factors to define specific screening entry criteria with a prespecified sensitivity requirement.

METHODS

Data regarding individuals aged 40-70 years from Finnish health-examination surveys (FINRISK 2002-2012 and Health 2000, n=15,057) and the UK Biobank (n=454,990) were linked with healthcare registries for liver cirrhosis-related events (LREs; liver-related hospitalizations, cancer, or death). The predictive performance of 1919 combinations of risk factors, including alcohol consumption, metabolic disturbances, abnormal liver function tests, and Chronic Liver Disease risk score, was assessed for 10-year LRE risk requiring a minimum 90% sensitivity. Validations were performed using liver stiffness measurement (LSM) >12 kPa in the NHANES 2017-2020 sample (n=3367).

RESULTS

Optimal entry criteria for predicting 10-year LRE risk with >90% sensitivity included any one of: hazardous alcohol use, severe obesity, metabolic syndrome, an AST-to-ALT ratio >0.8 with elevated ALT, and an intermediate-to-high Chronic Liver Disease risk score. The sensitivity and specificity for this strategy were 91% and 51% for LREs, respectively, in the Finnish cohort, and 91% and 41% for LSM >12 kPa in the US sample. In the US sample, applying these entry criteria followed by fibrosis-4 ≥1.3 for predicting LSM >12 kPa reduced the sensitivity to 45% (specificity: 85%), which was attributed to the suboptimal sensitivity of fibrosis-4.

CONCLUSIONS

This study identifies an inexpensive risk factor-based strategy with >90% sensitivity for predicting LRE and LSM >12 kPa, which is practical and scalable for targeted liver fibrosis screening to improve population outcomes. However, a more sensitive first-line noninvasive fibrosis test is needed.

Increasing engagement with liver disease management across the UK: a follow-up cross-sectional survey

BACKGROUND

Liver disease is an increasing cause of premature mortality. Early detection of liver disease in primary care gives opportunity to intervene and change outcomes. Engagement in liver disease care by NHS bodies responsible for primary care pathway development could drive improvements. The formation of integrated care systems (ICS) in England provides an opportunity to reassess engagement with liver disease nationally.

AIM

To update the level of engagement with community chronic liver disease management among ICSs and health authorities across the UK.

DESIGN & SETTING

A cross-sectional follow-up survey to ICS and UK health boards.

METHOD

Questions used for a previous survey in 2020 were adapted and sent electronically to NHS bodies responsible for health care across the UK, using a freedom of information request. Quantitative analysis was undertaken using Microsoft Excel.

RESULTS

There were 67 responses from 68 possible ICS and health board areas, representing 99% UK coverage. Twenty-seven per cent had a named individual responsible for liver disease. Monitoring of local liver disease health statistics happened in 34% of all UK areas. Comprehensive care pathways were available in n = 24/67 (36%) of areas, an increase from 26% in the 2020 survey. Areas with no liver pathways in place fell from 58% to 36% between the two surveys. Regional variations persist, with Wales and Scotland moving towards comprehensive coverage. Almost double the number of areas were making use of transient elastography within community pathways of care, up from 25% to 46%.

CONCLUSION

The results of this re-survey highlight improvements, but emphasise the need to build on regional success to further reduce inequality in care commissioning.

Molecular Landscape and Diagnostic Model of MASH: Transcriptomic, Proteomic, Metabolomic, and Lipidomic Perspectives

Metabolic dysfunction-associated steatohepatitis (MASH), a progressive form of fatty liver disease, presents a significant global health challenge. Despite extensive research, fully elucidating its complex pathogenesis and developing accurate non-invasive diagnostic tools remain key goals. Multi-omics approaches, integrating data from transcriptomics, proteomics, metabolomics, and lipidomics, offer a powerful strategy to achieve these aims. This review summarizes key findings from multi-omics studies in MASH, highlighting their contributions to our understanding of disease mechanisms and the development of improved diagnostic models. Transcriptomic studies have revealed widespread gene dysregulation affecting lipid metabolism, inflammation, and fibrosis, while proteomics has identified altered protein expression patterns and potential biomarkers. Metabolomic and lipidomic analyses have further uncovered significant changes in various metabolites and lipid species, including ceramides, sphingomyelins, phospholipids, and bile acids, underscoring the central role of lipid dysregulation in MASH. These multi-omics findings have been leveraged to develop novel diagnostic models, some incorporating machine learning algorithms, with improved accuracy compared to traditional methods. Further research is needed to validate these findings, explore the complex interplay between different omics layers, and translate these discoveries into clinically useful tools for improved MASH diagnosis and prognosis.

ALADDIN: A Machine Learning Approach to Enhance the Prediction of Significant Fibrosis or Higher in Metabolic Dysfunction-Associated Steatotic Liver Disease

INTRODUCTION

The recent US Food and Drug Administration approval of resmetirom for treating metabolic dysfunction-associated steatohepatitis in patients necessitates patient selection for significant fibrosis or higher (≥F2). No existing vibration-controlled transient elastography (VCTE) algorithm targets ≥F2.

METHODS

The mAchine Learning ADvanceD fibrosis and rIsk metabolic dysfunction-associated steatohepatitis Novel predictor (ALADDIN) study addressed this gap by introducing a machine-learning-based web calculator that estimates the likelihood of significant fibrosis using routine laboratory parameters with and without VCTE. Our study included a training set of 827 patients, a testing set of 504 patients with biopsy-confirmed metabolic dysfunction-associated steatotic liver disease from 6 centers, and an external validation set of 1,299 patients from 9 centers. Five algorithms were compared using area under the curve (AUC) in the test set: ElasticNet, random forest, gradient boosting machines, XGBoost, and neural networks. The top 3 (random forest, gradient boosting machines, and XGBoost) formed an ensemble model.

RESULTS

In the external validation set, the ALADDIN-F2-VCTE model, using routine laboratory parameters with VCTE (AUC 0.791, 95% confidence interval [CI]: 0.764-0.819), outperformed VCTE alone (0.745, 95% CI 0.717-0.772, P < 0.0001), FibroScan-aspartate aminotransferase (0.710, 0.679-0.748, P < 0.0001), and Agile-3 model (0.740, 0.710-0.770, P < 0.0001) regarding the AUC, decision curve analysis, and calibration. The ALADDIN-F2-Lab model, using routine laboratory parameters without VCTE, achieved an AUC of 0.706 (95% CI: 0.668-0.749) and outperformed Fibrosis-4, steatosis-associated fibrosis estimator, and LiverRisk scores.

DISCUSSION

Along with the steatosis-associated fibrosis estimator model developed to target significant fibrosis or higher, ALADDIN-F2-VCTE ( https://aihepatology.shinyapps.io/ALADDIN1 ) uniquely supports a refined noninvasive approach to patient selection for resmetirom without the need for liver biopsy. In addition, ALADDIN-F2-Lab ( https://aihepatology.shinyapps.io/ALADDIN2 ) offers an effective alternative when VCTE is unavailable.

Diagnosis and Management of Early Stages of ALD

Early forms of alcohol-associated liver disease (ALD) include different stages in the progression of compensated liver disease ranging from steatosis to steatohepatitis and fibrosis. ALD has been classically diagnosed at advanced stages more frequently than other liver diseases. This fact probably contributed to the scarcity of studies on early forms of ALD. Recent studies have investigated the prevalence of early ALD in the general population and have described the natural history of alcohol-induced steatosis and fibrosis, which have been linked to worse prognosis compared with early stages of other chronic liver diseases. In addition, studies on screening and early diagnosis of ALD in at-risk populations have shown that these strategies allow early detection and intervention. Of note, up to 28% of the United States population has concurrent alcohol use and metabolic syndrome, and estimated prevalence of advanced fibrosis among heavy drinkers with metabolic syndrome has increased from 3% in the 1990s to more than 10% in the 2010s. Therefore, new challenges and treatment opportunities will emerge for patients with ALD. In this review, we provide an overview of the state of the art in early ALD, focusing on natural history, diagnosis, and management, and provide insights into future perspectives.

Liver Cirrhosis: ancient disease, new challenge

Liver cirrhosis is a common cause of morbidity and mortality worldwide. Excessive alcohol consumption and metabolic associated steatotic liver disease are the most common etiological factors of cirrhosis in our region. Cirrhosis occurs in two well-differentiated phases, compensated and decompensated, depending on the absence or presence of complications, respectively. Current therapeutic strategies are aimed at controlling these complications (such as ascites, hepatic encephalopathy, bacterial infections, or digestive hemorrhage, among others) or performing a liver transplant if there are no contraindications. However, it is important to eliminate the etiological factor responsible for the disease, as this can lead to the disappearance of complications, a state known as recompensation. This article proposes an updated review of the epidemiology of cirrhosis and its main causes, and offers an overview of the clinical features and treatment of the disease's complications, in addition to outlining future lines of research in this field.

Using Incidental Radiologic Findings of Hepatic Steatosis to Improve the Diagnosis of Metabolic Dysfunction-Associated Steatotic Liver Disease

Metabolic dysfunction-associated steatotic liver disease (MASLD) is a common cause of liver disease worldwide. In patients with MASLD, liver fibrosis stage is the most significant predictor of mortality; therefore, early identification of patients at the greatest risk of advanced fibrosis is essential. Noninvasive tests predict advanced fibrosis and are recommended for use in primary care settings to determine which patients would benefit most from specialty care. The adoption of these tools is not widespread, and several studies have reported underrecognition of cirrhosis in patients with MASLD and diabetes. The finding of hepatic steatosis on imaging performed for evaluation of nonliver conditions may present an avenue for opportunistic screening to identify more patients with MASLD. This article will review recommendations for when hepatic steatosis is found on imaging and noninvasive tests that can be used to help predict fibrosis staging. This is a significant area of research because a new treatment for MASLD has been approved, and other treatments may follow.

The use of ELF in predicting liver fibrosis prevalence and fibrosis progression in the general population

BACKGROUND AND AIMS

The enhanced liver fibrosis (ELF) test has good discrimination performance in detecting advanced liver fibrosis. The chronic liver disease (CLivD) risk score based on clinical data accurately predicts risk for future severe liver disease. Considering the ELF test as a surrogate marker for liver fibrosis, we analyzed predictors of elevated ELF (eELF) and its change.

METHODS

The study cohort consisted of Finnish general population-based health surveys Health2000 and a follow-up study 10 years later Health2011 with 6084 and 2937 individuals, respectively with phenotype and ELF data. eELF was defined as ELF ≥ 9.8, and clinically relevant fibrosis progression as an ELF change ≥0.6. CLivD risk score was calculated at baseline. Analyses were age-adjusted.

RESULTS

Obesity measures and diabetes predicted eELF at baseline. Only waist-hip ratio (WHR) could predict clinically relevant fibrosis progression over the follow-up consistently among men and women (OR 1.35 and 1.41, respectively). High-risk alcohol use was a significant risk factor for eELF only among men (OR 1.72, p = 0.049), and it did not predict fibrosis progression in either sex. Although elevated transaminases were associated with eELF, in most individuals with eELF they were within reference limits. Increased CLivD scores correlated with baseline and the change of ELF values over the 10-year follow-up independent of baseline ELF (p < 0.001).

CONCLUSIONS

Liver fibrosis progression is difficult to predict based on single risk factors or liver enzymes. ELF had limited value to predict fibrosis progression. The CLivD score, based on multiple risk factors, predicted both occurrence of baseline eELF and its progression over a 10-year follow-up.

Use of noninvasive fibrosis calculators in an urban diabetes center suggests a large burden of undetected advanced liver disease

BACKGROUND

Metabolic dysfunction associated steatotic liver disease (MASLD) is prevalent in up to 60% of patients with type 2 diabetes mellitus (T2DM). T2DM accelerates the risk of hepatic fibrosis and hepatocellular carcinoma in patients with MASLD. Our goal in this study was to identify patients with suspected MASLD and hepatic fibrosis in a large T2DM clinic by using noninvasive fibrosis scoring systems.

METHODS

We conducted a retrospective study of patients with T2DM seen by our endocrinologists at the Medical Faculty Associates (MFA) Diabetes Center in Washington, DC, from November 1, 2021, until November 1, 2022. We included all subjects who were over 18 years old with a hemoglobin A1c (HbA1c) of 6.5 or higher. Patients with a history of significant alcohol consumption, decompensated cirrhosis, previous bariatric surgery, or prior chronic liver disease were excluded from the study. We identified patients at risk for hepatic fibrosis by using the Fibrosis-4 (FIB-4) Index, NAFLD Fibrosis Score (NFS) and AST to Platelet Ratio Index (APRI) when lab values were available.

RESULTS

A total of 1,411 patients were evaluated for T2DM by an endocrinology provider during the one-year period. Out of these, 336 patients met one or more of the exclusion criteria, leaving a total of 1075 patients included in the analysis. The majority were African American (n = 582, 54%), 261 were Caucasian (24.3%), and 85 were Hispanic (7.9%). Most patients were females (n = 675, 62.7%). The mean HbA1c was 8.1 ± 2.3. 643 patients (59.8%) were insulin dependent. Based on FIB-4 scores, we found that 35 (3.9%) patients had a score of > 2.67 associated with advanced fibrosis and 257 (29%) patients with scores of 1.3-2.67 had moderate fibrosis. Using the NFS calculator, there were 281 (28%) patients with values of > 0.675 consistent with F3-F4 disease. 715 (71.8%) patients with values of < 0.675 consistent with F0-F2 fibrosis. A total of 6(< 1%) patients met criteria for advanced fibrosis by APRI scoring.

CONCLUSION

In our urban Diabetes Center, utilizing the NFS calculator may detect many patients with advanced liver disease. Further research is needed to ensure the internal validity of the non-invasive tests in predicting liver fibrosis and to correlate these findings with transient elastography and other imaging evidence of fatty liver disease.

CLINICAL TRIAL NUMBER

Non-applicable.

Association of Sensitivity to Thyroid Hormones and Non-Alcoholic Fatty Liver Disease and the Severity of Liver Fibrosis in Euthyroid Adults: A Retrospective Study

Purpose

The relationship between non-alcoholic fatty liver disease (NAFLD) and thyroid function is controversial. A mild acquired thyroid hormone resistance may exist and explain these contradictions. This study aims to investigate the associations of thyroid hormone sensitivity with NAFLD and the severity of liver fibrosis in euthyroid populations.

Patients and Methods

Twenty-nine thousand three hundred and eighty-six adult subjects were recruited from the medical examination center of the Beijing Chao-Yang Hospital. Free triiodothyronine (FT3)/free thyroxine (FT4), thyroid feedback quartile-based index for FT4 (TFQIFT4) and for FT3 (TFQIFT3), thyroid stimulating hormone index (TSHI), thyrotropin thyroxine resistance index (TT4RI), and thyrotropin triiodothyronine resistance index (TT3RI) were calculated. Logistic regression analysis was used to analyze the associations of thyroid hormone sensitivity indices with the risks of NAFLD and related metabolic disorders. The correlation between thyroid hormone sensitivity and the severity of liver fibrosis evaluated by noninvasive fibrosis indices was analyzed through ordinal logistic regression.

Results

Euthyroid adults with NAFLD had elevated levels of serum FT3 and FT4, reduced TSH, and impaired sensitivity to thyroid hormones. Compared with participants in the first quartile group, the risk of NAFLD was higher in the fourth quartile of TFQIFT3 (OR 1.25, 95% CI 1.13-1.39, P < 0.001) and FT3/FT4 (OR 1.45, 95% CI 1.32-1.60, P < 0.001) after adjusting for metabolic confounders. Among NAFLD patients, higher FT3/FT4 positively correlated with increased severity of liver fibrosis, with ORs per SD of 10.80 (95% CI 4.12-28.53, P < 0.001) for aminotransferase-to-platelet ratio index, 4.74 (95% CI 1.56-14.38, P = 0.006) for NAFLD fibrosis score and 3.21 (95% CI 1.02-10.08, P = 0.046) for fibrosis-4 index.

Conclusion

Impaired central sensitivity to FT3 and higher FT3/FT4 were associated with increased risks of NAFLD and related metabolic disorders. In patients with NAFLD, higher FT3/FT4 correlated with its progression to liver fibrosis. These findings might provide novel insight into the monitoring and evaluation of the risk of NAFLD and the severity of liver fibrosis.

Role of noninvasive tests in the prognostication of metabolic dysfunction-associated steatotic liver disease

In managing metabolic dysfunction-associated steatotic liver disease, which affects over 30% of the general population, effective noninvasive biomarkers for assessing disease severity, monitoring disease progression, predicting the development of liver-related complications, and assessing treatment response are crucial. The advantage of simple fibrosis scores lies in their widespread accessibility through routinely performed blood tests and extensive validation in different clinical settings. They have shown reasonable accuracy in diagnosing advanced fibrosis and good performance in excluding the majority of patients with a low risk of liver-related complications. Among patients with elevated serum fibrosis scores, a more specific fibrosis and imaging biomarker has proved useful to accurately identify patients at risk of liver-related complications. Among specific fibrosis blood biomarkers, enhanced liver fibrosis is the most widely utilized and has been approved in the United States as a prognostic biomarker. For imaging biomarkers, the availability of vibration-controlled transient elastography has been largely improved over the past years, enabling the use of liver stiffness measurement (LSM) for accurate assessment of significant and advanced fibrosis, and cirrhosis. Combining LSM with other routinely available blood tests enhances the ability to diagnose at-risk metabolic dysfunction-associated steatohepatitis and predict liver-related complications, some reaching an accuracy comparable to that of liver biopsy. Magnetic resonance imaging-based modalities provide the most accurate quantification of liver fibrosis, though the current utilization is limited to research settings. Expanding their future use in clinical practice depends on factors such as cost and facility availability.

Serum ECM1 is a promising biomarker for staging and monitoring fibrosis in patients with chronic hepatitis B

It is critical to assess the extent and progression of liver fibrosis for patients to receive suitable treatments, but its diagnostic methods remain unmet. Extracellular matrix protein 1 (ECM1) has previously been reported to be a key factor in the induction and progression of liver fibrosis. However, little is known about the use of ECM1 as a biomarker to evaluate fibrosis. In a CCl4-induced mouse model of liver fibrosis, the present study demonstrated that ECM1 decreased with gradually increasing fibrosis. Using biopsy as a reference, the serum ECM1 levels decreased with increasing fibrosis stage in 247 patients with liver fibrosis, but there were no significant changes between fibrosis stage 2 and stage 0-1. To improve the performance of ECM1, age, platelet count, and ECM1 concentration were combined to calculate an EPA (ECM1-platelet-age) score (ranging from 0 to 10). The areas under the receiver operating characteristic curve of the EPA scores for the detection of F⩾2, F⩾3, and F4 were 0.6801, 0.7377, and 0.8083, respectively, which showed a comparable or significantly greater diagnostic performance for assessing fibrosis than that of the AST/ALT ratio, APRI score, or FIB-4 score. In HBV patients following antiviral treatment, the dynamics of the EPA score depended on the status of liver fibrosis development. The accuracy of the EPA score in predicting fibrosis regression and progression was 66.00% and 71.43%, respectively, while that of the LSM, another useful method for monitoring hepatic fibrosis changes during treatment, was only 52.00% and 7.14%, respectively. Compared with healthy controls, there were lower levels of serum ECM1 in HBV patients and individuals with HCV infection, MAFLD, ALD, PBC, and DILI. These findings suggested that individuals with reduced ECM1 levels may have a risk of developing liver injury, and further examinations or medical care are needed. In conclusion, the ECM1-containing EPA score is a valuable noninvasive test for staging fibrosis and predicting the progression of liver fibrosis. Additionally, ECM1 alone is an indicator for distinguishing patients with liver injury from healthy controls.

Moving diagnosis of liver fibrosis into the community

Chronic liver disease (CLD) is a leading cause of death worldwide, with alcohol consumption and metabolic risk factors accounting for the majority of cases of CLD in many developed countries. Currently, specific strategies for the early diagnosis of CLD are lacking and consequently most cases are diagnosed at an advanced stage, which is associated with negative consequences for disease management and prognosis. Screening for CLD is based on either detection of chronic viral hepatitis B and C, or detection of liver fibrosis in patients with steatotic liver disease related to alcohol or metabolic dysfunction. Non-invasive tools, including serological and imaging-based tests, can be used to detect liver fibrosis. Clinical practice guidelines recommend screening for liver fibrosis using algorithms that combine different non-invasive tests, with widely available but low accuracy tests, such as FIB-4, recommended as a first screening step in the primary care setting, and other tests with lower availability but higher accuracy, such as transient elastography or the enhanced liver fibrosis test, recommended as a second step. There are different pathways for early detection of patients with CLD from primary to specialised care, with primary care providers being key for early detection, management and referral of patients. In addition, interventions targeting metabolic risk factors and alcohol consumption should be carried out in collaboration between specialists and primary care. In this review, we describe liver fibrosis from the community perspective, highlighting gaps in knowledge on how to define the optimal combination of tests, target population, the ideal pathway of care for CLD, and how to increase implementation of programmes for early diagnosis of liver diseases in clinical practice.

Estimating the prevalence of adults at risk for advanced hepatic fibrosis using FIB-4 in a Swiss tertiary care hospital

BACKGROUND & AIMS

Chronic liver diseases pose a serious public health issue. Identifying patients at risk for advanced liver fibrosis is crucial for early intervention. The Fibrosis-4 score (FIB-4), a simple non-invasive test, classifies patients into three risk groups for advanced fibrosis. This study aimed to estimate the prevalence of patients at risk for advanced hepatic fibrosis at a Swiss tertiary care hospital by calculating the FIB-4 score in routine blood analysis.

METHODS

A retrospective study was conducted using data from 36,360 patients who visited outpatient clinics at eight main clinics of the University Hospital Bern in Switzerland. The data collection period ran from January 1st to December 31st, 2022. Patients attending the hepatology outpatient clinic were excluded. We then calculated the overall and clinic-specific prevalence of patients falling into the high risk category for advanced fibrosis according to FIB-4.

RESULTS

Among the 36,360 patients, 26,245 (72.2%) had a low risk of advanced fibrosis (FIB-4 <1.3), whereas 3913 (10.8%) and 2597 (7.1%) patients were flagged to have a high risk of advanced fibrosis (FIB-4 >2.67 and FIB-4 >3.25 respectively). Geriatrics and Cardiology had the highest proportions of patients at risk for advanced fibrosis over all clinics.

CONCLUSIONS

This study demonstrates a high prevalence of high FIB-4 score in a Swiss tertiary care hospital. The implementation of the automatically generated FIB-4 score in daily practice, not only in primary care, but also within tertiary care hospitals, could be crucial for early identification of outpatients at high risk of advanced liver fibrosis requiring further hepatological investigations.

Association of Liver Fibrosis Markers with Mortality Outcomes in Patients with Chronic Kidney Disease and Coronary Artery Disease: Insights from the NHANES 1999-2018 Data

INTRODUCTION

The objective of this research was to explore the possible link between markers of liver fibrosis and survival rates in a group of adults who have been diagnosed with both chronic kidney disease (CKD) and coronary artery disease (CAD).

METHODS

The National Health and Nutrition Examination Survey (NHANES) data (1999-2018) for participants with both CAD and CKD were analyzed. The fibrosis-4 index (FIB-4), Nonalcoholic Fatty Liver Score (NFS), Forns index, and aspartate aminotransferase/alanine aminotransferase (AST/ALT) ratio were identified as crucial biomarkers. All-cause and cardiovascular disease (CVD) mortality were primary outcomes, assessed using Cox models, Kaplan-Meier curves, and receiver operating characteristic (ROC) analysis.

RESULTS

A total of 1,192 CKD and CAD patients were included. The Cox regression analysis revealed substantial correlations between elevated FIB-4, NFS, Forns index, and AST/ALT levels and a heightened risk of all-cause (hazard ratio [HR]: 1.188, 95% confidence interval [CI]: 1.108-1.274; HR: 1.145, 95% CI: 1.069-1.227; HR: 1.142, 95% CI: 1.081-1.201; HR: 1.316, 95% CI: 1.056-1.639, respectively) and CVD mortality (HR: 1.133, 95% CI: 1.007-1.275; HR: 1.155, 95% CI: 1.024-1.303; HR: 1.208, 95% CI: 1.109-1.316 and HR: 1.636, 95% CI: 1.203-2.224, respectively). The ROC analysis indicated comparable predictive accuracy for all three biomarkers, with AST/ALT showing slightly superior performance.

CONCLUSION

Liver fibrosis markers, including AST/ALT, NFS, Forns index and FIB-4, are significant mortality predictors in CAD-CKD patients. The AST/ALT ratio, being easily measurable, may serve as an effective predictive tool for risk stratification in this population.

The fibrosis-4 index and its association with carotid atherosclerosis in type 2 diabetes: a cross-sectional study in China

BACKGROUND

The medical community has long been concerned about the cardiovascular disease risk in patients with type 2 diabetes. While liver fibrosis scores were originally designed for application in individuals with liver steatosis, an increasing number of studies have shown that they are also associated with cardiovascular disease risk. However, the association between Fibrosis-4 (Fib-4) in liver fibrosis scores and carotid atherosclerosis (CA) in patients with type 2 diabetes remains unclear.

OBJECTIVE

The aim of this study is to investigate the association between the Fib-4 index and CA in patients with Type 2 diabetes. Additionally, it seeks to determine whether this relationship is influenced by factors including gender, age, body mass index (BMI), hypertension, and other variables.

METHODS

Screening based on inclusion and exclusion criteria identified 2658 hospitalized patients with type 2 diabetes. Subsequently, patients were divided into three groups according to Fib-4 values (Fib-4 < 1.3, 1.3 ≤ Fib-4 < 2.67, Fib-4 ≥ 2.67). Logistic regression analysis was then applied to evaluate the association between Fib-4 and the presence of CA in type 2 diabetes. Further stratified analyses were conducted considering gender, age (using 60 years as the threshold), hypertension status, smoking, alcohol consumption, and BMI groups (using 24 kg/m2 as the threshold), aiming to investigate potential effect heterogeneity within predefined subgroups. ROC curve analysis was used to evaluate the predictive power of the Fib-4 value for CA, increased CIMT, and carotid plaques.

RESULTS

The study encompassed 2658 patients diagnosed with type 2 diabetes, comprising 1441 males and 1217 females, with an average age of 56.71 ± 10.22 years. Among them, 1736 individuals (65.3%) exhibited CA, 1243 (46.8%) had increased carotid intima-media thickness (CIMT), and 1273 (47.9%) manifested carotid plaques. Following adjustments for various factors, the prevalence of CA exhibited a progressive increase in the Fib-4 < 1.3, 1.3 ≤ Fib-4 < 2.67, and Fib-4 ≥ 2.67 groups, with statistically significant differences (P < 0.05). Moreover, the prevalence of increased CIMT and carotid plaques in the Fib-4 ≥ 2.67 group remained significantly higher than that in the Fib-4 < 1.3 group after considering various factors (P < 0.05). In the 1.3 ≤ Fib-4 < 2.67 group, subsequent to adjustments for gender, smoking, and drinking, the prevalence of increased CIMT and carotid plaques surpassed that in the Fib-4 < 1.3 group (P < 0.05). Despite further adjustments for multiple factors, the prevalence of increased CIMT and carotid plaques persisted higher than that in the Fib-4 < 1.3 group, yet the difference lacked statistical significance (P > 0.05). The results of the ROC curve analysis indicated that the AUC for Fib-4 predicting CA was 0.602 (P < 0.001, 95% CI: 0.579-0.625), while the AUC values for increased CIMT and carotid plaques were 0.561 (P < 0.001, 95% CI: 0.540-0.583) and 0.580 (P < 0.001, 95% CI: 0.558-0.601), respectively.

CONCLUSION

Elevated Fib-4 levels (Fib-4 ≥ 1.3) are positively associated with CA in patients with type 2 diabetes, including increased CIMT and the presence of carotid plaques. As such, Fib-4 may serve as a potential biomarker for the detection of CA in patients with type 2 diabetes. However, its clinical utility needs further validation, particularly in larger sample sizes and multicenter studies.

Non-invasive lipid panel of MASLD fibrosis transition underscores the role of lipoprotein sulfatides in hepatic immunomodulation

There exists a pressing need for a non-invasive panel that differentiates mild fibrosis from non-fibrosis in metabolic dysfunction-associated steatotic liver disease (MASLD). In this work, we applied quantitative lipidomics and sterolomics on sera from the PERSONS cohort with biopsy-based histological assessment of liver pathology. We trained a lasso regression model using quantitative omics data and clinical variables, deriving a combinatorial panel of lipids and clinical indices that differentiates mild fibrosis (>F1, n = 324) from non-fibrosis (F0, n = 195), with an area under receiver operating characteristic curve (AUROC) at 0.775 (95% confidence interval [CI]: 0.735-0.816). Circulating sulfatides (SLs) emerged as central lipids distinctly associated with fibrosis pathogenesis in MASLD. Lipidomics analysis of lipoprotein fractions revealed a redistribution of circulating SLs from high-density lipoproteins (HDLs) onto low-density lipoproteins (LDLs) in MASLD fibrosis. We further verified that patient LDLs with reduced SL content triggered a smaller activation of type II natural killer T lymphocytes, compared with control LDLs. Our results suggest that hepatic crosstalk with systemic immunity mediated by lipoprotein metabolism underlies fibrosis progression at early-stage MASLD.

Comparative efficacy of endoscopic variceal ligation versus non-selective beta-blockers in primary prevention of gastroesophageal varix type 2: an IPTW-adjusted study

BACKGROUND

Practice guidelines recommend non-selective beta-blockers (NSBB) and endoscopic variceal ligation (EVL) for primary prevention in cirrhosis patients with esophageal varices. However, there is no clear recommendation for primary prevention strategies for gastric varices, particularly GOV-2. Our objective is to investigate the incidence of initial bleeding and liver-related complications when NSBB and EVL are used for primary prevention in GOV-2.

METHODS

A retrospective analysis was conducted on data from patients with GOV-2 gastric varices. Patients were divided into the NSBB group or the EVL group. Differences in the incidence of initial bleeding within 1 year, as well as the occurrence of complications such as hepatic encephalopathy and ascites, were compared between the two groups before and after adjustment for Inverse Probability of Treatment Weighting (IPTW). A Cox proportional hazards model was used to identify independent risk factors for the first bleeding event.

RESULTS

There were 60 patients in the NSBB group and 66 patients in the EVL group. Before IPTW adjustment, there were differences between the two groups in sex, portal hypertensive gastropathy, esophageal variceal diameter, red signs, FIB-4, and MELD scores. After IPTW adjustment, these differences were balanced, with standardized mean differences (SMDs) within acceptable ranges. Kaplan-Meier survival analysis showed no difference in bleeding rates between the two groups before or after IPTW adjustment. After IPTW adjustment, Cox regression analysis identified esophageal variceal diameter (HR:5.59 (2.03-15.39), p < 0.001) and MELD score (HR:1.17 (1.01-1.23), p = 0.042) were independent risk factors for bleeding. NSBB treatment did not reduce the incidence of liver-related complications within one year compared to EVL.

CONCLUSION

For primary prevention of bleeding in cirrhotic patients with GOV-2, EVL does not significantly reduce initial bleeding episodes or liver-related complications compared to NSBB.

Development, validation, and prognostic evaluation of LiverPRO for the prediction of significant liver fibrosis in primary care: a prospective cohort study

BACKGROUND

Clinically significant liver fibrosis is associated with future adverse events in patients with steatotic liver disease. We designed a software tool for detection of clinically significant liver fibrosis in primary care.

METHODS

In this prospective cohort study, we developed and validated LiverPRO using six independent cohorts from Denmark, Germany, and England that included patients from primary and secondary care with steatotic liver disease related to alcohol or metabolic dysfunction. We used clinically significant fibrosis (histology stage ≥F2) and advanced fibrosis (≥F3) as outcomes for variable selection in the development cohort and built the model with fractional polynomial regression. In all cohorts, we independently validated the tool for prediction of elevated liver stiffness by transient elastography (≥8 kPa and ≥12 kPa) and for the 2-year and 5-year risk of liver-related events. Diagnostic performance was assessed using the area under the receiver operating curve (AUC), with clinical performance evaluated through sensitivity, specificity, and Harrell's C-statistic for prognostic purposes.

FINDINGS

In the development cohort (n=462), we derived 466 multivariable models consisting of age in combination with three to nine variables from a list of nine blood tests (aspartate aminotransferase, alkaline phosphatase, gamma-glutamyl transferase, international normalised ratio, albumin, sodium, bilirubin, platelet count, and cholesterol). In the development cohort, LiverPRO diagnosed clinically significant fibrosis with good accuracy (transient elastography ≥8 kPa area under the receiver operating characteristic curve [AUC] 0·86 [95% CI 0·83-0·90]). In the DECIDE validation cohort (n=6468), LiverPRO detected participants with a transient elastography of 8 kPa or higher with good accuracy (AUC 0·80 [95% CI 0·78-0·82]), comparable to enhanced liver fibrosis testing (0·78 [0·75-0·80]) and the LiverRisk score (0·81 [0·79-0·84]), but superior to the Fibrosis-4 index (0·69 [0·66-0·72]) and NAFLD Fibrosis Score (0·74 [0·72-0·77]). Findings were consistent in three other validation cohorts (n=2554), albeit accuracy was slightly lower. Using a rule-out cutoff of less than 25% (indicating no further examinations required), LiverPRO had a rule-out sensitivity of 80·6% (95% CI 76·4-84·3) and a rule-out negative predictive value of 98·0% (95% CI 97·5-98·4) in the DECIDE cohort. Similarly, with a rule-out cutoff of less than 1·3, FIB-4 had a rule-out sensitivity of 53·8% (48·5-58·9) and a rule-out negative predictive value of 95·8% (95·1-96·4). For rule-in thresholds, using a cutoff of more than 65% (indicating referral to a hepatologist required) LiverPRO had a rule-in specificity of 95·5% (95% CI 94·9-96·0) and a rule-in positive predictive value of 33·0% (95% CI 28·5-37·8) in the DECIDE cohort whereas FIB-4, with a rule-in threshold of 2·67, had a rule-in specificity of 98·7% (94·9-96·0) and a rule-in positive predictive value 35·6% (27·0-44·9). Using UK Biobank data, LiverPRO predicted liver-related events with a C-statistic of 0·80 (0·77-0·84) at 2 years.

INTERPRETATION

LiverPRO reliably identifies clinically significant liver fibrosis and elevated liver stiffness, predicts the risk of liver-related events in primary care, and is adaptable to the availability of different liver blood test analytes. On the basis of these results LiverPRO was certified according to IVDR class b, obtaining European CE approval in 2024.

FUNDING

EU Horizon 2020 research and innovation programme and Novo Nordisk Foundation.

Baseline FIB-4 May Be a Risk Factor of Recurrence After SBRT in Patients With HBV-Related Small HCC

AIMS

Exploring fibrosis index-4 (FIB-4)'s predictive value for HBV-related hepatocellular carcinoma (HCC) in assessing recurrence following stereotactic body radiation therapy (SBRT) in patients with HBV-related HCC.

METHODS

HBV-related HCC patients who underwent SBRT were retrospectively enrolled from March 2012 to March 2020. Patients were divided into recurrence and non-recurrence groups based on the HCC recurrence situation. Baseline data were collected from all patients before treatment and at 3 and 6 months after treatment, and FIB-4 was calculated at the corresponding time points. Risk factors were selected using Cox regression. The FIB-4 was stratified for survival analysis.

RESULTS

One hundred and fifty-two patients were included. With a mean age of 53.5 years old, 94.1% of them had liver cirrhosis. The median recurrence-free survival (RFS) time for recurrent patients was 17.5 months. The tumor response rate of SBRT was 94.8%. HCC recurrence rates at 12, 24, 36, 48, and 60 months were 19.7% (30/152), 38.2% (58/152), 48.0% (73/152), 52.0% (79/152), and 53.3% (81/152), respectively. Cox regression showed that baseline FIB-4 (95% CI: 1.030 ~ 1.144, p = 0.002) and 3 tumor nodules (95% CI: 3.727 ~ 260.663, p = 0.002) are risk factors for HCC recurrence. Patients with a baseline FIB-4 > 6.55 were at a higher risk of HCC recurrence than those with a baseline FIB-4 < 6.55 (p < 0.001).

CONCLUSION

Baseline FIB-4 is a risk factor for recurrence after SBRT in patients with HBV-related HCC, and the predictive threshold for FIB-4 is higher in patients with cirrhosis. For patients who received radiotherapy, postoperative FIB-4 levels are elevated.

Exploring Biomarkers in Nonalcoholic Fatty Liver Disease Among Individuals With Type 2 Diabetes Mellitus

Integrating biomarkers into a comprehensive strategy is crucial for precise patient management, especially considering the significant healthcare costs associated with diseases. Current studies emphasize the urgent need for a paradigm shift in conceptualizing nonalcoholic fatty liver disease (NAFLD), now renamed metabolic dysfunction-associated steatotic liver disease (MASLD). Biomarkers are emerging as indispensable tools for accurate diagnosis, risk stratification, and monitoring disease progression. This review classifies biomarkers into conventional and novel categories, such as lipids, insulin resistance, hepatic function, and cutting-edge imaging/omics, and evaluates their potential to transform the approach to MASLD among individuals with type 2 diabetes mellitus (T2D). It focuses on the critical role of biomarkers in early MASLD detection, enhancing predictive accuracy, and discerning responses to interventions (pharmacological or lifestyle modifications). Amid this discussion, the complexities of the relationship between T2D and MASLD are explored, considering factors like age, gender, genetics, ethnicity, and socioeconomic background. Biomarkers enhance the effectiveness of interventions and support global initiatives to reduce the burden of MASLD, thereby improving public health outcomes. This review recognizes the promising potential of biomarkers for diagnostic precision while candidly addressing the challenges in implementing these advancements in clinical practice. The transformative role of biomarkers emerges as a central theme, promising to reshape our understanding of disease trajectories, prognosis, and the customization of personalized therapeutic strategies for improved patient outcomes. From a future perspective, identifying early-stage biomarkers, understanding environmental impact through exposomes, and applying a multiomics approach may reveal additional insight into MASLD development.

Type 2 Diabetes Mellitus in Inflammatory Bowel Disease Patients: A Case-Control Study Through a Long Follow-Up Period

Background/Objectives: The characterization of patients with inflammatory bowel disease (IBD) and type 2 diabetes mellitus (T2DM) as a new group has not been well detailed. This study aimed to evaluate the impact of T2DM on IBD progression and analyze the prevalence of steatotic liver disease and liver damage in these patients. Methods: Through a retrospective case-control study, we compared severe IBD occurrence in patients with both IBD-T2DM (cases) versus those with IBD alone (controls). Among 1047 medical records, 79 IBD-T2DM patients were selected and compared to 308 controls in a 1:4 ratio. Severe IBD was defined by variables such as surgery, target therapy, corticosteroid use, and hospitalization. Liver damage was assessed using Fib-4 (>1.3), and hepatic steatosis was evaluated by imaging. Results: There was no significant difference in severe disease rates (59.5% vs. 59.7%; p = 0.97). IBD-T2DM patients had higher rates of hepatic steatosis (62.9% vs. 27.2%; p < 0.0001) and liver damage (55.4% vs. 26.6%; p < 0.0001). IBD-T2DM patients used more corticosteroids (p < 0.0001) and fewer anti-TNF-alpha drugs (p = 0.007). The median age at diagnosis was higher in IBD-T2DM patients (48 vs. 32; p < 0.0001). In Crohn's disease, 24.3% of IBD-T2DM patients had exclusive colonic involvement compared to 5% in the IBD-only group (p = 0.003). Conclusions: T2DM was not associated with worse IBD progression, but was linked to increased liver steatosis and damage. Differences such as age of onset, colonic involvement, and liver damage suggest that IBD-T2DM patients could configure a special population worthy of further studies.

Addressing the essentials of the recent guidelines for managing patients with metabolic dysfunction-associated steatotic liver disease

Metabolic dysfunction-associated steatotic liver disease (MASLD) is the leading cause of end-stage liver disease and liver transplantation in the Western world, with an approximate prevalence of 30% worldwide which is continuously rising. It is characterized by intrahepatic fat deposition along with at least one cardiometabolic risk factor, such as diabetes mellitus, obesity, hypertriglyceridemia, and hypertension. MASLD consists of a spectrum of liver diseases ranging from simple liver steatosis to steatohepatitis, liver fibrosis, and cirrhosis. Recently, the European Association for the Study of the Liver (EASL), the European Association for the Study of Diabetes (EASD), and the European Association for the Study of Obesity (EASO) released the latest guidelines regarding the management of patients with MASLD. This article highlights the critical points of these guidelines and emphasizes problematic issues that need further evaluation.

Diagnostic accuracy of 2D-SWE ultrasound for liver fibrosis assessment in MASLD: A multilevel random effects model meta-analysis

BACKGROUND AND AIMS

Metabolic dysfunction-associated steatotic liver disease (MASLD) imposes significant health care burdens. Early detection of advanced fibrosis and cirrhosis in MASLD is essential due to their unfavorable outcomes. This multilevel random-effects meta-analysis aimed to provide the best evidence for the diagnostic accuracy of 2-dimensional shear wave elastography in detecting liver fibrosis in biopsy-proven MASLD.

APPROACH AND RESULTS

This study involves systematic search in PubMed/MEDLINE, Embase, Scopus, Web of Science, LILACS, and Cochrane Library electronic databases for full-text articles published in any language up to February 26, 2024. Included studies reported liver stiffness measurement by 2-dimensional shear wave elastography and used histological diagnosis as the gold standard. A linear mixed-effects multiple thresholds model was employed, and summary estimates for sensitivity, specificity (Sp), and summary area under the receiver operator characteristic curve were computed. Twenty observational studies (SuperSonic Imagine, General Electric Healthcare, and Canon Medical Systems) fulfilled the inclusion criteria, comprising 2223 participants with biopsy-proven MASLD. The prevalence of mild fibrosis (F1), significant fibrosis (F2), advanced fibrosis (F3), and cirrhosis (F4) was 30.0%, 18.5%, 17.9%, and 10.9%, respectively. The summary area under the receiver operator characteristic curve [95% CI] in detecting ≥F1, ≥F2, ≥F3, and F4 for all ultrasound machines considered together were 0.82 [0.16-0.98], 0.82 [0.76-0.88], 0.86 [0.77-0.93], and 0.89 [0.80-0.95], respectively. The optimal cutoff values were 6.432 kPa for ≥F1, 8.174 kPa for ≥F2, 9.418 kPa for ≥F3, and 11.548 kPa for F4, respectively.

CONCLUSIONS

Our meta-analysis identified optimized cutoffs for fibrosis staging by 2-dimensional shear wave elastography in etiology-specific chronic liver diseases (MASLD), with excellent diagnostic performance, underscoring the potential for standardizing cutoff values.

Kidney function mediates the association of per- and poly-fluoroalkyl substances (PFAS) and heavy metals with hepatic fibrosis risk

Heavy metals and per- and polyfluoroalkyl substances (PFAS) are significantly associated with the risk of hepatic fibrosis. However, the potential mediating effect of kidney function in the relationship between heavy metals, PFAS, and hepatic fibrosis risk remains unexplored. This research gap limits the development of hepatic fibrosis prevention and treatment strategies. To address this, this study conducts a cross-sectional analysis based on data from 10,870 participants in NHANES 2005-2018 to explore the relationship between heavy metals, PFAS, and the risk of hepatic fibrosis, as well as the mediating effect of kidney function. Participants with a Fibrosis-4 index <1.45 are defined as not having hepatic fibrosis in this study. Results from generalized linear regression models and weighted quantile sum regression models indicate that both individual and combined exposures to heavy metals and PFAS are positively associated with the risk of hepatic fibrosis. Nonlinear exposure-response functions suggest that there may be a threshold for the relationship between heavy metals (except mercury) and PFAS with the risk of hepatic fibrosis. Furthermore, heavy metals and PFAS increase the risk of kidney function impairment. After stratification by kidney function stage, the relationship between heavy metals (except lead) and proteinuria is not significant, while PFAS show a significant negative association with proteinuria. The decline in kidney function has a significant mediating effect in the relationship between heavy metals and PFAS and the risk of hepatic fibrosis, with mediation effect proportions all above 20%. The findings suggest that individual or combined exposure to heavy metals and PFAS does not increase the risk of hepatic fibrosis until a certain threshold is reached, and the mediating role of declining kidney function is very important. These results highlight the need to consider kidney function in the context of hepatic fibrosis risk assessment and management.

Insights into ALD and AUD diagnosis and prognosis: Exploring AI and multimodal data streams

The rapid evolution of artificial intelligence and the widespread embrace of digital technologies have ushered in a new era of clinical research and practice in hepatology. Although its potential is far from realization, these significant strides have generated new opportunities to address existing gaps in the delivery of care for patients with liver disease. In this review, we discuss how artificial intelligence and opportunities for multimodal data integration can improve the diagnosis, prognosis, and management of alcohol-associated liver disease. An emphasis is made on how these approaches will also benefit the detection and management of alcohol use disorder. Our discussion encompasses challenges and limitations, concluding with a glimpse into the promising future of these advancements.

Non-invasive tests for alcohol-associated liver disease

Alcohol consumption is a global phenomenon and a major contributor to alcohol-associated liver disease (ALD). Detecting individuals at risk of ALD has been challenging, with only a small fraction of patients being identified at early stages compared to other chronic liver diseases. In response to this challenge, non-invasive tests (NITs) have become essential tools for the detection of ALD, offering opportunities for early identification and intervention to mitigate the disease burden. Noninvasive alcohol consumption biomarkers are crucial in estimating individuals' recent alcohol intake, providing valuable insights into their drinking patterns. Various NITs have been investigated for the initial screening of asymptomatic individuals at risk of ALD, as well as for identifying specific stages of the disease. These NITs are applied in 2 main clinical scenarios: population-based stratification for identifying and predicting liver-related symptoms and diagnosing and prognosticating compensated cirrhosis or advanced chronic liver disease in secondary or tertiary care settings. Moreover, NITs play a significant role in the prognostic assessment of patients with various manifestations of ALD, including alcohol-associated hepatitis (AH), decompensated cirrhosis, and metabolic-associated and ALD. These tests guide appropriate treatment decisions and predict outcomes. In this review, various NITs for the early detection and monitoring of alcohol consumption were discussed. Additionally, the evaluation of NITs for screening and predicting ALD and liver complications was addressed comprehensively. Future perspectives of NITs for ALD were explored, alongside a thorough discussion of the opportunities and challenges associated with NITs for ALD screening.

Interpreting elevated liver blood test results through a genetic lens: A genome-wide association study

BACKGROUND AND AIMS

Individuals with genetic polymorphisms in UGT1A1 exhibit bilirubin levels that belie their risk of liver disease (Gilbert's syndrome) but it is not known if this phenomenon extends to other common liver blood tests (LBTs).

METHODS

A genome-wide association analysis of 10 LBTs was conducted using the UK biobank. Polygenic scores (PGS) were created from discordant loci (e.g. loci associated with the LBT but not associated with cirrhosis morbidity risk). Participants were assigned to a low, intermediate or high PGS for each LBT. A high PGS approximates Gilbert's syndrome (i.e. elevated LBT without an analogous increase in disease risk). The prognostic significance of an 'elevated' LBT-and how this differs by PGS-was assessed through competing risk survival analysis.

RESULTS

This study included 157 005 and 166 871 participants for the discovery and validation phases, respectively. Elevated LBTs were more prevalent in the high versus low PGS group, yet the 10-year risk of cirrhosis morbidity was comparable. For example, in the low PGS group, 4.3% had an elevated gamma-glutamyltransferase (GGT) and the 10-year risk of cirrhosis morbidity was .45%. Conversely, in the high PGS group, 21.2% had an elevated GGT and the 10-year risk was .38%. Accordingly, the 10-year risk of cirrhosis morbidity for individuals with an elevated GGT was markedly different in the low vs. high group (4.2% vs. 1.2%; p < .001). Similar results were apparent for Fibrosis-4 index, total bilirubin, and platelet count.

CONCLUSION

Variability in LBTs is influenced by genetic polymorphisms that have a neutral effect on disease risk. These findings have implications for interpreting elevated LBTs in clinical practice.

Integrated and collaborative care across the spectrum of alcohol-associated liver disease and alcohol use disorder

The public health impact of alcohol-associated liver disease (ALD), a serious consequence of problematic alcohol use, and alcohol use disorder (AUD) is growing, with ALD becoming a major cause of alcohol-associated death overall and the leading indication for liver transplantation in the United States. Comprehensive care for ALD often requires treatment of AUD. Although there is a growing body of evidence showing that AUD treatment is associated with reductions in liver-related morbidity and mortality, only a minority of patients with ALD and AUD receive this care. Integrated and collaborative models that streamline both ALD and AUD care for patients with ALD and AUD are promising approaches to bridge this treatment gap and rely on multidisciplinary and interprofessional teams and partnerships. Here, we review the role of AUD care in ALD treatment, the effects of AUD treatment on liver-related outcomes, the impact of comorbid conditions such as other substance use disorders, obesity, and metabolic syndrome, and the current landscape of integrated and collaborative care for ALD and AUD in various treatment settings. We further review knowledge gaps and unmet needs that remain, including the role of precision medicine, the application of harm reduction approaches, the impact of health disparities, and the need for additional AUD treatment options, as well as further efforts to support implementation and dissemination.

The Association Between Brominated Flame Retardants Exposure and Liver-Related Biomarkers in US Adults

Background: Emerging studies demonstrate that exposure to brominated flame retardants (BFRs) can have harmful effects on human health. Our study focused on the relationship between exposure to various BFRs and markers of liver function. Methods: To further explore the association between BFR exposure and liver function impairment, we used data from the National Health and Nutrition Examination Surveys (NHANES) for three cycles from 2009 to 2014, leaving 4206 participants (≥20 years of age) after screening. Nine BFRs and eight liver function tests (LFTs) were measured in the participants' serum to represent BFRs and liver function impairment in vivo. To investigate whether there is a relationship between BFRs and health outcome, statistical research methods such as the weighted linear regression model, restricted cubic spline (RCS), weighted quantile sum (WQS), quantile-based g computing (QGC), and the Bayesian Kernel Machine Regression (BKMR) were used to evaluate the correlation between serum BFRs and LFTs. Results: The studies reveals that exposure to BFRs is associated with liver function biomarkers. In a weighted linear regression model, we found that PBB153, PBDE99, PBDE154, PBDE209, PBDE85 exposure was positively correlated with AST, ALT, GGT, ALP, TP, and SL risk. In RCS model, the nonlinear relationships between PBB153 and AST, ALT, and GGT and PBDE209 and ALT and TP are the most significant. The exposure to combined BFRs was positively correlated with AST, ALT, and GGT in WQS and QGC models. BKMR analysis showed that BFR exposure was positively correlated with AST, ALT, ALP, and GGT. Conclusions: Exposure to BFRs is associated with liver function impairment, suggesting that BFR exposure is potentially toxic to the human liver, but more in-depth studies are needed to explore this correlation.

Plasma FSTL-1 as a noninvasive diagnostic biomarker for patients with advanced liver fibrosis

BACKGROUND AND AIMS

Reliable novel noninvasive biomarkers for the diagnosis of advanced liver fibrosis are urgently needed in clinical practice. We aimed to investigate the accuracy of plasma Follistatin-like protein 1 (FSTL-1) in the diagnosis of advanced liver fibrosis in chronic liver diseases.

APPROACH AND RESULTS

We collected cross-sectional clinical data for a derivation cohort (n = 86) and a validation cohort (n = 431), totaling 517 subjects with liver biopsy. Advanced liver fibrosis was defined by the METAVIR pathological score (F ≥3). Dual cutoff values for diagnosis were explored. In the derivation cohort, plasma FSTL-1 levels were significantly elevated in patients with advanced liver fibrosis, with an AUROC of 0.85 (95% CI, 0.75-0.96). In the validation cohort, plasma FSTL-1 maintained good diagnostic performance, with an AUROC of 0.88 (95% CI, 0.83-0.92). Plasma FSTL-1 levels were significantly associated with individual histological features of the METAVIR scoring system, including interface hepatitis, lobular necrosis, and hepatocellular ballooning (p < 0.0001). A cutoff value ≤ 0.43 ng/mL was the optimal rule-out threshold, with a sensitivity of 84.62% (95% CI, 76.46%-90.30%) and a specificity of 79.51% (95% CI, 74.81%-83.53%), while ≥0.50 ng/mL was the best rule-in threshold, with a specificity of 86.41% (95% CI, 81.06%-90.43%) and a sensitivity of 70.67% (95% CI, 64.41%-76.23%).

CONCLUSIONS

Plasma FSTL-1 has high diagnostic accuracy and could potentially reduce the need for liver biopsy in identifying patients with advanced liver fibrosis.

Non-invasive testing in metabolic dysfunction-associated steatotic liver disease

Metabolic dysfunction-associated steatotic liver disease (MASLD), previously referred to as non-alcoholic fatty liver disease (NAFLD), is a leading cause of chronic liver disease, affecting up to 30% of the global population. MASLD is strongly associated with metabolic risk factors such as obesity and type 2 diabetes, and can progress to advanced stages including cirrhosis and hepatocellular carcinoma. Early diagnosis and accurate staging of fibrosis are critical in managing the disease and preventing complications. While liver biopsy has long been considered the gold standard for assessing fibrosis, it is invasive and carries associated risks. In response, non-invasive tests (NITs) have emerged as essential alternatives for the diagnosis and monitoring of MASLD. Key methods include blood-based biomarkers such as the Fibrosis-4 (FIB-4) score, NAFLD Fibrosis Score (NFS), and Enhanced Liver Fibrosis (ELF) test, as well as imaging modalities like vibration-controlled transient elastography (VCTE) and magnetic resonance elastography (MRE). These tests provide safer, more accessible methods for identifying liver fibrosis and guiding clinical management. They are integral in assessing disease severity, guiding treatment decisions, and monitoring disease progression, particularly in light of emerging therapies. NITs have become increasingly recommended by clinical guidelines as they reduce the need for invasive procedures like liver biopsy, improving patient care and outcomes. In conclusion, non-invasive testing plays a crucial role in the effective management of MASLD, offering reliable alternatives for diagnosis and monitoring while minimizing risks associated with traditional invasive methods.