Steatotic liver disease

Global Burden of Chronic Liver Disease and Temporal Trends: A Population-Based Analysis From 1990 to 2021 With Projections to 2050

BACKGROUND AND AIMS

Globally, the aetiology and epidemiology of chronic liver disease (CLD) are undergoing significant changes. We aimed to investigate the updated global burden of CLD, evaluate the cross-country inequalities, and provide 2050 predictions.

METHODS

Using the Global Burden of Disease Study (GBD) 2021 data resources, we analysed and forecasted CLD prevalence, incidence, and related death from 1990-2021 to 2050, respectively. We calculated average annual percent change (AAPC) by joinpoint regression model and quantified inequalities according to World Health Organisation-recommended health equity standards.

RESULTS

In 2021, the number of prevalent, incident CLD and related deaths globally were 1.7 billion (95% uncertainty interval (UI): 1.6-1.8), 58.4 million (95% UI: 54.2-62.8) and 1.4 million (95% UI: 1.3-1.5), respectively. During 1990-2021, the age-standardised incidence rate (ASIR) increased, especially in those aged 15-49 (AAPC: 0.49%; 95% confidence interval [CI]: 0.45%-0.53%), in Europe (AAPC: 0.41%; 95% CI: 0.41%-0.42%) and the Americas (AAPC: 0.41%; 95% CI: 0.39%-0.42%), whereas the age-standardised death rate (ASDR) decreased globally (AAPC: -1.26%; 95% CI: -1.35% [-1.17%]) and across subgroups. During 1990-2021, the ASIR of metabolic dysfunction-associated steatotic liver disease (MASLD) increased the most in those aged 15-49 (AAPC: 0.72%; 95% CI: 0.67%-0.77%) and in the Western Pacific region (AAPC: 0.73%; 95% CI: 0.59%-0.86%). Socio-demographic index (SDI)-related inequalities decreased for the age-standardised prevalence rate (ASPR) and ASIR of CLD but increased for ASDR, placing a disproportionately heavier burden on low-SDI countries. From 2022 to 2050, the ASIR of CLD is projected to increase (AAPC: 0.20%; 95% CI: 0.19%-0.20%), but the ASDR is projected to decline (AAPC: -1.91%; 95% CI: -1.96% [-1.85%]).

CONCLUSIONS

This study's findings highlight targeted interventions for CLD disparities, focusing on MASLD management, the younger population (15-49 years), and socio-demographic inequalities.

Noninvasive pathway for stratifying fibrosis in suspected metabolic dysfunction and alcohol-associated liver disease (MetALD)

BACKGROUND

Metabolic dysfunction and alcohol-associated liver disease (MetALD) may increase liver fibrosis progression, but data on screening are scarce. We aimed to assess the performance of noninvasive tests (NITs) for detecting significant fibrosis in individuals with suspected MetALD.

METHODS

This is a cross-sectional study of prospectively enrolled adults identified as overweight or obese. We included adults with suspected MetALD defined by ≥1 of 5 cardiometabolic criteria and self-reported alcohol use within MetALD ranges or lower self-reported alcohol use but with phosphatidylethanol (PEth) levels ≥25 ng/mL. Clinical assessment included contemporaneous magnetic resonance elastography (MRE) and vibration-controlled transient elastography (VCTE). Significant fibrosis was defined as MRE ≥3.14 kPa (or VCTE ≥7.6 kPa if MRE was missing). Analyses included AUROCs.

RESULTS

Among 617 individuals screened, we identified 97 (15.7%) with suspected MetALD. The mean age was 50.6±12.8 years, 67% were men, the mean body mass index was 31.4±6.5 kg/m2, 12.4% had diabetes, and 8% had significant fibrosis. Fibrosis-4 ≥1.3 demonstrated good performance for significant fibrosis (AUROC: 0.78, 95% CI: 0.58-0.98, sensitivity 80%, specificity 76%, positive predictive value 17%, and negative predictive value 98%). VCTE ≥8 kPa also had good performance (AUROC: 0.85, 95% CI: 0.66-1.00, sensitivity 80%, specificity 91%, positive predictive value 36%, and negative predictive value 99%). A stepwise approach using fibrosis-4 followed by VCTE yielded a low false negative rate (2% misclassified as low risk).

CONCLUSIONS

A clinical care algorithm utilizing a stepwise approach with fibrosis-4 and VCTE shows adequate performance in detecting significant fibrosis in individuals with suspected MetALD.

Hepatoprotective drug screening identifies daclatasvir a promising therapeutic candidate for MASLD by targeting PLIN2

Metabolic dysfunction-associated steatohepatitis (MASH) has become global health challenges with limited therapeutic strategy. Here, the present study aims to identify promising drug candidates for MASH and to clarify their pharmacological mechanism. By an extensive screening of FDA-approved hepatoprotective medicines using a PA/OA-stimulated hepatocytes model, we identified daclatasvir showing potent anti-MASH capacity against hepatic steatosis deposition and inflammatory response. The hepatoprotective benefits of daclatasvir was further validated in MASH mouse models, induced by a high-fat high-cholesterol (HFHC) diet for 16 weeks or a methionine-choline-deficient (MCD) diet for 4 weeks, as supported by markedly improved histopathological characteristics, serum biochemical level, and transcriptomic analyses. Using the molecular docking assay followed by isothermal titration calorimetry confirmation, we identified that daclatasvir functions as a new perilipin-2 (PLIN2) inhibitor by interrupting its stability. In specific, PLIN2 subjected to MARCH6-mediated protein degradation in a K11-type ubiquitination. Daclatasvir can directly bind to PLIN2 and enhance its interaction with MARCH6, leading to markedly strengthened PLIN2 ubiquitinational degradation and the subsequent decline in lipid droplet disintegration and lipotoxicity. The specific mutation at the binding amino acid sites of PLIN2 with daclatasvir largely abolished the anti-MASH benefit of daclatasvir. In conclusion, the findings of our present study for the first time identified the anti-HCV drug daclatasvir as a novel and potent PLIN2 protein degradant for MASH protection.

Association between weight fluctuation and the risk of metabolic dysfunction-associated steatotic liver disease

BACKGROUND

The global incidence of metabolic dysfunction-associated steatotic liver disease (MASLD) has increased in recent years. It has already been demonstrated that exercise and weight change are associated with the occurrence of MASLD; however, the association between weight fluctuation caused by different exercise intensities and the risk of MASLD remains to be studied.

AIM

To investigate the impact of weight fluctuation and physical activity intensity on the risk of MASLD prevalence.

METHODS

Data from the National Health and Nutrition Examination Survey database including five cycles from 2009 to 2018 were analyzed. The model included variables such as age, sex, and poverty income ratio. Weighted multivariate logistic regression was used to examine the influence of different weight fluctuation patterns within the two time intervals on the prevalence of MASLD. Nonparametric restricted cubic spline curves were used to analyze the non-linear relationship between net weight change and MASLD prevalence.

RESULTS

Among 3183 MASLD cases, the risk of MASLD increased with age for individuals transitioning from non-obese to obese or maintaining obesity, with odds ratio (OR) changing from 8.91 (95%CI: 7.40–10.88) and 11.87 (95%CI: 9.65–14.60) at 10 years before baseline to 9.58 (95%CI: 8.08–11.37) and 12.51 (95%CI: 9.33-16.78) at 25 years. Stable obesity correlated with age-dependent MASLD prevalence escalation, whereas increased physical activity attenuated MASLD risk in this group, with an OR changing from 13.64 (95%CI: 10.59–17.57) to 6.42 (95%CI: 4.24–9.72). Further analysis of the net weight changes revealed a paradoxical risk elevation with intensified physical activity during different time periods.

CONCLUSION

The risk of MASLD increases in individuals transitioning from non-obese to obese or maintaining obesity. High-intensity physical activity is beneficial for MASLD among individuals with stable obesity.

CiR-EIS alleviates metabolic dysfunction-associated steatohepatitis by modulating macrophage polarization involving the miR-548m/IGF1 axis

BACKGROUND & AIMS

Metabolic dysfunction-associated steatohepatitis (MASH) is a significant public health concern, with macrophage phenotypes implicated in its progression. Although extensive inflammation-suppressing circular RNA (ciR-EIS, formerly named as hsa_circ_0008882) has been implicated in inflammation regulation, its role in macrophage polarization within the context of MASH remains unexplored. This study aimed to clarify the effect of ciR-EIS on macrophage polarization in MASH.

METHODS

Immunofluorescence-fluorescence in situ hybridization was used to evaluate the localization of ciR-EIS in human liver sections. THP-1-derived macrophages (TDMs) were utilized to study ciR-EIS functions in vitro. Flow cytometry and RT-qPCR were employed to evaluate macrophage polarization after transfection. Bodipy assay was used to measure lipid buildup in HepG2 cells. Immunohistochemistry was used to confirm liver insulin-like growth factor 1 (IGF1) expression. Retrospective clinical records were analyzed to examine the association between cir-EIS, IGF1, and MASH.

RESULTS

CiR-EIS was downregulated in patients with MASH and colocalized with the macrophage marker CD68. CiR-EIS and mitochondrially encoded NADH dehydrogenase 5 (MT-ND5) were downregulated in M1 macrophages and upregulated in M2 macrophages. TDM-derived supernatants overexpressed ciR-EIS, significantly reducing HepG2 lipid deposition and inhibiting LX2 proliferation. Overexpression of ciR-EIS in TDMs significantly inhibited M1 macrophage markers CD86, interleukin-1 beta, and tumor necrosis factor-alpha while enhancing M2 macrophage markers CD163 and CD206. CiR-EIS regulated macrophage polarization in a manner involving the miR-548m/IGF1 axis. Serum IGF1 levels were positively correlated with ciR-EIS, and both of them were notably reduced in patients with MASH and inversely correlated with APRI and FIB-4 scores.

CONCLUSIONS

CiR-EIS regulates macrophage polarization in a manner involving the miR-548/IGF1 axis, thereby reducing hepatocyte lipid accumulation and stellate cell proliferation in MASH. It demonstrates potential as a diagnostic marker and therapeutic target for MASH.

Calorie-restriction treatment mitigates the aging in rat liver model

The aging process promotes progressive impairment of homeostasis and the increase of the risk of disease and death. A major hallmark of the aging process is the systemic chronic inflammation which strongly contributes to the onset of aging-related diseases. In the liver, the aging condition drives the hepatocytes to develop a metabolic dysfunction-associated steatosis. Caloric restriction (CR) is a remarkable strategy to delay biological aging, occurring through several mechanisms. In this study we aimed to explore, employing an in vivo rat model, the impact of CR on aging-mediated liver inflammation markers. The experiments were performed on 14 male Sprague-Dawley rats (24 months old). At 18 months old, rats were allocated into two groups: the normal diet (ND) group was continued ad libitum diet, and the CR regimen group was fed a diet of the same chow restricted to 60% of the intake. All animals were sacrificed at 24 months old. Compared to the ND group, morphological examination of the liver revealed a lower level of fibrosis in the CR group, concomitantly with a reduced expression of key fibrotic markers, such as collagen I, fibronectin, and αSMA. Furthermore, CR improved the liver oxidative balance, as showed by the increased expression of two scavenging enzymes, SOD1/SOD. Moreover, we reported concomitant reduction of NLRP3 inflammasome signalling. Interestingly, CR significantly improved the signalling of key members of the nutrition-sensitizing affected by aging, AMPK/SIRT1/LKB1. Collectively our findings support the evidence on the metabolic benefits of CR about aging-related liver inflammation, by inducing a morphological improvement that mirrors the decrease in the expression of inflammatory molecular markers.

Association Between Uric Acid to HDL-C Ratio and Metabolic Dysfunction-Associated Steatotic Liver Disease in Type 2 Diabetes Mellitus: A Cross-Sectional Study

Background

Patients with type 2 diabetes mellitus (T2DM) exhibit an elevated risk of developing metabolic dysfunction-associated steatotic liver disease (MASLD). The uric acid to high-density lipoprotein cholesterol ratio (UHR) has emerged as a novel metabolic biomarker implicated in MASLD pathogenesis. This study aimed to evaluate the association between UHR and MASLD in a T2DM population.

Methods

In this cross-sectional study, we analyzed clinical data from 1081 T2DM patients (464 without MASLD, 617 with MASLD). Physiological and biochemical parameters were collected and analyzed. UHR was calculated as [uric acid (mg/dL)/HDL-C (mg/dL)] × 100%. Univariate and multivariate logistic regression analyses were performed to examine the association between UHR and MASLD.

Results

T2DM patients with MASLD had significantly higher UHR levels than those without MASLD (12.12[9.06-16.83] vs 10.36[7.65-14.08], p<0.001). UHR showed a strong positive correlation with TG/HDL (r =0.673, p < 0.001), moderate correlations with TG (r = 0.516, p < 0.001) and TC/HDL (r =0.548, p < 0.001), weak but significant associations with BMI (r = 0.330), WHR (r = 0.289), HOMA-IR (r = 0.121), ALT (r = 0.123), and GGT (r = 0.267) (all p < 0.05). Multivariate logistic regression showed that elevated UHR levels were significantly associated with increased MASLD risk (adjusted OR = 1.057, 95% CI: 1.016-1.100, p = 0.006), after adjusting for age, diabetes duration, BMI, blood pressure, and biochemical confounders.

Conclusion

Elevated UHR is independently associated with MASLD in T2DM patients, suggesting its clinical relevance in MASLD screening among this high-risk population.

INCIDENTAL HEPATIC STEATOSIS IDENTIFIED ON ULTRASOUND IN PATIENTS UNDERGOING CHOLECYSTECTOMY: HIGH PREVALENCE AND INSUFFICIENT INVESTIGATIVE AND CLINICAL MANAGEMENT

BACKGROUND

Steatotic liver disease (SLD) affects about 1 billion people globally, making its proper management essential to prevent progression to more severe stages.

OBJECTIVE

The aim of this study was to evaluate medical management concerning hepatic steatosis incidentally identified by ultrasound in patients undergoing elective cholecystectomy.

METHODS

This observational, cross-sectional, and retrospective study included patients aged 18 years or older who underwent elective cholecystectomy at Hospital do Trabalhador, in Curitiba/PR, between 2018 and 2022. Patients with external ultrasound reports or incomplete data in their medical records were excluded. Medical records, laboratory tests, and ultrasound reports were analyzed to evaluate the prevalence of steatosis in these patients.

RESULTS

The study sample consisted of 355 patients, and 103 (29.01%) of them presented steatosis on ultrasound. Older age (P=0.0022), male sex (P=0.03009), higher body mass index (P<0.001), obesity (P<0.001), hypertension (P<0.001), dyslipidemia (P=0.0072), and elevated levels of oxaloacetic and pyruvic aminotransferases (P=0.02112) were associated with the presence of this finding. No action was taken regarding the presence of steatosis in 60.19% of patients. Approximately 39.81% had the finding recorded in their medical records, 6.80% received lifestyle change counseling, and 4.85% were investigated for the stage of steatosis.

CONCLUSION

A significant prevalence of hepatic steatosis was incidentally identified in the ultrasound of patients undergoing cholecystectomy. However, the approach to this finding was insufficient, highlighting the need for substantial improvements on its management and investigation.

Metabolic dysfunction-associated steatotic liver disease and the cardiovascular system

Metabolic dysfunction-associated steatotic liver disease (MASLD), previously termed nonalcoholic fatty-liver disease, is an important and rising health issue with a link with atherosclerotic cardiovascular (CV) disease (CVD), affecting ∼25-30 % of the adults in the general population; in patients with diabetes, its prevalence culminates to ∼70 %; its evolutive form, nonalcoholic steatohepatitis, is estimated to be the main cause of liver transplantation in the future. MASLD is a multisystem disease that affects, besides the liver, extra-hepatic organs and regulatory pathways; it raises the risk of type 2 diabetes mellitus (T2D), CVD, and chronic kidney disease; the disease may also progress to hepatocellular carcinoma. Its diagnosis requires hepatic steatosis and at least one cardiometabolic risk factor and the exclusion of both significant alcohol consumption and other competing causes of chronic liver disease. Beyond CV events, associated metabolic comorbidities comprise obesity (∼50 %), T2D (∼20 %), hyperlipidemia (∼70 %), hypertension (∼40 %), and metabolic syndrome (∼40 %). Among the various clinical events, CV events mostly determine prognosis as they are the leading cause of death in these patients. Regarding management, statins exert beneficial effects in improving liver injury; silybin, derived from Silybum marianum, has some protective effects; lifestyle modification, such as weight loss, dietary changes, physical exercise, and abstention from alcohol use combined with optimal management of comorbidities are most helpful. Bariatric surgery may be an option in persons with MASLD and obesity. Adults with non-cirrhotic MASLD and significant liver fibrosis may be candidates for targeted treatment with resmetirom, which has histological efficacy on steatohepatitis and fibrosis with an acceptable safety and tolerability profile, whereas, no MASLD-targeted pharmacotherapy can be beneficial in the cirrhotic stage, whereby other measures may include metabolic drugs, nutritional counseling, surveillance for portal hypertension and hepatocellular carcinoma, and finally, liver transplantation in decompensated cirrhosis.

MetALD: New Perspectives on an Old Overlooked Disease

Metabolic dysfunction-associated steatotic liver disease (MASLD) and alcohol-associated liver disease (ALD) are the major contributors to the liver disease burden globally. The rise in these conditions is linked to obesity, type 2 diabetes, metabolic syndrome and increased alcohol consumption. MASLD and ALD share risk factors, pathophysiology and histological features but differ in their thresholds for alcohol use, and the ALD definition does not require the presence of metabolic dysfunction. A recent multi-society consensus overhauled the nomenclature of liver steatosis and introduced the term MetALD to describe patients with metabolic dysfunction who drink more than those with MASLD and less than those with ALD. This new terminology aims to enhance the understanding and management of liver disease but poses challenges, such as the need to accurately measure alcohol consumption in research and clinical practice settings. Recent studies show that MetALD has significant implications for patient management, as it is associated with increased mortality risks and more severe liver outcomes compared to MASLD alone. MetALD patients face increased risks of liver disease progression, cancer and cardiovascular disease. The diagnosis of MetALD involves the adequate quantification of alcohol use through standardised questionnaires and/or biomarkers as well as proper assessment of liver disease stage and progression risk using non-invasive tools including serologic markers, imaging, elastography techniques and genetic testing. Effective management requires addressing both metabolic and alcohol-related factors to improve outcomes. This review intends to provide a comprehensive overview of MetALD, covering pathogenesis, potential diagnostic approaches, management strategies and emerging therapies.

Therapeutic intervention with anti-TNF alleviates colonic and hepatic toxicity induced by perfluorooctanoic acid (PFOA)

Perfluorooctanoic acid (PFOA) is a prevalent and chemically stable environmental contaminant. Our preliminary data suggest that chronic exposure to PFOA induces colonic damage in mice that resembles inflammatory bowel disease (IBD). Anti-TNF therapies are commonly used in the clinical management of IBD. Building upon our previous findings, we administered anti-TNF treatment to mice exposed to PFOA. Our results show that anti-TNF therapy significantly reduces the colonic inflammatory response, activation of the NLR family pyrin domain containing 3 (NLRP) inflammasome, and apoptosis induced by PFOA. Additionally, anti-TNF treatment restores intestinal barrier integrity, which is disrupted by PFOA exposure, and enhances the regenerative capacity of the colon by promoting intestinal stem cell function. Furthermore, anti-TNF therapy effectively mitigates hepatic inflammation, liver dysfunction, lipid metabolism disturbances, NLRP3 inflammasome activation, and apoptosis in the liver triggered by PFOA. In conclusion, our study provides compelling evidence that anti-TNF therapy can alleviate both colonic and hepatic injuries induced by PFOA exposure. This research expands our understanding of environmental toxin-induced diseases and offers potential therapeutic strategies for managing PFOA-related disorders in the future.

Metabolic dysfunction associated steatotic liver and kidney stones: what is going on?

PURPOSE OF REVIEW

Metabolic dysfunction associated steatotic liver disease (MASLD) is increasing throughout the world, affecting nearly one in three individuals. Kidney stone disease, which is also increasing, is associated with MASLD. Common risk factors for both, including obesity, diabetes, dyslipidemia, hypertension, and metabolic syndrome, are likely drivers of this association. We present here a review of the associations and possible interconnections between these two common disease processes.

RECENT FINDINGS

Epidemiological studies are discordant regarding the impact of sex on this association and on the impact of MASLD on incident stone risk. The nature of kidney stones is rarely taken into account.A favorable milieu for uric acid kidney stone formation may be created by a lower urine pH resulting from defective ammonium production associated with insulin resistance, common in MASLD.Endogenous oxalate synthesis, a major risk factor for calcium oxalate kidney stones, may be increased in MASLD via decline in the activity of enzymes involved in the detoxification of glyoxylate, the immediate precursor of oxalate.

SUMMARY

The nature of kidney stones associated with MASLD and factors driving this association remain to be elucidated. Potential mechanisms identified underlying this include an increase in the risk factors for both uric acid and calcium oxalate kidney stones.

The trend in incidence of non-alcoholic fatty liver disease and its impact on cirrhosis and liver cancer: An analysis from Global Burden of Disease 2021

OBJECTIVES

We aimed to recognize the burden of NAFLD and support public health policy development for its prevention and management.

STUDY DESIGN

A cross-sectional analysis of GBD 2021 results was conducted.

METHODS

We collected incidence data on NAFLD from 1990 to 2021 using Global Burden of Disease Study in 2021. Estimated annual percentage changes (EAPCs) in NAFLD age standardized incidence rate (ASR) were calculated to quantify the temporal trends in NAFLD ASR. Bayesian age-period-cohort models were constructed to project NAFLD incidence rates and cases up to 2050. Additionally, we assessed the percentage of cirrhosis and liver cancer attributable to NAFLD.

RESULTS

Globally, the newly-occurred cases of NAFLD increased by 94.49 % from 24, 856, 159 in 1990 to 48, 353, 272 in 2021. The case number will further increase to 78,602,984 in 2050, and ASR will increase from 5.93 per 1000 in 2021 to 7.26 per 1000 in 2050. The most pronounced increases were observed in young people and men. In 2021, NAFLD accounted for 82.7 % of cirrhosis and other chronic liver diseases and 8.0 % of liver cancer cases.

CONCLUSIONS

From 1990 to 2021, the incidence of NAFLD has been continuously increasing and is expected to continue rising until 2050. The increases in young people and men highlight their priority in future schedules. The rising proportions of cirrhosis and liver cancer caused by NAFLD further underscore the serious health risks.

Targeting Metabolism: Innovative Therapies for MASLD Unveiled

The recent introduction of the term metabolic-dysfunction-associated steatotic liver disease (MASLD) has highlighted the critical role of metabolism in the disease's pathophysiology. This innovative nomenclature signifies a shift from the previous designation of non-alcoholic fatty liver disease (NAFLD), emphasizing the condition's progressive nature. Simultaneously, MASLD has become one of the most prevalent liver diseases worldwide, highlighting the urgent need for research to elucidate its etiology and develop effective treatment strategies. This review examines and delineates the revised definition of MASLD, exploring its epidemiology and the pathological changes occurring at various stages of the disease. Additionally, it identifies metabolically relevant targets within MASLD and provides a summary of the latest metabolically targeted drugs under development, including those in clinical and some preclinical stages. The review finishes with a look ahead to the future of targeted therapy for MASLD, with the goal of summarizing and providing fresh ideas and insights.

Tanshinone IIA alleviate atherosclerosis and hepatic steatosis via down-regulation of MAPKs/NF-κB signaling pathway

OBJECTIVES

Tanshinone IIA (Tan IIA) exhibits therapeutic potential for atherosclerosis (AS) and hepatic steatosis (HS). The study aims to explore the mechanisms underlying the anti-atherosclerosis and anti-hepatic steatosis effects of Tan IIA.

METHODS

The LDLR-/-mice were divided into control, model, low/high Tan IIA and atorvastatin group, which fed with High-fat diet to build NAFLD-associated AS model, then administrated with 0.9 % saline, Tan IIA or atorvastatin. RAW264.7 cells divided into control, LPS, LPS plus low/high Tan IIA and LPS plus Tan IIA plus JNK activator group. The different goups' pathological changes visualized with H&E, Oil Red O and Immunofluorescence staining. The therapeutic effect of Tan IIA was reflected by lipids metabolism changes, hepatic indexes, inflammation levels. ELISA, RT-qPCR and Western blot assay were used to determine the inflammatory factors and upstream proteins. Molecular docking was used to reconfirm the importance of genes studied and locate the specific gene will study.

RESULTS

Tan IIA alleviated LDLR-/-mice AS and HS by reducing AS plaque area, lowering serum &liver lipid levels (TC, TG), improving liver function (AST, ALT). Tan IIA decreased serum inflammation levels (IL-1β, IL-6, TNF-α) and aorta & liver inflammatory-related cytokines levels (iNOS, VCAM-1, IL-6) and inhibited the phosphorylation of aorta & liver protein ERK1/2, JNK, p38 and NF-κB p65, which were validated in the LPS-stimulated macrophages supernatant and cells.

CONCLUSIONS

The study indicated that Tan IIA can alleviate atherosclerosis and hepatic steatosis via down-regulating MAPKs/NF-κB signaling pathway. This provides a potential therapeutic strategy for the co-existing situation of atherosclerosis and hepatic steatosis.

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.

Diverse Subsets of γδT Cells and Their Specific Functions Across Liver Diseases

γδT cells, a distinct group of T lymphocytes, serve as a link between innate and adaptive immune responses. They are pivotal in the pathogenesis of various liver disorders, such as viral hepatitis, nonalcoholic fatty liver disease (NAFLD), alcoholic liver disease (ALD), liver fibrosis, autoimmune liver diseases, and hepatocellular carcinoma (HCC). Despite their importance, the functional diversity and regulatory mechanisms of γδT cells remain incompletely understood. Recent advances in high-throughput single-cell sequencing and spatial transcriptomics have revealed significant heterogeneity among γδT cell subsets, particularly Vδ1+ and Vδ2+, which exhibit distinct immunological roles. Vδ1+ T cells are mainly tissue-resident and contribute to tumor immunity and chronic inflammation, while Vδ2+ T cells, predominantly found in peripheral blood, play roles in systemic immune surveillance but may undergo dysfunction in chronic liver diseases. Additionally, γδT17 cells exacerbate inflammation in NAFLD and ALD, whereas IFN-γ-secreting γδT cells contribute to antiviral and antifibrotic responses. These discoveries have laid the foundation for the creation of innovative solutions. γδT cell-based immunotherapeutic approaches, such as adoptive cell transfer, immune checkpoint inhibition, and strategies targeting metabolic pathways. Future research should focus on harnessing γδT cells' therapeutic potential through targeted interventions, offering promising prospects for precision immunotherapy in liver diseases.

Switching to Bictegravir/Emtricitabine/Tenofovir Alafenamide Fumarate Regimen and Its Effect on Liver Steatosis Assessed by Fibroscan

BACKGROUND

Antiretroviral therapy has transformed HIV infection from a fatal disease to a chronic and manageable condition, but increasing health issues beyond acquired immunodeficiency syndrome, such as metabolic, liver, and cardiovascular diseases, have been observed. Furthermore, the increasing prevalence of HIV strains resistant to older antiretroviral regimens has necessitated a re-evaluation of treatment strategies.

METHODS

We performed a retrospective, observational study to evaluate the long-term outcomes of an antiretroviral switch from a non-nucleoside reverse transcriptase inhibitor-based to bictegravir-based regimen; this study aimed to assess the impact of this antiretroviral switch on treatment adherence, the safety profile, and virologic outcomes. The secondary objectives were to analyze the changes in lipid, kidney function, liver function, and anthropometric parameters after switching.

RESULTS

A total of 25 patients were included in this analysis; virologic suppression was maintained over time, with 100% of patients demonstrating undetectable viral loads at 6, 12, 24, and 36 months. In parallel, a significant increase in CD4+ cell count was observed after switching. No significant differences were observed compared to the previous therapy regarding anthropometric parameters or laboratory parameters. However, a significant reduction in liver steatosis, as assessed by Fibroscan, was observed.

CONCLUSIONS

bictegravir-based regimens are a valid therapeutic option for people living with HIV, particularly for those with metabolic comorbidities.

Prediction of major liver-related events in the population using prognostic models

Liver disease poses a significant global health burden, with steatotic liver disease related to metabolic dysfunction and/or alcohol use being the most prevalent type. Current risk stratification strategies emphasize detecting advanced fibrosis as a surrogate marker for liver-related events (LREs), such as hospitalization, liver cancer, or death. However, fibrosis alone does not adequately predict imminent outcomes, particularly in fast-progressing individuals without advanced fibrosis at evaluation. This underscores the need for models designed specifically to predict LREs, enabling timely interventions. The Chronic Liver Disease (CLivD) risk score, the dynamic aspartate aminotransferase-to-alanine aminotransferase ratio (dAAR), and the Cirrhosis Outcome Risk Estimator (CORE) were explicitly developed to predict LRE risk rather than detect fibrosis. Derived from general population cohorts, these models incorporate either standard liver enzymes (dAAR and CORE) or risk factors (CLivD), enabling broad application in primary care and population-based settings. They directly estimate the risk of future LREs, improving on traditional fibrosis-focused approaches. Conversely, widely used models like the Fibrosis-4 index and newer ones, such as the LiverRisk and LiverPRO scores, were initially developed to detect significant/advanced fibrosis or liver stiffness. While not designed for LRE prediction, they have later been analyzed for this purpose. Integrating fibrosis screening with LRE-focused models like CLivD, dAAR, and CORE can help healthcare systems adopt proactive, preventive care. This approach emphasizes identifying individuals at imminent risk of severe outcomes, potentially ensuring better resource allocation and personalized interventions.

Research progress on AMPK in the pathogenesis and treatment of MASLD

Metabolic dysfunction-associated steatotic liver disease (MASLD; formerly known as non-alcoholic fatty liver disease, NAFLD) has become one of the most prevalent chronic liver diseases worldwide, with its incidence continuously rising alongside the epidemic of metabolic disorders. AMP-activated protein kinase (AMPK), as a key regulator of cellular energy metabolism, influences multiple pathological processes associated with MASLD. This review systematically summarizes the regulatory roles of AMPK in lipid metabolism, inflammatory response, cell apoptosis, and fibrosis. Additionally, it discusses the latest developments of AMPK activators from preclinical to clinical studies, while analyzing the major challenges currently faced and potential strategies for resolution. A deeper understanding of AMPK regulatory mechanisms will contribute to the development of more effective therapeutic approaches for MASLD.

Clinical Insights into Non-Alcoholic Fatty Liver Disease and the Therapeutic Potential of Flavonoids: An Update

Non-alcoholic fatty liver disease (NAFLD) is considered a significant global health issue related to serious metabolic disorders. However, effective pharmacological treatments are still limited. Flavonoids, a wide group of polyphenol substances, exert anti-inflammatory and lipid-lowering effects in preclinical data. Thus, implementing these research findings in clinical practice could significantly help manage NAFLD and its consequences. This narrative review assesses the therapeutic potential of flavonoids in managing NAFLD. The research collected randomized controlled trials (RCTs) and meta-analyses of RCTs from the past five years concerning the impact of flavonoids on NAFLD. A total of 20 studies were selected according to predetermined inclusion criteria, comprising thirteen randomized controlled trials (RCTs) and seven meta-analyses. The research underscores the beneficial effects of flavonoids in the management of NAFLD through the enhancement of lipid metabolism, the reduction in hepatic steatosis, and the provision of anti-inflammatory actions. Clinical trials demonstrate that interventions rich in flavonoids, including quercetin, epigallocatechin gallate, naringenin, and isoflavones, substantially reduce liver fat content and enhance liver enzyme profiles, with certain compounds exhibiting superior efficacy in particular subgroups, such as older adults and females. Nonetheless, whereas these therapies significantly diminish hepatic steatosis, their effect on fibrosis is constrained. To sum up, flavonoids exhibit significant potential as supplementary treatments for NAFLD by enhancing liver function, lipid metabolism, and inflammation. Additional extensive controlled clinical trials are necessary to create uniform treatment methods and ascertain their long-term therapeutic advantages.

Weight-adjusted waist circumference index with hepatic steatosis and fibrosis in adult females: a cross-sectional, nationally representative study (NHANES 2017-2020)

BACKGROUND

Obesity is detrimental to liver health. Weight-adjusted waist circumference (WWI) is a new indicator of obesity that is superior to body mass index (BMI) and waist circumference (WC) in predicting obesity. There are limited studies on the relationship between Metabolic Associated Fatty Liver Disease (MASLD) and WWI. Therefore, this study aimed to investigate the association between WWI, Controlled Attenuation Parameters (CAP), and Liver Stiffness Measurement (LSM), with special attention to gender differences.

METHODS

This cross-sectional study included participants from the 2017 to 2020 National Health and Nutrition Examination Survey (NHANES). The study used multiple linear regression models, smoothed curves, and threshold effects analyses to describe the relationships between variables. Multiple regression analyses were used to examine the associations between the four obesity indicators and CAP and LSM. Subject work characteristics (ROC) curves were used to assess the predictive value of WWI and other traditional obesity indicators for hepatic steatosis and liver fibrosis, and predictive power was assessed by area under the curve (AUC).

RESULTS

The study involved 6713 participants, including 3072 men (46%) and 3641 women (54%). The results showed that among female participants, higher WWI was associated with hepatic steatosis (OR = 1.71, 95% CI: 1.43, 2.04; P < 0.0001) and hepatic fibrosis (OR = 2.11, 95% CI: 1.58, 2.84; P < 0.0001). Smoothed curve fitting of WWI versus CAP showed a statistically significant positive correlation between WWI in male and female participants There was a statistically significant positive correlation with CAP for both male and female participants. The same significant non-linear relationship was found between WWI and LSM, with no significant difference between males and females. WWI was also a good predictor of hepatic steatosis compared to other obesity indicators and was more pronounced in male participants (AUC = 0.8224). Whereas in the comparison of WWI with LSM, wBMI was a better predictor in female participants (AUC = 0.7751).

CONCLUSIONS

Based on this study, WWI was significantly associated with the risk of hepatic steatosis and hepatic fibrosis in women, suggesting the potential of WWI as a screening tool. Due to the cross-sectional design, causality cannot be inferred. Longitudinal studies are needed to validate our findings.

Association of prebiotic/probiotic intake with MASLD: evidence from NHANES and randomized controlled trials in the context of prediction, prevention, and a personalized medicine framework

Objective

Metabolic-associated fatty liver disease (MASLD) is a growing global health concern. From the standpoint of preventive and personalized medicine, understanding the early determinants and modifiable risk factors is essential for targeted prevention and personalized treatment strategies. This study aimed to evaluate the specific association between probiotics/prebiotics and the occurrence of MASLD, contributing to the development of innovative preventive measures and personalized therapeutic approaches.

Methods

Data were obtained from the National Health and Nutrition Examination Survey (NHANES) from 2001 to 2018. The study employed logistic regression analysis to examine the relation between MASLD and probiotics/prebiotics. The efficacy of various MASLD predictive models was assessed using receiver operating characteristic (ROC) curves. A meta-analysis was conducted by searching databases up to 4 May 2024. The analysis included randomized controlled trials of liver function in patients with MASLD or nonalcoholic steatohepatitis treated with probiotics, prebiotics, or yogurt for a minimum of 6 months.

Results

A total of 5014 adults from NHANES were included in this study, with a weighted prevalence of MASLD observed at 24.47%. MASLD adults who consumed both probiotics and prebiotics exhibited a reduced risk of MASLD (OR = 0.71, 95% CI: 0.53 to 0.94). The use of probiotics/prebiotics can enhance the simplicity and practicality of the model. Model 1, adjusted for sex, BMI, race, and HEI-2015, achieved an area under the curve (AUC) of 0.8544, while Model 2, adjusted for sex, BMI, race, and prebiotics/probiotics use, showed a similar AUC of 0.8537. The comparison between the two models revealed no statistically significant difference (0.8544 vs. 0.8537; 95% CI: - 0.0010 to 0.0025; Z = 0.8332; p = 0.4047). Subgroup analysis of the NHANES data revealed that individuals aged 40 and older benefit from consuming probiotics or prebiotics. Furthermore, the meta-analysis demonstrated that probiotic or prebiotic interventions resulted in significant improvements in biochemical markers, including alanine aminotransferase, aspartate aminotransferase, low-density lipoprotein cholesterol, and triglycerides.

Conclusions

The consumption of probiotics/prebiotics has been linked to a reduced risk of developing MASLD in adults. Integrating probiotics/prebiotics into early intervention and personalized treatment plans may facilitate targeted prevention and management of MASLD, promoting a more individualized approach to disease prevention and care.

Supplementary information

The online version contains supplementary material available at 10.1007/s13167-025-00398-4.

Ultrasound-guided attenuation parameter for identifying metabolic dysfunction-associated steatotic liver disease: a prospective study

PURPOSE

This study assessed the performance of the ultrasound-guided attenuation parameter (UGAP) in diagnosing and grading hepatic steatosis in patients with metabolic dysfunctionassociated steatotic liver disease (MASLD). Magnetic resonance imaging proton density fat fraction (MRI-PDFF) served as the reference standard.

METHODS

Patients with hepatic steatosis were enrolled in this prospective study and underwent UGAP measurements. MRI-PDFF values of ≥5%, ≥15%, and ≥25% were used as references for the diagnosis of steatosis grades ≥S1, ≥S2, and S3, respectively. Spearman correlation coefficients and area under the receiver operating characteristic curves (AUCs) were calculated.

RESULTS

Between July 2023 and June 2024, the study included 88 patients (median age, 40 years; interquartile range [IQR], 36 to 46 years), of whom 54.5% (48/88) were men and 45.5% (40/88) were women. Steatosis grades exhibited the following distribution: 22.7% (20/88) had S0, 50.0% (44/88) had S1, 21.6% (19/88) had S2, and 5.7% (5/88) had S3. The success rate for UGAP measurements was 100%. The median UGAP value was 0.74 dB/cm/MHz (IQR, 0.65 to 0.82 dB/ cm/MHz), and UGAP values were positively correlated with MRI-PDFF (r=0.77, P<0.001). The AUCs of UGAP for the diagnoses of ≥S1, ≥S2, and S3 steatosis were 0.91, 0.90, and 0.88, respectively. In the subgroup analysis, 98.4% (60/61) of patients had valid controlled attenuation parameter (CAP) values. UGAP measurements were positively correlated with CAP values (r=0.65, P<0.001).

CONCLUSION

Using MRI-PDFF as the reference standard, UGAP demonstrates good diagnostic performance in the detection and grading of hepatic steatosis in patients with MASLD.

Diagnostic Uptake of Targeted Sequencing in Adults With Steatotic Liver Disease and a Suspected Genetic Contribution

BACKGROUND AND AIMS

In patients with steatotic liver diseases (SLD), genetic factors may account for severe liver involvement despite mild or absence of triggering factors or a strong family history. Aim of this study was to examine the diagnostic uptake of targeted sequencing (TS), covering both coding and non-coding regions, of a broad panel of 82 liver and lipid metabolism genes in patients with unexplained SLD.

METHODS

We enrolled 49 adult patients with SLD and a suspected genetic contribution. Genetic variants were detected through a customised TS panel, whereas the contribution of common genetic variation to the individual susceptibility to SLD was captured by a polygenic risk score (SLD-PRS).

RESULTS

A diagnosis of rare Mendelian disorder was established in 11 patients (22%), independently of age or family history. Rare variants possibly contributing to clinical phenotype were detected in additional 29 patients (59%). Increased SLD-PRS values were detected in 17 patients (35%), enabling an increase in diagnostic uptake of 24%, especially in those without a strong family history (p = 0.03). Genetic diagnosis allowed refinement of clinical management in 23 (47%) patients.

CONCLUSIONS

The diagnostic uptake of TS was 22% for Mendelian disorder and 59% for possible contribution to clinical phenotype in selected adult patients with SLD. Evaluation of common variants, as captured by SLD-PRS, yields complementary information increasing the overall utility of the genetic examination.

Association of high-sensitivity C-reactive protein with hepatic fibrosis in patients with metabolic dysfunction-associated steatotic liver disease

Objective

This study aimed to investigate the association between high-sensitivity C-reactive protein (hsCRP) levels and hepatic fibrosis in patients with metabolic dysfunction-associated steatotic liver disease (MASLD) and assess its predictive efficacy.

Methods

The study included 1,477 participants from the United States and 1,531 from China diagnosed with MASLD. Liver stiffness measurement (LSM) and controlled attenuation parameter (CAP) were assessed by vibration-controlled transient elastography (VCTE) to evaluate the presence and degree of hepatic fibrosis and steatosis. The relationship between hsCRP levels and hepatic fibrosis in MASLD patients was examined using multivariable-adjusted and restricted cubic spline (RCS) models. Additionally, subgroup analyses were conducted to investigate the potential heterogeneity among different characteristic subgroups.

Results

The results demonstrated a significant correlation between elevated hsCRP levels and an increased risk of significant fibrosis, advanced fibrosis, and cirrhosis in the US cohort of MASLD patients (OR 2.22, 1.69, and 2.85, respectively; all P <0.05). The results of the Chinese cohort were consistent with those of the US cohort, and there was a significant and positive correlation between hsCRP levels and the risk of hepatic fibrosis in patients with MASLD (OR 2.53, 3.85, and 3.78, respectively, all P <0.001). The RCS analysis revealed a significant non-linear relationship between hsCRP levels and the degree of hepatic fibrosis, with disparate inflection point values observed across different cohorts (approximately 9 mg/L in the US cohort and 4 mg/L in the Chinese cohort). The impact of hsCRP levels on the risk of hepatic fibrosis varied across different subgroups with distinct characteristics.

Conclusion

The present study demonstrated a significant correlation between hsCRP levels and the degree of hepatic fibrosis in patients with MASLD, with notable dose-response relationships and subgroup differences.

Molecular mechanisms behind the inhibitory effects of ginsenoside Rg3 on hepatic fibrosis: a review

Hepatitis is a chronic inflammatory liver disease and an important cause of liver fibrosis, which can progress to cirrhosis and even hepatocellular carcinoma if left untreated. However, liver fibrosis is a reversible disease, so finding new intervention targets and molecular markers is the key to preventing and treating liver fibrosis. Ginseng, the roots of Panax ginseng C. A. Meyer, is a precious Traditional Chinese Medicines with high medicinal value and is known as the "king of all herbs", and its active ingredient, ginsenoside Rg3 is a rare saponin and a new class of drug, one of the most thoroughly and extensively studied in a large number of studies. Ginsenoside Rg3 is an active ingredient extracted from ginseng that possesses a variety of biological activities, including anti-inflammatory, antioxidant, and anti-fibrotic effects. Several studies have suggested that ginsenoside Rg3 may help reduce hepatic inflammation and oxidative stress, thereby slowing the progression of liver fibrosis. Ginsenoside Rg3 may have some therapeutic effects on liver fibrosis, and the underlying molecular mechanisms behind these effects are attributed to cellular autophagy, apoptosis, and anti-inflammation, as well as the modulation of antioxidant activity and multiple signaling pathways. The molecular mechanisms behind the inhibitory effect of ginsenoside Rg3 on hepatic fibrosis are reviewed, with a view to providing reference for related studies.

From Dysbiosis to Hepatic Inflammation: A Narrative Review on the Diet-Microbiota-Liver Axis in Steatotic Liver Disease

The gut microbiota has emerged as a critical player in metabolic and liver health, with its influence extending to the pathogenesis and progression of steatotic liver diseases. This review delves into the gut-liver axis, a dynamic communication network linking the gut microbiome and liver through metabolic, immunological, and inflammatory pathways. Dysbiosis, characterized by altered microbial composition, contributes significantly to the development of hepatic steatosis, inflammation, and fibrosis via mechanisms such as gut barrier dysfunction, microbial metabolite production, and systemic inflammation. Dietary patterns, including the Mediterranean diet, are highlighted for their role in modulating the gut microbiota, improving gut-liver axis integrity, and attenuating liver injury. Additionally, emerging microbiota-based interventions, such as fecal microbiota transplantation and bacteriophage therapy, show promise as therapeutic strategies for steatotic liver disease. However, challenges such as population heterogeneity, methodological variability, and knowledge gaps hinder the translational application of current findings. Addressing these barriers through standardized approaches and integrative research will pave the way for microbiota-targeted therapies to mitigate the global burden of steatotic liver disease.

PNPLA3 in Alcohol-Related Liver Disease

The discovery of PNPLA3 as a genetic risk factor for liver disease has transformed our understanding of the pathogenesis of alcohol-related liver disease (ALD). The recent reclassification of fatty liver disease as steatotic liver disease (SLD), introducing metabolic dysfunction and alcohol-related liver disease (MetALD), has highlighted how genetic and environmental factors synergistically drive liver damage. The PNPLA3 rs738409 variant stands as a paradigmatic example of gene-environment interaction, where its effect on liver disease is dramatically amplified by alcohol consumption, obesity and type 2 diabetes. Understanding these interactions has revealed novel pathogenic mechanisms. The robust genetic evidence and a growing understanding of molecular mechanisms have made PNPLA3 an attractive therapeutic target. Several compounds targeting PNPLA3 are now in clinical development. While initial trials have focused on metabolic dysfunction-associated SLD, the recognition that almost all individuals with excessive alcohol consumption have metabolic comorbidities provides an unprecedented opportunity to evaluate these genetically informed therapies in MetALD. In this review, we examine the role of PNPLA3 in ALD, focusing on gene-environment interactions and therapeutic implications in the context of the new disease classification framework.

A simple, reliable and easily generalizable cell-based assay for screening potential drugs that inhibit lipid accumulation

Ectopic lipid deposition in the hepatocyte plays an important role in the development of nonalcoholic fatty liver disease (NAFLD), which has become one of the most common causes of chronic liver disease worldwide yet no approved drugs are currently available. In this study, a cell-based method was developed to screen potential drugs with low toxicity that inhibit lipid accumulation. In the same 96-well plate, cytotoxicity was measured using CCK8 assay, followed by lipid content detection using BODIPY 493/503 via fluorometry assay, a lipid droplet-specific fluorescent dye commonly used in microscopy and flow cytometry, but not previously reported in fluorometry. Lipid content was normalized to DAPI staining to control for cell number. The results of this assay were highly consistent with the fluorescence microscopy, with significantly lower intra-group variability in detecting lipid accumulation induced by free fatty acids in Huh7 cells. Validation was conducted using 10 well documented steatotic compounds and 5 negative controls, all of which were correctly identified by the assay. In addition, the inhibitory effect of ML261, a well-known inhibitor of hepatic lipid droplets formation, was also confirmed by the assay both in AML12 cells and Hepa1-6 cells. To our knowledge, this study is the first to quantify lipid droplets using BODIPY 493/503 by fluorometry assay, and to demonstrate that CCK8 does not interfere with subsequent BODIPY 493/503 staining, both of which will reduce the cost and increase the efficiency. In conclusion, the method is simple, reliable, efficient and does not rely on expensive instruments, making it an easily generalizable approach to identify potential drug candidates for NAFLD treatment.

PNPLA3 as a driver of steatotic liver disease: navigating from pathobiology to the clinics via epidemiology

Steatotic liver disease (SLD), particularly metabolic dysfunction-associated SLD, represents a significant public health concern worldwide. Among the various factors implicated in the development and progression of this condition, the patatin-like phospholipase domain-containing protein 3 (PNPLA3 ) gene has emerged as a critical player. Variants of PNPLA3 are associated with altered lipid metabolism, leading to increased hepatic fat accumulation and subsequent inflammation and fibrosis. Understanding the role of PNPLA3 not only enhances our comprehension of the pathomechanisms driving SLD but also informs potential therapeutic strategies. The molecular mechanisms through which PNPLA3 variants contribute to lipid dysregulation and hepatocyte injury in SLD are critically discussed in the present review article. We extensively analyze clinical cohorts and population-based studies underpinning the association between PNPLA3 polymorphisms and the risk of developing SLD, and its liver-related and protean extrahepatic outcomes, in concert with other risk modifiers, notably including age, sex, and ethnicity in adults and children. We also discuss the increasingly recognized role played by the PNPLA3 gene in liver transplantation, autoimmune hepatitis, and acquired immunodeficiency syndrome. Finally, we examine the clinical implications of PNPLA3 diagnostics regarding risk stratification and targeted therapies for patients affected by SLD in the context of precision medicine approaches.