Non-alcoholic fatty liver disease as a cause and a consequence of metabolic syndrome

Bridging the gap in obesity research: A consensus statement from the European Society for Clinical Investigation

BACKGROUND

Most forms of obesity are associated with chronic diseases that remain a global public health challenge.

AIMS

Despite significant advancements in understanding its pathophysiology, effective management of obesity is hindered by the persistence of knowledge gaps in epidemiology, phenotypic heterogeneity and policy implementation.

MATERIALS AND METHODS

This consensus statement by the European Society for Clinical Investigation identifies eight critical areas requiring urgent attention. Key gaps include insufficient long-term data on obesity trends, the inadequacy of body mass index (BMI) as a sole diagnostic measure, and insufficient recognition of phenotypic diversity in obesity-related cardiometabolic risks. Moreover, the socio-economic drivers of obesity and its transition across phenotypes remain poorly understood.

RESULTS

The syndemic nature of obesity, exacerbated by globalization and environmental changes, necessitates a holistic approach integrating global frameworks and community-level interventions. This statement advocates for leveraging emerging technologies, such as artificial intelligence, to refine predictive models and address phenotypic variability. It underscores the importance of collaborative efforts among scientists, policymakers, and stakeholders to create tailored interventions and enduring policies.

DISCUSSION

The consensus highlights the need for harmonizing anthropometric and biochemical markers, fostering inclusive public health narratives and combating stigma associated with obesity. By addressing these gaps, this initiative aims to advance research, improve prevention strategies and optimize care delivery for people living with obesity.

CONCLUSION

This collaborative effort marks a decisive step towards mitigating the obesity epidemic and its profound impact on global health systems. Ultimately, obesity should be considered as being largely the consequence of a socio-economic model not compatible with optimal human health.

Clinical characteristics of lean and non-lean non-alcoholic fatty liver disease: a cross-sectional study

INTRODUCTION

Non-alcoholic fatty liver disease (NAFLD) affects more than a quarter of the global population and has become the world's number one chronic liver disease, seriously jeopardizing public life and health. Despite the new terminology of metabolic dysfunction-associated steatotic liver disease (MASLD) has been proposed, the mechanisms underlying the heterogeneity across BMI stratification in non-alcoholic fatty liver disease (NAFLD) remain unclear. The aim of this study was to reveal the differences in metabolic and fibrotic characteristics between lean (BMI < 23 kg/m2) and non-lean NAFLD in an Asian population.

METHODS

The current study collected NAFLD patients from the physical examination population. Patients were divided into two groups by BMI to compare their clinical parameters, including lean (BMI < 23 kg/m2) and non-lean (BMI ≥ 23 kg/m2) and fibrosis subgroups (with a threshold of LSM = 8 kPa) and analyzed for risk factors by logistic regression models.

RESULTS

Of the 11,577 NAFLD patients who participated in the study, there were 916 lean and 10,661 non-lean. The non-lean group was younger than the lean group (median age 50 vs. 52 years, P < 0.001) and had a significantly higher prevalence of hypertension (28.0% vs. 18.3%), diabetes mellitus (10.1% vs. 6.1%), and liver fibrosis (9.1% vs. 5.1%) (all P < 0.001). Analysis of metabolic indexes showed that TyG, TyG-BMI, TG/HDL-C and APRI were higher in the non-lean group (all P < 0.001). Gender stratification revealed that ALT was significantly higher in the male non-lean group, while HDL-C was lower in the female non-lean group (1.35 vs. 1.47 mmol/L). Multiple regression suggested that the risk of fibrosis was independently associated with CAP values and fasting glucose, BMI, direct bilirubin, globulin, and age in the non-lean group, whereas the risk was mainly driven by GGT and ALP in the lean group.

CONCLUSIONS

Non-lean NAFLD patients showed more significant metabolic disturbances and risk of liver fibrosis. Although metabolic indicators (TyG, FIB-4) have limited predictive value for liver fibrosis, they are strongly associated with metabolic risk in MASLD.

Association between cumulative changes of the triglyceride glucose index and incidence of stroke in a population with cardiovascular-kidney-metabolic syndrome stage 0-3: a nationwide prospective cohort study

BACKGROUND

The triglyceride-glucose (TyG) index was associated with higher risk of mortality in individuals with Cardiovascular-Kidney-Metabolic (CKM) syndrome stages 0-3. However, the relationship between cumulative of TyG (cumTyG) and incidence of stroke remains unclear in individuals with CKM syndrome stages 0-3.

METHOD

Participants with CKM syndrome stage 0-3 were enrolled from the China Health and Retirement Longitudinal Study (CHARLS) from 2011 to 2015. TyG was calculated as ln [fasting triglyceride (mg/dL)×fasting glucose (mg/dL)/2], and the cumTyG, as an area-under-the-curve estimate (mean TyG × time span), was calculated as (TyG2012 + TyG 2015)/2 * time (2015-2012). TyG control levels were classified using k-mean clustering analysis. Logistic regression was used to analyze the effect of cumTyG and TyG control levels on the incidence of stroke. Restricted cubic spline models (RCS) were performed to explore the potential non-linear relationship between cumTyG and stroke risk at different CKM syndrome stages 0-3.

RESULTS

A total of 4,700 CKM syndrome stages 0-3 participants were enrolled, among 280 patients had developed stroke during the 3-year follow-up period. After adjusting for confounders, compared to class 1 group, the odds ratio (OR) of incidents of stroke for class 2 was 1.39 [95% confidence interval (CI) 1.003, 1.92], P = 0.046; the OR of incidents of stroke for class 3 was 1.28 (95% CI 0.92-1.77), P = 0.147, the OR of incidents of stroke for class 4 was 1.28 (95% CI 0.84-1.94), P = 0.238. Elevated cumTyG was associated with an increase in incidence of stroke (OR 1.13, 95% CI 1.05, 1.22, P = 0.002). The relationship between the cumTyG index and stroke was linear in restricted cubic spline regression.

CONCLUSIONS

Elevated cumTyG was associated with an increased risk of stroke events in the population of CKM syndrome stages 0-3. Long-term dynamic monitoring of changes of TyG may help in the early identification of patients at high risk of developing stroke in the individuals with CKM syndrome stages 0-3.

Multitissue single-cell analysis reveals differential cellular and molecular sensitivity between fructose and high-fat high-sucrose diets

Metabolic syndrome (MetS), a conglomerate of dysregulated metabolic traits that vary between individuals, is partially driven by modern diets high in fat, sucrose, or fructose and their interactions with host genes in metabolic tissues. To elucidate the roles of individual tissues and cell types in diet-induced MetS, we performed single-cell RNA sequencing on the hypothalamus, liver, adipose tissue, and small intestine of mice fed high-fat high-sucrose (HFHS) or fructose diets. We found that hypothalamic neurons were sensitive to fructose, while adipose progenitor cells and macrophages were responsive to HFHS. Ligand-receptor analysis revealed lipid metabolism and inflammation networks among peripheral tissues driven by HFHS, while both diets stimulated synaptic remodeling within the hypothalamus. mt-Rnr2, a top responder to both diets, mitigated diet-induced MetS by stimulating thermogenesis. Our study demonstrates that HFHS and fructose diets have differential cell type and network targets but also share regulators such as mt-Rnr2 to affect MetS risk.

Metabolic syndrome among a Ghanaian cohort living with HIV initiated on dolutegravir in a real-world setting: a prospective study

OBJECTIVES

The use of antiretroviral therapy has been linked to the development of some components of metabolic syndrome (MetS), specifically glucose intolerance, weight gain and defective lipid metabolism. This study determined the relationship between dolutegravir (DTG) and MetS in a cohort of persons living with HIV (PWH) initiating DTG-based regimen in Ghana.

DESIGN

A 2-year observational prospective study was conducted from September 2020 to August 2022.

SETTING

Five HIV high-burden facilities providing antiretroviral therapy services at the district and tertiary levels of care in Ghana.

PARTICIPANTS

Persons with HIV who were newly enrolled onto DTG.

PRIMARY AND SECONDARY OUTCOME MEASURES

Waist circumference, body mass index, blood pressure, fasting blood glucose and lipids were the primary outcomes measured at baseline, 3, 6, 12 and at 18 months follow-up to determine the incidence of MetS. MetS was defined using the Joint Consensus definition that combines the International Diabetes Federation and the National Cholesterol Education Programme Adult Treatment Panel III (ATP III) definitions. The Kaplan-Meier estimator was used to estimate the risk of developing MetS. The Cox proportional hazard model was used in estimating HRs.

RESULTS

Of 3664 PWH screened at baseline, 31.4% (1152/3664) had MetS. Of the remaining 2512 with no MetS at baseline, there were 960 incident cases of MetS over the 1.5 years follow-up. The estimated MetS incident rate is 384.2 (95% CI: 360.6 to 409.2) per 1000 person-years with a median time to development of MetS at 6 months (IQR; 3-12 months). Being female (adjsuted HR, aHR: 1.42, 95% CI: 1.19 to 1.70), age ≥50 years (aHR: 1.30, 95% CI: 1.12 to 1.51), having a comorbidity at baseline (aHR: 1.39, 95% CI: 1.12 to 1.51) and being overweight (aHR: 1.46, 95% CI: 1.25 to 1.71) and obese (aHR: 1.62, 95% CI: 1.36 to 1.93) were associated with higher risk of MetS development.

CONCLUSIONS

The incidence of MetS was high among our patients, with elevated fasting blood sugar and elevated blood pressure being the most common developed MetS defining components. HIV programmes should institute targeted interventions at addressing central obesity to reduce the risk of MetS.

Novel thiazolones for the simultaneous modulation of PPARγ, COX-2 and 15-LOX to address metabolic disease-associated portal inflammation

A hybrid pharmacophore model, based on structural motifs previously identified by our team, was employed to generate ligands that simultaneously target COX-2, 15-LOX, and PPARγ in the context of metabolic dysfunction-associated fatty liver disease (MAFLD). Notable COX-2 inhibitory activities (IC50 = 0.065-0.24 μM) were observed relative to celecoxib (IC50 = 0.049 μM). The two most effective 15-LOX inhibitors, 2a and 2b, exhibited 69 % and 57 % of quercetin's action, respectively. Utilizing the rat hemi-diaphragm model to assess in vitro glucose uptake capacity, compounds 2a and 2b demonstrated significant glucose uptake potential in the absence of insulin, surpassing that of pioglitazone. Compound 2a activated PPARγ with an EC50 value of 3.4 μM in a Gal4-hybrid reporter gene assay, indicating partial agonistic action. Interesting binding interactions with targets of interest were identified by molecular docking studies. As well, the expression levels of 20-HETE, Il-1β and TNF-α were decreased in LPS-challenged RAW264.7 macrophages upon treatment with compound 2a. The pharmacokinetic analysis of 2a and assessment of its in vivo efficacy in addressing hepatic impairment in rat models of diabetes and pre-diabetes were carried out. Together, these findings may offer preliminary insights into the potential of these compounds for further refinement in the existing therapeutic arsenals for metabolic diseases.

Correlation between environmental pollutant exposure and cardiopulmonary health by serum biomarker analysis in the Swedish elderly population

Persistent organic pollutants (POPs) affect human health through the aryl hydrocarbon receptor (AhR) pathway and are implicated in mitochondrial dysfunction. Using data from the PIVUS study, we investigated the associations of serum AhR ligand (POP)-mediated luciferase activity (AhRL), mitochondrial ATP production inhibiting substances (MIS-ATP), and those affecting reactive oxygen species (MIS-ROS) with several metabolic syndrome (MetS) and cardiopulmonary function parameters. These include insulin resistance (HOMA-IR), inflammation, oxidative stress, and cardiopulmonary variables (FVC, FEV1, LV-EF, CCA distensibility). MIS-ATP showed significant correlations with HOMA-IR and pulmonary functions, indicating its direct impact of MIS-ATP on metabolic and pulmonary health. MIS-ROS correlated with oxidative stress markers and CCA distensibility, suggesting a role in systemic inflammatory responses. This study highlights the intricate relationships between environmental pollutant mixture and cardiopulmonary health in MetS as indicated by biomarkers of POP exposure in the elderly population, suggesting POP exposure may influence MetS onset and progression through mitochondrial dysfunction.

Μetabolic dysfunction-associated steatotic liver disease: a condition of heterogeneous metabolic risk factors, mechanisms and comorbidities requiring holistic treatment

Μetabolic dysfunction-associated steatotic liver disease (MASLD) comprises a heterogeneous condition in the presence of steatotic liver. There can be a hierarchy of metabolic risk factors contributing to the severity of metabolic dysfunction and, thereby, the associated risk of both liver and extrahepatic outcomes, but the precise ranking and combination of metabolic syndrome (MetS) traits that convey the highest risk of major adverse liver outcomes and extrahepatic disease complications remains uncertain. Insulin resistance, low-grade inflammation, atherogenic dyslipidaemia and hypertension are key to the mechanisms of liver and extrahepatic complications. The liver is pivotal in MetS progression as it regulates lipoprotein metabolism and secretes substances that affect insulin sensitivity and inflammation. MASLD affects the kidneys, heart and the vascular system, contributing to hypertension and oxidative stress. To address the global health burden of MASLD, intensified by obesity and type 2 diabetes mellitus epidemics, a holistic, multidisciplinary approach is essential. This approach should focus on both liver disease management and cardiometabolic risk factors. This Review examines the link between metabolic dysfunction and liver dysfunction and extrahepatic disease outcomes, the diverse mechanisms in MASLD due to metabolic dysfunction, and a comprehensive, personalized management model for patients with MASLD.

Identification of CACNB1 protein as an actionable therapeutic target for hepatocellular carcinoma via metabolic dysfunction analysis in liver diseases: An integrated bioinformatics and machine learning approach for precise therapy

In addition to histological evaluation for nonalcoholic fatty liver disease (NAFLD), a comprehensive analysis of the metabolic landscape is urgently needed to categorize patients into distinct subgroups for precise treatment. In this study, a total of 806 NAFLD and 267 normal liver samples were comprehensively analyzed. Alterations in 114 metabolic pathways were investigated and two distinct metabolic clusters were identified. Single-cell RNA sequencing (scRNA-seq) analysis was utilized to decipher the metabolic activities within the microenvironment of NAFLD-derived liver cirrhosis. A refined fibrosis prediction model was developed using a Gaussian Mixture Model (GMM), demonstrating superior performance in fibrosis discrimination across multiple independent cohorts. Additionally, using The Cancer Genome Atlas (TCGA), CACNB1 protein was identified as a promising therapeutic target for hepatocellular carcinoma (HCC) patients with elevated metabolic dysfunction scores (MBDS). Machine learning algorithms were applied to MBDS-related genes to select an optimal prognostic model for HCC. All the models were trained in an HCC cohort obtained from the Gene Expression Omnibus (GEO), and the best model was validated in two independent HCC datasets: the TCGA-HCC cohort and LIRI-JP cohort. Overall, we provide insights of metabolic molecular subtyping and its potential clinical applicability in risk stratification for NAFLD and HCC individuals.

Atorvastatin and flaxseed dietary treatments improve dyslipidemia and liver injuries in a diet-induced rat model of non-alcoholic fatty liver disease

Objective

Non-alcoholic fatty liver disease (NAFLD) as the most common chronic liver disease is associated with metabolic disorders including dysregulated lipid and glucose metabolism. There is no approved drug treatment for NAFLD; thus, new therapies are needed. We studied the antidyslipidemic effects of atorvastatin and/or possibly hepatoprotective effects of flaxseed/ flaxseed oil in a rat model of NAFLD.

Materials and Methods

Fifty-six male Wistar rats were divided randomly into seven groups: 1) control, 2) high-fructose diet (HFD), 3) HFD +atorvastatin (20 mg/kg), 4) HFD+ flaxseed (40 g/kg), 5) HFD+ flaxseed oil (40 mg/kg), 6) HFD+flaxseed (40 g/kg) + atorvastatin (20 mg/kg) and 7) HFD+flaxseed oil (40 g/kg) +atorvastatin (20 mg/kg). The interventions were done for 23 weeks, after which anthropometric indices, lipid profile, liver enzymes, fasting blood glucose, and kidney indices were analyzed. Scoring of hematoxylin-eosin-stained liver sections was used to assess the severity of NAFLD.

Results

All the treatments reduced mesenteric fat mass, and the amount of fat around the liver, except in HFD+ flaxseed +atorvastatin group. The interventions improved NAFLD activity score, which considers steatosis, lobular inflammation, and hepatocyte ballooning. However, atorvastatin was most efficient in reducing inflammation and hepatocyte ballooning. While atorvastatin reduced only Gamma-glutamyltransferase (GGT) levels, flaxseed or flaxseed oil mono- and combination therapies reduced serum levels of all liver enzymes. The interventions improved the serum lipid profile and all, except atorvastatin decreased fasting blood glucose.

Conclusion

Flaxseed therapies improved NAFLD-associated liver injuries and dyslipidemia, while atorvastatin mostly reduced hepatocyte ballooning and lobular inflammation.

Cold atmospheric plasma control metabolic syndromes via targeting fat mass and obesity-associated protein

Both obesity and metabolic disorders are global medical problems. Driven by prolonged inflammation, obesity increases the risk of developing metabolic syndromes such as fatty liver, diabetes, cardiovascular diseases and cancers. The fat mass and obesity-associated protein (FTO) is an m6A demethylase, elevated activity of which is known to promote the pathogenesis of many metabolic disorders, leading to the establishment of various FTO inhibitors. By combing through intrinsic connections among obesity and the four primary metabolic problems, we attribute their shared pathological cause to prolonged inflammation. By reviewing the roles of FTO in promoting these disorders and the current status of existing FTO inhibitors in treating these syndromes, we underpinned the paramount potential of resolving these clinical issues by targeting FTO and the urgent need of establishing novel FTO inhibitors with maximized efficacy and minimized side effect. Cold atmospheric plasma (CAP) is the fourth state of matter with demonstrated efficacy in treating various diseases associated with chronic inflammation. By introducing the medical characteristics of CAP, we proposed it as a possible solution to unresolved issues of current FTO inhibitors given its anti-inflammation feature and demonstrated clinical safety. We also emphasized the need of intensive investigations in exploring the feasibility of using CAP in treating obesity and associated metabolic syndromes that might function through targeting FTO.

Sodium-Glucose Cotransporter2 inhibitors and associated Liver-Related outcomes in diabetes patients

AIMS

Metabolic dysfunction-associated steatotic liver disease (MASLD) is associated with poorer liver-related outcomes in type 2 diabetes (T2D) patients. We compared risk of liver-related outcomes and all-cause mortality between sodium-glucose cotransporter-2 inhibitor (SGLT-2i) users and nonusers in T2D patients.

METHODS

We identified 282,161 T2D patients from the Taiwan National Health Insurance Research Database (2009-2020), excluding those with viral hepatitis or alcohol-related disorders. Propensity score matching created patient pairs on SGLT-2i and other antidiabetic drugs, and Cox proportional hazard models assessed outcomes.

RESULTS

Over a mean follow-up of 2.7 years, SGLT-2i use was associated with significantly lower risk of liver cirrhosis (adjusted hazard ratio [aHR] 0.78, 95 % CI: 0.70-0.87), decompensated cirrhosis (aHR 0.79, 95 % CI: 0.70-0.89), liver failure (aHR 0.78, 95 % CI: 0.68-0.89), and all-cause mortality (aHR 0.52, 95 % CI: 0.51-0.54). Compared to dipeptidyl peptidase-4 inhibitors (DPP-4i), glucagon-like peptide-1 receptor agonists (GLP-1 RA), pioglitazone, and sulfonylureas, SGLT-2i use was associated with lower risk of cirrhosis, liver failure, and all-cause mortality. SGLT-2i use was associated with lower liver-related mortality than DPP-4i or GLP-1 RA use.

CONCLUSIONS

This cohort study suggests that SGLT-2i may reduce the risk of liver cirrhosis, decompensated cirrhosis, liver failure, and liver-related and all-cause mortality in T2D patients.

A metabolome-derived score predicts metabolic dysfunction-associated steatohepatitis and mortality from liver disease

BACKGROUND & AIMS

Metabolic dysfunction-associated steatohepatitis (MASH) is associated with a >10-fold increase in liver-related mortality. However, biomarkers predicting both MASH and mortality in patients with metabolic dysfunction-associated steatotic liver disease (MASLD) are missing. We developed a metabolome-derived prediction score for MASH and examined whether it predicts mortality in Chinese and European cohorts.

METHODS

The MASH prediction score was developed using a multi-step machine learning strategy, based on 44 clinical parameters and 250 serum metabolites measured by proton nuclear magnetic resonance in 311 Chinese adults undergoing a liver biopsy. External validation was conducted in a Finnish liver biopsy cohort (n = 305). We investigated associations of the score with all-cause and cause-specific mortality in the population-based Shanghai Changfeng study (n = 5,893) and the UK biobank (n = 111,673).

RESULTS

A total of 24 clinical parameters and 194 serum metabolites were significantly associated with MASH in the Chinese liver biopsy cohort. The final MASH score included BMI, aspartate aminotransferase, tyrosine, and the phospholipid-to-total lipid ratio in VLDL. The score identified patients with MASH with AUROCs of 0.87 (95% CI 0.83-0.91) and 0.81 (95% CI 0.75-0.88) in the Chinese and Finnish cohorts, with high negative predictive values. Participants with a high or intermediate risk of MASH based on the score had a markedly higher risk of MASLD-related mortality than those with a low risk in Chinese (hazard ratio 23.19; 95% CI 4.80-111.97) and European (hazard ratio 20.15; 95% CI 10.95-37.11) individuals after 7.2 and 12.6 years of follow-up, respectively. The MASH prediction score was superior to the Fibrosis-4 index and the NAFLD fibrosis score in predicting MASLD-related mortality.

CONCLUSION

The metabolome-derived MASH prediction score accurately predicts risk of MASH and MASLD-related mortality in both Chinese and European individuals.

IMPACT AND IMPLICATIONS

Metabolic dysfunction-associated steatohepatitis (MASH) is associated with more than a 10-fold increase in liver-related death. However, biomarkers predicting not only MASH, but also death due to liver disease, are missing. We established a MASH prediction score based on 44 clinical parameters and 250 serum metabolites using a machine learning strategy. This metabolome-derived MASH prediction score could accurately identify patients with MASH among both Chinese and Finnish individuals, and it was superior to the Fibrosis-4 index and the NAFLD fibrosis score in predicting MASLD-related death in the general population. Thus, the new MASH prediction score is a useful tool for identifying individuals with a markedly increased risk of serious liver-related outcomes among at-risk and general populations.

Association Between High Sensitivity Cardiac Troponin and All-Cause and Cardiovascular Mortality in Adults at Risk of Non-Alcoholic Fatty Liver Disease: A Cohort Study

Objective

Cardiovascular disease (CVD) is the leading cause of death among patients with non-alcoholic fatty liver disease (NAFLD). This study investigates the association between high-sensitivity cardiac troponin (hs-cTn) levels and mortality in adults at risk of NAFLD in a representative U.S. population sample.

Methods

Among participants aged 18 years and older in the 1999-2004 National Health and Nutrition Examination Survey, we measured high-sensitivity troponin T using a single assay (Roche) and high-sensitivity troponin I using three assays (Abbott, Siemens, and Ortho). Myocardial injury was identified by elevated levels of hs-cTn. Mortality outcomes were determined through linkage with the National Death Index database, with follow-up until December 31, 2019. A multivariable Cox proportional hazards model was used to evaluate the associations between myocardial injury and mortality in the NAFLD population. Sensitivity analyses were conducted to assess the robustness of the main findings.

Results

A total of 2581 at risk of NAFLD were included in this observational study, with myocardial injury identified in 7.01%. Over a median follow-up of 16.7 years, 937 all-cause deaths occurred, including 319 cardiovascular disease-related deaths. NAFLD individuals with myocardial injury had worse survival rates at 5, 10, and 15 years compared to those without myocardial injury. After adjusting for baseline characteristics, myocardial injury was associated with an increased risk of all-cause mortality (adjusted Hazard Ratio [aHR] 1.785, 95% CI 1.494-2.134, P < 0.001) and cardiovascular mortality (aHR 2.155, 95% CI 1.606-2.893, P < 0.001).

Conclusion

This large, nationally representative study demonstrates that myocardial injury, defined by elevated hs-cTn levels, is independently associated with increased all-cause and cardiovascular mortality risks in the adult population at risk of NAFLD in the United States. This association persisted after adjusting for various factors and in patients without pre-existing cardiovascular disease. The Siemens hs-cTn I assay demonstrated the strongest association with all-cause mortality. These findings highlight the potential of hs-cTn as a valuable prognostic marker in NAFLD patients, even in those without clinically apparent cardiovascular disease. Routine hs-cTn assessment may aid in risk stratification and guide targeted interventions to reduce mortality risk in this population.

Unlocking the gut-liver axis: microbial contributions to the pathogenesis of metabolic-associated fatty liver disease

Metabolic dysfunction-associated fatty liver disease (MAFLD) is a complex metabolic disorder characterized by hepatic lipid accumulation and subsequent inflammation. This condition is closely linked to metabolic syndrome and obesity, with its prevalence rising due to sedentary lifestyles and high-calorie diets. The pathogenesis of MAFLD involves multiple factors, including insulin resistance, lipotoxicity, oxidative stress, and inflammatory responses. The gut microbiota plays a crucial role in MAFLD development, with dysbiosis contributing to liver inflammation through various mechanisms, such as enhanced intestinal permeability and the translocation of bacterial products like lipopolysaccharide (LPS). Microbial metabolites, including short-chain fatty acids (SCFAs) and bile acids, influence hepatic function and immune responses, with potential implications for disease progression. Specific gut microbiome signatures have been identified in MAFLD patients, offering potential diagnostic and therapeutic targets. Moreover, gut-derived toxins, such as endotoxins, lipopolysaccharides, trimethylamine-N-oxide and bacterial metabolites, significantly influence liver damage and inflammation, highlighting the complex interplay between the gut microbiome and hepatic health. This review comprehensively examines the complex interplay between the gut microbiota and MAFLD, focusing on underlying pathogenic mechanisms, potential biomarkers, and emerging microbiome-targeted therapeutic strategies for disease management.

Gene-based therapies for steatotic liver disease

Advances in nucleic acid delivery have positioned the liver as a key target for gene therapy, with adeno-associated virus vectors showing long-term effectiveness in treating hemophilia. Steatotic liver disease (SLD), the most common liver condition globally, primarily results from metabolic dysfunction-associated and alcohol-associated liver diseases. In some individuals, SLD progresses from simple steatosis to steatohepatitis, cirrhosis, and eventually hepatocellular carcinoma, driven by a complex interplay of genetic, metabolic, and environmental factors. Genetic variations in various lipid metabolism-related genes, such as patatin-like phospholipase domain-containing protein 3 (PNPLA3), 17β-hydroxysteroid dehydrogenase type 13 (HSD17B13), and mitochondrial amidoxime-reducing component 1 (MTARC1), impact the progression of SLD and offer promising therapeutic targets. This review largely focuses on genes identified through clinical association studies, as they are more likely to be effective and safe for therapeutic intervention. While preclinical research continues to deepen our understanding of genetic factors, early-stage clinical trials involving gene-based SLD therapies, including transient antisense and small-molecule approaches, are helping prioritize therapeutic targets. Meanwhile, hepatocyte gene editing technologies are advancing rapidly, offering alternatives to transient methods. As such, gene-based therapies show significant potential for preventing the progression of SLD and enhancing long-term liver health.

Arterial stiffness as a complication of metabolic dysfunction-associated steatotic liver disease: a systematic review and meta-analysis

INTRODUCTION

The purpose of this systematic review and meta-analysis is to investigate the association of metabolic dysfunction-associated steatotic liver disease (MASLD) with arterial stiffness and enlighten on potential cardiometabolic co-factors.

METHODS

A literature search in PubMed/Medline, Embase, Scopus, and Web of Science databases was conducted. All the observational studies comparing arterial stiffness indices between adults with Non-alcoholic Fatty Liver Disease (NAFLD), Metabolic Dysfunction Associated-Fatty Liver Disease (MAFLD), or MASLD and apparently healthy individuals with normal liver function were included. Pulse wave velocity (PWV) and augmentation index (AIx) were mainly used as arterial stiffness indices.

RESULTS

Fourty one unique studies were included in the systematic review, with 27 deemed eligible for meta-analysis. Patients with MASLD had increased carotid-femoral PWV (14 studies, Mean difference (MD): 0.96 m/s, 95% confidence interval (CI) 0.65-1.27, p < 0.001) compared with healthy individuals. This finding was independent from body mass index, triglycerides, high-density lipoprotein, systolic blood pressure, and fasting plasma glucose. Moreover, patients with MASLD had higher brachial-ankle PWV (13 studies, MD: 78.14 cm/s, 95% CI 60.37-95.90, p < 0.001) and AIx (7 studies, MD: 3.85%, 95% CI 0.87-6.82, p = 0.0195) compared with controls.

CONCLUSIONS

MASLD is correlated with increased arterial stiffness. This relation is unaffected by common cardiometabolic risk factors.

REGISTRATION

PROSPERO (ID: CRD42023468258).

Inhibition of ATGL alleviates MASH via impaired PPARα signalling that favours hydrophilic bile acid composition in mice

BACKGROUND & AIMS

Adipose triglyceride lipase (ATGL) is an attractive therapeutic target in insulin resistance and metabolic dysfunction-associated steatotic liver disease (MASLD). This study investigated the effects of pharmacological ATGL inhibition on the development of metabolic dysfunction-associated steatohepatitis (MASH) and fibrosis in mice.

METHODS

Streptozotocin-injected male mice were fed a high-fat diet to induce MASH. Mice receiving the ATGL inhibitor atglistatin (ATGLi) were compared to controls using liver histology, lipidomics, metabolomics, 16s rRNA, and RNA sequencing. Human ileal organoids, HepG2 cells, and Caco2 cells treated with the human ATGL inhibitor NG-497, HepG2 ATGL knockdown cells, gel-shift, and luciferase assays were analysed for mechanistic insights. We validated the benefits of ATGLi on steatohepatitis and fibrosis in a low-methionine choline-deficient mouse model.

RESULTS

ATGLi improved serum liver enzymes, hepatic lipid content, and histological liver injury. Mechanistically, ATGLi attenuated PPARα signalling, favouring hydrophilic bile acid (BA) synthesis with increased Cyp7a1, Cyp27a1, Cyp2c70, and reduced Cyp8b1 expression. Additionally, reduced intestinal Cd36 and Abca1, along with increased Abcg5 expression, were consistent with reduced levels of hepatic triacylglycerol species containing polyunsaturated fatty acids, like linoleic acid, as well as reduced cholesterol levels in the liver and plasma. Similar changes in gene expression associated with PPARα signalling and intestinal lipid transport were observed in ileal organoids treated with NG-497. Furthermore, HepG2 ATGL knockdown cells revealed reduced expression of PPARα target genes and upregulation of genes involved in hydrophilic BA synthesis, consistent with reduced PPARα binding and luciferase activity in the presence of the ATGL inhibitors.

CONCLUSIONS

Inhibition of ATGL attenuates PPARα signalling, translating into hydrophilic BA composition, interfering with dietary lipid absorption, and improving metabolic disturbances. Validation with NG-497 opens a new therapeutic perspective for MASLD.

IMPACT AND IMPLICATIONS

Despite the recent approval of drugs novel mechanistic insights and pathophysiology-oriented therapeutic options for MASLD (metabolic dysfunction-associated steatotic liver disease) are still urgently needed. Herein, we show that pharmacological inhibition of ATGL, the key enzyme in lipid hydrolysis, using atglistatin (ATGLi), improves MASH (metabolic dysfunction-associated steatohepatitis), fibrosis, and key features of metabolic dysfunction in mouse models of MASH and liver fibrosis. Mechanistically, we demonstrated that attenuation of PPARα signalling in the liver and gut favours hydrophilic bile acid composition, ultimately interfering with dietary lipid absorption. One of the drawbacks of ATGLi is its lack of efficacy against human ATGL, thus limiting its clinical applicability. Against this backdrop, we could show that ATGL inhibition using the human inhibitor NG-497 in human primary ileum-derived organoids, Caco2 cells, and HepG2 cells translated into therapeutic mechanisms similar to ATGLi. Collectively, these findings reveal a possible new avenue for MASLD treatment.

Role of gliflozins on hepatocellular carcinoma progression: a systematic synthesis of preclinical and clinical evidence

INTRODUCTION

The risk of HCC is twice as high in diabetic patients compared to non-diabetic ones, suggesting that diabetes advances carcinogenesis in the liver through a variety of mechanisms. Sodium-glucose cotransporter 2 inhibitors (SGLT2i) have been shown to improve liver outcomes, emerging as promising agents to treat hepatocellular carcinoma (HCC) in patients with type 2 diabetes mellitus (T2DM).

METHODS

We searched PubMed and Scopus databases for articles presenting an association between SGLT2is and HCC to explore the putative mechanisms of action underlying the anti-proliferative activity of SGLT2is.

RESULTS

A total of 24 articles were selected for inclusion, of which 14 were preclinical and 10 were clinical. Preclinical studies were mainly focused on canagliflozin, used alone or in combination with other drugs.

CONCLUSIONS

Overall, canagliflozin had a negative effect on HCC cell proliferation by interfering with glucose-dependent and independent metabolic pathways, negatively impacting angiogenesis, and inducing apoptosis in in-vitro cell models. In-vivo, a protective effect on hepatic steatosis and fibrosis and HCC development has been reported. Human studies showed a lower risk of developing HCC in patients on SGLT2is. However, this is supported by retrospective cohort studies. Clinical trials are needed to confirm the causal relationship between SGLT2i administration and HCC development.

Deciphering significances of autophagy in the development and metabolism of adipose tissue

The mechanisms of adipose tissue activation and inactivation have been a hot topic of research in the last decade, from which countermeasures have been attempted to be found against obesity as well as other lipid metabolism-related diseases, such as type 2 diabetes mellitus and non-alcoholic fatty liver disease. Autophagy has been shown to be closely related to the regulation of adipocyte activity, which is involved in the whole process including white adipocyte differentiation/maturation and brown or beige adipocyte generation/activation. Dysregulation of autophagy in adipose tissue has been demonstrated to be associated with obesity. On this basis, we summarize the pathways and mechanisms of autophagy involved in the regulation of lipid metabolism and present a review of its pathophysiological roles in lipid metabolism-related diseases, in the hope of providing ideas for the treatment of these diseases.

Investigating the common genetic architecture and causality of metabolic disorders with neurodegenerative diseases

BACKGROUND

The co-occurrence of metabolic dysfunction and neurodegenerative diseases suggests a genetic link, yet the shared genetic architecture and causality remain unclear. We aimed to comprehensively characterise these genetic relationships.

METHODS

We investigated genetic correlations among four neurodegenerative diseases and seven metabolic dysfunctions, followed by bidirectional Mendelian randomisation (MR) to assess potential causal relationships. Pleiotropy analysis (PLACO) was used to detect the pleiotropic effects of genetic variants. Significant pleiotropic loci were refined and annotated using functional mapping and annotation (FUMA) and Bayesian colocalisation analysis. We further explored mapped genes with tissue-specific expression and gene set enrichment analyses.

RESULTS

We identified significant genetic correlations in nine out of 28 trait pairs. MR suggested causal relationships between specific trait pairs. Pleiotropy analysis revealed 25 931 significant single-nucleotide polymorphisms, with 246 pleiotropic loci identified via FUMA and 55 causal loci through Bayesian colocalisation. These loci are involved in neurotransmitter transport and immune response mechanisms, notably the missense variant rs41286192 in SLC18B1. The tissue-specific analysis highlighted the pancreas, left ventricle, amygdala, and liver as critical organs in disease progression. Drug target analysis linked 74 unique genes to existing therapeutic agents, while gene set enrichment identified 189 pathways related to lipid metabolism, cell differentiation and immune responses.

CONCLUSION

Our findings reveal a shared genetic basis, pleiotropic loci, and potential causal relationships between metabolic dysfunction and neurodegenerative diseases. These insights highlight the biological connections underlying their phenotypic association and offer implications for future research to reduce the risk of neurodegenerative diseases.

Vagus Nerve Mediated Liver-Brain-Axis Is a Major Regulator of the Metabolic Landscape in the Liver

The liver serves as a major energetic reservoir for other tissues and its metabolic function is controlled by humoral and neural factors. The vagus nerve innervating the gastrointestinal tract plays an important role in regulating peripheral metabolism and energy expenditure. Although the liver receives vagus nerve fibers, the impact of this circuitry in the regulation of hepatic metabolism is still poorly understood. Herein, we used a combination of quantitative proteomics and in vivo imaging techniques to investigate the impact of the vagus nerve on liver metabolism in male mice. Liver-brain axis was impaired by vagotomy (VNX) or knocking down of the vesicular acetylcholine transporter (VAChT-KD). Mice were challenged with high carbohydrate or high-fat feeding. The vagus nerve shapes the metabolic framework of the liver, as vagotomy led to a significant alteration of the hepatic proteome landscape. Differential protein expression and pathway enrichment analyses showed that glycolytic and fatty acid biosynthesis were increased following VNX, whereas β-oxidation was decreased. These results were corroborated in VAChT-KD mice. This metabolic shift facilitated lipid accumulation in hepatocytes in mice fed with a standard commercial diet. Furthermore, VNX worsened liver steatosis following high-carbohydrate or high-fat dietary challenges. This study describes the liver-brain axis mediated by the vagus nerve as an important regulator of the hepatic metabolic landscape.

Exploring the nexus between hypothyroidism and metabolic dysfunction-associated steatotic liver disease: a UK biobank cohort study

Non-alcoholic fatty liver disease (NAFLD) is a chronic liver disease characterised by lipid deposition in liver cells. The global prevalence of NAFLD has significantly increased from 8.2% in 1990 to 30.2% in 2023, establishing it as a growing public health concern. In recent years, the name NAFLD has been replaced by metabolic dysfunction-associated fatty liver disease (MASLD). Numerous observational studies have investigated the potential association between hypothyroidism and MASLD; however, the findings remain inconsistent. In this context, a systematic analysis was conducted to examine the relationship between hypothyroidism and MASLD using data from a large cohort within the UK Biobank. Utilising prospective data from the UK Biobank, a Cox proportional hazards model supplemented with multiple sensitivity analyses was applied to investigate the association between the incidence of hypothyroidism and the onset of MASLD. In addition, stratified analyses and prognostic assessments were performed to assess potential effect modifiers. To explore the underlying mechanisms, mediation analyses were conducted, along with restricted cubic spline regression, to examine potential non-linear relationships and mediation effects within this association. The study found that after fully adjusting for multiple covariates, the risk of MASLD in hypothyroidism patients was 1.711 times that of non-hypothyroidism patients (95% CI 1.560-1.877, P < 0.001). Both subtypes of hypothyroidism, namely non-surgical related hypothyroidism (NSRH) and surgical related hypothyroidism (SRH), were associated with a markedly elevated risk of MASLD onset. For NSRH, the risk is increased by 1.710 times (95% CI 1.557-1.878, P < 0.001), and for SRH, the risk is increased by 1.763 times (95% CI 1.344-2.313, P < 0.001). Stratified analysis revealed an interaction effect between gender and BMI in relation to the risk of MASLD among individuals with NSRH. Mediation analysis revealed the critical role of specific biomarkers in elucidating the relationship between hypothyroidism and MASLD. Notably, red cell distribution width, C-reactive protein, HbA1c, and total protein were identified as significant mediators in this association. Patients with hypothyroidism exhibit a significantly increased risk of developing MASLD, with inflammatory and metabolic markers playing a mediating role in this association. These findings suggest that individuals with hypothyroidism, particularly those with elevated levels of inflammatory markers, may be at heightened risk for MASLD. As such, enhanced clinical monitoring of liver function in these patients is recommended to facilitate early detection and intervention.

The relationship between serum uric acid level and non-alcoholic fatty liver disease in northern China: a retrospective cohort study

BACKGROUND

Non-alcoholic fatty liver disease (NAFLD) has become the most prevalent chronic liver disease among adults. High uric acid (UA) increases the incidence of NAFLD in the general population. However, further exploration is warranted to determine the relationship between UA levels and NAFLD in various populations. We conducted a historical cohort study to investigate the causality between UA and NAFLD across different weight categories.

METHODS

A historical cohort was established from the Jidong community cohort. All participants were enrolled and followed up from July 1st, 2013 to August 1st, 2018. The study participants were retrospectively assigned to four groups according to their UA levels (Q1, 69-210 μmol/L; Q2, 211-255 μmol/L; Q3, 256-310 μmol/L; Q4, 311-593 μmol/L). The NAFLD incidence was investigated in each group. We used the UA level determined by an automatic analyzer. NAFLD was diagnosed with abdominal ultrasonography examination. Demographic information, lifestyle history, clinical anthropometric data, and blood samples of participants were collected. Univariate analysis and multivariable Cox regression were applied to analyze the relationship between UA and NAFLD by stratification of participants' body mass index (BMI) categories (underweight, normal weight, overweight, and obese).

RESULTS

Two thousand nine hundred eighty four participants were enrolled. 740 (24.8%) were assigned to UA Q1 group, 755 (25.3%) to UA Q2, 743 (24.9%) to UA Q3, and 746 (25.0%) to UA Q4. The global incidence of NAFLD was 26.0% (777/2984). The risk of NAFLD significantly increased with elevated UA levels in underweight and normal-weight participants (HR = 3.498, 95% CI: 2.413-5.072, P < 0.05). In multivariable analysis, UA showed a positive association with NAFLD, independent of other risk factors in underweight and normal-weight participants (UA Q2: 1.152 (0.761-1.743), UA Q3: 2.168 (1.489-3.157), UA Q4: 3.075 (2.103-4.196), P < 0.05). In the absence of other risk factors, high UA levels independently explained 17% of NAFLD risk in underweight and normal-weight participants.

CONCLUSIONS

High UA levels serve as an independent risk factor for NAFLD in underweight and normal-weight individuals, highlighting the necessity of early NAFLD screening through monitoring liver function and UA levels, and personalized treatment plans for NAFLD patients with higher UA levels, which may include uric acid-lowering therapy and lifestyle modifications. However, the relationship between UA levels and NAFLD in overweight and obese individuals remains inconclusive.

Factors Associated with Nonalcoholic Fatty Liver Disease in a Non-Overweight/Obese and Overweight/Obese Chinese Population at Risk for Metabolic Syndrome: A Cross-Sectional Multicenter Study

Background: To investigate the association of demographic, clinical, and metabolic factors with nonalcoholic fatty liver disease (NAFLD) in a non-overweight/obese and overweight/obese Chinese population at risk for metabolic syndrome. Patients and Method: A cross-sectional multicenter study was conducted using convenience sampling from eight selected counties/cities in Zhejiang, China, between May 2021 and September 2022. Demographics, epidemiological, anthropometric, and clinical characteristics were obtained from a questionnaire. Least absolute shrinkage and selection operator (LASSO)-logistic regression analysis was used to identify the variables associated with NAFLD. Receiver operating characteristic (ROC) curve analysis and decision curve analysis (DCA) were performed to evaluate the diagnostic value and clinical utility of the variables and models. Results: A total of 1739 patients were enrolled in the final analysis, 345 (19.8%) were non-overweight/obese and 1394 (80.2%) were overweight/obese participants. There were 114 (33.0%) and 1094 (78.5%) patients who met the criteria for NAFLD in the non-overweight/obese participants and the overweight/obese participants respectively. Older age, current smoking, higher triglyceride (TG) levels, higher AST levels, higher albumin levels, lower insulin levels, and higher controlled attenuation parameter (CAP) scores were associated with NAFLD in both non-overweight/obese and overweight/obese participants. The combination of TG+CAP scores had strong predictive values for NAFLD, especially in non-overweight/obese (Area Under Curve = 0.812, 95% confidence interval: 0.764-0.863). DCA showed a superior net benefit of the TG+CAP score over other variables or models, suggesting a better clinical utility in identifying NAFLD. Conclusions: More stringent lipid management strategies remain essential, and the convenience and efficacy of transient elastography for liver steatosis should be recognized, especially in the non-overweight/obese population.

Fighting Amyotrophic Lateral Sclerosis by Protecting the Liver? A Prospective Cohort Study

BACKGROUND

Previous studies have observed liver abnormalities in amyotrophic lateral sclerosis (ALS) patients. This study aimed to investigate whether early signs of liver disease, measured by magnetic resonance imaging-derived iron-corrected T1-mapping (cT1), are risk factors for developing ALS.

METHODS

cT1 and proton density fat fraction were measured and automatically analyzed using LiverMultiScan® software. The Fibrosis-4 index was calculated using an established formula based on age and blood markers. Cox proportional hazard models were used to examine the relationship between liver disease, liver biomarkers, and incident ALS.

RESULTS

In a cohort of 533,707 individuals from UK Biobank, 24 ALS cases were identified among 28,328 participants with liver disease during the follow-up period. Among a total of 33,959 individuals with complete liver imaging data, 15 incident ALS cases were observed during a median follow-up period of 5.6 years. Individuals with liver disease had a higher risk of developing ALS, with an adjusted hazard ratio of 7.35 (95% CI 4.47-12.09; p < 0.001). An increase in cT1 was also associated with a higher risk of ALS. After adjusting for age, sex, Townsend deprivation index, smoking status, alcohol intake frequency, body mass index, proton density fat fraction, Fibrosis-4, and metabolic syndrome, an increase in cT1 remained significantly associated with a higher risk of ALS, with an adjusted hazard ratio of 3.15 (95% CI 1.79-5.55) per 1-SD increase. Sensitivity analyses confirmed these robust results.

INTERPRETATION

Liver disease activity, indicated by cT1, increases the risk of developing ALS, independent of metabolic syndrome, liver fat, or fibrosis. ANN NEUROL 2025;97:270-280.

Impact of Nonalcoholic Fatty Liver Disease on Weight Loss Outcomes After One Anastomosis Gastric Bypass

BACKGROUND

Obesity-associated nonalcoholic fatty liver disease (NAFLD) is a significant cause of chronic liver disease. Our study sought to investigate preoperative NAFLD and the effect at 6 months and 2 years after surgery of one anastomosis gastric bypass (OAGB) and its development 6 months after surgery regarding weight loss outcomes.

MATERIALS AND METHODS

A retrospective cohort study was conducted on patients with severe obesity who underwent primary OAGB at Hazrat-e-Rasool Hospital between March 2020 and June 2021. Preoperative assessments included abdominal ultrasound (US) for NAFLD grading, weight, and biochemical blood tests. Follow-up examinations were performed at 10 days and 1, 3, 6, 9, 12, and 24 months postsurgery, with subsequent US examinations at the 6-month follow-up.

RESULTS

Two hundred thirty-one patients were included, with an average age of 40.3±10.5 years and a percentage of 78.4 women. Their mean weight and BMI were 131.2±26.8 and 48.8±8.5, respectively. Six-month grades of NAFLD showed that patients with grade 3 NAFLD had significantly lower TWL% compared with the lower grades. NAFLD grades improved in 72.3% of our patients, remained the same at 21.2%, and worsened at 6.5%. The 6-month TWL% was 28.4±4.3 in the no-change group, 28.4±5.3 for the improved group, and 25.2±14.6 in the worse group.

CONCLUSION

The severity and progression of NAFLD can significantly impact weight loss outcomes post-OAGB, highlighting the importance of monitoring and managing NAFLD in patients undergoing bariatric surgery.

Advances in liver organoids: replicating hepatic complexity for toxicity assessment and disease modeling

The lack of in vivo accurate human liver models hinders the investigation of liver-related diseases, injuries, and drug-related toxicity, posing challenges for both basic research and clinical applications. Traditional cellular and animal models, while widely used, have significant limitations in replicating the liver's complex responses to various stressors. Liver organoids derived from human pluripotent stem cells, adult stem cells primary cells, or tissues can mimic diverse liver cell types, major physiological functions, and architectural features. Recent advancements in the field have shown that some liver organoids have sufficient accuracy to replicate specific aspects of the human liver's complexity. This review highlights recent progress in liver organoid research, with a particular emphasis on their potential for toxicity assessment and disease modeling. The intrinsic advantages of liver organoids include higher sensitivity and suitability for long-term studies, which enhance the predictive value in drug and nanomaterial toxicity testing. The integration of liver organoids with microfluidic devices enables the simulation of the liver microenvironment and facilitates high-throughput drug screening. The liver organoids also serve as ideal platforms for studying liver diseases such as hepatitis, liver fibrosis, viral liver diseases, and monogenic diseases. Additionally, this review discusses the advantages and limitations of liver organoids along with potential avenues for future research.

Association between SPISE and NAFLD in patients with type 2 diabetes

Aims

Non-alcoholic fatty liver disease (NAFLD) is closely related to type 2 diabetes (T2D), with reduced insulin sensitivity being a key factor in their disrupted metabolic processes. The single point insulin sensitivity estimator (SPISE) is a novel index. This study aims to explore the association between SPISE and NAFLD in T2D population.

Methods

This study included a total of 2,459 patients with T2D. SPISE was calculated based on high density lipoprotein-cholesterol (HDL-c), triglycerides (TG), and body mass index (BMI). Participants were categorized into NAFLD and non-NAFLD groups based on the results of ultrasonographic diagnosis. The relationship between SPISE and NAFLD was analyzed separately for each gender.

Results

The overall prevalence of NAFLD is 38.5%. In females and males, the SPISE was significantly reduced in the NAFLD group compared to the non-NAFLD group (both P < 0.05). The prevalence of NAFLD showed a significant reduction across quartiles of the SPISE in both genders (both P < 0.05).Additionally, univariate correlation analysis showed a negative correlation between SPISE and NAFLD (both P < 0.05). In multivariate regression analysis, a reduced SPISE was identified as an independent risk factor for NAFLD (odds ratios of 0.572 and 0.737, 95% CI of 0.477-0.687 and 0.587-0.926, respectively).Moreover, the area under the receiver operating characteristic (ROC) curve for SPISE was 0.209 in females and 0.268 in males (95% CI of 0.175-0.244 and 0.216-0.320, respectively). These results are more meaningful than those of other variables.

Conclusion

SPISE is significantly reduced in NAFLD patients with T2D. Compared to other indicators, SPISE demonstrates superior predictive value in diagnosing NAFLD, and it is independent of gender.

Metabolic dysfunction-associated fatty liver disease and risk of nephrolithiasis: a sizeable cross-sectional study

Objective

Metabolic dysfunction-associated fatty liver disease (MAFLD) and nephrolithiasis are two common metabolic diseases, but their relationship has not yet been thoroughly studied. Therefore, this study aimed to explore the association between MAFLD and nephrolithiasis and to assess the effect of MAFLD on the risk of nephrolithiasis.

Materials and methods

This cross-sectional study included 96,767 adults from China. All participants underwent medical examinations, including physical examinations, medical history tests, and laboratory tests. Based on ultrasound examination, participants were divided into MAFLD and non-MAFLD groups, and the severity of liver steatosis was determined based on ultrasound images. The relationship between MAFLD and nephrolithiasis was analyzed using a multivariate logistic regression model and subgroup analysis was performed.

Results

The proportion of participants with MAFLD was significantly higher in the nephrolithiasis group compared to the non-nephrolithiasis group (47.70% vs. 30.45%, P < 0.001). Multivariate logistic regression analysis showed a significant positive association between MAFLD and nephrolithiasis (adjusted OR=1.38, 95% CI: 1.29 to 1.47). Subgroup analyses indicated that, even after accounting for various factors such as age, diabetes, hypertension, obesity, lipid profiles, and renal function, the positive association between MAFLD and an increased risk of nephrolithiasis remained consistent. Further subgroup analysis revealed that in male patients with MAFLD, the risk of nephrolithiasis increased progressively with increasing severity of liver steatosis. The adjusted multivariable odds ratios were 1.43 (95% CI: 1.33 to 1.53) for mild, 1.48 (95% CI: 1.32 to 1.67) for moderate, and 1.94 (95% CI: 1.47 to 2.58) for severe hepatic steatosis.

Conclusions

This study found a significant positive association between MAFLD and nephrolithiasis. The risk of nephrolithiasis in males with MAFLD increased substantially with increasing severity of liver steatosis. Therefore, it is essential to strengthen prevention and screening for nephrolithiasis in individuals with MAFLD. More research is needed to elucidate the physiological and pathological mechanisms between MAFLD and nephrolithiasis.

Shiftwork and insulin resistance in professional drivers: exploring the association using non-insulin-based surrogate measures

BACKGROUND

Previous research has made use of the Homeostatic Model Assessment for Insulin Resistance (HOMA-IR) index to explore the association between shiftwork (SW) and insulin resistance (IR). However, the limitations of the HOMA-IR index restrict its use. This study aimed to investigate the relationship between SW and IR in professional drivers using four alternative non-insulin-based IR surrogate measures (NIRS), and to determine the predictors of elevated NIRS.

METHODS

A comparative cross-sectional study was conducted on professional drivers at four Egyptian companies, where 187 SW were compared to 193 dayworkers (DW). Measurements included: sociodemographic, work, and clinical characteristics. Laboratory and NIRS data included: triglyceride glucose (TyG), triglyceride glucose-body mass index (TyG-BMI), triglyceride to high density lipoprotein cholesterol (TG/HDL-C), and metabolic score of insulin resistance (METS-IR). Further assessments included insomnia severity index (ISI), and perceived stress scale (PSS-10).

RESULTS

Shiftwork-drivers showed significantly higher levels of NIRS compared to DW-drivers. Shiftwork was significantly associated with elevated TyG (OR: 5.04, 95% CI: 1.98-12.84), TyG-BMI (OR: 4.50, 95% CI: 2.45-8.26), and METS-IR (OR: 6.30, 95% CI: 2.72-14.58). Significant interactions between SW and insomnia or meal-timing habits existed, where SW-drivers with clinically significant insomnia had 11 times higher odds of elevated TyG compared to DW drivers without insomnia. Likewise, SW-drivers experiencing poor meal timing habits had 5.5- and 6.8-times higher odds of elevated TG/HDL-C and METS-IR, respectively, compared to DW divers without poor meal timing habits. Other significant predictors for elevated NIRS included: age, income, stress, overweight/obesity, and poor meal timing habits.

CONCLUSIONS

This study demonstrates a significant association between shiftwork and elevated insulin resistance in professional drivers. Insomnia and poor meal timing habits significantly increases the odds of insulin resistance among professional drivers, suggesting interventions targeting sleep quality, meal timing, and stress management.

Unraveling the Beneficial Role of Resveratrol in Fructose-Induced Non-Alcoholic Steatohepatitis with a Focus on the AMPK/Nrf2 Signaling Axis

Background and Objectives: High fructose intake is associated with non-alcoholic fatty liver disease (NAFLD), a chronic liver disease that is on the rise worldwide. New alternatives for treatment, such as bioactive phytochemicals, are needed. The aim of this study was to investigate the beneficial role of resveratrol in treating non-alcoholic steatohepatitis (NASH). Materials and Methods: Sixty male albino rats were allocated to three groups: group I, the normal control group; group II, the fructose-enriched diet group (FED), which was fed a 70% fructose diet for six weeks to induce NASH; and group III, the resveratrol-FED group (RES + FED), which was given the same FED diet plus an oral dose of 70 mg/kg resveratrol (RES) every day for an additional six weeks. We performed histological evaluations and assessed blood lipids and liver enzymes to study resveratrol's impact on NASH. Quantitative real-time PCR was used to assess the mRNA expression of nuclear factor E2-related factor 2 (Nrf2) in the liver samples. ELISA was used to measure Beclin 1, AMPK, IL-6, and the DNA-binding activity of Nrf2. Oxidative stress indicators, including GSH, SOD, and MDA, were evaluated spectrophotometrically. Results: Resveratrol effectively alleviated the biochemical and histopathological abnormalities associated with NASH, improving autophagy by raising Beclin 1 levels while reducing inflammation by decreasing IL-6 levels. Furthermore, resveratrol restored the liver architecture and the oxidative balance, as evidenced by the decreased MDA levels and improved antioxidant status via elevated GSH and SOD activities, as well as the activation of the AMPK/Nrf2 signaling axis. Conclusions: This study specifically examines resveratrol's therapeutic effects in a high-fructose diet-induced NASH model, focusing on the AMPK/Nrf2 signaling pathway to address oxidative stress and autophagy, providing novel insights into its molecular mechanism of action. Resveratrol reduces NASH by boosting autophagy and activating the AMPK/Nrf2 pathway. These findings underscore the potential of resveratrol as a promising therapeutic agent that can support treatment alongside conventional medications in the management of non-alcoholic steatohepatitis (NASH).

Association between lymphocyte to high-density lipoprotein cholesterol ratio and insulin resistance and metabolic syndrome in US adults: results from NHANES 2007-2018

BACKGROUND

Insulin resistance (IR) and metabolic syndrome (MetS) are significant global health challenges that increase the risk of various chronic diseases. The lymphocyte-to-high-density lipoprotein cholesterol ratio (LHR) has emerged as a novel inflammatory metabolic marker. The present study focused on evaluating the association between the LHR and both IR and MetS.

METHODS

We analyzed data from 14,779 adults aged ≥ 20 years from the National Health and Nutrition Examination Survey (2007-2018). To investigate the relationship between LHR and both IR and MetS, we conducted multivariable logistic regression analyses. The reliability of the results was validated through both stratified and sensitivity analyses. Furthermore, we thoroughly examined possible nonlinear associations by implementing a restricted cubic spline in conjunction with a threshold effect analysis.

RESULTS

Compared to the lowest LHR quartile, individuals in the highest quartile indicated significantly increased prevalence of IR (odds ratio = 3.72, 95% confidence intervals: 3.01-4.59) and MetS (odds ratio = 11.38, 95% confidence intervals: 8.85-14.63) in fully adjusted models. Subgroup analyses demonstrated that the association between the LHR and IR remained consistent across all subgroups, with no significant interaction effect observed. However, the association between LHR and MetS was more pronounced in female participants. Restricted cubic spline analyses revealed nonlinear associations between LHR and both IR and MetS. The threshold effect analyses identified inflection points at 0.055 for these non-linear relationships.

CONCLUSIONS

An elevated LHR was positively associated with the prevalence of IR and MetS, indicating its promising role in early screening and disease prevention through biological monitoring.

AZD2693, a PNPLA3 antisense oligonucleotide, for the treatment of MASH in 148M homozygous participants: Two randomized phase I trials

BACKGROUND & AIMS

A common genetic variant (rs738409) encoding an isoleucine to methionine substitution at position 148 in the PNPLA3 protein is a determinant of hepatic steatosis, inflammation, fibrosis, cirrhosis, and liver-related mortality. AZD2693 is a liver-targeted antisense oligonucleotide against PNPLA3 mRNA. We evaluated the safety, tolerability, pharmacokinetics, and pharmacodynamics in single and multiple ascending dose studies.

METHODS

AZD2693 was assessed in 3D cultures of homozygous PNPLA3 148M primary human hepatocytes and mice expressing human PNPLA3. The single ascending dose study investigated 2-110 mg doses in overweight/mildly obese but otherwise healthy volunteers. The multiple ascending dose study investigated three monthly doses (25 mg, 50 mg and 80 mg) in participants with MRI-proton density fat fraction (MRI-PDFF) ≥7%. Changes in liver fat content were assessed at baseline, weeks 8 and 12 by MRI-PDFF. PNPLA3 mRNA and protein knockdown levels were evaluated for the 80 mg dose.

RESULTS

AZD2693 potently reduced PNPLA3 expression in human hepatocytes and livers of mice. Clinically, AZD2693 was generally well tolerated (no adverse events leading to discontinuation or treatment-related serious adverse events). Half-life was 14-33 days across investigated doses. A least-square mean liver PNPLA3 mRNA knockdown of 89% and reduction of protein levels demonstrated target engagement. Changes in hepatic steatosis at week 12 were -7.6% and -12.2% (placebo-corrected least-square means) for the 25 mg and 50 mg doses, respectively. There was a dose-dependent increase of polyunsaturated fatty acids in serum triglycerides and decreases vs. placebo in high-sensitivity C-reactive protein and interleukin 6.

CONCLUSIONS

AZD2693 reduced liver PNPLA3 with an acceptable safety and tolerability profile. These findings support the continued development of AZD2693.

IMPACT AND IMPLICATIONS

Clinical treatment options for metabolic dysfunction-associated steatohepatitis (MASH) are limited. The genetic risk factor with the largest effect size for progressing to poor liver-related outcomes in MASH is a single-nucleotide polymorphism in the gene PNPLA3 (p.I148M). In phase I single and multiple ascending dose studies, AZD2693, a liver-targeted antisense oligonucleotide, was well tolerated, reduced liver PNPLA3 mRNA and protein levels, and dose-dependently reduced liver fat content in homozygous PNPLA3 148M risk allele carriers. These data support continued development of AZD2693 as a potential precision medicine treatment for MASH. The phase IIb FORTUNA study is now ongoing.

CLINICAL TRIAL NUMBER

NCT04142424, NCT04483947.

The association of fatty liver index and metabolic syndrome with cardiovascular outcomes, liver-related mortality, and all-cause mortality: a nationwide cohort study

We investigated the risk of cardiovascular events, all-cause mortality, and liver-related mortality according to the presence of metabolic syndrome (MetS) and fatty liver index (FLI). In this retrospective longitudinal population-based cohort study, we used Korean National Health Insurance Service data from 2009 to 2012. Nonalcoholic fatty liver disease (NAFLD) was defined as FLI ≥ 60. Risk of all-cause mortality, liver-related mortality, and major adverse cardiovascular events (MACE) including myocardial infarction (MI), stroke, heart failure (HF), and cardiovascular disease (CVD)-related mortality was assessed according to the presence of MetS and FLI among adults (aged 40 to 80 years) who underwent health examinations (n = 769,422). During a median 8.59 years of follow up, 44,356 (5.8%) cases of MACE, 24,429 (3.2%) cases of all-cause mortality, and 1114 (0.1%) cases of liver-related mortality were detected in the entire cohort. When the FLI < 30 without MetS group was set as a reference, the FLI ≥ 60 with MetS group had the highest risk of MACE (adjusted hazard ratio [aHR] 2.05, 95% confidence interval [CI] 1.98-2.13) and all-cause mortality (aHR 1.96, 95% CI 1.86-2.07). The risk of liver-related mortality (aHR 10.71, 95% CI 8.05-14.25) was highest in the FLI ≥ 60 without MetS group. The FLI ≥ 60 with MetS group had a higher risk of MACE (aHR 1.39, 95%CI 1.28-1.51), a lower risk of liver-related mortality (aHR 0.44, 95%CI 0.33-0.59), and no significant difference in all-cause mortality compared with the FLI ≥ 60 without MetS group. The FLI ≥ 60 with MetS group was associated with the highest risk of MACE and the FLI ≥ 60 without MetS group had the highest risk liver-related mortality, but there was no significant difference in all-cause mortality between two groups. In conclusion, as FLI levels increase, the risk of MACE increases, and the risk increases additively in the presence of MetS. The risk of liver-related mortality increases with higher FLI levels, the effect of high FLI on increased risk is more significant in groups without MetS compared to those with MetS.

Identification and Validation of T Cell-Related Hub Biomarkers for Early Diagnosis of Diabetic Kidney Disease Using Single-Cell and Bulk Dataset Analysis

Diabetic kidney disease (DKD) is the most common complication of diabetes and a leading cause of chronic kidney disease that frequently leads to end-stage renal disease (ESRD). The pathogenesis of DKD is complex and is not fully understood. This study was designed to identify key targets for DKD diagnosis and explore the underlying molecular mechanisms.

METHODS

DKD-specific clusters were selected from single-cell datasets. Gene modules were identified using hairpin-dynamic weighted gene co-expression network analysis (hdWGCNA). Multiple machine learning algorithms were applied to model and screen hub genes from two bulk datasets. Rat model of DKD was built using optical microscopes to observe the histopathological changes in the kidney by HE, PAS, and Masson staining. The expression of RASGRP3, PDE3B, and CD247 in DKD-Rat was verified by RT-PCR, and the expression of RASGRP3, PDE3B, and CD247 in the serum samples of DKD patients was verified by ELISA. The results of sex and age, RASGRP3, PDE3B, CD247 were calculated by multivariate logistic regression analysis.

RESULTS

Three hub genes were obtained through screening single-cell and two bulk datasets. In-depth exploration of the potential molecular mechanisms of the hub genes was conducted using gene set variation analysis (GSVA), immune infiltration analysis, and single-cell correlation analysis. Receiver operating characteristic (ROC) curve confirmed a high diagnostic value of the hub biomarkers, and a high-efficiency diagnostic model was constructed and mutually validated in the two datasets. We found that damaged tubular number and interstitial fibrotic percentage were significantly increased in DKD rat. As shown by HE, PAS and Masson staining, the mRNA levels of PDE3B and CD247 were markedly upregulated in DKD rat compared with those in the control group. Lower expression levels of RASGRP3 mRNA were manifested in DKD. The levels of RASGRP3, PDE3B, CD247 in DKD patients by ELISA were statistically significant (p < 0.05). PDE3B and CD247 had an AUC value greater than 0.9,RASGRP3 had an AUC value greater than 0.7.

CONCLUSION

This study identified 3 T cell-related hub biomarkers, providing references for the early diagnosis of DKD and changes in T cells during DKD progression.

Associations of Urinary Nickel with NAFLD and Liver Fibrosis in the USA: A Nationwide Cross‑Sectional Study

Despite the robust correlation between metabolic disorders and heavy metals, there has been limited research on the associations between nickel levels and non-alcoholic fatty liver disease (NAFLD) as well as liver fibrosis. This study aimed to examine the associations among urinary nickel, NAFLD, and liver fibrosis. The data utilized in this study were obtained from the National Health and Nutrition Examination Survey 2017-2020. A comprehensive screening process was conducted, resulting in the inclusion of a total of 3169 American adults in the analysis. The measurement of urinary nickel was conducted through inductively coupled-plasma mass spectrometry. Vibration-controlled transient elastography was employed to assess the controlled attenuation parameter and liver stiffness measurement as indicators for NAFLD and liver fibrosis, respectively. Multivariable logistic regression models were employed to evaluate the associations among urinary nickel, NAFLD, and liver fibrosis. Restricted cubic splines were employed to explored the nonlinear associations. After adjusting for all covariates, the correlation between the highest quartile of urinary nickel and NAFLD was found to be significant (OR = 1.65; 95% CI, 1.19-2.27). Subgroup analysis revealed that the correlation was significant only in men. A significant association occurred between the second quartile of urinary nickel and liver fibrosis (OR 1.88; 95% CI, 1.22-2.90). Restricted cubic spline showed that the relationship was linear between urinary nickel and NAFLD and non-monotonic, inverse U-shaped between urinary nickel and liver fibrosis. This cross-sectional study indicated that the risk of NAFLD is associated with urinary nickel, and this correlation was only present among males.

Ultrasound-based steatosis grading system using 2D-attenuation imaging: An individual patient data meta-analysis with external validation

BACKGROUND AND AIMS

Noninvasive tools assessing steatosis, such as ultrasonography-based 2D-attenuation imaging (ATI), are needed to tackle the worldwide burden of steatotic liver disease. This one-stage individual patient data (IPD) meta-analysis aimed to create an ATI-based steatosis grading system.

APPROACH AND RESULTS

A systematic review (EMBASE + MEDLINE, 2018-2022) identified studies, including patients with histologically or magnetic resonance imaging proton-density fat fraction (MRI-PDFF)-verified ATI for grading steatosis (S0 to S3). One-stage IPD meta-analyses were conducted using generalized mixed models with a random study-specific intercept. Created ATI-based steatosis grading system (aS0 to aS3) was externally validated on a prospective cohort of patients with type 2 diabetes and metabolic dysfunction-associated steatotic liver disease (n=174, histologically and MRI-PDFF-verified steatosis). Eleven enrolled studies included 1374 patients, classified into S0, S1, S2, and S3 in 45.4%, 35.0%, 9.3%, and 10.3% of the cases. ATI was correlated with histological steatosis ( r = 0.60; 95% CI: 0.52, 0.67; p < 0.001) and MRI-PDFF ( r = 0.70; 95% CI: 0.66, 0.73; p < 0.001) but not with liver stiffness ( r = 0.03; 95% CI: -0.04, 0.11, p = 0.343). Steatosis grade was an independent factor associated with ATI (coefficient: 0.24; 95% CI: [0.22, 0.26]; p < 0.001). ATI marginal means within S0, S1, S2, and S3 subpopulations were 0.59 (95% CI: [0.58, 0.61]), 0.69 (95% CI [0.67, 0.71]), 0.78 (95% CI: [0.76, 0.81]), and 0.85 (95% CI: [0.83, 0.88]) dB/cm/MHz; all contrasts between grades were significant ( p < 0.0001). Three ATI thresholds were calibrated to create a new ATI-based steatosis grading system (aS0 to aS3, cutoffs: 0.66, 0.73, and 0.81 dB/cm/MHz). Its external validation showed Obuchowski measures of 0.84 ± 0.02 and 0.82 ± 0.02 with histologically based and MRI-PDFF-based references.

CONCLUSIONS

ATI is a reliable, noninvasive marker of steatosis. This validated ATI-based steatosis grading system could be valuable in assessing patients with metabolic dysfunction-associated steatotic liver disease.

Novel proteomic signatures may indicate MRI-assessed intrahepatic fat state and changes: The DIRECT PLUS clinical trial

BACKGROUND AND AIMS

We demonstrated in the randomized 18-month DIRECT PLUS trial (n = 294) that a Mediterranean (MED) diet, supplemented with polyphenol-rich Mankai duckweed, green tea, and walnuts and restricted in red/processed meat, caused substantial intrahepatic fat (IHF%) loss compared with 2 other healthy diets, reducing NAFLD by half, regardless of similar weight loss. Here, we investigated the baseline proteomic profile associated with IHF% and the changes in proteomics associated with IHF% changes induced by lifestyle intervention.

APPROACH AND RESULTS

We calculated IHF% by proton magnetic resonance spectroscopy (normal IHF% <5% and abnormal IHF% ≥5%). We assayed baseline and 18-month samples for 95 proteomic biomarkers.Participants (age = 51.3 ± 10.8 y; 89% men; and body mass index = 31.3 ± 3.9 kg/m 2 ) had an 89.8% 18-month retention rate; 83% had eligible follow-up proteomics measurements, and 78% had follow-up proton magnetic resonance spectroscopy. At baseline, 39 candidate proteins were significantly associated with IHF% (false discovery rate <0.05), mostly related to immune function pathways (eg, hydroxyacid oxidase 1). An IHF% prediction based on the DIRECT PLUS by combined model ( R2 = 0.47, root mean square error = 1.05) successfully predicted IHF% ( R2 = 0.53) during testing and was stronger than separately inputting proteins/traditional markers ( R2 = 0.43/0.44). The 18-month lifestyle intervention induced changes in 18 of the 39 candidate proteins, which were significantly associated with IHF% change, with proteins related to metabolism, extracellular matrix remodeling, and immune function pathways. Thrombospondin-2 protein change was higher in the green-MED compared to the MED group, beyond weight and IHF% loss ( p = 0.01). Protein principal component analysis revealed differences in the third principal component time distinct interactions across abnormal/normal IHF% trajectory combinations; p < 0.05 for all).

CONCLUSIONS

Our findings suggest novel proteomic signatures that may indicate MRI-assessed IHF state and changes during lifestyle intervention. Specifically, carbonic anhydrase 5A, hydroxyacid oxidase 1, and thrombospondin-2 protein changes are independently associated with IHF% change, and thrombospondin-2 protein change is greater in the green-MED/high polyphenols diet.

Intrapatient Changes in CT-Based Body Composition After Initiation of Semaglutide (Glucagon-Like Peptide-1 Receptor Agonist) Therapy

BACKGROUND. The long-acting glucagon-like peptide-1 receptor agonist semaglutide is used to treat type 2 diabetes or obesity in adults. Clinical trials have observed associations of semaglutide with weight loss, improved control of diabetes, and cardiovascular risk reduction. OBJECTIVE. The purpose of this study was to evaluate intrapatient changes in body composition after initiation of semaglutide therapy by applying an automated suite of CT-based artificial intelligence (AI) body composition tools. METHODS. This retrospective study included adult patients who were receiving semaglutide treatment and who, between January 2016 and November 2023, underwent abdominopelvic CT within both 5 years before and 5 years after initiation of semaglutide. An automated suite of previously validated CT-based AI body composition tools was applied to scans obtained before semaglutide initiation (hereafter, presemaglutide scans) and scans obtained after semaglutide initiation (hereafter, postsemaglutide scans) to quantify visceral adipose tissue (VAT) and subcutaneous adipose tissue (SAT) area, skeletal muscle area and attenuation, intermuscular adipose tissue (IMAT) area, liver volume and attenuation, and trabecular bone mineral density (BMD). Patients with weight loss of 5 kg or more and those with weight gain of 5 kg or more between the scans were compared. RESULTS. The study included 241 patients (151 women and 90 men; mean age, 60.4 ± 12.4 [SD] years). In the weight-loss group (n = 67), the postsemaglutide scan, compared with the presemaglutide scan, showed a decrease in VAT area (309.4 vs 341.1 cm2, p < .001), SAT area (371.4 vs 410.7 cm2, p < .001), muscle area (179.2 vs 193.0, p < 0.001), and liver volume (2379.0 vs 2578 HU, p = .009) and an increase in liver attenuation (74.5 vs 67.6 HU, p = .03). In the weight-gain group (n = 48), the postsemaglutide scan, compared with the presemaglutide scan, showed an increase in VAT area (334.0 vs 312.8, p = .002), SAT area (485.8 vs 448.8 cm2, p = .01), and IMAT area (48.4 vs 37.6, p = .009) and a decrease in muscle attenuation (5.9 vs 13.1, p < .001). Other comparisons were not statistically significant (p > .05). CONCLUSION. Patients using semaglutide who lost versus gained weight showed distinct patterns of changes in CT-based body composition measures. Those with weight loss had overall favorable shifts in measures related to cardiometabolic risk. A decrease in muscle attenuation in those with weight gain is consistent with decreased muscle quality. CLINICAL IMPACT. Among patients using semaglutide, automated CT-based AI tools provide biomarkers of changes in body composition beyond those that are evident by standard clinical measures.

Risk of Adverse Events in Anticoagulated Patients With Atrial Fibrillation and Nonalcoholic Fatty Liver Disease

BACKGROUND

The clinical impact of nonalcoholic fatty liver disease (NAFLD) in patients with atrial fibrillation (AF) is still controversial.

AIM

To evaluate the 1-year risk of all-cause death, thromboembolic events, and bleeding in patients with AF-NAFLD.

METHODS

Retrospective study with a health research network (TriNetX). Patients with AF on oral anticoagulation (OAC) were categorized according to the presence of NAFLD into 2 groups. The primary outcomes were the 1-year risks of (1) a composite cardiovascular outcome (all-cause death, myocardial infarction, stroke, cardiac arrest, and pulmonary embolism) and (2) a composite hemorrhagic outcome (intracranial hemorrhage and gastrointestinal bleeding). Cox regression analysis before and after propensity score matching was used to estimate hazard ratio (HR) and 95% 95% CI,. Sensitivity analyses investigated the risk associated with cirrhosis, thrombocytopenia, and type of OAC (warfarin vs non-vitamin K antagonist oral anticoagulants (NOACs).

RESULTS

We identified 22 636 patients with AF-NAFLD (69 ± 12 years, 46.7% females) and 391 014 patients with AF and without liver disease (72 ± 12 years, 42.7% females). NAFLD was associated with a higher risk of composite cardiovascular (HR, 1.54; 95% CI, 1.47-1.61) and hemorrhagic (HR, 1.56; 95% CI, 1.42-1.72) outcomes. This was consistent also for all the single outcomes. Cirrhotic and thrombocytopenic patients with AF-NAFLD showed the highest risks. Compared to patients with AF-NAFLD on NOACs, those on warfarin were associated with a higher risk of cardiovascular and hemorrhagic outcomes.

CONCLUSION

In patients with AF, NAFLD is associated with a higher 1-year risk of adverse events, with the risk of adverse events progressively increasing from noncirrhotic to cirrhotic and from nonthrombocytopenic to thrombocytopenic patients. NOACs were associated with a better effectiveness and safety profile compared to warfarin.

Non-obese non-alcoholic fatty liver disease and the risk of chronic kidney disease: a systematic review and meta-analysis

Background

Data on risk of developing chronic kidney disease (CKD) between non-obese and obese non-alcoholic fatty liver disease (NAFLD) patients are limited. We aimed to reveal the risk difference of incident CKD between non-obese and obese NAFLD patients.

Methods

We searched PubMed, Embase, and Web of Science databases for studies which reported the incidence of CKD in non-obese and obese NAFLD from inception to 10 March 2024. The primary and secondary outcomes were pooled. Subgroup analysis was used to examine the heterogeneity.

Results

A total of 15 studies were incorporated. The incidence of CKD in non-obese and obese NAFLD were 1,450/38,720 (3.74%) and 3,067/84,154 (3.64%), respectively. Non-obese NAFLD patients had a comparable risk of CKD as obese NAFLD (odds ratio [OR] 0.92, 95% confidence interval [95% CI] [0.72-1.19], I2 = 88%). No differences in estimated glomerular filtration rate and serum creatinine between non-obese and obese NAFLD were found. The mean differences (MD) and 95% CI were 0.01 [-0.02 to 0.04] and 0.50 [-0.90 to 1.90], respectively. In subgroup analyses, non-obese NAFLD had higher eGFR when diagnosed with ultrasound (MD 1.45, 95% CI [0.11-2.79], I2 = 21%). Non-obese NAFLD had higher creatinine in non-Asian (MD 0.06, 95% CI [0.01-0.11], I2 = 55%) and when taking BMI > 30 as the criterion for obesity (MD 0.06, 95% CI [0.00-0.12], I2 = 76%). The occurrence of CKD did not differ when non-obese NAFLD were categorized into overweight and normal-weight types.

Conclusions

Non-obese NAFLD patients experienced the same risk of CKD compared to obese NAFLD.

Fanlian Huazhuo Formula: A promising herbal preparation for metabolic liver disease

The prevalence of metabolic dysfunction-associated steatotic liver disease (MASLD) has increased significantly in recent decades and is projected to increase further due to the rising obesity rates. MASLD patients are at higher risk of developing advanced liver diseases "cirrhosis and hepatocellular carcinoma" as well as liver- or cardiovascular-related mortality. Existing lipid-lowering therapies failed to reduce the risk of mortality in these patients. Therefore, there is an urgent need for pharmacotherapies that can control and even reverse this disease. Fanlian Huazhuo Formula (FLHZF) is a combination herbal preparation, and its various individual constituents regulate hepatic lipid metabolism, adipose tissue inflammation, and gut microbiota. Despite, these useful effects, limited information is available on its benefits in diet-induced hepatosteatosis. In this article, we discuss the research findings recently published about the therapeutic effects of FLHZF in suppressing MASLD development and underlying mechanisms. Utilizing a series of in vitro and in vivo experiments, the authors demonstrated for the first time that FLHZF suppresses MASLD in male mice possibly by inhibiting hepatic de novo lipogenesis pathways and reducing hepatocyte death. This study paves the way for future investigations aimed at investigating FLHZF's role in inhibiting lipogenesis particularly using radioactively-labeled glucose and acetate, and governing hepatocyte mitochondrial function, gut microbiome profile, and its effects in other models of MASLD, and female mice.

Causal associations of immunophenotypes with metabolic dysfunction-associated fatty liver disease and mediating pathways: a Mendelian randomization study

Background

Increasing evidence suggests that immunophenotypes play a crucial role in Metabolic dysfunction-associated fatty liver disease (MAFLD), but the specific immunophenotypes contributing to its pathogenesis remain unclear.

Objectives

This study aimed to elucidate the causal associations between immunophenotypes and MAFLD and identify the underlying mediation pathways involved.

Design

Mendelian randomization (MR) study.

Methods

This study is a quasi-causal inference analysis using univariable and multivariable MR (UVMR and MVMR). Five MAFLD genome-wide association studies (GWASs) and the largest immunophenotype GWAS were analyzed to assess their causal associations. Two-step MR identified potential mediators and quantified their mediation proportions. Comprehensive MR methods, multiple sensitivity analyses, meta-analyses, and false discovery rate (FDR) further enhanced the robustness of our findings.

Results

Pooled inverse-variance weighted (IVW) estimates in UVMR identified 47 immunophenotypes having a suggestive causal association with MAFLD. After adjusting for FDR, three lymphocyte phenotypes remained significant: CD20 on IgD-CD24- B cells (OR: 1.035, p fdr: 0.006), terminally differentiated CD8+ T cells %T cells (OR: 1.052, p fdr: 0.006), and CD4 on CD39+ secreting CD4+ regulatory T cells (OR: 1.036, p fdr: 0.046). Meta-analysis of IVW MVMR estimates with confounders adjustment confirmed that CD20 on IgD-CD24- B cells and terminally differentiated CD8+ T cells %T cells had significant direct causal associations on MAFLD (p fdr < 0.05). Additionally, two-step MR analysis identified the waist-to-hip ratio as a mediator, accounting for 42.64% of the causal association between CD20 on IgD-CD24- B cells and MAFLD.

Conclusion

The causal associations of three lymphocyte phenotypes with increased MAFLD risk were identified in this study. CD20 on IgD-CD24- B cells may both directly and indirectly elevate MAFLD risk, while terminally differentiated CD8+ T cells have a direct causal relationship with MAFLD. These findings suggest new possibilities for targeted therapies and underscore the potential for personalized immunotherapy in managing MAFLD.

Interaction between trouble sleeping and diabetes on metabolic dysfunction-associated fatty liver disease and liver fibrosis in adults results from the National Health and Nutrition Examination Survey 2017-2018

BACKGROUND

Metabolic dysfunction-associated fatty liver disease (MAFLD), trouble sleeping, and diabetes, as major public health problems, were closely related. The study examined the interaction between trouble sleeping and diabetes on MAFLD and liver fibrosis in adults with MAFLD.

METHODS

The data were obtained from the National Health and Nutrition Examination Survey 2017-2018. Multivariate logistic regression model and subgroup analyses were conducted to assess the relationship between either trouble sleeping or diabetes on MAFLD and liver fibrosis. Relative excess risk due to interaction (RERI), attributable proportion of interaction (AP), and synergy index (S) were utilized to assess the additive interaction.

RESULTS

Ultimately, 3747 participants were included, with 2229 known MAFLD subjects. Compared with participants without diabetes, those with diabetes had a higher risk of MAFLD [odds ratio (OR) = 5.55; 95% confidence interval (CI) = 4.07-7.56] and liver fibrosis risk (OR = 3.61; 95% CI = 2.67-4.89). We also found a significant association of trouble sleeping with an increased risk of MAFLD (OR = 1.54; 95% CI = 1.17-2.02) and liver fibrosis risk (OR = 1.51; 95% CI = 1.06-2.16), compared with those without trouble sleeping. Moreover, there was a significant interaction between diabetes and trouble sleeping on MAFLD [RERI = 1.76 (95% CI: -0.22 to 3.73), AP = 0.35 (95% CI: 0.08-0.63), S = 1.80 (95% CI: 1.02-3.16)] and liver fibrosis risk [RERI = 1.79 (95% CI: 0.37-3.21), AP = 0.44 (95% CI: 0.20-0.69), S = 2.44 (95% CI: 1.18-5.08)].

CONCLUSION

The findings highlight that trouble sleeping and diabetes had a synergistic effect on MAFLD and liver cirrhosis. The study highlights the importance of addressing both trouble sleeping and diabetes management in adults to mitigate the risk of MAFLD and liver fibrosis.

Targeting acetyl-CoA carboxylases for the treatment of MASLD

Hepatic accumulation of triglycerides is a hallmark feature of metabolic dysfunction-associated steatotic liver disease (MASLD). Growing evidence indicates that increased rates of de novo lipogenesis (DNL) are one of the earliest metabolic changes promoting hepatic steatosis in the onset of MASLD. The first step in DNL is catalyzed by acetyl-CoA carboxylases (ACC), which mediate the conversion of acetyl-CoA into malonyl-CoA. Given the critical role of ACC enzymes on DNL, ACC-based therapies have emerged as an attractive approach to address MASLD, leading to the development of pharmacologic inhibitors of ACC. In clinical trials, several of those compounds led to decreased DNL rates and improved hepatic steatosis in patients with MASLD. In this review, we describe the development of ACC dual inhibitors and isoform-specific inhibitors along with their clinical testing using monotherapy and combination therapy approaches. We also discuss their efficacy and safety profiles, identifying potential directions for future research. It is anticipated that advances in ACC-based therapies will be critical to the management of MASLD.

Metabolic signatures of metabolic dysfunction-associated steatotic liver disease in severely obese patients

BACKROUND

Metabolic dysfunction-associated steatotic liver disease (MASLD) can lead to liver fibrosis, cirrhosis, and hepatocellular carcinoma. Still, most patients with MASLD die from cardiovascular diseases indicating metabolic alterations related to both liver and cardiovascular pathology.

AIMS AND METHODS

The aim of this study was to assess biologic pathways behind MASLD progression from steatosis to metabolic dysfunction-associated steatohepatitis (MASH) using non-targeted liquid chromatography-mass spectrometry analysis in 106 severely obese individuals (78 women, mean age 47.7 7 ± 9.2 years, body mass index 41.8 ± 4.3 kg/m²) undergoing laparoscopic Roux-en-Y gastric bypass.

RESULTS

We identified several metabolites that are associated with MASLD progression. Most importantly, we observed a decrease of lysophosphatidylcholines LPC(18:2), LPC(18:3), and LPC(20:3) and increase of xanthine when comparing those with steatosis to those with MASH. We found that indole propionic acid and threonine were negatively correlated to fibrosis, but not with the metabolic disturbances associated with cardiovascular risk. Xanthine, ketoleucine, and tryptophan were positively correlated to lobular inflammation and ballooning but also with insulin resistance, and dyslipidemia, respectively. The results did not change when taking into account the most important genetic risk factors of MASLD.

CONCLUSIONS

Our findings suggest that there are several separate biological pathways, some of them independent of insulin resistance and dyslipidemia, associating with MASLD.

Metabolomic Hallmarks of Obesity and Metabolic Dysfunction-Associated Steatotic Liver Disease

From a detailed review of 90 experimental and clinical metabolomic investigations of obesity and metabolic dysfunction-associated steatotic liver disease (MASLD), we have developed metabolomic hallmarks for both obesity and MASLD. Obesity studies were conducted in mice, rats, and humans, with consensus biomarker groups in plasma/serum being essential and nonessential amino acids, energy metabolites, gut microbiota metabolites, acylcarnitines and lysophosphatidylcholines (LPC), which formed the basis of the six metabolomic hallmarks of obesity. Additionally, mice and rats shared elevated cholesterol, humans and rats shared elevated fatty acids, and humans and mice shared elevated VLDL/LDL, bile acids and phosphatidylcholines (PC). MASLD metabolomic studies had been performed in mice, rats, hamsters, cows, geese, blunt snout breams, zebrafish, and humans, with the biomarker groups in agreement between experimental and clinical investigations being energy metabolites, essential and nonessential amino acids, fatty acids, and bile acids, which lay the foundation of the five metabolomic hallmarks of MASLD. Furthermore, the experimental group had higher LPC/PC and cholesteryl esters, and the clinical group had elevated acylcarnitines, lysophosphatidylethanolamines/phosphatidylethanolamines (LPE/PE), triglycerides/diglycerides, and gut microbiota metabolites. These metabolomic hallmarks aid in the understanding of the metabolic role played by obesity in MASLD development, inform mechanistic studies into underlying disease pathogenesis, and are critical for new metabolite-inspired therapies.

Association of depression with severe non-alcoholic fatty liver disease: evidence from the UK Biobank study and Mendelian randomization analysis

The relationship between depression and severe non-alcoholic fatty liver disease (NAFLD) has not been clearly defined. We conducted a longitudinal cohort study and a two-sample Mendelian randomization (MR) analysis to assess the association of depression with severe NAFLD risk. We used individual data from the UK Biobank study with 481,181 participants, and summary data from published genome-wide association studies. The association between depression and severe NAFLD was assessed using Cox proportional hazards regression analysis. Two-sample MR for depression with NAFLD was conducted, the principal analysis employed the inverse variance weighted (IVW) approach. In the observational study, after a median follow-up of 13.46 years, 4,563 participants had severe NAFLD. In multivariable-adjusted model, participants with depression had an increased risk of severe NAFLD (hazards ratio:1.21, 95% confidence interval (CI):1.09-1.34), as compared to those without depression. In subgroup analyses, the association between depression and severe NAFLD risk was generally observed across different subgroups. For the MR, result also showed that genetically predicted depression was causally associated with a higher risk of NAFLD (odds ratio:1.55, 95%CI:1.10-2.19) in IVW. Our study revealed a prospective association of depression with severe NAFLD, thus potentially necessitating clinical monitoring of individuals with depression for severe NAFLD.