Prevalence of steatosis and fibrosis in young adults in the UK: a population-based study

Impact of NAFLD and Fibrosis on Adverse Cardiovascular Events in Patients With Hypertension

BACKGROUND

Nonalcoholic fatty liver disease (NAFLD) is a common comorbidity in hypertension. However, the impact of NAFLD and related fibrosis on hypertension and its control of cardiovascular disease (CVD) and mortality outcomes remains unclear.

METHODS

Participants with hypertension were sourced from two cohorts, with 12 907 individuals from the National Health and Nutrition Examination Survey (NHANES) and 120 639 from the UK Biobank (UKBB). Mendelian randomization analyses explored the causal relationship among hypertension, NAFLD, and CVD. Cox regression models estimated the hazard ratios for CVD and mortality associated with NAFLD (defined by fatty liver index) and liver fibrosis (defined by fibrosis-4 index or NAFLD fibrosis score).

RESULTS

The NHANES documented 3376 deaths over a median follow-up of 8.5 years, and the UKBB documented 15 864 deaths, 4062 incident ischemic strokes, and 5314 incident myocardial infarctions over a median follow-up of 13.5 years. The hazard ratios for CVD and mortality increased in accordance with NAFLD grading (ischemic stroke, 1.16 [95% CI, 1.01-1.33]; myocardial infarction, 1.64 [95% CI, 1.44-1.86] in UKBB; and all-cause mortality, 1.29 [95% CI, 1.09-1.54] in NHANES). High-risk fibrosis increased the hazard ratios for all-cause mortality by 91% and ischemic stroke by 42% in patients with NAFLD in UKBB and for all-cause mortality by 95% in NHANES. NAFLD partially mediates the risk of hypertension for incident CVD and mortality (NHANES, 6.45% of all-cause mortality; UKBB, 5.17% of all-cause mortality; and 8.20% of myocardial infarction).

CONCLUSIONS

NAFLD and related liver fibrosis are associated with a higher risk of incident CVD and mortality in hypertensives. NAFLD and related liver fibrosis seem to partially mediate hypertension-induced CVD and mortality.

Risk Factors for Liver Disease Cluster Geographically: A Precision Public Health Analysis of a UK City

These data describe the distribution of risk factors for liver disease in Leeds, a large city in the UK. Anonymised, unlinked data were aggregated to lower super output areas by the Leeds GP data extraction programme for deprivation, obesity, diabetes and alcohol use. Incident liver disease was quantified from coding of hospital admissions. Alcohol use, deprivation and obesity were associated with LD. Risk factors clustered together geographically. Liver blood tests were more frequently done in areas of low-disease prevalence. These results illustrate health inequalities and support public health policies to reduce incident liver disease.

A prospective comparison of two ultrasound attenuation imaging modes using different frequencies for assessing hepatic steatosis

PURPOSE

This study compared the diagnostic performance of two attenuation imaging (ATI) modes-low-frequency (3 MHz) and high-frequency (4 MHz)-for assessing hepatic steatosis, with histopathological hepatic fat fraction (HFF) as the reference standard.

METHODS

This prospective single-center study enrolled participants with suspected metabolic dysfunction-associated steatotic liver disease (MASLD) scheduled for liver biopsy or surgery between June 2023 and June 2024. Attenuation coefficient (AC) values were consecutively measured using low- and high-frequency ATI modes, while the skin-to-region of interest distance (SRD) was measured simultaneously. Spearman correlation analysis evaluated the relationships of AC with HFF and SRD, and linear regression identified factors affecting AC. Diagnostic performance was evaluated using the area under the receiver operating characteristic curve (AUROC).

RESULTS

In total, 119 participants (mean age, 37.2±12.0 years; 87 men) were included, with 73 (61.3%) diagnosed with MASLD. HFF ranged from 0% to 50%. The AC values in the lowfrequency mode were significantly higher than those in the high-frequency mode (0.61 vs. 0.54 dB/cm/MHz, P<0.001). HFF significantly influenced AC in both modes, whereas SRD affected AC only in the high-frequency mode (P<0.001). AC correlated positively with HFF in both modes (rs≥0.514, P<0.001) and negatively with SRD in the high-frequency mode (rs=-0.338, P<0.001). The AUROC for hepatic steatosis did not differ significantly between the two modes (0.751 vs. 0.771, P=0.609).

CONCLUSION

The low-frequency mode produced higher AC values than the high-frequency mode and demonstrated comparable diagnostic accuracy for assessing hepatic steatosis. Unlike the high-frequency mode, the low-frequency mode was not influenced by SRD.

Increased risk of young-onset ovarian cancer in women with non-alcoholic fatty liver disease: A nationwide cohort study of 2.3 million women aged 20-39 years

Little is known about modifiable risk factors for young-onset ovarian cancer, except for obesity and nulliparity. We investigated the association between non-alcoholic fatty liver disease (NAFLD) and the risk of young-onset ovarian cancer. A total of 2,376,482 women aged 20-39 years who underwent national health screening under the Korean National Health Insurance Service between 2009 and 2012 were included in this nationwide cohort study and followed-up until December 2022. The fatty liver index was used as a diagnostic biomarker for NAFLD. The risk was estimated using multivariable Cox proportional hazards models after adjusting for potential confounders. During 26.8 million person-years of follow-up (median: 11.5 years), 6,319 young women were newly diagnosed with young-onset ovarian cancer. The cumulative incidence probability was significantly higher for those with NAFLD than for those without (log-rank P < 0.01). NAFLD was associated with an increased risk of young-onset ovarian cancer (adjusted hazard ratio [aHR], 95% confidence interval [CI]: 1.30, 1.16-1.45). As the severity of NAFLD increased, the risk of young-onset ovarian cancer tended to increase (aHR, 95% CI: Moderate and severe NAFLD; 1.26, 1.12-1.41 and 1.45, 1.22-1.72, respectively; P for trend < 0.01). NAFLD was independently associated with an increased risk of young-onset ovarian cancer. As NAFLD is modifiable, our findings may benefit the next generation by reducing premature morbidity and mortality associated with young-onset ovarian cancer.

Prevalence of Metabolic Dysfunction-associated Steatotic Liver Disease and Cardiometabolic Risk Factor in US Adolescents

CONTEXT

Metabolic dysfunction-associated steatotic liver disease (MASLD) is widespread worldwide, and a strong link between MASLD and cardiometabolic risk factors (CMRFs) was highlighted in this study.

OBJECTIVE

This study characterized the prevalence of MASLD in adolescent population and overlapping CMRFs conditions in MASLD.

METHODS

This is a cross-sectional study of US adolescents aged 12 to 19 years in the 2017 through 2020 cycles of the National Health and Nutrition Examination Survey. The relationship between CMRFs and liver steatosis, evaluated by the median controlled attenuation parameter (CAP), was assessed.

RESULTS

The prevalence of MASLD in adolescents was 23.77%. Isolated overweight/obesity (35%) was the top CMRF. Non-Hispanic Black patients had the highest proportion of overweight/obesity plus elevated glucose (24%), whereas non-Hispanic Asians had the highest burden of dyslipidemia (2%, 14%, and 19%). Except for hypertension, overweight/obesity (β = 48.7; 95% CI, 43.4-54.0), hypertriglyceridemia (β = 15.5; 95% CI, 7.2-28.3), low HDL-C (β = 10.0; 95% CI, 3.1-16.9), elevated glucose (β = 6.9; 95% CI, 0.6-13.2) were all significantly associated with increased CAP values. Increased CAP was linked to the synergistic interactions between overweight/obesity and dyslipidemia or elevated glucose (overweight/obesity and elevated glucose: relative excess risk due to interaction [RERI] = 8.21, attributable proportion due to interaction [AP] = 0.45, synergy index [SI] = 1.91; overweight/obesity and hypertriglyceridemia: RERI = 19.00, AP = 0.69, SI = 3.53; overweight/obesity and low high-density lipoprotein cholesterol: RERI = 10.83, AP = 0.58, SI = 2.61). Adolescents with combination of overweight/obesity, dyslipidemia (β = 15.1; 95% CI, 0.1-30.2) and combination of overweight/obesity, dyslipidemia and elevated glucose (β = 48.0; 95% CI, 23.3-72.6) had a significantly higher CAP values.

CONCLUSION

The prevalence of MASLD was alarmingly high in adolescents, and overweight/obesity was the most important CMRF. Overweight/obesity and dyslipidemia or elevated glucose had positive additive interaction effects on liver steatosis.

Hepatic steatosis development as a long-term complication among testicular germ cell tumor survivors

BACKGROUND

Hepatic steatosis (HS) development and its risk factors in testicular germ cell tumor (TGCT) survivors have not been investigated.

METHODS

The study was designed as a retrospective observational study. Patients with existing HS at diagnosis were excluded. Serial imaging was utilized to detect HS.

RESULTS

A total of 106 TGCT survivors were included. HS developed in 57% (n = 61) during a median follow-up of 51.8 months (8.5-241.5); 77% (n = 47) of those had persistent HS. Patients who developed HS had a higher baseline body mass index (BMI) (median 26.5 vs. 23.6 kg/m2, p = 0.000). Higher baseline BMI [adjusted odds ratio (aOR): 1.35, (95% CI: 1.10-1.65) p = 0.004] and S0 stage [aOR: 3.87, (95% CI: 1.18-12.67), p = 0.025] were associated with a higher risk of HS development. The median time from the diagnosis of TGCT to the detection of HS was 44.7 months (29.5-59.8). Higher baseline BMI was associated with earlier development of HS both in all patients [hazard ratio (HR): 1.16, (95% CI: 1.04-1.30), p = 0.007] and patients treated with the BEP regimen [HR: 1.21, (95% CI: 1.01-1.47), p = 0.038].

CONCLUSION

HS may be considered a long-term complication in TGCT patients. The risk is associated with baseline BMI. Diagnosis and management of HS should be implemented in the survivorship care plan of TGCT survivors.

Current burden of steatotic liver disease and fibrosis among adults in the United States, 2017-2023

BACKGROUND/AIMS

Multi-society experts proposed the adoption of new terminology, metabolic dysfunctionassociated steatotic liver disease (MASLD) and steatotic liver disease (SLD). We studied the current prevalence of SLD and its subcategories in the US.

METHODS

Using the recent National Health and Nutrition Examination Survey from 2017 to 2023, we analyzed data from 12,199 participants (≥18 years) who completed transient elastography. SLD and its subcategories, including MASLD, metabolic and alcohol-related liver disease (MetALD), and alcohol-related liver disease (ALD), were categorized according to consensus nomenclature.

RESULTS

The age-adjusted prevalence of SLD (cut-off: 285 dB/m) was 35.0% (95% confidence interval [CI] 33.4-36.7). Within this category, the age-adjusted prevalence for MASLD was 31.9% (95% CI 30.4-33.4), MetALD 2.2% (95% CI 1.8-2.6), and ALD 0.8% (95% CI 0.6-1.1). The prevalence of SLD and MASLD showed a statistically insignificant decrease during COVID-19, while ALD increased without significance. In contrast, the prevalence of advanced fibrosis in SLD was significantly higher during the COVID-19 era, at 9.8% for 285 dB/m and 7.8% for 263 dB/m, compared to 7.4% (P=0.039) and 6% (P=0.041) in the pre-COVID-19 era. The proportion of advanced fibrosis and cirrhosis in individuals with ALD was two-fold higher than MASLD and MetALD, largely due to increases during the COVID-19 era.

CONCLUSION

While the prevalence of SLD and its subcategories remained stable, there was a significant increase in advanced fibrosis among SLD individuals during the COVID-19 era, with ALD having a proportion of advanced fibrosis and cirrhosis that was twice as high as MASLD and MetALD.

Development and validation of pFIB scores for exclusion of significant liver fibrosis in pediatric MASLD

BACKGROUND AND AIMS

Metabolic dysfunction-associated steatotic liver disease (MASLD) is the most prevalent pediatric liver disease, yet accurate risk scores for referral of children/adolescents with suspected clinically significant liver fibrosis are currently lacking.

APPROACH AND RESULTS

Clinical and biochemical variables were collected in a prospective cohort of 327 children and adolescents with severe obesity, in whom liver fibrosis was evaluated by transient elastography. Logistic regression was performed to establish continuous (pFIB-c) and simplified (pFIB-6) diagnostic scores that accurately exclude significant (≥F2) fibrosis. Performance for each was compared to established noninvve fibrosis scores. These scores were validated in elastography (n=504) and multiple biopsy-proven MASLD (n=261) cohorts. Patient sex, ethnicity, weight z-score, homeostatic model assessment of insulin resistance index, ALT, and presence of hypertension were included in the scores. The pFIB-c and pFIB-6 exhibited good discriminatory capacity (c-statistic of 0.839 and 0.826), outperforming existing indices. Negative predictive values were >90% for both scores in the derivation and elastography validation cohorts. Performance in the histological cohorts varied (AUROCs for the pFIB-c between 0.710 and 0.770), as the scores were less accurate when applied to populations in tertiary referral centers characterized by a high prevalence of significant fibrosis and high ALT levels.

CONCLUSIONS

Analyzing several cohorts totaling approximately 1100 children and adolescents, we developed novel risk scores incorporating readily available clinical variables. In accordance with the aim of excluding pediatric MASLD-associated fibrosis, the scores performed better in nonselected cohorts of children and adolescents living with obesity than in patients referred to tertiary liver units.

Sustainability of General Population Screening for Steatotic Liver Disease: A Proof-of-Concept Study

BACKGROUND

Steatotic liver disease (SLD) is a growing global health concern and may progress to more advanced liver diseases (i.e., fibrosis, cirrhosis, and hepatocellular carcinoma). Early identification of individuals at risk through effective screening strategies is crucial for timely intervention and management. The aim of this population-based study was to evaluate the feasibility of mean/large-scale screening and its importance by analyzing key risk factors, such as metabolic and lifestyle-related determinants.

METHODS

This cross-sectional study involved 387 subjects aged 18 to 89 years in a remote rural area that stretches among the valleys at the foot of the Apennines and the Apuan Alps. Anthropometric and demographic data were recorded, together with the measurement of blood pressure and cardiac rhythm. Furthermore, US-based liver stiffness (LS) and the ultrasound attenuation parameter (UAP) using the ILivTouch (Hisky Medical, Wuxi, China) device were performed. All data were analyzed with SPSS version 28. Univariate and multivariate analyses were conducted to identify significant predictors of both LS and UAP.

RESULTS

Significant associations are observed between elevated LS and UAP values and risk factors, such as BMI and waist circumference (BMI and waist with R = 0.45 and R = 0.34, R = 0.29 and R = 0.28; respectively, for UAP and LS; all with p < 0.001). The presence of hypertension is associated with a high value of LS (p < 0.05), and high UAP with alcohol consumption and sugary coffee intake habit (p < 0.001 and, p < 0.05, respectively).

CONCLUSIONS

General population screening for SLD is feasible, sustainable, and useful to identify both individuals at risk and patients with progressive liver disease.

The development of a food-group, tree classification method and its use in exploring dietary associations with metabolic dysfunction-associated Steatotic liver disease (MASLD) and other health-related outcomes in a UK population

Background

Metabolic dysfunction-Associated Steatotic Liver Disease (MASLD) affects up to one in five people in the UK, with persistent overeating and a sedentary lifestyle being significant risk factors. Exploring dietary patterns at a food level is a novel approach to understand associations between diet and disease.

Methods

This cross-sectional case-control study included 168 MASLD patients and 34 healthy controls from Nottingham (UK). Dietary data were collected using the EPIC-food frequency questionnaire. A food-group, tree classification method was developed which categorized 923 ingredients into three levels (main food group, sub-types, and cooking methods) and intakes were associated with clinical outcomes using logistic regression and degree of liver fibrosis using linear regression.

Results

Significant associations were found for red meat intake with MASLD (OR [CI]: 1.013 [1.001-1.025]) and fibrosis (Beta [SE]: +0.048 [0.013]); intakes of nuts (OR [CI]: 0.951 [0.905-0.999]); and fish (OR [CI]: 0.985 [0.971-0.999]) with MASLD; "Cereals and cereals products", "salt and gravy" and baked foods with fibrosis (Beta [SE]: +0.018 to +0.057 [0.005-0.23]); white and organ meat (Beta [SE]: -0.04 to -0.61 [0.015-0.249]); diet soda (OR [CI]: +0.01 [1-1.003]) and red meat intakes (OR [CI]:+0.002 [1.002-1.016]) with T2DM; wholegrain wheat, red meat, and semi-skimmed dairy intakes with hypercholesterolemia (ORs [CI]: -0.003 to -0.023 [1-1.043]); "herbs and spices" and wholegrain rice with hypercholesterolaemia (ORs [CI]: -0.08 to -0.98 [0.159-0.989); fresh herbs and boiled foods intakes with hypertension (ORs [CI]: -0.001 to -2.21 [0.013-1]).

Conclusion

The study introduces a new food-group, tree classification method to characterise UK diet data and identify risk factors for MASLD, potentially informing the development of culturally applicable dietary guidelines designed to improve public health.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Consistency analysis of two US techniques for evaluating hepatic steatosis in patients with metabolic dysfunction-associated steatotic liver disease

BACKGROUND

US tools to quantify hepatic steatosis have recently been made clinically available by different manufacturers, but comparative data on their consistency are lacking.

OBJECTIVE

US tools to quantify hepatic steatosis have recently been made clinically available by different manufacturers, but comparative data on their consistency are lacking. The aim of our study was to compare the diagnostic consistency for evaluating hepatic steatosis by two different US techniques, hepatorenal index by B-mode Ratio and attenuation coefficient by attenuation imaging (ATI).

METHODS

Patients with suspicion or previously diagnosed of metabolic dysfunction-associated steatotic liver disease (MASLD) who attended fatty liver consulting room from June 2023 to September 2023 were prospectively recruited. Patients underwent two different US techniques of B-mode Ratio and ATI, and laboratory test were collected. According to previously proposed cut-off values, B-mode Ratio ≥ 1.22, 1.42, 1.54, and ATI ≥ 0.62, 0.70, and 0.78 dB/cm/MH were used for assessing of mild, moderate, and severe hepatic steatosis, respectively. Kappa consistency test was used to evaluate the consistency of hepatic steatosis.

RESULTS

A total of 62 patients were enrolled, including 44 males (71.0%) with an age of (41 ± 13) years and a body mass index of (27.0 ± 3.5) kg/m2. In the hyperlipidemia group, the B-mode Ratio and ATI were significantly higher than those in the non-hyperlipidemia group, with values of 1.68 ± 0.39 vs. 1.28 ± 0.35 (p = 0.001) and 0.74 ± 0.12 dB/cm/MH vs. 0.64 ± 0.11 dB/cm/MH (p = 0.005), respectively. The correlation coefficient between B-mode Ratio and ATI was 0.732 (p < 0.001). Using B-mode Ratio and ATI as diagnostic criteria for MASLD, the proportion of patients with MASLD was 79% and 82%, respectively. The Kappa coefficient for assessing MASLD was 0.90 (p < 0.001). Furthermore, these two different US techniques were used for grading hepatic steatosis, with no, mild, moderate, and severe steatosis accounting for 21%, 18%, 13%, and 48%, as well as 18%, 29%, 22%, and 31%, respectively. The linear weighted Kappa coefficient for staging hepatic steatosis was 0.78 (95% confidence interval: 0.68-0.87, p < 0.001).

CONCLUSION

The non-invasive methods of two different US techniques based on B-mode Ratio and ATI have good consistency for evaluating hepatic steatosis, and can be used for large-scale community screening.

Association between Body Fat Distribution and Nonalcoholic Fatty Liver Disease/Fibrosis Based on Race/Ethnicity

BACKGROUND

Body fat distribution may impact nonalcoholic fatty liver disease (NAFLD) and significant fibrosis differently according to race/ethnicity. We determined the relationship between body fat distribution and NAFLD/significant fibrosis according to race/ethnicity.

METHODS

A cross-sectional study of 2,395 participants used the National Health and Nutrition Examination Survey 2017 to 2018. NAFLD and significant fibrosis (≥F2) were defined by controlled attenuation parameter scores and liver stiffness measurements on transient elastography, respectively. Visceral and subcutaneous fat volumes were defined by dual-energy X-ray absorptiometry.

RESULTS

The odds ratio (OR) for NAFLD per 1-standard deviation in visceral fat volume and subcutaneous fat volume was 2.05 (95% confidence interval [CI], 1.36 to 3.09) and 1.48 (95% CI, 1.04 to 2.09) in total population, respectively. Visceral fat in non-Hispanic Blacks had the highest odds for NAFLD (OR, 2.86; 95% CI, 1.45 to 5.62), and non-Hispanic Whites (OR, 2.29; 95% CI, 1.19 to 4.40) and non-Hispanic Asians (OR, 1.61; 95% CI, 1.13 to 2.29) were in order. Significant associations between subcutaneous fat volume (OR, 2.10; 95% CI, 1.34 to 3.29; P=0.003) or visceral fat volume (OR, 1.35; 95% CI, 1.05 to 1.73; P=0.023) and significant fibrosis were noted among individuals with NAFLD. Hispanics had the highest odds for NAFLD-associated significant fibrosis (OR, 2.74; 95% CI, 1.32 to 5.70 per 1-standard deviation in subcutaneous fat volume), and non-Hispanic Whites (OR, 2.35; 95% CI, 1.11 to 4.98) and non-Hispanic Asians (OR, 2.01; 95% CI, 1.01 to 4.01) were in order.

CONCLUSION

Visceral adiposity was associated with NAFLD and significant fibrosis despite the association of subcutaneous adiposity in NAFLD and significant fibrosis. Racial/ethnic differences in the association between body fat distribution on NAFLD and significant fibrosis were noted.

Alcohol-associated liver disease-Global epidemiology

Alcohol-associated liver disease (ALD), as highlighted in this narrative review, is a major public health concern, increasingly impacting global disease burden and premature mortality. In 2019, ALD accounted for the loss of 11 million life-years worldwide. The rising number of deaths and disability-adjusted life-years attributed to ALD, particularly pronounced in the United States, are alarming. Projections suggest that the economic impact of ALD, as seen in the United States, could potentially double by 2040. ALD is increasingly prevalent among younger adults (20-45 y) and has become the leading cause of liver transplantation in both United States and Europe. During the COVID-19 pandemic, the existing trend was further amplified as high-risk drinking patterns coincided with a rise in hospital admissions for alcohol-associated hepatitis and increased ALD-related mortality. The prevalence of ALD is estimated at 3.5% in the general population, 26.0% among hazardous drinkers, and 55.1% among those with alcohol use disorders. Alarmingly, 5-year mortality rates for patients with ALD exceed 50%, with even higher rates in more advanced disease stages. Methodological challenges, such as underreporting, diagnostic difficulties, and variability in registry data quality, complicate the accurate assessment of the impact of ALD. Additionally, the contribution of alcohol to the progression of other liver diseases is often under acknowledged in health care registries, leading to a significant underestimation of its broader implications for liver health. Addressing the growing ALD concern requires robust public health initiatives, heightened awareness, refined diagnostic techniques, and comprehensive epidemiological studies. These measures are vital to tackle the increasing prevalence of ALD and mitigate its extensive impact on individuals and health care systems.

Alcohol and Metabolic Syndrome Interaction

Alcohol-related liver disease and metabolic-dysfunction-associated steatotic liver disease are the most common causes of chronic liver disease. Globally, alcohol intake, and metabolic syndrome driven by excessive caloric intake and sedentary lifestyle have steadily increased over the past decades. Given the high prevalence rates of both excessive alcohol consumption and components of metabolic syndrome, both can frequently coexist in the same individuals and impact their lives. In this article, we review the impact of alcohol and metabolic syndrome on liver-related outcomes.

Prevalence of steatotic liver disease (MASLD, MetALD, ALD) and clinically significant fibrosis in US adolescents : Authors' name

We aim to evaluate the prevalence of steatotic liver disease (SLD) in United States (US) adolescents and explore whether metabolic dysfunction-associated steatotic liver disease (MASLD) can identify individuals with clinically significant fibrosis (CSF) in this study. The prevalence of SLD and its categories, including MASLD, metabolic dysfunction and alcohol associated liver disease (MetALD), alcohol related liver disease (ALD) and other SLD were determined. Weighted multivariable logistic regression analysis was conducted to evaluate the association between MASLD and CSF in adolescents with SLD. Among the total 1,446 US adolescents, SLD was present in 291 (20.1%) of individuals, including 260 (17.9%) for MASLD, 9 (0.6%) for MetALD and 5 (0.3%) for ALD. Only 58 (4%) had CSF. Patients with SLD showed a higher prevalence of CSF (9.6% vs. 2.6%, p < 0.001). Among patients with SLD, 89.3% met the MASLD criteria. The risk of CSF in patients with MASLD was not significantly different (odds ratio [OR] = 1.07, 95% confidence interval [CI] = 0.30-3.83, p = 0.9180) compared with those without MASLD. MASLD was met by most of the US adolescents with SLD. Moreover, MASLD was not associated with higher prevalence of CSF among adolescents with SLD.

A significant and persistent rise in the global burden of adolescent NAFLD and NASH estimated by BMI

BACKGROUND

Currently, there is a lack of global or even country/regional level data on adolescent non-alcoholic fatty liver disease (NAFLD) prevalence. However, an evidenced dose-dependent relationship exists between body mass index (BMI) and the risk of NAFLD. We aim to estimate the global and regional prevalence of adolescent NAFLD and related non-alcoholic steatohepatitis (NASH) based on BMI.

METHODS

Sigmoidal fitting curves were generated between BMI and the risk of NAFLD/NASH using the data extracted from the NHANES database. With global and regional BMI data from the NCD-RisC database, adolescent NAFLD/NASH prevalence was estimated at the international, regional, and country levels from 1975 to 2016. The prevalence of adolescent NAFLD/NASH from 2017 to 2030 was also forecasted.

RESULTS

The mean NAFLD prevalence was 15.31, and 12.68%, while the mean NASH prevalence was 2.50, and 2.47%, in boys, and girls aged 12-18, respectively. For both boys and girls, NAFLD/NASH prevalence increased with increasing BMI, and age. The global prevalence of adolescent NAFLD/NASH has gradually increased in the period from 1975 to 2016 and will maintain a similar trend between 2017 and 2030. High-income Western Countries had higher adolescent NAFLD/NASH whereas South Asia and Sub-Saharan Africa exhibited relatively lower adolescent NAFLD/NASH prevalence. The estimated annual percentage change (EAPC) of NAFLD prevalence in boys ranged from 0.72% (age 18) to 1.16% (age 12) while that in girls ranged from 0.69% (age 18) to 0.92% (age 12). EAPC of NASH prevalence in boys ranged from 1.65% (age 18) to 1.77% (age 12), and in girls from 1.48% (age 18) to 1.68% (age 12).

CONCLUSION

The adolescent NAFLD/NASH prevalence increases year by year, and its burden varies significantly among different countries and regions. BMI is a precise predictor of NAFLD/NASH prevalence.

Pediatric metabolic (dysfunction)-associated fatty liver disease: current insights and future perspectives

The historical use of the term non-alcoholic fatty liver disease (NAFLD) in obese/overweight children has been controversial as to the appropriateness of this terminology in children, and lately, in adults too. Newer game-changer terminology, metabolic (dysfunction)-associated fatty liver disease (MAFLD), for this condition signifies a positive step forward that addresses the limitations of the previous definition for both adults and children. The prevalence of MAFLD has surged in tandem with the global rise in obesity rates, establishing itself as a predominant cause of chronic liver disease in both adult and pediatric populations. The adoption of the recently proposed nomenclature reflects a more encompassing comprehension of the disease and its etiology compared to its predecessor, NAFLD. Notably, the revised terminology facilitates the recognition of MAFLD as an autonomous condition while acknowledging the potential coexistence of other systemic fatty liver disorders. Particularly in children, this includes various paediatric-onset genetic and inherited metabolic disorders, necessitating thorough exclusion, especially in cases where weight loss interventions yield no improvement or in the absence of obesity. MAFLD presents as a multifaceted disorder; evidence suggests its origins lie in a complex interplay of nutritional, genetic, hormonal, and environmental factors. Despite advancements, current non-invasive diagnostic biomarkers exhibit limitations in accuracy, often necessitating imaging and histological evaluations for definitive diagnosis. While dietary and lifestyle modifications stand as cornerstone measures for MAFLD prevention and management, ongoing evaluation of therapeutic agents continues. This article provides an overview of the latest developments and emerging therapies in the realm of paediatric MAFLD.

Correlation between controlled attenuation parameter values with SYNTAX score in patients with significant coronary artery disease

Non-alcoholic fatty liver disease (NAFLD) is an emerging cause of chronic liver disease, with coronary artery disease (CAD) as the main cause of death in NAFLD patients. However, correlation between the severity of liver steatosis and coronary atherosclerosis is yet to be understood. Here we aim to explore the correlation between controlled attenuation parameter (CAP) values and SYNTAX (Synergy Between Percutaneous Coronary Intervention with Taxus and Cardiac Surgery) score in adult patients with significant CAD, defined as ≥ 50% stenosis of the left main coronary artery, or ≥ 70% stenosis of the other major coronary arteries. A cross-sectional study was conducted on 124 adult patients with significant CAD who underwent coronary angiography. Transient elastography with CAP was used to assess liver steatosis severity, resulting in a mean CAP value of 256.5 ± 47.3 dB/m, with 52.5% subjects had significant steatosis (CAP value of ≥ 248 dB/m). Median SYNTAX score was 22. A statistically significant correlation was observed between CAP value and SYNTAX score (r = 0.245, p < 0.0001). The correlation was more pronounced in patients with prior history of PCI (r = 0.389, p = 0.037). Patients with high-risk SYNTAX score (> 32) had the highest CAP value (285.4 ± 42.6 dB/m), and it was significantly higher than those with low-risk SYNTAX score (0-22), with a mean difference of 38.76 dB/m (p = 0.006). Patients with significant liver steatosis should undergo periodic CAD assessment and lifestyle modification, especially those with severe liver steatosis.

Prevalence and Predictors for Lean Fatty Liver Disease in General Population Attending a COVID-19 Vaccination Center in a Tertiary Care Hospital in India

Background

There is an international consensus among experts advocating for the classification of fatty liver disease as a metabolic condition. However, some authors have raised concerns that this metabolic-centric framing may result in the underdiagnosis of metabolicdysfunction-associated steatotic liver disease (MASLD) in lean individuals. The present study was carried out with the objective of describing metabolic characteristics in MASLD and the prevalence of lean MASLD in the general population.

Methods

We carried out a hospital-based cross-sectional study. A pre-tested proforma was used to collect data on socio-demographic factors, lifestyle factors, and medical history. Transient elastography and blood investigations were carried out in all patients. The identification of independent predictors for MASLD and liver fibrosis was carried out using multivariable logistic regression. A test of interaction was conducted for studying effect modification in the association of diabetes and MASLD by subgroups of body mass index (BMI).

Results

A total of 1,243 participants were interviewed and screened for MASLD. The overall prevalence of MASLD was 43.7% (n = 543), with the prevalence of lean MASLD being 4.3% (n = 53). The prevalence of MASLD in lean vs non-lean subjects differed (21.3 vs 66.7%, p < 0.001). Of the total MASLD cases, lean MASLD constituted 9.7% of cases. The association of diabetes and MASLD did not differ in subgroups by BMI. The test for interaction to detect effect modification was not statistically significant (p = 0.673).

Conclusion

The results support laying emphasis on metabolic dysfunction as a key criterion when defining fatty liver disease. The findings emphasize the shared metabolic underpinnings between lean and non-lean MASLD and advocate for inclusive approaches in diagnosis, management, and public health initiatives.

How to cite this article

Prasad M, Bhardwaj N, Gupta E, et al. Prevalence and Predictors for Lean Fatty Liver Disease in General Population Attending a COVID-19 Vaccination Center in a Tertiary Care Hospital in India. Euroasian J Hepato-Gastroenterol 2024;14(2):145-150.

The prevalence and predictors of metabolic dysfunction-associated steatotic liver disease and fibrosis/cirrhosis among adolescents/young adults

OBJECTIVES

We investigated the current prevalence of metabolic dysfunction-associated steatotic liver disease (MASLD) and fibrosis/cirrhosis and identified at-risk populations for MASLD and MASLD-related fibrosis among US adolescents and young adults in the United States.

METHODS

Utilizing the National Health and Nutrition Examination Survey 2017-2020, the prevalence of MASLD and fibrosis/cirrhosis was assessed via controlled attenuation parameter (CAP) score and liver stiffness measurements by transient elastography in participants aged 12-29 years with at least one cardiometabolic criteria and absence of other chronic liver disease. Multivariable logistic regression was performed to determine predictors of MASLD and MASLD-related fibrosis.

RESULTS

The overall prevalence of MASLD was 23.9% (95% confidence interval [CI]: 21.3-26.5 for CAP ≥ 263 dB/m) and 17.3% (95% CI: 14.7-20.0 for ≥285 dB/m), respectively. The prevalence of fibrosis and cirrhosis in MASLD was 11.0% and 3.1%, respectively. When categorized by age, the prevalence of MASLD varied from 16.8% (of which 6.2% [fibrosis], 1.8% [cirrhosis]) in early and middle adolescents (12-17 years), to 25.5% (11.8% [fibrosis], 4.8% [cirrhosis]) in late adolescents and young adults (18-24 years), and to 30.4% (of which 13.2% [fibrosis] and 2.1% [cirrhosis]) in older young adults (25-29 years). The independent predictors for MASLD included male sex, Hispanic, non-Hispanic Asian, body mass index, and low HDL-cholesterol. In contrast, diabetes and body mass index were associated with an increased risk of fibrosis in individuals with MASLD.

CONCLUSIONS

The prevalence of MASLD and related fibrosis in adolescents and young adults in the United States has reached a significant level, with a substantial proportion of cirrhosis.

Global burden of adult non-alcoholic fatty liver disease (NAFLD) and non-alcoholic steatohepatitis (NASH) has been steadily increasing over the past decades and is expected to persist in the future

BACKGROUND

At present, there is a dearth of comprehensive data at the global, national, and regional levels regarding the adult non-alcoholic fatty liver disease (NAFLD) prevalence. This cross-sectional study aims at ascertaining the prevalence of NAFLD and non-alcoholic steatohepatitis (NASH), utilizing body mass index (BMI) as a determining factor.

METHODS

Based on the NHANES database, sigmoidal fitting curves were generated to establish the relationship between BMI and the risk of NAFLD/NASH. Utilizing BMI data from the NCD Risk Factor Collaboration (NCD-RisC) database at both global and regional levels, the prevalence of NAFLD/NASH among adults was estimated from 1975 to 2016, encompassing global, regional, and national perspectives. Additionally, projections were made to forecast the prevalence of adult NAFLD/NASH from 2017 to 2030.

RESULTS

In 2016, the global prevalence of NAFLD was 41.12% for males and 37.32% for females, while the global prevalence of NASH was 15.79% for males and 16.48% for females. The prevalence of NAFLD/NASH increased with higher BMI in both genders. Over the period from 1975 to 2016, there has been a gradual increase in the global prevalence of NAFLD/NASH in adults, and this trend is expected to continue between 2017 and 2030. In males, the prevalence of adult NAFLD/NASH was found to be highest in High-income Western countries, while it was highest in Central Asia, Middle East, and North African countries after 1995.

CONCLUSIONS

The prevalence of adult NAFLD/NASH has been observed to increase annually, with significant variations in burden across different countries and regions.

Metabolic dysfunction-associated steatotic liver disease-related hepatic fibrosis increases risk of insulin resistance, type 2 diabetes, and chronic kidney disease

Metabolic dysfunction-associated steatotic liver disease (MASLD) (previously called nonalcoholic fatty liver disease, NAFLD) is associated with cardiometabolic risk factors and chronic kidney disease (CKD). However, evidence is lacking regarding whether the severity of fibrosis is affected by these risk factors and diseases and to what degree. We aimed to determine the correlation between these factors and vibration-controlled transient elastography-determined liver stiffness measurements (LSMs) and controlled attenuation parameter (CAP) values in a sample of the US population. Data from the 2017-2018 cycle of the National Health and Nutrition Examination Survey were pooled. The association between LSM and cardiometabolic risk factors and CKD was assessed using generalized linear or logistic regression analyses. In multivariate regression analyses, CAP and BMI were adjusted as confounders. Of 3647 participants, 2079 (57.1%) had NAFLD/MASLD [weighted prevalence 54.8%; 95% confidence interval (CI) 51.8-57.9%]; the weighted prevalence of significant fibrosis (LSM ≥ 7.9 kPa) was 9.7% (95% CI 8.2-11.3%). Log LSM was associated with higher levels of homeostatic model assessment of insulin resistance ( β  = 2.19; P  = 0.017), hepatic steatosis (CAP > 248 dB/m) [odds ratio (OR) 3.66; 95% CI 2.22-6.02], type 2 diabetes (OR 2.69; 95% CI 1.72-4.20), and CKD (OR 1.70; 95% CI 1.24-2.34). These correlations did not change notably after adjustments were made for waist circumference, CAP, and BMI. LSM and CAP, although influenced by waist circumference and BMI, are good indicators of hepatic fibrosis and steatosis. LSM is associated with insulin resistance, diabetes, and CKD independent of hepatic steatosis and obesity.

Red meat intake, faecal microbiome, serum trimethylamine N-oxide and hepatic steatosis among Chinese adults

BACKGROUND AND AIMS

Emerging evidence suggests a detrimental impact of high red meat intake on hepatic steatosis. We investigated the potential interplay between red meat intake and gut microbiome on circulating levels of trimethylamine N-oxide (TMAO) and hepatic steatosis risk.

METHODS

This cross-sectional study was conducted in a representative sample of 754 community-dwelling adults in Huoshan, China. Diet was collected using 4 quarterly 3 consecutive 24-h dietary (12-day) recalls. We profiled faecal microbiome using 16S ribosomal RNA sequencing and quantified serum TMAO and its precursors using LC-tandem MS (n = 333). We detected hepatic steatosis by FibroScan. The adjusted odds ratios (aORs) and 95% confidence intervals (CIs) were calculated using logistic regression.

RESULTS

TMAO levels but not its precursors were positively associated with the likelihood of hepatic steatosis (aOR per 1-SD increment 1.86, 95% CI 1.04-3.32). We identified 14 bacterial genera whose abundance was associated with TMAO concentration (pFDR < .05) belonging to the phyla Firmicutes, Bacteroidetes, Actinobacteria and Proteobacteria families. Per 10 g/day increase in red meat intake was positively associated with TMAO levels among participants who had higher red meat intake (>70 g/day) and higher TMAO-predicting microbial scores (TMS, β = .045, p = .034), but not among others (pinteraction = .030). TMS significantly modified the positive association between red meat and steatosis (pinteraction = .032), with a stronger association being observed among participants with higher TMS (aOR 1.30, 95% CI 1.07-1.57).

CONCLUSIONS

The bacterial genera that predicted TMAO levels may jointly modify the association between red meat intake and TMAO levels and the subsequent risk of hepatic steatosis.

Prevalence, trends, and characteristics of metabolic dysfunction-associated steatotic liver disease among the US population aged 12-79 years

BACKGROUND AND AIMS

Clinical observation revealed an increase in metabolic dysfunction-associated steatotic liver disease (MASLD) prevalence among adults and adolescents and young adults (AYA). However, its prevalence trend in specific subgroups and its characteristics are unclear.

APPROACH AND RESULTS

This cross-sectional study included adults and AYA aged 20-79 and 12-19 years, respectively, from the National Health and Nutrition Examination Survey from 1999 to 2018. MASLD was defined as US Fatty Liver Index ≥30 in adults and alanine amino transaminase elevation and obesity in AYA. Joinpoint and logistic regression were used to evaluate the MASLD prevalence trend and its associated characteristics. MASLD was diagnosed in 17 156 892 of 51 109 914 (33.6%) adults and 1 705 586 of 29 278 666 AYA (5.8%). During the study period, MASLD prevalence significantly increased from 30.8% to 37.7% ( P  < 0.01) in adults and in subgroups of female participants, individuals aged 20-45 and 61-79 years, and non-Hispanic white individuals. Conversely, MASLD prevalence did not significantly change in AYA (from 5.1% to 5.2%, P  = 0.139), except in the subgroup of Mexican Americans (from 8.2% to 10.8%, P  = 0.01). Among adults, high MASLD prevalence was associated with male sex, Mexican American ethnicity, age >50 years, being unmarried, poverty income ratio <130, poor or fair health condition, obesity or overweight, and chronic conditions. Among AYA, high MASLD prevalence was associated with male sex, poverty income ratio <130, and education.

CONCLUSION

Accordingly, we concluded that health care providers should prevent and treat conditions associated with MASLD by raising awareness of the increasing trend of MASLD.

Changes in Fatty Liver Disease and Incident Diabetes Mellitus in Young Korean Adults

INTRODUCTION

This study sought to assess the association between the changes in nonalcoholic fatty liver disease (NAFLD) and risk of type 2 diabetes in young individuals with prediabetes.

METHODS

Data from the Korean National Health Insurance System database were collected from 2009 to 2019 and analyzed in 2022. A total of 446,813 young adults aged 20-39 years with prediabetes who underwent two National Health Screening examinations from 2009 to 2012 were followed up. NAFLD was defined as a fatty liver index≥60 without liver disease or history of alcohol abuse. Multivariable Cox proportional hazards regression was used to calculate the HR and CIs for type 2 diabetes according to NAFLD changes.

RESULTS

During a median follow-up of 8.3 years, 26,464 (5.9%) young individuals developed type 2 diabetes. Multivariable adjusted HR of type 2 diabetes according to the NAFLD change was 5.38 (95% CI 5.08-5.70) in individuals with persistent NAFLD when compared to those who never had NAFLD. Even in individuals who were consistently nonobese, resolved NAFLD, new NAFLD, and persistent NAFLD were associated with>3-fold increased risk of type 2 diabetes compared to nonobese individuals without NAFLD. The risk of type 2 diabetes also increased in obese individuals without NAFLD by 2-fold when compared to nonobese individuals without NAFLD.

CONCLUSIONS

NAFLD that either existed persistently or ever existed plays a critical role in the development of type 2 diabetes in young adults with or without obesity. Nonobese individuals with NAFLD warrant special attention.

Empagliflozin Reduces Liver Fat in Individuals With and Without Diabetes

OBJECTIVE

To examine the effect of empagliflozin on liver fat content in individuals with and without type 2 diabetes (T2D) and the relationship between the decrease in liver fat and other metabolic actions of empagliflozin.

RESEARCH DESIGN AND METHODS

Thirty individuals with T2D and 27 without were randomly assigned to receive in double-blind fashion empagliflozin or matching placebo (2:1 ratio) for 12 weeks. Participants underwent 75-g oral glucose tolerance testing and measurement of liver fat content with MRS before therapy and at study end. Hepatic glucose production before the start of therapy was measured with 3-3H-glucose.

RESULTS

Empagliflozin caused an absolute reduction of 2.39% ± 0.79% in liver fat content compared with an increase of 0.91% ± 0.64% in participants receiving placebo (P < 0.007 with ANOVA). The decrease in liver fat was comparable in both individuals with diabetes and those without (2.75% ± 0.81% and 1.93% ± 0.78%, respectively; P = NS). The decrease in hepatic fat content caused by empagliflozin was strongly correlated with baseline liver fat content (r = -0.62; P < 0.001), decrease in body weight (r = 0.53; P < 0.001), and improvement in insulin sensitivity (r = -0.51; P < 0.001) but was not related to the decrease in fasting plasma glucose or HbA1c or the increase in hepatic glucose production.

CONCLUSIONS

Empagliflozin is effective in reducing liver fat content in individuals with and without T2D. The decrease in liver fat content is independent of the decrease in plasma glucose concentration and is strongly related to the decrease in body weight and improvement in insulin sensitivity.

The Metabolic Impact of Nonalcoholic Fatty Liver Disease on Cognitive Dysfunction: A Comprehensive Clinical and Pathophysiological Review

Nonalcoholic fatty liver disease (NAFLD) exponentially affects the global healthcare burden, and it is currently gaining increasing interest in relation to its potential impact on central nervous system (CNS) diseases, especially concerning cognitive deterioration and dementias. Overall, scientific research nowadays extends to different levels, exploring NAFLD's putative proinflammatory mechanism of such dysmetabolic conditions, spreading out from the liver to a multisystemic involvement. The aim of this review is to analyze the most recent scientific literature on cognitive involvement in NAFLD, as well as understand its underlying potential background processes, i.e., neuroinflammation, the role of microbiota in the brain-liver-gut axis, hyperammonemia neurotoxicity, insulin resistance, free fatty acids, and vitamins.

ITGAV Promotes the Progression of Head and Neck Squamous Cell Carcinoma

Head and neck squamous cell carcinoma (HNSCC) refers to the malignancy of squamous cells in the head and neck region. Ranked as the seventh most common cancer worldwide, HNSCC has a very low survival rate, highlighting the importance of finding therapeutic targets for the disease. Integrins are cell surface receptors that play a crucial role in mediating cellular interactions with the extracellular matrix (ECM). Within this protein family, Integrin αV (ITGAV) has received attention for its important functional role in cancer progression. In this study, we first demonstrated the upregulation of ITGAV expression in HNSCC, with higher ITGAV expression levels correlating with significantly lower overall survival, based on TCGA (the Cancer Genome Atlas) and GEO datasets. Subsequent in vitro analyses revealed an overexpression of ITGAV in highly invasive HNSCC cell lines UM1 and UMSCC-5 in comparison to low invasive HNSCC cell lines UM2 and UMSCC-6. In addition, knockdown of ITGAV significantly inhibited the migration, invasion, viability, and colony formation of HNSCC cells. In addition, chromatin immunoprecipitation (ChIP) assays indicated that SOX11 bound to the promoter of ITGAV gene, and SOX11 knockdown resulted in decreased ITGAV expression in HNSCC cells. In conclusion, our studies suggest that ITGAV promotes the progression of HNSCC cells and may be regulated by SOX11 in HNSCC cells.

Liver fibrosis and outcomes of atrial fibrillation: the FIB-4 index

BACKGROUND AND AIMS

Liver diseases play an important role in the development and progression of atrial fibrillation (AF). The Fibrosis-4 (FIB-4) index is a non-invasive score recommended for detecting liver fibrosis. Since the association between liver fibrosis and outcomes of AF patients is still not well defined, we aim to analyze prognosis impact of FIB-4 index in those patients.

METHODS

A retrospective population-based cohort study was performed with 12,870 unselected patients from a single health area in Spain with AF from 2014 to 2019. Cox regression models were used to estimate the association of FIB-4 index with mortality. The association with ischemic stroke (IS), major bleeding (MB), acute myocardial infarction (AMI), and heart failure (HF) was assessed by competing risk analysis.

RESULTS

A total of 61.1%, 22.0%, and 16.9% were classified as low, moderate and high risk of liver fibrosis according to FIB-4 index, respectively. During a mean follow-up of 4.5 ± 1.7 years, FIB-4 index was associated with mortality (adjusted HR 1.04; 95% CI 1.01-1.06; p = 0.002), MB and HF (adjusted sHR 1.03, 95% CI 1.01-1.04; p = 0.004), but not with IS or with AMI. The association between FIB-4 and MB was only found in patients treated with vitamin K antagonists, not in patients on direct oral anticoagulants.

CONCLUSIONS

The FIB-4 index, a non-invasive scoring method for evaluating liver fibrosis, is independently associated with all-cause mortality, MB and HF in patients with AF, suggesting that it may be useful as a risk assessment tool to identify adverse outcomes in patients with AF.

The Use of Noninvasive Velacur® for Discriminating between Volunteers and Patients with Chronic Liver Disease: A Feasibility Study

Background and Aims

Nonalcoholic fatty liver disease is the leading cause of chronic liver disease globally and can progress to cirrhosis, liver failure, and liver cancer. Current AASLD, AGA, and ADA guidelines recommend assessment for liver fibrosis in all patients with NAFLD. Serum biomarkers for fibrosis, while widely available, have notable limitations. Imaging-based noninvasive testing for liver fibrosis/cirrhosis is more accurate and is becoming more widespread.

Methods

We evaluated the feasibility of a novel shear wave absolute vibroelastography (S-WAVE) modality called Velacur® for assessing liver stiffness measurement (LSM) for fibrosis and attenuation coefficient estimation (ACE) in differentiating patients with chronic liver disease from normal healthy controls.

Results

Fifty-four healthy controls and 89 patients with NAFLD or cured HCV with a prior known LSM of >8 kPa were enrolled, and all subjects were evaluated with FibroScan® and Velacur®. Velacur® was able to discriminate patients with increased liver stiffness as determined by a FibroScan® score of >8 kPa from healthy controls with an AUC of 0.938 (0.88-0.96). For assessment of steatosis in NAFLD patients only, Velacur® could identify patients with steatosis from healthy controls with an AUC of 0.831 (0.777-0.880). The Velacur® scan quality assessment was superior in healthy controls, as compared to patients, and the scan quality, as assessed by the quality factor (QF) and interquartile range (IQR)/median, was affected by BMI. Velacur® was safe and well tolerated by patients, and there were no adverse events.

Conclusion

Velacur® assessment of liver stiffness measurement and liver attenuation is comparable to results obtained by FibroScan® and is an alternative technology for monitoring liver fibrosis progression in patients with chronic liver disease. This trial is registered with NCT03957070.

Prevalence of hepatic steatosis and fibrosis in apparently healthy airline pilots: A transient elastography study

Background and Aim

Airline pilots (APs) are often characterized by a sedentary lifestyle, predisposing them to adverse cardiometabolic consequences. In this cross-sectional study, we used transient elastography (TE) to investigate the prevalence of hepatic steatosis and fibrosis among apparently healthy APs.

Materials and Methods

The study cohort consisted of 137 male APs of Caucasian descent who voluntarily underwent TE. To evaluate the extent and severity of hepatic steatosis and fibrosis, we employed established cutoff values for the controlled attenuation parameter (CAP) and liver stiffness measurement (LSM).

Results

Of the APs, 34 (24.8%) were diagnosed with TE-defined steatosis. Specifically, 25 APs (18.2%) exhibited mild steatosis, 6 (4.4%) moderate steatosis, and 3 (2.2%) severe steatosis. The majority of participants (80 APs or 58.4%) showed no signs of liver fibrosis based on LSM values. However, 49 APs (35.8%) were diagnosed with mild fibrosis (F1), 7 (5.1%) with significant fibrosis (F2), and one (0.7%) with advanced fibrosis (F3). None of the pilots had F4 (cirrhosis). In multivariable linear regression analysis, BMI was the sole independent predictor of both CAP (β=0.34, p<0.001) and LSM (β=0.41, p<0.001) values in our sample of male APs.

Conclusion

TE is a straightforward and convenient non-invasive method for detecting hepatic steatosis and fibrosis in high-risk occupational groups such as APs.

A systematic review and meta-analysis of randomized controlled trials to evaluate plant-based omega-3 polyunsaturated fatty acids in nonalcoholic fatty liver disease patient biomarkers and parameters

CONTEXT

Nonalcoholic fatty liver disease (NAFLD) is prevalent in 25-30% of British and European populations, representing a potential global public health crisis. Marine omega-3 (n-3) polyunsaturated fatty acids offer well-evidenced benefits to NAFLD biomarkers; however, the effect of plant-based n-3 has not been evaluated with a systematic review and meta-analysis.

OBJECTIVE

The review aimed to systematically evaluate the effect of plant-based n-3 supplementation on NAFLD surrogate biomarkers and parameters.

DATA SOURCES

Medline (EBSCO), PubMed, CINAHL (EBSCO), Cochrane Central Register of Controlled Trials, the International Clinical Trials Registry Platform, and Google Scholar databases were searched to identify randomized controlled trials published between January 1970 and March 2022 evaluating the impact of plant-based n-3 interventions on diagnosed NAFLD. The review followed the PRISMA checklist and is PROSPERO registered (CRD42021251980).

DATA EXTRACTION

A random-effects model and generic inverse variance methods synthesized quantitative data, followed by a leave-one-out method for sensitivity analysis. We identified 986 articles; after the application of selection criteria, six studies remained with 362 patients with NAFLD.

RESULTS

The meta-analysis showed that plant-based n-3 fatty acid supplementation significantly reduced alanine aminotransferase (ALT) (mean difference: 8.04 IU/L; 95% confidence interval: 14.70, 1.38; I2 = 48.61%) and plasma/serum triglycerides (44.51 mg/dL; 95% confidence interval: -76.93, -12.08; I2 = 69.93%), alongside body-composition markers in patients with NAFLD (P < 0.05).

CONCLUSION

Plant-based n-3 fatty acid supplementation improves ALT enzyme biomarkers, triglycerides, body mass index, waist circumference, and weight loss when combined with lifestyle interventions to increase physical activity and a calorie-controlled diet. Further research is needed to identify the most effective plant-based n-3 sources in larger numbers of patients with NAFLD over longer study durations.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO registration no. CRD42021251980.

Non-alcoholic fatty liver disease increases the risk of cardiovascular disease in young adults and children: a systematic review and meta-analysis of cohort studies

Background and aims

It is uncertain if there is a link between non-alcoholic fatty liver disease (NAFLD) and cardiovascular diseases (CVD) in young adults and children. To evaluate the potential link between these two conditions, we conducted a systematic review and meta-analysis of cohort studies.

Methods

A comprehensive search was conducted in PubMed, Web of Science and Embase in order to locate all relevant cohort studies published until August 2023. Random effects meta-analyses were conducted using the generic inverse variance method, with additional subgroup and sensitivity analyses. The Newcastle-Ottawa Scale was employed to evaluate the methodological quality.

Results

Four cohort studies (eleven datasets) involving 10,668,189 participants were included in this meta-analysis. This meta-analysis demonstrated that NAFLD increases the risk of CVD in young adults and children (HR = 1.63, 95% CI: 1.46-1.82, P < 0.00001). Further subgroup analyses showed that individuals with NAFLD were at a heightened risk of coronary heart disease (CHD) (HR = 3.10, 95% CI: 2.01-4.77, P < 0.00001), myocardial infarction (MI) (HR = 1.69, 95% CI: 1.61-1.78, P < 0.00001), atrial fibrillation (AF) (HR = 2.00, 95% CI: 1.12-3.57, P = 0.02), congestive heart failure (CHF) (HR = 3.89, 95% CI: 1.20-12.61, P = 0.02), and stroke (HR = 1.47, 95% CI: 1.39-1.55, P < 0.00001). The results of subgroup analyses based on the study location, NAFLD definition, and follow-up time also showed consistency with the overall results. Sensitivity analyses showed that our results were robust. All of the included studies were judged to be of medium to high quality.

Conclusion

Current evidence reveals that NAFLD is linked to an increased risk of major CVD (including CHD, MI, AF, CHF and stroke) in young adults and children. Further research is needed to strengthen this association and provide stronger evidence for primary prevention of CVD in young adults and children with NAFLD.

Systematic Review Registration

https://www.crd.york.ac.uk/PROSPERO/, PROSPERO registration number: CRD42023457817.

Association between liver fibrosis and stroke recurrence in young patients with ischemic stroke

BACKGROUND AND AIM

Stroke incidence rates are rising among young adults. Liver fibrosis has recently been recognized as a risk factor for cardiovascular events and stroke in the general population. It remains unclear whether liver fibrosis influences the prognosis of stroke. We aimed to evaluate the association between liver fibrosis and stroke recurrence in young stroke patients.

METHODS AND RESULTS

Young adults with first-ever ischemic stroke were enrolled from a prospective stroke registry and were followed up for stroke recurrence. Liver fibrosis was evaluated by Fibrosis-4 (FIB-4) score and was stratified into three categories. Cox regression analysis was performed to assess the relationship between liver fibrosis and stroke recurrence. Over a median follow-up of 3.1 (1.7-4.6) years, 72 (11.6%) recurrent strokes occurred among 621 patients. According to the FIB-4 score, 73 (11.7%) patients had indeterminate fibrosis, while 11 (1.8%) had advanced fibrosis. Univariate Cox analysis revealed that patients with a high FIB-4 score were more likely to experience stroke recurrence than those with a low FIB-4 score (hazard ratio 3.748, 95% confidence interval 1.359-10.332, P = 0.011). After adjusting for potential confounders in the multivariate analysis, FIB-4 score remained an independent risk factor.

CONCLUSIONS

Young stroke patients with advanced liver fibrosis were at a greater risk of stroke recurrence. Evaluating liver fibrosis may provide valuable information for stroke risk stratification, and the FIB-4 score could serve as a useful tool.

Analysis of the mediating role of BMI in associations of different folate forms with hepatic steatosis and liver fibrosis in adolescents in the USA: results from the NHANES 2017-2018

Background

Most studies have explored the relationship between serum total folate and nonalcoholic fatty liver disease (NAFLD) in adults, but there has been no study on the relationship between different folate forms and hepatic steatosis or liver stiffness in adolescents.

Objective

To investigate the association of different folate forms with hepatic steatosis or liver stiffness in adolescents, and further explore the intermediary role of BMI in this relationship.

Methods

The cross-sectional study included 549 participants from the 2017-2018 National Health and Nutrition Inspection Survey (NHANES) survey cycle who had complete data. Four folate data (red blood cell folate, serum total folate, 5-methyl-tetrahydrofolate and folic acid) were included in our study. Controlled attenuation parameters (CAP) and liver stiffness came from the results of liver ultrasound transient elastography. We used linear regression to analyze the relationship between different forms of folate and CAP or liver stiffness, and logistic regression to analyze the relationship between different forms of folate and NAFLD or significant fibrosis. We also used restricted cubic splines to analyze the nonlinear relationship between different forms of folate and NAFLD or significant fibrosis. Finally, we used regression-based intermediary analysis to distinguish the direct and BMI-mediated effects of folate on CAP or liver stiffness. All the analyses adjusted the relevant covariates.

Results

The means of CAP and liver hardness in this study were 223.02dB/m and 5.03kPa, respectively. We found that in model 2, there was a negative correlation between serum total folate (β: -18.53; 95%CI: -29.32 to -7.73) or 5-methyltetrahydrofolate (β: -14.13; 95%CI: -28.98 to -7.86) and CAP. However, when the BMI was further adjusted in model 3, this negative correlation no longer existed (serum total folate: β: -8.36; 95%CI: -17.69 to 0.97; 5-methyltetrahydrofolate: β: -8.05; 95%CI: -17.19 to 1.09). Similarly, we found a negative correlation between serum total folate or 5-Methyl-tetrahydrofolate and liver stiffness in model 2. There was no significant correlation between red blood cell folate or folic acid and CAP or liver stiffness in either model 2 or model 3. The nonlinear relationship between different folate forms and NAFLD or significant fibrosis was not significant. It is estimated that 76% of the total association between serum total folate and CAP is mediated by BMI. The mediating proportion of BMI in the total correlation between serum total folate and liver stiffness was 50%. Similarly, we found that BMI significantly mediated the relationship between 5-Methyl-tetrahydrofolate and CAP or liver stiffness, with a mediating ratio of 77% and 49%, respectively.

Conclusion

Our results show that serum total folate or 5-Methyl-tetrahydrofolate are negatively correlated with hepatic steatosis or liver stiffness in adolescents, and BMI plays major mediating role in this relationship. Our findings emphasize the importance of monitoring the concentration of serum folate, not just the serum total folate concentration.

No effect of multi-strain probiotic supplementation on metabolic and inflammatory markers and newborn body composition in pregnant women with obesity: Results from a randomized, double-blind placebo-controlled study

BACKGROUND AND AIMS

Modulation of the gut microbiome composition with probiotics may have beneficial metabolic effects in pregnant women with obesity. The aim was to investigate the effect of probiotic supplementation during pregnancy on metabolic and inflammatory markers and the body composition of the offspring.

METHODS AND RESULTS

A randomized double-blind trial in 50 pregnant women (pre-pregnancy BMI ≥30 and < 35 kg/m2) comparing multi-strain probiotics (Vivomixx®; 450 billion CFU/d) versus placebo from 14 to 20 weeks of gestation until delivery was carried out. Participants were followed with two predelivery visits at gestational week 27-30 and 36-37 and with one postdelivery visit. All visits included fasting blood samples (C-reactive protein (CRP), alanine aminotransferase (ALT), aspartate aminotransferase (AST), insulin, C-peptide, glucose, glucagon, and glucagon-like peptide-1 (GLP-1)). At delivery, umbilical cord blood samples were collected (GLP-1 and glucagon). At the postdelivery visit, a dual-energy X-ray absorptiometry (DXA) scan of the newborn was performed. Forty-nine of 50 participants completed the study until delivery, and 36 mother-offspring dyads underwent postdelivery examinations including a DXA scan. There were no significant differences in changes in measured biomarkers between the probiotic versus the placebo group. No differences were found in newborn body composition or GLP-1 and glucagon. GLP-1 measured in umbilical blood samples was positively correlated to fat percent in offspring from the probiotic group.

CONCLUSION

In this study of pregnant women with obesity and their newborns, there was no effect of probiotic supplementation in mothers or babies on metabolic or inflammatory biomarkers or on body composition of offspring. This study was registered at clinicaltrials.gov as NCT02508844.

Updates in Metabolic Dysfunction-Associated Fatty Liver Disease (MAFLD) in Children

The obesity epidemic is one of the major health concerns of the 21st century. Nonalcoholic fatty liver disease (NAFLD) is linked with the increased adiposity associated with obesity. NAFLD has become the most frequent cause of chronic liver disease in adults and children worldwide. Metabolic dysfunction-associated fatty liver disease (MAFLD) also known in children as pediatric fatty liver disease (PeFLD) type 2 has begun to supersede NAFLD as the preferred nomenclature in the pediatric population. Evidence suggests the etiology of MAFLD is multifactorial, related to the complex interplay of hormonal, nutritional, genetic, and environmental factors. Current limitations in accurate diagnostic biomarkers have rendered it a diagnosis of exclusion and it is important to exclude alternative or coexisting causes of PeFLD. Lifestyle changes and modifications remains the primary treatment modality in MAFLD in children. Weight loss of 7%-10% is described as reversing MAFLD in most patients. The Mediterranean diet also shows promise in reversing MAFLD. Pharmacological intervention is debatable in children, and though pediatric trials have not shown promise, other agents undergoing adult clinical trials show promise. This review outlines the latest evidence in pediatric MAFLD and its management.

Vibration Controlled Transient Elastography in Screening for Silent Liver Diseases

OBJECTIVES

The objective of this study was to screen for significant hepatic fibrosis or steatosis in asymptomatic, apparently healthy subjects by using Vibration-controlled transient elastography and controlled attenuation parameter (CAP).

METHODS

Prospectively, 433 asymptomatic apparently healthy adults were included. Fibroscan/CAP examination was performed for all of them. Subjects with liver stiffness measurement > 6 kPa or CAP >248 dB/m were further evaluated to assess underlying chronic liver disease.

RESULTS

According to fibroscan/CAP examination, subjects were classified into four subgroups: normal (119) with CAP score of 215.85 ± 24.81 dB/m and fibrosis score of 4.47 ± 0.81 kPa, subjects with steatosis only 133 with CAP score of 309.41 ± 42.6 dB/m and fibrosis score of 4.74 ± 0.82 kPa, subjects with both steatosis and fibrosis 95 with CAP score of 318.20 ± 39.89 dB/m and fibrosis score of 7.92 ± 2.58 kPaand subjects with fibrosis only 86 with CAP score of 213.48 ± 22.62 dB/m and fibrosis score of 6.96 ± 1.11 kPa. S0 was present in 205 (47.3%), S1 in 48 (10.2%), S2 in 16 (3.7%) and S3 in 168 (38.8%) of studied subjects, whereas F0-1 was present in 371 (85.7%), F2 in 44 (10.16%), F3 in 16 (3.7%) subjects and F4 in only one (0.23%) subject. Subjects with both steatosis and fibrosis showed significantly higher transaminases, triglycerides and total cholesterol levels than other subgroups.

CONCLUSIONS

Most asymptomatic, apparently healthy subjects (72%) have significant steatosis and fibrosis. Liver stiffness measurement and CAP might represent promising first-line noninvasive procedures to screen for silent liver diseases in the general population.

Prevalence and Determinants of Undiagnosed Liver Steatosis and Fibrosis in a Nationally Representative Sample of US Adults

Background Chronic liver diseases account for approximately 1.9 million deaths globally every year and negatively affect health-related quality of life. Early detection of liver disease may enable timely treatment, potentially improving patient outcomes. This study aimed to determine the prevalence and determinants of liver steatosis and fibrosis in US adults with no previously diagnosed liver condition. Methods We conducted an observational, nationally representative, cross-sectional study using data from the National Health and Nutrition Examination Survey (NHANES) conducted from January 2017 to March 2020. Study participants were 7,391 adults aged 21 and older with no history of diagnosed liver disorders who underwent vibration-controlled transient elastography (VCTE) to determine liver steatosis and fibrosis. Controlled attenuation parameter (CAP) values between 248 and 267 dB/m were classified as mild steatosis, and those over 267 dB/m as advanced steatosis. Liver stiffness measurement (LSM) values between 7.65 and 13 kPa were classified as moderate/severe fibrosis, and those over 13 kPa as cirrhosis. Covariates included age, sex, race, body mass index (BMI), diabetes mellitus, kidney disease, smoking history, alcohol intake, alanine aminotransferase (ALT), aspartate aminotransferase (AST), physical activity, sedentary time, and sleep time. The associations of subject characteristics with liver CAP and LSM were evaluated using survey multivariable linear regression. Shapley Additive Explanations values determined the relative importance of each attribute in the model. The discriminative performance of classification models was assessed using the area under the receiver operating characteristic (AUROC) curve. Results The population prevalence of liver steatosis was 57.2% (10.2% mild; 47.0% advanced). The relative importance of covariates in predicting liver CAP was 63.1% for BMI, 10.7% for ALT, and less than 10% for the other covariates. The prevalence of significant fibrosis was 11.4% (8.3% moderate/severe fibrosis; 3.1% cirrhosis). The relative importance of covariates in predicting LSM was 67.3% for BMI and less than 10% for the other covariates. BMI alone demonstrated acceptable discriminative performance in classifying varying severities of steatosis and fibrosis (AUROC range 72%-78%) at cutoffs between 28 and 33 kg/m2. Conclusions Undiagnosed chronic liver disease based on VCTE findings is highly prevalent among US adults, particularly in obese individuals. Efforts to increase awareness about liver disease and to reconsider existing BMI thresholds for liver disease screening may be warranted.

Prevalence of Liver Steatosis and Fibrosis in the General Population and Various High-Risk Populations: A Nationwide Study With 5.7 Million Adults in China

BACKGROUND & AIMS

This study aimed to estimate the prevalence of liver steatosis and fibrosis in the general population and populations with potential risk factors in China, so as to inform policies for the screening and management of fatty liver disease and liver fibrosis in general and high-risk populations.

METHODS

This cross-sectional, population-based, nationwide study was based on the database of the largest health check-up chain in China. Adults from 30 provinces who underwent a check-up between 2017 and 2022 were included. Steatosis and fibrosis were assessed and graded by transient elastography. Overall and stratified prevalence was estimated among the general population and various subpopulations with demographic, cardiovascular, and chronic liver disease risk factors. A mixed effect regression model was used to examine predictors independently associated with steatosis and fibrosis.

RESULTS

In 5,757,335 participants, the prevalence of steatosis, severe steatosis, advanced fibrosis, and cirrhosis was 44.39%, 10.57%, 2.85%, and 0.87%, respectively. Participants who were male, with obesity, diabetes, hypertension, dyslipidemia, metabolic syndrome, or elevated alanine aminotransferase or aspartate aminotransferase had a significantly higher prevalence of all grades of steatosis and fibrosis, and those with fatty liver, decreased albumin or platelet count, and hepatitis B virus infection also had a significantly higher prevalence of fibrosis than their healthy counterparts. Most cardiovascular and chronic liver disease risk factors were independent predictors for steatosis and fibrosis, except for dyslipidemia for fibrosis.

CONCLUSIONS

A substantial burden of liver steatosis and fibrosis was found in China. Our study provides evidence for shaping future pathways for screening and risk stratification of liver steatosis and fibrosis in the general population. The findings of this study highlight that fatty liver and liver fibrosis should be included in disease management programs as targets for screening and regular monitoring in high-risk populations, especially in those with diabetes.

Effect of functional resistance training on the structure and function of the heart and liver in patients with non-alcoholic fatty liver

The current study is of the quasi-experimental type, with a pre-and post-test design, and subjects were randomly assigned to one of two groups: control (n = 8) and experimental (test) (n = 8). Based on the patient's self-report and using daily diet control tables, the patient's diet planning percentage of energy supply was managed and controlled for 3 days. The protocol for functional resistance training for these circular exercises, including the squat, lunge, bear crawl, rock press, jumping jack, and back fly lunge, was performed three times per week without specialized apparatus. Ejection fraction (EF) and fractional shortening (FS) were measured before and after functional resistance training, using echocardiography. Liver Stiffness and steatosis were measured using FibroScan, and the liver function was determined using biochemical assays. The average age of patients in the control group and the test group were 46.02 ± 5.4 and 48.6 ± 2.51, respectively. Pre-test and post-test of the body mass index were 32.06 ± 5.06 and 30.02 ± 3.97, and for the body fat percentage were 33.65 ± 6.09 and 25.41 ± 4.99. In non-alcoholic fatty liver patients, due to functional resistance training, EF (p-value = 0.003) and FS (p-value = 0.03) significantly increased, and C-reactive protein (Hs-CRP) (p-value = 0.001), steatosis (p-value = 0.04), and stiffness (p-value = 0.01) decreased. According to the results and without considering clinical trials, functional resistance training affects the structure and function of the heart and Liver in NAFLD patients.

Fibroscan-Aspartate Aminotransferase Score Predicts Liver-Related Outcomes, but Not Extrahepatic Events, in a Multicenter Cohort of People With Human Immunodeficiency Virus

BACKGROUND

Nonalcoholic fatty liver disease (NAFLD) is frequent in people with human immunodeficiency virus (PWH). The Fibroscan-aspartate aminotransferase (FAST) score was developed to identify patients with nonalcoholic steatohepatitis (NASH) and significant fibrosis. We investigated prevalence of NASH with fibrosis and the value of FAST score in predicting clinical outcomes in PWH.

METHODS

Transient elastography (Fibroscan) was performed in PWH without viral hepatitis coinfection from 4 prospective cohorts. We used FAST >0.35 to diagnose NASH with fibrosis. Incidence and predictors of liver-related outcomes (hepatic decompensation, hepatocellular carcinoma) and extrahepatic events (cancer, cardiovascular disease) were evaluated through survival analysis.

RESULTS

Of the 1472 PWH included, 8% had FAST >0.35. Higher body mass index (adjusted odds ratio [aOR], 1.21 [95% confidence interval {CI}, 1.14-1.29]), hypertension (aOR, 2.24 [95% CI, 1.16-4.34]), longer time since HIV diagnosis (aOR, 1.82 [95% CI, 1.20-2.76]), and detectable HIV RNA (aOR, 2.22 [95% CI, 1.02-4.85]) were associated with FAST >0.35. A total of 882 patients were followed for a median of 3.8 years (interquartile range, 2.5-4.2 years). Overall, 2.9% and 11.1% developed liver-related and extrahepatic outcomes, respectively. Incidence of liver-related outcomes was higher in patients with FAST >0.35 versus FAST ≤0.35 (45.1 [95% CI, 26.2-77.7] vs 5.0 [95% CI, 2.9-8.6] per 1000 person-years). FAST >0.35 remained an independent predictor of liver-related outcomes (adjusted hazard ratio, 4.97 [95% CI, 1.97-12.51]). Conversely, FAST did not predict extrahepatic events.

CONCLUSIONS

A significant proportion of PWH may have NASH with significant liver fibrosis. FAST score predicts liver-related outcomes and can help management of this high-risk population.

Waist to height ratio in nonalcoholic fatty liver disease - Systematic review and meta-analysis

BACKGROUND AND AIMS

Current nonalcoholic fatty liver disease (NAFLD) guidelines do not provide any recommendations regarding the waist-to-height ratio (WHtR), a simple obesity metric calculated by dividing waist circumference by height. Therefore, we performed a systematic review and meta-analysis aiming to evaluate WHtR in NAFLD.

METHODS

We performed a systematic electronic search on PubMed, Embase, and Scopus, identifying observational studies assessing WHtR in NAFLD. QUADAS-2 tool was used to evaluate the quality of included studies. The two main statistical outcomes were the area under the curve (AUC) and the mean difference (MD).

RESULTS

We included a total of 27 studies in our quantitative and qualitative synthesis, with a total population of 93,536 individuals. WHtR was significantly higher in NAFLD patients compared to controls with an MD of 0.073 (95% CI 0.058 - 0.088). This was also confirmed after conducting a subgroup analysis according to the hepatic steatosis diagnosis method, for ultrasound (MD 0.066 [96% CI 0.051 - 0.081]) and transient elastography (MD 0.074 [96% CI 0.053 - 0.094]). Moreover, NAFLD male patients presented significantly lower WHtR compared to female patients (MD -0.022 [95% CI -0.041 - -0.004]). The AUC of WHtR for predicting NAFLD was 0.815 (95% CI 0.780 - 0.849).

CONCLUSIONS

WHtR is considerably higher in NAFLD patients compared to controls. Female NAFLD patients present higher WHtR compared to NAFLD male patients. In comparison to other presently suggested scores and markers, the WHtR's accuracy in predicting NAFLD is considered acceptable.