Global prevalence, incidence, and outcomes of non-obese or lean non-alcoholic fatty liver disease: a systematic review and meta-analysis

Decreased intestinal abundance of Akkermansia muciniphila is associated with metabolic disorders among people living with HIV

BACKGROUND

Previous studies have shown changes in gut microbiota after human immunodeficiency virus (HIV) infection, but there is limited research linking the gut microbiota of people living with HIV (PLWHIV) to metabolic diseases.

METHODS

A total of 103 PLWHIV were followed for 48 weeks of anti-retroviral therapy (ART), with demographic and clinical data collected. Gut microbiome analysis was conducted using metagenomic sequencing of fecal samples from 12 individuals. Nonalcoholic fatty liver disease (NAFLD) was diagnosed based on controlled attenuation parameter (CAP) values of 238 dB/m from liver fibro-scans. Participants were divided based on the presence of metabolic disorders, including NAFLD, overweight, and hyperlipidemia. Akkermansia abundance in stool samples was measured using RT-qPCR, and Pearson correlation and logistic regression were applied for analysis.

RESULTS

Metagenomic sequencing revealed a significant decline in gut Akkermansia abundance in PLWHIV with NAFLD. STAMP analysis of public datasets confirmed this decline after HIV infection, while KEGG pathway analysis identified enrichment of metabolism-related genes. A prospective cohort study with 103 PLWHIV followed for 48 weeks validated these findings. Akkermansia abundance was significantly lower in participants with NAFLD, overweight, and hyperlipidemia at baseline, and it emerged as an independent predictor of NAFLD and overweight. Negative correlations were observed between Akkermansia abundance and both CAP values and body mass index (BMI) at baseline and at week 48. At the 48-week follow-up, Akkermansia remained a predictive marker for NAFLD.

CONCLUSIONS

Akkermansia abundance was reduced in PLWHIV with metabolic disorders and served as a predictive biomarker for NAFLD progression over 48 weeks of ART.

MASLD and liver fibrosis in patients with psoriasis receiving IL-17 or IL-23 inhibitors: a systematic review

Background

Metabolic dysfunction-associated steatotic liver disease (MASLD) is more prevalent in patients with psoriasis compared to healthy individuals. Interleukin (IL)-17 and IL-23 inhibitors may have beneficial effects on MASLD by reducing systemic inflammation and improving metabolic parameters.

Objectives

To assess the effect of IL-17 and IL-23 inhibitors on MASLD and liver fibrosis in patients with psoriasis.

Design

We performed a systematic review that followed the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines.

Data sources and methods

A literature search was conducted across four databases: MEDLINE, Embase, Web of Science, and Cochrane Central Register of Controlled Trials, from database inception to September 27, 2024. Observational studies and clinical trials that reported the presence of MASLD and/or liver fibrosis in patients with psoriasis/psoriatic arthritis treated with IL-17 or IL-23 inhibitors were included. The Newcastle Ottawa Scale (NOS) was used for risk of bias assessment in cohort studies, the Revised Cochrane Risk of Bias Tool (RoB2.0) in randomized controlled trials, and the Risk of Bias in non-randomized studies-of Interventions (ROBINS-I v.2) tool in non-randomized trials.

Results

Fourteen studies were included: four clinical trials, five retrospective cohort studies, three prospective cohort studies, and two post hoc studies. Two cohort studies and one clinical trial showed a low risk of bias. Both post hoc studies had a high risk of bias. Eleven studies assessed the effect of IL-17 inhibitors on MASLD or liver fibrosis; six reported a neutral effect, while five demonstrated improvements in liver tests. Three studies evaluated IL-23 inhibitors; one showed neutral effects, another reported improvement in fibrosis-4 index (FIB-4) scores at 6 months, and the third was still in the recruitment phase.

Conclusion

IL-17 and IL-23 inhibitors may provide beneficial effects on MASLD and liver fibrosis in patients with psoriasis. Larger, well-designed studies are needed to confirm these findings.

Trial registration

PROSPERO CRD42024599350.

Modeling hepatic steatosis with human adult stem cell-derived liver organoids

Metabolic dysfunction-associated steatotic liver disease (MASLD) remains the most common chronic liver disease worldwide, and appropriate in vitro models are of great significance for investigating pathogenesis and drug screening of MASLD. In this study, human expandable cholangiocyte organoids were derived from adult stem cells of normal liver tissue. After differentiation, liver organoids (LOs) exhibited the functional characteristics and genomic features of mature hepatocytes. To induce steatosis, LOs were incubated with a gradient concentration oleic acid, and it was found that the model could recapitulate the development of lipid accumulation and inflammation. In addition, the drug sensitivity of the hepatic steatosis model was further verified through anti-steatosis drug testing. In summary, LOs have great potential for disease modeling, and the results indicate that the hepatic steatosis model may serve as a useful tool for exploring the molecular mechanisms and drug screening of MASLD.

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.

Maternal Abnormal Liver Function in Early Pregnancy and Spontaneous Pregnancy Loss: A Retrospective Cohort Study

BACKGROUND

Spontaneous pregnancy loss (SPL) precedes an increased risk of reduced fertility, while its etiology mechanism remains largely unknown. Liver dysfunction presenting in early pregnancy may represent a pre-existing undiagnosed liver condition affecting fetal development. Here, we investigated whether maternal abnormal liver function in early pregnancy contributed to the incidence of SPL.

METHODS

Data on pregnant women were leveraged from the Maternal Health Care Information System in Shanghai City from 2017 to 2021. Liver dysfunction status was defined as having any elevated liver function biomarker levels (LFBs) at the first antenatal visit. SPL cases were defined as fetal death occurring before 28 weeks gestation. Generalized linear models were used to estimate crude and adjusted risk ratios (RRs and aRRs, respectively) and 95% confidence intervals (CIs).

RESULTS

Among 10,175 leveraged pregnant women, 918 (9.0%) SPL cases were recorded. Maternal liver dysfunction in early pregnancy was associated with a 49% increased risk of SPL (RR 1.49; 95% CI, 1.22-1.84). This positive association persisted after adjustment for covariates (aRR 1.55; 95% CI, 1.26-1.92). Higher γ-glutamyl transferase (GGT) and alkaline phosphatase (ALP) levels were also linked with increased risk of SPL in a linear fashion (aRRs per 1 standard deviation increase: 1.13; 95% CI, 1.08-1.17 and 1.13; 95% CI, 1.07-1.20, respectively). Similar magnitudes of associations were observed between normal weight and overweight pregnant women in subgroup analysis.

CONCLUSION

We provide new evidence that maternal abnormal liver function in early pregnancy, as well as GGT and ALP, predisposes to an increased risk of SPL.

Nonlinear association between body roundness index and metabolic dysfunction associated steatotic liver disease in nondiabetic Japanese adults

The global rise in obesity and diabetes has been paralleled by a rising incidence of metabolic dysfunction-associated steatotic liver disease (MASLD). Although previous studies have explored the association between body roundness index (BRI) and MASLD, the specific relationship in non-diabetic Japanese adults requires further investigation. This study analyzed data from 15,299 participants enrolled in the NAGALA cohort (2004-2015) to explore the association between BRI and MASLD through multivariable logistic regression, stratified analysis, and restricted cubic spline modeling. The prevalence of MASLD was 14.46%, with 13.73% occurring in non-obese individuals (BMI < 30). After adjusting for all confounding factors, BRI demonstrated a significant association with MASLD, yielding an adjusted odds ratio of 1.72 (95% CI 1.48-1.99). The restricted cubic spline model revealed a nonlinear relationship, with an inflection point at 3.06. Stratified analyses revealed stronger associations in individuals with lower BMI (≤ 24 kg/m2).

Serum 25(OH)D Levels and Risk of Nonalcoholic Fatty Liver Disease in Nonobese and Lean Individuals

PURPOSE

The impact of vitamin D deficiency on nonalcoholic fatty liver disease (NAFLD) risk in individuals without obesity or insulin resistance has not been thoroughly evaluated. We aimed to identify whether low serum levels of 25(OH)D independently contribute to NAFLD risk in nonobese or lean individuals.

MATERIALS AND METHODS

This study analyzed 241208 asymptomatic health check-up examinees who had abdominal ultrasonography. NAFLD risk was evaluated based on obesity status and serum 25(OH)D levels.

RESULTS

The overall NAFLD prevalence was 25.5%. Among the 178630 nonobese and 126909 lean participants, the prevalence rates were 13.4% and 6.7%, respectively. The multivariable adjusted odds ratios (ORs) [95% confidence intervals (CI)] for the prevalence of NAFLD, comparing serum 25(OH)D levels of 10-19 and ≥20 ng/mL with <10 ng/mL, were 0.96 (0.93-0.99) and 0.80 (0.77-0.83), respectively. Among nonobese participants, the corresponding adjusted ORs (95% CI) were 0.94 (0.90-0.99) and 0.77 (0.73-0.81), respectively. Similar results were observed among lean participants, with those having a 25(OH)D level of ≥20 ng/mL demonstrating a significantly lower odds of NAFLD (adjusted OR, 0.76; 95% CI, 0.70-0.83). Moreover, these results were consistent even among nonobese and lean individuals who showed no signs of insulin resistance.

CONCLUSION

Insufficient 25(OH)D levels independently increased the risk of NAFLD, suggesting its role in the NAFLD pathogenesis, regardless of obesity or insulin resistance status. Considering the established relationship between vitamin D deficiency and nonobese/lean NAFLD, maintaining adequate 25(OH)D levels may aid in preventing the development of NAFLD, even among nonobese or lean individuals.

New steatotic liver disease criteria diagnostic performance in an agricultural population in Chile

INTRODUCTION AND OBJECTIVES

This study aims to assess the performance of Steatotic Liver Disease (SLD) criteria in identifying liver steatosis compared to the NAFLD and MAFLD definitions in an agricultural population in Chile.

PATIENTS AND METHODS

We performed a cross-sectional analysis on the MAUCO cohort, composed of 9,013 individuals aged 38 to 74. Health conditions, socio-demographics, anthropometrics, hepatic ultrasonography, blood pressure, and biological samples were obtained. Participants were classified as NAFLD, MAFLD, or any of the five SLD categories: Metabolic dysfunction-associated steatosis liver disease (MASLD), Metabolic and Alcohol-Associated Liver Disease (MetALD), Alcohol-Associated Liver Disease (ALD), Specific aetiologies, and Cryptogenic. The Framingham cardiovascular risk score and BARD liver fibrosis score were used to assess clinical relevance.

RESULTS

Liver steatosis was present in 4,082 participants (45%); SLD criteria captured an additional 176 individuals not classified under NAFLD and 103 not included under MAFLD definition. The main SLD subgroups were MASLD (95%), MetALD (1.9%) and ALD (1.3%). Individuals classified in the MetALD and ALD subgroups exhibited more severe liver steatosis and a higher cardiovascular risk. Notably, participants categorized under specific etiologies and cryptogenic subgroups were younger and had a higher risk for liver fibrosis.

CONCLUSIONS

The study reveals that SLD offers a more inclusive classification to identify high-risk individuals in the Chilean population, capturing cases that could be missed by NAFLD or MAFLD definitions by using the same resources.

Association between metabolic dysfunction-associated steatotic liver disease, metabolic dysfunction subtypes and risk of colorectal cancer: A prospective cohort study

BACKGROUND

To evaluate the association between a new definition of metabolic dysfunction-associated steatotic liver disease (MASLD), different metabolic dysfunction subtypes and risk of colorectal cancer(CRC).

METHODS

A total of 99,979 participants who met the criteria were included from the Kailuan Study. Participants were categorized into three groups based on fatty liver disease and metabolic status: Non-SLD with metabolic normal group(NMN), Non-SLD with metabolic abnormal group(NMA) and MASLD group. Incident of CRC were confirmed by review of medical records. The Cox proportional hazard regression models were used to assess the association MASLD with the risk of CRC by calculating the hazard ratios (HR) and 95 % confidence interval (CI).

RESULTS

During a mean 13.54 ± 2.78 years of follow-up, we documented 669 CRC. Multivariate Cox regression analysis showed that compared with the NMN group, MASLD participants demonstrated an increased risk of developing CRC (HR 1.54 95 %CI 1.12-2.13). The greater the number of metabolic dysfunctions, the greater the risks of CRC (P < 0.05). The HR for CRC was 1.93 (95 % CI 1.27-2.92) in MASLD participants with 4-5 items of metabolic dysfunctions. In the subtype analysis, the HR for CRC was 1.97 (95 % CI 1.13-3.45) in lean-MASLD participants and 1.55(95 %CI 1.12-2.15) in diabetes-MASLD participants.

CONCLUSION

MASLD was associated with increased risk of CRC. Moreover, MASLD individuals who complicated by lean or diabetes have an increased risk of developing CRC.

Association of daily sleep duration with risk of metabolic dysfunction-associated steatotic liver disease and adverse liver outcomes

BACKGROUND

Metabolic dysfunction-associated steatotic liver disease (MASLD) is the most common liver disease worldwide, leading to substantial disease burden globally. Whether sleep duration is associated with the risk of MASLD, cirrhosis, hepatocellular carcinoma (HCC), and liver-related mortality remains underexplored.

METHODS

A total of 489,261 middle-aged and older adults from the UK Biobank without prior liver diseases were included. The primary outcome was MASLD, with secondary outcomes, including cirrhosis, HCC, and liver-related mortality ascertained through linked hospital records and death registries. Sleep duration was self-reported at baseline survey and categorized into ≤ 5, 6, 7, 8 and ≥ 9 hours.

RESULTS

During a median (IQR) follow-up of 13.8 (1.5) years, 7,133 MASLD, 5,527 cirrhosis, 1,126 HCC, and 1,125 liver-related mortality cases were identified. After adjusting for potential confounders, the HRs [95% CIs] of MASLD were 1.44 [1.32;1.57], 1.17 [1.09;1.24], 1.00 (reference), 1.05 [0.99;1.11] and 1.35 [1.24;1.46] for ≤ 5, 6, 7, 8 and ≥ 9 hours of sleep duration, respectively. Similar trends were also observed for cirrhosis, HCC, and liver-related mortality. In addition, the U-shaped association between sleep duration and MASLD was more pronounced among participants without abnormal body mass index (overweight and obese), hypertension or insomnia (P for interaction <0.05).

CONCLUSIONS

Both short and long sleep duration are associated with an increased risk of MASLD, cirrhosis, HCC, and liver-related mortality. Maintaining a moderate sleep duration of 7 to 8 hours per day could be crucial to prevent against this escalating public health concern.

Pathophysiological underpinnings of metabolic dysfunction-associated steatotic liver disease

Metabolic dysfunction-associated steatotic liver disease (MASLD) is emerging as the leading cause of chronic liver disease worldwide, reflecting the global epidemics of obesity, metabolic syndrome, and type 2 diabetes. Beyond its strong association with excess adiposity, MASLD encompasses a heterogeneous population that includes individuals with normal body weight ("lean MASLD") highlighting the complexity of its pathogenesis. This disease results from a complex interplay between genetic susceptibility, epigenetic modifications, and environmental factors, which converge to disrupt metabolic homeostasis. Adipose tissue dysfunction and insulin resistance trigger an overflow of lipids to the liver, leading to mitochondrial dysfunction, oxidative stress, and hepatocellular injury. These processes promote hepatic inflammation and fibrogenesis, driven by cross talk among hepatocytes, immune cells, and hepatic stellate cells, with key contributions from gut-liver axis perturbations. Recent advances have unraveled pivotal molecular pathways, such as transforming growth factor-β signaling, Notch-induced osteopontin, and sphingosine kinase 1-mediated responses, that orchestrate fibrogenic activation. Understanding these interconnected mechanisms is crucial for developing targeted therapies. This review integrates current knowledge on the pathophysiology of MASLD, emphasizing emerging concepts such as lean metabolic dysfunction-associated steatohepatitis (MASH), epigenetic alterations, hepatic extracellular vesicles, and the relevance of extrahepatic signals. It also discusses novel therapeutic strategies under investigation, aiming to provide a comprehensive and structured overview of the evolving MASLD landscape for both basic scientists and clinicians.

Peripheral blood lymphocyte subsets of Chinese adults with liver steatosis

To evaluate the effect of liver steatosis on systematic cellular immunity through the changes of peripheral blood lymphocyte subsets, we retrospectively reviewed subjects receiving lymphocyte subtyping during annual medical check-ups. Liver steatosis was detected by abdominal computerized tomography or ultrasound. Immunophenotyping of peripheral blood lymphocytes was analyzed by flow cytometry. Cell counts of lymphocyte subsets were calculated using a dual-platform method. The relationship between lymphocyte subsets and liver steatosis was analyzed using multivariate linear models. Using the database from January 2017 to December 2022, we included 5042 subjects, including 1441 participants with liver steatosis. After adjusting for age, gender, and metabolic dysfunctions, the presence of liver steatosis increased the absolute values of CD19+, CD16+56+, CD3+, CD4+, CD4+CD28+, CD4+CD45RA-, CD4+CD45RA+, CD4+CD45RA+62L+, CD8+, CD8+CD28+, CD8+DR+, and CD8+CD38+ cell. In males, T lymphocyte counts of all T subsets increased in liver steatosis. In females, the significant differences in subsets included increased CD4+CD28+, CD4+CD45RA-, CD8+, and CD8+DR+ cells. Significant decreases were revealed in functional and naïve T cells with aging. Metabolic factors such as hypertension and abnormal glucose metabolism increase CD4+, CD4+CD28+, and CD4+CD45RA subsets. Hyperlipidaemia appears not to affect T cell counts, whereas obesity has some effect on both CD4+ (β = 0.041, 95% CI 0.032-0.051) and CD8+ cells (β = 0.036, 95% CI 0.025-0.048). Liver steatosis potentially affects peripheral blood lymphocyte subsets, while age, gender, and metabolic dysfunctions are also associated with these immune alterations.

A Noninvasive Method of Diagnosing Metabolic Dysfunction-Associated Steatohepatitis Using Cytokeratin-18 Fragment and FIB-3 Index

Background/Objectives: We aim to determine if cytokeratin-18 fragment (CK-18F) could be used to diagnose metabolic dysfunction-associated steatohepatitis (MASH). Methods: A total of 289 patients with metabolic dysfunction-associated steatotic liver disease (MASLD) were enrolled in the analysis. To evaluate the association between CK-18F levels and the histological features of MASH, weighted receiver operating characteristic (ROC) curve analyses were performed. The diagnostic utility of CK-18F was compared with that of the Mac-2 binding protein glycan isomer (M2BPGi). Additionally, we assessed the predictive performance of combining CK-18F with either the FIB-4 index or the FIB-3 index for diagnosing MASH and investigated predictors of future progression to cirrhosis. Results: CK-18F was more useful for MASH diagnosis than M2BPGi and the FIB-4 index in the multivariate analysis, with a sensitivity of 47% and specificity of 80% at a CK-18F cutoff value of 750 U/L. Because CK-18F decreases with advanced liver fibrosis, the combination of the FIB-4 or FIB-3 index with CK-18F was examined to identify cases with cirrhosis. The combination of the CK-18F level and the FIB-3 index better predicted MASH than the combination of the CK-18F level and the FIB-4 index. The FIB-3 index was the most useful predictor of cirrhosis on imaging five years after diagnosis with F2 or less disease. Conclusions: CK-18F is useful for MASH diagnosis, and the diagnostic algorithm combining CK-18F with the FIB-3 index may be more useful than the previously reported MASH diagnostic algorithm that combined it with the FIB-4 index.

Cardiovascular Health Trajectories and Prevalent Metabolic Dysfunction-Associated Steatotic Liver Disease in Midlife: The CARDIA Study

BACKGROUND

Metabolic-dysfunction associated steatotic liver disease (MASLD) is associated with prevalent cardiovascular disease. More favorable cardiovascular health (CVH) profiles are associated with a lower prevalence of MASLD in cross-sectional studies. The relationship between long-term CVH patterns and MASLD prevalence in midlife remains unknown.

METHODS AND RESULTS

Participants (aged 18-30 years at baseline) of the CARDIA (Coronary Artery Risk Development in Young Adults) study who had individual CVH components measured at 7 examinations over 20 years and liver fat assessed by noncontrast computed tomography at year 25 follow-up were included. CVH score was defined using published American Heart Association definitions. Group-based trajectory modeling was used to identify CVH trajectories. MASLD was defined as liver attenuation of ≤51 Hounsfield units with at least 1 metabolic risk factor after excluding other causes of liver fat. Logistic regression was used to examine associations of CVH trajectory groups and MASLD prevalence. At baseline, 39% of 2529 participants had high and 5% had low CVH, respectively. MASLD prevalence at year 25 was 23% (n=587). Five distinct CVH trajectories were identified. Between the 2 groups that started at similar CVH scores, those whose CVH declined over time had a higher prevalence of MASLD at year 25 (7.0% in high-stable versus 23.0% high-decreasing; 24.4% in moderate-stable versus 35.7% in moderate-decreasing). Lower and decreasing trajectories were associated with higher year-25 MASLD prevalence compared with the high-stable trajectory.

CONCLUSIONS

Achieving and maintaining high CVH scores starting in young adulthood lowers the risk of prevalent MASLD in midlife.

The association of advanced lung cancer inflammation index with non-alcoholic fatty liver disease in NHANES 2017-2020

Background

The advanced lung cancer inflammation index (ALI) is a composite index that combines inflammation and nutritional status, and non-alcoholic fatty liver disease (NAFLD) is associated with inflammation, nutritional status, and obesity. This study aimed to investigate the possible relationship between ALI and NAFLD.

Methods

We extracted cohort datasets from the 2017-2020 National Health and Nutrition Examination Survey (NHANES) for the study. Weighted analyses and multivariate linear regression models were applied to assess the association between ALI and NAFLD. Fitted curves and threshold effects analyses were used to characterize nonlinear relationships.

Results

A total of 6,595 adults aged 18-80 years were included in this study. In multivariate linear regression analysis, there was a significant positive association between ALI and NAFLD [OR: 1.02, 95% CI (1.01, 1.02)]. In subgroup analyses, this positive association was maintained in females [OR: 1.02, 95% CI (1.01, 1.02)] and not in males. In addition, we found that the association between ALI and NAFLD was nonlinear, with an L-shaped relationship and an inflection point of 32.47. ALI showed a U-shaped association with NAFLD in the male population, with an inflection point of 40.65, and an L-shaped association in the female population, with an inflection point of 30.61.

Conclusion

Our study suggests that there is a significant positive association between high ALI levels and NAFLD prevalence in the US adult population. However, more clinical cohort studies are needed to confirm this finding.

Predictive value of triglyceride glucose index in non-obese non-alcoholic fatty liver disease

OBJECTIVES

A large number of patients with non-obese non-alcoholic fatty liver disease (NAFLD) in China remain undiagnosed and untreated due to insufficient awareness and ineffective pharmacotherapy. Therefore, a convenient, predictive marker and diagnostic tools are imperative. This study aimed to investigate the ability of the triglyceride glucose index (TyG) in predicting non-obese NAFLD.

DESIGN

An observational cross-sectional study.

SETTING

Department of Health Management, large urban academic medical centre and DRYAD database data.

PARTICIPANTS

This study included 456 patients with non-obese NAFLD and matched 456 non-fatty liver controls according to age, sex and body mass index (BMI).

PRIMARY AND SECONDARY OUTCOME MEASURES

The receiver operating characteristic (ROC) curve was used to evaluate the predictive role of the TyG index in non-obese NAFLD. Based on the TyG index, a clinical prediction model for non-obese NAFLD was constructed, then the prediction model was verified by the DRYAD database (n=11 562).

RESULTS

TyG in non-obese NAFLD was higher than that in controls (9.00 (8.66-9.40) vs 8.46 (8.10-8.83), p<0.001). Logistic regression analysis showed that TyG was an independent risk factor for non-obese NAFLD (OR=9.03, 95% CI: 5.46 to 14.94, p<0.001). ROC analysis showed that the area under the curve (AUC) was 0.78, the sensitivity was 82.5%, the specificity was 60.5%. Based on the TyG index, sex, age and BMI, the AUC of the predictive model for non-obese NAFLD was 0.78 (95% CI: 0.75 to 0.81, p<0.001). Using the DRYAD database to verify the prediction model, the AUC of the verification group was 0.85 (95% CI: 0.84 to 0.86, p<0.001).

CONCLUSIONS

The high level of the TyG may be an independent risk factor for non-obese NAFLD. The prediction model for non-obese NAFLD based on the TyG index has good clinical prediction value.

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

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

Impact of PNPLA3 in Lean Individuals and in Cryptogenic Steatotic Liver Disease

BACKGROUND

Although metabolic dysfunction-associated steatotic liver disease (MASLD) is strongly associated with obesity, around 20% of individuals with hepatic steatosis may nonetheless have normal body mass index, a condition often referred to as lean nonalcoholic fatty liver disease (NAFLD). Under the new nomenclature and definition of MASLD, lean NAFLD can be further divided into lean MASLD (when there is one or more cardiometabolic risk factors) and cryptogenic steatotic liver disease (when there is no cardiometabolic risk factor).

RESULTS

Current studies suggest that the at-risk PNPLA3 rs738409 variant is more common among individuals with lean NAFLD than their overweight and obese counterparts. However, even in this group, cardiometabolic risk factors are often required for the development of hepatic steatosis and liver injury. In the general population, PNPLA3 gene polymorphism is associated with an increased risk of MASLD, more severe liver histology (i.e., the presence of steatohepatitis and fibrosis) and future development of hepatocellular carcinoma and cirrhotic complications. Emerging data also suggest that individuals carrying the PNPLA3 GG genotype might have a greater reduction in hepatic steatosis and liver enzymes with lifestyle intervention and metabolic treatments, such as glucagon-like peptide-1 receptor agonists.

CONCLUSION

Studies have not specifically examined the impact of PNPLA3 in lean individuals.

Role of serum endotoxin, FGF19, TLR2, TNF-α, IL-12 and IL-10 in NAFLD-associated T2DM pathogenesis: Insights into Th1 bias and protective mechanisms

BACKGROUND

Non-alcoholic fatty liver disease (NAFLD) in non-obese patients is pathophysiologically distinct, exhibiting common immunological link with type-2 diabetes mellitus (T2DM). This study aims to delineate the role of Toll-like receptor 2 (TLR2)-mediated immuno-modulation along with its association with fibroblast growth factor receptor 4 (FGFR4) and its ligand fibroblast growth factor 19 (FGF19) in the pathogenesis of NAFLD without or with T2DM.

METHODOLOGY

Blood samples were collected from patients with NAFLD (n = 90), NAFLD with T2DM (n = 90) and healthy cohorts (n = 90) with consent and clinical records. Real-time polymerase chain reaction (PCR), enzyme-linked immunoassay (ELIZA) and polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP) were used to analyze messenger ribonucleic acid (mRNA), protein expression and gene polymorphism.

RESULTS

The molecular genetic analysis revealed the prevalence of variant allele(A) in FGFR4 gene in both cases compared to controls. The mRNA expression of FGF19 and TLR2 exhibited significant upregulation in NAFLD without T2DM compared to NAFLD with T2DM. Tumor necrosis factor-α (TNF-α) and interleukin-12 (IL-12) showed upregulation in both disease cohorts compared to control while IL-10 showed significant downregulation in NAFLD with T2DM compared to the other two cohorts. Correlation analysis between FGF19 and TLR2 revealed significant positive association in both NAFLD with and without T2DM. The Th1:Th2 ratio showed significant upregulation in NAFLD with T2DM compared to NAFLD without T2DM.

CONCLUSION

In conclusion, elevated serum endotoxin levels appear to contribute to NAFLD and T2DM development. Upregulated FGF19 seems to be protective against developing T2DM in NAFLD patients. Higher TLR2, TNF-α and IL-12 expression in NAFLD without T2DM suggests a Th1 bias in its pathogenesis, while reduced IL-10 in NAFLD with T2DM implies a more skewed Th1 state in this condition.

Post-hoc analysis of the tofogliflozin post-marketing surveillance study (J-STEP/LT): Tofogliflozin improves liver function in type 2 diabetes patients regardless of BMI

AIMS/INTRODUCTION

Patients with type 2 diabetes are at high risk of developing steatotic liver disease (SLD). Weight loss has proven effective in treating metabolic dysfunction-associated steatotic liver disease (MASLD) in obese patients with type 2 diabetes, with sodium-glucose cotransporter 2 (SGLT2) inhibitors showing promising results. However, lean MASLD is more prevalent in Japan, necessitating alternative approaches to body weight reduction.

MATERIALS AND METHODS

We used the J-STEP/LT dataset including up to 3-year treatment data to analyze the effects of the SGLT2 inhibitor tofogliflozin on liver function and treatment safety and conducted a subgroup analysis based on body mass index (BMI; kg/m2, <20, 20-<23, 23-<25, 25-<30, and ≥30).

RESULTS

This study included 4,208 participants. Tofogliflozin significantly reduced alanine aminotransferase (ALT) levels in participants with baseline ALT levels >30 U/L across all BMI groups, with median changes of -12, -16, -13, -15, and -15 U/L, respectively (P = 0.9291 for trends). However, median changes in body weight with tofogliflozin were -2.00, -2.75, -2.00, -3.00, and -3.80 kg, respectively (P < 0.0001 for trends), with no significant weight loss observed in the BMI <20 group. ALT levels were also significantly decreased in participants who did not lose weight. Safety assessments according to BMI and age categories revealed no clear differences in the frequency of adverse events.

CONCLUSIONS

Tofogliflozin reduced ALT levels without substantial body weight reduction among lean participants. These findings suggest that SGLT2 inhibitors may be a viable treatment option for non-obese patients with type 2 diabetes and SLD.

Construction and evaluation of a diagnostic model for metabolic dysfunction-associated steatotic liver disease based on advanced glycation end products and their receptors

Background

Effective biomarkers for the diagnosis of metabolic dysfunction-associated steatotic liver disease (MASLD) remain limited. This study aims to evaluate the potential of advanced glycation end products (AGEs) and their endogenous secretory receptor (esRAGE) as non-invasive biomarkers for diagnosing MASLD, to explore differences between obese and non-obese MASLD patients, and to develop a novel diagnostic model based on these biomarkers.

Methods

This study enrolled 341 participants, including 246 MASLD patients (118 non-obese, 128 obese) and 95 healthy controls. Serum AGEs and esRAGE levels were measured by ELISA. Key predictors were identified using the Lasso algorithm, and a diagnostic model was developed with logistic regression and visualized as nomograms. Diagnostic accuracy and utility were evaluated through the area under the curve (AUC), bootstrap validation, calibration curves, and decision curve analysis (DCA).

Results

Serum AGEs and esRAGE levels were significantly higher in MASLD patients compared to controls. Moreover, obese MASLD patients had higher esRAGE levels than non-obese ones, but no significant difference in AGEs levels was found. A diagnostic model incorporating age, WC, BMI, ALT, TG, HDL, AGEs, and esRAGE achieved an AUC of 0.963, with 94.3% sensitivity and 85.3% specificity. The AUC for bootstrap internal validation was 0.963 (95% CI: 0.944-0.982). Calibration curves showed strong predictive accuracy, and DCA demonstrated high net clinical benefit.

Conclusion

Serum AGEs and esRAGE serve as non-invasive biomarkers for distinguishing MASLD patients. We developed and validated diagnostic models for MASLD, offering valuable tools to identify at-risk populations and improve prevention and treatment strategies.

Heterogeneity of cardiometabolic and hepatic fibrosis risks in nonalcoholic fatty liver disease among lean, overweight, and obese populations: a multicenter cross-sectional study

OBJECTIVE

Given that cardiovascular events induced by metabolic disorders are the leading cause of death in nonalcoholic fatty liver disease (NAFLD), this study aimed to explore the heterogeneity of cardiometabolic and liver fibrosis risks among lean, overweight, and obese NAFLD individuals.

METHODS

A multicenter cross-sectional study was conducted across three hospitals in Pudong from July 2022 to June 2023. Health checkup data were obtained and stratified by BMI categories. Multivariable logistic regression was performed to analyze the association between NAFLD and risk factors for cardiometabolic diseases and liver fibrosis across different BMI categories.

RESULTS

The study included 37,122 patients, with 25.25% diagnosed with NAFLD. Over 97% of these patients met the criteria for metabolic dysfunction-associated fatty liver disease. NAFLD detection rates were 7.72% in lean, 33.99% in overweight, and 63.56% in obese individuals. Non-obese patients had significantly lower cardiometabolic disease prevalence than obese patients (P < 0.001). All NAFLD subtypes, except lean NAFLD (negatively associated with total cholesterol) and obese NAFLD (no significant association with total triglycerides), were linked to other cardiometabolic or liver fibrosis risk factors (P < 0.05). Additioinally, only obese NAFLD demonstrated a negative correlation with age.

CONCLUSION

Non-obese NAFLD, despite a relatively better metabolic profile than obese NAFLD, still poses significant cardiometabolic and fibrosis risks. Interventions targeting cardiovascular events and liver disease progression are essential for all NAFLD subtypes, customized to their metabolic characteristics. The detection rates in this study provide a valuable reference for estimating local NAFLD prevalence.

Macrophage-specific PHGDH protects against MAFLD by suppressing TAK1

Metabolic dysfunction-associated fatty liver disease (MAFLD) is a progressive disease with only one approved treatment currently available. Hepatic phosphoglycerate dehydrogenase (PHGDH), the rate-limiting enzyme of the serine biosynthesis pathway, regulates MAFLD development. However, the role of macrophage PHGDH in MAFLD progression remains unclear. Here, we demonstrate that the lipotoxicity inducer palmitic acid (PA) significantly increases macrophage PHGDH expression and that PHGDH deficiency in macrophages promotes PA-induced inflammatory responses. Myeloid-specific PHGDH deficiency exacerbates MAFLD in mice. Mechanistically, tetrameric PHGDH binds to transforming growth factor-β-activated kinase 1 (TAK1) to inhibit its interaction with TAK1 binding protein 1 (TAB1), sequentially suppressing the activation of TAK1 and downstream NF-κB and MAPK signaling. Inhibition of TAK1 activation slows the development of metabolic dysfunction-associated steatohepatitis (MASH) caused by myeloid PHGDH knockout. Importantly, adeno-associated virus-mediated PHGDH overexpression in liver macrophages alleviates MAFLD in mice. Collectively, these results identify macrophage PHGDH as a promising therapeutic agent for MAFLD.

Metabolic-Dysfunction-Associated Steatotic Liver Disease: Molecular Mechanisms, Clinical Implications, and Emerging Therapeutic Strategies

Metabolic-dysfunction-associated steatotic liver disease (MASLD), previously known as non-alcoholic fatty liver disease (NAFLD), is a highly prevalent metabolic disorder characterized by hepatic steatosis in conjunction with at least one cardiometabolic risk factor, such as obesity, type 2 diabetes, hypertension, or dyslipidemia. As global rates of obesity and metabolic syndrome continue to rise, MASLD is becoming a major public health concern, with projections indicating a substantial increase in prevalence over the coming decades. The disease spectrum ranges from simple steatosis to metabolic-dysfunction-associated steatohepatitis (MASH), fibrosis, cirrhosis, and hepatocellular carcinoma, contributing to significant morbidity and mortality worldwide. This review delves into the molecular mechanisms driving MASLD pathogenesis, including dysregulation of lipid metabolism, chronic inflammation, oxidative stress, mitochondrial dysfunction, and gut microbiota alterations. Recent advances in research have highlighted the role of genetic and epigenetic factors in disease progression, as well as novel therapeutic targets such as peroxisome proliferator-activated receptors (PPARs), fibroblast growth factors, and thyroid hormone receptor beta agonists. Given the multifaceted nature of MASLD, a multidisciplinary approach integrating early diagnosis, molecular insights, lifestyle interventions, and personalized therapies is critical. This review underscores the urgent need for continued research into innovative treatment strategies and precision medicine approaches to halt MASLD progression and improve patient outcomes.

Impact of Alcohol Intake on Body Composition in Patients with Steatotic Liver Disease

Objectives: To examine the effect of alcohol intake on body composition in patients with steatotic liver disease (SLD). Methods: In men, group A (n = 819) was defined as non-drinkers, group B (n = 1147) as <30 g of ethanol equivalent per day, group C (n = 125) as between 30 and 60 g/day, and group D (n = 344) as >60 g/day. In women, group A (n = 749) was defined as non-drinkers, group B (n = 354) as <20 g/day, group C (n = 36) as between 20 and 50 g/day, and group D (n = 68) as >50 g/day. The fat-free (FF) index and fat (F) index were defined as FF mass and F mass divided by height squared (kg/m2). Results: The average FF index and F index in groups A, B, C, and D in men were 19.01, 19.29, 18.50, and 18.55 kg/m2 (overall p < 0.0001), and 6.28, 6.71, 5.66, and 6.03 kg/m2 (overall p < 0.0001). The average FF index and F index in groups A, B, C, and D in women were 16.03, 15.96, 15.62, and 15.07 kg/m2 (overall p < 0.0001), and 9.89, 9.02, 9.32, and 7.53 kg/m2 (overall p < 0.0001). Conclusions: Heavy drinking has a negative effect on skeletal muscle and fat, but complete abstinence from alcohol may not be necessary in SLD patients.

Low HDL cholesterol levels in women and hypertriglyceridemia in men: predictors of MASLD onset in individuals without steatosis

BACKGROUND

Individuals with metabolic-associated steatotic liver disease (MASLD) have a worse prognosis compared to patients without steatosis, and its prevalence is increasing. However, detailed risk factors based on obesity and sex remain unclear. We aimed to investigate the impact of cardiometabolic risk factors (CMRFs) on the risk of MASLD in individuals without pre-existing SLD.

METHODS

SLD was diagnosed by ultrasonography. Non-SLD individuals were followed 65,657 person-years. Incidence rates of MASLD were assessed by Kaplan-Meier analysis. Furthermore, independent factors associated with the development of MASLD were identified using Cox regression analysis, stratified by four groups: obese men, non-obese men, obese women, and non-obese women.

RESULTS

The overall incidence rate of MASLD was 39.3/1,000 person-years. The cumulative incidence was highest in obese men, followed by obese women, non-obese men, and non-obese women. Two or more CMRFs increased the risk of MASLD in all groups. Low HDL cholesterol level was the strongest independent risk factor in both obese and non-obese women and hypertriglyceridemia for both obese and non-obese men. The impact of these CMRFs was stronger in non-obese individuals. (HR [95% CI]: women non-obese 1.9 [1.5-2.4], obese 1.4 [1.1-1.8]; men non-obese 2.3 [1.9-2.9], obese 1.5 [1.2-2.0]).

CONCLUSIONS

Multiple CMRFs are important to MASLD development, regardless of sex and obesity. In this Japanese cohort, low HDL cholesterol in women and hypertriglyceridemia in men were the most significant risk factors, especially among the non-obese group. These findings suggest that sex-specific CMRFs may play a role in the development of MASLD.

Global prevalence, metabolic characteristics, and outcomes of lean-MAFLD: a systematic review and meta-analysis

BACKGROUND

Metabolic Dysfunction-Associated Fatty Liver disease (MAFLD) among lean individuals is increasingly recognized. We aimed to compare the prevalence, metabolic characteristics, and outcomes of lean vs overweight/obese-MAFLD patients.

METHODS

Databases of Embase, Medline, and Web of Science were searched from inception till October 2023. Only cohorts adhering to the lean-MAFLD criteria as defined by the international consensus statement were included.

RESULTS

In the pooled analysis of 10,013,382 individuals, the prevalence of lean-MAFLD in the general population was 1.94% (95% CI 1.10-3.39%, I2 = 98.7%). Lean and overweight/obese-MAFLD patients had similar metabolic characteristics for blood pressure, LDL, TG, blood glucose, and HbA1c. There was an increased incidence rate and likelihood for liver-related mortality for lean-MAFLD vs overweight/obese-MAFLD [1.33 per 1000 patient-years (95% CI 1.28-1.39) vs 0.76 (95% CI 0.25-2.28), (OR 3.56 (95% CI 3.45-3.67), p < 0.01). There were similar incidence rates and odds ratios between lean vs overweight/obese-MAFLD for: (1) all-cause mortality [10.08 per 1000 patient-years (95% CI 9.93-10.23) vs 8.94 per 1000 patient-years (95% CI 4.08-19.57), (OR 1.92 (95% CI 0.01-220.57), p = 0.33)]; (2) cardiovascular-related mortality [2.53 per 1000 patient-years (95% CI 0.65-9.96) vs 2.07 per 1000 patient-years (95% CI 0.80-5.39), (OR 1.91 (95% CI 0.02-142.76), p = 0.58)]; and (3) cancer-related mortality [3.42 per 1000 patient-years (95% CI 3.33-3.51) vs 3.15 per 1000 patient-years (95% CI 1.21-8.19), (OR 1.99 (95% CI 0.29-13.52), p = 0.13).

CONCLUSION

Lean-MAFLD patients have an equivalent metabolic burden compared to overweight/obese-MAFLD patients and thus a similar incidence rate of major extrahepatic complications. However, they have an increased risk of liver-related mortality.

Metabolic dysfunction-associated steatotic liver disease in adults

Metabolic dysfunction-associated steatotic liver disease (MASLD) is the umbrella term that comprises metabolic dysfunction-associated steatotic liver, or isolated hepatic steatosis, through to metabolic dysfunction-associated steatohepatitis, the progressive necroinflammatory disease form that can progress to fibrosis, cirrhosis and hepatocellular carcinoma. MASLD is estimated to affect more than one-third of adults worldwide. MASLD is closely associated with insulin resistance, obesity, gut microbial dysbiosis and genetic risk factors. The obesity epidemic and the growing prevalence of type 2 diabetes mellitus greatly contribute to the increasing burden of MASLD. The treatment and prevention of major metabolic comorbidities such as type 2 diabetes mellitus and obesity will probably slow the growth of MASLD. In 2023, the field decided on a new nomenclature and agreed on a set of research and action priorities, and in 2024, the US FDA approved the first drug, resmetirom, for the treatment of non-cirrhotic metabolic dysfunction-associated steatohepatitis with moderate to advanced fibrosis. Reliable, validated biomarkers that can replace histology for patient selection and primary end points in MASH trials will greatly accelerate the drug development process. Additionally, noninvasive tests that can reliably determine treatment response or predict response to therapy are warranted. Sustained efforts are required to combat the burden of MASLD by tackling metabolic risk factors, improving risk stratification and linkage to care, and increasing access to therapeutic agents and non-pharmaceutical interventions.

Subphenotypes of body composition and their association with cardiometabolic risk - Magnetic resonance imaging in a population-based sample

BACKGROUND

For characterizing health states, fat distribution is more informative than overall body size. We used population-based whole-body magnetic resonance imaging (MRI) to identify distinct body composition subphenotypes and characterize associations with cardiovascular disease (CVD) risk.

METHODS

Bone marrow, visceral, subcutaneous, cardiac, renal, hepatic, skeletal muscle and pancreatic adipose tissue were measured by MRI in n = 299 individuals from the population-based KORA cohort. Body composition subphenotypes were identified by data-driven k-means clustering. CVD risk was calculated by established scores.

RESULTS

We identified five body composition subphenotypes, which differed substantially in CVD risk factor distribution and CVD risk. Compared to reference subphenotype I with favorable risk profile, two high-risk phenotypes, III&V, had a 3.8-fold increased CVD risk. High-risk subphenotype III had increased bone marrow and skeletal muscle fat (26.3 % vs 11.4 % in subphenotype I), indicating ageing effects, whereas subphenotype V showed overall high fat contents, and particularly elevated pancreatic fat (25.0 % vs 3.7 % in subphenotype I), indicating metabolic impairment. Subphenotype II had a 2.7-fold increased CVD risk, and an unfavorable fat distribution, probably smoking-related, while BMI was only slightly elevated. Subphenotype IV had a 2.8-fold increased CVD risk with comparably young individuals, who showed high blood pressure and hepatic fat (17.7 % vs 3.0 % in subphenotype I).

CONCLUSIONS

Whole-body MRI can identify distinct body composition subphenotypes associated with different degrees of cardiometabolic risk. Body composition profiling may enable a more comprehensive risk assessment than individual fat compartments, with potential benefits for individualized prevention.

Association of PNPLA3 rs738409 C > G and rs2896019 T > G Polymorphisms with Nonalcoholic Fatty Liver Disease in a Turkish Population from Adıyaman Province

Objectives: The purpose of this study was to investigate the effect of patatin-like phospholipase domain-containing protein 3 (PNPLA3) rs738409 C > G and rs2896019 T > G polymorphisms on genetic susceptibility to nonalcoholic fatty liver disease (NAFLD) in a Turkish population from Adıyaman province, located in the Southeast Anatolia Region of Turkey. Materials and Methods: This hospital-based molecular epidemiological case-control study analyzed the PNPLA3 rs738409 C > G and rs2896019 T > G polymorphisms in 335 NAFLD cases and 410 healthy controls. Genotype frequencies were determined using real-time polymerase chain reaction with the TaqMan assay. The association with NAFLD susceptibility was evaluated by calculating odds ratios (ORs) and 95% confidence intervals (CIs) using an unconditional logistic regression model. Results: We found that the PNPLA3 rs738409 C > G (CC vs. GG: OR = 1.90, 95% CI = 1.05-3.44) and rs2896019 T > G (TT vs. GG: OR = 3.24, 95% CI = 1.44-7.27) polymorphisms were linked to an increased risk of NAFLD in almost all genetic models (p < 0.05). In addition, the PNPLA3 Grs738409/Grs2896019 haplotype was associated with NAFLD development (p < 0.05). Significant differences in alanine aminotransferase and aspartate aminotransferase enzyme levels were observed across the genotypes of these polymorphisms (p < 0.05). Conclusion: This is the first study on PNPLA3 single nucleotide polymorphisms (SNPs) and NAFLD in the Turkish population of Adıyaman Province, Southeast Anatolia. Our findings suggest that the PNPLA3 rs738409 C > G and rs2896019 T > G polymorphisms, along with their haplotypes, may influence NAFLD susceptibility. Further independent studies with larger sample sizes and diverse populations are needed to confirm these results.

Risk factor analysis and predictive model construction of lean MAFLD: a cross-sectional study of a health check-up population in China

AIM

Cardiovascular disease morbidity and mortality rates are high in patients with metabolic dysfunction-associated fatty liver disease (MAFLD). The objective of this study was to analyze the risk factors and differences between lean MAFLD and overweight MAFLD, and establish and validate a nomogram model for predicting lean MAFLD.

METHODS

This retrospective cross-sectional study included 4363 participants who underwent annual health checkup at Yuyao from 2019 to 2022. The study population was stratified into three groups: non-MAFLD, lean MAFLD (defined as the presence of fatty liver changes as determined by ultrasound in individuals with a BMI < 25 kg/m2), and overweight MAFLD (BMI ≥ 25.0 kg/m2). Subsequent modeling analysis was conducted in a population that included healthy subjects with < 25 kg/m2 (n = 2104) and subjects with lean MAFLD (n = 849). The study population was randomly split (7:3 ratio) to a training vs. a validation cohort. Risk factors for lean MAFLD was identify by multivariate regression of the training cohort, and used to construct a nomogram to estimate the probability of lean MAFLD. Model performance was examined using the receiver operating characteristic (ROC) curve analysis and k-fold cross-validation (k = 5). Decision curve analysis (DCA) was applied to evaluate the clinical usefulness of the prediction model.

RESULTS

The multivariate regression analysis indicated that the triglycerides and glucose index (TyG) was the most significant risk factor for lean MAFLD (OR: 4.03, 95% CI 2.806-5.786). The restricted cubic spline curves (RCS) regression model demonstrated that the relationships between systolic pressure (SBP), alanine aminotransferase (ALT), serum urate (UA), total cholesterol (TCHO), triglyceride (TG), triglyceride glucose (TyG) index, high density lipoprotein cholesterol (HDLC), and MAFLD were nonlinear and the cutoff values for lean MAFLD and overweight MAFLD were different. The nomogram was constructed based on seven predictors: glycosylated hemoglobin A1c (HbA1c), serum ferritin (SF), ALT, UA, BMI, TyG index, and age. In the validation cohort, the area under the ROC curve was 0.866 (95% CI 0.842-0.891), with 83.8% sensitivity and 76.6% specificity at the optimal cutoff. The PPV and NPV was 63.3% and 90.8%, respectively. Furthermore, we used fivefold cross-validation and the average area under the ROC curve was 0.866 (Figure S3). The calibration curves for the model's predictions and the actual outcomes were in good agreement. The DCA findings demonstrated that the nomogram model was clinically useful throughout a broad threshold probability range.

CONCLUSIONS

Lean and overweight MAFLD exhibit distinct metabolic profiles. The nomogram model developed in this study is designed to assist clinicians in the early identification of high-risk individuals with lean MAFLD, including those with a normal BMI but at metabolic risk, as well as those with abnormal blood lipid, glucose, uric acid or transaminase levels. In addition, this model enhances screening efforts in communities and medical screening centers, ultimately ensuring more timely and effective medical services for patients.

Lean Metabolic Dysfunction-Associated Steatotic Liver Disease: A Comparative Analysis of Hepatic and Oncological Outcomes

GOALS

To compare outcomes of MASLD in obese and nonobese populations.

BACKGROUND

MASLD is emerging as one of the leading causes of liver failure and liver-related morbidity and mortality, with an increasing prevalence in the nonobese or lean population. The purpose of this study is to compare hepatic and oncological outcomes between MASLD patients with lean BMI and nonlean BMI.

STUDY

The National Inpatient Sample (NIS) was queried from 2016 to 2020 for adult hospitalizations with MASLD. Exclusion criteria included concurrent diagnoses of viral hepatitis, alcoholic hepatitis, primary biliary cholangitis, hereditary hemochromatosis, autoimmune hepatitis, or Wilson disease. Outcomes of MASLD and its complications were compared between the lean and nonlean subgroups.

RESULTS

Patients with lean BMI had higher mortality rates (odds ratio: 2.10, P<0.001). The lean cohort also had higher odds of cirrhosis, portal hypertension, SBP, and ascites. The lean subgroup had higher odds of gastrointestinal malignancies including esophageal cancer, gastric cancer, pancreatic cancer, and colorectal cancer.

CONCLUSIONS

Hospitalized lean MASLD patients had higher odds of mortality, ​​hepatic morbidities, and gastrointestinal malignancies. These results challenge the use of BMI as a predictor of morbidity and mortality for MASLD patients. Future studies should focus on therapeutic options for MASLD and compare their efficacies between lean and nonlean populations.

Differential levels of thyroid hormones, cortisol, and apolipoprotein M in fatty liver disease

OBJECTIVES

Non-alcoholic fatty liver disease (NAFLD), recently reclassified as metabolic dysfunction-associated fatty liver disease (MAFLD), can also manifest in patients classified as non-MAFLD who do not meet MAFLD criteria. The involvement of cortisol and thyroid hormones may play a role in the pathogenesis of FLD by modifying the metabolism of specific lipoproteins, particularly apolipoprotein M (Apo M). This study investigated cortisol and thyroid hormones levels and Apo M gene expression in white blood cells (WBCs) of individuals with MAFLD, non-MAFLD, and healthy controls.

METHODS

The serum and WBCs of the study subjects were collected from patients with FLD (n=99) including 58 MAFLD and 41 non-MAFLD and healthy individuals (n=23). To investigate the gene expression of Apo M and thyroid and cortisol hormones, qRT-PCR and ELISA methods were used, respectively.

RESULTS

The Apo M gene expression was significantly lower in FLD patients, both non-MAFLD, and MAFLD patients compared to the control group (p<0.05). Total T4 and TSH hormone levels in the MAFLD patients were significantly decreased and increased compared to the control group, respectively (p<0.05). The cortisol level was significantly elevated in the FLD and MAFLD patients compared to the control group (p<0.01).

CONCLUSIONS

Alterations in Apo M gene expression also cortisol and thyroid hormones levels in non-MAFLD patients were milder than MAFLD patients when compared to the control. Also, likely Apo M may be involved in FLD pathogenesis.

Serum uric acid trajectories and risk of metabolic dysfunction-associated steatotic liver disease in China: a 2019-2021 cohort health survey

OBJECTIVE

To investigate the associations between serum uric acid (UA) trajectories and the risk of metabolic dysfunction-associated steatotic liver disease (MASLD) in large cohort survey 2019-2021.

METHODS

This cohort health survey included 11,644 participants without MASLD before January 1, 2021. Among them, 5578 (47.90%) were men and 6066 (52.10%) were women. The group-based trajectory model method was applied to identify serum UA trajectories from January 1, 2019, to December 30, 2021. New-onset MASLD events in 2021 were treated as outcomes. A logistic regression model was used to assess associations between UA trajectories and incidence of MASLD.

RESULTS

Four distinct serum UA trajectories among both sexes were identified: "low-stable" trajectory 1 (n = 783 men; n = 1143 women), "moderate-moderate increasing" trajectory 2 (n = 2794 men; n = 3266 women), "moderate high-moderate increasing" trajectory 3 (n = 1660 men; n = 1464 women), and "high-increasing" trajectory 4 (n = 341 men; n = 193 women). During the 3-year follow-up period, 840 (15.06%) men and 408 (6.72%) women developed MASLD, respectively. Compared with the trajectory 1 group, the trajectory 4 group had the highest risk (odds ration [OR] 2.99 [95% confidence interval {CI} 1.70, 5.24] for men; OR 2.37 [95% CI 1.04, 5.33] for women), followed by the trajectory 3 (OR 2.23 [95% CI 1.52, 3.30] for men; OR 2.37 [95% CI 1.45, 3.92] for women) and trajectory 2 (OR 1.43 [95% CI 1.07, 1.94] for men; OR 1.37 [95% CI 0.93, 2.03] for women) groups.

CONCLUSIONS

High serum UA trajectories were independent risk factors for MASLD in both sexes, which is critical for informing prevention and treatment strategies in public health initiatives and clinical practice.

Lean MASLD and IBD: Exploring the Intersection of Metabolic Dysfunction and the Gut-Liver Axis

Metabolic dysfunction-associated steatotic liver disease (MASLD) challenges traditional paradigms by manifesting in lean individuals. The link between MASLD and inflammatory bowel disease (IBD) underscores the importance of the gut-liver axis in disease progression and chronic inflammation. This study evaluates MASLD prevalence, clinical characteristics, and diagnostic predictors in lean individuals with and without IBD. This prospective study included 387 lean patients. Hepatic steatosis and fibrosis were assessed using vibration-controlled transient elastography (VCTE). Anthropometric, clinical and biological data were compared. The subgroup analyses focused on MASLD patients with and without IBD. MASLD was present in 34.1% of lean individuals and 46.3% of those who were lean with IBD. MASLD patients had increased visceral adiposity (CUN-BAE: 31.21 ± 5.42 vs. 24.57 ± 6.49, p < 0.001) and metabolic dysfunction, including dyslipidemia and elevated fasting glucose. IBD-MASLD patients exhibited greater hepatic steatosis and systemic inflammation. CUN-BAE outperformed FLI and HSI in predicting liver steatosis, especially in IBD patients (AUC = 0.806). Lean MASLD, particularly in IBD patients, highlights the need for tailored diagnostic and management strategies. The gut-liver axis plays a key role in disease progression, and the CUN-BAE index demonstrates superior accuracy for identifying liver steatosis.

Reactive Dicarbonyl Scavenging with 2-Hydroxybenzylamine Improves MASH

Background: Products of lipid peroxidation include a number of reactive lipid aldehydes including reactive dicarbonyl electrophiles (DEs) and contribute to disease processes. DEs play a significant role in the development and progression of metabolic-associated steatotic liver disease (MASLD) by contributing to oxidative stress, inflammation, protein dysfunction, and mitochondrial impairment. Reducing DE stress may be a potential strategy for managing MASLD. We hypothesized that the DE scavenger 2-hydroxybenzylamine (2-HOBA) would reduce liver injury by reducing liver protein adduct formation by DE in mouse models of MASLD. Methods: Protein adducts were measured in human livers by immunohistochemistry and immunoblot. The effects of 2-HOBA were assessed in two different mouse models of MASLD. Results: Isolevuglandin (IsoLG) protein adducts were increased in MASH-staged human livers relative to histologically normal controls. Diet-Induced Animal Model of Nonalcoholic Fatty Liver Disease (DIAMOND) mice treated with 2-HOBA exhibited significantly lower fibrosis scores (* p = 0.012) and reduced liver transaminases (AST, p = 0.03) and ALT, p = 0.012) by over 40%. In STAM (Stelic Animal Model) mice, 2-HOBA improved NAFLD activity scores (p = 0.03, NAS), hyperglycemia, and inflammatory cytokines and reduced serum F2-isoprostanes (IsoPs) by 30%, p = 0.05. These improvements were absent mRNA changes in hepatic antioxidant enzymes (Cat, Gpx1, or Sod2) or ROS-generating proteins (p22PHOX, p47PHOX, NOX4 or COX1). Conclusions: DE scavenging with 2-HOBA may be a promising therapeutic strategy for managing MASLD. While findings are currently limited to male mice, a nutraceutical that reduces liver fibrosis could significantly improve the management of MASH by offering a non-invasive treatment option to potentially slow or reverse liver scarring, delay progression to cirrhosis, and improve patient outcomes, while also providing a potential treatment option for patients who may not be suitable for other interventions like liver transplantation.

Dietary and lifestyle indices for hyperinsulinemia and odds of MAFLD in overweight and obese children and adolescents

Lifestyle and dietary intake play a pivotal role in development of metabolic dysfunction-associated fatty liver disease(MAFLD). We performed this cross-sectional study to evaluate the association between lifestyle and dietary insulinemic potential and odds of MAFLD in overweight and obese children and adolescents. The insulinemic potential of the diet and lifestyle was assessed by computing the scores of the empirical dietary index for hyperinsulinemia(EDIH), the empirical lifestyle index for hyperinsulinemia(ELIH), the empirical dietary index for insulin resistance(EDIR), and the empirical lifestyle index for insulin resistance(ELIR). MAFLD was diagnosed according to the consensus definitions. Odds ratios (ORs) and 95% confidence intervals (CIs) were calculated by logistic regression. A total of 334 (49.1% boys) with mean ± SD age and BMI-for-age-Z-score of 9.3 ± 1.8 and 2.55 ± 0.69, respectively, were enrolled. After adjusting for all potential confounders, participants in the highest quartile of ELIH score had greater odds of developing MAFLD (OR:3.50;95%CI:1.49-8.22) compared with those in the lowest quartile. This association remained significant among boys and pubertal ones. However, no significant association between EDIH, EDIR, or ELIR and odds of MAFLD was found. Our study suggests that the collective insulinemic potential of dietary intake, BMI, and physical activity is associated with increased odds of MAFLD.

Impaired RelA signaling and lipid metabolism dysregulation in hepatocytes: driving forces in the progression of metabolic dysfunction-associated steatotic liver disease

RelA, also known as nuclear factor kappa B p65, plays a crucial role in the pathogenesis of various liver diseases. However, the specific role of RelA in hepatocytes during the progression of metabolic dysfunction-associated steatotic liver disease (MASLD) is not well understood. This study explored the relationship between impaired RelA signaling and lipid metabolism disorders in hepatocytes, and how they synergistically contribute to the advancement of MASLD. We assessed the changes, regulatory relationships, and impacts of RelA signaling and lipid metabolism remodeling on disease progression both in vitro and in vivo. During MASLD, there was a decrease in the expression of RelA and hepatocyte nuclear factor 1 alpha (HNF1α), with both factors showing mutual enhancement of each other's expression under normal conditions. This synergistic effect was absent during hepatocyte steatosis. RelA or HNF1α depletion in hepatocytes intensified MASLD symptoms, whereas overexpression of RELA or treatment with necrostatin-1 (a necroptosis inhibitor) or Z-VAD (a caspase inhibitor) significantly mitigated these effects. Mechanistically, during hepatic steatosis, altered lipid profiles exhibited lipotoxicity, inducing hepatocyte apoptosis and necroptosis, whereas endoplasmic reticulum (ER) stress triggered lipid remodeling processes similar to those observed in MASLD. RelA signaling upregulated the expression of activating transcription factor 4 and glucose-regulated protein 78, thereby alleviating ER stress. Impaired RelA signaling remodeled the ER stress response and lipid metabolism, and enhanced lipid accumulation and lipid toxicity. In conclusion, impaired RelA signaling and disrupted lipid metabolism form a detrimental feedback loop in hepatocytes that promotes MASLD progression. Lipid accumulation suppresses RelA signaling, remodeling the ER stress response and exacerbating lipid metabolism disorder, ultimately leading to hepatocyte apoptosis and necroptosis.

Higher risk of carotid plaque among lean individuals with non-alcoholic fatty liver disease: A retrospective study

BACKGROUND

Lean individual with non-alcoholic fatty liver disease (L-NAFLD) is a prominent area of research, yet its pathogenesis and association with other diseases such as atherosclerotic cardiovascular disease remain uncertain.

OBJECT

A retrospective study, investigate the association between non-alcoholic fatty liver disease (NAFLD) and carotid plaque (CP) in lean [body mass index (BMI) <24Kg/m2] and non-lean (BMI≥24Kg/m2) populations, as well as identify the related influence factors.

METHOD

3,587 participants were eligible and categorized into 4 groups based on the presence with CP and BMI, binary logistic regression analysis was utilized alongside other statistical methods.

RESULTS

L-NAFLD participants had a 1.395-fold higher risk of CP compared to lean individuals without NAFLD. Age, gender, systolic blood pressure, low-density lipoprotein cholesterol, fasting blood glucose, and Fibrosis-4 index (FIB-4) were identified as independent risk factors with cutoff values lower than the normal upper limits. However, this association was not observed among non-lean participants, regardless of confounding factors adjustment. Moreover, the impact of FIB-4 on the association of NAFLD and CP was more significant in lean CP participants (OR = 1.360 for 1.30 ~ 2.67, and OR = 2.002 for >2.67~<3.48) than in non-lean CP ones.

CONCLUSION

The L-NAFLD population had a higher risk of CP, while lean CP individuals experienced more severe liver fibrosis. Implementing stricter management of risk factors may improve the health status of high-risk populations.

MASH as an emerging cause of hepatocellular carcinoma: current knowledge and future perspectives

Hepatocellular carcinoma is one of the deadliest and fastest-growing cancers. Among HCC etiologies, metabolic dysfunction-associated fatty liver disease (MAFLD) has served as a major HCC driver due to its great potential for increasing cirrhosis. The obesogenic environment fosters a positive energy balance and results in a continuous rise of obesity and metabolic syndrome. However, it is difficult to understand how metabolic complications lead to the poor prognosis of liver diseases and which molecular mechanisms are underpinning MAFLD-driven HCC development. Thus, suitable preclinical models that recapitulate human etiologies are essentially required. Numerous preclinical models have been created but not many mimicked anthropometric measures and the course of disease progression shown in the patients. Here we review the literature on adipose tissues, liver-related HCC etiologies and recently discovered genetic mutation signatures found in MAFLD-driven HCC patients. We also critically review current rodent models suggested for MAFLD-driven HCC study.

The dynamic patterns of metabolic-associated fatty liver disease and its severity and risk of cardiovascular disease

BACKGROUND

While metabolic-associated fatty liver disease (MAFLD) is widely recognized as a risk factor for cardiovascular disease (CVD), the connection between the dynamic patterns of severity of hepatic steatosis and the associated CVD risk remains uncertain.

METHOD

This study included 71,098 participants from the Kailuan Study without CVD or cancer who underwent two consecutive biennial health screenings between 2006 and 2008 and were followed up until 2022. MAFLD and its severity were assessed using ultrasound. Participants were categorized into four groups based on dynamic MAFLD patterns: MAFLD-free, MAFLD-progression, MAFLD-regression, and MAFLD-persistence. MAFLD-regression was further divided into regression from mild MAFLD and regression from moderate/severe MAFLD. Cox proportional hazard regression models analyzed the association between the progression and regression of MAFLD and CVD risk.

RESULT

After a mean follow-up of 12.63 ± 3.16 years, 7838 individuals experienced incident CVD, 5374 had strokes, 1321 had myocardial infarctions, and 1819 developed heart failure. After adjusting for potential confounders, MAFLD-progression was associated with a higher CVD risk compared to MAFLD-free (HR 1.25, 95% CI 1.17-1.33), but this risk decreased with increasing age. Individuals with MAFLD-persistence had the highest CVD risk (HR 1.54, 95% CI 1.46-1.62). Compared to persistent MAFLD, regression from mild MAFLD was associated with a lower CVD risk (HR 0.83, 95% CI 0.76-0.91).

CONCLUSION

The progression of MAFLD can increase the risk of CVD, while regression of MAFLD can decrease the risk of CVD. These findings suggest that the dynamic patterns of MAFLD significantly influence CVD risk.

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.

Dietary inflammatory potential and metabolic (dysfunction)-associated steatotic liver disease and its complications: A comprehensive review

Metabolic (dysfunction)-associated steatotic liver disease (MASLD) represents a spectrum of liver pathologies linked to metabolic syndrome components. Inflammation emerges as a pivotal player in MASLD pathogenesis, initiating and perpetuating hepatic injury. Diet, a modifiable risk factor, influences inflammation levels and MASLD progression. This review synthesizes existing evidence on the association between pro-inflammatory diets, assessed via the Dietary Inflammatory Index (DII) and Empirical Dietary Inflammatory Potential (EDIP), and MASLD. Evidence suggests a significant association between higher DII/EDIP scores and MASLD risk, with studies revealing a positive correlation between inflammatory diet intake and MASLD occurrence, particularly in males. However, inconsistencies exist regarding the influence of body mass index (BMI) on this association and criticisms regarding adjustment for BMI and reliance on surrogate markers necessitate cautious interpretation. Limited data suggest a potential link between dietary inflammatory potential and advanced liver fibrosis and heightened risk of hepatocellular carcinoma (HCC) with increased DII/EDIP scores, albeit requiring further confirmation through gold-standard assessment methods. Dietary-induced inflammation exacerbates MASLD pathogenesis through multiple pathways, including insulin resistance, adipose tissue dysfunction, gut microbiota alterations, and oxidative stress, culminating in hepatic steatosis, inflammation, and fibrosis. Further research utilizing robust methodologies is imperative to confirm these findings and elucidate underlying mechanisms, thus informing targeted dietary interventions for MASLD management.

Association Between Serum Uric Acid and Non-alcoholic Fatty Liver Disease in Non-obese Young Population: A Prospective Cohort Study

OBJECTIVE

The prevalence of non-alcoholic fatty liver disease (NAFLD) is gradually increasing among non-obese people and shows a trend of younger age. The objective of this study was to investigate the potential association between serum uric acid (SUA) and NAFLD in a non-obese young population.

PATIENTS AND METHODS

The study recruited 10,938 participants without NAFLD (18 ≤ age < 45,18.5 ≤ BMI < 25) in 2006. After a median follow-up of 9.95 years, 4835 (44.20%) participants were diagnosed with NAFLD. According to the baseline SUA level, the research subjects were divided into 4 groups by the quartile method. The association between SUA and NAFLD was predicted using the Kaplan -Meier survival curve and Cox hazard regression model.

RESULTS

After adjusting for all the confounders, the HRs and 95%CI for NAFLD in the quartile 2, quartile 3 and quartile 4 were 1.095(1.004 ~ 1.193), 1.195(1.095 ~ 1.304) and 1.409(1.289 ~ 1.541). The restrictive cubic spline (RCS) functions confirmed the existence of a non-linear association between the initial SUA and NAFLD (non-linearity association P < 0.05). Kaplan-Meier Survival Curve shows that the risk of NAFLD increased with increasing levels of SUA. The cumulative incidences of the four groups were 46.19, 51.99, 56.52 and 65.87%, respectively (log-rank test P < 0.001).

CONCLUSION

It has been confirmed through a prospective cohort study that in non-obese young population, SUA can serve as an independent predictor of NAFLD. An increase in SUA within the physiological range, even if it doesn't reach the level of hyperuricemia, can impose a significant burden on the occurrence of NAFLD.

TRIAL REGISTRATION

Trial registration number: ChiCTR-TNC-11001489, registration site: http://www.chictr.org.cn/index.aspx .

Epidemiology of metabolic dysfunction-associated steatotic liver disease

As the rates of obesity and type 2 diabetes (T2D) continue to increase globally, so does the prevalence of metabolic dysfunction-associated steatotic liver disease (MASLD). Currently, 38% of all adults and 7-14% of children and adolescents have MASLD. By 2040, the MASLD prevalence rate for adults is projected to increase to more than 55%. Although MASLD does not always develop into progressive liver disease, it has become the top indication for liver transplant in the United States for women and those with hepatocellular carcinoma (HCC). Nonetheless, the most common cause of mortality among patients with MASLD remains cardiovascular disease. In addition to liver outcomes (cirrhosis and HCC), MASLD is associated with an increased risk of developing de novo T2D, chronic kidney disease, sarcopenia, and extrahepatic cancers. Furthermore, MASLD is associated with decreased health-related quality of life, decreased work productivity, fatigue, increased healthcare resource utilization, and a substantial economic burden. Similar to other metabolic diseases, lifestyle interventions such as a heathy diet and increased physical activity remain the cornerstone of managing these patients. Although several obesity and T2D drugs are available to treat co-morbid disease, resmetirom is the only MASH-targeted medication for patients with stage 2-3 fibrosis that has approved by the Food and Drug Administration for use in the United States. This review discusses MASLD epidemiology and its related risk factors and outcomes and demonstrates that without further global initiatives, MASLD incidence could continue to increase.

Current Status of Glucagon-like Peptide-1 Receptor Agonists in Metabolic Dysfunction-associated Steatotic Liver Disease: A Clinical Perspective

Metabolic dysfunction-associated steatotic liver disease (MASLD) is currently a pressing public health issue associated with adverse outcomes such as cirrhosis, malignancy, transplantation, and mortality. Lifestyle modifications constitute the most effective and fundamental management approach, but they often pose challenges in sustaining long-term clinical benefits. Hence, there is a critical need to enhance our understanding through pharmacological management, which unfortunately remains limited. Glucagon-like peptide-1 receptor agonists (GLP-1RAs) have emerged as a leading treatment in the fields of diabetes and obesity, with recent preclinical and clinical studies indicating significant benefits in the management and treatment of MASLD. Our article begins by reviewing the beneficial therapeutic components of GLP-1RAs in MASLD. Subsequently, from a clinical research perspective, we concluded with the liver outcomes of current primary GLP-1RAs and co-agonists. Finally, we presented our insights on clinical concerns such as appropriate trial endpoints, management of comorbidities, and future developments. In conclusion, the benefits of GLP-1RAs in MASLD are promising, and background therapy involving metabolic modulation may represent one of the future therapeutic paradigms.

BMI gain and dietary characteristics are risk factors of MASLD in non-obese individuals

This longitudinal observational study aimed to evaluate whether cardiometabolic factors and dietary characteristics are determinants of metabolic dysfunction-associated steatotic liver disease (MASLD) in non-obese individuals (body mass index [BMI] < 25 kg/m²). The study was conducted at the Japanese Red Cross Society Kyoto Daiichi Hospital. Clinical data were longitudinally recorded at annual health checks. The diagnosis of MASLD was based on the results of abdominal ultrasonography and cardiometabolic criteria. Lifestyle behaviors and dietary characteristics were assessed using a self-administered questionnaire. A total of 4,100 non-obese middle-aged and older participants (1,636 men and 2,464 women) were followed up for an average of 6.44 ± 4.16 years. During the follow-up period, there were 410 new cases of MASLD in men (25.1%) and 484 in women (19.6%). The incidence rate was higher for men (39.7 per 1,000 person-years) than for women (30.1 per 1,000 person-years). Multivariable-adjusted logistic regression analyses using the rate of change per year with standardized values found that BMI gain was strongly associated with the onset of MASLD for both men (OR: 1.90, 95% CI: 1.64-2.19) and women (OR: 1.95, 95% CI: 1.72-2.21). Increased waist circumference and triglycerides were also associated with MASLD onset for both men and women. Lowering of high-density lipoprotein cholesterol was identified as a risk factor for MASLD in both men and women. Regarding dietary characteristics, the onset of MASLD was significantly and negatively associated with "often eating vegetables" for men (OR: 0.73, 95% CI: 0.57-0.93) and "often eating soy products" for women (OR: 0.71, 95% CI: 0.58-0.88), even after adjusting for BMI change and other covariates. These findings suggest that maintaining body weight and favorable dietary characteristics are key factors in the prevention of MASLD in non-obese individuals.

Nonalcoholic Fatty Liver Disease Increases the Risk of Lung Abscess: Findings from a Nationwide Cohort Study

Objectives: This study aimed to investigate the association between nonalcoholic fatty liver disease (NAFLD), assessed by the Fatty Liver Index (FLI), and the occurrence of lung abscess within a large population-based cohort. Method: We conducted a nationwide retrospective study using data from 367,930 subjects who underwent National Health check-ups between 2009 and 2018. Cox proportional hazards regression was performed to evaluate the association between the FLI and the incidence of lung abscess and community-acquired pneumonia (CAP) after adjusting for age, sex, and relevant covariates. Results: Among the study population, 455 (0.12%) and 44,934 (12.2%) patients were diagnosed with lung abscesses and CAP, respectively. The cumulative incidence of lung abscess was higher in individuals with elevated FLI values (FLI < 30, 0.10%; 30 ≤ FLI < 60, 0.16%; FLI ≥ 60, 0.18%; p < 0.001), whereas the incidence of CAP decreased across FLI groups (FLI < 30, 12.4%; 30 ≤ FLI < 60, 12.3%; FLI ≥ 60, 11.0%; p < 0.001). After adjusting for covariates, the risk of lung abscess significantly increased in the 30 ≤ FLI < 60 (Hazard ratio (HR) = 1.26; 95% confidence interval (CI), 0.95-1.68; p = 0.115) and the FLI ≥ 60 (HR = 1.67; 95% CI, 1.37-2.29; p < 0.001) groups, although the risk of CAP was relatively small in both groups (30 ≤ FLI < 60; HR = 1.06; 95% CI, 1.03-1.09; p < 0.001) (FLI ≥ 60; HR = 1.13; 95% CI, 1.08-1.12; p < 0.001). Conclusions: Our study provides compelling evidence supporting a potential link between NAFLD, as measured by FLI, and the incidence of lung abscess. These findings suggest the importance of vigilant monitoring of respiratory health in patients with NAFLD and emphasise the need for early detection of possible complications.