Sampling variability of liver biopsy in nonalcoholic fatty liver disease

Liver Discard Rate Attributable to Conservative Estimations of Steatosis: An Inference-based Approach

BACKGROUND

On-site conservative estimations of steatosis could result in the unnecessary discard of donor livers. This study applied the body mass index as an independent statistical indicator to determine the extent of this problem. We aimed to quantitatively evaluate if decisions based nonbiopsy donor liver assessments are more conservative (inclined to reject marginal fatty livers) than biopsy-based evaluations.

METHODS

The study processed intradatabase comparisons using 177 081 datasets from Organ Procurement and Transplantation Network spanning 2004 to 2022 September in the United States. Postmatching body mass index was applied as an independent indicator of statistical risk of hepatic steatosis (HS).

RESULTS

A total of 7420, 4990, 5994, and 7523 pair of donors with/without biopsy records were matched in 2004-2010, 2011-2014, 2015-2018, and 2019-2022 September, respectively. Consistent with our hypothesis, absent biopsies and evaluations before and during organ procurement were observed to be more conservative, leading to the discard of 16.4% (2004-2010), 16.9% (2011-2014), 10.6% (2015-2018), and 10.3% (2019-2022 September) of potential donor livers.

CONCLUSIONS

The study concludes that there was a significant (10.3%-16.9%) disparity caused by on-site nonbiopsy assessments of HS, leading to the unnecessary discard of potential donor livers. The findings emphasize the need to develop more accurate intraoperative techniques for assessing HS to optimize donor liver procurement.

Cardiac and liver impairment on multiorgan MRI and risk of major adverse cardiovascular and liver events

Cardiovascular disease and metabolic dysfunction-associated steatotic liver disease are common conditions associated with high mortality and morbidity, yet opportunities for integrated prevention are underinvestigated. We explored the association between impairment in the liver (defined by increased iron-corrected T1 (cT1) time) and/or heart (reduced left ventricular ejection fraction ≤ 50) and risk of experiencing cardiovascular- or liver-related events or all-cause mortality among 28,841 UK Biobank participants who underwent magnetic resonance imaging. Using Cox proportional hazard models, adjusted for age, sex, body mass index, type 2 diabetes and dyslipidaemia, we observed that cardiac impairment was associated with increased incidence of cardiovascular events (hazard ratio (HR) 2.3 (1.9-2.7)) and hospitalization (HR 2.1 (1.8-2.4)). Liver impairment was associated with incident cardiovascular hospitalization (cT1 ≥ 800 ms, HR 1.3 (1.1-1.5)), liver events (cT1 ≥ 875 ms, HR 9.2 (3.2-26) and hospitalization (cT1 ≥ 875 ms, HR 5.5 (3.2-9.3). Associations between cT1 and liver events were maintained in participants with metabolic dysfunction-associated steatotic liver disease (N = 6,223). Reduced left ventricular ejection fraction (≤50) combined with elevated cT1 (≥800 ms) were associated with earlier cardiovascular events (time to event 0.8 versus 2.4 years; P < 0.05). Cardiac and liver impairment are independently, or in combination, associated with cardiovascular or liver events, suggesting a dual role for magnetic resonance imaging in integrated prevention pathways.

High inherited risk predicts age-associated increases in fibrosis in patients with MASLD

BACKGROUND & AIMS

Limited data have prevented routine genetic testing from being integrated into clinical practice in metabolic dysfunction-associated steatotic liver disease (MASLD). We aimed to quantify the effect of genetic variants on changes in fibrosis severity per decade in MASLD.

METHODS

This cross-sectional study included prospectively recruited adults with MASLD aged 18-70 who underwent magnetic resonance elastography (MRE) and genotyping for PNPLA3, TM6SF2, MBOAT7, GCKR, and HSD17B13. A genetic risk score (GRS) was calculated as the sum of established risk alleles in PNPLA3 minus protective variants in HSD17B13 (0=low risk, 1=high risk). We also estimated the polygenic risk score-hepatic fat content (PRS-HFC) and the adjusted version (PRS-5). The primary endpoint was the age-related change in liver stiffness measurement (LSM) on MRE by GRS. Findings were validated using an external cohort from Latin America.

RESULTS

Among 570 participants, the median age was 57 [49-64] years, 56.8% were women, and 34.2% were Hispanic. Median MRE was 2.4 [2.1-3.0] kPa, and 51% had high GRS. High GRS was independently associated with increased LSM (β=0.28 kPa, 95%CI:0.12-0.44, p=0.001) per 10-year age increase, while the low GRS group showed no significant difference. Similar findings were observed using PRS-HFC and PRS-5. PNPLA3 genotype alone also predicted higher LSM (C/G: β=0.32 kPa, 95%CI:0.02-0.61, p=0.034; G/G: β=0.87 kPa, 95%CI:0.52-1.22, p<0.0001) and G/G genotype was associated with significantly higher LSM by age 44, which was consistent in the validation population.

CONCLUSION

GRS, PRS-HFC, PRS-5, and PNPLA3 genotypes alone are associated with greater fibrosis per decade, resulting in divergent disease trajectories starting in midlife. Assessing genetic risk in MASLD will identify high-risk patients who require more frequent monitoring.

IMPACT AND IMPLICATIONS

This study provides granular evidence that genetic predisposition, particularly the PNPLA3 G/G genotype, significantly influences the trajectory of liver fibrosis in patients with metabolic dysfunction-associated steatotic liver disease (MASLD), with a more pronounced impact emerging after the fourth decade of life. These findings highlight the importance of incorporating genetic risk assessment into MASLD management, as it allows for the early identification of high-risk individuals who may benefit from more frequent monitoring and targeted interventions. Given the rising global burden of MASLD, clinicians, researchers, and policymakers should consider integrating genetic stratification into existing risk assessment frameworks to refine screening and surveillance strategies. By optimizing patient selection for non-invasive fibrosis assessment and potential therapeutic interventions, this approach could enhance precision medicine efforts and may improve long-term outcomes.

Liver stiffness progression in biopsy-proven metabolic dysfunction-associated steatotic disease among people with diabetes versus people without diabetes: A prospective multicenter study

BACKGROUND AND AIMS

There are limited data on the progression of liver stiffness measurement (LSM) by vibration-controlled transient elastography (VCTE) in people with type 2 diabetes mellitus (T2DM) versus those without T2DM in biopsy-proven metabolic dysfunction-associated steatotic liver disease. We examined LSM progression in participants with T2DM versus those without T2DM in a large, prospective, multicenter cohort study.

APPROACH AND RESULTS

This study included 1231 adult participants (62% female) with biopsy-proven metabolic dysfunction-associated steatotic liver disease who had VCTEs at least 1 year apart. LSM progression and regression were defined by a ≥20% increase and an upward or downward change, respectively, in the LSM category in the Baveno VII categories for compensated advanced chronic liver disease, compared between participants with T2DM (n = 680) versus no T2DM (n = 551) at baseline. The mean (±SD) age and body mass index were 51.8 (±12.0) years and 34.0 (±6.5) kg/m 2 , respectively. The median (IQR) time between the first and last VCTE measurements was 4.1 (2.5-6.5) years. Participants with T2DM had higher LSM progression at 4 years (12% vs. 10%), 6 years (23% vs. 16%), and 8 years (50% vs. 39%), p = 0.04. Using a multivariable Cox proportional hazards model adjusted for multiple confounders, the presence of T2DM remained an independent predictor of LSM progression (adjusted HR: 1.35, 95% CI: 1.01-1.81, p = 0.04). T2DM was not associated with LSM regression ( p = 0.71). Mean HbA1c was significantly associated with LSM progression ( p = 0.003) and regression ( p = 0.02).

CONCLUSIONS

Using serial VCTE data from a multicenter study of participants with biopsy-proven metabolic dysfunction-associated steatotic liver disease, we demonstrate that T2DM and HbA1c are associated with LSM progression.

The Emerging Role of Second Harmonic Generation/Two Photon Excitation for Precision Digital Analysis of Liver Fibrosis in MASH Clinical Trials

Conventional histopathological evaluation of liver biopsy slides has been invaluable in assessing the causes of liver injury, the severity of the underlying disease processes, and the degree of resulting fibrosis. However, the use of conventional histologic assessments as endpoints in clinical trials is limited by the reliability of scoring systems, variability in interpretation of histologic features and translation of continuous variables into categorical scores. To increase the precision and reproducibility of liver biopsy assessment, several artificial intelligence/machine learning (AI/ML) approaches have been developed to analyse high resolution digital images of liver biopsy specimens. Multiple AI/ML platforms are in development with promising results in post-hoc analyses of clinical trial biopsies. One such technique employs images generated by Second Harmonic Generation/Two Photon Excitation (SHG/TPE) microscopy that uniquely uses unstained liver biopsies to provide high resolution images of collagen fibres to assess and quantify collagen morphometry, and avoid challenges related to staining variability. One SHG/TPE microscopy methodology coupled with AI/ML based analysis, qFibrosis™, has been used post-hoc as an exploratory endpoint in several clinical trials for metabolic dysfunction-associated steatohepatitis (MASH) demonstrating its ability to provide a consistent and more nuanced assessment of liver fibrosis that still correlates well with traditional staging. This review summarizes the development of qFibrosis and outlines the need for additional studies to validate it as a sensitive marker for changes in fibrosis in the context of treatment trials and correlate these changes with subsequent liver-related outcomes.

Change in cT1 Following Interventions in MASLD: A Systematic Review and Meta-Analysis

BACKGROUND AND AIMS

Liver corrected T1 (cT1), measured with multiparametric magnetic resonance imaging, offers an alternative to liver biopsy to monitor treatment response and liver disease activity. We aimed to perform a systematic evaluation of change in cT1 following a treatment intervention in adults with metabolic dysfunction-associated steatotic liver disease (MASLD).

METHODS

We searched the Cochrane Library, PubMed Central, and MEDLINE from 2014 to September 2024 for studies that examined cT1 responses following intervention in metabolic dysfunction-associated liver disease. Two authors independently screened records, assessed risk of bias, and extracted data. Meta-analyses were performed to explore the mean change in cT1 between baseline and end of study.

RESULTS

A total of 16 studies (n = 1134 individuals) were analyzed (13 randomized controlled trials [n = 1077]) and 3 prospective diet, lifestyle and bariatric surgery studies [n = 57]). The mean change in cT1 was -57 ms (95% confidence interval [CI], -62 to -52 ms) over a median 17 weeks (interquartile range: 12-24 weeks). By treatment type, fibroblast growth factor analogues, glucagon-like peptide-1 receptor agonists, and farnesoid X receptor agonists, cT1 had a mean change of -79 ms (95% CI, -90 to -68 ms) to -68 ms (95% CI, -77 to -58 ms) and -62 ms (95% CI, -74 to -49 ms), respectively. In contrast, the placebo arms showed a mean change in cT1 of 0 ms (95% CI, -8 to 8 ms).

CONCLUSIONS

Evidence to date supports a significant treatment-induced reduction in cT1 as compared with minimal changes in the placebo group. Our findings could inform study designs for investigational therapies and support monitoring of treatment response in individuals with metabolic dysfunction-associated liver disease in clinical trials and clinical practice.

Quantification of the Proton Density Fat Fraction and Iron Content: A Comparative Study Between 3.0 T and 5.0 T MRI

BACKGROUND

Proton density fat fraction (PDFF) and R2* are noninvasive MRI biomarkers for quantifying fat and iron in abdominal organs. While 3.0 T MRI is widely used clinically, 5.0 T may offer improved accuracy and reliability. With the increasing availability of 5.0 T, assessing its feasibility and utility for quantifying PDFF and R2* in abdominal organs is needed.

PURPOSE

To determine the agreement of the PDFF and R2* in the liver, pancreas, kidney, and paraspinal muscle at 2 different field strengths.

STUDY TYPE

Prospective.

POPULATION

A total of 127 participants, including 60 healthy volunteers and 67 with metabolic dysfunction-associated steatotic liver disease (100 women and 27 men, 52 ± 9 years old).

FIELD STRENGTH/SEQUENCE

3.0 T and 5.0 T; Chemical shift-encoded multi-echo gradient echo sequence.

ASSESSMENT

PDFF and R2* values in the liver, pancreas, kidney, and paraspinal muscle were measured by three observers to evaluate the interobserver and interfield agreement using two 3.0 T scanners (scanner 1 and scanner 2) and one 5.0 T scanner.

STATISTICAL TESTS

Linear regression, Bland-Altman analyses, and intraclass correlation coefficients (ICCs). The p-value < 0.05 indicated statistically significant.

RESULTS

PDFF and R2* at 5.0 T were strongly correlated with those at two 3.0 T scanners for all organs (R2 = 0.905-0.998 for PDFF; 0.831-0.991 for R2*), indicating high interfield ICCs (0.892-0.993 for PDFF; 0.910-0.981 for R2*). Comparisons between 5.0 T and two 3.0 T scanners showed good interfield agreement for PDFF (mean bias, -0.57% to 0.03%) while a higher bias for R2* (mean bias, -16.53 to -2.64 s-1, 95% LoA, -34.28 to 1.21 s-1) at 5.0 T compared to the comparison between 3T scanners.

DATA CONCLUSION

5.0 T revealed high interfield agreement between the PDFF and R2* with 3.0 T, which could provide reliable quantification of fat and iron contents in abdominal organs.

EVIDENCE LEVEL

2.

TECHNICAL EFFICACY

Stage 2.

SIAD (Societé d'Imagerie Abdominale et Digestive) and AFEF (Association Française pour l'Etude du Foie) best practice position paper on the implementation of ultrasound elastography in clinical practice

PURPOSE

The diagnosis of liver fibrosis is critical in managing chronic liver diseases. The EASL guidelines now recognize ultrasound elastography as a valuable, non-invasive method for assessing liver fibrosis. However, there is a lack of uniform use and reporting of the technique. The purpose of this position paper was to provide guidance on using ultrasound elastography techniques and interpreting results in clinical practice.

MATERIALS AND METHODS

A French national consensus panel of experts in radiology and hepatology, convened by SIAD (Société d'Imagerie Abdominale et Digestive) and AFEF (Association Française pour l'Etude du Foie), developed a position statement paper on best practices in ultrasound elastography. They were established using an online Delphi methodology that included an online panel discussion and item preparation. Consensus was achieved when ≥ 80 % of the participants agreed with a specific recommendation.

RESULTS

The accuracy and reliability of ultrasound elastography results could be significantly affected by a variety of operator-related and patient-related factors. Standard recommendations have been established in two areas, including recommendations for measurements and factors affecting results and reliability, and guidelines for standardized reporting of ultrasound elastography results.

CONCLUSION

This position paper is a comprehensive and accessible guide for clinicians that outlines best practices and standardized protocols to improve the reliability of ultrasound elastography assessments.

Three-Dimensional Vector MR Elastography for Evaluating Tissue Mechanical Heterogeneity to Assess Liver Disease Progression

Background Metabolic dysfunction-associated steatotic liver disease (MASLD) is a growing global health challenge, with evidence indicating that hepatic inflammation and fibrosis are heterogeneous processes. Purpose To measure liver mechanical property heterogeneity using MR elastography (MRE) and evaluate its potential as a biomarker for tissue inflammation and fibrosis in patients with MASLD. Materials and Methods Mechanical tissue heterogeneity in MASLD was assessed at three-dimensional vector MRE pixel-wise histogram analysis of shear stiffness and loss modulus in preclinical and clinical studies. The preclinical study involved 25 rats that were examined monthly, whereas the clinical study analyzed data from 179 participants across two prospective studies (September 2015 to November 2022), including some who underwent bariatric surgery at pretreatment and posttreatment MRE examinations. Mean and coefficient of variation (CV) of shear stiffness and loss modulus were calculated for each examination. Nonparametric tests and Spearman correlation coefficient were used to compare MRE-derived tissue mechanics with biopsy-confirmed fibrosis and inflammation and assess correlations with portal pressure and histopathologic hepatic fibrosis. Results The preclinical study showed that, in cirrhotic livers, CV of loss modulus positively correlated with portal pressure and fibrosis area ratio variation (ρ = 0.52 [P = .008] and 0.55 [P = .005], respectively). The clinical study showed that, in 10 healthy volunteers (median age, 36.5 years; IQR, 34.0-38.8 years; five females) and 169 participants with MASLD (median age, 50.1 years; IQR, 41.0-58.2 years; 118 females), CV of sheer stiffness (from 0.12 to 0.30 in healthy participants to participants with stage 4 fibrosis) and loss modulus (from 0.31 to 0.51 in healthy participants to participants with grade 3 inflammation) increased with increasing severity of fibrosis and inflammation, respectively. In 36 participants who underwent bariatric surgery, the CV of sheer stiffness decreased at the 1-year follow-up, from 0.16 (IQR, 0.14-0.18) to 0.14 (IQR, 0.12-0.16) (P = .009). Conclusion Tissue mechanical heterogeneity assessed at MRE positively correlated with progression of MASLD, demonstrating potential as a biomarker for liver disease severity and therapeutic intervention. ClinicalTrials.gov Identifier: NCT02565446 Published under a CC BY 4.0 license. Supplemental material is available for this article. See also the editorial by Moura Cunha in this issue.

Aspartate aminotransferase-to-platelet ratio index outperforms Fibrosis-4 in 2843 Korean patients with metabolic dysfunction-associated steatotic liver disease

AIM

The definition of metabolic dysfunction-associated steatotic liver disease (MASLD) has recently been proposed. We aim to investigate the diagnostic efficacy of noninvasive fibrosis markers in predicting liver fibrosis in patients with nonalcoholic fatty liver disease (NAFLD), metabolic dysfunction-associated fatty liver disease (MAFLD), and MASLD.

METHODS

This retrospective study involved 2843 patients diagnosed with steatotic liver disease at six tertiary hospitals in South Korea. Liver fibrosis was assessed using vibration-controlled transient elastography, and various noninvasive markers, including the aspartate aminotransferase-to-platelet ratio index (APRI), Fibrosis-4 index (FIB-4), NAFLD fibrosis score (NFS), and serum Mac-2-binding protein glycosylation isomer were analyzed.

RESULTS

Among 1106 patients, 79.9% met criteria for NAFLD, MAFLD, and MASLD. The APRI had area under the receiver operating characteristic curve (AUC) values of 0.819, 0.821, and 0.818 for liver fibrosis ≥F2, and 0.819, 0.824, and 0.884 for liver fibrosis ≥F3, and 0.890, 0.884, and 0.889 for fibrosis ≥F4 in NAFLD, MAFLD, and MASLD, respectively. The FIB-4 index showed AUC values of 0.776, 0.793, and 0.778 for fibrosis ≥F2, 0.788, 0.814, and 0.79 for fibrosis ≥F3, and 0.846, 0.859, and 0.856 for fibrosis ≥F4. The APRI consistently had the highest AUC values, except in individuals older than 64 years for fibrosis ≥F4.

CONCLUSIONS

The APRI was the most effective noninvasive fibrosis marker across NAFLD, MAFLD, and MASLD, particularly in age-stratified analyses. Further research is needed to establish standardized cut-off values and enhance the clinical utility of these markers in managing liver fibrosis.

Correlation Between Liver-to-Spleen Hounsfield Unit Ratio and Metabolic Improvement in Patients With Bariatric Surgery

Purpose

Non-alcoholic fatty liver disease (NAFLD) is becoming increasingly common, especially among obese individuals. This study evaluated the liver/spleen Hounsfield unit (HU) ratio (L/S ratio) as an indicator of steatosis and related metabolic diseases using contrast-enhanced computed tomography (CT).

Materials and Methods

A retrospective analysis was conducted on 34 patients who underwent bariatric surgery at Eunpyeong St. Mary's Hospital between March 2019 and July 2023. All patients underwent CT scans before and 6 months after surgery. The L/S ratio was calculated by dividing the average value of 3 HU of the liver by that of the spleen. The ratio correlated with pre- and post-surgery weight changes, comorbidities, and laboratory findings.

Results

The mean preoperative body mass index (BMI) was 40.5. Post-surgery, BMI significantly decreased to 31.5, and the number of patients with diabetes reduced from 18 (52.9%) to 4 (11.8%). Significant reductions were observed in hemoglobin A1c (HbA1c), aspartate transaminase (AST), and alanine transaminase (ALT) levels after surgery. The L/S ratio increased from 0.7±0.2 to 0.9±0.1, correlating with liver function improvements and weight loss (all with P<0.001). Patients with a larger change in L/S ratio demonstrated more significant improvements in AST, ALT, and HbA1c levels and a higher total weight loss percentage.

Conclusion

This study demonstrated a strong correlation between changes in the L/S ratio and metabolic improvements, including diabetes remission, following bariatric surgery. The L/S ratio could serve as a valuable index for assessing NAFLD severity and monitoring the outcomes in patients undergoing bariatric surgery.

Clinical Trial to Assess the Safety and Tolerability of Anti-IL 23 Monoclonal Antibody Guselkumab in Patients With Alcohol-Associated Liver Disease

BACKGROUND

There are no FDA-approved therapies for alcohol-associated liver disease (ALD). Preclinical studies indicate that blocking IL-23/IL-17 signalling may reverse liver injury. Guselkumab, an IL-23-specific antibody approved for psoriasis, may be beneficial for ALD.

AIMS

We aimed to assess the safety and tolerability of guselkumab in patients with ALD.

METHODS

This phase-1 dose-escalation study included patients with ≥ 2 DSM-5 criteria for alcohol use disorder, significant steatosis (MRI-PDFF ≥ 8%) and MRE < 3.63 kPa (to exclude advanced disease). Guselkumab was given subcutaneously on Days 1 and 29 in 30, 70 or 100 mg dose cohorts. Primary endpoints were adverse events (AEs) and dose-limiting toxicity.

RESULTS

We enrolled 13 patients (three 30 mg, three 70 mg, and seven 100 mg). Eleven completed the study and two early discontinued in the 100 mg group. Of them, 77% were men, and the median age was 53 [IQR 49-61] years. The median MRI-PDFF and MRE were 18.4% [IQR 8.4%-34.0%] and 2.5 [2.2-2.6] kPa, respectively. The most frequent AEs were hyperuricemia (13%, mild only) and elevated lipase (11%, mild and moderate). There were no serious adverse events or significant variations in liver enzymes. There was a suppression of peripheral interleukin (IL)-17, IL-23, IL-1b and TNF-α in the 70 and 100 mg groups, and a significant decrease in alcohol consumption over time (AUDIT-C: 6 [3-7] vs. 5 [1-6], p = 0.023).

CONCLUSIONS

Guselkumab is safe in doses up to 100 mg and may reduce inflammation markers in ALD. These findings support further phase 2 studies to evaluate the efficacy of guselkumab in ALD, particularly in patients with severe phenotypes.

Human genetics of metabolic dysfunction-associated steatotic liver disease: from variants to cause to precision treatment

Metabolic dysfunction-associated steatotic liver disease (MASLD) is characterized by increased hepatic steatosis with cardiometabolic disease and is a leading cause of advanced liver disease. We review here the genetic basis of MASLD. The genetic variants most consistently associated with hepatic steatosis implicate genes involved in lipoprotein input or output, glucose metabolism, adiposity/fat distribution, insulin resistance, or mitochondrial/ER biology. The distinct mechanisms by which these variants promote hepatic steatosis result in distinct effects on cardiometabolic disease that may be best suited to precision medicine. Recent work on gene-environment interactions has shown that genetic risk is not fixed and may be exacerbated or attenuated by modifiable (diet, exercise, alcohol intake) and nonmodifiable environmental risk factors. Some steatosis-associated variants, notably those in patatin-like phospholipase domain-containing 3 (PNPLA3) and transmembrane 6 superfamily member 2 (TM6SF2), are associated with risk of developing adverse liver-related outcomes and provide information beyond clinical risk stratification tools, especially in individuals at intermediate to high risk for disease. Future work to better characterize disease heterogeneity by combining genetics with clinical risk factors to holistically predict risk and develop therapies based on genetic risk is required.

Evaluation of MRI proton density fat fraction in hepatic steatosis: a systematic review and meta-analysis

BACKGROUND

Amidst the global rise of metabolic dysfunction-associated steatotic liver disease (MASLD), driven by increasing obesity rates, there is a pressing need for precise, non-invasive diagnostic tools. Our research aims to validate MRI Proton Density Fat Fraction (MRI-PDFF) utility, compared to liver biopsy, in grading hepatic steatosis in MASLD.

METHODS

A systematic search was conducted across Embase, PubMed/Medline, Scopus, and Web of Science until January 13, 2024, selecting studies that compare MRI-PDFF with liver biopsy for hepatic steatosis grading, defined as grades 0 (< 5% steatosis), 1 (5-33% steatosis), 2 (34-66% steatosis), and 3 (> 66% steatosis).

RESULTS

Twenty-two studies with 2844 patients were included. The analysis showed high accuracy of MRI-PDFF with AUCs of 0.97 (95% CI = 0.96-0.98) for grade 0 vs ≥ 1, 0.91 (95% CI = 0.88-0.93) for ≤ 1 vs ≥ 2, and 0.91 (95% CI = 0.88-0.93) for ≤ 2 vs 3, diagnostic odds ratio (DOR) from 98.74 (95% CI = 58.61-166.33) to 23.36 (95% CI = 13.76-39.68), sensitivity and specificity from 0.93 (95% CI = 0.88-0.96) to 0.76 (95% CI = 0.63-0.85) and 0.93 (95% CI = 0.88-0.96) to 0.89 (95% CI = 0.84-0.93), respectively. Likelihood ratio (LR) + ranged from 13.3 (95% CI = 7.4-24.0) to 7.2 (95% CI = 4.9-10.5), and LR - from 0.08 (95% CI = 0.05-0.13) to 0.27 (95% CI = 0.17-0.42). The proposed MRI-PDFF threshold of 5.7% for liver fat content emerges as a potential cut-off for the discrimination between grade 0 vs ≥ 1 (p = 0.075).

CONCLUSION

MRI-PDFF is a precise non-invasive technique for diagnosing and grading hepatic steatosis, warranting further studies to establish its diagnostic thresholds.

CLINICAL RELEVANCE STATEMENT

This study underscores the high diagnostic accuracy of MRI-PDFF for distinguishing between various grades of hepatic steatosis for early detection and management of MASLD, though further research is necessary for broader application.

KEY POINTS

MRI-PDFF offers precision in diagnosing and monitoring hepatic steatosis. The diagnostic accuracy of MRI-PDFF decreases as the grade of hepatic steatosis advances. A 5.7% MRI-PDFF threshold differentiates steatotic from non-steatotic livers.

Diagnostic Accuracy of Red Cell Distribution Width to Platelet Ratio for the Prediction of Liver Fibrosis in Patients With Chronic Liver Disease From Eastern India

Background Early diagnosis of liver cirrhosis in patients with chronic liver disease (CLD) can help delay/prevent complications and thereby improve survival. The currently available diagnostic modalities for the non-invasive assessment of hepatic fibrosis, especially FibroScan, are costly and not widely available, whereas various non-invasive scores for the assessment of fibrosis are cumbersome. Hence, we aimed to develop an easy and simple score for predicting cirrhosis in patients from Eastern India suffering from CLD with a better diagnostic accuracy. Methodology This cross-sectional, observational study was conducted between September 2019 and September 2021 in East India. Our study participants were patients who had CLD of etiologies such as alcohol-related liver disease, non-alcoholic fatty liver disease, chronic viral hepatitis B, chronic viral hepatitis C, primary biliary cholangitis, and autoimmune hepatitis, who had undergone FibroScan of the liver. All demographic details were noted, and the patients were subjected to physical examination, followed by hematological as well as biochemical investigations, including liver function tests. Non-invasive scores (such as aspartate aminotransferase (AST) to platelet ratio index (APRI) and Fibrosis-4 score (FIB-4) and red cell distribution width (RDW) to platelet ratio (RPR)) were computed, and their diagnostic accuracy for prediction of advanced fibrosis and cirrhosis were evaluated by receiver operating characteristic curve (ROC curve) analysis with comparison of area under the ROC curves. Pearson correlation and logistic regression analysis were also performed to study the association of these scores with advanced fibrosis and cirrhosis. Results The area under the ROC (AUROC) curve of the APRI score, FIB-4 score, RPR, and RPR × AST for prediction of advanced liver fibrosis was 0.817, 0.799, 0.706, and 0.811, respectively. Similarly, the AUROC of the above scores for the prediction of cirrhosis was 0.889, 0.858, 0.797, and 0.898. However, the product of RPR and AST was superior than APRI and FIB-4 for predicting cirrhosis. An RPR × AST value above the cut-off of 4.818 can help predict liver cirrhosis with 85.7% sensitivity and 85.5% specificity. Pearson correlation and logistic regression analysis also proved the association of these scores with liver fibrosis. Conclusions RPR is a simple, inexpensive, and easily available marker for predicting liver cirrhosis. Nevertheless, the variable RPR × AST can predict liver cirrhosis in patients with CLD with even greater diagnostic accuracy.

Non-invasive liver fibrosis markers are increased in obese individuals with non-alcoholic fatty liver disease and the metabolic syndrome

The need for early non-invasive diagnostic tools for chronic liver fibrosis is growing, particularly in individuals with obesity, non-alcoholic fatty liver disease (NAFLD), and the metabolic syndrome (MetS) since prevalence of these conditions is increasing. This case-control study compared non-invasive liver fibrosis markers in obesity with NAFLD and MetS (NAFLD-MetS, n = 33), in obese (n = 28) and lean (n = 27) control groups. We used MRI (T1 relaxation times (T1) and liver stiffness), circulating biomarkers (CK18, PIIINP, and TIMP1), and algorithms (FIB-4 index, Forns score, FNI, and MACK3 score) to assess their potential in predicting liver fibrosis risk. We found that T1 (892 ± 81 ms vs. 818 ± 64 ms, p < 0.001), FNI (15 ± 12% vs. 9 ± 7%, p = 0.018), CK18 (166 ± 110 U/L vs. 113 ± 41 U/L, p = 0.019), and MACK3 (0.18 ± 0.15 vs. 0.05 ± 0.04, p < 0.001) were higher in the NAFLD-MetS group compared with the obese control group. Moreover, correlations were found between CK18 and FNI (r = 0.69, p < 0.001), CK18 and T1 (r = 0.41, p < 0.001), FNI and T1 (r = 0.33, p = 0.006), MACK3 and FNI (r = 0.79, p < 0.001), and MACK3 and T1 (r = 0.50, p < 0.001). We show that liver fibrosis markers are increased in obese individuals with NAFLD and MetS without clinical signs of liver fibrosis. More studies are needed to validate the use of these non-invasive biomarkers for early identification of liver fibrosis risk.

Validation of a B-mode ultrasonography scoring system for assessing liver steatosis: A comparison with MRI-Derived proton density fat fraction

AIM

Noninvasive detection of liver steatosis and monitoring its progression are essential for effective therapeutic management. We validated the diagnostic performance of an ultrasonography (US)-based steatotic liver scoring system, derived from the B-mode method and the hepatic steatosis index (HSI) for the detection of liver steatosis, as identified by proton density fat fraction (PDFF) measurements on magnetic resonance imaging (MRI).

METHODS

A total of 916 patients with chronic liver disease were included in the analysis.

RESULTS

The median MRI-PDFF value was 4.0% (interquartile range: 2.0-9.7). The distribution of scores (0/1/2/3/4/5/6) according to the US-based steatotic liver scoring system was as follows: 475, 36, 99, 78, 141, 66, and 21, respectively. The median HSI was 32.8 (28.9-37.4). A significant positive association between advancing scores of the US-based steatotic liver scoring system and increasing MRI-PDFF values was observed (p < 0.001). The diagnostic performance of the US-based steatotic liver scoring system and HSI for detecting steatosis grades ≥1, ≥2, and 3, as determined by MRI-PDFF, showed areas under the receiver operating characteristic curve of 0.940 and 0.842 (p < 0.001), 0.949 and 0.847 (p < 0.001), and 0.945 and 0.864 (p < 0.001), respectively. When the cutoff values of the scoring system were set at 2, 3, and 4 for steatosis grades ≥1, ≥2, and 3, the sensitivity and specificity were 90.6% and 90.5%, 92.9% and 83.0%, and 93.3% and 84.0%, respectively.

CONCLUSION

The B-mode US-based steatotic liver scoring system demonstrated robust diagnostic capability in detecting liver steatosis.

Biomarkers of Histological Response in Lanifibranor-treated Patients With Metabolic Dysfunction-associated Steatohepatitis

BACKGROUND & AIMS

Lanifibranor, a pan-peroxisome proliferator-activated receptor agonist, has demonstrated therapeutic efficacy on metabolic dysfunction-associated steatohepatitis (MASH) resolution and fibrosis improvement in the Phase IIb NATIVE study. The histologic endpoints of MASH resolution and fibrosis improvement (E1), MASH resolution without worsening of fibrosis (E2), and fibrosis improvement without worsening of MASH (E3) were investigated with the aim of identifying biological signatures of E1, E2, and E3 responders based on serum biomarkers in patients treated with lanifibranor.

METHODS

NATIVE evaluated lanifibranor 800 and 1200 mg daily vs placebo in patients with non-cirrhotic MASH treated over 24 weeks. Liver biopsy was obtained at baseline and the end of treatment. Patients receiving lanifibranor were pooled, and those with liver biopsies were selected (n = 142). A panel of 65 biomarkers were evaluated by assessing baseline and absolute as well as relative changes at the end of treatment.

RESULTS

The biomarkers included in E1 score (baseline adiponectin and ferritin; delta of matrix metalloproteinase 9 and transferrin), E2 score (baseline cytokeratin 18 Fragment M65; delta of hyaluronic acid, fructosamine, and alanine aminotransferase), and E3 score (baseline cytokeratin 18 Fragment M65 and gamma-glutamyl transferase; delta of aspartate aminotransferase, insulin, and urea) represented metabolic, apoptotic, and fibrosis aspects of the disease. These signatures provided good accuracy for the noninvasive identification of histologic response under lanifibranor with area under the receiver operating characteristic curve at 0.81 ± 0.08 for E1 score, 0.80 ± 0.08 for E2 score, and 0.81 ± 0.08 for E3 score.

CONCLUSIONS

Results from this analysis show evidence that baseline values and changes in selected serum biomarkers can aid in predicting histologic response in MASH under lanifibranor treatment. These findings support utilizing a similar approach in a larger sample size (NATiV3, NCT03008070).

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.

Decreases in cT1 and liver fat content reflect treatment-induced histological improvements in MASH

BACKGROUND & AIMS

MRI biomarkers of liver disease are robust and reproducible alternatives to liver biopsy. Emerging data suggest that absolute reduction in iron-corrected T1 (cT1) of ≥80 ms and relative reduction in liver fat content (LFC) of 30% reflect histological improvement. We aimed to validate the associations of changes to these non-invasive biomarkers with histological improvement, specifically the resolution of steatohepatitis.

METHODS

We performed a retrospective analysis of participants from three interventional clinical trials who underwent multiparametric MRI to measure liver cT1 and LFC (LiverMultiScan) alongside biopsies at baseline and end of study. Responders were defined as those achieving resolution of steatohepatitis with no worsening in fibrosis. Differences in the magnitude of change in cT1 and LFC between responders and non-responders were assessed.

RESULTS

Individual patient data from 150 participants were included. There was a significant decrease in liver cT1 (-119 ms vs. -49 ms) and LFC (-65% vs. -29%) in responders compared to non-responders (p <0.001), respectively. The diagnostic accuracy to identify responders was 0.72 (AUC) for both. The Youden's index for cT1 to separate responders from non-responders was -82 ms and for liver fat was a 58% relative reduction. Those achieving a ≥80 ms reduction in cT1 were 5-fold more likely to achieve histological response (sensitivity 0.68; specificity 0.70). Those achieving a 30% relative reduction in liver fat were ∼4-fold more likely to achieve a histological response (sensitivity 0.77; specificity 0.53).

CONCLUSIONS

These results, from a pooled analysis of three drug trials, demonstrate that changes in multiparametric MRI markers of liver health (cT1 and LFC) can predict histological response for steatohepatitis following therapeutic intervention.

IMPACT AND IMPLICATIONS

We investigated the utility of two MRI-derived non-invasive tests, iron-corrected T1 mapping (cT1) and liver fat content from proton density fat fraction (PDFF), to predict histological improvement in patients who had undergone experimental treatment for metabolic dysfunction-associated steatohepatitis. Using data from 150 people who participated in one of three clinical trials, we observed that a reduction in cT1 by over 80 ms and a relative reduction in PDFF of over 58% were the optimal thresholds for change that predicted resolution of steatohepatitis on histology. PDFF as a marker of liver fat, and cT1 as a specific measure of liver disease activity, are both effective at identifying those who are likely responding to drug interventions and experiencing improvements in overall liver health.

CLINICAL TRIAL NUMBER(S)

NCT02443116, NCT03976401, NCT03551522.

Automated liver volumetry and hepatic steatosis quantification with magnetic resonance imaging proton density fat fraction

BACKGROUND

Preoperative imaging evaluation of liver volume and hepatic steatosis for the donor affects transplantation outcomes. However, computed tomography (CT) for liver volumetry and magnetic resonance spectroscopy (MRS) for hepatic steatosis are time consuming. Therefore, we investigated the correlation of automated 3D-multi-echo-Dixon sequence magnetic resonance imaging (ME-Dixon MRI) and its derived proton density fat fraction (MRI-PDFF) with CT liver volumetry and MRS hepatic steatosis measurements in living liver donors.

METHODS

This retrospective cross-sectional study was conducted from December 2017 to November 2022. We enrolled donors who received a dynamic CT scan and an MRI exam within 2 days. First, the CT volumetry was processed semiautomatically using commercial software, and ME-Dixon MRI volumetry was automatically measured using an embedded sequence. Next, the signal intensity of MRI-PDFF volumetric data was correlated with MRS as the gold standard.

RESULTS

We included the 165 living donors. The total liver volume of ME-Dixon MRI was significantly correlated with CT (r = 0.913, p < 0.001). The fat percentage measured using MRI-PDFF revealed a strong correlation between automatic segmental volume and MRS (r = 0.705, p < 0.001). Furthermore, the hepatic steatosis group (MRS ≥5%) had a strong correlation than the non-hepatic steatosis group (MRS <5%) in both volumetric (r = 0.906 vs. r = 0.887) and fat fraction analysis (r = 0.779 vs. r = 0.338).

CONCLUSION

Automated ME-Dixon MRI liver volumetry and MRI-PDFF were strongly correlated with CT liver volumetry and MRS hepatic steatosis measurements, especially in donors with hepatic steatosis.

Endoscopic Ultrasound-based Shear Wave Elastography for Detection of Advanced Liver Disease

BACKGROUND AND AIMS

Endoscopic ultrasound shear wave elastography (EUS-SWE) is a novel modality for liver stiffness measurement. The aims of this study are to evaluate the performance and reliability of EUS-SWE for detecting advanced liver disease in a prospective cohort.

METHODS

EUS-SWE measurements were prospectively obtained from patients undergoing EUS between August 2020 and March 2023. Liver stiffness measurements were compared between patients with and without advanced liver disease (ALD), defined as stage ≥3, to determine diagnostic accuracy for advanced fibrosis and portal hypertension. Logistic regression was performed to identify variables that impact the reliability of EUS-SWE readings. Select patients underwent paired magnetic resonance elastography (MRE) for liver fibrosis correlation.

RESULTS

Patients with ALD demonstrated higher liver stiffness compared to healthy controls (left lobe: 17.6 vs. 12.7 kPa, P <0.001; median right lobe: 24.8 vs. 11.0 kPa, P <0.001). The area under the receiver operator characteristic (AUROC) for the detection of ALD was 0.73 and 0.80 for left and right lobe measurements, respectively. General anesthesia was associated with reliable EUS-SWE liver readings (odds ratio: 2.73, 95% CI: 1.07-7.39, P =0.040). Left lobe measurements correlated significantly with MRE with an increase of 0.11 kPa (95% CI: 0.05-0.17 kPA) for every 1 kPa increase on EUS-SWE. D.

CONCLUSIONS

SWE is a promising technology that can readily be incorporated into standard EUS examinations for the assessment of ALD.

Deep phenotyping of patients with MASLD upon high-intensity interval training

Background & Aims

Exercise is a key component of lifestyle management in patients with metabolic dysfunction-associated steatotic liver disease (MASLD), but neither its therapeutic effect on the active stage of the disease, that is metabolic dysfunction-associated steatohepatitis (MASH) nor the mediating mechanisms have been characterized. Therefore, we performed multi-omic phenotyping of patients with MASLD-MASH on an exercise program.

Methods

Fifteen patients with MASLD conducted high-intensity interval training (HIIT) combined with home-based training for 12 weeks. MASLD was evaluated using histology, transient elastography, and multiparametric magnetic resonance imaging (MRI) before and after the intervention. Change in maximal oxygen consumption (VO2max) and MRI-determined liver fat were compared with a control group of patients with MASLD (n = 22). RNA sequencing was performed on liver, muscle, and fat biopsies of patients in the exercise group. Stool was analyzed by shotgun metagenomics and untargeted metabolomics was performed on plasma, urine, adipose, and stool.

Results

HIIT increased VO2max by 10.1% and improved mitochondrial metabolism in skeletal muscle, indicating improved cardiorespiratory fitness and adherence. VO2max increased significantly in the exercise group compared with controls. Histologically, no reduction in steatosis, MASH, or liver fibrosis was observed; however, transient elastography tended to improve. MRI-determined liver fat did not change in the exercise group compared with controls. HIIT induced changes in mRNA expression of genes related to beiging of adipose tissue and fibrogenesis in liver. In addition, specific gut microbial taxa and metabolites changed.

Conclusions

HIIT increased cardiorespiratory fitness and induced beneficial gene expression changes in muscle, adipose tissue, and liver, but without translation into histological improvement of MASLD. Longer exercise intervention trials are warranted to validate or refute current recommendations for exercise as a cornerstone treatment for MASLD-MASH.

Impact and implications

Despite exercise being considered as a key component of lifestyle management for steatotic liver disease, neither the clinical effects nor the mechanisms involved are completely understood. We show that a high-intensity interval training (HIIT) program in 15 patients with metabolic dysfunction-associated steatotic liver disease (MASLD) improved cardiorespiratory fitness, compared with 22 control patients with MASLD who did not participate in an exercise program, however, it did not improve MASLD. HIIT induced a positive effect on fat tissue and muscle metabolism which was accompanied with changes in certain gut bacteria and metabolites in blood and urine. These findings improve our understanding of the effects of exercise on the whole-body metabolism in relation to steatotic liver disease. As such, this study provides a basis for future exercise interventions in patients with MASLD, required to thoroughly test current guideline advice for exercise as a cornerstone treatment for MASLD of all stages.

Clinical trial registry

Dutch Trial Register (registration number NL7932).

Quantitative Liver Fat Assessment by Handheld Point-of-Care Ultrasound: A Technical Implementation and Pilot Study in Adults

OBJECTIVES

To implement, examine the feasibility of, and evaluate the performance of quantitative ultrasound (QUS) with a handheld point-of-care US (POCUS) device for assessing liver fat in adults.

MATERIALS AND METHODS

This prospective IRB-approved, HIPAA-compliant pilot study enrolled adults with overweight or obesity. Participants underwent chemical-shift-encoded magnetic resonance imaging to estimate proton density fat fraction (PDFF) and, within 1 mo, QUS with a POCUS device by expert sonographers and novice operators (no prior US scanning experience). Radiofrequency data from the liver collected with the POCUS device were analyzed offline using probe-specific calibrations to estimate two QUS parameters: attenuation coefficient (AC) and backscatter coefficient (BSC). Area under the receiver operating characteristic curve (AUC) of each parameter was estimated for classifying presence/absence of hepatic steatosis (defined as PDFF ≥ 5%). Spearman rank correlation between each parameter and PDFF was estimated and its significance assessed.

RESULTS

Of 18 participants (mean age, 43 y ± 14; 17 women), 8 had hepatic steatosis (PDFF ≥ 5%). Both AC and BSC classified hepatic steatosis accurately with AUCs of 0.96-0.97 for expert and 0.88-0.89 for novice operators (p < 0.01 for all) and correlated significantly with PDFF with rho's of 0.65-0.69 for expert and 0.58-0.65 for novice operators (p < 0.02 for all).

CONCLUSION

QUS can be implemented on a POCUS device and can be performed by expert or novice operators after limited training in adults with overweight or obesity with promising initial results.

Optimization of regions of interest sampling strategies for proton density fat-fraction MRI of hepatic steatosis before liver transplantation in ex vivo livers

Objectives

The quantity of regions of interest (ROIs) constitutes the primary determinant of the time investment in image analysis. In the context of proton density fat-fraction (PDFF) magnetic resonance imaging (MRI) conducted on liver grafts in ex vivo conditions, this research systematically examines various ROI sampling strategies. The findings of this study furnish essential insights, offering a foundation for optimizing time efficiency while ensuring precise assessment of hepatic steatosis before the crucial process of liver transplantation.

Methods

This was a retrospective analysis of a prospective study and included 35 liver grafts with histopathological steatosis that underwent 3T PDFF MRI in ex vivo. One ROI of 1 cm2 was selected for each hepatic segment, and any combination of ROIs in 1-8 liver segments was used, resulting in 511 combinations. Using intraclass correlation coefficients (ICCs) and Bland-Altman analyses, the PDFFs of all these combinations were compared with the 9-ROI average PDFF. There was a moderate correlation between the average PDFF and the histological findings (R = 0.47, P＜0.01).

Results

The average 9-ROI PDFF of all liver grafts was 4.07 ± 4.35 % (0.870-20.904). All strategies with ≥5 ROIs had intraclass correlation coefficient (ICC) ≥ 0.995 and absolute limits of agreement (|LOA|)≤ 1.5 %. Overall, 54 of 84 (67.5 %) 3-ROI sampling strategy had ICC ≥0.995, and 70 of 84 (70 %) had |LOA|≤ 1.5 %. A total of 111 of 126 (88.1 %) 4-ROI sampling strategy had ICC ≥0.995, and 125 of 126 (99.2 %) had |LOA| ≤ 1.5 %.

Conclusions

The employment of the 5-ROI sampling strategy proves instrumental in both time conservation and precise assessment of hepatic steatosis within liver grafts during the ex vivo phase preceding liver transplantation.

Diagnosis and Staging of Metabolic Dysfunction-Associated Steatotic Liver Disease Using Biomarker-Directed Aptamer Panels

Metabolic dysfunction-associated steatotic liver disease (MASLD) affects one-third of adults globally. Despite efforts to develop non-invasive diagnostic tools, liver biopsy remains the gold standard for diagnosing metabolic dysfunction-associated steatohepatitis (MASH) and assessing fibrosis. This study investigated RNA aptamer panels, selected using APTASHAPE technology, for non-invasive MASLD diagnosis and fibrosis stratification. Aptamer panels were selected in a cohort of individuals with MASLD (development cohort, n = 77) and tested in separate cohorts: one with MASLD (test cohort, n = 57) and one assessed for bariatric surgery (bariatric cohort, n = 62). A panel distinguishing MASLD without steatohepatitis from MASH accurately stratified individuals in the developmentcohort (AUC = 0.83) but failed in the test and bariatric cohorts. It did, however, distinguish healthy controls from individuals with MASLD, achieving an AUC of 0.72 in the test cohort. A panel for fibrosis stratification differentiated F0 from F3-4 fibrosis in the development cohort (AUC = 0.68) but not in other cohorts. Mass spectrometry identified five plasma proteins as potential targets of the discriminative aptamers, with complement factor H suggested as a novel MASLD biomarker. In conclusion, APTASHAPE shows promise as a non-invasive tool for diagnosing and staging MASLD and identifying associated plasma biomarkers.

Comparison of the diagnostic accuracy of shear wave elastography with transient elastography in adult nonalcoholic fatty liver disease: a systematic review and network meta-analysis of diagnostic test accuracy

PURPOSE

To compare the diagnostic test accuracy (DTA) of shear wave elastography (SWE) to that of transient elastography (TE) for liver fibrosis grade assessment in nonalcoholic fatty liver disease adults.

METHODS

MEDLINE, The Cochrane Library, and Web of Science were searched. Inclusion criteria were primary studies examining DTA of TE, point SWE (pSWE), two-dimensional SWE (2D-SWE), or magnetic resonance elastography (MRE) with liver biopsy. Network meta-analysis was conducted using a Bayesian bivariate mixed-effects model.

RESULTS

For fibrosis grade 2 or higher, 15 studies with 25 observations (16 observations for TE, 1 for MRE, 4 for pSWE and 2D-SWE; 2,066 patients) were included; the pooled sensitivity and specificity were 0.79 (95% credible interval (CrI) 0.70-0.86; 95% prediction interval (PI) 0.36-0.96) and 0.73 (95% CrI 0.62-0.82; 95% PI 0.23-0.96) for TE, 0.68 (95% CrI 0.48-0.83; 95% PI 0.23-0.94) and 0.75 (95% CrI 0.53-0.88; 95% PI 0.24-0.97) for pSWE, 0.85 (95% CrI 0.70-0.93; 95% PI 0.40-0.98) and 0.72 (95% CrI 0.49-0.86; 95% PI 0.20-0.96) for 2D-SWE, respectively. The proportion of studies classified as unclear in QUADAS-2 was high, and the results were heterogeneous.

CONCLUSION

2D-SWE could be recommended as TE is for liver fibrosis assessment. The protocol of this systematic review and network meta-analysis has been registered in PROSPERO (CRD42022327249). All included primary papers have already been published and the information and data can be used freely.

Liver and pancreatic fat fractions as predictors of disease severity in acute pancreatitis: an MRI IDEAL-IQ study

PURPOSE

Metabolic dysfunction-associated steatotic liver disease (MASLD) and non-alcoholic fatty pancreatic disease (NAFPD) are metabolic diseases with rising incidence. Fatty infiltration may lead to dysfunction of the liver and pancreatic tissues. This study aims to quantify liver and pancreatic fat fractions and examine their correlation with disease severity in acute pancreatitis patients.

METHODS

The severity of acute pancreatitis was assessed using the revised Atlanta classification (RAC), computed tomography severity index (CTSI), and modified CTSI (mCTSI). Proton density fat fraction (PDFF) levels of the liver and pancreas were measured via IDEAL MRI. Patients were categorized into biliary and non-biliary pancreatitis groups. Correlations between PDFF levels and the RAC, CTSI, and mCTSI scores were analyzed.

RESULTS

A total of 127 patients were included, with MASLD present in 40.9% and NAFPD in 30%. Liver PDFF values were significantly higher in non-biliary pancreatitis (p = 0.040). Patients with MASLD exhibited higher CTSI and mCTSI scores (p = 0.009, p = 0.033, respectively). No significant differences were observed in severity scales between patients with and without NAFPD. Liver PDFF was positively correlated with CTSI and mCTSI scores in biliary pancreatitis. ROC analysis identified a liver PDFF > 3.9% (p = 0.002) and pancreatic corpus PDFF > 12.1% (0.028) as diagnostic markers for severe pancreatitis. In addition, a liver PDFF < 4.5% (p = 0.042) was an indicator for biliary pancreatitis.

CONCLUSION

MASLD is associated with increased severity in acute pancreatitis. IDEAL MRI-derived PDFF levels of the liver and pancreas show potential in predicting severe acute pancreatitis and distinguishing between biliary and non-biliary etiologies.

Potential alternative and novel biomarkers for paediatric MAFLD: exploratory evidence from a Chinese cohort

BACKGROUND

While the associations between pediatric non-obese metabolic dysfunction-associated fatty liver disease (MAFLD) and multiple diagnostic biomarkers are well-established, the role of a broader range of blood-based, urine-based, and body composition-based biomarkers for monitoring MAFLD are needed.

METHODS

A pediatric cohort was established in Wuxi, China. We measured body composition biomarkers, blood-based and urine-based biomarkers, and liver stiffness in participants to diagnose MAFLD and identify alternative and novel potential biomarkers for MAFLD. Body mass index (BMI), high-density lipoprotein cholesterol (HDLC), triglycerides, glucose, systolic blood pressure (SBP), diastolic blood pressure (DBP), and waist perimeter were used as MAFLD diagnostic biomarkers. To identify alternative biomarkers, we performed correlation analysis to determine biomarkers exhibited strong correlation (|r| > 0.8, p-value < 0.05) with diagnostic biomarkers. To identify novel potential biomarkers, we performed regression analysis to determine biomarkers associated with MAFLD (p-value < 0.05 in stepwise multivariate regression) among the remaining biomarkers that are not related to the diagnostic biomarkers.

RESULTS

Out of 1,108 participants who completed all examinations (N biomarker = 91), 113 participants were diagnosed with MAFLD (prevalence: 14.99% in boys and 5.18% in girls). 27 biomarkers that were strongly correlated with diagnostic biomarkers were identified as alternative biomarkers. A multivariate logistic regression analysis identified 9 novel potential biomarkers including 5 blood-based biomarkers (plateletocrit, calcium, insulin, AST/ALT ratio, total bilirubin), urine pH, and body fat measurements in the arm, leg, and thigh.

CONCLUSIONS

This study illustrated the characteristics and potential alternative and novel biomarkers of MAFLD based on a Chinese paediatric cohort. These findings posed new paths in guiding the prevention and early diagnosis and prevention.

TRIAL REGISTRATION

This trial was registered in the Chinese Clinical Trials Registry (ChiCTR2400080508). The date of first registration, 01/31/2024. Retrospectively registered.

The relationship between anthropometric indices and non-alcoholic fatty liver disease in adults: a cross-sectional study

Background

Non-alcoholic fatty liver disease (NAFLD) is a widespread liver condition associated with diabetes, metabolic syndrome, and cardiovascular diseases, yet public awareness remains low. Early detection of risk factors is crucial, but liver biopsy, the diagnostic gold standard, is invasive and costly. Non-invasive anthropometric indices provide a safer alternative. This study examines these indices to identify the most reliable predictor of NAFLD in adults.

Methods

In the present cross-sectional study, we used the Fasa Cohort Data, conducted on about 10,000 people, of whom 1,047 were diagnosed with NAFLD. NAFLD diagnosis in this study was confirmed by physicians based on medical history and ultrasonographic evaluations, ensuring accurate and reliable identification of cases. General, anthropometric, and dietary assessments were performed using interviews, tools, and valid questionnaires. Biochemical evaluation was also done. Waist-to-hip ratio (WHR), waist-to-height ratio (WHtR), Body mass index (BMI), a body shape index (ABSI), body roundness index (BRI), and visceral fat index (VAI) were also calculated using these measurements and formulas. This study used descriptive tests, binary logistic regression, and ROC curve analysis.

Results

In both crude and adjusted models, significant associations were found between WHR, WHtR, BMI, and VAI with NAFLD. ROC analysis revealed that WHtR and BMI were the most accurate predictors of NAFLD in both genders (WHtR: men AUC = 0.750, women AUC = 0.702; BMI: men AUC = 0.754, women AUC = 0.701). BRI showed significant accuracy, but WHR (men: AUC = 0.727, women: AUC = 0.640) and VAI (men: AUC = 0.621, women: AUC = 0.622) were less effective. ABSI demonstrated poor predictive power (men: AUC = 0.530, women: AUC = 0.505) and is not recommended for NAFLD prediction.

Conclusion

Based on the findings, BMI and WHtR emerge as the most practical and accessible indicators for early screening of NAFLD in both men and women, while ABSI shows minor effectiveness in identifying the disease.

Obesity in Prediabetic Patients: Management of Metabolic Complications and Strategies for Prevention of Overt Diabetes

Obesity and prediabetes affect a substantial part of the general population, but are largely underdiagnosed, underestimated, and undertreated. Prediabetes differs from diabetes only in the degree of hyperglycaemia consequent to the progressive decline in residual beta-cell function. Both prediabetes and diabetes occur as a consequence of insulin resistance that starts several years before the clinical onset of overt diabetes. Macrovascular complications in patients with diabetes are mainly caused by insulin resistance. This is why in prediabetes, the overall cardiovascular risk is, by all means, similar to that in patients with diabetes. It is important, therefore, to identify prediabetes and treat patients not only to prevent or delay the onset of diabetes, but to reduce the cardiovascular risk associated with prediabetes. This review provides an overview of the pathophysiology of prediabetes in patients with obesity and the progression toward overt diabetes. We have reviewed nutritional and pharmacological approaches to the management of obesity and reduced glucose tolerance, and the treatment of the major comorbidities in these patients, including hypertension, dyslipidaemia, and Metabolic dysfunction-associated Steatotic Liver Disease (MASLD), has also been reviewed. In patients with obesity and prediabetes, the nutritional approach is similar to that adopted for patients with obesity and diabetes; treatments of dyslipidaemia and hypertension also have the same targets compared to patients with diabetes. MASLD is a critical issue in these patients; in the prediabetic state, MASLD rarely progresses into fibrosis. This highlights the importance of the early recognition of this pathological condition before patients become diabetic when the risk of fibrosis is much higher. It is necessary to raise awareness of the clinical relevance of this pathological condition in order to prompt early intervention before complications occur. The single most important therapeutic goal is weight loss, which must be early and persistent.

Effects of hepatic fibrosis on the quantification of hepatic steatosis using the controlled attenuation parameter in patients with chronic hepatitis B

PURPOSE

This study assessed the impact of hepatic fibrosis on the diagnostic performance of the controlled attenuation parameter (CAP) in quantifying hepatic steatosis in patients with chronic hepatitis B (CHB).

METHODS

CHB patients who underwent liver stiffness measurement (LSM) and CAP assessment using transient elastography before liver resection between 2019 and 2022 were retrospectively evaluated. Clinical data included body mass index (BMI) and laboratory parameters. The histologically determined hepatic fat fraction (HFF) and fibrosis stages were reviewed by pathologists blinded to clinical and radiologic data. The Pearson correlation coefficient between CAP and HFF was calculated. The diagnostic performance of CAP for significant hepatic steatosis (HFF ≥10%) was assessed using areas under the receiver operating curve (AUCs), stratified by fibrosis stages (F0-1 vs. F2-4). Factors significantly associated with CAP were determined by univariable and multivariable linear regression analyses.

RESULTS

Among 399 CHB patients (median age 59 years; 306 men), 16.3% showed significant steatosis. HFF ranged from 0% to 60%. Of these patients, 9.8%, 19.8%, 29.3%, and 41.1% had fibrosis stages F0-1, F2, F3, and F4, respectively. CAP positively correlated with HFF (r=0.445, P<0.001). The AUC of CAP for diagnosing significant steatosis was 0.786 (95% confidence interval [CI], 0.726 to 0.845) overall, and significantly lower in F2-4 (0.772; 95% CI, 0.708 to 0.836) than in F0-1 (0.924; 95% CI, 0.835 to 1.000) (P=0.006). Multivariable analysis showed that BMI (P<0.001) and HFF (P<0.001) significantly affected CAP, whereas LSM and fibrosis stages did not.

CONCLUSION

CAP evaluations of significant hepatic steatosis are less reliable in CHB patients with significant or more advanced (F2-4) than with no or mild (F0-1) fibrosis.

Multiparametric Ultrasound for Chronic Liver Disease

Diffuse liver disease is a substantial world-wide problem. With the combination of conventional ultrasound of the abdomen, fat quantification and elastography, appropriate staging of the patient can be assessed. This information allows for the diagnosis of steatosis and detection of fibrosis as well as prognosis, surveillance, and prioritization for treatment. With the potential for reversibility with appropriate treatment accurate assessment for the stage of chronic liver disease is critical.

Noninvasive assessment of hepatic steatosis grades by ultrasound derived fat fraction in metabolic dysfunction associated steatotic liver disease

To evaluate the diagnostic performance of ultrasound-derived fat fraction (UDFF) and clinical prediction models in assessing hepatic steatosis grades in MASLD patients, with liver biopsy as reference standard.A total of 85 obese patients who were found to have fatty liver by B-mode ultrasound and underwent UDFF measurement, with liver biopsy available, were enrolled. The diagnostic performance of UDFF, clinical prediction models including fatty liver index (FLI), hepatic steatosis index (HSI), ZheJiang University index (ZJU index) and lipid accumulation product (LAP) for hepatic steatosis was assessed. The areas under receiver operating characteristics curves (AUROCs) were utilized to determine the diagnostic efficacy. DeLong test was used to compare the diagnostic performance of different noninvasive methods for hepatic steatosis. The UDFF values of S1, S2 and S3 groups were 17.53 ± 7.49%, 25.00 ± 5.41% and 27.58 ± 6.55%, respectively (P < 0.001). UDFF values were significantly positively correlated with histologic steatosis grades (r = 0.531, P < 0.001). In the ≥ S2 group, the AUROC of UDFF was higher than that of FLI and LAP (P < 0.05), but not significantly different from that of HSI and ZJU index (P > 0.05). In the ≥ S3 group, the AUROC of UDFF was higher than that of FLI, ZJU index and LAP (P < 0.05), but not significantly different from that of HSI (P > 0.05). The UDFF proves effective in assessing hepatic steatosis in patients with MASLD, and its diagnostic efficacy exceeded that of FLI and LAP, but there was no significant difference with HSI, ZJU index in the ≥ S2 group, and with HSI in the ≥ S3 group.

Diagnostic accuracy of Fatty Liver Index (FLI) for detecting Metabolic Associated Fatty Liver Disease (MAFLD) in adults attending a tertiary care hospital, a cross-sectional study

BACKGROUND

Metabolic-associated fatty liver disease (MAFLD) is a major public health problem worldwide. This study aimed to determine the prevalence of MAFLD and evaluate the diagnostic accuracy of the Fatty Liver Index (FLI) compared to ultrasonography for detecting fatty liver in adults attending a tertiary care hospital in Gujarat, India.

METHODS

This cross-sectional study included 500 adults visiting the outpatient department between January 2023 and December 2023. MAFLD was diagnosed on ultrasound. FLI was calculated using body mass index, waist circumference, triglycerides, and gamma-glutamyl transpeptidase levels. FLI ≥ 60 indicated fatty liver. Logistic regression analysis identified factors associated with fatty liver.

RESULTS

MAFLD prevalence was 32.2% on ultrasound. High FLI (≥ 60) was present in 26.2%. Male sex, higher BMI, waist circumference, night shift work, diabetes, and triglycerides were independent predictors of fatty liver. FLI showed excellent diagnostic accuracy with a sensitivity of 96%, specificity of 92.5%, and AUC of 0.92 for detecting fatty liver on ultrasound.

CONCLUSION

MAFLD prevalence among adults was high in this hospital-based sample. FLI can serve as an accurate non-invasive tool for identifying individuals with a high probability of MAFLD. These findings emphasize the need for larger population-based studies and the implementation of regular MAFLD screening programs in high-risk groups.

Protocol for a Longitudinal Cohort Study to Understand Characteristics and Risk Factors Underlying Vibration-Controlled Transient Elastography-Diagnosed Metabolic Dysfunction-Associated Fatty Liver Disease Children

Background

Metabolic-associated steatotic liver disease (MASLD) is a novel term proposed in 2023 to replace non-alcoholic fatty liver disease (NAFLD) with the aim of better reflecting its pathogenesis and clinical manifestations. Vibration-controlled transient elastography (VCTE) is an evidence-based, non-invasive imaging device used to evaluate liver fat deposition and fibrosis. It can effectively detect liver fat infiltration greater than 5%, which is much higher than the previous ultrasound detection rate (it is difficult to detect liver fat deposition below 30%). Nevertheless, the prevalence and characteristics of MASLD children diagnosed based on these updated criteria are currently not well established.

Methods

Currently, a prospective multi-center population-based cohort study is being conducted in Wuxi, China, spanning from 2023 to 2035, involving 5600 children from four primary schools. Throughout the study's baseline and follow-up periods, yearly physical examinations, laboratory tests, VCTE assessments, and bioelectrical impedance analysis are being conducted to measure MASLD-related biomarkers. Additionally, a questionnaire is being administered to inquire about dietary habits. MASLD is being diagnosed based on clinical and laboratory criteria, and the corresponding prevalence is being assessed.

Results

Recruitment began in March 13, 2023. To date, 1475 participants have completed the physical examination and questionnaire survey.

Discussion

Our study investigated the prevalence of MASLD and its influencing factors in Chinese school-age children and adolescents. By collecting and analyzing data from physical examinations and survey questionnaires, it may propose new avenues for guiding the treatment and early-stage prevention of MASLD in children.

Trial Registration

Chinese Clinical Trials Registry (NO. ChiCTR2400080508).

Diffuse and focal liver fat: advanced imaging techniques and diagnostic insights

The fatty liver disease represents a complex, multifaceted challenge, requiring a multidisciplinary approach for effective management and research. This article uses conventional and advanced imaging techniques to explore the etiology, imaging patterns, and quantification methods of hepatic steatosis. Particular emphasis is placed on the challenges and advancements in the imaging diagnostics of fatty liver disease. Techniques such as ultrasound, CT, MRI, and elastography are indispensable for providing deep insights into the liver's fat content. These modalities not only distinguish between diffuse and focal steatosis but also help identify accompanying conditions, such as inflammation and fibrosis, which are critical for accurate diagnosis and management.

The assessment of impaired liver function and prognosis in hepatocellular carcinoma

INTRODUCTION

The impairment of liver function strongly limits the therapeutic options for hepatocellular carcinoma (HCC), and the assessment of liver function is key to finding the appropriate therapy for patients suffering from this disease. Furthermore, preexisting liver dysfunction has a negative impact on the prognosis of patients in addition to the malignant potential of HCC. Hence, defining the optimal treatment of patients with HCC requires a comprehensive examination with liver function being a crucial part of it.

AREAS COVERED

This review will provide an overview of the currently existing methods for evaluating the liver function in patients with HCC. Assessment of liver function includes scoring systems but also functional and technical methods. In addition, the role of these tests in different treatment facilities such as liver resection, transplantation, interventional and systemic therapy is summarized.

EXPERT OPINION

A comprehensive pretherapeutic assessment of the liver function includes laboratory-based scoring systems, as well as imaging- and non-imaging-based functional tests. Combining diverse parameters can help to improve the safety and efficacy of HCC therapy particularly in patients with compromised liver function. Future research should focus on optimizing pretherapeutic assessment recommendations for each therapy.

Diagnostic accuracy of exhaled nitric oxide for the non-invasive identification of patients with fibrotic metabolic dysfunction-associated steatohepatitis

BACKGROUND

Fibrotic metabolic dysfunction-associated steatohepatitis (MASH) is a condition at risk of progressing to advanced liver disease. We examined whether an innovative exhaled nitric oxide (eNO) breath test (BT) can accurately diagnose fibrotic MASH without requiring blood tests.

METHODS

One hundred and forty-seven patients with MASH were recruited, and all tests were undertaken within 1 week of recruitment. With fibrotic MASH (NAS ≥ 4 and fibrosis stage ≥ 2) as the main outcome indicator, the diagnostic efficacy of eNO in identifying fibrotic MASH was compared to other validated models for advanced fibrosis requiring venesection, namely FAST, Agile 3+, and FIB-4 scores.

RESULTS

The mean age was 40.36 ± 12.28 years, 73.5% were men. Mean body mass index was 28.83 ± 4.31 kg/m2. The proportion of fibrotic MASH was 29.25%. The area under the receiver operating curve for eNO in diagnosing fibrotic MASH was 0.737 [95% CI 0.650-0.823], which was comparable to FAST (0.751 [0.656-0.846]), Agile 3+ (0.764 [0.670-0.858]), and FIB-4 (0.721 [0.620-0.821]) (all DeLong test p > 0.05). A cut-off of eNO <8.5 ppb gave a sensitivity of 86.0% and a negative predictive value of 88.5% for ruling-out fibrotic MASH. A cut-off of eNO >13.5 ppb provided a specificity of 91.3% and a positive predictive value of 65.4% for ruling-in fibrotic MASH. Sensitivity analyses demonstrated that the diagnostic efficacy of eNO was similar across characteristics such as age. Moreover, adding vibration-controlled transient elastography-LSM (liver stiffness measurement) reduced the uncertainty interval from 46.9% to 39.5%.

CONCLUSIONS

The eNO-BT is a promising simple test for non-invasively identifying fibrotic MASH, and its performance is further improved by adding LSM measurement.

Fasting intact insulin by mass spectrometry is associated with metabolic dysfunction-associated steatotic liver disease in youth

BACKGROUND

Fasting intact insulin concentrations can predict metabolic dysfunction-associated steatotic liver disease (MASLD) in adults without diabetes; however, research in youth is limited. We sought to determine whether fasting intact insulin, measured by liquid chromatography-tandem mass spectrometry, is associated with MASLD in children.

METHODS

This retrospective cross-sectional analysis used data and samples from children who participated in studies across 3 universities between 2014 and 2022. Key measurements included fasting intact insulin, ALT, and hepatic steatosis assessed by MRI techniques. MASLD was defined as hepatic steatosis ≥5% by MRI with at least 1 cardiometabolic risk factor. The optimal cutoff points to identify MASLD were determined by maximizing the Youden index, and the AUROC curves were compared using the DeLong test.

RESULTS

The analysis included 184 children (28% male; 14.9 ± 2.6 y; 57% Hispanic race/ethnicity; body mass index 32.5 ± 8.1 kg/m2; 64% with MASLD, 43% with polycystic ovary syndrome, and 5% with other liver diseases). Fasting intact insulin and ALT levels were significantly higher in children with MASLD (p < 0.05). Fasting intact insulin was strongly associated with MASLD with an AUROC of 0.83 (0.77-0.90), sensitivity of 71%, and specificity of 85%. When combined with ALT (intact insulin × ALT [μU/mL × U/L]), the AUROC was 0.88 (0.83-0.94), with a sensitivity of 89% and specificity of 81%. The improvement in AUROC over intact insulin alone was not statistically significant (p = 0.089) but was statistically significant from ALT (p = 0.022). Optimal cutoff points for intact insulin and intact insulin × ALT were 20 μU/mL and 522 μU/mL × U/L, respectively.

CONCLUSIONS

In pediatric patients, measurements of fasting intact insulin alone and combined with ALT provide a noninvasive strategy for identifying the presence of MASLD.

Non-invasive prediction nomogram for predicting significant fibrosis in patients with metabolic-associated fatty liver disease: a cross-sectional study

BACKGROUND AND AIM

This study aims to validate the efficacy of the conventional non-invasive score in predicting significant fibrosis in metabolic-associated fatty liver disease (MAFLD) and to develop a non-invasive prediction model for MAFLD.

METHODS

This cross-sectional study was conducted among 7701 participants with MAFLD from August 2018 to December 2023. All participants were divided into a training cohort and a validation cohort. The study compared different subgroups' demographic, anthropometric, and laboratory examination indicators and conducted logistic regression analysis to assess the correlation between independent variables and liver fibrosis. Nomograms were created using the logistic regression model. The predictive values of noninvasive models and nomograms were evaluated using receiver operating characteristic (ROC) curve analysis and decision curve analysis (DCA).

RESULTS

Four nomograms were developed for the quantitative analysis of significant liver fibrosis risk based on the multivariate logistic regression analysis results. The nomogram's area under ROC curves (AUC) was 0.710, 0.714, 0.748, and 0.715 in overall MAFLD, OW-MAFLD, Lean-MAFLD, and T2DM-MAFLD, respectively. The nomogram had a higher AUC in all MAFLD participants and OW-MAFLD than the other non-invasive scores. The DCA curve showed that the net benefit of each nomogram was higher than that of APRI and FIB-4. In the validation cohort, the AUCs of the nomograms were 0.722, 0.750, 0.719, and 0.705, respectively.

CONCLUSION

APRI, FIB-4, and NFS performed poorly predicting significant fibrosis in patients with MAFLD. The new model demonstrated improved diagnostic accuracy and clinical applicability in identifying significant fibrosis in MAFLD.

Simultaneous 3D T 1 $$ {\mathrm{T}}_1 $$ , T 2 $$ {\mathrm{T}}_2 $$ , and fat-signal-fraction mapping with respiratory-motion correction for comprehensive liver tissue characterization at 0.55 T

PURPOSE

To develop a framework for simultaneous three-dimensional (3D) mapping ofT 1 $$ {\mathrm{T}}_1 $$ ,T 2 $$ {\mathrm{T}}_2 $$ , and fat signal fraction in the liver at 0.55 T.

METHODS

The proposed sequence acquires four interleaved 3D volumes with a two-echo Dixon readout.T 1 $$ {\mathrm{T}}_1 $$ andT 2 $$ {\mathrm{T}}_2 $$ are encoded into each volume via preparation modules, and dictionary matching allows simultaneous estimation ofT 1 $$ {\mathrm{T}}_1 $$ ,T 2 $$ {\mathrm{T}}_2 $$ , andM 0 $$ {M}_0 $$ for water and fat separately. 2D image navigators permit respiratory binning, and motion fields from nonrigid registration between bins are used in a nonrigid respiratory-motion-corrected reconstruction, enabling 100% scan efficiency from a free-breathing acquisition. The integrated nature of the framework ensures the resulting maps are always co-registered.

RESULTS

T 1 $$ {\mathrm{T}}_1 $$ ,T 2 $$ {\mathrm{T}}_2 $$ , and fat-signal-fraction measurements in phantoms correlated strongly (adjustedr 2 > 0 . 98 $$ {r}^2>0.98 $$ ) with reference measurements. Mean liver tissue parameter values in 10 healthy volunteers were427 ± 22 $$ 427\pm 22 $$ ,47 . 7 ± 3 . 3   ms $$ 47.7\pm 3.3\;\mathrm{ms} $$ , and7 ± 2 % $$ 7\pm 2\% $$ forT 1 $$ {\mathrm{T}}_1 $$ ,T 2 $$ {\mathrm{T}}_2 $$ , and fat signal fraction, giving biases of71 $$ 71 $$ ,- 30 . 0   ms $$ -30.0\;\mathrm{ms} $$ , and- 5 $$ -5 $$ percentage points, respectively, when compared to conventional methods.

CONCLUSION

A novel sequence for comprehensive characterization of liver tissue at 0.55 T was developed. The sequence provides co-registered 3DT 1 $$ {\mathrm{T}}_1 $$ ,T 2 $$ {\mathrm{T}}_2 $$ , and fat-signal-fraction maps with full coverage of the liver, from a single nine-and-a-half-minute free-breathing scan. Further development is needed to achieve accurate proton-density fat fraction (PDFF) estimation in vivo.

GLCV-NET: An automatic diagnosis system for advanced liver fibrosis using global-local cross view in B-mode ultrasound images

BACKGROUND AND OBJECTIVE

Advanced liver fibrosis is a critical stage in the evaluation of chronic liver disease (CLD), holding clinical significance in the development of treatment strategies and estimating the disease progression.

METHODS

This paper proposes an innovative Global-Local Cross-View Network (GLCV-Net) for the automatic diagnosis of advanced liver fibrosis from ultrasound (US) B-mode images. The proposed method consists of three main components: 1. A Segmentation-enhanced Global Hybrid Feature Extractor for segmenting the liver parenchyma and extracting global features; 2. A Heatmap-weighted Local Feature Extractor for selecting candidate regions and automatically identifying suspicious areas to construct local features; 3. A Scale-adaptive Fusion Module to balance the contributions of global and local scales in evaluating advanced liver fibrosis.

RESULTS

The predictive performance of the model was validated on an internal dataset of 1003 chronic liver disease (CLD) patients and an external dataset of 46 CLD patients, both subjected to liver fibrosis staging through pathological assessment. On the internal dataset, GLCV-Net achieved 86.9% accuracy, 85.0% recall, 85.4% precision, and 85.2% F1-score. Further validation on the external dataset confirmed its robustness, with scores of 86.1% in accuracy, 83.1% in recall, 80.8% in precision, and 81.9% in F1-score.

CONCLUSION

These results underscore the GLCV-Net's potential as a promising approach for non-invasively and accurately diagnosing advanced liver fibrosis in CLD patients, breaking through the limitations of traditional methods by integrating global and local information of liver fibrosis, significantly enhancing diagnostic accuracy.

Pemafibrate for treating MASLD complicated by hypertriglyceridaemia: a multicentre, open-label, randomised controlled trial study protocol

INTRODUCTION

Non-alcoholic fatty liver disease, now known as metabolic dysfunction-associated steatotic liver disease (MASLD), is a phenotype of the metabolic syndrome in the liver and is clearly associated with metabolic abnormalities such as hyperglycaemia and dyslipidaemia. Although the prevalence of MASLD is increasing worldwide, there is currently no consensus on the efficacy and safety of the drugs used to treat MASLD/metabolic dysfunction-associated steatohepatitis (MASH). Pemafibrate, a selective peroxisome proliferator-activated receptor alpha modulator, was designed to have higher peroxisome proliferator-activated receptor alfa (PPARα) agonist activity and selectivity than existing PPARα agonists, and in development trials, without increasing creatinine levels, lipid parameters and alanine aminotransferase (ALT) were significantly improved. Thus, pemafibrate may effectively ameliorate the pathogenesis and metabolic abnormalities in MASLD/MASH. In this trial, we evaluated the efficacy and safety of pemafibrate in patients with MASLD/MASH.

METHODS AND ANALYSIS

This trial was designed as an open-label, three-arm, randomised controlled study. After obtaining informed consent, patients aged 20-80 years who met the selection criteria were enrolled. Patients were randomised to receive pemafibrate 0.4 mg/day, 0.2 mg/day or fenofibrate (n=120 per group). The duration of treatment was 48 weeks. The primary endpoint was a change in ALT levels after 24 weeks of administration. Secondary endpoints included changes from baseline in liver fibrosis markers (fibrosis-4 index, type IV collagen 7s, enhanced liver fibrosis and Mac-2 binding protein glycosylation isomer) at 48 weeks as well as changes in liver fat mass and liver stiffness measured by MRI and ultrasound (US) at centres equipped with MRI and US capabilities.

ETHICS AND DISSEMINATION

Ethical approval was obtained from the Yokohama City University Certified Institutional Review Board before participant enrolment (CRB20-014). The results of this study will be submitted for publication in international peer-reviewed journals and the key findings will be presented at international scientific conferences. Participants wishing to understand the results of this study will be contacted directly on data publication.

TRIAL REGISTRATION NUMBER

This trial was registered in the Japan Registry of Clinical Trials (number: jRCTs031200280).

PROTOCOL VERSION

V.1.9, 23 November 2023.

Pediatric MASLD: current understanding and practical approach

Metabolic dysfunction-associated steatotic liver disease (MASLD) is now the most prevalent chronic liver disease in children in industrialized countries mainly due to the rise in obesity and overweight. Besides risk of progressive liver damage, MASLD also carries an increased risk of extra-hepatic morbidity, most importantly type 2 diabetes mellitus and cardiovascular disease. Important challenges remain in the prevention, detection, and treatment of this prevalent disorder. This review outlines the epidemiology and risk factors of MASLD and provides an approach to screening, diagnosis, and treatment based on current best available evidence and expert opinion. What is known: • NAFLD/MASLD is a common disorder in children strongly related to obesity/overweight and insulin resistance. • This silent disorder is underdiagnosed due to lack of awareness and lack of simple diagnostic criteria. What is new: • New diagnostic criteria have transformed NAFLD/MASLD from a diagnosis of exclusion to a positive diagnosis with simple criteria. • Effective treatments are emerging for adults and will likely become available for children. • Identifying children with NAFLD/MASLD has become even more important due to this new treatment perspective.

Liver fibrosis as a barometer of systemic health by gauging the risk of extrahepatic disease

This review article proposes the theory that liver fibrosis, the abnormal accumulation of excessive extracellular matrix, is not just an indicator of liver disease but also a negative reflection of overall systemic health. Liver fibrosis poses a heavy financial burden on healthcare systems worldwide and can develop due to chronic liver disease from various causes, often due to sustained inflammation. Liver fibrosis may not generate symptoms and become apparent only when it reaches the stage of cirrhosis and is associated with clinically significant portal hypertension and leads to decompensation events or promotes the development of hepatocellular carcinoma. While chronic viral hepatitis and excessive alcohol consumption were once the primary causes of chronic liver disease featuring fibrosis, this role is now increasingly taken over by metabolic dysfunction-associated steatotic liver disease (MASLD). In MASLD, endothelial dysfunction is an essential component in pathogenesis, promoting the development of liver fibrosis, but it is also present in endothelial cells of other organs such as the heart, lungs, and kidneys. Accordingly, liver fibrosis is a significant predictor of liver-related outcomes, as well as all-cause mortality, cardiovascular risk, and extrahepatic cancer. Physicians should be aware that individuals seeking medical attention for reasons unrelated to liver health may also have advanced fibrosis. Early identification of these at-risk individuals can lead to a more comprehensive assessment and the use of various treatment options, both approved and investigational, to slow or reverse the progression of liver fibrosis.

Modernizing metabolic dysfunction-associated steatotic liver disease diagnostics: the progressive shift from liver biopsy to noninvasive techniques

Metabolic dysfunction-associated steatotic liver disease (MASLD) is a growing public health concern worldwide. Liver biopsy is the gold standard for diagnosing and staging MASLD, but it is invasive and carries associated risks. In recent years, there has been significant progress in developing noninvasive techniques for evaluation. This review article discusses briefly current available noninvasive assessments and the various liver biopsy techniques available for MASLD, including invasive techniques such as transjugular and transcutaneous needle biopsy, intraoperative/laparoscopic biopsy, and the evolving role of endoscopic ultrasound-guided biopsy. In addition to discussing the various biopsy techniques, we review the current state of knowledge on the histopathologic evaluation of MASLD, including the various scoring systems used to grade and stage the disease. We also explore current and alternative modalities for histopathologic evaluation, such as whole slide imaging and the utility of immunohistochemistry. Overall, this review article provides a comprehensive overview of the progress in liver biopsy techniques for MASLD and compares invasive and noninvasive modalities. However, beyond clinical trials, the practical application of liver biopsy may be limited, as ongoing advancements in noninvasive fibrosis assessments are expected to more effectively identify candidates for MASLD treatment in real-world settings.

NAFLD No More: A Review of Current Guidelines in the Diagnosis and Evaluation of Metabolic Dysfunction-Associated Steatotic Liver Disease (MASLD)

PURPOSE OF REVIEW

Provide a concise update on metabolic dysfunction-associated steatotic liver disease (MASLD), formerly known as non-alcoholic fatty liver disease (NAFLD), as well as a practical approach to screening and initial evaluation.

RECENT FINDINGS

Nomenclature changes have placed a greater focus on cardiometabolic risk factors in the definition of MASLD. Screening for MASLD is by stepwise noninvasive serum and imaging tests which can identify patients at risk for advanced fibrosis and liver-related complications. MASLD has been increasing in prevalence and disease burden but is underrecognized in primary care and endocrinology clinics. Multiple society guidelines, synthesized here, provide a framework for the initial approach in the diagnosis and evaluation of MASLD. Recent advances in pharmacologic treatment underline the importance of screening for patients who are at risk for advanced fibrosis as they are most likely to benefit from new drug classes, such as the liver-directed thyroid receptor agonist resmiterom.