Biopsy and Noninvasive Methods to Assess Progression of Nonalcoholic Fatty Liver Disease

Metabolic dysfunction-associated fatty liver disease indicates more hepatic fibrosis than nonalcoholic fatty liver disease

The term metabolic dysfunction-associated fatty liver disease (MAFLD) has been proposed based on a redefinition of the nonalcoholic fatty liver disease (NAFLD) criteria. Our study aimed to address the knowledge gap by comparing the diagnostic accuracy of MAFLD and NAFLD criteria in identifying significant fibrosis among patients with hepatic steatosis. A cross-sectional study was conducted on 2626 patients with hepatic steatosis treated at Beijing Ditan Hospital between January 2009 and December 2022. Patients with viral hepatitis were excluded. Significant fibrosis was defined as a Meta-analysis of Histological Data in Viral Hepatitis (METAVIR) score F ≥ 2. MAFLD and NAFLD were diagnosed in 478 and 428 patients, respectively. Clinicopathological characteristics were compared between the MAFLD+ NAFLD- group (patients who met the criteria for MAFLD but not NAFLD) and MAFLD- NAFLD+ group (patients who met the criteria for NAFLD but not MAFLD). A total of 743 patients with histologically verified hepatic steatosis were analyzed. The MAFLD+ NAFLD- group comprised 163 (21.9%) and the MAFLD- NAFLD+ group comprised 113 (15.2%) patients. Patients in the MAFLD+ NAFLD- group were older and more likely to be male and had higher body mass index and liver stiffness levels than those in the MAFLD- NAFLD+ group. The prevalence of significant fibrosis was higher in the MAFLD+ NAFLD- group than in the MAFLD- NAFLD+ group (43.6% vs 15.9%, P < .001). The MAFLD criteria may be a better indicator of fibrosis than the NAFLD criteria. Fibrosis in patients with MAFLD can be determined by metabolic disorders, not excessive alcohol consumption.

A blood-based biomarker panel for non-invasive diagnosis of metabolic dysfunction-associated steatohepatitis

The current diagnosis of metabolic dysfunction-associated steatotic liver disease (MASLD) and its severe form, metabolic dysfunction-associated steatohepatitis (MASH), is suboptimal. Here, we recruited 700 individuals, including 184 from Hong Kong as a discovery cohort and 516 from San Diego, Wenzhou, and Hong Kong as three validation cohorts. A panel of 3 parameters (C-X-C motif chemokine ligand 10 [CXCL10], cytokeratin 18 fragments M30 [CK-18], and adjusted body mass index [BMI]) was formulated (termed N3-MASH), which discriminated patients with MASLD from healthy controls with an area under the receiver operating characteristic (AUROC) of 0.954. Among patients with MASLD, N3-MASH could identify patients with MASH with an AUROC of 0.823, achieving 90.0% specificity, 62.9% sensitivity, and 88.6% positive predictive value. The diagnostic performance of N3-MASH was confirmed in three validation cohorts with AUROC of 0.802, 0.805, and 0.823, respectively. Additionally, N3-MASH identifies patients with MASH improvement with an AUROC of 0.857. In summary, we developed a robust blood-based panel for the non-invasive diagnosis of MASH, which might help clinicians reduce unnecessary liver biopsies.

Liver Fibrosis and Cardiovascular Events

OBJECTIVES

Liver fibrosis represents a common sequela of nonalcoholic fatty liver disease (NAFLD) and other chronic liver diseases. Noninvasive liver fibrosis scores (LFSs) aim to evaluate the severity of liver fibrosis. Whether LFSs can predict the risk of future cardiovascular events (CVEs) remains unclear. This systematic review aimed to clarify the association between liver fibrosis and CVEs by studying the value of LFSs, namely the Fibrosis-4 (FIB-4) Index for Liver Fibrosis score and the NAFLD Fibrosis Score (NFS), for predicting CVEs.

METHODS

PubMed, Scopus, Web of Science, and Cochrane Library were searched for relevant prospective studies. Retrieved articles were screened to confirm their eligibility for the systematic review. We evaluated the quality of the included studies using the National Institutes of Health tool.

RESULTS

Twelve studies of high to fair quality were included in this systematic review. Of note, 10/12 studies reported an independent association between high LFSs and the risk of CVEs, cardiovascular mortality, and all-cause mortality (all P < 0.05). In addition, an advanced histological grade of liver fibrosis (grade 3 or 4) was suggestive of CVE occurrence. NAFLD also appeared to be associated with a higher risk of CVEs at any severity of fibrosis (all P < 0.05).

CONCLUSIONS

The findings of this review suggest that liver fibrosis in patients with NAFLD is an independent predictor of future adverse CVEs, cardiovascular mortality, and all-cause mortality. Noninvasive and easy-to-perform LFSs, including FIB-4 score and the NFS, appear useful in predicting such events in patients with a spectrum of cardiovascular diseases and the general population without known cardiovascular disease.

Non-alcoholic fatty liver disease: The importance of physical activity and nutrition education-A randomized controlled study

BACKGROUND AND AIM

Non-alcoholic fatty liver disease (NAFLD) is characterized by the accumulation of excess fat in the liver, causing liver cell damage, increased inflammation, and weight gain. Despite its high prevalence, diagnosis and follow-up of the disease is difficult. Irisin, a slimming myokine produced in response to physical activity (PA), exhibits anti-inflammatory and anti-obesity effects. This study aimed to investigate changes in irisin levels, inflammation markers (tumor necrosis factor-α [TNF-α] and interleukin-6 [IL-6]), and myeloid differentiation factor-2 (MD2) levels in NAFLD, as well as anthropometric and routine biochemical parameters, by providing PA recommendations and nutrition education (NE) to individuals diagnosed with NAFLD over a period of 12 weeks.

METHODS

The study included 62 patients diagnosed with NAFLD who did not use alcohol. They were divided into groups: PA, NE, both (NE + PA), and untreated (control) patients. Patients receiving NE were provided with 1-h NE sessions every 4 weeks for 12 weeks, and their personal information, nutritional status, 24-h retrospective food consumption record, and anthropometric measurements were recorded at the beginning (day 0) and end (week 12) of the study. The PA group was recommended aerobic walking for 30 min, 5 days a week. At the beginning (day 0) and end (week 12) of the study, patients' anthropometric and routine biochemical tests were conducted, and irisin, MD2, TNF-α, and IL-6 levels were measured using the ELISA method.

RESULTS

All groups were similar in demographic characteristics and dietary habits. After 12 weeks, there were no significant differences in biochemical parameters among the groups. Glucose levels increased in the untreated group but decreased in the PA and PA + NE groups compared to baseline, with a significant decrease in the PA group. Insulin levels significantly decreased in the NE group. The PA + NE group showed decreased aspartate aminotransferase (AST), gamma-glutamyl transferase, alkaline phosphatase, total cholesterol, low-density lipoprotein, and triglyceride levels and significant decrease in ALT levels. AST decreased significantly in the PA group while high-density lipoprotein increased significantly. There were no statistically significant differences between the groups in irisin, MD2, IL-6, and TNF-α levels. After 12 weeks, irisin levels significantly increased in nutrition and PA groups except the untreated group. There were no statistically significant differences in IL-6 and MD2 levels compared with baseline after 12 weeks. PA recommendations alone were not effective in observing significant changes in anthropometric measurements in individuals with NAFLD. It was detected that only nutritional recommendations provided a significant decrease in body fat ratio but were insufficient for the change in other anthropometric measurements. In the group where NE and PA were recommended together, a significant decrease in anthropometric measurements was found. The NE group significantly reduced their energy and carbohydrates (%EI) intake after 12 weeks of intervention compared with the baseline.

CONCLUSION

NE and PA recommendations led to improvements in liver-related biochemical parameters and significant reductions in anthropometric measurements among individuals with NAFLD. Moreover, patients receiving NE experienced a decrease in energy and carbohydrates intake as a percentage of total energy intake (%EI). Increased irisin levels in NE, PA, and NE + PA groups may have contributed to the decrease in body fat percentage.

Deep learning for predicting fibrotic progression risk in diabetic individuals with metabolic dysfunction-associated steatotic liver disease initially free of hepatic fibrosis

Objective

Metabolic dysfunction-associated steatotic liver disease (MASLD) significantly impacts patients with type 2 diabetes mellitus (T2DM), where current non-invasive assessment methods show limited predictive power for future fibrotic progression. This study aims to develop an enhanced deep learning (DL) model that integrates ultrasound elastography images with clinical data, refining the prediction of fibrotic progression in T2DM patients with MASLD who initially exhibit no signs of hepatic fibrosis.

Methods

We enrolled 946 diabetic MASLD patients without advanced fibrosis, confirmed by initial liver stiffness measurements (LSM) below 6.5 kPa. Patients were divided into a training dataset of 671 and a testing dataset of 275. Hepatic shear wave elastography (SWE) images measured liver stiffness, classifying participants based on progression. A DL integrated model (DI-model) combining SWE images and clinical data was trained and its predictive performance compared with individual Image and Tabular models, as well as a logistic regression model on the testing dataset.

Results

Fibrotic progression was observed in 18.1 % of patients over three years. During the training phase, the DI-model outperformed other models, achieving the lowest validation loss of 0.161 and highest accuracy of 0.933 through cross-validation. In the testing phase, it demonstrated robust discrimination with AUCs of 0.884 and 0.903 for the receiver operating characteristic and precision-recall curves, respectively, clearly outperforming other models. Shapley analysis identified BMI, LSM, and glycated hemoglobin as critical predictors.

Conclusion

The DI-model significantly enhances the prediction of future fibrotic progression in diabetic MASLD patients, demonstrating the benefit of combining clinical and imaging data for early diagnosis and intervention.

Metabolic Dysfunction-Associated Steatohepatitis Detected by Neutrophilic Crown-Like Structures in Morbidly Obese Patients: A Multicenter and Clinicopathological Study

Metabolic dysfunction-associated steatohepatitis (MASH) is the progressive form of metabolic dysfunction-associated steatotic liver disease (MASLD), and closely associated with a high risk of liver-related morbidity and mortality. Although enhanced neutrophil infiltration of the liver is a histological hallmark of MASH, the morphological pattern of hepatic neutrophils and their relevance to the definition of MASH remain unknown. This clinicopathological study aimed to determine the association of neutrophilic crown-like structures (CLSs) in liver biopsies and evaluate their relevance to the histological diagnosis of MASH. A total of 483 morbidly obese adults who underwent bariatric surgery were recruited. Neutrophilic CLSs in liver biopsies were detected by immunohistochemistry for neutrophil elastase and proteinase 3. All participants were classified into 4 histological subgroups: no MASLD (118, 24.4%), MASLD (76, 15.7%), borderline MASH (185, 38.3%), and definite MASH (104, 21.5%). In the discovery cohort (n = 379), the frequency of neutrophilic CLSs increased in line with the severity of liver disease. The number of neutrophilic CLSs was positively correlated with established histological characteristics of MASH. At a cutoff value of <0.3 per 20× microscopic field, the number of neutrophilic CLSs yielded a robust diagnostic accuracy to discriminate no MASLD and MASLD from borderline MASH and definite MASH; a cutoff at >1.3 per 20× microscopic field exhibited a statistically significant accuracy to distinguish definite MASH from other groups (no MASLD, MASLD, and borderline MASH). The significance of neutrophilic CLSs in identifying borderline MASH and definite MASH was confirmed in an external validation cohort (n = 104). The frequency of neutrophilic CLSs was significantly higher than that of macrophagic CLSs. In conclusion, neutrophilic CLSs in the liver represent a typical histological characteristic of MASH and may serve as a promising indicator to improve the diagnostic accuracy of MASH during histological assessment of liver biopsies.

The association between platelet-related parameters and nonalcoholic fatty liver disease in a metabolically healthy nonobese population

Nonalcoholic fatty liver disease (NAFLD) is the most common chronic liver disease characterized by subclinical inflammation and is related to obesity and metabolic syndrome (MS), but it is also frequently observed in nonobese populations. We aimed to evaluate the relationship between the white blood cell count-to-mean platelet volume ratio (WBC/MPV), platelet-to-lymphocyte count ratio (PLR) and lymphocyte-monocyte ratio (LMR) in association with NAFLD, considering the presence of obesity and MS. Additionally, we aimed to investigate whether these parameters exhibited similar correlations in metabolic dysfunction-associated steatotic liver disease (MASLD) as observed in NAFLD. This cross-sectional study included subjects who underwent a comprehensive health evaluation, including blood tests and abdominal ultrasonography. Subgroup analyses were conducted based on obesity and MS. Out of a total 5929 subjects (3271 males, mean age 49.7 ± 10.6 years), 2253 (38.0%) had NAFLD. WBC/MPV was significantly higher, and PLR was significantly lower in subjects with NAFLD. In the analysis restricted to the nonobese (BMI < 25 kg/m2) population without MS, both WBC/MPV and PLR were independently associated with NAFLD: WBC/MPV (adjusted OR 3.366; 95% CI 2.238-5.066) and PLR (adjusted OR 0.997; 95% CI 0.996-0.999). When assessing the risk of NAFLD based on the WBC/MPV and PLR quartiles, the adjusted OR and 95% CI for the lowest quartile compared to the highest were 2.055 (95% CI 1.626-2.602) for WBC/MPV and 0.660 (95% CI 0.523-0.832) for PLR in the nonobese, metabolically healthy group. The levels of WBC/MPV and PLR were independently associated with NAFLD. Furthermore, in MASLD, an association with WBC/MPV, PLR and LMR was identified, similar to the results observed in NAFLD, even after adjusting for confounding variables. In conclusion, the present study demonstrated a significant association between NAFLD and platelet-related parameters, especially in nonobese, metabolically healthy subjects.

Elevated Kallistatin promotes the occurrence and progression of non-alcoholic fatty liver disease

Non-alcoholic fatty liver disease (NAFLD) is the most common chronic liver disease worldwide, and the development of non-alcoholic steatohepatitis (NASH) might cause irreversible hepatic damage. Hyperlipidemia (HLP) is the leading risk factor for NAFLD. This study aims to illuminate the causative contributor and potential mechanism of Kallistatin (KAL) mediating HLP to NAFLD. 221 healthy control and 253 HLP subjects, 62 healthy control and 44 NAFLD subjects were enrolled. The plasma KAL was significantly elevated in HLP subjects, especially in hypertriglyceridemia (HTG) subjects, and positively correlated with liver injury. Further, KAL levels of NAFLD patients were significantly up-regulated. KAL transgenic mice induced hepatic steatosis, inflammation, and fibrosis with time and accelerated inflammation development in high-fat diet (HFD) mice. In contrast, KAL knockout ameliorated steatosis and inflammation in high-fructose diet (HFruD) and methionine and choline-deficient (MCD) diet-induced NAFLD rats. Mechanistically, KAL induced hepatic steatosis and NASH by down-regulating adipose triglyceride lipase (ATGL) and comparative gene identification 58 (CGI-58) by LRP6/Gɑs/PKA/GSK3β pathway through down-regulating peroxisome proliferator-activated receptor γ (PPARγ) and up-regulating kruppel-like factor four (KLF4), respectively. CGI-58 is bound to NF-κB p65 in the cytoplasm, and diminishing CGI-58 facilitated p65 nuclear translocation and TNFα induction. Meanwhile, hepatic CGI-58-overexpress reverses NASH in KAL transgenic mice. Further, free fatty acids up-regulated KAL against thyroid hormone in hepatocytes. Moreover, Fenofibrate, one triglyceride-lowering drug, could reverse hepatic steatosis by down-regulating KAL. These results demonstrate that elevated KAL plays a crucial role in the development of HLP to NAFLD and may be served as a potential preventive and therapeutic target.

Portal hypertension in patients with nonalcoholic fatty liver disease: Current knowledge and challenges

Portal hypertension (PH) has traditionally been observed as a consequence of significant fibrosis and cirrhosis in advanced non-alcoholic fatty liver disease (NAFLD). However, recent studies have provided evidence that PH may develop in earlier stages of NAFLD, suggesting that there are additional pathogenetic mechanisms at work in addition to liver fibrosis. The early development of PH in NAFLD is associated with hepatocellular lipid accumulation and ballooning, leading to the compression of liver sinusoids. External compression and intra-luminal obstacles cause mechanical forces such as strain, shear stress and elevated hydrostatic pressure that in turn activate mechanotransduction pathways, resulting in endothelial dysfunction and the development of fibrosis. The spatial distribution of histological and functional changes in the periportal and perisinusoidal areas of the liver lobule are considered responsible for the pre-sinusoidal component of PH in patients with NAFLD. Thus, current diagnostic methods such as hepatic venous pressure gradient (HVPG) measurement tend to underestimate portal pressure (PP) in NAFLD patients, who might decompensate below the HVPG threshold of 10 mmHg, which is traditionally considered the most relevant indicator of clinically significant portal hypertension (CSPH). This creates further challenges in finding a reliable diagnostic method to stratify the prognostic risk in this population of patients. In theory, the measurement of the portal pressure gradient guided by endoscopic ultrasound might overcome the limitations of HVPG measurement by avoiding the influence of the pre-sinusoidal component, but more investigations are needed to test its clinical utility for this indication. Liver and spleen stiffness measurement in combination with platelet count is currently the best-validated non-invasive approach for diagnosing CSPH and varices needing treatment. Lifestyle change remains the cornerstone of the treatment of PH in NAFLD, together with correcting the components of metabolic syndrome, using nonselective beta blockers, whereas emerging candidate drugs require more robust confirmation from clinical trials.

The application of a novel platform of multiparametric magnetic resonance imaging in a bioenvironmental toxic carbon tetrachloride-induced mouse model of liver fibrosis

The use of multiparametric magnetic resonance imaging (MRI) to distinguish complex histopathological changes in liver fibrosis has not yet been systematically established. The purpose of this study is to gauge the efficacy of a cutting-edge MRI platform for evaluating ecotoxicologically hazardous carbon tetrachloride (CCl4) induced liver fibrosis, while also scrutinizing the relationship between MRI and its histopathological features. Thirty-six mice were randomly divided into 6 groups, each with 6 mice. Control mice received an intraperitoneal injection of olive oil, while the experimental mice received different doses of intraperitoneal injection of CCl4. Both sets underwent this process twice per week over a duration of 5 weeks. MRI measurements encompassed T1WI, T2WI, T1 mapping, T2 mapping, T2* mapping. Liver fibrosis and inflammation were assessed and classified using Metavir and activity scoring systems. CCl4 successfully induced liver fibrosis in mice, showing an increasing extent of liver fibrosis and liver function damage with the increasing dosage of CCl4. Compared with the control group, T1, ΔT1, and T2 in the experimental group were considerably elevated (P < 0.05) than those in the control group. Spearman's correlation showed that the correlation of Native T1 and △T1 with fibrosis (r = 0.712, 0.678) was better than with inflammation (r = 0.688, 0.536). T2 correlation with inflammation (r = 0.803) was superior to fibrosis (r = 0.568). ROC analysis showed that the AUC of Native T1 was highest (0.906), followed by ΔT1 (0.852), while the AUC increased to 0.945 when all relevant MRI parameters were combined. T1 is the most potent MRI parameter for evaluating CCl4-induced liver fibrosis, followed by ΔT1. Meanwhile, T2 may not be suitable for evaluating liver fibrosis but is more suitable for evaluating liver inflammation.

Novel urinary protein panels for the non‐invasive diagnosis of non‐alcoholic fatty liver disease and fibrosis stages

Background & Aims

There is an unmet clinical need for non‐invasive tests to diagnose non‐alcoholic fatty liver disease (NAFLD) and individual fibrosis stages. We aimed to test whether urine protein panels could be used to identify NAFLD, NAFLD with fibrosis (stage F ≥ 1) and NAFLD with significant fibrosis (stage F ≥ 2).

Methods

We collected urine samples from 100 patients with biopsy‐confirmed NAFLD and 40 healthy volunteers, and proteomics and bioinformatics analyses were performed in this derivation cohort. Diagnostic models were developed for detecting NAFLD (UPNAFLD model), NAFLD with fibrosis (UPfibrosis model), or NAFLD with significant fibrosis (UPsignificant fibrosis model). Subsequently, the derivation cohort was divided into training and testing sets to evaluate the efficacy of these diagnostic models. Finally, in a separate independent validation cohort of 100 patients with biopsy‐confirmed NAFLD and 45 healthy controls, urinary enzyme‐linked immunosorbent assay analyses were undertaken to validate the accuracy of these new diagnostic models.

Results

The UPfibrosis model and the UPsignificant fibrosis model showed an AUROC of .863 (95% CI: .725–1.000) and 0.858 (95% CI: .712–1.000) in the training set; and .837 (95% CI: .711–.963) and .916 (95% CI: .825–1.000) in the testing set respectively. The UPNAFLD model showed an excellent diagnostic performance and the area under the receiver operator characteristic curve (AUROC) exceeded .90 in the derivation cohort. In the independent validation cohort, the AUROC for all three of the above diagnostic models exceeded .80.

Conclusions

Our newly developed models constructed from urine protein biomarkers have good accuracy for non‐invasively diagnosing liver fibrosis in NAFLD.

Applying Lipidomics to Non-Alcoholic Fatty Liver Disease: A Clinical Perspective

The prevalence of Non-alcoholic fatty liver disease (NAFLD) and associated complications, such as hepatocellular carcinoma (HCC), is growing worldwide, due to the epidemics of metabolic risk factors, such as obesity and type II diabetes. Among other factors, an aberrant lipid metabolism represents a crucial step in the pathogenesis of NAFLD and the development of HCC in this population. In this review, we summarize the evidence supporting the application of translational lipidomics in NAFLD patients and NAFLD associated HCC in clinical practice.

The role of platelet-related parameters for the prediction of NAFLD in OSAHS patients

PURPOSE

As the detection of non-alcoholic fatty liver disease (NAFLD) is imperative for the prevention of its complications, we aimed to explore the predictive value of platelet to lymphocyte count ratio (PLR) and white blood cell count to mean platelet volume ratio (WBC/MPV) in relation to the occurrence of NAFLD among patients with obstructive sleep apnea-hypopnea syndrome (OSAHS).

METHODS

This was a cross-sectional study consisting of 351 patients with OSAHS (279 with and 72 without NAFLD). The logistic regression analysis was performed to estimate associations between PLR, WBC/MPV, and NAFLD. Finally, the receiver operating characteristic curve (ROC curve) was used to analyze the efficacy of PLR and WBC/MPV in NAFLD prediction.

RESULTS

Compared to the OSAHS-only group, there was a rising trend in AHI and TS90% in the OSAHS + NAFLD group. And the logistic regression analysis identified average oxygen saturation (MaSO₂), WBC/MPV and PLR as predicted factors (odds ratio [OR] = 1.134, P = 0.031; OR = 7.559, P = 0.018, OR = 0.980, P < 0.001, respectively) for NAFLD in OSAHS patients. Moreover, compared with WBC/MPV, PLR, FLI, and APRI, a combination of WBC/MPV and PLR presented the largest AUC for the detection of NAFLD in BMI < 28 kg/m² (0.753, 95% CI 0.684-0.822), and in age ≥ 60 years subgroup (0.786, 95% CI 0.692-0.880) in ROC analysis. Meanwhile, a combination of WBC/MPV and PLR presented the second largest AUC for the detection of NAFLD in all subjects (0.743, 95% CI 0.708-0.831), as well as in the age < 60 years subgroup (0.729, 95% CI 0.652-0.806), only ranked after FLI, suggesting the combination of WBC/MPV and PLR has a good predictive value for NAFLD in OSAHS patients.

CONCLUSION

We confirmed that the levels of WBC/MPV, PLR, and MaSO₂ were closely related to the occurrence of NAFLD among OSAHS patients. Furthermore, our results highlighted the clinical combination of WBC/MPV and PLR levels could act as a simple and effective biomarker for screening NAFLD in patients with OSAHS.

Prevalence estimation of significant fibrosis because of NASH in Spain combining transient elastography and histology

BACKGROUND & AIMS

Non-alcoholic fatty liver disease (NAFLD) has become a major public health problem, but the prevalence of fibrosis associated with non-alcoholic steatohepatitis (NASH) is largely unknown in the general population. This study aimed to provide an updated estimation of the prevalence of NASH fibrosis in Spain.

METHODS

This was an observational, retrospective, cross-sectional, population-based study with merged data from two Spanish datasets: a large (N = 12 246) population-based cohort (ETHON), including transient elastography (TE) data, and a contemporary multi-centric biopsy-proven NASH cohort with paired TE data from tertiary centres (N = 501). Prevalence for each NASH fibrosis stage was estimated by crossing TE data from ETHON dataset with histology data from the biopsy-proven cohort.

RESULTS

From the patients with valid TE in ETHON dataset (N = 11 440), 5.61% (95% confidence interval [95% CI]: 2.53-11.97) had a liver stiffness measurement (LSM) ≥ 8 kPa. The proportion attributable to NAFLD (using clinical variables and Controlled Attenuation Parameter) was 57.3% and thus, the estimated prevalence of population with LSM ≥ 8 kPa because of NAFLD was 3.21% (95% CI 1.13-8.75). In the biopsy-proven NASH cohort, 389 patients had LSM ≥ 8 kPa. Among these, 37% did not have significant fibrosis (F2-4). The estimated prevalence of NASH F2-3 and cirrhosis in Spain's adult population were 1.33% (95% CI 0.29-5.98) and 0.70% (95% CI 0.10-4.95) respectively.

CONCLUSIONS

These estimations provide an accurate picture of the current prevalence of NASH-related fibrosis in Spain and can serve as reference point for dimensioning the therapeutic efforts that will be required as NASH therapies become available.

Association of serum creatinine with hepatic steatosis and fibrosis: a cross-sectional study

Background

Recent studies have shown that chronic kidney disease (CKD) prevalence is significantly higher in patients with hepatic steatosis (HS); however, it remains unclear whether HS is associated with serum creatinine (SCr). We aimed to explore the association between SCr levels and HS in a Chinese population.

Methods

We performed a cross-sectional study among 56,569 Chinese individuals. SCr level, other clinical and laboratory parameters, abdominal ultrasound and noninvasive fibrosis scores were extracted, and the fibrosis 4 score (FIB-4) was calculated.

Results

A total of 27.1% of the subjects had HS. After 1:1 propensity score matching (PSM) according to sex and age, we included 13,301 subjects with HS and 13,301 subjects without HS. SCr levels were significantly higher in the HS group than in the non-HS group [73.19 ± 15.14(μmoI/L) vs. 71.75 ± 17.49(μmoI/L), p < 0.001]. Univariate and multivariate regression analyses showed a positive association between SCr and the prevalence of HS. Stepwise regression analysis showed that the association between SCr and HS was independent of other metabolic syndrome components. The prevalence of HS increased significantly with increasing SCr levels. Metabolism-related indicators and liver enzymes were significantly higher in the HS group than in the non-HS group; furthermore, these parameters increased with increasing SCr levels. FIB-4 was significantly higher in the HS group than in the non-HS group but did not show an increasing trend with increasing SCr levels.

Conclusions

Our results showed an independent association between SCr level and HS risk in a Chinese population.

Utility of Metabolomic Biomarkers to Identify Nonalcoholic Fatty Liver Disease in Liver Transplant Recipients

Nonalcoholic fatty liver disease (NAFLD) is a rising indication for liver transplantation (LT). Identification of NAFLD recurrence and those at risk for more progressive disease after LT remains elusive as the diagnosis requires biopsy, which is invasive and impractical for serial monitoring. We therefore aimed to identify metabolites in the blood associated with recurrent NAFLD that could potentially be used for detection and monitoring.

Nonalcoholic fatty liver disease: scintigraphy in the diagnosis of steatohepatitis

OBJECTIVE

Nonalcoholic fatty liver disease is the most prevalent cause of chronic liver disease worldwide. Nonalcoholic steatohepatitis is associated with increased mortality rates due to the liver and cardiovascular diseases. The gold standard for discriminating nonalcoholic fatty liver disease activity and staging is the anatomopathological examination, which is an invasive method. In this regard, noninvasive methods, such as scintigraphy, have been under investigation. This study investigated the role of scintigraphy in the diagnosis of nonalcoholic steatohepatitis in obese patients with nonalcoholic fatty liver disease undergoing bariatric surgery.

METHODS

Patients undergoing bariatric surgery and liver biopsy were prospectively included. 99mTc-phytate scintigraphy was performed to assess liver/spleen, spleen/heart, and liver/heart uptake ratios, while 99mTc-isonitrile scintigraphy assessed liver/heart ratio. To evaluate the presence of nonalcoholic steatohepatitis, the results of 99mTc-phytate scintigraphy and 99mTc-isonitrile scintigraphy were compared with the anatomopathological examination.

RESULTS

Sixty-one patients with nonalcoholic fatty liver disease were allocated into two groups, namely, nonalcoholic steatohepatitis (n=49) and non-nonalcoholic steatohepatitis (n=12). The results of scintigraphic images obtained after the infusion of radiopharmaceutical 99mTc-phytate in liver/spleen, spleen/heart, liver/heart ratios and 99mTc-isonitrile liver/heart ratio presented no difference between groups with and without nonalcoholic steatohepatitis with an accuracy of 47.5, 37.7, 50.8, and 52.5%, respectively.

CONCLUSION

Scintigraphy was not proven to be a useful method to differentiate patients with and without nonalcoholic steatohepatitis.

A Stepwise Algorithmic Approach and External Validation Study for Noninvasive Prediction of Advanced Fibrosis in Nonalcoholic Fatty Liver Disease

BACKGROUND AND AIMS

Advanced F3-4 fibrosis predicts liver-related mortality in nonalcoholic fatty liver disease (NAFLD). Noninvasive tests, designed to rule in/out advanced fibrosis, are limited by indeterminates, necessitating biopsy. We aimed to determine whether stepwise combinations of noninvasive serum-based tests and elastography (VCTE) could predict F3-4, reduce indeterminates, and decrease liver biopsies.

METHODS AND RESULTS

Five hundred forty-one biopsy-proven NAFLD cases were identified between 2010 and 2018 from two Canadian centers. Characteristics of training (n = 407)/validation (n = 134) cohorts included: males 54%/59%; mean age 48.5/52.5 years; mean body mass index 32.3/33.6 kg/m²; diabetes mellitus 30%/34%; and F3-4 48%/43%. For training/validation cohorts, area under the receiver operating curve (AUROC) for FIB-4, AST-platelet ratio index (APRI), NAFLD fibrosis score (NFS), BARD score, and AST/ALT ratio ranged from 0.70 to 0.83/0.68 to 0.81, with indeterminates 25-39%/34-45%, for F3-4. In the training cohort, parallel FIB-4 + NFS had good accuracy (AUROC = 0.81) but was limited by 38% indeterminates and 16% misclassified. Sequential FIB-4 → NFS reduced indeterminates to 10%, and FIB-4 → VCTE to 0%, misclassified 20-22%, while maintaining high specificity (0.88-0.92) and accuracy (AUROC 0.75-0.78) for combined cohorts. Liver biopsy could have been avoided in 27-29% of patients using sequential algorithms.

CONCLUSIONS

Sequential FIB-4 ➔ NFS/VCTE predicts F3-4 with high specificity and good accuracy, while reducing indeterminates and need for biopsy. Parallel algorithms are limited by high indeterminates. Sequential FIB-4 ➔ NFS had similar accuracy to VCTE-containing algorithms. Validation in low-prevalence cohorts may allow for potential use in community or resource-limited areas for risk stratification.

Novel artificial intelligent/neural network system for staging of nonalcoholic steatohepatitis

AIM

To develop a novel noninvasive test using an artificial intelligence (AI)/neural network (NN) system (named Fibro-Scope) to determine the fibrosis stage in nonalcoholic steatohepatitis (NASH).

METHODS

Three hundred twenty-four and 110 patients with histologically diagnosed nonalcoholic fatty liver disease (NAFLD) were enrolled for training and validation studies, respectively. Two independent pathologists histologically diagnosed patients with NAFLD for the validation study. Fibro-Scope was undertaken using 12 items: age, sex, height, weight, waist circumference, aspartate aminotransferase, alanine aminotransferase, γ-glutamyl transferase, cholesterol, triglyceride, platelet count, and type 4 collagen 7s.

RESULTS

Differentiation of F0 versus F1-4 using the Fibro-Scope revealed 99.5% sensitivity, 90.9% specificity, 97.4% positive predictive value, and 98.0% negative predictive value in a training study with gray zone analysis, which was also effective in the analysis without gray zone. Discrimination was also excellent when comparing F0-1 versus F2-4 and F0-2 versus F3-4. In a validation study with gray zone analysis, differentiation of F0 from F1-4 using Fibro-Scope was also excellent. The discrimination of F0-1 from F2-4 using Fibro-Scope with gray zone analysis showed over 80% sensitivity and specificity in the histological diagnosis of both pathologists, but was lower without the gray zone analysis. The discrimination of F0-2 from F3-4 was effective in the analysis with gray zone; however, their sensitivity and specificity were slightly inferior in the analysis without gray zone.

CONCLUSIONS

Artificial intelligence/neural network algorithms termed Fibro-Scope are easy to use and can accurately differentially diagnose minimal, moderate, and advanced fibrosis. Fibro-Scope will promote rapid NASH diagnosis and facilitate diagnosing the fibrosis stage in NASH.

A clinical model to predict fibrosis on liver biopsy in paediatric subjects with nonalcoholic fatty liver disease

The incidence of nonalcoholic fatty liver disease (NAFLD) in children is rapidly increasing. Liver fibrosis is a poor prognostic feature that independently predicts cirrhosis. The time that intercedes the first medical encounter and biopsy is rate-limiting to multi-modal treatment. This study aimed to identify non-invasive parameters to predict advanced NAFLD and fibrosis. We conducted a single-center, retrospective 10-year analysis of 640 paediatric patients who underwent liver biopsy. 55 patients, age 3-21 years, had biopsy-confirmed NAFLD. We assessed primary outcomes, NAFLD activity score (NAS) and fibrosis scores, against non-invasive parameters by linear regression, by using binary cutoff values, and by a multivariate logistic regression fibrosis prediction model. NAS correlated with platelets and female sex. Fibrosis scores correlated with platelet counts, gamma glutamyl transferase (GGT), and ultrasound shear wave velocity. 25-hydroxy-vitamin D and GGT differentiated mild versus moderate-to-advanced fibrosis. Our multivariate logistical regression model-based scoring system predicted F2 or higher (parameters: BMI%, vitamin D, platelets, GGT), with sensitivity and specificity of 0.83 and 0.95 (area under the ROC curve, 0.944). We identify a clinical model to identify high-risk patients for expedited biopsy. Stratifying patients to abbreviate time-to-biopsy can attenuate delays in aggressive therapy for high-risk patients.

Risk factors differentially associated with non-alcoholic fatty liver disease in males and females with metabolic syndrome

BACKGROUND AND AIMS

non-alcoholic fatty liver disease (NAFLD) is the most common chronic liver disease in western countries. This study aimed to investigate putative risk factors differentially related with NAFLD in obese males and females diagnosed with metabolic syndrome (MetS), stratified using the non-invasive hepatic steatosis index (HSI).

METHODS AND RESULTS

a cross-sectional analysis of the PREDIMED Plus study was performed of 278 participants with MetS (141 males and 137 females) of the Navarra-Nutrition node. Subjects were categorized by HSI tertiles and gender. Baseline clinical, biochemical variants and adherence to a Mediterranean diet and physical activity were evaluated.

RESULTS

multivariate analyses showed that females had 4.54 more units of HSI (95% CI: 3.41 to 5.68) than males. Both sexes showed increased levels of triglycerides, TG/HDL cholesterol ratio and triglyceride glucose index across the HSI tertiles. Physical activity exhibited a negative statistical association with HSI (males: r = -0.19, p = 0.025; females: r = -0.18, p = 0.031). The amount of visceral fat showed a positive association with HSI in both sexes (males: r = 0.64, p < 0.001; females: r = 0.46, p < 0.001). Adherence to the Mediterranean diet was lower in those subjects with higher HSI values (males: r = -0.18, p = 0.032; females r= -0.19, p = 0.027).

CONCLUSION

females had a poor liver status, suggesting gender differences related to NAFLD. Adherence to a Mediterranean diet and physical activity were associated with beneficial effects on cardiovascular disease features. Thus, reducing the risk of hepatic steatosis in subjects with MetS and obesity.

Impact of liver fibrosis score on prognosis in patients with previous myocardial infarction: A prospective cohort study

BACKGROUND & AIMS

Liver fibrosis score (LFS) has been used for predicting the cardiovascular outcomes (CVOs) in diverse populations. However, the association of LFS with CVOs in patients with previous myocardial infarction (MI) remains undetermined. We aimed to examine the prognostic value of LFS in patients with prior MI in a prospective cohort.

METHODS

A total of 3718 patients with previous MI were consecutively enrolled from March 2009 to January 2019. Five LFSs including the fibrosis-4 (FIB-4) score, non-alcohol fatty liver disease fibrosis score (NFS), Forns score, HUI score and BARD score were used. The CVOs covered major adverse cardiac event (MACEs), cardiovascular mortality and all-cause mortality. Cox proportional hazards model was used to calculate hazard ratios (HRs) with 95% confidence intervals (CIs).

RESULTS

During a mean follow-up of 47.4 ± 24.8 months, 431 (11.6%) MACEs occurred. Kaplan-Meier analysis demonstrated that higher LFSs resulted in a significantly higher probability of CVOs. Compared to the lowest score group, multivariable-adjusted HRs (95% CIs) of the highest group of FIB-4, NFS, Forns score, HUI score and BARD score were 1.75 (1.32-2.33), 2.37 (1.70-3.33), 2.44 (1.61-3.73), 1.58 (1.16-2.14) and 1.27 (1.03-1.57) respectively. These LFSs were also independent predictors of cardiovascular mortality and all-cause mortality. Similar results were observed across subgroups analysis. The addition of LFSs to a prediction model significantly increased the C-statistic for CVOs.

CONCLUSIONS

The present study firstly demonstrated that LFS could be used as a risk stratification tool for predicting CVOs in patients with previous MI, which should be evaluated further.

Machine learning algorithm outperforms fibrosis markers in predicting significant fibrosis in biopsy-confirmed NAFLD

BACKGROUND

The presence of significant liver fibrosis is a key determinant of long-term prognosis in non-alcoholic fatty liver disease (NAFLD). We aimed to develop a novel machine learning algorithm (MLA) to predict fibrosis severity in NAFLD and compared it with the most widely used non-invasive fibrosis biomarkers.

METHODS

We used a cohort of 553 adults with biopsy-proven NAFLD, who were randomly divided into a training cohort (n = 278) for the development of both logistic regression model (LRM) and MLA, and a validation cohort (n = 275). Significant fibrosis was defined as fibrosis stage F ≥ 2. MLA and LRM were derived from variables that were selected using a least absolute shrinkage and selection operator (LASSO) logistic regression algorithm.

RESULTS

In the training cohort, the variables selected by LASSO algorithm were body mass index, pro-collagen type III, collagen type IV, aspartate aminotransferase and albumin-to-globulin ratio. The diagnostic accuracy of MLA showed the highest values of area under the receiver operator characteristic curve (AUROC: 0.902, 95% CI 0.869-0.904) for identifying fibrosis F ≥ 2. The LRM AUROC was 0.764, 95% CI 0.710-0.816 and significantly better than the AST-to-Platelet ratio (AUROC 0.684, 95% CI 0.605-0.762), FIB-4 score (AUROC 0.594, 95% CI 0.503-0.685) and NAFLD Fibrosis Score (AUROC 0.557, 95% CI 0.470-0.644). In the validation cohort, MLA also showed the highest AUROC (0.893, 95% CI 0.864-0.901). The diagnostic accuracy of MLA outperformed that of LRM in all subgroups considered.

CONCLUSIONS

Our newly developed MLA algorithm has excellent diagnostic performance for predicting fibrosis F ≥ 2 in patients with biopsy-confirmed NAFLD.

Magnetic Resonance Spectroscopy of Hepatic Fat from Fundamental to Clinical Applications

The number of individuals suffering from fatty liver is increasing worldwide, leading to interest in the noninvasive study of liver fat. Magnetic resonance spectroscopy (MRS) is a powerful tool that allows direct quantification of metabolites in tissue or areas of interest. MRS has been applied in both research and clinical studies to assess liver fat noninvasively in vivo. MRS has also demonstrated excellent performance in liver fat assessment with high sensitivity and specificity compared to biopsy and other imaging modalities. Because of these qualities, MRS has been generally accepted as the reference standard for the noninvasive measurement of liver steatosis. MRS is an evolving technique with high potential as a diagnostic tool in the clinical setting. This review aims to provide a brief overview of the MRS principle for liver fat assessment and its application, and to summarize the current state of MRS study in comparison to other techniques.

Artificial intelligence/neural network system for the screening of nonalcoholic fatty liver disease and nonalcoholic steatohepatitis

AIM

We aimed to develop a novel noninvasive test using an artificial intelligence (AI)/neural network (NN) system (named nonalcoholic steatohepatitis [NASH]-Scope) to screen nonalcoholic fatty liver disease (NAFLD) and NASH.

METHODS

We enrolled 324 and 74 patients histologically diagnosed with NAFLD for training and validation studies, respectively. Two independent pathologists histologically diagnosed patients with NAFLD for validation study. Additionally, 48 subjects who underwent a medical health checkup and did not show fatty liver ultrasonographically and had normal serum aminotransferase levels were categorized as the non-NAFLD group. NASH-Scope was based on 11 clinical values: age, sex, height, weight, waist circumference, aspartate aminotransferase, alanine aminotransferase, γ-glutamyl transferase, cholesterol, triglyceride, and platelet count.

RESULTS

The sensitivity, specificity, positive predictive value, negative predictive value, and area under the receiver operator characteristic curve of NASH-Scope for distinguishing NAFLD from non-NAFLD in the training study and validation study were 99.7% versus 97.2%, 97.8% versus 97.8%, 99.7% versus 98.6%, 97.8% versus 95.7%, and 0.999 versus 0.950, respectively. Those for distinguishing NASH with fibrosis from NAFLD without fibrosis were 99.5% versus 90.7%, 84.3% versus 93.3%, 94.2% versus 98.0%, 98.6% versus 73.7%, and 0.960 versus 0.950. These results were excellent, even when the output data were divided into two categories without any gray zone.

CONCLUSIONS

The AI/NN system, termed as NASH-Scope, is practical and can accurately differentially diagnose between NAFLD and non-NAFLD and between NAFLD without fibrosis and NASH with fibrosis. Thus, NASH-Scope is useful for screening nonalcoholic fatty liver and NASH.

Agreement between wedged hepatic venous pressure and portal pressure in non-alcoholic steatohepatitis-related cirrhosis

BACKGROUND & AIMS

Wedge hepatic vein pressure (WHVP) accurately estimates portal pressure (PP) in alcohol- or viral hepatitis-related cirrhosis. Whether this also holds true in cirrhosis caused by non-alcoholic steatohepatitis (NASH) is unknown. We aimed to evaluate the agreement between WHVP and PP in patients with NASH cirrhosis in comparison to patients with alcohol- or HCV-related cirrhosis.

METHODS

All consecutive patients with NASH cirrhosis treated with a transjugular intrahepatic portosystemic shunt (TIPS) in 3 European centres were included (NASH group; n = 40) and matched with 2 controls (1 with alcohol-related and 1 with HCV-related cirrhosis) treated with TIPS contemporaneously (control group; n = 80). Agreement was assessed by Pearson's correlation (R), intra-class correlation coefficient (ICC), and Bland-Altman method. Disagreement between WHVP and PP occurred when both pressures differed by >10% of PP value. A binary logistic regression analysis was performed to identify factors associated with this disagreement.

RESULTS

Correlation between WHVP and PP was excellent in the control group (R 0.92; p <0.001; ICC 0.96; p <0.001) and moderate in the NASH group (R 0.61; p <0.001; ICC 0.74; p <0.001). Disagreement between WHVP and PP was more frequent in the NASH group (37.5% vs. 14%; p = 0.003) and was mainly because of PP underestimation. In uni- and multivariate analyses, only NASH aetiology was associated with disagreement between WHVP and PP (odds ratio 4.03; 95% CI 1.60-10.15; p = 0.003).

CONCLUSIONS

In patients with decompensated NASH cirrhosis, WHVP does not estimate PP as accurately as in patients with alcohol- or HCV-related cirrhosis, mainly because of PP underestimation. Further studies aimed to assess this agreement in patients with compensated NASH cirrhosis are needed.

LAY SUMMARY

Portal pressure is usually assessed by measuring wedge hepatic vein pressure because of solid evidence demonstrating their excellent agreement in alcohol- and viral hepatitis-related cirrhosis. Our results show that in patients with decompensated cirrhosis caused by non-alcoholic steatohepatitis, wedge hepatic vein pressure estimates portal pressure with less accuracy than in patients with other aetiologies of cirrhosis, mainly because of portal pressure underestimation.

Hepatorenal index for grading liver steatosis with concomitant fibrosis

Introduction

Ultrasonography is widely used as the first tool to evaluate fatty liver disease, and the hepatorenal index is a semi-quantitative method that improves its performance. Fibrosis can co-exist with steatosis or even replace it during disease progression. This study aimed to evaluate the influence of fibrosis on the measurement of steatosis using the hepatorenal index.

Materials and methods

This cross-sectional study included 89 patients with nonalcoholic fatty liver disease and in whom liver fibrosis was determined by ultrasound elastography. The Pearson’s correlation coefficient was used to compare between the results of the sonographic hepatorenal index and the quantification of steatosis using magnetic resonance spectroscopy as well the accuracy of detecting moderate to severe steatosis using sonography in two groups of patients: (A) without advanced fibrosis and (B) with advanced fibrosis. Advanced fibrosis was defined as a shear wave speed ≥ 1.78 m/s on ultrasound elastography. We calculated the area under the curve (AUC-ROC) to detect the ability of the hepatorenal index to differentiate light from moderate to severe steatosis in both groups. Moderate to severe steatosis was defined as a fat fraction > 15% on the magnetic resonance spectroscopy. The intra-observer variability was assessed using the Bland-Altman plot.

Results

Among patients, the mean age was 54.6 years and 59.6% were women, 50.6% had a body mass index ≥ 30 kg/m², 29.2% had moderate to severe steatosis, and 27.2% had advanced fibrosis. There was a correlation between steatosis grading by ultrasonography and magnetic resonance in group A (0.73; P < 0.001), but not in Group B (0.33; P = 0.058). The AUC-ROC for detecting a steatosis fraction ≥ 15% was 0.90 and 0.74 in group A and group B, respectively. The intra-observer variability for the hepatorenal index measurements was not significant (-0.036; P = 0.242).

Conclusion

The hepatorenal index is not appropriate for estimating steatosis in livers with advanced fibrosis.

Obesity as a multisystem disease: Trends in obesity rates and obesity-related complications

Obesity is a chronic multisystem disease associated with increased morbidity and mortality. The increasing prevalence of obesity makes it a major healthcare challenge across both developed and developing countries. Traditional measures such as body mass index do not always identify individuals at increased risk of comorbidities, yet continue to be used in deciding who qualifies for weight loss treatment. A better understanding of how obesity is associated with comorbidities, in particular non-metabolic conditions, is needed to identify individuals at risk in order to prioritize treatment. For metabolic disorders such as type 2 diabetes (T2D), weight loss can prevent T2D in individuals with prediabetes. It can improve and reverse T2D if weight loss is achieved early in the course of the disease. However, access to effective weight loss treatments is a significant barrier to improved health for people with obesity. In the present paper, we review the rising prevalence of obesity and why it should be classed as a multisystem disease. We will discuss potential mechanisms underlying its association with various comorbidities and how these respond to treatment, with a particular focus on cardiometabolic disease, malignancy and mental health.

Liver biopsy in the quantitative assessment of liver fibrosis in nonalcoholic fatty liver disease

Nonalcoholic fatty liver disease/nonalcoholic steatohepatitis (NAFLD/NASH) is a major cause of liver fibrosis/cirrhosis and liver-related mortality. Despite emergence of noninvasive tests, liver biopsy remains the mainstay for the diagnosis and assessment of disease severity and chronicity. Accurate detection and quantification of liver fibrosis with architectural localization are essential for assessing the severity of NAFLD and its response to antifibrotic therapy in clinical trials. Conventional histological scoring systems for liver fibrosis are semiquantitative. Collagen proportionate area is morphometric by measuring the percentage of fibrosis on a continuous scale but is limited by the absence of architectural input. Ultra-fast laser microscopy, e.g., second harmonic generation (SHG) imaging, has enabled in-depth analysis of fibrillary collagen based on intrinsic optical signals. Quantification and calculation of different detailed variables of collagen fibers can be used to establish algorithm-based quantitative fibrosis scores (e.g. qFibrosis, q-FPs) in NAFLD. Artificial intelligence is being explored to further develop quantitative fibrosis scoring methods. SHG microscopy should be considered the new gold standard for the quantitative assessment of liver fibrosis, reaffirming the pivotal role of the liver biopsy in NAFLD, at least for the near-future. The ability of SHG-derived algorithms to intuitively detect subtle nuances in liver fibrosis changes over a continuous scale should be employed to redress the efficacy endpoint for fibrosis in NASH clinical trials. The current decrease by 1-point or more in fibrosis stage may not be realistic for the evaluation of therapeutic response to antifibrotic drugs in relatively short-term trials.

Updates in the quantitative assessment of liver fibrosis for nonalcoholic fatty liver disease: Histological perspective

Nonalcoholic fatty liver disease/nonalcoholic steatohepatitis (NAFLD/NASH) is a major cause of liver fibrosis and cirrhosis. Accurate assessment of liver fibrosis is important for predicting disease outcomes and assessing therapeutic response in clinical practice and clinical trials. Although noninvasive tests such as transient elastography and magnetic resonance elastography are preferred where possible, histological assessment of liver fibrosis via semiquantitative scoring systems remains the current gold standard. Collagen proportionate area provides more granularity by measuring the percentage of fibrosis on a continuous scale, but is limited by the absence of architectural input. Although not yet used in routine clinical practice, advances in second harmonic generation/two-photon excitation fluorescence (SHG/TPEF) microscopy imaging show great promise in characterising architectural features of fibrosis at the individual collagen fiber level. Quantification and calculation of different detailed variables of collagen fibers can be used to establish algorithm-based quantitative fibrosis scores (e.g., qFibrosis, q-FPs), which have been validated against fibrosis stage in NAFLD. Artificial intelligence is being explored to further refine and develop quantitative fibrosis scoring methods. SHG-microscopy shows promise as the new gold standard for the quantitative measurement of liver fibrosis. This has reaffirmed the pivotal role of the liver biopsy in fibrosis assessment in NAFLD, at least for the near-future. The ability of SHG-derived algorithms to intuitively detect subtle nuances in liver fibrosis changes over a continuous scale should be employed to redress the efficacy endpoint for fibrosis in NASH clinical trials; this approach may improve the outcomes of the trials evaluating therapeutic response to antifibrotic drugs.

Discovery, validation and sequencing of urinary peptides for diagnosis of liver fibrosis-A multicentre study

Background

Liver fibrosis is a consequence of chronic inflammation and is associated with protein changes within the hepatocytes structure. In this study, we aimed to investigate if this is reflected by the urinary proteome and can be explored to diagnose liver fibrosis in patients with chronic liver disease.

Methods

In a multicentre combined cross-sectional and prospective diagnostic test validation study, 129 patients with varying degrees of liver fibrosis and 223 controls without liver fibrosis were recruited. Additionally, 41 patients with no liver, but kidney fibrosis were included to evaluate interference with expressions of kidney fibrosis. Urinary low molecular weight proteome was analysed by capillary electrophoresis coupled to mass spectrometry (CE-MS) and a support vector machine marker model was established by integration of peptide markers for liver fibrosis.

Findings

CE-MS enabled identification of 50 urinary peptides associated with liver fibrosis. When combined into a classifier, LivFib-50, it separated patients with liver fibrosis (N = 31) from non-liver disease controls (N = 123) in cross-sectional diagnostic phase II evaluation with an area under the curve (AUC) of 0.94 (95% confidence intervals (CI): 0.89–0.97, p<0.0001). When adjusted for age, LivFib-50 demonstrated an AUC of 0.94 (95% CI: 0.89–0.97, p<0.0001) in chronic liver disease patients with (N = 19) or without (N = 17) liver fibrosis progression. In this prospective diagnostic phase III validation set, age-adjusted LivFib-50 showed 84.2% sensitivity (95% CI: 60.4–96.6) and 82.4% specificity (95% CI: 56.6–96.2) for detection of liver fibrosis. The sequence-identified peptides are mainly fragments of collagen chains, uromodulin and Na/K-transporting ATPase subunit γ. We also identified ten putative proteolytic cleavage sites, eight were specific for matrix metallopeptidases and two for cathepsins.

Interpretation

In liver fibrosis, urinary peptides profiling offers potential diagnostic markers and leads to discovery of proteolytic sites that could be targets for developing anti-fibrotic therapy.

Efficacy of Glucagon-Like Peptide-1 Analogs in Nonalcoholic Fatty Liver Disease: A Systematic Review

Background

Nonalcoholic fatty liver disease (NAFLD) is the most common chronic liver disease. It is believed to be the hepatic manifestation of the metabolic syndrome. Many treatment approaches have been suggested so far, and several types of studies have been done to find treatment for NAFLD, the most promising of which are those with lifestyle interventions.

Objective

The aim of this systematic review was to evaluate the efficacy and safety of glucagon-like peptide-1 (GLP-1) analogs on the management of NAFLD.

Methods

The PubMed, MEDLINE, and Cochrane Central Library were searched to identify randomized controlled trials, single arm trials, and cohorts that compared GLP-1 analogs with a control treatment or baseline values with respect to efficacy and safety in patients living with NAFLD. The key outcomes were a change in serum transaminase, resolution of disease status measured by imaging or histological techniques, improvement in insulin resistance, and reduction in body weight.

Results

Initial searching retrieved 201 peer-reviewed articles and abstracts. Ten studies met all inclusion criteria. The review included a total of 590 participants with NAFLD. Following administration of GLP-1 analogs, a decrease in serum transaminases, improvement in liver histology and insulin resistance, and a reduction in body weight were observed. Compared with baseline, body weight, alanine aminotransferase, aspartate aminotransferase, and gamma glutamyltransferase were decreased by 5.5%, 59.5%, 52.8%, and 44.8%, respectively, due to GLP-1. Likewise, a reduction of proinflammatory cytokines and fibrosis markers and an enhancement of protective adipokines were observed in some of the studies.

Conclusion

The decrease in a key biochemical marker of liver injury following treatment with GLP-1 analogs, as well as improvements in imaging and histology, suggests that these agents may be effective alternatives for managing NAFLD.

Registration

CRD42018087262.

Progress in evaluating the status of hepatitis C infection based on the functional changes of hepatic stellate cells (Review)

Hepatitis C virus (HCV) infection is a global public health problem. Cirrhosis and hepatocellular carcinoma are the main causes of death in patients with chronic hepatitis C (CHC) infection. Liver fibrosis is an important cause of cirrhosis and end‑stage liver disease after CHC infection. Along with the course of infection, liver fibrosis exhibits a progressive exacerbation. Hepatic stellate cells (HSCs) are involved in both physiological and pathological processes of the liver. During the chronic liver injury process, the activated HSCs transform into myofibroblasts, which are important cells in the development of liver fibrosis. At present, HCV infection still lacks specific markers for the accurate detection of the disease condition and progression. Therefore, the present review focused on HSCs, which are closely related to HCV‑infected liver fibrosis, and analyzed the changes in the HSCs, including their surface‑specific markers, cytokine production, activation, cell function and morphological structure. The present review aimed to propose novel diagnostic markers, at both the cellular and molecular level, which would be of great significance for the timely diagnosis of the disease. According to this aim, the characteristic changes of HSCs during HCV infection were reviewed in the present article.

MRI-determined liver fat correlates with risk of metabolic syndrome in patients with nonalcoholic fatty liver disease

BACKGROUND AND AIM

Little is known about that the relationship between hepatic fat content (HFC) and metabolic syndrome (MetS). We aimed to determine whether HFC correlated with MetS in patients with nonalcoholic fatty liver disease (NAFLD).

METHODS

HFC was measured by MRI-determined proton density fat fraction (MRI-PDFF) for 131 suspected NAFLD subjects. Patients with NAFLD defined as MRI-PDFF ≥5% were stratified into two groups based on whether they were above or below the median MRI-PDFF value; the MRI-PDFF value for the control group was <5%. The primary outcome was the presence of MetS. Logistic regression models were used to obtain the associations between the severity of liver fat and MetS, and the corresponding odds ratios (ORs) and 95% confidence intervals (CIs) were recorded.

RESULTS

Compared to NAFLD patients with low-HFC (n = 48) and the control group (n = 35), NAFLD patients with high-HFC (n = 48) had significantly greater prevalence of central obesity, hypertension, hyperglycemia, and hypertriglyceridemia (all P < 0.05). NAFLD patients with high-HFC had a higher prevalence of MetS than NAFLD patients with low-HFC (79.2% vs. 56.2%, P < 0.05). The multivariate-adjusted OR for the prevalence of MetS comparing NAFLD patient with low-HFC and high-HFC to the control group were 4.56 (95% CI: 0.54-38.79, P = 0.165) and 22.91 (95% CI: 1.80-292.21, P = 0.016), respectively (Ptrend = 0.014).

CONCLUSION

Increased hepatic fat quantitatively measured by MRI-PDFF had a significant dose-relationship with the presence of MetS, and the amount of liver fat may affect cardiovascular risk.

Non-Alcoholic Fatty Liver Disease in Patients with Type 2 Diabetes Mellitus: A Position Statement of the Fatty Liver Research Group of the Korean Diabetes Association

This clinical practice position statement, a product of the Fatty Liver Research Group of the Korean Diabetes Association, proposes recommendations for the diagnosis, progression and/or severity assessment, management, and follow-up of non-alcoholic fatty liver disease (NAFLD) in patients with type 2 diabetes mellitus (T2DM). Patients with both T2DM and NAFLD have an increased risk of non-alcoholic steatohepatitis (NASH) and fibrosis and a higher risk of cardiovascular diseases and diabetic complications compared to those without NAFLD. With regards to the evaluation of patients with T2DM and NAFLD, ultrasonography-based stepwise approaches using noninvasive biomarker models such as fibrosis-4 or the NAFLD fibrosis score as well as imaging studies such as vibration-controlled transient elastography with controlled attenuation parameter or magnetic resonance imaging-proton density fat fraction are recommended. After the diagnosis of NAFLD, the stage of fibrosis needs to be assessed appropriately. For management, weight reduction achieved by lifestyle modification has proven beneficial and is recommended in combination with antidiabetic agent(s). Evidence that some antidiabetic agents improve NAFLD/NASH with fibrosis in patients with T2DM is emerging. However, there are currently no definite pharmacologic treatments for NAFLD in patients with T2DM. For specific cases, bariatric surgery may be an option if indicated.

Noninvasive Serum Fibrosis Markers are Associated with Coronary Artery Calcification in Patients with Nonalcoholic Fatty Liver Disease

Background/Aims

Advanced hepatic fibrosis is associated with cardiovascular disease (CVD) in patients with nonalcoholic fatty liver disease (NAFLD). We investigated the association between noninvasive serum fibrosis markers and the coronary artery calcium score (CACS) in subjects with NAFLD.

Methods

We analyzed 665 NAFLD subjects without chronic liver disease or heart disease between 2011 and 2015. The noninvasive fibrosis markers that were used to evaluate the severity of hepatic fibrosis included the NAFLD fibrosis score (NFS), fibrosis-4 (FIB-4) score, Forn's index, and the aspartate aminotransferase to platelet ratio index (APRI).

Results

The areas under the receiver operating characteristics curves for the NFS, FIB-4 score, Forn's index and APRI for predicting CACS >100 were 0.689, 0.683, 0.659, and 0.595, respectively. According to the multivariate analysis, older age, increased body mass index (BMI), and decreased estimated glomerular filtration rate (eGFR) were significant factors associated with CACS >100. The NFS, FIB-4 score and APRI were significantly associated with CACS >100 after adjusting for age and gender (p=0.006, p=0.012, and p=0.012, respectively) and after adjusting for age, gender, BMI and eGFR (p=0.013, p=0.022, and p=0.027, respectively). Scores integrating noninvasive fibrosis markers and other risk factors improved the predictive accuracy.

Conclusions

The NFS and FIB-4 score were associated with coronary atherosclerosis in subjects with NAFLD. Furthermore, scores integrating these noninvasive scores and risk factors for CVD showed good discriminatory power in predicting CACS >100. Therefore, noninvasive serum fibrosis markers may be useful tools for identifying NAFLD subjects at a high risk for CVD.

Risk stratification of patients with nonalcoholic fatty liver disease using a case identification pathway in primary care: a cross-sectional study

BACKGROUND

Identification of patients with nonalcoholic fatty liver disease (NAFLD) with advanced liver fibrosis in primary care remains an unmet need. Our primary objective was to implement a pathway driven by shear wave elastography (SWE) to facilitate risk stratification of patients with NAFLD within primary care and evaluate whether SWE assessment can reduce referrals of patients with NAFLD at low risk for fibrosis to hepatology.

METHODS

A multidisciplinary NAFLD clinical care pathway was codeveloped by hepatologists, radiologists and primary care physicians in Calgary to provide access to SWE-based screening of patients with NAFLD risk factors in primary care. The study outcome measures were estimated NAFLD-related referrals to the hepatology service in Calgary after implementation of the NAFLD pathway and characteristics of patients with NAFLD at risk for advanced fibrosis. The NAFLD pathway was implemented in January 2018 and was made available to all primary care physicians in the Calgary Health Zone. Patients with NAFLD who had liver stiffness (SWE value ≥ 8.0 kPa) or an inconclusive assessment were referred to hepatology. A serum liver fibrosis score was also measured with the fibrosis-4 (FIB-4) index, and performance of an FIB-4 index score of 1.30 or greater to risk stratify patients with NAFLD was evaluated. Demographic, clinical and laboratory characteristics of study groups were compared.

RESULTS

Between March and October 2018, 2084 patients with suspected NAFLD were evaluated. Nonalcoholic fatty liver disease was confirmed by ultrasonography in 1958 (94.1%). A majority of the cohort had elevated liver enzyme values (1028 [52.5%]) and obesity (body mass index ≥ 30) (1063/1764 [60.3%]). Most patients with NAFLD (1791 [91.5%]) had an SWE value less than 8.0 kPa and were not referred to hepatology. Sixty-seven patients (3.4%) had an SWE value of 8.0 kPa or more, and 100 (5.1%) had an inconclusive SWE; these patients were referred to hepatology. Using an FIB-4 index score cut-off of 1.30 would have led to hepatology referral of 396/1251 patients (31.6%).

INTERPRETATION

Implementation of a primary care-accessible SWE pathway for patients with NAFLD facilitated fibrosis risk stratification and greatly reduced hepatology referrals. Using the FIB-4 index score alone would led to higher rates of referral of patients with NAFLD.

Serum SHBG Is Associated With the Development and Regression of Nonalcoholic Fatty Liver Disease: A Prospective Study

CONTEXT

SHBG, a homodimeric glycoprotein produced by hepatocytes has been shown to be associated with metabolic disorders. Whether circulating SHBG levels are predictive of later risk of nonalcoholic fatty liver disease (NAFLD) remains unknown. In this study, we prospectively investigated the association between SHBG and NAFLD progression through a community-based cohort comprising 3389 Chinese adults.

METHODS

NAFLD was diagnosed using abdominal ultrasonography. Serum SHBG levels were measured by chemiluminescent enzyme immunometric assay, and their relationship with NAFLD development and regression was investigated after a mean follow-up of 3.09 years using multivariable logistic regression.

RESULTS

Basal SHBG was negatively associated with NAFLD development, with a fully adjusted odds ratio (OR) and its 95% confidence interval (CI) of 0.22 (0.12-0.40) (P < .001). In contrast, basal SHBG was positively associated with NAFLD regression, with a fully adjusted OR of 4.83 (2.38-9.81) (P < .001). Multiple-stepwise logistic regression analysis showed that SHBG concentration was an independent predictor of NAFLD development (OR, 0.28 [0.18-0.45]; P < .001) and regression (OR, 3.89 [2.43-6.22]; P < .001). In addition, the area under the receiver operating characteristic curves were 0.764 (95% CI, 0.740-0.787) and 0.762 (95% CI, 0.738-0.785) for the prediction models of NAFLD development and regression, respectively.

CONCLUSIONS

Serum SHBG concentration is associated with the development and regression of NAFLD; moreover, it can be a potential biomarker for predicting NAFLD progression, and also a novel preventive and therapeutic target for NAFLD.

Limitations of non-invasive tests for assessment of liver fibrosis

The diagnostic assessment of liver injury is an important step in the management of patients with chronic liver disease (CLD). Although liver biopsy is the reference standard for the assessment of necroinflammation and fibrosis, the inherent limitations of an invasive procedure, and need for repeat sampling, have led to the development of several non-invasive tests (NITs) as alternatives to liver biopsy. Such non-invasive approaches mostly include biological (serum biomarker algorithms) or physical (imaging assessment of tissue stiffness) assessments. However, currently available NITs have several limitations, such as variability, inadequate accuracy and risk factors for error, while the development of a newer generation of biomarkers for fibrosis may be limited by the sampling error inherent to the reference standard. Many of the current NITs were initially developed to diagnose significant fibrosis in chronic hepatitis C, subsequently refined for the diagnosis of advanced fibrosis in patients with non-alcoholic fatty liver disease, and further adapted for prognostication in CLD. An important consideration is that despite their increased use in clinical practice, these NITs were not designed to reflect the dynamic process of fibrogenesis, differentiate between adjacent disease stages, diagnose non-alcoholic steatohepatitis, or follow longitudinal changes in fibrosis or disease activity caused by natural history or therapeutic intervention. Understanding the strengths and limitations of these NITs will allow for more judicious interpretation in the clinical context, where NITs should be viewed as complementary to, rather than as a replacement for, liver biopsy.

Ultrasound elastography in patients with fatty liver disease

Hepatic steatosis, or fatty liver disease, occurs due to the accumulation of lipids in hepatocytes. When it becomes chronic, lobular inflammation develops and the disease can evolve to hepatic fibrosis, liver cirrhosis, or hepatocellular carcinoma. Early diagnosis is desirable because patients diagnosed in the early stage of the disease respond better to treatment. In the early stages of fatty liver disease, the physical examination is often unremarkable. Fatty liver disease and hepatic fibrosis can be diagnosed and monitored through laboratory tests, imaging, and biopsy. Among the imaging methods, ultrasound stands out as an effective means of diagnosing and following patients with liver disease. Ultrasound used in conjunction with elastography (ultrasound elastography) has recently shown great utility in the follow-up of such patients. Ultrasound elastography studies the degree of deformation (stiffness) of an organ or lesion, so that when there is hardening, fibrosis, or cirrhosis of the liver, those alterations are well demonstrated. In this review article, we discuss the application of the different types of ultrasound elastography for liver studies: transient elastography, point shear wave elastography, and two-dimensional shear wave elastography. Although magnetic resonance elastography may also be used in the analysis of liver fibrosis, it will not be addressed in this article.

[Pathogenesis of non-alcoholic fatty liver disease]

Non-Alcoholic Fatty Liver Disease (NAFLD) is a complex chronic disease resulting from an interaction between genetic and environmental factors. The phenotype and pathophysiology of NAFLD is heterogeneous. NAFLD is a continuum of histological lesions of the liver from steatosis, Non-Alcoholic SteatoHepatitis (NASH), NASH with fibrosis, cirrhosis to hepatocellular carcinoma. The pathophysiology encompasses a dysfunction in fatty tissue (sub-cutaneous and visceral) associated with insulin-resistance and metabolic inflammation. NAFLD is a "multi-systemic" disease. Reciprocal and aggravating interactions exist between NAFLD, cardiovascular anomalies and diabetes. The understanding of the mechanisms responsible for NAFLD allows the identification of potential novel therapeutic targets.

Variation in diagnostic NAFLD/NASH read-outs in paired liver samples from rodent models

INTRODUCTION

In animal models of non-alcoholic fatty liver disease (NAFLD), assessment of disease severity and treatment effects of drugs rely on histopathological scoring of liver biopsies. However, little is known about the sampling variation in liver samples from animal models of NAFLD, even though several histopathological hallmarks of the disease are known to be affected by sampling variation in patients. The aim of this study was to assess the sampling variation in multiple paired liver biopsies from three commonly used diet-induced rodent models of NAFLD.

METHODS

Eight male C57BL/6 mice, 8 male Sprague Dawley rats and 16 female Hartley guinea pigs were fed a NAFLD-inducing high-fat diet for 16 weeks (mice and rats), 20 or 24 weeks (guinea pigs). After the initial diet period, liver sections were sampled and subsequently assessed by histopathological scoring and biochemical analyses.

RESULTS

Fibrosis was heterogeneously distributed throughout the liver in mice, manifesting as both intra- and interlobular statistically significant differences. Hepatic triglyceride content showed interlobular differences in mice, and both intra- and interlobular differences in guinea pigs (24-week time point) all of which were statistically significant. Also, hepatic cholesterol content was subject to significant intra-lobular sampling variation in mice, and hepatic glycogen content differed significantly between lobes in mice and guinea pigs.

DISCUSSION

Dependent on animal model, both histopathological and biochemical end-points differed between sampling sites in the liver. Based on these findings, we recommend that sample site location is highly standardized and properly reported in order to minimize potential sampling variation and to optimize reproducibility and meaningful comparisons of preclinical studies of NAFLD.

Ultrasonographic Evaluation of Fatty Pancreas in Serbian Patients with Non Alcoholic Fatty Liver Disease-A Cross Sectional Study

Background and Objectives: The aim of the study was to determine the association between presences of fatty pancreas (FP) with the features of metabolic syndrome (MeS) in patients with non-alcoholic fatty liver disease (NAFLD) and to establish a new noninvasive scoring system for the prediction of FP in patients with NAFLD. Material and Methods: 143 patients with NAFLD were classified according to FP severity grade into the two groups and evaluated for diagnostic criteria of MeS. All patients underwent sonographic examination with adiposity measurements and the liver biopsy. Liver fibrosis was evaluated semi-quantitatively according to the METAVIR scoring system and using non-invasive markers of hepatic fibrosis. Results: Waist circumference (WC) was predictive for increased risk of FP in NAFLD patients. Elevated fasting plasma glucose, total cholesterol, serum amylase and lipase levels were associated with presence of severe FP (p value = 0.052, p value = 0.007, p value = 0.014; p value = 0.024, respectively). Presence of increased amounts of mesenteric fat was associated with severe FP (p value = 0.013). The results of this study demonstrated highly significant association between NAFLD and presence of FP. The model for predicting the presence of FP was designed with probability value above 6.5. Conclusion: Pancreatic fat accumulation leads to worsening of pancreatic function which in turns exacerbates severity of metabolic syndrome associated with both, NAFLD and NAFPD.