Prevalence, distribution, and hepatic fibrosis burden of the different subtypes of steatotic liver disease in primary care settings

Decoding the Liver-Heart Axis in Cardiometabolic Diseases

The liver and heart are closely interconnected organs, and their bidirectional interaction plays a central role in cardiometabolic disease. In this review, we summarize current evidence linking liver dysfunction-particularly metabolic dysfunction-associated steatotic liver disease, alcohol-associated liver disease, and cirrhosis-with an increased risk of heart failure and other cardiovascular diseases. We discuss how these liver conditions contribute to cardiac remodeling, systemic inflammation, and hemodynamic stress and how cardiac dysfunction in turn impairs liver perfusion and promotes hepatic injury. Particular attention is given to the molecular mediators of liver-heart communication, including hepatokines and cardiokines, as well as the emerging role of advanced research methodologies, including omics integration, proximity labeling, and organ-on-chip platforms, that are redefining our understanding of interorgan cross talk. By integrating mechanistic insights with translational tools, this review aims to support the development of multiorgan therapeutic strategies for cardiometabolic disease.

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

BACKGROUND

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

AIMS

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

MATERIALS AND METHODS

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

RESULTS

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

DISCUSSION

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

CONCLUSION

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

Role of Alcohol in Steatotic Liver Disease: Impact on Patients with Cardiometabolic Risk Factors

The new definition of steatotic liver disease (SLD), as a broader concept, was a step forward in the increasing recognition of the substantial overlap between alcohol and cardiometabolic risk factors (CMRFs), in a continuum way. The spectrum of pathophysiological aspects, ranging from liver steatosis to fibrosis, has similarities in MASLD and ALD. Also, there is now considerable evidence that the association of metabolic dysfunction with increased alcohol consumption impacts on the risk of severe liver disease and prognosis. The new MetALD class, as recently proposed, shows clear differences in prognosis when comparing with MASLD and ALD groups. However, there is room for improvement, such as considering the role of previous alcohol intake, fluctuations of consumption over time, including binge drinking, refinement of alcohol assessment, and better understanding of the role of biomarkers. In summary, SLD is no doubt a significant improvement, but the new classification needs to be dynamic and adapting to patients needing frequent reassessment. Furthermore, it brings opportunities for research on the interaction between alcohol consumption and CMRFs.

Metabolic dysfunction-associated steatotic liver disease is a risk factor for gallstones: A multicenter cohort study

AIM

Gallstone formation is associated with metabolic dysfunction. Recently, new definitions of steatotic liver disease (SLD) have been proposed, including metabolic dysfunction-associated SLD (MASLD) and moderate alcohol intake (MetALD). We investigated the effects of MASLD/MetALD on gallstone formation.

METHODS

This multicenter observational cohort study enrolled 8766 consecutive health-check examinees who underwent abdominal ultrasonography between 2008 and 2021 (total observation period 39,105.9 person-years). All patients were classified into non-SLD, MASLD, or MetALD groups. The effect of MASLD on gallstone development was evaluated using multivariate Cox regression analysis.

RESULTS

Age, male sex, and MASLD were identified as independent risk factors for gallstone development. MASLD was associated with a significantly higher risk of developing gallstones than non-SLD (hazard ratio [HR] 1.7112; 95% confidence interval [CI] 1.4294-2.0486; p < 0.0001) and MetALD (HR 1.3516, 95% CI 1.0130-1.8033, p = 0.0406). However, the risk of MetALD did not significantly differ between the SLD and non-SLD groups. Hypertension was the only significant independent cardiometabolic risk factor for gallstone development in the MASLD group (HR 1.4350, 95% CI 1.0545-1.9528; p = 0.0216). Random forest analysis and directed acyclic graphs identified hypertension as the most important direct factor affecting gallstone development in patients with MASLD.

CONCLUSIONS

MASLD was an independent risk factor for gallstone development, whereas MetALD presented a similar risk as non-SLD. Moderate alcohol consumption may reduce the risk of gallstone formation in patients with MASLD. Hypertension may be the most significant cardiometabolic risk factor for gallstone development in patients with MASLD.

MetALD: New Perspectives on an Old Overlooked Disease

Metabolic dysfunction-associated steatotic liver disease (MASLD) and alcohol-associated liver disease (ALD) are the major contributors to the liver disease burden globally. The rise in these conditions is linked to obesity, type 2 diabetes, metabolic syndrome and increased alcohol consumption. MASLD and ALD share risk factors, pathophysiology and histological features but differ in their thresholds for alcohol use, and the ALD definition does not require the presence of metabolic dysfunction. A recent multi-society consensus overhauled the nomenclature of liver steatosis and introduced the term MetALD to describe patients with metabolic dysfunction who drink more than those with MASLD and less than those with ALD. This new terminology aims to enhance the understanding and management of liver disease but poses challenges, such as the need to accurately measure alcohol consumption in research and clinical practice settings. Recent studies show that MetALD has significant implications for patient management, as it is associated with increased mortality risks and more severe liver outcomes compared to MASLD alone. MetALD patients face increased risks of liver disease progression, cancer and cardiovascular disease. The diagnosis of MetALD involves the adequate quantification of alcohol use through standardised questionnaires and/or biomarkers as well as proper assessment of liver disease stage and progression risk using non-invasive tools including serologic markers, imaging, elastography techniques and genetic testing. Effective management requires addressing both metabolic and alcohol-related factors to improve outcomes. This review intends to provide a comprehensive overview of MetALD, covering pathogenesis, potential diagnostic approaches, management strategies and emerging therapies.

Metabolic Dysfunction-Associated Steatotic Liver Disease in the Korean General Population: Epidemiology, Risk Factors, and Non-Invasive Screening

Background/Objectives: Metabolic dysfunction-associated steatotic liver disease (MASLD) represents a contemporary classification of liver disease linked to metabolic dysfunction. It is recognized as the main form of chronic liver disease and significantly contributes to liver-related morbidity and mortality rates. The epidemiology of MASLD is affected by ethnic background, sex, age, and environmental factors. South Korea is one of the countries that has experienced rapid urbanization. Geographical differences also play a crucial role in the prevalence and progression of the disease. Consequently, it is essential to investigate the prevalence of MASLD; its associated risk factors, particularly in relation to liver fibrosis; and the effectiveness of non-invasive screening techniques within the Korean population. Methods: This review describes the prevalence of MASLD, the risk factors related to MASLD with liver fibrosis, and the non-invasive screening approaches suitable for the Korean general population. Results: This review underscores the rising incidence and implications of MASLD in South Korea. Notably, among younger demographics, there is a swift increase in both the prevalence of MASLD and its associated risk factors, indicating that MASLD is poised to become a significant public health concern. Non-invasive testing methods are increasingly utilized within at-risk groups to determine the presence of advanced fibrosis. Conclusions: Addressing these complex liver diseases necessitates not only ongoing monitoring of MASLD epidemiological patterns but also a unified approach to care that integrates medical interventions with lifestyle changes.

Association of advanced lung cancer inflammation index with all-cause and cardiovascular mortality in metabolic dysfunction associated steatotic liver disease

Metabolic dysfunction-associated steatotic liver disease (MASLD), formerly known as non-alcoholic fatty liver disease (NAFLD), is a growing global health concern due to its rising prevalence and association with hepatic and cardiovascular diseases. This study aimed to assess the prognostic value of the Advanced Lung Cancer Inflammation Index (ALI)-a combined indicator of nutritional and inflammatory status-in predicting all-cause and cardiovascular mortality in MASLD patients.Data were drawn from MASLD-diagnosed adults (≥ 18 years) in the National Health and Nutrition Examination Survey (NHANES) from 1999 to 2018, with mortality tracked until December 31, 2019. ALI was calculated for each participant, and its relationship with long-term mortality was analyzed using multivariable Cox regression, restricted cubic spline (RCS) regression, and subgroup analyses. Additionally, the mediating role of biological age, including Klemera-Doubal method biological age (KDM BA) and homeostatic model assessment (HD), was assessed in this relationship through mediation analysis. Among 7,534 MASLD patients, higher ALI quintiles were significantly associated with reduced all-cause (aHR = 0.591, P = 0.004) and cardiovascular mortality (aHR = 0.393, P = 0.026). A nonlinear relationship was observed between ALI and mortality outcomes (P < 0.001). Subgroup analysis indicated ALI's stronger predictive value in older adults (≥ 60), females, and lifelong non-smokers. Mediation analysis showed that KDM BA and HD partially mediated the ALI-mortality relationship (34.02% and 37.87% for all-cause mortality; 37.60% and 58.69% for cardiovascular mortality, respectively). Higher values of the ALI are associated with reduced all-cause and cardiovascular mortality in patients with MASLD, with biological age serving as a partial mediator. Improved nutritional and inflammatory status enhances the prognosis of MASLD patients.

Association between alcohol consumption and hepatic fibrosis in Chinese adult males with metabolic dysfunction-associated steatotic liver disease

Background

The impact of moderate drinking on the risk of liver fibrosis in non-alcoholic fatty liver disease (NAFLD) remains controversial worldwide. Notably, China, with the fastest-growing incidence of NAFLD and the highest number of alcohol-attributable deaths globally, has relatively few studies addressing this issue. This study aimed to explore the association between alcohol consumption and liver fibrosis in Chinese men with metabolic dysfunction-associated steatotic liver disease (MASLD).

Methods

We recruited 4,683 male employees diagnosed with MASLD from southwest China, including 4,287 with pure MASLD and 396 with metabolic and alcohol-related liver disease (MetALD) who consumed increased alcohol (30-60 g/d). Advanced fibrosis was defined as a fibrosis-4 index (FIB-4) ≥ 2.67, and FIB-4 ≥ 1.30 indicated an intermediate/high probability of hepatic fibrosis. Logistic regression models were used to assess the association between alcohol consumption and hepatic fibrosis, and analyze the modification effect of body mass index (BMI) and waist-to-hip ratio (WHR) on the association. Propensity score matching method was used to test the robustness of the regression results.

Results

Compared with non-drinkers, both moderate (OR = 3.02, 95% CI: 1.16-10.31) and increased alcohol consumption (OR = 4.64, 95% CI: 1.60-16.82) were significantly associated with an increased risk of advanced fibrosis in males with MASLD. Additionally, moderate (OR = 1.33, 95% CI: 1.07-1.66) and increased drinking (OR = 1.74, 95% CI: 1.28-2.34) were associated with intermediate/high probability of hepatic fibrosis, with similar results from logistic regression analysis in propensity score-matched cases. Trend analysis revealed the risk of hepatic fibrosis increased with increasing alcohol intake (FIB-4 ≥ 1.30, p for trend < 0.001; FIB-4 ≥ 2.67, p for trend = 0.007). Further subgroup analysis showed that the association between moderate drinking and intermediate/high probability of hepatic fibrosis was predominantly observed in males with BMI ≥ 23 kg/m2 (OR = 1.35, 95% CI: 1.08-1.69) and those with WHR ≥ 0.9 (OR = 1.40, 95% CI: 1.11-1.78).

Conclusion

In China, moderate alcohol intake may heighten the risk of hepatic fibrosis in males with MASLD who are overweight/obese or have abdominal obesity. Moreover, males with MetALD may have a higher risk of fibrosis compared to those with pure MASLD.

Metabolic score for visceral fat is correlated with all-cause and cardiovascular mortality among individuals with non-alcoholic fatty liver disease

BACKGROUND

Metabolic score for visceral fat (METS-VF) as an effective marker of visceral obesity has been correlated with non-alcoholic fatty liver disease (NAFLD). This study aims to explore the correlation between METS-VF and both all-cause mortality and cardiovascular disease (CVD)-related mortality among individuals with NAFLD.

METHODS

A cohort of 6,759 subjects diagnosed with NAFLD was selected from the NHANES during the period from 1999 to 2018. Within this cohort, the prognostic utility of METS-VF for predicting CVD-related and all-cause mortality was assessed.

RESULTS

There was a total of 1254 all-cause deaths (18.6%) and 418 CVD-related deaths (6.2%) at a median follow-up for 9.3 years. Multivariate Cox regression analysis and restricted cubic splines analysis indicated that METS-VF can exhibit a positive non-linearly correlation with CVD mortality (HR: 4.15, 95% CI: 2.31-7.44, p < 0.001) and all-cause mortality (HR: 5.27, 95% CI: 3.75-7.42, p < 0.001), with an identified inflection point at 7.436. Subgroup analyses further revealed a stronger correlation between METS-VF and all-cause mortality among subjects without diabetes. Furthermore, the areas under the curve (AUC) for 1-, 3-, 5-, and 10-year survival rates were 0.756, 0.740, 0.747 and 0.746 for all-cause mortality, and 0.774, 0.751, 0.746 and 0.758 for CVD mortality, respectively, which performs better than the other obesity and IR related index.

CONCLUSION

Elevated METS-VF independently contributes to an increased risk of both all-cause and CVD mortality in individuals with NAFLD.

CLINICAL TRIAL NUMBER

Not applicable.

The steatotic liver disease burden paradox: unravelling the key role of alcohol

The classification of steatotic liver disease (SLD) has evolved, incorporating all conditions characterized by hepatic lipid accumulation. SLD represents a continuum of disorders that are shaped by the dynamic factors of alcohol intake and cardiometabolic risk factors. This updated classification has profound implications for both the management and research of SLD, especially with the new distinct category of patients with both metabolic and alcohol-related liver disease. In this Perspective, we highlight the pivotal role of alcohol within the SLD framework. We introduce the 'SLD burden paradox': a concept illustrating the disparity in which metabolic dysfunction-associated steatotic liver disease is more prevalent, yet individuals with SLD and excessive alcohol intake (such as in metabolic and alcohol-related liver disease and in alcohol-related liver disease) account for greater global liver-related morbidity and mortality. We explore strategies to mitigate the effect of SLD on morbidity and mortality, emphasizing the importance of early detection and reducing stigma associated with alcohol intake. Our discussion extends to methods for assessing and monitoring alcohol intake together with the critical role of managing cardiometabolic risk factors in patients across the SLD spectrum. Conclusively, we advocate for a coordinated care framework that adopts a person-centric approach when managing SLD, aiming to improve outcomes and patient care.

Steatotic Liver Disease Prevalence in China: A Population-Based Study and Meta-Analysis of 17.4 Million Individuals

BACKGROUND

Steatotic liver disease (SLD), including metabolic dysfunction-associated SLD (MASLD), has emerged as a leading cause of chronic liver disease in China.

AIMS

We aimed to provide a comprehensive and updated description of SLD prevalence in China.

METHODS

We described the prevalence, subgroup distribution, and clinical characteristics of SLD in the Taizhou Study of Liver Diseases (T-SOLID). Additionally, we searched for studies reporting SLD prevalence in five databases. Eligible data were analysed using a generalised linear mixed model. Linear regression was applied to estimate the annual average percentage change (AAPC).

RESULTS

Of the 28,623 participants in T-SOLID, 30.8% were diagnosed with SLD, among which 83.8% were classified as MASLD. Prevalence of SLD increased from 22.1% in 2018 to 36.7% in 2021. The meta-analysis included 792 publications and 17,404,296 subjects. Nationwide, the pooled SLD prevalence rose from 23.8% (95% CI 21.9%-25.9%) during 2001-2010 to 27.9% (26.0%-29.8%) during 2016-2023 in the general population (AAPC = 2.56, p < 0.0001), equating to approximately 402.0 million cases. An increase in SLD prevalence was observed in subpopulations by region, sex, and age, and in high-risk groups. Northeast China had the highest prevalence (35.0%). Males had a higher prevalence rate than females (35.0% vs. 20.6%). SLD prevalence increased with age, ranging from 8.1% in children and adolescents to 31.8% in the elderly. Meta-regression identified calendar period, age, sex, geographical area, and residence area as significant determinants of SLD prevalence.

CONCLUSION

The ubiquitously rising prevalence of SLD in Chinese populations underscores the urgent need for targeted public health interventions.

Unmet needs of metabolic dysfunction - Associated "fatty or steatotic" liver disease

Nonalcoholic fatty liver disease (NAFLD), first named in 1980, is currently the most common chronic liver disease, imposing significant health, social, and economic burdens. However, it is defined as a diagnosis of exclusion, lacking a clear underlying cause in its diagnostic criteria. In 2020, metabolic dysfunction-associated fatty liver disease (MAFLD) was proposed as a replacement for NAFLD, introducing additional criteria related to metabolic dysfunction. In 2023, metabolic dysfunction-associated steatotic liver disease (MASLD) was suggested to replace NAFLD, aiming to avoid the stigmatizing term "fatty" and incorporating cardiometabolic criteria for metabolic dysfunction. This divergence in nomenclature and diagnostic criteria between MAFLD and MASLD presents challenges to medical communication and progress. This review outlines the pros and cons of both terminologies, based on current research evidence, in the hope of fostering global consensus in the future.

Echinacoside Alleviates Non-Alcoholic Fatty Liver Disease in Rats: Potential Involvement of AMPK Pathway and Autophagy

The primary objective aims to evaluate the therapeutic efficacy of echinacoside in ameliorating hepatic steatosis and exploring its role in modulating autophagic flux through AMP-activated protein kinase (AMPK) signaling, positioning it as a potential treatment for non-alcoholic fatty liver disease (NAFLD). A well-established NAFLD rat model was employed, administering varying concentrations of echinacoside. Biochemical parameters, including triglycerides (TG), total cholesterol (TC), low-density lipoprotein cholesterol (LDL-C), high-density lipoprotein cholesterol (HDL-C), alongside liver enzymes alanine aminotransferase (ALT), aspartate aminotransferase (AST), and alkaline phosphatase (ALP), were measured to assess liver function. To elucidate the molecular mechanisms, western blot analyses were performed to assess the expressions of p-AMPK, total AMPK, and key autophagy markers LC-3 I/II and Beclin-1. Echinacoside significantly improved the lipid profile by lowering plasma TG, TC, and LDL-C levels while increasing HDL-C. It also reduced serum ALT, AST, and ALP activities, demonstrating hepatoprotective effects. Notably, echinacoside reversed the p-AMPK levels in NAFLD rats in a dose-dependent manner, with the highest dosage showing the strongest effect. This was accompanied by increased expression of LC-3 I/II and Beclin-1. Echinacoside is expected to be a therapeutic drug for NAFLD by activating AMPK activity and enhancing autophagy to improve liver function. These findings suggest its clinical potential, with autophagy modulation via the AMPK pathway as a possible therapeutic mechanism for NAFLD treatment.

Adherence to the planetary health diet index and metabolic dysfunction-associated steatotic liver disease: a cross-sectional study

Backgrounds

Adherence to the Planetary Health Diet Index (PHDI) has been shown to benefit both individual health and the planet. However, its impact on Metabolic Dysfunction-Associated Steatotic Liver Disease (MASLD) remains unclear. This study aimed to investigate the relationship between PHDI adherence and the MASLD risk.

Methods

We analyzed a cohort of 15,865 adults (aged ≥18 years) using data from the National Health and Nutrition Examination Survey (NHANES, 2005-2018). The PHDI was derived from 24-h dietary assessments and comprised the scores of 15 food groups. Multivariate logistic regression was used to investigate the association between PHDI and MASLD, while restricted cubic spline (RCS) regression and threshold analysis were employed to explore potential non-linear relationship. Subgroup analyses were conducted to assess the influence of various demographic and clinical characteristics on the observed associations. Mediation analysis was performed to evaluate the indirect effect of PHDI on MASLD, and weighted quantile sum (WQS) regression was used to assess the influence of individual PHDI nutrients on MASLD.

Results

Among the cohort, 6,125 individuals were diagnosed with MASLD. Multivariate logistic regression revealed that a higher quintile of PHDI was significantly associated with reduced MASLD risk in the fully adjusted model (OR = 0.610, 95%CI 0.508-0.733, p < 0.001). Notably, nonlinear relationships between PHDI and MASLD risk were observed through RCS analysis (p = 0.002). Subgroup analyses indicated that PHDI was particularly effective in reducing MASLD risk among females, those with higher education attainment, and those living with a partner. WQS regression identified saturated fatty acids as the most significant factor contributing to MASLD risk (weight = 0.313). Additionally, BMI and waist circumference (81.47 and 87.66%, respectively) partially mediated the association between PHDI and MASLD risk, suggesting that the effect of PHDI on MASLD operates, in part, through its impact on BMI and waist circumference. The association between PHDI and MASLD remained robust across multiple sensitivity analyses.

Conclusion

Our findings indicate that adherence to PHDI is linked to a lower risk of MASLD, providing crucial insights for strategies aimed at mitigating the MASLD epidemic while simultaneously fostering environmental sustainability.

Impact of steatotic liver disease subtypes, sarcopenia, and fibrosis on all-cause and cause-specific mortality: a 15.7-year cohort study

BACKGROUND

Steatotic liver disease (SLD) was a newly proposed disease category derived from metabolic dysfunction-associated fatty liver disease (MAFLD). MAFLD and sarcopenia were independent risk factors for mortality. We aimed to evaluate the impacts of SLD subtypes, MAFLD, and sarcopenia on mortality.

METHODS

A total of 6543 subjects were identified from the National Health and Nutrition Examination Survey 1999-2006 with the latest Linked Mortality file. Hepatic steatosis, advanced fibrosis, and sarcopenia were determined by the laboratory- and anthropometry- based fatty liver index and fibrosis-4 index, and dual-energy X-ray absorptiometry-based appendicular skeletal muscle mass index, respectively. Associations of SLD subtypes, MAFLD, and sarcopenia with mortality were estimated using the weighted Cox proportional hazards model.

RESULTS

During a mean follow-up time of 15.7 years, 1567 (16.7%) deaths occurred including 494 (4.9%) deaths from cardiovascular diseases and 372 (4.1%) from cancer. The all-cause mortality rates of MAFLD, metabolic dysfunction-associated steatotic liver disease (MASLD), metabolic dysfunction and alcohol-associated liver disease (MetALD), other aetiology SLD, MASLD without sarcopenia, and MASLD with sarcopenia were 21.0%, 19.8%, 30.2%, 30.9%, 19.2%, and 75.5%, respectively. MAFLD increased the risk of all-cause mortality (hazard ratio [HR] 1.26, 95% confidence interval [CI] 1.00-1.59). MASLD predicted all-cause mortality (HR 1.17, 95% CI 1.03-1.33) but this prediction became insignificant after adjustment for metabolic risks. In contrast, MetALD and other aetiology SLD were significantly associated with all-cause mortality (HR 1.83, 95% CI 1.21-2.76; HR 2.50, 95% CI 1.82-3.44, respectively), predominantly associated with cancer-specific mortality (HR 2.42, 95% CI 1.23-4.74; HR 2.49, 95% CI 1.05-5.90, respectively). MASLD with sarcopenia increased the risk of all-cause mortality by almost twice (HR 2.19, 95% CI 1.37-3.49) and further coexisting advanced fibrosis additively increased mortality (HR 3.41, 95% CI 1.92-6.05).

CONCLUSION

SLD definition identified a more homogeneous group with metabolically hepatic steatosis at higher risks of mortality. MASLD or MASLD-related advanced fibrosis and sarcopenia additively increased mortality.

Prevalence, characteristics and outcomes of patients with metabolic and alcohol related/associated liver disease (MetALD): a systematic review and meta-analysis

BACKGROUND

In light of the new nomenclature of steatotic liver disease (SLD), we aimed to enhance the existing knowledge on the epidemiology and clinical outcomes of metabolic and alcohol related/associated liver disease (MetALD).

METHODS

A systematic review and meta-analysis were performed in Medline/PubMed, Embase, Scopus and Cochrane databases to evaluate the prevalence and outcomes of MetALD within the SLD population and to compare the characteristics between MetALD patients and those with metabolic dysfunction associated steatotic liver disease (MASLD) and alcohol-related liver disease (ALD). Nineteen studies from nine countries that evaluated 4,543,341 adult participants with SLD were included.

RESULTS

The pooled overall prevalence of MetALD among the SLD population was 10 % (95%CI:7-13 %) without significant difference between Asian and non-Asian populations. However, MetALD was more frequent in men than women (86 % vs 14 %, p < 0.01), while Asian MetALD patients, were more frequent men (92 % vs 66 %, p < 0.01) compared to non-Asians. Additionally, in terms of metabolic characteristics there were no significant differences between MetALD, MASLD and ALD patients. Regarding outcomes, patients with MetALD, compared to non-SLD, were at increased risk of all-cause [HR 1.44 (95%CI:1.24-1.66)], cardiovascular disease (CVD) [HR 1.17 (95%CI:1.12-1.21)] and cancer-related mortality [HR 2.07 (95%CI:1.32-3.25)]. Finally, patients with MetALD, had increased incidence of CVD and liver decompensating events, compared to non-SLD participants [HR 1.49 (95%CI:1.03-2.15); HR 10.55 (95%CI:3.46-32.16) respectively].

CONCLUSIONS

Based on the existing literature, patients with MetALD consist a significant part of the SLD population, with high all-cause, CVD and cancer-related mortality and increased risk for CVD and hepatic decompensation.

MetALD: Clinical aspects, pathophysiology and treatment

Metabolic dysfunction-associated steatotic liver disease (MASLD) and alcohol-related liver disease (ALD) are the most prevalent causes of chronic liver disease worldwide. Both conditions have many pathophysiological mechanisms in common, such as altered lipid and bile acid metabolism, and share some similar clinical features. Furthermore, metabolic risk factors and alcohol often co-exist in the same individuals and have recently been shown to act synergistically to markedly increase the risk of liver disease. Given the high prevalence and impact of this interaction, steatotic liver disease due to the combination of metabolic dysfunction and moderate-to-high alcohol intake has been termed MetALD in the new steatotic liver disease nomenclature, attracting the interest of the scientific community. Subsequent studies have investigated the prevalence of MetALD, which ranges from 1.7% to 17% in cohorts of patients with steatotic liver disease, depending on the population setting and study design. A few cohort studies have also assessed the prognosis of this patient population, with preliminary data suggesting that MetALD is associated with an intermediate risk of liver fibrosis, decompensation and mortality among steatotic liver disease subtypes. In this review article, we examine the clinical evidence and the experimental models of MetALD and discuss the clinical implications of the term for early detection and management. We provide insight into the pathophysiological mechanisms of the synergistic effect of alcohol and metabolic risk factors, possible screening strategies, the use of biomarkers and emerging models of care, as well as potential therapeutic interventions with a special focus on medications for MASLD, highlighting the most promising drugs for patients with MetALD.

Molecular Clustering of Metabolic Dysfunction-Associated Steatotic Liver Disease Based on Transcriptome Analysis

Background: Metabolic dysfunction-associated steatotic liver disease (MASLD) is a complex metabolic disorder with a diverse spectrum. This study aimed to classify patients with MASLD into molecular subtypes based on the underlying pathophysiology. Methods: We performed high-throughput RNA sequencing on 164 liver tissue samples from healthy controls and patients with MASLD. The clustering was based on individual genes or pathways that showed high variation across the samples. Second, the clustering was based on single-sample gene set enrichment analysis. Results: Optimal homogeneity was achieved by dividing the samples into four clusters (one healthy control and three MASLD clusters I-III) based on the top genes or pathways with differences across the samples. No significant differences were observed in waist circumference, blood pressure, glucose, alanine transaminase (ALT), or aspartate transferase (AST) levels between cluster I patients with MASLD and the healthy controls. Cluster I showed the clinical features of lean MASLD. Cluster III of MASLD demonstrated hypertension and a T2DM prevalence of 57.1% and 50.0%, respectively, with a significantly higher fibrosis burden (stage of fibrosis, liver stiffness, and FIB-4 value) than clusters I and II. Cluster III was associated with severe fibrosis and abnormal glucose homeostasis. In MASLD cluster I, the sphingolipid and GPCR pathways were upregulated, whereas the complement and phagocytosis pathways were downregulated. In MASLD cluster II, the cell cycle and NOTCH3 pathways increased, whereas the PI3K and insulin-related pathways decreased. In MASLD cluster III, increased activity occurred in the interleukin-2 and -4 and extracellular matrix pathways, coupled with decreased activity in the serotonin 2A and B pathways. Conclusions: MASLD can be divided into three distinct molecular phenotypes, wherein each is characterized by a specific molecular pathway.

Associations between systemic inflammatory biomarkers and metabolic dysfunction associated steatotic liver disease: a cross-sectional study of NHANES 2017-2020

BACKGROUND

Metabolic dysfunction-associated steatotic liver disease (MASLD) is a primary cause of chronic liver disease, with potential progression to cirrhosis and hepatocellular carcinoma (HCC). Although systemic inflammatory biomarkers are associated with liver diseases, their specific role in MASLD remains unclear. This study examines the association between systemic inflammatory biomarkers and MASLD.

METHODS

This cross-sectional study enrolled 6613 adults aged 20 years or older from the National Health and Nutrition Examination Survey (NHANES) spanning from 2017 to March 2020. Among these participants,, 34.67% were aged 40-59 years, 50.85% were female, and 63.26% were Non-Hispanic White. We investigated 10 inflammatory biomarkers: ALI, SIRI, SII, SIPS, IBI, NLR, PLR, CAR, LMR, and PNI. Logistic regression models were performed to assess the linear association between systemic inflammatory biomarkers and MASLD. Restricted cubic spline (RCS) regression was employed to explore potential nonlinear relationships between biomarkers and MASLD risk. Additionally, subgroup analyses were conducted to examine the influence of various demographic and clinical characteristics on the observed associations.

RESULTS

After adjusting for key confounders, NLR and PLR exhibited negative association with MASLD risk, while ALI, CAR, and PNI exhibited the opposite association (P < 0.05). Most biomarkers, including ALI, SIRI, IBI, CAR, LMR, and PNI, exhibited significant non-linear correlations with MASLD (P < 0.05). Subgroup analyses revealed substantial age-related differences in the association between ALI and MASLD risk, as well as varying relationships between PNI and MASLD risk across various cardiovascular outcomes (P < 0.05).

CONCLUSION

Systemic inflammatory biomarkers are significantly associated with MASLD risk. Large-scale prospective studies are warranted to confirm these findings and elucidate the underlying mechanisms.

Associations between multiple metabolic biomarkers with steatotic liver disease subcategories: A 5-year Chinese cohort study

The effectiveness of established biomarkers for non-alcoholic fatty liver disease (NAFLD) within the updated framework of steatotic liver disease (SLD) remains uncertain. This cohort study examines the association of four metabolic biomarkers-retinol-binding protein 4 (RBP-4), fibroblast growth factor 21 (FGF-21), adiponectin, and osteocalcin-with SLD and its subtypes: metabolic dysfunction-associated steatotic liver disease (MASLD) and metabolic dysfunction with alcohol-related liver disease (MetALD)/alcohol-related liver disease (ALD). Among 3,504 Chinese participants aged 55-70, 938 (26.8%) have developed SLD over 5 years, including 871 with MASLD and 67 with MetALD/ALD. The findings indicate that models incorporating RBP-4, FGF-21, adiponectin, and osteocalcin improve predictive accuracy for SLD beyond conventional models. Notably, adiponectin emerges as the most versatile marker, while elevated baseline levels of FGF-21 or RBP-4 indicate specific needs for metabolic or alcohol-related interventions, respectively, supporting tailored precision medicine strategies.

The fibrosis-4 index and its association with carotid atherosclerosis in type 2 diabetes: a cross-sectional study in China

BACKGROUND

The medical community has long been concerned about the cardiovascular disease risk in patients with type 2 diabetes. While liver fibrosis scores were originally designed for application in individuals with liver steatosis, an increasing number of studies have shown that they are also associated with cardiovascular disease risk. However, the association between Fibrosis-4 (Fib-4) in liver fibrosis scores and carotid atherosclerosis (CA) in patients with type 2 diabetes remains unclear.

OBJECTIVE

The aim of this study is to investigate the association between the Fib-4 index and CA in patients with Type 2 diabetes. Additionally, it seeks to determine whether this relationship is influenced by factors including gender, age, body mass index (BMI), hypertension, and other variables.

METHODS

Screening based on inclusion and exclusion criteria identified 2658 hospitalized patients with type 2 diabetes. Subsequently, patients were divided into three groups according to Fib-4 values (Fib-4 < 1.3, 1.3 ≤ Fib-4 < 2.67, Fib-4 ≥ 2.67). Logistic regression analysis was then applied to evaluate the association between Fib-4 and the presence of CA in type 2 diabetes. Further stratified analyses were conducted considering gender, age (using 60 years as the threshold), hypertension status, smoking, alcohol consumption, and BMI groups (using 24 kg/m2 as the threshold), aiming to investigate potential effect heterogeneity within predefined subgroups. ROC curve analysis was used to evaluate the predictive power of the Fib-4 value for CA, increased CIMT, and carotid plaques.

RESULTS

The study encompassed 2658 patients diagnosed with type 2 diabetes, comprising 1441 males and 1217 females, with an average age of 56.71 ± 10.22 years. Among them, 1736 individuals (65.3%) exhibited CA, 1243 (46.8%) had increased carotid intima-media thickness (CIMT), and 1273 (47.9%) manifested carotid plaques. Following adjustments for various factors, the prevalence of CA exhibited a progressive increase in the Fib-4 < 1.3, 1.3 ≤ Fib-4 < 2.67, and Fib-4 ≥ 2.67 groups, with statistically significant differences (P < 0.05). Moreover, the prevalence of increased CIMT and carotid plaques in the Fib-4 ≥ 2.67 group remained significantly higher than that in the Fib-4 < 1.3 group after considering various factors (P < 0.05). In the 1.3 ≤ Fib-4 < 2.67 group, subsequent to adjustments for gender, smoking, and drinking, the prevalence of increased CIMT and carotid plaques surpassed that in the Fib-4 < 1.3 group (P < 0.05). Despite further adjustments for multiple factors, the prevalence of increased CIMT and carotid plaques persisted higher than that in the Fib-4 < 1.3 group, yet the difference lacked statistical significance (P > 0.05). The results of the ROC curve analysis indicated that the AUC for Fib-4 predicting CA was 0.602 (P < 0.001, 95% CI: 0.579-0.625), while the AUC values for increased CIMT and carotid plaques were 0.561 (P < 0.001, 95% CI: 0.540-0.583) and 0.580 (P < 0.001, 95% CI: 0.558-0.601), respectively.

CONCLUSION

Elevated Fib-4 levels (Fib-4 ≥ 1.3) are positively associated with CA in patients with type 2 diabetes, including increased CIMT and the presence of carotid plaques. As such, Fib-4 may serve as a potential biomarker for the detection of CA in patients with type 2 diabetes. However, its clinical utility needs further validation, particularly in larger sample sizes and multicenter studies.

Prevalence of steatotic liver disease, advanced fibrosis and cirrhosis among community-dwelling overweight and obese individuals in the USA

BACKGROUND

There are limited prospective data among overweight and obese individuals on the prevalence of advanced fibrosis, and cirrhosis using advanced MRI-based methods in the USA. The aim of this study was to fill that gap in knowledge by prospectively determining the MRI-based prevalence of steatotic liver disease (SLD) and its subcategories, advanced fibrosis and cirrhosis among overweight and obese individuals residing in the USA.

METHODS

This is a cross-sectional analysis of prospectively enrolled overweight or obese adults aged 40-75 years from primary care and community-based settings in Southern California. Participants were classified as having SLD if MRI proton density fat fraction ≥5%, and subclassified as metabolic dysfunction-associated steatotic liver disease (MASLD), metabolic dysfunction and alcohol-associated liver disease (MetALD) and alcohol-related liver disease (ALD) consistently with the new nomenclature guidance per AASLD-EASL-ALEH. Advanced fibrosis and cirrhosis were defined as magnetic resonance elastography (MRE) ≥3.63 kPa and MRE ≥4.67 kPa, respectively.

RESULTS

The cohort included 539 participants with mean (±SD) age of 51.5 (±13.1) years and body mass index of 32.6 (±6.2) kg/m2, respectively. The prevalence of SLD, advanced fibrosis and cirrhosis was 75%, 10.8% and 4.5%, respectively. The prevalence of MASLD, MetALD and ALD was 67.3%, 4.8% and 2.6%, respectively. There was no difference in prevalence of advanced fibrosis and cirrhosis among subcategories.

CONCLUSIONS

Using advanced MRI methods among community-dwelling overweight and obese adults, the prevalence of cirrhosis was 4.5%. Most common SLD subcategory was MASLD with 67% of individuals, whereas MetALD and ALD were less common. Systematic screening for advanced fibrosis among overweight/obese adults may be considered.

Modified FIB-4 Index in Type 2 Diabetes Mellitus with Steatosis: A Non-Linear Predictive Model for Advanced Hepatic Fibrosis

Background: The Fibrosis-4 (FIB-4) index is widely recommended as a first-tier method for screening advanced hepatic fibrosis; however, its diagnostic performance is known to be suboptimal in patients with Type 2 diabetes mellitus (T2DM). We aim to propose a modified FIB-4, using the parameters of the existing FIB-4, tailored specifically for diabetic patients with metabolic dysfunction-associated steatotic liver disease (MASLD). Methods: A total of 1503 patients who underwent liver biopsy were divided into T2DM (n = 517) and non-T2DM (n = 986) groups. The model was developed using multiple regression analysis in the derivation cohort and validated in the validation cohort. Diagnostic accuracy was evaluated using the area under the receiver operating characteristic (AUC) curves. Results: Among the 1503 individuals, those with T2DM were older, more likely to be male, and had a higher prevalence of advanced hepatic fibrosis (≥F3) compared to non-T2DM individuals. Independent risk factors for advanced fibrosis in T2DM included age, AST, AST/ALT ratio, albumin, triglycerides, and platelet count. The optimized FIB-4 model for T2DM with MASLD (Diabetes Fibrosis Index) demonstrated superior diagnostic accuracy (AUC 0.771) compared to the FIB-4 (AUC 0.735, p = 0.012). The model showed a higher negative predictive value than the original FIB-4 across all age groups in the diabetic group. Conclusions: The newly optimized FIB-4 model for T2DM with MASLD (Diabetes Fibrosis Index), incorporating a non-linear predictive model, improves diagnostic performance (AUC) and the negative predictive value in MASLD with T2DM.

Metabolic Dysfunction-Associated Steatotic Liver Disease in Type 2 Diabetes Mellitus: A Review and Position Statement of the Fatty Liver Research Group of the Korean Diabetes Association

Since the role of the liver in metabolic dysfunction, including type 2 diabetes mellitus, was demonstrated, studies on non-alcoholic fatty liver disease (NAFLD) and metabolic dysfunction-associated fatty liver disease (MAFLD) have shown associations between fatty liver disease and other metabolic diseases. Unlike the exclusionary diagnostic criteria of NAFLD, MAFLD diagnosis is based on the presence of metabolic dysregulation in fatty liver disease. Renaming NAFLD as MAFLD also introduced simpler diagnostic criteria. In 2023, a new nomenclature, steatotic liver disease (SLD), was proposed. Similar to MAFLD, SLD diagnosis is based on the presence of hepatic steatosis with at least one cardiometabolic dysfunction. SLD is categorized into metabolic dysfunction-associated steatotic liver disease (MASLD), metabolic dysfunction and alcohol-related/-associated liver disease, alcoholrelated liver disease, specific etiology SLD, and cryptogenic SLD. The term MASLD has been adopted by a number of leading national and international societies due to its concise diagnostic criteria, exclusion of other concomitant liver diseases, and lack of stigmatizing terms. This article reviews the diagnostic criteria, clinical relevance, and differences among NAFLD, MAFLD, and MASLD from a diabetologist's perspective and provides a rationale for adopting SLD/MASLD in the Fatty Liver Research Group of the Korean Diabetes Association.

Lights and shadows in the new definition of steatotic liver disease

The presence of marked hepatic steatosis in patients with high alcohol consumption was first described in 1836 by Addison et al.1 Many years later, in 1980, Ludwig and colleagues described a histological picture very similar to that seen in patients with alcoholic hepatitis but who did not consume alcohol, coining the term non-alcoholic steatohepatitis (NASH).2 In recent years, the terminology used to describe conditions related to hepatic steatosis has undergone significant evolution. In 2020, Eslam et al.3 subsequently modified it to MAFLD (Metabolic Associated Fatty Liver Disease) to better reflect its association with metabolic dysfunction, a nomenclature that, from the beginning, generated some reluctance due to the absence of clear international consensus.

Impact of Korean Military Service on the Prevalence of Steatotic Liver Disease: A Longitudinal Study of Pre-enlistment and In-Service Health Check-Ups

Background/Aims

Young Korean men are obligated to serve in the military for 18 to 21 months. We investigated the effects of military service on steatotic liver disease (SLD) and other metabolic parameters.

Methods

Pre-enlistment health check-up performed from 2019 to 2022 and in-service health check-up performed from 2020 to 2022 were merged as paired data. SLD was defined as a hepatic steatosis index of 36 or higher. Hypertension (HTN) and hypertriglyceridemia were also included in the analysis.

Results

A total of 503,136 paired cases were included in the analysis. Comparing pre-enlistment and in-service health check-ups, the prevalence of SLD (22.2% vs 17.6%, p<0.001), HTN (7.6% vs 4.3%, p<0.001), and hypertriglyceridemia (8.1% vs 2.9%, p<0.001) decreased during military service. In terms of body mass index, the proportion of underweight (8.2% vs 1.4%, p<0.001) and severely obese (6.1% vs 4.9%, p<0.001) individuals decreased over time. Regarding factors associated with SLD development and resolution, age was positively associated with SLD development (odds ratio, 1.146; p<0.001) and a health check-up interval of <450 days was a protective factor for SLD development (odds ratio, 0.746; p<0.001). Those serving in the marines were less likely to develop SLD, whereas those serving in the navy were more likely to develop SLD. Serving in the army or the navy was negatively associated with SLD resolution, whereas serving in the air force was positively associated with SLD resolution.

Conclusions

The prevalence of SLD, HTN, and hypertriglyceridemia decreased substantially during Korean military service.

From NAFLD to MAFLD and MASLD: a tale of alcohol, stigma and metabolic dysfunction

Liver steatosis is a frequent finding in clinical practice and it is estimated to affect 30% of the general adult population worldwide. It became one of the leading causes of end-stage liver disease and hepatocellular carcinoma. From its first description, a diagnosis of nonalcoholic fatty liver disease (NAFLD) required the exclusion of excessive alcohol consumption and concomitant chronic liver diseases of different origins, making it a diagnosis of exclusion. In recent years, the need to stress the strict association between liver steatosis and metabolic dysfunction (i.e., insulin resistance, overweight/obesity, type 2 diabetes, and metabolic syndrome), as well as the desire to define a condition in a positive rather than negative way, led to new definitions and new diagnostic criteria. Metabolic dysfunction-associated fatty liver disease (MAFLD) was proposed by Eslam et al. in 2020. More recently, a Delphi consensus endorsed by several international hepatologic societies proposed a new terminology [metabolic dysfunction-associated steatotic liver disease (MASLD)] and a new set of diagnostic criteria. The MAFLD and MASLD definitions have a good degree of concordance. They mainly differ in the number of metabolic derangements needed to define “metabolic dysfunction” in normal-weight individuals and in alcohol consumption. Indeed, while MAFLD does not exclude patients with significant alcohol consumption, the recent Delphi consensus included the metabolic dysfunction and alcohol-related liver disease (MetALD) disease entity, a condition in which steatosis, metabolic dysfunction, and moderate alcohol intake coexist. In the present narrative review, we underline the strengths and possible limitations of each definition and summarize available evidence from epidemiologic studies evaluating the clinical usefulness of each set of diagnostic criteria.

Barriers to care linkage and educational impact on unnecessary MASLD referrals

Background

The importance of primary care physicians (PCPs) in managing metabolic dysfunction-associated steatotic liver disease (MASLD) has increased. This study aimed to assess the effectiveness of an online educational program on MASLD among physicians.

Methods

In total, 869 physicians (72 physicians at referral centers and 797 PCPs) participated in this study. They completed an initial survey regarding their clinical practices for patients with MASLD, followed by a second online survey 8 weeks after receiving a series of seven weekly sets of educational materials on MASLD.

Results

In the baseline survey, most PCPs did not routinely evaluate the stage of hepatic fibrosis in MASLD; they typically initiated assessments based on elevated liver enzyme levels. Only a limited number of PCPs used vibration-controlled transient elastography. The main hurdles in managing MASLD were "the absence of a fee for patient education" for PCPs and "short consultation time" for referral-center physicians. In the follow-up survey, the percentage of liver fibrosis assessments using noninvasive tests increased from 7.0 to 11.2%. Additionally, evaluations for cardiovascular disease increased from 3.9 to 8.2%, and the risk of ischemic stroke increased from 13.7 to 16.9%. The percentage of immediate referrals of patients to specialists after an MASLD diagnosis decreased from 15.4 to 12.3%.

Conclusion

The discrepancies in management strategies and viewpoints regarding MASLD between PCPs and referral-center physicians can hinder efforts to mitigate the disease burden. Increasing awareness among PCPs regarding MASLD through a 7-week education program led to a reduction in unnecessary referral rates and an increase in cardiovascular evaluations.

Emerging Roles and Therapeutic Applications of Arachidonic Acid Pathways in Cardiometabolic Diseases

Cardiometabolic disease has become a major health burden worldwide, with sharply increasing prevalence but highly limited therapeutic interventions. Emerging evidence has revealed that arachidonic acid derivatives and pathway factors link metabolic disorders to cardiovascular risks and intimately participate in the progression and severity of cardiometabolic diseases. In this review, we systemically summarized and updated the biological functions of arachidonic acid pathways in cardiometabolic diseases, mainly focusing on heart failure, hypertension, atherosclerosis, nonalcoholic fatty liver disease, obesity, and diabetes. We further discussed the cellular and molecular mechanisms of arachidonic acid pathway-mediated regulation of cardiometabolic diseases and highlighted the emerging clinical advances to improve these pathological conditions by targeting arachidonic acid metabolites and pathway factors.

Metabolic dysfunction-associated steatotic liver disease: Evolution of the final terminology

The medical term nonalcoholic fatty liver disease (NAFLD) was coined in 1986 for a condition that has since become the most prevalent liver disorder worldwide. In the last 3 years, the global professional community launched 2 consecutive efforts to purge NAFLD from the medical dictionary and recommended new terms based on disease pathophysiology rather than distinction from similar conditions featuring liver steatosis. A consensus by renowned clinical scholars primarily residing in the Asian-Pacific region introduced metabolic dysfunction-associated fatty liver disease (MAFLD) as a new name to replace NAFLD in 2020. In 2023, a nomenclature and classification resulting in the term metabolic dysfunction-associated steatotic liver disease (MASLD) was developed by a large expert panel under the auspices of leading liver societies from Europe and Americas. These marked and rapid shifts in nomenclature have garnered the attention of many researchers and clinicians across the globe due to the multilevel impact of a frequent and potentially progressive chronic liver disease in both adult and pediatric populations. The proposed terminologies differ in several ways but they have more in common than differences. They both capture key features of liver disease associated with cardiometabolic risk factors and with significant impact on all-cause and liver-related mortality. The framework of MASLD has incorporated many innovative aspects of MAFLD and while several conceptual disparities remain a work in progress, global efforts should focus on new insights into disease pathogenesis, outcome trajectories, prevention, and treatment. Here, some of these challenges are discussed to facilitate this process.

Metabolic Dysfunction-Associated Steatotic Liver Disease: From Pathogenesis to Current Therapeutic Options

The epidemiological burden of liver steatosis associated with metabolic diseases is continuously growing worldwide and in all age classes. This condition generates possible progression of liver damage (i.e., inflammation, fibrosis, cirrhosis, hepatocellular carcinoma) but also independently increases the risk of cardio-metabolic diseases and cancer. In recent years, the terminological evolution from "nonalcoholic fatty liver disease" (NAFLD) to "metabolic dysfunction-associated fatty liver disease" (MAFLD) and, finally, "metabolic dysfunction-associated steatotic liver disease" (MASLD) has been paralleled by increased knowledge of mechanisms linking local (i.e., hepatic) and systemic pathogenic pathways. As a consequence, the need for an appropriate classification of individual phenotypes has been oriented to the investigation of innovative therapeutic tools. Besides the well-known role for lifestyle change, a number of pharmacological approaches have been explored, ranging from antidiabetic drugs to agonists acting on the gut-liver axis and at a systemic level (mainly farnesoid X receptor (FXR) agonists, PPAR agonists, thyroid hormone receptor agonists), anti-fibrotic and anti-inflammatory agents. The intrinsically complex pathophysiological history of MASLD makes the selection of a single effective treatment a major challenge, so far. In this evolving scenario, the cooperation between different stakeholders (including subjects at risk, health professionals, and pharmaceutical industries) could significantly improve the management of disease and the implementation of primary and secondary prevention measures. The high healthcare burden associated with MASLD makes the search for new, effective, and safe drugs a major pressing need, together with an accurate characterization of individual phenotypes. Recent and promising advances indicate that we may soon enter the era of precise and personalized therapy for MASLD/MASH.

Associations between estimated glucose disposal rate and arterial stiffness and mortality among US adults with non-alcoholic fatty liver disease

Background

The estimated glucose disposal rate (eGDR), an effective indicator of insulin resistance, has been related to acute coronary syndrome, ischemic stroke and heart failure. This study aims to explore the relationship between eGDR and arterial stiffness, all-cause mortality and cardiovascular mortality in patients with non-alcoholic fatty liver disease (NAFLD).

Methods

Participants with NAFLD were chosen from the National Health and Nutrition Examination Survey (NHANES) between 1999 and 2018. The main outcomes are arterial stiffness (represented by estimated pulse wave velocity, ePWV), all-cause and cardiovascular mortality. Multiple cox regression models, restricted cubic spline, sensitivity analysis and subgroup analysis were carried out to investigate the correlation between the insulin resistance indicators and mortality and arterial stiffness. Furthermore, receiver operating characteristic curves were used to compare the predictive value of the eGDR with the triglyceride-glucose (TyG) index and the homeostasis model assessment of insulin resistance (HOMA-IR) for all-cause and cardiovascular mortality.

Results

In this study, a total of 4,861 participants were included for analysis. After adjusting confounding factors in the multivariate weighted cox regression model, the eGDR was inversely associated with the all-cause mortality (Q4 vs. Q1, HR =0.65 (0.48-0.89, P=0.01) and cardiovascular mortality (Q4 vs. Q1, HR =0.35 (0.19-0.65, P<0.001). Compared with TyG index and HOMA-IR, the eGDR shows excellent predictive value in all-cause mortality (0.588 vs. 0.550 vs. 0.513, P < 0.001) and cardiovascular mortality (0.625 vs. 0.553 vs. 0.537, P < 0.001). In addition, we found a significant negative correlation between eGDR and arterial stiffness (β=-0.13(-0.14-0.11, P< 0.001). However, TyG index and HOMA-IR showed no significant correlation to arterial stiffness.

Conclusions

Low eGDR (an indicator of insulin resistance) levels are related to an increased risk of arterial stiffness and mortality in NAFLD patients in the United States.