Clinical utility of liver fat quantification for determining cardiovascular disease risk among patients with type 2 diabetes

Association of High-Sensitivity Troponins in Metabolic Dysfunction-Associated Steatotic Liver Disease With All-Cause and Cause-Specific Mortality

BACKGROUND

Characterising the phenotypic features of individuals with metabolic dysfunction-associated steatotic liver disease (MASLD) can help identify high-risk subpopulations within this group. High-sensitivity troponin (hs-troponin) is a significant risk factor for future cardiovascular disease events.

AIMS

We studied the association of hs-troponin in the absence of cardiovascular disease with all-cause and cause-specific mortality among individuals with MASLD.

METHODS

We used the National Health and Nutrition Examination Survey 1999-2004 and linked the mortality dataset through 2019. We used Cox regression models to assess the association between hs-troponin with all-cause and cause-specific mortality among individuals with MASLD and without cardiovascular disease.

RESULTS

During the median follow-up period of 17.5 years (IQR: 15.9-19.1), higher levels of hs-troponin T among individuals with MASLD were associated with progressively higher hazards of all-cause and cardiovascular mortality, which remained significant after adjustment for demographic, clinical, lifestyle and metabolic risk factors. There was a 29% (hazard ratio [HR]: 1.29, 95% confidence interval [CI]: 1.16-1.44) increase in all-cause mortality and a 44% (HR: 1.44, 95% CI: 1.20-1.72) increase in cardiovascular mortality for every rise in 1-standard deviation of hs-troponin T. A significant association between hs-troponin (p for trend) and cardiovascular mortality was noted with 3 hs-troponin I assays, similar to hs-troponin T. There was no significant association between hs-troponin and cancer-related mortality.

CONCLUSION

Screening hs-troponin T or I in individuals with MASLD can identify at-risk subpopulations within this group that have a higher risk for future all-cause mortality, predominantly due to cardiovascular disease-related mortality in the population without cardiovascular 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.

Liver-Kidney-Metabolic Health, Sex, and Menopause Impact Total Scores and Monovessel vs. Multivessel Coronary Artery Calcification

INTRODUCTION

Liver-kidney-metabolic health (LKMH) depends on complex interactions between metabolic dysfunction-associated steatotic liver disease (MASLD), chronic kidney disease (CKD), sex, and reproductive status. This study evaluates in a holistic manner how LKMH, sex, and menopause influence coronary artery calcification (CAC) burden.

METHODS

Patients without previous cardiovascular disease were prospectively recruited. Liver fat was assessed via ultrasonography and categorized as mild or moderate-to-severe. CKD was classified using estimated glomerular filtration rate (eGFR). CAC burden was quantified as 0, 1-299, ≥ 300, single-vessel, or multivessel with coronary computed tomography. Stepwise backward multinomial logistic regression was applied for analysis.

RESULTS

A total of 446 patients (59.2% female, average age 52.9 years) were included. Moderate-to-severe MASLD was independently associated with an increased risk of CAC 1-299 [OR 2.30 (1.21-4.36)], CAC ≥ 300 [OR 4.93 (1.46-16.59)], and single-vessel CAC [OR 2.03 (1.03-4.00)]. Mild MASLD [OR 2.47 (1.20-4.21)], moderate-to-severe MASLD [OR 3.74 (1.76-7.93)], and CKD stage 2 [OR 2.27 (1.26-4.08)] were independently associated with increased multivessel CAC risk. Liver fat content showed a dose-response association with CAC burden. Subgroup analysis revealed that MASLD and CKD increased CAC risk in male but not female patients, with menopause significantly modifying LKMH's effect.

CONCLUSION

LKMH's impact on CAC burden is significantly influenced by liver fat content, eGFR, sex, and menopause, suggesting that MASLD, CKD, sex, and reproductive status should be integrated into CAC risk prediction models.

Advances in research on metabolic dysfunction-associated steatotic liver disease

The global increase in obesity-related metabolic disorders has led to metabolic dysfunction-associated steatotic liver disease (MASLD) emerging as one of the most prevalent chronic liver disease worldwide. Despite growing concerns, the exact pathogenesis of MASLD remains unclear and no definitive treatments have been made available. Consequently, the need for comprehensive research on MASLD is more critical than ever. Gaining insight into the mechanisms of the disease can lay the groundwork for identifying new therapeutic targets and can facilitate the development of diagnostic tools that enable the early detection and intervention of MASLD. Research has discovered a multifactorial etiology for MASLD, suggesting that potential therapeutic strategies should be considered from a variety of perspectives. This review delves into the pathogenesis of MASLD, current diagnostic approaches, potential therapeutic targets, the status of clinical trials for emerging drugs, and the most promising treatment methods available today. With a focus on therapeutic targets, the aim is to offer fresh insights and guide for future research in the treatment of MASLD.

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

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

The gut-liver axis: emerging mechanisms and therapeutic approaches for nonalcoholic fatty liver disease and type 2 diabetes mellitus

Nonalcoholic fatty liver disease (NAFLD), more appropriately known as metabolic (dysfunction) associated fatty liver disease (MAFLD), a prevalent condition in type 2 diabetes mellitus (T2DM) patients, is a complex condition involving hepatic lipid accumulation, inflammation, and liver fibrosis. The gut-liver axis is closely linked to metabolic dysfunction, insulin resistance, inflammation, and oxidative stress that are leading to the cooccurrence of MAFLD and T2DM cardiovascular diseases (CVDs). The purpose of this review is to raise awareness about the role of the gut-liver axis in the progression of MAFLD, T2DM and CVDs with a critical analysis of available treatment options for T2DM and MAFLD and their impact on cardiovascular health. This study analysed over 100 articles on this topic, using online searches and predefined keywords, to understand and summarise published research. Numerous studies have shown a strong correlation between gut dysfunction, particularly the gut microbiota and its metabolites, and the occurrence and progression of MAFLD and type 2 diabetes mellitus (T2DM). Herein, this article also examines the impact of the gut-liver axis on MAFLD, T2DM, and related complications, focusing on the role of gut microbiota dysbiosis in insulin resistance, T2DM and obesity-related cardiovascular complications. The study suggests potential treatment targets for MAFLD linked to T2DM, focusing on cardiovascular outcomes and the molecular mechanism of the gut-liver axis, as gut microbiota dysbiosis contributes to obesity-related metabolic abnormalities.

Intersystem and Interoperator Agreement of US Attenuation Coefficient for Quantifying Liver Steatosis

Background The extent of liver steatosis can be assessed using US attenuation coefficient (AC) algorithms currently implemented in several US systems. However, little is known about intersystem and interoperator variability in measurements. Purpose To assess intersystem and interoperator agreement in US AC measurements for fat quantification in individuals with varying degrees of liver steatosis and to assess the correlation of each manufacturer's AC algorithm results with MRI proton density fat fraction (PDFF). Materials and Methods This prospective study was conducted at Southwoods Imaging, Youngstown, Ohio, September 30-October 1, 2023. Two operators independently obtained AC measurements using eight US systems equipped with an AC algorithm from different manufacturers. On the same day, MRI PDFF measurement was performed by a different operator. Correlation between US AC and MRI PDFF was assessed using a mixed-effects model. Agreement between systems and operators was evaluated using the intraclass correlation coefficient (ICC). Results Twenty-six individuals (mean age, 55.4 years ± 10.7 [SD]; 16 female participants) were evaluated. The correlation of US AC with MRI PDFF was high for five AC algorithms (r range, 0.70-0.86), moderate for two (r = 0.62 for both), and poor for one (r = 0.47). In pairwise comparisons, none of the pairs of systems achieved excellent agreement (overall ICC = 0.33 [95% CI: 0.15, 0.52]). One pair showed good agreement (ICC = 0.79 [95% CI: 0.66, 0.87]), eight pairs showed moderate agreement (ICC range, 0.50 [95% CI: 0.22, 0.69] to 0.73 [95% CI: 0.49, 0.85]), and 19 pairs showed poor agreement (ICC range, 0.11 [95% CI: -0.06, 0.37] to 0.48 [95% CI: 0.20, 0.67]). Interoperator agreement on AC value was excellent for the Samsung Medison algorithm (ICC = 0.90 [95% CI: 0.80, 0.96]), good for the Siemens Healthineers (ICC = 0.76 [95% CI: 0.54, 0.89]) and Canon Medical Systems (ICC = 0.76 [95% CI: 0.16, 0.92]) algorithms, and moderate for the remaining algorithms (ICC range, 0.50 [95% CI: 0.16, 0.73] to 0.74 [95% CI: 0.51, 0.88]). The mean AC value obtained by the two operators did not differ for any system except the system from Canon Medical Systems. Conclusion There was substantial variability in AC values obtained with different US systems, precluding interchangeability between systems for liver steatosis diagnosis and follow-up imaging. Interoperator agreement ranged from moderate to excellent. © RSNA, 2024 Supplemental material is available for this article. See also the editorial by Han in this issue.

Effects of luseogliflozin on suspected MASLD in patients with diabetes: a pooled meta-analysis of phase III clinical trials

BACKGROUND

Luseogliflozin, a sodium-glucose cotransporter 2 inhibitor, potentially exerts pleiotropic effects on the liver. However, the sufficient evidence is still lacking. We aimed to investigate the effects of luseogliflozin on hepatic steatosis, fibrosis, and cardiometabolic risk factors in diabetic patients by a pooled meta-analysis.

METHODS

In this pooled meta-analysis, we enrolled diabetic patients who participated in phase III clinical trials of luseogliflozin (luseogliflozin group n = 302, placebo group n = 191). The primary outcomes were changes in fatty liver index (FLI) and Hepamet fibrosis score (HFS) after 24 weeks. The secondary outcomes were changes in cardiometabolic risk factors after 24 weeks. Statistical analysis was performed using propensity scoring analysis by the inverse probability of treatment weighting method.

RESULTS

Primary outcomes: Luseogliflozin significantly decreased FLI compared to placebo after 24 weeks (adjusted coefficient - 5.423, 95%CI - 8.760 to - 2.086, P = 0.0016). There was no significant difference in changes in HFS between the two groups. However, luseogliflozin significantly decreased HFS compared to placebo in diabetic patients with ALT > 30 U/L (adjusted coefficient - 0.039, 95%CI - 0.077 to - 0.001, P = 0.0438) and with FIB-4 index > 1.3 (adjusted coefficient - 0.0453, 95%CI - 0.075 to - 0.016, P = 0.0026). Secondary outcom8es: Luseogliflozin significantly decreased HbA1c level, HOMA-IR value, BMI, and uric acids level, and increased HDL cholesterol level compared to placebo.

CONCLUSIONS

This pooled meta-analysis demonstrated that 24-week treatment with luseogliflozin improved hepatic steatosis and fibrosis indexes in diabetic patients, especially those with liver injury. Furthermore, luseogliflozin improved various cardiometabolic risk factors. Thus, luseogliflozin may be useful for improving MASLD in diabetic patients.

WFUMB Guidelines/Guidance on Liver Multiparametric Ultrasound. Part 2: Guidance on Liver Fat Quantification

The World Federation for Ultrasound in Medicine and Biology (WFUMB) has promoted the development of this document on multiparametric ultrasound. Part 2 is a guidance on the use of the available tools for the quantification of liver fat content with ultrasound. These are attenuation coefficient, backscatter coefficient, and speed of sound. All of them use the raw data of the ultrasound beam to estimate liver fat content. This guidance has the aim of helping the reader in understanding how they work and interpret the results. Confounding factors are discussed and a standardized protocol for measurement acquisition is suggested to mitigate them. The recommendations were based on published studies and experts' opinion but were not formally graded because the body of evidence remained low at the time of drafting this document.

Validation of AGA clinical care pathway and AASLD practice guidance for nonalcoholic fatty liver disease in a prospective cohort of patients with type 2 diabetes

BACKGROUND AND AIMS

Recently, the American Gastroenterological Association and the American Association for the Study of Liver Diseases developed clinical pathways to evaluate populations at high risk for NAFLD. We assessed the diagnostic performance of the new guidance in a well-phenotyped cohort of patients with Type 2 diabetes mellitus (T2DM).

APPROACH AND RESULTS

This prospective study enrolled patients age ≥50 years with T2DM. Participants underwent a standardized clinical research visit with MRI and ultrasound-based assessment of liver fat and stiffness and Enhanced Liver Fibrosis (ELF) testing. Of 417 participants (36% men) with T2DM with FIB-4 and MRE data, the prevalence of NAFLD was 64% and 12% had advanced fibrosis (MRE≥3.63 kPa). Applying the American Gastroenterological Association pathway of FIB-4 and vibration-controlled transient elastography, the false negative rate was 3.3% and 18% would qualify for specialty referral. Applying the FIB-4 + ELF American Association for the Study of Liver Diseases pathway, the false negative rate was 4.5%, but 50% would qualify for specialty referral. Applying higher ELF cut points improved the pathway, yielding a similar false negative rate of 4.9% but decreased specialty referral to 27%.

CONCLUSION

Validation of the American Gastroenterological Association clinical pathway in a prospectively recruited cohort with T2DM revealed a low false negative rate and avoided specialty referral in a large percentage of patients. The American Association for the Study of Liver Diseases pathway with FIB-4 + ELF resulted in a high rate of specialty referral, which improved with the utilization of higher ELF cut points and may serve as an alternative for primary care and endocrinology clinics without access to vibration-controlled transient elastography.

Systematic review with meta-analysis: Steatosis severity and subclinical atherosclerosis in metabolic dysfunction-associated steatotic liver disease

BACKGROUND

Metabolic dysfunction-associated steatotic liver disease (MASLD) is a prevalent liver condition recognised as an independent risk factor for cardiovascular disease (CVD). However, there is ongoing debate regarding the effective strategy for cardiovascular risk assessment in MASLD.

AIM

To investigate the relationship between liver imaging, specifically focusing on the severity of steatosis and subclinical atherosclerosis.

METHODS

We conducted a thorough search across four databases, from 1950 to April 2023, to identify eligible studies employing imaging to explore the relationship between different degrees of steatosis and subclinical atherosclerosis among MASLD. Additionally, we conducted a quality assessment using the Newcastle Ottawa Scale, performed a meta-analysis employing the DerSimonian-Liard random-effects model, and conducted subgroup analyses for validation.

RESULTS

In total, 19 studies, encompassing 147,411 middle-aged individuals without previous CVD (74.94% male; mean age 45.53 years [SD 10.69]; mean BMI 24.3 kg/m2 [SD 3.35]), were included. The pooled odds ratio for subclinical atherosclerosis was 1.27 (95% CI: 1.13-1.41, I2  = 76.68%) in mild steatosis and significantly increased to 1.68 (95% CI: 1.41-2.00, I2  = 89.02%) in moderate to severe steatosis. Sensitivity analysis, focusing on high-quality studies, consistently supported this finding and the results remained robust across subgroup analyses. Furthermore, meta-regression revealed that a higher mean AST and ALT, alongside a lower mean HDL, were significant moderators of this association.

CONCLUSIONS

Even mild steatosis is associated with CVD risk, and steatosis severity further intensifies this association. These findings suggest that liver fat quantification enhances CVD risk stratification in patients with MASLD.

Letter: Are we forgetting the importance of steatosis in steatotic liver disease? Authors' reply

This article is linked to Kuo et al papers. To view these articles, visit https://doi.org/10.1111/apt.17637 and https://doi.org/10.1111/apt.17759

Letter: Are we forgetting the importance of steatosis in steatotic liver disease?

This article is linked to Kuo et al papers. To view these articles, visit https://doi.org/10.1111/apt.17637 and https://doi.org/10.1111/apt.17825

Editorial: Can liver fat quantification stratify cardiovascular risk in type 2 diabetes? Authors' reply

This article is linked to Kuo et al papers. To view these articles, visit https://doi.org/10.1111/apt.17637 and https://doi.org/10.1111/apt.17677

Editorial: Can liver fat quantification stratify cardiovascular risk in type 2 diabetes?

This article is linked to Kuo et al papers. To view these articles, visit https://doi.org/10.1111/apt.17637 and https://doi.org/10.1111/apt.17742