Practical approach to non-alcoholic fatty liver disease in patients with diabetes

Impact of PNPLA3 and TM6SF2 polymorphisms on the prognosis of patients with MASLD and type 2 diabetes mellitus

BACKGROUND/AIMS

Longitudinal studies assessing the impact of genetic polymorphisms on outcomes in patients with Type 2 Diabetes Mellitus (T2DM) and Metabolic Dysfunction-Associated Steatotic Liver Disease (MASLD) are scarce. This study aimed to evaluate the effect of PNPLA3 and TM6SF2 risk alleles on hepatic and extrahepatic outcomes in T2DM-MASLD individuals.

METHODS

Patients' polymorphisms were analysed as follows: PNPLA3 CC, CG and GG; TM6SF2 CC and CT + TT; combined comparing no mutant allele, one allele G or T or ≥2 alleles G or T. Hierarchical models were built to assess associations between polymorphisms and outcomes, independently of confounding factors. Multivariate logistic regression was used for cirrhosis and its complications and extrahepatic cancer, and Cox regression for cardiovascular events (CVEs) and all-cause mortality.

RESULTS

In total, 407 T2DM-MASLD patients (62.1 ± 10.5 years, 67.6% women) were followed for 11 (6-13) years. Having at least one G or T allele independently increased the risk of cirrhosis in the separate analysis of PNPLA3 and TM6SF2. Combined polymorphism analysis demonstrated an even higher risk of cirrhosis if two or more risk alleles were present (OR 18.48; 95% CI 6.15-55.58; p < .001). Regarding cirrhosis complications, the risk was higher in PNPLA3 GG and TM6SF2 CT + TT, also with an even higher risk when two or more risk alleles were present in the combined evaluation (OR 27.20; 95% CI 5.26-140.62; p < .001). There were no associations with CVEs or mortality outcomes.

CONCLUSION

In T2DM, PNPLA3 and TM6SF2 polymorphisms, individually and additively, impact MASLD severity, with an increased risk of cirrhosis and its complications.

Effect of exercise intervention on clinical parameters in patients with non-alcoholic fatty liver disease and type 2 diabetes mellitus: a meta-analysis of randomized controlled trials

The effect of exercise on clinical parameters in patients with non-alcoholic fatty liver disease (NAFLD) combined with type 2 diabetes mellitus (T2DM) is unknown. In this meta-analysis, we identified and evaluated the effect of exercise on clinical parameters (BMI, ALT, lipid metabolism, glucose metabolism) in patients with NAFLD combined with T2DM. We conducted a comprehensive search of Medline, Embase, Web of Science, Cochrane Database of Systematic Reviews, and CNKI in December 2022. Data from relevant randomized controlled trials were collected according to inclusion and exclusion criteria. 6 eligible studies with 238 subjects were finally included. We used Review Manager 5.3 for meta-analysis. The study found that exercise improved BMI, ALT, TC, LDL-C, HbA1c, and HOMA-IR, TG, but did not significantly improve HDL-C. Subgroup analysis showed that high-intensity interval training significantly improved BMI (SMD: -0.43, 95% CI: -0.80, -0.06), ALT (SMD: -4.63, 95% CI: -8.42, -0.83), TC (SMD: -0.94, 95% CI: -1.82, -0.07), LDL-C (SMD: -0. 87, 95% CI: -1.26, -0.49), HbA1c (SMD: -1.12, 95% CI: -1.75, -0.48), HOMA-IR (SMD: -0.59, 95% CI: -0.94, -0.25); moderate-intensity continuous training improved ALT (SMD: -3.96, 95% CI: -7.71, -0.21), TG (SMD: -1.59, 95% CI: -2.58, -0.61), HbA1c (SMD: -0.71, 95% CI: -1.37, -0.05), HOMA-IR (SMD: -1.73, 95% CI: -3.40, -0. 06), and to some extent HDL-C levels (SMD: 0.53, 95% CI: 0.04, 1.02); resistance training improved LDL-C (SMD: -2.06, 95% CI: -3.14, -0.98). In conclusion, exercise improved indicators in patients with NAFLD combined with T2DM, but the improvement indicators varied by type of exercise.

Incidence and risk factors of nonalcoholic fatty liver disease after total pancreatectomy: A first multicenter prospective study in Japan

BACKGROUND/PURPOSE

In the present study we aimed to prospectively assess the current prevalence and risk factors of nonalcoholic fatty liver disease (NAFLD) after total pancreatectomy (TP).

METHODS

Between August 2015 and December 2017, we prospectively collected data from 68 Japanese centers on 148 consecutive patients who underwent TP whose computed tomography (CT) attenuation values were evaluated for 12 months. We defined post-TP NAFLD as a liver parenchyma CT value of less than 40 Hounsfield units (HU). Data on perioperative variables were retrieved from all patients and evaluated using univariate and multivariate analyses to identify the perioperative risk factors of NAFLD.

RESULTS

In this prospective cohort study, supplementation of pancreatic exocrine enzymes was provided to all 148 patients, and 97% of them were treated with high-titer pancrelipase (median dosage: 1800 mg) postoperatively. Indeed, 29 patients (19.6%) developed NAFLD within a year after TP. Multivariate analysis revealed that female sex (P = .002), higher body mass index (BMI) (P = .001), and postoperative diarrhea (P = .038) were independent risk factors for post-TP NAFLD. However, post-TP NAFLD ameliorated in 11 patients (37.9%) at 12 months after surgery.

CONCLUSIONS

Among patients with risk factors such as female sex, higher BMI, and postoperative diarrhea, attention should be paid to the occurrence of NAFLD after TP.

Non-alcoholic fatty liver disease and type 2 diabetes - An Update

The global prevalence of non‐alcoholic fatty liver disease (NAFLD) is rising, along with the epidemic of diabesity. NAFLD is present in >70% of individuals with type 2 diabetes. Although the mutually detrimental relationship between NAFLD and type 2 diabetes has been well established, a multitude of recent studies have further shown that type 2 diabetes is closely linked to the development of cirrhosis, hepatocellular carcinoma, liver‐related morbidity and mortality. In contrast, NAFLD also negatively impacts type 2 diabetes both in terms of its incidence and related adverse clinical outcomes, including cardiovascular and chronic kidney diseases. In response to these global health threats, clinical care pathways for NAFLD and guidelines for metabolic dysfunction‐associated fatty liver disease have been developed. Several antidiabetic agents have been evaluated for their potential hepatic benefits with promising results. Furthermore, type 2 diabetes patients are increasingly represented in clinical trials of novel therapeutics for NAFLD. However, despite the wealth of knowledge in NAFLD and type 2 diabetes, lack of awareness of the disease and the potential weight of this problem remains a major challenge, especially among clinicians who are outside the field of hepatology and gastroenterology. This review therefore aimed to provide all diabetes care providers with a summary of the latest evidence that supports NAFLD as an emerging diabetic complication of increasing importance, and to present the current recommendations, focusing on the assessment and therapeutic strategies, on the management of NAFLD among type 2 diabetes patients.

Comparison of knowledge and awareness between consultant physicians and resident doctors about non-alcoholic fatty liver disease

AIM OF THE STUDY

Non-alcoholic fatty liver disease (NAFLD) is a multisystem disease and is commonly associated with diabetes mellitus, dyslipidaemia, hypertension and obesity. These illnesses are usually treated by physicians, and hence they need to stay updated on NAFLD. The aim of the study was to assess and compare the knowledge and awareness about NAFLD among consultant physicians and resident doctors.

MATERIAL AND METHODS

A questionnaire concerning epidemiology, risk factors, complications, diagnostic methods, management options, progression and screening of NAFLD was given to the consultant physicians and resident doctors and their responses were sought. The comparison of responses was carried out between residents and consultants using Pearson's χ2 test.

RESULTS

A total of 240 doctors participated in the study with 60 resident doctors and 180 consultant physicians. 45% of the total participants did not consider NAFLD as a major health hazard. Consultants had better knowledge than residents about the prevalence of NAFLD, and the risks due to various factors. Also they had better knowledge about non-invasive diagnostic modalities. Resident doctors advocated use of antioxidants more than consultants. There was no statistically significant difference of perception between residents and physicians about association of NAFLD with diabetes and obesity, diet advice, dietary modification and exercise, usage of medications, avoidance of hepatotoxic drugs and alcohol.

CONCLUSIONS

This study revealed that physicians participating in our survey appreciate the prevalence of NAFLD but are unaware of the seriousness and the optimal management. This has implications for targeting 'at-risk' populations and appropriate referral of patients to gastroenterology/hepatology clinics.

Bariatric and metabolic surgery during and after the COVID-19 pandemic: DSS recommendations for management of surgical candidates and postoperative patients and prioritisation of access to surgery

The coronavirus disease 2019 pandemic is wreaking havoc on society, especially health-care systems, including disrupting bariatric and metabolic surgery. The current limitations on accessibility to non-urgent care undermine postoperative monitoring of patients who have undergone such operations. Furthermore, like most elective surgery, new bariatric and metabolic procedures are being postponed worldwide during the pandemic. When the outbreak abates, a backlog of people seeking these operations will exist. Hence, surgical candidates face prolonged delays of beneficial treatment. Because of the progressive nature of obesity and diabetes, delaying surgery increases risks for morbidity and mortality, thus requiring strategies to mitigate harm. The risk of harm, however, varies among patients, depending on the type and severity of their comorbidities. A triaging strategy is therefore needed. The traditional weight-centric patient-selection criteria do not favour cases based on actual clinical needs. In this Personal View, experts from the Diabetes Surgery Summit consensus conference series provide guidance for the management of patients while surgery is delayed and for postoperative surveillance. We also offer a strategy to prioritise bariatric and metabolic surgery candidates on the basis of the diseases that are most likely to be ameliorated postoperatively. Although our system will be particularly germane in the immediate future, it also provides a framework for long-term clinically meaningful prioritisation.

Association between Fatty Liver Index and Periodontitis: the Korea National Health and Nutrition Examination Survey

It has been suggested that periodontitis is associated with metabolic abnormalities including non-alcoholic fatty liver disease (NAFLD). The fatty liver index (FLI) is a non-invasive surrogate marker and predictor of NAFLD. We aimed to determine whether FLI itself would be associated with periodontitis through a secondary analysis of previously reported nationally representative probability sample data of the Korean population. FLI was calculated from a previously developed algorithm which combines measures of body mass index (BMI), waist circumference, triglyceride, and gamma-glutamyl transferase (GGT). Periodontitis was diagnosed based on the Community Periodontal Index (CPI) developed by the World Health Organization. Of 4,272 participants, 26.1% were diagnosed with periodontitis. Higher FLI was associated with a higher prevalence of periodontitis (Odds ratio (OR) _{highest vs. lowest quartile of FLI},1.63; 95% confidence interval (CI), 1.23–2.16; P = 0.001 for trend) adjusting for confounding factors. In the highest FLI quartile, prevalence of periodontitis was higher in individuals with diabetes (OR _{highest vs. lowest quartile of FLI}, 2.89; 95% CI, 1.01–8.27 for diabetic subgroup; OR _{highest vs. lowest quartile of FLI}, 1.45; 95% CI, 1.07–1.96 for non-diabetic subgroup). In summary, FLI was associated with prevalent periodontitis.

Hepatic nitric oxide synthase 1 adaptor protein regulates glucose homeostasis and hepatic insulin sensitivity in obese mice depending on its PDZ binding domain

BACKGROUND

NOS1AP is an adaptor protein and its SNP rs12742393 was associated with type 2 diabetes (T2D). However, it remains uncertain whether NOS1AP plays a role in regulation of insulin sensitivity. Hepatic insulin resistance contributed to the development of T2D. Here, our investigation was focused on whether NOS1AP is involved in the regulation of hepatic insulin sensitivity and its underlying mechanisms.

METHODS

Liver specific NOS1AP condition knockout (CKO) and NOS1AP overexpression mice were generated and given a high fat diet. SNPs of NOS1AP gene were genotyped in 86 human subjects.

FINDINGS

NOS1AP protein is expressed in human and mouse liver. CKO mice exhibited impaired pyruvate, glucose and insulin tolerance, and increased lipid deposits in the liver. Conversely, NOS1AP overexpression in livers of obese mice improved pyruvate and/or glucose, and insulin tolerance, and attenuated liver lipid accumulation. Moreover, hepatocytes from CKO mice exhibited an elevated glucose production and mRNA expressions of Pc and Pck1. Overexpression of NOS1AP potentiated insulin-stimulated activation of IR/Akt in livers from obese mice. The insulin sensitizing effect of NOS1AP could be mimicked by overexpression of C-terminal domain of NOS1AP in ob/ob mice. Furthermore, NOS1AP overexpression in liver significantly inhibited p38 MAPK phosphorylation, and maintained ER homeostasis through p-eIF2a-ATF4-CHOP pathway. Subjects with rsl2742393 of NOS1AP have higher risk to develop hepatic steatosis.

INTERPRETATION

Our data demonstrate a novel role of NOS1AP in regulating hepatic insulin sensitivity and p38 MAPK inactivation in obese mice, which makes NOS1AP a potential therapeutic target for the prevention and treatment of T2D. FUND: This work was supported by the National Natural Science Foundation of China (81670707, 31340072) (to C. Wang), and National Basic Research Program of China (Nation 973 Program) (2011CB504001) (to W. Jia).

Real-world data reveal a diagnostic gap in non-alcoholic fatty liver disease

BACKGROUND

Non-alcoholic fatty liver disease (NAFLD) is the most common cause of liver disease worldwide. It affects an estimated 20% of the general population, based on cohort studies of varying size and heterogeneous selection. However, the prevalence and incidence of recorded NAFLD diagnoses in unselected real-world health-care records is unknown. We harmonised health records from four major European territories and assessed age- and sex-specific point prevalence and incidence of NAFLD over the past decade.

METHODS

Data were extracted from The Health Improvement Network (UK), Health Search Database (Italy), Information System for Research in Primary Care (Spain) and Integrated Primary Care Information (Netherlands). Each database uses a different coding system. Prevalence and incidence estimates were pooled across databases by random-effects meta-analysis after a log-transformation.

RESULTS

Data were available for 17,669,973 adults, of which 176,114 had a recorded diagnosis of NAFLD. Pooled prevalence trebled from 0.60% in 2007 (95% confidence interval: 0.41-0.79) to 1.85% (0.91-2.79) in 2014. Incidence doubled from 1.32 (0.83-1.82) to 2.35 (1.29-3.40) per 1000 person-years. The FIB-4 non-invasive estimate of liver fibrosis could be calculated in 40.6% of patients, of whom 29.6-35.7% had indeterminate or high-risk scores.

CONCLUSIONS

In the largest primary-care record study of its kind to date, rates of recorded NAFLD are much lower than expected suggesting under-diagnosis and under-recording. Despite this, we have identified rising incidence and prevalence of the diagnosis. Improved recognition of NAFLD may identify people who will benefit from risk factor modification or emerging therapies to prevent progression to cardiometabolic and hepatic complications.

Physical training reverses changes in hepatic mitochondrial diameter of Alloxan-induced diabetic rats

OBJECTIVE

To investigate the effects of physical training on metabolic and morphological parameters of diabetic rats.

METHODS

Wistar rats were randomized into four groups: sedentary control, trained control, sedentary diabetic and trained diabetic. Diabetes mellitus was induced by Alloxan (35mg/kg) administration for sedentary diabetic and Trained Diabetic Groups. The exercise protocol consisted of swimming with a load of 2.5% of body weight for 60 minutes per day (5 days per week) for the trained control and Trained Diabetic Groups, during 6 weeks. At the end of the experiment, the rats were sacrificed and blood was collected for determinations of serum glucose, insulin, albumin and total protein. Liver samples were extracted for measurements of glycogen, protein, DNA and mitochondrial diameter determination.

RESULTS

The sedentary diabetic animals presented decreased body weight, blood insulin, and hepatic glycogen, as well as increased glycemia and mitochondrial diameter. The physical training protocol in diabetic animals was efficient to recovery body weight and liver glycogen, and to decrease the hepatic mitochondrial diameter.

CONCLUSION

Physical training ameliorated hepatic metabolism and promoted important morphologic adaptations as mitochondrial diameter in liver of the diabetic rats.

Non-invasive markers of liver fibrosis in fatty liver disease are unreliable in people of South Asian descent

OBJECTIVE

Liver biopsy is the most accurate method for determining stage and grade of injury in non-alcoholic fatty liver disease (NAFLD). Given risks and limitations of biopsy, non-invasive tests such as NAFLD fibrosis score, aspartate transaminase (AST) to platelet ratio index, Fib-4, AST/alanine transaminase ratio and BARD are used. Prevalence and severity of NAFLD and metabolic syndrome vary by ethnicity, yet tests have been developed in largely white populations. We tested our hypothesis that non-invasive tests that include metabolic parameters are less accurate in South Asian compared with white patients.

DESIGN

Retrospective cross-sectional.

SETTING

Specialist liver centre.

PATIENTS

Patients with histologically confirmed NAFLD.

INTERVENTIONS

Scores calculated using clinical data taken within 1 week and compared with histology (Kleiner).

MAIN OUTCOME MEASURES

Diagnostic test characteristics.

RESULTS

175 patients were identified. South Asians (n=90) were younger, had lower body mass index and lower proportion of obesity compared with white patients (n=79), with comparable rates of diabetes and liver injury. Tests are less sensitive at detecting advanced fibrosis in South Asian compared with white patients. Relative risk of correct diagnosis in white patients compared with South Asians is 1.86 (95% CI 1.4 to 2.6). In binary logistic regression models, ethnicity and platelet count predicted accuracy. Transient elastography was equally and highly accurate in both ethnicities.

CONCLUSIONS

Blood test-based non-invasive scores are less accurate in South Asian patients, irrespective of metabolic parameters. Ethnicity should be considered when devising risk-stratification algorithms for NAFLD.

Periodontitis is associated with significant hepatic fibrosis in patients with non-alcoholic fatty liver disease

Background and aims

Non-alcoholic fatty liver disease (NAFLD) has a bidirectional association with metabolic syndrome. It affects up to 30% of the general population, 70% of individuals with diabetes and 90% with obesity. The main histological hallmark of progressive NAFLD is fibrosis. There is a bidirectional epidemiological link between periodontitis and metabolic syndrome. NAFLD, periodontitis and diabetes share common risk factors, are characterised by inflammation and associated with changes in commensal bacteria. Therefore we tested the hypothesis that periodontitis is associated with NAFLD and with significant fibrosis in two study groups.

Methods

We analyzed data from a population-based survey and a patient-based study. NHANES III participants with abdominal ultrasound and sociodemographic, clinical, and oral examination data were extracted and appropriate weighting applied. In a separate patient-based study, consenting patients with biopsy-proved NAFLD (or with liver indices too mild to justify biopsy) underwent dental examination. Basic Periodontal Examination score was recorded.

Results

In NHANES, periodontitis was significantly associated with steatosis in 8172 adults even after adjusting for sociodemographic factors. However, associations were fully explained after accounting for features of metabolic syndrome. In the patient-based study, periodontitis was significantly more common in patients with biopsy-proven NASH and any fibrosis (F0-F4) than without NASH (p = 0.009). Periodontitis was more common in patients with NASH and significant fibrosis (F2-4) than mild or no fibrosis (F0-1, p = 0.04).

Conclusions

Complementary evidence from an epidemiological survey and a clinical study show that NAFLD is associated with periodontitis and that the association is stronger with significant liver fibrosis.

Association between osteocalcin gamma-carboxylation and insulin resistance in overweight and obese postmenopausal women

AIM

In mice, osteocalcin (OCN) acts as a bone-derived hormone promoting insulin sensitivity and glucose tolerance. In that species, OCN endocrine action is inhibited when its first glutamic acid residue (Glu13) is γ-carboxylated (Gla). The importance of this posttranslational modification for OCN function in human is still unclear. Our objectives were to identify an assay to assess γ-carboxylation of human OCN on its first Glu residue (Glu17) and to test its association with insulin resistance and inflammation profile in overweight women.

METHODS

Several ELISAs were tested to determine their specificity toward various forms of human OCN. Associations between OCN γ-carboxylation and determinants of glucose tolerance, insulin sensitivity, liver function and subclinical inflammation were then investigated in 129 non-diabetic overweight and obese postmenopausal women.

RESULTS

We identified assays allowing the measurement of total OCN (tOCN) and the ratio of Gla17/tOCN. Circulating Gla17/tOCN levels correlated negatively with insulin sensitivity assessed by hyperinsulinemic-euglyceamic clamp (P=0.02) or insulin sensitivity index derived from oral glucose tolerance test (P=0.00003), and positively with insulin resistance assessed by HOMA-IR (P=0.0005) and with markers of subclinical inflammation and liver enzymes, including C-reactive protein (CRP; P=0.007) and aspartate aminotransferase (AST; P=0.009).

CONCLUSIONS

γ-carboxylation of OCN on Glu17 residue correlates with insulin resistance and subclinical inflammation, suggesting that γ-carboxylation of OCN negatively regulates its endocrine action in humans.

Prevention and treatment of nonalcoholic fatty liver disease in patients with type 2 diabetes mellitus

Nonalcoholic fatty liver disease (NAFLD) is frequently seen in the type 2 diabetes mellitus (T2DM) population. Insulin resistance is the pathophysiologic bridge which links T2DM and NAFLD. Coexistence of both diseases indicates more severe diseases and higher risk of death. As a result, it is urgent to effectively control NAFLD in patients with T2DM. The advent of glucagon like peptide-1 (GLP-1) agonists and dipeptidyl peptidase-4 (DPP-4) inhibitors brings new hope for effectively managing NAFLD in T2DM patients. Bariatric surgery provides obese T2DM patients with a powerful means to treat NAFLD. The discovery of adipokines such as adiponectin and fibroblast growth factor 21 (FGF21) may point to a new research direction for NAFLD. In this paper, we present therapeutic options currently available for NAFLD in T2DM patients as well as the present research progress in NAFLD with T2DM, with regards to epidemiology and pathophysiologic links between them.