Patient-reported outcomes in patients with non-alcoholic fatty liver disease: A narrative review of Chronic Liver Disease Questionnaire-non-alcoholic fatty liver disease/non-alcoholic steatohepatitis

Addressing the High and Rising Global Burden of Metabolic Dysfunction-Associated Steatotic Liver Disease (MASLD) and Metabolic Dysfunction-Associated Steatohepatitis (MASH): From the Growing Prevalence to Payors' Perspective

BACKGROUND

The continuum of metabolic syndrome encompasses a spectrum of dysfunctions impacting obesity-linked insulin resistance, glucose homeostasis, lipid metabolism and pro-inflammatory immune responses. The global prevalence of metabolic diseases, including diabetes, chronic liver disease, cardiometabolic disease and kidney disease, has surged in recent decades, contributing significantly to population mortality. Metabolic dysfunction-associated steatotic liver disease (MASLD), formerly known as non-alcoholic fatty liver disease, is a leading cause of liver disease worldwide. MASLD poses a significant global health challenge with its rising prevalence, placing a substantial burden on healthcare systems, impacts patient well-being and incurs significant economic costs. Addressing MASLD requires a comprehensive understanding of its interconnected factors, including its prevalence, healthcare burden and economic implications. Lack of awareness, imprecise non-invasive diagnostic methods and ineffective preventive interventions are core components of the MASLD-related problem.

AIM

The aim of this article was to summarise the global burden of MASLD from the payer's perspective.

METHODS

We carried out a review of the global comprehensive burden of MASLD. These topics led to discussions and insights by an expert panel during the 7th Metabolic Continuum Roundtable meeting, which took place in November 2023. This meeting focused on the burden, patient-reported outcomes and health economics, from payor and societal perspectives, and aimed to identify opportunities for improving patient care, optimise resource allocation and mitigate the overall impact on individuals and society related to MASLD. During the roundtable, an emphasis emerged on the need for greater awareness and strategic deployment of diagnostic, therapeutic and preventative measures to address MASLD effectively.

CONCLUSION

The global burden of MASLD is high and growing. Prioritising the prevention of metabolic dysregulation and timely therapeutic interventions can yield a holistic strategy to combat MASLD, its progression and potentially lower disease costs.

TRIAL REGISTRATION

NCT06309992.

Illness perception, coping and psychological distress among patients with metabolic dysfunction-associated fatty liver disease (MAFLD) in China

OBJECTIVES

The study examined the effects of illness perception on mental health among patients with metabolic dysfunction-associated fatty liver disease (MAFLD) and the moderating role of coping style in this effect.

METHODS

The current study has collected the data of MAFLD patients at baseline and 8 months after. In both baseline and follow-up surveys, structural questionnaires were adopted to assess participants' illness perception (BIPQ), coping strategies (Brief COPE) and psychological distress (GHQ-12). A cross-lagged panel model was constructed to examine the associations between illness perception and psychological distress over 8 months. The moderating role of coping in the relationship between illness perception and psychological distress was addressed.

RESULTS

A total of 155 participants diagnosed with MAFLD were enrolled in the baseline survey, of which 71 patients engaged in the 8-month follow-up. The results showed that severe illness perceptions (perceiving MAFLD with more negative consequence, more negative emotions, lower coherence, and less treatment control) were associated with increased psychological distress 8 months later (β = 0.171, p < 0.05). Though approach coping showed an overall positive effect (β = 0.169, p < 0.05), people using it as a dominant strategy tend to be more subjected to the impacts of negative illness perceptions.

CONCLUSION

Threatening perceptions about MAFLD were associated with more psychological distress over time, and coping style has moderated the effects of illness perceptions. Healthcare providers should be aware of the impacts of negative illness perceptions, particularly when developing coping skill training programs to promote well-being and recovery.

Fast score is associated with patient-reported outcomes in patients with metabolic dysfunction-associated steatotic liver disease

BACKGROUNDS

People with metabolic dysfunction-associated steatotic liver disease (MASLD) frequently report fatigue. This symptom is associated with hepatic inflammation and fibrosis. FibroScan-aspartate aminotransferase (FAST) score is a noninvasive measurement tool that can be used to assess the severity of MASLD. We aimed to investigate the independent factors associated with patient-reported outcomes (PROs) including fatigue, and their FAST scores.

METHODS

We enrolled 116 patients with MASLD. PROs were assessed by the Chronic Liver Disease Questionnaire for nonalcoholic fatty liver disease (CLDQ-NAFLD), which consists of six domains including fatigue. Each domain score that was less than 6 was classified into the impairment group. A cutoff value of 0.67 in the FAST score was used to categorize a high or low FAST score. Independent factors associated with impaired PROs and fatigue were analyzed using logistic regression analysis and a graphical model.

RESULTS

For factor total, in the logistic regression analysis, the high FAST score was only identified as a negative independent factor for impaired total CLDQ-NAFLD (odds ratio: 5.9, 95% confidence interval: 1.11-31.20, P  = 0.034). The graphical model revealed that FAST score, BMI, and age directly interact with impaired total CLDQ-NAFLD. For fatigue, there was no statistically significant factor in the logistic regression analysis. The graphical model revealed that the FAST score, BMI, estimated glomerular filtration rate, and age directly interact with fatigue.

CONCLUSION

We found that the FAST score directly interacted with total CLDQ-NAFLD and the domain of fatigue. The FAST score may be a useful tool to assess impaired CLDQ-NAFLD.

Parallel randomised trial testing community fibrosis assessment for suspected non-alcoholic fatty liver disease: outcomes from LOCATE-NAFLD

OBJECTIVE

Non-alcoholic fatty liver disease (NAFLD) is estimated to affect a third of Australian adults, and its prevalence is predicted to rise, increasing the burden on the healthcare system. The LOCal Assessment and Triage Evaluation of Non-Alcoholic Fatty Liver Disease (LOCATE-NAFLD) trialled a community-based fibrosis assessment service using FibroScan to reduce the time to diagnosis of high-risk NAFLD and improve patient outcomes.

METHODS

We conducted a 1:1 parallel randomised trial to compare two alternative models of care for NAFLD diagnosis and assessment. Participants had suspected NAFLD and were referred to a hepatology clinic in one of three major hospitals in South-East Queensland. Eligible consenting participants were randomised to receive usual care or the intervention (LOCATE). Participants in the intervention arm received a FibroScan outside of the hospital setting, with results provided to their primary care provider and the referring hepatologist. All participants were followed up 12 months after randomisation to measure their clinical and patient-reported outcomes.

RESULTS

97 participants were recruited from October 2020 to December 2022. Of the 50 participants randomised to the intervention arm, one failed to attend their appointment, and of the 48 (98%) who had a FibroScan 13 (27%) had a liver stiffness measurement of 8.0 kPa or greater. The HR for the time to diagnosis of high risk was 1.28 (95% CI 0.59 to 2.79), indicating a faster average time to diagnosis with the intervention, but failing to conclusively demonstrate a faster time. The intervention did greatly reduce the time to FibroScan by almost 1 year (median difference 0.92 years, 95% CI 0.56 to 1.45). Other clinical outcomes showed minimal changes.

CONCLUSION

The LOCATE model shows potential for impact, particularly in reducing waiting times for patients at high risk of developing severe liver disease due to NAFLD. A larger sample and longer follow-ups are needed to measure additional clinical outcomes.

TRIAL REGISTRATION NUMBER

ACTRN12620000158965.

A comprehensive review of patient-reported outcomes in metabolic dysfunction-associated steatotic liver disease

The global prevalence of obesity and type 2 diabetes has increased, contributing to an increased worldwide prevalence of metabolic dysfunction-associated steatotic liver disease (MASLD). Currently, one in three adults is affected by MASLD and/or its progressive form, metabolic dysfunction-associated steatohepatitis (MASH), making this liver disease a significant public health challenge. Along with MASH-related cirrhosis, these conditions are poised to become the leading causes of chronic liver disease and liver transplants in the near future. Given the growing burden of MASLD and MASH, it is crucial to understand their impact from the patients’ perspective. One way to do this is by assessing patient-reported outcomes (PROs), including health-related quality of life (HRQL). HRQL can be assessed using generic instruments like the short form 36 version (SF-36) and the European quality of life-5 dimensions questionnaire (EQ-5D), or disease-specific tools such as the chronic liver disease questionnaire for nonalcoholic steatohepatitis (CLDQ-NASH). Given the limitations of each instrument, the best approach generally involves using both generic and disease-specific instruments. Evidence indicates that HRQL scores are significantly lower in individuals with MASLD, especially in areas assessing physical activity and the ability to perform daily living tasks. Fatigue and impaired work productivity are also important PROs for those with MASLD/MASH. These decrements in PROs worsen with disease progression but appear to improve with disease regression, including improvements linked to treatment. In this context, measuring PROs enhances the assessment of other patient-centric outcomes and provides insights for the healthcare community to develop interventions that could improve both clinical and humanistic outcomes for individuals living with MASLD/MASH.

Patient-Reported Outcomes in Metabolic Dysfunction-Associated Steatotic Liver Disease

Metabolic dysfunction-associated steatotic liver disease (MASLD) is the most common chronic liver disease worldwide and can progress to serious complications, including metabolic dysfunction-associated steatohepatitis (MASH), cirrhosis, end-stage liver disease, and hepatocellular carcinoma. Predisposing risk factors for MASH include obesity, type 2 diabetes, dyslipidemia, and metabolic syndrome. Patients with MASH often experience significant impairments in their health-related quality of life and other patient-reported outcomes (PROs), particularly in physical functioning domains, fatigue, and vitality. Incorporating PROs offers valuable insights into patients' perspectives on their symptoms, treatment efficacy, and overall well-being, thereby guiding more holistic and patient-centered care strategies. This review aims to investigate the utilization of patient-reported outcome measures (PROMs) in the context of MASLD and MASH care, identify which PROMs are employed, and summarize the outcomes reported.

Rate and Associated Factors of Fatigue in Chinese Patients with Non-Alcoholic Fatty Liver Disease: A Cross-Sectional Survey

Purpose

Fatigue was a common symptom of non-alcoholic fatty liver disease (NAFLD), which seriously affected patients' quality of life. The aim of this study was to detect fatigue rate and to evaluate factors associated with fatigue in NAFLD patients.

Patients and Methods

A cross-sectional study was carried out from the Huadong Sanatorium between April 2022 and May 2023, and 133 NAFLD patients were included in this study. They completed Fatigue Severity Scale to assess fatigue, the Hospital Anxiety and Depression Scale to estimate psychological status, and the Pittsburgh Sleep Quality Index for sleep quality. Data were analyzed by independent samples t-tests, χ2 tests and logistic regression models.

Results

We found that 51.1% of NAFLD patients had fatigue. Exercise, anxiety, depression, subjective sleep quality, sleep latency, sleep duration, habitual sleep efficiency, sleep disorders, daytime dysfunction and overall sleep quality were related to fatigue among NAFLD patients. Moreover, logistic regression models indicated anxiety, habitual sleep efficiency and sleep disorders as important predictors of fatigue.

Conclusion

This was the first time to explore demographic, clinical, psychological and sleeping correlated factors for fatigue in Chinese NAFLD patients. Our study showed that more than half of NAFLD patients had fatigue, and anxiety, habitual sleep efficiency and sleep disorders were significantly associated with fatigue in NAFLD. The findings indicated that it was very necessary to pay more attention to fatigue of NAFLD patients, especially those with negative emotions and poor sleep quality by favorable intervention to relieve fatigue symptoms, so as to improve quality of life.

Mobile App-Based Lifestyle Coaching Intervention for Patients With Nonalcoholic Fatty Liver Disease: Randomized Controlled Trial

BACKGROUND

Lifestyle modification in patients with nonalcoholic fatty liver disease (NAFLD) is key to improving health outcomes. Mobile health technologies may offer potential effective and efficient health care support to facilitate self-management.

OBJECTIVE

This study aims to develop a lifestyle coaching intervention using a mobile app for patients with NAFLD and evaluate physiological and psychological health outcomes for 6 months.

METHODS

This study was a randomized controlled trial. The personalized lifestyle coaching intervention using a mobile app was developed through established guidelines and literature reviews. This intervention consisted of information on NAFLD management, diet and physical activity self-monitoring, and coaching sessions based on patient records and SMS text messages. A total of 102 individuals were enrolled in the study and randomly assigned to the intervention group (n=48) or the control group (n=54). The outcomes were improvements in physiological (weight, liver fat score, aspartate aminotransferase, alanine transferase, and gamma-glutamyl transferase) and clinical outcomes (self-management, NAFLD self-management knowledge, self-efficacy, fatigue, depression, and quality of life). Data were analyzed using descriptive analysis and a linear mixed model to test the effects of the intervention.

RESULTS

All participants completed the study. The mean age of the participants was 48.9 (SD 13.74) years, 38.2% (39/102) were female participants, and 65.7% (67/102) were married. There were no differences in baseline demographic and clinical data between the intervention and control groups. Changes from baseline to 6 months were significant only within the intervention group for weight (P<.001), liver fat score (P=.01), aspartate aminotransferase (P=.03), alanine transferase (P=.002), gamma-glutamyl transferase (P=.04), self-management (P<.001), fatigue (P=.005), depression (P=.003), and quality of life (P<.001). The differences between the 2 groups for the changes over the 6 months were significant in self-management (P=.004), self-management knowledge (P=.04), fatigue (P=.004), depression (P=.04), and quality of life (P=.01). However, the intervention-by-time interaction was significantly effective only for self-management (P=.006) and fatigue (P=.02).

CONCLUSIONS

Nonpharmacological interventions using a mobile app may be effective in improving the physiological and psychological health outcomes of patients with NAFLD.

TRIAL REGISTRATION

Clinical Research Information Service KCT0005549; http://tinyurl.com/y2zb6usy.

Early diagnosis of non-alcoholic fatty liver disease: the role of biomarkers and complex indices of non-alcoholic fatty liver steatosis

Metabolic syndrome is a series of pathologies united by a similar pathogenesis, the end of which, most often, is cardiovascular accidents, which are leaders among the causes of death in the population around the world. Non-alcoholic fatty liver disease (NAFLD) is the hepatic equivalent of the metabolic syndrome, registered earlier than all other equivalents, on the rights of the liver as a first-line energy depot. At the same time, according to multicenter studies, 95% of people with NAFLD (any stage) are not diagnosed with the disease. Clarification of additional risk factors for NAFLD and the presence of a specific biomarker of non-alcoholic liver steatosis would make it possible to stop the vicious cascade of metabolic processes, which in the future can lead to a significant increase in the life expectancy of the population. The potentially high role of Secreted Frizzled Related Protein-4 (SFRP4) adipokine in the early diagnosis of NAFLD is known. The aim of the study was to optimize the early diagnosis of non-alcoholic fatty liver disease using modern indices and biomarkers. Materials and methods. The work was carried out at the Department of Faculty and Hospital Therapy of the Chuvash State University named after I. N. Ulyanov” in the period from 2016 to 2020. This study included several stages: first of all, a retrospective analysis of 1150 outpatient records of patients from several medical organizations of the Chuvash Republic for the period 2016-2018 was carried out. to form two study groups: experimental and control. At the second stage, as a result of applying the exclusion criteria, 162 people remained in the experiment: 110 from the experimental group, 52 from the control group. The subjects of both groups were compared by gender and age, the age range of the subjects varied from 18 to 80 years old with an average value of 48.3 years. Further, the patients undergo a detailed examination, according to the presented plan: Collection of complaints, medical history, objective examination. Laboratory studies (general and biochemical blood tests, lipidogram, assessment of the level of serum adipokine SFRP4). Instrumental studies (ultrasound of the OBP, TE (SAR), ESP with elastometry). Evaluation of the most informative complex indices for the early diagnosis of NAFLD: MI, IVO indices, HSI, FLD-I. Further, all the necessary statistical processing and analysis of the obtained data were performed (Microsoft Office Excel 2016, StatTech v. 2.8.8 (developer - Stattech LLC, Russia)). Results. Accessible (not requiring the use of additional time and material costs) NAFLD indices with the highest sensitivity rates (99.1% and 98.2%, respectively) were MI and IVO. A noticeable direct correlation was traced between MI (p=0.640), moderate - between the IVO (p=0.398) and the elastographically determined index of non-alcoholic liver steatosis. High sensitivity and specificity of skin manifestations (xanthoma, xanthelasma - 69.6% and 89.7% and seborrheic dermatitis - 82.0% and 71.4%) were found in relation to early manifestations of NAFLD. From anthropometric indicators: the CW/CF index has a pronounced (ρ=0.643), CW - moderate (ρ=0.238), and BMI - a weak direct (ρ=0.223) correlation with the elastographically determined index of non-alcoholic liver steatosis. Adipokine SFRP4 correlates (ρ=0.841) with early manifestations of hepatic steatosis in patients, as determined by TE in CAP mode.

Metabolic Dysfunction-Associated Steatotic Liver Disease and Metabolic Dysfunction-Associated Steatohepatitis: The Patient and Physician Perspective

Diagnosing and managing metabolic dysfunction-associated steatotic liver disease (MASLD) remains a major challenge in primary care due to lack of agreement on diagnostic tools, difficulty in identifying symptoms and determining their cause, absence of approved pharmacological treatments, and limited awareness of the disease. However, prompt diagnosis and management are critical to preventing MASLD from progressing to more severe forms of liver disease. This highlights the need to raise awareness and improve understanding of MASLD among both patients and physicians. The patient perspective is invaluable to advancing our knowledge of this disease and how to manage it, as their perspectives have led to the growing recognition that patients experience subtle symptoms and that patient-reported outcomes should be incorporated into drug development. This review and expert opinion examine MASLD and metabolic dysfunction-associated steatohepatitis from the patient and physician perspective from pre-diagnosis to diagnosis and early care, through to progression to advanced liver damage. Specifically, the paper dives into the issues patients and physicians experience, and, in turn, what is required to improve diagnosis and management, including tips and tools to empower patients and physicians dealing with MASLD.

Impact of Mediterranean Dietary Education on Symptoms for Adults at Risk for Nonalcoholic Fatty Liver Disease

This 2-month quasi-experimental study focused on the impact of education regarding the Mediterranean diet on symptoms for adults who are at risk for nonalcoholic fatty liver disease (NAFLD). The study was conducted on a sample of 28 adults who presented to Pinnacle clinical research for NAFLD screening via a fibroscan. These individuals who are at risk for NAFLD received a single 15-minute one-on-one in person education regarding the Mediterranean diet. The diet encourages fruits, vegetables, whole grains, legumes, nuts, seeds, fish, and olive oil. The results of the study showed that the Mediterranean diet education was associated with significant improvement of abdominal symptoms ( t = 3.34, p = .03), improvement of fatigue symptoms ( t = 5.88, p < .001), and decrease in hepatic steatosis ( t = 5.77, p < .001). Our study suggests that the education on the Mediterranean diet may be associated with improvement of self-reported abdominal symptoms, fatigue, and steatosis score.

The combination of the enhanced liver fibrosis and FIB-4 scores to determine significant fibrosis in patients with nonalcoholic fatty liver disease

BACKGROUND

The presence of fibrosis in NAFLD is the most significant risk factor for adverse outcomes. We determined the cutoff scores of two non-invasive te sts (NITs) to rule in and rule out significant fibrosis among NAFLD patients.

METHODS

Clinical data and liver biopsies were used for NAFLD patients included in this analysis (2001-2020). The enhanced liver fibrosis (ELF) and FIB-4 NITs were calculated. Liver biopsies were read by a single hematopathologist and scored by the NASH CRN criteria. Significant fibrosis was defined as stage F2-F4.

RESULTS

There were 463 NAFLD patients included: 48 ± 13 years old, 31% male, 35% type 2 diabetes; 39% had significant fibrosis; mean ELF score was 9.0 ± 1.2, mean FIB-4 score was 1.22 ± 1.05. Patients with significant fibrosis were older, more commonly male, had lower BMI but more components of metabolic syndrome, higher ELF and FIB-4 (p < 0.0001). The performance of the two NITs in identifying significant fibrosis was: AUC (95% CI) = 0.78 (0.74-0.82) for ELF, 0.79 (0.75-0.83) for FIB-4. The combination of ELF score ≥9.8 and FIB-4 ≥ 1.96 returned a positive predictive value of 95% which can reliably rule in significant fibrosis (sensitivity 22%, specificity >99%), while an ELF score ≤7.7 or FIB-4 ≤ 0.30 had a negative predictive value of 95% ruling out significant fibrosis (sensitivity 98%, specificity 22%).

CONCLUSIONS

The combination of ELF and FIB-4 may provide practitioners with easily obtained information to risk stratify patients with NAFLD who could be referred to specialists or for enrollment in clinical trials.

Reliability and validity of the Chinese version of chronic liver disease questionnaire-nonalcoholic fatty liver disease in patients with nonalcoholic fatty liver disease: a multicenter cross-sectional survey in China

PURPOSE

The Chronic Liver Disease Questionnaire (CLDQ)-Nonalcoholic Fatty Liver Disease (NAFLD) is a disease-specific instrument to assess the health-related quality of life (HRQL) of patients with NAFLD. In order to provide further evidence for the cross-cultural utility of this instrument in the Chinese population, we translated the CLDQ-NAFLD into Chinese and examined its reliability and validity.

METHODS

Patients with NAFLD in 90 hospitals across China were enrolled in this multicenter cross-sectional survey. Eligible patients completed the Chinese version of CLDQ-NAFLD at enrollment to assess HRQL. Internal consistency of the questionnaire was assessed using Cronbach's alpha coefficient and split-half reliability. Convergent and discriminant validity were assessed using Spearman correlation coefficient. Factor analysis was used to test the construct validity.

RESULTS

Between March and August 2019, 5181 patients with a mean age of 43.8 ± 13.3 years were enrolled. All domains exhibited good internal consistency, with Cronbach's alpha and split-half reliability greater than 0.70. The scaling success rate of all domains was 100% for convergent validity and 99.4% (179/180) for discriminant validity. The inter-scale correlations indicated a significant correlation between all CLDQ-NAFLD domains (r = 0.608 to 0.832, all p < 0.001). Factor analysis of 36 items extracted 6 factors, which explained 69.14% of the total variance.

CONCLUSION

The Chinese version of CLDQ-NAFLD is a reliable and valid instrument for assessing the HRQL of Chinese patients with NAFLD.

Vigorous physical activity provides protection against all-cause deaths among adults patients with nonalcoholic fatty liver disease (NAFLD)

BACKGROUND

Mortality benefits of vigorous leisure time physical activity (LTPA) among adults with NAFLD is not known.

AIM

To investigate association between LTPA and reduction in all-cause mortality among adults with NAFLD.

METHODS

We used NHANES (1999-2006) self-reported PA data for adults (≥40 years) with mortality follow-up through December 31, 2015. US-Fatty Liver Index in absence of secondary causes identified NAFLD. Moderate and vigorous LTPA were calculated by the 2018 PA Guidelines for Americans.

RESULTS

NAFLD prevalence among 5211 adults (46.2% male; 75.8% white; mean age 53.2 years) was 32.7%. Adults with NAFLD were less likely to report the recommended minimal PA (≥ 150 min/week, 55.5% vs 64.8%) or highly active PA (≥300 min/week, 39.2% vs 48.5%) compared to adults without NAFLD. Over a median follow-up of 12.3 years, 355 deaths among adults with NAFLD and 510 deaths among adults without NAFLD were registered. In the metabolic comorbidities-adjusted model, adults with NAFLD who reported ≥50% of their total PA as vigorous activity had a 56% reduction in all-cause mortality risk (HR:0.44, 95%CI: 0.25-0.76) and cancer-specific mortality risk (HR: 0.21, 0.06-0.66) but not cardiac-specific mortality (p > 0.05) compared to adults with NAFLD who did not report any LTPA. This association remained significant even among adults with NAFLD who met the recommended minimal PA, among adults with NAFLD who reported any LTPA, and among adults with NAFLD who had metabolic abnormalities and in sensitivity analysis.

CONCLUSIONS

Engaging in vigorous activity is beneficial for adults with NAFLD - especially those with metabolic abnormalities.

Vitality, mental health and role-physical mediate the influence of coping on depressive symptoms and self-efficacy in patients with non-alcoholic fatty liver disease: A cross-sectional study

OBJECTIVE

Our aim was to determine whether the association between active coping and depressive symptoms in patients with non-alcoholic fatty liver disease (NAFLD) was mediated by vitality, and whether diabetes and obesity could impact on this relationship. We also wanted to find out whether mental health and role-physical modulated the relationship between passive/avoidance coping and self-efficacy, and the role of liver fibrosis.

METHODS

Depressive symptoms (BDI-II), self-efficacy (GSE), coping (COPE-28) and quality of life (SF-12) were evaluated in 509 biopsy-proven NAFLD patients in this cross-sectional study. Mediation and moderated mediation models were conducted using the SPSS PROCESS v3.5 macro.

RESULTS

Vitality mediated the relationship between active coping and depressive symptoms (-2.254, CI = -2.792 to -1.765), with diabetes (-0.043, p = 0.017) and body mass index (BMI) (-0.005, p = 0.009) moderating the association. In addition, mental health (-6.435, CI = -8.399 to -4.542) and role-physical (-1.137, CI = -2.141 to -0.315) mediated the relationship between passive/avoidance coping and self-efficacy, with fibrosis stage (0.367, p < 0.001) moderating this association. Specifically, the presence of diabetes and significant fibrosis, and a higher BMI, were associated with greater negative impact on participant depressive symptoms or self-efficacy.

CONCLUSION

A maladaptive coping style was associated with poorer vitality, mental health and role-physical in NAFLD patients, which along with the presence of metabolic comorbidity (diabetes and obesity) and significant fibrosis predicted more depressive symptoms or poorer self-efficacy in these patients. These results suggested incorporating emotional and cognitive evaluation and treatment in patients with NAFLD.

Association between hepatic steatosis and fibrosis indices and dietary habits, physical activity, and quality of life

BACKGROUND AND STUDY AIMS

This cross-sectional study aimed to evaluate the association between hepatic steatosis and fibrosis indices and adherence to the Mediterranean diet (MD), physical activity (PA), and quality of life (QoL) in individuals unaware of the status of their liver.

PATIENTS AND METHODS

Participants were asked to complete three questionnaires validated in Greek, namely: (1) the Chronic Liver Disease Questionnaire (CLDQ) for QoL assessment; (2) the semi-quantitative Food Frequency Questionnaire (FFQ), from which the MedDietScore was calculated; and (3) the International Physical Activity Questionnaire (IPAQ) for PA evaluation. Hepatic steatosis was evaluated using the Fatty Liver Index (FLI), Hepatic Steatosis Index (HSI), and Lipid Accumulation Product (LAP). Hepatic fibrosis was evaluated using the NAFLD Fibrosis Score (NFS), Fibrosis-4 (FIB-4), and AST-to-platelet ratio index (APRI).

RESULTS

This study recruited 200 participants (90% men) aged 36 ± 6 years. Hepatic steatosis indices were not associated with MedDietScore and QoL. In terms of PA, univariable analysis showed that higher values of hepatic steatosis indices were associated with less intense activity. This association remained significant only for HSI during multivariable analysis (moderate activity vs. low activity: beta: -2.0, 95% confidence interval (CI): -3.5, -0.37, p = 0.016; and high activity vs. low activity: beta: -3.3, 95% CI: -5.03, -1.60, p < 0.001), after controlling for age, waist circumference, and the presence of metabolic syndrome. When using hepatic fibrosis indices, none of the participants had high probability of advanced hepatic fibrosis or cirrhosis (F3-F4). Consequently, we were unable to extensively evaluate the association between hepatic fibrosis indices and lifestyle characteristics or QoL.

CONCLUSION

We showed that HSI, but not other steatosis indices, remained robustly associated with PA after adjusting for potential confounders in a population unaware of the presence of fatty liver.

Association of changes in histologic severity of nonalcoholic steatohepatitis and changes in patient-reported quality of life

Nonalcoholic steatohepatitis (NASH) is a prevalent chronic disease that is associated with a spectrum of liver fibrosis and can lead to cirrhosis. Patients with NASH report lower health-related quality of life (HRQoL) than the general population. It remains uncertain how changes in histologic severity are associated with changes in HRQoL. This is a secondary analysis of the Farnesoid X Receptor Ligand Obeticholic Acid in NASH Treatment (FLINT) and Pioglitazone, Vitamin E, or Placebo for Nonalcoholic Steatohepatitis (PIVENS) randomized controlled trials in patients with biopsy-proven NASH. HRQoL was assessed using short form-36 at baseline and at follow-up biopsy (at 72 and 96 weeks, respectively). Adjusted linear regression models were used to examine the association between changes in liver fibrosis (primary analysis), nonalcoholic fatty liver disease (NAFLD) activity score (secondary analysis), and changes in HRQoL scores. Compared with stable fibrosis, improvement of fibrosis by at least one stage was significantly associated with improvements only in the physical function component by 1.8 points (95% confidence interval, 0.1, 3.5). Worsening of fibrosis by at least one stage was not associated with statistically significant changes in any HRQoL domain compared with stable fibrosis. Associations between HRQoL and NAFLD disease activity score in the secondary analysis were of similar magnitude. Weight loss was associated with small improvements in physical function, general health, and energy levels. Conclusion: Improvements in fibrosis stage were associated with improvements in the physical component of HRQoL, but the clinical impact was modest. As improving fibrosis may not meaningfully improve well-being, treatment for NASH will be cost effective only if it prevents long-term hepatic and cardiovascular disease.

MAFLD: Renovation of clinical practice and disease awareness of fatty liver

Recently, international expert panels have proposed a new definition of fatty liver: metabolic dysfunction-associated fatty liver disease (MAFLD). MAFLD is not just a simple renaming of non-alcoholic fatty liver disease (NAFLD). The unique feature of MAFLD is the inclusion of metabolic dysfunctions, which are high-risk factors for events. In addition, MAFLD is independent of alcohol intake and the co-existing causes of liver disease. This new concept of MAFLD may have a widespread impact on patients, medical doctors, medical staff, and various stakeholders regarding fatty liver. Thus, MAFLD may renovate clinical practice and disease awareness of fatty liver. In this review, we introduce the definition of and rationale for MAFLD. We further describe representative cases showing how the diagnostic processes differ between MAFLD and NAFLD. We also summarize recent studies comparing MAFLD with NAFLD and discuss the impact of MAFLD on clinical trials, Japanese populations, and disease awareness.

Healthcare practitioners' diagnostic and treatment practice patterns of nonalcoholic fatty liver disease in Poland: a cross-sectional survey

BACKGROUND

Nonalcoholic fatty liver disease (NAFLD) awareness is low. NAFLD diagnosis and management by gastroenterologists (GEs) and general practitioners (GPs) in Poland were evaluated.

METHODS

RESTORE was an observational, noninterventional, retrospective cross-sectional survey performed among GEs and GPs with at least 3 years' experience. Computer-assisted web interviews were completed. GEs provided information from patient records.

RESULTS

Mean experience was 14.2 (95 GEs) and 22.6 (115 GPs) years. Mean patient numbers with liver disorders consulted per month were 36 (13%; GEs) and 51 (6%; GPs); ~50% were patients with NAFLD. All GEs/GPs used ultrasound; most evaluated transaminases and gamma-glutamyl transferase. More GEs used other imaging techniques and a larger spectrum of laboratory tests than GPs. Physician-identified NAFLD key symptoms were similar for GEs/GPs. GEs noticed less obvious symptoms (abdominal discomfort, drowsiness, fatigability, lack of energy) vs. GPs (abdominal pain/discomfort, dyspepsia). Common comorbidities in NAFLD were similar in GE/GP responses. NAFLD interventions by GEs/GPs (% patients) were diet/lifestyle/pharmacological interventions (54%/59%), diet/lifestyle changes alone (41%/31%) or pharmacological interventions alone (5%/10%). The top three criteria for supportive pharmacological selection were efficacy, tolerability and quality of life improvement for GEs/GPs. The five supportive treatments most commonly prescribed by GEs/GPs were essential phospholipids, ursodeoxycholic acid, timonacic, silybinin/silymarin and ornithine + choline. Information from patient records (n = 380) confirmed GEs responses.

CONCLUSIONS

NAFLD is not a silent disease as physicians and patients reported many, albeit nonspecific, symptoms. This cross-sectional survey provides important insights into clinical management of NAFLD by GEs and GPs in Poland.

Nonalcoholic fatty liver disease: lifestyle and quality of life

Nonalcoholic fatty liver disease (NAFLD) is a metabolic disorder whose current rapidly expanding prevalence is causing it to develop into a major global health concern. NAFLD is closely linked to the modern, unhealthy lifestyle. The Western diet, characterized by excessive energy intake, frequent consumption of red meat, processed meat and foods, soft drinks, and sugar-sweetened beverages (SSBs), irregular meal distribution throughout the day, and unhealthy ways of cooking, predisposes to development of NAFLD. Low levels of physical activity and prolonged sedentary time are additional lifestyle risk factors for NAFLD. Given the present lack of effective pharmacological treatment, lifestyle modifications are regarded as the cornerstone of NAFLD management. Reducing daily calorie intake together with following the Mediterranean diet (MD) is an increasingly accepted approach. Furthermore, increasing the level of physical activity and limiting sedentary behavior are additional measures proposed to improve the outcomes of the disease. Apart from being affected by lifestyle, NAFLD may also affect patients' quality of life (QoL), mostly in the domain of physical function. In this regard, while the early and more benign form of the disease, i.e., simple hepatic steatosis, may not affect QoL, there is evidence, though conflicting, of the impact of nonalcoholic steatohepatitis (NASH) on this index, with, however, most studies showing that QoL is consistently affected in advanced disease, i.e., hepatic fibrosis, cirrhosis, and hepatocellular carcinoma. Considering all the above, appropriate management of lifestyle is likely to attenuate the severity of the disease and improve the QoL of NAFLD patients.

Polygoni Multiflori Radix Praeparata Ethanol Extract Exerts a Protective Effect Against High-Fat Diet Induced Non-Alcoholic Fatty Liver Disease in Mice by Remodeling Intestinal Microbial Structure and Maintaining Metabolic Homeostasis of Bile Acids

In the prescription of Traditional Chinese Medicine for lipid metabolism, Polygoni Multiflori Radix Preparata (ZhiHeShouWu, RPMP) was widely used. In recent years, RPMP ethanol extract has been reported for the treatment of non-alcoholic fatty liver disease (NAFLD). However, the role of RPMP ethanol extract in the treatment of NAFLD has not been fully elucidated. Therefore, we examined the optimal therapeutic dose of RPMP ethanol extracts. Afterward, a mouse model of non-alcoholic fatty liver induced by a high-fat diet (HFD) was treated with RPMP ethanol extract to further evaluate the mechanism of action of RPMP ethanol extract treatment. And the serum lipid metabolism indexes and liver function indexes showed that the RPMP ethanol extract in the 1.35 g/kg dose group exhibited better therapeutic effects than the 2.70 g/kg dose group. Meanwhile, RPMP ethanol extract can regulate the biochemical indicators of serum and liver to normal levels, and effectively reduce liver steatosis and lipid deposition. RPMP ethanol extract treatment restored HFD-induced disruption of the compositional structure of the intestinal microbial (IM) and bile acids (BAs) pools. And restore the reduced expression of intestinal barrier-related genes caused by HFD administration, which also effectively regulates the expression of genes related to the metabolism of BAs in mice. Thus, RPMP ethanol extract can effectively improve the abnormal lipid metabolism and hepatic lipid accumulation caused by HFD, which may be related to the regulation of IM composition, maintenance of intestinal barrier function, and normal cholesterol metabolism in the body.

First-line sorafenib sequential therapy and liver disease etiology for unresectable hepatocellular carcinoma using inverse probability weighting: A multicenter retrospective study

BACKGROUND AND AIMS

Sequential therapy with molecular-targeted agents (MTAs) is considered effective for unresectable hepatocellular carcinoma (HCC) patients. This study purposed to evaluate the efficacy of sequential therapy with sorafenib (SORA) as a first-line therapy and to investigate the therapeutic impact of SORA in nonalcoholic fatty liver disease (NAFLD) or nonalcoholic steato hepatitis (NASH)-related HCC.

METHODS

We evaluated 504 HCC patients treated with SORA (Study-1). The times of administration for sorafenib from 2009 to 2015, 2016 to 2017, and 2018 and later were defined as the early-, mid-, and late-term periods, respectively. Among them, 180 HCC patients treated with SORA in addition to MTAs in the mid- and late-term periods were divided into groups based on disease etiology (NAFLD or NASH [n = 37] and viral or alcohol [n = 143]), and outcomes were compared after inverse probability weighting (IPW) (Study-2).

RESULTS

Overall survival (OS) of HCC patients who received sequential MTA therapy after first-line SORA was significantly longer. The median survival times (MST) were 12.6 versus 17.6 versus 17.4 months in the early-term group, mid-term group, and the later-time group (early vs. mid, p = 0.014, early vs. later. p = 0.045), respectively. (Study-1). In Study-2, there was no significant differences in OS between the Virus/alcohol group and the NAFLD/NASH group in patients who received sequential therapy (MST was 23.4 and 27.0 months p = 0.173, respectively). The NAFLD or NASH, female sex, albumin-bilirubin (ALBI) grade 2b, and major Vp (Vp3/Vp4) were significant factors for OS treated with SORA.

CONCLUSIONS

Sequential therapy with SORA as the first-line treatment improved the prognosis of unresectable HCC patients and was effective regardless of HCC etiology.

Association between Activity and Brain-Derived Neurotrophic Factor in Patients with Non-Alcoholic Fatty Liver Disease: A Data-Mining Analysis

Reduction in activity links to the development and progression of non-alcoholic fatty liver disease (NAFLD). Brain-derived neurotrophic factor (BDNF) is known to regulate an activity. We aimed to investigate the association between reduction in activity and BDNF in patients with NAFLD using data-mining analysis. We enrolled 48 NAFLD patients. Patients were classified into reduced (n = 21) or normal activity groups (n = 27) based on the activity score of the Chronic Liver Disease Questionnaire-NAFLD/non-alcoholic steatohepatitis. Circulating BDNF levels were measured using an enzyme-linked immunoassay. Factors associated with reduced activity were analyzed using decision-tree and random forest analyses. A reduction in activity was seen in 43.8% of patients. Hemoglobin A1c and BDNF were identified as negative independent factors for reduced activity (hemoglobin A1c, OR 0.012, p = 0.012; BDNF, OR 0.041, p = 0.039). Decision-tree analysis showed that "BDNF levels ≥ 19.1 ng/mL" was the most important classifier for reduced activity. In random forest analysis, serum BDNF level was the highest-ranked variable for distinguishing between the reduced and normal activity groups (158 valuable importance). Reduced activity was commonly seen in patients with NAFLD. Data-mining analyses revealed that BNDF was the most important independent factor corresponding with the reduction in activity. BDNF may be an important target for the prevention and treatment of NAFLD.

Diversity in NAFLD: A Review of Manifestations of Nonalcoholic Fatty Liver Disease in Different Ethnicities Globally

Globally, the rise in prevalence of obesity and metabolic syndrome as a whole has been linked to increased access to processed foods, such as refined sugars and saturated fats. Consequently, nonalcoholic fatty liver disease (NAFLD) is on the rise in both developed and developing nations. However, much is still unknown on the NAFLD phenotype with regards to the effect of ethnic diversity. Despite similarities in dietary habits, it appears that certain ethnicities are more protected against NAFLD than others. However, manifestations of the same genetic polymorphisms in different groups of people increase those individuals' predisposition to NAFLD. Diets from different regions have been associated with a lower prevalence of NAFLD and have even been linked to regression of hepatic steatosis. Socioeconomic variations amongst different regions of the world also contribute to NAFLD prevalence and associated complications. Thus, a thorough understanding of ethnic variability in NAFLD is essential to tailoring treatment recommendations to patients of different backgrounds.