Ethnic influence on nonalcoholic fatty liver disease prevalence and lack of disease awareness in the United States, 2011-2016

Rurality and Neighborhood Socioeconomic Status are Associated With Overall and Cause-Specific Mortality and Hepatic Decompensation in Type 2 Diabetes

INTRODUCTION

Social determinants of health are key factors driving disease progression. In type 2 diabetes there is limited literature on how distal or intermediate factors (eg, those at the neighborhood level) influence cause-specific mortality or liver disease outcomes.

METHODS

This was a single-center retrospective study of patients with type 2 diabetes seen at an integrated healthcare system in the United States. The primary outcomes were overall mortality; death due to cardiovascular disease, cancer, or liver disease; or hepatic decompensation. The primary predictors were neighborhood-level (intermediate) factors measuring neighborhood poverty (Area Deprivation Index [ADI], affluence score, disadvantage score) and rurality (Rural-Urban Commuting Area scores). Associations were modeled using Cox proportional hazards or Fine-Grey competing risk models.

RESULTS

28,424 participants were included. Higher neighborhood poverty associated with increased overall mortality, with hazard ratio (HR) 1.11 (95% confidence interval 1.10-1.12, P < .001) per 10 points of ADI and HR 1.32 (95% CI 1.26-1.37, P < .001) for 10 points of disadvantage. Conversely, higher neighborhood affluence associated with lower overall mortality with HR 0.87 (95% CI 0.86-0.89, P < .001) per 10 points of affluence. Living in a rural region associated with increased overall mortality: HR 1.08 (95% CI 1.01-1.15, P = .031). Associations were consistent across cause-specific mortality, though effect sizes were larger for liver-related mortality than for other causes. Living in a more rural neighborhood was associated with increased risk of hepatic decompensation.

CONCLUSIONS

Intermediate neighborhood-level socioeconomic status was associated with overall and cause-specific mortality in type 2 diabetes, with larger effects on liver-related mortality than other causes.

Social Determinants of Health Associated With Metabolic Dysfunction-Associated Steatotic Liver Disease Prevalence and Severity: A Systematic Review and Meta-Analysis

INTRODUCTION

Social determinants of health (SDOHs) affect disease risk and severity leading to health disparities. SDOH impacting metabolic dysfunction-associated steatotic liver disease (MASLD) prevalence and severity are poorly characterized, and results are conflicting. The aim of this systematic review and meta-analysis was to assess the impact of individual SDOH factors on MASLD burden for adults in the United States.

METHODS

We searched MEDLINE, Embase, and Cochrane databases per the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Studies from January 2010 to May 2024 were included. Quantitative studies of adults in the United States that evaluated SDOH beyond race/ethnicity were included. Outcomes included prevalence of MASLD, metabolic dysfunction-associated steatohepatitis (MASH), MASH-associated advanced fibrosis or cirrhosis, and clinical outcomes.

RESULTS

We identified 18 studies comprising 547,634 total subjects from 11 unique cohorts. Nine studies evaluated MASLD prevalence, 3 MASH prevalence, 6 MASH-associated advanced fibrosis/cirrhosis prevalence, and 9 clinical outcomes. High-diet quality was the most consistent SDOH factor associated with both MASLD and MASH-associated advanced fibrosis/cirrhosis prevalence (summarized odds ratio of 0.76, P < 0.01, and 0.74, P < 0.01, respectively). Lower income was most consistently associated with risk of clinical outcomes (significant in 3/9 studies).

DISCUSSION

Diet quality was the most consistent SDOH associated with disease prevalence and severity in MASLD, with other SDOH showing inconsistent associations. Prospective assessments using consensus, validated tools to assess the impact of specific SDOH on MASLD burden in heterogenous patient populations are needed to inform public health interventions.

Physical activity, diet, and social determinants of health associate with health related quality of life and fibrosis in MASLD

Metabolic dysfunction-associated steatotic liver disease (MASLD) is a leading cause of end-stage liver disease. MASLD and liver fibrosis are associated with cardiometabolic risk factors and health-related quality of life (HRQOL) while being affected by dietary/exercise patterns and social determinants of health (SDOH). However, previous studies have not assessed in conjunction exercise, diet, SDOH, and HRQOL in patients with MASLD. This was a cross-sectional study of patients with MASLD seen in hepatology clinic at University of Michigan. Participants completed validated surveys on HRQOL, diet, and physical activity, and a subset also underwent vibration controlled transient elastography (VCTE). The primary outcomes were HRQOL (measured by Short Form-8) and cirrhosis, and predictors were physical activity, dietary patterns, cardiometabolic comorbidities, and social determinants of health. The primary analysis included 304 patients, with median body mass index 32.4 kg/m2 and prevalence of type 2 diabetes, hypertension, and dyslipidemia 38%, 45%, and 42%, respectively (Table 1). The majority of the participants had a FIB-4 score of less than 1.3 and LSM of less than 8 (Table 1). HRQOL was lower with higher BMI, type 2 diabetes, hypertension, and increased liver fibrosis, and higher in people with adequate fruit intake. Neighborhood-level SDOH were also associated with HRQOL. Factors associated with cirrhosis or higher liver stiffness measurement by VCTE included body mass index, diabetes, and living in an impoverished neighborhood, while increased vegetable intake and exercise were associated with lower prevalence of cirrhosis/fibrosis. In multivariable models including demographic and cardiometabolic factors, dietary patterns and SDOH were independently associated with HRQOL and cirrhosis. Cardiometabolic risk factors, physical activity, diet, and social determinants of health are associated with HRQOL and liver fibrosis.

Health disparities in cirrhosis care and liver transplantation

Morbidity and mortality from cirrhosis are substantial and increasing. Health disparities in cirrhosis and liver transplantation are reflective of inequities along the entire spectrum of chronic liver disease care, from screening and diagnosis to prevention and treatment of liver-related complications. The key populations experiencing disparities in health status and healthcare delivery include racial and ethnic minority groups, sexual and gender minorities, people of lower socioeconomic status and underserved rural communities. These disparities lead to delayed diagnosis of chronic liver disease and complications of cirrhosis (for example, hepatocellular carcinoma), to differences in treatment of chronic liver disease and its complications, and ultimately to unequal access to transplantation for those with end-stage liver disease. Calling out these disparities is only the first step towards implementing solutions that can improve health equity and clinical outcomes for everyone. Multi-level interventions along the care continuum for chronic liver disease are needed to mitigate these disparities and provide equitable access to care.

Epidemiology of metabolic dysfunction-associated steatotic liver disease

As the rates of obesity and type 2 diabetes (T2D) continue to increase globally, so does the prevalence of metabolic dysfunction-associated steatotic liver disease (MASLD). Currently, 38% of all adults and 7-14% of children and adolescents have MASLD. By 2040, the MASLD prevalence rate for adults is projected to increase to more than 55%. Although MASLD does not always develop into progressive liver disease, it has become the top indication for liver transplant in the United States for women and those with hepatocellular carcinoma (HCC). Nonetheless, the most common cause of mortality among patients with MASLD remains cardiovascular disease. In addition to liver outcomes (cirrhosis and HCC), MASLD is associated with an increased risk of developing de novo T2D, chronic kidney disease, sarcopenia, and extrahepatic cancers. Furthermore, MASLD is associated with decreased health-related quality of life, decreased work productivity, fatigue, increased healthcare resource utilization, and a substantial economic burden. Similar to other metabolic diseases, lifestyle interventions such as a heathy diet and increased physical activity remain the cornerstone of managing these patients. Although several obesity and T2D drugs are available to treat co-morbid disease, resmetirom is the only MASH-targeted medication for patients with stage 2-3 fibrosis that has approved by the Food and Drug Administration for use in the United States. This review discusses MASLD epidemiology and its related risk factors and outcomes and demonstrates that without further global initiatives, MASLD incidence could continue to increase.

Association between the composite dietary antioxidant index and non-alcoholic fatty liver disease: evidence from National Health and Nutrition Examination Survey 2005-2016

Importance

Oxidative stress contributes to the progression of non-alcoholic fatty liver disease (NAFLD). Antioxidants from food can reduce NAFLD incidence, and the Composite Dietary Antioxidant Index (CDAI) measures total antioxidant capacity (TAC). However, the relationship between CDAI and NAFLD in the US adult population remains unclear.

Objective

To assess whether CDAI is associated with NAFLD in US adults.

Design setting and participants

This population-based cross-sectional study used data on US adults from the National Health and Nutrition Examination Survey (NHANES) 2005-2016 cycles. Data were analyzed from January to February 2024.

Exposures

CDAI obtained from the dietary intake questionnaire.

Main outcomes and measures

The main outcome was NAFLD which defined by the US fatty liver score (USFLI) ≥30. Sampling weights were calculated according to NHANES guidelines.

Results

Among 9,746 adults included in this study [mean age, 48.3 years; 4,662 (47.6%) males], 3,324 (33.0%) were classified as having NAFLD using USFLI. In the fully adjusted of multivariable logistic regression, CDAI was negatively associated with NAFLD (odds ratio [OR], 0.95; 95% CI, 0.93-0.98). Furthermore, individuals in the highest quartile of CDAI were 34% less likely to have NAFLD compared to those in the lowest quartile (OR, 0.66; 95% CI, 0.52-0.85). In subgroup analyses, CDAI was inversely associated with NAFLD among participants with a BMI <25 (OR, 0.89; 95% CI, 0.83-0.95) and without metabolic syndrome (OR, 0.93; 95% CI, 0.91-0.96). The interaction tests revealed significant differences in these subgroups (P for interaction = 0.04 for BMI and 0.003 for metabolic syndrome). Sensitivity analyses confirmed this association using the hepatic steatosis index (HSI) to define NAFLD, applying unweighted logistic regression, adjusting for physical activity or after excluding non-Hispanic Black participants, and after excluding medications known for their potential hepatotoxic effects.

Conclusions and relevance

In this cross-sectional study based on six cycles (2005-2016) of the NHANES, CDAI was negatively associated with NAFLD in US adult population. This association highlights the potential for dietary interventions to reduce NAFLD incidence and underscores the need for future research, including clinical trials and mechanistic studies, to further explore the role of dietary antioxidants in NAFLD prevention and management.

MAFLD in adults: non-invasive tests for diagnosis and monitoring of MAFLD

Metabolic dysfunction-associated fatty liver disease (MAFLD) is the liver manifestation of a metabolic syndrome and is highly prevalent in the general population. There has been significant progress in non-invasive tests for MAFLD, from the diagnosis of fatty liver and monitoring of liver fat content in response to intervention, to evaluation of liver fibrosis and its change over time, and from risk stratification of patients within the context of clinical care pathways, to prognostication. Various non-invasive tests have also been developed to assess for fibrotic metabolic dysfunction-associated steatohepatitis, which has emerged as an important diagnostic goal, particularly in the context of clinical trials. Non-invasive tests can be used to diagnose clinically significant portal hypertension so that intervention can be administered to reduce the risk of decompensation. Furthermore, the use of risk stratification algorithms can identify at-risk patients for hepatocellular carcinoma surveillance. Beyond the liver, various tests that evaluate cardiovascular disease risk, assess sarcopenia and measure patient reported outcomes, can be utilized to improve the care of patients with MAFLD. This review provides an up-to-date overview of these non-invasive tests and the limitations of liver biopsy in the management of patients with MAFLD.

Knowledge about metabolic dysfunction-associated steatotic liver disease among the medical professionals from countries in the MENA region

INTRODUCTION AND OBJECTIVES

Given the substantial burden of metabolic dysfunction-associated steatotic liver disease (MASLD), there is an urgent need to assess knowledge and awareness levels among physicians. We assessed MASLD knowledge among healthcare providers from Saudi Arabia, Egypt, and Türkiye.

MATERIALS AND METHODS

Two global surveys containing 54-59 items assessed awareness and knowledge of MASLD/NAFLD- one was for hepatologists and gastroenterologists, and the second was for non-specialists (e.g. endocrinologists, primary care providers [PCPs], and other healthcare professionals). Data were collected using an electronic data collection form. Knowledge scores and variables associated with higher knowledge scores were compared across all specialties.

RESULTS

A total of 584 physicians completed the survey (126 hepatologists, 178 gastroenterologists (GEs), 38 endocrinologists, 242 PCPs/others). Practice guidelines were the primary source for knowledge across all specialties (43-51%), then conferences (24-31%) except PCPs/others who selected the internet as the second common source (25%). Adherence to societal guidelines varied by specialty (81-84% of specialists vs 38-51% of non-specialists). Hepatologists and GEs showed similar mean knowledge scores (51-72% correct answers across three knowledge domains, p > 0.05); endocrinologists outperformed PCPs/others in knowledge scores in all knowledge domains, including Epidemiology/Pathogenesis (72% vs. 60%), Diagnostics (73% vs. 67%), and Treatment (78% vs. 67%) (all p < 0.01). Hospital-based practice and seeing a greater number of patients with MASLD/NAFLD were identified as independent predictors of higher knowledge scores among specialists (both p < 0.05).

CONCLUSIONS

A knowledge gap in the identification, diagnosis, and management of MASLD/NAFLD was found despite the growing burden of MASLD/NAFLD in Saudi Arabia, Egypt, and Türkiye. Education to increase awareness is needed.

Sex and Race-Ethnic Disparities in Metabolic Dysfunction-Associated Steatotic Liver Disease: An Analysis of 40,166 Individuals

BACKGROUND

To overcome the limitations of the term "non-alcoholic fatty liver disease" (NAFLD), the term metabolic-associated steatotic liver disease (MASLD) was introduced. While epidemiologic studies have been conducted on MASLD, there is limited evidence on its associated sex and ethnic variations.

AIMS

This study assesses the differences across sex and race-ethnicity on the prevalence, associated risk factors and adverse outcomes in individuals with MASLD.

METHODS

Data retrieved from the National Health and Nutrition Examination Survey between 1999 to 2018 was analyzed. Prevalence, clinical characteristics, and outcomes were evaluated according to sex and race-ethnicity. Adverse outcomes and mortality events were analyzed using multivariate analyses.

RESULTS

Of 40,166 individuals included, 37.63% had MASLD. There was a significant increase in MASLD prevalence from 1999 to 2018 among Mexican Americans (Annual Percentage Change [APC] + 1.889%, p < 0.001), other Hispanics (APC + 1.661%, p = 0.013), NH Whites (APC + 1.084%, p = 0.018), NH Blacks (APC + 1.108%, p = 0.007), and females (APC + 0.879%, p = 0.030), but not males. Females with MASLD were at lower risk of all-cause (HR: 0.766, 95%CI 0.711 to 0.825, p < 0.001), cardiovascular disease-related (CVD) (SHR: 0.802, 95% CI 0.698 to 0.922, p = 0.002) and cancer-related mortality (SHR: 0.760, 95% CI 0.662 to 0.873, p < 0.001). Significantly, NH Blacks have the highest risk of all-cause and CVD-related mortality followed by NH Whites then Mexican Americans.

CONCLUSION

There has been an increase in prevalence in most race-ethnicities over time. While the change in definition shows no significant differences in previous associations found in NAFLD, the increased mortality in NH Whites relative to Mexican Americans remains to be explored.

Updates in characteristics and survival rates of cirrhosis in a nationwide cohort of real-world U.S. patients, 2003-2021

BACKGROUND

Adverse outcomes of cirrhosis remain a top priority.

AIMS

We examined the distribution of cirrhosis causes, HCC incidence and mortality and related changes over time in a nationwide U.S.

COHORT

METHODS

A retrospective study of a national sample of commercially insured patients with cirrhosis from Optum's de-identified Clinformatics® Data Mart Database (CDM).

RESULTS

A total of 628,743 cirrhosis cases were identified with 45% having NAFLD, 19.5% HCV, and 16.3% ALD. African Americans had the highest rate of decompensation (60.6%), while Asians had the highest rate of HCC (2.4%), both p < 0.001. African Americans more frequently had HCV (28.4%) while Hispanic/Latinos more frequently had NAFLD (49.2%, p < 0.001). Patients in the 2014-2021 cohort were significantly older (63.0 ± 12.8 vs. 57.0 ± 14.3), less frequently decompensated (54.5% vs. 58.3%) but more frequently had HCC (1.7% vs. 0.6%) and NAFLD (46.5% vs. 44.2%), all p < 0.001. The overall annual incidence of HCC was 0.76% (95% CI: 0.75-0.77) with a 5-year cumulative incidence of 4.03% (95% CI: 3.98-4.09), with significant variation by sex, race/ethnicity, and cirrhosis aetiology. The overall median years of survival were 11.4 (95% CI: 11.3-11.5) with a 5-year cumulative survival of 73.4% (95% CI: 73.3%-73.6%), also with significant disparities in similar subgroups (lowest in cryptogenic cirrhosis and worse in 2014-2021 vs. 2003-2013). The 2014-2021 period was independently associated with worse survival (aHR: 1.14, 95% CI: 1.08-1.20).

CONCLUSIONS

HCC incidence and survival vary by aetiology among patients with cirrhosis, with cryptogenic cirrhosis having the lowest survival and lower survival in the more recent time period.

Prevalence of Steatotic Liver Disease Among US Adults with Rheumatoid Arthritis

BACKGROUND

The prevalence of steatotic liver disease (SLD) among patients with rheumatoid arthritis (RA) remains largely unknown.

AIMS

To investigate the prevalence of SLD and liver fibrosis among patients with RA.

METHODS

We utilized data from the United States (US)-based National Health and Nutrition Examination Survey (NHANES) 2017-2020 cycle. After applying established sample weights, we estimated the age-adjusted prevalence of SLD and its subclassifications (CAP ≥ 285 dB/m), high-risk NASH (FAST score) and liver fibrosis (LSM) among participants with self-reported RA. Multivariable logistic regression was performed to identify independent risk factors for metabolic dysfunction associated SLD (MASLD), high-risk NASH and fibrosis, respectively, among participants with RA. We present adjusted odds ratios (aORs) and 95% confidence intervals (CIs).

RESULTS

Age-adjusted prevalence of MASLD among US adults with RA was 34.91% (95% CI: 24.02-47.65%). We also found that the age-adjusted prevalence of high-risk NASH (FAST score > 0.35) and significant fibrosis (LSM > 8.6 kPa) was 12.97% (95% CI: 6.89-23.07%) and 10.35% (95% CI: 5.55-18.48%), respectively. BMI ≥ 30 kg/m2, (aOR 6.23; 95% CI: 1.95-19.88), diabetes (aOR 5.90; 95% CI: 1.94-17.94), and dyslipidemia (aOR 2.83; 95% CI: 1.12-7.11) were independently associated with higher odds of MASLD among participants with RA. Diabetes (aOR 19.34; 95% CI: 4.69-79.70) was also independently associated with high-risk NASH.

CONCLUSIONS

The prevalence of MASLD, high-risk NASH, and liver fibrosis among patients with RA is equal or higher than the general population. Future studies of large cohorts are needed to substantiate the role of systemic inflammation in the pathophysiology of MASLD.

Prevalence of Nonalcoholic Steatohepatitis and Associated Fibrosis Stages Among US Adults Using Imaging-Based vs Biomarker-Based Noninvasive Tests

Introduction: Nonalcoholic fatty liver disease (NAFLD) is believed to be the most common chronic liver disease worldwide. Therapies are under development for nonalcoholic steatohepatitis (NASH), the progressive form of NAFLD, such that the prevalence of NASH with liver fibrosis, which is likely to require treatment, may be of interest to healthcare decision makers. Noninvasive tests are used in initial screening for NASH, as well as in observational studies of NASH prevalence. However, existing evidence does not address how estimated prevalence varies with different noninvasive tests. This analysis estimated the prevalence of NASH among US adults and assessed variation with different noninvasive tests. Methods: A cross-sectional analysis was conducted using the 2017-March 2020 National Health and Nutrition Examination Survey cycle. Participants with presumed NAFLD (steatosis and without alternative causes of liver disease) were identified, among whom NASH was predicted based on FAST score, Fibrosis-4 (FIB-4), and AST-to-Platelet Ratio Index (APRI) cutoffs across 11 scenarios. Among NASH participants, fibrosis stages were explored based on distribution across the spectrum of liver-stiffness measurements. Results: Among participants with complete data for the analysis (N=6969), prevalence of presumed NAFLD was 25.6%. Within presumed NAFLD, prediction of NASH using imaging-based NIT cutoffs yielded estimated prevalence of 1.3%-4.8% (3.3 million-12.2 million) based on FAST score cutoffs from 0.35-0.67. Using biomarker-based NIT cutoffs yielded estimated prevalence of 0.4%-12.3% (1.0 million-14.5 million) based on FIB-4 cutoffs from 0.90-2.67, and 0.1%-1.9% (0.2-5.0 million) based on APRI cutoffs from 0.50-1.50. Conclusion: Prevalence of NASH among US adults was estimated to range from 1.3% to 4.8% when predicted using imaging-based noninvasive test values for participants with presumed NAFLD, generally aligning with estimates in the literature of prevalence of biopsy-confirmed NASH. Use of biomarker-based noninvasive test values for prediction of NASH yielded a wider range of estimates with FIB-4, and a considerably lower range of estimates with APRI.

Updates in Characteristics and Survival Rates of Hepatocellular Carcinoma in a Nationwide Cohort of Real-World US Patients, 2003-2021

Background & Aim

Causes of hepatocellular carcinoma (HCC) may change as treatments become available for some liver diseases. We examined the distribution of HCC cause and survival of a nationwide cohort of insured patients.

Methods

Optum's de-identified Clinformatics® Data Mart Database (CDM), 2003-2021.

Results

A total of 34707 patients with HCC were included: mean age: 68.3±11.6 years, 61% male, 62% Caucasian, 74% cirrhosis. Non-alcoholic fatty liver disease (NAFLD) was the most common etiology (38.9%), then hepatitis C virus (HCV) (25.3%), cryptogenic (18.0%), alcohol-associated liver disease (9.4%), other liver diseases (5.8%) and hepatitis B virus (HBV) at 2.6%. NAFLD patients were the oldest (mean age 71.1±11.2) and had the highest Charlson Comorbidity Index (CCI) (mean 10.5±3.9), while HCV were the youngest (mean age 64.2±9.2 years) and HBV had the lowest CCI (mean 7.2±4.4) (both P<0.0001). The overall 5-year survival was 18.8% (95% CI 18.2-19.3) but was lower in the recent 2014-2021 period vs 2003-2013 (18.1% vs 19.5%, P=0.003). The 2014-2021 cohort (inclusive of HCV treatment advances) was significantly older, with more females, fewer Caucasians, more African Americans, more Hispanics, fewer Asians, more cirrhosis, more NAFLD, and higher CCI (all P<0.001). On multivariable analysis, males (aHR: 1.13), Caucasians (aHR: 1.46), African Americans (aHR: 1.53) and Hispanics (aHR: 1.28) vs Asians, 2014-2021 (vs 2003-2013) cohort (aHR: 1.12), NAFLD (aHR: 1.14) or cryptogenic liver disease (aHR: 1.45) were associated with increased mortality (all P<0.001).

Conclusion

HCC patients in more recent time 2014-2021 were more likely to be older, more likely to have nonviral etiology, and had worse survival compared to those from 2003 to 2013.

Rucker L, Johnson J, Ghosh S. Transcriptomics of MASLD Pathobiology in African American Patients in the Washington DC Area †

Metabolic-dysfunction-associated steatotic liver disease (MASLD) is becoming the most common chronic liver disease worldwide and is of concern among African Americans (AA) in the United States. This pilot study evaluated the differential gene expressions and identified the signature genes in the disease pathways of AA individuals with MASLD. Blood samples were obtained from MASLD patients (n = 23) and non-MASLD controls (n = 24) along with their sociodemographic and medical details. Whole-blood transcriptomic analysis was carried out using Affymetrix Clarion-S Assay. A validation study was performed utilizing TaqMan Arrays coupled with Ingenuity Pathway Analysis (IPA) to identify the major disease pathways. Out of 21,448 genes in total, 535 genes (2.5%) were significantly (p < 0.05) and differentially expressed when we compared the cases and controls. A significant overlap in the predominant differentially expressed genes and pathways identified in previous studies using hepatic tissue was observed. Of note, TGFB1 and E2F1 genes were upregulated, and HMBS was downregulated significantly. Hepatic fibrosis signaling is the top canonical pathway, and its corresponding biofunction contributes to the development of hepatocellular carcinoma. The findings address the knowledge gaps regarding how signature genes and functional pathways can be detected in blood samples ('liquid biopsy') in AA MASLD patients, demonstrating the potential of the blood samples as an alternative non-invasive source of material for future studies.

Differences in liver and mortality outcomes of non-alcoholic fatty liver disease by race and ethnicity: A longitudinal real-world study

BACKGROUND/AIMS

Understanding of nonalcoholic fatty liver disease (NAFLD) continues to expand, but the relationship between race and ethnicity and NAFLD outside the use of cross-sectional data is lacking. Using longitudinal data, we investigated the role of race and ethnicity in adverse outcomes in NAFLD patients.

METHODS

Patients with NAFLD confirmed by imaging via manual chart review from any clinics at Stanford University Medical Center (1995-2021) were included. Primary study outcomes were incidence of liver events and mortality (overall and non-liver related).

RESULTS

The study included 9,340 NAFLD patients: White (44.1%), Black (2.29%), Hispanic (27.9%), and Asian (25.7%) patients. For liver events, the cumulative 5-year incidence was highest among White (19.1%) patients, lowest among Black (7.9%) patients, and similar among Asian and Hispanic patients (~15%). The 5-year and 10-year cumulative overall mortality was highest for Black patients (9.2% and 15.0%, respectively, vs. 2.5-3.5% and 4.3-7.3% in other groups) as well as for non-liver mortality. On multivariable regression analysis, compared to White patients, only Asian group was associated with lower liver-related outcomes (aHR: 0.83, P=0.027), while Black patients were at more than two times higher risk of both non-liver related (aHR: 2.35, P=0.010) and overall mortality (aHR: 2.13, P=0.022) as well as Hispanic patients (overall mortality: aHR: 1.44, P=0.022).

CONCLUSION

Compared to White patients, Black patients with NAFLD were at the highest risk for overall and non-liver-related mortality, followed by Hispanic patients with Asian patients at the lowest risk for all adverse outcomes. Culturally sensitive and appropriate programs may be needed for more successful interventions.

Racial, Gender, and Size Bias in a Medical Graphical Abstract Gallery: A Content Analysis

Introduction

Graphical abstracts may enhance dissemination of scientific and medical research but are also prone to reductionism and bias. We conducted a systematic content analysis of the Journal of Internal Medicine (JIM) Graphical Abstract Gallery to assess for evidence of bias.

Materials and Methods

We analyzed 140 graphical abstracts published by JIM between February 2019 and May 2020. Using a combination of inductive and deductive approaches, we developed a set of codes and code definitions for thematic, mixed-methods analysis.

Results

We found that JIM graphical abstracts disproportionately emphasized male (59.5%) and light-skinned (91.3%) bodies, stigmatized large body size, and overstated genetic and behavioral causes of disease, even relative to the articles they purportedly represented. Whereas 50.7% of the graphical surface area was coded as representing genetic factors, just 0.4% represented the social environment.

Discussion

Our analysis suggests evidence of bias and reductionism promoting normative white male bodies, linking large bodies with disease and death, conflating race with genetics, and overrepresenting genes while underrepresenting the environment as a driver of health and illness. These findings suggest that uncritical use of graphical abstracts may distort rather than enhance our understanding of disease; harm patients who are minoritized by race, gender, or body size; and direct attention away from dismantling the structural barriers to health equity.

Conclusion

We recommend that journals develop standards for mitigating bias in the publication of graphical abstracts that (1) ensure diverse skin tone and gender representation, (2) mitigate weight bias, (3) avoid racial or ethnic essentialism, and (4) attend to sociostructural contributors to disease.

Global incidence of non-alcoholic fatty liver disease: A systematic review and meta-analysis of 63 studies and 1,201,807 persons

BACKGROUND & AIMS

The prevalence of non-alcoholic fatty liver disease (NAFLD) is increasing. We aimed to estimate the pooled global NAFLD incidence.

METHODS

We performed a systematic review and meta-analysis of cohort studies of adults without NAFLD at baseline to evaluate the global incidence of ultrasound-diagnosed NAFLD.

RESULTS

A total of 63 eligible studies (1,201,807 persons) were analyzed. Studies were from Mainland China/Hong Kong (n = 26), South Korea (n = 22), Japan (n = 14), other (n = 2, Sri Lanka, Israel); 63.8% were clinical center studies; median study year 2000 to 2016; 87% were good quality. Among the 1,201,807 persons at risk, 242,568 persons developed NAFLD, with an incidence rate of 4,612.8 (95% CI 3,931.5-5,294.2) per 100,000 person-years and no statistically significant differences by study sample size (p = 0.90) or study setting (p = 0.055). Males had higher incidence vs. females (5,943.8 vs. 3,671.7, p = 0.0013). Both the obese (vs. non-obese) and the overweight/obese groups (vs. normal weight) were about threefold more likely to develop NAFLD (8,669.6 vs. 2,963.9 and 8,416.6 vs. 3,358.2, respectively) (both p <0.0001). Smokers had higher incidence than non-smokers (8,043.2 vs. 4,689.7, p = 0.046). By meta-regression, adjusting for study year, study setting, and study location, study period of 2010 or after and study setting were associated with increased incidence (p = 0.010 and p = 0.055, respectively). By country, China had a higher NAFLD incidence compared to non-China regions (p = 0.012) and Japan a lower incidence compared to non-Japan regions (p = 0.005).

CONCLUSIONS

NAFLD incidence is increasing with a current estimate of 4,613 new cases per 100,000 person-years. Males and overweight/obese individuals had significantly higher incidence rates compared to females and those of normal weight. Public health interventions for prevention of NAFLD are needed with a special emphasis on males, overweight/obese individuals, and higher risk regions.

IMPACT AND IMPLICATIONS

Non-alcoholic fatty liver disease (NAFLD) affects approximately 30% of people worldwide and appears to be increasing, but data to estimate the incidence rate are limited. In this meta-analytic study of over 1.2 million people, we estimated an incidence rate of NAFLD of 46.13 per 1,000 person-years with significant differences by sex, BMI, geography, and time-period. As treatment options for NAFLD remain limited, prevention of NAFLD should remain the focus of public health strategies. Studies such as these can help policy makers in determining which and whether their interventions are impactful.

Nonalcoholic Fatty Liver Disease: Disease Burden and Disease Awareness

Nonalcoholic fatty liver disease (NAFLD) has become the most common chronic liver disease worldwide and has been implying an unprecedented burden to health care systems. The prevalence of NAFLD has exceeded 30% in developed countries. Considering the asymptomatic nature of undiagnosed NAFLD, high suspicion and noninvasive diagnosis have utmost importance especially in primary care level. At this point, patient and provider awareness should be optimal for early diagnosis and risk stratification for patients at risk of progression.

Screening for At-Risk Nonalcoholic Fatty Liver Disease in the Primary Care Setting

While nonalcoholic fatty liver disease is a leading cause of end-stage liver disease, most patients with nonalcoholic fatty liver disease do not develop cirrhosis and its complications. Therefore, risk stratification using inexpensive, noninvasive screening modalities is critical to avoid overdiagnosis and overtreatment of a large proportion of the population. In this review, we discuss the data supporting screening and current professional society recommendations on this topic. Screening for at-risk nonalcoholic fatty liver disease is recommended in patients with risk factors including diabetes, the metabolic syndrome, hepatic steatosis, and elevated aminotransferases. Screening typically consists of noninvasive testing using serum biomarkers followed by elastography using specialized imaging modalities. This sequential screening approach accurately identifies both high- and low-risk patients and is cost-effective when applied to at-risk populations. In conclusion, screening for advanced nonalcoholic fatty liver disease in the primary care setting is a crucial part of identifying high-risk patients who may benefit from aggressive intervention while avoiding overtreatment of patients at low risk of liver-related complications.

The Growing Economic and Clinical Burden of Nonalcoholic Steatohepatitis (NASH) in the United States

Background

Nonalcoholic steatohepatitis (NASH) is a cause of chronic liver disease.

Aim

Model the burden of NASH in the United States according to obesity.

Methods

The discrete-time Markov model comprised adult NASH subjects moving through 9 health states and 3 absorbing death states (liver, cardiac, and other deaths) with 1-year cycles and a 20-year horizon. Given that reliable natural history data for NASH are not available, transition probabilities were estimated from the literature and population-based data. These rates were disaggregated to determine age-obesity group rates by applying estimated age-obesity patterns. The model considers 2019 prevalent NASH cases and new incident NASH cases (2020-2039), assuming that recent trends will continue. Annual per-patient costs by health state were based on published data. Costs were standardized to 2019 US dollars and inflated by 3% annually.

Results

NASH cases in the United States are forecasted to increase by +82.6%, from 11.61 million (2020) to 19.53 million (2039). During the same period, cases of advanced liver disease increased +77.9%, from 1.51 million to 2.67 million, while its proportion remained stable (13.46%-13.05%). Similar patterns were observed in both obese and non-obese NASH. Among NASH, 18.71 million overall deaths, 6.72 million cardiac-specific deaths, and 1.71 million liver-specific deaths were observed by 2039. During this period, the projected cumulative direct healthcare costs were $1208.47 billion (obese NASH) and $453.88 billion (non-obese NASH). By 2039, the projected NASH attributable healthcare cost per patient increased from $3636 to $6968.

Conclusions

There is a substantial and growing clinical and economic burden of NASH in the United States.

Liver Inflammation Is Common and Linked to Metabolic Derangements in Persons With Treated Human Immunodeficiency Virus (HIV)

BACKGROUND

We sought to characterize in people with human immunodeficiency virus (PWH) the potential etiologies of elevated alanine aminotransferase (ALT) levels, which are common and often unexplained.

METHODS

Participants from the longitudinal observational AIDS Clinical Trials Group HAILO cohort without a history of hepatitis C virus (HCV) or hepatitis B virus (HBV) infection nor reported heavy alcohol use were included. Clinical and demographic characteristics, including medication use, the hepatic steatosis index (HSI), and metabolic syndrome (MetS) were compared between participants with and without ALT elevation.

RESULTS

Six hundred sixty-two participants were included; 444 (67%) had ≥1 and 229 (35%) ≥2 consecutive ALT elevations during a median of 4.0 years of follow-up. HSI and Hispanic or other (non-White or Black) race/ethnicity were consistently associated with higher odds of abnormal ALT (odds ratio [OR] 1.1 for HSI as a continuous variable, OR 1.9-2.8 for Hispanic/other race/ethnicity for ≥1 or ≥2 ALT elevations); older age and current smoking were associated with lower odds of abnormal ALT. Associations with metabolic disease, as well as with incident HBV and HCV infection, were strengthened by restricting outcomes to persistent and higher degrees of ALT elevation.

CONCLUSIONS

ALT elevation was common in this cohort of PWH and associated with metabolic disease and hepatic steatosis markers. Nonalcoholic fatty liver disease is likely a common cause of liver inflammation in PWH receiving suppressive antiretrovirals, deserving targeted diagnosis and intervention.

Screening strategy for non-alcoholic fatty liver disease

Non-alcoholic fatty liver disease (NAFLD) is the most common chronic liver disease, affecting approximately 25% of the general population worldwide, and is forecasted to increase global health burden in the 21st century. With the advancement of non-invasive tests for assessing and monitoring of steatosis and fibrosis, NAFLD screening is now feasible, and is increasingly highlighted in international guidelines related to hepatology, endocrinology, and pediatrics. Identifying high-risk populations (e.g., diabetes mellitus, obesity, metabolic syndrome) based on risk factors and metabolic characteristics for non-invasive screening is crucial and may aid in designing screening strategies to be more precise and effective. Many screening modalities are currently available, from serum-based methods to ultrasonography, transient elastography, and magnetic resonance imaging, although the diagnostic performance, cost, and accessibility of different methods may impact the actual implementation. A two-step assessment with serum-based fibrosis-4 index followed by imaging test vibration-controlled transient elastography can be an option to stratify the risk of liverrelated complications in NAFLD. There is a need for fibrosis surveillance, as well as investigating the cost-effectiveness of different screening algorithms and engaging primary care for first-stage triage screening.

2019 Global NAFLD Prevalence: A Systematic Review and Meta-analysis

BACKGROUND & AIMS

The increasing rates of obesity and type 2 diabetes mellitus may lead to increased prevalence of nonalcoholic fatty liver disease (NAFLD). We aimed to determine the current and recent trends on the global and regional prevalence of NAFLD.

METHODS

Systematic search from inception to March 26, 2020 was performed without language restrictions. Two authors independently performed screening and data extraction. We performed meta-regression to determine trends in NAFLD prevalence.

RESULTS

We identified 17,244 articles from literature search and included 245 eligible studies involving 5,399,254 individuals. The pooled global prevalence of NAFLD was 29.8% (95% confidence interval [CI], 28.6%-31.1%); of these, 82.5% of included articles used ultrasound to diagnose NAFLD, with prevalence of 30.6% (95% CI, 29.2%-32.0%). South America (3 studies, 5716 individuals) and North America (4 studies, 18,236 individuals) had the highest NAFLD prevalence at 35.7% (95% CI, 34.0%-37.5%) and 35.3% (95% CI, 25.4%-45.9%), respectively. From 1991 to 2019, trend analysis showed NAFLD increased from 21.9% to 37.3% (yearly increase of 0.7%, P < .0001), with South America showing the most rapid change of 2.7% per year, followed by Europe at 1.1%.

CONCLUSIONS

Despite regional variation, the global prevalence of NAFLD is increasing overall. Policy makers must work toward reversing the current trends by increasing awareness of NAFLD and promoting healthy lifestyle environments.

Current status of disparity in liver disease

Disparities have emerged as an important issue in many aspects of healthcare in developed countries and may be based on race, ethnicity, sex, geographical location, and socioeconomic status. For liver disease specifically, these potential disparities can affect access to care and outcome in viral hepatitis, chronic liver disease, and hepatocellular carcinoma. Shortages in hepatologists and medical providers versed in liver disease may amplify these disparities by compromising early detection of liver disease, surveillance for hepatocellular carcinoma, and prompt referral to subspecialists and transplant centers. In the United States, continued efforts have been made to address some of these disparities with better education of healthcare providers, use of telehealth to enhance access to specialists, reminders in electronic medical records, and modifying organ allocation systems for liver transplantation. This review will detail the current status of disparities in liver disease and describe current efforts to minimize these disparities.

Non-alcoholic fatty liver disease establishment and progression: genetics and epigenetics as relevant modulators of the pathology

BACKGROUND

Non-alcoholic fatty liver disease (NAFLD) results from metabolic dysfunctions that affect more than one-third of the world population. Over the last decades, scientific investigations have clarified many details on the pathology establishment and development; however, effective therapeutics approaches are still evasive. In addition, studies demonstrated that NAFLD establishment and progression are related to several etiologies. Recently, genetics and epigenetics backgrounds have emerged as relevant elements to the pathology onset, and, hence, deserve deep investigation to clarify molecular details on NAFLD signaling, which may be correlated with population behavior. Thus, to minimize the global problem, public health and public policies should take advantage of studies on NAFLD over the next following decades.

METHODS

In this context, we have performed a selective literature review focusing on biochemistry of lipid metabolism, genetics, epigenetics, and the ethnicity as strong elements that drive NAFLD establishment.

RESULTS

Considering the etiological agents that acts on NAFLD development and progression, the genetics and the epigenetics emerged as relevant factors. Genetics acts as a powerful element in the establishment and progression of the NAFLD. Over the last decades, details concerning genes and their polymorphisms, as well as epigenetics, have been considered relevant elements in the systems biology of diseases, and their effects on NAFLD should be considered in-depth, as well as the ethnicity, clarifying whether people are susceptible to liver diseases. Moreover, the endemicity and social problems of hepatic disfunction are far to be solved, which require a combined effort of various sectors of society.

CONCLUSION

Hence, the elements presented and discussed in this short review demonstrated their relevance to the physiological control of NAFLD, opening perspectives for research to develop new strategy to treat fatty liver diseases.

Are there outcome differences between NAFLD and metabolic-associated fatty liver disease?

BACKGROUND

Given the association of NAFLD with metabolic risks, a name change to MAFLD is proposed. We compared the long-term outcomes of NAFLD and MAFLD.

METHODS

We included patients with fatty liver disease (FLD) from NHANES III and NHANES 2017-2018 (FLD defined as moderate to severe hepatic steatosis by ultrasound for NHANES III and as having a controlled attenuation parameter ≥285 dB/m for NHANES 2017-2018). NAFLD was defined as FLD without other liver diseases and excess alcohol use. Metabolic-associated fatty liver disease (MAFLD) was defined as FLD and metabolic dysfunction per criteria. All NHANES III participants had linked mortality data through December 31, 2015.

RESULTS

NHANES III participants (n = 12,878): mean age 43.1 years old; 49.5% male; 20.3% with FLD, 16.5% with NAFLD, and 18.1% with MAFLD. NHANES 2017-2018 participants (n = 4328): mean age 48.0 years old; 49.1% male; 36.8% with FLD, 34.2% with NAFLD, and 36.3% with MAFLD. Excellent concordance was noted between MAFLD and NAFLD diagnosis in both data sets (kappa coefficient = 0.83-0.94). Except for components of each definition (e.g., alcohol use for MAFLD), no other major differences in clinical characteristics were noted. During up to 27 years of follow-up (median of 22.8 years), no differences in cumulative all-cause and cause-specific mortality were noted. In addition to the stage of fibrosis, insulin resistance was a predictor of liver mortality in NAFLD, and alcohol-associated liver disease (ALD) was a predictor of mortality in MAFLD.

CONCLUSIONS

MAFLD and NAFLD have similar clinical profiles and long-term outcomes. The increased liver-related mortality among NAFLD is driven by insulin resistance, and among MAFLD is primarily driven by ALD.

Research trends analysis of chronic hepatitis C versus nonalcoholic fatty liver disease: A literature review text-mining analysis of publications

Background

Hepatits C virus (HCV) rates have lowered due to direct-acting antiviral treatment. Nonalcoholic steatohepatitis (NASH)/nonalcoholic fatty liver disease (NAFLD) is rising with no available therapy. We employed text-mining to analyze trends in HCV and NAFLD research from the past two decades.

Materials and Methods

We queried PubMed for all HCV and NASH/NAFLD entries published between 2000 and 2020. We compared the total number of publications on both etiologies. We performed subanalyses for different terms of interest and for geographic origin.

Results

Overall, 75,934 HCV-related entries and 24,987 NASH/NAFLD-related entries were published during the study period. Up to 2015, there was a linear upward slope in the number of annual HCV publications (154.9 publications/year, p < 0.001). In 2015, the yearly number of HCV publications started showing a downward slope (-242.2 publications/year, p < 0.001). The number of NASH/NAFLD publications showed a continuous upward slope during the study period. The NASH/NAFLD field lacks publications on screening and treatment methods.

Conclusion

Trends in publications varied between both etiologies. They reflect the success of antiviral treatment for HCV. The growing rates of NAFLD/NASH and the lack of a targeted cure explain the rise in related publications.

Accuracy of Non-invasive Indices for Diagnosing Hepatic Steatosis Compared to Imaging in a Real-World Cohort

BACKGROUND & AIMS

Nonalcoholic fatty liver disease is common and under-diagnosed. This study evaluated the accuracy of several previously reported indices, including hepatic steatosis index, alanine aminotransferase (ALT) method, Framingham steatosis index, and Dallas steatosis index, to diagnose hepatic steatosis in a real-world cohort.

METHODS

This study included 701 randomly selected adult patients seen in our integrated healthcare system between 2015 and 2020 with appropriate abdominal imaging and routine outpatient laboratory studies. Information on demographics, comorbidities and existing liver disease, anthropometrics, laboratory studies, and abdominal imaging was collected. The sensitivity, specificity, and C-statistic of each method in detecting hepatic steatosis based on abdominal imaging were determined.

RESULTS

202/701 patients (28.8%) had hepatic steatosis on abdominal imaging. These patients were more likely to have metabolic syndrome components and higher body mass index. All indices performed similarly with moderate accuracy in detecting hepatic steatosis based on the C-statistic (95% confidence interval): Hepatic steatosis index 0.76 (0.72-0.79), Framingham steatosis index 0.78 (0.74-0.82), and Dallas steatosis index 0.80 (0.76-0.83). ALT method had sensitivity 44.7% (36.9-52.7%) and specificity 88.6% (85.0-91.7%). Several sensitivity analyses were performed, which did not significantly alter the performance of any index.

CONCLUSION

The findings support both the clinical utility of these indices in diagnosing hepatic steatosis in the absence of imaging in real-world settings and the research utility of these indices in generating reliable electronic medical record-based nonalcoholic fatty liver disease cohorts.

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.

Nonalcoholic fatty liver disease versus metabolic-associated fatty liver disease: Prevalence, outcomes and implications of a change in name

Nonalcoholic fatty liver disease (NAFLD) affects about a third of the world's adult population and is a major public health concern. NAFLD is defined by the presence of hepatic steatosis and the absence of other causes of liver disease. As NAFLD is closely associated with the presence of the metabolic syndrome, several experts have called for a change in nomenclature from NAFLD to metabolic-associated fatty liver disease (MAFLD) to better reflect the underlying pathophysiology of NAFLD as a metabolically driven disease and shift to a "positive" diagnostic criteria rather than one of exclusion. Recent studies have suggested that the global prevalence of MAFLD is higher than that of NAFLD, and patients with MAFLD have more metabolic comorbidities compared to those with NAFLD. Emerging data also suggest that all-cause and cardiovascular mortality may be higher in MAFLD compared with NAFLD. In this synopsis, we discuss differences in clinical features, prevalence and clinical outcomes between NAFLD and MAFLD. In addition, we highlight the advantages and disadvantages of a name change from NAFLD to MAFLD from the perspective of the scientific community, care providers and patients.

Forecasted 2040 global prevalence of nonalcoholic fatty liver disease using hierarchical bayesian approach

BACKGROUND/AIMS

Due to increases in obesity and type 2 diabetes, the prevalence of nonalcoholic fatty liver disease (NAFLD) has also been increasing. Current forecast models may not include non-obese NAFLD. Here, we used the Bayesian approach to forecast the prevalence of NAFLD through the year 2040.

METHODS

Prevalence data from 245 articles involving 2,699,627 persons were used with a hierarchical Bayesian approach to forecast the prevalence of NAFLD through 2040. Subgroup analyses were performed for age, gender, presence of metabolic syndrome, region, and smoking status. Sensitivity analysis was conducted for clinical setting and study quality.

RESULTS

The forecasted 2040 prevalence was 55.7%, a three-fold increase since 1990 and a 43.2% increase from the 2020 prevalence of 38.9%. The estimated average yearly increase since 2020 was 2.16%. For those aged <50 years and ≥50 years, the 2040 prevalence were not significantly different (56.7% vs. 61.5%, P=0.52). There was a significant difference in 2040 prevalence by sex (males: 60% vs. 50%) but the trend was steeper for females (annual percentage change: 2.5% vs. 1.5%, P=0.025). There was no difference in trends overtime by region (P=0.48). The increase rate was significantly higher in those without metabolic syndrome (3.8% vs. 0.84%, P=0.003) and smokers (1.4% vs. 1.1%, P=0.011). There was no difference by clinical/community setting (P=0.491) or study quality (P=0.85).

CONCLUSION

By 2040, over half the adult population is forecasted to have NAFLD. The largest increases are expected to occur in women, smokers, and those without metabolic syndrome. Intensified efforts are needed to raise awareness of NAFLD and to determine long-term solutions addressing the driving factors of the disease.

Review article: the epidemiologic burden of non-alcoholic fatty liver disease across the world

BACKGROUND

The prevalence of non-alcoholic fatty liver disease (NAFLD) is increasing in parallel with obesity and type 2 diabetes.

AIM

To review the global epidemiology of NAFLD METHODS: We retrieved articles from PubMed using search terms of NAFLD, epidemiology, prevalence, incidence, and comorbidities.

RESULTS

Over 250 articles were reviewed. In 2016, the global NAFLD prevalence was 25%; this increased to >30% in 2019. Prevalence in Asia, Latin America and Middle East-North Africa (MENA) was 30.8%, 34.5% and 42.6%, respectively. Prevalence increased with age. Although prevalence was higher in men, prevalence in post-menopausal women was similar. NAFLD prevalence was higher in certain subpopulations, especially among the obese and those with metabolic syndrome (MS). However, the prevalence of lean NAFLD was 11.2%. The global prevalence of non-alcoholic steatohepatitis (NASH) is estimated between 2% and 6% in the general population. Approximately 7% of patients with NAFLD have advanced fibrosis; rates were between 21% and 50% among patients with NASH. Overall mortality related to NAFLD was 15-20 per 1000 person-years, and increased substantially in patients with NASH, especially in those with components of MS. Recent data suggest mortality/morbidity from NAFLD is increasing globally but NAFLD awareness remains low among patients and healthcare providers.

CONCLUSIONS

NAFLD poses a global public health problem with a very high disease burden in Asia, MENA and Latin America. Research is needed to better quantify the full impact of NAFLD and to develop strategies to improve awareness and risk stratification.

Tamoxifen use and potential effects on liver parenchyma: A long-term prospective transient elastographic evaluation

Tamoxifen is a commonly prescribed drug in both early and metastatic breast cancer. Prospective studies in Asian populations demonstrated that tamoxifen‐related liver steatosis occurred in more than 30% of the patients within 2 years after start of treatment. No well‐designed prospective studies on potential tamoxifen‐related liver steatosis have been conducted in Caucasian patients so far. Therefore, our prospective study aimed to assess the incidence of tamoxifen‐related liver steatosis for a period of 2 years in a population of Caucasian breast cancer patients treated with tamoxifen. Patients with an indication for adjuvant treatment with tamoxifen were included in this study. Data were collected at 3 months (T1) and at 2 years (T2) after start of tamoxifen treatment (follow‐up period of 21 months). For the quantification of liver steatosis, patients underwent liver stiffness measurement by transient elastography with simultaneous controlled attenuation parameter (CAP) determination using the FibroScan. A total of 95 Caucasian breast cancer patients were included in this evaluation. Liver steatosis was observed in 46 of 95 (48%) and 48 of 95 (51%) of the patients at T1 and T2, respectively. No clinically relevant increase in liver steatosis was observed during the treatment period of 2 years with tamoxifen (median CAP = 243 ± 49 dB/m (T1) and 253 ± 55 dB/m (T2), respectively; p = 0.038). Conclusion: In this prospective longitudinal study in Caucasian breast cancer patients, no clinically relevant alterations in liver steatosis in terms of CAP values and liver/lipid parameters were observed after 2 years of tamoxifen treatment. This study therefore demonstrates an absence of tamoxifen‐related adverse events such as steatosis and (early) development of fibrosis or cirrhosis during a treatment period of at least 2 years.

Nonalcoholic fatty liver disease prevalence and severity in Asian Americans from the national health and nutrition examination surveys 2017–2018

Studies have examined nonalcoholic fatty liver disease (NAFLD) prevalence and severity in Asians; however, this is not well understood in Asian Americans (both East and South Asian Americans) as few studies have analyzed this population. We aimed to describe characteristics, prevalence of NAFLD, and its severity in Asian Americans in the National Health and Nutrition Examination Surveys (NHANES) from 2017 to 2018. Respondents 18 years and older with interview, laboratory testing, and transient elastography data were included. Other causes of liver disease were excluded. Controlled attenuation parameter (CAP) cutoff ≥ 274 dB/m, as published in the literature, defined NAFLD. Sensitivity analysis for CAP cutoffs ≥ 248 and ≥302 dB/m were performed. We found that 450 out of 3639 respondents were Asian Americans, and prevalence using CAP ≥ 274 dB/m was 43.23%. Using sensitivity analysis cutoffs of CAP ≥ 248 dB/m and CAP ≥ 302 dB/m, the prevalence was 57.38% and 28.03%, respectively. Compared with non‐Asian Americans with NAFLD, Asian Americans with NAFLD had significantly lower body mass index (BMI) and less prevalent smoking history. Comorbidities, such as prediabetes, diabetes, and hypertension, were not significantly different between Asian and non‐Asian Americans with NAFLD. Compared to non‐Asian Americans with NAFLD, Asian Americans with NAFLD exhibited higher aminotransferases and triglycerides. Fibrosis assessed by transient elastography was not significantly different between Asian and non‐Asian Americans with NAFLD. Despite decreased prevalence of BMI ≥ 30 kg/m², Asian Americans experienced similar NAFLD prevalence with increased hepatocellular injury and triglyceridemia compared to non‐Asian Americans. Fibrosis stages were similar to non‐Asian Americans.

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.

Association of the serum transaminase with mortality among the US elderly population

BACKGROUND AND AIM

Considering the inconsistent findings of research into the associations between serum levels of liver enzymes (alanine aminotransferase [ALT], aspartate aminotransferase [AST], and gamma-glutamyltransferase [GGT]) and mortality among elderly people, we aimed to investigate the associations of ALT, AST, GGT, and De-Ritis ratio (DRR, defined as AST/ALT) and all-cause or cause-specific mortality among the US elderly people using National Health and Nutrition Examination Surveys data.

METHODS

We included 6415 elderly participants (≥ 65 years). Exclusion criteria included positive test for hepatitis B virus, hepatitis C virus, and human immunodeficiency virus infection at baseline. Multivariable-adjusted Cox regression models calculating hazard ratios (HR) and 95% confidence intervals were developed for each of the liver enzyme measures.

RESULTS

All-cause cumulative mortality was 33.8%, of which 23.8% were cardiovascular disease (CVD) deaths, 15.6% were cancer deaths, and 60.6% were other cause deaths. Adjusted Cox models found increased all-cause mortality risk for low ALT (HR: 1.70), low AST (HR: 1.13), high GGT (HR: 1.25), and high DRR (HR: 1.68). Low ALT and high DRR predicted CVD mortality. Low ALT (HR: 1.91), low AST (HR: 1.16), high GGT (HR: 1.40), and high DRR (HR: 1.76) predicted other cause mortality.

CONCLUSIONS

Low ALT and high DRR were associated with increased CVD and cancer mortality. All serum liver enzyme measures were associated with all-cause mortality and other cause mortality in the US elderly population. Further studies may validate these findings in other elderly populations.

Impact of renaming NAFLD to MAFLD in an Australian regional cohort: Results from a prospective population-based study

BACKGROUND AND AIMS

Clinical and public health implications of the recent redefining of non-alcoholic fatty liver disease (NAFLD) to metabolic-associated fatty liver disease (MAFLD) remain unclear. We sought to determine the prevalence and compare MAFLD with NAFLD in a well-defined cohort.

METHODS

A cross-sectional study was conducted in regional Victoria with participants from randomly selected households. Demographic and health-related clinical and laboratory data were obtained. Fatty liver was defined as a fatty liver index ≥ 60 with MAFLD defined according to recent international expert consensus.

RESULTS

A total of 722 participants were included. Mean age was 59.3 ± 16 years, and 55.3% were women with a median body mass index of 27.8 kg/m² . Most (75.2%) participants were overweight or obese. MAFLD was present in 341 participants giving an unadjusted prevalence of 47.2% compared with a NAFLD prevalence of 38.7%. Fifty-nine (17.5%) participants met the criteria of MAFLD but not NAFLD. The increased prevalence of MAFLD in this cohort was primarily driven by dual etiology of fatty liver. All participants classified as NAFLD met the new definition of MAFLD. Compared with NAFLD subjects, participants with MAFLD had higher ALT (26.0 [14.0] U/L vs 30.0 [23] U/L, P = 0.024), but there were no differences in non-invasive markers for steatosis or fibrosis.

CONCLUSION

Metabolic-associated fatty liver disease is a highly prevalent condition within this large community cohort. Application of the MAFLD definition increased prevalence of fatty liver disease by including people with dual etiologies of liver disease.

Platelet-Activating Factor Promotes the Development of Non-Alcoholic Fatty Liver Disease

Non-alcoholic fatty liver disease (NAFLD) is a multifaceted clinicopathological syndrome characterised by excessive hepatic lipid accumulation that causes steatosis, excluding alcoholic factors. Platelet-activating factor (PAF), a biologically active lipid transmitter, induces platelet activation upon binding to the PAF receptor. Recent studies have found that PAF is associated with gamma-glutamyl transferase, which is an indicator of liver disease. Moreover, PAF can stimulate hepatic lipid synthesis and cause hypertriglyceridaemia. Furthermore, the knockdown of the PAF receptor gene in the animal models of NAFLD helped reduce the inflammatory response, improve glucose homeostasis and delay the development of NAFLD. These findings suggest that PAF is associated with NAFLD development. According to reports, patients with NAFLD or animal models have marked platelet activation abnormalities, mainly manifested as enhanced platelet adhesion and aggregation and altered blood rheology. Pharmacological interventions were accompanied by remission of abnormal platelet activation and significant improvement in liver function and lipids in the animal model of NAFLD. These confirm that platelet activation may accompany a critical importance in NAFLD development and progression. However, how PAFs are involved in the NAFLD signalling pathway needs further investigation. In this paper, we review the relevant literature in recent years and discuss the role played by PAF in NAFLD development. It is important to elucidate the pathogenesis of NAFLD and to find effective interventions for treatment.

Poor Awareness of Liver Disease Among Adults With NAFLD in the United States

Population-based studies that estimate awareness of nonalcoholic fatty liver disease (NAFLD) in the United States are scant. We aimed to understand public awareness of NAFLD and its temporal trends. Our study included 11,700 adults (18+ years old) from five National Health and Nutrition Examination Surveys (2007-2016). NAFLD was determined by the improved Fatty Liver Index for the multiethnic U.S. population (US-FLI) in the absence of secondary causes of liver disease. Overall prevalence of NAFLD, hepatitis C virus, and hepatitis B virus were 36.6%, 1.02% and 0.35%, respectively. From 2007-2008 to 2015-2016, awareness of liver disease among adults with NAFLD improved from 4.4% to 6.3% (trend P = 0.026) but 4 to 10 times lower than awareness about viral hepatitis. In 2015-2016, among adults with NAFLD, awareness of liver disease was lower among young adults (aged 18-29 years) compared with those aged ≥ 30 years (0% vs. 6.9%) and lower among non-Hispanic Blacks compared with other races (0.7% vs. 6.6%) (all P < 0.001). In multivariable analysis, young adults (adjusted odds ratio [aOR] = 0.29; confidence interval [CI] 0.10-0.87) and non-Hispanic Blacks (aOR = 0.43; CI 0.20-0.96) were negatively associated with awareness of liver disease among adults with NAFLD, whereas diabetes (aOR = 2.22; CI 1.37-3.58), advanced fibrosis (aOR = 2.34; CI 1.17-4.68), and a higher number of health care visits (aOR = 1.33; CI 1.15-1.50) were positively associated with awareness of liver disease. Nearly 96% of adults with NAFLD in the United States were unaware they had liver disease, especially among young adults and non-Hispanic Blacks. Findings indicate efforts are needed to improve awareness of NAFLD.

Insights into Nonalcoholic Fatty-Liver Disease Heterogeneity

The acronym nonalcoholic fatty-liver disease (NAFLD) groups a heterogeneous patient population. Although in many patients the primary driver is metabolic dysfunction, a complex and dynamic interaction of different factors (i.e., sex, presence of one or more genetic variants, coexistence of different comorbidities, diverse microbiota composition, and various degrees of alcohol consumption among others) takes place to determine disease subphenotypes with distinct natural history and prognosis and, eventually, different response to therapy. This review aims to address this topic through the analysis of existing data on the differential contribution of known factors to the pathogenesis and clinical expression of NAFLD, thus determining the different clinical subphenotypes observed in practice. To improve our understanding of NAFLD heterogeneity and the dominant drivers of disease in patient subgroups would predictably impact on the development of more precision-targeted therapies for NAFLD.

The Changing Epidemiology of Liver Disease Among US Children and Adolescents From 1999 to 2016

INTRODUCTION

Nonalcoholic fatty liver disease (NAFLD) and infection with hepatitis B virus (HBV) or hepatitis C virus (HCV) are major causes of liver disease in adults. However, data for children and adolescents are limited. Our study aimed to characterize the prevalence, trend, and risk factors of infection of HBV and HCV and possible NAFLD for this population.

METHODS

We analyzed 6,647 children and adolescents (aged 6-21 years) from the 1999-2016 National Health and Nutrition Examination Survey.

RESULTS

Among individuals aged 6-21 years, HBV prevalence decreased after 2011, from 0.72% in 1999-2004 and 0.85% in 2005-2010 to 0.27% in 2011-2016 (P < 0.001), whereas HCV prevalence increased to 0.26% in 2011-2016 after an initial decline from 0.15% in 1999-2004 to 0.02% in 2005-2010 (P = 0.01). Possible NAFLD prevalence also increased by approximately 40% in individuals aged 12-21 years, from 8.54% in 1999-2004 to 10.1% in 2005-2010 and then 11.8% in 2011-2016 (P = 0.033), with most possible NAFLD individuals being male, being obese, or having higher glucose, fasting insulin, hemoglobin A1c, homeostatic model assessment of insulin resistance, liver enzymes, lipids, and uric acid (all P < 0.01). On multivariate logistic regression, hypertension (odds ratio 4.79, 95% confidence interval 1.44-15.9) and dyslipidemia (odds ratio 11.6, 95% confidence interval 5.65-23.9) increased risk for possible NAFLD but not income:poverty ratio, hours spent on computer use, or added sugars.

DISCUSSION

Although HBV prevalence has decreased in recent years among US children and adolescents, HCV and possible NAFLD have increased. Public health efforts must seek further understanding of the driving factors of this increase so that age-appropriate interventions can be developed and implemented.

Differential Clinical Characteristics and Mortality Outcomes in Persons With NAFLD and/or MAFLD

BACKGROUND & AIMS

Metabolic dysfunction-associated fatty liver disease (MAFLD) establishes new criteria for diagnosing fatty liver disease independent of alcohol intake and concomitant viral hepatitis infection. However, the long-term outcomes of patients with MAFLD are sparse. We aimed to describe the characteristics and long-term survival of persons meeting criteria for nonalcoholic fatty liver disease (NAFLD) only (non-MAFLD NAFLD), for both NAFLD and MAFLD (NAFLD-MAFLD), and for MAFLD only (non-NAFLD MAFLD).

METHODS

Using data from the Third National Health and Nutrition Examination Survey (NHANES III) 1988-1994, 2997 participants with fatty liver identified via ultrasound were categorized into 3 distinct groups: non-MAFLD NAFLD, NAFLD-MAFLD, and non-NAFLD MAFLD.

RESULTS

Participants in the NAFLD-MAFLD and non-NAFLD MAFLD groups were older, had more metabolic traits and higher mean liver enzymes. Nearly 8% of participants in the non-NAFLD MAFLD group had advanced fibrosis (Fibrosis-4 index >2.67), while only 1.3% and 1.9% in the NAFLD-MAFLD and non-MAFLD NAFLD groups did, respectively (P < .0001). Non-NAFLD MAFLD participants had the highest cumulative incidence of all-cause mortality (26.2%) followed by those with NAFLD-MAFLD then non-MAFLD NAFLD participants (21.1% and 10.6%, respectively; P < .0001). Similar findings were observed for cardiovascular disease-related and other-cause (noncardiovascular disease, noncancer) mortality. Non-NAFLD MAFLD was independently associated with all-cause mortality compared with non-MAFLD NAFLD (adjusted hazard ratio, 2.4; 95% confidence interval, 1.2-4.6; P = .01).

CONCLUSIONS

MAFLD criteria identified a significant group of people with more comorbidities and worse prognosis compared with those with NAFLD only. These criteria should be considered in the general population to identify high-risk groups for early interventions.

Incorporating fatty liver disease in multidisciplinary care and novel clinical trial designs for patients with metabolic diseases

With the global epidemics of obesity and associated conditions, including type 2 diabetes, metabolic dysfunction-associated fatty liver disease, chronic kidney disease, hypertension, stroke, cardiovascular disease, osteoporosis, cancer, and cognitive changes, the prevalence of multimorbidity is rapidly increasing worldwide. In this Review, a panel of international experts from across the spectrum of metabolic diseases come together to identify the challenges and provide perspectives on building a framework for a virtual primary care-driven, patient-centred, multidisciplinary model to deliver holistic care for patients with metabolic dysfunction-associated fatty liver disease and associated metabolic diseases. We focus on clinical care and innovative trial design for metabolic dysfunction-associated fatty liver disease and associated metabolic diseases. This work represents a call to action to promote collaboration and partnerships between stakeholders for improving the lives of people with, or at risk of, metabolic dysfunction-associated fatty liver disease and associated metabolic diseases.

Associations of Dietary Lipid-Soluble Micronutrients with Hepatic Steatosis among Adults in the United States

Lipid-soluble micronutrients may be beneficial to non-alcoholic fatty liver disease due to their important roles in metabolism and maintaining tissue functions. Utilizing 2017-2018 National Health and Nutrition Examination Survey, this study examined the potential overall and race/ethnicity-specific (black, Hispanic and white) associations of dietary lipid-soluble micronutrients (α-tocopherol, retinol, vitamin D, β-carotene and total carotenoids) with hepatic steatosis. The analysis included 4376 adults (1037 blacks, 981 Hispanics, 1549 whites) aged ≥20 years who completed the transient elastography examination with dietary data available. Odds ratios (OR) and 95% confidence intervals (95%CI) were estimated using logistic regressions. The age-adjusted prevalence of steatosis was 20.9% for blacks, 34.0% for Hispanics and 28.7% for whites. Overall, dietary α-tocopherol was inversely associated with steatosis (highest vs. lowest quartile: OR = 0.51, 95%CI = 0.35-0.74, P_trend = 0.0003). The associations remained significant among blacks (highest vs. lowest tertile: OR = 0.45, 95%CI = 0.26-0.77, P_trend = 0.002) and whites (highest vs. lowest tertile: OR = 0.56, 95%CI = 0.33-0.94, P_trend = 0.02). Higher α-tocopherol intake was associated with lower odds of steatosis among all (P_trend = 0.016) and black participants (P_trend = 0.003) classified as never/rare/occasional alcohol drinkers. There was a trend suggesting higher β-carotene intake with lower odds of steatosis (P_trend = 0.01). Our results suggest potential protective effects of dietary vitamin E as α-tocopherol on steatosis particularly among blacks.

ALT Levels in Treatment-Naive, Chronic Hepatitis B Patients with Concurrent Fatty Liver Disease: A US Nationwide Study

INTRODUCTION

Treatment criteria for chronic hepatitis B (CHB) relies on ALT, which can be impacted by concurrent nonalcoholic fatty liver disease (NAFLD), but ALT data on patients with CHB and NAFLD are limited. We aimed to characterize ALT distribution in untreated CHB patients with NAFLD.

METHODS

We retrospectively analyzed untreated US adults with CHB (533 with NAFLD, 3,172 without NAFLD) using the Clinformatics™ Data Mart Database (2003-2019). The main outcome was ALT elevation (>1× upper limit of normal, 35/25 U/L for men/women, respectively). Secondary outcomes were advanced fibrosis (via FIB-4 index) and factors associated with fibrosis.

RESULTS

The majority of patients were Asian (61.0%) and hepatitis B e-antigen (HBeAg)-negative (90.4%). Patients with CHB and NAFLD were older (57.2 vs. 49.5 years, p < 0.001), more likely male (59.3% vs. 46.2%, p < 0.001), with higher percentages of advanced fibrosis (3.6% vs. 2.6%, p < 0.001) than those with CHB alone. CHB-NAFLD patients were more likely to have elevated ALT than those with CHB only, but this difference was only significant among those with low hepatitis B virus (HBV) DNA (38.1% vs. 25.6%, p < 0.001), not those with higher HBV DNA (>2,000 IU/mL). After adjusting for HBeAg, HBV DNA, and diabetes, NAFLD was not independently associated with advanced fibrosis (odds ratio 1.18, 95% confidence interval: 0.30-4.59, p = 0.81).

DISCUSSION

CHB-NAFLD patients with HBV DNA below treatment threshold were more likely to have elevated ALT but not those with higher HBV DNA, suggesting that ALT threshold does not need to be raised for antiviral eligibility for CHB with NAFLD.