How good is controlled attenuation parameter and fatty liver index for assessing liver steatosis in general population: correlation with ultrasound

Proteomic variation underlies the heterogeneous risk of metabolic dysfunction-associated steatotic liver disease for subsequent chronic diseases

BACKGROUND

Metabolic dysfunction-associated steatotic liver disease (MASLD) is a heterogeneous condition. Whether and how the plasma proteome underlies the heterogeneous associations between MASLD and subsequent health outcomes remain unclear.

METHODS

This study included 42 508 participants from the UK Biobank. Steatosis was defined by the fatty liver index. Individuals' MASLD-related proteomic signature was derived from 2911 plasma proteins. Cox models were used to assess the associations of the proteomic signature with 8 chronic diseases: liver fibrosis, cardiovascular disease (CVD), chronic kidney disease (CKD), chronic respiratory disease (CRD), dementia, depression, anxiety, and cancers. Adjusted survival curves were fitted to compare the cumulative incidence rate of diseases across quantiles of the proteomic signature; we further adjusted for the steatosis degree and cardiometabolic factors to test whether the association was independent of them. Mediation analyses were performed to identify mediating proteins.

RESULTS

The proteomic signature was significantly associated with liver fibrosis, CVD, CKD, CRD, and depression in the MASLD population, with adjusted hazard ratios ranging from 1.30 to 4.94. Survival curves showed that individuals with the highest proteomic signature had the highest risk for these 5 diseases. These risk differences by signature persisted after adjustment for steatosis degree and cardiometabolic factors, except for depression. Proteins including ADM, ASGR1, and FABP4 were identified as common mediators of the association between MASLD and multiple diseases. Mediators of liver fibrosis showed specificity, with CDHR2 being the key protein.

CONCLUSIONS

Metabolic dysfunction-associated steatotic liver disease patients with the same steatosis severity but different proteomic responses may have different risks for future outcomes. Several key proteins may contribute to the progression of MASLD-related diseases.

Quantitative ultrasound analysis for non-invasive assessment of hepatic steatosis in metabolic dysfunction-associated steatotic liver disease

ObjectiveTo evaluate the diagnostic performance of novel tissue attenuation imaging (TAI) and tissue scatter distribution imaging (TSI) tools in detecting and grading hepatic steatosis using controlled attenuation parameter (CAP) as reference standard.MethodsA total of 185 participants with suspected metabolic dysfunction-associated steatotic liver disease (MASLD) were prospectively enrolled, and all underwent CAP and quantitative ultrasound (QUS) testing. Correlations between CAP, biological data, TAI and TSI were assessed. The influence factors of TAI and TSI as well as the diagnostic performance of TAI and TSI in detecting hepatic steatosis were evaluated.ResultsThe QUS parameters (TAI and TSI) showed good intra-observer reliability with ICC of 0.972 and 0.777, respectively. The correlation of CAP with TAI was higher than that of TSI (0.724 vs 0.360, P < 0.05). Multivariate Regression analysis showed that CAP was an important influence factor of TAI and TSI (P < 0.001). The area under the ROC curve (CAP > 250 dB/m) of TAI and TSI tools for detecting hepatic steatosis was 0.876 (95% CI: 0.813-0.923; P < 0.0001) and 0.797(95% CI: 0.724-0.857; P < 0.001), respectively; the sensitivity was 67.18% and 83.21%, the specificity was 95.65% and 69.57%, and the cut-off values were 0.93 dB/cm/MHz and 91.28, respectively. When TAI and TSI were combined, the area under the ROC curve was 0.881, with a sensitivity of 80.92% and a specificity of 82.61%. The Delong test showed that the combined diagnosis of TAI and TSI was equivalent to the use of TAI alone (P > 0.05).ConclusionTAI and TSI provided good intra-observer reliability, correlated well with CAP, and helped to detect and stage hepatic steatosis.

Association Between Live Microbe Intake and NAFLD: Evidence From NHANES 2003-2018

OBJECTIVE

This study aimed to shed light on the potential relationship between live microbe intake and nonalcoholic fatty liver disease (NAFLD).

METHOD

By using a cross-sectional study design, the researchers were able to investigate the possible causal association between the two variables in a rigorous and systematic manner.

RESULTS

Our study investigated the correlation between the intake of live microbe-containing foods and NAFLD in a representative sample of adults. The study found that the intake of live microbe-containing foods was associated with lower blood pressure, plasma glucose, NAFLD, body mass index, glycated hemoglobin, alanine aminotransferase, aspartate aminotransferase, gamma-glutamyl transpeptidase, and low-density lipoprotein cholesterol, as well as higher high-density lipoprotein cholesterol levels (p < 0.05). In univariate logistic regression, high dietary live microbe intake was associated with lower NAFLD prevalence than low intake (OR = 0.830; 95% CI, 0.759 to 0.908; p < 0.001). After adjusting for multiple variables, the same conclusion was supported (p < 0.05). In subgroup analyses, there was a significant difference in the race and smoking groups, with p for interaction of 0.01 and 0.02, respectively. This study's findings serve to augment the existing body of evidence linking live microbes with favorable health outcomes.

CONCLUSIONS

Our study revealed a robust correlation between dietary intake of live microbes and the prevalence of NAFLD in a cross-sectional analysis. Our findings offer a novel perspective on NAFLD research, highlighting the potential of targeted modulation of specific bacterial taxa, including the promotion of beneficial bacteria and suppression of harmful ones, as a promising strategy for preventing and treating NAFLD.

Prevalence and Characteristics of Metabolic Hyperferritinemia in a Population-Based Central-European Cohort

BACKGROUND

Hyperferritinemia (HF) is a common finding and can be considered as metabolic HF (MHF) in combination with metabolic diseases. The definition of MHF was heterogenous until a consensus statement was published recently. Our aim was to apply the definition of MHF to provide data on the prevalence and characteristics of MHF in a Central-European cohort.

METHODS

This study was a retrospective analysis of the Paracelsus 10,000 study, a population-based cohort study from the region of Salzburg, Austria. We included 8408 participants, aged 40-77. Participants with HF were divided into three categories according to their level of HF and evaluated for metabolic co-morbidities defined by the proposed criteria for MHF.

RESULTS

HF was present in 13% (n = 1111) with a clear male preponderance (n = 771, 69% of HF). Within the HF group, 81% (n = 901) of subjects fulfilled the metabolic criteria and were defined as MHF, of which 75% (n = 674) were characterized by a major criterion. In the remaining HF cohort, 52% (n = 227 of 437) of subjects were classified as MHF after application of the minor criteria.

CONCLUSION

HF is a common finding in the general middle-aged population and the majority of cases are classified as MHF. The new classification provides useful criteria for defining MHF.

Ultrasound Attenuation Imaging vs MRI-PDFF, Echogenicity and Liver Function for Assessing Degree of Steatosis in NAFLD and Non-NAFLD Patients

ABSTRACT

Nonalcoholic fatty liver disease (NAFLD) is a primary cause of parenchymal liver disease globally. There are currently several methods available to test the degree of steatosis in NAFLD patients, but all have drawbacks that limit their use.The objective of this study is to determine if a new technique, ultrasound (US) attenuation imaging (ATI), correlates with magnetic resonance proton density fat fraction imaging and hepatic echogenicity as seen on gray scale US imaging.Fifty-four patients were recruited at the University of Washington Medical Center from individuals who had already been scheduled for hepatic US or magnetic resonance imaging (MRI). All participants then underwent both hepatic MRI proton density fat fraction and US. Ultrasound images were then evaluated using ATI with 2 observers who individually determined relative grayscale echogenicity.Analysis showed positive correlation between ATI- and MRI-determined fat percentage in the case group (Spearman correlation: 0.50; P = 0.015). Furthermore, participants with NAFLD tended to have a higher ATI than controls (median: 0.70 vs 0.54 dB/cm/MHz; P < 0.001).This study demonstrates that US ATI combined with grayscale imaging is an effective way of assessing the degree of steatosis in patients with moderate to severe NAFLD.

Noninvasive biomarkers of non-alcoholic fatty liver disease in patients with metabolic syndrome: insights from the RESOLVE Study

BACKGROUND

The aim of the present study was to evaluate: 1) the presence of liver steatosis using Fatty Liver Index (FLI), Hepatic Steatosis Index (HSI) and Liver Fat Score (LFS) in patients suffering from metabolic syndrome (MS); and 2) the association of FLI, HSI and LFS with the cardiometabolic risks.

METHODS

A total of 91 patients with MS (39 men, 52 women) and 44-age matched healthy subjects (control; 23 men and 21 women) were enrolled in the study. A continuous cardiometabolic score (MetsScore) and the noninvasive tests of hepatic steatosis were calculated for comparison and association analysis.

RESULTS

Liver steatosis was detected in 86%, 84% and 80% of people diagnosed with MS using FLI, HSI and LFS respectively and MetsScore increases with FLI severity (P<0.05). Also, FLI and LFS were positively associated with MetsScore (P<0.01 and P<0.05 respectively) but not HSI. Multivariate linear regression models revealed that FLI has a stronger association with MetsScore compared with HSI and LFS (P<0.001).

CONCLUSIONS

FLI is associated with the severity of MS and represent a good indicator to assess the relation between liver steatosis and a cardiometabolic disorders in clinical routine.

Development and validation of a nomogram for predicting metabolic-associated fatty liver disease in the Chinese physical examination population

AIM

We aim to develop and validate a nomogram including readily available clinical and laboratory indicators to predict the risk of metabolic-associated fatty liver disease (MAFLD) in the Chinese physical examination population.

METHODS

The annual physical examination data of Chinese adults from 2016 to 2020 were retrospectively analyzed. We extracted the clinical data of 138 664 subjects and randomized participants to the development and validation groups (7:3). Significant predictors associated with MAFLD were identified by using univariate and random forest analyses, and a nomogram was constructed to predict the risk of MAFLD based on a Lasso logistic model. Receiver operating characteristic curve analysis, calibration curves, and decision curve analysis were used to verify the discrimination, calibration, and clinical practicability of the nomogram, respectively.

RESULTS

Ten variables were selected to establish the nomogram for predicting MAFLD risk: sex, age, waist circumference (WC), uric acid (UA), body mass index (BMI), waist-to-hip ratio (WHR), systolic blood pressure (SBP), fasting plasma glucose (FPG), triglycerides (TG), and alanine aminotransferase (ALT). The nomogram built on the nonoverfitting multivariable model showed good prediction of discrimination (AUC 0.914, 95% CI: 0.911-0.917), calibration, and clinical utility.

CONCLUSIONS

This nomogram can be used as a quick screening tool to assess MAFLD risk and identify individuals at high risk of MAFLD, thus contributing to the improved management of MAFLD.

Nonalcoholic fatty liver disease and cognitive impairment: A prospective cohort study

BACKGROUND & AIMS

Nonalcoholic fatty liver disease (NAFLD) is prevalent and may affect cognitive function. We studied associations of NAFLD with risk of cognitive impairment. Secondarily we evaluated liver biomarkers (alanine aminotransferase (ALT), aspartate aminotransferase (AST), their ratio, and gamma-glutamyl transpeptidase).

METHODS

In a prospective cohort study, the REasons for Geographic and Racial Differences in Stroke, among 30,239 black and white adults aged ≥45,495 cases of incident cognitive impairment were identified over 3.4 years follow up. Cognitive impairment was identified as new impairment in two of three cognitive tests administered every two years during follow up; word list learning and recall, and verbal fluency. 587 controls were selected from an age, race, sex-stratified sample of the cohort. The fatty liver index was used to define baseline NAFLD. Liver biomarkers were measured using baseline blood samples.

RESULTS

NAFLD at baseline was associated with a 2.01-fold increased risk of incident cognitive impairment in a minimally adjusted model (95% CI 1.42, 2.85). The association was largest in those aged 45-65 (p interaction by age = 0.03), with the risk 2.95-fold increased (95% CI 1.05, 8.34) adjusting for cardiovascular, stroke and metabolic risk factors. Liver biomarkers were not associated with cognitive impairment, except AST/ALT >2, with an adjusted OR 1.86 (95% CI 0.81, 4.25) that did not differ by age.

CONCLUSIONS

A laboratory-based estimate of NAFLD was associated with development of cognitive impairment, particularly in mid-life, with a tripling in risk. Given its high prevalence, NAFLD may be a major reversible determinant of cognitive health.

Combining serum uric acid and fatty liver index to improve prediction quality of nonalcoholic fatty liver disease

Background

The significant association between serum uric acid (SUA) and nonalcoholic fatty liver disease (NAFLD) is well documented. In this report, we tested the hypothesis that SUA might improve the widely studied fatty liver index (FLI) to predict NAFLD.

Methods

A cross-sectional study was performed in a community of Nanjing, China. The population data on sociodemographics, physical examinations, and biochemical tests were collected from July to September 2018. The associations of SUA and FLI with NAFLD were analyzed using linear correlation, multiple linear regressions, binary logistic analyses, and area under receiver-operating characteristic curve (AUROC).

Results

A total of 3,499 people were included in this study, of which 36.9% had NAFLD. The prevalence of NAFLD increased with the increase of SUA levels (all P <.05). Logistic regression analyses revealed that SUA was significantly associated with an increased risk of NAFLD (all P <.001). The NAFLD predictive value after combining SUA with FLI was superior to FLI, especially in females (AUROC_{SUA + FLI} = 0.911 vs. AUROC_FLI = 0.903, P <.05). The reclassification of NAFLD also significantly improved, based on net reclassification improvement (0.053, 95% confidence interval [CI]: 0.022-0.085, P <.001) and integrated discrimination improvement (0.096, 95% CI: 0.090-0.102, P <.001). A regression formula of this combined algorithm was proposed as: The novel formula = 0.032* waist circumference + 0.303* body mass index + 1.301* natural logarithm of triglyceride + 0.478* natural logarithm of glutamyl transpeptidase + 0.002* SUA- 18.823. At the cutoff value of 13.3, the sensitivity and specificity of this model were 89.2% and 78.4%, respectively.

Conclusions

SUA level was positively associated with NAFLD prevalence. A new formula combining SUA with FLI may serve as a better indicator to predict NAFLD compared to FLI, especially in females.

Development and validation of a new nomogram to screen for MAFLD

BACKGROUND AND AIM

Metabolic dysfunction-associated fatty liver disease (MAFLD) poses significant health and economic burdens on all nations. Thus, identifying patients at risk early and managing them appropriately is essential. This study's goal was to develop a new predictive model for MAFLD. Additionally, to improve the new model's clinical utility, researchers limited the variables to readily available simple clinical and laboratory measures.

METHODS

Based on the National Health and Nutrition Examination Survey (NHANES) cycle 2017-2020.3, the study was a retrospective cross-sectional study involving 7300 participants. By least absolute shrinkage and selection operator (LASSO) regression, significant indicators independently associated with MAFLD were identified, and a predictive model called the MAFLD prediction nomogram (MPN) was developed. The study then compared the MPN with six existing predictive models for MAFLD. The model was evaluated by measuring the area under receiver operating characteristic curve (AUC), net reclassification index (NRI), integrated discrimination improvement (IDI), calibration curve, and decision curve analysis (DCA) curve.

RESULTS

In this study, researchers identified nine predictors from 33 variables, including age, race, arm circumference (AC), waist circumference (WC), body mass index (BMI), alanine aminotransferase (ALT)-to-aspartate aminotransferase (AST) ratio, triglyceride-glucose index (TyG), hypertension, and diabetes. The diagnostic accuracy of the MPN for MAFLD was significantly better than that of the other six existing models in both the training and validation cohorts (AUC 0.868, 95% confidence interval (CI) 0.858-0.877, and AUC 0.863, 95% CI 0.848-0.878, respectively). The MPN showed a higher net benefit than the other existing models.

CONCLUSIONS

This nonimaging-assisted nomogram based on demographics, laboratory factors, anthropometrics, and comorbidities better predicted MAFLD than the other six existing predictive models. Using this model, the general population with MAFLD can be assessed rapidly.

Non-Alcoholic Fatty Liver Disease Defined by Fatty Liver Index and Incidence of Heart Failure in the Korean Population: A Nationwide Cohort Study

Fatty liver index (FLI) is a simple and useful index that evaluates non-alcoholic fatty liver disease (NAFLD), particularly in large epidemiologic studies. Heart failure (HF) is becoming a burden to public health as the global trend toward an aging society continues. Thus, we investigated the effect of FLI on the incidence of HF using large cohort data from the Korean National Health Insurance health database. Methods and Results: A total of 7,958,538 subjects aged over 19 years without baseline HF (men = 4,142,264 and women = 3,816,274) were included. Anthropometric and biochemical measurements were evaluated. FLI scores were calculated and FLI ≥ 60 was considered as having NAFLD. Hazard ratios (HRs) and 95% confidence intervals (CIs) for HF incidence were analysed using multivariable time-dependent Cox proportional hazard models. During a mean follow up of 8.26 years, 17,104 participants developed HF. The FLI components associated with the incidence of HF and FLI showed a causal relationship with HF; the FLI ≥ 60 group had a higher HR for HF (HR 1.493; 95% CIs 1.41−1.581) than the FLI < 30 group. Subgroup analysis showed that fatty liver (FLI ≥ 60) with age ≥ 65 years or women displayed higher HR for HF than fatty liver with age < 65 or men, respectively. An increase in FLI score significantly increased the HR for HF except for those with a FLI score change from <30 to 30−60. Conclusion: NAFLD defined by FLI and increase in FLI score were associated with the incidence of HF. Further detailed prospective studies are needed.

A problem of proportions: estimates of metabolic associated fatty liver disease and liver fibrosis in Australian adults in the nationwide 2012 AusDiab Study

Metabolic Associated Fatty Liver Disease (MAFLD) is the most common cause of liver disease in Australia, but prevalence data are limited. We aimed to describe the frequency of alanine aminotransferase (ALT) elevation, and MAFLD within a large prospective Australian cohort. Cross-sectional analysis of the 2012 survey of the Australian Diabetes, Obesity and Lifestyle (AusDiab) study which included 4747 Australian adults (aged 34–97 yrs) was performed. Frequency of ALT elevation (men ≥ 40 IU/L, women ≥ 30 IU/L) and MAFLD (Fatty Liver Index (FLI) > 60 alongside metabolic risk factors) was determined and risk of advanced fibrosis stratified using the BARD score. Elevated ALT was found in 13% of the cohort, including 22% of people with diabetes, 18% with obesity, and 17% with the metabolic syndrome. 37% of the cohort had MAFLD, and those with MAFLD were more likely to be older (OR 1.01 per 1 year (95% CI 1.00–1.02)), male (OR 1.37 (95% CI 1.17–1.59)), have ALT elevation (OR 3.21 (95% CI 2.59–3.99)), diabetes (OR 3.39 (95% CI 2.61–4.39)), lower HDL-C (OR 0.15 per 1 mmol/L (95% CI 0.12–0.19)), higher diastolic blood pressure (OR 1.05 per 10 mmHg (95% CI 1.05–1.06)), a sedentary lifestyle (OR 1.99 (95% CI 1.59–2.50)) and less likely to have tertiary education (OR 0.81 (95% CI 0.7–0.94) compared to those without MAFLD. Of those with MAFLD, 61% had a BARD score suggesting risk of advanced fibrosis and 22% had an elevated ALT. Over 10% of this Australian cohort had elevated ALT, and 37% had MAFLD, with many at risk for advanced fibrosis.

Comparison and development of advanced machine learning tools to predict nonalcoholic fatty liver disease: An extended study

BACKGROUND

Nonalcoholic fatty liver disease (NAFLD) is a public health challenge and significant cause of morbidity and mortality worldwide. Early identification is crucial for disease intervention. We recently proposed a nomogram-based NAFLD prediction model from a large population cohort. We aimed to explore machine learning tools in predicting NAFLD.

METHODS

A retrospective cross-sectional study was performed on 15 315 Chinese subjects (10 373 training and 4942 testing sets). Selected clinical and biochemical factors were evaluated by different types of machine learning algorithms to develop and validate seven predictive models. Nine evaluation indicators including area under the receiver operating characteristic curve (AUROC), area under the precision-recall curve (AUPRC), accuracy, positive predictive value, sensitivity, F1 score, Matthews correlation coefficient (MCC), specificity and negative prognostic value were applied to compare the performance among the models. The selected clinical and biochemical factors were ranked according to the importance in prediction ability.

RESULTS

Totally 4018/10 373 (38.74%) and 1860/4942 (37.64%) subjects had ultrasound-proven NAFLD in the training and testing sets, respectively. Seven machine learning based models were developed and demonstrated good performance in predicting NAFLD. Among these models, the XGBoost model revealed the highest AUROC (0.873), AUPRC (0.810), accuracy (0.795), positive predictive value (0.806), F1 score (0.695), MCC (0.557), specificity (0.909), demonstrating the best prediction ability among the built models. Body mass index was the most valuable indicator to predict NAFLD according to the feature ranking scores.

CONCLUSIONS

The XGBoost model has the best overall prediction ability for diagnosing NAFLD. The novel machine learning tools provide considerable beneficial potential in NAFLD screening.

Validation of fatty liver disease scoring systems for ultrasound diagnosed non-alcoholic fatty liver disease in adolescents

BACKGROUND AND AIMS

The incidence of non-alcoholic fatty liver disease (NAFLD) is increasing in young populations. However, there are inadequate data regarding diagnosis of NAFLD. We aimed to validate three scoring systems against a previous standard of suprailiac skinfold thickness for diagnosing NAFLD in population-based adolescents.

METHODS

Seventeen-year-old adolescents (n = 899), participating in the Raine Study, attended a cross-sectional follow-up. NAFLD was diagnosed using liver ultrasound. Scores for Fatty liver index (FLI), Hepatic Steatosis Index (HSI) and Zhejiang University index (ZJU index) were calculated. Diagnostic accuracy of these diagnostic tests was evaluated through discrimination and calibration.

RESULTS

NAFLD was diagnosed 9% in males and 15% in females. The three scoring systems demonstrated better discrimination performance for NAFLD in males (AUC was FLI:0.82, HSI: 0.83 and ZJU index: 0.83) compared to females (AUC was FLI: 0.67, HSI: 0.67 and ZJU index: 0.67). Suprailiac skinfold performed better than the scoring systems (overall AUC: 0.82; male AUC:0.88; female AUC:0.73). FLI had best calibration performance.

CONCLUSION

Suprailiac skinfold thickness was a better predictor of ultrasound-diagnosed NAFLD than the three diagnostic scoring systems investigated. The higher performance characteristics of the algorithmic scoring systems in males compared with females may have implications for use in population assessments.

Prevalence of non-alcoholic fatty liver disease in regional Victoria: a prospective population-based study

OBJECTIVES

To investigate the prevalence of non-alcoholic fatty liver disease (NAFLD) and its risk factors in regional Victoria.

DESIGN

Prospective cross-sectional observational study (sub-study to CrossRoads II health study in Shepparton and Mooroopna).

SETTING

Four towns (populations, 6300-49 800) in the Goulburn Valley of Victoria.

PARTICIPANTS

Randomly selected from households selected from residential address lists provided by local government organisations for participation in the CrossRoads II study.

MAIN OUTCOME MEASURES

Age- and sex-adjusted estimates of NAFLD prevalence, defined by a fatty liver index score of 60 or more in people without excessive alcohol intake or viral hepatitis.

RESULTS

A total of 705 invited adults completed all required clinical, laboratory and questionnaire evaluations of alcohol use (participation rate, 37%); 392 were women (56%), and their mean age was 59.1 years (SD, 16.1 years). Of the 705 participants, 274 met the fatty liver index criterion for NAFLD (crude prevalence, 38.9%; age- and sex-standardised prevalence, 35.7%). The mean age of participants with NAFLD (61 years; SD, 15 years) was higher than for those without NAFLD (58 years; SD, 16 years); a larger proportion of people with NAFLD were men (50% v 41%). Metabolic risk factors more frequent among participants with NAFLD included obesity (69% v 15%), hypertension (66% v 48%), diabetes (19% v 8%), and dyslipidaemia (63% v 33%). Mean serum alanine aminotransferase levels were higher (29 U/L; SD, 17 U/L v 24 U/L; SD, 14 U/L) and mean median liver stiffness greater (6.5 kPa; SD, 5.6 kPa v 5.3kPa; SD, 2.0 kPa) in participants with NAFLD.

CONCLUSION

The prevalence of NAFLD among adults in regional Victoria is high. Metabolic risk factors are more common among people with NAFLD, as are elevated markers of liver injury.

Diagnostic Accuracy of Non-Imaging and Ultrasound-Based Assessment of Hepatic Steatosis Using Controlled Attenuation Parameter (CAP) as Reference

Background & Aims: In view of the limited reliability of biopsies in the assessment of liver fat, a non-invasive, trustworthy, and more accessible method estimating a degree of steatosis is urgently needed. While the controlled attenuation parameter (CAP) is used to quantify hepatic fat, its availability in routine practice is limited. Therefore, the aim of this study was to compare the diagnostic accuracy of biomarker- and ultrasound-based techniques for the diagnosis and grading of hepatic steatosis. Methods: This was a prospective study of 167 adults with and without non-alcoholic fatty liver disease. As measured against CAP, we assessed Hamaguchi’s score and the hepatorenal index (HRI), and the following biochemical measures: the fatty liver index, hepatic steatosis index, and lipid accumulation product scores during a single out-patient visit. Area under the receiver operating curve (AUROC) analyses were used to evaluate the diagnostic accuracy of each test and to calculate optimal thresholds for the ultrasound techniques. Results: All non-invasive methods displayed high accuracy in detecting steatosis (mean AUC value ≥ 0.90), with Hamaguchi’s score and the HRI being the most precise. These two tests also had the highest sensitivity and specificity (82.2% and 100%; 86.9% and 94.8%, respectively). We propose new thresholds for Hamaguchi’s score and HRI for hepatic steatosis grading, indicated by optimal sensitivity and specificity. Conclusions: Ultrasound-based techniques are the most accurate for assessing liver steatosis compared to other non-invasive tests. Given the accessibility of ultrasonography, this finding is of practical importance for the assessment of liver steatosis in clinical settings.

Fatty liver index and left ventricular mass: prospective associations from two independent cohorts

OBJECTIVES

Heart disease is the most common cause of death in patients with nonalcoholic fatty liver disease (NAFLD). Emerging data have shown that NAFLD may affect subclinical myocardial remodeling, mainly left ventricular hypertrophy; however, evidence from the prospective studies is still lacking.

METHODS

Prospective analyses were performed to investigate the association of fatty liver index (FLI) with left ventricular mass (LVM) among 1962 participants from the Bogalusa Heart Study (BHS, 1995-2010) and 1547 participants from the Cardiovascular Risk in Young Finns Study (YFS, 2001-2011) free of cardiovascular diseases (CVD) at baseline. LVM was assessed by two-dimensional guided M-mode echocardiography and indexed (LVMI) to body height (m2.7). Multivariable regression models were applied after adjustment for traditional CVD risk factors.

RESULTS

In both cohorts, we observed significant and positive associations between FLI and LVM (BHS: β=0.59, P < 0.001; YFS: β=0.41, P < 0.001) and LVMI (BHS: β=0.14, P < 0.001; YFS: β=0.09, P < 0.001). In addition, we found that the relationship between FLI and LVMI was stronger in women than men (BHS: P-interaction = 0.01; YFS: P-interaction < 0.01); and the relationship between FLI and LVM/LVMI was stronger in black than white individuals (LVM: P-interaction = 0.02; LVMI: P-interaction = 0.04). Moreover, we found that the associations of FLI with LVM and LVMI were attenuated by high physical activity, especially in BHS (P-interaction = 0.02).

CONCLUSION

Our findings from two independent prospective cohorts indicate that FLI is positively associated with LVM/LVMI, independent of traditional cardiovascular risk factors. Such relationships are more pronounced among women and black individuals and are attenuated by high physical activity.

Effect of silibinin capsules combined with lifestyle modification on hepatic steatosis in patients with chronic hepatitis B

The coexistence of HBV infection and hepatic steatosis is a novel characteristic of liver disease. Silibinin capsules (SC) is a silybin-phospholipid complex containing silybin as the bioactive component, which exerts a remarkable biological effect on various liver diseases, including nonalcoholic fatty liver disease (NAFLD). The purpose of this study was to investigate (1) the prevalence of hepatic steatosis in the general population and patients with chronic hepatitis B (CHB) and (2) to evaluate the effect of SC combined with therapeutic lifestyle changes (TLC) compared with TLC alone on hepatic steatosis in patients with CHB. A total of 16,451 individuals underwent transient elastography (TE) with the control attenuation parameter (CAP) measurement, among which the prevalence of hepatic steatosis was 31.1% in patients with CHB and 42.2% in the general population. The prevalence of hepatic steatosis differed between patients with CHB and the general population at an age of 40 years or older but was similar in individuals aged 39 years or younger (p < 0.05). Furthermore, in patients with CHB presenting hepatic steatosis, the post-6-month relative reduction in CAP in the SC combined with TLC group (p = 0.001) was significantly greater than in the TLC alone group (p = 0.183). The CAP distribution of different steatosis grades (S1, S2, and S3) in the SC combined with TLC group was decreased and S0 (CAP < 248 dB/m) increased significantly, but not significant in the TLC group. Thus, SC combined with TLC may effectively improve hepatic steatosis in patients with CHB.

Links between gut microbiome composition and fatty liver disease in a large population sample

Fatty liver disease is the most common liver disease in the world. Its connection with the gut microbiome has been known for at least 80 y, but this association remains mostly unstudied in the general population because of underdiagnosis and small sample sizes. To address this knowledge gap, we studied the link between the Fatty Liver Index (FLI), a well-established proxy for fatty liver disease, and gut microbiome composition in a representative, ethnically homogeneous population sample of 6,269 Finnish participants. We based our models on biometric covariates and gut microbiome compositions from shallow metagenome sequencing. Our classification models could discriminate between individuals with a high FLI (≥60, indicates likely liver steatosis) and low FLI (<60) in internal cross-region validation, consisting of 30% of the data not used in model training, with an average AUC of 0.75 and AUPRC of 0.56 (baseline at 0.30). In addition to age and sex, our models included differences in 11 microbial groups from class Clostridia, mostly belonging to orders Lachnospirales and Oscillospirales. Our models were also predictive of the high FLI group in a different Finnish cohort, consisting of 258 participants, with an average AUC of 0.77 and AUPRC of 0.51 (baseline at 0.21). Pathway analysis of representative genomes of the positively FLI-associated taxa in (NCBI) Clostridium subclusters IV and XIVa indicated the presence of, e.g., ethanol fermentation pathways. These results support several findings from smaller case-control studies, such as the role of endogenous ethanol producers in the development of the fatty liver.

Correlation of the grade of hepatic steatosis between controlled attenuation parameter and ultrasound in patients with fatty liver: a multi-center retrospective cohort study

BACKGROUND/AIMS

The controlled attenuation parameter (CAP), based on transient elastography, is widely used for noninvasive assessment of the degree of hepatic steatosis (HS). We investigated the correlation of the degree HS between CAP and ultrasound (US) in patients with HS.

METHODS

In total, 986 patients with US-based HS who underwent transient elastography within 1 month were evaluated. The US-based grade of HS was categorized as mild (grade 1), moderate (grade 2), or severe (grade 3).

RESULTS

The CAP was significantly correlated with the US-based grade of HS (r = 0.458, p < 0.001). The median CAP value of each US-based HS grade showed a positive correlation with grade (271.1, 303.7, and 326.7 dB/m for grades 1, 2, and 3). In a multivariate analysis, the US-based HS grade, body mass index, serum albumin, alanine aminotransferase, and total cholesterol, and liver stiffness were all significantly correlated with the CAP value (all p < 0.05). The areas under the receiver operating characteristic curves for grade 2 to 3 and grade 3 HS were 0.749 (95% confidence interval [CI], 0.714 to 0.784) and 0.738 (95% CI, 0.704 to 0.772). The optimal cut-off CAP values to maximize the sum of the sensitivity and specificity for grade 2 to 3 and grade 3 HS were 284.5 dB/m (sensitivity 78.6%, specificity 61.7%) and 298.5 dB/m (sensitivity 84.6%, specificity 55.6%).

CONCLUSION

The correlation of the degree of HS between CAP and US was significantly high in patients with HS, and the optimal cut-off CAP values for grade 2 to 3 and grade 3 HS were 284.5 and 298.5 dB/m.

Association between liver fibrosis and appendicular skeletal muscle mass during antiviral therapy in chronic hepatitis B

BACKGROUND AND AIMS

Sarcopenia is associated with fibrotic burden in patients with chronic hepatitis B. We investigated the dynamic association between fibrosis changes and appendicular skeletal muscle mass during antiviral therapy in patients with chronic hepatitis B.

METHODS

Between 2015 and 2018, chronic hepatitis B patients who received paired transient elastography to assess fibrotic burden in the liver and bioelectrical impedance analysis to assess appendicular skeletal muscle mass were recruited retrospectively. The sarcopenia index was calculated as total appendicular skeletal muscle mass/body mass index. Significant liver fibrosis was defined as a liver stiffness value≥8 kPa.

RESULTS

In total, 223 (53.7%) received antiviral therapy, whereas 192 (46.3%) did not. Appendicular skeletal muscle mass decreased significantly in the antiviral therapy group (mean 21.16→21.00 kg, P = 0.01), but not in the non-antiviral therapy group (mean 20.77→20.64 kg, P = 0.134). In a subgroup with significant liver fibrosis, similar findings were observed (mean 20.73→20.54 kg in antiviral therapy group, P = 0.037; mean 21.39→21.07 kg in the non-antiviral therapy group, P = 0.097). Older age, male gender, higher body mass index, and higher aspartate aminotransferase were significantly associated with the increased risk of appendicular skeletal muscle mass reduction (≥5% from the baseline).

CONCLUSIONS

Appendicular skeletal muscle mass significantly decreased during antiviral therapy in patients with chronic hepatitis B patients.

Development and validation of a clinical and laboratory-based nomogram to predict nonalcoholic fatty liver disease

BACKGROUND AND AIM

Nonalcoholic fatty liver disease (NAFLD) is becoming the leading cause of chronic liver disease in China. The early identification and management of patients at risk are essential. We aimed to develop a novel clinical and laboratory-based nomogram (CLN) model to predict NAFLD with high accuracy.

METHODS

We designed a retrospective cross-sectional study and enrolled 21,468 participants (16,468 testing and 5000 validation). Clinical information and laboratory/imaging results were retrieved. Significant variables independently associated with NAFLD were identified by a logistic regression model, and a NAFLD prediction CLN was constructed. The CLN was then compared with four existing NAFLD-related prediction models: the fatty liver index (FLI), the hepatic steatosis index (HSI), the visceral adiposity index (VAI) and the triglycerides and glucose (TyG) index. Area under the receiver operator characteristic curve (AUROC) and decision curve analysis (DCA) were performed.

RESULTS

A total of 6261/16,468 (38.02%) and 1759/5000 (35.18%) participants in the testing and validation datasets, respectively, had ultrasound-proven NAFLD. Six variables were selected to build the CLN: body mass index (BMI), diastolic blood pressure (DBP), uric acid (UA), fasting blood glucose (FBG), triglyceride (TG), and alanine aminotransferase (ALT). The diagnostic accuracy of the CLN for NAFLD (AUROC 0.857, 95% CI 0.852-0.863) was significantly superior to that of the FLI (AUROC 0.849, 95% CI 0.843-0.855), the VAI (AUROC 0.752, 95% CI 0.745-0.760), the HSI (AUROC 0.828, 95% CI 0.822-0.834), and the TyG index (AUROC 0.774, 95% CI 0.767-0.781) (all p < 0.001). DCA confirmed the clinical utility of the CLN.

CONCLUSIONS

This physical examination and laboratory test-based, nonimage-assisted novel nomogram has better performance in predicting NAFLD than the FLI, the VAI, the HSI and the TyG index alone. This model can be used as a quick screening tool to assess NAFLD in the general population.

PNPLA3 I148M gene variant and chronic kidney disease in type 2 diabetic patients with NAFLD: Clinical and experimental findings

BACKGROUND AND AIMS

Emerging evidence suggests an association between patatin-like phospholipase domain-containing protein-3 (PNPLA3) rs738409 (I148M protein variant) and risk of chronic kidney disease (CKD), but the mechanisms underpinning this association are poorly understood.

METHODS

We studied 157 patients with type 2 diabetes (T2DM) who underwent ultrasonography and vibration-controlled transient elastography for diagnosing nonalcoholic fatty liver disease (NAFLD). CKD was defined as estimated glomerular filtration rate (e-GFR) <60 mL/min/1.73 m² and/or abnormal albuminuria. We surveyed PNPLA3 mRNA expression in human tissues, using the liver as a positive control, and also measured PNPLA3 mRNA and protein expression levels in human cell lines represented in the kidney and the liver.

RESULTS

In all, 112 patients had NAFLD and 43 had CKD. Patients homozygous for the I148M variant (n = 11) had lower e-GFR levels (60.6 ± 11.7 vs 77.8 ± 15.9 vs 83.5 ± 16.5 mL/min/1.73 m² , P = .0001) and higher prevalence of CKD (63.6% vs 24.2% vs 25.0%, P = .028), compared to those with I/M (n = 66) and I/I (n = 80) PNPLA3 genotype. The association of I148M homozygosity with lower e-GFR levels (P < .0001) and higher risk of CKD (adjusted-odds ratio 6.65; 95% CI 1.65-26.8, P = .008) was independent of liver disease severity (as detected by liver stiffness ≥7kPa) and other risk factors. PNPLA3 mRNA expression was greatest in liver and renal cortex, and podocytes showed high PNPLA3 mRNA and protein levels, comparable to that of hepatocytes and hepatic stellate cells respectively.

CONCLUSIONS

The PNPLA3 I148M variant was associated with CKD, independently of common renal risk factors and severity of NAFLD PNPLA3 expression levels were particularly high in renal podocytes.

Sarcopenia assessed using bioimpedance analysis is associated independently with significant liver fibrosis in patients with chronic liver diseases

AIM

Sarcopenia is common in patients with advanced fibrosis or cirrhosis. We investigated the correlation between sarcopenia and other clinical variables, in particular, significant liver fibrosis in patients with chronic liver diseases (CLDs).

PATIENTS AND METHODS

Patients with CLDs who underwent transient elastography (TE) and bioelectrical impedance analysis between 2015 and 2017 were retrospectively recruited. The sarcopenia index (SI) was calculated as follows: SI = total appendicular skeletal muscle mass (kg)/ body mass index (BMI) (kg/m). Sarcopenia was defined as SI less than 0.789 for men and less than 0.521 for women. Significant liver fibrosis and fatty liver were defined using TE liver stiffness value more than 7 kPa and controlled attenuation parameter more than 250 dB/m, respectively.

RESULTS

Of 2168 patients recruited, 218 (10.1%) had sarcopenia. Age, BMI, diabetes, hypertension, fasting glucose, aspartate aminotransferase, and liver stiffness value were correlated positively with sarcopenia (all P < 0.05), whereas male sex, viral etiology, obesity (BMI > 25 kg/m), total bilirubin, and serum albumin were correlated negatively with sarcopenia (all P < 0.05). On multivariate analysis, TE-defined significant liver fibrosis was associated independently with sarcopenia (odds ratio = 1.597; 95% confidence interval: 1.174-2.172; P = 0.003), together with age, male sex, viral etiology, and TE-defined fatty liver (all P < 0.05). Among the subgroups with ultrasonography-defined nonalcoholic fatty liver disease (n = 957), sarcopenia was also associated independently with TE-defined significant liver fibrosis (odds ratio = 1.887; 95% confidence interval: 1.261-2.823; P < 0.001).

CONCLUSION

Sarcopenia is associated independently with significant liver fibrosis in patients with CLDs. Further studies are required to determine whether interventions to improve muscle mass can improve liver fibrosis.

A newly noninvasive model for prediction of non-alcoholic fatty liver disease: utility of serum prolactin levels

BACKGROUNDS

To investigate the value of prolactin (PRL) in diagnosing non-alcoholic fatty liver disease (NAFLD).

METHODS

Metabolic parameters and serum PRL levels were measured in 452 males and 421 females, who were randomized to the estimation or the validation group as a 1:1 ratio. Hepatic steatosis was diagnosed via abdominal ultrasound. Variables that significantly associated with NAFLD in univariate analysis were included in multiple logistic regression. We used the receiver operator characteristic (ROC) curves to test the model performance. Besides, 147 patients underwent metabolic and liver biopsy were analyzed to validate the diagnostic value of this model.

RESULTS

Body mass index, alanine aminotransferase, prolactin, high density lipoprotein cholesterol and HbA1c were included into models. In males, the area under ROC curve (AUC) was 0.86 (95%CI: 0.82-0.91) for the validation group. With two cut-off points (- 0.79 and 1.71), the sensitivity and specificity for predicting NALFD was 95.2 and 91.1% in the validation group, respectively. In females, the AUC was 0.82 (95%CI: 0.76-0.88) for the validation group. With two cut-off points (- 0.68 and 2.16), the sensitivity and specificity for predicting NALFD was 97.1 and 91.4% in the validation group, respectively. In subjects with liver pathology, the AUC was higher than that of fatty liver index. A positive correlation between the scores of the model and the severities of NAFLD was observed. Importantly, we demonstrated a potential value of this model in predicting nonalcoholic steatohepatitis.

CONCLUSION

We established a mathematic model that can conveniently and effectively diagnose the existence and severities of NAFLD.

Liver Fat Content and Body Fat Distribution in Youths with Excess Adiposity

This study had two main objectives: To examine the association between body fat distribution and non-alcoholic fatty liver disease (NAFLD) and liver fat content, and to determine whether the relationship between NAFLD and regional body fat distribution, with respect to liver fat content in youths with excess adiposity, is independent of cardiorespiratory fitness (CRF) and a healthy diet. Liver fat content (controlled attenuation parameter (CAP)), body fat distribution (body mass index (BMI) z-score, waist circumference, waist-to-height ratio, fat mass/height, body fat percentage, total fat mass, android-to-gynoid fat mass ratio, visceral adipose tissue (VAT), and lean mass index, determined by dual-energy X-ray absorptiometry (DXA)), CRF (20-m shuttle-run test), and healthy diet (adherence to the Mediterranean diet by KIDMED questionnaire) were measured in 126 adolescents (66% girls) aged between 11 and 17 years. Participants were assigned to two groups according to the presence or absence of hepatic steatosis (CAP values ≥225 dB/m or <225 dB/m of liver fat, respectively). Considering the similar total fat values for the two groups (>30% by DXA), youths with NAFLD had higher fat distribution parameters than those without NAFLD, regardless of sex, age, puberty stage, lean mass index, CRF, and healthy diet (p < 0.01). In the non-NAFLD group, the association between hepatic fat and fat distribution parameters presented a similar pattern, although the association was statistically insignificant after adjusting for a potential confounding variable (ps > 0.05), except for the case of VAT. Body fat distribution parameters were higher in youths with NAFLD compared to those without NAFLD. Additionally, body fat distribution showed a significant association with liver fat content as assessed by CAP in youths with NAFLD independent of CRF and adherence to the Mediterranean diet, supporting the notion that upper body fat distribution might play a pivotal role in the development of NAFLD in adolescents. These results may have implications for the clinical management of youths with excess adiposity given the high prevalence of NAFLD in children and young adults.

Liver Ultrasound Elastography: An Update to the World Federation for Ultrasound in Medicine and Biology Guidelines and Recommendations

The World Federation for Ultrasound in Medicine and Biology has produced these guidelines for the use of elastography techniques in liver diseases. For each available technique, the reproducibility, results and limitations are analyzed, and recommendations are given. This set of guidelines updates the first version, published in 2015. Since the prior guidelines, there have been several advances in technology. The recommendations are based on the international published literature, and the strength of each recommendation is judged according to the Oxford Centre for Evidence-Based Medicine. The document has a clinical perspective and is aimed at assessing the usefulness of elastography in the management of liver diseases.

Quantitative Hepatic Fat Quantification in Non-alcoholic Fatty Liver Disease Using Ultrasound-Based Techniques: A Review of Literature and Their Diagnostic Performance

Non-alcoholic fatty liver disease is a condition that is characterized by the presence of >5% fat in the liver and affects more than one billion people worldwide. If adequate and early precautions are not taken, non-alcoholic fatty liver disease can progress to cirrhosis and death. The current reference standard for detecting hepatic steatosis is a liver biopsy. However, because of the potential morbidity associated with liver biopsies, non-invasive imaging biomarkers have been extensively investigated. Magnetic resonance imaging-based methods have proven accuracy in quantifying liver steatosis; however, these techniques are costly and have limited availability. Ultrasound-based quantitative imaging techniques are increasingly utilized because of their widespread availability, ease of use and relative cost-effectiveness. Several ultrasound-based liver fat quantification techniques have been investigated, including techniques that measure changes in the acoustic properties of the liver caused by the presence of fat. In this review, we focus on quantitative ultrasound approaches and their diagnostic performance in the realm of non-alcoholic fatty liver disease.

Liver fat scores predict liver disease mortality in the United States population

BACKGROUND

Fatty liver is a significant global public health burden, contributing to premature death.

AIM

To examine whether liver fat scores were associated with increased overall and disease-specific mortality in a United States (US) population-based survey with up to 27 years of linked mortality data.

METHODS

We studied 9200 fasted viral hepatitis-negative adults in the third National Health and Nutrition Examination Survey, 1988-1994. Liver fat was predicted using the US fatty liver index (US FLI), fatty liver index (FLI), non-alcoholic fatty liver disease liver fat score (NAFLD LFS), and hepatic steatosis index (HSI). Participants were passively followed up for mortality, identified by death certificate underlying or contributing causes, by linkage to National Death Index records through 2015. Mortality hazard ratios (HR) were calculated using Cox proportional hazards regression to adjust for mortality risk factors.

RESULTS

During follow-up (median, 23.3 years), cumulative mortality was 31.4% overall and 1.1% with liver disease, including primary liver cancer. Elevated liver disease mortality was associated with a high US FLI (HR, 5.7; 95% confidence interval (CI), 1.3-24.5), and intermediate (HR, 3.1; 95% CI, 1.1-9.1) or high (HR, 11.4; 95% CI, 2.9-44.4) NAFLD LFS, but not with a higher FLI or HSI. Overall and cardiovascular disease mortality was unassociated with higher liver fat scores.

CONCLUSIONS

In the US population, a higher US FLI and NAFLD LFS were associated with increased liver disease mortality, but not with other mortality outcomes. Liver fat scores may be useful for metabolic health surveillance and long-term liver disease risk stratification and may complement fibrosis markers for tracking.

Non-alcoholic fatty liver disease: Relationship with cardiovascular risk markers and clinical endpoints

Non-alcoholic fatty liver disease (NAFLD) is a common diagnosis and is increasing in prevalence worldwide. NAFLD is usually asymptomatic at presentation; progression of the disease is unpredictable, leading to the development of a variety of techniques for screening, diagnosis and risk stratification. Clinical methods in current use include serum biomarker panels, hepatic ultrasound, magnetic resonance imaging, and liver biopsy. NAFLD is strongly associated with the metabolic syndrome, and the most common cause of death for people with the condition is cardiovascular disease. Whether NAFLD is an independent cardiovascular risk factor needs exploration. NAFLD has been associated with surrogate markers of cardiovascular disease such as carotid intima-media thickness, the presence of carotid plaque, brachial artery vasodilatory responsiveness and CT coronary artery calcification score. There is no effective medical treatment for NAFLD and evidence is lacking regarding the efficacy of interventions in mitigating cardiovascular risk. Health care professionals managing patients with NAFLD should tackle the issue with early identification of risk factors and aggressive modification. Current management strategies therefore comprise lifestyle change, with close attention to known cardiovascular risk factors.

Relationship between Serum Cytokeratin-18, Control Attenuation Parameter, NAFLD Fibrosis Score, and Liver Steatosis in Nonalcoholic Fatty Liver Disease

BACKGROUNDS

The aim of this study was to appraise the relationship between serum fragmented cytokeratin-18(CK-18), controlled attenuation parameter (CAP), and liver steatosis assessed by ultrasound (US) in nonalcoholic fatty liver disease (NAFLD) patients.

METHODS

Patients who underwent abdominal US were recruited, followed with measurement of CAP using Fibroscan^® and serum fragmented CK-18 using enzyme-linked immunosorbent assay. The degree of liver steatosis assessed by US was categorized into mild (S1), moderate (S2), and severe (S3).

RESULTS

A total of 109 patients were included in our study. CAP and fragmented CK-18 level were significantly correlated with liver steatosis grade with r_s = 0.56 and 0.68, p=0.001, respectively. NAFLD Fibrosis Score was poorly correlated with liver steatosis grade (r_s=-0.096, p=0.318). Using fragmented CK-18 level, area under receiver operating characteristic (AUROC) curves for S≥2 and S≥3 were excellent (0.82 and 0.84, respectively). Using CAP, AUROC curves for detection of S≥2 and S≥3 were good (0.76, 0.77, respectively). We also proposed cut-off value of CAP to detect S≥2 and S≥3 to be 263 and 319db/m, respectively, and fragmented CK-18 level to detect S≥2 and S≥3 (194 and 294 U/L, respectively).

CONCLUSIONS

Both the fragmented CK-18 level and the CAP, but not NAFLD Fibrosis Score, were well correlated with hepatic steatosis grade as assessed by US.

Prevalence of hepatic steatosis as assessed by controlled attenuation parameter (CAP) in subjects with metabolic risk factors in primary care. A population-based study

Background

Primary care is the ideal setting for early identification of patients with non-alcoholic fatty liver disease (NAFLD). NAFLD is a potentially progressive disease that may lead to cirrhosis and liver cancer but is frequently underrecognized because subjects at risk are often not evaluated. Controlled attenuation parameter (CAP) is a reliable method for non-invasive quantification of liver fat. It has the advantage of simultaneous measurement of liver stiffness (LS), an estimate of liver fibrosis. There is no information on CAP in subjects with risk factors from primary care.

Aim

To investigate the prevalence of hepatic steatosis, as estimated by CAP, in subjects from the community with metabolic risk factors and correlate findings with clinical and biochemical characteristics and LS.

Patients and methods

Population-based study of 215 subjects with metabolic risk factors without known liver disease identified randomly from a primary care center. A control group of 80 subjects matched by age and sex without metabolic risk factors was also studied. CAP and LS were assessed using Fibroscan.

Results

Subjects with risk factors had CAP values higher than those of control group (268±64 vs 243±49dB/m,p<0.001). Prevalence of severe steatosis (CAP> 280dB/m) in subjects with risk factors was 43%. In multivariate analysis, fatty liver index (FLI) and HOMA were independent predictive factors of severe steatosis. There was a direct correlation between CAP and FLI values (r = 0.52,p<0.001). Interestingly, prevalence of increased LS was 12.6% in the risk group vs 0% in the control group (p<0.001). Increased LS occurred predominantly in subjects with high CAP values.

Conclusions

A high proportion of subjects with metabolic risk factors seen in primary care have severe steatosis. FLI could be used as a surrogate of CAP. Increased LS was found in a significant proportion of subjects with risk factors but not in control subjects.

Clinical implications of controlled attenuation parameter in a health check-up cohort

BACKGROUND & AIMS

Evaluation of the controlled attenuation parameter (CAP) is a promising noninvasive method for assessing hepatic steatosis. Despite the increasing reliability of the CAP for assessing steatosis in subjects with chronic liver disease, few studies have evaluated the CAP in asymptomatic subjects without overt liver disease. Therefore, we aimed to evaluate the usefulness of the CAP for a health check-up population.

METHODS

We enrolled subjects who underwent abdominal ultrasonography (US), FibroScan (Echosens, France) and blood sampling during medical health check-ups. The CAP was measured using FibroScan, and increased CAP was defined as CAP ≥ 222 dB/m.

RESULTS

A total of 1133 subjects were included; 589 subjects (52.0%) had fatty liver based on US, and 604 subjects (53.3%) had increased CAP. Increased CAP was significantly associated with metabolic abnormalities, including higher body mass index (BMI)[odds ratio (OR) = 1.33;95% confidence interval (CI),1.24-1.43; P < .001], higher alanine aminotransferase (ALT) (OR = 1.02; 95% CI, 1.01-1.04; P = .003), higher insulin (OR = 1.04; 95% CI, 1.00-1.08; P = .037), higher triglyceride (OR = 1.00; 95% CI, 1.00-1.01; P = 0.042) and older age (OR = 1.02; 95% CI, 1.00-1.03; P = .05). Furthermore, a comparison of clinical parameters among three groups (normal vs no fatty liver by US but increased CAP vs fatty liver based on US) revealed that metabolic parameters, including blood pressure, BMI, waist circumference, aspartate aminotransferase (AST), ALT, triglycerides, fasting glucose, uric acid, insulin, homeostasis model assessment-estimated insulin resistance and liver stiffness measurements, gradually increased across the three groups (all P < .001).

CONCLUSIONS

In conclusion, increased CAP could be an early indicator of fatty liver disease with metabolic abnormalities that manifests even before a sonographic fatty change appears.

Clinical relevance of liver histopathology and different histological classifications of NASH in adults

Nonalcoholic fatty liver disease (NAFLD) encompasses simple steatosis and steatohepatitis (NASH) with or without fibrosis/cirrhosis and hepatocellular carcinoma. NAFLD occurs epidemically in most areas of the world, contributes to cardiovascular events and liver-related mortality and therefore exacts a major economic toll. Areas covered: Here we summarize what clinicians should know about NAFLD histopathology in adults. We report on the individual histological features and scoring systems of NAFLD: the NAFLD activity score (NAS) introduced by the NASH-Clinical Research Network, the 'Fatty Liver Inhibition of Progression' algorithm and Steatosis, Activity, and Fibrosis (SAF) score. Pros and cons of histological classifications in NASH are discussed. Special emphasis is given to liver histopathology in some high-risk patient groups, such as those with severe obesity and type 2 diabetes. Moreover, we also examine the relationship between liver histopathology and clinical features, and the impact of liver histopathology on the long-term prognosis of NAFLD. Finally, we propose an integrated diagnostic approach which utilizes both non-invasive tools and liver biopsy in those individual patients with suspected NAFLD. Expert commentary: Based on expert opinions, we conclude with a research agenda on NAFLD which focuses on the most burning topics to be addressed over the next five years.

Non-alcoholic fatty liver disease, liver biomarkers and stroke risk: The Reasons for Geographic and Racial Differences in Stroke cohort

BACKGROUND AND PURPOSE

Liver disease, particularly non-alcoholic fatty liver disease (NAFLD), is a risk factor for cardiovascular disease, but little is known about its relationship with ischemic stroke.

METHODS

In the Reasons for Geographic and Racial Differences in Stroke (REGARDS) cohort of 30,239 American black and white adults, we assessed baseline NAFLD as fatty liver index (FLI) >60, and assessed liver biomarkers aspartate aminotransferase (AST), alanine aminotransferase (ALT), γ-glutamyl transpeptidase (GGT), and the AST/ALT ratio and risk of incident ischemic stroke over 5.8 years using a case-cohort study design.

RESULTS

Considering 572 strokes and a 1,017-person cohort sample, NAFLD was inversely associated with stroke risk in men (HR: 0.50; 95% CI: 0.26, 0.96), as was being in the highest ALT quintile versus the lowest (HR: 0.39; 95% CI: 0.19, 0.78) and the highest versus lowest GGT quintile (HR: 0.45, 95% CI: 0.24, 0.85), but not in women. Conversely, FLI score above the 90th percentile was associated with increased stroke risk among women (HR: 2.26; 95% CI: 1.14-4.47), but not men. AST was not associated with stroke risk in either sex. AST/ALT ratio >2 was strongly associated with increased stroke risk in whites, but not blacks (HRs: 3.64; 95% CI: 1.42-9.35 and 0.97; 95% CI: 0.45-1.99, respectively; p for interaction = 0.03).

CONCLUSIONS

The relationships between NAFLD, liver biomarkers, and ischemic stroke are complex, and sex and race differences we observed require further study and confirmation.

Characterization and evaluation of nanoencapsulated diethylcarbamazine in model of acute hepatic inflammation

Previous studies from our laboratory have demonstrated that Diethylcarbamazine (DEC) is a potent anti-inflammatory drug. The aim of the present study was to characterize the nanoencapsulation of DEC and to evaluate its effectiveness in a model of inflammation for the first time. C57BL/6 mice were divided into six groups: 1) Control; 2) Carbon tetrachloride (CCl4); 3) DEC 25mg/kg+CCl4; 4) DEC 50mg/kg+CCl4; 5) DEC-NANO 05mg/kg+CCl4 and 6) DEC-NANO 12.5mg/kg+CCl4. Liver fragments were stained with hematoxylin-eosin, and processed for Western blot, ELISA and immunohistochemistry. Serum was also collected for biochemical measurements. Carbon tetrachloride induced hepatic injury, observed through increased inflammatory markers (TNF-α, IL-1β, PGE2, COX-2 and iNOS), changes in liver morphology, and increased serum levels of total cholesterol, triglycerides, TGO and TGP, LDL, as well as reduced HDL levels. Nanoparticles containing DEC were characterized by diameter, polydispersity index and zeta potential. Treatment with 12.5 nanoencapsulated DEC exhibited a superior anti-inflammatory action to the DEC traditional dose (50mg/kg) used in murine assays, restoring liver morphology, improving serological parameters and reducing the expression of inflammatory markers. The present formulation of nanoencapsulated DEC is therefore a potential therapeutic tool for the treatment of inflammatory hepatic disorders, permitting the use of smaller doses and reducing treatment time, while maintaining high efficacy.

Ideal cardiovascular health predicts lower risk of abnormal liver enzymes levels in the Chilean National Health Survey (2009-2010)

High levels of gamma glutamyltransferase (gamma-GT) and alanine aminotransferase (ALT), as well as fatty liver index (FLI) has been associated with higher cardiovascular disease risk factors in adults. The aim of this study was to examine the relationship between gamma-GT, ALT, and fatty liver index FLI levels across a gradient number of ideal cardiovascular health metrics in a representative sample of adults from the Chilean National Health Survey 2009-2010. Data from 1,023 men and 1,449 women (≥ 15 years) from the Chilean Health Survey 2009-2010 were analyzed. Ideal cardiovascular health was defined as meeting ideal levels of the following components: four behaviours (smoking, body mass index, physical activity and diet adherence) and three factors (total cholesterol, blood pressure and fasting glucose). Adults were grouped into three categories according to their number of ideal cardiovascular health metrics: ideal (5-7 metrics), intermediate (3-4 metrics), and poor (0-2 metrics). Blood levels of gamma-GT and ALT were measured and the FLI was calculated. A higher number of ideal cardiovascular health index metric was associated with lower gamma-GT, ALT and FLI (p from trend analysis <0.001). Also, adults meeting at least 3-4 metrics were predicted less likely to have prevalence of abnormal levels of gamma-GT and FLI (p<0.001) compared to adults who met only 0-2 metrics. These findings reinforce the usefulness of the ideal cardiovascular health metrics proposed by the American Heart Association as a tool to identify target subjects and promote cardiovascular health in South-American adults.

The correlation of controlled attenuation parameter results with ultrasound-identified steatosis in real-world clinical practice

BACKGROUND/PURPOSE

Controlled attenuation parameter (CAP) is a method for measuring steatosis based on FibroScan. Despite observer dependency, ultrasound (US) robustly diagnoses moderate and severe steatosis. Here, we aimed to evaluate the correlation of CAP with US-identified steatosis in real-world clinical practice.

METHODS

CAP and US were performed for 1554 chronic liver disease (CLD) patients. CAP was performed by two technicians, and US was performed by 30 hepatologists. The performance of the CAP as compared with the US results was assessed using the area under the receiver operating characteristic curve (AUROC).

RESULTS

532 (34.2%) of the patients had hepatitis C virus (HCV) infection, 723 (46.5%) of the patients had hepatitis B virus (HBV) infection, and the rest were patients with metabolic risk factors. CAP values were significantly correlated with the steatosis grades identified by US for all the patients (ρ = 0.497, P < 0.001), for the HBV-infected patients (ρ = 0.495, P < 0.001), for the HCV-infected patients (ρ = 0.343, P < 0.001), and for the patients with metabolic risk factors (ρ = 0.515, P < 0.001). Using CAP, the AUROC values were 0.759, 0.795, 0.715, and 0.716 for ≥moderate steatosis identified by US in, respectively, all the patients, the HBV-infected patients, the HCV-infected patients, and the patients with metabolic risk factors. The AUROC values were 0.791, 0.868, 0.807 and 0.701 for severe steatosis identified by US in, respectively, all the patients, the HBV-infected patients, the HCV-infected patients, and the patients with metabolic risk factors.

CONCLUSION

CAP values were well correlated with the steatosis grades assessed by US in real-world clinical practice.

Is there a J-shaped relationship between the fatty liver index and risk of microalbuminuria in the general population?

BACKGROUND

We investigated whether the fatty liver index (FLI), as a clinical indicator of hepatic fat accumulation based on body mass index, gamma-glutamyl-transferase, triglycerides, and waist circumference, has an association with microalbuminuria.

METHODS

We analyzed anthropometric and biochemical data from a nation-wide, population-based, cross-sectional study. A total of 1605 participants included were healthy native Korean 40years or older and divided into quintiles according to their log-FLI and sex. Microalbuminuria was defined as urine albumin/creatinine ratio (UACR) between 30 and 300mg/g.

RESULTS

Participants in higher quintiles of log-FLI were more obese and hypertensive and had greater glycemic exposure, poorer lipid profiles, and greater increases in log-UACR compared with lower quintiles. Linear regression analysis demonstrated that log-FLI was associated with systolic and diastolic blood pressure, body mass index, waist circumference, fasting plasma glucose, glycated hemoglobin, and log-UACR. In logistic regression adjusted for age, sex, body mass index, waist circumference, and fasting plasma glucose, the OR of microalbuminuria was elevated in quintile 1 (adjusted OR=2.161, 95% CI=0.453-10.31) and quintile 5 (adjusted OR=6.387, 95% CI=1.317-51.58), when compared to quintile 2.

CONCLUSIONS

There appears to be a J-shaped association between FLI and UACR in healthy general population.

A comparison of hepatic steatosis index, controlled attenuation parameter and ultrasound as noninvasive diagnostic tools for steatosis in chronic hepatitis B

AIMS

To evaluate the value of noninvasive tools for diagnosis of hepatic steatosis in patients with chronic hepatitis B (CHB).

METHODS

Consecutive treatment-naïve patients with CHB with body mass index less than 30kg/m2 who underwent liver biopsy, ultrasound and FibroScan® were enrolled. The diagnostic performance of controlled attenuation parameter (CAP), hepatic steatosis index (HSI) and ultrasound for hepatic steatosis compared with liver biopsy was assessed. The areas under receiver operating characteristics curves (AUROCs) were calculated to determine the diagnostic efficacy, with comparisons using the DeLong test.

RESULTS

CAP and HSI accuracies were significantly higher than that of ultrasound to detect patients with biopsy-proven mild steatosis (S1, 65.3%, 56.5%, respectively, vs. 17.7%, χ2=46.305, 31.736, both P<0.05)and moderate-severe (S2-3) steatosis (92.3%, 100%, respectively, vs. 53.8%, χ2=4.887, 7.800, P=0.037, 0.007, respectively). Both CAP and HSI had lower underestimation rates of steatosis grade than ultrasound (12%, 14.8%, respectively, vs. 29.5%, χ2=9.765, 6.452; P<0.05 for both), but they exhibited higher overestimation rates (30.5%, 38.2%, respectively, vs. 12.4%, χ2=39.222, 70.986; both P<0.05). The AUROCs of CAP and HSI were 0.780 (95% confidence intervals [CIs] 0.735-0.822) and 0.655 (95%CI 0.604-0.704) for S ≥1, 0.932 (95%CI 0.902-0.956) and 0.755 (95%CI 0.707-0.799) for S ≥2, 0.990 (95%CI 0.974-0.998) and 0.786 (95% CI 0.740-0.827) for S3, respectively.

CONCLUSION

CAP might be more accurate for detecting hepatic steatosis than HSI and ultrasound in patients with CHB, but further studies are needed to reduce the overestimation rates.

Screening for non-alcoholic fatty liver disease in children and adolescents with type 1 diabetes mellitus: a cross-sectional analysis

The liver is intensely involved in glucose metabolism and is thereby closely related to diabetes pathophysiology. Adult patients with type 1 diabetes mellitus (DM) are at an increased risk for non-alcoholic fatty liver disease (NAFLD). Here, we studied the prevalence of NAFLD in a cohort of children and adolescents with type 1 DM in a tertiary care paediatric diabetes centre in Germany. We screened 93 children and adolescents with type 1 DM using ultrasound, laboratory investigations, and liver stiffness measurements (Fibroscan® [FS] and acoustic radiation force imaging [ARFI]). Of these, 82 (88.1%) had completely normal results in all examined aspects. Only one patient (1.1%) fulfilled the criteria as potential NAFLD with ALT > twice the upper limit of normal. Ten of the 93 patients (10.8%) showed any mild abnormality in at least one examined category including ALT, conventional ultrasounds and liver stiffness measurements. However, none of these ten fulfilled the NAFLD case definition criteria. Therefore, these slightly abnormal results were judged to be unspecific or at least of unknown significance in terms of NAFLD indication.

CONCLUSION

Compared to data from the general population, our results do not indicate a significantly increased prevalence of NAFLD in this cohort, and advocate against the systematic screening for NAFLD in paediatric type 1 DM. What is Known: • Non-alcoholic fatty liver disease (NAFLD) is common in adults with type 1 DM, and paediatric patients with type 1 DM in Egypt and Saudi Arabia. What is New: • Our results do not indicate a significantly increased prevalence of NAFLD in a cohort of children and adolescents with type 1 DM from Germany compared to prevalence data from the general population. • This finding advocates against the systematic screening for NAFLD in paediatric type 1 DM in western countries.

Management of Nonalcoholic Fatty Liver Disease in Patients With Type 2 Diabetes: A Call to Action

Traditionally a disease of hepatologists, nonalcoholic fatty liver disease (NAFLD) has recently become a major concern for a broad spectrum of health care providers. Endocrinologists and those caring for patients with type 2 diabetes mellitus (T2DM) are at center stage, as T2DM appears to worsen the course of NAFLD and the liver disease makes diabetes management more challenging. However, the nature of this relationship remains incompletely understood. Although the increasing prevalence of NAFLD is frequently attributed to the epidemic of obesity and is often oversimplified as the "hepatic manifestation of the metabolic syndrome," it is a much more complex disease process that may also be observed in nonobese individuals and in patients without clinical manifestations of the metabolic syndrome. It carries both metabolic and liver-specific complications that make its approach unique among medical conditions. Diabetes appears to promote the development of nonalcoholic steatohepatitis (NASH), the more severe form of the disease, and increases the risk of cirrhosis and hepatocellular carcinoma. Patients and physicians face many uncertainties, including fragmented information on the natural history of the disease, challenges in the diagnosis of NASH, and few pharmacological agents with proven efficacy. However, recent advances in diagnosis and treatment, combined with the risk of serious consequences from inaction, call for health care providers to be more proactive in the management of patients with T2DM and NASH.

Lysosomal acid lipase deficiency: A hidden disease among cohorts of familial hypercholesterolemia?

BACKGROUND

Lysosomal acid lipase deficiency (LALD) is an autosomal recessive disorder and an unrecognized cause of dyslipidemia. Patients usually present with dyslipidemia and altered liver function and mutations in LIPA gene are the underlying cause of LALD.

OBJECTIVE

The aim of this study was to investigate LALD in individuals with severe dyslipidemia and/or liver steatosis.

METHODS

Coding, splice regions, and promoter region of LIPA were sequenced by Sanger sequencing in a cohort of mutation-negative familial hypercholesterolemia (FH) patients (n = 492) and in a population sample comprising individuals with several types of dyslipidemia and/or liver steatosis (n = 258).

RESULTS

This study led to the identification of LALD in 4 children referred to the Portuguese FH Study, all with a clinical diagnosis of FH. Mild liver dysfunction was present at the age of FH diagnosis; however, a diagnosis of LALD was not considered. No adults at the time of referral have been identified with LALD.

CONCLUSION

LALD is a life-threatening disorder, and early identification is crucial for the implementation of specific treatment to avoid premature mortality. FH cohorts should be investigated to identify possible LALD patients, who will need appropriate treatment. These results highlight the importance of correctly identifying the etiology of the dyslipidemia.

Relationship between Controlled Attenuation Parameter and Hepatic Steatosis as Assessed by Ultrasound in Alcoholic or Nonalcoholic Fatty Liver Disease

Background/Aims

The aim of this study was to evaluate the relationship between controlled attenuation parameter (CAP) and hepatic steatosis, as assessed by ultrasound (US) in patients with alcoholic liver disease (ALD) or non-alcoholic fatty liver disease (NAFLD).

Methods

Patients with either ALD or NAFLD who were diagnosed with fatty liver with US and whose CAP scores were measured, were retrospectively enrolled in this study. The degree of hepatic steatosis assessed by US was categorized into mild (S1), moderate (S2), and severe (S3).

Results

A total of 186 patients were included: 106 with NAFLD and 80 with ALD. Regarding hepatic steatosis, the CAP score was significantly correlated with US (ρ=0.580, p<0.001), and there was no significant difference between the NAFLD and ALD groups (ρ=0.569, p<0.001; ρ=0.519, p<0.001; p=0.635). Using CAP, area under receiver operating characteristic curves for ≥S2 and ≥S3 steatosis were excellent (0.789 and 0.843, respectively). For sensitivity ≥90%, CAP cutoffs for the detection of ≥S2 and ≥S3 steastosis were separated with a gap of approximately 35 dB/m in all patients and in each of the NAFLD and ALD groups.

Conclusions

The CAP score is well correlated with hepatic steatosis, as assessed by US, in both ALD and NAFLD.

The clinical value of controlled attenuation parameter for the noninvasive assessment of liver steatosis

BACKGROUND & AIMS

Ultrasound is the imaging modality most widely utilized in the general population for diagnostic purposes. Controlled attenuation parameter is a novel noninvasive method for assessing steatosis. Our aim was to investigate whether the clinical value of controlled attenuation parameter in patients referred for abdominal ultrasound examinations is affected by liver fibrosis.

METHODS

Consecutive patients referred for abdominal ultrasound examinations were enrolled. Controlled attenuation parameter and liver stiffness were assessed with the FibroScan (Echosens, France). Liver fibrosis was staged according to published cutoffs of liver stiffness measurements. Pearson's or Spearman's rank correlation coefficient was used to test the association between two study variables. Optimal cutoff of controlled attenuation parameter for diagnosing liver steatosis (S≥2) was 256 dB/m. The diagnostic performance and accuracy of dichotomized controlled attenuation parameter, ultrasound and body mass index were analysed using the imperfect gold standard methodology.

RESULTS

A total of 726 subjects (464 males and 262 females) were studied. Five hundred and eight-nine (81.1%) patients were affected by chronic viral hepatitis. Correlation of controlled attenuation parameter with ultrasound score was 0.48 and 0.57 in patients with and without chronic viral hepatitis respectively. In patients with chronic viral hepatitis, ultrasound, dichotomized controlled attenuation parameter and body mass index showed performance of 58.2%, 82.3% and 46.7%, respectively, whereas in patients without chronic viral hepatitis, the performance was 86.4%, 68.6% and 48.6% respectively.

CONCLUSIONS

In patients with chronic viral hepatitis and advanced liver fibrosis, controlled attenuation parameter performs better than ultrasound for assessing liver steatosis, whereas in patients without viral hepatitis and with nonsignificant liver disease ultrasound shows the best performance.

Non-invasive diagnosis of hepatic steatosis

Non-invasive diagnosis and quantification of hepatic steatosis rely on two different but complementary approaches: biomarkers or imaging techniques, either ultrasound-based such as liver ultrasonography and controlled attenuation parameter (CAP), or computed tomography (CT) and magnetic resonance imaging (MRI). Scores for the detection of steatosis have not gained much popularity in clinical practice so far. CAP, using the M probe, is the most promising technique but needs to be implemented with the XL probe and compared to ultrasound that, despite its limitations, remains the most widely used method. CT, owing to its low sensitivity and the fact that it involves a potential radiation hazard, is inappropriate. Finally, proton density fat fraction measurement by MRI is currently the most accurate and sensitive imaging method, simpler and more practical than magnetic resonance spectroscopy, but restricted, up to now, just to research and clinical trials.