Repeated measurements of non-invasive fibrosis tests to monitor the progression of non-alcoholic fatty liver disease: A long-term follow-up study

Association between longitudinal biomarkers and major adverse liver outcomes in patients with non-cirrhotic metabolic dysfunction-associated steatotic liver disease

BACKGROUND AND AIMS

Noninvasive biomarkers provide prognostic information for the development of major adverse liver outcomes (MALOs) in patients with metabolic dysfunction-associated steatotic liver disease (MASLD), but the predictive value of longitudinal biomarker measurements has not been evaluated. We assessed whether changes in biomarkers could predict incident MALO in MASLD.

APPROACH AND RESULTS

We analyzed a cohort of 1260 patients (71.7% on biopsy) with non-cirrhotic MASLD between 1974 and 2019. Data at baseline and follow-up visits were obtained from medical charts. MALO was determined through medical charts and linkage to national registers until the end of 2020. A joint modeling approach was used to quantify the associations between the trajectory of biomarkers and the risk of MALO. MASLD was diagnosed at a median age of 52 years (IQR: 39-60), and 59% were male. During a median follow-up of 12.2 years, 111 (8.8%) patients developed MALO. The joint modeling showed that an elevated fibrosis-4 score (HR: 2.60, 95% CI: 1.89-3.50), aspartate aminotransferase (HR: 2.69, 95% CI: 2.57-3.05), and lower platelet count (HR: 0.93, 95% CI: 0.90-0.97) at any time point were associated with an increased risk of MALO, whereas the rate of change in these biomarkers had no association with this risk.

CONCLUSIONS

In addition to baseline measurements of noninvasive biomarkers such as fibrosis-4 score, aspartate aminotransferase, and platelets taken at MASLD diagnosis, monitoring their values over time is important, as the latest value of these biomarkers is closely associated with the risk of future MALO. The rate of change may not be as important.

Prediction of major liver-related events in the population using prognostic models

Liver disease poses a significant global health burden, with steatotic liver disease related to metabolic dysfunction and/or alcohol use being the most prevalent type. Current risk stratification strategies emphasize detecting advanced fibrosis as a surrogate marker for liver-related events (LREs), such as hospitalization, liver cancer, or death. However, fibrosis alone does not adequately predict imminent outcomes, particularly in fast-progressing individuals without advanced fibrosis at evaluation. This underscores the need for models designed specifically to predict LREs, enabling timely interventions. The Chronic Liver Disease (CLivD) risk score, the dynamic aspartate aminotransferase-to-alanine aminotransferase ratio (dAAR), and the Cirrhosis Outcome Risk Estimator (CORE) were explicitly developed to predict LRE risk rather than detect fibrosis. Derived from general population cohorts, these models incorporate either standard liver enzymes (dAAR and CORE) or risk factors (CLivD), enabling broad application in primary care and population-based settings. They directly estimate the risk of future LREs, improving on traditional fibrosis-focused approaches. Conversely, widely used models like the Fibrosis-4 index and newer ones, such as the LiverRisk and LiverPRO scores, were initially developed to detect significant/advanced fibrosis or liver stiffness. While not designed for LRE prediction, they have later been analyzed for this purpose. Integrating fibrosis screening with LRE-focused models like CLivD, dAAR, and CORE can help healthcare systems adopt proactive, preventive care. This approach emphasizes identifying individuals at imminent risk of severe outcomes, potentially ensuring better resource allocation and personalized interventions.

Predictors of liver fibrosis progression in cohort of type 2 diabetes mellitus patients with MASLD

AIM

To investigate predictors of liver fibrosis progression in patients with type 2 diabetes mellitus (T2DM) over a minimum follow-up duration of three years.

METHODS

Two hundred and thirty-three patients completed the follow-up period and their clinical, laboratory and liver FibroScan data are reported. Patients were categorized into progressors 42 (18.0 %) and non-progressors 191 (82.0 %) based on liver fibrosis progression. Factors influencing fibrosis progression were identified by comparing these groups.

RESULTS

Progressors showed significantly increased aspartate aminotransferase (AST) (p = 0.010), increased alkaline phosphatase (ALP) (p = 0.001) and decreased platelet count (p = 0.002). Non-progressors exhibited significant decreases in diastolic blood pressure (DBP) (p = 0.050), body mass index (BMI) (p < 0.001), waist circumference (p < 0.001), gamma-glutamyl transferase (GGT) (p < 0.001), albumin (p < 0.001), alanine aminotransferase (ALT) (p = 0.022), glycosylated haemoglobin (HbA1c) (p = 0.002) and fasting blood sugar (FBS) (p = 0.030) with increase in HDL-cholesterol (p < 0.001), creatinine (p < 0.001), bilirubin (p < 0.001), and ALP (p = 0.007). Baseline parameters predictive of liver fibrosis progression included elevated AST and reduced platelet count. Delta changes from baseline to follow-up revealed that increases in ALP, BMI, waist circumference, and reduction in platelet count were correlated with fibrosis progression. Use of GLP-1 receptor agonist was associated with reduced progression.

CONCLUSION

In conclusion, increase in ALP and waist circumference and reduction in platelet count are predictive of liver fibrosis progression in patients with T2DM. GLP-1 receptor agonists use seems to have a promising protective effect against liver fibrosis progression.

CLINICALTRIALS

govID:NCT05697991.

Golgi protein 73: charting new territories in diagnosing significant fibrosis in MASLD: a prospective cross-sectional study

Objectives

To explore the correlation between serum Golgi protein 73 (GP73) levels and the degree of fibrosis in Metabolic dysfunction associated steatotic liver disease (MASLD); to establish a non-invasive diagnostic algorithm based on serum GP73 and liver elasticity.

Methods

This is a prospective cross-sectional study, including 228 patients diagnosed with MASLD from May 2018 to January 2024 at two tertiary hospitals. Clinical data and hepatic pathological features and the correlation between serum GP73 and liver fibrosis were assessed. A new algorithm was conducted after logistic regression. Receiver Operating Characteristic (ROC) curve was used to compare its diagnostic performance with traditional models.

Results

Significant fibrosis was diagnosed in 37.2% (85/228) patients. Serum GP73 levels were markedly higher in patients with significant fibrosis than in those without (128 ng/mL v.s 46 ng/mL, p< 0.001). Serum GP73 levels independently predicted significant liver fibrosis (adjusted odds ratio, aOR 1.028, p< 0.001). A new algorithm based on GP73 was developed with a higher area under ROC (AUC) of 0.840 than that of Fibrosis index-4 (p< 0.001).

Conclusions

Serum GP73 is an independent risk factor for significant liver fibrosis in MASLD, and the GFA (GP73-Fibroscan-Age) model has good diagnostic efficacy for significant liver fibrosis.

The role of noninvasive biomarkers for monitoring cell injury in advanced liver fibrosis

INTRODUCTION

Accurate and reliable diagnosis and monitoring of hepatic fibrosis is increasingly important given the variable natural history in chronic liver disease (CLD) and expanding antifibrotic therapeutic options targeting reversibility of early-stage cirrhosis. This highlights the need to develop more refined and effective noninvasive techniques for the dynamic assessment of fibrogenesis and fibrolysis.

AREAS COVERED

We conducted a literature review on PubMed, from 1 December 1970, to 1 November 2024, to evaluate and compare available blood-based and imaging-based noninvasive tools for hepatic fibrosis diagnosis and monitoring. Simple scores such as FIB-4 and NAFLD fibrosis score are suitable for excluding significant or advanced fibrosis, while tertiary centers should adopt complex scores and liver stiffness measurement as part of a secondary diagnostic and more comprehensive evaluation. Moreover, the advent of multiomics for high-resolution molecular profiling, and integration of artificial intelligence for noninvasive diagnostics holds promise for revolutionizing fibrosis monitoring and treatment through novel biomarker discovery and predictive omics-based algorithms.

EXPERT OPINION

The increased shift toward noninvasive diagnostics for liver fibrosis needs to align with personalized medicine, enabling more effective, tailored management strategies for patients with liver disease in the future.

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.

Coexistence of metabolic-associated fatty liver disease and autoimmune or toxic liver disease

Fatty liver disease (FLD) affects approximately 25% of global adult population. Metabolic-associated fatty liver disease (MAFLD) is a term used to emphasize components of metabolic syndrome in FLD. MAFLD does not exclude coexistence of other liver disease, but impact of coexisting MAFLD is unclear. We investigated prevalence and characteristics of MAFLD in patients with biopsy-proven autoimmune hepatitis (AIH), primary biliary cholangitis (PBC), primary sclerosing cholangitis (PSC), or toxic liver disease. Liver histopathology and clinical data from Helsinki University Hospital district (1.7 million inhabitants) between 2009 and 2019 were collected from patients with AIH, PBC, PSC, or toxic liver disease at the time of diagnosis. MAFLD was diagnosed as macrovesicular steatosis ≥5% together with obesity, type-2 diabetes, or signs of metabolic dysregulation. Of 648 patients included, steatosis was observed in 15.6% (n = 101), of which 94.1% (n = 95) was due to MAFLD. Prevalence of coexisting MAFLD in the four liver diseases varied between 12.4 and 18.2% (P = 0.483). Fibrosis was more severe in MAFLD among patients with toxic liver disease (P = 0.01). Histopathological characteristics otherwise showed similar distribution among MAFLD and non-FLD controls. Alcohol consumption was higher in MAFLD group among patients with AIH or PBC (P < 0.05 for both). In AIH, smoking was more common in patients with coexisting MAFLD (P = 0.034). Prevalence of coexisting MAFLD in other primary liver diseases is lower than reported in general population. Histopathology of MAFLD patients did not clearly differ from non-FLD ones. Alcohol and smoking were associated with MAFLD in AIH.

Optimizing surveillance of low-risk metabolic dysfunction associated steatotic liver disease using transient elastography

BACKGROUND

Most people with metabolic dysfunction-associated steatotic liver disease (MASLD) lack significant fibrosis and are considered low-risk. Surveillance strategy for low-risk MASLD remains uncertain.

AIM

Identify which low-risk subjects can avoid follow-up vibration-controlled transient elastography (VCTE) within 1 year.

METHODS

Retrospective analysis of two independent low-risk MASLD cohorts (baseline liver stiffness [LS] < 8kPa) with routine 6-12 months follow-up VCTE. The primary outcome was LS ≥ 8kPa on follow-up, requiring referral and further work-up according to current guidance. Predictors of the primary outcome on univariate and multivariate logistic regression were incorporated into a decision algorithm, and validated in an independent cohort.

RESULTS

Of 206 subjects in the derivation cohort, 96 were low-risk. After a median of 10 months, 24 (25%) low-risk subjects had LS ≥ 8kPa. Baseline LS ( P  < 0.01) and ALT change from baseline ( P  = 0.02) (multivariate AUROC = 0.84 [0.74-0.94]) predicted the primary outcome, and were incorporated to a two-step decision algorithm. Low-risk subjects with baseline LS < 5.5 kPa can avoid repeating VCTE in a year, while those with LS > 6.8 kPa require one. For intermediate baseline LS (5.5-6.8kPa), repeat VCTE is only indicated when ALT increase > 6 U/L. The algorithm had 92% negative predictive value, 78% specificity, and 78% accuracy in the derivation cohort. In the validation cohort (n = 64), it had 91% NPV, 72% specificity, and 71% accuracy.

CONCLUSION

In low-risk MASLD, a simple algorithm combining baseline LS and ALT change can be used to safely avoid a repeat VCTE in a year.

Navigating Cirrhosis: A Comprehensive Review of Liver Scoring Systems for Diagnosis and Prognosis

This comprehensive review navigates the landscape of liver scoring systems for the diagnosis and prognosis of cirrhosis. Cirrhosis, a chronic and progressive liver disease, presents significant challenges in its diagnosis and management. The review begins by defining and providing an overview of cirrhosis, emphasizing its clinical implications. Highlighting the significance of liver scoring systems, including the Child-Pugh score, end-stage liver disease, albumin-bilirubin (ALBI) score, and fibrosis-4 (FIB-4) index, the study explores their role in assessing liver dysfunction severity and predicting outcomes. A meticulous analysis identifies the strengths and limitations of these scoring systems, offering valuable insights for clinicians. The recommendations emphasize incorporating these tools into routine clinical practice for early intervention and personalized treatment plans. Interdisciplinary collaboration is underscored as crucial for a holistic approach to cirrhosis management. The conclusion calls for future research to refine existing scoring systems, explore emerging biomarkers and imaging techniques, and conduct prospective studies to enhance precision. By embracing these recommendations, the medical community can advance the understanding and management of cirrhosis, ultimately improving patient outcomes and revolutionizing liver disease approaches.

Noninvasive Assessment of Liver Fibrosis in NAFLD

Nonalcoholic fatty liver disease (NAFLD) has emerged as a leading cause of liver-related morbidity and mortality worldwide, afflicting approximately a billion individuals. NAFLD is a slowly progressive disease that may evolve in a subset of patients toward cirrhosis, hepatocellular carcinoma, and end-stage liver disease. Liver fibrosis severity is the strongest predictor of clinical outcomes. The emergence of effective therapeutics on the horizon highlights the need to identify among patients with NAFLD, those with severe fibrosis or cirrhosis, who are the most at risk of developing complications and target them for therapy. Liver biopsy has been the reference standard for this purpose. However, it is not suitable for large-scale population evaluation, given its well-known limitations (invasiveness, rare but severe complications, and sampling variability). Thus, there have been major efforts to develop simple noninvasive tools that can be used in routine clinical settings and in drug development. Noninvasive approaches are based on the quantification of biomarkers in serum samples or on the measurement of liver stiffness, using either ultrasound- or magnetic resonance-based elastography techniques. This review provides a roadmap for future development and integration of noninvasive tools in clinical practice and in drug development in NAFLD. We discuss herein the principles for their development and validation, their use in clinical practice, including for diagnosis of NAFLD, risk stratification in primary care and hepatology settings, prediction of long-term liver-related and non-liver-related outcomes, monitoring of fibrosis progression and regression, and response to future treatment.

Noninvasive serum biomarkers for liver fibrosis in NAFLD: current and future

In the last 20 years, noninvasive serum biomarkers to identify liver fibrosis in patients with non-alcoholic fatty liver disease (NAFLD) have been developed, validated against liver biopsy (the gold standard for determining the presence of liver fibrosis) and made available for clinicians to use to identify ≥F3 liver fibrosis. The aim of this review is firstly to focus on the current use of widely available biomarkers and their performance for identifying ≥F3. Secondly, we discuss whether noninvasive biomarkers have a role in identifying F2, a stage of fibrosis that is now known to be a risk factor for cirrhosis and overall mortality. We also consider whether machine learning algorithms offer a better alternative for identifying individuals with ≥F2 fibrosis. Thirdly, we summarise the utility of noninvasive serum biomarkers for predicting liver related outcomes (e.g., ascites and hepatocellular carcinoma) and non-liver related outcomes (e.g., cardiovascular-related mortality and extra hepatic cancers). Finally, we examine whether serial measurement of biomarkers can be used to monitor liver disease, and whether the use of noninvasive biomarkers in drug trials for non-alcoholic steatohepatitis can accurately, compared to liver histology, monitor liver fibrosis progression/regression. We conclude by offering our perspective on the future of serum biomarkers for the detection and monitoring of liver fibrosis in NAFLD.

Does aerobic exercise reduce NASH and liver fibrosis in patients with non-alcoholic fatty liver disease? A systematic literature review and meta-analysis

Background

Exercise is an effective strategy for the prevention and regression of hepatic steatosis in patients with non-alcoholic fatty liver disease (NAFLD), but it is unclear whether it can reduce advanced stages of NAFLD, i.e., steatohepatitis and liver fibrosis. Furthermore, it is not evident which modality of exercise is optimal to improve/attenuate NAFLD.

Objectives

The aim is to systematically review evidence for the effect of aerobic exercise (AE) on NAFLD, in particular non-alcoholic steatohepatitis (NASH) and liver fibrosis.

Methods

A systematic literature search was conducted in Medline and Embase. Studies were screened and included according to predefined criteria, data were extracted, and the quality was assessed by Cochrane risk of bias tools by two researchers independently according to the protocol registered in the PROSPERO database (CRD42021270059). Meta-analyses were performed using a bivariate random-effects model when there were at least three randomized intervention studies (RCTs) with similar intervention modalities and outcome.

Results

The systematic review process resulted in an inclusion a total of 24 studies, 18 RCTs and six non-RCTs, encompassing 1014 patients with NAFLD diagnosed by histological or radiological findings. Studies were grouped based on the type of AE: moderate-intensity continuous training (MICT) and high-intensity interval training (HIIT). A total of twelve meta-analyses were conducted. Compared to controls, MICT resulted in a mean difference (MD) in the NAFLD biomarkers alanine transaminase (ALT) and aspartate aminotransferase (AST) of -3.59 (CI: -5.60, -1.59, p<0.001) and -4.05 (CI: -6.39, -1.71, p<0.001), respectively. HIIT resulted in a MD of -4.31 (95% CI: -9.03, 0.41, p=0.07) and 1.02 (95% CI: -6.91, 8.94, p=0.8) for ALT and AST, respectively. Moreover, both AE types compared to controls showed a significantly lower magnetic resonance spectroscopy (MRS) determined liver fat with a MD of -5.19 (95% CI: -7.33, -3.04, p<0.001) and -3.41 (95% CI: -4.74, -2.08, p<0.001), for MICT and HIIT respectively. MICT compared to controls resulted in a significantly higher cardiorespiratory fitness (MD: 4.43, 95% CI: 0.31, 8.55, p=0.03).

Conclusion

Liver fat is decreased by AE with a concomitant decrease of liver enzymes. AE improved cardiorespiratory fitness. Further studies are needed to elucidate the impact of different types of AE on hepatic inflammation and fibrosis.

Systematic Review Registration

https://www.crd.york.ac.uk/prospero/, identifier (CRD42021270059).