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

Steatotic liver disease is a marker of multimorbidity, not underlying cirrhosis, in older adults

Steatotic liver disease (SLD) prevalence in adults is estimated at 30%, but older populations are understudied. Here, SLD prevalence and associated risk factors were assessed 1,021 Whitehall II study participants (mean age 72.5) using transient elastography (FibroScan). SLD was present in 33.3% (CAP ≥ 275 dB/m), with most classified as metabolic dysfunction-associated SLD. Only 2.4% had significant fibrosis ( ≥ 7.9 kPa). Adjusted for age and sex, SLD was associated with low physical activity (OR 1.60, 95% CI 1.13-2.27), poorer motor function (SF-36 PCS OR 1.21, 95% CI 1.05-1.40), difficulties in activities of daily living (OR 3.19, 95% CI 1.17-8.64), and multimorbidity (OR 1.45, 95% CI 1.22-1.73). These associations persisted after adjustment for socioeconomic, behavioural, and cardiometabolic risk factors. Frailty was associated with SLD at higher CAP thresholds ( ≥ 290 dB/m). In this older adult sample, SLD is common and appears more as a marker of multimorbidity and low physical activity than significant fibrosis.

Possible link between steatotic liver diseases, severe COVID-19 and cognitive impairment in post-COVID-19 syndrome

PURPOSE

Steatotic liver diseases (SLD) have become more prevalent over the last decade and are associated not only with cardiometabolic diseases but also with psychological symptoms (depression, fatigue). These symptoms are also common in post-COVID syndrome (PCS). Therefore, the aim of the study was to analyze the burden of SLD in PCS patients.

METHODS

We systematically screened all PCS patients from our post-COVID outpatient clinic using transient elastography, structured questionnaires for neurocognitive evaluation and blood sample analysis. Controls without PCS and without known liver diseases were also recruited and assessed with the same approach.

RESULTS

560 PCS patients and 103 healthy controls were included. The overall prevalence of SLD was high in both cohorts (57 vs. 53%). PCS patients with SLD were more frequently male (41 vs. 24%), older (52 vs. 44 years) and had more cardiometabolic diseases (87.0 vs. 46.4%). Cognitive impairment was more related to SLD in PCS patients than in the no-SLD group (OR: 1.68, CI: 1.14-2.46, p = 0.008). The presence of SLD was related to severe COVID-19 with hospitalization (OR: 2.91, CI: 1.85-4.56, p < 0.001). Within 1 year of the follow-up, 152 of 289 patients described a resolution in PCS irrespective of the presence or absence of SLD (log-rank p = 0.96).

CONCLUSIONS

SLD is associated with severe COVID-19 and cognitive dysfunction in PCS. Longitudinal studies are needed to assess the role of hepatic steatosis, development of post-acute infection regulation (e.g., SARS-CoV-2) and to differentiate between SLD-associated symptoms and PCS.

Screening for advanced liver disease incorporating the use of transitional elastography in primary care

OBJECTIVES

To describe the proportion of patients with liver fibrosis in at-risk populations in primary care (PC). To know the agreement between FIB-4 and transitional elastography (TE), interobserver agreement between PC and hospital care (HC) in TE, and associated risk Factors (RF).

METHODS

Observational, descriptive, cross-sectional study in ≥16 years of age with RF for chronic liver disease. Sex and age, RF (alteration of liver tests [LT], metabolic syndrome, diabetes, obesity, alcohol consumption, hepatic steatosis), and FIB-4, controlled attenuation parameter and TE in PC and in HC, were collected. According to a consensus algorithm, vibration-controlled TE was performed in PC in patients with FIB-4≥1,3, and those with measurement ≥8kPa were referred to HC.

RESULTS

326 patients were studied. 71% were not referred to HC, due to liver stiffness <8kPa. 83 of the 95 derivations did TE in HC. 45 (54%) had TE ≥8, and 25 (30%) ≥12. The proportion of patients with stiffness ≥8kPa was 13,8% (45/326) and ≥12kPa, 7,6% (25/326). The predictive values of the FIB-4 were low. The interobserver correlation coefficient between TE in PC and HC was 0,433. Variables associated with TE ≥8 in PC: LT alteration, diabetes and steatosis. With TE ≥12: LT alteration, diabetes and obesity.

PREDICTOR VARIABLES

LT alteration and obesity.

CONCLUSIONS

The study supports the sequential performance of serum indices and TE as a screening for fibrosis in the at-risk population in PC, which allows a reduction in the percentage of patients referred to AH, and a better stratification of risk patients.

Prevalence of metabolic dysfunction-associated steatotic liver disease and fibrosis defined by liver elastography in the United States using National Health and Nutrition Examination Survey 2017-March 2020 and August 2021-August 2023 data

BACKGROUND AND AIMS

Steatotic liver disease (SLD) is a significant public health burden. Previously, we estimated prepandemic SLD prevalence determined by transient elastography-assessed hepatic steatosis and fibrosis in the United States. We now estimate the prevalence of metabolic dysfunction-associated steatotic liver disease (MASLD) and examine associations with lifestyle, socioeconomic, and other factors.

APPROACH AND RESULTS

Liver stiffness and controlled attenuation parameters were assessed on 13,538 non-Hispanic White, non-Hispanic Black, non-Hispanic Asian, and Hispanic men and women aged 20 years and over in the National Health and Nutrition Examination Survey 2017 to March 2020 and August 2021 to August 2023. The prevalence of SLD (controlled attenuation parameter >300 dB/m) was 28.7%, fibrosis (liver stiffness >8 kPa) was 11.3%, and MASLD was 25.6%. Between the 2 survey cycles, the age-standardized SLD prevalence was not significantly different, MASLD prevalence decreased (26.8%-23.6%), and fibrosis prevalence increased (10.4%-12.7%). In multivariable-adjusted analysis, both MASLD and fibrosis were associated with diabetes, higher body mass index, higher waist-to-hip ratio, elevated blood pressure, and inversely associated with non-Hispanic Black race-ethnicity. MASLD was also associated with male sex, non-Hispanic Asian race-ethnicity, prediabetes, higher total cholesterol, lower HDL cholesterol, and greater sedentary lifestyle. Fibrosis was also associated with SLD, lower total cholesterol, and less education.

CONCLUSIONS

In the US population, MASLD and fibrosis prevalence are high along with obesity and diabetes. Our findings suggest that early detection of chronic liver disease and targeting lifestyle and other modifiable risk factors may slow disease progression toward advanced fibrosis and cirrhosis.

Diagnostic and prognostic performance of the LiverRisk score in tertiary care

Background & Aims

The LiverRisk score has been proposed as a blood-based tool to estimate liver stiffness measurement (LSM), thereby stratifying the risk of compensated advanced chronic liver disease (cACLD, LSM ≥10 kPa) and liver-related events in patients without known chronic liver disease (CLD). We aimed to evaluate its diagnostic/prognostic performance in tertiary care.

Methods

Patients referred to two hepatology outpatient clinics (cohort I, n = 5,897; cohort II, n = 1,558) were retrospectively included. Calibration/agreement of the LiverRisk score with LSM was assessed, and diagnostic accuracy for cACLD was compared with that of fibrosis-4 (FIB-4)/aspartate aminotransferase-to-platelet ratio index (APRI). The prediction of hepatic decompensation and utility of proposed cut-offs were evaluated.

Results

In cohort I/II, mean age was 48.3/51.8 years, 44.2%/44.7% were female, predominant etiologies were viral hepatitis (51.8%)/metabolic dysfunction-associated steatotic liver disease (63.7%), median LSM was 6.9 (IQR 5.1-10.9)/5.8 (IQR 4.5-8.8) kPa, and 1,690 (28.7%)/322 (20.7%) patients had cACLD.Despite a moderate correlation (Pearson's r = 0.325/0.422), the LiverRisk score systematically underestimated LSM (2.93/1.80 points/kPa lower), and range of agreement was wide, especially at higher values.The diagnostic accuracy of the LiverRisk score for cACLD (area under the receiver operator characteristics curve [AUROC] 0.757/0.790) was comparable to that of FIB-4 (AUROC 0.769/0.813) and APRI (AUROC 0.747/0.765). The proposed cut-off of 10 points yielded an accuracy of 74.2%/81.2%, high specificity (91.9%/93.4%), but low negative predictive value (76.6%/84.5%, Cohen's κ = 0.260/0.327).In cohort I, 208 (3.5%) patients developed hepatic decompensation (median follow-up 4.7 years). The LiverRisk score showed a reasonable accuracy for predicting hepatic decompensation within 1-5 years (AUROC 0.778-0.832). However, it was inferior to LSM (AUROC 0.847-0.901, p <0.001) and FIB-4 (AUROC 0.898-0.913, p <0.001). Similar to the strata of other non-invasive tests, the proposed LiverRisk groups had distinct risks of hepatic decompensation.

Conclusions

The LiverRisk score did not improve the diagnosis of cACLD or prediction of hepatic decompensation in the tertiary care setting.

Impact and implications

The LiverRisk score has been proposed as a non-invasive tool to estimate liver stiffness measurement and thus the risk of compensated advanced chronic liver disease and liver-related events. As automatic implementation into lab reports is being discussed, the question of its applicability outside of opportunistic screening in the general population arises. In two large cohorts of patients referred to hepatology outpatient clinics, the LiverRisk score did not accurately predict liver stiffness, did not improve cACLD identification, and had a lower predictive performance for hepatic decompensation as compared with FIB-4. Although it represents a major step forward for screening patients without known liver disease in primary care, our findings indicate that the LiverRisk score does not improve patient management outside the primary care setting, that is, in cohorts with a higher pre-test probability of cACLD.

Development, validation, and prognostic evaluation of a risk score for long-term liver-related outcomes in the general population: a multicohort study

BACKGROUND

Liver cirrhosis is a major cause of death worldwide. Cirrhosis develops after a long asymptomatic period of fibrosis progression, with the diagnosis frequently occurring late, when major complications or cancer develop. Few reliable tools exist for timely identification of individuals at risk of cirrhosis to allow for early intervention. We aimed to develop a novel score to identify individuals at risk for future liver-related outcomes.

METHODS

We derived the LiverRisk score from an international prospective cohort of individuals from six countries without known liver disease from the general population, who underwent liver fibrosis assessment by transient elastography. The score included age, sex, and six standard laboratory variables. We created four groups: minimal risk, low risk, medium risk, and high risk according to selected cutoff values of the LiverRisk score (6, 10, and 15). The model's discriminatory accuracy and calibration were externally validated in two prospective cohorts from the general population. Moreover, we ascertained the prognostic value of the score in the prediction of liver-related outcomes in participants without known liver disease with median follow-up of 12 years (UK Biobank cohort).

FINDINGS

We included 14 726 participants: 6357 (43·2%) in the derivation cohort, 4370 (29·7%) in the first external validation cohort, and 3999 (27·2%) in the second external validation cohort. The score accurately predicted liver stiffness in the development and external validation cohorts, and was superior to conventional serum biomarkers of fibrosis, as measured by area under the receiver-operating characteristics curve (AUC; 0·83 [95% CI [0·78-0·89]) versus the fibrosis-4 index (FIB-4; 0·68 [0·61-0·75] at 10 kPa). The score was effective in identifying individuals at risk of liver-related mortality, liver-related hospitalisation, and liver cancer, thereby allowing stratification to different risk groups for liver-related outcomes. The hazard ratio for liver-related mortality in the high-risk group was 471 (95% CI 347-641) compared with the minimal risk group, and the overall AUC of the score in predicting 10-year liver-related mortality was 0·90 (0·88-0·91) versus 0.84 (0·82-0·86) for FIB-4.

INTERPRETATION

The LiverRisk score, based on simple parameters, predicted liver fibrosis and future development of liver-related outcomes in the general population. The score might allow for stratification of individuals according to liver risk and thus guide preventive care.

FUNDING

European Commission under the H20/20 programme; Fondo de Investigación Sanitaria de Salud; Instituto de Salud Carlos III; Spanish Ministry of Economy, Industry, and Competitiveness; the European Regional Development Fund; and the German Ministry of Education and Research (BMBF).

Associations between dietary flavonoid intake with hepatic steatosis and fibrosis quantified by VCTE: Evidence from NHANES and FNDDS

BACKGROUND AND AIM

Flavonoids are natural products of plant origin and have been shown to be beneficial for nonalcoholic fatty liver disease (NAFLD) in animal studies. However, relevant epidemiological evidence is still lacking, and the relationship between flavonoid and subclass intake with quantified hepatic steatosis and fibrosis has not been investigated.

METHODS AND RESULTS

This study was based on the Food and Nutrient Database for Dietary Studies (FNDDS) expanded flavonoid intake database and the National Health and Nutrition Examination Survey (NHANES) 2017-2018 and included a total of 4113 participants with vibration-controlled transient elastography (VCTE) data. Multiple logistic regression was used to assess linear relationships between flavonoids and hepatic steatosis and fibrosis. Smoothed curve fit and a generalized additive model were used to investigate the non-linear relationship, and a two-tailed linear regression model was used to find potential inflection points. Of the 4113 participants, 1045 (25.41%) were diagnosed with NAFLD. After adjusting for energy and major non-dietary covariates, significant linear negative correlations were observed between total flavonoids and CAP [-1.53 (-2.59, -0.47)] and LSM [-0.17 (-0.27, -0.07)]. After adjusting for all covariates, flavones had the strongest and most significant negative association with hepatic steatosis [-1.98 (-3.79, -0.17)]. The results of smooth curve fitting and subgroup analysis demonstrated gender differences, and threshold effect analysis further identified a U-shaped relationship and inflection point between flavonoid intake and hepatic steatosis (infection point: 287.25 mg/d).

CONCLUSIONS

Our findings suggest negative associations between flavonoid and subclass intake with hepatic steatosis and fibrosis.

Prepandemic Prevalence Estimates of Fatty Liver Disease and Fibrosis Defined by Liver Elastography in the United States

BACKGROUND AND AIMS

Fatty liver disease is a growing public health burden. We estimated prepandemic fatty liver disease prevalence determined by transient elastography-assessed hepatic steatosis and fibrosis, and examined associations with lifestyle and other factors in a United States population sample.

METHODS

Liver stiffness and controlled attenuation parameter (CAP) were assessed on 7923 non-Hispanic white, non-Hispanic black, non-Hispanic Asian, and Hispanic men and women aged 20 years and over in the National Health and Nutrition Examination Survey (NHANES) 2017-March 2020 prepandemic data.

RESULTS

The prevalence of fatty liver disease (CAP > 300 dB/m) was 28.8% and of fibrosis (liver stiffness > 8 kPa) was 10.4%. Only 7.2% of participants with fatty liver disease and 10.9% with fibrosis reported being told by a health care provider that they had liver disease. In addition to known risk factors such as metabolic factors and ALT, persons with fatty liver disease were less likely to meet physical activity guidelines, more likely to be sedentary for ≥ 12 h a day, and reported a less healthy diet. Persons with fibrosis were less likely to have a college degree and reported a less healthy diet.

CONCLUSIONS

In the U.S. population, most persons with fatty liver disease are unaware of their condition. Physical activity and dietary modifications might reduce the fatty liver disease burden. There is an urgent need for fatty liver disease management in high-risk individuals using transient elastography or other noninvasive methods to intervene in disease progression.

Creatine consumption and liver disease manifestations in individuals aged 12 years and over

Despite the overwhelming safety evidence concerning creatine intake in various settings, there is still incomplete information whether dietary creatine affects liver health at the population level. The main aim of this cross-sectional population-based study was to evaluate the association between creatine intake through regular diet and liver disease manifestations, including liver fibrosis and hepatic steatosis, among individuals aged 12 years and over, using open-source data from the 2017-2018 U.S. National Health and Nutrition Examination Survey (NHANES). A total of 9254 male and female participants of all ages were included in the 2017-2018 NHANES round. We extracted data from the total sample population for participants who provided dietary data for individual foods via dietary interviews and examination data from liver ultrasound transient elastography. The final study sample consisted of 5957 participants (mean age 44.7 ± 21.0 years; 50.1% women), and the mean dietary creatine intake across the study population was 0.88 ± 0.71 g/day. Liver fibrosis and cirrhosis were diagnosed in 1703 (28.7%) and 288 (4.8%) participants, respectively; hepatic steatosis was identified in 2595 (43.7%) individuals. Binary logistic regression with multivariable model adjusted for age, gender, family income to poverty ratio, body mass index, total energy intake, and alcohol consumption showed that consuming more creatine (≥2 g/day) did not significantly increase the risk of liver fibrosis (OR = 0.92, 95% CI 0.70-1.21, p = .57), cirrhosis (OR = 0.94, 95% CI 0.53-1.65, p = .82), or hepatic steatosis (OR = 0.77, 95% CI 0.59-1.02, p = .07), as compared to participants who ingested <1 g of creatine daily. Dietary exposure to creatine through a regular diet is not associated with an increase in disease manifestations in individuals 12 years and over; further research is warranted to address the effects of excessive creatine intake (≥5 g/day) through a regular diet on liver health at the population level.

Association of family income to poverty ratio and vibration-controlled transient elastography quantified degree of hepatic steatosis in U.S. adolescents

INTRODUCTION

Inequality in socioeconomic status plays an important role in the prevalence of metabolic diseases in adolescents. The purpose of this study was to explore the association between family income and the degree of hepatic steatosis quantified by vibration-controlled transient elastography (VCTE) among U.S. adolescents.

METHODS

This cross-sectional study included two cycles of the National Health and Nutrition Examination Survey (NHANES) 2017-2020. Multivariate linear regression and smoothing curve fitting were used to investigate the linear and nonlinear relationship between PIR and hepatic steatosis, respectively. Subgroup analysis and interaction tests were used to test whether this relationship was stable across groups.

RESULTS

Of the 1,574 adolescent participants, 456 lived in poor households and 307 lived in wealthy households. After adjusting for all covariates, PIR (Ratio of family income to poverty) was significantly negatively associated with the degree of hepatic steatosis [-4.78 (-7.39, -2.17)], and this remained stable after converting PIR to a categorical variable. In addition, this significant negative association was more pronounced in women [-7.62 (-11.38, -3.87)], non-Hispanic blacks [-7.19 (-14.43, 0.06)], Mexican Americans [-6.80 (-13.63, 0.03)], and participants with BMI >30 cm² [-10.83 (-19.70, -1.96)].

CONCLUSIONS

PIR was significantly and negatively associated with the degree of hepatic steatosis in US adolescents. Additional prospective studies are needed to confirm our findings.

Effects of time-restricted feeding (16/8) combined with a low-sugar diet on the management of non-alcoholic fatty liver disease: A randomized controlled trial

OBJECTIVES

Emerging studies have employed time-restricted feeding (TRF) and a low-sugar diet alone in the management of non-alcoholic fatty liver disease (NAFLD), but their combination has not been tested. The aim of this study was to investigate the effects of TRF combined with a low-sugar diet on NAFLD parameters, cardiometabolic and inflammatory biomarkers, and body composition in patients with NAFLD.

METHODS

A 12-wk randomized controlled trial was performed to compare the effects of TRF (16 h fasting/8 h feeding daily [16/8]) plus a low-sugar diet versus a control diet based on traditional meal distribution in patients with NAFLD. Changes in body composition, anthropometric indices, and liver and cardiometabolic markers were investigated.

RESULTS

TRF 16/8 with a low-sugar diet reduced body fat (26.7 ± 5.4 to 24.2 ± 4.9 kg), body weight (83.8 ± 12.7 to 80.5 ± 12.1 kg), waist circumference (104.59 ± 10.47 to 101.91 ± 7.42 cm), and body mass index (29.1 ± 2.6 to 28 ± 2.7 kg/m2), as well as circulating levels of fasting blood glucose and liver (alanine aminotransferase, 34 ± 13.9 to 21.2 ± 5.4 U/L; aspartate aminotransferase, 26.3 ± 6.2 to 20.50 ± 4 U/L; γ-glutamyl transpeptidase, 33 ± 15 to 23.2 ± 11.1 U/L; fibrosis score, 6.3 ± 1 to 5.2 ± 1.2 kPa; and controlled attenuation parameter, 322.9 ± 34.9 to 270.9 ± 36.2 dB/m), lipids (triacylglycerols, 201.5 ± 35.3 to 133.3 ± 48.7 mg/dL; total cholesterol, 190 ± 36.6 to 157.8 ± 33.6 mg/dL; and low-density lipoprotein cholesterol, 104.6 ± 27.3 to 84 ± 26.3 mg/dL), and inflammatory markers (high-sensitivity C-reactive protein, 3.1 ± 1.1 to 2 ± 0.9 mg/L; and cytokeratin-18, 1.35 ± 0.03 to 1.16 ± 0.03 ng/mL). These results were statistically significant (P < 0.05) compared with the control group.

CONCLUSIONS

TRF plus a low-sugar diet can reduce adiposity and improve liver, lipid, and inflammatory markers in patients with NAFLD.

Low Accuracy of FIB-4 and NAFLD Fibrosis Scores for Screening for Liver Fibrosis in the Population

BACKGROUND & AIMS

Fibrosis-4 (FIB-4) and the nonalcoholic fatty liver disease fibrosis score (NFS) are the 2 most popular noninvasive blood-based serum tests proposed for widespread fibrosis screening. We therefore aimed to describe the accuracy of FIB-4 and NFS to detect elevated liver stiffness as an indicator of hepatic fibrosis in low-prevalence populations.

METHODS

This study included a total of 5129 patients with concomitant measurement of FIB-4, NFS, and liver stiffness measurement (LSM) by Fibroscan (Echosens, France) from 5 independent population-based cohorts from Spain, Hong Kong, Denmark, England, and France; 3979 participants from the general population and 1150 from at-risk cohorts due to alcohol, diabetes, or obesity. We correlated LSM with FIB-4 and NFS, and calculated pre- and post-test predictive values of FIB-4 and NFS to detect elevated LSM at 8 kPa and 12 kPa cutoffs. The mean age was 53 ± 12 years, the mean body mass index was 27 ± 5 kg/m², and 2439 (57%) were women. One in 10 patients (552; 11%) had liver stiffness ≥8 kPa, but 239 of those (43%) had a normal FIB-4, and 171 (31%) had normal NFS. The proportion of false-negatives was higher in at-risk patients than the general population. FIB-4 was false-negative in 11% of diabetic subjects, compared with 2.5% false-negatives with NFS. Waist circumference outperformed FIB-4 and NFS for detecting LSM ≥8 kPa in the general population. Almost one-third (28%-29%) of elevated FIB-4/NFS were false-positive in both the general population and at-risk cohorts.

CONCLUSIONS

FIB-4 and NFS are suboptimal for screening purposes due to a high risk of overdiagnosis and a non-negligible percentage of false-negatives, especially in patients with risk factors for chronic liver disease. Waist circumference emerged as a potential first step to identify patients at risk for liver fibrosis in the general population.

Prevalence estimation of significant fibrosis because of NASH in Spain combining transient elastography and histology

BACKGROUND & AIMS

Non-alcoholic fatty liver disease (NAFLD) has become a major public health problem, but the prevalence of fibrosis associated with non-alcoholic steatohepatitis (NASH) is largely unknown in the general population. This study aimed to provide an updated estimation of the prevalence of NASH fibrosis in Spain.

METHODS

This was an observational, retrospective, cross-sectional, population-based study with merged data from two Spanish datasets: a large (N = 12 246) population-based cohort (ETHON), including transient elastography (TE) data, and a contemporary multi-centric biopsy-proven NASH cohort with paired TE data from tertiary centres (N = 501). Prevalence for each NASH fibrosis stage was estimated by crossing TE data from ETHON dataset with histology data from the biopsy-proven cohort.

RESULTS

From the patients with valid TE in ETHON dataset (N = 11 440), 5.61% (95% confidence interval [95% CI]: 2.53-11.97) had a liver stiffness measurement (LSM) ≥ 8 kPa. The proportion attributable to NAFLD (using clinical variables and Controlled Attenuation Parameter) was 57.3% and thus, the estimated prevalence of population with LSM ≥ 8 kPa because of NAFLD was 3.21% (95% CI 1.13-8.75). In the biopsy-proven NASH cohort, 389 patients had LSM ≥ 8 kPa. Among these, 37% did not have significant fibrosis (F2-4). The estimated prevalence of NASH F2-3 and cirrhosis in Spain's adult population were 1.33% (95% CI 0.29-5.98) and 0.70% (95% CI 0.10-4.95) respectively.

CONCLUSIONS

These estimations provide an accurate picture of the current prevalence of NASH-related fibrosis in Spain and can serve as reference point for dimensioning the therapeutic efforts that will be required as NASH therapies become available.

Transient Elastography-Assessed Hepatic Steatosis and Fibrosis Are Associated With Body Composition in the United States

BACKGROUND & AIMS

We examined transient elastography assessed hepatic steatosis and fibrosis distributions and relationships with body composition in a representative United States population sample.

METHODS

Liver stiffness and controlled attenuation parameter (CAP) were assessed on 4870 non-Hispanic White, non-Hispanic Black, non-Hispanic Asian, and Hispanic men and women aged 20 years and over in the National Health and Nutrition Examination Survey (NHANES) 2017-2018. Participants underwent anthropometry and dual-energy x-ray absorptiometry (DXA).

RESULTS

Compared to women, men had higher mean CAP (274.2 dB/m vs 254.4 dB/m) and liver stiffness (6.4 kPa vs 5.5 kPa). CAP and liver stiffness increased through middle age and markedly with BMI. In multivariate-adjusted analysis, CAP in the upper quartile was associated with increased age, BMI, waist-to-hip ratio, diabetes, hypertension, alanine aminotransferase (ALT) and C-reactive protein and decreased HDL cholesterol. After adjustment, non-Hispanic Blacks had lower CAP and non-Hispanic Asians had higher CAP. In multivariate-adjusted analysis, liver stiffness in the upper quartile was associated with male sex, increased age, BMI, diabetes, hepatitis C virus positivity, ALT and CAP. Lower stiffness among Non-Hispanic Asians was not significant after adjustment for BMI. DXA trunk and extremity fat mass were positively related to both CAP and liver stiffness with multivariate adjustment (P < .001 for each). Results were similar with CAP and liver stiffness as continuous characteristics.

CONCLUSIONS

In the United States population, increased anthropometric and DXA body composition measures were associated with higher CAP and liver stiffness. Racial-ethnic differences observed merit further research to elucidate the burden of obesity and liver health disparities.

Diagnostic Modalities of Non-Alcoholic Fatty Liver Disease: From Biochemical Biomarkers to Multi-Omics Non-Invasive Approaches

Non-Alcoholic Fatty Liver Disease (NAFLD) is currently the most common cause of chronic liver disease worldwide, and its prevalence is increasing globally. NAFLD is a multifaceted disorder, and its spectrum includes steatosis to steatohepatitis, which may evolve to advanced fibrosis and cirrhosis. In addition, the presence of NAFLD is independently associated with a higher cardiometabolic risk and increased mortality rates. Considering that the vast majority of individuals with NAFLD are mainly asymptomatic, early diagnosis of non-alcoholic steatohepatitis (NASH) and accurate staging of fibrosis risk is crucial for better stratification, monitoring and targeted management of patients at risk. To date, liver biopsy remains the gold standard procedure for the diagnosis of NASH and staging of NAFLD. However, due to its invasive nature, research on non-invasive tests is rapidly increasing with significant advances having been achieved during the last decades in the diagnostic field. New promising non-invasive biomarkers and techniques have been developed, evaluated and assessed, including biochemical markers, imaging modalities and the most recent multi-omics approaches. Our article provides a comprehensive review of the currently available and emerging non-invasive diagnostic tools used in assessing NAFLD, also highlighting the importance of accurate and validated diagnostic tools.

Agreement Between the Prevalence of Nonalcoholic Fatty Liver Disease Determined by Transient Elastography and Fatty Liver Indices

Nonalcoholic fatty liver disease (NAFLD) is a global public health problem linked to the rising prevalence of obesity and metabolic disorders.1 Accurate estimates of NAFLD in populations are challenging because the gold standard for detection is liver biopsy, an invasive procedure that precludes its use in research settings.2 NAFLD can also be detected via noninvasive imaging, such as ultrasound, magnetic resonance imaging-determined proton density fat fraction, magnetic resonance spectroscopy, and the controlled attenuation parameter derived via transient elastography (CAP-TE).2 Given the complexities of imaging in population studies, however, many estimates have been based on calculated indices, such as the Fatty Liver Index (FLI)3 and the Hepatic Steatosis Index (HSI).4 Concern has been raised that the indices underestimate the prevalence of NAFLD,5 thus downplaying the scope of the public health challenge. Ability to examine whether these concerns are substantive has been provided by a recent study of the US population. Using data from the study, it was reported that the US prevalence of CAP-TE-determined NAFLD was 47.8%.6 The current analysis used data from the same national study to examine how well the fatty liver indices corresponded to CAP-TE-determined NAFLD. Because most persons with NAFLD reportedly have elevated alanine aminotransferase (ALT) levels,7 the correspondence between elevated ALT and CAP-TE was also examined.

Population screening for liver fibrosis: Toward early diagnosis and intervention for chronic liver diseases

Cirrhosis, highly prevalent worldwide, develops after years of hepatic inflammation triggering progressive fibrosis. Currently, the main etiologies of cirrhosis are non-alcoholic fatty liver disease and alcohol-related liver disease, although chronic hepatitis B and C infections are still major etiological factors in some areas of the world. Recent studies have shown that liver fibrosis can be assessed with relatively high accuracy noninvasively by serological tests, transient elastography, and radiological methods. These modalities may be utilized for screening for liver fibrosis in at-risk populations. Thus far, a limited number of population-based studies using noninvasive tests in different areas of the world indicate that a significant percentage of subjects without known liver disease (around 5% in general populations and a higher rate -18% to 27%-in populations with risk factors for liver disease) have significant undetected liver fibrosis or established cirrhosis. Larger international studies are required to show the harms and benefits before concluding that screening for liver fibrosis should be applied to populations at risk for chronic liver diseases. Screening for liver fibrosis has the potential for changing the current approach from diagnosing chronic liver diseases late when patients have already developed complications of cirrhosis to diagnosing liver fibrosis in asymptomatic subjects providing the opportunity of preventing disease progression.

Interaction between metabolic syndrome and alcohol consumption, risk factors of liver fibrosis: A population-based study

BACKGROUND AND AIMS

Alcohol and metabolic syndrome (MS) coexist frequently as cofactors of liver disease. Previous studies suggest a deleterious effect of MS in advanced alcohol-related liver disease (ArLD). However, it is unknow whether MS can increase the risk of liver fibrosis in early stages of ArLD. The aim of this study was to investigate the effect of MS on liver fibrosis in subjects with alcohol consumption from a population-based cohort.

METHODS

The number of subjects include 1760(58%) of 3014 who were randomly selected from the community consumed alcohol and were classified as current drinkers, divided in moderate (n = 1222) or high-risk drinkers (n = 275) (>21 units/week men, >14 units/week women for high-risk drinkers), or former drinkers (n = 263). Liver fibrosis was estimated by measuring liver stiffness(LS) with transient elastography (TE).

RESULTS

Prevalence of significant LS using cutoff values of TE of 8 and 9.1kPa was increased in high-risk compared with moderate or former drinkers and lifetime abstainers. In subjects with alcohol consumption, LS was associated with male gender, AST, ALT, years of consumption, and MS. In high-risk drinkers, MS and intensity of consumption were the only factors associated with significant LS (OR 3.7 and 4.6 for LS ≥ 8 kPa and 3.9 and 9.2 kPa for LS ≥ 9.1 kPa, respectively). Presence of significant liver fibrosis in the liver biopsy was higher among high-risk as compared with moderate or former drinkers.

CONCLUSION

MS increases the risk of liver fibrosis in subjects with alcohol consumption. Among high-risk drinkers, only MS and consumption of high amount of alcohol are associated with risk of liver fibrosis.

Is there an association between commonly employed biomarkers of liver fibrosis and liver stiffness in the general population?

INTRODUCTION AND OBJECTIVES

Surrogate biomarkers of liver fibrosis developed in tertiary care are increasingly used in general populations. We evaluated the association between liver stiffness (LS) and five continuous (AST/ALT, APRI, Forns Index, FIB-4, GGT) and two discrete biomarkers (BARD, BAAT) in a general population.

PATIENTS AND METHODS

636 (29%) of the 2159 citizens of the Bagnacavallo Study had LS measured by transient elastography. Using linear regression with univariate multiple imputation, we evaluated the association of LS with the above biomarkers in the total sample of 2159 citizens.

RESULTS

The mean change of LS between the 5^th and 9^5th internal percentile of any continuous biomarker was ≤1kPa. The mean change of LS between scores 0 and 3 of BARD and scores 0 and ≥3 of BAAT was >1kPa but of doubtful clinical relevance.

CONCLUSION

We found a modest association between LS and seven biomarkers of liver fibrosis in a general population.

Prevalence and factors associated with NAFLD detected by vibration controlled transient elastography among US adults: Results from NHANES 2017-2018

BACKGROUND

Non-alcoholic fatty liver disease (NAFLD) is increasingly common in the adult population. In the United States, the overall burden of NAFLD is unknown due to challenges with population-level NAFLD detection. The purpose of this study was to estimate prevalence of NAFLD and significant NAFLD fibrosis and identify factors associated with them in the U.S.

METHODS

Data came from the 2017-2018 cycle of National Health and Nutrition Examination Survey. We defined NAFLD by controlled attenuation parameter (CAP) scores of ≥248 dB/m in absence of excessive alcohol use and viral hepatitis. We defined significant fibrosis as Vibration controlled transient elastography (VCTE) liver stiffness measurements (LSM) value ≥7.9 kPa. We calculated the adjusted odds ratio (OR) and 95% confidential intervals (CI) for associations with NAFLD and significant NAFLD fibrosis using multivariable logistic regression.

RESULTS

Overall, among 4,024 individuals aged ≥20 years included in the analysis, 56.7% had NAFLD by CAP. In comparison, when defined by elevated liver enzymes, NAFLD prevalence was 12.4%. The prevalence of significant NAFLD fibrosis by VCTE LSM was 14.5%. NAFLD prevalence increased with age, was higher among men than women and among Hispanics compared with non-Hispanic whites. Individuals who were obese, had metabolic syndrome (MetS) and type 2 diabetes were more likely to have NAFLD compared to those that who were not obese or without MetS/diabetes. Inadequate physical activity (OR = 1.57, 95% CI: 1.18-2.08) was also a factor associated with NAFLD. MetS, high waist circumstance, diabetes and hypertension were independently associated with significant NAFLD fibrosis.

CONCLUSIONS

NAFLD and significant NAFLD fibrosis are highly prevalent in U.S. general population.

Assessment of hepatic fibrosis and steatosis by vibration-controlled transient elastography and controlled attenuation parameter versus non-invasive assessment scores in patients with non-alcoholic fatty liver disease

Background

Non-alcoholic fatty liver disease (NAFLD) is regarded as the most common liver disease in the twenty-first century, and a condition leaving individuals at increased risk of extra-hepatic morbidity. Liver biopsy has long been regarded as the gold standard for diagnosis and prognostication of patients with NAFLD. However, due to its invasive nature and potential complications (e.g., bleeding), other methods for non-invasive laboratory and radiological assessment of hepatic steatosis and fibrosis in NAFLD have evolved and include scores such as AST/Platelet Ratio Index (APRI), Fibrosis-4 (FIB-4) score, NAFLD fibrosis score (NFS), and fatty liver index (FLI), in addition to radiological methods such as transient elastography (TE), which is a well-validated non-invasive ultrasound-based technique for assessment of hepatic fibrosis. Recently, novel development of controlled attenuation parameter (CAP) in TE allowed simultaneous assessment of hepatic steatosis. This provided a chance to assess both hepatic fibrosis and steatosis in the same setting and without any unwanted complications. This study aimed at assessing the role of TE and CAP versus other non-invasive assessment scores for liver fibrosis and steatosis in patients with NAFLD.

Results

This study included 90 patients diagnosed with NAFLD based on abdominal ultrasonography, body mass index, and serum liver enzymes. All patients were assessed with TE and non-invasive scores (APRI score, FIB-4 score, NFS, and FLI). There was a highly significant positive correlation between fibrosis and steatosis grades assessed by TE and other non-invasive respective scores. Both TE and CAP achieved acceptable sensitivity and specificity compared to other non-invasive assessment methods.

Conclusions

TE with CAP can be used as a screening method for patients suspected with NAFLD or patients without a clear indication for liver biopsy. CAP allows a non-invasive method of assessment of hepatic steatosis in patients with NAFLD.

Toward precision prescribing for methadone: Determinants of methadone deposition

BACKGROUND

Despite the World Health Organization listing methadone as an essential medication, effective dose selection is challenging, especially in racial and ethnic minority populations. Subtherapeutic doses can result in withdrawal symptoms while supratherapeutic doses can result in overdose and death. Although CYP3A4 was conventionally considered the principal methadone metabolizing enzyme, more recent data have identified CYP2B6 as the principal enzyme. CYP2B6 has ethnically-associated polymorphisms that affect the metabolic rate. Our objective was to investigate the effects of genetic and nongenetic factors on methadone metabolism.

METHODS

We measured trough plasma methadone levels in 100 participants with opioid use disorder. We assessed methadone metabolism by calculating the metabolite ratio (major metabolite: 2-ethylidene-1,5-dimethyl-3,3-diphenylpyrrolidine [EDDP] divided by methadone concentration). We assessed hepatic fibrosis and steatosis by transient elastography and CYP2B6 alleles, principally responsible for methadone metabolism. Mixed effects models modeled the data in 97 participants.

RESULTS

Participants were largely male (58%), minority (61% African American) and non-Hispanic (68%). Forty percent were HCV mono-infected, 40% were uninfected, and 20% were HCV/HIV co-infected. Female sex had significant effects on (R)- and (S)-methadone metabolism (p = 0.016 and p = 0.044, respectively). CYP2B6 loss of function (LOF) alleles significantly affected (S)-methadone metabolism (p = 0.012). Body mass index (BMI) significantly affected (R)-methadone metabolism (p = 0.034). Methadone metabolism appeared to be lower in males, in individuals with LOF alleles, and elevated BMI.

CONCLUSIONS

Genetic analysis, especially in minority populations, is essential to delivering individualized treatments. Although the principal methadone metabolizing enzyme remains controversial, our results suggest that sex, CYP2B6 genotype, and BMI should be incorporated into multivariate models to create methadone dosing algorithms. Methadone dosing algorithms should facilitate medication delivery, improve patient satisfaction, and diminish overdose potential.

Transient elastography for screening of liver fibrosis: Cost-effectiveness analysis from six prospective cohorts in Europe and Asia

BACKGROUND & AIMS

Non-alcoholic fatty liver disease and alcohol-related liver disease pose an important challenge to current clinical healthcare pathways because of the large number of at-risk patients. Therefore, we aimed to explore the cost-effectiveness of transient elastography (TE) as a screening method to detect liver fibrosis in a primary care pathway.

METHODS

Cost-effectiveness analysis was performed using real-life individual patient data from 6 independent prospective cohorts (5 from Europe and 1 from Asia). A diagnostic algorithm with conditional inference trees was developed to explore the relationships between liver stiffness, socio-demographics, comorbidities, and hepatic fibrosis, the latter assessed by fibrosis scores (FIB-4, NFS) and liver biopsies in a subset of 352 patients. We compared the incremental cost-effectiveness of a screening strategy against standard of care alongside the numbers needed to screen to diagnose a patient with fibrosis stage ≥F2.

RESULTS

The data set encompassed 6,295 participants (mean age 55 ± 12 years, BMI 27 ± 5 kg/m², liver stiffness 5.6 ± 5.0 kPa). A 9.1 kPa TE cut-off provided the best accuracy for the diagnosis of significant fibrosis (≥F2) in general population settings, whereas a threshold of 9.5 kPa was optimal for populations at-risk of alcohol-related liver disease. TE with the proposed cut-offs outperformed fibrosis scores in terms of accuracy. Screening with TE was cost-effective with mean incremental cost-effectiveness ratios ranging from 2,570 €/QALY (95% CI 2,456-2,683) for a population at-risk of alcohol-related liver disease (age ≥45 years) to 6,217 €/QALY (95% CI 5,832-6,601) in the general population. Overall, there was a 12% chance of TE screening being cost saving across countries and populations.

CONCLUSIONS

Screening for liver fibrosis with TE in primary care is a cost-effective intervention for European and Asian populations and may even be cost saving.

LAY SUMMARY

The lack of optimized public health screening strategies for the detection of liver fibrosis in adults without known liver disease presents a major healthcare challenge. Analyses from 6 independent international cohorts, with transient elastography measurements, show that a community-based risk-stratification strategy for alcohol-related and non-alcoholic fatty liver diseases is cost-effective and potentially cost saving for our healthcare systems, as it leads to earlier identification of patients.