Development of a simple nonalcoholic fatty liver disease scoring system indicative of metabolic risks and insulin resistance

Validity of fatty liver prediction scores for diagnosis of fatty liver by Fibroscan

BACKGROUND

The Korea National Health and Nutrition Examination Survey nonalcoholic fatty liver disease (K-NAFLD) score was recently developed with the intent to operationally define nonalcoholic fatty liver disease (NAFLD). However, there remained an external validation that confirmed its diagnostic performance, especially in patients with alcohol consumption or hepatitis virus infection.

METHODS

Diagnostic accuracy of the K-NAFLD score was evaluated in a hospital-based cohort consisting of 1388 participants who received Fibroscan®. Multivariate-adjusted logistic regression models and the contrast estimation of receiver operating characteristic curves were used for validation of the K-NAFLD score, fatty liver index (FLI), and hepatic steatosis index (HSI).

RESULTS

K-NAFLD-moderate [adjusted odds ratio (aOR) = 2.53, 95% confidence interval (CI): 1.13-5.65] and K-NAFLD-high (aOR = 4.14, 95% CI: 1.69-10.13) groups showed higher risks of fatty liver compared to the K-NAFLD-low group after adjustments for demographic and clinical characteristics, and FLI-moderate and FLI-high groups revealed aORs of 2.05 (95% CI: 1.22-3.43) and 1.51 (95% CI: 0.78-2.90), respectively. In addition, the HSI was less predictive for Fibroscan®-defined fatty liver. Both K-NAFLD and FLI also demonstrated high accuracy in the prediction of fatty liver in patients with alcohol consumption and chronic hepatitis virus infection, and the adjusted area under curve values were comparable between K-NAFLD and FLI.

CONCLUSIONS

Externally validation of the K-NAFLD and FLI showed that these scores may be a useful, noninvasive, and non-imaging modality for the identification of fatty liver. In addition, these scores also predicted fatty liver in patients with alcohol consumption and chronic hepatitis virus infection.

Diagnosis and non-invasive assessment of MASLD in type 2 diabetes and obesity

BACKGROUND

Metabolic dysfunction-associated steatotic liver disease (MASLD) is currently the most common chronic liver disease and an important cause of cirrhosis and hepatocellular carcinoma. It is strongly associated with type 2 diabetes and obesity. Because of the huge number of patients at risk of MASLD, it is imperative to use non-invasive tests appropriately.

AIMS

To provide a narrative review on the performance and limitations of non-invasive tests, with a special emphasis on the impact of diabetes and obesity.

METHODS

We searched PubMed and Cochrane databases for articles published from 1990 to August 2023.

RESULTS

Abdominal ultrasonography remains the primary method to diagnose hepatic steatosis, while magnetic resonance imaging proton density fat fraction is currently the gold standard to quantify steatosis. Simple fibrosis scores such as the Fibrosis-4 index are well suited as initial assessment in primary care and non-hepatology settings to rule out advanced fibrosis and future risk of liver-related complications. However, because of its low positive predictive value, an abnormal test should be followed by specific blood (e.g. Enhanced Liver Fibrosis score) or imaging biomarkers (e.g. vibration-controlled transient elastography and magnetic resonance elastography) of fibrosis. Some non-invasive tests of fibrosis appear to be less accurate in patients with diabetes. Obesity also affects the performance of abdominal ultrasonography and transient elastography, whereas magnetic resonance imaging may not be feasible in some patients with severe obesity.

CONCLUSIONS

This article highlights issues surrounding the clinical application of non-invasive tests for MASLD in patients with type 2 diabetes and obesity.

Association between Dietary Quality and Non-Alcoholic Fatty Liver Disease in Korean Adults: A Nationwide, Population-Based Study Using the Korean Healthy Eating Index (2013-2021)

This study explored the relationship between the Korean Healthy Eating Index (KHEI) and non-alcoholic fatty liver disease (NAFLD). This cross-sectional study included 34,174 Korean adults. The KHEI was composed of three subcomponents (adequacy, moderation, and energy balance) and calculated based on a 24 h dietary recall. The total score ranged from 0 to 100, with a higher score indicating a greater adherence to the Korean dietary guidelines. The total KHEI scores were categorized into quartiles (Q1-Q4). NAFLD was classified using the hepatic steatosis index. Logistic regressions were used to estimate odds ratios (ORs) and 95% confidence intervals (CIs). The adjusted OR (95% CI) of NAFLD was 0.95 (0.87-1.03) for the Q2 group, 0.90 (0.83-0.98) for the Q3 group, and 0.79 (0.72-0.87) for the Q4 group, compared with the Q1 group. Among the subcomponents of the KHEI, individuals with high scores in the adequacy component, characterized by an abundant consumption of fruits, vegetables, and dairy products, exhibited the most pronounced association with NAFLD. A higher KHEI score was negatively associated with NAFLD in Korean adults. Therefore, the promotion of healthy dietary patterns can play a beneficial role in the prevention or management of NAFLD.

Two-Year Therapeutic Efficacy and Safety of Initial Triple Combination of Metformin, Sitagliptin, and Empagliflozin in Drug-Naïve Type 2 Diabetes Mellitus Patients

BACKGRUOUND

We investigated the long-term efficacy and safety of initial triple therapy using metformin, a dipeptidyl peptidase-4 inhibitor, and a sodium-glucose cotransporter-2 inhibitor, in patients with type 2 diabetes mellitus.

METHODS

We enrolled 170 drug-naïve patients with glycosylated hemoglobin (HbA1c) level >7.5% who had started triple therapy (metformin, sitagliptin, and empagliflozin). Glycemic, metabolic, and urinary parameters were measured for 24 months.

RESULTS

After 24 months, HbA1c level decreased significantly from 11.0%±1.8% to 7.0%±1.7%. At 12 and 24 months, the rates of achievement of the glycemic target goal (HbA1c <7.0%) were 72.5% and 61.7%, respectively, and homeostasis model assessment of β-cell function and insulin resistance indices improved. Whole-body fat percentage decreased by 1.08%, and whole-body muscle percentage increased by 0.97% after 24 months. Fatty liver indices and albuminuria improved significantly. The concentration of ketone bodies was elevated at the baseline but decreased after 24 months. There were no serious adverse events, including ketoacidosis.

CONCLUSION

Initial triple combination therapy with metformin, sitagliptin, and empagliflozin led to achievement of the glycemic target goal, which was maintained for 24 months without severe hypoglycemia but with improved metabolic function and albuminuria. This combination therapy may be a good strategy for drug-naïve patients with type 2 diabetes mellitus.

Application of artificial intelligence techniques for non-alcoholic fatty liver disease diagnosis: A systematic review (2005-2023)

BACKGROUND AND OBJECTIVES

Non-alcoholic fatty liver disease (NAFLD) is a common liver disease with a rapidly growing incidence worldwide. For prognostication and therapeutic decisions, it is important to distinguish the pathological stages of NAFLD: steatosis, steatohepatitis, and liver fibrosis, which are definitively diagnosed on invasive biopsy. Non-invasive ultrasound (US) imaging, including US elastography technique, and clinical parameters can be used to diagnose and grade NAFLD and its complications. Artificial intelligence (AI) is increasingly being harnessed for developing NAFLD diagnostic models based on clinical, biomarker, or imaging data. In this work, we systemically reviewed the literature for AI-enabled NAFLD diagnostic models based on US (including elastography) and clinical (including serological) data.

METHODS

We performed a comprehensive search on Google Scholar, Scopus, and PubMed search engines for articles published between January 2005 and June 2023 related to AI models for NAFLD diagnosis based on US and/or clinical parameters using the following search terms: "non-alcoholic fatty liver disease", "non-alcoholic steatohepatitis", "deep learning", "machine learning", "artificial intelligence", "ultrasound imaging", "sonography", "clinical information".

RESULTS

We reviewed 64 published models that used either US (including elastography) or clinical data input to detect the presence of NAFLD, non-alcoholic steatohepatitis, and/or fibrosis, and in some cases, the severity of steatosis, inflammation, and/or fibrosis as well. The performances of the published models were summarized, and stratified by data input and algorithms used, which could be broadly divided into machine and deep learning approaches.

CONCLUSION

AI models based on US imaging and clinical data can reliably detect NAFLD and its complications, thereby reducing diagnostic costs and the need for invasive liver biopsy. The models offer advantages of efficiency, accuracy, and accessibility, and serve as virtual assistants for specialists to accelerate disease diagnosis and reduce treatment costs for patients and healthcare systems.

Liver Fat Scores for Noninvasive Diagnosis and Monitoring of Nonalcoholic Fatty Liver Disease in Epidemiological and Clinical Studies

Nonalcoholic fatty liver disease (NAFLD) is strongly associated with the metabolic syndrome and type 2 diabetes and independently contributes to long-term complications. Being often asymptomatic but reversible, it would require population-wide screening, but direct diagnostics are either too invasive (liver biopsy), costly (MRI) or depending on the examiner's expertise (ultrasonography). Hepatosteatosis is usually accommodated by features of the metabolic syndrome (e.g. obesity, disturbances in triglyceride and glucose metabolism), and signs of hepatocellular damage, all of which are reflected by biomarkers, which poorly predict NAFLD as single item, but provide a cheap diagnostic alternative when integrated into composite liver fat indices. Fatty liver index, NAFLD LFS, and hepatic steatosis index are common and accurate indices for NAFLD prediction, but show limited accuracy for liver fat quantification. Other indices are rarely used. Hepatic fibrosis scores are commonly used in clinical practice, but their mandatory reflection of fibrotic reorganization, hepatic injury or systemic sequelae reduces sensitivity for the diagnosis of simple steatosis. Diet-induced liver fat changes are poorly reflected by liver fat indices, depending on the intervention and its specific impact of weight loss on NAFLD. This limited validity in longitudinal settings stimulates research for new equations. Adipokines, hepatokines, markers of cellular integrity, genetic variants but also simple and inexpensive routine parameters might be potential components. Currently, liver fat indices lack precision for NAFLD prediction or monitoring in individual patients, but in large cohorts they may substitute nonexistent imaging data and serve as a compound biomarker of metabolic syndrome and its cardiometabolic sequelae.

Prevalence of metabolic syndrome and metabolic dysfunction-associated fatty liver disease in Malaysia 2023: study protocol for a community-based nationwide cross-sectional survey

INTRODUCTION

Metabolic syndrome (MetS) is a cluster of cardio-metabolic dysfunctions characterised by increased fasting plasma glucose, waist circumference, blood pressure, triglycerides and reduction in high-density lipoprotein cholesterol. Meanwhile, metabolic dysfunction-associated fatty liver disease (MAFLD) is the new term for fatty liver associated with MetS. People with MetS or MAFLD have higher risks for adverse cardiovascular outcomes and mortalities. However, large-scale data on MetS and MAFLD prevalence in Malaysia is mainly unknown. This study aims to determine the prevalence of MetS and MAFLD among the general adult population in Malaysia.

METHODS AND ANALYSIS

This is a community-based nationwide cross-sectional study in Malaysia. The data collection period is from July 2023 until September 2023, with a planned sample size of 1296 participants. We use a two-stage proportionate stratified random sampling method to ensure national representativeness. The definition of MetS follows the Harmonised Joint Interim Statement in 2009. A diagnosis of MAFLD is made if a participant has fatty liver, defined as having a Fatty Liver Index ≥60 and has type 2 diabetes, a body mass index ≥23 kg/m2, or ≥2 metabolic risk abnormalities. Complex sample analysis will be conducted, and the disease prevalence will be reported with 95% CIs, unweighted counts and estimated populations.

ETHICS AND DISSEMINATION

The protocol has been approved by the Medical Research and Ethics Committee of the Ministry of Health Malaysia (NMRR ID-22-02845-GUT). The findings will be disseminated through a formal report, policy brief, scientific publications, conference presentations, social media, print media and stakeholder engagement activities.

The Role of the Fatty Liver Index (FLI) in the Management of Non-Alcoholic Fatty Liver Disease: A Systematic Review

Currently, non-alcoholic fatty liver disease is the most common liver disease worldwide, with a prevalence of 32%. It is much more common among men (40%) and among patients with metabolic comorbidities such as obesity, diabetes and dyslipidemia. Being an asymptomatic disease, the diagnosis is often established on the basis of imaging methods, with an important role given to abdominal ultrasonography, computed tomography and magnetic resonance imaging. In order to facilitate diagnosis, experts have introduced a series of blood biomarkers. Two biomarker panels are currently validated for the diagnosis of non-alcoholic fatty liver disease: the fatty liver index, and the hepatic steatosis index. The fatty liver index has been in use in medical practice for over 17 years and has demonstrated its accuracy in various studies that compared it with other diagnostic methods, highlighted its role in screening patients with cardiovascular risk and validated the effects of different diets and drugs that are proposed for the treatment of the disease. In the management of non-alcoholic fatty liver disease, the fatty liver index is an important algorithm in the diagnosis and prognosis of patients with metabolic risk. Taking into account the diversity of drugs to be approved in the treatment of non-alcoholic fatty liver disease, the fatty liver index will become an effective tool in monitoring the effects of these therapies.

Comparison of the diagnostic performance of twelve noninvasive scores of metabolic dysfunction-associated fatty liver disease

BACKGROUND

The absence of distinct symptoms in the majority of individuals with metabolic dysfunction-associated fatty liver disease (MAFLD) poses challenges in identifying those at high risk, so we need simple, efficient and cost-effective noninvasive scores to aid healthcare professionals in patient identification. While most noninvasive scores were developed for the diagnosis of nonalcoholic fatty liver disease (NAFLD), consequently, the objective of this study was to systematically assess the diagnostic ability of 12 noninvasive scores (METS-IR/TyG/TyG-WC/TyG-BMI/TyG-WtHR/VAI/HSI/FLI/ZJU/FSI/K-NAFLD) for MAFLD.

METHODS

The study recruited eligible participants from two sources: the National Health and Nutrition Examination Survey (NHANES) 2017-2020.3 cycle and the database of the West China Hospital Health Management Center. The performance of the model was assessed using various metrics, including area under the receiver operating characteristic curve (AUC), net reclassification index (NRI), integrated discrimination improvement (IDI), decision curve analysis (DCA), and subgroup analysis.

RESULTS

A total of 7398 participants from the NHANES cohort and 4880 patients from the Western China cohort were included. TyG-WC had the best predictive power for MAFLD risk in the NHANES cohort (AUC 0.863, 95% CI 0.855-0.871), while TyG-BMI had the best predictive ability in the Western China cohort (AUC 0.903, 95% CI 0.895-0.911), outperforming other models, and in terms of IDI, NRI, DCA, and subgroup analysis combined, TyG-WC remained superior in the NAHANES cohort and TyG-BMI in the Western China cohort.

CONCLUSIONS

TyG-BMI demonstrated satisfactory diagnostic efficacy in identifying individuals at a heightened risk of MAFLD in Western China. Conversely, TyG-WC exhibited the best diagnostic performance for MAFLD risk recognition in the United States population. These findings suggest the necessity of selecting the most suitable predictive models based on regional and ethnic variations.

Cardiovascular Implications of Metabolic Dysfunction-Associated Fatty Liver Disease

Both nonalcoholic fatty liver disease (NAFLD) and metabolic dysfunction-associated fatty liver disease (MAFLD) have been associated with incident cardiovascular disease (CVD), independent of confounders. Causality has recently been inferred by Mendelian randomization studies. Although these findings have contributed to current guidelines that recommend screening for and treatment of cardiovascular risk factors, it not yet clear how to position NAFLD/MAFLD in cardiovascular risk estimation scores and, consequently, which treatment targets should be used. This review aims to provide practical tools as well as suggestions for further research in order to effectively prevent CVD events in patients with NAFLD/MAFLD.

Increased risk of cardiometabolic disease in normal-weight individuals with non-alcoholic fatty liver disease

BACKGROUND

Non-alcoholic fatty liver disease (NAFLD) is strongly associated with obesity, but there is increasing evidence that not all individuals who are overweight/obese also develop NAFLD. Currently, it is unclear whether normal-weight (Nw) individuals with NAFLD have a higher risk of cardiometabolic disease risk compared with individual sub-groups (Nw and Obesity [Ob]) of non-NAFLD.

AIMS

This study aimed to compare the cardiometabolic profiles, cardiovascular disease, and diabetes between Nw vs. Ob with non-NAFLD vs. NAFLD.

METHODS

This study utilized the Korea National Health and Nutrition Examination Surveys collected from 2019 to 2021. Individuals were stratified into Nw vs. Ob categories and further divided into non-NAFLD and NAFLD groups based on the hepatic steatosis index and liver fat score (N = 6615).

RESULTS

The prevalence of non-NAFLD Nw, non-NAFLD Ob, NAFLD Nw, and NAFLD Ob groups was 36%, 20%, 7%, and 37%, respectively. NAFLD Nw vs. non-NAFLD Ob manifests deteriorated cardiometabolic disease risk profiles and surrogate markers of insulin resistance despite having higher weight, waist circumference, and BMI. In addition, compared to non-NAFLD Nw, individuals with NAFLD Nw had a significantly higher risk of CVDs (738%, p < .001) and diabetes (408%, p < .001), with no difference between NAFLD Nw and NAFLD Ob groups.

CONCLUSIONS

Cardiometabolic disease risk is more closely related to NAFLD developments than adiposity status. Therefore, not all overweight/obese individuals have a higher cardiometabolic disease risk, and NAFLD in Nw is an aggressive disease that is associated with cardiometabolic disease risk compared with Ob individuals without NAFLD.

Association of post-smoking cessation changes in fasting serum glucose with changes in predicted fatty liver score

Major post-cessation metabolic changes include weight gain and hyperglycemia. However, the association of post-cessation change in fasting serum glucose (FSG) with risk of fatty liver remains unclear. A total of 111,106 participants aged 40 and above who underwent health screening at least once in two examination periods were extracted from the Korean National Health Insurance Service-National Sample Cohort. Fatty liver status was evaluated using the Korean National Health and Nutrition Examination Survey nonalcoholic fatty liver disease (K-NAFLD) score. Linear and logistic regression were used to calculate the adjusted mean (aMean) and adjusted odds ratio (aOR) with 95% confidence intervals. Compared to stable (aMean 0.10; 95% CI 0.03-0.18) and decline (aMean - 0.60; 95% CI - 0.71 to 0.49) groups, FSG elevation (aMean 1.28; 95% CI 1.16-1.39) was associated with higher K-NAFLD score even within different body mass index change groups. Risk of fatty liver was significantly reduced among participants with stable (aOR 0.38; 95% CI 0.31-0.45) and declined (aOR 0.17; 95% CI 0.13-0.22) FSG levels after smoking cessation compared to FSG elevation group. This study suggests that quitters with elevated FSG are associated with higher NAFLD risk and may benefit from careful monitoring of FSG levels and management of other cardiovascular risk factors.

Association between the dual use of electronic and conventional cigarettes and NAFLD status in Korean men

INTRODUCTION

This study investigated the association between smoking types, including dual use (usage of both combustible cigarettes and e-cigarettes), and non-alcoholic fatty liver disease (NAFLD) status in Korean men.

METHODS

Data from the 7th and 8th Korea National Health and Nutrition Examination Survey (KNHANES) 2016-2020 were used. The presence of NAFLD was defined by the respective cut-off values for the Hepatic Steatosis Index (HSI), NAFLD Ridge Score (NRS), and Korea National Health and Nutrition Examination Survey NAFLD score (KNS). Multivariate logistic regression analyses were used to determine the associations between smoking types and NAFLD as determined by HSI, NRS, and KNS.

RESULTS

After adjustment for confounders, an independent association was observed between dual use and NAFLD (HSI: AOR=1.47; 95% CI: 1.08-1.99, p=0.014; NRS: AOR=2.21; 95% CI: 1.70-2.86, p=0.000; KNS: AOR=1.35; 95% CI: 1.01-1.81, p=0.045). Cigarette only smokers also had significantly higher odds of NAFLD compared to never smokers for all of the NAFLD indices (HSI: AOR=1.22; 95% CI: 1.05-1.42, p=0.008; NRS: AOR=2.13; 95% CI: 1.87-2.42, p=0.000; KNS: AOR=1.33; 95% CI: 1.14-1.55, p=0.000). In subgroup analyses, no significant interaction effects were found for age, BMI, alcohol consumption, income, physical activity, and the diagnosis of T2DM. Moreover, cigarette only smokers and dual users differed significantly in terms of log-transformed urine cotinine and pack-years. The relationship between smoking type and pack-years was attenuated after stratification by age.

CONCLUSIONS

This study shows that the dual use of e-cigarettes and combustible cigarettes is associated with NAFLD. Age differences may explain why dual users, with a greater proportion of young people, appear to have fewer pack-years than cigarette only smokers. Further research should be conducted to investigate the adverse effects of dual use on hepatic steatosis.

Noninvasive serum biomarkers for liver steatosis in nonalcoholic fatty liver disease: Current and future developments

Nonalcoholic fatty liver disease (NAFLD) affects approximately 30% of the population worldwide and includes nonalcoholic fatty liver, nonalcoholic steatohepatitis (NASH), and cirrhosis. Since NAFLD-associated diseases begin with steatosis, the early diagnosis of steatosis helps to prevent the progression of NASH and fibrosis. In addition, more convenient and easily diagnosable serum biomarkers are becoming crucial in disease diagnosis. In this report, we summarize the known serum biomarkers for liver steatosis and provide guidance for their application in clinical practice.

Association of Change in Smoking Status and Subsequent Weight Change with Risk of Nonalcoholic Fatty Liver Disease

Background/Aims

Smoking is considered a risk factor for the development of nonalcoholic fatty liver disease (NAFLD). However, the association of a weight change after a change in smoking status and the risk of NAFLD remains undetermined.

Methods

This study used the Korean National Health Insurance Service-National Sample Cohort. Based on the first (2009 to 2010) and second (2011 to 2012) health examination periods, 139,180 adults aged at least 40 years were divided into nonsmoking, smoking cessation, smoking relapse, and sustained smoking groups. NAFLD was operationally defined using the fatty liver index. The adjusted odds ratio (aOR) and 95% confidence interval (CI) were calculated using multivariable-adjusted logistic regression.

Results

Compared to nonsmoking with no body mass index (BMI) change, the risk of NAFLD was significantly increased among subjects with BMI gain and nonsmoking (aOR, 4.07; 95% CI, 3.77 to 4.39), smoking cessation (aOR, 5.52; 95% CI, 4.12 to 7.40), smoking relapse (aOR, 7.51; 95% CI, 4.81 to 11.72), and sustained smoking (aOR, 6.65; 95% CI, 5.33 to 8.29), whereas the risk of NAFLD was reduced among participants with BMI loss in all smoking status groups. In addition, smoking cessation (aOR, 1.76; 95% CI, 1.35 to 2.29) and sustained smoking (aOR, 1.64; 95% CI, 1.39 to 1.94) were associated with higher risk of NAFLD among participants with no BMI change. The liver enzyme levels were higher among participants with smoking cessation and BMI gain.

Conclusions

Monitoring and management of weight change after a change in smoking status may be a promising approach to reducing NAFLD.

Immunotherapy for NAFLD and NAFLD-related hepatocellular carcinoma

The progression of non-alcoholic fatty liver disease (NAFLD), the most common liver disease, leads to non-alcoholic steatohepatitis and hepatocellular carcinoma. Despite the increasing incidence and prevalence of NAFLD, its therapeutic and preventive strategies to lower the disease burden is limited. In recent years, immunotherapy, including anti-programmed cell death 1/programmed cell death 1 ligand 1 treatment, has emerged as a potential approach to reach satisfactory modulation for the progression of NAFLD and treatment of NAFLD-related hepatocellular carcinoma. However, the effectiveness of immunotherapy against NAFLD and NAFLD-related hepatocellular carcinoma is in the early phase and it is yet not advanced. In addition, conflicting results are being reported regarding the prognosis of patients with NAFLD-related hepatocellular carcinoma and high expression of programmed cell death 1/programmed cell death 1 ligand 1. Herein, this review will discuss and elucidate the attempts and underlying mechanisms of immunotherapy against NAFLD and NAFLD-related hepatocellular carcinoma.

Curcumin Offers No Additional Benefit to Lifestyle Intervention on Cardiometabolic Status in Patients with Non-Alcoholic Fatty Liver Disease

Cardiovascular disease (CVD) is the leading cause of death in patients with non-alcoholic fatty liver disease (NAFLD). Curcumin has been shown to exert glucose-lowering and anti-atherosclerotic effects in type 2 diabetes. Hence, we investigated curcumin’s effects on atherogenesis markers, fatty liver, insulin resistance, and adipose tissue-related indicators in patients with NAFLD. In this secondary analysis of a 12-week randomized controlled trial, fifty-two patients with NAFLD received lifestyle modification. In addition, they were randomly allocated to either the curcumin group (1.5 g/day) or the matching placebo. Outcome variables (assessed before and after the study) were: the fatty liver index (FLI), hepatic steatosis index (HSI), fatty liver score (FLS), BMI, age, ALT, TG score (BAAT), triglyceride glucose (TyG) index, Castelli risk index-I (CRI-I), Castelli risk index-II (CRI-II), TG/HDL–C ratio, atherogenic coefficient (AC), atherogenic index of plasma (AIP), lipoprotein combine index (LCI), cholesterol index (CHOLINDEX), lipid accumulation product (LAP), body adiposity index (BAI), visceral adiposity index (VAI), metabolic score for visceral fat (METS-VF), visceral adipose tissue (VAT), and waist-to-height ratio (WHtR) values. The TyG index decreased in the curcumin group and increased in the placebo group, with a significant difference between the groups (p = 0.029). However, a between-group change was not significant after adjustment for multiple testing. Other indices were not significantly different between the groups either before or after multiple test correction. After the intervention, there was a lower number of patients with severe fatty liver (FLI ≥ 60) and metabolic syndrome in the curcumin group compared to the placebo (p = 0.021 and p = 0.012, respectively). In conclusion, curcumin offers no additional cardiometabolic benefits to lifestyle intervention in patients with NAFLD.

MAFLD/NAFLD Biopsy-Free Scoring Systems for Hepatic Steatosis, NASH, and Fibrosis Diagnosis

Metabolic dysfunction-associated fatty liver disease (MAFLD), formerly known as nonalcoholic fatty liver disease, is the most prevalent liver disorder worldwide. Historically, its diagnosis required biopsy, even though the procedure has a variable degree of error. Therefore, new non-invasive strategies are needed. Consequently, this article presents a thorough review of biopsy-free scoring systems proposed for the diagnosis of MAFLD. Similarly, it compares the severity of the disease, ranging from hepatic steatosis (HS) and nonalcoholic steatohepatitis (NASH) to fibrosis, by contrasting the corresponding serum markers, clinical associations, and performance metrics of these biopsy-free scoring systems. In this regard, defining MAFLD in conjunction with non-invasive tests can accurately identify patients with fatty liver at risk of fibrosis and its complications. Nonetheless, several biopsy-free scoring systems have been assessed only in certain cohorts; thus, further validation studies in different populations are required, with adjustment for variables, such as body mass index (BMI), clinical settings, concomitant diseases, and ethnic backgrounds. Hence, comprehensive studies on the effects of age, morbid obesity, and prevalence of MAFLD and advanced fibrosis in the target population are required. Nevertheless, the current clinical practice is urged to incorporate biopsy-free scoring systems that demonstrate adequate performance metrics for the accurate detection of patients with MAFLD and underlying conditions or those with contraindications of biopsy.

Non-invasive tests of non-alcoholic fatty liver disease

ABSTRACT

For the detection of steatosis, quantitative ultrasound imaging techniques have achieved great progress in past years. Magnetic resonance imaging proton density fat fraction is currently the most accurate test to detect hepatic steatosis. Some blood biomarkers correlate with non-alcoholic steatohepatitis, but the accuracy is modest. Regarding liver fibrosis, liver stiffness measurement by transient elastography (TE) has high accuracy and is widely used across the world. Magnetic resonance elastography is marginally better than TE but is limited by its cost and availability. Several blood biomarkers of fibrosis have been used in clinical trials and hold promise for selecting patients for treatment and monitoring treatment response. This article reviews new developments in the non-invasive assessment of non-alcoholic fatty liver disease (NAFLD). Accumulating evidence suggests that various non-invasive tests can be used to diagnose NAFLD, assess its severity, and predict the prognosis. Further studies are needed to determine the role of the tests as monitoring tools. We cannot overemphasize the importance of context in selecting appropriate tests.

Metabolic Dysfunction-Associated Fatty Liver Disease Better Predicts Incident Cardiovascular Disease

Background/Aims

Metabolic dysfunction (MD)-associated fatty liver disease is a new positive diagnostic criterion based on hepatic steatosis and MD. However, a comprehensive evaluation on the association of MD and hepatic steatosis with incident cardiovascular disease (CVD) has yet to be performed.

Methods

This retrospective cohort study included 333,389 participants from the Korean National Health Insurance Service database who received a health examination between 2009 and 2010. Hepatic steatosis was defined using the Korean National Health and Nutrition Examination Survey-derived nonalcoholic fatty liver disease scoring system. Cox proportional hazards regression was adopted to determine the adjusted hazard ratio (aHR) with 95% confidence interval (CI) for CVD according to the presence of hepatic steatosis and MD, as well as the composite term.

Results

This study included 179,437 men and 153,952 women with a median age of 57 years. Hepatic steatosis with MD (aHR, 2.00; 95% CI, 1.89 to 2.13) and without MD (aHR, 1.30; 95% CI, 1.10 to 1.54) significantly increased the risk of CVD compared to no steatosis without MD (reference). However, steatosis revealed no significant difference in the risk of CVD compared to no steatosis among participants with one MD (aHR, 1.09; 95% CI, 0.91 to 1.30). In participants with steatosis, the presence of one and ≥2 MDs had aHR values of 1.25 (95% CI, 0.87 to 1.79) and 1.71 (95% CI, 1.22 to 2.41), respectively, compared to no MD.

Conclusions

Combined consideration of hepatic steatosis and MD was significantly associated with increased CVD risk and showed better predictive performance for CVD than hepatic steatosis or MD alone.