Recent research trends and updates on nonalcoholic fatty liver disease

Molecular Docking Study of Phytosterols in Lygodium microphyllum Towards SIRT1 and AMPK, the in vitro Brine Shrimp Toxicity Test, and the Phenols and Sterols Levels in the Extract

Background

Lygodium microphyllum is a fern plant with various pharmacological activities, and phytosterols were reported contained in the n-hexane and ethyl acetate extract of this plant. Phytosterols are known to inhibit steatosis, oxidative stress, and inflammation. Sirtuin 1 (SIRT1) and adenosine monophosphate-activated protein kinase (AMPK) are the key proteins that control lipogenesis. However, information about L. microphyllum on SIRT1 and AMPK is still lacking.

Purpose

This study aims to investigate the binding mode of phytosterols in L. microphyllum extract towards AMPK and SIRT1, and the toxicity of the extract against brine shrimp (Artemia salina) larvae, and to determine the phenols and sterols levels in the extract.

Methods

The molecular docking was performed towards SIRT1 and AMPK using AutoDock v4.2.6, the toxicity of the extract was assayed against brine shrimp (Artemia salina) larvae, and the phytosterols were analyzed by employing a thin layer chromatography densitometry, and the total phenols were by spectrophotometry.

Results

The molecular docking study revealed that β-sitosterol and stigmasterol could occupy the active allosteric-binding site of SIRT1 and AMPK by binding to important residues similar to the protein's activators. The cold extraction of the plant yields 15.86% w/w. Phytochemical screening revealed the presence of phenols, steroids, flavonoids, alkaloids, and saponins. The total phenols are equivalent to 126 mg gallic acid (GAE)/g dry extract, the total sterols are 954.04 µg/g, and the β-sitosterol level is 283.55 µg/g. The LC50 value of the extract towards A. salina larvae is 203.704 ppm.

Conclusion

Lygodium microphyllum extract may have the potential to be further explored for its pharmacology activities, particularly in the discovery of plant-based anti-dyslipidemic drug candidates. However, further studies are needed to confirm their roles in alleviating lipid disorders.

Prognostication in NAFLD: physiological bases, clinical indicators, and newer biomarkers

Non-alcoholic fatty liver disease (NAFLD) is becoming an epidemic in Western countries. Notably, while the majority of NAFLD patients will not evolve until advanced liver disease, a minority of them will progress towards liver-related events. Therefore, risk stratification and prognostication are emerging as fundamental in order to optimize human and economic resources for the care of these patients.Liver fibrosis has been clearly recognized as the main predictor of poor hepatic and extrahepatic outcomes. However, a prediction based only on the stage of fibrosis is near-sighted and static, as it does not capture the propensity of disease to further progress, the speed of progression and their changes over time. These determinants, which result from the interaction between genetic predisposition and acquired risk factors (obesity, diabetes, etc.), express themselves in disease activity, and can be synthesized by biomarkers of hepatic inflammation and fibrogenesis.In this review, we present the currently available clinical tools for risk stratification and prognostication in NAFLD specifically with respect to the risk of progression towards hard hepatic outcomes, i.e., liver-related events and death. We also discuss about the genetic and acquired drivers of disease progression, together with the physiopathological bases of their come into action. Finally, we introduce the most promising biomarkers in the direction of repeatedly assessing disease activity over time, mainly in response to future therapeutic interventions.

The empirical dietary inflammatory pattern score and the risk of nonalcoholic fatty liver disease and cirrhosis

BACKGROUND

Diet plays an important role in the pathogenesis of NAFLD. Inflammation is a potential mechanism linking diet to NAFLD development and its progression to cirrhosis.1 We analyzed data from a large, prospective cohort of US women to examine the influence of dietary inflammatory potential on the long-term risk of developing NAFLD and cirrhosis.

METHODS

We prospectively followed 96,016 women in the Nurses' Health Study II cohort (1995-2017) who were free of chronic liver disease, including NAFLD, at baseline. The inflammatory potential of the diet was ascertained using an established, food-based empirical dietary inflammatory pattern score. Cox proportional hazard models were used to estimate multivariable-adjusted hazard ratios and 95% CIs for incident NAFLD and cirrhosis.

RESULTS

Over 2,085,947 person-years of follow-up, we documented 4389 cases of incident NAFLD and 102 cases of incident cirrhosis. Increasing cumulative average empirical dietary inflammatory pattern (EDIP) score was significantly and positively associated with incident NAFLD (multivariable-adjusted HR 1.31 per each 1-U increase in EDIP score, p-trend < 0.0001) and cirrhosis (p-trend of 0.034). Our findings also were consistent when examining recent diets using simple updated EDIP scores. In analyses of specific EDIP components, we observed an increased risk of incident NAFLD and cirrhosis with higher consumption of certain proinflammatory components of the EDIP score.

CONCLUSIONS

Dietary patterns with a higher proinflammatory potential may be associated with a higher risk of developing both NAFLD and cirrhosis. Reducing the inflammatory potential of diet may potentially provide an effective strategy for preventing the development of NAFLD and progression to cirrhosis.

Role of microRNA in non-alcoholic fatty liver disease (NAFLD) and non-alcoholic steatohepatitis (NASH): a comprehensive review

Non-alcoholic fatty liver disease (NAFLD) is a prevalent liver condition that affects people who do not overconsume alcohol. Uncertainties exist over how microRNAs (miRNAs) in the blood and liver relate to NAFLD. The aim of this narrative review was to investigate the role of miRNAs in the onset and progression of non-alcoholic steatohepatitis (NASH) from NAFLD, and explore their potential as diagnostic tools and treatment targets for NAFLD patients. Liver miRNA-34a levels were found to accurately represent the degree of liver damage, with lower levels suggesting more damage. In patients with NAFLD and severe liver fibrosis, higher levels of miRNA-193a-5p and miRNA-378d were found. Moreover, miRNA-34a, miRNA-122, and miRNA-192 levels might aid in differentiating NASH from NAFLD. Similar to this, miRNA-21 and miRNA-27 levels in rats were able to distinguish between steatosis and steatohepatitis. High-fat diets enhanced the expression of 15 distinct miRNAs in rats, and there were substantial differences in the miRNA expression patterns between obese and lean people. The results from the present review imply that miRNA microarrays and sequencing may be helpful diagnostic tools, and miRNAs may be a possible treatment target for patients with NAFLD.

Effect of spironolactone on pharmacological treatment of nonalcoholic fatty liver disease

Nonalcoholic fatty liver disease (NAFLD) was recently renamed to metabolic (dysfunction)-associated fatty liver disease (MAFLD) to better characterize its pathogenic origin. NAFLD represents, at least in western societies, a potential epidemic with raising prevalence. Its multifactorial pathogenesis is partially unraveled and till now there is no approved pharmacotherapy for NAFLD. A plethora of various choices are investigated in clinical trials, targeting an arsenal of different pathways and molecules. Since the mineralocorticoid receptor (MR) and renin-angiotensin-aldosterone system (RAAS) appear to be implicated in NAFLD, within this concise review, we focus on a rather classical and inexpensive pharmacological agent, spironolactone. We present the current lines of evidence of MR and RAAS-related preclinical models and human trials reporting an association with NAFLD. In conclusion, evidence about spironolactone of RAAS is commented, as potential future pharmacological management of NAFLD.

Non-Traditional Blood Lipid Indices for Metabolism Dysfunction-Associated Fatty Liver Disease Prediction in Non-Obese Type 2 Diabetes Mellitus

Objective

This study aims to investigate the predictive value of non-traditional blood lipid indices for metabolism dysfunction-associated fatty liver disease (MAFLD) in non-overweight/obese patients with type 2 diabetes mellitus (T2DM).

Methods

A retrospective observational study was conducted, including non-overweight/obese patients with T2DM who visited the Fourth Hospital of Hebei Medical University between August 2018 and August 2022. The low-density lipoprotein cholesterol (LDL-C)/high-density lipoprotein cholesterol (HDL-C) ratio, the triacylglycerol-glucose index (TyG) multiplied by body mass index (BMI), and TyG/HDL-C ratio were calculated.

Results

The study involved 190 participants, of whom 34 were diagnosed with MAFLD (24 males and 10 females), while 156 did not have MAFLD (64 males and 92 females). Multivariable analysis revealed that aspartate transaminase (AST) (OR=1.216, 95% CI: 1.059-1.374, P=0.006), blood uric acid (BUA) (OR=1.017, 95% CI: 1.002-1.032, P=0.022), TyG*BMI (OR=1.231, 95% CI: 1.051-1.442, P=0.010), and TyG/HDL-C (OR=3.162, 95% CI: 1.228-8.141, P=0.017) were independently associated with MAFLD. The TyG*BMI index exhibited an area under the ROC curve (AUC) of 0.812, with 91.2% sensitivity and 69.2% specificity for MAFLD. The TyG/HDL-C index had an AUC of 0.929, with 85.3% sensitivity and 88.5% specificity for MAFLD.

Conclusion

The results indicate that TyG*BMI and TyG/HDL-C are independently associated with MAFLD in non-overweight/obese patients with T2DM.

Associations between Adipokines and Metabolic Dysfunction-Associated Fatty Liver Disease Using Three Different Diagnostic Criteria

Background: A panel of experts proposed a new definition of metabolic dysfunction-associated fatty liver disease (MAFLD) in 2020. To date, the associations between adipokines, such as adiponectin, adipsin, and visfatin and MAFLD remain unclear. Therefore, we aimed to evaluate the associations between each of these three adipokines and MAFLD using different diagnostic criteria. Methods: In total, 221 participants were included in our study based on medical examination. Detailed questionnaire information, physical examination, abdominal ultrasound, and blood-biochemical-test indexes were collected. The levels of adipokines were tested by using an enzyme immunoassay. Logistic regression models were used to assess the associations of the adipokines with MAFLD. Results: In total, 122 of the participants were diagnosed with MAFLD. Higher levels of adipsin and lower levels of adiponectin were found in the MAFLD group than in the non-MAFLD group (all p < 0.05). According to the logistic regression analysis, the ORs were 0.11 (95% CI: 0.05–0.23) for adiponectin, 4.46 (95% CI: 2.19–9.12) for adipsin, and 0.51 (95% CI: 0.27–0.99) for visfatin when comparing the highest tertile with the lowest tertile (all p-trend < 0.05). The inverse association between adiponectin and MAFLD was strongest when T2DM was used as the diagnostic criterion alone, and the positive association between adipsin and MAFLD was strongest when BMI was used as the diagnostic criterion alone. There was no significant association between visfatin and MAFLD, regardless of whether each of BMI, T2DM, or metabolic dysregulation (MD) was used as the diagnostic criterion for MAFLD alone. Conclusion: Adipsin levels were positively associated with MAFLD and adiponectin levels were inversely associated with MAFLD. The strength of these associations varied according to the different diagnostic criteria for MAFLD.

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.

Global incidence and prevalence of nonalcoholic fatty liver disease

Nonalcoholic fatty liver disease (NAFLD) is a leading cause of liver disease worldwide. The estimated global incidence of NAFLD is 47 cases per 1,000 population and is higher among males than females. The estimated global prevalence of NAFLD among adults is 32% and is higher among males (40%) compared to females (26%). The global prevalence of NAFLD has increased over time, from 26% in studies from 2005 or earlier to 38% in studies from 2016 or beyond. The prevalence of NAFLD varies substantially by world region, contributed by differing rates of obesity, and genetic and socioeconomic factors. The prevalence of NAFLD exceeds 40% in the Americas and South-East Asia. The prevalence of NAFLD is projected to increase significantly in multiple world regions by 2030 if current trends are left unchecked. In this review, we discuss trends in the global incidence and prevalence of NAFLD and discuss future projections.

Impact of thyroid cancer on the cancer risk in patients with non-alcoholic fatty liver disease or dyslipidemia

The raised prevalence of obesity has increased the incidence of obesity-related metabolic diseases such as dyslipidemia (DL) and non-alcoholic fatty liver disease (NAFLD), along with the development and progression of various types of cancer, including thyroid cancer. In this study, we investigated whether thyroid cancer in patients with DL and NAFLD could be a risk factor for other cancers. To achieve our goal, we generated two independent cohorts from our institution and from the National Health Insurance System in South Korea. Based on the ICD-10 code, we conducted exact matching (1:5 matching) and estimated the overall risk of thyroid cancer for other cancers in patients with DL or NAFLD. Univariate and multivariate analyses showed that the hazard ratio (HR) of thyroid cancer was 2.007 (95% Confidence Interval [CI], 1.597-2.522) and 2.092 (95% CI, 1.546-2.829), respectively in the institutional cohort and 1.329 (95% CI, 1.153-1.533) and 1.301 (95% CI, 1.115-1.517), respectively in the nationwide cohort. Risk analysis revealed a significant increase in the HR in lip, tongue, mouth, lung, bone, joint, soft tissue, skin, brain, male cancers and lymphoma after thyroid cancer occurred. Thyroid cancer in patients with DL or NAFLD might be a valuable factor for predicting the development of other cancers.

A Nomogram Based on Preoperative Lab Tests, BMI, ICG-R15, and EHBF for the Prediction of Post-Hepatectomy Liver Failure in Patients with Hepatocellular Carcinoma

Background: Liver cancer is one of the most common malignant tumors, and worldwide, its incidence ranks sixth, and its morality third. Post-hepatectomy liver failure (PHLF) is the leading cause of death in patients who have undergone liver resection. This retrospective study investigated the risk factors for PHLF by predicting and constructing an index to evaluate the risk. This was achieved by combining the lab tests with an indocyanine green (ICG) clearance test. Methods: The study analyzed 1081 hepatocellular carcinoma (HCC) patients who had received liver resection at Sun Yat-sen University Cancer Center between 2005 and 2020. The patients were divided into a PHLF group (n = 113) and a non-PHLF group (n = 968), according to the International Study Group of Liver Surgery (ISGLS) criteria. Receiver operating characteristics (ROC) curves were then used to estimate the optimal cut-off values. Univariate and multivariate logistic regression analyses were performed to identify the independent risk factors. Finally, a nomogram was constructed where the calibration plot, the areas under the ROC curve (AUC), and the decision curve analysis (DCA) showed good predictive ability. Results: Correlation analysis revealed that body mass index (BMI) was positively correlated with ICG-R15 and with effective hepatic blood flow (EHBF). Univariate and multivariate logistics regression analysis revealed that BMI, ICG-R15, international normalized ratio (INR), tumor size, hepatic inflow occlusion (HIO) time, and operation method were independent predictive factors for PHLF. When these factors and EHBF were included in the nomogram, the nomogram showed a good predictive value, with a C-index of 0.773 (95% Confidence Interval [CI]: 0.729-0.818). The INR had the largest ROC areas (AUC INR = 0.661). Among the variables, ICG-R15 (AUC ICG-R15 = 0.604) and EHBF (AUC EHBF = 0.609) also showed good predictive power. Conclusions: The risk of PHLF in HCC patients can be precisely predicted by this model prior to the operation. By integrating EHBF into the model, HCC patients at higher risk for PHLF can be identified more effectively.

Environmental exposure to organophosphate esters and suspected non-alcoholic fatty liver disease among US adults: A mixture analysis

Objectives

Non-alcoholic fatty liver disease (NAFLD) is the most common chronic liver disease worldwide. We evaluated NAFLD using the US FLI to determine whether there is an association between urinary organophosphorus (OPE) levels and the "prevalence" of NAFLD in US individuals.

Methods

The current study included 1,102 people aged 20 years and older with information from the 2011-2014 U.S. National Health and Nutrition Examination Survey. NAFLD was assessed using the U.S. FLI. Individual OPE metabolites and OPE combinations were linked to NAFLD using logistic regression and weighted quantile sum (WQS) regression. All analyzes were carried out separately on males and females. The possible impacts of age, serum total testosterone (TT), and menopausal state, as well as the importance of the interaction term with exposure, were investigated using stratified analysis.

Results

Bis (2-chloroethyl) phosphate and bis (1,3-dichloro-2-propyl) phosphate were associated with NAFLD in all males after adjusting for covariates (P < 0.05). A combination of OPEs (OPE index) was positively linked with NAFLD in the WQS analysis of all males (odds ratio for OPE index: 1.52; 95% CI: 1.06, 2.19). Stratified analyzes for males revealed that considerable connections were largely confined to individuals over 60 years old or with low total testosterone. In women, the connection was limited and inconsistent, except for the OPE index, which was positively linked with NAFLD in post-menopausal women.

Conclusions

In this study, environmental exposure to OPE was linked to an elevated risk of NAFLD in males, particularly those over 60 years old or with low TT levels. Aside from the continuous positive connection of a combination of OPEs with NAFLD risk in post-menopausal women, these correlations were weaker in women. However, these findings should be taken with caution and verified in future investigations by collecting numerous urine samples in advance to strengthen OPE exposure estimates.

Exercise Reduces the Risk of Chronic Kidney Disease in Individuals with Nonalcoholic Fatty Liver Disease: A Nationwide Cohort Study

AIMS

Recent studies of individuals with nonalcoholic fatty liver disease (NAFLD) have indicated benefits of exercise in improving outcomes. We investigated whether exercise reduces the risk of chronic kidney disease (CKD) in individuals with NAFLD.

METHODS

A total of 7,275 participants from the Korea National Health and Nutrition Examination Survey (KNHANES) cohort, and 40,418 participants with NAFLD from the National Health Insurance Service (NHIS) cohort were included for the cross-sectional and longitudinal analyses, respectively. For the cross-sectional analysis, the primary outcome was prevalent CKD, defined as an estimated glomerular filtration rate (eGFR) <60 mL/min/1.73m². For the longitudinal analysis, the primary outcome was incident CKD, defined as the occurrence of eGFR <60 mL/min/1.73m² or proteinuria (≥trace) on two consecutive measurements during follow-up.

RESULTS

In the KNHANES cohort, prevalent CKD was observed in 229 (6.1%), 48 (2.6%), and 36 (2.1%) participants in the 0, 1-2, and ≥3 exercise sessions/week groups, respectively. The likelihood of prevalent CKD was lowest in participants allocated to the ≥3 sessions/week group (adjusted OR 0.49; 95% CI, 0.33-0.71; P<0.001). During a median follow-up of 5.0 years in the NHIS cohort, incident CKD occurred in 1,047 (9.7/1,000 person-years), 188 (7.3/1,000 person-years), and 478 (7.4/1,000 person-years) participants in the 0, 1-2, and ≥3 sessions/week groups, respectively. The risk of incident CKD was lowest in participants allocated to the ≥3 sessions/week group (adjusted HR 0.85; 95% CI, 0.76-0.95; P=0.004).

CONCLUSIONS

Exercise was significantly associated with a reduced risk of both prevalent and incident CKD in individuals with NAFLD.

MRE-based NASH score for diagnosis of nonalcoholic steatohepatitis in patients with nonalcoholic fatty liver disease

BACKGROUND AND AIMS

As the prevalence of nonalcoholic fatty liver disease (NAFLD) is approximately 30% in the general population, it is important to develop a non-invasive biomarker for the diagnosis of nonalcoholic steatohepatitis (NASH). This prospective cross-sectional study aimed to develop a scoring system for NASH diagnosis through multiparametric magnetic resonance (MR) and clinical indicators.

METHODS

Medical history, laboratory tests, and MR parameters of patients with NAFLD were assessed. A scoring system was developed using a logistic regression model. In total, 127 patients (58 with nonalcoholic fatty liver [NAFL] and 69 with NASH) were enrolled. After evaluating 23 clinical characteristics of the patients (4 categorical and 19 numeric variables) for the NASH diagnostic model, an equation for MR elastography (MRE)-based NASH score was obtained using 3 demographic factors, 2 laboratory variables, and MRE.

RESULTS

The MRE-based NASH score showed a satisfactory accuracy for NASH diagnosis (c-statistics, 0.841; 95% CI 0.772-0.910). At a cut-off MRE-based NASH score of 0.68 for NASH diagnosis, its sensitivity was 0.68 and specificity was 0.91. When an MRE-based NASH score of 0.37 was used as a cut-off for NASH exclusion, the sensitivity was 0.91 and specificity was 0.55. Overall, 35% (44/127) of patients were in the gray zone (between 0.37 and 0.68). Internal validation via bootstrapping also indicated the satisfactory accuracy of NASH diagnosis (optimism-corrected statistics, 0.811).

CONCLUSION

MRE-based NASH score is a useful and accurate non-invasive biomarker for diagnosis of NASH in patients with NAFLD.

Advanced liver fibrosis measured by transient elastography predicts chronic kidney disease development in individuals with non-alcoholic fatty liver disease

AIMS/HYPOTHESIS

Non-alcoholic fatty liver disease (NAFLD) and chronic kidney disease (CKD) are progressive chronic conditions that share important cardiometabolic risk factors and pathogenic mechanisms. We investigated the association between liver fibrosis measured by transient elastography (TE) and the risk of incident CKD in individuals with NAFLD.

METHODS

A total of 5983 participants with NAFLD (defined as controlled attenuation parameter >222 dB/m) but without CKD who underwent TE between March 2012 and August 2018 were selected. The primary outcome was incident CKD, defined as the occurrence of eGFR <60 ml min^-1 [1.73 m]^-2 or proteinuria (≥1+ on dipstick test) on two consecutive measurements during follow-up. The secondary outcome was a 25% decline in eGFR measured on two consecutive visits.

RESULTS

The mean age was 51.8 years and 3756 (62.8%) participants were male. During 17,801 person-years of follow-up (mean follow-up of 3.0 years), 62 participants (1.0%) developed incident CKD. When stratified into TE-defined fibrosis stages (F0-F4), multivariable Cox models revealed that risk of incident CKD was 5.40-fold (95% CI 2.46, 11.84; p < 0.001) higher in the F3/F4 group (≥9.5 kPa) than in the F0 group (<5.5 kPa). During 17,577 person-years of follow-up (mean follow-up of 3.0 years), 201 participants (3.4%) experienced the secondary outcome, for which the F3/F4 group had a 3.22-fold higher risk (95% CI 1.96, 5.28; p < 0.001) than the F0 group.

CONCLUSIONS/INTERPRETATION

In this large cohort of individuals with NAFLD but without baseline CKD, advanced liver fibrosis measured by TE was significantly associated with a higher risk of incident CKD.

DNA Methylation Patterns According to Fatty Liver Index and Longitudinal Changes from the Korean Genome and Epidemiology Study (KoGES)

The role of differentially methylated regions (DMRs) in nonalcoholic fatty liver disease (NAFLD) is unclear. This study aimed to identify the role of DMR in NAFLD development and progression using the Korean Genome and Epidemiology Study (KoGES) cohort. We used laboratory evaluations and Illumina Methylation 450 k DNA methylation microarray data from KoGES. The correlation between fatty liver index (FLI) and genomic CpG sites was analyzed in 322 subjects. Longitudinal changes over 8 years were confirmed in 33 subjects. To identify CpG sites and genes related to FLI, we obtained enrichment terms for 6765 genes. DMRs were identified for both high (n = 128) and low (n = 194) groups on the basis of FLI 30 in 142 men and 180 women. To confirm longitudinal changes in 33 subjects, the ratio of follow-up and baseline investigation values was obtained. Correlations and group comparisons were performed for the 8 year change values. PITPNM3, RXFP3, and THRB were hypermethylated in the increased FLI groups, whereas SLC9A2 and FOXI3 were hypermethylated in the decreased FLI groups. DMRs describing NAFLD were determined, and functions related to inflammation were identified. Factors related to longitudinal changes are suggested, and blood circulation-related functions appear to be important in the management of NAFLD.

Red meat consumption, obesity, and the risk of nonalcoholic fatty liver disease among women: Evidence from mediation analysis

BACKGROUND

Previous studies have suggested consumption of red meat may be associated with an increased risk of developing nonalcoholic fatty liver disease (NAFLD). However, large-scale, prospective data regarding red meat consumption in relation to the incidence of NAFLD are lacking, nor is it known whether any association is mediated by obesity.

OBJECTIVE

We aimed to evaluate the relationship between red meat consumption and the subsequent risk of developing NAFLD.

DESIGN

This prospective cohort study included 77,795 women in the Nurses' Health Study II cohort without NAFLD at baseline (in 1995), who provided detailed, validated information regarding diet, including consumption of red meat, every 4 years, followed through 2015. Lifestyle factors, clinical comorbidities and body mass index (BMI), were updated biennially. Cox proportional hazard models were used to estimate multivariable adjusted hazard ratios (HRs) and 95% confidence intervals (CIs).

RESULTS

Over 1,444,637 person years of follow-up, we documented 3130 cases of incident NAFLD. Compared to women who consumed ≤1 serving/week of red meat, the multivariable-adjusted HRs of incident NAFLD were 1.20 (95% CI: 0.97, 1.50) for 2-4 servings/week; 1.31 (95% CI: 1.06, 1.61) for 5-6 servings/week; 1.41 (95% CI: 1.13, 1.75) for 1 serving/day; and 1.52 (95% CI: 1.23, 1.89) for ≥2 servings/day. However, after further adjustment for BMI, all associations for red meat, including unprocessed and processed red meat, were attenuated and not statistically significant (all P-trend>0.05). BMI was estimated to mediate 66.1% (95% CI: 41.8%, 84.2%; P < 0.0001) of the association between red meat consumption and NAFLD risk.

CONCLUSIONS

Red meat consumption, including both unprocessed and processed red meat, was associated with significantly increased risk of developing NAFLD. This association was mediated largely by obesity.

Both full length-cholesteryl ester transfer protein and exon 9-deleted cholesteryl ester transfer protein promote triacylglycerol storage in cultured hepatocytes

We previously reported that overexpression of full-length cholesteryl ester transfer protein (FL-CETP), but not its exon 9-deleted variant (∆E9-CETP), in an adipose cell line reduces their triacylglycerol (TAG) content. This provided mechanistic insight into several in vivo studies where FL-CETP levels are inversely correlated with adiposity. However, increased FL-CETP is also associated with elevated hepatic lipids, suggesting that the effect of CETP on cellular lipid metabolism may be tissue-specific. Here, we directly investigated the role of FL-CETP and ∆E9-CETP in hepatic lipid metabolism. FL- or ∆E9-CETP was overexpressed in HepG2-C3A by adenovirus transduction. Overexpression of either FL or ∆E9-CETP in hepatocytes increased cellular TAG mass by 25% but reduced TAG secretion. This cellular TAG was contained in larger and more numerous lipid droplets. Analysis of TAG synthetic and catabolic pathways showed that this elevated TAG content was due to increased incorporation of fatty acid into TAG (24%), and higher de novo synthesis of fatty acid (50%) and TAG from acetate (40%). siRNA knockdown of CETP had the opposite effect on TAG synthesis and lipogenesis, and decreased cellular TAG. This novel increase in cellular TAG by FL-CETP overexpression was reproduced in Caco-2 intestinal epithelial cells. We conclude that, unlike that seen in adipocyte cells, overexpression of either CETP isoform in lipoprotein-secreting cells promotes the accumulation of TAG. These data suggest that the in vivo correlation between CETP levels and hepatic steatosis can be explained, in part, by a direct effect of CETP on hepatocyte cellular metabolism.

Association between telomere length and hepatic fibrosis in non-alcoholic fatty liver disease

Telomere length has been linked to the prevalence and progression of metabolic disease. However, clinical implications of telomere length in biopsy-proven non-alcoholic fatty liver disease (NAFLD) patients remain unclear. Therefore, this study aimed to investigate the association of telomere length with the histological severity of NAFLD. The cross-sectional data derived from the prospectively enrolled Boramae NAFLD registry (n = 91) were analyzed. The liver tissues and clinical information were obtained from both NAFLD patients and non-NAFLD subjects. Binary logistic regression was performed to identify the independent association between telomere length and the histological severity of NAFLD. A total of 83 subjects with or without biopsy-proven NAFLD were included for analysis: non-NAFLD in 23 (27.7%), non-alcoholic fatty liver in 15 (18.1%), and non-alcoholic steatohepatitis (NASH) in 45 (54.2%). Telomere length measured from liver tissues showed a strong negative correlation (p < 0.001) with age, regardless of NAFLD status. Therefore, telomere length was corrected for age. Age-adjusted telomere length than decreased gradually with an increasing severity of fibrosis in patients with NAFLD (p < 0.028). In multivariate analysis, age-adjusted telomere length (odds ratio [OR] 0.59; 95% CI 0.37–0.92; p = 0.019) and high-density lipoprotein cholesterol (OR 0.94; 95% CI 0.80–0.99; p = 0.039) were independently associated with significant fibrosis. The age-adjusted telomere length tends to decrease along with the fibrosis stage of NAFLD. In particular, among the histological components of NAFLD, fibrosis severity seems to be related to telomere length in the liver.

Evaluation of the severity of nonalcoholic fatty liver disease through analysis of serum exosomal miRNA expression

Noninvasive techniques for evaluating the severity of nonalcoholic fatty liver disease (NAFLD) have shown limited diagnostic performance. MicroRNAs (miRNAs) are useful biomarkers for diagnosing and monitoring the progression and treatment response to several diseases. Here, we evaluated whether serum exosomal miRNAs could be used for the diagnosis and prognosis of NAFLD severity. Exosomal miRNAs were isolated from the sera of 41 patients with NAFLD (diagnosed using liver biopsy) for microarray profiling. The degree of NAFLD severity was determined using inflammation, steatosis, and ballooning scores and the NAFLD activity score (NAS). Correlations between miRNA expression, clinical and biochemical parameters, and mRNA expression were analyzed. Overall, 25, 11, 13, and 14 miRNAs correlated with the inflammation score, steatosis score, ballooning score, and NAS, respectively, with 33 significant correlations observed between 27 miRNAs and six clinical variables. Eight miRNAs (let-7b-5p, miR-378h, -1184, -3613-3p, -877-5p, -602, -133b, and 509-3p) showed anticorrelated patterns with the corresponding mRNA expression. In fibrosis, 52 and 30 interactions corresponding to high miRNA-low mRNA and low miRNA-high mRNA expression, respectively, were observed. The present results therefore suggest that serum exosomal miRNAs can be used to evaluate NAFLD severity and identify potential targets for NAFLD treatment.

Circulating miRNA is a useful diagnostic biomarker for nonalcoholic steatohepatitis in nonalcoholic fatty liver disease

Nonalcoholic steatohepatitis (NASH) is considered as a progressive form of nonalcoholic fatty liver disease (NAFLD). To distinguish NASH from nonalcoholic fatty liver (NAFL), we evaluated the diagnostic value of circulating miRNAs. Small RNA sequencing was performed on 12 NAFL patients and 12 NASH patients, and the miRNA expression was compared. After selecting miRNAs for the diagnosis of NASH, we analyzed the diagnostic accuracy of each miRNA and the combination of miRNAs. External validation was performed using quantitative reverse transcription PCR. Among the 2,588 miRNAs, 26 miRNAs significantly increased in the NASH group than in the NAFL group. Among the 26 elevated miRNAs in the NASH group, 8 miRNAs were selected, and in silico analysis was performed. Only four miRNAs (miR-21-5p, miR-151a-3p, miR-192-5p, and miR-4449) showed significant area under the receiver operating characteristic curve (AUC) values for NASH diagnosis. The combination of the four miRNAs showed satisfactory diagnostic accuracy for NASH (AUC 0.875; 95% CI 0.676–0.973). External validation revealed similar diagnostic accuracy for NASH (AUC 0.874; 95% CI 0.724–0.960). NASH represents significantly distinct miRNA expression profile compared with NAFL. The combination of serum circulating miRNAs can be used as a novel biomarker for the NASH diagnosis in NAFLD.

Cardiovascular Risk Is Elevated in Lean Subjects with Nonalcoholic Fatty Liver Disease

Background/Aims

Nonalcoholic fatty liver disease (NAFLD) and obesity are independently associated with an increased risk for atherosclerotic cardiovascular disease (ASCVD), the leading cause of mortality in patients with NAFLD. Many NAFLD patients are lean, but their ASCVD risk compared to obese subjects with NAFLD is unclear.

Methods

Data from the 2008 to 2011 Korea National Health and Nutrition Examination Surveys database were analyzed (n=4,786). NAFLD was defined as a comprehensive NAFLD score ≥40 or a liver fat score ≥–0.640. ASCVD risk was evaluated using the American College of Cardiology/American Heart Association guidelines.

Results

The frequency of subjects without NAFLD, with obese NAFLD, and with lean NAFLD was 62.4% (n=2,987), 26.6% (n=1,274), and 11.0% (n=525), respectively. Subjects with lean NAFLD had a significantly higher ASCVD score and prevalence of a high ASCVD risk (mean 15.6±14.0, 51.6%) than those with obese NAFLD and without NAFLD (mean 11.2±11.4, 39.8%; mean 7.9±10.9, 25.5%; all p<0.001). Subjects with lean NAFLD and significant liver fibrosis showed a significantly higher odds ratio for a high risk for ASCVD than those with obese NAFLD with or without significant liver fibrosis (odds ratio, 2.60 vs 1.93; p=0.023).

Conclusions

Subjects with lean NAFLD had a significantly higher ASCVD score and prevalence of high risk for ASCVD than those with obese NAFLD. Similarly, lean subjects with significant liver fibrosis had a higher probability of ASCVD than obese subjects in the subpopulation with NAFLD.

Association of Skeletal Muscle and Adipose Tissue Distribution with Histologic Severity of Non-Alcoholic Fatty Liver

Adipose tissue and skeletal muscle is associated with non-alcoholic fatty liver disease (NAFLD). This study evaluates the association between body composition and histologic severity in patients with NAFLD. Using the cross-sectional CT images at the level of L3 vertebra and the histologic findings of 178 patients with biopsy-proven NAFLD, we analyzed the correlation of the histologic findings to the skeletal muscle index (SMI), subcutaneous adipose tissue index (SATI), and visceral adipose tissue index (VATI), which is defined as the body composition area (cm²) by height squared (m²). The clinical and laboratory features with body composition were analyzed to determine the risk factors for advanced fibrosis. The VATI significantly increased in severe non-alcoholic steatohepatitis (NASH) or advanced fibrosis. In addition, the VATI was correlated with the NAFLD activity score (NAS) and the fibrosis stage. In multivariate analyses, age (odds ratio (OR), 1.09; 95% confidence interval (CI), 1.02–1.19; p = 0.025), severe NASH (OR, 8.66; 95% CI, 2.13–46.40; p = 0.005), and visceral adiposity (OR, 6.77; 95% CI, 1.81–29.90; p = 0.007) were independently associated with advanced fibrosis in patients with NAFLD. Visceral adiposity is correlated with the histologic severity of NAFLD, which is independently associated with advanced fibrosis.

Association between the severity of liver fibrosis and cardiovascular outcomes in patients with type 2 diabetes

BACKGROUND AND AIM

Cardiovascular disease (CVD) is the principal cause of death in patients with type 2 diabetes (T2D). In this study, we assessed whether liver fibrosis predicted the risk of CVD in patients with T2D.

METHODS

A total of 1481 patients who had commenced oral antidiabetic drugs to treat newly diagnosed T2D between 2006 and 2010 were recruited. The fibrosis-4 index (FIB-4), non-alcoholic fatty liver disease fibrosis score (NFS), and BARD score were used to assess fibrotic burden at the time of T2D diagnosis.

RESULTS

During the follow-up period (median 88.1 [interquartile range 36.6-113.6] months), 242 (16.3%) patients developed CVD. CVD occurred frequently in older patients and was associated with hypertension; metabolic syndrome; obesity; smoking; administration of statin, which is an antihyperlipidemic drug; lower platelet counts; lower alanine aminotransferase, total cholesterol, and HbA1c levels; higher C-peptide and homeostatic model assessment of insulin resistance levels; and higher FIB-4, NFS, and BARD score (all P < 0.05). FIB-4 (hazard ratio [HR] = 1.163), NFS (HR = 1.322), BARD score (HR = 1.564), metabolic syndrome (HR = 1.556), smoking (HR = 2.829), and statin use (HR = 0.603) independently predicted the risk of CVD (all P < 0.05). The cumulative incidence of CVD was significantly different among groups stratified by liver fibrotic burden (all P < 0.05, log-rank test). Competing risk analysis showed a significant association between the severity of liver fibrosis and CVD development (all P < 0.001, Gray's test).

CONCLUSIONS

The severity of liver fibrosis independently predicted CVD in patients with T2D. Thus, assessment of liver fibrosis might allow physicians to optimize the timing of appropriate cardiovascular interventions in such patients.

Low Skeletal Muscle Mass Is a Risk Factor for Subclinical Atherosclerosis in Patients with Nonalcoholic Fatty Liver Disease

Sarcopenia and nonalcoholic fatty liver disease (NAFLD) are associated with subclinical atherosclerosis. We aimed to investigate the association between low skeletal muscle mass (LSMM) and subclinical atherosclerosis in patients with NAFLD. A total of 683 patients with ultrasound-confirmed NAFLD who underwent carotid ultrasonography were enrolled retrospectively. The appendicular skeletal muscle mass divided by the body mass index was used to define LSMM. Using carotid ultrasound, increased carotid intima–media thickness (cIMT, >1 mm) and the presence of carotid plaques were measured. Of the 683 patients, 75 (11.0%) had LSMM. In multivariate analyses, LSMM was associated with increased cIMT (odds ratios (ORs) = 2.26 to 2.95, all p < 0.05) and carotid plaques (ORs = 2.05 to 2.90, all p < 0.05). The proportion of increased cIMT and carotid plaques was significantly higher in obese NAFLD patients with LSMM than in those without LSMM (33.3% vs. 17.6% for cIMT and 12.7% vs. 5.7% for carotid plaques, respectively; p < 0.001). Furthermore, LSMM was independently associated with increased cIMT (ORs = 2.44 to 3.30, all p < 0.05) and carotid plaques (ORs = 2.56 to 3.54, all p < 0.05) in obese NAFLD patients. LSMM is associated with subclinical atherosclerosis in patients with NAFLD.

Multiparametric MR Is a Valuable Modality for Evaluating Disease Severity of Nonalcoholic Fatty Liver Disease

Because nonalcoholic fatty liver disease (NAFLD) is becoming a leading cause of chronic liver disease, noninvasive evaluations of its severity are immediately needed. This prospective cross-sectional study evaluated the effectiveness of noninvasive assessments of hepatic steatosis, fibrosis, and steatohepatitis.

Liver stiffness by magnetic resonance elastography is associated with increased risk of cardiovascular disease in patients with non-alcoholic fatty liver disease

BACKGROUND

Magnetic resonance elastography (MRE) is a reliable non-invasive alternative to liver biopsy for assessing liver fibrosis. There are limited data regarding an association between liver fibrosis by MRE and risk of cardiovascular disease (CVD).

AIM

To investigate the association of high-risk CVD phenotype determined by coronary artery calcification (CAC) with liver fibrosis by MRE in patients with non-alcoholic fatty liver disease (NAFLD).

METHOD

This was a cross-sectional analysis of well-characterised, prospective cohorts including 105 patients with NAFLD (MR imaging-derived proton density fat fraction ≥ 5%) with contemporaneous cardiac computed tomography (CT) and MRE. Patients were assessed using MRE for liver stiffness, and cardiac CT for the presence of CAC (defined as coronary artery calcium score > 0). Odds of presence of CAC were analysed using logistic regression analysis.

RESULTS

The average age and body mass index were 54.9 years and 32.9 kg/m² respectively. In this cohort, 49.5% of patients had CAC and 35.2% had significant liver fibrosis (defined as MRE ≥2.97 kPa). Compared to patients without CAC, those with CAC were older (50.0 [39.0-59.0] vs 63.0 [55.5-67.5], P < 0.001) and had higher Framingham risk score (FRS, 1.0 [0.5-3.5] vs 6.0 [2.0-12.0], P < 0.001). In multivariable-adjusted analysis, liver stiffness as a continuous trait on MRE was independently associated with the presence of CAC in a sex and age-adjusted model (adjusted odd ratios [aOR] = 2.23, 95% confidence interval [CI] = 1.31-4.34, P = 0.007) as well as in a FRS-adjusted model (aOR = 2.16, 95% CI = 1.29-4.09, P = 0.008). When analysed as a dichotomous trait, significant fibrosis (MRE-stiffness ≥2.97 kPa) remained independently associated with the presence of CAC in both FRS-adjusted model and sex and age-adjusted model (aOR = 3.21-3.53, P = 0.013-0.017). In addition, CAC was more prevalent in patients with significant fibrosis than those without as determined by MRE (67.6% vs 39.7%, P = 0.012).

CONCLUSION

Liver stiffness determined by MRE is an independent predictor for the presence of CAC in patients with NAFLD. Patients with NAFLD and significant fibrosis by MRE should be considered for further cardiovascular risk assessment, regardless of their FRS.

Body weight variability and the risk of cardiovascular outcomes in patients with nonalcoholic fatty liver disease

We investigated the association between body weight variability and the risks of cardiovascular disease and mortality in patients with nonalcoholic fatty liver disease (NAFLD) using large-scale, nationwide cohort data. We included 726,736 individuals with NAFLD who underwent a health examination between 2009 and 2010. NAFLD was defined as a fatty liver index ≥ 60, after excluding significant alcohol intake, viral hepatitis, and liver cirrhosis. Body weight variability was assessed using four indices, including variability independent of the mean (VIM). During a median 8.1-year follow-up, we documented 11,358, 14,714, and 22,164 cases of myocardial infarction (MI), stroke, and all-cause mortality, respectively. Body weight variability was associated with an increased risk of MI, stroke, and mortality after adjusting for confounding variables. The hazard ratios (HRs) (95% confidence intervals) for the highest quartile, compared with the lowest quartile, of VIM for body weight were 1.15 (1.10-1.20), 1.22 (1.18-1.26), and 1.56 (1.53-1.62) for MI, stroke, and all-cause mortality, respectively. Body weight variability was associated with increased risks of MI, stroke, and all-cause mortality in NAFLD patients. Appropriate interventions to maintain a stable weight could positively affect health outcomes in NAFLD patients.

From nonalcoholic fatty liver disease to metabolic-associated fatty liver disease: Big wave or ripple?

There is some dissatisfaction with the term "nonalcoholic fatty liver disease (NAFLD)," which overemphasizes alcohol and underemphasizes the importance of metabolic risk factors in this disease. Recently, a consensus recommended "metabolic (dysfunction)-associated fatty liver disease (MAFLD)" as a more appropriate term to describe fatty liver diseases (FLD) associated with metabolic dysfunction. During the definition change from NAFLD to MAFLD, subjects with FLD and metabolic abnormalities, together with other etiologies of liver diseases such as alcohol, virus, or medication who have been excluded from the NAFLD criteria, were added to the MAFLD criteria, while subjects with FLD but without metabolic abnormality, who have been included in the NAFLD criteria, were excluded from the MAFLD criteria. This means that there is an emphasis on the metabolic dysfunction in MAFLD which may underestimate the prognostic value of hepatic steatosis itself, whereas the MAFLD criteria might better identify subjects who are at a higher risk of hepatic or cardiovascular outcomes. However, non-metabolic risk NAFLD subjects who are excluded from the MAFLD criteria are missed from the diagnosis, and their potential risk can be the cause of future diseases. Although huge controversies remain, this review focused on summarizing recent studies that compared the clinical and prognostic characteristics between subjects with NAFLD and MAFLD.

Inhaled exposure to air fresheners aggravated liver injury in a murine model of nonalcoholic fatty acid liver disease

At present, the consumption and use of air fresheners (AFs) is rapidly increasing worldwide for the purposes of odor removal and to create a pleasant odor. Many recent studies have strongly suggested that the potentially hazardous chemicals emitted from AFs may be the primary source of indoor air pollutants and may cause adverse health effects. Despite the presence of hazardous chemicals in AFs, potential adverse health effects and risk assessment of AFs have not yet been established. The incidence of nonalcoholic fatty acid liver disease (NAFLD) around the world is rapidly increasing, as with obesity and diabetes, and is one of the most common causes of liver disease worldwide. Based on the demonstrated evidence that NAFLD could eventually develop into further health complications such as liver failure, cardiovascular disease, liver cirrhosis, or liver cancer, the current study was performed to clarify the relationship between inhaled AF exposure and NAFLD using a high-fructose diet (HFr)-induced murine model. The results from current study clearly demonstrated that AF exposure further exacerbated liver injury in NAFLD-induced mice. Interestingly, the increased expression of fibrosis-related factors and collagen accumulation in the liver of AF-exposed NAFLD-induced mice resulted in nonalcoholic steatohepatitis (NASH)-like phenotype and fibrosis. Taken together, these results strongly suggest that AF exposure may not only induce liver injury but may also exacerbate NAFLD to lead to NASH-like symptoms. Further study is needed to shed light on the detailed mechanisms behind AF-induced liver effects and its potential role in exacerbating NAFLD to more detrimental disease in order to better scientific evidence for risk assessments of indoor AF exposure.

Comparative study of the effects of Abexol and atorvastatin in patients with non-alcoholic fatty liver disease

AIM OF THE STUDY

To investigate the efficacy and safety of Abexol and atorvastatin in patients with non-alcoholic fatty liver disease (NAFLD).Material and methods: The present study had a monocentric, randomized, double-blinded, comparative design with 4 parallel groups - group 1 (Abexol), group 2 (atorvastatin), group 3 (combined therapy) and group 4 (placebo) - to which dietary recommendations and physical activity practice were provided twice a day, for 24 weeks. Significant changes in the ultrasound analysis of the liver were considered a primary efficacy variable. Insulin resistance improvement (HOMA2-IR) was considered as a co-primary efficacy criterion. Significant changes in the serum levels of alanine aminotransferase (ALT) and aspartate aminotransferase (AST), lipid profile variables and the anthropometric variables were evaluated as secondary variables of effectiveness. Statistical analysis of all data was according to the intention to treat method.

RESULTS

The groups were statistically homogeneous at baseline conditions. At the end of the 6 months of treatment about 50% of the patients in all groups showed a decrease of at least one degree in echogenicity, while the rest remained the same. There were no significant changes in the values of liver enzymes or anthropometric variables evaluated. Treatment with atorvastatin and combined therapy significantly reduced levels of low-density lipoprotein-cholesterol (LDL-C) and total cholesterol. The treatments were safe and well tolerated, although in the atorvastatin group the number of adverse events reported was greater than in the rest of the groups.

CONCLUSIONS

Abexol and atorvastatin showed comparable efficacy and safety in patients with NAFLD, with advantages for treatment with atorvastatin with respect to its effects on the lipid profile of these patients.

Clinical implications of renin-angiotensin system inhibitors for development and progression of non-alcoholic fatty liver disease

Recently, there has been an increasing interest in the therapeutic efficacy of RAS inhibitors (RASi) in patients with non-alcoholic fatty liver disease (NAFLD) because they may reduce oxidative stress, inflammatory markers, and enhanced fibrosis. An objective of this study was to investigate the role of RASi on NAFLD development and progression in a large cohort. We conducted a nested case-control study. Study subjects were classified into two study cohorts according to baseline NAFLD status: non-NAFLD (n = 184,581) and established NALFD (n = 27,565). An NAFLD development or progression case was defined as a patient with newly developed NAFLD or new progression of advanced fibrosis from non-NAFLD and established NALFD cohorts, respectively. A conditional logistic regression analysis was conducted to estimate the associations between RASi exposure and NAFLD development/progression. Overall, no significant association was evident between RASi use and NAFLD development or progression (NAFLD development; ever-user vs. never-user: OR 1.017; 95% CI 0.842-1.230, NAFLD progression; ever-user vs. never-user: aOR 0.942; 95% CI 0.803-1.105). RASi ever-use in cases of individuals who were obese or who had normal fasting plasma glucose (FPG) was associated with reduced risk of both NAFLD development (body mass index (BMI) ≥ 25 kg/m2: 0.708 [95% confidence interval (CI) 0.535-0.937], FPG of < 100 mg/mL: 0.774 [95% CI 0.606-0.987]) and progression (BMI ≥ 25 kg/m2: 0.668 [95% CI 0.568-0.784], FPG of < 100 mg/mL: 0.732 [95% CI 0.582-0.921]). The present study did not verify a significant overall association between RASi use and NAFLD development/progression but suggested that RASi might prevent NAFLD development and progression among specific subjects.

Nonalcoholic Fatty Liver Disease: A Global Perspective

The prevalence of nonalcoholic fatty liver disease (NAFLD) has been increasing over the years and is now as high in Asia as in the Western world, so much so that it should no longer be considered a Western disease. In fact, China is expected to have the largest increase in the number of NAFLD cases in the coming years. The increase in prevalence of NAFLD in Asia lags behind that of the Western world; thus, there will be a lag in more severe liver disease in Asia despite a similar prevalence of the disease. NAFLD is more prevalent among patients with diabetes mellitus, which is also an important risk factor for more severe liver disease. Patients with diabetes mellitus thus represent an important target for screening for NAFLD and more severe liver disease. Although the PNPLA3 gene polymorphism is the most studied in NAFLD, it is increasingly clear that the cumulative effect of multiple genes likely predisposes to NAFLD and more severe liver disease in the different ethnic groups, and polygenic risk scores are emerging. Lean NAFLD has been largely reported in Asia but is increasingly recognized worldwide. Multiple risk factors have been identified for the disease that manifests in metabolically unhealthy normal weight individuals; however, it responds to lifestyle intervention, similar to the disease in obese individuals. Lastly, the newer term "metabolic dysfunction-associated fatty liver disease" provides a more accurate reflection of the disease, giving more focus to clinicians and researchers in tackling this increasingly common and challenging disease.

Hepatic Steatosis Index in the Detection of Fatty Liver in Patients with Chronic Hepatitis B Receiving Antiviral Therapy

Background/Aims

The hepatic steatosis index (HSI) is a noninvasive method to assess the severity of hepatic steatosis. Antiviral therapy (AVT) can impact aspartate aminotransferase and alanine aminotransferase levels, which are the main components of the HSI. Thus, we investigated the accuracy of the HSI in detecting hepatic steatosis in patients with chronic hepatitis B (CHB) receiving AVT, compared with those not receiving AVT and in those with nonalcoholic fatty liver disease (NAFLD).

Methods

Patients with CHB or NAFLD who underwent a magnetic resonance imaging proton density fat fraction (MRI-PDFF) evaluation between March 2010 and March 2019 were recruited. Hepatic steatosis was diagnosed when the PDFF exceeded 5%. Area under the receiver operating characteristic curve (AUROC) analysis was used to assess the diagnostic accuracy of the HSI in the detection of hepatic steatosis.

Results

The mean age of the study population (189 men and 116 women; 244 with CHB [184 with and 60 without AVT] and 61 with NAFLD) was 55.6 years. The AUROC values for detecting hepatic steatosis were similar between patients with CHB (0.727; p<0.001) and those with NAFLD (0.739; p=0.002). However, when patients with CHB were subdivided into those receiving and not receiving AVT, the AUROC value decreased slightly in patients with CHB receiving AVT compared to those without not receiving AVT (0.707; p=0.001 vs 0.779; p=0.001).

Conclusions

Despite a slight attenuation, the diagnostic accuracy of the HSI in patients with CHB receiving AVT in detecting hepatic steatosis was still acceptable. Further large-scale studies are required for validation.

Association between depression and nonalcoholic fatty liver disease: Contributions of insulin resistance and inflammation

BACKGROUND

It is unclear whether depression is linked to nonalcoholic fatty liver disease (NAFLD). The purpose of this study was to examine the association between depression and NAFLD and whether the association is partly explained by insulin resistance or inflammation.

METHODS

Subjects consisted of 4,688 adults who participated in the 2016 Korea National Health and Nutrition Examination Survey. Depression was defined by Patient Health Questionnaire-9 score ≥ 10 or a previous diagnosis of depression. NAFLD was defined by hepatic steatosis index >36. Insulin resistance was assessed by triglycerides and glucose (TyG) index. Inflammation was measured with C-reactive protein (CRP).

RESULTS

Depression had a significant association with TyG index (p = 0.005), but not with CRP. Depression was a significant predictor of NAFLD (OR = 1.63; 95% CI, 1.26-2.10; p < 0.001). Adjustment for sociodemographic features and waist circumference did not substantially affect the results. Further adjustment for comorbidities reduced the estimate for depression by 23% (OR = 1.56; 95% CI, 1.18-2.06; p = 0.002). Inclusion of CRP in a fully adjusted model did not affect the results. Addition of the TyG index decreased the estimate for depression by 28% (OR = 1.39; 95% CI, 0.88-2.19; p = 0.161), and the resulting estimate became no longer significant. The TyG index remained the independent predictor of outcome.

LIMITATIONS

The absence of a structured diagnostic interview for depression and histological diagnosis of NAFLD.

CONCLUSIONS

These data support an association of depression with NAFLD. Insulin resistance seems to play a major role in modulating the association between depression and NAFLD risk.

Evolution of liver fibrosis and steatosis markers in patients with type 2 diabetes after metformin treatment for 2 years

BACKGROUND/AIMS

Type 2 diabetes mellitus (T2DM) and nonalcoholic fatty liver disease (NAFLD) share pathophysiological mechanism. Metformin is a widely used first-line anti-diabetic drug. We investigated the evolution of liver fibrosis and steatosis during 2-year use of metformin in patients with T2DM.

METHODS

Between 2006 and August 2010, patients newly diagnosed with T2DM who received metformin as the first-line treatment were recruited. Fibrosis-4 index (FIB-4) > 2.67 and hepatic steatosis index (HSI) > 36.0 was used to define advanced liver fibrosis and fatty liver, respectively.

RESULTS

A total of 1292 (mean age 60.8 years, 57% men and 43% women) patients were recruited. The mean FIB-4 and HSI scores were 1.38 and 27.3, respectively. At enrollment, 83 (6.4%) patients had advanced liver fibrosis and 429 (33.2%) had fatty liver. After 2 years of metformin treatment, the mean FIB-4 score increased from 1.38 to 1.51 (p < 0.001), whereas the mean HSI score decreased from 27.3 to 26.5 (p < 0.001). During follow-up, advanced liver fibrosis additionally developed in 52/1209 (4.3%) patients, whereas 48/83 (57.8%) experienced fibrosis regression. Older age (odds ratio [OR] = 1.007), lower platelet count (OR = 0.993), and lower serum albumin (OR = 0.325) were independently associated with the increased risk of advanced liver fibrosis development after 2-years of metformin treatment.

CONCLUSION

In our cohort of patients with metformin treatment, a small proportion of patients developed liver fibrosis and steatosis after 2 years. Optimized follow-up strategy is required according to different risk of liver fibrosis progression in patients with T2DM.

Weight gain during early adulthood, trajectory of body shape and the risk of nonalcoholic fatty liver disease: A prospective cohort study among women

BACKGROUND & AIMS

Obesity is established as a major risk factor for the development of nonalcoholic fatty liver disease (NAFLD). However, the influence of dynamic changes in adiposity over the life course on NAFLD risk remains poorly understood.

METHODS

We collected data from 110,054 women enrolled in the Nurses' Health Study II cohort. Early adulthood weight was ascertained at age 18 years, and weight gain since early adulthood was defined prospectively every 2 years. We used a group-based modeling approach to identify five trajectories of body shape from age 5 years up to age 50 years. NAFLD was defined by physician-confirmed diagnoses of fatty liver, after excluding excess alcohol intake and viral hepatitis, using validated approaches.

RESULTS

We documented 3798 NAFLD cases over a total of 20 years of follow-up. Compared to women who maintained stable weight (±2 kg), women with ≥20 kg of adulthood weight gain had the multivariable aHR of 6.96 (95% CI, 5.27-9.18), and this remained significant after further adjusting for early adulthood BMI and updated BMI (both P trend <0.0001). Compared to women with a medium-stable body shape trajectory, the multivariable aHRs for NAFLD were, 2.84 (95% CI, 2.50-3.22) for lean-marked increase, 2.60 (95% CI, 2.27-2.98) for medium-moderate increase, and 3.39 (95% CI, 2.95-3.89) for medium-marked increase.

CONCLUSIONS

Both early adulthood weight gain and lifetime body shape trajectory were significantly and independently associated with excess risk of developing NAFLD in mid-life. Maintaining both lean and stable weight throughout life may offer the greatest benefit for the prevention of NAFLD.

Updates in the quantitative assessment of liver fibrosis for nonalcoholic fatty liver disease: Histological perspective

Nonalcoholic fatty liver disease/nonalcoholic steatohepatitis (NAFLD/NASH) is a major cause of liver fibrosis and cirrhosis. Accurate assessment of liver fibrosis is important for predicting disease outcomes and assessing therapeutic response in clinical practice and clinical trials. Although noninvasive tests such as transient elastography and magnetic resonance elastography are preferred where possible, histological assessment of liver fibrosis via semiquantitative scoring systems remains the current gold standard. Collagen proportionate area provides more granularity by measuring the percentage of fibrosis on a continuous scale, but is limited by the absence of architectural input. Although not yet used in routine clinical practice, advances in second harmonic generation/two-photon excitation fluorescence (SHG/TPEF) microscopy imaging show great promise in characterising architectural features of fibrosis at the individual collagen fiber level. Quantification and calculation of different detailed variables of collagen fibers can be used to establish algorithm-based quantitative fibrosis scores (e.g., qFibrosis, q-FPs), which have been validated against fibrosis stage in NAFLD. Artificial intelligence is being explored to further refine and develop quantitative fibrosis scoring methods. SHG-microscopy shows promise as the new gold standard for the quantitative measurement of liver fibrosis. This has reaffirmed the pivotal role of the liver biopsy in fibrosis assessment in NAFLD, at least for the near-future. The ability of SHG-derived algorithms to intuitively detect subtle nuances in liver fibrosis changes over a continuous scale should be employed to redress the efficacy endpoint for fibrosis in NASH clinical trials; this approach may improve the outcomes of the trials evaluating therapeutic response to antifibrotic drugs.

Plasma Long Noncoding RNA LeXis is a Potential Diagnostic Marker for Non-Alcoholic Steatohepatitis

Non-invasive diagnostic markers are needed to ease the diagnosis of non-alcoholic steatohepatitis (NASH) among patients with non-alcoholic fatty liver disease (NAFLD). The long noncoding RNA (lncRNA) LeXis is related to cholesterol metabolism and hepatic steatosis in mice, and its batch genome conversion in humans is TCONS_00016452. Here, we aimed to evaluate the potential of lncRNA LeXis as a non-invasive diagnostic marker for NASH. We analyzed a total of 44 NAFLD patients whose diagnosis was confirmed by a pathologist through analysis of a percutaneous liver biopsy. The expression of LeXis in the plasma of NAFLD patients with and without NASH was compared using quantitative real-time polymerase chain reaction. The expression of plasma LeXis was significantly higher in patients with NASH than in those with NAFL (8.2 (5.0-14.9); 4.6 (4.0-6.6), p = 0.025). The area under the receiver operating characteristic curve was 0.743 (95% CI 0.590-0.895, p < 0.001), and a sensitivity of 54.3% and specificity of 100% could be achieved for NASH diagnosis. Low LeXis was independently associated with NASH diagnosis in patients with NAFLD (p = 0.0349, odds ratio = 22.19 (5% CI, 1.25-395.22)). Therefore, circulating lncRNA LeXis could be a potential non-invasive diagnostic biomarker for NASH.

Nonalcoholic Fatty Liver Disease: A Drug Revolution Is Coming

The worldwide prevalence of non-alcoholic fatty liver disease is around 25%, and that of nonalcoholic steatohepatitis (NASH) ranges from 1.5% to 6.45%. Patients with NASH, especially those with fibrosis, are at higher risk for adverse outcomes such as cirrhosis and liver-related mortality. Although vitamin E, pioglitazone, and liraglutide improved liver histology in randomized trials, there are currently no Food and Drug Administration-approved drugs for NASH. Five pharmacologic agents-obeticholic acid, elafibranor, cenicriviroc, resmetirom, and aramchol-are being evaluated in large, histology-based phase 3 trials. Within 2 to 4 years, new and effective drugs for the treatment of NASH are expected. Additionally, many phase 2 trials are ongoing for various agents. Based on the results of phase 2 and 3 trials, combination treatments are also being investigated. Future treatment strategies will comprise drug combinations and precision medicine based on the different phenotypes of NASH and treatment response of the individual patient.

Association between Atrial Fibrillation and Advanced Liver Fibrosis in Patients with Non-Alcoholic Fatty Liver Disease

PURPOSE

Non-alcoholic fatty liver disease (NAFLD) is independently associated with the development of atrial fibrillation (AF). However, the association of AF with advanced liver fibrosis, which is related to all-cause, cardiovascular, and liver-related mortality, has not been established in NAFLD patients. We aimed to investigate the association between AF and advanced liver fibrosis in NAFLD patients.

MATERIALS AND METHODS

Out of 53704 adults who participated in the health check-up program, 6293 subjects aged 35 years and older were diagnosed as NAFLD using ultrasound. The stage of liver fibrosis was assessed based on the newly adjusted NAFLD fibrosis score (NFS) and Fibrosis-4 (Fib-4) Index, which were used to determine the low and high cut-off values (COVs).

RESULTS

Of 6293 patients with NAFLD, 59 (0.9%) were diagnosed with AF. Patients with AF were older (52.0 vs. 64.6 years, p<0.001), had higher body mass index (25.2 vs. 26.6 kg/m², p<0.001), and had bigger waist circumference (84.0 vs. 89.9 cm, p<0.001) than those without AF. In NAFLD patients, AF was independently associated with advanced liver fibrosis, assessed using both COVs of NFS [low-COV group: final adjusted odds ratios (aORs)=2.85, p=0.004; high-COV group: ORs=12.29, p<0.001). AF was independently associated with advanced liver fibrosis, assessed using both COVs of Fib-4 (low-COV group: aORs=2.49, p<0.001; high-COV group: aORs=3.84, p=0.016).

CONCLUSION

AF is independently associated with advanced liver fibrosis in patients with NAFLD.

Clinical Patterns and Outcome of Hepatocellular Carcinoma in Patients with Nonalcoholic Fatty Liver Disease

BACKGROUND

Nonalcoholic fatty liver disease (NAFLD) may develop into liver cirrhosis and hepatocellular carcinoma (HCC). The aim of this study was to compare the clinical patterns and survival outcomes of NAFLD-related HCC patients and those of alcoholic liver disease (ALD)-related or hepatitis B virus (HBV)-related HCC patients.

METHODS

A total of 622 HCC patients with associated NAFLD (n = 56), ALD (n = 173), or HBV infection (n = 393) were enrolled. The clinical characteristics and survival were analyzed according to the underlying liver diseases.

RESULTS

NAFLD-related HCC patients were more commonly older women and had more metabolic risk factors but were less likely to have cirrhosis and ascites, compared to ALD-related or HBV-related HCC patients. NAFLD-related HCC more often had an infiltrative pattern (P=0.047), a larger tumor (P=0.001), more macrovascular invasion (P=0.022), and exceeded the Milan criteria (P=0.001), but was less frequently diagnosed during tumor surveillance (P=0.025). Survival analysis did not show any difference among NAFLD-related, ALD-related, and HBV-related HCC patients. Furthermore, propensity score matching analysis did not reveal a significant difference in the median survival between the different groups (NAFLD vs. ALD, 14.0 months [95% confidence interval (CI), 2.0-26.0] vs. 13.0 months [95% CI, 0-26.3]; P=0.667, NAFLD vs. HBV, 14.0 months [95% CI, 2.0-26.0] vs. 12.0 months [95% CI, 4.3-17.8]; P=0.573).

CONCLUSIONS

NAFLD-related HCCs were more often detected at an advanced stage with infiltrative patterns, although they showed no significant difference in survival compared to ALD-related or HBV-related HCCs. A future prospective research should be focused on identifying NAFLD patients who require strict surveillance in order to early detect and timely treat HCC.

Clinical application of ultrasonography-guided percutaneous liver biopsy and its safety over 18 years

BACKGROUND/AIMS

Liver biopsy (LB) remains the gold standard for the evaluation of liver disease. However, over the past two decades, many noninvasive tests have been developed and utilized in clinical practice as alternatives to LB. The aim of this study was to evaluate the clinical use and safety of LB in the era of noninvasive assessment of liver fibrosis.

METHODS

This retrospective study included 1,944 consecutive cases of LB performed between 2001 and 2018 in a tertiary hospital. All of the LBs were conducted under ultrasonography guidance with 18-gauge cutting needles.

RESULTS

LBs were performed an average of approximately 108 times per year during the study period. Chronic hepatitis B (25.3%) and suspected malignancy (20.5%) were the two most common indications for LB. The use of LB for nonalcoholic fatty liver disease increased from 8.1% to 17.2% in the past 5 years compared to the last 10 years, while that for viral hepatitis decreased from 40.3% to 18.9%. Discordance rate between the suspected diagnosis and the final diagnosis was 2.6% (51 cases). The overall rate of major adverse events was 0.05% (one case), which involved delayed bleeding at the biopsy site. Liver cirrhosis was observed in 563 cases (28.9%), and the presence of cirrhosis did not affect the frequency of complications (P=0.289).

CONCLUSION

LB is widely used in clinical practice as an irreplaceable diagnostic tool, even in the era of noninvasiveness. Ultrasonography-guided LB can be performed safely in patients with liver cirrhosis.

Survival Outcomes According to Body Mass Index in Hepatocellular Carcinoma Patient: Analysis of Nationwide Cancer Registry Database

BACKGROUND AND AIMS

Body mass index (BMI) is known to be closely related to the prognosis and mortality of various diseases. The aim of our study was to evaluate differences in post-treatment overall survival (OS) according to BMI with hepatocellular carcinoma (HCC) and to understand the meaning of BMI. Among the records of 10,578 HCC patients registered at the Korean Central Cancer Registry from 2008 through 2014, we selected Barcelona Clinic Liver Cancer (BCLC) 0, A, and B staged HCC patients (n = 4,926). HCC patients showed a good prognosis in the order of overweight, normal weight, obesity, and underweight. However, comparing normal-weight (BMI 18.5-24.9 kg/m2) to overweight (BMI 25-29.9 kg/m2) after propensity score matching (PSM), there was no significant difference in OS (p = 0.153). Overweight males had a better prognosis than normal-weight males (p = 0.014), but, normal-weight females had a better prognosis than overweight. To determine the gender-specific OS differences, we examined the differences according to the HCC treatment type. In males, overweight patients had better OS after transarterial chemoembolization (TACE) (p = 0.039) than normal-weight, but not after surgical resection (p = 0.618) nor radiofrequency ablation (p = 0.553). However, in females, all of those HCC treatments resulted in significantly better OS in normal-weight patients than overweight. In patients with HCC of BCLC stages 0-B, unlike females, overweight males had a better prognosis than normal-weight, especially among TACE-treated patients. Our results carefully suggest that the meaning of normal BMI in patients with HCC may have gender difference.

Benefits of the Therapy With Abexol in Patients With Non-Alcoholic Fatty Liver Disease

Background

Non-alcoholic fatty liver disease (NAFLD) encompasses a spectrum of diseases ranging from steatosis to steatohepatitis and cirrhosis. Given the increasing incidence of NAFLD and the long-term consequences of this disease, it is important to identify the risk factors and therapeutic measures. Abexol is a mixture of beeswax alcohols with antioxidant, gastro-protective and anti-inflammatory effects. The aim was to conduct a pooled analysis of clinical trials data of the effects of Abexol treatment in patients with NAFLD.

Methods

The present analysis includes the data of all patients with NAFLD obtained from medium-term randomized, double-blinded, placebo controlled clinical studies with Abexol. One hundred patients with NAFLD received Abexol (100 mg/day) or placebo for 6 months. Significant changes in the ultrasound analysis of the liver were considered a primary efficacy variable. Secondary endpoints were decreased homeostasis model assessment (HOMA) index and insulin levels, and improved clinical symptoms. Statistical analysis of all data was according to the intention-to-treat method.

Results

Both groups were statistically homogeneous at baseline conditions. At 6 months of treatment, the number of Abexol-treated patients exhibiting a normal liver echo pattern on ultrasonography was greater than that of the placebo patients (P < 0.05). Abexol significantly reduced (P < 0.05) insulin levels and HOMA index. The proportion of Abexol patients showing symptom improvement was higher (P < 0.01) than that of the placebo group. Treatments were safe and well tolerated.

Conclusions

Treatment of Abexol during 6 months significantly ameliorates liver fat accumulation and insulin resistances, meanwhile improving clinical evolution in patients with NAFLD. The treatment was safe and well tolerated in these patients.