Differences in liver and mortality outcomes of non-alcoholic fatty liver disease by race and ethnicity: A longitudinal real-world study

Racial and Ethnic Disparities in NAFLD: Harnessing Epigenetic and Gut Microbiota Pathways for Targeted Therapeutic Approaches

Nonalcoholic fatty liver disease (NAFLD) is a growing global health concern, impacting approximately 32.4% of the worldwide population. As a disease linked to metabolic dysfunction, NAFLD continues to rise alongside global increases in obesity, type 2 diabetes mellitus (T2DM), and metabolic syndrome. There is considerable evidence indicating that NAFLD disproportionately affects racial, ethnic, and minority groups, although the exact reasons for these disparities remain elusive. Contributing factors to this disease may include socioeconomic status, cultural influences, stress, genetic factors, and lifestyle choices. Emerging evidence suggests that these causal factors could influence epigenetic mechanisms, particularly DNA methylation and histone modifications, as well as the composition and diversity of gut microbiota. Nevertheless, there is a scarcity of research that comprehensively examines the interplay between epigenetic changes and gut microbiome variations in relation to NAFLD disparities across different racial and ethnic populations globally. This paper intends to (i) explore the connections between NAFLD, ethnic disparities, gut microbiota composition, and epigenetic alterations, while reviewing pertinent studies that illustrate how these factors contribute to health inequities among various ethnic groups impacted by this disease; (ii) explore potential therapeutic targets and biomarkers to advance the management of NAFLD; and (iii) provide insights to enhance our understanding of the mechanisms associated with this disease, thereby promoting further research in this field. Advancements in this area are anticipated to enhance our understanding of disease susceptibilities in at-risk groups and to provide new therapeutic options for NAFLD and its associated complications.

Differential Characteristics and Survival Outcomes of Patients With Cirrhosis According to Underlying Liver Aetiology

BACKGROUND AND AIMS

Updated data on the survival of patients with cirrhosis are limited, especially for subgroups by specific liver disease aetiology. To inform practice, future modelling studies, and public health planning, our study aimed to provide updated and granular data on survival outcomes of patients with cirrhosis stratified by liver disease aetiology. We also assessed their changes over time.

METHODS

We analysed 8726 consecutive adult patients with cirrhosis who presented at Stanford university medical center during 1/2005-1/2022.

RESULTS

8726 Patients had the following etiologies: hepatitis C virus (HCV) (28.1%), hepatitis B virus (HBV) (4.8%), alcohol-associated (ALD, 33.3%), metabolic-associated steatotic liver disease (MASLD) (9.5%), autoimmune (9.6%), cryptogenic (8.2%) and other etiologies (6.5%). Patients with cryptogenic cirrhosis had the lowest overall 5-, 10-, and 15-year cumulative survival (57.5%, 34.3% and 21.4%), as well as for liver and nonliver-related death, followed by ALD, MASLD, HCV, and autoimmune, while HBV patients had the best survival (86.0%, 70.1% and 65.1%), respectively. On multivariable Cox regression, cryptogenic cirrhosis (vs. HBV) was associated with the highest risk of all-cause death (aHR: 2.24, 95% CI 1.67-3.00), followed by MASLD and ALD (all p < 0.001). Post-2010 time was associated with a 33% lower risk of all-cause death (p = 0.0011); While in the post-2010 period, MASLD (vs. HBV) was associated with the highest risk of all-cause death (aHR: 1.92, 95% CI 1.32-2.80, p < 0.001) followed by cryptogenic and ALD.

CONCLUSIONS

Survival outcomes in patients with cirrhosis varied by aetiology and have changed over time, which should be taken into account for future practice guidelines and modelling studies.

Representation of Sex, Race and Ethnicity in MASH Randomised Controlled Trials: A Systematic Review and Meta-Analysis

BACKGROUND AND AIMS

Randomised controlled trials (RCTs) have historically underrepresented female, racial and ethnic minorities across various fields. This systematic review and meta-analysis aims to examine the global distribution, reporting and participation of diverse groups based on sex, race and ethnicity in trials focused on metabolic dysfunction-associated steatohepatitis (MASH).

METHODS

PubMed and Cochrane Library databases were systematically searched for MASH RCTs (through December 13, 2024) that included any pharmacotherapy as an intervention arm. RCTs were qualitatively reviewed to assess their global distribution and reporting of populations. A meta-analysis of proportions was performed using a generalised linear mixed model.

RESULTS

One hudred and nine studies were identified, reporting data from 112 RCTs and 19 516 MASH participants. Of the 49 countries that conducted trials, 34 were high-income countries (69.4%). Sex, race and ethnicity were reported in 111 (99.1%), 69 (61.6%) and 56 (50.0%) of the 112 RCTs, respectively, with reporting improving in recent years. We found no reporting of sexual and gender minorities. The pooled proportions of female, White, Asian, Black and Hispanic/Latino groups were 54.23% (95% confidence interval [CI]: 51.31-57.12), 87.63% (95% CI: 85.37-89.58), 4.95% (95% CI: 3.42-7.10), 2.27% (95% CI: 1.89-2.71) and 31.42% (95% CI: 26.61-36.66), respectively. Meta-regressions showed a trend toward more female, White and Hispanic/Latino participants in RCTs over time.

CONCLUSIONS

Although female and Hispanic/Latino representation has increased over time, racial minorities are underrepresented in MASH trials. These data provide an overview of participant representation in MASH trials and call for collaborative efforts among researchers, sponsors, regulators and other relevant stakeholders to improve diversity in these trials.

Statin use and liver-related prognosis among patients with MASLD

Background & Aims

Metabolic dysfunction-associated steatotic liver disease (MASLD) is a highly prevalent liver condition. We investigated whether statin use reduces liver-related events (LREs) risk among patients with MASLD or MASLD with increased alcohol intake (MetALD).

Methods

This nationwide cohort study included individuals aged ≥40 years with MASLD/MetALD undergoing health examinations between 2012 and 2013. The primary outcome was LREs; hepatocellular carcinoma (HCC), decompensated liver cirrhosis (DLC), and liver-related mortality. Secondary outcomes included HCC, DLC, and steatotic liver disease (SLD) regression, all-cause mortality, cardiovascular diseases (CVD)-related mortality, and liver-related mortality, respectively. Multivariable Cox regression was performed to estimate the risk of LREs associated with statin use.

Results

Among 516,575 individuals (median follow-up: 10.1 years), statin users experienced significantly lower LRE rates (1.6%) compared with non-users (2.0%, p <0.001). Multivariable Cox regression analysis revealed that statin use was associated with reduced risks of LREs (adjusted hazard ratio [aHR] 0.64, 95% CI 0.61-0.68), HCC (aHR 0.52, 95% CI 0.47-0.58), DLC (aHR 0.58, 95% CI 0.52-0.65), all-cause mortality (aHR 0.81, 95% CI 0.78-0.84), CVD-related mortality (aHR 0.87, 95% CI 0.80-0.95), and liver-related mortality (aHR 0.51, 95% CI 0.46-0.57). Furthermore, statin use was associated with SLD regression (aHR 1.18, 95% CI 1.15-1.21). Stratified analyses consistently demonstrated risk reductions across all subgroups, particularly in patients with elevated alanine aminotransferase levels. Sensitivity analyses confirmed the robustness of these associations.

Conclusions

Statins are significantly associated with reduced LRE risk in patients with MASLD, especially among those with elevated alanine aminotransferase levels, suggesting a viable preventive strategy for such population.

Impact and implications

Our study provides critical evidence supporting the role of statins in reducing liver-related events in patients with metabolic dysfunction-associated steatotic liver disease (MASLD), a condition with significant global health impact. These findings are particularly relevant for clinicians managing high-risk patients with MASLD, especially those with elevated alanine aminotransferase levels, as they highlight the potential for statins to mitigate both liver and cardiovascular risks. By demonstrating the robustness of these results through comprehensive sensitivity and stratified analyses, our research underscores the importance of integrating statin therapy into the management of MASLD. This has practical implications for physicians, researchers, and policymakers in developing guidelines and preventive strategies to improve long-term liver and cardiovascular outcomes.

Ethnic differences in metabolic and histologic features among White, Hispanic, Black and Asian patients with metabolic-associated Steatotic liver disease: A network meta-analysis

INTRODUCTION AND OBJECTIVES

Current evidence on the impact of ethnic disparities on metabolic-associated steatotic liver disease (MASLD) is limited to individual studies with small sample sizes from specific regions. This network meta-analysis aimed to assess variations in metabolism and histological characteristics of MASLD among four ethnicities.

MATERIALS AND METHODS

Observational studies on MASLD involving at least two ethnic groups (White, Black, Asian, and Hispanic) were identified from PubMed, Embase, and Web of Science databases up to May 7th, 2024, for inclusion in this study. The results were reported as unstandardized mean differences (MDs) and odds ratios (ORs) with 95% confidence intervals (CIs).

RESULTS

A total of twenty-seven articles involving 14,440 non-Hispanic Whites, 4,927 non-Hispanic Blacks, 5,254 Asians, and 8,344 Hispanic MASLD patients were included in this study. The prevalence of type 2 diabetes mellitus of all ethnic groups combined was 33%, without significant difference among the four ethnicities. Asians showed higher levels of total cholesterol compared to the other groups, while Blacks had the lowest levels of alanine aminotransferase. Among biopsy-proven MASLD patients, Blacks individuals had a lower risk of significant fibrosis compared to Whites (OR=0.63, 95% CI: 0.45 to 0.87), as well as lower risks of liver inflammation (OR=0.53, 95% CI: 0.29 to 0.95) and nonalcoholic steatohepatitis (NASH) (OR=0.53, 95% CI: 0.29 to 0.95) compared to Hispanics.

CONCLUSIONS

Asians MASLD patients had higher risk of suffering from abnormal lipid metabolism while Black MASLD patients presented milder liver histologic features than both Whites and Hispanics individuals.

Meta-Analysis: Global Prevalence and Mortality of Cirrhosis in Metabolic Dysfunction-Associated Steatotic Liver Disease

BACKGROUND AND AIMS

Metabolic dysfunction-associated steatotic liver disease (MASLD) is responsible for a significant global health burden. Despite this burden, the prevalence and mortality of MASLD-related cirrhosis remain inadequately defined, hindering effective public health strategies. This study aimed to estimate the global prevalence and mortality associated with MASLD-related cirrhosis.

METHODS

A systematic search of PubMed, Ovid MEDLINE, EMBASE, Web of Science and SCOPUS was conducted using keywords related to MASLD and cirrhosis from inception of each database used through June 2024. COVIDENCE was used for abstract and manuscript review. MASLD populations were categorised into 'general practice setting' and 'high risk setting', which indicated studies from inpatient setting or those referred for liver biopsy for an indication (elevated liver enzymes). Our data extraction and quality assessment followed PRISMA guidelines. A random-effects model was utilised for meta-analysis.

RESULTS

From 7924 identified articles, 35 studies comprising 513,742 patients with MASLD met the inclusion criteria. The pooled global prevalence of cirrhosis among MASLD patients was 3.26% (95% CI: 2.47%-4.31%) in general practice settings (4 studies) and 14.51% (95% CI: 11.22%-18.57%) among those in inpatient settings or referred for liver biopsy (31 studies). Regionally, higher prevalence rates in high-risk settings were observed in North America and Australia (18.38%; 95% CI: 9.06%-33.75%), followed by Europe (10.16%; 95% CI: 5.71%-17.44%) and Asia (9.12%; 95% CI: 6.11%-13.40%) (p = 0.007). Notably, ICD-based diagnoses indicated a significantly higher prevalence of cirrhosis (27.43%) compared to those diagnosed by liver biopsy (13.24%; p < 0.001). The pooled all-cause mortality rate for MASLD-cirrhosis patients was estimated at 7.91 per 100 person-years (95% CI: 4.44-13.71) (9 studies).

CONCLUSIONS

This meta-analysis underscores the substantial prevalence of cirrhosis among MASLD patients and highlights significant geographic and demographic variability, calling for improved screening and management strategies.

Intervening on Metabolic Dysfunction-Associated Steatotic Liver Disease in Latino/a and Black Patients with Diabetes: A Feasibility Pilot

INTRODUCTION

Patients with type 2 diabetes (T2D), particularly those from historically marginalized racial and ethnic groups, are at high risk of poor outcomes from metabolic dysfunction-associated steatotic liver disease (MASLD). Evidence-based management (EBM) of MASLD can prevent its progression to cirrhosis and poor outcomes, yet rates of EBM of MASLD are low in T2D.

METHODS

In this pilot study of ten participants, we examined the feasibility and acceptability of a telehealth intervention that delivered EBM of MASLD in Latino/a and Black patients with T2D in the Duke Healthcare System. The intervention included: (a) MASLD education; (b) diet/lifestyle counseling; (c) T2D medication adjustment (i.e., to promote liver health) and (d) ordering of clinically indicated tests and referrals. This 3-month intervention was delivered by an endocrinologist over three virtual study visits. Phone interviews were conducted at study conclusion. We examined rates of recruitment, retention, T2D medication adjustment, and ordering of clinically indicated tests/referrals.

RESULTS

The median age of our cohort was 54.0 (44.0, 59.0); six and four participants self-identified as Latino/a ethnicity and Black race, respectively. Retention rate in this study was 100% (n = 10/10), and all scheduled visits were completed (n = 30/30). Recruitment occurred over one month, and the rate was 25.8% (n = 8/31) by telephone call and 10% (n = 2/20) by electronic health record message. The intervention was highly acceptable based on a median Treatment Acceptability and Preferences score of 4.0 (4.0, 4.0). In exit interviews, all participants reported improved understanding of MASLD and its link to diabetes. All participants received T2D medication adjustment (n = 5/10) and/or clinically indicated testing/referral (n = 10/10) for the purpose of improving MASLD.

CONCLUSIONS

We demonstrated that a telehealth intervention designed to proactively deliver EBM of MASLD was feasible and acceptable in a cohort of Latino/a and Black patients with T2D. Opportunities existed to better align each participants' care with guideline-based care of MASLD.

Disparities in Heart Failure Deaths among Patients with Cirrhosis

Background: Heart failure deaths have increased in recent years in the United States and are projected to continue to increase in the future. Rates of liver disease and cirrhosis have similarly increased in the United States. Patients with cirrhosis are at an elevated risk of heart failure with a worsened prognosis. As such, investigations of the epidemiology of these comorbid conditions are important. Methods: We obtained data on heart failure deaths among people with cirrhosis in the United States from 1999 to 2020 from the Centers for Disease Control Wide-ranging Online Data for Epidemiologic Research multiple cause of death database. Rates were analyzed for the population as a whole and for demographic subgroups. Results: From 1999 to 2020, there were 7424 cirrhosis-related heart failure deaths. Rates were higher among Black (AAMR ratio = 1.288, 95% CI: 1.282-1.295) and Asian people (AAMR ratio = 3.310, 95% CI: 3.297-3.323) compared to White people. Rates were also higher in rural areas than in urban areas (AAMR ratio = 1.266, 95% CI: 1.261-1.271). Rates increased over time across demographic subgroups. Conclusions: People with cirrhosis are at an elevated risk of heart failure death compared to the general population. Rates were particularly elevated in Asian people, Black people, males, and people living in rural areas. These data indicate a significant and previously underappreciated disease burden. Clinicians taking care of cirrhosis patients should be aware of the risk of heart failure and should collaborate with cardiac specialists as needed.

Metabolic Dysfunction-Associated Steatotic Liver Disease Is Associated with Increased Risk of Kidney Cancer: A Nationwide Study

Background: This study investigated the association between metabolic dysfunction-associated steatotic liver disease (MASLD) and Kidney Cancer Risk, as the incidence of both diseases gradually increases owing to metabolic health issues. Methods: Participants (aged 20-79) undergoing a national health examination between 2009 and 2010 were monitored for new-onset kidney cancer. The MASLD spectrum was classified as non-MASLD, MASLD, or MASLD with increased alcohol uptake (MetALD). Kidney Cancer Risk associated with the MASLD spectrum was estimated using multivariate Cox proportional hazard models. Age- and sex-stratified analyses were also performed. Results: Among 8,829,510 participants (median follow-up 13.3 years), the proportion of non-MASLD, MASLD, and MetALD was 64.9%, 30.3%, and 4.7%, respectively, with newly developed kidney cancer in 17,555 participants. Kidney cancer was significantly increased with MASLD (adjusted hazard ratio [aHR] 1.51, 95% confidence interval [CI] 1.46-1.56) and MetALD (aHR 1.51, 95% CI 1.42-1.61), compared with the non-MASLD group. Kidney Cancer Risk was the highest among young populations (aHR 1.93, 95% CI 1.77-2.11 for MASLD and aHR 1.91, 95% CI 1.65-2.22 for MetALD), according to stratification analysis. Furthermore, the cumulative relationship between metabolic dysfunction and Kidney Cancer Risk was confirmed across all MASLD spectra. Conclusions: Our study highlights the positive association between MASLD and Kidney Cancer Risk, emphasizing a comprehensive approach to metabolic health. This also serves as a call to devote closer attention to the metabolic health of younger patients.

Sex and Race-Ethnic Disparities in Metabolic Dysfunction-Associated Steatotic Liver Disease: An Analysis of 40,166 Individuals

BACKGROUND

To overcome the limitations of the term "non-alcoholic fatty liver disease" (NAFLD), the term metabolic-associated steatotic liver disease (MASLD) was introduced. While epidemiologic studies have been conducted on MASLD, there is limited evidence on its associated sex and ethnic variations.

AIMS

This study assesses the differences across sex and race-ethnicity on the prevalence, associated risk factors and adverse outcomes in individuals with MASLD.

METHODS

Data retrieved from the National Health and Nutrition Examination Survey between 1999 to 2018 was analyzed. Prevalence, clinical characteristics, and outcomes were evaluated according to sex and race-ethnicity. Adverse outcomes and mortality events were analyzed using multivariate analyses.

RESULTS

Of 40,166 individuals included, 37.63% had MASLD. There was a significant increase in MASLD prevalence from 1999 to 2018 among Mexican Americans (Annual Percentage Change [APC] + 1.889%, p < 0.001), other Hispanics (APC + 1.661%, p = 0.013), NH Whites (APC + 1.084%, p = 0.018), NH Blacks (APC + 1.108%, p = 0.007), and females (APC + 0.879%, p = 0.030), but not males. Females with MASLD were at lower risk of all-cause (HR: 0.766, 95%CI 0.711 to 0.825, p < 0.001), cardiovascular disease-related (CVD) (SHR: 0.802, 95% CI 0.698 to 0.922, p = 0.002) and cancer-related mortality (SHR: 0.760, 95% CI 0.662 to 0.873, p < 0.001). Significantly, NH Blacks have the highest risk of all-cause and CVD-related mortality followed by NH Whites then Mexican Americans.

CONCLUSION

There has been an increase in prevalence in most race-ethnicities over time. While the change in definition shows no significant differences in previous associations found in NAFLD, the increased mortality in NH Whites relative to Mexican Americans remains to be explored.

Prevalence and Characteristics of Metabolic Dysfunction-Associated Fatty Liver Disease among an Iranian Adult Population with Ethnic and Genetic Diversity: Results of the PolyIran-Liver Study

Background

Metabolic dysfunction-associated fatty liver disease (MAFLD) is a rising global public health concern. It has been demonstrated that its prevalence and characteristics vary by region and racial/ethnicity. We aimed to investigate the prevalence of MAFLD and its characteristics among Turkmen and non-Turkmen ethnic groups in a multiethnic population region of Iran.

Methods

In this cross-sectional study, we analyzed baseline data for 1614 participants, aged above 50 years, from the PolyIran-Liver trial who were randomly selected from Gonabad city and determined the prevalence of MAFLD and its demographic and metabolic disorders for both the Turkmen and non-Turkmen ethnic groups. Multivariate binary logistic regressions were applied to identify MAFLD-associated factors for men and women separately for the Turkmen and non-Turkmen populations.

Results

The mean (SD) age of the participants was 59.1(6.7) years. Of the participants, 51.5% (n=831) were men, and 52.9% (n=854) were Turkmen. The prevalence of MAFLD among the overall study population was 39.8% (n=614). It was more common among women (45.8% vs. 34.1% in men, P<0.001), non-Turkmens (43.9% vs. 36.1% in Turkmens, P<0.001), and at age 50-64 (41.5% vs.36.1% in age≥65 P=0.004). The fully adjusted multivariate analysis in sex strata exhibited an independent negative association between Turkmen ethnicity only among men but not among women. The increased waist circumference (WC) was the most common metabolic disorder, observed in more than 95.5% of patients with MAFLD (P<0.001). Multivariate analysis in sex/ethnic strata with adjustment for potential confounders revealed an independent association of MAFLD with increased WC, insulin resistance, impaired fasting glucose/diabetes type 2, and high alanine aminotransferase (ALT) among women in both ethnic groups while with elevated triglyceride (TG) only among Turkmen and high body mass index (BMI) only among non-Turkmen women. Increased WC had the strongest independent association with MAFLD among women and the highest odds ratio (OR) with MAFLD in Turkmen women (OR: 6.10; 95% CI 1.56-23.86 vs. 4.80 in non-Turkmen women). Among men, MAFLD was independently associated with insulin resistance, high BMI, and high ALT in both ethnic groups and elevated TG only in non-Turkmen men (all P<0.001). Insulin resistance had the strongest independent OR with MAFLD among men with similar size in both ethnic groups (4.68 [95% CI 2.56-8.55]) in non-Turkmen men and 4.37 (95% CI 2.27-8.42 in Turkmen men).

Conclusion

This study revealed the high prevalence of MAFLD with a sex and ethnic disparity in the middle-aged population of Gonabad city. Further research is needed to understand the factors contributing to the higher prevalence of MAFLD in this region, particularly in women. Furthermore, considering the diverse ethnic population of Iran, it is suggested that future investigations on the sex and ethnic aspects of MAFLD in the Iranian population be conducted to provide targeted prevention strategies better suited for the Iranian population.