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

Visceral Obesity and Its Association with Severe Coronary Artery Calcification in Patients with Metabolic Dysfunction-Associated Steatotic Liver Disease

Background/Objectives: The role of body composition parameters in patients with metabolic dysfunction-associated steatotic liver disease (MASLD) with presence and severity of coronary artery calcification (CAC) is still not fully elucidated. We aimed to evaluate the impact of computed tomography (CT)-based body composition parameters in patients with MASLD with CAC severity. Methods: In this multicenter study, 1870 individuals underwent cardiac CT for the detection of CAC as well as ultrasonography for the diagnosis of hepatic steatosis. The presence of CAC was defined by a CAC score threshold of >0, while severe CAC was defined by a threshold of >300. Using the abdominal cross-sectional CT images at the L3 vertebra level, we analyzed the skeletal muscle index, visceral to subcutaneous adipose tissue ratio, and muscle density using the Hounsfield unit. Results: Of 648 patients with MASLD, the proportions of presence of CAC and severe CAC were 45.2% and 9.9%, respectively. Visceral obesity was not associated with the presence of CAC after adjustment for age, sex, smoking, statin therapy, type 2 diabetes, and advanced fibrosis (adjusted odds ratio (aOR), 1.38; 95% confidence interval (CI), 0.86-2.23; p = 0.180). However, visceral obesity was independently associated with severe CAC after adjustment for several metabolic risk factors (aOR, 3.54; 95% CI, 1.25-14.90; p = 0.039), and adjustment for atherosclerotic cardiovascular disease risk scores (aOR, 3.74; 95% CI, 1.31-15.79; p = 0.032). Conclusions: Visceral obesity may serve as a novel prognostic CT-based radiological biomarker for patients with MASLD with severe CAC.

Clinical Characteristics of Sarcopenia in Nonalcoholic Fatty Liver Disease: A Systemic Scoping Review

INTRODUCTION

This systematic scoping review aimed to synthesize existing research findings on the clinical manifestations in patients with nonalcoholic fatty liver disease (NAFLD) and sarcopenia.

METHODS

Adhering to scoping review guidelines, we comprehensively searched five databases for literature on sarcopenia's clinical manifestations in NAFLD patients from December 2013 to December 2023, meticulously compiling and synthesizing the findings.

RESULTS

A total of 312 articles were identified, with 9 studies included in the final review. Of these, 90% were cross-sectional investigations, with 70% from Asian cohorts. Comparative analysis between patients solely afflicted with NAFLD and those additionally experiencing sarcopenia revealed discernible trends. Individuals with both conditions tended to be older, have a higher body mass index, and show a higher prevalence among females, underscoring the influence of unhealthy lifestyles and obesity. Furthermore, comorbidities like metabolic syndrome, hypertension, and diabetes have been implicated in sarcopenia manifestation among NAFLD patients. Nonetheless, the lack of standardized diagnostic criteria and patterns poses an ongoing clinical challenge for this subgroup.

CONCLUSIONS

Our review highlights distinct clinical characteristics evident in NAFLD patients with sarcopenia. However, comprehensive investigations remain scarce, impeding accurate early detection and intervention. Future research should prioritize bridging these gaps and fostering enhanced clinical management strategies.

The prevalence and effects of sarcopenia in patients with metabolic dysfunction-associated steatotic liver disease (MASLD): A systematic review and meta-analysis

BACKGROUND AND AIMS

Sarcopenia is a common complication in patients with metabolic dysfunction-associated steatotic liver disease (MASLD). However, the prevalence and its impact on the survival of sarcopenia in patients with MASLD is unknown. In this study, we aimed to assess the prevalence and effects of sarcopenia in patients with MASLD.

METHODS

Systematic review and meta-analysis of full texts of relevant studies were searched from inception until June 12, 2024 in five databases (PubMed, Cochrane Library, Embase, Web of Science, and the China National Knowledge Infrastructure). Next, we assessed the prevalence of sarcopenia in MASLD, and calculated the ORs and HRs between sarcopenia and MASLD based on the adjusted data from individual studies. Statistical analyses were performed using Stata 11.0.

RESULTS

Of the 2984 records considered, 29 studies recruiting 63,330 patients were included. The pooled prevalence of sarcopenia in patients with MASLD was 23.5% overall (95% CI; 19.1%-27.9%, I2 = 99.6%), and was higher in Asian patients, male, cross-sectional studies, when BIA were employed to measure muscle mass, one criterion of diagnosis sarcopenia, MASLD was diagnosed employing MRI, and moderate-quality studies. Sarcopenia was associated with MASLD patients (adjusted odds ratio [aOR] 2.08, 95% CI 1.58-2.74, I2 = 93.6%) with similar findings in subgroups stratified by age, study design, methods for measuring muscle mass, assessment method to detect sarcopenia, and study quality. The association between all-cause mortality further supports the association between sarcopenia and poor prognosis with MASLD (aHR 1.59, 95% CI 1.33-1.91, I2 = 0%).

CONCLUSIONS

Sarcopenia was strongly associated with MASLD progression and was a risk factor not only for MASLD pathogenesis but was also markedly correlated with MASLD-associated mortality.

Prevalence and outcome of sarcopenia in non-alcoholic fatty liver disease

BACKGROUND

Nonalcoholic fatty liver disease (NAFLD) includes a spectrum of conditions, progressing from mild steatosis to advanced fibrosis. Sarcopenia, characterized by decreased muscle strength and mass, shares common pathophysiological traits with NAFLD. An association exists between sarcopenia and increased NAFLD prevalence. However, data on the prevalence of sarcopenia in NAFLD and its impact on the outcomes of NAFLD remain inconsistent.

AIM

To analyze the prevalence and outcomes of sarcopenia in patients with NAFLD.

METHODS

We conducted a comprehensive search for relevant studies in MEDLINE, Embase, and Scopus from their inception to June 2023. We included studies that focused on patients with NAFLD, reported the prevalence of sarcopenia as the primary outcome, and examined secondary outcomes, such as liver fibrosis and other adverse events. We also used the Newcastle-Ottawa scale for quality assessment.

RESULTS

Of the 29 studies included, the prevalence of sarcopenia in NAFLD varied widely (1.6% to 63.0%), with 20 studies reporting a prevalence of more than 10.0%. Substantial heterogeneity was noted in the measurement modalities for sarcopenia. Sarcopenia was associated with a higher risk of advanced fibrosis (odd ratio: 1.97, 95% confidence interval: 1.44-2.70). Increased odds were consistently observed in fibrosis assessment through biopsy, NAFLD fibrosis score/body mass index, aspartate aminotransferase to alanine aminotransferase ratio, diabetes (BARD) score, and transient elastography, whereas the fibrosis-4 score showed no such association. Sarcopenia in NAFLD was associated with a higher risk of steatohepatitis, insulin resistance, cardiovascular risks, and mortality.

CONCLUSION

This systematic review highlights the critical need for standardized diagnostic criteria and measurement methods for sarcopenia in NAFLD patients. The variability in study designs and assessment methods for sarcopenia and liver fibrosis may account for the inconsistent findings. This review demonstrates the multidimensional impact of sarcopenia on NAFLD, indicating its importance beyond liver-related events to include cardiovascular risks, mortality, and metabolic complications.

Relationship between neck vessel abnormalities and sarcopenia: results of a study examining trends in health and aging in western China

OBJECTIVE

To elucidate the association between cervical vascular abnormalities (high Crouse score, high carotid intima-media thickness [CIMT], high plaque score [PS]) and sarcopenia and its diagnostic elements.

STUDY DESIGN

This cross-sectional investigation selected patients from the Western China Health and Aging Trends Study (WCHAT) aged 60 years and older. High CIMT and high Crouse score was defined as values ≥ upper quartile cutoff. Moreover, PS ≥ 3 was set as an high PS. Sarcopenia diagnosis and the definition of sarcopenia diagnostic elements were based on the Asian Working Group on Sarcopenia (AWGS) 2019 consensus. Lastly, associations between high Crouse score, high PS, high CIMT, and sarcopenia and its diagnostic elements were assessed using logistic regression.

RESULT

In all, we recruited 932 subjects in this study, among which, 138 people (14.81%) were diagnosed with sarcopenia. The rates of high Crouse score (sarcopenia vs. non-sarcopenia: 37.68% vs. 23.30%, P < 0.001) and high PS (sarcopenia vs. non-sarcopenia: 34.78% vs. 18.39%, P < 0.001) in subjects with sarcopenia were higher than those in subjects without sarcopenia. Logistic regression analysis and the correction of possible confounding factors showed that high Crouse score and high PS were related to sarcopenia (high Crouse score: OR = 1.573; 95%CI: 1.032-2.4; high PS: OR = 1.845; 95%CI: 1.195-2.851). Further analysis indicated that high Crouse score were associated with low muscle mass (OR = 1.403; 95%CI: 1.002-1.966) and low physical function (OR = 1.93; 95%CI: 1.3-2.866). High PS was found to be related to low physical function (OR = 1.83; 95%CI: 1.209-2.771).

CONCLUSION

While both high Crouse score and high PS are related to sarcopenia, further analysis showed that high Crouse score were mainly associated with low muscle mass and low physical function while high PS was associated with low physical function.

Higher mortality among lean patients with non-alcoholic fatty liver disease despite fewer metabolic comorbidities

BACKGROUND & AIMS

Non-alcoholic fatty liver disease (NAFLD) can develop in individuals who are not overweight. Whether lean persons with NAFLD have lower mortality and lower incidence of cirrhosis, cardiovascular diseases (CVD), diabetes mellitus (DM) and cancer than overweight/obese persons with NAFLD remains inconclusive. We compared mortality and incidence of cirrhosis, CVD, DM and cancer between lean versus non-lean persons with NAFLD.

METHODS

This is a retrospective study of adults with NAFLD in a single centre from 2012 to 2021. Primary outcomes were mortality and new diagnosis of cirrhosis, CVD, DM and cancer. Outcomes were modelled using competing risk analysis and Cox proportional hazards regression analysis.

RESULTS

A total of 18,594 and 13,420 patients were identified for cross-sectional and longitudinal analysis respectively: approximately 11% lean, 25% overweight, 28% class 1 obesity and 35% class 2-3 obesity. The median age was 51.0 years, 54.6% were women. The median follow-up was 49.3 months. Lean patients had lower prevalence of metabolic diseases at baseline and lower incidence of cirrhosis and DM than non-lean patients and no difference in CVD, any cancer or obesity-related cancer during follow-up. However, lean patients had significantly higher mortality with incidence per 1000 person-years of 16.67, 10.11, 7.37 and 8.99, respectively, in lean, overweight, obesity class 1 and obesity class 2-3 groups respectively.

CONCLUSIONS

Lean patients with NAFLD had higher mortality despite lower incidence of cirrhosis and DM, and similar incidence of CVD and cancer and merit similar if not more attention as non-lean patients with NAFLD.

Non-Alcoholic Fatty Liver Disease with Sarcopenia and Carotid Plaque Progression Risk in Patients with Type 2 Diabetes Mellitus

BACKGROUND

We aimed to evaluate whether non-alcoholic fatty liver disease (NAFLD) with or without sarcopenia is associated with progression of carotid atherosclerosis in patients with type 2 diabetes mellitus (T2DM).

METHODS

We investigated 852 T2DM patients who underwent abdominal ultrasonography, bioelectrical impedance analysis, and carotid artery ultrasonography at baseline and repeated carotid ultrasonography after 6 to 8 years. NAFLD was confirmed by abdominal ultrasonography, and sarcopenia was defined as a sex-specific skeletal muscle mass index (SMI) value <2 standard deviations below the mean for healthy young adults. SMI was calculated by dividing the sum of appendicular skeletal mass by body weight. We investigated the association between NAFLD with or without sarcopenia and the progression of carotid atherosclerosis.

RESULTS

Of the 852 patients, 333 (39.1%) were classified as NAFLD without sarcopenia, 66 (7.7%) were classified as sarcopenia without NAFLD, and 123 (14.4%) had NAFLD with sarcopenia at baseline. After 6 to 8 years, patients with both NAFLD and sarcopenia had a higher risk of atherosclerosis progression (adjusted odds ratio, 2.20; P<0.009) than controls without NAFLD and sarcopenia. When a subgroup analysis was performed on only patients with NAFLD, female sex, absence of central obesity, and non-obesity were significant factors related to increased risk of plaque progression risk in sarcopenic patients.

CONCLUSION

NAFLD with sarcopenia was significantly associated with the progression of carotid atherosclerosis in T2DM patients.

Diagnostic Value of Inflammatory Markers in Elderly Arab Women with Sarcopenia

Several studies have found a correlation between inflammatory markers and sarcopenia; however, limited research has been conducted on the Arabic population. Therefore, this study aimed to investigate the value of inflammatory parameters in Saudi elderly women with sarcopenia. In this cross-sectional study, 76 elderly Saudi women (>65 years) were stratified according to the presence (n = 26) or absence (n = 50) of sarcopenia, using the operational definition of the Asian Working Group for Sarcopenia (AWGS). Demographics and clinical data were collected. Muscle mass, muscle strength, and physical performance were assessed using bioelectrical impedance, hand grip and timed-up-and-go (TUG) tests, respectively. Inflammatory markers such as interleukin-6 (IL-6), tumor necrosis factor alpha (TNF-α) and C-reactive protein (CRP) were assessed using commercially available assays. Muscle mass and strength indicators were lower in the sarcopenia group (p-value < 0.05). Moreover, interleukin 6 (IL-6) was positively correlated with TUG (r = 0.48, p-value < 0.05), while CRP showed an inverse correlation with the right leg muscle (R-Leg-M) and a positive correlation with triceps skinfold (TSF) (r = −0.41, r = 0.42, respectively, p-values < 0.05). Additionally, TSF and R-Leg-M were independent predictors of CRP variation (R2 = 0.35; p < 0.01). Lastly, participants with a TNF-α > 71.2 were five times more likely to have sarcopenia [(OR = 5.85), 95% CI: 1.07−32.08; p = 0.04]. In conclusion, elevated levels of TNF-α are significantly associated with the risk of sarcopenia, while variations perceived in circulating CRP can be explained by changes in the muscle mass indices only among individuals with sarcopenia. The present findings, while promising, need further investigations on a larger scale to determine whether inflammatory markers hold any diagnostic value in assessing sarcopenia among elderly Arab women.

Association of High Muscle Mass with Carotid Atherosclerosis: A Community-Based Population Cohort Study

OBJECTIVES

Although low muscle mass may make an under-appreciated contribution to increasing the risk of cardiovascular diseases, no prospective studies have explored the association between low muscle mass and carotid atherosclerosis. We investigated whether muscle mass was related to a higher carotid intima-media thickness (C-IMT) and carotid artery plaque in a community-based population.

METHODS

The study included 1,253 asymptomatic participants without known cardiovascular disease, who underwent carotid ultrasonography at baseline in 2013-2014 and received a re-examination in 2015-2016. The skeletal muscle mass index was estimated using a bioelectrical impedance analyzer. We assessed the relationship between the skeletal muscle mass index and the development of C-IMT and carotid plaque, both, using multivariate-adjusted logistic regression models.

RESULTS

During the follow up, 400 (51.0%) subjects with normal C-IMT at baseline developed elevated C-IMT and 215 (17.2%) subjects developed carotid plaque. The risk of elevated C-IMT occurrence linearly decreased with an increase in skeletal muscle mass index quintiles or its continuous data, after multivariate-adjustment in men and women, respectively (both P for trend < 0.05; both P < 0.05). Subgroup analyses showed that this association was BMI-dependent. Besides, there was an inverse association between a high skeletal muscle mass index and carotid artery plaque in women, but the association disappeared after multivariate adjustment. In men, the skeletal muscle mass index was not associated with the incidence of carotid plaque.

CONCLUSIONS

Skeletal muscle mass was inversely associated with the incidence of carotid atherosclerosis, suggesting muscle mass maintenance may play a role in modifying atherosclerosis.

Association between Fasting Ketonuria and Advanced Liver Fibrosis in Non-Alcoholic Fatty Liver Disease Patients without Prediabetes and Diabetes Mellitus

Ketone body production, an alternative fuel upon low glucose availability, reduces hepatic fat accumulation. However, its clinical implications have not been established in patients with nonalcoholic fatty liver disease (NAFLD). We investigated the association between spontaneous fasting ketonuria and liver fibrosis in patients with NAFLD without prediabetes and diabetes mellitus (DM). A total of 6202 patients with ultrasound confirmed NAFLD without prediabetes and DM were enrolled in the study. Using low cut off values of NAFLD fibrosis score (NFS) and fibrosis-4, liver fibrosis was defined as an intermediate-high probability of advanced liver fibrosis. Of the 6202 NAFLD patients, 360 (5.8%) had ketonuria. Compared to the patients without ketonuria, patients with ketonuria were younger (41.1 vs. 44.6 years, p < 0.001), had lower levels of glucose (87.2 vs. 91.0 mg/dL, p < 0.001), and homeostatic model assessment for insulin resistance (1.0 vs. 1.5, p < 0.001). The presence of ketonuria had an inverse association with liver fibrosis, assessed using both NFS (final adjusted odds ratio [aOR], 0.67; 95% confidence interval [CI], 0.45-1.01) and fibrosis-4 (aOR, 0.58; 95% CI, 0.40-0.84). The presence of ketonuria in NAFLD patients without prediabetes and DM may have favorable metabolic effects compared to the absence of ketonuria, independent of traditional metabolic factors.

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.