Non-alcoholic fatty liver disease and increased risk of cardiovascular disease

Coronary artery disease and non-alcoholic fatty liver disease: Clinical correlation using computed tomography coronary calcium scans

Background and Aim

Non‐alcoholic fatty liver disease (NAFLD) and coronary artery disease (CAD) have been explored using coronary angiography, which showed a link between severe NAFLD and cardiovascular disease risk. This study's aim is to determine if computed tomography (CT) coronary artery calcium (CAC) scores used to determine CAD severity in asymptomatic populations can help predict the presence of NAFLD.

Methods

This was a retrospective cross‐sectional study of positive CT CAC scores and liver imaging with either CT; ultrasound; magnetic resonance imaging of the abdomen; or CT of the chest, which included liver images. Drinking 7 or 14 drinks per week for a female or male, respectively, and chronic viral hepatitis diagnosis were the exclusion criteria. CT CAC scores, hepatic steatosis, age, gender, lipid and liver panels, weight, blood pressure, F‐4/BARD scores, and hemoglobin A1c were correlated to CAD severity and NAFLD by logistic regression.

Results

A total of 134 patients with a mean age of 62.3 years (σ = 9.1), with 65% males, body mass index 28.5 (σ = 6.0), and 8% diabetics, were recruited. CAD severity was not associated with the presence of hepatic steatosis (odds ratio 1.96 [95% confidence interval, confidence interval 0.74–5.23] P = 0.36). Adjusted for variables, a link between hepatic steatosis, CAD severity, body mass index over 30 (odds ratio 6.77 [95% confidence interval 1.40–32.66] P = 0.02), and diabetes (odds ratio 9.60 [95% confidence interval 0.56–165.5] P = 0.01) was observed.

Conclusions

In patients with CAD detected using a positive CT CAC scan, we determined that BMI over 30 and diabetes were correlated with the presence of NAFLD. There was no direct relationship between CAD presence and hepatic steatosis presence.

Alcohol Binge Drinking Selectively Stimulates Protein S-Glutathionylation in Aorta and Liver of ApoE -/- Mice

Background: Binge drinking has become the most common and deadly pattern of excessive alcohol use in the United States, especially among younger adults. It is closely related to the increased risk of cardiovascular disease. Oxidative stress as a result of ethanol metabolism is the primary pathogenic factor for alcohol-induced end organ injury, but the role of protein S-glutathionylation-a reversible oxidative modification of protein cysteine thiol groups that mediates cellular actions by oxidants-in binge drinking-associated cardiovascular disease has not been explored. The present study defines the effect of alcohol binge drinking on the formation of protein S-glutathionylation in a mouse model of atherosclerosis. Methods and Results: To mimic the weekend binge drinking pattern in humans, ApoE deficient (ApoE -/-) mice on the Lieber-DeCarli liquid diet received ethanol or isocaloric maltose (as a control) gavages (5 g/kg/day, 2 consecutive days/week) for 6 weeks. The primary alcohol-targeted organs (liver, brain), and cardiovascular system (heart, aorta, lung) of these two groups of the mice were determined by measuring the protein S-glutathionylation levels and its regulatory enzymes including [Glutaredoxin1(Grx1), glutathione reductase (GR), glutathione-S-transferase Pi (GST-π)], as well as by assessing aortic endothelial function and liver lipid levels. Our results showed that binge drinking selectively stimulated protein S-glutathionylation in aorta, liver, and brain, which coincided with altered glutathionylation regulatory enzyme expression that is downregulated Grx1 and upregulated GST-π in aorta, massive upregulation of GST-π in liver, and no changes in Grx1 and GST-π in brain. Functionally, binge drinking induced aortic endothelial cell function, as reflected by increased aortic permeability and reduced flow-mediated vasodilation. Conclusions: This study is the first to provide in vivo evidence for differential effects of binge drinking on formation of protein S-glutathionylation and its enzymatic regulation system in major alcohol-target organs and cardiovascular system. The selective induction of protein S-glutathionylation in aorta and liver is associated with aortic endothelial dysfunction and fatty liver, which may be a potential redox mechanism for the increased risk of vascular disease in human binge-drinkers.

Risk of fatal and nonfatal coronary heart disease and stroke events among adult patients with hypertension: basic Markov model inputs for evaluating cost-effectiveness of hypertension treatment: systematic review of cohort studies

Objectives

Hypertension is a risk factor for a number of vascular and cardiac complications. A Markov like simulation based on cardiovascular disease (CVD) policy model is being used for evaluating cost-effectiveness of hypertension treatment. Stroke, angina, myocardial infarction (MI), cardiac arrest and all-cause mortality were only included CVD outcome variables in the model. Therefore this systematic review was conducted to evaluate completeness of CVD policy model for evaluation of cost-effectiveness across different regions.

Key findings

Fourteen cohort studies involving a total of 1 674 773 hypertensive adult population and 499 226 adults with treatment resistant hypertension were included in this systematic review. Hypertension is clearly associated with coronary heart disease (CHD) and stroke mortality, unstable angina, stable angina, MI, heart failure (HF), sudden cardiac death, transient ischemic attack, ischemic stroke, sub-arachnoid hemorrhage, intracranial hemorrhage, peripheral arterial disease (PAD), and abdominal aortic aneurism (AAA). Lifetime risk of developing HF is higher among hypertensives across all ages, with slight variation among regions. Treatment resistant hypertension is associated with higher relative risk of developing major CVD events and mortality when compared with the non-resistant hypertension.

Summary

The CVD policy model can be used in most of the regions for evaluation of cost-effectiveness of hypertension treatment. However, hypertension is highly associated with HF in Latin America, Eastern Europe, and Sub-Saharan Africa. Therefore, it is important to consider HF in CVD policy model for evaluating cost-effectiveness of hypertension treatment in these regions. We do not suggest the inclusion of PAD and AAA in CVD policy model for evaluating cost-effectiveness of hypertension treatment due to lack of sufficient evidence. Researchers should consider the effect of treatment resistant hypertension either through including in the basic model or during setting the model assumptions.

Cardiac and Pulmonary Vascular Risk Stratification in Liver Transplantation

Cardiovascular disease complications are the leading cause of early (short-term) mortality among liver transplant recipients. The increasingly older candidate pool has multiple comorbidities necessitating cardiac and pulmonary vascular disease risk stratification of patients for optimal allocation of scarce donor livers. Arrhythmias, heart failure, stroke, and coronary artery disease are common pretransplant cardiovascular comorbidities and contribute to cardiovascular complications after liver transplant. Valvular heart disease and portopulmonary hypertension present intraoperative challenges during liver transplant surgery. The Cardiovascular Risk in Orthotopic Liver Transplantation score estimates the risk of cardiovascular complications in liver transplant candidates within the first year after transplant.

Nonalcoholic Fatty Liver Disease-Associated Liver Fibrosis Is Linked with the Severity of Coronary Artery Disease Mediated by Systemic Inflammation

METHODS AND RESULTS

We conducted a retrospective study of 531 patients with ultrasonogram-confirmed NAFLD who underwent percutaneous coronary intervention (PCI). Then, all patients were separated into four categories by Gensini score (0, 0-9, 9-48, and ≥48) for use in ordinal logistic regression analysis to determine whether NAFLD fibrosis was associated with increased Gensini scores. Mediation analysis was used to investigate whether systemic inflammation is a mediating factor in the association between NAFLD fibrosis and CAD severity. FIB - 4 > 2.67 (OR = 5.67, 95% CI 2.59-12.38) and APRI > 1.5 (OR = 14.8, 95% CI 3.24-67.60) remained to be independent risk factors for the severity of CAD after adjusting for conventional risk factors, whereas among the inflammation markers, only neutrophils and neutrophil-to-lymphocyte ratio (NLR) were independently associated with CAD. Multivariable ordinal regression analysis suggested that increasing Gensini score (0, 0-9, 9-48, and ≥48) was associated with advanced NAFLD fibrosis. ROC curve showed that either fibrosis markers or inflammation markers, integrating with traditional risk factors, could increase the predictive capacity for determining CAD. Inflammation markers, especially neutrophils and NLR, were mediators of the relationship between NAFLD fibrosis and CAD severity.

CONCLUSIONS

NAFLD patients with advanced fibrosis are at a high risk of severe coronary artery stenosis, and inflammation might mediate the association between NAFLD fibrosis and CAD severity.

Assessment of Intramyocardial Fat Content Using Computed Tomography: Is There a Relationship With Obesity?

BACKGROUND

Fat deposition in the liver and the skeletal muscle are linked to cardiovascular risk factors. Fat content in tissues can be estimated by measuring attenuation on noncontrast computed tomography (CT). Quantifying intramyocardial fat content is of interest as it may be related to myocardial dysfunction or development of heart failure. We hypothesized that myocardial fat content would correlate with severity of obesity, liver fat, and components of the metabolic syndrome.

METHODS

We measured attenuation values on 121 noncontrast CT scans from the spleen, liver, erector spinae muscle, and myocardial septum. A chart review was performed for patient demographics and clinical characteristics. We tested for correlations between attenuation values in each of the tissues and various clinical parameters.

RESULTS

We studied 78 females and 43 males, with a mean age of 54.5±11.2 years. Weak, but significant inverse Spearman correlation between body mass index and attenuation values were found in the liver (ρ=-0.228, P=0.012), spleen (ρ=-0.225, P=0.017), and erector spinae muscle (ρ=-0.211, P=0.022) but not in the myocardial septum (ρ=0.012, P=0.897). Mean attenuation in the nonobese group versus obese group (body mass index >30 kg/m2) were 41.1±5.0 versus 42.3±6.9 (P=0.270) in myocardial septum, 56.1±8.7 versus 51.7±10.9 (P=0.016) in the liver, 43.9±8.9 versus 40.1±10.4 (P=0.043) in the spleen, and 41.7±8.3 versus 39.0±8.8 (P=0.087) in the erector spinae muscle.

CONCLUSIONS

Although CT is a theoretically appealing modality to assess fat content of the myocardium, we did not find a relationship between myocardial CT attenuation and obesity, or other cardiovascular risk factors. These findings suggest that the degree of myocardial fat accumulation in obesity or metabolic syndrome is too small to be detected with this modality.

Acute Coronary Syndromes and Nonalcoholic Fatty Liver Disease: "Un Affaire de Coeur"

BACKGROUND AND AIMS

Both nonalcoholic fatty liver disease (NAFLD) and ischemic heart disease have common pathogenic links. Evidence for the association of NAFLD with acute coronary syndromes (ACS), complex multivessel coronary artery disease (CAD), and increased mortality risk in ACS patients is still under investigation. Therefore, we conducted a systematic review aiming to clarify these gaps in evidence.

METHODS

We conducted a systematic search on PubMed and EMBASE with predefined keywords searching for observational studies published till August 2020. NAFLD diagnosis was accepted if confirmed through biopsy, imaging techniques, surrogate markers, or codes. Full articles that satisfied our inclusion and exclusion criteria were included in the systematic review. We used the NHLBI quality assessment tool to evaluate included studies.

RESULTS

Seventeen observational studies with a total study population of approximately 21 million subjects were included. Eleven studies evaluated whether NAFLD is an independent risk factor for developing ACS with conflicting results, of which eight studies demonstrated a significant association between NAFLD and ACS, mainly in Asian populations, while three reported a lack of an independent association. Conflicting results were reported in studies conducted in Europe and North America. Moreover, a total of five studies evaluated whether NAFLD and fatty liver severity in ACS patients are associated with a complex multivessel CAD disease, where all studies confirmed a significant association. Furthermore, seven out of eight studies evaluating NAFLD and hepatic steatosis severity as a predictor of all-cause and cardiovascular mortality and in-hospital major adverse cardiovascular events (MACE) in ACS patients demonstrated a significant independent association.

CONCLUSIONS

NAFLD patients are associated with an independently increased risk of developing ACS, mainly in Asian populations, with inconsistent results in North American and European individuals. Moreover, NAFLD and hepatic steatosis severity were both independently correlated with complex multivessel CAD, mortality, and in-hospital MACE in ACS patients.

Estimation of visceral fat is useful for the diagnosis of significant fibrosis in patients with non-alcoholic fatty liver disease

BACKGROUND

Obesity is a risk factor for non-alcoholic fatty liver disease (NAFLD), although obese patients with NAFLD do not always develop significant fibrosis. The distribution of body fat could predict the risk of NAFLD progression. 

AIM

To investigate the role of bioelectrical impedance-estimated visceral fat (VF) in assessing NAFLD severity.

METHODS

In this cross-sectional study, patients with biopsy-proven NAFLD were prospectively included. All patients underwent anthropometric evaluation, blood tests and bioelectrical impedance analysis.

RESULTS

Between 2017 and 2020, 119 patients were included [66.4% male, 56 years (SD 10.7), 62.2% obese, 61.3% with metabolic syndrome]. Sixty of them (50.4%) showed significant fibrosis (≥ F2) in liver biopsy. Age, VF and metabolic syndrome were associated with significant fibrosis (61 years vs 52 years, 16.4 vs 13.1, 73.3% vs 49.2%, respectively; P < 0.001 for all). In the multivariate analysis, VF and age were independently associated with significant fibrosis (VF, OR: 1.11, 95%CI: 1.02-1.22, P = 0.02; age, OR: 1.08, 95%CI: 1.03-1.12, P < 0.01). A model including these variables showed and area under the receiver operating characteristic curve (AUROC) of 0.75, which was not inferior to transient elastography or NAFLD fibrosis score AUROCs. We developed a nomogram including age and VF for assessing significant fibrosis in routine practice.

CONCLUSION

VF is a surrogate marker of liver fibrosis in patients with NAFLD. Bioelectrical impedance analysis is an inexpensive and simple method that can be combined with age to guide patient referral when other resources may be unavailable.

Nonalcoholic Fatty Liver Disease-Evidence for a Thrombophilic State?

Nonalcoholic fatty liver disease is the leading cause of liver disease worldwide. It has expansive extrahepatic morbidity and mortality including increased rates of both cardiovascular disease and venous thromboembolism. Derangements in primary, secondary and tertiary hemostasis are found in nonalcoholic fatty liver disease independent of those ascribed to end-stage liver disease. The abnormalities across all stages of hemostasis explain the increased rates of clinically relevant thrombotic events, including pulmonary embolism, deep vein thrombosis and portal vein thrombosis, which on an epidemiologic basis appears to be independent of obesity and other traditional venous thromboembolic risk factors. However, given the complex interaction between obesity, body composition and nonalcoholic fatty liver disease and the potential for exercise to benefit all three, more research is needed to further define the role of each in contributing to the prohemostatic state of nonalcoholic fatty liver disease in order to improve patient oriented outcomes.

Relationship between non-alcoholic fatty liver disease and coronary heart disease

Non-alcoholic fatty liver disease (NAFLD) is the leading cause of chronic liver disease and considered a liver manifestation of metabolic syndrome. It is in close relationship with insulin resistance, obesity, diabetes mellitus, all of which increase risk of cardiovascular disease (CVD). Besides, many studies point out that NAFLD independently contributes to the development of atherosclerosis and CHD. On the other hand, CVDs are the leading cause of death in NAFLD patients. Many pathophysiological changes and molecular mechanisms play an important role in NAFLD for CVD formation. Atherosclerosis is common in NAFLD, which also mainly contributes to the CVD formation and CHD. Many studies linking atherosclerotic CHD and NAFLD are present in the literature. Subclinical CHD, mainly detected by coronary computed tomography views, have been detected more common in NAFLD patients. Presence of NAFLD has been found to be more common in patients with severe CHD and in stable CHD, NAFLD has been found to be associated with more diffuse disease. In acute coronary syndromes, especially in acute myocardial infarction, patients with NAFLD have been found to have poor prognosis when compared with NAFLD free patients. In this review, our aim is to evaluate the relationship between NAFLD and CHD in detail and go over the pathophysiological mechanisms underlying this relationship.

Clusterin overexpression protects against western diet-induced obesity and NAFLD

Obesity is a significant risk factor for various metabolic diseases and is closely related to non-alcoholic fatty liver disease (NAFLD) characterized by inflammation and oxidative stress. Clusterin is a multi-functional protein that is up-regulated in the pathogenesis of various metabolic diseases, including obesity and NAFLD. Our previous studies indicated that hepatocyte-specific overexpression of clusterin alleviates methionine choline-deficient (MCD) diet-induced non-alcoholic steatohepatitis (NASH) by activating nuclear factor erythroid 2-related factor 2 (Nrf2). Here we generated transgenic mice with whole-body clusterin overexpression (wCLU-tg) and investigated the role of clusterin in Western diet-induced obesity and NAFLD. We confirmed that obesity parameters and the spectrum of NAFLD of wCLU-tg mice were improved compared to wild type mice. Contrarily, clusterin deficiency deteriorated metabolic disruptions. We also found that clusterin activates target molecules for obesity and NAFLD, namely Nrf2 and AMPK, suggesting that clusterin protects against Western diet-induced obesity and NAFLD by activating Nrf2 and AMPK.

Hepatocellular carcinoma in patients with non-alcoholic steatohepatitis - epidemiology, risk factors, clinical implications and treatment

In recent years, rapid growth of incidence of metabolic syndrome, obesity and diabetes has been noted worldwide. Concurrent non-alcoholic steatohepatitis (NASH) has become a dominant factor of hepatic cirrhosis and hepatocellular carcinoma (HCC). The most important risk factors of transition from NASH to HCC are the degree of liver fibrosis, diabetes, obesity, age and male gender. Body mass index (BMI) reduction and increase of physical activity limit the risk of occurrence of HCC. Also, treatment of diabetes with metformin and application of statins have potential anticancer effects. Patients with HCC due to NASH should be treated in line with BCLC staging. Distant results of HCC therapy in the course of non-alcoholic fatty liver disease (NAFLD) are similar to the results of cancer of different aetiologies. However, patients with the metabolic syndrome are at high perioperative risk, and thus require accurate preparation, especially cardiological, in order to avoid that risk.

Predictors of Nonalcoholic Fatty Liver Disease Among Middle-Aged Iranians

BACKGROUND

The prevalence of nonalcoholic fatty liver disease (NAFLD) is increasing worldwide. Therefore, we sought to determine the most important predictors of NAFLD among middle-aged men and women in Isfahan, Iran.

METHODS

A total of 413 individuals (163 men and 250 women) aged 30-60 years were selected by stratified random sampling. The participants had safe alcohol consumption habits (<2 drinks/day) and no symptoms of hepatitis B and C. NAFLD was diagnosed through ultrasound. Blood pressure, anthropometric, and body composition measurements were made and liver function tests were conducted. Biochemical assessments, including the measurement of fasting blood sugar (FBS) and ferritin levels, as well as lipid profile tests were also performed. Metabolic syndrome was evaluated according to the International Diabetes Federation (IDF) criteria.

RESULTS

The overall prevalence of ultrasound-diagnosed NAFLD was 39.3%. The results indicated a significantly higher prevalence of NAFLD in men than in women (42.3% vs 30.4%; P < 0.05). Binary logistic regression analysis was performed to determine the significant variables as NAFLD predictors. Overall, male gender, high body mass index (BMI), high alanine aminotransferase (ALT), high FBS, and high ferritin were identified as the predictors of NAFLD. The only significant predictors of NAFLD among men were high BMI and high FBS. These predictors were high BMI, high FBS, and high ferritin in women (P < 0.05 for all variables).

CONCLUSIONS

The metabolic profile can be used for predicting NAFLD among men and women. BMI, FBS, ALT, and ferritin are the efficient predictors of NAFLD and can be used for NAFLD screening before liver biopsy.

Tea polyphenols attenuate liver inflammation by modulating obesity-related genes and down-regulating COX-2 and iNOS expression in high fat-fed dogs

Background

Tea polyphenols (TPs) attenuate obesity related liver inflammation; however, the anti-obesity effects and anti-inflammatory mechanisms are not clearly understood. This study aimed to determine whether the anti-obesity and anti-inflammatory TPs mechanisms associated with cyclooxygenase-2 (COX-2) and inducible nitric oxide synthase (iNOS) expression levels, and obesity-related gene response in dogs.

Results

Dogs fed TPs displayed significantly decreased (p < 0.01) mRNA expression of tumor necrosis factor-α (TNF-α), interleukin-1 beta (IL-1β), and interleukin-6 (IL-6) compared to dogs that consumed high-fat diet (HFD) alone. TPs significantly (p < 0.01) inhibited COX-2 and iNOS expression level, and decreased liver fat content and degeneration.

Conclusion

These results suggested that TPs act as a therapeutic agent for obesity, liver inflammation, and fat degeneration via COX-2 and iNOS inhibition, with TNF-α, IL-1β, and IL-6 involvement.

The Role of Bone Morphogenetic Protein Signaling in Non-Alcoholic Fatty Liver Disease

Non-alcoholic fatty liver disease (NAFLD) affects over 30% of adults in the United States. Bone morphogenetic protein (BMP) signaling is known to contribute to hepatic fibrosis, but the role of BMP signaling in the development of NAFLD is unclear. In this study, treatment with either of two BMP inhibitors reduced hepatic triglyceride content in diabetic (db/db) mice. BMP inhibitor-induced decrease in hepatic triglyceride levels was associated with decreased mRNA encoding Dgat2, an enzyme integral to triglyceride synthesis. Treatment of hepatoma cells with BMP2 induced DGAT2 expression and activity via intracellular SMAD signaling. In humans we identified a rare missense single nucleotide polymorphism in the BMP type 1 receptor ALK6 (rs34970181;R371Q) associated with a 2.1-fold increase in the prevalence of NAFLD. In vitro analyses revealed R371Q:ALK6 is a previously unknown constitutively active receptor. These data show that BMP signaling is an important determinant of NAFLD in a murine model and is associated with NAFLD in humans.

Nonalcoholic Fatty Liver Disease and Coronary Artery Disease: Big Brothers in Patients with Acute Coronary Syndrome

Background

The prevalence of nonalcoholic fatty liver disease (NAFLD) has been increasing. This study aimed to evaluate the prevalence of NAFLD, as diagnosed by ultrasound, in patients with acute coronary syndrome (ACS) and to assess whether NAFLD is associated with the severity of coronary obstruction as diagnosed by coronary angiography.

Methods

We performed a prospective single-center study in patients hospitalized due to acute coronary syndrome who underwent diagnostic coronary angiography. Consecutive patients who presented to the emergency room were diagnosed with acute coronary syndrome and were included. All patients underwent ultrasonography of the upper abdomen to determine the presence or absence of NAFLD; NAFLD severity was graded from 0 to 3 based on a previously validated scale. All patients underwent diagnostic coronary angiography in the same hospital, with the same team of interventional cardiologists, who were blinded to the patients' clinical and ultrasonographic data. CAD was then angiographically graded from none to severe based on well-established angiographic criteria.

Results

This study included 139 patients, of whom 83 (59.7%) were male, with a mean age of 59.7 years. Of the included patients, 107 (77%) patients had CAD, 63 (45%) with serious injury. Regarding the presence of NAFLD, 76 (55.2%) had NAFLD including 18 (23.6%) with grade III disease. In severe CAD, 47 (60.5%) are associated with NAFLD, and 15 (83.3%) of the patients had severe CAD and NAFLD grade III.

Conclusions

NAFLD is common in patients with ACS. The intensity of NAFLD detected by ultrasonography is strongly associated with the severity of coronary artery obstruction on angiography.

Efficacy of Liraglutide in clinical practice: Single centre experience

Background and Objective:

GLP-one receptor agonists are amongst the unique antidiabetes medications that have significant metabolic and cardiovascular benefits in addition to glucose lowering effect. To best of our knowledge, there is no published data on efficacy of liraglutide use among Pakistani population.Our objective was to ascertain the efficacy of liraglutide use among type two diabetes patients.

Methods:

This retrospective study was conducted at the Endocrinology Clinics of Aga Khan University Hospital (AKUH) Karachi, Pakistan during the period from July 01, 2016 to 30th June, 2017. Liraglutide was prescribed to 68 obese type two diabetes patients with uncontrolled diabetes taking more than one oral medication ± insulin. Starting dose of Liraglutide was 0.6 mg, which was increased to 1.2 mg after 1-2 weeks with further increment to 1.8 mg/day based on tolerance and individual patient preference. Dose of other diabetes medications was adjusted according to clinical judgment whereas Dipeptidyl peptidase-4(DPP-4) inhibitors were discontinued.

Results:

Mean age of cohort was 55 years (SD=10.94 years) with median body mass index of 36.45 kg/m² and majority (57.35%) were on a dose of 1.2 mg of Liraglutide per day. Median HbA₁c reduced to 7.50% and 7.40% at three months and six months respectively vs 8.45% at baseline. Mean reduction in weight after three month was two kilograms and at six months, it was 1.38 kilograms respectively.

Conclusion:

Liraglutide as add on therapy demonstrated favourable HbA1c and weight reduction in obese uncontrolled type two Diabetes Pakistani subjects.

Preoperative Evaluation Before Noncardiac Surgery

The medical complexity of surgical patients is increasing and medical specialties are frequently asked to assist with the perioperative management surgical patients. Effective pre-anesthetic medical evaluations are a valuable tool in providing high-value, patient-centered surgical care and should systematically address risk assessment and identify areas for risk modification. This review outlines a structured approach to the pre-anesthetic medical evaluation, focusing on the asymptomatic patient. It discusses the evidence supporting the use of perioperative risk calculation tools and focused preoperative testing. We also introduce important key topics that will be explored in greater detail in upcoming reviews in this series.

Role of gut microbiota in sex- and diet-dependent metabolic disorders that lead to early mortality of androgen receptor-deficient male mice

The gut microbiota is involved in metabolic disorders induced by androgen deficiency after sexual maturation in males (late-onset hypogonadism). However, its role in the energy metabolism of congenital androgen deficiency (e.g., androgen-insensitive syndrome) remains elusive. Here, we examined the link between the gut microbiota and metabolic disease symptoms in androgen receptor knockout (ARKO) mouse by administering high-fat diet (HFD) and/or antibiotics. HFD-fed male, but not standard diet-fed male or HFD-fed female, ARKO mice exhibited increased feed efficiency, obesity with increased visceral adipocyte mass and hypertrophy, hepatic steatosis, glucose intolerance, insulin resistance, and loss of thigh muscle. In contrast, subcutaneous fat mass accumulated in ARKO mice irrespective of the diet and sex. Notably, all HFD-dependent metabolic disorders observed in ARKO males were abolished after antibiotics administration. The ratios of fecal weight-to-food weight and cecum weight-to-body weight were specifically reduced by ARKO in HFD-fed males. 16S rRNA sequencing of fecal microbiota from HFD-fed male mice revealed differences in microbiota composition between control and ARKO mice. Several genera or species (e.g., Turicibacter and Lactobacillus reuteri, respectively) were enriched in ARKO mice, and antibiotics treatment spoiled the changes. Furthermore, the life span of HFD-fed ARKO males was shorter than that of control mice, indicating that androgen deficiency causes metabolic dysfunctions leading to early death. These findings also suggest that AR signaling plays a role in the prevention of metabolic dysfunctions, presumably by influencing the gut microbiome, and improve our understanding of health consequences in subjects with hypogonadism and androgen insensitivity.

Coronary Artery Disease is More Severe in Patients with Non-Alcoholic Steatohepatitis than Fatty Liver

Non-alcoholic fatty liver disease (NAFLD) is associated with a higher risk of atherosclerotic disease. However, the relationships between the severity of coronary atherosclerosis and pathologic findings in patients with NAFLD remain unknown. We aimed to characterize the coronary artery lesions in patients with NAFLD using coronary computed tomography angiography (CCTA). Overall, 101 patients with liver biopsy-proven NAFLD who had chest pain or electrocardiographic abnormalities underwent CCTA. Coronary artery lesions, including coronary artery stenosis (CAS), calcium score (CACS, Agatston score), and coronary artery non-calcified plaque were assessed using multi-slice CT. Multivariate analysis showed that age, smoking status, prevalence of dyslipidemia (DLP) and non-alcoholic steatohepatitis (NASH), and stage of fibrosis were independent risk factors for CAS. Age, and the prevalence of DM and DLP, were independent risk factors for CACS, and the prevalence of NASH tended to be an independent risk factor. In addition, the prevalence of DLP and NASH were independent risk factors for non-calcified plaques. Coronary artery lesions are more common in patients with NASH than in those with non-alcoholic fatty liver, suggesting a higher risk in patients with NASH. Therefore, patients with NASH should be closely followed, with particular vigilance for coronary artery diseases.

MELD-XI Score and Coronary Artery Disease Prevalence and Extent Among In-Hospital Patients With End-Stage Liver Failure Awaiting Transplant

OBJECTIVES

Liver transplant is a life-saving procedure for a variety of end-stage liver diseases. Cardiovascular disorders are among the leading cause of death among patients with end-stage liver disease and those undergoing liver transplant procedures. MELD-XI score is a newly developed score for mortality prediction in patients with end-stage liver failure. In this study, we investigated the relationships among MELD-XI score, total in-hospital mortality, and coronary artery disease severity and extent among patients with end-stage liver failure who were awaiting transplant.

MATERIALS AND METHODS

We retrospectively reviewed medical records of 121 patients with end-stage liver failure on transplant wait list. Study patients had undergone coronary angiography as part of pretransplant cardiac evaluation. We determined prevalence of coronary artery disease and Gensini score (which indicates extent of coronary artery disease) using coronary angiography and reviewed MELD-XI score and in-hospital mortality rates. We compared MELD-XI score and Gensini score in deceased and surviving patients and correlated both scores with mortality and with each other.

RESULTS

Of 121 patients, 79 (65.3%) were men; mean age of the study population was 59.6 ± 10.2 years. Twenty-eight patients (23.1%) had coronary artery disease, and 13 (10.7%) had severe coronary artery disease on coronary angiography. Twenty-three patients (19%) died while on the transplant wait list. Gensini score and MELD-XI scores were significantly higher in those who died (P < .05). MELD-XI score, but not Gensini score, was a significant independent predictor of death among patients awaiting liver transplant (hazard ratio = 1.35; 95% confidence interval, 1.04-1.78; P < .05).

CONCLUSIONS

MELD-XI score independently predicted in-hospital death among patients scheduled to undergo liver transplant. These patients also had increased prevalence and extent of coronary artery disease.

Association of Nonalcoholic Fatty Liver Disease and Coronary Artery Disease with FADS2 rs3834458 Gene Polymorphism in the Chinese Han Population

Background

Nonalcoholic fatty liver disease (NAFLD) patients are often prone to coronary artery disease (CAD), and CAD is found to be the main cause of death in NAFLD patients. The purpose of this study was to investigate the association between fatty acid desaturase 2 (FADS2) rs3834458 polymorphism and serum FADS2 level with NAFLD and CAD in Chinese Han population.

Materials and Methods

The serum level of FADS2 was detected by enzyme-linked immunosorbent assay (ELISA) in healthy people, NAFLD patients, and NAFLD patients combined with CAD (NAFLD+CAD). Polymerase chain reaction (PCR) was used to detect the genotypes of FADS2 rs3834458 in the three groups.

Results

Body mass index (BMI), glucose (GLU), total cholesterol (TC), and low-density lipoprotein cholesterol (LDL-C) of the NAFLD group and the NAFLD+CAD group were higher than those of the healthy control group (P < 0.05); the HDL-C of the NAFLD+CAD group was significantly lower than that of the healthy people and the NAFLD group (P < 0.05). The serum FADS2 concentration in the NAFLD+CAD group was significantly higher than that in the NAFLD group (P < 0.05) and the healthy people (P < 0.05). There was no significant difference in genotype distribution (χ² = 5.347, P < 0.497) and allele frequency (χ² = 3.322, P = 0.345) between the three groups. Logistic regression analysis showed that the T allele was not an independent risk factor for CAD with NAFLD (OR = 1.62, 95% CI: 0.422-6.180).

Conclusions

Serum FADS2 concentration was positively correlated with the susceptibility of NAFLD with CAD, while the polymorphism of rs3834458 was not associated with NAFLD with CAD.

Overview of the Pathogenesis, Genetic, and Non-Invasive Clinical, Biochemical, and Scoring Methods in the Assessment of NAFLD

Nonalcoholic fatty liver disease (NAFLD) is the most prevalent chronic liver disease worldwide. It represents a range of disorders, including simple steatosis, nonalcoholic steatohepatitis (NASH), and liver cirrhosis, and its prevalence continues to rise. In some cases, hepatocellular carcinoma (HCC) may develop. The develop;ment of non-invasive diagnostic and screening tools is needed, in order to reduce the frequency of liver biopsies. The most promising methods are those able to exclude advanced fibrosis and quantify steatosis. In this study, new perspective markers for inflammation, oxidative stress, apoptosis, and fibrogenesis; emerging scoring models for detecting hepatic steatosis and fibrosis; and new genetic, epigenetic, and multiomic studies are discussed. As isolated biochemical parameters are not specific or sensitive enough to predict the presence of NASH and fibrosis, there is a tendency to use various markers and combine them into mathematical algorithms. Several predictive models and scoring systems have been developed. Current data suggests that panels of markers (NAFLD fibrosis score, Fib-4 score, BARD score, and others) are useful diagnostic modalities to minimize the number of liver biopsies. The review unveils pathophysiological aspects related to new trends in current non-invasive biochemical, genetic, and scoring methods, and provides insight into their diagnostic accuracies and suitability in clinical practice.

Nonalcoholic Fatty Liver Disease Is Associated With Arterial Distensibility and Carotid Intima-Media Thickness: (from the Multi-Ethnic Study of Atherosclerosis)

Nonalcoholic fatty liver disease (NAFLD) is considered a potential independent risk factor for cardiovascular disease (CVD). The Multi-Ethnic Study of Atherosclerosis cohort enrolled 6,814 adults without previous CVD. We excluded 2,692 participants who had missing variables, were heavy drinkers, or history of steroid use and/or chronic liver disease. NAFLD was defined using noncontrast cardiac CT and a liver/spleen Hounsfield Unit attenuation ratio <1. Ultrasound-measured carotid arterial compliance and stiffness, was expressed as distensibility coefficient and Young's modulus. Common and internal carotid intima-media thickness (CIMT) and coronary artery calcium (CAC) >0 were used as markers of subclinical CVD. A multivariate robust linear regression and logistic regression analysis were done to evaluate the association of NAFLD and this subclinical CVD markers. Our analysis of 4,123 participants showed 55% were female with a mean age of 63 (±10) years, 39% white, 10% Chinese, 28% black, and 23% were Hispanic. The prevalence of NAFLD was 17% (n = 729). Patients with NAFLD had higher distensibility coefficient and higher CIMT. Multivariate linear regression analysis showed the presence of NAFLD was associated with both the common carotid and internal carotid IMT and logCAC. Logistic analysis showed an independent association with CAC > 0 (odds ratio [OR] 1.44 95% confidence interval [CI] 1.18, 1.75) and CIMT > 1 mm (OR 1.30 95% 1.08, 1.56). When stratified by race the association with CIMT > 1 mm was significant in whites (OR 1.37 95% 1.00, 1.90) and Hispanic (OR 1.53 95% 1.08, 2. 17) and CAC > 0 was significant in Hispanics (OR 1.52 95% 1.06, 2.19). In conclusion, NAFLD is modestly associated with carotid IMT and coronary artery calcification in a multiethnic population.

Rationale, Design for the ASSET Study: A Prospective Randomized Study Comparing Empagliflozin's Effect to Sitagliptin on Cardiac Fat Accumulation/Function in Patients with Type 2 Diabetes

INTRODUCTION

Ectopic fat accumulation has been found to play a pathophysiological role in insulin resistance, type 2 diabetes (T2DM), and coronary artery diseases. Findings from a number of previous studies suggest that sodium glucose cotransporter 2 (SGLT2) inhibitors reduce lipid accumulation, including myocardial and pericardial fat, while dipeptidyl peptidase 4 (DPP4) inhibitors suppress ectopic lipid accumulation and improve cardiac function. However, a clinical study that precisely explains and compares the efficacy of SGLT2 inhibitors and DPP4 inhibitors on cardiac fat accumulation has not been performed. Moreover, the association between cardiac fat accumulation and cardiac function or metabolic changes, such as tissue-specific insulin resistance, remains unclear. It is our intention to conduct the first study to assess the effects of empagliflozin compared to sitagliptin in reducing ectopic fat accumulation, specifically pericardial fat, and its association with improvement in cardiac function and tissue-specific insulin sensitivity.

METHODS

We have designed a prospective, randomized open-label, and blinded-endpoint study with the intention to enroll 44 Japanese patients with T2DM. The patients are to be divided them into two groups, an empagliflozin group and an sitagliptin group, with the former to be supplemented with empagliflozin 10 mg and the latter to be supplemented with sitagliptin 100 mg, both groups for 12 weeks. The primary endpoint of the study is the change in the amount of pericardial fat. The secondary endpoints are the changes in the amount of intracellular fat in the myocardium, cardiac function, tissue-specific insulin sensitivity, fatty acid metabolism in myocardial tissue, assessed by parameters of iodine-123-β-methyl-iodophenyl pentadecanoic acid myocardial scintigraphy, blood and urine biomarkers, and lifestyle evaluation.

PLANNED OUTCOMES

The results of this study will be available in 2020. The aim of this study is to provide an effective treatment strategy for patients with T2DM by considering cardiac fat accumulation, cardiac function, and insulin resistance.

FUNDING

Boehringer Ingelheim & Eli Lilly and Company Diabetes Alliance.

TRIAL REGISTRATION

University Hospital Medical Information Network Clinical Trial Registry: UMIN000026340.

Elevated liver enzymes and cardiovascular mortality: a systematic review and dose-response meta-analysis of more than one million participants

Gamma glutamyl transferase (GGT), alanine aminotransferase (ALT), aspartate aminotransferase (AST), and alkaline phosphatase (ALP) are commonly used liver function markers. We performed a dose-response meta-analysis to investigate the association between liver enzymes and cardiovascular disease (CVD) mortality in prospective cohort studies. We conducted a systematic search up to April 2018 in Medline/PubMed, Scopus, Cochrane, and Embase databases. Combined hazard ratios (HRs) with 95% confidence intervals (CIs) were estimated using a random-effects model as described by DerSimonian and Laird. Dose-response analysis was also carried out. Twenty-three studies with 1 067 922 participants reported association between GGT and CVD mortality and were included in our analysis. Pooled results showed a significant association between GGT and risk of CVD mortality (HR: 1.62; 95% CI: 1.47-1.78, P=0.001, P-heterogeneity=0.001) and it was HR: 0.87; 95% CI: 0.73-1.07; P=0.221, P-heterogeneity=0.028, for ALT. There was a direct association between baseline levels of ALP and AST/ALT ratio with CVD mortality (HR: 1.45; 95% CI: 1.11-1.89; P=0.005, P-heterogeneity=0.026, and HR: 2.20; 95% CI: 1.60-3.04; P=0.001, P-heterogeneity=0.540, respectively). Pooled results did not show any significant association between AST and the risk of CVD mortality (HR: 1.20; 95% CI: 0.83-1.73; P=0.313, P-heterogeneity=0.024). Moreover, there was a significant nonlinear association between GGT and ALP levels and the risk of CVD mortality (P=0.008 and 0.016, respectively). Our dose-response meta-analysis revealed a direct relationship between GGT and ALP levels and the risk of CVD mortality. High levels of GGT, ALP and AST/ALT were associated with an increased CVD mortality rate.

Obesity genetics and cardiometabolic health: Potential for risk prediction

The increasing burden of obesity worldwide and its effect on cardiovascular disease (CVD) risk is an opportunity for evaluation of preventive approaches. Both obesity and CVD have a genetic background and polymorphisms within genes which enhance expression of variant proteins that influence CVD in obesity. Genome-based prediction may therefore be a feasible strategy, but the identification of genetically driven risk factors for CVD manifesting as clinically recognized phenotypes is a major challenge. Clusters of such risk factors include hyperglycaemia, hypertension, ectopic liver fat, and inflammation. All involve multiple genetic pathways having complex interactions with variable environmental influences. The factors that make significant contributions to CVD risk include altered carbohydrate homeostasis, ectopic deposition of fat in muscle and liver, and inflammation, with contributions from the gut microbiome. A futuristic model depends on harnessing the predictive power of plausible genetic variants, phenotype reversibility, and effective therapeutic choices based on genotype-phenotype interactions. Inverting disease phenotypes into ideal cardiovascular health metrics could improve genetic and epigenetic assessment, and form the basis of a future model for risk detection and early intervention.

Risk factors for thromboembolic and bleeding events in anticoagulated patients with atrial fibrillation: the prospective, multicentre observational PREvention oF thromboembolic events - European Registry in Atrial Fibrillation (PREFER in AF)

OBJECTIVES

We identified factors associated with thromboembolic and bleeding events in two contemporary cohorts of anticoagulated patients with atrial fibrillation (AF), treated with either vitamin K antagonists (VKA) or non-VKA oral anticoagulants (NOACs).

DESIGN

Prospective, multicentre observational study.

SETTING

461 centres in seven European countries.

PARTICIPANTS

5310 patients receiving a VKA (PREvention oF thromboembolic events - European Registry in Atrial Fibrillation (PREFER in AF), derivation cohort) and 3156 patients receiving a NOAC (PREFER in AF Prolongation, validation cohort) for stroke prevention in AF.

OUTCOME MEASURES

Risk factors for thromboembolic events (ischaemic stroke, systemic embolism) and major bleeding (gastrointestinal bleeding, intracerebral haemorrhage and other life-threatening bleeding).

RESULTS

The mean age of patients enrolled in the PREFER in AF registry was 72±10 years, 40% were female and the mean CHA₂DS₂-VASc Score was 3.5±1.7. The incidence of thromboembolic and major bleeding events was 2.34% (95% CI 1.93% to 2.74%) and 2.84% (95% CI 2.41% to 3.33%) after 1-year of follow-up, respectively.Abnormal liver function, prior stroke or transient ischaemic attack, labile international normalised ratio (INR), concomitant therapy with antiplatelet or non-steroidal anti-inflammatory drugs, heart failure and older age (≥75 years) were independently associated with both thromboembolic and major bleeding events.With the exception of unstable INR values, these risk factors were validated in patients treated with NOACs (PREFER in AF Prolongation Study, 72±9 years, 40% female, CHA₂DS₂-VASc 3.3±1.6). For each single point decrease on a modifiable bleeding risk scale we observed a 30% lower risk for major bleeding events (OR 0.70, 95% CI 0.64 to 0.76, p<0.01) and a 28% lower rate of thromboembolic events (OR 0.72, 95% CI 0.66 to 0.82, p<0.01).

CONCLUSION

Attending to modifiable risk factors is an important treatment target in anticoagulated AF patients to reduce thromboembolic and bleeding events. Initiation of anticoagulation in those at risk of stroke should not be prevented by elevated bleeding risk scores.

Effect of Fish Oil Supplementation on Hepatic and Visceral Fat in Overweight Men: A Randomized Controlled Trial

Being overweight increases the risk of the development of metabolic conditions such as non-alcoholic fatty liver disease (NAFLD), which is itself an independent predictor of cardiovascular disease. Omega-3 polyunsaturated fatty acid (PUFA) supplementation is recommended for prevention of chronic disease, and is thought to reduce raised liver fat, yet there have been few randomized controlled trials with accurate measurement of liver fat. We assessed the effect of 12 weeks of supplementation with omega-3 PUFA from fish oil versus placebo on quantified liver fat, liver tests, and body composition including visceral adipose tissue (VAT) in a double-blind randomized controlled trial. Fifty apparently healthy overweight men (BMI 25.0–29.9 kg/m²; waist > 94 cm) were randomly allocated to consume fish oil (total daily dose: 1728 mg marine triglycerides, of which 588 mg EPA and 412 mg DHA, combined with 200 mg antioxidant, coenzyme Q10) or placebo (olive oil capsules) daily for 12 weeks. Liver fat was assessed using proton magnetic resonance spectroscopy. All outcomes were assessed at baseline and following 6 and 12 weeks of supplementation. Baseline liver fat was 4.6 ± 0.5% (range: 0.6 to 18.2%); 16 (32%) participants met the criteria for NAFLD (>5.5% liver fat). Repeated measures ANOVA revealed no significant time or group × time effect for fish oil versus placebo for liver fat, liver enzymes, anthropometry, or body composition including VAT (p > 0.05 for all), with similar finding for sub-analysis of participants with NAFLD. Omega-3 PUFA did not appear to be an effective agent for reducing liver fat in overweight men. The factors determining the health benefits of omega-3 PUFA supplementation on an individual level need to be clarified.

Disease progression of nonalcoholic steatohepatitis in Taiwanese patients: a longitudinal study of paired liver biopsies

OBJECTIVES

Nonalcoholic steatohepatitis (NASH) might progress to fibrosis, cirrhosis, and hepatocellular carcinoma. However, the natural history of NASH has not been fully clarified. This study aimed to investigate the disease progression in NASH patients receiving paired liver biopsies. We also aimed to examine the factors associated with NASH progression.

PATIENTS AND METHODS

Ten NASH patients who had received liver biopsies during June 2001 and February 2010 were consecutively enrolled. The histopathological changes were examined retrospectively, including nonalcoholic fatty liver disease activity score (NAS) and fibrosis stage. The associated clinical profiles were also analyzed.

RESULTS

The median duration between paired biopsies was 20.5 months (range: 12-106 months). According to NAS and fibrosis stage, disease progression, stable disease, and disease regression were observed in seven patients, two patients, and one patient, respectively. Six (60%) patients had increased NAS on second biopsy, and two were lean NASH patients. The only patient with an improvement in NAS had achieved body weight reduction (13.3%) between paired biopsies. None of the 10 patients experienced an improvement in fibrosis. Five (50%) patients showed progression of fibrosis on second biopsy and the annual fibrosis progression rate was 0.32/year. Two of the five patients who showed progression of fibrosis were of the nonobese phenotype, whereas three patients were nondiabetic.

CONCLUSION

NASH is a progressive disease in Taiwanese patients. The disease progression should be further clarified in lean and nondiabetic NASH patients.

The association between white blood cell subtypes and prevalence and incidence of nonalcoholic fatty liver disease

The association between white blood cell (WBC) and nonalcoholic fatty liver disease (NAFLD) has been studied before, but whether different WBC subtypes were related to NAFLD was not detailed. The aim of our study was to investigate the relationship between WBC subtypes and NAFLD cross-sectionally and prospectively. The detailed research design has been described previously. At baseline, there were 9930 participants who had complete information, in the end a total of 8079 participants (2588 men and 5491 women) were eventually included in this study. Hepatic ultrasound examination was performed on each participant at baseline and at the end of follow-up. Alcohol abuse and hepatitis were excluded. WBC subtypes and other serum indices were measured at baseline. We found that the total WBC, neutrophil, and lymphocyte counts were independently associated with the prevalence and incidence of NAFLD. After multiple adjustments for age, gender, body mass index (BMI), insulin, HOMA-IR, TG, TC, LDL, and HDL, increased odds ratios (ORs) for new onset NAFLD were observed from the 1st to the 4th quartiles of WBC, neutrophil, and lymphocyte (all P < 0.001 for trend). In conclusion, total WBC counts, neutrophils, and lymphocytes were all independent risk factors for NAFLD in the rural Chinese population. The association was independent of insulin resistance.

Dual-release hydrocortisone improves hepatic steatosis in patients with secondary adrenal insufficiency: a real-life study

BACKGROUND

Conventional glucocorticoid treatment has a significant impact on liver in patients with adrenal insufficiency. Dual-release hydrocortisone (DR-HC) provides physiological cortisol exposure, leading to an improvement in anthropometric and metabolic parameters. We aimed to evaluate the effects of 12-month DR-HC treatment on the hepatic steatosis index (HSI), a validated surrogate index of hepatic steatosis, in patients with secondary adrenal insufficiency (SAI).

METHODS

A total of 45 patients with hypopituitarism, 22 with hypogonadism, hypothyroidism, ACTH, and GH deficiencies, and 23 with hypogonadism, hypothyroidism, and ACTH deficiency, on replacement therapy for all the pituitary deficiencies, were switched from conventional hydrocortisone to DR-HC. At baseline and after 12 months, glucose and insulin levels, surrogate estimates of insulin sensitivity, and hepatic steatosis were evaluated through ultrasonography and HSI.

RESULTS

At diagnosis, ultrasonography documented steatosis in 31 patients (68.8%) while 33 (73.3%) showed high HSI. Hydrocortisone (HC) dose (β = 1.231, p = 0.010), insulin resistance index (HOMA-IR) (β = 1.431, p = 0.002), and insulin sensitivity index (ISI)-Matsuda (β = -1.389, p = 0.034) were predictors of HSI at baseline. After 12 months of DR-HC, a significant decrease in body mass index (BMI) (p = 0.008), waist circumference (WC) (p = 0.010), fasting insulin (p = 0.041), HOMA-IR (p = 0.047), HSI (p < 0.001) and number of patients with HSI ⩾36 (p = 0.003), and a significant increase in sodium (p < 0.001) and ISI-Matsuda (p = 0.031) were observed. HOMA-IR (β = 1.431, p = 0.002) and ISI-Matsuda (β = -9.489, p < 0.001) were identified as independent predictors of HSI at 12 months.

CONCLUSIONS

In adults with SAI, DR-HC is associated with an improvement in HSI, regardless of the dose used, mainly related to an improvement in insulin sensitivity.

The fatty liver index, a simple and useful predictor of metabolic syndrome: analysis of the Korea National Health and Nutrition Examination Survey 2010-2011

PURPOSE

Nonalcoholic fatty liver disease (NAFLD) is the most common chronic liver disease worldwide, and it is the hepatic manifestation of metabolic syndrome (MetS). We aimed to estimate the prevalence of NAFLD defined by the fatty liver index (FLI), in order to investigate the association between FLI and metabolic disorders and to determine the cutoff value of FLI to screen for MetS.

SUBJECTS AND METHODS

This study utilized a national representative sample of Korean adults (the Korean National Health and Nutrition Examination Surveys) which was conducted in 2010-2011. A total of 10,107 adults aged 19 years or older were selected. NAFLD was diagnosed on the basis of an increased FLI (≥60) after the exclusion of alcohol or viral liver disease.

RESULTS

NAFLD was identified in 1,134 subjects (age-standardized prevalence, 10.0%). When subjects were categorized into three groups by FLI (<20, 20-59, and ≥60), the higher FLI group showed a higher prevalence of hypertension (49.7% vs 14.4%), diabetes mellitus (DM; 20.4% vs 3.8%), and MetS (74.9% vs 7.4%). FLI was positively associated with age, body mass index, blood pressure, hemoglobin A1c, and homeostasis model assessment of insulin resistance (P for trend <0.001). In the multivariate analysis, the higher FLI group had a significantly higher risk for hypertension (OR =2.92, 95% CI =2.18-3.90, P<0.001), DM (OR =4.38, 95% CI =2.96-6.49, P<0.001), and MetS (OR =24.85, 95% CI =17.33-35.64, P<0.001). However, no increase was observed for cardiovascular disease after adjustment of other risk factors. The cutoff value of the FLI estimated to predict the presence of MetS was 20 (area under the curve 0.849, sensitivity 0.828, and negative predictive value 91.9%).

CONCLUSION

NAFLD prevalence using FLI is significantly higher in subjects with metabolic disorder including MetS. FLI might be a useful screening tool to detect subjects who may require early management of MetS and who have a high cardiovascular risk.

Non-HDL-cholesterol to HDL-cholesterol ratio is an independent risk factor for liver function tests abnormalities in geriatric population

Background

Excessive lipid depositing in liver cells could induce pathophysiological development of liver. Our study aimed to assess whether non-HDL cholesterol to HDL-cholesterol ratio (NonHDLc/HDLc) is an independent risk factor for liver function tests (LFTs) abnormalities in geriatric population.

Methods

We enrolled 1745 eligible subjects (714 males, 1031 females) with normal liver function tests at baseline who participated in annual health checkup for liver disease in 2015. Logistic regression models were used to examine the independent relationship between NonHDLc/HDLc ratio and LFTs abnormalities.

Results

After one year follow-up, there were 6.1% (n = 107) participants developed new-onset LFTs abnormalities in 2016. Equally dividing participants into tertiles according to their baseline NonHDLc/HDLc ratio levels, we found compared with tertile 1, the multivariable-adjusted ORs (95% CIs) for new-onset LFTs abnormalities of tertile 3 were 2.85 (1.18–6.93), P = 0.021. In stratified analysis, compared with controls, the correlation between NonHDLc/HDLc ratio and incidence of LFTs abnormalities was more remarkable in female individuals, BMI > 24 individuals and free of diabetes individuals.

Conclusion

Our study suggests that NonHDLc/HDLc ratio is an independent risk factor for LFTs abnormalities in geriatric population, and assessment of NonHDLc/HDLc ratio may help early identify high risk people of liver diseases.

Trial registration

Trial registration in the Ethics Committee of Tongji Medical College, Huazhong University of Science and Technology (IORG No: IORG0003571). Registered 3 March 2015.

Electronic supplementary material

The online version of this article (10.1186/s12944-018-0940-0) contains supplementary material, which is available to authorized users.

Oxidative Stress and Nonalcoholic Fatty Liver Disease in Hemodialysis Patients

INTRODUCTION

Nonalcoholic fatty liver disease (NAFLD) is becoming more common around the world and it may progress to cirrhosis and liver failure, increasing mortality risk. In hemodialysis (HD) patients, NAFLD may be a novel risk factor for their high cardiovascular mortality. Heightened oxidative stress is highly prevalent in HD patients. However, the relationship between oxidative stress and NAFLD in HD patients is not well defined.

METHODS

We studied seventy-one stable nondiabetic HD patients. Nineteen patients had the diagnosis of NAFLD by ultrasonography. Blood levels of oxidative stress markers were measured in each patient, including thiobarbituric acid reactive substances (TBARS), free thiols, superoxide dismutase (SOD) activities, and glutathione peroxidase (GPx) activity. The copy numbers of mitochondrial DNA (mtDNA) in peripheral leukocytes were also determined. Demographic, biochemistry, and hemogram data were recorded. The two groups of patients were compared in order to determine the factors associated with NAFLD in HD patients.

FINDINGS

Compared to those without NAFLD, nondiabetic HD patients with NAFLD had significantly higher mtDNA copy number and GPx levels. The two groups did not differ significantly in dialysis adequacy, hemoglobin, serum calcium, phosphorus, albumin, liver function tests, or lipid profiles. Regression analysis confirmed mtDNA copy numbers and GPx levels as two independent factors associated with NAFLD. Compared to those with polysulfone, patients dialyzed with cellulose membrane have significantly higher levels of TBARS. However, patients with or without NAFLD did not differ in their use of either dialysis membrane.

DISCUSSION

Oxidative stress (represented by antioxidant defense, GPx) and mitochondrial DNA copy numbers are independently associated with fatty liver disease in nondiabetic HD patients. The diagnostic and therapeutic implications of this key observation warrant further exploration.

Body Composition Profiling in the UK Biobank Imaging Study

OBJECTIVE

This study aimed to investigate the value of imaging-based multivariable body composition profiling by describing its association with coronary heart disease (CHD), type 2 diabetes (T2D), and metabolic health on individual and population levels.

METHODS

The first 6,021 participants scanned by UK Biobank were included. Body composition profiles (BCPs) were calculated, including abdominal subcutaneous adipose tissue, visceral adipose tissue (VAT), thigh muscle volume, liver fat, and muscle fat infiltration (MFI), determined using magnetic resonance imaging. Associations between BCP and metabolic status were investigated using matching procedures and multivariable statistical modeling.

RESULTS

Matched control analysis showed that higher VAT and MFI were associated with CHD and T2D (P < 0.001). Higher liver fat was associated with T2D (P < 0.001) and lower liver fat with CHD (P < 0.05), matching on VAT. Multivariable modeling showed that lower VAT and MFI were associated with metabolic health (P < 0.001), and liver fat was nonsignificant. Associations remained significant adjusting for sex, age, BMI, alcohol, smoking, and physical activity.

CONCLUSIONS

Body composition profiling enabled an intuitive visualization of body composition and showed the complexity of associations between fat distribution and metabolic status, stressing the importance of a multivariable approach. Different diseases were linked to different BCPs, which could not be described by a single fat compartment alone.

Saturated fatty acid combined with lipopolysaccharide stimulates a strong inflammatory response in hepatocytes in vivo and in vitro

Nonalcoholic fatty liver disease (NAFLD) is the most common chronic liver disease and consumption of high-fat diet (HFD) is a risk factor for NAFLD. The HFD not only increases intake of saturated fatty acid (SFA) but also induces metabolic endotoxemia, an HFD-associated increase in circulating lipopolysaccharide (LPS). Although it is known that SFA or LPS promote hepatic inflammation, a hallmark of NAFLD, it remains unclear how SFA in combination with LPS stimulates host inflammatory response in hepatocytes. In this study, we performed both in vivo and in vitro experiments to investigate the effect of SFA in combination with LPS on proinflammatory gene expression in hepatocytes. Our animal study showed that feeding low-density lipoprotein-deficient mice HFD enriched with SFA and injection of low-dose LPS cooperatively stimulated IL-6 expression in livers. To understand how SFA and LPS interact to promote IL-6 expression, our in vitro studies showed that palmitic acid (PA), a major SFA, and LPS exerted synergistic effect on the expression of IL-6 in hepatocytes. Furthermore, coculture of hepatocytes with macrophages resulted in a greater IL-6 expression than culture of hepatocytes without macrophages in response to the combination of PA and LPS. Finally, we observed that LPS and PA increased ceramide production by cooperatively stimulating ceramide de novo synthesis, which played an essential role in the synergistic stimulation of proinflammatory gene expression by LPS and PA. Taken together, this study showed that SFA in combination with LPS stimulated a strong inflammatory response in hepatocytes in vivo and in vitro.

Association of fatty liver index with the risk of incident cardiovascular disease and acute myocardial infarction

BACKGROUND

Fatty liver disease (FLD) has been identified as constituting cardiometabolic risk. However, evidence on the association of fatty liver index (FLI) with cardiovascular disease (CVD) is largely cross-sectional, with limited evidence on the predictability of incident CVD, and specifically, acute myocardial infarction (AMI). Therefore, we aimed to investigate the prospective associations between fatty liver as estimated by FLI and incident CVD, and specifically AMI, in the Kuopio Ischaemic Heart Disease Risk Factor Study cohort.

PATIENTS AND METHODS

Our patients were 1205 middle-aged men free of CVD at baseline. The associations of baseline FLI with incident CVD and incident AMI were analyzed using multivariable-adjusted Cox regression models.

RESULTS

During a median follow-up of 17 years, a total of 690 incident cases of CVD and 269 cases of AMI were recorded through Finnish registries. For incident CVD, for the high (FLI≥60) versus the low (≤30) FLI category, the hazard ratio (HR) was 1.77 [95% confidence interval (CI): 1.46-2.14] in the minimally adjusted model. With increasing adjustment, the association was attenuated progressively. In the most adjusted model, the HR was 1.41 (95% CI: 1.10-1.79). For incident AMI, for the high FLI category, the HR was 1.65 (95% CI: 1.22-2.23) in the minimally adjusted model, but in most comprehensive models when we included metabolic factors, the HR was not significant (HR=1.136, 95% CI: 0.777-1.662).

CONCLUSION

FLI can predict incident CVD. However, the predictability of AMI using FLI is subject to interactions of metabolic factors. Individuals with FLI in the moderate to high category should be evaluated and monitored for subclinical or overt cardiovascular (including coronary) disease.

Assessment of Subclinical Myocardial Changes in Non-Alcoholic Fatty Liver Disease: A Case-Control Study Using Speckle Tracking Echocardiography

BACKGROUND

Considering the association between cardiac abnormalities and non-alcoholic fatty liver disease (NAFLD), the present study aimed to evaluate the relationship between biopsy-proven NAFLD and functional echocardiographic parameters, including left ventricular (LV) global longitudinal strain (GLS) in asymptomatic individuals.

METHODS

Thirty asymptomatic patients with liver biopsy-proven NAFLD and the same number with no evidence of fatty liver in ultrasonography were enrolled in the study as cases and controls, respectively. The measured echocardiographic parameters included LV ejection fraction (LVEF), LV end-systolic and end-diastolic dimensions (ESD, EDD), LV end-systolic and end-diastolic volumes (ESV, EDV), E/e' ratio (early-diastolic mitral inflow velocity/early-diastolic myocardial velocity), E/A ratio (early-diastolic mitral inflow velocity/late-diastolic mitral inflow velocity), and GLS. Data were analyzed using the SPSS statistical software (version 18.0) by performing the independent t test, Chi-square, and non-parametric Mann-Whitney U tests. P values <0.05 were considered statistically significant.

RESULTS

A significant difference in ESD (32.1±1.4 mm vs. 34±1.8 mm), EDD (41.9±1.7 mm vs. 45.2±3.1 mm), and E/e' ratio (8.4±0.8 vs. 7.4±1.2) was detected among individuals with NAFLD compared with those without NAFLD (P<0.001 for the first two parameters and P=0.002 for the last one). GLS was also significantly lower in NAFLD patients than in controls, but within normal levels (19.3%±2.0 vs. 21.2%±1.4, P<0.001).

CONCLUSION

The findings support the presence of subclinical cardiovascular structural and functional changes in patients affected by NAFLD. It also indicates that the use of GLS is more sensitive than LVEF for the detection of LV systolic dysfunction in NAFLD patients.

Impaired HDL cholesterol efflux capacity in patients with non-alcoholic fatty liver disease is associated with subclinical atherosclerosis

Non-alcoholic fatty liver disease (NAFLD) is associated with a substantial increased risk of atherosclerotic cardiovascular disease (ASCVD), which is partly related to dyslipidemia and low HDL-C level. The cardioprotective activity of HDL in the body is closely connected to its role in promoting cholesterol efflux, which is determined by cholesterol efflux capacity (CEC). Hitherto, the role of HDL, as defined by CEC has not been assessed in NAFLD patients. In this research study, we present the results of a study of cAMP-treated J774 CEC and THP-1 macrophage CEC in ApoB-depleted plasma of 55 newly diagnosed NAFLD patients and 30 controls. Circulating levels of ApoA-I, ApoB, preβ-HDL, plasma activity of CETP, PLTP, LCAT and carotid intima-media thickness (cIMT) were estimated. cAMP-treated J774 and THP-1 macrophage CEC were found to be significantly lower in NAFLD patients compared to controls (P < 0.001 and P = 0.003, respectively). In addition, it was discovered that both ApoA-I and preβ1-HDL were significantly lower in NAFLD patients (P < 0.001). Furthermore, cAMP-treated J774 CEC showed independent negative correlation with cIMT, as well as the presence of atherosclerotic plaque in NAFLD patients. In conclusion, our findings showed that HDL CEC was suppressed in NAFLD patients, and impaired cAMP-treated J774 CEC was an independent risk factor for subclinical atherosclerosis in NAFLD patients, suggesting that impaired HDL functions as an independent risk factor for atherosclerosis in NAFLD.

Swimming, but not vitamin E, ameliorates prothrombotic state and hypofibrinolysis in a rat model of nonalcoholic fatty liver disease

BACKGROUND

Nonalcoholic fatty liver disease (NAFLD) is associated with a systemic procoagulant hypofibrinolysis state that is considered as a risk factor for microangiopathy and peripheral vascular diseases. Swimming exercise ameliorates the metabolic dysfunction in type 2 diabetes. Vitamin E is a natural antioxidant that reduces the risk of endothelial dysfunction in metabolic syndrome. The aim of the present study is to investigate the effect of combined swimming exercise with vitamin E on coagulation as well as blood fibrinolysis markers in rats with NAFLD.

METHODS

Eighty male rats were divided into control, control+vitamin E, control+exercise, high-fat diet (HFD), HFD+vitamin E, HFD+exercise, and HFD+vitamin E+exercise groups. Glucose, insulin, homeostatic model assessment for insulin resistance (HOMA-IR), triglycerides, cholesterol, low-density lipoprotein (LDL) and high-density lipoprotein (HDL), alanine transaminase (ALT) and aspartate transaminase (AST), intercellular adhesion molecule (ICAM-1), vascular cell adhesion molecule (VCAM-1), endothelin-1, von Willebrand factor (vWF), fibrinogen, plasminogen activator inhibitor (PAI-1), fibrin degradation products (FDP), platelet count and aggregation, bleeding and clotting times, activated partial thromboplastin time (aPTT), and prothrombin time (PT) were determined.

RESULTS

HFD increased lipid profile, insulin, glucose, HOMA-IR, liver enzymes, adhesion molecules, endothelin-1, vWF, platelet aggregation, fibrinogen, FDP, and PAI-1, and decreased clotting and bleeding times and HDL. Although exercise reduced lipid profile, glucose, insulin, HOMA-IR, vWF, platelet aggregation, fibrinogen, FDP, and PAI-1 and increased PT, aPTT, bleeding and clotting times, and HDL, vitamin E had no effect.

CONCLUSIONS

Exercise, but not vitamin E, ameliorated the HFD-induced prothrombotic state and enhanced fibrinolytic activity.

Hepatocyte steatosis increases the expression of adhesion molecules in endothelial cells

Background: Non-alcoholic fatty liver disease is considered a hepatic manifestation of the metabolic syndrome. It is associated with endothelial dysfunction as an early event of generalized atherosclerosis. However, it is unclear whether steatotic hepatocytes influence endothelial function directly. Objective: Explore the influence of hepatocyte steatosis on the function of endothelial cells. Methods: Oleic and palmitic acid (2:1 mixture, final concentration: 1 mM for 24 hours) was used to induce a normal adult hepatocyte strain (L-02) for transformation into steatosis cells. This was followed by oil red O staining and transmission electron microscopy (TEM) for verification. The culture solution of steatotic L-02 cells was filtered and collected, and added into the culture substrate of human umbilical vein endothelial cells (HUVECs). The expression of vascular cellular adhesion molecule -1 (VCAM-1), intercellular adhesion molecule-1 (ICAM-1), and E-selectin in HUVECs was detected by real-time polymerase chain reaction and Western blot assays. The apoptosis and proliferation of HUVECs was determined using flow cytometry. The experimental results were compared with the controls. Results: Oil red O staining and microscopic observation showed that the cytoplasm of induced L-02 cells contained a large amount of red lipid droplets. TEM results showed that the cytoplasm had lipid accumulation, swelling mitochondria, fewer cristae, and reduced number of rough endoplasmic reticula accompanied with degranulation. However, these changes were not observed in normal L-02 cells. As to the group of HUVECs treated by the filtrate of steatosis L-02 cells, the mRNA and protein expression of VCAM-1, ICAM-1, and E-selectin was higher than that in the control group. The difference was statistically significant (p <0.01). No significant difference was found when HUVECs apoptosis and proliferation were assessed by flow cytometry. Conclusion: Secretion from steatotic hepatocytes could boost the expression of VCAM-1, ICAM-1, and E-selectin in endothelial cells, indicating that hepatocyte steatosis could induce endothelial cell dysfunction. The proliferation and apoptosis of endothelial cells did not change, suggesting that hepatocyte steatosis had no influence on the viability of endothelial cells under this condition.

Severity of nonalcoholic fatty liver disease is associated with subclinical cerebro-cardiovascular atherosclerosis risk in Korean men

BACKGROUND

No studies have reported the relationship between nonalcoholic fatty liver disease (NAFLD) and concurrent cerebral artery and coronary artery atherosclerosis simultaneously. We aimed at determining whether NAFLD, as assessed by ultrasound, is associated with subclinical cerebro-cardio vascular atherosclerosis (CCVA) by multidetector-row computed tomography (MDCT), and high resolution-magnetic resonance angiography (HR-MRA). This cross-sectional study included men in the general Korean population aged 20-70 years.

RESULTS

A total of 1,652 men participated in the study (normal, n = 835; mild-to-moderate NAFLD, n = 512; severe NAFLD, n = 305). The risk of subclinical CCVA was positively associated with age (odds ratio [OR] 1.068; 1.054-1.081, p < 0.001), body mass index (OR 1.120; 1.08 0-1.162, p < 0.001), hepatic enzyme levels (OR 1.012; 1.001-1.023, p = 0.027; OR 1.006; 1.001-1.012, p = 0.036), fasting glucose (OR 1.021; 1.015-1.027, p < 0.001), triglycerides (OR 1.002; 1.000-1.003, p = 0.016), hypertension (OR 2.836; 2.268-3.546, p < 0.001), and diabetes (OR 2.911; 2.137-3.964, p < 0.001). Also, high-density lipoprotein cholesterol was inversely associated with subclinical CCVA (OR 0.974; 0.965-0.982, p < 0.001). Compared with normal controls, the OR for subclinical CCVA after full adjustment was 1.46 in the mild-to-moderate NAFLD group (95% confidence interval [CI]: 1.10 to 1.93) and 2.04 in the severe NAFLD group (95% CI: 1.44 to 2.89).

CONCLUSIONS

Our data show that NAFLD is common among Korean men, and NAFLD severity on ultrasonography is associated with subclinical CCVA, as assessed by MDCT, and HR-MRA.

Components of metabolic syndrome increase the risk of mortality in nonalcoholic fatty liver disease (NAFLD)

Nonalcoholic fatty liver disease (NAFLD) is the most common cause of chronic liver disease in the United States. Metabolic syndrome (MS) components are highly prevalent in NAFLD. Our aim is to assess the relationship of NAFLD and MS with long-term outcome of mortality.The Third National Health and Nutrition Examination Survey (NHANES) was utilized. NAFLD was diagnosed by ultrasound in the presence of hepatic steatosis and no other causes of chronic liver disease. History of MS and its components were obtained from self-reported NHANES questionnaires. Mortality was obtained from Mortality-Linkage File, through December 31, 2011. Chi-square test was used for categorical variables and Cox proportional models estimated hazard ratios with 95% confidence interval.NAFLD cohort (n = 3613) had a median age of 43 years, 73% white, and 50% male. NAFLD group with at least one MS condition was significantly older, had higher body mass index, more likely to have insulin resistance, and heart disease compared to NAFLD group without MS. Over 19-years of follow-up, 1039 people died. Compared to NAFLD patients without MS, presence of one MS component increased the risk of mortality at 8-year (2.6% vs 4.7%) and 16-year (6% vs 11.9%) (P < .001). After adjusting for socio-demographic factors, NAFLD with all MS components was associated with overall, cardiac and liver-mortality. Increased number of MS components was associated with lower survival (P < .0001).Patients with NAFLD and MS have higher mortality risk compared to NAFLD patients without MS. These NAFLD patients should be prioritized for the development of treatment regimens.

Pattern of some risk factors of cardiovascular diseases and liver enzymes among Iranian seafarers

Background: Little information is available on the trend in cardiovascular risk factors and hepatic enzymes in Iranian seafarers. The present study aimed at assessing the pattern of obesity, hypertension, diabetes, elevated serum glutamic oxaloacetate transaminase (SGOT), and serum glutamate pyruvate transaminase (SGPT) in Iranian seafarers during 2010 to 2014.

Methods: Data on cardiovascular risk factors and hepatic enzymes were extracted from seafarers’ annual health examination of National Iranian Tanker Company (NITC) of 2010, 2012, and 2014. The repeated measure ANOVA was used to compare continuous variables across 3 years. Categorical data were analyzed using Chi-square test. Over weight was defined as BMI (Body Mass Index) >25 kg/m²; obesity was defined as BMI>=30 kg/m²; hypertension was defined as systolic blood pressure (SBP)> 140 mmHg, and diastolic blood pressure (DBP)> 90 mmHg, or a history of antihypertensive drug use. Diabetes (DM) was defined as fasting blood sugar (FBS) > 110 mg/dl, or having a history of oral hypoglycemic agents; and elevated SGOT and SGPT were defined as SGOT > 40 U/L and SGPT > 40 U/L, respectively.

Results: The BMI mean±SD values of Iranian seafarers were 24.81±3.07 kg/m², 25.51±2.96 kg/m², and 25.96 ± 3.02 kg/m² in 2010, 2012, and 2014, respectively. A significant difference was observed in BMI over the study period. The mean of systolic and diastolic blood pressure did not significantly increase over time. The SGOT and SGPT means were not significantly different from 2010 to 2014. The prevalence of overweight increased significantly from 46.7% to 60.9% over the study period; however, the prevalence of obesity, hypertension, elevated SGOT, and elevated SGPT did not change significantly.

Conclusion: The current survey showed that the obesity problem has increased among Iranian seafarers working on tankers, which is a concerning problem because obesity has negative effects on seafarers’ health.

Exendin-4, a glucagon-like peptide-1 receptor agonist downregulates hepatic receptor for advanced glycation end products in non-alcoholic steatohepatitis rat model

CONTEXT

Exendin-4, a glucagon-like peptide-1 receptor agonist has been shown to have curative effects on hepatic steatosis in murine models.

OBJECTIVE

The present study aimed to elucidate the effect of Exendin-4 on hepatic receptor for advanced glycation end products (RAGE) mRNA expression in non-alcoholic steatohepatitis (NASH) rat model induced by high-fat diet.

METHODS

NASH was induced by high-fat diet intake, and Exendin-4 was given in two different doses. After 12 weeks, liver enzyme levels, hepatic triglycerides, antioxidant enzymes and malondialdehyde (MDA) levels, and mRNA RAGE was detected using RT-PCR.

RESULTS

Exendin-4 in high dose reduced significantly liver enzymes activity, hepatic triglycerides, MDA levels and hepatic mRNA RAGE expression levels with significantly higher antioxidant enzymes activity.

CONCLUSIONS

Our results give further insights into the mechanisms underlying the curative role of Exendin-4 in NASH, suggesting that interference with RAGE may be a useful therapeutic approach to NASH.