Noninvasive Assessment of Liver Disease in Patients With Nonalcoholic Fatty Liver Disease

Association between Body Fat Distribution and Nonalcoholic Fatty Liver Disease/Fibrosis Based on Race/Ethnicity

Background

Body fat distribution may impact nonalcoholic fatty liver disease (NAFLD) and significant fibrosis differently according to race/ethnicity. We determined the relationship between body fat distribution and NAFLD/significant fibrosis according to race/ethnicity.

Methods

A cross-sectional study of 2,395 participants used the National Health and Nutrition Examination Survey 2017 to 2018. NAFLD and significant fibrosis (≥F2) were defined by controlled attenuation parameter scores and liver stiffness measurements on transient elastography, respectively. Visceral and subcutaneous fat volumes were defined by dual-energy X-ray absorptiometry.

Results

The odds ratio (OR) for NAFLD per 1-standard deviation in visceral fat volume and subcutaneous fat volume was 2.05 (95% confidence interval [CI], 1.36 to 3.09) and 1.48 (95% CI, 1.04 to 2.09) in total population, respectively. Visceral fat in non-Hispanic Blacks had the highest odds for NAFLD (OR, 2.86; 95% CI, 1.45 to 5.62), and non-Hispanic Whites (OR, 2.29; 95% CI, 1.19 to 4.40) and non-Hispanic Asians (OR, 1.61; 95% CI, 1.13 to 2.29) were in order. Significant associations between subcutaneous fat volume (OR, 2.10; 95% CI, 1.34 to 3.29; P=0.003) or visceral fat volume (OR, 1.35; 95% CI, 1.05 to 1.73; P=0.023) and significant fibrosis were noted among individuals with NAFLD. Hispanics had the highest odds for NAFLD-associated significant fibrosis (OR, 2.74; 95% CI, 1.32 to 5.70 per 1-standard deviation in subcutaneous fat volume), and non-Hispanic Whites (OR, 2.35; 95% CI, 1.11 to 4.98) and non-Hispanic Asians (OR, 2.01; 95% CI, 1.01 to 4.01) were in order.

Conclusion

Visceral adiposity was associated with NAFLD and significant fibrosis despite the association of subcutaneous adiposity in NAFLD and significant fibrosis. Racial/ethnic differences in the association between body fat distribution on NAFLD and significant fibrosis were noted.

Association between the ratio of serum uric acid to high-density lipoprotein cholesterol and liver fat content: evidence from a Chinese health examination dataset

Despite numerous studies investigating the correlation between the serum uric acid and high-density lipoprotein cholesterol ratio (UHR) and fatty liver disease, the evidence for the dose-response relationship between UHR and liver fat content (LFC) remains uncertain. This study employs quantitative computed tomography (CT) to quantify LFC and aims to investigate the correlation and dose-response relationship between UHR levels and LFC in Chinese adults. Based on the health check-up data from 2021 at Henan Provincial People's Hospital, China, the objective of this cross-sectional study was to investigate the association between UHR levels and LFC among individuals of different genders. The analytical approach encompassed one-way ANOVA, multiple regression analysis, subgroup analysis, smooth curve fitting, and the evaluation of threshold and saturation effects. Upon adjusting for potential influencing factors, the multiple regression analysis indicated a positive correlation between UHR and LFC in both male and female subjects. This positive correlation was more significant in the highest UHR quartile (Male Q4 in model II: β = 2.119, 95% CI: 1.353-2.886, P < 0.05; Female Q4 in model II: β = 1.312, 95% CI: 0.499-2.124, P < 0.05). Subgroup and threshold saturation effect analyses demonstrated a positive correlation between UHR and LFC in the male population, independent of age, although the linear correlation trend was influenced by different body mass index (BMI) groups. In the female population, age also affected the association between UHR and LFC, with a negative association observed when age ≥ 45 years and UHR > 30.63. A positive association exists between UHR levels and LFC in both genders among Chinese adults, albeit exhibiting variations across different age and BMI groups. Consequently, early monitoring of UHR levels may be crucial for the early detection and intervention in high-risk groups exhibiting increased LFC.

Statin Monotherapy Not Inferior to Aspirin or Combined Aspirin and Statins Reducing the Incidences of Cirrhosis, HCC, and Mortality in MAFLD/MASH Patients: A Population Cohort Study

Purpose

Metabolic dysfunction-associated fatty liver disease (MAFLD) and metabolic dysfunction-associated steatohepatitis (MASH) pose significant risks for liver cirrhosis and hepatocellular carcinoma (HCC). Daily aspirin and statins could reduce HCC in patients with MAFLD/MASH. We aimed to clarify whether combined aspirin and statins exert a synergistic effect on prevention of cirrhosis and HCC in patients with MAFLD/MASH.

Patients and Methods

Patients and their clinical data were collected from the National Health Insurance Research Database (NHIRD), encompassing about 20 million population. A total of 735,574 MAFLD/MASH patients between January 1, 2009, and December 31, 2020 were identified. After applying exclusion criteria, 662,004 cases were enrolled, with a follow-up period of 3 years. Propensity score matching was employed for comparative analysis.

Results

Our findings indicate that combined statin and aspirin use significantly reduced the incidence of liver cirrhosis (p < 0.001) compared to statin or aspirin alone, or non-use of both drugs. However, the combined therapy did not confer additional benefits in reducing mortality rates and HCC. Furthermore, statin monotherapy exhibited a more pronounced effect in reducing mortality and HCC compared to aspirin alone or combined therapy.

Conclusion

Our study underscores that statin monotherapy was not inferior to aspirin or aspirin-statin combined therapies in terms of chemoprevention of cirrhosis, HCC, and overall mortality in MAFLD/MASH patients.

Addressing the essentials of the recent guidelines for managing patients with metabolic dysfunction-associated steatotic liver disease

Metabolic dysfunction-associated steatotic liver disease (MASLD) is the leading cause of end-stage liver disease and liver transplantation in the Western world, with an approximate prevalence of 30% worldwide which is continuously rising. It is characterized by intrahepatic fat deposition along with at least one cardiometabolic risk factor, such as diabetes mellitus, obesity, hypertriglyceridemia, and hypertension. MASLD consists of a spectrum of liver diseases ranging from simple liver steatosis to steatohepatitis, liver fibrosis, and cirrhosis. Recently, the European Association for the Study of the Liver (EASL), the European Association for the Study of Diabetes (EASD), and the European Association for the Study of Obesity (EASO) released the latest guidelines regarding the management of patients with MASLD. This article highlights the critical points of these guidelines and emphasizes problematic issues that need further evaluation.

Circulating irisin levels in patients with MAFLD: an updated systematic review and meta-analysis

Objective

Current research suggests that irisin is closely linked to the pathogenesis and progression of metabolic dysfunction-associated fatty liver disease (MAFLD). This systematic review and meta-analysis updates our previous meta-analysis and further explores the relevance between circulating irisin levels and MAFLD.

Methods

Nine databases (PubMed, EMBASE, Cochrane Library, CNKI, Wanfang, Weipu, CBM, Clinicaltrials.gov and gray literature) were retrieved as of 1st August, 2024. The standardized mean difference (SMD) and 95% confidence interval (CI) represent pooled effect size. We used the Newcastle-Ottawa Scale to evaluate the quality of articles and the certainty of evidence assessed by GRADE system. All statistical analyses were performed using RevMan 5.3 and Stata 12(Stata Corporation, yi TX).

Results

Fifteen case-control studies were included. Circulating irisin levels in the MAFLD group were markedly lower than those in the healthy group (SMD=-1.04 [-1.93, -0.14]). Subgroup analyses by race, age, severity and T2DM revealed that circulating irisin levels were lower in the MAFLD group compared to those in the healthy controls in the Asian population (SMD=-1.38 [-2.44, -0.31], P<0.05) and in those above 50 years old (SMD=-2.23 [-3.64, -0.81], P<0.05) and higher in the mild MAFLD groups than those in moderate to severe MAFLD groups (SMD = 11.68 [9.05, 14.31], P<0.05). And the circulating irisin levels in MAFLD patients with T2DM were significantly lower than those in healthy group (SMD = -2.90 [-4.49, -1.30]). ELISA kits from different companies also presented different relationships.

Conclusions

There were significantly lower circulating irisin levels in the MAFLD group than in the healthy control group. Although these results differed from our previous results, there is no denying that circulating irisin levels are closely associated with the advancement of MAFLD.

MAFLD but not MASLD increases risk of all-cause mortality in regional Australia, with components of metabolic syndrome exacerbating factors: 20 year longitudinal, cohort study

BACKGROUND AND AIMS

Controversy remains whether the mortality risk in people with fatty liver disease (FLD) including metabolic-(dysfunction) associated steatotic liver disease (MASLD) and metabolic-(dysfunction) associated fatty liver disease (MAFLD) is higher than observed in those without FLD. We aimed to determine the mortality rate and mortality rate ratio (MRR) for these FLDs.

METHODS

The study population was a randomly selected cohort of community-dwelling adults in regional Victoria, Australia between 2001 and 2003 with sufficient data evaluable for Fatty Liver Index and determination on alcohol consumption. MASLD and MAFLD were diagnosed by established criteria. The primary outcome was overall mortality and main secondary outcome was major adverse liver outcomes (MALO) (i.e., decompensated liver disease, primary liver cancer and liver-related death). Non-fatal and fatal outcomes were captured via data linkage to hospital admission, cancer registry, and death registries. MRR was calculated with non-FLD participants as the comparator.

RESULTS

1444 (99.3%) and 1324 (91.1%) individuals from a total of 1454 were included in the final MAFLD and MASLD analyses. The median follow-up was 19.7 years (IQR 19.1-20.1) and there were 298 deaths. The MRR for MAFLD and MASLD was 1.39 (95% CI 1.10-1.76) and 1.25 (95% CI 0.96-1.61), respectively. MAFLD persisted as a risk factor for all-cause death on multivariable models correcting for lifestyle and socioeconomic variables, but not when adjusted for metabolic risk factors. MALOs were increased in MAFLD [incidence rate ratio (IRR) 3.03, 95% CI 1.22-8.18] and MASLD (IRR 2.80, 95% CI 1.05-7.90). Metabolic risk factors increased the risk of overall mortality and MALO, and cancer (34.3-34.6%) and cardiovascular disease (30.1-33.7%) were the most common cause of death in FLD.

CONCLUSION

In this population-based longitudinal study, MAFLD but not MASLD increases the risk of overall mortality, with metabolic syndrome components key risk factors increasing risk of death.

Diagnostic accuracy of Fatty Liver Index (FLI) for detecting Metabolic Associated Fatty Liver Disease (MAFLD) in adults attending a tertiary care hospital, a cross-sectional study

BACKGROUND

Metabolic-associated fatty liver disease (MAFLD) is a major public health problem worldwide. This study aimed to determine the prevalence of MAFLD and evaluate the diagnostic accuracy of the Fatty Liver Index (FLI) compared to ultrasonography for detecting fatty liver in adults attending a tertiary care hospital in Gujarat, India.

METHODS

This cross-sectional study included 500 adults visiting the outpatient department between January 2023 and December 2023. MAFLD was diagnosed on ultrasound. FLI was calculated using body mass index, waist circumference, triglycerides, and gamma-glutamyl transpeptidase levels. FLI ≥ 60 indicated fatty liver. Logistic regression analysis identified factors associated with fatty liver.

RESULTS

MAFLD prevalence was 32.2% on ultrasound. High FLI (≥ 60) was present in 26.2%. Male sex, higher BMI, waist circumference, night shift work, diabetes, and triglycerides were independent predictors of fatty liver. FLI showed excellent diagnostic accuracy with a sensitivity of 96%, specificity of 92.5%, and AUC of 0.92 for detecting fatty liver on ultrasound.

CONCLUSION

MAFLD prevalence among adults was high in this hospital-based sample. FLI can serve as an accurate non-invasive tool for identifying individuals with a high probability of MAFLD. These findings emphasize the need for larger population-based studies and the implementation of regular MAFLD screening programs in high-risk groups.

Association between triglyceride glucose-body mass index and the staging of non-alcoholic steatohepatitis and fibrosis in patients with non-alcoholic fatty liver disease

OBJECTIVE

The objective of this study was to thoroughly investigate the clinical value of triglyceride glucose-body mass index (TyG-BMI) in patients diagnosed with non-alcoholic fatty liver disease (NAFLD). Specifically, we aimed to determine its association with non-alcoholic steatohepatitis (NASH) and the progression of liver fibrosis.

METHODS

The study included 393 patients diagnosed with NAFLD after liver biopsy. The patients were divided into two distinct cohorts: a training cohort (N = 320) and a validation cohort (N = 73). The training cohort was further divided into four groups based on TyG-BMI quartiles. The clinical characteristics of the patients in each group were compared in detail, and the association between TyG-BMI and NASH, NAFLD Activity Score (NAS) ≥ 4, at-risk NASH, significant fibrosis, advanced fibrosis, and cirrhosis was analyzed using multiple models. Additionally, we generated receiver operating characteristic (ROC) curves to evaluate the predictive ability of TyG-BMI for NASH and fibrosis staging in patients with NAFLD.

RESULTS

Patients with higher TyG-BMI values had a significantly higher prevalence of NASH, NAS ≥ 4, at-risk NASH, significant fibrosis, advanced fibrosis, and cirrhosis (all p < .05). TyG-BMI was an independent predictor of these diseases in both unadjusted and adjusted models (all p < .05). ROC curve analysis further revealed the excellent performance of TyG-BMI in predicting NASH, NAS ≥ 4, at-risk NASH, significant fibrosis, advanced fibrosis, and cirrhosis. The validation cohort yielded analogous results. Furthermore, we constructed three multivariate models of TyG-BMI in conjunction with elastography metrics, which demonstrated elevated diagnostic AUC values of 0.782, 0.792, 0.794, 0.785, 0.834, and 0.845, respectively.

CONCLUSION

This study confirms a significant association between insulin resistance and NAFLD, including at-risk NASH and fibrosis staging, as assessed using the TyG-BMI index. TyG-BMI and its associated multivariate models can be valuable noninvasive indicators for NAFLD diagnosis, risk stratification, and disease course monitoring.

Resmetirom and Metabolic Dysfunction-Associated Steatohepatitis: Perspectives on Multidisciplinary Management from Global Healthcare Professionals

PURPOSE OF REVIEW

The approval of resmetirom brings great hope to patients with metabolic dysfunction-associated steatohepatitis (MASH). The purpose of this review is to explore its impact on the global health environment. The implementation of multidisciplinary management MASH is proposed.

RECENT FINDINGS

Resmetirom has benefits in the treatment of MASH, and its safety and effectiveness have been studied. The adverse events (AEs) need to be noticed. To improve patient outcomes, a multimodal approach with medication such as resmetirom, combined with metabolic and bariatric surgery (MBS) and lifestyle interventions can be conducted. MASH, a liver disease linked with obesity, is a challenging global healthcare burden compounded by the absence of any approved pharmacotherapy. The recent conditional approval by the Food and Drug Administration (FDA) in the United States of resmetirom, an oral, liver-directed, thyroid hormone receptor beta-selective agonist, marks a significant milestone, offering a treatment option for adults with non-cirrhotic MASH and who have moderate to advanced liver fibrosis. This narrative review discusses the efficacy and safety of resmetirom and its role in the therapeutic landscape of MASH treatment. Despite the promising hepatoprotective effect of resmetirom on histological liver endpoints, its use need further research, particularly regarding ethnic differences, effectiveness and cost-effectiveness, production scalability, social acceptance and accessibility. In addition, integrating resmetirom with other multidisciplinary therapeutic approaches, including lifestyle changes and MBS, might further improve clinical liver-related and cardiometabolic outcomes of individuals with MASH. This review highlights the importance of a comprehensive treatment strategy, supporting continued innovation and collaborative research to refine treatment guidelines and consensus for managing MASH, thereby improving clinical patient outcomes in the growing global epidemic of MASH. Studies done to date have been relatively short and ongoing, the course of the disease is highly variable, the conditions of various patients vary, and given this complex clinical phenotype, it may take many years of clinical trials to show long-term benefits.

Diffuse and focal liver fat: advanced imaging techniques and diagnostic insights

The fatty liver disease represents a complex, multifaceted challenge, requiring a multidisciplinary approach for effective management and research. This article uses conventional and advanced imaging techniques to explore the etiology, imaging patterns, and quantification methods of hepatic steatosis. Particular emphasis is placed on the challenges and advancements in the imaging diagnostics of fatty liver disease. Techniques such as ultrasound, CT, MRI, and elastography are indispensable for providing deep insights into the liver's fat content. These modalities not only distinguish between diffuse and focal steatosis but also help identify accompanying conditions, such as inflammation and fibrosis, which are critical for accurate diagnosis and management.

Interaction between trouble sleeping and diabetes on metabolic dysfunction-associated fatty liver disease and liver fibrosis in adults results from the National Health and Nutrition Examination Survey 2017-2018

BACKGROUND

Metabolic dysfunction-associated fatty liver disease (MAFLD), trouble sleeping, and diabetes, as major public health problems, were closely related. The study examined the interaction between trouble sleeping and diabetes on MAFLD and liver fibrosis in adults with MAFLD.

METHODS

The data were obtained from the National Health and Nutrition Examination Survey 2017-2018. Multivariate logistic regression model and subgroup analyses were conducted to assess the relationship between either trouble sleeping or diabetes on MAFLD and liver fibrosis. Relative excess risk due to interaction (RERI), attributable proportion of interaction (AP), and synergy index (S) were utilized to assess the additive interaction.

RESULTS

Ultimately, 3747 participants were included, with 2229 known MAFLD subjects. Compared with participants without diabetes, those with diabetes had a higher risk of MAFLD [odds ratio (OR) = 5.55; 95% confidence interval (CI) = 4.07-7.56] and liver fibrosis risk (OR = 3.61; 95% CI = 2.67-4.89). We also found a significant association of trouble sleeping with an increased risk of MAFLD (OR = 1.54; 95% CI = 1.17-2.02) and liver fibrosis risk (OR = 1.51; 95% CI = 1.06-2.16), compared with those without trouble sleeping. Moreover, there was a significant interaction between diabetes and trouble sleeping on MAFLD [RERI = 1.76 (95% CI: -0.22 to 3.73), AP = 0.35 (95% CI: 0.08-0.63), S = 1.80 (95% CI: 1.02-3.16)] and liver fibrosis risk [RERI = 1.79 (95% CI: 0.37-3.21), AP = 0.44 (95% CI: 0.20-0.69), S = 2.44 (95% CI: 1.18-5.08)].

CONCLUSION

The findings highlight that trouble sleeping and diabetes had a synergistic effect on MAFLD and liver cirrhosis. The study highlights the importance of addressing both trouble sleeping and diabetes management in adults to mitigate the risk of MAFLD and liver fibrosis.

Medium chain triglycerides alleviate non-alcoholic fatty liver disease through bile acid-mediated FXR signaling pathway: A comparative study with common vegetable edible oils

With the global epidemic trend of obesity, non-alcoholic fatty liver disease (NAFLD) has become a significant cause of chronic liver disease, seriously affecting human health. Medium-chain triglycerides (MCT) with a fatty acid chain length varying between 6 and 10 carbon atoms (most sources from coconut and palm kernel oils), which exhibited activities to improve lipid metabolism, prevent cardiovascular diseases, and enhance immunity. However, the efficacy differences and potential mechanisms between MCT and traditional long-chain vegetable oils (palm oil, PA; high oleic peanut oil, OA) in obesity-induced NAFLD were still unclear. The present study treated obesity-induced NAFLD mice with different dietary lipids for 16 weeks. The results showed that MCT supplements significantly improved abnormal elevation of weight gain and blood lipids and reduced hepatic lipid accumulation to a greater extent than PA and OA. Furthermore, bile acid profiling results indicated that MCT significantly changed the composition of bile acids in the liver, reduced the concentrations of cholic acid (CA), deoxycholic acid (DCA), β-muricholic acid (β-MCA), and ursodeoxycholic acid (UDCA) and increased the concentrations of chenodeoxycholic Acid (CDCA), taurochenodeoxycholic acid （TCDCA), hyodeoxycholic acid (HDCA), and taurohyodeoxycholic acid (THDCA). Mechanistically, MCT supplement upregulated FXR signal and inhibited the expression of key genes for triglyceride synthesis in the liver, thereby reducing hepatic lipid accumulation. In summary, MCT exerted a superior effect on PA and OA in improving obesity-induced NAFLD. These results provided new evidence for the application of MCT in treating NAFLD.

Impact of metabolic disorders on gallstone disease and perioperative recovery after laparoscopic cholecystectomy

BACKGROUND

Gallstone disease (GSD), nonalcoholic fatty liver disease (NAFLD), metabolic dysfunction-associated fatty liver disease (MAFLD), and metabolic syndrome (MetS) are common medical disorders worldwide. This study aimed to ascertain how NAFLD, MAFLD, MetS, and other factors affect the development of GSD, and how the GSD-associated factors influence patient recovery after laparoscopic cholecystectomy (LC).

METHODS

We included 200 patients who were diagnosed with GSD and underwent LC between January 2017 and February 2022. A total of 200 subjects without GSD and "non-calculous causes" during the same period were also included as controls. We compared the metabolic disorder differences between GSD patients and controls. Furthermore, we sub-grouped patients based on the comorbidities of preoperative NAFLD, MAFLD, and MetS, and compared the impacts of these comorbidities on short-term post-LC functional recovery of the patients.

RESULTS

The prevalence of NAFLD and MetS were higher in GSD patients (P < 0.05). Based on multivariate logistic regression analysis, hyperglycemia [odds ratio (OR) = 2.2, 95% confidence interval (CI): 1.4-3.4, P = 0.001] and low high-density lipoprotein cholesterol (HDL-C) level (OR = 1.8, 95% CI: 1.1-3.1, P = 0.048) were linked to GSD. NAFLD and MetS linked to liver enzymes after LC (P < 0.05). MetS also linked to the levels of inflammatory indicators after LC (P < 0.05). The obesity, hyperlipidemia, low HDL-C level, and hyperglycemia linked to liver enzymes after LC (P < 0.05). Hyperlipidemia, low HDL-C level, and hypertension linked to inflammation after LC (P < 0.05).

CONCLUSIONS

The prevalence of GSD may be linked to NAFLD and MetS. Hyperglycemia and low HDL-C level were independent risk factors of GSD.

FibroScan compared to liver biopsy for accurately staging recurrent hepatic steatosis and fibrosis after transplantation for MASH

BACKGROUND AND AIMS

Metabolic dysfunction-associated steatotic liver disease (MASLD) recurrence after liver transplantation (LT) seems unavoidable and gradual. We aimed to evaluate the diagnostic accuracy in the post-LT setting of patients transplanted for metabolic dysfunction-associated steatohepatitis (MASH) of recurrent hepatic steatosis and fibrosis identified with FibroScan, compared to biopsy findings.

METHODS

This prospective cohort study included adults transplanted for MASH between 2010 and 2022 in three LT centres in Spain who underwent FibroScan and biopsy at least 1-year after LT.

RESULTS

In total, 44 patients transplanted for MASH after LT were included. The median time from LT to biopsy and FibroScan was 24.5 (interquartile range [IQR]:16-46) and 26.0 (IQR: 16.8-41.5) months, respectively. The median time between biopsy and FibroScan was 2.0 (IQR: 0-5) months. On FibroScan, significant steatosis was diagnosed in about half of the patients (n = 21, 47.7%), yet advanced fibrosis in only two cases (4.6%). On biopsy, a quarter of biopsied patients (n = 11, 25%) had a MASH diagnosis, two (4.6%) with significant fibrosis and one (2.3%) with cirrhosis. All patients with liver stiffness measurement (LSM) values <8 kPa (n = 35, 79.5%) had a fibrosis stage ≤F1 (negative predictive value = 100%). The combination of post-LT hypertension (odds ratio [OR]: 12.0, 95% confidence interval [CI]: 1.8-80.4, p = .010) and post-LT dyslipidaemia (OR: 7.9, 95% CI: 1.3-47.1, p = .024) with LSM (OR: 1.7, 95% CI: 1.1-2.8, p = .030) was independently associated with MASLD.

CONCLUSIONS

Although biopsy remains the gold standard for detecting fibrosis, our results suggest that LSM values <8 kPa after LT for MASH are strongly correlated with absence of significant/advanced fibrosis.

Noninvasive tools for the assessment of fibrosis in metabolic dysfunction-associated steatotic liver disease

Metabolic dysfunction-associated steatotic liver disease (MASLD), previously nonalcoholic fatty liver disease (NAFLD), is the number one chronic liver disorder worldwide. Progression to advanced fibrosis marks the emergence of a significant risk of liver-related negative outcomes. However, only a minority of patients will present at this stage. Since widespread liver biopsy in unfeasible at such high disease prevalence, there was a need to develop noninvasive tests (NITs) that could easily and reliably be applied to patients with MASLD, regardless of clinical setting. The NITs include simple scores, like the fibrosis-4 (FIB-4) Index, patented serum tests, like the Enhanced Liver Fibrosis test (ELF™), and imaging-based modalities, like the vibration-controlled transient elastography (VCTE). Guidelines suggests a stepwise approach that utilizes more than one NIT, with FIB-4 <1.30 being used as a first step to rule out patients that do not need further testing. Subsequent choice of NIT will be influenced by setting, cost, and local availability. While these NITs are accurate, they are not perfect. As such, research is ongoing. A promising avenue is that of omics, a group of technologies that provide concomitant results on a large number of molecules (and other variables). With the advance of artificial intelligence, new NITs may arise from large demographic, biochemical, and radiological data sets.

Current status and new directions for hepatocellular carcinoma diagnosis

Liver cancer ranks as the sixth most common cancer globally, with hepatocellular carcinoma (HCC) accounting for approximately 75%-85% of cases. Most patients present with moderately advanced disease, while those with advanced HCC face limited and ineffective treatment options. Despite diagnostic efforts, no ideal tumor marker exists to date, highlighting the urgent clinical need for improved early detection of HCC. A key research objective is the development of assays that target specific pathways involved in HCC progression. This review explores the pathological origin and development of HCC, providing insights into the mechanistic rationale, clinical statistics, and the advantages and limitations of commonly used diagnostic tumor markers. Additionally, it discusses the potential of emerging biomarkers for early diagnosis and offers a brief overview of relevant assay methodologies. This review aims to summarize existing markers and investigate new ones, providing a basis for subsequent research.

Metabolic signatures of metabolic dysfunction-associated steatotic liver disease in severely obese patients

BACKROUND

Metabolic dysfunction-associated steatotic liver disease (MASLD) can lead to liver fibrosis, cirrhosis, and hepatocellular carcinoma. Still, most patients with MASLD die from cardiovascular diseases indicating metabolic alterations related to both liver and cardiovascular pathology.

AIMS AND METHODS

The aim of this study was to assess biologic pathways behind MASLD progression from steatosis to metabolic dysfunction-associated steatohepatitis (MASH) using non-targeted liquid chromatography-mass spectrometry analysis in 106 severely obese individuals (78 women, mean age 47.7 7 ± 9.2 years, body mass index 41.8 ± 4.3 kg/m²) undergoing laparoscopic Roux-en-Y gastric bypass.

RESULTS

We identified several metabolites that are associated with MASLD progression. Most importantly, we observed a decrease of lysophosphatidylcholines LPC(18:2), LPC(18:3), and LPC(20:3) and increase of xanthine when comparing those with steatosis to those with MASH. We found that indole propionic acid and threonine were negatively correlated to fibrosis, but not with the metabolic disturbances associated with cardiovascular risk. Xanthine, ketoleucine, and tryptophan were positively correlated to lobular inflammation and ballooning but also with insulin resistance, and dyslipidemia, respectively. The results did not change when taking into account the most important genetic risk factors of MASLD.

CONCLUSIONS

Our findings suggest that there are several separate biological pathways, some of them independent of insulin resistance and dyslipidemia, associating with MASLD.

Non-invasively differentiate non-alcoholic steatohepatitis by visualizing hepatic integrin αvβ3 expression with a targeted molecular imaging modality

BACKGROUND

Non-invasive methods to diagnose non-alcoholic steatohepatitis (NASH), an inflammatory subtype of non-alcoholic fatty liver disease (NAFLD), are currently unavailable.

AIM

To develop an integrin αvβ3-targeted molecular imaging modality to differentiate NASH.

METHODS

Integrin αvβ3 expression was assessed in Human LO2 hepatocytes Scultured with palmitic and oleic acids (FFA). Hepatic integrin αvβ3 expression was analyzed in rabbits fed a high-fat diet (HFD) and in rats fed a high-fat, high-carbohydrate diet (HFCD). After synthesis, cyclic arginine-glycine-aspartic acid peptide (cRGD) was labeled with gadolinium (Gd) and used as a contrast agent in magnetic resonance imaging (MRI) performed on mice fed with HFCD.

RESULTS

Integrin αvβ3 was markedly expressed on FFA-cultured hepatocytes, unlike the control hepatocytes. Hepatic integrin αvβ3 expression significantly increased in both HFD-fed rabbits and HFCD-fed rats as simple fatty liver (FL) progressed to steatohepatitis. The distribution of integrin αvβ3 in the liver of NASH cases largely overlapped with albumin-positive staining areas. In comparison to mice with simple FL, the relative liver MRI-T1 signal value at 60 minutes post-injection of Gd-labeled cRGD was significantly increased in mice with steatohepatitis (P < 0.05), showing a positive correlation with the NAFLD activity score (r = 0.945; P < 0.01). Hepatic integrin αvβ3 expression was significantly upregulated during NASH development, with hepatocytes being the primary cells expressing integrin αvβ3.

CONCLUSION

After using Gd-labeled cRGD as a tracer, NASH was successfully distinguished by visualizing hepatic integrin αvβ3 expression with MRI.

TAT as a new marker and its use for noninvasive chemical biopsy in NASH diagnosis

BACKGROUND

Early diagnosis of Nonalcoholic steatohepatitis (NASH) is crucial to prevent its progression to hepatocellular carcinoma, but its gold standard diagnosis still requires invasive biopsy. Here, a new marker-based noninvasive chemical biopsy approach is introduced that uses urine-secreted tyrosine metabolites.

METHODS

We first identified NASH-specific decrease in TAT expression, the first enzyme in the tyrosine degradation pathway (TDP), by employing exometabolome-transcriptome correlations, single-cell RNA -seq, and tissue staining on human NASH patient samples. A selective extrahepatic monitoring of the TAT activity was established by the chemical biopsy exploiting the enzyme's metabolic conversion of D2-tyrosine into D2-4HPP. The approach was applied to a NASH mouse model using the methionine-choline deficient diet, where urine D2-4HPP level was measured with a specific LC-MS detection, following oral administration of D2-tyrosine.

RESULTS

The noninvasive urine chemical biopsy approach could effectively differentiate NASH from normal mice (normal = 14, NASH = 15, p = 0.0054), correlated with the NASH pathology and TAT level decrease observed with immunostaining on the liver tissue. In addition, we showed that the diagnostic differentiation could be enhanced by measuring the downstream metabolites of TDP. The specificity of the TAT and the related TDP enzymes in NASH were also addressed in other settings employing high fat high fructose mouse NASH model and human obesity vs. NASH cohort.

CONCLUSIONS

Overall, we propose TAT and TDP as pathology-relevant markers for NASH and present the urine chemical biopsy as a noninvasive modality to evaluate the NASH-specific changes in urine that may help the NASH diagnosis.

Hybrid Deep Learning and Machine Learning for Detecting Hepatocyte Ballooning in Liver Ultrasound Images

BACKGROUND

Hepatocyte ballooning (HB) is a significant histological characteristic linked to the advancement of non-alcoholic fatty liver disease (NAFLD) and non-alcoholic steatohepatitis (NASH). Although clinicians now consider liver biopsy the most reliable method for identifying HB, its invasive nature and related dangers highlight the need for the development of non-invasive diagnostic options.

OBJECTIVE

This study aims to develop a novel methodology that combines deep learning and machine learning techniques to accurately identify and measure hepatobiliary abnormalities in liver ultrasound images.

METHODS

The research team expanded the dataset, consisting of ultrasound images, and used it for training deep convolutional neural networks (CNNs) such as InceptionV3, ResNet50, DenseNet121, and EfficientNetB0. A hybrid approach, combining InceptionV3 for feature extraction with a Random Forest classifier, emerged as the most accurate and stable method. An approach of dual dichotomy classification was used to categorize images into two stages: healthy vs. sick, and then mild versus severe ballooning.. Features obtained from CNNs were integrated with conventional machine learning classifiers like Random Forest and Support Vector Machines (SVM).

RESULTS

The hybrid approach achieved an accuracy of 97.40%, an area under the curve (AUC) of 0.99, and a sensitivity of 99% for the 'Many' class during the third phase of evaluation. The dual dichotomy classification enhanced the sensitivity in identifying severe instances of HB. The cross-validation process confirmed the strength and reliability of the suggested models.

CONCLUSIONS

These results indicate that this combination method can decrease the need for invasive liver biopsies by providing a non-invasive and precise alternative for early identification and monitoring of NAFLD and NASH. Subsequent research will prioritize the validation of these models using larger datasets from multiple centers to evaluate their generalizability and incorporation into clinical practice.

Development and validation of a risk score for detecting non-alcoholic fatty liver disease

The development of an easy-to-use noninvasive model to screen nonalcoholic fatty liver disease (NAFLD) is warranted. This study aimed to develop and validate a simple noninvasive NAFLD risk score (NARS). We used the National Health and Nutrition Examination Survey 2017 to March 2020 cycle data. The sample size of derivation and validation cohort were 4056 and 2502, separately. The NAFLD was determined by FibroScan® measured controlled attenuation parameter scores of >285 dB/m in the absence of excessive alcohol use, steatogenic medications use, and viral hepatitis. The NARS was derived from a multivariable logistic regression model and variables were selected based on Boruta analysis. The performance of NARS was internally validated and compared with previous models using receiver-operating characteristics curve and C-statistics. The NARS was established using waist circumference, triglycerides, alanine aminotransferase, and fasting glucose, and the total score ranges from 0 to 8, with an increasing risk of NAFLD. NARS demonstrated ideal discrimination in the validation cohort, with C-statistics of 0.832 (95% confidence interval, 0.801-0.824), and was not inferior to any existing models. The optimal cutoff point for predicting NAFLD was obtained at 4 scores with a sensitivity of 82% and specificity of 69%. We reported the derivation and internal validation of a novel and easy-to-use risk score for detecting the presence of NAFLD. NARS demonstrated ideal discrimination performance and was practical in clinical practice for selecting individuals at higher risk of NAFLD for further examination or intervention.

Blood-based MASH diagnostic in candidates for bariatric surgery using mid-infrared spectroscopy: a European multicenter prospective study

Metabolic dysfunction-associated steatotic liver disease (MASLD) is common in individuals with obesity. Sexual dimorphism is present in MASLD. A noninvasive test to diagnose the severity of the disease, in particular the presence of Metabolic dysfunction-associated steatohepatitis (MASH), is lacking. This European multicenter prospective study uses a blood test based on mid-infrared (MIR) metabolic fingerprinting of individuals with severe or morbid obesity to diagnose MASH. Three hundred eighty-two individuals with severe or morbid obesity undergoing bariatric surgery were enrolled prospectively. Liver biopsies were obtained during surgery and assessed centrally. An algorithm was defined to calculate a score from the recorded MIR spectrum and to establish a diagnostic threshold to classify patients with MASH. Among the women (n = 217), MASH was diagnosed in 14.3% of cases. For women, the performance in terms of AUC were 0.83 and 0.82 in the calibration and validation groups, respectively. For a threshold of 0.1817, sensitivities were 86% and 70%, specificities were 81% and 75%, PPV were 43% and 32%, NPV were 97% and 94% and ACC were 82% and 74% for the calibration and validation groups, respectively. For men (n = 78; MASH: 33.3%), the performance of the spectral model was poor. The metabolic fingerprint obtained by MIR spectroscopy can rule out MASH in women with severe or morbid obesity. Its value in men needs new studies.Trial registration: ClinicalTrials.gov identifier: ClinicalTrials.gov identifier: NCT03978247 (04/06/2019).

Diabetes as a risk factor for MASH progression

Non-alcoholic (now: metabolic) steatohepatitis (MASH) is the progressive inflammatory form of metabolic dysfunction-associated steatotic liver disease (MASLD), which often coexists and mutually interacts with type 2 diabetes (T2D), resulting in worse hepatic and cardiovascular outcomes. Understanding the intricate mechanisms of diabetes-related MASH progression is crucial for effective therapeutic strategies. This review delineates the multifaceted pathways involved in this interplay and explores potential therapeutic implications. The synergy between adipose tissue, gut microbiota, and hepatic alterations plays a pivotal role in disease progression. Adipose tissue dysfunction, particularly in the visceral depot, coupled with dysbiosis in the gut microbiota, exacerbates hepatic injury and insulin resistance. Hepatic lipid accumulation, oxidative stress, and endoplasmic reticulum stress further potentiate inflammation and fibrosis, contributing to disease severity. Dietary modification with weight reduction and exercise prove crucial in managing T2D-related MASH. Additionally, various well-known but also novel anti-hyperglycemic medications exhibit potential in reducing liver lipid content and, in some cases, improving MASH histology. Therapies targeting incretin receptors show promise in managing T2D-related MASH, while thyroid hormone receptor-β agonism has proven effective as a treatment of MASH and fibrosis.

Precision-cut liver slices as an ex vivo model to evaluate antifibrotic therapies for liver fibrosis and cirrhosis

BACKGROUND

Considering the lack of successful treatment options and poor prognosis for cirrhosis and cirrhosis-induced HCC, new platforms to investigate antifibrotic therapies are urgently needed. Precision-cut liver slice (PCLS) is a powerful ex vivo culture model that can supplement and potentially replace the traditional models.

METHODS

PCLS were prepared from 4 different murine cirrhotic models (choline-deficient, l-amino acid-defined, high-fat diet, thioacetamide, diethylnitrosamine, and carbon tetrachloride) and compared with in vivo murine experiments, in vitro hepatic stellate cells, and human cirrhotic PCLS.

RESULTS

PCLS viability in culture was stable for 72 hours. Treatment of erlotinib, an EGF receptor inhibitor, significantly inhibited profibrogenic gene expressions in PCLS from choline-deficient, l-amino acid-defined, high-fat diet or thioacetamide-induced cirrhotic rats. Erlotinib treatment of PCLS from diethylnitrosamine or carbon tetrachloride-induced cirrhotic rats inhibited the expression of profibrogenic genes, which was consistent with the impact of erlotinib on these genes in in vivo diethylnitrosamine or carbon tetrachloride-induced cirrhosis. In addition, in hepatic stellate cells at PCLS from normal mice, erlotinib treatment inhibited TGF-β1-upregulated expression of Acta2. Similar expression results were observed in in vitro hepatic stellate cells. Expression of key regulators of fibrosis progression and regression were also significantly altered. Changes in profibrogenic gene expression under erlotinib treatment were also corroborated with human cirrhotic PCLS.

CONCLUSIONS

Responses to antifibrotic interventions can be detected and quantified with PCLS at the gene expression level. The antifibrotic effects of erlotinib are consistent between PCLS models of murine cirrhosis and those observed in vivo and in vitro. These results were verified in human cirrhotic PCLS. PCLS is an excellent model for assessing antifibrotic therapies that are aligned with the principles of replacement, reduction, and refinement (3Rs), and it will benefit preclinical and clinical research for human fibrosis and cirrhosis.

Helicobacter pylori Infection Is Not Associated with Nonalcoholic Fatty Liver Disease: A Two-Year Cohort Study

INTRODUCTION

Previous studies reported inconsistent results of the association between Helicobacter pylori infection and nonalcoholic fatty liver disease (NAFLD).

METHODS

A cohort study of 2,063 adults without NAFLD at baseline, who participated in a repeated health checkup including a 13C-urea breath test and abdominal ultrasonography, was conducted to evaluate the link between H. pylori infection and NAFLD development.

RESULTS

During a mean follow-up period of 1.7 years, we did not find a significant association between H. pylori infection and NAFLD (hazard ratio = 1.10 (0.86, 1.40), p = 0.4689). We also found that higher age, body mass index (BMI), systolic blood pressure (systolic BP), diastolic blood pressure (diastolic BP), fasting blood glucose, triglycerides, total cholesterol, low-density lipoprotein cholesterol (LDL-C), alanine aminotransferase (ALT), and aspartate aminotransferase (AST) were risk factors, and high-density lipoprotein cholesterol (HDL-C) was a protective factor for NAFLD development.

CONCLUSION

H. pylori infection might not be positively related to NAFLD development.

Identification of key markers for the stages of nonalcoholic fatty liver disease: An integrated bioinformatics analysis and experimental validation

BACKGROUND

The identification of biomarkers for the early diagnosis of nonalcoholic fatty liver disease (NAFLD) is urgently needed. Here, we aimed to identify NAFLD biomarkers in the early stages of steatosis (SS) and nonalcoholic steatohepatitis (NASH) based on differential gene expression from bioinformatics data.

METHODS

A meta-analysis was performed from transcriptomic databases retrieved from public repositories containing data from biopsies of patients at various stages of NAFLD development. The status of the selected molecules was validated in the serum of patients with NAFLD by ELISA.

RESULTS

We identified 121 differentially expressed genes (DEGs) associated with SS and 402 associated with NASH. Gene Ontology (GO) enrichment revealed that the altered genes were primarily associated with dysfunction of primary cellular processes, and pathway analyses were mainly related to cholesterol metabolism. We identified ACSS2, PCSK9, and CYP7A1 as candidate biomarkers for SS and ANGPTL3, CD36, CYP51A1, FASN, FAS, FDFT1, and LSS as candidate biomarkers for NASH.

CONCLUSIONS

By experimental validation of bioinformatics data from patients with NAFLD, we identified promising biomarkers for detecting SS and NASH that might be useful for screening and diagnosing early NAFLD stages in humans.

Liver fibrosis is associated with left ventricular remodeling: insight into the liver-heart axis

OBJECTIVE

In nonalcoholic fatty liver disease (NAFLD), liver fibrosis is the strongest predictor of adverse outcomes. We sought to investigate the relationship between liver fibrosis and cardiac remodeling in participants from the general population using magnetic resonance imaging (MRI), as well as explore potential mechanistic pathways by analyzing circulating cardiovascular biomarkers.

METHODS

In this cross-sectional study, we prospectively included participants with type 2 diabetes and individually matched controls from the SCAPIS (Swedish CArdioPulmonary bioImage Study) cohort in Linköping, Sweden. Between November 2017 and July 2018, participants underwent MRI at 1.5 Tesla for quantification of liver proton density fat fraction (spectroscopy), liver fibrosis (stiffness from elastography), left ventricular (LV) structure and function, as well as myocardial native T1 mapping. We analyzed 278 circulating cardiovascular biomarkers using a Bayesian statistical approach.

RESULTS

In total, 92 participants were enrolled (mean age 59.5 ± 4.6 years, 32 women). The mean liver stiffness was 2.1 ± 0.4 kPa. 53 participants displayed hepatic steatosis. LV concentricity increased across quartiles of liver stiffness. Neither liver fat nor liver stiffness displayed any relationships to myocardial tissue characteristics (native T1). In a regression analysis, liver stiffness was related to increased LV concentricity. This association was independent of diabetes and liver fat (Beta = 0.26, p = 0.0053), but was attenuated (Beta = 0.17, p = 0.077) when also adjusting for circulating levels of interleukin-1 receptor type 2.

CONCLUSION

MRI reveals that liver fibrosis is associated to structural LV remodeling, in terms of increased concentricity, in participants from the general population. This relationship could involve the interleukin-1 signaling.

CLINICAL RELEVANCE STATEMENT

Liver fibrosis may be considered a cardiovascular risk factor in patients without cirrhosis. Further research on the mechanisms that link liver fibrosis to left ventricular concentricity may reveal potential therapeutic targets in patients with non-alcoholic fatty liver disease (NAFLD).

KEY POINTS

Previously, studies on liver fibrosis and cardiac remodeling have focused on advanced stages of liver fibrosis. Liver fibrosis is associated with left ventricular (LV) concentricity and may relate to interleukin-1 receptor type 2. Interleukin-1 signaling is a potential mechanistic interlink between early liver fibrosis and LV remodeling.

Diagnostic role of the fibrosis-4 index and nonalcoholic fatty liver disease fibrosis score as a noninvasive tool for liver fibrosis scoring

Nonalcoholic fatty liver disease (NAFLD) is characterized by liver fibrosis, which serves as a crucial indicator of its progression and prognosis. Owing to the limitations of biopsy, which is the gold standard for measuring liver fibrosis, a reliable and noninvasive marker is required. We evaluated the diagnostic role of the fibrosis-4 (FIB-4) index and nonalcoholic fatty liver disease fibrosis score (NFS) in patients with NAFLD with varying severities of liver fibrosis. The FIB-4 index and NFS were calculated using laboratory data from 121 patients who underwent liver biopsies between January 2022 and December 2023. The results were compared with those of the Scheuer scoring system for liver biopsies (F0, F1 + F2, and F3 + F4) to determine the sensitivity and specificity of the FIB-4 index and the liver disease fibrosis score in detecting and staging liver fibrosis. Twenty-one patients had advanced fibrosis (F3-F4), and 100 had minimal or mild fibrosis (F0-F2). The degree of liver fibrosis increased with decreased albumin, alanine aminotransferase and platelet count levels, and increasing age. Receiver operating characteristic curve analysis for the FIB-4 index and NFS revealed that the areas under the curve for the FIB-4 index and NFS were 0.895 (95% confidence interval: 0.836-0.954) and 0.882 (95% confidence interval: 0.813-0.952), respectively. The FIB-4 indices showed 95.24% sensitivity at a cutoff point of 1.30, and 85% specificity at a cutoff point of 2.67, while the NFS indices showed 95.24% sensitivity at -1.455 cutoff point and 95% specificity at a cutoff point of 0.676. The FIB-4 index and NFS may replace biopsy for the detection of fibrosis in patients with NAFLD.

Clinical validation of the suppressive impact of letrozole on liver fibrosis in patients with breast cancer undergoing continuous letrozole administration: A retrospective study

Treatment strategies for preventing liver fibrosis have not yet been established. Letrozole, widely used for breast cancer, has recently been reported to suppress liver fibrosis in murine models. Therefore, we aimed to validate the suppressive effects of letrozole on liver fibrosis in the clinical setting. From 2006 to 2020, 23 consecutive patients who received continuous letrozole treatment for 24 months or more and had a liver fibrosis marker FIB-4 index of ≥ 2.30, were included. Forty-three patients who underwent anastrozole treatment for 24 months or more and had a liver fibrosis marker FIB-4 index of ≥ 2.30, were also included as controls. The Fisher exact, chi-square, unpaired Student t, and paired Student t test were used to analyze the data. The patient characteristics were similar between the letrozole- and anastrozole-treated patient groups. Among the letrozole-treated patients, the mean FIB-4 index tended to decline during letrozole treatment; a significant decrease was observed at 18 and 24 months compared with the baseline values (p = 0.044 and p = 0.013). In addition, the mean aspartate aminotransferase-to-platelet ratio index (APRI) decreased during letrozole treatment; the values at 18 and 24 months were significantly lower than those at baseline (p = 0.024 and p = 0.026). In contrast, among anastrozole-treated patients, the mean FIB-4 index and APRI did not change during anastrozole treatment. When changes in the FIB-4 index were further examined in a limited number of patients with a FIB-4 index ≥ 2.67, a significant reduction in the FIB-4 index at 24 months compared with baseline was also observed in letrozole-treated patients (p = 0.023), but not in anastrozole-treated patients. In conclusion, our findings support a possible suppressive effect of letrozole on liver fibrosis in the clinical setting. Further studies are required to better understand the pharmacological effects of letrozole.

The Different Predictive Effects of Multiple Body Fat Indexes on Metabolic Dysfunction-Associated Fatty Liver Disease

Purpose

The aim of this study was to comprehensively compare the predictive effect of 10 body fat indexes on MAFLD in different sex, age and BMI subgroups.

Patients and Methods

A total of 5403 physical examination data were included and divided into the MAFLD group (N=2632) and non-MAFLD group (N=2771). The differences and correlation of 10 promising indicators between the two groups were compared, including fatty liver index (FLI), hepatic steatosis index (HSI), lipid accumulation product (LAP), visceral fat index (VAI), cardiometabolic index (CMI), body adiposity index (BAI), and triglyceride-glucose index (TyG), waist circumference index (WC), body mass index (BMI), waist to height ratio (WHtR). Logistic regression was used to analyze the risk of MAFLD under different adjustment conditions. The operating characteristic curve of different genders, BMI levels and age subgroups was plotted.

Results

Male gender, smoking, alcohol drinking, and higher age are risk factors for MAFLD. In addition to BAI, the other 9 indicators had a high correlation with MAFLD, the area under the curve (AUC) value was >0.7, and the prediction effect was better in females, BMI<24 kg/m2, age <35 years subgroup, among which FLI (AUC: 0.912, 95% CI: 0.905-0.920), LAP (AUC: 0.894, 95% CI: 0.8866-0.903), and HSI (AUC: 0.881, 95% CI: 0.872-0.890) have better prediction effects.

Conclusion

Our study confirmed the accuracy of body fat-related indexes in predicting MAFLD in people of different sexes, ages, and BMI levels. Among them, FLI, LAP and HSI have high predictive value and can be utilized as simple and cost-effective tools for screening MAFLD in clinical settings.

Biological aging accelerates hepatic fibrosis: Insights from the NHANES 2017-2020 and genome-wide association study analysis

INTRODUCTION AND OBJECTIVES

This study aimed to investigate the association between biological aging and liver fibrosis in patients with metabolic dysfunction-associated steatotic liver disease (MASLD).

MATERIALS AND METHODS

We analyzed NHANES 2017-2020 data to calculate phenotypic age. Hepatic steatosis and fibrosis were identified using controlled attenuation parameters (CAP), fatty liver index (FLI) and transient elastography (TE). The odds ratios (ORs) and 95 % confidence intervals (CI) for significant MASLD fibrosis were calculated using multivariate logistic regression, and subgroup analyses were performed. We explored the potential causal relationship between telomere length and liver fibrosis using Mendelian randomization (MR). Additionally, we used the expression quantitative trait loci (eQTL) method and GSE197112 data to identify genes related to liver fibrosis and senescence. Finally, the APOLD1 expression was validated using GSE89632.

RESULTS

Phenotypic age was associated with liver fibrosis occurrence in MASLD (OR = 1.08, 95 % CI 1.05-1.12). Subgroup analyses by BMI and age revealed differences. For obese or young to middle-aged MASLD patients, phenotypic age is significantly associated with liver fibrosis. (OR = 1.14, 95 % CI 1.10-1.18; OR = 1.07, 95 % CI 1.01-1.14 and OR = 1.14, 95 % CI 1.07-1.22). MR revealed a negative association between telomere length and liver fibrosis (IVW method: OR = 0.63288, 95 % CI 0.42498-0.94249). The gene APOLD1 was identified as a potential target through the intersection of the GEO dataset and eQTL genes.

CONCLUSIONS

This study emphasized the link between biological aging and fibrosis in young to middle-aged obese MASLD patients. We introduced phenotypic age as a clinical indicator and identified APOLD1 as a potential therapeutic target.

The effect of probiotic supplementation on non-alcoholic fatty liver disease (NAFLD) fibrosis score in patients attending a tertiary hospital clinic in Cairo, Egypt

BACKGROUND

Non-alcoholic fatty liver disease (NAFLD) is characterized by hepatic fat accumulation (> 5% of liver tissue) in the absence of alcohol abuse or other chronic liver diseases. NAFLD can progress to non-alcoholic steatohepatitis (NASH), fibrosis, cirrhosis, and hepatocellular carcinoma (HCC). This study aimed to assess the efficacy of probiotic (lactobacillus) supplementation on NAFLD fibrosis score.

METHODOLOGY

A double-arm randomized controlled trial was conducted in the family medicine clinic of a tertiary hospital, enrolling patients with sonographic evidence of NAFLD. Fifty patients were divided into two groups: the Probiotic group received lifestyle modification instructions along with daily probiotic supplementation for twelve weeks, with regular monthly follow-up visits. The Standard Treatment group received low-fat diet and lifestyle modification instructions only.

RESULTS

The mean age of participants was 46.10 years (SD 10.11), with 70% females and 30% males. The study found a statistically significant difference in liver enzymes (ALT and AST) and BMI in the probiotic group before and after intervention. However, there was no significant difference in NAFLD fibrosis score between the two groups.

CONCLUSION

Short-term probiotic treatment resulted in improvements in ALT, AST, and BMI in the probiotic group, but did not significantly affect NAFLD fibrosis score. Further research with larger sample sizes and longer follow-up periods is warranted.

TRIAL REGISTRATION

The clinical trial was registered at Protocol Registration and Results System with number NCT06074094 (12/09/2021).

Fibrosis-4 score for screening of metabolic dysfunction-associated steatotic liver disease (MASLD): Data from a population-based sample in Tuscany

BACKGROUND AND AIM

To verify the prevalence of positive Fibrosis-4 (FIB-4) score, a screening test for metabolic-associated liver disease, in a large population-based sample in the Tuscany Italian Region, and to identify sub-populations at higher risk which could be targeted by specific screening programs.

METHODS AND RESULTS

Population-based survey performed in the Italian region of Tuscany, with Tuscany health informative system's administrative data. We included 594,923 subjects, of which 32% had available data for the FIB-4 calculation. The overall proportion of subjects with an FIB-4 value > 1.3, was 41.6% of those with available exams, and 12,8% of the whole population, whereas 5.4% and 1.7% had FIB-4 >2.67. In those younger than 80 years, FIB >1.3 had a 33.1% and 9.4%. People with diabetes mellitus had higher figures (52.8.% and 28.9% for FIB>1.3). Among subjects aged 70 years or over, 74.9% of those with available data and 38.4% of the general population had a FIB-4>1.3, whereas 32% and 16% had a FIB-4 > 2.

CONCLUSIONS

The relevant proportion of FIB-4 positivity in the general population poses a significant burden for further screening with liver elastography. Targeting people with diabetes, excluding people older than 80 years and/or adopting a FIB-4 threshold of 2 in those aged more than 70 years could increase the cost-effectiveness of the screening procedures.

Inflammation activity affects liver stiffness measurement by magnetic resonance elastography in MASLD

BACKGROUND

Magnetic resonance elastography (MRE) is recognized as the most precise imaging technology for assessing liver fibrosis in individuals with metabolic dysfunction-associated steatotic liver disease (MASLD). We aimed to investigate the clinical factors and pathological characteristics that may impact LSM in MASLD patients.

METHODS

This cross-sectional study recruited 124 patients who concurrently performed MRE, MRI-PDFF, and biopsy-proven MASLD. Linear regression models, Spearman's correlation, and subgroup analysis were employed to identify the variables affecting LSM.

RESULTS

The AUROC (95 % CI) of MRE for diagnosing fibrosis stage ≥ 1, 2, 3, and 4 was 0.80 (0.70-0.90), 0.76 (0.66-0.85), 0.92 (0.86-0.99), and 0.99 (0.99-1.00), with corresponding cutoffs of 2.56, 2.88, 3.35, and 4.76 kPa, respectively. Multivariate analyses revealed that AST was the only independent clinical variable significantly correlated with LSM. Furthermore, LSM exhibited a notable association with the grade of lobular inflammation and hepatocellular ballooning. Subgroup analysis showed that when AST ≥ 2 ULN or inflammation grade ≥ 2, LSM of patients with early fibrosis stages showed a slight but significant increase.

CONCLUSION

MRE demonstrates significant diagnostic accuracy in predicting liver fibrosis stages for MASLD patients, especially for advanced liver fibrosis and cirrhosis. However, elevated AST and the severity of liver inflammation may impact its accuracy in staging early liver fibrosis.

Diagnosis and Management of Lean Metabolic Dysfunction-Associated Steatotic Liver Disease (MASLD): A Systematic Review

Lean metabolic dysfunction-associated steatotic liver disease (MASLD) defies traditional views of fatty liver diseases by manifesting in nonobese individuals. The renaming from nonalcoholic fatty liver disease to MASLD underscores a broader understanding of its pathophysiology, highlighting the complex interplay of metabolic factors beyond obesity. Despite its clinical importance, diagnosing and managing lean MASLD remains challenging due to its historical ties to obesity and a general lack of awareness about its unique characteristics. On December 4, 2023, a systematic literature search was conducted across six databases, focusing on peer-reviewed studies in English related to the diagnosis and management of lean MASLD. This study was registered with the International Prospective Register of Systematic Reviews (CRD42023489308). Out of 95 studies following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, 43 addressed diagnosis and surveillance, whereas 52 explored management strategies. The results revealed the difficulties in diagnosing lean MASLD, pointing out the limitations of traditional markers and the potential of advanced imaging techniques. Management strategies discussed included lifestyle changes and possible pharmacological treatments tailored to the specific metabolic features of this patient group. The study highlights the necessity for increased clinical awareness, regular monitoring, and personalized therapeutic approaches for lean MASLD. It calls for further research to refine diagnostic criteria and develop targeted treatments, aiming to enhance care for individuals with lean MASLD.

Natural history and progression of metabolic dysfunction-associated steatotic liver disease

The natural history of metabolic dysfunction-associated steatotic liver disease (MASLD), previously referred to as non-alcoholic fatty liver disease (NAFLD), is complex and long. A minority of patients develop inflammation and risk progressive fibrosis that can result in cirrhosis. Progression to cirrhosis occurs in 3-5% of patients and often takes more than 20 years. This narrative review presents an update on the natural history of MASLD, discussing studies and risk estimates for progression to severe outcomes, such as decompensated cirrhosis or hepatocellular carcinoma. We highlight the dynamic progression of liver damage, how to identify patients whose disease progresses over time, and how risk factors might be mitigated to reduce the risk for disease progression.

Liver fibrosis in inflammatory arthritis patients treated with methotrexate and hydroxychloroquine: A FIB-4 index analysis

OBJECTIVES

To evaluate the risk of liver fibrosis and associated factors with the non-invasive fibrosis score-4 (FIB-4) index in patients with inflammatory arthritis using methotrexate (MTX).

METHODS

Patients with rheumatoid arthritis (RA) and psoriatic arthritis (PsA) who were followed up in the rheumatology outpatient clinic, who were on methotrexate only and for whom FIB-4 index was could be calculated at methotrexate initiation and follow-up were included. The FIB-4 index was calculated according to the following formula: age (years) × AST(IU/L)/(platelet count(10 (9)/L) × √ALT(IU/L)). The patients' demographics, comorbidities, other treatments, cumulative MTX dose, and reasons for MTX cessation were assessed. For the multivariate analysis, possible factors associated with intermediate-high risk FIB-4 index at last visit were determined.

RESULTS

A total of 107 patients were enrolled in the study, of whom 82 (76.6%) had RA and 25 (23.4%) had PsA. At the initiation of MTX, 24 (22.4%) patients had intermediate-high risk FIB-4 index. Comorbidities and the rate of ≥3-4 Charlson comorbidity index were more common in patients with intermediate-high risk FIB-4 index. A total of 37 (34.5%) patients had intermediate-high risk FIB-4 index at the last visit after median 3.6 (0.3-22.06) years follow-up. The median cumulative MTX dose was 2550 mg (1050-13.991). Cumulative MTX dose [OR 1.18 (1.01-1.33), p = .03] and diabetes mellitus [OR 4.60 (1.74-12.50), p = .002] were associated factors with intermediate-high risk FIB-4 index. The concomitant use of hydroxychloroquine (HCQ) was found to be a low-risk factor for FIB-4 index [OR 0.28 (0.10-0.78) p = .015].

CONCLUSION

The FIB-4 index is a non-invasive method that can be used in daily rheumatology practice for the evaluation and follow-up of patients who will use methotrexate. Comorbidities and cumulative MTX dose seem to be related with the risk of liver fibrosis. Concomitant use of HCQ with MTX may reduce the risk of liver fibrosis.

Altered gut microbial profile accompanied by abnormal short chain fatty acid metabolism exacerbates nonalcoholic fatty liver disease progression

Dysregulation of the gut microbiome has associated with the occurrence and progression of non-alcoholic fatty liver disease (NAFLD). To determine the diagnostic capacity of this association, we compared fecal microbiomes across 104 participants including non-NAFLD controls and NAFLD subtypes patients that were distinguished by magnetic resonance imaging. We measured their blood biochemical parameters, 16 S rRNA-based gut microbiota and fecal short-chain fatty acids (SCFAs). Multi-omic analyses revealed that NAFLD patients exhibited specific changes in gut microbiota and fecal SCFAs as compared to non-NAFLD subjects. Four bacterial genera (Faecalibacterium, Subdoligranulum, Haemophilus, and Roseburia) and two fecal SCFAs profiles (acetic acid, and butyric acid) were closely related to NAFLD phenotypes and could accurately distinguish NAFLD patients from healthy non-NAFLD subjects. Twelve genera belonging to Faecalibacterium, Subdoligranulum, Haemophilus, Intestinibacter, Agathobacter, Lachnospiraceae_UCG-004, Roseburia, Butyricicoccus, Actinomycetales_unclassified, [Eubacterium]_ventriosum_group, Rothia, and Rhodococcus were effective to distinguish NAFLD subtypes. Of them, combination of five genera can distinguish effectively mild NAFLD from non-NAFLD with an area under curve (AUC) of 0.84. Seven genera distinguish moderate NAFLD with an AUC of 0.83. Eight genera distinguish severe NAFLD with an AUC of 0.90. In our study, butyric acid distinguished mild-NAFLD from non-NAFLD with AUC value of 0.83. And acetic acid distinguished moderate-NAFLD and severe-NAFLD from non-NAFLD with AUC value of 0.84 and 0.70. In summary, our study and further analysis showed that gut microbiota and fecal SCFAs maybe a method with convenient detection advantages and invasive manner that are not only a good prediction model for early warning of NAFLD occurrence, but also have a strong ability to distinguish NAFLD subtypes.

Artificial Intelligence in Identifying Patients With Undiagnosed Nonalcoholic Steatohepatitis

Background: Although increasing in prevalence, nonalcoholic steatohepatitis (NASH) is often undiagnosed in clinical practice. Objective: This study identified patients in the Veterans Affairs (VA) health system who likely had undiagnosed NASH using a machine learning algorithm. Methods: From a VA data set of 25 million adult enrollees, the study population was divided into NASH-positive, non-NASH, and at-risk cohorts. We performed a claims data analysis using a machine learning algorithm. To build our model, the study population was randomly divided into an 80% training subset and a 20% testing subset and tested and trained using a cross-validation technique. In addition to the baseline model, a gradient-boosted classification tree, naïve Bayes, and random forest model were created and compared using receiver operator characteristics, area under the curve, and accuracy. The best performing model was retrained on the full 80% training subset and applied to the 20% testing subset to calculate the performance metrics. Results: In total, 4 223 443 patients met the study inclusion criteria, of whom 4903 were positive for NASH and 35 528 were non-NASH patients. The remainder was in the at-risk patient cohort, of which 514 997 patients (12%) were identified as likely to have NASH. Age, obesity, and abnormal liver function tests were the top determinants in assigning NASH probability. Conclusions: Utilization of machine learning to predict NASH allows for wider recognition, timely intervention, and targeted treatments to improve or mitigate disease progression and could be used as an initial screening tool.

Association between dietary intake of carotenoids and metabolic dysfunction-associated fatty liver disease in US adults: National Health and Nutrition Examination Survey 2017-March 2020

OBJECTIVE

To assess the relationship between dietary intake of α-carotene, β-carotene, β-cryptoxanthin, lycopene and lutein+zeaxanthin (LZ) and occurrence of metabolic dysfunction-associated fatty liver disease (MAFLD).

DESIGN

Cross-sectional study design. The MAFLD diagnosis was based on hepatic steatosis and metabolic dysregulation. Carotenoid intake was adjusted for using an energy-adjusted model. Logistic regression and restricted cubic spline (RCS) analyses were used to assess the relationships, with sensitivity analysis to validate the findings. Weighted quantile sum regression (WQS) was used to explore the combined effect of these carotenoids on MAFLD. Subgroup analyses were conducted to identify population-specific associations.

SETTING

National Health and Nutrition Examination Survey (NHANES) 2017-March 2020.

PARTICIPANTS

This study included 5098 individuals aged 18 years and older.

RESULTS

After adjusting for potential confounders, a weak inverse association was observed between α-carotene and β-carotene intakes and MAFLD occurrence (all P value <0·05). The highest quartile of β-carotene intake showed a significantly lower occurrence of MAFLD compared with the lowest quartile (OR = 0·65; 95 % CI: 0·44, 0·97). RCS analysis showed that a significantly lower occurrence of MAFLD was associated with a higher intake of the four carotenoids, excluding lycopene. Furthermore, the WQS analysis revealed a negative relationship between combined carotenoid intake and MAFLD occurrence (OR = 0·95, 95 % CI: 0·90, 1·00, P = 0·037). Subgroup analyses showed dietary carotenoid intake was associated with reduced MAFLD occurrence in populations aged 50-69 years, females, physically active individuals and non-drinkers.

CONCLUSION

Higher dietary intake of carotenoids is associated with lower MAFLD occurrence. However, this relationship varies among individuals of different ages, sexes and lifestyles.

Positron emission tomography combined with serum biomarkers detects fibrotic MASH

Metabolic dysfunction-associated steatohepatitis (MASH) is a rising global disease signaling the urgent need for non-invasive tests (NITs). Recent work demonstrated that dynamic 18F-fluorodeoxyglucose (FDG) positron emission tomography (PET)/computed tomography (CT) imaging can identify MASH by measuring liver glucose transport rate, K1, and liver CT attenuation. By combining dynamic PET/CT with the serum-based fibrosis-4 (FIB-4) test, we were able to better distinguish clinical MASH from fibrotic subtypes, enabling determination of the core tenets of MASH: steatosis, inflammation, and fibrosis. Future studies using FDG-PET technology can further enable concomitant prediction of MASH severity and extrahepatic comorbidities such as cardiovascular disease.

Converging Pathways between Metabolic Dysfunction-Associated Steatotic Liver Disease (MASLD) and Diabetes in Children

In the past thirty years, childhood obesity rates have risen significantly worldwide, affecting over 340 million children in affluent nations. This surge is intricately tied to metabolic disorders, notably insulin resistance, type 2 diabetes mellitus (T2DM), and the continually evolving spectrum of metabolic-associated (dysfunction) steatotic liver disease (MASLD). This review underscores the alarming escalation of childhood obesity and delves comprehensively into the evolving and dynamic changes of nomenclature surrounding diverse conditions of hepatic steatosis, from the initial recognition of non-alcoholic fatty liver disease (NAFLD) to the progressive evolution into MASLD. Moreover, it emphasizes the crucial role of pediatric endocrinologists in thoroughly and accurately investigating MASLD onset in children with T2DM, where each condition influences and exacerbates the progression of the other. This review critically highlights the inadequacies of current screening strategies and diagnosis, stressing the need for a paradigm shift. A proposed solution involves the integration of hepatic magnetic resonance imaging assessment into the diagnostic arsenal for children showing insufficient glycemic control and weight loss post-T2DM diagnosis, thereby complementing conventional liver enzyme testing. This holistic approach aims to significantly enhance diagnostic precision, fostering improved outcomes in this vulnerable high-risk pediatric population.

Dietary patterns in the progression of metabolic dysfunction-associated fatty liver disease to advanced liver disease: a prospective cohort study

BACKGROUND

Metabolic dysfunction-associated fatty liver disease (MAFLD) is a significant health problem. Dietary intervention plays an important role in patients with MAFLD.

OBJECTIVES

We aimed to provide a reference for dietary patterns in patients with MAFLD.

METHODS

The presence of MAFLD was determined in the United Kingdom Biobank cohort. Nine dietary pattern scores were derived from the dietary records. Multivariable Cox regression models were used to estimate the hazard ratios (HRs) and 95% confidence intervals (CIs). The contrast test was employed to calculate the heterogeneity across MAFLD statuses.

RESULTS

We identified 175,300 patients with MAFLD at baseline. Compared with non-MAFLD, MAFLD was significantly associated with chronic liver disease (CLD) (HR: 3.48; 95% CI: 3.15, 3.84), severe liver disease (SLD) (HR: 2.87; 95% CI: 2.63, 3.14), liver cancer (HR: 1.93; 95% CI: 1.67, 2.23), and liver-related death (LRD) (HR: 1.93; 95% CI: 1.67, 2.23). In the overall cohort, the alternate Mediterranean diet (aMED) (HRCLD: 0.53; 95% CI: 0.37, 0.76; HRSLD: 0.52; 95% CI: 0.37, 0.72), planetary health diet (PHD) (HRCLD: 0.62; 95% CI: 0.47, 0.81; HRSLD: 0.65; 95% CI: 0.51, 0.83), plant-based low-carbohydrate diet (pLCD) (HRCLD: 0.65; 95% CI: 0.49, 0.86; HRSLD: 0.66; 95% CI: 0.51, 0.85), and healthful plant-based diet index (hPDI) (HRCLD: 0.63; 95% CI: 0.47, 0.84; HRSLD: 0.61; 95% CI: 0.47, 0.78) were associated with a lower risk of CLD and SLD. Additionally, unhealthful plant-based diet index (uPDI) was associated with increased risk of CLD (HR: 1.42; 95% CI: 1.09,1.85), SLD (HR: 1.50; 95% CI: 1.19, 1.90), and LRD (HR: 1.88; 95% CI: 1.28-2.78). The aforementioned associations remained consistently strong within the MAFLD subgroup while exhibiting less pronounced in the non-MAFLD group. However, no significant heterogeneity was observed across different MAFLD statuses.

CONCLUSIONS

These findings highlight the detrimental effects of MAFLD on the development of subsequent liver diseases and the importance of dietary patterns in managing MAFLD.

Non-invasive Scores and Serum Biomarkers for Fatty Liver in the Era of Metabolic Dysfunction-associated Steatotic Liver Disease (MASLD): A Comprehensive Review From NAFLD to MAFLD and MASLD

PURPOSE OF REVIEW

The prevalence of non-alcoholic fatty liver disease (NAFLD) is rapidly increasing worldwide, making it the leading cause of liver related morbidity and mortality. Currently, liver biopsy is the gold standard for assessing individuals with steatohepatitis and fibrosis. However, its invasiveness, sampling variability, and impracticality for large-scale screening has driven the search for non-invasive methods for early diagnosis and staging. In this review, we comprehensively summarise the evidence on the diagnostic performance and limitations of existing non-invasive serum biomarkers and scores in the diagnosis and evaluation of steatosis, steatohepatitis, and fibrosis.

RECENT FINDINGS

Several non-invasive serum biomarkers and scores have been developed over the last decade, although none has successfully been able to replace liver biopsy. The introduction of new NAFLD terminology, namely metabolic dysfunction-associated fatty liver disease (MAFLD) and more recently metabolic dysfunction-associated steatotic liver disease (MASLD), has initiated a debate on the interchangeability of these terminologies. Indeed, there is a need for more research on the variability of the performance of non-invasive serum biomarkers and scores across the diagnostic entities of NAFLD, MAFLD and MASLD. There remains a significant need for finding valid and reliable non-invasive methods for early diagnosis and assessment of steatohepatitis and fibrosis to facilitate prompt risk stratification and management to prevent disease progression and complications. Further exploration of the landscape of MASLD under the newly defined disease subtypes is warranted, with the need for more robust evidence to support the use of commonly used serum scores against the new MASLD criteria and validation of previously developed scores.

Liver fibrosis and liver stiffness in patients with obesity and type 1 diabetes

AIM

To compare hepatic stiffness and fat fraction in patients with obesity and type 1 diabetes (T1D) with type 2 diabetes (T2D) with a similar body mass index (BMI).

METHODS

In this prospective cross-sectional study, 90 participants with T1D (BMI 30.5 ± 4.5 kg/m2; diabetes duration 20.5 ± 9.8 years; HbA1c 8.2% ± 1.4%) and 69 with T2D (BMI: 30.8 ± 4.6 kg/m2; diabetes duration: 11.7 ± 7.8 years; HbA1c: 7.3% ± 1.4%) were included. Liver fat fraction and stiffness were examined by magnetic resonance imaging and elastography, respectively. Logistic regressions were used to evaluate associations with biomedical variables.

RESULTS

The mean liver stiffness score in patients with obesity and T1D was 2.2 ± 0.5 kPa, while in T2D it was 2.6 ± 0.8 kPa (P < .001). The liver fat fraction in patients with obesity and T1D was 3.7% ± 6.3%, and in T2D it was 10.6% ± 7.9% (P < .001). Metabolic dysfunction-associated steatotic liver disease (MASLD) was present in 13.3% of patients with T1D and in 69.6% of patients with T2D, whereas fibrosis was suggested in 7.8% of patients with T1D and in 27.5% of patients with T2D. Liver stiffness was four times higher in patients with T2D compared with those with T1D (odds ratio = 5.4, 95% confidence interval: 2.1-13.6, P < .001). Aspartate transaminase (AST), alanine transaminase, gamma-glutamyl transferase (GGT), triglycerides and the android-to-gynoid ratio were associated with elevated fat fraction in both cohorts. AST and GGT were associated with elevated liver stiffness in both cohorts.

CONCLUSIONS

Patients with obesity and T1D had lower liver fat and liver stiffness compared with those patients with T2D, despite similar levels of BMI, a longer duration of diabetes and worse glycaemic control.

Reproducibility and Repeatability of US Shear-Wave and Transient Elastography in Nonalcoholic Fatty Liver Disease

Background US shear-wave elastography (SWE) and vibration-controlled transient elastography (VCTE) enable assessment of liver stiffness, an indicator of fibrosis severity. However, limited reproducibility data restrict their use in clinical trials. Purpose To estimate SWE and VCTE measurement variability in nonalcoholic fatty liver disease (NAFLD) within and across systems to support clinical trial diagnostic enrichment and clinical interpretation of longitudinal liver stiffness. Materials and Methods This prospective, observational, cross-sectional study (March 2021 to November 2021) enrolled adults with NAFLD, stratified according to the Fibrosis-4 (FIB-4) index (≤1.3, >1.3 and <2.67, ≥2.67), at two sites to assess SWE with five US systems and VCTE with one system. Each participant underwent 12 elastography examinations over two separate days within 1 week, with each day's examinations conducted by a different operator. VCTE and SWE measurements were reported in units of meters per second. The primary end point was the different-day, different-operator reproducibility coefficient (RDCDDDO) pooled across systems for SWE and individually for VCTE. Secondary end points included system-specific RDCDDDO, same-day, same-operator repeatability coefficient (RCSDSO), and between-system same-day, same-operator reproducibility coefficient. The planned sample provided 80% power to detect a pooled RDCDDDO of less than 35%, the prespecified performance threshold. Results A total of 40 participants (mean age, 60 years ± 10 [SD]; 24 women) with low (n = 17), intermediate (n = 15), and high (n = 8) FIB-4 scores were enrolled. RDCDDDO was 30.7% (95% upper bound, 34.4%) for SWE and 35.6% (95% upper bound, 43.9%) for VCTE. SWE system-specific RDCDDDO varied from 24.2% to 34.3%. The RCSDSO was 21.0% for SWE (range, 13.9%-35.0%) and 19.6% for VCTE. The SWE between-system same-day, same-operator reproducibility coefficient was 52.7%. Conclusion SWE met the prespecified threshold, RDCDDDO less than 35%, with VCTE having a higher RDCDDDO. SWE variability was higher between different systems. These estimates advance liver US-based noninvasive test qualification by (a) defining expected variability, (b) establishing that serial examination variability is lower when performed with the same system, and (c) informing clinical trial design. ClinicalTrials.gov Identifier NCT04828551 © RSNA, 2024 Supplemental material is available for this article.

Exploring hepatic fibrosis screening via deep learning analysis of tongue images

Background

Tongue inspection, an essential diagnostic method in Traditional Chinese Medicine (TCM), has the potential for early-stage disease screening. This study aimed to evaluate the effectiveness of deep learning-based analysis of tongue images for hepatic fibrosis screening.

Methods

A total of 1083 tongue images were collected from 741 patients and divided into training, validation, and test sets. DenseNet-201, a convolutional neural network, was employed to train the AI model using these tongue images. The predictive performance of AI was assessed and compared with that of FIB-4, using real-time two-dimensional shear wave elastography as the reference standard.

Results

The proposed AI model achieved an accuracy of 0.845 (95% CI: 0.79-0.90) and 0.814 (95% CI: 0.76-0.87) in the validation and test sets, respectively, with negative predictive values (NPVs) exceeding 90% in both sets. The AI model outperformed FIB-4 in all aspects, and when combined with FIB-4, the NPV reached 94.4%.

Conclusion

Tongue inspection, with the assistance of AI, could serve as a first-line screening method for hepatic fibrosis.

Multi-echo three-dimensional (3D) Dixon sequence combined with disodium gadolinium for risk stratification of advanced fibrosis in metabolic dysfunction-associated steatotic liver disease

Background

The hepatic steatosis and fibrosis related to metabolic dysfunction-associated steatotic liver disease (MASLD) are important factors in the progression. The Multi echo three-dimensional (3D) Dixon sequence can obtain a single breath hold scan for a fat fraction map and an R2* map. The R2* value is usually used to evaluate iron deposition. Whether the change in R2* value is related to liver fibrosis after injection of gadolinium disulfide (Gd) should be noted. This study evaluates the value of enhanced magnetic relaxation time in the risk stratification of liver fibrosis by analyzing the changes in R2* before and after Gd enhancement, and explores the potential application of Multi echo 3D Dixon sequence in one-stop evaluation of MASLD.

Methods

This retrospective study included 138 MASLD patients who underwent Gadolinum ethoxybenzyl diethylenetriaminepentaacetic acid (Gd-EOB-DTPA) magnetic resonance imaging (MRI) examination in The First Affiliated Hospital of Chongqing Medical University from June 2020 to December 2021. Finally, 90 subjects were divided into moderate and high-risk fibrosis group and low-risk fibrosis group by two-step assessment of liver fibrosis. Multi-echo 3D chemical shift imaging sequence (Q-Dixon) sequences and gradient-echo T1WI (Vibe-Dixon) sequence were performed during the non-enhanced phase and hepatobiliary phase, respectively, and then the signal-intensity enhancement (SE) and magnetic relaxation-time enhancement (RE) values were calculated. The interobserver correlation coefficient was used to evaluate the consistency between observers. Univariate t-test was used to analyze the differences in RE and SE of liver fibrosis among different risk levels. Delong analysis was performed on receiver operating characteristic (ROC) curve to evaluate the difference in diagnostic efficacy between RE and SE in differentiating the risk level of liver fibrosis.

Results

Among the 90 patients, 55 (61.1%) belonged to the low-risk group and 35 (38.9%) belonged to the medium-to-high-risk group. The average RE and SE values were 1.23±0.15 and 1.57±0.23 in the low-risk group and 0.99±0.09 and 1.38±0.21 in both the medium-to-high-risk group (P<0.01). The ROC curve showed that the area under the curve (AUC) value of RE was 0.922, with a corresponding optimal threshold of 0.713, sensitivity of 0.852, and specificity of 0.861. The AUC value of SE was 0.724, with a corresponding optimal threshold of 0.352, sensitivity of 0.519, and specificity of 0.833. The AUC difference between RE and SE for the predictive value of different risk assessments was 0.198, and the 95% confidence interval of the difference was 0.084-0.312. The Delong test showed that the difference was significant (P<0.01).

Conclusions

Magnetic RE had high effectiveness for distinguishing between liver-fibrosis risk levels. The combination of the Q-Dixon sequence and Gd-EOB-DTPA has the potential of one-stop evaluation of MASLD.