Prevalence of nonalcoholic fatty liver disease in mainland of China: a meta-analysis of published studies

Ferritin as a key risk factor for nonalcoholic fatty liver disease in children with obesity

Background

The association between serum ferritin and nonalcoholic fatty liver disease (NAFLD) in children with obesity is not clear. This study was designed to investigate whether serum ferritin can be an independent predictor for NAFLD.

Methods

According to the hepatic ultrasound results, a total of 347 children with obesity were enrolled in this study. Among them, 95 patients with NAFLD and 95 without NAFLD were matched for gender, age, blood pressure and body mass index, the odds ratios (OR) and 95% confidence intervals (CI) for the association of ferritin and the risk of NAFLD were analyzed.

Results

After propensity score matching, ferritin values of the patients with NAFLD were significantly higher than those without NAFLD group. Alanine aminotransferase and ferritin were strongly associated with NAFLD in multivariate stepwise logistic regression analysis. The medium and high levels of ferritin increased risk of NAFLD, and the adjusted ORs were 3.298 (95% CI:1.326‐8.204), 7.322 (95% CI:2.725‐19.574) across the ferritin concentration tertiles after adjustment for confounders. Ferritin was shown to be the best predictor for NAFLD with sensitivity and specificity of 60.0% and 77.9%, respectively, area under the curve was 0.733.

Conclusion

The results show that serum ferritin can usefully be considered as a predictor of NAFLD in children with obesity.

Nineteen-year prognosis in Japanese patients with biopsy-proven nonalcoholic fatty liver disease: Lean versus overweight patients

Background

Many studies have investigated the prognosis of nonalcoholic fatty liver disease (NAFLD); however, most studies had a relatively short follow-up. To elucidate the long-term outcome of NAFLD, we conducted a retrospective cohort study of patients with biopsy-proven NAFLD.

Methods

We re-evaluated 6080 patients who underwent liver biopsy from 1975 to 2012 and identified NAFLD patients without other etiologies. With follow-up these patients, we evaluated the outcome-associated factors.

Results

A total of 223 patients were enrolled, 167 (74.9%) was non-alcoholic steatohepatitis (NASH). The median follow-up was 19.5 (0.5–41.0) years and 4248.3 person-years. The risk of type 2 diabetes mellitus (T2DM) and hypertension was 11.7 (95% confidence interval [CI] 8.70–15.6) and 7.99 (95% CI 6.09–10.5) times higher, respectively, in NAFLD patients than in the general population. Twenty-three patients died, 22 of whom had NASH. Major causes of death were extrahepatic malignancy and cardiovascular disease (21.7%) followed by liver-related mortality (13.0%). All-cause mortality was significantly higher in NASH patients than in nonalcoholic fatty liver patients (P = 0.041). In multivariate analysis, older age (hazard ratio [HR] 1.09 [95% CI 1.05–1.14], P<0.001) and T2DM (HR 2.87 [95% CI 1.12–7.04], P = 0.021) were significantly associated with all-cause mortality. The factors significantly associated with liver-related events were older age, T2DM, milder hepatic steatosis, and advanced liver fibrosis. Body mass index wasn’t associated with either mortality or liver-related events.

Conclusions

T2DM was highly prevalent in NAFLD patients and was significantly associated with both all-cause mortality and liver-related events. The lean patients’ prognosis wasn’t necessarily better than that of overweight patients.

Nonalcoholic fatty liver disease impacts the control of the international normalized ratio in patients with atrial fibrillation

Background

It is unclear whether the therapeutic effect of warfarin in patients with atrial fibrillation (AF) and normal liver function differs between those with and without nonalcoholic fatty liver disease (NAFLD). With this in mind, we aimed to evaluate the impact of NAFLD on the international normalized ratio (INR) control in warfarin-treated AF patients with normal liver function.

Methods

We enrolled 600 AF patients aged 28–94 (median 68) with normal liver function who were receiving daily warfarin therapy, 172 with NAFLD and 428 without. The INR and INR/warfarin dosage rate were measured. Four nested multivariable linear regression models adjusted for potential confounders were used to assess whether there were differences in INR and INR/warfarin dose rate between patients with and without NAFLD.

Results

The INR, the percentage of patients with INR within the target range of 2.0–3.0, and the INR/warfarin dose rate were lower in patients with NAFLD than those without. In the maximally adjusted multivariable linear regression models, the INR in NAFLD patients (0.22±0.07, P=0.003) was lower than in non-NAFLD patients, and the INR/warfarin dose rate was slightly lower (0.09±0.06, P=0.10) in NAFLD than in non-NAFLD patients.

Conclusions

Our findings suggest that among AF patients, the therapeutic effect of warfarin is impaired in patients who have NAFLD. Therefore, a slightly higher or personally optimized dosage of warfarin might be necessary among AF patients with NAFLD in order to achieve the INR target range.

Association Between Leukocyte Mitochondrial DNA Copy Number and Non-alcoholic Fatty Liver Disease in a Chinese Population Is Mediated by 8-Oxo-2'-Deoxyguanosine

Background: Alterations in mitochondrial DNA are potentially associated with oxidative stress and may be involved in the pathogenesis of non-alcoholic fatty liver disease (NAFLD). However, the association between mitochondrial DNA copy number (mtDNAcn) and NAFLD was not consistent. In addition, the association between inflammation and NAFLD has not been established yet. The present study, based on a Chinese population of individuals with different glucose statuses, aimed to explore the association between leukocyte mtDNAcn, markers of oxidative stress, and inflammation and NAFLD.

Methods: A total of 318 participants from a diabetes project were included. NAFLD was diagnosed by ultrasonography. Leukocyte mtDNAcn was determined by PCR assay. The levels of the inflammation markers tumor necrosis factor α (TNF-α) and interleukin 6 (IL-6) and the oxidative stress markers glutathione reductase (GR), superoxide dismutase (SOD), and 8-oxo-2′-deoxyguanosine (8-oxo-dG) were also measured.

Results: Participants with NAFLD (n = 105) exhibited significantly higher leukocyte mtDNAcn, IL-6, and 8-oxo-dG (all P < 0.05). Pearson correlation analysis indicated mtDNAcn was negatively associated with age, uric acid, SOD, and TNF-α, but was positively associated with 8-oxo-dG (all P < 0.05). Univariate logistic regression analysis revealed that mtDNAcn was positively associated with NAFLD [odds ratio (OR) = 1.617, 95% confidence interval (CI) = 1.036–2.525; P = 0.034]. However, after adjustment for 8-oxo-dG, this association was no longer statistically significant (OR = 1.534, 95% CI = 0.979–2.403, P = 0.062). Moreover, the stress marker 8-oxo-dG was independently associated with NAFLD after adjustment for mtDNAcn, IL-6, glucose tolerance status, and other conventional NAFLD risk factors (OR = 1.707, 95% CI =1.142–2.550, P = 0.009). Mediation analysis indicated that 8-oxo-dG fully mediated the effect of mtDNAcn on the incidence of NAFLD (direct effect β = 0.5221, 95% CI = −0.0648 to 1.2504; indirect effect β = 0.0946, 95% CI = 0.0049–0.2463).

Conclusions: In a Chinese population, the association between leukocyte mtDNAcn and NAFLD was fully mediated by high levels of 8-oxo-dG. Thus, oxidative stress may be an important driver of NAFLD, and clinical interventions aimed at decreasing oxidative stress to improve NAFLD warrant further research.

Hyperuricemia precedes non-alcoholic fatty liver disease with abdominal obesity moderating this unidirectional relationship: Three longitudinal analyses

BACKGROUND AND AIMS

The temporal relationship between hyperuricemia and non-alcoholic fatty liver disease (NAFLD) is debatable. This study aimed to explore whether there exists a bidirectional or temporal relationship between them.

METHODS

A total of 11,585 participants were recruited from the Beijing Health Management Cohort during the period 2012-2016. We evaluated whether hyperuricemia was associated with NAFLD development (part I) and whether NAFLD was associated with hyperuricemia incidence (part II) using a logistic regression model. Further, the cross-lagged panel analysis model was used to simultaneously examine the bidirectional relationship between hepatic steatosis and serum uric acid (SUA) (part III). Subgroup and interaction analyses were also performed to assess whether other variables moderated those relationships.

RESULTS

In part I, multiple logistic regression indicated that baseline hyperuricemia was associated with the development of NAFLD (OR = 1.5970, p < 0.0001). In part II, multiple logistic regression showed that baseline NAFLD was not correlated with hyperuricemia incidence (OR = 0.8600, p = 0.1976). In part III, cross-lagged panel analyses indicated that the standard regression coefficient of baseline SUA to follow-up hepatic steatosis (0.1516) was significantly greater than the coefficient from the baseline hepatic steatosis to follow-up SUA (-0.0044) with p < 0.0001 for the difference. This indicated a unidirectional relationship from baseline SUA to follow-up hepatic steatosis, suggesting hyperuricemia may precede NAFLD; and this relationship was not affected by age, sex, dyslipidemia, metabolism syndrome, diabetes but was moderated by abdominal obesity.

CONCLUSIONS

This study demonstrated a unidirectional relationship from hyperuricemia to NAFLD incidence, and suggested that lowering SUA levels in hyperuricemia patients may prevent subsequent NAFLD.

Green Tea Consumption May Be Associated with Cardiovascular Disease Risk and Nonalcoholic Fatty Liver Disease in Type 2 Diabetics: A Cross-Sectional Study in Southeast China

Dietary factors play a crucial role in the management of type 2 diabetes mellitus (T2DM) by reducing cardiovascular disease (CVD) risk. Therefore, we aimed to examine the associations between habitual green tea consumption and risk factors of CVD among T2DM patients. A total of 1013 patients with T2DM were included in a community-based cross-sectional study. Data on dietary habits, including tea consumption, were collected using a food frequency questionnaire. A multivariable logistic regression model was used to analyze the associations. In men, as compared with nongreen tea drinkers, odds ratios (ORs) (95% confidence interval [CI]) of nonalcoholic fatty liver disease (NAFLD) were 2.06 (95% CI, 1.20-3.55) for those with green tea consumption of once per day and 2.45 (95% CI, 1.31-4.58) for more than or equal to twice per day (P-trend = .004); ORs (95% CI) of general obesity were 2.19 (95% CI, 1.02-4.68) and 2.70 (95% CI, 1.18-6.21), respectively (P-trend = .021); whereas no such association was found in women. Sensitivity analysis according to self-awareness of their T2DM status revealed that the positive association between green tea consumption and general obesity was not reliable. Higher intake of green tea was still positively associated with NAFLD, but it only persisted in participants aged ≥52 years or the lower dietary quality subgroup in further analyses. Our findings suggest that tea consumption was associated with an increased risk of NAFLD among male T2DM patients aged 52 years or older, and those with lower dietary quality, which needs to be confirmed in future prospective studies.

FTO Polymorphisms are Associated with Metabolic Dysfunction-Associated Fatty Liver Disease (MAFLD) Susceptibility in the Older Chinese Han Population

Background

As fat and obesity play a vital role in the pathophysiology of metabolic dysfunction-associated fatty liver disease (MAFLD), this study aims to investigate the association between the fat mass and obesity-associated gene (FTO) and MAFLD.

Methods

Six SNPs (rs6499640, rs1421085, rs8050136, rs3751812, rs9939609 and rs9930506) within FTO were genotyped for 741 MAFLD patients (median age, 69.98; interquartile range, 66.55–75.93) and 825 healthy people (median age, 69.94; interquartile range, 66.39–75.64). Allele and genotype frequencies, pairwise linkage disequilibrium (LD) and haplotype analysis were calculated.

Results

BMI, waist circumference, systolic blood pressure, diastolic blood pressure, fasting plasma glucose, triglyceride, alanine transaminase, glutamyl transpeptidase and the prevalence of diabetes were found to be higher in the MAFLD individuals comparing to the control ones (P < 0.05). For rs1421085, the C allele frequency was remarkably higher in MAFLD after Bonferroni correction (OR [95% CI] =1.353 [1.095–1.671]; P_corr =0.030), and a significantly different genotype result was observed in log-additive model (OR [95% CI] =1.369 [1.108–1.691]; P_corr =0.024). For rs8050136, significantly increased A allele frequency was observed in MAFLD (OR [95% CI] =1.371 [1.109–1.695]; P_corr =0.024), and A-allele carriers showed increased MAFLD risk (OR [95% CI] =1.393 [1.103–1.759]; P_corr =0.030). For rs3751812, the T allele frequency was remarkably higher in MAFLD (OR [95% CI] =1.369 [1.108–1.691]; P_corr =0.024), and T-allele carriers demonstrated high MAFLD risk (OR [95% CI] =1.392 [1.103–1.756]; P_corr =0.030). For rs9939609, A allele frequency was also remarkably high in MAFLD (OR [95% CI] =1.369 [1.108–1.691]; P_corr =0.024), and A-allele carriers were more susceptible to MAFLD (OR [95% CI] =[1.103–1.756]; P_corr =0.030). A strong LD was found among rs1421085, rs8050136, rs3751812 and rs9939609 (r² >0.8), and individuals with C-A-T-A haplotype had an elevated MAFLD risk (P =0.005).

Conclusion

The case-control study indicated that C variant of rs1421085, A variant of rs8050136, T variant of rs3751812 and A variant of rs9939609 are associated with elevated MAFLD risk in the older Chinese Han population.

Association of Genetic and Environmental Factors with Non-Alcoholic Fatty Liver Disease in a Chinese Han Population

Lifestyle choices such as the intake of sweets, history of diseases, and genetic variants seem to play a role in the pathogenesis of non-alcoholic fatty liver disease (NAFLD). To explore which genetic and environmental factors are associated with NAFLD in a Chinese Han population, we conducted this study. We collected the medical reports, lifestyle details, and blood samples of individuals and used the polymerase chain reaction-ligase detection reaction method to genotype the single-nucleotide polymorphism (SNPs) from the 2113 eligible people. The GG genotype of the additive model of rs7493 in the PON2, the CC genotype of the additive and recessive models of rs7593130 in the ADCY3, together with dyslipidemia, regular intake of egg and sweets and hypertension, increased the risk of NAFLD (adjusted OR > 1, p < 0.05). The TT genotype of the additive and dominant models of rs11583680 in the PCSK9, together with the regular intake of vegetable, reduced the risk of NAFLD (adjusted OR < 1, p < 0.05). In addition, interactions between some variables were found. Eventually, we identified three SNPs and six environmental factors associated with NAFLD. These results provide the theoretical basis for gene and other risk factors screening to prevent NAFLD.

Downregulation of GNAI3 Promotes the Pathogenesis of Methionine/Choline-Deficient Diet-Induced Nonalcoholic Fatty Liver Disease

Background/Aims

The pathogenesis of nonalcoholic fatty liver disease (NAFLD) has not be fully elucidated, and the lack of therapeutic strategies for NAFLD is an urgent health problem. Guanine nucleotide binding protein, alpha inhibiting activity polypeptide 3 (GNAI3) participates in several biological processes, but its relationship with lipid metabolism and NAFLD has not yet been reported. We aimed to determine the function of GNAI3 in the development of NAFLD.

Methods

Mice were fed a methionine and choline-deficient diet to induce NAFLD. An NAFLD model in HepG2 cells was induced by free fatty acid treatment. GNAI3 levels in HepG2 cells were downregulated by shRNA. Protein levels of related proteins were evaluated by Western blotting, and mRNA levels were determined by quantitative reverse transcription polymerase chain reaction. Hematoxylin and eosin and Oil Red O staining were used to observe histological changes in liver tissue.

Results

The dysregulated hepatic lipid metabolism in the NAFLD mouse model was enhanced by GNAI3 knockout, which also provoked worse liver damage. In the NAFLD model in HepG2 cells, the downregulation of GNAI3 promoted cellular lipid accumulation and enhanced the changes in lipid metabolic enzyme levels.

Conclusions

This study demonstrates that GNAI3 participates in the development of NAFLD in both cellular and mouse models. The data indicate that GNAI3 is a potential new target for the treatment of NAFLD in humans.

Risk Prediction for Non-alcoholic Fatty Liver Disease Based on Biochemical and Dietary Variables in a Chinese Han Population

Nonalcoholic fatty liver disease (NAFLD) is a common liver disease globally, but there are no optimal methods for its prediction or diagnosis. The present cross-sectional study proposes a non-invasive tool for NAFLD screening. The study included 2,446 individuals, of whom 574 were NAFLD patients. Multivariable logistic regression analysis was used to identify risk factors for NAFLD and incorporate them in a risk prediction nomogram model; the variables included both clinical and lifestyle-related variables. Following stepwise regression, BMI, waist circumference, serum triglyceride, high-density lipoprotein cholesterol, alanine aminotransferase, presence of diabetes and hyperuricemia, tuber and fried food consumption were identified as significant risk factors and used in the model. The final nomogram was found to have good discrimination ability (area under the receiver operating characteristic curve = 0.843 [95% CI: 0.819-0.867]), and reasonable accuracy for the prediction of NAFLD risk. A cut-off score of <180 for the nomogram was found to have high sensitivity and predictivity for the exclusion of individuals from screening. The model can be used as a non-invasive tool for mass screening.

Sexual Dimorphism of NAFLD in Adults. Focus on Clinical Aspects and Implications for Practice and Translational Research

Nonalcoholic fatty liver disease (NAFLD) embraces the clinico-pathological consequences of hepatic lipotoxicity and is a major public health problem globally. Sexual dimorphism is a definite feature of most human diseases but, under this aspect, NAFLD lags behind other medical fields. Here, we aim at summarizing and critically discussing the most prominent sex differences and gaps in NAFLD in humans, with emphasis on those aspects which are relevant for clinical practice and translational research. Sexual dimorphism of NAFLD is covered with references to the following areas: disease prevalence and risk factors, pathophysiology, comorbidities, natural course and complications. Finally, we also discuss selected gender differences and whether sex-specific lifestyle changes should be adopted to contrast NAFLD in men and women.

Selenium-enriched Bifidobacterium longum protected alcohol and high fat diet induced hepatic injury in mice

The objective of this study was to verify the protective effect of Bifidobacterium longum (BL) and the synergistical effect of Selenium and BL on alcohol plus high fat diet (HFD) induced hepatic injury in mice. We also want to explore the mechanism of Selenium-enriched Bifidobacterium longum (SeBL). C57BL/6 mice were treated with alcohol plus HFD with or without different dosage of BL or SeBL for 4 weeks. Serum levels of ALT, AST, TC, TG, LDL-C, HDL-C, FFAs, TNF-α, IL-6 and IL-1β, hepatic MDA level, SOD activity, the mRNA levels of AMPK, PPAR-α and SREBP1 were invested. SeBL inhibited lipid accumulation in hepatocytes; reduced serum AST and ALT levels; improved dyslipidemia; decreased serum FFAs, TC, TG and LDL-C levels. SeBL also inhibited alcohol plus HFD-induced hepatocyte oxidative stress through decrease in hepatic MDA levels and increase in SOD activity. SeBL also regulated lipid metabolism related genes such as AMPK, PPAR-α and SREBP1. Although BL had similar effect as SeBL, SeBL is more effective than BL. SeBL protected mice from alcohol plus HFD-induced hepatic injury in mice because of its inhibitory effect on hepatocellular oxidative stress, lipogenesis and inflammation. Selenium enhanced the protective effect of BL.

Non-alcoholic Fatty Liver Disease: Growing Burden, Adverse Outcomes and Associations

Nonalcoholic fatty liver disease (NAFLD) is a systemic disorder with a complex multifactorial pathogenesis and heterogenous clinical manifestations. NAFLD, once believed to be an innocuous condition, has now become the most common cause of chronic liver disease in many countries worldwide. NAFLD is already highly prevalent in the general population, and owing to a rising incidence of obesity and diabetes mellitus, the incidence of NAFLD and its impact on global healthcare are expected to increase in the future. A subset of patients with NAFLD develops progressive liver disease leading to cirrhosis, hepatocellular carcinoma, and liver failure. NAFLD has emerged as one of the leading causes of cirrhosis and hepatocellular carcinoma in recent years. Moreover, HCC can occur in NAFLD even in absence of cirrhosis. Compared with the general population, NAFLD increases the risk of liver-related, cardiovascular and all-cause mortality. NAFLD is bidirectionally associated with metabolic syndrome. NAFLD increases the risk and contributes to aggravation of the pathophysiology of atherosclerosis, cardiovascular diseases, diabetes mellitus, and chronic kidney disease. In addition, NAFLD is linked to colorectal polyps, polycystic ovarian syndrome, osteoporosis, obstructive sleep apnea, stroke, and various extrahepatic malignancies. Extended resection of steatotic liver is associated with increased risk of liver failure and mortality. There is an increasing trend of NAFLD-related cirrhosis requiring liver transplantation, and the recurrence of NAFLD in such patients is almost universal. This review discusses the growing burden of NAFLD, its outcomes, and adverse associations with various diseases.

Changing trajectories of serum uric acid and risk of non-alcoholic fatty liver disease: a prospective cohort study

BACKGROUND

It is unclear the role of longitudinal trajectory of serum uric acid (SUA) on the development of non-alcoholic fatty liver disease (NAFLD). We aimed to determine whether longitudinal SUA trajectories are associated with the risk of new-onset NAFLD.

METHODS

We explored the relationship between SUA trajectories and NAFLD in a cohort including 3822 participants. Individual's SUA trajectories from 2012 to 2014 were defined using group-based trajectory modeling analysis in four distinct patterns: trajectory 1 (n = 991, 25.93%), trajectory 2 (n = 1421, 37.18%), trajectory 3 (n = 1156, 30.22%), and trajectory 4 (n = 254, 6.67%). The logistic regression model was used to evaluate the association between SUA changing trajectories and subsequent NAFLD until 2016. Dose-response relationship between SUA changing trajectories and NAFLD risk was evaluated through the testing of trajectory groups as a continuous variable.

RESULTS

The 2-year incidence of NAFLD was 13.27%. Compared with trajectory 1, the adjusted odds risk for NAFLD development was in a dose-response relationship as follows: 1.27 (95% CI 0.91-1.78) for trajectory 2, 1.89 (95% CI 1.29-2.75) for trajectory 3, and 2.34 (95% CI 1.43-3.83) for trajectory 4. And this dose-response relationship was not affected by age, sex, and abdominal obesity.

CONCLUSIONS

Higher SUA changing trajectory is a risk factor for NAFLD. This finding highlights the importance of paying attention to SUA changing trajectory on the detection and prevention of NAFLD.

Physical activity intervention for non-diabetic patients with non-alcoholic fatty liver disease: a meta-analysis of randomized controlled trials

Background

Non-alcoholic fatty liver disease (NAFLD) is currently the most common cause of chronic liver disease nowadays. Changes in diet and lifestyle have led to a dramatic increase in the prevalence of NAFLD around the world. This meta-analysis is to investigate the efficacy of physical activity intervention on liver-specific endpoints in the population with NAFLD, including hepatic enzyme, serum lipid, glucose metabolism and intra-hepatic lipid.

Methods

PubMed and China National Knowledge Infrastructure (CNKI) databases were searched for randomized clinical trials of physical activity intervention on NAFLD patients through April 20th, 2019. Effect sizes were reported as standardized mean difference (SMD) and 95% confidence intervals (CI). Quality of included studies was assessed according to the Cochrane risk of bias tool. Meta-analyses were conducted using random-effect or fixed-effect models depending on the significance of heterogeneity. Subgroup analyses according to types and duration of physical activity were conducted to investigate clinical variability.

Results

Nine studies with a cumulative total of 951 participants met selection criteria. Physical activity was found associated with small reductions in hepatic enzyme parameters: ALT (SMD -0.17, 95% CI:-0.30 to − 0.05), AST (SMD -0.25, 95% CI: − 0.38, − 0.13) and GGT (SMD -0.22, 95% CI: − 0.36, − 0.08). Significant small improvements were also found in serum lipid parameters including TC (SMD = − 0.22, 95% CI: − 0.34, − 0.09), TG (SMD = − 0.18, 95% CI: − 0.31 to − 0.06) and LDL-C (SMD = − 0.26, 95% CI: − 0.39 to − 0.13). Significant improvement was also found in intra-hepatic lipid content (SMD = − 0.21, 95% CI: − 0.36 to − 0.06) There was no difference between physical intervention group and control group in HDL and three glucose metabolism parameters. Subgroup analysis suggested both aerobic exercise alone and resistance exercise alone can improve most liver function and longer period of exercise generally had better improvement effect.

Conclusions

Our findings suggest that physical activity alone can only slightly improve hepatic enzyme levels, most serum lipid levels and intra-hepatic lipid content in non-diabetic patients with NAFLD.

Prevalence and Risk Factors of Metabolic Associated Fatty Liver Disease in Xinxiang, China

Metabolic associated fatty liver disease (MAFLD) is recognized as the liver disease component of metabolic syndrome, which is mainly related to insulin resistance and genetic susceptibility. It is the most prevalent chronic liver disease worldwide. With rapid lifestyle transitions, its prevalence worldwide is increasing, and tremendous challenges in controlling this pandemic are arising. The objective of this study was to investigate the prevalence and risk factors of MAFLD in rural areas of Xinxiang, Henan in 2017. We conducted a cross-sectional analysis of rural inhabitants aged 20–79 years in Xinxiang, Henan in 2017, using cluster random sampling (N = 9140). Physical examinations were conducted at local clinics from April to June 2017. After overnight fasting, all participants underwent physical examinations, blood routine tests, biochemical examinations, and liver ultrasound and completed questionnaires. We investigated the crude and age-adjusted MAFLD prevalence and analyzed the characteristics of those with, and without, MAFLD, using logistic regression. Approximately 2868 (31.38%) participants were diagnosed with MAFLD. The overall age-adjusted MAFLD prevalence was 29.85% (men: 35.36%; women: 26.49%). The MAFLD prevalence increased with age, and peaked at the 50–59-year age group, and then began to decline. Higher body mass index, waist circumference, percentage of lymphocytes, levels of hemoglobin, platelet count, triglyceride, fasting plasma glucose, and serum uric acid were independently and positively correlated with MAFLD; In contrary, active physical activity and high-density lipoprotein cholesterol were negatively correlated with MAFLD. In summary, the MAFLD prevalence in the study population was 29.85%. Higher body mass index, waist circumference, percentage of lymphocytes, levels of hemoglobin, platelet count, triglyceride, fasting plasma glucose, and serum uric acid were risk factors for MAFLD.

Liver diseases in the Asia-Pacific region: a Lancet Gastroenterology & Hepatology Commission

The Asia-Pacific region is home to more than half of the global population and accounted for 62·6% of global deaths due to liver diseases in 2015. 54·3% of global deaths due to cirrhosis, 72·7% of global deaths due to hepatocellular carcinoma, and more than two-thirds of the global burden of acute viral hepatitis occurred in this region in 2015. Chronic hepatitis B virus (HBV) infection caused more than half of the deaths due to cirrhosis in the region, followed by alcohol consumption (20·8%), non-alcoholic fatty liver disease (NAFLD; 12·1%), and chronic infection with hepatitis C virus (HCV; 15·7%). In 2015, HBV accounted for about half the cases of hepatocellular carcinoma in the region. Preventive strategies for viral hepatitis-related liver disease include increasing access to clean drinking water and sanitation. HBV vaccination programmes for neonates have been implemented by all countries, although birth-dose coverage is extremely suboptimal in some. Availability of screening tests for blood and tissue, donor recall policies, and harm reduction strategies are in their initial stages in most countries. Many governments have put HBV and HCV drugs on their essential medicines lists and the availability of generic versions of these drugs has reduced costs. Efforts to eliminate viral hepatitis as a public health threat, together with the rapid increase in per-capita alcohol consumption in countries and the epidemic of obesity, are expected to change the spectrum of liver diseases in the Asia-Pacific region in the near future. The increasing burden of alcohol-related liver diseases can be contained through government policies to limit consumption and promote less harmful patterns of alcohol use, which are in place in some countries but need to be enforced more strictly. Steps are needed to control obesity and NAFLD, including policies to promote healthy lifestyles and regulate the food industry. Inadequate infrastructure and insufficient health-care personnel trained in liver diseases are issues that also need to be addressed in the Asia-Pacific region. The policy response of most governments to liver diseases has thus far been inadequate and poorly funded. There must be a renewed focus on prevention, early detection, timely referral, and research into the best means to introduce and improve health interventions to reduce the burden of liver diseases in the Asia-Pacific region.

Epidemiology of non-alcoholic fatty liver disease in Asia

The growing burden of non-alcoholic fatty liver disease (NAFLD) parallels the increasing prevalence of obesity in Asia. The overall prevalence of NAFLD in Asia is now estimated to be 29.6% and may have surpassed that in Western populations. NAFLD increases with increasing age and is closely associated with metabolic syndrome. Ethnic differences exist in the prevalence of NAFLD, but the underlying factors are unclear. There were initial concerns about lean NAFLD being associated with more severe liver disease and increased mortality, but subsequent studies suggested otherwise. Only some NAFLD patients progress to develop advanced liver fibrosis and cirrhosis, while the liver status remains unchanged in the majority; fibrosis stage is the most important predictor of disease-specific mortality in NAFLD. Surveillance for hepatocellular carcinoma (HCC) remains a challenge due to undiagnosed cirrhosis and the development of HCC in non-cirrhotic NAFLD patients. Diabetes mellitus shares a bidirectional relationship with NAFLD; NAFLD is highly prevalent among patients with diabetes mellitus, and diabetes mellitus is associated with more severe NAFLD. Chronic hepatitis B (CHB) is a major cause of chronic liver disease in Asia; NAFLD and CHB are increasingly observed together because of the increasing prevalence of NAFLD. Despite studies reporting favorable virologic outcome in CHB patients with NAFLD, NAFLD has been found to be independently associated with fibrosis progression and poorer prognosis in CHB patients. Therefore, NAFLD in CHB patients should be given more attention.

Atorvastatin promotes AMPK signaling to protect against high fat diet-induced non-alcoholic fatty liver in golden hamsters

Non-alcoholic fatty liver disease (NAFLD) is characterized by diffuse fatty acid degeneration and excess fat accumulation in the liver. Notably, the currently available medications used to treat NAFLD remain limited. The aim of the present study was to investigate the protective role of atorvastatin (Ato) against NAFLD in golden hamsters fed a high fat diet (HFD) and in HepG2 cells treated with palmitate, and identify the underlying molecular mechanism. Ato (3 mg/kg) was administered orally every day for 8 weeks to the hamsters during HFD administration. Hamsters in the model group developed hepatic steatosis with high serum levels of triglyceride, cholesterol, insulin and C-reactive protein, which were effectively reduced by treatment with Ato. Additionally, the relative liver weight of hamsters treated with Ato was markedly lower compared with that of the model group. Hematoxylin and eosin, and oil red O staining indicated that the livers of the animals in the model group exhibited large and numerous lipid droplets, which were markedly decreased after Ato treatment. Western blot analysis indicated that Ato inhibited fat accumulation in the liver through the AMP-activated protein kinase (AMPK)-dependent activation of peroxisome proliferator activated receptor α (PPARα), peroxisome proliferator-activated receptor-γ coactivator 1 α and their target genes. Furthermore, in vitro, Ato inhibited PA-induced lipid accumulation in HepG2 cells. This inhibitory effect was attenuated following Compound C treatment, indicating that AMPK may be a potential target of Ato. In conclusion, the increase in AMPK-mediated PPARα and its target genes may represent a novel molecular mechanism by which Ato prevents NAFLD.

Nonalcoholic Fatty Liver Disease in Adults: Current Concepts in Etiology, Outcomes, and Management

Nonalcoholic fatty liver disease (NAFLD) is a spectrum of disease, extending from simple steatosis to inflammation and fibrosis with a significant risk for the development of cirrhosis. It is highly prevalent and is associated with significant adverse outcomes both through liver-specific morbidity and mortality but, perhaps more important, through adverse cardiovascular and metabolic outcomes. It is closely associated with type 2 diabetes and obesity, and both of these conditions drive progressive disease toward the more advanced stages. The mechanisms that govern hepatic lipid accumulation and the predisposition to inflammation and fibrosis are still not fully understood but reflect a complex interplay between metabolic target tissues including adipose and skeletal muscle, and immune and inflammatory cells. The ability to make an accurate assessment of disease stage (that relates to clinical outcome) can also be challenging. While liver biopsy is still regarded as the gold-standard investigative tool, there is an extensive literature on the search for novel noninvasive biomarkers and imaging modalities that aim to accurately reflect the stage of underlying disease. Finally, although no therapies are currently licensed for the treatment of NAFLD, there are interventions that appear to have proven efficacy in randomized controlled trials as well as an extensive emerging therapeutic landscape of new agents that target many of the fundamental pathophysiological processes that drive NAFLD. It is highly likely that over the next few years, new treatments with a specific license for the treatment of NAFLD will become available.

High Protein Diet and Metabolic Plasticity in Non-Alcoholic Fatty Liver Disease: Myths and Truths

Non-alcoholic fatty liver disease (NAFLD) is characterized by lipid accumulation within the liver affecting 1 in 4 people worldwide. As the new silent killer of the twenty-first century, NAFLD impacts on both the request and the availability of new liver donors. The liver is the first line of defense against endogenous and exogenous metabolites and toxins. It also retains the ability to switch between different metabolic pathways according to food type and availability. This ability becomes a disadvantage in obesogenic societies where most people choose a diet based on fats and carbohydrates while ignoring vitamins and fiber. The chronic exposure to fats and carbohydrates induces dramatic changes in the liver zonation and triggers the development of insulin resistance. Common believes on NAFLD and different diets are based either on epidemiological studies, or meta-analysis, which are not controlled evidences; in most of the cases, they are biased on test-subject type and their lifestyles. The highest success in reverting NAFLD can be attributed to diets based on high protein instead of carbohydrates. In this review, we discuss the impact of NAFLD on body metabolic plasticity. We also present a detailed analysis of the most recent studies that evaluate high-protein diets in NAFLD with a special focus on the liver and the skeletal muscle protein metabolisms.

Fat Accumulation, Liver Fibrosis, and Metabolic Abnormalities in Chinese Patients With Moderate/Severe Versus Mild Hepatic Steatosis

Several drugs in development for nonalcoholic fatty liver disease (NAFLD) aim to decrease the amount of fat in the liver. We compared quantity and quality of fat in subcutaneous, visceral and muscle compartments, liver fibrosis, and prevalence of metabolic abnormalities between Chinese patients with moderate/severe hepatic steatosis versus those with mild hepatic steatosis. NAFLD patients were prospectively recruited from Peking University People's Hospital in Beijing, China. All patients had baseline body composition measurements using computed tomography and analytic morphomics, clinical evaluation, labs and Fibroscan® controlled attenuation parameter and liver stiffness measurement. Moderate/severe hepatic steatosis was defined as computed tomography liver attenuation of 40 Hounsfield units or less. Calorie intake and physical activity were based on self-report. A total of 160 NAFLD patients were included (46% men, median age 47 years): 50% had normal body mass index (BMI), 24% were diabetic, and 56% had metabolic syndrome (MS). Fifty-three (33%) had moderate/severe steatosis, of whom 19 (35.8%) had normal BMI, and the rest had mild steatosis. Patients who had moderate/severe steatosis had significantly higher BMI, waist circumference, aminotransferases, controlled attenuation parameter, liver stiffness measurement, and prevalence of MS compared to those with mild steatosis. They also had larger visceral fat area, subcutaneous fat area, and low density dorsal muscle area. In addition, their calorie intake was higher and time spent on recreation activities was shorter. Conclusion: NAFLD patients with moderate/severe steatosis, including those with normal BMI, had higher prevalence of MS and more fat in visceral, subcutaneous, and muscle compartments than those with mild steatosis. They also had more advanced liver disease. Strategies to decrease hepatic fat may benefit both liver and metabolic diseases.

Trends in the prevalence of chronic liver disease in the Korean adult population, 1998-2017

Data on the trends in the prevalence of chronic liver disease (CLD) in Korea are scarce. This study aimed to evaluate whether the CLD prevalence changed between 1998-2001 and 2016-2017. Data were extracted from the Korea National Health and Nutrition Examination Survey (1998-2001 to 2016-2017; n=25,893). Non-alcoholic fatty liver disease (NAFLD) was defined as a hepatic steatosis index >36 in the absence of any other evidence of CLD. The definition of alcoholrelated liver disease (ALD) was excessive alcohol consumption (≥210 g/week for men and ≥140 g/week for women) and an ALD/NAFLD index >0. The prevalence of NAFLD increased from 18.6% (95% confidence interval [CI], 17.8-19.5%) in 1998-2001 to 21.5% (95% CI, 20.6-22.6%) in 2016-2017. During the same time period, increases were observed in the prevalence of obesity (27.0 vs. 35.1%), central obesity (29.4 vs. 36.0%), diabetes (7.5 vs. 10.6%), and excessive drinking (7.3 vs. 10.5%). ALD prevalence also increased from 3.8% (95% CI, 3.4-4.2%) to 7.0% (95% CI, 6.4-7.6%). In contrast, chronic hepatitis B decreased from 5.1% (95% CI, 4.6-5.5%) to 3.4% (95% CI, 3.0-3.8%). The prevalence of chronic hepatitis C was approximately 0.3% in 2016-2017. The prevalence of NAFLD and ALD increase among Korean adults. Our results suggest potential targets for interventions to reduce the future burden of CLD.

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.

Whether a Short or Long Alimentary Limb Influences Weight Loss in Gastric Bypass: a Systematic Review and Meta-Analysis

Roux-en-Y gastric bypass, the most commonly performed procedure in bariatric surgery, still lacks a consensus on whether alimentary limb length (ALL) influences weight loss. Studies were identified by searching multiple electronic databases. Studies with enough data including body mass index (BMI) loss and percent excess weight loss (% EWL) were eligible. The statistical analysis was performed with Stata 14.0. In total, eight studies with 1714 patients were included. The meta-analysis suggested that short ALLs weakened the efficacy of Roux-en-Y gastric bypass in terms of BMI loss (standard mean deviation (SMD), - 0.33 [95% confidence intervals (CI), - 0.60, - 0.05], p = 0.021) with 3 years of follow-up and % EWL (SMD, - 0.17 [95% CI, - 0.31, - 0.04], p = 0.013) with 2 years of follow-up. The subgroup analysis demonstrated that the group with a BMI ≥ 50 kg/m² had a significant SMD between the use of short and the standard ALLs (- 0.71 [95% CI, - 1.07, - 0.35], p = 0.000), while the subgroup with a BMI < 50 kg/m² (SMD, - 0.29 [95% CI, - 0.78, 0.20], p = 0.247) did not. Compared with a standard ALL (130-150 cm), a short ALL (40-100 cm) may reduce the efficacy of the Roux-en-Y gastric bypass surgery, while a long ALL (170-250 cm) did not significantly improve the effects in terms of BMI loss and % EWL. In addition, a potential view of the meta-analysis indicated patients with a BMI < 50 kg/m² might get more benefits with a short ALL, while those patients with a BMI ≥ 50 kg/m² might benefit more from a standard ALL.

Unexpected Rapid Increase in the Burden of NAFLD in China From 2008 to 2018: A Systematic Review and Meta-Analysis

With rapid lifestyle transitions, the increasing burden of nonalcoholic fatty liver disease (NAFLD) in China has emerged as a major public health issue. To obtain a comprehensive overview of the status of NAFLD over the past decade, we evaluated the epidemiology, risk factors, complications, and management of NAFLD in China through a systematic review and meta-analysis. Five English literature databases and three Chinese databases were searched for relevant topics from 2008 to 2018. A total of 392 studies with a population of 2,054,554 were included. National prevalence of NAFLD was 29.2%, with a heavier disease burden among the middle-aged, males, those in northwest China and Taiwan, regions with a gross domestic product per capita greater than 100,000 yuan, and Uygur and Hui ethnic groups. Currently, original studies on natural history and complications of NAFLD in China are scarce. Several studies revealed that NAFLD is positively correlated with the incidence of extrahepatic tumors, diabetes, cardiovascular disease and metabolic syndrome. The Chinese population may have a higher hereditary risk of NAFLD due to more frequent nonsynonymous mutations in genes regulating lipid metabolism. Ultrasonography is the primary imaging tool in the detection of NAFLD in China. Serum tests and risk stratification algorithms for staging NAFLD remain under investigation. Specific pharmaceutical treatments for NAFLD are still undergoing clinical trials. It is noteworthy that the Chinese are underrepresented compared with their proportion of the NAFLD population in such trials. Conclusion: China experienced an unexpected rapid increase in the burden of NAFLD over a short period. Rising awareness and urgent actions need to be taken in order to control the NAFLD pandemic in China.

Sex Differences in Nonalcoholic Fatty Liver Disease: State of the Art and Identification of Research Gaps

Despite tremendous research advancements in nonalcoholic fatty liver disease (NAFLD), our understanding of sex differences in NAFLD remains insufficient. This review summarizes the current knowledge on sex differences in NAFLD, identifies gaps, and discusses important considerations for future research. The prevalence and severity of NAFLD are higher in men than in women during the reproductive age. However, after menopause, NAFLD occurs at a higher rate in women, suggesting that estrogen is protective. Sex differences also exist for the major risk factors of NAFLD. In general, animal models of NAFLD recapitulate the sex differences observed in patients, with more severe steatosis and steatohepatitis, more proinflammatory/profibrotic cytokines, and a higher incidence of hepatic tumors in male than female subjects. Based on computer modeling, female and male livers are metabolically distinct with unique regulators modulating sex-specific metabolic outcomes. Analysis of the literature reveals that most published clinical and epidemiological studies fail to examine sex differences appropriately. Considering the paucity of data on sex differences and the knowledge that regulators of pathways relevant to current therapeutic targets for NAFLD differ by sex, clinical trials should be designed to test drug efficacy and safety according to sex, age, reproductive stage (i.e., menopause), and synthetic hormone use. Conclusion: Sex differences do exist in the prevalence, risk factors, fibrosis, and clinical outcomes of NAFLD, suggesting that, while not yet incorporated, sex will probably be considered in future practice guidelines; adequate consideration of sex differences, sex hormones/menopausal status, age, and other reproductive information in clinical investigation and gene association studies of NAFLD are needed to fill current gaps and implement precision medicine for patients with NAFLD.

Association between dietary iron intake and the prevalence of nonalcoholic fatty liver disease: A cross-sectional study

The aim was to test the association between dietary iron intake and the prevalence of nonalcoholic fatty liver disease (NAFLD) in a large sample of middle-aged and elderly Chinese population.The data included in this analysis were collected from a population-based cross-sectional study, that is, the Xiangya Hospital Health Management Center Study. Dietary iron intake was assessed using a validated semiquantitative food frequency questionnaire. The relationship between dietary iron intake and the prevalence of NAFLD was examined using logistic and spline regressions.A cross-sectional study including 5445 subjects was conducted. The prevalence of NAFLD was 36.9%. Compared with the lowest quintile, the energy-adjusted odds ratios (ORs) of NAFLD were 1.33 (95% confidence interval [CI]: 1.07-1.64), 1.80 (95% CI: 1.41-2.29) and 2.11 (95% CI: 1.60-2.80) in the 3rd, 4th, and 5th quintile of iron intake, respectively (P-value for trend <.001). In addition, dietary iron intake was positively associated with the OR of NAFLD in a dose-response relationship manner (test for trend P < .001). However, after stratifying the data by gender, such association only remained in the male, but not in the female population. With adjustment of additional potential confounders, the results did not change materially.Subjects with higher dietary iron intake were subject to a higher prevalence of NAFLD in a dose-response relationship manner. However, such association probably only exists in males, but not in females.

[Correlation between serum 25(OH) vitamin D and liver fat content in nonalcoholic fatty liver disease]

OBJECTIVE

To investigate the relationship between serum 25(OH) vitamin D and liver fat content in nonalcoholic fatty liver disease (NAFLD).

METHODS

A total of 120 patients with NAFLD admitted in our hospital between June and August, 2017 were enrolled and divided into 4 groups with different serum 25 (OH) vitamin D levels: >75 nmol/L (group A, n=25), 50-75 nmol/L (group B, n=35), 25-50 nmol/L (group C, n=32), and < 25 nmol/L (group D, n=28). For all the patients, serum 25 (OH) vitamin D level was measured by ELISA, and liver fat content was determined using in-phase opposed-phase T1WI sequences. The measurement data were compared among the 4 groups to assess the association between serum 25(OH) vitamin D level and liver fat content.

RESULTS

The liver fat content appeared to be higher in group B (28.66±6.45%) and group C (38.74±11.47%) than in group A (22.79 ± 6.10%), but the difference was not statistically significant (P>0.05); the liver fat content in group D (54.79 ± 5.28%) was significantly higher than that in the other 3 groups (P>0.05). Liver fat content increased significantly as serum 25(OH) vitamin D level decreased, showing an inverse correlation between them in these patients (P < 0.05, r=-0.125).

CONCLUSIONS

In patients with NAFLD, a decreased serum 25(OH) vitamin D level is associated with an increased liver fat content, suggesting the value of serum 25(OH) vitamin D as a predictor of NAFLD.

Effects of probiotics on nonalcoholic fatty liver disease: a systematic review and meta-analysis

BACKGROUND

Nonalcoholic fatty liver disease (NAFLD) has become prevalent in recent decades, especially in developed countries, and approaches for the prevention and treatment of NAFLD are not clear. The aim of this research was to analyze and summarize randomized controlled trials that investigated the effects of probiotics on NAFLD.

METHODS

Seven databases (PubMed, Embase, the Web of Science, the Cochrane Library, China National Knowledge Infrastructure, Wan Fang Data, and VIP Database) were searched. Then, eligible studies were identified. Finally, proper data extraction, synthesis and analysis were performed by trained researchers.

RESULTS

Anthropometric parameters: with use of probiotics weight was reduced by 2.31 kg, and body mass index (BMI) was reduced by 1.08 kg/m². Liver function: probiotic treatment reduced the alanine aminotransferase level by 7.22 U/l, the aspartate aminotransferase level by 7.22 U/l, the alkaline phosphatase level by 25.87 U/l, and the glutamyl transpeptidase level by -5.76 U/l. Lipid profiles: total cholesterol, low-density lipoprotein cholesterol, and triglycerides were significantly decreased after probiotic treatment. Their overall effects (shown as standard mean difference) were -0.73, -0.54, and -0.36, respectively. Plasma glucose: probiotics reduced the plasma glucose level by 4.45 mg/dl and the insulin level by 0.63. Cytokines: probiotic treatment decreased tumor necrosis factor alpha by 0.62 and leptin by 1.14. Degree of liver fat infiltration (DFI): the related risk of probiotics for restoring DFI was 2.47 (95% confidence interval, 1.61-3.81, p < 0.001).

CONCLUSION

Probiotic treatment or supplementation is a promising therapeutic method for NAFLD.

Relationship between Muscle Mass/Strength and Hepatic Fat Content in Post-Menopausal Women

Background and Objectives: Recent studies have shown that low skeletal muscle mass can contribute to non-alcoholic fatty liver disease through insulin resistance. However, the association between muscle mass/strength and hepatic fat content remains unclear in postmenopausal women. Methods: In this study, we assessed the associations between muscle mass/strength and various severities of non-alcoholic fatty liver disease. Using single-voxel proton magnetic resonance spectroscopy, 96 postmenopausal women between the ages of 50 and 65 were divided into four groups (G0–G3) by hepatic fat content: G0 (hepatic fat content <5%, n = 20), G1 (5% ≤ hepatic fat content < 10%, n = 27), G2 (10% ≤ hepatic fat content < 25%, n = 31), and G3 (hepatic fat content ≥25%, n = 18). Muscle mass indexes were estimated as skeletal muscle index (SMI)% (total lean mass/weight × 100) and appendicular skeletal muscular mass index (ASM)% (appendicular lean mass/weight × 100) by dual energy X-ray absorptiometry. Maximal isometric voluntary contraction of the handgrip, elbow flexors, and knee extensors was measured using an adjustable dynamometer chair. Fasting plasma glucose, insulin, and follicle-stimulating hormones were assessed in venous blood samples. Results: The results showed negative correlations between hepatic fat content and SMI% (r = −0.42, p < 0.001), ASM% (r = −0.29, p = 0.005), maximal voluntary force of grip (r = −0.22, p = 0.037), and knee extensors (r = −0.22, p = 0.032). Conclusions: These significant correlations almost remained unchanged even after controlling for insulin resistance. In conclusion, negative correlations exist between muscle mass/strength and the progressed severity of non-alcoholic fatty liver disease among post-menopausal women, and the correlations are independent of insulin resistance.

Screening for non-alcoholic fatty liver disease in community setting: A cohort study using controlled attenuation parameter-transient elastography

Background/Aim

The global problems of chronic liver disease and non‐alcoholic fatty liver disease (NAFLD) are increasing. We examined the prevalence of NAFLD and significant liver stiffness in an asymptomatic population and identified the predictors of significant fibrosis in NAFLD.

Method

We prospectively enrolled Thai subjects, aged 18–80 years, from four regions (Bangkok, Central, North, South) of Thailand from March 2013 to November 2016. All participants underwent controlled attenuation parameter (CAP) measurement for liver fat quantification and transient elastography (TE) for liver stiffness measurement (LSM). NAFLD was defined as liver fat ≥10% (CAP ≥ 306 dB/m). Of 1145 participants, 782 (68.3%) were eligible for analysis.

Result

The mean age ± standard deviation (SD) was 53.1 ± 4.6 years, and 71.6% were female. The mean ± SD values of CAP and LSM of the overall cohort were 241.9 ± 61.4 dB/m and 5.5 ± 3.8 kPa, respectively. The prevalence of NAFLD was 18.0%, whereas 5.4% of the cohort had nonobese NAFLD (BMI < 25 kg/m²), and 2.8% had lean NAFLD (BMI < 23 kg/m²). The prevalence of significant liver fibrosis (≥F2) in NAFLD subjects was 18.4%. On multivariate analysis, the degree of significant fibrosis in NAFLD was significantly associated with male gender and a history of dyslipidemia.

Conclusion

NAFLD with significant fibrosis (≥F2) is prevalent in asymptomatic populations. The predictors of significant fibrosis in NAFLD were male gender and dyslipidemia. Screening for NAFLD using CAP/TE in asymptomatic populations should be considered in hospitals with available facilities.

Association between habitual yogurt consumption and newly diagnosed non-alcoholic fatty liver disease

BACKGROUND/OBJECTIVES

Many studies have suggested that probiotics may be applied as a therapeutic agent for non-alcoholic fatty liver disease (NAFLD). However, the effects of frequent yogurt consumption (as a natural probiotic source) on NAFLD remain poorly understood. This study was to examine the association of habitual yogurt consumption with newly diagnosed NAFLD in the general adult population.

SUBJECT/METHODS

Overall, 24,389 adults were included in this cross-sectional study. Yogurt consumption was estimated by using a validated self-administered food frequency questionnaire. NAFLD was diagnosed by abdominal ultrasonography. We used logistic regression models to assess the association between yogurt consumption categories and newly diagnosed NAFLD.

RESULTS

The multivariable odds ratios with 95% confidence interval of newly diagnosed NAFLD were 1.00 (0.88, 1.14) for 1 time/week, 0.91 (0.81, 1.02) for 2-3 times/week, and 0.86 (0.76, 0.98) for ≥4 times/week (P for trend = 0.01), compared with those who consumed <1 time/week yogurt. The inverse association was observed in a sensitivity analysis.

CONCLUSION

Higher yogurt consumption was inversely associated with the prevalence of newly diagnosed NAFLD. These results are needed to be confirmed in randomized controlled trials or prospective studies.

Effect of Lactobacillus paracasei N1115 and fructooligosaccharides in nonalcoholic fatty liver disease

INTRODUCTION

Nonalcoholic fatty liver disease (NAFLD) is a growing health concern worldwide. Administration of probiotics and prebiotics has been proposed as a convenient and effective treatment. Our study aims to evaluate the therapeutic benefits of Lactobacillus paracasei N1115 (N1115) and fructooligosaccharides (FOS) by examining the histopathogenesis and underlying molecular events of NAFLD.

MATERIAL AND METHODS

An NAFLD mouse model was established by feeding C57BL/6 mice with a high-fat diet (HFD). N1115, FOS and synbiotics were administered for 16 weeks.

RESULTS

N1115, FOS and synbiotics alleviated HFD-induced hepatic steato-sis and release of tumor necrosis factor-α, and slowed the progression of cirrhosis. Compared to the HFD group, these dietary supplements reduced serum total triglyceride and cholesterol, and appeared to decrease the fasting blood glucose and insulin. Intraperitoneal glucose tolerance tests, homeostatic model assessment of insulin resistance and real-time PCR showed that the regimens could overcome insulin resistance. These findings were associated with the transcriptional repression of inflammatory factors such as lipopolysaccharides, Toll-like receptor 4 and nuclear factor-κB. Lastly, N1115, FOS, and synbiotics improved the intestinal barrier functions and histologic integrity. This was accompanied by the restoration of the p38 MAPK pathway and in-creased expression of the tight junction components occludin-1 and claudin-1.

CONCLUSIONS

N1115, FOS and synbiotics are effective in the prevention and treatment of NAFLD. Our data support the translation of these agents into clinical evaluation in human subjects with NAFLD and/or associated risk factors.

miR-222 targets ACOX1, promotes triglyceride accumulation in hepatocytes

BACKGROUND

Non-alcoholic fatty liver disease (NAFLD) is one of the most prevalent chronic liver diseases. However, the exact pathogenesis of NAFLD remains to be elucidated. Despite the association with tumors and cardiovascular diseases, the role of miR-222 in NAFLD remains unclear. The present study was to investigate the role of miR-222 in NAFLD.

METHODS

Wild-type C57BL/6 mice were fed a high-fat diet for 12 weeks to induce NAFLD. Normal human liver cell line (L02) was cultured with free fatty acid (FFA)-containing medium to stimulate cell steatosis. The mRNA levels of miR-222 and acyl Coenzyme A xidase 1 (ACOX1) were detected by quantitative-PCR (Q-PCR). The prediction of ACOX1 as the target gene for miR-222 was conducted via TargetScan. The overexpression or inhibition of miR-222 was mediated by miR-222 mimics or antagomir, and intracellular triglyceride levels were measured using a triglyceride kit. Luciferase reporter assays verified ACOX1 as the target gene for miR-222.

RESULTS

miR-222 was significantly elevated in both the in vivo and in vitro NAFLD models. Overexpression of miR-222 significantly increased triglyceride content in the L02 cells, while inhibition of miR-222 expression restricted the accumulation of triglyceride. Overexpression of miR-222 significantly inhibited ACOX1 expression. Transient transfection assays verified that ACOX1 3'-UTR luciferase reporter activity could be inhibited by miR-222 overexpression.

CONCLUSIONS

The present study suggested that miR-222 promotes the accumulation of triglycerides by inhibiting ACOX1.

Global liver disease burdens and research trends: Analysis from a Chinese perspective

Liver diseases affect millions of people worldwide. In most developed countries, the incidence of viral hepatitis is waning as a result of modern advances in disease prevention, diagnosis, and therapies. Expanded programmes for systematic immunisation against hepatitis B virus have also significantly brought down the number of new cases in many countries, including China. In contrast, with the improvement in living standards, the prevalence of metabolic liver diseases including non-alcoholic fatty liver disease and alcohol-related liver disease is set to rise, ultimately leading to more cases of end-stage liver diseases (liver failure, cirrhosis, and liver cancer). Over the past 30 years, visionary governments of major nations have provided strong incentives for basic/clinical research, vaccination programmes, and drug discovery and development in the field of hepatology. To get rid of her unflattering title as the "leader in liver diseases", China has also made a serious effort to initiate nationwide preventive measures for liver diseases, global partnerships, and mentoring programmes for young hepatologists. Instrumental to such progress is the continuous support of the National Natural Science Foundation of China (NSFC), which has helped hepatology to thrive in virtually all research directions within the country. In this article, we seek to provide stimulating glimpses into the evolving liver disease epidemiology, institutional research profiles, funding landscape, and drug development trends in China, with an attempt to compare her status and achievements with those of the United States, European countries, and Japan.

Sex, Age, and BMI Modulate the Association of Physical Examinations and Blood Biochemistry Parameters and NAFLD: A Retrospective Study on 1994 Cases Observed at Shuguang Hospital, China

Objective

Previous studies have shown that some metabolic risk factors are related to nonalcoholic fatty liver disease (NAFLD). This retrospective study was performed to investigate the associations between physical examinations and blood biochemistry parameters and NAFLD status and to identify possible risk factors of NAFLD.

Methods

Study participants underwent general physical examinations, blood biochemistry, and abdominal ultrasound evaluations. In addition, data regarding sex, age, ethnicity, medical history, and alcohol consumption of participants were recorded. Among the study participants (N=1994), 57.8% were male, 41.2% over the age of 50, and 52.6% with BMI≥24. 986 patients had NAFLD and 1008 had no NAFLD. We used effect size analysis and logistic regression to determine which physical examinations and blood biochemistry parameters were significant for the association between these parameters and NAFLD status.

Results

Both the effect size and logistic regression indicated that BMI, diastolic blood pressure (DBP), triglycerides (TG), and serum uric acid (SUA) show a significant association with NAFLD. Females are overall at a higher risk of NAFLD, but factors such as high BMI, DBP, TG, and SUA increase the associated risk for both sexes. Compared with males, females have a higher risk of NAFLD given that they are over 50, overweight and obese (BMI at or over 24), or have high SUA. In terms of age, people older than 50 with high SUA, and people younger than 50 with high DBP and low-density lipoprotein cholesterol (LDL-C) all increase the risk of NAFLD. For BMI, high DBP and low high-density lipoprotein cholesterol (HDL-C) are risk factors for NAFLD in overweight and obese people (BMI at or over 24), whereas in normal weight and underweight people (BMI under 24), elevated LDL-C increases the risk of NAFLD.

Conclusions

Our results revealed sex, age, and BMI modulate the association of physical examinations and blood biochemistry parameters and NAFLD, which may facilitate the development of personalized early warning and prevention strategies of NAFLD for at-risk populations.

Mitochondria-Mediated Pathogenesis and Therapeutics for Non-Alcoholic Fatty Liver Disease

Non-alcoholic fatty liver disease (NAFLD) has become a worldwide epidemic over the last decade. Remarkable progress has been made in understanding the pathogenesis of NAFLD and, subsequently, in developing medications to treat this disease. Although the mechanisms of NAFLD are complex and multifactorial, accumulating and emerging evidence indicates that mitochondria play a critical role in the pathogenesis and progression of NAFLD. Pharmacologic therapies acting on mitochondria may therefore pave the way to novel strategies for the prevention and protection against NAFLD. This review focuses on new insights into the role of hepatic mitochondrial dysfunction in NAFLD, and summarizes recent studies on mitochondria-centric therapies for NAFLD utilizing new medications or repurposing of currently available drugs. Although some studies presented may feature controversial results or are still in lack of clinical verification, it is undoubted that medications that may spare the mitochondria from multiple levels of damage are highly promising, and have begun to be used with some degree of success.

Association Between Dietary Selenium Intake and the Prevalence of Nonalcoholic Fatty Liver Disease: A Cross-Sectional Study

Objective: The aim was to examine the association between dietary selenium intake and nonalcoholic fatty liver disease (NAFLD) in a large group of middle-aged and elderly Chinese persons.Method: The data included in this analysis were from a population-based study, the Xiangya Hospital Health Management Center Study. NAFLD was diagnosed by (1) imaging or histological evidence of hepatic steatosis; (2) absence of specific etiologies of NAFLD; and (3) no heavy consumption of alcohol. Dietary selenium intake was assessed using a validated semi-quantitative food frequency questionnaire. The association between dietary selenium intake and the prevalence of NAFLD was evaluated using logistic and spline regression in a cross-sectional study of 5436 subjects.Results: The prevalence of NAFLD was 36.8%. Compared with the lowest quintile, the energy-adjusted odds ratios for NAFLD were 1.27 (95% confidence interval [CI], 1.07-1.52), 1.30 (95% CI, 1.09-1.55), and 1.58 (95% CI, 1.33-1.89) for the third, fourth, and fifth quintiles of selenium intake, respectively, and there was a positive dose-response relationship (r = 0.88, p for trend = 0.008). Similar results were observed for men and women separately. The findings were not materially altered by adjustment for potential confounders (i.e., age, gender, body mass index, smoking status, diabetes, hypertension, activity level, nutritional supplements, energy intake, fat intake, fiber intake, cholesterol and saturated fatty acid intake).Conclusions: In this middle-aged and elderly population, subjects with higher dietary selenium intake, even below the recommended nutrient intake in China, had higher prevalence of NAFLD in a dose-response relationship manner.

Effects of Qutanhuoxue Decoction on AQP7 and AQP9 Expression in Nonalcoholic Fatty Liver Model Rats

The purpose of this study was to investigate the effect of Qutanhuoxue decoction on AQP7 and AQP9 expression in nonalcoholic fatty liver model rats. Nighty male SD rats (six weeks old, 250 ± 10 g) were randomly divided into 5 groups: normal diet group (ND group), high-fat diet (HFD group), HFD + low dose Qd group, HFD + middle dose Qd group, and HFD + high dose Qd group. Rats in ND group were fed with a regular diet, while rats in other groups were fed with high-fat diet. After the success of the molding, HFD + low dose Qd group, HFD + middle dose Qd group, and HFD + high dose Qd group were, respectively, gavaged by Qutanhuoxue decoction with concentration of 4.5g.kg-1.d-1, 9.0g.kg-1.d-1, and 18g.kg-1.d-1. The ND group and HFD group were gavaged by the same volume of physiological saline lavage, once a day. During the period of gavaging, the other four groups continue to be fed with high-fat fodder except ND group. All rats were killed at 14d, 21d, and 28d, respectively. HE staining was used to observe the pathological changes of liver tissues and serum level of ALT AST GGT and TC TG was detected by automatic analyzer. The expression levels of liver AQP9 mRNA and adipose tissue AQP7 mRNA were detected by real-time PCR. Quhuoxue decoction can significantly reduce the liver function (ALT, AST, and GGT) and blood fat (TG, TC) levels of NAFLD rats and reduce the degree of liver fat degeneration. The effect was the best in the HFD + high dose Qd group of 28d. Qutanhuoxue decoction can decrease the expression of liver AQP9 mRNA and increase the expression of adipose tissue AQP7 mRNA. In conclusion, Qutanhuoxue decoction can reduce the degree of hepatic steatosis, which may be closely related to the increase of AQP7 expression in adipose tissue and the decrease of AQP9 expression in liver.

Inhibition of soluble epoxide hydrolase ameliorates hyperhomocysteinemia-induced hepatic steatosis by enhancing β-oxidation of fatty acid in mice

Hepatic steatosis is the beginning phase of nonalcoholic fatty liver disease, and hyperhomocysteinemia (HHcy) is a significant risk factor. Soluble epoxide hydrolase (sEH) hydrolyzes epoxyeicosatrienoic acids (EETs) and other epoxy fatty acids, attenuating their cardiovascular protective effects. However, the involvement of sEH in HHcy-induced hepatic steatosis is unknown. The current study aimed to explore the role of sEH in HHcy-induced lipid disorder. We fed 6-wk-old male mice a chow diet or 2% (wt/wt) high-metnionine diet for 8 wk to establish the HHcy model. A high level of homocysteine induced lipid accumulation in vivo and in vitro, which was concomitant with the increased activity and expression of sEH. Treatment with a highly selective specific sEH inhibitor (0.8 mg·kg^-1·day^-1 for the animal model and 1 μM for cells) prevented HHcy-induced lipid accumulation in vivo and in vitro. Inhibition of sEH activated the peroxisome proliferator-activated receptor-α (PPAR-α), as evidenced by elevated β-oxidation of fatty acids and the expression of PPAR-α target genes in HHcy-induced hepatic steatosis. In primary cultured hepatocytes, the effect of sEH inhibition on PPAR-α activation was further confirmed by a marked increase in PPAR-response element luciferase activity, which was reversed by knock down of PPAR-α. Of note, 11,12-EET ligand dependently activated PPAR-α. Thus increased sEH activity is a key determinant in the pathogenesis of HHcy-induced hepatic steatosis, and sEH inhibition could be an effective treatment for HHcy-induced hepatic steatosis. NEW & NOTEWORTHY In the current study, we demonstrated that upregulation of soluble epoxide hydrolase (sEH) is involved in the hyperhomocysteinemia (HHcy)-caused hepatic steatosis in an HHcy mouse model and in murine primary hepatocytes. Improving hepatic steatosis in HHcy mice by pharmacological inhibition of sEH to activate peroxisome proliferator-activated receptor-α was ligand dependent, and sEH could be a potential therapeutic target for the treatment of nonalcoholic fatty liver disease.

Dose-response association between physical activity and non-alcoholic fatty liver disease: a case-control study in a Chinese population

AIM

Physical activity plays an important role in the development of non-alcoholic fatty liver disease (NAFLD).However, the optimal intensity and dose of physical activity for the treatment of NAFLD have yet to be found. In the present study, we aimed to provide a dose-response association between physical activity and NAFLD in a Chinese population.

METHODS

We recruited 543 patients with NAFLD diagnosed by abdominal ultrasonography, and 543 age-matched and sex-matched controls. The amount of physical activity, sedentary time and energy intake was collected through a structured questionnaire. Logistic regression analyses were performed to investigate the association between physical activity and NAFLD.

RESULTS

After adjusting for hypertension, diabetes, body mass index, fasting blood glucose, energy intake and sedentary time, the total amount of physical activity was found to be inversely associated with NAFLD in a dose-dependent manner in men (>3180 metabolic equivalent of energy [MET]-min/week vs ≤1440 MET-min/week: OR 0.60, 95% CI 0.40 to 0.91, p for trend=0.01). In addition, both moderate-intensity and vigorous-intensity physical activity were effective in reducing the risk of NAFLD, independent of confounding variables in men (moderate-intensity physical activity: >684 MET-min/week vs none: OR 0.58, 95% CI 0.40 to 0.86, p for trend=0.01; vigorous-intensity physical activity: >960 MET-min/week vs none: OR 0.63, 95% CI 0.41 to 0.95, p for trend=0.02).

CONCLUSIONS

Physical activity was inversely associated with risk of NAFLD in a dose-dependent manner in men. Vigorous-intensity and moderate-intensity physical activity were both beneficial to NAFLD, independent of sedentary time and energy intake.

Noninvasive evaluation of nonalcoholic fatty liver disease: Current evidence and practice

With the increasing number of individuals with diabetes and obesity, nonalcoholic fatty liver disease (NAFLD) is becoming increasingly prevalent, affecting one-quarter of adults worldwide. The spectrum of NAFLD ranges from simple steatosis or nonalcoholic fatty liver (NAFL) to nonalcoholic steatohepatitis (NASH). NAFLD, especially NASH, may progress to fibrosis, leading to cirrhosis and hepatocellular carcinoma. NAFLD can impose a severe economic burden, and patients with NAFLD-related terminal or deteriorative liver diseases have become one of the main groups receiving liver transplantation. The increasing prevalence of NAFLD and the severe outcomes of NASH make it necessary to use effective methods to identify NAFLD. Although recognized as the gold standard, biopsy is limited by its sampling bias, poor acceptability, and severe complications, such as mortality, bleeding, and pain. Therefore, noninvasive methods are urgently needed to avoid biopsy for diagnosing NAFLD. This review discusses the current noninvasive methods for assessing NAFLD, including steatosis, NASH, and NAFLD-related fibrosis, and explores the advantages and disadvantages of measurement tools. In addition, we analyze potential noninvasive biomarkers for tracking disease processes and monitoring treatment effects, and explore effective algorithms consisting of imaging and nonimaging biomarkers for diagnosing advanced fibrosis and reducing unnecessary biopsies in clinical practice.

Ethnic differences and heterogeneity in genetic and metabolic makeup contributing to nonalcoholic fatty liver disease

Obesity is the most prevalent noncommunicable disease in the 21st century, associated with triglyceride deposition in hepatocytes leading to nonalcoholic fatty liver disease (NAFLD). NAFLD is now present in around a third of the world's population. Epidemiological studies have concluded that ethnicity plays a role in complications and treatment response. However, definitive correlations of ethnicity with NAFLD are thoroughly under-reported. A comprehensive review was conducted on ethnic variation in NAFLD patients and its potential role as a crucial effector in complications and treatment response. The highest NAFLD prevalence is observed in Hispanic populations, exhibiting a worse disease progression. In contrast, African-Caribbeans exhibit the lowest risk, with less severe steatosis and inflammation, lower levels of triglycerides, and less metabolic derangement, but conversely higher prevalence of insulin resistance. The prevalence of NAFLD in Asian cohorts is under-reported, although reaching epidemic proportions in these populations. The most well-documented NAFLD patient population is that of Caucasian ethnicity, especially from the US. The relative paucity of available literature suggests there is a vital need for more large-scale multi-ethnic clinical cohort studies to determine the incidence of NAFLD within ethnic groups. This would improve therapy and drug development, as well as help identify candidate gene mutations which may differ within the population based on ethnic background.

Adiposity in relation to risks of fatty liver, cirrhosis and liver cancer: a prospective study of 0.5 million Chinese adults

Adiposity is an increasing public health problem in China. We aimed to examine the associations of adiposity with non-alcoholic fatty liver disease (NAFLD) and other chronic liver diseases in Chinese adults. The prospective China Kadoorie Biobank recruited 512,891 adults aged 30-79 years from 10 areas. During 10 years of follow-up, 7,386 incident liver disease cases were recorded among 503,991 participants without prior cancer or chronic liver disease at baseline. The mean body mass index (BMI) (SD) was 23.7 (3.3) kg/m² and mean waist circumference (WC) 80.3 (9.8) cm, with 33% having BMI ≥25 kg/m². Throughout the range examined (BMI 15-50) BMI showed a log-linear positive association with NAFLD (n = 1,298), with adjusted HR per 5 kg/m² of 2.81 (95% CI 2.63-3.01), adjusting for regression dilution. There were also positive associations of percent body fat, WC, and waist-to-hip ratio with NAFLD, with HRs per 1-SD of 2.27 (2.14-2.41), 2.60 (2.44-2.76), and 1.84 (1.76-1.92). BMI was unrelated to viral hepatitis (n = 1,477), and had a U-shaped association with cirrhosis (n = 2,082) and an inverse association with liver cancer (n = 2,568), which disappeared after excluding the first 5 years of follow-up. Among Chinese adults, adiposity was a major risk factor for NAFLD but not other chronic liver diseases.