Diagnostic accuracy and reliability of ultrasonography for the detection of fatty liver: a meta-analysis

[Intersectoral management of patients with abnormal liver enzymes and non-alcoholic fatty liver disease (NAFLD)]

The prevalence of fatty liver disease has increased significantly in Germany in recent years. With an estimated 18 million German citizens being affected, it is now among the most prevalent diseases. Furthermore, it is also considered a relevant and independent risk factor for other common cardiovascular diseases such as heart attack or stroke. Finally, diabetes mellitus promotes the development of and an unfavorable course of fatty liver disease. Given the high prevalence and complications, the German healthcare system is reaching its limits.Therefore, close coordination of all healthcare providers and specialists involved in the treatment of these patients is essential. In an expert consensus involving private practice and hospital doctors from the fields of gastroenterology, endocrinology, cardiology, general practitioners and laboratory physicians, as well as in close coordination with patient representatives, we have designed a concept for the care of these patients in the German healthcare system. Necessary developments are also addressed. In addition to being useful as a practical guideline, this should also support health policy work, especially in the development of practical care solutions at the medical level.

Effect of Cornus mas L. fruit extract on blood pressure, anthropometric and body composition indices in patients with non-alcoholic fatty liver disease: A double-blind randomized controlled trial

BACKGROUND & AIMS

Obesity is linked to the pathogenesis of non-alcoholic fatty liver disease (NAFLD). Patients with NAFLD are at increased risk for hypertension. Some investigations have hypothesized that Cornus mas L. fruit can improve obesity and hypertension. We investigated the effect of C. mas L. fruit extract on blood pressure, anthropometric and body composition indices in patients with NAFLD.

METHODS

This 12-week double-blind randomized controlled trial was conducted on fifty patients with NAFLD. Patients received 20 cc/d C. mas L. fruit extract or placebo. We measured diastolic blood pressure (DBP), systolic blood pressure (SBP), weight, waist circumference (WC), hip circumference (HC), waist-to-hip ratio (WHR), body fat mass (BFM), body fat percent (BFP) and fat free mass (FFM) before and after intervention.

RESULTS

Treatment group compared to control group showed a significant reduction in DBP (-8.62 ± 11.86 mmHg vs. 0.53 ± 8.53 mmHg; P_crude = 0.003; P_adjucted = 0.03) and SBP (-8.63 ± 14.37 mmHg vs. 0.0 ± 12.67 mmHg; P_crude = 0.02; P_adjucted = 0.02). We found no difference between groups in weight, WC, HC, WHR, BFM, BFP and FFM (P > 0.05). After adjusting for confounding factors, a significant reduction was observed in treatment group compared to control group in BFM (-0.2 ± 3.9 kg vs. 0.7 ± 2.4 kg; P = 0.01) and BFP (-0.2 ± 4.9% vs. 0.8 ± 2.8%; P = 0.02).

CONCLUSIONS

C. mas L. fruit extract statistically reduced blood pressure and body fat. However, it had no effect on other anthropometric and body composition indices. Studies with larger sample sizes and higher dosages of extract are needed.

TRIAL REGISTRATION

Registered on 30/9/2018 at Iranian Registry of Clinical Trials IRCT20180419039359N1 (https://www.irct.ir/trial/30707).

The independent and combined effects of dietary and sleep patterns on the risk of metabolic dysfunction-associated fatty liver disease: a population-based cohort study

Background & aims: accumulating evidence shows that various sleep behaviors are related to metabolic dysfunction-associated fatty liver disease (MAFLD), and that diet plays an important role in both preventing and treating this condition. However, the overall effect of a healthy sleep pattern and its joint effect with diet on the risk of MAFLD remain unclear. The aim of this study is to explore the independent and combined effects of dietary and sleep patterns on the MAFLD risk. Methods: this population-based prospective cohort study was conducted in China with a sample size of 13 687 participants. MAFLD was diagnosed through abdominal ultrasound and international expert consensus. Five healthy sleep behaviors were identified to create a healthy sleep pattern, while factor analysis was used to determine dietary patterns. Cox proportional hazards regression was utilized to estimate hazard ratios (HRs) and 95% confidence intervals (CIs). Results: during a total of 49 912 person-years of follow-up, 2977 new cases of MAFLD were identified. The adjusted HRs (95% CIs) of MAFLD in relation to the healthy sleep pattern score were 0.87 (0.78-0.97), 0.83 (0.75-0.92), and 0.77 (0.68-0.87) for scores of 3, 4, and 5, respectively, compared to participants with the lowest score (0-2). A higher intake of animal food (adjusted HR_{4th quartile vs. 1st quartile}, 1.15, 95% CI, 1.03-1.27) and a lower intake of vegetables (adjusted HR_{4th quartile vs. 1st quartile}, 0.88, 95% CI, 0.78-0.99) were associated with a higher risk of MAFLD. Participants who adhered to both healthy dietary and sleep patterns had the lowest MAFLD risk compared to those who followed only one or neither of them. Conclusions: a healthy sleep pattern, especially in combination with a healthy diet, was associated with a lower risk of MAFLD. Future prevention strategies for MAFLD should include consideration of sleep behaviors, in addition to the current recommendations.

Long working hours and increased risks of lean non-alcoholic fatty liver disease among Korean men and women

Despite the increasing prevalence of lean nonalcoholic fatty liver disease (NAFLD), its risk factors are not well established. We examined the association between long working hours and incident NAFLD in lean Korean workers with emphasis on sex-based effect modification. This cohort study involved 46,113 non-overweight (BMI < 23 kg/m²) and NAFLD-free Korean workers (mean age, 35.5 years). Working hours were categorized into 35-40 (reference), 41-52, and ≥ 53 h. The presence of fatty liver and its severity were determined using ultrasonography and NAFLD fibrosis score (NFS), respectively. Hazard ratios (HRs) and 95% confidence intervals (CIs) were estimated using parametric proportional hazards models. Incident cases of 5901 lean NAFLD developed over a median follow-up of 3.8 years. The incidence of lean NAFLD increased with increasing working hours with a stronger association in men than in women (P for interaction < 0.001). For men, multivariable-adjusted HRs (95% CIs) for lean NAFLD in time-dependent models comparing working hours of 41-52 and ≥ 53 h compared to the reference category were 1.17 (1.07-1.28) and 1.25 (1.12-1.39), respectively. The excess relative risk of developing lean NAFLD with intermediate/high NFS was observed in working hours of 41-52 and ≥ 53 h with a corresponding HR of 1.66 (1.13-2.43) and 1.54 (0.94-2.51), respectively. Conversely, no significant associations were found between working hours and incidence of lean NAFLD in women. In conclusion, long working hours were significantly associated with an increased incidence of lean NAFLD and its severe form in men but not in women.

PEMT rs7946 Polymorphism and Sex Modify the Effect of Adequate Dietary Choline Intake on the Risk of Hepatic Steatosis in Older Patients with Metabolic Disorders

In humans, PEMT rs7946 polymorphism exerts sex-specific effects on choline requirement and hepatic steatosis (HS) risk. Few studies have explored the interaction effect of the PEMT rs7946 polymorphism and sex on the effect of adequate choline intake on HS risk. In this cross-sectional study, we investigated the association between PEMT polymorphism and adequate choline intake on HS risk. We enrolled 250 older patients with metabolic disorders with (n = 152) or without (n = 98; control) ultrasonically diagnosed HS. An elevated PEMT rs7946 A allele level was associated with a lower HS risk and body mass index in both men and women. Dietary choline intake-assessed using a semiquantitative food frequency questionnaire-was associated with reduced obesity in men only (p for trend < 0.05). ROC curve analysis revealed that the cutoff value of energy-adjusted choline intake for HS diagnosis was 448 mg/day in women (AUC: 0.62; 95% CI: 0.57-0.77) and 424 mg/day in men (AUC: 0.63, 95% CI: 0.57-0.76). In women, GG genotype and high choline intake (>448 mg/day) were associated with a 79% reduction in HS risk (adjusted OR: 0.21; 95% CI: 0.05-0.82); notably, GA or AA genotype was associated with a reduced HS risk regardless of choline intake (p < 0.05). In men, GG genotype and high choline intake (>424 mg/day) were associated with a 3.7-fold increase in HS risk (OR: 3.7; 95% CI: 1.19-11.9). Further adjustments for a high-density lipoprotein level and body mass index mitigated the effect of choline intake on HS risk. Current dietary choline intake may be inadequate for minimizing HS risk in postmenopausal Taiwanese women carrying the PEMT rs7946 GG genotype. Older men consuming more than the recommended amount of choline may have an increased risk of nonalcoholic fatty liver disease; this risk is mediated by a high-density lipoprotein level and obesity.

Liver lipophagy ameliorates nonalcoholic steatohepatitis through extracellular lipid secretion

Nonalcoholic steatohepatitis (NASH) is a progressive disorder with aberrant lipid accumulation and subsequent inflammatory and profibrotic response. Therapeutic efforts at lipid reduction via increasing cytoplasmic lipolysis unfortunately worsens hepatitis due to toxicity of liberated fatty acid. An alternative approach could be lipid reduction through autophagic disposal, i.e., lipophagy. We engineered a synthetic adaptor protein to induce lipophagy, combining a lipid droplet-targeting signal with optimized LC3-interacting domain. Activating hepatocyte lipophagy in vivo strongly mitigated both steatosis and hepatitis in a diet-induced mouse NASH model. Mechanistically, activated lipophagy promoted the excretion of lipid from hepatocytes, thereby suppressing harmful intracellular accumulation of nonesterified fatty acid. A high-content compound screen identified alpelisib and digoxin, clinically-approved compounds, as effective activators of lipophagy. Administration of alpelisib or digoxin in vivo strongly inhibited the transition to steatohepatitis. These data thus identify lipophagy as a promising therapeutic approach to prevent NASH progression.

Prevalence and Predictors of Prediabetes in Adolescents and Young Adults with Turner Syndrome: A Cross-Sectional Study from Eastern India

Background

Individuals with Turner syndrome (TS) have a high risk for prediabetes/type 2 Diabetes Mellitus (T2DM). There is scarce data regarding risk factors for prediabetes in TS, specially from South Asia.

Methods

We conducted a cross-sectional study on girls with TS aged 12-30 years who had achieved pubertal stage B3 and above-spontaneously or with oestrogen. Anthropometric measurements and biochemical tests were conducted, and medical records were reviewed for details about pubertal onset and progression, growth hormone (GH) and oestrogen therapy.

Results

Out of 129 patients with TS in our database, 99 met the criteria for inclusion, mean age 18.33+/-3.78 years and mean BMI 20.57+/- 3.71 kg/m2. Prevalence of prediabetes was 23.23%. Plasma-glucose measured after 75 g-oral-anhydrous-glucose-load (OGTT-PPG) identified five additional prediabetes cases, who had normal fasting plasma glucose (FPG) or HbA1c%. Compared to those without prediabetes, TS with prediabetes (n = 23) had higher mean body weight, BMI, waist circumference (WC) [42.02+/- 5.83 vs 36.22+/-8.07, 22.77+/-2.78 vs 19.91+/- 3.72, 85.26+/- 3.52 vs 81.08+/- 4.59, pall < 0.03 ], higher median WC-to-height ratio (WHtR) and WC-to-hip ratio (WHR)((0.64 [0.6-0.69] vs 0.59[0.56- 0.66], 0.9[0.84-1.12] vs 0.85[0.75-1.01], pboth < 0.02), and higher LDL-cholesterol, triglycerides, and greater prevalence of hepatosteatosis (47.1% vs 21.1%, P < 0.01). Among GH recipients (n = 36), those with prediabetes had delayed initiation and shorter duration of GH therapy. There were no differences in cardiometabolic parameters or the prevalence of diabetes between different karyotypic variants of TS. BMI, WC and WHR had significant positive correlation with FBG, OGTT-PPG and HbA1c% (pall < 0.004). Delay in oestrogen initiation had a significant correlation with OGTT-PPG (Spearman's-rho = 0.69, P < 0.004). BMI, WHR and pubertal status were independent predictors for prediabetes (OR: 1.27 [1.03-1.57]), 1.18 [1.04-1.34]) and 0.09[0.02-0.38], respectively, pall < 0.02), but karyotype was not. BMI had the highest sensitivity [cut-off: 21.04 kg/m2 (sensitivity: 82.6%, specificity: 62.2%) and WHR had the highest specificity [cut-off: 0.89 (sensitivity: 73.9%, specificity 78.4%)] for predicting prediabetes.

Conclusion

Indian girls with TS have a high risk for prediabetes, irrespective of underlying karyotype and should be screened with oral glucose challenge to identify prediabetes. Timely intervention against central obesity and early initiation of GH and oestrogen should be ensured in TS. Late presenting girls should be closely monitored for dysglycaemia before and during treatment with GH and/or oestrogen.

Increased risk of incident diabetes in patients with MAFLD not meeting the criteria for NAFLD

We aimed to compare the risk of incident diabetes according to fatty liver disease (FLD) definition, focusing on the comparison between those who met criteria for either metabolic dysfunction-associated fatty liver disease (MAFLD) or nonalcoholic fatty liver disease (NAFLD) but not the other. This was a 5.0-year (interquartile range, 2.4-8.2) retrospective longitudinal cohort study of 21,178 adults who underwent at least two serial health checkup examinations. The presence of hepatic steatosis was determined by abdominal ultrasonography at the first health examination. Cox proportional hazard analyses were used to compare the risk of incident diabetes among five groups. Incident diabetes cases occurred in 1296 participants (6.1%). When non-FLD without metabolic dysfunction (MD) group was set as a reference, the risk of incident diabetes increased in the order of NAFLD-only, non-FLD with MD, both FLD, and MAFLD-only groups. The presence of excessive alcohol consumption and/or hepatitis B virus (HBV)/hepatitis C virus (HCV) infection, FLD, and MD synergistically increased the risk of incident diabetes. MAFLD-only group showed a greater increase in incidence of diabetes than non-FLD with MD and NAFLD-only groups. The interaction among excessive alcohol consumption, HBV/HCV infection, MD, and hepatic steatosis on the development of diabetes should not be overlooked.

[Elevated liver values caused by nonalcoholic steatohepatitis (NASH)]

Non-alcoholic steatohepatitis (NASH) is the progressive entity of non-alcoholic fatty liver disease (NAFLD) and characterised by increased inflammatory activity, potentially resulting in liver fibrosis and ultimately cirrhosis. NASH activity and hepatic fibrosis are the prognosis determinating risk factors - rational stepwise diagnostic approaches are urgently needed as therapeutic options beyond lifestyle modifications are limited.

Serum Alkaline Phosphate Level Associates with Metabolic Syndrome Components Regardless of Non-Alcoholic Fatty Liver; A Population-Based Study in Northern Iran

Background: Serum alkaline phosphatase (ALP) is an indicator of hepatobiliary disorders, such as metabolic syndrome (MetS). To assess the association between serum ALP levels and MetS, with or without non-alcoholic fatty liver disease (NAFLD), in a cohort study in northern Iran. Methods: Data from approximately 5257 subjects aged more than 18 years participating in the Amol cohort were used. We extracted the required data and investigated the correlation between liver enzyme levels and MetS. Multiple logistic regression analyses based on the serum ALP quartiles were performed. Results: Of them, 2860 were male with a mean age of 42.11±16.1 years. A positive linear trend was observed between serum ALP levels and the number of MetS components in both sexes. In both sexes, systolic blood pressure, waist circumferences, and high-density lipoprotein (HDL) had a significant association with ALP. After adjusting for age, both sexes with NAFLD showed an increased risk of developing MetS. The risk of NAFLD increased in individuals with>2nd quartile of ALP. Furthermore, higher ALP levels were associated with an increased risk of MetS in males (1.1014 [0.782-1.315]) and females (1.441 [1.085-1.913]). Conclusion: There is a significant association between serum ALP levels and MetS, independent of fatty liver changes, suggesting that this marker can be considered as a feasible predictor of MetS.

Prevalence, risk factors and diagnostic accuracy of non-invasive tests for NAFLD in people with type 1 diabetes

Background & Aims

The epidemiology of non-alcoholic fatty liver disease (NAFLD) in people with type 1 diabetes (T1D) is not yet elucidated. This study aimed to assess the diagnostic accuracy of non-invasive tests for NAFLD, to investigate the prevalence and severity of NAFLD, and to search for factors contributing to NAFLD in people with T1D.

Methods

In this prospective cohort study, we consecutively screened 530 adults with T1D from a tertiary care hospital, using ultrasound (US), vibration-controlled transient elastography equipped with liver stiffness measurement (LSM) and controlled attenuation parameter, and the fatty liver index. Magnetic resonance spectroscopy (MRS) was performed in a representative subgroup of 132 individuals to validate the diagnostic accuracy of the non-invasive tests.

Results

Based on MRS as reference standard, US identified individuals with NAFLD with an AUROC of 0.98 (95% CI 0.95-1.00, sensitivity: 1.00, specificity: 0.96). The controlled attenuation parameter was also accurate with an AUROC of 0.85 (95% CI 0.77-0.93). Youden cut-off was ≥270 dB/m (sensitivity: 0.90, specificity: 0.74). The fatty liver index yielded a similar AUROC of 0.83 (95% CI 0.74-0.91), but the conventional cut-off used to rule in (≥60) had low sensitivity and specificity (0.62, 0.78). The prevalence of NAFLD in the overall cohort was 16.2% based on US. Metabolic syndrome was associated with NAFLD (OR: 2.35 [1.08-5.12], p = 0.031). The overall prevalence of LSM ≥8.0 kPa indicating significant fibrosis was 3.8%, but reached 13.2% in people with NAFLD.

Conclusions

NAFLD prevalence in individuals with T1D is 16.2%, with approximately one in 10 featuring elevated LSM. US-based screening could be considered in people with T1D and metabolic syndrome.

Impact and Implications

We aimed to report on the prevalence, disease severity, and risk factors of NAFLD in type 1 diabetes (T1D), while also tackling which non-invasive test for NAFLD is the most accurate. We found that ultrasound is the best test to diagnose NAFLD. NAFLD prevalence is 16.2%, and is associated with metabolic syndrome and BMI. Elevated liver stiffness indicating fibrosis is overall not prevalent in people with T1D (3.8%), but it reaches 13.2% in those with T1D and NAFLD.

US Quantification of Liver Fat: Past, Present, and Future

Fatty liver disease has a high and increasing prevalence worldwide, is associated with adverse cardiovascular events and higher long-term medical costs, and may lead to liver-related morbidity and mortality. There is an urgent need for accurate, reproducible, accessible, and noninvasive techniques appropriate for detecting and quantifying liver fat in the general population and for monitoring treatment response in at-risk patients. CT may play a potential role in opportunistic screening, and MRI proton-density fat fraction provides high accuracy for liver fat quantification; however, these imaging modalities may not be suited for widespread screening and surveillance, given the high global prevalence. US, a safe and widely available modality, is well positioned as a screening and surveillance tool. Although well-established qualitative signs of liver fat perform well in moderate and severe steatosis, these signs are less reliable for grading mild steatosis and are likely unreliable for detecting subtle changes over time. New and emerging quantitative biomarkers of liver fat, such as those based on standardized measurements of attenuation, backscatter, and speed of sound, hold promise. Evolving techniques such as multiparametric modeling, radiofrequency envelope analysis, and artificial intelligence-based tools are also on the horizon. The authors discuss the societal impact of fatty liver disease, summarize the current state of liver fat quantification with CT and MRI, and describe past, currently available, and potential future US-based techniques for evaluating liver fat. For each US-based technique, they describe the concept, measurement method, advantages, and limitations. © RSNA, 2023 Online supplemental material is available for this article. Quiz questions for this article are available through the Online Learning Center.

Association of aspirin with all-cause and cardiocerebrovascular mortality in patients with metabolic associated fatty liver disease

BACKGROUND

Studies on aspirin's effects on metabolic-associated fatty liver disease (MAFLD) are limited. The aim of this study was to assess the association between aspirin and all-cause and cardiovascular disease (CVD) mortality in individuals with MAFLD.

METHODS

Data were acquired from the National Health And Nutrition Examination Survey (NHANES) III. MAFLD diagnosis was consistent with that of international expert consensus. The independent association between aspirin and all-cause and CVD mortality in participants with MAFLD was evaluated by multiple Cox regression. Stratified analyses and interaction tests were performed to investigate whether covariates modified the association between aspirin and MAFLD mortality.

RESULTS

Of 4594 eligible participants, 3,162 (68.83%) never took aspirin (0 times/month), 962 (20.94%) took it occasionally (1-14 times/month) and 470 (10.23%) took it regularly (≥15 times/month). Multiple cox regression showed that aspirin was not associated with overall mortality for MAFLD individuals. Stratified analysis revealed that in middle-aged (45-59 years) participants with MAFLD, occasional aspirin use was associated with low all-cause mortality risk (HR = 0.61, 95% CI = 0.43-0.86), while there was no significant association between aspirin and all-cause mortality among the young or the elderly.

CONCLUSIONS

We found that the association between aspirin and all-cause MAFLD mortality varies by both age and frequency of administration. More prospective studies are needed to explore aspirin's influence on MALFD mortality.

Non-alcoholic fatty liver disease in patients with chylomicronemia syndromes

BACKGROUND

Chylomicronemia syndrome is a form of severe hypertriglyceridemia (HTG) caused by the familial chylomicronemia syndrome (FCS) or multifactorial chylomicronemia syndrome (MCS). Non-alcoholic fatty liver disease (NAFLD) has been associated with components of the metabolic syndrome and is more prevalent in subjects with elevated triglycerides.

OBJECTIVE

The primary objective was to compare the prevalence of hepatic steatosis assessed by conventional imaging between HTG groups (FSC, MCS and moderate HTG (mHTG)). The secondary objective was to determine the difference in the prevalence of liver fibrosis.

METHODS

This cross-sectional observational study was performed on adult patients from the lipid clinic of the Montreal Clinical Research Institute (IRCM). We retrospectively reviewed the imaging reports available in the patients' files for signs of NAFLD. We also used the FIB-4 index as a surrogate marker of liver fibrosis.

RESULTS

We reviewed the medical files of 300 patients; 22 with FCS, 82 with MCS and 196 with mHTG. There was significantly more hepatic steatosis in the MCS group compared to the mHTG and FCS groups (79%, 66% and 43% respectively p=0.02). There was a significantly higher prevalence of subjects within the "unlikely fibrosis" category in the mHTG group (91%) compared to the MCS (84%) and FCS groups (59%), p=0.0004.

CONCLUSION

We found that the prevalence of hepatic steatosis was 3-, 2.5-, and 2-fold higher in MCS, mHTG and FCS patients than in the general population. This suggests that patients with elevated triglycerides, regardless of the underlying etiology, are at higher risk of hepatic steatosis and NAFLD.

A greater ratio of thigh subcutaneous fat to abdominal fat is associated with protection against non-alcoholic fatty liver disease

Background & Aims

No prospective studies have examined the association between thigh subcutaneous fat distribution and non-alcoholic fatty liver disease (NAFLD). We investigated the associations of thigh subcutaneous fat distribution with incidence and remission of NAFLD in a community-based prospective cohort.

Methods

We followed 1,787 subjects, who underwent abdominal ultrasonography, abdominal and femoral magnetic resonance imaging scans, and anthropometric assessments. Associations of thigh subcutaneous fat area/abdominal fat area ratio and thigh circumference/waist circumference ratio with incidence and remission of NAFLD were estimated using the modified Poisson regression model.

Results

Over a mean 3.6-year follow-up, 239 incident cases of NAFLD and 207 regressed cases of NAFLD were identified. Increasing thigh subcutaneous fat area/abdominal fat area ratio was associated with a lower risk of incident NAFLD and a higher likelihood of remission of NAFLD [risk ratio (RR) per SD: 0.69, 95% CI 0.59-0.81; 1.20, 95% CI 1.07-1.34, respectively). Each one SD increase in thigh circumference/waist circumference ratio was associated with a 16% lower risk of incident NAFLD (RR 0.84, 95% CI 0.76-0.94) and a 22% higher likelihood of remission of NAFLD (RR 1.22, 95% CI 1.11-1.34). Additionally, the effects of thigh subcutaneous fat area/abdominal fat area ratio on the incidence and remission of NAFLD were mediated through adiponectin (14.9% and 26.6%), homeostasis model assessment of insulin resistance (9.5% and 23.9%), and triglyceride (7.5% and 19.1%).

Conclusions

These results demonstrated that a favourable fat distribution, characterised by a greater ratio of thigh subcutaneous fat to abdominal fat, had a protective role against NAFLD.

Impact and implications

The associations of thigh subcutaneous fat distribution with NAFLD incidence and remission have not been prospectively examined in a community-based cohort. Our findings suggest that greater thigh subcutaneous fat relative to a given amount of abdominal fat has a protective effect against NAFLD among the middle-aged and older Chinese populations.

The evaluation of liver abnormalities in inflammatory bowel disease patients

PURPOSE OF REVIEW

Develop a clinical presentation-based approach for common liver abnormalities encountered by providers caring for patients with inflammatory bowel disease (IBD). Develop a treatment pathway for those with nonalcoholic fatty liver disease (NAFLD) arising in IBD. Discuss recent studies of prevalence, incidence, risk factors, and prognosis NAFLD in the IBD population.

RECENT FINDINGS

The work-up for liver abnormalities should be approached systematically in IBD patients, similar to the general population, while still appreciating the differing prevalence of underlying liver diagnoses. Although immune mediated liver diseases occur commonly in patients with IBD, NAFLD is still the most common liver disease in patients with IBD paralleling its expanding prevalence in the general population. IBD is also an independent risk factor for NAFLD, developing in many patients with lower degrees of adiposity. Furthermore, the more severe histologic subtype, nonalcoholic steatohepatitis, is both more common and difficult to treat considering the lower effectiveness of weight loss interventions.

SUMMARY

Having a standard approach to the most common liver disease presentations and care pathway for NAFLD will improve the quality of care provided and ease the medical decision making complexity for IBD patients. The early identification of these patients should prevent the development of irreversible complications like cirrhosis or hepatocellular carcinoma.

Probiotics, prebiotics, and synbiotics in nonalcoholic fatty liver disease and alcohol-associated liver disease

The use of probiotics, prebiotics, and synbiotics has become an important therapy in numerous gastrointestinal diseases in recent years. Modifying the gut microbiota, this therapeutic approach helps to restore a healthy microbiome. Nonalcoholic fatty liver disease and alcohol-associated liver disease are among the leading causes of chronic liver disease worldwide. A disrupted intestinal barrier, microbial translocation, and an altered gut microbiome metabolism, or metabolome, are crucial in the pathogenesis of these chronic liver diseases. As pro-, pre-, and synbiotics modulate these targets, they were identified as possible new treatment options for liver disease. In this review, we highlight the current findings on clinical and mechanistic effects of this therapeutic approach in nonalcoholic fatty liver disease and alcohol-associated liver disease.

The association between regional adiposity, cognitive function, and dementia-related brain changes: a systematic review

Background

Adiposity has been previously associated with cognitive impairment and Alzheimer's disease and related disorders (ADRD). Body mass index (BMI) is the most common measure of global adiposity, but inconsistent results were found since it is a global measurement. BMI does not represent regional fat distribution which differs between sexes, race, and age. Regional fat distribution may contribute differently to cognitive decline and Alzheimer's disease (AD)-related brain changes. Fat-specific targeted therapies could lead to personalized improvement of cognition. The goal of this systematic review is to explore whether regional fat depots, rather than central obesity, should be used to understand the mechanism underlying the association between adiposity and brain.

Methods

This systematic review included 33 studies in the English language, conducted in humans aged 18 years and over with assessment of regional adiposity, cognitive function, dementia, and brain measures. We included only studies that have assessed regional adiposity using imaging technics and excluded studies that were review articles, abstract only or letters to editor. Studies on children and adolescents, animal studies, and studies of patients with gastrointestinal diseases were excluded. PubMed, PsychInfo and web of science were used as electronic databases for literature search until November 2022.

Results

Based on the currently available literature, the findings suggest that different regional fat depots are likely associated with increased risk of cognitive impairment, brain changes and dementia, especially AD. However, different regional fat depots can have different cognitive outcomes and affect the brain differently. Visceral adipose tissue (VAT) was the most studied regional fat, along with liver fat through non-alcoholic fatty liver disease (NAFLD). Pancreatic fat was the least studied regional fat.

Conclusion

Regional adiposity, which is modifiable, may explain discrepancies in associations of global adiposity, brain, and cognition. Specific regional fat depots lead to abnormal secretion of adipose factors which in turn may penetrate the blood brain barrier leading to brain damage and to cognitive decline.

Development and validation of a nomogram for predicting metabolic-associated fatty liver disease in the Chinese physical examination population

AIM

We aim to develop and validate a nomogram including readily available clinical and laboratory indicators to predict the risk of metabolic-associated fatty liver disease (MAFLD) in the Chinese physical examination population.

METHODS

The annual physical examination data of Chinese adults from 2016 to 2020 were retrospectively analyzed. We extracted the clinical data of 138 664 subjects and randomized participants to the development and validation groups (7:3). Significant predictors associated with MAFLD were identified by using univariate and random forest analyses, and a nomogram was constructed to predict the risk of MAFLD based on a Lasso logistic model. Receiver operating characteristic curve analysis, calibration curves, and decision curve analysis were used to verify the discrimination, calibration, and clinical practicability of the nomogram, respectively.

RESULTS

Ten variables were selected to establish the nomogram for predicting MAFLD risk: sex, age, waist circumference (WC), uric acid (UA), body mass index (BMI), waist-to-hip ratio (WHR), systolic blood pressure (SBP), fasting plasma glucose (FPG), triglycerides (TG), and alanine aminotransferase (ALT). The nomogram built on the nonoverfitting multivariable model showed good prediction of discrimination (AUC 0.914, 95% CI: 0.911-0.917), calibration, and clinical utility.

CONCLUSIONS

This nomogram can be used as a quick screening tool to assess MAFLD risk and identify individuals at high risk of MAFLD, thus contributing to the improved management of MAFLD.

Metabolic Dysfunction-associated fatty liver disease and incident heart failure risk: the Kailuan cohort study

BACKGROUND

Recently, metabolic dysfunction-associated fatty liver disease (MAFLD) has been proposed to replace non-alcoholic fatty liver disease (NAFLD) to emphasize the pathogenic association between fatty liver disease and metabolic dysfunction. Studies have found that MAFLD independently increases the risk of myocardial infarction and stroke. But the relationship between MAFLD and heart failure (HF) is not fully understood.

OBJECTIVES

This study aimed to explore the association between MAFLD and the risk of HF.

METHODS

The study included 98,685 participants without HF selected from the Kailuan cohort in 2006. All participants were divided into non-MAFLD group and MAFLD group according to MAFLD diagnostic criteria. After follow-up until December 31, 2020, the Cox regression analysis model was used to calculate the effect of MAFLD on the risk of HF.

RESULTS

During the median follow-up of 14.01 years,3260 cases of HF were defined, the HF incidence density of non-MAFLD group and MAFLD group was 2.19/1000pys and 3.29/1000pys, respectively. Compared with the non-MAFLD group, participants with MAFLD had an increased risk of HF (HR: 1.40, 95% CI: 1.30-1.50); in addition, an exacerbation of fatty liver disease was associated with an increased risk of HF in people with MAFLD. We also observed a higher risk of HF among the different metabolic dysfunction of MAFLD in people with both fatty liver disease and type 2 diabetes (HR, 1.95; 95% CI, 1.73-2.20).

CONCLUSIONS

Our findings suggest that the risk of HF was significantly increased in participants with MAFLD, and an exacerbation of fatty liver disease was associated with an increased risk of HF in people with MAFLD. In addition, we should pay more attention to people with MAFLD with type 2 diabetes.

Risk of cardiovascular disease in lean patients with nonalcoholic fatty liver disease

BACKGROUND

Patients with nonalcoholic fatty liver disease (NAFLD) are highly at risk for cardiovascular disease (CVD). However, the risk of developing CVD in patients with lean NAFLD is not yet fully understood. Therefore, this study aimed to compare the CVD incidence in Japanese patients with lean NAFLD and those with non-lean NAFLD.

METHODS

A total of 581 patients with NAFLD (219 with lean and 362 with non-lean NAFLD) were recruited. All patients underwent annual health checkups for at least 3 years, and CVD incidence was investigated during follow-up. The primary end-point was CVD incidence at 3 years.

RESULTS

The 3-year new CVD incidence rates in patients with lean and non-lean NAFLD were 2.3% and 3.9%, respectively, and there was no significant difference between two groups (p = 0.3). Multivariable analysis adjusted for age, sex, hypertension, diabetes, and lean NAFLD/non-lean NAFLD revealed that age (every 10 years) as an independent factor associated with CVD incidence with an odds ratio (OR) of 2.0 (95% confidence interval [CI]: 1.3-3.4), whereas lean NAFLD was not associated with CVD incidence (OR: 0.6; 95% CI: 0.2-1.9).

CONCLUSIONS

CVD incidence was comparable between patients with lean NAFLD and those with non-lean NAFLD. Therefore, CVD prevention is needed even in patients with lean NAFLD.

Impact of Thyroid Function on the Prevalence and Mortality of Metabolic Dysfunction-Associated Fatty Liver Disease

CONTEXT

Thyroid function variation within the thyroxine reference range has negative metabolic effects. Metabolic dysfunction-associated fatty liver disease (MAFLD) is a recently proposed definition.

OBJECTIVE

We aim to explore the effects of thyroid function status on prevalence and mortality of MAFLD.

METHODS

Data of 10 666 participants from the Third National Health and Nutrition Examination Survey (NHANES III) were used. MAFLD was diagnosed based on the new definition. Thyroid function variation within the thyroxine reference range was defined based on thyroid-stimulating hormone (TSH) levels: subclinical hyperthyroidism, <0.39 mIU/L; strict-normal thyroid function, 0.39-2.5 mIU/L; and low thyroid function, >2.5 mIU/L, which comprised low-normal thyroid function (2.5-4.5 mIU/L) and subclinical hypothyroidism (> 4.5 mIU/L). Logistic and Cox regression were used in multivariate analysis.

RESULTS

Low thyroid function is independently associated with MAFLD (odds ratio: 1.27). Compared with strict-normal thyroid function, subclinical hypothyroidism was significantly associated with increased risk for all-cause and cardiovascular mortality in the total population (hazard ratio [HR] for all-cause: 1.23; cardiovascular: 1.65) and MAFLD population (HR for all-cause: 1.32; cardiovascular: 1.99); meanwhile, in the low-normal thyroid function group, an increasing trend in mortality risk was observed. Furthermore, low thyroid function also showed significant negative impact on mortality in the total and MAFLD population. Among thyroid function spectrum, mild subclinical hypothyroidism showed the highest HRs on mortality.

CONCLUSIONS

Low thyroid function is independent risk factor of MAFLD and is associated with increased risk for all-cause and cardiovascular mortality in the MAFLD population. Reevaluation of TSH reference range should be considered.

Prospective study comparing hepatic steatosis assessment by magnetic resonance imaging and four ultrasound methods in 105 successive patients

BACKGROUND

Non-alcoholic fatty liver disease (NAFLD) is becoming a major health problem, resulting in hepatic, metabolic and cardio-vascular morbidity.

AIM

To evaluate new ultrasonographic tools to detect and measure hepatic steatosis.

METHODS

We prospectively included 105 patients referred to our liver unit for NAFLD suspicion or follow-up. They underwent ultrasonographic measurement of liver sound speed estimation (SSE) and attenuation coefficient (AC) using Aixplorer MACH 30 (Supersonic Imagine, France), continuous controlled attenuation parameter (cCAP) using Fibroscan (Echosens, France) and standard liver ultrasound with hepato-renal index (HRI) calculation. Hepatic steatosis was then classified according to magnetic resonance imaging proton density fat fraction (PDFF). Receiver operating curve (ROC) analysis was performed to evaluate the diagnostic performance in the diagnosis of steatosis.

RESULTS

Most patients were overweight or obese (90%) and had metabolic syndrome (70%). One third suffered from diabetes. Steatosis was identified in 85 patients (81%) according to PDFF. Twenty-one patients (20%) had advanced liver disease. SSE, AC, cCAP and HRI correlated with PDFF, with respective Spearman correlation coefficient of -0.39, 0.42, 0.54 and 0.59 (P < 0.01). Area under the receiver operating characteristic curve (AUROC) for detection of steatosis with HRI was 0.91 (0.83-0.99), with the best cut-off value being 1.3 (Se = 83%, Sp = 98%). The optimal cCAP threshold of 275 dB/m, corresponding to the recent EASL-suggested threshold, had a sensitivity of 72% and a specificity of 80%. Corresponding AUROC was 0.79 (0.66-0.92). The diagnostic accuracy of cCAP was more reliable when standard deviation was < 15 dB/m with an AUC of 0.91 (0.83-0.98). An AC threshold of 0.42 dB/cm/MHz had an AUROC was 0.82 (0.70-0.93). SSE performed moderately with an AUROC of 0.73 (0.62-0.84).

CONCLUSION

Among all ultrasonographic tools evaluated in this study, including new-generation tools such as cCAP and SSE, HRI had the best performance. It is also the simplest and most available method as most ultrasound scans are equipped with this module.

Identifying Patients with Nonalcoholic Fatty Liver Disease in Primary Care: How and for What Benefit?

Despite its increasing prevalence, nonalcoholic fatty liver disease (NAFLD) remains under-diagnosed in primary care. Timely diagnosis is critical, as NAFLD can progress to nonalcoholic steatohepatitis, fibrosis, cirrhosis, hepatocellular carcinoma, and death; furthermore, NAFLD is also a risk factor linked to cardiometabolic outcomes. Identifying patients with NAFLD, and particularly those at risk of advanced fibrosis, is important so that healthcare practitioners can optimize care delivery in an effort to prevent disease progression. This review debates the practical issues that primary care physicians encounter when managing NAFLD, using a patient case study to illustrate the challenges and decisions that physicians face. It explores the pros and cons of different diagnostic strategies and tools that physicians can adopt in primary care settings, depending on how NAFLD presents and progresses. We discuss the importance of prescribing lifestyle changes to achieve weight loss and mitigate disease progression. A diagnostic and management flow chart is provided, showing the key points of assessment for primary care physicians. The advantages and disadvantages of advanced fibrosis risk assessments in primary care settings and the factors that influence patient referral to a hepatologist are also reviewed.

The Accuracy of Ultrasound Controlled Attenuation Parameter in Diagnosing Hepatic Fat Content

Purpose

The Controlled Attenuation Parameter (CAP score) is based on ultrasonic properties of retropropagated radiofrequency signals acquired by Fibroscan^TM (Echosens, Paris, France). Since ultrasound propagation is influenced by the presence of fat, CAP score was developed to quantify steatosis. The aim of this study was to delineate the accuracy of CAP in diagnosing hepatic steatosis, compared to the gold standard of liver biopsy.

Patients and Methods

A total of 150 patients underwent same-day liver biopsy and measurement of hepatic steatosis with Fibroscan. Only examinations with 10 satisfactory measurements, and an inter-quartile range of less than 30% of the median liver stiffness values were included for data analysis. Histological staging was then correlated with median values and Spearman correlation calculated. P values of <0.05 were considered statistically significant.

Results

For diagnosis of hepatic steatosis (HS), CAP could predict the steatosis S2 with AUROC 0.815 (95% CI 0.741-0.889), sensitivity (0.81) and specificity (0.73) when the optimal cut-off value was set at 288 dB/m. CAP detected histological grade S3 with AUROC 0.735 (95% CI 0.618-0.851), sensitivity (0.71) and specificity (0.74), with a cut-off value of 330 dB/m. The AUROC for steatosis grade S1 was 0.741 (95% CI 0.650-0.824), with a cut-off value of 263 dB/m with sensitivity 0.75 and specificity 0.70. Univariate analysis showed a correlation between CAP and diabetes (p 0.048).

Conclusion

The performance of CAP to diagnose steatosis severity decreases as steatosis progresses. CAP is associated with diabetes but not other clinical factors and parameters of the metabolic syndrome.

Accuracy of ultrasonographic fatty liver index using point-of-care ultrasound in stratifying non-alcoholic fatty liver disease patients

BACKGROUND

The prevalence of non-alcoholic fatty liver disease (NAFLD) is increasing in the USA. Some of these patients develop non-alcoholic steatohepatitis (NASH), which can progress to cirrhosis. Ultrasound imaging is one of the most used modalities for diagnosing hepatic steatosis. Primary care providers are increasingly using point-of-care ultrasound (POCUS), which could increase the number of subjects diagnosed with NAFLD. This study evaluates the accuracy of POCUS in identifying patients with NASH.

METHODS

Patients with hepatic steatosis without excess alcohol intake or other liver diseases undergoing liver biopsy were included in this study. These patients underwent POCUS and vibration-controlled transient elastography (VCTE) evaluations within 3 months of a liver biopsy. A comparison of POCUS data with liver histology and VCTE were made to assess the validity of POCUS evaluation in diagnosing NAFLD and NASH.

RESULTS

The steatosis score from the liver histology had a low correlation with the controlled attenuation parameter score from VCTE ( r  = 0.27) and a moderate correlation with the grade of steatosis detected by the POCUS exam ( r  = 0.57). The NAFLD activity score on histology was found to correlate with the ultrasonographic fatty liver index (USFLI) from the POCUS exam ( r  = 0.59). A USFLI ≥ 6 diagnosed NASH with a sensitivity of 81%, and a value of ≤3 ruled out the diagnosis of NASH with a sensitivity of 100%.

CONCLUSION

The provider can use the POCUS exam in clinical practice to diagnose NAFLD and reliably stratify patients who have NASH.

Diagnostic Performance of Greyscale Ultrasound in Detecting Fatty Liver Disease in a Type 2 Diabetes Population Using FibroScan as the Reference Standard

Introduction Brightness mode ultrasound (B-mode US) and FibroScan (Echosens, Paris, France) are the two ultrasound methods often recommended for screening non-alcoholic fatty liver disease (NAFLD) in persons with type 2 diabetes mellitus (T2DM). This study assessed the diagnostic performance of B-mode US using FibroScan as the reference standard. Methods Persons with a known history of T2DM were invited to screen for NAFLD using B-mode US and FibroScan on separate days within a one-month period. Assessors of B-mode US and FibroScan were blinded to each other's findings. Both B-mode US and FibroScan independently assessed and graded each participant for the presence of NAFLD. Using the diagnostic test findings of FibroScan as a reference standard, the sensitivity and specificity of B-mode US were analyzed. The area under the receiver operating characteristic curve (AUROC) was analyzed using Jamovi (version 2.3.21). A multinomial logistic regression of the B-mode US and FibroScan in predicting NAFLD grade was also analyzed. Results A total of 171 participants were assessed. B-mode US detected NAFLD in T2DM patients with 63.6% sensitivity, 65.6% specificity, and 0.646 AUROC. Sensitivity and specificity in overweight and obese participants were 36-43% and 76-85%, respectively. Multinomial logistic regression demonstrated an insignificant statistical relationship between FibroScan and B-mode US in predicting grade 1 steatosis (p-value = 0.397), which was significantly affected by a higher BMI (p-value = 0.034) rather than a higher liver fibrosis level (p-value = 0.941). The logistic regression further showed a significant relationship between B-mode US and FibroScan in predicting steatosis grade 2 (p-value = 0.045) and grade 3 (p-value < 0.001), which was not significantly affected by BMI (p-value = 0.091). Conclusion B-mode US can replace FibroScan for severe steatosis; however, it cannot be used to screen for NAFLD in T2DM patients due to lower sensitivity for early detection in the overweight.

Blood lactate levels are associated with an increased risk of metabolic dysfunction-associated fatty liver disease in type 2 diabetes: a real-world study

Aim

To investigate the association between blood lactate levels and metabolic dysfunction-associated fatty liver disease (MAFLD) in type 2 diabetes mellitus (T2DM).

Methods

4628 Chinese T2DM patients were divided into quartiles according to blood lactate levels in this real-world study. Abdominal ultrasonography was used to diagnosis MAFLD. The associations of blood lactate levels and quartiles with MAFLD were analyzed by logistic regression.

Results

There were a significantly increased trend in both MAFLD prevalence (28.9%, 36.5%, 43.5%, and 54.7%) and HOMA2-IR value (1.31(0.80-2.03), 1.44(0.87-2.20), 1.59(0.99-2.36), 1.82(1.15-2.59)) across the blood lactate quartiles in T2DM patients after adjustment for age, sex, diabetic duration, and metformin use (all p<0.001 for trend). After correcting for other confounding factors, not only increased blood lactate levels were obviously associated with MAFLD presence in the patients with (OR=1.378, 95%CI: 1.210-1.569, p<0.001) and without taking metformin (OR=1.181, 95%CI: 1.010-1.381, p=0.037), but also blood lactate quartiles were independently correlated to the increased risk of MAFLD in T2DM patients (p<0.001 for trend). Compared with the subjects in the lowest blood lactate quartiles, the risk of MAFLD increased to 1.436-, 1.473-, and 2.055-fold, respectively, in those from the second to the highest lactate quartiles.

Conclusions

The blood lactate levels in T2DM subjects were independently associated with an increased risk of MAFLD, which was not affected by metformin-taking and might closely related to insulin resistance. Blood lactate levels might be used as a practical indicator for assessing the risk of MAFLD in T2DM patients.

Non-invasive evaluation of liver steatosis with imaging modalities: New techniques and applications

In the world, nonalcoholic fatty liver disease (NAFLD) accounts for majority of diffuse hepatic diseases. Notably, substantial liver fat accumulation can trigger and accelerate hepatic fibrosis, thus contributing to disease progression. Moreover, the presence of NAFLD not only puts adverse influences for liver but is also associated with an increased risk of type 2 diabetes and cardiovascular diseases. Therefore, early detection and quantified measurement of hepatic fat content are of great importance. Liver biopsy is currently the most accurate method for the evaluation of hepatic steatosis. However, liver biopsy has several limitations, namely, its invasiveness, sampling error, high cost and moderate intraobserver and interobserver reproducibility. Recently, various quantitative imaging techniques have been developed for the diagnosis and quantified measurement of hepatic fat content, including ultrasound- or magnetic resonance-based methods. These quantitative imaging techniques can provide objective continuous metrics associated with liver fat content and be recorded for comparison when patients receive check-ups to evaluate changes in liver fat content, which is useful for longitudinal follow-up. In this review, we introduce several imaging techniques and describe their diagnostic performance for the diagnosis and quantified measurement of hepatic fat content.

The Role of Metabolic Dysfunction-Associated Fatty Liver Disease in Developing Chronic Kidney Disease: Longitudinal Cohort Study

BACKGROUND

The association between metabolic dysfunction-associated fatty liver disease (MAFLD) and chronic kidney disease (CKD) is unclear.

OBJECTIVE

This longitudinal cohort study aimed to test whether MAFLD plays an important role in the development of CKD.

METHODS

This cohort study included 41,246 participants who had undergone 3 or more health examinations from 2008 to 2015 at the People's Hospital of Guangxi Zhuang Autonomous Region, China. Participants were categorized into 2 groups according to whether they presented with or without MAFLD. The occurrence of new-onset CKD was stated as either an estimated glomerular filtration rate of <60 mL/min per 1.73 m² or a higher level of albuminuria during their follow-up appointment. The association between MAFLD and CKD was evaluated using a Cox regression method.

RESULTS

Of the 41,246 participants, 11,860 (28.8%) were diagnosed with MAFLD. Over the course of the 14-year follow-up (median 10.0 years), 5347 (13%) participants experienced a new incident of CKD (135.73 per 10,000 person-years). MAFLD was discovered as an important risk factor for new incidents of CKD (hazard ratio 1.18, 95% CI 1.11-1.26) by using the multivariable Cox proportional hazard regression model. When stratified by gender, the adjusted hazard ratio for the incidence of CKD in men and women with MAFLD were 1.16 (95% CI 1.07-1.26) and 1.32 (95% CI 1.18-1.48), respectively. According to the subgroup analysis results, after adjusting for confounding factors, the MAFLD-related CKD risk was greater in men aged <60 years (P_interaction=.001) and in those with combined dyslipidemia (P_interaction=.02), but this relationship was not found in women (all P_interaction>.05).

CONCLUSIONS

MAFLD plays an important role in the development of new incidents of CKD in the long run.

TRIAL REGISTRATION

Chinese Clinical Trial Registry ChiCTR2200058543; https://www.chictr.org.cn/showproj.html?proj=153109.

Association between triglyceride glucose-related markers and the risk of metabolic-associated fatty liver disease: a cross-sectional study in healthy Chinese participants

OBJECTIVES

This study aimed to evaluate the performance of the triglyceride glucose (TyG) index and its related markers in predicting metabolic-associated fatty liver disease (MAFLD) in healthy Chinese participants.

DESIGN

This was a cross-sectional study.

SETTING

The study was conducted at Health Management Department of the Affiliated Hospital of Xuzhou Medical University.

PARTICIPANTS

A total of 20 922 asymptomatic Chinese participants (56% men) were enrolled.

OUTCOME MEASURES

Hepatic ultrasonography was performed to diagnose MAFLD based on the latest diagnostic criteria. The TyG, TyG-body mass (TyG-BMI) and TyG-waist circumference indices were calculated and analysed.

RESULTS

Compared with the lowest quartile of the TyG-BMI, the adjusted ORs and 95% CIs for MAFLD were 20.76 (14.54 to 29.65), 92.33 (64.61 to 131.95) and 380.87 (263.25 to 551.05) in the second, third and fourth quartiles, respectively. According to the subgroup analysis, the TyG-BMI in the female and the lean groups (BMI<23 kg/m²) showed the strongest predictive value, with optimal cut-off values for MAFLD of 162.05 and 156.31, respectively. The areas under the receiver operating characteristic curves in female and lean groups were 0.933 (95% CI 0.927 to 0.938) and 0.928 (95% CI 0.914 to 0.943), respectively, with 90.7% sensitivity and 81.2% specificity in female participants with MAFLD and 87.2% sensitivity and 87.1% specificity in lean participants with MAFLD. The TyG-BMI index demonstrated superior predictive ability for MAFLD compared with other markers.

CONCLUSIONS

The TyG-BMI is an effective, simple and promising tool for predicting MAFLD, especially in lean and female participants.

Noninvasive Tests Used in Risk Stratification of Patients with Nonalcoholic Fatty Liver Disease

As the prevalence of obesity and type 2 diabetes increases around the world, the prevalence of nonalcoholic fatty liver disease (NAFLD) has grown proportionately. Although most patients with NAFLD do not experience progressive liver disease, about 15% to 20% of those with nonalcoholic steatohepatitis can and do progress. Because liver biopsy's role in NAFLD has become increasingly limited, efforts have been undertaken to develop non-invasive tests (NITs) to help identify patients at high risk of progression. The following article discusses the NITs that are available to determine the presence of NAFLD as well as high-risk NAFLD.

Low-Normal Thyroid Function Is Not Associated with Either Non-Alcoholic Fatty Liver Disease or with Metabolic Dysfunction-Associated Fatty Liver Disease

BACKGROUND

The association of low-normal thyroid function (LNTF) with non-alcoholic fatty liver disease (NAFLD) or metabolic dysfunction-associated fatty liver disease (MAFLD) is controversial; thus, the aim of this study is to determine this association.

METHODS

NAFLD was evaluated by controlled attenuation parameter of transient elastography. Patients were classified by MAFLD criteria. LNTF was defined as TSH levels of 2.5 to 4.5 mIU/L and were divided into three different cut-off points (>4.5 to 5.0, >3.1, and >2.5 mIU/L). Associations between LNTF, NAFLD, and MAFLD were evaluated by univariate and multivariate logistic regression analyses.

RESULTS

A total of 3697 patients were included; 59% (n = 2179) were male, and median age and body mass index were 48 (43-55) years and 25.9 (23.6-28.5) kg/m², respectively, and 44% (n = 1632) were diagnosed with NAFLD. THS levels of 2.5 and 3.1 showed significant associations with the presence of NAFLD and MAFLD; however, LNTF did not show an independent association with the presence of NAFLD or MAFLD in multivariate analysis. According to different cut-off points, patients with LNTF presented similar risks for NAFLD as the general population.

CONCLUSION

LNTF is not associated with NAFLD or MAFLD. Patients with high LNTF are equally at risk for NAFLD as the general population.

Waist Circumference as a Risk Factor for Non-Alcoholic Fatty Liver Disease in Older Adults in Guayaquil, Ecuador

Non-alcoholic liver steatosis is currently considered an epidemic. It involves a broad spectrum of liver diseases, in which older adults constitute a susceptible group. The aim of this study is to identify the role of waist circumference as a risk factor for non-alcoholic fatty liver disease.

METHODS

A cross-sectional study was carried out in 99 older adults who regularly attended five gerontological centers in the city of Guayaquil, Ecuador. The variables studied were age, gender, independent life, access to complete meals, waist circumference, and NAFLD diagnosed by ultrasound.

RESULTS

A significant relationship exists between waist circumference, body mass index, and fat mass percentage. However, only age and waist circumference were significant in the multivariate logistic regression model. Our results suggest that in the presence of waist circumference, body mass index loses its significance and age may be a protective factor due to adipose tissue loss and redistribution.

CONCLUSION

Anthropometric measurements such as waist circumference can be used as complement indicators of NAFLD.

Practical guideline on obesity care in patients with gastrointestinal and liver diseases - Joint ESPEN/UEG guideline

BACKGROUND

Patients with chronic gastrointestinal disease such as inflammatory bowel disease (IBD), irritable bowel syndrome (IBS), celiac disease, gastroesophageal reflux disease (GERD), pancreatitis, and chronic liver disease (CLD) often suffer from obesity because of coincidence (IBD, IBS, celiac disease) or related pathophysiology (GERD, pancreatitis and CLD). It is unclear if such patients need a particular diagnostic and treatment that differs from the needs of lean gastrointestinal patients. The present guideline addresses this question according to current knowledge and evidence.

OBJECTIVE

The present practical guideline is intended for clinicians and practitioners in general medicine, gastroenterology, surgery and other obesity management, including dietitians and focuses on obesity care in patients with chronic gastrointestinal diseases.

METHODS

The present practical guideline is the shortened version of a previously published scientific guideline developed according to the standard operating procedure for ESPEN guidelines. The content has been re-structured and transformed into flow-charts that allow a quick navigation through the text.

RESULTS

In 100 recommendations (3× A, 33× B, 24 × 0, 40× GPP, all with a consensus grade of 90% or more) care of gastrointestinal patients with obesity - including sarcopenic obesity - is addressed in a multidisciplinary way. A particular emphasis is on CLD, especially metabolic associated liver disease, since such diseases are closely related to obesity, whereas liver cirrhosis is rather associated with sarcopenic obesity. A special chapter is dedicated to obesity care in patients undergoing bariatric surgery. The guideline focuses on adults, not on children, for whom data are scarce. Whether some of the recommendations apply to children must be left to the judgment of the experienced pediatrician.

CONCLUSION

The present practical guideline offers in a condensed way evidence-based advice how to care for patients with chronic gastrointestinal diseases and concomitant obesity, an increasingly frequent constellation in clinical practice.

Comparative analyses of surrogates of metabolic syndrome in children and adolescents with metabolically healthy obesity vs. metabolically unhealthy obesity according to Damanhoury's criteria

OBJECTIVES

Metabolically healthy obesity (MHO) has been reported with varying frequencies in children. The reasons of metabolically healthy phenotype in some obese subjects are unclear. Our aim was to identify the frequency of MHO in obese subjects, to assess the potential associations of demographic characteristics, serum uric acid, alanine transaminase (ALT), pediatric nonalcoholic fatty liver disease fibsosis score probability (PNFS p) with MHO status and to evaluate the differences between MHO and metabolically unhealthy obesity (MUO) with regard to metabolic syndrome surrogates.

METHODS

251 consecutive obese subjects (125 females) aged 7-18 years were included. Subjects were classified as having MHO according to Damanhoury's criteria. Several metabolic variables were measured, PNFS p was calculated by using the formula: z=1.1+(0.34*sqrt(ALT))+ (0.002*ALP)-(1.1*log(platelets)-(0.02*GGT).

RESULTS

Median age of the subjects was 12.5 yr (range: 7.0-17.0 yr). The frequency of MHO was 41 %. Subjects with MHO were significantly younger, had lower waist circumference (WC) and waist height ratio (WHtR) and lower HOMA-IR than those without MHO(p<0.05 for all). Frequencies of hyperuricemia, hypertransaminasemia, hepatosteatosis and PNFS p values≥8 were similar betwen the groups. When putatively influential factors associated with MHO status were assessed with logistic regression analysis, only WC(β=1.03) and HOMA-IR(β=1.166) emerged as significant factors(Nagelkerke R2=0.142). None of the investigated demographic factors were associated with MHO status.

CONCLUSIONS

We found a remarkably high frequency of MHO status. Nevertheless, the absence of decreased frequencies of hyperuricemia, hypertransaminasemia and PNFS in subjects with MHO may suggest the need to reconsider the validity of the criteria defining MHO.

Effect of fatty liver and fibrosis on hepatocellular carcinoma development in patients with chronic hepatitis B who received nucleic acid analog therapy

The number of patients with fatty liver has been increasing worldwide; however, the significance of fatty liver in patients with chronic hepatitis B who are receiving nucleic acid analog (NA) therapy remains unclear. Thus, we aimed to determine whether fatty liver affects the development of hepatocellular carcinoma (HCC) in patients receiving NA therapy. This study included 445 patients who received NA therapy, and the development of HCC was investigated. The primary outcome was the association between fatty liver and HCC development. During a mean follow-up period of 7.4 years, 46 patients (10.3%) developed HCC. No significant difference in the cumulative incidence of HCC was observed between patients with fatty liver and those without (p = 0.17). Multivariable analysis for age, gender, platelet count, alanine aminotransferase level at 1 year following NA therapy, and fatty liver revealed that the presence of fatty liver was not a significant factor for HCC development (hazard ratio [HR]: 0.96, 95% confidence interval [CI]: 0.5-1.9). In another multivariable analysis for advanced fibrosis, gender, and fatty liver, advanced fibrosis was found to be a significant factor for HCC development (HR: 9.50, 95% CI: 5.1-18) but not fatty liver (HR: 0.90, 95% CI: 0.5-1.7). In conclusion, in patients with chronic hepatitis B who received NA therapy, advanced fibrosis was found to be an important risk factor for HCC development but not fatty liver, suggesting the importance of providing treatment before the progression of liver fibrosis regardless of the presence of fatty liver.

Gallstone Disease and Its Association With Nonalcoholic Fatty Liver Disease, All-Cause and Cause-Specific Mortality

BACKGROUND & AIMS

Presence of gallstone disease may influence outcomes in patients with nonalcoholic fatty liver disease (NAFLD). We studied the impact of gallstone disease on mortality in individuals with and without NAFLD.

METHODS

Prospective cohort study used the Third National Health and Nutrition Examination Survey (1988-1994) with mortality data through 2015. Gallstone disease was defined as ultrasonographic evidence of gallstones or absence of the gallbladder (prior cholecystectomy). NAFLD was defined using standardized ultrasonographic criteria.

RESULTS

Gallstone disease and cholecystectomy were independently associated with NAFLD (odds ratio [OR], 1.75; 95% confidence interval [CI], 1.43-2.15 for gallstone disease and OR, 2.77; 95% CI, 2.01-3.83 for cholecystectomy compared with no gallstone disease). During the median follow-up of 23 years, gallstone disease was associated with a higher risk of all-cause mortality (hazard ratio [HR], 1.19; 95% CI, 1.05-1.37) and cause-specific mortality. Gallstone disease was associated with a higher risk of all-cause mortality in non-NAFLD sub-cohort (HR, 1.42; 95% CI, 1.23-1.64) but not in NAFLD (HR, 1.03; 95% CI, 0.87-1.22). Gallstone disease was associated with a higher risk of cardiovascular-related (HR, 1.40; 95% CI, 1.10-1.78) and cancer-related (HR, 1.71; 95% CI, 1.18-2.48) mortality in non-NAFLD sub-cohort. Gallstone disease was associated with increased cardiovascular mortality (HR, 1.36; 95% CI, 1.05-1.77) in NAFLD.

CONCLUSIONS

Gallstone disease is an independent risk factor for NAFLD, but gallstone disease is not associated with all-cause mortality in individuals with NAFLD. Screening for gallstone disease in individuals at risk for developing NAFLD may help with risk stratification for all-cause mortality related to gallstone disease.

Development and validation of an online dynamic nomogram based on the atherogenic index of plasma to screen nonalcoholic fatty liver disease

BACKGROUND

Nonalcoholic fatty liver disease (NAFLD), a common liver disease worldwide, can be reversed early in life with lifestyle and medical interventions. This study aimed to develop a noninvasive tool to screen NAFLD accurately.

METHODS

Risk factors for NAFLD were identified using multivariate logistic regression analysis, and an online NAFLD screening nomogram was developed. The nomogram was compared with reported models (fatty liver index (FLI), atherogenic index of plasma (AIP), and hepatic steatosis index (HSI)). Nomogram performance was evaluated through internal and external validation (National Health and Nutrition Examination Survey (NHANES) database).

RESULTS

The nomogram was developed based on six variables. The diagnostic performance of the present nomogram for NAFLD (area under the receiver operator characteristic curve (AUROC): 0.863, 0.864, and 0.833, respectively) was superior to that of the HSI (AUROC: 0.835, 0.833, and 0.810, respectively) and AIP (AUROC: 0.782, 0.773, and 0.728, respectively) in the training, validation, and NHANES sets. Decision curve analysis and clinical impact curve analysis presented good clinical utility.

CONCLUSION

This study establishes a new online dynamic nomogram with excellent diagnostic and clinical performance. It has the potential to be a noninvasive and convenient method for screening individuals at high risk for NAFLD.

Multifocal nodular lesions in fatty liver mimicking neoplastic disease: a case report

Usually, fatty hepatic infiltration is diffuse and homogeneous. However, in some cases, it can be localized simulating benign or malignant tumors. We present a case of a 61-year-old female patient with family history of malignancy: sister with lung cancer, an other sister with colon cancer and a mother with breast cancer; who presented with multiple hepatic nodules at the ultrasonography images. CT scan and MRI were not sufficient to pose a certain diagnosis which was later confirmed by liver biopsy.

Risk Scores for Prediction of Major Cardiovascular Events in Non-Alcoholic Fatty Liver Disease: A No Man's Land?

Over the past 100 years, cardiovascular disease (CVD) has become a leading cause of mortality and morbidity in developed countries, and similar trends have occurred for chronic liver disease. Subsequent research also indicated that people with non-alcoholic fatty liver disease (NAFLD) had a twofold increased risk of CV events and that this risk was doubled in those with liver fibrosis. However, no validated CVD risk score specific for NAFLD patients has yet been validated, as traditional risk scores tend to underestimate the CV risk in NAFLD patients. From a practical perspective, identifying NAFLD patients and assessing severity of liver fibrosis when concurrent atherosclerotic risk factors are already established may serve as an important criterion in new CV risk scores. The current review aims to assess current risk scores and their utility for the prediction of CV events among patients with NAFLD.

TASL Practice Guidance on the Clinical Assessment and Management of Patients with Nonalcoholic Fatty Liver Disease

Nonalcoholic fatty liver disease (NAFLD) is a multisystem disease and is significantly associated with obesity, insulin resistance, type 2 diabetes mellitus, metabolic syndrome, and cardiovascular disease. NAFLD has become the most prevalent chronic liver disease in Western countries, and the proportion of NAFLD-related cirrhosis among patients on liver transplantation waiting lists has increased. In light of the accumulated data about NAFLD, and to provide a common approach with multi-disciplines dealing with the subject, it has become necessary to create new guidance for diagnosing and treating NAFLD. This guidance was prepared following an interdisciplinary study under the leadership of the Turkish Association for the Study of the Liver (TASL), Fatty Liver Special Interest Group. This new TASL Guidance is a practical application guide on NAFLD and was prepared to standardize the clinical approach to diagnosing and treating NAFLD patients. This guidance reflects many advances in the field of NAFLD. The proposals in this guidance are meant to aid decision-making in clinical practice. The guidance is primarily intended for gastroenterology, endocrinology, metabolism diseases, cardiology, internal medicine, pediatric specialists, and family medicine specialists.

Small Intestinal Bacterial Overgrowth and Non-Alcoholic Fatty Liver Disease: What Do We Know in 2023?

Non-alcoholic fatty liver disease (NAFLD) is a chronic liver disease associated with the pathological accumulation of lipids inside hepatocytes. Untreated NAFL can progress to non-alcoholic hepatitis (NASH), followed by fibrosis, cirrhosis, and hepatocellular carcinoma (HCC). The common denominator of the above-mentioned metabolic disorders seems to be insulin resistance, which occurs in NAFLD patients. Obesity is the greatest risk factor for lipid accumulation inside hepatocytes, but a part of the NAFLD patient population has a normal body weight according to the BMI index. Obese people with or without NAFLD have a higher incidence of small intestinal bacterial overgrowth (SIBO), and those suffering from NAFLD show increased intestinal permeability, including a more frequent presence of bacterial overgrowth in the small intestine (SIBO). The health consequences of SIBO are primarily malabsorption disorders (vitamin B12, iron, choline, fats, carbohydrates and proteins) and bile salt deconjugation. Undetected and untreated SIBO may lead to nutrient and/or energy malnutrition, thus directly impairing liver function (e.g., folic acid and choline deficiency). However, whether SIBO contributes to liver dysfunction, decreased intestinal barrier integrity, increased inflammation, endotoxemia and bacterial translocation is not yet clear. In this review, we focus on gut–liver axis and discuss critical points, novel insights and the role of nutrition, lifestyle, pre- and probiotics, medication and supplements in the therapy and prevention of both SIBO and NAFLD.

Development and validation of risk prediction models for new-onset type 2 diabetes in adults with impaired fasting glucose

AIMS

To develop and validate sex-specific risk prediction models based on easily obtainable clinical data for predicting 5-year risk of type 2 diabetes (T2D) among individuals with impaired fasting glucose (IFG), and generate practical tools for public use.

METHODS

The data used for model training and internal validation came from a large prospective cohort (N = 18,384). Two independent cohorts were used for external validation. A two-step approach was applied to screen variables. Coefficient-based models were constructed by multivariate Cox regression analyses, and score-based models were subsequently generated. The predictive power was evaluated by the area under the curve (AUC).

RESULTS

During a median follow-up of 7.55 years, 5697 new-onset T2D cases were identified. Predictor variables included age, body mass index, waist circumference, diastolic blood pressure, triglycerides, fasting plasma glucose, and fatty liver. The proposed models outperformed five existing models. In internal validation, the AUCs of the coefficient-based models were 0.741 (95% CI 0.723-0.760) for men and 0.762 (95% CI 0.720-0.802) for women. External validation yielded comparable prediction performance. We finally constructed a risk scoring system and a web calculator.

CONCLUSIONS

The risk prediction models and derived tools had well-validated performance to predict the 5-year risk of T2D in IFG adults.

Association between metabolic dysfunction-associated fatty liver disease and supraventricular and ventricular tachyarrhythmias in patients with type 2 diabetes

BACKGROUND

Currently, it remains uncertain whether metabolic dysfunction-associated fatty liver disease (MAFLD) is associated with increased risk of supraventricular and ventricular tachyarrhythmias in people with type 2 diabetes mellitus (T2DM).

METHODS

We retrospectively examined the data of 367 ambulatory patients with T2DM who underwent 24-hour Holter monitoring between 2015 and 2022 for clinical indications, and who did not have pre-existing permanent atrial fibrillation (AF), kidney failure or known liver diseases. Paroxysmal supraventricular tachycardia (PSVT), paroxysmal AF and episodes of ventricular tachyarrhythmias (i.e., presence of ventricular tachycardia, >30 premature ventricular complexes per hour, or both) were recorded. The presence and severity of MAFLD was diagnosed by ultrasonography and fibrosis-4 (FIB-4) index.

RESULTS

Patients with T2DM who had MAFLD (n = 238) had a significantly greater prevalence of PSVT (51.7% vs. 38.8%), paroxysmal AF (6.3% vs. 1.3%) and combined ventricular tachyarrhythmias (31.9% vs. 20.2%) compared to their counterparts without MAFLD (n = 129). MAFLD was significantly associated with a greater than two-fold risk of having PSVT (adjusted-odds ratio [OR] 2.04, 95% confidence interval 1.04-4.00) or ventricular tachyarrhythmias (adjusted-OR 2.44, 95%CI 1.16-5.11), after adjusting for age, sex, smoking, alcohol intake, diabetes-related factors, comorbidities, medication use and left ventricular ejection fraction on echocardiography. The risk of supraventricular and ventricular tachyarrhythmias was even greater amongst patients with MAFLD and FIB-4 ≥ 1.3.

CONCLUSIONS

In ambulatory patients with T2DM, the presence and severity of MAFLD was strongly associated with an increased risk of supraventricular and ventricular arrhythmias on 24-hour Holter monitoring.

Protein foods from animal sources and risk of nonalcoholic fatty liver disease in representative cohorts from North and South China

BACKGROUND

Emerging evidence suggests that animal protein foods may increase the risk of nonalcoholic fatty liver disease (NAFLD). We therefore examined the NAFLD risk reduction related to substituting plant protein foods for animal protein foods.

METHODS

The cohort in North China included 14,541 participants from the Tianjin Chronic Low-Grade Systemic Inflammation and Health (TCLSIH) study, and the cohort in South China included 1297 participants from the Guangzhou Nutrition and Health Study (GNHS). Dietary intake was assessed using validated food frequency questionnaires. NAFLD was ascertained by abdominal ultrasound. The Cox model was used to fit the substitution analysis.

RESULTS

In the TCLSIH cohort, when replacing one type of animal protein food (eggs, processed meat, unprocessed red meat, poultry, and fish) with an equivalent serving of plant protein foods (nuts, legumes, and whole grains), the replacement of animal protein foods with whole grains showed the strongest benefit; substituting one serving per day of whole grains for an equal amount of eggs (hazard ratio [HR] = 0.89; 95% confidence interval [CI]: 0.79, 1.00), processed meat (HR = 0.76; 95% CI: 0.64, 0.91), unprocessed red meat (HR = 0.90; 95% CI: 0.81, 1.00), poultry (HR = 0.81; 95% CI: 0.72, 0.92), or fish (HR = 0.87; 95% CI: 0.78, 0.97) was associated with a lower risk of NAFLD. In both the TCLSIH and GNHS cohorts, replacing poultry with fish, nuts, legumes, or whole grains was associated with a lower risk of NAFLD. When different numbers of protein foods were simultaneously replaced, the risk reduction of NAFLD was stronger.

CONCLUSIONS

Our findings suggest that replacing animal protein foods with plant protein foods is related to a significant reduction in NAFLD risk.

Ultrasound-based hepatic fat quantification: current status and future directions

Non-alcoholic fatty liver disease (NAFLD) is a spectrum of disease from fatty accumulation (steatosis), necro-inflammation though to fibrosis. It is of increasing global prevalence as a hepatic manifestation of the metabolic syndrome. Although accurate histopathology and magnetic resonance imaging techniques for hepatic fat quantification exist, these are limited by invasiveness and availability, respectively. Ultrasonography is potentially ideal for assessing and monitoring hepatic steatosis given the examination is rapid and readily available. Traditional ultrasound methods include qualitative B-mode for imaging markers, such as increased hepatic parenchymal echogenicity compared to adjacent renal cortex are commonplace; however, there is acknowledged significant interobserver variability and they are suboptimal for detecting mild steatosis. Recently quantitative ultrasound metrics have been investigated as biomarkers for hepatic steatosis. These methods rely on changes in backscatter, attenuation, and speed of sound differences encountered in a steatotic liver. Prospective studies using quantitative ultrasound parameters show good diagnostic performance even at low steatosis grades and in NAFLD. This review aims to define the clinical need for ultrasound-based assessments of liver steatosis, to describe briefly the physics that underpins the various techniques available, and to assess the evidence base for the effectiveness of the techniques that are available commercially from various ultrasound vendors.

Metabolic dysfunction-associated fatty liver disease can significantly increase the risk of chronic kidney disease in adults with type 2 diabetes

AIMS

This study is to explore the relationship between metabolic dysfunction-associated fatty liver disease (MAFLD) and chronic kidney disease (CKD) among populations with type 2 diabetes through longitudinal cohort study.

METHODS

3,627 subjects who had received at least three health examinations between 2008 and 2015 were included. CKD was stated as subjects with an eGFR < 60 mL/min per 1·73 m2 or the occurrence of 2 or more proteinuria during their follow-up.

RESULTS

After median of 10·0 years follow up, 837 (23·1%) developed CKD (244·7 per 10,000 person-years; 95 % CI, 228.4 - 261·8). MAFLD ([HR] 1·46; 95 % CI 1·26-1·70, P < 0.001) acts as an important risk factor of developing CKD. After adjusting for confounding factors, this association was consistent (HR 1·30; 95 % CI 1·11-1·53, P < 0.001). In stratified analysis, subjects aged < 60 years were likely to have greater risk of MAFLD-related CKD (HR 1·58 and 1·03; 95 % CI 1·28-1·95 and 0·79-1·33, P < 0.001 in both cases, respectively).

CONCLUSIONS

The risk of developing CKD in type 2 diabetes adults with MAFLD was higher, especially if they are below 60 years old. This study underscores the importance of early prevention strategies for MAFLD to reduce the occurrence of CKD in type 2 diabetes adults.

Hepatobiliary manifestations following two-stages elective laparoscopic restorative proctocolectomy for patients with ulcerative colitis: A prospective observational study

BACKGROUND

Hepatobiliary manifestations occur in ulcerative colitis (UC) patients. The effect of laparoscopic restorative proctocolectomy (LRP) with ileal pouch anal anastomosis (IPAA) on hepatobiliary manifestations is debated.

AIM

To evaluate hepatobiliary changes after two-stages elective laparoscopic restorative proctocolectomy for patients with UC.

METHODS

Between June 2013 and June 2018, 167 patients with hepatobiliary symptoms underwent two-stage elective LRP for UC in a prospective observational study. Patients with UC and having at least one hepatobiliary manifestation who underwent LRP with IPAA were included in the study. The patients were followed up for four years to assess the outcomes of hepatobiliary manifestations.

RESULTS

The patients' mean age was 36 ± 8 years, and males predominated (67.1%). The most common hepatobiliary diagnostic method was liver biopsy (85.6%), followed by Magnetic resonance cholangiopancreatography (63.5%), Antineutrophil cytoplasmic antibodies (62.5%), abdominal ultrasonography (35.9%), and Endoscopic retrograde cholangiopancreatography (6%). The most common hepatobiliary symptom was Primary sclerosing cholangitis (PSC) (62.3%), followed by fatty liver (16.8%) and gallbladder stone (10.2%). 66.4% of patients showed a stable course after surgery. Progressive or regressive courses occurred in 16.8% of each. Mortality was 6%, and recurrence or progression of symptoms required surgery for 15%. Most PSC patients (87.5%) had a stable course, and only 12.5% became worse. Two-thirds (64.3%) of fatty liver patients showed a regressive course, while one-third (35.7%) showed a stable course. Survival rates were 98.8%, 97%, 95.8%, and 94% at 12 mo, 24 mo, 36 mo, and at the end of the follow-up.

CONCLUSION

In patients with UC who had LRP, there is a positive impact on hepatobiliary disease. It caused an improvement in PSC and fatty liver disease. The most prevalent unchanged course was PSC, while the most common improvement was fatty liver disease.

Ultrasound-Based Machine Learning Approach for Detection of Nonalcoholic Fatty Liver Disease

OBJECTIVES

Current diagnosis of nonalcoholic fatty liver disease (NAFLD) relies on biopsy or MR-based fat quantification. This prospective study explored the use of ultrasound with artificial intelligence for the detection of NAFLD.

METHODS

One hundred and twenty subjects with clinical suspicion of NAFLD and 10 healthy volunteers consented to participate in this institutional review board-approved study. Subjects were categorized as NAFLD and non-NAFLD according to MR proton density fat fraction (PDFF) findings. Ultrasound images from 10 different locations in the right and left hepatic lobes were collected following a standard protocol. MRI-based liver fat quantification was used as the reference standard with >6.4% indicative of NAFLD. A supervised machine learning model was developed for assessment of NAFLD. To validate model performance, a balanced testing dataset of 24 subjects was used. Sensitivity, specificity, positive predictive value, negative predictive value, and overall accuracy with 95% confidence interval were calculated.

RESULTS

A total of 1119 images from 106 participants was used for model development. The internal evaluation achieved an average precision of 0.941, recall of 88.2%, and precision of 89.0%. In the testing set AutoML achieved a sensitivity of 72.2% (63.1%-80.1%), specificity of 94.6% (88.7%-98.0%), positive predictive value (PPV) of 93.1% (86.0%-96.7%), negative predictive value of 77.3% (71.6%-82.1%), and accuracy of 83.4% (77.9%-88.0%). The average agreement for an individual subject was 92%.

CONCLUSIONS

An ultrasound-based machine learning model for identification of NAFLD showed high specificity and PPV in this prospective trial. This approach may in the future be used as an inexpensive and noninvasive screening tool for identifying NAFLD in high-risk patients.