Non-alcoholic fatty liver disease: a new and important cardiovascular risk factor?

Risk factors for cardiovascular disease in patients with non-alcoholic fatty liver disease with polymorbidity

Aim.To study the associations of the frequency and values of parameters of the main risk factors (RF) of cardiovascular diseases (CVD) and the degree of transnosological polymorbidity (PM) in patients with nonalcoholic fatty liver disease (NAFLD).

Material and methods. The analysis of 3667 medical records (men, women) treated in the clinic of Research Institute of Experimental and Clinical Medicine (Novosibirsk) was carried out. Index of polymorbidity was evaluated by the number of nosological forms in accordance with the International Classification of Diseases, 10th revision (ICD-10). The following risk factors were assessed according to clinical and laboratory tests: arterial hypertension, dyslipidemia, hyperglycemia, obesity.

Results.Both among men and women with increasing index of PM there was identified growth of the parameters that determine the main RF: systolic BP, diastolic BP, obesity (both in men and women), atherogenicity index (in women), glucose concentration in the blood serum (in women). Frequency of AH occurrence in persons with a high degree of PM among men was 49%, and among women — 69% higher, compared with persons with a low degree of PM. Among men, there was an increase in the incidence of AH (by 9%) and obesity (by 9%) in individuals with a high degree of PM, compared with individuals with an average degree of PM. Among women, there was an increase in the incidence of AH (by 15%), obesity (by 9%), hyperglycemia (by 11%) in persons with a high degree of PM, compared with individuals with an average degree of PM.

Conclusion.There was established the role of risk factors for cardiovascular diseases, arterial hypertension mainly, in the development of polymorbidity in patients with NAFLD. The findings indicate the need for personified prevention and treatment of such patients with mandatory identification and correction of modifiable CVD RF.

Non-alcoholic fatty liver disease and risk of incident acute myocardial infarction and stroke: findings from matched cohort study of 18 million European adults

OBJECTIVE

To estimate the risk of acute myocardial infarction (AMI) or stroke in adults with non-alcoholic fatty liver disease (NAFLD) or non-alcoholic steatohepatitis (NASH).

DESIGN

Matched cohort study.

SETTING

Population based, electronic primary healthcare databases before 31 December 2015 from four European countries: Italy (n=1 542 672), Netherlands (n=2 225 925), Spain (n=5 488 397), and UK (n=12 695 046).

PARTICIPANTS

120 795 adults with a recorded diagnosis of NAFLD or NASH and no other liver diseases, matched at time of NAFLD diagnosis (index date) by age, sex, practice site, and visit, recorded at six months before or after the date of diagnosis, with up to 100 patients without NAFLD or NASH in the same database.

MAIN OUTCOME MEASURES

Primary outcome was incident fatal or non-fatal AMI and ischaemic or unspecified stroke. Hazard ratios were estimated using Cox models and pooled across databases by random effect meta-analyses.

RESULTS

120 795 patients with recorded NAFLD or NASH diagnoses were identified with mean follow-up 2.1-5.5 years. After adjustment for age and smoking the pooled hazard ratio for AMI was 1.17 (95% confidence interval 1.05 to 1.30; 1035 events in participants with NAFLD or NASH, 67 823 in matched controls). In a group with more complete data on risk factors (86 098 NAFLD and 4 664 988 matched controls), the hazard ratio for AMI after adjustment for systolic blood pressure, type 2 diabetes, total cholesterol level, statin use, and hypertension was 1.01 (0.91 to 1.12; 747 events in participants with NAFLD or NASH, 37 462 in matched controls). After adjustment for age and smoking status the pooled hazard ratio for stroke was 1.18 (1.11 to 1.24; 2187 events in participants with NAFLD or NASH, 134 001 in matched controls). In the group with more complete data on risk factors, the hazard ratio for stroke was 1.04 (0.99 to 1.09; 1666 events in participants with NAFLD, 83 882 in matched controls) after further adjustment for type 2 diabetes, systolic blood pressure, total cholesterol level, statin use, and hypertension.

CONCLUSIONS

The diagnosis of NAFLD in current routine care of 17.7 million patient appears not to be associated with AMI or stroke risk after adjustment for established cardiovascular risk factors. Cardiovascular risk assessment in adults with a diagnosis of NAFLD is important but should be done in the same way as for the general population.

Cardiovascular Risk in Fatty Liver Disease: The Liver-Heart Axis-Literature Review

According to the World Health Organization, cardiovascular disease (CVD) remains the leading cause of death worldwide, accounting for approximately 18 million deaths per year. Nevertheless, the worldwide prevalence of metabolic diseases, such as type 2 diabetes mellitus, obesity, and non-alcoholic fatty liver disease (NAFLD), also known to be common risk factors for CVD, have dramatically increased over the last decades. Chronic alcohol consumption is a major cause of chronic liver diseases (CLD) as well as being a major health care cost expenditure accounting for the spending of tremendous amounts of money annually. NAFLD has become one of the major diseases plaguing the world while standing as the most common cause of liver disease in the Western countries by representing about 75% of all CLD. Currently, the most common cause of death in NAFLD remains to be CVD. Several mechanisms have been suggested to be responsible for associating FLD with CVD through several mechanisms including low-grade systemic inflammation, oxidative stress, adipokines, endoplasmic reticulum stress, lipotoxicity and microbiota dysbiosis which may also be influenced by other factors such as genetic and epigenetic variations. Despite of all this evidence, the exact mechanisms of how FLD can causally contribute to CVD are not fully elucidated and much remains unknown. Moreover, the current literature supports the increasing evidence associating FLD with several cardiovascular (CV) adverse events including coronary artery disease, increased subclinical atherosclerosis risk, structural alterations mainly left ventricular hypertrophy, increased epicardial fat thickness, valvular calcifications including aortic valve sclerosis and mitral annular calcification and functional cardiac modifications mainly diastolic dysfunction in addition to cardiac arrhythmias such as atrial fibrillation and ventricular arrythmias and conduction defects including atrioventricular blocks and bundle branch blocks. Patients with FLD should be evaluated and managed accordingly in order to prevent further complications. Possible management methods include non-pharmacological strategies including life style modifications, pharmacological therapies as well as surgical management. This review aims to summarize the current state of knowledge regarding the pathophysiological mechanisms linking FLD with an increased CV risk, in addition to associated CV adverse events and current management modalities.

Alcoholic and non-alcoholic fatty liver disease and associations with coronary artery calcification: evidence from the Kangbuk Samsung Health Study

OBJECTIVE

Recent evidence suggests that alcoholic fatty liver disease (AFLD) and non-alcoholic fatty liver disease (NAFLD) may differentially affect risk of cardiovascular mortality. To investigate whether early liver disease due to AFLD or NAFLD have similar or dissimilar effects on risk of early coronary artery atherosclerosis, we have investigated the associations between AFLD and NAFLD and coronary artery calcium (CAC).

DESIGN

A cross-sectional study was performed in 105 328 Korean adults who attended a health check-up programme. CAC score was assessed using CT, daily alcohol intake was recorded as grams/day and liver fat by ultrasound. Logistic regression model was used to calculate ORs with 95% CIs for prevalent CAC.

RESULTS

Both NAFLD and AFLD were positively associated with CAC score. After adjusting for potential confounders, multivariable-adjusted OR (95% CIs) for CAC >0 comparing NAFLD and AFLD to the reference (absence of both excessive alcohol use and fatty liver disease) were 1.10 (95% CI 1.05 to 1.16) and 1.20 (95% CI 1.11 to 1.30), respectively. In post hoc analysis, OR (95% CI) for detectable CAC comparing AFLD to NAFLD was 1.09 (95% CI 1.01 to 1.17). Associations of NAFLD and AFLD with CAC scores were similar in both non-obese and obese individuals without significant interaction by obesity (p for interaction=0.088). After adjusting for homeostasis model assessment of insulin resistance and high-sensitivity C reactive protein, the associations between fatty liver disease and CAC scores remained statistically significant.

CONCLUSION

In this large sample of young and middle-aged individuals, early liver disease due to NAFLD and AFLD were both significantly associated with the presence of coronary artery calcification.

Nonalcoholic Fatty Liver Disease and Diabetes: An Epidemiological Perspective

Nonalcoholic fatty liver disease (NAFLD) is thought to stem from the body's inability to store excess energy in adipocytes; as such, it is commonly viewed as the hepatic manifestation of metabolic syndrome. The pathogenesis of NAFLD involves ectopic fat accumulation, which also takes place in the liver, muscle and visceral fat. NAFLD is rapidly becoming more widespread in Korea, with an estimated prevalence of 30% in adults. Type 2 diabetes mellitus (T2DM) and NAFLD share insulin resistance as a common pathophysiological mechanism, and each of these two diseases affects the development of the other. Recent studies have suggested that NAFLD is often present as a comorbidity in T2DM patients. The mutual interrelationship between these conditions is shown by findings suggesting that T2DM can exacerbate NAFLD by promoting progression to nonalcoholic hepatosteatosis or fibrosis, while NAFLD causes the natural course of diabetic complications to worsen in T2DM patients. It remains unknown whether one disease is the cause of the other or vice versa. In this review, I would like to discuss current epidemiological data on the associations between NAFLD and T2DM, and how each disease affects the course of the other.

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

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

Vitamin D and Cardio-Metabolic Risk Factors in Overweight Adults: An Overview of the Evidence

BACKGROUND

Several studies have suggested a potential association between low vitamin D serum levels and several pathological conditions apart from the well-known bone disorders. Thus, vitamin D insufficiency has been linked to cardiometabolic risk factors including obesity, insulin resistance, hypertension, dyslipidemia, as well as type 2 diabetes and cardiovascular disease.

OBJECTIVE

This review intends to provide an overview of recent evidence from clinical studies on vitamin D [25- hydroxyvitamin D (25(OH)D)] and cardiometabolic risk factors in overweight adults. Furthermore, we also discussed potential mechanisms and limits of the retrieved results.

METHODS

The search process was based on the selection of publications (RCT) listed in PubMed and Cochrane Library databases.

RESULTS

Vitamin D status evidenced an inversely strong association with subcutaneous adipose tissue and visceral adiposity, but not significantly related to other bodyweight measures (i.e., body mass index). Studies have shown a potential inverse association of hypovitaminosis D with insulin resistance and cardiovascular risk factors.

CONCLUSION

The mechanisms by which vitamin D deficiency enhances adiposity, as well as putative association with metabolic syndrome features, remain still unclear. Further investigation would be required to conclude whether vitamin D has an independent role in preventing cardiometabolic disorders.

Evaluation of left atrial function in type 2 diabetes mellitus patients with nonalcoholic fatty liver disease by two-dimensional speckle tracking echocardiography

OBJECTIVE

To assess left atrial function in type 2 diabetes mellitus (T2DM) patients with nonalcoholic fatty liver disease (NAFLD) by two-dimensional speckle tracking echocardiography (2D-STE).

METHODS

We classified 97 patients with T2DM into three groups according to the results of liver ultrasonography: group A (without NAFLD), group B (mild fatty liver), and group C (moderate to severe fatty liver). Conventional echocardiography parameters included left atrial end-systolic diameter (LAD), left ventricular end-systolic and end-diastolic diameter (LVDs, LVDd), end-diastolic thickness of ventricular septumi and LV posterior wall (IVSTd, LVPWTd), peak E and A of mitralis (E, A), septal and lateral early (e') mitral annular diastolic tissue velocities, then calculated E/A and E/mean e'. We measured LV ejection fraction (LVEF) and left atrial (LA) volumes (max, min, and preatrial contraction volume) by Simpson's rule, then calculated LA passive and active ejection fraction (LAPEF, LAAEF), left atrial maximum volume index (LAVImax). The global peak longitudinal systolic strain (LASRs), early diastolic strain (LASRe), and late diastolic strain (LASRa) rates of the LA were obtained by 2D-STE.

RESULTS

No differences were found between groups A and B (all P > 0.05). In group C, LAAEF and LASRa were obviously higher, while LAPEF, LASRe, and LASRs were obviously decreased compared with those values in groups A and B (all P < 0.05). The association between the severity of NAFLD and the differences in LA strain values remained significant after adjustment for confounders.

CONCLUSION

Two-dimensional speckle tracking echocardiography can evaluate the left atrial function in T2DM patients with NAFLD.

Atrial fibrillation is highly prevalent yet undertreated in patients with biopsy-proven nonalcoholic steatohepatitis

BACKGROUND & AIMS

Nonalcoholic steatohepatitis (NASH) is associated with increased cardiovascular disease. Atrial fibrillation is a prominent risk marker for underlying cardiovascular disease with a prevalence of 2% in patients <65 years old. Atrial fibrillation prevalence in NASH is unknown. We sought to assess the prevalence and impact of atrial fibrillation on healthcare utilization in NASH.

METHODS

Patients were identified from a tertiary care centre Electronic Database from 2002 to 2015. International Classification of Diseases 9 (ICD9) codes identified comorbidities and atrial fibrillation. Descriptive statistics were used to compare characteristics between patients with NASH with and without atrial fibrillation.

RESULTS

Of 9108 patients with ICD9 diagnosis of NASH, 215 (2.3%, mean age 57 years, 32% male) had biopsy-proven NASH. Atrial fibrillation prevalence was 4.6%. Patients with NASH and atrial fibrillation had a higher prevalence of heart failure (54.5% vs 8.8%, P < 0.001) and cerebrovascular (27.3% vs 2.0%, P < 0.001) or vascular disease (54.5% vs 13.2%, P = 0.002), compared to NASH without atrial fibrillation. All patients with NASH and atrial fibrillation had a CHA2DS2VASc score ≥2 indicating high stroke risk and need for anticoagulation. Eight of 10 patients were eligible for anticoagulation and 5 of 8 (62.5%) received appropriate therapy.

CONCLUSION

Atrial fibrillation prevalence is two-fold higher in patients with NASH compared to the general population. Patients with NASH have a high risk of stroke; however, many do not receive appropriate guideline-directed therapy. Future studies are needed to identify whether guideline-based management of atrial fibrillation in NASH reduces cardiovascular morbidity and mortality.

Association between Non-Alcoholic Fatty Liver Disease and Intracerebral Hemorrhage

To determine whether non-alcoholic fatty liver disease (NAFLD) and intracerebral hemorrhage (ICH) are connected, and assess the role played by NAFLD in ICH development. A retrospective study evaluated inpatients treated at the First Affiliated Hospital of Zhejiang University. We divided the patients into Group A (ICH with NAFLD) and Group B (ICH alone). Moreover, univariate and multivariate logistic regression analyses were performed to identify the risk factors for unfavorable outcomes. A total of 128 patients were included: 34 ICH with NAFLD (group A) and 94 ICH (group B). Sixteen patients exhibited an unfavorable outcome. There was no significant difference among the two groups on the underlying diseases hypertension and heart disease. Group A had more diabetes mellitus cases (35.29% vs 12.76%, p = 0.004). Levels of alanine aminotransferase and triglyceride were higher in group A than in group B (all p < 0.05), while differences in other blood biochemistry tests were statistically insignificant (all p > 0.05). There was a similarity in bleeding sites except for brainstem hemorrhage, which was higher in group B patients (p = 0.036). Multivariate logistic regression analysis revealed that low-density lipoprotein (OR, 0.278; 95% CI (0.107–0.702), p = 0.008) was a protective factor for ICH patients with NAFLD. The National Institute of Health Stroke Scale (NIHSS) score at discharge (OR, 3.152; 95% CI (1.532–6.486), p = 0.002) was independent of risk factors for unfavorable outcomes. Serum levels of LDL was a protective factor. NAFLD did not increase the unfavorable outcome of ICH patients in our study.

G Protein-Coupled Receptor Kinase 2 (GRK2) as a Potential Therapeutic Target in Cardiovascular and Metabolic Diseases

G protein-coupled receptor kinase 2 (GRK2) is a central signaling node involved in the modulation of many G protein-coupled receptors (GPCRs) and also displaying regulatory functions in other cell signaling routes. GRK2 levels and activity have been reported to be enhanced in patients or in preclinical models of several relevant pathological situations, such as heart failure, cardiac hypertrophy, hypertension, obesity and insulin resistance conditions, or non-alcoholic fatty liver disease (NAFLD), and to contribute to disease progression by a variety of mechanisms related to its multifunctional roles. Therefore, targeting GRK2 by different strategies emerges as a potentially relevant approach to treat cardiovascular disease, obesity, type 2 diabetes, or NAFLD, pathological conditions which are frequently interconnected and present as co-morbidities.

Nonalcoholic Fatty Liver Disease in Diabetes. Part I: Epidemiology and Diagnosis

Nonalcoholic fatty liver disease (NAFLD) and diabetes are common metabolic disorders whose prevalence rates are expected to rise worldwide, corresponding to aging and increasingly obese populations. Compared to the general population (around 25%), 50% to 70% of people with diabetes have NAFLD, and NAFLD severity (including fibrosis) tends to be worsened by the presence of diabetes. NAFLD is considered an emerging risk factor for type 2 diabetes mellitus and a contributor to the development of chronic diabetes-related complications. This reciprocal relationship demonstrates the importance of confirming suspected NAFLD in patients with diabetes. Due to the invasive nature of liver biopsy to assess NAFLD status, various alternative non-invasive modalities have been developed and validated. Here, we summarized the epidemiology of NAFLD in patients with diabetes and reviewed currently available imaging modalities and biomarker-based prediction models for their ability to detect liver steatosis and/or fibrosis.

Effects of liver function, insulin resistance and inflammatory factors on vascular endothelial dilation function and prognosis of coronary heart disease patients complicated with NAFLD

Effects of liver function, insulin resistance (IR) and inflammatory factors on vascular endothelial dilation function and prognosis of coronary heart disease (CHD) patients complicated with non-alcoholic fatty liver disease (NAFLD) were investigated. A total of 80 patients with CHD treated in Jinan Central Hospital from October 2016 to July 2017 were randomly enrolled and divided into the NAFLD group (n=41) and the simple CHD group (n=39). The IR, the vascular endothelial dilation function and the related inflammatory factors were also detected, followed by statistical analysis. The level of high-sensitivity C-reactive protein (hs-CRP), serum total bilirubin and alanine aminotransferase (ALT) levels and body mass index in the NAFLD group was decreased and the expression of tumor necrosis factor-α was increased compared with that in the simple CHD group (P<0.05). There was a linearly positive correlation between ALT and brachial artery diameter in the NAFLD group (r=0.311, P<0.05). There was a correlation between homeostasis model assessment-IR (HOMA-IR) and HOMA-β indexes and brachial artery diameter, hs-CRP and brachial artery diameter in both groups (r=−0.128, r=0.219, P<0.05). The HOMA indexes in the NAFLD group were increased compared with those in the simple CHD group (P<0.01). There were significant differences in the intima-media thickness, number of carotid plaques and detection rate of carotid plaques (P<0.05). The risk of cardiovascular events within 10 years in the NAFLD group was increased compared with that in the simple CHD group. The differences of incidence of cardiovascular diseases (CVD)s were statistically significant (P<0.05). Therefore, The changes in liver function indexes, IR and related inflammatory factors in CHD patients complicated with NAFLD significantly affect the vascular endothelial dilation function, which also have some effects on the occurrence of CVDs.

Impact of Non-alcoholic Fatty Liver Disease on long-term cardiovascular events and death in Chronic Obstructive Pulmonary Disease

Chronic Obstructive Pulmonary Disease (COPD) and Non-Alcoholic Fatty Liver Disease (NAFLD) both independently increase cardiovascular risk. We hypothesized that NAFLD might increase the incidence of cardiovascular disease and death in COPD patients. The relationship between NAFLD, incident cardiovascular events, and death was assessed in a prospective cohort of COPD patients with 5-year follow-up. Noninvasive algorithms combining biological parameters (FibroMax®) were used to evaluate steatosis, non-alcoholic steatohepatitis (NASH) and liver fibrosis. Univariate and multivariate Cox regression models were used to assess the hazard for composite outcome at the endpoint (death or cardiovascular event) for each liver pathology. In 111 COPD patients, 75% exhibited liver damage with a prevalence of steatosis, NASH and fibrosis of 41%, 37% and 61%, respectively. During 5-year follow-up, 31 experienced at least one cardiovascular event and 7 died. In univariate analysis, patients with liver fibrosis had more cardiovascular events and higher mortality (Hazard ratio [95% CI]: 2.75 [1.26; 6.03]) than those with no fibrosis; this remained significant in multivariate analysis (Hazard ratio [95% CI]: 2.94 [1.18; 7.33]). We also found that steatosis and NASH were not associated with increased cardiovascular events or mortality. To conclude, early assessment of liver damage might participate to improve cardiovascular outcomes in COPD patients.

Association of alanine aminotransferase concentration with cardiometabolic risk factors in children and adolescents: the CASPIAN-V cross-sectional study

BACKGROUND

It has been suggested that the levels of some liver enzymes, and especially alanine aminotransferase (ALT), might be correlatable with cardiometabolic risk factors. We investigated the relationship between ALT concentration and cardiometabolic risk factors among children and adolescents.

DESIGN AND SETTING

This nationwide study in Iran was conducted within the framework of the fifth survey of a national surveillance program known as the Childhood and Adolescence Surveillance and PreventIon of Adult Non-communicable disease study (CASPIAN-V).

METHODS

The participants comprised 4200 students aged 7-18 years, who were recruited through multi-stage random cluster sampling in 30 provinces in Iran. Physical examinations and laboratory tests were conducted in accordance with standard protocols.

RESULTS

Overall, 3843 students (participation rate: 91.5%) completed the survey. Mean ALT levels were significantly higher in individuals with dyslipidemia, in terms of elevated total cholesterol (TC) or LDL-cholesterol or triglycerides (TG), excess weight and dyslipidemia. Some cardiometabolic risk factors were associated with higher levels of ALT, with the following odds ratio (OR) and 95% confidence interval (CI):metabolic syndrome (OR: 1.013; 95% CI: 1.001-1.025); elevated TC (OR: 1.060; 95% CI: 1.039-1.081), elevated LDL (OR: 1.031; 95% CI: 1.016-1.046), elevated TG (OR: 1.056; 95% CI: 1.040-1.072) and dyslipidemia (OR: 1.051; 95% CI: 1.034-1.068).

CONCLUSION

This large population-based study revealed that some cardiometabolic risk factors were significantly associated with ALT levels. These findings suggest that an association with fatty liver is an underlying mechanism for development of cardiometabolic risk factors.

Perivascular adipose tissue (PVAT) in atherosclerosis: a double-edged sword

Perivascular adipose tissue (PVAT), the adipose tissue that surrounds most of the vasculature, has emerged as an active component of the blood vessel wall regulating vascular homeostasis and affecting the pathogenesis of atherosclerosis. Although PVAT characteristics resemble both brown and white adipose tissues, recent evidence suggests that PVAT develops from its own distinct precursors implying a closer link between PVAT and vascular system. Under physiological conditions, PVAT has potent anti-atherogenic properties mediated by its ability to secrete various biologically active factors that induce non-shivering thermogenesis and metabolize fatty acids. In contrast, under pathological conditions (mainly obesity), PVAT becomes dysfunctional, loses its thermogenic capacity and secretes pro-inflammatory adipokines that induce endothelial dysfunction and infiltration of inflammatory cells, promoting atherosclerosis development. Since PVAT plays crucial roles in regulating key steps of atherosclerosis development, it may constitute a novel therapeutic target for the prevention and treatment of atherosclerosis. Here, we review the current literature regarding the roles of PVAT in the pathogenesis of atherosclerosis.

Non-alcoholic fatty liver disease-From the cardiologist perspective

Non-alcoholic fatty liver disease (NAFLD) includes a range of disorders characterized by excess accumulation of triglycerides within the liver. While simple steatosis may be clinically stable, non-alcoholic steatohepatitis (NASH) can be progressive. Inflammation is believed to be the driving force behind NASH and the progression to fibrosis and subsequent cirrhosis. NAFLD is globally considered a significant health concern not only because of its incidence but also because of its economic impact. The fact that NAFLD is associated with cardiovascular disease is widely recognized, as well as the fact that NAFLD patient mortality rises when such an association is present. In particular, NAFLD is associated with coronary and carotid atherosclerosis, endothelial dysfunction and arterial rigidity, ventricles function, valves morphology, congestive heart failure, and arrhythmias (especially atrial fibrillation). Additionally, the hypercoagulability status in NAFLD patient may be suggested by the presence of inflammatory and coagulation markers. In order to differentiate between milder forms and the more severe ones that necessitate aggressive therapy, individualized risk scores may be used. This narrative review will analyze and interpret the papers published in PubMed in the last 16 years, in an attempt to expand our understanding of the NASH as a possible cardiovascular risk factor.

Association of non-alcoholic fatty liver disease with cardiovascular disease and subclinical atherosclerosis

Non-alcoholic fatty liver disease (NAFLD) refers to fatty infiltration of liver in the absence of significant alcohol intake, use of steatogenic medication, or hereditary disorders. It is a common cause of chronic liver disease with a worldwide estimated prevalence ranging from 6.3% to 33%. The NAFLD is considered a hepatic manifestation of the metabolic syndrome. Insulin resistance and increased oxidative stress are central to pathogenesis of NAFLD, and risk factors include metabolic syndrome, diabetes mellitus, obesity, lack of physical activity, smoking, and high fat diet. NAFLD is associated with higher mortality as compared to the general population with cardiovascular disease being the most common cause of death. The NAFLD is associated with a higher prevalence of subclinical atherosclerosis as evidenced by odds of higher coronary artery calcification, higher average and maximum carotid intima-media thickness. It is also associated with stiff arteries as evidenced by higher cardio-ankle vascular index and higher brachial-ankle pulse wave velocity. Increasing evidence has linked NAFLD with atherosclerotic cardiovascular diseases. The NAFLD is associated with a higher prevalence of coronary artery disease (CAD), more severe CAD, poor coronary collateral development, and higher incidence of coronary events. The NAFLD is also associated with ischemic stroke. Studies have shown that the association between NAFLD and atherosclerotic cardiovascular diseases is independent of shared risk factors.

Characterization of different fat depots in NAFLD using inflammation-associated proteome, lipidome and metabolome

Non-alcoholic fatty liver disease (NAFLD) is recognized as a liver manifestation of metabolic syndrome, accompanied with excessive fat accumulation in the liver and other vital organs. Ectopic fat accumulation was previously associated with negative effects at the systemic and local level in the human body. Thus, we aimed to identify and assess the predictive capability of novel potential metabolic biomarkers for ectopic fat depots in non-diabetic men with NAFLD, using the inflammation-associated proteome, lipidome and metabolome. Myocardial and hepatic triglycerides were measured with magnetic spectroscopy while function of left ventricle, pericardial and epicardial fat, subcutaneous and visceral adipose tissue were measured with magnetic resonance imaging. Measured ectopic fat depots were profiled and predicted using a Random Forest algorithm, and by estimating the Area Under the Receiver Operating Characteristic curves. We have identified distinct metabolic signatures of fat depots in the liver (TAG50:1, glutamate, diSM18:0 and CE20:3), pericardium (N-palmitoyl-sphinganine, HGF, diSM18:0, glutamate, and TNFSF14), epicardium (sphingomyelin, CE20:3, PC38:3 and TNFSF14), and myocardium (CE20:3, LAPTGF-β1, glutamate and glucose). Our analyses highlighted non-invasive biomarkers that accurately predict ectopic fat depots, and reflect their distinct metabolic signatures in subjects with NAFLD.

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

BACKGROUND

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

PATIENTS AND METHODS

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

RESULTS

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

CONCLUSION

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

Fast Morphological Gallbladder Changes Triggered by a Hypercholesterolemic Diet

INTRODUCTION AND AIM

Obesity is a worldwide epidemic problem, described as a risk factor for hepatic diseases, such as non-alcoholic fatty liver disease and other pathologies related to development of cholesterol crystals and cholesterol gallbladder stones. It has been reported that cholesterol overload may cause hepatic damage; however, little is known about the effects of an acute hypercholesterolemic diet on the gallbladder. The aim of this manuscript was to evaluate the impact of a cholesterol-rich diet on the gallbladder.

MATERIAL AND METHODS

The study included ten eight-week-old C57BL6 male mice, which were divided into two study groups and fed different diets for 48 h: a hypercholesterolemic diet and a balanced Chow diet. After 48 h, the mice were analyzed by US with a Siemens Acuson Antares equipment. Mice were subsequently sacrificed to carry out a cholesterol analysis with a Refloton System (Roche), a crystal analysis with a Carl Zeiss microscope with polarized light, and a histological analysis with Hematoxylin-eosin staining.

RESULTS

The hypercholesterolemic diet induced an increase in gallbladder size and total cholesterol content in the bile, along with important histological changes.

CONCLUSION

Cholesterol overloads not only trigger hepatic damage, but also affect the gallbladder significantly.

Ultrasound Grade of Liver Steatosis Is Independently Associated with the Risk of Metabolic Syndrome

The aim of the study was to explore (a) prevalence and grade of nonalcoholic fatty liver (NAFL) among outpatients referred for abdominal ultrasound (US) examination and (b) relationship between the presence and severity of liver steatosis and metabolic syndrome (MS). This was a retrospective analysis of patients without history of liver disease examined by abdominal US in the University hospital setting. US was used to detect and semiquantitatively grade (0-3) liver steatosis. Data on patients' age, gender, body mass index (BMI), impaired glucose metabolism (IGM), atherogenic dyslipidaemia (AD), raised blood pressure (RBP), transaminases, and platelet counts were obtained from medical records. MS was defined as having at least 3 of the following components: obesity, IGM, AD, and RBP. Of the 631 patients (median age 60 years, median BMI 27.4 kg/m2, and 57.4% females) 71.5% were overweight and 48.5% had NAFL. In the subgroup of 159 patients with available data on the components of MS, patients with higher US grade of steatosis had significantly higher BMI and increased prevalence of obesity, IGM, AD, RBP, and accordingly more frequently had MS, whereas they did not differ in terms of age and gender. NAFL was independently associated with the risk of having MS in a multivariate model adjusted for age, gender, BMI, and IGM. The grade of liver steatosis did not correlate with the presence of liver fibrosis. We demonstrated worrisome prevalence of obesity and NAFL in the outpatient population from our geographic region. NAFL is independently associated with the risk of having MS implying worse prognosis.

Changes in the immune system - the key to diagnostics and therapy of patients with non-alcoholic fatty liver disease

Non-alcoholic fatty liver disease (NAFLD) is one of the most common pathologies of that organ. The development of the disease involves a variety of mechanisms, including insulin resistance, oxidative stress, endoplasmic reticulum stress, endotoxins from the intestinal flora and genetic predispositions. Additionally, clinical data suggest that the presence of NAFLD is associated with excessive activation of the immune system. For practical purposes, attention should be paid to the moment when the subjects predisposed to NAFLD develop inflammatory infiltration and signs of fibrosis in the liver (non-alcoholic steatohepatitis - NASH). Their presence is an important risk factor for hepatic cirrhosis, hepatic failure, and hepatocellular carcinoma, as well as for the occurrence of cardiovascular events. Regardless of the diagnostic methods used, including laboratory tests and imaging, liver biopsy remains the gold standard to identify and differentiate patients with NAFLD and NASH. The search for other, safer, cheaper and more readily available diagnostic tests is still being continued. Attention has been drawn to the usefulness of markers of immune status of the organism, not only for the diagnosis of NASH, but also for the identification of NAFLD patients at risk of disease progression. Despite the effectiveness of medication, no recommendations have been established for pharmacotherapy of NAFLD. Data indicate the primary need for non-pharmacological interventions to reduce body weight. However, there is evidence of the applicability of certain drugs and dietary supplements, which, by their effect on the immune system, inhibit its excessive activity, thus preventing the progression of NAFLD to NASH.

Angiopoietin-like protein 2 and angiopoietin-like protein 6 levels in patients with nonalcoholic fatty liver disease

INTRODUCTION

The aim of the current study was to examine the difference between patients detected with nonalcoholic fatty liver disease (NAFLD) and healthy subjects in terms of serum angiopoietin-like protein (ANGPTL) 2 and ANGPTL6 levels and to evaluate the correlation between ANGPTL2 and ANGPTL6 levels and liver enzyme levels, fasting glucose, lipid levels, and steatosis degree on ultrasonography (USG).

MATERIAL AND METHODS

A total of 159 participants were included in the study. The participants were divided into 3 groups depending on the steatosis degree on USG and serum alanine aminotransferase (ALT) levels: the NAFLD group with increased ALT, the NAFLD group with normal ALT, and the healthy control group. The groups were compared in terms of biochemical and ultrasonographic findings, insulin resistance, metabolic syndrome (MetS), and anthropometric parameters.

RESULTS

There was no significant difference between NAFLD patients and healthy subjects with respect to serum ANGPTL2 and ANGPTL6 levels (p > 0.05). ANGPTL2 levels did not correlate with serum, biochemical, or ultrasonographic findings, or anthropometric parameters (p > 0.05). A positive correlation was found between serum ANGPTL6 levels and fasting blood glucose, ALT, alkaline phosphatase, γ-glutamyl transpeptidase, fasting insulin, and HOMA-IR levels.

CONCLUSIONS

While our findings suggest no relationship between serum ANGPTL2 and ANGPTL6 levels and NAFLD, ANGPTL6 levels may be related to metabolic and biochemical parameters. The effects of ANGPTL2 and ANGPTL6 in the pathogenesis of NAFLD should be investigated further.

Both alcoholic and non-alcoholic steatohepatitis association with cardiovascular risk and liver fibrosis

BACKGROUND

Non-alcoholic fatty liver disease (NAFLD) is the most common cause of liver disease worldwide. Mortality in NAFLD is mainly related to cardiovascular disease (CVD) and cancer. NAFLD and its association with both CVD and liver disease risk have been well evaluated, but the association of NAFLD with alcohol, known as "both alcoholic and non-alcoholic steatohepatitis" (BASH), remains uncertain. The objective of this study was to assess the influence of alcohol and obesity in the development of liver and cardiovascular disease risk.

METHODS

This was a case-control study that included patients from a regular check-up. Alcohol consumption was evaluated with MAST, AUDIT, and CAGE. Cardiovascular risk was evaluated using the Framingham score, and liver fibrosis was evaluated with APRI and NAFLD score. Patients were classified in five groups: healthy patients, steatosis with obesity, steatosis with alcoholism, BASH, and idiopathic steatosis.

RESULTS

A total of 414 patients were included. The BASH group represented 16% of patients, and showed a greater proportion of patients with high cardiovascular risk with 17% (p = 0.001), and liver fibrosis with 9%, according to the APRI score (p = 0.10). A multivariate logistic regression showed that alcohol consumption >140 g/week (OR 2.546, 95% CI 1.11-5.81, p = 0.003) and BMI >25 kg/m² (OR 12.64, 95% CI 1.66 96.20, p = 0.001) were related to high cardiovascular risk. Liver fibrosis according to APRI was only related to alcohol consumption >140 g/week (OR 2.74, 95% CI 1-7.48, p = 0.03).

CONCLUSIONS

BASH remains an area not well explored, and of great implication given the increasing number of patients affected. We observed an additive effect of both etiologies in the development of high cardiovascular and liver disease risk.

Cardiometabolic effects of antidiabetic drugs in non-alcoholic fatty liver disease

PURPOSE

Non-alcoholic fatty liver disease (NAFLD) affects about 25% of the population worldwide. NAFLD may be viewed as the hepatological manifestation of metabolic syndrome. Patients with metabolic syndrome due to diabetes or obesity have an increased risk of cardiovascular disease. This narrative review describes cardiometabolic effects of antidiabetic drugs in NAFLD.

METHODS

We conducted a systematic search in PubMed and manually scanned bibliographies in trial databases and reference lists in relevant articles.

RESULTS

Heart disease is the leading cause of death in NAFLD. Conversely, NAFLD is an independent cardiovascular risk factor in patients suffering from metabolic syndrome. NAFLD is associated with markers of atherosclerosis, and patients have increased risk of ischaemic heart disease. Additionally, patients with NAFLD have increased risk of cardiac dysfunction and heart failure. There are no randomized controlled trials showing clear effects of medical treatment on clinical outcomes in patients with NAFLD. However, based on evidence from small trials and extrapolation from trials evaluating patients with type 2 diabetes, some antidiabetic drugs may be beneficial on cardiovascular function in patients with NAFLD.

CONCLUSION

At present, there is promising evidence of a potential effect of antidiabetic drugs for patients with NAFLD. Future studies should address the treatment of NAFLD and the liver-related consequences but also aim at improving the cardiometabolic outcomes.

Association of the ideal cardiovascular behaviors and factors with the incidence of nonalcoholic fatty liver disease: a prospective study

OBJECTIVE

This study aimed to investigate the association of ideal cardiovascular behaviors and factors with the incidence of nonalcoholic fatty liver disease (NAFLD) prospectively.

PATIENTS AND METHODS

We analyzed 25 278 (21 433 men and 11 895 women) participants in the study. Participants were divided into four categories according to the number of ideal cardiovascular behaviors and factors: 0-2, 3, 4, and 5-7 groups. Multivariate logistic regression was used to calculate the odds ratios with 95% confidence intervals (CIs).

RESULTS

After adjustment for confounding factors, the multivariate logistic regression model showed that the risk of NAFLD among the groups with 3, 4, 5-7 ideal factors was lower than the 0-2 group; after adjustment for age, sex, income, education level, and other confounders, the odds ratios were 0.74 (95% CI: 0.68-0.80), 0.49 (95% CI: 0.45-0.53), and 0.37 (95% CI: 0.33-0.41), respectively.

CONCLUSION

The incidence of NAFLD decreased gradually with increasing ideal cardiovascular health behaviors and factors.

High circulatory leptin mediated NOX-2-peroxynitrite-miR21 axis activate mesangial cells and promotes renal inflammatory pathology in nonalcoholic fatty liver disease

High circulatory insulin and leptin followed by underlying inflammation are often ascribed to the ectopic manifestations in non-alcoholic fatty liver disease (NAFLD) but the exact molecular pathways remain unclear. We have shown previously that CYP2E1-mediated oxidative stress and circulating leptin in NAFLD is associated with renal disease severity. Extending the studies, we hypothesized that high circulatory leptin in NAFLD causes renal mesangial cell activation and tubular inflammation via a NOX2 dependent pathway that upregulates proinflammatory miR21. High-fat diet (60% kcal) was used to induce fatty liver phenotype with parallel insulin and leptin resistance. The kidneys were probed for mesangial cell activation and tubular inflammation that showed accelerated NASH phenotype and oxidative stress in the liver. Results showed that NAFLD kidneys had significant increases in α-SMA, a marker of mesangial cell activation, miR21 levels, tyrosine nitration and renal inflammation while they were significantly decreased in leptin and p47 phox knockout mice. Micro RNA21 knockout mice showed decreased tubular immunotoxicity and proinflammatory mediator release. Mechanistically, use of NOX2 siRNA or apocynin,phenyl boronic acid (FBA), DMPO or miR21 antagomir inhibited leptin primed-miR21-mediated mesangial cell activation in vitro suggesting a direct role of leptin-mediated NOX-2 in miR21-mediated mesangial cell activation. Finally, JAK-STAT inhibitor completely abrogated the mesangial cell activation in leptin-primed cells suggesting that leptin signaling in the mesangial cells depended on the JAK-STAT pathway. Taken together the study reports a novel mechanistic pathway of leptin-mediated renal inflammation that is dependent on NOX-2-miR21 axis in ectopic manifestations underlying NAFLD-induced co-morbidities.

Consensus document. Management of non-alcoholic fatty liver disease (NAFLD). Clinical practice guideline

Non-alcoholic fatty liver disease (NAFLD) is the main cause of liver diseases in Spain and the incidence is raising due to the outbreak of type 2 diabetes and obesity. This CPG suggests recommendation about diagnosis, mainly non-invasive biomarkers, and clinical management of this entity. Life-style modifications to achieve weight loss is the main target in the management of NAFLD. Low caloric Mediterranean diet and 200 minutes/week of aerobic exercise are encouraged. In non-responders patients with morbid obesity, bariatric surgery or metabolic endoscopy could be indicated. Pharmacological therapy is indicated in patients with NASH and fibrosis and non-responders to weight loss measures. NAFLD could influence liver transplantation, as a growing indication, the impact of steatosis in the graft viability, de novo NAFLD rate after OLT and a raised cardiovascular risk that modify the management of this entity. The current CPG was the result of the First Spanish NAFLD meeting in Seville.

Association of non-alcoholic steatohepatitis with subclinical myocardial dysfunction in non-cirrhotic patients

BACKGROUND & AIMS

Non-alcoholic fatty liver disease (NAFLD) is associated with increased cardiovascular risk. Among categories of NAFLD, hepatic fibrosis is most likely to affect mortality. Myocardial function and its energy metabolism are tightly linked, which might be altered by an insulin resistant condition such as NAFLD. We investigated whether hepatic steatosis and fibrosis were associated with myocardial dysfunction relative to myocardial glucose uptake.

METHODS

A total of 308 patients (190 without NAFLD, 118 with NAFLD) were studied in a tertiary care hospital. Myocardial glucose uptake was evaluated at fasted state using [¹⁸F]-fluorodeoxyglucose-positron emission tomography (¹⁸FDG-PET). Hepatic steatosis and fibrosis were assessed by transient liver elastography (Fibroscan®) with controlled attenuation parameter, which quantifies hepatic fat and by surrogate indices (fatty liver index and NAFLD fibrosis score). Cardiac structure and function were examined by echocardiogram.

RESULTS

Compared to those without NAFLD, patients with NAFLD had alterations in cardiac remodeling, manifested by increased left ventricular mass index, left ventricular end-diastolic diameter, and left atrial volume index (all p <0.05). Hepatic steatosis was significantly associated with left ventricular filling pressure (E/e' ratio), which reflects diastolic dysfunction (p for trend <0.05). Those without NAFLD were more likely to have higher myocardial glucose uptake compared to those with NAFLD. Significant hepatic fibrosis was also correlated with diastolic dysfunction and impaired myocardial glucose uptake. Using multivariable linear regression, E/e' ratio was independently associated with hepatic fibrosis (standardized β = 0.12 to 0.27; all p <0.05). Association between hepatic steatosis and E/e' ratio was also significant (standardized β = 0.10 to 0.15; all p <0.05 excluding the model adjusted for adiposity).

CONCLUSIONS

Hepatic steatosis and fibrosis are significantly associated with diastolic heart dysfunction. This association is linked with myocardial glucose uptake evaluated by ¹⁸FDG-PET.

LAY SUMMARY

Non-alcoholic fatty liver disease is associated with an increased risk of cardiovascular disease. More severe forms of non-alcoholic fatty liver disease, where hepatic fibrosis occurs, are linked to increased mortality. In this study, we have shown that hepatic steatosis and fibrosis are associated with subclinical myocardial dysfunction. This association is linked to altered myocardial glucose uptake.

Resolution of fatty liver and weight loss: Independent associations with changes in serum lipids and apolipoproteins

BACKGROUND AND AIMS

It is uncertain whether resolution of fatty liver can improve cardiovascular disease risk factors, independently of changes in body mass index (BMI). Our aim was to test whether resolution of fatty liver is associated with improvements in components of the lipid profile, independently of changes in BMI, and to quantify and compare the magnitude of benefit of resolution of liver fat, and decreases in BMI on the lipid profile.

METHODS

36,195 subjects with fatty liver were studied. Persistence/resolution of fatty liver was determined by ultrasound at follow up (mean = 4.93 years). Total cholesterol, triglycerides, low-density lipoprotein cholesterol, high-density lipoprotein cholesterol, and apolipoproteins were measured at baseline and follow up. Regression modelling was undertaken to test the independence of associations between change in fatty liver status or change in BMI, with any change in lipid profile concentrations between baseline and follow up.

RESULTS

Mean (SD) age was 36.3 ± 6.6 and 39.8 ± 8.7 years (men and women, respectively). Resolution of fatty liver occurred in 7,086, and persisted in 29,109 subjects. Mean ± SD weight change was -3.2 ± 4.3 (∼1 kg/m² decrease in BMI) with resolution of, and +0.5 ± 3.5 kg with persistence of fatty liver, respectively. Both resolution of fatty liver and decrease in BMI were independently associated with improvements in all components of the lipid profile and there was a similar magnitude of benefit associated with resolution of fatty liver, or 1 kg/m² decrease in BMI.

CONCLUSIONS

Resolution of fatty liver improves the lipid profile, independently of weight loss.

Nonalcoholic fatty liver disease contributes to subclinical atherosclerosis: A systematic review and meta-analysis

Nonalcoholic fatty liver disease (NAFLD) is associated with an increased risk of atherosclerotic cardiovascular disease. In our meta‐analysis, we aimed to assess the correlation of NAFLD and four surrogate markers of subclinical atherosclerosis. PubMed, Embase, and the Cochrane Library were searched up until April 2017. Original studies investigating the association between NAFLD and subclinical atherosclerosis were included. The outcome data were extracted and pooled for the effect estimate by using a random‐effects model. We used the Newcastle‐Ottawa Quality Assessment Scale to assess the quality of the included studies. Of the 434 initially retrieved studies, 26 studies involving a total of 85,395 participants (including 29,493 patients with NAFLD) were included in this meta‐analysis. The Newcastle‐Ottawa Quality Assessment Scale scores suggested the included studies were of high quality. The pooled effects estimate showed that subjects with NAFLD exhibited a significant independent association with subclinical atherosclerosis compared to the non‐NAFLD group (odds ratio, 1.60; 95% confidence interval, 1.45‐1.78). Subgroup analysis suggested that the presence of NAFLD yielded a remarkable higher risk of increased carotid artery intima‐media thickness/plaques, arterial stiffness, coronary artery calcification, and endothelial dysfunction with odds ratios (95% confidence interval) of 1.74 (1.47‐2.06), 1.56 (1.24‐1.96), 1.40 (1.22‐1.60), and 3.73 (0.99‐14.09), respectively. Conclusion: Our meta‐analysis revealed a close link between NAFLD and subclinical atherosclerosis in light of four different indices. Patients with NAFLD might benefit from screening and surveillance of early atherosclerosis, which would facilitate the prediction of potential cardiovascular disease burden, risk stratification, and appropriate intervention in the long term. (Hepatology Communications 2018;2:376‐392)

Being Metabolically Healthy, the Most Responsible Factor for Vascular Health

The prevalence of obesity is rapidly increasing worldwide. One-thirds of world population is suffering from the deleterious effects of excessive fat and adipose tissue in their body. At the same time, the average life expectancy is becoming higher and higher every decade. Therefore, living healthy and longer is the dream for everyone. Simply being obese is not the primary cause for the consequence of obesity; rather, the depot where the fat is accumulated, is the primary key for the deleterious effects of obesity. Results from historical research suggest that visceral fat increases the risk for cardiovascular and metabolic diseases, such as diabetes, myocardial infarction and ischemic stroke, not subcutaneous fat. Therefore, body mass index (BMI), which reflects body weight relative to height might not reflect the appropriate size of metabolic burden of fat in our body. In contrast, waist circumference, which reflects abdominal obesity, would mirror the metabolic burden of fat better than BMI. Visceral fat is the marker of ectopic fat accumulation. In this review, I will introduce my researches mainly involved in uncovering the clues to the link between metabolic health and cardiovascular disease.

Correlation between PPAR-α methylation level in peripheral blood and atherosclerosis of NAFLD patients with DM

We investigated the correlation between the methylation levels of peroxisome proliferator-activated receptor-α (PPAR-α) in the peripheral blood and atherosclerosis in patients with nonalcoholic fatty liver disease (NAFLD) with diabetes mellitus (DM). A total of 50 normal subjects (group N) and 50 NAFLD patients with DM (group M) were selected at Qilu Hospital of Shandong University. The levels of total cholesterol (TC), triglyceride (TG), high-density lipoprotein (HDL) and low-density lipoprotein (LDL) in groups N and M were detected. The mRNA and protein expressions of PPAR-α in groups N and M were detected using reverse transcription polymerase chain reaction (PCR) and immunofluorescence. The differences in expression of PPAR-α in group N and M and the correlation between PPAR-α methylation level and atherosclerosis were analyzed using SPSS17.0 statistical software. TC, TG, HDL and LDL in groups N and M were significantly different (P<0.01). Hematoxylin and eosin staining showed that the histopathological damage was severe in group M. PCR and immunofluorescence showed that PPAR-α was significantly higher in N than in group M (P<0.01). The abnormal expression of PPAR-α is closely related to atherosclerosis, indicating that the correlation between PPAR-α methylation levels in peripheral blood and atherosclerosis of NAFLD patients with DM can provide a new direction of diagnosis and treatment.

Effects of Chinese Medicinal Formula BNG-1 on Phosphodiesterase 3B Expression, Hepatic Steatosis, and Insulin Resistance in High Fat Diet-induced NAFLD Mice

Background: Chinese medicinal formula BNG-1, a non-specific inhibitor of phospho-diesterases (PDEs), can be considered as a potential anti-inflammatory agent. The present study was aimed at determining the effects of BNG-1 on the development of non-alcoholic fatty liver disease (NAFLD) in mice. Design and Methods: Male CD1 mice were randomly divided into seven groups, the control Con (4) and Con (8)+saline groups were fed a standard control diet for four or eight weeks; the experimental HFD (4) and HFD (8)+saline groups were fed a high fat diet for four or eight weeks; the HFD (8)+LBNG, HFD (8)+MBNG, and HFD (8)+HBNG groups received a high fat diet along with low, moderate or high doses of BNG-1 (0.026, 0.035, and 0.052g/30g body weight) which was administered for the last four weeks of an eight-week experimental period. After the end of experiment, blood and tissue samples were taken and analyzed. Results: Mice in the HFD (4) group had higher levels of alanine aminotransferase (ALT), plasma and hepatic triglyceride and cholesterol, and homeostasis model assessment-estimated insulin resistance (HOMA-IR) compared with mice in the Con (4) group. Mice receiving the high fat diet along with the BNG-1 supplement had decreased body weight gains and lower visceral fat weights compared with the HFD (8)+saline group. They had also significantly reduced levels of abnormal ALT and HOMA-IR, and improved blood lipid profile. BNG-1-treated mice exhibited reduced hepatic lipid accumulation, lower oxidative stress, and decreased expression of pro-inflammatory cytokines (TNF-α and IL-1β). Furthermore, BNG-1 treatment resulted in down-regulation of hepatic cyclic-AMP dependent PDE3B and up-regulation of PDE3B expression in epididymis adipose tissue. Conclusions: BNG-1 mediated changes in PDE3B expression along with reduction in oxidative stress and inflammation. BNG-1 may ameliorate insulin resistance and hepatic steatosis in the NAFLD mouse model.

Association between MRI-derived hepatic fat fraction and blood pressure in participants without history of cardiovascular disease

OBJECTIVES

We assessed whether liver fat content, as determined by MRI, correlates with blood pressure (BP), a major vascular risk factor, in individuals from the general population without history of stroke and coronary or peripheral artery disease.

METHODS

Cross-sectional data from 384 participants (161 women; aged 39-73 years) of a MRI substudy of the KORA FF4 survey were used. Hepatic fat fraction (HFF) was measured in the left and right lobe of the liver using single voxel multiecho H-spectroscopy and at the level of the portal vein using a multiecho Dixon-sequence. Associations of HFF with SBP and DBP as well as hypertension were assessed by right censored normal regression (accounting for antihypertensive treatment) and by logistic regression, respectively.

RESULTS

High levels of HFF measured on the level of the portal vein (90th percentile, 21.8%), compared with low HFF levels (10th percentile, 1.7%), were associated with higher SBP (131 vs. 122 mmHg; overall P = 0.001), higher DBP (82 vs. 76 mmHg, P < 0.001) and with higher odds of hypertension [odds ratio (OR) = 2.16, P = 0.025]. A level of 5.13% (54th percentile) was identified as optimal HFF cut-off for the prediction of hypertension (OR = 2.00, P = 0.015). Alcohol consumption emerged as an effect modifier for the association between HFF and hypertension (nonalcohol drinker: OR = 3.76, P = 0.025; alcohol drinker: OR = 1.59, P = 0.165).

CONCLUSION

MRI-derived subclinical HFF is associated with SBP and DBP as well as with hypertension in participants from the general population without history of cardiovascular disease.

Liver fibrosis score predicts mortality in heart failure patients with preserved ejection fraction

AIMS

Heart failure with preserved ejection fraction (HFpEF) has several pathophysiological aspects, including stiffness and/or congestion of multiple organs. Poor prognosis is expected in heart failure patients with liver stiffness, which has recently been assessed by non-alcoholic fatty liver disease fibrosis score (NFS; based on aspartate aminotransferase to alanine aminotransferase ratio, platelet counts, and albumin). We aimed to investigate the impact of NFS on prognosis of HFpEF patients, with consideration for the peripheral collagen markers such as procollagen type III peptide (PIIIP), type IV collagen 7S, and hyaluronic acid.

METHODS AND RESULTS

We performed a prospective observational study. Consecutive 492 hospitalized HFpEF patients were divided into four groups based on their NFS: first-fourth quartiles (n = 123). The fourth quartile group had the highest levels of PIIIP, type IV collagen 7S, hyaluronic acid, and B-type natriuretic peptide (P<0.001 each). In addition, there were significant positive correlations between PIIIP, type IV collagen 7S, hyaluronic acid, B-type natriuretic peptide, and NFS (P < 0.001 each). In the follow-up period (mean 1107 days), 93 deaths occurred. All-cause mortality increased in all four quartiles (8.1%, 12.2%, 23.6%, and 31.7%, P < 0.001). In the multivariable Cox proportional hazard analysis, NFS was an independent predictor of all-cause mortality in the HFpEF patients.

CONCLUSIONS

NFS, a novel indicator of liver fibrosis, correlates with circulating systemic markers of fibrosis and congestion and is associated with higher all-cause mortality in HFpEF patients. NFS can be calculated simply and may be a useful tool to assess liver stiffness and prognosis in HFpEF patients.

An assessment of racial differences in the upper limits of normal ALT levels in children and the effect of obesity on elevated values

OBJECTIVES

Childhood obesity is a risk factor for non-alcoholic fatty liver disease and poses important public health issues for children. Racial differences in alanine aminotransferase (ALT) levels among children have not been described. This study aimed to identify racial differences in upper limit normal (ULN) ALT levels and evaluate the effect of obesity on elevated levels in children without other metabolic risk factors.

METHODS

National Health and Nutrition Examination Surveys and clinical data from the Loyola University Health System were used to determine ULN ALT by race and gender. Quantile regression was used to evaluate the impact of obesity on elevated ALT and to identify potential risk factors for ALT above the ULN.

RESULTS

Upper limit normal (ULN) ALT was approximately 28.0 and 21.0-24.0 U/L for boys and girls, respectively. No significant difference in ULN ALT across race was observed. Obesity was significantly associated with elevated ALT; obese children with elevated ALT had values 10 U/L higher than normal-weight children.

CONCLUSIONS

Racial differences in ALT levels among adults are not evident in children. Obesity, in the absence of metabolic risk factors and other causes of liver disease, is associated with elevated ALT, providing evidence against the concept of healthy obesity in children.