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

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.

Liver involvement in patients with COVID-19 infection: A comprehensive overview of diagnostic imaging features

During the first wave of the pandemic, coronavirus disease 2019 (COVID-19) infection has been considered mainly as a pulmonary infection. However, different clinical and radiological manifestations were observed over time, including involvement of abdominal organs. Nowadays, the liver is considered one of the main affected abdominal organs. Hepatic involvement may be caused by either a direct damage by the virus or an indirect damage related to COVID-19 induced thrombosis or to the use of different drugs. After clinical assessment, radiology plays a key role in the evaluation of liver involvement. Ultrasonography (US), computed tomography (CT) and magnetic resonance imaging (MRI) may be used to evaluate liver involvement. US is widely available and it is considered the first-line technique to assess liver involvement in COVID-19 infection, in particular liver steatosis and portal-vein thrombosis. CT and MRI are used as second- and third-line techniques, respectively, considering their higher sensitivity and specificity compared to US for assessment of both parenchyma and vascularization. This review aims to the spectrum of COVID-19 liver involvement and the most common imaging features of COVID-19 liver damage.

Advances in the Diagnosis and Treatment of Non-Alcoholic Fatty Liver Disease

Non-alcoholic fatty liver disease (NAFLD) is the most prevalent chronic liver disease that affects approximately one-quarter of the global adult population, posing a significant threat to human health with wide-ranging social and economic implications. The main characteristic of NAFLD is considered that the excessive fat is accumulated and deposited in hepatocytes without excess alcohol intake or some other pathological causes. NAFLD is a progressive disease, ranging from steatosis to non-alcoholic steatohepatitis (NASH), cirrhosis, hepatocellular carcinoma, liver transplantation, and death. Therefore, NAFLD will probably emerge as the leading cause of end-stage liver disease in the coming decades. Unlike other highly prevalent diseases, NAFLD has received little attention from the global public health community. Liver biopsy is currently considered the gold standard for the diagnosis and staging of NAFLD because of the absence of noninvasive and specific biomarkers. Due to the complex pathophysiological mechanisms of NAFLD and the heterogeneity of the disease phenotype, no specific pharmacological therapies have been approved for NAFLD at present, although several drugs are in advanced stages of development. This review summarizes the current evidence on the pathogenesis, diagnosis and treatment of NAFLD.

Alcohol-Related Liver Disease Including New Developments

The prevalence of alcohol consumption, alcohol use disorder (AUD), and alcohol-related liver disease (ALD) has exponentially increased over the last several years and rates continue to increase. Significant alcohol use can cause progression from steatosis in the liver to inflammation, fibrosis, and eventually cirrhosis. Additional risk factors for the progression of ALD disease include gender, race, and genetic predisposition. As such, it is essential for clinicians to understand and implement screening tools for early diagnosis of both AUD and ALD and be aware of emerging novel treatment options.

Hepatorenal Index by B-Mode Ratio Versus Imaging and Fatty Liver Index to Diagnose Steatosis in Alcohol-Related and Nonalcoholic Fatty Liver Disease

OBJECTIVES

We aimed to evaluate the accuracy of the hepatorenal index by B-mode ratio to diagnose hepatic steatosis, compared to ultrasound steatosis score, controlled attenuation parameter, and the fatty liver index using histology as the gold standard.

METHODS

We prospectively included participants with alcohol-related or nonalcoholic fatty liver disease for same-day noninvasive investigations and liver biopsy.

RESULTS

We included 137 participants, 72% male, median age 60 years (53-65) and body mass index 32 kg/m² (28-38). Eighty percent had steatosis (S0/S1/S2/S3 = 20/37/24/19%). B-mode ratio had moderate diagnostic accuracy for any steatosis (≥S1, area under the receiver operating characteristics curve [AUROC] = 0.79; 95% confidence interval 0.70-0.88), significant steatosis (≥S2, AUROC = 0.76; 0.66-0.85), and severe steatosis (=S3, AUROC = 0.74; 0.62-0.86), independent of disease etiology. The cutoff values to rule-out and rule-in any steatosis were 1.09 and 1.45. While B-mode ratio and controlled attenuation parameter correlated poorly, their diagnostic accuracies were comparable to each other and to ultrasound steatosis scoring. Fatty liver index did not differ from B-mode ratio in detecting any steatosis but had poor accuracy to detect higher steatosis grades. B-mode ratio measurements failed in 12% of patients, compared to 1% for ultrasound steatosis scoring and 2% for controlled attenuation parameter.

CONCLUSION

The hepatorenal index by B-mode ratio diagnose steatosis with moderate accuracy in patients with alcohol-related or nonalcoholic fatty liver disease, comparable to B-mode ultrasound steatosis scoring and controlled attenuation parameter. However, its clinical use is limited by a high failure rate.

Non-invasive multispectral optoacoustic tomography resolves intrahepatic lipids in patients with hepatic steatosis

Hepatic steatosis is characterized by intrahepatic lipid accumulation and may lead to irreversible liver damage if untreated. Here, we investigate whether multispectral optoacoustic tomography (MSOT) can offer label-free detection of liver lipid content to enable non-invasive characterization of hepatic steatosis by analyzing the spectral region around 930 nm, where lipids characteristically absorb. In a pilot study, we apply MSOT to measure liver and surrounding tissues in five patients with liver steatosis and five healthy volunteers, revealing significantly higher absorptions at 930 nm in the patients, while no significant difference was observed in the subcutaneous adipose tissue of the two groups. We further corroborated the human observations with corresponding MSOT measurements in high fat diet (HFD) - and regular chow diet (CD)-fed mice. This study introduces MSOT as a potential non-invasive and portable technique for detecting/monitoring hepatic steatosis in clinical settings, providing justification for larger studies.

Non-invasive imaging biomarkers for liver steatosis in non-alcoholic fatty liver disease: present and future

Non-alcoholic fatty liver disease is currently the most common chronic liver disease, affecting up to 25% of the global population. Simple fatty liver, in which fat is deposited in the liver without fibrosis, has been regarded as a benign disease in the past, but it is now known to be prognostic. In the future, more emphasis should be placed on the quantification of liver fat. Traditionally, fatty liver has been assessed by histological evaluation, which requires an invasive examination; however, technological innovations have made it possible to evaluate fatty liver by non-invasive imaging methods, such as ultrasonography, computed tomography, and magnetic resonance imaging. In addition, quantitative as well as qualitative measurements for the detection of fatty liver have become available. In this review, we summarize the currently used qualitative evaluations of fatty liver and discuss quantitative evaluations that are expected to further develop in the future.

Non-invasive biomarkers for liver inflammation in non-alcoholic fatty liver disease: present and future

Inflammation is the key driver of liver fibrosis progression in non-alcoholic fatty liver disease (NAFLD). Unfortunately, it is often challenging to assess inflammation in NAFLD due to its dynamic nature and poor correlation with liver biochemical markers. Liver histology keeps its role as the standard tool, yet it is well-known for substantial sampling, intraobserver, and interobserver variability. Serum proinflammatory cytokines and apoptotic markers, namely cytokeratin-18, are well-studied with reasonable accuracy, whereas serum metabolomics and lipidomics have been adopted in some commercially available diagnostic models. Ultrasound and computed tomography imaging techniques are attractive due to their wide availability; yet their accuracies may not be comparable with magnetic resonance imaging-based tools. Machine learning and deep learning models, be they supervised or unsupervised learning, are promising tools to identify various subtypes of NAFLD, including those with dominating liver inflammation, contributing to sustainable care pathways for NAFLD.

Improving data adequacy of ultrasonography reports for non-alcoholic fatty liver disease (NAFLD) through a national structured template

BACKGROUND

Non-alcoholic fatty liver disease (NAFLD) is a prevalent disorder that increases due to lifestyle, the rising rate of obesity, and population ages worldwide. Diagnostic ways, including sonography, do not have an explicit reporting structure.

PURPOSE

To create a structure template for NAFLD reporting, investigate its completeness, and assess the specialist opinions of using it in clinical practice.

MATERIAL AND METHODS

A structured reporting template (SRT) was designed and implemented in four stages. At first, important features were extracted from a comprehensive literature review and were evaluated by 10 radiologists and gastroenterologists using the Likert scale. Finally, the usefulness of the SRT in comparison with the conventional reporting template (CRT) was judged by 10 gastroenterologists completing the questionnaire.

RESULTS

Demographic information and sonography of the liver, gallbladder, and spleen organs were the most critical features. The completeness scores of SRT reports were higher than CRT scores for almost all the factors studied. The difference in the scores was significant for most of the parameters. Moreover, the total completeness score increased from 42% in CRT to 92% in SRT. A comparison of the report adequacy of two reports was seen in all items. The SRT obtained more rates from specialists.

CONCLUSION

Introduction of the SRT for NAFLD significantly enhanced the completeness of reporting to reduce variability in the interpretation of the related reports by clinicians. Nevertheless, more studies are needed to generalize the results in real scales for patients with NAFLD.

Screening strategy for non-alcoholic fatty liver disease

Non-alcoholic fatty liver disease (NAFLD) is the most common chronic liver disease, affecting approximately 25% of the general population worldwide, and is forecasted to increase global health burden in the 21st century. With the advancement of non-invasive tests for assessing and monitoring of steatosis and fibrosis, NAFLD screening is now feasible, and is increasingly highlighted in international guidelines related to hepatology, endocrinology, and pediatrics. Identifying high-risk populations (e.g., diabetes mellitus, obesity, metabolic syndrome) based on risk factors and metabolic characteristics for non-invasive screening is crucial and may aid in designing screening strategies to be more precise and effective. Many screening modalities are currently available, from serum-based methods to ultrasonography, transient elastography, and magnetic resonance imaging, although the diagnostic performance, cost, and accessibility of different methods may impact the actual implementation. A two-step assessment with serum-based fibrosis-4 index followed by imaging test vibration-controlled transient elastography can be an option to stratify the risk of liverrelated complications in NAFLD. There is a need for fibrosis surveillance, as well as investigating the cost-effectiveness of different screening algorithms and engaging primary care for first-stage triage screening.

MAFLD and NAFLD in the prediction of incident chronic kidney disease

Whether metabolic dysfunction-associated fatty liver disease (MAFLD) can replace nonalcoholic fatty liver disease (NAFLD) is under debate. This study evaluated which definition better predicted incident chronic kidney disease (CKD). This was a 5.3-year (range, 2.8-8.3) retrospective cohort study of 21,713 adults who underwent at least two serial health examinations. Cox analyses were used to compare the risk of incident CKD among non-fatty liver disease (FLD) without metabolic dysregulation (MD; reference), non-FLD with MD, MAFLD-only, NAFLD-only, or both-FLD groups. Non-FLD with MD group (hazard ratio [HR] 1.23, 95% confidence interval [CI] 1.00-1.53), both-FLD group (HR 1.50, 95% CI 1.19-1.89), and MAFLD-only group (HR 1.97, 95% CI 1.49-2.60), but not NAFLD-only group (HR 1.06, 95% CI 0.63-1.79) demonstrated an increased risk of CKD. The increased risk of CKD was significant in MAFLD subgroups with overweight/obesity (HR 2.94, 95% CI 1.91-4.55), diabetes (HR 2.20, 95% CI 1.67-2.90), MD only (HR 1.50, 95% CI 1.19-1.89), excessive alcohol consumption (HR 2.71, 95% CI 2.11-3.47), and viral hepatitis (HR 2.38, 95% CI 1.48-3.84). The switch from NAFLD to MAFLD criteria may identify a greater number of individuals at CKD risk. The association was also significant in MAFLD patients with excessive alcohol consumption or viral hepatitis.

Understanding NAFLD: From Case Identification to Interventions, Outcomes, and Future Perspectives

While non-alcoholic fatty liver disease (NAFLD) is a prevalent and frequent cause of liver-related morbidity and mortality, it is also strongly associated with cardiovascular disease-related morbidity and mortality, likely driven by its associations with insulin resistance and other manifestations of metabolic dysregulation. However, few satisfactory pharmacological treatments are available for NAFLD due in part to its complex pathophysiology, and challenges remain in stratifying individual patient's risk for liver and cardiovascular disease related outcomes. In this review, we describe the development and progression of NAFLD, including its pathophysiology and outcomes. We also describe different tools for identifying patients with NAFLD who are most at risk of liver-related and cardiovascular-related complications, as well as current and emerging treatment options, and future directions for research.

Effect modification of hepatitis B viral load on the association between metabolic risk factors and hepatic steatosis

Background

It is not clear if chronic hepatitis B (CHB) infection potentiates the severity of hepatic steatosis (HS) in patients with metabolic risk factors. We tested for the effect modification of hepatitis B viral load on the association between metabolic risk factors and HS.

Methods

In this retrospective cross-sectional study, we included adult subjects, who had non-cirrhotic nonalcoholic fatty liver disease and CHB infection with positive hepatitis B envelope antibody. We reported descriptive statistics, stratified by detectable and undetectable hepatitis B viral load, by Kruskal-Wallis Rank Sum Test and chi-square. We reported coefficients of two multivariate regression predicting odds of HS > stage 2, testing for interaction between metabolic risk factors and hepatitis B viral load.

Results

When controlled for age, sex, and hepatitis B treatment, the odds of HS > stage 2 increased significantly by 77% for each additional metabolic risk factor [odds ratio (OR) 1.77, 95% confidence interval (CI): 1.20-2.69, P=0.005]. The odds of HS > stage 2 was not associated with detectable hepatitis B viral load (OR 1.00, 95% CI: 0.83-1.19, P=0.986). The association between the odds of HS > stage 2 and metabolic risk factors did not significantly change as hepatitis B viral load increased [ratio of odds ratio (ROR) 1.01, 95% CI: 0.94-1.08, P=0.839].

Conclusions

Our study does not find evidence of effect modification of hepatitis B viral load on the association between metabolic risk factors and HS in non-cirrhotic and hepatitis B envelope antibody positive patients with CHB viral infection. It suggests that the odds of HS in CHB infected patients is affected by metabolic risk factors and not by hepatitis B viremia.

Impact of Evolutionary Changes in Nonalcoholic Fatty Liver Disease on Lung Function Decline

Background/Aims

A relationship between fatty liver and lung function impairment has been identified, and both are independently associated with metabolic dysfunction. However, the temporal relationship between changes in fatty liver status and lung function and their genome-wide association remain unclear.

Methods

This longitudinal cohort consisted of subjects who received serial health check-ups, including liver ultrasonography and spirometry, for ≥3 years between 2003 and 2015. Lung function decline rates were classified as "slow" and "accelerated" and compared among four different sonographic changes in steatosis status: "normal," "improved," "worsened," and "persistent." A genome-wide association study was conducted between the two groups: normal/improved steatosis with a slow decline in lung function versus worsened/persistent steatosis with an accelerated decline in lung function.

Results

Among 6,149 individuals, the annual rates of decline in forced vital capacity (FVC) and forced expiratory volume measured in the first second of exhalation (FEV₁) were higher in the worsened/persistent steatosis group than in the normal/improved steatosis group. In multivariable analysis, persistent or worsened status of fatty liver was significantly associated with accelerated declines in FVC (persistent status, odds ratio [OR]=1.22, 95% confidence interval [CI]=1.04-1.44; worsened status, OR=1.30, 95% CI=1.12-1.50), while improved status of fatty liver was significantly associated with slow declines in FEV₁ (OR=0.77, 95% CI=0.64-0.92). The PNPLA3 risk gene was most strongly associated with steatosis status change and accelerated declines in FVC (rs12483959, p=2.61×10^-7) and FEV₁ (rs2294433, p=3.69×10^-8).

Conclusions

Regression of fatty liver is related to lung function decline. Continuing efforts to improve fatty liver may preserve lung function, especially for subjects with a high genetic risk.

Association of Myosteatosis with Nonalcoholic Fatty Liver Disease, Severity, and Liver Fibrosis Using Visual Muscular Quality Map in Computed Tomography

BACKGROUND

The association of myosteatosis measured using visual muscular quality map in computed tomography (CT) with nonalcoholic fatty liver disease (NAFLD), its severity, and fibrosis was analyzed in a large population.

METHODS

Subjects (n=13,452) with abdominal CT between 2012 and 2013 were measured total abdominal muscle area (TAMA) at L3 level. TAMA was segmented into intramuscular adipose tissue and skeletal muscle area (SMA), which was further classified into normal attenuation muscle area (NAMA) and low attenuation muscle area (LAMA). The following variables were adopted as indicators of myosteatosis: SMA/body mass index (BMI), NAMA/BMI, NAMA/TAMA, and LAMA/BMI. NAFLD and its severity were assessed by ultrasonography, and liver fibrosis was measured by calculating the NAFLD fibrosis score (NFS) and fibrosis-4 index (FIB-4) scores.

RESULTS

According to multiple logistic regression analyses, as quartiles of SMA/BMI, NAMA/BMI, and NAMA/TAMA increased, the odds ratios (ORs) for NAFLD decreased in each sex (P for trend <0.001 for all). The ORs of moderate/severe NAFLD were significantly higher in the Q1 group than in the Q4 group for SMA/BMI, NAMA/BMI, and NAMA/TAMA in men. The ORs of intermediate/high liver fibrosis scores assessed by NFS and FIB-4 scores increased linearly with decreasing quartiles for SMA/BMI, NAMA/BMI, and NAMA/TAMA in each sex (P for trend <0.001 for all). Conversely, the risk for NAFLD and fibrosis were positively associated with LAMA/BMI quartiles in each sex (P for trend <0.001 for all).

CONCLUSION

A higher proportion of good quality muscle was associated with lower risks of NAFLD and fibrosis.

Genetic Polymorphisms and Diversity in Nonalcoholic Fatty Liver Disease (NAFLD): A Mini Review

Nonalcoholic fatty liver disease (NAFLD) is a common liver disease with a wide spectrum of liver conditions ranging from hepatic steatosis to nonalcoholic steatohepatitis (NASH), fibrosis, cirrhosis, and hepatocellular carcinoma. The prevalence of NAFLD varies across populations, and different ethnicities have specific risks for the disease. NAFLD is a multi-factorial disease where the genetics, metabolic, and environmental factors interplay and modulate the disease's development and progression. Several genetic polymorphisms have been identified and are associated with the disease risk. This mini-review discussed the NAFLD's genetic polymorphisms and focusing on the differences in the findings between the populations (diversity), including of those reports that did not show any significant association. The challenges of genetic diversity are also summarized. Understanding the genetic contribution of NAFLD will allow for better diagnosis and management explicitly tailored for the various populations.

Effects of homocysteine on nonalcoholic fatty liver related disease: A mendelian randomization study

Background: Since the association of homocysteine and clinical results of observational studies are controversial on non-alcoholic fatty liver related disease, we compute the two-sample Mendelian Randomization (MR) study. Objective: To evaluate whether the plasma level of homocysteine has an effect on the risk of Non-alcoholic fatty liver disease (NAFLD), non-alcoholic steatohepatitis (NASH), and Cirrhosis after its progress, we investigated the causal relationships between plasma homocysteine and the three non-alcoholic fatty liver related diseases mentioned above. Design and methods: Summary estimates were elicited from the inverse-variance weighted (IVW) method through 12 single nucleotide polymorphisms (SNPs) which related to the plasma homocysteine, the SNPs were obtained from a large genome-wide association studies (GWAS) of 44,147 European participants. And the summary statistics for the latest and largest GWAS datasets for NAFLD (307576 in total and 1,578 cases), NASH (309055 in total and 99 cases) and Cirrhosis (306145 in total and 826 cases) were collected from Ristey FinnGen website where the association of genetic variations with blood metabolite levels was conducted using comprehensive metabolite profiling. The study was performed through two-sample MR method. Results: The result indicated that the plasma homocysteine is not significantly associated with NAFLD, and its progression, NASH and Cirrhosis. Conclusion: The evidence in this study is quite deficient to support the causal association of the individual plasma homocysteine with NAFLD, NASH and Cirrhosis, the putative of associations is not exist.

Serum Uric Acid but Not Ferritin Level Is Associated with Hepatic Fibrosis in Lean Subjects with Metabolic Dysfunction-Associated Fatty Liver Disease: A Community-Based Study

Elevated serum ferritin and uric acid levels are common in patients with fatty liver disease. This study assessed the association between serum ferritin and uric acid levels and liver fibrosis in subjects with lean metabolic dysfunction-associated fatty liver disease (MAFLD). This cross-sectional study used data from a community screening examination for metabolic syndrome from December 2018 to September 2019 at Keelung Chang Gung Memorial Hospital. Subjects with lean MAFLD were defined as those with a body mass index (BMI) < 23 kg/m2 and hepatic steatosis according to the MAFLD criteria. A total of 182 lean subjects were included and were divided into lean MAFLD and lean healthy groups. Serum ferritin and uric acid concentrations were positively correlated with liver fibrosis, regardless of whether FIB-4, APRI, or NFS were used as references. Univariate logistic regression analysis showed that age and uric acid were associated with advanced liver fibrosis. After adjusting for potential confounders, only uric acid level was statistically significant in predicting the advanced liver fibrosis (OR = 6.907 (1.111−42.94), p = 0.038) in the lean MAFLD group. We found that an elevated serum uric acid level is an independent factor associated with advanced liver fibrosis in lean MAFLD subjects by noninvasive fibrosis scores.

The relationship between metabolic dysfunction-associated fatty liver disease and low muscle mass in an asymptomatic Korean population

BACKGROUND

Metabolic (dysfunction)-associated fatty liver disease (MAFLD) emphasizes the metabolic dysfunction in nonalcoholic fatty liver disease (NAFLD). Although the relationship between low muscle mass and NAFLD has been suggested, the effect of MAFLD on low muscle mass is yet to be investigated. In this study, we examined the relationship between MAFLD and low muscle mass in an asymptomatic Korean population.

METHODS

Examinees who underwent FibroScan® and bioelectrical impedance analyses on the same day during the period of June 2017 to December 2019 were included. Hepatic steatosis was diagnosed using controlled attenuation parameter (CAP) with two cut-off values of 248 and 294 dB/m. Low muscle mass was defined based on appendicular skeletal muscle mass/body weight (wt) or body mass index (BMI) ratios of two standard deviations below the sex-specific mean for healthy young adults. Subjects were divided into four subgroups: diabetic MAFLD (presence of diabetes mellitus [DM]), metabolic dysfunction (MD) MAFLD (≥2 metabolic abnormalities without DM), overweight MAFLD (overweight/obese without DM and <2 metabolic abnormalities) and no MAFLD.

RESULTS

Among all of the 6414 subjects (mean 53.9 years of age; 85.4% male), the prevalence of MAFLD was 49.9% and 22.7% for CAP cut-off values of 248 and 294 dB/m, respectively. In the multivariate analysis, MAFLD was associated with an increased risk of both low muscle mass_wt (odds ratio [OR] 1.80, 95% confidence interval [CI] 1.38-2.35, P < 0.001) and low muscle mass_BMI (OR 1.31, 95% CI 1.01-1.70, P = 0.042). The risk of low muscle mass_wt and low muscle mass_BMI increased the most in the diabetic MAFLD subgroup compared with the no-MAFLD group (OR 2.11, 95% CI 1.51-2.96, P < 0.001 and OR 1.51, 95% CI 1.08-2.13, P = 0.017). There was an increased risk of low muscle mass_wt in the MD MAFLD subgroup (OR 1.73, 95% CI 1.31-2.28, P < 0.001). Comparable results were observed when the CAP cut-off value of 294 dB/m was applied.

CONCLUSIONS

The presence of MAFLD is significantly associated with increased risk of low muscle mass with varying risks according to the MAFLD subgroups. Clinicians should be aware of the differentiated risk of low muscle mass across the subgroups of MAFLD.

Prevalence of High and Moderate Risk Nonalcoholic Fatty Liver Disease Among Adults in the United States, 1999-2016

BACKGROUND AND AIMS

Nonalcoholic fatty liver disease (NAFLD) subjects with fibrosis stage ≥2 are at high risk for mortality. We aimed to provide national estimates and temporal trends for NAFLD, based on different fibrosis severity.

METHODS

Data from the National Health and Nutrition Examination Survey (NHANES) (1999-2016) and NHANES III (1988-1994) were utilized. NAFLD was determined by ultrasound showing moderate to severe steatosis. For those without ultrasound, NAFLD was determined by the U.S. Fatty Liver Index score of ≥30. Hepatic fibrosis was assessed using Fibrosis-4 (FIB-4) score (FIB-4 <1.3 = low risk; FIB-4 1.3-2.67 = moderate risk; and FIB-4 >2.67 = high risk). Annual percent change (APC) was calculated by using the joinpoint regression model.

RESULTS

From NHANES III, 10,854 individuals were included (mean age 43.5 years; 47.5% male; 75.7% non-Hispanic White) and 37.7% had NAFLD. Among them, based on FIB-4, 80% had low-risk, 18.6% had moderate-risk, and 1.4% had high-risk NAFLD. NAFLD with moderate or high risk was more likely to have hypertension, hyperlipidemia, diabetes, cardiovascular disease, and metabolic syndrome than was low-risk NAFLD (all P < .02). NAFLD prevalence increased from 29.5% in 1999-2000 to 40.3% in 2015-2016 (APC, 2.78%; P < .02), moderate-risk NAFLD increased from 6.26% to 14.17% (APC, 5.34%; P < .02), and high-risk NAFLD increased from 0.49% to 1.15% (APC, 9.72%; P < .02). Independent predictors of advanced fibrosis were age (OR, 1.11; 95% CI, 1.06-1.17; P = .001) and diabetes (OR, 2.28; 95% CI, 1.03-5.05; P = .04). Compared with low-risk NAFLD, high-risk NAFLD was associated with significantly increased all-cause (HR, 1.53; 95% CI, 1.09-2.15; P = .01), cardiovascular disease-specific (HR, 1.99; 95% CI, 1.22-3.24, P < .01) and liver-specific (HR, 4.57; 95% CI, 1.03-28.79; P = .04) mortality.

CONCLUSIONS

The prevalence of moderate- or high-risk NAFLD is increasing and is associated with increased all-cause, liver-related, and cardiovascular mortality.

Nonalcoholic Fatty Liver Disease before Kidney Transplantation Correlates with New Onset Diabetes and Poor Metabolic Outcomes

INTRODUCTION

Cardiovascular disease (CVD) is the leading cause of morbidity and mortality after kidney transplantation. Metabolic syndrome is common in renal transplant recipients and is associated with increased CVD risk in those patients. Nonalcoholic fatty liver disease (NAFLD) is considered to be the hepatic manifestation of a multi-system disorder, including CVD and metabolic syndrome. The data about prevalence of NAFLD before kidney transplantation and its consequences following transplantation are scarce.

METHODS

A retrospective study of metabolic parameters and sonographic evidence of NAFLD, and an analysis of its metabolic outcomes, was performed in 341 consecutive kidney transplant recipients.

RESULTS

One-hundred twenty-four (36.4%) kidney recipients had NAFLD before transplantation. The risk of NAFLD before kidney transplantation was independently and significantly related to diabetes (OR = 1.8), male gender (OR = 1.4), older age (every year of age increased the risk by 4%), higher BMI (every increase of 1 kg/m2 increased the risk by 15%), and higher triglycerides level. Mean levels of liver enzymes were similar in patients with and without NAFLD. Recipients with NAFLD before transplantation had a higher prevalence of new onset diabetes, even after adjustment to covariables. In addition, they had a higher increase in liver enzymes, triglycerides, and FIB-4 score, as an indication of liver fibrosis, after transplantation. Furthermore, NAFLD pre-transplantation was independently associated with cardiovascular mortality (HR = 4.4) following kidney transplantation.

CONCLUSIONS

Sonographic evidence of NAFLD before kidney transplantation is associated with significant metabolic outcomes including de novo diabetes and cardiovascular mortality following transplantation and should be included as part of the assessment of kidney transplant candidate.

Diagnosis of hepatic steatosis based on ultrasound attenuation imaging is not influenced by liver fibrosis

AIM

Recently, a new technique using attenuation imaging (ATI) was developed to diagnose hepatic steatosis. The aim of this study was to investigate whether ATI for the evaluation of hepatic steatosis is influenced by liver fibrosis.

METHODS

A total of 328 patients with chronic liver disease were enrolled to study the associations between histological hepatic steatosis or liver fibrosis and ATI findings. The interaction between liver fibrosis and ATI was also analyzed.

RESULTS

Median ATI values according to steatosis grade and fibrosis stage increased in line with the progression of liver steatosis (p < 0.001) and fibrosis (p < 0.05). However, in each steatosis grade, ATI values according to fibrosis stage were not significantly increased. In multiple regression analyses for assessment of the effect of their interaction, the p values for fibrosis stage, steatosis grade, and fibrosis stage × steatosis grade were 0.096, <0.001, and 0.077, respectively. Variance inflation factor values for fibrosis stage, steatosis grade, and fibrosis stage × steatosis grade were 1.079, 1.094, and 1.074, respectively.

CONCLUSION

Attenuation imaging values are not influenced by liver fibrosis.

Association between metabolically healthy obesity and non-alcoholic fatty liver disease

BACKGROUND

The risks of NAFLD and NAFLD with fibrosis progression among metabolically healthy obesity (MHO) individuals are largely unexplored. This cohort study investigated the association between MHO as well as other metabolic syndrome-obesity combined phenotypes and NAFLD and its fibrosis progression.

METHODS

Participants included 31,010 adults from a health check-up cohort free from NAFLD and intermediate or high probability of advanced fibrosis at baseline. Metabolically healthy was defined as not having any component of metabolic syndrome. Obesity was identified by body mass index (BMI) and waist circumference (WC). Participants were cross-classified by metabolic health and obesity at baseline. The outcomes were NAFLD, and NAFLD with fibrosis progression, as assessed by abdominal B-type ultrasound and noninvasive fibrosis score.

RESULTS

During a median follow-up of 2.2 (interquartile range, 1.2-4.9) years, 7,393 participants developed NAFLD. MHO individuals (HR 5.51, 95% CI 4.98, 6.09 for BMI criteria; HR 6.76, 95% CI 6.04, 7.57 for WC criteria) had a significantly higher risk of NAFLD than those with metabolically healthy normal weight or low WC. The corresponding HRs (95% CIs) for metabolically healthy overweight (defined by BMI) and medium WC were 2.74 (2.49-3.02) and 2.93 (2.65-3.24), respectively. Furthermore, 557 participants developed NAFLD with fibrosis progression. The association between different obesity phenotypes and NAFLD with fibrosis progression also showed a similar pattern.

CONCLUSION

MHO was associated with significantly higher risks of NAFLD and its fibrosis progression, suggesting that regarding NAFLD prevention, MHO individuals might still benefit from lifestyle interventions aimed at body weight and WC maintenance.

To do one and to get more: Part II. Diabetes and metabolic dysfunction-associated fatty liver diseases

Type 2 diabetes mellitus (DM) is characterized by inability of faulty pancreatic β-cells to secret a normal amount of insulin to maintain normal body consumption, and/or peripheral tissue has a decreased susceptibility to insulin, resulting in hyperglycemia and insulin resistance. Similar to other chronic systemic inflammatory diseases, DM is a result from dysregulated interactions between ethnic, genetic, epigenetic, immunoregulatory, hormonal, and environmental factors. Therefore, it is rational to suppose the concept as "To do one and to get more", while using antidiabetic agents (ADA), a main pharmacologic agent for the treatment of DM, can provide an extraglycemia effect on comorbidities or concomittent comorbidities to DM. In this review, based on the much strong correlation between DM and metabolic dysfunction-associated fatty liver diseases (MAFLD) shown by similar pathophysiological mechanisms and a high prevalence of DM in MAFLD and its vice versa (a high prevalence of MAFLD in DM), it is possible to use the strategy to target both diseases simultaneously. We focus on a new classification of ADA, such as glucagon-like peptide-1 receptor (GLP1R) agonist and sodium-glucose cotransporter-2 (SGLT-2) inhibitors to show the potential benefits of extraglycemic effect on MAFLD. We conclude that the management of DM patients, especially for those who need ADA as adjuvant therapy should include healthy lifestyle modification to overcome the metabolic syndrome, contributing to the urgent need of an effective weight-reduction strategy. GLP1R agonist is one of effective body weight-lowering medications, which may be a better choice for DM complicated with MAFLD or its-associated severe form as metabolic associated steatohepatitis (MASH), although the role of SGLT-2 inhibitors is also impressive. The prescription of these two classes of ADA may satisfy the concept "To do one and to get more", based on successful sugar-lowering effect for controlling DM and extraglycemia benefits of hepatoprotective activity in DM patients.

GA/HbA1c ratio is a simple and practical indicator to evaluate the risk of metabolic dysfunction-associated fatty liver disease in type 2 diabetes: an observational study

BACKGROUND

It is still debatable whether glycated albumin/glycated hemoglobin A1C (GA/HbA1C) ratio is associated with metabolic dysfunction-associated fatty liver disease (MAFLD), and few studies have been conducted in type 2 diabetes mellitus (T2DM). Therefore, we aimed to investigate the association between GA/HbA1C ratio and MAFLD and to evaluate whether GA/HbA1C ratio can be used an indicator of MAFLD in Chinese patients with T2DM.

METHODS

This cross-sectional study consisted of 7117 T2DM patients including 3296 men and 3821 women from real-world settings. Abdominal ultrasonography was performed to diagnose MAFLD. In addition to comparing the clinical characteristics among the GA/HbA1C ratio quartile groups, we also investigated the associations of GA/HbA1C ratio and quartiles with MAFLD in T2DM subjects.

RESULTS

There was a significantly decreased trend in the MAFLD prevalence across the GA/HbA1C ratio quartiles (56.3%, 47.4%, 37.8%, and 35.6% for the first, second, third, and fourth quartile, respectively, P < 0.001 for trend) after adjusting for gender, age, and diabetes duration. Fully adjusted Binary logistic regression indicated that both GA/HbA1C ratio (OR: 0.575, 95% CI: 0.471 to 0.702, P < 0.001) and quartiles (P < 0.001 for trend) were inversely associated with the presence of MAFLD among T2DM patients. Additionally, HOMA2-IR values were clearly increased in the T2DM subjects with MAFLD compared with those without MAFLD (P < 0.001), and markedly increased from the highest to the lowest GA/HbA1C ratio quartile (P < 0.001 for trend).

CONCLUSIONS

GA/HbA1C ratio is closely and negatively associated with MAFLD in T2DM subjects, which may attribute to that GA/HbA1C ratio reflects the degree of insulin resistance. GA/HbA1C ratio may act as a simple and practical indicator to evaluate the risk of MAFLD in T2DM.

Ultrasound and FibroScan® Controlled Attenuation Parameter in patients with MAFLD: head to head comparison in assessing liver steatosis

BACKGROUND

Controlled attenuation parameter (CAP) has been suggested as a new non-invasive measurement performed during transient elastography (TE) to assess liver steatosis. The aim of this study was to evaluate CAP values head to head with ultrasound (US) as reference standard.

METHODS

A consecutive cohort of patients attending abdominal US in an outpatient liver unit was included in this study with simultaneous CAP determination using the FibroScan^® M probe and fibrosis scored by TE. Patients were subdivided in four groups on the basis of risk factors for Metabolically Associated Fatty Liver Disease (MAFLD).

RESULTS

Four hundred thirty-five patients were included in the analysis: 221 (51%) were male; 117 (26.9%) were in control group, 144 (33.1%) in group 2 with inactive HCV or HBV infection and at low-risk for MAFLD, 134 (30.8%) in group 3 at high-risk of MAFLD, 40 (9.2%) in group 4 at high-risk of MAFLD and concomitant inactive HCV or HBV infection. Liver steatosis detected with US evaluation was observed in the 41% of the entire cohort; in particular in the 3.4%, 20.1%, 83.6% and 87.4% of the group 1, 2, 3 and 4, respectively (p < 0.001). In patients at high-risk factor for MAFLD (group 3 and 4), CAP median levels were found statistically different among the severity-grading groups for US steatosis (S0 [n.27], ≥S1 [n.59], ≥S2 + S3 [n.89]), observing higher CAP levels in patients with a higher steatosis grade (≥S2 + S3 327.5 [±40.6] vs ≥S1 277.7 [±45.6] vs S0 245.1 [±47.4]; p < 0.001 for the whole cohort analysis) (p < 0.001 between ≥S2 + S3 and ≥S1) (p < 0.001 between ≥S2 + S3 and S0) (p = 0.004 between ≥S1 and S0). ROC analysis showed that the global performance of the CAP median level ≥ 258 to predict liver steatosis (S0 vs S1-3), was excellent with an Area Under the Curve (AUC) value of 0.87 [CI 95% 0. 835-0.904] with an 84% of sensitivity and a 78% of specificity, and a positive predictive value (PPV) of 73% and negative predictive value (NPV) of 88%. A TE-kPa median value <8.0 was detected in the 100%, 84%, 83.6% and 60% of patients in group 1, 2, 3 and 4, respectively. A TE-kPa median value >13.0 was detected in the 0%, 4.2%, 5.2% and 17.5% of patients in group 1, 2, 3 and 4, respectively.

CONCLUSIONS

CAP values are strongly associated with the standard US criteria for different degree of steatosis. Integrating TE up to 5% of patients may be identified at risk for advanced fibrosis.

Prevalence of fatty liver and advanced fibrosis by ultrasonography and FibroScan in a general population random sample

AIM

Fatty liver is the most common liver disease. This study examined fatty liver and advanced fibrosis prevalence in a random sample of the Japanese general population.

METHODS

A total of 6000 people randomly selected from two cities in Hiroshima Prefecture were invited to participate in this cross-sectional study originally carried out for hepatitis virus screening. Ultrasonography and FibroScan (controlled attenuation parameter [CAP] and liver stiffness measurement [LSM]) were provided as additional tests.

RESULTS

Of 6000 invited individuals, 1043 participated in hepatitis virus screening, of which 488 randomly selected individuals (median age, 56 years; interquartile range, 45-68 years; male participants, 49.8%) underwent ultrasonography, CAP, and LSM. Ultrasonography showed fatty liver in 24.6% and mild fatty liver in 32.8%. Controlled attenuation parameter showed severe steatosis in 27.5%, moderate steatosis in 12.5%, and mild steatosis in 11.1%. Overall, 62.1% were diagnosed with fatty liver based on ultrasonography or CAP. Nonalcoholic fatty liver disease (NAFLD) prevalence was 50.6%. Liver stiffness measurement found cirrhosis in 1.0% and severe fibrosis in 1.8%. Multivariate analysis of risk factors associated with ≥F2 or higher liver fibrosis showed that age ≥60 years and above (adjusted odds ratio [AOR], 3.2; 95% confidence interval [CI], 1.5-6.9; p = 0.0031), hepatitis C virus antibody positivity (AOR, 8.4; 95% CI, 1.0-68.4; p = 0.0467), and fatty liver (AOR, 2.3; 95% CI, 1.1-6.2; p = 0.0317) are independent risk factors.

CONCLUSIONS

In the general population, 62.1% had fatty liver, and NAFLD prevalence was twice as high as previously reported. Screening that is noninvasive, low-cost, and does not require special techniques or equipment is needed to detect advanced liver fibrosis.

Pulse-Echo Quantitative US Biomarkers for Liver Steatosis: Toward Technical Standardization

Excessive liver fat (steatosis) is now the most common cause of chronic liver disease worldwide and is an independent risk factor for cirrhosis and associated complications. Accurate and clinically useful diagnosis, risk stratification, prognostication, and therapy monitoring require accurate and reliable biomarker measurement at acceptable cost. This article describes a joint effort by the American Institute of Ultrasound in Medicine (AIUM) and the RSNA Quantitative Imaging Biomarkers Alliance (QIBA) to develop standards for clinical and technical validation of quantitative biomarkers for liver steatosis. The AIUM Liver Fat Quantification Task Force provides clinical guidance, while the RSNA QIBA Pulse-Echo Quantitative Ultrasound Biomarker Committee develops methods to measure biomarkers and reduce biomarker variability. In this article, the authors present the clinical need for quantitative imaging biomarkers of liver steatosis, review the current state of various imaging modalities, and describe the technical state of the art for three key liver steatosis pulse-echo quantitative US biomarkers: attenuation coefficient, backscatter coefficient, and speed of sound. Lastly, a perspective on current challenges and recommendations for clinical translation for each biomarker is offered.

Fatty Liver Is an Independent Risk Factor for Elevated Intraocular Pressure

Elevated intraocular pressure (EIOP) is a major risk factor for glaucoma. Both EIOP and fatty liver share metabolic risk factors, which implies a possible link between EIOP and fatty liver. We aimed to determine the association of fatty liver with EIOP and estimate the effect of fatty liver on EIOP directly and indirectly through insulin resistance. Data from 16,240 adults who underwent health examinations at a single center were analyzed. Multiple logistic regression analyses revealed that fully adjusted odds ratio (OR) and 95% confidence interval (CI) for EIOP in the fatty liver group compared to the non-fatty liver group were 1.36 and 1.08-1.71. Alcoholic liver disease was associated with EIOP in subgroup analysis (OR = 1.80, 95% CI: 1.27-2.56). There was a linear dose-response relationship between EIOP and the severity of fatty liver. Mediation analysis revealed that the total effect of fatty liver on intraocular pressure was 0.90 (0.81-0.99), with a direct effect of 0.81 (0.71-0.90) and an indirect effect of 0.09 (0.06-0.11) through insulin resistance. Fatty liver is independently associated with EIOP. It primarily has a direct effect on intraocular pressure. This suggests that evaluation of EIOP should be considered in patients with fatty liver.

Non-obese NAFLD had no better cardio-metabolic risk profile than obese NAFLD in type 2 diabetic patients

Background

Non-obese non-alcoholic fatty liver disease (NAFLD) has been reported to share clinical outcomes with its obese counterpart in the general population. However, conflicting results have been observed regarding the cardio-metabolic risk profile of non-obese NAFLD as compared to obese NAFLD. Moreover, in the context of type 2 diabetes mellitus (T2DM), this issue has been even less addressed. We hence aimed to examine the association of NAFLD with the cardio-metabolic risk profile in patients with T2DM according to their obesity status.

Methods

A total of 2,708 patients with T2DM who were hospitalized between June 2018 and May 2021 were cross-sectionally assessed.

Results

The prevalence of NAFLD was 49.3%. NAFLD was found in 34.1% of non-obese patients and 66.0% of obese patients. Non-obese NAFLD patients had more and worse metabolic disorders than obese patients without NAFLD in both men and women. Comparable cardio-metabolic risk profiles were noted between non-obese and obese NAFLD subjects. The associations of worse cardio-metabolic risk profiles with NAFLD were overall stronger in non-obese than in obese subjects among women with T2DM, while more pronounced in obese than in non-obese subjects among men with T2DM.

Conclusion

In patients with T2DM, non-obese NAFLD had no better cardio-metabolic risk profile than obese NAFLD. The associations of metabolic disorders with NAFLD were stronger in non-obese than in obese patients in women patients with T2DM.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12933-022-01648-9.

Role of non-invasive methods in detecting liver impairment in familial Mediterranean fever adult patients with persistent hepatic cytolysis

Familial Mediterranean fever (FMF) patients may have hepatic cytolysis, although its origin is not formally elucidated. We aimed to evaluate liver involvement in familial Mediterranean fever (FMF) using non-invasive methods. All adult FMF patients harboring two non-ambiguous mutations of the MEFV gene with hepatic cytolysis were identified in a French tertiary adult center for FMF. Liver impairment was explored with FibroMax (a non-invasive method to estimate hepatic steatosis, necrosis, inflammation and fibrosis) and liver ultrasound. Among 520 FMF adult patients, 43 had persistent hepatic cytolysis and 20 patients were included (11 women, median age at inclusion: 49.5 years). According to the FibroMax results, patients were classified as having steatosis, fibrosis, and possible or definite nonalcoholic steato-hepatitis in 10 (50%), 9 (45%) and 7 (35%) of cases, respectively. The score of steatosis did not seem associated with the usual metabolic risk factors. No significant association was found between the cumulated dose of colchicine and any of the scores included in FibroMax. In adult FMF patients with persistent hepatic cytolysis, steatosis is the first cause to consider even in the absence of usual metabolic risk factors, suggesting other mechanisms. Colchicine did not seem to be involved in this toxicity.

Liver stiffness not fatty liver disease is associated with atrial fibrillation: The Rotterdam study

BACKGROUND & AIMS

Fatty liver disease has become the most prevalent chronic liver disease globally and is linked to cardiovascular disease, including arrhythmias. However, there have been inconsistent reports on the association between fatty liver disease and atrial fibrillation, while the role of liver stiffness in this association remains unclear.

METHODS

Within the Rotterdam Study, a large prospective ongoing cohort, participants attending the abdominal ultrasound program between 2009-2014 were included. Exclusion criteria were no atrial fibrillation data or >20% missing data across analysis variables. Steatosis was assessed by ultrasound, liver stiffness by transient elastography and atrial fibrillation by 12-lead electrocardiograms. Incident atrial fibrillation was based on medical records and complete until 2014. Logistic and Cox-regression were used to quantify associations between fatty liver disease and atrial fibrillation.

RESULTS

We included 5,825 participants (aged 69.5±9.1, 42.9% male), 35.7% had steatosis, liver stiffness measurement was available in 73.3%, and 7.0% had prevalent atrial fibrillation. Steatosis was not associated with prevalent atrial fibrillation in fully adjusted models (odds ratio [OR] 0.80; 95% CI 0.62-1.03), findings were consistent for non-alcoholic or metabolic dysfunction-associated fatty liver disease. Liver stiffness was significantly associated with prevalent atrial fibrillation (OR 1.09 per kPa, 95% CI 1.03-1.16); however, this was only persistent among those without steatosis (OR 1.18 per kPa, 95% CI 1.08-1.29). Lastly, no associations were found between steatosis (hazard ratio 0.88; 95% CI 0.59-1.33; follow-up 2.1 [1.1-3.2] years) and incident atrial fibrillation.

CONCLUSIONS

Fatty liver disease was not associated with prevalent or incident atrial fibrillation, while liver stiffness was significantly associated with atrial fibrillation, especially among those without steatosis. This association might be driven by venous congestion instead of fibrogenesis, but this awaits further validation. We recommend assessing cardiovascular health in participants with high liver stiffness, especially in the absence of overt liver disease.

CLINICAL TRIAL NUMBER

NTR6831.

LAY SUMMARY

There have been inconsistent reports about the potential links between fatty liver disease and atrial fibrillation (an irregular and often very fast heart rhythm). Herein, we show that liver stiffness (which is a marker of liver fibrosis), but not fatty liver disease, was associated with a higher prevalence of atrial fibrillation. We hypothesis that atrial fibrillation, rather than fibrosis, may be the cause of increased liver stiffness in participants without overt liver disease.

The impact of body mass index on clinicopathological features of nonalcoholic fatty liver disease in Taiwan

BACKGROUND AND AIM

The aim of this study was to assess the impact of body mass index (BMI) on the clinical and histological characteristics of patients with nonalcoholic fatty liver disease (NAFLD).

METHODS

Patients with clinically diagnosed NAFLD who received liver biopsy were retrospectively enrolled from 2007 to 2019. For comparison, all of the patients were divided into lean body mass (< 23 kg/m² ), overweight (23-24.9 kg/m² ), and obesity (BMI ≧ 25 kg/m² ).

RESULTS

A total of 572 patients with histologically confirmed NAFLD, including 40 (6.99%) lean body mass, 54 (9.44%) overweight, and 478 (83.57%) obese patients, were recruited. Obese NAFLD patients had significantly higher grade of steatosis (grade 3: 29.92% vs 22.22% vs 12.5%, P < 0.0001) and hepatocyte ballooning (grade 2: 14.85% vs 12.96% vs 12.5%, P < 0.0001) than overweight and lean NAFLD patients. The prevalence of nonalcoholic steatohepatitis (NASH) was 22.5%, 25.93%, and 36.19% in lean, overweight, and obese NAFLD patients, respectively. Obesity was significantly associated with fibrosis severity (P = 0.03). The fibrosis index based on four factors (FIB-4) score can identify NAFLD patients without significant fibrosis or with cirrhosis. The areas under the receiver-operating characteristic curve of FIB-4 score to identify patients without significant fibrosis or with cirrhosis were 0.82 (95% confidence interval [CI]: 0.69-0.96) and 0.87 (95% CI: 0.76-0.99) in lean patients; 0.77 (95% CI: 0.61-0.93) and 0.81 (95% CI: 0.59-1.0) in overweight patients; and 0.77 (95% CI: 0.72-0.82) and 0.89 (95% CI: 0.85-0.92) in obese patients.

CONCLUSIONS

The majority of NAFLD patients are obese, as defined by BMI. Obesity was significantly associated with NASH and hepatic fibrosis severity in patients with NAFLD.

The prevalence of nonalcoholic fatty liver disease in Chinese adults screened by vibration controlled transient elastography and its diagnostic discrepancy compared with ultrasound

BACKGROUND

The prevalence of non-alcoholic fatty liver disease (NAFLD) in China as assessed using vibration-controlled transient elastography (VCTE) and its consistency with ultrasound is still unknown. We aimed to conduct a head-to-head comparison of consecutive measurements of NAFLD with ultrasound or VCTE to evaluate the discrepancy in the prevalence and distribution of NAFLD screened by two non-invasive techniques.

METHODS

We collected VCTE and ultrasound examination data from 4,388 participants who underwent health check-ups at the Health Promotion Center of Jiangsu Province Hospital between January 2017 and December 2019. The major outcome was the presence of hepatic steatosis, which was defined as a median controlled attenuation parameter (CAP) ≥ 248 dB/m by VCTE or the definition of steatosis by ultrasound.

RESULTS

Among the 4,388 participants, 2,214 were diagnosed with NAFLD by VCTE (CAP ≥ 248 dB/m, 50.46%). Participants with severe steatosis (CAP ≥ 280 dB/m) were commonly male (77.94% vs. 50.38%, P < 0.001), were obese (45.09% vs. 1.79%, P < 0.001), had a worse metabolic profile, had elevated liver enzyme levels, and had advanced fibrosis. The prevalence of ultrasound-diagnosed NAFLD was 56.42%. After consistency analysis, VCTE and ultrasound showed moderate agreement regarding the diagnosis of NAFLD (κ = 0.475). We then compared the characteristics and clinical features of the four groups classified by the diagnosis results of the two techniques. NAFLD participants diagnosed by VCTE only were older, more obese, and had worse metabolic and biochemical profiles than NAFLD participants diagnosed by ultrasound only; in particular, the former had a higher proportion of abnormal alanine aminotransferase and aspartate aminotransferase levels and a higher proportion of advanced fibrosis than the latter.

CONCLUSIONS

More than half of Chinese adults were affected by NAFLD according to VCTE. Screening based on VCTE is more likely to identify NAFLD patients with severe clinical features than ultrasound. Therefore, VCTE is a more practical non-invasive tool for the screening and follow-up of NAFLD in China.

Comparative Study of Raw Ultrasound Data Representations in Deep Learning to Classify Hepatic Steatosis

Adiposity accumulation in the liver is an early-stage indicator of non-alcoholic fatty liver disease. Analysis of ultrasound (US) backscatter echoes from liver parenchyma with deep learning (DL) may offer an affordable alternative for hepatic steatosis staging. The aim of this work was to compare DL classification scores for liver steatosis using different data representations constructed from raw US data. Steatosis in N = 31 patients with confirmed or suspected non-alcoholic fatty liver disease was stratified based on fat-fraction cutoff values using magnetic resonance imaging as a reference standard. US radiofrequency (RF) frames (raw data) and clinical B-mode images were acquired. Intermediate image formation stages were modeled from RF data. Power spectrum representations and phase representations were also calculated. Co-registered patches were used to independently train 1-, 2- and 3-D convolutional neural networks (CNNs), and classifications scores were compared with cross-validation. There were 67,800 patches available for 2-D/3-D classification and 1,830,600 patches for 1-D classification. The results were also compared with radiologist B-mode annotations and quantitative ultrasound (QUS) metrics. Patch classification scores (area under the receiver operating characteristic curve [AUROC]) revealed significant reductions along successive stages of the image formation process (p &lt; 0.001). Patient AUROCs were 0.994 for RF data and 0.938 for clinical B-mode images. For all image formation stages, 2-D CNNs revealed higher patch and patient AUROCs than 1-D CNNs. CNNs trained with power spectrum representations converged faster than those trained with RF data. Phase information, which is usually discarded in the image formation process, provided a patient AUROC of 0.988. DL models trained with RF and power spectrum data (AUROC = 0.998) provided higher scores than conventional QUS metrics and multiparametric combinations thereof (AUROC = 0.986). Radiologist annotations indicated lower hepatic steatosis classification accuracies (Acc = 0.914) with respect to magnetic resonance imaging proton density fat fraction that DL models (Acc = 0.989). Access to raw ultrasound data combined with artificial intelligence techniques may offer superior opportunities for quantitative tissue diagnostics than conventional sonographic images.

Triglyceride affects the association between estimated glomerular filtration rate and the onset of non-alcoholic fatty liver disease: A second analysis of a Chinese cohort study

Objective

The role of triglyceride (TG) and estimated glomerular filtration rate (eGFR) effect modifiers on the risk of non-alcoholic fatty liver disease (NAFLD) is unknown. This study examined whether TG modifies the relationship between eGFR and incident NAFLD.

Methods

In a Chinese hospital from January 2010 to December 2014, 15,555 non-obese subjects were collected systematically for this retrospective cohort study. The target-independent and dependent variables were eGFR measured at baseline and NAFLD appearing during follow-up. The modified variable was TG measured at baseline. The multivariate Cox proportional hazards model was used to explore eGFR and TG’s association with NAFLD risk. We explored a priori interaction between eGFR and TG, and performed subgroup analyses to further assess whether the relationship between eGFR and incident NAFLD was modified by TG. We also explored the effect of TG and eGFR interaction on the risk of NAFLD.

Results

The mean age was 43.09 ± 14.92 years, and 8,131 (52.27%) were males. During a median follow-up time of 35.8 months, 2,077 (13.35%) individuals developed NAFLD. In the adjusted model, eGFR was negatively associated with incident NAFLD (HR = 0.984, 95% CI: 0.982, 0.987), while TG was positively related to NAFLD (HR = 1.582, 95% CI: 1.490, 1.681). TG could modify the relationship between eGFR and incident NAFLD. A stronger association between eGFR and NAFLD could be found in the participants without hypertriglyceridemia (HTG) (HR = 0.981, 95% CI: 0.978–0.984, P for interaction = 0.0139). In contrast, the weaker association was probed in the population with HTG (HR = 0.986, 95% CI: 0.983–0.989). At the same time, we also found an interaction between eGFR and TG in influencing NAFLD risk. In participants with decreased eGFR and HTG, the risk of NAFLD was significantly increased. Further, compared to non-HTG subjects with eGFR ≥ 116.56 ml/min/1.73 m², participants with HTG and eGFR < 82.88 ml/min/1.73 m² had about a fourfold increase in the risk (HR = 4.852 95% CI: 3.943–5.970) of NAFLD.

Conclusion

eGFR and TG is independently associated with NAFLD risk. The association of eGFR with incident NAFLD is likely to be modified by TG in the Chinese non-obese population. There was an interactive effect between eGFR and TG in affecting NAFLD risk. In participants with decreased eGFR and hypertriglyceridemia, the risk of NAFLD is significantly increased.

Non-alcoholic fatty liver disease: Is surgery the best current option and can novel endoscopy play a role in the future?

Over the last decade, non-alcoholic fatty liver disease (NAFLD) has overtaken alcohol as the leading cause of cirrhosis in the Western world. There remains to be a licensed pharmacological treatment for NAFLD. Weight loss is advised for all patients with NAFLD. Many patients however, struggle to lose the recommended weight with lifestyle modification alone. Many drugs have either failed to show significant improvement of steatosis or are poorly tolerated. Bariatric surgery has been shown to reduce liver steatosis and regress liver fibrosis. The pathophysiology is not fully understood, however recent evidence has pointed towards changes in the gut microbiome following surgery. Novel endoscopic treatment options provide a minimally invasive alternative for weight loss. Randomised controlled trials are now required for further clarification.

Added sugar intake and its forms and sources in relation to risk of non-alcoholic fatty liver disease: results from the Tianjin Chronic Low-grade Systemic Inflammation and Health cohort study

It has been suggested that added sugar intake is associated with non-alcoholic fatty liver disease (NAFLD). However, previous studies only focused on sugar-sweetened beverages; the evidence for associations with total added sugars and their sources is scarce. This study aimed to examine the associations of total added sugars, their physical forms (liquid v. solid) and food sources with risk of NAFLD among adults in Tianjin, China. We used data from 15 538 participants, free of NAFLD, other liver diseases, CVD, cancer or diabetes at baseline (2013-2018 years). Added sugar intake was estimated from a validated 100-item FFQ. NAFLD was diagnosed by ultrasonography after exclusion of other causes of liver diseases. Multivariable Cox proportional hazards models were fitted to calculate hazard ratios (HR) and corresponding 95 % CI for NAFLD risk with added sugar intake. During a median follow-up of 4·2 years, 3476 incident NAFLD cases were documented. After adjusting for age, sex, BMI and its change from baseline to follow-up, lifestyle factors, personal and family medical history and overall diet quality, the multivariable HR of NAFLD risk were 1·18 (95 % CI 1·06, 1·32) for total added sugars, 1·20 (95 % CI 1·08, 1·33) for liquid added sugars and 0·96 (95 % CI 0·86, 1·07) for solid added sugars when comparing the highest quartiles of intake with the lowest quartiles of intake. In this prospective cohort of Chinese adults, higher intakes of total added sugars and liquid added sugars, but not solid added sugars, were associated with a higher risk of NAFLD.

Accuracy of Ultrasound Elastography and Fibrosis-4 Index (FIB-4) in Ruling Out Cirrhosis in Obese Non-Alcoholic Fatty Liver Disease (NAFLD) Patients

Introduction: Non-alcoholic fatty liver disease (NAFLD) is the most common cause of advanced liver disease in the USA. Liver biopsy, the gold standard diagnostic test for evaluating liver fibrosis, is associated with significant risk and expense. The accuracy of ultrasound elastography and Fibrosis-4 index (FIB-4) in the obese NAFLD population is unknown. We aimed to compare the accuracy of ultrasound elastography and FIB-4 to liver biopsy in ruling out cirrhosis in NAFLD patients at a tertiary, transplant referral center in the US.

Methods: We retrospectively evaluated 93 patients with a mean age of 53 years (SD: 13 years) who underwent liver ultrasound elastography and liver biopsy, and additionally calculated their FIB-4 at the time of biopsy. We compared the liver stiffness measurement (LSM) obtained from ultrasound elastography and FIB-4 with the pathology results for ruling out cirrhosis.

Results: 85% of the patients were white, 53% were female, average BMI was 34.7 (SD: 6.7), 52% had diabetes, and 53% had hypertension. For biopsy-proven cirrhosis (prevalence 15%), a cut-off value of 12.5 kilopascals (kPa) for F4 had a sensitivity of 92% and a specificity of 54%. Values below this threshold excluded cirrhosis with 98% certainty. Compared to FIB-4, ultrasound elastography showed higher accuracy in ruling out cirrhosis (92% vs. 80% sensitivity, 98% vs. 95% negative predictive value (NPV), respectively).

Conclusion: To our knowledge, this is the first study in a tertiary transplant referral center in the USA to show that ultrasound elastography was superior to FIB-4 and can be used as a reliable screening test to rule out cirrhosis in obese NAFLD patients at a 12.5 kPa cut-off. Therefore, helping to avoid the risk and expense associated with liver biopsy.

Ultrasound Methods for the Assessment of Liver Steatosis: A Critical Appraisal

The prevalence of the non-alcoholic fatty liver disease has reached major proportions, being estimated to affect one-quarter of the global population. The reference techniques, which include liver biopsy and the magnetic resonance imaging proton density fat fraction, have objective practical and financial limitations to their routine use in the detection and quantification of liver steatosis. Therefore, there has been a rising necessity for the development of new inexpensive, widely applicable and reliable non-invasive diagnostic tools. The controlled attenuation parameter has been considered the point-of-care technique for the assessment of liver steatosis for a long period of time. Recently, many ultrasound (US) system manufacturers have developed proprietary software solutions for the quantification of liver steatosis. Some of these methods have already been extensively tested with very good performance results reported, while others are still under evaluation. This manuscript reviews the currently available US-based methods for diagnosing and grading liver steatosis, including their classification and performance results, with an appraisal of the importance of this armamentarium in daily clinical practice.

A reappraisal of the diagnostic performance of B-mode ultrasonography for mild liver steatosis

OBJECTIVES

Previous studies have shown that ultrasonography has high specificity (80-100%) but low sensitivity (50-70%) in diagnosing fatty liver, sensitivity is especially low for mild steatosis. In this study, we aimed to reappraise the diagnostic performance of B-mode ultrasonography for fatty liver disease.

METHODS

We performed a retrospective, multinational, multi-center, cross-sectional, observational study (six referral centers from three nations). We included 5056 participants who underwent both B-mode ultrasonography and magnetic resonance proton density fat fraction (MRI-PDFF) within a 6-month period. The diagnostic performance of B-mode ultrasonography was compared to MRI-PDFF as a reference standard for fatty liver diagnosis, using sensitivity, specificity, positive and negative predictive values, diagnostic accuracy, and area under the receiver operating characteristic curve (AUC).

RESULTS

B-mode ultrasonography showed a sensitivity of 83.4%, specificity of 81.0%, and AUC of 0.822 in diagnosing mild liver steatosis (6.5% ≤ MRI-PDFF ≤ 14%). The sensitivity, specificity, and AUC in diagnosing the presence of fatty liver disease (MRI-PDFF ≥ 6.5%) were 83.4%, 81.0%, and 0.822, respectively. Mean PDFF of B-mode ultrasonography-diagnosed non-fatty liver differed significantly from that of diagnosed mild liver steatosis (3.5 ± 2.8% vs. 8.5 ± 5.0%, p < 0.001). The inter-institutional variability of B-mode ultrasonography in diagnosing fatty liver was similar in diagnostic accuracy among the six centers (range, 82.8-88.6%, p = 0.416).

CONCLUSIONS

B-mode ultrasonography was an effective, objective method to detect mild liver steatosis using MRI-PDFF as comparison, regardless of the etiologies and comorbidities.

Nonalcoholic fatty liver disease and diabetes

Nonalcoholic fatty liver disease (NAFLD) is the most prevalent chronic liver disease in the world and represents a clinical-histopathologic entity where the steatosis component may vary in degree and may or may not have fibrotic progression. The key concept of NAFLD pathogenesis is excessive triglyceride hepatic accumulation because of an imbalance between free fatty acid influx and efflux. Strong epidemiological, biochemical, and therapeutic evidence supports the premise that the primary pathophysiological derangement in most patients with NAFLD is insulin resistance; thus the association between diabetes and NAFLD is widely recognized in the literature. Since NAFLD is the hepatic manifestation of a metabolic disease, it is also associated with a higher cardio-vascular risk. Conventional B-mode ultrasound is widely adopted as a first-line imaging modality for hepatic steatosis, although magnetic resonance imaging represents the gold standard noninvasive modality for quantifying the amount of fat in these patients. Treatment of NAFLD patients depends on the disease severity, ranging from a more benign condition of nonalcoholic fatty liver to nonalcoholic steatohepatitis. Abstinence from alcohol, a Mediterranean diet, and modification of risk factors are recommended for patients suffering from NAFLD to avoid major cardiovascular events, as per all diabetic patients. In addition, weight loss induced by bariatric surgery seems to also be effective in improving liver features, together with the benefits for diabetes control or resolution, dyslipidemia, and hypertension. Finally, liver transplantation represents the ultimate treatment for severe nonalcoholic fatty liver disease and is growing rapidly as a main indication in Western countries. This review offers a comprehensive multidisciplinary approach to NAFLD, highlighting its connection with diabetes.

Association of Nonalcoholic Fatty Liver Disease with Ventricular Tachycardia and Sinus Arrest in Patients with Non-ST-Segment Elevation Myocardial Infarction

Nonalcoholic fatty liver disease (NAFLD) is an emerging driver of cardiac arrhythmias. However, the relationship between NAFLD and malignant arrhythmia in non-ST-segment elevation myocardial infarction (NSTEMI) patients is still unclear.In this study, 358 NSTEMI inpatients were enrolled. They all received 24-hour Holter monitoring after percutaneous coronary intervention. All inpatients were divided into two groups: the non-NAFLD group (236 cases, 65.9%) and the NAFLD group (122 cases, 34.1%). Compared with the non-NAFLD group, the NAFLD group had a significantly higher incidence of PVCs/hour > 5 (premature ventricular complexes, 32.0% versus 9.3%, P < 0.001), ventricular tachycardia (VT, 22.1% versus 5.9%, P < 0.001), and sinus arrest (SA, 7.4% versus 1.3%, P = 0.002). We found that NAFLD was closely associated with the occurrence of VT [unadjusted odds ratio (OR) 4.507, 95% confidence interval (CI) 2.263-8.974, P < 0.001] and SA (OR 6.186, 95%CI 1.643-23.291, P = 0.007). After adjusting for age, sex, body mass index, and other confounding factors, the above differences were still statistically significant (VT: OR 4.808, 95%CI 2.254-10.253, P < 0.001; SA: OR 9.589, 95%CI 2.027-45.367, P = 0.004).NAFLD is associated with the occurrence of VT and SA in NSTEMI patients. It indicates that NAFLD might be a risk factor for malignant arrhythmias in post-NSTEMI patients.