Relative contribution of iron burden, HFE mutations, and insulin resistance to fibrosis in nonalcoholic fatty liver

The role of Triglyceride Glucose-Waist Circumference (TyG_WC) in predicting metabolic dysfunction-associated steatotic liver disease among individuals with hyperuricemia

BACKGROUND/AIMS

The incidence of metabolic dysfunction-associated steatotic liver disease (MASLD) among individuals with hyperuricemia is significantly high. The aim of this study was to identify effective biomarkers for the detection of MASLD among patients with hyperuricemia.

METHOD

We conducted an analysis involving 3424 participants with hyperuricemia from the National Health and Nutrition Examination Survey (1999-2020). To identify potential significant variables, we employed Boruta's algorithm, SHapley Additive exPlanations (SHAP) and random forests. Multivariable logistic regression models were utilized to assess the odds ratio (OR) of developing MASLD. To evaluate the accuracy and clinical value of our prediction model, we employed receiver operating characteristic (ROC) curves and decision curve analysis (DCA) curves.

RESULTS

Among the study population of 3424 participants (mean [SD] age, 54 [20] years, 1788 [52.22%] males) with hyperuricemia, 1670 participants had MASLD. Using Boruta's algorithm, SHAP and random forests, our analysis suggested that Triglyceride Glucose-Waist Circumference (TyG_WC) was one of the most significant variables in predicting MASLD risk, with an area under the receiver operating characteristic (AUROC) of 0.865. The restricted curve spline (RCS) revealed a positive association between the odds ratio of TyG_WC and MASLD, when compared with lowest quantile of TyG_WC, the risk of MASLD for highest quantile was 137.96 times higher. The predictive strategy incorporating TyG_WC notably enhanced the clinical model, with threshold probabilities spanning from approximately 0% to 100%, resulting in a significant improvement of the net benefit.

CONCLUSIONS

Our analysis found that TyG_WC was one of the most significant variables in predicting MASLD risk among individuals with hyperuricemia.

Noninvasive Assessment of Liver Fibrosis in Patients With Iron Overload

OBJECTIVE

We assessed the diagnostic performance of ultrasound two-dimensional shear wave elastography (US 2D-SWE) to predict clinically significant fibrosis (CSF) in patients with serologic iron overload (SIO) and the subgroup with histologic liver iron overload (LIO).

METHODS

A single-center retrospective cross-sectional study of adults with SIO (serum ferritin ≥ 200 ng/mL in females and ≥ 300 ng/mL in males) and suspected chronic liver disease with nonfocal liver biopsy results and US 2D-SWE exams within 1 year was performed. Histopathological fibrosis stage ≥2 and liver iron ≥2+ was considered CSF and LIO, respectively. Univariate logistic regression to assess prediction of CSF by Young's modulus (YM) and serum ferritin was performed. Sensitivity and specificity were reported at optimal YM threshold determined by the Youden Index.

RESULTS

272 cases were included (211 (77.6%) females, 88 (32.4%) CSF cases) with mean (± standard deviation) age of 50.0 (13.6) years. Median YM predicted CSF in patients with SIO (AUC 0.73, 95% confidence intervals (CI) 0.66 -0.80, odds ratio (OR) 1.12), p < 0.001. Optimal YM threshold was 11 kPa (sensitivity 58%, specificity 79%). Subgroup analysis of 47 LIO cases (39 women, mean age 52.5 ± 11.6 years, 17 (36.2%) CSF) showed that median YM predicted CSF (AUC 0.85, 95% CI 0.73-0.97, OR 1.39), p < 0.001. Optimal YM threshold was 11 kPa (sensitivity 77%, specificity 87%).

CONCLUSION

2D-SWE is a promising, widely available, and noninvasive tool for diagnosing liver fibrosis in iron overload, including when magnetic resonance elastography may be nondiagnostic due to iron-related artifact.

Dose-response relationship of serum ferritin and dietary iron intake with metabolic syndrome and non-alcoholic fatty liver disease incidence: a systematic review and meta-analysis

Aim

This study aims to assess the dose-response impact of iron load on systemic and hepatic metabolic disorders including metabolic syndrome (MetS) and non-alcoholic fatty liver disease (NAFLD).

Methods

Serum ferritin (SF) and dietary iron intake were selected to represent the indicators of iron load in the general population. PubMed, EMBASE and Web of Science databases were searched for epidemiological studies assessing the impact of SF/dietary iron intake on MetS/NAFLD occurrence. All literature was published before September 1st, 2023 with no language restrictions.

Results

Fifteen and 11 papers were collected with a focus on connections between SF and MetS/NAFLD, respectively. Eight papers focusing on dietary iron and MetS were included in the following meta-analysis. For the impact of SF on MetS, the pooled odds ratio (OR) of MetS was 1.88 (95% CI: 1.58-2.24) for the highest versus lowest SF categories. In males, the OR was 1.15 (95% CI: 1.10-1.21) per incremental increase in SF of 50 μg/L, while for females, each 50 μg/L increase in SF was associated with a 1.50-fold higher risk of MetS (95% CI: 1.15-1.94). For connections between SF and NAFLD, we found higher SF levels were observed in NAFLD patients compared to the control group [standardized mean difference (SMD) 0.71; 95% CI: 0.27-1.15], NASH patients against control group (SMD1.05; 95% CI:0.44-1.66), NASH patients against the NAFLD group (SMD 0.6; 95% CI: 0.31-1.00), each 50 μg/L increase in SF was associated with a 1.08-fold higher risk of NAFLD (95% CI: 1.07-1.10). For the impact of dietary iron on MetS, Pooled OR of MetS was 1.34 (95% CI: 1.10-1.63) for the highest versus lowest dietary iron categories.

Conclusion

Elevated SF levels is a linear relation between the incidence of MetS/NAFLD. In addition, there is a positive association between dietary iron intake and metabolic syndrome. The association between serum ferritin and metabolic syndrome may be confounded by body mass index and C-reactive protein levels.

Iron metabolism and ferroptosis in nonalcoholic fatty liver disease: what is our next step?

Nonalcoholic fatty liver disease (NAFLD) is the most common chronic liver disease with increasing prevalence worldwide. NAFLD could develop from simple hepatic steatosis to nonalcoholic steatohepatitis (NASH), NASH-related fibrosis, cirrhosis, and even hepatocellular carcinoma. However, the mechanism of NAFLD development has not yet been fully defined. Recently, emerging evidence shows that the dysregulated iron metabolism marked by elevated serum ferritin, and ferroptosis are involved in the NAFLD. Understanding iron metabolism and ferroptosis can shed light on the mechanisms of NAFLD development. Here, we summarized studies on iron metabolism and the ferroptosis process involved in NAFLD development to highlight potential medications and therapies for treating NAFLD.

Circulating Ferritin in Patients with Nonalcoholic Fatty Liver Disease: A Systematic Review and Meta-analysis

Objectives

To synthesize data on circulating ferritin between patients with histologically confirmed nonalcoholic fatty liver disease (NAFLD) and non-NAFLD controls.

Methods

A systematic literature search was conducted in PubMed, Scopus, and the Cochrane Library. Thirty-one studies comprising data on 5631 individuals (2929 biopsy-proven NAFLD patients and 2702 controls) were included in the meta-analysis.

Results

Higher circulating ferritin levels were observed in NAFLD patients than in controls [standardized mean difference (SMD) 1.14; 95% confidence interval (95% CI) 0.73-1.55], in patients with simple nonalcoholic fatty liver (NAFL) than in controls (SMD 0.57; 95% CI 0.34-0.80), in patients with nonalcoholic steatohepatitis (NASH) than in controls (SMD 0.95; 95% CI 0.69-1.22), and in NASH than in NAFL patients (SMD 0.62; 95% CI 0.25-0.99). There was moderate-to-high heterogeneity among studies in the above pairs of comparisons (I2 = 68-97%); no risk of publication bias was observed by Egger's test (P = 0.81, P = 0.72, P = 0.59, P = 0.42, respectively). The heterogeneity was reduced in the subgroup of biopsy-proven controls in all pairs of comparisons (I2 = 0-65%). The heterogeneity was also reduced after excluding studies with the Newcastle-Ottawa Scale (NOS) score <7 (n = 10) for the comparison of NAFLD patients vs. controls (I2 = 54%, P = 0.02). The meta-regression analysis revealed that the male ratio was positively associated with ferritin SMD in the comparison between NAFLD patients and controls and accounted for 32.7% (P = 0.002) of the heterogeneity in this pair of comparison.

Conclusions

Circulating ferritin was higher in NAFLD (or NAFL or NASH) patients compared with controls. Higher levels of circulating ferritin were also associated with the severity of the disease, which, however, should be cautiously interpreted.PROSPERO registration ID: CRD42022354025.

Serum ferritin levels can predict long-term outcomes in patients with metabolic dysfunction-associated steatotic liver disease

OBJECTIVE

Hyperferritinaemia is associated with liver fibrosis severity in patients with metabolic dysfunction-associated steatotic liver disease (MASLD), but the longitudinal implications have not been thoroughly investigated. We assessed the role of serum ferritin in predicting long-term outcomes or death.

DESIGN

We evaluated the relationship between baseline serum ferritin and longitudinal events in a multicentre cohort of 1342 patients. Four survival models considering ferritin with confounders or non-invasive scoring systems were applied with repeated five-fold cross-validation schema. Prediction performance was evaluated in terms of Harrell's C-index and its improvement by including ferritin as a covariate.

RESULTS

Median follow-up time was 96 months. Liver-related events occurred in 7.7%, hepatocellular carcinoma in 1.9%, cardiovascular events in 10.9%, extrahepatic cancers in 8.3% and all-cause mortality in 5.8%. Hyperferritinaemia was associated with a 50% increased risk of liver-related events and 27% of all-cause mortality. A stepwise increase in baseline ferritin thresholds was associated with a statistical increase in C-index, ranging between 0.02 (lasso-penalised Cox regression) and 0.03 (ridge-penalised Cox regression); the risk of developing liver-related events mainly increased from threshold 215.5 µg/L (median HR=1.71 and C-index=0.71) and the risk of overall mortality from threshold 272 µg/L (median HR=1.49 and C-index=0.70). The inclusion of serum ferritin thresholds (215.5 µg/L and 272 µg/L) in predictive models increased the performance of Fibrosis-4 and Non-Alcoholic Fatty Liver Disease Fibrosis Score in the longitudinal risk assessment of liver-related events (C-indices>0.71) and overall mortality (C-indices>0.65).

CONCLUSIONS

This study supports the potential use of serum ferritin values for predicting the long-term prognosis of patients with MASLD.

Association between circulating biomarkers and non-alcoholic fatty liver disease: An integrative Mendelian randomization study of European ancestry

BACKGROUND AND AIM

Circulating biomarkers provide potential diagnostic or prognostic information on disease presentation, progression or both. Early detection of circulating risk biomarkers is critical for non-alcoholic fatty liver disease (NAFLD) prevention. We aimed to systematically assess the potential causal relationship of genetically predicted 60 circulatory biomarkers with NAFLD using a two-sample Mendelian randomization (MR) design.

METHODS AND RESULTS

We extracted instrumental variables for 60 circulating biomarkers, and obtained genome-wide association data for NAFLD from 3 sources [(including Anstee, FinnGen and UK Biobank (N ranges: 19264-377988)] among individuals of European ancestry. Our primary method was inverse-variance weighted (IVW) MR, with a series of additional and sensitivity analyses to test the hypothesis of MR. MR results showed that genetically predicted higher density lipoprotein-cholesterol (odds ratio (OR) = 0.86, 95% confidence interval (CI): 0.77-0.96) and vitamin D (OR = 0.39, 95% CI: 0.19-0.78) levels decreased the risk of NAFLD, whereas genetically predicted higher alanine (OR = 1.68, 95% CI: 1.21-2.33), histidine (OR = 1.21, 95% CI: 1.00-1.46), lactate (OR = 2.64, 95% CI: 1.09-6.39), triglycerides (OR = 1.16, 95% CI: 1.05-1.13), ferritin (OR = 1.17, 95% CI: 1.01-1.37), serum iron (OR = 1.23, 95% CI: 1.07-1.41) and transferrin saturation (OR = 1.16, 95% CI: 1.05-1.29), component 4 (OR = 1.10, 95% CI: 1.01-1.20), interleukin-1 receptor antagonist (OR = 1.12, 95% CI: 1.04-1.21) and interleukin-6 (OR = 1.62, 95% CI: 1.14-2.30) levels increased the risk of NAFLD.

CONCLUSIONS

The findings might aid in elucidating the underlying processes of these causal relationships and provide strong evidence for focusing on high-risk populations and the therapeutic management of specific biomarkers.

Associations between higher plasma ferritin and hepcidin levels with liver stiffness in patients with type 2 diabetes: An exploratory study

BACKGROUND

Currently, there is no information about the association between circulating levels of ferritin and hepcidin and liver fibrosis in patients with type 2 diabetes mellitus (T2DM) and non-alcoholic fatty liver disease (NAFLD).

METHODS

We enrolled 153 patients with T2DM with no known liver diseases, who consecutively attended our diabetes outpatient service and who underwent liver ultrasonography and liver stiffness measurement (LSM) by vibration-controlled transient elastography (Fibroscan® for the non-invasive assessment of liver fibrosis). Plasma ferritin and hepcidin concentrations were measured with an electrochemiluminescence immunoassay and mass spectrometry-based assay, respectively.

RESULTS

After stratification of patients by LSM tertiles [1st tertile median LSM: 3.6 (interquartile range: 3.3-4.0) kPa, 2nd tertile: 5.3 (4.9-5.9) kPa and 3rd tertile: 7.9 (6.7-9.4) kPa], we found that plasma ferritin and hepcidin concentrations increased across LSM tertiles [median ferritin: 68.7 (interquartile range: 25.1-147) vs. 85.8 (48.3-139) vs. 111 (59.3-203) μg/L, p = 0.021; median hepcidin: 2.5 (1.1-5.2) vs. 4.4 (2.5-7.3) vs. 4.1 (1.9-6.8) nmol/L, p = 0.032]. After adjustment for age, sex, diabetes duration, waist circumference, haemoglobin A1c, HOMA-insulin resistance score, triglycerides, haemoglobin, presence of hepatic steatosis on ultrasonography and patatin-like phospholipase domain-containing-3 (PNPLA3) rs738409 genetic variant, higher plasma ferritin levels were associated with greater LSM values (adjusted-odds ratio 2.10, 95% confidence interval 1.23-3.57, p = 0.005). Higher plasma hepcidin levels were also associated with greater LSM values (adjusted-odds ratio 1.90, 95% confidence interval 1.15-3.13, p = 0.013).

CONCLUSIONS

Higher levels of plasma ferritin and hepcidin were associated with greater NAFLD-related liver fibrosis (assessed by LSM) in patients with T2DM, even after adjustment for established cardiometabolic risk factors, diabetes-related variables and other potential confounders.

Presence of Alpha 1 Antitrypsin Risk Variants is Not Associated With Histologic Severity of Pediatric NAFLD

BACKGROUND

Among adults with nonalcoholic fatty liver disease (NAFLD), alpha-1-antitrypsin (A1AT) heterozygosity has been linked to advanced liver disease; pediatric data remain unclear.

OBJECTIVE

The objective of this study is to determine whether A1AT PiZ or PiS variants are associated with liver disease severity in youth with NAFLD.

METHODS

Retrospective study of youth with confirmed NAFLD. Multivariable logistic regression used to determine independent associations between A1AT risk variants and histologic severity [NAFLD activity score (NAS) ≥5 and/or significant fibrosis (stage ≥2)].

RESULTS

The cohort included 269 patients, mean age 12 [±3] years with NAFLD and A1AT phenotyping (n = 260) and/or A1AT levels (n = 261). The mean NAS of the cohort was 4.2 [±1.5]; 50% had any, and 18% had significant fibrosis. Most (86%) had the MM A1AT phenotype, while 7% had the MS and 3% the MZ phenotype (the rest had other, nonpathogenic variants). Mean A1AT level was 123 mg/dL [±20]. A1AT levels did not differ by low versus high NAS (122 ± 2 vs 126 ± 19 mg/dL, P = 0.12) or by no/mild versus significant fibrosis (123 ± 20 vs 126 ± 20 mg/dL, P = 0.23, respectively). Carriers and noncarriers of the PiS or PiZ variants had similar NAS (mean NAS 3.8 ± 1.6 vs 4.2 ± 1.4; P = 0.25, respectively). Fibrosis severity did not differ by carrier vs noncarrier group: 38% versus 52% had any fibrosis ( P = 0.17) and 14% versus 18% had significant fibrosis ( P = 0.80, respectively). Multivariable modeling showed no association between A1AT risk variants and histologic severity.

CONCLUSION

While not uncommon, carriage of the A1AT PiZ or PiS risk variants was not associated with histologic severity in children with NAFLD.

Roles of the peroxisome proliferator-activated receptors (PPARs) in the pathogenesis of nonalcoholic fatty liver disease (NAFLD)

Non-alcoholic fatty liver disease (NAFLD) encompasses a spectrum of disease phenotypes which start with simple steatosis and lipid accumulation in the hepatocytes - a typical histological lesions characteristic. It may progress to non-alcoholic steatohepatitis (NASH) that is characterized by hepatic inflammation and/or fibrosis and subsequent onset of NAFLD-related cirrhosis and hepatocellular carcinoma (HCC). Due to the central role of the liver in metabolism, NAFLD is regarded as a result of and contribution to the metabolic abnormalities seen in the metabolic syndrome. Peroxisome proliferator-activated receptors (PPARs) has three subtypes, which govern the expression of genes responsible for energy metabolism, cellular development, inflammation, and differentiation. The agonists of PPARα, such as fenofibrate and clofibrate, have been used as lipid-lowering drugs in clinical practice. Thiazolidinediones (TZDs) - ligands of PPARγ, such as rosiglitazone and pioglitazone, are also used in the treatment of type 2 diabetes (T2D) with insulin resistance (IR). Increasing evidence suggests that PPARβ/δ agonists have potential therapeutic effects in improving insulin sensitivity and lipid metabolism disorders. In addition, PPARs ligands have been considered as potential therapeutic drugs for hypertension, atherosclerosis (AS) or diabetic nephropathy. Their crucial biological roles dictate the significance of PPARs-targeting in medical research and drug discovery. Here, it reviews the biological activities, ligand selectivity and biological functions of the PPARs family, and discusses the relationship between PPARs and the pathogenesis of NAFLD and metabolic syndrome. This will open new possibilities for PPARs application in medicine, and provide a new idea for the treatment of fatty liver and related diseases.

Incidence of Type 2 Diabetes in Children With Nonalcoholic Fatty Liver Disease

BACKGROUND & AIMS

Type 2 diabetes (T2D) is a growing problem in children. Children with NAFLD are at potentially high risk for developing T2D; however, the incidence of T2D in this population is unknown. This study aimed to determine the incidence of T2D in children with NAFLD and identify associated risk factors.

METHODS

Children with NAFLD enrolled in the Nonalcoholic Steatohepatitis Clinical Research Network were followed longitudinally. Incidence of T2D was determined by using clinical history and fasting laboratory values. Cumulative incidence curves were developed for time to T2D. A Cox regression multivariable model was constructed using best subsets Akaike's Information Criteria selection.

RESULTS

This study included 892 children with NAFLD and with a mean age of 12.8 years (2.7) followed for 3.8 years (2.3) with a total 3234 person-years at risk. The incidence rate of T2D was 3000 new cases per 100,000 person-years at risk. At baseline, 63 children had T2D, and during follow-up, an additional 97 children developed incident T2D, resulting in a period prevalence of 16.8%. Incident T2D was significantly higher in females versus males (hazard ratio [HR], 1.8 [1.0-2.8]), associated with BMI z-score (HR, 1.8 [1.0-3.0]), and more severe liver histology including steatosis grade (HR, 1.3 [1.0-1.7]), and fibrosis stage (HR, 1.3 [1.0-1.5]).

CONCLUSIONS

Children with NAFLD are at high risk for existing and incident T2D. In addition to known risk factors for T2D (female and BMI z-score), severity of liver histology at the time of NAFLD diagnosis was independently associated with T2D development. Targeted strategies to prevent T2D in children with NAFLD are needed.

Relationship between iron overload caused by abnormal hepcidin expression and liver disease: A review

Iron is essential to organisms, the liver plays a vital role in its storage. Under pathological conditions, iron uptake by the intestine or hepatocytes increases, allowing excess iron to accumulate in liver cells. When the expression of hepcidin is abnormal, iron homeostasis in humans cannot be regulated, and resulting in iron overload. Hepcidin also regulates the release of iron from siderophores, thereby regulating the concentration of iron in plasma. Important factors related to hepcidin and systemic iron homeostasis include plasma iron concentration, body iron storage, infection, inflammation, and erythropoietin. This review summarizes the mechanism and regulation of iron overload caused by hepcidin, as well as related liver diseases caused by iron overload and treatment.

Risk Factors of Non-alcoholic Fatty Liver Disease in the Iranian Adult Population: A Systematic Review and Meta-analysis

Context: Non-alcoholic fatty liver disease (NAFLD) is progressing considerably worldwide. Identifying the risk factors of NAFLD is a critical step in preventing its progression. Methods: In November 2022, two independent researchers studied seven databases, including PubMed, ISI/WoS, ProQuest, Scopus, SID, Magiran, and Google Scholar, and reference list of relevant articles, searching studies that assessed NAFLD risk factors in the Iranian adult population. Heterogeneity between studies was assessed by Cochran’s test and its composition using I2 statistics. A random-effects model was used when heterogeneity was observed; otherwise, a fixed-effects model was applied. Egger’s regression test and Trim-and-Fill analysis were used to assess publication bias. Comprehensive Meta-analysis software (version 3) was used for the analyses of the present study. Results: The results of this study showed significant associations between NAFLD with age (n = 15, odds ratio (OR) = 2.12, 95% CI: 1.79 - 2.51), body mass index (n = 46, OR = 5.00, 95% CI: 3.34 - 7.49), waist circumference (n = 20, OR = 6.37, 95% CI: 3.25 - 12.48), waist-to-hip ratio (n = 17, OR = 4.72, 95% CI: 3.93 - 5.66), total cholesterol (n = 39, OR = 1.80, 95% CI: 1.52 - 2.13), high-density lipoprotein (n = 37, OR = 0.53, 95% CI: 0.44 - 0.65), low-density lipoprotein (n = 31, OR = 1.68, 95% CI: 1.38 - 2.05), triglyceride (n = 31, OR = 3.21, 95% CI: 2.67 - 3.87), alanine aminotransferase (n = 26, OR = 4.06, 95% CI: 2.94 - 5.62), aspartate aminotransferase (n = 27, OR = 2.16, 95% CI: 1.50 - 3.12), hypertension (n = 13, OR = 2.53, 95% CI: 2.32 - 2.77), systolic blood pressure (n = 13, OR = 1.83, 95% CI: 1.53 - 2.18), diastolic blood pressure (n = 14, OR = 1.80, 95% CI: 1.48 - 2.20), fasting blood sugar (n = 31, OR = 2.91, 95% CI: 2.11- 4.01), homeostatic model assessment for insulin resistance (n = 5, OR = 1.92, 95% CI: 1.48 - 2.59), diabetes mellitus (n = 15, OR = 3.04, 95% CI: 2.46 - 3.75), metabolic syndrome (n = 10, OR = 3.56, 95% CI: 2.79 - 4.55), and physical activity (n = 11, OR = 0.32, 95% CI: 0.24 - 0.43) (P < 0.05). Conclusions: In conclusion, several factors are significantly associated with NAFLD. However, anthropometric indices had the strongest relationship with NAFLD in the Iranian adult population.

Glutathione: Pharmacological aspects and implications for clinical use in non-alcoholic fatty liver disease

Glutathione is a tripeptide synthesized at cytosolic level, that exists in cells in a reduced form (thiol-reduced-GSH-) and in an oxidized form (disulfide-oxidized). The antioxidant function of GSH has led to speculation about its therapeutic role in numerous chronic diseases characterized by altered redox balance and reduced GSH levels, including, for instance, neurodegenerative disorders, cancer, and chronic liver diseases. Among these latter, non-alcoholic fatty liver disease (NAFLD), characterized by lipid accumulation in hepatocytes, in the absence of alcohol abuse or other steatogenic factors, is one of the most prevalent. The umbrella term NAFLD includes the pure liver fat accumulation, the so-called hepatic steatosis or non-alcoholic fatty liver, and the progressive form with inflammation, also known as non-alcoholic steatohepatitis, which is related to the increase in oxidative stress and reactive oxygen species, eventually leading to liver fibrosis. Although the pathogenetic role of oxidative stress in these diseases is well established, there is still limited evidence on the therapeutic role of GSH in such conditions. Hence, the aim of this review is to depict the current molecular and pharmacological knowledge on glutathione, focusing on the available studies related to its therapeutic activity in NAFLD.

Non-invasive methods to evaluate liver fibrosis in patients with non-alcoholic fatty liver disease

Non-alcoholic Fatty Liver Disease (NAFLD) is a chronic liver disease that is strongly related to insulin resistance and metabolic syndrome, and it has become the most common liver disorder in developed countries. NAFLD embraces the full pathological process of three conditions: steatosis, non-alcoholic steatohepatitis, and finally, cirrhosis. As NAFLD progresses, symptoms will become increasingly severe as fibrosis develops. Therefore, evaluating the fibrosis stage is crucial for patients with NAFLD. A liver biopsy is currently considered the gold standard for staging fibrosis. However, due to the limitations of liver biopsy, non-invasive alternatives were extensively studied and validated in patients with NAFLD. The advantages of non-invasive methods include their high safety and convenience compared with other invasive approaches. This review introduces the non-invasive methods, summarizes their benefits and limitations, and assesses their diagnostic performance for NAFLD-induced fibrosis.

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.

Oral Administration of Recombinant Lactoferrin-Expressing Probiotics Ameliorates Diet-Induced Lipid Accumulation and Inflammation in Non-Alcoholic Fatty Liver Disease in Mice

We have recently developed probiotics that can express bovine, human, or porcine lactoferrin (LF), and the present study evaluated the effect of these probiotics in improving non-alcoholic fatty liver disease (NAFLD). Three kinds of probiotic supplements, including lactic acid bacteria (LAB), LAB/LF, and inactivated LAB/LF, were prepared. The LAB supplement was prepared from 10 viable LAB without recombinant LF-expression, the LAB/LF supplement was prepared from 10 viable probiotics expressing LF, and the inactivated LAB/LF supplement was prepared from 10 inactivated probiotics expressing LF. A model of obese/NAFLD mice induced by a high-fat diet was established, and the mice were randomly divided into four groups and fed with a placebo, LAB, LAB/LF, or inactivated LAB daily for four weeks via oral gavage. The body weight, food intake, organ weight, biochemistry, and hepatic histopathological alterations and severity scoring were measured. The results revealed that the obese mice fed with any one of the three probiotic mixtures prepared from recombinant probiotics for four weeks exhibited considerably improved hepatic steatosis. These findings confirmed the assumption that specific probiotic strains or LF supplements could help to control NAFLD, as suggested in previous reports. Our data also suggest that the probiotics and LFs in probiotic mixtures contribute differently to improving the efficacy against NAFLD, and the expressed LF content in probiotics may help to boost their efficacy in comparison with the original probiotic mixtures. Moreover, when these LF-expressing probiotics were further inactivated by sonication, they displayed better efficacies than the viable probiotics against NAFLD. This study has provided intriguing data supporting the potential of recombinant probiotics in improving hepatic steatosis.

Association between serum ferritin level and the various stages of non-alcoholic fatty liver disease: A systematic review

Introduction

Non-alcoholic fatty liver disease (NAFLD) has become the most common liver disorder across the world, and non-invasive evaluation approaches are in need to assess NAFLD disease progression. Serum ferritin has been proposed as one of the biomarkers for NAFLD diagnosis in previous studies. This systematic review aims to identify, report, and synthesize studies that investigated the association of serum ferritin level with the various stages of NAFLD among the adult population.

Methods

Three databases - MEDLINE, EMBASE, and Scopus - were systematically searched to obtain potentially relevant publications before July 2022. No restrictions were applied to geographical region, study design, publication type and language. The association between serum ferritin level or different ferritin categories and the various stages of NAFLD was the primary outcome of interest. Title and abstract screenings, data extraction and coding, and quality assessment were independently completed by two authors with discrepancies resolved through discussion with a third author.

Results

Thirty-two studies were included and heterogeneity was considerable. The associations between serum ferritin level and the stages of hepatic steatosis, fibrosis, inflammation and ballooning and the occurrence of non-alcoholic steatohepatitis (NASH) were investigated but inconsistent associations were reported. Most studies identified serum ferritin to be a predictor of advanced NAFLD, while several revealed the opposite end.

Conclusions

Serum ferritin could be considered to act as a non-invasive biomarker for assessing various stages of NAFLD. Nevertheless, further studies are still in need to confirm its predictive value since this study reported inconsistent associations based on the qualitative synthesis.

Systematic Review Registration

http://www.crd.york.ac.uk/PROSPERO, identifier: CRD42021275630.

Iron overload disorders

Iron overload disorders represent a variety of conditions that lead to increased total body iron stores and resultant end-organ damage. An elevated ferritin and transferrin-iron saturation can be commonly encountered in the evaluation of elevated liver enzymes. Confirmatory homeostatic iron regulator (HFE) genetic testing for C282Y and H63D, mutations most encountered in hereditary hemochromatosis, should be pursued in evaluation of hyperferritinemia. Magnetic resonance imaging with quantitative assessment of iron content or liver biopsy (especially if liver disease is a cause of iron overload) should be used as appropriate. A secondary cause for iron overload should be considered if HFE genetic testing is negative for the C282Y homozygous or C282Y/H63D compound heterozygous mutations. Differential diagnosis of secondary iron overload includes hematologic disorders, iatrogenic causes, or chronic liver diseases. More common hematologic disorders include thalassemia syndromes, myelodysplastic syndrome, myelofibrosis, sideroblastic anemias, sickle cell disease, or pyruvate kinase deficiency. If iron overload has been excluded, evaluation for causes of hyperferritinemia should be pursued. Causes of hyperferritinemia include chronic liver disease, malignancy, infections, kidney failure, and rheumatic conditions, such as adult-onset Still's disease or hemophagocytic lymphohistiocytosis. In this review, we describe the diagnostic testing of patients with suspected hereditary hemochromatosis, the evaluation of patients with elevated serum ferritin levels, and signs of secondary overload and treatment options for those with secondary iron overload.

The Pathogenesis of HCC Driven by NASH and the Preventive and Therapeutic Effects of Natural Products

Nonalcoholic steatohepatitis (NASH) is a clinical syndrome with pathological changes that are similar to those of alcoholic hepatitis without a history of excessive alcohol consumption. It is a specific form of nonalcoholic fatty liver disease (NAFLD) that is characterized by hepatocyte inflammation based on hepatocellular steatosis. Further exacerbation of NASH can lead to cirrhosis, which may then progress to hepatocellular carcinoma (HCC). There is a lack of specific and effective treatments for NASH and NASH-driven HCC, and the mechanisms of the progression of NASH to HCC are unclear. Therefore, there is a need to understand the pathogenesis and progression of these diseases to identify new therapeutic approaches. Currently, an increasing number of studies are focusing on the utility of natural products in NASH, which is likely to be a promising prospect for NASH. This paper reviews the possible mechanisms of the pathogenesis and progression of NASH and NASH-derived HCC, as well as the potential therapeutic role of natural products in NASH and NASH-derived HCC.

Serum ferritin levels are associated with advanced liver fibrosis in treatment-naive autoimmune hepatitis

Background and aim

The association between iron-metabolism-related variables and liver fibrosis in chronic hepatitis C and nonalcoholic fatty liver disease is now well known. However, the relationship has not been extensively studied in autoimmune hepatitis (AIH). We aimed to investigate the association between variables associated with iron metabolism and advanced liver fibrosis among untreated patients with AIH.

Methods

Ninety-seven untreated AIH patients were enrolled in this cross-sectional study. All participants underwent iron metabolism index detection and liver biopsy. Multiple logistic regression analysis was used to explore the association of iron-metabolism-related variables with advanced liver fibrosis.

Results

Among the 97 AIH patients, 38 (39.2%) had advanced liver fibrosis, and 59 (60.8%) did not. In multivariate logistic regression analysis, immunoglobulin G (odds ratio [OR], 1.123; 95% confidence interval [CI] 1.023–1.232, P = 0.014), platelet count (OR 0.988; 95% CI 0.979–0.997, P = 0.013), prothrombin time (OR 1.758; 95% CI 1.143–2.704, P = 0.010) and ferritin (OR 1.002; 95% CI 1.001–1.004, P = 0.012) were independent risk factors for predicting advanced liver fibrosis in AIH patients.

Conclusion

Higher serum ferritin was independently associated with advanced liver fibrosis among patients with treatment-naive AIH.

Genome-wide gene and serum ferritin interaction in the development of type 2 diabetes in adults aged 40 years or older

BACKGROUND AND AIMS

Elevated serum ferritin is associated with incident Type 2 diabetes (T2D), but the interactions between serum ferritin and genetic factors which may improve understanding underlying mechanism in the development of T2D are still unclear. We determined the gene-ferritin interactions on the development of T2D by genome-wide gene-ferritin interaction analyses.

METHODS AND RESULTS

A total of 3405 participants from two prospective cohorts of community living residents were included, and the median follow-time was 3.99 years. Genome-wide gene-ferritin interactions were analyzed using the joint test with two degrees of freedom and the interaction test with one degree of freedom. There were 18 SNPs selected in the joint test. Finally, four independent variants [rs355140 (LINC00312), rs4075576 (nearby PDGFA), rs1332202 (PTPRD), and rs713157 (nearby LINC00900)] with low pairwise linkage disequilibrium (r2<0.2) and located at least 1000 kb from the index SNP showed interactions with serum ferritin level. In the association analyses between serum ferritin levels (tertiles of ferritin and ferritin status) and the incidence of T2D according to genotype, the Incidence Rate Ratios (IRRs) in the highest tertile of ferritin level (vs. the lowest tertile) were greater for participants with heterozygotes of risk alleles of each of the four SNP than IRRs for those with wild type. Compared with the normal group, the elevated ferritin group also had a higher risk of T2D for all genetic variants of risk alleles, particularly its homozygotes.

CONCLUSION

Serum ferritin level interacts with genetic variants (rs355140, rs4075576, rs1332202, and rs713157) in the development of T2D.

Non-alcoholic fatty liver disease and hematologic manifestations (Review)

Non-alcoholic fatty liver disease (NAFLD) is a multisystem disease, and it is associated with numerous extra-hepatic manifestations or additional co-occurring diseases. The aim of the present review was the identification and management of the hematologic manifestations of NAFLD. One of the triggers is considered to be iron abnormalities. Increased ferritin levels, hepatic iron deposits and iron overload are associated with NAFLD. The iron overload degree and severity are associated with the level of liver fibrosis and with the risk for hepatocellular carcinoma. Excess iron deposits refers to the dysmetabolic iron overload syndrome (DIOS) and it is characterized by steatosis associated with moderate tissue iron deposition and increased levels of serum ferritin, while the serum transferrin saturation was normal. Further prospective studies are necessary to determine whether NAFLD has an independent risk for hematologic symptoms, besides the known risk factors. Future studies are also needed in order to assess the increasing impact of NAFLD on the micro- and macro-vascular complications of this systemic disease.

MRI-Based Quantitative R2* Mapping at 3 Tesla Reflects Hepatic Iron Overload and Pathogenesis in Nonalcoholic Fatty Liver Disease Patients

BACKGROUND

The role of hepatic iron overload (HIO) in nonalcoholic fatty liver disease (NAFLD) pathogenesis has not been fully elucidated.

PURPOSE

This study aimed to investigate the effect of HIO and examine the diagnostic usefulness of magnetic resonance imaging (MRI)-based R2^* quantification in evaluating hepatic iron content (HIC) and pathological findings in NAFLD.

STUDY TYPE

Prospective and retrospective.

POPULATION

A prospective study of 168 patients (age, 57.2 ± 15.0; male/female, 80/88) and a retrospective validation study of 202 patients (age, 57.0 ± 14.4; male/female, 113/89) with liver-biopsy-confirmed NAFLD were performed.

FIELD STRENGTH/SEQUENCE

3 T; chemical-shift encoded multi-echo gradient echo.

ASSESSMENT

Using liver tissues obtained by liver biopsy, HIC was prospectively evaluated in 168 patients by atomic absorption spectrometry. Diagnostic accuracies of HIC and R2^* for grading hepatic inflammation plus ballooning (HIB) as an indicator of NAFLD activity were assessed.

STATISTICAL TESTS

Student's t-test and analysis of variance (ANOVA) with Scheffe's multiple testing correction for univariate comparisons; multivariate logistic analysis. P-value less than 0.05 is statistically significant.

RESULTS

HIC was significantly correlated with HIB grades (r = 0.407). R2^* was significantly correlated with HIC (r = 0.557) and HIB grades (r = 0.569). R2^* mapped an area under the receiver operating characteristic (AUROC; 0.774) for HIC ≥808 ng/mL (median value) with cutoff value of 62.5 s^-1 . In addition, R2^* mapped AUROC of HIB for grades ≥3 was 0.799 with cutoff value of 58.5 s^-1 . When R2^* was <62.5 s^-1 , R2^* correlated weakly with HIC (r = 0.372) as it was affected by fat deposition and did not correlate with HIB grades (P = 0.052). Conversely, when R2^* was ≥62.5 s^-1 , a significant correlation of R2^* with HIC (r = 0.556) and with HIB grades was observed (P < 0.0001) with being less affected by fat deposition.

DATA CONCLUSION

R2^*  ≥ 62.5 s^-1 is a promising modality for non-invasive diagnosis of clinically important high grades (≥3) of HIB associated with increased HIC.

LEVEL OF EVIDENCE

1 TECHNICAL EFFICACY STAGE: 2.

Soy diet for nonalcoholic fatty liver disease: A meta-analysis of randomized controlled trials

INTRODUCTION

The efficacy of soy diet for nonalcoholic fatty liver disease remains controversial. We conduct a systematic review and meta-analysis to explore the influence of soy diet vs placebo on the treatment of non-alcoholic fatty liver disease.

METHODS

We search PubMed, EMbase, Web of science, EBSCO, and Cochrane library databases through October 2020 for randomized controlled trials assessing the efficacy of soy diet vs placebo for nonalcoholic fatty liver disease. This meta-analysis is performed using the random-effect model.

RESULTS

Five randomized controlled trials are included in the meta-analysis. Overall, compared with control group for nonalcoholic fatty liver disease, soy diet is associated with significantly reduced HOMA-IR (standard mean difference [SMD] = -0.42; 95% confidence interval [CI] = -0.76 to -0.08; P = .01), increased insulin (SMD = -0.64; 95% CI = -0.98 to -0.30; P = .0002) and decreased malondialdehyde (SMD = -0.43; 95% CI = -0.74 to -0.13; P = .005), but demonstrated no substantial impact on body mass index (SMD = 0.17; 95% CI = -0.20 to 0.53; P = .37), alanine aminotransferase (SMD = -0.01; 95% CI = -0.61 to 0.60; P = .98), aspartate-aminotransferase (SMD = 0.01; 95% CI = -0.47 to 0.49; P = .97), total cholesterol (SMD = 0.05; 95% CI = -0.25 to 0.35; P = .73) or low density lipoprotein (SMD = 0; 95% CI = -0.30 to 0.30; P = .99).

CONCLUSIONS

Soy diet may benefit to alleviate insulin resistance for nonalcoholic fatty liver disease.

Meta-analysis of the effect of sodium-glucose cotransporter 2 inhibitors on hepatic fibrosis in patients with type 2 diabetes mellitus complicated with non-alcoholic fatty liver disease

AIM

This study aimed to analyze the effects of sodium-glucose cotransporter 2 (SGLT2) inhibitors on the indexes of liver fibrosis in patients with type 2 diabetes mellitus complicated with non-alcoholic fatty liver disease, and also to observe the effects on liver enzymes and liver fat.

METHODS

This meta-analysis was performed using RevMan 5.3 statistical software.

RESULTS

SGLT2 inhibitors could significantly reduce the level of hepatic fibrosis index: fibrosis-4 (mean difference [MD] 0.25, 95% CI -0.39 to -0.11, p = 0.0007); serum type Ⅳ collagen 7s (MD 0.32, 95% CI -0.59 to -0.04, p = 0.02); and ferritin (MD 26.7, 95% CI 50.64, 2.76, p = 0.03). SGLT2 inhibitors could significantly reduce the level of liver enzymes: alanine aminotransferase (MD 3.49, 95% CI -5.1 to 1.58, p < 0.0001); aspartate aminotransferase (MD 3.64, 95% CI -5.10 to -2.18, p < 0.00001); and glutamate aminotransferase (MD 7.13, 95% CI -12.95 to -1.32, p = 0.02). SGLT2 inhibitors could significantly reduce the level of liver fat: liver-to-spleen attenuation ratio (MD 0.16, 95% CI 0.10-0.22, p < 0.00001); magnetic resonance imaging proton density fat fraction (MD 1.97, 95% CI -3.49 to -0.45, p = 0.01); liver controlled attenuation parameter (MD 0.29, 95% CI -26.95 to -13.64, p < 0.00001); liver fat score (MD 0.55, 95% CI 1.04 to -0.05, p = 0.03); and liver fat index (MD 11.21, 95% CI -16.53 to -5.89, p < 0.0001).

CONCLUSION

SGLT2 inhibitors could improve liver fibrosis, liver enzymes, liver fat, and metabolic indexes in patients with type 2 diabetes mellitus complicated with non-alcoholic fatty liver disease.

Mechanisms and disease consequences of nonalcoholic fatty liver disease

Nonalcoholic fatty liver disease (NAFLD) is the leading chronic liver disease worldwide. Its more advanced subtype, nonalcoholic steatohepatitis (NASH), connotes progressive liver injury that can lead to cirrhosis and hepatocellular carcinoma. Here we provide an in-depth discussion of the underlying pathogenetic mechanisms that lead to progressive liver injury, including the metabolic origins of NAFLD, the effect of NAFLD on hepatic glucose and lipid metabolism, bile acid toxicity, macrophage dysfunction, and hepatic stellate cell activation, and consider the role of genetic, epigenetic, and environmental factors that promote fibrosis progression and risk of hepatocellular carcinoma in NASH.

Digital pathology: accurate technique for quantitative assessment of histological features in metabolic-associated fatty liver disease

BACKGROUND

Histological evaluation of metabolic-associated fatty liver disease (MAFLD) biopsies is subjective, descriptive and with interobserver variability.

AIMS

To examine the relationship between different histological features (fibrosis, steatosis, inflammation and iron) measured with automated whole-slide quantitative digital pathology and corresponding semiquantitative scoring systems, and the distribution of digital pathology measurements across Fatty Liver Inhibition of Progression (FLIP) algorithm and Steatosis, Activity and Fibrosis (SAF) scoring system METHODS: We prospectively included 136 consecutive patients who underwent liver biopsy for MAFLD at three Spanish centres (January 2017-January 2020). Biopsies were scored by two blinded pathologists according to the Non-alcoholic Steatohepatitis (NASH) Clinical Research Network system for fibrosis staging, the FLIP/SAF classification for steatosis and inflammation grading and Deugnier score for iron grading. Proportionate areas of collagen, fat, inflammatory cells and iron deposits were measured with computer-assisted digital image analysis. A test-retest experiment was performed for precision repeatability evaluation.

RESULTS

Digital pathology showed strong correlation with fibrosis (r = 0.79; P < 0.001), steatosis (r = 0.85; P < 0.001) and iron (r = 0.70; P < 0.001). Performance was lower when assessing the degree of inflammation (r = 0.35; P < 0.001). NASH cases had a higher proportion of collagen and fat compared to non-NASH cases (P < 0.005), whereas inflammation and iron quantification did not show significant differences between categories. Repeatability evaluation showed that all the coefficients of variation were ≤1.1% and all intraclass correlation coefficient values were ≥0.99, except those of collagen.

CONCLUSION

Digital pathology allows an automated, precise, objective and quantitative assessment of MAFLD histological features. Digital analysis measurements show good concordance with pathologists´ scores.

NAFLD-related HCC

Nonalcoholic fatty liver disease (NAFLD) is one of the major drivers for the rising trend in hepatocellular carcinoma (HCC). Over the past three decades, the incidence of both NAFLD and HCC have increased two- to threefold. It has been forecasted that the number of patients with NAFLD in the Unites States will reach 101 million by 2030; global increase is also foreseen. This trend will likely continue to translate into increased HCC in the Unites States and across the globe. In this chapter, we summarize the current evidence linking NAFLD, metabolic syndrome, particularly obesity and type 2 diabetes mellitus, and HCC. We describe the main molecular mechanisms connecting these metabolic perturbations and hepatocarcinogenesis.

The Relationship between Insulin Resistance and Liver Damage in non-alcoholic Fatty Liver Patients

Objectives:

Non-alcoholic fatty liver disease (NAFLD) is closely associated with diseases, such as obesity, diabetes mellitus, metabolic syndrome, which are characterized by insulin resistance. NAFLD is thought to be a manifestation of metabolic syndrome in the liver. Liver fibrosis has a high prognostic significance in non-alcoholic steatohepatitis (NASH). In this study, the relationship between insulin resistance and the histopathological changes in the liver was investigated in biopsy-proven NAFLD patients.

Methods:

In this study, 85 biopsy-proven NAFLD patients (64 NASH, 21 non-NASH) and 40 healthy control subjects were enrolled. Insulin resistance was calculated using the “homeostasis model assessment of insulin resistance” (HOMA-IR).

Results:

C reactive protein, total cholesterol, low-density lipoprotein, triglyceride, body mass index (BMI), HOMA-IR levels were significantly higher in the NAFLD group compared to the control group. In the NASH group, the HOMA-IR level was significantly higher than the non-NASH group (p=0.026). When NAFLD patients with advanced fibrosis (stage 3-4, n=27) and without fibrosis (stage 0-2, n=58) are compared, in advanced fibrosis group BMI (35.2±4.6 kg/m² and 32.7±4.1 kg/m², respectively; p=0.031) and HOMA-IR (6.3 [5.8-6.8] and 3.4 [2.6-4.8], respectively, p=0.001) levels were higher significantly. In the covariance analysis, when confounding factors, such as BMI, age and gender, were corrected, it was observed that the elevation of HOMA-IR level in the advanced fibrosis group continued statistically significantly.

Conclusion:

HOMA-IR levels were high in NAFLD patients with advanced fibrosis. HOMA-IR, which can be easily measured in daily practice, is an independent predictor for fibrosis.

Established and emerging factors affecting the progression of nonalcoholic fatty liver disease

Nonalcoholic fatty liver disease (NAFLD) has become the most common chronic liver disease affecting approximately 25% of the global population. Although a majority of NAFLD patients will never experience liver-related symptoms it is estimated that 5-10% will develop cirrhosis-related complications with risk of death or need for liver transplantation. NAFLD is closely associated with cardiovascular disease and components of the metabolic syndrome. However, NAFLD is not uncommon in lean individuals and may in these subjects represent a different entity with separate pathophysiological mechanisms involved implying a higher risk for development of end-stage liver disease. There is considerable fluctuation in the histopathological course of NAFLD that may partly be attributed to lifestyle factors and dietary composition. Nutrients such as fructose, monounsaturated fatty acids, and trans-fatty acids may aggravate NAFLD. Presence of type 2 diabetes mellitus seems to be the most important clinical predictor of liver-related morbidity and mortality in NAFLD. Apart from severity of the metabolic syndrome, genetic polymorphisms and environmental factors, such as moderate alcohol consumption, may explain the variation in histopathological and clinical outcome among NAFLD patients.

Recombinant human lactoferrin attenuates the progression of hepatosteatosis and hepatocellular death by regulating iron and lipid homeostasis in ob/ob mice

Lactoferrin (Lf), an iron-binding glycoprotein, has been shown to possess antioxidant and anti-inflammatory properties and exert modulatory effects on lipid homeostasis and non-alcoholic fatty liver disease (NAFLD), but our understanding of its regulatory mechanisms is limited and inconsistent. We used leptin-deficient (ob/ob) mice as the rodent model of NAFLD, and administered recombinant human Lf (4 mg per kg body weight) or control vehicle by intraperitoneal injection to evaluate the hepatoprotective effects of Lf. After 40 days of treatment with Lf, insulin sensitivity and hepatic steatosis in ob/ob mice were significantly improved with the down-regulation of sterol regulatory element binding protein-2 (SREBP2), indicating an improvement in hepatic lipid metabolism and function. We further explored the mechanism, and found that Lf may increase the hepatocellular iron output by targeting the hepcidin-ferroportin (FPn) axis, and then maintains the liver oxidative balance through a nonenzymatic antioxidant system, ultimately suppressing the death of hepatocytes. In addition, the cytoprotective role of Lf may be associated with the inhibition of endoplasmic reticulum (ER) stress and inflammation, promotion of autophagy of damaged hepatocytes and induction of up-regulation of hypoxia inducible factor-1α/vascular endothelial growth factor (HIF-lα/VEGF) to facilitate liver function recovery. These findings suggest that recombinant human Lf might be a potential therapeutic agent for mitigating or delaying the pathological process of NAFLD.

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

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

Non-alcoholic fatty liver disease: A review with clinical and pathological correlation

Non-alcoholic fatty liver disease (NAFLD) is the most common chronic liver disease in North America and Europe, with increasing prevalence in other regions of the world. Its spectrum encompass steatosis, non-alcoholic steatohepatitis (NASH), fibrosis and cirrhosis. It is considered as the manifestation of metabolic syndrome in liver, and its development and progression is influenced by complex interaction of environmental and genetic factors. In this review we discuss the histopathological features, differential diagnoses, and the commonly used grading and staging systems of NAFLD. NAFLD associated with other diseases, histological changes after therapeutic intervention and recurrence or occurrence of NAFLD after liver transplantation are also addressed.

Role of micronutrients in staging of nonalcoholic fatty liver disease: A retrospective cross-sectional study

BACKGROUND

Nonalcoholic fatty liver disease (NAFLD) presents high incidence throughout the world and has been progressively increasing in prevalence. This disease has a heterogeneous natural history, including simple steatosis, nonalcoholic steatohepatitis (NASH), and cirrhosis. The factors that determine its evolution to more severe forms of the disease are still poorly understood, and micronutrients with antioxidant potential may be involved in the pathophysiology of the disease.

AIM

To evaluate the relationship between serum levels of micronutrients and the severity of NAFLD.

METHODS

A retrospective, observational and cross-sectional study was conducted. This study included all patients undergoing bariatric surgery who experienced liver biopsy during the procedure, and had serum levels of micronutrients (vitamin D, vitamin B12, zinc, iron, and magnesium), which was assessed in a preoperative evaluation conducted at a reference center in southern Brazil.

RESULTS

A total of 614 patients were analyzed, of which 93% had steatosis, 70.7% had NASH, and 49.3% had some degree of fibrosis. Serum levels of vitamin D were negatively correlated with the severity of steatosis and NASH, and serum levels of vitamin B12 were positively correlated with the severity of steatosis and fibrosis. The other micronutrients showed no association with NAFLD staging.

CONCLUSION

Serum levels of vitamin D are inversely related to the severity of steatosis and NASH, and serum levels of vitamin B12 are higher in more advanced stages of simple steatosis and liver fibrosis. Serum levels of zinc, iron, and magnesium were not associated with NAFLD severity.

Serum cytokines, adipokines and ferritin for non-invasive assessment of liver fibrosis in chronic liver disease: a systematic review

Chronic liver disease (CLD) is a major health problem worldwide. Non-alcoholic fatty liver disease (NAFLD), chronic hepatitis C (CHC), chronic hepatitis B (CHB), and alcoholic liver disease (ALD) are the most common etiologies of CLD. Liver biopsy is the gold standard for assessment of liver fibrosis, however, it is an invasive method. This review attempts to evaluate the usefulness of serum adiponectin, serum leptin, serum ferritin, serum transforming growth factor-β1 (TGF-β1), and serum platelet derived growth factor-BB (PDGF-BB) as non-invasive markers in the diagnosis of liver fibrosis/cirrhosis. A systematic search in MEDLINE, Web of Science, Scopus, and local databases was performed to identify articles published in English or Persian as of November 2017. Studies conducted among CLD patients, with biopsy proven fibrosis/cirrhosis, and providing sufficient details of patients' clinicopathological characteristics were included. In the 95 studies included, there were a total of 15,548 CLD patients. More than 83% of studies were carried out in Asia and Europe. The relationship between liver fibrosis/cirrhosis and serum levels of ferritin, adiponectin, leptin, TGF-β1, and PDGF-BB was assessed in 42, 33, 27, nine, and three studies, respectively. Serum levels of the markers, particularly ferritin, could successfully predict liver fibrosis/cirrhosis, however, these data might not be clinically replicated and further studies are needed.

The effects of iron and zinc status on prognosis in pediatric Wilson's disease

OBJECTIVES

Wilson's disease (WD) is a metabolic disorder leading to hepatic and extrahepatic copper deposition. Several studies have reported that besides copper (Cu), iron (Fe) and zinc (Zn) are also accumulated at varying levels in various tissues in WD. However, there is not an adequate number of studies investigating the effects of Fe and Zn status on WD presentation and prognosis. We aimed to evaluate serum levels of ferritin (SFr), copper (SCu), and zinc (SZn) in WD and determine their role in disease presentation and prognosis.

MATERIALS-METHOD

We retrospectively reviewed the medical records of 97 pediatric patients with WD who were diagnosed and followed at İnönü University Pediatric Gastroenterology, Hepatology and Nutrition Department between January 2006 and May 2017. Serum Cu and Zn levels were analyzed by using flame atomic absorption spectrophotometer. Ferritin was analyzed by chemiluminescence immunoassay method.

RESULTS

Analysis of serum levels of the elements according to the type of presentation, there was no significant difference between the groups for ceruloplasmin. However, SCU, FSCu, SFr and 24 h urinary copper levels were significantly higher (p = 0.002, p = 0.003, p = 0.023 and p < 0.001, respectively) and SZn and CSZn levels were significantly lower (fulminant WD). p < 0.001, p < 0.001). There was a positive correlation between SFr, SCu serum levels and mortality scores (respectively, r: 0.501, 0.564 for PELD, r:0.490, 0.504 for MELD, r: 0.345, 0.374 for Dhwan), and a negative correlation between SZn level and mortality scores. (r:-0.650 for PELD, r:-0.703 for MELD, r:-0.642 for Dhwan) We used the ROC curves to determine the worst prognosis for fulminant Wilson disease. According to these limit values, we found that the sensitivity and specificity of FWD development was significantly higher. (for SZn sensitivity of 91.5%, a specificity of 100%, p=<0,001, for SCu predicted FWD development with a sensitivity of 100%, a specificity of 73.7%, p=<0,001, for SFr predicted FWD development with a sensitivity of 92.9%, a specificity of 66.2%, p < 0,001) CONCLUSION: Our study suggests that SFr, SCu, SZn levels might have prognostic importance for WD.

[The role of iron overload in the progression of nonalcoholic steatohepatitis (NASH)]

Non-alcoholic steatohepatitis (NASH), one of the most common chronic liver diseases (CLD), is getting the most important cause of cirrhosis and hepatocellular carcinoma. Iron is an essential micronutrient for organisms. Once excess iron is accumulated in vital organs, dysfunctions of these organs can occur via the generation of reactive oxygen species. Hepatic iron overload is often seen in CLD patients. In NASH patients, iron accumulation in the liver is positively correlated with histological severity. Thus iron overload can contribute to progression of nonalcoholic fatty liver disease (NAFLD) to NASH. In a rat model of NASH, feeding of high-fat and high-iron diet increases hepatic inflammation with increased hepatic cytokine expression compared with feeding of high-fat diet only. In this model, iron is intensely accumulated in Kupffer cells/macrophages within the lesion, raising the possibility that iron-laden Kupffer cells/macrophages can play a key role in the enhancement of hepatic inflammation in NASH condition. On the other hand, in a rat model of liver cirrhosis, dietary iron overload clearly abrogates the development and progression of liver cirrhosis induced by repeated administration of thioacetamide (TAA). These findings suggest that iron overload can promote or suppress chronic liver diseases depending on the tissue microenvironment. Here we review and introduce the recent findings on the pathological roles of iron overload in the development and progression of NAFLD/NASH.

The Long-term Efficacy of Sodium Glucose Co-transporter 2 Inhibitor in Patients with Non-alcoholic Fatty Liver Disease

Objective Sodium glucose co-transporter 2 inhibitor (SGLT-2i), recommended for patients with type 2 diabetes, has been reported to improve the liver function test results in non-alcoholic fatty liver disease (NAFLD). However, the long-term effects of SGLT-2i on the liver function and body weight in NAFLD patients have not been fully elucidated. In this study, we investigated the long-term effects of SGLT-2i in NAFLD patients. Methods Twenty-two diabetic patients with NAFLD were enrolled in this study. We assessed the body weight, liver enzyme levels, metabolism, and glucose levels at 12 months (22 cases) and 24 months (15 cases) after the initiation of SGLT-2i. The changes in controlled attenuation parameter (CAP) and liver stiffness in 20 of the 22 patients were evaluated using transient elastography (TE) and acoustic radiation force impulse (ARFI) elastography before the initiation of treatment and 1 year later. Results Body weight and aspartate aminotransferase (AST) and alanine aminotransferase (ALT) levels were significantly decreased at 12 and 24 months after SGLT-2i treatment. The decrease in the levels of ALT at 12 and 24 months was significantly correlated with the level of ALT at the initiation of SGLT-2i (r=0.813, p=0.001 and r=0.867, p=0.0001, respectively). SGLT-2i also reduced the CAP and velocity of shear wave (Vs) values at 12 months (CAP 315.1±43.4 db/mL→293.1±27.2 db/mL, p=0.027; Vs 1.87±0.8 m/s→ 1.48±0.6 m/s, p=0.011). Conclusion SGLT-2i treatment improved the liver function test results and reduced the body weight in NAFLD patients over a period of 12-24 months. This improvement was greater in patients with higher ALT values at baseline than in those with lower values.

Noninvasive Differential Diagnosis of Liver Iron Contents in Nonalcoholic Steatohepatitis and Simple Steatosis Using Multiecho Dixon Magnetic Resonance Imaging

RATIONALE AND OBJECTIVES

The roles of iron stores in nonalcoholic fatty liver disease have not yet been clearly identified, and it is lack of uniform criteria and a standardized study design for assessing the liver iron content (LIC) in nonalcoholic steatohepatitis (NASH). This study was to compare LICs in biopsy-proven simple steatosis (SS) and NASH based on T₂^⁎-relaxometry.

MATERIAL AND METHODS

A total of 32 subjects divided to three groups, consisting of 10 healthy controls, 12 SS and 10 NASH. All MRI examinations were performed on a 3 T MRI with a 32-channel body coil. To measure T₂^⁎-value, we used a gradient echo sequence with six multiechoes within a single breath-hold. Hepatic iron contents among three groups were compared using Kruskal-Wallis H test and Mann-Whitney's posthoc tests. Diagnostic accuracy was determined by calculating the area under the receiver operating characteristics curve. To identify the reliability of iron measurements in the different region of interests, coefficient of variance (CV) was calculated overall CV values for the variability of measurements. Interobserver agreement and reliability were estimated by calculating the intraclass correlation coefficient.

RESULTS

The variations of all LIC measurements are not exceeded 20%, as a mean CV value 18.3%. intraclass correlation coefficients were higher than 0.9. Mean T₂^⁎-values at localized region of interests were healthy controls 45.42 ± 7.19 ms, SS 20.96 ± 4.28 ms, and NASH 15.49 ± 2.87 ms. The mean T₂^⁎-value in NASH is significantly shorter than that in SS (p = 0.008). The area under the receiver operating characteristics curve to distinguish NASH from SS was 0.908 (95% confidence interval 0.775-1.000, p = 0.001) at a cut-off of iron contents greater than 17.95 ms, and its diagnostic accuracy had 0.833 sensitivity and 0.800 specificity.

CONCLUSION

This study demonstrates that the T₂^⁎ calculation can help to differentially diagnose NASH.

Review article: iron disturbances in chronic liver diseases other than haemochromatosis - pathogenic, prognostic, and therapeutic implications

BACKGROUND

Disturbances in iron regulation have been described in diverse chronic liver diseases other than hereditary haemochromatosis, and iron toxicity may worsen liver injury and outcome.

AIMS

To describe manifestations and consequences of iron dysregulation in chronic liver diseases apart from hereditary haemochromatosis and to encourage investigations that clarify pathogenic mechanisms, define risk thresholds for iron toxicity, and direct management METHODS: English abstracts were identified in PubMed by multiple search terms. Full length articles were selected for review, and secondary and tertiary bibliographies were developed.

RESULTS

Hyperferritinemia is present in 4%-65% of patients with non-alcoholic fatty liver disease, autoimmune hepatitis, chronic viral hepatitis, or alcoholic liver disease, and hepatic iron content is increased in 11%-52%. Heterozygosity for the C282Y mutation is present in 17%-48%, but this has not uniformly distinguished patients with adverse outcomes. An inappropriately low serum hepcidin level has characterised most chronic liver diseases with the exception of non-alcoholic fatty liver disease, and the finding has been associated mainly with suppression of transcriptional activity of the hepcidin gene. Iron overload has been associated with oxidative stress, advanced fibrosis and decreased survival, and promising therapies beyond phlebotomy and oral iron chelation have included hepcidin agonists.

CONCLUSIONS

Iron dysregulation is common in chronic liver diseases other than hereditary haemochromatosis, and has been associated with liver toxicity and poor prognosis. Further evaluation of iron overload as a co-morbid factor should identify the key pathogenic disturbances, establish the risk threshold for iron toxicity, and promote molecular interventions.

Iron and liver fibrosis: Mechanistic and clinical aspects

Liver fibrosis is characterised by excessive deposition of extracellular matrix that interrupts normal liver functionality. It is a pathological stage in several untreated chronic liver diseases such as the iron overload syndrome hereditary haemochromatosis, viral hepatitis, alcoholic liver disease, non-alcoholic fatty liver disease, non-alcoholic steatohepatitis and diabetes. Interestingly, regardless of the aetiology, iron-loading is frequently observed in chronic liver diseases. Excess iron can feed the Fenton reaction to generate unquenchable amounts of free radicals that cause grave cellular and tissue damage and thereby contribute to fibrosis. Moreover, excess iron can induce fibrosis-promoting signals in the parenchymal and non-parenchymal cells, which accelerate disease progression and exacerbate liver pathology. Fibrosis regression is achievable following treatment, but if untreated or unsuccessful, it can progress to the irreversible cirrhotic stage leading to organ failure and hepatocellular carcinoma, where resection or transplantation remain the only curative options. Therefore, understanding the role of iron in liver fibrosis is extremely essential as it can help in formulating iron-related diagnostic, prognostic and treatment strategies. These can be implemented in isolation or in combination with the current approaches to prepone detection, and halt or decelerate fibrosis progression before it reaches the irreparable stage. Thus, this review narrates the role of iron in liver fibrosis. It examines the underlying mechanisms by which excess iron can facilitate fibrotic responses. It describes the role of iron in various clinical pathologies and lastly, highlights the significance and potential of iron-related proteins in the diagnosis and therapeutics of liver fibrosis.

Elevated serum ferritin level associated with hepatic steatosis and fibrosis in hepatitis C virus-infected patients

BACKGROUND

Serum ferritin is an indicator of iron accumulation in a human body, and it is frequently elevated in patients with systemic inflammatory state in chronic hepatitis C (CHC). Iron accumulation is associated with hepatic fibrosis, steatosis, and unfavorable outcome in CHC patients. We studied the status of elevated serum ferritin level and its association with the liver fibrosis or steatosis in Taiwanese CHC patients.

METHODS

Seven hundred and thirty-eight Taiwanese CHC patients were consecutively included in this study. Laboratory analysis, four indexes of fibrosis (FIB4), histological assessment of fibrosis, and steatosis were assessed by appropriate elevation of serum ferritin level.

RESULTS

Three hundred and one patients (40.8%) had elevated serum ferritin level (sex-specific threshold >1.5 × upper limit of normal). Serum iron level (odds ratio [OR], 1.02; 95% CI, 1.01%-1.03%, p < 0.001), female gender (OR, 1.49; 95% CI, 1.07%-2.08%, p = 0.018), serum gamma-glutamyl transferase level (OR, 1.007; 95% CI, 1.003%-1.01%, p < 0.001), steatosis grade (OR, 1.56; 95% CI, 1.13%-2.16%, p = 0.006), and FIB4 ≥3.25 (OR, 1.63; 95% CI, 1.18%-2.27%, p = 0.003) indexes were associated with high serum ferritin level by multivariate logistic regression analysis. Patients with steatosis (>5%) were associated with older age (OR, 1.01; 95% CI, 1.00%-1.03%, p = 0.015), body mass index (OR, 1.10; 95% CI, 1.05%-1.15%, p < 0.001), and elevated serum ferritin level (OR, 1.001; 95% CI, 1.00%-1.001%, p = 0.024) by multivariate logistic regression analysis. Serum ferritin level also associated with high FIB4 (≥3.25) (OR, 1.001; 95% CI, 1.001%-1.002%, p = 0.010) when multivariate model adjusted together with advanced liver fibrosis by biopsy.

CONCLUSION

Elevated serum ferritin level was noted in 40.8% of Taiwanese CHC patients, and the serum ferritin level was associated with liver steatosis and high FIB4.

Trivalent Chromium Supplementation Ameliorates Oleic Acid-Induced Hepatic Steatosis in Mice

Trivalent chromium [Cr(III)] is recognized as an essential trace element for human health, whereas its effect on hepatic lipid metabolism has not yet been fully understood. This study aimed to investigate the beneficial effects and potential mechanisms of Cr(III) on hepatic steatosis in an oleic acid (OA) induced mice model. Mice were fed with high OA for 12 weeks to induce lipid accumulation, and co-administrated with Cr(III) supplementation. Indexes of liver lipid accumulation, associated lipid genes expression, fatty acids (FAs) profile and inflammatory cytokines were analyzed. The data showed that Cr(III) supplementation could attenuate disease progress of hepatic steatosis and protect liver from high OA. After Cr(III) supplementation, elevated body weight and liver injury in steatosis mice were reversed, excessive lipid accumulation and FAs were also reduced. The up-regulation of cluster of differentiation 36 (CD36) and diacylglycerol acyltransferase 2 (DGAT2) following steatosis induction were inhibited by Cr(III). Cr(III) reduced the content of pro-inflammatory cytokines (IL-1β and TNF-α, IL-12) and restored the level of anti-inflammatory cytokine (IL-10) to the control values. Our results suggest that Cr(III) supplementation is a novel strategy for alleviating OA-induced hepatic steatosis.

Clinical, anthropometric, biochemical and histological character of nonalcoholic fatty liver disease without Insulin Resistance

OBJECTIVES

Nonalcoholic Fatty Liver Disease (NAFLD) is thought to be a hepatic manifestation of Metabolic Syndrome (MS) or Insulin Resistance (IR). The aim of the study was to explore the clinical, anthropometric, metabolic, biochemical and histological profile of NAFLD patients without IR by comparing it with NAFLD with IR.

METHODS

Total 851 patients with sonographic evidence of fatty liver were included. These patients underwent clinical, anthropometric, biochemical and histological evaluation. IR was calculated using the homeostatic model assessment. Liver biopsy done in 285 patients who consented for the procedure and who had MS or raised ALT.

RESULTS

Among 851 NAFLD patients, 561(65.9%) patients were without IR and 290 (34.1%) patients were with IR. The proportion of male sex [230 (41.0%) vs. 89 (30.7%); P = 0.046] were higher but diabetes [19.10% vs. 39.0%; P = 0.000] and MS were [58.80%vs. 78.10%; P = 0.014] significantly lower in non IR group. Body Mass Index (BMI) kg/m² and Waist Circumference (WC) in cm were also lower in non IR group: [26.6 ± 3.5 vs. 27.9 ± 4.3; P = 0.002] and [93.3 ± 8.4 vs. 95.9 ± 8.4; P = .003]. Lipid profile, ALT, AST and ALP were not differed between the groups. Histopathology reports revealed that lobular inflammation, ballooning and fibrosis were similar in two groups, only steatosis score was higher in IR group [2.0 ± 0.7 vs. 1.8 ± 0.8; P = 0.007].

CONCLUSION

There are significant proportion of NAFLD patients without IR in Bangladesh. NAFLD patients without IR predominantly male, had lower BMI, WC, MS and diabetes. Histologically NAFLD without IR equally severe with ballooning, lobular inflammation and fibrosis except steatosis. Insulin resistance is the principal but not the sole factor for NAFLD in our population.

Molecular Pathogenesis of Nonalcoholic Steatohepatitis- (NASH-) Related Hepatocellular Carcinoma

The proportion of obese or diabetic population has been anticipated to increase in the upcoming decades, which rises the prevalence of nonalcoholic fatty liver disease (NAFLD) and its progression to nonalcoholic steatohepatitis (NASH). Recent evidence indicates that NASH is the main cause of chronic liver diseases and it is an important risk factor for development of hepatocellular carcinoma (HCC). Although the literature addressing NASH-HCC is growing rapidly, limited data is available about the etiology of NASH-related HCC. Experimental studies on the molecular mechanism of HCC development in NASH reveal that the carcinogenesis is relevant to complex changes in signaling pathways that mediate cell proliferation and energy metabolism. Genetic or epigenetic modifications and alterations in metabolic, immunologic, and endocrine pathways have been shown to be closely related to inflammation, liver injury, and fibrosis in NASH along with its subsequent progression to HCC. In this review, we provide an overview on the current knowledge of NASH-related HCC development and emphasize molecular signaling pathways regarding their mechanism of action in NASH-derived HCC.

Validation of water-fat MRI and proton MRS in assessment of hepatic fat and the heterogeneous distribution of hepatic fat and iron in subjects with non-alcoholic fatty liver disease

BACKGROUND

Research studies demonstrated pathologic lesions were unevenly distributed in patients with non-alcoholic fatty liver disease (NAFLD) and non-alcoholic steatohepatitis. As hepatic steatosis occurs prior to steatohepatitis and other late stage liver conditions, the distribution pattern of hepatic fat and iron concentration should be investigated to prevent sampling variability. The first purpose of this study was to perform comparison and validation of in-house hepatic fat measurements using water-fat MRI and MRS. The second objective was to quantify hepatic fat-fraction and T2* values in left and right liver lobes using water-fat MRI.

METHOD

Fifty-four non-alcoholic adults (27 NAFLD, age: 42.8 ± 11.8), 27 non-NAFLD, age: 45.5 ± 11.2) and 46 non-alcoholic teenagers (23 NAFLD (age: 15.4 ± 2.6), 23 non-NAFLD (age: 13.9 ± 2.3) were recruited. All participants underwent chemical shift water-fat MRI and 1H MRS at 3 T. Hepatic steatosis was defined by intrahepatic triglyceride more than the threshold of 5.56% using MRS (clinical reference) and non-alcoholic was defined by alcohol ingestion of no more than 30 g and 20 g per day for male and female respectively. Hepatic fat-fractions in left and right liver lobes were measured using regions-of-interest (ROIs) approach. Three ROIs were drawn on the fat-fraction images and duplicated on to the co-registered T2* images at the inferior right, superior right and superior left liver lobes. Comparison and validation of water-fat MRI and MRS were performed using intraclass correlation coefficient (ICC) and Bland-Altman plot. Hepatic fat-fraction and T2* measured from the ROIs were compared using repeated measures ANOVA. Independent t-test was used for between groups analysis.

RESULTS

Statistical analysis indicated good correlation (R = 0.987) and agreement (ICC = 0.982) between MRS and water-fat MRI in hepatic fat measurements. Results indicated that hepatic fat was significantly higher in the right lobe compared to the left in NAFLD adults (p < 0.001) and NAFLD teenagers (p < 0.001). For T2*, significant difference between left and right lobes was observed in NAFLD adults (p < 0.001) and non-NAFLD adults (p < 0.001) but not in teenagers.

CONCLUSION

Hepatic fat measurements using MRS and water-fat MRI are statistically equivalent. In subjects with NAFLD regardless of their age, hepatic fat is stored preferentially in the right live lobe probably due to the streamline of blood flow to the right liver. T2* value is significantly higher in the right liver lobe in adults but not in the teenagers regardless of their hepatic fat contents probably due to the longer time span of hepatic iron accumulation.