Severity of nonalcoholic fatty liver disease on sonography and risk of coronary heart disease

Metabolomics to identify fingerprints of carotid atherosclerosis in nonobese metabolic dysfunction-associated fatty liver disease

BACKGROUND/AIMS

Nonobese metabolic dysfunction-associated fatty liver disease (MAFLD) is paradoxically associated with improved metabolic and pathological features at diagnosis but similar cardiovascular diseases (CVD) prognosis to obese MAFLD. We aimed to utilize the metabolomics to identify the potential metabolite profiles accounting for this phenomenon.

METHODS

This prospective multicenter cross-sectional study was conducted in China enrolling derivation and validation cohorts. Liquid chromatography coupled with mass spectrometry and gas chromatography-mass spectrometry were applied to perform a metabolomics measurement.

RESULTS

The study involved 120 MAFLD patients and 60 non-MAFLD controls in the derivation cohort. Controls were divided into two groups according to the presence of carotid atherosclerosis (CAS). The MAFLD group was further divided into nonobese MAFLD with/without CAS groups and obese MAFLD with/without CAS groups. Fifty-six metabolites were statistically significant for discriminating the six groups. Among the top 10 metabolites related to CAS in nonobese MAFLD, only phosphatidylethanolamine (PE 20:2/16:0), phosphatidylglycerol (PG 18:0/20:4) and de novo lipogenesis (16:0/18:2n-6) achieved significant areas under the ROC curve (AUCs, 0.67, p = 0.03; 0.79, p = 0.02; 0.63, p = 0.03, respectively). The combination of these three metabolites and liver stiffness achieved a significantly higher AUC (0.92, p < 0.01). In obese MAFLD patients, cystine was found to be significant with an AUC of 0.69 (p = 0.015), followed by sphingomyelin (SM 16:1/18:1) (0.71, p = 0.004) and de novo lipogenesis (16:0/18:2n-6) (0.73, p = 0.004). The combination of these three metabolites, liver fat content and age attained a significantly higher AUC of 0.91 (p < 0.001). The AUCs of these metabolites remained highly significant in the independent validation cohorts involving 200 MAFLD patients and 90 controls.

CONCLUSIONS

Diagnostic models combining different metabolites according to BMI categories could raise the accuracy of identifying subclinical CAS. Trial registration The study protocol was approved by the local ethics committee and all the participants have provided written informed consent (Approval number: [2014] No. 112, registered at the Chinese Clinical Trial Registry, ChiCTR-ChiCTR2000034197).

2019 Global NAFLD Prevalence: A Systematic Review and Meta-analysis

BACKGROUND & AIMS

The increasing rates of obesity and type 2 diabetes mellitus may lead to increased prevalence of nonalcoholic fatty liver disease (NAFLD). We aimed to determine the current and recent trends on the global and regional prevalence of NAFLD.

METHODS

Systematic search from inception to March 26, 2020 was performed without language restrictions. Two authors independently performed screening and data extraction. We performed meta-regression to determine trends in NAFLD prevalence.

RESULTS

We identified 17,244 articles from literature search and included 245 eligible studies involving 5,399,254 individuals. The pooled global prevalence of NAFLD was 29.8% (95% confidence interval [CI], 28.6%-31.1%); of these, 82.5% of included articles used ultrasound to diagnose NAFLD, with prevalence of 30.6% (95% CI, 29.2%-32.0%). South America (3 studies, 5716 individuals) and North America (4 studies, 18,236 individuals) had the highest NAFLD prevalence at 35.7% (95% CI, 34.0%-37.5%) and 35.3% (95% CI, 25.4%-45.9%), respectively. From 1991 to 2019, trend analysis showed NAFLD increased from 21.9% to 37.3% (yearly increase of 0.7%, P < .0001), with South America showing the most rapid change of 2.7% per year, followed by Europe at 1.1%.

CONCLUSIONS

Despite regional variation, the global prevalence of NAFLD is increasing overall. Policy makers must work toward reversing the current trends by increasing awareness of NAFLD and promoting healthy lifestyle environments.

Association between Non-alcoholic Fatty Liver Disease and the Severity of Coronary Artery Stenosis in Eastern Chinese Population

Background: The present study aimed to investigate the relationship of non-alcoholic fatty liver disease (NAFLD) with the severity and extent of coronary stenotic lesions calculated by the Gensini score. In addition, the ability of Fibrosis-4 (FIB4) score to differentiate coronary artery calcification (CAC) and its severity is assessed. Methods: The current retrospective study was performed on a total of 342 patients examined between January and December 2016 in an affiliated hospital of Jiaxing University, Zhejiang, China. The study used liver ultrasonography for the assessment of NAFLD. Furthermore, the FIB4 and Gensini scores were used to predict hepatic fibrosis risk and the severity of coronary stenotic lesions. Results: The present study revealed that the serum levels of triglycerides, fasting glucose, alanine aminotransferase, and uric acid were significantly higher in patients with NAFLD than in participants without NAFLD (P < 0.001, P < 0.001, P = 0.032, and P = 0.002). Moreover, cases with NAFLD had a higher percentage of diabetes mellitus and hypertension (P < 0.001 and 0.001) than those without NAFLD. It was noted that the level of high-density lipoprotein was lower in patients with NAFLD than in participants without NAFLD (P = 0.006). In addition, we observed that the Gensini score was higher in patients with NAFLD than in participants without NAFLD (P = 0.033). It was found that 27.3%, 25.8%, 45.7%, and 56.3% of the participants had NAFLD in control, single, double, and multi lesion groups, respectively, and the difference was statistically significant (P = 0.008). The number of diseased vessels in patients with severe NAFLD was higher than in the control group (P < 0.001). It was also evident that the number of affected vessels significantly increased (P = 0.010 and P = 0.001) with the stages of NAFLD predicted by the FIB4 and Gensini scores. Furthermore, the Gensini score in patients with moderate and severe NAFLD was higher than in the control group (P = 0.013 and P = 0.019). We also conducted univariate logistic regression analyses to examine the relationship of CAC with FIB4 scores, and it was not significant (P = 0.191). Conclusions: The present study showed a positive relationship between NAFLD severity and coronary stenotic lesions in the eastern Chinese population. Furthermore, it was found that the higher the degree of FIB4 score, the higher the risk of CAC in patients with NAFLD. Therefore, assessing NAFLD severity using the FIB4 score may be useful for differentiating the patients at a higher risk of CAC. However, further prospective studies are required to establish the link between the FIB4 score and CAC.

Apolipoproteins and liver parameters optimize cardiovascular disease risk-stratification in nonalcoholic fatty liver disease

BACKGROUND

Advanced Non-alcoholic fatty liver disease (NAFLD) is associated with increased risk of cardiovascular disease (CVD).

AIM

We determine whether combinations of ultrasound graphic steatosis grades, fibrosis scores and apolipoprotein levels add value to CVD risk prediction in NAFLD patients.

METHODS

The retrospective cohort study enrolled 10,453 individuals (3519 NAFLD; 6934 non NAFLD) from 2004 to 2018. Hepatic ultrasound measurements, lipid and apolipoprotein profiles, Fibrosis-4 and the NAFLD fibrosis scores (NFS) were assessed. The primary outcome included both clinical and subclinical CVD.

RESULTS

During 116-month follow-up period, there were 957 clinical and 752 subclinical CVD events. NAFLD patients had a higher incidence of CVD than non NAFLD patients as the steatosis degree, NFS, and FIB4 scores increased (25.1% vs 11.9%, Log Rank: p < 0.001). For the lipid and apolipoprotein profiles excluding triglyceride or ApoE, subjects with varied steatosis severity in the upper two tertiles had different risk of CVD (p for interaction < 0.001). A nomogram model combination of Framingham Risk Score (FRS), NFS and apolipoprotein profiles presented a higher AUC than FRS in a time-dependent ROC curve (0.816 vs 0.752, p < 0.001).

CONCLUSION

The novel risk score considering ultrasonography-defined steatosis grades, non-invasive liver fibrosis scores and apolipoprotein profiles accurately predicted the 10-year risk of CVD.

Interplay between Heart Disease and Metabolic Steatosis: A Contemporary Perspective

The liver-heart axis is a growing field of interest owing to rising evidence of complex bidirectional interplay between the two organs. Recent data suggest non-alcoholic fatty liver disease (NAFLD) has a significant, independent association with a wide spectrum of structural and functional cardiac diseases, and seems to worsen cardiovascular disease (CVD) prognosis. Conversely, the effect of cardiac disease on NAFLD is not well studied and data are mostly limited to cardiogenic liver disease. We believe it is important to further investigate the heart-liver relationship because of the tremendous global health and economic burden the two diseases pose, and the impact of such investigations on clinical decision making and management guidelines for both diseases. In this review, we summarize the current knowledge on NAFLD diagnosis, its systemic manifestations, and associations with CVD. More specifically, we review the pathophysiological mechanisms that govern the interplay between NAFLD and CVD and evaluate the relationship between different CVD treatments and NAFLD progression.

Prevalence of non-alcoholic fatty liver disease among patients with non-diabetic chronic kidney disease detected by transient elastography

PURPOSE

Non-alcoholic fatty liver disease (NAFLD) shares a close relationship with cardiovascular morbidity and mortality. The purpose of this study is to evaluate the frequency of NAFLD in the patients with non-diabetic chronic kidney disease (CKD).

METHODS

This cross-sectional study included 80 patients with non-diabetic CKD, of which, 50 patients were on hemodialysis (HD) and 30 patients had CKD stage G3-5 not on dialysis. These patients were randomly selected from Ain Shams University Hospitals, Cairo, Egypt. Patients with diabetes mellitus, obesity, alcohol intake, viral hepatitis, or drug-induced liver steatosis were excluded from this study. Importantly, the controlled attenuation parameter (CAP) (dB/m) of liver steatosis (S0-S3) and liver stiffness/fibrosis measurement (F0-F4) were measured using transient elastography (Fibroscan^®). Other evaluations included complete blood count, routine blood chemistry, and C-reactive protein (CRP) titer.

RESULTS

In total, 45 (56.25%) (30 males, 15 females) out of total 80 studied patients were reported to have NAFLD. There were 29 patients with end-stage renal disease who were on regular HD and 16 patients with pre-dialysis CKD G3-5. The mean CAP values of hepatic steatosis in the patients with CKD on dialysis and patients with pre-dialysis CKD were 265.41 ± 52.73 and 259 ± 44.8 dB/m, respectively. A significant association between the severity of hepatic steatosis degree with decreased glomerular filtration rate and increased CKD stage was observed in this study. The degree of liver stiffness was significantly related to an increased hepatic steatosis grade. A significant positive correlation was found between the degree of NAFLD and serum levels of alanine aminotransferase, aspartate transaminase, total cholesterol, triglycerides, low-density lipoprotein, and CRP titer (P < 0.05). Importantly, NAFLD was significantly associated with an evident history of cardiovascular disease (CVD) among the studied patients.

CONCLUSION

A high frequency of NAFLD (56%) was observed among the patients with non-diabetic CKD on hemodialysis and patients with pre-dialysis CKD. NAFLD may be associated with an increased liver stiffness grade and CVD among those patients.

Visceral fat in different locations assessed by ultrasound: Correlation with computed tomography and cut-off values in patients with metabolic syndrome

The aim of this study was to evaluate the correlation between ultrasound measurements of visceral adipose tissue (VAT) in different locations and visceral fat area parameters estimated by computed tomography (CT), as well as to determine the cut-off values of ultrasound measurements in patients with metabolic syndrome and in normal controls. Altogether, 304 patients aged 18 to 65 years were enrolled in the study. Ultrasound measurements of visceral fat volume were performed using a number of already described techniques. The correlations of ultrasound indices of VAT and СТ (104 patients) ranged from 0.420 to 0.726. For the most effective diagnostic VAT ultrasound indices, the cut-off values in metabolic syndrome were (200 patients): 21.12 cm² for the inferior part of perirenal fat (AUC = 0.983); and 47.00, 61.3 and 72.7 mm for the distance between the internal surface of the rectus abdominis muscle and the anterior wall of the aorta, the posterior wall of the aorta and the lumbar vertebra (AUC = 0.960, 0.966, 0.968, respectively). Ultrasound VAT measurements highly correlated with CT results. Cut-off VAT values, determined by ultrasound for the patients with metabolic syndrome, yielded good diagnostic operational characteristics.

Association between non-alcoholic fatty liver disease and myocardial glucose uptake measured by 18F-fluorodeoxyglucose positron emission tomography

BACKGROUND

Non-alcoholic fatty liver disease (NAFLD) has emerged as an independent risk factor for cardiovascular diseases. However, there were few studies evaluating the condition of myocardial glucose metabolism in patients with NAFLD. Therefore, the aim of this study was to investigate the association between NAFLD and myocardial glucose uptake assessed by using 18F-fluorodeoxyglucose (18F-FDG) positron emission tomography (PET) and whether or not alteration of myocardial glucose uptake could be an indicator linking to cardiac dysfunction in NAFLD individuals.

METHODS AND RESULTS

A total of 743 asymptomatic subjects (201 with NAFLD, 542 without NAFLD) were retrospectively studied. The ratio of maximum myocardium FDG uptake to the mean standardized uptake value of liver (SUVratio) was calculated to estimate myocardial glucose uptake by using 18F-FDG PET. The diagnosis of fatty liver and fatty liver grading was confirmed by unenhanced CT according to diagnostic criterion of previous studies. The myocardial geometric and functional data were obtained by echocardiogram. Myocardial glucose uptake was significantly lower in individuals with NAFLD compared with those without fatty liver (P < .001). When analysis of association trend was performed, SUVratio quartiles showed correlated inversely and strongly with liver steatosis (P < .001). NAFLD patients with lower myocardial glucose uptake were more likely to have higher proportion of increased LV filling pressure (P < .05). A significant relationship between myocardial SUVratio and E/e' ratio was presented in the trend analysis (P < .05). Moreover, multivariate regression analysis showed that myocardial glucose uptake was independently associated with NAFLD after adjusting for clinical important factors (all P < .001).

CONCLUSIONS

The presence of NAFLD in otherwise healthy subjects is closely associated with decreased myocardial glucose uptake assessing by 18F-FDG PET imaging. Furthermore, the NAFLD individuals with lower myocardial glucose uptake are more likely to have high risk of having impaired diastolic heart function.

Early Predictors of Cardiovascular Disease Risk in Nonalcoholic Fatty Liver Disease: Non-obese Versus Obese Patients

BACKGROUND

Nonalcoholic fatty liver disease (NAFLD) is regarded as a risk factor of cardiovascular disease (CVD). However, the association between non-obese NAFLD and CVD has not been well established.

AIM

We aimed to compare the CVD risk between non-obese and obese NAFLD patients, and explored the factors associated with subclinical atherosclerosis.

METHOD

Consecutive NAFLD patients estimated by magnetic resonance imaging-based proton density fat fraction (MRI-PDFF) were recruited. Liver fat content (LFC) and liver stiffness were measured with MRI-PDFF and shear wave elastography, respectively. CVD risk was estimated by atherosclerosis index (AI), carotid intima-media thickness, carotid plaque, and Framingham risk score (FRS).

RESULTS

This study included 543 NAFLD patients. The presence of carotid intima-media thickening and carotid plaque, FRS, and AI were comparable between non-obese and obese patients. Age increased per 10 years (OR 9.68; P < 0.001) and liver fibrosis (liver stiffness > 6.1 kPa, OR 4.42; P = 0.004) were significant factors associated with carotid intima-media thickening in non-obese patients, while age increased per 10 years (OR 2.02; P < 0.001), liver fibrosis (OR 2.18; P = 0.039), and LFC > 10% (OR 2.29; P = 0.021) were independent predictors in obese patients. Only elevated triglyceride was significantly associated with carotid plaque in non-obese patients (OR 2.42; P = 0.033), while age increased per 10 years (OR 1.77; P = 0.002) and LFC > 10% (OR 2.83; P = 0.019) were significant predictors in obese patients.

CONCLUSIONS

Liver stiffness and age were strongly predictive of subclinical atherosclerosis in all NAFLD, while LFC was an additional predictor in obese NAFLD patients. Our findings highlight that early CVD screening strategy should be established for NAFLD patients according to different BMIs.

Different predictors of steatosis and fibrosis severity among lean, overweight and obese patients with nonalcoholic fatty liver disease

BACKGROUNDS

Non-obese nonalcoholic fatty liver disease (NAFLD) is paradoxically associated with improved metabolic and pathological features at diagnosis but worse prognosis relative to obese NAFLD.

AIM

To compare predictors of disease severity in NAFLD with different body mass index (BMI) categories.

METHODS

All 1509 consecutive NAFLD patients were classified as lean (20.2%), overweight (23.1%) and obese (56.7%). Liver fat content (LFC) and fibrosis were estimated with magnetic resonance imaging-based proton density fat fraction and shear wave elastography respectively.

RESULTS

Lipid profiles and uric acid (UA) were significantly increased in parallel with BMI categories (pairwise comparison P < 0.001), but insulin resistance (IR) was significantly different between the non-obese and obese groups. For LFC ≥ 10%, increased waist circumference (WC) was an independent predictor in all groups, while UA elevation (P = 0.02) was predictive in the overweight patients, but BMI ≥ 28 kg/m² (P = 0.029) and IR (P = 0.026) were significant in the obese patients. For fibrosis, alanine aminotransferase (ALT) > 40 U/L (P = 0.031), increased WC (P = 0.012) and BMI ≥ 28 kg/m² (P < 0.001) plus ALT > 40 U/L (P = 0.007) were predictors in the lean, overweight and obese patients, respectively.

CONCLUSIONS

WC was strongly predictive of disease severity in all NAFLD, while UA and BMI plus IR were additional predictors in the overweight and obese NAFLD respectively. Individualized screening strategies should be established for NAFLD according to different BMIs.

Risk Factors for Asymptomatic Colon Diverticulosis

Backgrounds/Aims

The etiology of colon diverticulosis is related to a range of genetic, biological, and environmental factors, but the risk factors for asymptomatic diverticulosis of the colon are unclear. This study examined the risk factors for asymptomatic colon diverticulosis.

Methods

This retrospective study included examinees who underwent a colonoscopy for screening at the health check-up center of SAM Hospital between January 2016 and December 2016. The examinees with colon diverticulosis found by colonoscopy were compared with those without diverticulosis. The comparison factors were age, gender, alcohol consumption, smoking status, medical history, lipid profile, body mass index, visceral fat area, waist-hip ratio, and severity of a fatty liver.

Results

This study included 937 examinees and the overall prevalence of diverticulosis was 8.1% (76/937). Fatty liver was found in 69.7% (53/76) in cases of colon diverticulosis and 50.3% (433/861) in the control group (p=0.001). The average waist-hip ratio was 0.92±0.051 in colon diverticulosis and 0.90±0.052 in the control group (p=0.052). Multivariate analysis revealed the waist-hip ratio (OR=1.035, 95% CI 1.000-1.070, p=0.043), moderate fatty liver (OR=2.238, 95% CI 1.026-4.882, p=0.043), and severe fatty liver (OR=5.519, 95% CI 1.236-21.803, p=0.025) to be associated with an increased risk of asymptomatic colon diverticulosis.

Conclusions

The waist-hip ratio, moderate fatty liver, and severe fatty liver are risk factors for asymptomatic colon diverticulosis. Central obesity, which can be estimated by the waist-hip ratio, and fatty liver might affect the pathogenesis of asymptomatic colon diverticulosis.

Total cholesterol to high-density lipoprotein cholesterol ratio is a significant predictor of nonalcoholic fatty liver: Jinchang cohort study

BACKGROUND

Some studies found out that TC/HDL-C ratio is a predictor of Cardiovascular disease (CVD) and Nonalcoholic fatty liver (NAFLD) is related to CVD. And some researches have already studied that Apolipoprotein B to Apolipoprotein A1 ratio (ApoB/ApoA1) and Triglyceride to High-density lipoprotein cholesterol ratio (TG/HDL-C) were both related with CVD and NAFLD, but few studied the association between TC/HDL-C ratio and NAFLD. So, we suspected the ratio was also related to NAFLD. The research aims to study the predictive value of TC/HDL-C to NAFLD and to help the early detection of NAFLD.

METHODS

Based on the Jinchang Cohort, the study contained 32,121 participants. We assessed the incidence of NAFLD by the quartiles of TC, HDL-C and TC/HDL-C. Then, the does-response relationship between these indicators and the risk of NAFLD was obtained. Finally, the receiver operator characteristic curve (ROC) was applied to decide the predictive value of TC/HDL-C.

RESULTS

Among the study participants, the cumulative incidence of NAFLD was 6.30% and the rate of dyslipidemia was 40.37%. The biochemical indicators of NAFLD had a difference with general population. The incidence of NAFLD raised with the quartiles of TC, TG and LDL-C raising, while decreased with the HDL-C' quartiles raising. After controlling confounding factors, TC and TC/HD-C had a positive relationship with NAFLD, while HDL-C had the opposite. Finally, the ROC analysis showed the area under the curve (AUC) of TC/HDL-C (0.645) was greater than TC (0.554), HDL-C (0.627) and Apolipoprotein B to Apolipoprotein A1 (ApoB/ApoA1) (0.613).

CONCLUSIONS

The TC/HDL-C ratio has significant predictive value to NAFLD.

Developmental origins of nonalcoholic fatty liver disease as a risk factor for exaggerated metabolic and cardiovascular-renal disease

Intrauterine growth restriction (IUGR) is linked to increased risk for chronic disease. Placental ischemia and insufficiency in the mother are implicated in predisposing IUGR offspring to metabolic dysfunction, including hypertension, insulin resistance, abnormalities in glucose homeostasis, and nonalcoholic fatty liver disease (NAFLD). It is unclear whether these metabolic disturbances contribute to the developmental origins of exaggerated cardiovascular-renal disease (CVRD) risk accompanying IUGR. IUGR impacts the pancreas, adipose tissue, and liver, which are hypothesized to program for hepatic insulin resistance and subsequent NAFLD. NAFLD is projected to become the major cause of chronic liver disease and contributor to uncontrolled type 2 diabetes mellitus, which is a leading cause of chronic kidney disease. While NAFLD is increased in experimental models of IUGR, lacking is a full comprehension of the mechanisms responsible for programming of NAFLD and whether this potentiates susceptibility to liver injury. The use of well-established and clinically relevant rodent models, which mimic the clinical characteristics of IUGR, metabolic disturbances, and increased blood pressure in the offspring, will permit investigation into mechanisms linking adverse influences during early life and later chronic health. The purpose of this review is to propose mechanisms, including those proinflammatory in nature, whereby IUGR exacerbates the pathogenesis of NAFLD and how these adverse programmed outcomes contribute to exaggerated CVRD risk. Understanding the etiology of the developmental origins of chronic disease will allow investigators to uncover treatment strategies to intervene in the mother and her offspring to halt the increasing prevalence of metabolic dysfunction and CVRD.

Inhibition of CCL19 benefits non‑alcoholic fatty liver disease by inhibiting TLR4/NF‑κB‑p65 signaling

Non‑alcoholic fatty liver disease (NAFLD), which affects approximately one‑third of the general population, has become a global health problem. Thus, more effective treatments for NAFLD are urgently required. In the present study, high levels of C‑C motif ligand 19 (CCL19), signaling pathways such as Toll‑like receptor 4 (TLR4)/nuclear factor‑κB (NF‑κB), and proinflammatory factors including interleukin‑6 (IL‑6) and tumor necrosis factor‑α (TNF‑α) were detected in NAFLD patients, thereby indicating that there may be an association between CCL19 and these factors in NAFLD progression. Using a high‑fat diet (HFD), the present study generated a Sprague‑Dawley rat model of NAFLD, which displayed dyslipidemia with increased levels of plasma aspartate aminotransferase, alanine aminotransferase, total cholesterol and triglyceride. Dyslipidemia, liver histopathology and gene expression analyses indicated that the NAFLD model was successfully induced by HFD, and metformin and berberine (BBR) were effective treatments for NAFLD. HFD‑induced CCL19 levels and associated factors were markedly reduced by the two drug treatments. In addition, metformin or BBR alone significantly promoted adenosine monophosphate‑activated protein kinase (AMPK) phosphorylation, which was inhibited by HFD. These results demonstrated that metformin and BBR could improve NAFLD, which may be via the activation of AMPK signaling, and the high expression of CCL19 in NAFLD was significantly reduced by metformin and BBR. It could be inferred that inhibition of CCL19 may be an effective treatment for NAFLD.