Comorbidities Are Associated with Fibrosis in NAFLD Subjects: A Nationwide Study (NASH-CO Study)

Global prevalence of nonalcoholic fatty liver disease: an updated meta-analysis on 78 million population over 38 countries

BACKGROUND

Nonalcoholic fatty liver disease (NAFLD) is a global health challenge, with a rising rate in line with other metabolic diseases. We aimed to assess the global prevalence of NAFLD in adult and pediatric populations.

METHODS

PubMed, Scopus and Web of Science databases were systematically searched up to May 2023. Heterogeneity was assessed using Cochran's Q test and I2 statistics, and random-effects model was used for meta-analysis. Analyses were performed using STATA version 18.

RESULTS

A total of 479 studies with 78,001,755 participants from 38 countries were finally included. The global prevalence of NAFLD was estimated to be 30.2% (95% CI: 28.7-31.7%). Regionally, the prevalence of NAFLD was as follows: Asia 30.9% (95% CI: 29.2-32.6%), Australia 16.1% (95% CI: 9.0-24.8%), Europe 30.2% (95% CI: 25.6-35.0%), North America 29% (95% CI: 25.8-32.3%), and South America 34% (95% CI: 16.9-53.5%). Countries with a higher human development index (HDI) had significantly lower prevalence of NAFLD (coefficient = -0.523, p = 0.005). Globally, the prevalence of NAFLD in men and women was 36.6% (95% CI: 34.7-38.4%) and 25.5% (95% CI: 23.9-27.1%), respectively. The prevalence of NAFLD in adults, adults with obesity, children, and children with obesity was 30.2% (95% CI: 28.8-31.7%), 57.5% (95% CI: 43.6-70.9%), 14.3% (95% CI: 10.3-18.8%), and 38.0% (95% CI: 31.5-44.7%), respectively.

CONCLUSION

The prevalence of NAFLD is remarkably high, particularly in countries with lower HDI. This substantial prevalence in both adults and children underscores the need for disease management protocols to reduce the burden.

Increased risk of chronic kidney disease and mortality in a cohort of people diagnosed with metabolic dysfunction associated steatotic liver disease with hepatic fibrosis

BACKGROUND AND AIMS

Metabolic dysfunction associated steatotic liver disease (MASLD) increases the risk of incident chronic kidney disease (CKD). However, the relative risk of CKD associated with increasing hepatic fibrosis, and consequent mortality risk, remains underexplored in real-world cohorts. In this study, we sought to establish whether hepatic fibrosis is associated with increased CKD risk and explore differences in mortality risk in a cohort of people living with MASLD, contingent on liver fibrosis and CKD status.

METHODS

This was an observational study of people who underwent routine liver function testing in Tayside, Scotland. MASLD was defined as: elevated ALT (>30 U/L) or GGT (>73 U/L); presence of diabetes, and/or hypertension, and/or obesity; weekly alcohol consumption <14 units (112g (+/-8g) alcohol); and negative screen for other aetiologies. Data was collected from digital health records. We used log-binomial models to quantify the risk of CKD among those with and without fibrosis, and Cox regression models to estimate differences in mortality risk dependent on fibrosis and CKD.

RESULTS

In our cohort (n = 2,046), 1,448 (70.8%) people had MASLD without fibrosis and 598 (29.2%) with fibrosis; 161 (11.1%) and 117 (19.6%) respectively also had CKD. After excluding individuals with structural, autoimmune, or malignant CKD (n = 22), liver fibrosis (n = 593; 18.9% with CKD) was associated with increased CKD risk (aRR = 1.31, 1.04-1.64, p = 0.021). Increased mortality risk was observed for those with liver fibrosis (aHR = 2.30, 1.49-3.56, p = <0.001) and was higher again among people with both fibrosis and CKD (aHR = 5.07, 3.07-8.39, p = <0.014).

CONCLUSIONS

Liver fibrosis was an independent risk factor for CKD in this cohort of people living with MASLD. Furthermore, those with MASLD with liver fibrosis had higher risk for mortality and this risk was further elevated among those with co-morbid CKD. Given the increased risk of CKD, and consequent mortality risk, among people living with MASLD fibrosis, renal function screening should be considered within liver health surveillance programmes and guidelines.

Physical activity intensity and markers of inflammation in those with non-alcoholic fatty liver disease

AIMS

To investigate associations between objectively measured light (LPA) and moderate-to-vigorous (MVPA) physical activity on plasma homocysteine and serum C-reactive protein (CRP) in individuals with Non-Alcoholic Fatty Liver Disease (NAFLD).

METHODS

This study was a secondary analysis using data from 2003 to 2006 National Health and Nutrition Examination Survey including a total of 983 individuals with NAFLD. Physical activity was assessed over 7 days with accelerometers. Participants were split into tertiles based on average daily minutes of LPA or MVPA and CRP and homocysteine were assessed across tertiles.

RESULTS

Adjusted plasma homocysteine and CRP were not different between groups regarding levels of LPA (Homocysteine: 1st tertile - 10.4 ± 0.7 µmol/L; 2nd tertile - 9.6 ± 0.4 µmol/L; 3rd tertile - 9.6 ± 0.4 µmol/L; p = 0.28; CRP: 1st tertile - 0.79 ± 0.12 mg/dL; 2nd tertile - 0.73 ± 0.09 mg/dL; 3rd tertile - 0.73 ± 0.09 mg/dL; p = 0.72). Adjusted CRP was significantly (p = 0.02) different across MVPA tertiles (1st: 0.87 ± 0.13 mg/dL; 2nd: 0.75 ± 0.10 mg/dL; 3rd:0.65 ± 0.09).

CONCLUSIONS

LPA does not appear to be effective at improving homocysteine or CRP levels in individuals with NAFLD. However, MVPA may be an effective therapy for decreasing CRP in NAFLD patients.

Association between elevated serum transaminase and moderately increased albuminuria: a cross-sectional study in western Tokushima, Japan

BACKGROUND

This study aimed to identify the factors relating to moderately increased albuminuria among middle-aged and older individuals in Japan.

METHODS

We conducted specific health examinations in which we measured albuminuria levels, and administered a questionnaire survey to record participants' lifestyles in western Tokushima Prefecture, Japan. A total of 1,660 people whose albuminuria was less than 300 mg/g creatinine (Cr) were analyzed. We divided participants into two groups-those with normal albuminuria (< 30 mg/gCr) and those with moderately increased albuminuria (≥ 30 mg/gCr, > 300 mg/gCr)-and compared their characteristics. To investigate all relevant factors, we conducted a multivariate logistic regression analysis.

RESULTS

The moderately increased albuminuria group were significantly older and had, among them, significantly higher percentages of a body mass index (BMI) ≥ 25 kg/m2, diabetes, hypertension, and mild liver disorder (aspartate transaminase ≥ 31 U/L or alanine aminotransferase ≥ 31 U/L or gamma-glutamyl transferase ≥ 51 U/L). (p < 0.01) In a multivariate logistic regression analysis that used microalbuminuria as an independent variable, we found the adjusted odds ratio (AOR) and 95% confidence interval (CI) to be significantly higher among individuals with diabetes (AOR: 2.04, 95% CI: 1.40-2.99); hypertension (AOR: 1.90, 95% CI: 1.36-2.65); BMI ≥ 25 kg/m2 (AOR: 1.76, 95% CI: 1.27-2.44); and mild liver disorder (AOR: 1.54, 95% CI: 1.10-2.18).

CONCLUSIONS

In addition to diabetes, hypertension, and BMI ≥ 25 kg/m2, this study found that among the middle-aged and older general population living in western Tokushima Prefecture, there were cases of mild liver disorder (elevated serum transaminase), which independently associated with moderately increased albuminuria. Therefore, in health checkups targeting the general population, there is a need to consider measuring albuminuria, even in those who have only mild liver dysfunction (health guidance level).

TRIAL REGISTRATION

N/A.

Serum uric acid is related to liver and kidney disease and 12-year mortality risk after myocardial infarction

Objective

To study the associations of non-alcoholic fatty liver disease (NAFLD), chronic kidney disease (CKD), and serum uric acid (SUA) in patients with post-myocardial infarction (MI) patients, and the relationship of SUA with 12-year mortality risk.

Methods

We included 3,396 patients (60-80 years old, 78% men) of the Alpha Omega Cohort. Multivariable prevalence ratios (PRs) were obtained for the association of NAFLD [fatty liver index (FLI), ≥77 (women) and ≥79 (men)] with CKD [estimated glomerular filtration rate (eGFR), <60 mL/min per 1.73 m2]. We calculated sensitivity and specificity of SUA to detect the (combined) presence and absence of NAFLD and CKD. Cause-specific mortality was monitored from enrolment (2002-2006) through December 2018. Hazard ratios (HRs) for all-cause and cardiovascular disease (CVD) mortality in SUA categories were obtained from multivariable Cox models.

Results

Median baseline FLI was 67 (men, 68; women, 64), and mean ± SD eGFR was 81 ± 20 mL/min per 1.73 m2 (17% with CKD). Sex-specific FLI was associated with higher CKD prevalence (PRtertile3 vs. tertile1, 1.94; 95% confidence interval: 1.57, 2.39). Baseline SUA was 0.36 ± 0.09 mmol/L. With increasing SUA concentrations, specificity for the presence of NAFLD, CKD, or both increased, and sensitivity decreased. During 12 (interquartile range, 9-14) years of follow-up, 1,592 patients died (713 from CVD). HRs ranged from 1.08 (0.88, 1.32) for SUA ≤0.25 mmol/L to 2.13 (1.75, 2.60) for SUA >0.50 mmol/L vs. SUA >0.30-0.35 mmol/L for all-cause mortality. For CVD mortality, HRs ranged from 1.05 (0.77, 1.44) to 2.43 (1.83, 3.25).

Conclusions

NAFLD and CKD were strongly associated, which was reflected by higher SUA concentrations. SUA was a strong predictor of 12-year mortality risk after MI.

Lean individuals with NAFLD have more severe liver disease and poorer clinical outcomes (NASH-CO Study)

BACKGROUND AND AIMS

The severity of liver injury and clinical outcomes in lean individuals with NAFLD is a subject of debate and very few studies have been performed in the general population. The aim of this study was to compare subject characteristics and mortality between lean and nonlean NAFLD in a community setting.

APPROACH AND RESULTS

The study population included 169,303 participants from the nationwide Constances cohort. Subjects with excessive alcohol consumption, viral hepatitis, or other liver diseases were excluded and 137,206 subjects were analyzed. The diagnosis of NAFLD and fibrosis was performed using the Fatty Liver Index and the Forns Index. The median follow-up was 3.58 years. The prevalence of NAFLD was 5.3% (95% CI: 5.2-5.4) in lean subjects, while 16.3% (95% CI: 15.7-16.8) of NAFLD subjects were lean. Despite their better metabolic profile, the prevalence of advanced fibrosis was significantly higher in lean than in nonlean NAFLD (3.7% vs. 1.7%, respectively, p < 0.01). Among NAFLD subjects and after adjustment for demographics, metabolic risk factors and lifestyle, lean status was associated with advanced fibrosis (OR=1.26, 95% CI: 1.20-1.65, p = 0.005), an increased risk of liver-related events (adjusted HR=5.84, 95% CI: 4.03-8.46), chronic kidney disease (adjusted HR=2.49, 95% CI: 1.49-4.16), and overall mortality (adjusted HR=3.01, 95% CI: 2.21-4.11). Liver-related events and overall mortality were related to the severity of fibrosis, both in lean and nonlean NAFLD subjects, whatever the usual risk factors.

CONCLUSION

This study in a large community-based cohort confirms that NAFLD in lean subjects is more severe for fibrosis, the progression of liver disease, chronic kidney disease, and overall mortality.

Prospective Metabolomic Studies in Precision Medicine: The AKRIBEA Project

For a long time, conventional medicine has analysed biomolecules to diagnose diseases. Yet, this approach has proven valid only for a limited number of metabolites and often through a bijective relationship with the disease (i.e. glucose relationship with diabetes), ultimately offering incomplete diagnostic value. Nowadays, precision medicine emerges as an option to improve the prevention and/or treatment of numerous pathologies, focusing on the molecular mechanisms, acting in a patient-specific dimension, and leveraging multiple contributing factors such as genetic, environmental, or lifestyle. Metabolomics grasps the required subcellular complexity while being sensitive to all these factors, which results in a most suitable technique for precision medicine. The aim of this chapter is to describe how NMR-based metabolomics can be integrated in the design of a precision medicine strategy, using the Precision Medicine Initiative of the Basque Country (the AKRIBEA project) as a case study. To that end, we will illustrate the procedures to be followed when conducting an NMR-based metabolomics study with a large cohort of individuals, emphasizing the critical points. The chapter will conclude with the discussion of some relevant biomedical applications.

Association of metabolic dysfunction-associated fatty liver disease, type 2 diabetes mellitus, and metabolic goal achievement with risk of chronic kidney disease

Background

Although type 2 diabetes mellitus (T2DM) plays a significant role in the association between metabolic dysfunction-associated fatty liver disease (MAFLD) and chronic kidney disease (CKD), how T2DM development and glycemic deterioration affect CKD and its renal function indicators, estimated glomerular filtration rate (eGFR) and urine albumin-to-creatinine ratio (UACR), remains unknown. We aimed to assess the association between MAFLD, along with T2DM, and risk of CKD, and then evaluate the effect of metabolic goal achievement in MAFLD on the risk of CKD.

Methods

In this cross-sectional study, 5,594 participants were included. Multivariate logistic regression and linear regression were used to examine the association between MAFLD with its T2DM status and metabolic goal achievement and risk of CKD, as well as eGFR and UACR.

Results

The MAFLD group had a higher prevalence of CKD (16.2 vs. 7.6%, P < 0.001) than the non-MAFLD group. MAFLD was independently associated with an increased risk of CKD (odds ratio [OR]: 1.35, 95% CI: 1.09-1.67) and increased eGFR and UACR. Among the three MAFLD subtypes, only the T2DM subtype exhibited significant associations with increased risk of CKD (OR: 2.85, 95% CI: 2.24-3.63), as well as increased eGFR and UACR. Glycemic deterioration in MAFLD was dose-dependently associated with an increased risk of CKD (P-trend < 0.001). Achieved metabolic goals in MAFLD decreased the risk of CKD, eGFR, and UACR; MAFLD with 2 or 3 achieved metabolic goals was not significantly associated with the risk of CKD (OR: 0.81, 95% CI: 0.59-1.12) and albuminuria.

Conclusion

MAFLD was independently associated with an increased risk of CKD, as well as increased eGFR and UACR. This association is strongly driven by T2DM status. Glycemic deterioration in MAFLD was dose-dependently associated with an increased risk of CKD. Achieved metabolic goals in MAFLD decreased the risk of CKD by reducing the risk of albuminuria.

Liver Stiffness Is Associated with the Burden of Carotid and Systemic Atherosclerosis in an Unorganized Cohort of Patients 40-64 Years Old

Background: The aim of the study is to research the relationship between the severity of liver fibrosis and the burden of carotid and systemic atherosclerosis. Methods: The study includes 163 patients 40 to 64 years of age without atherosclerotic CVD or liver disease. All patients underwent duplex scanning of the carotid and lower limb arteries. All patients underwent transient liver elastometry using the FibroScan (Echosens, France). Results: Carotid plaque was detected in 110 (67.5%) patients. Based on the results of linear regression analysis, relationships between liver stiffness and carotid total plaque area (r = 0.21; p = 0.025) were found. Significant relationships were established between liver stiffness and atherosclerosis burden score based on the results of linear regression (r = 0.17; p = 0.029). Liver stiffness showed moderate diagnostic performance (AUC 0.666; p = 0.01) with regard to generalized atherosclerosis. An increase in liver stiffness >4.5 kPa was associated with an odds ratio of generalized atherosclerosis of 3.48 (95% CI 1.07−11.3; p = 0.038) after adjusting confounding factors. Conclusion: Among patients 40−64 years of age without established atherosclerotic CVD and liver disease, liver stiffness directly correlates with the burden of carotid and systemic atherosclerosis. Liver stiffness showed moderate diagnostic performance (AUC 0.666; p = 0.01) with regard to generalized atherosclerosis.

The Regulatory Roles of Polysaccharides and Ferroptosis-Related Phytochemicals in Liver Diseases

Liver disease is a global health burden with high morbidity and mortality worldwide. Liver injuries can develop into severe end-stage diseases, such as cirrhosis or hepatocellular carcinoma, without valid treatment. Therefore, identifying novel drugs may promote liver disease treatment. Phytochemicals, including polysaccharides, flavonoids, alkaloids, and terpenes, are abundant in foods and medicinal plants and have various bioactivities, such as antioxidation, immunoregulation, and tumor killing. Recent studies have shown that many natural polysaccharides play protective roles in liver disease models in vitro and in vivo, such as fatty liver disease, alcoholic liver disease, drug-induced liver injury, and liver cancer. The mechanisms of liver disease are complex. Notably, ferroptosis, a new type of cell death driven by iron and lipid peroxidation, is considered to be the key mechanism in many hepatic pathologies. Therefore, polysaccharides and other types of phytochemicals with activities in ferroptosis regulation provide novel therapeutic strategies for ferroptosis-related liver diseases. This review summarizes our current understanding of the mechanisms of ferroptosis and liver injury and compelling preclinical evidence of natural bioactive polysaccharides and phytochemicals in treating liver disease.

Percutaneous radiofrequency ablation for hepatocellular carcinoma developed on non-alcoholic fatty liver disease

BACKGROUND & AIMS

Long-term outcomes after percutaneous radiofrequency ablation (RFA) for hepatocellular carcinoma (HCC) in patients with non-alcoholic fatty liver disease (NAFLD) have been poorly studied. We aim to determine the outcomes after multibipolar RFA in these patients compared to other aetiologies as well as the prognostic impact of metabolic syndrome (MS).

METHODS

Patients who underwent multibipolar RFA as the first treatment for HCC within Milan criteria (2008-2018) were enrolled in this multicentre retrospective cohort from four tertiary centres in France. The association of MS and NAFLD with adverse events and outcomes after percutaneous RFA were assessed using Kaplan Meier method, log-rank test and uni/multivariate analysis with the Cox models.

RESULTS

Among 520 patients, 390 patients (75%) had at least one component of MS including obesity (30%) and 95% had cirrhosis. Sixty-two patients (12.6%) had NAFLD-HCC, 225 (45.5%) had alcohol-related-HCC, 36 (7.3%) had HBV-HCC and 171 (34.6%) had HCV-HCC. Patients with NAFLD-HCC were significantly older (median age 72.6 years, P < .001), more obese (median BMI 30.3 kg/m² , P < .001) and had more components of MS. Patients with NAFLD-HCC achieved a median overall survival (OS) of 79 months (1-year, 3-year and 5-year OS of 90%, 71% and 59%). There were no differences in morbidity, tumour recurrence and OS among patients with NAFLD-HCC vs other aetiologies as well as no prognostic impact of metabolic components.

CONCLUSIONS

Percutaneous multibipolar RFA is an efficient treatment in HCC patients with NAFLD or metabolic syndrome and achieved similar long-term oncological outcomes compared to other aetiologies.