Unraveling the link between insulin resistance and Non-alcoholic fatty liver disease (or metabolic dysfunction-associated steatotic liver disease): A Narrative Review

Pharmacological treatment options for metabolic dysfunction-associated steatotic liver disease in patients with type 2 diabetes mellitus: A systematic review

BACKGROUND

Metabolic dysfunction-associated steatotic liver disease (MASLD) is closely related to type 2 diabetes mellitus (T2DM) through a common root in insulin resistance. The more severe stage, metabolic dysfunction-associated steatohepatitis (MASH), increases the risk for cardiovascular complications, liver cirrhosis and hepatocellular carcinoma. Several trials investigating established antidiabetic-drugs in patients with T2DM and MASLD have yielded promising results. Therefore, we aimed to systematically review the effect of T2DM-drug treatment on MALSD parameters.

METHODS

Medical databases were searched until January 2025 for controlled trials in patients with T2DM and MASLD/MASH. Studies that evaluated the effect of T2DM-medication on the severity of MASLD/MASH in T2DM patients were included. The quality of the studies was assessed by three independent reviewers using a set of Cochrane risk-of-bias tools.

RESULTS

Of 1748 references, 117 studies fulfilled the inclusion-criteria and were assessed for eligibility in full-text. Fifty-two articles were included. Data included a total of 64.708 patients and study populations ranged from 9 to 50.742. Heterogeneity in study-design and analysis hampered the comparability of the results. Most evidence was present for GLP-1 receptor agonists, SGLT2-inhibitors and PPAR-γ-agonists for regression of liver fibrosis and MASH.

CONCLUSION

Studies on the value of T2DM-drug treatment in the improvement of MASLD vary significantly in study design, size and quality. GLP-1 receptor agonists, PPAR-γ-agonists, SGLT2-inhibitors may all be preferred pharmacological interventions for patients with MASLD/MASH and T2DM. Newer agents like dual GLP-1/GIP or triple GLP-1/GIP/Glucagon agonists will likely play an important role in the treatment of MASLD/MASH in the near future.

The Triad of Risk: Linking MASLD, Cardiovascular Disease and Type 2 Diabetes; From Pathophysiology to Treatment

Metabolic dysfunction-associated steatotic liver disease (MASLD) is an emerging global health concern, and it is not only the keystone precursor of eventual liver-related morbidity, but it also places patients at considerably higher cardiovascular risk, which is still a leading cause of death in these patients. The most important common underlying pathophysiological mechanisms in these diseases are primarily related to insulin resistance, chronic inflammation and oxidative stress. The presence of MASLD with cardiovascular disease (CVD) and type 2 diabetes mellitus (T2DM) elevates the risk for poor outcomes, thus this review highlights a method to the therapeutic approaches. Given the intertwined nature of MASLD, T2DM, and CVD, there is an urgent need for therapeutic strategies that address all three conditions. Although lifestyle changes are important as treatment, medication plays a crucial role in managing hyperglycemia, enhancing liver function and lowering cardiovascular risk. The onset and progression of MASLD should be addressed through a multifaceted therapeutic approach, targeting inflammatory, immune, metabolic, oxidative stress, hormonal and gutaxis pathways, alongside the treatment strategies for T2DM. In this review, we discuss the effects of antidiabetic drugs with an impact on both liver outcomes and cardiovascular risk in patients affected by MASLD, T2DM and CDV.

Understanding Insulin Resistance in NAFLD: A Systematic Review and Meta-Analysis Focused on HOMA-IR in South Asians

Non-alcoholic fatty liver disease (NAFLD), a metabolic condition, is becoming increasingly common in South Asia. While its clinical diagnosis primarily relies on sonography and altered hepatic biomarkers, the significance of non-hepatic indicators, such as Homeostasis Model Assessment of Insulin Resistance (HOMA-IR), in relation to NAFLD requires further examination in the South Asian population due to ethnic differences in these markers. This study examined the relationship between insulin resistance, quantified using the Homeostasis Model Assessment of Insulin Resistance (HOMA-IR), and NAFLD, along with other non-hepatic biomarkers. A thorough literature review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. We searched the PubMed, Embase, and Google Scholar databases, yielding 287 articles. After applying the selection criteria and screening, 22 studies were selected for inclusion in the analysis. We extracted and meta-analyzed the data on HOMA-IR in patients with NAFLD, along with other relevant parameters. The Newcastle-Ottawa Scale (NOS) was used to assess the quality of observational studies, whereas the RoB 2.0 tool was employed for randomized controlled trials (RCTs). The systematic review uncovered that individuals with NAFLD demonstrated statistically significant elevations in HOMA-IR levels, with a weighted mean difference (WMD) of 1.28 (95% confidence interval (CI): 1.00-1.58, I² = 98%, p < 0.0001) when compared to healthy subjects. Additionally, NAFLD patients showed markedly higher fasting blood glucose (FBG) levels, with a combined mean difference of 15.64 mg/dL (95% CI: 11.03-20.25, I² = 92%, p < 0.0001). The analysis also revealed increased triglyceride levels in NAFLD patients, with a pooled mean difference of 42.49 mg/dL (95% CI: 29.07-55.91, I² = 97%, p < 0.0001), and elevated C-reactive protein (CRP) levels, with a pooled mean difference of 2.17 mg/L (95% CI: 2.01-2.33, I² = 23%, p < 0.0001). Interestingly, subgroup analysis indicated that obese NAFLD patients exhibited significantly higher HOMA-IR levels than their non-obese counterparts, with a weighted mean difference of 5.85 (95% CI: 4.88-6.81, I² = 0%, p < 0.0001). Variations in study methodology, diagnostic techniques, and subject demographics were identified as sources of heterogeneity. The analysis found little evidence of publication bias, which lends credibility to the results. In South Asian populations, higher HOMA-IR, triglyceride-glucose (TyG) index, and CRP levels are associated with an increased risk of NAFLD. To improve the understanding and treatment of NAFLD in this specific demographic group, it is necessary to establish uniform diagnostic criteria and conduct additional studies, particularly RCTs.

Association between non-alcoholic fatty liver disease and the risk of pulmonary nodules in patients with intestinal polyps

Background

Associations between metabolic risk factors and lung cancer remain elusive, and evidence on the linkage between non-alcoholic fatty liver disease (NAFLD) and pulmonary nodules is limited. This study sought to examine the independent association between NAFLD and the risk of pulmonary nodules.

Methods

Cross-sectional analyses of 1,119 patients with intestinal polyps hospitalized at the Department of Gastroenterology, Minhang District Central Hospital of Shanghai, China, were conducted. NAFLD was diagnosed based on hepatic ultrasonography or computed tomography (CT) findings of hepatic steatosis, with exclusion criteria ensuring patients had no history of significant alcohol consumption, viral infections, or hepatic autoimmune diseases. The currently accepted definition of a pulmonary nodule is a solid or sub-solid shadow ≤3 cm in diameter that appears as a solid or semi-solid pattern on a chest CT scan (our specific treatment is pulmonary nodule size: 5 mm to 3 cm). Adjusted 95% confidence intervals (CIs) and odds ratios (ORs) for NAFLD and the clinical features connected with pulmonary nodule risk were determined using a multivariable logistic regression analysis.

Results

Among the 979 intestinal polyp patients, the prevalence rates of NAFLD and pulmonary nodules were 25.9% and 32.8%, respectively. Patients with pulmonary nodules exhibited higher rates of NAFLD (31.5% vs. 23.3%, P=0.006) and obesity (41.4% vs. 32.5%, P=0.006) compared to those without pulmonary nodules. After removing all the possible confounding variables, the adjusted ORs for NAFLD, an older age, smoking, and obesity were 1.370 (95% CI: 1.006-1.867, P=0.04), 1.022 (95% CI: 1.010-1.033), 1.599 (95% CI: 1.033-2.475), and 1.410 (95% CI: 1.057-1.880), respectively (all P values <0.05). NAFLD showed a significant association with an increased risk of pulmonary nodules.

Conclusions

NAFLD was independently linked to an increased incidence of pulmonary nodules in intestinal polyp patients, which emphasizes the importance of screening and managing these conditions in lung cancer prevention.

Hypoglycemia in non-diabetic in-patients at a teaching referral hospital in Iran

Purpose

This study aims to investigate comorbidities, clinical features, laboratory values, and diagnoses in non-diabetic patients experiencing hypoglycemic episodes.

Methods

A retrospective observational study was conducted at Shariati Hospital in Iran from 2016 to 2023. Seventy-four non-diabetic patients admitted with a diagnosis of hypoglycemia were included, while patients with diabetes were excluded. Demographic data, symptoms, and biochemical assessments were obtained from the hospital information system. Hypoglycemic episodes were identified based on low measured blood glucose, recorded medications for hypoglycemia treatment, or recorded codes indicating hypoglycemia. Hypoglycemia was defined as blood glucose below 70 mg/dL (3.9 mmol/L) along with two other criteria of the Whipple triad. Statistical analysis was performed using SPSS software (version 26).

Results

Among the enrolled patients, 63.5% were female, and 13.5% were elderly (≥ 65 years). The most common comorbidities observed were cardiovascular disease (20.3%), psychological disorders (20.3%), hypothyroidism (14.9%), and hypertension (8.1%). The prevalent symptoms included weakness, loss of consciousness, sweating, palpitations, dizziness, and tremors. Non-diabetic hypoglycemia was caused by factitious disorders, insulinoma, organ failure, and infection, respectively.

Conclusion

Due to the diverse range of clinical symptoms, hypoglycemia in non-diabetic patients may be diagnosed late, leading to misdiagnoses such as psychological disorders or seizures. It is crucial to consider the possibility of hypoglycemia in non-diabetic patients and determine its underlying cause. Given the poor prognosis associated with hypoglycemia, timely interventions are essential.

Associations between estimated glucose disposal rate and arterial stiffness and mortality among US adults with non-alcoholic fatty liver disease

Background

The estimated glucose disposal rate (eGDR), an effective indicator of insulin resistance, has been related to acute coronary syndrome, ischemic stroke and heart failure. This study aims to explore the relationship between eGDR and arterial stiffness, all-cause mortality and cardiovascular mortality in patients with non-alcoholic fatty liver disease (NAFLD).

Methods

Participants with NAFLD were chosen from the National Health and Nutrition Examination Survey (NHANES) between 1999 and 2018. The main outcomes are arterial stiffness (represented by estimated pulse wave velocity, ePWV), all-cause and cardiovascular mortality. Multiple cox regression models, restricted cubic spline, sensitivity analysis and subgroup analysis were carried out to investigate the correlation between the insulin resistance indicators and mortality and arterial stiffness. Furthermore, receiver operating characteristic curves were used to compare the predictive value of the eGDR with the triglyceride-glucose (TyG) index and the homeostasis model assessment of insulin resistance (HOMA-IR) for all-cause and cardiovascular mortality.

Results

In this study, a total of 4,861 participants were included for analysis. After adjusting confounding factors in the multivariate weighted cox regression model, the eGDR was inversely associated with the all-cause mortality (Q4 vs. Q1, HR =0.65 (0.48-0.89, P=0.01) and cardiovascular mortality (Q4 vs. Q1, HR =0.35 (0.19-0.65, P<0.001). Compared with TyG index and HOMA-IR, the eGDR shows excellent predictive value in all-cause mortality (0.588 vs. 0.550 vs. 0.513, P < 0.001) and cardiovascular mortality (0.625 vs. 0.553 vs. 0.537, P < 0.001). In addition, we found a significant negative correlation between eGDR and arterial stiffness (β=-0.13(-0.14-0.11, P< 0.001). However, TyG index and HOMA-IR showed no significant correlation to arterial stiffness.

Conclusions

Low eGDR (an indicator of insulin resistance) levels are related to an increased risk of arterial stiffness and mortality in NAFLD patients in the United States.

The clinician's view on the advantages and contradictions of the new nomenclature of steatotic liver disease: A review

In September 2023, the European Association for the Study of the Liver (EASL) updated the disease nomenclature for non-alcoholic (metabolically associated) fatty liver disease. The goals of the revision were to increase awareness among health care professionals, civil society and patients about the disease, its course, treatment and outcomes; combating stigma; focusing on the initial etiological factor, including the main (cardiometabolic) risk of disease progression; improved diagnosis based on disease biomarkers; positive impact on the potency to search for new drugs; the ability to provide personalized medical care. The terms “non-alcoholic” and “fatty” were considered stigmatizing, and therefore, it was proposed to use the term steatotic liver disease (SLD) as the name of this nosology. The terms non-alcoholic fatty liver disease (NAFLD) or metabolic associated fatty liver disease (MAFLD) have been replaced by the term metabolic dysfunction-associated steatotic liver disease (MASLD). In the case of being combined with an alcohol factor, a diagnosis in which metabolic dysfunction is combined with alcoholic liver disease is referred to as MetALD. The fundamental principle in the diagnosis of MASLD is the presence of at least one of the cardiometabolic risk factors. Alcohol consumption interacts with cardiometabolic risk factors and increases the risk of SLD decompensation. The term nonalcoholic steatohepatitis (NASH), according to the new nomenclature, has been replaced by the term metabolic dysfunction-associated steatohepatitis (MASH). The adoption of the new nomenclature should help to increase awareness about the disease, its course and outcomes, as well as improve the quality of diagnosis and treatment.

Novel Anthropometric Indices as Screening Tools for Obesity: A Study on Healthy Iranians

Background and Aims

Upper body fat distribution is more related to cardiometabolic diseases than central obesity. Neck circumference (NC) and neck-to-height ratio (NHtR) are two indicators of upper body obesity that are affordable, easy to obtain, highly reproducible, and more practical in the crowded health centers than the classic anthropometric indices.

Methods

18-65-year-old individuals with no past medical history were included. After obtaining written informed consent, they were screened for hypertension, high blood glucose, and other abnormal laboratory results. Data were analyzed using SPSS and Mann-Whitney U test, Chi square test, Spearman's correlation coefficient, and ROC curve.

Results

In our 2,812 participants, NC had the lowest area under the curve (AUC) in both male and female obese and overweight subjects. NHtR and hip circumference (HC) had the highest AUC in men and women with obesity, respectively. The highest sensitivity for overweight men and women belonged to waist circumference (WC) and waist-to-height ratio (WHtR), respectively, and for both males and females with obesity, NHtR had the highest sensitivity. The cutoff point of NHtR had the same value for males and females. HC and NHtR had the highest positive likelihood ratio (PLR) for obesity in men. In addition, HC and WC had the highest PLR for obesity in women.

Conclusion

In this study, we revealed that NC had the lowest and NHtR and HC had the highest predictive value for obesity. Furthermore, for both males and females with obesity, NHtR had the highest sensitivity. HC had the highest PLR for obesity in both genders. Our results warrant prospective studies to evaluate the role of NHtR and other novel anthropometric indices in the risk of cardiometabolic diseases.