New FIB-4 and NFS cutoffs to guide sequential non-invasive assessment of liver fibrosis by magnetic resonance elastography in NAFLD

The predictive value of triglyceride-glucose-high density lipoprotein-body mass index (TGH-BMI) for different degrees of hepatic steatosis and liver fibrosis in metabolic dysfunction-associated steatotic liver disease (MASLD)

BACKGROUND & AIMS

The triglyceride-glucose index (TyG) and triglyceride-glucose body mass index (TyG-BMI) have been identified as potential predictive factors for metabolic dysfunction-associated steatotic liver disease (MASLD). However, they do not include high density lipoprotein (HDL-C), which is closely related to lipid metabolism. Furthermore, there is a lack of comprehensive and longitudinal data to determine the cut-off points for different degrees of hepatic steatosis and liver fibrosis in MASLD. This study aimed to investigate the predictive capability of triglyceride-glucose-high density lipoprotein-body mass index (TGH-BMI) in determining hepatic steatosis and liver fibrosis in MASLD, as well as to establish the predictive cut-off points.

METHODS

We analyzed the relationships of TGH-BMI (TGH-BMI = ln [TG (mg/dL) ∗FBG (mg/dL)/HDL-C (mg/dL)] ∗ BMI (kg/m2)) with different degrees of hepatic steatosis and fibrosis in 35,114 participants who underwent health check-ups. A total of 2262 subjects without MASLD were selected for the analysis of cumulative hazard of hepatic steatosis and liver fibrosis in TGH-BMI dichotomous groups over a follow-up period of 1001 days.

RESULTS

Controlled attenuation parameter (CAP) and liver stiffness measurement (LSM) demonstrated a consistent upward trend as TGH-BMI increased across quartile groups, as determined by One-way analysis of variance (P < 0.001). TGH-BMI and CAP, LSM exhibit distinct curve-like relationships between males and females when utilizing smoothing functions and conducting threshold effect analysis (P < 0.05). In males, prior to the inflection point at TGH-BMI = 177.733, there was a significant increase of 0.807 in CAP for every 1 unit increase in TGH-BMI (P < 0.05), after the inflection point, there was still an increase of 0.417 in CAP for every 1 unit increase in TGH-BMI (P < 0.05); There was no significant correlation between LSM and TGH-BMI before the first inflection point at TGH-BMI = 131.689 (P > 0.05) and after the second inflection point at TGH-BMI = 253.268 (P > 0.05). Between the first and the second inflection, LSM showed an increase of 0.015 for every 1 unit increase in TGH-BMI (P < 0.05). In females, before the inflection point at TGH-BMI = 94.686, there was a significant increase of 0.272 in CAP for every 1 unit increase in TGH-BMI (P < 0.05), after the inflection point, there was a notable change as CAP increased by 0.806 for every 1 unit increase in TGH-BMI (P < 0.05). There was no significant correlation between LSM and TGH-BMI before the inflection point at TGH-BMI = 118.098 (P > 0.05), after the inflection point, LSM showed an increase of 0.017 for every 1 unit increase in TGH-BMI (P < 0.05). Notably, TGH-BMI has been shown to be a strong predictor for the severity of hepatic steatosis and liver fibrosis in MASLD. The Area Under Curves (AUCs) for hepatic steatosis, moderate or above hepatic steatosis, severe hepatic steatosis and liver fibrosis in males were 0.845, 0.846, 0.882 and 0.668 respectively, the AUCs for hepatic steatosis, moderate or above hepatic steatosis, severe hepatic steatosis and liver fibrosis in females were 0.855, 0.895, 0.939 and 0.705 respectively (P < 0.05). In individuals without MASLD, the cumulative hazard of hepatic steatosis was found to be strongly associated with the dichotomy of increased TGH-BMI (TGH-BMID2: Hazard Ratio (HR) = 2.412, 95 % Confidence interval (CI): 2.0164-2.9071, P < 0.0001), while the same is true in liver fibrosis (TGH-BMID2: HR = 1.454, 95 % CI: 1.0633-1.9883, P = 0.0191).

CONCLUSIONS

The TGH-BMI demonstrates a strong predictive value for hepatic steatosis and liver fibrosis, with significantly different cut-off points for men and women. Therefore, it is important to consider the potential need for gender-specific cut-off points for triglyceride, glucose, high density lipoprotein and body mass index in clinical practice. In individuals without MASLD, a higher TGH-BMI is associated with an increased risk of developing MASLD in the future.

Sequential Diagnostic Approach Using FIB-4 and ELF for Predicting Advanced Fibrosis in Metabolic Dysfunction-Associated Steatotic Liver Disease

Background and Aims: Multiple non-invasive tests (NITs) for identifying advanced fibrosis in patients with non-alcoholic fatty liver disease (NAFLD) are available, but, due to the limitations of single NITs, the American Association for the Study of Liver Disease (AASLD) guidelines suggest a two-step strategy, combining the Fibrosis-4 Index (FIB-4) score with the Enhanced Liver Fibrosis (ELF) test to improve diagnostic accuracy and minimize unnecessary liver biopsies. However, few real-world studies have used such a sequential approach. We here evaluated the diagnostic accuracy of the ELF test in patients with recently established metabolic dysfunction-associated steatotic liver disease (MASLD) and assessed the clinical utility of applying a two-step strategy, including the ELF test following the FIB-4 score assessment, in patients with MASLD. Methods: We enrolled 153 patients diagnosed with MASLD who underwent liver biopsy at the Dong-A University Hospital between June 2018 and August 2023. The degree of fibrosis was determined based on liver biopsy results. Various NITs were used, including the Aminotransferase-to-Platelet Ratio Index (APRI), FIB-4 score, NAFLD Fibrosis score (NFS) and ELF test. The diagnostic efficacy of these NITs was evaluated based on the area under the receiver operating characteristic curve (AUROC). Additionally, the performance of each test was further examined both when applied individually and in a two-step approach, where FIB-4 was used followed by ELF testing. Key metrics such as sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy were used for this analysis. Results: Overall, 153 patients with MASLD (mean age: 46.62 years; 52.3% men; 28.1% with type 2 diabetes) were included. The performance of the NITs in identifying advanced fibrosis was as follows: the AUROC of the APRI, FIB-4, NFS, and ELF tests were 0.803 (95% confidence interval (CI), 0.713-0.863), 0.769 (95% CI, 0.694-0.833), 0.699 (95% CI, 0.528-0.796), and 0.829 (95% CI, 0.760-0.885), respectively. The combination of the FIB-4 score ≥ 1.30 and the ELF score ≥ 9.8 showed 67.86% sensitivity, 90.40% specificity, a PPV of 75.18%, an NPV of 86.78%, an accuracy of 83.64%, and an AUROC of 0.791 for predicting the diagnosis of advanced fibrosis. This approach excluded 28 patients (71.8%) from unnecessary liver biopsies. Conclusions: Our study demonstrated that ELF testing maintained diagnostic accuracy in assessing liver fibrosis in patients with MASLD in real-world practice. This test was used as a second step in the evaluation, reducing clinically unnecessary invasive liver biopsies and referrals to tertiary institutions. This approach allows assessment of MASLD severity in primary care settings without requiring additional equipment.

NAFLD in the 21st Century: Current Knowledge Regarding Its Pathogenesis, Diagnosis and Therapeutics

Non-alcoholic fatty liver disease (NAFLD) is a major public health issue worldwide. It is the most common liver disease in Western countries, andits global prevalence is estimated to be up to 35%. However, its diagnosis may be elusive, because liver biopsy is relatively rarely performed and usually only in advanced stages of the disease. Therefore, several non-invasive scores may be applied to more easily diagnose and monitor NAFLD. In this review, we discuss the various biomarkers and imaging scores that could be useful in diagnosing and managing NAFLD. Despite the fact that general measures, such as abstinence from alcohol and modulation of other cardiovascular disease risk factors, should be applied, the mainstay of prevention and management is weight loss. Bariatric surgery may be suggested as a means to confront NAFLD. In addition, pharmacological treatment with GLP-1 analogues or the GIP agonist tirzepatide may be advisable. In this review, we focus on the utility of GLP-1 analogues and GIP agonists in lowering body weight, their pharmaceutical potential, and their safety profile, as already evidenced inanimal and human studies. We also elaborate on other options, such as the use of vitamin E, probiotics, especially next-generation probiotics, and prebiotics in this context. Finally, we explore future perspectives regarding the administration of GLP-1 analogues, GIP agonists, and probiotics/prebiotics as a means to prevent and combat NAFLD. The newest drugs pegozafermin and resmetiron, which seem to be very promising, arealso discussed.

The effect of soy isoflavones on non-alcoholic fatty liver disease and the level of fibroblast growth factor-21 and fetuin A

A two-arm randomized open labeled controlled clinical trial was conducted on 50 patients with non-alcoholic fatty liver disease (NAFLD). Subjects were randomized to either receive two tablets of soy isoflavone (100 mg/day) or placebo. At week 12, the serum levels of alanine amino transferase (ALT), aspartate amino transferase (AST) and controlled attenuation parameter (CAP) score were significantly decreased only in the soy isoflavone group (P < 0.05). A significant decline in the gamma glutamyl transferase (GGT) level was observed only in the placebo group (P = 0.017). A significant increase in the serum level of fetuin A was shown in both groups at the end of the trial with a significantly greater increment in the soy isoflavone group compared to the placebo group (P < 0.05). The changes in the serum level of FGF-21 were not significant in any of the two groups. Steatosis grade significantly improved only in the soy isoflavone group (P = 0.045). There was no significant change in the fibrosis grade in the groups. Soy isoflavone intake led to a decrease in ALT, AST, CAP score, steatosis grade and an increase in the level of fetuin A. However, no significant changes were observed in the fibrosis grade and serum levels of GGT and FGF-21.

Application and Diagnostic Performance of Two-Dimensional Shear Wave Elastography and Liver Fibrosis Scores in Adults with Class 3 Obesity

There are no ideal non-invasive tests for assessing the severity of liver fibrosis in people with metabolic dysfunction-associated steatotic liver disease (MASLD) and class 3 obesity, where body habitus often makes imaging technically challenging. This study aimed to assess the applicability and diagnostic performance of two-dimensional shear wave elastography (2D-SWE), alongside several serum-based liver fibrosis scoring methods, in individuals with class 3 obesity. A cross-sectional study was conducted in patients aged ≥18 years and with a body mass index (BMI) ≥ 40 kg/m2 who were participants in a publicly funded multidisciplinary weight management program in South Western Sydney. The 2D-SWE was performed using the ElastQ Imaging (EQI) procedure with the Phillips EPIQ Elite series ultrasound. An EQI Median value of ≥6.43 kPa was taken as a cutoff score for significant fibrosis, and the scan was considered valid when the liver EQI IQR/Med value was <30%. The Fibrosis-4 (FIB-4) index, AST-to-platelet ratio index (APRI), NAFLD fibrosis score (NFS), and circulating fibroblast activation protein index (FAP index) were calculated from fasting blood samples. The participants (n = 116; 67.2% female) were aged 47.2 ± 12.9 years, with BMI 54.5 ± 11.0 kg/m2. EQI Median values were obtained for 97.4% (113/116) of the 2D-SWE scans, and 91.4% (106/116) of the scans were considered valid. The EQI Median values exhibited a moderately positive correlation with the FIB-4 index (r = 0.438; p < 0.001) and a weakly positive correlation with the APRI (r = 0.388; p < 0.001), NFS (r = 0.210; p = 0.036) and FAP index (r = 0.226; p = 0.020). All liver fibrosis scores were positively correlated with one another. Among those referred for a liver biopsy based on the 2D-SWE and serum scores, half (11/22) underwent liver biopsy, and their 2D-SWE scores exhibited 72.7% accuracy (sensitivity: 71.4%; specificity: 75%) in detecting significant fibrosis. Our results show that 2D-SWE is a feasible, non-invasive test to assess liver fibrosis among people with class 3 obesity. Further research is needed to assess how 2D-SWE can be used alongside existing serum-based risk scores to reliably detect significant fibrosis, which would potentially reduce the need for invasive liver biopsy.

The Association between Advanced Liver Fibrosis and Mortality Is Modified by Dietary Quality among Korean Adults: Results from the Korea National Health and Nutrition Examination Survey with Mortality Data

Advanced fibrosis in nonalcoholic fatty liver disease (NAFLD) is associated with an increased risk of mortality; however, an independent association of liver fibrosis with mortality is not well defined. We aimed to investigate the association between advanced liver fibrosis and all-cause and cardiovascular mortality and the mediation effect of diet quality. We analyzed 35,531 participants with suspected NAFLD, excluding competing etiologies of chronic liver disease, from the Korea National Health and Nutrition Examination Survey 2007-2015, and followed up until 31 December 2019. The severity of liver fibrosis was assessed using the NAFLD fibrosis score (NFS) and the fibrosis-4 index (FIB-4). The Cox proportional hazards model was used to examine the association of advanced liver fibrosis with mortality. During a mean 8.1 years of follow-up, 3426 deaths occurred. Advanced liver fibrosis determined by NFS and FIB-4 was associated with increased risks of all-cause and cardiovascular mortality after adjusting for confounders. When NFS and FIB-4 were combined, the high NFS + high FIB-4 group was significantly associated with higher risks of all-cause mortality (hazard ratio [HR] 1.85, 95% CI 1.42-2.43) and cardiovascular mortality (HR 2.04, 95% CI 1.23-3.39), respectively, compared with the low NFS + low FIB-4 group. However, these associations were attenuated in people with high diet quality. Advanced liver fibrosis is an independent risk factor for all-cause and cardiovascular mortality in people with NAFLD, and the association between advanced liver fibrosis and mortality is modified by a high-quality diet.