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Wang L, Pan Y, Ye X, Zhu Y, Lian Y, Zhang H, Xu M, Liu M, Ruan X. Perirenal fat thickness and liver fat fraction are independent predictors of MetS in adults with overweight and obesity suspected with NAFLD: a retrospective study. Diabetol Metab Syndr 2023; 15:56. [PMID: 36949492 PMCID: PMC10035216 DOI: 10.1186/s13098-023-01033-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Accepted: 03/15/2023] [Indexed: 03/24/2023] Open
Abstract
BACKGROUND Nonalcoholic fatty liver disease (NAFLD) has a multidirectional relationship with metabolic syndrome (MetS) and used to be considered a hepatic manifestation of MetS. Perirenal fat, as a part of visceral adipose tissue (VAT), was reported to be correlated with MetS components, but data for intraorgan fat are lacking. This study was undertaken to assess the value of peripheral and intraorgan fat to predict MetS in adults with overweight and obesity with suspected NAFLD. METHODS We studied 134 sequential adults (mean age, 31.5 years; 47% female) with overweight and obesity with suspected NAFLD. All participants underwent abdominal magnetic resonance imaging (MRI) examination. Anthropometric and metabolic parameters and perirenal fat thickness (PRFT), subcutaneous adipose tissue thickness (SATT), liver fat fraction (LFF), pancreas fat fraction (PFF), and lumbar spine fat fraction (LSFF) were collected. MetS was defined according to the International Diabetes Federation (IDF) criteria. Statistical analyses included basic statistics, linear correlation and logistic regression analysis. RESULTS A total of 63 adults with MetS and 71 adults with advanced liver steatosis (grades 2 and 3) were included in our study. Patients with MetS had greater PRFT (p = 0.026) and LFF (p < 0.001), as well as greater homeostasis model assessment of insulin resistance (HOMA-IR), alanine transaminase (ALT), aspartate transaminase (AST), and decreased SATT. MetS patients had a higher proportion of advanced steatosis than those without MetS (P < 0.001). The MetS score was associated with PRFT and LFF. Logistic regression analysis showed that the PRFT and LFF were independent predictors of MetS after adjusting for age and sex. A cutoff of 9.15 mm for PRFT and 14.68% for LFF could be predictive of MetS. CONCLUSIONS This study shows that the absolute cutoff level of 9.15 mm for PRFT and 14.68% for LFF may be clinically important markers for identifying patients who are at high risk of MetS among adults with overweight and obesity with suspected NAFLD, irrespective of sex and age. Moreover, ectopic fat levels in pancreas and lumbar spine are positively associated with PRFT. TRIAL REGISTRATION Not applicable.
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Affiliation(s)
- Li Wang
- Department of Radiology, Ningbo First Hospital, No. 59, Liuting Street, Haishu District, Ningbo, Zhejiang 315010 China
| | - Yuning Pan
- Department of Radiology, Ningbo First Hospital, No. 59, Liuting Street, Haishu District, Ningbo, Zhejiang 315010 China
| | - Xianwang Ye
- Department of Radiology, Ningbo First Hospital, No. 59, Liuting Street, Haishu District, Ningbo, Zhejiang 315010 China
| | - Yongmeng Zhu
- Department of Radiology, Ningbo First Hospital, No. 59, Liuting Street, Haishu District, Ningbo, Zhejiang 315010 China
| | - Yandong Lian
- Department of Radiology, Ningbo First Hospital, No. 59, Liuting Street, Haishu District, Ningbo, Zhejiang 315010 China
| | - Hui Zhang
- Department of Radiology, Ningbo First Hospital, No. 59, Liuting Street, Haishu District, Ningbo, Zhejiang 315010 China
| | - Miao Xu
- Department of Endocrinology, Ningbo First Hospital, No. 59, Liuting Street, Haishu District, Ningbo, Zhejiang 315010 China
| | - Mengxiao Liu
- MR Collaborations, Siemens healthineers, No.278, Zhouzhu Road, Pudong New District, Shanghai, 200090 China
| | - Xinzhong Ruan
- Department of Radiology, Ningbo First Hospital, No. 59, Liuting Street, Haishu District, Ningbo, Zhejiang 315010 China
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Kim HN, Jeon HJ, Choi HG, Kwon IS, Rou WS, Lee JE, Lee TH, Kim SH, Lee BS, Shin KS, Lee HJ, Eun HS. CT-based Hounsfield unit values reflect the degree of steatohepatitis in patients with low-grade fatty liver disease. BMC Gastroenterol 2023; 23:77. [PMID: 36932382 PMCID: PMC10022198 DOI: 10.1186/s12876-023-02717-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2022] [Accepted: 03/09/2023] [Indexed: 03/19/2023] Open
Abstract
BACKGROUND/AIMS Nonalcoholic fatty liver disease (NAFLD) is the most common liver disease worldwide. Ultrasound, the most used tool for diagnosing NAFLD, is operator-dependent and shows suboptimal performance in patients with mild steatosis. However, few studies have been conducted on whether alternative noninvasive methods are useful for diagnosing mild hepatic steatosis. Also, little is known about whether noninvasive tests are useful for grading the severity of hepatic steatosis or the degree of intrahepatic inflammation. Therefore, we aimed to evaluate whether the HSI, the FLI and HU values in CT could be used to discriminate mild hepatic steatosis and to evaluate the severity of hepatic steatosis or the degree of intrahepatic inflammation in patients with low-grade fatty liver disease using liver biopsy as a reference standard. METHODS Demographic, laboratory, CT imaging, and histological data of patients who underwent liver resection or biopsy were analyzed. The performance of the HSI, HU values and the FLI for diagnosing mild hepatic steatosis was evaluated by calculating the area under the receiver operating characteristic curve. Whether the degree of hepatic steatosis and intrahepatic inflammation could be predicted using the HSI, HU values or the FLI was also analyzed. Moreover, we validate the results using magnetic resonance imaging proton density fat fraction as an another reference standard. RESULTS The AUROC for diagnosing mild hepatic steatosis was 0.810 (p < 0.001) for the HSI, 0.732 (p < 0.001) for liver HU value, 0.802 (p < 0.001) for the difference between liver and spleen HU value (L-S HU value) and 0.813 (p < 0.001) for the FLI. Liver HU and L-S HU values were negatively correlated with the percentage of hepatic steatosis and NAFLD activity score (NAS) and significantly different between steatosis grades and between NAS grades. The L-S HU value was demonstrated the good performance for grading the severity of hepatic steatosis and the degree of intrahepatic inflammation. CONCLUSIONS The HU values on CT are feasible for stratifying hepatic fat content and evaluating the degree of intrahepatic inflammation, and the HSI and the FLI demonstrated good performance with high sensitivity and specificity in diagnosing mild hepatic steatosis.
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Affiliation(s)
- Ha Neul Kim
- Department of Medical Sciences, Chungnam National University, 266 Munwha-Ro, Jung-Gu, Daejeon, 35015, Republic of Korea
- Brain Korea 21 FOUR Project for Medical Science, Chungnam National University, 266 Munwha-ro, Jung-gu, Daejeon, 35015, Republic of Korea
| | - Hong Jae Jeon
- Department of Internal Medicine, Chungnam National University Sejong Hospital, 20, Bodeum 7-Ro, Sejong, 30099, Republic of Korea
- Department of Internal Medicine, Chungnam National University School of Medicine, 266 Munwha-Ro, Jung-Gu, Daejeon, 35015, Republic of Korea
| | - Hei Gwon Choi
- Brain Korea 21 FOUR Project for Medical Science, Chungnam National University, 266 Munwha-ro, Jung-gu, Daejeon, 35015, Republic of Korea
- Research Institute of Medical Sciences, Chungnam National University School of Medicine, 266 Munwha-Ro, Jung-Gu, Daejeon, 35015, Republic of Korea
| | - In Sun Kwon
- Statistical Consultation of Clinical Trials Center, Chungnam National University Hospital, 266 Munwha-Ro, Jung-Gu, Daejeon, 35015, Republic of Korea
| | - Woo Sun Rou
- Department of Internal Medicine, Chungnam National University Sejong Hospital, 20, Bodeum 7-Ro, Sejong, 30099, Republic of Korea
- Department of Internal Medicine, Chungnam National University School of Medicine, 266 Munwha-Ro, Jung-Gu, Daejeon, 35015, Republic of Korea
| | - Jeong Eun Lee
- Department of Radiology, Chungnam National University Hospital, 282 Munwha-Ro, Jung-Gu, Daejeon, 35015, Republic of Korea
- Department of Radiology, Chungnam National University School of Medicine, 266 Munwha-Ro, Jung-Gu, Daejeon, 35015, Republic of Korea
| | - Tae Hee Lee
- Department of Biomedical Laboratory Science, Daegu Health College, Chang-Ui Building, 15 Yeongsong-Ro, Buk-Gu, Daegu, 41453, Republic of Korea
| | - Seok Hyun Kim
- Department of Internal Medicine, Chungnam National University School of Medicine, 266 Munwha-Ro, Jung-Gu, Daejeon, 35015, Republic of Korea
- Department of Internal Medicine, Chungnam National University Hospital, 282 Munwha-Ro, Jung-Gu, Daejeon, 35015, Republic of Korea
| | - Byung Seok Lee
- Department of Internal Medicine, Chungnam National University School of Medicine, 266 Munwha-Ro, Jung-Gu, Daejeon, 35015, Republic of Korea
- Department of Internal Medicine, Chungnam National University Hospital, 282 Munwha-Ro, Jung-Gu, Daejeon, 35015, Republic of Korea
| | - Kyung Sook Shin
- Department of Radiology, Chungnam National University Hospital, 282 Munwha-Ro, Jung-Gu, Daejeon, 35015, Republic of Korea
- Department of Radiology, Chungnam National University School of Medicine, 266 Munwha-Ro, Jung-Gu, Daejeon, 35015, Republic of Korea
| | - Hyun Jung Lee
- Department of Pathology, Chungnam National University Hospital, 282 Munwha-Ro, Jung-Gu, Daejeon, 35015, Republic of Korea.
- Department of Pathology, Chungnam National University School of Medicine, 266 Munwha-Ro, Jung-Gu, Daejeon, 35015, Republic of Korea.
| | - Hyuk Soo Eun
- Department of Internal Medicine, Chungnam National University School of Medicine, 266 Munwha-Ro, Jung-Gu, Daejeon, 35015, Republic of Korea.
- Department of Internal Medicine, Chungnam National University Hospital, 282 Munwha-Ro, Jung-Gu, Daejeon, 35015, Republic of Korea.
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Zambon Azevedo V, Silaghi CA, Maurel T, Silaghi H, Ratziu V, Pais R. Impact of Sarcopenia on the Severity of the Liver Damage in Patients With Non-alcoholic Fatty Liver Disease. Front Nutr 2022; 8:774030. [PMID: 35111794 PMCID: PMC8802760 DOI: 10.3389/fnut.2021.774030] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2021] [Accepted: 12/21/2021] [Indexed: 12/12/2022] Open
Abstract
An extensive body of the literature shows a strong interrelationship between the pathogenic pathways of non-alcoholic fatty liver disease (NAFLD) and sarcopenia through the muscle-liver-adipose tissue axis. NAFLD is one of the leading causes of chronic liver diseases (CLD) affecting more than one-quarter of the general population worldwide. The disease severity spectrum ranges from simple steatosis to non-alcoholic steatohepatitis (NASH), cirrhosis, and its complications: end-stage chronic liver disease and hepatocellular carcinoma. Sarcopenia, defined as a progressive loss of the skeletal muscle mass, reduces physical performances, is associated with metabolic dysfunction and, possibly, has a causative role in NAFLD pathogenesis. Muscle mass is a key determinant of the whole-body insulin-mediated glucose metabolism and impacts fatty liver oxidation and energy homeostasis. These mechanisms drive the accumulation of ectopic fat both in the liver (steatosis, fatty liver) and in the muscle (myosteatosis). Myosteatosis rather than the muscle mass per se, seems to be closely associated with the severity of the liver injury. Sarcopenic obesity is a recently described entity which associates both sarcopenia and obesity and may trigger worse clinical outcomes including hepatic fibrosis progression and musculoskeletal disabilities. Furthermore, the muscle-liver-adipose tissue axis has a pivotal role in changes of the body composition, resulting in a distinct clinical phenotype that enables the identification of the "sarcopenic NAFLD phenotype." This review aims to bring some light into the complex relationship between sarcopenia and NAFLD and critically discuss the key mechanisms linking NAFLD to sarcopenia, as well as some of the clinical consequences associated with the coexistence of these two entities: the impact of body composition phenotypes on muscle morphology, the concept of sarcopenic obesity, the relationship between sarcopenia and the severity of the liver damage and finally, the future directions and the existing gaps in the knowledge.
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Affiliation(s)
- Vittoria Zambon Azevedo
- Doctoral School Physiology, Physiopathology and Therapeutics 394, Sorbonne Université, Paris, France
- Centre de Recherche de Cordeliers, INSERM UMRS 1138, Paris, France
| | - Cristina Alina Silaghi
- Department of Endocrinology, “Iuliu Hatieganu” University of Medicine and Pharmacy Cluj-Napoca, Cluj-Napoca, Romania
| | - Thomas Maurel
- Institute of Cardiometabolism and Nutrition, Paris, France
- Assistance Publique Hôpitaux de Paris, Hôpital Pitié-Salpêtrière, Paris, France
| | - Horatiu Silaghi
- Department of Surgery V, “Iuliu Hatieganu” University of Medicine and Pharmacy Cluj-Napoca, Cluj-Napoca, Romania
| | - Vlad Ratziu
- Centre de Recherche de Cordeliers, INSERM UMRS 1138, Paris, France
- Institute of Cardiometabolism and Nutrition, Paris, France
- Assistance Publique Hôpitaux de Paris, Hôpital Pitié-Salpêtrière, Paris, France
- Sorbonne Université, Paris, France
| | - Raluca Pais
- Institute of Cardiometabolism and Nutrition, Paris, France
- Assistance Publique Hôpitaux de Paris, Hôpital Pitié-Salpêtrière, Paris, France
- Sorbonne Université, Paris, France
- Centre de Recherche Saint Antoine, INSERM UMRS 938, Paris, France
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Non-invasive diagnosis and follow-up of non-alcoholic fatty liver disease. Clin Res Hepatol Gastroenterol 2022; 46:101769. [PMID: 34332133 DOI: 10.1016/j.clinre.2021.101769] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2021] [Accepted: 07/23/2021] [Indexed: 02/04/2023]
Abstract
NAFLD is a frequent disease that affects 25% of the worldwide population. There is no specific diagnostic test for NAFLD, and the diagnosis mainly relies on the elimination of the other causes of chronic liver diseases with liver biopsy kept for unsure diagnoses. Non-invasive tests are now available to assess NAFLD severity and therefore to help physicians decide on the patient management and follow-up. These non-invasive tests can also be used to define pathways that organize referrals from primary care and diabetology clinics to the liver specialist, with the ambition to improve the screening of asymptomatic patients with NAFLD and advanced liver disease. NAFLD being the liver expression of the metabolic syndrome, physicians need also take care to screen for diabetes and to evaluate the cardiovascular risk in those patients. These recommendations from the French Association for the Study of the Liver (AFEF) aim at providing guidance on the following questions: how to diagnose NAFLD; how non-invasive tests should be used to assess NAFLD severity; how to follow patients with NAFLD; when to perform liver biopsy in NAFLD; and how to decide referral to the liver specialist for a patient with NAFLD.
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Lind L, Strand R, Michaëlsson K, Ahlström H, Kullberg J. Voxel-wise Study of Cohort Associations in Whole-Body MRI: Application in Metabolic Syndrome and Its Components. Radiology 2019; 294:559-567. [PMID: 31891319 DOI: 10.1148/radiol.2019191035] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Background The metabolic syndrome is related to obesity and ectopic fat distribution. Purpose To investigate whether an image analysis approach that uses image registration for whole-body voxel-wise analysis could provide additional information about the relationship between metabolic syndrome and body composition compared with traditional image analysis. Materials and Methods Whole-body quantitative water-fat MRI was performed in a population-based prospective study on obesity, energy, and metabolism between October 2010 and November 2016. Fat mass was measured with dual-energy x-ray absorptiometry (DXA). Whole-body voxel-wise analysis of tissue volume and fat content was applied in more than 2 million voxels from the whole-body examinations by automated interindividual deformable image registration of the water and fat MRI data. Metabolic syndrome was diagnosed by the harmonized National Cholesterol Education Program criteria. Two-tailed t tests were used and P values less than .05 were considered to indicate statistical significance. Results This study evaluated 167 women and 159 men (mean age, 50 years) by using voxel-wise analysis. Metabolic syndrome (13.5%; 44 of 326) was related to traditional measurements of fat distribution, such as total fat mass at DXA, visceral and subcutaneous adipose tissue, and liver and pancreatic fat at MRI. Voxel-wise analysis found metabolic syndrome related to liver, heart, and perirenal fat volume; fat content in subcutaneous fat in the hip region in both sexes; fatty infiltration of leg muscles in men, especially in gluteus maximus; and pericardial and aortic perivascular fat mainly in women. Sex differences in associations with subcutaneous adipose tissue were identified. In women, metabolic syndrome diagnosis was linked to regional differences in associations to adipose tissue volumes in upper versus lower body, and dorsal versus ventral abdominal depots. In men similar gradients were only seen in individual components. Conclusion In addition to showing the relationships between metabolic syndrome and body composition in a detailed and intuitive fashion in the whole body, the voxel-wise analysis provided additional information compared with traditional image analysis. © RSNA, 2020 Online supplemental material is available for this article.
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Affiliation(s)
- Lars Lind
- From the Department of Medical Sciences (L.L.), Section of Radiology, Department of Surgical Sciences (R.S., H.A., J.K.), and Department of Surgical Sciences (K.M.), Uppsala University, Uppsala Academic Hospital, Entrance 24, 751 85 Uppsala, Sweden; and Antaros Medical AB, BioVenture Hub, Mölndal, Sweden (H.A., J.K.)
| | - Robin Strand
- From the Department of Medical Sciences (L.L.), Section of Radiology, Department of Surgical Sciences (R.S., H.A., J.K.), and Department of Surgical Sciences (K.M.), Uppsala University, Uppsala Academic Hospital, Entrance 24, 751 85 Uppsala, Sweden; and Antaros Medical AB, BioVenture Hub, Mölndal, Sweden (H.A., J.K.)
| | - Karl Michaëlsson
- From the Department of Medical Sciences (L.L.), Section of Radiology, Department of Surgical Sciences (R.S., H.A., J.K.), and Department of Surgical Sciences (K.M.), Uppsala University, Uppsala Academic Hospital, Entrance 24, 751 85 Uppsala, Sweden; and Antaros Medical AB, BioVenture Hub, Mölndal, Sweden (H.A., J.K.)
| | - Håkan Ahlström
- From the Department of Medical Sciences (L.L.), Section of Radiology, Department of Surgical Sciences (R.S., H.A., J.K.), and Department of Surgical Sciences (K.M.), Uppsala University, Uppsala Academic Hospital, Entrance 24, 751 85 Uppsala, Sweden; and Antaros Medical AB, BioVenture Hub, Mölndal, Sweden (H.A., J.K.)
| | - Joel Kullberg
- From the Department of Medical Sciences (L.L.), Section of Radiology, Department of Surgical Sciences (R.S., H.A., J.K.), and Department of Surgical Sciences (K.M.), Uppsala University, Uppsala Academic Hospital, Entrance 24, 751 85 Uppsala, Sweden; and Antaros Medical AB, BioVenture Hub, Mölndal, Sweden (H.A., J.K.)
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Liao YY, Yeh CK, Huang KC, Tsui PH, Yang KC. Metabolic Characteristics of a Novel Ultrasound Quantitative Diagnostic Index for Nonalcoholic Fatty Liver Disease. Sci Rep 2019; 9:7922. [PMID: 31138858 PMCID: PMC6538602 DOI: 10.1038/s41598-019-44453-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2018] [Accepted: 05/14/2019] [Indexed: 02/06/2023] Open
Abstract
Nonalcoholic fatty liver disease (NAFLD) is an emerging epidemic worldwide and is regarded as a hepatic manifestation of metabolic syndrome (MetS). Only a few studies have discussed the biological features associated with quantitative assessment of ultrasound for characterizing NAFLD. Our aim was to delineate relevant metabolic characteristics using a new quantitative tool, the ultrasound quantitative diagnostic index (QDI). A total of 394 ultrasound data were analyzed to extract texture-feature parameters, the signal-to-noise ratio (SNR), and the slope of the center frequency downshift (CFDS) for determining the QDI. The texture index, SNR, and CFDS slope were all negatively correlated with high-density lipoprotein and positively correlated with other anthropometric indices and metabolic factors (all P < 0.05). The SNR had the greatest contribution to anthropometric and biochemical factors, followed by the texture index and CFDS slope. An increase in 1 unit of QDI score engendered a 9% higher risk of MetS, reflecting that the tool is feasible for use in identifying MetS (area under the receiver operating characteristic curve: 0.89). The QDI was correlated with metabolic factors and an independent predictor for MetS. Thus, this QDI might be a feasible method for use in clinical surveillance, epidemiology research, and metabolic function evaluations in patients with NAFLD.
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Affiliation(s)
- Yin-Yin Liao
- Department of Biomedical Engineering, Hungkuang University, Taichung, Taiwan
| | - Chih-Kuang Yeh
- Department of Biomedical Engineering and Environmental Sciences, National Tsing Hua University, Hsinchu, Taiwan
| | - Kuo-Chin Huang
- Department of Family Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan
- Department of Family Medicine, National Taiwan University Hospital, Taipei, Taiwan
- Department of Family Medicine, National Taiwan University Hospital, BeiHu Branch, Taipei, Taiwan
| | - Po-Hsiang Tsui
- Department of Medical Imaging and Intervention, Chang Gung Memorial Hospital at Linkou, Taoyuan, Taiwan
- Department of Medical Imaging and Radiological Sciences, College of Medicine, Chang Gung University, Taoyuan, Taiwan
- Medical Imaging Research Center, Institute for Radiological Research, Chang Gung University and Chang Gung Memorial Hospital at Linkou, Taoyuan, Taiwan
| | - Kuen-Cheh Yang
- Department of Family Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan.
- Department of Family Medicine, National Taiwan University Hospital, BeiHu Branch, Taipei, Taiwan.
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Zhang Y, Wang C, Duanmu Y, Zhang C, Zhao W, Wang L, Cheng X, Veronese N, Guglielmi G. Comparison of CT and magnetic resonance mDIXON-Quant sequence in the diagnosis of mild hepatic steatosis. Br J Radiol 2018; 91:20170587. [PMID: 30028193 PMCID: PMC6475942 DOI: 10.1259/bjr.20170587] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2017] [Revised: 07/09/2018] [Accepted: 07/11/2018] [Indexed: 12/16/2022] Open
Abstract
OBJECTIVE: To determine the diagnostic performance of CT in the assessment of mild hepatic steatosis by comparison with MR mDIXON-Quant as a reference standard, and to explore their clinical applications. METHODS: In this prospective study 169 volunteers were included. Each subject underwent CT and MR mDIXON-Quant examinations. Hepatic steatosis evaluations were performed via liver attenuation alone (CT L), liver to spleen attenuation ratio (CT L/S), difference between liver and spleen attenuation (CT L-S), and MR mDIXON-Quant imaging. The effectiveness of CT L, CT L/S, and CT L-S in diagnosing hepatic steatosis severity of ≥5%, ≥10%, and ≥15% was compared, using mDIXON-Quant results as standard. RESULTS: 65 subjects exhibited mild hepatic steatosis. Hepatic steatosis measurement with mDIXON-Quant was strongly correlated with the three CT methods. Using cutoff value, the sensitivity and specificity of diagnosing hepatic steatosis ≥5, ≥10, and ≥15% were 64.6, 91.3, 100%, and 90.4, 89.7, 93.0% for CT L; 50.8, 87.0, 100%, and 96.2, 98.6, 97.5% for CT L/S; and 67.7, 87.0, 100%, and 81.7, 98.6, 97.5% for CT L-S, respectively. ROC analysis indicated that 58.9, 56.5, and 52.8 HU for CT L; 1.06, 0.98, and 0.90 HU for CT L/S; and 6.21,-1.04, and -4.93 HU for CT L-S were cutoff values for diagnosing hepatic steatosis ≥5%,≥10%, and ≥15%, respectively. CONCLUSIONS: The three CT methods exhibit better agreements with mDIXON-Quant imaging for diagnosing hepatic steatosis ≥10%. Hence, CT and mDIXON-Quant could serve as suitable tools for the accurate quantification of mild hepatic steatosis. SIGNIFICANT FINDS OF THE STUDY: The close agreement between the three different CT methods (based on our cutoff values) and mDIXON-Quant imaging suggests that CT could accurately diagnose hepatic steatosis ≥10%. Thus, CT and mDIXON-Quant imaging can accurately measure mild hepatic steatosis. WHAT THIS STUDY ADDS: Only few studies have compared hepatic steatosis quantification between CT and mDIXON-Quant. We are the first to determine the diagnostic performance of unenhanced CT for quantitatively assessing mild hepatic steatosis, in reference to magnetic resonance mDIXON-Quant imaging.
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Affiliation(s)
- Yong Zhang
- Radiology Department of The Fourth Clinical Medical College of Peking University (Beijing Jishuitan Hospital), Beijing, China
| | - Chao Wang
- Department of Orthopedics, Beijing Institute of Traumatology and Orthopedics, Beijing, China
| | - Yangyang Duanmu
- Radiology Department of The Fourth Clinical Medical College of Peking University (Beijing Jishuitan Hospital), Beijing, China
| | - Chenxin Zhang
- Radiology Department of The Fourth Clinical Medical College of Peking University (Beijing Jishuitan Hospital), Beijing, China
| | - Wei Zhao
- Radiology Department of The Fourth Clinical Medical College of Peking University (Beijing Jishuitan Hospital), Beijing, China
| | - Ling Wang
- Radiology Department of The Fourth Clinical Medical College of Peking University (Beijing Jishuitan Hospital), Beijing, China
| | - Xiaoguang Cheng
- Radiology Department of The Fourth Clinical Medical College of Peking University (Beijing Jishuitan Hospital), Beijing, China
| | - Nicola Veronese
- Department of Geriatric, National Research Council, Neuroscience Institute, Aging Branch, Padova, Italy
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Lorbeer R, Bayerl C, Auweter S, Rospleszcz S, Lieb W, Meisinger C, Heier M, Peters A, Bamberg F, Hetterich H. Association between MRI-derived hepatic fat fraction and blood pressure in participants without history of cardiovascular disease. J Hypertens 2017; 35:737-744. [PMID: 28253218 DOI: 10.1097/hjh.0000000000001245] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
OBJECTIVES We assessed whether liver fat content, as determined by MRI, correlates with blood pressure (BP), a major vascular risk factor, in individuals from the general population without history of stroke and coronary or peripheral artery disease. METHODS Cross-sectional data from 384 participants (161 women; aged 39-73 years) of a MRI substudy of the KORA FF4 survey were used. Hepatic fat fraction (HFF) was measured in the left and right lobe of the liver using single voxel multiecho H-spectroscopy and at the level of the portal vein using a multiecho Dixon-sequence. Associations of HFF with SBP and DBP as well as hypertension were assessed by right censored normal regression (accounting for antihypertensive treatment) and by logistic regression, respectively. RESULTS High levels of HFF measured on the level of the portal vein (90th percentile, 21.8%), compared with low HFF levels (10th percentile, 1.7%), were associated with higher SBP (131 vs. 122 mmHg; overall P = 0.001), higher DBP (82 vs. 76 mmHg, P < 0.001) and with higher odds of hypertension [odds ratio (OR) = 2.16, P = 0.025]. A level of 5.13% (54th percentile) was identified as optimal HFF cut-off for the prediction of hypertension (OR = 2.00, P = 0.015). Alcohol consumption emerged as an effect modifier for the association between HFF and hypertension (nonalcohol drinker: OR = 3.76, P = 0.025; alcohol drinker: OR = 1.59, P = 0.165). CONCLUSION MRI-derived subclinical HFF is associated with SBP and DBP as well as with hypertension in participants from the general population without history of cardiovascular disease.
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Affiliation(s)
- Roberto Lorbeer
- aInstitute of Clinical Radiology, Ludwig Maximilian University Hospital, MunichbInstitute of Epidemiology II, Helmholtz Zentrum München, NeuherbergcInstitute of Epidemiology, Christian Albrecht University, KieldKORA Myocardial Infarction Registry, Central Hospital of Augsburg, AugsburgeGerman Center for Diabetes Research (DZD e.V.), NeuherbergfGerman Center for Cardiovascular Disease Research (DZHK e.V.), MunichgDepartment of Diagnostic and Interventional Radiology, Eberhard Karl University Tübingen, Tübingen, Germany
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Abstract
Hepatic steatosis is an underlying feature of nonalcoholic fatty liver disease (NAFLD), which is the most common form of liver disease and is present in up to ∼70% of individuals who are overweight. NAFLD is also associated with hypertriglyceridaemia and low levels of HDL, glucose intolerance, insulin resistance and type 2 diabetes mellitus. Hepatic steatosis is a strong predictor of the development of insulin resistance and often precedes the onset of other known mediators of insulin resistance. This sequence of events suggests that hepatic steatosis has a causal role in the development of insulin resistance in other tissues, such as skeletal muscle. Hepatokines are proteins that are secreted by hepatocytes, and many hepatokines have been linked to the induction of metabolic dysfunction, including fetuin A, fetuin B, retinol-binding protein 4 (RBP4) and selenoprotein P. In this Review, we describe the factors that influence the development of hepatic steatosis, provide evidence of strong links between hepatic steatosis and insulin resistance in non-hepatic tissues, and discuss recent advances in our understanding of how steatosis alters hepatokine secretion to influence metabolic phenotypes through inter-organ communication.
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Affiliation(s)
- Ruth C R Meex
- Monash Biomedicine Discovery Institute, Metabolic Disease and Obesity Program and the Department of Physiology, Monash University, Wellington Road, Clayton, Victoria 3800, Australia
- Department of Human Biology, School of Nutrition and Translational Research in Metabolism (NUTRIM), Maastricht University, Universiteitssingel 50, 6229 ER Maastricht, The Netherlands
| | - Matthew J Watt
- Monash Biomedicine Discovery Institute, Metabolic Disease and Obesity Program and the Department of Physiology, Monash University, Wellington Road, Clayton, Victoria 3800, Australia
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10
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Multifeature analysis of an ultrasound quantitative diagnostic index for classifying nonalcoholic fatty liver disease. Sci Rep 2016; 6:35083. [PMID: 27734972 PMCID: PMC5062088 DOI: 10.1038/srep35083] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2016] [Accepted: 09/26/2016] [Indexed: 12/11/2022] Open
Abstract
Nonalcoholic fatty liver disease (NAFLD) is a chronic liver disease related to metabolic syndrome. This study applied an integrated analysis based on texture, backscattering, and attenuation features in ultrasound imaging with the aim of assessing the severity of NAFLD. Ultrasound radiofrequency data obtained from 394 clinical cases were analyzed to extract three texture features (autocorrelation, sum average, and sum variance), the signal-to-noise ratio (SNR), and the slope of the center-frequency downshift (CFDS slope). The texture, SNR, and CFDS slope were combined to produce a quantitative diagnostic index (QDI) that ranged from 0 to 6. We trained the QDI using training data and then applied it to test data to assess its utility. In training data, the areas (AUCs) under the receiver operating characteristic curves for NAFLD and severe NAFLD were 0.81 and 0.84, respectively. In test data, the AUCs were 0.73 and 0.81 for NAFLD and severe NAFLD, respectively. The QDI was able to distinguish severe NAFLD and a normal liver from mild NAFLD, and it was significantly correlated with metabolic factors. This study explored the potential of using the QDI to supply information on different physical characteristics of liver tissues for advancing the ability to grade NAFLD.
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11
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Yang KC, Hung HF, Lu CW, Chang HH, Lee LT, Huang KC. Association of Non-alcoholic Fatty Liver Disease with Metabolic Syndrome Independently of Central Obesity and Insulin Resistance. Sci Rep 2016; 6:27034. [PMID: 27246655 PMCID: PMC4887873 DOI: 10.1038/srep27034] [Citation(s) in RCA: 83] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2016] [Accepted: 05/13/2016] [Indexed: 02/08/2023] Open
Abstract
Non-alcoholic fatty liver disease (NAFLD) is an emerging chronic liver disease that may lead to liver cirrhosis and hepatocellular carcinoma. We aimed to determine the association between the prevalence of metabolic syndrome (MetS) and NAFLD severity using semi-quantitative ultrasonography (US). A total of 614 participants were recruited from the community. NAFLD was evaluated according to the ultrasonographic Fatty Liver Indicator (US-FLI), which is a semi-quantitative liver ultrasound score. Insulin resistance was estimated with the homeostasis model assessment index for insulin resistance (HOMA-IR). NAFLD and MetS were found in 53.7 and 17.3% of the participants, respectively. Linear relationships were found between the severity of NAFLD and waist circumference, fasting glucose, HOMA-IR, triglycerides, HDL-C and blood pressure. After adjusting for confounding factors, i.e., body mass index and HOMA-IR, the odds ratios for MetS were 3.64 (95% confidence interval (CI): 1.5-8.83) for those with mild NAFLD and 9.4 (95% CI: 3.54-24.98) for those with moderate-to-severe NAFLD compared to those without NAFLD. The combination of the HOMA-IR and US-FLI scores better differentiated MetS than the HOMA-IR alone. In addition to obesity, the severity of NAFLD and the HOMA-IR both play important roles in MetS. Whether NAFLD is a component of MetS warrants further research.
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Affiliation(s)
- Kuen Cheh Yang
- Department of Community and Family Medicine, National Taiwan University Hospital Hsinchu Branch, Hsinchu City, Taiwan.,Department of Family Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Hui-Fang Hung
- Department of Community and Family Medicine, National Taiwan University Hospital Hsinchu Branch, Hsinchu City, Taiwan.,Department of Family Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Chia-Wen Lu
- Department of Family Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Hao-Hsiang Chang
- Department of Family Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Long-Teng Lee
- Department of Family Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Kuo-Chin Huang
- Department of Family Medicine, National Taiwan University Hospital, Taipei, Taiwan.,Department of Family Medicine, National Taiwan University Hospital Bei-Hu Branch, Taipei, Taiwan.,Department of Family Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan
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12
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Monseu M, Dubois S, Boursier J, Aubé C, Gagnadoux F, Lefthériotis G, Ducluzeau PH. Osteoprotegerin levels are associated with liver fat and liver markers in dysmetabolic adults. DIABETES & METABOLISM 2016; 42:364-367. [PMID: 27016890 DOI: 10.1016/j.diabet.2016.02.004] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/21/2015] [Revised: 02/18/2016] [Accepted: 02/24/2016] [Indexed: 12/11/2022]
Abstract
AIM This study aimed to determine the association between visceral adipose tissue (VAT), liver fat (LF) content, and other markers of the metabolic syndrome (MetS) and osteoprotegerin (OPG) in dysmetabolic adults. METHODS Subjects from the NUMEVOX cohort were included if they fulfilled at least one MetS criterion. They then underwent a thorough metabolic and cardiovascular evaluation, including arterial stiffness, atherosclerotic plaques, homoeostasis model assessment for insulin resistance (HOMA-IR) indices and OPG. VAT and LF content were measured by magnetic resonance imaging (MRI). Ultrasound examination of arteries and arterial stiffness were recorded, and age- and gender-adjusted paired correlations calculated. RESULTS Body mass index, waist circumference and MRI-derived VAT correlated with OPG, whereas abdominal subcutaneous fat did not. OPG levels were strongly correlated with LF content (r=0.25, P=0.003), liver markers such as alanine aminotransferase (r=0.39, P<0.001) and HOMA-IR index (r=0.39, P<0.0001). Plasma OPG also correlated with arterial stiffness and the number of atherosclerotic sites. CONCLUSION Plasma OPG levels are positively associated with both liver markers and increased LF content, but not with subcutaneous fat in dysmetabolic men. These findings suggest that elevated OPG levels may play a role in the link between fatty liver disease and enhanced cardiovascular risk.
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Affiliation(s)
- M Monseu
- Department of Internal Medicine, CHU Tours, 2, boulevard Tonnellé, Tours, France.
| | - S Dubois
- Department of Diabetology, CHU, Angers, France.
| | - J Boursier
- Department of Hepatology, CHU, Angers, France.
| | - C Aubé
- Department of Radiology, CHU, Angers, France.
| | - F Gagnadoux
- Department of Pneumology, CHU, Angers, France.
| | - G Lefthériotis
- Department of Vascular Explorations, CHU, Angers, France.
| | - P-H Ducluzeau
- Inserm UMR1069, "Nutrition, Growth and Cancer", CHRU Bretonneau, University of Tours, 37044 Tours, France.
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13
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Clinical and biochemical determinants of the extent of liver steatosis in type 2 diabetes mellitus. Eur J Gastroenterol Hepatol 2015; 27:1386-91. [PMID: 26398456 DOI: 10.1097/meg.0000000000000462] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
OBJECTIVE Nonalcoholic fatty liver disease is very frequent in both type 2 diabetes mellitus (T2DM) and the metabolic syndrome (MS), which share clinical and metabolic characteristics. Whether and to which extent these characteristics can predict the degree of liver steatosis are not entirely clear. PATIENTS AND METHODS We determined liver fat (divided into four classes) by standard sonographic images, and clinical and biochemical variables, in 60 consecutive patients with T2DM and with features of the MS. We examined both simple and multiple correlations between the degree of liver steatosis and the variables measured. RESULTS Increased liver fat (defined as >5% of liver mass) was detected in 88% of the participants. Using simple regression analysis, the class of steatosis correlated positively with BMI, waist, number of factors of the MS, sex (female>male), diastolic blood pressure, insulin resistance, metabolic control, inflammation, C-reactive protein, fibrinogen, and leptin, whereas it correlated negatively with high-density lipoprotein-cholesterol. Using multiple regression analysis, only metabolic control, insulin resistance and/or plasma insulin, and waist, remained correlated significantly with the degree of steatosis. Using an ordered probit statistical model, metabolic control, waist, and insulin concentration predicted the steatosis class in 58% of the cases (≤97% with allowance for one class in either excess or deficit). CONCLUSION In patients with T2DM, the extent of liver steatosis is correlated with variables associated with metabolic control and features of the MS. The combination of metabolic control, visceral obesity, and insulin resistance may reasonably predict the degree of liver steatosis in T2DM.
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Gorla JI, Costa e Silva ADA, Borges M, Tanhoffer RA, Godoy PS, Calegari DR, Santos ADO, Ramos CD, Nadruz Junior W, Cliquet Junior A. Impact of Wheelchair Rugby on Body Composition of Subjects With Tetraplegia: A Pilot Study. Arch Phys Med Rehabil 2015; 97:92-6. [PMID: 26433046 DOI: 10.1016/j.apmr.2015.09.007] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2015] [Revised: 09/02/2015] [Accepted: 09/16/2015] [Indexed: 10/23/2022]
Abstract
OBJECTIVE To investigate the longitudinal effects of wheelchair rugby (WR) training on body composition of subjects with tetraplegia. DESIGN Subjects were evaluated at baseline and after WR training. SETTING Faculty of physical education settings. PARTICIPANTS Individuals with tetraplegia (N=13; age, 26.6±6.0y). INTERVENTIONS Four sessions per week of WR training composed by aerobic and anaerobic activities and technical and tactical aspects of WR. The average time of intervention was 8.1±2.5 months. MAIN OUTCOME MEASURES Body composition assessed by dual-energy x-ray absorptiometry. RESULTS After training, fat mass was significantly reduced in the whole body (15,191±4603 vs 13,212±3318 g, P=.016), trunk (7058±2639 vs 5693±1498 g, P=.012), and legs (2847±817 vs 2534±742 g, P=.003). Conversely, increased bone mineral content (183±35 vs 195±32 g, P=.01) and fat-free mass (2991±549 vs 3332±602 g, P=.016) in the arms and reduced bone mineral content in the trunk (553±82 vs 521±86 g, P=.034) were observed after training. Furthermore, no significant correlation between the duration of training and changes in body composition was detected. CONCLUSIONS Regular WR training increased lean mass and bone mineral content in the arms and decreased total body fat mass. Conversely, WR training was associated with decreased bone mineral content in the trunk. These results suggest that regular WR training improves body composition in subjects with tetraplegia.
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Affiliation(s)
- José I Gorla
- School of Physical Education, University of Campinas, Campinas, SP, Brazil.
| | - Anselmo de A Costa e Silva
- School of Physical Education, University of Campinas, Campinas, SP, Brazil; Faculty of Physical Education, Federal University of Pará, Castanhal, PA, Brazil
| | - Mariane Borges
- School of Physical Education, University of Campinas, Campinas, SP, Brazil
| | | | - Priscila S Godoy
- School of Physical Education, University of Campinas, Campinas, SP, Brazil
| | - Décio R Calegari
- School of Physical Education, University of Maringá, Maringá, Pr, Brazil
| | - Allan de O Santos
- Service of Nuclear Medicine, School of Medical Sciences, University of Campinas, Campinas, SP, Brazil
| | - Celso D Ramos
- Service of Nuclear Medicine, School of Medical Sciences, University of Campinas, Campinas, SP, Brazil
| | - Wilson Nadruz Junior
- Department of Internal Medicine, School of Medical Sciences, University of Campinas, Campinas, SP, Brazil
| | - Alberto Cliquet Junior
- Department of Orthopaedics, School of Medical Sciences, University of Campinas, Campinas, SP, Brazil; Department of Electrical Engineering University of São Paulo, São Carlos, SP, Brazil
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15
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MRI versus histological methods for time course monitoring of steatosis amount in a murine model of NAFLD. Diagn Interv Imaging 2015; 96:915-22. [DOI: 10.1016/j.diii.2015.03.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2015] [Revised: 03/21/2015] [Accepted: 03/23/2015] [Indexed: 12/21/2022]
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16
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Xia MF, Bian H, Yan HM, Lin HD, Chang XX, Li XM, Ma H, He WY, Zhao NQ, Xia P, Gao X. Assessment of liver fat content using quantitative ultrasonography to evaluate risks for metabolic diseases. Obesity (Silver Spring) 2015; 23:1929-37. [PMID: 26239703 DOI: 10.1002/oby.21182] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2015] [Accepted: 05/15/2015] [Indexed: 12/16/2022]
Abstract
OBJECTIVE The ultrasound quantitative method for liver fat content (LFC) is a recent established method for non-invasive assessment of liver steatosis. Its use in clinical practice is further explored by investigating the quantitative relationships between LFC measured by quantitative ultrasonography and metabolic diseases in a middle-aged and elderly Chinese population. METHODS Liver fat content was measured by the quantitative ultrasound method in 4,916 participants from the Shanghai Changfeng Community Study. The anthropometric and serum biochemical parameters related to glucose and lipid metabolism were detected for each participant. The carotid artery intima-media thickness (CIMT) was measured by ultrasonography. RESULTS The LFC displayed a non-Gaussian and positively skewed distribution in the community population and was significantly correlated with body weight, serum glucose, lipid profile, and CIMT. The 95th percentile of LFC in the subgroup of participants without any metabolic disease was 10.8%, and a LFC ≥ 10% was correlated with remarkable increases in the risks for glucose and lipid metabolic diseases. CONCLUSIONS The quantitative ultrasound method that was developed for measuring LFC was useful in a population study. A LFC ≥ 10% might help to identify the subjects with an increased risk for metabolic diseases.
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Affiliation(s)
- Ming-Feng Xia
- Department of Endocrinology and Metabolism, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Hua Bian
- Department of Endocrinology and Metabolism, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Hong-Mei Yan
- Department of Endocrinology and Metabolism, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Huan-Dong Lin
- Department of Endocrinology and Metabolism, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Xin-Xia Chang
- Department of Endocrinology and Metabolism, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Xiao-Ming Li
- Department of Endocrinology and Metabolism, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Hui Ma
- Department of Geriatrics, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Wan-Yuan He
- Department of Ultrasonography, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Nai-Qing Zhao
- Department of Health Statistics and Social Medicine, School of Public Health, Fudan University, Shanghai, China
| | - Pu Xia
- Department of Endocrinology and Metabolism, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Xin Gao
- Department of Endocrinology and Metabolism, Zhongshan Hospital, Fudan University, Shanghai, China
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Abstract
Non-alcoholic fatty liver disease (NAFLD) is the liver disease of this century, increasing in parallel with obesity, insulin resistance and the metabolic syndrome. NAFLD can be seen as a component of the metabolic syndrome, and as such, contributing as a risk factor for cardiovascular disease. In fact, these patients die more often from cardiovascular disease than from direct consequences of liver disease. In this review, we will summarize the data that link NAFLD as a central player in this dysmetabolism, as well as the evidence for appropriate therapy, in order to improve not only liver disease prognosis, but also the overall prognosis and risk of mortality, with particular focus on cardiovascular risk.
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Affiliation(s)
- Mariana Verdelho Machado
- Departamento de Gastrenterologia, Hospital Santa Maria, CHLN, Unidade de Nutrição e Metabolismo, Faculdade de Medicina de Lisboa, IMM, Lisbon, Portugal
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