American Association of Clinical Endocrinology Clinical Practice Guideline for the Diagnosis and Management of Nonalcoholic Fatty Liver Disease in Primary Care and Endocrinology Clinical Settings: Co-Sponsored by the American Association for the Study of Liver Diseases (AASLD)

Noninvasive tests and diagnostic pathways to MASH diagnosis in the United States: a retrospective observational study

AIM

Although liver biopsy is considered the most reliable diagnostic tool for metabolic dysfunction-associated steatohepatitis (MASH), it is invasive and can be costly. Clinicians are increasingly relying on routine biomarkers and other noninvasive tests (NITs) for diagnosis. We examined real-world diagnostic pathways for patients newly diagnosed with MASH with a primary focus on NITs.

MATERIALS AND METHODS

This retrospective, observational study analyzed healthcare claims data (Merative MarketScan Commercial and Medicare Databases) from patients in the United States newly diagnosed with MASH from October 1, 2016, to March 31, 2023. Patients ≥18 years old with ≥12 months of continuous enrollment with medical and pharmacy benefits prior to diagnosis were included. Diagnostic pathways leading up to MASH diagnosis, including NITs (blood-based and imaging-based tests) and liver biopsies were assessed. Prevalence of comorbid conditions, MASH-associated medication use, and the diagnosing physician specialty were also examined.

RESULTS

A total of 18,396 patients were included in the analysis. Routine laboratory tests (alanine aminotransferase [ALT], albumin, aspartate aminotransferase [AST], cholesterol, complete blood count, and hemoglobin A1c) were performed among ≥70% of patients prior to MASH diagnosis, including 89% of patients with a liver enzyme test (ALT and/or AST). More than 75% of patients had necessary laboratory tests to calculate AST to platelet ratio index (APRI) and fibrosis-4 index (FIB-4) scores. The most common imaging performed was ultrasound (62%); liver biopsy was only performed in 10% of patients. There was a high prevalence of cardio metabolic risk factors such as hyperlipidemia (66%), hypertension (62%), obesity (58%), type 2 diabetes (40%), and cardiovascular disease (21%). Nearly half of the patients (49%) were diagnosed by a primary care physician.

LIMITATIONS AND CONCLUSIONS

This study highlights real-world diagnostic pathways among patients newly diagnosed with MASH, supporting previous findings that liver biopsies are infrequently used in favor of noninvasive methods.

Untargeted lipidomic analysis of metabolic dysfunction-associated steatohepatitis in women with morbid obesity

Metabolic Dysfunction-Associated Steatohepatitis (MASH) represents the severe condition of Metabolic Dysfunction-Associated Steatotic Liver Disease (MASLD). Currently, there is a need to identify non-invasive biomarkers for an accurate diagnosis of MASH. Previously, omics studies identified alterations in lipid metabolites involved in MASLD. However, these studies require validation in other cohorts. In this sense, our aim was to perform lipidomics to identify the circulating lipid metabolite profile of MASH. We assessed a liquid chromatography coupled to a mass spectrometer-based untargeted lipidomic assay in serum samples of 216 women with morbid obesity that were stratified according to their hepatic diagnosis into Normal Liver (NL, n =  44), Simple Steatosis (SS, n =  66) and MASH (n =  106). First, we identified a profile of lipid metabolites that are increased in MASLD, composed of ceramides, triacylglycerols (TAG) and some phospholipids. Then, we identified that patients with SS have a characteristic profile of increased levels of ceramides, diacylglycerols DG (36:2) and DG (36:4), some TAG and a few phospholipids such as PC (32:1), PE (38:3), PE (40:6), PI (32:0) and PI (32:1). Later, in MASH patients, we found increased levels of ceramides, deoxycholic acid, a set of TAG, and some phospholipids such as PC, PE, PI and LPI; while we found decreased levels of the DG (36:0). Finally, we have reported a panel of lipid metabolites that might be used to differentiate patients with MASH from SS patients, made up of increased levels of 9-HODE some PC and PE, the LPI (16:0) and decreased levels of DG (36:0). To conclude, our investigation has suggested a lipid metabolite profile associated with MASLD and MASH. Specifically, a set of lipid metabolites seems to be discriminatory in MASH subjects compared to SS individuals. Thus, this panel of lipid metabolites could be used as a non-invasive diagnostic tool.

Efficacy and safety of resmetirom for the treatment of nonalcoholic steatohepatitis: a GRADE assessed systematic review and meta-analysis

There are no Food and Drug Administration (FDA)-approved treatment options for nonalcoholic steatohepatitis (NASH) which is a prevailing disease that leads to fibrosis, cirrhosis, or hepatocellular carcinoma. Hence, this systematic review and meta-analysis aims to determine the efficacy and safety of resmetirom, the first FDA-approved drug, for the treatment of NASH. A Grading of Recommendations, Assessment, Development, and Evaluation assessed systematic search of Cochrane Library , MEDLINE , Scopus , and Google Scholar database was conducted from inception till 31 March 2024. Meta-analyses were carried out in accordance with the PRISMA statement. Heterogeneity was determined to be significant if found above 50%. This meta-analysis encompasses three randomized clinical trials, including a total of 2231 patients. The findings show resmetirom's significant efficacy in several key outcomes, including improvement in fibrosis risk ratios, 1.67 [95% confidence intervals (CI), 1.26-2.20], reductions in liver fat content (95% CI, -39.58 to -23.5), and enhanced liver fibrosis score (95% CI, -0.37 to -0.13) along with improved levels of liver enzymes. Resmetirom was found to be associated with nausea and diarrhea. This is the first systematic review and meta-analysis to determine the safety and efficacy of resmetirom which showed significant positive results in fibrosis improvement, liver fat content, lipid profiles, and liver enzymes in comparison to placebo. Moreover, moderate side effects, such as diarrhea and nausea, were seen in few patients indicating a satisfactory safety profile.

Screening for advanced liver disease incorporating the use of transitional elastography in primary care

OBJECTIVES

To describe the proportion of patients with liver fibrosis in at-risk populations in primary care (PC). To know the agreement between FIB-4 and transitional elastography (TE), interobserver agreement between PC and hospital care (HC) in TE, and associated risk Factors (RF).

METHODS

Observational, descriptive, cross-sectional study in ≥16 years of age with RF for chronic liver disease. Sex and age, RF (alteration of liver tests [LT], metabolic syndrome, diabetes, obesity, alcohol consumption, hepatic steatosis), and FIB-4, controlled attenuation parameter and TE in PC and in HC, were collected. According to a consensus algorithm, vibration-controlled TE was performed in PC in patients with FIB-4≥1,3, and those with measurement ≥8kPa were referred to HC.

RESULTS

326 patients were studied. 71% were not referred to HC, due to liver stiffness <8kPa. 83 of the 95 derivations did TE in HC. 45 (54%) had TE ≥8, and 25 (30%) ≥12. The proportion of patients with stiffness ≥8kPa was 13,8% (45/326) and ≥12kPa, 7,6% (25/326). The predictive values of the FIB-4 were low. The interobserver correlation coefficient between TE in PC and HC was 0,433. Variables associated with TE ≥8 in PC: LT alteration, diabetes and steatosis. With TE ≥12: LT alteration, diabetes and obesity.

PREDICTOR VARIABLES

LT alteration and obesity.

CONCLUSIONS

The study supports the sequential performance of serum indices and TE as a screening for fibrosis in the at-risk population in PC, which allows a reduction in the percentage of patients referred to AH, and a better stratification of risk patients.

Role of triggering receptor expressed on myeloid cells 2 in the pathogenesis of non-alcoholic fatty liver disease

Non-alcoholic fatty liver disease (NAFLD) is a progressive disease. Without effective interventions, NAFLD can gradually develop to non-alcoholic steatohepatitis, fatty liver fibrosis, liver cirrhosis and even hepatocellular carcinoma. It is still to investigate the precise molecular mechanism behind the pathophysiology of NAFLD. Triggering receptor expressed on myeloid cells 2 (TREM2) can sense tissue injury and mediate immune remodeling, thereby inducing phagocytosis, lipid metabolism, and metabolic transfer, promoting cell survival and combating inflammatory activation. NAFLD might develop as a result of TREM2's regulatory role. We here briefly summarize the biological characteristics of TREM2 and its functions in the disease progression of NAFLD. Moreover, we propose to broaden the therapeutic strategy for NAFLD by targeting TREM2.

The Asian Pacific association for the study of the liver clinical practice guidelines for the diagnosis and management of metabolic dysfunction-associated fatty liver disease

Metabolic dysfunction-associated fatty liver disease (MAFLD) affects over one-fourth of the global adult population and is the leading cause of liver disease worldwide. To address this, the Asian Pacific Association for the Study of the Liver (APASL) has created clinical practice guidelines focused on MAFLD. The guidelines cover various aspects of the disease, such as its epidemiology, diagnosis, screening, assessment, and treatment. The guidelines aim to advance clinical practice, knowledge, and research on MAFLD, particularly in special groups. The guidelines are designed to advance clinical practice, to provide evidence-based recommendations to assist healthcare stakeholders in decision-making and to improve patient care and disease awareness. The guidelines take into account the burden of clinical management for the healthcare sector.

The pleiotropic effects of glucagon-like peptide-1 receptor agonists in patients with metabolic dysfunction-associated steatohepatitis: a review for gastroenterologists

INTRODUCTION

Glucagon-like peptide-1 receptor agonists (GLP-1RAs), and dual GLP-1/glucose-dependent insulinotropic peptide (GIP) or glucagon receptor agonists have emerged as promising agents to treat metabolic dysfunction-associated steatotic liver disease (MASLD)/metabolic dysfunction-associated steatohepatitis (MASH). Although the beneficial effects of GLP-1RAs on glycemic control and weight are well-established, clinicians may be unfamiliar with other potential benefits of this class.

AREAS COVERED

We examined the pleiotropic effects of GLP-1RAs and how they relate to gastroenterologists for MASLD/MASH treatment. Our narrative review of English articles included four GLP-1RAs (subcutaneous semaglutide, liraglutide, dulaglutide, and efpeglenatide), a dual GLP-1/GIP agonist (tirzepatide), a dual GLP-1/glucagon receptor agonist (survodutide), MASLD/MASH, related disorders, clinical management, treatment outcomes and landscape.

EXPERT OPINION

In Phase I - III trials, GLP-1RAs are associated with clinically relevant hepatic improvements including MASH resolution, liver fat reduction, and preventing worsening fibrosis. Effects on cardiometabolic parameters align with type 2 diabetes/obesity Phase III data, comprising substantial improvements in glycemic, weight, and cardiovascular outcomes. Promising data also suggest benefits in common comorbidities, including obstructive sleep apnea, polycystic ovary syndrome, chronic kidney disease, and heart failure with preserved ejection fraction.GLP-1RAs represent a valuable pharmacotherapeutic option for gastroenterologists managing individuals with MASLD/MASH and cardiometabolic comorbid conditions.

Glycemic Targets and Prevention of Complications

CONTEXT

Complications of diabetes mellitus have significant impacts on morbidity, mortality, quality of life, and health costs for individuals. Setting and achieving glycemic targets to prevent these complications is a top priority when managing diabetes. However, patients often already have complications when diagnosed with diabetes mellitus. Therefore, methods to prevent disease progression become a crucial component of diabetes management. The purpose of this article is to review glycemic targets and methods of screening and managing diabetes-related complications.

EVIDENCE ACQUISITION

A PubMed review of the literature pertaining to diabetes mellitus, glycemic targets, microvascular complications, and macrovascular complications was conducted. We reviewed articles published between 1993 and 2024. Guidelines published by nationally recognized organizations in the fields of diabetes, nephrology, and cardiology were referenced. Public health statistics obtained by the Center for Disease Control and Prevention and the National Kidney Foundation were used.

EVIDENCE SYNTHESIS

Achieving glycemic targets and screening for diabetes-related complications at appropriate intervals remains the key factor for early detection and intervention. An algorithmic approach to glycemic management based on individual risk factors is beneficial in choosing pharmacotherapy.

CONCLUSION

The consequences of diabetes-related complications can be detrimental. However, achieving and maintaining glycemic targets combined with diligent screening, reduction of risk factors, and prompt treatment can halt disease progression.

Effects of Semaglutide on Muscle Structure and Function in the SLIM LIVER Study

BACKGROUND

Semaglutide is highly effective for decreasing weight. Concomitant loss of muscle mass often accompanies weight loss and may have consequences on muscle function.

METHODS

This is a secondary analysis from the SLIM LIVER (Advancing Clinical Therapeutics Globally for HIV/AIDS and Other Infections, ACTG A5371) study, a single-arm study of semaglutide in people with human immunodeficiency virus (HIV, PWH) with metabolic dysfunction-associated steatotic liver diseases (MASLD). Participants received subcutaneous semaglutide for 24 weeks (titrated to 1 mg/week by week 4). Psoas volume and fat fraction were assessed from liver magnetic resonance imaging, and physical function was assessed by 10-time chair rise test and 4 m gait speed. Mean change from baseline to week 24 was estimated with linear regression modeling.

RESULTS

Fifty-one PWH were enrolled (muscle measures n = 46). The mean age was 50 years (standard deviation, 11), body mass index was 35.5 kg/m2 (5.6), 43% were women, 33% Black, and 39% Hispanic/Latino. Psoas muscle volume decreased by 9.3% (95% confidence interval [CI]: -13.4 to -5.2; P < .001) over 24 weeks, but psoas muscle fat did not significantly change (-0.42%; 95% CI: -1.00 to .17; P = .16). Chair rise and gait speed showed nonsignificant improvements of 1.27 seconds (95% CI: -2.7 to .10) and 0.05 m/sec (95% CI: -.01 to .10), respectively (both P > .07). The prevalence of slow gait speed (<1 m/sec) decreased from 63% to 46% (P = .029).

CONCLUSIONS

In PWH receiving semaglutide for MASLD, despite decreased psoas muscle volume, there was no significant change in physical function, suggesting function was maintained despite significant loss of muscle.

CLINICAL TRIALS REGISTRATION

NCT04216589.

The effects of HAPA theory-based case management in patients with metabolic dysfunction-associated steatotic liver disease

INTRODUCTION AND OBJECTIVES

Metabolic dysfunction-associated steatotic liver disease (MASLD) is the most common liver disease affecting people's health, with its incidence increasing year by year. This study aims to determine the effects of Health Action Process Approach (HAPA)-based health management on patients diagnosed with MASLD.

PATIENTS AND METHODS

204 MASLD patients were selected from the hospital's physical examination center from January 1, 2023, through April 1, 2023. Patients are randomly assigned to two groups (n = 102 each) using an envelope-based. Individuals in the experimental group received case management based on the HAPA theory, while standard health management was employed for control group patients. All subjects were monitored over a 6-month period, comparing body mass index (BMI), waist-to-hip ratio (WHR), levels of liver function (AST, ALT), blood lipid levels (total cholesterol (TC), triglyceride (TG), low-density lipoprotein cholesterol (LDL-C), high-density lipoprotein cholesterol (HDL-C), and health behaviours (as assessed with the HPLP-II health promotion lifestyle scale) before and after the intervention.

RESULTS

Post-intervention, the experimental group showed significant improvement in fatty liver (P < 0.01) and reductions in biochemical indices, BMI, and WHR levels (P < 0.05), and a corresponding improvement in HDL-C levels (P < 0.001), compared to the control group. Additionally, patients in the experimental group exhibited significantly better health behaviour scores related to stress management, exercise, diet, and health responsibility compared to controls (P < 0.01).

CONCLUSIONS

HAPA theory-based case management can improve blood lipid profiles, liver function, and health-related behaviours in MASLD patients, highlighting its potential as an effective management strategy for this condition.

Caffeine intake associated with a lower risk of liver fibrosis in different glucose status

BACKGROUND AND AIMS

To investigate the prevalence of liver fibrosis, and the association between caffeine intake and fibrosis in populations with different glucose metabolism status.

METHODS

This was a cross-sectional study based on the National Health and Nutrition Examination Survey (2005-March 2020). Of the 39,221 adult individuals with no necessary laboratory results missing, a total of 23,711 eligible individuals were included in the study. Individuals were divided into T2DM, prediabetes, and diabetes-free groups. Fibrosis-4 index was calculated to evaluate the risk of liver fibrosis. Caffeine intake was obtained through a 24-hour dietary recall.

RESULTS

The mean ± SE age of prediabetes group was 53 ± 0·4 years, and in type 2 diabetes mellitus group, the individuals have a mean ± SE age of 62 ± 0·3 years. The participants with type 2 diabetes mellitus had significantly higher risk of liver fibrosis than those with prediabetes or normal glucose tolerance (5·9% vs. 3·2% vs. 2·5%, P < 0·001). Compared to individuals with daily caffeine intake < 78 mg, individuals with daily caffeine intake ≥ 78 mg had significantly lower risk of liver fibrosis in all subgroups (odds ratio: diabetes-free group: 0·698[0·577-0·846]; prediabetes group: 0·553[0·397-0·769]; type 2 diabetes mellitus group: 0·720[0·556-0·933]; all P < 0·05).

CONCLUSIONS

Prevalence of liver fibrosis is high in patients with type 2 diabetes mellitus and prediabetes. It is indicated that individuals with prediabetes should also be screened for fibrosis. Caffeine intake ≥ 78 mg per day is associated with a lower risk of liver fibrosis.

Economic evaluation of non-invasive test pathways for high-risk metabolic dysfunction-associated steatotic liver disease (MASLD) in the United Kingdom (UK)

INTRODUCTION AND OBJECTIVES

Non-invasive tests (NITs) identifying high-risk MASLD in primary care is suggested but, these strategies cost-effectiveness remain uncertain in the United Kingdom (UK).

MATERIALS AND METHODS

A cost-utility/budget impact model was developed for cost-effectiveness evaluation of two screening strategies (1) FIB-4 followed by Enhanced Liver Fibrosis (ELF) (FIB-4/ELF); (2) FIB-4 followed by Transient Elastography (FIB-4/TE) compared to standard of care (SoC). A cohort of primary care MASLD patients with an advanced fibrosis prevalence of 4.20 % was simulated. A decision tree classified patients as true positives, false positives, true negatives, or false negatives based on NIT diagnostic accuracy, followed by a 3-year Markov model to estimate costs and quality-adjusted life years (QALYs). The model included 11 health states: MASLD, fibrosis stages (F0-F3), cirrhosis, decompensated cirrhosis, liver transplant, and death. Costs came from the National Tariff, National Schedule of Costs and Personal Social Services Research Unit.

RESULTS

SoC had a false diagnosis rate of 36.26 %, while FIB-4 with ELF or TE reduced false positive rates to 23.20 % and 20.91 %, respectively. Compared to 112,807 unnecessary hepatology referrals under SoC, FIB-4/ELF or FIB-4/TE reduced unnecessary referrals by 38,031 (33.71 %) and 45,767 (40.57 %), respectively. Both strategies demonstrated cost-effectiveness relative to SoC with total cost per patient of GBP 983.37 for FIB-4/TE, GBP 993.15 for FIB-4/ELF compared to SoC, GBP 1,014.15.

CONCLUSIONS

Sequential NIT screening strategies, combining FIB-4 with ELF or TE, are cost-saving, reduce unnecessary hepatology referrals, and offer an efficient (improve outcomes and reduce healthcare costs) approach for managing high-risk MASLD in UK primary care.

Impact of shear wave elastography and attenuation imaging for predicting life-threatening event in patients with metabolic dysfunction-associated steatotic liver disease

We aimed to elucidate the value of ultrasound-based biomarkers for predicting the major life-threatening events in metabolic dysfunction-associated steatotic liver disease (MASLD). We established a prospective cohort of 279 patients who underwent two-dimensional shear wave elastography (2D-SWE), ultrasound-guided attenuation parameter (UGAP). An area under the curve analysis was performed to determine the cutoff values of liver stiffness measurements (LSM) by 2D-SWE and attenuation coefficient (AC) by UGAP for a moderate fibrosis and a moderate steatosis. We then classified the cohort into Groups A (low LSM and low AC), B (low LSM and high AC), C (high LSM and high AC), and D (high LSM and low AC). We compared the incidence of events between the groups, and estimated the hazard ratios (HRs) with 95% confidence intervals (CIs). The LSM and AC cut off values were 8.37 kPa and 0.62 dB/cm/MHz, respectively. The cumulative incidence rate in Groups A, B, C, and D were 11.2%, 12.2%, 29.5%, and 31.0%/5years, respectively (p < 0.05). LSM (HRs = 1.20, 95%CIs: 1.09-1.32, p < 0.01), and AC (HRs = 1.62, 95%CIs: 1.04-2.51, p = 0.03) were associated with life-threatening events. A combination of 2D-SWE and UGAP may help identify patients with MASLD at high risk for subsequent life-threatening events.

Effects of time restricted feeding combined with Lacto Ovo vegetarian diet on metabolic associated fatty liver disease management: a randomized clinical trial

Metabolic Associated Fatty Liver Disease (MAFLD) is becoming a major global health concern due to its links with obesity, insulin resistance, and cardiovascular risk. This randomized clinical trial assessed the effects of combining time-restricted feeding (TRF; 16/8) with a Lacto-Ovo-Vegetarian (LOV) diet on various factors in overweight and obese patients with MAFLD. Forty-six participants were randomly assigned to either the intervention group (TRF with LOV diet) or the control group, with 21 participants completing the 12-week study in each group. The intervention group showed significant reductions in weight (-8.07 ± 4.31 kg), BMI (-2.70 ± 1.32 kg/m2), waist circumference (-8.00 ± 4.06 cm), as well as ALT (-17.14 ± 14.33 U/L), GGT (-21.09 ± 24.06 U/L), Fatty Liver Index (-26.90 ± 15.81), insulin levels (-3.89 ± 4.69 mU/L), and TNF-α (-11.85 ± 12.52 pg/mL) compared to the control group (all P < 0.05). Lipid profiles also improved with a reduction in triglycerides (-46.85 ± 54.55 mg/dL) and an increase in HDL-C (3.91 ± 5.07 mg/dL) in the intervention group compared to the control group (P < 0.05). These findings imply that TRF combined with a LOV diet enhances metabolic markers, liver health, and weight loss, thus potentially offering a practical dietary approach for managing MAFLD. Further long-term studies are necessary to validate these results and investigate their clinical applications.

Therapeutic Targets and Approaches to Manage Inflammation of NAFLD

Non-alcoholic fatty liver disease (NAFLD) and its advanced form, non-alcoholic steatohepatitis (NASH), are the leading causes of chronic liver disease globally. They are driven by complex mechanisms where inflammation plays a pivotal role in disease progression. Current therapies, including lifestyle changes and pharmacological agents, are limited in efficacy, particularly in addressing the advanced stages of the disease. Emerging approaches targeting inflammation, metabolic dysfunction, and fibrosis offer promising new directions, though challenges such as treatment complexity and heterogeneity persist. This review concludes the main therapeutic targets and approaches to manage inflammation currently and emphasizes the critical need for future drug development and combination therapy for NAFLD/NASH management.

Liver diseases: epidemiology, causes, trends and predictions

As a highly complex organ with digestive, endocrine, and immune-regulatory functions, the liver is pivotal in maintaining physiological homeostasis through its roles in metabolism, detoxification, and immune response. Various factors including viruses, alcohol, metabolites, toxins, and other pathogenic agents can compromise liver function, leading to acute or chronic injury that may progress to end-stage liver diseases. While sharing common features, liver diseases exhibit distinct pathophysiological, clinical, and therapeutic profiles. Currently, liver diseases contribute to approximately 2 million deaths globally each year, imposing significant economic and social burdens worldwide. However, there is no cure for many kinds of liver diseases, partly due to a lack of thorough understanding of the development of these liver diseases. Therefore, this review provides a comprehensive examination of the epidemiology and characteristics of liver diseases, covering a spectrum from acute and chronic conditions to end-stage manifestations. We also highlight the multifaceted mechanisms underlying the initiation and progression of liver diseases, spanning molecular and cellular levels to organ networks. Additionally, this review offers updates on innovative diagnostic techniques, current treatments, and potential therapeutic targets presently under clinical evaluation. Recent advances in understanding the pathogenesis of liver diseases hold critical implications and translational value for the development of novel therapeutic strategies.

Focused Recommendations for the Management of Metabolic Dysfunction-Associated Steatohepatitis (MASH) by Advanced Practice Providers in the United States

Metabolic dysfunction-associated steatohepatitis (MASH) has become the dominant cause of liver disease in the United States. With the growing burden of this disease in gastroenterology practices, the identification and treatment of those at risk of developing adverse outcomes (cirrhosis, hepatocellular carcinoma, or liver-related death) has become urgent. In recent years, the development of noninvasive tests (NITs) to identify "at-risk MASH" patients have provided cost-effective algorithms to identify these patients. Although treatment has historically been limited to lifestyle modification, recent FDA approval of resmetirom for noncirrhosis MASH with stages 2 and 3 fibrosis has provided a new  opportunity in the United States to provide these patients with novel treatment options. Other new effective treatment regimens are on the horizon. Given that gastroenterology and hepatology practices in the United States heavily rely on advanced practice providers (APPs) to manage patients with MASLD, the APP Committee of the Global NASH/MASH Council has curated the essentials of day-to-day MASH management for our busy gastrohepatology providers and their APP colleagues. The goal of this document is to equip and mobilize more GI providers with the requisite competencies for the management of at-risk MASH, given the rapidly evolving MASH treatment landscape.

Screening for advanced liver fibrosis due to metabolic dysfunction-associated steatotic liver disease alongside retina scanning in people with type 2 diabetes: a cross-sectional study

BACKGROUND

International guidelines suggest screening for advanced fibrosis due to metabolic dysfunction-associated steatotic liver disease in people with type 2 diabetes, but how to implement these guidelines in clinical care remains unclear. We hypothesise that examination with VCTE could be implemented simultaneously with retina scanning with a high acceptance rate in people with type 2 diabetes.

METHODS

In this cross-sectional study, we offered VCTE to people with type 2 diabetes referred to routine retina scanning in a large retina scanning facility in Stockholm, Sweden. We excluded people with type 1 diabetes, currently pregnant, with known liver disease, reporting high alcohol consumption, who did not speak Swedish, or younger than 18 years. Between Nov 6, 2020, and June 20, 2023, we conducted surveys with included participants and collected data from medical records on diabetes retinopathy, sex, and VCTE measurements. Increased liver stiffness was defined as at least 8·0 kPa, and possible advanced fibrosis as more than 12·0 kPa. Presence of metabolic dysfunction-associated steatotic liver disease was defined as a controlled attenuation parameter (CAP) value of 280 dB/m or higher. Participants with a liver stiffness measurement of at least 8·0 kPa or those with unreliable measurements were subsequently referred for a secondary evaluation at a liver specialist, including a follow-up liver stiffness measurement with VCTE. The primary outcome was the proportion of eligible people approached for screening who accepted. Secondary outcomes were the prevalence of elevated liver stiffness (≥8·0 kPa or >12·0 kPa), presence of metabolic dysfunction-associated steatotic liver disease, and the proportion of elevated liver stiffness readings at the first VCTE examination that were not elevated in the secondary evaluation with a liver specialist. Secondary outcomes were assessed in all participants who accepted screening, except false positives, which were assessed only in participants who had a second examination.

FINDINGS

1301 participants were eligible to undergo assessment with VCTE, which was accepted by 1005 (77·2%). 973 (96·8%) participants had complete measurements, of whom 504 (51·8%) had CAP values of 280 dB/m or higher, indicating metabolic dysfunction-associated steatotic liver disease. Of 977 participants with reliable liver stiffness measurements, 154 (15·8%) had values of at least 8·0 kPa, suggestive of liver fibrosis, and 49 (5·0%) had values higher than 12·0 kPa, indicating possible advanced fibrosis. However, upon reassessment with a second VCTE after referral, 56 (45·2%) of 124 individuals had values less than 8·0 kPa. 74 (7·4%) of 1005 participants had a final liver stiffness of at least 8·0 kPa; 29 (2·9%) had values greater than 12·0 kPa.

INTERPRETATION

Simultaneous examination with VCTE alongside retina scanning had a high acceptance rate among people with type 2 diabetes and could be a strategy for case-finding of people with fibrosis due to metabolic dysfunction-associated steatotic liver disease. However, a high proportion of participants in our study with elevated liver stiffness measurement at the screening visit did not have an elevated liver stiffness measurement at secondary evaluation, suggesting false-positive findings were common.

FUNDING

Gilead Sciences, Pfizer, Region Stockholm, Åke Wiberg Foundation, and Bengt Ihre Foundation.

Similar weight loss with semaglutide regardless of diabetes and cardiometabolic risk parameters in individuals with metabolic dysfunction-associated steatotic liver disease: Post hoc analysis of three randomised controlled trials

AIMS

Weight loss mediated by glucagon-like peptide-1 (GLP-1) analogues is lower in patients with type 2 diabetes versus those without. Type 2 diabetes and obesity are risk factors for metabolic dysfunction-associated steatotic liver disease (MASLD) and associated steatohepatitis (MASH). We evaluated weight changes in adults with MASLD/MASH with or without type 2 diabetes receiving the GLP-1 analogue semaglutide.

MATERIALS AND METHODS

This was a post hoc analysis of data from three 48-72-week randomised trials investigating the effect of semaglutide versus placebo in adults with MASLD (NCT03357380) or biopsy-confirmed MASH (NCT02970942 and NCT03987451). Pooled data for semaglutide (0.4 mg once daily and 2.4 mg once weekly [n = 163]) and placebo (n = 137) were analysed at 1 year. Weight changes were analysed by type 2 diabetes status (type 2 diabetes [n = 209], pre-type 2 diabetes [n = 51] and no diabetes [n = 40]) and by other cardiometabolic risk parameters using analysis of covariance and Spearman's rank correlations.

RESULTS

The overall mean weight change was -11.1 kg (-11.7%) and -0.7 kg (-0.6%) with semaglutide and placebo, respectively. While numerically higher for people without type 2 diabetes, estimated treatment differences with semaglutide versus placebo were similar overall for people with type 2 diabetes (-10.2 kg; -10.8%), pre-type 2 diabetes (-9.8 kg; -10.2%) and no diabetes (-11.6 kg; -13.1%). Differences between groups were not statistically significant (p > 0.50 for all). Baseline fasting plasma glucose, glycated haemoglobin, insulin levels, insulin resistance and lipids did not correlate with weight change.

CONCLUSIONS

People with MASLD/MASH had similar semaglutide-mediated weight loss regardless of type 2 diabetes status and other cardiometabolic risk parameters.

A European Survey to Identify Challenges in the Management of Metabolic Dysfunction-Associated Steatotic Liver Disease

BACKGROUND AND AIMS

Metabolic dysfunction-associated steatotic liver disease (MASLD) and its more severe subtype, metabolic dysfunction-associated steatohepatitis (MASH), are highly prevalent and strongly associated with obesity and type 2 diabetes (T2D). This study sought to identify challenges to the diagnosis, treatment and management of people living with MASLD and MASH and understand the key barriers to adopting relevant clinical guidelines.

METHODS

A real-world, cross-sectional study (BARRIERS-MASLD) consisting of a quantitative survey and qualitative interviews of physicians in France, Germany, Italy, Spain and the United Kingdom was conducted from March to September 2023. Descriptive statistics were used for data analysis.

RESULTS

A total of 626 physicians completed the survey; n = 10 from each country participated in the qualitative interviews. Physicians considered the presence of MASH to be highly impactful on how they treated people living with obesity (66%) and T2D (69%). Over one-third (35%) of the respondents could not identify any MASH-specific clinical guidelines issued by medical societies or associations top-of-mind, but overall awareness rose when prompted about country-specific guidelines. Physicians said they would need evidence of success (48%) and clinical guidelines that address common MASLD comorbidities (38%) to increase their adoption.

CONCLUSIONS

This study found that lack of awareness around MASLD and MASH clinical guidelines and clearly established care pathways, particularly for addressing common comorbidities, was a key factor preventing physicians from optimising care for people living with MASH in Europe. This research highlights opportunities to improve education and training about clinical guidelines and care coordination.

Accuracy of Controlled Attenuation Parameter for Liver Steatosis in High-Risk Patients for MASLD Using MRI-Proton Density Fat Fraction as Reference Standard

AIM

Controlled attenuation parameter (CAP) enables the noninvasive diagnosis of liver steatosis. Magnetic resonance imaging proton density fat fraction (MRI-PDFF) is increasingly used over biopsy for the assessment of steatosis in patients at risk for metabolic dysfunction-associated steatotic liver disease (MASLD). We assessed the accuracy of CAP for liver steatosis defined as MRI-PDFF ≥ 5%.

METHODS

We performed a cross-sectional, diagnostic accuracy study. We prospectively recruited consecutive adult participants with type 2 diabetes and body mass index (BMI) ≥ 25 kg/m2, who underwent CAP and MRI-PDFF within two weeks.

RESULTS

We included 113 participants. The area under the receiver operating characteristic (AUROC) of CAP for MRI-PDFF ≥ 5% was 0.82 [95% confidence interval (CI) 0.74-0.89]. CAP thresholds for ruling-out (sensitivity > 90%) and ruling-in (specificity > 90%) liver steatosis were below 249 and over 328 dB/m respectively. The AUROC of CAP for the detection of MRI-PDFF ≥ 10% was 0.81 (0.73-0.88). CAP thresholds for ruling-out and ruling-in MRI-PDFF ≥ 10% were below 271 and over 345 dB/m respectively. CAP measurements with an interquartile range (IQR) < 30 dB/m improved the detection of higher steatosis grades.

CONCLUSION

CAP has acceptable accuracy for diagnosing MRI-PDFF defined steatosis. Values below 249 dB/m can be used to rule-out liver steatosis, while values over 328 dB/m can set the diagnosis. An IQR < 30 dB/m might improve the accuracy of CAP for higher steatosis grades.

CLINICAL TRIAL REGISTRATION

Not applicable.

Identifying and Linking Patients At Risk for MASLD with Advanced Fibrosis to Care in Primary Care

BACKGROUND AND AIMS

Severity of fibrosis is the driver of liver-related outcomes in metabolic dysfunction-associated steatotic liver disease (MASLD), and non-invasive testing such as fibrosis-4 (FIB-4) score is utilized for risk stratification. We aimed to determine if primary care patients at risk for MASLD and advanced fibrosis were evaluated with subsequent testing. A secondary aim was to determine if at-risk patients with normal aminotransferases had advanced fibrosis.

METHODS

Primary care patients at increased risk for MASLD with advanced fibrosis (n = 91,914) were identified using previously established criteria. Patients with known alternative/concomitant etiology of liver disease or cirrhosis were excluded. The study cohort included patients with calculated FIB-4 score in 2020 (n = 52,006), and stratified into low, indeterminate, and high likelihood of advanced fibrosis. Among those at indeterminate/high risk, rates of subsequent testing were measured.

RESULTS

Risk stratification with FIB-4 characterized 77% (n = 40,026) as low risk, 17% (n = 8847) as indeterminate, and 6% (n = 3133) as high risk. Among indeterminate/high-risk patients (n = 11,980), 78.7% (n = 9433) had aminotransferases within normal limits, 0.95% (n = 114) had elastography, and 8.2% (n = 984) were referred for subspecialty evaluation.

CONCLUSION

In this cohort of primary care patients at risk for MASLD with fibrosis, the FIB-4 score identified a substantial proportion of indeterminate/high-risk patients, the majority of which had normal aminotransferase levels. Low rates of subsequent testing were observed. These data suggest that a majority of patients at increased risk for liver-related outcomes remain unrecognized and highlight opportunities to facilitate their identification.

Resmetirom: The First Food and Drug Administration-Approved Medication for Nonalcoholic Steatohepatitis (NASH)

OBJECTIVE

To review the literature leading to the Food and Drug Administration (FDA) approval of the first medication, resmetirom, for the treatment of nonalcoholic steatohepatitis (NASH), including the pharmacology, pharmacokinetics, clinical studies, dosing, and adverse effects. Relevant data will be used to discuss how resmetirom impacts clinical practice.

DATA SOURCES

A literature search was conducted using MEDLINE from database inception to May 12, 2024. Keywords included non-alcoholic steatohepatitis, nonalcoholic fatty liver disease, and resmetirom. Study selection, data extraction and all English-language studies involving the use of resmetirom for nonalcoholic fatty liver disease (NAFLD)/NASH were included.

DATA SYNTHESIS

Resmetirom, a thyroid hormone receptor agonist, is administered at daily doses of either 80 mg or 100 mg. The drug was shown to provide NASH resolution as assessed by the NAFLD activity score, 80 mg-24.2%, 100 mg-25.9% compared to 14.2% with the placebo group (P < 0.001). Resmetirom, improved liver fibrosis, 80 mg-25.9%, 100 mg-29.9% compared to 9.7% with the placebo group (P < 0.001). Resmetirom's ability to improve fibrosis in patients with F2-F3 fibrosis offers valuable benefit for patients at risk of progressing to cirrhosis.

RELEVANCE TO PATIENT CARE AND CLINICAL PRACTICE

Resmetirom expands the medication options available to treat patients with NASH which can be given alongside other medications to optimize metabolic factors such as glucagon-like peptide-1 and hydroxymethylglutaryl-coenzyme A reductase inhibitors. Resmetirom was well tolerated in studies.

CONCLUSION

Resmetirom serves as an attractive option in patients diagnosed with NASH with evidence of advanced fibrosis (F2-F3) in combination with exercise, diet, and other multimodal therapies targeting metabolic risk factors.

Transjugular Intrahepatic Portosystemic Shunt (TIPS): A Bridge to Bariatric Surgery in Morbidly Obese Patients with Cirrhosis and Clinically Significant Portal Hypertension

BACKGROUND

In cirrhotic patients, portal hypertension increases mortality after surgery. We evaluated the impact of pre-operative transjugular intrahepatic portosystemic shunt (TIPS) on the outcomes of bariatric surgery in cirrhosis.

METHODS

Multicentric retrospective cohort. The decision for TIPS placement has been made according to hepatic venous pressure gradient (HVPG) values and centers' policy. The primary outcome: 1-year decompensation-free survival; secondary outcomes: 1-year acute-on-chronic liver failure (ACLF) and survival.

RESULTS

Fifty-three patients were included (2010-2022): 92% Child-Pugh A, MELD score 8, age 55 years, BMI 38.3 ± 13 kg/m2, 9 (18%) had TIPS. At baseline, patients with TIPS had more esophageal varices (89% vs 10%, p < 0.001), more previous decompensations (22% vs 0%, p = 0.002), and a higher HVPG (14 vs 7 mmHg, p < 0.001). All patients in the TIPS group had clinically significant portal hypertension vs 11% of patients without TIPS, p < 0.001. One-year decompensation-free survival was 77.8% and 93.2% in patients with and without TIPS, p = 0.064. ALCF occurred in 3 patients (6.8%) without TIPS and none with TIPS. All patients were alive 1 year after surgery.

CONCLUSIONS

In patients with cirrhosis and clinically significant portal hypertension (CSPH) undergoing bariatric surgery, TIPS placement was safe and had similar outcomes after surgery as patients without TIPS.

MOVING DIAGNOSIS OF LIVER FIBROSIS INTO THE COMMUNITY

Chronic liver diseases (CLD) are a leading cause of death worldwide, with alcohol consumption and metabolic risk factors as the two reasons accounting for the majority of cases of CLD in many developed countries. Currently there is a lack of specific strategies for early diagnosis of CLD and consequently most cases are diagnosed in advanced stages of the disease, which is associated with negative consequences for disease management and prognosis. Screening for CLD is based on either detection of chronic viral hepatitis B and C, or detection of liver fibrosis in patients with steatotic liver disease related to alcohol or metabolic dysfunction. There are non-invasive tools available for detection of liver fibrosis, including serological and imaging-based tests. Clinical practice guidelines recommend screening for liver fibrosis using algorithms that combine different non-invasive tests, with widely available but low accuracy tests such as FIB-4 for a first screening step in primary care setting, and other tests with less availability but higher accuracy, such as Transient Elastography or Enhanced Liver Fibrosis Test as a second step. There are different pathways for early detection of patients with CLD from primary to specialized care, where primary care providers are key for early detection, management and referral of patients. In addition, intervention on metabolic risk factors and alcohol consumption should be carried out in collaboration between specialized therapy and primary care. This review describes liver fibrosis from the community perspective, highlighting gaps in knowledge on how to define the optimal combination of tests, target population, the ideal pathway of care for CLD, and how to increase implementation of programs for early diagnosis of liver diseases in clinical practice.

Navigating liver health with metabolomics: A comprehensive review

Non-alcoholic fatty liver disease (NAFLD) is the main cause of chronic liver disease worldwide, affecting one-fourth of the world's population. With more than half of the world's population, the Asia-Pacific region contributed 62.6 % of liver-related fatal incidents in 2015. Currently, liver imaging techniques such as computed tomography (CT), nuclear magnetic resonance (NMR) spectroscopy, and ultrasound are non-invasive imaging methods to diagnose the disease. A liver biopsy is the gold standard test for establishing the definite diagnosis of non-alcoholic steatohepatitis (NASH). However, there are still significant problems with sample variability and the procedure's invasiveness. Numerous studies have indicated various non-invasive biomarkers for both fibrosis and steatosis to counter the invasiveness of diagnostic procedures. Metabolomics could be a promising method for detecting early liver diseases, investigating pathophysiology, and developing drugs. Metabolomics, when utilized with other omics technologies, can result in a deeper understanding of biological systems. Metabolomics has emerged as a prominent research topic, offering extensive opportunities to investigate biomarkers for liver diseases that are both sensitive and specific. In this review, we have described the recent studies involving the use of a metabolomics approach in the diagnosis of liver diseases, which would be beneficial for the early detection and treatment of liver diseases.

Diagnostic Accuracy of Non-Invasive Diagnostic Tests for Nonalcoholic Fatty Liver Disease: A Systematic Review and Network Meta-Analysis

Purpose

In recent decades, numerous non-invasive tests (NITs) for diagnosing nonalcoholic fatty liver disease (NAFLD) have been developed, however, a comprehensive comparison of their relative diagnostic accuracies is lacking. We aimed to assess and compare the diagnostic accuracy of various NITs for NAFLD using network meta-analysis (NMA).

Materials and Methods

We conducted a systematic search in seven databases up to April 2024 to identify studies evaluating the diagnostic values of NITs, with liver biopsy as the gold standard. The participants included patients with suspected or confirmed NAFLD, irrespective of age, sex, ethnicity. Statistical analysis was conducted using R 4.0.3 for Bayesian NMA and STATA 17.0 for pairwise meta-analysis. Sensitivity, specificity, diagnostic odds ratio (DOR), area under the receiver operating characteristic curve (AUC), and superiority index were calculated. Bayesian calculations were performed using the Rstan package, specifying parameters like MCMC chain count, iteration count, and operational cycles. The methodological quality of included studies was assessed using the QUADAS-2 tool.

Results

Out of 15,877 studies, 180 were included in the quantitative synthesis, and 102 were used in head-to-head meta-analyses. For diagnosing steatosis stage 1, Hydrogen Magnetic Resonance Spectroscopy (H-MRS, DOR 15,745,657.6, 95% CI 17.2-1,014,063.59) proved to be the most accurate. For significant fibrosis, HRI leading (DOR 80.94, 95% CI 6.46-391.41), For advanced fibrosis, CK-18 showed the highest performance (DOR 102654.16, 95% CI 1.6-134,059.8). For high-risk NASH, Real-Time Elastography showing the highest performance (DOR 18.1, 95% CI 0.7-96.33). Meta-regression analyses suggested that variability in the diagnostic accuracy of NITs for NAFLD may result from differences in study design, thresholds, populations, and performance indicators.

Conclusion

We conducted a network meta-analysis to rank the accuracy of these tests. While some results are promising, not all NITs demonstrate substantial accuracy, highlighting the need for validation with larger datasets. Future research should concentrate on studying the thresholds of NITs and enhancing the clarity of methodological reporting.

Factors Influencing Knowledge-Action Gap in Patients With Metabolic Dysfunction-Associated Fatty Liver Disease: A Qualitative Study

OBJECTIVE

To explore the knowledge-action gap regarding health behaviors and their influencing factors among patients with metabolic dysfunction-associated fatty liver disease (MAFLD), using the Health Belief Model as a theoretical framework.

DESIGN

A qualitative approach was adopted, involving semistructured interviews with individuals with MAFLD.

SETTING

Participants were recruited from a community hospital and a tertiary hospital in Nanjing, China, between July and October 2022.

PARTICIPANTS

A purposive sample of 21 adults with MAFLD, who were primarily overweight or obese (86%), males (52%), and aged ≥ 60 years (52%).

PHENOMENON OF INTEREST

This study focused on the knowledge-action gap in health behaviors among MAFLD patients.

ANALYSIS

Data were analyzed using content analysis, with the Health Belief Model guiding the identification of themes and categorization of specific domains.

RESULTS

This study found that perceptions of disease susceptibility and severity, perceived barriers to healthy lifestyles, and various modifying factors impeded the adoption of healthy behaviors. In contrast, perceived benefits, cues to action, and self-efficacy facilitated the implementation of these behaviors.

CONCLUSIONS AND IMPLICATIONS

This research highlights the factors contributing to the knowledge-action gap in health behaviors among MAFLD patients. The findings suggest potential targets for interventions aimed at enhancing the alignment between patients' knowledge and their actions, ultimately promoting better health outcomes.

Lipid nanosystems for fatty liver therapy and targeted medication delivery: a comprehensive review

Fatty liver is considered to be the most common chronic liver disease with a high global incidence, which can lead to cirrhosis and liver cancer in severe cases, and there is no specific drug for the treatment of fatty liver in the clinic. The use of lipid nanosystems has the potential to be an effective means of fatty liver treatment. The pathogenesis and intervening factors associated with the development of fatty liver are reviewed, and the advantages and the disadvantages of different lipid nanosystems for the treatment of fatty liver are comprehensively discussed, including liposomes, solid lipid nanoparticles, nanostructured lipid carriers, nanoemulsions, microemulsions, and phospholipid complexes. The composition and characterisation of these lipid nanosystems are highlighted and summarised with a view to improving the efficiency of lipid nanosystems for the treatment of fatty liver. In addition, active targeting and passive targeting strategies used for fatty liver therapy are discussed in detail.

Estimating the prevalence of adults at risk for advanced hepatic fibrosis using FIB-4 in a Swiss tertiary care hospital

BACKGROUND & AIMS

Chronic liver diseases pose a serious public health issue. Identifying patients at risk for advanced liver fibrosis is crucial for early intervention. The Fibrosis-4 score (FIB-4), a simple non-invasive test, classifies patients into three risk groups for advanced fibrosis. This study aimed to estimate the prevalence of patients at risk for advanced hepatic fibrosis at a Swiss tertiary care hospital by calculating the FIB-4 score in routine blood analysis.

METHODS

A retrospective study was conducted using data from 36,360 patients who visited outpatient clinics at eight main clinics of the University Hospital Bern in Switzerland. The data collection period ran from January 1st to December 31st, 2022. Patients attending the hepatology outpatient clinic were excluded. We then calculated the overall and clinic-specific prevalence of patients falling into the high risk category for advanced fibrosis according to FIB-4.

RESULTS

Among the 36,360 patients, 26,245 (72.2%) had a low risk of advanced fibrosis (FIB-4 <1.3), whereas 3913 (10.8%) and 2597 (7.1%) patients were flagged to have a high risk of advanced fibrosis (FIB-4 >2.67 and FIB-4 >3.25 respectively). Geriatrics and Cardiology had the highest proportions of patients at risk for advanced fibrosis over all clinics.

CONCLUSIONS

This study demonstrates a high prevalence of high FIB-4 score in a Swiss tertiary care hospital. The implementation of the automatically generated FIB-4 score in daily practice, not only in primary care, but also within tertiary care hospitals, could be crucial for early identification of outpatients at high risk of advanced liver fibrosis requiring further hepatological investigations.

Prognostic performance of the two-step clinical care pathway in metabolic dysfunction-associated steatotic liver disease

BACKGROUND & AIMS

Current guidelines recommend a 2-step approach for risk stratification in patients with metabolic dysfunction-associated steatotic liver disease (MASLD) with Fibrosis-4 index (FIB-4) followed by liver stiffness measurement (LSM) by vibration-controlled transient elastography (VCTE) or similar second-line tests. This study aimed to examine to prognostic performance of this approach.

METHODS

The VCTE-Prognosis Study was a longitudinal study of patients with MASLD who had undergone VCTE examinations at 16 centres from the US, Europe and Asia with subsequent follow-up for clinical events. The primary endpoint was incident liver-related events (LREs), defined as hepatic decompensation and/or hepatocellular carcinoma.

RESULTS

Of 12,950 patients (mean age 52 years, 41% female, 12.1% LSM >12 kPa), baseline FIB-4, at cut-offs of 1.3 (or 2.0 for age ≥65) and 2.67, classified 66.3% as low-risk and 9.8% as high-risk, leaving 23.9% in intermediate-risk zone. After classifying intermediate FIB-4 patients as low-risk if LSM was <8.0 kPa and high-risk if LSM was >12.0 kPa, 81.5%, 4.6%, and 13.9% of the full cohort were classified as low-, intermediate-, and high-risk respectively. At a median (IQR) follow-up of 47 (23-72) months, 248 (1.9%) patients developed LREs. The 5-year cumulative incidence of LREs was 0.5%, 1.0% and 10.8% in the low-, intermediate- and high-risk groups, respectively. Replacing LSM with Agile 3+, Agile 4, and FAST did not reduce the intermediate-risk zone or improve event prediction. Classifying intermediate FIB-4 patients by LSM <10 kPa (low-risk) and >15 kPa (high-risk) reduced the intermediate-risk zone while maintaining prediction performance.

CONCLUSIONS

Non-invasive 2-step approach by FIB-4 followed by LSM is effective in classifying patients at different risks of LREs.

IMPACT AND IMPLICATIONS

Metabolic dysfunction-associated steatotic liver disease (MASLD) is emerging as one of the leading causes of cirrhosis and hepatocellular carcinoma worldwide, but only a minority of patients will develop these complications. Therefore, it is necessary to use non-invasive tests instead of liver biopsy for risk stratification. Additionally, as most patients with MASLD are seen in primary care instead of specialist settings, cost and availability of the tests should be taken into consideration. In this multicentre study, the use of Fibrosis-4 index followed by liver stiffness measurement by vibration-controlled transient elastography effectively identified patients who would later develop liver-related events. The results support current recommendations by various regional guidelines on a clinical care pathway based on non-invasive tests to diagnose advanced liver fibrosis.

Noninvasive Assessment of the Severity of Liver Fibrosis in MASLD Patients with Long-Standing Type 2 Diabetes

BACKGROUND

Type 2 diabetes mellitus (T2DM) and metabolic dysfunction-associated steatotic liver disease (MASLD), which have a reciprocal relationship compounded by obesity, are highly prevalent in the Middle East affecting morbidity, mortality, and healthcare costs.

OBJECTIVE

This study aimed to assess the severity of MASLD and liver fibrosis among adult Emirati patients with long-standing T2DM.

DESIGN AND PARTICIPANTS

This cross-sectional study used noninvasive methods to assess the severity of MASLD and fibrosis progression in an adult cohort of Emirati patients (N = 546) with a mean T2DM duration of 16 years.

MAIN MEASURES

Fatty liver infiltration was assessed by hepatic steatosis index (HSI), while fibrosis was assessed by the fibrosis-4 (FIB-4) index and aspartate aminotransferase/platelet ratio index (APRI). Of those, 108 patients were randomly subjected to ultrasound-based FibroScan® to assess controlled attenuation parameter (CAP) and liver stiffness measurement (LSM).

KEY RESULTS

All patients had fatty liver with ~ 83% being categorized as having severe steatosis. Serum-based fibrosis biomarker panels detected significant liver fibrosis in ~ 2.5% of these patients. The APRI appeared to be more restrictive in detecting moderate fibrosis (1.5%) than the FIB-4 index (25.5%). CAP significantly correlated with the LSM, indicating that the two methods contributed to the same underlying pathophysiology. Liver steatosis was more severe in female patients, who were older and had a higher body mass index (BMI) than those with moderate or no significant fibrosis. They also had higher serum liver enzymes and were more likely to have age-related changes in kidney function. Interestingly, severity of both steatosis and fibrosis remained unaffected by age and duration of T2D except for fibrosis severity detected by FibroScan®.

CONCLUSIONS

This study highlights the critical need for routine screening of MASLD among Emirati patients with long-standing T2DM, given the high point prevalence of severe steatosis (~ 83%), predominantly among women in this population.

Cardiac metabolic index as a predictor of new-onset diabetes in non-alcoholic fatty liver disease patients: a longitudinal cohort analysis

OBJECTIVE

The purpose of this investigation is to assess the clinical risk linked to the onset of diabetes in individuals with non-alcoholic fatty liver disease (NAFLD) through the utilization of the cardiac metabolic index (CMI), which is derived from triglycerides, high-density lipoprotein, height, and waist circumference. Research focusing on the application of CMI for evaluating diabetes risk among NAFLD patients remains scarce, and an exploration of the association between CMI and the emergence of diabetes within this demographic has not been conducted. This investigation aims to illuminate this connection, thereby providing novel insights into the prevention of diabetes progression in individuals with NAFLD.

METHODS

Data were procured from a cross-sectional study involving 15,435 participants conducted by the Japanese government, resulting in a final cohort of 2,503 adults aged 18 and above who met the eligibility criteria for evaluation. The CMI is determined using the formula: TG (mmol/L) / HDL-C (mmol/L) * WHtR. CMI values were categorized into quartiles (Q1 to Q4) based on their scores, arranged from low to high. The investigation utilized logistic regression models, restricted cubic spline analysis, and subgroup analyses, with adjustments made for continuous models to elucidate the association between CMI and diabetes development among individuals with NAFLD, as well as the non-linear relationship between CMI and this outcome.

RESULTS

The investigation comprised 2,503 subjects with an average age of 44.79 ± 8.33 years, of whom 204 were diagnosed with new-onset diabetes (8.15%). Multivariate logistic regression analysis indicated that within the CMI quartile groupings, individuals with NAFLD in the uppermost quartile (Q4) exhibited the greatest likelihood of new-onset diabetes relative to those in the lowest quartile (Q1) (odds ratio, OR = 3.239, 95% confidence interval [CI]: 1.993-5.264, P < 0.001). Additionally, escalating CMI values corresponded to an increasing probability of new-onset diabetes in NAFLD subjects (OR = 1.705, 95% CI: 1.362-2.133, P < 0.001). Restricted cubic spline analysis demonstrated a non-linear connection between CMI and new-onset diabetes in NAFLD patients (P overall < 0.001, P non-linear = 0.035), with a risk inflection point identified at a CMI of 0.5554. Subgroup analysis revealed no significant interactions between gender, age, physical activity, alcohol consumption, or smoking status and the likelihood of new-onset diabetes in this patient population (P for interaction > 0.05).

CONCLUSION

Findings from this study indicate a notable positive non-linear connection between elevated CMI scores and the probability of new-onset diabetes in individuals afflicted with NAFLD.

CLINICAL TRIAL NUMBER

Not applicable.

Association of exposure to multiple volatile organic compounds with ultrasound-defined hepatic steatosis and fibrosis in the adult US population: NHANES 2017-2020

Objective

Volatile organic compounds (VOCs) are pervasive environmental pollutants known to impact human health, but their role in liver steatosis or fibrosis is not fully understood. This study investigates the association of urinary VOC mixtures with the risk of liver steatosis and fibrosis in U.S. adult population.

Methods

Data of 1854 adults from the National Health and Nutrition Examination Survey (NHANES) from 2017.01 to 2020.03 were collected. Vibration Controlled Transient Elastography (VCTE) assessed hepatic steatosis and liver fibrosis via the controlled attenuation parameter (CAP) and liver stiffness measurement (LSM), respectively. The study examined the relationship between urinary exposure biomarkers for 20 VOCs and liver health outcomes using multivariate logistic regression and Bayesian Kernel Machine Regression (BKMR) to evaluate the effects of both individual and mixed VOC exposures.

Results

Multivariate logistic regression analysis revealed that exposure biomarkers for acrolein and crotonaldehyde were positively associated with hepatic steatosis. Conversely, biomarkers for styrene, ethylbenzene, and propylene oxide were negatively associated with hepatic steatosis. Furthermore, biomarkers for 1,3-butadiene and xylene were positively associated with liver fibrosis, while ethylbenzene was negatively associated with this condition. BKMR analysis identified a significant positive joint effect of VOC biomarkers on CAP. Notably, when other VOC-EBs were held at median levels, biomarkers for acrolein and 1,3-butadiene exhibited linear correlations with Ln CAP and hepatic Ln LSM, respectively.

Conclusion

The study highlights the potential hepatotoxic effects of VOC mixtures, particularly noting the roles of acrolein and 1,3-butadiene in exacerbating liver steatosis and fibrosis. These findings advocate for further research to explore the mechanistic pathways and conduct longitudinal studies to establish causality and enhance understanding of VOCs' impact on liver health.

Dietary Interventions and Physical Activity as Crucial Factors in the Prevention and Treatment of Metabolic Dysfunction-Associated Steatotic Liver Disease

Metabolic dysfunction-associated steatotic liver disease (MASLD) is the most common chronic liver disease worldwide and affects nearly 30% of the adult population and 10% of the pediatric population. It is estimated that this number will double by 2030. MASLD is one of the leading causes of hepatocellular carcinoma, cirrhosis, and liver transplantation, as well as a significant risk factor for cardiovascular disease and mortality. Due to the ever-increasing number of patients, the long-term asymptomatic course of the disease, serious complications, and lack of preventive programs, as well as insufficient awareness of the disease among patients and doctors themselves, MASLD is a growing interdisciplinary problem and a real challenge for modern medicine. The main cause of MASLD is an inappropriate lifestyle-inadequate nutrition and insufficient physical activity, which lead to various components of metabolic syndrome. Lifestyle changes-appropriate diet, weight reduction, and systematic physical activity-are also the basis for the prevention and treatment of MASLD. Hence, in recent years, so much importance has been attached to lifestyle medicine, to non-pharmacological treatment as prevention of lifestyle diseases. The narrative review presents possible therapeutic options for non-pharmacological management in the prevention and treatment of MASLD. The best documented and available diets used in MASLD were discussed, focusing on the benefits and drawbacks of the Mediterranean, high-protein, ketogenic, and intermittent fasting diets. In addition, the most recent recommendations regarding physical activity are summarized.

Pan-PPAR agonist lanifibranor improves insulin resistance and hepatic steatosis in patients with T2D and MASLD

BACKGROUND & AIMS

Lanifibranor is a pan-PPAR agonist that improves glucose/lipid metabolism and reverses steatohepatitis and fibrosis in adults with MASH. We tested its effect on insulin resistance at the level of different target tissues in relationship to change in intrahepatic triglyceride (IHTG) content.

METHODS

This phase 2, single center, study randomized (1:1) 38 patients with T2D and MASLD to receive lanifibranor 800 mg or placebo for 24 weeks. The primary endpoint was the change in IHTG (1H-MRS). The main prespecified secondary endpoint was the change in hepatic, muscle and adipose tissue insulin sensitivity using the gold-standard euglycemic hyperinsulinemic clamp technique measuring glucose turnover. Other secondary endpoints included changes in cardiometabolic parameters (i.e., HbA1c, lipid profile, adiponectin).

RESULTS

Lanifibranor compared to placebo significantly lowered IHTG (full analysis set [FAS] -44% vs. -12%, respectively; least squares mean difference -31%, 95% CI -51 to -12%; in completers -50% vs. -16%; both p<0.01). More patients reached ≥30% IHTG reduction with lanifibranor compared to placebo (FAS 65% vs. 22%; completers 79% vs. 29%; both p<0.01) and steatosis resolution (FAS 25% vs. 0%; p<0.05). Lanifibranor significantly improved hepatic and peripheral insulin resistance (i.e., fasting endogenous [primarily hepatic] glucose production, hepatic IR, and insulin-stimulated muscle glucose disposal or Rd). Secondary metabolic endpoints also improved (fasting glucose, insulin, HOMA-IR, HbA1c; HDL-C), and adiponectin increased 2.4-fold (all p<0.001). Lanifibranor caused modest weight gain (+2.7%). Adverse events were mild (gastrointestinal side effects, hemoglobin decrease) and drug-related TEAE leading to study discontinuation were balanced between groups.

CONCLUSIONS

Lanifibranor significantly improves hepatic, muscle and adipose tissue insulin resistance. Lanifibranor treatment was safe and effective in reducing hepatic steatosis and cardiometabolic risk factors associated with metabolic dysfunction.

IMPACT AND IMPLICATIONS

No prior studies have evaluated the effect of lanifibranor on insulin sensitivity at the level of muscle, liver and adipose tissue and its relationship to changes in intrahepatic triglyceride (IHTG) content in insulin resistant subjects with MASLD and T2D. We observed a significant decrease in IHTG after 24 weeks of treatment (by ∼50%, p < 0.001 versus placebo) that was associated with a major improvement in hepatic and peripheral (Rd) insulin sensitivity, restoration of adipose tissue function with more than two-fold increase in plasma adiponectin concentration and improvement in cardiometabolic risk factors. This is the first in-depth study on how a pan-PPAR approach reverses steatosis and metabolic dysfunction in patients with T2D and MASLD. It has important clinical implications because it offers proof-of-concept that by targeting the key underlying metabolic defects in MASLD (i.e., insulin resistance, lipotoxicity and hyperglycemia) one can restore cardiometabolic health and offers a compelling rationale for treating with lanifibranor individuals with MASLD, either alone or in combination with weight loss and other treatment strategies.

CLINICALTRIALS

GOV IDENTIFIER

NCT03459079.

Comparison of Referral Rates and Costs Using Fibrosis-4 and Enhanced Liver Fibrosis (ELF) Testing Strategies for Initial Evaluation of Metabolic Dysfunction-Associated Steatotic Liver Disease (MASLD) in a Veteran Population

BACKGROUND

Global metabolic dysfunction-associated steatotic liver disease (MASLD) prevalence is estimated at 30% and projected to reach 55.7% by 2040. In the Veterans Affairs (VA) healthcare system, an estimated 1.8 million veterans have metabolic dysfunction-associated steatohepatitis (MASH).

METHODS

Adult patients at risk for MASLD in a VA healthcare system underwent Fibrosis-4 (FIB-4) and Enhanced Liver Fibrosis (ELF®) testing. Referral rates and cost savings were compared among 6 noninvasive testing (NIT) strategies using these 2 tests independently or sequentially at various cutoffs.

RESULTS

Enrolled patients (N = 254) had a mean age of 65.3 ± 9.3 years and mean body mass index (BMI) of 31.7 ± 6, 87.4% male: 78.3% were non-Hispanic/Latino, and 96.5% had type 2 diabetes mellitus (T2DM). Among the 6 evaluated strategies, using FIB-4 followed by ELF at a 9.8 cutoff yielded the highest proportion of patients retained in primary care without need of referral to hepatology clinic (165/227; 72.7%), and was associated with the lowest costs ($407.62). Compared to the FIB-4 only strategy, FIB-4/ELF with a 9.8 cutoff strategy resulted in 26% fewer referrals and 8.47% lower costs. In the subgroup of patients with BMI >32, there were 25.17% fewer referrals and costs were 8.31% lower.

CONCLUSIONS

Our study suggests that sequential use of ELF with a 9.8 cutoff following indeterminate FIB-4 tests results in lower referral rates and lower care costs in a veteran population at risk of MASLD. Adding ELF as a sequential test after indeterminate FIB-4 might help reduce the number of referrals and overall cost of care.

Association between neutrophil-to-high-density lipoprotein cholesterol ratio and non-alcoholic fatty liver disease or metabolic dysfunction-associated steatotic liver disease: evidence from NHANES 2017-2020

Background

Non-alcoholic fatty liver disease (NAFLD) or metabolic dysfunction-associated steatotic liver disease (MASLD) is closely associated with chronic inflammation and lipid metabolism disorders. The neutrophil-to-high-density lipoprotein cholesterol ratio (NHR) is an integrative marker reflecting inflammatory responses and lipid metabolism disorders and is associated with various diseases. This cross-sectional study aimed to determine the association between NHR and NAFLD, MASLD, and liver fibrosis.

Methods

Data for this study were obtained from the 2017-2020 National Health and Nutrition Examination Survey (NHANES), we employed weighted multiple regression and restricted cubic spline (RCS) analysis to assess the relationship between NHR and NAFLD, MASLD, and liver fibrosis. Additionally, we performed stratified analyses based on gender, age, body mass index, diabetes, hypertension, smoking status, and history of cardiovascular disease to evaluate the consistency of these associations across different subgroups.

Results

A total of 6,526 participants were included in the study. 2,839 (weighted 44.1%) participants were diagnosed with NAFLD and 2,813 (weighted 43.7%) participants were diagnosed with MASLD. After adjusting for confounders, NHR was positively associated with the risk of NAFLD/MASLD, and the correlation was particularly significant in the subgroups of females, those without hypertension, and those without diabetes (p < 0.05). By the NHR quartile, the risk of NAFLD/MASLD increased progressively with higher NHR levels (P for trend <0.001). In addition, RCS analysis showed a nonlinear association between NHR and NAFLD/MASLD and liver fibrosis (P-non-linear <0.05).

Conclusion

NHR may serve as a potential marker for NAFLD/MASLD and liver fibrosis, and lowering NHR levels could help reduce the incidence of these conditions.

BMI trajectories are associated with NAFLD and advanced fibrosis via aging-inflammation mediation

BACKGROUND

As the global epidemic of obesity fuels metabolic conditions, the burden of nonalcoholic fatty liver disease (NAFLD) will become enormous. Abundant studies revealed the association between high body mass index (BMI) and NAFLD but overlooked the BMI patterns across life stages. We aimed to explore how BMI trajectories over age relate to NAFLD.

METHODS

Selecting 3212 participants in NHANES 2017-2020, we tracked BMI records at different ages. Using a latent class trajectory model (LCTM), we identified BMI trajectories over age. Multinomial logistic regression assessed their association with NAFLD and advanced fibrosis. Structural equation modeling (SEM) revealed mediation effects.

RESULTS

We identified 3 BMI trajectories: Steady Progression, Increase to Decrease, and Rapid Ascending. There was no significant difference in NAFLD/advanced fibrosis risk between the increase-to-decrease group and the steady progression group. The Rapid Ascending trajectory significantly correlated with NAFLD (OR = 2.21, 95% CI 1.29-3.77) and advanced fibrosis (OR = 3.04, 95% CI 1.13-8.22). This association was influenced by a chain-mediated process of phenotypic age and C-reactive protein (mediated effect to NAFLD = 0.010, p < 0.01; mediated effect to advanced fibrosis = 0.003, p < 0.05). This mediation on NAFLD was independent of insulin resistance (IR). The association between rapid ascending trajectory and advanced fibrosis was more pronounced among the male subgroup (p for interaction = 0.008).

CONCLUSION

The rapid ascending trajectory of BMI correlates with an increased susceptibility to NAFLD and advanced fibrosis independent of BMI, mediated by aging and inflammation. Our results suggest that long-term maintenance of BMI is pivotal in NAFLD prevention. Aging-inflammation may represent a distinct mechanism of sustained obesity to NAFLD, independent of IR.

Nutritional Strategies for Battling Obesity-Linked Liver Disease: the Role of Medical Nutritional Therapy in Metabolic Dysfunction-Associated Steatotic Liver Disease (MASLD) Management

PURPOSE OF REVIEW

This narrative review explores the role of Medical Nutritional Therapy (MNT) in managing Metabolic-Associated Steatotic Liver Disease (MASLD), previously known as nonalcoholic fatty liver disease. It aims to examine the effectiveness of specific nutritional strategies in preventing and treating this obesity-linked liver disease.

RECENT FINDINGS

Emerging evidence underscores the benefits of the Mediterranean diet, low-carbohydrate diets, and intermittent fasting in reducing liver fat, improving insulin sensitivity, and mitigating inflammation. Supplementing with vitamin E, omega-3 fatty acids, and silymarin can potentially reduce liver fibrosis and promote liver health. MNT is a key intervention for MASLD management, emphasizing dietary patterns, caloric restriction, and nutraceutical supplementation. Integrating these strategies with lifestyle modifications, including regular physical activity, offers a comprehensive approach to improving metabolic and liver outcomes in patients with MASLD. Further research is needed to refine and personalize these therapeutic interventions.

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.

A novel human specific lncRNA MEK6-AS1 regulates adipogenesis and fatty acid biosynthesis by stabilizing MEK6 mRNA

BACKGROUND

Obesity is becoming one of the major non-communicable diseases with increasing incidence and risks that cannot be ignored. However effective and safe clinical treatment strategies still need to be deeply explored. Increased number and volume of adipocytes lead to overweight and obesity. The aim of our work is to identify lncRNAs that have important regulatory in differentiation of human mesenchymal stem cells (MSCs) into adipocytes, and to provide effective targets for clinical prevention and treatment of obesity and related metabolic disorders.

METHODS

We extracted primary MSCs from human adipose tissue, and conducted expression profile analysis of lncRNAs during adipogenic differentiation of MSCs to screen changed lncRNAs. Characteristics of lncRNA were revealed mainly by RACE and RNA FISH. Loss- and gain-of function experiments in vivo and in vitro were used to analyze effects of lncRNA. Targeted metabolomics was utilized to detect levels of free fatty acids. RNA pull-down, mRNA stability tests, etc. were employed to explore mechanisms of lncRNA.

RESULTS

Human-specific lncRNA, we named it MEK6-AS1, was the most up-regulated transcript during adipogenic differentiation of MSCs. MEK6-AS1 was highly expressed in adipose tissue samples from individuals with BMI ≥ 25 and positively correlated with adipogenic marker genes in these samples. Knocking down lncRNA inhibited expression of adipogenic differentiation markers and ectopic adipogenesis, reducing contents of various free fatty acids, as well as promoting osteogenic differentiation. Overexpression of lncRNA had the opposite effects to the above processes. We also found that MEK6-AS1 was elevated during hepatic steatosis organoid generation. Mechanistically, MEK6-AS1 worked partially through stabilization of MEK6 mRNA by NAT10.

CONCLUSIONS

We have identified a human-specific lncRNA (MEK6-AS1) with position information in the genomic database but has not been extensively reported. We demonstrated that MEK6-AS1 as a novel lncRNA involved in adipogenic differentiation and adipogenesis, fatty acid metabolism, and osteogenic differentiation. We found that MEK6-AS1 may exert its effect by enhancing MEK6 mRNA stability through NAT10. Our study may provide insights into implication of lncRNAs in stem cell biology and offer a new potential therapeutic target for the prevention and treatment of obesity and other related disease.

Pediatric Non-Alcoholic Fatty Liver Disease (NAFLD): Trends, Mortality, and Socioeconomic Disparities in the U.S., 1998-2020

BACKGROUND/OBJECTIVES

We aim to describe the changing inpatient epidemiology of NAFLD in the U.S. and identify major risk factors associated with mortality in the disease among hospitalized pediatric patients.

METHODS

Hospitalization data from the 1998-2020 National Inpatient Sample were utilized. ICD-9 and ICD-10 codes were used to identify pediatric patients (age less than 18 years old) with NAFLD, and risk factors for mortality were analyzed by logistic regression.

RESULTS

We identified 68,869 pediatric hospitalizations involving NAFLD. Among those, 970 (1.4%) died during hospitalization. Hospitalization rates have been rapidly increasing from 1998 to 2020 (incidence rate ratio (IRR): 1.07; 95% CI: 1.06-1.07; p < 0.001). There was a significant difference in mortality based on the type of hospital (rural, non-teaching urban, or teaching urban) in pediatric patients with NAFLD (p < 0.05). Coagulopathy was significantly associated with increased odds of mortality, while age ≥ 12 years, diabetes and obesity were associated with decreased odds of mortality (p < 0.05). Sex, race/ethnicity, hepatitis B, hepatitis C, HIV, and IV drug use were not significantly associated with mortality.

CONCLUSIONS

Our study has shown ever increasing hospitalization rates for NAFLD in pediatric populations and well as significant risk factors associated with mortality. Further studies should be performed as more data on this patient population are collected.

Natural History of Metabolic Dysfunction-Associated Steatotic Liver Disease: From Metabolic Syndrome to Hepatocellular Carcinoma

Introduction: Metabolic Dysfunction-Associated Steatotic Liver Disease (MASLD) stems from disrupted lipid metabolism in the liver, often linked to obesity, type 2 diabetes, and dyslipidemia. In Mexico, where obesity affects 36.9% of adults, MASLD prevalence has risen, especially with metabolic syndrome affecting 56.31% by 2018. MASLD can progress to Metabolic Dysfunction-Associated Steatohepatitis (MASH), affecting 5.27% globally, leading to severe complications like cirrhosis and hepatocellular carcinoma. Background: Visceral fat distribution varies by gender, impacting MASLD development due to hormonal influences. Insulin resistance plays a central role in MASLD pathogenesis, exacerbated by high-fat diets and specific fatty acids, leading to hepatic steatosis. Lipotoxicity from saturated fatty acids further damages hepatocytes, triggering inflammation and fibrosis progression in MASH. Diagnosing MASLD traditionally involves invasive liver biopsy, but non-invasive methods like ultrasound and transient elastography are preferred due to their safety and availability. These methods detect liver steatosis and fibrosis with reasonable accuracy, offering alternatives to biopsy despite varying sensitivity and specificity. Conclusions: MASLD as a metabolic disorder underscores its impact on public health, necessitating improved awareness and early management strategies to mitigate its progression to severe liver diseases.

Evidence summary of lifestyle interventions in adults with metabolic dysfunction-associated steatotic liver disease

Objective

In this study, our objective was to provide practice recommendations by thoroughly examining lifestyle interventions for adults diagnosed with metabolic dysfunction-associated steatotic liver disease (MASLD). This was achieved through a systematic review of the literature, specifically focusing on lifestyle modification interventions in adults with MASLD.

Methods

The PIPOST (Population, Intervention, Professional, Outcome, Setting, and Type of evidence) framework was used to identify the questions for summarizing evidence. Utilizing the 6S model for the hierarchy of evidence, a computerized search was conducted to retrieve articles pertaining to lifestyle interventions for adults with MASLD from websites such as the UpToDate Clinical Advisor, BMJ Best Practice, JBI Library, Cochrane Library, International Guidelines Library, and PubMed, among others. The available research included clinical decisions, clinical practice guidelines, evidence summaries, systematic evaluation, expert consensus, and expert opinions. Two researchers independently evaluated the methodology of the studies, and evidence was subsequently extracted and grouped thematically. Our review encompassed publications from January 2018 to March 2023.

Results

A total of 26 publications were identified for the final review, consisting of seven guidelines, nine systematic evaluations, and 10 expert consensuses/opinions. From these sources, we derived six themes, 28 pieces of evidence: intervention modalities, diet management, exercise management, weight loss management, personalized management, and multidisciplinary collaboration.

Conclusion

In the management of adults with MASLD, healthcare professionals should embrace a multidisciplinary team approach, adhere to the best available evidence, and develop structured and personalized interventions based on the best evidence for lifestyle modifications.

Elevated GGT to HDL ratio as a marker for the risk of NAFLD and liver fibrosis

This study investigated the association between NAFLD and liver fibrosis and the ratio of gamma-glutamyl transferase to high-density lipoprotein cholesterol (GGT/HDL-C). In this cross-sectional study, we included 4764 subjects who participated in the National Health and Nutrition Examination Survey (NHANES) during 2017-2018. Adjusted multivariate logistic regression analysis was utilized to evaluate the relationships between GGT/HDL-C levels and NAFLD, fatty liver degree, and liver fibrosis. The non-linear link between NAFLD and the GGT/HDL-C ratio was examined using generalized additive models. There was a non-linear association between GGT/HDL-C and the risk of NAFLD, and all regression models demonstrated a strong relationship between GGT/HDL-C levels and the risk of liver fibrosis, the degree of hepatic steatosis, and the prevalence of NAFLD. Subgroup analyses revealed a significant correlation between the risk of NAFLD and the GGT/HDL-C ratio among Mexican Americans and young people in the 20-40 age range. The receiver operating characteristic (ROC) study showed that GGT/HDL-C was a more accurate predictor of NAFLD than GGT or HDL-C alone. In the U.S. population, an increased risk of NAFLD, the severity of hepatic steatosis, and the risk of liver fibrosis are independently correlated with an elevated GGT/HDL-C ratio.

Estimated Burden of Metabolic Dysfunction-Associated Steatotic Liver Disease in US Adults, 2020 to 2050

Importance

Metabolic dysfunction-associated steatotic liver disease (MASLD) is the most common cause of chronic liver disease and is projected to become the leading indication for liver transplant (LT) in the US. Understanding its clinical burden can help to identify opportunities for prevention and treatment.

Objective

To project the burden of MASLD in US adults from 2020 to 2050.

Design, Setting, and Participants

This decision analytical modeling study used an agent-based state transition model that simulates the natural history of MASLD progression among adults 18 years of age or older. Primary data sources for model inputs were the published literature.

Exposure

Natural history of MASLD.

Main Outcomes and Measures

Cases of MASLD, metabolic dysfunction-associated steatohepatitis (MASH), fibrosis, hepatocellular carcinoma (HCC), LT, and liver-related death.

Results

The model simulated 2 821 624 individuals (mean age. 35.8 years; 50.9% female). The model predicted a steady increase in the prevalence of MASLD from 33.7% (86.3 million people) in 2020 to 41.4% (121.9 million people) by 2050. Cases of MASH would increase from 14.9 million (5.8% of US adults) in 2020 to 23.2 million (7.9% of US adults) by 2050. The number of cases of MASH and clinically significant fibrosis (ie, F≥F2, centrilobular and periportal fibrosis or more severe disease) were estimated to increase from 6.7 million to 11.7 million. By 2046 to 2050, MASLD would cause 22 440 new cases of HCC and 6720 new cases of LT per year compared with 11 483 new cases of HCC and 1717 new cases of LT in 2020 to 2025. Liver-related mortality was estimated to increase from 30 500 deaths (1.0% of all-cause deaths in adults) in 2020 to 95 300 deaths (2.4%) in 2050.

Conclusions and Relevance

In this decision analytical modeling study, the model forecast a substantial increase in clinical burden of MASLD over the next 3 decades in the absence of effective treatments. These results suggest that health systems should plan for large increases in the number of HCC cases and in the need for LT.

U-shaped associations between body mass index and serum liver enzyme levels

Liver enzymes are associated with liver function, but their relationship with body mass index (BMI) remains unclear. This cross-sectional study aimed to identify correlations between serum liver enzyme levels and BMI in the general population. The data were derived from the Dryad Digital Repository. Smooth curve and multiple linear regression analyses were performed to evaluate the associations between BMI and serum liver enzyme levels. A total of 15,464 participants, including 8430 males (54.5%), were included in the study, with a median age of 43.7 years. Smooth curve regression revealed that BMI followed U-shaped curves with respect to serum levels of liver enzymes (AST, ALT, and GGT). For AST serum levels, the turning points were BMI = 19.0 and 23.3 kg/m2; for ALT serum levels, the inflection points were BMI = 19.0 and 23.1 kg/m2; and for GGT serum levels, the inflection point was BMI = 19.5 kg/m2. In addition, stratified analysis revealed that sex, fatty liver, and smoking status as covariates modified the associations between BMI and AST and ALT serum levels in participants with higher BMIs (all interactions P < 0.01). Specifically, in the higher BMI range, the positive associations between BMI and liver enzymes were more robust in men (AST and ALT), participants with fatty liver disease (AST and ALT), and participants with a history of smoking (AST, ALT, and GGT). Interestingly, alcohol consumption modified the association between BMI and GGT serum levels, regardless of BMI. Our study is the first to identify a U-shaped association between BMI and serum levels of liver enzymes in the general population, which suggests a new target for regulating liver enzyme levels.

Influence of glucagon-like peptide-1 receptor agonists on hepatic events in type 2 diabetes: a systematic review and meta-analysis

BACKGROUND AND AIM

Type 2 diabetes mellitus (T2DM) is intrinsically linked to various etiologies of liver disease, with 69% of patients having concomitant metabolic dysfunction-associated steatotic liver disease (MASLD). Studies suggest glucagon-like peptide-1 receptor agonists (GLP-1RAs) can ameliorating liver disease. With this analysis, we address the gap in knowledge about the effectiveness of these agents in preventing different major adverse liver outcomes (MALOs).

METHODS

PubMed, Embase, and The Cochrane Central of Trials were searched for articles reporting MALOs in T2DM patients. Publication bias-identifying methods, quality assessment and sensitivity analyses (subgroup analyses, leave-one-out meta-analyses, and meta-regression) were employed. Statistical analyses were performed in R using the "meta" and "metafor" packages.

RESULTS

Nine cohort studies from 535 identified articles encompassing 579 256 T2DM patients were included in the main analyses. GLP-1RA use was associated with reduced risks of hepatocellular carcinoma (HR 0.74, 95% CI 0.56-0.96) and cirrhosis decompensation (HR 0.68, 95% CI 0.65-0.72). Within the latter, variceal bleeding and hepatic encephalopathy prevention were found to be significantly reduced. Egger's test, Begg's test, and funnel-plot analysis yielded no publication bias. No significant differences were observed in preventing cirrhosis or hepatic failure. Meta-regression analysis revealed a positive correlation between hepatocellular carcinoma incidence and both male sex and longer follow-up duration.

CONCLUSIONS

This meta-analysis improves our understanding of the hepatoprotective effects of GLP-1RAs in T2DM patients and supports existing research, exhibiting superiority over other antidiabetic medications for hepatoprotection in this subgroup. Additional long-term follow-up studies are necessary to further validate these findings.

Elevated concurrent carotid atherosclerosis rates in patients with metabolic dysfunction-associated fatty liver disease (MAFLD) compared to non-alcoholic fatty liver disease (NAFLD): A cross-sectional observational study

BACKGROUND AND AIM

Non-alcoholic fatty liver disease (NAFLD) has been recognized as an independent risk factor for atherosclerotic cardiovascular disease. Recently, there has been a shift towards diagnosing metabolic dysfunction-associated fatty liver disease (MAFLD), offering simplified criteria and improved risk assessment. However, the association between MAFLD and carotid atherosclerosis remains poorly understood.

METHODS AND RESULTS

The study analyzed the association of concurrent carotid atherosclerosis between NAFLD and MAFLD patients with a retrospective cohort design. The study enrolled participants who underwent abdominal and carotid artery ultrasounds from a medical center in Taiwan. NAFLD and MAFLD were diagnosed based on imaging and specific criteria. Associations between NAFLD, MAFLD, and carotid atherosclerosis were analyzed using logistic regression. Among 11,194 participants, 57.1 % were diagnosed with fatty liver disease, among which the NAFLD-MAFLD group comprised 4689 individuals, with 900 in the NAFLD-only group and 669 in the MAFLD-only group. Significant demographic and clinical differences were observed between groups. Logistic regression showed that the MAFLD-NAFLD group and MAFLD-only group had significantly higher odds of concomitant carotid atherosclerosis. Among MAFLD patients, 65.5 % had concurrent carotid arteriosclerosis with an odds ratio of 2.35 compared to non-MAFLD patients. The odds ratios for variables in MAFLD patients, such as diabetes mellitus, Fibrosis-4(FIB-4), number of FIB-4 > 1.3, and number of NAFLD fibrosis score > -1.455 were all greater than 2.

CONCLUSIONS

MAFLD is associated with a higher prevalence of carotid atherosclerosis, compared to NAFLD. This suggests that MAFLD may serve as a significant risk factor for cardiovascular complications.