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Brodosi L, Stecchi M, Musio A, Bazzocchi M, Risi E, Marchignoli F, Marchesini G, Petroni ML. Anxiety and depression in metabolic-associated steatotic liver disease: relation with socio-demographic features and liver disease severity. Acta Diabetol 2024; 61:1041-1051. [PMID: 38684539 PMCID: PMC11329404 DOI: 10.1007/s00592-024-02287-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2024] [Accepted: 04/09/2024] [Indexed: 05/02/2024]
Abstract
PURPOSE We aimed to evaluate the prevalence of anxiety and depression traits in Italian patients with metabolic dysfunction-associated steatotic liver disease (MASLD), and the possible relation with the severity of liver disease. METHODS Demographic, anthropometric, clinical and laboratory parameters were collected in patients referred to a metabolic unit for a comprehensive evaluation of possible liver disease. Hepatic steatosis and fibrosis were evaluated by surrogate biomarkers. Imaging (controlled attenuation parameter-CAP and vibration-controlled transient elastography-VCTE). Beck depression inventory (BDI) and state-trait anxiety inventory-Y (STAI-Y) were used to define depressive/anxiety states; calorie intake and lifestyle were self-assessed by questionnaires. RESULTS The whole sample comprised 286 patients (61.9% females; mean age 52.0 years; BMI, 34.6 kg/m2); 223 fulfilled MASLD criteria. BDI and trait anxiety scores were lower in the MASLD cohort, and the prevalence of both moderate/severe depression and severe trait anxiety was reduced compared with non-MASLD cases, despite VCTE-diagnosed fibrosis F3-F4 present in over 15% of cases. However, after correction for demographic and anthropometric confounders, MASLD was not associated with a lower risk of moderate/severe depression or severe anxiety trait (odds ratio, 0.34; 95% confidence interval, 0.12-1.01 and 0.79, 0.27-2.34). Additional adjustment for the severity of fibrosis did not change the results. No differences in state anxiety were observed. CONCLUSION The risk of anxiety and depression in MASLD is not different from that generated by diabetes and obesity per se. MASLD patients do not perceive liver disease as a specific source of psychological distress, possibly as a consequence of the unawareness of progressive liver disease.
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Affiliation(s)
- Lucia Brodosi
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
- Clinical Nutrition and Metabolism Unit, IRCCS-Azienda Ospedaliero-Universitaria Di Bologna, Bologna, Italy
| | - Michele Stecchi
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Alessandra Musio
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
- Clinical Nutrition and Metabolism Unit, IRCCS-Azienda Ospedaliero-Universitaria Di Bologna, Bologna, Italy
| | - Matilde Bazzocchi
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Eleonora Risi
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Francesca Marchignoli
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
- Clinical Nutrition and Metabolism Unit, IRCCS-Azienda Ospedaliero-Universitaria Di Bologna, Bologna, Italy
| | | | - Maria Letizia Petroni
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy.
- Clinical Nutrition and Metabolism Unit, IRCCS-Azienda Ospedaliero-Universitaria Di Bologna, Bologna, Italy.
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Dallio M, Sangineto M, Romeo M, Cipullo M, Coppola A, Mammone S, Di Gioia G, Masarone M, Persico M, Serviddio G, Federico A. The influence of acute lifestyle changes on NAFLD evolution in a multicentre cohort: a matter of body composition. Nutr Diabetes 2024; 14:33. [PMID: 38802382 PMCID: PMC11130147 DOI: 10.1038/s41387-024-00294-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2023] [Revised: 05/14/2024] [Accepted: 05/15/2024] [Indexed: 05/29/2024] Open
Abstract
BACKGROUND Unhealthy lifestyles represent a key element fueling Non-alcoholic fatty liver disease (NAFLD) onset and worsening. We aimed to evaluate the effects of forced acute lifestyle changes on NAFLD evolution. METHODS 187 NAFLD patients were followed two years pre- and two years during the lockdown social restrictions in three Italian medical centers. For each patient, biochemical, clinical, non-invasive liver fibrosis, nutritional, and body composition data were collected. RESULTS An increase in fats and carbohydrate intake associated with impaired weekly physical activity during the lockdown was demonstrated as well as an increase in body mass index and waist-hip-ratio (p < 0.0001 for all). Total cholesterol, low-density lipoprotein, high-density lipoprotein, triglycerides, glucose, insulin, homeostatic model assessment for insulin resistance, and transaminases worsened during the lockdown (glucose: p = 0.0007; p < 0.0001 for the others). Moreover, NAFLD fibrosis score, liver stiffness, and controlled attenuation parameter were also impaired during the same period (p < 0.0001 for all). The bioelectrical impedance analysis (BIA) evidenced an increase of fat mass (FM), and a reduction of free fat mass (FFM) and body cell mass (BCM) (p < 0.0001 for all). The lockdown overall hepatocellular carcinoma (HCC) and Milan-out HCC occurrence revealed Hazard Ratio (HR): 2.398, 95% Confidence Interval (CI):1.16-5, p = 0.02, and HR:5.931, CI:2-17.6, p = 0.008 respectively. A liver disease stage and comorbidities independent association between both the assessed outcomes and body composition analysis in terms of mean values and variation (T1-T2 Δ) was demonstrated. CONCLUSIONS The acute lifestyle changes impacted NAFLD evolution via body composition modifications negatively influencing the HCC occurrence.
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Affiliation(s)
- Marcello Dallio
- Hepatogastroenterology Division, Department of Precision Medicine, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Moris Sangineto
- University Center for Research and Treatment of Liver Diseases (C.U.R.E.), Liver Unit, University of Foggia, Foggia, Italy
| | - Mario Romeo
- Hepatogastroenterology Division, Department of Precision Medicine, University of Campania "Luigi Vanvitelli", Naples, Italy.
| | - Marina Cipullo
- Hepatogastroenterology Division, Department of Precision Medicine, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Annachiara Coppola
- Hepatogastroenterology Division, Department of Precision Medicine, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Simone Mammone
- Hepatogastroenterology Division, Department of Precision Medicine, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Giuseppe Di Gioia
- University Center for Research and Treatment of Liver Diseases (C.U.R.E.), Liver Unit, University of Foggia, Foggia, Italy
| | - Mario Masarone
- Department of Medicine and Surgery, "Scuola Medica Salernitana", Internal Medicine and Hepatology Unit, University of Salerno, Salerno, Italy
| | - Marcello Persico
- Department of Medicine and Surgery, "Scuola Medica Salernitana", Internal Medicine and Hepatology Unit, University of Salerno, Salerno, Italy
| | - Gaetano Serviddio
- University Center for Research and Treatment of Liver Diseases (C.U.R.E.), Liver Unit, University of Foggia, Foggia, Italy
| | - Alessandro Federico
- Hepatogastroenterology Division, Department of Precision Medicine, University of Campania "Luigi Vanvitelli", Naples, Italy
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Moore E, Patanwala I, Jafari A, Davies IG, Kirwan RP, Newson L, Mazidi M, Lane KE. A systematic review and meta-analysis of randomized controlled trials to evaluate plant-based omega-3 polyunsaturated fatty acids in nonalcoholic fatty liver disease patient biomarkers and parameters. Nutr Rev 2024; 82:143-165. [PMID: 37290426 PMCID: PMC10777680 DOI: 10.1093/nutrit/nuad054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023] Open
Abstract
CONTEXT Nonalcoholic fatty liver disease (NAFLD) is prevalent in 25-30% of British and European populations, representing a potential global public health crisis. Marine omega-3 (n-3) polyunsaturated fatty acids offer well-evidenced benefits to NAFLD biomarkers; however, the effect of plant-based n-3 has not been evaluated with a systematic review and meta-analysis. OBJECTIVE The review aimed to systematically evaluate the effect of plant-based n-3 supplementation on NAFLD surrogate biomarkers and parameters. DATA SOURCES Medline (EBSCO), PubMed, CINAHL (EBSCO), Cochrane Central Register of Controlled Trials, the International Clinical Trials Registry Platform, and Google Scholar databases were searched to identify randomized controlled trials published between January 1970 and March 2022 evaluating the impact of plant-based n-3 interventions on diagnosed NAFLD. The review followed the PRISMA checklist and is PROSPERO registered (CRD42021251980). DATA EXTRACTION A random-effects model and generic inverse variance methods synthesized quantitative data, followed by a leave-one-out method for sensitivity analysis. We identified 986 articles; after the application of selection criteria, six studies remained with 362 patients with NAFLD. RESULTS The meta-analysis showed that plant-based n-3 fatty acid supplementation significantly reduced alanine aminotransferase (ALT) (mean difference: 8.04 IU/L; 95% confidence interval: 14.70, 1.38; I2 = 48.61%) and plasma/serum triglycerides (44.51 mg/dL; 95% confidence interval: -76.93, -12.08; I2 = 69.93%), alongside body-composition markers in patients with NAFLD (P < 0.05). CONCLUSION Plant-based n-3 fatty acid supplementation improves ALT enzyme biomarkers, triglycerides, body mass index, waist circumference, and weight loss when combined with lifestyle interventions to increase physical activity and a calorie-controlled diet. Further research is needed to identify the most effective plant-based n-3 sources in larger numbers of patients with NAFLD over longer study durations. SYSTEMATIC REVIEW REGISTRATION PROSPERO registration no. CRD42021251980.
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Affiliation(s)
- Ella Moore
- Research Institute for Sport and Exercise Sciences, Liverpool John Moores University, Liverpool, United Kingdom
| | | | - Alireza Jafari
- Physiology Research Center, Institute of Neuropharmacology, Kerman University of Medical Sciences, Kerman, Iran
| | - Ian G Davies
- Research Institute for Sport and Exercise Sciences, Liverpool John Moores University, Liverpool, United Kingdom
| | - Richard P Kirwan
- Research Institute for Sport and Exercise Sciences, Liverpool John Moores University, Liverpool, United Kingdom
| | - Lisa Newson
- School of Psychology, Liverpool John Moores University, Liverpool, United Kingdom
| | - Mohsen Mazidi
- Medical Research Council Population Health Research Unit, Clinical Trial Service Unit and Epidemiological Studies Unit (CTSU), Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom
- Department of Twin Research and Genetic Epidemiology, King’s College London, London, United Kingdom
| | - Katie E Lane
- Research Institute for Sport and Exercise Sciences, Liverpool John Moores University, Liverpool, United Kingdom
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Mantovani A, Morieri ML, Aldigeri R, Palmisano L, Masulli M, Bonomo K, Baroni MG, Cossu E, Cimini FA, Cavallo G, Buzzetti R, Mignogna C, Leonetti F, Bacci S, Trevisan R, Pollis RM, Cas AD, de Kreutzenberg SV, Targher G. MASLD, hepatic steatosis and fibrosis are associated with the prevalence of chronic kidney disease and retinopathy in adults with type 1 diabetes mellitus. DIABETES & METABOLISM 2024; 50:101497. [PMID: 37992857 DOI: 10.1016/j.diabet.2023.101497] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/23/2023] [Revised: 10/23/2023] [Accepted: 11/14/2023] [Indexed: 11/24/2023]
Abstract
AIM We examined whether metabolic dysfunction-associated steatotic liver disease (MASLD) with or without significant fibrosis (assessed by validated non-invasive biomarkers) was associated with an increased risk of prevalent chronic kidney disease (CKD) or diabetic retinopathy in people with type 1 diabetes mellitus (T1DM). METHODS We performed a retrospective multicenter cross-sectional study involving 1,409 adult outpatients with T1DM, in whom hepatic steatosis index (HSI) and fibrosis (FIB)-4 index were calculated for non-invasively detecting hepatic steatosis (defined by HSI > 36), with or without coexisting significant fibrosis (FIB-4 index ≥ 1.3 or < 1.3). CKD was defined as an estimated glomerular filtration rate (eGFR) < 60 mL/min/1.73 m2 or urine albumin/creatinine ratio ≥ 3.0 mg/mmol. The presence of diabetic retinopathy was also recorded in all participants. RESULTS Patients with MASLD and significant fibrosis (n = 93) had a remarkably higher prevalence of CKD and diabetic retinopathy than their counterparts with MASLD without fibrosis (n = 578) and those without steatosis (n = 738). After adjustment for sex, diabetes duration, hemoglobin A1c, hypertension, and use of antihypertensive or lipid-lowering medications, patients with SLD and significant fibrosis had a higher risk of prevalent CKD (adjusted-odds ratio 1.76, 95 % confidence interval 1.05-2.96) than those without steatosis. Patients with MASLD without fibrosis had a higher risk of prevalent retinopathy (adjusted-odds ratio 1.49, 95 % CI 1.13-1.46) than those without steatosis. CONCLUSION This is the largest cross-sectional study showing that MASLD with and without coexisting significant fibrosis was associated, independently of potential confounders, with an increased risk of prevalent CKD and retinopathy in adults with T1DM.
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Affiliation(s)
- Alessandro Mantovani
- Section of Endocrinology, Diabetes and Metabolism, Department of Medicine, University of Verona, Verona, Italy
| | - Mario Luca Morieri
- Metabolic Diseases, Department of Medicine, University of Padua, Padua, Italy
| | | | - Luisa Palmisano
- Department of Clinical Medicine and Surgery, Federico II University, Naples, Italy
| | - Maria Masulli
- Department of Clinical Medicine and Surgery, Federico II University, Naples, Italy
| | - Katia Bonomo
- Diabetes and Metabolic Diseases Unit, San Luigi Gonzaga University Hospital, Turin, Italy
| | - Marco Giorgio Baroni
- Department of Clinical Medicine, Life, Health & Environmental Sciences, University of Aquila, L'Aquila, Italy; Neuroendocrinology and Metabolic Diseases, IRCCS Neuromed, Pozzilli, Italy
| | - Efisio Cossu
- Diabetology Unit, Policlinico Universitario of Cagliari, Cagliari, Italy
| | | | - Gisella Cavallo
- Department of Experimental Medicine, Sapienza University, Rome, Italy
| | | | - Carmen Mignogna
- Department of Experimental Medicine, Sapienza University, Rome, Italy
| | - Frida Leonetti
- Department of Medical-Surgical Sciences and Biotechnologies, Sapienza University, Rome, Italy
| | - Simonetta Bacci
- Section of Endocrinology, Department of Medicine, IRCCS Casa Sollievo della Sofferenza Hospital, San Giovanni Rotondo, Italy
| | - Roberto Trevisan
- Metabolic Diseases, Department of Medicine, University of Padua, Padua, Italy; Department of Medicine and Surgery, University of Milan Bicocca, Milan, Italy
| | | | - Alessandra Dei Cas
- Department of Medicine and Surgery, University of Parma, Parma, Italy; Division of Nutritional and Metabolic Sciences, Azienda Ospedaliero-Universitaria di Parma, Parma, Italy
| | | | - Giovanni Targher
- Section of Endocrinology, Diabetes and Metabolism, Department of Medicine, University of Verona, Verona, Italy; IRCCS Sacro Cuore - Don Calabria Hospital, Negrar di Valpolicella, Italy.
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Brodosi L, Stecchi M, Marchignoli F, Lucia E, Magnani L, Guarneri V, Petroni ML, Marchesini G, Pironi L. Risk of binge eating disorder in patients with metabolic dysfunction-associated steatotic liver disease. Eat Weight Disord 2023; 28:100. [PMID: 38055131 DOI: 10.1007/s40519-023-01628-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2023] [Accepted: 11/27/2023] [Indexed: 12/07/2023] Open
Abstract
PURPOSE Very few data exist on the association between metabolic dysfunction-associated steatotic liver disease (MASLD) and eating disorders. The study aimed to evaluate the presence of binge eating disorder (BED), in MASLD subjects. METHODS Demographic, clinical investigation, anthropometric measurements and laboratory were collected in 129 patients with MASLD (34.1% males; age, 53.7 years; BMI, 34.4 kg/m2) addressed by general practitioners to a hospital-based unit of metabolic disorders. The risk of binge eating was tested by the binge eating scale (BES); values in the range 17-26 were considered "possible" BED, values > 26 were considered "probable" BED. Hepatic steatosis and fibrosis were tested by surrogate biomarkers and imaging (transient elastography). Calorie intake and lifestyle were self-assessed by questionnaires. RESULTS Possible BED was present in 17.8% of cases, probable BED in another 7.6%, and were neither associated with gender, obesity class, diabetes, features of metabolic syndrome, nor with presence and severity of hepatic steatosis and fibrosis. Also steatosis grade by CAP and fibrosis stage by liver stiffness did not correlate with BES. However, an association was present between the daily caloric intake and "possible" BED (odds ratio, 1.14; 95% confidence interval, 1.05-1.24; "probable" BED, 1.21; 1.07-1.37), after adjustment for confounders. CONCLUSION Binge eating, as scored by BES, is present in a significant proportion of MASLD cases screened for metabolic disorders in a specialized center. It may impact behavioral treatment, reducing the chance of weight loss without systematic psychological support. LEVEL OF EVIDENCE Level III, cohort analytic study.
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Affiliation(s)
- Lucia Brodosi
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy.
- Clinical Nutrition and Metabolism Unit, IRCCS-Azienda Ospedaliero-Universitaria Di Bologna, Bologna, Italy.
| | - Michele Stecchi
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Francesca Marchignoli
- Clinical Nutrition and Metabolism Unit, IRCCS-Azienda Ospedaliero-Universitaria Di Bologna, Bologna, Italy
| | - Elisabetta Lucia
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Lucia Magnani
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Valeria Guarneri
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Maria Letizia Petroni
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
- Clinical Nutrition and Metabolism Unit, IRCCS-Azienda Ospedaliero-Universitaria Di Bologna, Bologna, Italy
| | | | - Loris Pironi
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
- Clinical Nutrition and Metabolism Unit, IRCCS-Azienda Ospedaliero-Universitaria Di Bologna, Bologna, Italy
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Csermely A, Mantovani A, Morieri ML, Palmisano L, Masulli M, Cossu E, Baroni MG, Bonomo K, Cimini FA, Cavallo G, Buzzetti R, Mignogna C, Leonetti F, Bacci S, Trevisan R, Pollis RM, Aldigeri R, Cas AD, de Kreutzenberg SV, Targher G. Association between different modalities of insulin administration and metabolic dysfunction-associated fatty liver disease in adults with type 1 diabetes mellitus. DIABETES & METABOLISM 2023; 49:101477. [PMID: 37708990 DOI: 10.1016/j.diabet.2023.101477] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Revised: 08/30/2023] [Accepted: 09/04/2023] [Indexed: 09/16/2023]
Abstract
AIM We examined whether different insulin administration modalities, i.e., multiple daily injections (MDI) or continuous subcutaneous insulin infusion (CSII by insulin pumps), are differently associated with the risk of having metabolic dysfunction-associated fatty liver disease (MAFLD), with or without coexisting significant liver fibrosis (assessed by validated non-invasive biomarkers), in adults with type 1 diabetes mellitus (T1DM). METHODS We conducted a retrospective, multicenter, cross-sectional study involving 1,417 adult individuals with established T1DM treated with MDI or CSII. We calculated hepatic steatosis index (HSI) and fibrosis (FIB)-4 index for non-invasively detecting MAFLD (defined by HSI >36), with or without coexisting significant fibrosis (defined by FIB-4 index ≥ 1.3 or <1.3, respectively). RESULTS Compared to the MDI group (n = 1,161), insulin-pump users (n = 256; 18.1%) were more likely to be younger (mean age: 40 vs. 48 years, P < 0.001), had better glycemic control (mean hemoglobin A1c: 7.7% vs. 7.9%, P = 0.025) and a markedly lower prevalence of MAFLD with coexisting significant fibrosis (2.7% vs. 8.1%, P = 0.010), but a comparable prevalence of MAFLD without fibrosis. In multinomial logistic regression analysis, CSII therapy was associated with a ∼70%-lower risk of MAFLD with significant fibrosis (unadjusted odds ratio 0.32, 95% confidence interval 0.14-0.70; P = 0.004), but this association was no longer significant after adjustment for age, hemoglobin A1c and other potential confounders. CONCLUSION The lower prevalence of MAFLD with coexisting significant fibrosis we observed in adults with T1DM using CSII therapy, compared to those using MDI therapy, is primarily mediated by inter-group differences in age.
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Affiliation(s)
- Alessandro Csermely
- Section of Endocrinology, Diabetes and Metabolism, Department of Medicine, University of Verona, Verona, Italy
| | - Alessandro Mantovani
- Section of Endocrinology, Diabetes and Metabolism, Department of Medicine, University of Verona, Verona, Italy
| | - Mario Luca Morieri
- Metabolic Diseases, Department of Medicine, University of Padua, Padua, Italy
| | - Luisa Palmisano
- Department of Clinical Medicine and Surgery, Federico II University, Naples, Italy
| | - Maria Masulli
- Department of Clinical Medicine and Surgery, Federico II University, Naples, Italy
| | - Efisio Cossu
- Diabetology Unit, Policlinico Universitario of Cagliari, Cagliari, Italy
| | - Marco Giorgio Baroni
- Department of Clinical Medicine, Life, Health and Environmental Sciences, University of Aquila, L'Aquila, Italy; Neuroendocrinology and Metabolic Diseases, IRCCS Neuromed, Pozzilli, Italy
| | - Katia Bonomo
- Diabetes and Metabolic Diseases Unit, San Luigi Gonzaga University Hospital, Turin, Italy
| | | | - Gisella Cavallo
- Department of Experimental Medicine, Sapienza University, Rome, Italy
| | | | - Carmen Mignogna
- Department of Experimental Medicine, Sapienza University, Rome, Italy
| | - Frida Leonetti
- Department of Medical-Surgical Sciences and Biotechnologies, Sapienza University, Rome, Italy
| | - Simonetta Bacci
- Section of Endocrinology, Department of Medicine, IRCCS Casa Sollievo della Sofferenza Hospital, San Giovanni Rotondo, Italy
| | - Roberto Trevisan
- Department of Medicine and Surgery, University of Milan Bicocca, Milan, Italy
| | | | | | - Alessandra Dei Cas
- Department of Medicine and Surgery, University of Parma, Parma, Italy; Division of Nutritional and Metabolic Sciences, Azienda Ospedaliero-Universitaria, Parma, Italy
| | | | - Giovanni Targher
- Section of Endocrinology, Diabetes and Metabolism, Department of Medicine, University of Verona, Verona, Italy; Metabolic Diseases Research Unit, IRCCS Sacro Cuore - Don Calabria Hospital, Negrar di Valpolicella, Italy.
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Testino G, Pellicano R. Corrected and republished from: Metabolic associated liver disease. Panminerva Med 2023; 65:391-399. [PMID: 37750860 DOI: 10.23736/s0031-0808.23.04850-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/27/2023]
Abstract
Alcohol consumption (AC) and metabolic syndrome (MS) represent the first cause of liver disease, hepatocellular carcinoma and liver transplantation. The habit of consuming alcoholic beverages and the presence of MS and non-alcoholic fatty liver disease (NAFLD) often coexist in the same patient. The histoclinical boundaries between alcohol related liver disease (ALD) and NAFLD are often not well defined. The co-presence of AC and MS increases the risk of hepatic and extra-hepatic disease. The terminological evolution from NAFLD to metabolic associated fatty liver disease (MAFLD) is certainly a useful advance. However, it is known that the appearance of liver fibrosis increases oncologic and cardiovascular disease risk, which in the case of cirrhosis can be present even in the absence of steatosis and that the mechanisms of fibrogenesis can act independently of the presence of steatosis/steatohepatitis. For this reason, as already stated recently, a further terminological evolution can be hypothesized. This article was originally published with mistakes in the text. The new corrected citable version appears below.
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Affiliation(s)
- Gianni Testino
- Unit of Addiction and Hepatology/Alcohological Regional Centre, ASL3 c/o Polyclinic San Martino Hospital, Genoa, Italy -
| | - Rinaldo Pellicano
- Unit of Gastroenterology, Molinette-SGAS Hospital, Turin, Italy, Corrected and republished from: Panminerva Medica 2022 December
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Chow KW, Futela P, Saharan A, Saab S. Comparison of Guidelines for the Screening, Diagnosis, and Noninvasive Assessment of Nonalcoholic Fatty Liver Disease. J Clin Exp Hepatol 2023; 13:783-793. [PMID: 37693272 PMCID: PMC10483000 DOI: 10.1016/j.jceh.2023.01.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2022] [Accepted: 01/29/2023] [Indexed: 09/12/2023] Open
Abstract
Background Nonalcoholic fatty liver disease (NAFLD) is the most common cause of chronic liver disease worldwide. However, there is no clear consensus on optimal screening strategies and risk stratification. We conducted a systematic review of society guidelines to identify differences in recommendations regarding the screening, diagnosis, and assessment of NAFLD. Methods We searched PubMed, Web of Science, and Embase databases from January 1, 2015, to August 2, 2022. Two researchers independently extracted information from the guidelines about screening strategies, risk stratification, use of noninvasive tests (NITs) to assess hepatic fibrosis, and indications for liver biopsy. Results Twenty clinical practice guidelines and consensus statements were identified in our search. No guidelines recommended routine screening for NAFLD, while 14 guidelines recommended case finding in high-risk groups. Of the simple risk stratification models to assess for fibrosis, the fibrosis-4 score was the most frequently recommended, followed by the NAFLD fibrosis score. However, guidelines differed on which cutoffs to use and the interpretation of "high-risk" results. Conclusion Multiple guidelines exist with varying recommendations on the benefits of screening and interpretation of NIT results. Despite their differences, all guidelines recognize the utility of NITs and recommend their incorporation into the clinical assessment of NAFLD.
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Affiliation(s)
- Kenneth W. Chow
- Department of Medicine, Harbor-UCLA Medical Center, Los Angeles, CA, USA
| | - Pragyat Futela
- Department of Medicine, University of California at Los Angeles, Los Angeles, CA, USA
| | - Aryan Saharan
- Department of Medicine, University of California at Los Angeles, Los Angeles, CA, USA
| | - Sammy Saab
- Department of Medicine, University of California at Los Angeles, Los Angeles, CA, USA
- Department of Surgery, University of California at Los Angeles, Los Angeles, CA, USA
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9
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Mantovani A, Morieri ML, Palmisano L, Masulli M, Cossu E, Baroni MG, Bonomo K, Cimini FA, Cavallo G, Buzzetti R, Mignogna C, Leonetti F, Bacci S, Trevisan R, Pollis RM, Aldigeri R, Cas AD, de Kreutzenberg SV, Targher G. Hepatic steatosis with significant fibrosis is associated with an increased 10-year estimated risk of cardiovascular disease in adults with type 1 diabetes mellitus. Cardiovasc Diabetol 2023; 22:204. [PMID: 37563618 PMCID: PMC10416459 DOI: 10.1186/s12933-023-01945-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Accepted: 07/28/2023] [Indexed: 08/12/2023] Open
Abstract
BACKGROUND We assessed whether hepatic steatosis with or without significant fibrosis (determined by validated non-invasive biomarkers) is associated with an increased 10-year estimated risk for cardiovascular disease (CVD) in people with type 1 diabetes mellitus (T1DM). METHODS We conducted a retrospective, multicenter, cross-sectional study involving 1,254 adults with established T1DM without pre-existing CVD. We used the hepatic steatosis index (HSI) and fibrosis (FIB)-4 index for non-invasively detecting hepatic steatosis (defined as HSI > 36), with or without coexisting significant fibrosis (defined as FIB-4 index ≥ 1.3 or < 1.3). We calculated the Steno type 1 risk engine and the atherosclerotic CVD (ASCVD) risk score to estimate the 10-year risk of developing a first fatal or nonfatal CVD event. RESULTS Using the Steno type 1 risk engine, a significantly greater proportion of patients with hepatic steatosis and significant fibrosis (n = 91) had a high 10-year estimated CVD risk compared to those with hepatic steatosis alone (n = 509) or without steatosis (n = 654) (75.8% vs. 23.2% vs. 24.9%, p < 0.001). After adjustment for sex, BMI, diabetes duration, hemoglobin A1c, chronic kidney disease, and lipid-lowering medication use, patients with hepatic steatosis and significant fibrosis had an increased 10-year estimated risk of developing a first fatal or nonfatal CVD event (adjusted-odds ratio 11.4, 95% confidence interval 3.54-36.9) than those without steatosis. We observed almost identical results using the ASCVD risk calculator. CONCLUSIONS The 10-year estimated CVD risk is remarkably greater in T1DM adults with hepatic steatosis and significant fibrosis than in their counterparts with hepatic steatosis alone or without steatosis.
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Affiliation(s)
- Alessandro Mantovani
- Section of Endocrinology, Diabetes and Metabolism, Department of Medicine, University of Verona, Verona, Italy
| | - Mario Luca Morieri
- Metabolic Diseases, Department of Medicine, University of Padua, Padua, Italy
| | - Luisa Palmisano
- Department of Clinical Medicine and Surgery, Federico II University, Naples, Italy
| | - Maria Masulli
- Department of Clinical Medicine and Surgery, Federico II University, Naples, Italy
| | - Efisio Cossu
- Diabetology Unit, Policlinico Universitario of Cagliari, Cagliari, Italy
| | - Marco Giorgio Baroni
- Department of Clinical Medicine, Life, Health and Environmental Sciences, University of Aquila, L'Aquila, Italy
- Neuroendocrinology and Metabolic Diseases, IRCCS Neuromed, Pozzilli, Italy
| | - Katia Bonomo
- Diabetes and Metabolic Diseases Unit, San Luigi Gonzaga University Hospital, Turin, Italy
| | | | - Gisella Cavallo
- Department of Experimental Medicine, Sapienza University, Rome, Italy
| | | | - Carmen Mignogna
- Department of Experimental Medicine, Sapienza University, Rome, Italy
| | - Frida Leonetti
- Department of Medical-Surgical Sciences and Biotechnologies, Sapienza University, Rome, Italy
| | - Simonetta Bacci
- Section of Endocrinology, Department of Medicine, IRCCS Casa Sollievo della Sofferenza Hospital, San Giovanni Rotondo, Italy
| | - Roberto Trevisan
- Department of Medicine and Surgery, University of Milan Bicocca, Milan, Italy
| | | | - Raffaella Aldigeri
- Division of Nutritional and Metabolic Sciences, Azienda Ospedaliero-Universitaria, Parma, Italy
| | - Alessandra Dei Cas
- Division of Nutritional and Metabolic Sciences, Azienda Ospedaliero-Universitaria, Parma, Italy
- Department of Medicine and Surgery, University of Parma, Parma, Italy
| | | | - Giovanni Targher
- Section of Endocrinology, Diabetes and Metabolism, Department of Medicine, University of Verona, Verona, Italy.
- IRCCS Sacro Cuore Don Calabria Hospital, Negrar di Valpolicella, VR, Italy.
- Section of Endocrinology, Diabetes and Metabolism, Department of Medicine, University and Azienda Ospedaliera Universitaria Integrata, Piazzale Stefani, 1, Verona, 37126, Italy.
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10
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Inciardi RM, Mantovani A, Targher G. Non-Alcoholic Fatty Liver Disease as an Emerging Risk Factor for Heart Failure. Curr Heart Fail Rep 2023; 20:308-319. [PMID: 37402108 PMCID: PMC10421789 DOI: 10.1007/s11897-023-00613-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/14/2023] [Indexed: 07/05/2023]
Abstract
PURPOSE OF THE REVIEW Non-alcoholic fatty liver disease (NAFLD) and heart failure (HF) are two chronic diseases that have become important global public health problems. This narrative review provides a comprehensive overview of the association between NAFLD and increased risk of new-onset HF, briefly discusses the putative biological mechanisms linking these two conditions, and summarizes targeted pharmacotherapies for NAFLD that might also beneficially affect cardiac complications leading to new-onset HF. RECENT FINDINGS Recent observational cohort studies supported a significant association between NAFLD and the long-term risk of new-onset HF. Notably, this risk remained statistically significant even after adjustment for age, sex, ethnicity, adiposity measures, pre-existing type 2 diabetes and other common cardiometabolic risk factors. In addition, the risk of incident HF was further increased with more advanced liver disease, especially with higher severity of liver fibrosis. There are multiple potential pathophysiological mechanisms by which NAFLD (especially in its more advanced forms) may increase the risk of new-onset HF. Because of the strong link existing between NAFLD and HF, more careful surveillance of these patients will be needed. However, further prospective and mechanistic studies are required to better decipher the existing but complex link between NAFLD and risk of new-onset HF.
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Affiliation(s)
- Riccardo M Inciardi
- ASST Spedali Civili Di Brescia, Division of Cardiology and Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - Alessandro Mantovani
- Department of Medicine, Section of Endocrinology, Diabetes, and Metabolism, University of Verona, Verona, Italy
| | - Giovanni Targher
- Department of Medicine, Section of Endocrinology, Diabetes, and Metabolism, University of Verona, Verona, Italy.
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11
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Armandi A, Michel M, Gjini K, Emrich T, Bugianesi E, Schattenberg JM. Emerging concepts in the detection of liver fibrosis in non-alcoholic fatty liver disease. Expert Rev Mol Diagn 2023; 23:771-782. [PMID: 37505901 DOI: 10.1080/14737159.2023.2242779] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Revised: 06/24/2023] [Accepted: 07/27/2023] [Indexed: 07/30/2023]
Abstract
INTRODUCTION The non-invasive identification of liver fibrosis related to Non-Alcoholic Fatty Liver Disease is crucial for risk-stratification of patients. Currently, the reference standard to stage hepatic fibrosis relies on liver biopsy, but multiple approaches are developed to allow for non-invasive diagnosis and risk stratification. Non-invasive tests, including blood-based scores and vibration-controlled transient elastography, have been widely validated and represent a good surrogate for risk stratification according to recent European and American guidelines. AREAS COVERED Novel approaches are based on 'liquid' biomarkers of liver fibrogenesis, including collagen-derived markers (PRO-C3 or PRO-C6), or 'multi-omics' technologies (e.g. proteomic-based molecules or miRNA testing), bearing the advantage of tailoring the intrahepatic disease activity. Alternative approaches are based on 'dry' biomarkers, including magnetic resonance-based tools (including proton density fat fraction, magnetic resonance elastography, or corrected T1), which reach similar accuracy of liver histology and will potentially help identify the best candidates for pharmacological treatment of fibrosing non-alcoholic steatohepatitis. EXPERT OPINION In the near future, the sequential use of non-invasive tests, as well as the complimentary use of liquid and dry biomarkers according to the clinical need (diagnosis, risk stratification, and prognosis, or treatment response) will guide and improve the management of this liver disease.
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Affiliation(s)
- Angelo Armandi
- Division of Gastroenterology and Hepatology, Department of Medical Sciences, University of Turin, Corso Dogliotti 14, 10126 Turin, Italy
- Metabolic Liver Research Program, I. Department of Medicine, University Medical Centre Mainz, Langenbeckstrasse 1, 55131 Mainz, Germany
| | - Maurice Michel
- Metabolic Liver Research Program, I. Department of Medicine, University Medical Centre Mainz, Langenbeckstrasse 1, 55131 Mainz, Germany
- I. Department of Medicine, University Medical Centre Mainz, Langenbeckstrasse 1, 55131 Mainz, Germany
| | - Kamela Gjini
- Division of Gastroenterology and Hepatology, Department of Medical Sciences, University of Turin, Corso Dogliotti 14, 10126 Turin, Italy
| | - Tilman Emrich
- Department of Radiology, University Medical Centre Mainz, Langenbeckstrasse 1, 55131 Mainz, Germany
| | - Elisabetta Bugianesi
- Division of Gastroenterology and Hepatology, Department of Medical Sciences, University of Turin, Corso Dogliotti 14, 10126 Turin, Italy
| | - Jorn M Schattenberg
- Metabolic Liver Research Program, I. Department of Medicine, University Medical Centre Mainz, Langenbeckstrasse 1, 55131 Mainz, Germany
- I. Department of Medicine, University Medical Centre Mainz, Langenbeckstrasse 1, 55131 Mainz, Germany
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12
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Scoditti E, Marchesini G, Gastaldelli A. Hunting for Progressive NAFLD in Type 2 Diabetes: Do Not Trust Liver Enzymes! Diabetes Care 2023; 46:1332-1334. [PMID: 37339349 DOI: 10.2337/dci23-0027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/22/2023]
Affiliation(s)
- Egeria Scoditti
- 1Institute of Clinical Physiology, National Research Council, Lecce, Italy
| | - Giulio Marchesini
- 2Department of Medical and Surgical Sciences, Alma Mater University, Bologna, Italy
- 3Azienda Ospedaliera di Bologna Sant'Orsola-Malpighi, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Bologna, Italy
| | - Amalia Gastaldelli
- 4Institute of Clinical Physiology, National Research Council, Pisa, Italy
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13
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Yoo TK, Lee MY, Kim SH, Zheng MH, Targher G, Byrne CD, Sung KC. Comparison of cardiovascular mortality between MAFLD and NAFLD: A cohort study. Nutr Metab Cardiovasc Dis 2023; 33:947-955. [PMID: 36746687 DOI: 10.1016/j.numecd.2023.01.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Revised: 12/16/2022] [Accepted: 01/16/2023] [Indexed: 01/27/2023]
Abstract
BACKGROUND AND AIMS A new diagnostic criterion of metabolic dysfunction-associated fatty liver disease (MAFLD) has been proposed. However, only few studies have shown that MAFLD predicts cardiovascular disease (CVD) mortality better than non-alcoholic fatty liver disease (NAFLD). Therefore, a cohort study was conducted to assess this relationship. METHODS AND RESULTS Health examination data from health care centers in South Korea were assessed after excluding participants with missing covariates and cancer history (n = 701,664). Liver ultrasonography reports, laboratory and anthropometric data were extracted. Diagnoses of NAFLD and MAFLD were performed according to standard definitions. Participants were categorized based on the presence of NAFLD and MAFLD. In addition, participants were classified into five categories: no fatty liver disease (no FLD), NAFLD-only, MAFLD-only, both FLDs, and alcoholic FLD (AFLD) and non-MAFLD. Multivariable regression modeling was performed. The median follow-up duration was 8.77 years, and 52.56% of participants were men. After stratifying the cohort into no-MAFLD and MAFLD groups, MAFLD was associated with increased CVD mortality (adjusted HR 1.14, 95% CI 1.02-1.28). When participants were divided into no-NAFLD and NAFLD groups, there was a non-significant trend towards an increase in CVD mortality in NAFLD group (adjusted HR 1.07, 95% CI 0.95-1.21). When participants were divided into five categories, MAFLD-only group showed increased CVD mortality (adjusted HR 1.35, 95% CI 1.07-1.70) while NAFLD-only group showed no significant association with CVD mortality (adjusted HR 0.67, 95% CI 0.38-1.19). CONCLUSIONS In conclusion, MAFLD is associated with increased CVD mortality in a relatively young Korean population.
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Affiliation(s)
- Tae Kyung Yoo
- Department of Medicine, MetroWest Medical Center, Framingham, MA, USA
| | - Mi Yeon Lee
- Division of Biostatistics, Department of R&D Management, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Seong Hwan Kim
- Division of Cardiology, Department of Internal Medicine, Korea University Ansan Hospital, Ansan, Republic of Korea
| | - Ming-Hua Zheng
- MAFLD Research Center, Department of Hepatology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China; Wenzhou Key Laboratory of Hepatology, Wenzhou, China; Institute of Hepatology, Wenzhou Medical University, Wenzhou, China; Key Laboratory of Diagnosis and Treatment for the Development of Chronic Liver Disease in Zhejiang Province, Wenzhou, China
| | - Giovanni Targher
- Section of Endocrinology, Diabetes and Metabolism, Department of Medicine, University and Azienda Ospedaliera Universitaria Integrata of Verona, Verona, Italy
| | - Christopher D Byrne
- Nutrition and Metabolism, Faculty of Medicine, University of Southampton, Southampton, UK; Southampton National Institute for Health Research, Biomedical Research Centre, University Hospital Southampton, UK
| | - Ki-Chul Sung
- Division of Cardiology, Department of Internal Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea.
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14
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Small Intestinal Bacterial Overgrowth and Non-Alcoholic Fatty Liver Disease: What Do We Know in 2023? Nutrients 2023; 15:nu15061323. [PMID: 36986052 PMCID: PMC10052062 DOI: 10.3390/nu15061323] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Revised: 02/27/2023] [Accepted: 03/03/2023] [Indexed: 03/11/2023] Open
Abstract
Non-alcoholic fatty liver disease (NAFLD) is a chronic liver disease associated with the pathological accumulation of lipids inside hepatocytes. Untreated NAFL can progress to non-alcoholic hepatitis (NASH), followed by fibrosis, cirrhosis, and hepatocellular carcinoma (HCC). The common denominator of the above-mentioned metabolic disorders seems to be insulin resistance, which occurs in NAFLD patients. Obesity is the greatest risk factor for lipid accumulation inside hepatocytes, but a part of the NAFLD patient population has a normal body weight according to the BMI index. Obese people with or without NAFLD have a higher incidence of small intestinal bacterial overgrowth (SIBO), and those suffering from NAFLD show increased intestinal permeability, including a more frequent presence of bacterial overgrowth in the small intestine (SIBO). The health consequences of SIBO are primarily malabsorption disorders (vitamin B12, iron, choline, fats, carbohydrates and proteins) and bile salt deconjugation. Undetected and untreated SIBO may lead to nutrient and/or energy malnutrition, thus directly impairing liver function (e.g., folic acid and choline deficiency). However, whether SIBO contributes to liver dysfunction, decreased intestinal barrier integrity, increased inflammation, endotoxemia and bacterial translocation is not yet clear. In this review, we focus on gut–liver axis and discuss critical points, novel insights and the role of nutrition, lifestyle, pre- and probiotics, medication and supplements in the therapy and prevention of both SIBO and NAFLD.
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15
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Targher G, Mantovani A, Byrne CD. Mechanisms and possible hepatoprotective effects of glucagon-like peptide-1 receptor agonists and other incretin receptor agonists in non-alcoholic fatty liver disease. Lancet Gastroenterol Hepatol 2023; 8:179-191. [PMID: 36620987 DOI: 10.1016/s2468-1253(22)00338-7] [Citation(s) in RCA: 34] [Impact Index Per Article: 34.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2022] [Revised: 09/22/2022] [Accepted: 09/29/2022] [Indexed: 01/07/2023]
Abstract
Glucagon-like peptide-1 (GLP-1) and glucose-dependent insulinotropic polypeptide (GIP) are incretins that stimulate insulin secretion from pancreatic β cells in response to food ingestion. Modified GLP-1 and GIP peptides are potent agonists for their incretin receptors, and some evidence shows that the dual GLP-1 and GIP receptor agonist tirzepatide is effective in promoting marked weight loss. GLP-1 receptor agonists signal in the CNS to suppress appetite, increase satiety, and thereby decrease calorie intake, but many other effects of incretin signalling have been recognised that are relevant to the treatment of non-alcoholic fatty liver disease (NAFLD). This Review provides an overview of the literature supporting the notion that endogenous incretins and incretin-receptor agonist treatments are important not only for decreasing risk of developing NAFLD, but also for treating NAFLD and NAFLD-related complications. We discuss incretin signalling and related incretin-receptor agonist treatments, mechanisms in key relevant tissues affecting liver disease, and clinical data from randomised controlled trials. Finally, we present future perspectives in this rapidly developing field of research and clinical medicine.
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Affiliation(s)
- Giovanni Targher
- Section of Endocrinology, Diabetes and Metabolism, Department of Medicine, University and Azienda Ospedaliera Universitaria Integrata of Verona, Verona, Italy.
| | - Alessandro Mantovani
- Section of Endocrinology, Diabetes and Metabolism, Department of Medicine, University and Azienda Ospedaliera Universitaria Integrata of Verona, Verona, Italy
| | - Christopher D Byrne
- Nutrition and Metabolism, Faculty of Medicine, University of Southampton, UK; Southampton National Institute for Health Research Biomedical Research Centre, University Hospital Southampton, Southampton General Hospital, Southampton, UK
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16
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Byrne CD, Targher G. How should endocrinologists diagnose and treat non-alcoholic fatty liver disease? Lancet Diabetes Endocrinol 2022; 10:478-480. [PMID: 35662401 DOI: 10.1016/s2213-8587(22)00167-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Accepted: 05/23/2022] [Indexed: 11/19/2022]
Affiliation(s)
- Christopher D Byrne
- Nutrition and Metabolism, Faculty of Medicine, University of Southampton, Southampton, UK; Southampton National Institute for Health and Care Research Biomedical Research Centre, University Hospital Southampton, Southampton, UK.
| | - Giovanni Targher
- Division of Endocrinology, Diabetes and Metabolism, Department of Medicine, University and Azienda Ospedaliera Universitaria Integrata of Verona, Verona, Italy
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