Transient elastography in non-alcoholic fatty liver disease

Dietary inflammatory index in relation to the progression of hepatic steatosis and liver fibrosis: evaluation by elastography/Fibroscan

One of the proposed mechanisms by which nutrition influences the progression of hepatic steatosis to fibrosis is inflammation. The study investigated how the inflammatory potential of the diet affects the risk of liver damage in patients with nonalcoholic fatty liver disease (NAFLD), a condition where fat accumulates in the liver. This cross-sectional study included 170 outpatients with newly diagnosed NAFLD. This study used a device called Fibroscan® to measure the degree of liver fibrosis, which is the scarring of the liver tissue due to chronic inflammation. The study also used a tool called the Dietary Inflammatory Index (DII) to measure the inflammatory potential of the diet based on the intake of different foods and nutrients. In the findings of the study, patients with more severe fat accumulation in the liver (hepatic steatosis) had higher DII scores, meaning they had more inflammatory diets. The study also found that higher DII scores were associated with higher weight and body mass index (BMI). One standard deviation (SD) increase in DII scores was associated with a 0.29 kilopascal (95% CI: 0.10-0.44; P-value 0.001) increase in the mean liver stiffness, an indicator of liver fibrosis. The study concluded that patients with higher DII scores had a higher risk of developing liver fibrosis than those with lower DII scores, even after adjusting for confounding factors (odds ratio: 5.89; P-value: 0.001). The study suggested that eating less inflammatory foods may help prevent or slow down the progression of hepatic steatosis and liver in patients with NAFLD.

Serum remnant cholesterol is a potential predictor of liver stiffness in patients with nonalcoholic fatty liver disease

BACKGROUND

Nonalcoholic fatty liver disease (NAFLD) is associated with dyslipidemia, and the connection between dyslipidemia and remnant cholesterol (RC), a component of triglyceride-rich lipoproteins, remains enigmatic.

METHODS

In this cross-sectional study, our primary aim was to investigate the role of RC in the progression of NAFLD and to provide robust evidence of RC's involvement in the pathogenesis of NAFLD. We enrolled 2800 NAFLD patients from the National Health and Nutrition Examination Survey (NHANES). Logistic regression was employed to examine the relationship between serum RC levels and liver stiffness, while receiver operating characteristic (ROC) curve analysis was used to assess the diagnostic capability of RC.

RESULTS

RC exhibited an independent correlation with the extent of liver stiffness, with odds ratios (OR) of 1.02 for liver steatosis (p = 0.014) and 1.02 for liver fibrosis (p = 0.014). To predict NAFLD, the optimal RC thresholds were 17.25 mg/dL for males and 15.25 mg/dL for females in the case of liver steatosis. For advanced liver fibrosis, the best thresholds were 17.25 mg/dL for males and 16.25 mg/dL for females.

CONCLUSIONS

RC demonstrated a positive correlation with the degree of liver stiffness and exhibited superior diagnostic efficacy for liver steatosis and fibrosis compared to other cholesterol indicators.

Liver Fibrosis and Cirrhosis in Patients with Non-alcoholic Fatty Liver with and without History of Cholecystectomy: A Pilot Study

Background

Non-alcoholic fatty liver disease (NAFLD) is one of the most common chronic liver diseases in the world. Previous studies revealed that cholecystectomy may be considered a risk factor for the development of NAFLD. The aim of this study was to compare the amount of liver fibrosis, determined by elastography, between patients with NAFLD with and without a history of cholecystectomy.

Methods

In this descriptive-analytical cross-sectional study, 50 patients with NAFLD were divided into two groups: one with a history of cholecystectomy and the other without. No significant differences were found between these two groups in terms of age or sex distribution. Liver fibrosis was measured for all patients using an elastography imaging system. Subsequently, the data related to liver fibrosis, along with the demographic information of the patients, were statistically analyzed using SPSS software version 22.

Results

The mean elastography score in all patients was 10.66±12.18 kPa (the elasticity scale ranging from 3.80 to 66.40 kPa). The group with a history of cholecystectomy had a significantly higher mean elastography score (13.39±16.20 kPa) compared with the group without cholecystectomy (7.93±4.99 kPa) (P=0.02). Additionally, there was a significant positive correlation between body mass index (BMI) and the mean elastography score in the group of patients with a history of cholecystectomy.

Conclusion

The mean elastography score of patients with NAFLD with a history of cholecystectomy was approximately twice as high as that of non-cholecystectomy patients.

Ultrasound Prevalence and Clinical Features of Nonalcoholic Fatty Liver Disease in Patients with Inflammatory Bowel Diseases: A Real-Life Cross-Sectional Study

Background and Objectives: Inflammatory bowel disease (IBD) is a condition characterized by chronic intestinal inflammation. We can identify two major forms: Crohn's disease (CD) and ulcerative colitis (UC). One of the extraintestinal manifestations of IBD is nonalcoholic fatty liver disease (NAFLD). IBD and NAFLD share common pathogenetic mechanisms. Ultrasound (US) examination is the most commonly used imaging method for the diagnosis of NAFLD. This cross-sectional observational retrospective study aimed to evaluate the US prevalence of NAFLD in IBD patients and their clinical features. Materials and Methods: A total of 143 patients with IBD underwent hepatic US and were divided into two different groups according to the presence or absence of NAFLD. Subsequently, new exclusion criteria for dysmetabolic comorbidities (defined as plus) were applied. Results: The US prevalence of NAFLD was 23% (21% in CD and 24% in UC, respectively). Most IBD-NAFLD patients were male and older and showed significantly higher values for body mass index, waist circumference, disease duration, and age at onset than those without NAFLD. IBD-NAFLD patients showed a significantly higher percentage of stenosing phenotype and left-side colitis. Regarding metabolic features, IBD-NAFLD patients showed a significantly higher percentage of hypertension and IBD plus dysmetabolic criteria. Also, higher values of alanine aminotransferase and triglycerides and lower levels of high-density lipoproteins are reported in these patients. Conclusions: We suggest performing liver US screening in subjects affected by IBD to detect NAFLD earlier. Also, patients with NAFLD present several metabolic comorbidities that would fall within the new definition of metabolic-associated fatty liver disease. Finally, we encourage larger longitudinal studies, including healthy controls, to provide further confirmation of our preliminary data.

Role of Oxidative Stress and Carcinoembryonic Antigen-Related Cell Adhesion Molecule 1 in Nonalcoholic Fatty Liver Disease

Nonalcoholic fatty liver disease (NAFLD) has become a widely studied subject due to its increasing prevalence and links to diseases such as type 2 diabetes and obesity. It has severe complications, including nonalcoholic steatohepatitis, cirrhosis, hepatocellular carcinoma, and portal hypertension that can lead to liver transplantation in some cases. To better prevent and treat this pathology, it is important to understand its underlying physiology. Here, we identify two main factors that play a crucial role in the pathophysiology of NAFLD: oxidative stress and the key role of carcinoembryonic antigen-related cell adhesion molecule 1 (CEACAM1). We discuss the pathophysiology linking these factors to NAFLD pathophysiology.

Metabolic determinants of NAFLD in adults with type 1 diabetes

AIM

To assess the main metabolic determinants of non-alcoholic fatty liver disease (NAFLD) in adult patients with type 1 diabetes (T1D).

METHODS

115 patients with T1D were divided into 4 groups according to NAFLD grade. NAFLD was diagnosed via transient elastography when CAP > 233 dB/m. Body composition was evaluated by Inbody720, Biospace. Serum lipids, liver enzymes, uric acid, creatinine, hsCRP and HbA1c were evaluated at fasting.

RESULTS

The overall prevalence of NAFLD was 47% (n = 54). In the subgroup with BMI > 25 kg/m² NAFLD prevalence was 66%; and positive family history of type 2 diabetes brought the risk up to 76%. 37% of the lean individuals also had NAFLD. HbA1c > 7% doubled the risk of NAFLD. Waist circumference > 82.5 cm was independently related to NAFLD, accounting for 24% of its variation in females. Accumulation of two and three metabolic syndrome (MetS) components, besides hyperglycemia, increased the risk of NAFLD by 14% (p < 0.0001) and 6% (p = 0.024), respectively. Lean NAFLD correlated with total insulin dose; NAFLD in overweight T1D patients correlated with triglycerides.

CONCLUSIONS

NAFLD is highly prevalent in adults with T1D and obesity or other metabolic derangements and might be independently related to poor long-term glycemic control and waist circumference in females.

Pediatric percentiles for transient elastography measurements - effects of age, sex, weight status and pubertal stage

BACKGROUND AND AIMS

Transient Elastography is a non-invasive, cost-efficient, non-ionizing, observer-independent and reliable method to detect liver fibrosis using Liver Stiffness Measurement (LSM) and the degree of fat accumulation in the liver using Controlled Attenuation Parameter (CAP). This study aims to derive reference values for both measures from healthy children and adolescents. Further, we aim to assess the potential influence of age, sex, puberty, and BMI-SDS on CAP and LSM.

METHODS

Within the LIFE Child study, amongst others, anthropometric data and pubertal status were assessed. Transient Elastography (TE) was performed using the FibroScan^® device in a population-based cohort at 982 study visits of 482 healthy children aged between 10 and 18 years. Percentiles for LSM and CAP were estimated, and the effects of age, sex, puberty and weight status were assessed through hierarchical regression models.

RESULTS

There was a strong age dependency for LSM with higher values for older children, most pronounced in the upper percentiles in boys. Contrarily, CAP was relatively stable across the age span without considerable difference between boys and girls. We found a significant positive correlation between BMI-SDS and both CAP and LSM for BMI-SDS >1.28. For BMI-SDS < 1.28, the association was also positive but reached statistical significance only for CAP. Further, the association between BMI-SDS and CAP was significantly stronger in younger than in older children. There was no association between pubertal status and CAP. For LSM, we found that children with a high BMI-SDS but not children with normal weight had significantly higher LSM values in Tanner stage 4.

CONCLUSIONS

Age, sex, pubertal status and weight status should be considered when interpreting LSM and CAP in pediatric patients to facilitate and improve early detection of abnormal liver function, which is associated with common pathologies, such as NAFLD.

Triglycerides to high-density lipoprotein cholesterol ratio for diagnosing nonalcoholic fatty liver disease

BACKGROUND

Nonalcoholic Fatty Liver Disease (NAFLD) is a widespread disease in the western world. It can develop into more serious pathological conditions (i.e. liver cirrhosis). Therefore it is important to diagnose it in order to prevent this evolution. For diagnosis it is possible to use both imaging methods and biomarkers, such as the Triglycerides To High-Density Lipoprotein Cholesterol Ratio (TG/HDL-C). Aim of our study is to determine whether TG/HDL-C ratio is significantly associated with NAFLD and Metabolic Syndrome (MetS).

METHODS

We recruited 231 patients, 131 with and 100 without NAFLD. The Body Mass Index had been calculated and different laboratory parameters had been obtained. TG/HDL-C ratio was calculated for each.

RESULTS

In our sample HDL-C was not significantly reduced in NAFLD group (p = 0.49), but higher TG and TG/HDL-C ratio were significantly associated with NAFLD: in both p < 0.001. According to receiver operating characteristic curve, the best cut-off of TG/HDL-C in NAFLD population was 1.64 [area under the curve (AUC) 0.675 (95% CI 0.604-0.746), p < 0.001]. TG/HDL-C higher ratio was significantly associated with MetS (p < 0.001). The best cut-off of TG/HDL-C in patients with MetS was 2.48 [AUC 0.871 (95% CI 0.808-0.935), p < 0.001].

CONCLUSIONS

We demonstrated that higher TG/HDL-C ratio is associated with NAFLD and MetS. Though nowadays TG/HDL-C ratio is not a criteria for NAFLD diagnosis, we believe that in the future it could be used as a reliable non-invasive marker in routine diagnostics of NAFLD.

Improvements in clinical characteristics of patients with non-alcoholic fatty liver disease, after an intervention based on the Mediterranean lifestyle: a randomised controlled clinical trial

Lifestyle interventions remain the cornerstone therapy for non-alcoholic fatty liver disease (NAFLD). This randomised controlled single-blind clinical trial investigated the effect of Mediterranean diet (MD) or Mediterranean lifestyle, along with weight loss, in NAFLD patients. In all, sixty-three overweight/obese patients (50 (sd 11) years, BMI=31·8 (sd 4·5) kg/m2, 68 % men) with ultrasonography-proven NAFLD (and elevated alanine aminotransferase (ALT) and/or γ-glutamyl transpeptidase (GGT) levels) were randomised to the following groups: (A) control group (CG), (B) Mediterranean diet group (MDG) or (C) Mediterranean lifestyle group (MLG). Participants of MDG and MLG attended seven 60-min group sessions for 6 months, aiming at weight loss and increasing adherence to MD. In the MLG, additional guidance for increasing physical activity and improving sleep habits were given. Patients in CG received only written information for a healthy lifestyle. At the end of 6 months, 88·8 % of participants completed the study. On the basis of intention-to-treat analysis, both MDG and MLG showed greater weight reduction and higher adherence to MD compared with the CG (all P<0·05) at the end of intervention. In addition, MLG increased vigorous exercise compared with the other two study groups (P<0·001) and mid-day rest/naps compared with CG (P=0·04). MLG showed significant improvements in ALT levels (i.e. ALT<40 U/l (P=0·03) and 50 % reduction of ALT levels (P=0·009)) and liver stiffness (P=0·004) compared with CG after adjusting for % weight loss and baseline values. MDG improved only liver stiffness compared with CG (P<0·001) after adjusting for the aforementioned variables. Small changes towards the Mediterranean lifestyle, along with weight loss, can be a treatment option for patients with NAFLD.

The promising role of probiotic and synbiotic therapy in aminotransferase levels and inflammatory markers in patients with nonalcoholic fatty liver disease - a systematic review and meta-analysis

BACKGROUND

Nonalcoholic fatty liver disease (NAFLD) is the most prevalent chronic liver disease worldwide. The pathogenesis of NAFLD is complex and multifactorial. There is growing evidence that altered gut microbiota plays a key role in NAFLD progression. Probiotics/synbiotics, by modifying gut microbiota, may be a promising treatment choice for NAFLD management.

AIM

The aim of this study was to study the effect of probiotics/synbiotics on various laboratory and radiographic parameters in NAFLD management.

MATERIALS AND METHODS

A systematic review and meta-analysis were carried out according to Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. We searched PubMed, Medline, and Google Scholar for randomized-controlled trials that studied the role of probiotics/synbiotics in NAFLD. The primary outcome was change in baseline alanine aminotransferase and aspartate aminotransferase in the treatment arm. We used a random-effects model and inverse variance for the continuous data to estimate the mean difference (MD) and the standard mean difference (SMD) in RevMan Version 5.3.

RESULTS

We included 12 randomized-controlled trials for analysis. The intervention arm, which comprised of the probiotic and/or the synbiotic arm, showed a significant improvement in alanine aminotransferase levels, MD=-13.93, confidence interval (CI)=-20.20 to -7.66, P value of less than 0.0001, I=92% and aspartate aminotransferase levels MD=-11.45, CI=-15.15 to -7.74, P value of less than 0.00001, I=91%. There was a reduction in high-sensitivity C-reactive protein levels in the intervention arm, SMD=-0.68, CI=-1.10 to -0.26, P value of 0.001, I=0%. The liver fibrosis score improved in the intervention arm, MD=-0.71, CI=-0.81 to -0.61, P value less than 0.00001, I=0%.

CONCLUSION

Probiotic/synbiotic use improves aminotransaminase levels and reduces proinflammatory marker high-sensitivity C-reactive protein and liver fibrosis in NAFLD patients.

Inflammatory markers response to citrulline supplementation in patients with non-alcoholic fatty liver disease: a randomized, double blind, placebo-controlled, clinical trial

Objectives

The aim of this study was to investigate the effects of citrulline (Cit) supplementation on inflammatory markers and liver histopathology in patients with non-alcoholic fatty liver disease (NAFLD). In this clinical trial, fifty NAFLD patients were assigned to receive 2 g/day Cit or placebo for 3 months.

Results

At the end of study, serum high sensitive C-reactive protein (hs-CRP) and activity of nuclear factor kappa B (NF-κB) were reduced in Cit group significantly more than placebo group (P-value = 0.02 and < 0.01 respectively). Serum concentrations of tumor necrosis factor-α (TNF-α) was reduced in Cit group significantly more than placebo after adjusting for levels of baseline (P-value < 0.001). Moreover, Cit supplementation decreased serum alanine aminotransferase (ALT) and hepatic steatosis significantly (P = 0.04). Anthropometric measurements and hepatic enzymes did not change significantly in any group (P ≥ 0.05). In conclusion, our results showed that 12 weeks supplementation with 2 g/day Cit improved inflammatory markers in patients with NAFLD. Further studies with longer period of supplementation and different dosages of Cit are needed to be able to conclude.

Trial registration IRCT201703194010N18 on 2017-10-13

Nonalcoholic Fatty Liver Disease and Type 2 Diabetes Mellitus

Type 2 diabetes mellitus (T2DM) and nonalcoholic fatty liver disease (NAFLD) commonly exist together. It has been regarded as a manifestation of the metabolic syndrome. The presentations of NAFLD range from simple steatosis (NAFL), nonalcoholic steatohepatitis (NASH), and cirrhosis. NAFLD has a prevalence of 70% among T2DM patients. Overweight/obesity and insulin resistance (IR) have been strongly linked with NAFLD. Noninvasive assessment and staging of disease are based on clinical parameters such as age, sex, liver function test, platelet count, lipid profile, BMI, and imaging modalities such as USG, transient elastography (TE), and magnetic resonance imaging mass spectroscopy. Such clinical scoring systems and TE are useful in the early detection of NAFLD and predicting fibrosis. The principle behind the management of NAFLD with T2DM involves an indirect effect through improvement in IR and glycemia and thus is used for the treatment of T2DM as well.

Prospective comparison among transient elastography, supersonic shear imaging, and ARFI imaging for predicting fibrosis in nonalcoholic fatty liver disease

The diagnostic performance of supersonic shear imaging (SSI) in comparison with those of transient elastography (TE) and acoustic radiation force impulse imaging (ARFI) for staging fibrosis in nonalcoholic fatty liver disease (NAFLD) patients has not been fully assessed, especially in Asian populations with relatively lean NAFLD compared to white populations. Thus, we focused on comparing the diagnostic performances of TE, ARFI, and SSI for staging fibrosis in a head-to-head manner, and identifying the clinical, anthropometric, biochemical, and histological features which might affect liver stiffness measurement (LSM) in our prospective biopsy-proven NAFLD cohort. In this study, ninety-four patients with biopsy-proven NAFLD were included prospectively. Liver stiffness was measured using TE, SSI, and ARFI within 1 month of liver biopsy. The diagnostic performance for staging fibrosis was assessed using receiver operating characteristic (ROC) analysis. Anthropometric data were evaluated as covariates influencing LSM by regression analyses. Liver stiffness correlated with fibrosis stage (p < 0.05); the area under the ROC curve of TE (kPa), SSI (kPa), and ARFI (m/s) were as follows: 0.757, 0.759, and 0.657 for significant fibrosis and 0.870, 0.809, and 0.873 for advanced fibrosis. Anthropometric traits were significant confounders affecting SSI, while serum liver injury markers significantly confounded TE and ARFI. In conclusion, the LSM methods had similar diagnostic performance for staging fibrosis in patients with NAFLD. Pre-LSM anthropometric evaluation may help predict the reliability of SSI.

Association of fetuin B with markers of liver fibrosis in nonalcoholic fatty liver disease

OBJECTIVE

The liver-derived plasma protein fetuin B is associated with nonalcoholic fatty liver disease (NAFLD) and impaired glucose homeostasis in mice. However, its association with non-invasive ultrasound- and magnetic resonance (MR)-based markers of liver fibrosis and steatosis, the enhanced liver fibrosis (ELF) score, liver biopsy, as well as rs738409 in PNPLA3, has not been elucidated in NAFLD, so far.

DESIGN AND METHODS

The association of circulating fetuin B and transient elastography (TE), controlled attenuation parameter (CAP), ¹H-MR-spectroscopy, the ELF score, liver biopsy, as well as risk alleles in rs738409 in PNPLA3, was studied in 101 NAFLD patients as compared to 15 healthy controls.

RESULTS

Serum fetuin B levels did not differ between NAFLD patients and controls (p = 0.863). Fetuin B was independently and negatively associated with transient elastography liver stiffness measurement (LSM) (p = 0.002), but not with the steatosis markers CAP or ¹H-MR-spectroscopy. Fetuin B serum concentrations were significantly lower in individuals with LSM > 7.0 kPa as compared to patients with LSM < 7.0 kPa (p = 0.024). Furthermore, the ELF score and histologically proven fibrosis were independent and negative predictors of circulating fetuin B. Moreover, serum fetuin B significantly depended on number of rs738409 risk alleles (p = 0.026).

CONCLUSIONS

Fetuin B is independently and negatively associated with non-invasive markers of liver fibrosis and PNPLA3 status in NAFLD patients but does not show a correlation with the hepatic lipid content. Future studies need to elucidate the pathophysiological significance of fetuin B in NAFLD and its potential value as predictor for disease severity.

Effect of Mediterranean Diet and Antioxidant Formulation in Non-Alcoholic Fatty Liver Disease: A Randomized Study

Non-alcoholic fatty liver disease (NAFLD) is the most common liver disease worldwide, characterized by liver fatty acid accumulation and fibrosis, not due to excessive alcohol consumption. Notably, nutritional habits have been reported to be implicated in the onset and severity of the hepatic damage, while the Mediterranean diet has shown beneficial effects on NAFLD. Free radicals and oxidative stress were suggested to be involved in the pathogenesis and progression of NAFLD, and several data highlighted the efficacy of antioxidant supplementation in its treatment. The aim of this study was to compare the effects of the Mediterranean diet, with or without an antioxidant complex supplement, in overweight patients suffering from NAFLD. In this prospective study, fifty Caucasian overweight patients were randomized into three groups (Groups A-C). A personalized moderately hypocaloric Mediterranean diet was prescribed to all patients included in the A and B groups. In addition to the diet, Group B was administered antioxidant supplementation daily and for the period of six months. Group C did not have any type of treatment. The study proved that the Mediterranean diet alone or in association with the antioxidant complex improved anthropometric parameters, lipid profile and reduced hepatic fat accumulation and liver stiffness. However, Group B patients, in which the diet was associated with antioxidant intake, showed not only a significant improvement in insulin sensitivity, but also a more consistent reduction of anthropometric parameters when compared with Group A patients. Taken together, these results support the benefit of antioxidant supplementation in overweight patients with NAFLD.

Synbiotic supplementation in lean patients with non-alcoholic fatty liver disease: a pilot, randomised, double-blind, placebo-controlled, clinical trial

Although non-alcoholic fatty liver disease (NAFLD) is the leading aetiology of liver disorders in the world, there is no proven treatment for NAFLD patients with normal or low BMI. The aim of this study was to evaluate the efficacy of synbiotics supplementation in NAFLD patients with normal or low BMI. In this randomised, double-blind, placebo-controlled, clinical trial, fifty patients with NAFLD were assigned to take either a synbiotic supplement or a placebo capsule for 28 weeks. Both groups were advised to follow a healthy lifestyle. At the end of the study, hepatic steatosis and fibrosis reduced in both groups; however, the mean reduction was significantly greater in the synbiotic group rather than in the placebo group (P<0·001). Furthermore, serum levels of fasting blood sugar, TAG and most of the inflammatory mediators reduced in the synbiotic group significantly compared with the placebo group (P<0·05). Our results provide evidence that synbiotic supplementation improves the main features of NAFLD in patients with normal and low BMI, at least partially through reduction in inflammatory indices. Further studies are needed to address the exact mechanism of action of these effects.

Associations Between Lifestyle Characteristics and the Presence of Nonalcoholic Fatty Liver Disease: A Case-Control Study

BACKGROUND

Dietary and physical activity (PA) habits have been suggested as important factors for nonalcoholic fatty liver disease (NAFLD). Published data are mainly focused on the effect of either diet or exercise, whereas data on other aspects like sleep remain sparse. The aim of this study was to explore potential associations between dietary intake, PA, and sleeping habits, and the presence of NAFLD.

METHODS

One hundred patients with ultrasound-proven NAFLD and 55 healthy controls matched for age, sex, and body mass index were included. Dietary habits were assessed through a semiquantitative validated food frequency questionnaire. PA level was assessed with a validated questionnaire. Total night sleep hours and duration of midday rest were also recorded. Optimal sleep duration was defined as sleep hours ≥7 and ≤9 hr/day.

RESULTS

Patients compared to controls consumed less vegetables and nuts, more sweets, drank less coffee and alcohol (all P < 0.05), and exhibited a lower level of PA (P = 0.006). PA level [odds ratio (OR) per 100 metabolic equivalent of task-min/day = 0.74, 95% confidence interval (CI) 0.61-0.89, P = 0.002] was associated with lower probability of having NAFLD, whereas sweets consumption (OR = 2.13, 95% CI 1.22-3.71, P = 0.008) was associated with increased probability, after adjusting for several confounders, including body weight status. Optimal sleep duration was marginally and inversely associated with NAFLD presence (OR = 0.38, 95% CI 0.14-1.01, P = 0.05).

CONCLUSION

Higher PA level and optimal sleep duration are associated with lower likelihood, whereas sweets consumption is associated with higher likelihood of having NAFLD. These associations are independent of body weight status and energy intake.

A "healthy diet-optimal sleep" lifestyle pattern is inversely associated with liver stiffness and insulin resistance in patients with nonalcoholic fatty liver disease

Several lifestyle habits have been described as risk factors for nonalcoholic fatty liver disease (NAFLD). Given that both healthy and unhealthy habits tend to cluster, the aim of this study was to identify lifestyle patterns and explore their potential associations with clinical characteristics of individuals with NAFLD. One hundred and thirty-six consecutive patients with ultrasound-proven NAFLD were included. Diet and physical activity level were assessed through appropriate questionnaires. Habitual night sleep hours and duration of midday naps were recorded. Optimal sleep duration was defined as sleep hours ≥ 7 and ≤ 9 h/day. Lifestyle patterns were identified using principal component analysis. Eight components were derived explaining 67% of total variation of lifestyle characteristics. Lifestyle pattern 3, namely high consumption of low-fat dairy products, vegetables, fish, and optimal sleep duration was negatively associated with insulin resistance (β = -1.66, P = 0.008) and liver stiffness (β = -1.62, P = 0.05) after controlling for age, sex, body mass index, energy intake, smoking habits, adiponectin, and tumor necrosis factor-α. Lifestyle pattern 1, namely high consumption of full-fat dairy products, refined cereals, potatoes, red meat, and high television viewing time was positively associated with insulin resistance (β = 1.66, P = 0.005), although this association was weakened after adjusting for adiponectin and tumor necrosis factor-α. A "healthy diet-optimal sleep" lifestyle pattern was beneficially associated with insulin resistance and liver stiffness in NAFLD patients independent of body weight status and energy intake.

Flaxseed supplementation in non-alcoholic fatty liver disease: a pilot randomized, open labeled, controlled study

A two-arm randomized open labeled controlled clinical trial was conducted on 50 patients with non-alcoholic fatty liver disease (NAFLD). Participants were assigned to take either a lifestyle modification (LM), or LM +30 g/day brown milled flaxseed for 12 weeks. At the end of the study, body weight, liver enzymes, insulin resistance and hepatic fibrosis and steatosis decreased significantly in both groups (p< 0.05); however, this reduction was significantly greater in those who took flaxseed supplementation (p < 0.05). The significant mean differences were reached in hepatic markers between flaxseed and control group, respectively: ALT [-11.12 compared with -3.7 U/L; P< 0.001], AST [-8.29 compared with -4 U/L; p < 0.001], GGT [-15.7 compared with -2.62 U/L; p < 0.001], fibrosis score [-1.26 compared with -0.77 kPa; p = 0.013] and steatosis score [-47 compared with -15.45 dB/m; p = 0.022]. In conclusion, flaxseed supplementation plus lifestyle modification is more effective than lifestyle modification alone for NAFLD management.

Diagnostic usefulness of FibroMeter VCTE for hepatic fibrosis in patients with nonalcoholic fatty liver disease

BACKGROUND

Liver fibrosis is an important prognostic determinant in patients with nonalcoholic fatty liver disease (NAFLD). The FibroMeter VCTE is a diagnostic tool comprising both biochemical markers and transient elastography (TE) originally developed for the diagnosis of fibrosis in patients with chronic viral hepatitis. In this pilot study, we investigated the diagnostic performance of the FibroMeter VCTE tool for determining fibrosis in patients with biopsy-proven NAFLD. Its diagnostic accuracy was also compared with those of the NAFLD fibrosis score (NFSA) and TE alone.

PATIENTS AND METHODS

FibroMeter VCTE, NFSA, and TE were determined in 52 patients with NAFLD. The results of liver biopsies were considered the gold standard. Areas under the receiver operating characteristic curve were used to express the diagnostic accuracy of each test.

RESULTS

Significant (F≥2) and severe (F≥3) fibrosis were detected in 20 (38%) and 10 (19%) patients, respectively. The sensitivity of FibroMeter VCTE, NFSA, and TE for detecting significant fibrosis was 70, 65, and 75%, respectively, whereas specificity was 88, 81, and 78%. The sensitivity of FibroMeter VCTE, NFSA, and TE for diagnosing severe fibrosis was 90, 90, and 100%, respectively, whereas specificity was 93, 78, and 76%. Receiver operating characteristic analysis showed that FibroMeter VCTE had a significantly larger areas under the receiver operating characteristic curve (0.968) compared with both NFSA (0.833, P<0.001) and TE (0.922, P<0.05) for the detection of severe fibrosis.

CONCLUSION

Our preliminary findings indicate that FibroMeter VCTE is superior to both NFSA and TE for the diagnosis of severe fibrosis in patients with NAFLD.

Measurements of serum procollagen-III peptide and M30 do not improve the diagnostic accuracy of transient elastography for the detection of hepatic fibrosis in patients with nonalcoholic fatty liver disease

BACKGROUND

Transient elastography (TE) has recently emerged as an accurate noninvasive imaging method for the diagnosis of liver fibrosis in nonalcoholic fatty liver disease (NAFLD). Here, we tested whether adding serum measures of serum procollagen-III peptide (PIIIP) and caspase-cleaved cytokeratin 18 fragment (M30) to TE could improve its diagnostic accuracy in patients with biopsy-proven NAFLD.

PATIENTS AND METHODS

TE was performed in 87 patients with NAFLD. Serum PIIIP and M30 levels were determined by enzyme-linked immunosorbent assay. Liver histology was considered the gold standard. The diagnostic accuracies were assessed by measuring the area under the receiver operating curve.

RESULTS

At histopathological examination, 34 patients (39.1%) had significant fibrosis (F2-F4) and 19 patients (21.8%) had advanced fibrosis (F3-F4). Both TE and serum M30 levels were independent predictors of fibrosis, whereas no association was found with PIIIP. No significant differences in terms of sensitivity and specificity for both significant and advanced fibrosis were evident for TE, serum M30, or their combination. Moreover, the area under the receiver operating curves of serum M30 combined with TE did not differ significantly from those of either test alone.

CONCLUSION

Both TE and serum M30 levels are accurate for the noninvasive diagnosis of fibrosis in NAFLD. However, their combination did not improve the overall diagnostic accuracy.

Liver stiffness measurement for risk assessment of hepatocellular carcinoma

AIM

Liver fibrosis is a risk factor for hepatocellular carcinoma (HCC), but at what fibrotic stage the risk for HCC is increased has been poorly investigated quantitatively. This study aimed to determine the appropriate cut-off value of liver stiffness for HCC concurrence by FibroScan, and its clinical significance in hepatitis B virus (HBV), hepatitis C virus (HCV) and non-B, non-C (NBNC) liver disease.

METHODS

Subjects comprised 1002 cases (246 with HCC and 756 without HCC) with chronic liver disease (HBV, 104; HCV, 722; and NBNC, 176).

RESULTS

Liver stiffness was significantly greater in all groups with HCC, and the determined cut-off value for HCC concurrence was more than 12.0 kPa in those with HCV, more than 8.5 kPa in those with HBV and more than 12.0 kPa in those with NBNC. Liver stiffness of more than 12.0 kPa was an independent risk factor for new HCC development in HCV. For HCV, risk factors for HCC concurrence were old age, male sex, low albumin, low platelets and liver stiffness, while for HBV they were old age, low platelets and liver stiffness, and for NBNC they were old age, elevated α-fetoprotein and liver stiffness.

CONCLUSION

Liver stiffness cut-off values and their association with HCC concurrence were different depending on the etiology. In HCV, liver stiffness of more than 12.0 kPa was an independent risk factor for new HCC development. Collectively, determining the fibrotic cut-off values for HCC concurrence would be important in evaluating HCC risks.

A new method for measuring the speed of sound in rat liver ex vivo using an ultrasound system: correlation of sound speed with fat deposition

The speed of sound correlates well with the fat content of the liver. Therefore, non-invasive quantification of sound speed in the liver might be of diagnostic value. Here we describe a new non-invasive method that would be clinically applicable for measurement of sound speed in the liver. Sprague-Dawley rats were divided into two groups: a control group and a fatty liver group prepared by keeping the rats on a choline-deficient diet for 6 wk. The livers were subjected to pathologic and biochemical analysis; the speed of sound through the liver tissue was measured using our proposed method and a pulser-receiver as standard. Our results indicated that use of the proposed method makes it feasible to diagnose fatty liver with good accuracy on the basis of sound speed. This approach would have considerable potential for non-invasive diagnosis of fatty liver and would be a valuable adjunct to conventional liver diagnostic procedures.

Non-alcoholic fatty liver disease in obese adults: clinical aspects and current management strategies

Non-alcoholic fatty liver disease (NAFLD) is the most common chronic liver disorder whose prevalence is strongly linked to the current epidemic of obesity in many western countries. The prevalence of NAFLD is two to four times higher in populations with pre-existing metabolic comorbidities than in the general population. The diagnosis of primary NAFLD involves establishing the presence of hepatic steatosis or steatohepatitis by imaging or histology, along with establishing the non-alcoholic nature of the disease process and excluding competing aetiologies for hepatic steatosis. Among the indirect serum biomarkers, the NAFLD fibrosis score can help to identify patients with NAFLD and with higher likelihood of having fibrosis or cirrhosis. A liver biopsy should be considered in NAFLD patients at increased risk for steatohepatitis/advanced fibrosis and in cases where a liver biopsy is necessary to exclude co-existing chronic liver diseases and other aetiologies for hepatic steatosis. The treatment and management recommendations for obesity-associated NAFLD are aimed towards weight reduction. The currently available interventions employed to promote weight loss and improve the metabolic responses in NAFLD include lifestyle modification, pharmacotherapy and bariatric surgery.

Relationship of liver stiffness and controlled attenuation parameter measured by transient elastography with diabetes mellitus in patients with chronic liver disease

High prevalence of diabetes mellitus in patients with liver cirrhosis has been reported in many studies. The aim of our study was to evaluate the relationship of hepatic fibrosis and steatosis assessed by transient elastography with diabetes in patients with chronic liver disease. The study population consisted of 979 chronic liver disease patients. Liver fibrosis and steatosis were assessed by liver stiffness measurement (LSM) and controlled attenuation parameter (CAP) on transient elastography. Diabetes was diagnosed in 165 (16.9%) of 979 patients. The prevalence of diabetes had significant difference among the etiologies of chronic liver disease. Higher degrees of liver fibrosis and steatosis, assessed by LSM and CAP score, showed higher prevalence of diabetes (F0/1 [14%], F2/3 [18%], F4 [31%], P<0.001; S0/1 [15%], S2 [17%], S3 [26%], P=0.021). Multivariate analysis showed that the independent predictive risk factors for diabetes were hypertension (OR, 1.98; P=0.001), LSM F4 (OR, 1.86; P=0.010), male gender (OR, 1.60; P=0.027), and age>50 yr (OR, 1.52; P=0.046). The degree of hepatic fibrosis but not steatosis assessed by transient elastography has significant relationship with the prevalence of diabetes in patients with chronic liver disease.

Non-alcoholic fatty liver disease: a diabetologist's perspective

In the recent years, non-alcoholic fatty liver disease (NAFLD) has emerged as the commonest cause of chronic liver disease in the developed world. The global epidemic of obesity secondary to physical inactivity and adverse food habits accounts for the alarming rise in NAFLD. Metabolic syndrome plays a major role in the pathogenesis of both NAFLD and type 2 diabetes mellitus (T2DM). Whilst most cases of NAFLD remain asymptomatic with only hepatic steatosis, about 30 % progress to non-alcoholic steatohepatitis with chronic liver inflammation that can lead on to fibrosis, cirrhosis, liver failure, and hepatocellular carcinoma. Because of the similar pathogenesis shared between T2DM and NAFLD, T2DM occurs as an important complication in many cases of NAFLD, and many cases of T2DM are further complicated by NAFLD. Rapid progression and increased complications of the individual diseases is the end result of this dual coexistence. Diagnosis of NAFLD relies upon hepatic imaging, serum biochemical markers, and liver biopsy. As in T2DM, the most important management option for patients with NAFLD is lifestyle changes targeted at weight reduction. Other treatment options include insulin sensitizers (metformin and pioglitazone), vitamin E, incretin mimetics, omega-3 fatty acids, cholesterol lowering agents, orlistat, and bariatric surgery. The clinical spectrum, patho-physiological features and therapeutic options of NAFLD share many things in common with T2DM and therefore, this review is to highlight the diabetologist's perspective of the disease.

Synbiotic supplementation in nonalcoholic fatty liver disease: a randomized, double-blind, placebo-controlled pilot study

BACKGROUND

Nonalcoholic fatty liver disease (NAFLD) is the most common chronic liver disease in the world. Oral administration of synbiotic has been proposed as an effective treatment of NAFLD because of its modulating effect on the gut flora, which can influence the gut-liver axis.

OBJECTIVE

The objective was to evaluate the effects of supplementation with synbiotic on hepatic fibrosis, liver enzymes, and inflammatory markers in patients with NAFLD.

DESIGN

In a randomized, double-blind, placebo-controlled clinical trial conducted as a pilot study, 52 patients with NAFLD were supplemented twice daily for 28 wk with either a synbiotic or a placebo capsule. Both groups were advised to follow an energy-balanced diet and physical activity recommendations.

RESULTS

At the end of the study, the alanine aminotransferase (ALT) concentration decreased in both groups; this reduction was significantly greater in the synbiotic group. At the end of the study, the following significant differences [means (95% CIs)] were seen between the synbiotic and placebo groups, respectively: ALT [-25.1 (-26.2, -24) compared with -7.29 (-9.5, -5.1) IU/L; P < 0.001], aspartate aminotransferase [-31.33 (-32.1, -30.5) compared with -7.94 (-11.1, -4.8) IU/L; P < 0.001], γ-glutamyltransferase [-15.08 (-15.5, -14.7) compared with -5.21 (-6.6, -3.9) IU/L; P < 0.001], high-sensitivity C-reactive protein [-2.3 (-3, -1.5) compared with -1.04 (-1.5, -0.6) mmol/L; P < 0.05], tumor necrosis factor-α [-1.4 (-1.7, -1.1) compared with -0.59 (-0.8, -0.3) mmol/L; P < 0.001], total nuclear factor κ-B p65 [-0.016 (-0.022, -0.011) compared with 0.001 (-0.004, -0.007) mmol/L; P < 0.001], and fibrosis score as determined by transient elastography [- 2.98 (-3.6, -2.37) compared with -0.77 (-1.32, -0.22) kPa; P < 0.001].

CONCLUSIONS

Synbiotic supplementation in addition to lifestyle modification is superior to lifestyle modification alone for the treatment of NAFLD, at least partially through attenuation of inflammatory markers in the body. Whether these effects will be sustained with longer treatment durations remains to be determined.

Diagnostic imaging in obesity

Magnetic resonance of the body offers different techniques for mapping fat deposits (MR Imaging) and analysis of organs with small amounts of lipids (MR Spectroscopy). Possible approaches for whole-body assessment of adipose tissue are presented and discussed and spectroscopic examinations in different organs are depicted. With magnetic resonance imaging (MRI) it has been shown that obesity per se is not a marker for metabolic failure, but depends on regional variations of body composition and ectopic lipid accumulation. In addition MRI of the brain is a powerful research tool to understand the brain's role in the development and maintenance of obesity and the overconsumption of foods in obese individuals. Sonography has a low accuracy in estimating hepatic steatosis until now. New sonographic methods have been evaluated to detect hepatic steatosis by physical properties of fatty tissue as tissue stiffness, sound absorption or sound speed. Nuclear medicine and in particular Positron Emission Tomography (PET) methods are used to explore central pathophysiology, brown adipose tissue activity and alterations in homeostatic feedback and gut-brain communication.

Association between anthropometric parameters and measurements of liver stiffness by transient elastography

BACKGROUND & AIMS

We investigated the association between anthropometric parameters and results of liver stiffness measurements (LSMs) by transient elastography in healthy subjects and patients with nonalcoholic fatty liver disease (NAFLD).

METHODS

We analyzed anthropometric and LSM data from 658 healthy subjects (37% male; mean age, 47 ± 11 years; body mass index [BMI], 21.8 ± 3.0 kg/m(2); LSM, 4.4 ± 1.6 kPa) and 247 patients with biopsy-proven NAFLD (50% male; mean age, 48 ± 11 years; BMI, 28.6 ± 6.5 kg/m(2); LSM, 9.6 ± 8.7 kPa). Healthy subjects were defined as individuals without viral hepatitis, alcoholic liver disease, or NAFLD. We investigated associations between anthropometric parameters, including BMI and waist circumference, and LSM.

RESULTS

LSMs were slightly higher among healthy subjects with BMIs ≤ 18.5 kg/m(2) (n = 84, 4.8 ± 1.5 kPa) and BMIs of 25-29.9 kg/m(2) (n = 76, 5.3 ± 2.2 kPa) than those with BMIs of 18.5-24.9 kg/m(2) (n = 492, 4.5 ± 1.9 kPa; P = .16 by analysis of variance). Among patients with NAFLD of Brunt fibrosis stage 0 or 1, LSMs were lowest among those with BMIs of 18.5-24.9 kg/m(2) (stage 0: n = 34, 5.5 ± 2.2 kPa; stage 1: n = 18, 7.2 ± 3.8 kPa). LSMs were higher among those with BMIs of 25-29.9 kg/m(2) (stage 0: n = 41, 6.1 ± 1.3 kPa; stage 1: n = 26, 7.9 ± 3.5 kPa) and highest for those with BMIs ≥30 kg/m(2) (stage 0: n = 13, 8.5 ± 2.2 kPa; stage 1: n = 22, 11.7 ± 5.2 kPa) (P < .001 and P = .002, respectively, by analysis of variance). High BMI was independently associated with high LSM, in addition to fibrosis stage, among patients with NAFLD. Patients with different waist circumferences had comparable LSMs.

CONCLUSIONS

BMI ≥30 kg/m(2) is associated with higher LSMs in patients with NAFLD, after adjusting for fibrosis stage.