A multisociety Delphi consensus statement on new fatty liver disease nomenclature

Causal associations of metabolic dysfunction-associated steatotic liver disease with gestational hypertension and preeclampsia: a two-sample Mendelian randomization study

BACKGROUND

Hypertensive disorders of pregnancy (HDPs), which include gestational hypertension (GH) and preeclampsia (PE), are the primary causes of maternal morbidity and mortality worldwide. Recent studies have found a correlation between metabolic dysfunction-associated steatotic liver disease (MASLD) and HDPs, but the causality of this association remains to be identified. Therefore, this study aims to evaluate the causal relationship between MASLD and HDPs through Mendelian randomization (MR) analysis.

METHODS

The summary statistics from genome-wide association studies were employed to conduct a two-sample MR analysis. Five complementary MR methods, including inverse variance weighting (IVW), MR-Egger, weighted median, simple mode and weighted mode were performed to assess the causality of MASLD on GH and PE. Furthermore, we conducted various sensitivity analyses to ensure the stability and reliability of the results.

RESULTS

Genetically predicted MASLD significantly increased the risk of GH (IVW: OR = 1.138, 95% CI: 1.062-1.220, p < 0.001), while there was little evidence of a causal relationship between MASLD and PE (IVW: OR = 0.980, 95% CI: 0.910-1.056, p = 0.594). The sensitivity analyses indicated no presence of heterogeneity and horizontal pleiotropy.

CONCLUSION

This MR study provided evidence supporting the causal effect of MASLD on GH. Our findings underscore the significance of providing more intensive prenatal care and early intervention for pregnant women with MASLD to prevent potential adverse obstetric outcomes.

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

AIM

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

MATERIALS AND METHODS

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

RESULTS

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

LIMITATIONS AND CONCLUSIONS

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

Engineered extracellular vesicles with surface FGF21 and enclosed miR-223 for treating metabolic dysfunction-associated steatohepatitis

Metabolic dysfunction-associated steatohepatitis (MASH) is a progressive liver disorder with a complex pathogenesis that requires combination therapies rather than monotherapies. Extracellular vesicles (EVs) exhibit inherently efficient delivery to the liver and can be engineered to carry various therapeutic substances, making them promising agents. In this study, EVs were engineered to display fibroblast growth factor 21 (FGF21) on their surface and encapsulate miR-223 (223/F-EVs), aiming to improve steatosis and alleviate inflammation and fibrosis, respectively. Introducing the 223/F-EVs into human liver cell lines significantly reduced both basal and induced levels of lipid storage, inflammation, and fibrosis markers. Furthermore, using an FGF21-blocking antibody or miR-223 inhibitor effectively diminished the efficacy of the 223/F-EVs, confirming the essential roles of FGF21 and miR-223 in these processes. In a Choline-Deficient, l-Amino acid-defined, High-Fat Diet (CDAHFD)-fed mouse model, intravenously administered 223/F-EVs demonstrated liver-preferential delivery and a marked reduction in the MASH phenotype without compromising bone density, unlike conventional FGF21 treatment. Collectively, 223/F-EVs convey FGF21 and miR-223 exclusively to the liver, offering strategic advantages by mitigating MASH progression via multiple pathways. This study lays a solid foundation for further investigation of engineered EVs as a transformative therapeutic approach for treating MASH.

Disparities in liver transplantation for metabolic dysfunction-associated steatohepatitis-associated hepatocellular carcinoma

BACKGROUND

Metabolic dysfunction-associated steatohepatitis (MASH) is increasingly common, as is hepatocellular carcinoma (HCC) in the background of MASH. Liver transplantation (LT) provides superior long-term survival for patients with unresectable MASH-HCC, but not all patients have equal access to transplant. MASH-HCC disproportionately affects Hispanic patients, but minorities are less likely to undergo LT for HCC. Additionally, females also undergo LT at lower rates than males.

AIM

To investigate whether race/ethnicity and sex affect LT waitlist outcomes.

METHODS

Records of adults with MASH-HCC in the United States Organ Procurement and Transplantation Network database listed for LT between 1/2015 and 12/2021 were analyzed.

RESULTS

Most of the 3810 patients waitlisted for LT for MASH-HCC were non-Hispanic (NH) white (71.2%) or Hispanic (23.4%), with only 49 (1.1%) NH Black candidates. Hispanics underwent LT at lower rates than NH whites (71.6% vs 78.4%, P < 0.001), but race/ethnicity did not affect waitlist mortality (P = 0.06). Patients with Hispanic [hazard ratio (HR) = 0.85, 95%CI: 0.77-0.95, P = 0.002] or Asian (HR = 0.79, 95%CI: 0.63-0.98, P = 0.04) race/ethnicity were less likely to undergo LT. Women were also less likely to receive LT (male: HR = 1.16, 95%CI: 1.04-1.29, P = 0.01). Patients in regions 1 and 9 were less likely to be transplanted as well (P = 0.07).

CONCLUSION

Hispanic patients are less likely to undergo LT for MASH-HCC, concerning given their susceptibility to MASH and HCC. There were very few NH Black candidates. Disparities were also unequal across regions, which is particularly concerning in states where at-risk populations have rising cancer incidence. Additional research is needed to identify strategies for mitigating these differences in access to LT for MASH-HCC.

Heavy metals are liver fibrosis risk factors in people without traditional liver disease etiologies

Liver fibrosis is an important predictor of mortality. Liver disease case definitions changed in 2023. These definitions include an easily over-looked group with no traditional etiology (NTE) of liver disease and no steatosis. We analyzed heavy metals and cardiometabolic risk factors (CMRFs) as fibrosis risk factors in the NTE group and in people with another newly-defined condition, metabolic dysfunction-associated steatotic liver disease (MASLD). Two National Health and Nutrition Examination Survey (NHANES) datasets were analyzed. In NHANES III (1988-1994), fibrosis and steatosis were defined by Fibrosis-4 scores and ultrasound, respectively, in 12,208 adults. In NHANES 2017-2020, fibrosis and steatosis were defined by transient elastography and the controlled attenuation parameter (CAP) in 5525 adults. Fibrosis risk factors varied over time and by race/ethnicity. In the earlier dataset, NTE-fibrosis had a positive, non-significant, association with high blood levels of lead (Pb). MASLD-fibrosis was associated with Pb (OR = 2.5, 95 % CI, 1.4-4.4) and not with CMRFs in non-Hispanic Blacks but was associated with CMRFs in non-Hispanic Whites. Heavy metal exposures fell between the two time periods. In the later dataset, NTE-fibrosis was associated with Pb (OR = 4.2, 95 % CI, 2.6-6.8) and cadmium (OR = 1.8, 95 % CI, 1.1-3.0) in the total population, but not with most CMRFs. MASLD-fibrosis was strongly-significantly associated with CMRFs in every racial/ethnic group except non-Hispanic Blacks in whom CMRFs were only weakly associated with MASLD-fibrosis. Heavy metal pollution, which disproportionately impacts minoritized populations, decreased over time, but remained strongly associated with liver fibrosis in people lacking traditional etiological factors for liver disease.

Efficacy, Safety, and Tolerability of Farnesoid X Receptor Agonists in the Treatment of Metabolic Dysfunction-associated Steatotic Liver Disease: A Systematic Review and Meta-analysis

Background/Aims

Metabolic dysfunction-associated steatotic liver disease (MASLD) is a leading cause of chronic liver disease. Farnesoid X receptor (FXR) agonists are emerging as promising therapies for fibrosis, steatosis, and metabolic dysfunctions. However, its efficacy and safety remain unclear.

Methods

A systematic search of PubMed, Embase, and Cochrane databases identified randomized controlled trials (RCTs) comparing FXR agonists with placebo in patients with MASLD. The main outcomes included improvement in fibrosis without worsening steatohepatitis, changes in liver chemistry and lipid profiles, and liver fat content (LFC). The safety outcomes assessed included side effects and treatment discontinuation rates. Heterogeneity was evaluated using I² statistics, with a random-effects model applied to the pooled analyses.

Results

Ten RCTs involving 3,779 patients were included, of which 2,527 (67%) were randomized to receive FXR agonists. FXR agonists significantly improved fibrosis by ≥ 1 stage (RR, 1.52; 95% CI: [1.23, 1.88]; P < 0.0001) and reduced LFC (mean difference: -4.9%; 95% CI: [-8.26, -1.55]; P < 0.001). A higher proportion of patients achieved a ≥30% reduction in LFC (42.8% vs. 18.4%; RR, 2.42; 95% CI: [1.69, 3.46]; P < 0.00001). Significant reductions in alanine aminotransferase and gamma glutamyltransferase levels were observed, whereas alkaline phosphatase levels were increased. FXR agonists were associated with a slight reduction in High-Density Lipoprotein (HDL) cholesterol levels and a higher incidence of pruritus (37.8% vs. 18.7%; RR, 2.67; 95% CI: [1.63, 4.38]; P < 0.00001), leading to higher treatment discontinuation rates.

Conclusion

FXR agonists have the potential to improve fibrosis and steatosis in MASLD patients. However, safety concerns still remain. Further research is required to determine the long-term efficacy and tolerability of these drugs.

Serum Bile Acid Elevation is an Independently Associated With Pruritus in Patients With At-risk Metabolic Dysfunction-associated Steatotic Liver Disease

Background and aims

Elevated serum bile acids are associated with pruritus in cholestatic liver diseases. We assessed the association of serum bile acids and other putative biomarkers of cholestatic pruritus (autotaxin and interleukin-31 (IL-31) with pruritus in patients with metabolic dysfunction-associated steatotic liver disease (MASLD).

Methods

We used serum from patients with MASLD and metabolic dysfunction-associated steatohepatitis (MASH), viral hepatitis B, viral hepatitis C, and healthy blood donors to measure the levels of bile acids, autotaxin, and IL-31. Clinically significant pruritus was defined from the Chronic Liver Disease Questionnaire.

Results

Six hundred fifty-one subjects were included [MASLD (N = 497, 88 MASH), viral hepatitis B and C (VH, N = 98), healthy controls (N = 56)]. Post hoc definitions of high biomarker levels associated with the presence of clinically significant pruritus were as follows: high bile acids ≥5.9 μmol/L, high autotaxin ≥220 ng/mL, and high IL-31 ≥ 25 pg/mL. The VH patients had the highest bile acids levels and lowest levels were in healthy controls (P < 0.0001). The highest autotaxin levels were seen in hepatitis C, while the highest IL-31 levels in MASH. MASH patients had higher levels of all three biomarkers than non-MASH-MASLD. Also, at-risk MASLD or MASLD with advanced fibrosis (AF) had higher bile acids and autotaxin (all P < 0.01) but not IL-31 (P > 0.05). MASLD patients with high bile acids had more pruritus (all MASLD: 25% vs. 17%; MASH 30% vs. 13%; at-risk MASLD: 33% vs. 12%; AF: 41% vs. 8%). In multivariable logistic regressions, having high bile acids was an independent predictor of pruritus in at-risk MASLD [odds ratio (OR) (95% CI) = 4.4 (1.6-12.1)] and MASLD with advanced fibrosis [OR = 7.5 (2.0-29.0)]; but not autotaxin or IL-31 (all P > 0.05).

Conclusions

High serum bile acid level is independently associated with pruritus in at-risk MASLD.

The prognostic role of Fibrosis-4 score in heart failure with reduced ejection fraction

BACKGROUND

Heart failure with reduced ejection fraction (HFrEF) and metabolic dysfunction-associated steatotic liver disease (MASLD) are both associated with liver fibrosis. HFrEF patients may develop liver fibrosis due to hepatic congestion, MASLD, or a combination of both. The Fibrosis-4 (FIB-4) score calculated using age, aspartate aminotransferase, alanine aminotransferase, and platelet count, serves as a screening tool for advanced liver fibrosis. This study examines the association between the FIB-4 score and all-cause mortality, cardiovascular mortality, and major adverse liver outcomes (MALO) in patients with HFrEF.

METHOD AND RESULTS

This study included 4523 HFrEF patients from the Danish Heart Failure Registry. Based on FIB-4 score, 25.5 % were low-risk, 45.7 % were indeterminate-risk, and 28.8 % were high-risk for advanced liver fibrosis. After five years, the cumulative incidence of all-cause mortality was 43 % for the high-risk group, 36 % for the indeterminate-risk group, and 23 % for the low-risk group. The indeterminate-risk and high-risk group had an increased hazard ratio (HR) for all-cause mortality (HR 1.33, 95 % confidence interval [CI] 1.16-1.52; HR 1.51, 95 % CI 1.31-1.74) compared to the low-risk group. Similarly, HRs were elevated for cardiovascular mortality (HR 1.61, 95 % CI 1.27-2.05; HR 2.14, 95 % CI 1.67-2.74) and MALO (HR 1.77, 95 % CI 1.01-3.31; HR 2.54, 95 % CI 1.43-4.52).

CONCLUSION

A high FIB-4 score in patients with HFrEF is associated with increased mortality and MALO.

Comparative association of MAFLD/MASLD and Subtypes with Cardiovascular Diseases Outcomes

BACKGROUND AND AIMS

Metabolic dysfunction-associated steatotic liver disease (MASLD) acts as an alternative for demarcating metabolic dysfunction-associated fatty liver disease (MAFLD). This study aimed to investigate the factors that significantly influence the relationship between MAFLD and MASLD in relation to the incidence of major cardiovascular outcomes.

METHODS AND RESULTS

A total of 340,998 participants in the UK Biobank study were included. Multivariable Cox proportional hazards models were used to estimate the effect of MAFLD and MASLD on the outcomes of cardiovascular diseases (CVDs) (coronary artery disease, stroke, heart failure, and CVD-related death) with hazard ratios (HRs) and 95 % confidence intervals (CIs). A total of 126,077 (36.97 %) participants had MAFLD and 97,418 (28.57 %) had MASLD. Over a median follow-up of 13.5 years (interquartile range 12.6-14.2), there were 41,548 new events of CVDs recorded. MAFLD (HR = 1.52; 95 % CI: 1.49-1.55) and MASLD (HR = 1.42; 95 % CI: 1.39-1.45) were associated with high risks of CVDs. Among the subtypes of MAFLD and steatotic liver disease (SLD), MAFLD diabetes subtype (HR = 2.26; 95 % CI: 2.17-2.35) and alcohol-associated liver disease (ALD) (HR = 1.65; 95 % CI: 1.55-1.76) exhibited the highest risk of CVDs. MAFLD overweight without MD subtype were not associated with CVDs. The effect of MAFLD on the CVD outcomes was consistent regardless of the presence of MASLD.

CONCLUSION

The metabolic health status and alcohol consumption function as more critical factors than obesity in assessing CVD outcomes in participants with MAFLD or MASLD.

GLP-1 receptor agonists efficacy in managing comorbidities associated with diabetes mellitus: a narrative review

Objectives

Diabetes mellitus (DM) is often accompanied by various comorbidities, including cardiovascular diseases, Metabolic Dysfunction-Associated Steatotic Liver Disease (MASLD), renal dysfunction, polycystic ovary syndrome (PCOS), neurological disorders, psychiatric conditions, and others. These comorbidities complicate diabetes management and contribute to worsened health outcomes. This narrative review explores the efficacy of glucagon-like peptide-1 (GLP-1) receptor agonists in managing a broad range of diabetes-related comorbidities, assessing their therapeutic potential beyond glycemic control.

Methods

A comprehensive review of the literature was conducted by searching scientific databases including PubMed, Scopus, and Web of Science. Additionally, AI-based tools like ChatGPT were employed from September 2024 to January 2025 to enhance the accuracy of data collection and analysis. The search was conducted using keywords such as "GLP-1 receptor agonists", "diabetes and comorbidities", "cardiovascular diseases", "MASLD", "renal dysfunction", "PCOS", "neurological disorders", "psychiatric disorders", "sleep apnea", "osteoarthritis", and "diabetic retinopathy". Boolean operators (AND/OR) were used to combine the keywords for efficient searching. Studies were selected and analyzed based on predefined criteria to evaluate the efficacy of GLP-1 receptor agonists (GLP1RAs) in managing diabetes-related comorbidities.

Results

GLP1RAs have demonstrated significant benefits in managing various comorbidities, including cardiovascular diseases, liver conditions (such as MASLD), renal dysfunction, and metabolic disorders like PCOS. They also show promise in addressing neurological and psychiatric disorders, likely due to their anti-inflammatory, neuroprotective, and metabolic effects.

Conclusion

GLP1RAs offer a multifaceted approach to treating not only diabetes but also its associated comorbidities, improving patient outcomes across multiple health domains. However, further research is required to confirm these benefits and optimize treatment strategies for diverse patient populations.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40200-025-01604-w.

Impact of cardiometabolic risk factors for metabolic dysfunction-associated steatotic liver disease on mortality

BACKGROUND AND AIMS

Metabolic dysfunction-associated steatotic liver disease (MASLD) is a potential independent risk factor for cardiovascular disease (CVD)-associated and all-cause mortalities as they share common risk factors. We investigated the association between cardiometabolic risk factors for MASLD and CVD-associated and all-cause mortality risks in middle-aged and older Korean adults.

METHODS AND RESULTS

We used data from the Korean Genome and Epidemiology Study, a population-based prospective cohort study. Five cardiometabolic risk factors were assessed. MASLD was defined as liver steatosis with a fatty liver index (FLI) ≥60 and at least one cardiometabolic risk factor. The non-MASLD group included individuals with a FLI <60 or FLI ≥60 without cardiometabolic risk factors. The primary outcomes were CVD-associated and all-cause mortalities. Cox proportional hazard models were used to evaluate the association between cardiometabolic risk factors for MASLD and mortalities, adjusting for covariates. Multivariable Cox regression analysis revealed that the MASLD group had increased CVD-associated and all-cause mortality risks compared to the non-MASLD group. The presence of three or more and one or more cardiometabolic risk factors significantly increased the CVD-associated and all-cause mortality rate, respectively. The combination of hypertriglyceridemia, low high-density lipoprotein cholesterol (HDL-C), and high glucose concentrations significantly increased both CVD-associated (hazard ratio [HR] 3.64; 95 % confidence interval [CI] 1.44-9.22; p = 0.006) and all-cause (HR 4.57; 95 % CI: 1.74-12.05; p = 0.002) mortality risks.

CONCLUSION

Cardiometabolic risk factors for MASLD are strongly associated with higher CVD-associated and all-cause mortality risks, highlighting the need to manage hypertriglyceridemia, low HDL-C, and high glucose concentrations.

Iron overload exacerbates metabolic dysfunction-associated steatohepatitis via the microbiota-gut-liver axis through lipopolysaccharide-mediated Akr1b8 activation

Iron homeostatic is closely linked to the development of metabolic dysfunction-associated steatohepatitis (MASH). However, the underlying mechanisms remain poorly understood. HFE knockout (KO) mice were used to generate mild iron-overload models. MASH was induced by feeding mice a methionine- and choline-deficient (MCD) diet for 4 weeks. Iron overload significantly exacerbated the pathologies of MCD-induced MASH, including liver injury, hepatic lipid accumulation, inflammation, and fibrosis. Additionally, iron overload reshaped the composition of gut microbiota, and fecal microbiota transplantation assay proved that gut microbiota from iron-overload mice contributed to hepatic lipid accumulation in control mice. Furthermore, iron overload-induced dysbacteriosis altered the metabolite profiles, reducing short-chain fatty acid levels and increasing lipopolysaccharide (LPS) levels. Notably, elevated LPS levels upregulated the expression of aldo-keto reductase family 1 member B8 (Akr1b8), which accelerated lipid accumulation and inflammation in hepatocytes. Above results indicated that iron overload promoted MASH progression through the microbiota-gut-liver axis, mediated by LPS-induced activation of Akr1b8. These findings highlight the critical role of iron homeostasis and gut microbiota in MASH pathogenesis.

Characterization of brain morphology associated with metabolic dysfunction-associated steatotic liver disease in the UK Biobank

BACKGROUND

Emerging evidence has linked metabolic dysfunction-associated steatotic liver disease (MASLD) with accelerated cognitive decline and dementia. We aimed to investigate the associations of MASLD with volumes of total brain tissue and subcortical grey matter, and white matter microstructures in the UK Biobank.

METHODS

This cross-sectional study included 29,195 individuals (aged 45-82 years) from the UK Biobank who undertook a magnetic resonance imaging (MRI) sub-study between 2014 and 2022. The brain MRI covers three modalities (T1, T2 FLAIR, and diffusion). Volumes of grey matter, subcortical grey matter structures, and regional cortex were derived from T1-weighted images. Fractional anisotropy (FA) and mean diffusivity (MD) were derived from diffusion tensor imaging (DTI) to assess global and tract-specific microstructure. MASLD was defined as the MRI-derived proton density fat fraction (MRI-PDFF) ≥5% and the presence of at least one cardiometabolic criterion. Data were analysed using multiple linear regression models.

RESULTS

MASLD was significantly associated with smaller volumes of total grey matter and subcortical grey matter (p < 0.05) and reduced Alzheimer's disease (AD)-signature cortical thickness (multivariable-adjusted β = -0.04; 95% confidence interval [CI]: -0.07, -0.01). Having MASLD was associated with higher total white matter hyperintensity (WMH) volume (multivariable-adjusted β = 0.12; 95% CI: 0.10, 0.15). For white matter microstructure, MASLD was associated with increased global FA (multivariable-adjusted β = 0.05; 95% CI: 0.03, 0.08) and reduced global MD (multivariable-adjusted β = -0.04; 95% CI: -0.07, -0.01).

CONCLUSIONS

Brain morphology associated with MASLD is characterized by smaller subcortical grey matter volume and higher coherence but lower magnitudes of white matter microstructure.

Platelet-activating cytokines potentially associated with MASLD-induced liver injury significantly decreased following CPAP therapy: A translational study using a fatty liver mouse model

BACKGROUND AND AIM

Patients with obstructive sleep apnea (OSA) and metabolic dysfunction associated steatotic liver disease (MASLD) frequently overlap due to the high prevalence of obesity. This translational study aimed to identify cytokines linking these conditions, beginning with an analysis of fatty liver in mice. Serum cytokine levels upregulated in the fatty liver mice were subsequently examined in human OSA serum samples.

METHODS

Mice were fed a high-fat diet to induce fatty liver. Liver proteins were analyzed using cytokine arrays. Serum samples from seventy (70) OSA patients (with 20 non-MASLD and 50 MASLD, pre- and 6-month post-continuous positive airway pressure [CPAP] therapy) were analyzed for the cytokines identified in the mouse experiment using enzyme-linked immunosorbent assays.

RESULTS

Four platelet-activation chemokines/cytokines (CCL5/RANTES, P-selectin, CXCL4/PF4, and CXCL5/LIX) were upregulated in mice with fatty liver. While serum levels of these factors were not significantly higher in MASLD-OSA compared to non-MASLD-OSA patients, their levels significantly decreased 6 months after the initiation of CPAP therapy, along with a reduction in mean platelet volume. CPAP compliance was significantly associated with a reduction in CCL5 levels. Additionally, a decrease in ALT levels following 6 months of CPAP therapy was significantly associated with CPAP compliance in MASLD-OSA patients.

CONCLUSIONS

While platelet-activation cytokines were not directly implicated in liver injury in MASLD-OSA patients, they decreased with CPAP therapy. CPAP compliance may play a key role in ALT reduction in MASLD-OSA patients independently of body weight changes. CCL5/RANTES may be indirectly associated with liver injury in MASLD-OSA, potentially induced through intermittent hypoxia.

Risks of liver cirrhosis, hepatocellular carcinoma, hepatic-related complications, and mortality in patients with type 2 diabetes in Taiwan

BACKGROUND

Hepatitis B and C and alcoholic liver disease are the principal causes of hepatic-related morbidity and mortality. However, evidence of the associations between diabetes without the above risk factors and hepatic-related study endpoints is not well understood. In addition, the effects of associated metabolic dysfunction and exercise on hepatic outcomes are still not clear.

AIM

To investigate the incidence and relative hazards of cirrhosis of the liver, hepatocellular carcinoma (HCC), hepatic-related complications and mortality in patients with type 2 diabetes (T2D) who were nonalcoholic and serologically negative for hepatitis B and C in Taiwan.

METHODS

A total of 33184 T2D patients and 648746 nondiabetic subjects selected from Taiwan’s adult preventive health care service were linked to various National Health Insurance databases, cancer registry, and death registry to identify cirrhosis of the liver, HCC, hepatic-related complications, and mortality. The Poisson assumption and Cox proportional hazard regression model were used to estimate the incidences and relative hazards of all hepatic-related study endpoints, respectively. We also compared the risk of hepatic outcomes stratified by age, sex, associated metabolic dysfunctions, and regular exercise between T2D patients and nondiabetic subjects.

RESULTS

Compared with nondiabetic subjects, T2D patients had a significantly greater incidence (6.32 vs 17.20 per 10000 person-years) and greater risk of cirrhosis of the liver [adjusted hazard ratio (aHR) 1.45; 95%CI: 1.30-1.62]. The aHRs for HCC, hepatic complications, and mortality were 1.81, 1.87, and 2.08, respectively. An older age, male sex, obesity, hypertension, and dyslipidemia further increased the risks of all hepatic-related study endpoints, and regular exercise decreased the risk, irrespective of diabetes status.

CONCLUSION

Patients with T2D are at increased risk of cirrhosis of the liver, HCC, hepatic-related complications, and mortality, and associated metabolic dysfunctions provide additional hazard. Coordinated interprofessional care for high-risk T2D patients and diabetes education, with an emphasis on the importance of physical activity, are crucial for minimizing hepatic outcomes.

Ultrasound-derived fat fraction for diagnosing hepatic steatosis: a systematic review and meta-analysis

OBJECTIVE

To perform a systematic review and meta-analysis to evaluate the diagnostic performance of Ultrasound-Derived Fat Fraction (UDFF) in detecting hepatic steatosis using Magnetic Resonance Imaging-Proton Density Fat Fraction (MRI-PDFF) as the reference standard.

MATERIALS AND METHODS

Relevant databases were searched through November 2024. Studies that evaluated the UDFF to detect hepatic steatosis using MRI-PDFF as the reference standard met the inclusion criteria. Our primary outcome was the sensitivity and specificity of UDFF compared to MRI-PDFF in distinguishing steatosis from non-steatosis. Analyses were performed using a bivariate random-effects approach, and heterogeneity was considered substantial if I2 > 50%. A sensitivity analysis was performed to detect potential studies that contribute to heterogeneity.

RESULTS

Nine studies comprising 1150 patients (mean age range, 14-62 years; 51.2% women) were included. Eight studies were performed using the same vendor platform. The pooled sensitivity of UDFF for detecting hepatic steatosis was 90.4% (95% CI: 84.0%, 94.4%), and the pooled specificity was 83.8% (95% CI: 75.1%, 89.8%). The AUC for the summary receiver-operating characteristic curve was 0.93 (95% CI: 0.83, 0.95). Heterogeneity among the studies was low (I² = 22.2%).

CONCLUSION

UDFF demonstrates high sensitivity and specificity for detecting hepatic steatosis, supporting its value as a noninvasive tool for screening.

KEY POINTS

Question Small individual studies suggest that US-Derived Fat Fraction (UDFF) may effectively detect hepatic steatosis compared to MRI, but no meta-analysis has been performed. Findings In nine studies including 1150 patients, UDFF demonstrated high pooled sensitivity (90.4%) and specificity (83.8%) relative to MRI with low between-study heterogeneity. Clinical relevance UDFF demonstrates high diagnostic accuracy compared with MRI, supporting its use as a noninvasive tool with potentially lower cost and wider availability for large-scale screening of hepatic steatosis.

Efruxifermin in Compensated Liver Cirrhosis Caused by MASH

BACKGROUND

In phase 2 trials involving patients with stage 2 or 3 fibrosis caused by metabolic dysfunction-associated steatohepatitis (MASH), efruxifermin, a bivalent fibroblast growth factor 21 (FGF21) analogue, reduced fibrosis and resolved MASH. Data are needed on the efficacy and safety of efruxifermin in patients with compensated cirrhosis (stage 4 fibrosis) caused by MASH.

METHODS

In this phase 2b, randomized, placebo-controlled, double-blind trial, we assigned patients with MASH who had biopsy-confirmed compensated cirrhosis (stage 4 fibrosis) to receive subcutaneous efruxifermin (at a dose of 28 mg or 50 mg once daily) or placebo. The primary outcome was a reduction of at least one stage of fibrosis without worsening of MASH at week 36. Secondary outcomes included the same criterion at week 96.

RESULTS

A total of 181 patients underwent randomization and received at least one dose of efruxifermin or placebo. Of these patients, liver biopsy was performed in 154 patients at 36 weeks and in 134 patients at 96 weeks. At 36 weeks, a reduction in fibrosis without worsening of MASH occurred in 8 of 61 patients (13%) in the placebo group, in 10 of 57 patients (18%) in the 28-mg efruxifermin group (difference from placebo after adjustment for stratification factors, 3 percentage points; 95% confidence interval [CI], -11 to 17; P = 0.62), and in 12 of 63 patients (19%) in the 50-mg efruxifermin group (difference from placebo, 4 percentage points; 95% CI, -10 to 18; P = 0.52). At week 96, a reduction in fibrosis without worsening of MASH occurred in 7 of 61 patients (11%) in the placebo group, in 12 of 57 patients (21%) in the 28-mg efruxifermin group (difference from placebo, 10 percentage points; 95% CI, -4 to 24), and in 18 of 63 patients (29%) in the 50-mg efruxifermin group (difference from placebo, 16 percentage points; 95% CI, 2 to 30). Gastrointestinal adverse events were more common with efruxifermin; most events were mild or moderate.

CONCLUSIONS

In patients with compensated cirrhosis caused by MASH, efruxifermin did not significantly reduce fibrosis at 36 weeks. (Funded by Akero Therapeutics; SYMMETRY ClinicalTrials.gov number, NCT05039450.).

Conjugated Lithocholic Acid Activates Hepatic TGR5 to Promote Lipotoxicity and MASLD-MASH Transition by Disrupting Carnitine Biosynthesis

Conjugated lithocholic acid (LCA) plays a critical role in the development of metabolic dysfunction-associated steatotic liver disease (MASLD). In this process, hepatocyte inflammation-caused upregulation of its receptor, Takeda G protein-coupled receptor 5 (TGR5) is a crucial factor. Serum bile acid profiling shows an increase in conjugated LCA, which correlates with disease severity. Depletion of Gpbar1 in hepatocytes significantly protects against the progression from MASLD to metabolic dysfunction-associated steatohepatitis (MASH) that is related to conjugated LCA. In vivo and in vitro experiments indicate that TGR5 activation in hepatocytes promotes lipotoxicity-induced cell death and inflammation by suppressing de novo carnitine biosynthesis. Mechanistically, TGR5 binding to CD36 facilitates E3 ubiquitin ligase TRIM21 recruitment, leading to the degradation of BBOX1, a crucial enzyme in de novo carnitine biosynthesis. Targeting TGR5 therapeutically can restore carnitine biosynthesis, which may offer a potent strategy to prevent or reverse the transition from MASLD to MASH.

Synergistic benefit of thiazolidinedione and sodium-glucose cotransporter 2 inhibitor for metabolic dysfunction-associated steatotic liver disease in type 2 diabetes: a 24-week, open-label, randomized controlled trial

BACKGROUND

The close interplay between metabolic dysfunction-associated steatotic liver disease (MASLD) and type 2 diabetes supports the need to identify beneficial combination therapies of antidiabetic medications targeted for the treatment of MASLD. This study aimed to investigate the complementary effects of combination therapy with pioglitazone (PIO) and empagliflozin (EMPA) on MASLD in individuals with type 2 diabetes.

METHODS

In a randomized, open-label trial, 50 participants with type 2 diabetes and MASLD were assigned 1:1:1 to receive PIO 15 mg, EMPA 10 mg, or a combination (PIO 15 mg plus EMPA 10 mg) daily for 24 weeks. Liver fat fraction and stiffness were evaluated using magnetic resonance imaging-proton density fat fraction (MRI-PDFF) and magnetic resonance elastography (MRE), respectively.

RESULTS

Combination therapy resulted in the largest reduction in liver fat and stiffness among treatment groups. Participants experiencing a relative reduction ≥ 30% or an absolute reduction ≥ 5% in liver fat were the most prevalent in the combination group (100.0% vs. 57.1% in PIO and 87.5% in EMPA, p = 0.010). In addition, the combination group showed the highest proportion of individuals with a relative reduction ≥ 30% in liver fat and ≥ 20% in liver stiffness than the monotherapy groups (50.0% vs. 21.4% in PIO and 6.3% in EMPA, p = 0.029). Combination therapy did not induce the changes in subcutaneous fat deposition observed in the monotherapy groups, but it did show the most substantial reduction in visceral fat, concurrently showing the largest increase in adiponectin level across the three groups (p = 0.036).

CONCLUSIONS

Combination therapy of PIO with EMPA showed synergistic benefits for MASLD in individuals with type 2 diabetes, compensating for the inadequate or unfavorable effects of monotherapies; ClincialTrials.gov number, NCT03646292.

TRIAL REGISTRATION

The trial was registered at ClinicalTrials.gov (registration number: NCT03646292).

Cardiac and liver impairment on multiorgan MRI and risk of major adverse cardiovascular and liver events

Cardiovascular disease and metabolic dysfunction-associated steatotic liver disease are common conditions associated with high mortality and morbidity, yet opportunities for integrated prevention are underinvestigated. We explored the association between impairment in the liver (defined by increased iron-corrected T1 (cT1) time) and/or heart (reduced left ventricular ejection fraction ≤ 50) and risk of experiencing cardiovascular- or liver-related events or all-cause mortality among 28,841 UK Biobank participants who underwent magnetic resonance imaging. Using Cox proportional hazard models, adjusted for age, sex, body mass index, type 2 diabetes and dyslipidaemia, we observed that cardiac impairment was associated with increased incidence of cardiovascular events (hazard ratio (HR) 2.3 (1.9-2.7)) and hospitalization (HR 2.1 (1.8-2.4)). Liver impairment was associated with incident cardiovascular hospitalization (cT1 ≥ 800 ms, HR 1.3 (1.1-1.5)), liver events (cT1 ≥ 875 ms, HR 9.2 (3.2-26) and hospitalization (cT1 ≥ 875 ms, HR 5.5 (3.2-9.3). Associations between cT1 and liver events were maintained in participants with metabolic dysfunction-associated steatotic liver disease (N = 6,223). Reduced left ventricular ejection fraction (≤50) combined with elevated cT1 (≥800 ms) were associated with earlier cardiovascular events (time to event 0.8 versus 2.4 years; P < 0.05). Cardiac and liver impairment are independently, or in combination, associated with cardiovascular or liver events, suggesting a dual role for magnetic resonance imaging in integrated prevention pathways.

Exosome-derived miR-548ag drives hepatic lipid accumulation via upregulating FASN through inhibition of DNMT3B

Metabolic dysfunction-associated steatotic liver disease (MASLD) is the leading cause of chronic liver disease worldwide. This study investigates the role of serum miR-548ag in regulating lipid metabolism and its contribution to MASLD in obesity. We found that miR-548ag levels were significantly elevated in the serum of both obese and MASLD patients, and positively correlated with body mass index (BMI), fasting plasma glucose (FPG), triglycerides (TG), total cholesterol (TC), LDL, HDL, aspartate aminotransferase (AST) and alanine aminotransferase (ALT) levels. Additionally, miR-548ag expression was significantly higher in the liver and abdominal adipose tissue of obese individuals compared to those of normal weight. In vitro studies in HepG2 and L02 cells, along with previous findings, demonstrated that miR-548ag promotes fatty acid synthase (FASN) expression by inhibiting DNA methyltransferase 3B (DNMT3B), thereby enhancing lipid synthesis. This was confirmed in two mouse models: one with tail vein injections of miR-548ag mimic/inhibitor adeno-associated viruses, and another with tail vein injections of exosomes from serum of normal-weight and obese individuals. Both models showed that miR-548ag upregulated FASN through DNMT3B inhibition, leading to increased lipid synthesis and larger hepatic lipid droplets, effects that were reversed by miR-548ag inhibition. Taken together, elevated miR-548ag expression in obesity enhances hepatic lipid synthesis by targeting DNMT3B to upregulate FASN, contributing to the development of MASLD.

Lipogenesis and MASLD: re-thinking the role of SREBPs

Metabolic dysfunction-associated steatotic liver disease (MASLD) is the most common chronic liver disease worldwide and a major risk factor for hepatocellular carcinoma (HCC). Lipid metabolism, particularly de novo lipogenesis (DNL) regulated by sterol regulatory element-binding proteins (SREBPs), plays a key role in MASLD progression. While excessive SREBP activation contributes to hepatic steatosis, our recent findings indicate that strong SREBP inhibition paradoxically exacerbates liver injury and accelerates carcinogenesis in murine MASLD models. Mechanistically, SREBP dysfunction disrupts phospholipid homeostasis, leading to impaired endoplasmic reticulum (ER) membrane fluidity, ER stress, and hepatocyte injury. Transcriptomic analysis of clinical samples revealed a dynamic shift in SREBP activity, with upregulation in early MASLD but significant downregulation in advanced, burned-out MASH. This suggests that SREBP dysfunction in advanced disease may contribute to fibrosis progression and increased HCC risk. Given these findings, therapeutic strategies targeting lipid metabolism in MASLD must be carefully tailored to disease stage. This review provides an updated perspective on the biphasic role of SREBP in MASLD, emphasizing the need to re-think lipid metabolism-targeted therapies and develop personalized interventions to mitigate disease progression and HCC development.

Induction of Fructose Mediated De Novo Lipogenesis Co-exists with the Upregulation of Mitochondrial Oxidative Function in Mice Liver

BACKGROUND

Dysfunctional mitochondrial metabolism and sustained de novo lipogenesis (DNL) are characteristics of metabolic dysfunction-associated steatotic liver disease (MASLD), a comorbidity of obesity and type 2 diabetes. Fructose, a common sweetener and a potent inducer of lipogenesis, contributes to the etiology of MASLD.

OBJECTIVES

Our goal was to determine whether higher rates of DNL, through its biochemical relationships with mitochondria, can contribute to dysfunctional induction of oxidative networks in the liver.

METHODS

Male C57BL/6JN mice were given a low-fat (LF; 10% fat Kcal, 49.9% corn starch Kcal), high-fat (HF; 60% fat Kcal), or HF/ high-fructose diet (HF/HFr; 25% fat Kcal, 34.9% fructose Kcal) for 24-wks. In a follow-up study, mice on normal chow were provided either 30% fructose in drinking water (FW) to induce hepatic DNL or regular water (NW) for 14 days. Hepatic mitochondria and liver tissue were used to determine oxygen consumption, reactive oxygen species (ROS) generation, tricarboxylic acid (TCA) cycle activity and gene/protein expression profiles.

RESULTS

Hepatic steatosis remained similar between HF and HF/HFr fed mice livers. However, lipogenic and lipid oxidation gene expression profiles and the induction of TCA cycle metabolism were all higher (P ≤ 0.05) in HF/HFr livers. Under fed conditions, the upregulation of DNL in FW livers occurred in concert with higher mitochondrial oxygen consumption (basal; 1.7±0.21 vs. 3.3±0.14 nmoles/min, P ≤ 0.05), higher ROS (0.87±0.09 vs. 1.25±0.12 μM, P ≤ 0.05) and higher flux through TCA cycle components P ≤ 0.05. Further, TCA cycle activity and lipid oxidation remained higher during fasting in the FW livers P ≤ 0.05.

CONCLUSIONS

Our results show that fructose administration to mice led to the concurrent induction of mitochondrial oxidative networks and DNL in the liver. Sustained induction of both de novo lipogenesis and mitochondrial oxidative function could accelerate cellular stress and metabolic dysfunction during MASLD.

Impact of High-Fat Diet-induced Metabolic Dysfunction-associated Steatotic Liver Disease on Heart, Kidney, and Skeletal Muscle Metabolomes in Wild-Type Mice

Background: Metabolic dysfunction-associated steatotic liver disease (MASLD) can be recapitulated in mice fed a high-fat diet. The development of MASLD and the diet per se can both perturb metabolism in key extrahepatic tissues such as the heart, kidney, and skeletal muscle. To date, these alterations have not been well described in this animal model of diet-induced MASLD. Methodology: Male C57BL/6J mice were fed either standard (SC, n = 12) or high-fat chow (HF, n = 11) for 18 weeks. Metabolites were extracted from the heart, kidney, and skeletal muscle and analyzed by 1H nuclear magnetic resonance (NMR) spectroscopy, along with multivariate and univariate statistical analyses. Results: Kidney metabolite profiles exhibited the largest differences between HF and SC diets, followed by those of skeletal muscle and then the heart. Some alterations were common across all tissues, namely decreased trimethylamine and elevated levels of linoleic acid and polyunsaturated fatty acids in HF compared to SC (p < 0.05 for all three metabolites). Overall, the metabolite variations were consistent with shifts in carbohydrate and lipid substrate selection for oxidation, increased tissue stress in the heart and kidneys, and altered choline metabolism. These findings may serve as additional important descriptors of MASLD onset and progression.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Assessment of fetal hepatic lipid content by magnetic resonance imaging and association of results with clinical maternal and fetal parameters

PURPOSE

To quantify hepatocellular lipids in the fetal liver, we tested the feasibility of the multiecho mDixon Quant sequence (chemical shift encoded magnetic resonance imaging (MRI)) during clinically routine fetal whole-body MRI and investigated the correlation of hepatocellular lipids with different clinical maternal and fetal parameters.

METHODS

The livers of 155 fetuses were prospectively investigated with multiecho CSE-MRI sequences during clinically indicated whole-body MRI, performed between gestational weeks 19 and 38 on a 1.5 Tesla scanner. The hepatocellular lipids were quantified by measuring the proton density fat fraction in the left and right liver lobe. Results of the right liver lobe were correlated with the maternal body mass index, maternal age, presence of maternal diabetes, gestational age at assessment, estimated fetal weight, fetal sex, and birth weight.

RESULTS

Quantification of fetal hepatocellular lipids was feasible in 151/155 (97.4 %) fetuses. Four examinations were excluded due to strong motion artifacts and poor image quality. The proton density fat fraction values ranged from 0 % to 5.7 % (mean 2.26; SD 1.37). Hepatocellular lipids were associated with the presence of maternal diabetes (p = 0.027). No association was found between hepatocellular lipids and maternal body mass index (p = 0.306), maternal age (p = 0.582), gestational age (p = 0.456), estimated fetal weight (p = 0.176), fetal sex (p = 0.181), or birth weight (p = 0.957).

CONCLUSION

Quantification of fetal hepatocellular lipids is feasible and may routinely be performed during whole-body MRI to detect early liver fat accumulation, particularly in the presence of maternal diabetes.

Clinical Insights on Resmetirom: Clinical Indications, Patient Selection, and Monitoring Response to Therapy

The recent conditional approval by the Food and Drug Administration of resmetirom for treating metabolic dysfunction-associated steatohepatitis (MASH) with significant or advanced fibrosis represents a pivotal milestone in the history of metabolic dysfunction-associated steatotic liver disease (MASLD) treatment. As the first liver-directed pharmacological therapy option for MASLD, resmetirom offers a novel approach that specifically targets liver pathology, marking a transformative step forward in managing this widespread and challenging condition. For initiating therapy with resmetirom, a liver biopsy is not required. Consequently, accurately excluding patients with less severe liver histology or cirrhosis using noninvasive tests (NITs) is essential. In addition, monitoring the therapy response should be conducted using NITs. Given the recent approval, our current clinical understanding of resmetirom is primarily informed by phase 3 clinical trials. The long-term effects of the drug should be evaluated in further studies by encouraging the use of the drug in eligible patients. This review highlights key aspects of clinical resmetirom use, including identifying the target population, monitoring therapeutic response, determining appropriate discontinuation criteria, and strategies to prevent unnecessary treatment interruptions.

Sex-Specific Impact of Metabolic Dysfunction-Associated Fatty Liver Disease on Incident Cardiovascular Diseases and Mortality

BACKGROUND AND AIMS

Considering recent revisions in the nomenclature for fatty liver disease, alongside limited data on sex-specific differences in its cardiovascular/mortality outcomes, this study aims to investigate the prevalence and impact of metabolic-associated fatty liver disease (MAFLD) on cardiovascular disease (CVD) and mortality in men and women over a 12-year follow-up period.

METHODS

In this large population-based cohort study, 7101 individuals aged ≥ 30 were enrolled. The prevalence of MAFLD was investigated in both genders. After excluding individuals with a history of previous CVD, 6331 participants were followed up for CVD and mortality over 12 years. Steatosis was defined as fatty liver index (FLI) ≥ 60. Multivariate-adjusted hazard ratios (HRs) were calculated for CVD and mortality.

RESULTS

The prevalence of MAFLD was 43.2%, higher in men (46.5%) than women (40.6%). Men with MAFLD (47.7 ± 12.1) were younger than women (52.2 ± 11.1). In the 12-year follow-up of 6331 individuals, multivariable-adjusted CVD HRs for MAFLD were 1.36 (1.10-1.67) in men and 1.48 (1.16-1.88) in women. Adjusted mortality HRs were 1.17 (0.86-1.59) and 1.38 (1.00-1.91) in men and women, respectively. Among patients with MAFLD, a subgroup with diabetes faced the highest hazard for CVD and mortality.

CONCLUSION

This study found that MAFLD is more common in men at a younger age. Despite the higher prevalence in men, women with MAFLD face a greater risk of cardiovascular events and mortality. Findings highlight the importance of gender-specific considerations in primary prevention programmes for MAFLD-related cardiovascular disease and mortality.

Liver Transplantation: Changing Indications and Changing Candidates

Indications for liver transplantation continue to evolve rapidly, with the number of transplant procedures and donor organs more than doubling in the last 20 years. Despite the increase in donors and transplantation, there is broad geographic disparity in access to liver transplantation. Effective therapies for hepatitis C virus (HCV) have resulted in deep, sustained declines in HCV-related cirrhosis as an indication, with simultaneous increases in the frequency of liver transplantation for metabolic dysfunction-associated steatohepatitis and alcohol-related liver disease, especially among patients with brief periods of sobriety. MELD score-based allocation policies do not serve all indications for liver transplantation equally.

Sleep Duration, Midpoint, Variability, Irregularity and Metabolic Dysfunction-Associated Steatotic Liver Disease

OBJECTIVES

The relationship between actigraphy-derived sleep parameters, day-to-day deviations in sleep parameters, and metabolic dysfunction-associated steatotic liver disease (MASLD), a new definition of nonalcoholic fatty liver disease (NAFLD), remains unclear. We aimed to explore the associations of sleep duration, midpoint, variability and irregularity with MASLD risk.

METHODS

We used data from the National Health and Nutrition Examination Survey (NHANES) 2011-2014. Sleep duration and midpoint were estimated from 4 to 7 days of 24-hour actigraphy measurements. Sleep duration and midpoint standard deviation were used as indicators of sleep variability and irregularity, respectively. MASLD was diagnosed according to the multi-society Delphi consensus. Hepatic steatosis was defined as fatty liver index ≥ 60. Multivariable weighted logistic regression models were used to explore correlations and perform subgroup analyses.

RESULTS

A total of 5,316 participants were included, of whom 2,339 had MASLD. After adjusting for socio-demographic characteristics, lifestyle factors, and depression, compared to sleep variability < 60 minutes, the odds ratio (OR) [95% confidence interval (CI)] was 1.13 (0.96-1.34) for 60-90 minutes, and 1.17 (1.00-1.38) for > 90 minutes (P for trend = .034). After further adjustment for other sleep variables, short sleep duration (<7 hours) was associated with a 24% higher risk of MASLD (OR: 1.24, 95% CI: 1.01-1.53); compared to sleep irregularity < 38 minutes, OR (95% CI) was 1.27 (1.02-1.59) for 38-61 minutes and 1.43 (1.24-1.65) for > 61 minutes (P for trend = .003).

CONCLUSION

In addition to sleep duration, sleep irregularity may need to be considered in the prevention of MASLD.

Challenges in Histological Endpoints for MASH Therapies: An Exercise in Statistical Modelling

BACKGROUND

Regulatory-accepted efficacy endpoints for nonalcoholic steatohepatitis (NASH; recently updated to metabolic-dysfunction associated steatohepatitis, MASH) clinical trials include fibrosis improvement with no worsening of NASH or NASH resolution with no worsening of fibrosis determined by liver biopsy using the NASH Clinical Research Network criteria. These endpoints involve the scoring of four liver histology parameters, all of which are associated with significant inter-/intra-reader variability. Since few trials have shown positive results with these endpoints, we evaluated the effects of imprecision in histologic scoring on trial results from a statistical perspective.

METHODS

Estimating the probability (sensitivity) of accurately scoring histology is based on the relationship between measures of agreement and sensitivity. We simulated kappa values for a range of sensitivities. Then, using published kappa values from NASH trials, we selected corresponding sensitivities for histology parameters. Finally, simulations assuming a range of "overscore" and "underscore" probabilities were conducted to estimate the dilution of the true effect size.

RESULTS

Simulations for 2-arm trials with sample sizes of 400 (mix of stage 2/3 fibrosis) subjects showed ~50% dilution of the true effect size for both approvable endpoints due to scoring imprecision. Such dilution remains constant regardless of sample size.

CONCLUSION

Imprecise histologic scoring disproportionately impacts the 'superior' arm as the error is proportional to the true response rate. This dilution of effect size should be considered when weighing the clinical benefit and the overall risk-benefit profile in the review of NASH studies. This argues for the adoption of non-invasive biomarkers rather than histologic endpoints.

Addressing the High and Rising Global Burden of Metabolic Dysfunction-Associated Steatotic Liver Disease (MASLD) and Metabolic Dysfunction-Associated Steatohepatitis (MASH): From the Growing Prevalence to Payors' Perspective

BACKGROUND

The continuum of metabolic syndrome encompasses a spectrum of dysfunctions impacting obesity-linked insulin resistance, glucose homeostasis, lipid metabolism and pro-inflammatory immune responses. The global prevalence of metabolic diseases, including diabetes, chronic liver disease, cardiometabolic disease and kidney disease, has surged in recent decades, contributing significantly to population mortality. Metabolic dysfunction-associated steatotic liver disease (MASLD), formerly known as non-alcoholic fatty liver disease, is a leading cause of liver disease worldwide. MASLD poses a significant global health challenge with its rising prevalence, placing a substantial burden on healthcare systems, impacts patient well-being and incurs significant economic costs. Addressing MASLD requires a comprehensive understanding of its interconnected factors, including its prevalence, healthcare burden and economic implications. Lack of awareness, imprecise non-invasive diagnostic methods and ineffective preventive interventions are core components of the MASLD-related problem.

AIM

The aim of this article was to summarise the global burden of MASLD from the payer's perspective.

METHODS

We carried out a review of the global comprehensive burden of MASLD. These topics led to discussions and insights by an expert panel during the 7th Metabolic Continuum Roundtable meeting, which took place in November 2023. This meeting focused on the burden, patient-reported outcomes and health economics, from payor and societal perspectives, and aimed to identify opportunities for improving patient care, optimise resource allocation and mitigate the overall impact on individuals and society related to MASLD. During the roundtable, an emphasis emerged on the need for greater awareness and strategic deployment of diagnostic, therapeutic and preventative measures to address MASLD effectively.

CONCLUSION

The global burden of MASLD is high and growing. Prioritising the prevention of metabolic dysregulation and timely therapeutic interventions can yield a holistic strategy to combat MASLD, its progression and potentially lower disease costs.

TRIAL REGISTRATION

NCT06309992.

Prevalence and Predictors of Suspected Metabolic Dysfunction-Associated Steatotic Liver Disease in Adolescents in the United States

BACKGROUND

Nomenclature for steatotic liver disease has been updated to include metabolic dysfunction-associated steatotic liver disease (MASLD), which requires the presence of hepatic steatosis and at least one cardiometabolic risk factor. The prevalence of MASLD in adolescents is understudied.

AIM

To determine the prevalence of suspected MASLD among adolescents in the United States and to examine the relationships between elevated alanine aminotransferase (ALT) and cardiometabolic risk factors.

METHODS

A cross-sectional analysis of the National Health and Nutrition Examination Survey from 2011 to 2020 was conducted for adolescents aged 12-19 years. Elevated ALT was defined using sex-specific biological upper limits: > 26 U/L for males and > 22 U/L for females. Suspected MASLD was identified by elevated ALT and at least one cardiometabolic risk factor. Adolescents with elevated ALT were categorised as having suspected MASLD, elevated ALT due to other causes or cryptogenic ALT elevation.

RESULTS

Overall, 14.6% of adolescents had elevated ALT. Of these, 77.2% had suspected MASLD, 20.2% had cryptogenic ALT elevation, 1.9% took hepatotoxic medications and 0.7% had viral hepatitis. Body mass index had the strongest association with elevated ALT (OR 3.55), followed by high triglycerides (OR 2.09), low HDL cholesterol (OR 2.05) and high blood pressure (OR 1.93).

CONCLUSIONS

Most adolescents with elevated ALT met MASLD criteria, yet a portion lacked cardiometabolic risk factors or other identifiable causes. These results support the adoption of MASLD criteria in adolescents while indicating a need for further research into cryptogenic ALT elevation in paediatric populations.

Prevalence and Clinical Correlation of Cardiometabolic Risk Factors in Alcohol-Related Liver Disease and Metabolic Dysfunction and Alcohol Associated Liver Disease (MetALD)

Background

Recent introduction of new steatotic liver disease categorizations has necessitated updated epidemiologic studies. Specifically, recognition of (1) "MetALD" defined as where metabolic dysfunction-associated steatotic liver disease (MASLD) overlaps with alcohol use and (2) alcohol-related liver disease (ALD) without cardiometabolic risk factors (CMRFs) creates new clinical phenotypes with undefined prevalence.

Methods

We conducted a cross-sectional multicenter analysis of liver disease associated with alcohol use (ALD and MetALD). We included adults with an International Classification of Diseases (ICD) diagnosis of ALD or both metabolic dysfunction associated liver disease and alcohol use disorder assigned from 1/1/2000-1/1/2024.

Results

Among 4057 patients, only 118 (2.9%) did not have any CMRF ("pure ALD"). Compared to patients with CMRF, patients with pure ALD were more commonly female (56% [0 CRMF] vs. 48%, 45%, 38%, and 42% [1, 2, 3, and 4 CMRFs, respectively]; P < 0.01) and younger (54 vs. 53, 60, 68, and 67 years [1, 2, 3, and 4 CMRFs, respectively]; P < 0.01). Those with pure ALD had higher rates of cirrhosis (49% vs. 39%, 31%, 30%, 34% [1, 2, 3, and 4 CMRFs, respectively]; P < 0.01), hepatocellular carcinoma (10% vs. 6.9%, 5.7%, 4.3%, and 5.1% [1, 2, 3, and 4 CMRFs, respectively]), and death (21% vs. 15%, 17%, 18%, and 21% [1, 2, 3, and 4 CMRFs, respectively]; P = 0.04). Patients whose only CMRF was body mass index (BMI) 25-30 kg/m2 did not differ significantly from patients with pure ALD. Factors associated with cirrhosis in univariable analysis included male sex (odds ratio [OR]: 1.47, confidence interval [CI]: 1.29-1.67), age (OR: 1.08 per 10 years, CI: 1.03-1.13), and diabetes (OR: 1.21, CI: 1.05-1.40) but not BMI 25-30 kg/m2 (OR: 0.86, CI: 0.64-1.14). No differences in single-nucleotide polymorphisms (PNPLA3, GCKR, TM6SF2, MBOAT7, or HSD17B12) were identified between groups.

Conclusions

ALD without diagnosed metabolic disease is uncommon and associated with higher rates of cirrhosis, HCC, and all-cause mortality than ALD with concurrent CMRF. Having a BMI measuring 25-30 kg/m2 did not impact these clinical outcomes, raising the question of optimal BMI cut-off for MetALD. Further investigating these novel disease categories is essential for better understanding their biology and clinical impact.

Oryzanol ameliorates MCD-induced metabolic dysfunction-associated steatohepatitis in mice via gut microbiota reprogramming and TLR4/NF-κB signaling suppression

Metabolic dysfunction-associated steatohepatitis (MASH) has emerged as a major global health concern that affects about a quarter of the global population. Recently, host-gut microbiota metabolic interactions have emerged as key mechanistic pathways in MASH development. Oryzanol (ORY), a rice bran bioactive compound, exhibits antioxidant, anti-inflammatory, hypolipidemic, and hypoglycemic properties. Here, we investigated the potential of ORY in alleviating MASH and its association with gut microbiota and MASH progression. Male C57BL/6J mice were fed normal chow diet or methionine-choline-deficient diet and received ORY supplementation at 300 mg/kg/day via gavage for 4 wk. Liver injury, inflammation, lipid accumulation, and TLR4/NF-κB signaling protein levels were assessed. In addition, changes in gut microbiota diversity and abundance across groups were evaluated using 16S rDNA sequencing. Our results demonstrated that ORY significantly reduced lipid accumulation and liver enzymes, ameliorated liver and ileum damage, and restored intestinal barrier function in MASH mice. Furthermore, ORY decreased plasma lipopolysaccharide levels, and inflammatory cytokines and downregulated TLR4, MyD88, and NF-κB protein levels in the liver. ORY enhanced tight junction protein level (ZO-1, occludin) in the gut. Microbial analysis revealed that ORY positively impacted Firmicutes and Bacteroidetes abundance, promoted beneficial bacteria like Lactobacillus and Lachnospiraceae_NK4A136_group, and inhibited harmful bacteria such as Mucispirillum, Bacteroides, and Colidextribacter. Notably, ORY increased Akkermansia abundance, potentially modulating metabolic and inflammatory pathways. ORY exerted restorative and reversible effects on the pathophysiological damage within the gut-liver axis in MASH mice. The therapeutic mechanism may be related to the modulation of the gut microbiota and TLR4/NF-κB signaling pathway.NEW & NOTEWORTHY This study demonstrates that oryzanol (ORY), a bioactive rice bran compound, alleviates metabolic dysfunction-associated steatohepatitis (MASH) in mice by reducing lipid accumulation and inflammation. ORY beneficial effects are associated to the modulation of gut microbiota, enhancing gut barrier integrity, and lowering endotoxemia and TLR4/NF-κB signaling pathway. These findings suggest ORY potential in MASH prevention and treatment, highlighting its influence on gut-liver axis dynamics.

Mechanism of liver x receptor alpha in intestine, liver and adipose tissues in metabolic associated fatty liver disease

Metabolism associated fatty liver disease (MAFLD) has emerged as a growing global health challenge with limited effective treatments. Research on nuclear receptors offers promising new therapeutic avenues for MAFLD. The liver X receptor (LXR) has gained attention for its roles in tumors and metabolic and inflammatory diseases; However, its effects on MAFLD treatment remain a subject of debate. This review explores the therapeutic role of LXRα in MAFLD, focusing on its functions in the intestine, hepatic and adipose tissue, and summarizes recent advancements in LXRα ligands over the past five years. In the intestine, LXRα activation enhances the efflux of non-biliary cholesterol and reduces inflammation in the gut-liver axis by regulating intestinal high-density lipoprotein synthesis and its interaction with lipopolysaccharide. In the liver, LXRα activation facilitates cholesterol transport, influences hepatic lipid synthesis, and exerts anti-inflammatory effects. In adipose tissue, LXRα helps delay MAFLD progression by managing lipid autophagy and insulin resistance. Ligands that modulate LXRα transcriptional activity show considerable promise for MAFLD treatment.

Per- and polyfluoroalkyl substances exposures are associated with non-alcoholic fatty liver disease, particularly fibrosis

Per- and polyfluoroalkyl substances (PFAS) have been reported to exert hepatotoxic effects; however, their impact on nonalcoholic fatty liver disease (NAFLD) remains unclear. This study aimed to investigate the association between PFAS exposure and NAFLD in Korean adults, thereby contributing to the generalization of PFAS's hepatotoxic effects. Using data from the 2018-2020 Korean National Environmental Health Survey (KoNEHS), we analyzed 2635 Korean adults. PFAS exposure levels were estimated based on the serum concentrations of five PFAS. NAFLD was assessed using two steatosis-related indices (hepatic steatosis index [HSI] and fatty liver index [FLI]) and two fibrosis-related indices (fibrosis-4 index [FIB-4] and aspartate aminotransferase to platelet ratio index [APRI]). The models included these indices as continuous and dichotomous variables, the latter based on diagnostic criteria from previous studies. Associations with PFAS exposure were examined using multiple linear regression and robust Poisson regression models. Positive associations were observed between PFAS exposure and three of the four continuous indices, excluding the FLI, as well as the prevalence of NAFLD diagnosed using these indices. Specifically, the HSI showed a significant association only with perfluorononanoic acid, whereas fibrosis-related indices (FIB-4 and APRI) were significantly associated with all five individual PFAS. The associations were stronger in female and non-obese groups when stratified by sex and obesity status. The results of the Bayesian kernel machine regression analysis evaluating the health effects of PFAS mixtures indicated an association between PFAS mixtures and NAFLD, particularly fibrosis-related indices. Additionally, significant associations with NAFLD indices were mostly observed in females and non-obese groups, supporting the findings from the individual PFAS exposure analyses. Our findings suggest that PFAS are associated with NAFLD, particularly for fibrosis. Considering the high serum PFAS concentrations in the Korean population, continuous monitoring and prospective cohort studies are warranted.

Single-cell landscape of peripheral immune cells in MASLD/MASH

BACKGROUND

Metabolic dysfunction-associated steatotic liver disease (MASLD) progresses to metabolic dysfunction-associated steatohepatitis (MASH) and is a major cause of liver cirrhosis. Although liver inflammation is the hallmark feature of MASH versus MASLD, the involvement of the peripheral immune cell compartments in disease progression is poorly understood, and single-cell profiles of peripheral immune cells in MASLD/MASH are not known.

METHODS

Patients with MASLD/MASH and healthy volunteers have been prospectively enrolled in a cross-sectional study. Patients have been histologically stratified and further characterized by liver bulk RNA sequencing (RNA-Seq). Peripheral immune cells from patients and control blood samples have been comprehensively profiled using bulk and single RNA-Seq.

RESULTS

Twenty-two patients with fibrosis stage less than F3 have been histologically stratified into patients with low, medium, and high disease activity scores (NAFLD activity score [NAS]). In contrast to fibrosis, the NAS group correlated with noninvasive imaging readouts and blood biomarkers of liver damage and inflammation (ALT, AST). The prevalence of type 2 diabetes and obesity increased with the NAS stage. Bulk RNA-seq profiling of patient liver biopsies revealed gene signatures that were positively and negatively associated with NAS. Known marker genes for liver fibrosis where upregulated on RNA level. Blood bulk RNA-seq showed only moderate differences in patients versus healthy controls. In contrast, single-cell analysis of white blood cells revealed multiple alterations of immune (sub-)populations, including an increased abundance of immature B cells and myeloid suppressor cells in patients with MASLD/MASH as compared to healthy controls.

CONCLUSIONS

The study gives new insights into the pathophysiology of MASLD/MASH already manifesting relatively early in peripheral immune cell compartments. This opens new avenues for the development of new biomarker diagnostics and disease therapies.

Statin Use in Special Populations for the Prevention of Cardiovascular Disease in Adults

PURPOSE OF REVIEW

Outcome benefits for HMG-CoA reductase inhibitor (statin) use in the prevention of atherosclerotic cardiovascular disease (ASCVD) are well established and yet, statins remain underutilized with only half of eligible individuals receiving them among certain vulnerable populations. This review critically examines available data to provide a summary of the current evidence for statin use in select populations.

RECENT FINDINGS

Lipid management can be more complex in patients with chronic kidney disease (CKD), organ transplants, metabolic dysfunction associated with steatotic liver disease (MASLD), and human immunodeficiency virus (HIV). Statins are generally safe and effective to reduce the burden of ASCVD among these highly heterogeneous groups of patients and should be considered with careful attention to their concomitant disease state. Herein, we focus on appropriate statin use in these challenging to treat conditions, their relationship with increased ASCVD risk, and approaches to statin use for ASCVD risk reduction. Although further research is needed to define optimal therapy in select high risk groups for ASCVD prevention, statins are proven to be clinically efficacious, safe, and cost-effective for ASCVD prevention, warranting greater efforts to increase their use.

Cirrhosis epidemiology in Denmark 1998-2022, and 2030 forecast

Background & Aims

The incidence of cirrhosis resulting from alcohol-related liver disease (ALD) is decreasing in Denmark, whereas the incidence of obesity is increasing, driving an increase in metabolic dysfunction-associated steatotic liver disease (MASLD). We aimed to perform an up-to-date study of the epidemiology of cirrhosis in Denmark, including etiologies, and a forecast through to 2030.

Methods

We identified all patients diagnosed with cirrhosis between 1998 and 2022, categorized into ALD and non-ALD cirrhosis, in nationwide Danish healthcare registries. Cirrhosis prevalence and incidence were computed. We used an age-period-cohort model to visualize impacts of age, calendar year, and birthyear on etiology-specific cirrhosis incidence rates (alcohol or non-alcohol, interpreted as mainly the result of MASLD), with predicted incidence rates for 2023-2030. The Kaplan-Meier function was used for survival probabilities.

Results

We included 30,747 (76%) patients with ALD cirrhosis and 9,548 (24%) with non-ALD cirrhosis. Patients with non-ALD cirrhosis were older and had more comorbidities compared with patients with ALD cirrhosis; median age at diagnosis was 66 vs. 59 years, increasing in both groups overall, from 56 years in 1998 to 66 years in 2022. The ALD cirrhosis proportion was stable at around 80% from 1998 to the end of 2014, and gradually declined to 58% in 2022. Overall cirrhosis prevalence will have peaked in 2024, and non-ALD cirrhosis will outnumber ALD cirrhosis from 2027. Thus, mortality among patients with cirrhosis is declining owing to fewer deaths the first year after cirrhosis diagnosis.

Conclusions

We forecast a change in cirrhosis epidemiology affecting hepatology practice in Denmark: patients will be older, fewer will have ALD, more will have MASLD, and their longer life expectancy and comorbidities will be more burdensome for healthcare systems.

Impact and implications

Alcohol-related liver (ALD) cirrhosis poses a substantial and growing burden on hospitals worldwide. Information about the current and imminent epidemiology of cirrhosis is important for our understanding of the public health, for researchers designing trials of interventions, and for planning of future assignments of healthcare systems. In the current study, we used Danish nationwide healthcare registries to study past, current, and future trends in the epidemiology of cirrhosis. Our results forecast a change in cirrhosis epidemiology and thereby a change in hepatology practice in Denmark. We expect that patients with ALD cirrhosis will be outnumbered by increasingly older patients who present in the outpatient clinic with cirrhosis from MASLD and a higher burden of comorbidities.

New advances in novel pharmacotherapeutic candidates for the treatment of metabolic dysfunction-associated steatohepatitis (MASH) between 2022 and 2024

Metabolic dysfunction-associated steatotic liver disease (MASLD) covers a broad spectrum of profile from simple fatty liver, evolving to metabolic dysfunction-associated steatohepatitis (MASH), to hepatic fibrosis, further progressing to cirrhosis and hepatocellular carcinoma (HCC). MASLD has become a prevalent disease with 25% in average over the world. MASH is an active stage, and requires pharmacological intervention when there is necroptotic damage with fibrotic progression. Although there is an increased understanding of MASH pathogenesis and newly approved resmetirom, given its complexity and heterogeneous pathophysiology, there is a strong necessity to develop more drug candidates with better therapeutic efficacy and well-tolerated safety profile. With an increased list of pharmaceutical candidates in the pipeline, it is anticipated to witness successful approval of more potential candidates in this fast-evolving field, thereby offering different categories of medications for selective patient populations. In this review, we update the advances in MASH pharmacotherapeutics that have completed phase II or III clinical trials with potential application in clinical practice during the latest 2 years, focusing on effectiveness and safety issues. The overview of fast-evolving status of pharmacotherapeutic candidates for MASH treatment confers deep insights into the key issues, such as molecular targets, endpoint selection and validation, clinical trial design and execution, interaction with drug administration authority, real-world data feedback and further adjustment in clinical application.

Impact of Choice of Tariff When Calculating Clinically Meaningful EQ-5D Scores in Metabolic Dysfunction-Associated Steatohepatitis

BACKGROUND & AIMS

Self-reported health varies across countries, as populations attribute different degrees of value to EQ-5D domains. Country-specific EQ-5D tariffs were developed to account for this but are not always stated in the literature. We aim to assess the reporting of EQ-5D in the literature and the impact of applying country-specific tariffs.

METHODS

We reviewed literature-reported EQ-5D utilities for patients with metabolic dysfunction-associated steatohepatitis versus real-world EQ-5D utilities from the Adelphi Real World Non-alcoholic steatohepatitis Disease Specific Programme (DSP), a cross-sectional survey in France, Germany, Italy, Spain, the United Kingdom and the United States. Matching-adjusted indirect comparison analysis balanced DSP data with literature studies by age, sex, comorbidities and fibrosis stage. DSP utility scores generated using national tariffs were compared with literature utilities using weighted t tests.

RESULTS

Ten studies with varying recruitment criteria, patient demographics and clinical characteristics were identified. Country-specific tariffs were not used or not reported. EQ-5D utilities varied, reflecting geographic, clinical and demographic characteristics. The comparison of literature and matched utilities derived using DSP data and five national tariffs revealed ≥ two comparisons for each study with a difference not exceeding the minimal clinically important difference versus the matched DSP value.

CONCLUSIONS

Literature-reported EQ-5D utilities vary considerably depending on study methodology and country-specific EQ-5D tariff, and even if stated may not always use the most appropriate tariff. This suggests a need for consistent use of country-specific tariffs and sensitivity analyses confirming results and conclusions that include EQ-5D-based utility measurement to inform decision-making by health authorities.

Individualized Effects of Weight Gain in Adulthood on the Development of MASLD in Japanese Non-Obese Individuals

BACKGROUND

This study aimed to estimate the individualized effect of weight change since age 20 on the development of metabolic dysfunction-associated steatotic liver disease (MASLD) in Japanese non-obese individuals. We also assessed the clinical characteristics of high-risk individuals with weight gain.

METHOD

This retrospective cohort study included non-obese individuals who underwent health examinations at St. Luke's International Hospital between 2008 and 2018. We developed a counterfactual prediction model using logistic regression to predict the risk of MASLD onset within 3 years and predicted counterfactual risks for 5 weight change scenarios: (i) weight loss < -3 kg, (ii) weight maintenance: ±3 kg, (iii) 3.1-6 kg gain, (iv) 6.1-9.9 kg gain, and (v) major weight gain ≥ 10 kg. Individualized effects of weight change were estimated using a risk difference scale, with variability assessed through their distributions and forest plots.

RESULTS

A total of 20 886 individuals (64.4% women) were included, and 2016 (9.6%) developed MASLD within 3 years. The counterfactual prediction model showed the average risk difference for major weight gain ≥ 10 kg was 6.6% (median: 5.1%), with individual risk differences varied from 2% to 19% across individuals. Forest plot showed an increased average risk of 5% for men, abdominal obesity, dyslipidemia, hyperuricemia, and high ALT levels.

CONCLUSION

Weight change since age 20 is a significant risk factor for MASLD development in non-obese populations, but its impact varies widely among individuals. Men and individuals with abdominal obesity, dyslipidemia, hyperuricemia, and high ALT levels are particularly susceptible to the effects of weight gain.

Rurality and Neighborhood Socioeconomic Status are Associated With Overall and Cause-Specific Mortality and Hepatic Decompensation in Type 2 Diabetes

INTRODUCTION

Social determinants of health are key factors driving disease progression. In type 2 diabetes there is limited literature on how distal or intermediate factors (eg, those at the neighborhood level) influence cause-specific mortality or liver disease outcomes.

METHODS

This was a single-center retrospective study of patients with type 2 diabetes seen at an integrated healthcare system in the United States. The primary outcomes were overall mortality; death due to cardiovascular disease, cancer, or liver disease; or hepatic decompensation. The primary predictors were neighborhood-level (intermediate) factors measuring neighborhood poverty (Area Deprivation Index [ADI], affluence score, disadvantage score) and rurality (Rural-Urban Commuting Area scores). Associations were modeled using Cox proportional hazards or Fine-Grey competing risk models.

RESULTS

28,424 participants were included. Higher neighborhood poverty associated with increased overall mortality, with hazard ratio (HR) 1.11 (95% confidence interval 1.10-1.12, P < .001) per 10 points of ADI and HR 1.32 (95% CI 1.26-1.37, P < .001) for 10 points of disadvantage. Conversely, higher neighborhood affluence associated with lower overall mortality with HR 0.87 (95% CI 0.86-0.89, P < .001) per 10 points of affluence. Living in a rural region associated with increased overall mortality: HR 1.08 (95% CI 1.01-1.15, P = .031). Associations were consistent across cause-specific mortality, though effect sizes were larger for liver-related mortality than for other causes. Living in a more rural neighborhood was associated with increased risk of hepatic decompensation.

CONCLUSIONS

Intermediate neighborhood-level socioeconomic status was associated with overall and cause-specific mortality in type 2 diabetes, with larger effects on liver-related mortality than other causes.

Ultrasound-guided attenuation parameter: a liver fat quantification technique for forecasting the progression of metabolic dysfunction-associated steatotic liver disease in overweight/obese patients

AIM

To investigate the application value of ultrasonic attenuation parameter imaging (UGAP) in the assessment of metabolic dysfunction-associated steatotic liver disease (MASLD) in overweight and obese patients.

MATERIAL AND METHODS

A total of 328 overweight/obese patients-225 in the MASLD group and 103 in the simple overweight/obese group-were chosen from XX between August 2023 and August 2024. As the typical control group, 236 healthy individuals who were matched for age and gender were chosen during the same period. The attenuation coefficient (AC) differences between the groups were compared, and Pearson correlation analysis was used to look into the relationship between AC and clinical indicators. A prediction model was created, the diagnostic efficacy was examined, and MASLD risk factors in overweight and obese patients were screened using the independent sample T-test and multiple logistic regression analysis.

RESULTS

AC of the MASLD group, overweight and obese group, and normal control group were (0.73 ± 0.08), (0.57 ± 0.04), and (0.54 ± 0.07) dB-1·cm-1·MHz-1. There was a statistically significant difference between the groups (P<0.05). In patients who were overweight or obese, AC, BMI, and visceral fat were the risk factors for predicting MASLD. The optimal cut-off values were AC ≥0.635dB-1·cm-1·MHz-1, BMI ≥27.58kg/m2, and visceral fat thickness (VFT) ≥66.115 mm. The areas under the receiver operating characteristic (ROC) curve were 0.993, 0.792, and 0.708. The area under ROC curve of AC combined with BMI and visceral fat was 0.997, and the prediction efficiency was greater than that of the single AC index and that of the AC + BMI bivariate prediction model. The diagnostic sensitivity and specificity were 96.4% and 98.1%.

CONCLUSION

UGAP can be utilised for clinical screening to assess the prevalence of MASLD in patients who are overweight or obese and to dynamically track the progression of the disease. In patients who are overweight or obese, the accuracy of the UGAP assessment of MASLD can be increased by combining AC with BMI and a visceral fat prediction model.

Mitochondrial antiviral signaling protein enhances MASLD progression through the ERK/TNFα/NFκβ pathway

BACKGROUND AND AIMS

Mitochondrial antiviral signaling protein (MAVS) is a critical regulator that activates the host's innate immunity against RNA viruses, and its signaling pathway has been linked to the secretion of proinflammatory cytokines. However, the actions of MAVS on inflammatory pathways during the development of metabolic dysfunction-associated steatotic liver disease (MASLD) have been little studied.

APPROACH AND RESULTS

Liver proteomic analysis of mice with genetically manipulated hepatic p63, a transcription factor that induces liver steatosis, revealed MAVS as a target downstream of p63. MAVS was thus further evaluated in liver samples from patients and in animal models with MASLD. Genetic inhibition of MAVS was performed in hepatocyte cell lines, primary hepatocytes, spheroids, and mice. MAVS expression is induced in the liver of both animal models and people with MASLD as compared with those without liver disease. Using genetic knockdown of MAVS in adult mice ameliorates diet-induced MASLD. In vitro, silencing MAVS blunts oleic and palmitic acid-induced lipid content, while its overexpression increases the lipid load in hepatocytes. Inhibiting hepatic MAVS reduces circulating levels of the proinflammatory cytokine TNFα and the hepatic expression of both TNFα and NFκβ. Moreover, the inhibition of ERK abolished the activation of TNFα induced by MAVS. The posttranslational modification O -GlcNAcylation of MAVS is required to activate inflammation and to promote the high lipid content in hepatocytes.

CONCLUSIONS

MAVS is involved in the development of steatosis, and its inhibition in previously damaged hepatocytes can ameliorate MASLD.