Association of fatty liver index with the risk of incident cardiovascular disease and acute myocardial infarction

Nonalcoholic Fatty Liver Disease and Cardiovascular Disease: Causation or Association

Nonalcoholic fatty liver disease (NAFLD) is a disease process that is gaining increasing recognition. The global prevalence of NAFLD is increasing in parallel with growing rates of risk factors for NAFLD such as hypertension, obesity, diabetes, and metabolic syndrome. NAFLD has been referred to as a risk factor for cardiovascular disease (CVD). As CVD is the leading cause of morbidity and mortality worldwide, there are constant efforts to describe and alleviate its risk factors. Although there is conflicting data supporting NAFLD as a causative or associative factor for CVD, NAFLD has been shown to be associated with structural, electrical, and atherosclerotic disease processes of the heart. Shared risk factors and pathophysiologic mechanisms between NAFLD and CVD warrant further explication. Pathologic mechanisms such as endothelial dysfunction, oxidative stress, insulin resistance, genetic underpinnings, and gut microbiota dysregulation have been described in both CVD and NAFLD. The mainstay of treatment for NAFLD is lifestyle intervention including physical exercise and hypocaloric intake in addition to bariatric surgery. Investigations into various therapeutic targets to alleviate hepatic steatosis and fibrosis by way of maintaining the balance between lipid synthesis and breakdown. A major obstacle preventing the success of many pharmacologic approaches has been the effects of these medications on CVD risk. The future of pharmacologic treatment of NAFLD is promising as effective medications with limited CVD harm are being investigated.

Prediction and Validation of Metabolic Dysfunction-Associated Fatty Liver Disease Using Fatty Liver-Related Indices in a Japanese Population

Background: Recently, metabolic dysfunction-associated fatty liver disease (MAFLD) has been proposed. It is uncertain how indices that predict fatty liver are associated with MAFLD in Japanese. Methods: Among subjects who underwent a health examination at our hospital, 1257 (men: 787, women: 474) subjects participated in fatty liver evaluation of the fatty liver index (FLI) and fatty liver predicting index (FLPI) were included in this cross-sectional study. The discriminatory ability of each index for MAFLD was tested using receiver operating characteristic curve analysis. The association between FLI, FLPI, and MAFLD was investigated using multiple logistic regression analysis. Results: FLI and FLPI had good discriminatory ability for identifying MAFLD in both men and women, with specific cutoff values. Both FLI and FLPI were significantly higher in subjects with MAFLD, and the odds of MAFLD were higher among those in the highest tertile relative to the lowest tertile in both men and women. FLI and FLPI were higher in subjects who met the criteria for both MAFLD and metabolic syndrome (MetS) compared to those who had MAFLD or MetS alone, and most of the examined parameters in subjects with both conditions indicated a high metabolic risk profile. Conclusions: The study suggests that FLI and FLPI are valuable tools for predicting MAFLD and are similarly correlated with the disease. Furthermore, the highest values of these indices were observed in subjects who met the criteria for both MAFLD and MetS, emphasizing the importance of considering both conditions when assessing metabolic risk.

Non-invasive tools for liver steatosis and steatohepatitis predict incidence of diabetes, cardiovascular disease and mortality 20 years later: The ATTICA cohort study (2002-2022)

BACKGROUND & AIMS

Non-alcoholic fatty liver disease (NAFLD) or, as recently renamed, metabolic dysfunction-associated steatotic liver disease (MASLD), has common metabolic pathways with diabetes and cardiovascular disease (CVD). Non-invasive tools (NITs) for liver steatosis and steatohepatitis (MASH) were studied as potential predictors of diabetes, cardiovascular disease (CVD) and mortality over a 20-year period.

METHODS

In 2001-02, 3042 individuals from the Attica region of Greece were recruited randomly, and were stratified by subgroups of sex, age and region to reflect the general urban population in Athens, Greece. Validated NITs for hepatic steatosis (Hepatic Steatosis Index (HIS), Fatty Liver Index (FLI), Lipid Accumulation Product (LAP), NAFLD liver fat score (NAFLD-LFS)) and steatohepatitis (Index of non-alcoholic steatohepatitis (ION), aminotransferase-creatinine-clearance non-alcoholic steatohepatitis (acNASH)) were calculated. Incidence of diabetes, CVD and mortality were recorded 5, 10 and 20 years later.

RESULTS

Within a 20-year observation period, the diabetes and CVD incidence was 26.3% and 36.1%, respectively. All hepatic steatosis and steatohepatitis NITs were independently associated with diabetes incidence. ION and acNASH presented independent association with CVD incidence [(Hazard Ratio (HR)per 1 standard deviation (SD) = 1.33, 95% Confidence Interval (95% CI) (1.07, 1.99)) and (HRper 1 SD = 1.77, 95% CI (1.05, 2.59)), respectively]. NAFLD-LFS which is a steatosis NIT indicating features of steatohepatitis, was linked with increased CVD mortality (HRper 1 SD = 1.35, 95% CI (1.00, 2.30)) and all-cause mortality (HRper 1 SD = 1.43, 95% CI (1.08, 2.01)). Overall, steatohepatitis NITs (i.e., ION and acNASH) presented stronger associations with the outcomes of interest compared with steatosis NITs. Clinically important trends were observed in relation to diabetes and CVD incidence progressively over time, i.e. 5, 10 and 20 years after baseline.

CONCLUSIONS

Easily applicable and low-cost NITs representing steatohepatitis may be early predictors of diabetes and CVD onset. More importantly, these NITs increased the attributable risk conveyed by conventional CVD risk factors by 10%. Thus, their potential inclusion in clinical practice and guidelines should be studied further.

Fatty Liver Index as a proxy for non-alcoholic fatty liver disease and the risk of stroke and coronary heart disease: The Suita Study

BACKGROUND

Non-alcoholic fatty liver disease (NAFLD) is the most common chronic liver disease in developed countries, but its role in predicting cardiovascular disease (CVD) needs further investigation. Herein, we studied the association between NAFLD and the risk of CVD, stroke, and coronary heart disease (CHD) among Japanese people.

METHODS

This prospective cohort study analyzed data from 2,517 men and 3,958 women, aged 30-84 years, who were registered in the Suita Study. NAFLD was defined as Fatty Liver Index (FLI) ≥ 60. Cox proportional hazard models were applied to calculate the hazard ratios (HRs) and 95% confidence intervals (95% CIs) of incident CVD, stroke, and CHD events by baseline FLI. The results were adjusted for age, smoking, alcohol consumption, hypertension, diabetes, lipid profile, chronic kidney disease, and cardiac murmur or valvular diseases.

RESULTS

Within 16.6 years of median follow-up, 590 participants developed CVD (346 stroke events and 244 CHD events). Women with NAFLD (FLI ≥ 60) showed a higher risk of CVD and stroke: HRs (95% CIs) = 1.69 (1.16, 2.46) and 2.06 (1.31, 3.24), respectively. Besides, women in the fourth and fifth (highest) FLI quintiles showed a higher risk of CVD and stroke than those in the third (middle) quintile: HRs (95% CIs) = 1.60 (1.08, 2.36) and 1.67 (1.13, 2.45) for CVD and 1.73 (1.07, 2.79) and 1.90 (1.18, 3.05) for stroke, respectively. No corresponding associations were detected in men. NAFLD was not associated with CHD risk in either sex.

CONCLUSIONS

NAFLD, diagnosed by FLI, was associated with a higher risk of CVD and stroke in Japanese women. From a preventive perspective, women with NAFLD should be targeted for CVD screenings and interventions.

Biomarkers of Hepatic Dysfunction and Cardiovascular Risk

PURPOSE OF REVIEW

The objective of this manuscript is to examine the current literature on non-alcoholic fatty liver disease (NAFLD) biomarkers and their correlation with cardiovascular disease (CVD) outcomes and cardiovascular risk scores.

RECENT FINDINGS

There has been a growing appreciation for an independent link between NAFLD and CVD, culminating in a scientific statement by the American Heart Association in 2022. More recently, studies have begun to identify biomarkers of the three NAFLD phases as potent predictors of cardiovascular risk. Despite the body of evidence supporting a connection between hepatic biomarkers and CVD, more research is certainly needed, as some studies find no significant relationship. If this relationship continues to be robust and readily reproducible, NAFLD and its biomarkers may have an exciting role in the future of cardiovascular risk prediction, possibly as risk-enhancing factors or as components of novel cardiovascular risk prediction models.

Fatty Liver Index and the Risk of Atrial Fibrillation in a General Japanese Population - The Suita Study

BACKGROUND

Atrial fibrillation (AF) is the most diagnosed arrhythmia in clinical settings. The fatty liver index (FLI) is a marker of liver steatosis with potential cardiovascular implications. This study investigated whether FLI could predict the risk of AF.Methods and Results: We used data from the Suita Study, a Japanese population-based prospective cohort study. A total of 2,346 men and 3,543 women, aged 30-84 years, without prevalent AF were included and followed up. The diagnosis of AF was established during follow-up using electrocardiograms, hospital records, and death certificates. FLI was assessed during a baseline health checkup. Hazard ratios (HRs) and 95% confidence intervals (CIs) were calculated for incident AF per FLI quintile and log-transformed FLI. Within a median 14.5 years of follow-up, 142 men and 105 women developed AF. Compared with women in the third (middle) FLI quintile, women in the first (lowest), fourth, and fifth (highest) quintiles showed a higher risk of AF, with multivariable-adjusted HRs of 2.37 (95% CI 1.06-5.31), 2.60 (95% CI 1.30-5.17), and 2.04 (95% CI 1.00-4.18), respectively. No corresponding associations were observed in men. The change in log-transformed FLI was not associated with the risk of AF in either sex.

CONCLUSIONS

A U-shaped association between FLI and AF risk was detected in Japanese women. FLI could be a screening tool to detect women at high risk of developing AF.

Impacts of Non-alcoholic Fatty Liver Disease on Acute Coronary Syndrome: Evidence and Controversies

PURPOSE OF REVIEW

Acute coronary syndrome (ACS) and non-alcoholic fatty liver disease (NAFLD) are two clinically common disease entities that share numerous risk factors. This review aimed to discuss the impacts of NAFLD on ACS.

RECENT FINDINGS

In an era of improved control of traditional risk factors, the substantial burden of cardiometabolic abnormalities has caused widespread concern. NAFLD is considered the hepatic component of metabolic syndrome, which can exert an impact on human health beyond the liver. Accumulating studies have demonstrated that NAFLD is closely related to cardiovascular disease, especially coronary artery disease. Interestingly, although recent data have suggested an association between NAFLD and the incidence and outcomes of ACS, the results are not consistent. In this review, we comprehensively summarized evidence and controversies regarding whether NAFLD is a contributor to either the development of ACS or worse outcomes in patients with ACS. The potential pathophysiological and molecular mechanisms involved in the impacts of NAFLD on ACS were also elucidated.

Fatty Liver Index (FLI) Identifies Not Only Individuals with Liver Steatosis but Also at High Cardiometabolic Risk

A fatty liver index (FLI) greater than sixty (FLI ≥ 60) is an established score for metabolic dysfunction-associated steatotic liver disease (MASLD), which carries a high risk for diabetes and cardiovascular disease, while a FLI ≤ 20 rules out the presence of steatosis. Thus, we investigated whether FLI was associated with cardiometabolic risk factors, i.e., visceral (VAT), subcutaneous (SC), epicardial (EPI), extrapericardial (PERI), and total cardiac (CARD-AT) adipose tissue, hepatic fat ((by magnetic resonance imaging, MRI, and spectroscopy, MRS), and insulin resistance (IR, HOMA-IR and OGIS-index), and components of metabolic syndrome. All individuals with FLI ≥ 60 had MASLD, while none with FLI ≤ 20 had steatosis (by MRS). Subjects with FLI ≥ 60 had a higher BMI and visceral and cardiac fat (VAT > 1.7 kg, CARD-AT > 0.2 kg). FLI was positively associated with increased cardiac and visceral fat and components of metabolic syndrome. FLI, VAT, and CARD-AT were all associated with IR, increased blood pressure, cholesterol, and reduced HDL. For FLI ≥ 60, the cut-off values for fat depots and laboratory measures were estimated. In conclusion, FLI ≥ 60 identified not only subjects with steatosis but also those with IR, abdominal and cardiac fat accumulation, increased blood pressure, and hyperlipidemia, i.e., those at higher risk of cardiometabolic diseases. Targeted reduction of FLI components would help reduce cardiometabolic risk.

The first external validation of the Dallas steatosis index in biopsy-proven Non-alcoholic fatty liver Disease: A multicenter study

AIMS

A new non-invasive tool (NIT) for non-alcoholic fatty liver disease (NAFLD) proposed in 2022 by the multi-ethnic Dallas Heart Study, i.e. the Dallas Steatosis Index (DSI), was validated herein using for the first time the gold standard i.e. liver biopsy-proven NAFLD.

METHODS

This is a multicenter study based on samples and data from two Gastroenterology-Hepatology Clinics (Greece and Australia) and one Bariatric-Metabolic Surgery Clinic (Italy). Overall, n = 455 patients with biopsy-proven NAFLD (n = 374) and biopsy-proven controls (n = 81) were recruited.

RESULTS

The ability of DSI to correctly classify participants as NAFLD or controls was very good, reaching an Area Under the Curve (AUC) = 0.887. The cut-off point that could best differentiate the presence vs. absence of NAFLD corresponded to DSI = 0.0 (risk threshold: 50% | Sensitivity: 0.88; Positive Predictive Value (PPV): 93.0%; F1-score = 0.91). DSI demonstrated significantly better performance characteristics than other liver steatosis indexes. Decision curve analysis revealed that the benefit of DSI as a marker to indicate the need for invasive liver assessment was confirmed only when higher DSI values, i.e. ≥ 1.4, were used as risk thresholds. DSI performance to differentiate disease progression was inadequate (all AUCs < 0.700).

CONCLUSIONS

DSI is more useful for disease screening (NAFLD vs. controls) than to differentiate diseases stages or progression. The value of any inclusion of DSI to guidelines needs to be further studied.

Fatty Liver Index and Its Association with 10-Year Atherosclerotic Cardiovascular Disease Risk: Insights from a Population-Based Cross-Sectional Study in China

This cross-sectional study aimed to investigate the association between non-alcoholic fatty liver disease (NAFLD) and atherosclerotic cardiovascular disease (ASCVD), a global public health concern. A total of 9044 out of 10,104 adults from Guangzhou, China, were included in the analysis. We utilized the fatty liver index (FLI), a noninvasive indicator of NAFLD, and the pooled cohort equations (PCE) based on the 2013 ACC/AHA Guideline, the China-PAR model, and the Framingham Risk Score to assess the 10-year ASCVD risk. The results demonstrated a significant association between FLI and 10-year ASCVD risk (p < 0.001). Adjusted for age, individuals with high FLI (≥60) had an odds ratio of 3.91 (95% CI 2.52-6.08) compared to those with low FLI (<30). These findings persisted after adjusting for metabolic indicators. Notably, this association was consistently observed across all three risk prediction models: the PCE model, the China-PAR model, and the Framingham Risk Score. In conclusion, our study provides evidence supporting FLI as a reliable indicator of increased 10-year ASCVD risk in Chinese NAFLD patients. FLI serves as a valuable marker for early detection of ASCVD, highlighting its potential in clinical practice for risk assessment and prevention strategies.

New Insights into Non-Alcoholic Fatty Liver Disease and Coronary Artery Disease: The Liver-Heart Axis

Non-alcoholic fatty liver disease (NAFLD) represents the hepatic expression of the metabolic syndrome and is the most prevalent liver disease. NAFLD is associated with liver-related and extrahepatic morbi-mortality. Among extrahepatic complications, cardiovascular disease (CVD) is the primary cause of mortality in patients with NAFLD. The most frequent clinical expression of CVD is the coronary artery disease (CAD). Epidemiological data support a link between CAD and NAFLD, underlain by pathogenic factors, such as the exacerbation of insulin resistance, genetic phenotype, oxidative stress, atherogenic dyslipidemia, pro-inflammatory mediators, and gut microbiota. A thorough assessment of cardiovascular risk and identification of all forms of CVD, especially CAD, are needed in all patients with NAFLD regardless of their metabolic status. Therefore, this narrative review aims to examine the available data on CAD seen in patients with NAFLD, to outline the main directions undertaken by the CVD risk assessment and the multiple putative underlying mechanisms implicated in the relationship between CAD and NAFLD, and to raise awareness about this underestimated association between two major, frequent and severe diseases.

High fatty liver index is an independent predictor of ischemic heart disease during a 10-year period in a Japanese population

AIM

Fatty liver index (FLI), which is calculated by using body mass index, waist circumference and levels of γ-glutamyl transferase and triglycerides, is a validated surrogate marker of nonalcoholic fatty liver disease. We retrospectively investigated the relationship between FLI and the development of ischemic heart disease (IHD) during a 10-year period.

METHODS

Among subjects who received annual health checkups (n = 28 990), a total of 18 851 subjects (men/women: 11 659/7192) were enrolled after exclusion of subjects with missing data and those with IHD at baseline.

RESULTS

FLI at baseline was significantly higher in men than in women. During the 10-year period, 450 men (3.9%) and 123 women (1.7%) had new onset of IHD determined by a self-reported questionnaire survey. Multivariable Cox proportional hazard models with a restricted cubic spline showed that hazard risk (HR) for the development of IHD increased with a higher FLI at baseline after adjustment of age, sex, current smoking habit, family history of IHD and diagnosis of diabetes mellitus, hypertension, dyslipidemia and chronic kidney disease at baseline. There was no significant interaction between FLI and sex for the adjusted HR. When divided by tertiles of FLI at baseline (T1∼T3), the adjusted risk for development of IHD in the T3 group (HR [95% confidence interval]: 1.34 [1.05-1.71]) was significantly higher than that in the T1 group as the reference. The addition of FLI into traditional risk factors for IHD significantly improved the discriminatory capability.

CONCLUSIONS

A high level of FLI is an independent predictor of new onset of IHD during a 10-year period.

Prediction and validation of nonalcoholic fatty liver disease by fatty liver index in a Japanese population

Fatty liver index (FLI) calculated by using body mass index (BMI), waist circumference and levels of γ-glutamyl transferase and triglycerides is a non-invasive predictor of nonalcoholic fatty liver disease (NAFLD). The original study in Italy showed that the cutoff level for prediction of NAFLD was FLI ≥60. However, the sex difference in FLI was not taken into consideration, and it is unclear whether the cutoff value can be applied to other races. We investigated the cutoff value of FLI for prediction of NAFLD determined by abdominal ultrasonography using receiver operating characteristic curve analyses in 14,471 Japanese subjects (men/women: 9,240/5,231; mean age: 48 ± 9 years). There was a significant interaction between sex and FLI for detection of NAFLD (p < 0.001). The cutoff values of FLI in men and women were 35.1 (area under the curve [AUC]: 0.82) and 15.6 (AUC: 0.91), respectively. When the subjects were divided by the absence and presence of obesity (BMI ≥25), there was a significant interaction between FLI and obesity for detection of NAFLD in women (p < 0.001) but not in men (p = 0.679). The cutoff values of FLI in non-obese/obese men and women were 22.6/52.6 and 11.2/33.2, respectively. In conclusion, the cutoff value of FLI for prediction of NAFLD in Japanese individuals was lower than that in the original study, and there is a significant sex difference. The simple and useful cutoff values in Japanese men and women are FLI ≥35 (non-obese/obese: 23/53) and FLI ≥16 (non-obese/obese: 11/33), respectively.

Relationship between the prevalence and severity of non‐alcoholic fatty liver disease and coronary artery disease: Findings from a cross‐sectional study of a referral center in northeast Iran

Background and Aim

Non‐alcoholic fatty liver disease (NAFLD) is becoming increasingly prevalent worldwide, and cardiovascular diseases are the most common cause of death in NAFLD patients. The present study aimed to evaluate the possible relationship between the presence and severity of NAFLD and coronary artery disease (CAD).

Methods

A cross‐sectional study was conducted on 296 patients (122 men and 174 women, with mean age 54.10 ± 9.33 years) referred to the catheterization laboratory of Imam Reza Hospital affiliated to the Mashhad University of Medical Sciences, Mashhad, Iran, for elective coronary angiography to investigate the presence and severity of CAD. Additionally, all patients underwent abdominal ultrasonography (USG) to detect NAFLD and its severity.

Results

Among the 296 patients, 187 (63.2%) had CAD and 160 (50.1%) had NAFLD. NAFLD patients had significantly higher prevalence of obesity (odds ratio [OR] = 1.047, 95% confidence interval [CI] = 1.002–1.094), hypertension (OR = 1.909, 95% CI = 1.027–3.55), hyperlipidemia (OR = 3.474, 95% CI = 1.862–6.482), and CAD (OR = 2.009, 95% CI = 1.100–3.669). The percentage of patients with normal vessels was higher in the non‐NAFLD group, followed by the group with mild and severe NAFLD (P < 0.001). However, single‐ and multi‐vessel disease incidences among the non‐NAFLD, mild, and severe NAFLD groups were 36.1, 43.1, and 63.7%, respectively. Interestingly, the percentage of patients with two‐vessel stenosis was significantly higher in severe NAFLD patients than mild and non‐NAFLD patients (P < 0.001).

Conclusion

The prevalence and severity of NAFLD were independently associated with CAD. Mild NAFLD was primarily observed among patients with normal and non‐obstructive coronary artery patients, while severe NAFLD was more frequent in extensive CAD patients with multi‐vessel disease.

Association of Metabolic Dysfunction-Associated Fatty Liver Disease With Left Ventricular Diastolic Function and Cardiac Morphology

BACKGROUND AND AIM

Non-alcoholic fatty liver disease (NAFLD) is closely related to cardiovascular diseases (CVD). A newly proposed definition is metabolic dysfunction-associated fatty liver disease (MAFLD), which was changed from NAFLD. The clinical effect of this change on abnormalities of cardiac structure and function is yet unknown. We aimed to examine whether MAFLD is associated with left ventricular (LV) diastolic dysfunction (LVDD) and cardiac remolding and further identify the impact of different subgroups and severity of MAFLD.

METHOD

We evaluated 228 participants without known CVDs. Participants were categorized by the presence of MAFLD and the normal group. Then, patients with MAFLD were subclassified into three subgroups: MAFLD patients with diabetes (diabetes subgroup), overweight/obesity patients (overweight/obesity subgroup), and lean/normal-weight patients who had two metabolic risk abnormalities (lean metabolic dysfunction subgroup). Furthermore, the severity of hepatic steatosis was assessed by transient elastography (FibroScan^®) with a controlled attenuation parameter (CAP), and patients with MAFLD were divided into normal, mild, moderate, and severe hepatic steatosis groups based on CAP value. Cardiac structure and function were examined by echocardiography.

RESULTS

LVDD was significantly more prevalent in the MAFLD group (24.6% vs. 60.8%, p < 0.001) compared to the normal group. The overweight subgroup and diabetes subgroup were significantly associated with signs of cardiac remolding, including interventricular septum thickness, LV posterior wall thickness, left atrial diameter (all p < 0.05), relative wall thickness, and LV mass index (all p < 0.05). Additionally, moderate-to-to severe steatosis patients had higher risks for LVDD and cardiac remolding (all p-values < 0.05).

CONCLUSION

MAFLD was associated with LVDD and cardiac remolding, especially in patients with diabetes, overweight patients, and moderate-to-to severe steatosis patients. This study provides theoretical support for the precise prevention of cardiovascular dysfunction in patients with MAFLD.

Liver biomarkers, genetic and lifestyle risk factors in relation to risk of cardiovascular disease in Chinese

Background and aims

Liver biomarkers and metabolic associated fatty liver disease (MAFLD) have been shown to be associated with cardiovascular disease (CVD). However, there is limited evidence on CVD subtypes [myocardial infarction (MI), ischemic stroke (IS), and intracerebral hemorrhage (ICH)], especially in the Chinese population. We examined these associations overall, by genetic predisposition to non-alcoholic fatty liver disease (NAFLD), and by lifestyle risk factors.

Approach and results

This is a nested case-control study of CVD (10,298 cases and 5,388 controls) within the China Kadoorie Biobank. Cox regression was used to estimate adjusted hazard ratios (HRs) for CVD associated with liver biomarkers and MAFLD and by stratum of genetic risk and a combined high-risk lifestyle score. For liver enzymes, there were positive associations with MI and IS, but no associations with ICH or carotid plaque. There were positive associations of NAFLD with risks of MI, IS, and ICH (HR 1.43 [95% CI 1.30-1.57], 1.25 [1.16-1.35], and 1.12 [1.02-1.23]) as well as carotid plaque (odds ratio 2.36 [1.12-4.96]). The associations of NAFLD with CVD and carotid plaque were stronger among individuals with a high genetic risk (ICH: p-interaction < 0.05), while the associations with stroke were stronger among those with a favorable lifestyle (p-interaction < 0.05). The results for MAFLD mirrored those for NAFLD.

Conclusion

In Chinese adults, liver biomarkers and MAFLD were associated with risk of CVD, with different magnitudes of associations by CVD subtypes. Genetic predisposition to NAFLD and lifestyle factors modified the associations of fatty liver with stroke.

Links between metabolic syndrome and metabolic dysfunction-associated fatty liver disease

Metabolic dysfunction-associated fatty liver disease (MAFLD) is a chronic condition characterized by hepatic fat accumulation combined with underlying metabolic dysregulation. Having evolved from the previous term of nonalcoholic fatty liver disease (NAFLD), the term MAFLD more closely implicates the presence of overweight/obesity, type 2 diabetes, or metabolic dysregulation as essential pathogenic factors, leading to better identification of individuals with this metabolic liver disease. Low-grade inflammation, increased oxidative stress, mitochondrial dysfunction, and intestinal dysbiosis are also involved in its pathogenesis. MAFLD is not only associated with liver-related complications, but also with adverse cardiometabolic outcomes. Further studies are needed to assess whether the newly proposed definition of MAFLD is more accurate than the NAFLD in predicting the adverse liver-related and extrahepatic outcomes.

Fatty Liver Index and Development of Cardiovascular Disease: Findings from the UK Biobank

BACKGROUND

Nonalcoholic fatty liver disease is common and is associated with rising morbidity and mortality in the UK. Cardiovascular disease is the main cause of death in people with nonalcoholic fatty liver disease.

AIMS

To determine the association between baseline cardiovascular risk factors with fatty liver index, and to investigate the association between fatty liver index and the incidence of cardiovascular disease in the UK.

METHODS

This study is a population-based retrospective cohort study using the UK Biobank database.

RESULTS

The mean fatty liver index in the study cohort was 44.9, and 33.7% met the criteria for nonalcoholic fatty liver disease. Fatty liver index was significantly associated with a wide range of cardiovascular risk factors at baseline. During a mean follow-up of 7.86 years, the combined incidence of cardiovascular disease was 6.92 per 1000-person years at risk. We found significant association between fatty liver index and incident cardiovascular disease in the fully adjusted model. We found significant association between fatty liver index and incident cardiovascular disease in subgroups stratified by BMI as well as subgroups with fatty liver index < 30, < 60, and ≥ 60.

CONCLUSIONS

Fatty liver index not only predicts NAFLD diagnosis, but also indicates baseline and future development of cardiovascular disease on long-term follow-up across weight categories and fatty liver index spectrum. These findings can inform clinicians and other stakeholders on cardiovascular disease management and preventive efforts. Patients with high fatty liver index should be counseled on the increased future risk of developing cardiovascular disease.

Nanodiagnosis and Nanotreatment of Cardiovascular Diseases: An Overview

Cardiovascular diseases (CVDs) are the world’s leading cause of mortality and represent a large contributor to the costs of medical care. Although tremendous progress has been made for the diagnosis of CVDs, there is an important need for more effective early diagnosis and the design of novel diagnostic methods. The diagnosis of CVDs generally relies on signs and symptoms depending on molecular imaging (MI) or on CVD-associated biomarkers. For early-stage CVDs, however, the reliability, specificity, and accuracy of the analysis is still problematic. Because of their unique chemical and physical properties, nanomaterial systems have been recognized as potential candidates to enhance the functional use of diagnostic instruments. Nanomaterials such as gold nanoparticles, carbon nanotubes, quantum dots, lipids, and polymeric nanoparticles represent novel sources to target CVDs. The special properties of nanomaterials including surface energy and topographies actively enhance the cellular response within CVDs. The availability of newly advanced techniques in nanomaterial science opens new avenues for the targeting of CVDs. The successful application of nanomaterials for CVDs needs a detailed understanding of both the disease and targeting moieties.

Cardio-Metabolic Indices and Metabolic Syndrome as Predictors of Clinical Severity of Gastroenteropancreatic Neuroendocrine Tumors

BACKGROUND

Obesity, mainly visceral obesity, and metabolic syndrome (MetS) are major risk factors for the development of type 2 diabetes, cardiovascular diseases, and cancer. Data analyzing the association of obesity and MetS with gastroenteropancreatic neuroendocrine neoplasms (GEP-NEN) are lacking. Fatty liver index (FLI) is a non-invasive tool for identifying individuals with non-alcoholic fatty liver disease (NAFLD). Visceral adiposity index (VAI) has been suggested as a gender-specific indicator of adipose dysfunction. Both indexes have been proposed as early predictors of MetS. This study aimed to investigate the association of FLI VAI as early predictors of MetS with gastroenteropancreatic neuroendocrine tumors (GEP-NETs).

METHODS

A cross-sectional, case-control, observational study was carried out at the ENETS Centers of Excellence Multidisciplinary Group for Neuroendocrine Tumors, University "Federico II". VAI and FLI were calculated.

RESULTS

We enrolled 109 patients with histologically confirmed G1/G2 GEP-NET (53 M; 57.06 ± 15.96 years), as well as 109 healthy subjects, age, sex- and body mass index-matched. Forty-four GEP-NET patients were G2, of which 21 were with progressive disease, and 27 patients had metastases. GEP-NET patients had a higher value of VAI (p < 0.001) and FLI (p = 0.049) and higher MetS presence (p < 0.001) compared with controls. VAI and FLI values and MetS presence were higher in G2 than in G1 patients (p < 0.001), in patients with progressive disease, and in metastatic vs non-metastatic patients (p < 0.001). In addition, higher values of VAI and FLI and higher MetS presence were significantly correlated with the worst clinical severity of NENs. The cut-off values for the FLI and MetS to predict high grading of GEP-NETs and the presence of metastasis were also provided.

CONCLUSIONS

This is the first study investigating an association between VAI and FLI as early predictors of MetS and GEP-NET. Our findings report that the worsening of clinicopathological characteristics in GEP-NET is associated with higher presence of MetS, NAFLD, evaluated by FLI, and visceral adiposity dysfunction, evaluated by VAI. Addressing the clinical evaluation of MetS presence, NAFLD, and visceral adiposity dysfunction might be of crucial relevance to establish targeted preventive and treatment interventions of NEN-related metabolic comorbidities.

Fatty liver index and risk of diabetes incidence: A systematic review and dose-response meta-analysis of cohort studies

AIMS

Fatty Liver Index (FLI) is a surrogate index for diagnosis of Fatty Liver Disease (FLD). We performed a dose-response meta-analysis to investigate the relationship between FLI and diabetes incidence in prospective cohort studies.

METHODS

We conducted a systematic search of articles up to November 2019 in PubMed, SCOPUS, Cochrane library, and Embase. Hazard Ratios (HRs) with corresponding 95% confidence intervals (CIs) of studies were pooled using meta-analysis with DerSimonian and Laird random-effects models to find combined HRs. Dose-response effect of this relationship was also assessed.

RESULTS

Twenty-seven studies providing 70,918 participants were included in the meta-analysis. Pooled results showed that the highest category of FLI was associated with an increased incidence of diabetes [HR: 2.88, 95% CI: 2.18-3.81; P for heterogeneity: 0.001]. Subgroup analysis based on sex, continent, and the quality of study could not explain the source of heterogeneity. The pooled HR from the random-effects dose-response model indicated a significant association between FLI level and risk of diabetes incidence (Coef=0.0239, p=0.001).

CONCLUSION

Our dose-response meta-analysis revealed a direct relationship between FLI and HR of diabetes incidence.

Acute Coronary Syndromes and Nonalcoholic Fatty Liver Disease: "Un Affaire de Coeur"

BACKGROUND AND AIMS

Both nonalcoholic fatty liver disease (NAFLD) and ischemic heart disease have common pathogenic links. Evidence for the association of NAFLD with acute coronary syndromes (ACS), complex multivessel coronary artery disease (CAD), and increased mortality risk in ACS patients is still under investigation. Therefore, we conducted a systematic review aiming to clarify these gaps in evidence.

METHODS

We conducted a systematic search on PubMed and EMBASE with predefined keywords searching for observational studies published till August 2020. NAFLD diagnosis was accepted if confirmed through biopsy, imaging techniques, surrogate markers, or codes. Full articles that satisfied our inclusion and exclusion criteria were included in the systematic review. We used the NHLBI quality assessment tool to evaluate included studies.

RESULTS

Seventeen observational studies with a total study population of approximately 21 million subjects were included. Eleven studies evaluated whether NAFLD is an independent risk factor for developing ACS with conflicting results, of which eight studies demonstrated a significant association between NAFLD and ACS, mainly in Asian populations, while three reported a lack of an independent association. Conflicting results were reported in studies conducted in Europe and North America. Moreover, a total of five studies evaluated whether NAFLD and fatty liver severity in ACS patients are associated with a complex multivessel CAD disease, where all studies confirmed a significant association. Furthermore, seven out of eight studies evaluating NAFLD and hepatic steatosis severity as a predictor of all-cause and cardiovascular mortality and in-hospital major adverse cardiovascular events (MACE) in ACS patients demonstrated a significant independent association.

CONCLUSIONS

NAFLD patients are associated with an independently increased risk of developing ACS, mainly in Asian populations, with inconsistent results in North American and European individuals. Moreover, NAFLD and hepatic steatosis severity were both independently correlated with complex multivessel CAD, mortality, and in-hospital MACE in ACS patients.

Association between non alcoholic fatty liver disease, metabolic and vascular risk

BACKGROUND

Hepatic steatosis is a public health problem with increased incidence and prevalence OBJECTIVE: To determine whether the liver steatosis, as measured by the Fatty Liver Index (FLI), is related to metabolic risk and vascular factors and, if so, to identify the clinical-metabolic factor that explains the higher vascular risk.

METHODS

Cross-sectional study including a sample of 531 men who came to the University of Navarra Clinic Check-up Unit. The degree of steatosis was determined by the FLI. The metabolic risk was assessed using a scale based on determinations of HDL, LDL, triglycerides, blood glucose, HOMA-IR, neutrophil/lymphocyte index, and systolic blood pressure. The vascular risk was assessed by the presence of carotid and/or femoral atheromatous plaques. The dose-response association between FLI and both risks was analysed using non-parametric models (splines) and logistic regression.

RESULTS

The sample studied had a mean age of 52.70years, with 49.3% having an FLI ≥60, as well as 33.6% with metabolic syndrome, and 43.9% with carotid and/or femoral atheromatous plaques. The relationship between FLI and metabolic risk and vascular was linear (metabolic: non-linear P=.097; linear P<.001; vascular: non-linear P=1.000; linear P=.028). For every 10 units of increase in FLI, the odds of presenting with atheroma plaques increased by 9.7% (OR=1.097; 95% confidence interval 1.010-1.191). When adjusting for triglyceridaemia, the association disappeared (OR=1.001).

CONCLUSIONS

Patients with fatty liver disease had an increased metabolic and vascular risk. The increased vascular risk is associated with the triglyceride level. On a clinical level, this study suggests that these patients could benefit from treatment of hypertriglyceridaemia.

Correlation of the Fatty Liver Index with the Pathophysiological Abnormalities Associated with Cardiovascular Risk Markers in Japanese Men without any History of Cardiovascular Disease: Comparison with the Fibrosis-4 Score

Aim: Fatty liver and the liver fibrosis are known risk factors for cardiovascular disease (CVD). The severity of fatty liver can be assessed by determining the fatty liver index (FLI), and the severity of liver fibrosis can be assessed by determining the fibrosis-4 (FIB-4) score. We examined the differences in the associations of these two liver scoring systems with the pathophysiological abnormalities associated with the risk of development of CVD.

Methods: The FLI and FIB-4 score were calculated in 2,437 Japanese men without any history of CVD. The serum NT-pro-BNP levels and brachial-ankle pulse wave velocity (baPWV) were also measured at the start of the study and the end of three years’ follow-up.

Results: The FLI was significantly correlated with the baPWV ( p ＜0.01) and the FIB-4 score was significantly correlated with the serum NT-pro-BNP level ( p ＜0.01). Furthermore, the delta change of the FLI was significantly correlated with the delta change of the baPWV during the study period ( p =0.01), and the delta change of the FIB-4 score was significantly correlated with the delta change of the serum NT-pro-BNP level during the study period ( p ＜0.01).

Conclusions: While the FIB-4 score may serve as a marker of the risk of development of heart failure, the FLI may be a marker of arterial stiffness in Japanese men without any history of CVD.

Post-transplant diabetes mellitus and preexisting liver disease - a bidirectional relationship affecting treatment and management

Liver cirrhosis and diabetes mellitus (DM) are both common conditions with significant socioeconomic burden and impact on morbidity and mortality. A bidirectional relationship exists between DM and liver cirrhosis regarding both etiology and disease-related complications. Type 2 DM (T2DM) is a well-recognized risk factor for chronic liver disease and vice-versa, DM may develop as a complication of cirrhosis, irrespective of its etiology. Liver transplantation (LT) represents an important treatment option for patients with end-stage liver disease due to non-alcoholic fatty liver disease (NAFLD), which represents a hepatic manifestation of metabolic syndrome and a common complication of T2DM. The metabolic risk factors including immunosuppressive drugs, can contribute to persistent or de novo development of DM and NAFLD after LT. T2DM, obesity, cardiovascular morbidities and renal impairment, frequently associated with metabolic syndrome and NAFLD, may have negative impact on short and long-term outcomes following LT. The treatment of DM in the context of chronic liver disease and post-transplant is challenging, but new emerging therapies such as glucagon-like peptide-1 receptor agonists (GLP-1RAs) and sodium–glucose cotransporter 2 inhibitors (SGLT2i) targeting multiple mechanisms in the shared pathophysiology of disorders such as oxidative stress and chronic inflammation are a promising tool in future patient management.

Non-alcoholic fatty liver disease and the incidence of myocardial infarction: A cohort study

BACKGROUND AND AIM

Non-alcoholic fatty liver disease (NAFLD) is a multisystem disease associated with an increased risk of cardiovascular disease (CVD), diabetes, and chronic kidney disease. Indeed, CVD is the most common cause of death in NAFLD patients. This study aimed to evaluate the association between NAFLD and the risk of incident myocardial infarction.

METHODS

This is a retrospective cohort study involving 111 492 adults over 40 years old without history of CVD, liver disease, or cancer at baseline who participated in a regular health screening exam between 2003 and 2013. Fatty liver was diagnosed by ultrasonography.

RESULTS

During 725 706.9 person-years of follow-up, 183 participants developed myocardial infarction (incidence rate 0.3 cases per 1000 person-years). The age, sex, and year of visit-adjusted hazard ratio (HR) for incident myocardial infarction comparing participants with NAFLD with those without it was 2.14 (95% confidence interval 1.59, 2.89). This association remained significant in fully adjusted models (HR 1.54; 95% confidence interval 1.11, 2.14). Compared with participants without NAFLD, in participants with low NAFLD fibrosis score (NFS) (< -1.455) and with intermediate-to-high NFS (≥ -1.455), the fully adjusted HRs for incident myocardial infarction were 1.70 (1.22, 2.36) and 1.88 (1.24, 2.87), respectively.

CONCLUSION

In this large cohort study, NAFLD was associated with an increased incidence of myocardial infarction independently of established risk factors. In addition, this association was similar in participants with and without evidence of more advanced NAFLD as indicated by the NFS. NAFLD patients may need to be carefully monitored and managed early to prevent myocardial infarction.

Validation of fatty liver index and hepatic steatosis index for screening of non-alcoholic fatty liver disease in adults with obstructive sleep apnea hypopnea syndrome

Background:

Obstructive sleep apnea hypopnea syndrome (OSAHS) is a contributing factor for non-alcoholic fatty liver disease (NAFLD). Non-invasive algorithms including fatty liver index (FLI) and hepatic steatosis index (HSI) have been used as a screening test for NAFLD in epidemiologic studies. The aim of this study is to compare the diagnostic accuracy of FLI and HSI for NAFLD detection in adults with OSAHS.

Methods:

We enrolled consecutive adult subjects who were newly diagnosed with OSAHS from March 2016 to January 2018. NAFLD was diagnosed by ultrasonography. The accuracy and cut-off point of the FLI and HSI to detect NAFLD were assessed by analyzing the area under the receiver operating characteristic (AUROC) curve and the maximum Youden index analysis, respectively.

Results:

The 326 subjects were diagnosed as NAFLD according to ultrasound findings, while 105 subjects who had normal abdominal ultrasonography were grouped as controls. Both FLI and HSI values were significantly higher in patients with NAFLD compared with controls. The AUROC of FLI and HSI for predicting NAFLD was 0.802 (95% confidence interval [CI] 0.762–0.839) and 0.753 (95% CI 0.710–0.793), respectively. The AUROC of FLI was significantly higher than that of HSI (P = 0.0383). The optimal cut-off value of FLI and HSI was 60 (sensitivity 66% and specificity 80%) and 35 (sensitivity 81% and specificity 60%), respectively.

Conclusions:

Both FLI and HSI can serve as screening tools for NAFLD in OSAHS adults. The FLI shows better performance in diagnosing NAFLD than HSI.

Trial registration:

Chinese Clinical Trial Registry (No. ChiCTR-OOB-15007253), http://www.chictr.org.cn/showproj.aspx?proj=11606.

Fatty liver index as a predictor of increased risk of cardiometabolic disease: finding from the Kuopio Ischaemic Heart Disease Risk Factor Study Cohort

OBJECTIVE

Fatty liver disease (FLD), a global epidemic, is also a predictor of cardiometabolic disease (CMD) (type 2 diabetes or cardiovascular disease). Our objective was to examine whether progressive FLD, as assessed by fatty liver index (FLI), predicts increasing future CMD risk compared with relatively stable FLD, among middle-aged men.

DESIGN

Prospective epidemiological study.

SETTING

University affiliated research centre in Kuopio, Eastern Finland.

PARTICIPANTS

Our subjects were 501 men without CMD during the initial 4-year follow-up in the Kuopio Ischaemic Heart Disease Risk Factor Study cohort.

OUTCOME MEASURE

Over the initial 4-year follow-up, 135 men (26.9%) had a significant (≥10) FLI increase. The association of 4-year FLI increase with incident CMD was analysed in multivariable-adjusted Cox regression models, adjusting for baseline constitutional and lifestyle factors (model 1) and, in addition, metabolic and inflammation biomarker factors (model 2).

RESULTS

During a mean follow-up of 15 years, 301 new CMD cases occurred. We used subjects with low baseline FLI and no significant 4-year FLI increase as the reference. For subjects with intermediate baseline FLI and significant 4-year FLI increase, the HRs and 95% CIs for incident CMD in model 1 (2.13 (1.45 to 3.13)) and model 2 (1.73 (1.13 to 2.66)) exceeded values for subjects with similar baseline FLI without a significant 4-year change (HRs (95% CIs) were 1.36 (0.94 to 1.97) for model 1 and 1.18 (0.81 to 1.70) for model 2). They approached HRs (95% CI) for subjects who maintained high FLI over the 4 years (HRs (95% CIs) were 2.18 (1.54 to 3.10) in model 1 and 1.85 (1.21 to 2.82) in model 2).

CONCLUSION

Persons with significant FLI increase are likely with increasing CMD risk. Such persons should be evaluated for progressive FLD and CMD and managed to reduce CMD risk.

Association of fatty liver index with risk of incident type 2 diabetes by metabolic syndrome status in an Eastern Finland male cohort: a prospective study

OBJECTIVE

Fatty liver disease (FLD) is increasingly recognised as a predictor of cardiometabolic risk. Our objective was to examine if metabolic syndrome (MS) status affects the association of FLD with incident type 2 diabetes (T2D) in middle-aged men.

DESIGN

Prospective epidemiological study.

SETTING

University affiliated research centre in Kuopio, Eastern Finland.

PARTICIPANTS

Our subjects were 1792 Finnish men without diabetes at baseline in the KuopioIschaemicHeart Disease Risk Factor Study cohort.

OUTCOME MEASURE

Using fatty liver index (FLI), the association of baseline FLD with incident T2D was analysed in multivariable-adjusted Cox regression models, considering their MS statuses. The main models were adjusted for constitutional factors, lifestyle factors, biomarkers of inflammation and for high (FLI ≥60) versus low (FLI <30) FLI categories.

RESULTS

During a mean follow-up of 19 years, 375 incident cases of T2D were recorded. In the full model, the HR (HR (95% CI)) for T2D was 3.68 (2.80 to 4.82). The association was attenuated, but maintained, with further adjustment for metabolic factors. When MS status was adjusted for in place of metabolic factors, the HRs (95% CIs) were 2.63 (1.92 to 3.59) for FLI ≥60 and 1.77 (1.35 to 2.31) for MS.In MS-stratified analysis, FLI predicted T2D only among persons without MS. In unstratified analysis with subjects categorised by FLI-MS, persons with FLI ≥60 without MS had increased risk for T2D (HR=3.19 (2.26 to 4.52)) compared with persons with FLI <30 without MS. Persons with FLI <30 and MS had greater risk (HR=4.31 (2.15 to 8.61)) and persons with both FLI ≥60 and MS had the greatest risk (HR=4.66 (3.42 to 6.35)).

CONCLUSION

Generally, FLD (FLI ≥60) predicts T2D. It specifically predicted T2D among men without MS but not among men with MS, for whom MS alone already increases the risk. Both FLI and MS can complement each other in screening and surveillance for persons with increased T2D risk.

The selective peroxisome proliferator-activated receptor alpha modulator (SPPARMα) paradigm: conceptual framework and therapeutic potential : A consensus statement from the International Atherosclerosis Society (IAS) and the Residual Risk Reduction Initiative (R3i) Foundation

In the era of precision medicine, treatments that target specific modifiable characteristics of high-risk patients have the potential to lower further the residual risk of atherosclerotic cardiovascular events. Correction of atherogenic dyslipidemia, however, remains a major unmet clinical need. Elevated plasma triglycerides, with or without low levels of high-density lipoprotein cholesterol (HDL-C), offer a key modifiable component of this common dyslipidemia, especially in insulin resistant conditions such as type 2 diabetes mellitus. The development of selective peroxisome proliferator-activated receptor alpha modulators (SPPARMα) offers an approach to address this treatment gap. This Joint Consensus Panel appraised evidence for the first SPPARMα agonist and concluded that this agent represents a novel therapeutic class, distinct from fibrates, based on pharmacological activity, and, importantly, a safe hepatic and renal profile. The ongoing PROMINENT cardiovascular outcomes trial is testing in 10,000 patients with type 2 diabetes mellitus, elevated triglycerides, and low levels of HDL-C whether treatment with this SPPARMα agonist safely reduces residual cardiovascular risk.

Crosstalk between nonalcoholic fatty liver disease and cardiometabolic syndrome

Nonalcoholic fatty liver disease (NAFLD) is a chronic condition characterized by fat accumulation combined with low-grade inflammation in the liver. A large body of clinical and experimental data shows that increased flux of free fatty acids from increased visceral adipose tissue and de novo lipogenesis can lead to NAFLD and insulin resistance. Thus, individuals with obesity, insulin resistance, and dyslipidaemia are at the greatest risk of developing NAFLD. Conversely, NAFLD is a phenotype of cardiometabolic syndrome. Notably, researchers have discovered a close association between NAFLD and impaired glucose metabolism and focused on the role of NAFLD in the development of type 2 diabetes. Moreover, recent studies provide substantial evidence for an association between NAFLD and atherosclerosis and cardiometabolic disorders. Even if NAFLD can progress into severe liver disorders including nonalcoholic steatohepatitis (NASH) and cirrhosis, the majority of subjects with NAFLD die from cardiovascular disease eventually. In this review, we propose a potential pathological link between NAFLD/NASH and cardiometabolic syndrome. The potential factors that can play a pivotal role in this link, such as inflammation, insulin resistance, alteration in lipid metabolism, oxidative stress, genetic predisposition, and gut microbiota are discussed.

Beneficial effects of SGLT2 inhibitors on fatty liver in type 2 diabetes: A common comorbidity associated with severe complications

Patients with type 2 diabetes mellitus (T2DM) are exposed to non-alcoholic fatty liver disease (NAFLD), a comorbidity associated with cardiovascular disease and chronic kidney disease, and which may progress to non-alcoholic steatohepatitis (NASH), fibrosis and cirrhosis. Sodium-glucose cotransporter type-2 (SGLT2) inhibitors are glucose-lowering agents that improve glucose control while promoting weight loss and lowering serum uric acid levels. These agents may exert cardiovascular and renal protection in T2DM patients with established cardiovascular disease. Recent findings from both randomized controlled trials and open-label studies have also shown that SGLT2 inhibitors are able to reduce fatty liver content, as assessed by different imaging techniques, and improve biological markers of NAFLD, especially serum liver enzymes, in patients with T2DM. In addition, there are emerging data to suggest a mechanism beyond the reduction of hyperglycaemia and body weight, and a potential role for the decrease in low-grade inflammation and oxidative stress associated with SGLT2 inhibitor therapy. This positive effect of SGLT2 inhibitors on NAFLD complements their already well-known effects on cardiovascular and chronic kidney diseases.