Fatty liver in adolescents on the U.S.-Mexico border

Missed Opportunities in Guideline-Based Fatty Liver Screening Among 3.5 Million Children

OBJECTIVE

Determine screening rates and examine socio-demographic characteristics of metabolic dysfunction-associated steatotic liver disease (MAFLD) screening in a large population of obese children.

METHODS

We used Explorys (IBM) which contains aggregated population-level electronic health record data from approximately 360 hospitals and 317,000 providers across the United States to determine MAFLD screening rates. In children 10 to 14 years, obesity was determined based on body mass index ≥ 95%, or encounter with an international classification of disease obesity code. We determined screening rates by calculating the percentage of children with obesity who had an alanine aminotransferase tested, further analyzed by gender, race, and insurance.

RESULTS

Of 3,558,420 children, 513,170 (14.4%) were obese. Of obese children, only 9.3% were screened for MAFLD. Females were more likely screened than males (odds ratio (OR) 1.09 (95% confidence intervals (CI): 1.07-1.12)); White children were more likely screened than non-White children (OR 1.21 (95% CI: 1.18-1.23)), and children with Medicaid more likely screened than children with non-Medicaid insurance (OR 1.34 (95% CI: 1.32-1.37)).

CONCLUSIONS

The percentage of obese children receiving screening for MAFLD was low. Female gender, White race, and Medicaid insurance were associated with increased screening rates. These findings highlight the need to increase adherence to MAFLD screening. Reporting screening as a health quality measure may reduce implementation gaps in MAFLD screening.

Relationships Between Alanine Aminotransferase, Serum Triglycerides, Body Mass Index and Nonalcoholic Fatty Liver Disease in an Outpatient Pediatric Clinic Population

Nonalcoholic fatty liver disease (NAFLD) is the most prevalent chronic liver disease in children and adolescents. The goal of this study was to describe the demographic, anthropometric and biochemical data of children and adolescents diagnosed with NAFLD during a seven-year period in an outpatient pediatric clinic in the Southwest region of the US and to evaluate relationships between race, BMI, ALT, triglyceride levels, age and gender with a diagnosis of NAFLD. A retrospective medical record review of patients who attended an outpatient pediatric clinic with a billing diagnosis ICD-9 code of 571.8 was conducted. Forty-one patients met these criteria. The majority was male (74%) Hispanic (32%), Hispanic/Latino (68%) and obese. The small number of patients diagnosed with NAFLD in our study is consistent with previously reported results. Our results indicate that the population of this culturally diverse, high-risk population has significant clinical markers that are indicative of NAFLD.

Genetic analysis of nonalcoholic fatty liver disease within a Caribbean-Hispanic population

We explored potential genetic risk factors implicated in nonalcoholic fatty liver disease (NAFLD) within a Caribbean–Hispanic population in New York City. A total of 316 individuals including 40 subjects with biopsy‐proven NAFLD, 24 ethnically matched non‐NAFLD controls, and a 252 ethnically mixed random sampling of Bronx County, New York were analyzed. Genotype analysis was performed to determine allelic frequencies of 74 known single‐nucleotide polymorphisms (SNPs) associated with NAFLD risk based on previous genome‐wide association study (GWAS) and candidate gene studies. Additionally, the entire coding region of PNPLA3, a gene showing the strongest association to NAFLD was subjected to Sanger sequencing. Results suggest that both rare and common DNA variations in PNPLA3 and SAMM50 may be correlated with NAFLD in this small population study, while common DNA variations in CHUK and ERLIN1, may have a protective interaction. Common SNPs in ENPP1 and ABCC2 have suggestive association with fatty liver, but with less compelling significance. In conclusion, Hispanic patients of Caribbean ancestry may have different interactions with NAFLD genetic modifiers; therefore, further investigation with a larger sample size, into this Caribbean–Hispanic population is warranted.

Plasma dihydroceramide species associate with waist circumference in Mexican American families

OBJECTIVE

Waist circumference (WC), the clinical marker of central obesity, is gaining popularity as a screening tool for type 2 diabetes (T2D). While there is epidemiologic evidence favoring the WC-T2D association, its biological substantiation is generally weak. Our objective was to determine the independent association of plasma lipid repertoire with WC.

METHODS

Samples and data from the San Antonio Family Heart Study of 1208 Mexican Americans from 42 extended families were used. Association of plasma lipidomic profiles with the cross-sectionally assessed WC was determined. Plasma lipidomic profiling entailed liquid chromatography with mass spectrometry. Statistical analyses included multivariable polygenic regression models and bivariate trait analyses using the SOLAR software.

RESULTS

After adjusting for age and sex interactions, body mass index, homeostasis model of assessment-insulin resistance, total cholesterol, triglycerides, high density lipoproteins and use of lipid lowering drugs, dihydroceramides as a class were associated with WC. Dihydroceramide species 18:0, 20:0, 22:0, and 24:1 were significantly associated and genetically correlated with WC. Two sphingomyelin species (31:1 and 41:1) were also associated with WC.

CONCLUSIONS

Plasma dihydroceramide levels independently associate with WC. Thus, high resolution plasma lipidomic studies can provide further credence to the biological underpinnings of the association of WC with T2D.

Prevalence and predictors of alanine aminotransferase elevation among normal weight, overweight and obese youth in Mexico

OBJECTIVE

This study aimed to determine the prevalence of and risk factors associated with elevated alanine aminotransferase (ALT) levels among a sample of normal weight, overweight and obese youth from two urban populations in Central Mexico.

METHODS

Baseline data from 1262 youth aged 8-19 years who participated in the Mexican Health Worker Cohort Study from March 2004 to April 2006 were reviewed, including 680 girls and 582 boys, with a total of 83 participants with elevated ALT level (>40 U/L). Information was obtained from self-administered questionnaires, anthropometric results and clinical measurements. Associations of interest were examined using multivariate logistic regression models.

RESULTS

A total of 3.8% of girls and 9.8% of boys had elevated ALT levels. Elevated ALT was observed in 28.9% of the obese and 14.2% of the overweight participants. Metabolic syndrome (MS) occurred in 6.1% of the study population and those with MS had a high percentage of elevated ALT (14.5% of girls and 40.0% of boys, respectively). Abdominal obesity and insulin resistance were also associated with a greater risk of elevated ALT.

CONCLUSIONS

Obesity and certain metabolic risk factors are important predictors for elevated ALT. Screening for ALT levels in obese youth could help to identify those at risk and reduce the possibility of future liver diseases.

Nonalcoholic fatty liver disease: the hepatic metabolic syndrome

PURPOSE

To examine a case of nonalcoholic fatty liver disease (NAFLD) and review the incidence, pathophysiology, appropriate diagnostic procedures and imaging, clinical considerations, and treatment options.

DATA SOURCES

Findings from the history, physical examination, and diagnostic testing of a 39-year-old man with elevated liver enzymes presenting to the hepatology clinic; a search of evidence-based literature in the PubMed and CINAHL database with the terms "fatty liver,""nonalcoholic fatty liver disease," and "nonalcoholic steatohepatitis."

CONCLUSIONS

NAFLD is the deposition of fat in the liver that can progress to nonalcoholic steatohepatitis, resulting in fibrosis and cirrhosis. The exact pathophysiology is unknown, but risk factors can include those criteria associated with metabolic syndrome. NAFLD is a diagnosis of exclusion and can lead to serious health consequences if it is not identified and interventions are not implemented promptly. Treatment options remain limited but currently focus on weight loss, exercise, and diet.

IMPLICATION FOR PRACTICE

The clinician must include the spectrum of NAFLD in the differential diagnosis for any patient with elevated liver enzymes. The key actions for diagnosing NAFLD are identifying risk factors and ordering appropriate testing for confirmation. These considerations will lead to early diagnosis and implementation of treatment interventions.