Prevalence of nonalcoholic fatty liver disease in mainland of China: a meta-analysis of published studies

Altitude and Metabolic Dysfunction-Associated Fatty Liver Disease (MAFLD) in China: A Population-Based Study

Yufei Wang, Qiong Meng, Jin Zhang, Bing Guo, Nanyan Li, Qian Deng, Julinling Hu, Deji Quzong, Han Guan, Danzhen Wangjiu, Hui Yu, Zhifeng Li, and Junmin Zhou. Altitude and metabolic dysfunction-associated fatty liver disease (MAFLD) in China: a population-based study. High Alt Med Biol. 00:00-00, 2024. Objectives: The epidemiological evidence for the relationship between altitude and metabolic dysfunction-associated fatty liver disease (MAFLD) is scarce. This study aims to examine the altitude-MAFLD relationship and explore the potential mediators explaining the relationship. Methods: Data were derived from the China Multi-Ethnic Cohort. The participants' altitude information was extracted from their residential addresses. MAFLD was diagnosed based on radiographically confirmed hepatic steatosis and any one of the following three items: overweight/obese status, diabetes mellitus, or metabolic dysregulation. We performed multivariable logistic regression and mediation analyses to assess the altitude-MAFLD associations and potential mediators, respectively. In the mediation analysis, mediation proportion is an estimate of the extent to which the total effect (altitude-MAFLD association) is accounted for by the pathway through the mediators. Results: In total, 87,679 participants (female: 60.7%, mean age: 51.36 years) were included. The odds ratio of MAFLD was 1.61 (95% confidence interval [CI]: 1.52-1.71) between high and low altitudes, 1.52 (95% CI: 1.43-1.62) between high and middle altitudes, and 1.06 (95% CI: 1.01-1.10) between middle and low altitudes. Of the total estimated effect between high and low altitude, physical activity and vegetable intake accounted for 15.7% (95% CI: 12.8-19.1) and 3.8% (95% CI: 1.2-6.6), respectively. Of the total estimated effect between high and middle altitude, physical activity and vegetable intake accounted for 31.4% (95% CI: 26.2-34.8) and 2.3% (95% CI: 0.6-3.8), respectively. Of the total estimated effect between middle and low altitude, vegetable intake accounted for 11.8% (95% CI: 3.2-61.5). Conclusion: Higher altitude was associated with increased odds of MAFLD, and physical activity and vegetable intake mediated such association. Multifaceted efforts should be taken in public health to promote healthy lifestyles among higher altitude residents.

Altered gut microbial profile accompanied by abnormal short chain fatty acid metabolism exacerbates nonalcoholic fatty liver disease progression

Dysregulation of the gut microbiome has associated with the occurrence and progression of non-alcoholic fatty liver disease (NAFLD). To determine the diagnostic capacity of this association, we compared fecal microbiomes across 104 participants including non-NAFLD controls and NAFLD subtypes patients that were distinguished by magnetic resonance imaging. We measured their blood biochemical parameters, 16 S rRNA-based gut microbiota and fecal short-chain fatty acids (SCFAs). Multi-omic analyses revealed that NAFLD patients exhibited specific changes in gut microbiota and fecal SCFAs as compared to non-NAFLD subjects. Four bacterial genera (Faecalibacterium, Subdoligranulum, Haemophilus, and Roseburia) and two fecal SCFAs profiles (acetic acid, and butyric acid) were closely related to NAFLD phenotypes and could accurately distinguish NAFLD patients from healthy non-NAFLD subjects. Twelve genera belonging to Faecalibacterium, Subdoligranulum, Haemophilus, Intestinibacter, Agathobacter, Lachnospiraceae_UCG-004, Roseburia, Butyricicoccus, Actinomycetales_unclassified, [Eubacterium]_ventriosum_group, Rothia, and Rhodococcus were effective to distinguish NAFLD subtypes. Of them, combination of five genera can distinguish effectively mild NAFLD from non-NAFLD with an area under curve (AUC) of 0.84. Seven genera distinguish moderate NAFLD with an AUC of 0.83. Eight genera distinguish severe NAFLD with an AUC of 0.90. In our study, butyric acid distinguished mild-NAFLD from non-NAFLD with AUC value of 0.83. And acetic acid distinguished moderate-NAFLD and severe-NAFLD from non-NAFLD with AUC value of 0.84 and 0.70. In summary, our study and further analysis showed that gut microbiota and fecal SCFAs maybe a method with convenient detection advantages and invasive manner that are not only a good prediction model for early warning of NAFLD occurrence, but also have a strong ability to distinguish NAFLD subtypes.

Association of Aortic Stiffness and Pressure Pulsatility With Noninvasive Estimates of Hepatic Steatosis and Fibrosis: The Framingham Heart Study

BACKGROUND

Arterial stiffening may contribute to the pathogenesis of metabolic dysfunction-associated steatotic liver disease. We aimed to assess relations of vascular hemodynamic measures with measures of hepatic steatosis and fibrosis in the community.

METHODS

Our sample was drawn from the Framingham Offspring, New Offspring Spouse, Third Generation, Omni-1, and Omni-2 cohorts (N=3875; mean age, 56 years; 54% women). We used vibration-controlled transient elastography to assess controlled attenuation parameter and liver stiffness measurements as measures of liver steatosis and liver fibrosis, respectively. We assessed noninvasive vascular hemodynamics using arterial tonometry. We assessed cross-sectional relations of vascular hemodynamic measures with continuous and dichotomous measures of hepatic steatosis and fibrosis using multivariable linear and logistic regression.

RESULTS

In multivariable models adjusting for cardiometabolic risk factors, higher carotid-femoral pulse wave velocity (estimated β per SD, 0.05 [95% CI, 0.01-0.09]; P=0.003), but not forward pressure wave amplitude and central pulse pressure, was associated with more liver steatosis (higher controlled attenuation parameter). Additionally, higher carotid-femoral pulse wave velocity (β=0.11 [95% CI, 0.07-0.15]; P<0.001), forward pressure wave amplitude (β=0.05 [95% CI, 0.01-0.09]; P=0.01), and central pulse pressure (β=0.05 [95% CI, 0.01-0.09]; P=0.01) were associated with more hepatic fibrosis (higher liver stiffness measurement). Associations were more prominent among men and among participants with obesity, diabetes, and metabolic syndrome (interaction P values, <0.001-0.04). Higher carotid-femoral pulse wave velocity, but not forward pressure wave amplitude and central pulse pressure, was associated with higher odds of hepatic steatosis (odds ratio, 1.16 [95% CI, 1.02-1.31]; P=0.02) and fibrosis (odds ratio, 1.40 [95% CI, 1.19-1.64]; P<0.001).

CONCLUSIONS

Elevated aortic stiffness and pressure pulsatility may contribute to hepatic steatosis and fibrosis.

Associations between metabolic dysfunction-associated fatty liver disease and atherosclerotic cardiovascular disease

Non-alcoholic fatty liver disease (NAFLD) is closely related to metabolic syndrome and remains a major global health burden. The increased prevalence of obesity and type 2 diabetes mellitus (T2DM) worldwide has contributed to the rising incidence of NAFLD. It is widely believed that atherosclerotic cardiovascular disease (ASCVD) is associated with NAFLD. In the past decade, the clinical implications of NAFLD have gone beyond liver-related morbidity and mortality, with a majority of patient deaths attributed to malignancy, coronary heart disease (CHD), and other cardiovascular (CVD) complications. To better define fatty liver disease associated with metabolic disorders, experts proposed a new term in 2020 - metabolic dysfunction associated with fatty liver disease (MAFLD). Along with this new designation, updated diagnostic criteria were introduced, resulting in some differentiation between NAFLD and MAFLD patient populations, although there is overlap. The aim of this review is to explore the relationship between MAFLD and ASCVD based on the new definitions and diagnostic criteria, while briefly discussing potential mechanisms underlying cardiovascular disease in patients with MAFLD.

The association between circadian syndrome and chronic kidney disease in an aging population: a 4-year follow-up study

Introduction

Circadian syndrome (CircS) is proposed as a novel risk cluster based on reduced sleep duration, abdominal obesity, depression, hypertension, dyslipidemia and hyperglycemia. However, the association between CircS and chronic kidney disease (CKD) remains unclear. To investigate the cross-sectional and longitudinal association between CircS and CKD, this study was performed.

Methods

A national prospective cohort (China Health and Retirement Longitudinal Study, CHARLS) was used in this study. To define CKD, the estimated glomerular filtration rate (eGFR) was calculated based on the 2012 CKD-EPI creatinine-cystatin C equation. Participants with eGFR <60 mL.min-1/1.73/m2 were diagnosed with CKD. Multivariate binary logistic regression was used to assess the cross-sectional association between CircS and CKD. Subgroup and interactive analyses were performed to determine the interactive effects of covariates. In the sensitivity analysis, the obese population was excluded and another method for calculating the eGFR was used to verify the robustness of previous findings. In addition, participants without CKD at baseline were followed up for four years to investigate the longitudinal relationship between CircS and CKD.

Results

A total of 6355 participants were included in this study. In the full model, CircS was positively associated with CKD (OR = 1.28, 95% CI = 1.04-1.59, P < 0.05). As per one increase of CircS components, there was a 1.11-fold (95% CI = 1.04-1.18, P < 0.05) risk of prevalent CKD in the full model. A significant interactive effect of hyperuricemia in the CircS-CKD association (P for interaction < 0.01) was observed. Sensitivity analyses excluding the obese population and using the 2009 CKD-EPI creatinine equation to diagnose CKD supported the positive correlation between CircS and CKD. In the 2011-2015 follow-up cohort, the CircS group had a 2.18-fold risk of incident CKD (95% CI = 1.33-3.58, P < 0.01) in the full model. The OR was 1.29 (95% CI = 1.10-1.51, P < 0.001) with per one increase of CircS components.

Conclusion

CircS is a risk factor for CKD and may serve as a predictor of CKD for early identification and intervention.

Prevalence and Risk Factors of Non-Alcoholic Fatty Liver Disease (NAFLD) in Non-Obese Patients with Schizophrenia: A Retrospective Study

Background

To assess the prevalence and risk factors of NAFLD in non-obese patients with schizophrenia in a public psychiatric hospital in China.

Methods

A total of 1,305 adult inpatients with schizophrenia in 2019 were included in this retrospective study. Body mass index (BMI) ≥ 25 kg/m2 was considered obese, and BMI < 25 kg/m2 was considered non-obese. We obtained the data from electronic records of the Affiliated Brain Hospital of Guangzhou Medical University.

Results

A total of 1,045 non-obese patients and 260 obese patients were included in this study. The prevalence of NAFLD in non-obese patients was 25.0%, and it was much lower that in the obese patients (25.0% vs 64.6%, p < 0.001). Among the non-obese patients, there were significant differences in age, BMI, alanine aminotransferase (ALT), metabolic indices, and the prevalence of diabetes and hypertension between patients with NAFLD and patients without NAFLD. According to the results of binary logistic regression analysis, age, BMI, ALT, triglyceride (TG) and diabetes were significantly related to NAFLD among non-obese patients with schizophrenia. In contrast, HDL-C was was negatively associated with NAFLD among non-obese patients.

Conclusion

This study suggested that NAFLD was common in patients with schizophrenia, even in non-obese patients with schizophrenia. In non-obese patients with schizophrenia, age, BMI, ALT, TG and diabetes are significantly associated with NAFLD. Moreover, HDL-C level was an independent protective factor against NAFLD. Given the adverse outcomes of NAFLD, it is necessary to increase awareness of NAFLD in patients with schizophrenia, especially in non-obese patients with schizophrenia.

Swimming exercise ameliorates insulin resistance and nonalcoholic fatty liver by negatively regulating PPARγ transcriptional network in mice fed high fat diet

BACKGROUND

Recent findings elucidated hepatic PPARγ functions as a steatogenic-inducer gene that activates de novo lipogenesis, and is involved in regulation of glucose homeostasis, lipid accumulation, and inflammation response. This study delved into a comprehensive analysis of how PPARγ signaling affects the exercise-induced improvement of insulin resistance (IR) and non-alcoholic fatty liver disease (NAFLD), along with its underlying mechanism.

METHODS

Chronic and acute swimming exercise intervention were conducted in each group mice. IR status was assessed by GTT and ITT assays. Serum inflammatory cytokines were detected by Elisa assays. PPARγ and its target genes expression were detected by qPCR assay. Relative protein levels were quantified via Western blotting. ChIP-qPCR assays were used to detect the enrichment of PPARγ on its target genes promoter.

RESULTS

Through an exploration of a high-fat diet (HFD)-induced IR and NAFLD model, both chronic and acute swimming exercise training led to significant reductions in body weight and visceral fat mass, as well as hepatic lipid accumulation. The exercise interventions also demonstrated a significant amelioration in IR and the inflammatory response. Meanwhile, swimming exercise significantly inhibited PPARγ and its target genes expression induced by HFD, containing CD36, SCD1 and PLIN2. Furthermore, swimming exercise presented significant modulation on regulatory factors of PPARγ expression and transcriptional activity.

CONCLUSION

The findings suggest that swimming exercise can improve lipid metabolism in IR and NAFLD, possibly through PPARγ signaling in the liver of mice.

Analysis of the association between dietary patterns and nonalcoholic fatty liver disease in a county in Guangxi

BACKGROUND

This study aims to investigate the relationship between different dietary patterns and non-alcoholic fatty liver disease (NAFLD).

METHODS

Residents over 30 years old in the ecological longevity cohort in Gongcheng Yao Autonomous County, Guangxi Province were the research objects selected from 2018 to 2019. Physical examination, baseline population survey, and food frequency questionnaire (FFQ) survey were conducted. Dietary patterns were analyzed by factor analysis. Influencing factors of NAFLD were analyzed by multiple logistic regression.

RESULTS

NAFLD was diagnosed in 241 of 2664 participants based on ultrasonography, and the detection rate was 9.0%. Factor analysis yielded a total of three dietary patterns, namely, traditional Chinese, Western, and cereal-potato dietary patterns. Results of multivariate logistic regression analysis showed that after adjusting for confounding factors, participants in the highest quartile of the Western dietary pattern exhibited a higher prevalence of NAFLD (OR = 2.799; 95% CI: 1.620-4.837; p < 0.05) than participants in the lowest quartile. Participants in the highest quartile of the cereal-potato pattern exhibited a decreased risk of NAFLD compared with those in the lowest quartile (OR = 0.581; 95% CI: 0.371-0.910, p < 0.05). The traditional Chinese patterns did not show any association with the risk of NAFLD.

CONCLUSIONS

The Western dietary pattern increases the risk of NAFLD, whereas the cereal-potato dietary pattern reduces the risk of NAFLD. It is important for the prevention and control of NAFLD to adhere to the cereal-potato dietary.

The efficacy of L-carnitine in patients with nonalcoholic steatohepatitis and concomitant obesity

BACKGROUND

In light of the high prevalence of nonalcoholic fatty liver disease and obesity, treatment options for nonalcoholic steatohepatitis are of particular interest. The purpose of the study is to assess the efficacy of L-carnitine and its effects on the functional state of the liver, as well as on lipid and carbohydrate metabolism in patients with nonalcoholic steatohepatitis and concomitant obesity.

METHODS

People in the control group followed a hypocaloric diet and received 1 tablet of simvastatin 20 mg once a day and 2 capsules of essential phospholipids 600 mg three times a day for 90 days. People in the experimental group followed a hypocaloric diet and received 1 tablet of simvastatin 20 mg once a day and L-carnitine 10 mL orally two times a day for 90 days.

RESULTS

L-carnitine normalized the blood lipid profile of subjects, as demonstrated by a significant decrease in the blood levels of total cholesterol, triglycerides, low-density lipoproteins, atherogenic index, and insulin resistance. The use of L-carnitine in patients with nonalcoholic steatohepatitis and concomitant obesity contributes to the steady reduction of the main clinical and biochemical symptoms of nonalcoholic steatohepatitis.

CONCLUSIONS

L-carnitine produces positive effects on the blood lipid profile and carbohydrate metabolism.

The Role of ElastPQ in Assessing Liver Stiffness for Non-Alcoholic Fatty Liver Disease in Patients Treated with Atypical Antipsychotic Drugs

Objective

To evaluate the role of elastography point quantification (ElastPQ) for the quantitative assessment of stiffness in the fatty liver disease in mental disorder patients and to provide a noninvasive detection method for non-alcoholic fatty liver (NAFLD) caused by atypical antipsychotics drugs (AAPDs).

Methods

A total number of 168 mental disorder patients treated with AAPDs and 58 healthy volunteers were enrolled in this study. All the subjects underwent ultrasound and ElastPQ tests. The basic data of the patients were analyzed.

Results

BMI, liver function, and the value of ElastPQ were considerably higher in the patient group than that in the healthy volunteers. The values of liver stiffness obtained by ElastPQ were increased gradually from 3.48(3.14-3.81) kPa in the normal liver to 8.15(6.44-9.88) in the severe fatty liver. The receiver operating characteristic (ROC) for the diagnosis of fatty liver with ElastPQ were 0.85, 0.79, 0.80, and 0.87 for the diagnosis of normal, mild, moderate, and severe steatosis, respectively, with a sensitive/specificity of 79%/76.4%, 85.7%/78.3%, 86.2%/73%, and 81.3%/82.1%, correspondingly. Moreover, ElastPQ in the olanzapine group was higher than those in the risperidone and aripiprazole groups (5.11(3.83-5.61) kPa vs 4.35(3.63-4.98) kPa, P < 0.05; 5.11(3.83-5.61) kPa vs 4.79(4.18-5.24) kPa, P < 0.05). After one-year treatment, the value of ElastPQ was 4.43(3.85-5.22) kPa, but it was 5.81(5.09-7.33) kPa in patients treated for more than three years. This value increased with treatment prolongation (P < 0.05).

Conclusion

ElastPQ is a real-time, quantitative method for assessing the stiffness of NAFLD. The liver stiffness value could be varied in the different stages of fatty liver. Olanzapine has a considerable influence on liver stiffness. The long-term use of AAPDs can increase the stiffness value of fatty liver.

Patatin-like phospholipase domain-containing 3 gene (PNPLA3) polymorphic (rs738409) single nucleotide polymorphisms and susceptibility to nonalcoholic fatty liver disease: A meta-analysis of twenty studies

BACKGROUND

To investigate the correlation between rs738409 polymorphism of patatin-like phospholipase domain-containing protein 3 (PNPLA3) gene (encoding I148m) and genetic susceptibility to nonalcoholic fatty liver disease (NAFLD).

METHODS

Web of Science, Embase, PubMed, Cochrane Library, China National Knowledge Infrastructure, Wanfang Data Knowledge Service Platform databases were subjected to study retrieving, from the earliest records to November 2022. International databases were searched using the key words (PNPLA3 gene or PNPLA3 polymorphism or patatin-like phospholipase domain-containing pro-tein3) and (nonalcoholic fatty liver disease or NAFLD or nonalcoholic steatohepatitis) and their possible combination. There was no limitation to language. Ethnicity and country restrictions were not applied. Hardy-Weinberg equilibrium about the genotype frequencies of rs738,409 polymorphism in group of controls was assessed using a chi-square goodness-of-fit test (P > .05). A chi-square-based Q test was applied to assess heterogeneity among studies. The random-effect model (DerSimonian-Laird method) was used when a probability value of P < .10, I2 > 50%. If not, the fixed-effect model (Mantel-Haenszel method) was adopted. The current meta-analysis was done by using STATA 16.0.

RESULTS

Twenty studies are selected for this meta-analysis, which includes totally 3240 patients in the treatment group and 5210 patients in the control group. These studies demonstrated a significant increased association between rs738,409 and NAFLD under 5 models: allelic contrast (odds ratio [OR] = 1.98, 95% confidence interval [CI] = 1.65-2.37, Pheterogeneity = 0.000, Z = 7.346, P = .000), homozygote comparison (OR = 3.59, 95% CI = 2.56-5.04, Pheterogeneity = 0.000, Z = 7.416, P = .000), heterozygote comparison (OR = 1.93, 95% CI = 1.63-2.30, Pheterogeneity = 0.002, Z = 7.507, P = .000), the dominant allele model (OR = 2.33, 95% CI = 1.89-2.88, Pheterogeneity = 0.000, Z = 7.856, P = .000), and the recessive allele model (OR = 2.56, 95% CI = 1.96-3.35, Pheterogeneity = 0.000, Z = 6.850, P = .000). Subgroup analysis shows that the rs738,409 polymorphism of PNPLA3 gene in Caucasians and those with a sample size of < 300 is significantly associated with the susceptibility to nonalcoholic fatty liver. Sensitivity analysis shows that the results of meta-analysis are stable.

CONCLUSION

PNPLA3 rs738,409 may play a significant role in increasing risk of NAFLD.

Regulation of Liver Glucose and Lipid Metabolism by Transcriptional Factors and Coactivators

The prevalence of nonalcoholic fatty liver disease (NAFLD) worldwide is on the rise and NAFLD is becoming the most common cause of chronic liver disease. In the USA, NAFLD affects over 30% of the population, with similar occurrence rates reported from Europe and Asia. This is due to the global increase in obesity and type 2 diabetes mellitus (T2DM) because patients with obesity and T2DM commonly have NAFLD, and patients with NAFLD are often obese and have T2DM with insulin resistance and dyslipidemia as well as hypertriglyceridemia. Excessive accumulation of triglycerides is a hallmark of NAFLD and NAFLD is now recognized as the liver disease component of metabolic syndrome. Liver glucose and lipid metabolisms are intertwined and carbon flux can be used to generate glucose or lipids; therefore, in this review we discuss the important transcription factors and coactivators that regulate glucose and lipid metabolism.

Prevalence of non-alcoholic fatty liver disease in pediatric mental disorder inpatients: a tertiary mental health referral hospital study

BACKGROUND AND AIM

Studies have revealed a high prevalence of non-alcoholic fatty liver disease (NAFLD) among adult patients with mental disorders, as well as its associate risk factors, however little is known about these in pediatric population. The aim of the present study is to investigate the prevalence of NAFLD in pediatric inpatients with mental disorder, as well as to explore the risk factors.

METHODS

In this retrospective study, we included 1156 pediatric inpatients with mental disorder admitted to our hospital between January 2020 and December 2021, including inpatients with schizophrenia, bipolar disorder, depressive disorder and other mental disorders. Relevant clinical data were obtained from the electronic medical records. We calculated the prevalence rate of NAFLD, and compared NAFLD prevalence between gender, mental disorders types, antipsychotics use, and comorbidities. Multivariable logistic regression was used to examine risk factors associated with NAFLD.

RESULTS

The prevalence of NAFLD in pediatric inpatients with mental disorders was 7.35% (85/1156). Patients with NAFLD had senior age than those without NAFLD (15.33±1.75 vs 14.21±1.95 year-old, P<0.001). The NAFLD prevalence in participants with schizophrenia (12.11%) was higher than in participants with bipolar disorder (8.45%), depressive disorder (7.06%) and other mental disorders (2.97%)(p=0.002). The NAFLD prevalence was higher in participants who used antipsychotics (8.70%) than those who didn't (5.45%) (p=0.038). Multivariate analysis revealed that senior age, body weight (overweight/obese) and dyslipidemia were independent risk factors for NAFLD in pediatric inpatients with mental disorders.

CONCLUSIONS

The NAFLD prevalence was is higher in those patients with schizophrenia and receiving antipsychotic medication. Metabolic factors and longer evolution may explain these differences.

Shift work and nonalcoholic fatty liver disease incidence among Chinese rail workers: a 4-year longitudinal cohort study

PURPOSE

Occupational harmful factors, such as shift work, are attracting increasing attention as a potential cause of nonalcoholic fatty liver disease (NAFLD). In this study, we aimed to identify the association between shift work and NAFLD incidence in Chinese rail population.

METHODS

A cohort study was conducted among 14,112 rail workers for 4-year follow-up. Shift work frequency and other potential variables were recorded by questionnaires, including demographic, lifestyle, and occupation information. Besides, body mass index, blood pressure, fasting blood glucose, total cholesterol, triglyceride, alanine aminotransferase, and aspartate aminotransferase were measured by anthropometric measurement and blood test. Diagnosis of new NAFLD case was based on abdominal ultrasonography. Cox proportional hazards regression model was used to determine whether shift work has effect on occurrence of NAFLD.

RESULTS

The incidence of NAFLD was 30.43% in total subjects. After adjustment for possible confounders, the RRs of NAFLD were 1.069 (95% CI 0.998-1.146) and 1.179 (95% CI 1.059-1.312) in occasionally shift work group and frequently shift work group respectively, compared to the seldom shift work group. In stratified analyses, the RRs of NAFLD incidence linked to shift work exposure seems increase among female and elder. The results of three sensitivity analyses were similar with main analysis.

CONCLUSIONS

This research provided further evidence of positive harmful effect of shift work on NAFLD incidence in Chinese rail workers, particularly in frequently shift work population. The risk estimate of shift work on NAFLD was higher in female and elder.

Genetic variants in promoter region of TFR2 is associated with the risk of non-alcoholic fatty liver disease in a Chinese Han population: a case-control study

Background

Iron overload is frequently observed in non-alcoholic fatty liver disease (NAFLD). Transferrin receptor 2 (TFR2) is an important key factor in iron regulation. We aimed to investigate whether TFR2 single nucleotide polymorphisms (SNPs) contribute to susceptibility to NAFLD in a Chinese Han population.

Methods

Five tag SNPs (rs10247962, rs4434553, rs2075672, rs1052897, and rs3757859) in the TFR2 gene were selected and genotyped in a case–control study on participants who visited two affiliated hospitals of Fujian Medical University between June 2011 and August 2017. Propensity score matching and inverse probability of treatment weighting analyses were used to verify the risk associated with TFR2 SNPs.

Results

Logistic regression analyses suggested that subjects with the rs4434553 GA or GG genotype had a lower risk of NAFLD than those carrying the AA genotype (odds ratio = 0.630, 95% confidence interval = 0.504–0.788). Moreover, the rs4434553 GA or GG genotype was negatively correlated with body mass index, hepatic steatosis index, and serum ferritin (b = −0.363, P = 0.008; b = −1.040, P = 0.009; b = −35.258, P = 0.015, respectively), and positively associated with serum hepcidin level (b = 35.308, P < 0.001). Moreover, rs10247962 and rs1052897 had multiplicative interactions with age in relation to the risk of NAFLD (P for interactions, 0.041 and 0.034, respectively). The cumulative effects of the rs10247962, rs1052897, and rs4434553 SNPs were positively associated with the risk of NAFLD (adjusted P_trend = 0.012).

Conclusions

In this Chinese Han population, the rs4434553 polymorphism in TFR2 may be an independent influencing factor associated with the susceptibility to NAFLD. The ageing effect on the development of NAFLD may be inhibited by SNPs rs10247962 and rs1052897.

Effects of Six Weeks of Hypoxia Exposure on Hepatic Fatty Acid Metabolism in ApoE Knockout Mice Fed a High-Fat Diet

Nonalcoholic fatty liver disease (NAFLD) is the most common liver disease with a characteristic of abnormal lipid metabolism. In the present study, we employed apolipoprotein E knockout (ApoE KO) mice to investigate the effects of hypoxia exposure on hepatic fatty acid metabolism and to test whether a high-fat diet (HFD) would suppress the beneficial effect caused by hypoxia treatment. ApoE KO mice were fed a HFD for 12 weeks, and then were forwarded into a six-week experiment with four groups: HFD + normoxia, normal diet (ND) + normoxia, HFD + hypoxia exposure (HE), and ND + HE. The C57BL/6J wild type (WT) mice were fed a ND for 18 weeks as the baseline control. The hypoxia exposure was performed in daytime with normobaric hypoxia (11.2% oxygen, 1 h per time, three times per week). Body weight, food and energy intake, plasma lipid profiles, hepatic lipid contents, plasma alanine aminotransferase (ALT) and aspartate aminotransferase (AST), and molecular/biochemical makers and regulators of the fatty acid synthesis and oxidation in the liver were measured at the end of interventions. Six weeks of hypoxia exposure decreased plasma triglycerides (TG), total cholesterol (TC), and low-density lipoprotein cholesterol (LDL-C) contents but did not change hepatic TG and non-esterified fatty acid (NEFA) levels in ApoE KO mice fed a HFD or ND. Furthermore, hypoxia exposure decreased the mRNA expression of Fasn, Scd1, and Srebp-1c significantly in the HFD + HE group compared with those in the HFD + normoxia group; after replacing a HFD with a ND, hypoxia treatment achieved more significant changes in the measured variables. In addition, the protein expression of HIF-1α was increased only in the ND + HE group but not in the HFD + HE group. Even though hypoxia exposure did not affect hepatic TG and NEFA levels, at the genetic level, the intervention had significant effects on hepatic metabolic indices of fatty acid synthesis, especially in the ND + HE group, while HFD suppressed the beneficial effect of hypoxia on hepatic lipid metabolism in male ApoE KO mice. The dietary intervention of shifting HFD to ND could be more effective in reducing hepatic lipid accumulation than hypoxia intervention.

Association of Non-alcoholic Fatty Liver Disease With Salt Intake and Dietary Diversity in Chinese Medical Examination Adults Aged 18-59 Years: A Cross-Sectional Study

Objectives

Given the significance of dietary factors in the development of non-alcoholic fatty liver disease (NAFLD). We conducted a cross-sectional study to investigate the association of NAFLD with salt intake and dietary diversity in a medical examination population aged 18–59 years.

Methods

Data from two Chinese health management centers were utilized between January 2017 and December 2019. The general information, laboratory tests, lifestyle habits, and diet of the participants were all evaluated. Based on alcohol consumption and abdominal ultrasound results, a total of 23,867 participants were divided into the NAFLD (n = 7,753) and control (n = 16,114) groups. Salt intake and dietary diversity were calculated separately for study participants using the spot urine method and dietary diversity scores (DDS). The multilevel logistic model and subgroup analysis were used to analyze the relationship between salt intake, dietary diversity, and NAFLD.

Results

We found that the prevalence of NAFLD was 32.48%. Salt intake was associated with increased NAFLD (Q2 vs. Q1: OR = 1.201, 95% CI 1.094-1.317, P < 0.001; Q3 vs. Q1: OR = 1.442, 95% CI 1.316-1.580, P < 0.001; Q4 vs. Q1: OR = 1.604, 95% CI 1.465-1.757, P < 0.001), whereas sufficient dietary diversity was a protective factor for NAFLD (Sufficient DDS vs. Insufficient DDS: OR: 0.706, 95% CI 0.517-0.965, P < 0.05). The effects of salt intake and dietary diversity on NAFLD were equally stable in the subgroup analysis.

Conclusions

We can conclude that NAFLD is highly prevalent in medical examination adults aged 18-59 years in China. Furthermore, the risk of salt intake for NAFLD and the protective effect of dietary diversity on NAFLD should be taken into account in the management of NAFLD.

Gender Differences in Nonalcoholic Fatty Liver Disease

Nonalcoholic fatty liver disease (NAFLD) has currently emerged as the most common liver disorder in both developed and developing countries. It has been observed that NAFLD exhibits sexual dimorphism, and there is limited understanding on the sex differences in adults with NAFLD. Nonalcoholic fatty liver disease shows marked differences in prevalence and severity with regards to gender. There are considerable biological disparities between males and females attributed to differences in the chromosomal makeup and sex hormone levels, distinct from the gender differences resulting from the sociocultural influences that lead to differences in lifestyle, which have a significant impact on the pathogenesis of this complex disorder. A multitude of factors contributes to the gender disparities seen and need to be researched in-depth to better understand the mechanisms behind them and the therapeutic measures that can be taken. In this article, we will review the gender disparities seen in NAFLD, as well as recent studies highlighting certain gender-specific factors contributing to its varying prevalence and severity.

HOW TO CITE THIS ARTICLE

Nagral A, Bangar M, Menezes S, et al. Gender Differences in Nonalcoholic Fatty Liver Disease. Euroasian J Hepato-Gastroenterol 2022;12(Suppl 1):S19-S25.

Evaluated Glomerular Filtration Rate Is Associated With Non-alcoholic Fatty Liver Disease: A 5-Year Longitudinal Cohort Study in Chinese Non-obese People

Objective

Evidence regarding the association between evaluated glomerular filtration rate (eGFR) and non-alcoholic fatty liver disease (NAFLD) is still limited. On that account, the purpose of our research is to survey the link of evaluated eGFR on NAFLD.

Methods

This study is a retrospective cohort study. Which consecutively and non-selectively collected a total of 16,138 non-obese participants in a Chinese hospital from January 2010 to December 2014. We then used the Cox proportional-hazards regression model to explore the relationship between baseline eGFR and NAFLD risk. A Cox proportional hazards regression with cubic spline functions and smooth curve fitting (the cubic spline smoothing) was used to identify the non-linear relationship between eGFR and NAFLD. Additionally, we also performed a series of sensitivity analyses and subgroup analyses. Data had been uploaded to the DATADRYAD website.

Results

The mean age of the included individuals was 43.21 ± 14.95 years old, and 8,467 (52.47%) were male. The mean baseline eGFR was 98.83 ± 22.80 mL/min per 1.73m2. During a median follow-up time of 35.8 months, 2,317 (14.36%) people experienced NAFLD. After adjusting covariates, the results showed that eGFR was negatively associated with incident NAFLD (HR = 0.983, 95%CI: 0.980, 0.985). There was also a non-linear relationship between eGFR and NAFLD, and the inflection point of eGFR was 103.489 mL/min per 1.73 m2. The effect sizes (HR) on the left and right sides of the inflection point were 0.988 (0.984, 0.991) and 0.971 (0.963, 0.979), respectively. And the sensitive analysis demonstrated the robustness of our results. Subgroup analysis showed that eGFR was more strongly associated with incident NAFLD in diastolic blood pressure (DBP) &lt; 90 mmHg, fasting plasma glucose (FPG) ≤ 6.1 mmol/L, high-density lipoprotein cholesterol (HDL-c) &lt; 1 mmol/L, and alanine aminotransferase (ALT) ≥ 40 U/L participants. In contrast, the weaker association was probed in those with DBP ≥ 90 mmHg, ALT &lt; 40 U/L, FPG &gt; 6.1 mmol/L, and HDL-c ≥ 1 mmol/L.

Conclusion

This study demonstrates a negative and non-linear association between eGFR and incident NAFLD in the Chinese non-obese population. eGFR is strongly related to NAFLD when eGFR is above 103 mL/min per 1.73 m2. From a therapeutic perspective, it makes sense to maintain eGFR levels within the inflection point to 130 mL/min/1.73 m2.

A Machine Learning Based Framework to Identify and Classify Non-alcoholic Fatty Liver Disease in a Large-Scale Population

Non-alcoholic fatty liver disease (NAFLD) is a common serious health problem worldwide, which lacks efficient medical treatment. We aimed to develop and validate the machine learning (ML) models which could be used to the accurate screening of large number of people. This paper included 304,145 adults who have joined in the national physical examination and used their questionnaire and physical measurement parameters as model's candidate covariates. Absolute shrinkage and selection operator (LASSO) was used to feature selection from candidate covariates, then four ML algorithms were used to build the screening model for NAFLD, used a classifier with the best performance to output the importance score of the covariate in NAFLD. Among the four ML algorithms, XGBoost owned the best performance (accuracy = 0.880, precision = 0.801, recall = 0.894, F-1 = 0.882, and AUC = 0.951), and the importance ranking of covariates is accordingly BMI, age, waist circumference, gender, type 2 diabetes, gallbladder disease, smoking, hypertension, dietary status, physical activity, oil-loving and salt-loving. ML classifiers could help medical agencies achieve the early identification and classification of NAFLD, which is particularly useful for areas with poor economy, and the covariates' importance degree will be helpful to the prevention and treatment of NAFLD.

Ginsenoside Rg1 exerts anti‑apoptotic effects on non‑alcoholic fatty liver cells by downregulating the expression of SGPL1

Non‑alcoholic fatty liver disease (NAFLD) has a high incidence, and can lead to liver cirrhosis and even hepatocellular carcinoma in severe cases. To the best of our knowledge, there is currently no safe and effective treatment for the management of this disease. Ginsenoside Rg1 (Rg1) is an active monomer derived from ginseng and notoginseng. In the present study, HHL‑5 hepatocytes were used to establish an in vitro cell model of NAFLD by medium‑ and long‑chain fat emulsion treatment, and the effects of Rg1 on adipose accumulation, apoptosis and the expression levels of apoptosis‑related proteins in HHL‑5 hepatocytes were examined. The results demonstrated that Rg1 inhibited the accumulation of fat in HHL‑5 cells, while inhibiting apoptosis, and Rg1 downregulated the expression levels of the pro‑apoptotic protein Bax and upregulated the expression levels of the anti‑apoptotic protein Bcl‑2, indicating that Rg1 could promote the stability or integrity of mitochondria and exert an anti‑apoptotic effect by regulating Bcl‑2 family proteins. In addition, Rg1 markedly downregulated the expression levels of sphingosine‑1‑phosphate lyase 1 (SGPL1), a key enzyme in the sphingosine signaling pathway, in HHL‑5 cells with steatosis, and increased the expression levels of the downstream pro‑survival signals phosphorylated (p‑)Akt and p‑Erk1/2. Furthermore, overexpression of SGPL1 abolished the anti‑apoptotic effect of Rg1 on SGPL1‑overexpressing HHL‑5 cells with steatosis, and downregulated the expression levels of pro‑survival proteins, such as Bcl‑2, p‑Akt and p‑Erk1/2, whereas the expression levels of pro‑apoptotic Bax were markedly increased. In conclusion, although there are some reports regarding the protective effect of Rg1 on fatty liver cells, to the best of our knowledge, the present study is the first to report that Rg1 may exert an anti‑apoptotic effect on fatty liver cells by regulating SGPL1 in the sphingosine signaling pathway. Rg1 is the main component of the prescription drug Xuesaitong in China; therefore, the findings of the present study may provide a theoretical molecular basis for the use of Rg1 or Xuesaitong in the treatment of patients with NAFLD.

Preliminary Study on Risk Factors for Morbidity of Nonalcoholic Fatty Liver Disease in High-Income Male Population

OBJECTIVES

Believed to be a result of metabolic syndrome and unhealthy lifestyle, the incidence of nonalcoholic fatty liver disease (NAFLD) has become a serious public health problem. Among the high-income male population, metabolic syndrome and unhealthy lifestyle are particularly prominent. Therefore, we conducted a survey on 375 high-income male subjects, expecting to understand the risk factors and related factors for morbidity of NAFLD among the high-income male population being physically examined in Shanghai.

METHODS

A cross-sectional study was applied to 375 high-income male subjects (including 190 patients with NAFLD and 185 non-NAFLD subjects) who were examined in the special needs clinic at Huadong Hospital affiliated to Fudan University. In combination with medical history, physical examination, and laboratory test results and by use of a self-made NAFLD health questionnaire, the basic data of the research objects were collected and the obtained data were subject to a correlation analysis.

RESULTS

This study investigated 375 high-income males, and the morbidity rate of NAFLD was 50.67%. The NAFLD group was higher than the non-NAFLD group in terms of body weight, BMI, systolic blood pressure, and diastolic blood pressure (P < 0.05). Hypertension (OR = 2.944), diabetes (OR = 7.278), and hyperuricemia (OR = 1.922) are the risk factors for NAFLD; compared with no metabolic diseases, one (OR = 1.848), two (OR = 2.417), and three metabolic diseases (OR = 14.788) are risk factors for the development of NAFLD. Compared with the non-NAFLD group, the NAFLD group had a higher level of WBC, RBC, Hb, PLT, FPG, HbA1c, ALT, AST, GGT, ALP, TP, and UA (P < 0.05). There was a statistically significant difference in the intake of supper and staple foods between the NAFLD group and the non-NAFLD group, and the highly greasy diet was a risk factor for NAFLD (OR = 2.173) as opposed to the nongreasy diet.

CONCLUSION

High-income male population is a high-risk group of NAFLD. Most of the patients with NAFLD have abnormal biochemical indicators as opposed to the healthy population and are more likely to be complicated with other chronic diseases or abnormal health status. And the occurrence of hypertension, diabetes, and hyperuricemia is the risk factor for the development of NAFLD. At the same time, the number of metabolic diseases complicated is also a risk factor for NAFLD as compared with the absence of complications with such metabolic diseases. Compared with a diet that is not greasy, the fact that high-income male NAFLD patients have a very greasy diet increases the risk of NAFLD.

Prevalence and Risk Factors of Metabolic-Associated Fatty Liver Disease among 73,566 Individuals in Beijing, China

The prevalence of metabolic-associated fatty liver disease (MAFLD) is rarely reported in Beijing. The goal of this study was to estimate the prevalence and risk factors of MAFLD among Beijing adults aged ≥25 years old. A cross-sectional, community-based survey with multistage stratified cluster sampling was used. Demographic, transient elastography (TE), biochemical and blood examination information was collected in all the subjects in this study. The prevalence of MAFLD was 32.40% (23,832/73,566). Risk factors independently associated with MAFLD included male gender (OR = 1.47, 95%CI, 1.43–1.52), urban residence (OR = 1.06, 95% CI, 1.02–1.10), older age (30–39 years: OR = 1.29; 40–49 years: OR = 1.43; 50–59 years: OR = 1.09; ≥60 years: OR = 1.52) and lower education (middle school: OR = 2.03; high school: OR = 1.89; undergraduate: OR = 1.69). MAFLD was more common in females than in males after 50 years of age. Lean/normal weight MAFLD patients account for approximately 3.04% (724/23,832) of MAFLD. Compared to non-MAFLD subjects, the lean/normal MAFLD patients had a higher prevalence of hypertension and diabetes, and had a higher degree of hepatic steatosis and liver function enzymology parameters (all p < 0.001). MAFLD was highly prevalent among the general population aged ≥25 years old in Beijing. MAFLD was closely associated with male gender, older age, lower education and urban residence. Even lean/normal-weight people were under risk of MAFLD.

Dietary Vitamin C Intake Is Associated With Improved Liver Function and Glucose Metabolism in Chinese Adults

Background

Non-alcoholic fatty liver disease (NAFLD) is one of the most prevalent chronic liver diseases worldwide. Dietary vitamin C intake might play an important role in reducing the risk of NAFLD. This study assesses the relationship between dietary vitamin C intake and diagnostic biomarkers of NAFLD.

Methods

The data from the 2009 China Health and Nutrition Survey (CHNS), nine provinces across four diverse regions (Northeast, East Coast, Central, and West) were included in the study. The dietary vitamin C intake of participants was calculated based on 3-day 24-h diet questionnaires at the individual level. The associations of dietary vitamin C intake and the biochemical indicators of liver function and glucose/lipid metabolism were determined.

Results

A total of 8,307 participants were included in the final analysis. The mean dietary vitamin C intake for the overall, male and female subjects was 79.8 ± 58.6, 81.6 ± 55.3, and 78.2 ± 61.2 mg/day, respectively. The prevalence of inadequate dietary vitamin C intake for the overall, male and female subjects was 24.4, 26.5, and 22.6%, respectively. Intake of vitamin C was associated with both lower concentrations of plasma ferritin and hemoglobin A1c (HbA1c). Higher dietary vitamin C intake was associated with higher albumin, even further adjusted for body mass index (BMI), residence, and smoking status. No improvement in lipid metabolism was found.

Conclusion

This study demonstrated that higher dietary vitamin C intake is a benefit for improving glucose metabolism and liver function in which reducing ferritin, a biomarker of iron accumulation, may be involved.

A nationwide survey of the association between nonalcoholic fatty liver disease and the incidence of asthma in Korean adults

Background

Asthma and nonalcoholic fatty liver disease (NAFLD) are chronic diseases known to be associated with metabolic abnormalities. We aimed to clarify the association between NAFLD and asthma incidence in a large population-based cohort.

Methods and findings

We selected 160,603 individuals without comorbidities from the National Health Insurance Service-National Sample cohort between 2009 and 2014. NAFLD was defined using a surrogate marker, fatty liver index (FLI). During a median of 5.08 years’ follow-up, 16,377 subjects (10.2%) were newly diagnosed with asthma and categorized into three groups according to FLI. The cumulative incidence of asthma was higher in subjects with higher vs. lower FLIs (FLI < 30, 10.1%; 30 ≤ FLI < 60, 10.8%; FLI ≥ 60, 10.5%). Higher FLI was associated with an increased incidence of asthma (Hazard ratios (HR)_{highest vs. lowest FLI}, 1.25; 95% CI, 1.15–1.36). The results using another definition of NAFLD, as measured by the hepatic steatosis index (HSI), were similar to the primary results. This association was more pronounced in women than in men (HR 1.46; 95% CI, 1.13–1.64 vs. HR 1.07; 95% CI, 0.94–1.20).

Conclusions

This study demonstrated that NAFLD, as measured by FLI and HSI, may influence the incidence rates of asthma in adults, especially in women.

Non-alcoholic Fatty Liver Disease and Longitudinal Cognitive Changes in Middle-Aged and Elderly Adults

Background and Purpose

Non-alcoholic fatty liver disease (NAFLD) and cognitive impairment are common aging-related disorders. This study aims to explore the changes of cognitive function in middle-aged and elderly population with NAFLD from a Jidong impairment cohort.

Methods

A total of 1,651 middle-aged and elderly participants (&gt;40 years) without cognitive impairment were recruited into the current study in 2015 and were followed up until to 2019. Abdominal ultrasonography was used for diagnosis of NAFLD. Global cognitive function was assessed with the Mini-Mental State Examination (MMSE). Cognitive impairment was defined as a score &lt;18 for illiterates, a score &lt;21 for primary school graduates, and a score &lt;25 for junior school graduates or above. Multivariable regression analysis was performed to evaluate the association between NAFLD and the four-year cognitive changes.

Results

Out of 1,651 participants, 795 (48.2%) of them had NAFLD in 2015. Cognitive impairment occurred in 241 (14.6%) participants in 2019. Patients with NAFLD had higher 4-year incidence of cognitive impairment than non-NAFLD patients did (17.7 vs. 11.7%, p &lt; 0.001). Multivariable linear regression analysis showed significant association of baseline NAFLD with lower MMSE score in 2019 (β = −0.36, p &lt; 0.05). Multivariable logistic analysis found that the adjusted odds ratio (OR) with 95% confidence interval (CI) of baseline NAFLD was 1.45 (1.00–2.11) for cognitive impairment in 2019 (p = 0.05). We also identified effects of baseline NAFLD on subsequent cognitive impairment as modified by age (interaction p &lt; 0.01) and carotid stenosis (interaction p = 0.05) but not by gender.

Conclusions

NAFLD is associated with cognitive decline, especially in middle-aged and with carotid stenosis population.

Pharmacodynamic Evaluation of the Gexia Zhuyu Decoction in the Treatment of NAFLD and the Molecular Mechanism Underlying the TRPM4 Pathway Regulation

Nonalcoholic fatty liver disease (NAFLD) is a clinicopathological syndrome of abnormal lipid deposition in the liver mediated by nonalcohol intake. The Gexia Zhuyu decoction, a classic traditional Chinese medicine compound, is widely used in the clinical treatment of NAFLD. However, its specific efficacy and underlying mechanisms have not been elucidated yet. This study aimed to quantitatively evaluate the efficacy of the Gexia Zhuyu decoction using pharmacodynamics and to explore its molecular mechanisms in conjunction with proteomics. High-fat diets and methionine choline-deficient diets were used to induce various NAFLD progression stages in mouse models. The effects of oral Gexia Zhuyu decoction administration on NAFLD were evaluated by measuring the serum and liver indicators of the treated mice before and after drug intervention and by comparing the changes in liver tissue. Liver TRPM4 mRNA and protein levels were measured using reverse transcription-polymerase chain reaction and Western blotting, respectively. Experimental data showed that serum ALT, AST, and liver triglyceride (TG) levels in each disease stage group of drug intervention mice decreased, and high-density lipoprotein (HDL) and superoxide dismutase (SOD) levels increased. Liver TG levels decreased after drug intervention in the liver fibrosis mice, but serum TG levels increased. Furthermore, cellular fatty changes, inflammatory changes, and fibrous tissue proliferation were all relieved. The TRPM4 protein and mRNA levels in the liver tissue were decreased, and the microRNA (miRNA)-24 expression was increased. The Gexia Zhuyu decoction has a clear therapeutic effect at each stage of NAFLD. It likely acts by altering miRNA-24 expression and regulating the target TRPM4 protein pathway to achieve NAFLD treatment.

NFI, a clinical scoring tool for predicting non-alcoholic fatty liver in the Chinese population

OBJECTIVES

Accurate assessment of early non-alcoholic fatty liver disease (NAFLD) is important to reduce the possible complications. The purpose of the present study was to develop a simple algorithm for the screening of NAFLD in the Chinese population based on routine anthropometric data and laboratory tests.

STUDY DESIGN

This is a cross-sectional design.

METHODS

The subjects (1145) underwent routine physical examinations. The variables in the NAFLD index (NFI) were obtained by a stepwise multiple logistic regression analysis on 1000 bootstrap samples. The area under the receiver-operating characteristic (AUROC) was used to evaluate the accuracy of the NFI.

RESULTS

Multivariate analysis showed that body mass index, fasting blood glucose, ratio of alanine aminotransferase to aspartate aminotransferase, and triglyceride were included in the final equation. The AUROC of the NFI was 0.919 (95% confidence interval = 0.901-0.937). An NFI of <31.0 excluded the possibility of NAFLD with a sensitivity of 96.9%, and at a value of >36.0, the NFI could detect NAFLD with a specificity of 98.9%.

CONCLUSIONS

NFI was a cost-effective NAFLD-screening model, which had a high accuracy for predicting NAFLD at early stages in the Chinese population.

Association between non-alcoholic fatty liver disease with the susceptibility and outcome of COVID-19: A retrospective study

This study aims to evaluate the effect of non-alcoholic fatty liver disease (NAFLD) on the susceptibility and consequences of coronavirus disease 2019 (COVID-19). We retrospectively collected data from 218 adult COVID-19 patients who showed no evidence of excessive alcohol consumption and underwent abdominal ultrasound examinations. Of these patients, 39.4% patients had been diagnosed with NAFLD, which indicates a much higher prevalence of NAFLD than that reported in the general population. Significantly elevated white blood cell count (p = 0.008), alanine aminotransferase (p = 0.000), aspartate aminotransferase (p = 0.006) and C reactive protein (p = 0.012) were found in the patients with NAFLD. These patients also had significantly higher proportions of hypertension (p = 0.006) and diabetes (p = 0.049) than the non-NAFLD cases. No significant differences existed in the severity, mortality, viral shedding time and length of hospital stay between patients with or without NAFLD in the sample population. However, subgroup analyses found that in patients with normal body mass index (BMI), NAFLD sufferers were more likely to experience a severe event (30.0% vs 11.5%, p = 0.021). Kaplan-Meier curve (log-rank p = 0.017) and Cox regression (HR = 3.26, 95% CI: 1.17-9.04, p = 0.023) analyses confirmed that before and after adjusting for gender, age and comorbidities, NAFLD patients with normal BMI had a higher incidence of suffering severe events. People with NAFLD may have a higher proportion of COVID-19. NAFLD may be correlated with the severity of COVID-19 patients in the normal BMI group.

Risk factors and characteristics associated with nonalcoholic fatty liver disease in patients with ischemic colitis

BACKGROUND

Ischemic colitis (IC) was investigated to be associated with dyslipidemia and subcutaneous adipose tissue. Nonalcoholic fatty liver disease (NAFLD) is associated with ischemic diseases such as coronary heart disease, ischemic stroke. But there is a paucity of data regarding the association between NAFLD and IC. NAFLD may be associated with the treatment and prognosis of IC. We investigated risk factors and characteristics associated with NAFLD in patients with IC.

METHODS

Patients with IC (NAFLD: 34 and controls: 81) from Zhongnan Hospital were investigated retrospectively from January 2012 to December 2018. Clinical data were compared by chi-square tests or independent samples T-tests. Binary logistic regressions and Kaplan-Meier analysis were performed to evaluate risk factors and prognosis, respectively.

RESULTS

NAFLD was diagnosed in 28.19% patients with IC. In the logistic regression analysis, hypertension [odds ratio (OR) 3.523; P = 0.019], elevated alanine aminotransferase (ALT) (OR 6.278; P = 0.048), elevated triglyceride (OR 4.667; P = 0.003) and increased weight (OR 1.055; P = 0.039) were risk factors of NAFLD in patients with IC. Patients with NAFLD were more likely to require the vasodilators (P = 0.011) and get a relapse of IC (P = 0.011).

CONCLUSION

NAFLD was found in 28.19% of patients with IC. Hypertension, increased weight, elevated ALT and triglyceride are independent predictors of NAFLD in patients with IC. NAFLD in patients with IC is associated with a greater probability of requiring for the vasodilators. NAFLD in IC and period of bowel rest are risk factors for the recurrence of IC.

Use of GP73 in the diagnosis of non-alcoholic steatohepatitis and the staging of hepatic fibrosis

OBJECTIVE

To evaluate the utility of Golgi protein 73 (GP73) in the diagnosis of non-alcoholic steatohepatitis (NASH) and hepatic fibrosis (HF) staging.

METHODS

Ninety-one patients with non-alcoholic fatty liver disease (NAFLD) were allocated to NAFL (n = 46) and NASH (n = 45) groups according to their NAFLD activity score (NAS), and there were 30 healthy controls. Serum GP73 was measured by ELISA, GP73 protein expression was evaluated using immunohistochemistry, and FibroScan was used to determine liver hardness.

RESULTS

The serum GP73 concentrations of the NAFL and NASH groups were significantly higher than those of controls. GP73 expression in the liver of the patients gradually progressed from absent or low to moderate or high. Serum GP73 positively correlated with liver expression, and the serum and liver GP73 of the patients positively correlated with FibroScan value and HF stage. There was a strong positive correlation of the combination of alanine aminotransferase, gamma glutamyl transferase and GP73 with NASH. The combination of serum GP73 and FibroScan value was found to predict NASH (NAS > 4) and advanced HF (stage ≥2) in patients with NAFLD using receiver operating characteristic analysis.

CONCLUSION

Serum GP73 may be useful in the diagnosis of NASH and the staging of HF.

Main Risk Factors of Type 2 Diabetes Mellitus with Nonalcoholic Fatty Liver Disease and Hepatocellular Carcinoma

Type 2 diabetes mellitus (T2DM) with nonalcoholic fatty liver disease (NAFLD) is a pathological metabolic disease characterized by high ketone lipid based on abnormal lipid metabolism. Compared with patients with single T2DM or NAFLD, T2DM complicated with NAFLD has more complicated pathogenic factors and pathological processes. Hepatocellular carcinoma (HCC), the leading malignancy arising from cirrhosis, is the second most lethal cancer globally. The purpose of this study was to clarify the main risk factors of T2DM with NAFLD and HCC. There are many challenges in the diagnosis and treatment of T2DM patients with NAFLD and HCC. The current gold standard is to adjust treatment strategy, optimize metabolic control, and improve liver phenotype. It is necessary to identify further the risk factors driving the progression of T2DM with NAFLD and HCC and evaluate new therapeutic targets, in addition to exploring the syndromic forms of T2DM combined with NAFLD and providing a theoretical basis for early prevention, diagnosis, and treatment of the disease using traditional Chinese medicine (TCM).

The effect of turmeric on lipid profile, malondialdehyde, liver echogenicity and enzymes among patients with nonalcoholic fatty liver disease: a randomized double blind clinical trial

BACKGROUND

Nonalcoholic fatty liver disease (NAFLD) is one of the most common causes of liver transaminases elevation and a global health concern.

PURPOSE

This study designed to evaluate the effects of turmeric rhizomes (Curcumalonga Linn.) on liver enzymes, Lipid profiles and Malondialdehyde (MDA) in patients with NAFLD.

STUDY DESIGN

Randomized double-blind placebo controlled trial.

METHODS

64 cases of NAFLD randomly assigned to receive either turmeric (2 gr/day) or placebo for 8 weeks. The changes of liver transaminases, lipid profiles and MDA were measured before and after study period and compared between two groups (IRCT 2015092924262N1).

RESULTS

At the end of the study, the Turmeric group showed a significant reduction in liver enzymes (AST before 26.81 ± 10.54 after 21.19 ± 5.67, P = 0.044, ALT before 39.56 ± 22.41, after 30.51 ± 12.61, P = 0.043 and GGT before33.81 ± 17.50, after 25.62 ± 9.88, P = 0.046) compared with the placebo group. The serum levels of triglycerides, LDL, HDL and MDA had also a significant decrease among turmeric group as compared to baseline while there was no significant change in placebo group (P < 0.05). The serum cholesterol, VLDL level and sonographic grades of NAFLD had not any significant change in both groups.

CONCLUSION

In conclusion this study suggests that daily consumption of turmeric (and its active phenolic ingredients as curcumin) supplementation could be effective in management of NAFLD and decreasing serum level of liver transaminases.

Comprehensive Analysis of NAFLD and the Therapeutic Target Identified

Objective: Non-alcoholic fatty liver disease (NAFLD) is a serious health threat worldwide. The aim of this study was to comprehensively describe the metabolic and immunologic characteristics of NAFLD, and to explore potential therapeutic drug targets for NAFLD. Methods: Six NAFLD datasets were downloaded from the Gene Expression Omnibus (GEO) database, including GSE48452, GSE63067, GSE66676, GSE89632, GSE24807, and GSE37031. The datasets we then used to identify and analyze genes that were differentially expressed in samples from patients with NAFLD and normal subjects, followed by analysis of the metabolic and immunologic characteristics of patients with NAFLD. We also identified potential therapeutic drugs for NAFLD using the Connectivity Map (CMAP) database. Moreover, we constructed a prediction model using minimum depth random forest analysis and screened for potential therapeutic targets. Finally, therapeutic targets were verified in a fatty liver model stimulated by palmitic acid (PA). Results: A total of 1,358 differentially expressed genes (DEGs) were obtained, which were mainly enriched in carbohydrate metabolism, lipid metabolism, and other metabolic pathways. Immune infiltration analysis showed that memory B cells, regulatory T cells and M1 macrophage were significantly up-regulated, while T cells follicular helper were down regulated in NAFLD. These may provide a reference for the immune-metabolism interaction in the pathogenesis of NAFLD. Digoxin and helveticoside were identified as potential therapeutic drugs for NAFLD via the CMAP database. In addition, a five-gene prediction model based on minimum depth random forest analysis was constructed, and the receiver operating characteristic (ROC) curves of both training and validation set reached 1. The five candidate therapeutic targets were ENO3, CXCL10, INHBE, LRRC31, and OPTN. Moreover, the efficiency of hepatocyte adipogenesis decreased after OPTN knockout, confirming the potential use of OPTN as a new therapeutic target for NAFLD. Conclusion: This study provides a deeper insight into the molecular pathogenesis of NAFLD. We used five key genes to construct a diagnostic model with a strong predictive effect. Therefore, these five key genes may play an important role in the diagnosis and treatment of NAFLD, particularly those with increased OPTN expression.

Relationship between non-alcoholic fatty liver disease and cardiac arrhythmia: a systematic review and meta-analysis

Objective

We performed a meta-analysis to create a quantitative estimate of the association between non-alcoholic fatty liver disease (NAFLD) and the risk of cardiac arrhythmia (including atrial fibrillation (AF), prolonged QT interval, premature atrial/ventricular contraction [PAC/PVC] and heart block).

Methods

A literature review was conducted using PubMed, Embase, Web of Science and the Cochrane Library database to identify observational studies of the link between NAFLD and cardiac arrhythmia. Effect sizes were expressed as odds ratios (ORs) or hazard ratios (HRs) with 95% confidence intervals (CIs). The method of analysis of AF was also analysed separately, according to the effect estimate (OR or HR).

Results

Nineteen studies of 7,012,960 individuals were included. NAFLD was independently associated with higher risks of AF (OR 1.71, 95% CI: 1.14–2.57; HR 1.12, 95% CI: 1.11–1.13), prolonged QT interval (OR 2.86, 95% CI: 1.64–4.99), PAC/PVC (OR 2.53, 95% CI: 1.70–3.78) and heart block (OR 2.65, 95% CI: 1.88–3.72). The heterogeneity of the data with respect to AF and prolonged QT was moderate on sensitivity analysis.

Conclusions

We found a significantly higher risk of cardiac arrhythmia in patients with NAFLD, but the observational design of the studies does not permit conclusions regarding causality.

Circ_0057558 promotes nonalcoholic fatty liver disease by regulating ROCK1/AMPK signaling through targeting miR-206

Nonalcoholic fatty liver disease (NAFLD) is one of the most prevalent chronic liver disorders that is featured by the extensive deposition of fat in the hepatocytes. Current treatments are very limited due to its unclear pathogenesis. Here, we investigated the function of circ_0057558 and miR-206 in NAFLD. High-fat diet (HFD) feeding mouse was used as an in vivo NAFLD model and long-chain-free fatty acid (FFA)-treated liver cells were used as an in vitro NAFLD model. qRT-PCR was used to measure levels of miR-206, ROCK1 mRNA, and circ_0057558, while Western blotting was employed to determine protein levels of ROCK1, p-AMPK, AMPK, and lipogenesis-related proteins. Immunohistochemistry were performed to examine ROCK1 level. Oil-Red O staining was used to assess the lipid deposition in cells. ELISA was performed to examine secreted triglyceride (TG) level. Dual-luciferase assay was used to validate interactions of miR-206/ROCK1 and circ_0057558/miR-206. RNA immunoprecipitation was employed to confirm the binding of circ_0057558 with miR-206. Circ_0057558 was elevated while miR-206 was reduced in both in vivo and in vitro NAFLD models. miR-206 directly bound with ROCK1 3'-UTR and suppressed lipogenesis and TG secretion through targeting ROCK1/AMPK signaling. Circ_0057558 directly interacted with miR-206 to disinhibit ROCK1/AMPK signaling. Knockdown of circ_0057558 or overexpression of miR-206 inhibited lipogenesis, TG secretion and expression of lipogenesis-related proteins. ROCK1 knockdown reversed the effects of circ_0057558 overexpression. Injection of miR-206 mimics significantly ameliorated NAFLD progression in vivo. Circ_0057558 acts as a miR-206 sponge to de-repress the ROCK1/AMPK signaling and facilitates lipogenesis and TG secretion, which greatly contributes to NAFLD development and progression.

The Chinese Society of Hepatology position statement on the redefinition of fatty liver disease

Fatty liver disease associated with metabolic dysfunction is of increasing concern in mainland China, the world's most populous country. The incidence of fatty liver disease is highest in China, surpassing the incidence in European countries and the USA. An international consensus panel recently published an influential report recommending a novel definition of fatty liver disease associated with metabolic dysfunction. This recommendation includes a switch in name from non-alcoholic fatty liver disease (NAFLD) to metabolic (dysfunction)-associated fatty liver disease (MAFLD) and adoption of a set of positive criteria for disease diagnosis that are independent of alcohol intake or other liver diseases. Given the unique importance of this proposal, the Chinese Society of Hepatology (CSH) invited leading hepatologists and gastroenterologists representing their respective provinces and cities to reach consensus on alternative definitions for fatty liver disease from a national perspective. The CSH endorses the proposed change from NAFLD to MAFLD (supported by 95.45% of participants). We expect that the new definition will result in substantial improvements in health care for patients and advance disease awareness, public health policy, and political, scientific and funding outcomes for MAFLD in China.

Nutritional supplementation for nonalcohol-related fatty liver disease: a network meta-analysis

BACKGROUND

The prevalence of non-alcohol-related fatty liver disease (NAFLD) varies between 19% and 33% in different populations. NAFLD decreases life expectancy and increases risks of liver cirrhosis, hepatocellular carcinoma, and the requirement for liver transplantation. Uncertainty surrounds relative benefits and harms of various nutritional supplements in NAFLD. Currently no nutritional supplement is recommended for people with NAFLD.

OBJECTIVES

• To assess the benefits and harms of different nutritional supplements for treatment of NAFLD through a network meta-analysis • To generate rankings of different nutritional supplements according to their safety and efficacy SEARCH METHODS: We searched the Cochrane Central Register of Controlled Trials, MEDLINE, Embase, Science Citation Index Expanded, Conference Proceedings Citation Index-Science, the World Health Organization International Clinical Trials Registry Platform, and trials registers until February 2021 to identify randomised clinical trials in people with NAFLD.

SELECTION CRITERIA

We included only randomised clinical trials (irrespective of language, blinding, or status) for people with NAFLD, irrespective of method of diagnosis, age and diabetic status of participants, or presence of non-alcoholic steatohepatitis (NASH). We excluded randomised clinical trials in which participants had previously undergone liver transplantation.

DATA COLLECTION AND ANALYSIS

We performed a network meta-analysis with OpenBUGS using Bayesian methods whenever possible and calculated differences in treatments using hazard ratios (HRs), odds ratios (ORs), and rate ratios with 95% credible intervals (CrIs) based on an available-case analysis, according to National Institute of Health and Care Excellence Decision Support Unit guidance.

MAIN RESULTS

We included in the review a total of 202 randomised clinical trials (14,200 participants). Nineteen trials were at low risk of bias. A total of 32 different interventions were compared in these trials. A total of 115 trials (7732 participants) were included in one or more comparisons. The remaining trials did not report any of the outcomes of interest for this review. Follow-up ranged from 1 month to 28 months. The follow-up period in trials that reported clinical outcomes was 2 months to 28 months. During this follow-up period, clinical events related to NAFLD such as mortality, liver cirrhosis, liver decompensation, liver transplantation, hepatocellular carcinoma, and liver-related mortality were sparse. We did not calculate effect estimates for mortality because of sparse data (zero events for at least one of the groups in the trial). None of the trials reported that they measured overall health-related quality of life using a validated scale. The evidence is very uncertain about effects of interventions on serious adverse events (number of people or number of events). We are very uncertain about effects on adverse events of most of the supplements that we investigated, as the evidence is of very low certainty. However, people taking PUFA (polyunsaturated fatty acid) may be more likely to experience an adverse event than those not receiving an active intervention (network meta-analysis results: OR 4.44, 95% CrI 2.40 to 8.48; low-certainty evidence; 4 trials, 203 participants; direct evidence: OR 4.43, 95% CrI 2.43 to 8.42). People who take other supplements (a category that includes nutritional supplements other than vitamins, fatty acids, phospholipids, and antioxidants) had higher numbers of adverse events than those not receiving an active intervention (network meta-analysis: rate ratio 1.73, 95% CrI 1.26 to 2.41; 6 trials, 291 participants; direct evidence: rate ratio 1.72, 95% CrI 1.25 to 2.40; low-certainty evidence). Data were sparse (zero events in all groups in the trial) for liver transplantation, liver decompensation, and hepatocellular carcinoma. So, we did not perform formal analysis for these outcomes. The evidence is very uncertain about effects of other antioxidants (antioxidants other than vitamins) compared to no active intervention on liver cirrhosis (HR 1.68, 95% CrI 0.23 to 15.10; 1 trial, 99 participants; very low-certainty evidence). The evidence is very uncertain about effects of interventions in any of the remaining comparisons, or data were sparse (with zero events in at least one of the groups), precluding formal calculations of effect estimates. Data were probably because of the very short follow-up period (2 months to 28 months). It takes follow-up of 8 to 28 years to detect differences in mortality between people with NAFLD and the general population. Therefore, it is unlikely that differences in clinical outcomes are noted in trials providing less than 5 to 10 years of follow-up.

AUTHORS' CONCLUSIONS

The evidence indicates considerable uncertainty about effects of nutritional supplementation compared to no additional intervention on all clinical outcomes for people with non-alcohol-related fatty liver disease. Accordingly, high-quality randomised comparative clinical trials with adequate follow-up are needed. We propose registry-based randomised clinical trials or cohort multiple randomised clinical trials (study design in which multiple interventions are trialed within large longitudinal cohorts of patients to gain efficiencies and align trials more closely to standard clinical practice) comparing interventions such as vitamin E, prebiotics/probiotics/synbiotics, PUFAs, and no nutritional supplementation. The reason for the choice of interventions is the impact of these interventions on indirect outcomes, which may translate to clinical benefit. Outcomes in such trials should be mortality, health-related quality of life, decompensated liver cirrhosis, liver transplantation, and resource utilisation measures including costs of intervention and decreased healthcare utilisation after minimum follow-up of 8 years (to find meaningful differences in clinically important outcomes).

Liver Fibrosis Indices for the Prediction of Mortality in Korean Subjects: A 16-Year Prospective Cohort Study

Context

Nonalcoholic fatty liver disease (NAFLD) and its progression to liver fibrosis are related to higher mortality.

Objective

We investigated whether noninvasive indices of NAFLD and liver fibrosis could predict mortality in a Korean prospective cohort study.

Methods

We followed 4163 subjects from the Korean Genome and Epidemiology Study biannually over 16 years. Cox proportional hazards regression was used to calculate the hazard ratios (HRs) of NAFLD or liver fibrosis indices in the total group of subjects and subgroups according to body mass index (BMI) and glucose metabolism status.

Results

The mean age (± SD) of the subjects was 55.7 ± 8.7 years and 39.2% were men. During a median follow-up period of 15.6 years, 643 subjects (15.4%) died. The Fibrosis-4 (FIB-4), NAFLD fibrosis score (NFS), and aspartate aminotransferase to platelet ratio index were consistently higher in deceased subjects regardless of baseline glucose metabolism status. The FIB-4 and NFS displayed acceptable discrimination power for mortality, with area under the receiver operating characteristic curve values of 0.686 and 0.666, respectively. The adjusted HRs for FIB-4 and NFS were 1.41 (95% CI, 1.18-1.68) and 1.43 (95% CI, 1.21-1.68), respectively. Both FIB-4 and NFS were significantly associated with liver-specific mortality but not cardiovascular mortality. The association between mortality with fibrosis indices were more prominent in subjects with a lower BMI (<25 kg/m²).

Conclusion

Noninvasive indices of liver fibrosis might be a significant predictor of all-cause and liver-specific mortality in Korean subjects.

Lifestyle modifications for nonalcohol-related fatty liver disease: a network meta-analysis

BACKGROUND

The prevalence of nonalcohol-related fatty liver disease (NAFLD) varies between 19% and 33% in different populations. NAFLD decreases life expectancy and increases the risks of liver cirrhosis, hepatocellular carcinoma, and requirement for liver transplantation. There is uncertainty surrounding the relative benefits and harms of various lifestyle interventions for people with NAFLD.

OBJECTIVES

To assess the comparative benefits and harms of different lifestyle interventions in the treatment of NAFLD through a network meta-analysis, and to generate rankings of the different lifestyle interventions according to their safety and efficacy.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, Science Citation Index Expanded, Conference Proceedings Citation Index - Science, World Health Organization International Clinical Trials Registry Platform, and trials registers until February 2021 to identify randomised clinical trials in people with NAFLD.

SELECTION CRITERIA

We included only randomised clinical trials (irrespective of language, blinding, or status) in people with NAFLD, whatever the method of diagnosis, age, and diabetic status of participants, or presence of non-alcoholic steatohepatitis (NASH). We excluded randomised clinical trials in which participants had previously undergone liver transplantation.

DATA COLLECTION AND ANALYSIS

We planned to perform a network meta-analysis with OpenBUGS using Bayesian methods and to calculate the differences in treatments using hazard ratios (HRs), odds ratios (ORs), and rate ratios (RaRs) with 95% credible intervals (CrIs) based on an available-participant analysis, according to National Institute of Health and Care Excellence Decision Support Unit guidance. However, the data were too sparse for the clinical outcomes. We therefore performed only direct comparisons (head-to-head comparisons) with OpenBUGS using Bayesian methods.

MAIN RESULTS

We included a total of 59 randomised clinical trials (3631 participants) in the review. All but two trials were at high risk of bias. A total of 33 different interventions, ranging from advice to supervised exercise and special diets, or a combination of these and no additional intervention were compared in these trials. The reference treatment was no active intervention. Twenty-eight trials (1942 participants) were included in one or more comparisons. The follow-up ranged from 1 month to 24 months. The remaining trials did not report any of the outcomes of interest for this review. The follow-up period in the trials that reported clinical outcomes was 2 months to 24 months. During this short follow-up period, clinical events related to NAFLD such as mortality, liver cirrhosis, liver decompensation, liver transplantation, hepatocellular carcinoma, and liver-related mortality were sparse. This is probably because of the very short follow-up periods. It takes a follow-up of 8 years to 28 years to detect differences in mortality between people with NAFLD and the general population. It is therefore unlikely that differences by clinical outcomes will be noted in trials with less than 5 years to 10 years of follow-up. In one trial, one participant developed an adverse event. There were no adverse events in any of the remaining participants in this trial, or in any of the remaining trials, which seemed to be directly related to the intervention.

AUTHORS' CONCLUSIONS

The evidence indicates considerable uncertainty about the effects of the lifestyle interventions compared with no additional intervention (to general public health advice) on any of the clinical outcomes after a short follow-up period of 2 months to 24 months in people with nonalcohol-related fatty liver disease. Accordingly, high-quality randomised clinical trials with adequate follow-up are needed. We propose registry-based randomised clinical trials or cohort multiple randomised clinical trials (a study design in which multiple interventions are trialed within large longitudinal cohorts of participants to gain efficiencies and align trials more closely to standard clinical practice), comparing aerobic exercise and dietary advice versus standard of care (exercise and dietary advice received as part of national health promotion). The reason for the choice of aerobic exercise and dietary advice is the impact of these interventions on indirect outcomes which may translate to clinical benefit. The outcomes in such trials should be mortality, health-related quality of life, decompensated liver cirrhosis, liver transplantation, and resource use measures including costs of intervention and decreased healthcare use after a minimum follow-up of eight years, to find meaningful differences in the clinically important outcomes.

The circadian syndrome predicts cardiovascular disease better than metabolic syndrome in Chinese adults

BACKGROUND

To compare the predictive value of the circadian syndrome (CircS) and Metabolic syndrome (MetS) for cardiovascular disease.

METHOD

We used the data of 9360 Chinese adults aged ≥40 years from the 2011 China Health and Retirement Longitudinal Study (CHARLS). Of the participants, 8253 people were followed in the 2015 survey. MetS was defined using the harmonized criteria. CircS was based on the components of the International Diabetes Federation (IDF) MetS plus short sleep and depression. The cut-off for CircS was set as ≥4. Multivariable logistic regression analysis was used to examine the associations.

RESULTS

The prevalence of CircS and MetS was 39.0% and 44.7%. Both MetS and CircS were directly associated with prevalent CVD. The odds ratios for prevalent CVD comparing CircS with MetS, respectively, were 2.83 (95%CI 2.33-3.43) and 2.34 (1.93-2.83) in men, and 2.33 (1.98-2.73) and 1.79 (1.53-2.10) in women. Similar associations were found for incident CVD. The five-year incidence of CVD was 15.1% in CircS and 14.0% in MetS. The number of CircS components has a better predictive power for both prevalent and incident CVD than those of Mets components as indicated by the area under the ROC (AUC). AUC values for CVD in 2011 were higher for CircS than MetS in both men (0.659 (95%CI 0.634-0.684) vs 0.635 (95%CI 0.610-0.661)) and women (0.652 (95%CI 0.632-0.672) vs 0.619 (95%CI 0.599-0.640)).

CONCLUSION

The circadian syndrome is a strong and better predictor for CVD than the metabolic syndrome in Chinese adults.

Fatty Liver Disease Prediction Model Based on Big Data of Electronic Physical Examination Records

Fatty liver disease (FLD) is a common liver disease, which poses a great threat to people's health, but there is still no optimal method that can be used on a large-scale screening. This research is based on machine learning algorithms, using electronic physical examination records in the health database as data support, to a predictive model for FLD. The model has shown good predictive ability on the test set, with its AUC reaching 0.89. Since there are a large number of electronic physical examination records in most of health database, this model might be used as a non-invasive diagnostic tool for FLD for large-scale screening.

Expert Opinion on the Management of Non-Alcoholic Fatty Liver Disease (NAFLD) in the Middle East with a Focus on the Use of Silymarin

Non-alcoholic fatty disease (NAFLD) is amongst the leading causes of chronic liver disease worldwide. The prevalence of NAFLD in the Middle East is 32%, similar to that observed worldwide. The clinicians in this region face several challenges in diagnosing and treating patients with NAFLD. Additionally, there are no national or regional guidelines to address the concerns faced with current treatment options. Silymarin, derived from milk thistle, provides a rational and clinically proven approach to hepatoprotection. This article focuses on addressing regional diagnostic challenges and provides clear guidance and potential solutions for the use of Silymarin in the treatment of NAFLD in the Middle East. Both clinical and preclinical studies have highlighted the efficiency of Silymarin in managing NAFLD by reducing liver disease progression and improving patient symptoms and quality of life, alongside being safe and well tolerated. An expert panel of professionals from the Middle East convened to establish a set of regional-specific diagnostics. A consensus was established to aid general physicians to address the diagnostic challenges in the region. In conclusion, Silymarin can be considered beneficial in treating NAFLD and should be initiated as early as possible and continued as long as necessary.

Associations Between Nonalcoholic Fatty Liver Disease and Cancers in a Large Cohort in China

BACKGROUND & AIMS

The relationship between nonalcoholic fatty liver disease (NAFLD) and cancer, especially extrahepatic cancers, has not been fully clarified. We analyzed data from a large prospective cohort study to determine the relationship between NAFLD and development of cancers in men.

METHODS

We collected data from the Kailuan cohort, a community-based cohort of 54,187 adult men in China, from June 2006 through October 2007. NAFLD was diagnosed by ultrasonography after excluding other causes related to chronic liver disease. Fine and Gray competing risk regression model was used to evaluate associations between NAFLD (without cirrhosis) and cancers.

RESULTS

The prevalence of NAFLD was 32.3%. NAFLD was associated with increased risk of all cancers (hazard ratio [HR], 1.22; 95% CI, 1.10-1.36; P = .0001), thyroid cancer (HR, 2.79; 95% CI, 1.25-6.21; P = .01), and lung cancer (HR, 1.23; 95% CI, 1.02-1.49; P = .03). The association between NAFLD and risk of thyroid cancer increased with level of alanine aminotransferase (ALT). In men with NAFLD, level of ALT 80 U/L or more was associated with hepatocellular carcinoma (HR, 8.08; 95% CI, 2.46-26.56; P = .0006). NAFLD increased risk of colorectal cancer (HR, 1.96; 95% CI, 1.17-3.27) and lung cancer (HR, 1.38; 95% CI, 1.03-1.84) only in smokers. An association between NAFLD and kidney cancer (HR, 1.57; 95% CI, 1.03-2.40) was only observed in men without diabetes.

CONCLUSIONS

A cohort study from China found that men with NAFLD have a higher risk of extrahepatic cancers, including thyroid and lung cancer. In men with NAFLD, higher levels of ALT were associated with higher risk of thyroid and hepatocellular cancer. NAFLD increased risk of colorectal and lung cancer only in smokers, and increased risk of kidney cancer in men without diabetes.

High-normal thyroid function predicts incident non-alcoholic fatty liver disease among middle-aged and elderly euthyroid subjects

BACKGROUND

Thyroid hormones (THs) influence hepatic lipid homeostasis through multiple pathways, suggesting that THs may predict the risk of non-alcoholic fatty liver disease (NAFLD). However, prospective studies on the association between THs levels and incident NAFLD in euthyroid subjects are limited. This prospective cohort study aimed to explore whether THs were associated with the development of NAFLD in middle-aged and elderly euthyroid subjects.

METHODS

A total of 6,462 subjects without baseline NAFLD were included in the cohort study (~6-year follow-up period, median: 4.2 years). Chemiluminescence immunoassay was used to measure serum free triiodothyronine (FT3), free thyroxine (FT4), and thyroid-stimulating hormone (TSH), and NAFLD was diagnosed by abdominal ultrasonography. Multivariable Cox proportional hazards regression models were used to assess the association between baseline THs, TSH, and the risk of NAFLD.

RESULTS

During the follow-up period, 1,675 subjects developed NAFLD. The incidence rate of NAFLD was 85.0 per 1000 person-years. Compared with the lowest FT3, FT4, and TSH quartiles, the multivariable-adjusted hazard ratios (95% confidence interval) of incident NAFLD for highest quartiles were 1.30 (1.12, 1.51), 1.07 (0.93, 1.23), 0.82 (0.71, 0.95) (P <0.001, =0.56, =0.01, respectively), respectively.

CONCLUSIONS

In middle-aged and elderly euthyroid subjects, high-normal FT3 and low-normal TSH are independently associated with a higher incidence of NAFLD.

Role of Noninvasive Tests in Clinical Gastroenterology Practices to Identify Patients With Nonalcoholic Steatohepatitis at High Risk of Adverse Outcomes: Expert Panel Recommendations

Nonalcoholic fatty liver disease (NAFLD) is generally considered a silent and potentially reversible condition. The subtype of NAFLD that can be classified as nonalcoholic steatohepatitis (NASH) can progress to advanced fibrosis and cirrhosis. Because of the metabolic nature of the pathogenic mechanism underlying NAFLD and NASH, it is often accompanied by common comorbidities such as obesity, insulin resistance, and type 2 diabetes mellitus. The increase in the prevalence of these comorbidities has resulted in a parallel increase in the prevalence of NAFLD and NASH, globally, nationally, and even in children. In recent years, it has been identified that the stage of fibrosis is the most important predictor of liver outcomes; therefore, identifying patients with NAFLD and NASH with more advanced stages of fibrosis can be essential for optimal management. Several noninvasive tools for diagnosing and staging NAFLD and NASH are available, but simple and straightforward recommendations on the use of these tools are not. Recognizing these unmet needs, hepatologists who are members of the American College of Gastroenterology and the Chronic Liver Disease Foundation created a practical decision tree/algorithm to risk stratify NAFLD/NASH as a resource in gastroenterology/hepatology clinical practices. This review will provide insight into how this algorithm was developed, describe it in detail, and provide recommendations for its use in clinical practice.

Nonalcoholic Fatty Liver Disease: A Global Perspective

The prevalence of nonalcoholic fatty liver disease (NAFLD) has been increasing over the years and is now as high in Asia as in the Western world, so much so that it should no longer be considered a Western disease. In fact, China is expected to have the largest increase in the number of NAFLD cases in the coming years. The increase in prevalence of NAFLD in Asia lags behind that of the Western world; thus, there will be a lag in more severe liver disease in Asia despite a similar prevalence of the disease. NAFLD is more prevalent among patients with diabetes mellitus, which is also an important risk factor for more severe liver disease. Patients with diabetes mellitus thus represent an important target for screening for NAFLD and more severe liver disease. Although the PNPLA3 gene polymorphism is the most studied in NAFLD, it is increasingly clear that the cumulative effect of multiple genes likely predisposes to NAFLD and more severe liver disease in the different ethnic groups, and polygenic risk scores are emerging. Lean NAFLD has been largely reported in Asia but is increasingly recognized worldwide. Multiple risk factors have been identified for the disease that manifests in metabolically unhealthy normal weight individuals; however, it responds to lifestyle intervention, similar to the disease in obese individuals. Lastly, the newer term "metabolic dysfunction-associated fatty liver disease" provides a more accurate reflection of the disease, giving more focus to clinicians and researchers in tackling this increasingly common and challenging disease.

Prevalence of nonalcoholic fatty liver disease in mental disorder inpatients in China: an observational study

Background and Purpose

Non-alcoholic fatty liver disease (NAFLD) is becoming the most common liver disease in China. However, the understanding of NAFLD prevalence among Chinese mental disorder inpatients remains insufficient. We aim to investigate the prevalence of NAFLD among mental disorder inpatients in Beijing, China.

Methods

In this observational study, we included 66,273 mental disorder inpatients between 2014 and 2018, including inpatients with schizophrenia, bipolar disorder, depressive disorder and other mental disorders. Data were obtained from electronic health records of 19 specialized psychiatric hospitals in Beijing. NAFLD was defined by ICD-10 code, excluding other causes of liver disease. We calculated the overall and annual prevalence rates of NAFLD from 2014 to 2018, and compared NAFLD prevalence between sexes, age groups, mental disorders types, antipsychotics use, and comorbidities. Multivariable logistic regression was used to examine risk factors associated with NAFLD. Subgroup analysis was performed in different mental disorder types.

Results

The prevalence of NAFLD was 17.63% (95% CI 17.34–17.92%) in mental disorder inpatients, increasing from 16.88% in 2014 to 19.07% in 2018. The NAFLD prevalence in participants with schizophrenia (22.44%) was higher than that in participants with bipolar disorder (17.89%), depressive disorder (12.62%), and other mental disorders (12.99%). Women had similar or even higher NAFLD prevalence than men after 50 years. Men, 50–59 years (aOR = 1.71), schizophrenia (aOR = 1.56), bipolar disorder (aOR = 1.47), antipsychotics use (aOR = 1.46), hypertension (aOR = 1.50), diabetes (aOR = 1.83), dyslipidemia (aOR = 2.50) were risk factors for NAFLD in mental disorder inpatients.

Conclusion

NAFLD was common among Chinese mental disorder inpatients, and increased over years. The prevalence of NAFLD was higher among men, old women, inpatients with schizophrenia, bipolar disorder, antipsychotics, hypertension, diabetes, and dyslipidemia. Fatty liver disease among mental disorder population warrants the attention of psychiatric specialists and health policy-makers.

Supplementary Information

The online version contains supplementary material available at 10.1007/s12072-020-10132-z.

Identification of Hepatic Steatosis in Premenopausal and Postmenopausal Women Based on Phenotypes Combining Triglyceride Levels and Anthropometric Indices: A Cross-Sectional Study

BACKGROUND

The hypertriglyceridemic waist phenotype (HWP) has exhibited a strong association with metabolic syndrome, a condition closely linked with nonalcoholic fatty liver disease (NAFLD). However, no study has investigated whether the HWP can accurately predict NAFLD among premenopausal and postmenopausal women or whether alternative anthropometric indexes could replace waist circumference (WC) in the HWP. We examined the power of phenotypes combining triglyceride (TG) levels with anthropometric indexes such as body mass index (BMI), WC, waist-to-hip ratio, waist-to-height ratio, and percent body fat, to detect NAFLD among premenopausal and postmenopausal women.

METHODS

We conducted a cross-sectional study of 1125 premenopausal women and 654 postmenopausal women who had received an annual health checkup. For all the participating women, we measured both anthropometric and biochemical indexes, such as serum lipid levels. NAFLD diagnoses were made on the basis of abdominal ultrasonography findings. The receiver operating characteristic curve and area under the curve (AUC) were used to evaluate the indicators' ability to detect NAFLD.

RESULTS

Among the indicators of hepatic steatosis, the combined phenotypes of TG level (≥1.50 mmol/L) and BMI (≥24.0 kg/m²) exhibited the largest AUC (0.841, 95%confidence interval [CI] 0.812-0.871, P< 0.001) for premenopausal women, whereas WC alone exhibited the highest predictive potential (0.765, 95% CI 0.729-0.801, P< 0.001) for postmenopausal women.

CONCLUSION

Out of all the phenotypes combining a single anthropometric index with TG level or WC and TG level, the combination of TG level and BMI was the best indicator of NAFLD for premenopausal women. For screening NAFLD in postmenopausal women, WC alone was superior to all other indicators.