Studies on non-alcoholic fatty liver disease should stratify by disease severity

Association Between Non-alcoholic Fatty Liver Disease and Risk of Stroke: A Systematic Review and Meta-Analysis

Background/Objectives

Recent observational studies have explored the association between non-alcoholic fatty liver disease (NAFLD) and stroke with controversial results. We therefore performed a meta-analysis to investigate this possible association.

Methods

PubMed, EMBASE and Web of Science database were searched from inception until December 2019, and updated on May 2021. Random-effects meta-analyses were performed by generic inverse variance method. Subgroup and sensitivity analyses were also conducted. The PROSPERO registered number of this study is CRD42020167330.

Results

Twenty observational (15 cohort, 4 cross-sectional, and 1 case-control) studies with 17,060,388 participants were included in the meta-analysis. Meta-analysis of data from 18 studies with 17,031,672 participants has shown that NAFLD was associated with mildly increased risk of stroke (OR = 1.18, 95% CI: 1.08–1.30, P = 0.0005). Similar results were observed in most of the subgroup analyses we performed. Sensitivity analyses did not alter these findings. Meta-analysis of data from 3 studies with 29,614 participants has shown that insufficient evidence to support the proposed association between NAFLD-fibrosis and an increased risk of stroke.

Conclusions

We found that NAFLD was associated with increased risk of stroke. However, there was insufficient evidence to support the proposed association between NAFLD-fibrosis and an increased risk of stroke. To better understand any association, future well-designed prospective studies that take fully account of specific population, type of stroke, and confounding factors are warranted.

Systematic Review Registration

Unique Identifier: CRD42020167330.

National digestive disease specialists survey on cardiovascular risk management in non-alcoholic fatty liver disease in spanish hospitals

BACKGROUND & AIMS

Cardiovascular disease (CVD) is the main cause of mortality among non-alcoholic fatty liver disease (NAFLD) patients. The aim was to explore the level of knowledge and clinical management of cardiovascular risk (CVR) in NAFLD patients by Digestive Disease specialists.

METHODS

An anonymous web-based survey was designed with 44 close-ended questions, divided into five sections, that were based on current guidelines on CVD prevention. Between November 2019 and January 2020, Digestive Disease specialists from Spanish hospitals were invited to participate in this survey via email and Twitter. Student's t, chi-square and Fishers' exact tests, and logistic regression were used for data analysis.

RESULTS

208 clinicians completed the survey. Most respondents (83.2%) believe that NAFLD is an independent risk factor for CVD, especially in the presence of NASH and fibrosis. Personal history of CVDs and cardiovascular risk-related comorbidities are collected by more than 75% of respondents. However, less than 17% perform an elementary physical examination to address the CVR, except weight which is evaluated by 69.8%. Over 54% of respondents do not perform or request any supplementary tests for CVR assessment, and only 10.2% use specific calculators. Furthermore, 54.3% spend less than 5 minutes giving lifestyle advice, and more than 52% do not start drug treatment after a recent diagnosis of any cardiovascular comorbidity. Only 25.6% have a multidisciplinary Unit for metabolic comorbidities in their hospitals, although 89% of the respondents would support the implementation of this Unit.

CONCLUSIONS

Cardiovascular risk management in daily clinical practice by Digestive Disease specialists in Spain remains suboptimal.

Severity of Nonalcoholic Fatty Liver Disease and Risk of Future Ischemic Stroke Events

BACKGROUND AND PURPOSE

We assessed prospectively whether nonalcoholic fatty liver disease (NAFLD) and its severity predict future ischemic stroke (IS) events in a community-based cohort.

METHODS

From the Kailuan study, participants free of history of stroke, cancer, or myocardial infarction were enrolled after excluding alcohol abuse and other liver diseases. NAFLD was evaluated through ultrasonography. Participants with NAFLD were further stratified into mild, moderate, and severe groups. The outcome was the first occurrence of IS. The secondary outcomes included myocardial infarction and combined vascular events. We used Cox proportional hazards models to estimate hazard ratios and 95% CIs of incident IS according to presence and severity of NAFLD, adjusting for age, sex, physical activity, body mass index, smoker, history of hypertension, diabetes, hypercholesterolemia, lipid-lowering medication, HDL (high-density lipoprotein), triglyceride, hsCRP (high-sensitivity C-reactive protein), and fasting blood glucose.

RESULTS

During a median of 10.34 years of follow-up, we documented 3490 incident stroke cases among 79 905 participants. NAFLD was found in 24 874 (31.18%) participants. Relative to participants without NAFLD at the baseline, those with NAFLD had a 16% higher risk (95% CI, 1.07-1.26) of developing ischemic stroke, after adjusted for confounding variables. The hazard ratios for patients with mild, moderate, and severe NAFLD were 1.15 (95% CI, 1.05-1.25), 1.19 (95% CI, 1.06-1.34), and 1.21 (95% CI, 1.08-1.50), respectively.

CONCLUSIONS

The severity of NAFLD is associated with a higher risk of future ischemic stroke events.