Development and validation of a simple NAFLD clinical scoring system for identifying patients without advanced disease

Cardiovascular events and incident diabetes in 220 patients with MASLD according to basal liver fibrosis: a 10-year follow-up historic cohort

AIM

The aim of this study is to analyze association between liver fibrosis with CVE, incident diabetes, and cirrhosis complications.

METHODS

Historic cohort of biopsy-proven MASLD patients, divided into two groups: F0-F2 vs F3-F4 fibrosis. Baseline data included metabolic traits and liver function tests. Patients were contacted and scheduled for laboratory analysis and elastography. Endpoints were (a) CVE, defined as any of acute myocardial infarction, coronary stenting, ischemic cardiopathy, and stroke; (b) incident diabetes; (c) cirrhosis complications. Baseline data were collected at the time of liver biopsy, while follow-up data were recovered through personal interview or medical records. A stepwise logistic regression determined predictive variables for each endpoint.

RESULTS

Study population included 220 patients with median age 53 years, and 145 were women; baseline fibrosis was F0-F2 in 165 patients and F3-F4 in 55 patients; median follow-up was 9.9 years. A higher percentage of F3-F4 patients had CVE (29.4%) than F0-F2 ones (13.1%) (hazard ratio 2.42; 95% CI: 1.26-4.6; P  = 0.008). Incident diabetes occurred in 53.3% of F3-F4 and 20.2% of F0-F2 cohort (hazard ratio 3.04; 95% CI: 1.99-4.86; P  < 0.001); cirrhosis complications occurred in 9/55 F3-F4 patients and in 1/165 F0-F2 ones (hazard ratio 26.3; 95% CI: 3.3-208.3; P  = 0.002). Multivariate analysis confirmed liver fibrosis as an independent predictor of incident diabetes and cirrhosis complications. CVE were associated with baseline diabetes and aspartate aminotransferase (AST)/alanine aminotransferase (ALT) ratio.

CONCLUSION

In a cohort of 220 MASLD patients followed for 9.9 years, baseline F3-F4 was associated with incident diabetes and cirrhosis complications. AST/ALT ratio and diabetes were associated with CVE.

Enhancing outcome prediction in patients with colorectal liver metastases undergoing hepatectomy: the synergistic impact of FIB-4 index and tumor burden score across KRAS profiles

BACKGROUND

The prognostic value of Fibrosis-4 (FIB-4) index, concerning KRAS status (wild-type [wtKRAS] vs. mutated [mutKRAS]) remains unclear in post-hepatectomy colorectal liver metastases (CRLM). We evaluated the combined impact of FIB-4 and Tumor Burden Score (TBS) on overall survival (OS)/recurrence-free survival (RFS), stratified by KRAS status.

METHODS

CRLM patients undergoing hepatectomy (2000-2020) were analyzed, grouped by TBS/FIB-4.

RESULTS

Among 828 patients, 196 had high FIB-4. High TBS had worse 5-year OS (P < 0.001). In wtKRAS, high TBS correlated with worse OS (P < 0.001), but not in mutKRAS. High FIB-4 correlated with worse OS (P = 0.01). Sub-stratification showed no OS difference by FIB-4 in wtKRAS, but a difference in mutKRAS (P = 0.03). Multivariable analysis identified mutKRAS (HR: 1.90), high TBS (HR: 1.62), and FIB-4 (HR: 1.15) as mortality risk factors. The TBS-FIB-4-KRAS index had highest predictive accuracy. For RFS, TBS and FIB-4 independently stratified outcomes. High TBS was associated with worse RFS in wtKRAS (P < 0.001) but not in mutKRAS. High FIB-4 decreased RFS in mutKRAS (P = 0.001) but not in wtKRAS. FIB-4 was associated with a 10% increased recurrence risk.

CONCLUSION

TBS and FIB-4, alongside KRAS status, should be considered to improve outcome predictions.

Impact of steatotic liver disease categories on atrial fibrillation in type 2 diabetes: a nationwide study

This study aims to investigate the incidence of new-onset atrial fibrillation (AF) in individuals with type 2 diabetes mellitus (T2DM) across different categories of steatotic liver disease (SLD). Using a health examination database between 2009 and 2012, this study included 2,480,880 patients. Participants were categorized into five groups based on hepatic steatosis (fatty liver index ≥ 60), cardiometabolic risk factors, and alcohol consumption. Cox regression analyses were performed. The metabolic dysfunction-associated steatotic liver disease (MASLD) group showed an increased risk of new-onset AF (adjusted hazard ratio (aHR), 1.10; 95% confidence interval (CI), 1.08-1.11). The MASLD with other combined group demonstrated increased AF development (aHR, 1.22; 95% CI, 1.18-1.26). In metabolic dysfunction and alcohol-related steatotic liver disease (MetALD) and alcohol-related liver disease (ALD) with metabolic groups, heavy to excessive alcohol consumption increased the risk of AF incidence, with the highest aHR associated with greater alcohol intake (aHR, 1.26; 95% CI, 1.22-1.29, 1.48; 95% CI, 1.41-1.55). MASLD increased the risk of AF in patients with T2DM, with a higher risk observed when accompanied by other liver diseases. Alcohol consumption was associated with proportional increase in the risk of AF, with excessive alcohol consumption associated with the highest risk of AF.

Perirenal fat area is a preoperative predictor of hypertension resolution after laparoscopic sleeve gastrectomy: Generalized additive models

BACKGROUND

Laparoscopic sleeve gastrectomy (LSG) can lead to complete resolution of hypertension in most patients with obesity within one year. However, the preoperative factors related to this resolution are still unclear.

AIM

To clarify the impact of relevant factors, particularly perirenal fat, on postoperative hypertension resolution.

METHODS

In this retrospective single-center study, a total of 138 patients with obesity and hypertension were included, all of whom underwent LSG in the hospital and were followed up for one year. Multivariate logistic regression models were used to identify independent risk factors for postoperative hypertension resolution. Generalized additive models were employed to clarify the nonlinear relationships between these factors and hypertension resolution, and their predictive values were compared using fivefold cross-validation.

RESULTS

After LSG, 107 patients (77.5%) experienced hypertension resolution, while 31 patients (22.5%) did not achieve resolution. Both the preoperative perirenal fat area (PrFA) and perirenal fat thickness were independent risk factors for postoperative hypertension resolution (P < 0.001 vs P = 0.002). These factors are curvilinearly correlated with the hypertension resolution rate, but PrFA has a better predictive value than perirenal fat thickness dose (area under the curve = 0.846 vs 0.809). Compared with those with PrFA ≥ 18 cm2, patients with PrFA < 18 cm2 had a higher hypertension resolution rate [87% vs 68.1%; odds ratio (95% confidence interval) = 3.513 (1.367-9.902), P = 0.012].

CONCLUSION

PrFA is a preoperative predictor of postoperative hypertension resolution. It is curvilinearly associated with the resolution rate, and patients with PrFA < 18 cm² have better hypertension resolution outcomes after LSG.

Development and validation of a scoring system to predict MASLD patients with significant hepatic fibrosis

To address the need for a simple model to predict ≥ F2 fibrosis in metabolic dysfunction-associated steatotic liver disease (MASLD) patients, a study utilized data from 791 biopsy-proven MASLD patients from the NASH Clinical Research Network and Jinan University First Affiliated Hospital. The data were divided into training and internal testing sets through randomized stratified sampling. A multivariable logistic regression model using key categorical variables was developed to identify ≥ F2 fibrosis. External validation was performed using data from the FLINT trial and multiple centers in China. The DA-GAG score, incorporating diabetes, age, GGT, aspartate aminotransferase/ platelet ratio, and globulin/ total protein ratio, demonstrated superior performance in distinguishing ≥ F2 fibrosis with an area under the receiver operating characteristic curve of 0.79 in training and over 0.80 in testing datasets. The DA-GAG score efficiently identifies MASLD patients with ≥ F2 fibrosis, significantly reducing the medical burden.

Clinical utility of liver function tests for resolution of metabolic dysfunction-associated steatotic liver disease after weight loss in the Diabetes Remission Clinical Trial

AIMS

Ectopic fat is reduced by effective weight management, but difficult to assess clinically.

METHODS

We evaluated paired data on 42 participants in the intervention group of the Diabetes Remission Clinical Trial (DiRECT) at baseline, 12 and 24 months after weight loss as indicators of liver fat content measured by 3-point Dixon MRI.

RESULTS

Baseline liver fat was elevated at 13.0 [7.8-23.3]% with fasting plasma glucose 7.9 [7.1-10.1] mmol/L. Prevalence of baseline MASLD was 86.4%. After weight loss of 11.9 ± 1.2 kg (0-37 kg) at 12 months, remission of MASLD occurred in 74% and liver fat normalised for many (1.8 [1.2-5.2]%; p < 0.0001) as did fasting glucose (5.9 [5.5-7.2] mmol/L; p < 0.0001). Alanine aminotransferase (ALT) and gamma glutamyl transferase (GGT) decreased at 12 months by 38 [19-60]% (p < 0·0001) and 38 [16-53]% (p < 0.0001) respectively. The positive predictive value for decrease in liver fat, with baseline values of >40 IU/L, was 100% for ALT and 87.5% for GGT. As expected, change in liver fat correlated with change in ALT (r = 0.64; p < 0.0001), GGT (r = 0.38; p = 0.013), AST (r = 0.36; p = 0.018), fatty liver index (r = 0.50; p < 0.0001) and hepatic steatosis index (r = 0.44; p < 0.0001).

CONCLUSION

Metabolic dysfunction-associated steatotic liver disease, an important marker of ill-health is improved by intentional weight loss. If enzyme levels are raised at baseline, following weight loss, changes in ALT and GGT usefully reflect change in liver fat content, with high positive predictive value. Monitoring liver enzymes can provide a simple way to assess change in liver fat following weight loss in day-to-day clinical practice.

Head-to-Head Comparison Between Phosphatidylethanol Versus Indirect Alcohol Biomarkers for Diagnosis of MetALD Versus MASLD: A Prospective Study

BACKGROUND

The current subclassification of steatotic liver disease (SLD) relies on validated questionnaires, such as Alcohol Use Disorders Identification Test (AUDIT) and Lifetime Drinking History (LDH), which, while useful, are impractical and lack precision for their use in routine clinical practice. Phosphatidylethanol (PEth) is a quantitative, objective alcohol biomarker with high sensitivity and specificity.

AIMS

To assess the diagnostic accuracy of PEth for differentiating metabolic dysfunction and alcohol-associated liver disease (MetALD) from metabolic dysfunction-associated steatotic liver disease (MASLD) in a large, population-based, prospective, multiethnic cohort of individuals with overweight or obesity.

METHODS

This is a cross-sectional analysis of a prospective study including 374 adults with overweight or obesity residing in Southern California who had SLD as defined by MRI-PDFF ≥ 5%. The clinical research visit included medical history, biochemical and PEth testing, standardised validated questionnaires (including AUDIT and LDH), physical examination, and advanced imaging using MRI-PDFF and MRE.

RESULTS

Among 374 adults with SLD, the prevalence of MASLD, MetALD, and ALD was 90.1%, 6.4%, and 3.5%, respectively. PEth had a robust diagnostic accuracy in the detection of MetALD (AUROC 0.81, 95%CI 0.73-0.89) and the Youden cut-off was 25 ng/mL. In head-to-head comparative efficacy analysis, PEth was both statistically and clinically superior to all previously used indirect alcohol biomarkers for diagnosing MetALD, including aspartate aminotransferase/alanine aminotransferase ratio, mean corpuscular volume, gamma glutamyltransferase, and ALD/NAFLD index (p < 0.05).

CONCLUSIONS

PEth outperforms previously used non-invasive tests in differentiating MetALD from MASLD and has the potential to change clinical practice by enhancing the subclassification of SLD.

The relationship between the ratio of non-high-density lipoprotein cholesterol to high-density lipoprotein cholesterol (NHHR) and both MASLD and advanced liver fibrosis: evidence from NHANES 2017-2020

Background

The non-HDL-C to HDL-C ratio (NHHR) is a dependable lipid marker linked to atherosclerotic traits. This study examines the potential relationship between NHHR and both metabolic dysfunction-associated steatotic liver disease (MASLD) and advanced liver fibrosis.

Methods

This study investigated the relationship between NHHR levels and both MASLD and advanced liver fibrosis using data from the 2017-2020 National Health and Nutrition Examination Survey (NHANES) in the United States. First, we conducted a baseline characteristics analysis of the population based on NHHR quartiles. Second, we employed multivariable weighted linear regression models to examine the associations between NHHR and MASLD, as well as advanced liver fibrosis. Third, we utilized restricted cubic splines (RCS) to assess potential non-linear relationships. Fourth, we performed subgroup analyses. Finally, ROC curve analysis was conducted to evaluate the effectiveness of NHHR.

Results

In the main analysis, this study included a total of 9,864 participants. Following multivariable logistic regression and comprehensive adjustments, elevated NHHR levels in the Q3 and Q4 groups were significantly linked to MASLD, with odds ratios of 1.59 (95% CI: 1.20-2.11) and 1.83 (95% CI: 1.40-2.39), respectively (P for trend < 0.0001). Elevated NHHR levels in the Q2 and Q3 groups remained significantly linked to a decreased risk of advanced liver fibrosis, with odds ratios of 0.61 (95% CI 0.40-0.94, P = 0.03) and 0.64 (95% CI 0.47-0.89, P = 0.01), respectively. RCS analysis revealed a U-shaped nonlinear association between NHHR and both MASLD (P = 0.000; P for nonlinear = 0.029) and advanced liver fibrosis (P = 0.0001; P for nonlinear = 0.000). In the subgroup analysis, we found that this relationship was significant only in certain subgroups. The ROC curve analysis revealed that NHHR exhibited the best predictive performance for diagnosing MASLD based on the fatty liver index (FLI). The optimal cutoff point for NHHR in predicting MASLD using FLI was determined to be 2.476, with sensitivity and specificity values of 0.589 and 0.698, respectively.

Conclusion

NHHR may serve as a predictive marker for MASLD and advanced liver fibrosis, highlighting its potential significance in risk assessment and prevention strategies.

The relationship between dose of methotrexate and incidence of liver fibrosis in patients with rheumatoid arthritis

Introduction

Methotrexate (MTX) is a chemotherapy agent and immune system suppressant that can cause liver fibrosis in long-term usage. This study aimed to investigate the relationship between the dose of MTX and the incidence of liver fibrosis in patients with rheumatoid arthritis (RA).

Material and methods

This cohort study was conducted on RA patients with normal liver function who took MTX. Liver FibroScan and laboratory tests, including α2-macroglobulin, total bilirubin, g-glutamyltransferase, apolipoprotein A1, haptoglobin, and alanine transaminase was performed. The patients were divided into 2 groups regarding their cumulative dose of MTX and the rate of liver fibrosis incidence was compared between the 2 groups.

Results

In total, 60 RA patients with the mean age of 55.2 ±11.8 years were enrolled. The mean duration of MTX use in patients was 6.9 ±3.8 years, and it was higher in the higher cumulative dose MTX group (> 2 g) than in the lower cumulative dose group (< 2 g; p < 0.0001). The overall prevalence of grade 3 fibrosis was 3.33%. The prevalence of second- and third-degree liver fibrosis in patients receiving a lower cumulative dose was respectively 9 (28.1%) and 1 (3.1%), and in patients receiving a higher cumulative dose it was 7 (25%) and 1 (3.6%), respectively. There was no statistically significant difference between the 2 groups regarding the prevalence of liver fibrosis (p = 0.88). Both aspartate aminotransferase to platelet ratio index and Fibrosis Index Based on 4 Factors indices showed no significant difference between the 2 groups (p = 0.594, p = 0.232).

Conclusions

These results suggest that long-term treatment with a higher cumulative dose of MTX is not associated with a higher incidence of liver fibrosis in RA patients.

The effect of healthy eating index-2015 in the associations of biological aging and non-alcoholic fatty liver disease: an interaction and mediation analysis

BACKGROUND

The present study explored the association between biological aging (BA), healthy eating index-2015 (HEI-2015) and non-alcoholic fatty liver disease (NAFLD) in the general population of the United States.

METHODS

We used data from the NHANES database between 2017-2018 years to conduct the study. Weighted multivariable logistic regression analysis, restricted cubic spline (RCS), and subgroup analysis were performed to analyze the association of BA and HEI-2015 with prevalence of NAFLD and the mediation effect of HEI-2015 was also discussed. Additionally, generalized additive model was conducted to investigate the association of BA and HEI-2015 with ZJU index, BARD score, and NAFLD fibrosis score.

RESULTS

There was a total of 2,421 individuals. RCS shown that BA was positively correlated with prevalence of NAFLD, while HEI-2015 was negative correlated with NAFLD risk. After adjusting for interfering factors, compared with the lowest quartiles of BA and HEI-2015, the odds ratios with 95% confidence intervals for NAFLD across the quartiles were (1.24 (0.84, 1.84), 2.07 (1.15, 3.73) and 2.49 (1.16, 5.38)) and (0.89 (0.66, 1.18), 0.87 (0.65, 1.16) and 0.64 (0.46, 0.87)), respectively. The BA was linear positive with ZJU index, BARD score and NAFLD fibrosis score. However, the linear negative correlation existed between HEI-2015 and ZJU index, BARD score and NAFLD fibrosis score. Mediation analysis showed that the positive correlation between BA and NAFLD could be mediated and weakened by HEI-2015.

CONCLUSIONS

The prevalence of NAFLD gradually increases with BA, but this positive association can be weakened by the healthy diet.

FLAME: Training and Validating a Newly Conceived Model Incorporating Alpha-Glutathione-S-Transferase Serum Levels for Predicting Advanced Hepatic Fibrosis and Acute Cardiovascular Events in Metabolic Dysfunction-Associated Steatotic Liver Disease (MASLD)

Alpha-Glutathione-S-transferase (alphaGST) is a liver enzyme whose serum levels increase with the worsening of fibrosis in alcoholic and viral chronic hepatitis. Its usefulness in Metabolic Dysfunction-Associated Steatotic Liver Disease (MASLD) remains unexplored. From January 2016 to December 2017, 200 patients with MASLD and 30 controls were enrolled. AlphaGST serum levels were measured. Variables related to advanced fibrosis (AF) were selected via Principal Component Analysis (PCA), and the best cut-off (BCO) was estimated using ROC analysis. Liver stiffness measurement (LSM), NAFLD fibrosis (NFS), Fibrosis-4 (FIB-4), and BMI-AST/ALT Ratio-Diabetes (BARD) scores were determined. The first acute cardiovascular events (ACE) in ACE-naïve subjects were recorded over five years. A validation cohort of 60 MASLD patients was enrolled from January 2018 to May 2019 and followed for five years. AlphaGST levels increased with fibrosis stage (p < 0.0001) in both cohorts, showing high accuracy in predicting AF (TrC: AUC 0.89, VlC: AUC 0.89). PCA-selected variables were HbA1c, HDL, and alphaGST, forming the "FLAME" model. FLAME showed superior predictive performance for AF and ACEs compared to other models and scores. FLAME represents a novel tool that accurately predicts AF and ACEs in MASLD.

Extracellular vesicle-mediated approaches for the diagnosis and therapy of MASLD: current advances and future prospective

Metabolic dysfunction-associated steatotic liver disease (MASLD) is an asymptomatic, multifaceted condition often associated with various risk factors, including fatigue, obesity, insulin resistance, metabolic syndrome, and sleep apnea. The increasing burden of MASLD underscores the critical need for early diagnosis and effective therapies. Owing to the lack of efficient therapies for MASLD, early diagnosis is crucial. Consequently, noninvasive biomarkers and imaging techniques are essential for analyzing disease risk and play a pivotal role in the global diagnostic process. The use of extracellular vesicles has emerged as promising for early diagnosis and therapy of various liver ailments. Herein, a comprehensive summary of the current diagnostic modalities for MASLD is presented, highlighting their advantages and limitations while exploring the potential of extracellular vesicles (EVs) as innovative diagnostic and therapeutic tools for MASLD. With this aim, this review emphasizes an in-depth understanding of the origin of EVs and the pathophysiological alterations of these ectosomes and exosomes in various liver diseases. This review also explores the therapeutic potential of EVs as key components in the future management of liver disease. The dual role of EVs as biomarkers and their therapeutic utility in MASLD essentially highlights their clinical integration to improve MASLD diagnosis and treatment. While EV-based therapies are still in their early stages of development and require substantial research to increase their therapeutic value before they can be used clinically, the diagnostic application of EVs has been extensively explored. Moving forward, developing diagnostic devices leveraging EVs will be crucial in advancing MASLD diagnosis. Thus, the literature summarized provides suitable grounds for clinicians and researchers to explore EVs for devising diagnostic and treatment strategies for MASLD.

Non-invasive lipid panel of MASLD fibrosis transition underscores the role of lipoprotein sulfatides in hepatic immunomodulation

There exists a pressing need for a non-invasive panel that differentiates mild fibrosis from non-fibrosis in metabolic dysfunction-associated steatotic liver disease (MASLD). In this work, we applied quantitative lipidomics and sterolomics on sera from the PERSONS cohort with biopsy-based histological assessment of liver pathology. We trained a lasso regression model using quantitative omics data and clinical variables, deriving a combinatorial panel of lipids and clinical indices that differentiates mild fibrosis (>F1, n = 324) from non-fibrosis (F0, n = 195), with an area under receiver operating characteristic curve (AUROC) at 0.775 (95% confidence interval [CI]: 0.735-0.816). Circulating sulfatides (SLs) emerged as central lipids distinctly associated with fibrosis pathogenesis in MASLD. Lipidomics analysis of lipoprotein fractions revealed a redistribution of circulating SLs from high-density lipoproteins (HDLs) onto low-density lipoproteins (LDLs) in MASLD fibrosis. We further verified that patient LDLs with reduced SL content triggered a smaller activation of type II natural killer T lymphocytes, compared with control LDLs. Our results suggest that hepatic crosstalk with systemic immunity mediated by lipoprotein metabolism underlies fibrosis progression at early-stage MASLD.

The association of fatty liver index and metabolic syndrome with cardiovascular outcomes, liver-related mortality, and all-cause mortality: a nationwide cohort study

We investigated the risk of cardiovascular events, all-cause mortality, and liver-related mortality according to the presence of metabolic syndrome (MetS) and fatty liver index (FLI). In this retrospective longitudinal population-based cohort study, we used Korean National Health Insurance Service data from 2009 to 2012. Nonalcoholic fatty liver disease (NAFLD) was defined as FLI ≥ 60. Risk of all-cause mortality, liver-related mortality, and major adverse cardiovascular events (MACE) including myocardial infarction (MI), stroke, heart failure (HF), and cardiovascular disease (CVD)-related mortality was assessed according to the presence of MetS and FLI among adults (aged 40 to 80 years) who underwent health examinations (n = 769,422). During a median 8.59 years of follow up, 44,356 (5.8%) cases of MACE, 24,429 (3.2%) cases of all-cause mortality, and 1114 (0.1%) cases of liver-related mortality were detected in the entire cohort. When the FLI < 30 without MetS group was set as a reference, the FLI ≥ 60 with MetS group had the highest risk of MACE (adjusted hazard ratio [aHR] 2.05, 95% confidence interval [CI] 1.98-2.13) and all-cause mortality (aHR 1.96, 95% CI 1.86-2.07). The risk of liver-related mortality (aHR 10.71, 95% CI 8.05-14.25) was highest in the FLI ≥ 60 without MetS group. The FLI ≥ 60 with MetS group had a higher risk of MACE (aHR 1.39, 95%CI 1.28-1.51), a lower risk of liver-related mortality (aHR 0.44, 95%CI 0.33-0.59), and no significant difference in all-cause mortality compared with the FLI ≥ 60 without MetS group. The FLI ≥ 60 with MetS group was associated with the highest risk of MACE and the FLI ≥ 60 without MetS group had the highest risk liver-related mortality, but there was no significant difference in all-cause mortality between two groups. In conclusion, as FLI levels increase, the risk of MACE increases, and the risk increases additively in the presence of MetS. The risk of liver-related mortality increases with higher FLI levels, the effect of high FLI on increased risk is more significant in groups without MetS compared to those with MetS.

A Comprehensive Review of the Effects of Diabetes Mellitus on the Gastrointestinal System

Diabetes mellitus (DM) is a worldwide epidemic, making it a major non-communicable disease of public health concern. DM is a chronic disease affecting various organs of the body, leading to increased morbidity and frequently causing patients to seek medical care. Patients with DM often suffer from gastrointestinal disturbances, indicating the involvement of the gastrointestinal system (GIS). Common effects on the gastrointestinal tract (GIT) include esophageal dysmotility, gastroesophageal reflux disease (GERD), non-alcoholic fatty liver disease (NAFLD), glycogenic hepatopathy, gastroparesis, and enteropathy. Despite the high rates of GIT complications associated with diabetes, they are often under-recognized by physicians, leading to suboptimal treatment and a poor quality of life for patients. This article reviews the GIT manifestations of DM from the esophagus to the anal canal, including their pathophysiology and current management strategies.

Validation of serum non-invasive tests of liver fibrosis as prognostic markers of clinical outcomes in people with fatty liver disease in Australia

BACKGROUND AND AIM

The validity of non-invasive tests (NITs) of liver fibrosis for the prediction of liver and mortality outcomes in an Australian cohort is unknown. We aimed to verify the utility of available NITs to predict overall and cause-specific mortality and major adverse liver outcome (MALO).

METHODS

This was an analysis from the Crossroads 1 clinic sub-study of a randomly sampled adult cohort from regional Australia between 2001 and 2003. Baseline variables included demographic details, anthropometry, health and lifestyle data, and laboratory tests. Non-alcoholic fatty liver disease (NAFLD) and metabolic-(dysfunction) associated fatty liver disease (MAFLD) were defined by fatty liver index ≥ 60 and other accepted criteria. Outcomes were defined by the International Statistical Classification of Diseases and Related Health Problems 10th Revision codes for linked hospitalization and death registry data. Available serum-based NITs were analyzed as predictors of overall, cardiovascular disease-related, and cancer-related mortality and MALO in those with fatty liver disease (FLD).

RESULTS

In total, 1324 and 1444 participants were included for NAFLD and MAFLD analysis (prevalence 35.4% and 40.7%, respectively). There were 298 deaths (89 cardiovascular disease-related and 98 cancer-related) and 24 MALO over a median 19.7 years of follow-up time. In both forms of FLD, fibrosis-4 index, Steatosis-Associated Fibrosis Estimator score, and Forns fibrosis score consistently had the highest area under the receiver operating characteristic curve (AUROC) for overall and cause-specific mortality, with AUROC > 0.70 for each outcome. However, all had poor discriminatory ability for determining MALO in each FLD.

CONCLUSIONS

Several liver fibrosis NITs perform similarly reasonably well in predicting the risk of mortality outcomes in those with FLD but are poorly discriminatory for MALO prediction.

Cardiovascular Risk From Metabolic Dysfunction-Associated Steatotic Liver Disease, Cardiometabolic Risk Factor Count, and Their Longitudinal Changes: A Nationwide Cohort Study

INTRODUCTION

Metabolic dysfunction-associated steatotic liver disease (MASLD) is associated with incident cardiovascular disease (CVD). However, CVD risk could vary across and within individuals with MASLD. We investigated the cardiovascular implications of MASLD, cardiometabolic risk factor count, and their longitudinal changes.

METHODS

From nationwide health screening data, we included adults aged 20-79 years without increased/excessive alcohol intake, concomitant liver diseases, and prior CVD at baseline examination in 2009 (N = 7,292,497). Participants were classified according to MASLD status; those with MASLD were further categorized by their count of qualifying cardiometabolic risk factors (1-5). Individuals who underwent follow-up examinations in 2011 (N = 4,198,672) were additionally classified according to their baseline and follow-up MASLD status; those with persistent MASLD were further categorized by combination of baseline and follow-up cardiometabolic risk factor counts. The risk of incident CVD was assessed using multivariable-adjusted Cox model.

RESULTS

Over a median follow-up of 12.3 years, 220,088 new CVD events occurred. The presence of MASLD was associated with higher incidence of CVD. Among participants with MASLD, the risk of CVD increased gradually with higher cardiometabolic risk factor count (per 1-higher; hazard ratio [HR] 1.18, 95% confidence interval [CI] 1.18-1.19). The development of MASLD during follow-up was associated with higher risk of CVD (HR 1.28, 95% CI 1.25-1.31), whereas the regression of MASLD was associated with lower risk of CVD (HR 0.84, 95% CI 0.82-0.86). Among individuals with persistent MASLD, gaining and losing cardiometabolic risk factor count during follow-up were associated with elevated and reduced risk of CVD, respectively.

DISCUSSION

MASLD status, cardiometabolic risk factor count, and their longitudinal changes were all associated with the risk of incident CVD. Accurate identification of these markers may facilitate personalized management of MASLD-related CVD risk.

Incidence of metabolic dysfunction-associated steatotic liver disease and advanced fibrosis and impact of overweight/obesity in elderly population: a nationwide cohort study

BACKGROUND AND AIM

The prevalence of metabolic dysfunction-associated steatotic liver disease (MASLD) is increasing worldwide, coinciding with aging population. However, limited studies have evaluated its incidence and progression to advanced fibrosis in the elderly population. Therefore, our study aimed to investigate the incidence of MASLD and advanced fibrosis in this age group.

METHODS

We included 878 686 individuals aged ≥60 years from the Korea National Health Insurance Service-Senior cohort. After excluding participants with preexisting MASLD, 329 388 individuals were finally analyzed. Participants were categorized into four groups based on the presence of overweight/obesity and additional risk factors (aRF) included in the cardiometabolic diagnostic criteria of MASLD.

RESULTS

The overall incidence of MASLD was 1.94 per 100 person-years, and the incidence of advanced fibrosis in MASLD patients was 1.78 per 100 person-years. MASLD development was significantly higher in overweight/obese patients (2.65 per 100 person-years) compared to lean patients (1.09 per 100 person-years), and this trend persisted after stratification by the presence of aRF. Similarly, the incidence of advanced fibrosis among MASLD patients was higher in overweight/obese individuals (2.06 per 100 person-years) compared to lean counterparts (0.87 per 100 person-years), irrespective of aRF.

CONCLUSIONS

The lower incidence of MASLD in the elderly population compared to the general population underscores the importance of identifying age-specific risk factors. Overweight/obesity emerged as a robust predictor of MASLD development and advanced fibrosis. Additionally, the presence of additional cardiometabolic risk factors further increased the risk of incident MASLD and advanced fibrosis among the elderly.

Metabolic dysfunction-associated steatotic liver disease and MetALD increases the risk of liver cancer and gastrointestinal cancer: A nationwide cohort study

BACKGROUND

The new nomenclature of metabolic dysfunction-associated steatotic liver disease (MASLD) substituting nonalcoholic fatty liver disease was proposed along with a new category of MASLD with increased alcohol intake (MetALD).

AIMS

We aimed to explore the cancer risk by MASLD and MetALD.

METHODS

This nationwide cohort study included 3,596,709 participants who underwent a health check-up in 2011 in South Korea. Steatotic liver disease (SLD) was defined as a fatty liver index ≥30. Participants were categorized into four exclusive groups: MASLD, MetALD, other combination aetiology and no SLD. The subdistribution hazard ratio (SHR) was calculated using the Fine-Gray model after adjusting other variables.

RESULTS

During the 33.9 million person-years of follow-up, 285,845 participants (7.9%) developed cancers. Compared with no SLD, MASLD, MetALD and other combination aetiology had an increased risk of all cancer. Liver cancer risk escalated from no SLD to MASLD (SHR, 1.16; 95% CI, 1.12-1.21), MetALD (SHR, 2.06; 95% CI, 1.92-2.20) and other combination aetiology (SHR, 8.16; 95% CI, 7.69-8.67). Gastrointestinal cancers including oesophagus, stomach, colorectal, biliary and pancreas cancers increased in MASLD (SHR, 1.13; 95% CI, 1.11-1.15), MetALD (SHR, 1.17; 95% CI, 1.14-1.21) and other combination aetiology (SHR, 1.09; 95% CI, 1.05-1.13). A modest increase in lung cancer and hormone-sensitive cancer was observed with MASLD.

CONCLUSIONS

This study showed that MASLD and MetALD are associated with an increased risk of cancer, particularly liver and gastrointestinal cancers. The findings build new evidence for the clinical outcomes of MetALD while highlighting the importance of managing alcohol intake properly in MASLD and MetALD.

Metabolic and hepatic phenotypes in sarcopenic obesity and impact of bariatric surgery

BACKGROUND & AIMS

Sarcopenic obesity (SO) is associated with cardiometabolic disorders and steatotic liver disease and carries major health risks. We assessed the hepatic and metabolic clinical phenotype associated with SO in patients with obesity undergoing bariatric surgery (BS). We also evaluated whether weight-loss and metabolic improvement post-surgery differ between patients with and without SO.

METHODS

972 consecutive patients from a single-center BS cohort who underwent whole-body dual-energy X-ray absorptiometry (DXA) and peri-operative liver biopsy were included. SO was diagnosed using the AIM-SO score, an AI-assisted unbiased clustering algorithm based on body composition. One-year post-surgery, 862 patients were reassessed for AIM-SO score changes.

RESULTS

Pre-operatively, 207 (21.3 %) patients were diagnosed with SO. These patients had significantly higher prevalence of type-2 diabetes (T2D), arterial hypertension and obstructive sleep apnea (OSA) compared to patients without SO (all p ≤ 0.003). Patients with SO had more severe liver damage: higher grades of moderate/advanced steatosis (64.2 % vs. 47.3 %), steatohepatitis (44.4 % vs. 32.3 %) and advanced fibrosis (12.1 % vs. 6.0 %) (all p ≤ 0.01). One-year post-BS, 58.5 % of patients had remission of SO. Patients with persistent SO exhibited less weight-loss than those with SO remission (-23.8 kg vs. -29.1 kg, p < 0.001) and had lower rates of remission for T2D (41.9 % vs. 69.8 %), arterial hypertension (20.8 % vs. 45.3 %), and metabolic syndrome (47.6 % vs. 75.0 %) (all p ≤ 0.009).

CONCLUSION

The DXA-based AIM-SO score identifies patients with SO who are at greater risk of hepatic and cardiometabolic comorbidities, and predicts less favorable weight-loss and metabolic improvements post-BS.

Non-invasive prediction nomogram for predicting significant fibrosis in patients with metabolic-associated fatty liver disease: a cross-sectional study

BACKGROUND AND AIM

This study aims to validate the efficacy of the conventional non-invasive score in predicting significant fibrosis in metabolic-associated fatty liver disease (MAFLD) and to develop a non-invasive prediction model for MAFLD.

METHODS

This cross-sectional study was conducted among 7701 participants with MAFLD from August 2018 to December 2023. All participants were divided into a training cohort and a validation cohort. The study compared different subgroups' demographic, anthropometric, and laboratory examination indicators and conducted logistic regression analysis to assess the correlation between independent variables and liver fibrosis. Nomograms were created using the logistic regression model. The predictive values of noninvasive models and nomograms were evaluated using receiver operating characteristic (ROC) curve analysis and decision curve analysis (DCA).

RESULTS

Four nomograms were developed for the quantitative analysis of significant liver fibrosis risk based on the multivariate logistic regression analysis results. The nomogram's area under ROC curves (AUC) was 0.710, 0.714, 0.748, and 0.715 in overall MAFLD, OW-MAFLD, Lean-MAFLD, and T2DM-MAFLD, respectively. The nomogram had a higher AUC in all MAFLD participants and OW-MAFLD than the other non-invasive scores. The DCA curve showed that the net benefit of each nomogram was higher than that of APRI and FIB-4. In the validation cohort, the AUCs of the nomograms were 0.722, 0.750, 0.719, and 0.705, respectively.

CONCLUSION

APRI, FIB-4, and NFS performed poorly predicting significant fibrosis in patients with MAFLD. The new model demonstrated improved diagnostic accuracy and clinical applicability in identifying significant fibrosis in MAFLD.

Evaluation of Liver Fibrosis through Noninvasive Tests in Steatotic Liver Disease

Liver fibrosis, a critical predictor of the prognosis of metabolic dysfunction-associated steatotic liver disease (MASLD), is traditionally diagnosed via biopsy. Nevertheless, non-invasive alternatives, such as serum biomarkers, vibration-controlled transient elastography, and magnetic resonance elastography, have become prominent because of the limitations of biopsies. Serum biomarkers, such as fibrosis-4 index and NFS Score, are also used widely, offering reliable diagnostic performance for advanced fibrosis. Vibration-controlled transient elastography and shear wave elastography provide further non-invasive evaluations with high diagnostic accuracy, particularly for advanced fibrosis, but the results may be affected by factors such as obesity. Magnetic resonance elastography, with superior diagnostic accuracy and operator independence, is a promising method, but its high cost and limited availability restrict its widespread use. Emerging algorithms, such as NIS4, FAST, or MAST score, have strong potential in identifying high-risk metabolic dysfunction-associated steatohepatitis patients. The integration of multiple non-invasive methods can optimize diagnostic accuracy, reducing the need for invasive biopsies while identifying patients at risk of liver-related complications. Further research is needed to refine these diagnostic tools and improve accessibility.

[Serological Markers to Assess Liver Fibrosis and Their Roles]

Chronic liver disease is a significant public health issue worldwide, with the degree of liver fibrosis and its progression significantly influencing the treatment and prognosis. A liver biopsy is the standard diagnostic method, but it is invasive and presents various issues. Therefore, numerous non-invasive diagnostic methods have been developed. Serum markers are categorized into indirect markers, which reflect liver damage, inflammation, or functional changes, and direct markers, which measure the components released into the bloodstream during fibrosis. In addition, various kinds of formulas that combined direct/indirect markers and demographic variables were developed and validated with encouraging outcomes. Nevertheless, despite their convenience, serum indicators require cautious interpretation because they are affected by a number of factors. More research will be needed to determine if the clinical course of chronic liver disease under a disease-specific treatment could be monitored appropriately using serological markers.

Improving Recurrence Prediction in Intrahepatic Cholangiocarcinoma: The Synergistic Impact of the FIB-4 Index and Tumor Burden Score on Post-hepatectomy Outcomes

BACKGROUND

The prognostic role of the fibrosis-4 (FIB-4) index relative to intrahepatic cholangiocarcinoma (ICC) after hepatectomy remains unclear. This study sought to characterize the impact of the FIB-4 index and tumor burden score (TBS) on recurrence and overall survival (OS).

METHODS

ICC patients undergoing hepatectomy (2000-2020) were identified using a multi-institutional database. Patients were categorized as low (low TBS/low FIB-4 index), intermediate (low TBS/high FIB-4 index or high TBS/low FIB-4 index), and high (high TBS/high FIB-4 index).

RESULTS

Among 1168 patients in different TBS and FIB-4 index cohorts, 3-year recurrence varied considerably. For instance, among the patients with low TBS, individuals with a high FIB-4 index had a greater risk of recurrence than patients with a low FIB-4 index (59.9 vs. 47.7%; P = 0.01). Among patients with a high TBS, individuals with a high versus a low FIB-4 index had a higher incidence of recurrence (76.8 vs. 69.0%; P = 0.04). A similar pattern was observed among patients with both a low FIB-4 index (low [47.7%] vs. high [69.0%] TBS) and a high FIB-4 index (low [59.9%] vs. high [76.8%] TBS; both P < 0.001). Patients with a high [27.5%] versus a low [48.8%] TBS; P < 0.001) and patients with a high [34.2%] versus a low [43.5%] FIB-4 index; P = 0.01) had a worse OS. The multivariable analysis demonstrated an increasing risk of recurrence in the intermediate-index (hazard ratio [HR], 1.61; 95% confidence interval [CI], 1.20-2.16; P = 0.001) and high-index (HR, 2.13; 95% CI 1.45-3.13; P < 0.001) groups versus the low-index group.

CONCLUSIONS

Both tumor-related and non-tumorous characteristics should be used to predict risk of recurrence and survival more accurately among patients with ICC following hepatic resection.

Association between Helicobacter pylori infection, MASLD, and liver fibrosis in patients with severe obesity: a single-center experience

BACKGROUND AND METHODS

Our study sought to evaluate if an association exists between Helicobacter pylori (H. pylori), metabolic dysfunction- associated steatotic liver disease (MASLD), and liver fibrosis in patients with severe obesity (BMI > 35). Our retrospective study included 584 patients over the age of 18 years with severe obesity, who underwent preoperative liver transient elastography (VCTE), upper endoscopy, blood work, and intra-operative liver biopsy concurrent with bariatric surgery at a single institution from July 2020 to September 2021. Liver fibrosis scores including FIB-4, APRI, NAFLD fibrosis score, BARD score, AST: ALT ratio, and NAFLD activity score (NAS) were calculated from the laboratory results and liver biopsy findings. The presence or absence of H. pylori was determined based on gastric biopsies obtained during upper endoscopy. Other variables collected included age, gender, mean preoperative weight, BMI, and the presence or absence of comorbidities. Student's t-test and non-parametric testing were used for the analysis of continuous variables and Chi-square analysis was used for categorical data.

RESULTS

Of the 584 patients, 14.7% were H. pylori positive and 85.3% were negative. Liver fibrosis scores including FIB-4, APRI, and NAFLD fibrosis scores were significantly higher in the positive group (p < 0.05), but there was no difference in AST: ALT ratio and BARD score. A significantly higher VCTE steatosis and fibrosis scores were noted in the H. pylori-positive group (p < 0.05). Similarly, a significantly higher NAS (NAFLD activity score) on liver biopsies was noted in the positive group, with all the individual components of NAS (steatosis, lobular inflammation, and hepatocyte ballooning) being significantly higher in the positive group (p < 0.05). A significantly higher incidence of fibrosis on liver biopsies was noted in the positive group overall and across all stages of fibrosis (p < 0.05). There were no significant differences between the groups in relation to gender, mean weight, BMI, presence of comorbidities including Diabetes Mellitus, and laboratory values.

CONCLUSION

Our study demonstrates that H. pylori colonization or infection is associated with a higher risk of development of MASLD and progression to fibrosis. Further, population-based studies are needed to corroborate our findings.

A roadmap for clinical trials in MASH-related compensated cirrhosis

Although metabolic dysfunction-associated steatohepatitis (MASH) is rapidly becoming a leading cause of cirrhosis worldwide, therapeutic options are limited and the number of clinical trials in MASH-related compensated cirrhosis is low as compared to those conducted in earlier disease stages. Moreover, designing clinical trials in MASH cirrhosis presents a series of challenges regarding the understanding and conceptualization of the natural history, regulatory considerations, inclusion criteria, recruitment, end points and trial duration, among others. The first international workshop on the state of the art and future direction of clinical trials in MASH-related compensated cirrhosis was held in April 2023 at Vall d'Hebron University Hospital in Barcelona (Spain) and was attended by a group of international experts on clinical trials from academia, regulatory agencies and industry, encompassing expertise in MASH, cirrhosis, portal hypertension, and regulatory affairs. The presented Roadmap summarizes important content of the workshop on current status, regulatory requirements and end points in MASH-related compensated cirrhosis clinical trials, exploring alternative study designs and highlighting the challenges that should be considered for upcoming studies on MASH cirrhosis.

The risk stratification and predictive performance of a new combined polygenic risk score for hepatocellular carcinoma

BACKGROUND

Recent genome-wide association studies (GWASs) in liver diseases have generated some polygenic risk scores (PRSs), but their predictive effectiveness on hepatocellular carcinoma (HCC) risk assessment remains unclear.

METHODS

Here, we constructed a novel combined polygenic risk score and evaluated its increment to the well-established risk model. We used 15 HCC-associated genetic loci from two PRSs and FinnGen GWAS data to calculate a PRS-combined score and to fit the related PRS model in the UK Biobank cohort (N = 436,162). The PRS-combined score was further assessed for risk stratification for HCC integrating with the recommended clinical risk scores.

RESULTS

The PRS-combined model achieved a better AUC (0.657) than that of PRS-HFC (0.637) and PRS-cirrhosis (0.645). The top 20% of the PRS-combined distribution had a 3.25 increased risk of HCC vs. the middle decile (45-55%). At the population level, the addition of PRS-combined to the CLivD score significantly increased the C-statistic (from 0.716 to 0.746) and provided a remarkable improvement in reclassification (NRI = 0.088) at the 10-year risk threshold of 0.2%. In clinic, additional assessment of PRS-combined would reclassify 34,647 intermediate-risk participants as high genetic risk, corresponding to an increase of 63.92% (62/97) of the HCC events classified at high risk using the Fibrosis-4 alone.

CONCLUSIONS

The PRS may enhance HCC risk prediction effectiveness in the general population and refine risk stratification of the conventional clinical indicator.

Global prevalence of advanced fibrosis in patients with type 2 diabetes mellitus: a systematic review and meta-analysis

BACKGROUND AND AIM

Patients with type 2 diabetes mellitus (T2DM) face a heightened susceptibility to advanced fibrosis, a condition linked to adverse clinical outcomes. However, reported data on liver fibrosis severity among individuals with T2DM vary significantly across studies with diverse characteristics. This meta-analysis aimed to estimate the global prevalence of advanced fibrosis among T2DM patients.

METHODS

A comprehensive systematic search of the EMBASE and MEDLINE databases from inception to November 2022 was conducted to identify studies assessing advanced fibrosis in individuals with T2DM. Random-effects models were utilized to calculate point estimates of prevalence, accompanied by 95% confidence interval (CI). Meta-regression with subgroup analysis was employed to address heterogeneity.

RESULTS

We identified 113 eligible studies involving 244,858 individuals from 29 countries. Globally, the prevalence of advanced fibrosis among T2DM patients was 19.5% (95% CI 16.8-22.4%). Regionally, the prevalence rates were as follows: 60.5% in West Asia (95% CI 50.3-70.4%), 24.4% in South Asia (95% CI 16.2-33.7%), 20.1% in East Asia (95% CI 14.7-26.1%), 20.0% in Europe (95% CI 15.8-24.6%), 15.8% in North America (95% CI 11.0-21.3%), and 11.3% in South America (95% CI 6.2-17.5%). The prevalence of advanced fibrosis varied notably based on the study setting and diagnostic methodology employed. Meta-regression models highlighted that 45.13% of the observed heterogeneity could be attributed to combined diagnostic modality and study setting.

CONCLUSIONS

Globally, approximately one fifth of the T2DM population presents advanced fibrosis, with prevalence differing across geographical regions. Our findings underscore the need for effective strategies to alleviate its global burden.

A Systematic Review of Metabolic Syndrome: Key Correlated Pathologies and Non-Invasive Diagnostic Approaches

Background and Objectives: Metabolic syndrome (MetS) is a condition marked by a complex array of physiological, biochemical, and metabolic abnormalities, including central obesity, insulin resistance, high blood pressure, and dyslipidemia (characterized by elevated triglycerides and reduced levels of high-density lipoproteins). The pathogenesis develops from the accumulation of lipid droplets in the hepatocyte (steatosis). This accumulation, in genetically predisposed subjects and with other external stimuli (intestinal dysbiosis, high caloric diet, physical inactivity, stress), activates the production of pro-inflammatory molecules, alter autophagy, and turn on the activity of hepatic stellate cells (HSCs), provoking the low grade chronic inflammation and the fibrosis. This syndrome is associated with a significantly increased risk of developing type 2 diabetes mellitus (T2D), cardiovascular diseases (CVD), vascular, renal, pneumologic, rheumatological, sexual, cutaneous syndromes and overall mortality, with the risk rising five- to seven-fold for T2DM, three-fold for CVD, and one and a half-fold for all-cause mortality. The purpose of this narrative review is to examine metabolic syndrome as a "systemic disease" and its interaction with major internal medicine conditions such as CVD, diabetes, renal failure, and respiratory failure. It is essential for internal medicine practitioners to approach this widespread condition in a "holistic" rather than a fragmented manner, particularly in Western countries. Additionally, it is important to be aware of the non-invasive tools available for assessing this condition. Materials and Methods: We conducted an exhaustive search on PubMed up to July 2024, focusing on terms related to metabolic syndrome and other pathologies (heart, Lung (COPD, asthma, pulmonary hypertension, OSAS) and kidney failure, vascular, rheumatological (osteoarthritis, rheumatoid arthritis), endocrinological, sexual pathologies and neoplastic risks. The review was managed in accordance with the PRISMA statement. Finally, we selected 300 studies (233 papers for the first search strategy and 67 for the second one). Our review included studies that provided insights into metabolic syndrome and non-invasive techniques for evaluating liver fibrosis and steatosis. Studies that were not conducted on humans, were published in languages other than English, or did not assess changes related to heart failure were excluded. Results: The findings revealed a clear correlation between metabolic syndrome and all the pathologies above described, indicating that non-invasive assessments of hepatic fibrosis and steatosis could potentially serve as markers for the severity and progression of the diseases. Conclusions: Metabolic syndrome is a multisystem disorder that impacts organs beyond the liver and disrupts the functioning of various organs. Notably, it is linked to a higher incidence of cardiovascular diseases, independent of traditional cardiovascular risk factors. Non-invasive assessments of hepatic fibrosis and fibrosis allow clinicians to evaluate cardiovascular risk. Additionally, the ability to assess liver steatosis may open new diagnostic, therapeutic, and prognostic avenues for managing metabolic syndrome and its complications, particularly cardiovascular disease, which is the leading cause of death in these patients.

Liver fibrosis prediction models in a population of Latina and White women

Point-of-care tools to assess advanced liver fibrosis, including the NFS, BARD, FIB-4, and APRI, are of major interest due to their noninvasive nature. However, these tools have not been investigated extensively in the Latina population. Given that the highest rate of NAFLD in Latinos and the most severe presentation of non-alcoholic fatty liver disease (NAFLD) is more common in women, we hypothesize that ethnicity may play a role in predicting liver fibrosis, particularly in women. We determined whether ethnicity alone or in association with other parameters can predict the severity of fibrosis in women with NAFLD when included in four tools. We retrospectively included 562 Latina and 133 White Caucasian women with a history of NAFLD. Associations between ethnicity and liver fibrosis severity using the four fibrosis predictor models were studied using backward selection multinomial logistic regression. Latina women compared to White showed lower body mass index (p < 0.001), higher HbA1c (p < 0.001), lower prevalence of bariatric surgery (p < 0.001), lower likelihood to smoke (p = 0.003), and higher prevalence of chronic kidney disease stages 3-5 (p = 0.01). Some clinical variables were associated with fibrosis but not univocally in each tool. We did not find differences in the outcome of the four models when holding all other factors and examining ethnicity alone between Latina and White women. Although we did not include data on liver histology, this is the first study examining the role of ethnicity in predicting the severity of fibrosis using established noninvasive scores and documenting no association between Latina ethnicity and the severity of fibrosis in women with NAFLD.

Association of nonalcoholic fatty liver disease with new-onset atrial fibrillation stratified by age groups

BACKGROUND

The association between nonalcoholic fatty liver disease (NAFLD) and atrial fibrillation (AF) has been inconsistent, and the impact of hepatic fibrosis on this relationship remains uncertain. We investigated the association between NAFLD and the risk of new-onset AF across different age groups.

METHODS

A total of 3,179,582 participants from the 2009 Korean National Health Screening Program were divided into five groups based on NAFLD status: no NAFLD (fatty liver index [FLI] < 30); grade 1 NAFLD without advanced fibrosis (FLI 30-59 & BARD < 2); grade 1 NAFLD with advanced fibrosis (FLI 30-59 & BARD ≥ 2); grade 2 NAFLD without advanced fibrosis (FLI ≥ 60 & BARD < 2); and grade 2 NAFLD with advanced fibrosis (FLI ≥ 60 & BARD ≥ 2). The primary outcome was incident AF.

RESULTS

During the median follow-up of 9.3 years, 62,542 patients were diagnosed with new-onset AF. In the age- and sex-adjusted model, the risk of new-onset AF increased across NAFLD grades and fibrosis categories: grade 1 NAFLD without advanced fibrosis (hazard ratio [HR] 1.120, 95% confidence interval [CI]: 1.081-1.161); grade 1 NAFLD with advanced fibrosis (HR 1.275, 95% CI 1.251-1.300); grade 2 NAFLD without advanced fibrosis (HR 1.305, 95% CI: 1.252-1.360); and grade 2 NAFLD with advanced fibrosis (HR 1.627, 95% CI: 1.586-1.670). In the multivariate model, the excess risk of AF in patients with NAFLD and advanced fibrosis remained significant, even in participants aged 20-39 years.

CONCLUSION

Patients with NAFLD had a higher risk of new-onset AF, which increased progressively with NAFLD severity, particularly in those aged 20-29 years.

Non-invasive Scores and Serum Biomarkers for Fatty Liver in the Era of Metabolic Dysfunction-associated Steatotic Liver Disease (MASLD): A Comprehensive Review From NAFLD to MAFLD and MASLD

PURPOSE OF REVIEW

The prevalence of non-alcoholic fatty liver disease (NAFLD) is rapidly increasing worldwide, making it the leading cause of liver related morbidity and mortality. Currently, liver biopsy is the gold standard for assessing individuals with steatohepatitis and fibrosis. However, its invasiveness, sampling variability, and impracticality for large-scale screening has driven the search for non-invasive methods for early diagnosis and staging. In this review, we comprehensively summarise the evidence on the diagnostic performance and limitations of existing non-invasive serum biomarkers and scores in the diagnosis and evaluation of steatosis, steatohepatitis, and fibrosis.

RECENT FINDINGS

Several non-invasive serum biomarkers and scores have been developed over the last decade, although none has successfully been able to replace liver biopsy. The introduction of new NAFLD terminology, namely metabolic dysfunction-associated fatty liver disease (MAFLD) and more recently metabolic dysfunction-associated steatotic liver disease (MASLD), has initiated a debate on the interchangeability of these terminologies. Indeed, there is a need for more research on the variability of the performance of non-invasive serum biomarkers and scores across the diagnostic entities of NAFLD, MAFLD and MASLD. There remains a significant need for finding valid and reliable non-invasive methods for early diagnosis and assessment of steatohepatitis and fibrosis to facilitate prompt risk stratification and management to prevent disease progression and complications. Further exploration of the landscape of MASLD under the newly defined disease subtypes is warranted, with the need for more robust evidence to support the use of commonly used serum scores against the new MASLD criteria and validation of previously developed scores.

A Validation Study of Non-invasive Scoring Systems for Assessing Severity of Hepatic Fibrosis in a Cohort of South Indian Patients With Non-alcoholic Fatty Liver Disease

Introduction

Liver biopsy is the gold standard for diagnosing and staging non-alcoholic fatty liver disease (NAFLD), but liver biopsy has its limitations. Non-invasive tests (NITs) eliminate many of the drawbacks of liver biopsy. We did a retrospective observational study to validate the NAFLD Fibrosis Score (NFS score) and Fibrosis Score 4 (FIB-4 index) against the gold standard liver biopsy in a cohort of South Indian patients with NAFLD.

Aims

The aim of this study was to validate the diagnostic accuracy of non-invasive fibrosis scoring systems (FIB-4 index and NFS), compared to that of liver histology, to predict AF in a cohort of south Indian patients with NAFLD.

Material and methods

A retrospective observational analytical study of patients who had a liver biopsy with a diagnosis of NAFLD and had all the data for aetiology assessment and NIT calculation within 4 weeks of biopsy were included in the study. On liver biopsy, NAFLD was scored as per NIH's NASH committee grading system. NFS and FIB-4 index were calculated, and scores more than 0.676 and 2.67, respectively, were taken as the cut-off to predict advanced fibrosis (AF). The sensitivity, specificity, positive predictive value, negative predictive value, and area under the receiver operating characteristic curve for NFS score and FIB-4 score to diagnose AF were calculated.

Results

A total of 147 patients were included in the study. Of these, 56 (38.1%) patients had AF (Stage 3, 4). Patients with AF were more likely to be older and have diabetes mellitus (DM). Patients with AF had lower platelet count, higher aspartate aminotransferase (AST), lower albumin, and higher AST/alanine aminotransferase ratio. An NFS of >0.676 had a sensitivity of 68% and specificity of 100%, and an FIB-4 index of >2.67 had a sensitivity of 67% and specificity of 95.6 % in diagnosing AF in our study.

Conclusion

The non-invasive scoring systems NFS and FIB-4 index can be used as a bedside tool for diagnosing liver fibrosis in NAFLD allowing liver biopsy to be used in a more targeted manner for patients diagnosed with AF on NITs.

Establishment and Evaluation of a Noninvasive Metabolism-Related Fatty Liver Screening and Dynamic Monitoring Model: Cross-Sectional Study

BACKGROUND

Metabolically associated fatty liver disease (MAFLD) insidiously affects people's health, and many models have been proposed for the evaluation of liver fibrosis. However, there is still a lack of noninvasive and sensitive models to screen MAFLD in high-risk populations.

OBJECTIVE

The purpose of this study was to explore a new method for early screening of the public and establish a home-based tool for regular self-assessment and monitoring of MAFLD.

METHODS

In this cross-sectional study, there were 1758 eligible participants in the training set and 200 eligible participants in the testing set. Routine blood, blood biochemistry, and FibroScan tests were performed, and body composition was analyzed using a body composition instrument. Additionally, we recorded multiple factors including disease-related risk factors, the Forns index score, the hepatic steatosis index (HSI), the triglyceride glucose index, total body water (TBW), body fat mass (BFM), visceral fat area, waist-height ratio (WHtR), and basal metabolic rate. Binary logistic regression analysis was performed to explore the potential anthropometric indicators that have a predictive ability to screen for MAFLD. A new model, named the MAFLD Screening Index (MFSI), was established using binary logistic regression analysis, and BFM, WHtR, and TBW were included. A simple rating table, named the MAFLD Rating Table (MRT), was also established using these indicators.

RESULTS

The performance of the HSI (area under the curve [AUC]=0.873, specificity=76.8%, sensitivity=81.4%), WHtR (AUC=0.866, specificity=79.8%, sensitivity=80.8%), and BFM (AUC=0.842, specificity=76.9%, sensitivity=76.2%) in discriminating between the MAFLD group and non-fatty liver group was evaluated (P<.001). The AUC of the combined model including WHtR, HSI, and BFM values was 0.900 (specificity=81.8%, sensitivity=85.6%; P<.001). The MFSI was established based on better performance at screening MAFLD patients in the training set (AUC=0.896, specificity=83.8%, sensitivity=82.1%) and was confirmed in the testing set (AUC=0.917, specificity=89.8%, sensitivity=84.4%; P<.001).

CONCLUSIONS

The novel MFSI model was built using WHtR, BFM, and TBW to screen for early MAFLD. These body parameters can be easily obtained using a body fat scale at home, and the mobile device software can record specific values and perform calculations. MFSI had better performance than other models for early MAFLD screening. The new model showed strong power and stability and shows promise in the area of MAFLD detection and self-assessment. The MRT was a practical tool to assess disease alterations in real time.

Trajectories of hepatic steatosis and incidence of cardiovascular disease over a 29-year follow-up

AIM

To examine the dynamic change in hepatic steatosis status during repeated assessments over time, and its potential impact on the risk of developing cardiovascular disease (CVD).

METHODS

We assessed trajectories of hepatic steatosis and other metabolic disorders in 3134 middle-aged adults undergoing longitudinal assessment of ultrasonography during a pre-baseline period (1993-2009) in a population-based cohort study of liver health. Subsequently, we determined the association of hepatic steatosis trajectories with the incidence of CVD among 2185 CVD-free individuals, followed until 2021. Metabolic risk factors and cardiovascular events (including coronary heart disease and stroke) were determined through medical examination and linkage with nationwide health databases.

RESULTS

We identified three discrete trajectories of hepatic steatosis according to changing pattern over time through group-based trajectory modeling: "stable, non-steatosis" (n = 1298), "intermittent" (n = 921), and "persistent steatosis" (n = 915). During the pre-baseline period, hepatic steatosis trajectories were associated with trajectories of developing diabetes and hypertension, and persistent steatosis (vs. other trajectories) was associated with higher risks and rapidly progressive disease patterns. At a median 13.6 years of follow-up, 629 CVD events occurred. A persistent (vs. non-steatosis: HR 1.44, 95% CI 1.17-1.76), but not intermittent, steatosis pattern predicted the future risk of CVD, after adjustment for age, sex, smoking, and obesity. This association was independent of genetic background, and remained after accounting for pre-baseline body-mass index, other cardiometabolic risk factors, Framingham risk score, medications, and hepatic fibrosis score.

CONCLUSIONS

The persistence of hepatic steatosis is associated with trajectories of metabolic disorder development and increased risk of CVD. These data have important implications for practice and further research.

Incorporating artificial intelligence in portable infrared thermal imaging for the diagnosis and staging of nonalcoholic fatty liver disease

Metabolic Dysfunction-Associated Steatotic Liver Disease (MASLD) is one of the most prevalent chronic liver diseases worldwide. Thermal imaging combined with advanced image-processing and machine learning analysis accurately classified disease status in a study on mice; this study aimed to develop this tool for humans. This prospective study included 46 patients who underwent liver biopsy. Liver thermal imaging was performed on the same day as liver biopsy. We developed an image-processing algorithm that measured the relative spatial thermal variation across the skin covering the liver. The texture parameters obtained from the thermal images were input into the machine learning algorithm. Patients were diagnosed with MASLD and stratified according to nonalcoholic fatty liver disease activity score (NAS) and fibrosis stage using the METAVIR score. Twenty-one of 46 patients were diagnosed with MASLD. Using thermal imaging followed by processing, detection accuracy for patients with NAS >4 was 0.72.

Comparison of liver fibrosis scores and fatty liver on computed tomography as risk factors for severity of COVID-19

Background and Aim

Increased liver fibrosis scores (LFS), such as fibrosis-4 index (FIB-4) or non-alcoholic fatty liver disease fibrosis score (NFS), and fatty liver are known risk factors for severe coronavirus disease 2019 (COVID-19). The purpose of this study was to identify the best scores, which predict the prognosis of COVID-19.

Methods

Participants comprised consecutive Japanese COVID-19 patients admitted to our hospital between February 14, 2020, and April 14, 2021. Multivariate logistic regression analysis was performed to evaluate the relationships between LFS (FIB-4, NFS, aspartate aminotransferase-to-platelet ratio index [APRI], BARD score, and hepatic steatosis index [HSI]) or fatty liver on computed tomography (CT), and severity of COVID-19.

Results

Of the 415 patients (mean age, 59 years), 177 patients (42.7%) needed oxygen therapy, 90 patients (21.7%) worsened to severe COVID-19, and 45 patients (10.8%) died during admission. Multivariate logistic regression analysis showed that increased FIB-4 and NFS were risk factors for death, severe COVID-19, and oxygen demand; that increased BARD was a risk factor for severe COVID-19 and oxygen demand; and that increased APRI and HSI were not risk factors for any status of COVID-19. Furthermore, increased NFS or BARD and fatty liver were independent risk factors for severe COVID-19 and oxygen demand.

Conclusions

This study showed that FIB-4 and NFS were the best liver fibrosis scores that predicted worse prognosis for COVID-19, and that increased NFS or BARD and fatty liver evident on CT represented independent risk factors for severe COVID-19 and oxygen demand.

Manifestation and Progression of Metabolic Dysfunction-Associated Steatotic Liver Disease in a Predominately African American Population at a Multi-Specialty Healthcare Organization

African Americans (AA) have a high incidence of risk factors associated with MASLD (metabolic dysfunction-associated steatotic liver disease); the AA population has a lower incidence of MASLD and MASH (metabolic-associated steatotic hepatitis) than Caucasian and Hispanic Americans (non-AA). We investigated if underlying risk factor variation between AA and non-AA individuals could provide a rationale for the racial diversity seen in MASLD/MASH. Using ICD-10 codes, patients from 2017 to 2020 with MASLD/MASH were identified and confirmed to have either MASLD or MASH. Despite the large (>80%) AA population in our clinics, only 54% of the MASLD/MASH patients were African American. When the non-invasive NAFLD Fibrosis Scores (NFS) evaluated at early diagnosis were compared to the most recent values, the only increase in fibrosis score by NFS over time was in non-AA MASH patients. The increase in fibrosis only in non-AA MASLD patients is consistent with racial disparity in the disease progression in non-AA as compared to AA patients. Even with the large proportion of AA patients in our study, there was no significant racial disparity in the earliest assessment of either risk factors, laboratory values, or fibrosis scores that would account for racial disparity in the development and progression of MASLD.

Cumulative methotrexate dose is not associated with liver fibrosis in patients with a history of moderate-to-severe psoriasis

BACKGROUND

There are established risk factors for liver fibrosis (LF), but data on the impact of methotrexate on LF in patients with psoriasis are lacking.

OBJECTIVES

This cross-sectional study aimed to determine the prevalence of LF in patients with psoriasis and to evaluate the relationship between LF, cumulative methotrexate dose and other LF risk factors.

METHODS

Adults with a history of moderate-to-severe chronic plaque psoriasis were recruited between June 2020 and March 2021. Patients underwent transient elastography to evaluate LF. Three values for liver stiffness measurement (LSM) were assessed, indicating mild or worse LF (≥ 7 kPa), moderate or worse LF (≥ 7.9 kPa) and advanced LF (≥ 9.5kPa). Cumulative methotrexate dose and other potential risk factors for LF were assessed.

RESULTS

Overall, 240 patients were recruited and 204 participants with valid LSM values were included in the analysis [median age 48 years [interquartile range (IQR) 37-57]; 51% female sex; 56% body mass index (BMI) ≥ 30 (kg m-2) and a median Alcohol Use Disorders Identification Test (AUDIT) score of 4 (IQR 1-7, 23% score ≥ 8)]. In total, 91% had received methotrexate [median duration 36 months (IQR 14-78)]. Prevalence of LF was 36%, 25% and 17% using LSM ≥ 7 kPa, ≥ 7.9 kPa and ≥ 9.5 kPa, respectively. There was no association between cumulative methotrexate dose [median 2.16 (IQR 0.93-5.2)] and continuous LSM values [unstandardized coefficient 0.16, 95% confidence interval (CI) -0.49 to 0.82, P = 0.626] or using the categorical LSM cutoff values: ≥ 7 kPa [unadjusted odds ratio 1.06 (95% CI 0.97-1.15), P = 0.192], ≥ 7.9 kPa [unadjusted odds ratio 1.03 (95% CI 0.94-1.12), P = 0.577] and ≥ 9.5 kPa (unadjusted odds ratio 1.01, 95% CI 0.91-1.12; P = 0.843). The following risk factors were associated with higher LSM values: BMI (P ≤ 0.001), waist circumference (P ≤ 0.001), metabolic syndrome (P ≤ 0.001), AUDIT score (P = 0.020) and FIB-4 score (P = 0.03). BMI ≥ 28, diabetes and metabolic syndrome were shown to be better predictors of LF compared with FIB-4 score.

CONCLUSIONS

This study confirms a high prevalence of significant LF in patients with psoriasis. Cumulative methotrexate dose was not associated with LF. Patients with BMI ≥ 28, metabolic syndrome and diabetes are at higher risk for LF. These risk factors may help to identify when a more detailed liver health assessment is needed.

Evolutionary changes in metabolic dysfunction-associated steatotic liver disease and risk of hepatocellular carcinoma: A nationwide cohort study

BACKGROUND/AIMS

To determine the association between evolutionary changes in metabolic dysfunction-associated steatotic liver disease (MASLD) status and the risk of hepatocellular carcinoma (HCC) in a nationwide population-based cohort.

METHODS

Information on study participants was derived from the Korea National Health Insurance Service database. The study population consisted of 5,080,410 participants who underwent two consecutive biennial health screenings between 2009 and 2012. All participants were followed up until HCC, death, or 31 December 2020. The association of evolutionary changes in MASLD status, as assessed by the fatty liver index and cardiometabolic risk factors, including persistent non-MASLD, resolved MASLD, incident MASLD, and persistent MASLD, with HCC risk was evaluated using multivariable-adjusted Cox proportional hazards regression.

RESULTS

Among the 5,080,410 participants with 39,910,331 person-years of follow-up, 4,801 participants developed HCC. The incidence of HCC in participants with resolved, incident, and persistent MASLD was approximately 2.2-, 2.3-, and 4.7-fold higher, respectively, than that in those with persistent non-MASLD among the Korean adult population. When stratifying the participants according to the evolutionary change in MASLD status, persistent (adjusted hazard ratio [aHR], 2.94; 95% confidence interval [CI], 2.68-3.21; P<0.001), incident (aHR, 1.85; 95% CI, 1.63-2.10; P<0.001), and resolved MASLD (aHR, 1.33; 95% CI, 1.18-1.50; P<0.001) had an increased risk of HCC compared to persistent non-MASLD.

CONCLUSION

The evolutionary changes in MASLD were associated with the differential risk of HCC independent of metabolic risk factors and concomitant medications, providing additional information on the risk of HCC stratification in patients with MASLD.

Screening patients in general practice for advanced chronic liver disease using an innovative IT solution: The Liver Toolkit

BACKGROUND

Identifying patients with undiagnosed advanced chronic liver disease (ACLD) is a public health challenge. Patients with advanced fibrosis or compensated cirrhosis have much better outcomes than those with decompensated disease and may be eligible for interventions to prevent disease progression.

METHODS

A cloud-based software solution ("the Liver Toolkit") was developed to access primary care practice software to identify patients at risk of ACLD. Clinical history and laboratory results were extracted to calculate aspartate aminotransferase-to-platelet ratio index and fibrosis 4 scores. Patients identified were recalled for assessment, including Liver Stiffness Measurement (LSM) via transient elastography. Those with an existing diagnosis of cirrhosis were excluded.

RESULTS

Existing laboratory results of more than 32,000 adults across nine general practices were assessed to identify 703 patients at increased risk of ACLD (2.2% of the cohort). One hundred seventy-nine patients (26%) were successfully recalled, and 23/179 (13%) were identified to have ACLD (LSM ≥10.0 kPa) (10% found at indeterminate risk [LSM 8.0-9.9 kPa] and 77% low risk of fibrosis [LSM <8.0 kPa]). In most cases, the diagnosis of liver disease was new, with the most common etiology being metabolic dysfunction-associated steatotic liver disease (n=20, 83%). Aspartate aminotransferase-to-platelet ratio index ≥1.0 and fibrosis 4 ≥3.25 had a positive predictive value for detecting ACLD of 19% and 24%, respectively. Patients who did not attend recall had markers of more severe disease with a higher median aspartate aminotransferase-to-platelet ratio index score (0.57 vs. 0.46, p=0.041).

CONCLUSIONS

This novel information technology system successfully screened a large primary care cohort using existing laboratory results to identify patients at increased risk ACLD. More than 1 in 5 patients recalled were found to have liver disease requiring specialist follow-up.

Non-invasive biomarkers prognostic of decompensation events in NASH cirrhosis: a systematic literature review

Liver cirrhosis due to nonalcoholic steatohepatitis (NASH) is a life-threatening condition with increasing incidence world-wide. Although its symptoms are unspecific, it can lead to decompensation events such as ascites, hepatic encephalopathy, variceal hemorrhage, and hepatocellular carcinoma (HCC). In addition, an increased risk for cardiovascular events has been demonstrated in patients with NASH. Pharmacological treatments for NASH cirrhosis are not yet available, one of the reasons being the lack in surrogate endpoints available in clinical trials of NASH cirrhosis. The feasibility of non-invasive prognostic biomarkers makes them interesting candidates as possible surrogate endpoints if their change following treatment would result in better outcomes for patients in future clinical trials of NASH cirrhosis. In this systematic literature review, a summary of the available literature on the prognostic performance of non-invasive biomarkers in terms of cardiovascular events, liver-related events, and mortality is outlined. Due to the scarcity of data specific for NASH cirrhosis, this review includes studies on NAFLD whose evaluation focuses on cirrhosis. Our search strategy identified the following non-invasive biomarkers with prognostic value in studies of NASH patients: NAFLD fibrosis score (NFS), Fibrosis-4 (FIB-4), aspartate aminotransferase (AST) to platelet ratio index (APRI), enhanced liver fibrosis (ELF™), BARD (BMI, AST/ALT (alanine aminotransferase) ratio, diabetes), Hepamet Fibrosis Score (HFS), liver enzymes (AST + ALT), alpha-fetoprotein, platelet count, neutrophil to lymphocyte ratio (NLR), Lysyl oxidase-like (LOXL) 2, miR-122, liver stiffness, MEFIB (liver stiffness measured with magnetic resonance elastography (MRE) + FIB-4), and PNPLA3 GG genotype. The aim of the present systematic literature review is to provide the reader with a summary of the non-invasive biomarkers with prognostic value in NASH cirrhosis and give an evaluation of their utility as treatment monitoring biomarkers in future clinical trials.

Serum biomarkers for liver fibrosis assessment

Liver fibrosis is the result of chronic liver injury of different etiologies produced by an imbalance between the synthesis and degeneration of the extracellular matrix and dysregulation of physiological mechanisms. Liver has a high regenerative capacity in the early stage of chronic diseases so a prompt liver fibrosis detection is important. Consequently, an easy and economic tool that could identify patients with liver fibrosis at the initial stages is needed. To achieve this, many non-invasive serum direct, such as hyaluronic acid or metalloproteases, and indirect biomarkers have been proposed to evaluate liver fibrosis. Also, there have been developed formulas that combine these biomarkers, some of them also introduce clinical and/or demographic parameters, like FIB-4, non-alcoholic fatty liver disease fibrosis score (NFS), enhance liver fibrosis (ELF) or Hepamet fibrosis score (HFS). In this manuscript we critically reviewed different serum biomarkers and formulas for their utility in the diagnosis and progression of liver fibrosis.

Biomarcadores séricos para la evaluación de la fibrosis hepática

La fibrosis hepática se desarrolla como respuesta a la presencia de daño hepático crónico de diferentes etiologías, provocando un desequilibrio entre la síntesis y degeneración de la matriz extracelular y la desregulación de diversos mecanismos fisiológicos. En los estadios iniciales de las patologías crónicas, el hígado posee una elevada capacidad de regeneración, por lo que la detección temprana de la fibrosis hepática resulta esencial. En este contexto, es preciso contar con herramientas sencillas y económicas que permitan detectar la fibrosis hepática en sus fases iniciales. Para evaluar la fibrosis hepática, se han propuesto multitud de biomarcadores séricos no invasivos, tanto directos, como el ácido hialurónico o las metaloproteasas, como indirectos. Así mismo, se han desarrollado diversas fórmulas que combinan dichos biomarcadores junto con parámetros demográficos, como el índice FIB-4, el índice de fibrosis en la enfermedad de hígado graso no alcohólico (NFS, por sus siglas en inglés), la prueba ELF o el score de fibrosis Hepamet (HFS, por sus siglas en inglés). En el presente manuscrito, realizamos una revisión crítica del valor diagnóstico y pronóstico de los diferentes biomarcadores séricos y fórmulas actualmente existentes.

Relationship of Liver Blood Tests and T1 Relaxation Time With Intra-pancreatic Fat Deposition

BACKGROUND

Liver is well recognised as a metabolically active organ. While intra-pancreatic fat deposition (IPFD) is emerging as an important player in the whole-body metabolism, the interplay between the liver and IPFD has been poorly investigated. This study aimed to investigate the associations of liver blood tests and non-invasive tests for hepatic fibrosis with IPFD.

METHODS

Participants underwent a 3.0 Tesla magnetic resonance imaging to measure IPFD and map liver T1 (longitudinal relaxation time). Four liver tests were done on the same sample of blood. Hepatic fibrosis risk score (BARD) was calculated. Linear regression models were built, accounting for age, sex, visceral-to-subcutaneous fat ratio, and other covariates.

RESULTS

A total of 143 individuals were studied. In the most adjusted model, alkaline phosphatase (P < 0.001), alanine aminotransferase (P < 0.001), and γ-glutamyl transferase (P = 0.042) were significantly positively associated with IPFD. The BARD score was not significantly associated with IPFD in the most adjusted model (P = 0.295). T1 relaxation time of the liver was not significantly associated with IPFD in the most adjusted model (P = 0.782).

CONCLUSIONS

Elevated alkaline phosphatase, alanine aminotransferase, and γ-glutamyl transferase are associated with increased IPFD. Hepatic fibrosis does not appear to be associated with IPFD.

Referral to hepatologists or a second-line examination requirement is common in patients with type 2 diabetes mellitus

BACKGROUND AND AIMS

To estimate the number of patients who required a referral to hepatologists following the 2016 EASL-EASD-EASO guideline and a second-line vibration controlled transient elastography (VCTE) examination following the 2021 EASL guideline according to obesity, glycated hemoglobin (HbA1c), blood pressure (BP), and low-density lipoprotein cholesterol (LDL-C) control status in patients with type 2 diabetes mellitus (T2DM).

METHODS AND RESULTS

A total of 2515 T2DM patients who were hospitalized were cross-sectionally assessed. When we applied the 2016 EASL-EASD-EASO guideline, 26.8 %-46.4 % (depending on the scores used for diagnosing fibrosis) of T2DM patients needed a referral to hepatologists. When we applied the 2021 EASL guideline, a VCTE examination was required in 10.9 %-35 % (depending on the scores used for diagnosing fibrosis) of T2DM patients. The referral rates and the VCTE requirement were even higher in patients who were obese and/or had poor HbA1c, BP, and/or LDL-C control.

CONCLUSIONS

Application of the screening guidelines would lead to a referral to hepatologists or a second-line VCTE examination requirement for a substantial number of T2DM patients, regardless of obesity and metabolic goal attainment status.

Chronic exposure to ambient air pollution and the risk of non-alcoholic fatty liver disease: A cross-sectional study in Taiwan and Hong Kong

BACKGROUND

Information on the relation of air pollution with non-alcoholic fatty liver disease (NAFLD) is scarce. We thus conducted a large cross-sectional study in Asia to investigate the role of air pollution in NAFLD.

METHODS

We recruited 329,048 adults (mean age: 41.0 years) without other liver disease (hepatitis and cirrhosis) or excessive alcohol consumption in Taiwan and Hong Kong from 2001 to 2018. The concentrations of nitrogen dioxide (NO2) and ozone (O3) were estimated using a space-time regression model, and the concentrations of fine particulate matter (PM2.5) was evaluated using a satellite-based spatio-temporal model. NAFLD was determined using either the fatty liver index (FLI) or the hepatic steatosis index (HSI). The NAFLD-related advanced fibrosis was defined according to BARD score or the fibrosis-4 (FIB-4). A logistic regression model was adopted to explore the relationships of ambient air pollution with the odds of NAFLD and NAFLD-related advanced fibrosis.

RESULTS

We found positive relationships between PM2.5 and the odds of NAFLD and advanced fibrosis, with every standard deviation (SD, 7.5 µg/m3) increases in PM2.5 exposure being associated with a 10% (95% confidence interval [CI]: 9%-11%) increment in the prevalence of NAFLD and an 8% (95% CI: 7%-9%) increment in the prevalence of advanced fibrosis. Similarly, the prevalence of NAFLD and advanced fibrosis increased by 8% (95% CI: 7%-9%) and 7% (95% CI: 6%-8%) with per SD (18.9 µg/m3) increasement in NO2 concentration, respectively. Additionally, for every SD (9.9 µg/m3) increasement in O3 concentration, the prevalence of NAFLD and advanced fibrosis decreased by 12% (95% CI: 11%-13%) and 11% (95% CI: 9%-12%), respectively.

CONCLUSION

Higher ambient PM2.5 and NO2 are linked with higher odds of NAFLD and advanced fibrosis. Our findings indicate that reducing PM2.5 and NO2 concentrations may be an effective way for preventing NAFLD. Further studies on O3 are warranted.

Noninvasive tests for liver fibrosis in 2024: are there different scales for different diseases?

Liver fibrosis is the common pathway from various chronic liver diseases and its progression leads to cirrhosis which carries a significant risk for the development of portal hypertension-related complications and hepatocellular carcinoma. It is crucial to identify and halt the worsening of liver fibrosis given its important prognostic implication. Liver biopsy is the gold standard for assessing the degree of liver fibrosis but is limited due to its invasiveness and impracticality for serial monitoring. Many noninvasive tests have been developed over the years trying to assess liver fibrosis in a practical and accurate way. The tests are mainly laboratory- or imaging-based, or in combination. Laboratory-based tests can be derived from simply routine blood tests to patented laboratory parameters. Imaging modalities include ultrasound and magnetic resonance elastography, in which vibration-controlled transient elastography is the most widely validated and adopted whereas magnetic resonance elastography has been proven the most accurate liver fibrosis assessment tool. Nonetheless, noninvasive tests do not always apply to all liver diseases, nor does a common cut-off value of a test mean the same degree of liver fibrosis in different scenarios. In this review, we discuss the diagnostic and prognostic performance, as well as the confounders and limitations, of different noninvasive tests on liver fibrosis assessment in various liver diseases.