MASLD: a systemic metabolic disorder with cardiovascular and malignant complications

Lipid profile and non-alcoholic fatty liver disease detected by ultrasonography: is systemic inflammation a necessary mediator?

AIMS

To examine the relationship between lipid profile and non-alcoholic fatty liver (NAFL), compare the predictive strengths of different lipid indicators to NAFL, and explore the possible mechanisms.

METHODS

Male workers from a baseline survey of a cohort of workers in southern China were included. Basic information was collected through face-to-face interviews. Plasma concentrations of fasting plasma glucose (FPG), total cholesterol (TC), triglycerides (TG), high-density lipoprotein cholesterol (HDL-C), and low-density lipoprotein cholesterol (LDL-C) were determined using a blood biochemical analyzer. Liver sonography was used to identify NAFL cases. Regression models were used to calculate ORs, and examine the association between C-reactive protein (CRP) levels and lipid profiles. Restricted cubic spline regression with four knots was used to examine the dose-response relationship, and mediation analysis was employed to examine the mediation effect.

RESULTS

h Among the 4016 male workers, 829 (20.64%) were diagnosed with NAFL. Compared with normal lipid profile, individuals with abnormal lipid profile had higher prevalence of NAFL (OR=2.27, 95%CI: 1.85-2.79 for TG; OR=1.45, 95%CI: 1.03-2.04 for TC; OR=1.56, 95%CI: 1.21-2.02 for HDL; OR=1.65, 95%CI: 1.25-2.18 for LDL; OR=2.28, 95%CI: 1.87-2.77 for dyslipidaemia) after adjusting for potential confounders. Dose-response relationships were observed among TG, HDL, and NAFL. In addition, no significant mediation effect of C-reactive protein (CRP) was found in the association between lipid profiles and NAFL.

CONCLUSIONS

Abnormal TG, TC, HDL, and LDL levels were all positively associated with NAFL, while CRP has no mediating effect, and TG tended to be a better predictor of NAFL.

Causal associations of metabolic dysfunction-associated steatotic liver disease with gestational hypertension and preeclampsia: a two-sample Mendelian randomization study

BACKGROUND

Hypertensive disorders of pregnancy (HDPs), which include gestational hypertension (GH) and preeclampsia (PE), are the primary causes of maternal morbidity and mortality worldwide. Recent studies have found a correlation between metabolic dysfunction-associated steatotic liver disease (MASLD) and HDPs, but the causality of this association remains to be identified. Therefore, this study aims to evaluate the causal relationship between MASLD and HDPs through Mendelian randomization (MR) analysis.

METHODS

The summary statistics from genome-wide association studies were employed to conduct a two-sample MR analysis. Five complementary MR methods, including inverse variance weighting (IVW), MR-Egger, weighted median, simple mode and weighted mode were performed to assess the causality of MASLD on GH and PE. Furthermore, we conducted various sensitivity analyses to ensure the stability and reliability of the results.

RESULTS

Genetically predicted MASLD significantly increased the risk of GH (IVW: OR = 1.138, 95% CI: 1.062-1.220, p < 0.001), while there was little evidence of a causal relationship between MASLD and PE (IVW: OR = 0.980, 95% CI: 0.910-1.056, p = 0.594). The sensitivity analyses indicated no presence of heterogeneity and horizontal pleiotropy.

CONCLUSION

This MR study provided evidence supporting the causal effect of MASLD on GH. Our findings underscore the significance of providing more intensive prenatal care and early intervention for pregnant women with MASLD to prevent potential adverse obstetric outcomes.

Lachnospiraceae-bacterium alleviates ischemia-reperfusion injury in steatotic donor liver by inhibiting ferroptosis via the Foxo3-Alox15 signaling pathway

Ischemia-reperfusion injury (IRI) is a major obstacle in liver transplantation, especially with steatotic donor livers. Dysbiosis of the gut microbiota has been implicated in modulating IRI, and Lachnospiraceae plays a pivotal role in regulating host inflammatory and immune responses, but its specific role in liver transplantation IRI remains unclear. This study explores whether Lachnospiraceae can mitigate IRI and its underlying mechanisms. We found Lachnospiraceae-bacterium (Lachn.) abundance was significantly reduced in rats with liver cirrhosis. Lachn.-treated rats exhibited improved intestinal permeability, reduced IRI severity in both normal and steatotic donor livers, and decreased levels of neutrophil and macrophage infiltration, and inflammatory cytokines. Multi-omics analysis revealed elevated pyruvate levels in transplanted livers after Lachn. treatment, alongside reduced Alox15 and Foxo3 expression. Mechanistically, Lachn.-derived pyruvate inhibited Alox15 expression and reduced ferroptosis in normal and steatotic donor livers. Furthermore, reduced nuclear translocation of Foxo3 further suppressed Alox15 expression, alleviating IRI, especially in steatotic donor livers. Clinical samples confirmed reduced donor livers IRI in cirrhotic recipients with high Lachn. abundance after liver transplantation. In conclusion, Lachn. alleviates IRI in steatotic donor liver transplantation by inhibiting ferroptosis via the Foxo3-Alox15 axis, providing a potential therapeutic strategy to modulate gut microbiota to alleviate IRI following liver transplantation.

Cardiovascular events, mortality, and incident type 2 diabetes in patients with metabolic dysfunction-associated steatohepatitis: a claims-based analysis of commercial and Medicare Advantage enrollees

BACKGROUND

The objective of this study was to examine the risks of cardiovascular events, incident type 2 diabetes (T2D), and mortality in patients with newly diagnosed metabolic dysfunction-associated steatohepatitis (MASH) compared with those without MASH in a large real-world setting in the US.

METHODS

We retrospectively analyzed US claims data from Optum®'s de-identified Clinformatics® Data Mart database from October 2015 to December 2022. Patients with newly diagnosed MASH were matched 1:1 on age, sex, region, and index month-year with patients without MASH, and repeated for a subgroup without baseline diabetes. Risks of clinical outcomes associated with MASH were assessed using Cox proportional hazard models.

RESULTS

The study comprised 24,278 matched pairs in the patients with and without MASH cohorts. Patients with MASH had increased risks for any cardiovascular event (adjusted HR: 1.48 [95% CI = 1.38-1.58]), and all-cause mortality (1.31; 1.20-1.42) compared to those without MASH. For the subgroup without baseline diabetes (10,027 matched pairs), the adjusted HRs were 1.94 (95% CI = 1.68-2.23) for incident T2D and 1.40 (95% CI = 1.20-1.64) for all-cause mortality.

CONCLUSION

Our findings suggest increased risks of cardiovascular events, incident T2D, and mortality among patients newly diagnosed with MASH compared with patients without MASH.

Helicobacter pylori infection is linked to metabolic dysfunction and associated steatotic liver disease: A large cross-sectional study

BACKGROUND

Helicobacter pylori (H. pylori), a globally widespread pathogen affecting half of the global population, has been increasingly implicated in metabolic disorders, including obesity, dyslipidemia, and metabolic dysfunction-associated steatotic liver disease (MASLD). MASLD is a common condition, impacting nearly one in four adults globally. It also shares significant pathophysiological links with metabolic syndrome. Despite the fact that mechanistic hypotheses (such as oxidative stress and inflammation) have been proposed to explain these relationships, large-scale studies comprehensively assessing multifactorial metabolic associations are lacking. We proposed that H. pylori infection may independently correlate with unfavorable metabolic profiles and the presence of MASLD among adults in a large cohort.

AIM

To investigate the associations of H. pylori infection with obesity, glucose, lipids, blood pressure, and MASLD in Chinese adults.

METHODS

This study included 28624 adults recruited from the Physical Examination Center at Nanchang University's Second Affiliated Hospital. The 13C-urea breath test was used to identify H. pylori infection, while abdominal ultrasound was employed for MASLD diagnosis. The relationships between H. pylori infection and metabolic factors were analyzed via multivariate logistic regression.

RESULTS

The overall H. pylori infection incidence was 26.8%, with higher rates observed in older adults (≥ 70 years: 26.1% vs 18-29 years: 24.6%, P < 0.001) and obese individuals [body mass index (BMI) ≥ 28 kg/m²: 30.0% vs normal BMI: 25.3%, P < 0.001]. H. pylori-positive individuals exhibited elevated blood glucose (5.43 ± 1.55 mmol/L vs 5.27 ± 1.23 mmol/L, P < 0.001), low-density lipoprotein cholesterol (2.97 ± 0.76 mmol/L vs 2.94 ± 0.75 mmol/L, P < 0.001), and blood pressure (systolic: 123.49 ± 19.06 mmHg vs 122.85 ± 18.33 mmHg, P = 0.009; diastolic: 75.48 ± 12.37 vs 74.9 mmHg ± 11.9 mmHg, P < 0.001) levels. Among MASLD patients, infection was associated with increased glucose (5.82 ± 1.95 mmol/L vs 5.60 ± 1.60 mmol/L, P < 0.001), total cholesterol (5.05 ± 1.03 mmol/L vs 5.00 ± 1.00 mmol/L, P = 0.039), BMI (26.23 ± 3.00 kg/m² vs 26.04 ± 2.96 kg/m², P = 0.004), and blood pressure (systolic: 129.5 ± 20.00 mmHg vs 128.49 ± 17.62 mmHg, P = 0.009; diastolic: 79.87 ± 12.07 mmHg vs 79.04 ± 11.76 mmHg, P = 0.002) levels. Multivariate analysis demonstrated elevated glucose [odds ratio (OR) = 1.079, P < 0.001], BMI (OR = 1.016, P = 0.002), and diastolic pressure (OR = 1.003, P = 0.048) levels as independent risk factors, with high-density lipoprotein (HDL) being observed as a protective factor (OR = 0.837, P < 0.001).

CONCLUSION

H. pylori infection correlates with older age, obesity, elevated glucose levels, and elevated diastolic blood pressure, whereas HDL protects against H. pylori infection, thus underscoring its role in metabolic disturbances and MASLD.

The promise of incretin-based pharmacotherapies for metabolic dysfunction-associated fatty liver disease

BACKGROUND

The presence of excess liver fat secondary to metabolic dysregulation represents the end-organ manifestation of a systemic disease that can progress to steatohepatitis, cirrhosis and its feared complications of clinical decompensation and hepatocellular cancer. Since metabolic dysfunction-associated fatty liver disease (MAFLD) is highly prevalent globally, there is a pressing need to augment lifestyle interventions with pharmacotherapies to ameliorate disease burden and reduce adverse liver-related events.

PURPOSE

This review summarises current evidence for the utility of incretin mimetics in the MAFLD/MASH arena.

METHODS

A literature review that encompassed multiple database searches to inform the evidence base for incretin drugs in MAFLD/MASH.

RESULTS

Incretin mimetics demonstrate multifarious benefits across the metabolic diseases spectrum with mounting evidence for their role in remitting steatohepatitis and liver fibrosis. Weight loss and insulin sensitisation contribute, but additional mechanisms may also be engaged. Gastrointestinal adverse effects are common but for most, can be managed while preserving the hepatic and cardiometabolic benefits.

CONCLUSION

The literature reveals benefits from incretin-based therapies for MASH, but data on whether they improve long-term hepatic outcomes are awaited to support their future incorporation into routine clinical care.

Gout drives metabolic dysfunction-associated steatotic liver disease through gut microbiota and inflammatory mediators

This study explores the relationship between gout and metabolic dysfunction-associated steatotic liver disease (MASLD), two metabolic conditions linked to worsening health outcomes. While hyperuricemia's association with MASLD is established, the specific connection between gout and MASLD remains less explored. Using data from the UK Biobank, the study employs COX proportional hazard models, multi-state survival analysis, and Mendelian randomization to assess the independent and mutual risks of gout and MASLD. Findings indicate a mutual risk increase: male gout patients, those younger than 60, and those with high BMI are particularly susceptible to MASLD, while female MASLD patients are at heightened risk for gout. Shared risk factors for both conditions include high BMI, hypertension, diabetes, and hyperuricemia. The study further identifies a bidirectional causal link, with gout leading to MASLD, mediated by gut microbiota Ruminococcaceae and proteins like IL-2 and GDF11, implicating specific metabolic pathways. The findings highlight a clinical and mechanistic correlation, emphasizing the need for targeted interventions to address these overlapping metabolic pathways in future treatments.

Mitochondrial mt12361A>G increased risk of metabolic dysfunction-associated steatotic liver disease among non-diabetes

BACKGROUND

Insulin resistance, lipotoxicity, and mitochondrial dysfunction contribute to the pathogenesis of metabolic dysfunction-associated steatotic liver disease (MASLD). Mitochondrial dysfunction impairs oxidative phosphorylation and increases reactive oxygen species production, leading to steatohepatitis and hepatic fibrosis. Artificial intelligence (AI) is a potent tool for disease diagnosis and risk stratification.

AIM

To investigate mitochondrial DNA polymorphisms in susceptibility to MASLD and establish an AI model for MASLD screening.

METHODS

Multiplex polymerase chain reaction was performed to comprehensively genotype 82 mitochondrial DNA variants in the screening dataset (n = 264). The significant mitochondrial single nucleotide polymorphism was validated in an independent cohort (n = 1046) using the Taqman® allelic discrimination assay. Random forest, eXtreme gradient boosting, Naive Bayes, and logistic regression algorithms were employed to construct an AI model for MASLD.

RESULTS

In the screening dataset, only mt12361A>G was significantly associated with MASLD. mt12361A>G showed borderline significance in MASLD patients with 2-3 cardiometabolic traits compared with controls in the validation dataset (P = 0.055). Multivariate regression analysis confirmed that mt12361A>G was an independent risk factor of MASLD [odds ratio (OR) = 2.54, 95% confidence interval (CI): 1.19-5.43, P = 0.016]. The genetic effect of mt12361A>G was significant in the non-diabetic group but not in the diabetic group. mt12361G carriers had a 2.8-fold higher risk than A carriers in the non-diabetic group (OR = 2.80, 95%CI: 1.22-6.41, P = 0.015). By integrating clinical features and mt12361A>G, random forest outperformed other algorithms in detecting MASLD [training area under the receiver operating characteristic curve (AUROC) = 1.000, validation AUROC = 0.876].

CONCLUSION

The mt12361A>G variant increased the severity of MASLD in non-diabetic patients. AI supports the screening and management of MASLD in primary care settings.

Sleep Duration, Midpoint, Variability, Irregularity and Metabolic Dysfunction-Associated Steatotic Liver Disease

OBJECTIVES

The relationship between actigraphy-derived sleep parameters, day-to-day deviations in sleep parameters, and metabolic dysfunction-associated steatotic liver disease (MASLD), a new definition of nonalcoholic fatty liver disease (NAFLD), remains unclear. We aimed to explore the associations of sleep duration, midpoint, variability and irregularity with MASLD risk.

METHODS

We used data from the National Health and Nutrition Examination Survey (NHANES) 2011-2014. Sleep duration and midpoint were estimated from 4 to 7 days of 24-hour actigraphy measurements. Sleep duration and midpoint standard deviation were used as indicators of sleep variability and irregularity, respectively. MASLD was diagnosed according to the multi-society Delphi consensus. Hepatic steatosis was defined as fatty liver index ≥ 60. Multivariable weighted logistic regression models were used to explore correlations and perform subgroup analyses.

RESULTS

A total of 5,316 participants were included, of whom 2,339 had MASLD. After adjusting for socio-demographic characteristics, lifestyle factors, and depression, compared to sleep variability < 60 minutes, the odds ratio (OR) [95% confidence interval (CI)] was 1.13 (0.96-1.34) for 60-90 minutes, and 1.17 (1.00-1.38) for > 90 minutes (P for trend = .034). After further adjustment for other sleep variables, short sleep duration (<7 hours) was associated with a 24% higher risk of MASLD (OR: 1.24, 95% CI: 1.01-1.53); compared to sleep irregularity < 38 minutes, OR (95% CI) was 1.27 (1.02-1.59) for 38-61 minutes and 1.43 (1.24-1.65) for > 61 minutes (P for trend = .003).

CONCLUSION

In addition to sleep duration, sleep irregularity may need to be considered in the prevention of MASLD.

Updated recommendations for the management of metabolic dysfunction-associated steatotic liver disease (MASLD) by the Latin American working group

Metabolic dysfunction-associated steatotic liver disease (MASLD) is one of the leading causes of chronic liver disease globally. Based on the 2023 definition, MASLD is characterized by the presence of metabolic dysfunction and limited alcohol consumption (<140 grams/week for women, <210 grams/week for men). Given the significant burden of MASLD in Latin America, this guidance was developed by the Latin American Association for the Study of the Liver (ALEH) Working Group to address key aspects of its clinical assessment and therapeutic strategies. In Latin America, ultrasonography is recommended as the initial screening tool for hepatic steatosis due to its accessibility, while Fibrosis-4 (FIB-4) is preferred for fibrosis risk stratification, with further evaluation using more specific techniques (i.e., vibration-controlled transient elastography or Enhanced Liver Fibrosis [ELF] test). A Mediterranean diet is advised for all MASLD patients, with a target of 7-10% weight loss for those with excess weight. Complete alcohol abstinence is recommended for patients with significant fibrosis, and smoking cessation is encouraged regardless of fibrosis stage. Pharmacological options should be tailored based on the presence of steatohepatitis, liver fibrosis, excess weight, and diabetes, including resmetirom, incretin-based therapies, pioglitazone, and sodium-glucose cotransporter-2 inhibitors. Bariatric surgery may be considered for MASLD patients with obesity unresponsive to lifestyle and medical interventions. Hepatocellular carcinoma screening is advised for all cirrhotic patients, with consideration given to those with advanced fibrosis based on individual risk. Finally, routine cardiovascular risk assessment and proper diabetes prevention and management remain crucial for all patients with MASLD.

Association between the non-high-density lipoprotein cholesterol to high-density lipoprotein cholesterol ratio and metabolic dysfunction-associated steatotic liver disease

Background

Metabolic dysfunction-associated steatotic liver disease (MASLD) is one of the most widespread chronic liver diseases and a serious global public health problem. Further research to identify novel risk factors associated with MASLD is urgently needed. The non-high-density lipoprotein cholesterol to high-density lipoprotein cholesterol ratio (NHHR) was identified as a novel lipid marker. The objective of this research was to assess the association between NHHR and MASLD in adults.

Methods

This cross-sectional study utilized data from the 2017-2020 National Health and Nutrition Examination Survey (NHANES). MASLD was diagnosed in accordance with controlled attenuation parameter scores and a combination of cardiometabolic risk factors. Multivariate logistic regression analyses, in conjunction with the restricted cubic spline method, were employed to investigate the association between NHHR and MASLD risk. Furthermore, subgroup and interaction analyses were conducted.

Results

This study included 5,269 individuals, with 2,031 individuals diagnosed with MASLD and 3,238 without MASLD. Logistic regression analyses revealed a significant positive correlation between NHHR and MASLD. After the confounding factors were adjusted, each unit rise in NHHR was correlated with a 39% higher probability of MASLD (OR = 1.39, 95% CI: 1.13-1.69). Subgroup and interaction analyses revealed that the positive correlation between NHHR and MASLD held steady regardless of age, gender, race, poverty-to-income ratio, education level, physical activity, body mass index, diabetes, hypertension, dyslipidemia and smoking status (P for interaction >0.05). In addition, a non-linear relationship with an S-shaped manner between NHHR and MASLD was found, with an inflection point at 1.59.

Conclusion

Our findings imply that an increasing trend in NHHR is associated with a greater risk of MASLD development. NHHR has the potential to function as an indicator for estimating the likelihood of developing MASLD.

Bile acids and their receptors in hepatic immunity

Similarly to conventional steroids, bile acids function as signaling molecules, acting on a family of membrane and nuclear receptors. The best-characterized bile acid-regulated receptors are the farnesoid X receptor, activated by primary bile acids, and the G-protein-coupled bile acid receptor 1 (also known as Takeda G protein-coupled receptor 5), which is activated by secondary bile acids, such as lithocholic acid (LCA) and deoxycholic acid. Both the farnesoid X receptor and G-protein-coupled bile acid receptor 1 are expressed in cells of innate immunity, monocytes/macrophages, and natural killer cells. Their activation in these cells provides counter-regulatory signals that are inhibitory in nature and attenuate inflammation. In recent years, however, it has been increasingly appreciated that bile acids biotransformations by intestinal microbiota result in the formation of chemically different secondary bile acids that potently regulate adaptive immunity. The 3-oxoLCA and isoalloLCA, two LCA derivatives, bind receptors such as the retinoic acid receptor-related orphan receptor gamma t (RORγt) and the vitamin D receptor (VDR) that are expressed only by lymphoid cells, extending the regulatory role of bile acids to T cells, including T-helper 17 cells and type 3 innate lymphoid cells (ILC3). In this novel conceptual framework, bile acids have emerged as one of the main components of the postbiota, the waste array of chemical mediators generated by the intestinal microbiota. Deciphering the interaction of these mediators with the immune system in the intestine and liver is a novel and fascinating area of bile acid renaissance.

The socioeconomic and environmental determinants of metabolic dysfunction-associated steatotic liver disease: understanding inequalities in prevalence and outcomes

Metabolism-associated steatotic liver disease (MASLD) is the most prevalent chronic liver condition worldwide and affects nearly 30% of the global population. While traditionally associated with metabolic risk factors, such as obesity and insulin resistance, increasing attention is being directed toward socioeconomic and environmental determinants that contribute to disparities in MASLD prevalence and outcomes. Low-income populations often experience higher rates of MASLD owing to limited access to healthcare, poor diet quality, and reduced opportunities for physical activity. Conversely, high-income countries are witnessing a paradoxical rise in MASLD cases, driven by sedentary lifestyles and excessive consumption of ultra-processed foods. This review examined the effects of socioeconomic status, education, healthcare access, and environmental exposure on the epidemiology of MASLD. The findings revealed that individuals from lower socioeconomic backgrounds and migrant populations experience a disproportionately higher burden of MASLD due to systemic healthcare barriers, dietary transitions, and occupational exposure. Children and adolescents face increasing susceptibility owing to rising obesity rates, and geographic disparities highlight Europe as the most affected region, followed by Asia and North America. Given the growing public health impact of MASLD, addressing both socioeconomic and environmental determinants is essential. Future efforts should prioritize policy-driven interventions, including equitable healthcare access, lifestyle modifications, and research into novel therapeutic approaches to mitigate the disease burden and improve patient outcomes.

Potential association of neutrophil-albumin ratio with non-alcoholic fatty liver disease: A cross-sectional study based on NHANES

BACKGROUND

Non-alcoholic fatty liver disease (NAFLD) has become a major public health problem in the world. Exploring objective biomarkers for the prevention, monitoring, and clinical evaluation of NAFLD is of guiding significance for clinical targeted prevention and treatment. There is a complex interaction between inflammation and NAFLD. Exploring NAFLD-related inflammatory markers is helpful for elucidating its pathogenic mechanism.

AIM

To explore the potential association between the inflamma-tory marker neutrophil to albumin ratio (NAR) and NAFLD based on the National Health and Nutrition Examination Survey (NHANES) database.

METHODS

The participant data set of the NHANES database from 2017 to 2018 was selected. They were divided into NAFLD group and non-NAFLD group according to the occurrence of NAFLD or not. The clinical data of the two groups were compared. Logistic regression analysis was used to analyze the relationship between NAR and NAFLD, and restricted cubic spline (RCS) and threshold effect analysis were performed to explore the potential turning point.

RESULTS

A total of 4526 participants were enrolled, including 1503 patients with NAFLD. The NAR level in the NAFLD group was significantly higher than that of the non-NAFLD group (P < 0.05). There were also significant differences in gender, age, body mass index, smoking status, hypertension, antihypertensive drugs, diabetes, hypoglycemic agents, alanine aminotransferase, aspartate aminotransferase, blood urea nitrogen, creatinine, uric acid, triglyceride, and total cholesterol between the two groups (P < 0.05 for), and these variables were therefore included in the adjusted model analyses. In model 1 without any adjustment, NAR levels were associated with the risk of NAFLD (OR = 2.154). In the model 2 (OR = 1.375), model 3 (OR = 1.693), and model 4 (OR = 1.817) adjusting for some variables, their independent association still existed. RCS curve analysis showed that there was a nonlinear relationship between NAR and NAFLD (P_{for overall} < 0.001, P_{for nonlinear} < 0.001). Threshold effect analysis showed that the inflection point of NAR influencing NAFLD risk was 1.436, and when NAR was lower than 1.436, the risk of NAFLD occurrence increased by 3.304 times for each additional unit of NAR (OR = 3.304; 95% confidence interval: 2.649-4.122; P < 0.001). However, this study did not found the potential value of NAR in distinguishing non-alcoholic steatohepatitis.

CONCLUSION

The levels of NAR show an independent association with NAFLD. When NAR is lower than 1.436, the risk of NAFLD increases with the increase of NAR level.

Assessment of skeletal muscle alterations and circulating myokines in metabolic dysfunction-associated steatotic liver disease: A cross-sectional study

BACKGROUND

Skeletal muscle alterations (SMAs) are being increasingly recognized in patients with metabolic dysfunction-associated steatotic liver disease (MASLD) and appear to be associated with deleterious outcomes in these patients. However, their actual prevalence and pathophysiology remain to be elucidated.

AIM

To determine the prevalence of SMAs and to assess the significance of circulating myokines as biomarkers in patients with MASLD.

METHODS

Skeletal muscle strength and muscle mass were measured in a cross-sectional study in a cohort of 62 patients fulfilling MASLD criteria, recruited from the outpatient clinics of a tertiary level hospital. The degree of fibrosis and liver steatosis was studied using abdominal ultrasound and transitional elastography. Anthropometric and metabolic characteristics as well as serum levels of different myokines were also determined in the MASLD cohort. Statistical analysis was performed comparing results according to liver fibrosis and steatosis.

RESULTS

No significant differences were found in both skeletal muscle strength and skeletal muscle mass in patients with MASLD between different stages of liver fibrosis. Interestingly, serum levels of fibroblast growth factor-21 (FGF21) were significantly higher in patients with MASLD with advanced hepatic fibrosis (F3-F4) than in those with lower fibrosis stages (F0-F2) (197.49 ± 198.27 pg/mL vs 95.62 ± 83.67 pg/mL; P = 0.049). In addition, patients with MASLD with severe hepatosteatosis (S3) exhibited significantly higher serum levels of irisin (1116.87 ± 1161.86 pg/mL) than those with lower grades (S1-S2) (385.21 ± 375.98 pg/mL; P = 0.001).

CONCLUSION

SMAs were uncommon in the patients with MASLD studied. Higher serum levels of irisin and FGF21 were detected in patients with advanced liver steatosis and fibrosis, respectively, with potential implications as biomarkers.

Enpp1 ameliorates MAFLD by regulating hepatocyte lipid metabolism through the AMPK/PPARα signaling pathway

BACKGROUND

Metabolic dysfunction-associated fatty liver disease (MAFLD) has become the leading chronic liver disease globally, and there are no approved pharmacotherapies to treat this disease. Ectonucleotide pyrophosphatase/phosphodiesterase 1 (Enpp1) has been found to be related to insulin resistance and lipid accumulation. However, the role and mechanism of Enpp1 in the development of MAFLD remain unknown.

RESULTS

Here we discovered that Enpp1 is lowly expressed in the liver of MAFLD patients by clinical investigation. Knocking out Enpp1 in the liver of mice aggravated obesity, insulin resistance and hepatic steatosis, and these effects were reversed by liver-specific Enpp1 overexpression. Through transcriptomic data mining and experimental validation, we demonstrated that Enpp1 deficiency inhibited the expression of AMPK (energy receptor) and PPARα (nuclear transcription factor for lipid metabolism), thereby promoting the transcription of lipid synthesis factors and mediating the progression of MAFLD. Mechanistically, Enpp1 enhanced the activity of AMPK by increasing the AMP-to-ATP ratio, which in turn raised PPARα levels and promoted the transcription of its downstream lipid metabolism factors. Pharmacological inhibition of AMPK activity abolished the promoting effect of Enpp1 on PPARα protein expression.

CONCLUSIONS

This study indicate that Enpp1 can effectively ameliorate MAFLD through effects on AMPK/PPARα signaling pathway-mediated lipid metabolism, revealing the significance of Enpp1 as a promising therapeutic target against MAFLD.

Irisin alleviates hepatic steatosis by activating the autophagic SIRT3 pathway

BACKGROUND

Disruption of hepatic lipid homeostasis leads to excessive hepatic triglyceride accumulation and the development of metabolic dysfunction-associated steatotic liver disease (MASLD). Autophagy, a critical process in liver lipid metabolism, is impaired in MASLD pathogenesis. Irisin, a skeletal muscle-driven myokine, regulates lipid metabolism, but its impact on hepatic lipid metabolism is not well understood. Here, we aimed to explore the role of irisin in hepatic steatosis and the underlying mechanisms involved.

METHODS

A high-fat diet (HFD)-induced MASLD mouse model was used, and the recombinant irisin protein, herein referred to as "Irisin", was intraperitoneally administered for 4 weeks to evaluate the effects of irisin on hepatic lipid accumulation. Liver tissues were stained with Oil red O (ORO), and triglyceride (TG) and total cholesterol (TC) contents were measured in serum and liver homogenates. The expression of the autophagosome marker microtubule-associated protein 1 light chain 3 (LC3), the autophagy receptor protein sequestosome-1 (SQSTM1/p62), autophagy initiation complex unc-51-like kinase 1 (ULK1) and the lysosomal functional protein cathepsin B was measured via Western blotting, and the expression of the transcription factor EB (TFEB) was analyzed via immunofluorescence to explore autophagic changes. The effect of irisin on autophagic flux was further evaluated in palmitic acid-induced HepG2 cells by measuring autophagic degradation with chloroquine (CQ), and analyzing the colocalization of LC3 and lysosome-associated protein 1 (LAMP1). The possible mechanism was examined by measuring the expression of the autophagic sirtuin 3 (SIRT3) pathway and further validated using overexpression of SIRT3 with plasmid transfection or siRNA-mediated knockdown. Student's t-test was utilized for statistical analysis.

RESULTS

Irisin significantly reduces hepatic lipid accumulation in mice fed with HFD, accompanied by enhanced hepatocyte autophagy and upregulation of the SIRT3 pathway. In HepG2 cells, Irisin attenuated palmitic acid-induced lipid accumulation, which was partially dependent on SIRT3 levels. Mechanistically, Irisin treatment upregulated SIRT3 and phosphorylated AMP-activated protein kinase (AMPK), inhibited mammalian target of rapamycin (mTOR) activity, promoted TFEB nucleus translocation, increased cathepsin B expression, enhanced autophagic degradation, and alleviated hepatic steatosis. No significant changes in phosphorylation of ULK1 in the hepatocytes were observed. However, when siRNA was used to knock down SIRT3, the changes of those protein were partially reversed, and hepatic steatosis was further exacerbated.

CONCLUSIONS

Our findings highlight irisin as a potential therapeutic for hepatic steatosis by modulating autophagy and lipid metabolism, potentially providing a novel therapeutic target for the management of MASLD. Further research is needed to elucidate the underlying mechanisms and explore the potential clinical applications of this approach in the treatment of MASLD.

What is the role of nonalcoholic fatty liver disease in pulmonary carcinoma development?

This article summarizes the epidemiological characteristics and clinical manifestations of nonalcoholic fatty liver disease (NAFLD). The incidence of NAFLD has been increased dramatically and become the leading cause of chronic liver disease worldwide. In addition to its adverse outcomes of liver fibrosis, cirrhosis, and hepatocellular carcinoma, and related complications, NAFLD has recently been found to be associated with the high-risk extrahepatic carcinomas, such as various types of lung cancer (i.e., lung adenocarcinoma, squamous cell carcinoma, and small cell lung cancer). The presence of hepatic steatosis also predisposes lung cancer to liver metastasis, but has better response to immune checkpoint inhibitors. Whether other factors (i.e., gender, smoking, etc.) are associated with NAFLD and lung cancer remains controversial. We also comment on the reciprocal relationships between NAFLD and components of metabolic syndrome. Most metabolic syndrome components are suggested to facilitate lung cancer development via activating insulin/insulin-like growth factor axis. In addition, suppressed anti-tumor immunity and accelerated tumor progression could be attributed to the cell-specific metabolic reprogramming in condition of high-fat diet and related obesity. These findings may reveal the role of NAFLD in pulmonary carcinoma and help develop new treatment strategies for this disease.

Recent advances in incretin-based therapy for MASLD: from single to dual or triple incretin receptor agonists

Clinically effective pharmacological treatment(s) for metabolic dysfunction-associated steatotic liver disease (MASLD) and its progressive form metabolic dysfunction-associated steatohepatitis (MASH) represent a largely unmet need in medicine. Since glucagon-like peptide-1 receptor agonists (GLP-1RAs) have been licensed for the treatment of type 2 diabetes mellitus and obesity, they were one of the first drug classes to be examined in individuals with MASLD/MASH. Successful phase 2 randomised clinical trials with these agents have resulted in progression to phase 3 clinical trials (principally testing the long-term efficacy of subcutaneous semaglutide). Over the last few years, in addition to GLP-1RAs, newer agents with glucose-dependent insulinotropic peptide and/or glucagon receptor agonist functions have been tested, with increasing evidence from phase 2 randomised clinical trials of histological improvements in MASLD/MASH, as well as benefits on MASLD-related extrahepatic complications. Based on this background of evidence, single, dual or triple incretin receptor agonists are becoming an attractive and promising treatment option for MASLD or MASH, particularly in individuals with coexisting obesity or type 2 diabetes mellitus. In this narrative review, we examine the rapidly expanding body of clinical evidence supporting a role of incretin-based pharmacotherapies in delaying or reversing MASH progression. We also discuss the biology of incretins and the putative hepatoprotective mechanisms of incretin-based pharmacotherapies for managing MASLD or MASH.

Advances in research on metabolic dysfunction-associated steatotic liver disease

The global increase in obesity-related metabolic disorders has led to metabolic dysfunction-associated steatotic liver disease (MASLD) emerging as one of the most prevalent chronic liver disease worldwide. Despite growing concerns, the exact pathogenesis of MASLD remains unclear and no definitive treatments have been made available. Consequently, the need for comprehensive research on MASLD is more critical than ever. Gaining insight into the mechanisms of the disease can lay the groundwork for identifying new therapeutic targets and can facilitate the development of diagnostic tools that enable the early detection and intervention of MASLD. Research has discovered a multifactorial etiology for MASLD, suggesting that potential therapeutic strategies should be considered from a variety of perspectives. This review delves into the pathogenesis of MASLD, current diagnostic approaches, potential therapeutic targets, the status of clinical trials for emerging drugs, and the most promising treatment methods available today. With a focus on therapeutic targets, the aim is to offer fresh insights and guide for future research in the treatment of MASLD.

Epidemiology of metabolic dysfunction-associated steatotic liver disease

As the rates of obesity and type 2 diabetes (T2D) continue to increase globally, so does the prevalence of metabolic dysfunction-associated steatotic liver disease (MASLD). Currently, 38% of all adults and 7-14% of children and adolescents have MASLD. By 2040, the MASLD prevalence rate for adults is projected to increase to more than 55%. Although MASLD does not always develop into progressive liver disease, it has become the top indication for liver transplant in the United States for women and those with hepatocellular carcinoma (HCC). Nonetheless, the most common cause of mortality among patients with MASLD remains cardiovascular disease. In addition to liver outcomes (cirrhosis and HCC), MASLD is associated with an increased risk of developing de novo T2D, chronic kidney disease, sarcopenia, and extrahepatic cancers. Furthermore, MASLD is associated with decreased health-related quality of life, decreased work productivity, fatigue, increased healthcare resource utilization, and a substantial economic burden. Similar to other metabolic diseases, lifestyle interventions such as a heathy diet and increased physical activity remain the cornerstone of managing these patients. Although several obesity and T2D drugs are available to treat co-morbid disease, resmetirom is the only MASH-targeted medication for patients with stage 2-3 fibrosis that has approved by the Food and Drug Administration for use in the United States. This review discusses MASLD epidemiology and its related risk factors and outcomes and demonstrates that without further global initiatives, MASLD incidence could continue to increase.

Association Between Active DNA Demethylation and Liver Fibrosis in Individuals with Metabolic-Associated Steatotic Liver Disease (MASLD)

Metabolic-associated steatotic liver disease (MASLD) represents the most common chronic hepatopathy worldwide and an independent risk factor for cardiovascular disease and mortality, particularly when liver fibrosis occurs. Epigenetic alterations, such as DNA methylation, may influence MASLD susceptibility and progression; yet mechanisms underlying this process are limited. This study aimed to investigate whether active DNA demethylation in peripheral blood mononuclear cells (PBMCs) from individuals with MASLD, alongside the methylation and mRNA levels of inflammation- and fibrosis-related candidate genes, is associated with liver fibrosis. For this study, global demethylation intermediates (5-hydroxymethylcytosine [5hmC], 5-formylcytosine [5fC]) were quantified in PBMCs from 89 individuals with/without MASLD using ELISA. Site-specific DNA methylation of SOCS3, SREBF1, and TXNIP was analyzed by mass spectrometry-based bisulfite sequencing; mRNA expression was assessed via RT-PCR. Individuals with MASLD and moderate-to-high fibrosis risk (estimated by the fibrosis non-alcoholic steatohepatitis (NASH) index, FNI) progressively exhibited greater global 5hmC and 5fC levels. Higher FNI was associated with reduced methylation of the SOCS3 gene and increased mRNA expression of the SOCS3, TXNIP, IL-6, and MCP-1 genes. In conclusion, elevated fibrosis risk in MASLD is associated with active global DNA demethylation, as well as differential methylation and expression patterns of genes, which are key regulators of inflammation and fibrosis. These epigenetic alterations in PBMCs may mirror DNA methylation changes in the liver, which may potentially contribute to liver fibrogenesis and represent novel biomarkers for MASLD progression toward fibrosis.

Ultra-Processed Food Consumption and Metabolic-Dysfunction-Associated Steatotic Liver Disease (MASLD): A Longitudinal and Sustainable Analysis

BACKGROUND

The rising prevalence of metabolic-dysfunction-associated steatotic liver disease (MASLD) is a significant health challenge, and the consumption of ultra-processed foods (UPFs) could play a key role.

AIM

The aim is assess the impact of UPF consumption changes on the development and progression of MASLD in adults.

DESIGN

This is a longitudinal study to assess how changes in UPF consumption affect liver fat and MASLD parameters over 6 months in 70 participants.

METHODS

Dietary intake was assessed using a validated food frequency questionnaire, and foods were classified according to the NOVA system. Participants were divided into three groups based on UPF consumption changes: maximum (T1), medium (T2), and minimum reduction (T3). Fatty liver parameters were assessed with magnetic resonance imaging and ultrasonography. Mediterranean diet (Med-diet) adherence and sociodemographic parameters were also recorded. The General Linear Model was used to determine relationships between UPF consumption, fatty liver disease parameters, and diet.

RESULTS

Participants in T1 experienced a 7.7% reduction in intrahepatic fat content (IFC) compared to 2.6% in T3. T1 showed increased Med-diet adherence and decreased meat and sweets consumption. The energy intake decreased by 605.3 kcal/day in T1, while T3 showed an increase of 209.5 kcal/day.

CONCLUSIONS

Reducing UPF consumption leads to a decrease in IFC, associated with high Med-diet adherence and low calorie intake. Adopting these dietary patterns aligns with global sustainability goals and could further benefit MASLD patients by addressing environmental challenges alongside improving liver health.

Impact of Sexual Dimorphism on Therapy Response in Patients with Metabolic Dysfunction-Associated Steatotic Liver Disease: From Conventional and Nutritional Approaches to Emerging Therapies

Metabolic dysfunction-associated steatotic liver disease (MASLD) represents a spectrum of liver disease ranging from hepatic fat accumulation to steatohepatitis (metabolic dysfunction-associated steatohepatitis, MASH), fibrosis, cirrhosis, and potentially hepatocellular carcinoma in the absence of excessive alcohol consumption. MASLD is characterized by substantial inter-individual variability in terms of severity and rate of progression, with a prevalence that is generally higher in men than in women. Steroids metabolism is characterized by sexual dimorphism and may have an impact on liver disease progression; indeed, several therapeutic strategies targeting hormone receptors are under phase 2/3 development. Despite the fact that the importance of sexual dimorphism in the setting of MASLD is well recognized, the underlying molecular mechanisms that can potentially drive the disease toward progression are not clear. The aim of this review is to delve into the crosstalk between sexual dimorphism and steroid hormone perturbation under nutritional and pharmacological intervention.

Metabolic dysfunction-associated steatotic liver disease and type 2 diabetes: A dual threat to cardiac dysfunction progression

Metabolic dysfunction-associated steatotic liver disease (MASLD), particularly in patients with type 2 diabetes mellitus (T2DM), is increasingly recognized as a multi-system disease that affects both hepatic and cardiovascular health. This study explores the association between MASLD-related liver fibrosis and cardiac dysfunction, focusing on how liver fibrosis contributes to cardiac remodeling and dysfunction. Cernea et al's research highlights the strong correlation between liver fibrosis and changes in left ventricular mass, left atrial dimensions, and systolic and diastolic function in diabetic patients. Notably, the study suggests a protective role of sex-hormone binding protein against cardiac remodeling. These findings underline the importance of early detection of liver fibrosis using non-invasive markers like fibrosis-4 index and nonalcoholic fatty liver disease fibrosis scores, which may offer dual protection for both liver and heart health in T2DM patients. Moreover, this study calls for further research into the shared pathogenic mechanisms, including inflammation and fibrosis pathways, between the liver and heart. It advocates for the integration of liver fibrosis screening into cardiovascular risk management, urging clinicians to adopt a more holistic approach in treating patients with MASLD and T2DM. The research has broad implications for preventing cardiovascular complications and improving outcomes in this high-risk population.

The fibrosis-4 index and its association with carotid atherosclerosis in type 2 diabetes: a cross-sectional study in China

BACKGROUND

The medical community has long been concerned about the cardiovascular disease risk in patients with type 2 diabetes. While liver fibrosis scores were originally designed for application in individuals with liver steatosis, an increasing number of studies have shown that they are also associated with cardiovascular disease risk. However, the association between Fibrosis-4 (Fib-4) in liver fibrosis scores and carotid atherosclerosis (CA) in patients with type 2 diabetes remains unclear.

OBJECTIVE

The aim of this study is to investigate the association between the Fib-4 index and CA in patients with Type 2 diabetes. Additionally, it seeks to determine whether this relationship is influenced by factors including gender, age, body mass index (BMI), hypertension, and other variables.

METHODS

Screening based on inclusion and exclusion criteria identified 2658 hospitalized patients with type 2 diabetes. Subsequently, patients were divided into three groups according to Fib-4 values (Fib-4 < 1.3, 1.3 ≤ Fib-4 < 2.67, Fib-4 ≥ 2.67). Logistic regression analysis was then applied to evaluate the association between Fib-4 and the presence of CA in type 2 diabetes. Further stratified analyses were conducted considering gender, age (using 60 years as the threshold), hypertension status, smoking, alcohol consumption, and BMI groups (using 24 kg/m2 as the threshold), aiming to investigate potential effect heterogeneity within predefined subgroups. ROC curve analysis was used to evaluate the predictive power of the Fib-4 value for CA, increased CIMT, and carotid plaques.

RESULTS

The study encompassed 2658 patients diagnosed with type 2 diabetes, comprising 1441 males and 1217 females, with an average age of 56.71 ± 10.22 years. Among them, 1736 individuals (65.3%) exhibited CA, 1243 (46.8%) had increased carotid intima-media thickness (CIMT), and 1273 (47.9%) manifested carotid plaques. Following adjustments for various factors, the prevalence of CA exhibited a progressive increase in the Fib-4 < 1.3, 1.3 ≤ Fib-4 < 2.67, and Fib-4 ≥ 2.67 groups, with statistically significant differences (P < 0.05). Moreover, the prevalence of increased CIMT and carotid plaques in the Fib-4 ≥ 2.67 group remained significantly higher than that in the Fib-4 < 1.3 group after considering various factors (P < 0.05). In the 1.3 ≤ Fib-4 < 2.67 group, subsequent to adjustments for gender, smoking, and drinking, the prevalence of increased CIMT and carotid plaques surpassed that in the Fib-4 < 1.3 group (P < 0.05). Despite further adjustments for multiple factors, the prevalence of increased CIMT and carotid plaques persisted higher than that in the Fib-4 < 1.3 group, yet the difference lacked statistical significance (P > 0.05). The results of the ROC curve analysis indicated that the AUC for Fib-4 predicting CA was 0.602 (P < 0.001, 95% CI: 0.579-0.625), while the AUC values for increased CIMT and carotid plaques were 0.561 (P < 0.001, 95% CI: 0.540-0.583) and 0.580 (P < 0.001, 95% CI: 0.558-0.601), respectively.

CONCLUSION

Elevated Fib-4 levels (Fib-4 ≥ 1.3) are positively associated with CA in patients with type 2 diabetes, including increased CIMT and the presence of carotid plaques. As such, Fib-4 may serve as a potential biomarker for the detection of CA in patients with type 2 diabetes. However, its clinical utility needs further validation, particularly in larger sample sizes and multicenter studies.

Risk of hepatic events associated with use of sodium-glucose cotransporter-2 inhibitors versus glucagon-like peptide-1 receptor agonists, and thiazolidinediones among patients with metabolic dysfunction-associated steatotic liver disease

OBJECTIVE

To examine the hepatic effectiveness of sodium-glucose cotransporter-2 inhibitors (SGLT-2i) through a head-to-head comparison with glucagon-like peptide-1 receptor agonists (GLP-1RA) or thiazolidinediones (TZD) in patients with metabolic dysfunction-associated steatotic liver disease (MASLD).

DESIGN

This population-based cohort study was conducted using a nationwide healthcare claims database (2014-2022) of Korea. We included individuals with MASLD (aged ≥40 years) who initiated SGLT-2i or comparator drugs (GLP-1RA or TZD). Primary outcome was a composite of hepatic decompensation events, including ascites, oesophageal varices with bleeding, hepatic failure or liver transplant. Liver-cause death and all-cause death were also assessed as secondary outcomes. Cox proportional hazards models were used to estimated HRs with 95% CIs.

RESULTS

After 1:1 propensity score matching, we included 22 550 patients who initiated SGLT-2i and GLP-1RA (median age=57 years, 60% male), and 191 628 patients who initiated SGLT-2i and TZD (median age=57 years, 72% male). Compared with GLP-1RA, SGLT-2i showed a similar risk of hepatic decompensation events (HR 0.93, 95% CI 0.76 to 1.14). Compared with TZD, SGLT-2i demonstrated a reduced risk of hepatic decompensation events (HR 0.77, 95% CI 0.72 to 0.82). As compared with TZD, the results of secondary analyses showed significantly lower hepatic decompensation event risks with SGLT-2i when stratified by sex (male: HR 0.87 (95% CI 0.80-0.94); female: HR 0.62 (95% CI 0.55-0.69)).

CONCLUSIONS

In this nationwide cohort study, SGLT-2i was associated with a lower risk of hepatic decompensation events in patients with MASLD compared with TZD, while demonstrating similar effectiveness to GLP-1RA.

Exploring the molecular mechanisms of tirzepatide in alleviating metabolic dysfunction-associated fatty liver in mice through integration of metabolomics, lipidomics, and proteomics

Clinical studies have suggested that tirzepatide may also possess hepatoprotective effects; however, the molecular mechanisms underlying this association remain unclear. In our study, we performed biochemical analyses of serum and histopathological examinations of liver tissue in mice. To preliminarily explore the molecular mechanisms of tirzepatide on metabolic dysfunction-associated fatty liver disease (MAFLD), liquid chromatography-mass spectrometry (LC-MS) was employed for comprehensive metabolomic, lipidomic, and proteomic analyses in MAFLD mice fed a high-fat diet (HFD). The results demonstrated that tirzepatide significantly reduced serum levels of alanine transaminase (ALT) and aspartate transaminase (AST), as well as hepatic triglycerides (TG) and total cholesterol (TC), indicating its efficacy in treating MAFLD. Further findings revealed that tirzepatide reduced fatty acid uptake by downregulating Cd36 and Fabp2/4, as well as enhance the mitochondrial-lysosomal function by upregulating Lamp1/2. In addition, tirzepatide promoted cholesterol efflux and reduced cholesterol reabsorption by upregulating the expression of Hnf4a, Abcg5, and Abcg8. These results suggest that tirzepatide exerts its therapeutic effects on MAFLD by reducing fatty acid uptake, promoting cholesterol excretion, and enhancing mitochondrial-lysosomal function, providing a theoretical basis for a comprehensive understanding of tirzepatide.

The correlation between heavy metal ions in blood and metabolic dysfunction-associated steatotic liver disease from 1999 to 2018 based on NHANES data

Background

Metabolic-associated steatohepatitis and liver fibrosis (MASLD) is a growing public health concern, with environmental factors potentially playing a role in its development. This study aimed to investigate the associations between serum cadmium and mercury levels and the risk of MASLD in a nationally representative sample from the United States.

Methods

Data from the National Health and Nutrition Examination Survey from 1999 to 2018 were analyzed. Serum cadmium and mercury concentrations were measured, and MASLD was defined based on established criteria. Logistic regression models were used to assess the associations between serum metal levels and MASLD, with adjustments for potential confounders. Stratified analyses and restricted cubic spline curves were employed to examine subgroup differences and nonlinear relationships.

Results

The study revealed significant inverse associations between serum cadmium and mercury levels and the likelihood of MASLD. Individuals in the highest quartiles of cadmium and mercury had lower odds of MASLD compared to those in the lowest quartiles (Model 3: Cadmium Q4 vs. Q1, Mercury Q4 vs. Q1). Stratified analyses showed stronger inverse associations in older adults, males, and never smokers for cadmium, and in females and individuals without diabetes for mercury. Nonlinear dose-response curves indicated critical thresholds beyond which the risk dynamics changed.

Conclusion

Higher serum levels of cadmium and mercury were associated with a lower risk of MASLD, with notable variations across subgroups. These findings challenge the conventional understanding of these heavy metals as universally harmful and highlight the need for further research to unravel the complex interplay between environmental exposures and MASLD pathophysiology.

Association Between Metabolic Dysfunction-Associated Steatotic Liver Disease and Thyroid Cancer

Background: Metabolic dysfunction-associated steatotic liver disease (MASLD) represents a hepatic manifestation of metabolic syndrome. This study investigated the association between newly developed nomenclature MASLD and the risk of thyroid cancer in the Korean population. Methods: After excluding individuals with a history of liver disease or malignancy, we analyzed a cohort of 214,502 Korean adults aged 40 years and above who participated in the National Health Screening Program from 2009 to 2010. Participants were categorized into four groups: no steatotic liver disease (SLD) without a cardiometabolic risk factor (CMRF), no SLD with at least one CMRF, MASLD, and metabolic and alcohol-related/associated liver disease (MetALD). SLD was diagnosed using a fatty liver index threshold of ≥30. The primary outcome was the diagnosis of new thyroid cancer during the follow-up period. We examined the relationship between CMRF/SLD and thyroid cancer incidence using the multivariable-adjusted Cox proportional hazards model. Results: A total of 2761 participants (1.3%) were newly diagnosed with thyroid cancer over an average follow-up of 9.61 years. Compared with participants without CMRF and SLD, those with CMRF (hazard ratio [HR] 1.33, confidence interval [CI] 1.16-1.52), those with MASLD (HR 1.36, CI 1.17-1.58), and the MetALD group (HR 1.40, CI 1.04-1.88) exhibited a significantly higher risk of thyroid cancer. In addition, MetALD is significantly associated with thyroid cancer incidence solely in men. Conclusions: In addition to CMRF, MASLD and MetALD were associated with a higher incidence of thyroid cancer in the Korean population. This study is the first to demonstrate the association between thyroid cancer and the CMRF-MASLD-MetALD continuum.

Immune Microenvironment and the Effect of Vascular Endothelial Growth Factor Inhibition in Hepatocellular Carcinoma

Systemic therapy for unresectable hepatocellular carcinoma (HCC) has progressed with the development of multiple kinases, such as vascular endothelial growth factor (VEGF) signaling, targeting cancer growth and angiogenesis. Additionally, the efficacy of sorafenib, regorafenib, lenvatinib, ramucirumab, and cabozantinib has been demonstrated in various clinical trials, and they are now widely used in clinical practice. Furthermore, the development of effective immune checkpoint inhibitors has progressed in systemic therapy for unresectable HCC, and atezolizumab + bevacizumab (atezo/bev) therapy and durvalumab + tremelimumab therapy are now recommended as first-line treatment. Atezo/bev therapy, which combines an anti-programmed cell death 1 ligand 1 antibody with an anti-VEGF antibody, is the first cancer immunotherapy to demonstrate efficacy against unresectable HCC. With the increasing popularity of these treatments, VEGF inhibition is attracting attention from the perspective of its anti-angiogenic effects and impact on the cancer-immune cycle. In this review, we outline the role of VEGF in the tumor immune microenvironment and cancer immune cycle in HCC and outline the potential immune regulatory mechanisms of VEGF. Furthermore, we consider the potential significance of the dual inhibition of angiogenesis and immune-related molecules by VEGF, and ultimately aim to clarify the latest treatment strategies that maximizes efficacy.

Small intestinal bacterial overgrowth and metabolic dysfunction-associated steatotic liver disease

Small intestinal bacterial overgrowth (SIBO), characterized by alterations in both the type and quantity of bacteria in the small intestine, leads to impaired intestinal digestion and absorption that can cause a range of clinical symptoms. Recent studies have identified significant changes in the composition of the small intestinal microbiota and metabolomic profiles of patients with metabolic dysfunction-associated steatotic liver disease (MASLD). This study systematically reviewed and synthesized the available data to explore the association between SIBO and MASLD. Comprehensive literature searches of the Embase, PubMed, Web of Science, Ovid, and Cochrane databases were conducted. Article quality screening was performed using the Newcastle-Ottawa Quality Assessment Scale. Cross-sectional, cohort, and case-control studies were included. A total of 7,200 articles were initially screened, of which 14 were ultimately included for analysis. Individuals with SIBO in both the MASLD and non-MASLD groups were extracted and a chi-square test was performed to calculate the odds ratio (OR) and 95% confidence interval (CI). The I2 index was used to measure heterogeneity. For heterogeneity >50%, a random effects model was used. There was a clear association between SIBO and MASLD (OR = 3.09; 95% CI 2.09-4.59, I 2 = 66%, p < 0.0001). Subgroup analyses by MASLD stage showed that the probability of SIBO positivity increased with MASLD lesion severity. After stratifying by the diagnostic methods for SIBO and MASLD, the meta-analysis results suggest a reduction in inter-group heterogeneity. For the MASLD subgroup diagnosed via liver biopsy, the OR was 4.89. A subgroup analysis of four studies that included intestinal permeability testing revealed an OR of 3.86 (95% CI: 1.80-8.28, I 2 = 9%, p = 0.0005). A meta-regression analyses revealed that both race and regional development level significantly influenced the relationship between SIBO and MASLD (p = 0.010, p = 0.047). In conclusion, this meta-analyses provides strong evidence that SIBO may contribute to the development and progression of MASLD. The strongest associations were observed between lactulose breath testing, gut microbiota culture, liver biopsy diagnosis of MASLD, and SIBO detected through intestinal permeability testing. The primary sources of heterogeneity are race and developed regions.

Systematic Review Registration

https://www.crd.york.ac.uk/PROSPERO/display_record.php?RecordID=427040.

Exploring the Role of Peroxisome Proliferator-Activated Receptors and Endothelial Dysfunction in Metabolic Dysfunction-Associated Steatotic Liver Disease

The endothelium is a well known regulator of vascular homeostasis. Several factors can influence the balance of the bioavailability of active substances. This imbalance can lead to inflammation and, consequently, endothelial dysfunction, which is an underlying pathology in cardiovascular disease that commonly coexists with metabolic and chronic diseases such as metabolic dysfunction-associated steatotic liver disease (MASLD). In MASLD, a reduction in nitric oxide availability is observed, and as a result, hepatic stellate cells and liver sinusoidal endothelial cells are activated. Considering the extensive research dedicated to finding several targets with diagnostic and therapeutic effects, nuclear hormone receptors such as peroxisome proliferator-activated receptors have been highlighted as being highly influential in the gut-liver-adipose axis and are considered potential regulators of metabolism and inflammation in several pathologies. Currently, PPAR agonists are widely explored in clinical trials and experimental studies. Agents such as lanifibranor, elafibranor, daidzein, and Icariin have shown promise in improving the metabolic, hepatic, and cardiovascular health of patients with MASLD. This review aims to provide a comprehensive overview of the role of peroxisome proliferator-activated receptors in endothelial dysfunction and MASLD, exploring their mechanisms in disease progression and potential pharmacological targeting.

Resmetirom and Metabolic Dysfunction-Associated Steatohepatitis: Perspectives on Multidisciplinary Management from Global Healthcare Professionals

PURPOSE OF REVIEW

The approval of resmetirom brings great hope to patients with metabolic dysfunction-associated steatohepatitis (MASH). The purpose of this review is to explore its impact on the global health environment. The implementation of multidisciplinary management MASH is proposed.

RECENT FINDINGS

Resmetirom has benefits in the treatment of MASH, and its safety and effectiveness have been studied. The adverse events (AEs) need to be noticed. To improve patient outcomes, a multimodal approach with medication such as resmetirom, combined with metabolic and bariatric surgery (MBS) and lifestyle interventions can be conducted. MASH, a liver disease linked with obesity, is a challenging global healthcare burden compounded by the absence of any approved pharmacotherapy. The recent conditional approval by the Food and Drug Administration (FDA) in the United States of resmetirom, an oral, liver-directed, thyroid hormone receptor beta-selective agonist, marks a significant milestone, offering a treatment option for adults with non-cirrhotic MASH and who have moderate to advanced liver fibrosis. This narrative review discusses the efficacy and safety of resmetirom and its role in the therapeutic landscape of MASH treatment. Despite the promising hepatoprotective effect of resmetirom on histological liver endpoints, its use need further research, particularly regarding ethnic differences, effectiveness and cost-effectiveness, production scalability, social acceptance and accessibility. In addition, integrating resmetirom with other multidisciplinary therapeutic approaches, including lifestyle changes and MBS, might further improve clinical liver-related and cardiometabolic outcomes of individuals with MASH. This review highlights the importance of a comprehensive treatment strategy, supporting continued innovation and collaborative research to refine treatment guidelines and consensus for managing MASH, thereby improving clinical patient outcomes in the growing global epidemic of MASH. Studies done to date have been relatively short and ongoing, the course of the disease is highly variable, the conditions of various patients vary, and given this complex clinical phenotype, it may take many years of clinical trials to show long-term benefits.

Association of healthy lifestyles with risk of all-cause and cause-specific mortality among individuals with metabolic dysfunction-associated steatotic liver disease: results from the DFTJ cohort

AIM

To examine the associations of healthy lifestyles with risk of all-cause and cause-specific mortality among adults with metabolic dysfunction-associated steatotic liver disease (MASLD), and whether the association was mediated by systemic immune-inflammatory biomarkers (SIIBs).

METHODS

The study included 10,347 subjects with MASLD, who were enrolled in the Dongfeng-Tongji cohort study. The healthy lifestyles referred to non-smoking, being physically active (≥7.5 metabolic equivalents-hours/week), low-risk alcohol consumption (1-14 g/day for women and 1-28 g/day for men), and optimal sleep duration (≥6 to ≤8 h/day). Cox proportional hazard models were used to examine the relationship between each lifestyle and SIIBs with the risk of all-cause and cause-specific mortality. A mediation analysis was conducted to investigate the role of SIIBs on the association between healthy lifestyles and mortality.

RESULTS

There were 418 MASLD subjects dead till the follow-up of 2018, including 259 deaths from cardiovascular disease (CVD). Compared to MASLD participants with 0-1 healthy lifestyle score (HLS), those with 3-4 HLS had the lowest risk of all-cause mortality [hazard ratio (HR), 0.46; 95% CI, (0.36-0.60)], and CVD mortality [HR (95%CI), 0.41 (0.29-0.58)]. Mediation analyses indicated that SIIBs mediated the association between healthy lifestyles and mortality, with proportions ranging from 2.5% to 6.1%.

CONCLUSIONS

These findings suggest that adherence to healthy lifestyles can significantly reduce mortality for MASLD patients, and the decreased SIIBs may partially explain the protection mechanism of healthy lifestyles.

Liver fibrosis as a barometer of systemic health by gauging the risk of extrahepatic disease

This review article proposes the theory that liver fibrosis, the abnormal accumulation of excessive extracellular matrix, is not just an indicator of liver disease but also a negative reflection of overall systemic health. Liver fibrosis poses a heavy financial burden on healthcare systems worldwide and can develop due to chronic liver disease from various causes, often due to sustained inflammation. Liver fibrosis may not generate symptoms and become apparent only when it reaches the stage of cirrhosis and is associated with clinically significant portal hypertension and leads to decompensation events or promotes the development of hepatocellular carcinoma. While chronic viral hepatitis and excessive alcohol consumption were once the primary causes of chronic liver disease featuring fibrosis, this role is now increasingly taken over by metabolic dysfunction-associated steatotic liver disease (MASLD). In MASLD, endothelial dysfunction is an essential component in pathogenesis, promoting the development of liver fibrosis, but it is also present in endothelial cells of other organs such as the heart, lungs, and kidneys. Accordingly, liver fibrosis is a significant predictor of liver-related outcomes, as well as all-cause mortality, cardiovascular risk, and extrahepatic cancer. Physicians should be aware that individuals seeking medical attention for reasons unrelated to liver health may also have advanced fibrosis. Early identification of these at-risk individuals can lead to a more comprehensive assessment and the use of various treatment options, both approved and investigational, to slow or reverse the progression of liver fibrosis.

Protective Effects of Plum on Liver and Gut Injury in Metabolic Dysfunction-Associated Fatty Liver Disease

Metabolic dysfunction-associated fatty liver disease (MASLD), a persistent liver condition associated with metabolic syndrome, is primarily caused by excessive fructose intake and a typical Western diet. Because there is currently only one approved treatment, lifestyle and dietary interventions are crucial. This study assessed the effects of dietary intervention involving freeze-dried plum (FDP), a natural source of antioxidants containing diverse polyphenols. This study aimed to assess its potential as a protective agent against the gut-liver axis and its therapeutic effects on liver injury and gut permeability issues associated with MASLD. We indicate that 10% FDP intake restored gut barrier proteins and reduced serum endotoxin levels in the MASLD mouse models. Additionally, 10% FDP intake significantly reduced hepatic oxidative stress, lipid metabolism, and fibrosis marker levels. Interestingly, FDP intake significantly reduced the levels of inflammatory cytokine tumor necrosis factor-α and markers of liver damage, such as serum alanine aminotransferase/aspartate aminotransferase and hepatic triglycerides. These results highlight that dietary intervention with FDP that acts as a natural antioxidant may be a significant protective and therapeutic agent against liver and gut damage caused by MASLD.

A machine learning algorithm for stratification of risk of cardiovascular disease in metabolic dysfunction-associated steatotic liver disease

BACKGROUND

Steatotic liver disease (SLD) is associated with adverse cardiac events. Metabolic dysfunction-associated steatotic liver disease (MASLD) has emerged as a condition characterized by the abnormal accumulation of hepatic lipids that is closely linked to five metabolic disorders: overweight or obesity, impaired glucose regulation, hypertension, hypertriglyceridemia, and low high-density lipoprotein-cholesterol. This retrospective study aimed to stratify the risk of cardiac events in patients with MASLD.

METHODS

Patients diagnosed with MASLD through ultrasonography were evaluated. We implemented a machine learning-based approach using a survival classification and regression tree (CART) model to stratify patients based on age, and the number of risk scores was investigated as a predictor of adverse outcomes in the derivation cohort. The primary outcomes were major adverse cardiac events (MACE) including cardiac death, nonfatal myocardial infarction, and revascularization due to coronary artery disease.

RESULTS

Among 2,962 patients (median age, 62 years; men, 53.5 %), the distribution of risk factors was as follows: one (10.8 %), two (28.5 %), three (33.0 %), four (19.9 %), and five (7.8 %). Over a median follow-up period of 6.8 years, 170 (5.7 %) patients experienced MACE. In the derivation cohort of 2,073 patients, the CART model identified age ≥60 years old and risk factors ≥4 as significant predictors of MACE. These findings were corroborated in a validation cohort of 889 patients. Patients meeting both criteria exhibited the highest risk of MACE (log-rank test, p < 0.001).

CONCLUSIONS

Patients aged ≥60 years old with risk factors ≥4 indicates at high risk of MACE in patients with MASLD. This risk stratification system provides a practical tool for identifying high-risk individuals in the MASLD population.

Evaluating cardiovascular risk in metabolic steatosis with precision medicine non-invasive approaches: insights from a cohort study

Metabolic associated steatotic liver disease (MASLD) is the most common liver condition. It is associated with increased liver-related morbidity and mortality, and also with high risk of cardiovascular events (CVD), representing itself an independent risk factor for it. This makes MASLD a presentation of high interest for internal medicine, also because of its association with metabolic syndrome (MetS). It is crucial to assess its risks in a noninvasive way. With the aim of finding specific risk profiles for CVD development in MASLD by performing a noninvasive assessment of: (1) preclinical signs of endothelial dysfunction (ED); (2) clinical assessment of CVD risk by Framingham Heart Risk Score (FHRs); (3) genomic characterization of MASLD associated polymorphisms; (4) specific untargeted metabolomic profiles, we enrolled 466 MASLD patients non-invasively classified in 4 group of liver fibrosis severity (group-A: low-fibrosis risk, group-B: high-fibrosis risk, group-C: MASLD-cirrhosis, group-D: MASLD-HCC) and 73 healthy controls. FHRs was similar in controls and low-fibrosis group and significantly higher in high-fibrosis patients, cirrhosis, and HCC, increasing among classes. At a multivariable regression, FHRs was associated with liver disease severity and diabetes. 38.2% of patients had altered EndoPAT, resembling ED. Patients with high FHRs (> 40%) and ED had different metabolomics compared to those without ED. Our study reveals that a deep, non-invasive characterization of MASLD patients through precision medicine approaches (untargeted metabolomics, SNPs, ED assessment) was able to show a peculiar pattern in MASLD patients with increased CVD risk, mostly correlated with liver disease severity.

Discovery of N-Aryl-N'-[4-(aryloxy)cyclohexyl]squaramide-Based Inhibitors of LXR/SREBP-1c Signaling Pathway Ameliorating Steatotic Liver Disease: Navigating the Role of SIRT6 Activation

Metabolic dysfunction-associated steatotic liver disease (MASLD) is primarily attributed to the abnormal upregulation of hepatic lipogenesis, which is especially caused by the overactivation of the liver X receptor/sterol regulatory element-binding protein-1c (LXR/SREBP-1c) pathway in hepatocytes. In this study, we report the rational design and synthesis of a novel series of squaramides via bioisosteric replacement, which was evaluated for its inhibitory activity on the LXR/SREBP-1c pathway using dual cell-based assays. Compound 31 was found to significantly downregulate LXR, SREBP-1c, and their target genes associated with lipogenesis. Further investigation revealed that compound 31 may indirectly inhibit the LXR/SREBP-1c pathway by activating the upstream regulator sirtuin 6 (SIRT6). Encouragingly, compound 31 substantially attenuated lipid accumulation in HepG2 cells and in the liver of high-fat-diet-fed mice. These findings suggest that compound 31 holds promise as a candidate for the development of treatments for MASLD and other lipid metabolism-related diseases.

Long-term liver-related outcomes and liver stiffness progression of statin usage in steatotic liver disease

BACKGROUND

Statins have multiple benefits in patients with metabolic-associated steatotic liver disease (MASLD).

AIM

To explore the effects of statins on the long-term risk of all-cause mortality, liver-related clinical events (LREs) and liver stiffness progression in patients with MASLD.

METHODS

This cohort study collected data on patients with MASLD undergoing at least two vibration-controlled transient elastography examinations at 16 tertiary referral centres. Cox regression analysis was performed to examine the association between statin usage and long-term risk of all-cause mortality and LREs stratified by compensated advanced chronic liver disease (cACLD): baseline liver stiffness measurement (LSM) of ≥10 kPa. Liver stiffness progression was defined as an LSM increase of ≥20% for cACLD and from <10 kPa to ≥10 or LSM for non-cACLD. Liver stiffness regression was defined as LSM reduction from ≥10 kPa to <10 or LSM decrease of ≥20% for cACLD.

RESULTS

We followed up 7988 patients with baseline LSM 5.9 kPa (IQR 4.6-8.2) for a median of 4.6 years. At baseline, 40.5% of patients used statins, and cACLD was present in 17%. Statin usage was significantly associated with a lower risk of all-cause mortality (adjusted HR=0.233; 95% CI 0.127 to 0.426) and LREs (adjusted HR=0.380; 95% CI 0.268 to 0.539). Statin usage was also associated with lower liver stiffness progression rates in cACLD (HR=0.542; 95% CI 0.389 to 0.755) and non-cACLD (adjusted HR=0.450; 95% CI 0.342 to 0.592), but not with liver stiffness regression (adjusted HR=0.914; 95% CI 0.778 to 1.074).

CONCLUSIONS

Statin usage was associated with a relatively lower long-term risk of all-cause mortality, LREs and liver stiffness progression in patients with MASLD.

Immunological mechanisms in steatotic liver diseases: An overview and clinical perspectives

Steatotic liver diseases (SLD) are the principal worldwide cause of cirrhosis and end-stage liver cancer, affecting nearly a quarter of the global population. SLD includes metabolic dysfunction-associated alcoholic liver disease (MetALD) and metabolic dysfunction-associated steatotic liver disease (MASLD), resulting in asymptomatic liver steatosis, fibrosis, cirrhosis and associated complications. The immune processes include gut dysbiosis, adiposeliver organ crosstalk, hepatocyte death and immune cell-mediated inflammatory processes. Notably, various immune cells such as B cells, plasma cells, dendritic cells, conventional CD4+ and CD8+ T cells, innate-like T cells, platelets, neutrophils and macrophages play vital roles in the development of MetALD and MASLD. Immunological modulations targeting hepatocyte death, inflammatory reactions and gut microbiome include N-acetylcysteine, selonsertib, F-652, prednisone, pentoxifylline, anakinra, JKB-121, HA35, obeticholic acid, probiotics, prebiotics, antibiotics and fecal microbiota transplantation. Understanding the immunological mechanisms underlying SLD is crucial for advancing clinical therapeutic strategies.

Liver and cardiovascular outcomes in lean non-alcoholic fatty liver disease: an updated systematic review and meta-analysis of about 1 million individuals

BACKGROUND AND AIMS

Non-alcoholic fatty liver disease (NAFLD) is present in lean people. However, the magnitude of the prognostic hepatic and cardiovascular risk in these patients compared to non-lean counterparts remains unclear. We aimed to investigate this topic, and to explore whether these risks change based on factors related to NAFLD severity.

METHODS

PubMed and Embase databases were searched for cohort studies (published through April 2024) that evaluated liver and cardiovascular (CV) outcomes in lean and non-lean individuals with NAFLD and reported unadjusted or adjusted data. We pooled risk ratios (RRs) or hazard ratios (HRs) using a random-effects modeling and performed subgroup and meta-regressions analyses.

RESULTS

We identified 22 studies with over 1 million NAFLD patients (13.0% were lean). Lean NAFLD showed a similar risk of liver-related events in unadjusted analysis (RR 1.08, 95% CI 0.79-1.49, I2 = 31%), but a higher risk in adjusted analysis (HR 1.66, 95% CI 1.17-2.36, I2 = 83%) compared to non-lean NAFLD. Lean NAFLD had a higher risk of liver-related mortality (RR 2.22, 95% CI 1.57-3.15, I2 = 0%; HR 2.26, 95% CI 1.14-4.51, I2 = 0%). For CV outcomes, lean NAFLD had a lower risk of any cardiovascular disease in unadjusted analysis (RR = 0.82, 95% CI 0.70-0.95, I2 = 88%), but similar risk in adjusted analysis (HR 0.89, 95% CI 0.77-1.02, I2 = 78%), and similar risk of cardiovascular mortality (RR 1.09, 95% CI 0.71-1.66, I2 = 85%; HR 1.26, 95% CI 0.89-1.78, I2 = 46%) compared to non-lean NAFLD.

CONCLUSIONS

Lean NAFLD patients have worse liver outcomes, but similar CV outcomes compared to non-lean NAFLD patients, highlighting the importance of monitoring both groups closely.

Thyroid Hormone-Mediated Selective Autophagy and Its Implications in Countering Metabolic Dysfunction-Associated Steatotic Liver Disease

The influence of thyroid hormone (TH) on liver metabolism has attracted the attention of pharmacologists seeking new treatments for metabolic dysfunction-associated steatotic liver disease (MASLD), an increasingly common metabolic disorder. In this context, the selective induction of autophagy by TH in preclinical models has been identified as a promising mechanism. In this process, TH clears intrahepatic fat through lipophagy while protecting against inflammation and mitochondrial damage in hepatocytes via mitophagy. Furthermore, TH-induced aggrephagy may represent a protective mechanism to mitigate the development of MASLD-associated hepatocellular carcinoma. Considering the defects in autophagy observed during the progression of human MASLD, the induction of autophagy by TH, its metabolites, and its analogs represent a novel strategy to combat hepatic damage across the MASLD spectrum.