Non-invasive score identifies ultrasonography-diagnosed non-alcoholic fatty liver disease and predicts mortality in the USA

Non-invasive tools for liver steatosis and steatohepatitis predict incidence of diabetes, cardiovascular disease and mortality 20 years later: The ATTICA cohort study (2002-2022)

BACKGROUND & AIMS

Non-alcoholic fatty liver disease (NAFLD) or, as recently renamed, metabolic dysfunction-associated steatotic liver disease (MASLD), has common metabolic pathways with diabetes and cardiovascular disease (CVD). Non-invasive tools (NITs) for liver steatosis and steatohepatitis (MASH) were studied as potential predictors of diabetes, cardiovascular disease (CVD) and mortality over a 20-year period.

METHODS

In 2001-02, 3042 individuals from the Attica region of Greece were recruited randomly, and were stratified by subgroups of sex, age and region to reflect the general urban population in Athens, Greece. Validated NITs for hepatic steatosis (Hepatic Steatosis Index (HIS), Fatty Liver Index (FLI), Lipid Accumulation Product (LAP), NAFLD liver fat score (NAFLD-LFS)) and steatohepatitis (Index of non-alcoholic steatohepatitis (ION), aminotransferase-creatinine-clearance non-alcoholic steatohepatitis (acNASH)) were calculated. Incidence of diabetes, CVD and mortality were recorded 5, 10 and 20 years later.

RESULTS

Within a 20-year observation period, the diabetes and CVD incidence was 26.3% and 36.1%, respectively. All hepatic steatosis and steatohepatitis NITs were independently associated with diabetes incidence. ION and acNASH presented independent association with CVD incidence [(Hazard Ratio (HR)per 1 standard deviation (SD) = 1.33, 95% Confidence Interval (95% CI) (1.07, 1.99)) and (HRper 1 SD = 1.77, 95% CI (1.05, 2.59)), respectively]. NAFLD-LFS which is a steatosis NIT indicating features of steatohepatitis, was linked with increased CVD mortality (HRper 1 SD = 1.35, 95% CI (1.00, 2.30)) and all-cause mortality (HRper 1 SD = 1.43, 95% CI (1.08, 2.01)). Overall, steatohepatitis NITs (i.e., ION and acNASH) presented stronger associations with the outcomes of interest compared with steatosis NITs. Clinically important trends were observed in relation to diabetes and CVD incidence progressively over time, i.e. 5, 10 and 20 years after baseline.

CONCLUSIONS

Easily applicable and low-cost NITs representing steatohepatitis may be early predictors of diabetes and CVD onset. More importantly, these NITs increased the attributable risk conveyed by conventional CVD risk factors by 10%. Thus, their potential inclusion in clinical practice and guidelines should be studied further.

Mortality in metabolic dysfunction-associated steatotic liver disease: A nationwide population-based cohort study

BACKGROUND

A new fatty liver disease nomenclature, steatotic liver disease (SLD) has been proposed; however, there are no data on clinical outcomes. We investigated the impact of SLD with metabolic dysfunction (MD; SLD-MD) on all-cause mortality.

METHODS

We evaluated nationally representative participants aged ≥19 years using data from the Korea National Health and Nutrition Examination Survey 2007-2015 and their linked death data through 2019. The presence of fatty liver disease was assessed by liver fat score, fatty liver index and significant liver fibrosis was evaluated by the Fibrosis-4 Index, and fibrosis score. SLD-MD was categorized into three groups: metabolic dysfunction-associated steatotic liver disease (MASLD); metabolic alcoholic liver disease (MetALD); and SLD with other combination etiologies.

RESULTS

Among 26734 individuals (11561 men and 15173 women, mean age 48.8 years), 1833 (6.9 %) died during a mean follow-up period of 110.6 ± 33.9 months. Mortality risk was significantly higher in individuals with SLD-MD (hazard ratio [HR] = 1.35) than in those without (P < 0.001). Among the three groups, MASLD (HR = 1.32) and SLD with other combination etiologies (HR = 2.06) independently increased mortality risk (all P < 0.001). When individuals with SLD-MD had significant liver fibrosis or diabetes, mortality risk increased further (HR = 1.68 and 1.85, respectively; all P < 0.001). SLD-MD with both significant liver fibrosis and diabetes showed the highest mortality risk (HR = 2.29, P < 0.001). When applied fatty liver index and fibrosis score, similar results were observed.

CONCLUSIONS

SLD-MD is associated with a higher mortality risk. When SLD-MD was combined with significant liver fibrosis or diabetes, the mortality risk became much higher. Treatment strategies to reduce fibrotic burden and improve glycemic control in individuals with MASLD are needed.

Biomarkers of Hepatic Dysfunction and Cardiovascular Risk

PURPOSE OF REVIEW

The objective of this manuscript is to examine the current literature on non-alcoholic fatty liver disease (NAFLD) biomarkers and their correlation with cardiovascular disease (CVD) outcomes and cardiovascular risk scores.

RECENT FINDINGS

There has been a growing appreciation for an independent link between NAFLD and CVD, culminating in a scientific statement by the American Heart Association in 2022. More recently, studies have begun to identify biomarkers of the three NAFLD phases as potent predictors of cardiovascular risk. Despite the body of evidence supporting a connection between hepatic biomarkers and CVD, more research is certainly needed, as some studies find no significant relationship. If this relationship continues to be robust and readily reproducible, NAFLD and its biomarkers may have an exciting role in the future of cardiovascular risk prediction, possibly as risk-enhancing factors or as components of novel cardiovascular risk prediction models.

Lipid accumulation product (LAP) index for the diagnosis of nonalcoholic fatty liver disease (NAFLD): a systematic review and meta-analysis

BACKGROUND

Lipid accumulation product (LAP) is an index calculated by waist circumference (WC) and triglyceride (TG), which reflects lipid toxicity. This study aims to investigate the association between the LAP index and nonalcoholic fatty liver disease (NAFLD) in a systematic review and meta-analysis.

METHODS AND RESULTS

PubMed, Scopus, and Web of Science online databases were searched for eligible studies that investigated the association of the LAP index and NAFLD. Sixteen observational studies with 96,101 participants, including four cohort studies, one case‒control study and 11 cross-sectional studies with baseline data, were entered into this analysis. Fourteen studies reported a significant association between the LAP index and NAFLD, and two reported that this relation was not significant; two different meta-analyses (1- mean difference (MD) and 2- bivariate diagnostic test accuracy [DTA]) were conducted using Stata version 14. The LAP index was compared in subjects with and without NAFLD, and the difference was significant with 34.90 units (CI 95: 30.59-39.31, P < 0.001) of the LAP index. The DTA meta-analysis was conducted and showed that the LAP index pooled sensitivity and specificity for screening of NAFLD were 94% (CI95: 72%-99%, I2 = 99%, P < 0.001) and 85% (CI95: 62%-96%, I2 = 99%, P < 0.001), respectively.

CONCLUSION

The LAP Index is an inexpensive, sensitive, and specific method to evaluate NAFLD and may be valuable for NAFLD screening.

Diagnostic accuracy of blood biomarkers and non-invasive scores for the diagnosis of NAFLD and NASH: Systematic review and meta-analysis

INTRODUCTION AND OBJECTIVES

Fatty liver disease is an important public health problem. Early diagnosis is critical to lower its rate of progression to irreversible/terminal stages. This study aimed to evaluate the accuracy of non-invasive prediction scores for fatty liver disease (NAFLD and NASH) diagnosis in adults.

MATERIALS AND METHODS

A search was conducted in 10 databases, a qualitative synthesis of 45 studies, and quantitative analysis of the six most common scores. There were 23 risk scores found for NAFLD diagnosis and 32 for NASH diagnosis. The most used were Fatty Liver Index (FLI), aspartate aminotransferase (AST) to Platelet Ratio Index, Fibrosis-4 Index (FIB-4), AST/alanine aminotransferase (ALT) ratio, BARD score, and NAFLD fibrosis score (NFS).

RESULTS

The results from the meta-analysis for FLI: Area under the curve (AUC) of 0.76 (95% Confidence Interval [CI] 0.73, 0.80), sensitivity 0.67 (CI 95% 0.62, 0.72) and specificity 0.78 (CI 95% 0.74, 0.83). The AST to Platelet Ratio Index: AUC 0.83 (CI 95% 0.80, 0.86), sensitivity 0.45 (95% CI 0.29, 0.62), and specificity of 0.89 (95% CI 0.83, 0.92). The NFS: AUC of 0.82 (CI 95% 0.78, 0.85), sensitivity 0.30 (CI 95% 0.27, 0.33) and specificity 0.96 (CI 95% 0.95,0.96).

CONCLUSIONS

The FLI for NAFLD and AST to Platelet Ratio Index for NASH were the risk scores with the highest prognostic value in the included studies. Further research is needed for the application of new diagnostic risk scores for NAFLD and NASH.

Validation of five hepatic steatosis algorithms in metabolic-associated fatty liver disease: A population based study

BACKGROUND AND AIM

Non-invasive hepatic steatosis algorithms are recommended in detecting metabolic-associated fatty liver disease (MAFLD) in epidemiological studies. However, the diagnostic accuracy of these models is unclear. This study aimed to evaluate the diagnostic efficiency of five common models in a national survey population.

METHODS

The Third National Health and Nutrition Examination Survey (NHANES III) datasets were used in this study. The fatty liver index (FLI), hepatic steatosis index (HSI), non-alcoholic liver disease-liver fat score (NAFLD-LFS), the steato text (ST), and visceral adiposity index (VAI) were evaluated.

RESULTS

The prevalence of MAFLD in the general population was 31.2%. The proportion of MAFLD estimated using the NAFLD-LFS (30.8%) was the closest to the real number, whereas the ST model (66.1%) significantly overestimated the prevalence of MAFLD in this cohort. The FLI (36.9%) and HSI models (38.5%) also slightly overestimated the prevalence of MAFLD in the study population. The FLI had the highest area under the receiver operating characteristic (AUROC) value (0.793) among all models, with a sensitivity of 57.0%, a specificity of 83.8%, a positive predictive value (PPV) of 67.3%, and a negative predictive value (NPV) of 77.0%. The combination of the original algorithm with additional metabolic dysfunction criteria did not improve the diagnostic efficiency. The discriminative ability for MAFLD in all models was lower in participants with a normal body mass index (BMI).

CONCLUSIONS

Non-invasive models, especially the FLI, have satisfactory diagnostic performance in detecting MAFLD. However, models in people with normal BMIs require further development.

Prevalence of Metabolic-associated Fatty Liver Disease in Mexico and Development of a Screening Tool: The MAFLD-S Score

Background and Aims

Metabolic-associated fatty liver disease (MAFLD) is a leading cause of chronic liver disease. Nowadays, the prevalence of MAFLD in Mexico is unknown with no screening point-of-care tools. We aimed to estimate the prevalence of MAFLD in Mexico and to develop a score for MAFLD screening.

Methods

We conducted a cross-sectional study in 5 Mexican states, including adult subjects evaluated in checkup campaigns. Subjects underwent a liver ultrasound to look for hepatic steatosis. Based on the most clinically relevant variables associated with MAFLD, we developed the MAFLD-screening score (MAFLD-S). Discrimination and calibration of the score were evaluated using the area under the ROC curve and observed vs predicted plots, respectively.

Results

We included 3357 participants (60% female, mean age 47 ± 12 years). Fifty-two percent had hepatic steatosis, and 47% met MAFLD criteria. Subjects with MAFLD were older (48 ± 11 vs 45 ± 13 years, P < .001), were more frequently males (43% vs 36%, P < .001), and had a higher body mass index (31.6 + 4.9 vs 25.6 + 3.8 kg/m2, P < .001) than subjects without MAFLD. The MAFLD-S includes age, body mass index, gender, diabetes, hypertension, and dyslipidemia and has an area under the curve of 0.852, 95% CI = 0.828-0.877, with a sensitivity of 78.8% and a specificity of 82.8% for the optimal cutoff. Using data from the National Health and Nutrition Survey 2018-2019, we predicted a MAFLD national prevalence of 49.6%.

Conclusion

Nearly half of the Mexican population has MAFLD, representing a present and future challenge. With external validation, the MAFLD-S could be a valuable and practical screening tool.

Associations of liver volume and other markers of hepatic steatosis with all-cause mortality in the general population

AIMS

We examined the associations between liver volume and other quantitative and qualitative markers of hepatic steatosis with all-cause mortality in the general population.

METHODS

We included 2769 German middle-aged individuals with a median follow-up of 8.9 years (23,898 person-years). Quantitative markers used were serum liver enzymes and FIB-4 score, while qualitative markers of hepatic steatosis included magnetic resonance imaging (MRI) measurements of liver fat content and total liver volume. Cox proportional hazards models, adjusted for confounding factors, were undertaken to investigate the associations of liver volume and other markers of hepatic steatosis with all-cause mortality.

RESULTS

A larger MRI-assessed liver volume was associated with a nearly three-fold increased risk of all-cause mortality (Hazard Ratio = 3.16; 95% confidence interval 1.88; 5.30), independent of age, sex, body mass index, food frequency score, alcohol consumption and education level. This association was consistent in all subgroups considered (men vs. women; presence or absence of overweight/obesity, metabolic syndrome or diabetes). Higher serum liver enzyme levels and FIB-4 score were also significantly associated with higher all-cause mortality in the total population and in all subgroups. No independent associations were found between other quantitative and qualitative markers of hepatic steatosis and the risk of all-cause mortality.

CONCLUSIONS

We showed for the first time that larger liver volume was associated with a three-fold increase in long-term risk of all-cause mortality. This association remained significant after adjustment for age, sex, alcohol consumption, obesity and other coexisting metabolic disorders.

Long-term effects of the changes in hepatic steatosis status on the risk of incident type 2 diabetes mellitus: A 15-year community-based prospective cohort study

AIMS

We investigated the long-term effect of changes in hepatic steatosis on the risk of developing T2DM.

METHODS

We evaluated 3510 participants from the 2001-2016 Korean Genome and Epidemiology Study. Those with significant alcohol consumption or T2DM during 2001-2004 were excluded. Steatosis was defined as non-alcoholic fatty liver disease-liver fat score (NAFLD-LFS) of over -0.64, and baseline values were assessed between 2001 and 2002. Differences in NAFLD-LFS (ΔLFS) and changes in steatosis status (no, intermittent [resolved or incident], and persistent steatosis) were assessed between 2003 and 2004. Changes in the risk of diabetes status were observed until 2016.

RESULTS

Over 52,650 person-years of follow-up, T2DM developed in 296 participants (8.4%). The incidence of diabetes in those with no steatosis, intermittent steatosis, and persistent steatosis during follow-up increased by 5.1%, 14.1%, and 27.1% respectively. Multivariate-adjusted analysis revealed that the risk was higher in those with persistent steatosis than those with no steatosis and intermittent steatosis. Baseline NAFLD-LFS and ΔLFS was associated with increased risk of incident T2DM.

CONCLUSIONS

Initial severity as well as aggravation of steatosis is an independent predictor of incident T2DM. Strategies aimed at reducing liver fat may prevent future development of diabetes among patients with NAFLD.

The lipid accumulation product is a powerful tool to diagnose metabolic dysfunction-associated fatty liver disease in the United States adults

BACKGROUND & OBJECTIVES

Body mass index (BMI) and waist circumference (WC) are widely used to assess obesity, but they are limited in their ability to distinguish complicated body metabolic situations (fat mass, lean body mass, visceral and subcutaneous fat deposits in the abdomen). The purpose of this study was to evaluate the diagnostic efficacy of different anthropometric indices in metabolic dysfunction-associated fatty liver disease (MAFLD) and to identify the best cut-off point for the diagnosis of MAFLD in United States adults.

METHODS

A cross-sectional study among 4,195 participants over 18 years old in the National Health and Nutrition Examination Survey (NHANES) 2017-2018 was performed. All patients underwent vibration controlled transient elastography (VCTE). Assess the anthropometric measurements, including BMI, WC, waist-to-height ratio (WHtR), waist-to-hip ratio (WHR), cardiometabolic index (CMI), triglyceride-glucose (TyG) index, hepatic steatosis index (HSI), lipid accumulation product (LAP), body roundness index (BRI), visceral fat index (VAI), abdominal volume index (AVI), cone index (CI), and body fat index (BAI). Logistic regression analyses were conducted to estimate the impact of these indices, on the odds ratio (OR) values of MAFLD. Receiver operator characteristic (ROC) analyses were performed to assess the diagnosing capacity of these anthropometric indices for MAFLD and identify the optimal cut-offs points.

RESULTS

A total of 4,195 (2,069 men and 2,126 women) participants were performed, with 45.4 ± 0.64 (mean ± SD) years old. All anthropometric metrics were positively associated with MAFLD, irrespective of whether it was treated as continuous or categorical variable (P<0.05). Multivariate logistic regression showed a positive correlation between AVI, HSI, WHtR, BRI, and MAFLD, with significant interaction with gender. ROC curves results showed that LAP had the highest AUC [0.813 (95% CI, 0.800-0.826)], especially in participants aged between 18 and 50 years old. Furthermore, LAP showed the highest ROC in both the training set [0.812 (95% CI, 0.800-0.835)] and the validation set [0.809 (95% CI, 0.791-0.827)].

CONCLUSIONS

In the present study, we showed that those anthropometric indices were significantly associated with MAFLD in United States adults. Besides, the association of HSI, BRI, AVI, and WHtR with MAFLD was more obvious in men than in women. LAP may be a sensitive marker for diagnosing MAFLD in U.S. adults.

Prevalence and predictors of elevated liver enzyme levels in Mexico: The Mexican National Health and Nutrition Survey, 2016

INTRODUCTION AND OBJECTIVE

To determine the prevalence of elevated liver enzyme levels and the fatty liver index according to specific sociodemographic, clinical, anthropometric, and metabolic risk factors in Mexican adult population.

MATERIAL AND METHODS

The present analysis was conducted using data from the Mexican National Health and Nutrition Survey 2016. For the present study, 3,490 adults with complete information on liver enzymes, sociodemographic, lifestyle, and metabolic factors were analyzed. Alanine aminotransferase (ALT), aspartate aminotransferase (AST), and gamma-glutamyl transferase (GGT) levels were determined from blood samples. We computed the fatty liver Index (FLI), as a surrogate marker of non-alcoholic fatty liver disease. The associations are reported as adjusted odds ratios (OR) and 95% confidence intervals (95%CI).

RESULTS

At the national level, the prevalence of high serum levels of ALT, AST, and GGT were 7.9%, 13.5, and 12.9 respectively. We observed that men had higher prevalences of altered ALT, GGT and FLI compared to women. Additionally, we observe that individuals with obesity, metabolic syndrome and insulin resistance are significantly more likely to present elevated concentrations of AST, ALT, GGT and FLI. Finally, we found that the subjects of the lowest socioeconomic level and indigenous population were more likely to present elevated levels of AST, ALT, GGT, and FLI.

CONCLUSION

In Mexico, non-alcoholic fatty liver disease affect people with obesity, diabetes, and metabolic syndrome as well as men, subjects of low socioeconomic status, subjects who live in rural areas and indigenous population. Interventions to reduce this condition should be a public health priority.

Association between the liver fat score (LFS) and cardiovascular diseases in the national health and nutrition examination survey 1999-2016

BACKGROUND

The liver fat score (LFS) has been proposed to be a simple non-invasive marker of non-alcoholic fatty liver disease (NAFLD), which is highly prevalent in the general population. We tested its association with cardiovascular diseases (CVDs) and prognosis.

METHODS

17,244 adult participants from the National Health and Nutrition Examination Survey 1999-2016 were included. LFS is calculated from variables including serum aspartate transaminase/alanine transaminase (AST/ALT) ratio, fasting serum aspartate transaminase (AST) level, fasting serum insulin level, presence of metabolic syndrome and diabetes mellitus. In cross-sectional analysis, logistic regression was used to examine the association of the LFS with coronary heart disease (CHD), myocardial infarction (MI), congestive heart failure (CHF), stroke and angina pectoris. Mortality during follow-up was analysed using Cox proportional hazard regression.

RESULTS

LFS was associated with CHD (adjusted odds ratio [OR]: 1.09 per standard deviation [SD], 95% confidence interval [95% CI]: 1.03-1.15) (p = .003), CHF (1.11, 1.04-1.18) (p = .003) and angina pectoris (1.08, 1.02-1.13) (p = .005). LFS was not associated with MI or stroke, but was associated with increased all-cause and cardiovascular mortality with hazard ratios (HRs) of 1.10 (95% CI: 1.07-1.13) (p < .001) and 1.12 (95% CI: 1.06-1.17) (p < .001), respectively.

CONCLUSIONS

NAFLD is usually asymptomatic, but this large study of a large general population shows that LFS is associated with CHD, CHF, angina pectoris, cardiovascular and all-cause mortality. Determining the LFS is worthwhile, as it identifies people with NAFLD, who may also be at increased cardiovascular risk.Key MessagesLiver fat score (LFS), a non-invasive marker of non-alcoholic fatty liver disease (NAFLD), is associated with coronary heart disease (CHD), congestive heart failure (CHF) and angina.LFS is also associated with increased cardiovascular and all-cause mortality.Determining the LFS is worthwhile as it identifies people with NAFLD as well as increased cardiovascular risk.

Screening for nonalcoholic fatty liver disease-when, who and how?

Nonalcoholic fatty liver disease (NAFLD) is becoming a frequent liver disease, especially in patients with metabolic syndrome and especially in Western countries. Complications of NAFLD comprise progressive fibrosis, cirrhosis and hepatocellular carcinoma. NAFLD also represents an independent risk factor for cardiovascular disease, extrahepatic neoplasia and other organ damage, such as renal insufficiency. Given the epidemiological importance of the disease, new developments in specific treatment of the disease and the wide availability of noninvasive techniques in estimating steatosis and fibrosis, NAFLD should be subject to screening programs, at least in countries with a high prevalence of the disease. The review discusses prerequisites for screening, cost-effectiveness, current guideline recommendations, suitability of techniques for screening and propositions for the following questions: Who should be screened? Who should perform screening? How should screening be performed? It is time for a screening program in patients at risk for NAFLD.

Joint Effect of Hepatic Steatosis and Alanine Aminotransferase Within the Normal Range on Incident Ischemic Heart Disease: A Prospective Study in Koreans

Purpose

Hepatic steatosis has been associated with some cardiovascular risks. Increased alanine aminotransferase (ALT) was suggested to be linked to endothelial dysfunction. We prospectively investigated the joint effect of hepatic steatosis and elevated ALT within the normal range on incident ischemic heart disease (IHD) risk as an extrahepatic complication.

Patients and Methods

We assessed 16,541 participants without diabetes using data from a health risk assessment study (HERAS) and Korean Health Insurance Review and Assessment (HIRA) data. We defined elevated ALT within the normal range as 30-40 IU/L in men and 23-40 IU/L in women, according to previous Korean epidemiological data. We prospectively assessed hazard ratios (HRs) with 95% confidence intervals (CIs) for IHD using multivariate Cox proportional hazards regression models over a 50-month period after the baseline survey.

Results

During the follow-up period, 368 (2.2%) participants developed IHD. Compared to the group with no hepatic steatosis and controlled ALT, the HRs for IHD were 1.68 (95% CI, 1.16-2.42) in the group with hepatic steatosis and elevated ALT after adjusting for confounding variables.

Conclusion

Hepatic steatosis and elevated ALT levels within the normal range may jointly affect the development of IHD among nondiabetic adults. This indicates that lifestyle advice and vascular health management should be recommended among individuals with hepatic steatosis and elevated ALT, even if it falls within the normal range.

Liver fat content might be an appropriate measure for estimation of cardiovascular disease risk in non-alcoholic steatohepatitis patients

Background: Non-alcoholic steatohepatitis (NASH) is increasing worldwide due to the metabolic syndrome epidemy. According to the current evidence, a higher cardiovascular disease risk (CVDR) is observed in NASH individuals than the general population. Objective: The relationship between liver fat content (LFC) and CVDR in a cohort of NASH patients was evaluated in this research. Methods: Consecutively selected patients with increased aminotransferase levels and fatty change in liver ultrasonography were enrolled in the study. Those with known causes of viral hepatitis, any hepatotoxic medications or alcohol consumption, autoimmune hepatitis, cigarette smoking, and ischemic heart disease were excluded from the project. The remaining was presumed to have NASH. The Framingham risk score (FRS) and LFC were calculated by means of an online calculator and a valid formula, respectively. The correlation between LFC and independent variables was measured using the Pearson correlation test. The P-value of less than 0.05 was considered significant. The statistical analysis was performed using SPSS program version 18. Results: Finally, two hundred NASH patients were included in the study. Considering diabetes mellitus as a confounder, there was a fair relationship between LFC and FRS (R=0.26 and 0.23, respectively, p<0.05) in the second and third visits. Even after adjustment for known cardiovascular risk factors, LFC was associated with increased CVDR (OR=9.181; 95% CI: 2.00-42.14, p=0.01). The cut-off value of 9.1% for LFC had a sensitivity of 92% and a specificity of 87% for discrimination of the FRS >20% and <20%. Conclusion: LFC might independently be correlated with CVDR in NASH patients. If further research confirmed this relationship, the inclusion of LFC into the FRS formula would provide an appropriate CVDR estimation tool in NASH.

Comparison of four non-alcoholic fatty liver disease detection scores in a Caucasian population

BACKGROUND

Non-alcoholic fatty liver disease (NAFLD) is a common disorder, with an estimated prevalence ranging from 20% to 35% in the general population. Several scores based on easily measurable biochemical and clinical parameters, including the fatty liver index (FLI), hepatic steatosis index (HSI), lipid accumulation product (LAP), and NAFLD liver fat score (LFS), have been developed for the detection of NAFLD. However, comparative information regarding the efficacy of these scores for predicting NAFLD in population-based samples comprising normal and high-risk individuals is lacking.

AIM

To evaluate four NAFLD detection scores in two samples with different NAFLD risks.

METHODS

NAFLD screening was performed in a population-based sample of 50-year-old individuals in Uppsala, Sweden [n = 310; Prospective investigation of obesity, energy and metabolism (POEM) study] and a high-risk population comprising patients with a body mass index > 25 kg/m² and either high plasma triglycerides (≥ 1.7 mmol/L) or type 2 diabetes (n = 310; EFFECT studies). NAFLD was defined as liver fat > 5.5% using magnetic resonance imaging-proton density fat fraction. FLI, HSI, LAP, and NAFLD LFS were assessed. A logistic regression model was used to evaluate the effectiveness of the different scores.

RESULTS

The prevalence of NAFLD was 23% in POEM. FLI showed the highest receiver operating characteristic area under the curve (ROC AUC; 0.82) and was significantly better than the LAP score (P = 0.005 vs LAP, P = 0.08 vs LFS, P = 0.12 vs HSI) for detection of NAFLD. The other three indices performed equally in POEM (0.77-0.78). The prevalence of NAFLD was 74% in EFFECT; LFS performed best (ROC AUC 0.80) in this sample. The ROC AUC for LFS (0.80) was significantly higher than that for FLI (P = 0.0019) and LAP (P = 0.0022), but not HSI (P = 0.11). We performed a sensitivity analysis with stratification for the two high-risk subgroups (patients with diabetes or hypertriglyceridemia) from the EFFECT studies. LAP performed best in patients with hypertriglyceridemia. No major differences were observed between the other scores.

CONCLUSION

The four investigated NAFLD scores performed differently in the populationbased vs high-risk setting. FLI was preferable in the population-based setting, while LFS performed best in the high-risk setting.

Prevalence of NAFLD in Guatemala following exposure to a protein-energy nutrition intervention in early life

INTRODUCTION AND OBJECTIVES

The global prevalence of non-alcoholic fatty liver disease (NAFLD) is approximately 25%, with Hispanic populations at greatest risk. We describe the prevalence of NAFLD in a cohort of Guatemalan adults and examine whether exposure to a protein-energy supplement from conception to two years is associated with lower prevalence of NAFLD.

MATERIALS AND METHODS

From 1969 to 1977, four villages in Guatemala were cluster-randomized to receive a protein-energy supplement (Atole) or a no-protein, low-energy beverage (Fresco). We conducted a follow-up of participants from 2015 to 2017. We assessed blood samples (n=1093; 61.1% women; aged 37-53 years) for alanine aminotransferase (ALT) and aspartate aminotransferase (AST) and estimated NAFLD prevalence using the liver fat score. We used generalized linear and logistic models to estimate the difference-in-difference effect of Atole from conception to two years on NAFLD.

RESULTS

Median ALT and AST were 19.7U/L (interquartile range, IQR: 14.1, 27.4) and 26.0U/L (IQR: 21.4, 32.8), respectively. The median NAFLD liver fat score was 0.2 (IQR: -1.2, 1.6) in women and -1.2 (IQR: -2.2, 0.5) in men (p<0.0001). The prevalence of NAFLD was 67.4% among women and 39.5% among men (p<0.0001). The association between Atole exposure from conception to two years and NAFLD was not significant (OR: 0.90, 95% CI: 0.50-1.63).

CONCLUSIONS

NAFLD prevalence among Guatemalan adults exceeds the global average. Protein-energy supplementation in early life was not associated with later NAFLD. There is a need for further studies on the causes and onset of NAFLD throughout the life course.

Relationship of visceral adipose tissue with surrogate insulin resistance and liver markers in individuals with metabolic syndrome chronic complications

BACKGROUND

Visceral adipose tissue (VAT) has a hazardous influence on systemic inflammation, insulin resistance and an adverse metabolic profile, which increases the risk of developing non-alcoholic fatty liver disease (NAFLD) and chronic complications of diabetes. In our study we aimed to evaluate the association of VAT and the triglyceride glucose (TyG) as a proxy of insulin resistance surrogated with metabolic and liver risk factors among subjects diagnosed with metabolic syndrome (MetS).

METHODS

A cross-sectional study was performed including 326 participants with MetS (55-75 years) from the PREDIMED-Plus study. Liver-status markers, VAT and TyG were assessed. Participants were stratified by tertiles according to VAT (n = 254) and TyG (n = 326). A receiver operating characteristic curve was used to analyse the efficiency of TyG for VAT.

RESULTS

Subjects with greater visceral fat depots showed worse lipid profile, higher homeostatic model assessment for insulin resistance (HOMA-IR), TyG, alanine transaminase (ALT), fibroblast growth factor-21 (FGF-21), fatty liver index (FLI) and hepatic steatosis index (HSI) compared with participants in the first tertile. The multi-adjusted linear-regression analyses indicated that individuals in the third tertile of TyG (>9.1-10.7) had a positive association with HOMA-IR [β = 3.07 (95% confidence interval (CI) 2.28-3.86; p trend < 0.001)], ALT [β = 7.43 (95% CI 2.23-12.63; p trend = 0.005)], gamma glutamyl transferase (GGT) [β = 14.12 (95% CI 3.64-24.61; p trend = 0.008)], FGF-21 [β = 190.69 (95% CI 93.13-288.25; p trend < 0.001)], FLI [β = 18.65 (95% CI 14.97-22.23; p trend < 0.001)] and HSI [β = 3.46 (95% CI, 2.23-4.68; p trend < 0.001)] versus participants from the first tertile. Interestingly, the TyG showed the largest area under the receiver operating curve (AUC) for women (AUC = 0.713; 95% CI 0.62-0.79) compared with men (AUC = 0.570; 95% CI 0.48-0.66).

CONCLUSIONS

A disrupted VAT enlargement and impairment of TyG are strongly associated with liver status and cardiometabolic risk factors linked with NAFLD in individuals diagnosed with MetS. Moreover, the TyG could be used as a suitable and reliable marker estimator of VAT.

Noninvasive tool for the diagnosis of NAFLD in association with atherosclerotic cardiovascular risk

Background

Whether the severity of liver histology in non-alcoholic fatty liver disease (NAFLD) is associated with more pronounced cardiovascular disease is unsettled. There is a need to develop a noninvasive tool to help its diagnosis in association with atherosclerotic cardiovascular disease. We aimed to evaluate the diagnostic performance of NAFLD-liver fat score (NAFLD-LFS) and carotid intima-media thickness (CIMT) in magnetic resonance imaging-proved NAFLD. The study comprised 60 patients with NAFLD during the period from October 2015 to June 2017, diagnosed by clinical features, laboratory tests, and magnetic resonance study. Thirty healthy subjects served as controls. All included individuals were subjected to anthropometric measurements and measurement of NAFLD-LFS and CIMT.

Results

On doing ultrasonography, 30 cases showed mild, 24 showed moderate, and 6 cases showed severe steatosis. NAFLD-LFS at a cutoff value of − 1.628 showed a sensitivity of 96.7%, specificity 100%, positive predictive value 100%, negative predictive value 93.8%, and accuracy 97.8%. CIMT at a cutoff value of 0.6 had a sensitivity of 70%, specificity 53.3%, positive predictive value 75%, negative predictive value 47.1%, and accuracy 64.4%. The combination of CIMT at cutoff 0.7 and NAFLD-LFS at cutoff − 1.628 showed sensitivity, specificity, positive predictive value, negative predictive value, and diagnostic accuracy of 100%.

Conclusion

CIMT combined with NAFLD-LFS can produce a simple noninvasive tool for diagnosis of NAFLD.

Current Status in Testing for Nonalcoholic Fatty Liver Disease (NAFLD) and Nonalcoholic Steatohepatitis (NASH)

Nonalcoholic fatty liver disease (NAFLD) is the most common chronic liver disease in Western countries with almost 25% affected adults worldwide. The growing public health burden is getting evident when considering that NAFLD-related liver transplantations are predicted to almost double within the next 20 years. Typically, hepatic alterations start with simple steatosis, which easily progresses to more advanced stages such as nonalcoholic steatohepatitis (NASH), fibrosis and cirrhosis. This course of disease finally leads to end-stage liver disease such as hepatocellular carcinoma, which is associated with increased morbidity and mortality. Although clinical trials show promising results, there is actually no pharmacological agent approved to treat NASH. Another important problem associated with NASH is that presently the liver biopsy is still the gold standard in diagnosis and for disease staging and grading. Because of its invasiveness, this technique is not well accepted by patients and the method is prone to sampling error. Therefore, an urgent need exists to find reliable, accurate and noninvasive biomarkers discriminating between different disease stages or to develop innovative imaging techniques to quantify steatosis.

Effects of different exercise modalities on novel hepatic steatosis indices in overweight women with type 2 diabetes

BACKGROUND/AIMS

Fatty liver is a clinical and pathologic condition in individuals with type 2 diabetes (T2D). The purpose of this study is to examine the effects of different exercise modalities on non-alcoholic fatty liver indices (fatty liver index [FLI], lipid accumulation product [LAP], hepatic steatosis index [HSI], and Framingham Steatosis Index [FSI]) in women with T2D.

METHODS

Fifty-two women with T2D and a mean age of 55.07±5.92 yrs, body mass index (BMI) 28.94±4.09 kg/m2 , and hemoglobin A1c (HbA1c) 9.41±0.82% were randomized to a sprint interval training (SIT) (n=17), combined aerobic and resistance (A+R) training (n=17), or control group (n=18) for 10 weeks. Two-way repeated analysis of variance (ANOVA) was used to find differences between groups and the effects of time and Time×Group interactions after 10 weeks on non-alcoholic fatty liver indices. After this, ANOVA models were constructed to determine the effects of group allocation and change in non-alcoholic fatty liver indices.

RESULTS

There were significant time interactions for FLI (P<0.001), HSI (P<0.001), and LAP (P<0.001). Also, there were significant Time×Group interactions for fasting blood glucose (P=0.034), and HbA1c (P=0.006).

CONCLUSION

Results highlight that exercise training, independent of mode of training, is an effective strategy to improve some indices related to hepatic steatosis and blood glucose profiles in women with T2D.

Statin Therapy Does Not Reduce Liver Fat Scores in Patients Receiving Antiretroviral Therapy for HIV Infection

BACKGROUND & AIMS

Therapies are needed to limit progression of fatty liver diseases in patients with human immunodeficiency virus (HIV) infection. We analyzed data from a prospective study of the effects of rosuvastatin (a statin) on hepatic steatosis in HIV-positive adults.

METHODS

We performed a secondary analysis of data from a double-blind trial of adult patients with HIV infection (78% male; 68% African American; mean age, 46 y; body mass index, 29 kg/m²; HIV1 RNA < 1000 copies/mL; low-density lipoprotein cholesterol, <130 mg/dL) receiving antiretroviral therapy. The patients were randomly assigned to groups given 10 mg daily rosuvastatin (n = 72) or placebo (n = 75). Demographic and clinical data were collected, and blood samples were analyzed. Changes in liver fat score (LFS, a composite score calculated from metabolic and liver function parameters) and markers of systemic inflammation and immune activation were assessed through 96 weeks of drug or placebo administration. We performed multivariable linear and logistic regressions to study relationships among variables.

RESULTS

The placebo and rosuvastatin groups each had significant increases in LFS, compared with baseline, at 96 weeks (P = .01 and P < .01; P = .49 for difference increase between groups). Baseline LFS was independently associated with blood level of C-X-C motif chemokine ligand 10 (P = .04) and the soluble CD163 molecule (P = .01). After we adjusted for baseline characteristics, an increase in LFS over time was significantly associated with the blood level of C-X-C motif chemokine ligand 10 (P = .04), insulin resistance (P < .01), and viral load (P = .02), but not rosuvastatin use (P = .06).

CONCLUSIONS

In a secondary analysis of data from a trial of patients receiving treatment for HIV infection, hepatic steatosis increased over time, regardless of statin treatment, and was independently associated with markers of immune activation. Patients who received rosuvastatin appeared to have a nonsignificant increase in hepatic steatosis over 96 weeks. Despite their ability to reduce the risk of cardiovascular disease, statins do not appear to reduce hepatic steatosis. Clinicaltrials.gov no: NCT01218802.

A Comparison of the Liver Fat Score and CT Liver-to-Spleen Ratio as Predictors of Fatty Liver Disease by HIV Serostatus

Background and Aim

Non-alcoholic fatty liver disease (NAFLD) is common among HIV-infected (HIV+) adults. The Liver Fat Score (LFS) is a non-invasive, rapid, inexpensive diagnostic tool that uses routine clinical data and is validated against biopsy in HIV-uninfected (HIV-) persons. CT liver-to-spleen (L/S) attenuation ratio is another validated method to diagnose NAFLD. We compared NAFLD prevalence using the LFS versus L/S ratio among Multicenter AIDS Cohort Study participants to assess the LFS's performance in HIV+vs. HIV-men.

Methods

In a cross-sectional analysis of men reporting<3 alcoholic drinks daily (308 HIV+, 218 HIV-), Spearman correlations determined relationships between LFS and L/S ratio by HIV serostatus. Multivariable regression determined factors associated with discordance in LFS- and L/S ratio-defined NAFLD prevalence.

Results

NAFLD prevalence by LFS and L/S ratio were 28%/15% for HIV+men and 20%/19% for HIV-men, respectively. Correlations between LFS and L/S ratio were weaker among HIV+than HIV-men, but improved with increasing BMI and exclusion of HCV-infected men. LFS and L/S ratio discordance occurred more frequently and across BMI strata among HIV+men, but predominantly at BMI<30 kg/m² among HIV-men. In multivariate analysis, only lower total testosterone levels were significantly associated with discordance.

Conclusion

NAFLD prevalence was similar by LFS and L/S ratio identification among HIV-men, but dissimilar and with frequent discordance between the two tests among HIV+men. As discordance may be multifactorial, biopsy data are needed to determine the best non-invasive diagnostic test for NAFLD in HIV+persons.

Liver fat scores predict liver disease mortality in the United States population

BACKGROUND

Fatty liver is a significant global public health burden, contributing to premature death.

AIM

To examine whether liver fat scores were associated with increased overall and disease-specific mortality in a United States (US) population-based survey with up to 27 years of linked mortality data.

METHODS

We studied 9200 fasted viral hepatitis-negative adults in the third National Health and Nutrition Examination Survey, 1988-1994. Liver fat was predicted using the US fatty liver index (US FLI), fatty liver index (FLI), non-alcoholic fatty liver disease liver fat score (NAFLD LFS), and hepatic steatosis index (HSI). Participants were passively followed up for mortality, identified by death certificate underlying or contributing causes, by linkage to National Death Index records through 2015. Mortality hazard ratios (HR) were calculated using Cox proportional hazards regression to adjust for mortality risk factors.

RESULTS

During follow-up (median, 23.3 years), cumulative mortality was 31.4% overall and 1.1% with liver disease, including primary liver cancer. Elevated liver disease mortality was associated with a high US FLI (HR, 5.7; 95% confidence interval (CI), 1.3-24.5), and intermediate (HR, 3.1; 95% CI, 1.1-9.1) or high (HR, 11.4; 95% CI, 2.9-44.4) NAFLD LFS, but not with a higher FLI or HSI. Overall and cardiovascular disease mortality was unassociated with higher liver fat scores.

CONCLUSIONS

In the US population, a higher US FLI and NAFLD LFS were associated with increased liver disease mortality, but not with other mortality outcomes. Liver fat scores may be useful for metabolic health surveillance and long-term liver disease risk stratification and may complement fibrosis markers for tracking.

Plasma miR-17, miR-20a, miR-20b and miR-122 as potential biomarkers for diagnosis of NAFLD in type 2 diabetes mellitus patients

AIMS

Type 2 diabetes mellitus (T2DM), with non-alcoholic fatty liver disease (NAFLD) complication, may aggravate the disturbance of metabolism, increase the risk of non-alcoholic steatohepatitis, and promote the progress of liver fibrosis. Therefore, early detection of NAFLD in T2DM patients is critical in avoiding the adverse effects of the complication. This study aimed to identify circulating miRNAs for early diagnosis of the complication.

MATERIALS AND METHODS

Plasma miRNA expression profiles of T2DM patients complicated with or without NAFLD were examined by miRNA array analysis and then were validated by qRT-PCR. A new index for prediction the presence of NAFLD was developed based on the result of multivariate logistic regression analysis. STZ and high fat diet were used for construction a rat model of T2DM complicated with NAFLD.

KEY FINDINGS

Plasma miR-17, miR-20a, miR-20b, and miR-122 were up-regulated in T2DM patients with NAFLD complicated compared in those without NAFLD (P < 0.05). Moreover, the data from the rat model further showed that the above miRNAs were more sensitive than traditional serological markers for predicting the complication. Meanwhile, in order to improve the diagnostic accuracy, we try to construct an AUC by using the new index, 24.852 × WHR-1.121 × miR122 + 1.988 × LDL-21.838, which was significantly higher than a chance assignment (asymptotic significance P < 0.001) for predicting the presence of NAFLD.

SIGNIFICANCE

Plasma miRNAs and the new index involving WHR, LDL, and miR-122 are potential novel tools for the early diagnosis and risk estimation of NAFLD in T2DM patients.

Fatty liver index is associated to pulse wave velocity in healthy subjects: Data from the Brisighella Heart Study

BACKGROUND

Non-Alcoholic Fatty Liver Disease (NAFLD) is associated to increased risk of cardiovascular disease. Our aim was to evaluate association of indexes of fatty liver with arterial stiffness (AS).

METHODS

We analyzed data of adult volunteers visited during the last Brisighella survey. We evaluated the Pulse Wave Velocity (PWV) and the following non-invasive indexes of liver steatosis: Fatty Liver Index (FLI), Lipid Accumulation Product (LAP), Hepatic Steatosis Index (HSI). We compared patients according to the risk of Non-Alcoholic Steatohepatitis (NASH): low-risk (BMI < 28 and no diabetes), intermediate-risk (BMI ≥ 28 or diabetes), high-risk (BMI ≥ 28 and diabetes). Multiple Linear Regression analysis was assessed for predictors of AS.

RESULTS

We studied 1731 volunteers. In subjects with low metabolic risk, HSI (RR = 0.138, 95%CI 0.105-0.170, p < 0.001), FLI (RR = 0.024, 95%CI 0.016-0.032, p < 0.001), LAP (RR = 0.014, 95%CI 0.008-0.020, p < 0.001) and Serum Uric Acid (RR = 0.150, 95%CI 0.024-0.275, p = 0.019) were significant predictors of AS. HSI and FLI emerged as predictors of PWV in intermediate risk group (RR = 0.116, 95%CI 0.071-0.160, p < 0.001; RR = 0.010, 95%CI 0.001-0.020, p = 0.041). In volunteers with high risk, FLI and Uric Acid were related to PWV (RR = 0.049, 95%CI 0.011-0.087, p = 0.013; RR = 0.632, 95% CI 0.222-1.041, p = 0.003).

CONCLUSION

Fatty liver indirect indexes were associated to AS in subjects with different metabolic risk profiles.

A novel index including SNPs for the screening of nonalcoholic fatty liver disease among elder Chinese: A population-based study

Presently noninvasive methods were employed to the diagnosis of nonalcoholic fatty liver disease (NAFLD), including fatty liver index (FLI), hepatic steatosis index (HSI), product of fasting triglyceride and glucose levels (TyG), and single nucleotide polymorphism (SNP), whereas the accuracy of those indexes need to be improved. Our study aimed to investigate the feasibility of a new index comprehensive index (CI), consisting of 6 serum biomarkers and anthropometric parameters through multivariate logistic regression analysis, to the earlier detection of NAFLD, and the diagnostic value of 5 SNPs (S1: rs2854116 of apolipoprotein C3 [APOC3], S2: rs4149267 of ATP-binding cassette transporter [ABCA1], S3: rs13702 of lipoprotein lipase [LPL], S4: rs738409 of protein 3 [patatin-like phospholipase domain containing protein 3 (PNPLA3)], S5: rs780094 of glucokinase regulatory protein gene [GCKR]) for NAFLD were also explored. Area under the receiver operating characteristic curves (AUROC) and Youden index (YI) were calculated to assess the diagnostic value. The AUROC of CI was higher than FLI, HSI, and TyG (CI: 0.897, FLI: 0.873, HSI: 0.855, TyG: 0.793). Therefore, CI might be a better index for the diagnosis of NAFLD. Although there had no statistical significance (P = .123), the AUROC and YI were increased when CI combined with rs2854116 (S1) (AUROC = 0.902, YI = 0.6844). The combination of CI with S1 showed even better diagnostic accuracy than CI, which suggests the potential value of rs2854116 for the diagnosis of NAFLD.

Development and validation study of a non-alcoholic fatty liver disease risk scoring model among adults in China

BACKGROUND

Non-alcoholic fatty liver disease (NAFLD) is one of the most common liver diseases in China. It is usually asymptomatic and transabdominal ultrasound (USS) is the usual means for diagnosis, but it may not be feasible to have USS screening of the whole population.

OBJECTIVE

To develop a risk scoring model for predicting the presence of NAFLD using parameters that can be easily obtain in clinical settings.

METHODS

A retrospective study on the data of 672 adults who had general health check including a transabdominal ultrasound. Fractional polynomial and multivariable logistic regressions of sociodemographic and biochemical variables on NAFLD were used to identify the predictors. A risk score was assigned to each predictor using the scaled standardized β-coefficient to create a risk prediction algorithm. The accuracy for NAFLD detection by each cut-off score in the risk algorithm was evaluated.

RESULTS

The prevalence of NAFLD in our study population was 33.0% (222/672). Six significant factors were selected in the final prediction model. The areas under the curve (AUC) was 0.82 (95% CI: 0.78-0.85). The optimal cut-off score, based on the ROC was 35, with a sensitivity of 76.58% (95% CI: 70.44-81.98%) and specificity of 74.89% (95% CI: 70.62-78.83%).

CONCLUSION

A NAFLD risk scoring model can be used to identify asymptomatic Chinese people who are at risk of NAFLD for further USS investigation.

External validation of non-invasive prediction models for identifying ultrasonography-diagnosed fatty liver disease in a Chinese population

Several prediction models for fatty liver disease (FLD) are available with limited externally validation and less comprehensive evaluation. The aim was to perform external validation and direct comparison of 4 prediction models (the Fatty Liver Index, the Hepatic Steatosis Index, the ZJU index, and the Framingham Steatosis Index) for FLD both in the overall population and the obese subpopulation.This cross-sectional study included 4247 subjects aged 20 to 65 years recruited from the north of Shanxi Province in China. Anthropometric and biochemical features were collected using standard protocols. FLD was diagnosed by liver ultrasonography. We assessed all models in terms of discrimination, calibration, and decision curve analysis.The original models performed well in terms of discrimination for the overall population, with the area under the receiver operating characteristic curves (AUCs) around 0.85, while AUCs for obese individuals were around 0.68. Nevertheless, the predicted risks did not match well with the observed risks both in the overall population and the obese subpopulation. The FLI 2006 was 1 of the 2 best models in terms of discrimination (AUCs were 0.87 and 0.72 for the overall population and the obese subgroup, respectively) and had the best performance in terms of calibration, and attained the highest net benefit.The FLI 2006 is overall the best tool to identify high risk individuals and has great clinical utility. Nonetheless, it does not perform well enough to quantify the actual risk of FLD, which need to be (re)calibrated for clinical use.

Fatty Liver Index and Lipid Accumulation Product Can Predict Metabolic Syndrome in Subjects without Fatty Liver Disease

Background. Fatty liver index (FLI) and lipid accumulation product (LAP) are indexes originally designed to assess the risk of fatty liver and cardiovascular disease, respectively. Both indexes have been proven to be reliable markers of subsequent metabolic syndrome; however, their ability to predict metabolic syndrome in subjects without fatty liver disease has not been clarified. Methods. We enrolled consecutive subjects who received health check-up services at Taipei Veterans General Hospital from 2002 to 2009. Fatty liver disease was diagnosed by abdominal ultrasonography. The ability of the FLI and LAP to predict metabolic syndrome was assessed by analyzing the area under the receiver operating characteristic (AUROC) curve. Results. Male sex was strongly associated with metabolic syndrome, and the LAP and FLI were better than other variables to predict metabolic syndrome among the 29,797 subjects. Both indexes were also better than other variables to detect metabolic syndrome in subjects without fatty liver disease (AUROC: 0.871 and 0.879, resp.), and the predictive power was greater among women. Conclusion. Metabolic syndrome increases the cardiovascular disease risk. The FLI and LAP could be used to recognize the syndrome in both subjects with and without fatty liver disease who require lifestyle modifications and counseling.

Immune Imbalances in Non-Alcoholic Fatty Liver Disease: From General Biomarkers and Neutrophils to Interleukin-17 Axis Activation and New Therapeutic Targets

Non-alcoholic fatty liver disease (NAFLD) is an increasing problem worldwide and is associated with negative outcomes such as cirrhosis, hepatocellular carcinoma, insulin resistance, diabetes, and cardiovascular events. Current evidence shows that the immune response has an important participation driving the initiation, maintenance, and progression of the disease. So, various immune imbalances, from cellular to cytokines levels, have been studied, either for better compression of the disease pathophysiology or as biomarkers for severity assessment and outcome prediction. In this article, we performed a thorough review of studies that evaluated the role of inflammatory/immune imbalances in the NAFLD. At the cellular level, we gave special focus on the imbalance between neutrophils and lymphocytes counts (the neutrophil-to-lymphocyte ratio), and that which occurs between T helper 17 (Th17) and regulatory T cells as emerging biomarkers. By extension, we reviewed the reflection of these imbalances at the molecular level through pro-inflammatory cytokines including those involved in Th17 differentiation (IL-6, IL-21, IL-23, and transforming growth factor-beta), and those released by Th17 cells (IL-17A, IL-17F, IL-21, and IL-22). We gave particular attention to the role of IL-17, either produced by Th17 cells or neutrophils, in fibrogenesis and steatohepatitis. Finally, we reviewed the potential of these pathways as new therapeutic targets in NAFLD.

The common PNPLA3 variant p.I148M is associated with liver fat contents as quantified by controlled attenuation parameter (CAP)

BACKGROUND

Non-alcoholic fatty liver disease (NAFLD) is becoming the most prevalent liver disorder. The PNPLA3 (adiponutrin) variant p.I148M has been identified as common genetic modifier of NAFLD. Our aim was to assess the relationships between genetic risk and non-invasively measured liver fat content.

METHODS

Hepatic steatosis was quantified by transient elastography, using the controlled attenuation parameter (CAP) in 174 patients with chronic liver diseases (50% women, age 18-77 years). In addition, a cohort of 174 gender-matched healthy controls (50% women, age 32-77 years) was recruited. The PNPLA3 mutation as well as the novel NAFLD-predisposing genetic variant (TM6SF2 p.E167K) were genotyped with allele-specific probes.

RESULTS

The PNPLA3 genotype correlated significantly (P = 0.001) with hepatic CAP measurements. The p.148M risk allele increased the odds of developing liver steatosis (OR = 2.39, P = 0.023). In multivariate models, BMI and PNPLA3 mutation were both independently associated with CAP values (P < 0.001 and P = 0.007, respectively). Carriers of the TM6SF2 risk allele presented with increased aminotransferase activities (ALT: P = 0.007, AST: P = 0.004), but the presence of this variant did not affect CAP values.

CONCLUSIONS

The PNPLA3 p.I148M variant represents the most important prosteatotic genetic risk factor. NAFLD carriers of this variant should be followed up carefully, with elastography and CAP being ideally suited for this purpose.

Association of non-alcoholic fatty liver disease with impaired endothelial function by flow-mediated dilation: A meta-analysis

AIM

Endothelial dysfunction was observed in patients with non-alcoholic fatty liver disease. The aim of the present study was to evaluate the extent of endothelial function impairment in patients with non-alcoholic fatty liver disease.

METHODS

We systematically searched through the PubMed, Embase, China National Knowledge Infrastructure and Wanfang databases for studies dated up to January 2015. All observational studies that compared endothelial function between non-alcoholic fatty liver disease patients and healthy controls were included. Endothelial function was measured by brachial artery flow-mediated dilation and nitrate-induced dilatation techniques.

RESULTS

Eleven observational studies were identified. Meta-analysis indicated that non-alcoholic fatty liver disease patients were associated with a reduction in brachial artery flow-mediated dilation (weighted mean difference, -4.82%; 95% confidence interval [CI], -5.63 to -4.00) compared with the healthy controls. Subgroup analysis indicated that the patients with non-alcoholic steatohepatitis or a body mass index of more than 30 kg/m(2) appeared to have a greater reduction in their flow-mediated dilation. However, no significant differences were observed in the nitrate-induced dilation (weighted mean difference, -0.4%; 95% confidence interval, -2.19 to 1.39).

CONCLUSION

Non-alcoholic fatty liver disease is associated with a greater risk of endothelial dysfunction as indicated by the decreased brachial artery flow-mediated dilation. Assessment of endothelial function may be recommended to identify subclinical atherosclerosis and to create subgroups of non-alcoholic fatty liver disease patients who are at higher risk of future cardiovascular events.

Associations of coffee consumption with markers of liver injury in the insulin resistance atherosclerosis study

Background

Coffee consumption has been associated with reduced risk of developing type 2 diabetes mellitus (T2DM) however, the mechanism for this association has yet to be elucidated. Non-alcoholic fatty liver disease (NAFLD) characterizes and predicts T2DM yet the relationship of coffee with this disorder remains unclear. Our aim was to investigate the associations of coffee with markers of liver injury in 1005 multi-ethnic, non-diabetic adults in the Insulin Resistance Atherosclerosis Study.

Methods

Dietary intake was assessed using a validated 114-item food frequency questionnaire. Alanine aminotransferase (ALT), aspartate aminotransferase (AST) and fetuin-A were determined in fasting blood samples and the validated NAFLD liver fat score was calculated. Multivariate linear regression assessed the contribution of coffee to variation in markers of liver injury.

Results

Caffeinated coffee showed significant inverse associations with ALT (β = −0.08, p = 0.0111), AST (β = −0.05, p = 0.0155) and NAFLD liver fat score (β = −0.05, p = 0.0293) but not with fetuin-A (β = 0.04, p = 0.17). When the highest alcohol consumers were excluded, these associations remained (ALT β = −0.11, p = 0.0037; AST β = −0.05, p = 0.0330; NAFLD liver fat score β = −0.06, p = 0.0298). With additional adjustment for insulin sensitivity, the relationship with ALT remained significant (ALT β = −0.08, p = 0.0400; AST β = −0.03, p = 0.20; NAFLD liver fat score β = −0.03, p = 0.27). There were no significant associations of decaffeinated coffee with liver markers.

Conclusions

These analyses indicate a beneficial impact of caffeinated coffee on liver morphology and/or function, and suggest that this relationship may mediate the well-established inverse association of coffee with risk of T2DM.

Electronic supplementary material

The online version of this article (doi:10.1186/s12876-015-0321-3) contains supplementary material, which is available to authorized users.

Development of non-alcoholic fatty liver disease scoring system among adult medical check-up patients: a large cross-sectional and prospective validation study

BACKGROUND

Non-alcoholic fatty liver disease (NAFLD) is the most common liver disease in the community. However, NAFLD remains undiagnosed in most people with limited access to imaging facilities in most developing countries.

OBJECTIVE

To examine the prevalence of NAFLD and to develop the risk scoring model for predicting the presence of NAFLD among adult medical check-up patients.

METHOD

A large prospective cross-sectional study was conducted among medical check-up patients who underwent transabdominal ultrasound examination between January and December 2013 in Medistra Hospital, Jakarta. Data were obtained from the patients' medical records. Logistic regression analyses were undertaken to identify the best combination of risk factors for predicting fatty liver using the backward (likelihood ratio) approach. The adjusted odds ratio and 95% confidence interval were estimated using the logistic regression coefficient. The prediction model was assessed using the receiver operating characteristic curve and the Hosmer-Lemeshow goodness-of-fit test and was validated on a new, prospective cohort. Statistical analysis was done using SPSS version 17.

RESULTS

A total of 1,054 cases was included in this study. Fatty liver was present in 538 (51.0%) patients. Bivariate analyses found associations among fatty liver and several risk factors. Six risk factors were incorporated to build the final prediction model. All scores were summed up to obtain the total score. A probability equation was developed by applying linear regression analysis on the total score. The prediction model had good diagnostic performance with an area under the receiver operating characteristic curve =0.833 (95% confidence interval =0.809-0.857). The Hosmer-Lemeshow goodness-of-fit P-value was 0.232, which indicated the appropriateness of the logistic regression model to predict fatty liver. On the validation set, the scoring system proved to be moderately accurate and can potentially be applied to larger population setting.

CONCLUSION

The presence of fatty liver in NAFLD patients can be predicted using our proposed fatty liver scoring system.

Domain Analysis of Integrated Data to Reduce Cost Associated with Liver Disease

Liver cancer, the fifth most common cancer and second leading cause of cancer-related death among men worldwide, is plagued by not only lack of clinical research, but informatics tools for early detection. Consequently, it presents a major health and cost burden. Among the different types of liver cancer, hepatocellular carcinoma (HCC) is the most common and deadly form, arising from underlying liver disease. Current models for predicting risk of HCC and liver disease are limited to clinical data. A domain analysis of existing research related to screening for HCC and liver disease suggests that metabolic syndrome (MetS) may present oppportunites to detect early signs of liver disease. The purpose of this paper is to (i) provide a domain analysis of the relationship between HCC, liver disease, and metabolic syndrome, (ii) a review of the current disparate sources of data available for MetS diagnosis, and (iii) recommend informatics solutions for the diagnosis of MetS from available administrative (Biometrics, PHA, claims) and laboratory data, towards early prediction of liver disease. Our domain analysis and recommendations incorporate best practices to make meaningful use of available data with the goal of reducing cost associated with liver disease.