Association between noninvasive fibrosis markers and chronic kidney disease among adults with nonalcoholic fatty liver disease

Cocoa and Carob Supplementation, Alone or in Combination with Metformin, Protects against Hepatorenal Injury in Zucker Diabetic Fatty Rats

The liver and kidneys are crucial for glucose homeostasis and are seriously damaged in diabetes. Cocoa and carob possess antidiabetic activity, but their hepatorenal protective effects, especially when combined with antidiabetic drugs, are unknown. The aim of this study is to investigate the effects of a cocoa-carob-supplemented diet (CC), either alone or in combination with metformin, on liver and kidney damage in Zucker diabetic fatty (ZDF) rats, a type 2 diabetes model. Male ZDF animals received a control or CC-supplemented diet, with or without metformin, and Zucker lean rats were fed the control diet. The CC-supplemented diet improved glucose tolerance and insulin resistance and alleviated functional and structural alterations in the diabetic liver and renal cortex. The CC-supplemented diet also ameliorated oxidative stress, downregulated apoptosis, and improved insulin signalling and glucose homeostasis. The combination of CC and metformin boosted several benefits as certain parameters related to morphological and structural alterations, apoptosis, oxidative stress, glucose homeostasis, and insulin resistance, were improved in comparison to animals receiving the CC-supplemented diet or metformin alone; these include the following: apoptotic index, Bax, hepatic insulin receptor or glutathione content, among others. These results demonstrate that the CC-supplemented diet alleviates the hepatorenal damage in type 2 diabetic ZDF rats, highlighting its potential alone or as an adjuvant therapy.

A High Fibrosis-4 Index is Associated with a Reduction in the Estimated Glomerular Filtration Rate in Non-obese Japanese Patients with Type 2 Diabetes Mellitus

Liver fibrosis is associated with non-alcoholic fatty liver disease (NAFLD), and one of the most important risk factors for NAFLD is type 2 diabetes (T2DM). The Fibrosis-4 (FIB-4) index, a noninvasive liver fibrosis score, has been found to be useful for estimating liver fibrosis. Because individuals with non-obese NAFLD were recently reported to be metabolically unhealthy and have a higher risk of T2DM than individuals with obese NAFLD, we hypothesized that the clinical factors related to a high FIB-4 index would differ between non-obese and obese Japanese T2DM patients. Accordingly, we examined the relationship between clinical factors and the FIB-4 index in non-obese and obese Japanese patients with T2DM. We divided 265 patients into two groups by BMI level - a non-obese group (n = 149) and an obese group (n = 116) - and examined the correlation between the FIB-4 index and clinical parameters. Single regression analysis revealed that a high FIB-4 index was correlated with a reduction in the estimated glomerular filtration rate and hypertension in the non-obese group. Importantly, multiple regression analysis showed that only a reduction in the estimated glomerular filtration rate was significantly associated with a high FIB-4 index in the non-obese group. These results demonstrated that non-obese T2DM patients with a high FIB-4 index might be at risk of kidney dysfunction. Our findings may enable the more appropriate treatment of T2DM patients based on BMI level.

Clinical characterization and proteomic profiling of lean nonalcoholic fatty liver disease

Introduction

Obesity has been historically associated with nonalcoholic fatty liver disease (NAFLD), but it can also occur in lean individuals. However, limited data is available on this special group. To investigate the clinical and proteomic characteristics of lean subjects with NAFLD, and to identify potential clinical variables and plasma proteins for diagnosing NAFLD in lean individuals, we collected clinical data from a large cohort of 2,236 subjects.

Methods

Diagnosis of NAFLD relied on detecting pronounced hepatic steatosis through abdominal ultrasonography. Participants were categorized into four groups based on body mass index: overweight NAFLD, overweight control, lean NAFLD, and lean control. Plasma proteomic profiling was performed on samples from 20 subjects in each group. The lean NAFLD group was compared to both lean healthy and obese NAFLD groups across all data.

Results and discussion

The results indicated that the lean NAFLD group exhibited intermediate metabolic profiles, falling between those of the lean healthy and overweight NAFLD groups. Proteomic profiling of plasma in lean subjects with or without NAFLD revealed 45 statistically significant changes in proteins, of which 37 showed high diagnostic value (AUC > 0.7) for lean NAFLD. These potential biomarkers primarily involved lipid metabolism, the immune and complement systems, and platelet degranulation. Furthermore, AFM, GSN, CFH, HGFAC, MMP2, and MMP9 have been previously associated with NAFLD or NAFLD-related factors such as liver damage, insulin resistance, metabolic syndromes, and extracellular homeostasis. Overall, lean individuals with NAFLD exhibit distinct clinical profiles compared to overweight individuals with NAFLD. Despite having worse metabolic profiles than their healthy counterparts, lean NAFLD patients generally experience milder systemic metabolic disturbances compared to obese NAFLD patients. Additionally, the plasma proteomic profile is significantly altered in lean NAFLD, highlighting the potential of differentially expressed proteins as valuable biomarkers or therapeutic targets for diagnosing and treating NAFLD in this population.

Hepatic Fibrosis Evaluated in Patients with Type 2 Diabetes with and without Chronic Kidney Disease

BACKGROUND

Non-alcoholic fatty liver disease (NAFLD), and particularly liver fibrosis, has been suggested as a risk factor of chronic kidney disease (CKD). Given that NAFLD affects every fourth person globally, better insight is needed. Our aim was to investigate the association between hepatic fibrosis and CKD in patients with type 2 diabetes and to compare different methods for diagnosing liver fibrosis in this study population.

METHODS

Cross-sectional study including patients with type 2 diabetes with CKD stages 3-5 (N = 50) or without CKD (N = 50). CKD was defined as estimated glomerular filtration rate <60 mL/min/1.73 m2 with or without proteinuria. Three methods were used to detect significant liver fibrosis defined as either ≥8 kilopascal measured by transient elastography (FibroScan®), fibrosis-4 (FIB-4) score ≥2.67, or NAFLD fibrosis score (NFS) >0.675.

RESULTS

Significant liver fibrosis was found in 38% and 28% of the patients with and without CKD, respectively, using at least one of the three methods. Both FIB-4 score and NFS were significantly higher in patients with CKD (p < 0.0009 and p < 0.0001, respectively), although insignificant after adjustments for age, sex, body mass index, and duration of diabetes. In patients without CKD, a significant association between steatosis and fibrosis was observed (p = 0.0007).

CONCLUSION

Our data do not support any strong independent association between liver fibrosis and established CKD as assessed by FibroScan, FIB-4 score, and NFS, respectively.

Utility of non-invasive liver fibrosis markers to predict the incidence of chronic kidney disease (CKD): A systematic review, meta-analysis, and meta-regression

BACKGROUND AND AIMS

Chronic kidney disease (CKD) and non-alcoholic fatty liver disease (NAFLD) share common risk factors and pathogenesis mechanisms. However, the association between the degree of liver fibrosis and the incidence of CKD remains unclear. This study aims to examine the utility of non-invasive fibrosis markers to predict the occurrence of CKD.

METHODS

Cochrane Library, Scopus, and Medline were searched up to May 20th, 2023 using combined keywords. Literature that analyzes FIB-4, NFS, and APRI to predict CKD incidence was included in this review. We used random-effect models of odds ratio (OR) with 95% confidence intervals (CI) to express the outcomes in this review.

RESULTS

Twenty-one studies were included. Our meta-analysis showed that high FIB-4 was associated with a higher incidence of CKD (OR 2.51; 95%CI: 1.87-3.37, p < 0.00001, I2 = 96%). Further regression analysis revealed that this association was significantly influenced by hypertension (p = 0.0241), NAFLD (p = 0.0029), and body mass index (BMI) (p = 0.0025). Our meta-analysis also showed that high NFS (OR 2.49; 95%CI: 1.89-3.30, p < 0.00001, I2 = 96%) and high APRI (OR 1.40; 95%CI: 1.14-1.72, p = 0.001, I2 = 26%) were associated with a higher incidence of CKD.

CONCLUSIONS

This study suggests that these non-invasive liver fibrosis markers can be routinely measured both in NAFLD patients and the general population to enable better risk stratification and early detection of CKD.

Does hand stiffness reflect internal organ fibrosis in diabetes mellitus?

Fibrosis leads to irreversible stiffening of tissue and loss of function, and is a common pathway leading to morbidity and mortality in chronic disease. Diabetes mellitus (both type 1 and type 2 diabetes) are associated with significant fibrosis in internal organs, chiefly the kidney and heart, but also lung, liver and adipose tissue. Diabetes is also associated with the diabetic cheirarthropathies, a collection of clinical manifestations affecting the hand that include limited joint mobility (LJM), flexor tenosynovitis, Duypuytren disease and carpal tunnel syndrome. Histo-morphologically these are profibrotic conditions affecting various soft tissue components in the hand. We hypothesize that these hand manifestations reflect a systemic profibrotic state, and are potential clinical biomarkers of current or future internal organ fibrosis. Epidemiologically, there is evidence that fibrosis in one organ associates with fibrosis with another; the putative exposures that lead to fibrosis in diabetes (advanced glycation end product deposition, microvascular disease and hypoxia, persistent innate inflammation) are 'systemic'; a common genetic susceptibility to fibrosis has also been hinted at. These data suggest that a subset of the diabetic population is susceptible to multi-organ fibrosis. The hand is an attractive biomarker to clinically detect this susceptibility, owing to its accessibility to physical examination and exposure to repeated mechanical stresses. Testing the hypothesis has a few pre-requisites: being able to measure hand fibrosis in the hand, using clinical scores or imaging based scores, which will facilitate looking for associations with internal organ fibrosis using validated methodologies for each. Longitudinal studies would be essential in delineating fibrosis trajectories in those with hand manifestations. Since therapies reversing fibrosis are few, the onus lies on identification of a susceptible subset for preventative measures. If systematically validated, clinical hand examination could provide a low-cost, universally accessible and easily reproducible screening step in selecting patients for clinical trials for fibrosis in diabetes.

The association between liver fibrosis scores and chronic kidney disease

Purpose

This study aimed to clarify the relationship between liver fibrosis scores (Fibrosis-4, BARD score, and BAAT score) and chronic kidney disease (CKD).

Methods

We collected a range of data from 11,503 subjects (5,326 men and 6,177 women) from the rural regions of Northeastern China. Three liver fibrosis scores (LFSs) including fibrosis-4 (FIB-4), BARD score, and BAAT score were adopted. A logistic regression analysis was used to calculate odds ratios and the 95% confidence interval. A subgroup analysis showed the association between LFSs and CKD under different stratifications. Restricted cubic spline could further explore whether there is a linear relationship between LFSs and CKD. Finally, we used C-statistics, Net Reclassification Index (NRI), and Integrated Discrimination Improvement (IDI) to assess the effect of each LFS on CKD.

Results

Through the baseline characteristics, we observed that LFSs were higher in the CKD population than in non-CKD. The proportion of participants with CKD also increased with LFSs. In a multivariate logistic regression analysis, the ORs of CKD were 6.71 (4.45-10.13) in FIB-4, 1.88 (1.29-2.75) in the BAAT score, and 1.72 (1.28-2.31) in the BARD score by comparing the high level with the low level in each LFSs. Moreover, after adding LFSs to the original risk prediction model, which consisted of age, sex, drinking, smoking, diabetes, low-density lipoprotein cholesterol, total cholesterol, triglycerides, and mean waist circumference, we found the new models have higher C-statistics. Furthermore, NRI and IDI both indicate LFSs had a positive effect on the model.

Conclusions

Our study showed that LFSs are associated with CKD among middle-aged populations in rural areas of northeastern China.

A higher FIB-4 index is associated with an increased incidence of renal failure in the general population

The Fibrosis-4 index (FIB-4) is a recommended noninvasive fibrosis test in patients at risk of liver fibrosis. Chronic liver diseases are often associated with kidney diseases. This study aimed to investigate the association between FIB-4 and the development of renal failure among the general population. For this study, we used the Disease Analyzer database, which includes diagnoses and basic medical and demographic data of patients followed in general practices in Germany. Using these data, we extensively matched patients with a FIB-4 index ≥ 1.3 (n = 66,084) to patients with a FIB-4 index < 1.3 (n = 66,084). The primary outcome was the incidence of renal failure or chronic renal failure during a 10-year period. Within 10 years of the index date, 9.2% of patients with a FIB-4 < 1.3 and 10.6% of patients with a FIB-4 ≥ 1.3 were diagnosed with renal failure (p = 0.007). The endpoint chronic renal failure was reached by 7.9% with a FIB-4 < 1.3 and 9.5% with a FIB-4 ≥ 1.3 (p < 0.001). A FIB-4 index ≥ 1.3 was associated with a slight increase in renal failure incidence (hazard ratio [HR]: 1.08, p = 0.009). There was an increasing association between an increase in FIB-4 index and the incidence of renal failure with the strongest association for a FIB-4 index ≥ 2.67 (HR: 1.34, p = 0.001). In sensitivity analyses, a significant association was found for the age group of 51-60 years (HR: 1.38, p < 0.001), patients with arterial hypertension (HR: 1.15, p < 0.001), obese patients (HR: 1.25, p = 0.005), and patients with lipid metabolism disorders (HR:1.22, p < 0.001). Conclusion: A higher FIB-4 index is associated with an increased incidence of renal failure. Therefore, the FIB-4 index may be useful in identifying patients who are at risk not only for liver-related events but also for renal disease.

Fibrosis Risk in Nonalcoholic Fatty Liver Disease Is Related to Chronic Kidney Disease in Older Type 2 Diabetes Patients

CONTEXT

Nonalcoholic fatty liver disease (NAFLD) is a multisystem disease, associated with fibrosis and an increased risk of type 2 diabetes mellitus (T2DM) and chronic kidney disease (CKD).

OBJECTIVE

This work aimed to investigate the association of NAFLD fibrosis with the development of CKD in aged patients with T2DM.

METHODS

This cross-sectional study enrolled 13 915 participants. A further 1734 individuals who had been followed annually for 5 years comprised the retrospective cohort study. Noninvasive markers, NAFLD fibrosis score (NFS), and fibrosis index based on 4 factors (FIB-4) were applied to determine NAFLD fibrosis risk.

RESULTS

In the cross-sectional study, there was an additive interaction for NAFLD with increased risk of fibrosis and T2DM on CKD incidence. Logistic regression demonstrated that as NAFLD fibrosis risk progressed from low to intermediate and high, there was a stepwise increase in CKD in patients with NAFLD, T2DM, and those with coexistent NAFLD and T2DM when stratified by diabetes and fibrosis stage. FIB-4 had a much higher odds ratio (OR) value than NFS for prediction of CKD incidence. In the cohort study, individuals were grouped according to FIB-4 and NFS. Cox regression analysis showed that FIB-4 intermediate risk (hazard ratio [HR] 1.268; 95% CI, 1.056-1.521) and high risk (HR 2.516; 95% CI, 1.970-3.214) were significant predictors of CKD progression. When NFS was applied, only high risk was a significant predictor.

CONCLUSION

NAFLD with an increased risk of fibrosis and presence of T2DM had an additive interaction on CKD incidence. Increased risk of NAFLD fibrosis was closely associated with CKD incidence and progression in aged T2DM patients. FIB-4 outperformed NFS as a noninvasive means to predict CKD development.

Influence of Nonalcoholic Fatty Liver Disease on the Occurrence and Severity of Chronic Kidney Disease

Nonalcoholic fatty liver disease (NAFLD) is reported to affect 20-30% of adults and is accompanied by various metabolic comorbidities, where the economic and clinical burden of NAFLD is attributed to the progression of liver disease as well as the presence of extrahepatic diseases. Chronic kidney disease (CKD), which has a high incidence rate, high morbidity and mortality rates, and high medical costs, has been linked to NAFLD. CKD is associated with some metabolism-related risk factors that overlap with metabolic comorbidities of NAFLD. Therefore, to investigate the potential factors that influence CKD occurrence, the association between NAFLD and CKD should be clarified. Some studies have confirmed that NAFLD influences the occurrence and severity of CKD, whereas some studies have indicated that there is no correlation. In this review, the results of a few studies have been discussed, the potential risk factors for CKD in NAFLD are explored, and the respective biological mechanisms are elaborated to help clinicians identify CKD in patients much earlier than it is diagnosed now and thus help in reducing the incidence of liver and kidney transplants.

High FIB4 index is an independent risk factor of diabetic kidney disease in type 2 diabetes

Nonalcoholic fatty liver disease (NAFLD) and nonalcoholic steatohepatitis (NASH) may be linked to development of chronic kidney diseases (CKD). The FIB4 index, a noninvasive liver fibrosis score, has been reported to predict CKD in non-diabetic patients, but there are no reports yet in diabetic cases. Therefore, we evaluated the prognostic impact of FIB4 index on the risk of developing diabetic kidney disease (DKD) in Japanese patients with type 2 diabetes in a retrospective cohort study. We assessed patients with type 2 diabetes with an eGFR ≥ 60 mL/min/1.73 m² and without dipstick positive proteinuria (≥ 1 +) at their first visit to our department. Participants were divided into two groups based on the FIB4 index at their first visit: FIB4 index > 1.3 and FIB4 index ≤ 1.3. The primary endpoint was defined as a decrease in eGFR < 60 mL/min/1.73 m² or the onset of proteinuria during the course of treatment. The average age of all 584 type 2 diabetic participants (360 [61.6%] men) was 55 ± 11 years. There were 187 patients in the FIB4 index group > 1.3 (32.0%) and the median observation period was 6.0 (3.8–11.0) years. Kaplan–Meier survival analysis indicated that the risks of developing DKD, eGFR < 60 and proteinuria were all higher in FIB4 index > 1.3 patients than in FIB4 ≤ 1.3 patients. In the Cox regression analysis, an FIB4 index > 1.3 was a significant predictor for onset of DKD (HR 1.54, 95% CI 1.15–2.08) and proteinuria (HR 1.55, 95% CI 1.08–2.23), but not for an eGFR < 60 (HR 1.14, 95% CI 0.79–1.99). To the best of our knowledge, this is the first study to demonstrate that an FIB4 index > 1.3 has a prognostic impact on the development of CKD and proteinuria in type 2 diabetic patients. This warrants further investigation of the prognostic impact of the development of DKD or proteinuria.

Non-invasive fibrosis assessments of non-alcoholic fatty liver disease associated with low estimated glomerular filtration rate among CKD patients: the Fukuoka Kidney disease Registry Study

BACKGROUND

A growing body of evidence has shown that non-alcoholic fatty liver disease (NAFLD) is associated with chronic kidney disease (CKD). Non-invasive fibrosis assessments of NAFLD such as Fibrosis-4 (FIB-4) index and NAFLD fibrosis score (NFS) have been developed to substitute liver biopsy. Little is known about the association between FIB-4 index or NFS and the components of CKD.

METHODS

In the present cross-sectional study, we assessed of 3640 Japanese CKD patients. We examined the association between FIB-4index or NFS and the odds of having low estimated glomerular filtration rate (eGFR) defined as eGFR < 60 mL/min/1.73 m² or albuminuria defined as urinary albumin-to-creatinine ratio (UACR) ≥ 30 mg/g. Patients were divided into quartiles according to their baseline FIB-4 index and NFS levels. Linear and logistic regression analysis were conducted, with adjustment for potential confounding factors.

RESULTS

FIB-4 index and NFS were negatively associated with eGFR, but not UACR, after adjustment for potential confounding factors. Both FIB-4 index and NFS were significantly associated with low eGFR after adjustment for potential confounding factors. Meanwhile, in the multivariable-adjusted model, no associations were found between FIB-4 index or NFS and albuminuria. The addition of FIB-4 index or NFS to the established clinical CKD risk factors improved diagnostic accuracy of prevalence of low eGFR. We also found that there was a significant trend of higher FIB-4 index and NFS with more advanced renal fibrosis using the kidney biopsy data.

CONCLUSIONS

Higher non-invasive fibrosis assessments of NAFLD were associated with higher odds of decreased eGFR.

Prevalence of non-alcoholic fatty liver disease among patients with non-diabetic chronic kidney disease detected by transient elastography

PURPOSE

Non-alcoholic fatty liver disease (NAFLD) shares a close relationship with cardiovascular morbidity and mortality. The purpose of this study is to evaluate the frequency of NAFLD in the patients with non-diabetic chronic kidney disease (CKD).

METHODS

This cross-sectional study included 80 patients with non-diabetic CKD, of which, 50 patients were on hemodialysis (HD) and 30 patients had CKD stage G3-5 not on dialysis. These patients were randomly selected from Ain Shams University Hospitals, Cairo, Egypt. Patients with diabetes mellitus, obesity, alcohol intake, viral hepatitis, or drug-induced liver steatosis were excluded from this study. Importantly, the controlled attenuation parameter (CAP) (dB/m) of liver steatosis (S0-S3) and liver stiffness/fibrosis measurement (F0-F4) were measured using transient elastography (Fibroscan^®). Other evaluations included complete blood count, routine blood chemistry, and C-reactive protein (CRP) titer.

RESULTS

In total, 45 (56.25%) (30 males, 15 females) out of total 80 studied patients were reported to have NAFLD. There were 29 patients with end-stage renal disease who were on regular HD and 16 patients with pre-dialysis CKD G3-5. The mean CAP values of hepatic steatosis in the patients with CKD on dialysis and patients with pre-dialysis CKD were 265.41 ± 52.73 and 259 ± 44.8 dB/m, respectively. A significant association between the severity of hepatic steatosis degree with decreased glomerular filtration rate and increased CKD stage was observed in this study. The degree of liver stiffness was significantly related to an increased hepatic steatosis grade. A significant positive correlation was found between the degree of NAFLD and serum levels of alanine aminotransferase, aspartate transaminase, total cholesterol, triglycerides, low-density lipoprotein, and CRP titer (P < 0.05). Importantly, NAFLD was significantly associated with an evident history of cardiovascular disease (CVD) among the studied patients.

CONCLUSION

A high frequency of NAFLD (56%) was observed among the patients with non-diabetic CKD on hemodialysis and patients with pre-dialysis CKD. NAFLD may be associated with an increased liver stiffness grade and CVD among those patients.

Lower eGFR is associated with increased probability of liver fibrosis in Chinese diabetic patients

BACKGROUND

Kidney dysfunction is linked to nonalcoholic fatty liver disease (NAFLD) progression including fibrosis, steatosis, or inflammation. We aimed to explore whether lower levels of estimated glomerular filtration rate (eGFR) was associated with increased probability of liver fibrosis.

METHODS

Two thousand six hundred eighty-nine subjects enrolled from Shanghai, China, were included in this study. NAFLD fibrosis score (NFS) was used to risk stratify NAFLD patients for fibrosis. eGFR was used to assess kidney function. The association of eGFR level with elevated NFS, and thus high risk of fibrosis, was analysed by linear regression and multinomial logistic regression. The predictive power of eGFR was evaluated via receiver operating characteristic (ROC) curve.

RESULTS

A negative association was found between eGFR and NFS (B = -0.21, 95% CI, -0.37 to -0.04, P = .016). As eGFR quartiles decreased, the prevalence of probable fibrosis increased after adjusting for age, sex, current smoking, waist circumference, duration of diabetes, HbA_1c , hypertension, dyslipidaemia, and homeostasis model assessment index of insulin resistance (HOMA-IR) (Q4: reference; Q3: 1.49, 95% CI, 0.82-2.71; Q2: 1.88, 95% CI, 0.97-3.67; Q1: 2.70, 95% CI, 1.36-5.37, P_{for trend} = .002, 1SD increment: 0.73, 95% CI, 0.58-0.92). The eGFR level can be an effective indicator in differentiating patients with probable presence of fibrosis from those without (AUROC: 0.71, cut-off point: 92.78 mL/min/1.73 m² , P < .001).

CONCLUSIONS

Lower levels of eGFR were associated with higher NFS and thus greater risk of presence of fibrosis in patients with NAFLD and T2DM. Individuals with NAFLD and diabetes should carefully monitor eGFR and receive regular urinalysis, especially when advanced fibrosis is suspected.

Association between Non-Alcoholic Fatty Liver Disease and Chronic Kidney Disease: A Cross-Sectional Study

It is unclear whether the link between non-alcoholic fatty liver disease (NAFLD) and chronic kidney disease (CKD) is mediated by common risk factors. We aimed to elucidate the association between NAFLD and CKD using propensity score (PS)-matched analysis. We assessed 3725 Japanese individuals, excluding those with hepatitis B or C infection and men and women who consumed >30 and >20 g/day of alcohol, respectively. Of these, we enrolled 1097 Japanese subjects with NAFLD diagnosed by ultrasonography and 1097 PS-matched subjects without NAFLD. The prevalence of CKD was higher in subjects with NAFLD than in those without NAFLD before PS matching, but there was no significant difference between these groups in terms of CKD prevalence after PS matching. There was no difference in the prevalence of CKD between those with and without NAFLD in the subgroup analyses. Logistic regression analysis demonstrated that obesity, hypertension, and hyperuricemia were independent predictors of CKD, but NAFLD was not independently associated with CKD. In subjects with NAFLD, obesity, hypertension, and hyperuricemia were independent predictors of CKD. Thus, the link between NAFLD and CKD may be mediated by common risk factors. We recommend screening for CKD when patients with NAFLD have the aforementioned comorbidities.

Nonalcoholic Fatty Liver Disease-Related Chronic Kidney Disease

Nonalcoholic fatty liver disease has become the main concern of hepatologists around the world and the main research topic for identifying effective and safe therapy. Advances in the treatment of chronic viral hepatitis in recent years have opened the way towards reducing mortality in patients with chronic liver disease. This goal has not yet been reached, as the burden of chronic liver disease remains a future major health problem as the incidence of the nonalcoholic fatty liver disease continues to rise. The proportion of patients with liver cirrhosis and those with hepatocellular carcinoma due to nonalcoholic liver disease on the liver transplant waiting list has increased in the last years. The upward trend in the incidence and prevalence of the disease in recent decades raises concern over a possible global epidemic, especially as the disease is still underestimated and underdiagnosed. Chronic kidney disease presented an increase in incidence and prevalence during the last years, and it has been associated not only with increased morbidity and mortality but also with high costs for the health system. During the last decade, several studies have shown the association between nonalcoholic fatty disease and chronic kidney disease, two major worldwide health problems.

Metabolic syndrome and hepatic surgery

In Europe, the prevalence of metabolic syndrome (MS) has reached the endemic rate of 25%. Non-alcoholic fatty liver disease (NAFLD) is the hepatic manifestation of MS. Its definition is histological, bringing together the different lesions associated with hepatic steatosis (fat deposits on more than 5% of hepatocytes) without alcohol consumption and following exclusion of other causes. MS and NAFLD are implicated in the carcinogenesis of hepatocellular carcinoma (HCC) and intrahepatic cholangiocarcinoma (ICC). At present, HCC and ICC involving MS represent 15-20% and 20-30% respectively of indications for hepatic resection in HCC and ICC. Moreover, in the industrialized nations NAFLD is tending to become the most frequent indication for liver transplantation. MS patients combine the operative risk associated with their general condition and comorbidities and the risk associated with the presence and/or severity of NAFLD. Following hepatic resection in cases of HCC and ICC complicating MS, the morbidity rate ranges from 20 to 30%, and due to cardiovascular and infectious complications, post-transplantation mortality is heightened. The operative risk incurred by MS patients necessitates appropriate management including: (i) precise characterization of the subjacent liver; (ii) an accurately targeted approach privileging detection and optimization of treatment taking into account the relevant cardiovascular risk factors; (iii) a surgical strategy adapted to the histology of the underlying liver, with optimization of the volume of the remaining (postoperative) liver.

Relationship Between Serum Uric Acid Levels and Nonalcoholic Fatty Liver Disease in Non-Obese Patients

Background and objectives: Nonalcoholic fatty liver disease (NAFLD) is associated with multiple factors such as hypertension, diabetes, dyslipidemia, obesity, and hyperuricemia. We aim to investigate the relationship between uric acid and NAFLD in a non-obese and young population. Materials and Methods: This study was performed in January 2010–2019 with a group of 367 (225 patients in the NAFLD group and 142 in the control group) patients with liver biopsy-proven NAFLD or no NAFLD. Patients with NAFLD were classified according to the percentage of steatosis as follows, group I had 1–20% and group II >20%. Demographic, clinical, and laboratory (biochemical parameters) features were collected retrospectively. Results: The mean body mass index (BMI) and age of the patients were 26.41 ± 3.42 and 32.27 ± 8.85, respectively. The BMI, homeostatic model of assessment (HOMA-IR), and uric acid (UA) values of the NAFLD group were found to be significantly higher than those of the controls. A positive correlation was found between the NAFLD stage and UA. The following factors were independently associated with NAFLD: BMI, HOMA-IR, and UA. In addition, the cut-off value of UA was 4.75 mg/dl with a sensitivity of 45.8% and a specificity of 80.3%. Conclusions: UA is a simple, non-invasive, cheap, and useful marker that may be used to predict steatosis in patients with NAFLD.

Non-alcoholic fatty liver disease, liver fibrosis score and cognitive function in middle-aged adults: The Framingham Study

BACKGROUND

Non-alcoholic fatty liver disease (NAFLD) is common and has been recently related to brain health. We aimed to assess the relationships of NAFLD and its severity, using the NAFLD fibrosis score (NFS), with cognitive performance.

METHODS

Framingham study Offspring and 3rd generation participants were included if they attended exams 9 (2002-2008) and 2 (2008-2011), respectively, were free of dementia and stroke, and did not have excessive alcohol intake. Between 2008 and 2011, participants underwent Multi-detector computed tomography scans of the abdomen to determine NAFLD diagnosis and the NFS was used to categorize the severity of fibrosis. Cross-sectional relationships of NAFLD and the NFS with cognitive testing of memory, abstract reasoning, visual perception, attention and executive function were assessed, while adjusting for multiple cardiometabolic variables including visceral adipose tissue, diabetes and insulin resistance.

RESULTS

Of the 1287 participants (mean age = 61±12 years, 48% men), 378 (29%) had NAFLD. The presence of NAFLD was not associated with cognitive function. However, among those with NAFLD (mean age = 61±12 years; 58% men), high compared to low risk of advanced fibrosis was associated with poorer performance on similarities (β = -2.22 ± 0.83; P = 0.009) and trail-making B minus A (β = -0.11 ± 0.05; P = 0.028), independently of potential confounders.

CONCLUSIONS

Participants with high risk of advanced fibrosis may have poorer cognitive function compared to those with low risk, particularly in executive function and abstract reasoning. Future findings are necessary to evaluate the value of the NFS as a biomarker that predicts cognitive impairment and dementia and to explore the role of hepatic fibrosis in brain health.

Testing the ability of the nonalcoholic fatty liver disease fibrosis score to predict 1-year all-cause hospital admission

The nonalcoholic fatty liver disease fibrosis score (NFS) has been shown to be a cost-effective screening strategy in the primary care setting to determine when gastroenterology referral is needed, but NFS as a predictor of hospitalization within 1 year is uncertain. This retrospective observational cohort study involved 1803 patients with a diagnosis of nonalcoholic fatty liver disease or nonalcoholic steatohepatitis. The NFS was categorized into the following: low (less than -1.455), moderate (between -1.455 and 0.676), and high (>0.676). The average NFS score by hospital admission was -0.760, the average number of admissions was 1.81, and the median number of days to hospital admission was 135.8 days (45.5-363, 25th to 75th percentile). A univariate logistic regression model showed that NFS significantly predicted hospital admission (P = 0.007); however, a multivariate logistic regression model, after adjusting for hypertension and tobacco use, indicated that NFS was not significantly associated with hospital admission. Using the logistic regression model, hypertension predicted admission at low (P < 0.0001) and moderate (P = 0.0005) NFS. Using this same model, tobacco use also predicted admission at low (P < 0.0001) and moderate (P =  0.0002) NFS. The NFS should not be used to determine which patients are at increased risk of hospitalization.

The correlation between fatty liver disease and chronic kidney disease

BACKGROUND/PURPOSE

The impact of non-alcoholic fatty liver disease (NAFLD) on the prevalence of chronic kidney disease (CKD) is not fully elucidated. We aimed to assess the correlation between NAFLD and CKD in a large population study.

METHODS

We included consecutive subjects who had received health check-up service at Taipei Veterans General Hospital from 2002 to 2009. NAFLD was diagnosed with abdominal ultrasound, and advanced liver fibrosis was determined with NAFLD fibrosis score (NAFLD-FS). CKD was defined as estimated glomerular filtration rate (eGFR) < 60 mL/min/1.73 m².

RESULTS

Among the 29,797 subjects enrolled in this study, NAFLD and CKD were diagnosed in 44.5% and 20.2% of the population, respectively. Subjects with NAFLD had a higher proportion of CKD compared to those without NAFLD (24.1% vs. 17.1%, p < 0.001). However, NAFLD was not related to CKD with an odds ratio (OR) of 1.015 (95% confidence interval [CI] 0.954-1.081, p = 0.630) after multivariate analyses. Nevertheless, further analyses revealed that among patients with NAFLD, those with advanced fibrosis were more likely to have CKD after adjusting for confounding factors (OR 2.284, 95% CI 1.513-3.448, p < 0.001).

CONCLUSION

NAFLD per se was not a risk factor for CKD, but NAFLD patients with advanced fibrosis faced a higher possibility of CKD. Hence, patients with NAFLD and advanced fibrosis should be screened for CKD and prompted to receive treatment if the diagnosis was made.

Chronic kidney disease is independently associated with increased mortality in patients with nonalcoholic fatty liver disease

BACKGROUND & AIMS

Nonalcoholic fatty liver disease and chronic kidney disease share similar pathophysiologic features. Our aim was to assess the association between different stages of chronic kidney disease and mortality in patients with nonalcoholic fatty liver disease.

METHODS

Third National Health and Nutrition Examination Survey-linked mortality files were utilized. Nonalcoholic fatty liver disease was diagnosed by hepatic ultrasound and chronic kidney disease was defined according to the Kidney Disease Improving Global outcomes guideline. Multivariable Cox proportional hazard model was used to assess the effect of chronic kidney disease on overall and cardiovascular mortality.

RESULTS

Total cohort included 11 695 adult participants; mean age 43.3 years, 48.4% male, 76.4% white, 18.6% had nonalcoholic fatty liver disease and 9.3% had chronic kidney disease. 5.6% had diabetes, 21.3% had hypertension, 4.3% had cardiovascular disease. Compared to subjects without chronic kidney disease or nonalcoholic fatty liver disease, nonalcoholic fatty liver disease patients with chronic kidney disease were more likely to be older, had less income, and higher prevalence of comorbidities (all P < 0.001). Prevalence of chronic kidney disease among nonalcoholic fatty liver disease cohort was 11.31%. Compared to non-nonalcoholic fatty liver disease group, patients with nonalcoholic fatty liver disease had higher rates of stage 1, 2 and 3a chronic kidney disease, but similar rates for stage 3b, 4 and 5. Mortality rate was 18.5% in 17 years. Among nonalcoholic fatty liver disease cohort, the presence of chronic kidney disease stages 2-3a (HR = 2.31, 95% CI: 1.70-3.15) and stages 3b-5 (HR = 4.83, 95% CI: 2.40-9.71) were independently associated with increased overall mortality.

CONCLUSIONS

Among patients with nonalcoholic fatty liver disease, moderate to advanced stages of chronic kidney disease are associated with overall mortality. Identification of chronic kidney disease in nonalcoholic fatty liver disease has important prognostic implications.

Liver stiffness assessed by transient elastography as a potential indicator of chronic kidney disease in patients with nonalcoholic fatty liver disease

BACKGROUND

This study was designed to determine the diagnostic value of liver stiffness measured by transient elastography (TE) in identifying chronic kidney disease (CKD) in individuals with ultrasonography-diagnosed NAFLD.

METHODS

A total of 1439 adult patients with ultrasonography-diagnosed NAFLD between October 2015 and August 2017 in China-Japan union hospital of Jilin university were initially eligible. According to the exclusion criteria, 24 patients were excluded, and eventually, a total of 1415 patients were included in the study. The AST/ALT ratio and FIB-4 score were calculated from blood tests, and liver stiffness was measured using TE.

RESULTS

The liver stiffness measured by TE, FIB-4 score, ALT/AST ratio were significantly elevated in CKD patients, compared with those without CKD (P < 0.001). The areas under the curve (AUROC) of liver stiffness, FIB-4 score and AST/ALT ratio were 0.694 (0.670-0.718), 0.707 (0.682-0.730), 0.712 (0.688-0.736), showing no statistically significant difference between these three tests. Further, multivariate analysis identified four independent risk factors for CKD: age, diabetes mellitus, serum uric acid, and liver stiffness. Also, the performance of these four independent variables taken together in a logistic regression model for identifying CKD was 0.834 (AUROC; 95%CI: 0.814-0.853), showing a higher diagnostic performance than that of a single application of liver stiffness.

CONCLUSIONS

Liver stiffness assessed by TE is a potential indicator for CKD in ultrasonography-diagnosed NAFLD patients. Further, a four-variable model (liver stiffness, age, serum uric acid, and diabetes mellitus) could be a useful tool for identifying subjects at high risk for CKD in NAFLD patients.

Inflammatory Biomarkers and Risk of Atherosclerotic Cardiovascular Disease

Background

Non-alcoholic fatty liver disease is an increasing health issue that associates with the development of atherosclerotic cardiovascular disease. This study correlates the association between fatty liver and inflammatory biomarkers with cardiovascular risk scores.

Methodology

This cross-sectional study enrolled 10,181 health examination participants from Northern Taiwan and administered a standardized questionnaire with important biochemical tests and abdominal sonography. To assess concentrations of inflammatory markers high sensitivity C-reactive protein (hs-CRP) and fibrinogen were used.

Results

Inflammatory marker levels were significantly increased with increasing fatty liver. In multivariate logistic regression analysis adjusted for major confounding factors, the odds ratios of elevated hs-CRP and fibrinogen were significantly higher in participants with mild or moderate-to-severe fatty liver compared to healthy individuals. The cardiovascular risk scores, above cut-off level 10%, were associated with higher levels of inflammatory biomarkers and fatty liver; odds ratio, 3.52 (2.60-4.77) for non-alcoholic fatty liver disease with hs-CRP, and 2.92 (2.12-4.00) for non-alcoholic fatty liver disease with fibrinogen.

Conclusion

Inflammatory biomarkers (hs-CRP and fibrinogen) are significantly associated with augmentation of fatty liver. Non-alcoholic fatty liver disease may be a predictor of future atherosclerotic cardiovascular disease, and the prediction value increases on adding inflammatory biomarkers levels.

Renal dysfunction in patients with nonalcoholic fatty liver disease and risk factors

AIM

To assess the renal function in patients with nonalcoholic fatty liver disease (NAFLD) and to identify the risk factors for renal dysfunction.

METHODS

A total of 856 volunteers who underwent health examination were initially enrolled in this study to identify those with NAFLD. The biochemical indexes of patients with NAFLD and healthy volunteers were statistically analyzed, and the renal function with estimated glomerular filtration rate was calculated. In addition, the risk factors for renal damage were identified.

RESULTS

A total of 253 patients with NAFLD were identified, and the remaining 603 cases were used as a control group. There was no significant difference in serum BUN between the two groups (t = 1.678, P = 0.062), while other biochemical indexes differed significantly (P < 0.05). The prevalence of renal function impairment was higher in individuals with NAFLD compared to those without (28.8% vs 17.5%, P < 0.0001). Logistic regression analysis showed that NAFLD was associated with renal function impairment, even after adjustment for demographics and components of metabolic syndrome (OR = 2.85, 95%CI: 1.93-4.21, P = 0.000).

CONCLUSION

The biochemical indexes of NAFLD patients are significantly abnormal, and renal function impairment is associated with NAFLD. Patients with NAFLD should be regularly assessed for renal function to avoid progressing into chronic kidney disease and increasing the medical burden.

Noninvasive fibrosis markers and chronic kidney disease among adults with nonalcoholic fatty liver in USA

BACKGROUND/AIMS

Studies have shown that nonalcoholic fatty liver disease (NAFLD) is associated with an increased risk of chronic kidney disease (CKD). However, it is unknown whether severe liver fibrosis is associated with a higher prevalence of CKD among NAFLD. We examined the diagnostic performance of noninvasive fibrosis markers in identifying prevalent CKD among NAFLD.

METHODS

This study represents an analysis of the National Health and Nutrition Examination Survey conducted in the USA between 1988 and 1994. NAFLD was defined by ultrasonographic evidence of hepatic steatosis without other liver diseases. CKD was defined by estimated glomerular filtration rate less than 60 ml/min/1.73 m. The presence and severity of hepatic fibrosis were determined by the NAFLD fibrosis score (NFS), FIB-4 score, APRI score, and BARD score. Multiple logistic regression was performed to generate odds ratios (ORs) and receiver operating characteristic curves were used to assess the predictive values of each marker.

RESULTS

A total of 4142 individuals with NAFLD were included; 200 (4.8%) had CKD. The area under the receiver operating characteristic curves was 0.77, 0.75, 0.62, and 0.51 for the multivariable equation with FIB-4, NFS, BARD, and APRI score, respectively. Compared with patients with a low probability of developing advanced liver fibrosis, individuals with a high probability of developing fibrosis showed significantly increased odds of CKD as estimated by NFS (adjusted OR: 4.92, 95% confidence interval: 2.96-8.15) and FIB-4 (adjusted OR: 2.27, 95% confidence interval: 1.05-4.52).

CONCLUSION

Advanced liver fibrosis, defined by NFS and FIB-4 scores, is associated independently with CKD among individuals with NAFLD. FIB-4 is the best predictor of an increased risk of prevalent CKD.

Intrahepatic fat, abdominal adipose tissues, and metabolic state: magnetic resonance imaging study

BACKGROUND

Intrahepatic fat (IHF) is best known to associate with waist circumference (WC) and visceral adipose tissue (VAT), but its relation to abdominal subcutaneous adipose tissue is controversial. While IHF ≥ 5% dichotomously defines fatty liver, %IHF is rarely considered as a continuous variable that includes the normal range. In this study, we aimed to evaluate %IHF association with abdominal fat subdepots, pancreatic, and renal-sinus fats.

METHODS

We evaluated %IHF, abdominal fat subdepots, %pancreatic, and renal-sinus fats, among individuals with moderate abdominal obesity, using 3-Tesla magnetic resonance imaging.

RESULTS

Among 275 participants, %IHF widely ranged (0.01%-50.4%) and was lower in women (1.6%) than men (7.3%; P < .001). In an age, sex, and WC-adjusted models, VAT area (P < .006) was directly associated with %IHF, while superficial-subcutaneous adipose tissue proportion was inversely associated with %IHF (P < .006). In these models, renal-sinus fat was positively associated with %IHF (P = .005). In an age, sex, WC, and VAT-adjusted models, elevated liver enzymes, glycemic, lipid, and inflammatory biomarkers were associated with increased %IHF (P < .003 for all). In these models, the associations remained robust even within the normal range strata of IHF < 5% for triglycerides and chemerin (P ≤ .004 for all). For the diagnosis of fatty liver, the joint area under the curve of WC, alanine-aminotransferase, triglycerides/high-density lipoprotein cholesterol, and homeostasis model assessment of insulin resistance was 0.84(95% CI, 0.79-0.89).

CONCLUSIONS

Intrahepatic fat is differentially associated with abdominal fat subdepots. Intrahepatic-fat as a continuous variable could be predicted by specific traditional parameters, even within the current normal range, and partially independent of VAT.

Elevated hemoglobin glycation index identify non-diabetic individuals at increased risk of kidney dysfunction

Hemoglobin glycation index (HGI), calculated as the difference between the observed value of HbA1 and the predicted HbA1c based on plasma glucose concentration, is a measure of the individual tendency toward non-enzymatic hemoglobin glycation which has been found to be positively associated with nephropathy in subjects with diabetes. In this cross-sectional study we aimed to evaluate whether higher HGI levels are associated with impaired kidney function also among nondiabetic individuals.

The study group comprised 1505 White nondiabetic individuals stratified in quartiles according to HGI levels. Estimated glomerular filtration rate (eGFR) was calculated by using the MDRD equation.

Individuals in the intermediate and high HGI groups exhibited a worse metabolic phenotype with increased levels of visceral obesity, total cholesterol, triglycerides, inflammatory biomarkers such as hsCRP and white blood cells count and lower values of HDL and insulin sensitivity assessed by Matsuda index in comparison to the lowest quartile of HGI. Subjects in the intermediate and high HGI groups displayed a graded decrease of eGFR levels in comparison with the lowest quartile of HGI. In a logistic regression analysis individuals in the highest quartile of HGI exhibited a significantly 3.6-fold increased risk of having chronic kidney disease (95% CI: 1.13–11.24, P = 0.03) and a significantly 1.6-fold increased risk of having a mildly reduced kidney function (95% CI: 1.19–2.28, P = 0.003) in comparison to individuals in the lowest HGI group.

In conclusion HGI may be a useful tool to identify nondiabetic individuals with an increased risk of having kidney dysfunction.

Nonalcoholic fatty liver disease - A multisystem disease?

Non-alcoholic fatty liver disease (NAFLD) is one of the most common comorbidities associated with overweight and metabolic syndrome (MetS). Importantly, NAFLD is one of its most dangerous complications because it can lead to severe liver pathologies, including fibrosis, cirrhosis and hepatic cellular carcinoma. Given the increasing worldwide prevalence of obesity, NAFLD has become the most common cause of chronic liver disease and therefore is a major global health problem. Currently, NAFLD is predominantly regarded as a hepatic manifestation of MetS. However, accumulating evidence indicates that the effects of NAFLD extend beyond the liver and are negatively associated with a range of chronic diseases, most notably cardiovascular disease (CVD), diabetes mellitus type 2 (T2DM) and chronic kidney disease (CKD). It is becoming increasingly clear that these diseases are the result of the same underlying pathophysiological processes associated with MetS, such as insulin resistance, chronic systemic inflammation and dyslipidemia. As a result, they have been shown to be independent reciprocal risk factors. In addition, recent data have shown that NAFLD actively contributes to aggravation of the pathophysiology of CVD, T2DM, and CKD, as well as several other pathologies. Thus, NAFLD is a direct cause of many chronic diseases associated with MetS, and better detection and treatment of fatty liver disease is therefore urgently needed. As non-invasive screening methods for liver disease become increasingly available, detection and treatment of NAFLD in patients with MetS should therefore be considered by both (sub-) specialists and primary care physicians.

The Impact of Nonalcoholic Fatty Liver Disease on Renal Function in Children with Overweight/Obesity

The association between nonalcoholic fatty liver disease (NAFLD) and chronic kidney disease has attracted interest and attention over recent years. However, no data are available in children. We determined whether children with NAFLD show signs of renal functional alterations, as determined by estimated glomerular filtration rate (eGFR) and urinary albumin excretion. We studied 596 children with overweight/obesity, 268 with NAFLD (hepatic fat fraction ≥5% on magnetic resonance imaging) and 328 without NAFLD, and 130 healthy normal-weight controls. Decreased GFR was defined as eGFR < 90 mL/min/1.73 m². Abnormal albuminuria was defined as urinary excretion of ≥30 mg/24 h of albumin. A greater prevalence of eGFR < 90 mL/min/1.73 m² was observed in patients with NAFLD compared to those without liver involvement and healthy subjects (17.5% vs. 6.7% vs. 0.77%; p < 0.0001). The proportion of children with abnormal albuminuria was also higher in the NAFLD group compared to those without NAFLD, and controls (9.3% vs. 4.0% vs. 0; p < 0.0001). Multivariate logistic regression analysis revealed that NAFLD was associated with decreased eGFR and/or microalbuminuria (odds ratio, 2.54 (confidence interval, 1.16–5.57); p < 0.05) independently of anthropometric and clinical variables. Children with NAFLD are at risk for early renal dysfunction. Recognition of this abnormality in the young may help to prevent the ongoing development of the disease.

Nonalcoholic Steatohepatitis is the Most Rapidly Growing Indication for Simultaneous Liver Kidney Transplantation in the United States

BACKGROUND

Frequency of liver transplantation (LT) is increasing in nonalcoholic steatohepatitis (NASH) with good post-transplant outcomes. Similar data on simultaneous liver kidney (SLK) transplants are limited.

METHODS

United Network for Organ Sharing database (2002-2011) queried for deceased donor first LT for primary biliary cirrhosis, primary sclerosing cholangitis, or alcoholic cirrhosis (group I), NASH, and cryptogenic cirrhosis with body mass index greater than 30 (group II), and hepatitis C virus with and without alcohol, hepatitis B virus, and hepatocellular carcinoma (group III).

RESULTS

Of 38 533 LT (9495, 3665, and 25 383 in groups I-III, respectively), about 5.6% (N = 2162) received SLK with 584 (6.2%), 320 (8.7%), and 1258 (5%) in groups I-III, respectively. The SLK performed for group II increased from 6.3% in 2002 to 2003 to 19.2% in 2010 to 2011. Similar trends remained unchanged in group I (26.1 to 26.6%) and decreased in group III (67.6 to 54.5%). Five-year outcomes were similar comparing group II versus group I for liver graft (78 vs 74%, P = 0.14) and patient survival (81 vs 76%, P = 0.07). In contrast, kidney graft outcome was worse for group II (70 vs 79%, P = 0.002). Risk of kidney graft loss was over 1.5-fold higher among group II SLK recipients compared to group I after controlling for recipient characteristics. Estimated glomerular filtration rate remained lower in group II compared with group I at various time points after SLK transplantation.

CONCLUSIONS

The NASH is the most rapidly growing indication for SLK transplantation with poor renal outcomes. Studies are needed to examine mechanisms of these findings and develop strategies to improve renal outcomes in SLK recipients for NASH.

Association of blood pressure level with nonalcoholic fatty liver disease in nonhypertensive population: Normal is not the new normal

The functional crosstalk between nonalcoholic fatty liver disease (NAFLD) and hypertension has been reported by some literatures; however, in nonhypertensive individuals, there is no article describes the characteristic of NAFLD. In this study, we aimed to determine the strength of the association between NAFLD with normal blood pressure (BP) in nonhypertensive individuals. This cross-sectional study was conducted in the sixth Affiliated Hospital of Wenzhou Medical University, from October 2007 to December 2011. In brief, 24,200 subjects were enrolled to participate in the survey. Among those subjects, there were 5305 enrolled subjects, those with filling the diagnostic criteria for NAFLD (21.9%; 4803 males and 502 females). Nonhypertension was identified in 17,403 (71.9%; 8179 males and 9224 females). The PR% of NAFLD for the systolic blood pressure (SBP) in quartiles 1 to 4 was 10.83, 12.55, 20.38, and 19.97. SBP, diastolic blood pressure (DBP), sex, age, glutamic pyruvic transaminase, glutamic oxaloacetic transaminase, fasting plasma glucose, uric acid, triglyceride, high-density lipoprotein cholesterol, and low-density lipoprotein cholesterol are closely associated with the risk for NAFLD. SBP (odds ratio [OR]: 1.092, 95% confidence interval [CI]: 1.030-1.158; P < 0.05) and DBP (OR: 1.157, 95%CI: 1.094-1.223; P < 0.05) were found to be independent risk factors for NAFLD. Our analysis indicates that BP is significantly associated with NAFLD in nonhypertensive individuals; SBP and DBP are found to be independent risk factors for NAFLD.

The xanthine oxidase inhibitor febuxostat suppresses development of nonalcoholic steatohepatitis in a rodent model

Xanthine oxidase (XO) is an enzyme involved in the production of uric acid (UA) from purine nucleotides. Numerous recent studies have revealed the likelihood of metabolic syndrome including nonalcoholic fatty liver disease (NAFLD) or steatohepatitis (NASH) to be related to hyperuricemia. However, it remains unclear whether elevated serum UA during the development of NAFLD or NASH is a cause or a consequence of these diseases. In this study, the XO inhibitor febuxostat was administered to two types of NASH model mice. Febuxostat exerted a strong protective effect against NASH development induced by a high-fat diet containing trans fatty acid (HFDT). In contrast, methionine choline-deficient-diet-induced NASH development not accompanied by hyperuricemia showed no UA normalization, suggesting that the ameliorating effect of febuxostat occurs via the normalization of hyperuricemia itself and/or accompanying molecular mechanism(s) such as oxidative stress. In the HFDT-fed mice, hyperuricemia, elevated alanine aminotransferase, and increased Tunnel-positive cells in the liver were normalized by febuxostat administration. In addition, upregulation of fatty acid oxidation-related genes, fibrotic change, and increases in collagen deposition, inflammatory cytokine expressions, and lipid peroxidation in the HFDT-fed mice were also normalized by febuxostat administration. Taken together, these observations indicate that administration of febuxostat has a protective effect against HFDT-induced NASH development, suggesting the importance of XO in its pathogenesis. Thus XO inhibitors are potentially potent therapies for patients with NASH, particularly that associated with hyperuricemia.

Comorbidities and Metabolic Derangement of NAFLD

Nonalcoholic fatty liver disease (NAFLD) is an increasingly common cause of chronic liver disease worldwide and is becoming a major public health problem. NAFLD has been recognized as a hepatic manifestation of metabolic syndrome linked with insulin resistance. Growing evidence supports that NAFLD is associated with systemic diseases such as cardiovascular disease (CVD), chronic kidney disease (CKD), type 2 diabetes, obesity, and metabolic syndrome. The majority of deaths in patients with NAFLD come from cardiovascular disease. These findings are strongly attributed to nonalcoholic steatohepatitis (NASH) rather than simple steatosis. NAFLD should be considered not only a liver specific disease but also an early mediator of systemic disease. The underlying mechanisms and pathogenesis of NAFLD with regard to other medical disorders are not yet fully understood. Further investigation is needed for future therapeutic strategies for NAFLD. This review focuses on the relationship between NAFLD and various comorbid diseases and metabolic derangement.

Lean-non-alcoholic fatty liver disease increases risk for metabolic disorders in a normal weight Chinese population

AIM: To study the prevalence and clinical biochemical, blood cell and metabolic features of lean-non-alcoholic fatty liver disease (lean-NAFLD) and its association with other diseases.

METHODS: Demographic, biochemical and blood examinations were conducted in all the subjects in this study. We classified the subjects into four groups according to their weight and NAFLD status: lean-control, lean-NAFLD [body mass index (BMI) < 24 kg/m²], overweight-obese control and overweight-obese NAFLD. One-way analysis of variance (ANOVA) was used to compare the means of continuous variables (age, BMI, blood pressure, glucose, lipid, insulin, liver enzymes and blood cell counts) and the χ² test was used to compare the differences in frequency of categorical variables (sex, education, physical activity, smoking, alcohol consumption and prevalence of hypertension, hyperlipidemia, diabetes, metabolic syndrome central obesity and obesity). Both univariate and multivariate logistic regression models were adopted to calculate odds ratios (ORs) and predict hyperlipidemia, hypertension, diabetes and metabolic syndrome when we respectively set all controls, lean-control and overweight-obese-control as references. In multivariate logistic regression models, we adjusted potential confounding factors, including age, sex, smoking, alcohol consumption and physical activity.

RESULTS: The prevalence of NAFLD was very high in China. NAFLD patients were older, had a higher BMI, waist circumference, blood pressure, fasting blood glucose, insulin, blood lipid, liver enzymes and uric acid than the controls. Although lean-NAFLD patients had lower BMI and waist circumstance, they had significantly higher visceral adiposity index than overweight-obese controls. Lean-NAFLD patients had comparable triglyceride, cholesterin and low-density lipoprotein cholesterin to overweight-obese NAFLD patients. In blood cell examination, both lean and overweight-obese NAFLD was companied by higher white blood cell count, red blood cell count, hemoglobin and hematocrit value. All NAFLD patients were at risk of hyperlipidemia, hypertension, diabetes and metabolic syndrome (MetS). Lean-NAFLD was more strongly associated with diabetes (OR = 2.47, 95%CI: 1.14-5.35), hypertension (OR = 1.72, 95%CI: 1.00-2.96) and MetS (OR = 3.19, 95%CI: 1.17-4.05) than overweight-obese-NAFLD (only OR for MetS was meaningful: OR = 1.89, 95%CI: 1.29-2.77). NAFLD patients were more likely to have central obesity (OR = 1.97, 95%CI: 1.38-2.80), especially in lean groups (OR = 2.17, 95%CI: 1.17-4.05).

CONCLUSION: Lean-NAFLD has unique results in demographic, biochemical and blood examinations, and adds significant risk for diabetes, hypertension and MetS in lean individuals.

Association between noninvasive fibrosis markers and cardio-vascular organ damage among adults with hepatic steatosis

Evidence suggests that advanced fibrosis, as determined by the noninvasive NAFLD fibrosis score (NFS), is a predictor of cardiovascular mortality in individuals with ultrasonography-diagnosed NAFLD. Whether the severity of histology (i.e., fibrosis stage) is associated with more pronounced cardiovascular organ damage is unsettled. In this study, we analyzed the clinical utility of NFS in assessing increased carotid intima-media thickness (cIMT), and left ventricular mass index (LVMI). In this cross-sectional study NFS, cIMT and LVMI were assessed in 400 individuals with ultrasonography-diagnosed steatosis. As compared with individuals at low probability of liver fibrosis, individuals both at high and at intermediate probability of fibrosis showed an unfavorable cardio-metabolic risk profile having significantly higher values of waist circumference, insulin resistance, high sensitivity C-reactive protein (hsCRP), fibrinogen, cIMT, and LVMI, and lower insulin-like growth factor-1 (IGF-1) levels. The differences in cIMT and LVMI remained significant after adjustment for smoking and metabolic syndrome. In a logistic regression model adjusted for age, gender, smoking, and diagnosis of metabolic syndrome, individuals at high probability of fibrosis had a 3.9-fold increased risk of vascular atherosclerosis, defined as cIMT>0.9 mm, (OR 3.95, 95% CI 1.12-13.87) as compared with individuals at low probability of fibrosis. Individuals at high probability of fibrosis had a 3.5-fold increased risk of left ventricular hypertrophy (LVH) (OR 3.55, 95% CI 1.22-10.34) as compared with individuals at low probability of fibrosis. In conclusion, advanced fibrosis, determined by noninvasive fibrosis markers, is associated with cardiovascular organ damage independent of other known factors.

Elevated 1 h postload plasma glucose levels identify adults with normal glucose tolerance but increased risk of non-alcoholic fatty liver disease

OBJECTIVE

To determine the ability of the proposed diagnostic value of a 1-h OGTT glucose ≥155mg/dL to identify individuals with non-alcoholic fatty liver disease (NAFLD) diagnosed by ultrasonography in a cohort of adult white individuals.

DESIGN

The study group comprised 710 white individuals participating to the CATAnzaro MEtabolic RIsk factors (CATAMERI) Study, a cross-sectional study assessing cardio-metabolic risk factors in individuals carrying at least one risk factor including dysglycemia, overweight/obesity, hypertension, dyslipidemia. a 75 g oral Oral Glucose Tolerance Test (OGTT) was performed with 0, 30, 60, 90 and 120 min sampling for plasma glucose and insulin measurements. Cardio-metabolic risk factors including alanine aminotransferase (ALT), aspartate aminotransferase (AST), and gamma-glutamyltransferase (GGT) were assessed in the whole cohort.

RESULTS

Of the 710 participants examined, 295 had normal glucose tolerance (NGT) with 1-hour post-load plasma glucose <155 mg/dL (NGT 1h-low), 109 individuals had NGT 1h-high, 104 had isolated impaired fasting glucose (IFG), and 202 had impaired glucose tolerance (IGT). As compared with NGT 1h-low, NGT 1h-high and IGT subjects exhibited significantly higher body mass index (BMI), triglycerides, high sensitivity C reactive protein, ALT, GGT, and hepatic insulin resistance (IR), assessed by the liver IR index, as well as lower high density lipoprotein, and insulin-like growth factor-1 (IGF-1) levels. In a logistic regression analysis adjusted for age, gender, and BMI, NGT 1h-high participants had a 1.5-fold increased risk of having NAFLD and an even increased risk was observed in subjects with IGT (1.8-fold), but not in the isolated IFG group (1.01-fold).

CONCLUSIONS

These data suggest that the value of a 1-hour OGTT glucose ≥155 mg/dL may be helpful to identify a subset of NGT individuals at risk for NAFLD.