Fibrosis-4 Index vs Nonalcoholic Fatty Liver Disease Fibrosis Score in Identifying Advanced Fibrosis in Subjects With Nonalcoholic Fatty Liver Disease: A Meta-Analysis

Autotaxin-Lysophosphatidate Axis: Promoter of Cancer Development and Possible Therapeutic Implications

Autotaxin (ATX) is a member of the ectonucleotide pyrophosphate/phosphodiesterase (ENPP) family; it is encoded by the ENPP2 gene. ATX is a secreted glycoprotein and catalyzes the hydrolysis of lysophosphatidylcholine to lysophosphatidic acid (LPA). LPA is responsible for the transduction of various signal pathways through the interaction with at least six G protein-coupled receptors, LPA Receptors 1 to 6 (LPAR1-6). The ATX-LPA axis is involved in various physiological and pathological processes, such as angiogenesis, embryonic development, inflammation, fibrosis, and obesity. However, significant research also reported its connection to carcinogenesis, immune escape, metastasis, tumor microenvironment, cancer stem cells, and therapeutic resistance. Moreover, several studies suggested ATX and LPA as relevant biomarkers and/or therapeutic targets. In this review of the literature, we aimed to deepen knowledge about the role of the ATX-LPA axis as a promoter of cancer development, progression and invasion, and therapeutic resistance. Finally, we explored its potential application as a prognostic/predictive biomarker and therapeutic target for tumor treatment.

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

BACKGROUND AND AIM

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Development of a novel non-invasive biomarker panel for hepatic fibrosis in MASLD

Accurate non-invasive biomarkers to diagnose metabolic dysfunction-associated steatotic liver disease (MASLD)-related fibrosis are urgently needed. This study applies a translational approach to develop a blood-based biomarker panel for fibrosis detection in MASLD. A molecular gene expression signature identified from a diet-induced MASLD mouse model (LDLr-/-.Leiden) is translated into human blood-based biomarkers based on liver biopsy transcriptomic profiles and protein levels in MASLD patient serum samples. The resulting biomarker panel consists of IGFBP7, SSc5D and Sema4D. LightGBM modeling using this panel demonstrates high accuracy in predicting MASLD fibrosis stage (F0/F1: AUC = 0.82; F2: AUC = 0.89; F3/F4: AUC = 0.87), which is replicated in an independent validation cohort. The overall accuracy of the model outperforms predictions by the existing markers Fib-4, APRI and FibroScan. In conclusion, here we show a disease mechanism-related blood-based biomarker panel with three biomarkers which is able to identify MASLD patients with mild or advanced hepatic fibrosis with high accuracy.

Nonalcoholic steatohepatitis: A comprehensive updated review of risk factors, symptoms, and treatment

Non-alcoholic steatohepatitis (NASH) is a subtype of nonalcoholic fatty liver disease and a progressive and chronic liver disorder with a significant risk for the development of liver-related morbidity and mortality. The complex and multifaceted pathophysiology of NASH makes its management challenging. Early identification of symptoms and management of patients through lifestyle modification is essential to prevent the development of advanced liver disease. Despite the increasing prevalence of NASH, there is no FDA-approved treatment for this disease. Currently, medications targeting metabolic disease risk factors and some antifibrotic medications are used for NASH patients but are not sufficiently effective. The beneficial effects of different drugs and phytochemicals represent new avenues for the development of safer and more effective treatments for NASH. In this review, different risk factors, clinical symptoms, diagnostic methods of NASH, and current treatment strategies for the management of patients with NASH are reviewed.

Non-invasive testing and risk-stratification in patients with MASLD

The development and validation of non-invasive fibrosis tests (NITs) has changed clinical practice in Hepatology over the last 15 years. Metabolic associated steatotic liver disease (MASLD), formerly known as non-alcoholic fatty liver disease (NAFLD), is the most prevalent liver disease in western countries, with up to a third of the unselected adult population affected. In this article, we review the use of NITs in the diagnosis and staging of MASLD. We discuss their use in the diagnosis of steatosis, steatohepatitis and fibrosis and critically evaluate recently published data. These NITs include a variety of approaches, such as serum markers like FIB-4, pro-C3 and ELF, imaging techniques like Fibroscan® and MRE, and combined scores like Agile 3+ and Agile 4, offering a range of options for healthcare providers. Furthermore, these non-invasive tests also serve as valuable prognostic tools, allowing for better risk assessment and improved patient management, particularly in predicting liver-related events and overall mortality.

How Hepatologists Use Liver Biopsy in the Evaluation of Liver Disease?

This article focuses on how hepatologists view the role of liver biopsy in diagnosis, assessment, and management of chronic and acute liver disease, and its variable use among different etiologies of liver disease and in the evaluation of liver fibrosis.

Noninvasive Tests Used in Risk Stratification of Patients with Nonalcoholic Fatty Liver Disease

As the prevalence of obesity and type 2 diabetes increases around the world, the prevalence of nonalcoholic fatty liver disease (NAFLD) has grown proportionately. Although most patients with NAFLD do not experience progressive liver disease, about 15% to 20% of those with nonalcoholic steatohepatitis can and do progress. Because liver biopsy's role in NAFLD has become increasingly limited, efforts have been undertaken to develop non-invasive tests (NITs) to help identify patients at high risk of progression. The following article discusses the NITs that are available to determine the presence of NAFLD as well as high-risk NAFLD.

New FIB-4 and NFS cutoffs to guide sequential non-invasive assessment of liver fibrosis by magnetic resonance elastography in NAFLD

INTRODUCTION AND OBJECTIVES

Liver fibrosis is an important prognosis marker in non-alcoholic fatty liver disease (NAFLD). Biopsy has been considered the gold-standard method for measuring liver fibrosis; however, it is an invasive procedure. Non-invasive diagnostic tools have been developed, such as clinical scores and magnetic resonance elastography (MRE), which is the most accurate non-invasive method to determine liver fibrosis. Thus, the aim was to determine the NAFLD Fibrosis Score (NFS) and the Fibrosis-4 Score (FIB-4) cut-off points that best identify NAFLD patients at risk for developing liver fibrosis.

PATIENTS AND METHODS

Single-center cross-sectional study with prospective recruitment of NAFLD (training-cohort) and MAFLD (validation-cohort) patients undergoing MRE. The NFS and the FIB-4 cut-off points that best-differentiated patients with fibrosis, using the MRE as the standard method, were determined.

RESULTS

Two cohorts were analyzed, a training cohort that included the initial 183 patients with NAFLD and a validation cohort that included 289 patients. In the training cohort, 60.1% had mild steatosis and 11.5% had liver fibrosis ≥ F1 by MRE. ROC curves were developed for FIB-4 and NFS, and the cut-off points chosen were 1.505 (sensitivity=85% and specificity=86%) for FIB-4 and -0.835 (sensitivity=100% and specificity=70%) for NFS, showing greater specificity than the cut-off points currently used (51% and 76%, respectively). The two cohorts exhibited similar characteristics and similar sensitivity and specificity results for the chosen cut-off points.

CONCLUSIONS

This study has shown cut-off points with greater specificity and excellent sensitivity to guide the indication for further liver evaluation by MRE in NAFLD patients.

Comparative accuracy of endosonographic shear wave elastography and transcutaneous liver stiffness measurement: a pilot study

BACKGROUND AND AIMS

Vibration-controlled transient elastography (VCTE) is a validated test for assessing liver fibrosis but may be unreliable in select patients, including those with morbid obesity. The limitations of VCTE may be overcome by EUS-guided shear wave elastography (EUS-SWE).

METHODS

This single-center, prospective, nonrandomized tandem study compared the diagnostic accuracy of EUS-SWE and VCTE in consecutive patients undergoing liver biopsy sampling because of unreliable noninvasive testing. EUS-SWE of the left and right lobes were separately performed and then compared with VCTE. Liver elasticity cutoffs for different stages of fibrosis were estimated in 3 ways: optimized sensitivity and specificity using the Youden index; and with sensitivity and specificity fixed at 90% each, Diagnostic accuracy for fibrosis was compared with liver histology using the area under the receiver-operating characteristic curve (AUROC). The primary outcome was the diagnostic accuracy of EUS-SWE for advanced fibrosis. Secondary outcomes were diagnostic accuracy of VCTE, EUS-SWE for left and right hepatic lobes for significant/advanced fibrosis, and cirrhosis.

RESULTS

Forty-two patients (39 men, aged 54.5 ± 12.1 years) underwent EUS-SWE, VCTE, and liver biopsy sampling. The cross-validated AUROCs for advanced fibrosis were as follows: VCTE, .87 (95% confidence interval [CI], .76-.97); EUS-SWE left lobe, .8 (95% CI, .64-.96); and EUS-SWE right lobe, .78 (95% CI, .62-.95). The corresponding AUROCs for cirrhosis were as follows: VCTE, .9 (95% CI, .83-.97); EUS-SWE left lobe, .96 (95% CI, .9-1); and EUS-SWE right lobe, .9 (95% CI, .8-1). VCTE was unreliable in 8 patients who successfully underwent EUS-SWE. There was no statistically significant difference in the AUROCs for EUS-SWE and VCTE.

CONCLUSIONS

EUS-SWE correlates well with liver histology and is a safe and reliable diagnostic test for assessing liver fibrosis with accuracy comparable with VCTE. (Clinical trial registration number: NCT04533932.).

The role of noninvasive scoring systems for predicting cardiovascular disease risk in patients with nonalcoholic fatty liver disease: a systematic review and meta-analysis

BACKGROUNDS

Cardiovascular disease (CVD) is suggested as a leading cause of death among patients with nonalcoholic fatty liver disease (NAFLD). The aim of this work was to clarify the role of noninvasive scoring systems (NSSs) in predicting CVD risk among this population.

METHODS

The PubMed, Web of Science, and Cochrane databases were searched until 23 March 2022. Meta-analysis was performed for three most commonly used NSS separately, that is, fibrosis-4 index (FIB-4), NAFLD fibrosis score (NFS), and AST/platelet ratio index (APRI).

RESULTS

Totally, nine studies including 155 382 patients with NAFLD were enrolled. Patients with NAFLD had a higher risk of CVD with increasing FIB-4 score (1.94, 1.52-2.46), the association remained significant after adjustment for age, sex, body mass index, hypertension, and diabetes (2.44, 1.85-3.22). Similarly, a higher risk of CVD was also observed in patients with increasing NFS (2.17, 1.58-2.98) and APRI scores (1.36, 1.04-1.79) in the unadjusted model. However, in the adjusted model, the association was significant only for NFS (3.83, 1.40-10.43), but not for APRI (1.41, 0.79-2.51). Additionally, the increment in CVD risk was most noticeable in subgroup of FIB > 2.67 vs. FIB ≤ 1.3 (6.52, 3.07-13.86) and subgroup of NFS > 0.676 vs. NFS ≤ -1.455 (16.88, 5.68-50.23). All subgroup analyses showed significant associations between FIB-4, NFS, and risk of CVD. Sensitivity analyses did not modify these results.

CONCLUSIONS

FIB-4 and NFS might be useful in identifying those who are at higher risk of CVD among patients with NAFLD. However, APRI was not recommended for this use.

Nonalcoholic fatty liver disease and obesity: An Obesity Medicine Association (OMA) Clinical Practice Statement (CPS) 2022

Background

This Obesity Medicine Association (OMA) Clinical Practice Statement (CPS) provides clinicians an overview of nonalcoholic fatty liver disease (NAFLD), potential progression to nonalcoholic steatohepatitis (NASH), and their application to obesity.

Methods

The scientific information for this CPS is based upon published scientific citations, clinical perspectives of OMA authors, and peer review by the Obesity Medicine Association leadership.

Results

Topics of this CPS include the prevalence of NAFLD and NASH, the prevalence of NAFLD and NASH among patients with obesity, as well as NAFLD and NASH definitions, diagnosis, imaging, pathophysiology, differential diagnosis, role of high fructose corn syrup and other simple sugars, and treatment (e.g., nutrition, physical activity, medications).

Conclusions

This Obesity Medicine Association (OMA) Clinical Practice Statement (CPS) regarding NAFLD and obesity is one of a series of OMA CPSs designed to assist clinicians in the care of patients with the disease of obesity. Patients with obesity are at increased risk for NAFLD and NASH. Patients may benefit when clinicians who manage obesity understand the etiology, diagnosis, and optimal treatment of NAFLD with a goal to prevent NASH.

Accuracy of steatosis and fibrosis NAFLD scores in relation to vibration controlled transient elastography: An NHANES analysis

BACKGROUND

Non-alcoholic fatty liver disease (NAFLD) is highly prevalent and increasing in the United States. Based on patient characteristics and biochemical profiles, predictive indices have been formulated to evaluate the presence and severity of NAFLD. This study evaluates the accuracy of these indices versus vibration-controlled transient elastography (VCTE™) to screen at-risk populations for NAFLD.

METHODS

Subjects from the NHANES datasets (2017-2018) without other liver diseases with completed VCTE™ data were studied (n = 5062). Hepatic steatosis and fibrosis scores were calculated and compared with controlled attenuation parameter (CAP) and elastography measurements of VCTE™, respectively.

RESULTS

The prevalence of NAFLD was 58.5%. Against a CAP cut-off value of ≥238 dB/m for diagnosing fatty liver, the US fatty liver index [US-FLI] had the highest positive predictive value (90%) and specificity (63.7%). The coefficient of correlation against CAP was strong for fatty liver index [FLI] (r = 0.645) and US-FLI (r = 0.608). The hepatic steatosis index [HSI] had the highest negative predictive value (82.1%) and sensitivity (75%) for ruling out steatosis. HSI and FLI, which use commonly obtained clinical parameters, had a high diagnostic odds ratios (21.2 and 18.6, respectively) compared to US-FLI (4.97), which requires insulin levels in the calculation. These findings were similar across all ethnicities studied.

CONCLUSION

US-FLI is a reliable scoring system to diagnose patients with fatty liver. HSI and FLI are more easily calculated and can be used in clinical practices to diagnose NAFLD in at-risk populations.

Noninvasive assessment of liver fibrosis and its clinical significance in nonalcoholic fatty liver disease

Liver fibrosis is the most important prognostic factor in patients with nonalcoholic fatty liver disease (NAFLD). Several noninvasive markers for fibrosis, including blood-based markers and imaging based-markers have been developed. Indirect fibrosis markers (e.g., fibrosis-4 index and NAFLD fibrosis score) consist of standard laboratory data and clinical parameters. Given its availability and high negative predictive value for advanced fibrosis, these markers are suitable for screening at primary care. Blood-based fibrogenesis markers (enhanced liver fibrosis and N-terminal propeptide of type 3 collagen), ultrasound-based modalities (vibration-controlled transient elastography, point shear wave elastography [SWE], and two-dimensional SWE), and magnetic resonance elastography have high diagnostic accuracy for liver fibrosis and are suitable for diagnosing liver fibrosis at secondary care centers. Sequential use of these markers can increase diagnostic accuracy and reduce health care costs. Furthermore, combining noninvasive makers may assist in identifying candidates for pharmacological trials and reducing screening failure. Emerging data suggest that these noninvasive markers are associated with liver-related events (hepatocellular carcinoma and decompensation) and mortality. Furthermore, delta change in noninvasive markers over time is also associated with time-course change in fibrosis, liver-related event risk, and mortality risk. However, the association between liver fibrosis and cardiovascular disease (CVD) risk is still controversial. CVD risk may decrease in patients with decompensated liver disease and noninvasive markers may be useful for assessing CVD risk in these patients. Therefore, noninvasive markers may be utilized as measures of fibrosis as well as real-time prognostic tools, in place of liver biopsy.

Validation model of fibrosis-8 index score to predict significant fibrosis among patients with nonalcoholic fatty liver disease

BACKGROUND

Identifying hepatic fibrosis is crucial for nonalcoholic fatty liver disease (NAFLD) management. The fibrosis-8 (FIB-8) score, recently developed by incorporating four additional variables into the fibrosis-4 (FIB-4) score, showed better performance in predicting significant fibrosis in NAFLD.

AIM

To validate the FIB-8 score in a biopsy-proven NAFLD cohort and compare the diagnostic performance of the FIB-8 and FIB-4 scores and NAFLD fibrosis score (NFS) for predicting significant fibrosis.

METHODS

We collected the data of biopsy-proven NAFLD patients from three Asian centers in three countries. All the patients with available variables for the FIB-4 score (age, platelet count, and aspartate and alanine aminotransferase levels) and FIB-8 score (the FIB-4 variables plus 4 additional parameters: The body mass index (BMI), albumin to globulin ratio, gamma-glutamyl transferase level, and presence of diabetes mellitus) were included. The fibrosis stage was scored using nonalcoholic steatohepatitis CRN criteria, and significant fibrosis was defined as at least fibrosis stage 2.

RESULTS

A total of 511 patients with biopsy-proven NAFLD and complete data were included for validation. Of these 511 patients, 271 (53.0%) were female, with a median age of 51 (interquartile range: 41, 58) years. The median BMI was 29 (26.3, 32.6) kg/m², and 268 (52.4%) had diabetes. Among the 511 NAFLD patients, 157 (30.7%) had significant fibrosis (≥ F2). The areas under the receiver operating characteristic curves of the FIB-8 and FIB-4 scores and NFS for predicting significant fibrosis were 0.774, 0.743, and 0.680, respectively. The FIB-8 score demonstrated significantly better performance for predicting significant fibrosis than the NFS (P = 0.001) and was also clinically superior to FIB-4, although statistical significance was not reached (P = 0.073). The low cutoff point of the FIB-8 score for predicting significant fibrosis of 0.88 showed 92.36% sensitivity, and the high cutoff point of the FIB-8 score for predicting significant fibrosis of 1.77 showed 67.51% specificity.

CONCLUSION

We demonstrated that the FIB-8 score had significantly better performance for predicting significant fibrosis in NAFLD patients than the NFS, as well as clinically superior performance vs the FIB-4 score in an Asian population. A novel simple fibrosis score comprising commonly accessible basic laboratories may be beneficial to use for an initial assessment in primary care units, excluding patients with significant liver fibrosis and aiding in patient selection for further hepatologist referral.

Noninvasive assessment of fibrosis among patients with nonalcoholic fatty liver disease [NAFLD]

Nonalcoholic fatty liver disease [NAFLD] is a condition affecting a vast portion of the worldwide population. The presence of underlying fibrosis is the strongest predictor of long-term outcomes and mortality, with a graduated increase in liver-related morbidity and mortality with progression from moderate fibrosis tobiomarkers targeting collagen turnover and extracellular matrix remodeling FibroTest FAST™, Velacur™, MRE]. While many of these provide a robust, stand alone value, the accuracy of these noninvasive tests markedly increase when used in combination or in sequential order with one another. There is not a uniform consensus demonstrating superiority of any specific test. Given the growing role and accuracy of these tests, they should have an expanding role in the assessment of fibrosis across this patient population and obviate the need for liver biopsy in a large portion of patients. Future clinical studies should focus on validating these novel biomarkers, as well as optimizing the sequential or algorithmic testing when combining these noninvasive tests.

Risk Factors of Nonalcoholic Fatty Liver Disease and Liver Fibrosis in Non-Obese Patients with Obstructive Sleep Apnea

PURPOSE

Liver injury in non-obese obstructive sleep apnea (OSA) patients has received much attention in recent years. This study aimed to investigate risk factors of nonalcoholic fatty liver disease (NAFLD) and liver fibrosis in non-obese patients with OSA.

METHODS

A retrospective study was conducted in the Sleep Center of the First Affiliated Hospital of Fujian Medical University. All consecutive non-obese patients with suspected sleep apnea admitted to the center were enrolled. The clinical characteristics of patients with simple snoring and with different severity OSA were compared. Multivariate logistic regression models were used to analyze the risk factors of NAFLD and liver fibrosis.

RESULTS

A total of 410 patients were enrolled. The levels of triglyceride, alanine aminotransferase (ALT) and aspartate aminotransferase (AST) increased with the aggravation of OSA (All p<0.05). Among non-obese patients with OSA, 17 (5%) were diagnosed with liver fibrosis and 228 (65%) with NAFLD; Apnea‑hyponea index (AHI) was an independent predictor for NAFLD and liver fibrosis [OR (95% CI): 1.02 (1.00-1.03), 1.04 (1.00-1.07), both p<0.05]; hypertriglyceridemia was an independent predictor for NAFLD [OR (95% CI): 1.13 (1.12-1.99), p<0.05].

CONCLUSION

NAFLD and liver fibrosis were common in non-obese OSA patients and the severity of OSA was an independent risk factor for them.

Non-invasive assessment of metabolic dysfunction-associated fatty liver disease

Non-alcoholic fatty liver disease (NAFLD) affects an estimated one-quarter of the global adult population and has become one of the leading causes of end-stage liver disease and hepatocellular carcinoma with increased liver-related and overall morbidity and mortality. The new term, metabolic dysfunction-associated fatty liver disease (MAFLD), has a set of positive diagnostic criteria and has been shown to have better clinical utility, but it has yet to be universally adopted. This review addresses the non-invasive tests for MAFLD and is based mostly on studies on NAFLD patients, as the MAFLD term is relatively new and there are limited studies on non-invasive tests based on this new term, while a large body of research work on non-invasive tests has accumulated in the literature for NAFLD. This review focuses on blood-based biomarkers and scores for the assessment of hepatic steatosis, non-alcoholic steatohepatitis (NASH), and fibrosis, and two of the most widely studied imaging biomarkers, namely vibration-controlled transient elastography and magnetic resonance imaging. Fibrotic NASH has become a diagnostic target of interest and novel serum biomarkers and scores incorporating imaging biomarker for diagnosis of fibrotic NASH are emerging. Nonetheless, the degree of liver fibrosis remains the key predictor of liver-related morbidity and mortality in patients with MAFLD. A multitude of non-invasive biomarkers and scores have been studied for the detection of liver fibrosis, including use of sequential non-invasive tests for risk stratification of advanced liver fibrosis. In addition, this review will explore the utility of the non-invasive tests for prognostication and for monitoring of treatment response.