The heated debate over NAFLD renaming: An ongoing saga

Prevalence of metabolic dysfunction-associated steatotic liver disease and steatohepatitis in Türkiye: A forensic autopsy study

Background and aims

Metabolic dysfunction-associated steatotic liver disease (MASLD) is a growing global epidemic in Türkiye and worldwide. The aim of this study was to evaluate the prevalence and predictors of MASLD and steatohepatitis among adults who died of unnatural causes including sudden death and non-burn trauma.

Method

We conducted a prospective review of all consecutive adult forensic autopsies for natural (sudden unexpected) and non-natural (Suicidal, homicidal and accidental) suspicious deaths carried out at the Istanbul Council of Forensic Medicine from February to May 2022. Four wedge biopsies were extracted from sagittal sectioned liver specimens. A liver pathologist with 20 years of experience examined each case for steatosis, ballooning, inflammation, and fibrosis.

Results

Among 1797 autopsies, 62 met inclusion criteria. Overall, 43.3 % (n = 26) of autopsies showed evidence of steatotic liver disease, with a distribution of steatosis severity as: Grade I (28.3 %), Grade II (6.6 %), and Grade III (8.3 %). All these cases met at least one cardiometabolic criteria and diagnosed with MASLD. Ballooning was observed in 20.0 % of cases (5 cases grades 1 and 7 cases grade 2), and Inflammation was present in 51.7 % (9 cases with grade 0-1, 12 with 1-2, 7 with 2-3, and 3 with 5-6). Notably, 46.1 % (n = 12) of MASLD cases and 20.0 % (n = 12) of all cases were diagnosed with steatohepatitis, with three cases exhibiting delicate perisinusoidal fibrosis and one case showing portal fibrosis.

Conclusion

The histopathological findings from this autopsy study confirmed the markedly high prevalence of MASLD and steatohepatitis within the general adult population, highlighting the concerning burden of steatotic liver disease in Türkiye.

Endoscopic sleeve gastroplasty for metabolic dysfunction-associated steatotic liver disease

INTRODUCTION

Metabolic dysfunction-associated steatotic liver disease (MASLD, formerly nonalcoholic fatty liver disease - NAFLD) is a chronic liver condition linked to obesity and metabolic syndrome. It affects one-third of people globally and, in some cases, can lead to metabolic dysfunction-associated steatohepatitis (MASH, formerly nonalcoholic steatohepatitis, NASH) and fibrosis. Weight loss is crucial for the treatment of MASLD, but diet and lifestyle modifications often fail.

AREAS COVERED

In recent years, endoscopic sleeve gastroplasty (ESG) has gained popularity as an effective and minimally invasive option for obesity treatment, with widespread use worldwide. We present a current overview of the most significant studies conducted on ESG for the management of obesity and MASLD. Our report includes data from published studies that have evaluated the impact of ESG on noninvasive hepatic parameters used to estimate steatosis and fibrosis. However, at present, there are no data available on liver histology.

EXPERT OPINION

ESG has shown promising results in treating MASLD evaluated by noninvasive tests, but current data is limited to small, nonrandomized studies. More research is needed, particularly on the effects of ESG on histologically proven MASH. If future research confirms its efficacy, ESG may be incorporated into treatment guidelines in the future.

From NAFLD to MASLD: Meta-analysis and systematic review of NAFLD patients in Turkiye in terms of metabolic profile and MASLD potential

Non-alcoholic Fatty Liver Disease (NAFLD) is both a cause and a consequence of metabolic disturbances. Consequently, the disease term has recently changed to Metabolic Dysfunction-Associated Steatotic Liver Disease (MASLD). Turkiye is one of the leading countries with high incidences of diseases such as diabetes, obesity, metabolic syndrome, and fatty liver. This study aims to identify the metabolic parameters and MASLD potential of NAFLD in Turkiye. All NAFLD studies conducted in Turkiye were systematically searched using the keywords "fatty liver disease" AND " Turkiye " on PubMed, Scopus, and Web of Science databases. A total of 2653 articles were scanned, and 120 studies were eligible for meta-analysis. The metabolic parameters were meta-analyzed from a broad perspective. According to the meta-analysis results, there were significant increases in waist circumferences (mean difference: 10.90, p<0.00001), HOMA-IR (mean difference: 2.13, p<0.00001), aspartate aminotransferase (AST) (mean difference: 17.82, p<0.00001), systolic blood pressure (SBP) (mean difference: 5.86, p<0.00001), and C-reactive protein (CRP) levels (mean difference: 0.95, p<0.00001). These parameters are representative biochemical findings of disturbed glucose metabolism, lipid profile, blood pressure, and acute phase response mechanisms. Furthermore, the analysis of all related parameters commonly found among the articles confirmed these metabolic dysfunctions. NAFLD is a metabolic disease that encompasses multiple pathways related to glucose and lipid metabolism, vascular function, inflammation, and acute phase responses. Additionally, our results suggest that Turkish NAFLD patients identified in previous studies mostly have MASLD. This is the first meta-analysis study indicating changes in metabolism-related parameters with a cumulative meta-analysis of all Turkish NAFLD studies.

Associations between metabolic dysfunction-associated fatty liver disease and atherosclerotic cardiovascular disease

Non-alcoholic fatty liver disease (NAFLD) is closely related to metabolic syndrome and remains a major global health burden. The increased prevalence of obesity and type 2 diabetes mellitus (T2DM) worldwide has contributed to the rising incidence of NAFLD. It is widely believed that atherosclerotic cardiovascular disease (ASCVD) is associated with NAFLD. In the past decade, the clinical implications of NAFLD have gone beyond liver-related morbidity and mortality, with a majority of patient deaths attributed to malignancy, coronary heart disease (CHD), and other cardiovascular (CVD) complications. To better define fatty liver disease associated with metabolic disorders, experts proposed a new term in 2020 - metabolic dysfunction associated with fatty liver disease (MAFLD). Along with this new designation, updated diagnostic criteria were introduced, resulting in some differentiation between NAFLD and MAFLD patient populations, although there is overlap. The aim of this review is to explore the relationship between MAFLD and ASCVD based on the new definitions and diagnostic criteria, while briefly discussing potential mechanisms underlying cardiovascular disease in patients with MAFLD.

The association of triglyceride-glucose-waist circumference with metabolic associated fatty liver disease and the severity of liver steatosis and fibrosis in American adults: a population-based study

BACKGROUND

The global obesity pandemic has led to an alarming rise in the prevalence of metabolic-associated fatty liver disease (MAFLD), making it a substantial clinical and economic burden on society. Early detection and effective treatment of MAFLD are imperative to mitigate its impact.

METHODS

This cross-sectional study was conducted involving 4634 adults from the National Health and Nutrition Examination Surveys (NHANES) 2017-2018 cycle. Transient elastography (TE) was used to diagnose MAFLD and assess the extent of liver steatosis and fibrosis. Multivariate logistic regression models were utilized to examine the association between the triglyceride and glucose index-waist circumference (TyG-WC) and the risk of MAFLD, liver fibrosis, and steatosis.

RESULTS

A positive association between TyG-WC and MAFLD persisted across all three models: model1: OR = 8.44, 95% CI: 6.85-10.38 (unadjusted), model2: OR = 8.28, 95% CI: 6.53-10.50 (partially adjusted), and model3: OR = 7.98, 95% CI: 4.11-15.46 (fully adjusted). Further investigation through interaction and stratified analysis revealed that this association was more pronounced in the non-obese and Non-Hispanic White persons groups. Moreover, a non-linear relationship analysis unveiled threshold and saturation effects between TyG-WC and MAFLD. Specifically, a TyG-WC value of approximately 600 may represent the threshold effect for MAFLD risk, while 1200 may signify the saturation effect of MAFLD risk. Finally, a robust correlation between TyG-WC and the severity of liver steatosis and fibrosis was found.

CONCLUSIONS

The findings suggest that the TyG-WC index exhibits excellent predictive value for MAFLD in the general American population.

Elucidating cuproptosis in metabolic dysfunction-associated steatotic liver disease

Emerging research into metabolic dysfunction-associated steatotic liver disease (MASLD) up until January 2024 has highlighted the critical role of cuproptosis, a unique cell death mechanism triggered by copper overload, in the disease's development. This connection offers new insights into MASLD's complex pathogenesis, pointing to copper accumulation as a key factor that disrupts lipid metabolism and insulin sensitivity. The identification of cuproptosis as a significant contributor to MASLD underscores the potential for targeting copper-mediated pathways for novel therapeutic approaches. This promising avenue suggests that managing copper levels could mitigate MASLD progression, offering a fresh perspective on treatment strategies. Further investigations into how cuproptosis influences MASLD are essential for unraveling the detailed mechanisms at play and for identifying effective interventions. The focus on copper's role in liver health opens up the possibility of developing targeted therapies that address the underlying causes of MASLD, moving beyond symptomatic treatment to tackle the root of the problem. The exploration of cuproptosis in the context of MASLD exemplifies the importance of understanding metal homeostasis in metabolic diseases and represents a significant step forward in the quest for more effective treatments. This research direction lights path for innovative MASLD management and reversal.

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.

Application of intelligent tongue image analysis in Conjunction with microbiomes in the diagnosis of MAFLD

Background

Metabolic associated fatty liver disease (MAFLD) is a widespread liver disease that can lead to liver fibrosis and cirrhosis. Therefore, it is essential to develop early diagnosic and screening methods.

Methods

We performed a cross-sectional observational study. In this study, based on data from 92 patients with MAFLD and 74 healthy individuals, we observed the characteristics of tongue images, tongue coating and intestinal flora. A generative adversarial network was used to extract tongue image features, and 16S rRNA sequencing was performed using the tongue coating and intestinal flora. We then applied tongue image analysis technology combined with microbiome technology to obtain an MAFLD early screening model with higher accuracy. In addition, we compared different modelling methods, including Extreme Gradient Boosting (XGBoost), random forest, neural networks(MLP), stochastic gradient descent(SGD), and support vector machine(SVM).

Results

The results show that tongue-coating Streptococcus and Rothia, intestinal Blautia, and Streptococcus are potential biomarkers for MAFLD. The diagnostic model jointly incorporating tongue image features, basic information (gender, age, BMI), and tongue coating marker flora (Streptococcus, Rothia), can have an accuracy of 96.39%, higher than the accuracy value except for bacteria.

Conclusion

Combining computer-intelligent tongue diagnosis with microbiome technology enhances MAFLD diagnostic accuracy and provides a convenient early screening reference.

Role of the angiopoietin-like protein family in the progression of NAFLD

Non-alcoholic fatty liver disease (NAFLD) is the most frequent cause of chronic liver disease, with a range of conditions including non-alcoholic fatty liver, non-alcoholic steatohepatitis, cirrhosis, and hepatocellular carcinoma (HCC). Currently recognized as the liver component of the metabolic syndrome, NAFLD is intimately linked to metabolic diseases. Angiopoietin-like proteins (ANGPTLs) comprise a class of proteins that resemble angiopoietins structurally. It is closely related to obesity, insulin resistance and lipid metabolism, and may be the critical factor of metabolic syndrome. In recent years, many studies have found that there is a certain correlation between ANGPTLs and the occurrence and progression of NAFLD disease spectrum. This article reviews the possible mechanisms and roles of ANGPTL protein in the pathogenesis and progression of NAFLD.

Association of metabolic dysfunction-associated fatty liver disease with gallstone development: A longitudinal study

BACKGROUND AND AIM

The influence of metabolic dysfunction-associated fatty liver disease on gallstone development remains unclear. We aimed to investigate the longitudinal association between metabolic dysfunction-associated fatty liver disease and gallstone development in both men and women.

METHODS

This observational cohort study included 5398 patients without gallstones who underwent > 2 health check-ups between April 1, 2014, and March 31, 2020. A generalized estimation equation model was used to analyze the association between metabolic dysfunction-associated fatty liver disease and gallstone development according to repeated measures at baseline and most recent stage.

RESULTS

After adjustment, the odds ratios of metabolic dysfunction-associated fatty liver disease for gallstone development in men and women were 3.019 (95% confidence interval [CI]: 1.901-4.794) and 2.201 (95% CI: 1.321-3.667), respectively. Among patients aged ≥ 50 years, the odds ratio for gallstone development was significantly enhanced with increasing metabolic dysfunction-associated fatty liver disease component numbers in both sexes; however, no significance was observed in those aged < 50 years. Other significant risk factors for gallstone development were age (odds ratio: 1.093, 95% CI: 1.060-1.126) and waist circumference (odds ratio: 1.048, 95% CI: 1.018-1.079) in men and age (odds ratio: 1.035, 95% CI: 1.003-1.067) and current smoking (odd ratio: 5.465, 95% CI: 1.881-15.88) in women.

CONCLUSION

Although the risk factors for gallstone development differed between sexes, metabolic dysfunction-associated fatty liver disease was common. Paying attention to an increase in the number of metabolic dysfunction-associated fatty liver disease components in patients aged ≥ 50 years is important for gallstone prevention.

The association of Neuromedin U levels and non-alcoholic fatty liver disease: A comparative analysis

This comprehensive study delves into the potential link between Neuromedin U (NmU) serum levels and the development of non-alcoholic fatty liver disease (NAFLD), a condition of increasing global prevalence and significant public health concern. The research provides a nuanced understanding of the disease's etiology by examining a cohort of 112 participants, including individuals with and without NAFLD. The study meticulously considers a spectrum of variables such as demographic factors, body composition metrics, and blood parameters. Advanced diagnostic tools like Fibroscan® are employed to ascertain NAFLD presence, ensuring accurate and reliable results. The investigation reveals a noteworthy correlation between NAFLD and several risk factors, notably obesity, increased waist and neck circumferences, hypertriglyceridemia, and insulin resistance. These findings underscore the multifactorial nature of NAFLD and its intricate connection with metabolic syndromes. Intriguingly, the study observes lower NmU levels in individuals diagnosed with NAFLD. However, the role of NmU as an independent risk factor for NAFLD remains inconclusive, warranting further investigation. Although triglyceride level was observed to be an independent risk factor for NAFLD, this relationship was not associated with NmU. This research contributes significantly to the existing knowledge on NAFLD, highlighting the disease's complexity and the interplay of various risk factors. It also opens up new avenues for future research, particularly in exploring the role of NmU within the metabolic pathways associated with NAFLD. The insights gained from this study could guide the development of novel diagnostic and therapeutic strategies for NAFLD, addressing a crucial need in contemporary healthcare. In conclusion, the findings of this study not only enhance the understanding of NAFLD's pathophysiology but also emphasize the importance of comprehensive risk factor analysis in the management and prevention of this growing health concern.

Association of Metabolic Dysfunction-Associated Fatty Liver Disease with Cognitive Impairment and All-Cause Dementia: A Comprehensive Review

Metabolic dysfunction-associated fatty liver disease (MAFLD) is a significant public health concern, affecting one-third of the global population and posing a risk for progressive liver disease. MAFLD is characterized by hepatic steatosis and impaired metabolic status, which not only impact the liver but also other systems of the human body, making it a multisystemic disorder. Emerging evidence suggests that MAFLD and its associated pathological pathways may contribute to cognitive impairment, potentially through neuroinflammation and neurodegeneration. Studies have detected cognitive impairment in patients with MAFLD using magnetic resonance imaging, which revealed decreased brain volume and cerebral perfusion, in addition to self-reported cognitive tests. While numerous studies have demonstrated an association between MAFLD and cognitive impairment, the relationship between MAFLD and all-cause dementia remains controversial. However, the shared pathological pathways between MAFLD and dementia, such as systemic inflammation, insulin resistance, gut dysbiosis, hyperammonemia, and vascular dysfunction, indicate the possibility of a common prevention strategy for both diseases. In this review, we provide a summary of the current evidence regarding the association between cognitive impairment, all-cause dementia, and MAFLD.

The staging of nonalcoholic fatty liver disease fibrosis: A comparative study of MR elastography and the quantitative DCE-MRI exchange model

Objectives

To evaluate the efficacy and image processing time of the dynamic contrast-enhanced MRI (DCE-MRI) exchange model in liver fibrosis staging and compare it to the efficacy of magnetic resonance elastography (MRE).

Methods

The subjects were 45 patients with nonalcoholic fatty liver disease (NAFLD) who underwent MRE and DCE-MRI in our hospital. Liver biopsy results were available for all patients. Spearman rank correlation coefficients were used to compare the correlations among MRE, DCE-MRI and liver fibrosis parameters. Quantitative DCE-MRI parameters, MRE-derived liver stiffness measurement (LSM), and the results of a combined DCE-MRI + MRE logistic regression model were compared in terms of the area under the receiver operating characteristic curve (AUC). We also compared the scanning and postprocessing times of the MRE and DCE-MRI techniques.

Results

The correlation coefficients between the following parameters of interest and liver fibrosis were as follows: capillary permeability-surface area product (PS; DCE-MRI parameter), -0.761; portal blood flow (Fp; DCE-MRI parameter), -0.754; MRE-LSM, 0.835. Some DCE-MRI parameters (PS, Fp) had slightly greater AUC values than MRE-LSM for diagnosing the presence or absence of liver fibrosis, and the combined model had the highest AUC value for all stages except F4, but there was no significant difference in the diagnostic efficacy of the DCE-MRI, MRE, and combined models for any stage of fibrosis. The average scanning times for MRE and DCE-MRI were 17 s and 330 s, respectively, and the average postprocessing times were 45.5 s and 342.7 s, respectively.

Conclusions

In the absence of MRE equipment, DCE-MRI represents an alternative technique. However, MRE is a quicker and simpler method for assessing fibrosis than DCE-MRI in the clinic.

Correlation between ultrasonography and MR proton density fat fraction techniques in evaluating the severity of liver steatosis

Background and Aim

To investigate the relationship between ultrasonography (US) and magnetic resonance (MR) proton density fat fraction (PDFF) techniques, using the modified DIXON method, in determining the severity of liver steatosis.

Materials and Methods

This study included seventy consecutive patients who underwent upper abdominal MRI for various reasons between June 2016 and January 2017. Fatty liver staging was performed using US as indicated.The liver fat percentage was measured and staged according to PDFF values.

Results

In the study, of the 70 cases, 36 were male and 34 were female. On US, 18.5% of the cases had stage 0, 32.8% had stage 1, 42.8% had stage 2, and 5.7% had stage 3 liver steatosis. A significant correlation was found between ultrasonographic evaluation and PDFF in determining the percentage of liver fat (r=0.775, p<0.001). When comparing the percentages, MR-evaluated PDFF and ultrasonographic staging were most compatible at grade 3 and least compatible at grade 2. When the PDFF threshold value was set at 8.1%, the sensitivity of US in distinguishing between obvious and indistinct steatosis was 97.1%, and the specificity was 88.9%.

Conclusion

Ultrasound continues to be a useful tool for detecting fatty liver disease. However, magnetic resonance (MR) proton density fat fraction (PDFF) imaging is essential for accurately determining the severity and prevalence of steatosis. Our study revealed inconsistencies between US and MR PDFF in grading liver steatosis, showing higher agreement in severe cases and lower agreement in moderate cases. Therefore, we recommend classifying steatosis as either uncertain or apparent rather than using a grading system in US.

Prevalence of hepatic steatosis and fibrosis in apparently healthy airline pilots: A transient elastography study

Background and Aim

Airline pilots (APs) are often characterized by a sedentary lifestyle, predisposing them to adverse cardiometabolic consequences. In this cross-sectional study, we used transient elastography (TE) to investigate the prevalence of hepatic steatosis and fibrosis among apparently healthy APs.

Materials and Methods

The study cohort consisted of 137 male APs of Caucasian descent who voluntarily underwent TE. To evaluate the extent and severity of hepatic steatosis and fibrosis, we employed established cutoff values for the controlled attenuation parameter (CAP) and liver stiffness measurement (LSM).

Results

Of the APs, 34 (24.8%) were diagnosed with TE-defined steatosis. Specifically, 25 APs (18.2%) exhibited mild steatosis, 6 (4.4%) moderate steatosis, and 3 (2.2%) severe steatosis. The majority of participants (80 APs or 58.4%) showed no signs of liver fibrosis based on LSM values. However, 49 APs (35.8%) were diagnosed with mild fibrosis (F1), 7 (5.1%) with significant fibrosis (F2), and one (0.7%) with advanced fibrosis (F3). None of the pilots had F4 (cirrhosis). In multivariable linear regression analysis, BMI was the sole independent predictor of both CAP (β=0.34, p<0.001) and LSM (β=0.41, p<0.001) values in our sample of male APs.

Conclusion

TE is a straightforward and convenient non-invasive method for detecting hepatic steatosis and fibrosis in high-risk occupational groups such as APs.

Prevalence of metabolic syndrome and metabolic dysfunction-associated fatty liver disease in Malaysia 2023: study protocol for a community-based nationwide cross-sectional survey

INTRODUCTION

Metabolic syndrome (MetS) is a cluster of cardio-metabolic dysfunctions characterised by increased fasting plasma glucose, waist circumference, blood pressure, triglycerides and reduction in high-density lipoprotein cholesterol. Meanwhile, metabolic dysfunction-associated fatty liver disease (MAFLD) is the new term for fatty liver associated with MetS. People with MetS or MAFLD have higher risks for adverse cardiovascular outcomes and mortalities. However, large-scale data on MetS and MAFLD prevalence in Malaysia is mainly unknown. This study aims to determine the prevalence of MetS and MAFLD among the general adult population in Malaysia.

METHODS AND ANALYSIS

This is a community-based nationwide cross-sectional study in Malaysia. The data collection period is from July 2023 until September 2023, with a planned sample size of 1296 participants. We use a two-stage proportionate stratified random sampling method to ensure national representativeness. The definition of MetS follows the Harmonised Joint Interim Statement in 2009. A diagnosis of MAFLD is made if a participant has fatty liver, defined as having a Fatty Liver Index ≥60 and has type 2 diabetes, a body mass index ≥23 kg/m2, or ≥2 metabolic risk abnormalities. Complex sample analysis will be conducted, and the disease prevalence will be reported with 95% CIs, unweighted counts and estimated populations.

ETHICS AND DISSEMINATION

The protocol has been approved by the Medical Research and Ethics Committee of the Ministry of Health Malaysia (NMRR ID-22-02845-GUT). The findings will be disseminated through a formal report, policy brief, scientific publications, conference presentations, social media, print media and stakeholder engagement activities.