Can FIB4 and NAFLD fibrosis scores help endocrinologists refer patients with non-alcoholic fat liver disease to a hepatologist?

Diagnostic Value of Non-invasive Liver Function Tests in Liver Fibrosis and Changes in These Parameters Post-metabolic Surgery

PURPOSE

This study aimed to ascertain the diagnostic accuracy of non-invasive liver function tests in liver fibrosis and assess their changes after metabolic surgery.

MATERIALS AND METHODS

1005 individuals with severe obesity who were referred for metabolic surgery were analysed. All participants had blood samples taken for liver enzymes and lipid profile. In addition, hepatic indexes, including AAR, APRI, NFS and Fibrosis-4 (FIB4), were checked. Furthermore, all participants underwent two-dimensional shear wave elastography (2D-SWE). All investigations were repeated 6-8 months after metabolic surgery. The receiver operating characteristic (ROC) curve and the area under the ROC curve was utilised to determine the optimal cut-off values for baseline study parameters. Logistic regression was applied to predict the relationship between study parameters-as predictors-and change in 2D-SWE.

RESULTS

AST/ALT (AAR) was the most sensitive (79%) pre-operative non-invasive serological marker for detecting liver fibrosis, whereas NAFLD Fibrosis Score (NFS) was the most specific (84%). AST/upper limit of the normal AST range × 100/platelets (× 10⁹/L) (APRI) showed a positive correlation with 2D-SWE post-metabolic surgery (p-value = 0.021). Regression analysis from both adjusted and unadjusted models showed that baseline AAR was a predictor of postoperative liver status in terms of hepatic fibrosis.

CONCLUSION

AAR has a high sensitivity, whereas NFS exhibits a high specificity in diagnosing liver fibrosis. The authors recommend using both investigations in conjunction with 2D-SWE to increase the likelihood of detecting liver fibrosis.

Patients with type 2 diabetes and elevated fibrosis-4 are under-referred to hepatology and have unrecognized hepatic decompensation

BACKGROUND AND AIM

The American Association for the Study of Liver Diseases recommends a high index of suspicion for nonalcoholic steatohepatitis and advanced fibrosis in patients with type 2 diabetes (T2D) and an elevated fibrosis-4 index (FIB-4). We investigated the referral pattern of patients with T2D and FIB4 > 3.25 to the hepatology clinic and evaluated the clinical benefits to the patient.

METHODS

We included patients aged 18-80 years with T2D and a FIB4 score >3.25 who had visited the internal medicine, family medicine, endocrinology clinic from 01/01/2014-5/31/2019. The first time point of high-risk FIB-4 was identified as the baseline for time-to-event analysis. The patients were classified based on whether they had visited the hepatology clinic (referred vs not referred).

RESULTS

Of the 2174 patients, 290 (13.3%) were referred to the hepatology clinic, and 1884 (86.7%) were not referred. In multivariate analyses, the referred patients had a lower overall mortality risk (Hazard Ratio: 0.57; 95% CI: 0.38-87). Notably, the referred patients had the same rate of biochemical decompensation, as measured by progression to MELD ≥ 14, but a substantially higher rate of diagnosis in cirrhosis (27, 19-38) and cirrhosis complications, including ascites (2.9, 2.0-4.1), hepatic encephalopathy (99, 13-742), and liver cancer (14, 5-38).

CONCLUSIONS

We found that patients with T2D and high-risk FIB4 are associated with better overall survival after referral to a hepatology clinic. We speculate that the survival difference is due to the increased recognition of cirrhosis and cirrhosis complications in the referred populations.

Fibrosis-3 Index: A New Score to Predict Liver Fibrosis in Patients With Nonalcoholic Fatty Liver Disease Without Age as a Factor

Background and Aims

The Fibrosis-4 (FIB-4) index has been used to predict liver fibrosis in various liver diseases, including nonalcoholic fatty liver disease (NAFLD). Because the FIB-4 formula uses age, different cutoff values may be required for different age groups, making the interpretation difficult. To avoid the influence of age, we attempted to create a new score, the Fibrosis-3 (FIB-3) index.

Methods

The FIB-3 index was created using a training cohort of 735 NAFLD cases using aspartate aminotransferase, alanine amino transferase, and platelet for predicting fibrosis. The abilities of the FIB-3 and FIB-4 indices were compared among different age groups in the training cohort and validation cohort with 324 patients. The FIB-3 index was also compared with other liver fibrosis indices.

Results

The area under the receiver operating characteristic curve (AUROC) values of the FIB-3 and FIB-4 indices for predicting F3-F4 fibrosis were 0.764 and 0.762, respectively, in the training cohort. No difference in the AUROC values was observed between the 2 indices in the validation cohort. The differences in the accuracies of FIB-3 between elderly and nonelderly patients were 0.140 and 0.178, respectively, in each cohort and were smaller than those of FIB-4 index (0.199 and 0.336, respectively). Analysis using a joined cohort revealed that the AUROC of FIB-3 for predicting F3-F4 fibrosis (0.774) was the highest among the 5 fibrosis scores examined and was comparable to that of FIB-4.

Conclusion

The FIB-3 index is an improved version of the FIB-4 index and can effectively predict liver fibrosis in patients with NAFLD.

Comorbidities Are Associated with Fibrosis in NAFLD Subjects: A Nationwide Study (NASH-CO Study)

BACKGROUND

The relationship between the severity of NAFLD and extra-hepatic events such as cardiovascular disease (CVD), extra-hepatic cancer (EHC) or chronic kidney diseases (CKD) has not been clearly investigated in the general population.

AIMS

The aim of this study was to assess whether the severity of fibrosis in NAFLD subjects was associated with extra-hepatic diseases based on noninvasive markers in a large population-based cohort.

METHODS

The study population included a cohort of 118,664 participants from the nationwide CONSTANCES cohort. After excluding individuals with excessive alcohol consumption and other causes of liver disease, 102,344 were included. The noninvasive diagnosis of NAFLD and fibrosis was performed using a combination of the Fatty Liver Index (FLI) and the Forns Index. The history of CVD or EHC was recorded by a physician, and CKD was defined by a glomerular filtration rate < 60 ml/mn.

RESULTS

The prevalence of NAFLD (FLI > 60) was 18.2%, 10% with mild fibrosis (Forns Index < 4.2), 7.7% with intermediate fibrosis (Forns Index 4.2-6.9), and 0.4% with advanced fibrosis (Forns Index > 6.9). The prevalence of CVD, EHC, or CKD increased significantly with the severity of fibrosis (p < 0.0001). When adjusted for demographic, metabolic risk factors, and smoking, NAFLD with intermediate or advanced fibrosis remained associated with CVD (OR 1.36, p < 0.0001 and OR 3.07, p < 0.0001, respectively), EHC (OR 1.24, p = 0.001 and OR 1.64, p = 0.004, respectively), and CKD (OR 1.18, p = 0.03 and OR 2.09, p < 0.0001, respectively).

CONCLUSIONS

In a large adult population-based cohort, there is a dose-dependent relationship between the severity of fibrosis and CVD, EHC, or CKD in NAFLD subjects.

The burden of NAFLD in type 2 diabetic subjects from the general population: A Nationwide population-based follow-up study (NASHCO)

BACKGROUND

The epidemiology and natural history of non-alcoholic fatty liver disease (NAFLD) in diabetes have been mainly investigated in the hospital setting. The goal of this study was to evaluate the characteristics of NAFLD and its impact on morbidity and mortality in type 2 diabetic subjects in a community setting.

METHOD

This study included 199 341 participants in the nationwide Constances cohort. After patients with excessive alcohol consumption, viral hepatitis or other causes of liver disease were excluded, 164 285 were analysed and 8386 (5.3%) were considered to have type 2 diabetes. The non-invasive diagnosis of NAFLD and advanced fibrosis was made using a combination of the fatty liver index and Forns index. Median follow-up was 2.5 years.

RESULTS

Diabetes increased the risk of NAFLD by sixfold (adjusted OR 6.05, 95% CI 5.68-6.45) and the risk of advanced fibrosis by 3.76-fold (aOR 3.76, 95% CI 2.87-4.91) in NAFLD subjects. After controlling for confounders, the presence of NAFLD in diabetic subjects was associated with an increased risk of severe liver-related events (aHR 2.53, 95% CI 1.36-4.69), cardiovascular disease (CVD, aHR 2.71, 95% CI 1.72-4.26) and overall mortality (aHR 2.91, 95% CI 1.53-5.53). The risk of hepatic and extrahepatic complications in diabetic subjects with NAFLD significantly increased with the severity of fibrosis (P < .05).

CONCLUSION

This prospective, longitudinal study in a large community-based cohort provides real-world evidence of the risk for NAFLD and advanced fibrosis in diabetes, and its impact on liver disease progression, diabetes-related complications such as CVD, and overall mortality. These data could be used to estimate real clinical and economic burden of NAFLD in diabetic subjects.

Acoustic radiation force impulse elastography and liver fibrosis risk scores in severe obesity

Objective

Identifying significant fibrosis is crucial to evaluate the prognosis and therapeutic interventions in patients with nonalcoholic fatty liver disease (NAFLD). We assessed the performance of acoustic radiation force impulse (ARFI) elastography, APRI, FIB-4, Forns, NFS and BARD scores in determining liver fibrosis in severe obesity.

Methods

A prospective study included 108 patients undergoing bariatric surgery. Liver biopsy specimens were obtained intraoperatively and classified according to the NAFLD Activity Score. Patients were assessed with serological markers and shear wave velocity of the liver was measured with the Siemens S2000 ultrasound system preoperatively. Optimal cut-off values were determined using the area under the receiver operating characteristic curves (AUROC).

Results

In the entire cohort prevalence of NAFLD was 80.6%, steatohepatitis 25.9% and significant fibrosis 19.4%. The best tests for predicting significant fibrosis were FIB-4 and Forns scores (both AUROC 0.78), followed by APRI (AUROC 0.74), NFS (AUROC 0.68), BARD (AUROC 0.64) and ARFI (AUROC 0.62). ARFI elastography was successful in 73% of the patients. Higher body mass index (BMI) correlated with invalid ARFI measurements. In patients with BMI < 42 kg/m², ARFI showed 92.3% sensitivity and 82,6% specificity for the presence of significant fibrosis, with AUROC 0.86 and cut-off 1.32 m/s.

Conclusion

FIB-4 and Forns scores were the most accurate for the prediction of significant fibrosis in bariatric patients. Applicability and accuracy of ARFI was limited in individuals with severe obesity. In patients with BMI < 42 kg/m², ARFI elastography was capable for predicting significant fibrosis with relevant accuracy.

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

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

Non-alcoholic fatty liver disease in diabetes: When to refer to the hepatologist?

Non-alcoholic fatty liver disease (NAFLD) has become one of the most common chronic liver diseases worldwide. A strong relationship exists between NAFLD and diabetes mellitus. There is growing evidence of a mechanistically complex and strong association between the two diseases. Current data also shows that one disease actually leads to worsening of the other and vice versa. Understanding of the various pathophysiological mechanisms involved, natural history and spectrum of these two diseases is essential not only for early diagnosis and management but also for prevention of severe disease forms. Despite the tremendous progress made in recent times in acquiring knowledge about these highly prevalent diseases, the guidelines and recommendations for screening and management of diabetics with NAFLD remain ambiguous. An interdisciplinary approach is required to not only raise awareness of the prevalence of NAFLD in diabetics but also for better patient management. This can help attenuate the development of significant complications, such as cirrhosis, decompensation and hepatocellular carcinoma in these patients, thereby halting NAFLD in its tracks. This review focuses on the pivotal role of primary care physicians and endocrinologists in identification of NAFLD in diabetics in early stages and the role of proactive screening for prompt referral to hepatologist.

Non-invasive diagnosis of nonalcoholic fatty liver disease in patients with type 2 diabetes

Liver disease has emerged as a significant cause of death in people with type 2 diabetes (T2D). Due to a common underlying pathogenic mechanism, namely insulin resistance, T2D represents the main risk factor for nonalcoholic fatty liver disease (NAFLD), characterized by a buildup of fat in the liver. Globally, NAFLD is the most common liver disease, affecting a quarter of the general adult population. The development of nonalcoholic steatohepatitis (NASH) signifies an increased risk of liver fibrosis progression that can result in cirrhosis, hepatocellular carcinoma (HCC), and death. Liver fibrosis progression and development of cirrhosis is mostly asymptomatic until complications from decompensated end-stage liver disease arise. Traditionally, liver biopsy is used to diagnose NASH and stage fibrosis, however, it is invasive and costly. Non-invasive diagnostic alternatives include serum biomarkers and imaging techniques. Early identification of advanced liver fibrosis is pivotal to prompt initiation of targeted surveillance, including screening for HCC, as well as providing options for current and investigational therapeutic interventions to reduce fibrosis progression. This review gives an update on non-invasive diagnostic tools for NAFLD and liver fibrosis in the specific context of T2D, providing clinicians a pragmatic diagnostic approach to this frequent comorbidity in diabetes medicine.

Validity of routine biochemical and ultrasound scores for prediction of hepatic fibrosis and steatosis in NAFLD

Background

We evaluated the validity of some non-invasive scores and ultrasound findings to predict fibrosis and steatosis in a cohort of NAFLD patients who underwent liver biopsy. Ninety-seven NAFLD patients were enrolled and classified into NASH (66) and simple steatosis groups (31) based on liver biopsy. ROC curves were constructed for Fibrosis-4 index (FIB4), aspartate aminotransferase to platelet ratio index (APRI), and NAFLD fibrosis score (NFS) in fibrosis prediction, also for (hepatic steatosis index; HSI, fatty liver index; FLI) and ultrasonographic subcutaneous and visceral adipose tissue measurements (SAT and VAT) for steatosis prediction.

Results

FIB4 had AUC of 0.6, APRI and NFS at cutoffs of 0.3 and -.2.4 had AUC of 0.64 and 0.63 in detecting the presence of any grade of fibrosis, and of (0.52, 0.55, and 0.58) for significant fibrosis. FIB4 at a cut-off of (0.76) had the highest AUC in detecting any grade of fibrosis in the simple steatosis group (0.81). SAT (at cutoff of 2.1 and 2.5) was superior to VAT. HSI (at cutoff 45.35 and 45.7) was superior to FLI in detecting moderate or marked steatosis.

Conclusion

FIB4 and NFS can be used in screening for silent liver disease with ongoing fibrosis in simple steatosis. They are unsatisfactory predictors for significant fibrosis in NAFLD. SAT is better than VAT in predicting moderate steatosis and is slightly better than biochemical HSI.

Modelling the cost effectiveness of non-alcoholic fatty liver disease risk stratification strategies in the community setting

BACKGROUND

Non-alcoholic fatty liver disease (NAFLD) is highly prevalent worldwide. Identifying high-risk patients is critical to best utilize limited health care resources. We established a community-based care pathway using 2D ultrasound shear wave elastography (SWE) to identify high risk patients with NAFLD. Our objective was to assess the cost-effectiveness of various non-invasive strategies to correctly identify high-risk patients.

METHODS

A decision-analytic model was created using a payer's perspective for a hypothetical patient with NAFLD. FIB-4 [≥1.3], NAFLD fibrosis score (NFS) [≥-1.455], SWE [≥8 kPa], transient elastography (TE) [≥8 kPa], and sequential strategies with FIB-4 or NFS followed by either SWE or TE were compared to identify patients with either significant (≥F2) or advanced fibrosis (≥F3). Model inputs were obtained from local data and published literature. The cost/correct diagnosis of advanced NAFLD was obtained and univariate sensitivity analysis was performed.

RESULTS

For ≥F2 fibrosis, FIB-4/SWE cost $148.75/correct diagnosis while SWE cost $276.42/correct diagnosis, identifying 84% of patients correctly. For ≥F3 fibrosis, using FIB-4/SWE correctly identified 92% of diagnoses and dominated all other strategies. The ranking of strategies was unchanged when stratified by normal or abnormal ALT. For ≥F3 fibrosis, the cost/correct diagnosis was less in the normal ALT group.

CONCLUSIONS

SWE based strategies were the most cost effective for diagnosing ≥F2 fibrosis. For ≥F3 fibrosis, FIB-4 followed by SWE was the most effective and least costly strategy. Further evaluation of the timing of repeating non-invasive strategies are required to enhance the cost-effective management of NAFLD.

Comparison between non-invasive methods and liver histology to stratify liver fibrosis in obese patients submitted to bariatric surgery

BACKGROUND

Obesity is a multifactorial disease characterized by fat accumulation, usually associated with non-alcoholic fatty liver disease, which can lead to advanced fibrosis or even cirrhosis. Bariatric surgery (BS) is a treatment approved for weight loss in morbidly obese patients. However, complications from this modality of treatment have been reported and liver cirrhosis connotes more risk procedure.

AIMS

Evaluate non-invasive methods transient elastography (THE) and scores to establish the degree of liver fibrosis in patients submitted to BS, comparing their performance with liver histology.

METHODS

We calculated liver fibrosis by non-invasive scores AST to platelet ration index (APRI), fibrosis-4 (FIB-4) and non-alcoholic fatty liver disease (NAFLD) score and THE before and 6 months after the bariatric surgery. The results were compared to liver histology.

RESULTS

We included 85 patients, 69.4% females, with a mean age of 36 years, with a mean body mass index (BMI) of 41 kg/m². The non-invasive scores were able to exclude clinically significant fibrosis in 85.9% (APRI) and advanced fibrosis in 96.5% (FIB-4) and 51.8% (NAFLD score). When comparing with the histological findings, the correlation with elastography was 45.9% for the same degree of fibrosis, with high negative predictive value (94.4%) in pre-surgical analysis. In the post-surgical analysis, the correlation with histology was 69.4% for THE and the negative predictive value to exclude clinically significant fibrosis was 98.5%.

CONCLUSION

THE showed low correlation with histology in the pre-surgical analysis. All the methods had better results in post bariatric evaluation comparing with pre-bariatric data and the non-invasive FIB-4 score showed the best of them.

OBESIDADE E ESTEATOSE GRAVE: A IMPORTÂNCIA DA AVALIAÇÃO BIOQUÍMICA E ESCORES

Nonalcoholic fatty liver disease (NAFLD) is considered a public health problem, mainly in severely obese patients.

Non-invasive diagnosis of nonalcoholic fatty liver disease: impact of age and other risk factors

BACKGROUND AND OBJECTIVES

Little is known regarding the diagnostic performance of fibrosis scoring systems in the diagnosis of nonalcoholic fatty liver disease (NAFLD). We aimed to determine the risk factors of NAFLD and evaluate the diagnostic performance of noninvasive fibrosis scoring systems.

MATERIALS AND METHODS

The study included consecutive patients presented with dyspepsia from January 2017 to January 2019. Clinicodemographic and laboratory parameters including HOMA-IR were recorded. Anthropometric measurements were performed. NAFLD was diagnosed with ultrasonography. The FIB4, NAFLD, BARD, and Nippon scores were calculated.

RESULTS

Totally, 1008 patients were enrolled. The mean age was 52.3 ± 15 years in the NAFLD group (25.8%) and 36.7 ± 15.7 years in the non-NAFLD group (74.2%). The frequency of NAFLD was 25.8%. Age, body mass index (BMI), diabetes mellitus (DM), platelet count, HbA1c, HDL, ALT, and AST/ALT ratio were independent risk factors for NAFLD. The most sensitive and specific tests in diagnosing NAFLD were HOMA-IR and Nippon score, respectively.

CONCLUSIONS

Age, BMI, DM, HbA1c, platelet count, HDL, ALT, and AST/ALT ratio were independent predictors of NAFLD. The most specific and sensitive predictors of the presence of NAFLD were Nippon score and HOMA-IR value, respectively. The place of fibrosis scores in the diagnosis of NAFLD patients requires further scrutinization.

EVALUATION OF PROGRESSION OF HEPATIC FIBROSIS IN A GROUP OF PATIENTS WITH NON-ALCOHOLIC FATTY LIVER DISEASE ACCOMPANIED FOR 10 YEARS

BACKGROUND

Non-alcoholic fatty liver disease has been progressively diagnosed in the general population as a consequence of the increased prevalence of obesity and type 2 diabetes mellitus, its main risk factors. It is characterized by accumulation of fat in the hepatocytes associated with lobular inflammation and balonization, which can lead to cirrhosis and hepatocarcinoma. Thus, a characterization and follow-up of a progression of the fibrosis level of these patients becomes important, being that the transient hepatic elastography is a reliable method for this evaluation with a measure of the kapa index.

OBJECTIVE

To evaluate the progression of hepatic fibrosis through elastography in patients with non-alcoholic fatty liver disease.

METHODS

Patients who had previously performed hepatic biopsy and noninvasive scores for non-alcoholic steatohepatitis (NASH) and fibrosis were included in the study. These same subjects were then submitted to current clinical evaluation, laboratory and liver elastography tests, defining the level of liver fibrosis, about 10 years after the first evaluation.

RESULTS

Data were analyzed for 66 patients previously submitted to liver biopsy. Of these, 16 were not found, four could not participate because they were debilitated due to hepatic cirrhosis, two had died from an automobile accident and five from complications of cirrhosis of the liver. Therefore, of the 50 patients with a known history, 9 (18%) had died of cirrhosis or were unable to attend the examination because of their liver disease. The remaining population was predominantly female (61.5%), mean age of 63 years, being overweight, dyslipidemia (76.9%), disorders of the glycemic profile (76.9%), and metabolic syndrome (82.1%). Of the 39 cases evaluated, 35% had the same degree of fibrosis at the initial evaluation (biopsy) and at the current evaluation (elastography), 33% had an increase in the degree of fibrosis and another 30% had a decrease in the degree of fibrosis. Twenty-eight patients had NASH at baseline. Regarding these patients, it was observed in the current evaluation, that 25% remained stable in the degree of fibrosis, 39% progressed, and 35% regressed.

CONCLUSION

Despite some limitations of our study, such as the small number of patients, and the use of two different methods of evaluation (biopsy and elastography), the data obtained allow us to conclude that of the 39 evaluated cases, 33% (13) presented progression of fibrosis and the total group of 50 patients, 42% had cirrhosis or died due to liver disease. The presence of NASH on hepatic biopsy did not prove to be, in our study, a predictive of the evolution of hepatic fibrosis in the patients.

Overview of the Pathogenesis, Genetic, and Non-Invasive Clinical, Biochemical, and Scoring Methods in the Assessment of NAFLD

Nonalcoholic fatty liver disease (NAFLD) is the most prevalent chronic liver disease worldwide. It represents a range of disorders, including simple steatosis, nonalcoholic steatohepatitis (NASH), and liver cirrhosis, and its prevalence continues to rise. In some cases, hepatocellular carcinoma (HCC) may develop. The develop;ment of non-invasive diagnostic and screening tools is needed, in order to reduce the frequency of liver biopsies. The most promising methods are those able to exclude advanced fibrosis and quantify steatosis. In this study, new perspective markers for inflammation, oxidative stress, apoptosis, and fibrogenesis; emerging scoring models for detecting hepatic steatosis and fibrosis; and new genetic, epigenetic, and multiomic studies are discussed. As isolated biochemical parameters are not specific or sensitive enough to predict the presence of NASH and fibrosis, there is a tendency to use various markers and combine them into mathematical algorithms. Several predictive models and scoring systems have been developed. Current data suggests that panels of markers (NAFLD fibrosis score, Fib-4 score, BARD score, and others) are useful diagnostic modalities to minimize the number of liver biopsies. The review unveils pathophysiological aspects related to new trends in current non-invasive biochemical, genetic, and scoring methods, and provides insight into their diagnostic accuracies and suitability in clinical practice.

Development of liver surface nodularity quantification program and its clinical application in nonalcoholic fatty liver disease

The liver morphological changes in relation to fibrosis stage in nonalcoholic fatty liver disease (NAFLD) have not yet been clearly understood. This study was to develop a liver surface nodularity (LSN) quantification program and to compare the fibrosis grades in simple steatosis (SS) and nonalcoholic steatohepatitis (NASH). Thirty subjects (7 normal controls [NC], 12 SS and 11 NASH) were studied. LSN quantification procedure was bias correction, boundary detection, segmentation and LSN measurement. LSN scores among three groups and fibrosis grades compared using Kruskal–Wallis H test. Diagnostic accuracy was determined by calculating the area under the receiver operating characteristics (ROC) curve. Mean LSN scores were NC 1.30 ± 0.09, SS 1.54 ± 0.21 and NASH 1.59 ± 0.23 (p = 0.008). Mean LSN scores according to fibrosis grade (F) were F0 1.30 ± 0.09, F1 1.45 ± 0.17 and F2&F3 1.67 ± 0.20 (p = 0.001). The mean LSN score in F2&F3 is significantly higher than that in F1 (p = 0.019). The AUROC curve to distinguish F1 and F2&F3 was 0.788 (95% CI 0.595–0.981, p = 0.019) at a cut-off LSN score greater than 1.48, and its diagnostic accuracy had 0.833 sensitivity and 0.727 specificity. This study developed LSN program and its clinical application demonstrated that the quantitative LSN scores can help to differentially diagnose fibrosis stage in NAFLD.

Oxidative stress biomarkers in the serum and plasma of patients with non-alcoholic fatty liver disease (NAFLD). Can plasma AGE be a marker of NAFLD? Oxidative stress biomarkers in NAFLD patients

Still little is known about the redox abnormalities in patients with non-alcoholic fatty liver disease (NAFLD). The purpose of the study was to find the relationship between enzymatic and non-enzymatic antioxidants, redox homeostasis and oxidative damage in 67-patients with NAFLD. The study population was divided into patients with non-alcoholic fatty liver (early NAFLD, n = 29) and patients with non-alcoholic steatohepatitis (advanced NAFLD, n = 38). Redox biomarkers: enzymatic antioxidants (Cu - Zn-superoxide dismutase (SOD), catalase (CAT), glutathione peroxidase (GPx), glutathione reductase (GR)); non-enzymatic antioxidants and redox status (reduced glutathione (GSH), total antioxidant capacity (TAC)); and oxidative damage products (total oxidant status (TOS), advanced glycation end products (AGE), malondialdehyde (MDA), and DNA/RNA oxidative damage) were determined in the serum/plasma samples. The activity of SOD, GPx, GR and levels of GSH, TOS, AGE, MDA, and DNA/RNA oxidative damage were significantly elevated in early NAFLD and advanced NAFLD group compared to controls (p < .001). There was a positive correlation between AGE, TAC and ALT activity (R = 0.34, p = .04; R = 0.36, p = .03, respectively) in advanced NAFLD group. Interestingly, ROC analysis for AGE showed good discriminatory ratio for patients with minimal steatosis (BARD score 0-1) vs. moderate steatosis (BARD score 2-4), AUC = 0.76. Plasma AGE can be a potential non-invasive biomarker differentiating NAFLD patients.

Obesity and Weight Gain Are Associated With Progression of Fibrosis in Patients With Nonalcoholic Fatty Liver Disease

BACKGROUND & AIMS

The effects of weight change on the progression of liver fibrosis in patients with nonalcoholic fatty liver disease (NAFLD) in the general population are unclear. We evaluated the association of weight change and baseline body mass index (BMI) with fibrosis progression, determined by non-invasive measurement of a marker, in young and middle-aged adults with NAFLD.

METHODS

We performed a prospective cohort study of 40,700 adults with NAFLD in Korea who received regular health screening examinations and were followed for a median 6.0 years. Weight change was defined as the difference between weights measured at baseline and at a subsequent follow-up visit. The progression from a low to an intermediate or high probability of advanced fibrosis was assessed using the aspartate aminotransferase to platelet ratio index (APRI).

RESULTS

During 275,421.5 person-years of follow-up, 5454 subjects with a low APRI progressed to an intermediate or high APRI. Multivariable-adjusted hazard ratios for APRI progression, determined by comparing the first and second weight change quintiles (the weight-loss group) and the fourth and fifth quintiles (weight-gain group) with the third quintile (weight-stable group, reference), were 0.68 (95% CI, 0.62-0.74), 0.86 (95% CI, 0.78-0.94), 1.17 (95% CI, 1.07-1.28), and 1.71 (95% CI, 1.58-1.85), respectively. The multivariable-adjusted hazard ratios for APRI progression were determined by comparing subjects with BMIs of 23-24.9, 25-29.9, and ≥30 with subjects with BMIs of 18.5-22.9 kg/m² (reference); these ratios were 1.13 (95% CI, 1.02-1.26), 1.41 (95% CI, 1.28-1.55), and 2.09 (95% CI, 1.86-2.36), respectively.

CONCLUSIONS

In a prospective cohort study of 40,700 adults with NAFLD, we found obesity and weight gain to be independently associated with increased risk of fibrosis progression, based on APRI. Maintaining a normal healthy weight and preventing weight gain may help reduce fibrosis progression in individuals with NAFLD.

One-year weight management lowers lipopolysaccharide-binding protein and its implication in metainflammation and liver fibrosis

Background

Studies showed that the endotoxemia-related biomarker, lipopolysaccharide-binding protein (LBP), is associated with obesity and fatty liver. The level of LBP is reduced after surgical weight loss. This study aimed to verify the change of serum LBP levels after one-year medical weight management in subjects with obesity.

Methods and findings

A total of 62 subjects with obesity, 39 subjects with overweight, and 21 subjects with normal body mass index were enrolled for a one-year weight management program. Basic information, body composition analysis, clinical data, serum LBP level, and abdominal ultrasonography findings were collected. At baseline, the serum LBP levels of the obese and overweight subjects were significantly higher than that of the normal group (30.9±7.4 and 29.6±6.3 versus 23.1±5.6 μg/mL, respectively, p<0.001). Serum LBP in subjects with obesity was significantly reduced to 26.5±7.1 μg/mL (p-value < 0.001) after one year. In the multivariate analyses, LBP was associated with high sensitive C-reactive protein (hs-CRP) and non-alcoholic fatty liver disease (NAFLD) fibrosis score (NFS) before weight management in the obese group. Moreover, the change of LBP in response to weight management was significantly related to the changes of hs-CRP, leukocyte count and NFS by multivariate linear regression analysis also in the obese group.

Conclusion

The serum level of the endotoxemia-related biomarker, LBP, decreases after one-year weight management in the obese subjects. In addition to serving as a metainflammatroy biomarker like hs-CRP, LBP may also be a potential biomarker as a non-invasive biomarker for the evaluation of liver fibrosis in NAFLD.

Efficacy of canagliflozin against nonalcoholic fatty liver disease: a prospective cohort study

BACKGROUND

Nonalcoholic fatty liver disease (NAFLD) is a common cause of chronic liver disease worldwide and is characterized by insulin resistance, hepatic steatosis and often prediabetes or diabetes. Canagliflozin, a selective sodium glucose cotransporter 2 inhibitor, is a new oral anti-diabetic drug that reduces hyperglycaemia by promoting urinary glucose excretion. Glycosuria produced by canagliflozin is associated with weight loss, mainly due to reduced fat volume and improve insulin resistance. Reduced body weight and improvement of insulin resistance by canagliflozin may be an effective treatment for NAFLD.

METHODS

Thirty-five patients with NAFLD (17 men and 18 women) were enrolled and administered canagliflozin (100 mg). Body weight and serum levels of aspartate aminotransferase (AST), alanine aminotransferase (ALT), gamma-glutamyl transferase (γ-GTP), low-density lipoprotein cholesterol, high-density lipoprotein cholesterol, triglycerides (TG), blood sugar (BS), glycated haemoglobin (HbA1C), uric acid (UA) and ferritin, and fibrosis-4 (FIB-4) index values were measured at baseline and at 3-month and 6-month follow-up visits.

RESULTS

Body weight and serum levels of AST, ALT, γ-GTP, TG, UA, HbA1C, BS and ferritin decreased significantly after 3 and 6 months of canagliflozin treatment. Serum BS levels and FIB-4 index values decreased slightly following 3 months of treatment; these results reached significance after 6 months. Reduced serum ALT levels at 6 months were significantly correlated with baseline HbA1C and ferritin levels. Moreover, a significant correlation between reduced body weight and serum ALT levels was observed at 6 months. Decreased serum ALT levels were significantly correlated with decreased serum ferritin at 6 months.

CONCLUSIONS

Canagliflozin significantly reduced the serum levels of BS, HbA1C, TG, UA and ferritin, as well as FIB-4 index values and body weight, with improved liver function. Sodium glucose cotransporter 2 inhibitors may be an important therapeutic modality for improving liver injury in NAFLD patients.