MAFLD Criteria Guide the Subtyping of Patients with Fatty Liver Disease

Current Therapeutic Landscape for Metabolic Dysfunction-Associated Steatohepatitis

In recent years, "metabolic dysfunction-associated steatotic liver disease" (MASLD) has been proposed to better connect liver disease to metabolic dysfunction, which is the most common chronic liver disease worldwide. MASLD affects more than 30% of individuals globally, and it is diagnosed by the combination of hepatic steatosis and obesity, type 2 diabetes, or two metabolic risk factors. MASLD begins with the buildup of extra fat, often greater than 5%, within the liver, causing liver hepatocytes to become stressed. This can proceed to a more severe form, metabolic dysfunction-associated steatohepatitis (MASH), in 20-30% of people, where inflammation in the liver causes tissue fibrosis, which limits blood flow over time. As fibrosis worsens, MASH may lead to cirrhosis, liver failure, or even liver cancer. While the pathophysiology of MASLD is not fully known, the current "multiple-hits" concept proposes that dietary and lifestyle factors, metabolic factors, and genetic or epigenetic factors contribute to elevated oxidative stress and inflammation, causing liver fibrosis. This review article provides an overview of the pathogenesis of MASLD and evaluates existing therapies as well as pharmacological drugs that are currently being studied in clinical trials for MASLD or MASH.

Associations of MAFLD subtypes and air pollutants with multi-system morbidity and all-cause mortality: A prospective cohort study

BACKGROUND

Metabolic dysfunction-associated fatty liver disease (MAFLD) and air pollution are both significant health concerns. However, their combined effects on multi-system morbidity and all-cause mortality remain poorly understood.

METHODS

We analyzed data from 434,417 UK Biobank participants, categorizing them into four groups: non-MAFLD, MAFLD-diabetes, MAFLD-lean, and MAFLD-overweight/obesity. To evaluate the long-term effects of air pollution exposure, we used time-varying Cox proportional hazard models to assess four air pollutants: particulate matter with an aerodynamic diameter < 2.5 μm (PM2.5), PM10, nitrogen dioxide (NO2), and nitrogen oxides (NOx). We examined the associations between these air pollutants, MAFLD subtypes, and their joint impact on multi-system morbidity and all-cause mortality. Furthermore, we explored the additive and multiplicative interactions between air pollutants and MAFLD subtypes.

RESULTS

At baseline, 15,325 participants were classified as MAFLD-diabetes, 3341 as MAFLD-lean, and 140,934 as MAFLD-overweight/obesity. Among these groups, MAFLD-diabetes was most strongly associated with adverse outcomes compared to other subtypes. Air pollution exposure had a synergistic effect on cirrhosis risk across all MAFLD subtypes, with the most pronounced effects observed for PM2.5 [relative excess risk due to interaction (RERI): 2.10 (0.94, 3.26)] and NO2 [RERI:1.85 (0.67, 3.04)] in MAFLD-lean group. Positive additive and multiplicative interactions between air pollutants and MAFLD subtypes were also observed for coronary artery disease (CAD), with the exception of nitrogen oxide in the MAFLD-lean group. Additionally, only the MAFLD-diabetes demonstrated significant positive additive interactions with all four air pollutants in relation to chronic kidney disease (CKD).

CONCLUSIONS

This study highlights the distinct impacts of MAFLD subtypes on multi-system morbidity and all-cause mortality, underscoring the critical need for targeted prevention and treatment strategies, particularly for individuals with MAFLD-diabetes. Our findings reveal significant additive and synergistic effects of air pollution exposure on the risks of cirrhosis, CAD, and CKD among MAFLD patients.

Diagnostic accuracy of Fatty Liver Index (FLI) for detecting Metabolic Associated Fatty Liver Disease (MAFLD) in adults attending a tertiary care hospital, a cross-sectional study

BACKGROUND

Metabolic-associated fatty liver disease (MAFLD) is a major public health problem worldwide. This study aimed to determine the prevalence of MAFLD and evaluate the diagnostic accuracy of the Fatty Liver Index (FLI) compared to ultrasonography for detecting fatty liver in adults attending a tertiary care hospital in Gujarat, India.

METHODS

This cross-sectional study included 500 adults visiting the outpatient department between January 2023 and December 2023. MAFLD was diagnosed on ultrasound. FLI was calculated using body mass index, waist circumference, triglycerides, and gamma-glutamyl transpeptidase levels. FLI ≥ 60 indicated fatty liver. Logistic regression analysis identified factors associated with fatty liver.

RESULTS

MAFLD prevalence was 32.2% on ultrasound. High FLI (≥ 60) was present in 26.2%. Male sex, higher BMI, waist circumference, night shift work, diabetes, and triglycerides were independent predictors of fatty liver. FLI showed excellent diagnostic accuracy with a sensitivity of 96%, specificity of 92.5%, and AUC of 0.92 for detecting fatty liver on ultrasound.

CONCLUSION

MAFLD prevalence among adults was high in this hospital-based sample. FLI can serve as an accurate non-invasive tool for identifying individuals with a high probability of MAFLD. These findings emphasize the need for larger population-based studies and the implementation of regular MAFLD screening programs in high-risk groups.

Metabolic (dysfunction)-associated fatty liver disease metrics and contributions to liver research

BACKGROUND

The international consensus to revise non-alcoholic fatty liver disease to metabolic (dysfunction)-associated fatty liver disease (MAFLD) in 2020 attracted significant attention. The impact of the MAFLD definition on the research community has not been objectively assessed. We conducted an analysis of systematically collected literature on MAFLD to understand its research impact.

METHODS

From PubMed, Web of Science, and Scopus, the literature adopting MAFLD, written in English, and published from 2020 to 10 October 2023 was collected. The publication metrics, including publication counts, publishing journals, author countries, author keywords, and citation information, were analyzed to evaluate the research impact and key topics on MAFLD.

RESULTS

1469 MAFLD-related papers were published in 434 journals with a steady increase in the number. The intense publishing and citations activity on MAFLD indicates the large impact of the redefinition. Topic assessment with keyword and citation analysis revealed a transition from the proposal and discussion of the redefinition to clinical characterization of MAFLD with a focus on metabolic dysfunction. Moreover, the diagnostic criteria for MAFLD showed better performance in predicting hepatic and extrahepatic outcomes compared to NAFLD. The publications were from 99 countries with evidence of strong regional and global collaboration. Multiple international societies and stakeholders have endorsed MAFLD for its utility in clinical practice, improving patient management and promoting multidisciplinary care, while alleviating stigma.

CONCLUSION

This survey provides a quantitative measure of the considerable international impact and contributions of the MAFLD definition towards liver research and as part of the spectrum of cardiometabolic disorders.

Macrophage MAPK7/AhR/STAT3 Signaling Mediates Mitochondrial ROS Burst and Enterohepatic Inflammatory Responses Induced by Deoxynivalenol Relevant to Low-Dose Exposure in Children

Deoxynivalenol (DON) can induce endoplasmic reticulum (ER) stress, mitochondrial ROS burst, and macrophage polarization. Here, we investigated the mechanism linking the above three aspects with the dose range relevant to low-level exposure in children. At 0.5 μg/kg bw/day, we found remarkable liver and gut inflammatory responses after 6-week exposure in mice age comparable to humans 7-12 years old. Through antioxidant intervention, we found that ROS played a driver role in macrophage polarization and inflammatory responses induced by DON in the liver and gut. Further bioinformatics analysis uncovered that ER stress-associated protein MAPK7 (ERK5) may bind with AhR to initiate a mitochondrial ROS burst and macrophage M1 polarization. The downstream cellular events of MAPK7-AhR interaction may be mediated by the AhR/STAT3/p-STAT(Ser727) pathway. This mechanism was further supported by DON toxicity mitigation using cyanidin-3-glucoside (C-3-G), which docks to MAPK7 oligomerization region 200-400 aa and disrupts MAPK7-AhR interaction. Overall, our study provides novel evidence and mechanism for DON-induced inflammatory responses in the liver and gut system. Our findings call attention to the health risks associated with low-level DON exposure in the prepuberty children population.

Metabolic Dysfunction-Associated Steatotic Liver Disease in Severe Obesity and Concordance between Invasive (Biopsy) and Noninvasive (OWLiver®) Diagnoses

INTRODUCTION

Nonalcoholic fatty liver disease (NAFLD), now termed metabolic dysfunction-associated steatotic liver disease (MASLD), is an escalating health concern linked to obesity and type 2 diabetes. Despite liver biopsy being the gold standard, its invasiveness underscores the need for noninvasive diagnostic methods.

METHODS

A cross-sectional study was performed to assess MASLD using the noninvasive OWLiver® serum lipidomics test in a cohort of 117 patients with severe obesity undergoing bariatric surgery, comparing outcomes with liver biopsy. Exclusions (n = 24) included insufficient data, liver disease etiology other than MASLD, corticosteroid treatment, excessive alcohol consumption, low glomerular filtration rate, and declination to participate. Comprehensive laboratory tests, demographic assessments, and liver biopsies were performed. Serum metabolites were analyzed using OWLiver®, a serum lipidomic test that discriminates between healthy liver, steatosis, metabolic dysfunction-associated steatohepatitis (MASH), and MASH with fibrosis ≥2 by means of three algorithms run sequentially.

RESULTS

Liver biopsy revealed a MASLD prevalence of 95.7%, with MASH present in 28.2% of cases. OWLiver® demonstrated a tendency to diagnose more severe cases. Body mass index (BMI), rather than the presence of type 2 diabetes, emerged as the sole independent factor linked to the probability of concordance. Therefore, the all-population concordance of 63.2% between OWLiver® and liver biopsy notably raised to 77.1% in patients with a BMI <40 kg/m2. These findings suggest a potential correlation between lower BMI and enhanced concordance between OWLiver® and biopsy.

CONCLUSION

This study yields valuable insights into the concordance between liver biopsy and the noninvasive serum lipidomic test, OWLiver®, in severe obesity. OWLiver® demonstrated a tendency to amplify MASLD severity, with BMI values influencing concordance. Patients with BMI <40 kg/m2 may derive optimal benefits from this noninvasive diagnostic approach.

Genetic and Lifestyle Risk Factors of Metabolic Dysfunction-Associated Fatty Liver Disease and Its Relationship with Premature Coronary Artery Disease: A Study on the Pars Cohort

BACKGROUND

The main objective of this study is to identify the risk factors of metabolic dysfunction-associated fatty liver disease (MAFLD) in coronary artery disease (CAD) patients.

METHODS

The present retrospective cohort study is part of the Pars Cohort Study (PCS). The participants were categorized as having MAFLD or not. The pattern of independent variables in patients was compared with those who did not have MAFLD. All variables were retained in the multivariable logistic regression model.

RESULTS

Totally, 1862 participants with CAD were enrolled in this study. MAFLD was diagnosed in 647 (40.1%) participants. Gender, diabetes, hypertension, tobacco, opium, alcohol, age, weight, waist circumference, cholesterol, HDL, triglyceride, aspartate aminotransferase (AST), and alanine aminotransferase (ALT) were significantly different in MAFLD and non-MAFLD patients. Also, the results of multivariable logistic regression show male gender (OR=0.651, 95% CI: 0.470‒0.902, P value=0.01) and opium consumption (OR=0.563, 95% CI: 0.328‒0.968, P value<0.001) to be negative risk factors of MAFLD occurrence in CAD patients. Having diabetes (OR=2.414, 95% CI: 1.740-3.349, P value<0.001), high waist circumference (OR=1.078, 95% CI: 1.055‒1.102, P value<0.01), high triglyceride (OR=1.005, 95% CI: 1.001‒1.008, P value=0.006), and high ALT (OR=1.039, 95% CI: 1.026‒1.051, P value<0.01) were positive risk factors of MAFLD in CAD patients.

CONCLUSION

Our study found that consuming opium decreases the likelihood of MAFLD in CAD patients, since these patients have decreased appetite and lower body mass index (BMI). On the other hand, female gender, having diabetes, high waist circumference, high triglyceride levels, and high ALT levels increase the probability of MAFLD in CAD patients.

Metabolic dysfunction-associated fatty liver disease and nonalcoholic fatty liver disease from clinical to pathological characteristics: a multi-center cross-sectional study in real world

BACKGROUND

The evaluation of patients with fatty liver as defined by metabolic dysfunction-associated fatty liver disease (MAFLD) in the real world remains poorly researched. This study aimed to analyse the clinical and histological features of patients with MAFLD and nonalcoholic fatty liver disease (NAFLD) and to characterize each metabolic subgroup of MAFLD.

METHODS

A total of 2563 patients with fatty liver confirmed by ultrasonography and/or magnetic resonance tomography and/or liver biopsy-proven from three hospitals in China were included in the study. Patients were divided into different groups according to diagnostic criteria for MAFLD and NAFLD, and MAFLD into different subgroups.

RESULTS

There were 2337 (91.2%) patients fitting the MAFLD criteria, and 2095 (81.7%) fitting the NAFLD criteria. Compared to patients with NAFLD, those with MAFLD were more likely to be male, had more metabolic traits, higher liver enzyme levels, and noninvasive fibrosis scores. Among the patients with liver biopsy, the extent of advanced fibrosis in cases with MAFLD was significantly higher than those with NAFLD, 31.8% versus 5.2% (P < .001); there was no significant difference in advanced fibrosis between obese cases and lean individuals in MAFLD (P > .05); MAFLD complicated with diabetes had significantly higher advanced fibrosis than those without diabetes (43.3% and 17.2%, respectively; P < .001).

CONCLUSIONS

Patients with MAFLD have a higher degree of liver fibrosis than NAFLD patients. In addition, diabetic patients should be screened for fatty liver and liver fibrosis degree.

Global epidemiology of type 2 diabetes in patients with NAFLD or MAFLD: a systematic review and meta-analysis

BACKGROUND

Non-alcoholic fatty liver disease (NAFLD) and metabolic-associated fatty liver disease (MAFLD) shares common pathophysiological mechanisms with type 2 diabetes, making them significant risk factors for type 2 diabetes. The present study aimed to assess the epidemiological feature of type 2 diabetes in patients with NAFLD or MAFLD at global levels.

METHODS

Published studies were searched for terms that included type 2 diabetes, and NAFLD or MAFLD using PubMed, EMBASE, MEDLINE, and Web of Science databases from their inception to December 2022. The pooled global and regional prevalence and incidence density of type 2 diabetes in patients with NAFLD or MAFLD were evaluated using random-effects meta-analysis. Potential sources of heterogeneity were investigated using stratified meta-analysis and meta-regression.

RESULTS

A total of 395 studies (6,878,568 participants with NAFLD; 1,172,637 participants with MAFLD) from 40 countries or areas were included in the meta-analysis. The pooled prevalence of type 2 diabetes among NAFLD or MAFLD patients was 28.3% (95% confidence interval 25.2-31.6%) and 26.2% (23.9-28.6%) globally. The incidence density of type 2 diabetes in NAFLD or MAFLD patients was 24.6 per 1000-person year (20.7 to 29.2) and 26.9 per 1000-person year (7.3 to 44.4), respectively.

CONCLUSIONS

The present study describes the global prevalence and incidence of type 2 diabetes in patients with NAFLD or MAFLD. The study findings serve as a valuable resource to assess the global clinical and economic impact of type 2 diabetes in patients with NAFLD or MAFLD.

Association of serum asprosin with metabolic dysfunction-associated fatty liver disease in older adult type 2 diabetic patients: a cross-sectional study

BACKGROUND

To explore the association of serum asprosin levels with metabolic dysfunction-associated fatty liver disease (MAFLD) in older adults with type 2 diabetes mellitus (T2DM).

METHODS

The cross-sectional study enrolled patients ≥ 65 years old diagnosed with T2DM at two community health service centers between November 2019 and July 2021. Logistic regression was applied to analyze the influencing factors of MAFLD.

RESULTS

Totally 219 cases were included. Compared with diabetic individuals without MAFLD (n = 105), diabetics with MAFLD (n = 114) had younger ages, higher body mass index values, shorter time from T2DM diagnosis, increased waist-to-hip ratios, elevated triglycerides, reduced high-density lipoprotein cholesterol (HDL-C), elevated alanine aminotransferase (ALT), elevated γ-glutaryl transferase, elevated fasting insulin, and elevated HOMA-IR (all P < 0.05). Serum asprosin levels were elevated in diabetics with MAFLD in comparison with the non-MAFLD group (291.71 ± 73.69 vs. 255.24 ± 82.52 pg/ml, P = 0.001). Multivariable analysis revealed, after adjusted for age, time from T2DM diagnosis, HDL-C, and ALT, serum asprosin level (OR = 1.006, 95%CI: 1.001-1.010, P = 0.014) were independently associated with MAFLD in T2DM.

CONCLUSIONS

High asprosin level are associated with MAFLD in older patients with T2DM, after adjusted for age, time from T2DM diagnosis, WHR, TG, HDL-C, ALT, GGT, FINS, and HOMA-IR.

Metabolic puzzle: Exploring liver fibrosis differences in Asian metabolic-associated fatty liver disease subtypes

BACKGROUND

Metabolic-associated fatty liver disease (MAFLD) is a liver condition marked by excessive fat buildup in the absence of heavy alcohol use. It is primarily linked with metabolic issues like insulin resistance, obesity, and abnormal lipid levels, and is often observed with other conditions such as type 2 diabetes and cardiovascular disease. However, whether the subtypes of MAFLD based on the metabolic disorder differentially impact liver fibrosis is not well explicated, especially in the Asian population.

AIM

To compare the severity of liver fibrosis among different MAFLD subtypes.

METHODS

A total of 322 adult patients of either gender with fatty liver on ultrasound were enrolled between January to December 2021. MAFLD was defined as per the Asian Pacific Association for the Study of the Liver guidelines. Fibrosis-4 index (Fib-4) and nonalcoholic fatty liver disease fibrosis score (NFS) were employed to evaluate liver fibrosis.

RESULTS

The mean age was 44.84 ± 11 years. Seventy-two percent of the patients were female. Two hundred and seventy-three patients were classified as having MAFLD, of which 110 (40.3%) carried a single, 129 (47.3%) had two, and 34 (12.5%) had all three metabolic conditions. The cumulative number of metabolic conditions was related to elevated body mass index, triglyceride (TG) levels, and glycated hemoglobin, lower high-density lipoprotein (HDL) levels, higher liver inflammation (by aspartate aminotransferase and γ-glutamyl transferase), and higher likelihood of fibrosis (by NFS and Fib-4 scores) (P < 0.05 for all). The proportion of advanced fibrosis also increased with an increase in the number of metabolic conditions (4.1%, 25.5%, 35.6%, and 44.1% by NFS and 6.1%, 10.9%, 17%, and 26.5% by Fib-4 for no MAFLD and MAFLD with 1, 2, and 3 conditions, respectively). Among MAFLD patients, those with diabetes alone were the eldest and had the highest mean value of NFS score and Fib-4 score (P < 0.05), while MAFLD patients diagnosed with lean metabolic dysfunction exhibited the highest levels of TG and alanine aminotransferase but the lowest HDL levels (P < 0.05).

CONCLUSION

The study suggests that the severity of liver fibrosis in MAFLD patients is influenced by the number and type of metabolic conditions present. Early identification and management of MAFLD, particularly in patients with multiple metabolic conditions, are crucial to prevent liver-related complications.

Metabolic-associated fatty liver disease and liver fibrosis scores as COVID-19 outcome predictors: a machine-learning application

Patients with COVID-19 and metabolic-dysfunction associated fatty liver disease (MAFLD) appear to be at higher risk for severe manifestations, especially in the youngest decades. Our aim was to examine whether patients with MAFLD and/or with increased liver fibrosis scores (FIB-4) are at risk for severe COVID-19 illness, using a machine learning (ML) model. Six hundred and seventy two patients were enrolled for SARS-CoV-2 pneumonia between February 2020 and May 2021. Steatosis was detected by ultrasound or computed tomography (CT). ML model valuated the risks of both in-hospital death and prolonged hospitalizations (> 28 days), considering MAFLD, blood hepatic profile (HP), and FIB-4 score. 49.6% had MAFLD. The accuracy in predicting in-hospital death was 0.709 for the HP alone and 0.721 for HP + FIB-4; in the 55-75 age subgroup, 0.842/0.855; in the MAFLD subgroup, 0.739/ 0.772; in the MAFLD 55-75 years, 0.825/0.833. Similar results were obtained when considering the accuracy in predicting prolonged hospitalization. In our cohort of COVID-19 patients, the presence of a worse HP and a higher FIB-4 correlated with a higher risk of death and prolonged hospitalization, regardless of the presence of MAFLD. These findings could improve the clinical risk stratification of patients diagnosed with SARS-CoV-2 pneumonia.

Associations of MAFLD and MAFLD subtypes with the risk of the incident myocardial infarction and stroke

Metabolic dysfunction-associated fatty liver disease (MAFLD) is a condition characterized by liver fat accumulation and metabolic abnormalities. Given the potential impact of MAFLD on patient health, it is important to understand its association with major adverse cardiovascular events (MACE) such as myocardial infarction (MI) and stroke. In the prospective UK Biobank cohort, we sought to elucidate the association of MAFLD and its subtypes with incident MI and stroke. In this study, we analyzed the data of 325,129 participants in the UK Biobank and calculated relative risks for MI and stroke using Cox regression analysis. Among 325,129 participants over a median duration of 12.8 years follow-up, participants with MAFLD were significantly more likely to experience a MI (hazard ratio [HR] = 1.35, 95% confidence interval [CI: 1.29;1.41] P < 0.001) or a stroke (HR = 1.26 [1.18-1.33] P < 0.001) compared to those without MAFLD. In addition, diabetic, overweight with metabolic dysfunction (MD), and lean MAFLD subtypes were significantly associated with an increased risk for MI and stroke, whereas overweight without MD subtype did not appear to be associated with this risk. Our findings also revealed graded associations between liver fibrosis scores and risk of MI and stroke in MAFLD patients. However, only diabetic, and overweight patients with MD subtypes exhibited graded associations between liver fibrosis score and the risk of MI and stroke among the MAFLD subtypes. Furthermore, the risk alleles traits of fatty liver did not enhance the effect of MAFLD on the risk of MI and stroke. In conclusion, a diagnosis of MAFLD is associated with an increased risk of MI or stroke, and the assessment of MAFLD and its subtypes should be a component of the cardiovascular risk assessment.

Two years on, a perspective on MAFLD

To provide clarity for research studies and clinical care, a set of positive criteria for adults and children with metabolic (dysfunction) associated fatty liver disease (MAFLD) was recently published and has subsequently been widely endorsed. The development and subsequent validation of the criteria for MAFLD has created a positive momentum for change. During the course of the ongoing discussion on the redefinition, some concerns have surfaced that we thought needs clarification. In this review, we provide a perspective on MAFLD and bringing clarity to some of the key aspects that have been recently raised.

Long-term clinical outcomes of adults with metabolic dysfunction-associated fatty liver disease: a single-centre prospective cohort study with baseline liver biopsy

BACKGROUND

There are limited data on the long-term adverse clinical outcomes of adults with metabolic dysfunction-associated fatty liver disease (MAFLD).

METHODS

This is a single-centre prospective study of a well-characterized cohort of MAFLD patients who underwent liver biopsy and followed every 6-12 months for adverse clinical outcomes.

RESULTS

The data for 202 patients were analyzed [median age 55.0 (48.0-61.3) years old; male, 47.5%; obese, 88.6%; diabetes mellitus, 71.3%; steatohepatitis, 76.7%; advanced fibrosis, 27.2%]. The median follow-up interval was 7 (4-8) years. The cumulative incidence of liver-related events, cardiovascular events, malignancy and mortality was 0.43, 2.03, 0.60 and 0.60 per 100 person-years of follow-up, respectively. Liver-related events were only seen in patient with advanced fibrosis at 9.1% vs 0% in patient without advanced liver fibrosis (p < 0.001). The cumulative incidence of liver-related events among patients with advanced fibrosis was 1.67 per 100 person-years of follow-up. When further stratified to bridging fibrosis and cirrhosis, the cumulative incidence of liver-related events was 1.47 and 3.85 per 100 person-years of follow-up, respectively. Advanced fibrosis was not significantly associated with cardiovascular events, malignancy or mortality. The cumulative incidence of liver-related events, cardiovascular events, malignancy and mortality were not significantly different between patients with and without steatohepatitis and between obese and non-obese patients. However, liver-related events were only seen among obese patients.

CONCLUSION

Overall, the cumulative incidence of liver-related event is low in patients with MAFLD, but it is much higher among those with advanced fibrosis. However, there is a relatively high cumulative incidence of cardiovascular event among patients with MAFLD.

Impact and usefulness of the transition to the new MAFLD classification for non-B, non-C HCC: a retrospective cohort study

BACKGROUND

Metabolic dysfunction-associated fatty liver disease (MAFLD) represents a new classification system for fatty liver disease. In this study, we investigated the clinical characteristics of patients with MAFLD-hepatocellular carcinoma (HCC) in comparison with those with nonalcoholic fatty liver disease (NAFLD) and considered the validity and challenges of the new criteria.

METHODS

This study included 237 untreated non-B, non-C HCC patients with hepatic steatosis. We examined the profile and laboratory findings of patients with MAFLD-HCC and NAFLD-HCC. We also classified MAFLD-HCC patients according to the factors on which the diagnosis was based and compared their clinical characteristics.

RESULTS

A total of 222 (94%) and 101 (43%) patients were diagnosed with MAFLD and NAFLD, respectively. MAFLD-HCC patients were more likely to be male than NAFLD-HCC, but there were no significant differences in metabolic indices, noninvasive liver fibrosis score or HCC status. In a study of MAFLD-HCC patients by diagnostic factor, those with overweight only were younger and had advanced liver fibrosis histologically, and when limited to patients younger than 70 years, the majority were overweight. Redefinition of overweight as BMI ≥ 25 reduced the number of MAFLD-HCC patients by only 5, from 222 to 217.

CONCLUSIONS

MAFLD accounted for the majority of non-B, non-C HCC cases with hepatic steatosis. Examination of additional cases and revision of the detailed criteria is needed so that it can be used to efficiently select patients with fatty liver who are at high risk of developing HCC.

Compatibility of Polygonati Rhizoma and Angelicae Sinensis Radix enhance the alleviation of metabolic dysfunction-associated fatty liver disease by promoting fatty acid β-oxidation

Jiuzhuan Huangjing Pills (JHP) composed of Polygonati Rhizoma (PR) and Angelicae Sinensis Radix (ASR) remedied mitochondria to cure metabolic dysfunction-associated fatty liver disease (MAFLD). However, a comparison of the anti-MAFLD ability between JHP prescription and PR and ASR single-medicines in MAFLD has not been performed, and the action mechanisms and substances remain unknown. Our results show that JHP, PR and ASR decreased serum and liver lipid levels. The effects of JHP were stronger than those of PR and ASR. JHP, PR and ASR afforded protection to mitochondrial ultrastructure, and regulated oxidative stress and energy metabolism in mitochondria. JHP also regulated the expression of β-oxidation genes, which were not regulated by PR and ASR. JHP-, PR- and ASR-derived components in mitochondrial extracts regulated oxidative stress, energy metabolism, and β-oxidation gene expression and alleviated cellular steatosis. Four, six and eleven compounds were identified in mitochondrial extracts from PR-, ASR- and JHP-treated rats, respectively. The data suggest that JHP, PR and ASR alleviated MAFLD by remedying mitochondria, while the ability of JHP was stronger than that of PR and ASR, which was involved with the β-oxidation promotion. The compounds identified may be the main ingredients in the three extracts active in MAFLD improvement.

Blood pressure stratification for predicting liver fibrosis risk in metabolic dysfunction associated fatty liver disease

INTRODUCTION AND OBJECTIVES

The optimal blood pressure (BP) range for patients with metabolic dysfunction-associated fatty liver disease (MAFLD) is currently unknown. This study aimed to explore the relationship between stratified BP levels and MAFLD progression.

PATIENTS AND METHODS

The data of adults who underwent yearly health check-ups were screened to establish both a cross-sectional and a 6-year longitudinal cohort of individuals with MAFLD. BP was classified into the following categories optimal, normal, high-normal, and hypertension. Liver fibrosis was diagnosed with fibrosis-4 (FIB-4) score, nonalcoholic fatty liver disease fibrosis score (NFS), and aspartate aminotransferase-to-platelet ratio index (APRI).

RESULTS

A total of 10,232 individuals were included in the cross-sectional cohort. In the MAFLD population, individuals with liver fibrosis had significantly higher BP levels and hypertension prevalence (P < 0.001) than those without. Furthermore, liver fibrosis score was significantly associated with BP levels (P < 0.001). In the 6-year longitudinal cohort of 3661 individuals with MAFLD without liver fibrosis, the incidence rates of liver fibrosis increased with increasing BP levels as follows optimal=11.20%, normal=13.90%, high-normal=19.50%, hypertension=26.20% (log-rank 22.205; P < 0.001). Cox regression analysis showed that both baseline high-normal BP (hazard ratio [HR], 1.820; P=0.019) and hypertension (HR, 2.656; P < 0.001) were predictive of liver fibrosis.

CONCLUSIONS

BP stratification may be useful in predicting the progression of MAFLD. Individuals having MAFLD with concurrent hypertension or high-normal BP are at a higher risk of liver fibrosis. These findings may provide a criteria for early intervention of MAFLD to prevent liver fibrosis.

Non-alcoholic Fatty Liver Disease (NAFLD), Type 2 Diabetes, and Non-viral Hepatocarcinoma: Pathophysiological Mechanisms and New Therapeutic Strategies

In recent years, the incidence of non-viral hepatocellular carcinoma (HCC) has increased dramatically, which is probably related to the increased prevalence of metabolic syndrome, together with obesity and type 2 diabetes mellitus (T2DM). Several epidemiological studies have established the association between T2DM and the incidence of HCC and have demonstrated the role of diabetes mellitus as an independent risk factor for the development of HCC. The pathophysiological mechanisms underlying the development of Non-alcoholic fatty liver disease (NAFLD) and its progression to Non-alcoholic steatohepatitis (NASH) and cirrhosis are various and involve pro-inflammatory agents, oxidative stress, apoptosis, adipokines, JNK-1 activation, increased IGF-1 activity, immunomodulation, and alteration of the gut microbiota. Moreover, these mechanisms are thought to play a significant role in the development of NAFLD-related hepatocellular carcinoma. Early diagnosis and the timely correction of risk factors are essential to prevent the onset of liver fibrosis and HCC. The purpose of this review is to summarize the current evidence on the association among obesity, NASH/NAFLD, T2DM, and HCC, with an emphasis on clinical impact. In addition, we will examine the main mechanisms underlying this complex relationship, and the promising strategies that have recently emerged for these diseases' treatments.

Lack of Faecalibacterium prausnitzii and Bifidobacterium is associated with a higher risk of metabolic associated fatty liver disease in young-onset type 2 diabetes

Background

The incidence of comorbidity between type 2 diabetes mellitus (T2DM) and metabolic-associated fatty liver disease (MAFLD) is high, and patients tend to be younger. When people develop metabolic diseases such as T2DM and MAFLD, the original homeostasis of the gut microbiota in the body is disrupted, and gut flora drift occurs. This study investigated the relationship between the number of gut flora and MAFLD in young-onset T2DM.

Methods

This retrospective study analyzed 44 adolescent T2DM patients who were divided into a non-MAFLD group and a MAFLD group. Anthropometric measurements, clinical and biochemical markers, inflammatory markers, thyroid function assessments, and stool specimens were collected. Real-time PCR was performed to quantify several important gut flora constituents at the genus level. Student’s t-test and the chi-square test were applied for group comparisons, and binary regression models were used to explore the relationship between gut flora and MAFLD in young-onset T2DM.

Results

Among the 44 subjects, 26 (59.1%) were diagnosed with MAFLD, and 18 (40.9%) were not. Compared with the non-MAFLD group, body mass index (BMI), abdominal circumference, and levels of blood uric acid and thyroid stimulating hormone (TSH) in the MAFLD group were significantly increased, and age level and high-density lipoprotein cholesterol (HDL-C) were significantly decreased (p < 0.05). Compared with the non-MAFLD group, the abundance of Faecalibacterium prausnitzii and Bifidobacterium in the MAFLD group was significantly reduced, and the abundance of Enterococcus and Lactobacillus was significantly increased (p < 0.05). In the multivariate regression analysis, Faecalibacterium prausnitzii and Bifidobacterium were independent protective factors for MAFLD in young-onset T2DM, after excluding confounding factors.

Conclusion

In young-onset T2DM, there was a difference in gut flora between patients with MAFLD and those without MAFLD. Faecalibacterium prausnitzii and Bifidobacterium were independent protective factors for MAFLD in young-onset T2DM.

Metabolic dysfunction associated fatty liver disease: The new nomenclature and its impact

BACKGROUND

In 2020, an international expert panel proposed a new definition of fatty liver: Metabolic dysfunction-associated fatty liver disease (MAFLD). The MAFLD added the criteria for defining metabolic dysfunctions, which are high-risk factors for liver-related and cardiovascular events. Contrary to the non-alcoholic fatty liver disease (NAFLD) definition, it allows the coexistence of MAFLD and significant alcohol use in the same patient.

AIM

To review the existing data that evaluate the clinical profile and long-term outcome difference between the patients identified as MAFLD and NAFLD.

METHODS

Databases MEDLINE via PubMed and EMBASE were searched and relevant publications up to June 28, 2022 were assessed. Studies were included if they involved human participants diagnosed with MAFLD.

RESULTS

A total of 2324 records were reviewed, of which 1575 duplicate citations were removed. Of the 2324 records screened, 207 articles were excluded, and 542 articles were assessed for their eligibility, for which 511 were excluded. The remaining 31 articles were selected for review. MAFLD diagnostic criteria were able to identify more individuals with fatty liver. Studies have shown that patients included using the MAFLD criteria were associated with higher risks of hepatic fibrosis when compared to NAFLD. All-cause mortality, cardiovascular disease-related, and cancer-related mortality were shown to be higher in MAFLD patients. MAFLD patients also had higher baseline metabolic derangement, and risks of developing obesity, diabetes, and cardiovascular events. Of the 3 subtypes, diabetes mellitus has the strongest association with negative outcomes, followed by metabolic dysfunction and elevated body mass index. Within the subtypes of MAFLD, patients with more metabolic conditions at the time of diagnosis had worse hepatic and liver injury compared to those with a single metabolic condition.

CONCLUSION

MAFLD is a new definition of fatty liver disease that is gaining increasing acceptance. It is based on empirical clinical practice on positive inclusion of metabolic risk factors and recent evidence suggests that it helps to identify patients with higher risk for liver-related as well as cardiovascular events.

Examining the interim proposal for name change to steatotic liver disease in the US population

BACKGROUND AND AIMS

Fatty liver is the commonest liver condition globally and traditionally associated with NAFLD. A consensus meeting was held in Chicago to explore various terminologies. Herein, we explore the proposed changes in nomenclature in a population data set from the US.

APPROACH AND RESULTS

Statistical analysis was conducted using survey-weighted analysis. Assessment of fatty liver was conducted with vibration-controlled transient elastography. A controlled attenuation parameter of 288 dB/m was used to identify hepatic steatosis. Patients were classified into nonalcoholic steatotic liver disease, alcohol-associated steatotic liver disease, and viral hepatitis steatotic liver disease. Liver stiffness measures at ≥8.8, ≥11.7, and ≥14 kPa were used to identify clinically significant fibrosis, advanced fibrosis, and cirrhosis, respectively. A total of 5102 individuals were included in the analysis. Using a survey-weighted analysis, a total of 25.43%, 6.95%, and 0.73% of the population were classified as nonalcoholic steatotic liver disease, alcohol-associated steatotic liver disease, and viral hepatitis steatotic liver disease, respectively. A sensitivity analysis at controlled attenuation parameter of 248 dB/m and fatty liver index found similar distribution. In a comparison between nonalcoholic steatotic liver disease, alcohol-associated steatotic liver disease, and viral hepatitis steatotic liver disease, there was no significant difference between the odds of advanced fibrosis and cirrhosis between groups. However, viral hepatitis steatotic liver disease individuals were found to have a significantly higher odds of clinically significant fibrosis (OR: 3.76, 95% CI, 1.27-11.14, p =0.02) compared with nonalcoholic steatotic liver disease.

CONCLUSIONS

The current analysis assessed the proposed changes based on discussions from the consensus meeting. Although the definitions are an interim analysis of discussions, steatotic liver disease respects the underlying liver etiology and reduces stigma while increasing awareness of FL among viral and alcohol-associated steatosis/steatohepatitis.

Cardiometabolic characterization in metabolic dysfunction–associated fatty liver disease

Background

To better understand the patient's heterogeneity in fatty liver disease (FLD), metabolic dysfunction–associated fatty liver disease (MAFLD) was proposed by international experts as a new nomenclature for nonalcoholic fatty liver disease (NAFLD). We aimed to evaluate the cardiovascular risk, assessed through coronary artery calcium (CAC) and epicardial adipose tissue (EAT), of patients without FLD and patients with FLD and its different subtypes.

Methods

Cross sectional study of 370 patients. Patients with FLD were divided into 4 groups: FLD without metabolic dysfunction (non-MD FLD), MAFLD and the presence of overweight/obesity (MAFLD-OW), MAFLD and the presence of two metabolic abnormalities (MAFLD-MD) and MAFLD and the presence of T2D (MAFLD-T2D). MAFLD-OW included two subgroups: metabolically healthy obesity (MHO) and metabolically unhealthy obesity (MUHO). The patients without FLD were divided into 2 groups: patients without FLD and without MD (non-FLD nor MD; reference group) and patients without FLD but with MD (non-FLD with MD). EAT and CAC (measured through the Agatston Score) were determined by computed tomography.

Results

Compared with the reference group (non-FLD nor MD), regarding EAT, patients with MAFLD-T2D and MAFLD-MUHO had the highest risk for CVD (OR 15.87, 95% CI 4.26-59.12 and OR 17.60, 95% CI 6.71-46.20, respectively), patients with MAFLD-MHO were also at risk for CVD (OR 3.62, 95% CI 1.83-7.16), and patients with non-MD FLD did not have a significantly increased risk (OR 1.77; 95% CI 0.67-4.73). Regarding CAC, patients with MAFLD-T2D had an increased risk for CVD (OR 6.56, 95% CI 2.18-19.76). Patients with MAFLD-MUHO, MAFLD-MHO and non-MD FLD did not have a significantly increased risk compared with the reference group (OR 2.54, 95% CI 0.90-7.13; OR 1.84, 95% CI 0.67-5.00 and OR 2.11, 95% CI 0.46-9.74, respectively).

Conclusion

MAFLD–T2D and MAFLD–OW phenotypes had a significant risk for CVD. MAFLD new criteria reinforced the importance of identifying metabolic phenotypes in populations as it may help to identify patients with higher CVD risk and offer a personalized therapeutic management in a primary prevention setting.

Validation of Non-invasive Fibrosis Scores for Predicting Advanced Fibrosis in Metabolic-associated Fatty Liver Disease

BACKGROUND AND AIMS

Metabolic-associated fatty liver disease (MAFLD) is a newly proposed terminology from 2020; yet, the applicability of conventional noninvasive fibrosis models is still unknown for it. We aimed to evaluate the performance of conventional noninvasive fibrosis scores in MAFLD.

METHODS

The NHANES 2017-2018 datasets were used to compare the performances of different noninvasive fibrosis scores in MAFLD, including the aspartate aminotransferase (AST) to platelet ratio index (APRI), body mass index (BMI)-AST/alanine aminotransferase (ALT) ratio and diabetes score (BARD), fibrosis-4 index (FIB-4), and NAFLD fibrosis score (NFS). Moreover, Asian patients with biopsy-proven MAFLD were enrolled to further validate the findings.

RESULTS

A total of 2,622 participants in the National Health and Nutrition Examination Survey (NHANES) cohort and 293 patients with MAFLD in the Asian cohort were included. Patients in the Asian cohort had a lower BMI and higher liver enzymes (p<0.001). The area under the receiver operating characteristic curve (AUROC) of NFS was the largest in the NHANES cohort and Asian cohorts (0.679 and 0.699, respectively). The AUROC of NFS was followed by APRI, FIB-4, and BARD in the NHANES cohort (0.616, 0.601, and 0.589, respectively). In the Asian cohort, the AUROC of APRI, FIB-4, and BARD for predicting advanced fibrosis were 0.625, 0.683, and 0.615, respectively. The performance of FIB-4 was better in the Asian cohort than that in the NHANES cohort.

CONCLUSIONS

NFS is better for predicting advanced fibrosis in MAFLD. FIB-4 can be an alternative choice for MAFLD with high liver enzymes when NFS is unavailable. Novel efficient noninvasive fibrosis scoring systems are highly required for patients with MAFLD.

The Effect of Low Glycemic Index Mediterranean Diet and Combined Exercise Program on Metabolic-Associated Fatty Liver Disease: A Joint Modeling Approach

Background: Excessive caloric intake and reduced energy expenditure are associated with the onset of metabolic-associated fatty liver disease (MAFLD). The aim of this study was to probe the benefits of a low glycemic index Mediterranean diet (LGIMD) and a combined exercise program (CEP) on MAFLD by monitoring the clinical process through anthropometric measurement, body mass index (BMI), and specific biomarkers, such as the Homeostatic Model Assessment for Insulin Resistance (HOMA-IR). Methods: The study was conducted at the National Institute of Gastroenterology, ‘S. de Bellis’, Italy. Subjects were invited to join the study for 12 months. Results: 54 participants were enrolled. Joint modeling of longitudinal and time-to-event data was applied. Overall, a statistically significant direct effect of LGIMD/CEP adherence on ln (BMI), a statistically significant direct effect of LGIMD/CEP adherence on time-to-event and a strong statistically significant direct effect of log (BMI) on time-to-event were observed. In addition, a statistically significant direct effect of LGIMD/CEP adherence on ln(HOMA-IR), a statistically significant direct effect of LGIMD/CEP adherence on time-to-event and a statistically significant direct effect of ln(HOMA-IR) on time-to-event were observed. Conclusions: LGIMD/CEP significantly improved MAFLD status; in addition, longitudinal BMI and HOMA-IR were good predictors of the disappearance of diagnostic criteria for MAFLD.

A Noninvasive Scoring System for Liver Fibrosis in Patients With Metabolic Dysfunction-Associated Fatty Liver Disease

Background and Aims

Metabolic dysfunction-associated fatty liver disease (MAFLD) is diagnosed in patients with hepatic steatosis who meet at least one of the following criteria: body mass index >25, diabetes mellitus type 2, and metabolic dysfunction. Given about one-third of Americans meet the criteria for MAFLD, there is an unmet need for a score to noninvasively triage patients who need transient elastography and possible biopsy. We determined the risk factors for advanced fibrosis (F3+ on transient elastography) in a cohort of 2671 MAFLD patients and developed the MAFLD fibrosis-4 (FIB-4) score to help clinicians predict the risk of advanced fibrosis.

Methods

Multivariate logistic regression analysis and independent t-tests were used to evaluate the relationship between physical exam parameters, lab values, and interview responses and risk of advanced fibrosis. The most significant risk factors were used to build the MAFLD FIB-4 score, equivalent to -46.55 + (7.89∗log[waist circumference]) + (1.25∗log[fasting plasma glucose]) + (0.85∗FIB-4 score).

Results

Risk factors for advanced fibrosis in MAFLD patients are elevated body mass index (odds ratio [OR] = 5.90; P < .01), waist circumference (OR = 3.53; P < .01), high fasting plasma glucose (OR = 2.45; P < .01), high homeostasis model assessment-estimated insulin resistance score (OR = 2.18; P = .02), high triglycerides (OR = 1.94; P = .03), positive hepatitis C RNA (OR = 14.92; P = .02), high ferritin (OR = 1.58; P = .05), and alanine transaminase > aspartate aminotransferase (OR = 1.54; P = .04). The MAFLD FIB-4 score has a specificity of 80%, sensitivity of 97%, and receiver operating characteristic of 0.85 (compared to the receiver operating characteristic of 0.60 for FIB-4 and 0.68 for nonalcoholic fatty liver disease existing scores) for the detection of advanced fibrosis in MAFLD patients.

Conclusion

Clinicians can utilize the MAFLD FIB-4 score to noninvasively identify patients with advanced fibrosis risk for further evaluation and management.

Renaming NAFLD to MAFLD: Advantages and Potential Changes in Diagnosis, Pathophysiology, Treatment, and Management

Abstract

In recent years, with the increasing incidence of obesity and other metabolic diseases, the prevalence of non-alcoholic fatty liver disease (NAFLD) has increased and it has become a major health problem affecting more than one quarter of the world's population. Recently, experts reached a consensus that NAFLD does not reflect the current knowledge, and metabolic dysfunction-associated fatty liver disease (MAFLD) was suggested as a more appropriate term. MAFLD is not just a simple renaming of NAFLD. The definition of MAFLD allows a patient to have dual (or more) etiologies for their liver disease, which will help to exclude more heterogeneous patients. In this review, we introduce the significant differences between the definitions of NAFLD and MAFLD. In addition, we also describe the advantages of the term MAFLD in the pathophysiology, therapy, and patient management.

The Apparent Asymmetrical Relationship Between Small Bowel Bacterial Overgrowth, Endotoxemia, and Liver Steatosis and Fibrosis in Cirrhotic and Non-Cirrhotic Patients: A Single-Center Pilot Study

Introduction

Gut microbiota are a complex ecosystem harboring our intestine. They maintain human body equilibrium, while their derangement, namely, “dysbiosis“, has been associated with several gastrointestinal diseases, such as liver steatosis (NAFLD) and liver cirrhosis. Small intestinal bacterial overgrowth (SIBO) is an example of dysbiosis of the upper gastrointestinal (GI) tract.

Aim

The aim of this study is to evaluate the relationship between SIBO and levels of endotoxemia and grade of liver steatosis (LS) and liver fibrosis (LF) in hepatologic patients.

Materials and Methods

Consecutive outpatients referred to our hepatology clinic were tested for SIBO by the lactulose breath test (LBT) and peripheral blood levels of endotoxemia; LS grading and LF were assessed by abdominal ultrasound and transient elastography, respectively.

Results

Fifty-two consecutive patients (17 with alcohol abuse (4.5 ± 0.8 alcohol units per day), 4 with HCV and 2 with HBV infection, 24 of metabolic origin, 2 of autoimmune origin, and 3 with cholangiopathies; mean age 54.7 ± 8.3 years, 31 F, BMI 24.1 ± 1.1 Kg/m²) and 14 healthy volunteers (HV) (mean age 50.1 ± 4.3 years, 9 F, BMI 23.3 ± 1.1 Kg/m²) were enrolled. SIBO prevalence was significantly higher in cirrhotic (LC) vs. non-cirrhotic (LNC) patients and vs. HV (all, p < 0.05), with a significant positive trend according to Child-Pugh status (all, p < 0.05). SIBO prevalence was not correlated with LS stages (all, p = NS). Consensually, endotoxin levels were significantly higher in LC vs. LNC and vs. HV (all, p < 0.05) and significantly correlated with LF in patients with LC, according to Child-Pugh status (all, p < 0.05).

Conclusion

This study shows that SIBO prevalence and relative endotoxin blood levels seem to be significantly associated with the grade of LF vs. LS in LC. SIBO is also present under pre-cirrhotic conditions, but its prevalence seems to correlate with liver disease irreversible derangement.

The Prevalence of Metabolic Dysfunction-Associated Fatty Liver Disease and Its Association with Physical Function and Prognosis in Patients with Acute Coronary Syndrome

It is believed that patients with acute coronary syndrome (ACS) are at an increased risk of nonalcoholic fatty liver disease (NAFLD), which can lead to sarcopenia and physical dysfunction. However, the relationship between metabolic dysfunction-associated fatty liver disease (MAFLD) and physical dysfunction and prognosis remains unclear. We investigated the prevalence of MAFLD in patients with ACS to assess the relationship between MAFLD and muscle strength, walking speed, and 6-min walking distance (6 MWD). We reviewed patients with ACS who were assessed for hepatic steatosis using the fatty liver index, and the results were further assessed to determine the presence of MAFLD. Among 479 enrolled hospitalized patients, MAFLD was identified in 234 (48.9%) patients. Multiple regression analysis revealed that MAFLD was independently associated with lower leg strength, gait speed, and 6 MWD (leg strength, p = 0.020; gait speed, p = 0.003 and 6 MWD, p = 0.011). Furthermore, in multivariate Poisson regression models after adjustment for clinical confounding factors, combined MAFLD and reduced physical functions were significantly associated with a higher incidence of clinical events. MAFLD is common in hospitalized patients with ACS and is associated with impaired physical function. Also, the coexistence of MAFLD and lower physical function predict the incidence of clinical events in patients with ACS.

MAFLD/NAFLD Biopsy-Free Scoring Systems for Hepatic Steatosis, NASH, and Fibrosis Diagnosis

Metabolic dysfunction-associated fatty liver disease (MAFLD), formerly known as nonalcoholic fatty liver disease, is the most prevalent liver disorder worldwide. Historically, its diagnosis required biopsy, even though the procedure has a variable degree of error. Therefore, new non-invasive strategies are needed. Consequently, this article presents a thorough review of biopsy-free scoring systems proposed for the diagnosis of MAFLD. Similarly, it compares the severity of the disease, ranging from hepatic steatosis (HS) and nonalcoholic steatohepatitis (NASH) to fibrosis, by contrasting the corresponding serum markers, clinical associations, and performance metrics of these biopsy-free scoring systems. In this regard, defining MAFLD in conjunction with non-invasive tests can accurately identify patients with fatty liver at risk of fibrosis and its complications. Nonetheless, several biopsy-free scoring systems have been assessed only in certain cohorts; thus, further validation studies in different populations are required, with adjustment for variables, such as body mass index (BMI), clinical settings, concomitant diseases, and ethnic backgrounds. Hence, comprehensive studies on the effects of age, morbid obesity, and prevalence of MAFLD and advanced fibrosis in the target population are required. Nevertheless, the current clinical practice is urged to incorporate biopsy-free scoring systems that demonstrate adequate performance metrics for the accurate detection of patients with MAFLD and underlying conditions or those with contraindications of biopsy.

Association of Metabolic Dysfunction-Associated Fatty Liver Disease With Left Ventricular Diastolic Function and Cardiac Morphology

BACKGROUND AND AIM

Non-alcoholic fatty liver disease (NAFLD) is closely related to cardiovascular diseases (CVD). A newly proposed definition is metabolic dysfunction-associated fatty liver disease (MAFLD), which was changed from NAFLD. The clinical effect of this change on abnormalities of cardiac structure and function is yet unknown. We aimed to examine whether MAFLD is associated with left ventricular (LV) diastolic dysfunction (LVDD) and cardiac remolding and further identify the impact of different subgroups and severity of MAFLD.

METHOD

We evaluated 228 participants without known CVDs. Participants were categorized by the presence of MAFLD and the normal group. Then, patients with MAFLD were subclassified into three subgroups: MAFLD patients with diabetes (diabetes subgroup), overweight/obesity patients (overweight/obesity subgroup), and lean/normal-weight patients who had two metabolic risk abnormalities (lean metabolic dysfunction subgroup). Furthermore, the severity of hepatic steatosis was assessed by transient elastography (FibroScan^®) with a controlled attenuation parameter (CAP), and patients with MAFLD were divided into normal, mild, moderate, and severe hepatic steatosis groups based on CAP value. Cardiac structure and function were examined by echocardiography.

RESULTS

LVDD was significantly more prevalent in the MAFLD group (24.6% vs. 60.8%, p < 0.001) compared to the normal group. The overweight subgroup and diabetes subgroup were significantly associated with signs of cardiac remolding, including interventricular septum thickness, LV posterior wall thickness, left atrial diameter (all p < 0.05), relative wall thickness, and LV mass index (all p < 0.05). Additionally, moderate-to-to severe steatosis patients had higher risks for LVDD and cardiac remolding (all p-values < 0.05).

CONCLUSION

MAFLD was associated with LVDD and cardiac remolding, especially in patients with diabetes, overweight patients, and moderate-to-to severe steatosis patients. This study provides theoretical support for the precise prevention of cardiovascular dysfunction in patients with MAFLD.

MAFLD Criteria May Overlook a Subtype of Patient with Steatohepatitis and Significant Fibrosis

INTRODUCTION

Metabolic associated fatty liver disease (MAFLD) is a novel concept for fatty liver disease. Different from non-alcoholic fatty liver disease (NAFLD), the diagnosis of MAFLD requires the presence of metabolic risks. This study aimed to characterize patients with liver steatosis but without metabolic risks (non-MR-steatosis) which may not be diagnosed by MAFLD criteria.

METHODS

Consecutive patients who underwent biopsy were included in this study. The clinic-pathological characteristics of non-MR-steatosis, NAFLD and MAFLD were compared.

RESULTS

A total of 1217 cases were included. There were 426 (35.00%) cases with MAFLD, 585 (48.07%) with NAFLD and 168 (13.80%) with non-MR-steatosis. The majority of the cases were infected with HBV (93.26%). The age and metabolic profiles were highest in MAFLD and lowest in non-MR-steatosis. The body mass index (BMI) level was also lowest in non-MR-steatosis (20.78 ± 1.54 kg/m2). The ALT and AST levels of the non-MR-steatosis group were not statistically different from those of MAFLD or NAFLD groups (p > 0.05). Histologically, there was no significant difference in the degrees of inflammation and fibrosis among the three groups. The severity of steatosis in non-MR-steatosis group was lower than MAFLD or NAFLD groups (p < 0.05). These results were consistent in both HBV and non-HBV subgroups.

CONCLUSION

MAFLD criteria may overlook some steatotic patients without metabolic risks, who may also have steatohepatitis and significant fibrosis.

Editorial: International Consensus Recommendations to Replace the Terminology of Non-Alcoholic Fatty Liver Disease (NAFLD) with Metabolic-Associated Fatty Liver Disease (MAFLD)

In 2020, international consensus guidelines recommended the renaming of non-alcoholic fatty liver disease (NAFLD) to metabolic-associated fatty liver disease (MAFLD), supported by diagnostic criteria. MAFLD affects up to 25% of the global population. However, the rates of MAFLD are likely to be underestimated due to the increasing prevalence of type 2 diabetes mellitus (T2DM) and obesity. Within the next decade, MAFLD has been projected to become a major cause of cirrhosis and hepatocellular carcinoma (HCC) worldwide, as well as the most common indication for liver transplantation in the US. This transition in terminology and clinical criteria may increase momentum and clinical evidence at multiple levels, including patient diagnosis, management, and care, and provide the basis for new research areas and clinical development for therapeutics. The diagnostic criteria for MAFLD are practical, simple, and superior to the existing NAFLD criteria for identifying patients at increased risk of developing progressive liver disease. This Editorial aims to present the historical evolution of the terminology for fatty liver disease and the advantages of diagnosis, patient management, and future research on MAFLD.

Probiotics and gut health

BACKGROUND

Gut microbiota is a complex ecosystem of bacteria, viruses, archea, protozoa and yeasts in our intestine. It has several functions maintaining human body equilibrium. Microbial " dysbiosis " can be responsible for several gastrointestinal diseases.

METHODS

to build a narrative review we performed a Pubmed, Medline, EMBASE search for English language papers, reviews, meta-analyses, case series, and randomized controlled trials (RCTs) by keywords and their associations: gut microbiota, dysbiosis, gastrointestinal diseases, probiotics.

RESULTS

gut microbiota is altered in several gastrointestinal diseases with very different pathophysiology. They range from multi-factorial diseases such as irritable bowel syndrome (IBS), non-alcoholic fatty liver disease (NAFLD) and gastric and colorectal cancers, immunemediated such as celiac disease, inflammatory bowel diseases (IBD), antibioticrelated such as Clostridium Difficile infection (CDI). Microbial dysbiosis re-modulation by probiotics is feasible and safe in some of them.

CONCLUSIONS

gut microbial dysbiosis is statistically associated with several gastro-intestinal diseases, affecting their pathophysiology. Its reverse by probiotics has some promising evidences of efficacy.

Gut microbiota and non-alcoholic fatty liver disease: a narrative review

The gastrointestinal tract of the adult human represents the habitat of the ecological community of commensal, symbiotic and pathogenic microorganisms, defined as the gut microbiota, which has more than 100 trillion microorganisms representing one of the most complex ecosystems. Colonization of the gastrointestinal tract by microorganisms begins at the time of birth. Contrary to what was previously hypothesized, a large number of fundamental functions for the host are attributed to the gut microbiota to date. The gut microbiota, therefore, does not represent a passive set of microbes hosted inside the human organism but plays a crucial role in the balance of the organism itself. An alteration of the microbiota is a phenomenon known as dysbiosis. The latter can be implicated in the development of complex liver diseases like non-alcoholic fatty liver disease. The aim of this review is to describe the most interesting data linking the development of non-alcoholic fatty liver disease with the gut microbiota and, therefore, to underline the importance of the microbiota itself, as a potential therapeutic target in the treatment of non-alcoholic fatty liver disease.