The role of elastography in non-alcoholic fatty liver disease

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

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

Associations between muscle mass, strength, and performance and non-alcoholic fatty liver disease

BACKGROUND

Non-alcoholic fatty liver disease (NAFLD) is a rising global health issue. The influence of muscle in its pathophysiology has recently gained attention. Our aim was to investigate the association of low muscle mass, strength, and performance with the presence and severity of NAFLD.

METHODS

Patients with metabolic syndrome followed in an outpatient clinic, were consecutively included, between April 1st and December 31st, 2019. Abdominal ultrasound for the diagnosis of NAFLD, NAFLD fibrosis score (NFS) and Fibrosis-4 Index (FIB-4) for determination of significant fibrosis, dual-energy X-ray absorptiometry for calculation of skeletal muscle index (SMI = appendicular skeletal mass / weight x100) and sarcopenic index (SI = appendicular skeletal mass / Body Mass Index), and the Short Physical Performance Battery for muscle strength and performance assessment were performed. Sarcopenia was defined as low muscle strength and low SMI or SI.

RESULTS

A total of 157 patients were included, of which 68.8% had NAFLD, 66.2% low SMI, 50.3% low SI, 16.6% low performance and 11.5% low strength. In patients with NAFLD, prevalence of significant fibrosis by NFS was 15.7%. Low SMI was associated with presence of NAFLD when adjusted for age, sex, type 2 diabetes mellitus, hypertension, and dyslipidemia, but not for body mass index and waist circumference. Low SMI, low SI, and sarcopenia were associated with significant fibrosis in univariate analysis; the small number of events precluded a multivariable analysis.

CONCLUSIONS

Low SMI was associated with NAFLD independently of demographics and comorbidities but not of other parameters of body composition. This contrasts with most studies published on this matter.

Noninvasive biochemical markers and surrogate scores in evaluating nonalcoholic steatohepatitis

The histological features of nonalcoholic steatohepatitis (NASH) are the presence of hepatic steatosis with concomitant inflammation, ballooned hepatocytes, and potential fibrosis, which can lead to liver cirrhosis. To reduce the need for liver biopsy, that is still the gold standard for diagnosing NASH, various noninvasive biomarkers have been investigated. This narrative review summarizes the current knowledge about noninvasive diagnostic biomarkers and scores proposed for patients with NASH. A search was performed in the main medical literature databases. The following search terms were used: NASH, noninvasive biomarkers or NASH scores and panels. We focused only on studies assessing NASH diagnosis or predictive values for biomarkers, panels and scores. Data on their accuracy in predicting NASH were collected. Several panels such as NAFLD Fibrosis Score (NFS), Fibrosis-4 (FIB-4), and FibroMeter presented good predictive values of NASH, with novel proteomics panels such as the NAFLD Fibrosis Protein Panel (NFPP) using mainly the adisintegrin and metalloproteinase with thrombospondin motifs like 2 (ADAMTSL2) that showed an advantage in predicting NASH compared to NFS and FIB-4. Another novel panel, Index of NASH (ION) performed better than cytokeratin 18 (CK-18) in excluding severe fibrosis, but the overall accuracy of ION and CK-18 was modest compared to NFS and FIB-4 as it did not provide any significant advantage. Noninvasive biomarkers are currently unable to replace liver biopsy and histological assessment. However, they may play a key and vital role in triaging patients for liver biopsy, lowering the related financial burden. Future studies are needed to verify the predictive values of the newly emerging tests and panels as well as to find more affordable and reliable noninvasive early diagnostic tools.