The Role of Thyroid Hormones and Autoantibodies in Metabolic Dysfunction Associated Fatty Liver Disease: TgAb May Be a Potential Protective Factor

MAFLD as part of systemic metabolic dysregulation

Nonalcoholic fatty liver disease (NAFLD) is one of the most common chronic liver diseases worldwide. In recent years, a new terminology and definition of metabolic dysfunction-associated fatty liver disease (MAFLD) has been proposed. Compared to the NAFLD definition, MAFLD better emphasizes the pathogenic role of metabolic dysfunction in the development and progression of this highly prevalent condition. Metabolic disorders, including overweight/obesity, type 2 diabetes mellitus (T2DM), atherogenic dyslipidemia and hypertension, are often associated with systemic organ dysfunctions, thereby suggesting that multiple organ damage can occur in MAFLD. Substantial epidemiological evidence indicates that MAFLD is not only associated with an increased risk of liver-related complications, but also increases the risk of developing several extra-hepatic diseases, including new-onset T2DM, adverse cardiovascular and renal outcomes, and some common endocrine diseases. We have summarized the current literature on the adverse effect of MAFLD on the development of multiple extrahepatic (cardiometabolic and endocrine) complications and examined the role of different metabolic pathways and organ systems in the progression of MAFLD, thus providing new insights into the role of MAFLD as a multisystem metabolic disorder. Our narrative review aimed to provide insights into potential mechanisms underlying the known associations between MAFLD and extrahepatic diseases, as part of MAFLD as a multisystem disease, in order to help focus areas for future drug development targeting not only liver disease but also the risk of extrahepatic complications.

GlycA as a Novel Biomarker of Systemic Inflammation in Hypothyroidism

Background: GlycA is a novel glycoprotein biomarker of systemic inflammation and cardiovascular risk. Our objective was to assess the levels of GlycA in individuals with hypothyroidism. We also explored whether levothyroxine (LT4)-treated patients had different levels of GlycA, with attention to thyrotropin (TSH) levels. Methods: We performed a cross-sectional analysis, using baseline data from the ELSA-Brasil cohort study. We included only participants with serum TSH and GlycA levels measurements, using magnetic resonance spectroscopy (n = 4745). We excluded individuals with endogenous hyperthyroidism and those using drugs impacting thyroid function. Participants not taking LT4 and whose serum TSH was 0.4-4.0 mIU/L were classified as euthyroid (EU) and those with elevated TSH as undiagnosed hypothyroidism (UH). For those on LT4 (n = 345), adequacy of treatment was defined as TSH within the reference range. Those with TSH <0.4 mIU/L were considered over-treated (OT), and those >4.0 mIU/L, under-treated (UT). Both (UT+OT) were considered inadequately treated (IT). Group comparisons were performed by Kruskal-Wallis, adjusted Chi-square, and the post hoc Dunn test. Additional subgroup analysis were performed in patients with circulating thyroperoxidase antibodies (TPO-Ab+). Respective multivariable analyses were performed to evaluate the relationship between thyroid-related variables and GlycA levels (Generalized Linear Model), as well as an abnormal GlycA (>400 μmol/L; Logistic Binary Regression). Results: The prevalence rate of UH was 9.8% (467/4745) and, among those on LT4, only 61.7% (213/345) were adequately treated (AT). GlycA levels were higher in IT in comparison to EU (429 vs. 410 μmol/L, p < 0.01) but did not differ between UH (413 μmol/L) and euthyroidism. However, the subgroup analysis of those TPO-Ab+ showed that not only those with IT, but also those with UH, had higher levels of GlycA in comparison to euthyroidism (423 and 424 vs. 402 μmol/L, p = 0.04). This association between higher levels of GlycA and IT was maintained even in multivariable analysis (odds ratio 1.53, confidence interval 1.03 to 2.31) Lower levels of GlycA were detected in AT (405 μmol/L,) compared with OT (432 μmol/L, 0.04) and UT (423 μmol/L, p = 0.02). Conclusions: Patients with IT, both OT and UT, had higher GlycA levels, which may be associated with low-grade systemic inflammation and, possibly, increased cardiovascular risk.

[Establishment and Analysis of Risk Prediction Model for Metabolic Dysfunction-Associated Fatty Liver Disease in Physical Examination Population]

Objective

To analyze the risk factors of metabolic dysfunction-associated fatty liver disease (MAFLD) in the physical examination population, to establish a risk prediction model for the occurrence of MAFLD, and to provide management strategies for the prevention and occurrence of the disease.

Methods

A total of 14664 people who underwent physical examination at the Physical Examination Center, West China Hospital, Sichuan University between January 2018 and December 2021 were selected as research subjects. The subjects were divided into a MAFLD group ( n=4013) and a non-MAFLD group ( n=10651) according to whether they had MAFLD. The differences in biochemical indices, for example, glycolipid metabolism levels, were compared and logistic regression was conducted to analyze the risk factors for MAFLD, thereby establishing a nomogram prediction model. The prediction effect of the model was validated and evaluated with the consistency index (C-index) and the calibration curve.

Results

Among the 14664 subjects who underwent physical examination, 4013 were MAFLD patients, presenting an overall prevalence of 27.37%, with significantly higher prevalence in men than that in women (38.99% vs. 10.06%, P<0.001). Compared with those of the non-MAFLD group, the levels of glucose (GLU), total cholesterol (TC), triglyceride (TG), low density lipoprotein cholesterol (LDL-C), aspartate transaminase (AST), alanine transaminase (ALT), gamma-glutamyl transpeptidase (GGT) and uric acid (UA) were increased ( P<0.05), while the high density lipoprotein cholesterol (HDL-C) level was decreased ( P<0.05) in the MAFLD group. The results of logistic regression analysis showed that male sex, age, body mass index, GLU, TG and hypertension were all independent risk factors of MAFLD, while HDL-C was a protective factor of MAFLD. The risk factors were used to establish a nomogram risk prediction model and the C-index and calibration curve showed that the nomogram model produced good predictive performance. The receiver operating characteristic (ROC) curve showed that the nomogram model had good predictive value for the risk of MAFLD.

Conclusion

We found a relatively high prevalence of MAFLD in the physical examination population, and the nomogram model established with routine physical examination screening can provide indications for the clinical screening and analysis of high-risk patients, which has an early warning effect on the high-risk population.

Metabolic Dysfunction-Associated Fatty Liver Disease (MAFLD) Is Associated with Cervical Stromal Involvement in Endometrial Cancer Patients: A Cross-Sectional Study in South China

BACKGROUND

Metabolic dysfunction-associated fatty liver disease (MAFLD) is a significant health issue closely associated with multiple extrahepatic cancers. The association between MAFLD and clinical outcomes of endometrial cancer (EC) remains unknown.

METHODS

We retrospectively included 725 EC patients between January 2012 and December 2020. The odds ratios (ORs) were calculated using logistic regression analyses. Kaplan-Meier survival curves were used for survival analysis.

RESULTS

Among EC patients, the prevalence of MAFLD was 27.7% (201/725, 95% confidence interval (Cl) = 0.245-0.311). MAFLD was significantly associated with cervical stromal involvement (CSI) (OR = 1.974, 95% confidence interval (Cl) = 1.065-3.659, p = 0.031). There was a significant correlation between overall survival (OS) and CSI (HR = 0.31; 95%CI: 0.12-0.83; p = 0.020), while patients with MAFLD had a similar OS to those without MAFLD (p = 0.952). Moreover, MAFLD was significantly associated with CSI in the type I EC subgroup (OR = 2.092, 95% confidence interval (Cl) = 1.060-4.129, p = 0.033), but not in the type II EC subgroup (p = 0.838). Further logistic regression analysis suggested that the hepatic steatosis index (HSI) was significantly associated with CSI among type I EC patients without type 2 diabetes mellitus (T2DM) (OR = 1.079, 95% confidence interval (Cl) = 1.020-1.139, p = 0.012).

CONCLUSIONS

About one-quarter of our cohort had MAFLD. MAFLD was associated with the risk of CSI in EC patients, and this association existed in type I EC patients but not in type II EC patients. Furthermore, the HSI can help predict CSI in type I EC patients without T2DM.

Combined diabetic ketoacidosis and hyperosmolar hyperglycemic state in type 1 diabetes mellitus induced by immune checkpoint inhibitors: Underrecognized and underreported emergency in ICIs-DM

Background

Combined diabetic ketoacidosis (DKA) and hyperosmolar hyperglycemic state (HHS) secondary to immune checkpoint inhibitors (ICIs) is extremely rarely reported among ICIs- diabetes mellitus (DM) cases and is always ignored by physicians. This study aimed to conduct a systematic review to recognize better the rare adverse event of combined DKA-HHS associated with immune checkpoints.

Methods

A electronic search in Pubmed/Cochrane/Web of Science, complemented by manual searches in article references, was conducted to identify clinical features of ICIs-combined DKA-HHS.

Results

we identified 106 patients with ICIs- type 1 diabetes mellitus (T1DM) from 82 publications: 9 patients presented a coexistence of metabolic acidosis, severe hyperglycemia, and/or DKA; All patients were not diagnosed as combined DKA-HHS. Compared with ICIs-DKA patients, combined DKA-HHS cases were prone to higher hyperglycemia (1020 ± 102.5 vs 686.7 ± 252.6mg/dL). Moreover, acute kidney injury (87.5% vs 28.6%) and prior chemotherapy (66.7% vs 31.6%) showed higher occurrences with the onset of ICIs-HHS or combined DKA-HHS.B.

Conclusions

Combined DKA-HHS portends a poor diagnosis in patients with coexistence features of DKA and HHS, which healthcare professionals and patients should be aware of due to differences in treatment. Our observational retrospective case series shows that patients with more risk factors were more likely to develop combined DKA-HHS. We are the first to report this group of patients' clinical characteristics and outcomes.

Correlation between thyroid function, sensitivity to thyroid hormones and metabolic dysfunction-associated fatty liver disease in euthyroid subjects with newly diagnosed type 2 diabetes

PURPOSE

To estimate the prevalence of metabolic dysfunction-associated fatty liver disease (MAFLD) and to evaluate the associations between thyroid parameters, MAFLD and liver fibrosis in euthyroid patients with newly diagnosed type 2 diabetes mellitus (T2DM).

METHODS

Overall, 776 patients with newly diagnosed T2DM and 120 subjects without diabetes were included. All the participants were euthyroid, and were categorized as non-MAFLD and MAFLD. Demographic information, biochemical parameters, and serum thyroid hormones were collected. The thyroid hormone sensitivity indices were calculated. MAFLD was defined according to abdominal ultrasound and clinical manifestations. Noninvasive fibrosis indices were calculated to identify advanced liver fibrosis.

RESULTS

The prevalence of MAFLD was significantly higher in patients with T2DM than in subjects without diabetes. Levels of free triiodothyronine (FT3) and FT3 to free thyroxine (FT4) ratio were significantly higher in subjects with MAFLD. In patients with T2DM, levels of thyroid stimulating hormone (TSH), Thyroid feedback quantile-based index (TFQI_FT3) calculated using FT3 and TSH, thyrotroph T3 resistance index (TT3RI) and thyrotroph T4 resistance index (TT4RI) were significantly higher in subjects with MAFLD. The prevalence of MAFLD increased with the rise of FT3, FT3/FT4, TSH, and sensitivity to thyroid hormone indices (TFQI_FT3, TT3RI, and TT4RI). But significant correlations were not found between thyroid hormones, sensitivity to thyroid hormones and MAFLD, after adjustment for BMI and HOMA-IR. The incidence of advanced fibrosis tended to increase as the rise of TSH and sensitivity to thyroid hormone indices (TFQI_FT3, TT3RI, TT4RI, and TSHI).

CONCLUSION

MAFLD was prevalent in euthyroid patients with newly diagnosed T2DM. Higher normal FT3, TSH and impaired sensitivity to thyroid hormones are associated with increased incidence of MAFLD, being dependent on other metabolic factors.

Association of thyroid autoimmunity with the presence and severity of coronary atherosclerosis in patients undergoing coronary angiography

Studies on the association of thyroid autoimmunity with cardiometabolic risk and coronary artery disease (CAD) have produced conflicting results. This study aimed to investigate the relationship of thyroid autoimmune bodies (thyroid peroxidase antibody [TPOAb] and thyroglobulin antibody [TgAb]) with CAD in euthyroid subjects undergoing coronary angiography. A total of 307 subjects who underwent coronary angiography were included. The severity of coronary atherosclerosis was evaluated by using Gensini score. Serum TSH, total T3, total T4, TPOAb, TgAb, lipid levels et al were measured and compared between the groups with and without CAD. Logistic multivariate regression analysis were performed to assess the associations. Levels of thyroid hormones were comparable between the two groups. The positive percentage of anti-Tg antibodies was higher in non-CAD group (15.22% vs 7.91%, χ2 = 3.95, p = .047) while no significant difference was observed for anti-TPO antibodies (19.57% vs 17.21%, χ2 = 0.243, p = .622). The natural log-transformed Gensini score (ln (Gensini score)) was lower in the TgAb+ group (2.94 ± 1.11 vs 2.41 ± 1.18, P = .015). There was no significant difference for ln (Gensini score) between TPOAb- and TPOAb+ group (2.90 ± 1.14 vs 2.85 ± 1.09, P = .782). Logistical regression analysis revealed that positive TgAb was inversely associated with the presence of CAD (OR: 0.387, 95% CI: 0.157-0.952, p = .039) independent of other risk factors. The results showed that TgAb positivity might be an independent protective factor for CAD.

Association of thyroid autoimmunity with nonalcoholic fatty liver disease in euthyroid middle-aged subjects: A population-based study

BACKGROUND AND AIM

The association between thyroid autoimmunity and nonalcoholic fatty liver disease (NAFLD) remains unclear. In this study, we aimed to investigate the relationship between thyroid autoimmunity and NAFLD in a large cohort of euthyroid subjects.

METHODS

We analyzed clinical and biochemical data from a nationwide, population-based, cross-sectional survey (KNHANES VI). A total of 1589 middle-aged participants aged 45-65 years, with normal thyroid function, were included in this study. NAFLD was defined as a hepatic steatosis index of > 36. We estimated the odds ratios (ORs) for NAFLD according to anti-thyroid peroxidase antibody (TPOAb) positivity by using logistic regression models, and adjusted for potential confounders.

RESULTS

Overall, 24% (n = 378) of the subjects had NAFLD. Subjects with NAFLD showed a higher positivity for TPOAb (11% vs 7%, P = 0.014) compared with those without NAFLD. TPOAb positivity was a significant risk factor for NAFLD [OR 1.668, 95% confidence interval (CI) 1.019-2.730, P = 0.042] even after adjusting for confounding variables, including age, sex, household income, education, smoking, alcohol consumption, walking activity, abdominal obesity, elevated blood pressure, dyslipidemia and hyperglycemia. In addition, TPOAb positivity predicted the risk of advanced liver fibrosis (OR 3.112, 95% CI 1.256-7.713, P = 0.014) in subjects with NAFLD, independent of the confounding variables.

CONCLUSION

In euthyroid subjects, thyroid autoimmunity is associated with NAFLD and advanced liver fibrosis, independent of known metabolic risk factors. Large longitudinal studies in the future will help clarify the causality.

Targeting Thyroid Hormone/Thyroid Hormone Receptor Axis: An Attractive Therapy Strategy in Liver Diseases

Thyroid hormone/thyroid hormone receptor (TH/TR) axis is characterized by TH with the assistance of plasma membrane transporters to combine with TR and mediate biological activities. Growing evidence suggests that TH/TR participates in plenty of hepatic metabolism. Thus, this review focuses on the role of the TH/TR axis in the liver diseases. To be specific, the TH/TR axis may improve metabolic-associated fatty liver disease, hepatitis, liver fibrosis, and liver injury while exacerbating the progression of acute liver failure and alcoholic liver disease. Also, the TH/TR axis has paradoxical roles in hepatocellular carcinoma. The TH/TR axis may be a prospecting target to cure hepatic diseases.

High-Sensitive CRP Correlates With the Severity of Liver Steatosis and Fibrosis in Obese Patients With Metabolic Dysfunction Associated Fatty Liver Disease

BACKGROUND

Metabolic dysfunction associated fatty liver disease (MAFLD) is the most common hepatopathy worldwide due to the obesity epidemic and is associated with chronic low-grade inflammation. High-sensitive C-reactive protein (hsCRP) as an inflammatory marker has been used in diagnosing MAFLD. However, the association between hsCRP and the severity of liver steatosis and fibrosis among obese patients with MAFLD remains to be elucidated.

OBJECTIVE

To explore the correlation of hsCRP with the severity of liver steatosis and fibrosis among Chinese obese patients with MAFLD.

METHODS

A total of 393 obese patients with mean BMI 34.8 ± 6.6 kg/m² were selected and categorized as MAFLD and non-MAFLD groups. Anthropometric data, biochemical indices, and hsCRP were measured. The severity of hepatic steatosis and fibrosis was assessed using FibroScan. Multivariate logistic regression analysis was performed to determine the relationship between hsCRP and the risk of MAFLD and its disease severity.

RESULTS

Patients with MAFLD showed significantly elevated hsCRP levels and were more likely to have severe steatosis and fibrosis compared to those without MAFLD. The proportions of MAFLD, severe steatosis, and severe fibrosis were significantly increased across the hsCRP quartiles (P-trend = 0.004, 0.021, and 0.006, respectively). After multivariable adjustments, the adjusted ORs (AORs) and 95%CI for MAFLD were 1.00 (reference), 1.298 (0.587-2.872), 2.407 (1.002-5.781), and 2.637(1.073-6.482) (Q1-Q4, P-trend = 0.014). Likewise, the AORs (95%CI) for severe steatosis and severe fibrosis were remarkably increased with the increment of serum hsCRP quartiles (P-trend < 0.001, P-trend = 0.021, respectively).

CONCLUSIONS

Elevated serum hsCRP levels were associated with increased risk of MAFLD among Chinese obese patients and correlated positively with the severity of liver steatosis and fibrosis, suggesting that hsCRP can be used as a potential biomarker to monitor and predict disease severity among Chinese obese population with MAFLD.

J-Shaped Relationship Between Serum Prolactin and Metabolic-Associated Fatty Liver Disease in Female Patients With Type 2 Diabetes

BACKGROUND

Metabolic-associated fatty liver disease (MAFLD) has become a worldwide epidemic. Prolactin (PRL), a pituitary hormone, has been linked to MAFLD. As a result, we set out to look into the relationship between serum PRL and the risk of MAFLD in patients with type 2 diabetes mellitus (T2DM).

METHODS

A total of 724 adults with T2DM were enrolled and categorized as MAFLD and non-MAFLD groups. Anthropometric data, biochemical parameters, and serum PRL levels were collected. Liver steatosis and fibrosis were assessed using FibroScan. Patients were stratified into normal PRL (NP) and high PRL (HP) groups and divided into four groups based on serum PRL quartiles. Multivariate logistic regression analysis was performed to evaluate the association between serum PRL and MAFLD risk.

RESULTS

Female but not male patients with MAFLD, liver steatosis, and fibrosis had significantly lower PRL levels in the NP group but higher PRL levels in the HP group than their counterparts. The proportions of MAFLD, liver steatosis, and fibrosis were significantly decreased in the NP group but increased in the HP group across the PRL quartiles in females but not in males. After multivariate adjustment, the adjusted ORs (AORs) and 95% CI for MAFLD among females were 18.165 (3.425-96.336), 1.784 (0.658-5.002), 1.744 (0.608-4.832), and 1.00 (reference) in the NP group (Q1-Q4, P-trend < 0.001) and 1.00 (reference), 11.098 (1.819-110.356), 15.225 (1.996-116.112), and 18.211 (2.579-128.568) in the HP group (Q1-Q4, P-trend = 0.020). Such associations were also found between serum PRL and liver fibrosis in females but not in males.

CONCLUSION

We observed a J-shaped association between serum PRL and the risk of MAFLD and liver fibrosis in females but not in males with T2DM, indicating that PRL may be relevant to MAFLD and its progression in a gender-specific manner.

CLINICAL TRIAL REGISTRATION

Chinese Clinical Trial Registry, number ChiCTR-OCS-12002381.