Ultrasound-based techniques for the diagnosis of liver steatosis

Hyperhomocysteinemia is linked to MASLD

BACKGROUND AND AIMS

Homocysteine (Hcy) levels are elevated in different conditions, including cardiovascular diseases (CVD), diabetes, and metabolic-associated steatotic liver disease (MASLD). In this observational retrospective study, we analyzed Hcy levels in a population of 901 outpatients, considering its putative etiological role in MASLD.

METHODS

A total of 901 outpatients underwent physical and biochemical evaluations. Abdominal and carotid ultrasound were performed to assess liver steatosis, carotid intima-media thickness (IMT) and presence of atherosclerotic plaque.

RESULTS

Hyperhomocysteinemia (HHcy) was identified in 140 subjects (16 %). Patients with HHcy showed glucose metabolism impairment (p < 0.001), altered lipid profile (p < 0.001), low Vitamin D levels (p < 0.0001), increased cardiovascular risk (p < 0.001). We then investigated the relationship between Hcy and MASLD (OR=3.6, p < 0.0001), finding that the relationship remained significant also when accounting for confounding variables (age, sex) (OR=3.2, p < 0.0001). Hcy values were significantly higher (p < 0.0001) in patients with MASLD (n = 78, 29.4 ± 10.1μmol/l) compared to those without MASLD (20.4 ± 4.8 1μmol/l). Furthermore, in MASLD patients we found a direct correlation between Hcy level and waist circumference (r = 0.3, p < 0.001) and an inverse correlation with both HDL-c (r=-0.4, p < 0.001) and Vitamin D levels (r=-0.24, p < 0.05).

CONCLUSIONS

Our data suggest an intriguing scenario whereby HHcy is present in patients with MASLD and is associated to lower vitamin D and altered glucose and lipid profile. Thus, considering Hcy levels may help clinicians with the management of patients with increased MASLD risk.

Interobserver Reproducibility of Ultrasound Attenuation Imaging Technology in Liver Fat Quantification

PURPOSE

This study aims to investigate the interobserver variability in the quantitative assessment of liver fat content using ultrasound attenuation imaging technology (USAT).

METHODS

This prospective, single-center study included 96 adult patients who were either diagnosed with or suspected of having metabolic dysfunction-associated steatotic liver disease. Independent observers, blinded to each other's assessments, evaluated hepatic steatosis visually and through USAT measurements. Separate measurements were taken at five intercostal and subcostal sites, and the median values of these measurements were recorded. The correlation between USAT measurements and visual steatosis grades was examined using Spearman's correlation test. Intraclass correlation coefficient (ICC) and Bland-Altman analysis were used to evaluate the interobserver variability of USAT measurements.

RESULTS

Interobserver agreement for USAT measurements was excellent for the intercostal examination and good for the subcostal examination (p < 0.001). Body mass index did not significantly affect the level of interobserver agreement. Interobserver variability in Bland-Altman plots of USAT measurements was within the 95% limits of agreement. USAT measurements correlated very strongly with the visual degree of hepatic steatosis, both intercostal and subcostal (p < 0.001). USAT measurements were also significantly different between different visual degrees of hepatic steatosis (p < 0.001).

CONCLUSION

In the assessment of hepatic steatosis, USAT measurements obtained from the intercostal space showed excellent agreement in terms of interobserver reproducibility.

A microRNA signature for valproate-induced steatosis in human hepatocytes and its application to predict fatty liver in paediatric epileptic patients on valproate therapy

Valproate (VPA) has been the first-line, most frequently prescribed antiepileptic drug in children over the past 50 years. VPA causes, idiosyncratic hepatotoxicity in some patients, who often presents with hepatic steatosis. Experimental studies also support that VPA has high potential to induce steatosis. However, there is an apparent lack of significant hepatic problems in neuropediatric units, likely because iatrogenic liver steatosis lacks specific biomarkers. Thus, it is possible that a relevant number of children under VPA have asymptomatic fatty liver. AIMS: 1) to demonstrate VPA-induced triglyceride (TG) accumulation in cultured human upcyte hepatocytes, 2) to identify miRNAs that are deregulated by VPA and associated with TG levels in these cells, and 3) to test these miRNAs, as potential non-invasive biomarkers, in plasma of paediatric epileptic patients on VPA, to identify those with a potential risk of liver steatosis. Human upcyte hepatocytes were exposed to subcytotoxic VPA concentrations. Hepatocytes increased intracellular TGs by 27 % and 45 % after 2 and 4 mM VPA for 24 h. The profiling of cellular miRNAs by microarray analysis after 4 mM VPA identified 43 deregulated human miRNAs (fold-change > 1.5 or < -1.5; FDR p<0.05). Some of them (n=11), which were validated by RTqPCR and showed correlation (Pearson r≥ 0.6) with intracellular TG levels, were selected as potential VPA-induced steatosis biomarkers. Next, we investigated the expression of these miRNAs in human plasma and found that 9 of them could be reliably quantified by RTqPCR: miR-485-3p, miR-127-3p, miR-30a-3p, miR-92b-3p, miR-212-3p, miR-182-5p, miR-183-5p, miR-500a-5p and miR-675-5p. Screening of this 9-miRNA signature in 80 paediatric epileptic patients on VPA identified 18 patients (23 %) that clustered separately because of important alterations in the selected plasma miRNAs. These patients were younger and had higher VPA blood concentrations and serum liver enzyme levels. In conclusion, VPA induced both TG accumulation and deregulation of a set of miRNAs in cultured human hepatocytes. Nine of these miRNAs have demonstrated potential as circulating biomarkers to identify VPA-induced steatosis in epileptic patients, which should require closer clinical follow-up.

Comparing ultrasound-derived fat fraction and MRI-PDFF for quantifying hepatic steatosis: a real-world prospective study

OBJECTIVE

To compare the agreement between ultrasound-derived fat fraction (UDFF) with magnetic resonance proton density fat fraction (MRI-PDFF) for quantification of hepatic steatosis and verify its reliability and diagnostic performance by comparing with MRI-PDFF as the reference standard.

METHODS

This prospective study included a primary analysis of 191 patients who underwent MRI-PDFF and UDFF from February 2023 to February 2024. MRI-PDFF were derived from three liver segment measurements with calculation of an overall median PDFF. UDFF was performed by two different sonographers for each of the six measurements, and the median was taken. Intraclass correlation coefficient (ICC) and Bland-Altman analysis were used to assess agreement. Receiver operating characteristics (ROC) curves were used to evaluate the diagnostic performance of UDFF in detecting different degrees of hepatic steatosis.

RESULTS

A total of 176 participants were enrolled in the final cohort of this study (median age, 36.0 years; 82 men, 94 women). The median MRI-PDFF value was 11.3% (interquartile range (IQR) 7.5-18.9); 84.7% patients had a median MRI-PDFF value ≥ 6.4%. The median UDFF measured by different sonographers were 9.5% (IQR: 5.0-18.0) and 9.0% (IQR: 5.0-18.0), respectively. The interobserver agreement of UDFF measurement was excellent agreement (ICC = 0.951 [95% CI: 0.934-0.964], p < 0.001). UDFF was positively strongly correlated with MRI-PDFF with ICC of 0.899 (95% CI: 0.852-0.930). The Bland-Altman analysis showed high agreement between UDFF and MRI-PDFF measurements, with a mean bias of 1.7% (95% LOA, -8.7 to 12.2%). The optimal UDFF cutoff values were 5.5%, 15.5% and 17.5% for detecting MRI-PDFF at historic thresholds of 6.4%, 17.4%, and 22.1%, with AUC of 0.851, 0.952, and 0.948, respectively. The sensitivity was 79.2%, 87.5%, 88.9%, and specificity was 81.5%, 90.6%, 90.0%, respectively.

CONCLUSIONS

UDFF is a reliable and accurate method for quantification and classification of hepatic steatosis, with strong agreement to MRI-PDFF. The UDFF cutoff values of 5.5%, 15.5%, and 17.5% provide high sensitivity and specificity for the detection of mild, moderate, and severe hepatic steatosis, respectively.

KEY POINTS

Question Is ultrasound-derived fat fraction (UDFF) reliable for the quantitative detection of hepatic steatosis compared to MRI proton density fat fraction (MRI-PDFF)? Findings UDFF cutoff values of 5.5%, 15.5%, and 17.5% provided high sensitivity and specificity for the detection of mild, moderate, and severe hepatic steatosis, respectively. Clinical relevance UDFF is a reliable and accurate method for quantification and classification of hepatic steatosis, with strong agreement to MRI-PDFF and high reproducibility of liver fat content by different sonographers.

Effect of Ilex hainanensis Merr. On HFD-induced nonalcoholic fatty liver disease and rebalance of gut microbiota and bile acids metabolism in mice

Nonalcoholic fatty liver disease (NAFLD) is a clinicopathological syndrome characterized by excessive intracellular fat deposition in the hepatocytes, and the development is exacerbated by gut microbiota and bile acids metabolism disorders. Ilex hainanensis Merr. is a traditional medicine of the Zhuang nationality, historically esteemed for its efficacy in lowering blood pressure and lipid levels. This study aimed to investigate the pharmacodynamic effects in NAFLD mice and impacts on gut microbiota and bile acids (BAs) metabolism of I. hainanensis extract (IHA). 16 compounds were identified from IHA by HPLC-DAD-MS analysis. IHA significantly reduced body weight indexs, alanine transaminase (ALT) and aspartate transaminase (AST) activities, improved dyslipidemia and insulin resistance (IR), and effectively ameliorated hepatic steatosis in HFD-induced NAFLD mice. IHA also altered gut microbiota composition, particularly enhancing the abundance of bacteria involved in BAs metabolism, as well as augmented BAs synthesis in the liver and increased fecal excretion. In conclusion, our findings suggest that IHA holds promise in improving NAFLD conditions and modulating gut microbiota and BAs metabolism. These insights contribute to a deeper understanding of the mechanisms underlying IHA-mediated alleviation of lipid accumulation in NAFLD.

Multiparametric liver assessment in patients successfully treated for hepatitis C: a 4-year follow-up

BACKGROUND

Hepatitis C virus (HCV) is a major cause of chronic liver disease, in which liver stiffness increases. Liver stiffness measurements (LSM) are therefore essential in diagnosing liver diseases and predicting disease development. The study objective was to perform a comprehensive prospective assessment of the liver before, after and 4 years after treatment for HCV, including an assessment of the long-term outcome of fibrosis, steatosis and inflammation.

METHODS AND FINDINGS

Patients eligible for HCV treatment were included prospectively in 2018 (n = 47). Liver stiffness was measured using transient elastography and 2D shear-wave elastography (SWE). Blood tests, B-mode ultrasound (US) and SWE, were performed before, after (end of treatment [EOT]), 3 months after (EOT3) and 4 years after treatment (4Y). At the final visit, we added attenuation imaging and shear-wave dispersion slope (SWDS) measurements to assess steatosis and inflammation. Three months after treatment, the sustained virologic response rate was 93%. The median liver stiffness for baseline, EOT, EOT3 and 4Y was 8.1, 5.9, 5.6 and 6.3 kPa, respectively. There was a significant reduction in liver stiffness from baseline to EOT, and from EOT to EOT3. After 4 years, the mean attenuation coefficient (AC) was 0.58 dB/cm/MHz, and the mean SWDS value was 14.3 (m/s)/kHz.

CONCLUSION

The treatment for HCV was highly effective. Measurements of liver stiffness decreased significantly after treatment and remained low after 4 years. AC measurements indicated low levels of liver steatosis. Shear-wave dispersion values indicated inflammation of the liver, but the clinical implication is undetermined and should be explored in larger studies.Clinicaltrials.gov: NCT03434470.

ABBREVIATIONS

AC: attenuation coefficient; APRI: aspartate aminotransferase to platelet ratio index; ATI: attenuation imaging; cACLD: compensated advanced chronic liver disease; CAP: controlled attenuation parameter; FIB-4: Fibrosis-4 Index for liver fibrosis; HCC: hepatocellular carcinoma; LSM: liver stiffness measurement; NAFLD: non-alcoholic fatty liver disease; NASH: non-alcoholic steatohepatitis; SWDS: shear-wave dispersion slope; SWE: shear-wave elastography; US: ultrasound.

Intersystem and Interoperator Agreement of US Attenuation Coefficient for Quantifying Liver Steatosis

Background The extent of liver steatosis can be assessed using US attenuation coefficient (AC) algorithms currently implemented in several US systems. However, little is known about intersystem and interoperator variability in measurements. Purpose To assess intersystem and interoperator agreement in US AC measurements for fat quantification in individuals with varying degrees of liver steatosis and to assess the correlation of each manufacturer's AC algorithm results with MRI proton density fat fraction (PDFF). Materials and Methods This prospective study was conducted at Southwoods Imaging, Youngstown, Ohio, September 30-October 1, 2023. Two operators independently obtained AC measurements using eight US systems equipped with an AC algorithm from different manufacturers. On the same day, MRI PDFF measurement was performed by a different operator. Correlation between US AC and MRI PDFF was assessed using a mixed-effects model. Agreement between systems and operators was evaluated using the intraclass correlation coefficient (ICC). Results Twenty-six individuals (mean age, 55.4 years ± 10.7 [SD]; 16 female participants) were evaluated. The correlation of US AC with MRI PDFF was high for five AC algorithms (r range, 0.70-0.86), moderate for two (r = 0.62 for both), and poor for one (r = 0.47). In pairwise comparisons, none of the pairs of systems achieved excellent agreement (overall ICC = 0.33 [95% CI: 0.15, 0.52]). One pair showed good agreement (ICC = 0.79 [95% CI: 0.66, 0.87]), eight pairs showed moderate agreement (ICC range, 0.50 [95% CI: 0.22, 0.69] to 0.73 [95% CI: 0.49, 0.85]), and 19 pairs showed poor agreement (ICC range, 0.11 [95% CI: -0.06, 0.37] to 0.48 [95% CI: 0.20, 0.67]). Interoperator agreement on AC value was excellent for the Samsung Medison algorithm (ICC = 0.90 [95% CI: 0.80, 0.96]), good for the Siemens Healthineers (ICC = 0.76 [95% CI: 0.54, 0.89]) and Canon Medical Systems (ICC = 0.76 [95% CI: 0.16, 0.92]) algorithms, and moderate for the remaining algorithms (ICC range, 0.50 [95% CI: 0.16, 0.73] to 0.74 [95% CI: 0.51, 0.88]). The mean AC value obtained by the two operators did not differ for any system except the system from Canon Medical Systems. Conclusion There was substantial variability in AC values obtained with different US systems, precluding interchangeability between systems for liver steatosis diagnosis and follow-up imaging. Interoperator agreement ranged from moderate to excellent. © RSNA, 2024 Supplemental material is available for this article. See also the editorial by Han in this issue.

Association of liver multi-parameter quantitative metrics determined by dual-layer spectral detector computed tomography (SDCT) with coronary plaque scores

Background

Hepatic steatosis is closely related to the occurrence and development of coronary plaques. Spectral detector computed tomography (SDCT) can provide more precise multiparameter quantitative parameters for hepatic steatosis. Hence, the purpose of this cross-sectional study was to explore the effect of quantitative liver metrics measured using SDCT on the extent and severity of coronary plaques.

Methods

In patients who underwent upper abdomen unenhanced SDCT and coronary computed tomography angiography, plaque extent and severity were assessed using segmental involvement score (SIS) and segmental stenosis score (SSS). Liver fat quantification was evaluated by polychromatic and virtual mono-energetic images at 40 and 70 kev, spectral attenuation curve slope, and effective atomic number (CT40 keV, CT70 kev, λHU, and Zeff, respectively). A logistic regression model evaluated the factors influencing high SIS and SSS.

Results

Enrolled patients (n=644) were divided into groups: low SIS (<5) (n=451), high SIS (≥5) (n=193), low SSS (<5) (n=461), and high SSS (≥5) (n=183). Zeff was more closely correlated with SIS (standard partial regression coefficient =-0.422, P<0.001) and SSS (standard partial regression coefficient =-0.346, P<0.001). Zeff was divided into four groups using interquartile intervals. Compared with the patients in the lowest quartile, those in the second [odds ratio (OR) =2.116, 95% confidence interval (CI): 1.134-3.949, P=0.018], third (OR =2.832, 95% CI: 1.461-5.491, P=0.002), and fourth (OR =3.584, 95% CI: 1.857-6.918, P<0.001) quartiles showed higher risk for high SIS. And correspondingly, the second (OR =1.933, 95% CI: 1.040-3.592, P=0.037), third (OR =2.900, 95% CI: 1.499-5.609, P=0.002), and fourth (OR =3.368, 95% CI: 1.743-6.510, P<0.001) quartiles showed higher risk for high SSS, especially in those who were <60 years old, male and had visceral adipose tissue/subcutaneous adipose tissue <1.18.

Conclusions

The SDCT-Zeff was an independent factor associated with high SIS and SSS. The quantification of liver fat may be useful for evaluating the risk and prognosis of coronary atherosclerosis.

Epidemiology and diagnosis of metabolic dysfunction-associated fatty liver disease

The most common chronic liver illness worldwide is metabolic dysfunction linked to fatty liver disease (MAFLD), which is poorly understood by doctors and patients. Many people with this disease develop steatohepatitis, cirrhosis and its consequences, as well as extrahepatic manifestations; these conditions are particularly common if they are linked to diabetes mellitus or obesity. A breakthrough with numerous benefits is the switch from NAFLD to MAFLD in terms of terminology and methodology. The diagnosis of MAFLD is based on affirmative criteria; unlike NAFLD, it is no longer based on exclusion. The diagnosis of MAFLD and the evaluation of steatosis and fibrosis is achieved using liver biopsy and non-invasive laboratory or radiographic techniques. We briefly address the most recent developments in MAFLD epidemiology and diagnosis.

Long-term antibody response after the third dose of inactivated SARS-CoV-2 vaccine in MASLD patients

BACKGROUND

Metabolic dysfunction-associated steatotic liver disease (MASLD) patients are at an elevated risk of developing severe coronavirus disease 2019 (COVID-19). The objective of this study was to assess antibody responses and safety profiles six months after the third dose of the inactivated acute respiratory syndrome coronavirus 2 (SARS-CoV-2) vaccine in MASLD patients.

METHODS

This study included MASLD patients and healthy volunteers without a history of SARS-CoV-2 infection. Blood samples were collected six months after receiving the third dose of the inactivated vaccine to measure the levels of neutralizing antibodies (NAbs) and anti-spike IgG antibodies against SARS-CoV-2.

RESULTS

A total of 335 participants (214 MASLD patients and 121 healthy volunteers) were enrolled. The seroprevalence of NAb was 61.7% (132 of 214) in MASLD patients and 74.4% (90 of 121) in healthy volunteers, which was a significant difference (p = 0.018). Statistically significant differences in IgG seroprevalence were also observed between MASLD patients and healthy volunteers (p = 0.004). Multivariate analysis demonstrated that the severity of MASLD (OR, 2.97; 95% CI, 1.32-6.68; p = 0.009) and age (OR, 1.03; 95% CI, 1.01-1.06; p = 0.004) were independent risk factors for NAb negativity in MASLD patients. Moderate/severe MASLD patients had a lower NAb seroprevalence than mild MASLD patients (45.0% vs. 65.5%, p = 0.016).

CONCLUSION

Lower antibody responses were observed in MASLD patients six months after their third dose of the inactivated vaccine than in healthy volunteers, providing further assistance in monitoring patients who are more vulnerable to hypo-responsiveness to SARS-CoV-2 vaccines.

A national survey on the use of ultrasound as an educational tool to complement anatomy teaching at UK medical schools

Our aim was to investigate the current use of ultrasound (US) in anatomy teaching across the UK, and to discover potential obstacles in its implementation in the undergraduate medical curriculum. An electronic survey consisting of 31 questions was distributed to anatomy course organizers at all 42 UK medical schools from June to October 2022. Both quantitative and qualitative data were obtained. Analysis of quantitative data was performed using frequency tables while responses to open-ended questions were analyzed individually by authors, and themes were extracted for presentation. There was a 100% response rate, with 23 (55%) medical schools using US in anatomy teaching. Of these, 17 (74%) schools taught normal US anatomy only, while 6 (26%) included pathology. Only 3 (13%) schools delivered weekly sessions, while 3 (13%) schools delivered monthly sessions and 17 (74%) held less frequent sessions. Of the 17 schools with hands-on sessions, these were delivered by radiologists in 6 schools, while sessions in other schools were facilitated by sonographers, other clinicians, students, and anatomy department staff. Students were able to operate US machines themselves in all 17 schools delivering hands-on teaching. Limitations in resources and trained staff as well as time constraints were cited as barriers for the introduction of US in anatomy teaching. Our results indicate that only just over half of all UK medical schools use US in anatomy teaching. As US is increasingly used in screening and diagnosis by various clinicians, learning how to use US early in the medical course would be beneficial. Identifying the barriers to introducing US in the anatomical curriculum is the first step towards the successful development of an US teaching programme.

Ultrasound evaluation of chronic liver disease

Chronic liver disease is a world-wide epidemic. Any etiology that causes inflammation in the liver will lead to chronic liver disease. Presently, the most common inciting factor worldwide is steatotic liver disease. Recent advances in ultrasound imaging provide a multiparametric ultrasound methodology of diagnosing, staging, and monitoring treatment of chronic liver disease. Elastography has become a standard of care technique for the evaluation of liver fibrosis. Quantitative ultrasound allows for determination of the degree of fatty infiltration of the liver. Portal hypertension is the most important factor in determination of liver decompensation. B-mode findings combined with Doppler, and elastography techniques provide qualitative and quantitative methods of determining clinically significant portal hypertension. A newer method using contrast enhanced ultrasound may allow for a non-invasive quantitative estimation of the portal pressures. This paper reviews the use of multiparametric ultrasound in the evaluation of chronic liver disease including conventional B-mode ultrasound, Doppler, elastography and quantitative ultrasound for estimation of liver fat. The recent guidelines are presented and advised protocols reviewed.

Effect of uric acid on lipid metabolism assessed via restricted cubic splines: A new insight

Background

Hyperuricemia can promote both blood lipids and non-alcoholic fatty liver disease (NAFLD). However, the role of the entire uric acid (UA) span, especially low concentrations below hyperuricemia, on lipid metabolism remains unclear.

Methods

A cross-sectional study was designed. Data on the age, sex, UA, triglyceride (TG), total cholesterol (TC), high-density lipoprotein (HDL), and low-density lipoprotein (LDL) of 1977 participants, who underwent physical examination, were collected. NAFLD and non-alcoholic fatty pancreas disease (NAFPD) were diagnosed using abdominal ultrasound. Restricted cubic splines (RCS) linear regression model was used to evaluate the effect of the UA span on TG, TC, HDL, and LDL, respectively. RCS logistic regression model was employed to evaluate the effect of the UA span on NAFLD and NAFPD.

Results

RCS linear regression model showed that TG was negatively correlated with UA at first, then exhibiting a positive correlation. Meanwhile, HDL was positively correlated with UA at first, then negatively correlated. There was a positive linear correlation between TC and UA (P for nonlinear = 0.578) and a positive nonlinear correlation between LDL and UA (P for nonlinear = 0.021). RCS logistic regression model showed that NAFLD and NAFPD were negatively correlated with UA at first and then positively correlated with UA.

Conclusion

our study showed that the entire UA span has a J-shaped effect on some lipids, NAFLD, and NAFPD. Besides, TG and HDL, compared with TC or LDL, may better reflect the status of NAFLD and NAFPD.

Boundary-aware convolutional attention network for liver segmentation in ultrasound images

Liver ultrasound is widely used in clinical practice due to its advantages of non-invasiveness, non-radiation, and real-time imaging. Accurate segmentation of the liver region in ultrasound images is essential for accelerating the auxiliary diagnosis of liver-related diseases. This paper proposes BACANet, a deep learning algorithm designed for real-time liver ultrasound segmentation. Our approach utilizes a lightweight network backbone for liver feature extraction and incorporates a convolutional attention mechanism to enhance the network's ability to capture global contextual information. To improve early localization of liver boundaries, we developed a selective large kernel convolution module for boundary feature extraction and introduced explicit liver boundary supervision. Additionally, we designed an enhanced attention gate to efficiently convey liver body and boundary features to the decoder to enhance the feature representation capability. Experimental results across multiple datasets demonstrate that BACANet effectively completes the task of liver ultrasound segmentation, achieving a balance between inference speed and segmentation accuracy. On a public dataset, BACANet achieved a DSC of 0.921 and an IOU of 0.854. On a private test dataset, BACANet achieved a DSC of 0.950 and an IOU of 0.907, with an inference time of approximately 0.32 s per image on a CPU processor.

Correlation between ratio of fasting blood glucose to high density lipoprotein cholesterol in serum and non-alcoholic fatty liver disease in American adults: a population based analysis

Background

Based on previous research, elevated fasting blood glucose (FBG) and decreased high-density lipoprotein cholesterol (HDL-C) levels are associated with non-alcoholic fatty liver disease (NAFLD). It is hypothesized that the prevalence of NAFLD may be proportional to the FBG-to-HDL-C ratio (GHR).

Methods

In this study, 3,842 participants from the National Health and Nutrition Examination Survey (NHANES) (2013-2020) were investigated. Liver steatosis was assessed using vibration-controlled transient elastography (VCTE). NAFLD was defined as controlled attenuation parameter (CAP) ≥288 dB/m.

Results

After adjusting for race, gender, age, diabetes, BMI, moderate activities, uric acid, albumin, ALT, GGT, ALP, total bilirubin and creatinine, multiple logistic regression analysis indicated a positive correlation between GHR and the prevalence of NAFLD (OR = 1.22, 95% CI = 1.17-1.28). Additionally, multiple linear regression analysis showed a positive correlation between GHR and the severity of liver steatosis according to CA p-values (β = 4.97, 95% CI: 4.28, 5.66). According to the subgroup analysis, the correlation was stronger in other race, participants at the age <50 years old and those with non-diabetes. In this study, a non-linear relationship and saturation effect between GHR and the prevalence of NAFLD was also revealed, characterized by an inverted L-shaped curve, with an inflection point of 7.443. Finally, the receiver operating characteristic (ROC) analysis suggested that the area under the curve (AUC) of GHR (AUC = 0.731) significantly exceeded that of FBG and HDL-C.

Conclusion

Elevated GHR levels are independently associated with the severity of liver steatosis and the increased prevalence of NAFLD in American adults.

Altered probe pressure and body position increase diagnostic accuracy for men and women in detecting hepatic steatosis using quantitative ultrasound

OBJECTIVES

To evaluate the diagnostic performance of ultrasound guided attenuation parameter (UGAP) for evaluating liver fat content with different probe forces and body positions, in relation to sex, and compared with proton density fat fraction (PDFF).

METHODS

We prospectively enrolled a metabolic dysfunction-associated steatotic liver disease (MASLD) cohort that underwent UGAP and PDFF in the autumn of 2022. Mean UGAP values were obtained in supine and 30° left decubitus body position with normal 4 N and increased 30 N probe force. The diagnostic performance was evaluated by the area under the receiver operating characteristic curve (AUC).

RESULTS

Among 60 individuals (mean age 52.9 years, SD 12.9; 30 men), we found the best diagnostic performance with increased probe force in 30° left decubitus position (AUC 0.90; 95% CI 0.82-0.98) with a cut-off of 0.58 dB/cm/MHz. For men, the best performance was in supine (AUC 0.91; 95% CI 0.81-1.00) with a cut-off of 0.60 dB/cm/MHz, and for women, 30° left decubitus position (AUC 0.93; 95% CI 0.83-1.00), with a cut-off 0.56 dB/cm/MHz, and increased 30 N probe force for both genders. No difference was in the mean UGAP value when altering body position. UGAP showed good to excellent intra-reproducibility (Intra-class correlation 0.872; 95% CI 0.794-0.921).

CONCLUSION

UGAP provides excellent diagnostic performance to detect liver fat content in metabolic dysfunction-associated steatotic liver diseases, with good to excellent intra-reproducibility. Regardless of sex, the highest diagnostic accuracy is achieved with increased probe force with men in supine and women in 30° left decubitus position, yielding different cut-offs.

CLINICAL RELEVANCE STATEMENT

The ultrasound method ultrasound-guided attenuation parameter shows excellent diagnostic accuracy and performs with good to excellent reproducibility. There is a possibility to alter body position and increase probe pressure, and different performances for men and women should be considered for the highest accuracy.

KEY POINTS

• There is a possibility to alter body position when performing the ultrasound method ultrasound-guided attenuation parameter. • Increase probe pressure for the highest accuracy. • Different performances for men and women should be considered.

Correlation between Serum Levels of Nitric Oxide and Adropin and Erectile Dysfunction in Males with Nonalcoholic Fatty Liver Disease: An Observational Study

The current study aimed to evaluate the serum levels of nitric oxide (NO) and adropin in males with non-alcoholic fatty liver disease (NAFLD) induced erectile dysfunction (ED) and NAFLD patients without ED and controls. The current study selected 165 participants from the hepatology department from November 2021 to November 2022. The patients were either suffering from NAFLD with normal liver functions or non-alcoholic steatohepatitis with abnormal liver functions. They were diagnosed by abdominal ultrasonography. Participants were evaluated using the validated Arabic version of the International Index of Erectile Function (ArIIEF-5), the Arabic form of the Generalized Anxiety Disorder-7 (GAD-7) questionnaire and the Patient Health Questionnaire-9 (PHQ-9). Noteworthy, there were significant positive correlations between ArIIEF-5 score, NO, adropin and total testosterone (r = 0.380, p = 0.001; r = 0.507, p =  < 0.001; r = 0.246, p = 0.038, respectively). Meanwhile, there were significant negative correlations between ArIIEF-5 score, creatinine, duration of the disease and scores of GAD-7 and PHQ-9 (r = -0.656, p =  < 0.001; r = -0.368, p = 0.002; r = -0.663, p =  < 0.001; r = -0.248, p = 0.037, respectively). Finally, a linear regression analysis revealed that GAD-7, creatinine, and adropin were the only strong independent predictors of ArIIEF-5, as the 95% confidence interval in the form of upper and lower bounds was -0.349, -0.843, p < 0.001, -6.507, -18.402, p < 0.001, 0.476, 0.117, and p 0.002, respectively. Impaired NO and adropin levels play a potential role in the development of ED in patients with NAFLD.

Comparison of transient elastography and shear wave elastography in patients with MAFLD: A single-center experience

BACKGROUND

Metabolic-associated fatty liver disease and liver fibrosis are intimately linked to insulin resistance, type 2 diabetes, obesity, and metabolic syndrome. Transient elastography (TE) and point shear wave elastography (pSWE) were used to measure liver stiffness in patients who met the ultrasound criteria for steatotic liver diseases (SLD). This study compared two methods for estimating liver stiffness in patients with SLD, which in turn correlated with liver fibrosis.

METHOD

Ultrasound B-mode imaging was used to identify SLD. In total, 250 MAFLD patients were recruited. Patient characteristics, laboratory investigations, and liver stiffness measurements using TE and pSWE were assessed on the same day.

RESULTS

In the study, 56.0% of the patients were male, with a mean age of 41.5 ± 10.7 years. The correlation between TE and pSWE was significant (Spearman's r = 0.867*, p < 0.001). The Bland-Altman Plot analysis confirmed this, with 97.5% of variations in LSM falling within 95% agreement ranges. Cohen's κ was used to assess the agreement between TE and pSWE fibrosis stages, showing almost perfect agreement (83.5% kappa agreement) and a strong association between pSWE and TE in the assessment fibrosis stages.

CONCLUSION

In patients with MAFLD, TE, and SWE are reliable methods for measuring liver stiffness and can be used as non-invasive screening tools for the assessment of fibrosis in SLD.

Porto-sinusoidal vascular liver disorder with portal hypertension: Natural history and long-term outcome

BACKGROUND & AIMS

Current knowledge of the natural history of patients with porto-sinusoidal vascular disorder (PSVD) is derived from small studies. The aim of the present study was to determine the natural history of PSVD and prognostic factors in a large multicenter cohort of patients.

METHODS

We performed a retrospective study on patients with PSVD and signs of portal hypertension (PH) prospectively registered in 27 centers.

RESULTS

A total of 587 patients were included, median age of 47 years and 38% were women. Four-hundred and one patients had an associated condition, which was graded as severe in 157. Median follow-up was 68 months. At diagnosis, 64% of patients were asymptomatic while 36% had a PH-related complication: PH-related bleeding in 112 patients, ascites in 117, and hepatic encephalopathy in 11. In those not presenting with bleeding, the incidence of first bleeding was 15% at 5 years, with a 5-year rebleeding rate of 18%. The 5-year cumulative incidence of new or worsening ascites was 18% and of developing PVT was 16%. Fifty (8.5%) patients received a liver transplantation and 109 (19%) died, including 55 non-liver-related deaths. Transplant-free survival was 97% and 83% at 1 and 5 years, respectively. Variables independently associated with transplant-free survival were age, ascites, serum bilirubin, albumin and creatinine levels at diagnosis and severe associated conditions. This allowed for the creation of a nomogram that accurately predicted prognosis.

CONCLUSIONS

The prognosis of PSVD is strongly determined by the severity of the associated underlying conditions and parameters of liver and renal function.

IMPACT AND IMPLICATIONS

Porto-sinusoidal vascular liver disorder (PSVD) is a rare entity that usually affects young people, frequently causes severe complications of portal hypertension, and may reduce life expectancy. To date, there is scarce information regarding its clinical manifestations, natural history and prognostic factors. The present study, including the largest number of patients with PSVD reported so far, shows that overall, when managed at centers of expertise, the prognosis of patients with PSVD is good, with LT-free survival rates of 83% and 72% at 5 and 10 years, respectively. Presence and severity of an underlying associated condition, presence of ascites, age and bilirubin, albumin and creatinine levels were associated with poor prognosis. These results are important to know for hepatologists. A final model combining these parameters enabled development of a nomogram that predicts prognosis with good discrimination and calibration capacity and can be easily applied in clinical practice.

An observational cohort study to investigate the impact of dolutegravir in pregnancy and its obesogenic effects on the metabolic health of women living with HIV and their children: Study protocol

INTRODUCTION

Dolutegravir (DTG)-based antiretroviral therapy is the World Health Organization's preferred first-line regimen for all persons with HIV, including pregnant women. While DTG has been implicated as an obesogen associated with greater weight gain compared to other antiretrovirals, there is a paucity of data in pregnant women and their children. The Obesogenic oRigins of maternal and Child metabolic health Involving Dolutegravir (ORCHID) study is investigating associations between DTG, weight gain, and metabolic outcomes in the context of HIV.

MATERIALS & METHODS

ORCHID is a prospective observational study taking place in Cape Town, South Africa (NCT04991402). A total of 1920 pregnant women with and without HIV infection are being followed from ≤18 weeks gestational age to 24 months postpartum with their children. Participants attend eleven study visits: 3 antenatal, delivery, and 7 postnatal visits. Several embedded sub-studies address specific scientific aims. Primary outcome measurements in mothers include anthropometry, blood pressure, body composition, dysglycemia, insulin resistance (IR), and dyslipidemia. Other maternal measures include demographics, resting energy expenditure, viral load, physical activity, dietary intake, hepatic steatosis, and repository specimens. Sub-study measurements include markers of adipose inflammation, gut integrity, and satiety/hunger, subcutaneous adipose tissue morphology and mitochondrial function, and metabolomics. Primary outcome measurements in children include anthropometry, adipose tissue mass, dysglycemia, IR, and dyslipidemia. Other variables include fetal growth, birth outcomes, medical/breastfeeding history, caloric intake, neurodevelopment, and repository specimens. Sub-study measurements include metabolites/lipid subspecies in umbilical cord blood, as well as breast milk composition and DTG exposure.

DISCUSSION

ORCHID will play a pivotal role in defining obesogenic mechanisms and clinical consequences of DTG use in pregnancy in women with HIV and their children. It will provide insights into metabolic disease risk reduction in the context of HIV/DTG, identify intervention targets, and inform public health approaches to diminish chronic metabolic co-morbidities for women and children.

Correlation between ZJU index and hepatic steatosis and liver fibrosis in American adults with NAFLD

Background

ZJU index, a novel calculation combining blood glucose, body mass index (BMI), lipids and liver functions, is closely related with non-alcoholic fatty liver disease (NAFLD). However, the correlation between ZJU index and hepatic steatosis and liver fibrosis has not been reported in the studies. This study aims to examine the correlation between these variables.

Methods

Data from the 2017-2020 NHANES were collected for a cross-sectional study, to explore the linear relationship between ZJU, liver stiffness measurements (LSM) and controlled attenuation parameters (CAP) with multivariate linear regression models. Restricted cubic spline (RCS) regression and threshold effect analyses were utilized to describe the nonlinear relationship. The correlation in subgroups was analyzed based on race, gender, drinking, age, BMI, diabetes and moderate activities.

Results

In this population-based study, a total of 2,122 adults aged 18-80 years old with NAFLD were included. According to the multivariate linear regression analysis, ZJU had a significant positive correlation with liver fibrosis (LSM, β = 0.182, 95%CI = 0.154-0.211, p < 0.001) and hepatic steatosis (CAP, β = 2.35, 95%CI = 2.14-2.56, p < 0.001), which was stronger in males. According to the RCS analysis, an inverted L-shaped relationship between ZJU and CAP (inflection point at 60.56) and a J-shaped relationship between ZJU index and LSM (inflection point at 51.27) were observed.

Conclusion

ZJU had a positive correlation with CAP and LSM in American adults with NAFLD. The findings suggest that ZJU may be a valuable biomarker for assessing the severity of liver fibrosis and hepatic steatosis in individuals with NAFLD.

Use of transient elastography for hepatic steatosis and fibrosis evaluation in patients with subclinical hypothyroidism

Objective

To evaluate the association between subclinical hypothyroidism and hepatic steatosis and fibrosis using the noninvasive diagnostic methods transient hepatic elastography (TE) and controlled attenuation parameter (CAP) in patients with subclinical hypothyroidism.

Subjects and methods

This was a cross-sectional study including women with confirmed spontaneous subclinical hypothyroidism and an age- and body mass index (BMI)-matched control group without thyroid disease or circulating antithyroperoxidase (anti-TPO) antibodies. Exclusion criteria were age > 65 years, thyroid-stimulating hormone (TSH) > 10.0 mIUI/L, BMI ≥ 35 kg/m2, diabetes, or other chronic liver diseases. Liver stiffness was classified according to TE values (in kPa) and ranged from absence of fibrosis (F0) to advanced fibrosis (F3). Hepatic steatosis was classified according to CAP values (in dB/m) and ranged from low-grade (S1) to advanced (S3) steatosis.

Results

Of 68 women enrolled, 27 were included in the subclinical hypothyroidism group and 41 in the control group. Advanced steatosis (S3) was more frequent in the subclinical hypothyroidism group (25.9% versus 7.3%, respectively, p = 0.034). Circulating anti-TPO was an independent factor associated with advanced steatosis (odds ratio 9.5, 95% confidence interval 1.3-68.3). In multiple linear regression analysis, TE values (which evaluated fibrosis) correlated negatively with free thyroxine levels.

Conclusion

The results of this study strengthen the hypothesis that hepatic steatosis is associated with autoimmune (positive anti-TPO) subclinical hypothyroidism, independently from BMI. However, subclinical hypothyroidism alone does not appear to be associated with a significantly increased risk of hepatic fibrosis.

WFUMB Guidelines/Guidance on Liver Multiparametric Ultrasound. Part 2: Guidance on Liver Fat Quantification

The World Federation for Ultrasound in Medicine and Biology (WFUMB) has promoted the development of this document on multiparametric ultrasound. Part 2 is a guidance on the use of the available tools for the quantification of liver fat content with ultrasound. These are attenuation coefficient, backscatter coefficient, and speed of sound. All of them use the raw data of the ultrasound beam to estimate liver fat content. This guidance has the aim of helping the reader in understanding how they work and interpret the results. Confounding factors are discussed and a standardized protocol for measurement acquisition is suggested to mitigate them. The recommendations were based on published studies and experts' opinion but were not formally graded because the body of evidence remained low at the time of drafting this document.

WFUMB Guideline/Guidance on Liver Multiparametric Ultrasound: Part 1. Update to 2018 Guidelines on Liver Ultrasound Elastography

The World Federation for Ultrasound in Medicine and Biology (WFUMB) endorsed the development of this document on multiparametric ultrasound. Part 1 is an update to the WFUMB Liver Elastography Guidelines Update released in 2018 and provides new evidence on the role of ultrasound elastography in chronic liver disease. The recommendations in this update were made and graded using the Oxford classification, including level of evidence (LoE), grade of recommendation (GoR) and proportion of agreement (Oxford Centre for Evidence-Based Medicine [OCEBM] 2009). The guidelines are clinically oriented, and the role of shear wave elastography in both fibrosis staging and prognostication in different etiologies of liver disease is discussed, highlighting advantages and limitations. A comprehensive section is devoted to the assessment of portal hypertension, with specific recommendations for the interpretation of liver and spleen stiffness measurements in this setting.

Ultrasound screening of paediatric non-alcoholic fatty liver disease (NAFLD): A critical literature review

INTRODUCTION

Paediatric NAFLD is an increasing global health concern, which can be effectively managed with early detection. Screening, using accurate, affordable, and accessible tests is recommended, however, there is currently no consensus on the most appropriate tests. Although ultrasound techniques are widely used, their performance against reference tests have not been fully assessed.

METHODS

A literature search of related databases for peer-reviewed original articles published from January 2010-March 2024 was conducted. Appropriate tools were used to systematise and document the search results and selected studies were quality assessed and critically appraised. Extracted data was subjected to thematic analysis and narrative synthesis.

RESULTS

Eighteen articles met the inclusion criteria. B-mode and Quantitative ultrasound techniques were compared against MR spectroscopy, MRI-PDFF and Liver biopsy.

CONCLUSION

Liver echogenicity and Steato-scores were the B-mode methods used. The former was less effective, with a maximum reported sensitivity of 70%. The latter reached up to 100% sensitivity, and >80% specificity. Ultrasound performed better with moderate-severe steatosis. There was not enough evidence to support steatosis grading, possibly due to small sample sizes and lack of established cut-off values. QUS (Quantitative Ultrasound)) methods including Continuous Attenuation Parameter (CAP), Attenuation Coefficient (AC), Ultrasound derived fat fraction (UDFF), Tissue Scatter Imaging (TSI) Hepato-Renal Index (HRI), Heterogeneity Index (HIA), Computer Assisted Ultrasound (CAUS) and Picture Archiving and Communication System (PACS-based Image analysis performed better than B-mode methods. Although QUS demonstrated excellent performance, with sensitivity and specificity of up to 100%, this will require further verification before implementation in practice.

PRACTICE IMPLICATIONS

Ultrasound techniques can effectively be used for paediatric NAFLD screening, especially in higher-risk subjects. The steato-scores method is currently recommendable for this, with excellent potential for the use of QUS, after cut-off values and validation requirements have been addressed.

Does Meal or Water Intake Affect Ultrasound Attenuation Coefficient Estimate?

OBJECTIVES

To assess whether meal or water intake may affect the measurement of the ultrasound (US) attenuation coefficient (AC) imaging, a parameter that is directly related to liver fat content.

METHODS

The study was performed in two centers (Italy and USA). AC was obtained using the ATI algorithm implemented in the Aplio i-series US systems (Canon Medical Systems, Japan) by one operator at each center. Measurements were performed at baseline and 5, 15, 30, 45 minutes after drinking 500 mL of water (group 1), or 30, 45, 60, 90, 120 minutes after eating a meal of about 600 kcal (group 2). Multilevel generalized estimating equations for repeated measures were used for the statistical analysis to consider the clustered nature of the data.

RESULTS

Twenty-six individuals were enrolled: 11 (10 females; age, 43.7 ± 12.5 years) in Italy and 15 (10 females; age, 60.7 ± 6.3 years) in USA. At B-mode US, 10 (38.5%) had liver steatosis. The baseline AC values, in decibel/centimeter/megahertz, were 0.64 (0.12) in group 1 and 0.66 (0.13) in group 2. There was not any significant difference in AC values at every time-point after water or meal intake either in group 1 or group 2. This result did not change including sex, age, and skin-to-liver capsule into the models.

CONCLUSIONS

The measurement of the AC, which is a biomarker of liver steatosis, does not require a fasting state and drinking water does not affect the result.

Ultrasound backscatter coefficient for fat quantification is affected by the measurement depth

PURPOSE

It has been reported that the estimate of ultrasound attenuation coefficient (AC) is affected by depth of measurement, with linear decrease of values with depth. It is unknown whether backscatter coefficient (BSC) has similar behavior.

METHODS

This retrospective study was performed with Sequoia US system equipped with ultrasound derived fat fraction (UDFF) algorithm (Siemens Healthineers, Issaquah, WA, USA) that combines BSC with AC. UDFF was obtained positioning upper edge of the region of interest at 1.5,2,3,4,5 cm below liver capsule. BSC data were extracted from UDFF offline. A fractional polynomial regression, which selects the best model considering the polynomial development of the variables of interest, was used. Covariates included were age, sex, skin-to-liver-capsule distance, stiffness. Distance was included as linear factor or with a power ranging from - 2 to 3, and the best fitting model was chosen according to partial F test. Body mass index (BMI) was not included because of collinearity with skin-to-liver capsule distance.

RESULTS

104 individuals (56 females; age: 57.9 ± 13.0 years; BMI: 29.0 ± 6.5 kg/m2; skin-to-liver-capsule distance: 2.3 ± 0.7 cm; liver stiffness: 7.5 ± 5.5 kiloPascal) were studied. Best fitting model for BSC included a combination of depth as linear factor and square root. BSC showed a decrease of - 13.98 dB/cm-steradian for each logarithmic increase of 1 cm depth (coefficient: - 13.98; 95% CI: - 21.016; - 5.379; p = .001). Skin-to-liver-capsule distance and stiffness also were independent predictors of BSC.

CONCLUSIONS

The estimation of the BSC in the liver exhibits a depth dependence that significantly affects results. A standardized acquisition protocol is needed to compare results and reliably assess changes over time.

Inflammatory Bowel Disease Is an Independent Risk Factor for Metabolic Dysfunction-Associated Steatotic Liver Disease in Lean Individuals

BACKGROUND

Despite classical association between metabolic dysfunction-associated steatotic liver disease (MASLD) and obesity, there is increasing evidence on the development of MASLD in lean individuals. The aim of the study was to assess the prevalence and risk factors of MASLD and significant liver fibrosis in lean participants with inflammatory bowel disease (IBD).

METHODS

This was a cross-sectional, case-control study including 300 lean cases with IBD and 80 lean controls without IBD, matched by sex and age. All participants underwent a liver ultrasound, transient elastography, and laboratory tests.

RESULTS

The lean IBD group showed a significantly higher prevalence of MASLD compared with lean non-IBD group (21.3% vs 10%; P = .022), but no differences were observed in the prevalence of significant liver fibrosis (4.7% vs 0.0%; P = 1.000). No differences were found between the prevalence of MASLD in IBD and non-IBD participants who were overweight/obese (66.8% vs 70.8%; P = .442). In addition, the prevalence of MASLD was significantly higher in the overweight/obese IBD group compared with the lean IBD group (P < .001). IBD was an independent risk factor for MASLD in lean participants (odds ratio [OR], 2.71; 95% confidence interval [CI], 1.05-7.01; P = .04), after adjusting for classic metabolic risk factors and prior history of systemic steroid use. Nevertheless, no association between IBD related factors and MASLD was identified in lean IBD participants. When the overweight/obese and lean IBD groups with MASLD were compared, the overweight/obese IBD group with MASLD showed higher levels of the homeostatic model assessment of insulin resistance (OR, 1.49; 95% CI, 1.11-1.98; P = .007) and history of smoking (OR, 4.66; 95% CI, 1.17-18.49; P = .029).

CONCLUSIONS

MASLD prevalence was higher in the lean IBD group compared with lean non-IBD group, independent of classic metabolic risk factors.

Hepatic steatosis: Qualitative and quantitative sonographic assessment in comparison to histology

Introduction

Globally, B-mode ultrasound is the most common modality used for the diagnosis of hepatic steatosis. We aimed to assess the correlation between qualitative liver ultrasound parameters, attenuation imaging (ATI) and histopathology-diagnosed steatosis grade obtained from liver biopsy. Our secondary aim was to examine the interobserver variability of qualitative ultrasound features.

Methods

A retrospective cohort study was performed which included adult patients (age ≥ 18 years) who had same-day liver ultrasound, ATI and liver biopsy for grading hepatic steatosis severity between 2018 and 2022. The qualitative US features for hepatic steatosis were independently scored by three radiologists and interobserver variability was examined. Histologic steatosis grade, ATI and qualitative ultrasound parameters were compared.

Results

Ninety patients were included; 67% female with a median age of 54 (IQR 39-65) years. The radiologist's overall impression had the highest correlation (very strongly correlated) with histologic steatosis grade (r = 0.82, P < 0.001). ATI coefficient and all qualitative ultrasound B-mode features except for liver echotexture and focal fat sparing were strongly correlated with histologic steatosis grade (r ≥ 0.70, P < 0.001). Most qualitative ultrasound features had good agreement between observers (Kappa statistic 0.61-1.0, P < 0.001), (Kendall coefficient 0.92, P < 0.001).

Conclusion

The examined qualitative ultrasound parameters and ATI had good-excellent performance for diagnosing clinically significant hepatic steatosis; however, the radiologist's overall impression had the best correlation with histologic steatosis grade. Our findings suggest an ongoing role for qualitative liver ultrasound assessment of hepatic steatosis despite the emergence of newer quantitative measures.

Comparing similarities and differences between NAFLD, MAFLD, and MASLD in the general U.S. population

Background

Recently, the multisociety Delphi consensus renamed non-alcoholic fatty liver disease (NAFLD) terminology [previously renamed metabolic-associated fatty liver disease (MAFLD)] as metabolic dysfunction-associated steatotic liver disease (MASLD). The aim of this study was to compare the similarities and differences between NAFLD, MAFLD, and MASLD and to clarify the impact of this new name change.

Methods

A cross-sectional study of 3,035 general subjects with valid vibration-controlled transient elastography data was conducted based on data from the National Health and Nutrition Examination Survey (NHANES) 2017-2020. NAFLD, MAFLD, and MASLD were defined according to the corresponding consensus criteria.

Results

Using controlled attenuation parameter (CAP) ≥274 dB/m and liver stiffness measurements (LSM) ≥9.7 kPa as the cutoff values for the presence of hepatic steatosis and advanced liver fibrosis (ALF), the prevalence of NAFLD, MAFLD, and MASLD were 38.01% (95% CI 35.78-40.29%), 41.09% (39.09-43.12%), and 37.9% (35.70-40.14%), respectively, and the corresponding prevalence of ALF was 10.21% (7.09-14.48%), 10.13% (7.06-14.35%), and 10.24% (7.11-14.53%), respectively. The kappa values for the three definitions were above 0.9. The prevalence and severity of the three definitions remained similar when the sensitivity analyses were performed using different CAP thresholds. The prevalence of NAFLD, MAFLD, MASLD, and ALF increased as the number of cardiometabolic risk factors (CMRF) increased.

Conclusions

Our findings highlight the consistency among the three definitions, especially between NAFLD and MASLD, so that the new consensus will not disturb the original NAFLD-related findings. Additionally, more attention should be paid to patients with a high number of CMRFs.

Association between life's essential 8 and metabolic dysfunction-associated steatotic liver disease among US adults

BACKGROUND

Metabolic dysfunction-associated steatotic liver disease(MASLD) is the most common cause of chronic liver disease. Clinical evidences have demonstrated the link between MASLD and the increased risk of cardiovascular disease (CVD) development. We aimed to investigate the relationship between Life's Essential 8 (LE8), an enhanced approach to assessing cardiovascular health(CVH), and MASLD.

METHODS

Data were extracted from the National Health and Nutrition Examination Survey (NHANES) in 2017-2020 cycles. MASLD was assessed by the latest diagnostic criteria. LE8 scores (range 0-100) were obtained from measurements based on American Heart Association definitions, divided into health factor and health behavior scores. Multivariable logistic and restricted cubic spline models were used to assess the associations.

RESULTS

5646 participants were included based on the inclusion and exclusion criteria, 2616 (46.33%) participants were diagnosed with MASLD. After adjusting for confounding variables, higher LE8 scores were associated with a lower risk of MASLD (OR = 0.19, 95%CI 0.17-0.21; P < 0.001), similar associations were also observed between health behavior and health factor scores with MASLD. Subgroup analyses illustrated that the negative association between LE8 score and MASLD was stronger among younger, non - Hispanic White, and never married participants.

CONCLUSIONS

In this nationally representative sample of U.S. adults, LE8 scores, health behavior scores, and health factor scores were negatively associated with the prevalence of MASLD in non-linear fashions. Subjects maintaining ideal health factors and health behaviors are less likely to develop MASLD. Public health policies are needed to advocate healthy behaviors and factors.

Head-to-head comparison of three different US-based quantitative parameters for hepatic steatosis assessment: a prospective study

PURPOSE

To evaluate the diagnostic performance of attenuation coefficient (AC), hepato-renal index (HRI) and controlled attenuation parameter (CAP) in quantitative assessment of hepatic steatosis by employing histopathology as reference standard.

METHODS

Participants with suspected metabolic-associated fatty liver disease (MAFLD) who underwent US-based parameter examinations and liver biopsy were prospectively recruited. The distributions of US parameters across different grades of steatosis were calculated, and diagnostic performance was determined based on the areas under the receiver operating characteristic curve (AUC).

RESULTS

A total of 73 participants were included, with hepatic steatosis grades S0, S1, S2, and S3 distributed as follows: 13, 20, 27, and 13 respectively. The correlation coefficients for CAP, AC, and HRI ranged from 0.67 to 0.74. AC and HRI showed a strong correlation with steatosis grade. The AUC for CAP and AC in diagnosing steatosis ≥ S1 were significantly higher at 0.99 and 0.98 compared to HRI's value. For diagnosing steatosis ≥ S2, the AUC of CAP (AUC: 0.85) was lower than that of AC (AUC: 0.94), and HRI (AUC: 0.94). Similarly for diagnosing steatosis S3, the AUC of CAP (AUC: 0.68) was lower than that of AC (AUC: 0.88), and HRI (AUC: 0.88).

CONCLUSION

The AC and HRI values increased with the progression of hepatic steatosis grade, while CAP increased from S0 to S2 but not from S2 to S3. For mild steatosis diagnosis, CAP and AC showed superior diagnostic performance compared to HRI, while AC and HRI were more advantageous in differentiating moderate and severe steatosis.

Inflammatory markers as diagnostic and precision nutrition tools for metabolic dysfunction-associated steatotic liver disease: Results from the Fatty Liver in Obesity trial

BACKGROUND & AIMS

Metabolic dysfunction-associated steatotic liver disease (MASLD) is a growing public health concern. The disease is silent, and its diagnosis is often delayed. Inflammatory markers constitute an interesting tool to act as subrogate, non-invasive markers. This study aimed to evaluate the changes of inflammatory markers throughout a two-year dietary intervention in subjects presenting MASLD, to determine which of the markers are suitable to predict the disease, and act as a customizing tool for MASLD's dietary treatment.

METHODS

Ninety-eight subjects with MASLD and forty-five controls from the Fatty Liver in Obesity (FLiO) Study were analyzed. MASLD was diagnosed and graded by ultrasound. The MASLD subjects were randomly assigned to two different dietary strategies, the American Heart Association (AHA diet) or a dietary strategy based on the Mediterranean pattern, which was specially designed for the study (FLiO diet), and then followed for two years. Hepatic status was additionally assessed through Magnetic Resonance Imaging (MRI), elastography, and determination of transaminases.

RESULTS & DISCUSSION

Inflammatory markers improved throughout the intervention in the MASLD subjects and managed to reach similar levels to controls, especially at 6 and 12 months. Additionally, leptin, adiponectin, M30, and LECT2 managed to significantly diagnose the disease at all time marks of the intervention, making them candidates for subrogate non-invasive markers of the disease. Moreover, baseline chemerin, leptin, LECT2, and M65 were used to build a predictive score to achieve greater weight loss, and therefore, which strategy could be more useful for MASLD 's treatment. The predictive score was significantly able assign a specific diet to 55% of the study participants, meaning that the remaining 45% could achieve the same amount of weight loss following either diet equally.

CONCLUSION

Inflammatory markers constitute a potential non-invasive tool to be used in MASLD screening and could also constitute an interesting tool for MASLD's treatment customization, being able to predict the effectiveness of a dietary strategy based on the initial inflammatory state of each subject.

TRIAL REGISTRATION

www.

CLINICALTRIALS

gov (NCT03183193).

Prevalence, characteristics, and risk factors of non-alcoholic fatty liver disease in North East of Iran: a population-based study

BACKGROUND

Nonalcoholic fatty liver disease (NAFLD) is a common dietary disorder caused by fatty changes in the liver parenchyma and hepatocytes without alcohol consumption. The present study aimed to investigate the prevalence, characteristics, and risk factors of NAFLD in the Mashhad Persian Cohort Study population.

METHOD

The present population-based cross-sectional study included all PERSIAN Organizational Cohort study in Mashhad University of Medical Sciences (POCM), Mashhad, Iran by census sampling method. Eligible participants were divided into two groups due to their NAFLD condition (NAFLD positive or NAFLD negative). All enrolled participants were evaluated based on their clinical aspects, anthropometric measures, laboratory tests, and ultrasound features. Statistical analysis was conducted using SPSS software version 16 (SPSS Inc., Chicago, USA -version 16). A P-value less than 0.05 was considered as the significance level.

RESULTS

A total of 1198 individuals were included in the study, of which 638 (53.3%) were male and the rest were female. The mean age of the participants was 46.89 ± 8.98 years. A total of 246 patients (20.53%) were NAFLD positive, of which 122 (49.59%) were in grade 1, 112 (45.52%) were in grade 2, and 12 (4.87%) were in grade 3. The prevalence of fatty liver was significantly higher in males than in females (p < 0.001). There were significant differences between NAFLD positive and NAFLD negative participants in terms of having a history of hypertension (P = 0.044), body mass index (P < 0.001), body fat percentage (P = 0.001), waist circumference (P < 0.001), liver craniocaudal length (P = 0.012), fasting blood sugar (FBS) (P = 0.047), aspartate aminotransferase (AST) (P = 0.007), and alanine aminotransferase (ALT) (P = 0.001). Further analysis revealed a strong significant association between BMI, previous history of hypertension, higher levels of serum ALT, and NAFLD (P < 0.05).

CONCLUSION

It can be concluded that ultrasound findings accompanied by laboratory AST and ALT level enzymes could be a cost-benefit approach for NAFLD early diagnosis. The craniocaudal size of the liver could be a beneficent marker for estimating the severity of the disease; however, more studies are recommended to evaluate this variable for future practice against the issue.

DIAGNOSTIC ACCURACY OF THE NON-INVASIVE MARKERS NFLS, NI-NASH-DS, AND FIB-4 FOR ASSESSMENT OF DIFFERENT ASPECTS OF NON-ALCOHOLIC FATTY LIVER DISEASE IN INDIVIDUALS WITH OBESITY: CROSS-SECTIONAL STUDY

BACKGROUND

Non-invasive markers have been developed to assess the presence and severity of liver abnormalities related to non-alcoholic fatty liver disease (NAFLD).

OBJECTIVE

To analyze the diagnostic accuracy of non-invasive NAFLD markers (NAFLD liver fat score [NLFS], non-invasive non-alcoholic steatohepatitis detection score [NI-NASH-DS] and fibrosis score based on four variables [FIB-4]) in individuals with obesity undergoing bariatric surgery.

METHODS

A descriptive retrospective cross-sectional study was carried out enrolling 91 individuals who underwent bariatric surgery at a tertiary-level public university hospital. Non-invasive NAFLD markers were calculated using laboratory tests, clinical and anthropometric variables and diagnostic accuracy tests were calculated comparing them in relation to the gold-standard test for this analysis (histopathological evaluation).

RESULTS

A total of 85.7% of the participants were female and mean age was 39.1±9.8 years. The average body mass index was 38.4±3.6 kg/m2. At histopathological examination, 84 (92.3%) patients presented with steatosis, 82 (90.1%) with some type of fibrosis; 21 (23.1%) patients were diagnosed with NASH according to the NAFLD activity score criteria. The overall accuracy of NLFS score was 58.2% for general hepatic steatosis and 61.5% for moderate to severe steatosis. The overall accuracy of FIB-4 was 95.4% for advanced fibrosis. NI-NASH-DS had a 74.7% overall accuracy for NASH.

CONCLUSION

In a population of individuals with obesity, the FIB-4 score had high overall accuracy in assessing the presence of advanced liver fibrosis, whereas the NFLS and NI-NASH-DS had moderate accuracies for the assessment of steatosis and NASH, respectively.

Grape seed extract supplementation in non-alcoholic fatty liver disease

Background: Despite rising non-alcoholic fatty liver disease (NAFLD) prevalence and its impact on liver health, there's a lack of studies on grape seed extract's (GSE) effect on oxidative stress and quality of life (QoL) in NAFLD patients. This study aims to fill this gap by the potential benefits of GSE in reducing oxidative stress and improving QoL. Methods: In this randomized clinical trial study, fifty patients with NAFLD were randomly assigned to receive either 2 tablets of GSE containing 250 mg of proanthocyanidins or placebo (25 participants in each group) for two months. QoL was evaluated using the SF-36 questionnaire, and oxidative stress variables (TAC, MDA, SOD, GPx, CAT, and IL-6) were measured at the beginning and end of the study. Results: Compared with the control group, the group supplemented with GSE experienced greater reductions in IL-6 and MDA (3.14±1.43 pg/ml vs. 2.80±0.31 pg/ml; 4.16±2.09 μM vs. 4.59±1.19 μM, p for all <0.05), as well as greater increases in TAC, SOD, and GPx levels (0.18±0.08 mM vs. -0.03±0.09 mM; 10.5±6.69 U/ml vs. 8.93±1.63 U/ml; 14.7±13.4 U/ml vs. 8.24±3.03 U/ml, p for all <0.05). Furthermore, the QoL questionnaire showed that physical limitations, general health, and total physical health were significantly improved in the GSE group compared with the placebo (17.0±42.0 vs. -12.0±37.5; 3.80±14.8 vs. -3.92±9.55; 5.08 5.26 vs. -7.01±13.7, p for all <0.05). Conclusions: GSE can be effective in improving oxidative stress and QoL in patients with NAFLD. More studies are needed to confirm the results of this study.

Ultrasound-Derived Fat Fraction for Hepatic Steatosis Assessment: Prospective Study of Agreement With MRI PDFF and Sources of Variability in a Heterogeneous Population

BACKGROUND. Metabolic dysfunction-associated steatotic liver disease is a growing global public health concern. Quantitative ultrasound measurements, such as ultrasound-derived fat fraction (UDFF), could provide noninvasive, cost-effective, and portable steatosis evaluation. OBJECTIVE. The purpose of this article was to evaluate utility of UDFF for steatosis assessment using proton density fat fraction (PDFF) as reference in patients undergoing liver MRI for heterogeneous indications and to assess UDFF variability. METHODS. This prospective study included a primary analysis of 187 patients (mean age, 53.8 years; 112 men, 75 women) who underwent 3-T liver MRI for any clinical indication from December 2020 to July 2021. Patients underwent investigational PDFF measurement, including determination of PDFFwhole-liver (mean PDFF of entire liver), and PDFFvoxel (PDFF in single voxel within right lobe, measured by MR spectroscopy), as well as investigational ultrasound with UDFF calculation (mean of five inter-costal measurements) within 1 hour after MRI. In a subanalysis, 21 of these patients underwent additional UDFF measurements 1, 3, and 5 hours after meal consumption. The study also included repeatability and reproducibility analysis of 30 patients (mean age, 26.3 years; 10 men, 20 women) who underwent clinical abdominal ultrasound between November 2022 and January 2023; in these patients, three operators sequentially performed UDFF measurements. RESULTS. In primary analysis, UDFF and PDFFwhole-liver measurements showed intra-class correlation coefficient (ICC) of 0.79. In Bland-Altman analysis, UDFF and PDFFvoxel measurements showed mean difference of 1.5% (95% CI, 0.6-2.4%), with 95% limits of agreement from -11.0% to 14.0%. UDFF measurements exhibited AUC for detecting PDFFvoxel at historic thresholds of 6.5% and greater, 17.4% and greater, and 22.1% and greater of 0.90, 0.95, and 0.95, respectively. In subanalysis, mean UDFF was not significantly different across time points with respect to meal consumption (p = .21). In repeatability and reproducibility analysis, ICC for intraoperator repeatability ranged from 0.98 to 0.99 and for interoperator reproducibility from 0.90 to 0.96. Visual assessment of patient-level data plots indicated increasing variability of mean UDFF measurements across operators and of intercostal measurements within individual patients with increasing steatosis. CONCLUSION. UDFF showed robust agreement with PDFF, diagnostic performance for steatosis grades, and intraoperator repeatability and interoperator reproducibility. Nonetheless, UDFF exhibited bias toward slightly larger values versus PDFF; intraoperator and interoperator variation increased with increasing steatosis. CLINICAL IMPACT. UDFF shows promise for steatosis assessment across diverse populations, although continued optimization remains warranted.

Association between the arm circumference and non-alcoholic fatty liver disease in American children and adolescence: a population-based analysis

Background

The arm circumference (AC) has been used as an important tool to access the risk of non-alcoholic fatty liver disease (NAFLD) in adults. However, the association between AC and NAFLD in children and adolescence remains unclear. This study aims to explore the relationship between AC and NAFLD in American children and adolescence.

Methods

2017-2020 National Health and Nutrition Examination Survey (NHANES) was used to carry out the cross-sectional study. The association between AC and the risk of NAFLD, and liver steatosis was analyzed using weighted multivariable logistic regression and multivariate linear regression. Additionally, a two-part linear regression model was used to identify threshold effects in this study. Subgroup analysis, interaction tests and receiver operating characteristic (ROC) curve analysis were also carried out.

Results

A total of 1,559 children and adolescence aged 12-18 years old were included, and the prevalence of NAFLD was 27.3%. AC was positively correlated with the risk of NAFLD (OR = 1.25, 95% CI: 1.19, 1.32) and liver steatosis (β = 4.41, 95% CI: 3.72, 5.09). Subgroup analysis stratified by age and race showed a consistent positive correlation. A non-linear relationship and saturation effect between AC and NAFLD risk were identified, with an S shaped curve and an inflection point at 34.5 cm. Area under the ROC of AC to NAFLD was 0.812, with the sensitivity of 67.6%, the specificity of 83.8% and the cutoff value of 31.7 cm.

Conclusion

Our study shows that AC is independently correlated with an increased risk of NAFLD and the severity of liver steatosis in American children and adolescence.

The effects of grape seed extract supplementation on cardiovascular risk factors, liver enzymes and hepatic steatosis in patients with non-alcoholic fatty liver disease: a randomised, double-blind, placebo-controlled study

BACKGROUND

Despite the high antioxidant potential of grape seed extract (GSE), very limited studies have investigated its effect on non-alcoholic fatty liver disease (NAFLD). Therefore, this study was conducted with the aim of investigating the effect of GSE on metabolic factors, blood pressure and steatosis severity in patients with NAFLD.

METHODS

In this double-blind randomized clinical trial study, 50 NAFLD patients were divided into two groups of 25 participants who were treated with 520 mg/day of GSE or the placebo group for 2 months. The parameters of glycemic, lipid profile, blood pressure and steatohepatitis were measured before and after the intervention.

RESULTS

The GSE group had an average age of 43.52 ± 8.12 years with 15 women and 10 men, while the placebo group had an average age of 44.88 ± 10.14 years with 11 women and 14 men. After 2 months of intervention with GSE, it was observed that insulin, HOMA-IR, TC, TG, LDL-c, ALT, AST, AST/ALT, SBP, DBP and MAP decreased and QUICKi and HDL-c increased significantly (p-value for all < 0.05). Also, before and after adjustment based on baseline, the average changes indicated that the levels of insulin, HOMA-IR, TC, TG, LDL-c, SBP, DBP, MAP in the GSE group decreased more than in the control group (p for all < 0.05). Furthermore, the changes in HDL-c were significantly higher in the GSE group (p < 0.05). The between-groups analysis showed a significant decrease in the HOMA-β and AST before and after adjustment based on baseline levels (p < 0.05). Moreover, the changes in QUICKi after adjustment based on baseline levels were higher in the GSE group than in the control group. Also, between-groups analysis showed that the severity of hepatic steatosis was reduced in the intervention group compared to the placebo group (P = 0.002).

CONCLUSIONS

It seems that GSE can be considered one of the appropriate strategies for controlling insulin resistance, hyperlipidemia, hypertension and hepatic steatosis in NAFLD patients.

TRIAL REGISTRATION

The clinical trial was registered in the Iranian Clinical Trial Registration Center (IRCT20190731044392N1). https://irct.behdasht.gov.ir/trial/61413 . (The registration date: 30/03/2022).

Prospective Comparison of Attenuation Imaging and Controlled Attenuation Parameter for Liver Steatosis Diagnosis in Patients With Nonalcoholic Fatty Liver Disease and Type 2 Diabetes

BACKGROUND & AIMS

Similarly to the controlled attenuation parameter (CAP), the ultrasound-based attenuation imaging (ATI) can quantify hepatic steatosis. We prospectively compared the performance of ATI and CAP for the diagnosis of hepatic steatosis in patients with type 2 diabetes and nonalcoholic fatty liver disease using histology and magnetic resonance imaging-proton density fat fraction (MRI-PDFF) as references.

METHODS

Patients underwent ATI and CAP measurement, MRI, and biopsy on the same day. Steatosis was classified as S0, S1, S2, and S3 on histology (<5%, 5%-33%, 33%-66%, and >66%, respectively) while the thresholds of 6.4%, 17.4%, and 22.1%, respectively, were used for MRI-PDFF. The area under the curve (AUC) of ATI and CAP was compared using a DeLong test.

RESULTS

Steatosis could be evaluated in 191 and 187 patients with MRI-PDFF and liver biopsy, respectively. For MRI-PDFF steatosis, the AUC of ATI and CAP were 0.86 (95% confidence interval [CI], 0.81-0.91) vs 0.69 (95% CI, 0.62-0.75) for S0 vs S1-S3 (P = .02) and 0.71 (95% CI, 0.64-0.77) vs 0.69 (95% CI, 0.61-0.75) for S0-S1 vs S2-S3 (P = .60), respectively. For histological steatosis, the AUC of ATI and CAP were 0.92 (95% CI, 0.87-0.95) vs 0.95 (95% CI, 0.91-0.98) for S0 vs S1-S3 (P = .64) and 0.79 (95% CI, 0.72-0.84) vs 0.76 (95% CI, 0.69-0.82) for S0-S1 vs S2-S3 (P = .61), respectively.

CONCLUSION

ATI may be used as an alternative to CAP for the diagnosis and quantification of steatosis, in patients with type 2 diabetes and nonalcoholic fatty liver disease.

Berberine Effects in Pre-Fibrotic Stages of Non-Alcoholic Fatty Liver Disease-Clinical and Pre-Clinical Overview and Systematic Review of the Literature

Non-alcoholic fatty liver disease (NAFLD) is the predominant cause of chronic liver conditions, and its progression is marked by evolution to non-alcoholic steatosis, steatohepatitis, cirrhosis related to non-alcoholic steatohepatitis, and the potential occurrence of hepatocellular carcinoma. In our systematic review, we searched two databases, Medline (via Pubmed Central) and Scopus, from inception to 5 February 2024, and included 73 types of research (nine clinical studies and 64 pre-clinical studies) from 2854 published papers. Our extensive research highlights the impact of Berberine on NAFLD pathophysiology mechanisms, such as Adenosine Monophosphate-Activated Protein Kinase (AMPK), gut dysbiosis, peroxisome proliferator-activated receptor (PPAR), Sirtuins, and inflammasome. Studies involving human subjects showed a measurable reduction of liver fat in addition to improved profiles of serum lipids and hepatic enzymes. While current drugs for NAFLD treatment are either scarce or still in development or launch phases, Berberine presents a promising profile. However, improvements in its formulation are necessary to enhance the bioavailability of this natural substance.

Accuracy of a sequential algorithm based on FIB-4 and ELF to identify high-risk advanced liver fibrosis at the primary care level

Non-alcoholic fatty liver disease (NAFLD) is the leading cause of chronic liver disease, and liver fibrosis is the strongest predictor of morbimortality. We aimed to assess the performance of a sequential algorithm encompassing the Fibrosis 4 (FIB-4) and Enhanced Liver Fibrosis (ELF) scores for identifying patients at risk of advanced fibrosis. This cross-sectional study included one hospital-based cohort with biopsy-proven NAFLD (n = 140) and two primary care cohorts from different clinical settings: Type 2 Diabetes (T2D) follow-up (n = 141) and chronic liver disease (CLD) initial study (n = 138). Logistic regression analysis was performed to assess liver fibrosis diagnosis models based on FIB-4 and ELF biomarkers. The sequential algorithm retrieved the following accuracy parameters in predicting stages F3-4 in the biopsy-confirmed cohort: sensitivity (85%), specificity (73%), negative predictive value (79%) and positive predictive value (81%). In both T2D and CLD cohorts, a total of 28% of patients were classified as stages F3-4. Furthermore, of all F3-4 classified patients in the T2D cohort, 80% had a diagnosis of liver disease and 44% were referred to secondary care. Likewise, of all F3-4 classified patients in the CLD cohort, 71% had a diagnosis of liver disease and 44% were referred to secondary care. These results suggest the potential utility of this algorithm as a liver fibrosis stratifying tool in primary care, where updating referral protocols to detect high-risk F3-4 is needed. FIB-4 and ELF sequential measurement is an efficient strategy to prioritize patients with high risk of F3-4 in populations with metabolic risk factors.

The "Domino effect" in MASLD: The inflammatory cascade of steatohepatitis

Metabolic dysfunction-associated steatotic liver disease (MASLD) is an increasingly common complication of obesity, affecting over a quarter of the global adult population. A key event in the pathophysiology of MASLD is the development of metabolic-associated steatohepatitis (MASH), which greatly increases the chances of developing cirrhosis and hepatocellular carcinoma. The underlying cause of MASH is multifactorial, but accumulating evidence indicates that the inflammatory process in the hepatic microenvironment typically follows a pattern that can be roughly divided into three stages: (1) Detection of hepatocyte stress by tissue-resident immune cells including γδ T cells and CD4-CD8- double-negative T cells, followed by their secretion of pro-inflammatory mediators, most notably IL-17A. (2) Recruitment of pro-inflammatory cells, mostly of the myeloid lineage, and initiation of inflammation through secretion of effector-type cytokines such as TNF, TGF-β, and IL-1β. (3) Escalation of the inflammatory response by recruitment of lymphocytes including Th17, CD8 T, and B cells leading to chronic inflammation, hepatic stellate cell activation, and fibrosis. Here we will discuss these three stages and how they are consecutively linked like falling domino tiles to the pathophysiology of MASH. Moreover, we will highlight the clinical potential of inflammation as a biomarker and therapeutic target for the treatment of MASLD.

Non-alcoholic fatty liver disease in Tanzania: prevalence, determinants, and diagnostic performance of triglycerides-glucose index and triglycerides-glucose index -body mass index compared to the hepatic ultrasound in overweight and obese individuals

BACKGROUND

Non-alcoholic fatty liver disease (NAFLD), which is closely associated with metabolic syndrome (MetS), is rarely reported in Tanzania, where MetS is prevalent. The purpose of this study was to determine the prevalence and associated factors of this condition in overweight and obese individuals and to correlate standard ultrasound diagnosis with triglyceride-glucose index (TyG) and TyG-body mass index (TyG-BMI).

METHODS

A cross-sectional analysis was performed in 181 adult outpatients attending a general medical clinic. The presence of fatty liver was detected by ultrasound. Demographic, clinical, and laboratory data were collected and analyzed using STATA 15. To compare categorical variables, a chi-square test was employed, while a Student's t-test was used to compare continuous variables. Additionally, a multivariate regression analysis was conducted to identify the determinants of NAFLD. A significance level was set at p < 0.05. The discriminatory power of TyG and TyG-BMI for diagnosing NAFLD was evaluated using Receiver Operating Characteristic (ROC) Curve analysis and the Area Under the ROC Curve (AUC) was reported.

RESULTS

The overall prevalence of NAFLD was 30.4% (55/181). The prevalence's of NAFLD in patients with class III obesity, class II obesity, class I obesity and overweight were 50.0% (12/24),, 38% (19/50), 23.7% (18/76), and 19.5% (6/31),respectively. NAFLD was strongly predicted by hyperuricemia (≥ 360 μmol/L) (p = 0.04) and TyG ≥ 8.99 (p = 0.003). The best cut-off values of TyG and TyG-BMI to predict NAFLD were 8.99 [AUC 0.735; sensitivity 70.9%, specificity 79.3%] and 312 [AUC 0.711; sensitivity 60% and specificity 75.4%] respectively.

CONCLUSIONS

The prevalence of NAFLD is high among people with overweight and obesity in Tanzania. We did not find sufficient evidence to recommend the use of TyG and TyG-BMI as surrogates for hepatic ultrasound in detecting NAFLD, and further evaluation is recommended.

Plasma SHBG Levels as an Early Predictor of Response to Bariatric Surgery

BACKGROUND

Obesity is a growing global health problem, and currently, bariatric surgery (BS) is the best solution in terms of sustained total weight loss (TWL). However, a significant number of patients present weight regain (WR) in time. There is a lack of biomarkers predicting the response to BS and WR during the follow-up. Plasma SHBG levels, which are low in obesity, increase 1 month after BS but there is no data of plasma SHBG levels at long term. We performed the present study aimed at exploring the SHBG role in predicting TWL and WR after BS.

METHODS

Prospective study including 62 patients with obesity undergoing BS. Anthropometric and biochemical variables, including SHBG were analyzed at baseline, 1, 6, 12, and 24 months; TWL ≥ 25% was considered as good BS response.

RESULTS

Weight loss nadir was achieved at 12 months post-BS where maximum SHBG increase was reached. Greater than or equal to 25% TWL patients presented significantly higher SHBG increases at the first and sixth months of follow-up with respect to baseline (100% and 150% respectively, p = 0.025), than < 25% TWL patients (40% and 50% respectively, p = 0.03). Also, these presented 6.6% WR after 24 months. The first month SHBG increase predicted BS response at 24 months (OR = 2.71; 95%CI = [1.11-6.60]; p = 0.028) and TWL in the 12th month (r = 0.330, p = 0.012) and the WR in the 24th (r =  - 0.301, p = 0.028).

CONCLUSIONS

Our results showed for the first time that increase in plasma SHBG levels within the first month after BS is a good predictor of TWL and WR response after 2 years.

Approach to Abnormal Liver Biochemistries in the Primary Care Setting

Liver biochemistries are commonly ordered in the primary care setting, and they may return abnormal even in an asymptomatic patient. Primary care physicians need to have a systematic way of interpreting any derangement in these tests so that further investigations, referrals, and management can be arranged appropriately. This review dwells into patterns of liver biochemistry derangement, common aetiologies to consider, history and examinations that are required, initial investigations to order, and when to refer urgently to the emergency department.

Multimodality Imaging in Metabolic Syndrome: State-of-the-Art Review

Metabolic syndrome comprises a set of risk factors that include abdominal obesity, impaired glucose tolerance, hypertriglyceridemia, low high-density lipoprotein levels, and high blood pressure, at least three of which must be fulfilled for diagnosis. Metabolic syndrome has been linked to an increased risk of cardiovascular disease and type 2 diabetes mellitus. Multimodality imaging plays an important role in metabolic syndrome, including diagnosis, risk stratification, and assessment of complications. CT and MRI are the primary tools for quantification of excess fat, including subcutaneous and visceral adipose tissue, as well as fat around organs, which are associated with increased cardiovascular risk. PET has been shown to detect signs of insulin resistance and may detect ectopic sites of brown fat. Cardiovascular disease is an important complication of metabolic syndrome, resulting in subclinical or symptomatic coronary artery disease, alterations in cardiac structure and function with potential progression to heart failure, and systemic vascular disease. CT angiography provides comprehensive evaluation of the coronary and systemic arteries, while cardiac MRI assesses cardiac structure, function, myocardial ischemia, and infarction. Liver damage results from a spectrum of nonalcoholic fatty liver disease ranging from steatosis to fibrosis and possible cirrhosis. US, CT, and MRI are useful in assessing steatosis and can be performed to detect and grade hepatic fibrosis, particularly using elastography techniques. Metabolic syndrome also has deleterious effects on the pancreas, kidney, gastrointestinal tract, and ovaries, including increased risk for several malignancies. Metabolic syndrome is associated with cerebral infarcts, best evaluated with MRI, and has been linked with cognitive decline. ©RSNA, 2024 Test Your Knowledge questions for this article are available in the supplemental material. See the invited commentary by Pickhardt in this issue.

A Novel Score Based on Controlled Attenuation Parameter Accurately Predicts Hepatic Steatosis in Individuals With Metabolic Dysfunction Associated Steatotic Liver Disease: A Derivation and Independent Validation Study

INTRODUCTION

In metabolic dysfunction-associated steatotic liver disease, the diagnostic efficacy of controlled attenuation parameter (CAP) was not very accurate in evaluating liver fat content. The aim of this study was to develop a score, based on CAP and conventional clinical parameters, to improve the diagnostic performance of CAP regarding liver fat content.

METHODS

A total of 373 participants from 2 independent Chinese cohorts were included and divided into derivation (n = 191), internal validation (n = 75), and external validation (n = 107) cohorts. Based on the significant difference index between the 2 groups defined by the magnetic resonance imaging-proton density fat fraction (MRI-PDFF) in derivation cohort, the optimal model (CAP-BMI-AST score [CBST]) was screened by the number of parameters and the area under the receiver operating characteristic curve (AUROC). In the internal and external validation cohorts, the AUROC and corresponding 95% confidence intervals (CIs) were used to compare the diagnostic performance of CBST with that of CAP.

RESULTS

We constructed the CBST = -14.27962 + 0.05431 × CAP - 0.14266 × body mass index + 0.01715 × aspartate aminotransferase. When MRI-PDFF was ≥20%, ≥10%, and ≥5%, the AUROC for CBST was 0.77 (95% CI 0.70-0.83), 0.89 (95% CI 0.83-0.94), and 0.93 (95% CI 0.88-0.98), which was higher than that for CAP respectively. In the internal validation cohort, the AUROC for CBST was 0.80 (95% CI 0.70-0.90), 0.95 (95% CI 0.91-1.00), and 0.98 (95% CI 0.94-1.00). The optimal thresholds of CBST were -0.5345, -1.7404, and -1.9959 for detecting MRI-PDFF ≥20%, ≥10%, and ≥5%, respectively.

DISCUSSION

The CBST score can accurately evaluate liver steatosis and is superior to the CAP.

Evolving role of semaglutide in NAFLD: in combination, weekly and oral administration

Non alcoholic fatty disease (NAFLD) is the most common chronic liver disease that is managed in the liver departments. It seems that the prevalence of the disease is rising worldwide and as it has the same pathogenetic pathways with metabolic syndrome, treatments that target components of the metabolic syndrome seem promising for the therapy of NAFLD as well. In this review we discuss the evolving role of semaglutide, which is a glucagon-like peptide-1 receptor agonist (GLP-1 RA) that has been already approved for the treatment of type II diabetes mellitus (T2DM) and obesity.

Inter-platform reproducibility of ultrasound-based fat fraction for evaluating hepatic steatosis in nonalcoholic fatty liver disease

OBJECTIVES

To evaluate the inter-platform reproducibility of ultrasound-based fat fraction examination in nonalcoholic fatty liver disease (NAFLD).

METHODS

Patients suspected of having NAFLD were prospectively enrolled from January 2023. Ultrasound-based fat fraction examinations were performed using two different platforms (ultrasound-derived fat fraction [UDFF] and quantitative ultrasound-derived estimated fat fraction [USFF]) on the same day. The correlation between UDFF and USFF was assessed using Pearson correlation coefficient. Intraclass correlation coefficient (ICC), Bland-Altman analysis with 95% limits of agreement (LOAs), and the coefficient of variation (CV) were used to assess inter-platform reproducibility.

RESULTS

A total of 41 patients (21 men and 20 women; mean age, 53.9 ± 12.6 years) were analyzed. Moderate correlation was observed between UDFF and USFF (Pearson's r = 0.748; 95% confidence interval [CI]: 0.572-0.858). On Bland-Altman analysis, the mean difference between UDFF and USFF values was 1.3% with 95% LOAs ranging from -8.0 to 10.6%. The ICC between UDFF and USFF was 0.842 (95% CI: 0.703-0.916), with a CV of 29.9%.

CONCLUSION

Substantial inter-platform variability was observed among different ultrasound-based fat fraction examinations. Therefore, it is not appropriate to use ultrasound-based fat fraction values obtained from different vendors interchangeably.

CRITICAL RELEVANCE STATEMENT

Considering the substantial inter-platform variability in ultrasound-based fat fraction assessments, caution is imperative when interpreting and comparing fat fraction values obtained from different ultrasound platforms in clinical practice.

KEY POINTS

• Inter-platform reproducibility of ultrasound-based fat fraction examinations is important for its clinical application. • Significant variability across different ultrasound-based fat fraction examinations was observed. • Using ultrasound-based fat fraction values from different vendors interchangeably is not advisable.