From the liver to the heart: Cardiac dysfunction in obese children with non-alcoholic fatty liver disease

An international multidisciplinary consensus on pediatric metabolic dysfunction-associated fatty liver disease

BACKGROUND

Non-alcoholic fatty liver disease (NAFLD) is highly prevalent in children and adolescents, particularly those with obesity. NAFLD is considered a hepatic manifestation of the metabolic syndrome due to its close associations with abdominal obesity, insulin resistance, and atherogenic dyslipidemia. Experts have proposed an alternative terminology, metabolic dysfunction-associated fatty liver disease (MAFLD), to better reflect its pathophysiology. This study aimed to develop consensus statements and recommendations for pediatric MAFLD through collaboration among international experts.

METHODS

A group of 65 experts from 35 countries and six continents, including pediatricians, hepatologists, and endocrinologists, participated in a consensus development process. The process encompassed various aspects of pediatric MAFLD, including epidemiology, mechanisms, screening, and management.

FINDINGS

In round 1, we received 65 surveys from 35 countries and analyzed these results, which informed us that 73.3% of respondents agreed with 20 draft statements while 23.8% agreed somewhat. The mean percentage of agreement or somewhat agreement increased to 80.85% and 15.75%, respectively, in round 2. The final statements covered a wide range of topics related to epidemiology, pathophysiology, and strategies for screening and managing pediatric MAFLD.

CONCLUSIONS

The consensus statements and recommendations developed by an international expert panel serve to optimize clinical outcomes and improve the quality of life for children and adolescents with MAFLD. These findings emphasize the need for standardized approaches in diagnosing and treating pediatric MAFLD.

FUNDING

This work was funded by the National Natural Science Foundation of China (82070588, 82370577), the National Key R&D Program of China (2023YFA1800801), National High Level Hospital Clinical Research Funding (2022-PUMCH-C-014), the Wuxi Taihu Talent Plan (DJTD202106), and the Medical Key Discipline Program of Wuxi Health Commission (ZDXK2021007).

Relationship between adiponectin and blood pressure in obese Latino adolescent boys with a family history of type 2 diabetes

INTRODUCTION

Adipokines are associated with several pathological states including, metabolic syndrome, obesity, insulin resistance and type 2 diabetes. One of these adipokines, adiponectin is of particular interest as it has been shown to have numerous anti-inflammatory effects, However, the association between adiponectin and blood pressure remains inconclusive especially in the Latino adolescent with obesity.

PURPOSE

To investigate the relationship between plasma adiponectin and blood pressure in Latino adolescents' boys with obesity and a with a family history of Type 2 diabetes.

METHODS

Thirty two Latino adolescent males with obesity aged 14-17 years with a family history of type 2 diabetes underwent a frequently sampled glucose tolerance test (FSIVGTT) to measure insulin sensitivity. Body composition was assessed using dual energy x-ray absorptiometry. Obesity was defined as having a BMI percentile ≥95. Blood pressure was assessed using the Dinamap automated blood pressure monitor, and the average of three readings was used in the analysis. Fasting plasma adiponectin was determined using radioimmunoassay.

RESULTS

There were moderate positive significant correlations for adiponectin and Systolic blood pressure(SBP) (rho = 0.436, p < 0.027) and Diastolic blood pressure(DBP) (rho = 0.41,p < 0.028). A multivariate liner regression showed that plasma adiponectin could significantly detect 19% of the variance in SBP (p = 0.017, and 33% for DBP (p = 0.017). In a simple linear regression adiponectin was not related to any of our variables (p < 0.05).

CONCLUSION

In conclusion, adiponectin was positively and significantly correlated to blood pressure in Latino adolescent with obesity. Future studies should investigate this relationship in a large sample of Latino adolescent youth.

Attendance-Based Adherence and Outcomes of Obesity Management Program in Arab Adolescents

Pediatric obesity has become a global pandemic in the last century, contributing to short and long-term medical conditions that heighten the risk of morbidity and mortality in children. The 12-month school-based obesity management educational program aims to assess the effect of adherence to the lifestyle educational program and target outcomes, obesity, and hypertension. A total of 363 (nonadherent, N = 179; adherent, N = 184) Saudi school adolescents aged 12-18 were recruited from 60 schools in Riyadh City, Saudi Arabia. Anthropometrics, lipid profile, and blood glucose were measured at baseline and post-intervention. The level of adherence was based on the number of attended educational sessions, and participants were grouped accordingly into two groups: adherent group (attended ≥ 3 sessions) and nonadherent group (attended 1-2 sessions) out of a total of five sessions. Results demonstrated that significantly more participants in the adherent group achieved the primary program goal of reducing obesity indices [body weight, body mass index (BMI), and BMI z-score] than the nonadherent group. Additionally, among adherent obese participants, BMI z-score significantly decreased after the 12-month intervention (post-intervention: 1.5 ± 0.7 vs. baseline: 1.7 ± 0.6, p < 0.05), while the trend in BMI z-score modestly increased in the nonadherent obese participants post-intervention (post-intervention: 1.8 ± 0.7 vs. baseline: 1.7 ± 0.6, p > 0.05). Moreover, there was a substantial reduction in hypertension prevalence only in the adherent group (p = 0.003) and among adherent obese participants in particular (p = 0.03). Furthermore, adherence to session attendance was higher in girls than boys, which led to better outcomes among girls than boys. For the secondary outcomes, lipid profile indices increased in both groups, while no changes were observed in the glycemic profile. In conclusion, greater adherence to educational sessions achieved modest but favorable weight changes and improved blood pressure among obese adolescents. Future intervention studies should take into consideration the need to improve attendance to enhance adherence to the program among adolescents at risk.

Hypertension and Histopathology Severity of Non-Alcoholic Fatty Liver Disease Among Adults with Obesity: A Cross-Sectional Study

Background

Cardiovascular diseases are responsible for the majority of deaths resulting from non-alcoholic fatty liver disease (NAFLD). NAFLD is associated with hypertension and this is a key predictor of severe liver outcomes and an indicator of nonspecific portal fibrosis.

Aim

To assess the association between hypertension and NAFLD severity.

Methods

We conducted a secondary analysis of data from Peruvian adults with obesity and NAFLD who attended a Peruvian bariatric center. The severity of NAFLD was assessed using the Fatty Liver Inhibition of Progression algorithm / Steatosis, Activity and Fibrosis score. Hypertension was determined by either being recorded in the medical records or if the patient had a systolic pressure ≥ 140 mmHg or diastolic pressure ≥ 90 mmHg. To evaluate the association of interest, we calculated crude and adjusted prevalence ratios (aPR) using Poisson generalized linear models with logarithmic link function and robust variances. For the multivariable models, we adjusted for age, sex, physical activity and smoking.

Results

Our study included 234 participants. The prevalence of hypertension was 19.2%, while the prevalence of severe NAFLD was 46.2%. After adjusting for confounders, the prevalence of hypertension was found to be significantly higher in the severe NAFLD group compared to the non-severe group (aPR = 1.33; 95% CI: 1.03-1.74). When stratified by the presence of metabolic syndrome (MetS), the association remained significant only in the group without MetS (aPR = 1.80; 95% CI: 1.05-3.11).

Conclusion

We found an association between hypertension and severe NAFLD in adults with obesity, particularly in those without MetS.

Cirrhotic Cardiomyopathy Following Bile Duct Ligation in Rats-A Matter of Time?

Cirrhotic patients often suffer from cirrhotic cardiomyopathy (CCM). Previous animal models of CCM were inconsistent concerning the time and mechanism of injury; thus, the temporal dynamics and cardiac vulnerability were studied in more detail. Rats underwent bile duct ligation (BDL) and a second surgery 28 days later. Cardiac function was assessed by conductance catheter and echocardiography. Histology, gene expression, and serum parameters were analyzed. A chronotropic incompetence (P_d31 < 0.001) and impaired contractility at rest and a reduced contractile reserve (P_d31 = 0.03, P_dob-d31 < 0.001) were seen 31 days after BDL with increased creatine (P_d35, P_d42, and P_d56 < 0.05) and transaminases (P_d31 < 0.001). A total of 56 days after BDL, myocardial fibrosis was seen (P_d56 < 0.001) accompanied by macrophage infiltration (CD68: P_group < 0.001) and systemic inflammation (TNFα: P_group < 0.001, white blood cell count: P_group < 0.001). Myocardial expression of peroxisome proliferator-activated receptor gamma coactivator 1-alpha (PGC1α) was increased after 31 (P_d31 < 0.001) and decreased after 42 (P_d42 < 0.001) and 56 days (P_d56 < 0.001). Caspase-3 expression was increased 31 and 56 days after BDL (P_d31 = 0.005; P_d56 = 0.005). Structural changes in the myocardium were seen after 8 weeks. After the second surgery (second hit), transient myocardial insufficiency with secondary organ dysfunction was seen, characterized by reduced contractility and contractile reserve.

Risk of Heart Failure in Patients With Nonalcoholic Fatty Liver Disease: JACC Review Topic of the Week

Heart failure (HF) and nonalcoholic fatty liver disease (NAFLD) are 2 conditions that have become important global public health problems. Emerging evidence supports a strong and independent association between NAFLD and the risk of new-onset HF, and there are multiple potential pathophysiological mechanisms by which NAFLD may increase risk of new-onset HF. The magnitude of this risk parallels the underlying severity of NAFLD, especially the level of liver fibrosis. Patients with NAFLD develop accelerated coronary atherosclerosis, myocardial alterations (mainly cardiac remodeling and hypertrophy), and certain arrhythmias (mainly atrial fibrillation), which may precede and promote the development of new-onset HF. This brief narrative review aims to provide an overview of the association between NAFLD and increased risk of new-onset HF, discuss the underlying mechanisms that link these 2 diseases, and summarize targeted pharmacological treatments for NAFLD that might also reduce the risk of HF.

Epicardial adipose tissue is a robust measure of increased risk of myocardial infarction - a meta-analysis on over 6600 patients and rationale for the EPIC-ACS study

BACKGROUND

Epicardial adipose tissue (EAT) surrounds the heart and the coronary vessels. EAT produces pro- and anti-inflammatory cytokines. Several studies have already documented the association of EAT and cardiovascular risk factors as well as coronary artery disease manifestations. Currently computed tomography (CT) is considered the gold standard for measurement of 3-dimensional volume of EAT. In addition, echocardiography might be an easy accessible alternative in particular in an emergency setting.

METHODS

We performed a metaanalysis of existing studies describing the differences of EAT in patients with and without myocardial infarction. We used established databases and were searching for "epicardial adipose tissue" or "pericardial adipose tissue" and "myocardial infarction", "coronary events", or "acute coronary syndrome". We included over 6600 patients from 7 studies. Random effect models were calculated and all analyses were performed by using the Review Manager 5.3.

RESULTS

Patients with myocardial infarction had 37% (confidence interval [0.21-0.54], P value <.001)] higher measures of EAT compared to patients without myocardial infarction. Comparing studies using echocardiography vs CT for assessment of EAT thickness, similar relative differences in EAT with wide overlap of confidence intervals were observed (for echocardiography: 0.4 [0.04-0.76], for CT: 0.36 [0.16-0.57], P value <.001 for both).

CONCLUSIONS

Patients with myocardial infarction have more EAT as compared to patients without myocardial infarction independently of the used imaging modality. Further prospective studies are needed to evaluate, how quantification of EAT in clinical routine can improve patients management.

Pathophysiological Molecular Mechanisms of Obesity: A Link between MAFLD and NASH with Cardiovascular Diseases

Obesity is now a worldwide epidemic ensuing an increase in comorbidities’ prevalence, such as insulin resistance, type 2 diabetes (T2D), metabolic dysfunction-associated fatty liver disease (MAFLD), nonalcoholic steatohepatitis (NASH), hypertension, cardiovascular disease (CVD), autoimmune diseases, and some cancers, CVD being one of the main causes of death in the world. Several studies provide evidence for an association between MAFLD and atherosclerosis and cardio-metabolic disorders, including CVDs such as coronary heart disease and stroke. Therefore, the combination of MAFLD/NASH is associated with vascular risk and CVD progression, but the underlying mechanisms linking MAFLD/NASH and CVD are still under investigation. Several underlying mechanisms may probably be involved, including hepatic/systemic insulin resistance, atherogenic dyslipidemia, hypertension, as well as pro-atherogenic, pro-coagulant, and pro-inflammatory mediators released from the steatotic/inflamed liver. MAFLD is strongly associated with insulin resistance, which is involved in its pathogenesis and progression to NASH. Insulin resistance is a major cardiovascular risk factor in subjects without diabetes. However, T2D has been considered the most common link between MAFLD/NASH and CVD. This review summarizes the evidence linking obesity with MAFLD, NASH, and CVD, considering the pathophysiological molecular mechanisms involved in these diseases. We also discuss the association of MAFLD and NASH with the development and progression of CVD, including structural and functional cardiac alterations, and pharmacological strategies to treat MAFLD/NASH and cardiovascular prevention.

Cardiovascular Risk Factors in Children with Obesity, Preventive Diagnostics and Possible Interventions

The increasing burden of obesity plays an essential role in increased cardiovascular morbidity and mortality. The effects of obesity on the cardiovascular system have also been demonstrated in childhood, where prevention is even more important. Obesity is associated with hormonal changes and vascular dysfunction, which eventually lead to hypertension, hyperinsulinemia, chronic kidney disease, dyslipidemia and cardiac dysfunction—all associated with increased cardiovascular risk, leading to potential cardiovascular events in early adulthood. Several preventive strategies are being implemented to reduce the cardiovascular burden in children. This paper presents a comprehensive review of obesity-associated cardiovascular morbidity with the preventive diagnostic workup at our hospital and possible interventions in children.

Multifactorial Basis and Therapeutic Strategies in Metabolism-Related Diseases

Throughout the 20th and 21st centuries, the incidence of non-communicable diseases (NCDs), also known as chronic diseases, has been increasing worldwide. Changes in dietary and physical activity patterns, along with genetic conditions, are the main factors that modulate the metabolism of individuals, leading to the development of NCDs. Obesity, diabetes, metabolic associated fatty liver disease (MAFLD), and cardiovascular diseases (CVDs) are classified in this group of chronic diseases. Therefore, understanding the underlying molecular mechanisms of these diseases leads us to develop more accurate and effective treatments to reduce or mitigate their prevalence in the population. Given the global relevance of NCDs and ongoing research progress, this article reviews the current understanding about NCDs and their related risk factors, with a focus on obesity, diabetes, MAFLD, and CVDs, summarizing the knowledge about their pathophysiology and highlighting the currently available and emerging therapeutic strategies, especially pharmacological interventions. All of these diseases play an important role in the contamination by the SARS-CoV-2 virus, as well as in the progression and severity of the symptoms of the coronavirus disease 2019 (COVID-19). Therefore, we briefly explore the relationship between NCDs and COVID-19.

Pediatric obesity-related non-alcoholic fatty liver disease: waist-to-height ratio best anthropometrical predictor

BACKGROUND

Non-alcoholic fatty liver disease (NAFLD) is the most common chronic liver disorder in pediatric obesity. Our study aims to identify a predictive anthropometrical measure for NAFLD in obese children.

METHODS

We retrospectively enrolled children and adolescents with obesity. Physical, biochemical, and ultrasound assessments were available. ROC curve tests were performed to identify the best predictor of NAFLD among waist-to-height ratio (WHR), BMI z-score, and triponderal mass index (TMI, an anthropometric index recently associated with increased adiposity in children). Subsequently, a cut-off value was identified.

RESULTS

In total, 1900 children and adolescents (1011 with NAFLD) were included. WHR (AUC 0.62, 95% CI 0.59-0.64) was the best predictor of NAFLD compared to BMI z-score (AUC 0.58, 95% CI 0.55-0.60) and TMI (AUC 0.58, 95% CI 0.55-0.61). WHR ≥ 0.53 in boys and 0.63 in girls displayed the best sensitivity and specificity for NAFLD presence. In addition, children with high WHR showed a significantly higher risk of NAFLD (boys: OR 2.43, 95% CI 1.61-3.68, p < 0.0001; girls: OR 1.92, 95% CI 1.58-2.34, p < 0.0001) and elevated ALT (OR 5.71, 95% CI 2.09-15.56, p = 0.0007; girls: OR 2.16, 95% CI 1.70-2.74, p < 0.0001) independent of covariates.

CONCLUSIONS

WHR might represent a good anthropometric tool to candidate children and adolescents to NAFLD screening. WHR cut-off differs according to sex, being lower in boys than girls.

IMPACT

Waist-to-height ratio is a better predictor of non-alcoholic fatty liver disease risk compared to other anthropometric measures in obese children and adolescents. The predictive cut-off of waist-to-height ratio differs between boys and girls, being lower in boys than girls. The use of waist-to-height ratio measurement and its cut-off in clinical practice might help clinician in identifying obese children and adolescents at risk of non-alcoholic fatty liver disease.

Nonalcoholic fatty liver disease, diastolic dysfunction, and impaired myocardial glucose uptake in patients with type 2 diabetes

AIMS

To investigate whether degree of nonalcoholic fatty liver disease (NAFLD) is associated with myocardial dysfunction related to impaired myocardial glucose uptake in patients with type 2 diabetes.

MATERIALS AND METHODS

In total, 131 patients with type 2 diabetes from a tertiary care hospital were included in this study. Myocardial glucose uptake was assessed using [¹⁸ F]-fluorodeoxyglucose-positron emission tomography. Hepatic steatosis and fibrosis were determined using transient liver elastography. Echocardiography was performed to evaluate cardiac structure and function.

RESULTS

Patients with NAFLD had cardiac diastolic dysfunction with higher left ventricular filling pressure (E/e' ratio) and left atrial (LA) volume index than patients without NAFLD (all P < 0.05). Hepatic steatosis correlated with E/e' ratio and LA volume index, and hepatic fibrosis also correlated with E/e' ratio (all P < 0.05). Even after adjusting for confounding factors, a higher degree of hepatic steatosis (r² = 0.409, P = 0.041) and a higher degree of fibrosis (r² = 0.423, P = 0.009) were independent contributing factors to a higher E/e' ratio. Decreased myocardial glucose uptake was associated with a higher degree of steatosis (P for trend = 0.084) and fibrosis (P for trend = 0.012). At the same time, decreased myocardial glucose uptake was an independent contributing factor for a higher E/e' ratio (r² = 0.409; P = 0.040).

CONCLUSIONS

Hepatic steatosis and fibrosis were significantly associated with diastolic heart dysfunction in patients with type 2 diabetes coupled with impaired myocardial glucose uptake.

Pediatric Non-Alcoholic Fatty Liver Disease: Nutritional Origins and Potential Molecular Mechanisms

Non-alcoholic fatty liver disease (NAFLD) is the number one chronic liver disease worldwide and is estimated to affect nearly 40% of obese youth and up to 10% of the general pediatric population without any obvious signs or symptoms. Although the early stages of NAFLD are reversible with diet and lifestyle modifications, detecting such stages is hindered by a lack of non-invasive methods of risk assessment and diagnosis. This absence of non-invasive means of diagnosis is directly related to the scarcity of long-term prospective studies of pediatric NAFLD in children and adolescents. In the majority of pediatric NAFLD cases, the mechanisms driving the origin and rapid progression of NAFLD remain unknown. The progression from NAFLD to non-alcoholic steatohepatitis (NASH) in youth is associated with unique histological features and possible immune processes and metabolic pathways that may reflect different mechanisms compared with adults. Recent data suggest that circulating microRNAs (miRNAs) are important new biomarkers underlying pathways of liver injury. Several factors may contribute to pediatric NAFLD development, including high-sugar diets, in utero exposures via epigenetic alterations, changes in the neonatal microbiome, and altered immune system development and mitochondrial function. This review focuses on the unique aspects of pediatric NAFLD and how nutritional exposures impact the immune system, mitochondria, and liver/gastrointestinal metabolic health. These factors highlight the need for answers to how NAFLD develops in children and for early stage-specific interventions.

Pediatric non-alcoholic fatty liver disease and kidney function: Effect of HSD17B13 variant

BACKGROUND

Growing evidence supports a genetic link between non-alcoholic fatty liver disease (NAFLD) and chronic kidney disease (CKD). Interesting data demonstrated that both the major NAFLD risk polymorphisms such as the I148M polymorphism in the patatin like phospholipase containing domain 3 (PNPLA3) and the E167K allele in the transmembrane 6 superfamily member 2 gene (TM6SF2) affect renal function. Recently the hydroxysteroid 17-beta dehydrogenase 13 (HSD17B13) gene has been recognized as a novel genetic variant involved in NAFLD pathophysiology. In particular, it has been showed the protective effect of the rs72613567:TA variant of this gene against liver damage both in adults and children.

AIM

To investigate the impact of the rs72613567:TA variant of the HSD17B13 gene on estimated glomerular filtration rate (eGFR) in obese children.

METHODS

We enrolled 684 obese children (mean age 10.56 ± 2.94 years; mean BMI-SDS 2.98 ± 0.78) consecutively attending our Obesity Clinic. All the patients underwent a careful clinical assessment and a comprehensive biochemical evaluation. To detect hepatic steatosis, a liver ultrasound was performed. NAFLD was defined by ultrasound detected liver steatosis and/or alanine aminotransferase (ALT) levels > 40 IU/L. The study population was divided on the basis of the NAFLD presence. Genotyping for the rs72613567:TA variant of the HSD17B13 gene in all the enrolled subjects was also made.

RESULTS

Patients carrying the HSD17B13 rare A allele showed higher eGFR levels compared with homozygous patients both among subjects with and without NAFLD. A general linear model confirmed a direct and significant association of eGFR values with HSD17B13 genotype independently of PNPLA3 and TM6SF2 polymorphisms both in patients with and without NAFLD. A comparison of regression line confirmed the influence of HSD17B13 genotype on the relationship between eGFR and age both among patients with and without NAFLD. Homozygous patients for HSD17B13 genotype with NAFLD showed a significantly higher decline of eGFR with the increase of the age compared with the patients with NAFLD carrying the HSD17B13 rare A allele (P value for intercepts = 0.005; P value for slopes = 0.94). The same effect was observed among patients without NAFLD (P value for intercepts = 0.0012; P value for slopes = 0.87).

CONCLUSION

Carriers of the HSD17B13 rare A allele showed higher eGFR levels than homozygous subjects both among subjects with and without NAFLD and independently of PNPLA3 I148M and TM6SF6 E167K polymorphisms.

Pediatric obesity: prevention is better than care

Pediatric obesity is one of the most relevant health issues of the last century. Obesity-related short and long-term consequences are responsible of a large amount of economic cost. In addition, the different therapeutic strategies, such as lifestyle correction, drug, and bariatric surgery have displayed low effectiveness. Considering this evidence, prevention appears to be more promising than treatment in contrasting obesity epidemic. In this review, we summarize obesity pathogenesis with the aim of highlight the main obesity risk factors that can be addressed as target of preventive interventions. Moreover, we report the evidence about effectiveness of different interventions targeting family, school, and community. A multiple-component intervention, addressing different targets and settings, might be desirable, however more studies are needed to confirm long-term efficacy and to direct policy interventions.

Fructose and Uric Acid: Major Mediators of Cardiovascular Disease Risk Starting at Pediatric Age

Recently, there has been a growing interest in epidemiological and clinical studies supporting a pathogenetic role of fructose in cardio-metabolic diseases, especially in children and adolescents. In the present review, we summarize experimental data on the potential biological mechanisms linking fructose and uric acid in the development of insulin resistance, metabolic syndrome, obesity, diabetes, hypertension, non-alcoholic fatty liver disease and chronic renal disease, thereby contributing to an increase in cardiovascular risk at pediatric age.

The rs72613567: TA Variant in the Hydroxysteroid 17-beta Dehydrogenase 13 Gene Reduces Liver Damage in Obese Children

We first investigated in obese children the protective role of the hydroxysteroid 17-beta dehydrogenase 13 (HSD17B13) rs72613567:TA variant in liver damage. Six hundred eighty-five obese children were genotyped for HSD17B13, patatin-like phospholipase domain containing 3 (PNPLA3), transmembrane 6 superfamily member 2 (TM6SF2), and membrane bound O-acyltransferase domain containing 7 (MBOAT7) polymorphisms and underwent anthropometrical, ultrasonographic, and biochemical evaluation. Indirect measurement of liver fibrosis (Pediatric NAFLD Fibrosis Index [PNFI]) was calculated. The population was clustered in 2 genetic risk groups based on the numbers of steatogenic alleles (low: carriers up to 3 risk alleles, high: 4-6 risk alleles). Carriers of the HSD17B13 rare A allele showed lower percentage of hepatic steatosis and both lower serum transaminase and PNFI levels than noncarriers, even after adjustments for confounders. These findings were also confirmed in both risk groups. We demonstrated the protective effect of the rs72613567:TA HSD17B13 variant in reducing liver damage in obese children regardless of genetic predisposition.

New Perspectives on Genetic Prediction for Pediatric Metabolic Associated Fatty Liver Disease

Non-alcoholic or recently re-defined metabolic associated fatty liver disease (MAFLD), a spectrum of progressive hepatic disease, has become a public health issue in obese children and adolescents. MAFLD is a complex metabolic disease strongly associated with obesity and insulin resistance. It is not known why not every obese subject will develop MAFLD. Different ethnic/racial groups display differences in MAFLD prevalence, indicating genetic factor plays a role. In the past two decades, sequence variations in genetic loci, including PNPLA3, TM6SF2, GCKR, MBOAT7, HSD17B13, etc. have been shown to confer susceptibility to MAFLD in children and adults. This review article provides an updated viewpoint of genetic predictors related to pediatric MAFLD. We discuss whether these susceptible genes can be clinically used for risk stratification and personalized care. Understanding human genetics and molecular mechanisms can give important information not only for prediction of risk but also on how to design drugs. In view of current epidemic of MAFLD worldwide, it is necessary to identify which children with MAFLD progress rapidly and need earlier intervention. In the future, a comprehensive analysis of individualized genetic and environmental factors may help assess the risk of children with MAFLD and personalize their treatment.

Cardiac abnormalities in patients with nonalcoholic fatty liver disease : Insights from auxiliary examinations

Nonalcoholic fatty liver disease (NAFLD) is one of the most common forms of chronic liver disease in developed countries and is associated with type 2 diabetes mellitus, obesity, hypertension, dyslipidemia, and metabolic syndrome. It is defined as steatosis in over 5% of hepatocytes. The disease spectrum of NAFLD ranges from simple fatty liver to nonalcoholic steatohepatitis, liver fibrosis, even hepatic cirrhosis. The disease affects various extra-hepatic systems such as the cardiovascular system and urinary system. Heart-related disease is identified as the leading cause of mortality in NAFLD patients rather than liver-related disease. In this review, we summarize the cardiac abnormalities (structural, functional, arrhythmic cardiac complications etc.) seen in NAFLD patients with the assistance of auxiliary examinations, such as electrocardiography, echocardiography, computed tomography, magnetic resonance imaging etc. In addition, the epidemiology of NAFLD and how NAFLD affects the myocardium are also discussed.

High Burden of Subclinical Cardiovascular Target Organ Damage After Pediatric Liver Transplantation

Cardiovascular (CV) events account for 8%-13% of deaths after liver transplantation (LT) in adulthood. Although CV risk factors (RFs) are present, little is known about the prevalence of subclinical CV target organ damage (TOD) in children after LT. The aim of this prospective observational study was to assess the prevalence of subclinical CV TOD in children after LT and to identify RFs contributing to CV damage as potential targets for clinical intervention. In this study, 104 children after LT (54% female, 46% male; aged 11.5 ± 3.8 years) underwent cross-sectional assessment of subclinical TOD by carotid-femoral pulse wave velocity (PWV), carotid intima-media thickness (IMT), and left ventricular mass index (LVMI). Results were correlated with the presence of CV RFs (obesity, hypertension, dyslipidemia, renal impairment, anemia, and microinflammation). Of the patients, 22% were exposed to 2 CV RFs, and 36% displayed 3 or more CV RFs. Pathological results for PWV, IMT, and LVMI were found in 21.9%, 57.0%, and 11.1% of patients, respectively. In the multivariate analysis, diastolic blood pressure (P = 0.01) and estimated glomerular filtration rate (eGFR; P = 0.03) were independently associated with PWV, eGFR (P = 0.005), and age at LT (P = 0.048) with IMT and body mass index with LVMI (P = 0.004). In conclusion, patients after pediatric LT carry a substantial burden of subclinical CV TOD. Identification of modifiable CV RFs opens opportunities for targeted intervention in order to reduce CV morbidity and mortality in the future.

An update on cirrhotic cardiomyopathy

Cirrhosis with portal hypertension and related complications are associated with a high mortality. Excess of circulating vasodilators and cardiodepressive substances lead to a hyperdynamic circulation with changed myocardial structure and function. The entity cirrhotic cardiomyopathy seems to be involved in different aspects of hepatic decompensation, which focuses on new targets of treatment. Areas covered: This review deals with contemporary aspects of cirrhotic cardiomyopathy, and the literature search was undertaken by PubMed with 'cirrhotic' and 'cardiomyopathies' as MeSH Terms. Cirrhotic cardiomyopathy is defined as the presence of systolic and diastolic dysfunction and electrophysiological abnormalities. The diagnosis is based on contemporary Doppler/Echocardiography measurements or quantitative magnetic resonance imaging. Cirrhotic cardiomyopathy is independent of the etiology of the liver disease but related to severity and survival. Expert commentary: The outcome of invasive procedures and liver transplantation is influenced by the presence of cardiac dysfunction. Therefore, a cautious cardiac evaluation should be included in the patient evaluation prior to liver transplantation. Liver transplantation ameliorates most of the abnormalities seen in cirrhotic cardiomyopathy, but no specific treatment can yet be recommended.

Assessment of Subclinical Myocardial Changes in Non-Alcoholic Fatty Liver Disease: A Case-Control Study Using Speckle Tracking Echocardiography

BACKGROUND

Considering the association between cardiac abnormalities and non-alcoholic fatty liver disease (NAFLD), the present study aimed to evaluate the relationship between biopsy-proven NAFLD and functional echocardiographic parameters, including left ventricular (LV) global longitudinal strain (GLS) in asymptomatic individuals.

METHODS

Thirty asymptomatic patients with liver biopsy-proven NAFLD and the same number with no evidence of fatty liver in ultrasonography were enrolled in the study as cases and controls, respectively. The measured echocardiographic parameters included LV ejection fraction (LVEF), LV end-systolic and end-diastolic dimensions (ESD, EDD), LV end-systolic and end-diastolic volumes (ESV, EDV), E/e' ratio (early-diastolic mitral inflow velocity/early-diastolic myocardial velocity), E/A ratio (early-diastolic mitral inflow velocity/late-diastolic mitral inflow velocity), and GLS. Data were analyzed using the SPSS statistical software (version 18.0) by performing the independent t test, Chi-square, and non-parametric Mann-Whitney U tests. P values <0.05 were considered statistically significant.

RESULTS

A significant difference in ESD (32.1±1.4 mm vs. 34±1.8 mm), EDD (41.9±1.7 mm vs. 45.2±3.1 mm), and E/e' ratio (8.4±0.8 vs. 7.4±1.2) was detected among individuals with NAFLD compared with those without NAFLD (P<0.001 for the first two parameters and P=0.002 for the last one). GLS was also significantly lower in NAFLD patients than in controls, but within normal levels (19.3%±2.0 vs. 21.2%±1.4, P<0.001).

CONCLUSION

The findings support the presence of subclinical cardiovascular structural and functional changes in patients affected by NAFLD. It also indicates that the use of GLS is more sensitive than LVEF for the detection of LV systolic dysfunction in NAFLD patients.

Based serum metabolomics analysis reveals simultaneous interconnecting changes during chicken embryonic development

Metabolic disorder is a major health problem and is associated with a number of metabolic diseases. Due to native hyperglycaemia and resistance to exogenous insulin, chickens as a model had used in the studies of adipose tissue biology, metabolism and obesity. But no detailed information is available about the comprehensive changes of serum metabolites at different stages of chicken embryonic development. This study employed LC/MS-QTOF to determine the changes of major functional metabolites at incubation day 14 (E14d), 19 (E19d) and hatching day 1 (H1d), and the associated pathways of differential metabolites during chicken embryonic development were analysed using Metabolite Set Enrichment Analysis method. Results showed that 39 metabolites were significantly changed from E14d to E19d and 68 metabolites were significantly altered from E19d to H1d in chicken embryos. Protein synthesis was promoted by increasing the concentrations of L-glutamine and threonine, and gonadal development was promoted through increasing oestrone content from E14d to E19d in chicken embryos, which indicated that serum glutamine, threonine and oestrone contents may be considered as the candidate indicators for assessment of early embryonic development. 2-oxoglutaric acid mainly contributed to enhancing the citric cycle, and it plays an important role in improving the growth of chicken embryos at the late development; the decreasing of L-glutamine, L-isoleucine and L-leucine contents from E19d to H1d in chicken embryonic development implied their possible functions as the feed additive during early posthatch period of broiler chickens to satisfy the growth. These results provided insights into understand the roles of serum metabolites at different developmental stages of chicken embryos, it also provides available information for chicken as a model to study metabolic disease or human obesity.

Omega-3 polyunsaturated fatty acids as a treatment strategy for nonalcoholic fatty liver disease

Obese and type 2 diabetic (T2DM) patients have a high prevalence of nonalcoholic fatty liver disease (NAFLD). NAFLD is a continuum of chronic liver diseases ranging from benign hepatosteatosis to nonalcoholic steatohepatitis (NASH), cirrhosis and primary hepatocellular cancer (HCC). Because of its strong association with the obesity epidemic, NAFLD is rapidly becoming a major public health concern worldwide. Surprisingly, there are no FDA approved NAFLD therapies; and current therapies focus on the co-morbidities associated with NAFLD, namely, obesity, hyperglycemia, dyslipidemia, and hypertension. The goal of this review is to provide background on the disease process, discuss human studies and preclinical models that have examined treatment options. We also provide an in-depth rationale for the use of dietary ω3 polyunsaturated fatty acid (ω3 PUFA) supplements as a treatment option for NAFLD. This focus is based on recent studies indicating that NASH patients and preclinical mouse models of NASH have low levels of hepatic C_20-22 ω3 PUFA. This decline in hepatic PUFA may account for the major phenotypic features associated with NASH, including steatosis, inflammation and fibrosis. Finally, our discussion will address the strengths and limitations of ω3 PUFA supplements use in NAFLD therapy.

The Association between Non-Alcoholic Fatty Liver Disease and Cardiovascular Risk in Children

The rising prevalence of childhood obesity in the past decades has made Non-Alcoholic Fatty Liver Disease (NAFLD) the most common cause of pediatric chronic liver disease worldwide. Currently, a growing body of evidence links NAFLD with cardiovascular disease (CVD) even at an early age. Data on the pediatric population have shown that NAFLD could represent an independent risk factor not only for cardiovascular events but also for early subclinical abnormalities in myocardial structure and function. Briefly, we review the current knowledge regarding the relationship between pediatric NAFLD and cardiovascular risk in an attempt to clarify our understanding of NAFLD as a possible cardiovascular risk factor in childhood.