Non-alcoholic fatty liver disease and cardiovascular risk

Delphinidin or α-amyrin attenuated liver steatosis and metabolic disarrangement in rats fed a high-fat diet

Non-alcoholic fatty liver disease (NAFLD) is a liver pathology concomitant with metabolic disarrangement. This study assessed the therapeutic impacts of delphinidin, an anthocyanin, or α-amyrin, a pentacyclic triterpenoid, on NAFLD in rats and the underlying mechanisms involved. NAFLD was established by feeding a high-fat diet (HFD) for 10 weeks, either alone or in combination with delphinidin (40 mg/kg, oral) or α-amyrin (20 mg/kg, oral). Delphinidin or α-amyrin ameliorated the metabolic and histopathological perturbations induced by HFD. These compounds markedly attenuated NAFLD-induced hepatic steatosis, as evidenced by a substantial decrease in body weight, insulin resistance, and liver and adipose tissue indices. Alongside normalization of the atherogenic index, both improved HFD-mediated abnormalities in serum lipids, liver enzymes, leptin, and ghrelin levels. Moreover, their intervention activated the NFE2 like bZIP transcription factor 2 and heme oxygenase 1 pathways and abrogated HFD-triggered activation of mitogen-activated protein kinase 1 signaling. These remedies inhibited hepatic apoptosis and modulated the gene expression of lipogenic enzymes. Furthermore, histological analysis corroborated the suppression of lipid accumulation and amelioration of hepatic architecture in the treated rats. Our findings highlight the hepatoprotective value of delphinidin or α-amyrin against NAFLD and related metabolic diseases through their insulin-sensitizing, anti-inflammatory, antioxidant, and antiapoptotic effects.

Liver Fibrosis and Cardiovascular Events

OBJECTIVES

Liver fibrosis represents a common sequela of nonalcoholic fatty liver disease (NAFLD) and other chronic liver diseases. Noninvasive liver fibrosis scores (LFSs) aim to evaluate the severity of liver fibrosis. Whether LFSs can predict the risk of future cardiovascular events (CVEs) remains unclear. This systematic review aimed to clarify the association between liver fibrosis and CVEs by studying the value of LFSs, namely the Fibrosis-4 (FIB-4) Index for Liver Fibrosis score and the NAFLD Fibrosis Score (NFS), for predicting CVEs.

METHODS

PubMed, Scopus, Web of Science, and Cochrane Library were searched for relevant prospective studies. Retrieved articles were screened to confirm their eligibility for the systematic review. We evaluated the quality of the included studies using the National Institutes of Health tool.

RESULTS

Twelve studies of high to fair quality were included in this systematic review. Of note, 10/12 studies reported an independent association between high LFSs and the risk of CVEs, cardiovascular mortality, and all-cause mortality (all P < 0.05). In addition, an advanced histological grade of liver fibrosis (grade 3 or 4) was suggestive of CVE occurrence. NAFLD also appeared to be associated with a higher risk of CVEs at any severity of fibrosis (all P < 0.05).

CONCLUSIONS

The findings of this review suggest that liver fibrosis in patients with NAFLD is an independent predictor of future adverse CVEs, cardiovascular mortality, and all-cause mortality. Noninvasive and easy-to-perform LFSs, including FIB-4 score and the NFS, appear useful in predicting such events in patients with a spectrum of cardiovascular diseases and the general population without known cardiovascular disease.

Impact of metabolic-associated fatty liver disease on the cholesterol efflux capacity of high-density lipoproteins in adolescents with type 2 diabetes

CONTEXT

Type 2 diabetes (DM2) is an emerging disease in the pediatric population. DM2 is associated with metabolic-associated fatty liver disease (MAFLD). High-density lipoproteins (HDLs) are lipoproteins that are believed to have atheroprotective properties that reduce the risk of cardiovascular disease (CVD). Current evidence suggests that the physicochemical and functional features of HDLs may play a key role in the pathogenesis of atherosclerosis.

OBJECTIVE

We aimed to assess the impact of MAFLD on cholesterol efflux capacity (CEC) in adolescents with DM2.

DESIGN

A cross-sectional study.

SETTING

Attention clinic for Children with Diabetes of the Hospital Infantil de México Federico Gómez.

PATIENTS OR OTHER PARTICIPANTS

This study included a total of 70 adolescents, 47 of which had DM2 and 23 were healthy individuals.

INTERVENTIONS

The presence of MAFLD was determined by MR spectroscopy with proton density fat fraction. We compared the distribution of HDL subtypes (HDL2b, HDL2a, HDL3a, HDL3b, and HDL3c) and the chemical composition of HDLs (total protein, triglycerides, phospholipids, cholesteryl esters, and free cholesterol). HDL functionality was determined by the CEC, measuring the fluorescent cholesterol efflux from J774 macrophage cells.

MAIN OUTCOME MEASURES

We were expecting to observe a decrease in HDL efflux capacity in adolescents with type 2 diabetes and MAFLD.

RESULTS

In our study, we observed a prevalence of MAFLD in 66% of adolescents with DM2, similar to that reported in other international studies (60%-80%). In the population with DM2 and MAFLD, we did not observe a decrease in CEC. Initially we found a slight elevation of CEC in adolescents with DM2, however, with the increase in liver fat, a little decrease is observed, which could explain a probable metabolic phenomenon, since the physicochemical composition and distribution of the particles is associated with the percentage of liver fat. A positive correlation between the percentage of liver fat and the concentration of HDL2b (p = 0.011), HDL2a (p = 0.014) and average particle size (p = 0.011) and the proportion of triglycerides inside the particles (p = 0.007). Likewise, negative correlation were found with the percentage of liver fat, cholesterol esters (p = 0.010) and free cholesterol of the particles (p < 0.001). We observed a positive correlation between CEC and the percentage of triglycerides (p = 0.007), and a negative correlation with the percentage of cholesterol esters (p = 0.05) inside the HDL's particles.

CONCLUSIONS

In this group of adolescents with DM2, the presence of MAFLD was not associated with CEC; however, it is associated with abnormalities in the distribution and lipid composition of HDL particles. The momentum generated by the original proposal for MAFLD in the adult population and following the recommendations for pediatric MAFLD will be a step forward in helping to study the impact of MAFLD on the atheroprotective properties of HDL in the pediatric population.

Semaglutide 2.4 mg in Participants With Metabolic Dysfunction-Associated Steatohepatitis: Baseline Characteristics and Design of the Phase 3 ESSENCE Trial

BACKGROUND

Semaglutide, a glucagon-like peptide-1 receptor agonist, has demonstrated potential beneficial effects in metabolic dysfunction-associated steatohepatitis (MASH).

AIMS

To describe the trial design and baseline characteristics of the 'Effect of Semaglutide in Subjects with Non-cirrhotic Non-alcoholic Steatohepatitis' (ESSENCE) trial (NCT04822181).

METHODS

ESSENCE is a two-part, phase 3, randomised, multicentre trial evaluating the effect of subcutaneous semaglutide 2.4 mg in participants with biopsy-proven MASH and fibrosis stage 2 or 3. The primary objective of Part 1 is to demonstrate that semaglutide improves liver histology compared with placebo. The two primary endpoints are: resolution of steatohepatitis and no worsening of liver fibrosis, and improvement in liver fibrosis and no worsening of steatohepatitis. The Part 2 objective is based on clinical outcomes. The current work reports baseline characteristics of the first 800 randomised participants which includes demographics, laboratory parameters, liver histology, non-invasive tests and presence of metabolic dysfunction-associated steatotic liver disease (MASLD) cardiometabolic criteria.

RESULTS

Of 800 participants, 250 (31.3%) had fibrosis stage 2 and 550 (68.8%) had fibrosis stage 3. In the overall population, mean (standard deviation [SD]) age was 56 (11.6) years, 57.1% were female, mean (SD) body mass index was 34.6 (7.2) kg/m2, 55.5% had type 2 diabetes and > 99% had at least one MASLD cardiometabolic criterion according to the published definition.

CONCLUSION

The ESSENCE baseline population includes participants with clinically significant fibrosis stages 2 and 3. Although MASLD cardiometabolic criteria were not a requirement for study enrolment, almost all participants (> 99%) had at least one MASLD cardiometabolic criterion.

TRIAL REGISTRATION

NCT04822181.

Association between antibiotic use and cardiovascular diseases in metabolic dysfunction-associated steatotic liver disease: A nationally representative retrospective cohort study

AIM

Various subcategories for steatotic liver disease (SLD) were proposed globally. Previous studies suggested a heightened risk of cardiovascular diseases (CVD) with prolonged antibiotic exposure and metabolic dysfunction-associated SLD (MASLD), respectively. This study investigates the impact of antibiotic usage on CVD in MASLD patients.

METHODS

From the Korean National Health Insurance Service database, 276 520 adults aged 40 and older were included. Antibiotic exposure was defined by the cumulative prescription days and the number of classes. Participants were categorized into no SLD and MASLD groups. Hepatic steatosis was defined by using the fatty liver index ≥60. From 2013 to 2019, 16 197 CVD cases were recorded. A multivariate Cox model, adjusting for covariates, assessed adjusted hazard ratios (aHRs) and 95% confidence intervals (CIs) for CVD risk associated with MASLD and antibiotic prescriptions.

RESULTS

The group with ≥91 days of antibiotics prescribed and MASLD showed a significantly increased risk of CVD (aHR, 1.56; 95% CI, 1.39-1.74) compared with antibiotic non-users without SLD. Furthermore, the group with ≥4 classes of antibiotics prescribed and MASLD had an elevated risk of CVD (aHR, 1.49; 95% CI, 1.34-1.66) compared with antibiotic non-users without SLD. Consistent results were observed in several sensitivity analyses.

CONCLUSIONS

Our study identified prolonged antibiotic exposure may be a factor that increases the risk of CVD in MASLD patients. These findings suggest an epidemiological basis for the therapeutic application of antibiotics in MASLD patients, and emphasize the need for further studies to deepen the understanding of these intricate relationships.

Increased prevalence of high-risk coronary plaques in metabolic dysfunction associated steatotic liver disease patients: A meta-analysis

BACKGROUND

Metabolic dysfunction associated steatotic liver disease (MASLD) is associated with an increased risk of coronary artery disease. Computed Tomography Coronary Angiography (CTCA) can assess both the extent and the features of coronary plaques. We aimed to gather evidence about the prevalence and features of coronary plaques among MASLD patients.

METHODS

PubMed, Scopus, and Google Scholar databases were searched for randomized controlled trials and adjusted observational studies assessing the prevalence and features of coronary plaques by means of CTCA in MASLD patients as compared with a control group. The prevalence of coronary stenosis (defined as >30% and >50% diameter of stenosis), of increasing coronary artery calcium (CAC) score and of high-risk features (namely low-attenuation plaques, napkin ring sign, spotty calcification and positive remodelling) in MASLD patients were the endpoints of interest.

RESULTS

Twenty-four observational studies were included. MASLD was associated with an increased prevalence of critical coronary stenosis compared with controls (odds ratio [OR] 1.54, 95%CI 1.23-1.93). Increased values of CAC score were observed in MASLD patients (OR 1.35, 95%CI 1.02-1.78 and OR 2.26, 95%CI 1.57-3.23 for CAC score 0-100 and >100, respectively). An increased risk of 'high-risk' coronary plaques was observed in MASLD patients (OR 2.13, 95%CI 1.42-3.19). As high-risk features plaques, a higher prevalence of positive remodelling and spotty calcification characterize MASLD patients (OR 2.92, 95%CI 1.79-4.77 and OR 2.96, 95%CI 1.22-7.20).

CONCLUSIONS

Patients with MASLD are at increased risk of developing critical coronary stenosis and coronary plaques characterized by high-risk features as detected by CTCA.

Effect of statin use on liver enzymes and lipid profile in patients with non-alcoholic fatty liver disease (NAFLD)

BACKGROUND

Non-alcoholic fatty liver disease (NAFLD) is an independent risk factor for cardiovascular disease (CVD). Statins are recommended for treatment of dyslipidemia to reduce the overall cardiovascular risk in patients with NAFLD. However, statin treatment was underutilized and the effect of statins on liver enzymes remained unclear in this patient population.

OBJECTIVES

This study aimed to provide real-world evidence of the safety and effect of statin use in patients with NAFLD.

METHODS

We conducted a cross-sectional survey study of adults with NAFLD using pooled data from the US NHANES database 2009-2018. NAFLD was defined by Fatty Liver Index (FLI) ≥ 60 and United States Fatty Liver Index (USFLI) ≥ 30. Multivariate regression analyses adjusted for baseline clinical and demographic characteristics were performed to compare the liver enzymes and lipid profile between statin and non-statin users.

RESULTS

The study included 2,533 adults with NAFLD, representing 22.6 million individuals in the US, with 27% receiving statin treatment between 2009 and 2018. The mean differences of liver enzymes for AST, ALT, ALP, and GGT between statin and non-statin users were -0.86 (p=0.539), -3.49 (p=0.042), -0.25 (p=0.913), and 0.57 (p=0.901), respectively. In individuals with NAFLD and dyslipidemia, total cholesterol and LDL levels were significantly lower in statin users compared to non-statin users (mean difference, -28.9; p<0.001 and -27.7; p<0.001).

CONCLUSION

The use of statins was not associated with elevated liver enzymes in patients with NAFLD. Significantly lower levels of ALT, total cholesterol, and LDL were observed in statin users compared to non-statin users.

Can liquid biopsies for MASH help increase the penetration of metabolic surgery? A narrative review

This narrative review highlights current evidence on non-invasive tests to predict the presence or absence as well as the severity of metabolic dysfunction-associated steatohepatitis (MASH) and liver fibrosis. Metabolic dysfunction-associated steatotic liver disease (MASLD) is a common condition characterized by fat accumulation in the liver that affects 32 % of the world population. The most severe form of MASLD is MASH in which hepatocyte ballooning and inflammation are present together with steatosis; MASH is often associated with liver fibrosis. MASH diagnosis is determined by invasive liver biopsy. Hence, there is a critical need for non-invasive MASH tests. Plasma biomarkers for MASH diagnosis generally have low sensitivity (62-66 %), and specificity (78-82 %). Monocyte levels of Perilipin2 (PLIN2) predict MASH with an accuracy of 92-93 %, and sensitivity and specificity of 90-95 % and 88-100 %, respectively. This liquid biopsy test can facilitate the study of MASH prevalence in general populations and also monitor the effects of lifestyle, surgical, and pharmacological interventions. Without any FDA-approved MASH therapeutic, and with metabolic surgery markedly surpassing the efficacy of lifestyle modification, an accurate and reliable liquid biopsy could help more people choose surgery as a treatment for MASH.

Prevalence of non-alcoholic fatty liver and its related factors in Iran: Systematic review and meta-analysis

Non-alcoholic fatty liver disease (NAFLD) is a systemic disorder with a complex multifactorial and heterogeneous pathogenesis and has become the most common cause of chronic liver disease in many countries around the world. Numerous studies in Iran have presented different results on the prevalence and risk factors of NAFLD, in this study, which has been done in a systematic review and meta-analysis, provides a good estimate of the prevalence and risk factors of the disease in Iran. Following the peer review of electronic search strategies (PRESS and the preferred reporting items for systematic reviews and meta-analyses [PRISMA] statement, we searched Web of Science, PubMed, Embase, Scopus, and Persian scientific searcher (Elmnet) from inception to September 19, 2022. In the present study, 71 articles were reviewed for qualitative and meta-analysis. The overall mean prevalence of NAFLD in children studies was 22.4% (95% confidence interval [CI]: 10.9% to 33.9%). The prevalence was notably higher in adult studies 40.5% (95% CI: 35.1% to 46%). In 24 studies, the association between NAFLD and sex was reported, 10 of which showed significant relationships. Out of 46 studies observed that NAFLD prevalence increased significantly with body mass index (BMI). Eight out of 14 studies reported significant associations between FBS and NAFLD in children's studies. Though Iran has a high NAFLD prevalence compared to most areas, and due to the unfavorable situation of risk factors contributing to the NAFLD, it is necessary to take the necessary interventions to control these risk factors and prevent NAFLD.

Non-alcoholic fatty liver disease and risk of cardiovascular diseases: clinical association, pathophysiological mechanisms, and management

Non-alcoholic fatty liver disease (NAFLD) is a fatty liver disease associated with metabolic dysfunction in genetically susceptible individuals due to over-nutrition and lack of exercise. With the prevalence of obesity, metabolic syndrome, and type 2 diabetes mellitus, NAFLD has become the most common cause of chronic liver disease worldwide. NAFLD shares many risk factors with cardiovascular diseases (CVDs). NAFLD is associated with increased risk of major cardiovascular events and other cardiac complications even after adjustment for traditional cardiovascular risk factors. The primary pathology of NAFLD is within the liver, but the most common cause of deaths in patients with NAFLD is CVDs. This review summarizes the epidemiological evidence for the association between NAFLD and CVD risk and the pathophysiological mechanisms underlying this association. Current treatment strategies for NAFLD and their potential impact on CVD risk are also discussed.

Cardiac Syndromes in Liver Disease: A Clinical Conundrum

Understanding the interaction between the heart and liver is pivotal for managing patients in whom both organs are affected. Studies have shown that cardio-hepatic interactions are bidirectional and that their identification, assessment, and treatment remain challenging. Congestive hepatopathy is a condition that develops in the setting of long-standing systemic venous congestion. If left untreated, congestive hepatopathy may lead to hepatic fibrosis. Acute cardiogenic liver injury develops as a combination of venous stasis and sudden arterial hypoperfusion due to cardiac, circulatory, or pulmonary failure. The treatment of both conditions should be directed toward optimizing the cardiac substrate. Hyperdynamic syndrome may develop in patients with advanced liver disease and lead to multiorgan failure. Cirrhotic cardiomyopathy or abnormalities in pulmonary vasculature, such as hepatopulmonary syndrome and portopulmonary hypertension may also develop. Each complication has unique treatment challenges and implications for liver transplantation. The presence of atrial fibrillation and atherosclerosis in liver disease brings another layer of complexity, particularly in terms of anticoagulation and statin use. This article provides an overview of cardiac syndromes in liver disease, focusing on current treatment options and future perspectives.

Prevalence and Related Factors for Non-alcoholic Fatty Liver Disease in Obese Students

Background: Non-alcoholic fatty liver disease (NAFLD) occurs with the pathological accumulation of fat in the liver and is one of the most common liver disorders worldwide among adults and even children. Obesity is a risk factor for NAFLD. Objectives: Considering the increasing prevalence of obesity in Iran and worldwide, this study was conducted to determine the prevalence of NAFLD and its related factors in overweight and obese students of schools in Tehran, Iran. Methods: This cross-sectional study was performed on 115 overweight and obese students [body mass index (BMI) ≥ 25] with an age range of 7 - 17 years. Eligible individuals were classified into two groups with and without NAFLD. Liver ultrasonography and measurement of serum parameters, including fasting blood sugar, lipid profile, and liver enzymes, were performed. Next, the demographic and anthropometric characteristics were compared between the two groups. Results: Out of 115 studied students, 71 subjects were boys (61.7%). The results showed that the mean BMI in patients with fatty liver was significantly higher than in individuals without fatty liver (P = 0.03). According to our findings, the mean total cholesterol in NAFLD patients was significantly higher than in the group without NAFLD (P = 0.008). The univariate logistic regression model results for measuring factors related to fatty liver in students showed a significant positive correlation between male gender, BMI, total cholesterol, aspartate aminotransferase, and alanine aminotransferase. Conclusions: NAFLD is a substantial problem in school children and correlates with elevated BMI. Therefore, the measurement of BMI can be used as a useful predictor and screening tool for NAFLD in school children.

Allium sativum: A potential natural compound for NAFLD prevention and treatment

Introduction

Non-alcoholic fatty liver disease (NAFLD) results from an excessive accumulation of fat particles that causes liver inflammation, which ultimately causes liver damage. There is still considerable uncertainty about the effects of any nutritional supplements compared to no additional intervention. This review aimed to evaluate the efficacy of Allium sativum (A. sativum), known as garlic, in preventing and treating NAFLD.

Methods

A systematic search based on a search strategy consisting of two components of "NAFLD" and "Allium sativum" in databases including PubMed, Web of Science (WoS), and SCOPUS was conducted on papers evaluating the effects of A. sativum on NAFLD treatment and prevention. We obtained studies from inception until 20 September 2022, followed by study selection and data extraction based on our eligibility criteria. Consequently, qualitative and quantitative synthesis was conducted.

Results

Our qualitative analysis reveals that A. sativum consumption is linked to the prevention of NAFLD, especially in males, although qualitative data in this study regarding the therapeutic properties of NAFLD was controversial. Our meta-analysis showed that NAFLD patients treated with A. sativum have significantly declined aminotransferase levels. That is to say, our meta-analysis revealed a lower alanine transaminase (ALT) (SMD = -0.580, 95%CI = -0.822 to -0.338), and aspartate transaminase (AST(SMD = -0.526, 95%CI = -0.767 to -0.284) in NAFLD patients treated with A. sativum compared to the placebo group. Also, pooling data from case-control studies showed that A. sativum consumption decreases the odds of being diagnosed with NAFLD by 46% (OR = 0.538, 95%CI = 0.451-0.625).

Conclusion

A. sativum consumption is not merely associated with NAFLD prevention but also results in a considerable decline in blood aminotransferase levels in patients diagnosed with NAFLD. To put it simply, A. sativum is linked to a decline in AST and ALT, which are considered reliable biomarkers of NAFLD response to treatment. Nevertheless, A. sativum is insufficient to improve NAFLD independent of other dietary amendments and lifestyle modifications.

Oral 24-week probiotics supplementation did not decrease cardiovascular risk markers in patients with biopsy proven NASH: A double-blind placebo-controlled randomized study

INTRODUCTION AND OBJECTIVES

Cardiovascular disease (CVD) is the major cause of death in non-alcoholic fatty liver disease (NAFLD), a clinical condition without any approved pharmacological therapy. Probiotics are often indicated for the disease, but their results are controversial in part due to the poor quality of studies. Thus, we investigated the impact of 24-week probiotics supplementation on cardiovascular risk (CVR) in biopsy-proven non-alcoholic steatohepatitis (NASH) patients.

PATIENTS AND METHODS

Double-blind, placebo-controlled, single-center study (NCT03467282), adult NASH, randomized for 24 weeks daily sachets of probiotic mix (10⁹CFU of Lactobacillus acidophilus, Lactobacillus rhamnosus, Lactobacillus paracasei and Bifidobacterium lactis) or placebo. Clinical scores (atherogenic indexes, atherosclerotic cardiovascular disease-ASCVD and systematic coronary risk evaluation-SCORE), biochemistry, miR-122, miR-33a, plasminogen activator inhibitor-1 (PAI-1), intercellular adhesion molecule-1 (ICAM-1), vascular cell adhesion molecule-1 (VCAM-1), were determined before and after the intervention.

RESULTS

Forty-six patients were enrolled (23 received probiotics and 23 placebo), with a mean age of 51.7 years, most of them females and whites. Clinical and demographic features were similar between the groups at the baseline. The Median NAFLD activity score was 4.13 in both groups. Fibrosis was mild in most patients (15.2% and 65.2% F0 and F1, respectively). Treatment did not promote any clinically significant changes in body mass index or laboratory, including lipid and glucose profile. High CVR patients through atherogenic indexes decreased from baseline in both groups, as well as PAI-1 and miR-122 levels, although there was no difference between probiotics and placebo.

CONCLUSIONS

A 24-week probiotic mix administration was not superior to placebo in reducing CVR markers in patients with NASH.

Features of the management of coronary heart disease in patients with metabolically associated fatty liver disease

Among chronic non-communicable diseases, which make a significant contribution to mortality rates in the developed countries of the world, the leading positions are occupied by diseases of the circulatory system. According to statistics, one million people a year die from cardiovascular diseases in Russia. In an extensive nosological group of diseases of the circulatory system, coronary heart disease is the main cause of death and disability in the adult population. The annual mortality from coronary heart disease among the population of Russia is 27 %. To date, the number of patients with coronary heart disease with comorbid pathology, especially with diseases of the hepatobiliary system, metabolic syndrome, is increasing. The prevalence of metabolically associated fatty liver disease is 20 to 30 % in the population and tends to increase. The combined course of metabolically associated fatty liver disease and coronary heart disease occurs in 14-18 % of cases. Objective: to determine the impact of metabolically associated fatty liver disease on the course of coronary heart disease and the possibility of correcting metabolic disorders to prevent the development of cardiovascular complications. Materials and methods. 35 patients with coronary heart disease and metabolically associated fatty liver disease were examined; they were noted to have more severe clinical course of stenocardia and higher risk of cardiovascular complications, then those patients without liver diseases. Results and its discussion. It was estimated, that using thiotriazoline and ursodeoxycholic acid in addition to standard medicamentous therapy improves clinical course of stenocardia as well as overall quality of life due to high antianginal and antioxidant effects. Conclusions. Hepatoprotective therapy increases possibility of correction of metabolic defects, dyslipidemia, decreases the risk of oxidative stress, prevents development of life threatening cardiovascular conditions and can be used to optimize treatment of comorbid patients.

A Meta-Analysis on the Global Prevalence, Risk factors and Screening of Coronary Heart Disease in Nonalcoholic Fatty Liver Disease

BACKGROUND & AIMS

Cardiovascular disease remains the leading cause of death in patients with nonalcoholic fatty liver disease (NAFLD). Studies examining the association of coronary heart disease (CHD) and NAFLD are cofounded by various cardiometabolic factors, particularly diabetes and body mass index. Hence, we seek to explore such association by investigating the global prevalence, independent risk factors, and influence of steatosis grade on manifestation of CHD among patients with NAFLD.

METHODS

Two databases, Embase and Medline, were utilized to search for articles relating to NAFLD and CHD. Data including, but not limited to, continent, diagnostic methods, baseline characteristics, prevalence of CHD, CHD severity, NAFLD severity, and risk factors were extracted.

RESULTS

Of the 38 articles included, 14 reported prevalence of clinical coronary artery disease (CAD) and 24 subclinical CAD. The pooled prevalence of CHD was 44.6% (95% confidence interval [CI], 36.0%-53.6%) among 67,070 patients with NAFLD with an odds ratio of 1.33 (95% CI, 1.21%-1.45%; P &lt; .0001). The prevalence of CHD was higher in patients with moderate to severe steatosis (37.5%; 95% CI, 15.0%-67.2%) than those with mild steatosis (29.6%; 95% CI, 13.1%-54.0%). The pooled prevalence of subclinical and clinical CAD was 38.7% (95% CI, 29.8%-48.5%) and 55.4% (95% CI, 39.6%-70.1%), respectively.

CONCLUSION

Steatosis was found to be related with CHD involvement, with moderate to severe steatosis related to clinical CAD. Early screening and prompt intervention for CHD in NAFLD are warranted for holistic care in NAFLD.

Torularhodin Alleviates Hepatic Dyslipidemia and Inflammations in High-Fat Diet-Induced Obese Mice via PPARα Signaling Pathway

Torularhodin is a β-carotene-like compound from Sporidiobolus pararoseus, and its protective effect against high-fat diet (HFD)-induced hepatic dyslipidemia and inflammation was investigated. Compared to mice of C57BL/6J fed on HFD, the addition of Torularhodin into the HFD (HFD-T) significantly reduced body weight, serum triglyceride (TG), total cholesterol (TC), low-density lipoprotein (LDL), and the inflammatory mediators of TNF-α, IL-6, IL-1β, and lipopolysaccharide (LPS). A significant increase of high-density lipoprotein cholesterol (HDL-c), which is beneficial to cholesterol clearance, was also observed in HFD-T group. Proteomic analysis showed HDL-C-c is highly correlated with proteins (e.g., CPT1A and CYP7A1) involved in lipid β-oxidation and bile acid synthesis, whereas the other phenotypic parameters (TC, TG, LDL, and inflammatory cytokines) are highly associated with proteins (e.g., SLC27A4) involved in lipid-uptake. The up-regulated anti-inflammation proteins FAS, BAX, ICAM1, OCLN, GSTP1, FAF1, LRP1, APEX1, ROCK1, MANF, STAT3, and INSR and down-regulated pro-inflammatory proteins OPTN, PTK2B, FADD, MIF, CASP3, YAP1, DNM1L, and NAMPT not only demonstrate the occurrence of HFD-induced hepatic inflammation, but also prove the anti-inflammatory property of Torularhodin. KEGG signaling pathway analysis revealed that the PPARα signaling pathway is likely fundamental to the health function of Torularhodin through up-regulating genes related to fatty acid β-oxidation, cholesterol excretion, HDL-Cc formation, and anti-inflammation. Torularhodin, as a new food resource, may act as a therapeutic agent to prevent hepatic dyslipidemia and related inflammation for improved health.

Association between the LRP5 rs556442 gene polymorphism and the risks of NAFLD and CHD in a Chinese Han population

Background

Multiple studies have demonstrated the involvement of low-density lipoprotein receptor-related protein 5 (LRP5) in metabolism-related diseases. This study explored the relationship between the LRP5 rs556442 gene polymorphism and the risks of non-alcoholic fatty liver disease (NAFLD) and coronary heart disease (CHD) in a Chinese Han population.

Methods

This retrospective case–control study included 247 patients with NAFLD, 200 patients with CHD, 118 patients with both NAFLD and CHD, and 339 healthy controls from June 2018 to June 2019 at Qingdao Municipal Hospital. Basic information and clinical characteristics were collected for all subjects. The genotype and allele frequency of LRP5 rs556442 were determined.

Results

The genotype distributions of LRP5 rs556442 differed significantly between the CHD and NAFLD + CHD groups (P < 0.05). The LRP5 rs556442 GG genotype markedly promoted the risk of NAFLD in CHD patients [odds ratio (OR) = 2.857, 95% confidence interval (CI): 1.196–6.824, P = 0.018). After adjustment for sex, age, and body mass index (BMI), this association remained significant (OR = 3.252, 95% CI: 1.306–8.102, P = 0.011). In addition, the LRP5 rs556442 AA + AG genotype was associated with an increased BMI in obese NAFLD patients (OR = 1.526, 95% CI: 1.004–2.319, P = 0.048). However, after adjustment for sex and age, this association was no longer significant (OR = 1.504, 95% CI: 0.991–2.282, P = 0.055).

Conclusions

This study found that the LRP5 rs556442 GG genotype increased the risk of NAFLD in CHD patients and AA + AG genotype may be associated with an increased BMI in obese NAFLD patients among a Chinese Han population.

Trial registration ChiCTR, ChiCTR1800015426. Registered 28 March 2018—Retrospectively registered, http://www.chictr.org.cn/showproj.aspx?proj=26239.

Effects of naringenin supplementation on cardiovascular risk factors in overweight/obese patients with nonalcoholic fatty liver disease: a pilot double-blind, placebo-controlled, randomized clinical trial

OBJECTIVE

Although several experimental models have suggested promising pharmacological effects of naringenin in the management of obesity and its related disorders, the effects of naringenin supplementation on cardiovascular disorders as one of the main complications of nonalcoholic fatty liver disease (NAFLD) are yet to be examined in humans.

METHODS

In this double-blind, placebo-controlled, randomized clinical trial, 44 overweight/obese patients with NAFLD were equally allocated into either naringenin or placebo group for 4 weeks. Cardiovascular risk factors including atherogenic factors, hematological indices, obesity-related parameters, blood pressure, and heart rate were assessed pre- and postintervention.

RESULTS

The atherogenic index of plasma value, serum non-HDL-C levels as well as total cholesterol/high-density lipoprotein cholesterol (HDL-C), triglyceride/HDL-C, low-density lipoprotein cholesterol/HDL-C, and non-HDL-C/HDL-C ratios were significantly reduced in the intervention group, compared to the placebo group post intervention (P < 0.05). Moreover, there was a significant reduction in BMI and visceral fat level in the intervention group when compared with the placebo group (P = 0.001 and P = 0.039, respectively). Furthermore, naringenin supplementation could marginally reduce systolic blood pressure (P = 0.055). Mean corpuscular hemoglobin increased significantly in the naringenin group compared to the placebo group at the endpoint (P = 0.023). Supplementation with naringenin also resulted in a marginally significant increase in the mean corpuscular hemoglobin concentration when compared with the placebo group (P = 0.050). There were no significant between-group differences for other study outcomes post intervention.

CONCLUSION

In conclusion, these data indicate that naringenin supplementation may be a promising treatment strategy for cardiovascular complications among NAFLD patients. However, further trials are warranted.

Therapeutic potential of policosanol in the concurrent management of dyslipidemia and non-alcoholic fatty liver disease

Background

High-fat diet (HFD) possesses a major cause of cardiovascular disease, and hepatosteatosis. Unfortunately, long-term use of statins has a theoretical possibility of worsening of hepatic histology in the patients with non-alcoholic fatty liver disease (NAFLD). The objective of the study was to explore hepatoprotective potential of policosanol as an alternative to statins in experimental NAFLD. For the same, young male Wistar rats were fed with HFD for 8 weeks to induce NAFLD. 48 adult Wistar rats were distributed into six investigational groups: normal control, HFD control, and four treatment groups, receiving policosanol (50 and 100 mg/kg/day), atorvastatin (30 mg/kg/day), and silymarin (100 mg/kg/day) for 8 weeks along with HFD.

Result

HFD consumption caused profound hepatotoxicity evident by hepatic oxidative stress, increased Serum glutamic oxaloacetic transaminase (SGOT), Serum glutamic pyruvic transaminase (SGPT), Alkaline phosphatase (ALP), and bilirubin content. Treatment with policosanol (100 mg/kg) markedly reduced the elevated SGOT, SGPT, and ALP levels in HFD-fed rats. Moreover, policosanol significantly reduced hepatic oxidative stress manifest by reduced malondialdehyde (MDA) and increased glutathione (GSH) level. The treatment with policosanol (100 mg/kg) was found to be more active in attenuating the HFD-induced hepatotoxicity as compared to policosanol (50 mg/kg) and atorvastatin (30 mg/kg). Moreover, we observed that the hepatoprotective potential of policosanol was comparable to the silymarin.

Conclusions

The results of the study clearly indicated that the policosanol could be considered an intriguing approach for the treatment of NAFLD.

Cardiovascular Diseases and Non-Alcoholic Fatty Liver Disease: Relationship and Pathogenetic Aspects of Pharmacotherapy

The association of non-alcoholic fatty liver disease (NAFLD) and cardiovascular risk is currently one of the actively studied areas. The incidence of non-alcoholic fatty  liver disease continues to grow worldwide. In the structure of mortality rate of patients with non-alcoholic fatty  liver disease,  the first place is occupied by cardiovascular events: stroke and myocardial infarction. Studies have shown that the presence of severe liver fibrosis (F3-4) in NAFLD not only increases the risk of cardiovascular diseases (CVD), but also increases the risk  of  overall  mortality  by  69%  due  to mortality from cardiovascular causes. The degree of increased risk is associated with the degree of activity of non-alcoholic steatohepatitis (NASH). Despite the large number of works on this topic, we do not have a clear opinion on the impact on cardiovascular risk, interaction and the contribution of various factors, as well as algorithms for managing patients with non-alcoholic fatty liver disease to reduce the risk of cardiovascular diseases. This article describes the pathogenetic factors of formation of cardiovascular risks in patients with non-alcoholic fatty liver disease, proposed the idea of stratification of cardiovascular risks in these patients, taking into account changes in the structure of the liver (fibrosis) and function (clinical and biochemical activity) and also it describes the main directions of drug therapy, taking into account the common pathogenetic mechanisms for non-alcoholic fatty liver disease and cardiovascular diseases. The role of obesity, local fat depots, adipokines, and endothelial dysfunction as the leading pathogenetic factors of increased cardiovascular risk in patients with NAFLD is discussed. Among pathogenetically justified drugs in conditions of poly and comorbidity, hypolipidemic (statins, fibrates), angiotensin II receptor antagonists, beta-blockers, etc. can be considered. According to numerous studies, it becomes obvious that the assessment of cardiovascular risks in patients with NAFLD will probably allow prescribing cardiological drugs, selecting individualized therapy regimens, taking into account the form of NAFLD, and on the other hand, building curation taking into account the identified cardiovascular risks.

Non-alcoholic fatty liver disease as an independent factor of cardiometabolic risk of cardiovascular diseases

Non-alcoholic fatty liver disease (NAFLD) is a pressing public health problem affecting up to a third of the world's adult population. The main reasons for its high mortality rate are cardiovascular diseases. They are caused by subclinical atherosclerosis characteristic of NAFLD, venous thromboembolic complications, functional and structural myocardial disorders, calcification of heart valves, heart rhythm and conduction disturbances. At the same time, NAFLD can serve as an independent factor of the cardiometabolic risk of their development, which is associated with atherogenic dyslipidemia, as well as the release of numerous pro-inflammatory mediators both from the pathologically altered liver and as a result of systemic endotoxemia, which is the result of disturbance of the intestinal microbiota, accompanied by a decrease in intestinal microbial gene richness., a change in its composition and function, followed by bacterial translocation. Considering that most patients with NAFLD die from cardiovascular complications, it becomes obvious that exclusively “liver-oriented” principles of their treatment cannot be sufficient, but require a multidisciplinary team approach involving cardiologists, cardiac surgeons and doctors of other related specialties.

Xanthohumol Requires the Intestinal Microbiota to Improve Glucose Metabolism in Diet-Induced Obese Mice

SCOPE

The polyphenol xanthohumol (XN) improves dysfunctional glucose and lipid metabolism in diet-induced obesity animal models. Because XN changes intestinal microbiota composition, the study hypothesizes that XN requires the microbiota to mediate its benefits.

METHODS AND RESULTS

To test the hypothesis, the study feeds conventional and germ-free male Swiss Webster mice either a low-fat diet (LFD, 10% fat derived calories), a high-fat diet (HFD, 60% fat derived calories), or a high-fat diet supplemented with XN at 60 mg kg-1 body weight per day (HXN) for 10 weeks, and measure parameters of glucose and lipid metabolism. In conventional mice, the study discovers XN supplementation decreases plasma insulin concentrations and improves Homeostatic Model Assessment of Insulin Resistance (HOMA-IR). In germ-free mice, XN supplementation fails to improve these outcomes. Fecal sample 16S rRNA gene sequencing analysis suggests XN supplementation changes microbial composition and dramatically alters the predicted functional capacity of the intestinal microbiota. Furthermore, the intestinal microbiota metabolizes XN into bioactive compounds, including dihydroxanthohumol (DXN), an anti-obesogenic compound with improved bioavailability.

CONCLUSION

XN requires the intestinal microbiota to mediate its benefits, which involves complex diet-host-microbiota interactions with changes in both microbial composition and functional capacity. The study results warrant future metagenomic studies which will provide insight into complex microbe-microbe interactions and diet-host-microbiota interactions.

Non-alcoholic Steatohepatitis Pathogenesis, Diagnosis, and Treatment

There has been a rise in the prevalence of non-alcohol fatty liver disease (NAFLD) due to the popularity of western diets and sedentary lifestyles. One quarter of NAFLD patients is diagnosed with non-alcoholic steatohepatitis (NASH), with histological evidence not only of fat accumulation in hepatocytes but also of liver cell injury and death due to long-term inflammation. Severe NASH patients have increased risks of cirrhosis and liver cancer. In this review, we discuss the pathogenesis and current methods of diagnosis for NASH, and current status of drug development for this life-threatening liver disease.

Circulating levels of FAM19A5 are inversely associated with subclinical atherosclerosis in non-alcoholic fatty liver disease

BACKGROUND

Family with sequence similarity 19 (chemokine (C-C motif)-like) member A5 (FAM19A5) is a newly identified adipokine. There is a limited number of studies linking FAM19A5 to metabolic disorders. In the current study, we aimed to explore if FAM19A5 is associated with nonalcoholic fatty liver disease (NAFLD). We also sought to determine the possibility of FAM19A5 association with subclinical atherosclerosis in NAFLD patients.

METHODS

A total of 69 subjects including 37 NAFLD and 32 control subjects were included in this cross-sectional study. Plasma concentration of FAM19A5 was measured with the ELISA method. Carotid artery intima-media thickness (cIMT) was assessed by the ultrasonography.

RESULTS

Plasma concentration of FAM19A5 in patients with NAFLD was significantly lower in NAFLD patients than controls. Moreover, we observed significant negative correlations between plasma level of FAM19A5 and body mass index (BMI), visceral fat, alanine amino transferase (ALT), aspartate amino transferase (AST), liver stiffness (LS), and cIMT. Following stepwise multiple linear regression analysis, ALT and cIMT were the only determinants of FAM19A5 level.

CONCLUSIONS

This is the first report to describe association of circulating FAM19A5 levels with NAFLD. Our findings provide further evidence showing relation of FAM19A5 with the risk of atherosclerosis. However, more studies are necessary to unravel the contribution of lower FAM19A5 levels to the NAFLD pathogenesis and the higher risk of atherosclerosis in these patients.

The association of the steatosis severity, NAFLD fibrosis score and FIB-4 index with atherogenic dyslipidaemia in adult patients with NAFLD: A cross-sectional study

OBJECTIVES

Obesity and dyslipidaemia are the major risk factors for non-alcoholic fatty liver disease (NAFLD), and are known to increase cardiovascular disease (CVD), which is the leading cause of death in NAFLD patients. The present cross-sectional study aimed to investigate associations among severity of hepatic steatosis, NAFLD fibrosis score and atherogenic lipid profile.

METHODS

A total of 265 patients with NAFLD confirmed by ultrasonographic findings were included. The NAFLD fibrosis score and the fibrosis-4 (FIB-4) index were used to classify the probability of fibrosis as low, intermediate and high probability. Serum lipids including total cholesterol (TC), triglyceride (TG), low-density lipoprotein cholesterol (LDL-C) and high-density lipoprotein cholesterol (HDL-C) were measured, and then TC/HDL-C, LDL-C/HDL-C, TG/HDL-C and non HDL-C/HDL-C ratios were determined. Fasting blood sugar (FBS), alanine aminotransferase (ALT) and aspartate aminotransferase (AST) were also assessed. The homeostatic model assessment for insulin resistance (HOMA-IR) was calculated.

RESULTS

The severity of hepatic steatosis was positively correlated with TC/HDL-C (r = 0.29, P = .002), LDL-C/HDL-C (r = 0.32, P < .001), TG/HDL-C (r = 0.36, P < .001) and non-HDL-C/HDL-C (r = 0.24, P = .001) ratios. Similarly, these parameters were positively correlated with NAFLD fibrosis score and FIB-4 index (P < .05). In addition, alanine aminotransferase and aspartate aminotransferase levels were positively correlated with TG/HDL-C ratio (r = 0.31, P = .003; and r = 0.27, P = .001 respectively). With increasing the severity of hepatic steatosis and NAFLD fibrosis score, the mean of all lipid ratios increased significantly (P < .01 and P < .05, respectively). Importantly, after controlling for potential confounders including age, gender, physical activity level, body mass index, waist circumference and HOMA-IR, the severity of steatosis, NAFLD fibrosis score and FIB-4 index remained independent predictors of atherogenic lipid profile.

CONCLUSIONS

Severity of hepatic steatosis, NAFLD fibrosis score and FIB-4 index were significantly correlated with atherogenic lipid profile. As NAFLD is high among patients with metabolic risk factors for CVD, their dyslipidaemia should be aggressively managed.

Carotid Intima-media Thickness in Patients with Non-alcoholic Fatty Liver Disease Attending a Tertiary Care Center: A Descriptive Cross-sectional Study

INTRODUCTION

Non-alcoholic fatty liver disease is fatty infiltration of the liver in the absence of other causes of steatosis. It is strongly associated with central adiposity, high body mass index, insulin resistance states, hypertension, hyperlipidemia which are features of metabolic syndrome. The objective of study is to find out the carotid intima-media thickness of non alcoholic fatty liver disease patients attending a tertiary care center.

METHODS

This was a descriptive cross sectional study conducted at National Academy of Medical Sciences, Bir Hospital from July 2018 to June 2019 among 70 diagnosed cases of non alcoholic fatty liver disease based on ultrasound findings. Data collection was started after receiving ethical approval from Institutional Review Board of the Institute. Convenience sampling method was used. Data were entered using Microsoft Excel. The carotid intima-media thickness of both sides were measured by ultrasound. Statistical Package for Social Sciences version 20 was used for analysis.

RESULTS

Out of 70 cases, the mean carotid intima-media thickness was 0.7140±0.1796mm on right and 0.7161±0.1828mm on left side. Among 70 cases 45 (64.3%) were Grade II non alcoholic fatty liver disease and 25 (35.7%) were Grade I. It was 0.5720±0.1275mm and 0.7929±0.1546mm in Grade I and II non alcoholic fatty liver disease cases respectively on right side whereas it was 0.5676±0.1259mm and 0.7987±0.1557mm respectively on left side.

CONCLUSIONS

This study showed increased carotid intima-media thickness in non alcoholic fatty liver disease cases.

The ameliorative effect of Lactobacillus plantarum Y44 oral administration on inflammation and lipid metabolism in obese mice fed with a high fat diet

In our previous studies, Lactobacillus plantarum Y44 showed antioxidant activity and favorable gastric and intestinal transit tolerance. The purpose of this study is to determine whether L. plantarum Y44 could ameliorate intestinal inflammation and lipid metabolism disorder in obese mice fed with a high-fat diet. L. plantarum Y44 was administered by gavage to the mice fed with a high-fat diet for 12 weeks. The mice fed with a high fat diet only showed sustainably elevated body weight, liver lipid metabolism disorder, intestinal inflammation and a lower short chain fatty acid content in feces. Oral administration of L. plantarum Y44 regulated lipid metabolism disorder by inhibiting the expression of fatty acid synthase (FAS) and acetyl-CoA carboxylase (ACC) in the liver of obese mice, reducing the contents of total cholesterol (TC), triacylglycerols (TG), low density lipoprotein cholesterol (LDL-c), alanine aminotransferase (ALT), and aspartate transaminase (AST) and increasing the content of high-density lipoprotein cholesterol (HDL-c) in the serum of obese mice. Oral administration of L. plantarum Y44 up-regulated the expression of colon tight junction protein such as claudin-1 and occludin, down-regulated p38 and phospho-p38 levels and reduced serum interleukin-8 (IL-8) and tumor necrosis factor-α (TNF-α). Oral administration of L. plantarum Y44 increased Muribaculaceae, Rikenellaceae, and Lactobacillaceae levels, reduced the Firmicutes/Bacteroidetes ratio, and Desulfovibrionaceae and Proteobacteria levels in obese mice. Oral administration of L. plantarum Y44 also enhanced the contents of propionic acid, butyric acid, butanoicacid-3-methyl, pentanoic acid and acetic acid in the feces of the obese mice. Correlation analysis of Spearman revealed a significant correlation between changes in intestinal microflora and obesity-related symptoms. L. plantarum Y44 ameliorated intestinal inflammation and lipid metabolism disorders by modulating gut microbiota.

Carotid Intima-media Thickness in Patients with Non-alcoholic Fatty Liver Disease Attending a Tertiary Care Center: A Descriptive Cross-sectional Study

INTRODUCTION

Non-alcoholic fatty liver disease is fatty infiltration of the liver in the absence of other causes of steatosis. It is strongly associated with central adiposity, high body mass index, insulin resistance states, hypertension, hyperlipidemia which are features of metabolic syndrome. The objective of study is to find out the carotid intima-media thickness of non alcoholic fatty liver disease patients attending a tertiary care center.

METHODS

This was a descriptive cross sectional study conducted at National Academy of Medical Sciences, Bir Hospital from July 2018 to June 2019 among 70 diagnosed cases of non alcoholic fatty liver disease based on ultrasound findings. Data collection was started after receiving ethical approval from Institutional Review Board of the Institute. Convenience sampling method was used. Data were entered using Microsoft Excel. The carotid intima-media thickness of both sides were measured by ultrasound. Statistical Package for Social Sciences version 20 was used for analysis.

RESULTS

Out of 70 cases, the mean carotid intima-media thickness was 0.7140±0.1796mm on right and 0.7161±0.1828mm on left side. Among 70 cases 45 (64.3%) were Grade II non alcoholic fatty liver disease and 25 (35.7%) were Grade I. It was 0.5720±0.1275mm and 0.7929±0.1546mm in Grade I and II non alcoholic fatty liver disease cases respectively on right side whereas it was 0.5676±0.1259mm and 0.7987±0.1557mm respectively on left side.

CONCLUSIONS

This study showed increased carotid intima-media thickness in non alcoholic fatty liver disease cases.

Non-Alcoholic Fatty Liver Disease and Cardiovascular Comorbidities: Pathophysiological Links, Diagnosis, and Therapeutic Management

Non-alcoholic fatty liver disease (NAFLD) has a growing prevalence in recent years. Its association with cardiovascular disease has been intensively studied, and certain correlations have been identified. The connection between these two entities has lately aroused interest regarding therapeutic management. In order to find the best therapeutic options, a detailed understanding of the pathophysiology that links (NAFLD) to cardiovascular comorbidities is needed. This review focuses on the pathogenic mechanisms that are behind these two diseases and on the therapeutic management available at this time.

Interplay between Heart Disease and Metabolic Steatosis: A Contemporary Perspective

The liver-heart axis is a growing field of interest owing to rising evidence of complex bidirectional interplay between the two organs. Recent data suggest non-alcoholic fatty liver disease (NAFLD) has a significant, independent association with a wide spectrum of structural and functional cardiac diseases, and seems to worsen cardiovascular disease (CVD) prognosis. Conversely, the effect of cardiac disease on NAFLD is not well studied and data are mostly limited to cardiogenic liver disease. We believe it is important to further investigate the heart-liver relationship because of the tremendous global health and economic burden the two diseases pose, and the impact of such investigations on clinical decision making and management guidelines for both diseases. In this review, we summarize the current knowledge on NAFLD diagnosis, its systemic manifestations, and associations with CVD. More specifically, we review the pathophysiological mechanisms that govern the interplay between NAFLD and CVD and evaluate the relationship between different CVD treatments and NAFLD progression.

Serum Bilirubin and Coronary Artery Disease: Intricate Relationship, Pathophysiology, and Recent Evidence

Coronary artery disease (CAD) is a major cause of morbidity, mortality, and healthcare expenditure. A number of environmental and genetic risk factors have been known to contribute to CAD. More recently, a number of studies have supported as well as opposed a possible protective benefit of bilirubin in CAD, since it has anti-inflammatory, antioxidant, and antiaggregatory properties that may reduce atherogenesis. It also shares associations with different forms of CAD, namely stable CAD, unstable angina pectoris, stable angina pectoris, and acute myocardial infarction. Lack of sufficient evidence, however, has failed to elucidate a causal relationship between serum bilirubin level and risk of CAD. Therefore, in this update, we attempted to simplify this intricate relationship between bilirubin and CAD, revisit the pathophysiology of disease, how bilirubin may be protective, and to summarize the findings of the current literature.

CON: Noninvasive Imaging Is the Preferred Strategy for Cardiovascular Risk Stratification in This Patient

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Hepatoprotective properties of glycyrrhizic acid

The review is devoted to the problem of treatment of non-alcoholic fatty liver disease, which is the most common pathology of the hepato-biliary system worldwide and is characterized by an increasing frequency, including of more severe forms. A wide range of pathogenetic relationships of non-alcoholic fatty liver disease with diseases of other organ systems, primarily with diseases of the cardiovascular system, type 2 diabetes mellitus, chronic kidney disease and diseases of the biliary tract, is presented. The main mechanisms of comorbidity are insulin resistance, oxidative stress, inflammation, disorders of carbohydrate and fat metabolism. An approach to the therapy of this disease based on the concept of comorbidity has been substantiated. As a rational therapeutic choice, a molecule of glycyrrhizic acid is presented, which has pleiotropic effects, including anti-inflammatory, antioxidant, antifibrotic and immunomodulatory effects. The evidence base for glycyrrhizic acid is formed by a large array of clinical trials, including randomized placebo-controlled trials conducted both in Russia and abroad, in infectious and non-infectious liver diseases, including non-alcoholic fatty liver disease. Attention is focused on non-alcoholic fatty liver disease with intrahepatic cholestasis associated with a more severe course and high rates of disease progression. A theoretical justification for the use of a combination of glycyrrhizic acid and ursodeoxycholic acid in such patients is presented. The reason for this is the potential synergy of the two molecules, based on the induction of CYP3A4, and associated with the effect on inflammation, as a factor in the development of intrahepatic cholestasis and cholestasis itself.

Non-alcoholic fatty liver disease (NAFLD) and the cardiovascular disease (CVD) risk categories in primary care: is there an association?

Background

Non-alcoholic fatty liver disease (NAFLD) is an emerging novel cardiovascular disease (CVD) risk factor. It’s prevalence is increasing globally. However, there is paucity in the evidence showing the association between NAFLD and CVD risk in primary care setting. Therefore, the objectives of this study were to determine the prevalence and factors associated with NAFLD among patients with ≥1 risk factor for NAFLD or CVD attending primary care clinics.

Methodology

A cross sectional study was conducted in two clinics at a university primary care centre. Patients aged ≥18 years with ≥1 risk factor for NAFLD or CVD were recruited. Participants with history of established liver disease or chronic alcohol use were excluded. Socio-demographics, clinical related data, anthropometric measurements and blood investigation results were recorded in a proforma. Diagnosis of NAFLD was made using abdominal ultrasound. The 10-year CVD risk was calculated using the general Framingham Risk Score (FRS). Multiple logistic regression (MLogR) was performed to identify independent factors associated with NAFLD.

Results

A total of 263 participants were recruited. The mean age was 52.3 ± 14.7 years old. Male and female were equally distributed. Majority of the participants were Malays (79.8%). The overall prevalence of NAFLD was 54.4% (95%CI 48,60%). Participants in the high FRS category have higher prevalence of NAFLD (65.5%), followed by those in the moderate category (55.4%) and the low category (46.3%), p = 0.025. From MLogR, independent factors associated with NAFLD were being employed (OR = 2.44, 95%CI 1.26,4.70, p = 0.008), obesity with BMI ≥27.5 (OR = 2.89, 95%CI 1.21,6.91, p = 0.017), elevated fasting glucose ≥5.6 mmol/L (OR = 2.79, 95%CI 1.44,5.43, p = 0.002), ALT ≥34 U/L (OR = 3.70, 95%CI 1.85,7.44, p < 0.001) and high FRS category (OR = 2.82, 95%CI 1.28,6.23, p = 0.010).

Conclusion

NAFLD is highly prevalent among patients with ≥1 risk factor for NAFLD or CVD in these primary care clinics. Patients who were obese, have elevated fasting glucose, elevated ALT and in the high FRS category were more likely to have NAFLD. This study underscores the importance of targeted screening for NAFLD in those with risk factors in primary care. Aggressive intervention must be executed in those with NAFLD in order to reduce CVD complications and risk of progression.

A New, Non-Invasive Scale for Steatosis Developed Using Real-World Data From Russian Outpatients to Aid in the Diagnosis of Non-Alcoholic Fatty Liver Disease

INTRODUCTION

The current non-invasive tools for the diagnosis of non-alcoholic fatty liver disease (NAFLD) have methodological limitations. We aimed to develop a non-invasive scale to assist in the diagnosis of NAFLD. To achieve our aim, we conducted a secondary analysis of data from a large observational study conducted in Russia.

METHODS

This retrospective analysis assessed the frequency of NAFLD in the population of patients in the DIREG_L_06725 study, an epidemiological, observational, cross-sectional, multicenter study performed in 50,145 outpatients from 16 Russian cities. Among the cohort of patients diagnosed with NAFLD, we identified factors associated with the risk of NAFLD. To develop a non-invasive tool for diagnosing NAFLD, we also determined the frequency of steatohepatitis.

RESULTS

Our analysis included 48,297 patients; NAFLD was present in 20,281 patients (42.0%). The majority (64.1%) were women (80.3% post-menopause), and 87% had a body mass index (BMI) > 27.0 kg/m2. We developed a fully non-invasive scale (St-index) that showed a specificity of 91.4% for ruling in steatosis, and a sensitivity of 93.8% for ruling out steatosis. Multivariate regression analyses conducted in the subgroups of patients aged ≥ 12 and < 18 years and those with BMI < 25.0 kg/m2 produced area under the receiver operating characteristic (AUROC) curve values of 0.8243 and 0.7054, respectively. The factors most strongly associated with the development of NAFLD were age > 35 years, presence of type 2 diabetes mellitus, and a waist circumference/height ratio > 0.54.

CONCLUSION

Our non-invasive steatosis scale, St-index, can help physicians diagnose NAFLD in high-risk patients in the absence of ultrasound data.

Effects of fatty liver on the size and composition of high-density lipoprotein cholesterol subpopulations in adolescents with type 2 diabetes mellitus

BACKGROUND

Type 2 diabetes mellitus (T2DM) is an emerging disease in the pediatric population. The association between T2DM and non-alcoholic fatty liver disease (NAFLD) has been described. Recent evidence suggests that sizes and composition of high-density lipoprotein (HDL) may be more important that HDL-C levels in predicting coronary heart disease. There is not data regarding the HDL subclasses distribution and composition in T2DM youths with NAFLD.

METHODS

This cross-sectional study included 47 adolescents with T2DM and 23 non-diabetic controls of both sexes aged 10 to 18 years. The presence of NAFLD was determined estimated proton density fat fraction (PDFF) by magnetic resonance by spectroscopy. We compared the HDL subclasses distribution (HDL2b, HDL2a, HDL3a HDL3b and HDL3c) and the HDL chemical composition (total protein, triglyceride, phospholipid, cholesteryl esters, and free cholesterol) between the groups of adolescents with T2DM and the control group.

RESULTS

Patients with T2DM and NAFLD had a significantly lower proportion HDL2b (P = .040) and a higher proportion of HDL3c (P = .035); higher proportion of TG (P = .032) and a lower CE (P = .002) and FC (P < .001). A negative association was observed between PDFF and the percentages of HDL2b (r² = -0.341, P = .004) and the average particle size (r² = -0.327, P = .05), and a positive association with HDL3c subpopulations (r² = 0.327, P = .015); about composition inside HDL particle, a positive association with PDFF and the TG (r² = 0.299, P = .013) and negative with CE (r² = -0.265, P = .030).

CONCLUSIONS

In adolescents diagnosed with T2DM, the presence of NAFLD is associated with abnormalities in the distribution of HDL subpopulations and the lipid composition of HDL particles.

Relationship between non-alcoholic fatty liver disease and coronary heart disease

Non-alcoholic fatty liver disease (NAFLD) is the leading cause of chronic liver disease and considered a liver manifestation of metabolic syndrome. It is in close relationship with insulin resistance, obesity, diabetes mellitus, all of which increase risk of cardiovascular disease (CVD). Besides, many studies point out that NAFLD independently contributes to the development of atherosclerosis and CHD. On the other hand, CVDs are the leading cause of death in NAFLD patients. Many pathophysiological changes and molecular mechanisms play an important role in NAFLD for CVD formation. Atherosclerosis is common in NAFLD, which also mainly contributes to the CVD formation and CHD. Many studies linking atherosclerotic CHD and NAFLD are present in the literature. Subclinical CHD, mainly detected by coronary computed tomography views, have been detected more common in NAFLD patients. Presence of NAFLD has been found to be more common in patients with severe CHD and in stable CHD, NAFLD has been found to be associated with more diffuse disease. In acute coronary syndromes, especially in acute myocardial infarction, patients with NAFLD have been found to have poor prognosis when compared with NAFLD free patients. In this review, our aim is to evaluate the relationship between NAFLD and CHD in detail and go over the pathophysiological mechanisms underlying this relationship.

Genetic Variants Associated with Non-Alcoholic Fatty Liver Disease Do Not Associate with Measures of Sub-Clinical Atherosclerosis: Results from the IMPROVE Study

Non-alcoholic fatty liver disease (NAFLD) and atherosclerosis-related cardiovascular diseases (CVD) share common metabolic pathways. We explored the association between three NAFLD-associated single nucleotide polymorphisms (SNPs) rs738409, rs10401969, and rs1260326 with sub-clinical atherosclerosis estimated by the carotid intima-media thickness (c-IMT) and the inter-adventitia common carotid artery diameter (ICCAD) in patients free from clinically overt NAFLD and CVD. The study population is the IMPROVE, a multicenter European study (n = 3711). C-IMT measures and ICCAD were recorded using a standardized protocol. Linear regression with an additive genetic model was used to test for association of the three SNPs with c-IMT and ICCAD. In secondary analyses, the association of the three SNPs with c-IMT and ICCAD was tested after stratification by alanine aminotransferase levels (ALT). No associations were found between rs738409, rs1260326, rs10401969, and c-IMT or ICCAD. Rs738409-G and rs10401969-C were associated with ALT levels (p < 0.001). In patients with ALT levels above 28 U/L (highest quartile), we observed an association between rs10401969-C and c-IMT measures of c-IMT_max and c-IMT_mean-max (p = 0.018 and 0.021, respectively). In conclusion, NAFLD-associated SNPs do not associate with sub-clinical atherosclerosis measures. However, our results suggest a possible mediating function of impaired liver function on atherosclerosis development.

Lipoprotein and Metabolic Profiles Indicate Similar Cardiovascular Risk of Liver Steatosis and NASH

BACKGROUND AND AIM

Nonalcoholic fatty liver disease (NAFLD) affects about 25% of the global population, with no reliable noninvasive tests to diagnose nonalcoholic steatohepatitis (NASH) and to differentiate between NASH and nonalcoholic fatty liver (NAFL) (steatosis alone). It is unclear if NAFL and NASH differ in cardiovascular risk for patients. Here, we compared obese NAFLD patients with a healthy cohort to test whether cholesterol compounds could represent potential noninvasive markers and to estimate associated risks.

METHOD

Serum samples of 46 patients with histologically confirmed NAFLD (17 NAFL, 29 NASH) who underwent bariatric surgery were compared to 32 (9 males, 21 females) healthy controls (HCs). We analyzed epidemiological data, liver enzymes, cholesterol and lipid profile, and amino acids. The latter were analyzed by nuclear magnetic resonance spectroscopy.

RESULTS

Total serum and high-density lipoprotein (HDL) cholesterol were significantly lower in the NAFLD group than in HCs, with a stronger reduction in NASH. Similar observations were made for sub-specification of HDL-p, HDL-s, SHDL-p, and LHDL-p cholesterols. Low-density lipoprotein (LDL)-s and LLDL-p cholesterol were significantly reduced in NAFLD groups. Interestingly, SLDL-p cholesterol was significantly higher in the NAFL group with a stronger elevation in NASH than in HCs. The amino acids alanine, leucin, and isoleucine were significantly higher in the NAFL and NASH groups than in HCs.

CONCLUSION

We show in this study that cholesterol profiles, apolipoproteins, and amino acids could function as a potential noninvasive test to screen for NAFLD or even NASH in larger populations. However, few differences in cholesterol profiles were identified between the NAFL and NASH groups, indicating similar cardiovascular risk profiles.

Sex differences in cardiovascular diseases and associated risk factors in non-alcoholic steatohepatitis

BACKGROUND

Non-alcoholic steatohepatitis (NASH) is well recognized as an important cardiovascular disease (CVD) risk factor. However, not many studies have described the prevalence of traditional CVD risk factors and CV diseases, and respective sex differences, in patients with NASH.

METHODS

In this retrospective observational cohort study using the 2016 US National Readmissions Database, we studied adults with NASH to identify the prevalence of important CVD risk factors like age, obesity, hypertension, diabetes mellitus, renal failure, dyslipidemia, smoking, and drug abuse and cardiovascular diseases like coronary artery disease, myocardial infarction and coronary revascularization, peripheral vascular disease, cerebrovascular disease, and pulmonary vascular disease. We studied sex differences using the Pearson χ2 test for categorical variables, student t-test for continuous variables, and logistic regression for age-adjusted analysis.

RESULTS

Our study sample included 41,005 patients with NASH of which 15,758 (38.4%) were male and 25,247 (61.6%) were female. Hypertension was the most prevalent CVD risk factor (68%), followed by diabetes mellitus (62%), obesity (40%), dyslipidemia (37%), smoking (30%), and renal failure in 27%. Of the cardiovascular diseases studied, coronary artery disease (20.6%) and heart failure (19.6%) were highly prevalent followed by peripheral vascular disease (5.7%), stroke (4.7%), and pulmonary vascular disease (1.4%). Men had higher rates of most risk factors and diseases compared with women, except for higher rates of obesity and diabetes mellitus in women and a similar rate of drug abuse, stroke, and pulmonary vascular disease between the sex groups.

CONCLUSION

In patients with NASH, CVD risk factors and diseases were highly prevalent and important sex differences were present.

Liver fat content might be an appropriate measure for estimation of cardiovascular disease risk in non-alcoholic steatohepatitis patients

Background: Non-alcoholic steatohepatitis (NASH) is increasing worldwide due to the metabolic syndrome epidemy. According to the current evidence, a higher cardiovascular disease risk (CVDR) is observed in NASH individuals than the general population. Objective: The relationship between liver fat content (LFC) and CVDR in a cohort of NASH patients was evaluated in this research. Methods: Consecutively selected patients with increased aminotransferase levels and fatty change in liver ultrasonography were enrolled in the study. Those with known causes of viral hepatitis, any hepatotoxic medications or alcohol consumption, autoimmune hepatitis, cigarette smoking, and ischemic heart disease were excluded from the project. The remaining was presumed to have NASH. The Framingham risk score (FRS) and LFC were calculated by means of an online calculator and a valid formula, respectively. The correlation between LFC and independent variables was measured using the Pearson correlation test. The P-value of less than 0.05 was considered significant. The statistical analysis was performed using SPSS program version 18. Results: Finally, two hundred NASH patients were included in the study. Considering diabetes mellitus as a confounder, there was a fair relationship between LFC and FRS (R=0.26 and 0.23, respectively, p<0.05) in the second and third visits. Even after adjustment for known cardiovascular risk factors, LFC was associated with increased CVDR (OR=9.181; 95% CI: 2.00-42.14, p=0.01). The cut-off value of 9.1% for LFC had a sensitivity of 92% and a specificity of 87% for discrimination of the FRS >20% and <20%. Conclusion: LFC might independently be correlated with CVDR in NASH patients. If further research confirmed this relationship, the inclusion of LFC into the FRS formula would provide an appropriate CVDR estimation tool in NASH.

Semaglutide for the treatment of non-alcoholic steatohepatitis: Trial design and comparison of non-invasive biomarkers

Non-alcoholic steatohepatitis (NASH) is a chronic liver disease. There is a clear need to develop pharmacological treatment for patients with NASH as well as biomarkers that can diagnose the disease. We describe a trial of semaglutide treatment for NASH, identify key patient characteristics and compare the relationship of patient characteristics and non-invasive biomarkers/scores. NCT02970942 is a randomised, double-blind, placebo-controlled, multi-national Phase 2 trial of daily subcutaneous semaglutide (0.1 mg, 0.2 mg, 0.4 mg) in patients with biopsy-confirmed NASH, F1-F3 fibrosis, NAFLD Activity Score ≥ 4, and body mass index (BMI) > 25 kg/m². Exploratory analyses were performed to evaluate correlations between baseline parameters and biomarkers in NASH. Mean (standard deviation [SD]) age of 320 randomised patients was 55 (11) years, mean BMI was 36 (6) kg/m², and 199 (62%) had type 2 diabetes. Of the total patients, 28% had F1 fibrosis, 23% had F2 fibrosis and 49% had F3 fibrosis. The highest area under the receiver operating characteristic curve (0.69) for accuracy in classifying fibrosis stage, F2-3 versus F1, was observed for Fib-4 and Enhanced Liver Fibrosis (ELF). No substantial correlation between BMI or other clinical or biochemical parameters and fibrosis stage was observed. In this large Phase 2 trial of semaglutide treatment for NASH, the clinical profile of enrolled patients was typical for patients with NASH. Of the investigated biomarkers/scores, ELF and Fib-4 showed the most apparent correlation in classifying fibrosis stage, but had only moderate predictive value.

Editoral commentary: Understanding cardiovascular disease risk in women with polycystic ovary syndrome

In the accompanying paper, Osibogun et al. comprehensively review the risk contributors and primary endpoints for cardiovascular disease (CVD) in women in polycystic ovary syndrome (PCOS). The authors conclude that based on the available literature, women with PCOS do have increased CVD, although better quality data are sorely needed. The authors emphasize that screening and personalized treatment for all risk factors related to CVD must be performed across the lifespan in women with PCOS.

Fermented Rhus Verniciflua Stokes Extract Alleviates Nonalcoholic Fatty Liver through the AMPK/SREBP1/PCSK9 Pathway in HFD-Induced Nonalcoholic Fatty Liver Animal Model

Background: We have previously reported the anti-hepatic lipogenic effect of fermented Rhus verniciflua stokes extract (FRVE) in an oleic-acid-treated HepG2 cell model. Methods: Herein, we advanced our understanding and evaluated the impact of FRVE in HFD-fed C57BL/6 mice using an animal model of nonalcoholic fatty liver disease (NAFLD). Milk thistle extract was used as a positive control to compare the effects of FRVE. Results: FRVE decreased body weight, intra-abdominal fat weight, and liver weight. Furthermore, FRVE decreased HFD-induced elevated serum levels of ALT, AST, TC, and TG, and downregulated the increase in hepatic lipid accumulation and TG levels. FRVE reduced hepatic SREBP-1, PCSK-9, SREBP-2, and ApoB mRNA levels. IHC data showed that FRVE reduced the levels of nucleic SREBP-1, increased the levels of LDLR, and upregulated the expression of p-AMPK. Conclusion: Overall, these results demonstrate the anti-hepatic lipidemic effect of FRVE in an animal model. These findings are consistent with our previous study and strongly suggest that FRVE exerts anti-hepatic lipogenic effects by activating AMPK.

Phoenixin 14 Inhibits High-Fat Diet-Induced Non-Alcoholic Fatty Liver Disease in Experimental Mice

Introduction

Nonalcoholic fatty liver disease (NAFLD) is one of the most common chronic liver diseases. The development of NAFLD is closely associated with hepatic lipotoxicity, inflammation, and oxidative stress. The new concept of NAFLD treatment is to seek molecular control of lipid metabolism and hepatic redox hemostasis. Phoenixin is a newly identified neuropeptide with pleiotropic effects. This study investigated the effects of phoenixin 14 against high-fat diet (HFD)-induced NAFLD in mice.

Materials and Methods

For this study, we used HFD-induced NAFLD mice models to analyze the effect of phonenixin14. The mice were fed on HFD and normal diet and also given phoenixin 14 (100 ng/g body weight) by gastrogavage for 10 weeks. The peripheral blood samples were collected for biochemical assays. The liver tissues were examined for HFD-induced tissue fibrosis, lipid deposition and oxidative activity including SOD, GSH, and MDA. The liver tissues were analyzed for the inflammatory cytokines and oxidative stress pathway genes.

Results

The results indicate that phoenixin 14 significantly ameliorated HFD-induced obesity and fatty liver. The biochemical analysis of blood samples revealed that phoenixin 14 ameliorated HFD-induced elevated circulating alanine aminotransferase (ALT), aspartate aminotransferase (AST), total cholesterol, and triglyceride levels, suggesting that phoenixin 14 has a protective role in liver function and lipid metabolism. Hematoxylin-eosin (HE) and Oil Red O staining of the liver showed that phoenixin 14 alleviated HFD-induced tissue damage and lipid deposition in the liver. Furthermore, the mice administered with phoenixin 14 had increased hepatic SOD activity, increased production of GSH and reduced MDA activity, as well as reduced production of TNF-α and IL-6 suggesting that phoenixin 14 exerts beneficial effects against inflammation and ROS. The findings suggest an explanation of how mechanistically phoenixin 14 ameliorated HFD-induced reduced activation of the SIRT1/AMPK and NRF2/HO-1 pathways.

Conclusion

Collectively, this study revealed that phoenixin 14 exerts a protective effect in experimental NAFLD mice. Phoenixin could be of the interest in preventive modulation of NAFLD.

Nonalcoholic fatty liver disease: implications for endocrinologists and cardiologists

Type 2 diabetes mellitus is not just a risk factor but a progression factor for a plethora of multi-organ complications, including the liver and the vascular system. The profibrogenic-inflammatory liver disease nonalcoholic steatohepatitis affects patient's mortality and overall cardiovascular and liver-related complications. There is an evident overlap between these diseases; therefore, there are important implications for endocrinologists, cardiologists, and hepatologists when treating these patients. In addition, as newly approved nonalcoholic steatohepatitis pharmacotherapy is expected to be available early this year, clinicians need to be able to identify patients with type 2 diabetes mellitus that are at risk of advanced liver fibrosis to establish adequate and efficient management plans to limit or avoid cardiovascular or liver-related complications. In this review, we summarize the current knowledge in the nonalcoholic steatohepatitis field with potential value for clinicians focusing on the implications of the overlap between type 2 diabetes mellitus, cardiovascular disease, and nonalcoholic steatohepatitis, the available diagnostic tools for risk stratification, management pathways, and nonalcoholic steatohepatitis pharmacotherapy, including antidiabetic and cardiovascular drugs that may be beneficial or detrimental to their patients.

Association of worsening of nonalcoholic fatty liver disease with cardiometabolic function and intestinal bacterial overgrowth: A cross-sectional study

Background & aims

Non-alcoholic fatty liver disease (NAFLD) has been associated with small bowel bacterial overgrowth (SIBO) and cardiometabolic dysfunction. This cross-sectional study aimed to evaluate the cardio-metabolic parameters and SIBO in patients with different degrees of hepatic fibrosis estimated by NAFLD fibrosis score (NFS).

Methods

Subjects (n = 78) were allocated to three groups: Healthy control (n = 30), NAFLD with low risk of advanced fibrosis (NAFLD-LRAF, n = 17) and NAFLD with a high risk of advanced fibrosis (NAFLD-HRAF, n = 31). Anthropometrics, blood pressure, electrocardiogram and heart rate variability (HRV) were evaluated. Only the NAFLD-LRAF and NAFLD-HRAF groups were submitted to blood biochemical analysis and glucose hydrogen breath tests.

Results

The NAFLD-HRAF group had higher age and body mass index when compared to the control and NAFLD-LRAF groups. The prevalence of SIBO in the NAFLD group was 8.33%. The low frequency/high-frequency ratio (LF/HF ratio) was augmented in NAFLD-LRAF (p < 0.05) when compared with control group. NAFLD-HRAF group had a wide QRS complex (p < 0.05) and reduced LF/HF ratio (p < 0.05) compared to the control and NAFLD-LRAF groups. Serum levels of albumin and platelets were more reduced in the NAFLD-HRAF subjects (p < 0.05) than in the NAFLD-LRAF.

Conclusions

NAFLD impairs cardiac autonomic function. Greater impairment was found in subjects with a worse degree of hepatic fibrosis estimated by NFS. Hypoalbuminemia and thrombocytopenia were higher in subjects with a worse degree of hepatic fibrosis, whereas prevalence of SIBO positive was similar between the groups.