Investigating the Interplay of Toxic Metals and Essential Elements in Liver Disease

Liver diseases, including non-alcoholic fatty liver disease (NAFLD), are a growing global health issue. Environmental exposure to toxic metals can harm the liver, increasing the risk of NAFLD. Essential elements are vital for liver health, but imbalances or deficiencies can contribute to the development of NAFLD. Therefore, understanding the interplay between toxic metals and essential elements in liver disease is important. This study aims to assess the individual and combined effects of toxic metals (lead(Pb), cadmium (Cd), mercury (Hg)), and essential elements (manganese and selenium) on the risk of liver disease. Methods: We assessed the individual and combined effects of Pb, Cd, Hg, manganese (Mn), and selenium (Se) on liver disease risk using data from the National Health and Nutrition Examination Survey between 2017 and 2018. We performed descriptive statistics and linear regression analysis and then utilized Bayesian Kernel Machine Regression (BKMR) techniques such as univariate, bivariate, and overall effect analysis. BKMR enabled the assessment of non-linear exposure-response functions and interactions between metals and essential elements. Posterior Inclusion Probabilities (PIPs) were calculated to determine the importance of each metal and essential element in contributing to liver disease. Regarding our study results, the regression analysis of liver injury biomarkers ALT, AST, ALP, GGT, total bilirubin, and the FLI-an indicator of NAFLD-with toxic metals and essential elements, adjusting for covariates such as age, sex, BMI, alcohol consumption, ethnicity, income, and smoking status, demonstrated the differential effects of these contaminants on the markers of interest. Our BKMR analysis provided further insights. For instance, the PIP results underscored Pb's consistent importance in contributing to liver disease (PIP = 1.000), followed by Hg (PIP = 0.9512), Cd (PIP = 0.5796), Se (PIP = 0.5572), and Mn (PIP = 0.4248). Our univariate analysis showed a positive trend with Pb, while other exposures were relatively flat. Our analysis of the single-variable effects of toxic metals and essential elements on NAFLD also revealed that Pb significantly affected the risk of NAFLD. Our bivariate analysis found a positive (toxic) trend when Pb was combined with other metals and essential elements. For the overall exposure effect of exposure to all the contaminants together, the estimated risk of NAFLD showed a steady increase from the 60th to the 75th percentile. In conclusion, our study indicates that Pb exposure, when combined with other toxic metals and essential elements, plays a significant role in bringing about adverse liver disease outcomes.

Natural compounds proposed for the management of non-alcoholic fatty liver disease

Although non-alcoholic fatty liver disease (NAFLD) presents as an intricate condition characterized by a growing prevalence, the often-recommended lifestyle interventions mostly lack high-level evidence of efficacy and there are currently no effective drugs proposed for this indication. The present review delves into NAFLD pathology, its diverse underlying physiopathological mechanisms and the available in vitro, in vivo, and clinical evidence regarding the use of natural compounds for its management, through three pivotal targets (oxidative stress, cellular inflammation, and insulin resistance). The promising perspectives that natural compounds offer for NAFLD management underscore the need for additional clinical and lifestyle intervention trials. Encouraging further research will contribute to establishing more robust evidence and practical recommendations tailored to patients with varying NAFLD grades.

Physical activity intensity and markers of inflammation in those with non-alcoholic fatty liver disease

AIMS

To investigate associations between objectively measured light (LPA) and moderate-to-vigorous (MVPA) physical activity on plasma homocysteine and serum C-reactive protein (CRP) in individuals with Non-Alcoholic Fatty Liver Disease (NAFLD).

METHODS

This study was a secondary analysis using data from 2003 to 2006 National Health and Nutrition Examination Survey including a total of 983 individuals with NAFLD. Physical activity was assessed over 7 days with accelerometers. Participants were split into tertiles based on average daily minutes of LPA or MVPA and CRP and homocysteine were assessed across tertiles.

RESULTS

Adjusted plasma homocysteine and CRP were not different between groups regarding levels of LPA (Homocysteine: 1st tertile - 10.4 ± 0.7 µmol/L; 2nd tertile - 9.6 ± 0.4 µmol/L; 3rd tertile - 9.6 ± 0.4 µmol/L; p = 0.28; CRP: 1st tertile - 0.79 ± 0.12 mg/dL; 2nd tertile - 0.73 ± 0.09 mg/dL; 3rd tertile - 0.73 ± 0.09 mg/dL; p = 0.72). Adjusted CRP was significantly (p = 0.02) different across MVPA tertiles (1st: 0.87 ± 0.13 mg/dL; 2nd: 0.75 ± 0.10 mg/dL; 3rd:0.65 ± 0.09).

CONCLUSIONS

LPA does not appear to be effective at improving homocysteine or CRP levels in individuals with NAFLD. However, MVPA may be an effective therapy for decreasing CRP in NAFLD patients.

The Role of the Fatty Liver Index (FLI) in the Management of Non-Alcoholic Fatty Liver Disease: A Systematic Review

Currently, non-alcoholic fatty liver disease is the most common liver disease worldwide, with a prevalence of 32%. It is much more common among men (40%) and among patients with metabolic comorbidities such as obesity, diabetes and dyslipidemia. Being an asymptomatic disease, the diagnosis is often established on the basis of imaging methods, with an important role given to abdominal ultrasonography, computed tomography and magnetic resonance imaging. In order to facilitate diagnosis, experts have introduced a series of blood biomarkers. Two biomarker panels are currently validated for the diagnosis of non-alcoholic fatty liver disease: the fatty liver index, and the hepatic steatosis index. The fatty liver index has been in use in medical practice for over 17 years and has demonstrated its accuracy in various studies that compared it with other diagnostic methods, highlighted its role in screening patients with cardiovascular risk and validated the effects of different diets and drugs that are proposed for the treatment of the disease. In the management of non-alcoholic fatty liver disease, the fatty liver index is an important algorithm in the diagnosis and prognosis of patients with metabolic risk. Taking into account the diversity of drugs to be approved in the treatment of non-alcoholic fatty liver disease, the fatty liver index will become an effective tool in monitoring the effects of these therapies.

Application of machine learning in predicting non-alcoholic fatty liver disease using anthropometric and body composition indices

Non-alcoholic fatty liver disease (NAFLD) is the most common chronic liver disease, which can progress from simple steatosis to advanced cirrhosis and hepatocellular carcinoma. Clinical diagnosis of NAFLD is crucial in the early stages of the disease. The main aim of this study was to apply machine learning (ML) methods to identify significant classifiers of NAFLD using body composition and anthropometric variables. A cross-sectional study was carried out among 513 individuals aged 13 years old or above in Iran. Anthropometric and body composition measurements were performed manually using body composition analyzer InBody 270. Hepatic steatosis and fibrosis were determined using a Fibroscan. ML methods including k-Nearest Neighbor (kNN), Support Vector Machine (SVM), Radial Basis Function (RBF) SVM, Gaussian Process (GP), Random Forest (RF), Neural Network (NN), Adaboost and Naïve Bayes were examined for model performance and to identify anthropometric and body composition predictors of fatty liver disease. RF generated the most accurate model for fatty liver (presence of any stage), steatosis stages and fibrosis stages with 82%, 52% and 57% accuracy, respectively. Abdomen circumference, waist circumference, chest circumference, trunk fat and body mass index were among the most important variables contributing to fatty liver disease. ML-based prediction of NAFLD using anthropometric and body composition data can assist clinicians in decision making. ML-based systems provide opportunities for NAFLD screening and early diagnosis, especially in population-level and remote areas.

Comparison of non-invasive fibrosis scores to predict increased liver stiffness in the general population with unknown liver disease: Searching for the primary physician's best friend

BACKGROUND

Serum-based scores (SBS) appear to be a high applicability strategy for assessment of liver fibrosis in primary care. Aim of the study was to evaluate their performance to detect ≥F2 in a general population and to design a highly-applicable strategy for screening.

METHODS

prospective population-based cohort study in randomly identified subjects, aged 40-70y. Medical history, blood tests and elastography were obtained, ≥F2 was determined by using LSM cutoff ≥9.2/7.8 kPa for M/XL probe and SBS diagnostic accuracies were evaluated.

RESULTS

986 patients were analyzed. LSM prevalence estimate suggestive of ≥F2 was 1.9% and Metabolic Sindrome (MS) (OR 3.4, 1.3-9.0;p = 0.01), was the only factor independently associated with ≥F2, with increasing prevalence according to the number of criteria (0 criterion:0%,1:0.3%,2:2.8%,3:2.4%,4:6.9%,5:14.3%;p<0.001). FLI and NFS were the two best-performing tests in the cross-sectional study, with AUROCs for ≥F2 of 0.89 (95%CI,0.84- 0.95) and 0.82 (95%CI,0.74-0.90), respectively. Predefined cutoff for FLI≥60 (Sn89.5%, Sp72.1%, NPV99.9%) and NFS≥-1.455 (Sn83.3%, Sp68%, NPV99.6%) showed adequate diagnostic accuracy. Based on these findings, a 3- step algorithm strategy to detect liver fibrosis in the community setting is proposed (Sn84.2%, Sp75.2%, NVP99.6%).

CONCLUSIONS

A staged risk-stratification model improves the detection of ≥F2 in the community setting, while reducing unnecessary referrals.

Fatty Liver Index is a valid predictor of non-alcoholic fatty liver disease (NAFLD) in pregnancy

BACKGROUND

Despite the evidence for adverse pregnancy outcomes, non-alcoholic fatty liver disease (NAFLD) is not routinely addressed in early pregnancy. The Fatty Liver Index (FLI) has been proposed as a screening tool for NAFLD in the general population. We aim to develop mathematical models for predicting NAFLD in pregnancy and validate the FLI for first-trimester pregnant women.

METHODS

Biochemical and biophysical parameters were analysed in pregnant women with period of gestation <12 weeks was done among Rajarata Pregnancy Cohort, Sri Lanka. Fatty liver was graded as (FLG) 0, I or II by ultrasound scan. Binary logistic regression models were employed to identify the factors predicting FLG-II. Six FLIs were developed to predict FLG-II. Validity of the FLIs was compared using the receiver operating characteristic curves.

RESULTS

The study sample consisted of 632 pregnant women with a mean age of 28.8 years (SD: 5.8 years). Age (OR: 1.6, 95% CI 1.1 to 2.3), body mass index (OR: 1.7, 95% CI 1.1 to 2.5) and gamma-glutamyl transferase levels (OR: 2.1, 95% CI 1.5 to 3.0) were the independent predictors of FLG-II. While the model with liver enzymes provided the best prediction of NAFLD (both FLG I and II) (area under the curve [(AUC]): -0.734), the highest AUC (0.84) for predicting FLG-II was observed with the full model (model with all parameters). The proposed budget model (AUC >0.81) is the best model for screening fatty liver in community health setup.

CONCLUSION

FLIs could be used as screening tools for NAFLD based on resource availability in different settings. External validation of the FLI and further investigation of the proposed FLI as a predictor of adverse pregnancy outcomes are recommended.

Population-specific cut-off points of fatty liver index: a study based on the National Health and Nutrition Examination Survey data

BACKGROUND

Fatty liver index (FLI) is the most recognized blood biomarker for diagnosis of hepatic steatosis (HS), but lacks the reliable specific cut-off points (COPs). Therefore, we aim to investigate the population-specific COPs of FLI based on the results of liver ultrasound transient elastography (LUTE) and conventional ultrasonography in the National Health and Nutrition Examination Survey (NHANES).

METHODS

5948 participants who underwent LUTE from the NHANES 2017-2018 and 14,797 participants who underwent conventional ultrasonography from the Third NHANES (NHANES III) were recruited. FLI was calculated by using body mass index (BMI), waist circumference (WC), triglyceride, and gamma-glutamyl transferase, and its optimal COPs in a specific population (stratified by sex, BMI, and WC) were obtained from receiver operator characteristics (ROC) curve with ultrasonic-diagnosed HS as the reference standard.

RESULTS

Based on LUTE in NHANES 2017-2018, the prevalence of HS and metabolic dysfunction-associated fatty liver disease (MAFLD) were 58.7% and 56.2%, respectively, and the optimal COP of FLI for HS diagnosis in the overall population was 45.60, with an area under ROC curve (AUROC) of 0.833 (0.822-0.844). Based on conventional ultrasonography in NHANES III, the prevalence of HS and MAFLD were 34.4% and 27. 9%, respectively, and the optimal COP of FLI for HS was 59.5, with an AUROC of 0.681 (0.671-0.691). With the increase of BMI and WC, the COPs increased gradually with significant differences between different groups. Compared with conventional ultrasonography, the COPs of FLI based on LUTE were much more precise, with higher diagnostic ability. The population-specific COPs of FLI stratified by gender, WC, and BMI were tabulated.

CONCLUSION

In the United States, the incidences of HS and MAFLD were high, especially when assessed by LUTE. The FLI based on LUTE is well capable of predicting HS when stratified by gender, WC, and BMI.

Dietary and Lifestyle Inflammation Scores Are Inversely Associated with Metabolic-Associated Fatty Liver Disease among Iranian Adults: A Nested Case-Control Study

BACKGROUND

Diet and lifestyle may affect risk for metabolic-associated fatty liver disease (MAFLD) by chronically elevating systemic inflammation.

OBJECTIVES

In this study we investigated the separate and joint associations of dietary and lifestyle inflammation scores (DIS and LIS, respectively) with MAFLD risk.

METHODS

For this nested case-control study we identified and recruited 968 patients with MAFLD (defined as having a fatty liver index ≥60 plus ≥1 of the following conditions: overweight or obese, type II diabetes mellitus, evidence of metabolic dysregulation) and 964 controls from among 35-70-y-old men and women in the baseline phase of the Sabzevar Persian Cohort Study. We collected demographic, lifestyle, anthropometric, biochemical, and dietary intake information (via a validated FFQ) from which we calculated a circulating inflammation biomarker-weighted, predominantly whole foods and beverages-based, 19-component DIS and a 3-component LIS. We estimated DIS- and LIS-MAFLD associations using multivariable unconditional logistic regression. We also calculated equal-weight DIS and LIS to capture all potential mechanisms (inflammation plus other mechanisms) for associations of diet and lifestyle with MAFLD risk.

RESULTS

Among those in the highest relative to the lowest DIS and LIS tertiles, the multivariable-adjusted ORs and their 95% CIs were OR: 1.84; 95% CI: 1.61, 2.07; Ptrend < 0.001, and OR: 1.96; 95% CI: 1.69, 2.21; Ptrend < 0.001, respectively. For those in the highest relative to the lowest joint DIS and LIS tertile, the values were OR: 2.56; 95% CI: 2.19, 2.93; Pinteraction < 0.001. The findings were similar by sex. The third tertile values for the equal-weight DIS- and LIS-MAFLD associations were OR: 1.87; 95% CI: 1.41, 2.34; and OR: 2.16; 95% CI: 1.85, 2.46, respectively.

CONCLUSIONS

Our results suggest that higher balances of pro- relative to anti-inflammatory dietary and lifestyle exposures, separately and especially jointly, may be associated with higher MAFLD risk among adults. Also, inflammation may be the primary mechanism through which diet affects MAFLD risk.

Quality of Life in Adults with Metabolic Dysfunction-Associated Fatty Liver Disease

The aims of this study were as follows: to investigate the association between metabolic dysfunction-associated fatty liver disease (MAFLD) and health-related quality of life (HRQoL), to evaluate whether stress perception and mental health among patients with MAFLD affect HRQoL, and to identify the underrated burden on MAFLD patients. Nationwide data from the 5th Korean National Health and Nutrition Examination Survey (KNHANES V, 2010 to 2012) were used. MAFLD was defined by a fatty liver index (FLI) of ≥60, and the EuroQol-5D (EQ-5D) was used to assess HRQoL. Logistic regression analysis and odds ratios (ORs) were used to determine the associations of MAFLD with stress, mental health, and HRQoL. Previous suicidal impulse was not found to be significantly associated with HRQoL. The risk of MAFLD increased 1.265-fold with an increase in stress levels based on the stress perception rate (confidence index (CI): 1.046–1.530; p < 0.05), while it increased 1.091-fold with a 1-point decrease in the EQ-5D score (CI: 1.019–1.169; p < 0.05). HRQoL impairment and stress levels are associated with MAFLD. It is important to evaluate stress levels among MAFLD patients and implement stress management and HRQoL improvement strategies.

Anti-inflammatory diet consumption reduced fatty liver indices

The aim of this study was to assess the association between dietary inflammatory index (DII) and non-invasive markers of liver status in adults. This cross-sectional study was performed on 8520 adults, recruited in Ravansar Non-Communicable Diseases (RaNCD) cohort study, western Iran. The DII score was calculated based on participants’ dietary intakes obtained from Food Frequency Questionnaire (FFQ). Fatty Liver Index (FLI) score was calculated by anthropometric measurements and some non-invasive markers of liver status. Linear regression models were applied to estimate the associations and adjust the possible confounding factors. A greater DII score was significantly associated with higher energy intake, body mass index (BMI), body fat mass (BFM), blood pressure, and FLI (P < 0.001). Participants with the highest DII score had a significantly higher consumption saturated fat, trans fat and red meat than those in the lowest quartile (P < 0.001). After adjustments of age and sex, participants in the highest quartile of the DII score had a greater risk of FLI (β: 0.742, 95% CI: 0.254, 0.601). More pro-inflammatory diet in participants was associated with a higher FLI. The DII score was positively associated with non-invasive liver markers. Thus, having an anti-inflammatory diet can help balance liver enzymes, reduce obesity, and decrease fatty liver.

Pediatric non-alcoholic fatty liver disease predicted by anthropometric values through transient elastography

BACKGROUND

Non-alcoholic fatty liver disease (NAFLD) is the leading cause of pediatric chronic liver disease, which is strongly associated with obesity. Transient elastography, together with anthropometric values including waist-to-height ratio (WHtR) and body mass index (BMI) z-scores are a more precise diagnostic method of NAFLD than ultrasonography. Through transient elastography, we investigate the principal anthropometric values associated with pediatric NAFLD.

METHODS

Healthy children between the ages of 6-18 years whose BMIs were ≥85% of normal were recruited as the overweight-and-obese group, and children whose BMIs ranged between 5%-85% were recruited as the control group. Non-alcoholic fatty liver disease was evaluated via transient elastography. BMI z-score and WHtR were measured.

RESULTS

A total of 107 (58 overweight-and-obese, 49 control) children were recruited. As evaluated by transient elastography, children in the overweight-and-obese group had significantly higher controlled attenuation parameter and liver stiffness measurement values than the control group. To detect fatty liver, WHtR with a cut-off point of 0.481 and BMI z-score with cut-off point of 1.075 had the best sensitivity and specificity. To identify liver stiffness or inflammation, WHtR with cut-off point of 0.514 and BMI z-score with cut-off point of 1.62 had the best sensitivity and specificity. Controlled attenuation parameter demonstrated a fair correlation with WHtR and BMI z-scores, even in the normal range of these parameters.

CONCLUSIONS

Transient elastography together with anthropometric measurements demonstrate that pediatric NAFLD may develop earlier than expected. We present principal anthropometric values associated with pediatric NAFLD.

Assessment of hepatic fibrosis and steatosis by vibration-controlled transient elastography and controlled attenuation parameter versus non-invasive assessment scores in patients with non-alcoholic fatty liver disease

Background

Non-alcoholic fatty liver disease (NAFLD) is regarded as the most common liver disease in the twenty-first century, and a condition leaving individuals at increased risk of extra-hepatic morbidity. Liver biopsy has long been regarded as the gold standard for diagnosis and prognostication of patients with NAFLD. However, due to its invasive nature and potential complications (e.g., bleeding), other methods for non-invasive laboratory and radiological assessment of hepatic steatosis and fibrosis in NAFLD have evolved and include scores such as AST/Platelet Ratio Index (APRI), Fibrosis-4 (FIB-4) score, NAFLD fibrosis score (NFS), and fatty liver index (FLI), in addition to radiological methods such as transient elastography (TE), which is a well-validated non-invasive ultrasound-based technique for assessment of hepatic fibrosis. Recently, novel development of controlled attenuation parameter (CAP) in TE allowed simultaneous assessment of hepatic steatosis. This provided a chance to assess both hepatic fibrosis and steatosis in the same setting and without any unwanted complications. This study aimed at assessing the role of TE and CAP versus other non-invasive assessment scores for liver fibrosis and steatosis in patients with NAFLD.

Results

This study included 90 patients diagnosed with NAFLD based on abdominal ultrasonography, body mass index, and serum liver enzymes. All patients were assessed with TE and non-invasive scores (APRI score, FIB-4 score, NFS, and FLI). There was a highly significant positive correlation between fibrosis and steatosis grades assessed by TE and other non-invasive respective scores. Both TE and CAP achieved acceptable sensitivity and specificity compared to other non-invasive assessment methods.

Conclusions

TE with CAP can be used as a screening method for patients suspected with NAFLD or patients without a clear indication for liver biopsy. CAP allows a non-invasive method of assessment of hepatic steatosis in patients with NAFLD.