Introduction

An international expert panel recently proposed a new name for fatty liver disease, namely metabolic (dysfunction)-associated fatty liver disease (MAFLD), and a new definition regardless of alcohol consumption. In a large cohort study using the National Health and Nutrition Examination Survey III database, the definition of MAFLD was found to be more practical than the criteria for non-alcoholic fatty liver disease (NAFLD) for identifying subjects with fatty liver who are at high risk of advanced hepatic fibrosis.
The prevalence of NAFLD is approximately 25% of the world’s adult population, and the global prevalence of MAFLD is estimated to be even higher. Therefore, MAFLD is commonly managed in the primary care setting. In view of the economics of health care, the ability to detect hepatic steatosis in a noninvasive, non-imaging manner is desirable. The fatty liver index (FLI), which is calculated using the body mass index (BMI), waist circumference (WC), and levels of γ‐glutamyl transferase (GGT) and triglycerides, is a noninvasive and simple surrogate diagnostic marker for hepatic steatosis. The FLI has good capability for discriminating NAFLD. Furthermore, the FLI has been recommended as a biomarker to detect hepatic steatosis in subjects with MAFLD.
Although a few studies have examined the validity of the FLI in the diagnosis of MAFLD none have mentioned the amount of alcohol consumed. The predictive power of the FLI in moderate drinkers has not been determined to date; however, because moderate drinkers are so numerous, we considered that an analysis of this group is essential. In addition, alcohol consumption shows a complex association with hepatic steatosis, with substantial differences by race/ethnicity and sex. In the present study, we investigated the usefulness of the FLI as a noninvasive marker to predict hepatic steatosis according to alcohol consumption and sex in a large number of Asian subjects.

Aims & Methods

Aim: This study was performed to investigate the utility of the fatty liver index (FLI) as a noninvasive tool for predicting hepatic steatosis based on alcohol consumption and sex in a large Asian population.
Methods: We conducted a single-center observational cohort study at the HITO Medical Center in Japan and enrolled 1,976 Asian subjects. The participants were categorized into non-drinkers and light drinkers (0–19 g/day) and moderate drinkers (20–59 g/day) based on their self-reported alcohol intake. We used physical examinations, laboratory tests, and a questionnaire to collect information on various factors related to the FLI, including body mass index, waist circumference, and levels of γ-glutamyl transferase and triglycerides.

Results

The diagnostic accuracy of the FLI was assessed by calculating the area under the receiver operating characteristic curve (AUROC), and optimal cutoff values were determined using Youden’s index. The FLI had an acceptable performance index of >0.7 both overall and in all subgroups, with an overall AUROC of 0.844. The AUROCs were higher in women and moderate drinkers of both sexes. We also compared the cutoff values obtained in the present study with the previously reported values of 30 and 60. Optimal cutoff values for the FLI were calculated for the total population and subgroups and were found to differ from the previously established values in other countries.

Conclusion

Our study suggests that the FLI is a useful noninvasive marker for predicting hepatic steatosis in a large Asian population, irrespective of alcohol consumption and sex.

Disclosure

Kiyoyuki Kobayashi, Masafumi Ono: Division of Innovative Medicine for Hepatobiliary and Pancreatology is an endowment department, supported with an unrestricted grant from HITO Medical Center.

Introduction

Steatotic liver disease (SLD) is silent in its early stage of disease but associated with long-term cirrhosis complications and hepatocellular carcinoma. Individuals with cardiometabolic risks are the target population for SLD screening. Fatty Liver Index (FLI) is the most widely used scoring system for identifying individuals with SLD on a population level. However, FLI incorporates waist circumference and gamma-glutamyl transferase, which are not routinely measured in clinical practice. The Dallas Steatosis Index (DSI), which utilizes more readily available clinical parameters, was recently developed to detect SLD in the US population.

Aims & Methods

This study aims to validate the DSI for diagnosing SLD in Thai individuals with cardiometabolic risk. We conducted a cross-sectional study using retrospective data from 2019 to 2023 at a tertiary care hospital in Southern Thailand. Inclusion criteria were individuals aged 18 years and older who participated in health check-up programs that included abdominal ultrasound (USG), blood tests, and had at least one cardiometabolic risk according to the latest SLD nomenclature consensus statement. SLD was diagnosed when liver steatosis was identified on the USG report. Exclusion criteria included individuals with positive HBsAg and/or HCV antibodies, as well as those with incomplete data on variables required for calculating the DSI, i.e., age, sex, ALT, triglycerides, body mass index (BMI), fasting blood sugar (FBS), diabetes, and hypertension status. The performance of DSI in diagnosing SLD in individuals with cardiometabolic risk was assessed by calculating the area under the receiver operating characteristic curve (AUROC), and sensitivity and specificity were evaluated at the given cutoffs.

Results

Of 5987 individuals without exclusion criteria, 5466 (91.3%) had at least one cardiometabolic risk and were included in this analysis. The prevalence of SLD diagnosed by USG was 48.8% (N=2667) in these at-risk individuals. DSI was calculated using published formula (https://dsi.wustl.edu/) and presented as predictive probabilities. DSI showed a very good performance in diagnosing SLD with an AUROC of 0.816 (95%CI: 0.805-0.827). At the given cutoff of 0.2 and 0.5 as the low and high cutoffs for detecting SLD, DSI <0.2 showed a sensitivity of 87.5% and NPV of 82.2% for ruling out SLD, and at the DSI >0.5, the specificity and PPV were 91.2% and 83.97% to ascertain SLD status, respectively. Among those 2667 individuals with SLD, 1358 (51%) who had available alcohol consumption data were then categorized into MASLD, MetALD, and ALD subclassifications. We found that 95.1% met the definition of MASLD, whereas 2.1% and 2.8% were categorized as MetALD, and ALD, respectively. The prevalence of advanced fibrosis (defined as FIB4 > 2.67) were 1.5%, 10.7%, and 10.5% in the MASLD, MetALD, and ALD groups, respectively (p<0.001).

Conclusion

The DSI demonstrated satisfactory diagnostic performance for diagnosing SLD in Thai individuals with cardiometabolic risk with an AUROC of 0.816 and may serve as an alternative to FLI for identifying SLD at the population level, particularly in resource-limited settings where imaging techniques such as USG and transient elastography are not readily accessible. However, additional studies are warranted to directly compare the diagnostic accuracy of DSI and FLI. Among those with SLD, MASLD were far more common than MetALD and ALD, but the presence of advanced fibrosis was significantly more prevalent in the latter two groups than those with MASLD.

References

McHenry S, Park Y, Browning JD, Sayuk G, Davidson NO. Dallas Steatosis Index Identifies Patients With Nonalcoholic Fatty Liver Disease. Clin Gastroenterol Hepatol. 2020 Aug;18(9):2073-2080.e7. doi: 10.1016/j.cgh.2020.01.020. Epub 2020 Jan 23. PMID: 31982611; PMCID: PMC7913470.

Introduction

Metabolic dysfunction–associated steatotic liver disease (MASLD), formerly known as non-alcoholic fatty liver disease (NAFLD), is now recognized as the leading cause of chronic liver disease. Diagnosis can be made by simple tests available in primary care setting, particularly abdominal ultrasound and FIB4 index. More accurate assessment of fibrosis and specialized follow-up may be necessary to prevent progression to cirrhosis or hepatocellular carcinoma.

Aims & Methods

The aim of our study was to define the prevalence of hepatic steatosis and MASLD in a hospital cohort, to analyze the factors associated with MASLD in our population, and to select patients who need more accurate fibrosis assessment and closer follow up. A prospective descriptive and analytical study was conducted over a 7 months period. After consenting to participate to the study, patients consulting our department for gastroenterological or proctological complaints were included, excluding those followed up for known chronic liver disease. Epidemiologic and clinical data were collected, followed by abdominal ultrasonography. We first divided our population into 2 groups according to the presence of steatosis on ultrasound. FIB4 index were then calculated for patients with steatosis. Statistical analysis was performed with IBM SPSS Statistics 20.0 software.

Results

Among the 450 patients included, the prevalence of hepatic steatosis was 24.88 %. The mean age was 50.6 (16 - 98 years). Older age (p = 0.005), obesity (p = 0.02) and diabetes (p < 0.001) were significantly associated with the presence of steatosis. In the steatotic population, 37.5% were diabetic (88.09% of type 2 diabetes), and 20.5% hypertensive. All these patients were overweight or obese, with a mean BMI of 29.01 kg/m² and a mean waist circumference of 92.7 cm. Seven point forteen percent were drinking alcohol, with an average intake of 25 g/week. Twenty-two patients (29.34%) were found to have a Fib4 > 1.3. Comparing these two steatotic subgroups, we found a significant difference in diabetes and obesity, which were significantly more prevalent in the Fib4>1.3 group (p<0.001 and p=0.02, respectively).

Conclusion

Our study confirms the high prevalence of hepatic steatosis, especially MASLD, which becomes a major public health problem. Advanced age, diabetes and obesity were the main risk factors associated with MASLD in our study. These data highlight the importance of systematic screening for fibrosis in these populations, as well as specialized follow-up.

Introduction

Currently, about 25-30% of the world population is affected by non-alcoholic fatty liver disease (NAFLD); over time, about 20% tends to develop a certain degree of inflammation in the liver tissue, defying the non-alcoholic steatohepatitis (NASH). Moreover, approximately 20% of NASH patients evolve into a high-grade liver fibrosis condition that leads to severe liver impairment (cirrhosis) (1, 2, 3).
The serial use of non-invasive fibrosis tests can refine prognosis in patients with non-alcoholic fatty liver disease (NAFLD) and evaluate the progression or improvement of liver fibrosis.

Aims & Methods

We evaluated predictors of improvement or worsening of liver stiffness measurements (LSM) in well characterized cohorts of patients with NAFLD from London (UK) and Milan (Italy).
We included two consecutive cohorts of 405 patients with at least two outpatient visits between 2014 and 2022. The minimum time interval between baseline and follow-up LSM was >6 months. LSM worsening was defined as an increase of >20% kPa if the baseline LSM was ≥5 kPa, or a follow-up LSM >6 kPa if the baseline LSM was <5 kPa. An LSM improvement was defined as an LSM decrease of >20% kPa (if the baseline LSM was >6 kPa).
A significant change in weight was defined as a >5% reduction or increase at follow-up, while a significant change in glycated hemoglobin (HbA1c) was defined as a >10% reduction or increase.
The variation between the true and expected FIB-4 index (based on the patient’s age at the follow-up visit, but using the blood tests performed at the first visit) was calculated. A significant improvement or worsening in FIB-4 was defined as a >20% variation between the actual and “expected” FIB-4.

Results

Of the 405 patients, 282 (70%) were males; mean age was 54±11 years. The median time from the first visits was 20.3 (13.9 – 28.7) months.
128 and 54 patients had an LSM >8 kPa and LSM>12 KPa at follow-up, respectively.
77 patients (19.3%) had an LSM improvement, while 67 (16.8%) had an LSM worsening; 256 patients (63.9%) maintained a stable value.
In patients with an LSM improvement, 22 had an improvement, 12 had worsening, while 37 had stable FIB-4.
In patients with an LSM worsening, 10 had an improvement, 20 had worsening, while 33 had a stable FIB-4.
In multiple logistic regression analysis, LSM worsening was independently associated with an increase in ALT and in HbA1c levels (OR 1.02 and 1.03 respectively), but also with a reduction in total cholesterol and AST levels (OR 0.98 for both). LSM improvement was independently associated with weight and ALT reduction (OR 0.93 and 0.98 respectively), but also with an increased AST level (OR 1.02).

Conclusion

More than 35% of patients with NAFLD have significant changes in their LSM measurements over a period of 20 months, with worsening or improvement at similar rates. Improvement in weight is independently associated with significant improvement in LSM measurements. On the converse, worsening in metabolic comorbidities, particularly glycemic control, could be associated with significant worsening in LSM, further supporting a multidisciplinary model of care.

References

1. Younossi Z, et al. Global burden of NAFLD and NASH: trends, predictions, risk factors and prevention. Nat Rev Gastroenterol Hepatol 2018;15(1):11-20.
2. Sheka AC, et al. Nonalcoholic Steatohepatitis: A Review. JAMA 2020;323(12):1175-1183.
3. Liu J, et al. Estimating global prevalence, incidence, and outcomes of non-alcoholic fatty liver disease from 2000 to 2021: systematic review and meta-analysis. Chin Med J (Engl). 2022 Jul 20;135(14):1682-1691.

Introduction

Metabolic dysfunction-associated steatotic liver disease (MASLD) and metabolic dysfunction with alcohol-related steatotic liver disease (MetALD) are two separate entities within the spectrum of steatotic liver disease (SLD).

Aims & Methods

This meta-analysis aims to compare the risks of hepatic and extrahepatic outcomes between MASLD and MetALD. We systematically searched for observational cohort studies published up to March 1, 2025, comparing clinical outcomes between individuals with MASLD and MetALD. The primary outcome was liver-related events, while secondary outcomes included hepatocellular carcinoma (HCC), liver-related mortality, cardiovascular events, extrahepatic cancers, and all-cause mortality. We used random-effect models to calculate pooled hazard ratios (HRs) with 95% confidence intervals (95% CI).

Results

Twenty-four studies involving 11,396,962 individuals were analyzed (9,622,716 with MASLD and 1,774,246 with MetALD). Individuals with MetALD had significantly higher risks of liver-related events (HR 1.62, 95% CI 1.16-2.25, p=0.02) and HCC (HR 1.33, 95%CI 1.00-1.77, p=0.04) than those with MASLD. The risk of extrahepatic cancers was also increased in MetALD (HR 1.03, 95% CI 1.01-1.06, p<0.001), while the rates of cardiovascular events (HR 0.96, 95% CI 0.85-1.09, p=0.48), extrahepatic cancer-related mortality (HR 1.44, 95% CI 0.97-2.15, p=0.07), and all-cause mortality (HR 1.08, 95% CI 0.97-1.19, p=0.14) did not differ between these two conditions.

Conclusion

MetALD confers a higher risk of liver-related outcomes, HCC, and extrahepatic cancers than MASLD, while all-cause mortality and cardiovascular risk are similar between the two conditions. These findings emphasize the need for distinct clinical strategies for these related yet different entities within the SLD spectrum and highlight the importance of conducting pharmacological clinical trials in this context.

Disclosure

Nothing to disclose

Introduction

Liver fibrosis is the main prognostic driver and an independent risk factor for both hepatic and extrahepatic events and global mortality in patients with non-alcoholic fatty liver disease (NAFLD). Thus, many serum markers and scores for the assessment of fibrosis severity have been drawn up. Recently, researchers developed the easy Liver Fibrosis Test (eLIFT) and the BMI, AST/ALT ratio and Diabetes (BARD) score.

Aims & Methods

This study aimed to compare the eLIFT and the BARD scores with Transient Elastography for the assessment of liver fibrosis in obese patients with NAFLD.
We conducted a transversal study including obese patients recruited from the Department of Nutrition referred to our center for screening for liver steatosis and a non-invasive evaluation of liver fibrosis. We excluded patients who had pre-existing chronic liver disease, chronic alcohol consumers, or those with ongoing medication other than those for metabolic syndrome.
Demographic and clinical features of the participants were recorded. All participants underwent Transient Elastography (TE) and had their AST, ALT, gamma-glutamyl transferase (GGT), platelet count, and prothrombin time measured in a random blood sample, taken the same day of the TE. We calculated for each patient the eLIFT and BARD scores using standard formulas.
Liver stiffness measurements (LSM) used to define the risk for advanced fibrosis as low, indeterminate, and high, based on EASL guidelines 2021, were respectively: <8 kPa, ≥8 and < 12 kPa, and ≥12 kPa.
An eLIFT <8 indicated a low risk of advanced fibrosis, whereas a result ≥8 identified patients at risk of advanced fibrosis. The BARD score ranges from 0 to 4, considered low from 0 to 1 with a high negative predictive value (NPV) for advanced fibrosis, and considered high from 2 to 4 with a high risk of advanced fibrosis.

Results

A total of 213 obese patients with NAFLD were included, with a mean age of 49.04 ± 11.76 years, 88% were female. The mean body mass index (BMI) was 40.67 ± 10.16 kg/m² and the mean waist circumference (WC) was 115.07 ± 17.49 cm.
TE results revealed that 191 patients had a low risk of advanced fibrosis (89.7%), 13 had an indeterminate risk of advanced fibrosis (6.1%), and nine patients had a high risk of advanced fibrosis (4.2%). Using eLIFT, 195 patients were classified in the low-risk of advanced fibrosis group of which 187 had also a low risk based on TE and only 8 had a high risk of advanced fibrosis, which corresponds to a rate of sensitivity at 92.6%; specificity at 27.3%; NPV at 95.9%; and positive predictive value (PPV) at 16.7%.
The BARD score was low in 21 patients (9.9%) and high in 192 (90.1%). Among the 21 patients with a low BARD score, 19 had a low risk of advanced fibrosis based on LSM and two had a high risk of advanced fibrosis. In the group of patients with a high score, only nine had advanced fibrosis. Sensitivity was 8.5%; specificity was 90%; NPV was 94.4%; and PPV was 4.7%. Both scores had high NPV for a high risk of advanced fibrosis, but the BARD score had a lower sensibility than eLIFT, with better specificity.
AUROC were 0.515 (95% CI, 0.11-0.92) and 0.743 (95% CI, 0.49-0.99) for eLIFT and BARD scores, respectively.

Conclusion

Both eLIFT and BARD scores were useful for ruling out advanced fibrosis (NPV > 90%) in an obese population with NAFLD. As such, they are adequate for use in clinical practice or as a part of referral and follow-up programs.

Introduction

Although chronic alcohol consumption has progressively decreased in recent years, a third of people over 15 years declare at least one episode of excessive use every month, which ranks Romania on second position, with a rate of 35%, far above the average registered in the EU (20%). Therefore, Romania has one of the highest incidence rates of alcohol-related liver cirrhosis, which has become a major public health problem. This study aimed to investigate the prevalence of liver fibrosis in the asymptomatic alcohol-consuming population.

Aims & Methods

The study aimed to evaluate the relationship between advanced liver fibrosis measured by transient elastography, laboratory parameters, and the amount of alcohol consumed depending on non-modifiable risk factors such as age and gender. Between January 2022 and December 2022, we examined patients with day hospitalization in the Institute of Gastroenterology and Hepatology in Iasi, without liver history, who admitted a moderate or high consumption (women <7 versus >7 drinks/week; men <14 versus >14 drinks/week) for at least one year. The classification of the fibrosis stage by transient elastography was adjusted according to transaminase values. The results were analyzed by univariate analysis and logistic regression to establish models of prediction.

Results

The study included 689 patients with an average age of 49.32±14.31 years, a proportion of 63.7% represented by men. Advanced fibrosis (³ F3) was detected in 19.30% of the examined patients, predominantly in men (14.1%) and patients over 55 years old (12.5%). Excessive alcohol consumption is associated 2 times more with advanced fibrosis in women (OR=5.08; CI 95%: 3.45-9.50, p<0,001) and the group under 40 years old (OR=6.29; CI 95%: 1.67-9.43, p<0,001) compared to men (OR=2.27; CI 95%: 1.76-3.81, p=0,012) respectively patients over 55 years old (OR=3.21; CI 95% : 2.28-4.45 p<0,001). Using logistic regression, it was demonstrated that there was a strong correlation between advanced fibrosis, excessive alcohol consumption, low serum albumin level and the reduction of triglycerides in men (R² Nagelkerke = 0.854; p<0.001) supplemented with the reduction of cholesterol in the age group 40-55 years (R² Nagelkerke = 0.785; p<0.001), respectively of ferritin in those over 55 years old (R² Nagelkerke = 0.804; p<0.001). The association of excessive alcohol consumption, age, low levels of albumin, LDL-cholesterol and C-reactive protein generated a significant predictive model (R² Nagelkerke = 0.784; p<0.001) for female patients.

Conclusion

Screening using transient elastography represents an approach that could provide early diagnosis of advanced liver fibrosis in an asymptomatic population, with the possibility to prevent the evolution of ALD and the development of complications of cirrhosis.