Outcomes of fatty liver disease with and without metabolic comorbidities and risk factors for mortality

doi:10.21203/rs.3.rs-2110374/v1

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Outcomes of fatty liver disease with and without metabolic comorbidities and risk factors for mortality

https://doi.org/10.21203/rs.3.rs-2110374/v1

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Aims

Patients with fatty liver disease (FLD) frequently have metabolic risk factors; however, the clinical course of metabolic-associated FLD (MAFLD) in Asians is unclear. We compared the clinical courses of MAFLD and nonalcoholic FLD (NAFLD).

Methods

Asian FLD patients (n = 987) from 1991–2021 (biopsy-proven in 939, 497 males) were enrolled. The patients were divided into non-MAFLD/NAFLD (non-M/N, n = 92), both M/N (n = 785), and M/non-N (n = 90) groups. The clinical features, complications, and survival rates were compared among the three groups. Mortality risk factors were subjected to Cox regression analysis.

Results

1) Non-M/N patients were significantly younger (non-M/N, M/N, and M/non-N 50, 53, and 57 years, respectively), more frequently male (54.3, 52.6, and 37.8%), and had a low body mass index (BMI, 23.1, 27.1, and 26.7 kg/m²) and FIB-4 index (1.20, 1.46, and 2.10). Hypopituitarism (5.4%) and hypothyroidism (7.6%) were significantly observed in the non-M/N group. Hepatocellular carcinoma (HCC) developed in 0.0, 4.2, and 3.3% of the cases, and extrahepatic malignancies in 6.8, 8.4, and 4.7% of the cases, respectively, with no significant differences. The cardiovascular event rate was significantly higher in the M/non-N group (1, 37, and 11 cases, p < 0.01). Survival rates were not significantly different among the three groups. 2) The risk factors for mortality were age and BMI in the non-M/N group; age, HCC, alanine transaminase, and FIB-4 in the M/N group; and FIB-4 in the M/non-N group.

Conclusions

Although there was no significant difference in survival rates among the three groups of FLD, it should be considered that there would be different risk factors for mortality among the groups.

Metabolic-associated fatty liver disease (MAFLD)

nonalcoholic fatty liver disease (NAFLD)

mortality

In patients with fatty liver disease (FLD), metabolic factors are associated with its development. [1–3] The concept and diagnostic criteria of metabolic (dysfunction)-associated fatty liver disease (MAFLD) have been proposed. [4] MAFLD includes overweight/obese, type 2 diabetes, and metabolic dysfunction. Moreover, it could include other etiologies of chronic liver diseases, as it does not preclude alcohol intake in its diagnosis. [5] Conversely, nonalcoholic fatty liver disease (NAFLD) excludes patients with moderate or heavy alcohol intake and other etiologies of chronic liver diseases, and the presence of metabolic dysfunction is not required. [5] Not only the convenience of diagnosis of FLD; that MAFLD does not required the pathological diagnosis, but also the MAFLD can diagnose more advanced fibrosis cases. [6] Liver stiffness in higher in MAFLD compared to NAFLD. [7] The sensitivity for detecting significant fibrosis is also higher for MAFLD than for NAFLD (93.9% vs. 73.0%).

Bianco et al. [8] showed that non-MAFLD and NAFLD were present in 4.7% of the general population and the clinical features were younger age, lower body mass index (BMI), better metabolic profile, and less fibrosis. The clinical features of the two categories of FLD, MAFLD and NAFLD, frequently overlap. In the general population, about 3,700 cases fulfilled the criteria for both MAFLD and NAFLD. [8] The clinical features of MAFLD and NAFLD are reportedly older age, higher BMI, insulin resistance, and metabolic comorbidities. [8] Patients with MAFLD but not NAFLD represent 2.6% of the general population and are typically younger, predominantly male, and have a better metabolic profile and more severe fibrosis. [8]

Regarding hepatocellular carcinoma (HCC) development in FLD, the prevalence of NAFLD-HCC was 0.44/1000 person-years (95% confidence interval [CI], 0.29–0.66) and 5.29/1000 person-years (95% CI 0.75–37.56) in nonalcoholic steatohepatitis (NASH) patients in a global study. [9] Although the rate of HCC development is low, the number of FLD patients, and so the prevalence of HCC, is increasing. Therefore, high-risk patients need to be selected. Metabolic dysfunction has a significant impact on hepatocarcinogenesis in patients with FLD. [10] HCC screenings in MAFLD patients might be useful for diagnosing FLD-HCC.

In a large NAFLD cohort study, the liver-related death rate was 0.77/1000 man-years (95% CI 0.33–1.77) and overall mortality was 15.44/1000 man-years (95% CI 11.72–20.34). [9] In a NASH cohort study, the liver-related death rate was 11.77/1000 person-years (95% CI 7.10-19.53) and overall mortality was 25.56/1000 person-years (95% CI 6.29–103.8). Eguchi et al. reported that HCC was a prognostic factor and the mortality rate of NASH-HCC was 40.0% over 2.7 years. [11] A 7.7-year long-term follow-up showed higher mortality in F3/4 patients (F3/F4; 25.0%, F0/2; 0.0%). MAFLD increases all-cause mortality. [12] However, the clinical course of MAFLD and the difference between MAFLD and NAFLD are unclear.

We investigated the clinical course, HCC as a complication, extrahepatic malignancies, cardiovascular disease (CVD) events, and survival rates in Asian patients with MAFLD and NAFLD. We also identified risk factors for mortality.

Patients and study design

This observational single-center study was performed at Tokyo Women’s Medical University Hospital and enrolled 987 Asian NAFLD and/or MAFLD patients (diagnosed from 1991 to 2021). NAFLD was diagnosed according to evidence-based clinical practice guidelines [2, 3] and ≥ 95% of cases were biopsy-confirmed (n = 939). We rechecked the diagnoses of all patients and excluded cases that did not meet the diagnostic criteria. The pathological stage of NAFLD was evaluated in accordance with the classification system of Brunt et al. [13] MAFLD was diagnosed according to established criteria. [4] Briefly, MAFLD diagnosis was based on detection of hepatic steatosis by imaging or histology and at least one of overweight/obesity, type 2 diabetes, and metabolic dysregulation. The patients had at least two of increased waist circumference, arterial hypertension, hypertriglyceridemia, low level of high-density lipoprotein cholesterol (HDL-C), prediabetes, insulin resistance, and subclinical inflammation.

Study 1

We classified the patients into the non-MAFLD/NAFLD (non-M/N, n = 92), both M/N (n = 785), and M/non-N (n = 90) groups. Non-M/non-N (n = 20) patients were excluded.

The three groups were compared in terms of age, proportion of males, BMI (kg/m²), comorbid lifestyle-related dyslipidemia (%), hypertension (%), and diabetes mellitus (%). Laboratory parameters collected at the time of biopsy were albumin (g/dL), total bilirubin (mg/dL), aspartate aminotransferase (AST, U/L), alanine transaminase (ALT, U/L), γ-glutamyl transferase (GGT, U/L), fasting blood glucose (mg/dL), hemoglobin_A1c (Hb_A1c, %), immunoreactive insulin (IRI, µU/mL), triglycerides (mg/dL), total cholesterol (mg/dL), HDL-C (mg/dL), ferritin (ng/mL), platelet count (× 10⁴/µL), prothrombin time (%), and alfa-fetoprotein (AFP, ng/mL).

Insulin resistance was determined based on the homeostasis model of assessment-insulin resistance (HOMA-IR). [14] The FIB-4 index was defined as: age [years] × AST [IU/L]) ÷ (platelet count [10⁹/L] × √ALT [IU/L]). [15] Underlying liver disease was detected by evaluating serum markers of hepatitis B surface antigen, hepatitis C antibody, immunoglobulin (Ig) M, IgG, anti-nuclear antibody (ANA), and anti-mitochondrial antibodies (AMA); imaging; and pathological findings. The criteria, secondary FLD of drug-induced FLD, moderate alcohol intake (30–60 g of ethanol), and heavy alcohol intake (60 g ethanol) were included in MAFLD but excluded from NAFLD.

Hypopituitarism was diagnosed by measuring basal pituitary and target hormone levels including growth hormone (GH) and adrenocorticotropic hormone (ACTH), thyroid stimulating hormone (TSH), gonadotropin, and/or growth hormone (GH). [16] Hypothyroidism is a condition in which the thyroid gland cannot produce enough thyroid hormone. [17] Polycystic ovary syndrome (PCOS) was diagnosed based on the presence of irregular periods or infrequent periods of menses, high levels of male hormones, and polycystic ovaries. [18] Turner syndrome was diagnosed based on its characteristics and symptoms, such as short stature, a webbed neck, a broad chest, and widely spaced nipples, and karyotyping. [19] Inflammatory bowel disease (IBD)—ulcerative colitis and Crohn’s disease—was diagnosed based on evidence-based clinical practice guidelines. [20]

HCC development, extrahepatic malignancies, cardiovascular events, and survival rates were compared among patients followed-up for ≥ 6 months in the non-M/N (n = 74), both M/N (n = 667), and M/non-N (n = 85) groups. Risk factors for mortality were subjected to Cox regression analysis.

HCC diagnosis. Patients with NAFLD were followed-up at 1- to 3-month intervals at our outpatient clinic. HCC was diagnosed histologically or based on imaging findings consistent with the diagnosis, using at least two of the following modalities, in accordance with clinical guidelines: abdominal ultrasound, computed tomography, and/or magnetic resonance imaging. [21, 22]

Study 2

A second liver biopsy was performed in 121 cases during the 3.3 (0.5–14.2)-year follow-up period. Compared to the previous stage, fibrosis was classified as progressed, stable, or improvement. In cases of progressed fibrosis, the clinical features were compared between those with early (< 4 years) and late (≥ 4 years) progression based on the median observation period.

This study was conducted in accordance with the principles of the Declaration of Helsinki and the ethical guidelines of the Tokyo Women’s Medical University Hospital (Tokyo, Japan). The Institutional Review Board of Tokyo Women’s Medical University Hospital approved the study protocol. Informed consent was obtained from all participants.

Statistical analysis

Data are presented as medians and ranges at baseline. Differences were assessed by Kruskal–Wallis test or χ² test using SPSS software (version 25.0; IBM Corp., Armonk, NY, USA). A value of p < 0.05 was considered to indicate statistical significance. Cumulative curves for survival rates and new onset of HCC were constructed by the Kaplan–Meier method. The statistical significance of differences in survival among the three groups was evaluated by log-rank test. Survival rates were compared with those for HCC, extrahepatic malignancies, and cardiovascular events. Risk factors for mortality were evaluated by Cox regression analysis. Hazard ratios (HR) and 95% CI were assessed. The factors included age, BMI, ALT, new onset of HCC, extrahepatic malignancies, CVD events, and profile of non-M/N, M/N, and M/non-N. In study 2, fibrosis change was considered and progressed cases of < 4 and ≥ 4 years were compared by Mann–Whitney U-test.

Demographics and complication status of patients with NAFLD

A total of 987 Asian patients had FLD (939 biopsy-confirmed, diagnosed from 1991 to 2021). A flow chart of the study is shown in Fig. 1. After excluding non-M/non-N cases (n = 20), we enrolled 967 patients (497 males, 51.4%) with a median age of 53 years (range 18–89 years). The demographics of the patients at the time of liver biopsy are listed in Table 1. The non-M/N group had a median age of 50 (range, 21–77) years and was significantly younger than the M/N (53 [18–89] years) and M/non-N groups (57 [31–75] years, p < 0.01). The non-M/N group included 50 (54.3%) males, compared to 413 (52.6%) in the M/N group and 34 (37.8%) in the M/non-N group. The rate of male was significantly lower in the M/non-N group (p = 0.02). The median BMI was 23.1, 27.1, and 26.7 kg/m² in the non-M/N, M/N, and M/non-N groups, respectively. BMI was significantly lower in the non-M/N group (p < 0.01). Complications in the non-M/N group included dyslipidemia (n = 32) and hypertension (n = 9). These numbers were significantly lower in the non-M/N group because these complications are components of the definition of MAFLD. In the M/non-N group, 10 patients had a moderate alcohol intake (30–60 g of ethanol) and 11 a heavy alcohol intake (> 60 g of ethanol).

Table 1

Characteristics of patients with MAFLD and NAFLD.
Variable	Total (n = 967)	Non-MAFLD and NAFLD (n = 92)	MAFLD and NAFLD (n = 785)	MAFLD and non-NAFLD (n = 90)	p-value*
Age (years)	53 (18–89)	50 (21–77)	53 (18–89)	57 (31–75)	< 0.01
Male sex (%)	497 (51.4%)	50 (54.3%)	413 (52.6%)	34 (37.8%)	0.02
BMI (kg/m²)	26.6 (14.0–61.0)	23.1 (14.0–24.9)	27.1 (15.9–61.0)	26.7 (17.2–40.8)	< 0.01
Dyslipidemia (%)	609 (63.0%)	32 (34.8%)	515 (65.6%)	62 (68.9%)	< 0.01
Hypertension (%)	452 (46.7%)	9 (9.8%)	388 (49.4%)	55 (61.1%)	< 0.01
Diabetes Merits (%)	449 (46.4%)	0 (0.0%)	404 (51.5%)	45 (50.0%)	< 0.01
Laboratory data
Albumin (g/dL)	4.3 (1.8–5.5)	4.4 (2.8–5.5)	4.3 (1.8–5.5)	4.2 (1.9–5.2)	< 0.01
Total bilirubin (mg/dL)	0.7 (0.1–33.7)	0.8 (0.1–7.9)	0.7 (0.2–33.7)	0.6 (0.3–6.3)	0.62
Aspartate aminotransferase (U/L)	48 (6-435)	37 (16–401)	49 (6-435)	58 (15–339)	< 0.01
Alanine transaminase (U/L)	68 (5–911)	55 (11–408)	72 (5–911)	68 (10–556)	0.04
γ-Glutamyl transferase (U/L)	71 (2–1543)	70 (10–1543)	69 (2–912)	109 (15–1204)	< 0.01
Fasting blood glucose (mg/dL)	104 (10–433)	94 (66–148)	106 (10–433)	105 (77–293)	< 0.01
Hemoglobin _A1c (%)	5.8 (3.7–13.4)	5.2 (3.7–6.8)	5.9 (4.0–13.4)	5.9 (4.1–9.6)	< 0.01
IRI (µU/mL)	12.3 (0.7–181.0)	6.3 (2.0–102.0)	12.8 (0.7–181.0)	9.2 (3.0–75.0)	< 0.01
HOMA-IR	3.34 (0.34–47.37)	1.44 (0.48–23.17)	3.52 (0.34–47.37)	3.00 (0.63–33.70)	< 0.01
Triglycerides (mg/dL)	136 (28–833)	114 (35–433)	140 (28–809)	121 (53–833)	< 0.01
Total cholesterol (mg/dL)	198 (63–482)	201 (63–380)	198 (75–482)	195 (91–342)	0.83
Ferritin (ng/mL)	206 (4-7656)	136 (4-1095)	214 (4-7656)	184 (6-2906)	0.15
Platelet counts (× 10⁴/µL)	20.9 (3.7–96.0)	21.0 (4.2–45.1)	21.0 (3.7–96.0)	19.7 (4.7–39.4)	0.41
Prothrombin time (%)	96.0 (9.6–120.0)	98.7 (11.8–109.0)	96.2 (9.6–120.0)	92.7 (14.1–100.0)	0.31
AFP (ng/mL)	4 (1–1974)	4 (1–13)	4 (1–1974)	4 (1–14)	0.76
FIB-4 index	1.47 (0.10-17.78)	1.20 (0.28–16.71)	1.46 (0.10-17.78)	2.10 (0.12–8.29)	< 0.01
Pathological findings
Fibrosis; F3–4 (%)	282/939 (30.0%)	12/89 (13.5%)	244/764 (31.9%)	26/86 (30.2%)	< 0.01
Inflammation; A2-3 (%)	652/922 (70.7%)	43/87 (49.4%)	547/750 (72.9%)	62/85 (72.9%)	< 0.01
Steatosis; S2-3 (%)	688/922 (74.6%)	52/88 (59.1%)	576/750 (76.8%)	60/84 (71.4%)	< 0.01
MAFLD, metabolic-associated fatty liver disease; NAFLD, nonalcoholic fatty liver disease; BMI, body mass index; IRI, immunoreactive insulin; AFP, alpha-fetoprotein, FIB-4, fibrosis-4
*Compared between the NAFLD/non-MAFLD, NAFLD/MAFLD, and non-NAFLD/MAFLD groups by Kruskal–Wallis test.

Laboratory parameters at the time of biopsy are shown in Table 1. Among the non-M/N, M/N, and M/non-N groups, AST (37, 49, and 58 U/L), fasting blood sugar (94, 106, and 105 mg/dL), Hb_A1c (5.2, 5.9, and 5.9%), IRI (6.3, 12.8, and 9.2 µU/mL), and HOMA-IR (1.44, 3.52, and 3.00) (all p < 0.01) and ALT (55, 72, and 68 U/L, p = 0.04) were significantly lower in the non-M/N group. The FIB-4 index value was lower in the non-M/N group (1.20, 1.46, and 2.10, p < 0.01). The high FIB-4 index in the M/non-N group might be because of age and alcohol intake.

Regarding complications (Table 2), the numbers of hypopituitarism cases were 5 (5.4%), 16 (2.0%), and 0 (0.0%) in the non-M/N, M/N, and M/non-N groups, respectively, and those of hypothyroidism were 7 (7.6%), 6 (0.8%), and 1 (1.1%), respectively. The numbers of hypopituitarism and hypothyroidism cases were significantly higher in the non-M/N group (p = 0.04 and p < 0.01). The rates of short bowel syndrome and IBD were not significantly different among the three groups (p = 0.14).

Table 2

Complications of patients with different metabolic profiles and events after liver biopsy.
Variable	Total (n = 967)	Non-MAFLD and NAFLD (n = 92)	MAFLD and NAFLD (n = 785)	MAFLD and non-NAFLD (n = 90)	p-value*
Hypopituitarism (%)	21 (2.2%)	5 (5.4%)	16 (2.0%)	0 (0.0%)	0.04
Hypothyroidism (%)	14 (1.4%)	7 (7.6%)	6 (0.8%)	1 (1.1%)	< 0.01
PCOS (%)	1 (0.1%)	0 (0.0%)	1 (0.1%)	0 (0.0%)	0.89
Turner syndrome (%)	5 (0.5%)	0 (0.0%)	5 (0.6%)	0 (0.0%)	0.56
Pancreatic resection (%)	5 (0.5%)	0 (0.0%)	5 (0.6%)	0 (0.0%)	0.56
Short bowel syndrome or IBD (%)	2 (0.2%)	1 (1.1%)	1 (0.1%)	0 (0.0%)	0.14
HCC at diagnosis of FLD (%)	67 (6.9%)	2 (2.2%)	62 (7.9%)	3 (3.3%)	0.05
HCC post biopsy (%) *	31/826 (3.8%)	0/74 (0.0%)	28/667 (4.2%)	3/85 (3.5%)	0.20
Extrahepatic malignancies (post biopsy, %) *	65/826 (7.9%)	5/74 (6.8%)	56/667 (8.4%)	3/85 (4.7%)	0.49
CVD event (%) *	49/826 (5.9%)	1/74 (1.4%)	37/667 (5.5%)	11/85 (12.9%)	< 0.01
Death (Liver-related death/ non-liver related death)	45/ 35	1/ 6	42/ 24	2/ 5	0.01
MAFLD, metabolic-associated fatty liver disease; NAFLD, nonalcoholic fatty liver disease; HCC, hepatocellular carcinoma; CVD, cardiovascular disease; IBD, Inflammatory bowel disease; PCOS, polycystic ovarian syndrome. *Analysis of follow-up cases for more than half a year.

Pathological findings of the liver and NASH frequencies

Only 13.5% of the non-M/N group had advanced fibrosis, and 49.4% of A2-3 activity and 59.1% of S2-3 steatosis. Advanced cases were less frequent in the non-M/N group than in the M/N and M/non-N groups. Overall, 606 FLD patients showed ballooning and NASH was diagnosed in 555 cases (70.7%) after excluding other liver diseases (Fig. 1b). NASH was diagnosed in 53 (57.6%) non-M/N patients. In non-M/N cases, NASH was relatively frequently diagnosed.

Events after liver biopsy

HCC was present in 2 (2.2%), 62 (7.9%), and 3 (3.3%) cases in the non-M/N, the M/N, and M/non-N groups, respectively at the time of diagnosis. The incidence of HCC tended to be higher in M/N patients (p = 0.05). During the follow-up period of 5.7 (0.5–25.8) years after liver biopsy, HCC was observed in 0 (0.0%), 28 (4.2%), and 3 (3.5%) cases, respectively (p = 0.20). A Kaplan-Meier curve shows the HCC rates (Fig. 2). In the M/N and M/non-N groups, HCC developed in 3.1% and 1.8% at 5 years and in 5.7% and 5.8% at 10 years, respectively. Extrahepatic malignancies during follow-up were detected in 5 (6.8%), 56 (8.4%), and 4 (4.7%) cases in the non-M/N, M/N, and M/non-N groups, respectively. Figure 3 showed the percentage of each cancer. Cancers in the M/N group comprised gastrointestinal cancers (n = 19, 2.8%, gastroduodenum and colon), gynecologic cancers (n = 14, 2.1%, breast, and uterine cancers), urinary cancers (n = 9, 1.3%, prostate, kidney, and bladder), and others (n = 14). One case was complicated with two cancers. One each of pancreatic, maxillary gingival, testicular, and uterine cancer, and leukemia was observed in the non-M/N group. Three gastrointestinal cancers and one uterine cancer were detected in the M/non-N group. The rates of extrahepatic malignancies were similar in the three groups (p = 0.49).

During this period, 1 (1.4%), 37 (5.5%, 16 cardiovascular and 21 cerebrovascular events), and 11 (12.9%, 7 cardiovascular and 5 cerebrovascular events) CVD events occurred in the non-M/N, the M/N, and M/non-N groups, respectively. The number of CVD events was significantly higher in the M/non-N group than in the other two groups (p < 0.01).

Survival rates of MAFLD and NAFLD

FLD survival rates were estimated by generating Kaplan–Meier curves (Fig. 4a). The 5-year survival rate was 92.2%, 93.4%, and 95.0% and that at 10 years was 89.4%, 87.8%, and 91.5%, respectively, in the non-M/N, M/N, and M/non-N groups; the differences were not significant (p = 0.77). HCC cases had a significantly lower survival rate than non-HCC cases (p < 0.01, Fig. 4b). Survival was not significantly affected by extrahepatic malignancies and CVD events (p = 0.33 and p = 0.82, Fig. 4c and Fig. 4d).

Fibrosis changes

A second liver biopsy was performed in 121 cases during the 3.3 (0.5–14.2)-year follow-up period (Table 3). After excluding 17 cases of liver cirrhosis, 17 cases were improved, 38 cases were stable, and 49 cases had progressed fibrosis. There was no significant difference in progression between the non-M/N, M/N, and M/non-N groups (p = 0.97, Fig. 5). The first BMI and the serum level of ALT (both p = 0.02) were higher in early (< 4 years, n = 28) and late (≥ 4 years, n = 21) progression cases. Hypertension was frequent in early progression cases (p = 0.03). There was no significant difference in the rates of type 2 diabetes (p = 0.89) and dyslipidemia (p = 0.44) in relation to the categories of non-M/N, M/N, and M/non-N (p = 0.57).

Table 3

Pathological changes of paired biopsy cases.
	Total (n = 121)	Improved* (n = 17)	Stable* (n = 38)	Progressed* (n = 49)	p-value
Age (1st /2nd biopsy, years old)	55 (16–78)/59 (19–84)	53 (18–68)/55 (20–73)	50 (18–77)/52 (20–82)	58 (16–78)/62 (19–80)	0.13/0.09
Period of two biopsies (years)	3.3 (0.5–14.2)	2.3 (0.6–14.2)	2.7 (0.5–9.6)	3.7 (0.6–13.9)	0.23
BMI (kg/m², Δ2nd -1st /biopsy)	-0.4 (-2– -3.7)	1.8 (1 – -3.3)	-0.5 (-0.7–1.5)	-0.1 (-2– -4.2)	0.29
Dyslipidemia (%)	78 (64.5%)	9 (52.9%)	28 (73.7%)	33 (67.3%)	0.32
Hypertension (%)	68 (56.2%)	10 (58.8%)	17 (44.7%)	29 (59.2%)	0.43
Diabetes Merits (%)	53 (43.8%)	10 (58.8%)	13 (34.2%)	21 (42.9%)	0.19
Fibrosis stage; F3–4 (%)	43 (35.5%)	7 (41.2%)	8 (21.1%)	11 (22.4%)	0.25
Non-MAFLD and NAFLD/ MAFLD and NAFLD/ MAFLD and non-NAFLD	13/94/14	2/13/2	5/29/4	6/37/6	0.97
BMI, body mass index; MAFLD, metabolic-associated fatty liver disease; NAFLD, nonalcoholic fatty liver disease. * F4 cases (n = 17) were excluded.

Risk factors for mortality

Risk factors of mortality were assessed by Cox regression analysis (Table 4). The risk factors for mortality were age and BMI (HR 1.109, 95% CI 1.032–1.192; HR 0.586, 95% CI 0.409–0.840, both p < 0.01, respectively) in the non-M/N group; age, HCC, ALT, and FIB-4 index (HR 1.037, 95% CI 1.009–1.053; HR 0.992, 95% CI 0.985–0.998; HR 1.180, 95% CI 1.104–1.262; and HR 2.293, 95% CI 1.244–4.227, all p < 0.01) in the M/N group; and FIB-4 index (HR 1.461, 95% CI 1.028–2.076, p = 0.04) in the M/non-N group.

Table 4

Multivariate analysis of death according to MAFLD and NAFLD profiles.
	Hazard ratio	95% confidence interval	p-value
Non-MAFLD and NAFLD
Age	1.109	1.032–1.192	< 0.01
BMI	0.586	0.409–0.840	< 0.01
MAFLD and NAFLD
Age	1.037	1.009–1.053	< 0.01
ALT (U/L)	0.992	0.985–0.998	< 0.01
FIB-4 index	1.180	1.104–1.262	< 0.01
HCC complication	2.293	1.244–4.227	< 0.01
MAFLD and non-NAFLD
FIB-4 index	1.461	1.028–2.076	0.04
MAFLD, metabolic-associated fatty liver disease; NAFLD, nonalcoholic fatty liver disease; BMI, body mass index; ALT, alanine transaminase; HCC, hepatocellular carcinoma; FIB-4, fibrosis-4.

We assessed FLD with different metabolic profiles, given that FLD has shown differences in relation to racial, demographic, complications, and outcome categories. We analyzed the characteristics of ≥ 95% of biopsy-proven FLD patients. Non-M/N patients were younger and had a higher rate of hormonal disorders and a lower rate of HCC than MAFLD cases; however, the rates of extrahepatic malignancies were similar to those in MAFLD cases. CVD events were significantly observed in the M/non-N group. Moreover, although pathological fibrosis was mild, NASH was diagnosed in about half of the cases. The survival and fibrosis progression rates were not significantly different among the three groups. The risk factors for FLD differed according to metabolic profile.

In a large study, 7,761 community patients aged 20–74 years in the United States included 2,702 patients diagnosed with FLD by abdominal ultrasonography. [12] In that cohort, 2,044 (75.6%) fulfilled both the MAFLD and NAFLD definitions, 212 (7.8%) had MAFLD, 394 (14.6%) had NAFLD, and 52 (1.9%) did not have either. In this study, about 10% of FLD cases had one of NAFLD or MAFLD. In the M/non-N group, the number of females was significantly higher than in the other three groups; by contrast, other studies have reported a higher rate of males. This is likely to occur because of the small number of patients with ALD, which can be diagnosed without liver biopsy.

NAFLD patients were younger and MAFLD patients were older in the three groups, in agreement with Bianco et al. [8] Secondary causes of NAFLD (e.g., steroid or tamoxifen treatment for mammalian carcinoma) were included in the M/non-N group if there were metabolic complications. Primary NAFLD is reportedly a more severe type of liver disease—in terms of pathological features and fibrosis stage—than secondary NAFLD. [23]

BMI was significantly lower in the non-M/N group. This group had significantly higher rates of hypopituitarism and hypothyroidism than the other groups, as well as pathological findings of mild fibrosis, mild inflammation, and mild steatosis. In patients with hypopituitarism, FLD reportedly improves after hormone replacement therapy. [24, 25] Therefore, we should consider evaluating hormone levels in these patients.

The rate of HCC was highest in the N/M group. The risk factors for HCC in NAFLD are reportedly male gender and diabetes mellitus. [26] The incidence of HCC at 10 years was 20.1% in patients with advanced fibrosis, and the mortality rate was higher in patients who were older, had a history of HCC, a lower serum level of albumin, and a higher level of GGT. [26] In this study, the new-onset HCC incidence was highest in the M/N group (5.7% at 10 years). The HCC rate in the non-M/N group was not elevated because of the younger age and absence of diabetes. However, there was no significant difference among the three groups.

Regarding extrahepatic malignancies, colorectal cancers 1.4 (95% CI 1.1–1.7)/1000 person-years, breast cancers 1.2 (95% CI 1.0–1.6)/1000 person-years, and prostate cancers 1.3 (95% CI 1.0–1.7)/1000 person-years have been reported. [27] In this study, gastrointestinal cancers, gynecologic cancers, and urinary cancers were detected in the M/N group, non-gastrointestinal cancers in the non-M/N, and gastrointestinal cancers in the M/non-N group. The incidence of extrahepatic malignancies was non-significantly lower in the non-M/N and M/non-N groups (p = 0.49).

MAFLD patients reportedly have a high mortality rate. Patients with MAFLD had a 17% higher risk of all-cause mortality (HR 1.17, 95% CI 1.04–1.32).[12] MAFLD was associated with a higher risk of cardiovascular mortality. In a prior work, the overall 10-year survival rate was 86.2%. [26] In this study, the survival rate was 92.2%, 93.4%, and 95.0% at 5 years and 89.4%, 87.8%, and 91.5% at 10 years in the non-M/N, M/N, and M/non-N groups, respectively; the differences were not significant. Conversely, the rate of CVD events was increased in the M/N and M/non-N groups. Therefore, MAFLD is associated with an increased risk of CVD events.

There was early progression of fibrosis in patients with a high BMI and serum ALT level. The complications associated with lifestyle-related diseases without hypertension was not significantly different. Regardless of the classification of NAFLD or MAFLD, fibrosis significantly developed in cases with a high BMI and severe hepatic inflammation.

Regarding risk factors for mortality, a low BMI was associated with a poor outcome in the non-M/N group. In the M/N group, HCC development and fibrosis progression were risk factors for mortality. In the M/non-N group, fibrosis progression was a risk factor for mortality. Therefore, the risk factors for mortality in FLD differ according to the metabolic complications.

This study had several limitations. It was of a single-center observational design, and the majority of the cases underwent liver biopsy. Therefore, selection bias might have existed. Consideration of FLD without histological examination was necessary.

The survival and progression rates were not significantly different among the three FLD groups. A high BMI and serum ALT level were implicated in hepatic fibrosis progression. The risk factors for mortality in FLD differ according to the metabolic complications.

Financial support: N/A

Conflict of interest:

KT is the recipient of research funding from Sumitomo Dainippon Pharma Co., Ltd., Astellas Pharma Inc., Eisai Co., Ltd., Taiho Pharmaceutical Co., Ltd., Chugai Pharmaceutical Co., Ltd., Daiichi Sankyo Pharmaceutical Co., Ltd., AbbVie GK, Takeda Pharmaceutical Co. Ltd., Asahi Kasei Corporation. Ajinomoto Co., Inc., and Otsuka Pharmaceutical Co., Ltd.

Data availability:

The datasets used and/or analyzed in this study are available from the corresponding author upon reasonable request.

Specific author contributions: Conception and design: TK and KT; analysis and interpretation of the data: YO, KH, TK; drafting of the manuscript: TK; patient care, follow-up, and data acquisition: All authors. All authors approved the final manuscript and agree to be accountable for all aspects of the study; questions related to the accuracy or integrity of any part of the study will be addressed as appropriate.

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Outcomes of fatty liver disease with and without metabolic comorbidities and risk factors for mortality

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Abstract

Aims

Methods

Results

Conclusions

Figures

Introduction

Methods

Patients and study design

Statistical analysis

Results

Demographics and complication status of patients with NAFLD

Pathological findings of the liver and NASH frequencies

Events after liver biopsy

Survival rates of MAFLD and NAFLD

Fibrosis changes

Risk factors for mortality

Discussion

Conclusions

Declarations

References

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