New emerging therapeutic options for metabolic associated fatty liver disease

Introduction
Metabolic-associated liver disease (MAFLD) previously known as non-alcoholic liver disease
(NAFLD) represents the expression of hepatic damage through liver lipid accumulation induced by
a multisystem disease. The latest nomenclature was updated by an international group of experts in
an attempt to better reflect its underlying pathology and overthrow a diagnosis grounded on the
exclusion of other well-defined causes of liver disease and significant alcohol consumption.1,2,3
NAFLD is defined as hepatic steatosis (liver fat content ˃5% of hepatocytes) in the absence of other
causes of liver disease such as chronic viral infections, pharmacological therapies, autoimmune
hepatitis, metabolic and genetically induced diseases such as hemochromatosis or Wilsons disease
and alcohol use ˂30g per day. Furthermore, NAFLD has subclassified in NAFL defined by hepatic
steatosis with no evidence of hepatocellular injury in the form of hepatocyte ballooning and NASH
represented by the presence of hepatic steatosis and inflammation with hepatocyte injury, with or
without fibrosis. 7 The concept of MAFLD provides new criteria for diagnosis based on the proof of
lipid accumulation in the liver in addition to one of the following conditions: overweight/obesity,
type 2 diabetes mellitus (T2DM), or evidence of metabolic dysregulation. 1
NAFLD tends to become the most common cause of chronic liver disease with an important impact
on mortality and morbidity. The global prevalence of NAFLD reaches up to 25% with the highest
rates in Asia, the Middle East, South America, and Europe. 4 A Chinese meta-analysis reported an
overall NAFLD prevalence of 29.2% with higher rates in males and overweight persons. 5 The data
regarding the impact of the latest change in nomenclature on the epidemiologic are limited. A cross-
sectional study conducted by Ciardullo et.al highlights that patients with NAFLD and MAFLD
showed similar prevalence and risk of advanced liver fibrosis. 3 Also, a recent observational study
reports an estimated global MAFLD prevalence of up to 50% among overweight or obese subjects,
with higher rates observed in males compared to females. 6
Data regarding the pathogenesis of MAFLD remains controversial. The first step of development is
considered to be the accumulation of lipids in the hepatocytes due to increased fatty acids supply
through increased lipolysis and dietary intake accompanied by an unadapted utilization. The free
fatty acids in the hepatocytes either undergo mitochondrial β-oxidation or esterification. Free fatty
acids and cholesterol, accumulated in mitochondria, are considered toxic lipids generating
mitochondrial dysfunction with oxidative further promoting hepatic injury and inflammation.11,12
The cellular injury further leads to the activation of immune and apoptotic cell death pathways
leading to the progression of NAFLD. An important aspect to be remembered is the genomic risk
factors associated with the development of MAFLD, and also with increased severity and risk of
fibrosis. Among them, the polymorphism of the genes PNPLA3 and TM6SF2 is validated as a risk
factor, due to its association with higher lipid liver content, inflammation, and fibrosis. 13. It also
seems that gut microbiota plays an important role in the pathogenesis of MAFLD, given the fact
that metagenomic sequencing and bacterial metabolite screens allow insight into the functional
repertoire of complex bacterial communities. The metabolic profile includes acylcarnitines, amino
acids, phosphatidylcholines (PC), biogenic amines, sphingomyelins (SM), and
lysophosphatidylcholines (lyso-PC). It seems that Lyso-PC may help prevent insulin resistance,
while SM may promote it. 9,14 Furthermore several observational studies demonstrated a different
bacterial metabolite profile between lean and obese NAFLD patients, as well as significant
differences between NAFL and NASH.15
Although MAFLD seems to be responsible is likely to generate an important panel of extra-hepatic
chronic complications affecting other organs and regulatory pathways with a major focus on the
NAFLD-related chronic disease such as cardiovascular disease, type 2 diabetes, and chronic kidney
disease. Recent studies demonstrated that NAFLD increased overall mortality by 57% mainly from
liver-related and cardiovascular causes and was associated with an approximately two-fold
increased risk of chronic kidney disease. 2 The interest in chronic kidney disease related to MAFLD
has raised in the past years, which conducted to a complex clinical and biological profile of these
patients represented in figure 1. 1,2,3

Fig.1 Clinical and biological profile of the NAFLD-CKD patient

The ideal therapeutical management is far to be completely elucidated. Without Food and Drug
Administration approved drugs, current treatment options are centered mostly on dietary restrictions
and lifestyle modification. However, several pharmacological therapies aiming to alleviate NAFLD-
NASH are currently being examined at various phases of clinical trials. Most of the studies are
researching therapies targeting the main processes involved in physiopathology: oxidative stress,
inflammation, fibrosis, and metabolic disorders (figure 2). Emerging data from these studies with
drugs targeting diverse molecular mechanisms show promising outcomes.

1. Lifestyle approach in MAFLD

The primary therapeutic option for patients with MAFLD is weight loss because most of these
patients are either overweight or obese. Over the past decades, many authors have reported the
effects of different weight-loss strategies such as prolonged fasting, diet or diet, and exercise. There
is good evidence that weight loss not only reduces liver fat content, but the histological resolution
of NASH can occur with as little as 5% weight loss and almost half of the patients with 10% weight
loss will have fibrosis regression. Weight loss by both diet and exercise can improve insulin
resistance, steatosis, and transaminase levels, some studies showing the synergistic effect of those
two. However, large and comprehensive clinical trials are still to be expected regarding this issue.
16,17

One of the most significant trials by Promrat et al included 31 overweight individuals with biopsy-
proven NASH to compare the efficacy of an intensive lifestyle intervention (ILI) program
(combining diet, exercise, and behavior modification) with structured education only (control). The
primary outcome measure was liver histology as defined by Kleiner`s NAS. After 48 weeks,
patients in the ILI group achieved an average weight loss of 9.3% versus 0.2% in the control group.
Also, 72% of the those in ILI group presented a > 3 point reduction in NAS from baseline compared
to 30% in the control group. In addition, Lazo et al conducted a study that included a cohort of 96
overweight adults with type II diabetes. After 12 months, the subjects in the ILI group lost a
significantly greater amount of weight than the control who only received diabetes and support
education only 9 -8.5% vs -0.05%).
To conclude, Moderate exercise performed at least 3–4 times per week, with the expenditure of
approximately 400 calories per session, would appear adequate to generate an improved metabolic
profile in patients with NAFLD, although greater gains are likely with higher activity levels. Most
dietary recommendations in NAFLD have focused on caloric restriction, with insufficient evidence
to make recommendations regarding specific macronutrient composition. Both low-fat [63] and
low-carbohydrate diets have shown benefits in NAFLD, and general advice is to avoid an excess of
either of these macronutrients. In particular, increased intake of saturated fat and the n-6/n-3 fatty
acid ratio has been implicated in the pathogenesis of NAFLD, with a recent study of n3-
polyunsaturated fatty acid (PUFA) supplementation in patients with NASH demonstrating
improvements in liver enzymes, markers of oxidative stress, and liver histology. Various other
popular weight-loss diets have been studied, but there is insufficient safety or efficacy data at
present to recommend their use. General advice that overweight or obese patients should aim to lose
at least 5–10% of body weight over a 6–12 month period is based on studies demonstrating
improvements in insulin resistance and liver histology with this degree of weight loss and also
represents what can be achieved practically by most behavioral weight-loss regimens. Rapid weight
loss can exacerbate steatohepatitis and should be avoided. Therefore, current dietary advice for such
patients is to consume reduced portions of a balanced low-glycemic index diet with increased fruit
and vegetable intake, limited meat intake, and avoidance of soft drinks, saturated fats, and trans-fats.
16-19

Besides weight loss through the means presented above, another option is referring to weight loss
surgery/ bariatric surgery. The most commonly performed Roux-en-Y gastric bypass and adjustable
gastric banding procedures are now frequently undertaken laparoscopically, with low associated
perioperative morbidity and mortality. The jejunoileal bypass procedure was abandoned because of
the risk of significant worsening of liver disease. A meta-analysis examining the effect of bariatric
surgery on NAFLD, including 15 studies and 766 paired liver biopsies, demonstrated that the
pooled proportion of patients with improvement or resolution in steatosis was 92%, steatohepatitis
81%, and fibrosis 65.5%. Complete resolution of NASH was achieved in 69.5% of patients.
However, a recent prospective trial of patients undergoing bariatric surgery with liver biopsies
performed before and at 1 and 5 years post-surgery demonstrated improvements in steatosis and
ballooning, but no significant improvements in inflammation or fibrosis. Meta-analytic pooling of
data from 15 studies in over 3500 patients has highlighted that endoscopic intragastric balloon
insertion is a valuable, safe modality for weight reduction (approximately 5.7 kg/m2 reduction in
BMI) in resistant obesity. As a result of comparable efficacy to laparoscopic sleeve gastrectomy
(LSG) and avoidance of the related risks of general anesthesia, laparoscopic surgery, and digestive
anastomosis, Genco and his Italian colleagues consider IB to be a better option than LSG in the
short-term management of resistant obesity. Since 2008, single-center studies emerging from Italy
have shown that IB may be of benefit in metabolic disease, liver dysfunction, and steatosis. After
placement of an IB for 6 months, Ricci et al. reported a significant reduction in insulin resistance,
ALT, and GGT in patients with a baseline echo-bright liver on ultrasound scan and a BMI >30
kg/m2. This benefit, however, depended on a weight reduction of greater than 10%, which was
achieved in 59% of participants. These results were supported by Forlona et al., who prospectively
studied the effectiveness of 6-month IB placement on metabolic variables in 130 obese patients
(mean baseline BMI 43 kg/m2). Interestingly, 50% of responders maintained or continued to lose
weight nearly 2 years after IB removal. The limitations of this study refer to the lack of comparative
control arms and also to the subjective nature of liver fat quantification using an ultrasound scan,
highlighting the need for larger-scale controlled studies. Future In the future, the optimal duration
and frequency of IB placement in obese patients with NAFLD must be thoroughly addressed. 16-19

Figure 2. Main targets in the treatment of MAFLD

2. Targeting metabolomics: the role of probiotics

NAFLD and CKD may represent both end-result organ injuries that occur in intestinal barrier
derangement and dysbiosis. Bacterial overgrowth and microbiome alteration lead to liver and
kidney insults that manifest as inflammation, fibrosis, disease progression, oxidative stress, and
endothelial dysfunction. Although direct causality is difficult to prove, modulating the gut
microbiota composition and functionality by means of probiotics remains a promising hypothesis
and generates current ongoing trials. One interesting perspective focusing on CKD patients is that
of the putative mechanism of the probiotics to lower bacteria-derived uremic toxins (IS, p-cresyl
sulfate, trimethylamine n-oxide). In addition, CKD patients may benefit from a conundrum of
potential mechanistic actions of bacteriotherapy: delaying the progression of CKD, reduction of
inflammation markers, decelerating atherogenesis and protein-energy wasting, improving
constipation. However, safety issues seem to have been overlooked in recent trials given the
friendly profile of this class. Advanced CKD and ESKD patients represent a fragile group and
intervention with probiotics needs to be conducted with caution: severe immune deficiency
represents a contraindication to probiotics administration. Interesting efforts are ongoing in order to
select and describe the most efficient probiotic strain, their pharmacological profile, therapy
duration and side effects profile in CKD and NAFLD.25-26
3. Metabolic targeted therapies

3.1.Glucagon-like peptide (GLP-1) receptor agonists

GLP1 is an endogenous intestinal hormone, acting through the G protein-coupled GLP1 receptor
(GLP1R) stimulating the production and release of insulin and indirectly inhibiting glucagon
secretion and reducing food intake. The circulating half-life of GLP1 is 1–2 minutes due to the
action of dipeptidyl peptidase 4 (DPP4), which cleaves and inactivates GLP1. Multiple GLP1R
agonists (exenatide, liraglutide, dulaglutide, and semaglutide) are approved for the treatment of type
II diabetes. The treatment of patients with type II diabetes with either exenatide, liraglutide or
semaglutide has demonstrated efficacy in reducing hepatic lipid content as well as levels of liver
enzymes and inflammatory markers, an effect associated with improved HbA1c levels and body-
weight loss. Compared with control individuals given a placebo, a greater percentage of patients
with NASH who were treated with semaglutide achieved resolution of NASH with no worsening of
fibrosis. Many of the beneficial aspects of GLP1R agonism on MAFLD endpoints are closely
associated with weight loss and improved metabolic indexes. GLP1R is not expressed in most live
at appreciable levels and, thus, the effects of activating this receptor on NASH endpoints are
probably not due to direct hepatic actions but rather due to systemic improvements in metabolism.
In recent years, their application has been evaluated in NASH and MAFLD treatment, especially
liraglutide. An improvement in steatosis and a slowing down of the fibrosis progression has been
shown in the LEAN, LEAD, LEAN-J, and Lira-NAFLD trials. In the LEAN study, although in a
small number of patients, a biopsy-proven NASH resolution was shown in 9/23. A recent double-
blind, placebo-controlled 20-week trial comparing lifestyle intervention with either liraglutide or
orlistat in over 500 patients, has demonstrated that the benefits of GLP-1 analogues in inducing
weight loss are also found in non-diabetic patients. The study demonstrated a mean weight loss of
4.8 and 7.2 kg in those taking 1.8 and 3.0 mg liraglutide, respectively, versus 2.8 kg with placebo
and 4.1 kg with orlistat. Liraglutide also reduced blood pressure and the prevalence of prediabetes,
with adverse events mainly transient and very rarely leading to discontinuation of treatment.22-24

3.2.Peroxisome proliferator-activated receptor (PPAR) agonists

PPAR-ligands which include troglitazone, pioglitazone, and rosiglitazone, act by enhancing insulin
sensitivity and have been associated with decreased free fatty acids and serum triglycerides. Thus,
drugs in this class are of potential benefit in patients with MAFLD. Unfortunately, only a limited
number of small human studies of PPAR-ligand therapy for MAFLD exist and only one of these
trials is a randomized prospective study. Troglitazone was shown to decrease liver
aminotransferases when used alone or in combination with sulfonylureas. However, hepatic
steatosis often persists, the impact of troglitazone on hepatic inflammation and fibrosis being
variable. As a result of reports of severe idiosyncratic hepatotoxicity, troglitazone has been
withdrawn from the US market. Subsequent studies of the newer generation PPAR- ligands
pioglitazone and rosiglitazone have demonstrated improvement in liver aminotransferases, but the
effects on hepatic histology have not yet been reported. The preliminary nature of these findings
suggests that these drugs should not yet be used exclusively for the therapy of MAFLD but may
represent appropriate first-line therapy in patients with concomitant diabetes and histologically
progressive MAFLD.
In the published trials, the dosages used were as follows: troglitazone, 400 mg/day; rosiglitazone, 4
mg twice a day (in an ongoing trial); and pioglitazone, 500mg/day to 500 mg three times per day.
In a recent randomized, double-blind placebo-controlled trial in patients with MASH, elafibranor
was able to resolve MASH in patients with moderate or severe MASH. However, no or a limited
effect has been shown in the fibrosis improvement. The treatment was well tolerated with limited
side effects (i.e., mild and reversible increase in creatinine). A meta-analysis published in 2007
found that rosiglitazone use was associated with an increased risk of myocardial infarction and
cardiovascular death compared with placebo, resulting in a black-box warning and restriction of
rosiglitazone use by the FDA. However, the warning and restriction were later removed after
additional studies failed to replicate the findings regarding cardiovascular risks. Of the two
approved thiazolidinediones, rosiglitazone is the most potent activator of PPARγ.Studies have
demonstrated that patients with NASH receiving rosiglitazone had enhanced insulin sensitivity and
reduced hepatic steatosis; however, considerable weight gain and edema in the lower extremities
were reported. As the clinical use of rosiglitazone as an insulin sensitizer has largely been
discontinued, there has been very little further evaluation of the drug for the treatment of NASH
after the studies conducted almost 15 years ago. Pioglitazone is also an effective insulin sensitizer
but is a less potent PPARγ agonist and is associated with fewer adverse effects than rosiglitazone.
Treatment with pioglitazone in patients with type 2 diabetes and NASH resulted in improved
insulin sensitivity and reduced inflammation and hepatocyte degeneration as well as in reduced
fibrosis relative to pretreatment measurements, yet there was no difference in the resolution of
fibrosis compared with the placebo group. Additionally, patients with NASH but no type II diabetes
receiving pioglitazone had improved fasting glucose levels and a greater resolution of NASH,
though with no improvement in fibrosis, and increased weight gain versus patients receiving
placebo. 18-24

3.3.Mitochondrial pyruvate carrier (MPC) antagonist

During the glycolysis process, the metabolic chain reactions generate pyruvate. The pyruvate is then
transported by a carrier complex (MPC) into the mitochondria, further promoting gluconeogenesis
and lipogenesis. MPC complex is not fully characterized regarding structure and composition but
supports the transformation of pyruvate into acetyl-CoA or oxalacetate. Inhibition of MPC complex
increases insulin sensitivity with a decrease in the adipose tissue lipolysis with a decreased
accumulation of lipids in the liver. Also increasing hepatic insulin activity decreases de novo
lipogenesis with a reduction in oxidative stress and hepatic cell inflammation.15 The inflammation
of the hepatic tissue is thought to initiate the development of fibrosis in MAFLD. A study
demonstrated that the MPC1 deletion decreased hepatic inflammation and fibrosis after a long-time
follow-up. Also, it was demonstrated that a specific inhibitor of MPC is isolated hepatocytes
reduced the production of cytokines and inflammation in the hepatic tissue. These data led us to
believe that MPC inhibition may be a potential targeted therapy in lowering the progression of
hepatic damage.15,16 The results of the EMMINENCE study demonstrated that a specific inhibitor of
MPC (MSDC-0602K), which is a second-generation thiazolidinedione did not demonstrate a
significant effect on liver histology endpoints in patients with hepatic inflammation and fibrosis, but
reduced the serum levels of fasting glucose, fasting insulin and glycated hemoglobin.27
3.4.Farnesoid X receptor (FRX) agonist
Another important molecule involved in the metabolic pathways is represented by FXR, a
transcription factor that regulates several metabolic functions including glucose and lipids
metabolism. Due to its increased expression in the hepatic tissue, the activation of this factor
reduces hepatic steatosis in inflammation through inhibition of a rate-limiting enzyme that converts
cholesterol to bile acids. An example of a potent FXR agonist is represented by obeticholic acid. A
randomized clinical trial demonstrated an improvement of fibrosis with NASH with no worsening
or resolution of severe inflammation, but with some limitations regarding the toxicity profile,
pruritus being the most common adverse reaction. Also, the safety and efficacy of obeticholic acid
for the treatment of cirrhosis secondary to NASH are being evaluated. On the other side, tropifexor,
another FXR agonist did not demonstrate the significant effect in reducing hepatic inflammation
and fibrosis. 11,27
4. Inflammation and fibrosis targeted therapies
Although most studies developing medications have focused on initiating metabolic processes,
several attempts have been made to target downstream inflammatory and injury pathways.
4.1. Targeting Nrf2-KEAP1 pathway
Nrf2-KEAP1 pathway plays an important role in regulating oxidative stress at the cellular level,
with important implications in metabolic homeostasis. Through interaction with KEAP1, the Nrf2
inhibition molecule promotes translocation of transcriptional factors such as Nrf2 to the nucleus,
where it binds to antioxidant response molecules in the promoter region of its target genes, This
event induces the synthesis of antioxidant and cytoprotective enzymes and related proteins. Studies
reported that Nrf2 deficiency results in mitochondrial depolarization, reduced ATP production and
decreased oxygen consumption, as well as less efficient mitochondrial fatty acid oxidation. Also,
several studies showed that Nrf2 defective mice are more susceptible to oxidative stress in the liver
than wild-type mice, with a protective effect against steatohepatitis. There is also growing evidence
that activation of Nrf2 inhibits the synthesis of enzymes with a major role in the fatty acid synthesis,
with a secondary reduction in the levels of hepatic lipids. Therefore, Nrf2 appears to protect the
liver against steatosis by inhibiting lipogenesis and promoting fatty acid oxidation. In this case,
activation of Nrf2 seems a potential therapeutic target in the treatment of MAFLD, but there have
not been any clinical trials specifically on the effect of Nrf2 activation on liver disease in humans.
However, Bardoxolone methyl, a currently investigated drug, potently activates Nrf2 by selective
inhibition of KEAP1 in the Nrf2-KEAP pathway, with favorable effects in patients with metabolic
syndrome and chronic kidney disease. The BEAM study which included subjects with diabetic
chronic disease and type 2 diabetes demonstrated that the group treated with bardoxolone methyl
showed a significantly greater increase in eGFR than the placebo group, which persisted for up to
52 weeks. More recent studies like BEACON and TSUBAKI also pointed to an increase in the
eGFR levels in the group treated with bardoxolone methyl. The ongoing trial AYAME will evaluate
the efficacy of bardoxolone methyl in patients with diabetic kidney disease, with a primary endpoint
based on the increase in eGFR from baseline.27,28,29
4.2. Chasing the cytokines
In MAFLD various cytokines contribute to disease pathogenesis, as investigated in disease models
in mice. Over the last years, members of the IL-1 cytokine family are considered as major pylons in
inflammatory conditions including metabolic inflammation. IL-1 type cytokines generate
characteristic changes of MAFLD: hepatic steatosis, inflammatory infiltrates, fibrosis, insulin
resistance and adipose tissue inflammation. Some preclinical studies highlighted a central role for
IL-1 type cytokines in MAFLD. These experimental studies indicate that blocking IL-1β has
beneficial effects on certain aspects of metabolic diseases. The central role on the hepatic
inflammation scene belongs to the Kupffer cells (KCs), a major source of cytokines and
chemokines, including IL-1. Furthermore, activation of NLRP3 in KCs promotes IL-1β secretion,
thereby accelerating the development of MAFLD. Also, considering the panel of extra-hepatic
chronic complications of MAFLD, including cardiovascular disease, antiinflammatory therapy
targeting the interleukin-1β with canakinumab led to a significantly lower rate of recurrent
cardiovascular events than placebo, independent of lipid-level lowering. There are no data available
at the moment regarding the influence of the IL-1 specifically on the MAFLD from randomized
clinical trials. 20,21
4.3.Vitamine E
Considering the important role of oxidative stress as a major pathological pathway in developing
MAFLD, vitamin E, a lipid-soluble antioxidant, was tested in the PIVENS trial, which
demonstrated improvement of NASH in terms of steatosis, inflammation, ballooning at a dose of
800 IU/day, therefore a histological response in 43% of subjects and resolution of NASH in 36% of
subjects after 96 weeks of treatment. Also, long-term use of vitamin E may be associated with an
increased incidence of hemorrhagic stroke and an increased risk of prostate cancer. Vitamin
represents is the only medication to date that has been associated with improved clinical outcomes,
leading to increased transplant-free survival and decreased hepatic decompensation.
Supplementation with vitamin E also decreases steatosis through its antioxidant effect and by a
decrease in hepatic de novo lipogenesis. Currently, vitamin E appears to be a safe, effective, and
inexpensive therapy that is readily available.27-28

Conclusions
MAFLD is one of the most common causes of chronic liver disease, predicted to become also the
most frequent indication for liver transplantation. Over the past years, it has been shown that the
clinical burden of NAFLD is not only confined to liver-related morbidity and mortality but there is
now growing evidence that NAFLD is a multisystem disease, affecting extra-hepatic organs and
regulatory pathways. The pathophysiology is very complex with an important contribution of
metabolic disorders and immune system activity. Therefore, many inflammatory mediators have
been identified as being drivers of the progression and fibrosis of the hepatic and extra-hepatic
tissues. The current treatment options are centered mostly on dietary restrictions and lifestyle
modification but several inflammatory therapeutic targets have been or are currently being
evaluated in clinical trials for the treatment of AH and NASH. We expect more clinical trials using
inflammatory mediators as therapeutic targets for the treatment of fatty liver diseases to be
conducted in the future.

References

1. Eslam M, Newsome PN, Sarin SK et. al. A new definition for metabolic dysfunction-associated
fatty liver disease: An international expert consensus statement. Journal of Hepatology 2020
(73): 202-209.
2. Bryne CD, Targher G. NAFLD: A multisystem disease. Journal of Hepatology 2014 (62):S47-
S64.
3. Ciardullo S, Perseghin G. Prevalence of NAFLD, MAFLD and associated advanced fibrosis in
the contemporary United States population. Liver International 2021: 1-4.
4. Yaunossi ZM, Koenig AB, Abdelatif D et al., Global Epidemiology of Nonalcoholic Fatty Liver
Disease—Meta-Analytic Assessment of Prevalence, Incidence,and Outcomes. Hepatology 2016
64(1):73-84.
5. Wu Y, Zheng Q, Zou B et al. The epidemiology of NAFLD in Mainland China with analysis by
adjusted gross regional domestic product: a meta‑analysis. Hepathology International 2020
6. Liu J, Ayada I, Zhang X et al., Estimating global prevalence of metabolice dysfunction-
associated fatty liver disease in overweight or obese adults. Clinical Gastroenterology and
Hepatology 2021; (21)
7. Chen Y, Li H, Li S et al., Prevalence of and risk factors for metabolic associated fatty liver
disease in an urban population in China: a cross-sectional comparative study. BMC
Gastroenterol 2021; 21:212
8. Lim G, Tang A, Ng CH et al., An Observational Data Meta-analysis on the Differences in
Prevalence and Risk factors Between MAFLD vs NAFLD. Clinical Gastroenterology and
Hepatology 2021
9. Rodriguez-Duque JC, Callega JL, Iruzubieta P et al., Increased risk of MAFLD in inflamatory
bowel disease. Clinical Gastroenterology and Hepatology 2022
https://doi.org/10.1016/j.cgh.2022.01.039
10. Kuchay MS, Choudhary NS, Mishra SK. Pathophysiological mechanism underlying MAFLD.
Diabetes&Metabolic Syndrome: Clinical Research and Reviews 2020; 1875-1887
11. Negi CK, Babica P, Bajard L et al., Insights into the molecular targets and emerging
pharmacotherapeutic interventions for nonalcoholic fatty liver disease. Metabolism Clinical and
Experimental 2022; (126)
12. Tilg H, Moschen AR. Evolution of Inflammation in Nonalcoolic Fatty Liver Disease: The
multiple Parallel Hits Hypothesis. Hepathology 2010; 52(5): 1836-1846
13. Chen Y, Yeh M. Non-alcoholic fatty liver disease: A review with clinical and pathological
correlation. Journal of the Formosan Medical Association 2021; 120:68-77
14. McCommis KS, Finck BN, Treating Hepatic Steatosis and Fibrosis by Modulation
Mitochondrial Pyruvate Metabolism 2019;7:275-284
15. Rauckhorst AJ, Gray LR, Sheldon RD et. al, The mitochondrial pyruvate carrier mediates high
fat diet-induced increases in hepatic TCA cycle capacity. Molecular Metabolism 2017;6:1468-
1479.
16. Chander K. Negi , Pavel Babica , Lola Bajarda, Julie Bienertova-Vasku, Giovanni Tarantino,
Insights into the molecular targets and emerging pharmacotherapeutic interventions for
nonalcoholic fatty liver disease
17. Michele Finotti 1,*, Maurizio Romano 1, Pasquale Auricchio 2, Michele Scopelliti 1, Marco
Brizzolari 1,Ugo Grossi 1 , Marco Piccino 1, Stefano Benvenuti 3, Giovanni Morana 4 ,
Umberto Cillo 2 and Giacomo Zanus, Target Therapies for NASH/NAFLD: From the
Molecular Aspect to the Pharmacological and Surgical Alternatives
18. Jeffrey L. Tokar, MD Carl L. Berg, MD, Therapeutic Optionsin Nonalcoholic Fatty Liver
Disease
19. James Maurice A and Pinelopi Manousou B, Non-alcoholic fatty liver disease
20. Daniel Ferguson and Brian N. Finck, Emerging therapeutic approaches for the treatment o
NAFLD and type 2 diabetes mellitus
21. J. K. Dowman1,2, M. J. Armstrong1,2, J. W. Tomlinson3 & P. N. Newsome1,2, Current
therapeutic strategies in non-alcoholic fatty liver disease
22. Polyzos SA, Kang ES, Boutari C, Rhee EJ, Mantzoros CS. Current and emerging
pharmacological
options for the treatment of nonalcoholic steatohepatitis.
23. Armstrong, M. J. et al. Liraglutide safety and efficacy in patients with non-alcoholic
steatohepatitis
24. (LEAN): a multicentre, double-blind, randomised,placebo-controlled phase 2 study
25. Meroni, M., Longo, M., & Dongiovanni, P. (2019). The Role of Probiotics in Nonalcoholic
Fatty Liver Disease: A New Insight into Therapeutic Strategies. Nutrients, 11(11), 2642.
https://doi.org/10.3390/nu11112642
26. Koppe, L., Mafra, D., & Fouque, D. (2015). Probiotics and chronic kidney disease. Kidney

International, 88(5), 958–966. https://doi.org/10.1038/ki.2015.255