Validity of fatty liver disease indices in the presence of alcohol consumption

Figures & data

Table 1. Characteristics of the study populations.

Variables	Finnish sample				German sample
	All N= 1426	No FLD N= 1192	FLD N= 234	p-value	All N= 385	No FLD N= 217	FLD N= 168	p-value
Age, y	42.1 ± 5.0	41.8 ± 5.0	43.1 ± 4.7	<.001	55.8 ± 9.1	54.3 ± 9.2	57.8 ± 8.6	<.001
Males	42.6% (607)	37.8% (450)	67.1% (157)	<.001	57.7% (222)	46.1 % (102)	72.6 % (120)	<.001
Weight, kg	77.9 ± 16.9	74.7 ± 14.2	94.2 ± 19.6	<.001	83.1 ± 16.1	76.0 ± 14.0	92.2 ± 15.2	<.001
Height, cm	172.0 ± 9.1	171.4 ± 8.9	179.4 ± 9.3	<.001	171.8 ± 9.7	170.8 ± 9.8	173.2 ± 9.5	.01
BMI, kg/m^2	26.3 ± 4.9	25.4 ± 4.2	30.7 ± 5.6	<.001	28.1 ± 4.9	26.0 ± 4.0	30.8 ± 4.6	<.001
WC, cm	90.8 ± 13.7	88.1 ± 12.0	104.5 ± 14.1	<.001	98.6 ± 14.3	91.3 ± 11.6	107.9 ± 11.8	<.001
HC, cm	101.3 ± 8.9	100.2 ± 8.1	106.8 ± 10.4	<.001	106.9 ± 8.9	103.9 ± 7.8	110.9 ± 8.9	<.001
WHR	0.89 ± 0.09	0.88 ± 0.08	0.98 ± 0.08	<.001	0.92 ± 0.09	0.88 ± 0.08	0.97 ± 0.07	<.001
ALT, U/l	17.6 ± 21.0	14.5 ± 9.8	33.2 ± 43.7	<.001	31.2 ± 17.7	24.6 ± 12.7	39.7 ± 19.5	<.001
AST, U/l	23.5 ± 19.3	21.5 ± 10.8	33.5 ± 39.6	<.001	25.4 ± 12.9	23.0 ± 14.2	28.6 ± 10.1	<.001
ALT/AST	0.71 ± 0.27	0.66 ± 0.24	0.95 ± 0.30	<.001	1.23 ± 0.40	1.11 ± 0.37	1.38 ± 0.39	<.001
GGT, U/l	33.4 ± 45.5	26.9 ± 28.6	66.4 ± 84.7	<.001	40.0 ± 40.5	29.55 ± 34.8	53.4 ± 43.4	<.001
TC, mmol/l	5.16 ± 0.95	5.10 ± 0.9	5.44 ± 1.1	<.001	5.64 ± 0.94	5.61 ± 0.92	5.67 ± 0.98	.74
LDL-C, mmol/l	3.26 ± 0.83	3.22 ± 0.8	3.42 ± 1.0	.006	3.61 ± 0.86	3.57 ± 0.83	3.67 ± 0.89	.27
HDL-C, mmol/l	1.34 ± 0.33	1.37 ± 0.3	1.17 ± 0.3	<.001	1.60 ± 0.46	1.71 ± 0.47	1.45 ± 0.39	<.001
TG, mmol/l	1.31 ± 1.34	1.15 ± 1.2	2.1 ± 1.8	<.001	1.51 ± 0.97	1.24 ± 0.83	1.85 ± 1.04	<.001
PC, E9/l	255.9 ± 60.3	255.5 ± 59.7	258.2 ± 62.9	.53	230.2 ± 53.6	237.0 ± 56.2	221.3 ± 48.9	.007
Alcohol/day, g	9.37 ± 14.0	8.44 ± 12.7	14.12 ± 18.8	<.001	18.6 ± 23.9	14.92 ± 19.5	23.35 ± 27.98	.003
Alcohol (g/day), grouped
<10	69.7% (994)	72.1% (860)	57.3% (134)	<.001	50.9% (196)	57.1% (124)	42.9% (72)	.02
10–20/30	24.0% (342)	22.9% (273)	29.5% (69)		22.6% (87)	20.7% (45)	25.0% (42)
20/30–50	3.7% (53)	3.1% (37)	6.8% (16)		17.1% (66)	15.7% (34)	19.0% (32)
>50	2.6% (37)	1.8% (22)	6.4% (15)		9.4% (36)	6.5% (14)	13.1% (22)
Smoking status
Daily/Current	12.3% (175)	11.5% (135)	17.5% (40)	.01	17.1% (66)	22.1% (48)	10.7% (18)	.003
No/less than daily^1	86.0% (1227)	88.5% (1038)	82.5% (188)		82.9% (319)	77.9% (169)	89.3% (150)
Diabetes
Type 1 Diabetes	0.6% (9)	0.7% (8)	0.4% (1)	1.0	0.0% (0)	0.0% (0)	0.0% (0)
Type 2 Diabetes	1.8% (25)	0.6% (7)	7.7% (18)	<.001	13.2% (51)	5.1% (11)	23.8% (40)	<.001
No Diabetes	97.6% (1392)	98.7% (1177)	91.9% (215)		86.8% (334)	94.9% (206)	76.2% (128)
FLI	38.6 ± 30.5	31.5 ± 26.5	74.6 ± 23.8	<.001	54.6 ± 31.2	37.4 ± 27.0	76.7 ± 20.5	<.001
FLI <30	51.2% (730)	59.8% (712)	7.7% (18)	<.001	28.8% (111)	48.4% (105)	3.6% (6)	<.001
FLI 30–60	21.4% (305)	22.4% (267)	16.3% (38)		22.1% (85)	27.2% (59)	15.5% (26)
FLI ≥60	27.2% (388)	17.7% (211)	76.0% (177)		49.1% (189)	24.4% (53)	81.0% (136
HSI	33.1 ± 5.9	31.9 ± 4.9	39.1 ± 6.6	<.001	39.0 ± 6.5	36.0 ± 5.5	42.9 ± 5.8	<.001
HSI <30	32.7% (466)	39.7% (455)	4.9% (11)	<.001	6.5% (25)	11.1% (24)	0.6% (1)	<.001
HSI 30–36	38.6% (550)	42.3% (484)	29.6% (66)		30.4% (117)	45.6% (99)	10.7% (18)
HSI ≥36	24.7% (352)	18.0% (206)	65.5% (146)		63.1% (243)	43.3% (94)	88.7% (149)
LAP	43.2 ± 58.4	34.2 ± 45.4	89.3 ± 88.0	<.001	59.0 ± 49.3	39.5 ± 35.2	84.2 ± 53.5	<.001
LAP under cut-off*	45.2% (643)	51.9% (618)	10.7% (25)	<.001	27.5% (106)	43.3% (94)	7.1% (12)	<.001
LAP over cut-off*	54.8% (781)	48.1% (573)	89.3% (208)		72.5% (279)	56.7% (123)	92.9% (156)
DSI	−1.84 ± 1.41	−2.17±1.18	−0.13 ± 1.22	<.001	−0.53 ± 1.43	−1.29 ± 1.23	0.44 ± 1.03	<.001
DSI < −1.4	64.8% (924)	74.9% (893)	13.2% (31)	<.001	29.9% (115)	48.8% (106)	5.4% (9)	<.001
DSI −1.4 − 0	23.6% (336)	19.9% (237)	42.3% (99)		30.9% (119)	34.1% (74)	26.8% (45)
DSI ≥0	11.6% (166)	5.2% (62)	44.4% (104)		39.2% (151)	17.1% (37)	67.9% (114)

BMI: Body mass index; WC: waist circumference; HC: hip circumference; WHR: waist-hip ratio; TC: total cholesterol; TG: triglycerides; PC: platelet count; FLI: Fatty liver index; HSI: Hepatic steatosis index; LAP: Lipid accumulation product; DSI: Dallas steatosis index.

Values are expressed as mean ± SD for continuous variables and % (N) for categorical variables. Alcohol consumption cut-offs (g/day) for males were <10, 10–30, 30–50, and >50. Corresponding cut-offs for females were <10, 10–20, 20–50, and >50.

*LAP cut-off 30.5 for men and 23 for women.

¹Former or never smoker in KORA study.

Figure 2. Boxplots of differences in index distribution between no FLD or FLD shown for different alcohol consumption groups; Finnish sample (A), German sample (B). Boxes represent the middle two quartiles, the horizontal line inside box represents median. Upper and lower quartiles are expressed as vertical lines within the range. Outliers are marked by dots. Alcohol consumption cut-offs (g/day) for males were <10, 10–30, 30–50, and >50. Corresponding cut-offs for females were <10, 10–20, 20–50, and >50.

Table 2. AUROCs and 95% CIs for FLD indices to detect FLD according to alcohol consumption.

Finnish sample
Alcohol use (g/day)	FLI		HSI		LAP		DSI
	AUROC	95% CI	AUROC	95% CI	AUROC	95% CI	AUROC	95% CI
All	0.87	0.85–0.90	0.83	0.80–0.85	0.84	0.81–0.87	0.88	0.86–0.90
<10	0.88	0.85–0.91	0.84	0.81–0.88	0.86	0.83–0.90	0.90	0.87–0.93
10–20/30	0.86	0.82–0.91	0.82	0.77–0.88	0.82	0.77–0.87	0.86	0.81–0.90
20/30–50	0.87	0.77–0.96	0.87	0.76–0.97	0.82	0.69–0.94	0.89	0.80–0.98
>50	0.65	0.45–0.84	0.65	0.46–0.84	0.59	0.38–0.80	0.66	0.48–0.84
German sample
	FLI		HSI		LAP		DSI
	AUROC	95% CI	AUROC	95% CI	AUROC	95% CI	AUROC	95% CI
All	0.87	0.83–0.90	0.82	0.77–0.86	0.83	0.79–0.87	0.86	0.82–0.89
<10	0.90	0.85–0.94	0.85	0.80–0.90	0.89	0.84-0.93	0.91	0.87–0.95
10–20/30	0.82	0.73–0.90	0.83	0.74–0.92	0.78	0.68–0.88	0.82	0.73–0.90
20/30–50	0.93	0.87–0.99	0.84	0.75–0.94	0.84	0.75–0.93	0.88	0.8–0.96
>50	0.64	0.45–0.83	0.68	0.49–0.87	0.57	0.37–0.76	0.63	0.44–.082

AUROC: Area under receiver operating characteristic; CI: Confidence interval; FLD: Fatty liver disease; FLI: Fatty liver index; HSI: Hepatic steatosis index; LAP: Lipid accumulation product; DSI: Dallas steatosis index.

Alcohol consumption cut-offs (g/day) for males were <10, 10–30, 30–50, and >50. Corresponding cut-offs for females were <10, 10–20, 20–50, and >50.

Table 3. Performance measures for FLD indices.

Index	Low-risk cut-off					High-risk cut-off
	Alcohol use (g/day)	Sensitivity	Specificity	PPV	NPV	Sensitivity	Specificity	PPV	NPV
FLI	–	92.3/96.4%	59.8/48.4%	31.0/59.1%	97.5/94.6%	76.0/81.0%	82.3/75.6%	45.6/72.0%	94.6/83.7%
	<10	90.3/95.8%	64.1/53.2%	28.2/54.3%	97.7/95.7%	77.6/86.1%	85.0/76.6%	44.6/68.1%	96.0/90.5%
	10–20/30	98.6/97.6%	48.7/42.2%	32.7/61.2%	99.3/95.0%	78.3/71.5%	75.8/71.1%	45.0/69.8%	93.2/72.7%
	20/30–50	100.0/96.9%	54.1/55.9%	48.5/67.4%	100.0/95.0%	75.0/84.4%	73.0/88.2%	54.5/87.1%	87.1/85.7%
	>50	71.4/95.5%	40.9/7.1%	43.5/61.8%	69.2/50.0%	50.0/77.3%	72.7/50.0%	53.8/70.8%	69.6/58.3%
HSI	–	95.1/99.4%	39.7/11.1%	23.5/46.4%	97.6/96.0%	65.5/88.7%	82.0/56.7%	41.5/61.3%	92.4/86.6%
	<10	96.2/100.0%	41.1/9.7%	35.1/39.1%	98.5/100.0%	69.2/95.8%	81.5/54.0%	37.2/54.8%	94.4/95.7%
	10–20/30	95.4/100.0%	37.1/11.1%	21.2/51.2%	97.0/100.0%	63.1/88.1%	82.6/62.2%	47.7/68.5%	90.1/84.8%
	20/30–50	100.0/96.9%	32.4/20.6%	35.9/53.4%	100.0/87.5%	71.4/81.3%	83.8/58.8%	62.5/65.0%	88.6/76.9%
	>50	78.6/100.0%	33.3/0.0%	44.0/61.1%	70.0/n.c.%	35.7/77.3%	85.7/57.1%	62.5/73.9%	66.7/61.5%
LAP	–	–	–	–	–	89.3/92.9%	51.9/43.3%	26.6/55.9%	96.1/88.7%
	<10	–	–	–	–	91.8/97.2%	52.4/48.4%	23.1/52.2%	97.6/96.8%
	10–20/30	–	–	–	–	89.9/90.5%	52.0/35.6%	32.1/56.7%	95.3/80.0%
	20/30–50	–	–	–	–	81.3/90.6%	54.1/47.1%	43.3/61.7%	87.0/84.2%
	>50	–	–	–	–	71.4/86.4%	27.3/14.3%	38.5/61.3%	60.0/40.0%
DSI	–	86.8/94.6%	74.9/48.8%	40.4/58.9%	96.6/92.2%	44.4/67.9%	94.8/82.9%	62.7/75.5%	89.7/76.9%
	<10	87.3/98.6%	78.3/54.0%	38.5/55.5%	97.5/97.1%	45.5/79.2%	96.6/83.9%	67.8/74.0%	91.9/87.4%
	10–20/30	88.4/95.2%	67.0/42.2%	40.4/60.6%	95.8/90.5%	46.4/59.6%	89.7/80.0%	53.3/73.5%	86.9/67.9%
	20/30–50	93.8/93.8%	67.6/50.0%	55.6/63.8%	96.2/89.5%	56.3/56.3%	94.6/91.2%	81.8/85.7%	83.3/68.9%
	>50	66.7/81.8%	54.5/21.4%	50.0/62.1%	70.6/42.9%	13.3/63.6%	86.4/64.3%	40.0/73.7%	59.4/52.9%

FLI: Fatty liver index; HSI: Hepatic steatosis index; LAP: Lipid accumulation product; DSI: Dallas steatosis index; PPV: Positive predictive value; NPV: Negative predictive value; n.c.: No cases.

Values are shown in % for Finnish/German samples.

The following cut-off values were used FLI: 30 and 60, HSI: 30 and 36, LAP: 23 for women and 30.5 for men, DSI: −1.4 and 0.0.

Alcohol consumption cut-offs (g/day) for males were <10, 10–30, 30–50, and >50. Corresponding cut-offs for females were <10, 10–20, 20–50, and >50.

Kim D, Li AA, Gadiparthi C, et al. Changing trends in etiology-based annual mortality from chronic liver disease, from 2007 through 2016. Gastroenterology. 2018;155(4):1154–1163.e3.

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