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Hospitalized lean patients (body mass index [BMI] <25 kg/m²) with metabolic dysfunction-associated steatohepatitis (MASH) are at higher risk of mortality and health complications than non-lean (BMI 鈮� 25 kg/m²) patients with MASH, according to a recent study.¹

Chukwunonso Ezeani, MD, from the Department of Internal Medicine at Baton Rouge General Medical Center, Baton Rouge, LA, and colleagues and published their report in Cureus.¹ The findings highlight the necessity of early screening and treatment to improve outcomes in lean individuals with MASH.

In this retrospective analysis, the authors analyzed data from the National Inpatient Sample (NIS) database between 2016 and 2020. 鈥淲e used the largest publicly available all-payer care database, NIS, for this study,鈥� said Basile Njei, MD, MPH, PhD., one of the study鈥檚 authors.

The study included 539,275 patients diagnosed with MASH, of whom 324,330 (60%) were categorized as lean, while 214,945 (40%) were characterized as non-lean. The primary outcome measured was in-hospital mortality. Secondary outcomes included major adverse cardiovascular events, major adverse kidney outcomes, and hepatic decompensation.

Lean patients face greater risk of mortality

The investigators found that lean patients with MASH exhibited a 40% greater risk of mortality compared to non-lean patients (adjusted odds ratio [aOR] 1.40, 95% confidence interval [CI] 1.29-1.53; P<.001). Additionally, lean patients faced a 19% greater risk of major adverse cardiovascular events (aOR 1.19, 95% CI 1.14-1.24; P<.001), a 25% greater risk of renal decompensation (aOR 1.25, 95% CI 1.20-1.30; P<.001), and a 33% greater risk of hepatic decompensation (aOR 1.33, 95% CI 1.28-1.38; P<.001).¹

No statistically significant differences existed between the lean and non-lean groups in the rates of cardiac arrest or myocardial infarction. However, lean patients had an 11% greater risk of heart failure (aOR 1.11, 95% CI 1.06-1.16; P<.001), a 25% greater risk of stroke (aOR 1.25, 95% CI 1.21-1.34; P<.001), and a 27% greater risk of atrial fibrillation/flutter (aOR 1.27, 95% CI 1.21-1.34; P<.001) than non-lean patients.¹

While lean patients were less likely to develop acute kidney injury during hospitalization (aOR 0.90, 95% CI 0.86-0.93; P<.001), they were significantly more likely to require renal replacement therapy (aOR 1.56, 95% CI 1.42-1.71; P<.001). No notable difference existed in the incidence of renal cancer between the 2 groups.¹

Lean patients were more likely to develop hepatic complications than non-lean patients. Specifically, lean patients were 34% more likely to develop ascites (aOR 1.34, 95% CI 1.29-1.39; P<.001), 33% more likely to develop spontaneous bacterial peritonitis (aOR 1.33, 95% CI 1.21-1.47; P<.001), and 22% more likely to develop hepatorenal syndrome (aOR 1.22, 95% CI 1.13-1.32; P<.001).¹

Clinical implications

The increased risks observed in lean MASH patients suggest that higher BMI is not always linked to worse outcomes in metabolic diseases. 鈥淒espite lean MASH patients being generally considered to be at lower risk due to favorable metabolic profiles, our studies suggest this group of patients are at significantly higher risk of cardiovascular-, hepatic-, and renal-related adverse events,鈥� said Dr. Njei, who attributed this increased risk to delays in diagnosis and treatment due to favorable metabolic profiles as well as genetic predisposition to worsened clinical outcomes in the lean arm.

This understanding is essential for creating specialized intervention plans to address the unique health risks faced by this population. Dr. Njei told 番茄社区app that he recommends screening guidelines emphasizing lean MASH as well as increased awareness campaigns and continuing medical education programs to emphasize lean MASH with a goal for early diagnosis and treatment. Additionally, he emphasized the need for 鈥渧igilant assessment of cardiovascular and renal diseases鈥� in lean patients diagnosed with MASH.

This study underscores the need for close cardiovascular and renal monitoring in lean patients with MASH, given their potentially more severe disease progression. The authors note these findings call for a review of clinical guidelines to include personalized screening and treatment strategies for lean individuals. 

As far as limitations, the authors did note that since this is a retrospective study design, relying on ICD-10 coding in the database, potential biases could have been introduced due to miscoding or misdiagnosis. Also, the study used data from a US-based population only. Thus, future studies using a more diverse, international population could help validate and generalize the results to this population type worldwide.

Additionally, the authors emphasize the need for future research, including longitudinal studies to unravel the underlying mechanisms driving the increased risk in lean MASH patients as well as interventional studies to determine which treatments are most effective.

Published: August 22, 2024