Nonalcoholic fatty liver disease and the heart in children and adolescents

Table 3 Studies of the association between nonalcoholic fatty liver disease and alterations in cardiac structure and function in children and adolescents

Ref.	Study population and sample size	Diagnosis	Outcomes	Main results
Sert et al[30]	Obese adolescents with (n = 44), and without (n = 36) NAFLD; and control subjects (n = 37)	Liver ultrasound and elevated serum alanine aminotransferase	LV structure (M-mode echocardiography)	Increased LV mass was found in NAFLD group compared to both lean controls and obese subjects without NAFLD
Alp et al[34]	Obese children and adolescents with (n = 93), and without (n = 307) NAFLD matched for gender and age; and control subjects (n = 150)	Liver ultrasound	LV structure and function; Epicardial fat (M-mode echocardiography; Pulsed and Tissue Doppler echocardiography)	Increased end-systolic thickness of the interventricular septum, and larger LV mass, as well as LV systolic and diastolic dysfunction were found in NAFLD group. In addition, obese children with NAFLD had increased epicardial fat thickness
Singh et al[51]	Obese children and adolescents with (n = 15), and without (n = 15) NAFLD matched for age, gender, Tanner stage, and BMI z score; and control subjects (n = 15) matched for gender, age, and Tanner stage	Hepatic MRS	LV structure and function; Intracardiac triglyceride content (Integrated backscatter ultrasonography and speckle tracking echocardiography; cardiac MRS)	LV global longitudinal strain and early diastolic strain rates were significantly decreased in obese children with NAFLD compared to both lean controls and obese subjects without NAFLD. Intracardiac triglyceride content was not different among the 3 groups
Sert et al[33]	Obese adolescents with (n = 97), and without (n = 83) NAFLD; and control subjects (n = 68)	Liver ultrasound and elevated serum alanine aminotransferase	LV structure and function (M-mode echocardiography; Pulsed and Tissue Doppler echocardiography)	Obese adolescents with NAFLD exhibited increased LV dimensions and mass, as well as LV diastolic dysfunction
Pacifico et al[52]	Obese children and adolescents with (n = 54), and without (n = 54) NAFLD matched for age, gender, pubertal status, and BMI-SD score; and healthy control subjects (n = 18) matched for gender, age, and pubertal status	Hepatic magnetic resonance imaging; and liver biopsy in a subgroup of 41 NAFLD patients	LV structure and function; Epicardial fat (M-mode echocardiography; Pulsed and Tissue Doppler echocardiography)	Increased interventricular septum thickness at end-diastole and at end-systole, as well as LV systolic and diastolic dysfunction were found in NAFLD group. Children with more severe liver histology had worse LV dysfunction than those with more mild liver changes. NAFLD group had also increased epicardial fat thickness
Fintini et al[53]	Children with biopsy-proven NAFLD (n = 50). No patients without NAFLD, and no healthy control children were included	Liver biopsy	LV structure and function (M-mode echocardiography; and pulsed Doppler echocardiography)	About 35% (n = 18) of the 50 children with NAFLD had LV hypertrophy. Children with NASH showed, almost invariably, the presence of clear cut LV hypertrophy

NAFLD: Nonalcoholic fatty liver disease; LV: Left ventricular; BMI: Body mass index; MRS: Magnetic resonance spectroscopy; NASH: Nonalcoholic steatohepatitis.