The liver accumulates fat. Silently, constantly, painlessly. Until the problem becomes systemic and the heart begins to contend with rising blood pressure, threatening diabetes, and plummeting cholesterol. For decades, doctors have viewed diabetes as the main enemy of those suffering from it. MASLD (steatotic liver disease associated with metabolic dysfunction), the metabolic fatty liver that affects one-third of the world's population.
Now a new American study published Clinical Gastroenterology and Hepatology It turns everything around: hypertension kills more people than diabetes. And it does so with a clear difference: 40% versus 25%. This data emerges from an analysis of over 21.000 patients followed for thirty years. It's a wake-up call that's changing treatment priorities.
The three killers of fatty liver
Fatty liver develops when the organ stores more than 5% of its weight in fat. It is not a rare condition: it affects 38% of the world's adult population, with percentages rising to 65% in patients with type 2 diabetes. In Italy, according to the most recent estimates, approximately one in five adults suffers from it, with an estimated economic impact of 7,7 billion euros per year.
The team led by Matthew Dukewich of Keck Medicine of the University of Southern California They used data from the National Health and Nutrition Examination Survey (NHANES), which collected health information on over 134.000 American adults from 1988 to 2018. Of these, approximately 21.000 had fatty liver. The researchers monitored mortality rates for all cardiometabolic risk factors associated with the disease: obesity, type 2 diabetes, hypertension, high blood sugar, and low HDL cholesterol.
The results surprised the study's authors themselves. High blood pressure increases the risk of death by 40%, followed by prediabetes or type 2 diabetes (+25%) and low HDL cholesterol (+15%). These data are independent of the number or combination of risk factors present in the patient and remain constant regardless of gender, age, race, or ethnicity.
How do you explain Norah Terrault, a hepatologist at Keck Medicine and senior author of the study:
"Fatty liver is a complex disease, and this research sheds new light on where doctors might want to focus their efforts in treating patients. Knowing which aspects lead to worse outcomes helps us provide the best possible care."
The surprise of hypertension
The most unexpected finding concerns high blood pressure. "Until now, it was commonly thought that diabetes was the most pressing health problem for patients with fatty liver," says Dukewich. The data overturns consolidated beliefs and requires a rethinking of therapeutic strategies.
But there's more. The study found that obesity, the most common risk factor associated with fatty liver disease, can significantly increase the risk of mortality, depending on the patient's body mass index (BMI). The higher the BMI, the greater the association with death. Parallel research by Karolinska Institutet, published on The Journal of Hepatology, confirmed that people with fatty liver They have a mortality rate almost double that of the general population.
Every factor counts: the accumulation effect
The research also documented another worrying aspect: the risk of death increases by 15% for each additional cardiometabolic risk factor presentA patient with fatty liver who simultaneously has hypertension, diabetes, and obesity therefore has a significantly worse outlook than someone with only one risk factor.
Fatty liver is not just a liver problem. As highlighted by a study by the University of Verona published on New England Journal of MedicineThe disease represents a dangerous systemic risk factor. Among the most frequent complications are myocardial infarction, heart failure, chronic renal failure, and an increased incidence of extrahepatic tumors, such as colon and breast cancer.
In Italy, according to the 57th National Congress of the Italian Association for the Study of the Liver, the prevalence of fatty liver is particularly high in some regions: the ABCD study conducted in Sicily documented a prevalence of 48%. The risk of serious liver damage, such as cirrhosis or liver cancer, increases significantly in patients with diabetes and elevated transaminase levels, reaching up to 60% in the most critical cases.
Fatty liver, high blood pressure: what to do now
The clinical implications of the study are immediate. Doctors will need to reassess their treatment priorities for patients with fatty liver disease, placing greater emphasis on blood pressure control. Regular monitoring becomes crucial: as underlined by the Hospital Hepatologists ClubEarly diagnosis through blood tests (transaminases, GGT, alkaline phosphatase) and imaging (abdominal ultrasound, liver elastography) can make the difference.
The main therapy remains lifestyle modification: Weight loss of 7-10% for obese people, regular aerobic exercise (3-4 times a week for half an hour), and a Mediterranean diet are all examples. But now we know that blood pressure control must rise to the top of the list. New experimental molecules are showing promising results in restoring liver function, while drugs already used for diabetes and obesity have also shown results for fatty liver.
The study authors hope to conduct further research examining patients' genetic background, dietary habits, and alcohol consumption in relation to fatty liver disease outcomes, to provide more comprehensive risk profiles. "The more we understand the factors that drive the disease, the better we can identify those most in need of intervention and prioritize our resources to achieve better outcomes," Terrault concludes.
Fatty liver disease is no longer just a liver problem. It's a systemic problem that requires a comprehensive approach. And now we know exactly where to look first: blood pressure. Because a heart pumping too hard can kill an already struggling liver. And vice versa.
