Nonalcoholic fatty liver disease, liver fibrosis, and structural brain imaging: The Cross-Cohort Collaboration

Galit Weinstein, Adrienne O'Donnell, Stefan Frenzel, Tian Xiao, Amber Yaqub, Pinar Yilmaz, Robert J. de Knegt, Gladys E. Maestre, Debora Melo van Lent, Michelle Long, Monica Gireud-Goss, Till Ittermann, Fabian Frost, Robin Bülow, Ramachandran S. Vasan, Hans J. Grabe, M. Arfan Ikram, Alexa S. Beiser, Sudha Seshadri

Research output: Contribution to journalArticlepeer-review


Background and purpose: Prior studies reported conflicting findings regarding the association of nonalcoholic fatty liver disease (NAFLD) and liver fibrosis with measures of brain health. We examined whether NAFLD and liver fibrosis are associated with structural brain imaging measures in middle- and old-age adults. Methods: In this cross-sectional study among dementia- and stroke-free individuals, data were pooled from the Offspring and Third Generation cohorts of the Framingham Heart Study (FHS), the Rotterdam Study (RS), and the Study of Health in Pomerania. NAFLD was assessed through abdominal imaging. Transient hepatic elastography (FibroScan) was used to assess liver fibrosis in FHS and RS. Linear regression models were used to explore the relation of NAFLD and liver fibrosis with brain volumes, including total brain, gray matter, hippocampus, and white matter hyperintensities, adjusting for potential confounders. Results were combined using fixed effects meta-analysis. Results: In total, 5660 and 3022 individuals were included for NAFLD and liver fibrosis analyses, respectively. NAFLD was associated with smaller volumes of total brain (β = −3.5, 95% confidence interval [CI] = −5.4 to −1.7), total gray matter (β = −1.9, 95% CI = −3.4 to −0.3), and total cortical gray matter (β = −1.9, 95% CI = −3.7 to −0.01). In addition, liver fibrosis (defined as liver stiffness measure ≥8.2 kPa) was related to smaller total brain volumes (β = −7.3, 95% CI = −11.1 to −3.5). Heterogeneity between studies was low. Conclusions: NAFLD and liver fibrosis may be directly related to brain aging. Larger and prospective studies are warranted to validate these findings and identify liver-related preventive strategies for neurodegeneration.

Original languageEnglish
Article numbere16048
JournalEuropean Journal of Neurology
Issue number1
Early online date28 Aug 2023
StatePublished - Jan 2024

Bibliographical note

Publisher Copyright:
© 2023 The Authors. European Journal of Neurology published by John Wiley & Sons Ltd on behalf of European Academy of Neurology.


  • brain MRI
  • brain aging
  • liver fibrosis
  • nonalcoholic fatty liver disease
  • observational study

ASJC Scopus subject areas

  • Clinical Neurology
  • Neurology


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