The interplay between Helicobacter pylori infection and rs738409 PNPLA3 in metabolic dysfunction-associated steatotic liver disease

Abstract

Background: Recent studies have suggested an association between H. pylori and metabolic-disfunction associated fatty liver disease (MASLD). However, epidemiologic studies have yielded inconsistent results. We aim to evaluate the association of H. pylori and G-allele PNPLA3 in MASLD diagnosis, and markers of severity.

Methods: A multi-center cross-sectional study was conducted. A total 224 functional dyspepsia (FD) patients cohort who underwent gastroscopy was selected. Biochemical, clinical parameters, ultrasound, FIB-4 score, LSM by VCTE, gastric biopsies, H. pylori status, and rs738409 PNPLA3 were evaluated. A second retrospective cohort of 86 patients with biopsy-proven MASLD who underwent gastroscopy with gastric biopsies was analyzed.

Results: In the FD cohort MASLD was observed in 52%, and H. pylori-positive in 51%. H. pylori infection was associated with MASLD prevalence, but in multivariate analyses adjusted for G-allele PNPLA3, it became not significant. Then in MASLD-only dyspeptic cohort, H. pylori infection was significantly linked to elevated serum AST levels and increased liver stiffness measurements, suggesting a potential role in liver injury and fibrosis. Histopathological analysis in biopsy-proven MASLD patients further supported these findings, showing a significant association between H. pylori infection and increased NAS score, fibrosis stage, and prevalence of MASH. Notably, the combination of H. pylori infection and G-allele PNPLA3 appeared to exacerbate MASLD severity beyond individual effects.

Conclusions: Our results suggest that H. pylori infection may play a role in the progression of liver injury and fibrosis in patients with MASLD, especially in those with specific genetic predispositions.

Fig 1. Study flow-chart.

Functional dyspepsia (FD), H. pylori negative, H. pylori positive, metabolic dysfunction-associated steatotic liver disease (MASLD).

Fig 2. MASLD patients stratified according to H. pylori status and G-allele PNPLA3.

Data are expressed as (%) percentage of subjects. Chi-square test was used. * p < 0.05.

Fig 3. Non-invasive markers of high risk of significant/advanced fibrosis in patients with MASLD stratified according to H. pylori status.

A) FIB-4 score ≥ 1.3 or <1.3. B) Liver stiffness measurement by vibration controlled transient elastography (LSM by VCTE), stratified by LSM cut-offs to rule-out significant fibrosis < 5.8 kPa, intermediate risk ≥5.8 kPa-<8 kPa, and to rule-out advanced fibrosis ≥8 kPa [–52]. Data are expressed as (%) percentage of MASLD subjects. Chi-square test was used. * p < 0.05.

Fig 4. Non-invasive markers injury and fibrosis in patients with MASLD harboring G-allele PNPLA3 stratified according to H. pylori status.

A) AST values, UI/L. B) ALT values, IU/L. C) FIB-4. D) Liver stiffness measurement by vibration controlled transient elastography (LSM by VCTE), kPa. Data are expressed as median (IQR, interquartile range). Wilcoxon rank sum test was used. * p < 0.05.

Fig 5. Non-invasive markers of high risk of significant/advanced fibrosis in patients with MASLD harboring G-allele PNPLA3 stratified according to H. pylori status.

A) FIB-4 score ≥ 1.3 or <1.3. B) Liver stiffness measurement by vibration controlled transient elastography (LSM by VCTE), stratified by LSM cut-offs to rule-out significant fibrosis < 5.8 kPa, intermediate risk ≥5.8 kPa-<8 kPa, and to rule-out advanced fibrosis ≥8 kPa [–52]. Data are expressed as (%) percentage of MASLD subjects. Chi-square test was used.

Fig 6. Metabolic dysfunction-associated steatohepatitis (MASH) (NAS score ≥ 4), and significant/advanced fibrosis (Fibrosis ≥ 2) in patients with biopsy-proven MASLD stratified according to H. pylori status and G-allele PNPLA3.

A) NAS score ≥4 or <4. B) Fibrosis stage ≥ 2 or <2. Data are expressed as (%) percentage of MASLD subjects. Chi-square test was used.