Reduced Platelet Aggregation and Plasma Cytokine Levels Mitigate Progressive Metabolic Dysfunction-Associated Steatotic Liver Disease (MASLD)

Abstract

Purpose: Patients with metabolic syndrome and coronary artery disease (CAD) are at increased risk of metabolic dysfunction-associated steatotic liver disease (MASLD), which can progress to steatohepatitis, cirrhosis, and hepatocellular carcinoma. MASLD is the most common liver disease and a significant contributor to cardiovascular morbidity. Enhanced platelet aggregation is linked to steatohepatitis, and antiplatelet therapy has been suggested as a potential treatment.

Patients and methods: In a prospective study of 51 patients with type 2 diabetes mellitus and/or obesity (BMI≥30), we evaluated the impact of antiplatelet therapy on hepatic fat content, liver volume, and iron deposition using magnetic resonance imaging (MRI) at baseline and six months. Ex vivo platelet function testing and plasma levels of proinflammatory chemotactic cytokines were measured to characterize thromboinflammatory mechanisms underlying MASLD.

Results: Increased platelet reactivity correlated with greater hepatic fat, iron deposition, and liver volume. Antiplatelet therapy was associated with reductions in hepatic volume and iron accumulation. Progression of steatosis was linked to dyslipidemia, platelet hyperreactivity, and elevated plasma levels of profibrotic, inflammatory, and apoptotic chemokines/cytokines. A distinct systemic cytokine profile corresponded with morphological features of progressive MASLD.

Conclusion: Reduced platelet aggregation is associated with attenuation of MASLD features. Antiplatelet therapy correlates with decreased pro-inflammatory and pro-fibrotic chemokine signaling linked to the morphological characteristics of MASLD. Assessment of platelet reactivity and specific chemokines may enhance understanding of MASLD pathophysiology and support the development of novel therapeutic strategies.

Keywords: antiplatelet treatment; chemokine signaling; coronary artery disease; steatosis.

Graphical abstract

Figure 1

Morphological characterization of metabolic dysfunction-associated steatotic liver disease (MASLD) and the impact of antiplatelet therapy on disease progression. (A) Study flow-chart. Patients received six-months antiplatelet therapy according to CAD severity (eg, dual [DAPT], single [SAPT] or no antiplatelet therapy [naïve]). To determine the course MASLD, liver MRI was performed alongside assessment of platelet-derived mediators at baseline and after six-months follow-up. (B) Antiplatelet therapy, depending on its intensity, significantly (p<0.05) reduced platelet-hyperreactivity at baseline and after six-months of treatment, respectively. (C) Representative images of liver MRI assessing liver volume and hepatic fat content at baseline (left) and at six-months follow-up (right). (D) Bar charts showing the course of liver volume, hepatic fat content and iron storage. After six months of follow-up, most patients showed reduced liver volume, and iron accumulation, whereas hepatic fat content showed a heterogeneous trend. (E) Sankey-plots illustrating the course of liver volume, hepatic fat content and iron storage between patient receiving either no antiplatelet therapy, SAPT or DAPT. In the latter, liver volume, hepatic fat, and iron accumulation was predominantly reduced after six months-treatment.

Figure 2

Decreased platelet reactivity resulting from antiplatelet therapy is linked to halting the progression of MASLD. (A) Patients receiving antiplatelet therapy showed a significant (p<0.05) reduction of liver volume after six-months treatment. (B) Reduced platelet aggregation significantly (p<0.05) correlated with reduced liver volume at follow-up. (C) Patients with low AA-induced platelet aggregation showed significantly (p<0.05) reduced liver volume compared to those with high reactivity. (D) Likewise, COL-induced platelet aggregation was significantly (p<0.05) associated with reduced liver volume at follow-up. (E) Antiplatelet therapy, depending on its intensity, was associated with a significant (p<0.05) reduction of hepatic iron storage. (F) After six-months of follow-up, patients with low AA-induced platelet aggregation showed lowest accumulation of hepatic iron when compared to patients with high platelet reactivity. (G) Hepatic fat content, the major determinant of steatotic liver disease, was significantly (p<0.05) enhanced in patients with high COL-induced platelet activity after six-months of follow-up. (H) Reduced MPV, indicating changes in platelet turnover and maturation following antiplatelet therapy, was significantly (p<0.05) associated with reduced hepatic fat content at follow-up.

Figure 3

The plasma chemokine profile is influenced by the antiplatelet treatment and is associated with disease progression of patients with MASLD. (A) Bar charts showing concentrations of plasmatic chemokines at baseline and after six-months follow-up. (B) Venn diagram summarizing the most important chemokines that were significantly (p<0.05) associated with liver volume, hepatic fat content, and iron storage. Inflammatory mediators, which were susceptible to antiplatelet therapy in this study are labelled. (C) Bar charts of proinflammatory and profibrotic mediators significantly associated with liver volume at baseline. (D) Correlation analysis of mediators associated with liver volume at six-months follow-up. (E) Correlation analysis of circulatory and platelet-derived mediators associated with liver iron storage at baseline. (F) Correlation analysis of mediators and liver iron at six-months follow-up. (G) Concentrations of eotaxin (CCL11) were significantly reduced (p<0.05) in patients receiving antiplatelet therapy. (H) Among MASLD patients receiving antiplatelet therapy, concentrations of ENA-78 (CXCL5) were significantly reduced after six months of follow-up. (I) Concentrations of RANTES (CCL5) were reduced in patients receiving six months of antiplatelet therapy compared to those patients without antiplatelet therapy. *p<0.05, **p<0.01, ***p<0.001, ****p<0.0001.

Figure 4

Diminished platelet reactivity and alterations in the fibro-inflammatory chemokine profile are associated with a reduction in hepatic steatosis. (A) Low-density lipoprotein (LDL) was significantly (p<0.05) increased in patients with progressive steatosis compared to those patients with reduced hepatic fat content. (B) After six months of antiplatelet therapy, LDL concentrations were significantly reduced (p<0.05), with the extent of reduction depending on the intensity of the treatment regimen. However, statin-treatment did not impact LDL concentrations significantly. (C) Reduced platelet reactivity significantly (p<0.05) correlated with low concentrations of LDL indicating an association between platelet reactivity and dyslipoproteinemia in this study. (D) In patients who exhibited progressive steatosis on MRI, baseline levels of profibrotic TGF-ß1 were significantly (p<0.05) increased. (E) Likewise, baseline levels of anti-apoptotic, angiogenic, and proinflammatory high-mobility group box protein 1 (HMGB1) were significantly (p<0.05) enhanced in patients with progressive MASLD. (F) Baseline levels of inflammatory pCXCR4 were significantly (p<0.05) elevated in patients with enhanced steatosis. (G) Bar charts depicting plasmatic chemokine concentrations at baseline and after a six-month follow-up, comparing patients with increased fat content and progressive steatosis to those with decreased hepatic fat content after six months of follow-up. (H) Correlation analysis showing that circulatory and platelet-derived mediators are associated with hepatic fat content at baseline. (I) Correlation analysis of fibro-inflammatory mediators and hepatic fat content at six-months follow-up. *p<0.05, **p<0.01, ***p<0.001, ****p<0.0001.