Non-alcoholic fatty liver disease fibrosis score is a useful tool for carotid atherosclerosis screening in patients with obstructive sleep apnea

doi:10.3748/wjg.117715

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World Journal of Gastroenterology

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1007-9327

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Baishideng Publishing Group Inc, 7041 Koll Center Parkway, Suite 160, Pleasanton, CA 94566, USA

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Copyright: ©Author(s) 2026. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution-NonCommercial (CC BY-NC 4.0) license. No commercial re-use. See permissions. Published by Baishideng Publishing Group Inc.

World J Gastroenterol. Jul 21, 2026; 32(27): 117715
Published online Jul 21, 2026. doi: 10.3748/wjg.117715

Non-alcoholic fatty liver disease fibrosis score is a useful tool for carotid atherosclerosis screening in patients with obstructive sleep apnea

Carlos Ernesto Fernández-García, Miguel Á Hernández-García, Beatriz Aldave-Orzáiz, Elena Ávalos Pérez-Urría, José M Muñoz, Alfonsi Friera, Carmelo García-Monzón, Pedro Landete, Águeda González-Rodríguez

Carlos Ernesto Fernández-García, Miguel Á Hernández-García, Carmelo García-Monzón, Biomedical Research Unit, Hospital Universitario Santa Cristina, Instituto de Investigación Sanitaria Hospital Universitario de La Princesa, Madrid 28009, Spain

Beatriz Aldave-Orzáiz, Elena Ávalos Pérez-Urría, Pedro Landete, Department of Respiratory Medicine, Hospital Universitario de La Princesa, Instituto de Investigación Sanitaria Princesa Hospital Universitario de La Princesa, Madrid 28006, Spain

José M Muñoz, Alfonsi Friera, Radiodiagnostic Service, Hospital Universitario de La Princesa, Instituto de Investigación Sanitaria Princesa Hospital Universitario de La Princesa, Madrid 28006, Spain

Pedro Landete, Universidad Autónoma de Madrid, Madrid 28029, Spain

Pedro Landete, Águeda González-Rodríguez, Centro de Investigación Biomédica en Red de Diabetes y Enfermedades Metabólicas Asociadas, Instituto de Salud Carlos III, Madrid 28029, Spain

Águeda González-Rodríguez, Instituto de Investigaciones Biomédicas Sols-Morreale, Consejo Superior de Investigaciones Científicas-Universidad Autónoma de Madrid, Madrid 28029, Spain

Co-first authors: Carlos Ernesto Fernández-García and Miguel Á Hernández-García.

Co-corresponding authors: Pedro Landete and Águeda González-Rodríguez.

Author contributions: Fernández-García CE was primarily responsible for execution of all statistical methods; Hernández-García MÁ contributed to data curation; Fernández-García CE and Hernández-García MÁ contributed to formal statistical analysis, and writing/editing the manuscript, they contributed equally to this article, they are the co-first authors of this manuscript; Aldave-Orzáiz B, Ávalos Pérez-Urría E, Muñoz JM, Friera A, and García-Monzón C contributed to the investigation, collection of clinical data, and provided essential clinical resources; Fernández-García CE, Landete P, and González-Rodríguez Á interpreted and analyzed the data; Landete P and González-Rodríguez Á conceived the study, were responsible for project administration and funding acquisition, and provided expert supervision contributed significantly to the critical revision of the manuscript for intellectual content; they contributed equally to this article, they are the co-corresponding authors of this manuscript; and all authors revised the manuscript critically for intellectual content and approved the final version.

Supported by Instituto de Salud Carlos III and Fondo Europeo para el Desarrollo Regional, and Beca SEPAR 2019 from the Spanish Society of Pulmonology and Thoracic Surgery to Pedro Landete, No. PI20/00837; Instituto de Salud Carlos III and Fondo Europeo para el Desarrollo Regional to Águeda González-Rodríguez, No. PI22/01968; Comunidad de Madrid (Spain) and the European Social Fund Plus, No. PEJ-2024-AISAL-GL-32758 to Miguel Ángel Hernández-García; Centro de Investigación Biomédica en Red de Diabetes y Enfermedades Metabólicas Asociadas funded by Instituto de Salud Carlos III; and Scientific Network Enfermedades Metabólicas funded by the Consejo Superior de Investigaciones Científicas.

Institutional review board statement: This study was approved by the Medical Ethics Committee of Institution’s Clinical Research, approval No. PI/2800-16.

Informed consent statement: All participants signed a written informed consent before inclusion in the study, providing permission for their medical data to be anonymously used for research.

Conflict-of-interest statement: Drs. Landete and González-Rodríguez reports grants from Instituto de Salud Carlos III (ISCIII), grants from Fondo Europeo para el Desarrollo Regional (FEDER, EU), grants from Spanish Society of Pulmonology and Thoracic Surgery (SEPAR), and support from Centro de Investigación Biomédica en Red de Diabetes y Enfermedades Metabólicas Asociadas funded by Instituto de Salud Carlos III (ISCIII) and from Scientific Network Enfermedades Metabólicas funded by the Consejo Superior de Investigaciones Científicas (CSIC, Spain), during the conduct of the study.

STROBE statement: The authors have read the STROBE Statement-checklist of items, and the manuscript was prepared and revised according to the STROBE Statement-checklist of items.

Data sharing statement: All data generated or analysed during this study are included in this published article. Otherwise, the datasets analysed during the current study are available from the corresponding author upon reasonable request.

Corresponding author: Águeda González-Rodríguez, PhD, CSIC Principal Investigator, Instituto de Investigaciones Biomédicas Sols-Morreale, Consejo Superior de Investigaciones Científicas-Universidad Autónoma de Madrid, Instituto de Investigaciones Biomédicas Sols-Morreale (CSIC/UAM). C/Arturo Duperier 4, Madrid 28029, Spain. aguedagr@iib.uam.es

Received: December 24, 2025
Revised: February 12, 2026
Accepted: April 8, 2026
Published online: July 21, 2026
Processing time: 195 Days and 0.6 Hours

Abstract

BACKGROUND

Obstructive sleep apnea (OSA) is recognized as an independent cardiovascular risk factor since this respiratory disorder induces intermittent hypoxia and systemic inflammation, which are closely related to the development and progression of atherosclerosis. In parallel, there is a strong bidirectional association between OSA and metabolic dysfunction-associated steatotic liver disease (MASLD), the latter being a hepatic manifestation of the metabolic syndrome. There is increasing clinical evidence that high blood-based MASLD predictive scores are associated with increased vascular atherosclerotic damage. The significance of these algorithms as predictors of carotid atherosclerosis in patients with OSA is poorly understood.

AIM

To assess blood-based MASLD algorithms as predictors of carotid atherosclerosis in patients with OSA.

METHODS

This cross-sectional study comprises a cardiorespiratory polygraphic study and assessment of carotid artery damage by doppler ultrasonography carried out in well-characterized patients with OSA (n = 112) and in patients without OSA (n = 32) who were considered as controls. Logistic regression models were constructed to evaluate potential associations between distinct MASLD predictive scores and clinical, analytical and polygraphic features of the study population.

RESULTS

Both the presence and volume of carotid plaques were significantly higher in patients with OSA than in controls (P = 0.035 and 0.001, respectively). None of the polygraphic variables studied were associated with the presence of carotid atherosclerosis in OSA patients. However, multivariate logistic regression analysis revealed that non-alcoholic fatty liver disease fibrosis score (NFS) (odds ratio = 1.84, P = 0.010) and fibrosis-4 index (odds ratio = 5.53, P = 0.004) were significantly associated with carotid atherosclerosis and showed good diagnostic accuracy. When these scores were tested in OSA patients without MASLD, only high values of NFS seemed to be linked to carotid atherosclerosis (P = 0.0501) and positively correlated with carotid plaque volume (r = 0.665, P = 0.041).

CONCLUSION

Elevated NFS is significantly associated with carotid plaques in OSA. This predictive score might be an initial useful tool to identify patients at high cardiovascular risk to whom in-depth evaluation must be recommended.

Keywords: Obstructive sleep apnea; Carotid atherosclerosis; Vascular risk; Liver fibrosis scores; Metabolic dysfunction-associated steatotic liver disease; Metabolic dysfunction-associated steatohepatitis

Core Tip: The non-alcoholic fatty liver disease fibrosis score, a simple non-invasive blood-based algorithm, predicts the presence of subclinical carotid atherosclerosis in patients with obstructive sleep apnea. Importantly, this association is independent of the metabolic dysfunction-associated steatotic liver disease status of the patient, suggesting that non-alcoholic fatty liver disease fibrosis score is an effective, readily available tool for cardiovascular risk stratification in the obstructive sleep apnea population, even in the absence of liver disease.