Evidence of Pancreas Exocrine Insufficiency in Patients with Metabolic Associated Fatty Liver Disease Patients

Evidence of Pancreas Exocrine Insufficiency in Patients with Metabolic Associated Fatty Liver Disease Patients | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Evidence of Pancreas Exocrine Insufficiency in Patients with Metabolic Associated Fatty Liver Disease Patients Ghada A Hammam, Mohamed Omar Abdelmalek, Amal A Mahmoud, Mohamed Abdelghani This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7443549/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 13 Jan, 2026 Read the published version in Egyptian Liver Journal → Version 1 posted You are reading this latest preprint version Abstract Background Pancreatic exocrine insufficiency (PEI) is increasingly recognized in patients with metabolic-associated fatty liver disease (MAFLD), particularly those with metabolic comorbidities such as diabetes mellitus (DM). However, limited data exist on the prevalence and clinical implications of PEI in MAFLD. Patients and Methods: This prospective, case-control study included 70 MAFLD patients and 20 healthy controls. All participants underwent clinical assessment, anthropometric measurements, laboratory testing, liver imaging (Fibroscan with CAP score), and fecal pancreatic elastase-1 (FPE-1) testing. PEI was defined as FPE-1 < 200 µg/g. Subgroup analyses were performed comparing MAFLD patients with and without PEI, and with and without diabetes. Logistic regression identified independent predictors of PEI. Results MAFLD patients had significantly lower FPE-1 levels compared to controls (180.38 ± 26.80 µg/g vs. 240.12 ± 43.39 µg/g, p < 0.001). PEI was present in 84.3% of MAFLD patients. Patients with PEI had significantly higher HbA1c (7.65 ± 2.47% vs. 5.78 ± 2.13%, p = 0.042) and waist circumference (115.73 ± 9.70 cm vs. 110.36 ± 5.95 cm, p = 0.043). Among MAFLD patients with diabetes, PEI prevalence was higher (90.0% vs. 82.0%, p = 0.039), and FPE-1 levels were significantly lower (163.47 ± 19.83 µg/g vs. 187.54 ± 26.92 µg/g, p = 0.001). These patients also showed more severe metabolic derangements and advanced liver disease. Multivariate analysis identified MAFLD as an independent predictor of PEI (OR = 10.220, p = 0.008). Conclusion PEI is highly prevalent in MAFLD patients, particularly those with diabetes and poor metabolic control. Fecal elastase testing may be a useful tool for early identification of PEI in this population. Pancreatic exocrine insufficiency MAFLD diabetes mellitus fecal elastase metabolic dysfunction Figures Figure 1 Figure 2 Introduction Metabolic-associated fatty liver disease (MAFLD) is now the most prevalent cause of chronic liver disease worldwide, affecting nearly 25% of the global population and strongly associated with obesity, insulin resistance, and type 2 diabetes mellitus (T2DM) ( 1 ) . While the hepatic consequences of MAFLD are well documented, its impact on pancreatic function remains underrecognized. Pancreatic exocrine insufficiency (PEI), defined by inadequate secretion of digestive enzymes, can develop in the setting of metabolic dysfunction even in the absence of overt pancreatic pathology ( 2 ) . Recent studies suggest a pathophysiological overlap between hepatic steatosis and pancreatic dysfunction, both influenced by visceral adiposity, chronic hyperglycemia, and low-grade inflammation ( 3 ) . Fecal pancreatic elastase-1 (FPE-1) is a widely accepted, non-invasive biomarker for diagnosing PEI, with levels below 200 µg/g indicative of exocrine dysfunction ( 4 ) . Understanding the prevalence and metabolic correlates of PEI in MAFLD patients is critical, as impaired pancreatic function may worsen nutritional status, glycemic control, and liver disease progression. This study aims to assess PEI prevalence in MAFLD patients and its relationship with diabetes, metabolic parameters, and hepatic disease severity. Patients and Methods Study Design and Patient population This was a single-center, prospective, case-control study conducted at Assiut University Hospitals (Al Rajhi Hospital) from January 2023 to January 2024. The study enrolled 90 subjects: 70 patients with MAFLD and 20 age-matched healthy controls (case-to-control ratio of 3.5:1). Sample size was determined based on previously reported prevalence rates of pancreatic exocrine insufficiency (PEI) in liver disease (25–35%) compared with the general population (3–6%) Boga et al. (2020) (2) Inclusion Criteria Age ≥ 18 years , diagnosed with MAFLD based on imaging confirm hepatic steatosis and at least one of the following metabolic conditions: Overweight/Obesity : ( BMI ≥25 kg/m².) Diabetes Mellitus : (Fasting blood glucose (FBG) level >125 mg/dl and/or glycated hemoglobin (HbA1c) level > 6.4%). Metabolic Dysregulation (MD) in lean individuals with evidence of metabolic risk factors such as elevated triglycerides >150 mg/dl, (HOMA)-insulin resistance score ≥2.5 or low HDL cholesterol level <40 mg/dl. Exclusion Criteria Use of Steatogenic Medications , such as corticosteroids or amiodarone. Hormone Replacement Therapy or Herbal supplements Current or prior Alcohol Consumption within 12 months History of Pancreatic Diseases or pancreatic surgery . Known malignancy Clinical Assessment All participants underwent comprehensive history taking, clinical examination, and anthropometric measurements including height (cm), weight (kg), BMI (kg/m²), waist circumference (cm), and mid-arm circumference (cm). Medical comorbidities including diabetes mellitus, hypertension, and ischemic heart disease were documented. Laboratory Investigations Blood samples were collected after overnight fasting (12 hours) and analyzed for: Liver function tests: ALT, AST, albumin, total and direct bilirubin, GGT, and ALP Hematological and coagulation profile: hemoglobin, white blood cell count, platelet count, and international normalized ratio (INR) Metabolic profile: fasting glucose, HbA1c, HOMA-IR, and lipid profile (total cholesterol, triglycerides, HDL cholesterol) Thyroid function tests: T3, T4, and TSH Kidney function tests: serum urea and creatinine Electrolytes: sodium and potassium Inflammatory markers: C-reactive protein (CRP) Viral markers: HBsAg and HCV antibodies Pancreatic enzymes: serum amylase Fecal Pancreatic Elastase Measurement Stool samples were collected from all participants following standard collection procedures. Fecal elastase-1 levels were measured using a commercially available enzyme-linked immunosorbent assay (ELISA) kit (ScheBo Biotech AG, Giessen, Germany).. The ELISA test provides a quantitative analysis of fecal elastase-1, a marker of pancreatic exocrine function. All stool samples were processed according to the manufacturer's instructions to ensure accurate results. Imaging Studies Abdominal ultrasound: Performed using a high-resolution B-mode ultrasonography system with a 3.5 MHz convex probe to detect hepatic steatosis and exclude other liver pathologies Transient elastography (Fibroscan®): Performed after overnight fasting to assess: Liver stiffness for fibrosis staging (F0-F4) Controlled Attenuation Parameter (CAP) for steatosis quantification (S0-S4) Ethical Considerations Written informed consent was obtained from all participants. The study protocol was approved by the Institutional Review Board and Ethics Committee of Assiut University Hospitals (approval number: IRB-ASU-2022/12-45). All procedures were performed in accordance with the ethical standards of the Declaration of Helsinki. Statistical Analysis IBM SPSS Statistics version 28.0 was used for data analysis. Normality was assessed using the Shapiro-Wilk test. Parametric data are presented as mean ± SD, non-parametric as median with range, and categorical as numbers and percentages. Independent t-test or Mann-Whitney U test was used for comparing continuous variables between groups, while Chi-square or Fisher's exact test was used for categorical variables. Univariate and multivariate logistic regression analyses identified PEI predictors. ROC curve analysis evaluated fecal pancreatic elastase's discriminatory ability. Subgroup analysis compared diabetic versus non-diabetic MAFLD patients. P<0.05 was considered statistically significant. Results The main clinical and biochemical characteristics of the MAFLD patients and control subjects in Table (1) shows significant differences in pancreatic exocrine function between MAFLD patients and controls, with MAFLD patients exhibiting markedly lower fecal pancreatic elastase levels (180.38 ± 26.80 µg/g vs. 240.12 ± 43.39 µg/g, p < 0.001). MAFLD patients demonstrated significantly higher BMI, waist circumference, and insulin resistance (HOMA-IR), as well as elevated liver enzymes (ALT, GGT, ALP) and lipid parameters compared to controls. Additionally, MAFLD patients presented with varying degrees of liver fibrosis (F0-F4) and steatosis (S2-S4), while controls had no fibrosis or steatosis. The prevalence of comorbidities, particularly diabetes mellitus (28.6%) and hypertension (21.4%), was significantly higher in MAFLD patients. The ROC curve analysis for fecal pancreatic elastase as a diagnostic marker to discriminate between MAFLD patients with and without PEI. The analysis demonstrates excellent discriminatory power with an area under the curve (AUC) of 0.873 (p < 0.001). The curve exhibits a steep initial rise, indicating high sensitivity and specificity at the optimal cutoff value. This suggests that fecal pancreatic elastase measurement is a reliable biomarker for detecting PEI in MAFLD patients, with strong statistical significance (Fig. 1 ). Table (2) shows significant differences between MAFLD patients with and without PEI in fecal pancreatic elastase levels (172.93 ± 21.94 µg/g vs. 220.94 ± 9.71 µg/g, p < 0.001), waist circumference (115.73 ± 9.70 cm vs. 110.36 ± 5.95 cm, p = 0.043), and glycated hemoglobin (7.65 ± 2.47% vs. 5.78 ± 2.13%, p = 0.042). MAFLD patients with PEI had higher prevalence of comorbidities (44.1% vs. 18.2%) and diabetes mellitus (30.5% vs. 18.2%), though these differences did not reach statistical significance. No significant differences were observed in liver fibrosis stages, steatosis grades, or viral markers between groups. Our logistic regression, MAFLD is a significant independent predictor of PEI in both univariate (OR: 16.091, 95% CI: 4.849–24.395, p < 0.001) and multivariate analysis (OR: 10.220, 95% CI: 4.474–12.256, p = 0.008). In univariate analysis, male gender (OR: 13.091, 95% CI: 3.849–23.395, p < 0.001), increased mid-arm circumference (OR: 1.161, 95% CI: 1.078–1.252, p < 0.001), and elevated glycated hemoglobin (OR: 1.740, 95% CI: 1.311–2.310, p < 0.001) were also significant predictors of PEI. However, after adjustment in multivariate analysis, only MAFLD remained a significant independent predictor, while age, gender, mid-arm circumference, and glycated hemoglobin lost statistical significance. These findings indicate that MAFLD is the most important risk factor for developing PEI, with a greater than 10-fold increased risk after controlling for other variables Table (3). Figure (2) shows the ROC curve analysis of fecal pancreatic elastase as a discriminatory marker between MAFLD patients with and without diabetes. The analysis demonstrated good diagnostic performance with an area under the curve (AUC) of 0.799 (p < 0.001, 95% CI: 0.686–0.885). The optimal cutoff value was determined to be ≤ 166.67 µg/g, providing a sensitivity of 70.0% and specificity of 80.0% (Youden index: 0.5000). At this threshold, the positive likelihood ratio was 3.50, while the negative likelihood ratio was 0.38. Table (4) demonstrates significant differences between MAFLD patients with and without diabetes regarding pancreatic exocrine function and metabolic parameters. Diabetic MAFLD patients showed significantly higher prevalence of PEI (90.0% vs. 82.0%, p = 0.039) and markedly lower fecal pancreatic elastase levels (163.47 ± 19.83 µg/g vs. 187.54 ± 26.92 µg/g, p = 0.001). Metabolic derangements were more pronounced in diabetic patients, with significantly higher HOMA-IR (5.68 ± 2.27 vs. 3.21 ± 1.98, p < 0.001), HbA1c (9.65 ± 2.24% vs. 5.29 ± 0.87%, p < 0.001), and waist circumference (116.35 ± 9.78 cm vs. 109.90 ± 8.97 cm, p = 0.011). Liver disease was more advanced in diabetic MAFLD patients, with higher rates of significant fibrosis (35.0% vs. 10.0%, p = 0.009), severe steatosis (70.0% vs. 44.0%, p = 0.046), and elevated GGT (74.89 ± 43.51 U/L vs. 62.13 ± 39.15 U/L, p = 0.037) Discussion MAFLD represents a spectrum of liver diseases closely linked to metabolic disorders such as obesity, diabetes, and insulin resistance ( 5 ) . While its hepatic complications are well-documented, emerging evidence suggests MAFLD may also be associated with PEI, a condition where the pancreas fails to produce or deliver sufficient digestive enzymes ( 2 ) . This study aimed to investigate this relationship by screening for PEI in patients with MAFLD using fecal elastase testing. Our MAFLD group results demonstrated that classic features of metabolic syndrome, with significantly higher BMI, waist circumference, and increased prevalence of comorbidities including diabetes mellitus and hypertension compared to controls. These findings align with previous studies by Niriella et al. (2021) ( 6 ) and Yu et al. (2022) ( 7 ) , who reported similar demographic and clinical characteristics in MAFLD patients. Our MAFLD group exhibited significantly higher insulin resistance and glycated hemoglobin levels. Khan et al. (2018) ( 8 ) reported similar findings, with HOMA-IR values around 4.5 in patients with metabolic diseases versus 1.1 in controls. Rosettenstein et al. (2016) ( 9 ) noted that patients with metabolic syndrome had HOMA-IR levels exceeding 3.0 compared to controls with values near 1.0. According to Hou et al., 2016 ( 10 ) , HbA1c levels above 6.5% are linked to reduced β-cell function and increased insulin resistance in metabolic syndrome, supporting the current findings. Similarly, Saravia et al. (2015) ( 11 ) found HbA1c > 6% significantly increased metabolic syndrome risk, aligning with results seen in MAFLD patients. Liver function tests in our study showed elevated liver enzymes in the MAFLD group. Nguyen et al. (2021) ( 12 ) similarly found that MAFLD patients had significantly elevated ALT compared to controls (p < 0.001). Zdanowicz et al. (2023) ( 13 ) demonstrated strong correlations between liver stiffness and elevated ALT and GGT, with GGT being especially predictive of liver fibrosis. Our lipid profile findings reflected dyslipidemia commonly associated with MAFLD. Forlano et al. (2021) ( 14 ) also found that patients with metabolic liver diseases had significantly higher total cholesterol and triglycerides than healthy individuals. Fibroscan assessment in our study revealed varying degrees of liver fibrosis in MAFLD patients. Fujii et al. (2021) ( 15 ) reported similar findings, with fibrosis in 40% of NAFLD patients. Regarding steatosis, Shao et al. (2019) ( 16 ) found that the majority of MAFLD patients showed moderate-to-severe steatosis, consistent with our observations. The most significant finding of our study was the markedly reduced fecal pancreatic elastase levels in the MAFLD group, indicating impaired pancreatic exocrine function. Boga et al. (2020) ( 2 ) found significantly lower fecal elastase levels in NAFLD patients (297 µg/g [204–517]) compared to controls (500 µg/g [298–678], p < 0.01). In a study of Indian patients with diabetes, Shivaprasad et al. (2015) ( 17 ) reported that 31.4% of type 1 diabetics and 29.4% of type 2 diabetics had fecal elastase levels below 200 µg/g. Our findings are consistent with Herzig et al. (2011) ( 18 ) , who reported that 21.7% of older adults without GI disease or diabetes had fecal elastase levels below 200 µg/g, suggesting subclinical pancreatic dysfunction. Similarly, Naruse et al. ( 4 ) confirmed that fecal elastase is a specific marker for severe exocrine pancreatic insufficiency. Nunes et al. ( 19 ) also found reduced fecal elastase in 36% of diabetic patients versus 5% of controls, reinforcing the link between metabolic dysfunction and pancreatic insufficiency, as seen in our MAFLD cohort. ROC curve analysis demonstrated excellent discriminatory power of fecal pancreatic elastase in identifying MAFLD patients with PEI. Vanga et al. (2018) ( 20 ) reported in a meta-analysis that elastase levels below 200 µg/g were highly sensitive for detecting moderate-to-severe pancreatic insufficiency. Another study by Giuliani et al. (2020) ( 21 ) reported that FPE had a sensitivity of 83.3% and specificity of 70.4% for diagnosing PEI in chronic pancreatitis using a < 200 µg/g cutoff. Similarly, Chowdhury et al. (2016) ( 22 ) found FPE-1 sensitivity was 84.9% at < 100 µg/g and 90.9% at < 200 µg/g, though specificity at the higher cutoff was only 9.5%. While these studies focus on chronic pancreatitis, they reinforce the value of FPE in identifying PEI across various conditions, including MAFLD. When comparing MAFLD patients with and without PEI, waist circumference emerged as a significant differentiator, suggesting a link between abdominal fat distribution and PEI development. No significant differences were found in age, gender, or comorbidity prevalence, consistent with Zsóri (2019) ( 23 ) , who noted that PEI in metabolic liver disease stems from complex metabolic dysfunctions rather than traditional risk factors. Gopi et al. (2023) ( 24 ) found the role of visceral fat in worsening both hepatic and pancreatic functions in metabolic diseases. HbA1c levels were significantly higher in the PEI group aligning with Boga et al. (2020) ( 2 ) , who reported elevated HbA1c in NAFLD + PEI patients (7.9% [5.8–9.8]) compared to NAFLD-PEI patients (5.7% [5.5–6.2], p < 0.001). Multiple studies ( 25 – 27 ) have linked low pancreatic elastase with poor glycemic control. Notably, Rathmann et al. (2015) ( 28 ) demonstrated a negative correlation between HbA1c and pancreatic elastase even in non-diabetics, suggesting exocrine pancreatic dysfunction may develop early alongside metabolic disturbances. Our multivariate regression analysis identified MAFLD as an independent predictor of PEI, consistent with Boga et al. (2020) ( 1 ) , who similarly found NAFLD to be a major predictor of reduced pancreatic function. In subgroup analysis, diabetic MAFLD patients had significantly lower fecal pancreatic elastase levels compared to non-diabetics and higher PEI prevalence. These findings align with Lv et al. (2021) ( 29 ) , who found PEI in 18.8% of T2DM patients with FE-1 negatively correlated with HbA1c.. Similarly, Boga et al. (2020) ( 1 ) reported PEI in 25.7% of diabetic NAFLD patients with higher pancreatic fat content (p < 0.01). Gemechu et al. (2020) ( 30 ) showed T2DM patients with poor glycemic control had lower fecal elastase levels. Diabetic MAFLD patients in our study also demonstrated more severe metabolic disturbances (higher HOMA-IR, HbA1c, waist circumference) and more advanced liver disease (increased fibrosis, steatosis, and GGT levels), emphasizing the interrelated dysfunction of liver and pancreas in metabolic disorders. Conclusions In conclusion, our findings emphasis a significant association between MAFLD and PEI, with fecal elastase levels serving as a reliable marker for detecting pancreatic dysfunction in this population. The higher prevalence of PEI in MAFLD patients, particularly those with diabetes and central obesity, underscores the importance of screening for exocrine pancreatic function in this high-risk group. Declarations Declaration of Competing Interest The authors declare that they have no conflict of interest. Author Contribution G.A.H and M.O.A; concept, design, literature search, clinical studies, statistical analysis, manuscript preparation, editing and review; design, literature search, manuscript preparation and review. A.A.M and M.A.; clinical and laboratory work, literature search, clinical studies, manuscript editing and final draft.G.A.H, M.O.A, A.A.M and M.A: manuscript preparation, editing, review and final draft for journal submission. 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Clinica chimica acta; international journal of clinical chemistry. 2021. Gemechu TR, Baye MF, Awgichew GB, Chekole BB, Gemechu ZR, Mulugeta H, et al., editors. Magnitude of pancreatic exocrine insufficiency and associated factors among adult diabetic patients attending Madda Walabu University Goba referral hospital, south east Ethiopia, 20192020. Tables Table 1: Characteristics of MAFLD Patients and Controls with Focus on Pancreatic Exocrine Function Parameter MAFLD Group (N=70) Control Group (N=20) p-value Demographics Age (years) 42.96 ± 10.89 40.85 ± 11.31 0.450 Sex (male/female), n (%) 52 (74.3%)/18 (25.7%) 13 (65.0%)/7 (35.0%) 0.393 Comorbidities, n (%) Any comorbidity 28 (40.0%) 0 (0.0%) 0.001* Diabetes Mellitus 20 (28.6%) 0 (0.0%) 0.007* Hypertension 15 (21.4%) 0 (0.0%) 0.024* Ischemic Heart Disease 3 (4.3%) 0 (0.0%) 0.350 Anthropometric Measurements Height (cm) 163.82 ± 8.32 172.40 ± 8.25 0.003* Weight (kg) 91.15 ± 15.04 68.50 ± 7.55 <0.001* Body Mass Index (kg/m²) 33.66 ± 5.17 23.48 ± 1.21 <0.001* Waist circumference (cm) 111.72 ± 9.52 79.50 ± 4.43 <0.001* Mid-Arm Circumference (cm) 37.52 ± 3.80 22.70 ± 2.34 <0.001* Metabolic Parameters HOMA-IR 3.90 ± 2.33 1.03 ± 0.12 <0.001* HbA1c (% of total Hb) 6.51 ± 2.41 2.67 ± 0.77 <0.001* Liver Function Tests ALT (U/L) 24.59 ± 16.81 18.42 ± 11.79 0.046* AST (U/L) 22.35 ± 9.51 20.71 ± 14.05 0.192 Albumin (g/L) 40.10 ± 12.48 38.21 ± 14.79 0.746 Total Bilirubin (mg/dL) 5.01 ± 4.78 5.08 ± 4.90 0.996 Direct Bilirubin (mg/dL) 2.07 ± 2.24 1.73 ± 1.71 0.631 GGT (U/L) 65.79 ± 40.68 25.60 ± 17.94 <0.001* ALP (U/L) 93.75 ± 34.80 69.55 ± 18.99 <0.001* Lipid Profile Total Cholesterol (mg/dL) 186.93 ± 37.31 121.12 ± 27.05 <0.001* Triglycerides (mg/dL) 155.58 ± 69.09 104.45 ± 26.19 0.001* HDL Cholesterol (mg/dL) 48.34 ± 14.53 60.48 ± 9.77 <0.001* Inflammatory Markers CRP (mg/L) 2.62 ± 1.23 1.64 ± 1.00 0.003* Liver Stiffness (Fibroscan) F0, n (%) 38 (54.3%) 20 (100.0%) 0.008* F1, n (%) 20 (28.6%) 0 (0.0%) F2, n (%) 5 (7.1%) 0 (0.0%) F3, n (%) 5 (7.1%) 0 (0.0%) F4, n (%) 2 (2.9%) 0 (0.0%) Steatosis (CAP Score) S0, n (%) 0 (0.0%) 20 (100.0%) <0.001* S2, n (%) 34 (48.6%) 0 (0.0%) S3, n (%) 30 (42.9%) 0 (0.0%) S4, n (%) 6 (8.6%) 0 (0.0%) Viral Markers HBsAg positive, n (%) 13 (18.6%) 0 (0.0%) 0.039* HCV Ab positive, n (%) 4 (5.7%) 0 (0.0%) 0.278 Pancreatic Function Amylase (U/L) 76.94 ± 13.08 68.85 ± 12.01 0.732 Fecal Pancreatic Elastase (µg/g) 180.38 ± 26.80 240.12 ± 43.39 <0.001* Continuous data are presented as Mean ± SD Categorical data are presented as number (percentage) *p<0.05 statistically significant differences Abbreviation: MAFLD: Metabolic Associated Fatty Liver Disease; HOMA-IR: Homeostatic Model Assessment of Insulin Resistance; HbA1c: Glycated Hemoglobin; ALT: Alanine Aminotransferase; AST: Aspartate Aminotransferase; GGT: Gamma-Glutamyl Transferase; ALP: Alkaline Phosphatase; HDL: High-Density Lipoprotein; CRP: C-Reactive Protein; CAP: Controlled Attenuation Parameter; HBsAg: Hepatitis B Surface Antigen; HCV Ab: Hepatitis C Virus Antibody Table 2: Comprehensive Assessment of MAFLD Patients with and without PEI Parameter MAFLD with PEI (n=59) MAFLD without PEI (n=11) p-value Demographics Age (years) 43.05 ± 10.59 43.27 ± 13.09 0.796 Sex (male), n (%) 44 (74.6%) 8 (72.7%) 0.898 Comorbidities, n (%) Any comorbidity 26 (44.1%) 2 (18.2%) 0.108 Diabetes Mellitus 18 (30.5%) 2 (18.2%) 0.406 Hypertension 14 (23.7%) 1 (9.1%) 0.277 Anthropometric Measurements Weight (kg) 90.66 ± 15.75 93.36 ± 11.65 0.370 BMI (kg/m²) 33.64 ± 5.37 33.47 ± 4.30 0.961 Waist circumference (cm) 115.73 ± 9.70 110.36 ± 5.95 0.043* Metabolic Parameters HOMA-IR 3.99 ± 2.41 3.59 ± 1.96 0.392 HbA1c (%) 7.65 ± 2.47 5.78 ± 2.13 0.042* Liver Function Tests ALT (U/L) 25.39 ± 16.79 21.65 ± 17.62 0.144 GGT (U/L) 64.02 ± 40.37 78.91 ± 41.99 0.211 ALP (U/L) 95.69 ± 34.84 84.36 ± 36.15 0.093 Lipid Profile Total Cholesterol (mg/dL) 190.29 ± 38.19 172.73 ± 28.58 0.133 Triglycerides (mg/dL) 151.78 ± 62.29 177.36 ± 101.36 0.606 HDL-C (mg/dL) 39.51 ± 15.22 42.72 ± 9.31 0.305 Inflammatory Markers CRP (mg/L) 2.70 ± 1.26 2.12 ± 0.87 0.143 Liver Stiffness (Fibroscan) F0, n (%) 33 (55.9%) 5 (45.5%) 0.406 F1-F4, n (%) 26 (44.1%) 6 (54.5%) Steatosis (CAP Score) S0, n (%) 0 (0.0%) 0 (0.0%) 0.458 S2-S4, n (%) 59 (100.0%) 11 (100.0%) Viral Markers HBsAg positive, n (%) 10 (16.9%) 3 (27.3%) 0.419 HCV Ab positive, n (%) 4 (6.8%) 0 (0.0%) 0.374 Pancreatic Function Amylase (U/L) 79.37 ± 13.14 82.45 ± 9.35 0.146 Fecal Pancreatic Elastase (µg/g) 172.93 ± 21.94 220.94 ± 9.71 <0.001* Continuous data are presented as Mean ± SD Categorical data are presented as number (percentage) *p<0.05 statistically significant differences Abbreviation: MAFLD: Metabolic Associated Fatty Liver Disease; PEI: Pancreatic Exocrine Insufficiency; BMI: Body Mass Index; HOMA-IR: Homeostatic Model Assessment of Insulin Resistance; HbA1c: Glycated Hemoglobin; ALT: Alanine Aminotransferase; GGT: Gamma-Glutamyl Transferase; ALP: Alkaline Phosphatase; HDL-C: High-Density Lipoprotein Cholesterol; CRP: C-Reactive Protein; CAP: Controlled Attenuation Parameter; HBsAg: Hepatitis B Surface Antigen; HCV Ab: Hepatitis C Virus Antibody Table 3: Univariate and multivariate Regression Analysis for Predictors of PEI in Patients Variable Univariate Multivariate P value Odds ratio 95% C.I. P value Odds ratio 95% C.I. Age (years) 0.853 0.996 0.955 - 1.039 Gender (Male) <0.001* 13.091 3.849 - 23.395 0.781 1.194 0.342 - 4.168 Mid-Arm Circumference (cm) <0.001* 1.161 1.078 - 1.252 0.669 0.964 0.817 - 1.139 Glycated Hemoglobin (% of total hemoglobin) <0.001* 1.740 1.311 - 2.310 0.109 1.315 0.941 - 1.838 MAFLD <0.001* 16.091 4.849 - 24.395 0.008* 10.220 4.474 - 12.256 Abbreviation, PEI; pancreatic exocrine insufficiency *p < 0.05 indicates statistical significance. Table 4: Comparison of MAFLD Patients with Diabetes versus without Diabetes Regarding PEI Parameter MAFLD with DM (n=20) MAFLD without DM (n=50) p-value PEI Prevalence PEI present, n (%) 18 (90.0%) 41 (82.0%) 0.039* PEI absent, n (%) 2 (10.0%) 9 (18.0%) Pancreatic Function Fecal Pancreatic Elastase (µg/g) 163.47 ± 19.83 187.54 ± 26.92 0.001* Amylase (U/L) 81.22 ± 11.95 75.37 ± 13.14 0.084 Metabolic Parameters HOMA-IR 5.68 ± 2.27 3.21 ± 1.98 <0.001* HbA1c (%) 9.65 ± 2.24 5.29 ± 0.87 <0.001* BMI (kg/m²) 34.75 ± 5.43 33.26 ± 5.07 0.277 Waist circumference (cm) 116.35 ± 9.78 109.90 ± 8.97 0.011* Liver Assessment Advanced fibrosis (≥F2), n (%) 7 (35.0%) 5 (10.0%) 0.009* Severe steatosis (S3-S4), n (%) 14 (70.0%) 22 (44.0%) 0.046* ALT (U/L) 27.43 ± 18.26 23.51 ± 16.28 0.382 GGT (U/L) 74.89 ± 43.51 62.13 ± 39.15 0.037* Continuous data are presented as Mean ± SD Categorical data are presented as number (percentage) *p<0.05 statistically significant differences Abbreviation : MAFLD: Metabolic Associated Fatty Liver Disease; DM: Diabetes Mellitus; PEI: Pancreatic Exocrine Insufficiency; HOMA-IR: Homeostatic Model Assessment of Insulin Resistance; HbA1c: Glycated Hemoglobin; BMI: Body Mass Index; ALT: Alanine Aminotransferase; GGT: Gamma-Glutamyl Transferase Additional Declarations No competing interests reported. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7443549","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":509704348,"identity":"fd74bbd6-ee8d-42d9-9e5e-819e349ad2bb","order_by":0,"name":"Ghada A Hammam","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABB0lEQVRIiWNgGAWjYDACCSDmYTjAwHCA/eCDDxVAHjNzA7FaeJINZ5wBaWEkWguDmTRnG0iIgBb+2d2JD978uiPPd/xAsjHjvNpo/naglh8V23BbcufsZsO5fc8MZ55JPPi4cNvx3BmHGRsYe87cxm3Njdxt0rw9hxk3HEhINp657VhuA1ALM2Mbbi3yN3K3/wZqsd9w/oGZNO+cY7nzCWkxANrCzPPjcOKGGwlALQ01uRsIaTG8kbtZcm7D4eSZN94AA/nYgdyNQC0H8flF7kbuxg9v/hy27TufDozKmrrceecPH3zwowKP90GAsQ3OPAwmD+BXDwJ/4Kw6wopHwSgYBaNgxAEAkJBu9zt6OGgAAAAASUVORK5CYII=","orcid":"","institution":"Assiut University","correspondingAuthor":true,"prefix":"","firstName":"Ghada","middleName":"A","lastName":"Hammam","suffix":""},{"id":509704349,"identity":"ae1fe5a2-6db5-4aea-a0e5-70c773ac19e2","order_by":1,"name":"Mohamed Omar Abdelmalek","email":"","orcid":"","institution":"Assiut University","correspondingAuthor":false,"prefix":"","firstName":"Mohamed","middleName":"Omar","lastName":"Abdelmalek","suffix":""},{"id":509704350,"identity":"fbf11135-4a01-4765-a8c3-70fbd4b9587f","order_by":2,"name":"Amal A Mahmoud","email":"","orcid":"","institution":"Assiut University","correspondingAuthor":false,"prefix":"","firstName":"Amal","middleName":"A","lastName":"Mahmoud","suffix":""},{"id":509704351,"identity":"fb604d58-bb8f-4dc9-a74b-bcf4e55f7c83","order_by":3,"name":"Mohamed Abdelghani","email":"","orcid":"","institution":"Assiut University","correspondingAuthor":false,"prefix":"","firstName":"Mohamed","middleName":"","lastName":"Abdelghani","suffix":""}],"badges":[],"createdAt":"2025-08-24 00:53:09","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7443549/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7443549/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s43066-025-00474-4","type":"published","date":"2026-01-13T16:29:46+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":91068494,"identity":"72061732-fbd5-422c-be07-2ab50ea13110","added_by":"auto","created_at":"2025-09-11 10:21:36","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":46232,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eROC curve of Fecal Pancreatic Elastase (µg/g) to discriminate the NAFLD patients with PEI and without PEI\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-7443549/v1/273d2b0fec486534b7e3d537.jpg"},{"id":91067714,"identity":"67cd9362-f855-4b7f-a2c9-5b434a00a563","added_by":"auto","created_at":"2025-09-11 10:13:36","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":43295,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eROC curve of Fecal Pancreatic Elastase (µg/g) to discriminate the MAFLD Patients with Diabetes versus without Diabetes\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-7443549/v1/4d5bc6a2cf10f126fc678966.jpg"},{"id":100616173,"identity":"8c62eba9-4779-4d52-9295-6769ff229232","added_by":"auto","created_at":"2026-01-19 17:41:02","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1652368,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7443549/v1/c3b795f5-48bb-47d5-83bb-b09c97e203b6.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Evidence of Pancreas Exocrine Insufficiency in Patients with Metabolic Associated Fatty Liver Disease Patients","fulltext":[{"header":"Introduction","content":"\u003cp\u003eMetabolic-associated fatty liver disease (MAFLD) is now the most prevalent cause of chronic liver disease worldwide, affecting nearly 25% of the global population and strongly associated with obesity, insulin resistance, and type 2 diabetes mellitus (T2DM) \u003csup\u003e\u003cb\u003e(\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e)\u003c/b\u003e\u003c/sup\u003e. While the hepatic consequences of MAFLD are well documented, its impact on pancreatic function remains underrecognized. Pancreatic exocrine insufficiency (PEI), defined by inadequate secretion of digestive enzymes, can develop in the setting of metabolic dysfunction even in the absence of overt pancreatic pathology\u003csup\u003e\u003cb\u003e(\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e)\u003c/b\u003e\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003eRecent studies suggest a pathophysiological overlap between hepatic steatosis and pancreatic dysfunction, both influenced by visceral adiposity, chronic hyperglycemia, and low-grade inflammation \u003csup\u003e\u003cb\u003e(\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e)\u003c/b\u003e\u003c/sup\u003e. Fecal pancreatic elastase-1 (FPE-1) is a widely accepted, non-invasive biomarker for diagnosing PEI, with levels below 200 \u0026micro;g/g indicative of exocrine dysfunction \u003csup\u003e\u003cb\u003e(\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e)\u003c/b\u003e\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003eUnderstanding the prevalence and metabolic correlates of PEI in MAFLD patients is critical, as impaired pancreatic function may worsen nutritional status, glycemic control, and liver disease progression. This study aims to assess PEI prevalence in MAFLD patients and its relationship with diabetes, metabolic parameters, and hepatic disease severity.\u003c/p\u003e"},{"header":"Patients and Methods","content":"\u003cp\u003e\u003cstrong\u003eStudy Design and Patient population\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis was a single-center, prospective, case-control study conducted at Assiut University Hospitals (Al Rajhi Hospital) from January 2023 to January 2024. The study enrolled 90 subjects: 70 patients with MAFLD and 20 age-matched healthy controls (case-to-control ratio of 3.5:1).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eSample size was determined based on previously reported prevalence rates of pancreatic exocrine insufficiency (PEI) in liver disease (25\u0026ndash;35%) compared with the general population (3\u0026ndash;6%) Boga et al. (2020) \u003cstrong\u003e\u003csup\u003e(2)\u003c/sup\u003e\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eInclusion Criteria\u003c/strong\u003e\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003eAge \u0026ge; \u003cstrong\u003e18 years\u003c/strong\u003e, diagnosed with \u003cstrong\u003eMAFLD\u003c/strong\u003e based on imaging confirm \u003cstrong\u003ehepatic steatosis\u003c/strong\u003eand at least one of the following metabolic conditions:\u003cul\u003e\n \u003cli\u003e\u003cstrong\u003eOverweight/Obesity\u003c/strong\u003e: ( BMI \u0026nbsp;\u0026ge;25 \u0026nbsp; kg/m\u0026sup2;.)\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eDiabetes Mellitus\u003c/strong\u003e: (Fasting blood glucose (FBG) level \u0026gt;125 mg/dl and/or glycated hemoglobin (HbA1c) level \u0026gt; 6.4%).\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eMetabolic Dysregulation (MD)\u003c/strong\u003e in lean individuals with evidence of metabolic risk factors such as elevated triglycerides \u0026gt;150 mg/dl, (HOMA)-insulin resistance score \u0026ge;2.5 or low HDL cholesterol level \u0026lt;40 mg/dl.\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003e\u003cstrong\u003eExclusion Criteria\u003c/strong\u003e\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003e\u003cstrong\u003eUse of Steatogenic Medications\u003c/strong\u003e, such as corticosteroids or amiodarone.\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eHormone Replacement Therapy or Herbal supplements\u0026nbsp;\u003c/strong\u003e\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eCurrent or prior Alcohol Consumption within 12 months\u003c/strong\u003e\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eHistory of Pancreatic Diseases or pancreatic surgery\u003c/strong\u003e.\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eKnown malignancy\u003c/strong\u003e\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003e\u003cstrong\u003eClinical Assessment\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll participants underwent comprehensive history taking, clinical examination, and anthropometric measurements including height (cm), weight (kg), BMI (kg/m\u0026sup2;), waist circumference (cm), and mid-arm circumference (cm). Medical comorbidities including diabetes mellitus, hypertension, and ischemic heart disease were documented.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eLaboratory Investigations\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eBlood samples were collected after overnight fasting (12 hours) and analyzed for:\u003c/p\u003e\n\u003col start=\"1\" type=\"1\"\u003e\n \u003cli\u003eLiver function tests: ALT, AST, albumin, total and direct bilirubin, GGT, and ALP\u003c/li\u003e\n \u003cli\u003eHematological and coagulation profile: hemoglobin, white blood cell count, platelet count, and international normalized ratio (INR)\u003c/li\u003e\n \u003cli\u003eMetabolic profile: fasting glucose, HbA1c, HOMA-IR, and lipid profile (total cholesterol, triglycerides, HDL cholesterol)\u003c/li\u003e\n \u003cli\u003eThyroid function tests: T3, T4, and TSH\u003c/li\u003e\n \u003cli\u003eKidney function tests: serum urea and creatinine\u003c/li\u003e\n \u003cli\u003eElectrolytes: sodium and potassium\u003c/li\u003e\n \u003cli\u003eInflammatory markers: C-reactive protein (CRP)\u003c/li\u003e\n \u003cli\u003eViral markers: HBsAg and HCV antibodies\u003c/li\u003e\n \u003cli\u003ePancreatic enzymes: serum amylase\u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\u003e\u003cstrong\u003eFecal Pancreatic Elastase Measurement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eStool samples were collected from all participants following standard collection procedures. Fecal elastase-1 levels were measured using a commercially available enzyme-linked immunosorbent assay (ELISA) kit (ScheBo Biotech AG, Giessen, Germany).. The ELISA test provides a quantitative analysis of fecal elastase-1, a marker of pancreatic exocrine function. All stool samples were processed according to the manufacturer\u0026apos;s instructions to ensure accurate results.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eImaging Studies\u003c/strong\u003e\u003c/p\u003e\n\u003col start=\"1\" type=\"1\"\u003e\n \u003cli\u003eAbdominal ultrasound: Performed using a high-resolution B-mode ultrasonography system with a 3.5 MHz convex probe to detect hepatic steatosis and exclude other liver pathologies\u003c/li\u003e\n \u003cli\u003eTransient elastography (Fibroscan\u0026reg;): Performed after overnight fasting to assess:\u0026nbsp;\u003cul type=\"circle\"\u003e\n \u003cli\u003eLiver stiffness for fibrosis staging (F0-F4)\u003c/li\u003e\n \u003cli\u003eControlled Attenuation Parameter (CAP) for steatosis quantification (S0-S4)\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\u003e\u003cstrong\u003eEthical Considerations\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWritten informed consent was obtained from all participants. The study protocol was approved by the Institutional Review Board and Ethics Committee of Assiut University Hospitals (approval number: IRB-ASU-2022/12-45). All procedures were performed in accordance with the ethical standards of the Declaration of Helsinki.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStatistical Analysis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIBM SPSS Statistics version 28.0 was used for data analysis. Normality was assessed using the Shapiro-Wilk test. Parametric data are presented as mean \u0026plusmn; SD, non-parametric as median with range, and categorical as numbers and percentages. Independent t-test or Mann-Whitney U test was used for comparing continuous variables between groups, while Chi-square or Fisher\u0026apos;s exact test was used for categorical variables. Univariate and multivariate logistic regression analyses identified PEI predictors. ROC curve analysis evaluated fecal pancreatic elastase\u0026apos;s discriminatory ability. Subgroup analysis compared diabetic versus non-diabetic MAFLD patients. P\u0026lt;0.05 was considered statistically significant.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eThe main clinical and biochemical characteristics of the MAFLD patients and control subjects in Table\u0026nbsp;(1) shows significant differences in pancreatic exocrine function between MAFLD patients and controls, with MAFLD patients exhibiting markedly lower fecal pancreatic elastase levels (180.38\u0026thinsp;\u0026plusmn;\u0026thinsp;26.80 \u0026micro;g/g vs. 240.12\u0026thinsp;\u0026plusmn;\u0026thinsp;43.39 \u0026micro;g/g, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). MAFLD patients demonstrated significantly higher BMI, waist circumference, and insulin resistance (HOMA-IR), as well as elevated liver enzymes (ALT, GGT, ALP) and lipid parameters compared to controls. Additionally, MAFLD patients presented with varying degrees of liver fibrosis (F0-F4) and steatosis (S2-S4), while controls had no fibrosis or steatosis. The prevalence of comorbidities, particularly diabetes mellitus (28.6%) and hypertension (21.4%), was significantly higher in MAFLD patients.\u003c/p\u003e\u003cp\u003eThe ROC curve analysis for fecal pancreatic elastase as a diagnostic marker to discriminate between MAFLD patients with and without PEI. The analysis demonstrates excellent discriminatory power with an area under the curve (AUC) of 0.873 (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). The curve exhibits a steep initial rise, indicating high sensitivity and specificity at the optimal cutoff value. This suggests that fecal pancreatic elastase measurement is a reliable biomarker for detecting PEI in MAFLD patients, with strong statistical significance (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eTable\u0026nbsp;(2) shows significant differences between MAFLD patients with and without PEI in fecal pancreatic elastase levels (172.93\u0026thinsp;\u0026plusmn;\u0026thinsp;21.94 \u0026micro;g/g vs. 220.94\u0026thinsp;\u0026plusmn;\u0026thinsp;9.71 \u0026micro;g/g, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), waist circumference (115.73\u0026thinsp;\u0026plusmn;\u0026thinsp;9.70 cm vs. 110.36\u0026thinsp;\u0026plusmn;\u0026thinsp;5.95 cm, p\u0026thinsp;=\u0026thinsp;0.043), and glycated hemoglobin (7.65\u0026thinsp;\u0026plusmn;\u0026thinsp;2.47% vs. 5.78\u0026thinsp;\u0026plusmn;\u0026thinsp;2.13%, p\u0026thinsp;=\u0026thinsp;0.042). MAFLD patients with PEI had higher prevalence of comorbidities (44.1% vs. 18.2%) and diabetes mellitus (30.5% vs. 18.2%), though these differences did not reach statistical significance. No significant differences were observed in liver fibrosis stages, steatosis grades, or viral markers between groups.\u003c/p\u003e\u003cp\u003eOur logistic regression, MAFLD is a significant independent predictor of PEI in both univariate (OR: 16.091, 95% CI: 4.849\u0026ndash;24.395, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) and multivariate analysis (OR: 10.220, 95% CI: 4.474\u0026ndash;12.256, p\u0026thinsp;=\u0026thinsp;0.008). In univariate analysis, male gender (OR: 13.091, 95% CI: 3.849\u0026ndash;23.395, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), increased mid-arm circumference (OR: 1.161, 95% CI: 1.078\u0026ndash;1.252, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), and elevated glycated hemoglobin (OR: 1.740, 95% CI: 1.311\u0026ndash;2.310, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) were also significant predictors of PEI. However, after adjustment in multivariate analysis, only MAFLD remained a significant independent predictor, while age, gender, mid-arm circumference, and glycated hemoglobin lost statistical significance. These findings indicate that MAFLD is the most important risk factor for developing PEI, with a greater than 10-fold increased risk after controlling for other variables Table\u0026nbsp;(3).\u003c/p\u003e\u003cp\u003eFigure (2) shows the ROC curve analysis of fecal pancreatic elastase as a discriminatory marker between MAFLD patients with and without diabetes. The analysis demonstrated good diagnostic performance with an area under the curve (AUC) of 0.799 (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001, 95% CI: 0.686\u0026ndash;0.885). The optimal cutoff value was determined to be \u0026le;\u0026thinsp;166.67 \u0026micro;g/g, providing a sensitivity of 70.0% and specificity of 80.0% (Youden index: 0.5000). At this threshold, the positive likelihood ratio was 3.50, while the negative likelihood ratio was 0.38.\u003c/p\u003e\u003cp\u003eTable\u0026nbsp;(4) demonstrates significant differences between MAFLD patients with and without diabetes regarding pancreatic exocrine function and metabolic parameters. Diabetic MAFLD patients showed significantly higher prevalence of PEI (90.0% vs. 82.0%, p\u0026thinsp;=\u0026thinsp;0.039) and markedly lower fecal pancreatic elastase levels (163.47\u0026thinsp;\u0026plusmn;\u0026thinsp;19.83 \u0026micro;g/g vs. 187.54\u0026thinsp;\u0026plusmn;\u0026thinsp;26.92 \u0026micro;g/g, p\u0026thinsp;=\u0026thinsp;0.001). Metabolic derangements were more pronounced in diabetic patients, with significantly higher HOMA-IR (5.68\u0026thinsp;\u0026plusmn;\u0026thinsp;2.27 vs. 3.21\u0026thinsp;\u0026plusmn;\u0026thinsp;1.98, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), HbA1c (9.65\u0026thinsp;\u0026plusmn;\u0026thinsp;2.24% vs. 5.29\u0026thinsp;\u0026plusmn;\u0026thinsp;0.87%, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), and waist circumference (116.35\u0026thinsp;\u0026plusmn;\u0026thinsp;9.78 cm vs. 109.90\u0026thinsp;\u0026plusmn;\u0026thinsp;8.97 cm, p\u0026thinsp;=\u0026thinsp;0.011). Liver disease was more advanced in diabetic MAFLD patients, with higher rates of significant fibrosis (35.0% vs. 10.0%, p\u0026thinsp;=\u0026thinsp;0.009), severe steatosis (70.0% vs. 44.0%, p\u0026thinsp;=\u0026thinsp;0.046), and elevated GGT (74.89\u0026thinsp;\u0026plusmn;\u0026thinsp;43.51 U/L vs. 62.13\u0026thinsp;\u0026plusmn;\u0026thinsp;39.15 U/L, p\u0026thinsp;=\u0026thinsp;0.037)\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eMAFLD represents a spectrum of liver diseases closely linked to metabolic disorders such as obesity, diabetes, and insulin resistance \u003csup\u003e\u003cb\u003e(\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e)\u003c/b\u003e\u003c/sup\u003e. While its hepatic complications are well-documented, emerging evidence suggests MAFLD may also be associated with PEI, a condition where the pancreas fails to produce or deliver sufficient digestive enzymes \u003csup\u003e\u003cb\u003e(\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e)\u003c/b\u003e\u003c/sup\u003e. This study aimed to investigate this relationship by screening for PEI in patients with MAFLD using fecal elastase testing.\u003c/p\u003e\u003cp\u003eOur MAFLD group results demonstrated that classic features of metabolic syndrome, with significantly higher BMI, waist circumference, and increased prevalence of comorbidities including diabetes mellitus and hypertension compared to controls. These findings align with previous studies by Niriella et al. (2021) \u003csup\u003e\u003cb\u003e(\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e)\u003c/b\u003e\u003c/sup\u003e and Yu et al. (2022) \u003csup\u003e\u003cb\u003e(\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e)\u003c/b\u003e\u003c/sup\u003e, who reported similar demographic and clinical characteristics in MAFLD patients.\u003c/p\u003e\u003cp\u003eOur MAFLD group exhibited significantly higher insulin resistance and glycated hemoglobin levels. Khan et al. (2018) \u003csup\u003e\u003cb\u003e(\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e)\u003c/b\u003e\u003c/sup\u003e reported similar findings, with HOMA-IR values around 4.5 in patients with metabolic diseases versus 1.1 in controls. Rosettenstein et al. (2016) \u003csup\u003e\u003cb\u003e(\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e)\u003c/b\u003e\u003c/sup\u003e noted that patients with metabolic syndrome had HOMA-IR levels exceeding 3.0 compared to controls with values near 1.0. According to Hou et al., 2016 \u003csup\u003e\u003cb\u003e(\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e)\u003c/b\u003e\u003c/sup\u003e, HbA1c levels above 6.5% are linked to reduced β-cell function and increased insulin resistance in metabolic syndrome, supporting the current findings. Similarly, Saravia et al. (2015) \u003csup\u003e\u003cb\u003e(\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e)\u003c/b\u003e\u003c/sup\u003e found HbA1c\u0026thinsp;\u0026gt;\u0026thinsp;6% significantly increased metabolic syndrome risk, aligning with results seen in MAFLD patients.\u003c/p\u003e\u003cp\u003eLiver function tests in our study showed elevated liver enzymes in the MAFLD group. Nguyen et al. (2021) \u003csup\u003e\u003cb\u003e(\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e)\u003c/b\u003e\u003c/sup\u003e similarly found that MAFLD patients had significantly elevated ALT compared to controls (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Zdanowicz et al. (2023) \u003csup\u003e\u003cb\u003e(\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e)\u003c/b\u003e\u003c/sup\u003e demonstrated strong correlations between liver stiffness and elevated ALT and GGT, with GGT being especially predictive of liver fibrosis.\u003c/p\u003e\u003cp\u003eOur lipid profile findings reflected dyslipidemia commonly associated with MAFLD. Forlano et al. (2021) \u003csup\u003e\u003cb\u003e(\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e)\u003c/b\u003e\u003c/sup\u003e also found that patients with metabolic liver diseases had significantly higher total cholesterol and triglycerides than healthy individuals.\u003c/p\u003e\u003cp\u003eFibroscan assessment in our study revealed varying degrees of liver fibrosis in MAFLD patients. Fujii et al. (2021) \u003csup\u003e\u003cb\u003e(\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e)\u003c/b\u003e\u003c/sup\u003e reported similar findings, with fibrosis in 40% of NAFLD patients. Regarding steatosis, Shao et al. (2019) \u003csup\u003e\u003cb\u003e(\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e)\u003c/b\u003e\u003c/sup\u003e found that the majority of MAFLD patients showed moderate-to-severe steatosis, consistent with our observations.\u003c/p\u003e\u003cp\u003eThe most significant finding of our study was the markedly reduced fecal pancreatic elastase levels in the MAFLD group, indicating impaired pancreatic exocrine function. Boga et al. (2020) \u003csup\u003e\u003cb\u003e(\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e)\u003c/b\u003e\u003c/sup\u003e found significantly lower fecal elastase levels in NAFLD patients (297 \u0026micro;g/g [204\u0026ndash;517]) compared to controls (500 \u0026micro;g/g [298\u0026ndash;678], p\u0026thinsp;\u0026lt;\u0026thinsp;0.01). In a study of Indian patients with diabetes, Shivaprasad et al. (2015) \u003csup\u003e\u003cb\u003e(\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e)\u003c/b\u003e\u003c/sup\u003e reported that 31.4% of type 1 diabetics and 29.4% of type 2 diabetics had fecal elastase levels below 200 \u0026micro;g/g. Our findings are consistent with Herzig et al. (2011) \u003csup\u003e\u003cb\u003e(\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e)\u003c/b\u003e\u003c/sup\u003e, who reported that 21.7% of older adults without GI disease or diabetes had fecal elastase levels below 200 \u0026micro;g/g, suggesting subclinical pancreatic dysfunction. Similarly, Naruse et al. \u003csup\u003e\u003cb\u003e(\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e)\u003c/b\u003e\u003c/sup\u003e confirmed that fecal elastase is a specific marker for severe exocrine pancreatic insufficiency. Nunes et al. \u003csup\u003e\u003cb\u003e(\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e)\u003c/b\u003e\u003c/sup\u003e also found reduced fecal elastase in 36% of diabetic patients versus 5% of controls, reinforcing the link between metabolic dysfunction and pancreatic insufficiency, as seen in our MAFLD cohort.\u003c/p\u003e\u003cp\u003eROC curve analysis demonstrated excellent discriminatory power of fecal pancreatic elastase in identifying MAFLD patients with PEI. Vanga et al. (2018) \u003csup\u003e\u003cb\u003e(\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e)\u003c/b\u003e\u003c/sup\u003e reported in a meta-analysis that elastase levels below 200 \u0026micro;g/g were highly sensitive for detecting moderate-to-severe pancreatic insufficiency. Another study by Giuliani et al. (2020) \u003csup\u003e\u003cb\u003e(\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e)\u003c/b\u003e\u003c/sup\u003e reported that FPE had a sensitivity of 83.3% and specificity of 70.4% for diagnosing PEI in chronic pancreatitis using a\u0026thinsp;\u0026lt;\u0026thinsp;200 \u0026micro;g/g cutoff. Similarly, Chowdhury et al. (2016) \u003csup\u003e\u003cb\u003e(\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e)\u003c/b\u003e\u003c/sup\u003e found FPE-1 sensitivity was 84.9% at \u0026lt;\u0026thinsp;100 \u0026micro;g/g and 90.9% at \u0026lt;\u0026thinsp;200 \u0026micro;g/g, though specificity at the higher cutoff was only 9.5%. While these studies focus on chronic pancreatitis, they reinforce the value of FPE in identifying PEI across various conditions, including MAFLD.\u003c/p\u003e\u003cp\u003eWhen comparing MAFLD patients with and without PEI, waist circumference emerged as a significant differentiator, suggesting a link between abdominal fat distribution and PEI development. No significant differences were found in age, gender, or comorbidity prevalence, consistent with Zs\u0026oacute;ri (2019) \u003csup\u003e\u003cb\u003e(\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e)\u003c/b\u003e\u003c/sup\u003e, who noted that PEI in metabolic liver disease stems from complex metabolic dysfunctions rather than traditional risk factors. Gopi et al. (2023) \u003csup\u003e\u003cb\u003e(\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e)\u003c/b\u003e\u003c/sup\u003e found the role of visceral fat in worsening both hepatic and pancreatic functions in metabolic diseases. HbA1c levels were significantly higher in the PEI group aligning with Boga et al. (2020) \u003csup\u003e\u003cb\u003e(\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e)\u003c/b\u003e\u003c/sup\u003e, who reported elevated HbA1c in NAFLD\u0026thinsp;+\u0026thinsp;PEI patients (7.9% [5.8\u0026ndash;9.8]) compared to NAFLD-PEI patients (5.7% [5.5\u0026ndash;6.2], p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Multiple studies \u003csup\u003e\u003cb\u003e(\u003cspan additionalcitationids=\"CR26\" citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e)\u003c/b\u003e\u003c/sup\u003e have linked low pancreatic elastase with poor glycemic control. Notably, Rathmann et al. (2015) \u003csup\u003e\u003cb\u003e(\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e)\u003c/b\u003e\u003c/sup\u003e demonstrated a negative correlation between HbA1c and pancreatic elastase even in non-diabetics, suggesting exocrine pancreatic dysfunction may develop early alongside metabolic disturbances.\u003c/p\u003e\u003cp\u003eOur multivariate regression analysis identified MAFLD as an independent predictor of PEI, consistent with Boga et al. (2020) \u003csup\u003e\u003cb\u003e(\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e)\u003c/b\u003e,\u003c/sup\u003e who similarly found NAFLD to be a major predictor of reduced pancreatic function.\u003c/p\u003e\u003cp\u003eIn subgroup analysis, diabetic MAFLD patients had significantly lower fecal pancreatic elastase levels compared to non-diabetics and higher PEI prevalence. These findings align with Lv et al. (2021) \u003csup\u003e\u003cb\u003e(\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e)\u003c/b\u003e\u003c/sup\u003e, who found PEI in 18.8% of T2DM patients with FE-1 negatively correlated with HbA1c.. Similarly, Boga et al. (2020) \u003csup\u003e\u003cb\u003e(\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e)\u003c/b\u003e\u003c/sup\u003e reported PEI in 25.7% of diabetic NAFLD patients with higher pancreatic fat content (p\u0026thinsp;\u0026lt;\u0026thinsp;0.01). Gemechu et al. (2020) \u003csup\u003e\u003cb\u003e(\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e)\u003c/b\u003e\u003c/sup\u003e showed T2DM patients with poor glycemic control had lower fecal elastase levels. Diabetic MAFLD patients in our study also demonstrated more severe metabolic disturbances (higher HOMA-IR, HbA1c, waist circumference) and more advanced liver disease (increased fibrosis, steatosis, and GGT levels), emphasizing the interrelated dysfunction of liver and pancreas in metabolic disorders.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eIn conclusion, our findings emphasis a significant association between MAFLD and PEI, with fecal elastase levels serving as a reliable marker for detecting pancreatic dysfunction in this population. The higher prevalence of PEI in MAFLD patients, particularly those with diabetes and central obesity, underscores the importance of screening for exocrine pancreatic function in this high-risk group.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003ch2\u003eDeclaration of Competing Interest\u003c/h2\u003e\u003cp\u003eThe authors declare that they have no conflict of interest.\u003c/p\u003e\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eG.A.H and M.O.A; concept, design, literature search, clinical studies, statistical analysis, manuscript preparation, editing and review; design, literature search, manuscript preparation and review. A.A.M and M.A.; clinical and laboratory work, literature search, clinical studies, manuscript editing and final draft.G.A.H, M.O.A, A.A.M and M.A: manuscript preparation, editing, review and final draft for journal submission.\u003c/p\u003e\u003ch2\u003eAcknowledgement\u003c/h2\u003e\u003cp\u003eNil\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eThe datasets that were assessed in the present study are available from the corresponding author upon request.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eEslam M, Newsome PN, Sarin SK, Anstee QM, Targher G, Romero-Gomez M, et al. A new definition for metabolic dysfunction-associated fatty liver disease: An international expert consensus statement. Journal of hepatology. 2020;73(1):202-9.\u003c/li\u003e\n\u003cli\u003eBoga S, Koksal AR, Sen İ, Yeniay MK, Ozguven MBY, Serin E, et al. 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The FibroScan-aspartate aminotransferase score can stratify the disease severity in a Japanese cohort with fatty liver diseases. Scientific reports. 2021;11(1):13844.\u003c/li\u003e\n\u003cli\u003eShao C, Ye J, Li F, Feng S, Wang W, Zhong B. Different predictors of steatosis and fibrosis severity among lean, overweight and obese patients with nonalcoholic fatty liver disease. Digestive and Liver Disease. 2019;51(10):1392-9.\u003c/li\u003e\n\u003cli\u003eShivaprasad C, Pulikkal AA, Kumar KP. Pancreatic exocrine insufficiency in type 1 and type 2 diabetics of Indian origin. Pancreatology. 2015;15(6):616-9.\u003c/li\u003e\n\u003cli\u003eHerzig K-H, Purhonen A-K, R\u0026auml;s\u0026auml;nen KM, Idziak J, Juvonen P, Phillps R, et al. Fecal pancreatic elastase-1 levels in older individuals without known gastrointestinal diseases or diabetes mellitus. BMC geriatrics. 2011;11:1-5.\u003c/li\u003e\n\u003cli\u003eNunes AC, Pontes JM, Rosa A, Gomes L, Carvalheiro M, Freitas D. Screening for pancreatic exocrine insufficiency in patients with diabetes mellitus. Official journal of the American College of Gastroenterology| ACG. 2003;98(12):2672-5.\u003c/li\u003e\n\u003cli\u003eVanga RR, Tansel A, Sidiq S, El-Serag HB, Othman MO. Diagnostic performance of measurement of fecal elastase-1 in detection of exocrine pancreatic insufficiency: systematic review and meta-analysis. Clinical gastroenterology and hepatology. 2018;16(8):1220-8. e4.\u003c/li\u003e\n\u003cli\u003eGiuliani T, Andrianello S, Bortolato C, Marchegiani G, De Marchi G, Malleo G, et al. Preoperative fecal elastase-1 (FE-1) adds value in predicting post-operative pancreatic fistula: not all soft pancreas share the same risk\u0026ndash;A prospective analysis on 105 patients. HPB. 2020;22(3):415-21.\u003c/li\u003e\n\u003cli\u003eChowdhury SD, Kurien RT, Ramachandran A, Joseph AJ, Simon EG, Dutta AK, et al. Pancreatic exocrine insufficiency: Comparing fecal elastase 1 with 72-h stool for fecal fat estimation. Indian Journal of Gastroenterology. 2016;35:441-4.\u003c/li\u003e\n\u003cli\u003eZs\u0026oacute;ri G. Interactions between the exocrine and endocrine pancreas: Szegedi Tudomanyegyetem (Hungary); 2019.\u003c/li\u003e\n\u003cli\u003eGopi S, Singh N, Yegurla J, Tabish M, Agarwal S, Qamar S, et al. Utility of Fecal Elastase-1 to diagnose severe exocrine insufficiency in chronic pancreatitis: Real world experience. Pancreatology. 2023;23(2):151-7.\u003c/li\u003e\n\u003cli\u003eHardt PD, Hauenschild A, Nalop J, Marzeion AM, Jaeger C, Teichmann J, et al. High prevalence of exocrine pancreatic insufficiency in diabetes mellitus: a multicenter study screening fecal elastase 1 concentrations in 1,021 diabetic patients. Pancreatology. 2003;3(5):395-402.\u003c/li\u003e\n\u003cli\u003eTerzin V, V\u0026aacute;rkonyi T, Szabolcs A, Lengyel C, Tak\u0026aacute;cs T, Zs\u0026oacute;ri G, et al. Prevalence of exocrine pancreatic insufficiency in type 2 diabetes mellitus with poor glycemic control. Pancreatology. 2014;14(5):356-60.\u003c/li\u003e\n\u003cli\u003ePiciucchi M, Capurso G, Archibugi L, Delle Fave MM, Capasso M, Delle Fave G. Exocrine pancreatic insufficiency in diabetic patients: prevalence, mechanisms, and treatment. International journal of endocrinology. 2015;2015(1):595649.\u003c/li\u003e\n\u003cli\u003eRathmann W, Haastert B, Oscarsson J, Berglind N, Wareham NJ. Inverse association of HbA1c with faecal elastase 1 in people without diabetes. Pancreatology. 2015;15(6):620-5.\u003c/li\u003e\n\u003cli\u003eLv Y-x, Wei Q, Yuan X, Sun J-f, Zhang J, Qi L, et al. Two Sides of the Pancreas: Exocrine Insufficiency is Correlated with Endocrine Dysfunction in Type 2 Diabetes. Clinica chimica acta; international journal of clinical chemistry. 2021.\u003c/li\u003e\n\u003cli\u003eGemechu TR, Baye MF, Awgichew GB, Chekole BB, Gemechu ZR, Mulugeta H, et al., editors. Magnitude of pancreatic exocrine insufficiency and associated factors among adult diabetic patients attending Madda Walabu University Goba referral hospital, south east Ethiopia, 20192020.\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003e\u003cstrong\u003eTable 1: Characteristics of MAFLD Patients and Controls with Focus on Pancreatic Exocrine Function\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"3\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eParameter\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eMAFLD Group (N=70)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eControl Group (N=20)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003ep-value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eDemographics\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eAge (years)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e42.96 \u0026plusmn; 10.89\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e40.85 \u0026plusmn; 11.31\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.450\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eSex (male/female), n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e52 (74.3%)/18 (25.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e13 (65.0%)/7 (35.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.393\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eComorbidities, n (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eAny comorbidity\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e28 (40.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0 (0.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.001*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eDiabetes Mellitus\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e20 (28.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0 (0.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.007*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eHypertension\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e15 (21.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0 (0.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.024*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eIschemic Heart Disease\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e3 (4.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0 (0.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.350\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eAnthropometric Measurements\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eHeight (cm)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e163.82 \u0026plusmn; 8.32\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e172.40 \u0026plusmn; 8.25\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.003*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eWeight (kg)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e91.15 \u0026plusmn; 15.04\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e68.50 \u0026plusmn; 7.55\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026lt;0.001*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eBody Mass Index (kg/m\u0026sup2;)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e33.66 \u0026plusmn; 5.17\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e23.48 \u0026plusmn; 1.21\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026lt;0.001*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eWaist circumference (cm)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e111.72 \u0026plusmn; 9.52\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e79.50 \u0026plusmn; 4.43\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026lt;0.001*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eMid-Arm Circumference (cm)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e37.52 \u0026plusmn; 3.80\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e22.70 \u0026plusmn; 2.34\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026lt;0.001*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eMetabolic Parameters\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eHOMA-IR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e3.90 \u0026plusmn; 2.33\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1.03 \u0026plusmn; 0.12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026lt;0.001*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eHbA1c (% of total Hb)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e6.51 \u0026plusmn; 2.41\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e2.67 \u0026plusmn; 0.77\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026lt;0.001*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eLiver Function Tests\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eALT (U/L)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e24.59 \u0026plusmn; 16.81\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e18.42 \u0026plusmn; 11.79\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.046*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eAST (U/L)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e22.35 \u0026plusmn; 9.51\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e20.71 \u0026plusmn; 14.05\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.192\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eAlbumin (g/L)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e40.10 \u0026plusmn; 12.48\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e38.21 \u0026plusmn; 14.79\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.746\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eTotal Bilirubin (mg/dL)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e5.01 \u0026plusmn; 4.78\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e5.08 \u0026plusmn; 4.90\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.996\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eDirect Bilirubin (mg/dL)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e2.07 \u0026plusmn; 2.24\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1.73 \u0026plusmn; 1.71\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.631\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eGGT (U/L)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e65.79 \u0026plusmn; 40.68\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e25.60 \u0026plusmn; 17.94\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026lt;0.001*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eALP (U/L)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e93.75 \u0026plusmn; 34.80\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e69.55 \u0026plusmn; 18.99\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026lt;0.001*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eLipid Profile\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eTotal Cholesterol (mg/dL)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e186.93 \u0026plusmn; 37.31\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e121.12 \u0026plusmn; 27.05\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026lt;0.001*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eTriglycerides (mg/dL)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e155.58 \u0026plusmn; 69.09\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e104.45 \u0026plusmn; 26.19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.001*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eHDL Cholesterol (mg/dL)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e48.34 \u0026plusmn; 14.53\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e60.48 \u0026plusmn; 9.77\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026lt;0.001*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eInflammatory Markers\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eCRP (mg/L)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e2.62 \u0026plusmn; 1.23\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1.64 \u0026plusmn; 1.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.003*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eLiver Stiffness (Fibroscan)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eF0, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e38 (54.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e20 (100.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.008*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eF1, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e20 (28.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0 (0.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eF2, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e5 (7.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0 (0.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eF3, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e5 (7.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0 (0.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eF4, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e2 (2.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0 (0.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eSteatosis (CAP Score)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eS0, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0 (0.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e20 (100.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026lt;0.001*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eS2, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e34 (48.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0 (0.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eS3, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e30 (42.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0 (0.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eS4, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e6 (8.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0 (0.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eViral Markers\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eHBsAg positive, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e13 (18.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0 (0.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.039*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eHCV Ab positive, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e4 (5.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0 (0.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.278\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003ePancreatic Function\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eAmylase (U/L)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e76.94 \u0026plusmn; 13.08\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e68.85 \u0026plusmn; 12.01\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.732\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eFecal Pancreatic Elastase (\u0026micro;g/g)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e180.38 \u0026plusmn; 26.80\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e240.12 \u0026plusmn; 43.39\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026lt;0.001*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\"\u003e\n \u003cp\u003eContinuous data are presented as Mean \u0026plusmn; SD Categorical data are presented as number (percentage) *p\u0026lt;0.05 statistically significant differences\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eAbbreviation:\u003c/strong\u003e MAFLD: Metabolic Associated Fatty Liver Disease; HOMA-IR: Homeostatic Model Assessment of Insulin Resistance; HbA1c: Glycated Hemoglobin; ALT: Alanine Aminotransferase; AST: Aspartate Aminotransferase; GGT: Gamma-Glutamyl Transferase; ALP: Alkaline Phosphatase; HDL: High-Density Lipoprotein; CRP: C-Reactive Protein; CAP: Controlled Attenuation Parameter; HBsAg: Hepatitis B Surface Antigen; HCV Ab: Hepatitis C Virus Antibody\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2: Comprehensive Assessment of MAFLD Patients with and without PEI\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"3\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eParameter\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eMAFLD with PEI (n=59)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eMAFLD without PEI (n=11)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003ep-value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eDemographics\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eAge (years)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e43.05 \u0026plusmn; 10.59\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e43.27 \u0026plusmn; 13.09\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.796\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eSex (male), n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e44 (74.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e8 (72.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.898\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eComorbidities, n (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eAny comorbidity\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e26 (44.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e2 (18.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.108\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eDiabetes Mellitus\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e18 (30.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e2 (18.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.406\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eHypertension\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e14 (23.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1 (9.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.277\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eAnthropometric Measurements\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eWeight (kg)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e90.66 \u0026plusmn; 15.75\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e93.36 \u0026plusmn; 11.65\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.370\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eBMI (kg/m\u0026sup2;)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e33.64 \u0026plusmn; 5.37\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e33.47 \u0026plusmn; 4.30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.961\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eWaist circumference (cm)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e115.73 \u0026plusmn; 9.70\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e110.36 \u0026plusmn; 5.95\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.043*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eMetabolic Parameters\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eHOMA-IR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e3.99 \u0026plusmn; 2.41\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e3.59 \u0026plusmn; 1.96\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.392\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eHbA1c (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e7.65 \u0026plusmn; 2.47\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e5.78 \u0026plusmn; 2.13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.042*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eLiver Function Tests\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eALT (U/L)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e25.39 \u0026plusmn; 16.79\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e21.65 \u0026plusmn; 17.62\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.144\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eGGT (U/L)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e64.02 \u0026plusmn; 40.37\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e78.91 \u0026plusmn; 41.99\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.211\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eALP (U/L)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e95.69 \u0026plusmn; 34.84\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e84.36 \u0026plusmn; 36.15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.093\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eLipid Profile\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eTotal Cholesterol (mg/dL)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e190.29 \u0026plusmn; 38.19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e172.73 \u0026plusmn; 28.58\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.133\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eTriglycerides (mg/dL)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e151.78 \u0026plusmn; 62.29\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e177.36 \u0026plusmn; 101.36\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.606\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eHDL-C (mg/dL)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e39.51 \u0026plusmn; 15.22\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e42.72 \u0026plusmn; 9.31\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.305\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eInflammatory Markers\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eCRP (mg/L)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e2.70 \u0026plusmn; 1.26\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e2.12 \u0026plusmn; 0.87\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.143\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eLiver Stiffness (Fibroscan)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eF0, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e33 (55.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e5 (45.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.406\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eF1-F4, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e26 (44.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e6 (54.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eSteatosis (CAP Score)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eS0, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0 (0.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0 (0.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.458\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eS2-S4, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e59 (100.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e11 (100.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eViral Markers\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eHBsAg positive, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e10 (16.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e3 (27.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.419\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eHCV Ab positive, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e4 (6.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0 (0.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.374\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003ePancreatic Function\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eAmylase (U/L)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e79.37 \u0026plusmn; 13.14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e82.45 \u0026plusmn; 9.35\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.146\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eFecal Pancreatic Elastase (\u0026micro;g/g)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e172.93 \u0026plusmn; 21.94\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e220.94 \u0026plusmn; 9.71\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026lt;0.001*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\"\u003e\n \u003cp\u003eContinuous data are presented as Mean \u0026plusmn; SD Categorical data are presented as number (percentage) *p\u0026lt;0.05 statistically significant differences\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eAbbreviation:\u003c/strong\u003e MAFLD: Metabolic Associated Fatty Liver Disease; PEI: Pancreatic Exocrine Insufficiency; BMI: Body Mass Index; HOMA-IR: Homeostatic Model Assessment of Insulin Resistance; HbA1c: Glycated Hemoglobin; ALT: Alanine Aminotransferase; GGT: Gamma-Glutamyl Transferase; ALP: Alkaline Phosphatase; HDL-C: High-Density Lipoprotein Cholesterol; CRP: C-Reactive Protein; CAP: Controlled Attenuation Parameter; HBsAg: Hepatitis B Surface Antigen; HCV Ab: Hepatitis C Virus Antibody\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 3: \u0026nbsp; Univariate and multivariate Regression Analysis for Predictors of PEI in Patients\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"676\" class=\"fr-table-selection-hover\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 184px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cstrong\u003e\u003cspan dir=\"LTR\"\u003eVariable\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 246px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cstrong\u003e\u003cspan dir=\"LTR\"\u003eUnivariate\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 246px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cstrong\u003e\u003cspan dir=\"LTR\"\u003eMultivariate\u0026nbsp;\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 72px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eP value\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eOdds ratio\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e95% C.I.\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 72px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cstrong\u003e\u003cspan dir=\"LTR\"\u003eP value\u0026nbsp;\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cstrong\u003e\u003cspan dir=\"LTR\"\u003eOdds ratio\u0026nbsp;\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cstrong\u003e\u003cspan dir=\"LTR\"\u003e95% C.I.\u0026nbsp;\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 184px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAge (years)\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 72px;\"\u003e\n \u003cp\u003e0.853\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e0.996\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e0.955 - 1.039\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 72px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 184px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eGender (Male)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 72px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;0.001*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e13.091\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e3.849 - 23.395\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 72px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003e0.781\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003e1.194\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 114px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003e0.342 - 4.168\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 184px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMid-Arm Circumference (cm)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 72px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;0.001*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e1.161\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e1.078 - 1.252\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 72px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003e0.669\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003e0.964\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 114px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003e0.817 - 1.139\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 184px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eGlycated Hemoglobin (% of total hemoglobin)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 72px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;0.001*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e1.740\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e1.311 - 2.310\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 72px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003e0.109\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003e1.315\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 114px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003e0.941 - 1.838\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 184px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMAFLD\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 72px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;0.001*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e16.091\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e4.849 - 24.395\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 72px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cstrong\u003e\u003cspan dir=\"LTR\"\u003e0.008*\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003e10.220\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 114px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003e4.474 - 12.256\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eAbbreviation, PEI; pancreatic exocrine insufficiency\u003c/p\u003e\n\u003cp\u003e*p \u0026lt; 0.05 indicates statistical significance.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 4: Comparison of MAFLD Patients with Diabetes versus without Diabetes Regarding PEI\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"3\" cellpadding=\"0\"\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eParameter\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eMAFLD with DM (n=20)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eMAFLD without DM (n=50)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003ep-value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003ePEI Prevalence\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003ePEI present, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e18 (90.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e41 (82.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.039*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003ePEI absent, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e2 (10.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e9 (18.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003ePancreatic Function\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eFecal Pancreatic Elastase (\u0026micro;g/g)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e163.47 \u0026plusmn; 19.83\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e187.54 \u0026plusmn; 26.92\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.001*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eAmylase (U/L)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e81.22 \u0026plusmn; 11.95\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e75.37 \u0026plusmn; 13.14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.084\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eMetabolic Parameters\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eHOMA-IR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e5.68 \u0026plusmn; 2.27\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e3.21 \u0026plusmn; 1.98\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026lt;0.001*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eHbA1c (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e9.65 \u0026plusmn; 2.24\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e5.29 \u0026plusmn; 0.87\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026lt;0.001*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eBMI (kg/m\u0026sup2;)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e34.75 \u0026plusmn; 5.43\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e33.26 \u0026plusmn; 5.07\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.277\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eWaist circumference (cm)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e116.35 \u0026plusmn; 9.78\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e109.90 \u0026plusmn; 8.97\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.011*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eLiver Assessment\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eAdvanced fibrosis (\u0026ge;F2), n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e7 (35.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e5 (10.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.009*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eSevere steatosis (S3-S4), n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e14 (70.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e22 (44.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.046*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eALT (U/L)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e27.43 \u0026plusmn; 18.26\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e23.51 \u0026plusmn; 16.28\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.382\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eGGT (U/L)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e74.89 \u0026plusmn; 43.51\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e62.13 \u0026plusmn; 39.15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.037*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\"\u003e\n \u003cp\u003eContinuous data are presented as Mean \u0026plusmn; SD Categorical data are presented as number (percentage) *p\u0026lt;0.05 statistically significant differences\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eAbbreviation\u003c/strong\u003e: MAFLD: Metabolic Associated Fatty Liver Disease; DM: Diabetes Mellitus; PEI: Pancreatic Exocrine Insufficiency; HOMA-IR: Homeostatic Model Assessment of Insulin Resistance; HbA1c: Glycated Hemoglobin; BMI: Body Mass Index; ALT: Alanine Aminotransferase; GGT: Gamma-Glutamyl Transferase\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Pancreatic exocrine insufficiency, MAFLD, diabetes mellitus, fecal elastase, metabolic dysfunction","lastPublishedDoi":"10.21203/rs.3.rs-7443549/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7443549/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e\u003cp\u003ePancreatic exocrine insufficiency (PEI) is increasingly recognized in patients with metabolic-associated fatty liver disease (MAFLD), particularly those with metabolic comorbidities such as diabetes mellitus (DM). However, limited data exist on the prevalence and clinical implications of PEI in MAFLD.\u003c/p\u003e\u003ch2\u003ePatients and Methods:\u003c/h2\u003e\u003cp\u003eThis prospective, case-control study included 70 MAFLD patients and 20 healthy controls. All participants underwent clinical assessment, anthropometric measurements, laboratory testing, liver imaging (Fibroscan with CAP score), and fecal pancreatic elastase-1 (FPE-1) testing. PEI was defined as FPE-1\u0026thinsp;\u0026lt;\u0026thinsp;200 \u0026micro;g/g. Subgroup analyses were performed comparing MAFLD patients with and without PEI, and with and without diabetes. Logistic regression identified independent predictors of PEI.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003eMAFLD patients had significantly lower FPE-1 levels compared to controls (180.38\u0026thinsp;\u0026plusmn;\u0026thinsp;26.80 \u0026micro;g/g vs. 240.12\u0026thinsp;\u0026plusmn;\u0026thinsp;43.39 \u0026micro;g/g, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). PEI was present in 84.3% of MAFLD patients. Patients with PEI had significantly higher HbA1c (7.65\u0026thinsp;\u0026plusmn;\u0026thinsp;2.47% vs. 5.78\u0026thinsp;\u0026plusmn;\u0026thinsp;2.13%, p\u0026thinsp;=\u0026thinsp;0.042) and waist circumference (115.73\u0026thinsp;\u0026plusmn;\u0026thinsp;9.70 cm vs. 110.36\u0026thinsp;\u0026plusmn;\u0026thinsp;5.95 cm, p\u0026thinsp;=\u0026thinsp;0.043). Among MAFLD patients with diabetes, PEI prevalence was higher (90.0% vs. 82.0%, p\u0026thinsp;=\u0026thinsp;0.039), and FPE-1 levels were significantly lower (163.47\u0026thinsp;\u0026plusmn;\u0026thinsp;19.83 \u0026micro;g/g vs. 187.54\u0026thinsp;\u0026plusmn;\u0026thinsp;26.92 \u0026micro;g/g, p\u0026thinsp;=\u0026thinsp;0.001). These patients also showed more severe metabolic derangements and advanced liver disease. Multivariate analysis identified MAFLD as an independent predictor of PEI (OR\u0026thinsp;=\u0026thinsp;10.220, p\u0026thinsp;=\u0026thinsp;0.008).\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e\u003cp\u003ePEI is highly prevalent in MAFLD patients, particularly those with diabetes and poor metabolic control. Fecal elastase testing may be a useful tool for early identification of PEI in this population.\u003c/p\u003e","manuscriptTitle":"Evidence of Pancreas Exocrine Insufficiency in Patients with Metabolic Associated Fatty Liver Disease Patients","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-09-11 10:13:31","doi":"10.21203/rs.3.rs-7443549/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"c2484e95-ec8a-4a6c-81a7-704cfe918a97","owner":[],"postedDate":"September 11th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-01-19T17:06:15+00:00","versionOfRecord":{"articleIdentity":"rs-7443549","link":"https://doi.org/10.1186/s43066-025-00474-4","journal":{"identity":"egyptian-liver-journal","isVorOnly":false,"title":"Egyptian Liver Journal"},"publishedOn":"2026-01-13 16:29:46","publishedOnDateReadable":"January 13th, 2026"},"versionCreatedAt":"2025-09-11 10:13:31","video":"","vorDoi":"10.1186/s43066-025-00474-4","vorDoiUrl":"https://doi.org/10.1186/s43066-025-00474-4","workflowStages":[]},"version":"v1","identity":"rs-7443549","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7443549","identity":"rs-7443549","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}