Association between Helicobacter pylori infection and the severity of metabolic dysfunction-associated fatty liver disease: a large-scale cross-sectional study

Association between Helicobacter pylori infection and the severity of metabolic dysfunction-associated fatty liver disease: a large-scale cross-sectional study | 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 Association between Helicobacter pylori infection and the severity of metabolic dysfunction-associated fatty liver disease: a large-scale cross-sectional study Simin Zhang, Jiao Li, Cui Deng, Sheng Zheng This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8916798/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 6 You are reading this latest preprint version Abstract Background The relationship between Helicobacter pylori (H. pylori) infection and metabolic dysfunction-associated fatty liver disease (MAFLD) has garnered increasing attention; however, its correlation with disease severity remains inadequately characterized. This study aimed to investigate the association between H. pylori infection and the severity of MAFLD in a large Chinese cohort. Methods This cross-sectional study consecutively enrolled 2,610 patients diagnosed with MAFLD at the Department of Gastroenterology, The Third People's Hospital of Yunnan Province, between January 2023 and June 2025. Patients were stratified into mild, moderate, and severe MAFLD groups based on abdominal ultrasound findings and further categorized according to H. pylori status determined by ¹³C/¹⁴C-urea breath test. Clinical characteristics, metabolic profiles, and laboratory parameters were compared. Multivariate logistic regression analysis was employed to identify independent risk factors for MAFLD progression. Results Among the 2,610 participants (71.9% male; mean age 47.8 ± 11.6 years), the overall prevalence of H. pylori infection was 28.2%. Patients in the H. pylori-positive group exhibited significantly higher levels of fasting glucose (GLU), white blood cell count (WBC), and neutrophil count (NE) compared to the negative group (all P < 0.05). In subgroup analyses stratified by MAFLD severity, aspartate aminotransferase (AST) levels were consistently higher in H. pylori-positive patients across all severity grades (all P < 0.05). H. pylori positivity was associated with elevated WBC and lymphocyte (LYM) counts in the mild MAFLD group; higher alanine aminotransferase (ALT) and total cholesterol (TC) in the moderate group; and higher ALT and LYM in the severe group (all P < 0.05). A strong positive correlation was observed between H. pylori infection and MAFLD severity (*r* = 0.638, P < 0.001). Multivariate logistic regression confirmed H. pylori infection as an independent risk factor for severe MAFLD (mild vs. severe: OR = 297.00, 95% CI: 92.13–957.48, P < 0.001; moderate vs. severe: OR = 21.57, 95% CI: 5.91–78.75, P < 0.001). High-density lipoprotein cholesterol (HDL-C) and TC were also independently associated with MAFLD severity. Conclusions H. pylori infection is significantly and independently associated with the severity of MAFLD. The elevated GLU, WBC, and NE levels in infected patients suggest that H. pylori may exacerbate MAFLD through mechanisms involving glycemic dysregulation and low-grade systemic inflammation. Screening for H. pylori infection may have clinical utility in the risk stratification of patients with MAFLD. Metabolic dysfunction-associated fatty liver disease Non-alcoholic fatty liver disease Helicobacter pylori Insulin resistance Disease severity Inflammation Background Metabolic dysfunction-associated fatty liver disease (MAFLD), formerly termed non-alcoholic fatty liver disease (NAFLD), is defined as hepatic steatosis in the presence of overweight/obesity, type 2 diabetes mellitus (T2DM), or evidence of metabolic dysregulation [ 1 ]. It has emerged as the most prevalent chronic liver condition globally, affecting approximately 30% of the adult population and imposing a substantial burden of morbidity and mortality related to cirrhosis, hepatocellular carcinoma, and cardiovascular disease [ 2 , 3 ]. The pathogenesis of MAFLD is complex and multifactorial, involving insulin resistance (IR), adipose tissue dysfunction, chronic low-grade inflammation, oxidative stress, and genetic predisposition [ 4 , 5 ]. Helicobacter pylori (H. pylori) is a Gram-negative bacterium that colonizes the gastric mucosa of nearly half the world's population [ 6 ]. Beyond its well-established role in gastritis, peptic ulcer disease, and gastric malignancy, a growing body of evidence suggests that H. pylori infection may have significant extra-gastric manifestations, including an impact on metabolic disorders [ 7 , 8 ]. Proposed mechanisms linking H. pylori to metabolic diseases include the induction of a chronic, low-grade systemic inflammatory state, alteration of gut microbiota and intestinal barrier function, and modulation of host metabolic pathways, all of which could contribute to IR and hepatic steatosis [ 9 , 10 ]. Recent epidemiological studies and meta-analyses have suggested a positive association between H. pylori infection and the presence of MAFLD [ 11 , 12 ]. A comprehensive meta-analysis by Mantovani et al. demonstrated that H. pylori infection was associated with a modest but significant increase in both prevalent and incident MAFLD [ 13 ]. A systematic review by Osula and Qazi further confirmed that H. pylori-positive individuals exhibit higher rates of hepatic steatosis and elevated liver enzymes [ 14 ]. Furthermore, a longitudinal cohort study by Kim et al. provided evidence that persistently active H. pylori infection, rather than past infection, specifically increased the risk of developing MAFLD, suggesting a potential causal link and a window for intervention through eradication [ 15 ]. Despite this accumulating evidence, the specific relationship between H. pylori infection and the severity of MAFLD remains poorly characterized [ 13 , 15 ]. Most existing studies have focused on the presence or absence of the disease, with limited data on whether infection influences the progression from mild steatosis to more advanced stages. Understanding this relationship could have significant clinical implications, potentially identifying H. pylori as a modifiable risk factor in the management of MAFLD [ 16 , 17 ]. Therefore, this large-scale cross-sectional study aimed to investigate the association between H. pylori infection and the severity of MAFLD in a Chinese population, while also exploring its relationship with key metabolic and inflammatory parameters. Methods Study population This cross-sectional study retrospectively reviewed medical records of individuals who underwent health examinations at the Department of Gastroenterology, The Third People's Hospital of Yunnan Province, between January 2023 and June 2025. Consecutive patients diagnosed with MAFLD based on abdominal ultrasound and who had undergone ¹³C/¹⁴C-urea breath testing for H. pylori were considered for inclusion. A total of 2,610 patients with complete clinical and laboratory data were enrolled. The study protocol was approved by the Ethics Committee of The Third People's Hospital of Yunnan Province (Approval No. 2023-021) and was conducted in accordance with the principles of the Declaration of Helsinki. Due to the retrospective nature of the study, the requirement for informed consent was waived by the ethics committee. Inclusion and exclusion criteria The diagnosis of MAFLD was established according to the 2024 Chinese guidelines for the prevention and treatment of metabolic dysfunction-associated fatty liver disease [1]. Inclusion criteria were: (1) age 18–75 years; (2) diagnosis of MAFLD by abdominal ultrasound; (3) completion of ¹³C/¹⁴C-urea breath test; and (4) availability of complete clinical and laboratory data. Exclusion criteria were as follows [18]: (1) significant alcohol consumption (≥40 g/day for men, ≥20 g/day for women for >5 years, or binge drinking >80 g/day within the past 2 weeks); (2) other chronic liver diseases (e.g., viral hepatitis, autoimmune hepatitis, drug-induced liver injury, Wilson's disease); (3) history of upper gastrointestinal bleeding; (4) pyloric obstruction; (5) prior gastric surgery; (6) malignancy or current anti-cancer therapy; (7) use of bismuth, antibiotics, proton pump inhibitors, or H₂-receptor antagonists within 4 weeks prior to H. pylori testing; (8) active severe infection or systemic inflammatory disease; (9) severe mental or neurological disorders; (10) pregnancy or lactation; (11) missing essential clinical data; (12) use of steatogenic medications (e.g., corticosteroids, methotrexate, tamoxifen); and (13) consumption of foods potentially inhibiting H. pylori (e.g., lactobacillus-containing drinks, garlic, tea, ginger) within 2 weeks prior to testing. Data collection Demographic and clinical data, including age, sex, smoking history, alcohol consumption history, and medical history (hypertension, diabetes, cardiovascular disease), were collected from medical records. Anthropometric measurements, including height, weight, body mass index (BMI, calculated as weight in kilograms divided by height in meters squared), systolic blood pressure (SBP), and diastolic blood pressure (DBP), were obtained from the health examination database. Blood samples were collected after an overnight fast (8–12 hours) and analyzed using standardized automated analyzers. The following laboratory parameters were recorded: Liver function: alanine aminotransferase (ALT), aspartate aminotransferase (AST), total bilirubin (TBIL), direct bilirubin (DBIL) Glucose metabolism: fasting plasma glucose (GLU), glycated hemoglobin (HbA1c) Lipid profile: total cholesterol (TC), triglycerides (TG), high-density lipoprotein cholesterol (HDL-C), low-density lipoprotein cholesterol (LDL-C) Inflammatory markers: white blood cell count (WBC), neutrophil count (NE), lymphocyte count (LYM) H. pylori detection H. pylori status was determined using the ¹³C-urea breath test (HCBT-01, Headway, China) or the ¹⁴C-urea breath test (HUBP-01P, Headway, China). The test was considered positive if the delta over baseline (DOB) value was ≥4.0‰ for the ¹³C-UBT or if the disintegrations per minute (dpm) value was ≥100 for the ¹⁴C-UBT. Diagnosis and grading of MAFLD Abdominal ultrasound examinations were performed by experienced radiologists using a Philips EPIQ 7 ultrasound system. The diagnosis of MAFLD was based on the presence of characteristic ultrasonographic findings: diffuse hyperechogenicity of the liver parenchyma (bright liver), increased echo texture compared to the renal parenchyma, vascular blurring, and deep attenuation. The severity of hepatic steatosis was graded semi-quantitatively according to established criteria [19]: Mild: Slight diffuse increase in hepatic echogenicity, with normal visualization of the diaphragm and intrahepatic vessel borders. Moderate: Moderate diffuse increase in hepatic echogenicity, with slightly impaired visualization of the diaphragm and intrahepatic vessels. Severe: Marked increase in hepatic echogenicity, with poor or non-visualization of the diaphragm, intrahepatic vessels, and posterior portion of the right hepatic lobe. Statistical analysis Statistical analyses were performed using SPSS software version 27.0 (IBM Corp., Armonk, NY, USA). Continuous variables are presented as mean ± standard deviation (SD). Comparisons between two groups were performed using the independent samples t-test. Comparisons among multiple groups were performed using one-way analysis of variance (ANOVA) followed by the least significant difference (LSD) post-hoc test. Categorical variables are presented as frequencies and percentages (%), and group comparisons were made using the chi-square (χ²) test or Fisher's exact test, as appropriate. The correlation between H. pylori infection and MAFLD severity was assessed using Spearman's rank correlation coefficient. To identify independent risk factors for MAFLD severity, multivariate logistic regression analysis was performed. Variables with a P-value < 0.10 in univariate analysis, along with clinically relevant factors, were entered into the regression models. Odds ratios (ORs) and their 95% confidence intervals (CIs) were calculated. All statistical tests were two-tailed, and a P-value < 0.05 was considered statistically significant. Results Baseline characteristics of the study population A total of 2,610 patients with MAFLD were included in this study. The cohort comprised 1,876 (71.9%) men and 734 (28.1%) women, with a mean age of 47.8 ± 11.6 years. Based on ultrasound findings, 1,797 (68.9%) patients were classified as having mild MAFLD, 191 (7.3%) as moderate, and 622 (23.8%) as severe. The overall prevalence of H. pylori infection was 28.2% (736/2,610), with a similar male-to-female ratio between the H. pylori-positive and -negative groups (P > 0.05). Baseline characteristics, including age, SBP, DBP, and BMI, were comparable across different MAFLD severity groups and between H. pylori-positive and -negative groups (all P > 0.05), as shown in Table 1 . Table 1 Baseline characteristics of the study population Characteristic Mild MAFLD (n = 1,797) Moderate MAFLD (n = 191) Severe MAFLD (n = 622) P value Hp (+) (n = 736) Hp (-) (n = 1,874) P value Sex, n (%) 0.777 0.959 Male 1,288 (49.4) 144 (5.5) 444 (17.0) 529 (20.3) 1,347 (51.6) Female 509 (19.5) 47 (1.8) 178 (6.8) 207 (7.9) 527 (20.2) Age (years) 47.8 ± 11.6 49.4 ± 11.3 47.6 ± 11.6 0.403 48.9 ± 11.7 47.5 ± 11.5 0.133 SBP (mmHg) 132.0 ± 15.5 133.6 ± 12.5 135.0 ± 17.0 0.073 133.3 ± 16.6 132.7 ± 15.3 0.856 DBP (mmHg) 82.5 ± 10.9 83.8 ± 8.3 83.6 ± 11.6 0.181 82.6 ± 11.4 82.9 ± 10.7 0.368 BMI (kg/m²) 27.5 ± 4.3 27.4 ± 2.7 27.9 ± 3.9 0.676 27.2 ± 3.6 27.7 ± 4.3 0.080 Hp (+): H. pylori-positive; Hp (-): H. pylori-negative; Data are presented as mean ± SD unless otherwise indicated. Comparison of metabolic and laboratory parameters according to H. pylori status The prevalence of metabolic abnormalities (overweight, hyperglycemia, dyslipidemia, and hypertension) did not differ significantly between the H. pylori-positive and -negative groups (all P > 0.05, Table 2 ). However, as shown in Table 3 , patients in the H. pylori-positive group exhibited significantly higher levels of GLU (6.06 ± 2.10 vs. 5.76 ± 1.63 mmol/L, P = 0.029), WBC (6.46 ± 1.41 vs. 6.25 ± 1.41 ×10⁹/L, P = 0.032), and NE (3.75 ± 1.10 vs. 3.55 ± 1.07 ×10⁹/L, P = 0.005) compared to the negative group. No significant differences were observed in liver enzymes, bilirubin, HbA1c, or other lipid parameters between the two groups. Table 2 Prevalence of metabolic abnormalities by H. pylori status Parameter Hp (+) (n = 736) Hp (-) (n = 1,874) χ² P value Overweight (BMI ≥ 24 kg/m²) 388 (52.7) 1,031 (55.0) 3.572 0.059 Hyperglycemia 179 (24.3) 398 (21.2) 1.261 0.263 Dyslipidemia 571 (77.6) 1,422 (75.9) 0.368 0.546 Hypertension 271 (36.8) 592 (31.6) 2.838 0.093 Table 3 Laboratory parameters by H. pylori status Parameter Hp (+) (n = 736) Hp (-) (n = 1,874) P value Liver function AST (U/L) 26.7 ± 16.6 26.4 ± 18.8 0.769 ALT (U/L) 37.4 ± 30.5 35.3 ± 27.4 0.153 TBIL (µmol/L) 13.9 ± 5.2 14.0 ± 5.6 0.960 DBIL (µmol/L) 3.7 ± 1.4 3.7 ± 1.6 0.640 Glucose metabolism GLU (mmol/L) 6.06 ± 2.10 5.76 ± 1.63 0.029 HbA1c (%) 6.2 ± 1.2 6.0 ± 1.0 0.099 Lipid profile TC (mmol/L) 5.4 ± 3.0 5.4 ± 3.2 0.305 TG (mmol/L) 2.1 ± 1.7 2.5 ± 6.4 0.228 HDL-C (mmol/L) 1.36 ± 0.32 1.34 ± 0.29 0.742 LDL-C (mmol/L) 3.00 ± 0.70 2.96 ± 0.69 0.443 Inflammatory markers WBC (×10⁹/L) 6.46 ± 1.41 6.25 ± 1.41 0.032 NE (×10⁹/L) 3.75 ± 1.10 3.55 ± 1.07 0.005 LYM (×10⁹/L) 2.16 ± 0.58 2.16 ± 0.55 0.894 Data are presented as mean ± SD. Bold values indicate statistical significance (P < 0.05). Stratified analysis by MAFLD severity The impact of H. pylori infection on metabolic and laboratory parameters was further analyzed within each MAFLD severity subgroup. In the mild MAFLD group, the prevalence of hypertension was significantly higher in H. pylori-positive patients compared to negative patients (44.1% vs. 31.4%, P = 0.027, Table 4 ). No other significant differences in metabolic comorbidities were observed within the moderate and severe groups. Table 4 Prevalence of metabolic abnormalities stratified by MAFLD severity and H. pylori status Parameter Mild MAFLD (n = 1,797) Moderate MAFLD (n = 191) Severe MAFLD (n = 622) Hp+ (n = 177) Hp- (n = 1620) P Hp+ (n = 64) Hp- (n = 127) P Hp+ (n = 495) Hp- (n = 127) P Overweight 87 (49.2) 886 (54.7) 0.087 40 (62.5) 73 (57.5) 0.638 276 (55.8) 58 (45.7) 0.061 Hyperglycemia 47 (26.6) 330 (20.4) 0.189 19 (29.7) 16 (12.6) 0.075 130 (26.3) 31 (24.4) 0.777 Dyslipidemia 125 (70.6) 1,217 (75.1) 0.397 54 (84.4) 106 (83.5) 1.000 387 (78.2) 101 (79.5) 0.856 Hypertension 78 (44.1) 508 (31.4) 0.027 21 (32.8) 38 (29.9) 0.774 175 (35.4) 41 (32.3) 0.665 Table 5 presents the laboratory parameters stratified by MAFLD severity and H. pylori status. Notably, AST levels were consistently and significantly higher in H. pylori-positive patients across all three MAFLD severity grades (all P < 0.05). ALT levels were significantly higher in H. pylori-positive patients in both the moderate and severe MAFLD groups (both P < 0.01). In the mild MAFLD group, H. pylori-positive patients had significantly higher WBC and LYM counts. In the moderate group, they had significantly higher TC levels. In the severe group, they had significantly higher LYM counts. Table 5 Laboratory parameters stratified by MAFLD severity and H. pylori status Parameter Mild MAFLD (n = 1,797) Moderate MAFLD (n = 191) Severe MAFLD (n = 622) Hp+ (n = 177) Hp- (n = 1620) P Hp+ (n = 64) Hp- (n = 127) P Hp+ (n = 495) Hp- (n = 127) P AST (U/L) 27.4 ± 14.6 24.6 ± 16.7 0.026 20.9 ± 4.5 27.8 ± 12.2 0.010 26.5 ± 16.4 29.5 ± 18.2 0.004 ALT (U/L) 36.5 ± 25.9 34.6 ± 25.8 0.145 25.7 ± 7.9 40.0 ± 22.0 0.007 37.6 ± 32.8 51.7 ± 46.2 < 0.001 WBC (×10⁹/L) 6.51 ± 1.40 6.14 ± 1.46 0.020 6.65 ± 1.47 6.46 ± 1.05 0.223 6.40 ± 1.45 6.32 ± 1.22 0.367 LYM (×10⁹/L) 2.26 ± 0.60 2.08 ± 0.55 0.015 2.30 ± 0.59 2.25 ± 0.55 0.407 2.18 ± 0.56 2.24 ± 0.45 0.019 TC (mmol/L) 5.03 ± 1.24 5.50 ± 4.29 0.755 5.08 ± 0.91 5.40 ± 1.35 0.038 5.40 ± 0.90 4.97 ± 1.07 0.262 GLU (mmol/L) 6.18 ± 1.60 6.07 ± 2.04 0.226 6.02 ± 1.61 5.46 ± 0.86 0.662 6.22 ± 2.24 5.73 ± 0.91 0.439 Data are presented as mean ± SD. Bold values indicate statistical significance (P < 0.05). Correlation and regression analysis for MAFLD severity Spearman rank correlation analysis revealed a strong positive correlation between H. pylori infection and the severity of MAFLD (*r* = 0.638, P < 0.001). The prevalence of H. pylori infection increased progressively with MAFLD severity: 9.9% in the mild group, 33.5% in the moderate group, and 79.6% in the severe group (Table 6 ). Table 6 Correlation between MAFLD severity and H. pylori infection Severity N H. pylori infection n (%) r P value Mild 1797 177 (9.9) Moderate 191 64 (33.5) 0.638 < 0.001 Severe 622 495 (79.6) Total 2610 736 (28.2) Multivariate logistic regression analysis was performed to identify independent risk factors for advanced MAFLD. In the comparison between mild and severe MAFLD (Table 7 ), H. pylori infection (OR = 297.00, 95% CI: 92.13–957.48, P < 0.001), HDL-C (OR = 25.53, 95% CI: 4.47–145.87, P < 0.001), and TC (OR = 0.49, 95% CI: 0.28–0.87, P = 0.014) were significantly associated with disease severity. In the comparison between moderate and severe MAFLD (Table 8 ), H. pylori infection remained a powerful independent risk factor (OR = 21.57, 95% CI: 5.91–78.75, P < 0.001). Table 7 Multivariate logistic regression analysis for risk factors associated with severe vs. mild MAFLD Variable B S.E. Wald OR (95% CI) P value H. pylori infection 5.694 0.597 90.887 297.00 (92.13–957.48) < 0.001 HDL-C 3.240 0.889 13.271 25.53 (4.47–145.87) < 0.001 TC −0.707 0.289 5.990 0.49 (0.28–0.87) 0.014 Age 0.029 0.027 1.166 1.03 (0.98–1.09) 0.280 BMI 0.381 0.419 0.827 1.46 (0.64–3.33) 0.363 Table 8 Multivariate logistic regression analysis for risk factors associated with severe vs. moderate MAFLD Variable B S.E. Wald OR (95% CI) P value H. pylori infection 3.071 0.661 21.605 21.57 (5.91–78.75) < 0.001 Age 0.050 0.032 2.455 1.05 (0.99–1.12) 0.117 BMI 0.342 0.434 0.620 1.41 (0.60–3.23) 0.431 Models were adjusted for age, sex, BMI, SBP, DBP, WBC, NE, LYM, GLU, HbA1c, ALT, AST, TBIL, DBIL, TG, HDL-C, and LDL-C. Only significant and key variables are shown. Discussion In this large, cross-sectional study of 2,610 Chinese patients with MAFLD, we identified a robust and independent association between H. pylori infection and the severity of hepatic steatosis. Our findings demonstrate that H. pylori positivity is not merely linked to the presence of MAFLD, but is strongly correlated with its progression from mild to moderate and severe forms. This association persisted after rigorous adjustment for a wide range of potential confounders, including age, sex, BMI, and key metabolic parameters, highlighting H. pylori infection as a potentially significant, and modifiable, risk factor in the natural history of MAFLD [ 13 , 15 ]. The prevalence of H. pylori infection in our MAFLD cohort (28.2%) is consistent with previous reports from Chinese populations [ 18 ]. The demographic profile of our patients, predominantly middle-aged males with elevated BMI, aligns with the known epidemiology of MAFLD [ 2 , 3 , 13 ]. Our key finding—that H. pylori infection is an independent risk factor for disease severity—corroborates and significantly extends the existing literature. While prior meta-analyses have confirmed a link between H. pylori and the prevalence of MAFLD/NAFLD [ 11 , 12 ], data on its relationship with disease severity have been limited. Our results are in agreement with a study by Chen et al., which suggested that H. pylori infection might increase the severity of NAFLD by promoting liver damage and metabolic syndrome [ 20 ]. More recently, a longitudinal study by Kim et al. provided compelling evidence that persistently active H. pylori infection, as confirmed by repeated biopsies, was associated with a significantly higher risk of incident MASLD, whereas eradicated infection was not [ 15 ]. This temporal relationship strengthens the argument for a causal role and underscores the potential clinical benefit of screening and treatment. Our cross-sectional data, showing a gradient of infection prevalence from 9.9% in mild to 79.6% in severe MAFLD, provides complementary evidence for a "dose-response" relationship between the infection and disease stage. The mechanistic pathways linking H. pylori to MAFLD progression are likely multifactorial and interconnected. Our observation of significantly higher fasting glucose, WBC, and neutrophil counts in H. pylori-positive patients offers clinical clues to these underlying mechanisms. First, chronic low-grade inflammation is a central tenet in the pathogenesis of both conditions [ 4 , 5 ]. H. pylori colonization of the gastric mucosa triggers a persistent local and systemic immune response, characterized by the release of pro-inflammatory cytokines such as tumor necrosis factor-alpha (TNF-α), interleukin-6 (IL-6), and interleukin-1β (IL-1β) [ 9 , 21 ]. These cytokines can enter the portal circulation and directly impact the liver, activating Kupffer cells and hepatic stellate cells, thereby promoting hepatic inflammation, insulin resistance, and fibrogenesis [ 22 ]. Our finding of elevated WBC and NE in infected patients, particularly in those with mild MAFLD, supports the presence of a heightened systemic inflammatory state that could initiate or exacerbate liver injury. The higher lymphocyte counts observed in infected patients with mild and severe disease may reflect an adaptive immune response to the infection that also cross-reacts with hepatic antigens. Second, insulin resistance (IR) is a hallmark of MAFLD. The systemic inflammation induced by H. pylori can impair insulin signaling by interfering with insulin receptor substrate (IRS) function, contributing to both hyperglycemia and de novo lipogenesis in the liver [ 10 , 23 ]. Our finding of significantly elevated fasting glucose in the H. pylori-positive group is consistent with this mechanism and with other studies [ 24 ]. A recent transcriptomic study by Chen et al. provided deeper mechanistic insight, demonstrating in a mouse model that H. pylori infection, particularly CagA+ strains, exacerbated high-fat diet-induced hepatic steatosis by regulating hepatic lipid metabolism pathways, including the PPAR pathway and fatty acid degradation [ 25 ]. This study elegantly shows that the infection can directly influence the liver's transcriptional program related to fat handling. Third, the gut-liver axis is increasingly recognized as a critical player in MAFLD. H. pylori infection can alter the composition of the gut microbiota (dysbiosis) and increase intestinal permeability [ 7 , 26 ]. This "leaky gut" facilitates the translocation of bacterial products, such as lipopolysaccharide (LPS), into the portal circulation, where they can activate Toll-like receptors (TLRs) on hepatic immune cells, fueling inflammation and steatosis [ 27 ]. Our data, showing higher liver enzymes (ALT, AST) in infected patients with more advanced disease, could be a downstream effect of this gut-liver axis disruption. A recent metabolomics study by Thing et al. demonstrated that plasma short-chain fatty acids, key metabolites derived from gut microbiota, are significantly associated with MASLD, further supporting the importance of the gut-liver axis in disease pathogenesis [ 28 ]. Regarding the relationship between H. pylori infection and lipid metabolism, we found no significant differences in TC, TG, HDL-C, or LDL-C levels between the H. pylori-positive and -negative groups overall. This finding aligns with the Mendelian randomization study by Liu et al., which found no causal link between H. pylori infection and lipid profiles [ 29 ]. Similarly, Elizalde et al. reported that H. pylori eradication had minimal impact on blood lipid levels [ 30 ]. However, our subgroup analysis revealed significantly higher TC levels in H. pylori-positive patients within the moderate MAFLD group, suggesting that the metabolic impact of infection may vary depending on disease stage. The inconsistent findings in the literature [ 31 ] may be attributable to differences in study populations, genetic backgrounds, dietary habits, and H. pylori strain virulence factors such as CagA and VacA status [ 32 , 33 ]. Clinical implications Our findings have potential clinical relevance. If confirmed by prospective studies, H. pylori screening could be integrated into the risk stratification of patients with MAFLD. Identifying H. pylori infection in a patient with mild MAFLD might identify an individual at higher risk for progression, who could benefit from closer monitoring and more aggressive lifestyle interventions. More importantly, our results, viewed in the context of longitudinal studies [ 15 ], raise the possibility that H. pylori eradication could be a beneficial adjunctive therapy [ 16 , 17 ]. A pilot study by Polyzos et al. suggested that eradication might improve non-invasive markers of fibrosis in patients with nonalcoholic steatohepatitis [ 34 ]. Large-scale, randomized controlled trials are now urgently needed to determine whether H. pylori eradication can halt or reverse the progression of MAFLD [ 13 , 28 ]. Strengths and limitations The strengths of this study include its large sample size, the use of the updated MAFLD definition, and the comprehensive collection of clinical, metabolic, and inflammatory parameters, which allowed for robust multivariate adjustment. The use of the urea breath test, the gold standard for diagnosing active H. pylori infection, is another key strength. However, several limitations must be acknowledged. First, the cross-sectional design precludes any inference of causality. While we demonstrate a strong association, we cannot determine whether H. pylori infection leads to more severe MAFLD, or whether patients with more severe MAFLD are more susceptible to H. pylori infection or its persistence. Second, the diagnosis and grading of MAFLD were based on abdominal ultrasound rather than the gold standard of liver biopsy or more quantitative methods like transient elastography (FibroScan). Ultrasound has limited sensitivity for detecting mild steatosis (< 30%) and cannot reliably assess fibrosis, which is the key determinant of long-term prognosis [ 35 ]. Third, as a single-center study in China, our findings may not be generalizable to other ethnic populations with different genetic backgrounds, dietary habits, and prevalences of H. pylori strains with varying virulence. We also lacked data on H. pylori strain typing (e.g., CagA status), which may be an important effect modifier [ 25 , 32 ]. Finally, residual confounding from unmeasured variables such as dietary patterns, physical activity, socioeconomic status, and detailed medication use cannot be completely ruled out [ 36 , 37 ]. Conclusions In conclusion, this large-scale study demonstrates that H. pylori infection is significantly and independently associated with the severity of MAFLD. The association is strong, graded, and persists after adjustment for key metabolic confounders. The elevated levels of inflammatory markers and fasting glucose in infected patients support the hypothesis that H. pylori may contribute to MAFLD progression through mechanisms involving chronic systemic inflammation and insulin resistance. These findings provide a strong rationale for prospective longitudinal studies and, importantly, for randomized controlled trials to investigate whether H. pylori eradication can serve as a novel, safe, and cost-effective strategy to mitigate disease progression and improve outcomes in the growing population of patients with MAFLD [ 13 , 15 , 28 ]. Abbreviations ALT: Alanine aminotransferase AST: Aspartate aminotransferase BMI: Body mass index CI: Confidence interval DBIL: Direct bilirubin DBP: Diastolic blood pressure GLU: Fasting plasma glucose HbA1c: Glycated hemoglobin HDL-C: High-density lipoprotein cholesterol H. pylori: Helicobacter pylori IR: Insulin resistance LDL-C: Low-density lipoprotein cholesterol LYM: Lymphocyte count MAFLD: Metabolic dysfunction-associated fatty liver disease MASLD: Metabolic dysfunction-associated steatotic liver disease NAFLD: Non-alcoholic fatty liver disease NE: Neutrophil count OR: Odds ratio SBP: Systolic blood pressure TBIL: Total bilirubin TC: Total cholesterol TG: Triglycerides T2DM: Type 2 diabetes mellitus WBC: White blood cell count Declarations Ethics approval and consent to participate This study was approved by the Ethics Committee of The Third People's Hospital of Yunnan Province and was performed in accordance with the ethical standards of the 1964 Declaration of Helsinki and its later amendments. Due to the retrospective nature of the study, the requirement for informed consent was waived by the ethics committee. Consent for publication Not applicable. Availability of data and materials The datasets generated and analyzed during the current study are not publicly available due to patient privacy and institutional data protection policies but are available from the corresponding author upon reasonable request. Competing interests The authors declare that they have no competing interests. Funding This work was supported by the Yunnan health training project of high level talents (D-2024049), the Yunnan Province high-level scientific and technological talents and innovation team selection special - young and middle-aged academic and technical leaders reserve talent project (No: 202405AC350067). The funding bodies played no role in the study design, data collection, analysis, interpretation, or manuscript writing. Authors' contributions Simin Zhang and Sheng Zheng contributed to the study conception and design. Jiao Li and Cui Deng were responsible for data collection and analysis. Simin Zhang drafted the manuscript. Simin Zhang and Sheng Zheng critically revised the manuscript for important intellectual content. All authors read and approved the final manuscript. Acknowledgements Not applicable. References Chinese Society of Hepatology, Chinese Medical Association. Zhonghua Gan Zang Bing Za Zhi. 2024;32(6):498–516. 10.3760/cma.j.cn501113-20240520-00236 . [Guidelines for the prevention and treatment of metabolic dysfunction-associated fatty liver disease (2024 edition)]. Younossi ZM, Golabi P, Paik JM, et al. The global epidemiology of nonalcoholic fatty liver disease (NAFLD) and nonalcoholic steatohepatitis (NASH): a systematic review. Hepatology. 2023;77(4):1335–47. 10.1097/HEP.0000000000000004 . Riazi K, Azhari H, Charette JH, et al. The prevalence and incidence of NAFLD worldwide: a systematic review and meta-analysis. Lancet Gastroenterol Hepatol. 2022;7(9):851–61. 10.1016/S2468-1253(22)00165-0 . Bansal SK, Bansal MB. Pathogenesis of MASLD and MASH—role of insulin resistance and lipotoxicity. Aliment Pharmacol Ther. 2024;59(Suppl 1):S10–22. 10.1111/apt.17930 . Stienstra R, Saudale F, Duvall C, et al. Kupffer cells promote hepatic steatosis via interleukin-1beta-dependent suppression of peroxisome proliferator-activated receptor alpha activity. Hepatology. 2010;51(2):511–22. 10.1002/hep.23337 . Maleki N, Haghpanah V, Tajik N, et al. Helicobacter pylori infection and association with chronic diseases: a focus on cardiovascular disease, MASLD, and type 2 diabetes. Metabol Open. 2025;27:100385. 10.1016/j.metop.2025.100385 . Santos MLC, de Brito BB, da Silva FAF, et al. Helicobacter pylori infection: Beyond gastric manifestations. World J Gastroenterol. 2020;26(28):4076–93. 10.3748/wjg.v26.i28.4076 . Chen X, Peng R, Peng D, et al. An update: is there a relationship between H. pylori infection and nonalcoholic fatty liver disease? why is this subject of interest? Front Cell Infect Microbiol. 2023;13:1282956. 10.3389/fcimb.2023.1282956 . Polyzos SA, Kountouras J, Zavos C, et al. The association between Helicobacter pylori infection and insulin resistance: a systematic review. Helicobacter. 2020;25(3):e12689. 10.1111/hel.12689 . Xu G, Ma S, Dong L, et al. Relationship of Helicobacter pylori infection with nonalcoholic fatty liver disease: a meta-analysis. Can J Gastroenterol Hepatol. 2023;2023:5521239. 10.1155/2023/5521239 . He C, Cheng D, Wang H, et al. Helicobacter pylori infection and metabolic dysfunction-associated fatty liver disease: a systematic review and meta-analysis. Th Adv Gastroenterol. 2023;16:17562848231167233. 10.1177/17562848231167233 . Mantovani A, Lando MG, Borella N, et al. Relationship between Helicobacter pylori infection and risk of metabolic dysfunction-associated steatotic liver disease: an updated meta-analysis. Liver Int. 2024;44(7):1513–25. 10.1111/liv.15925 . Osula EA, Qazi A. S2475 Helicobacter pylori and the association with metabolic dysfunction-associated steatotic liver disease: a systematic review of population-based studies. Am J Gastroenterol. 2025;120(10S2):S531–2. 10.14309/01.ajg.0001137360.74066.2b . Kim JY, Song DS, Chang UI, et al. Persistently active Helicobacter pylori infection is associated with the development of metabolic dysfunction-associated steatotic liver disease. J Clin Med. 2025;14(4):1073. 10.3390/jcm14041073 . Abenavoli L, Milic N, Masarone M, et al. Association between non-alcoholic fatty liver disease, insulin resistance and Helicobacter pylori. Med Hypotheses. 2013;81(5):913–5. 10.1016/j.mehy.2013.08.018 . Mavilia-Scranton MG, Wu GY, Dharan M. Impact of Helicobacter pylori infection on the pathogenesis and management of nonalcoholic fatty liver disease. J Clin Transl Hepatol. 2023;11(3):670–4. 10.14218/JCTH.2022.00362 . Yu YY, Cai JT, Song ZY, et al. The associations among Helicobacter pylori infection, white blood cell count and nonalcoholic fatty liver disease in a large Chinese population. Medicine. 2018;97(46):e13271. 10.1097/MD.0000000000013271 . Rumack C, Levine D. Diagnostic ultrasound. 5th ed. Philadelphia: Elsevier; 2018. pp. 94–8. Chen C, Zhang C, Wang X, et al. Helicobacter pylori infection may increase the severity of nonalcoholic fatty liver disease via promoting liver function damage, glycometabolism, lipid metabolism, inflammatory reaction and metabolic syndrome. Eur J Gastroenterol Hepatol. 2020;32(7):857–66. 10.1097/MEG.0000000000001768 . Liu M, Li Q, Wang L, et al. Association between Helicobacter pylori infection and metabolic dysfunction-associated fatty liver disease: a meta-analysis. Chin J Hepatol. 2023;31(5):502–9. 10.3760/cma.j.cn501113-20230215-00058 . Abo-Amer YE, Sabal A, Ahmed R, et al. Relationship between Helicobacter pylori infection and nonalcoholic fatty liver disease (NAFLD) in a developing country: a cross-sectional study. Diabetes Metab Syndr Obes. 2020;13:619–25. 10.2147/DMSO.S237866 . Polyzos SA, Kountouras J, Zavos C, et al. The association between Helicobacter pylori infection and insulin resistance: a systematic review. Helicobacter. 2020;25(3):e12689. 10.1111/hel.12689 . Chen X, Peng R, Peng D, et al. Helicobacter pylori infection exacerbates metabolic dysfunction-associated steatotic liver disease through lipid metabolic pathways: a transcriptomic study. J Transl Med. 2024;22(1):701. 10.1186/s12967-024-05506-y . Gou GE, Zhuang Y, Wang Y, et al. Potential mechanisms and therapeutic prospects of the association between Helicobacter pylori infection and metabolic dysfunction-associated steatohepatitis. World J Hepatol. 2025;17(1):101798. 10.4254/wjh.v17.i1.101798 . Martín-Mateos R, Albillos A. The role of the gut-liver axis in metabolic dysfunction-associated fatty liver disease. Front Immunol. 2021;12:660179. 10.3389/fimmu.2021.660179 . Zhang W, Li M, Wang F, et al. Effects of Helicobacter pylori infection on gut microbiota and metabolic dysfunction-associated fatty liver disease. Chin J Microecol. 2024;36(2):176–81. 10.13381/j.cnki.cjm.202402010 . Thing M, Werge MP, Kimer N, et al. Targeted metabolomics reveals plasma short-chain fatty acids are associated with metabolic dysfunction-associated steatotic liver disease. BMC Gastroenterol. 2024;24(1):43. 10.1186/s12876-024-03129-7 . Liu Y, Xu H, Zhao Z, et al. No evidence for a causal link between Helicobacter pylori infection and nonalcoholic fatty liver disease: a bidirectional Mendelian randomization study. Front Microbiol. 2022;13:1018322. 10.3389/fmicb.2022.1018322 . Elizalde JI, Pique JM, Moreno V, et al. Influence of Helicobacter pylori infection and eradication on blood lipids and fibrinogen. Aliment Pharmacol Ther. 2002;16(3):577–86. 10.1046/j.1365-2036.2002.01197.x . Zhao XX, Wang RL, Liu MH, et al. Is the occurrence or reversal of nonalcoholic fatty liver disease associated with long-term Helicobacter pylori infection among Chinese adults? a cohort study. Gastroenterol Res Pract. 2021;2021:6696473. 10.1155/2021/6696473 . Nejati S, Karkhah A, Darvish H, et al. Influence of Helicobacter pylori virulence factors CagA and VacA on pathogenesis of gastrointestinal disorders. Microb Pathog. 2022;164:105437. 10.1016/j.micpath.2022.105437 . Sharndama HC, Mba IE. Helicobacter pylori: an up-to-date overview on the virulence and pathogenesis mechanisms. Braz J Microbiol. 2022;53:33–50. 10.1007/s42713-021-00015-3 . Polyzos SA, Nikolopoulos P, Stogianni A, et al. Effect of Helicobacter pylori eradication on hepatic steatosis, NAFLD fibrosis score and HSENSI in patients with nonalcoholic steatohepatitis: a MR imaging-based pilot open-label study. Arq Gastroenterol. 2014;51(3):261–8. 10.1590/S0004-28032014000300018 . Sasso M, Miette V, Sandrin L, et al. The controlled attenuation parameter (CAP): a novel tool for the non-invasive evaluation of steatosis using Fibroscan. Clin Res Hepatol Gastroenterol. 2012;36(1):13–20. 10.1016/j.clinre.2011.08.001 . Wong VW, Ekstedt M, Wong GL, et al. Changing epidemiology, global trends and implications for outcomes of NAFLD. J Hepatol. 2023;79(3):842–52. 10.1016/j.jhep.2023.04.036 . Targher G, Tilg H, Byrne CD. Non-alcoholic fatty liver disease: a multisystem disease requiring a multidisciplinary and holistic approach. Lancet Gastroenterol Hepatol. 2021;6(7):578–88. 10.1016/S2468-1253(21)00020-0 . Lonardo A, Nascimbeni F, Mantovani A, et al. Hypertension, diabetes, atherosclerosis and NASH: cause or consequence? J Hepatol. 2022;77(5):1417–29. 10.1016/j.jhep.2022.07.020 . Goo MJ, Ki MR, Lee HR, et al. Helicobacter pylori promotes hepatic fibrosis in the animal model. Lab Invest. 2009;89(11):1291–303. 10.1038/labinvest.2009.90 . Doulberis M, Srivastava S, Polyzos SA, et al. Active Helicobacter pylori infection is independently associated with nonalcoholic steatohepatitis in morbidly obese patients. J Clin Med. 2020;9(4):933. 10.3390/jcm9040933 . Ralser A, Dietl A, Jarosch S, et al. Helicobacter pylori promotes colorectal carcinogenesis by deregulating intestinal immunity and inducing a mucus-degrading microbiota signature. Gut. 2023;72:1258–70. 10.1136/gutjnl-2022-327076 . Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Reviewers agreed at journal 22 Mar, 2026 Reviewers invited by journal 05 Mar, 2026 Editor invited by journal 20 Feb, 2026 Editor assigned by journal 19 Feb, 2026 Submission checks completed at journal 19 Feb, 2026 First submitted to journal 19 Feb, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. 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-8916798","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":601520076,"identity":"a4ccb931-f4b2-4883-a34c-209a5fa494f5","order_by":0,"name":"Simin Zhang","email":"","orcid":"","institution":"Dali University","correspondingAuthor":false,"prefix":"","firstName":"Simin","middleName":"","lastName":"Zhang","suffix":""},{"id":601520077,"identity":"415873cd-a10b-4eb1-ba55-c369f4e1efaf","order_by":1,"name":"Jiao Li","email":"","orcid":"","institution":"Dali University","correspondingAuthor":false,"prefix":"","firstName":"Jiao","middleName":"","lastName":"Li","suffix":""},{"id":601520086,"identity":"e0719522-791b-406d-9a16-31abd0bac467","order_by":2,"name":"Cui Deng","email":"","orcid":"","institution":"Dali University","correspondingAuthor":false,"prefix":"","firstName":"Cui","middleName":"","lastName":"Deng","suffix":""},{"id":601520088,"identity":"cbf5aaec-d104-4380-9528-38f9569c52c2","order_by":3,"name":"Sheng Zheng","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABBUlEQVRIiWNgGAWjYDACCQiVAMTsHz78sGFgI0ULG+PMnjQStTDzsB0m7C752c3HHn5hqMvjl26/9oCH57w9n3TzA4YfFdtwamGccyzdWIbhcLHknDPlBhIWtxPbZI4ZMPacuY1TC7NEjpm0BMOBxA03chIkDHhuJ7BJJBgwM7bh1sImkf8NqKUucT9ISwLbOXs2ifQPeLXwSOSwSX5gYE7cIJF+TOIA2wHGNokc/LZISKSZSTMwHE6ccSOH2bCxJzkRqKXgID6/yM9Ifib5A+iw/hnpDx//+WFnLz8jfeODHxW4tYCDgPcf2I0GcJEDeNUDAeMPMMX+gJDCUTAKRsEoGKEAAI7MVF0JH2U5AAAAAElFTkSuQmCC","orcid":"","institution":"The Third People's Hospital of Yunnan Province","correspondingAuthor":true,"prefix":"","firstName":"Sheng","middleName":"","lastName":"Zheng","suffix":""}],"badges":[],"createdAt":"2026-02-19 10:57:06","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8916798/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8916798/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":104436789,"identity":"8f8706d8-4661-460b-9352-4183420163a5","added_by":"auto","created_at":"2026-03-11 16:55:42","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1049323,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8916798/v1/a4ca7aa1-923c-4690-8cb5-d8450c47a597.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Association between Helicobacter pylori infection and the severity of metabolic dysfunction-associated fatty liver disease: a large-scale cross-sectional study","fulltext":[{"header":"Background","content":"\u003cp\u003eMetabolic dysfunction-associated fatty liver disease (MAFLD), formerly termed non-alcoholic fatty liver disease (NAFLD), is defined as hepatic steatosis in the presence of overweight/obesity, type 2 diabetes mellitus (T2DM), or evidence of metabolic dysregulation [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. It has emerged as the most prevalent chronic liver condition globally, affecting approximately 30% of the adult population and imposing a substantial burden of morbidity and mortality related to cirrhosis, hepatocellular carcinoma, and cardiovascular disease [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. The pathogenesis of MAFLD is complex and multifactorial, involving insulin resistance (IR), adipose tissue dysfunction, chronic low-grade inflammation, oxidative stress, and genetic predisposition [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eHelicobacter pylori (H. pylori) is a Gram-negative bacterium that colonizes the gastric mucosa of nearly half the world's population [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Beyond its well-established role in gastritis, peptic ulcer disease, and gastric malignancy, a growing body of evidence suggests that H. pylori infection may have significant extra-gastric manifestations, including an impact on metabolic disorders [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Proposed mechanisms linking H. pylori to metabolic diseases include the induction of a chronic, low-grade systemic inflammatory state, alteration of gut microbiota and intestinal barrier function, and modulation of host metabolic pathways, all of which could contribute to IR and hepatic steatosis [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eRecent epidemiological studies and meta-analyses have suggested a positive association between H. pylori infection and the presence of MAFLD [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. A comprehensive meta-analysis by Mantovani et al. demonstrated that H. pylori infection was associated with a modest but significant increase in both prevalent and incident MAFLD [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. A systematic review by Osula and Qazi further confirmed that H. pylori-positive individuals exhibit higher rates of hepatic steatosis and elevated liver enzymes [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Furthermore, a longitudinal cohort study by Kim et al. provided evidence that persistently active H. pylori infection, rather than past infection, specifically increased the risk of developing MAFLD, suggesting a potential causal link and a window for intervention through eradication [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eDespite this accumulating evidence, the specific relationship between H. pylori infection and the severity of MAFLD remains poorly characterized [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Most existing studies have focused on the presence or absence of the disease, with limited data on whether infection influences the progression from mild steatosis to more advanced stages. Understanding this relationship could have significant clinical implications, potentially identifying H. pylori as a modifiable risk factor in the management of MAFLD [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. Therefore, this large-scale cross-sectional study aimed to investigate the association between H. pylori infection and the severity of MAFLD in a Chinese population, while also exploring its relationship with key metabolic and inflammatory parameters.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003e\u003cstrong\u003eStudy population\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis cross-sectional study retrospectively reviewed medical records of individuals who underwent health examinations at the Department of Gastroenterology, The Third People's Hospital of Yunnan Province, between January 2023 and June 2025. Consecutive patients diagnosed with MAFLD based on abdominal ultrasound and who had undergone ¹³C/¹⁴C-urea breath testing for H. pylori were considered for inclusion. A total of 2,610 patients with complete clinical and laboratory data were enrolled. The study protocol was approved by the Ethics Committee of The Third People's Hospital of Yunnan Province (Approval No. 2023-021) and was conducted in accordance with the principles of the Declaration of Helsinki. Due to the retrospective nature of the study, the requirement for informed consent was waived by the ethics committee.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eInclusion and exclusion criteria\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe diagnosis of MAFLD was established according to the 2024 Chinese guidelines for the prevention and treatment of metabolic dysfunction-associated fatty liver disease [1]. Inclusion criteria were: (1) age 18–75 years; (2) diagnosis of MAFLD by abdominal ultrasound; (3) completion of ¹³C/¹⁴C-urea breath test; and (4) availability of complete clinical and laboratory data.\u003c/p\u003e\n\u003cp\u003eExclusion criteria were as follows [18]: (1) significant alcohol consumption (≥40 g/day for men, ≥20 g/day for women for \u0026gt;5 years, or binge drinking \u0026gt;80 g/day within the past 2 weeks); (2) other chronic liver diseases (e.g., viral hepatitis, autoimmune hepatitis, drug-induced liver injury, Wilson's disease); (3) history of upper gastrointestinal bleeding; (4) pyloric obstruction; (5) prior gastric surgery; (6) malignancy or current anti-cancer therapy; (7) use of bismuth, antibiotics, proton pump inhibitors, or H₂-receptor antagonists within 4 weeks prior to H. pylori testing; (8) active severe infection or systemic inflammatory disease; (9) severe mental or neurological disorders; (10) pregnancy or lactation; (11) missing essential clinical data; (12) use of steatogenic medications (e.g., corticosteroids, methotrexate, tamoxifen); and (13) consumption of foods potentially inhibiting H. pylori (e.g., lactobacillus-containing drinks, garlic, tea, ginger) within 2 weeks prior to testing.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData collection\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDemographic and clinical data, including age, sex, smoking history, alcohol consumption history, and medical history (hypertension, diabetes, cardiovascular disease), were collected from medical records. Anthropometric measurements, including height, weight, body mass index (BMI, calculated as weight in kilograms divided by height in meters squared), systolic blood pressure (SBP), and diastolic blood pressure (DBP), were obtained from the health examination database. Blood samples were collected after an overnight fast (8–12 hours) and analyzed using standardized automated analyzers. The following laboratory parameters were recorded:\u003c/p\u003e\n\u003cp\u003eLiver function: alanine aminotransferase (ALT), aspartate aminotransferase (AST), total bilirubin (TBIL), direct bilirubin (DBIL)\u003c/p\u003e\n\u003cp\u003eGlucose metabolism: fasting plasma glucose (GLU), glycated hemoglobin (HbA1c)\u003c/p\u003e\n\u003cp\u003eLipid profile: total cholesterol (TC), triglycerides (TG), high-density lipoprotein cholesterol (HDL-C), low-density lipoprotein cholesterol (LDL-C)\u003c/p\u003e\n\u003cp\u003eInflammatory markers: white blood cell count (WBC), neutrophil count (NE), lymphocyte count (LYM)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eH. pylori detection\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eH. pylori status was determined using the ¹³C-urea breath test (HCBT-01, Headway, China) or the ¹⁴C-urea breath test (HUBP-01P, Headway, China). The test was considered positive if the delta over baseline (DOB) value was ≥4.0‰ for the ¹³C-UBT or if the disintegrations per minute (dpm) value was ≥100 for the ¹⁴C-UBT.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDiagnosis and grading of MAFLD\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAbdominal ultrasound examinations were performed by experienced radiologists using a Philips EPIQ 7 ultrasound system. The diagnosis of MAFLD was based on the presence of characteristic ultrasonographic findings: diffuse hyperechogenicity of the liver parenchyma (bright liver), increased echo texture compared to the renal parenchyma, vascular blurring, and deep attenuation. The severity of hepatic steatosis was graded semi-quantitatively according to established criteria [19]:\u003c/p\u003e\n\u003cp\u003eMild: Slight diffuse increase in hepatic echogenicity, with normal visualization of the diaphragm and intrahepatic vessel borders.\u003c/p\u003e\n\u003cp\u003eModerate: Moderate diffuse increase in hepatic echogenicity, with slightly impaired visualization of the diaphragm and intrahepatic vessels.\u003c/p\u003e\n\u003cp\u003eSevere: Marked increase in hepatic echogenicity, with poor or non-visualization of the diaphragm, intrahepatic vessels, and posterior portion of the right hepatic lobe.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStatistical analysis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eStatistical analyses were performed using SPSS software version 27.0 (IBM Corp., Armonk, NY, USA). Continuous variables are presented as mean ± standard deviation (SD). Comparisons between two groups were performed using the independent samples t-test. Comparisons among multiple groups were performed using one-way analysis of variance (ANOVA) followed by the least significant difference (LSD) post-hoc test. Categorical variables are presented as frequencies and percentages (%), and group comparisons were made using the chi-square (χ²) test or Fisher's exact test, as appropriate.\u003c/p\u003e\n\u003cp\u003eThe correlation between H. pylori infection and MAFLD severity was assessed using Spearman's rank correlation coefficient. To identify independent risk factors for MAFLD severity, multivariate logistic regression analysis was performed. Variables with a P-value \u0026lt; 0.10 in univariate analysis, along with clinically relevant factors, were entered into the regression models. Odds ratios (ORs) and their 95% confidence intervals (CIs) were calculated. All statistical tests were two-tailed, and a P-value \u0026lt; 0.05 was considered statistically significant.\u003c/p\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003eBaseline characteristics of the study population\u003c/h2\u003e \u003cp\u003eA total of 2,610 patients with MAFLD were included in this study. The cohort comprised 1,876 (71.9%) men and 734 (28.1%) women, with a mean age of 47.8\u0026thinsp;\u0026plusmn;\u0026thinsp;11.6 years. Based on ultrasound findings, 1,797 (68.9%) patients were classified as having mild MAFLD, 191 (7.3%) as moderate, and 622 (23.8%) as severe. The overall prevalence of H. pylori infection was 28.2% (736/2,610), with a similar male-to-female ratio between the H. pylori-positive and -negative groups (P\u0026thinsp;\u0026gt;\u0026thinsp;0.05). Baseline characteristics, including age, SBP, DBP, and BMI, were comparable across different MAFLD severity groups and between H. pylori-positive and -negative groups (all P\u0026thinsp;\u0026gt;\u0026thinsp;0.05), as shown in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eBaseline characteristics of the study population\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"8\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCharacteristic\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMild MAFLD (n\u0026thinsp;=\u0026thinsp;1,797)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eModerate MAFLD (n\u0026thinsp;=\u0026thinsp;191)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eSevere MAFLD (n\u0026thinsp;=\u0026thinsp;622)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eP value\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eHp (+) (n\u0026thinsp;=\u0026thinsp;736)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eHp (-) (n\u0026thinsp;=\u0026thinsp;1,874)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003eP value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSex, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.777\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e0.959\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1,288 (49.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e144 (5.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e444 (17.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e529 (20.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e1,347 (51.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e509 (19.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e47 (1.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e178 (6.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e207 (7.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e527 (20.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge (years)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e47.8\u0026thinsp;\u0026plusmn;\u0026thinsp;11.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e49.4\u0026thinsp;\u0026plusmn;\u0026thinsp;11.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e47.6\u0026thinsp;\u0026plusmn;\u0026thinsp;11.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.403\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e48.9\u0026thinsp;\u0026plusmn;\u0026thinsp;11.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e47.5\u0026thinsp;\u0026plusmn;\u0026thinsp;11.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e0.133\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSBP (mmHg)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e132.0\u0026thinsp;\u0026plusmn;\u0026thinsp;15.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e133.6\u0026thinsp;\u0026plusmn;\u0026thinsp;12.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e135.0\u0026thinsp;\u0026plusmn;\u0026thinsp;17.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.073\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e133.3\u0026thinsp;\u0026plusmn;\u0026thinsp;16.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e132.7\u0026thinsp;\u0026plusmn;\u0026thinsp;15.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e0.856\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDBP (mmHg)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e82.5\u0026thinsp;\u0026plusmn;\u0026thinsp;10.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e83.8\u0026thinsp;\u0026plusmn;\u0026thinsp;8.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e83.6\u0026thinsp;\u0026plusmn;\u0026thinsp;11.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.181\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e82.6\u0026thinsp;\u0026plusmn;\u0026thinsp;11.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e82.9\u0026thinsp;\u0026plusmn;\u0026thinsp;10.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e0.368\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBMI (kg/m\u0026sup2;)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e27.5\u0026thinsp;\u0026plusmn;\u0026thinsp;4.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e27.4\u0026thinsp;\u0026plusmn;\u0026thinsp;2.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e27.9\u0026thinsp;\u0026plusmn;\u0026thinsp;3.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.676\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e27.2\u0026thinsp;\u0026plusmn;\u0026thinsp;3.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e27.7\u0026thinsp;\u0026plusmn;\u0026thinsp;4.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e0.080\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"8\"\u003eHp (+): H. pylori-positive; Hp (-): H. pylori-negative; Data are presented as mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD unless otherwise indicated.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003eComparison of metabolic and laboratory parameters according to H. pylori status\u003c/h2\u003e \u003cp\u003eThe prevalence of metabolic abnormalities (overweight, hyperglycemia, dyslipidemia, and hypertension) did not differ significantly between the H. pylori-positive and -negative groups (all P\u0026thinsp;\u0026gt;\u0026thinsp;0.05, Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). However, as shown in Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e, patients in the H. pylori-positive group exhibited significantly higher levels of GLU (6.06\u0026thinsp;\u0026plusmn;\u0026thinsp;2.10 vs. 5.76\u0026thinsp;\u0026plusmn;\u0026thinsp;1.63 mmol/L, P\u0026thinsp;=\u0026thinsp;0.029), WBC (6.46\u0026thinsp;\u0026plusmn;\u0026thinsp;1.41 vs. 6.25\u0026thinsp;\u0026plusmn;\u0026thinsp;1.41 \u0026times;10⁹/L, P\u0026thinsp;=\u0026thinsp;0.032), and NE (3.75\u0026thinsp;\u0026plusmn;\u0026thinsp;1.10 vs. 3.55\u0026thinsp;\u0026plusmn;\u0026thinsp;1.07 \u0026times;10⁹/L, P\u0026thinsp;=\u0026thinsp;0.005) compared to the negative group. No significant differences were observed in liver enzymes, bilirubin, HbA1c, or other lipid parameters between the two groups.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ePrevalence of metabolic abnormalities by H. pylori status\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eParameter\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHp (+) (n\u0026thinsp;=\u0026thinsp;736)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eHp (-) (n\u0026thinsp;=\u0026thinsp;1,874)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eχ\u0026sup2;\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eP value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOverweight (BMI\u0026thinsp;\u0026ge;\u0026thinsp;24 kg/m\u0026sup2;)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e388 (52.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1,031 (55.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e3.572\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.059\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHyperglycemia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e179 (24.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e398 (21.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.261\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.263\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDyslipidemia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e571 (77.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1,422 (75.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.368\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.546\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHypertension\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e271 (36.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e592 (31.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2.838\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.093\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eLaboratory parameters by H. pylori status\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eParameter\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHp (+) (n\u0026thinsp;=\u0026thinsp;736)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eHp (-) (n\u0026thinsp;=\u0026thinsp;1,874)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eP value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLiver function\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAST (U/L)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e26.7\u0026thinsp;\u0026plusmn;\u0026thinsp;16.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e26.4\u0026thinsp;\u0026plusmn;\u0026thinsp;18.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.769\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eALT (U/L)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e37.4\u0026thinsp;\u0026plusmn;\u0026thinsp;30.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e35.3\u0026thinsp;\u0026plusmn;\u0026thinsp;27.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.153\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTBIL (\u0026micro;mol/L)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e13.9\u0026thinsp;\u0026plusmn;\u0026thinsp;5.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e14.0\u0026thinsp;\u0026plusmn;\u0026thinsp;5.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.960\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDBIL (\u0026micro;mol/L)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e3.7\u0026thinsp;\u0026plusmn;\u0026thinsp;1.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e3.7\u0026thinsp;\u0026plusmn;\u0026thinsp;1.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.640\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGlucose metabolism\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGLU (mmol/L)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e6.06\u0026thinsp;\u0026plusmn;\u0026thinsp;2.10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e5.76\u0026thinsp;\u0026plusmn;\u0026thinsp;1.63\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.029\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHbA1c (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e6.2\u0026thinsp;\u0026plusmn;\u0026thinsp;1.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e6.0\u0026thinsp;\u0026plusmn;\u0026thinsp;1.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.099\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLipid profile\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTC (mmol/L)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e5.4\u0026thinsp;\u0026plusmn;\u0026thinsp;3.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e5.4\u0026thinsp;\u0026plusmn;\u0026thinsp;3.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.305\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTG (mmol/L)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e2.1\u0026thinsp;\u0026plusmn;\u0026thinsp;1.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e2.5\u0026thinsp;\u0026plusmn;\u0026thinsp;6.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.228\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHDL-C (mmol/L)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e1.36\u0026thinsp;\u0026plusmn;\u0026thinsp;0.32\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e1.34\u0026thinsp;\u0026plusmn;\u0026thinsp;0.29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.742\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLDL-C (mmol/L)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e3.00\u0026thinsp;\u0026plusmn;\u0026thinsp;0.70\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e2.96\u0026thinsp;\u0026plusmn;\u0026thinsp;0.69\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.443\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInflammatory markers\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWBC (\u0026times;10⁹/L)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e6.46\u0026thinsp;\u0026plusmn;\u0026thinsp;1.41\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e6.25\u0026thinsp;\u0026plusmn;\u0026thinsp;1.41\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.032\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNE (\u0026times;10⁹/L)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e3.75\u0026thinsp;\u0026plusmn;\u0026thinsp;1.10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e3.55\u0026thinsp;\u0026plusmn;\u0026thinsp;1.07\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.005\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLYM (\u0026times;10⁹/L)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e2.16\u0026thinsp;\u0026plusmn;\u0026thinsp;0.58\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e2.16\u0026thinsp;\u0026plusmn;\u0026thinsp;0.55\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.894\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003eData are presented as mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD. Bold values indicate statistical significance (P\u0026thinsp;\u0026lt;\u0026thinsp;0.05).\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eStratified analysis by MAFLD severity\u003c/h2\u003e \u003cp\u003eThe impact of H. pylori infection on metabolic and laboratory parameters was further analyzed within each MAFLD severity subgroup. In the mild MAFLD group, the prevalence of hypertension was significantly higher in H. pylori-positive patients compared to negative patients (44.1% vs. 31.4%, P\u0026thinsp;=\u0026thinsp;0.027, Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e). No other significant differences in metabolic comorbidities were observed within the moderate and severe groups.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ePrevalence of metabolic abnormalities stratified by MAFLD severity and H. pylori status\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"10\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c10\" colnum=\"10\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eParameter\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMild MAFLD (n\u0026thinsp;=\u0026thinsp;1,797)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eModerate MAFLD (n\u0026thinsp;=\u0026thinsp;191)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003eSevere MAFLD (n\u0026thinsp;=\u0026thinsp;622)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHp+ (n\u0026thinsp;=\u0026thinsp;177)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eHp- (n\u0026thinsp;=\u0026thinsp;1620)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eP\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eHp+ (n\u0026thinsp;=\u0026thinsp;64)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eHp- (n\u0026thinsp;=\u0026thinsp;127)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eP\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eHp+ (n\u0026thinsp;=\u0026thinsp;495)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eHp- (n\u0026thinsp;=\u0026thinsp;127)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eP\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOverweight\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e87 (49.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e886 (54.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.087\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e40 (62.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e73 (57.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.638\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e276 (55.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e58 (45.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e0.061\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHyperglycemia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e47 (26.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e330 (20.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.189\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e19 (29.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e16 (12.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.075\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e130 (26.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e31 (24.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e0.777\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDyslipidemia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e125 (70.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1,217 (75.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.397\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e54 (84.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e106 (83.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e1.000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e387 (78.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e101 (79.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e0.856\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHypertension\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e78 (44.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e508 (31.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.027\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e21 (32.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e38 (29.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.774\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e175 (35.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e41 (32.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e0.665\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e presents the laboratory parameters stratified by MAFLD severity and H. pylori status. Notably, AST levels were consistently and significantly higher in H. pylori-positive patients across all three MAFLD severity grades (all P\u0026thinsp;\u0026lt;\u0026thinsp;0.05). ALT levels were significantly higher in H. pylori-positive patients in both the moderate and severe MAFLD groups (both P\u0026thinsp;\u0026lt;\u0026thinsp;0.01). In the mild MAFLD group, H. pylori-positive patients had significantly higher WBC and LYM counts. In the moderate group, they had significantly higher TC levels. In the severe group, they had significantly higher LYM counts.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab5\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eLaboratory parameters stratified by MAFLD severity and H. pylori status\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"10\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c10\" colnum=\"10\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eParameter\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMild MAFLD (n\u0026thinsp;=\u0026thinsp;1,797)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eModerate MAFLD (n\u0026thinsp;=\u0026thinsp;191)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003eSevere MAFLD (n\u0026thinsp;=\u0026thinsp;622)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHp+ (n\u0026thinsp;=\u0026thinsp;177)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eHp- (n\u0026thinsp;=\u0026thinsp;1620)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eP\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eHp+ (n\u0026thinsp;=\u0026thinsp;64)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eHp- (n\u0026thinsp;=\u0026thinsp;127)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eP\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eHp+ (n\u0026thinsp;=\u0026thinsp;495)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eHp- (n\u0026thinsp;=\u0026thinsp;127)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eP\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAST (U/L)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e27.4\u0026thinsp;\u0026plusmn;\u0026thinsp;14.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e24.6\u0026thinsp;\u0026plusmn;\u0026thinsp;16.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.026\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e20.9\u0026thinsp;\u0026plusmn;\u0026thinsp;4.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e27.8\u0026thinsp;\u0026plusmn;\u0026thinsp;12.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.010\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e26.5\u0026thinsp;\u0026plusmn;\u0026thinsp;16.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e29.5\u0026thinsp;\u0026plusmn;\u0026thinsp;18.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e0.004\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eALT (U/L)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e36.5\u0026thinsp;\u0026plusmn;\u0026thinsp;25.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e34.6\u0026thinsp;\u0026plusmn;\u0026thinsp;25.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.145\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e25.7\u0026thinsp;\u0026plusmn;\u0026thinsp;7.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e40.0\u0026thinsp;\u0026plusmn;\u0026thinsp;22.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.007\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e37.6\u0026thinsp;\u0026plusmn;\u0026thinsp;32.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e51.7\u0026thinsp;\u0026plusmn;\u0026thinsp;46.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWBC (\u0026times;10⁹/L)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6.51\u0026thinsp;\u0026plusmn;\u0026thinsp;1.40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6.14\u0026thinsp;\u0026plusmn;\u0026thinsp;1.46\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.020\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e6.65\u0026thinsp;\u0026plusmn;\u0026thinsp;1.47\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e6.46\u0026thinsp;\u0026plusmn;\u0026thinsp;1.05\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.223\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e6.40\u0026thinsp;\u0026plusmn;\u0026thinsp;1.45\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e6.32\u0026thinsp;\u0026plusmn;\u0026thinsp;1.22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e0.367\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLYM (\u0026times;10⁹/L)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.26\u0026thinsp;\u0026plusmn;\u0026thinsp;0.60\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.08\u0026thinsp;\u0026plusmn;\u0026thinsp;0.55\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.015\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2.30\u0026thinsp;\u0026plusmn;\u0026thinsp;0.59\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2.25\u0026thinsp;\u0026plusmn;\u0026thinsp;0.55\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.407\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e2.18\u0026thinsp;\u0026plusmn;\u0026thinsp;0.56\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e2.24\u0026thinsp;\u0026plusmn;\u0026thinsp;0.45\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e0.019\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTC (mmol/L)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5.03\u0026thinsp;\u0026plusmn;\u0026thinsp;1.24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5.50\u0026thinsp;\u0026plusmn;\u0026thinsp;4.29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.755\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e5.08\u0026thinsp;\u0026plusmn;\u0026thinsp;0.91\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e5.40\u0026thinsp;\u0026plusmn;\u0026thinsp;1.35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.038\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e5.40\u0026thinsp;\u0026plusmn;\u0026thinsp;0.90\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e4.97\u0026thinsp;\u0026plusmn;\u0026thinsp;1.07\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e0.262\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGLU (mmol/L)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6.18\u0026thinsp;\u0026plusmn;\u0026thinsp;1.60\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6.07\u0026thinsp;\u0026plusmn;\u0026thinsp;2.04\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.226\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e6.02\u0026thinsp;\u0026plusmn;\u0026thinsp;1.61\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e5.46\u0026thinsp;\u0026plusmn;\u0026thinsp;0.86\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.662\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e6.22\u0026thinsp;\u0026plusmn;\u0026thinsp;2.24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e5.73\u0026thinsp;\u0026plusmn;\u0026thinsp;0.91\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e0.439\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"10\"\u003eData are presented as mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD. Bold values indicate statistical significance (P\u0026thinsp;\u0026lt;\u0026thinsp;0.05).\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eCorrelation and regression analysis for MAFLD severity\u003c/h2\u003e \u003cp\u003eSpearman rank correlation analysis revealed a strong positive correlation between H. pylori infection and the severity of MAFLD (*r* = 0.638, P\u0026thinsp;\u0026lt;\u0026thinsp;0.001). The prevalence of H. pylori infection increased progressively with MAFLD severity: 9.9% in the mild group, 33.5% in the moderate group, and 79.6% in the severe group (Table\u0026nbsp;\u003cspan refid=\"Tab6\" class=\"InternalRef\"\u003e6\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab6\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 6\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eCorrelation between MAFLD severity and H. pylori infection\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSeverity\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eN\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eH. pylori infection n (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003er\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eP value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMild\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1797\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e177 (9.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eModerate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e191\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e64 (33.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.638\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSevere\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e622\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e495 (79.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2610\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e736 (28.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eMultivariate logistic regression analysis was performed to identify independent risk factors for advanced MAFLD. In the comparison between mild and severe MAFLD (Table\u0026nbsp;\u003cspan refid=\"Tab7\" class=\"InternalRef\"\u003e7\u003c/span\u003e), H. pylori infection (OR\u0026thinsp;=\u0026thinsp;297.00, 95% CI: 92.13\u0026ndash;957.48, P\u0026thinsp;\u0026lt;\u0026thinsp;0.001), HDL-C (OR\u0026thinsp;=\u0026thinsp;25.53, 95% CI: 4.47\u0026ndash;145.87, P\u0026thinsp;\u0026lt;\u0026thinsp;0.001), and TC (OR\u0026thinsp;=\u0026thinsp;0.49, 95% CI: 0.28\u0026ndash;0.87, P\u0026thinsp;=\u0026thinsp;0.014) were significantly associated with disease severity. In the comparison between moderate and severe MAFLD (Table\u0026nbsp;\u003cspan refid=\"Tab8\" class=\"InternalRef\"\u003e8\u003c/span\u003e), H. pylori infection remained a powerful independent risk factor (OR\u0026thinsp;=\u0026thinsp;21.57, 95% CI: 5.91\u0026ndash;78.75, P\u0026thinsp;\u0026lt;\u0026thinsp;0.001).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab7\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 7\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eMultivariate logistic regression analysis for risk factors associated with severe vs. mild MAFLD\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eB\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eS.E.\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eWald\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eOR (95% CI)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eP value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eH. pylori infection\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e5.694\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.597\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e90.887\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e297.00 (92.13\u0026ndash;957.48)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHDL-C\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3.240\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.889\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e13.271\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e25.53 (4.47\u0026ndash;145.87)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTC\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e\u0026minus;0.707\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.289\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e5.990\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.49 (0.28\u0026ndash;0.87)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.014\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.029\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.027\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.166\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e1.03 (0.98\u0026ndash;1.09)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.280\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBMI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.381\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.419\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.827\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e1.46 (0.64\u0026ndash;3.33)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.363\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab8\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 8\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eMultivariate logistic regression analysis for risk factors associated with severe vs. moderate MAFLD\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eB\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eS.E.\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eWald\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eOR (95% CI)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eP value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eH. pylori infection\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3.071\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.661\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e21.605\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e21.57 (5.91\u0026ndash;78.75)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.050\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.032\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2.455\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e1.05 (0.99\u0026ndash;1.12)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.117\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBMI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.342\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.434\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.620\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e1.41 (0.60\u0026ndash;3.23)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.431\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"6\"\u003eModels were adjusted for age, sex, BMI, SBP, DBP, WBC, NE, LYM, GLU, HbA1c, ALT, AST, TBIL, DBIL, TG, HDL-C, and LDL-C. Only significant and key variables are shown.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eIn this large, cross-sectional study of 2,610 Chinese patients with MAFLD, we identified a robust and independent association between H. pylori infection and the severity of hepatic steatosis. Our findings demonstrate that H. pylori positivity is not merely linked to the presence of MAFLD, but is strongly correlated with its progression from mild to moderate and severe forms. This association persisted after rigorous adjustment for a wide range of potential confounders, including age, sex, BMI, and key metabolic parameters, highlighting H. pylori infection as a potentially significant, and modifiable, risk factor in the natural history of MAFLD [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe prevalence of H. pylori infection in our MAFLD cohort (28.2%) is consistent with previous reports from Chinese populations [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. The demographic profile of our patients, predominantly middle-aged males with elevated BMI, aligns with the known epidemiology of MAFLD [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. Our key finding\u0026mdash;that H. pylori infection is an independent risk factor for disease severity\u0026mdash;corroborates and significantly extends the existing literature. While prior meta-analyses have confirmed a link between H. pylori and the prevalence of MAFLD/NAFLD [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e], data on its relationship with disease severity have been limited. Our results are in agreement with a study by Chen et al., which suggested that H. pylori infection might increase the severity of NAFLD by promoting liver damage and metabolic syndrome [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. More recently, a longitudinal study by Kim et al. provided compelling evidence that persistently active H. pylori infection, as confirmed by repeated biopsies, was associated with a significantly higher risk of incident MASLD, whereas eradicated infection was not [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. This temporal relationship strengthens the argument for a causal role and underscores the potential clinical benefit of screening and treatment. Our cross-sectional data, showing a gradient of infection prevalence from 9.9% in mild to 79.6% in severe MAFLD, provides complementary evidence for a \"dose-response\" relationship between the infection and disease stage.\u003c/p\u003e \u003cp\u003eThe mechanistic pathways linking H. pylori to MAFLD progression are likely multifactorial and interconnected. Our observation of significantly higher fasting glucose, WBC, and neutrophil counts in H. pylori-positive patients offers clinical clues to these underlying mechanisms.\u003c/p\u003e \u003cp\u003eFirst, chronic low-grade inflammation is a central tenet in the pathogenesis of both conditions [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. H. pylori colonization of the gastric mucosa triggers a persistent local and systemic immune response, characterized by the release of pro-inflammatory cytokines such as tumor necrosis factor-alpha (TNF-α), interleukin-6 (IL-6), and interleukin-1β (IL-1β) [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. These cytokines can enter the portal circulation and directly impact the liver, activating Kupffer cells and hepatic stellate cells, thereby promoting hepatic inflammation, insulin resistance, and fibrogenesis [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. Our finding of elevated WBC and NE in infected patients, particularly in those with mild MAFLD, supports the presence of a heightened systemic inflammatory state that could initiate or exacerbate liver injury. The higher lymphocyte counts observed in infected patients with mild and severe disease may reflect an adaptive immune response to the infection that also cross-reacts with hepatic antigens.\u003c/p\u003e \u003cp\u003eSecond, insulin resistance (IR) is a hallmark of MAFLD. The systemic inflammation induced by H. pylori can impair insulin signaling by interfering with insulin receptor substrate (IRS) function, contributing to both hyperglycemia and de novo lipogenesis in the liver [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. Our finding of significantly elevated fasting glucose in the H. pylori-positive group is consistent with this mechanism and with other studies [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. A recent transcriptomic study by Chen et al. provided deeper mechanistic insight, demonstrating in a mouse model that H. pylori infection, particularly CagA+ strains, exacerbated high-fat diet-induced hepatic steatosis by regulating hepatic lipid metabolism pathways, including the PPAR pathway and fatty acid degradation [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. This study elegantly shows that the infection can directly influence the liver's transcriptional program related to fat handling.\u003c/p\u003e \u003cp\u003eThird, the gut-liver axis is increasingly recognized as a critical player in MAFLD. H. pylori infection can alter the composition of the gut microbiota (dysbiosis) and increase intestinal permeability [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. This \"leaky gut\" facilitates the translocation of bacterial products, such as lipopolysaccharide (LPS), into the portal circulation, where they can activate Toll-like receptors (TLRs) on hepatic immune cells, fueling inflammation and steatosis [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. Our data, showing higher liver enzymes (ALT, AST) in infected patients with more advanced disease, could be a downstream effect of this gut-liver axis disruption. A recent metabolomics study by Thing et al. demonstrated that plasma short-chain fatty acids, key metabolites derived from gut microbiota, are significantly associated with MASLD, further supporting the importance of the gut-liver axis in disease pathogenesis [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eRegarding the relationship between H. pylori infection and lipid metabolism, we found no significant differences in TC, TG, HDL-C, or LDL-C levels between the H. pylori-positive and -negative groups overall. This finding aligns with the Mendelian randomization study by Liu et al., which found no causal link between H. pylori infection and lipid profiles [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. Similarly, Elizalde et al. reported that H. pylori eradication had minimal impact on blood lipid levels [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. However, our subgroup analysis revealed significantly higher TC levels in H. pylori-positive patients within the moderate MAFLD group, suggesting that the metabolic impact of infection may vary depending on disease stage. The inconsistent findings in the literature [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e] may be attributable to differences in study populations, genetic backgrounds, dietary habits, and H. pylori strain virulence factors such as CagA and VacA status [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e].\u003c/p\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eClinical implications\u003c/h2\u003e \u003cp\u003eOur findings have potential clinical relevance. If confirmed by prospective studies, H. pylori screening could be integrated into the risk stratification of patients with MAFLD. Identifying H. pylori infection in a patient with mild MAFLD might identify an individual at higher risk for progression, who could benefit from closer monitoring and more aggressive lifestyle interventions. More importantly, our results, viewed in the context of longitudinal studies [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e], raise the possibility that H. pylori eradication could be a beneficial adjunctive therapy [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. A pilot study by Polyzos et al. suggested that eradication might improve non-invasive markers of fibrosis in patients with nonalcoholic steatohepatitis [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e]. Large-scale, randomized controlled trials are now urgently needed to determine whether H. pylori eradication can halt or reverse the progression of MAFLD [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eStrengths and limitations\u003c/h2\u003e \u003cp\u003eThe strengths of this study include its large sample size, the use of the updated MAFLD definition, and the comprehensive collection of clinical, metabolic, and inflammatory parameters, which allowed for robust multivariate adjustment. The use of the urea breath test, the gold standard for diagnosing active H. pylori infection, is another key strength.\u003c/p\u003e \u003cp\u003eHowever, several limitations must be acknowledged. First, the cross-sectional design precludes any inference of causality. While we demonstrate a strong association, we cannot determine whether H. pylori infection leads to more severe MAFLD, or whether patients with more severe MAFLD are more susceptible to H. pylori infection or its persistence. Second, the diagnosis and grading of MAFLD were based on abdominal ultrasound rather than the gold standard of liver biopsy or more quantitative methods like transient elastography (FibroScan). Ultrasound has limited sensitivity for detecting mild steatosis (\u0026lt;\u0026thinsp;30%) and cannot reliably assess fibrosis, which is the key determinant of long-term prognosis [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e]. Third, as a single-center study in China, our findings may not be generalizable to other ethnic populations with different genetic backgrounds, dietary habits, and prevalences of H. pylori strains with varying virulence. We also lacked data on H. pylori strain typing (e.g., CagA status), which may be an important effect modifier [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e]. Finally, residual confounding from unmeasured variables such as dietary patterns, physical activity, socioeconomic status, and detailed medication use cannot be completely ruled out [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e, \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusions","content":"\u003cp\u003eIn conclusion, this large-scale study demonstrates that H. pylori infection is significantly and independently associated with the severity of MAFLD. The association is strong, graded, and persists after adjustment for key metabolic confounders. The elevated levels of inflammatory markers and fasting glucose in infected patients support the hypothesis that H. pylori may contribute to MAFLD progression through mechanisms involving chronic systemic inflammation and insulin resistance. These findings provide a strong rationale for prospective longitudinal studies and, importantly, for randomized controlled trials to investigate whether H. pylori eradication can serve as a novel, safe, and cost-effective strategy to mitigate disease progression and improve outcomes in the growing population of patients with MAFLD [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e].\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eALT: Alanine aminotransferase\u003c/p\u003e\n\u003cp\u003eAST: Aspartate aminotransferase\u003c/p\u003e\n\u003cp\u003eBMI: Body mass index\u003c/p\u003e\n\u003cp\u003eCI: Confidence interval\u003c/p\u003e\n\u003cp\u003eDBIL: Direct bilirubin\u003c/p\u003e\n\u003cp\u003eDBP: Diastolic blood pressure\u003c/p\u003e\n\u003cp\u003eGLU: Fasting plasma glucose\u003c/p\u003e\n\u003cp\u003eHbA1c: Glycated hemoglobin\u003c/p\u003e\n\u003cp\u003eHDL-C: High-density lipoprotein cholesterol\u003c/p\u003e\n\u003cp\u003eH. pylori: Helicobacter pylori\u003c/p\u003e\n\u003cp\u003eIR: Insulin resistance\u003c/p\u003e\n\u003cp\u003eLDL-C: Low-density lipoprotein cholesterol\u003c/p\u003e\n\u003cp\u003eLYM: Lymphocyte count\u003c/p\u003e\n\u003cp\u003eMAFLD: Metabolic dysfunction-associated fatty liver disease\u003c/p\u003e\n\u003cp\u003eMASLD: Metabolic dysfunction-associated steatotic liver disease\u003c/p\u003e\n\u003cp\u003eNAFLD: Non-alcoholic fatty liver disease\u003c/p\u003e\n\u003cp\u003eNE: Neutrophil count\u003c/p\u003e\n\u003cp\u003eOR: Odds ratio\u003c/p\u003e\n\u003cp\u003eSBP: Systolic blood pressure\u003c/p\u003e\n\u003cp\u003eTBIL: Total bilirubin\u003c/p\u003e\n\u003cp\u003eTC: Total cholesterol\u003c/p\u003e\n\u003cp\u003eTG: Triglycerides\u003c/p\u003e\n\u003cp\u003eT2DM: Type 2 diabetes mellitus\u003c/p\u003e\n\u003cp\u003eWBC: White blood cell count\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was approved by the Ethics Committee of The Third People's Hospital of Yunnan Province and was performed in accordance with the ethical standards of the 1964 Declaration of Helsinki and its later amendments. Due to the retrospective nature of the study, the requirement for informed consent was waived by the ethics committee.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets generated and analyzed during the current study are not publicly available due to patient privacy and institutional data protection policies but are available from the corresponding author upon reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis work was supported by the Yunnan health training project of high level talents (D-2024049), the Yunnan Province high-level scientific and technological talents and innovation team selection special - young and middle-aged academic and technical leaders reserve talent project (No: 202405AC350067). The funding bodies played no role in the study design, data collection, analysis, interpretation, or manuscript writing.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors' contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSimin Zhang and Sheng Zheng contributed to the study conception and design. Jiao Li and Cui Deng were responsible for data collection and analysis. Simin Zhang drafted the manuscript. Simin Zhang and Sheng Zheng critically revised the manuscript for important intellectual content. All authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eChinese Society of Hepatology, Chinese Medical Association. 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Gut. 2023;72:1258\u0026ndash;70. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1136/gutjnl-2022-327076\u003c/span\u003e\u003cspan address=\"10.1136/gutjnl-2022-327076\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-gastroenterology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bmge","sideBox":"Learn more about [BMC Gastroenterology](http://bmcgastroenterol.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bmge/default.aspx","title":"BMC Gastroenterology","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Metabolic dysfunction-associated fatty liver disease, Non-alcoholic fatty liver disease, Helicobacter pylori, Insulin resistance, Disease severity, Inflammation","lastPublishedDoi":"10.21203/rs.3.rs-8916798/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8916798/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eThe relationship between Helicobacter pylori (H. pylori) infection and metabolic dysfunction-associated fatty liver disease (MAFLD) has garnered increasing attention; however, its correlation with disease severity remains inadequately characterized. This study aimed to investigate the association between H. pylori infection and the severity of MAFLD in a large Chinese cohort.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eThis cross-sectional study consecutively enrolled 2,610 patients diagnosed with MAFLD at the Department of Gastroenterology, The Third People's Hospital of Yunnan Province, between January 2023 and June 2025. Patients were stratified into mild, moderate, and severe MAFLD groups based on abdominal ultrasound findings and further categorized according to H. pylori status determined by \u0026sup1;\u0026sup3;C/\u0026sup1;⁴C-urea breath test. Clinical characteristics, metabolic profiles, and laboratory parameters were compared. Multivariate logistic regression analysis was employed to identify independent risk factors for MAFLD progression.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eAmong the 2,610 participants (71.9% male; mean age 47.8\u0026thinsp;\u0026plusmn;\u0026thinsp;11.6 years), the overall prevalence of H. pylori infection was 28.2%. Patients in the H. pylori-positive group exhibited significantly higher levels of fasting glucose (GLU), white blood cell count (WBC), and neutrophil count (NE) compared to the negative group (all P\u0026thinsp;\u0026lt;\u0026thinsp;0.05). In subgroup analyses stratified by MAFLD severity, aspartate aminotransferase (AST) levels were consistently higher in H. pylori-positive patients across all severity grades (all P\u0026thinsp;\u0026lt;\u0026thinsp;0.05). H. pylori positivity was associated with elevated WBC and lymphocyte (LYM) counts in the mild MAFLD group; higher alanine aminotransferase (ALT) and total cholesterol (TC) in the moderate group; and higher ALT and LYM in the severe group (all P\u0026thinsp;\u0026lt;\u0026thinsp;0.05). A strong positive correlation was observed between H. pylori infection and MAFLD severity (*r* = 0.638, P\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Multivariate logistic regression confirmed H. pylori infection as an independent risk factor for severe MAFLD (mild vs. severe: OR\u0026thinsp;=\u0026thinsp;297.00, 95% CI: 92.13\u0026ndash;957.48, P\u0026thinsp;\u0026lt;\u0026thinsp;0.001; moderate vs. severe: OR\u0026thinsp;=\u0026thinsp;21.57, 95% CI: 5.91\u0026ndash;78.75, P\u0026thinsp;\u0026lt;\u0026thinsp;0.001). High-density lipoprotein cholesterol (HDL-C) and TC were also independently associated with MAFLD severity.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eH. pylori infection is significantly and independently associated with the severity of MAFLD. The elevated GLU, WBC, and NE levels in infected patients suggest that H. pylori may exacerbate MAFLD through mechanisms involving glycemic dysregulation and low-grade systemic inflammation. Screening for H. pylori infection may have clinical utility in the risk stratification of patients with MAFLD.\u003c/p\u003e","manuscriptTitle":"Association between Helicobacter pylori infection and the severity of metabolic dysfunction-associated fatty liver disease: a large-scale cross-sectional study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-03-11 16:53:58","doi":"10.21203/rs.3.rs-8916798/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"reviewerAgreed","content":"39350830575899734616114464304210702993","date":"2026-03-22T09:36:02+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-03-05T10:54:00+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2026-02-20T13:51:46+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-02-20T04:05:31+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-02-20T04:03:42+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Gastroenterology","date":"2026-02-19T10:48:40+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-gastroenterology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bmge","sideBox":"Learn more about [BMC Gastroenterology](http://bmcgastroenterol.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bmge/default.aspx","title":"BMC Gastroenterology","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"037094d0-e296-4f0e-9dc9-b229ab447c05","owner":[],"postedDate":"March 11th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-03-11T16:53:58+00:00","versionOfRecord":[],"versionCreatedAt":"2026-03-11 16:53:58","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8916798","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8916798","identity":"rs-8916798","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}