ISSN: 2641-2977
Arch Hepat Res
Research Article       Open Access      Peer-Reviewed

Non-Alcoholic Fatty Liver Disease Frequency among Healthy Blood Donors in the West of Iran

Amir Houshang Mohammad Alizadeh, Mohammad Hadizadeh, Maryam Padashi and Mitra Ranjbar*

Department of Infectious Diseases, Iran University of Medical Sciences, Tehran, Iran
*Corresponding author: Mitra Ranjbar, MD, Department of Infectious Diseases, Iran University of Medical Sciences, Tehran, Iran, E-mail:
Received: 16 August, 2016 | Accepted: 29 August, 2016 | Published: 30 August, 2016
Keywords: Non-alcoholic fatty liver disease; Body mass index; Metabolic syndrome; Blood donors

Cite this as

Mohammad Alizadeh AH, Hadizadeh M, Padashi M, Ranjbar M (2016) Non-Alcoholic Fatty Liver Disease Frequency among Healthy Blood Donors in the West of Iran. Arch Hepat Res 2(1): 001-004. DOI: 10.17352/ahr.000004

Objectives: To investigate the prevalence of NAFLD as well as the determination of associated metabolic abnormalities in Iranian blood donors. The aim of this study was to review cases of non-alcoholic fatty liver disease and to determine the prevalence of non-alcoholic fatty liver disease as a cause of elevated alanine aminotransferase in healthy blood donors and also assess risk factors of NAFLD such as BMI and correlation with metabolic syndrome in these subjects.

Background: Non-alcoholic fatty liver disease has been increasingly recognized as the most common pathological conditions affecting the liver. Non-alcoholic fatty liver disease is now recognized as the hepatic component of the metabolic syndrome, which includes hyperlipidemia, glucose intolerance, obesity, and systemic hypertension.

Methods: This cross-sectional study was conducted among a sample of 479 blood donor aged between 17-66 years in Hamedan, Iran. The donor answered a questionnaire that included age, gender, and medical history, and were submitted to a complete physical exam and abdominal ultrasound. Biochemical exams included: ALT, AST, ALP, fasting glucose, cholesterol and triglycerides. Criteria for NAFLD included: the presence of steatosis in ultrasound and/or elevated ALT/AST with negative intake of alcohol, negative use of drug, negative investigation for hepatitis A, B, C, auto-immune hepatitis, Wilson disease and hemochromatosis.

Results: From August, 2012 to January, 2013, the study included 479 subjects between 17 and 66 years of age and a mean age of 33.3 ± 10.5 years. The prevalence of NAFLD was 35.7% (mild 21.3%, moderate 13.4%, sever 1%). From lower to higher BMI category; alanine aminotransferase (ALT), total cholesterol, LDL cholesterol and triglycerides statistically increased significantly. In all BMI categories, ALT increased significantly by increasing the number of the components of the metabolic syndrome. Odds ratio for elevated liver enzymes and sonographic fatty liver increased significantly with higher BMI categories before and after adjustment for age.

Conclusion: There was a strong relationship between NAFLD and the abnormal metabolic variables in blood donors. It would be very useful if people are exposed to some determination such as waist circumference, blood pressure, FBS and serum lipid profile in order to screen those susceptible to NAFLD.


Nonalcoholic fatty liver disease (NAFLD) is a clinico-pathological condition of wide spectrum, which includes steatosis and steatohepatitis that has a potential to advance to cirrhosis and hepatocellular carcinoma [1]. NAFLD is probably the most common underlying cause of cryptogenic cirrhosis [2,3]. NAFLD is the most common liver disorder in the world, affecting 2.8% to 24% of the general population [4] and is the most common cause of persistently elevated serum ALT in the asymptomatic Iranian blood donors in Tehran [5]. In adults visceral obesity has been considered the main risk factor for the development of NAFLD [6,7]. Different studies have shown that NAFLD is associated with older age, diabetes mellitus, obesity and dyslipidemia (especially increased triglyceride) [8,9]. In most instances, an incidental finding of abnormal serum aminotransferase leads to the diagnosis of fatty liver or NAFLD in adults [10]. This study determined the prevalence of NAFLD as a cause of elevated alaninaminotransferase in healthy blood donors in hamedan and also risk factors of NAFLD, such as raised BMI and the metabolic syndrome in these subjects.

Materials and Methods

Population selection

In a cross-sectional study during six-month period from August, 2012 to January, 2013, we collected data from in the Blood Donation Center of Hamedan, 479 healthy blood donors (age between 17-66 years), were recruited in this study with no history of alcohol consumption and also any kind of liver diseases such as hepatitis and liver metabolic disease. According to the regulations of the Blood Transfusion Organization of Iran, the following individuals are not allowed to donate blood: those who have had major chronic disease, those with any mild to severe acute disease and intravenous drug users.

Exclusion criteria: Previous historic or serologic markers for liver diseases (hepatitis A, B, C), auto-immune disease, metabolic diseases such as Wilsons Disease and hemochromatosis and intake of alcohol above 140 g/wk.

Clinical evaluation

Demographic information, as well as baseline characteristics like age, drug and disease history was collected for each individual by trained interviewers.

Anthropometric measures: waist circumference (WC) was measured at the end of normal expiration in the middle portion between the last rib and the iliac ridge whereas hip circumference was similarly obtained at the widest point between the hip and the buttock. Participants were weighed while not wearing coats or shoes or carrying any objects. A Filizola balance was used, with a scale resolution of 0.1 kg. Height was measured by a stadiometer with no shoes and hair accessories; the resolution was 0.5 cm. BMI (Body Mass Index) was calculated by dividing weight by height squared and categorized according to the classification of National Heart, Lung and Blood Institute of the USA as follows: normal weight (18.5 24.9kg/m2), overweight (25-29.9 kg/m2) and obese (30-34.9 kg/M2) [11].

All patients underwent superior abdomen ultrasound scan (AUS). The AUS was performed by only one medical doctor. The scanner used was an Aloka, model DynaView II, with colored Doppler and a 3.5 MHz drill. The discrepancy of echogenicity between the liver and kidney was considered as a criterion. Hepatic steatosis was graded as mild, moderate or severe, according to the Saverumuttu et al. [12], classification. 

Serological assays

Blood samples were collected during the same session by the technical staff after a 12 h fasting. The samples were analyzed in a referential laboratory for Alanine aminotransferase(ALT) and aspartate aminotransferase (AST), Alkaline phosphatase(ALP), fasting blood sugar (FBS), total cholesterol, triglycerides (Tg), low-density cholesterol (LDL-C), high-density cholesterol (HDL-C), and anti-HCV antibody (anti-HCV) with the use of a third generation ELISA test (Ortho HCV 3.0 Enhanced SAVe ELISA, Ortho-Clinical Diagnostics, Amer­sham, UK and Hepanostika HCV Ultrakit, Beijing United Biomedical Co., Beijing, China),and HBsAg were also evaluated by an Enzygnost HBsAg 5.0 kit (Dade Behring, Germany). Normal upper limit for ALT was considered 40 units per liter (U/L).

Anthropometric measurements

Anthropometric measurements of individuals wearing light clothing and without shoes were conducted by well-trained examiners.

Height was measured to the nearest 0.1 cm with a portable stadiometer.

Weight was measured in an upright position to the nearest 0.1 kg with a calibrated scale.

Body mass index was calculated by dividing weight (kg) by height squared (m²).

Waist circumference measurements were taken at the end of normal expiration to the nearest 0.1 cm, measuring from the narrowest point between the lower borders of the rib cage and the iliac crest , whereas hip circumferences was similarly obtained at the widest point between hip and buttock.

Blood pressure measurements and biochemical analysis

A mercury sphygmomanometer (Baumanometer; WA Baum CO, Inc, Tokyo, Japan) was used to measure the blood pressure of each subject while in a sitting position after a 5-min rest period.

During the 30 minute preceding the measurement, the subjects were required to refrain from smoking or consuming caffeine.

The appearance of the first sound (phase 1 Korotkoff sound) was used to define systolic blood pressure, and the disappearance of sound (phase 5 Korotkoff sound) was used to define diastolic blood pressure.

Blood samples were collected from the antecubital vein in the morning where they had been fasted for 9-12 hours. The samples were subsequently analyzed at a central, certified laboratory. Plasma concentrations of glucose, total cholesterol, triglyceride, HDL cholesterol, and AST, ALT were measured with an auto analyzer.

Statistical analyses

The data were analyzed using Statistical Package for Social Science (SPSS) 17.0. Mistake type was estimated to be 5%. Spearman was used for the correlation between variables. The data are expressed as percentage, medium and standard deviation. Weighted logistic regression analyses were used to calculate the odds ratio (OR) and 95% confidence interval (95% CI) for each risk factor. A final logistic regression analysis was performed by a back­ward model selection for age, sex, BMI, Multivariate logistic regression analysis was used to identify independent risk factors for NAFLD. All analyses were two-tailed and P<0.05 was considered to be statistically significant.


The study included 479 subjects between 17 and 66 years of age and a mean age of 33.3 ± 10.5 years, 442(92.3%) were male and 37(7.7%) female. There was no significant difference between sex (P>0.3).

BMI (Body Mass Index) in these 479 subjects ranged from 19.1 to 38.2 and mean of BMI in all subjects was 28±4.3 .Overweight was observed in 201(42%) and obese 148(30.9%) of studied with central obesity. There was a positive correlation between BMI and WC values and the mean value of BMI was significantly higher in abnormal LFT than in normal LFT. The prevalence of elevated ALT as another diagnostic indicator was 25.3%. WC had a statistically significant correlation with ALT (P < 0.05). Fatty liver was diagnosed by ultrasound in 171(35.7%), divided between mild (21.3%), moderate (13.4%) and severe (1%). Non-alcoholic fatty liver disease was significantly more common in the hypertriglyceridemia and hypercholesterolemia (P<0.0001).The prevalence of NAFLD in obese, overweight and normal weight patients was 30.3%, 5.4% and 0.0% respectively (P<0.000) (Table 1).


Obesity is the most common entity associated with NAFLD and a significant risk factor for the development of fatty liver and is also predictive for the presence of fibrosis [13]. Many epidemiological studies demonstrated a strong correlation between body mass index and the presence of fatty liver diagnosed by ultrasonography. 30 to 100% of patients diagnosed with NAFLD are Obese [14], in obese persons 76% have NAFLD compare with 16% in normal weight persons [15]. BMI is an important predictor for hepatic steatosis. The risk of hepatic steatosis increase exponentially with the addition of each component of the metabolic syndrome. A study on 271 nondiabetic subjects demonstrated that liver fat was 4-fold higher in subjects with than without the metabolic syndrome. Among the components of metabolic syndrome the best correlation of liver fat was with waist circumference both in women and in men [16]. Positive correlation between BMI and WC in patients, as observed in this study, is also a common finding related to cardiovascular disease in other studies [17,18]. The characteristics of disease appear to be similar to those in other studies. Gender has not been considered to be a risk factor for NAFLD [19].

The diagnosis of NAFLD is often established after the identification of abnormal serum aminotransferase. The gold standard for diagnosis is liver biopsy. Although the procedure is effective as a prognostic indicator, liver biopsy is invasive and costly. Sonography has been used in assessing NAFLD but is lacking in the ability to assess fibrosis [20]. The frequency of NAFLD measured by sonography, which is more compared with the ALT determination, is in agreement with that in the study of Franzese in Italy (reported as 53% in sonography vs 25% through ALT determination) on obese patients [21]. The prevalence of an isolated elevated ALT levels (cut-off value of 41/UL for both men and women) after excluding individuals with viral hepatitis, alcohol and drug etiologies was 25.3% whereas 52(10.9%) of NAFLD had normal ALT. In the study which carried out on Tehran blood donation center prevalence elevated ALT reported 5.71% [22]. This prevalence in the Third National Health and Nutrition study of the population of the United States was 2.8% [23]. We found through sonography as a diagnostic method of NAFLD that elevated ALT and metabolic variables such as high total cholesterol, waist circumference, BMI and LDL were significantly associated with the disease. There are some reports from Korea and Mexico showing that the most important factors associated with NAFLD are high total cholesterol, LDL, triglyceride, ALT, insulin, obesity and low HDL [24,25], which confirms the results reported in our project.

In conclusion, NAFLD in asymptomatic Iranian was most frequent among patients with central obesity. These patients came from an area in Iran where it is relevant to consider the proportion of Asian descendants, and the influence of ethnicity on the prevalence the NAFLD may be an important factor in this population. However, this hypothesis deserves future study.

  1. Cotrim HP, Parana R, Braga E, Lyra L (2000) Nonalcoholic steatohepatitis and hepatocellular carcinoma: natural history? Am J Gastroenterol 95: 3018-3019 .
  2. Biornsson E (2008) The clinical aspects of non-alcoholic fatty liver disease. Minerva Gastroentrol Dietol 54: 7-18.
  3. Bugianesi E, Leone N, Vanni E, Marchesini G, Brunello F, et al. (2002) Expanding the natural history of non-alcoholic steatohepatitis: from cryptogenic cirrhosis to hepatocellular carcinoma. Gastroenterology 23: 134-140 .
  4. Caldwell SH, Oelsner DH, Iezzoni JC, Hespenheide EE, Battle EH (1999) Cryptogenic cirrhosis: clinical characterization and risk factors for underlying disease. Hepatology 29: 664-669 .
  5. Pourshams A, Malekzadeh R, Monavvari A, Akbari MR, Mohamadkhani A, et al. (2005) Prevalence and etiology of persistently elevated alanine aminotransferase level in healthy Iranian blood donors. J Gastroenterol Hepatol 20: 229-233 .
  6. Fishbein MH, Mogren C, Gleason T, Stevens WR (2006) Relationship of hepatic steatosis to adipose tissue distribution in pediatric nonalcoholic fatty liver disease. J Pediatr Gastroenterol Nutr 42: 83-88 .
  7. Kral JG, Schaffner F, Pierson RN Jr, Wang J (1993) Body fat topography as an independent predictor of fatty liver. Metabolism 42: 548-551 .
  8. Wanless IR, Lentz JS (1990) Fatty liver hepatitis (steatohepatitis) and obesity: an autopsy study with analysis of risk factors. Hepatology 12: 1106-1110 .
  9. de Luis DA, Aller R, Izaola O, Sagrado MG, Conde R, et al. (2008) Effect of a hypocaloric diet in transaminases in nonalcoholic fatty liver disease and obese patients, relation with insulin resistance. Diabetes Res Clin Pract 79: 74-78 .
  10. Papandreou D, Rousso I, Mavromichalis L (2007) Update on nonalcoholic fatty liver disease in children. Clin Nutrition 26: 409–415 .
  11. US Department of Health and Human Services (1998) Clinical guidelines on the identification, evaluation, and treatment of overweight and obesity in adults. Washington, DC: US Department of Health and Human Services .
  12. Saverymuttu SH, Joseph AE, Maxwell JD (1986) Ultrasound scanning in the detection of hepatic fibrosis and steatosis. Br Med J (Clin Res Ed) 292: 13-15
  13. Festi D, Colecchia A, Sacco T, Bondi M, Roda E, Marchesini G (2004) Hepatic steatosis in obese patients:clinical aspects and prognostic significance. Obesity reviews 5: 27-42 .
  14. Angulo P (2002) Nonalcoholic Fatty Liver Disease. N Engl J Med 346: 1221-1231 .
  15. Adams LA, Angulo P (2005) Recent concepts in non-alcoholic fatty liver disease. Diabet Med 22: 1129-1133 .
  16. Kotronen A, Westerbacka J, Bergholm R, Pietilainen KH, Yki-Jarvinen H (2007) Liver fat in the metabolic syndrom. J Clin Endocrinol Metab 92: 3490-3497 .
  17. Rosa ML, Mesquita ET, da Rocha ER, Fonseca Vde M (2007) Body mass index and waist circumference as markers of arterial hypertension in adolescents. Arq Bras Cardiol 88: 573-578.  
  18. Kelishadi R, Gheiratmand R, Ardalan G, Adeli K, Mehdi Gouya M, et al. (2007). Association of anthropometric indices with cardiovascular disease risk factors among children and adolescents: CASPIAN Study. Int J Cardiol 117: 340-348 .
  19. Quiros-Tejeira RE, Rivera CA, Ziba TT, Mehta N, Smith CW, et al. (2007) Risk for nonalcoholic fatty liver disease in Hispanic youth with BMI > or =95th percentile. J Pediatr Gastroenterol Nutr 44: 228-236.
  20. Fishbein MH1, Miner M, Mogren C, Chalekson J (2003) The spectrum of fatty liver in obese children and the relationship of serum aminotransferase to severity of steatosis. J Pediatr Gastroenterol Nutrition 36: 54–61 .
  21. Franzese A, Vajro P, Argenziano P, et al. (1997) Liver involvement in obese children: ultrasonography and liver enzyme levels at diagnosis and during follow up in an Italian population. Dig Dis Sci 42: 1428–1432 .
  22. Pourshams A, Malekzadeh R, Monavvari A, Akbari MR, Mohamadkhani A, et al. (2005) Prevalence and etiology of persistently elevated alanine aminotransferase level in healthy Iranian blood donors. J Gastroenterol Hepatol 20: 229-233 .
  23. Anderson NA, Raafat A, Shwe KH, Barbara J, Contreras M, et al. (1982) UK multicenter study on blood donors for surrogate marker of non-A nin-B hepatitis. Part I: alanine transferase and anti-HBC testing. Transfus Med 2: 301-310 .
  24. Park HS, Han JH, Choi KM, et al. (2005) Relation between elevated serum alanine aminotransferase and metabolic syndrome in Korean adolescents. Am J Clin Nutr 82: 1046–1051 .
  25. Flores-Calderón J, Gómez-Díaz RA, Rodríguez-Gómez G, Morán-Villota S (2005) Frequency of increased aminotransferase levels and associated metabolic abnormalities in obese and overweight children of an elementary school in Mexico City. Ann Hepatol 4: 279–283 .
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