{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,9,14]],"date-time":"2026-09-14T20:08:00Z","timestamp":1789416480686,"version":"build-2803163510"},"reference-count":34,"publisher":"MDPI AG","issue":"11","license":[{"start":{"date-parts":[[2021,11,1]],"date-time":"2021-11-01T00:00:00Z","timestamp":1635724800000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["Children"],"abstract":"<jats:p>Background: Owing to the increasing rate of pediatric obesity, its complications such as non-alcoholic fatty liver disease (NAFLD) and obstructive sleep apnea (OSA) have become prevalent already in childhood. We aimed to assess the relationship between these two diseases in a cohort of children with obesity. Methods: We enrolled 153 children with obesity (mean age 10.5 \u00b1 2.66, mean BMI 30.9 \u00b1 5.1) showing OSA. Subjects underwent a laboratory evaluation, a cardio-respiratory polysomnography (PSG), and a liver ultrasound. Results: All subjects had a clinical diagnosis of OSA based on the AHI &gt; 1\/h (mean AHI 8.0 \u00b1 5.9; range 2.21\u201319.0). Of these, 69 showed hepatic steatosis (62.3% as mild, 20.3% as moderate, and 17.4% as severe degree). A strong association between ALT and apnea\/hypopnea index (AHI) was observed (p = 0.0003). This association was not confirmed after adjusting for hepatic steatosis (p = 0.53). By subdividing our population according to the presence\/absence of steatosis, this association was found only in the steatosis group (p = 0.009). As the severity of steatosis increased, the significance of its association with AHI compared to the absence of steatosis became progressively stronger (all p &lt; 0.0001). Conclusions: Hepatic steatosis seems to drive the association between OSA and ALT levels, suggesting a potential pathogenic role of OSA in NAFLD.<\/jats:p>","DOI":"10.3390\/children8110984","type":"journal-article","created":{"date-parts":[[2021,11,1]],"date-time":"2021-11-01T22:21:08Z","timestamp":1635805268000},"page":"984","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":9,"title":["Association between Hepatic Steatosis and Obstructive Sleep Apnea in Children and Adolescents with Obesity"],"prefix":"10.3390","volume":"8","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-8136-7597","authenticated-orcid":false,"given":"Marco","family":"Carotenuto","sequence":"first","affiliation":[{"name":"Clinic of Child and Adolescent Neuropsychiatry, Department of Mental Health, Physical and Preventive Medicine, University of Campania \u201cLuigi Vanvitelli\u201d, 80100 Naples, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-5877-3757","authenticated-orcid":false,"given":"Anna","family":"Di Sessa","sequence":"additional","affiliation":[{"name":"Department of Woman, Child and General and Specialized Surgery, University of Campania \u201cLuigi Vanvitelli\u201d, 80138 Naples, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Maria","family":"Esposito","sequence":"additional","affiliation":[{"name":"Clinic of Child and Adolescent Neuropsychiatry, Department of Mental Health, Physical and Preventive Medicine, University of Campania \u201cLuigi Vanvitelli\u201d, 80100 Naples, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Anna","family":"Grandone","sequence":"additional","affiliation":[{"name":"Department of Woman, Child and General and Specialized Surgery, University of Campania \u201cLuigi Vanvitelli\u201d, 80138 Naples, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-4682-0170","authenticated-orcid":false,"given":"Pierluigi","family":"Marzuillo","sequence":"additional","affiliation":[{"name":"Department of Woman, Child and General and Specialized Surgery, University of Campania \u201cLuigi Vanvitelli\u201d, 80138 Naples, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Ilaria","family":"Bitetti","sequence":"additional","affiliation":[{"name":"Clinic of Child and Adolescent Neuropsychiatry, Department of Mental Health, Physical and Preventive Medicine, University of Campania \u201cLuigi Vanvitelli\u201d, 80100 Naples, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-5570-6620","authenticated-orcid":false,"given":"Giuseppina Rosaria","family":"Umano","sequence":"additional","affiliation":[{"name":"Department of Woman, Child and General and Specialized Surgery, University of Campania \u201cLuigi Vanvitelli\u201d, 80138 Naples, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Francesco","family":"Precenzano","sequence":"additional","affiliation":[{"name":"Clinic of Child and Adolescent Neuropsychiatry, Department of Mental Health, Physical and Preventive Medicine, University of Campania \u201cLuigi Vanvitelli\u201d, 80100 Naples, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Emanuele","family":"Miraglia del Giudice","sequence":"additional","affiliation":[{"name":"Department of Woman, Child and General and Specialized Surgery, University of Campania \u201cLuigi Vanvitelli\u201d, 80138 Naples, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Nicola","family":"Santoro","sequence":"additional","affiliation":[{"name":"Department of Pediatrics, Yale University, New Haven, CT 06510, USA"},{"name":"Department of Medicine and Health Sciences, \u201cV.Tiberio\u201d University of Molise, 86100 Campobasso, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1968","published-online":{"date-parts":[[2021,11,1]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"e4046","DOI":"10.1210\/clinem\/dgaa583","article-title":"Nonalcoholic Fatty Liver Disease and Estimated Insulin Resistance in Obese Youth: A Mendelian Randomization Analysis","volume":"105","author":"Morandi","year":"2020","journal-title":"J. Clin. Endocrinol. Metab."},{"key":"ref_2","doi-asserted-by":"crossref","unstructured":"Bhatt, S.P., Guleria, R., and Kabra, S.K. (2021). Metabolic alterations and systemic inflammation in overweight\/obese children with obstructive sleep apnea. PLoS ONE, 16.","DOI":"10.1371\/journal.pone.0252353"},{"key":"ref_3","doi-asserted-by":"crossref","first-page":"1840","DOI":"10.1016\/j.numecd.2020.05.024","article-title":"Elevated blood pressure, cardiometabolic risk and target organ damage in youth with overweight and obesity","volume":"30","author":"Pacifico","year":"2020","journal-title":"Nutr. Metab. Cardiovasc. Dis."},{"key":"ref_4","doi-asserted-by":"crossref","first-page":"7347","DOI":"10.3748\/wjg.v20.i23.7347","article-title":"Pediatric fatty liver disease: Role of ethnicity and genetics","volume":"20","author":"Marzuillo","year":"2014","journal-title":"World J. Gastroenterol."},{"key":"ref_5","doi-asserted-by":"crossref","first-page":"1817","DOI":"10.2337\/dc10-0284","article-title":"Central Role of Fatty Liver in the Pathogenesis of Insulin Resistance in Obese Adolescents","volume":"33","author":"Cali","year":"2010","journal-title":"Diabetes Care"},{"key":"ref_6","doi-asserted-by":"crossref","first-page":"1896","DOI":"10.1002\/hep.22858","article-title":"Glucose dysregulation and hepatic steatosis in obese adolescents: Is there a link?","volume":"49","author":"Cali","year":"2009","journal-title":"Hepatology"},{"key":"ref_7","doi-asserted-by":"crossref","first-page":"864","DOI":"10.1016\/S2468-1253(21)00183-7","article-title":"Defining paediatric metabolic (dysfunction)-associated fatty liver disease: An international expert consensus statement","volume":"6","author":"Eslam","year":"2021","journal-title":"Lancet Gastroenterol. Hepatol."},{"key":"ref_8","first-page":"e934134-1","article-title":"A Review of the Increasing Prevalence of Metabolic-Associated Fatty Liver Disease (MAFLD) in Children and Adolescents Worldwide and in Mexico and the Implications for Public Health","volume":"27","year":"2021","journal-title":"Med. Sci. Monit."},{"key":"ref_9","doi-asserted-by":"crossref","unstructured":"Di Sessa, A., Guarino, S., Umano, G., Arenella, M., Alfiero, S., Quaranta, G., del Giudice, E.M., and Marzuillo, P. (2021). MAFLD in Obese Children: A Challenging Definition. Children, 8.","DOI":"10.3390\/children8030247"},{"key":"ref_10","doi-asserted-by":"crossref","first-page":"49","DOI":"10.1055\/s-0032-1306426","article-title":"Obstructive Sleep Apnea-Hypopnea Syndrome and Nonalcoholic Fatty Liver Disease: Emerging Evidence and Mechanisms","volume":"32","author":"Musso","year":"2012","journal-title":"Semin. Liver Dis."},{"key":"ref_11","doi-asserted-by":"crossref","unstructured":"Almendros, I., Basoglu, \u00d6.K., Conde, S.V., Liguori, C., and Saaresranta, T. (2021). Metabolic dysfunction in OSA: Is there something new under the sun?. J. Sleep Res., e13418.","DOI":"10.1111\/jsr.13418"},{"key":"ref_12","doi-asserted-by":"crossref","unstructured":"Bachrach, K., Danis, I.D.O., Cohen, M.B., and Levi, J.R. (2021). The Relationship Between Obstructive Sleep Apnea and Pediatric Obesity: A Nationwide Analysis. Ann. Otol. Rhinol. Laryngol.","DOI":"10.1177\/00034894211028489"},{"key":"ref_13","doi-asserted-by":"crossref","first-page":"247","DOI":"10.1016\/j.prrv.2006.08.003","article-title":"Obesity and obstructive sleep apnea in children","volume":"7","author":"Tauman","year":"2006","journal-title":"Paediatr. Respir. Rev."},{"key":"ref_14","doi-asserted-by":"crossref","first-page":"92","DOI":"10.1378\/chest.07-0773","article-title":"Elevated Serum Aminotransferase Levels in Children at Risk for Obstructive Sleep Apnea","volume":"133","author":"Gozal","year":"2008","journal-title":"Chest"},{"key":"ref_15","doi-asserted-by":"crossref","first-page":"149","DOI":"10.3389\/fneur.2012.00149","article-title":"Obstructive Sleep Apnea and Non-Alcoholic Fatty Liver Disease: Is the Liver Another Target?","volume":"3","author":"Mirrakhimov","year":"2012","journal-title":"Front. Neurol."},{"key":"ref_16","doi-asserted-by":"crossref","first-page":"225","DOI":"10.1016\/j.jhep.2011.04.022","article-title":"Chronic intermittent hypoxia is a major trigger for non-alcoholic fatty liver disease in morbid obese","volume":"56","author":"Minville","year":"2012","journal-title":"J. Hepatol."},{"key":"ref_17","doi-asserted-by":"crossref","first-page":"1007","DOI":"10.1002\/hep.21593","article-title":"Chronic intermittent hypoxia predisposes to liver injury","volume":"45","author":"Savransky","year":"2007","journal-title":"Hepatology"},{"key":"ref_18","doi-asserted-by":"crossref","first-page":"G871","DOI":"10.1152\/ajpgi.00145.2007","article-title":"Chronic intermittent hypoxia causes hepatitis in a mouse model of diet-induced fatty liver","volume":"293","author":"Savransky","year":"2007","journal-title":"Am. J. Physiol.-Gastrointest. Liver Physiol."},{"key":"ref_19","doi-asserted-by":"crossref","first-page":"585","DOI":"10.1016\/j.jcmgh.2021.03.011","article-title":"Hypoxia via ERK Signaling Inhibits Hepatic PPAR\u03b1 to Promote Fatty Liver","volume":"12","author":"Mooli","year":"2021","journal-title":"Cell. Mol. Gastroenterol. Hepatol."},{"key":"ref_20","doi-asserted-by":"crossref","first-page":"357","DOI":"10.1016\/j.sleep.2006.01.005","article-title":"Waist circumference predicts the occurrence of sleep-disordered breathing in obese children and adolescents: A questionnaire-based study","volume":"7","author":"Carotenuto","year":"2006","journal-title":"Sleep Med."},{"key":"ref_21","doi-asserted-by":"crossref","first-page":"171","DOI":"10.1038\/sj.ejcn.1601314","article-title":"Italian cross-sectional growth charts for height, weight and BMI (6\u201320 y)","volume":"56","author":"Cacciari","year":"2002","journal-title":"Eur. J. Clin. Nutr."},{"key":"ref_22","doi-asserted-by":"crossref","first-page":"1143","DOI":"10.1016\/j.jhep.2013.06.027","article-title":"Weight loss allows the dissection of the interaction between abdominal fat and PNPLA3 (adiponutrin) in the liver damage of obese children","volume":"59","author":"Marzuillo","year":"2013","journal-title":"J. Hepatol."},{"key":"ref_23","doi-asserted-by":"crossref","first-page":"221","DOI":"10.1007\/s11325-010-0388-6","article-title":"Facial patterns and primary nocturnal enuresis in children","volume":"15","author":"Carotenuto","year":"2011","journal-title":"Sleep Breath."},{"key":"ref_24","doi-asserted-by":"crossref","first-page":"752","DOI":"10.1007\/BF03346531","article-title":"The insulin gene variable number of tandem repeats (INS VNTR) genotype and sleep disordered breathing in childhood obesity","volume":"32","author":"Carotenuto","year":"2009","journal-title":"J. Endocrinol. Investig."},{"key":"ref_25","doi-asserted-by":"crossref","first-page":"169","DOI":"10.5664\/jcsm.26818","article-title":"The Scoring of Respiratory Events in Sleep: Reliability and Validity","volume":"3","author":"Redline","year":"2007","journal-title":"J. Clin. Sleep Med."},{"key":"ref_26","doi-asserted-by":"crossref","first-page":"665","DOI":"10.5664\/jcsm.6576","article-title":"AASM Scoring Manual Updates for 2017 (Version 2.4)","volume":"13","author":"Berry","year":"2017","journal-title":"J. Clin. Sleep Med."},{"key":"ref_27","doi-asserted-by":"crossref","first-page":"793","DOI":"10.1148\/radiol.2343040142","article-title":"Appropriateness of a Donor Liver with Respect to Macrosteatosis: Application of Artificial Neural Networks to US Images\u2014Initial Experience","volume":"234","author":"Kim","year":"2005","journal-title":"Radiology"},{"key":"ref_28","doi-asserted-by":"crossref","first-page":"115","DOI":"10.1111\/ijpo.12032","article-title":"TM6SF2Glu167Lys polymorphism is associated with low levels of LDL-cholesterol and increased liver injury in obese children","volume":"11","author":"Grandone","year":"2015","journal-title":"Pediatr. Obes."},{"key":"ref_29","doi-asserted-by":"crossref","first-page":"472","DOI":"10.1097\/MPG.0000000000000463","article-title":"Novel Association Between a Nonsynonymous Variant (R270H) of the G-Protein\u2013Coupled Receptor 120 and Liver Injury in Children and Adolescents with Obesity","volume":"59","author":"Marzuillo","year":"2014","journal-title":"J. Pediatr. Gastroenterol. Nutr."},{"key":"ref_30","doi-asserted-by":"crossref","first-page":"1643","DOI":"10.1152\/japplphysiol.00522.2005","article-title":"Chronic intermittent hypoxia upregulates genes of lipid biosynthesis in obese mice","volume":"99","author":"Li","year":"2005","journal-title":"J. Appl. Physiol."},{"key":"ref_31","doi-asserted-by":"crossref","first-page":"2167","DOI":"10.1038\/oby.2011.240","article-title":"Intermittent Hypoxia Exacerbates Metabolic Effects of Diet-Induced Obesity","volume":"19","author":"Drager","year":"2011","journal-title":"Obesity"},{"key":"ref_32","doi-asserted-by":"crossref","first-page":"165","DOI":"10.1097\/MCG.0b013e31826df40a","article-title":"Diurnal Variation in Serum Alanine Aminotransferase Activity in the US Population","volume":"47","author":"Ruhl","year":"2013","journal-title":"J. Clin. Gastroenterol."},{"key":"ref_33","doi-asserted-by":"crossref","first-page":"1346","DOI":"10.1053\/j.gastro.2009.12.053","article-title":"Trunk Fat Is Associated with Increased Serum Levels of Alanine Aminotransferase in the United States","volume":"138","author":"Ruhl","year":"2010","journal-title":"Gastroenterology"},{"key":"ref_34","doi-asserted-by":"crossref","first-page":"190","DOI":"10.1097\/MPG.0b013e31821b4b61","article-title":"Ultrasonographic Quantitative Estimation of Hepatic Steatosis in Children with NAFLD","volume":"53","author":"Shannon","year":"2011","journal-title":"J. Pediatr. Gastroenterol. Nutr."}],"container-title":["Children"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/2227-9067\/8\/11\/984\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,10,11]],"date-time":"2025-10-11T07:24:06Z","timestamp":1760167446000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/2227-9067\/8\/11\/984"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2021,11,1]]},"references-count":34,"journal-issue":{"issue":"11","published-online":{"date-parts":[[2021,11]]}},"alternative-id":["children8110984"],"URL":"https:\/\/doi.org\/10.3390\/children8110984","relation":{},"ISSN":["2227-9067"],"issn-type":[{"value":"2227-9067","type":"electronic"}],"subject":[],"published":{"date-parts":[[2021,11,1]]}}}