This cross-sectional study of a representative 9,475 adults over the age of 20 in USA showed that blood concentrations of TBM, Br-THM, TTHM, and NAFLD were significantly positively associated with NAFLD, and that elevated levels of TCM and Cl-THM were also associated with an increased risk of NAFLD. Additionally, the positive association between TTHM and NAFLD was more pronounced in women, over the age of 60, below/normal weight, non-smokers, non-drinkers, and diabetics.
The previous experimental animal studies have shown that several disinfection by-products, such as dibromoacetic acid (DBAA) in haloacetic acid (HAA), significantly increase the incidence of hepatocellular tumors [37]. Furthermore, rats exposed to dichloroacetic acid (DCAA) and trichloroacetic acid (TCAA) in drinking water exhibited significant hepatotoxicity and liver damage [38, 39]. Seth et al. found that long-term exposure to BDCM could induce non-alcoholic NASH through free radical metabolism, which is co-mediated by the cytochrome P450 isoenzyme CYP2E1 and the adipokine leptin [21]. Dong et al. reported that exposure to THMs in mice led to an increase in hepatic macrophages, resulting in acute liver injury [40]. Epidemiological studies have also confirmed the association between disinfection by-products and liver injury. Burch et al. found that individuals with blood DBCM concentrations above the median had increased serum alanine aminotransferase (ALT) activity, and this association was more pronounced in non-drinking individuals [23]. Yang et al.'s cross-sectional study showed that Br-THMs and TTHMs were significantly and dose-dependently positively correlated with liver function indexes, such as alanine aminotransferase (ALT), aspartate aminotransferase (AST), total bilirubin (TBIL), and indirect bilirubin (IBIL) [41]. These findings confirm our results, and we further evaluated the association between blood THM exposure and NAFLD, which is the first systematic study of this association. We also found that blood THM concentrations had a negative impact on NAFLD. Blood TBM, Br-THM, and TTHM concentrations were significantly positively correlated with NAFLD in both unadjusted and fully adjusted models, and remained robust after sensitivity analyses. Blood TCM and Cl-THM also showed a tendency to be associated with NAFLD.
The mechanism of THMs promoting NAFLD is still unclear. THMs may contribute to the occurrence and progression of NAFLD through various mechanisms, such as interfering hepatocyte metabolism, inducing oxidative stress and inflammatory responses, and participating in the regulation of liver fibrosis. Firstly, THMs may induce NAFLD by interfering with glucolipid metabolism in hepatocytes. They can inhibit key glucose-metabolizing enzyme, such as hexokinase and pyruvate kinase, leading to glycolysis disorder, insulin resistance, and promoting lipogenesis, and fatty acid accumulation in the liver [42, 43]. Insulin resistance is a critical factor in the development of NAFLD, triggering lipotoxicity, oxidative stress, and inflammatory cascades [44, 45]. Additionally, studies have shown that THMs can significantly increase oxidative stress in hepatocytes, resulting in increased levels of reactive oxygen species (ROS), and activating protein-1 (AP-1) and nuclear factor-κB (NF-κB) pathways, promoting the release of inflammatory factors from hepatocytes and exacerbating hepatic inflammatory responses [46–48]. Therefore, THMs directly damages hepatocyte function by inducing oxidative stress and inflammation in hepatocytes, further aggravating the development of NAFLD. Furthermore, THMs may indirectly affect the activation of hepatic stellate cells by interfering with hepatocyte apoptosis and the release of inflammatory factors, resulting in a large number of collagen fibers and extracellular matrix synthesis, and accelerating hepatic fibrosis[49].
The present study included a large and nationally representative sample size, measured internal exposure to disinfection by-product (DBP) biomarkers, and used blood THM concentrations for assessmen to avoid the spatiotemporal variability of high THM concentrations in water [17] and included multiple models to systematically and comprehensively assess the association with NAFLD. Additionally, our study spanned 14 years and included seven cycles, filling in a gap regarding the relationship between disinfection by-products and NAFLD. However, there are some limitations in present study. Firstly, the cross-sectional study design only allowed us to observe data at a single point in time, and causality cannot be determined. In this case, we could only observe an association between blood THM exposure and NAFLD, but could not determine whether exposure was a cause or consequence of NAFLD. Secondly, although we have adjusted for numerous potential confounders, undetected confounders, random errors and so on may affect our results due to the complexity of NAFLD development. Thirdly, although blood concentrations were used as more reliable biomarkers of trihalomethane exposure, these concentrations can change over time, so exposure misclassification was still possible. Fourthly, due to the relatively low detection rates of DBCM and TBM concentrations in blood (55.5% and 32.6%, respectively), this may result in biased in risk estimates. Finally, our study did not explore the association of other DBPs with NAFLD, which may limit overall impact of disinfection by-products on NAFLD risk.
The results of this cross-sectional study, based on a nationally representative population, suggested that higher blood THM concentrations were associated with NAFLD in USA adults. This finding indicated that reducing exposure to THMs through improving water quality management could provide new strategy for NAFLD prevention. However, more prospective studies are needed to confirm this conclusion and elucidate the underlying mechanisms in the future.