Advanced Liver Fibrosis Is Common in Patients With Type 2 Diabetes Followed in the Outpatient Setting: The Need for Systematic Screening

Abstract

<b>Objective:</b> Assess the prevalence of NAFLD and of liver fibrosis associated with nonalcoholic steatohepatitis (NASH) in unselected patients with T2DM. <p><b>Research Design and Methods:</b> 561 patients with T2DM (age: 60±11; BMI: 33.4±6.2 kg/m<sup>2</sup>; HbA1c: 7.5±1.8%) attending primary care or endocrinology outpatient clinics and unaware of having NAFLD. At the visit, volunteers were invited to be screened by elastography for steatosis and fibrosis by CAP (≥274 dB/m) and LSM (≥7.0 kPa), respectively. Secondary causes of liver disease were ruled out. Diagnostic panels for prediction of advanced fibrosis, such as APRI and FIB-4, were also measured. A liver biopsy was performed if results were suggestive of fibrosis.</p> <p><b>Results:</b> The prevalence of steatosis was 70% and of fibrosis 21% (LSM≥7.0 kPa). Moderate fibrosis (F2: LSM≥8.2 kPa) was present in 6% and severe fibrosis or cirrhosis (F3-4: LSM≥9.7 kPa) in 9%, similar to that estimated by FIB-4 and APRI panels. Non-invasive testing was consistent with liver biopsy results. Elevated AST or ALT ≥40 U/L were present in a minority of patients with steatosis (8% and 13%, respectively) or with liver fibrosis (18% and 28%, respectively). This suggests that AST/ALT alone are insufficient as initial screening. However, performance may be enhanced by imaging (e.g., transient elastography) and plasma diagnostic panels (e.g., FIB-4, APRI).</p> <p><b>Conclusions: </b>Moderate-to-advanced fibrosis (F≥2), an established risk factor for cirrhosis and overall mortality, affects at least one-out-of-six (15%) patients with T2DM. These results support the ADA guidelines to screen for clinically significant fibrosis in patients with T2DM with steatosis or elevated ALT.</p>

Prevalence of clinically relevant liver fibrosis due to nonalcoholic fatty liver disease in Indian individuals with type 2 diabetes

“…In our study, the prevalence of CRLF was 28.2% among people with coexisting T2D and NAFLD, which is much higher than that of the general population 14,15,20 as well as of T2D population. The prevalence of increased LSM in subjects with T2D were 17.7% (Hong Kong), 15 21.0% (Malaysia), 16 13.08% (Singapore) 17 ; moderate (26.9%) and advanced (12.6%) liver fibrosis (Croatia) 18 ; and 21% (LSM ≥7.0 kPa) (United States) 19 . In our study, we found much higher prevalence of CRLF.…”

“…There are five large TE‐based studies among individuals with coexisting T2D and NAFLD, one each from Hong Kong (2015), Malaysia (2019), Singapore (2020), Croatia (2020), and the United States (2021) 15–19 . These studies revealed high prevalence of NAFLD among individuals with T2D, ranging from 70% in the United States, 72.4% in Malaysia, 72.8% in Hong Kong, 78.7% in Singapore, and 83.6% in Croatia.…”

Embedding assessment of liver fibrosis into routine diabetic review in primary care

“…This prevalence rate is slightly lower than in some other recent studies looking at advanced fibrosis in patients with T2DM; for example, in a recent study from the USA, 9.2% of patients with T2DM were found to have F3/F4 fibrosis. 33 However, these studies rely mainly on TE to determine advanced fibrosisin our study patients were only classed as having advanced disease if they had biopsy evidence of F3/F4 fibrosis or endoscopic or imaging evidence of portal hypertension or hepatocellular carcinoma. It should also be noted that, in contrast to most NAFLD studies, our pathway did not exclude patients with a history of potentially harmful alcohol consumptiontherefore we would expect a higher prevalence of advanced liver disease.…”