Prevalence of liver fibrosis in diabetes suggests need for earlier intervention, study finds

Moderate to advanced fibrosis, an established risk factor for cirrhosis and overall mortality, affects nearly one out of six patients with type 2 diabetes, a study found.

To assess the prevalence of nonalcoholic fatty liver disease (NAFLD) and liver fibrosis associated with nonalcoholic steatohepatitis (NASH) in diabetes, researchers recruited 561 adults with diabetes who were unaware of having NAFLD from internal medicine, family medicine, and endocrinology clinics at a single U.S. university health system between 2018 and July 2020. The researchers screened patients for steatosis by elastography and for fibrosis by controlled attenuation parameter and liver stiffness measurement. Diagnostic panels were done to predict advanced fibrosis, the aspartate aminotransferase (AST)-to-platelet ratio index (APRI), and fibrosis-4 (FIB-4) index. A liver biopsy was performed if results suggested fibrosis. The study was partly funded by Echosens, which makes devices that assess and manage liver disease. Results were published online Dec. 21, 2020, by Diabetes Care.

The prevalence of any suspected liver fibrosis in patients with diabetes was 21%. When analyzed by severity of fibrosis, 6% of patients had moderate fibrosis and 9% had severe fibrosis or cirrhosis. Elevated AST and alanine aminotransferase (ALT) levels were present in a minority of patients with steatosis (8% and 13%, respectively) or with liver fibrosis (18% and 28%, respectively). The study results suggest that AST and ALT levels alone are insufficient as initial screening for NASH but may be enhanced by imaging and by plasma diagnostic panels such as FIB-4 and APRI, the authors noted.

“The truly alarming finding was that almost one in six participants (15%) had unsuspected moderate-to-advanced fibrosis (F2 or higher),” the authors wrote. While fibrosis progression and regression in NASH are poorly understood in the context of obesity and diabetes, many patients with early disease may be at risk for being “rapid progressors” to more severe liver disease, they said. The study results support the notion that patients with obesity and diabetes are at the highest risk and in need of more aggressive screening, the authors wrote, adding that their findings help explain why 50% of patients with NASH from cryptogenic cirrhosis have diabetes and why diabetes is prevalent in patients with NASH needing liver transplantation.

“Use of APRI or FIB-4 to identify patients with fibrosis was helpful but primarily in the minority of patients with elevated AST or ALT, as expected from their formulas being strongly based on plasma aminotransferases,” the authors wrote. “This is different than in liver clinics, where an elevated AST and ALT are the most common cause for referral. This reality calls for a different diagnostic approach in primary care clinics, where imaging may play a bigger role.”