Fatty liver disease may not affect mortality risk in elderly patients

Fatty liver disease may not increase mortality risk in elderly patients, according to a recent Dutch cohort study.

Researchers used data from the Rotterdam Study to determine the relationship between fatty liver disease and mortality in the elderly, noting that current guidelines supporting screening for hepatic steatosis would affect an increasing proportion of people in this age group. Patients ages 65 years and older were enrolled in the study from 2009 to 2014 and followed through 2018. Ultrasound was used to assess steatosis, and transient elastography was used to assess liver stiffness. Cox regression analysis adjusted for age, sex, education, smoking, individual components of the metabolic syndrome, heart failure, coronary heart disease, and stroke was used to assess the association between hepatic steatosis, liver stiffness, and mortality. The study results were published June 26 by Hepatology.

A total of 4,093 elderly patients were included in the current study. The mean age was 74.4 years, 42.7% were men, and 36.8% had ultrasound-based steatosis. Because metabolic comorbidity was common (e.g., 18% had diabetes and 54.7% had metabolic syndrome), hepatic assessment would have been indicated in 85.4% of patients based on the 2021 European Association for the Study of the Liver guideline on noninvasive tests, the authors noted. During a median of 6.9 years of follow-up, 793 patients died (29.6 per 1,000 person-years).

Multivariable analysis found no association between steatosis and mortality in the overall population (adjusted hazard ratio, 0.87; 95% CI, 0.73 to 1.03). These findings remained consistent across clinically relevant subgroups, including age, sex, metabolic syndrome, elevated liver enzymes, and cardiac disease. In sensitivity analyses, results were similar for mortality rates beyond five years of follow-up and for cancer-related and cerebrocardiovascular mortality. Higher liver stiffness was not associated with mortality in patients with steatosis (adjusted hazard ratio, 1.04 per kPa; 95% CI, 0.95 to 1.14 per kPa).

The authors acknowledged that their study population was homogeneous, that follow-up was relatively short, and that they had no data on liver-related events, among other limitations. “In this large cohort of adults ≥65 years old, the presence of [fatty liver disease] was not associated with increased mortality, whereas a worrisome 85% of this group necessitated hepatic assessment according to recent guidelines,” the authors wrote. Their findings do not support screening for fatty liver disease or fibrosis in elderly patients, they concluded.

An accompanying editorial noted that the results could have been affected by selection bias and a survivor effect but are still applicable to older patients and provide valuable information on the effectiveness of potential screening initiatives. Combined with other research, the current study suggests that improvement is needed in defining which patients are at risk for hepatic fibrosis and cirrhosis, the editorialists wrote. “A careful balance must be made between screening too many persons, with the risk of overdiagnosis and cost-effectiveness issues, and examining too few, with the opposite risk of finding persons with cirrhosis too late,” they wrote. “Such a balance is difficult to achieve in any field but must be made a priority in hepatology.”