Advanced Liver Fibrosis Is Common in Patients With Type 2 Diabetes Followed in the Outpatient Setting: The Need for Systematic Screening
Open accessAbstract
OBJECTIVE: Assess the prevalence of nonalcoholic fatty liver disease (NAFLD) and of liver fibrosis associated with nonalcoholic steatohepatitis in unselected patients with type 2 diabetes mellitus (T2DM). RESEARCH DESIGN AND METHODS: A total of 561 patients with T2DM (age: 60 ± 11 years; BMI: 33.4 ± 6.2 kg/m2; and HbA1c: 7.5 ± 1.8%) attending primary care or endocrinology outpatient clinics and unaware of having NAFLD were recruited. At the visit, volunteers were invited to be screened by elastography for steatosis and fibrosis by controlled attenuation parameter (≥274 dB/m) and liver stiffness measurement (LSM; ≥7.0 kPa), respectively. Secondary causes of liver disease were ruled out. Diagnostic panels for prediction of advanced fibrosis, such as AST-to-platelet ratio index (APRI) and Fibrosis-4 (FIB-4) index, were also measured. A liver biopsy was performed if results were suggestive of fibrosis. RESULTS: 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. Noninvasive testing was consistent with liver biopsy results. Elevated AST or ALT ≥40 units/L was 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 and APRI). CONCLUSIONS: Moderate-to-advanced fibrosis (F2 or higher), an established risk factor for cirrhosis and overall mortality, affects at least one out of six (15%) patients with T2DM. These results support the American Diabetes Association guidelines to screen for clinically significant fibrosis in patients with T2DM with steatosis or elevated ALT.
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Clinically relevant fibrosis is detectable in about 15% of diabetic patients.
“In particular, clinically relevant fibrosis is detectable in about 15% of diabetic patients [95].”
From GLP-1 Receptor Agonists in Non-Alcoholic Fatty Liver Disease: Current Evidence and Future Perspectives (2023) · cites this paper as [95]
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References 62 · Cited by 354
- Authors
- Lomonaco, R., Godinez Leiva, E., Bril, F., Shrestha, S., Mansour, L., Budd, J., Portillo Romero, J., Schmidt, S., Chang, K.-L., Samraj, G., Malaty, J., Huber, K., Bedossa, P., Kalavalapalli, S., Marte, J., Barb, D., Poulton, D., Fanous, N., & Cusi, K.
- Affiliations
- University of Florida Health (US)
- Division of Endocrinology, Diabetes and Metabolism, University of Florida, Gainesville, FL
- University of Florida (US)
- Division of General Internal Medicine, University of Florida, Gainesville, FL
- Department of Pathology, Beaujon Hospital Paris Diderot University, Paris, France
- Corresponding author
- Cusi, Kenneth
- ORCID
- Venue
- Diabetes Care
- Publisher
- American Diabetes Association
- Published
- 2021-01-13
- Volume
- 44
- Issue
- 2
- Pages
- 399-406
- ISSN
- 0149-5992 (ISSN-L)
- 1935-5548
- PMC
- PMC7818321
- OpenAlex
- W3113754783
- Cited by
- 354
- References
- 62
- Citations by year
- 2026: 45 · 2025: 67 · 2024: 78 · 2023: 76 · 2022: 66 · 2021: 22
- FWCI
- 29.39
- Type
- journal article
- Language
- en
- Open access
- green
- europepmc.org
- Locations
- Diabetes Care (publishedVersion)
- Europe PMC (PubMed Central) (publishedVersion)
- PubMed Central (publishedVersion)
- PubMed (publishedVersion)
- Funders
- Echosens
- Topics
- Health Sciences › Medicine › Epidemiology › Liver Disease Diagnosis and Treatment
- Health Sciences › Medicine › Nephrology › Chronic Kidney Disease and Diabetes
- Health Sciences › Medicine › Hepatology › Liver Diseases and Immunity
- Keywords
- type 2 diabetes, non-alcoholic fatty liver disease, nonalcoholic steatohepatitis, liver fibrosis, hepatic steatosis, transient elastography, controlled attenuation parameter, liver stiffness measurement, FIB-4, AST to platelet ratio index, fibrosis screening, liver cirrhosis, liver biopsy
- MeSH terms
- Aged, Diabetes Mellitus, Type 2, Humans, Liver, Liver Cirrhosis, Middle Aged, Outpatients, Non-alcoholic Fatty Liver Disease
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