Fatty-Liver Disease in More Than 60% of Patients With Type 2 Diabetes

Pam Harrison

October 01, 2015

Almost two-thirds of patients with type 2 diabetes in the primary-care setting have evidence of nonalcoholic fatty-liver disease (NAFLD) on noninvasive MRI, while over 7% of them have advanced fibrosis on magnetic-resonance elastrography, new research shows.

"Most patients have no idea that they have fatty-liver disease until they develop cirrhosis, and that's why it's a silent killer," senior author Rohit Loomba, MD, associate professor of clinical medicine, University of California, San Diego, told Medscape Medical News.

"But the beautiful thing about the liver is that it can regenerate, and many new therapies are in the pipeline for the treatment of NAFLD and NAFLD-related fibrosis," he stressed.

"So identification of these patients is key: we will be able to be able to stop progression of disease; we will be able to reverse cirrhosis and fibrosis with these new therapies, and we already are doing so in some patients."

Dr Loomba and colleagues also showed that patients with certain components of the metabolic syndrome, including greater waist circumference, dyslipidemia, and hypertension, were more likely to have NAFLD than those without.

So until the screening methods they used are better established, they suggest that doctors use these clinical signs to guide them on assessing diabetes patients for fatty-liver disease.

Assess Diabetes Patients Early for NAFLD

The study, which was published online September 15 in Alimentary Pharmacology and Therapeutics, was a cross-sectional analysis and involved 100 consecutive adult patients with type 2 diabetes. The mean body mass index (BMI) was 30.8 kg/m2, and the mean duration of diabetes was 8.5 years.

Within 30 days of their initial research visit, patients underwent MRI to estimate the hepatic proton-density fat fraction (MRI-PDFF) and magnetic-resonance elastrography to estimate hepatic stiffness.

As the authors observe, these two measures are accurate, precise, and validated noninvasive image-based biomarkers of NAFLD and advanced fibrosis, respectively.

NAFLD as assessed by MRI-PDFF ≥5% was present in 65% of the group, and there were no technical failures. Advanced fibrosis, as reflected by a threshold magnetic-resonance elastrography stiffness ≥ 3.6 kPa, was evident in 7.1% of the group.

The findings emphasize the importance of initiating concomitant NAFLD and advanced fibrosis screening in diabetics early, perhaps at the time of diabetes diagnosis, to prevent further liver damage, the investigators stress.

Interestingly, the prevalence of NAFLD decreased with advancing age while the prevalence of advanced fibrosis increased.

In patients under the age of 58, NAFLD was present in almost 79% of this subset of patients compared with about 68% of patients between the ages of 58 and 65. For patients over the age of 65, NAFLD was detected in approximately 47% of the cohort.

Conversely, advanced fibrosis was detected in 3% of those under the age of 58; and in approximately 6% of those between 58 and 65 years of age, and about 13% of those over the age of 65.

Inaccurate Markers; Look for Clinical Signs Such as Waist Circumference, Obesity

Dr Loomba and colleagues observe that many currently performed tests are inaccurate markers of NAFLD, including liver enzymes.

Abdominal ultrasound also lacks sensitivity for mild steatosis and has high inter- and intra-observer variability. Similarly, computed tomography has limited sensitivity for mild disease and requires exposure to radiation.

However, certain risk factors significantly increase the likelihood that patients with diabetes have NAFLD and are readily accessible clinically, they stress.

For example, patients with NAFLD in the current study were significantly younger than those without (= .028) and had a higher mean BMI, at 32.5 kg/m2 compared with 27.6 kg/m2 for those without (= .0008).

NAFLD patients also had lower HDL-cholesterol levels and higher triglyceride levels than those without NAFLD, and both fasting glucose and fasting insulin levels were significantly higher in those with fatty-liver disease than those without.

Mean waist circumference, at 106.6 cm for patients with NAFLD in the study vs 95.1 cm for those without, was also a significant predictor of NAFLD (P < .0001), as was metabolic syndrome, which was present in 84.6% of patients with NAFLD vs 40% of those without (P < .0001).

Tests Not Ready for Prime Time

Dr Loomba cautioned, however, that neither of the screening tests they employed is ready for prime time yet, as they need to show that MRI-PDFF and magnetic-resonance elastrography are both cost-effective on a population level.

Nevertheless, predictors of NAFLD progression include weight gain, hypertension, and other features of metabolic syndrome, so doctors should be guided by these.

"If physicians have a patient with three or four features of the metabolic syndrome and they are diabetic, I can almost guarantee you that they have NAFLD, and they probably have some sort of fibrosis too, especially if they are 50 years of age or older," Dr Loomba noted.

"So if physicians have patients like this, they need to be asking themselves: 'Am I missing liver disease here?' and refer them to a hepatologist for evaluation."

The authors have no relevant financial relationships.

Aliment Pharmacol Ther. Published online September 15, 2015.Article


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