A prospective study on the prevalence of NAFLD, advanced fibrosis, cirrhosis and hepatocellular carcinoma in people with type 2 diabetes

Published:November 18, 2022DOI:


      • In prospectively-recruited type 2 diabetics ≥ 50 years the NAFLD prevalence 65%
      • The prevalence of advanced fibrosis (AF) was 14% and cirrhosis was 6%
      • Obesity amplified the risk of NAFLD and advanced fibrosis
      • Three patients with cirrhosis were diagnosed with hepatobiliary malignancy
      • A lower FIB-4 cut-point of 1 is required to maintain sensitivity > 90% for AF



      There are limited prospective data in a United States cohort of patients with type 2 diabetes mellitus (T2DM) specifically enrolled and systematically assessed for advanced fibrosis or cirrhosis due to nonalcoholic fatty liver disease (NAFLD). Therefore, we aimed to evaluate the prevalence of advanced fibrosis and cirrhosis in a prospectively recruited cohort of adults with T2DM.


      This prospective study enrolled adults age ≥ 50 years with T2DM recruited from primary care or endocrinology clinics. Participants underwent a standardized clinical research visit with magnetic resonance imaging proton-density-fat-fraction (MRI-PDFF), magnetic resonance elastography (MRE), vibration-controlled transient elastography (VCTE) and controlled attenuation parameter (CAP). NAFLD was defined as MRI-PDFF ≥ 5% after exclusion of other liver diseases. Advanced fibrosis and cirrhosis were defined by established liver stiffness cut points on MRE or VCTE if MRE was not available.


      Of 524 patients screened, 501 adults (63% female) with T2DM met eligibility. The mean age and BMI were 64.6 (±8.1) years and 31.4 (±5.9) kg/m2, respectively. The prevalence of NAFLD, advanced fibrosis and cirrhosis was 65%, 14% and 6%, respectively. In multivariable adjusted models, adjusted for age and sex, obesity and insulin use were associated with increased odds of advanced fibrosis OR=2.50 (95% CI: 1.38-4.54, p=0.003) and OR=2.71 (95% CI: 1.33-5.50, p=0.006), respectively. Among 29 patients with cirrhosis, two were found to have hepatocellular carcinoma and one patient had gallbladder adenocarcinoma.


      Utilizing a uniquely well-phenotyped prospective cohort of patients aged ≥ 50 years with T2DM, we found that the prevalence of advanced fibrosis was 14% and cirrhosis was 6%. These data underscore the high risk of advanced fibrosis/cirrhosis in adults ≥ 50 years with T2DM.

      Impact And Implications

      Nonalcoholic fatty liver disease (NAFLD) is common in patients with type 2 diabetes (T2DM), however, there are limited prospective data characterizing the prevalence of advanced fibrosis and cirrhosis using the most accurate non-invasive biomarkers of liver fat and fibrosis. We show that 14% of older adults with T2DM have advanced fibrosis and 6% have cirrhosis, which places them at risk for liver failure and liver cancer. Accurate prevalence rates and comparative analysis regarding the diagnostic accuracy of non-invasive tests in this population will guide the optimal screening strategy and future cost-effectiveness analysis. These results will inform future Hepatology and Endocrinology practice guidelines regarding NAFLD screening programs in older adults with T2DM.

      Graphical abstract


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