What is it about?

The prevalence of fatty liver (NAFLD) and fibrosis in patients with T2DM attending regular follow-up visits in the United States is unknown. This study aimed to assess how common both conditions were by doing a Fibroscan (CAP for liver fat and VCTE/elastography for fibrosis) in all patients with t2DM unaware of having NAFLD. We found that the prevalence of hepatic steatosis was 70% and that of liver fibrosis was 21%. almost 1 in 10 patients (9%) had either precirrhosis (F3) or cirrhosis (F4) and 15% moderate-to-advanced fibrosis (F2 or higher). Elevated AST or ALT ≥40 units/L was uncommon in patients with steatosis (8% and 13%, respectively) or with liver fibrosis (18% and 28%, respectively). This suggests that a screening strategy based on plasma aminotransferases alone is insufficient as initial screening and should be combined with additional tests, like imaging.

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Why is it important?

Moderate-to-advanced fibrosis (F2 or higher) 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, but also call for a screening strategy beyond aminotransferases alone that includes diagnostic panels (like FIB-4 or APRI) and/or imaging for liver fibrosis.


Patients with type 2 diabetes have the highest risk of NASH with liver fibrosis and cirrhosis. Given the high prevalence of NASH with fibrosis demonstrated in our study, and consistent with other recent work in the United States from a NHANES database (Ciardullo et al, Diabetes Care 2020) and others across the world (see references in our manuscript) it is time to include NAFLD as a complication of diabetes and screen all patients in the same way that we have for retinopathy and nephropathy for decades. Lifestyle intervention, as well as diabetes medications such as pioglitazone, have been shown to be cost-effective in RCTs (see Current Diabetes Reports 2020; Oct 5;20(11):59) and in studies that have modeled both to prevent cirrhosis (Noureddin et al, Gastroenterology 2020;159:1985–1987). Recently, semaglutide has also been shown to be effective to reverse NASH (Newsome P, Buchholtz K , Cusi K et al, N Engl J Med. 2020 Nov 13.doi: 10.1056/NEJMoa2028395). Therefore, early diagnosis and intervention is likely to change the natural history of the disease and calls physicians to act now.

Kenneth Cusi Cusi
University of Florida

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This page is a summary of: Advanced Liver Fibrosis Is Common in Patients With Type 2 Diabetes Followed in the Outpatient Setting: The Need for Systematic Screening, Diabetes Care, December 2020, American Diabetes Association,
DOI: 10.2337/dc20-1997.
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