Risk of Advanced Liver Disease Doubled in Patients with Diabetes 

Some metabolic factors, including type 2 diabetes, can increase the risk of severe non-alcoholic fatty liver disease (NAFLD). 

Contributing factors of type 2 diabetes include lifestyle, obesity, age, family history of diabetes, ethnicity, and metabolic syndrome. Insulin resistance is associated with other risks such as dyslipidemia, abdominal obesity, and hypertension. NAFLD is a leading cause of chronic liver disease. NAFLD can give rise to inflammation, an increase in scar tissue, cirrhosis, and possibly liver cancer development. Certain individuals are at an increased risk for these complications; identifying individuals with an increased risk of difficulties could lead to disease progression prevention. Tests used to pinpoint the disease’s severity and diagnosis are complete blood count, fasting blood sugar, lipid profile, liver enzyme, and liver function test. Symptoms of NAFLD are a decrease in weight, fatigue, and pain in the abdominal area. Some individuals do not experience any symptoms at all. Disease management prevention and care are helpful in conjunction with lifestyle modifications, including exercise and diet changes. 

There are metabolic risk factors that play a part in NAFLD outcomes in patients. Researchers composed a plan to figure out metabolic risk factors that lead to advanced liver disease. The studies that were reviewed consisted of a systemic review and meta-analysis cohort study based on population. The data analysis included outcomes of progressive stage liver disease. The results showed cirrhosis, NASH, and death related to liver disease. The metabolic risk factors were type 2 diabetes, abnormal lipid levels, metabolic syndrome, high blood pressure, and obesity. The data collected was reviewed from 22 observational studies from 16 cohorts. The data that linked liver disease and diabetes together were found in 12 of the studies. The studies showed 22.8 million individuals that had 72,792 liver events over ten years. Obesity was analyzed in 14 data studies. Within the 19.3 million individuals with diabetes, 49,541 individuals experienced liver events over 13.8 years.  

Twenty-two studies were obtained and met the inclusion criteria, with 18 of the studies contributing data in 2 random-effects meta-analyses. Studies were gathered from Europe, Italy, North America, Canada, Asia. UK, China, and the Netherlands. Type 2 diabetes was linked to a higher risk of severe liver disease events. The data showed an adjusted hazard ratio of 1.20, p-value < 0.001, CI 1.83-2.76. Obesity was linked to a moderate increase in severe liver disease. Patients having a BMI greater than 30 kg/m2 were associated with a higher risk of severe liver disease. The hazard ratio is 1.20; CI 95%, 1.12-1.28; P 0.001).  

Five studies investigated lipids. The analysis reviewed low high-density lipoproteins (HDL), triglycerides at a high level, abnormal lipids, and hypercholesterolemia. The study reported hazard ratio of 1.23; CI 95% 1.19-1.28; P-value < 0.0001. Four studies reported hypertension as a severe liver disease outcome. A mortality study found a negative association after adjustments of the other metabolic factors were made. The hazard ratio was 0.07, CI 95% 0.01-0.3; P = 0.007.  

In conclusion, the researchers found that type 2 diabetes was associated with a doubled increase in having advanced liver disease. The results were considered statistically significant. When compared to diabetes, obesity linked to liver disease showed a lower gain. The study showed a low risk of bias. The measuring tool used was the QUIPS tool. Data in this study included individuals who were not clinically diagnosed with NAFLD. There is a chance that some of the liver outcomes were not due to NAFLD, which would be considered a study limitation. The synthesis of observational data was also a limitation.  More research needs to be conducted to interpret if other metabolic risk factors such as metabolic syndrome play a role in increased NAFLD rates. More clinical trials should be conducted to see if any other metabolic risk factors would increase the risk of NAFLD. 

Practice Pearls: 

• Type 2 diabetes increases the risk of NAFLD twofold. 
• Obesity is linked to an increase in the risk of severe liver disease. 
• Not all of the liver outcomes shown in the study were due to NAFLD. 

Helen Jarvis, Dawn Craig, Robert Barker, Gemma Spiers, Daniel Stow, Quentin M. Anstee, Barbara Hanratty, “Metabolic risk factors and incident advanced liver disease in non-alcoholic fatty liver disease (NAFLD): A systematic review and meta-analysis of population-based observational studies,“  

Sukanya Charuchandra, “Diabetes More Than Doubles Risk of Advanced Liver Disease,”  

Shadrielle Robbins, PharmD Candidate, South College School of Pharmacy