More than half of patients with type 1 diabetes, especially those with obesity, have hepatic steatosis, according to findings of a single-center study recently published in the Journal of Diabetes and Its Complications.^1,2

Researchers from Cleveland Clinic and University Hospitals in Cleveland sought to examine the prevalence and risk factors for NAFLD in patients with type 1 diabetes utilising liver steatosis and fibrosis scores. In this retrospective, cross-sectional study, Lundholm and colleagues enrolled 447 adults with type 1 diabetes attending Cleveland Clinic from 2015 to 2018. More than half (54%) of the participants were women. The BMI was 28 kg/m² and the mean age of the study subjects was 38 years.

The markers of steatosis used in the study were hepatic steatosis index and Framingham steatosis index. Using a hepatic steatosis index score of ≥ 36, hepatic steatosis was detected in 61% patients and with a Framingham steatosis index score of ≥ 23, 52% had hepatic steatosis. Hepatic transaminases were normal in most of these patients. The fibrosis-4 (FIB-4) Index and aspartate transaminase to platelet ratio index were the markers of fibrosis. Four percent of patients with an APRI score of >0.7 had significant fibrosis. A similar percentage of patients with FIB-4 score of >2.67 had advanced fibrosis.

A positive correlation was observed between BMI ≥ 25 kg/m2 and steatosis scores. All subjects with obesity (BMI ≥30) had NAFLD by HSI (100% vs 45%) and FSI (98% vs. 34%). Nearly 65% of overweight participants and 22% of normal weight adults had positive hepatic steatosis index score and Framingham steatosis index score. No such association was noted between BMI and participants with high fibrosis scores. Of the 103 patients with metabolic syndrome, 86% were significantly more at risk using HIS score and 93% when FSI was used.

Age ≥40 years, dyslipidemia (hyperlipidemia, high triglycerides, low HDL cholesterol, higher triglyceride to HDL ratio), hypertension and history of heart disease were found to be associated with positive hepatic steatosis index and Framingham steatosis index scores. Only older age was found to be associated with high or indeterminate FIB-4 score, but none had a positive association with APRI.

Only 21% of the patients had abdominal imaging, which revealed hepatic steatosis; 2% were referred to a hepatologist and 1% underwent a liver biopsy. Just 5% and 4%, respectively of patients had been prescribed GLP-1 receptor agonists and thiazolidinediones

This study illustrates the high prevalence of nonalcoholic steatohepatitis (NASH) in patients with type 1 diabetes, particularly among those with obesity and metabolic syndrome detected via the use of steatosis scores. Hepatic fibrosis was uncommon. Older patients, hypertensive patients and those who have dyslipidemia or heart disease are at higher risk of hepatic steatosis. The take home message that can be drawn from this study is that patients with type 1 diabetes should be routinely screened for NAFLD. Most of the patients in this study had normal transaminases. Normal liver enzyme values therefore can give false reassurance. Inexpensive, noninvasive liver scores can be used for screening followed by imaging, biopsy as indicated. Early detection of the disease allows timely institution of interventions to prevent irreparable liver damage.

References

1. Lundholm MD, et al. Prevalence and clinical determinants of non-alcoholic fatty liver disease by liver scores in adults with type 1 diabetes. J Diabetes Complications. 2023 Feb;37(2):108405. doi: 10.1016/j.jdiacomp.2023.108405.

2. Lundholm MD, et al. 1104-P: Prevalence and Clinical Determinants of Nonalcoholic Fatty Liver Disease by Liver Scores in Adults with T1DM. Diabetes 2022;71(Supplement_1):1104-P. https://doi.org/10.2337/db22-1104-P.