Clin Mol Hepatol.  2022 Jul;28(3):565-574. 10.3350/cmh.2022.0096.

The effect of diabetes and prediabetes on the prevalence, complications and mortality in nonalcoholic fatty liver disease

Affiliations
  • 1Yong Loo Lin School of Medicine, National University of Singapore, Singapore
  • 2Division of Endocrinology, Department of Medicine, National University Hospital, Singapore
  • 3Division of Family Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
  • 4Department of Family Medicine, National University Health System, Singapore
  • 5Medical Informatics, Regional Health System, National University Health System, Singapore
  • 6Department of Hepatology, AIG Hospitals, Hyderabad, India
  • 7Department of Medicine, The University of Hong Kong, Queen Mary Hospital, Hong Kong
  • 8Division of Gastroenterology and Hepatology, Department of Medicine, National University Hospital, Singapore
  • 9National University Centre for Organ Transplantation, National University Health System, Singapore
  • 10Department of Cardiology, National University Heart Centre, National University Hospital, Singapore
  • 11Cedars-Sinai Fatty Liver Program, Division of Digestive and Liver Diseases, Department of Medicine, Comprehensive Transplant Centre, Cedars-Sinai Medical Centre, Los Angeles, CA, USA
  • 12Division of Gastroenterology, Hepatology and Nutrition, Department of Internal Medicine, Virginia Commonwealth University, Richmond, VA, USA

Abstract

Background/Aims
Nonalcoholic fatty liver disease (NAFLD) is closely associated with diabetes. The cumulative impact of both diseases synergistically increases risk of adverse events. However, present population analysis is predominantly conducted with reference to non-NAFLD individuals and has not yet examined the impact of prediabetes. Hence, we sought to conduct a retrospective analysis on the impact of diabetic status in NAFLD patients, referencing non-diabetic NAFLD individuals.
Methods
Data from the National Health and Nutrition Examination Survey 1999–2018 was used. Hepatic steatosis was defined with United States Fatty Liver Index (US-FLI) and FLI at a cut-off of 30 and 60 respectively, in absence of substantial alcohol use. A multivariate generalized linear model was used for risk ratios of binary outcomes while survival analysis was conducted with Cox regression and Fine Gray model for competing risk.
Results
Of 32,234 patients, 28.92% were identified to have NAFLD. 36.04%, 38.32% and 25.63% were non-diabetic, prediabetic and diabetic respectively. Diabetic NAFLD significantly increased risk of cardiovascular disease (CVD), stroke, chronic kidney disease, all-cause and CVD mortality compared to non-diabetic NAFLD. However, prediabetic NAFLD only significantly increased the risk of CVD and did not result in a higher risk of mortality.
Conclusions
Given the increased risk of adverse outcomes, this study highlights the importance of regular diabetes screening in NAFLD and adoption of prompt lifestyle modifications to reduce disease progression. Facing high cardiovascular burden, prediabetic and diabetic NAFLD individuals can benefit from early cardiovascular referrals to reduce risk of CVD events and mortality.

Keyword

Diabetes mellitus; Non-alcoholic fatty liver Disease; Prediabetic state
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