Progression of Nonalcoholic Fatty Liver Disease-Associated Fibrosis in a Large Cohort of Patients with Type 2 Diabetes

Background: Nonalcoholic fatty liver disease (NAFLD) can progress to advanced fibrosis, especially in patients with type 2 diabetes. Small studies have shown that fibrosis can also regress. Aim: We aimed to provide large-scale data on progression and regression of fibrosis in diabetics with NAFLD. Methods: Adult diabetic patients with the diagnosis of NAFLD based on ICD-9 codes were identified. We used scores from noninvasive tests to identify patients with advanced fibrosis, calculated at first assessment and last follow-up visit. Cutoff values for advanced fibrosis were AST: ALT ratio > 1.4, AST to platelet ratio index > 1.5, FIB-4 score > 2.67, and NAFLD fibrosis score > 0.676. Results: Our cohort included 50,695 diabetics with NAFLD (55.3% female; 71% Caucasian; mean age, 51.2 ± 11.6 y). During median follow-up of 84.4 months, 25.8% transitioned from no advanced fibrosis to advanced fibrosis (progression), 6.4% transitioned from advanced fibrosis to no advanced fibrosis (regression), and the rest remained stable. Factors associated with transition to advanced fibrosis were female sex, older age at first evaluation, African-American race, obesity, chronic kidney disease, or coronary artery disease. Use of insulin increased the risk of progression to advanced fibrosis (odds ratio,1.36; p <.001), whereas use of oral hypoglycemic agents, angiotensin 2 receptor blockers, and fibrates was associated with reduced risk (odds ratios, 0.92, 0.94 and 0.90, respectively; all p <.05). Conclusions: In a large cohort of patients with type 2 diabetes and NAFLD, more than a quarter progressed to advanced fibrosis. These findings indicate the need for early detection and staging of NAFLD in diabetics.