The association between non-alcoholic fatty liver disease (NAFLD) and Type 2 diabetes (T2DM) and obesity is well established yet current guidelines in the United Kingdom do not recommend screening for NAFLD these groups. Moreover, metabolic clinics have little hepatology support and few formalised NAFLD management pathways, Resulting in missed opportunities to diagnose, stage and treat NAFLD. We sought to determine the scale of clinically significant NAFLD in our T2DM and obese populations.Method
T2DM or obese patients attending metabolic clinic over a 3 month period were included. Fibrosis risk was assessed via a 2-step pathway. First, NAFLD fibrosis score (NFS) was calculated, followed by Fibroscan for those with indeterminate/high (‘abnormal’) NFS scores; Fibroscan readings of >8 kPa were considered abnormal.Results
89 people were screened. We excluded those with both normal liver function (LFT) and ultrasound (n=11), previously diagnosed liver disease (n=3) or insufficient data to calculate the NFS score (n=43), leaving 32 patients (20 T2DM; 12 obese) of whom the majority were middle-aged males with median age 53 [28–75] and BMI 38 [22.1–68].Results
Most of those with NAFLD had normal LFT (25/32; 78.2%; p<0.0001) including median ALT 26 [7–129] and AST 20 [12–88]. Median NFS was −0.381, with the majority having abnormal scores (84.4%; p<0.0001). A higher proportion of T2DM than obese patients had abnormal scores, but this did not reach significance (p=0.26). The vast majority of those with abnormal NFS had normal LFT (22/32 81.5%; p=0.005).Results
The 27/32 patients with abnormal score were invited for Fibroscan of whom 70.4% attended. Median Result was 7.05 kPa [2.8–26.3], with a non-significant trend to higher readings in obesity vs. T2DM (7.7 vs 6.6 kPa; p=0.29). 36.84% (7/19) had abnormal Fibroscan Result. ALT was significantly higher in those with abnormal Fibroscan (mean 66.9 vs. 18.83; p=0.43; 95% CI 33.76–62.32) but importantly, 42.9% (3/7) of those with abnormal Fibroscan had completely normal LFT.Conclusion
NAFLD was common in the cohort, usually undiagnosed and frequently associated with abnormal NFS and Fibroscan despite normal LFT, suggesting there is a sizeable population in metabolic services with potentially significant liver disease. We only included those with proven steatosis and sufficient data to calculate NFS, therefore the true prevalence of significant fibrosis is likely to be greater. Although biopsy has not yet been performed, abnormal 2-step non-invasive assessment alone mandates specialist input and as such active NAFLD screening in these groups should be considered.