Prevalence and clinical determinants of non-alcoholic fatty liver disease by liver scores in adults with type 1 diabetes

Non-alcoholic fatty liver disease (NAFLD) is defined by the histological presence of large lipid droplet accumulation in hepatocytes in the absence of other causes of steatosis. NAFLD represents a spectrum of liver disease which starts with steatosis (also known as non-alcoholic fatty liver; NAFL) then advances with lobular inflammation and ballooning to non-alcoholic steatohepatitis (NASH), then fibrosis, and, finally, end-stage liver disease with cirrhosis and/or hepatocellular carcinoma (HCC).

The prevalence of NAFLD is increasing; it is estimated that 1 in 4 globally and 1 in 3 in the U.S. population has NAFLD by imaging modalities.1., 2. Indeed, the global burden of NAFLD is so high that NAFLD-related CVD and HCC has escalated approximately 10-fold over a single decade.3., 4. Similarly, NAFLD is emerging as a major indicator for liver transplantation worldwide and is predicted to become the most common indication in coming years.5., 6. As of 2019, NAFLD liver disease is already the leading cause of liver transplantation in women and those over the age of 55 years.7 An important unmet medical need is, therefore, to diagnose NAFLD early so that appropriate cardiometabolic intervention and monitoring of disease can begin before damage is irreversible.

The highest prevalence of NAFLD is seen in populations with pre-existing type 2 diabetes (T2DM) and obesity.8., 9. It is estimated that over half of patients with T2DM have NAFLD, and at least 1 in 6 patients with T2DM has biopsy-proven liver fibrosis.8., 10. For this reason, The American Diabetes Association, American Association of Clinical Endocrinology, and European Association for the Study of Diabetes guidelines recommend screening for NAFLD in all patients with T2DM using liver function tests, validated liver scores, and pursing liver imaging with appropriate referrals to hepatology.11., 12., 13. In contrast, there is little guidance for screening patients with type 1 diabetes (T1DM), despite the rising prevalence of obesity and metabolic syndrome in this population. The lack of further specific guidance in T1DM stems from a paucity of knowledge and understanding about a potential association between NAFLD with T1DM and its comorbidities. The prevalence of NAFLD in T1DM have been conflicting, ranging widely from 8 to 44 %, with significant heterogeneity among studies.14., 15., 16.

The objective of this study is to use non-invasive liver scores to approximate the prevalence and clinical features of NAFLD in an adult population with T1DM at our large academic center's endocrinology clinic. We additionally investigate the percentage of these patients who have had any evaluation for NAFLD and the off-label use of various medications which are shown to halt or reverse NAFLD progression. We aim to highlight opportunities to screen, detect, and intervene on NAFLD at an earlier stage in the T1DM population.

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