Screening strategies for nonalcoholic fatty liver disease in type 2 diabetes: Insights from NHANES 2005-2016

Aim Nonalcoholic fatty liver disease (NAFLD) is prevalent in patients with type 2 diabetes mellitus (T2DM), but controversy exists on whether to screen and how to manage these patients in clinical practice. Here, we estimate the number of patients with T2DM and NAFLD in the United States that should be evaluated for advanced liver fibrosis according to proposed screening strategies. Methods In this cross-sectional analysis of 2940 adult patients with T2DM (projected to 15.3 million) from the 2005–2016 National Health and Nutrition Examination Survey (NHANES) we applied validated noninvasive scores of liver steatosis and fibrosis to estimate the number of referrals to hepatologists. We followed two different approaches: (1) the flow-chart from the European Association for the Study of the Liver (EASL), Diabetes (EASD) and Obesity (EASO) guidelines; (2) a strategy recently proposed in patients with T2DM aimed at excluding advanced liver fibrosis with a negative predictive value of 100%. Results NAFLD (based on fatty liver index) was present in 78% of patients (projected to 11.9 million). According to the EASL-EASD-EASO guidelines 37.2–48.5% of patients (projected to 5.7–7.4 million) should be referred to experts, depending on the specific biomarker of fibrosis used. The second strategy, which is based sequentially on aspartate aminotransferase and Fibrosis-4 was able to exclude advanced fibrosis in 67.0% of patients. Conclusions Screening strategies based on noninvasive scores are able to exclude advanced liver fibrosis in 50–67% of patients with T2DM. Novel biomarkers or combination of tests may be necessary to reduce the need for liver biopsy and related bleeding episodes in the remaining 33–50%.