Objectives Non-alcoholic fatty liver disease (NAFLD) is more common in patients with type 2 diabetes mellitus (T2DM) compared to individuals without. Recent guidelines recommend screening for NAFLD in patients with T2DM. Our aim was to investigate the prevalence of NAFLD in patients with T2DM in a Swedish primary health care setting, how they are cared for and assess the risk of biochemical signs of advanced fibrosis. Material and methods In this cohort study, patients with T2DM from five primary health care centers were included. Medical records were retrospectively reviewed and living habits, medical history, results of diagnostic imaging and anthropometric and biochemical features were noted in a standardized form. The risk of steatosis and advanced fibrosis was assessed using commonly used algorithms (FLI, HSI, NAFLD-LFS, NAFLD ridge score, FIB-4 and NFS). Results In total 350 patients were included. Diagnostic imaging had been performed in 132 patients and of these, 34 (26%) had steatosis, which was not noted in the medical records in 16 (47%) patients. One patient with steatosis had been referred to a hepatologist. Of assessable patients, 71-97% had a high to intermediate risk of steatosis and 29-65% had an intermediate to high risk of advanced fibrosis according to the algorithms used. Conclusion This study indicates a high prevalence of NAFLD among T2DM patients in Swedish primary care. Patients with known NAFLD were followed up to a very low extent. Using fibrosis algorithms in primary health care would result in many patients needing further assessment in secondary care.

BackgroundPrevious studies have shown inconsistent results for the microvascular complication risk in patients with type 2 diabetes and metabolic dysfunction-associated steatotic liver disease (MASLD). In addition, many of these studies have been done in specialist care setting. We therefore aimed to explore the association between MASLD and chronic kidney disease, retinopathy, neuropathy, and diabetic foot ulcers in a primary care setting.MethodsParticipants with type 2 diabetes were recruited in primary care. Hepatic triglyceride content was assessed using magnetic resonance imaging with liver proton density fat fraction (MASLD >= 5%) or vibration-controlled transient elastography with controlled attenuation parameter (MASLD >= 248 dB/m), and hepatic fibrosis was assessed using vibration-controlled transient elastography (advanced fibrosis >= 10 kPa). Data on chronic kidney disease, retinopathy, neuropathy, and diabetic foot ulcers were collected from medical records.ResultsA total of 308 participants were included. The median duration of diabetes was 7 years (IQR 3-13). MASLD was present in 181 participants (58.8%). Of these, 161 (52.3%) showed no evidence of advanced fibrosis, while 20 (6.5%) were assessed as having advanced fibrosis. Neuropathy was present in 64 participants (20.8%), retinopathy in 60 (19.5%), chronic kidney disease in 59 (19.2%), and diabetic foot ulcers in 13 (4.2%). No significant differences in these complications were observed between participants with and without MASLD. However, participants with MASLD and a higher histopathological fibrosis stage had an increased risk of microvascular complications in our study.ConclusionsParticipants with type 2 diabetes and concomitant MASLD recruited in primary care, did not have an increased risk of chronic kidney disease, neuropathy, or retinopathy, supporting previous findings of risk variation across different ethnicities and geographic locations.Trial registrationClinical trial number NCT03864510 (registration date 2019-02-12).

Background: Metabolic dysfunction-associated steatotic liver disease (MASLD) is the most prevalent chronic liver condition worldwide. There is an urgent need to develop new biomarkers to assess disease severity and to define patients with a progressive phenotype. Activin A is a new promising biomarker with conflicting results about liver fibrosis. In this study we investigate levels of Activin A in patients with biopsy proven MASLD. We assess levels of Activin A in regard to fibrosis stage and genetic variant I148M in the patatin-like phospholipase domain-containing protein 3 (PNPLA3). Methods: Activin A levels were assessed in plasma samples from patients with biopsy-proven MASLD in a cross-sectional study. All patients were clinically evaluated and the PNPLA3 I148M genotype of the cohort was assessed. Findings41 patients were included and 27% of these had advanced fibrosis. In MASLD patients with advanced fibrosis, Activin A levels was higher (p < 0.001) and could classify advanced fibrosis with an AUROC for activin A of 0.836 (p < 0.001). Patients homozygous for PNPLA3 I148M G/G had higher levels of activin A than non-homozygotes (p = 0.027). Conclusions: Circulating activin A levels were associated with advanced fibrosis and could be a potential blood biomarker for identifying advanced fibrosis in MASLD. Patients with the risk genotype PNPLA3 I148M G/G had higher levels of activin A proposing activin A as a contributor of the transition from simple steatosis to a fibrotic phenotype.

Background and aims The prevalence of metabolic dysfunction-associated steatotic liver disease (MASLD) has increased during the epidemic of obesity. Type 2 diabetes mellitus (T2DM) is associated with progressive MASLD. Therefore, many guidelines recommend screening for MASLD in patients with T2DM. Most studies in patients with MASLD have been conducted in specialist care. We investigated the prevalence and severity of MASLD in patients with T2DM from primary care. Methods Patients with T2DM were prospectively included from primary care facilities to undergo transient elastography with controlled attenuation parameter and whole-body magnetic resonance imaging (MRI) to assess liver fat, cardiac function, muscle composition, and distribution of body fat. Results Among 308 participants, 59% had MASLD, 7% had suspected advanced fibrosis (transient elastography >= 10 kPa), and 1.9% had cirrhosis. The mean age was 63.9 +/- 8.1 years; 37% were female, with no differences between the MASLD and the non-MASLD groups. Participants with MASLD had greater body mass index (31.1 +/- 4.4 vs. 27.4 +/- 4.1 kg/m(2), p < 0.001) and a higher prevalence of obesity (60% vs. 21%, p < 0.001). Obesity increased the risk of fibrotic MASLD eightfold, as confirmed by multivariable analysis. Participants with MASLD also had increased visceral and abdominal subcutaneous adipose tissue and muscle fat infiltration. On cardiac MRI, participants with MASLD had a lower left ventricular (LV) stroke volume index, a lower LV end-diastolic volume index, and an increased LV concentricity. Conclusions In this cohort of primary care patients with T2DM, 59% had MASLD, and 7% had suspected advanced fibrosis. Obesity was a strong predictor of fibrotic MASLD. MASLD was associated with alterations to the left ventricle and increased deposition of ectopic fat.