Combined screening can detect liver damage in diabetes patients

New research from Karolinska Institutet in Sweden highlights the possibility of screening people with type 2 diabetes for liver damage at the same time as they undergo screening for eye disease. The study is published in Lancet Gastroenterology and Hepatology.

More than half of all people with type 2 diabetes have steatotic (or fatty) liver disease, but most do not realise it since liver disease rarely causes any symptoms in the earlier stages. Over time, liver fibrosis can develop. This is a type of scarring of the liver that can lead to cirrhosis or liver cancer in some patients. International guidelines recommend screening for liver fibrosis in people at increased risk of it, including patients with type 2 diabetes.

“Unfortunately, severe liver disease is often detected late when the prognosis is poor,” says Hannes Hagström, adjunct professor at the Department of Medicine, Huddinge, Karolinska Institutet and consultant in hepatology at the Karolinska University Hospital. “Since there is now an approved treatment for steatotic liver disease with fibrosis, it would be good to be able to screen diabetic patients for liver fibrosis and thus prevent severe disease.”

In Sweden, retina scanning (fundus photography) is an established screening programme to detect eye damage in people with type 2 diabetes. In a new study, Hannes Hagström and his research colleagues investigated whether it would be possible to simultaneously screen for liver fibrosis using elastography. This ultrasound-based technique is painless and takes 5 to 10 minutes to perform.

“This would allow us to kill two birds with one stone and easily detect liver fibrosis in this patient group before it develops into cirrhosis or liver cancer,” says Hannes Hagström. “Our study shows that many patients with type 2 diabetes are willing to undergo such combined screening.”

The researchers asked more than 1,300 patients with type 2 diabetes who underwent retina scanning whether they would also consider having their liver examined by elastography. More than 1,000 people, 77 per cent of the study participants, said yes.

15.8 per cent of patients who had their livers examined by elastography had findings suggestive of liver fibrosis, whereas 5.0 per cent had findings suggestive of advanced liver fibrosis or cirrhosis. However, on repeat examination and reassessment, these figures were lower; 7.4 per cent and 2.9 per cent respectively.

“It shows that the method gives many false positives, partly because many people were probably not fasting as instructed at the first examination,” says Hannes Hagström. “The next step will be to conduct health economic analyses to see if the combined screening strategy for eye and liver disease is beneficial,” he concludes.

The study was conducted in collaboration with the eye clinic Capio Ögon Stockholm Globen. It was mainly funded by the pharmaceutical companies Gilead Sciences and Pfizer, and Region Stockholm.

Hannes Hagström’s research group has received research funding from Astra Zeneca, EchoSens, Gilead, Intercept, MSD, Novo Nordisk and Pfizer. He has also been a consultant or served on advisory committees for Astra Zeneca, Bristol Myers-Squibb, MSD and Novo Nordisk, and has served on review committees for Arrowhead, Boehringer Ingelheim, KOWA and GW Pharma.

Publication: ”Screening for advanced liver fibrosis due to metabolic dysfunction-associated steatotic liver disease alongside retina scanning in people with type 2 diabetes: a cross-sectional study”, Andrea Lindfors, Rickard Strandberg, Hannes Hagström, Lancet Gastroenterology and Hepatology, online 12 December 2024, doi: 10.1016/ S2468-1253(24)00313-3.