Fig. 1Algorithm for non-alcoholic fatty liver disease (NAFLD) evaluation. CV, cardiovascular; NFS, NAFLD fibrosis score; BMI, body mass index; IFG, impaired fasting glucose; DM, diabetes mellitus; AST, aspartate aminotransferase; ALT, alanine aminotransferase; FIB-4, fibrosis-4; PLT, platelet; APRI, AST to platelet ratio index; ULN, upper limit of normal; VCTE, vibration-controlled transient elastography; ELF, enhanced liver fibrosis; MRE, magnetic resonance elastography. aHigher cutoffs for patients aged >65 years, bVariable cutoffs have been suggested. Measured values are affected by body factors, cFurther validation is required.
Fig. 2Suggested algorithm for the management of patients with non-alcoholic fatty liver disease (NAFLD) and type 2 diabetes mellitus (T2DM).
Table 1The prevalence of NAFLD and NASH in patients with diabetes
Study |
Study population |
Diagnostic methods |
Categories |
Prevalence, % |
Mohan et al. (2009) [16] |
In 132 Indian adults with diabetes |
US |
NAFLD |
54.5 |
Kim et al. (2014) [17] |
In 4,437 Korean patients with T2DM |
US |
NAFLD |
72.7 |
Targher et al. (2007) [18] |
In 2,839 Italian patients with T2DM |
US |
NAFLD |
69.5 |
Portillo-Sanchez et al. (2015) [11] |
In 103 American patients with diabetes with normal plasma aminotransferases |
1H-MRS |
NAFLD |
50 |
Williams et al. (2011) [13] |
In 54 biopsied patients with diabetes |
Liver biopsy |
NASH |
22 |
Hyysalo et al. (2014) [12] |
In 115 biopsied participants in in the Finnish population-based D2D-study |
Liver biopsy |
NASH |
17.6 |
Kim et al. (2014) [15] |
In 929 Korean patients with diabetes |
US |
NAFLD |
63.3 |
Table 2Summary of the currently used imaging devices for the quantification of hepatic steatosis and fibrosis
Device |
Detection criteria |
Accuracy reproducibility quantification |
Hepatic volume of assessment |
Time accessibility |
Cost |
Specific comments |
Hepatic steatosis |
|
|
|
|
|
|
US |
Specific sonographic findings |
+ |
+++ |
+ (bedside) |
+ |
Cannot detect mild steatosis, observer dependency |
CT |
Liver HU <40 or liver HU-spleen HU <−10 |
++ |
+++ |
++ |
++ |
Radiation hazard |
Diverse criteria for definition (liver/spleen ratio of HU, etc.) |
Low sensitivity in mild steatosis |
MRI-PDFF |
≥5% liver fat |
+++ |
+++ |
+++ |
+++ |
Optimal for clinical trials |
1H-MRS |
≥5.6% liver fat |
+++ |
+ |
+++ |
+++ |
Gold standard |
Sampling errors |
Requires expertise/device |
CAP by VCTE |
≥248–≥288 dB/m (variable cutoffs) |
++ |
+ |
+ (bedside) |
+ |
Not linear with a higher liver fat content |
Results are affected by BMI, diabetes, etiology |
XL probe for the obese |
Hepatic fibrosis |
|
|
|
|
|
|
MRE |
Advanced fibrosis (F3) threshold >2.4–5.55 kPa |
+++ |
+++ |
+++ |
+++ |
Diverse cut-off points by type of modality (2D, 3D, etc.) |
Most accurate but expensive |
Failure risk in iron overload condition |
LSM by VCTE |
Diverse cutoffs (7.3–9.9 kPa) for advanced fibrosis (F3) |
++ |
+ |
+ (bedside) |
+ |
Affected by BMI (failure risk) |
XL probe for the obese |
VCTE can measure CAP and LSM simultaneously |