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Vol. 25. (In progress)
(November - December 2021)
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Vol. 25. (In progress)
(November - December 2021)
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DOI: 10.1016/j.aohep.2021.100346
Open Access
The presence of diabetes impacts liver fibrosis and steatosis by transient elastography in a primary care population
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Qunying Yang, Xiaofei Li
Corresponding author
icqwc46@163.com

Corresponding author.
Department of Infectious Diseases, YiWu Central Hospital, Zhejiang, 322000, China
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Tables (1)
Table 1. Baseline characteristics of study population.
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Dear Editor,

We read with great interest the study conducted by Hirsh D. The authors aim to explore the association between diabetes and liver fibrosis and steatosis in a primary care population [1]. In this study involving 437 participants, the authors found that diabetes was associated with liver fibrosis and steatosis in a primary care population after adjusting for independent predictors. After reading this article carefully, we noted that the following issues need to be carefully considered.

First, as described, this study aims to explore the association between diabetes and liver fibrosis and steatosis. However, it is indistinct whether those patients included in this study were new-onset diabetes patients or previously diagnosed with diabetes. There is no doubt that the duration of diabetes is related to the severity of liver fibrosis and steatosis, and patients with a longer duration of diabetes will inevitably have a higher degree of liver fibrosis and steatosis than patients with a short duration [2,3]. Therefore, it is recommended to provide the duration of diabetes to relieve readers’ doubts. On the other hand, for the diabetic patients included in this study, were their blood glucose levels controlled within the range recommended by the current guidelines? After all, poor glycemic control could also lead to worsening liver fibrosis [4,5]. Thus, the detailed definition of inclusion criteria and exclusion criteria is helpful to reduce confounding bias.

Second, as depicted in Table 1, there were significant differences in some baseline characteristics between diabetic and non diabetic patients. For example, the proportion of female diabetes is significantly higher than that of non-diabetics (53.2% versus 41.2%, P = 0.02), coronary artery disease, hyperlipidemia and obstructive sleep apnea (OAP) in diabetic patients is also considerably higher than that of non-diabetics. Additionally, previous studies have exhibited sex differences in the degree of liver fibrosis, and EZH1 and EZH2 might cause it [6]. Similarly, some scholars have concluded that OAP is associated with liver fibrosis severity [7]. However, in this study, those variables with significant differences between the groups (Table 1) were not included in the multivariate regression analysis for adjustment. There was no explanation for this adjustment strategy, which is highly confusing.

Table 1.

Baseline characteristics of study population.

Diabetes (N = 124)  No diabetes (N = 313)  P-value 
Age (years)58.4 (11.4)  52.4 (13.2)  <0.0001 
Female (%)66 (53.2)  129 (41.2)  0.02 
EthnicityCaucasian197 (64.8)  67 (54.9)  0.02
Hispanic50 (16.5)  17 (13.9) 
African American20 (6.6)  20 (16.4) 
Asian31 (10.2)  14 (11.5) 
Other6 (2)  4 (3.3) 
BMI (kg/m2)33.5 (6.7)  32.4 (11.3)  0.33 
Smoking (%)Never192 (68.8)  70 (56.9)  0.056
Former65 (23.3)  42 (34.2) 
Current22 (7.9)  11 (8.9) 
ALT level (IU/L)44.9 (30.8)  49.7 (39.3)  0.24 
Platelet level (K/uL)244.1 (67.3)  246.4 (71.3)  0.77 
HbA1c (%)7.3 (1.4)  5.9 (3.3)  <0.0001 
FIB-4 score (points)1.56 (1.03)  1.25 (0.87)  0.0041 
FIB-4 stageLow (<1.45)  169 (72.5)  61 (58.1)  0.008
Indeterminate-or-high (≥1.45)  64 (27.5)  44 (41.9) 
Steatosis on imaging69 (86.3)  142 (76.3)  0.07 
Coronary artery disease16 (12.9)  7 (2.2)  <0.001 
Hyperlipidemia93 (75)  109 (34.8)  <0.001 
Obstructive sleep apnea38 (30.7)  35 (11.2)  <0.001 
CAP Score (dB/m)322.1 (51.1)  296.1 (57)  <0.0001 
Steatosis by CAP (≥248 dB/m)113 (93.4)  245 (81.4)  0.002 
Severe steatosis by CAP (≥280 dB/m)102 (84.3)  187 (62.1)  <0.001 
TE score (kPa)8.3 (6)  6.4 (3.7)  0.0001 
TE score category<7 kPa  241 (77)  72 (58.1)  <0.001
≥7 kPa  72 (23)  52 (41.9) 
<10 kPa  284 (90.7)  100 (80.7)  0.004
≥10 kPa  29 (9.3)  24 (19.4) 
TE probeM probe  214 (68.4)  66 (53.2)  0.003
XL probe  99 (31.6)  58 (46.8) 

BMI: body mass index, ALT: alanine aminotransferase, HbA1c: hemoglobin A1c, CAP: controlled attenuation parameter, TE: transient elastography.

Bold values signifies P value <0.05.

Funding

None.

Conflict of interest

The authors have no conflicts of interest to declare.

References
[1]
H.D. Trivedi, J. Suri, D. Oh, J. Schwartz, D. Goyes, R. Idriss, et al.
The presence of diabetes impacts liver fibrosis and steatosis by transient elastography in a primary care population.
[2]
V. de Lédinghen, J. Vergniol, C. Gonzalez, J. Foucher, E. Maury, L. Chemineau, et al.
Screening for liver fibrosis by using FibroScan® and FibroTest in patients with diabetes.
Dig Liver Dis, 44 (2012), pp. 413-418
[3]
M.W. Yeung, G.L. Wong, K.C. Choi, A.O. Luk, R. Kwok, S.S. Shu, et al.
Advanced liver fibrosis but not steatosis is independently associated with albuminuria in Chinese patients with type 2 diabetes.
J Hepatol, 68 (2018), pp. 147-156
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K.A. Morbitzer, D.J. Taber, N.A. Pilch, H.B. Meadows, J.N. Fleming, C.F. Bratton, et al.
The impact of diabetes mellitus and glycemic control on clinical outcomes following liver transplant for hepatitis C.
Clin Transplant, 28 (2014), pp. 862-868
[5]
J. Hum, J.H. Jou, P.K. Green, K. Berry, J. Lundblad, B.D. Hettinger, et al.
Improvement in glycemic control of type 2 diabetes after successful treatment of hepatitis C virus.
Diabetes Care, 40 (2017), pp. 1173-1180
[6]
D. Lau-Corona, W.K. Bae, L. Hennighausen, D.J. Waxman.
Sex-biased genetic programs in liver metabolism and liver fibrosis are controlled by EZH1 and EZH2.
[7]
S. Petta, O. Marrone, D. Torres, M. Buttacavoli, C. Cammà, V. Di Marco, et al.
Obstructive sleep apnea is associated with liver damage and atherosclerosis in patients with non-alcoholic fatty liver disease.
Copyright © 2021. Fundación Clínica Médica Sur, A.C.
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