Liver fibrosis markers and all cause mortality in people with type 2 diabetes: A population based study (The Ayrshire Diabetes Outcomes Cohort (ADOC) Study)

Abstract Aims To describe the distribution of the biomarker scores Fibrosis‐4 (FIB4), nonalcoholic fatty liver disease (NAFLD) fibrosis score (NFS), and aspartate aminotransferase to platelet ratio index (APRI), and the associations between risk categories and all‐cause mortality. Materials and Methods This was a retrospective cohort study of 12 589 patients, with follow‐up from January 2012 until November 2021. The cut‐off points used to identify low risk were: FIB4 <1.3 if aged <65 years or <2.0 if aged ≥65 years; NFS < −1.455 if aged <65 years or <0.12 if aged ≥ 65 years; APRI <1 (independent of age). High‐risk cut‐off points were FIB4 >2.67, NFS >0.676 and APRI ≥1 (all independent of age). Multivariable Cox regression analysis was performed to assess the association between liver fibrosis scores and all‐cause mortality. Results The mean ± standard deviation age was 65.2 ± 12.1 years, 54.5% were men and the median (interquartile range) diabetes duration was 5.8 (2.8–9.3) years. The prevalence of high‐risk categories was 6.1% for FIB4, 23.5% for NFS and 1.6% for APRI. During a median follow‐up of 9.8 years, 3925 patients (31.1%) died, resulting in a crude mortality rate of 40.4 per 1000 person‐years. The overall adjusted all‐cause mortality hazard ratios (95% confidence intervals [CIs]) in the high‐ compared with low‐fibrosis‐risk groups were 3.69 (1.95–2.75) for FIB4, 2.32 (2.88–4.70) for NFS, and 3.92 (2.88–5.34) for APRI. Stratified adjusted all‐cause mortality hazard ratios for individuals under 65 years and people over 65 years of age at cohort entry were 3.89 (95% CI 2.99–5.05) and 1.44 (95% CI 1.28–1.61) for FIB4, 2.50 (95% CI 1.89–3.18) and 1.35 (95% CI 1.24–1.48) for NFS and 3.74 (95% CI 2.73–5.14) and 1.64 (95% CI 1.24–2.17) for APRI. Conclusions All three fibrosis risk scores were positively associated with all‐cause mortality in people with type 2 diabetes, with higher relative risks in younger than older people. Effective interventions are required to minimize excess mortality in people at high risk of liver fibrosis.