The impact of an increased Fibrosis-4 index and the severity of hepatic steatosis on mortality in diabetes patients

Abstract Background & aims: Data on the effects of liver fibrosis and hepatic steatosis on outcomes in diabetic patients are limited. Therefore, we investigated the predictive value of the fibrosis and the severity of hepatic steatosis for all-cause mortality in diabetes patients. Methods: A total of 1,903 patients with diabetes from the Third National Health and Nutrition Examination Survey (NHANES III) dataset were enrolled. Presumed hepatic fibrosis was evaluated with Fibrosis-4 index (FIB-4). The mortality risk and corresponding hazard ratio (HR) were analyzed with the Kaplan-Meier method and multivariable Cox proportional hazard models. Results: Over a median follow-up of 19.4 years, all-cause deaths occurred in 69.6%. An FIB-4 ≥1.3 was an independent predictor of mortality in diabetic patients (HR: 1.198, 95% confidence interval [CI]: 1.054-1.361, p =0.006). Overall, an FIB-4 ≥1.3 without moderate-severe steatosis increased the mortality risk (HR: 1.277; 95%CI: 1.077-1.513, p =0.005). The similar results were found in diabetes patients with metabolic dysfunction-associated fatty liver disease (MAFLD) (HR: 1.457; 95%CI: 1.045-2.032, p =0.027), metabolic syndrome (MetS) (HR: 1.343; 95%CI: 1.051-1.716, p =0.019) or abdominal obesity (HR: 1.325; 95%CI: 1.048-1.674, p =0.019). Conclusions: Liver fibrosis, as estimated by FIB-4, may serve as a more reliable prognostic indicator for diabetic patients than hepatic steatosis. Diabetes patients with an FIB-4 ≥1.3 without moderate-severe steatosis had a significantly increased all-cause mortality risk. These findings highlight the importance of identifying and monitoring those patients, as they may benefit from further evaluation and risk stratification.