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Screening for hepatic fibrosis and steatosis in Turkish patients with type 2 diabetes mellitus: A transient elastography study.


Patients with type 2 diabetes mellitus (T2DM) are at risk for non-alcoholic fatty liver disease (NAFLD)-most likely due to the widespread occurrence of obesity and insulin resistance in this patient group (1). Although NAFLD can lead to advanced fibrosis and cirrhosis (ultimately increasing liver-related mortality) (2), most patients are asymptomatic and typically identified when the liver enzymes alanine aminotransferase (ALT) and aspartate aminotransferase (AST) are found to be increased during routine laboratory examinations (3,4). However, ALT is not invariably elevated in NAFLD, and its levels do not accurately reflect the extent of hepatic fibrosis and fat accumulation (5,6). Routine liver ultrasound can also provide insight into the extent of hepatic fat deposition in T2DM but also does not have sufficient accuracy for identifying, or ruling out, fibrosis (7). Owing to the known limitations of liver biopsy, including its invasive nature and sampling errors, the role of novel non-invasive screening modalities for hepatic fibrosis and steatosis has been a subject of growing interest (8).

Transient elastography (TE) is increasingly being used as a non-invasive, operator-independent, simple-to-perform imaging modality to assess liver stiffness and hepatic fat deposition (9). In this regard, liver stiffness measurement (LSM) and controlled attenuation parameter (CAP) obtained from TE have been shown to be reliable imaging markers of liver fibrosis and steatosis, respectively (10). Recently, studies from Romania (11), Hong Kong (12), Korea (13), and France (14) have reported that TE-derived parameters may be a clinically useful screening tool for hepatic fibrosis and steatosis in T2DM. In the present study, since ethnicity has been shown to significantly affect the risk of NAFLD (15,16), we investigate the prevalence of TE-defined hepatic fibrosis and steatosis in a sample of Turkish patients with T2DM.



The study was conducted at Marmara University School of Medicine Hospital between August 2015 and August 2017. Patients aged between 18 and 65 years old were included in the study if (1) they had a diagnosis of T2DM according to the American Diabetes Association criteria (17) and (2) they expressed their willingness to undergo TE for LSM and CAP quantification. Exclusion criteria were as follows: (1) chronic liver diseases (viral hepatitis, autoimmune hepatitis, hemochromatosis, primary biliary cirrhosis, Wilson's disease, sclerosing cholangitis, biliary obstruction, alpha-1 antitrypsin deficiency), (2) malignancies, (3) heart failure (New York Heart Association class III-IV), (4) pregnancy, (5) implanted medical devices (e.g., cardiac pacemakers), (6) end-stage renal disease (glomerular filtration rate<15 mL/min/1.73 [m.sup.2]), (7) alcohol intake >20 g/day in women and >30 g/day in men, (8) use of steatogenic drugs (e.g., estrogens, amiodarone, steroids, and tamoxifen), and (9) measurement failure or unreliable measurements on TE (see below). Clinical and laboratory data were obtained from medical records. Body mass index (BMI) was calculated as weight in kilograms (kg) divided by the square of height in meters ([m.sup.2]). Overweight and obesity were defined by BMI >25 kg/[m.sup.2] and BMI >30 kg/[m.sup.2], respectively. Metabolic syndrome was diagnosed according to the Adult Treatment Panel III criteria (18). After 15 min of seated rest, two blood pressure measurements were obtained (1 min apart) from the right arm of the seated patient using an automated sphygmomanometer. The average of the two measurements was used for analysis. Smoking history was collected by a questionnaire. The AST and ALT levels were considered increased if >37 U/L and >40 U/L, respectively. Microalbuminuria and macroalbuminuria were defined as 30-300 mg/g creatinine and >300 mg/g creatinine, respectively (19). Written informed consent was obtained from all patients. The Institutional Review Board of the Marmara University School of Medicine approved the study.

Transient elastography

Patients were required to fast for at least 3 h before imaging. All TE examinations were performed by a single operator as previously described (20,21). LSM values were quantified by a Fibroscan 502 touch (Echosens SA, Paris, France) using the original M or XL probe (according to the patient's body weight or subcutaneous adipose tissue thickness) according to the manufacturer's instructions. After placing the patient in the dorsal decubitus position, the tip of the transducer probe was positioned on the skin between the ribs over the right lobe of the liver. The examination was conducted through the intercostal space on the right lobe of the liver. After identifying the appropriate area of measurement, the acquisition was started with a measurement depth of 25-65 mm for the M probe and 35-75 mm for the XL probe. TE examinations were considered reliable when at least 10 successful acquisitions were obtained, and the interquartile range-to-median ratio of the 10 acquisitions was [less than or equal to]0.3 (19).

The following probe-specific LSM cut-off values were used to define advanced fibrosis ([greater than or equal to]F3) and cirrhosis (F4): M probe: F3=9.6-11.4 kPa, F4 [greater than or equal to]11.5 kPa and XL probe: F3=9.3-10.9 kPa, F4 [greater than or equal to]11.0 kPa) (12). In accordance with the previously reported methodology (19), the CAP value (100-400 dB/m) was the median value of individual measurements. Mild, moderate, and severe steatosis were defined as CAP 222-232 dB/m, CAP 233-289 dB/m, and CAP [greater than or equal to]290 dB/m, respectively (12).

Statistical analysis

Normally distributed continuous data are expressed as mean[+ or -]standard deviation, whereas median and interquartile range were used for skewed variables. Categorical data are expressed as counts. The association between the continuous variables was tested using the Spearman's correlation coefficient. Multivariable stepwise linear regression analyses were used to identify the independent predictors of CAP and LSM in patients with T2DM. All of the variables were entered into the multivariable model as potential predictors/covariates (Table 1). Comparisons of ALT levels across different TE-defined groups were performed using the Mann-Whitney U test. All statistical analyses were performed using the SPSS 20.0 software (IBM Corp.; Armonk, NY, USA). A p value <0.05 (two-tailed) was considered statistically significant.


Of a total of 127 patients with T2DM who underwent TE examination, 3 (2.3%) were excluded due to unreliable results. Overall, the final study cohort consisted of 124 (46 male and 78 female) patients. The mean BMI of the patients was 33.2[+ or -]6.6 kg/[m.sup.2]. Table 1 shows the general characteristics of the study subjects.

Hepatic fibrosis

The M and XL probes were used in 115 (92.7%) and 9 (7.3%) patients, respectively. The mean LSM was 7.1[+ or -]3.4 kPa, with minimum and maximum values of 2.9 and 25.1 kPa, respectively. When probe-specific LSM cut-off values were used, we identified 21 (16.9%) and 10 (8.0%) patients with advanced fibrosis ([greater than or equal to]F3) and cirrhosis (F4), respectively. LSM values were found to be significantly correlated with BMI (r=0.41, p<0.001), waist circumference (r=0.36, p<0.001), hip circumference (r=0.32, p<0.001), systolic blood pressure (r=0.23, p=0.01), diastolic blood pressure (r=0.21, p=0.02), and AST (r=0.29, p<0.001). In multivariable stepwise linear regression analyses, BMI was retained as the only independent predictor of LSM (beta=0.35, t=4.1, p<0.001).

Hepatic steatosis

The mean CAP value was 317[+ or -]54 dB/m, with minimum and maximum values of 184 and 400 dB/m, respectively. TE-defined hepatic steatosis (CAP>222 dB/m) was detected in the large majority of the sample (n=117; 94.3%). Mild, moderate, and severe steatosis were identified in 0, 29, and 88 patients, respectively. Univariate correlation analyses revealed that CAP values were significantly associated with BMI (r=0.47, p<0.001), waist circumference (r=0.44, p<0.001), hip circumference (r=0.33, p<0.001), AST (r=0.20, p=0.02), ALT (r=0.22, p=0.01), triglycerides (r=0.25, p=0.006), and total cholesterol (r=0.19, p=0.02). BMI was the only independent predictor of CAP in multivariable stepwise linear regression analyses (beta=0.46, t=5.5, p<0.001).

ALT levels in patients with TE-defined fibrosis and steatosis

Since liver enzymes are commonly used to screen for NA-FLD in the clinical setting (5,6), we examine the ALT levels in patients with T2DM in relation to TE-defined hepatic fibrosis and steatosis (Table 2). Compared with patients without F3/4 fibrosis, higher ALT levels (p<0.05) were evident in patients with F3 fibrosis, but not in those with F4 fibrosis (p=0.54). Both patients with mild and severe steatosis had higher ALT levels than those without (both p<0.05). However, ALT values did not differ significantly according to steatosis severity (p=0.69).


Increasing evidence indicates that the epidemiology of NAFLD is significantly influenced by ethnicity (15,16). In addition to disease prevalence and risk factors, ethnic-related variables may also play a significant role in designing screening programs. Therefore, we specifically investigated whether TE, which has been previously shown to be clinically useful in different geographical populations (11-14), could serve as a non-invasive screening modality for identifying hepatic fibrosis and steatosis in a high-risk cohort of Turkish patients with T2DM. The main findings of the present study are as follows. First, we have shown that TE-defined advanced fibrosis ([greater than or equal to]F3) and cirrhosis (F4) were present in 16.9% and 8.0% of the study patients, respectively. Second, TE-defined steatosis was found to be extremely common, being identifiable in >94% of our subjects. Notably, all cases of steatosis were moderate-to-severe, with no mild forms being observed. Third, BMI was identified as the only independent predictor of both TE-defined fibrosis and steatosis in multivariable analysis. Finally, ALT levels, the most common laboratory parameter used to screen for NAFLD in the clinical routine, were surprisingly unaltered in patients with TE-defined cirrhosis and did not distinguish between different grades of TE-diagnosed steatosis. Generally, our results confirm that TE is a clinically useful non-invasive screening modality for identifying hepatic involvement in Turkish patients with T2DM.

In compliance with previous studies from Romania (11), Hong Kong (12), Korea (13), and France (14), hepatic fibrosis and steatosis were highly common in Turkish patients with T2DM. We believe that TE could serve as a valuable screening modality in this high-risk group owing to its well-known advantages over traditional ultrasound (e.g., ability to identify fibrosis and even low-grade fat deposition and absence of machine and operator dependency) (22). Owing to the strong association between BMI and both fibrosis and/steatosis observed in our study, TE examinations appear to be especially advisable for patients with T2DM who are overweight/obese. However, the costs of this imaging modality need to be weighed against the expected benefits before considering its implementation on a large scale (9). Since different ethnic groups may differ in terms of lifestyles, calorie consumption, levels of physical activity, and genetic determinants of NAFLD (16), not only the diagnostic accuracy of TE but also its cost-effectiveness may vary according to different geographical areas. Our study did not specifically compare the accuracy of TE and ultrasound for NAFLD screening in patients with T2DM. TE is considered to be more sensitive than ultrasound, which is nonetheless less expensive. Future studies should specifically compare the cost-effectiveness of the two techniques. However, our current data strongly suggest that the simple measurement of liver enzymes is not sufficient to detect liver involvement in the setting of T2DM. Accordingly, not only ALT was not elevated in patients with cirrhosis but also it did not distinguish the severity of TE-identified steatosis.

Our study has some limitations. Owing to ethical reasons, liver biopsy for diagnostic confirmation of TE findings was not performed. Although it may be argued that the prevalence of TE-defined steatosis in our sample is very high (94.3%), we believe that our data are in agreement with the published literature. For example, the study conducted in Hong Kong by Kwok et al. (12) reported a prevalence of 70% for TE-defined steatosis. However, the mean BMI of their patients was markedly lower than that observed in our cohort (26.6 kg/[m.sup.2] vs. 33.2[+ or -]6.6 kg/[m.sup.2], respectively). Since the sample size of our current study is relatively small, the generalizability of our findings needs to be confirmed in larger studies. Finally, repeated or serial measurements of LSM and CAP were not available. However, a significant strength of our study is that we were able to minimize the number of patients (n=3) who had unreliable measurements, possibly owing to our use of the XL probe in selected obese patients.

In conclusion, our results obtained in a Turkish population expand previous evidence in different ethnicities supporting the clinical value of LSM and CAP for simultaneous screening of hepatic fibrosis and steatosis in patients with T2DM.

Ethics Committee Approval: Ethics committee approval was received for this study from the Institutional Review Board of Marmara University School of Medicine.

Informed Consent: Written informed consent was obtained from all the patients who participated in the study.

Peer-review: Externally peer review.

Author Contributions: Concept - M.D., O.D., Y.Y.; Design - Y.Y., O.D.; Supervision - Y.Y.; Resources - Y.Y.; Materials - M.D., O.D.; Data Collection and/or Processing - M.D., Y.Y.; Analysis and/or Interpretation - M.D., O.D., Y.Y.; Literature Search - Y.Y., M.D.; Critical Review - M.D., O.D., Y.Y.

Conflict of Interest: The authors declare that they have no conflicts of interest.

Financial Disclosure: The authors declared that this study was financially supported by Marmara University Research Fund (Project Number: SAG-C-TUP-071015-0468).


(1.) Tilg H, Moschen AR, Roden M. NAFLD and diabetes mellitus. Nat Rev Gastroenterol Hepatol 2017; 14:32-42. [CrossRef]

(2.) Dulai PS, Singh S, Patel J, et al. Increased risk of mortality by fibrosis stage in nonalcoholic fatty liver disease: Systematic review and meta-analysis. Hepatology 2017; 65:1557-65. [CrossRef]

(3.) Sanyal D, Mukherjee P, Raychaudhuri M, Ghosh S, Mukherjee S, Chowdhury S. Profile of liver enzymes in non-alcoholic fatty liver disease in patients with impaired glucose tolerance and newly detected untreated type 2 diabetes. Indian J Endocrinol Metab 2015; 19:597-601. [CrossRef]

(4.) Obika M, Noguchi H. Diagnosis and evaluation of nonalcoholic fatty liver disease. Exp Diabetes Res 2012; 2012:145754.

(5.) Liu Z, Que S, Xu J, Peng T. Alanine aminotransferase-old biomarker and new concept: a review. Int J Med Sci 2014; 11:925-35. [CrossRef]

(6.) Kim WR, Flamm SL, Di Bisceglie AM, Bodenheimer HC; Public Policy Committee of the American Association for the Study of Liver Disease. Serum activity of alanine aminotransferase (ALT) as an indicator of health and disease. Hepatology 2008; 47: 1363-70. [CrossRef]

(7.) Khov N, Sharma A, Riley TR. Bedside ultrasound in the diagnosis of nonalcoholic fatty liver disease. World J Gastroenterol 2014; 20:6821-5. [CrossRef]

(8.) Maida M, Macaluso FS, Salomone F, Petta S. Non-invasive assessment of liver injury in non-alcoholic fatty liver disease: a review of literature. Curr Mol Med 2016; 16: 721-37. [CrossRef]

(9.) Brener S. Transient elastography for assessment of liver fibrosis and steatosis: an evidence-based analysis. Ont Health Technol Assess Ser 2015; 15:1-45.

(10.) Tsai E, Lee TP. Diagnosis and evaluation of nonalcoholic fatty liver disease/nonalcoholic steatohepatitis, including noninvasive biomarkers and transient elastography. Clin Liver Dis 2018; 22: 73-92. [CrossRef]

(11.) Sporea I, Mare R, Lupusoru R, et al. Liver stiffness evaluation by transient elastography in type 2 diabetes mellitus patients with ultrasound-proven steatosis. J Gastrointestin Liver Dis 2016;25:167-74.

(12.) Kwok R, Choi KC, Wong GL, et al. Screening diabetic patients for non-alcoholic fatty liver disease with controlled attenuation parameter and liver stiffness measurements: a prospective cohort study. Gut 2016; 65:1359-68. [CrossRef]

(13.) Chon YE, Kim KJ, Jung KS, et al. The relationship between type 2 diabetes mellitus and non-alcoholic fatty liver disease measured by controlled attenuation parameter. Yonsei Med J 2016; 57: 885-92. [CrossRef]

(14.) Roulot D, Roudot-Thoraval F, NKontchou G, et al. Concomitant screening for liver fibrosis and steatosis in French type 2 diabetic patients using Fibroscan. Liver Int 2017; 37:1897-906. [CrossRef]

(15.) Rich NE, Oji S, Mufti AR, et al. Racial and ethnic disparities in nonalcoholic fatty liver disease prevalence, severity, and outcomes in the United States: a systematic review and meta-analysis. Clin Gastroenterol Hepatol 2018; 16:198-210 [CrossRef]

(16.) Bambha K, Belt P, Abraham M, et al. Ethnicity and nonalcoholic fatty liver disease. Hepatology 2012; 55: 769-80. [CrossRef]

(17.) American Diabetes Association. Diagnosis and classification of diabetes mellitus. Diabetes Care 2014; 37 Suppl 1: S81-90. [CrossRef]

(18.) Grundy SM, Brewer HB, Jr, Cleeman JI, et al. Definition of metabolic syndrome: report of the National Heart, Lung, and Blood Institute/American Heart Association conference on scientific issues related to definition. Circulation 2004; 109: 433-8. [CrossRef]

(19.) Yilmaz Y, Alahdab YO, Yonal O, et al. Microalbuminuria in nondiabetic patients with nonalcoholic fatty liver disease: association with liver fibrosis. Metabolism 2010; 59:1327-30. [CrossRef]

(20.) Kaya E, Demir D, Alahdab YO, Yilmaz Y. Prevalence of hepatic steatosis in apparently healthy medical students: a transient elastography study on the basis of a controlled attenuation parameter. Eur J Gastroenterol Hepatol 2016; 28:1264-7. [CrossRef]

(21.) Yilmaz Y, Ergelen R, Akin H, Imeryuz N. Noninvasive detection of hepatic steatosis in patients without ultrasonographic evidence of fatty liver using the controlled attenuation parameter evaluated with transient elastography. Eur J Gastroenterol Hepatol 2013; 25: 1330-4. [CrossRef]

(22.) Liu K, Wong VW, Lau K, et al. Prognostic value of controlled attenuation parameter by transient elastography. Am J Gastroenterol 2017; 112:1812-23. [CrossRef]

Meryem Demir (1) [iD], Oguzhan Deyneli (2,3) [iD], Yusuf Yilmaz (4,5) [iD]

(1) Department of Internal Medicine, Marmara University School of Medicine, Istanbul, Turkey

(2) Department of Endocrinology and Metabolism, Marmara University School of Medicine, Istanbul, Turkey

(3) Department of Endocrinology and Metabolism, Koc University School of Medicine, Istanbul, Turkey.

(4) Department of Gastroenterology, Marmara University School of Medicine, Istanbul, Turkey

(5) Institute of Gastroenterology, Marmara University, Istanbul, Turkey

Cite this article as: Demir M, Deyneli O, Yilmaz Y. Screening for hepatic fibrosis and steatosis in Turkish patients with type 2 diabetes mellitus: A transient elastography study. Turk J Gastroenterol 2019; 30(3): 266-70.

Corresponding Author: Yusuf Yilmaz;

Received: July 9, 2018 Accepted: July 19, 2018 Available online date: November 9, 2018

DOI: 10.5152/tjg.2018.18559
Table 1. General characteristics of the 124 patients with type 2
diabetes mellitus


Sex, male/female                                  46/78
Age, years                                        53[+ or -]7
Body mass index, kg/m2                            33.2[+ or -]6.6
Lean/overweight/obese                              9/35/80
Waist circumference, cm                          111[+ or -]13
Hip circumference, cm                            113[+ or -]11
Homeostasis model assessment-insulin resistance    4.6 (2.9-6.5)
Metabolic syndrome, yes/no                        96/28
History of hypertension, yes/no                   75/49
Systolic blood pressure, mm Hg                   139[+ or -]19
Diastolic blood pressure, mm Hg                   78[+ or -]10
Smoking history, never/former/current             72/52/0
AST, U/L                                          23 (18-32)
ALT, U/L                                          26 (20-48)
Increased AST level, yes/no                       24/100
Increased ALT levels, yes/no                      37/87
Total cholesterol, mg/dL                         213[+ or -]46
HDL cholesterol, mg/dL                            49[+ or -]13
LDL cholesterol, mg/dL                           129[+ or -]40
Triglycerides, mg/dL                             146 (109-202)
Microalbuminuria/macroalbuminuria                 66/34

Table 2. ALT levels in patients with type 2 diabetes mellitus in
relation to transient elastography-defined hepatic fibrosis and

                      Severity of fibrosis

          No F3/4     [greater than or equal to]F3  F4
ALT, U/L  21 (17-29)  39 (23-50)                    24 (19-35)
                      Severity of steatosis
          None        Moderate                      Severe
ALT, U/L  19 (15-30)  31 (22-47)                    34 (20-54)
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Author:Demir, Meryem; Deyneli, Oguzhan; Yilmaz, Yusuf
Publication:The Turkish Journal of Gastroenterology
Article Type:Report
Date:Mar 1, 2019
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