India is the second highest contributor to global diabetes pool after China. About 74.2 million Individuals had diabetes in 2021, which is expected to increase to 124.9 million by 2024.[1] Obesity, diabetes, hyperlipidemia, and the Metabolic Syndrome are frequently related to NAFLD while Diabetes and NAFLD tightly linked in a strong, bidirectional relationship. NAFLD is present in over 80% of people with Metabolic Syndrome.[2] Patients with diabetes mellitus have a higher prevalence of non-alcoholic fatty liver disease(NAFLD).[3] According to recent data, individuals having type 2 diabetes are especially vulnerable to non-alcoholic steatohepatitis(NASH), with varying degrees of liver fibrosis.[4] NAFLD is associated with liver fibrosis in diabetics and has been associated with increased mortality. Liver biopsy is gold standard for assessment of liver fibrosis, however, simple serologic non-invasive tests(NITs) have been used as an alternative tests. A straightforward, non-invasive method for identifying advanced liver fibrosis is the Fibrosis-4 Index(FIB-4). According to national recommendations, the FIB-4 score has been suggested as a screening tool and should be repeated every one to three years to reevaluate the risk of clinical events, depending on the severity of disease or the presence or absence of cardiometabolic risk factors.[5,6] Individuals with DM and NAFLD are more likely to experience cardiovascular and liver-related complications. The main obstacle is accurately identifying these individuals using non-invasive techniques. The current gold standard of care involves tailoring a treatment strategy to optimize the metabolic control with the goal to improve liver phenotype. Thus, the present study was conducted to assess clinical and Biochemical parameters in Fatty liver disease in Type 2 Diabetes mellitus.

The present study was conducted as a Cross-Sectional Study in Department of Medicine, Gandhi Medical College and associated Hamidia Hospital Bhopal on 384 patients with type 2 diabetes mellitus over the study period of 18 months i.e. from 1st July 2023 to 31st December 2024. All the patients with type 2 diabetes belonging to more than 18 years of age, and with features of fatty liver on USG were included whereas patients with history of fatty liver due to other aetiologies such as alcohol, viral hepatitis, Metabolic liver diseases(Wilson disease and Hemochromatosis) and patients on Hepatotoxic drugs were excluded from the study. Sample size- Sample size was estimated using the formula n=z²pq/d² Where, n=sample size p-prevalence=48%[7] q=52% z=1.96 at 95% Confidence Interval d=5% Sample size was estimated to be 384. After obtaining ethical clearance from Institute’s ethical committee, all the patients satisfying inclusion criteria were enrolled and written consent was obtained in the consent form. All the participants were subjected to thorough history taking and detailed clinical examination. Baseline investigations including serum ferritin, Liver Function Test, Lipid Profile, glycemic parameters (Fasting Blood Sugar and HbA1c), viral markers (HbsAG, ANTIHCV, HIV), PT/ INR etc. were done and findings were documented in proforma. Further, Ultrasonography abdomen was done for all participants and findings were noted. Patients were categorized into different grades of fatty liver disease based on liver ultrasound findings, with steatosis classified as follows: • Grade 0(Absent)–Normal liver echotexture without increased echogenicity. • Grade 1(Mild)–Slight, diffuse elevation in liver echogenicity, with clear visualization of the diaphragm and portal vein walls. • Grade 2(Moderate)–Noticeable increase in liver echogenicity, accompanied by mild blurring of the portal vein walls and diaphragm. • Grade 3(Severe)–Substantial increase in liver echogenicity, resulting in poor or absent visualization of the diaphragm, portal vein walls, and the posterior portion of the right liver lobe.[8] FIB 4 score was also calculated using the formula-FIB-4=age(years)xAST(IU/L)]/[platelet count(x109/L)xALT(IU/L)1/2.[9] Based upon FIB 4 score, patients were stratified into 3 risk categories[10] Low risk of fibrosis <1.3 Intermediate risk of fibrosis 1.3- 2.67 High risk of fibrosis >2.67 Statistical analysis- Data was compiled using Microsoft Excel and analysed using IBM SPSS software version 20. Categorical data was expressed as frequency and percentage whereas continuous data was expressed as mean and standard deviation.

The present study was conducted on a total of 384 patients with type 2 diabetes mellitus and fatty liver. Baseline variables No. of patients (n=384) Percentage Age(years) 18-30 0 0 31-40 103 26.8 41-50 143 37.2 51-60 79 20.6 61-70 43 11.2 >70 16 4.2 Mean±SD 48.38±10.92 Gender Male 223 58.1 Female 161 41.9 Duration of Diabetes(years) ≤5 247 64.3 6-10 94 24.5 11-15 30 7.8 ≥15 13 3.4 Mean±SD 5.70±4.75 Body mass index(kg/m2) Normal(18.5 to 22.9) 4 1.0 Overweight(23 to 24.9) 22 5.7 Obese(≥25) 358 93.2 Mean±SD 28.06±2.02 Waist Circumference(cm) Male(n=223) 91.04±6.36 Female(n=161) 86.78±3.98 Table 1- Distribution of patients according to baseline variables The majority of patients enrolled in present study belonged to age range of 41 to 50 years (37.2%) and we reported slight male predominance (58.1%). Majority of patients presented with duration of diabetes of less than 5 years (64.3%). About 93.2% cases were obese, 5.7% were overweight and only 1% cases had normal BMI (Table 1). Table 2- Distribution according to findings of baseline investigations Baseline investigations No. of patients (n=384) Percentage Fasting blood glucose(mg/dl) Within target(80-130) 187 48.7 Above target(>130) 197 51.3 Mean±SD 133.76±17.48 HBA1c(%) Within target(<7) 33 8.6 Above target(≥7) 351 91.4 Mean±SD 8.02±0.96 Total Cholesterol Normal(<200) 92 24.0 Borderline High(200- 239) 180 46.9 High(≥240) 112 29.2 Mean±SD 224.52±36.01 Triglycerides Normal(<150) 260 67.7 Borderline High(150-199) 109 28.4 High(≥200) 15 3.9 Mean±SD 142.24±28.99 LDL Normal(<130) 126 32.8 Borderline High(130-159) 143 37.2 High(≥160) 115 29.9 Mean±SD 146.44±36.65 HDL Male (n=223) Reduced(≤40) 38 17.0 Normal(>40) 185 83 Mean±SD 48.16±8.95 Female (n=161) Reduced(≤50) 73 45.3 Normal(>50) 88 54.7 Mean±SD 51.67±10.95 Mean fasting blood glucose was 133.76±17.48 mg/dl and 51.3% cases had their FBS levels above the target values. Mean HbA1c levels were 8.02±0.96 and 91.4% cases had uncontrolled diabetes. Lipid derangements are depicted in above table (Table 2). Table 3- Distribution of patients according to liver function tests Liver function tests No. of patients (n=384) Percentage Total bilirubin(mg/dl) Normal(<1.2) 363 94.5 Increased(≥1.2) 21 5.5 Mean±SD 0.92±0.19 Direct bilirubin(mg/dl) Normal(<0.2) 297 77.3 Increased(≥0.2) 87 22.7 Mean±SD 0.15±0.08 SGOT(U/L) Normal(<40) 313 81.5 Increased(≥40) 71 18.5 Mean±SD 33.71±13.77 SGPT(U/L) Normal(<40) 264 68.8 Increased(≥40) 120 31.3 Mean±SD 36.84±11.73 Prothrombin Time(seconds) Normal(10-13) 338 88.0 Raised(>13) 46 12.0 Mean±SD 12.148±0.89 INR Normal(≤1.1) 345 89.8 Raised(>1.1) 39 10.2 Mean±SD 0.99±0.10 Ferritin(ng/ml) Male(n=223) Normal(≤300) 209 93.7 Raised(>300) 14 6.3 Mean±SD 177.72±67.2 Female(n=161) Normal(≤200) 138 85.7 Raised(>200) 23 14.3 Mean±SD 142.65±46.07 Total bilirubin was raised in 5.5% cases whereas direct bilirubin was raised in 22.7% cases. SGOT was raised in 18.5% cases whereas about 31.3% cases had raised SGPT levels. Prothrombin time was raised in 12% cases(>13 seconds) and INR was raised(>1.1) in 10.2% cases. Serum ferritin levels were raised(>300 ng/ml) in 6.3% males and 14.3% females (Table 3).

The present study was conducted on a total of 384 patients with type 2 diabetes mellitus and fatty liver. The mean duration of diabetes was 5.70±4.75 years, and the majority of patients (64.3%) had diabetes for less than 5 years at the time of presentation in our study. In a study of Pasham et al, patients with NAFLD had an average duration of DM of 10.54±4.98 years, while those without NAFLD had an average duration of 10.50±5.68 years(p=0.975), which showed that NAFLD was not significantly affected by duration of diabetes.[11] The median duration of diabetes in cases with NAFLD in a study of Al-Humayed et al was 9.3(IQR- 8.2–10.5).[12] In our study, 93.2% cases wwere obese, 5.7% being overerweight, and only 1% having a normal BMI. However, in a study of Bendwal et al, NAFLD was documented in 72.4% of patients with a BMI between 30 and 39.9 kg/m2, 58.9% of patients with a BMI between 25 and 29.9 kg/m2.[7] In a study of Pasham et al, 64.6% of the patients cases were overweight(>25 kg/m2).[11] In the present study, 51.3% of cases had FBS levels above the target values(>130 mg/dl), with the mean fasting blood glucose being 133.76±17.48 mg/dl. On the other hand, 91.4% of cases had HbA1c values above 7%, indicating uncontrolled diabetes, and the mean HbA1c levels were 8.02±0.96. The findings of the present study were supported by the findings of Xie et al, in which, the mean fasting blood glucose levels were found to be significantly higher in cases of diabetes with NAFLD as compared to cases with no NAFLD(94.6±9.3 vs. 90.1±8.2; p<0.05). Also, significantly higher proportions of patients with NAFLD had higher HbA1c levels as compared to patients with no NAFLD(5.7 to 6.4%- 34.5% vs. 18.5; p<0.05).[13] The findings of our study were also in line with the findings of Masoor et al, where the authors found that HbA1c levels were above 5.7% in significantly higher proportions of cases with NAFLD as compared to controls(66% vs. 32% p<0.05). The authors discovered a strong correlation between HbA1C and NAFLD, supporting the interpretation of the data as a possible retrospective predictor of the condition. Obese, thin, diabetic, and non-diabetic individuals all showed this positive connection, suggesting that those with a HbA1C more than 5.7% are four times more likely to develop fatty liver disease(cOR=4.12, p<0.001).[14] Thus, current evidence indicates that glycemic dysregulation and NAFLD coexist; yet, there is still disagreement over the cause-and-effect link between HbA1C and NAFLD. NAFLD is associated with derangements in HbA1c levels even in non diabetics. Furthermore, the hemoglobin glycation index demonstrated its capacity to detect non-diabetic people who are at risk of developing non-alcoholic fatty liver disease.[15] It is currently unclear whether glycemic derangement causes, contributes to, or results from non-alcoholic fatty liver disease. One of the two processes listed below might account for this association. First, it impacted insulin sensitivity in muscle and adipose tissue, which led to insulin resistance; it also played a critical role in hepatic insulin signaling, impaired insulin inhibition of hepatic glucose production, and increased oxidative stress in liver cells and impaired hepatic lipid settling. The third potential explanation is that insulin resistance contributes significantly to the pathophysiology of NAFLD by permitting the liver to store free fatty acids.[16] According to recent research, the development and progression of non-alcoholic fatty liver disease(NAFLD) are triggered by the activation of the receptor for advanced glycation end products pathway(AGEs/RAGE), which also disrupts insulin signaling and causes further inflammation and oxidative stress.[17] The mean total cholesterol in our study was 224.52±36.01 mg/dl in patients with diabetes and fatty liver, and the percentage of patients with borderline high and high cholesterol was 46.9% and 29.2%, respectively. Triglyceride readings were 142.24±28.99 mg/dl on average, with borderline high triglycerides present in 28.4% of patients and high triglycerides in 3.9% of instances. The average LDL levels, however, were 146.44±36.65 mg/dl. About 29.9% of cases had high HDL values and 37.2% had borderline high LDL levels. The mean HDL values were 48.16±8.95 mg/dl in males and 51.67±10.95 mg/dl in females. Males had lower HDL levels by 17%, while females had lower levels by 45.3%. In a study of Xie et al, mean serum cholesterol in diabetes with NAFLD cases were 195.4±38.2 mg/dl, whereas mean triglycerides levels were 161.8±118.1 mg/dl and mean HDL cholesterol levels were 50.1±13.5 mg/dl, on the other hand, mean cholesterol, triglycerides, and HDL cholesterol level in diabetes cases with no NAFLD was 186.0±38.2, 109.8±61.3 and 57.1±14.1 mg/dl respectively.[13] Tanwani et al observed abnormal cholesterol levels in 62% cases, abnormal triglycerides in 50.7% cases, abnormal HDL in 51.7% cases, abnormal LDL in 39% cases and abnormal VLDL in 39% cases with NAFLD and diabetes.[18] Deranged carbohydrate metabolism has an impact on lipid metabolism and leads to a rise in TG synthesis, which accumulates in the liver and other organs, causing fatty liver. A primary characteristic of non-alcoholic fatty liver disease(NAFLD) is dyslipidemia, which includes elevated TG, elevated LDL-C, and reduced HDL-C.[19] While direct bilirubin was elevated in 22.7% of instances, total bilirubin was elevated in 5.5% of cases. The average levels of direct and total bilirubin were 0.15 and 0.92 mg/dl, respectively. About 31.3% of cases had elevated SGPT levels, while 18.5% of cases had elevated SGOT. The mean prothrombin time in our study was 12.148±0.89 seconds, with 12% of cases having elevated prothrombin times(>13 seconds). 10.2% of cases had an INR increase(>1.1), with a mean INR of 0.99±0.10. Serum ferritin levels in males were 177.72±67.2 ng/ml on average, while 6.3% of males had elevated levels(>300 ng/ml). In females, the mean serum ferritin level was 142.65±46.07 ng/ml. In 14.3% of females, serum ferritin levels were elevated(>200 ng/ml). Literature suggests that normal transferrin saturation combined with hyperferritinemia is indicative of a glucose or lipid metabolism disorder.[20] Patients with iron overload are more likely to develop type 2 diabetes, and iron chelation treatment may help them manage their condition by lowering their iron overload levels. A number of factors, including oxidative stress, inflammation, insulin resistance, insulin insufficiency, and liver dysfunction, can make iron excess a risk factor for diabetes. A vicious loop, on the other hand, may result from diabetes's disruption of iron metabolism balance and subsequent iron excess. The hepatic iron itself is also linked to liver damage. One research suggested that NAFLD may be avoided by consuming less meals rich in iron. Iron levels in adipose tissue have been found to be significantly correlated with adipose tissue dysfunction related to adipokine dysregulation through inflammation and lipolysis.[20-22] Pasham et al found raised SGOT in 30%, SGPT in 58.6%, alkaline phosphate in 67% cases in their study.[11] In a study by Yan et al, patients with type 2 diabetes mellitus(T2DM) and non-alcoholic fatty liver disease(NAFLD) had significantly higher serum ferritin levels(168.47 [103.78, 248.00] ng/mL) compared to those without NAFLD(121.19 [76.97, 208.39] ng/mL).[23] Similarly, research by Mayneris-Perxachs et al found a positive correlation between serum ferritin levels and the extent of hepatic fat accumulation. The proposed mechanism behind this association involves interactions between the gut microbiome and iron metabolism, leading to specific metabolomic and transcriptomic changes. These shifts affect gluconeogenic pathways, ketone body production, and cellular transport processes, collectively contributing to liver fat accumulation. This highlights the significant cross-talk between gut microbiota, iron status, and hepatic steatosis.[24] Ogresta et al observed coagulation disorders to be common in patients with NAFLD. According to the authors, patients with NAFLD may have a prothrombotic condition due to endothelial vascular dysfunction, platelet abnormalities, and changes in components involved in the coagulation cascade and fibrinolysis. Low-grade chronic inflammation may be the cause of the changes. Patients with NAFLD have a significant morbidity and death rate because to the involvement of many organs and organ systems.[25] Grade of NAFLD was assessed using ultrasonography. In 83.6% of instances, USG showed grade I fatty liver disease, while in 15.6% of cases, grade II fatty liver was seen. However, grade III fatty liver disease was seen in 0.8% of individuals. Tanwani et al observed grade I NAFLD in 58.7% cases of diabetes, grade II in 27.3% cases with diabetes and grade III NAFLD in 14% cases with diabetes.[18] In a study of Pasham et al, 54.2% cases had grade I, 39.6% cases had grade II and 6.2% cases had grade III fatty liver disease.[11] Literature suggests that, in addition to being one of the best clinical indicators of the development of NAFLD to NASH and cirrhosis, diabetes appears to hasten the course of NAFLD. Additionally, there is a clear pathophysiological connection between diabetes and HCC. The elevated risk of HCC may be caused by the elevated levels of inflammatory biomarkers and hyperinsulinemia that are present in diabetics.[26] Our study population's mean Fibrosis-4 Index(FIB-4) was 1.05±0.64. With a FIB score below 1.3, nearly three-fourths of the patients(74.7%) had a low risk of fibrosis, whereas 22.9% had an intermediate risk(1.3-2.67) and 2.3% had a high risk(>2.67). Kim et al validated the utility of FIB 4 score for assessing the risk of fibrosis. With an Area Under Receiver Operating Characteristic(AUROC) of 0.79, FIB-4's overall performance was satisfactory. The AUROC of FIB-4 for advanced fibrosis was 0.68 vs. 0.85 for those without diabetes when only those with diabetes were included(P = 0.003).[6] In a study of Anstee et al, the majority i.e.29359 out of 44481 cases had low risk of fibrosis, 13189 cases had intermediate risk and 1933 cases had high risk of fibrosis based on FIB-4 score.[5] Since fibrosis is the most significant predictor of liver-related morbidity and death, screening methods for fibrosis must be precise. Diabetes patients are more likely to develop severe fibrosis, hence it's imperative to reduce false negative results in this group. A FIB-4 score of less than 1.3 may not accurately identify patients at risk of fibrosis since individuals with diabetes and nonalcoholic fatty liver disease(NAFLD), with or without steatohepatitis, may have normal aminotransferases. Our study had certain limitations. First, the study was conducted as a unicentric study on small proportions of sample, thus the population may be homogenous limiting the generalizability of the study findings. Second, although liver biopsy is gold standard for assessing the fibrosis, we used non invasive score(FIB 4) for assessing the risk of fibrosis. Third, being a cross sectional study, causal association of diabetes and NAFLD could not be established. Also, the progression of liver disease and fibrosis in these patients could not be studied.

Diabetes and non-alcoholic fatty liver disease(NAFLD) are tightly linked in a strong, bidirectional relationship. These conditions frequently co-exist and often act synergistically, contributing to adverse health outcomes. Despite growing evidence that hepatic involvement in T2DM is associated with poorer prognosis, awareness of advanced liver disease in this population remains remarkably low, even among healthcare professionals. This gap likely reflects a broader under- recognition of liver disease as a critical component of diabetes management. Ultrasound remains a widely available, cost-effective modality for assessing the grade of NAFLD, while the FIB-4 index provides a non-invasive score for estimating the risk of liver fibrosis.

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