Adipose Tissue Insulin Resistance Predicts the Severity of Liver Fibrosis in Patients with Type 2 Diabetes and NAFLD

CONTEXT

While T2D is a risk factor for liver fibrosis in NAFLD, the specific contribution of insulin resistance (IR) relative to other factors is unknown.

OBJECTIVE

Assess the impact on liver fibrosis in NAFLD of adipose tissue (Adipo-IR) and liver (HOMA-IR) IR in people with T2D and NAFLD.

DESIGN

Participants were screened by elastography in the outpatient clinics for hepatic steatosis and fibrosis, including routine metabolites, cytokeratin-18 (marker of hepatocyte apoptosis/steatohepatitis), and HOMA-IR/Adipo-IR.

SETTING

University ambulatory care practice.

PARTICIPANTS

483 participants with T2D.

INTERVENTION

Screening for steatosis and fibrosis with elastography.

MAIN OUTCOME MEASURES

Liver steatosis (CAP) and fibrosis (LSM) and measurements of IR (Adipo-IR, HOMA-IR) and fibrosis (cytokeratin-18).

RESULTS

Clinically significant liver fibrosis (stage F ≥ 2= LSM ≥8.0 kPa) was found in 11%, having more features of the metabolic syndrome, lower adiponectin, and higher AST, ALT, liver fat and cytokeratin-18 (p < 0.05-0.01). In multivariable analysis including just clinical variables (model 1), obesity (BMI) had the strongest association with fibrosis (OR: 2.56, CI:1.87-3.50; p < 0.01). When metabolic measurements and cytokeratin-18 were included (model 2), only BMI, AST and liver fat remained significant. When fibrosis stage was adjusted for BMI, AST, and steatosis (model 3), only adipo-IR remained strongly associated with fibrosis (OR: 1.51, CI:1.05-2.16; p = 0.03), but not BMI, hepatic IR or steatosis.

CONCLUSIONS

These findings pinpoint to the central role of dysfunctional, insulin-resistant adipose tissue to advanced fibrosis in T2D, beyond simply BMI or steatosis. The clinical implication is that targeting adipose tissue should be the priority of treatment in NAFLD.

Advanced Liver Fibrosis Is Common in Patients With Type 2 Diabetes Followed in the Outpatient Setting: The Need for Systematic Screening

OBJECTIVE

Assess the prevalence of nonalcoholic fatty liver disease (NAFLD) and of liver fibrosis associated with nonalcoholic steatohepatitis in unselected patients with type 2 diabetes mellitus (T2DM).

RESEARCH DESIGN AND METHODS

A total of 561 patients with T2DM (age: 60 ± 11 years; BMI: 33.4 ± 6.2 kg/m²; and HbA_1c: 7.5 ± 1.8%) attending primary care or endocrinology outpatient clinics and unaware of having NAFLD were recruited. At the visit, volunteers were invited to be screened by elastography for steatosis and fibrosis by controlled attenuation parameter (≥274 dB/m) and liver stiffness measurement (LSM; ≥7.0 kPa), respectively. Secondary causes of liver disease were ruled out. Diagnostic panels for prediction of advanced fibrosis, such as AST-to-platelet ratio index (APRI) and Fibrosis-4 (FIB-4) index, were also measured. A liver biopsy was performed if results were suggestive of fibrosis.

RESULTS

The prevalence of steatosis was 70% and of fibrosis 21% (LSM ≥7.0 kPa). Moderate fibrosis (F2: LSM ≥8.2 kPa) was present in 6% and severe fibrosis or cirrhosis (F3-4: LSM ≥9.7 kPa) in 9%, similar to that estimated by FIB-4 and APRI panels. Noninvasive testing was consistent with liver biopsy results. Elevated AST or ALT ≥40 units/L was present in a minority of patients with steatosis (8% and 13%, respectively) or with liver fibrosis (18% and 28%, respectively). This suggests that AST/ALT alone are insufficient as initial screening. However, performance may be enhanced by imaging (e.g., transient elastography) and plasma diagnostic panels (e.g., FIB-4 and APRI).

CONCLUSIONS

Moderate-to-advanced fibrosis (F2 or higher), an established risk factor for cirrhosis and overall mortality, affects at least one out of six (15%) patients with T2DM. These results support the American Diabetes Association guidelines to screen for clinically significant fibrosis in patients with T2DM with steatosis or elevated ALT.

Addressing Hospital Readmissions: Impact of Weekly Review

BACKGROUND AND OBJECTIVES

The prevention of hospital readmissions has become an area for improvement for most health care organizations. Systematic reviews have been unable to identify a single intervention or bundle of interventions that reliably reduced risk of readmission in a generalizable manner. The aim of this quality improvement project was to examine the readmission rate to a family medicine residency program inpatient service following the implementation of a once per week session that reviewed patients who were readmitted during the prior week.

METHODS

The inpatient admissions and readmission to the family medicine inpatient service associated with a large academic health center were used for analysis. The impact of a regularly scheduled multidisciplinary team meeting that reviewed a list of patients was examined. Readmitted patients who were at high risk for readmission were specifically identified. Descriptive statistics were used to characterize and summarize the integral data obtained. The weekly readmission rate was presented using a control chart.

RESULTS

The readmission rate for the patients hospitalized after the intervention was 18.4%, compared to the readmission rate prior to the intervention (23.0%). While not a statistically different rate, a significant signal was noted. Demographic differences were noted in the group of patients considered to be high risk for readmission.

CONCLUSIONS

Regular rounds of an inpatient team that focuses on readmissions during the previous week reduced hospital readmissions. The impact of these sessions appears to be multifactorial.