Martin Bergram

Clinical aspects of Non-alcoholic fatty liver disease (NAFLD) in patients with type 2 diabetes mellitus in primary care

NAFLD is estimated to affect 25% of the world population and patients with type 2 diabetes mellitus (T2DM) to an even greater extent. Most of the NAFLD-patients are unknown in primary health care and the benefits of screening are not fully known.

NAFLD is a heterogeneous disease ranging from steatosis to advanced fibrosis and hepatocellular cancer. The mortality is increased in advanced fibrosis. Some treatment can be offered in advanced fibrosis and these patients are screened for complications. NAFLD and T2DM are strongly connected and patients with both conditions develop more diabetic complications and more advanced liver disease. The golden standard for diagnosing NAFLD is liver biopsy, but the presence of steatosis or advanced fibrosis can be assessed non-invasively with, for example, magnetic resonance imaging (MRI) or magnetic resonance elastography (MRE). The risk of steatosis and advanced fibrosis can be assessed using algorithms, based on patient data. Benefits, risks and costs associated with screening for NAFLD in patients with T2DM have been partially studied and European guidelines from 2016 recommend screening while American guidelines from 2018 advice against screening.

How common is NAFLD in Swedish T2DM patients and how is it handled in Primary Care today? How could a screening for NAFLD in patients with T2DM in Primary Care be designed and what are the health benefits, risks and costs of such a screening?

Project 1: In this retrospective study a medical record review is planned for 350 randomly selected patients with T2DM who are followed in primary care. Patients with known NAFLD and their handling are registered. With algorithms, the probable prevalence of steatosis and advanced fibrosis are estimated in the group.

Project 2: Part of the larger study EPSONIP (Evaluating Prevalence and Severity Of NAFLD in Primary Care) where the prevalence of NAFLD is studied in 400 patients with T2DM who are followed in primary care. Patients are included from 4 primary care centers and they undergo MRI / MRE and, if necessary, liver biopsy. A medical record review is planned to study the differences of diabetic complications in EPSONIP patients with NAFLD with or without advanced disease compared to those with healthy livers.

Project 3 and 4: Based on data from EPSONIP and a literature study, an algorithm for screening for NAFLD and advanced fibrosis in patients with T2DM in primary care will be presented. A health economic analysis will be carried out to analyze effects of different screening algorithms.

NAFLD has mostly been studied in hospital settings and study results are most likely not representative for all NAFLD patients. To date, there are no studies on NAFLD in Swedish Primary Care. It is unclear if screening for NAFLD is beneficial to patients.

Linköping University

Main Supervisor: Karin Rådholm, Docent