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

Background and aims Data on the effects of liver fibrosis and hepatic steatosis on outcomes in individuals living with diabetes are limited. Therefore, we investigated the predictive value of the fibrosis and the severity of hepatic steatosis for all-cause mortality in individuals living with diabetes. Methods A total of 1903 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%. FIB-4 ≥ 1.3 was an independent predictor of mortality in individuals living with diabetes (HR 1.219, 95% confidence interval [CI]: 1.067–1.392, p = 0.004). Overall, FIB-4 ≥ 1.3 without moderate–severe steatosis increased the mortality risk (HR 1.365; 95%CI 1.147–1.623, p < 0.001). The similar results were found in individuals living with diabetes with metabolic dysfunction-associated fatty liver disease (MAFLD) (HR 1.499; 95%CI 1.065–2.110, p = 0.020), metabolic syndrome (MetS) (HR 1.397; 95%CI 1.086–1.796, p = 0.009) or abdominal obesity (HR 1.370; 95%CI 1.077–1.742, p = 0.010). Conclusions Liver fibrosis, as estimated by FIB-4, may serve as a more reliable prognostic indicator for individuals living with diabetes than hepatic steatosis. Individuals living with diabetes with 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 individuals, as they may benefit from further evaluation and risk stratification. Graphical abstract