Diabetes mellitus and the progression of non-alcoholic fatty liver disease to decompensated cirrhosis: a retrospective cohort study

Abstract

Objective: To determine the incidence of decompensated cirrhosis and associated risk factors in people hospitalised with non-alcoholic fatty liver disease (NAFLD) or non-alcoholic steatohepatitis (NASH) with or without cirrhosis. Design: Retrospective cohort study; analysis of linked Queensland Hospital Admitted Patient Data Collection, Queensland Registry of Births, Deaths and Marriages, and Queensland Cancer Register data. Setting, participants: Queensland residents aged 20 years or older admitted to Queensland hospitals with NAFLD/NASH during 1 July 2009 – 31 December 2018. Main outcome measures: Progression to decompensated cirrhosis (ascites, hepatic encephalopathy, or oesophageal variceal bleeding). Results: We included data for 8006 patients in our analysis (10 082 admissions), including 4632 women (58%) and 2514 people with diabetes mellitus (31%); median follow-up time was 4.6 years (interquartile range, 2.7–7.2 years). Three hundred and fifty-one people (4.4%) experienced decompensated cirrhosis during the follow-up period. Of the 6900 people without cirrhosis, 4.5% (95% confidence interval [CI], 3.6–5.7%) experienced decompensated cirrhosis within ten years (mean, 0.5% per year; 95% CI, 0.4–0.6% per year); risk of progression was greater for people aged 70 years or older (v 20–39 years: adjusted hazard ratio [aHR], 4.7; 95% CI, 2.0–11.0) and those who had extrahepatic cancers (aHR, 5.0; 95% CI, 3.0–8.2), history of major cardiovascular events (aHR, 1.9; 95% CI, 1.2–3.1), or diabetes mellitus (aHR, 2.8; 95% CI, 2.0–3.9). Of the 1106 people with cirrhosis, 32.4% (95% CI, 27.2–38.3%) experienced decompensated cirrhosis within ten years (mean, 5.5% per year; 95% CI, 4.8–6.3% per year); risk of progression was greater for those with portal hypertension (aHR, 1.8; 95% CI, 1.3–2.7), extrahepatic cancer (aHR, 1.8; 95% CI, 1.1–2.9), or diabetes mellitus (aHR, 1.5; 95% CI, 1.1–2.0). Compared with people who had neither cirrhosis nor diabetes mellitus, the risk of decompensation was greater for people with cirrhosis (aHR, 10.7; 95% CI, 7.6–15.0) or cirrhosis and diabetes mellitus (aHR, 14.4; 95% CI, 10.1–20.6). Conclusions: Given the greater risk of progression to cirrhosis decompensation in people with diabetes mellitus, a disorder common in people with NAFLD/NASH, identifying advanced fibrosis and providing appropriate treatment for averting disease progression is vital.