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. 2024 Feb 13:384:e076388.
doi: 10.1136/bmj-2023-076388.

Association of non-alcoholic fatty liver disease with cardiovascular disease and all cause death in patients with type 2 diabetes mellitus: nationwide population based study

Kyung-Soo Kim  1 , Sangmo Hong  2 , Kyungdo Han  3 , Cheol-Young Park  4
Affiliations

Association of non-alcoholic fatty liver disease with cardiovascular disease and all cause death in patients with type 2 diabetes mellitus: nationwide population based study

Kyung-Soo Kim et al. BMJ. .

Abstract

Objective: To investigate the risk of non-alcoholic fatty liver disease (NAFLD) for cardiovascular disease and all cause death in patients with type 2 diabetes mellitus (T2DM).

Design: Nationwide population based study.

Setting: Longitudinal cohort study in Korea.

Participants: 7 796 763 participants in the National Health Screening Programme in 2009 were divided into three groups based on NAFLD status: no NAFLD (fatty liver index<30); grade 1 NAFLD (30≤fatty liver index<60); and grade 2 NAFLD (fatty liver index≥60). Median follow-up was 8.13 years.

Main outcome measures: The primary outcome was incident cardiovascular disease (myocardial infarction, ischaemic stroke) or all cause death.

Results: Of 7 796 763 participants, 6.49% (n=505 763) had T2DM. More patients with T2DM had grade 1 NAFLD (34.06%) and grade 2 NAFLD (26.73%) than those without T2DM (grade 1 NAFLD: 21.20%; grade 2 NAFLD: 10.02%). The incidence rate (per 1000 person years) of cardiovascular disease and all cause death increased in the order of no NAFLD, grade 1 NAFLD, and grade 2 NAFLD, and the incidence rates in patients with T2DM were higher than those in patients without T2DM. The five year absolute risk for cardiovascular disease and all cause death increased in the order of no NAFLD, grade 1 NAFLD, and grade 2 NAFLD in patients without and with T2DM (no NAFLD, without T2DM: 1.03, 95% confidence interval 1.02 to 1.04, and 1.25, 1.24 to 1.26, respectively; grade 1 NAFLD, without T2DM: 1.23, 1.22 to 1.25, and 1.50, 1.48 to 1.51, respectively; grade 2 NAFLD, without T2DM: 1.42, 1.40 to 1.45, and 2.09, 2.06 to 2.12, respectively; no NAFLD, with T2DM: 3.34, 3.27 to 3.41, and 3.68, 3.61 to 3.74, respectively; grade 1 NAFLD, with T2DM: 3.94, 3.87 to 4.02, and 4.25, 4.18 to 4.33, respectively; grade 2 NAFLD, with T2DM: 4.66, 4.54 to 4.78, and 5.91, 5.78 to 6.05, respectively). Patients with T2DM and without NAFLD had a higher five year absolute risk for cardiovascular disease and all cause death than those without T2DM and with grade 2 NAFLD. Risk differences for cardiovascular disease and all cause death between no NAFLD and grade 1 or grade 2 NAFLD were higher in patients with T2DM than in those without T2DM.

Conclusions: NAFLD in patients with T2DM seems to be associated with a higher risk of cardiovascular disease and all cause death, even in patients with mild NAFLD. Risk differences for cardiovascular disease and all cause death between the no NAFLD group and the grade 1 or grade 2 NAFLD groups were higher in patients with T2DM than in those without T2DM.

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Conflict of interest statement

Competing interests: All authors have completed the ICMJE uniform disclosure form at www.icmje.org/disclosure-of-interest/ and declare: no support from any organisation for the submitted work; no financial relationships with any organisations that might have an interest in the submitted work in the previous three years; no other relationships or activities that could appear to have influenced the submitted work.

Figures

Fig 1
Fig 1
Kaplan-Meier survival curve for cardiovascular disease according to the presence of non-alcoholic fatty liver disease (NAFLD) in patients with and without type 2 diabetes mellitus after adjusting for age, sex, smoking status, alcohol consumption, physical activity, low income, hypertension, dyslipidemia, body mass index, diabetes mellitus, and estimated glomerular filtration rate (all P<0.001). Numbers at risk presented below graphs
Fig 2
Fig 2
Kaplan-Meier survival curve for myocardial infarction according to the presence of non-alcoholic fatty liver disease (NAFLD) in patients with and without type 2 diabetes mellitus after adjusting for age, sex, smoking status, alcohol consumption, physical activity, low income, hypertension, dyslipidemia, body mass index, diabetes mellitus, and estimated glomerular filtration rate (all P<0.001). Numbers at risk presented below graphs
Fig 3
Fig 3
Kaplan-Meier survival curve for ischaemic stroke according to the presence of non-alcoholic fatty liver disease (NAFLD) in patients with and without type 2 diabetes mellitus after adjusting for age, sex, smoking status, alcohol consumption, physical activity, low income, hypertension, dyslipidemia, body mass index, diabetes mellitus, and estimated glomerular filtration rate (all P<0.001). Numbers at risk presented below graphs
Fig 4
Fig 4
Kaplan-Meier survival curve for all cause death according to the presence of non-alcoholic fatty liver disease (NAFLD) in patients with and without type 2 diabetes mellitus after adjusting for age, sex, smoking status, alcohol consumption, physical activity, low income, hypertension, dyslipidemia, body mass index, diabetes mellitus, and estimated glomerular filtration rate (all P<0.001). Numbers at risk presented below graphs
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