Liver Stiffness Measurement and All-Cause Mortality in Individuals With Diabetes

Current guidance from the American Diabetes Association recommends liver stiffness measurement (LSM) only when the Fibrosis-4 (FIB-4) index is elevated. However, LSM may provide additional valuable information compared with FIB-4, which is known to underperform in certain populations, such as individuals with type 2 diabetes.

To assess whether liver fibrosis evaluated by LSM is associated with increased mortality in individuals with and without diabetes.

This cohort study included adult patients with complete vibration-controlled transient elastography (VCTE) and controlled attenuation parameter (CAP) data. Baseline data, including demographics and routine laboratory tests, were obtained from the 2017 to 2018 National Health and Nutrition Examination Survey and linked to data from the National Center for Health Statistics and National Death Index up to December 31, 2019. Patients with a history of liver disease other than metabolic dysfunction-associated steatotic liver disease were excluded. Data were analyzed from December 2024 to December 2025, accounting for the complex survey design using examination weights.

Liver disease based on CAP results and LSM by VCTE. CAP results 274 dB/m or higher indicate a diagnosis of metabolic dysfunction-associated steatotic liver disease (MASLD) and LSM results 9.7 kPa or higher indicate advanced liver fibrosis.

All-cause mortality. Mortality risk was expressed as hazard ratios (HRs) with 95% CIs calculated using Cox proportional hazards regression models.

A total of 4102 adult patients (mean [SEM] age, 47 [1] years; 50.7% female), were included in the study. The mean (SEM) body mass index (BMI), calculated as weight in kilograms divided by height in meters squared, was 29.5 (0.3). Diabetes was present in 14.5% of participants. After a mean (SEM) follow-up of 24 (2) months, 59 patients (1.4%) had died. Patients who died during follow-up vs those who did not were older (mean [SEM] age, 62 [3] years vs 47 [1] years; P < .001), had a higher prevalence of diabetes (35.7% vs 14.2%; P = .01), and were more likely to be of non-Hispanic White race (85.1% vs 62.7%, P = .002). Increased risk of all-cause mortality was associated with the coexistence of diabetes with MASLD (adjusted hazard ratio [AHR], 2.77; 95% CI, 1.16-6.65; P = .03) and diabetes with advanced liver fibrosis (AHR 6.41; 95% CI, 1.03-39.85; P = .047). In patients with diabetes, LSM (AHR, 1.06; 95% CI, 1.04-1.09; P < .001) but not FIB-4 index remained associated with all-cause mortality even after adjusting for other clinical variables, such as age, sex, BMI, and hemoglobin A1c.

In this cohort study, LSM was an independent risk factor for all-cause mortality in individuals with diabetes, even after a relatively short follow-up. Implementing LSM to screen for liver fibrosis as part of routine diabetes management could aid in early identification of patients with high mortality risk.