Liver Stiffness Measurement Linked to Higher Mortality Risk in Patients With Type 2 Diabetes

Liver stiffness measurement (LSM) may provide important prognostic information for patients with type 2 diabetes (T2D) based on new research showing that higher liver stiffness was associated with an increased risk of all-cause mortality, even when commonly used screening tools did not show elevated risk.¹

This cohort study is published in JAMA Network Open.

“These findings emphasize the urgent need to increase awareness among clinicians and patients about the need to screen for liver disease in patients with T2D,” wrote the researchers of the study. “Early identification of patients with liver disease is crucial to initiate appropriate therapies to achieve disease regression and improve overall mortality.”

The study analyzed data from the 2017–2018 National Health and Nutrition Examination Survey (NHANES) linked to mortality data from the National Death Index through December 31, 2019. Investigators evaluated whether liver fibrosis assessed through LSM was associated with mortality risk among adults with and without diabetes.

Current clinical guidance from the American Diabetes Association recommends assessing liver stiffness only after the Fibrosis-4 (FIB-4) index indicates potential liver fibrosis. However, researchers note that FIB-4 may underperform in certain populations, including individuals with T2D, potentially delaying identification of patients with advanced liver disease.²

To explore this issue, investigators included 4102 adult participants with complete vibration-controlled transient elastography data and controlled attenuation parameter (CAP) measurements. Participants with other known liver diseases were excluded to focus specifically on metabolic dysfunction–associated steatotic liver disease (MASLD).

MASLD was defined by CAP values of 274 dB/m or higher, while advanced liver fibrosis was defined as an LSM value of at least 9.7 kPa.

The study population had a mean (SD) age of 47 (1) years and was 50.7% female. The mean body mass index (BMI) was 29.5 (0.3), and 14.5% of participants had diabetes.

During an average follow-up period of approximately 24 months, 59 participants (1.4%) died. Individuals who died during the follow-up period were significantly older than survivors and were more likely to have diabetes.

Mortality risk increased substantially when diabetes coexisted with metabolic liver disease or advanced fibrosis. The presence of both diabetes and MASLD was associated with a nearly threefold increase in mortality risk (adjusted hazard ratio [AHR], 2.77; 95% CI, 1.16-6.65). Meanwhile, patients with diabetes and advanced liver fibrosis had more than a sixfold higher mortality risk (AHR, 6.41; 95% CI, 1.03-39.85).

Importantly, among patients with diabetes, LSM remained independently associated with all-cause mortality even after adjusting for age, sex, BMI, and hemoglobin A1c levels. Each increase in LSM was associated with a higher mortality risk (AHR, 1.06; 95% CI, 1.04-1.09). In contrast, the FIB-4 index did not remain significantly associated with mortality in adjusted analyses.

These findings suggest that relying solely on FIB-4 as a first-line screening tool may fail to identify some patients with clinically significant liver fibrosis.

The results align with a growing body of evidence highlighting the burden of liver disease among individuals with metabolic disorders.³ MASLD is closely linked to obesity, insulin resistance, and T2D and can progress to fibrosis, cirrhosis, and liver-related complications.

The study authors noted that implementing LSM more broadly as part of routine diabetes care could help identify patients at higher risk for adverse outcomes earlier in the disease course.¹

Although the follow-up period was relatively short, the strong association between LSM and mortality suggests that liver stiffness may serve as a valuable prognostic marker in patients with diabetes.

“From a population health standpoint, our findings have important diagnostic implications for liver fibrosis testing in individuals with diabetes,” wrote the researchers. “Reliance on aminotransferases is inadequate, as a substantial proportion of individuals have liver fibrosis despite normal aminotransferases.”

References

1. Bril F, Huynh K, Bolla P. Liver stiffness measurement and all-cause mortality in individuals with diabetes. JAMA Netw Open. 2026;9(3):e260762. doi:10.1001/jamanetworkopen.2026.0762

2. American Diabetes Association Professional Practice Committee. Comprehensive medical evaluation and assessment of comorbidities: standards of care in diabetes—2024. Diabetes Care. 2024;47(Suppl 1):S52-S76. doi:10.2337/dc24-S004

3. Younossi ZM, Kalligeros M, Henry L. Epidemiology of metabolic dysfunction-associated steatotic liver disease. Clin Mol Hepatol. 2025;31(Suppl):S32-S50. doi:10.3350/cmh.2024.0431