Tobacco Use and Type 2 Diabetes Have Additive Effect on Risk of Fibrosis in Patients With MASLD
Key findings
- This was the first study to explore whether there is an interaction between tobacco consumption and type 2 diabetes (T2DM) on the severity of metabolic dysfunction-associated steatotic liver disease (MASLD)
- The cohort included 97 patients with tobacco exposure and T2DM, 206 with T2DM who were never-smokers and a reference group of 257 patients with neither T2DM nor a history of tobacco use
- When fibrosis was defined by scores on the Fibrosis-4 index, both the T2DM+tobacco and T2DM groups had increased odds of fibrosis in multivariable analyses, and the association was significant in the T2DM+tobacco group (OR, 1.88; P=0.0037)
- When fibrosis was defined by the liver stiffness measurement on FibroScan, both groups had increased odds of advanced fibrosis, although the associations were not statistically significant
- Smoking cessation, in addition to standard care, may reduce the severity of MASLD among patients with T2DM
Risk factors for the incidence and progression of metabolic dysfunction-associated steatotic liver disease (MASLD, formerly called nonalcoholic fatty liver disease) include insulin resistance, type 2 diabetes mellitus (T2DM), and tobacco consumption.
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Now, researchers at Massachusetts General Hospital have found smoking and underlying T2DM have a synergistic effect on the severity of fibrosis in MASLD.
Oluwafemi Balogun, MBBS, MPH, a researcher in the Division of Gastroenterology, Kathleen E. Corey, MD, MPH, MMSc, director of the Mass General Fatty Liver Program in the Division of Gastroenterology and a researcher in the Clinical and Translational Epidemiology Unit, and colleagues report in Hepatology Communications.
Methods
The researchers studied 560 adults with MASLD who underwent a FibroScan at Mass General:
- 97 (16.2%) had T2DM and tobacco exposure
- 206 (34.4%) had T2DM and were nonsmokers
- 257 (43%) had no history of T2DM or tobacco use (reference group)
Fibrosis was assessed in two ways: using scores on the Fibrosis-4 index (FIB-4) and the liver stiffness measurement (LSM) on FibroScan. FIB-4 scores were stratified into "no fibrosis" and "fibrosis" with a cutoff score of 1.30. LSM was dichotomized into stages 0–2 and stages 3–4 ("advanced fibrosis") using a cutoff value of ≥11.4 kPa.
Results
In multivariable analyses where fibrosis was defined by FIB-4 scores, both the T2DM+tobacco and T2DM groups had increased odds of fibrosis, but the association was significant only in the T2DM+tobacco group:
- T2DM+tobacco—OR, 1.88; P=0.0037
- T2DM alone—OR, 1.13; P=0.6
In analyses where LSM defined fibrosis, both groups had increased odds of advanced fibrosis, although the associations weren't statistically significant:
- T2DM+tobacco—OR, 2.27; P=0.052
- T2DM alone—OR, 1.83; P=0.082
Multidisciplinary Management Needed
80% of the patients with T2DM alone and 93% of those with T2DM and tobacco exposure had dyslipidemia, and for hypertension, the figures were 81% and 89%. The coexistence of T2DM and smoking with these additional risk factors in patients with MASLD significantly amplifies their vulnerability to cardiovascular disease–related morbidity and mortality.
Therefore, the approach to treating MASLD should address not only liver health but also comprehensive cardiovascular risk assessment and management. Smoking cessation should be a linchpin in both efforts, and figures from this study give clinicians concrete risk estimates to cite when counseling patients.
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