Long-term hepatic and extrahepatic outcomes in type 2 diabetes: final results of the prospective DM-FibroScan Study

Background/Aims: International guidelines recommend routine liver assessment in patients with type 2 diabetes (T2D), but the long-term clinical implications remain unclear. We aimed to characterise the long-term hepatic and extrahepatic outcomes across the vibration-controlled transient elastography (VCTE) spectrum in T2D. Methods: The prospective DM-FibroScan Study consecutively enrolled adults with T2D in Hong Kong during 2013-2014. Baseline controlled attenuation parameter (CAP) and liver stiffness measurement (LSM) were assessed. Results: 1,862 patients were followed for a median of 11.9 years (interquartile range 11.5-12.1). The 10-year cumulative incidence of liver-related events (LREs) was 1.1% (95% CI 0.7-1.7), lower than those of all cause mortality (21.1% [19.2-22.9]), cardiovascular events (12.5% [11.0-14.2]), malignancies (9.7% [8.3-11.1]), and end-stage kidney disease (9.0% [7.7-10.3]). Most participants (84.2%) had baseline LSM <10 kPa and a low LRE incidence (0.4 [0.1-0.8] per 1,000 person-years), with cardiovascular events predominated (14.1 [12.2-16.2] per 1,000 person-years). Patients with LSM >15 kPa (5.3%) exhibited a markedly higher LRE incidence (12.2 [6.1-21.8] per 1,000 person years), approaching the incidences of malignancies and ESKD. LRE incidence per 1,000 person-years was 1.9 in patients with LSM regression (≥10 to <10 kPa) and 28.0 in those with persistently elevated LSM. Patients with elevated baseline LSM also showed higher incidences of extrahepatic outcomes. Conclusions: LREs were relatively uncommon in the overall T2D population but increased substantially with advanced fibrosis. This study provides natural history data across the VCTE spectrum in a relatively unselected T2D cohort and supports integrating fibrosis assessment into routine T2D care.