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Diabetes Care 30:e94 2007
DOI: 10.2337/dc07-0982
© 2007 by the American Diabetes Association
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Online Letters: Comments and Responses

Prevalence of Nonalcoholic Fatty Liver Disease and Its Association With Cardiovascular Disease Among Type 2 Diabetic Patients

Response to Targher et al.

Roger K. Schindhelm, MD, PHD, MEPI1,2, Robert J. Heine, MD, PHD, FRCP1 and Michaela Diamant, MD, PHD1

1 Department of Endocrinology/Diabetes Center, VU University Medical Center, Amsterdam, the Netherlands
2 Department of Clinical Chemistry, Isala Clinics, Zwolle, the Netherlands

Address correspondence to Roger K. Schindhelm, MD, PHD, Department of Clinical Chemistry, Isala Clinics, Loc. Sophia, P.O. Box 10400, 8000 GK Zwolle, Netherlands. E-mail: r.k.schindhelm{at}isala.nl

We read with great interest the recent article by Targher et al. (1) reporting the prevalence of nonalcoholic fatty liver disease (NAFLD) and associated cardiovascular disease (CVD) risk factors in patients with type 2 diabetes.

Proper identification of patients with NAFLD is of major importance for adequate treatment and reduction of CVD risk in type 2 diabetic patients. However, routine ultrasound examination of the abdomen for the screening of hepatic steatosis in combination with serologic tests for hepatitis infection in patients with type 2 diabetes may not be feasible in common practice in most countries; it is certainly not performed on a routine basis, even in university hospitals, in the Netherlands.

Furthermore, the authors comment on the use of alanine aminotransferase (ALT) as a marker of NAFLD and confirm previous studies demonstrating the limited use of this marker in clinical practice (2,3). However, even mild elevations of ALT or other liver enzymes, in combination with clinical characteristics including a waist circumference and fasting triglyceride levels suggestive of the metabolic syndrome, may prompt the clinician to initiate further diagnostic work-up for the presence of NAFLD in patients with type 2 diabetes. In addition, they cite a very interesting cross-sectional study by Ioannou et al. (4), who demonstrated that elevated ALT is associated with an increased CVD risk as calculated by the Framingham Risk Score. Because of low specificity and sensitivity, ALT is of limited use in clinical practice. Still, it might provide more insight in the mechanisms that link NAFLD to CVD. We have recently extended the cross-sectional data by Ioannou et al. (4) and demonstrated in the population-based Hoorn Study that ALT levels in the high range of the normal distribution are associated with an increased 10-year risk of coronary heart disease in elderly individuals. This association was independent of classical CVD risk factors and components of the Adult Treatment Panel III–defined metabolic syndrome (5), indicating that ALT may be a useful marker in the assessment of CVD risk in patients who may have NAFLD.

Despite the diagnostic difficulties of NAFLD in clinical practice, the increased CVD risk in type 2 diabetic patients with NAFLD necessitates the design and implementation of optimal treatment strategies. However, consensus on the optimal treatment does not yet exist.

References

  1. Targher G, Bertolini L, Padovani R, Rodella S, Tessari R, Zenari L, Day C, Arcaro G: Prevalence of nonalcoholic fatty liver disease and its association with cardiovascular disease among type 2 diabetic patients. Diabetes Care 30:1212–1218, 2007[Abstract/Free Full Text]
  2. Prati D, Taioli E, Zanella A, Della Torre E, Butelli S, Del Vecchio E, Vianello L, Zanuso F, Mozzi F, Milani S, Conte D, Colombo M, Sirchia G: Updated definitions of healthy ranges for serum alanine aminotransferase levels. Ann Intern Med 137:1–10, 2002[Abstract/Free Full Text]
  3. Zelber-Sagi S, Nitzan-Kaluski D, Halpern Z, Oren R: Prevalence of primary non-alcoholic fatty liver disease in a population-based study and its association with biochemical and anthropometric measures. Liver Int 26:856–863, 2006[Medline]
  4. Ioannou GN, Weiss NS, Boyko EJ, Mozaffarian D, Lee SP: Elevated serum alanine aminotrasferase activity and calculated risk of coronary heart disease in the United States. Hepatology 43:1145–1151, 2006[Medline]
  5. Schindhelm RK, Dekker JM, Nijpels G, Bouter LM, Stehouwer CD, Heine RJ, Diamant M: Alanine aminotransferase predicts coronary heart disease events: a 10-year follow-up of the Hoorn Study. Atherosclerosis 191:391–396, 2007[Medline]

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G. Targher, L. Bertolini, and C. Day
Prevalence of Nonalcoholic Fatty Liver Disease and Its Association With Cardiovascular Disease Among Type 2 Diabetic Patients: Response to Schindhelm, Heine, and Diamant
Diabetes Care, September 1, 2007; 30(9): e95 - e95.
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