Evaluation of Liver Fibrosis and Metabolic Risk in Non-Alcoholic Fatty Liver Disease

Abstract

Background:

Non-alcoholic fatty liver disease (NAFLD) has become one of the most common chronic liver disorders worldwide. In India, its burden is rising fast due to increasing metabolic problems like diabetes, obesity, and dyslipidemia. The disease varies from simple fat accumulation to steatohepatitis and cirrhosis. This study aimed to assess the clinical, biochemical and imaging profile of NAFLD patients in a tertiary hospital at Dehradun, Uttarakhand.

Methods:

A hospital-based cross-sectional study was done for 12 months in the Department of General Medicine, Himalayan Institute of Medical Sciences. Ninety-one adults (≥18 years) diagnosed with NAFLD on ultrasonography were included. Patients with alcohol intake, viral hepatitis, or hepatotoxic drug use were excluded. Demographic data, laboratory values, and imaging findings were recorded. Fibrosis was assessed using liver elastography and NAFLD Fibrosis Score (NFS).

Results:

Out of 91 patients, 56 (61.5%) were males, mean age 53.1 ± 11.6 years. All had type 2 diabetes and 73 (80.3%) were diabetic for ≥6 years. Dyslipidemia seen in 57.1% and albuminuria in 60.4%. On ultrasonography, 69 patients (75.8%) had Grade II/III steatosis. Elastography showed significant fibrosis (≥F3) in 31 (34.1%) and NFS showed advanced fibrosis in 16 (17.6%). Mean HbA1c was 9.2% showing poor glycemic control.

Conclusion:

NAFLD patients in north India had high metabolic burden with poor diabetes control, dyslipidemia, and early kidney changes. About one-third already showed significant fibrosis. Early screening and integrated management focusing on metabolic control are essential to prevent disease progression.

INTRODUCTION

Non-alcoholic fatty liver disease (NAFLD) is now a major cause of chronic liver disease, affecting nearly one-third of adults worldwide.[1] It results from excess liver fat in people with little or no alcohol intake. Over the past two decades, changing lifestyles and increasing metabolic syndrome have made NAFLD very common, especially in developing nations like India.[2]

The disease includes a wide range from simple steatosis to non-alcoholic steatohepatitis (NASH), fibrosis, and cirrhosis,[3] and is now one of the main causes of liver transplantation. In South Asia, around 27% of adults and more than half of diabetics or hypertensives have NAFLD.[4] Many non-obese individuals are also affected, likely due to visceral fat and genetic tendency.[4,5]

Insulin resistance plays the central role, causing fat buildup and inflammation.[6] Sedentary habits, calorie-rich diets, and oxidative stress further aggravate the process. Diagnosis is often delayed as early disease remains silent. Ultrasonography is a simple, inexpensive first-line tool, while elastography and NAFLD Fibrosis Score (NFS) provide non-invasive fibrosis evaluation.[7]

With increasing metabolic disorders, assessing biochemical and imaging features of NAFLD is essential. This study aimed to evaluate risk factors, fibrosis status, and clinical patterns of NAFLD patients attending a tertiary hospital in Dehradun to improve screening and management.

MATERIALS AND METHODS

This cross-sectional observational study was conducted in the Department of General Medicine, Himalayan Institute of Medical Sciences, Dehradun for 12 months. Ethical approval was obtained from the Institutional Ethics Committee. Written informed consent was taken from all participants.

Sample and Inclusion Criteria

Sample size was 91 adults (≥18 years) with NAFLD confirmed on ultrasonography. Patients with alcohol intake (>30 g/day men, >20 g/day women), viral hepatitis or hepatotoxic drug use were excluded.

Data collection

Demographic and clinical data were noted including diabetes duration, hypertension, smoking and thyroid status. Blood samples were tested for liver, renal, and lipid parameters. HbA1c measured glycemic control.

Imaging

Ultrasonography graded steatosis as Grade I (mild), II (moderate), and III (severe). Liver stiffness was measured using 8 MHz probe elastography. Fibrosis was classified as ≤7 kPa (≤F2), 7–15 kPa (F3), and >15 kPa (F4).

NAFLD fibrosis score

NFS was calculated from age, BMI, diabetes, AST/ALT ratio, platelets and albumin. Scores <–1.455 = no fibrosis, –1.455 to 0.676 = indeterminate, >0.676 = advanced fibrosis.[7]

Statistical analysis

Data analyzed using SPSS v26. Continuous variables as mean ± SD, categorical as percentage. P < 0.05 considered significant.

RESULTS

A total of 91 NAFLD patients were studied, with a mean age of 53.1 ± 11.6 years. Males slightly outnumbered females (56 vs 35). Smoking was seen in 32.9%, while hypertension and thyroid disorder were present in 19.8% each. All were diabetic; 80% had diabetes for over 6 years. Dyslipidemia occurred in 57.1% and albuminuria in 60.4%. Mean HbA1c was 9.2 ± 2.4%, reflecting poor sugar control [Table 1].

Table 1.

Baseline demographics and metabolic risk profile

Parameter		Values/Categories		n (%) or Mean±SD
Age (years)		53.1±11.6		—
Sex (Male:Female)		56:35		—
Smoking history		—		30 (32.9%)
Hypertension		—		18 (19.8%)
Thyroid disorder		—		18 (19.8%)
Diabetes duration		≤5/6–10/>10 yrs		18 (19.8%)/45 (49.5%)/28 (30.7%)
Dyslipidemia		—		52 (57.1%)
Albuminuria		—		55 (60.4%)
HbA1c (%)		—		9.2±2.4

On ultrasonography, 75.8% had Grade II/III fatty liver. Elastography showed fibrosis ≤F2 in 65.9%, F3 in 22%, and F4 in 12.1%. By NFS, 54.9% had no fibrosis, 27.5% were indeterminate, and 17.6% had advanced fibrosis. Mean ALT 37.8 U/L and AST 41.4 U/L showed mild enzyme rise. Lipids revealed high triglycerides (164.8 mg/dL), low HDL (39.5 mg/dL), and mean LDL 104.7 mg/dL. UACR 263.5 mg/g suggested early renal involvement [Table 2].

Table 2.

Imaging and biochemical findings

Parameter		Category/Mean±SD		n (%) or Value
USG Grade		I/II + III		22 (24.2%)/69 (75.8%)
Elastography		≤F2/F3/F4		60 (65.9%)/20 (22%)/11 (12.1%)
NFS Fibrosis		None/Indeterminate/Advanced		50 (54.9%)/25 (27.5%)/16 (17.6%)
ALT (U/L)		37.8±24.1		—
AST (U/L)		41.4±28.5		—
TG (mg/dL)		164.8±77.8		—
HDL (mg/dL)		39.5±15.6		—
LDL (mg/dL)		104.7±48.8		—
UACR (mg/g)		263.5±83.8		—

DISCUSSION

This study from north India shows NAFLD patients have high metabolic burden, mainly diabetes and dyslipidemia. Similar findings seen in studies by Pati and Singh and Duseja et al.[8,9] Men were slightly more affected (61.5%), though postmenopausal women tend to catch up due to loss of estrogen protection.[9]

Smoking was found in 32.9% cases. Smoking is not direct cause but worsens oxidative stress and insulin resistance. Joe et al.[10] reported higher NAFLD risk among smokers. In our study too, smokers had more advanced grades, though diabetes remained stronger driver.

All patients had type 2 diabetes, and 80.3% were diabetic for more than 6 years, matching reports that diabetics have nearly double risk of NAFLD.[4] Poor glycemic control (mean HbA1c 9.2%) probably accelerated fibrosis. Routine liver evaluation should be part of diabetes care.

Ultrasonography showed 75.8% with Grade II/III steatosis. Other Indian studies also found late presentation at moderate to severe stages.[8] The silent nature of NAFLD causes delay in diagnosis.

Elastography showed significant fibrosis (≥F3) in 34.1% and F4 in 12.1%, while NFS found advanced fibrosis in 17.6%, findings similar to Chen et al.[11] As results may differ in borderline cases, using both methods improves accuracy. Liver enzymes were only mildly raised, showing fibrosis can exist with near-normal values. Dyslipidemia was common with high triglycerides and low HDL, a typical South Asian pattern linked to visceral fat and insulin resistance.[12]

Albuminuria was present in 60.4%, indicating early kidney involvement. NAFLD shares pathways with diabetic kidney disease such as inflammation and lipid toxicity,[11,12] hence renal screening should be part of follow-up. Compared to Western data, fibrosis was milder but metabolic load higher, matching the Indian–South Asian phenotype of high visceral fat and insulin resistance even at lower BMI.[8,12] The study was single-center and cross-sectional, with self-reported alcohol intake and non-invasive fibrosis assessment, yet provides useful regional data stressing early screening in high-risk diabetics.

CONCLUSION

NAFLD patients in north India have heavy metabolic burden. Most have long-standing diabetes, poor glycemic control, dyslipidemia and early renal involvement. Majority already show moderate-to-severe steatosis and one-third have significant fibrosis. Early screening in diabetics, combined with metabolic control and renal monitoring, can help prevent disease progression and multi-organ complications.

Conflicts of interest

There are no conflicts of interest.

Funding Statement

Nil.