One in four adults with type-2 diabetes in India has clinically significant liver fibrosis, a large multi-centre study has found, highlighting a widely under-recognised complication that can progress to cirrhosis.

The findings suggest that advanced liver disease should be considered a “fourth major complication” of diabetes — after eye, kidney and nerve damage — and that all adults with diabetes might require liver assessment beyond routine blood tests.

The study found that among 9,202 patients under treatment for diabetes across 25 cities who underwent liver stiffness scans, 2,433 (26 per cent) had significant fibrosis, 14 per cent had advanced fibrosis, and 491 (or five per cent) had cirrhosis.

“None of the patients had symptoms of liver disease,” Ashish Kumar, a
senior gastroenterologist at the Sir Ganga Ram Hospital in New Delhi who led the study, told The Telegraph. “Yet those with significant fibrosis could be on the pathway to severe, possibly irreversible liver disease.”

Health surveys have estimated that India has over 100 million patients with diabetes. The study’s findings imply that even with conservative estimates, 25 million people may have undiagnosed liver fibrosis, underscoring the scale of the hidden burden.

Early detection in the early stages could help prevent progression to cirrhosis, liver cancer or liver failure, Kumar said.

The study also suggests that routine ultrasound screening for fatty liver may not be enough to detect underlying fibrosis. Among a subset of 8,136 patients, 65 per cent were found to have fatty liver during liver elastography or stiffness scans.

The absence of fatty liver did not rule out serious disease. Among patients without fatty liver, 13 per cent had significant fibrosis and five per cent had probable cirrhosis, the researchers said, describing their findings in The Lancet Regional Health Southeast Asia, an international medical journal.

“The liver damage in this context is insidious and clinically silent, becoming apparent only in advanced stages, when therapeutic options are limited and less effective,” said Anoop Misra, chief of the Fortis Centre for Diabetes, Obesity, and Cholesterol in New Delhi, and study co-author.

The 26 per cent prevalence of liver fibrosis in adults with diabetes is broadly consistent with earlier population-based studies in the US that have suggested a 15-20 per cent prevalence among patients with diabetes, with differences possibly driven by obesity, diet and geneticfactors.

High carbohydrate and fat consumption in India contributes directly to liver injury, Misra said.

Study team members also cautioned that relying exclusively on blood tests that measure liver-related enzymes may be misleading.

“Liver enzymes are often misunderstood — many people, including some doctors, assume that normal liver enzymes mean a healthy liver,” Kumar said. “A significant proportion of patients with active liver inflammation have normal enzymes. A patient can have extensive scarring of the liver — even early cirrhosis — yet have perfectly normal blood tests.”

The findings should mark a shift in how diabetes complications are viewed, said Viswanathan Mohan, at the Madras Diabetes Research Foundation in Chennai, one of the study centres.

“Until now, the eye, kidney, heart, and feet were recognised as major sites of diabetes complications. A liver stiffness scan should become a routine component of diabetes assessment,” Mohan said.

Ultrasound scans can detect fat in the liver but not fibrosis, Kumar said, adding that non-invasive liver stiffness scans are needed to directly assess scarring — a step that could identify patients earlier in the course of disease.

The study did not examine how well the patients’ blood sugar was controlled. But, the researchers said, the prevalence of fibrosis across all subgroups — including those with short-duration diabetes and without other metabolic disorders — suggests that poor sugar control alone does not explain the high burden of fibrosis.