Background <p>The prevalence of type 2 diabetes mellitus (T2DM) and its associated hepatic steatosis has surged with the obesity epidemic. The influence of T2DM on the natural history of primary biliary cholangitis (PBC) remains poorly characterized.</p> Aims <p>This study aims to assess the prevalence of T2DM in a PBC cohort and evaluate its impact on hepatic steatosis, liver fibrosis, and clinical outcomes.</p> Methods <p>A retrospective analysis was performed. The presence of hepatic steatosis was defined by a controlled attenuation parameter (CAP) ≥ 285&#xa0;dB/m, and clinically significant liver fibrosis was defined by a liver stiffness measurement (LSM) ≥ 8.5&#xa0;kPa assessed using vibration-controlled transient elastography (VCTE). The cohort was further stratified into four subgroups: PBC with T2DM (PBC/T2DM), PBC without T2DM (PBC/non-T2DM), PBC with hepatic steatosis (PBC/steatosis), and PBC without hepatic steatosis (PBC/no steatosis). Group comparisons were performed using t-tests, chi-squared analyses, and Kaplan–Meier survival curves.</p> Results <p>562 patients with PBC were identified. The prevalence of T2DM was 14.8%. 158 (28%) patients had VCTE measurements. The PBC/T2DM sub-cohort was more likely to have concomitant hepatic steatosis compared to PBC/non-T2DM (54% vs 28%, <i>p</i>-value 0.010). The prevalence of clinically significant fibrosis was similar between these two groups (69% vs 52%, <i>p</i>-value 0.097). All-cause mortality rates were similar between PBC/T2DM vs PBC/non-T2DM (<i>p</i>-value 0.960) and PBC/steatosis vs PBC/no steatosis (<i>p</i>-value 0.895).</p> Conclusion <p>T2DM is a risk factor for the development of hepatic steatosis in patients with PBC; however, it does not increase the likelihood of clinically significant liver fibrosis or all-cause mortality.</p>