Increased Prevalence of Advanced Metabolic Dysfunction-Associated Steatotic Liver Disease Fibrosis in Type 2 Diabetics Despite Low-Risk Fibrosis-4 Index Scores

Abstract

Background: The American Gastroenterology Association (AGA) guidelines for metabolic dysfunction-associated steatotic liver disease (MASLD) recommend screening for fibrosis in high-risk subjects with either type 2 diabetes, two or more metabolic risk factors, or steatosis on imaging. The 2021 AGA guidelines recommend calculating a fibrosis-4 index (FIB-4) score, and patients with scores above low-risk require further workup with FibroScan to assess liver stiffness measurement (LSM), a surrogate for liver fibrosis. However, FIB-4 scores have been suggested to be less accurate in patients with type 2 diabetes. The aim of our study was to identify the prevalence of significant to advanced fibrosis in subjects with a low-risk FIB-4 value with FibroScans LSM in type 2 diabetes.

Methods: A total of 1,153 subjects were referred to our liver center between August 2019 and September 2022; 1,114 subjects met MASLD criteria with data to calculate FIB-4 values. Subjects were categorized into age adjusted low-risk FIB-4 groups. Diagnosis of diabetes was determined by medical history.

Results: Low-risk age-adjusted FIB-4 scores were observed in 68.3% of older subjects and 73.4% of younger subjects (P = not significant (NS)). In the older group and younger cohorts, a LSM 10 kPa was noted in 21% suggesting advanced liver fibrosis. Seventy-one point six percent of older diabetic subjects had low FIB-4 values, similar to 67.2% of young diabetic subjects with low FIB4 values. Overall, 72% of subjects would not have been referred for FibroScan per AGA criteria. Despite low-risk FIB-4 scores, 257 subjects had LSM greater than or equal to 8 kPa and 148 underwent a liver biopsy. Forty-eight percent of patients with biopsies had significant fibrosis (F2-4), predominately affecting subjects with type 2 diabetes.

Conclusions: Diabetic subjects, despite having a low-risk FIB-4 tests, were four-fold more likely to demonstrate significant to advanced fibrosis, highlighting the limitations of FIB-4 in these individuals.

J Endocrinol Metab. 2024;14(1):40-47
doi: https://doi.org/10.14740/jem935