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

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 FibroScan's 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.