Implications of Expanded Advanced Fibrosis Screening Strategies for Metabolic Dysfunction-Associated Steatotic Liver...

Advanced fibrosis is associated with cirrhosis, cancer, and mortality in patients with metabolic dysfunction-associated steatotic liver disease (MASLD). Since MASLD is underdiagnosed in primary care, and diabetes mellitus type 2 (T2DM) is strongly associated with MASLD, the 2024 American Diabetes Association guidelines recommend screening for advanced fibrosis in patients with T2DM and prediabetes using the Fibrosis-4 Index (FIB-4). We aimed to determine the proportion of primary care patients with T2DM and prediabetes who had FIB-4s at risk for advanced fibrosis and required confirmatory testing.

This cross-sectional study evaluated primary care patients with T2DM or prediabetes and a FIB-4 score between 2022 and 2024. The outcome of interest was a FIB-4 score in need of confirmatory fibrosis risk assessment. Univariate analyses were used to describe the cohort. Logistic regression models evaluated the association between T2DM and a FIB-4 score at indeterminate risk or greater for advanced fibrosis.

Of 8366 patients with T2DM and prediabetes, 2064 (25%) had FIB-4s in need of confirmatory risk assessment. The expanded FIB-4 fibrosis screening for T2DM and prediabetes increased the number of patients needing confirmatory fibrosis risk assessment by 9.1 times compared to those with diagnoses of MASLD (n = 228). Further, patients with T2DM were not more likely to have an indeterminate risk or greater FIB-4 (odds ratio: 0.86; 95% CI: 0.77-0.96) compared to those with prediabetes in the fully adjusted model.

Expanded screening for advanced liver fibrosis would substantially increase the number of patients who need confirmatory testing for liver fibrosis, increasing cost and straining access.