Screening and diagnosis of liver disease in diabetes: a guide and evidence-based assessment

Most people with type 2 diabetes have metabolic dysfunction-associated steatotic liver disease (MASLD), yet fewer than 2% experience major adverse liver outcomes within 10 years. Because progression to end-stage liver disease is uncommon, identifying the small subset of individuals at highest risk remains a central clinical challenge. Liver fibrosis is the strongest prognostic determinant in MASLD, and a range of blood-based and imaging tests are used to assess the likelihood of advanced fibrosis (AF) in the clinic. Since 2023, major medical societies have recommended systematic screening for MASLD-related AF in individuals with type 2 diabetes, driven by reports suggesting a high prevalence of up to 20-40%. This review critically examines the evidence underlying these recommendations while providing a clinically oriented guide to diagnosing MASLD in type 2 diabetes. Re-analysis of data from prevalence studies suggests that the burden of AF in type 2 diabetes has been substantially overestimated and may be below 5-10%, which has profound implications for both the rationale for screening and its expected yield. Simulations and emerging real-world evidence suggest that current non-invasive tests may refer 30-50% of patients for costly second-line testing and 15% for specialist evaluation, while generating high false-positive rates and missing more than a third of all AF cases. Moreover, it remains uncertain whether diagnosing AF in type 2 diabetes currently leads to meaningful changes in management or outcomes. Existing cost-effectiveness analyses rely on assumptions about disease burden and therapeutic benefit that are not supported by available data. Together, these considerations call for a more rigorous, evidence-based approach to evaluating liver disease risk in type 2 diabetes and other populations.