Risk stratification of MASLD/MASH in type 2 diabetes: a pragmatic endocrinology outpatient pathway

Patients with type 2 diabetes mellitus (T2DM) have a high burden of metabolic dysfunction-associated steatotic liver disease (MASLD) and metabolic dysfunction-associated steatohepatitis (MASH), but liver fibrosis risk is still not assessed consistently in routine diabetes care. Recent guidelines now support active fibrosis risk stratification in metabolically high-risk populations, yet many endocrinology clinics lack a workable pathway for implementation. This narrative review proposes a risk-adapted outpatient pathway for MASLD/MASH assessment in patients with T2DM. The pathway starts with automated fibrosis-4 index (FIB-4) calculation using routine laboratory data, followed by second-line non-invasive assessment with FibroScan controlled attenuation parameter/liver stiffness measurement or enhanced liver fibrosis testing in patients with indeterminate or high-risk results. Patients at high risk should be referred for hepatology evaluation, with magnetic resonance imaging-proton density fat fraction or magnetic resonance elastography reserved for selected cases in which quantitative assessment or further staging would alter management. The review also addresses implementation barriers, appropriate use of non-invasive tests, treatment strategies with metabolic and liver-related evidence, and validation indicators for real-world assessment. By linking screening, referral, intervention, follow-up and quality control, the proposed pathway aims to move MASLD/MASH care in T2DM from incidental recognition toward structured, measurable and multidisciplinary risk management.