On January 21, Gut, an authoritative international journal of gastroenterology, online published a study entitled Two-step strategy for predicting advanced liver fibrosis and long-term outcomes in individuals with type 2 diabetes and metabolic dysfunction-associated fatty liver disease. This study provides an effective new approach for risk stratification in patients with type 2 diabetes mellitus (T2DM) complicated by metabolic dysfunction-associated fatty liver disease (sugar-liver comorbidity).
The study was completed by the Diabetes-Liver Integrated Management (DLIM) Collaborative Group and systematically evaluated the application value of the two-step strategy combining the FIB-4 index and liver stiffness measurement by vibration-controlled transient elastography (VCTE) in patients with diabetes-fatty liver comorbidity.
As the most common metabolic disease, type 2 diabetes has a clear bidirectional promoting relationship with metabolic dysfunction-associated fatty liver disease. Approximately 15% of patients with diabetes-fatty liver comorbidity may develop advanced liver fibrosis and even cirrhosis. Once entering this stage, the risks of disease progression and adverse outcomes increase significantly, making early identification of such patients particularly critical.
Current international guidelines recommend the two-step strategy combining FIB-4 index and liver stiffness for risk stratification in high-risk populations. However, the predictive value of this strategy for advanced liver fibrosis and liver-related adverse events in the high-risk population of type 2 diabetes has not been systematically evaluated. This study aimed to fill this evidence gap by assessing the predictive performance of the two-step strategy in patients with diabetes-fatty liver comorbidity.
The study confirmed that the two-step strategy can not only accurately identify advanced liver fibrosis but also effectively predict long-term adverse outcomes including hepatic decompensation and hepatocellular carcinoma.
This study is the first to systematically evaluate the predictive value of the two-step strategy for long-term prognosis in patients with diabetes-fatty liver comorbidity, and also represents the largest liver biopsy cohort evaluating this strategy for advanced liver fibrosis to date.
More importantly, the study proposed setting the cutoff values of liver stiffness in the second step at 10/15 kPa (instead of the internationally recommended 8/12 kPa). This adjustment improves the predictive performance for long-term prognosis and significantly reduces the proportion of intermediate-risk (gray zone) individuals, providing clearer and more reliable evidence for clinical decision-making and stratified management in patients with diabetes-fatty liver comorbidity.