Advanced Fibrosis Risk Stratification in MASLD Among Adults With Type 2 Diabetes: A Critical Narrative Review of Practical Gaps and Implementation Solutions

Abstract

Background: Metabolic dysfunction-associated steatotic liver disease (MASLD) affects approximately two-thirds of adults with type 2 diabetes (T2D), and about one in seven of those affected has advanced fibrosis. Effective fibrosis risk stratification is essential for identifying patients at risk of liver-related complications.

Objective: To critically appraise fibrosis risk-stratification tools in adults with T2D, identify gaps in routine care and propose practical implementation strategies.

Methods: A critical narrative review of evidence on non-invasive fibrosis tests, sequential diagnostic pathways and relevant therapeutic trials was undertaken. Direct T2D evidence was distinguished from mixed-cohort evidence and expert opinion. Literature selection was not systematic, and formal risk-of-bias assessment was not performed.

Results: FIB-4 remains an appropriate first-line triage test, but age-adjusted thresholds are needed in older adults, and poor rule-in sensitivity has been reported in a South Asian T2D cohort. Evidence that diabetes independently reduces test performance is inconsistent. Sequential testing with elastography or the Enhanced Liver Fibrosis test is guideline-supported, but prospective validation in T2D-only populations remains lacking. Semaglutide, resmetirom and dapagliflozin have shown histological benefit, while non-invasive monitoring of treatment-induced fibrosis regression remains unvalidated.

Conclusion: Fibrosis assessment should be integrated into routine diabetes care using existing tests and coordinated referral pathways. Prospective evaluation in T2D populations is needed to validate these pathways, rescreening intervals and treatment-monitoring strategies.