Evaluating performance of non-invasive tests for fibrosis detection in MASLD with Type 2 Diabetes Mellitus: Insights from VCTE-Based assessment

INTRODUCTION: Metabolic Dysfunction-Associated Steatotic Liver Disease (MASLD) affects over half of patients with type 2 diabetes (T2DM), and advanced fibrosis is the strongest predictor of liver-related mortality. Although liver biopsy is the diagnostic gold standard, its invasiveness limits routine use. The accuracy of serum-based non-invasive tests (NITs) compared with liver stiffness measurement (LSM) in T2DM remains uncertain. The Universal Index for Cirrhosis (UIC index) is a newer fibrosis score with strong performance across mixed liver disease etiologies and has not been evaluated in MASLD in T2DM. This study assessed the diagnostic accuracy of the UIC index compared with established NITs using vibration-controlled transient elastography (VCTE) as the comparator for clinically significant and advanced fibrosis in a referral-based T2DM outpatient population. METHODS: In this retrospective study, adults with T2DM evaluated across outpatient clinics between 2013 and 2024 were included. Demographic, clinical, and laboratory data were collected within 30 days of VCTE. Clinically significant fibrosis and advanced fibrosis/cirrhosis were defined as LSM >8 kPa and >12 kPa, respectively. Diagnostic performance was assessed, and the area under the receiver operating curve (AUROC) was calculated. Logistic regression identified predictors of fibrosis presence and severity. RESULTS: A total of 199 patients were analyzed (mean age 58.8 years; mean BMI 35 kg/m²). Fibrosis prevalence was 97.5% for LSM >8 kPa and 44% for LSM >12 kPa. Non-Caucasian race and higher serum albumin were independently associated with lower fibrosis risk, while increasing AST and declining platelet counts were associated with greater fibrosis severity. For LSM >8 kPa, FIB-4 ≥ 1.3, and UIC index ≥4.5, the diagnostic performance was similar (AUROC 0.69 vs. 0.68). For LSM >12 kPa, FIB-4 > 2.67 demonstrated the highest AUROC (0.72), while UIC index ≥8 showed balanced sensitivity (66%) and specificity (57%). The AUROC differences between FIB-4 and UIC were not statistically significant. CONCLUSIONS: FIB-4 and the UIC index demonstrated comparable diagnostic performance, each with distinct strengths and limitations.