Association between MASLD and macrovascular alteration in patients with type 2 diabetes mellitus

To investigate the association between different metabolic dysfunction-associated steatotic liver disease (MASLD) phenotypes and macrovascular alteration in patients with type 2 diabetes mellitus (T2DM). After propensity score matching, 2,238 T2DM patients were enrolled from the National Metabolic Management Center (MMC) database. Based on abdominal ultrasound and FIB-4 index (≥ 1.3), patients were categorized into four phenotypes: no steatosis/fibrosis, steatosis only, fibrosis only, and steatosis with fibrosis. Multivariable logistic regression models were applied to evaluate the associations. The prevalence of macrovascular alteration was 56.2%, 56.5%, 79.0%, and 71.5% across the four phenotypes, respectively (P < 0.001). In the fully adjusted model, compared with the no-steatosis/no-fibrosis group, the fibrosis-only group (OR = 1.63, 95%CI 1.25–2.13, P < 0.001) and the steatosis-with-fibrosis group (OR = 1.34, 95%CI 1.02–1.77, P = 0.037) had significantly higher risks of macrovascular alteration, whereas the steatosis-only group showed no significant association (OR = 1.02, P = 0.853). The fibrotic effect was more pronounced in males (OR = 2.57), patients with obesity (OR = 2.72), and those with a diabetes duration of 5–10 years (OR = 3.24). In T2DM patients, liver fibrosis, rather than simple hepatic steatosis, independently predicts macrovascular alteration. The incorporation of FIB-4 into routine cardiovascular risk assessment may facilitate early identification of high-risk individuals. Targeted fibrosis screening is particularly warranted in male, obese patients and those with a 5-10years diabetes duration. Not applicable. In patients with type 2 diabetes, simple hepatic steatosis without fibrosis does not confer an increased risk of macrovascular alteration. Liver fibrosis, assessed by the non-invasive FIB-4 index, independently predicts macrovascular alteration after full adjustment for traditional cardiovascular risk factors. The risk of macrovascular alteration attributable to fibrosis is particularly high in male, obese patients and those with a diabetes duration of 5–10 years. FIB-4-based fibrosis screening could serve as a practical and cost-effective strategy for cardiovascular risk stratification in T2DM patients.