The paradox of high metabolic risk and low FIB-4 scores in the elderly: a nationwide community-based analysis (DAHUDER geriatric MASLD study)

This study aimed to determine the prevalence of metabolic dysfunction–associated steatotic liver disease (MASLD) in community-dwelling Turkish adults aged ≥ 65 years with at least one cardiometabolic risk factor (CMRF) and to identify risk factors associated with liver fibrosis. This nationwide study is a retrospective cross-sectional analysis of prospectively collected data from 31 cities and 44 internal medicine outpatient clinics representing all statistical regions of Türkiye. A total of 2613 older individuals (mean age 71.55 ± 5.40, 62.8% female) were enrolled in the study. The prevalence of MASLD ( N = 1811) and high FIB-4 ( N = 412) was 69.3% and 15.8% in the all patient group, respectively. The mean FIB-4 score was significantly lower in MASLD group ( P < 0.001). The prevalence of smoking (8.7%, P = 0.034), type 2 diabetes mellitus (T2DM) (54.4%, P < 0.001), metabolic syndrome (83.7%, P < 0.001), obesity (42.2%, P = 0.004), dyslipidemia (45.6%, P = 0.001) and MASLD (59.2%, P < 0.001) was found to be lower in the high FIB-4 group. Moreover, the prevalence of high FIB-4 progressively decreased with the number of CMRFs, ranging from 35.9% in participants with one factor to 13.3% in those with all five factors. In the multivariable regression analysis; female sex [OR: 0.763, (95%CI: 0.605–0.961); ( P = 0.022), smoking [0.610, (95%CI: 0.419–0.889); ( P = 0.010)], T2DM [OR: 0.722, (95%CI: 0.575–0.905); P = 0.005], MASLD [OR: 0.671, (95%CI: 0.533–0.844); ( P = 0.001)] were independently and negatively associated with high FIB-4 score. Despite high MASLD prevalence in older Turkish adults, the FIB-4 score negatively correlates with CMRFs, rendering it unreliable. These findings suggest that FIB-4 may be driven by age and age-related changes rather than liver pathology in this population, significantly limiting its utility as a screening tool in geriatric care.