Diagnosis and non‐invasive assessment of MASLD in type 2 diabetes and obesity

Summary Background Metabolic dysfunction‐associated steatotic liver disease (MASLD) is currently the most common chronic liver disease and an important cause of cirrhosis and hepatocellular carcinoma. It is strongly associated with type 2 diabetes and obesity. Because of the huge number of patients at risk of MASLD, it is imperative to use non‐invasive tests appropriately. Aims To provide a narrative review on the performance and limitations of non‐invasive tests, with a special emphasis on the impact of diabetes and obesity. Methods We searched PubMed and Cochrane databases for articles published from 1990 to August 2023. Results Abdominal ultrasonography remains the primary method to diagnose hepatic steatosis, while magnetic resonance imaging proton density fat fraction is currently the gold standard to quantify steatosis. Simple fibrosis scores such as the Fibrosis‐4 index are well suited as initial assessment in primary care and non‐hepatology settings to rule out advanced fibrosis and future risk of liver‐related complications. However, because of its low positive predictive value, an abnormal test should be followed by specific blood (e.g. Enhanced Liver Fibrosis score) or imaging biomarkers (e.g. vibration‐controlled transient elastography and magnetic resonance elastography) of fibrosis. Some non‐invasive tests of fibrosis appear to be less accurate in patients with diabetes. Obesity also affects the performance of abdominal ultrasonography and transient elastography, whereas magnetic resonance imaging may not be feasible in some patients with severe obesity. Conclusions This article highlights issues surrounding the clinical application of non‐invasive tests for MASLD in patients with type 2 diabetes and obesity.