From fatty liver indices to the Zhejiang University index: Re-shaping risk stratification of metabolic liver disease in diabetes

This editorial comments on the study by Tao <i>et al</i>, emphasizing the scalable diagnostic tool for metabolic dysfunction-associated steatotic liver disease (MASLD) in type 2 diabetes mellitus (T2DM). Classical indices such as the fatty liver index (FLI), hepatic steatosis index (HSI), and non-alcoholic fatty liver disease-liver fat score have provided valuable insights. Still, their predictive accuracy often varies across populations and clinical settings. In Western cohorts, FLI and HSI are widely applied, yet they depend heavily on anthropometric or categorical variables, which limits their sensitivity in Asian populations. The Zhejiang University index (ZJU index), developed in China, integrates fasting glucose, triglycerides, hepatic enzyme ratios, and body mass index into a composite score of insulin resistance. Recent studies show that the ZJU index outperforms FLI and HSI in predicting MASLD among Chinese patients, particularly those with T2DM, where it demonstrates a nonlinear association with disease risk and identifies a critical threshold of 38.87. The ZJU index links to conditions like sarcopenia, sleep apnea, and gallstones, showing its versatility in metabolic health. This editorial compares its performance with other indices and emphasizes the ZJU index as a next-generation tool for MASLD risk stratification globally.