MASLD in type 2 diabetes: steatosis–fibrosis burden and metabolic determinants in a real-world cohort

Abstract Aims Metabolic dysfunction-associated steatotic liver disease (MASLD) is highly prevalent in type 2 diabetes mellitus (T2DM), but the burden of steatosis and fibrosis and their associated factors remain incompletely defined. We assessed the prevalence, severity, and factors associated with of MASLD in a real-world cohort of patients with T2DM. Methods In this cross-sectional study, 219 consecutive outpatients with T2DM underwent anthropometric laboratory, ultrasonographic and shear-wave elastographic assessment. MASLD was defined by the multisociety Delphi consensus. Independent associations were evaluated using multivariable logistic regression, with waist circumference as the primary adiposity measure. Results MASLD was diagnosed in 75.3% of participants. Severe steatosis (S3) was present in 11.9%, clinically significant fibrosis (F ≥ 2) in 7.3%, and advanced fibrosis (F ≥ 3) in 5.5%. Male sex (OR 2.49, 95% CI 1.26–4.94) and waist circumference (OR 1.04 per cm, 95% CI 1.01–1.07) were independently associated with MASLD. Severe steatosis was independently associated with male sex and waist circumference. MASLD prevalence increased across waist circumference quartiles (trend p = 0.001), while the adjusted odds plateaued in the upper half, paralleled by a higher prevalence of severe steatosis ( p < 0.001), whereas fibrosis was not associated with abdominal adiposity ( p = 0.65). HbA1c and diabetes duration did not differ between groups in univariable comparisons, and age was not associated with MASLD in the multivariable models. Conclusions MASLD is highly prevalent in T2DM and is independently associated with male sex and central adiposity. Abdominal adiposity identifies steatosis risk in a graded manner but does not discriminate fibrosis, supporting adiposity- and sex-informed hepatic phenotyping in patients with T2DM.