MASLD Cluster Derived Outcomes after Metabolic-Bariatric Surgery: a Retrospective Single-Center Analysis

BACKGROUND: Metabolic dysfunction-associated steatotic liver disease (MASLD) has become the most common chronic liver disease and is strongly associated with obesity. A novel approach of categorizing subtypes of MASLD has been proposed recently. Intent of this study was to investigate the influence of these clusters on weight loss and diabetes outcomes of metabolic-bariatric surgery (MBS). MATERIAL AND METHODS: We retrospectively analysed all patients undergone primary Roux-en-Y gastric bypass (RYGB) or sleeve gastrectomy (SG) between 2015 and 2025 in a german tertiary obsesty center. We performed the cluster differentiation proposed by Raverdy et al. along with a correlation of histolophathologic findings from liver biopsies collected during surgery and evaluated weight loss and diabetes remission at 12, 24 and 60 months after surgery. RESULTS: Overall, 588 out of 850 patients met the inclusion criteria for sufficient clustering of whom 49 were assigned to the cardiometabolic, 52 to the liver specific and 487 to the control cluster. Baseline characteristics differed regarding age, HbA1c, and type 2 diabetes (T2DM) (HbA1c: 8.4 in the cardiometabolic vs 6.2 liver specific; p < .001) between clusters. Liver fibrosis was found in 65% of the cardiometabolic, 41,4% in the liver specific cluster and 16.4% in the control cluster (p < .001). Postoperative complications did not differ between clusters. Total body weight loss (%TBWL) at 12, 24, 36 and 48 months was 22.1%, 19.7%, 17.9% and 18.7% in the cardiometabolic cluster vs. 29.5%, 29.9%, 29.3% and 25.2% in the liver specific cluster (p < .001). Secondary worsening of T2DM occurred in 36% at 24 months 37.5% at 60 months in the cardiometabolic cluster but in 0% in the liver specific (both p < .001). CONCLUSION: Preoperative data-driven clustering for MASLD identifies distinct types of MASLD in MBS candidates, correlating with histological results. Cluster subtypes are associated with weight loss and diabetes outcomes with inferior outcomes for the cariometabolic cluster. These findings may have an impact on the risk-benefit ratio and on expectation management of MBS. KEY POINTS: Data-driven MASLD Clustering is reproducible in MBS candidates and correlates with histological findings. Cluster subtypes are associated with weight loss and diabetes outcomes after MBS. Patients assigned to cardiometabolic cluster show inferior weigth loss and diabetes outcomes. Clustering may impact individual treatment planning, expectation management, and targeted follow-up strategies.