Poster - Best Clinical Abstract Award Finalist ESA-SRB-NZSE-CaSR 2026 in conjunction with ENSA

Comparison of four non-invasive fibrosis algorithms in adults with type 2 diabetes: implications for MASLD screening (#310)

Shu Yan Edwin Dr Wong 1 , Aongus Dr O'Brolchain 1 , Imran Dr Butt 1 , William Dr Newman 1 , Dylan Dr Young 1 , Caterina Dr Prada 1 , Julian Dr Lang-Lemckert 1 , Harshal Dr Deshmukh 1 , Samitha Dr Yamineni 1 , Chloe Dr Wong 2 , Athanasios Dr Malkopoulos 1 , Irwin Dr Kashani 1 , Jessica Dr Triay 1
  1. Gold Coast Hospital and Health Service, Gold Coast, QLD, Australia
  2. Gold Coast Hospital and Health Service, Southport, QLD, Australia

Background:
Adults with type 2 diabetes mellitus (T2DM) are at increased risk of metabolic dysfunction-associated steatotic liver disease (MASLD) and advanced liver fibrosis. Current guidelines recommend initial risk stratification using non-invasive fibrosis scores followed by second-line assessment for patients at intermediate or high risk. However, the impact of different fibrosis algorithms on referral burden in routine diabetes practice is uncertain.

Aim:
To compare fibrosis risk classification and projected referral burden generated by FIB-4, age-adjusted FIB-4, the NAFLD Fibrosis Score (NFS) and the Steatosis-Associated Fibrosis Estimator (SAFE) in adults with T2DM.

Methods:
We performed a retrospective cross-sectional study of 350 adults attending outpatient diabetes clinics at a tertiary referral centre with established T2DM. FIB-4, age-adjusted FIB-4, NFS and SAFE were recalculated from raw clinical variables using published equations. The primary outcome was the proportion of participants requiring second-line fibrosis assessment in accordance with international society guidelines.

Results:
Standard FIB-4 classified 34.3% of participants as requiring second-line assessment, while age-adjusted FIB-4 reduced this to 20.3%. In contrast, NFS and SAFE classified 86.0% and 81.8% of participants, respectively, as requiring further assessment. Agreement between algorithms was poor (κ=0.04–0.18). Patients classified as high risk by SAFE but low risk by age-adjusted FIB-4 were older and had higher body mass index, serum globulin concentrations and urinary albumin-creatinine ratios.

Conclusions:
Commonly used fibrosis algorithms produced a four-fold difference in projected referral rates when applied to the same tertiary T2DM cohort. Age-adjusted FIB-4 substantially reduced referral burden, whereas SAFE identified a distinct metabolic phenotype not captured by age-adjusted FIB-4. These findings have important implications for implementation of MASLD screening pathways and healthcare resource utilisation.

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