A new consensus statement from the American Diabetes Association (ADA), published in Diabetes Care (July 2025), outlines a clear and practical strategy for identifying and risk-stratifying patients with metabolic dysfunction–associated liver disease (MASLD). MASLD is becoming a leading cause of cirrhosis and liver failure, yet it remains underdiagnosed due to the complexity of available diagnostic tools. The ADA emphasizes the Fibrosis-4 (FIB-4) index as the best initial test for evaluating liver fibrosis in patients with prediabetes or type 2 diabetes, especially those with obesity.

FIB-4 testing is a simple and inexpensive tool that helps determine a patient’s risk for advanced liver fibrosis. Those with scores below 1.3 are at low risk and can be re-evaluated every one to two years. Scores between 1.3 and 2.67 represent intermediate risk and should be followed up with vibration-controlled transient elastography (VCTE), which measures liver stiffness. If VCTE results are 8.0 kPa or higher, the patient should be referred to a hepatologist. Patients with FIB-4 scores of 2.67 or higher are considered at high risk and should be referred directly without additional testing. When VCTE is unavailable, the proprietary Enhanced Liver Fibrosis (ELF) blood test can be used instead, with a referral threshold of 9.8.

A recent French cohort study evaluated the effectiveness of these noninvasive strategies in primary care. It confirmed that FIB-4 had the best performance among initial tests, ruling out advanced fibrosis in over half of the study population with a negative predictive value of 97%. Among combination strategies, FIB-4 followed by VCTE was the most effective.

These updated guidelines present a more straightforward approach for primary care clinicians to screen and manage MASLD in at-risk populations. The stepwise use of FIB-4 followed by VCTE—or ELF when VCTE is not an option—provides a balanced, accessible framework for early detection and intervention. The ADA also highlights evidence-based treatment options to improve outcomes across all stages of MASLD, making this guidance a valuable resource for improving liver health in patients with metabolic dysfunction.

Source: https://www.jwatch.org/na58957/2025/07/15/new-guidance-identifying-and-risk-stratifying-patients