The recent multicenter study by Caussy et al. (1) provides valuable evidence supporting the use of fibrosis-4 index (FIB-4) followed by vibration-controlled transient elastography (VCTE) to detect advanced fibrosis in metabolic dysfunction–associated steatotic liver disease (MASLD) patients with diabetes, particularly in diabetology clinics. Their prospective design is well-conceived and clinically relevant. However, the extent to which these findings apply to diverse populations and settings remains a critical question.
Real-world data from safety-net health systems in the U.S. have shown that the diagnostic performance of FIB-4 can be significantly compromised in patients with type 2 diabetes (T2D) and obesity, especially in predominantly Hispanic populations. In one such cohort, the area under the empirical receiver operating characteristic curve for FIB-4 dropped from 0.85 in patients who did not have diabetes to 0.68 in those with diabetes (2). Similarly, researchers at the University of California, Los Angeles, found that lowering the FIB-4 threshold from 1.3 to 1.0 in Hispanic patients with T2D improved diagnostic accuracy (area under the empirical receiver operating characteristic curve 0.81 vs. 0.74), suggesting that fixed cutoffs may not be appropriate for all subgroups (3).
This concern is amplified by international data. A recent multicenter study in Mexico City reported a 20.4% prevalence of advanced fibrosis among >2,000 patients with T2D—more than double the 9.3% seen in Caussy’s European cohort (1,4). In India, data from a large population with diabetes suggested that one-third of patients had FIB-4 scores ≥1.3 and that the conventional threshold lacked sensitivity (5). These findings imply a need for lower or tailored cutoffs in South Asian and Latin American populations.
To their credit, Caussy et al. acknowledge that their findings require external validation. However, current evidence strongly supports the need for population-specific adjustments to FIB-4 thresholds to avoid underdiagnosis, particularly in high-risk, underrepresented groups. A uniform approach may not achieve the screening sensitivity we aspire to in diverse clinical settings.
Article Information
Duality of Interest. No potential conflicts of interest relevant to this article were reported.
Handling Editors. The journal editor responsible for overseeing the review of the manuscript was Steven E. Kahn.
References
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