Del hígado graso a la esteatohepatitis indicación para la práctica diabetológica (la mirada del diabetólogo)

Mathematical steatohepatitis-associated liver disease (MASLD) and metabolic steatohepatitis (MASH) represent a growing epidemic, with a global prevalence of 34–38%. They affect up to 60–70% of individuals with obesity or type 2 diabetes (T2D), and between 20–40% of these high-risk patients present with significant fibrosis. Emerging evidence confirms that the stage of fibrosis is the strongest independent predictor of liver and all-cause mortality, demanding a fibrosis-focused approach rather than relying on isolated steatohepatitis. For diabetologists, this paradigm shift necessitates systematic risk stratification using accessible non-invasive testing (NIT). The Fibrosis-4 Index (FIB-4) is supported as the first-line assessment due to its high negative predictive value, followed by vibration-controlled transient elastography (VCTE) or the Enhanced Liver Fibrosis (ELF) test as second-line confirmatory modalities. Consensus thresholds define VCTE <8 kPa and ELF <9.2 as low risk, while VCTE ≥20 kPa and ELF >11.3 suggest probable cirrhosis. In patients with complicated type 2 diabetes, the diagnostic performance of FIB-4 may be reduced, justifying the use of VCTE or ELF as the initial test. Lifestyle optimization remains the cornerstone of management, achieving a sustained weight loss of ≥10% that is associated with significant histological improvements. However, diabetologists must address the high risk of sarcopenic obesity; aggressive weight-loss strategies can lead to considerable loss of lean muscle mass. Therefore, structured nutritional support with adequate protein intake (>1.0 g/kg/day, up to 1.5 g/kg/day during active weight loss) and combined aerobic and resistance exercise are essential to preserve muscle mass and functional capacity. The integrated, NIT-based algorithm allows the diabetologist to proactively identify high-risk patients, implement targeted lifestyle interventions, and reduce both hepatic and extrahepatic complications.