From fatty liver indices to the Zhejiang University index: Re-shaping risk stratification of metabolic liver disease in diabetes

Abstract

This editorial comments on the study by Tao et al, emphasizing the scalable diagnostic tool for metabolic dysfunction-associated steatotic liver disease (MASLD) in type 2 diabetes mellitus (T2DM). Classical indices such as the fatty liver index (FLI), hepatic steatosis index (HSI), and non-alcoholic fatty liver disease-liver fat score have provided valuable insights. Still, their predictive accuracy often varies across populations and clinical settings. In Western cohorts, FLI and HSI are widely applied, yet they depend heavily on anthropometric or categorical variables, which limits their sensitivity in Asian populations. The Zhejiang University index (ZJU index), developed in China, integrates fasting glucose, triglycerides, hepatic enzyme ratios, and body mass index into a composite score of insulin resistance. Recent studies show that the ZJU index outperforms FLI and HSI in predicting MASLD among Chinese patients, particularly those with T2DM, where it demonstrates a nonlinear association with disease risk and identifies a critical threshold of 38.87. The ZJU index links to conditions like sarcopenia, sleep apnea, and gallstones, showing its versatility in metabolic health. This editorial compares its performance with other indices and emphasizes the ZJU index as a next-generation tool for MASLD risk stratification globally.

Keywords: Metabolic dysfunction-associated; Type 2 diabetes mellitus; Zhejiang University index; Fatty liver index; Hepatic steatosis index; Non-invasive diagnostics; Risk stratification

Core Tip: Early identification of metabolic dysfunction-associated steatotic liver disease (MASLD) in diabetes requires reliable and easily applicable tools. The Zhejiang University index (ZJU index) combines metabolic and hepatic parameters, such as body mass index, fasting glucose, triglycerides, and enzyme ratios, into a simple score derived from routine clinical data. Unlike traditional indices such as fatty liver index and hepatic steatosis index, the ZJU index demonstrates superior accuracy for detecting MASLD and correlates with systemic complications, including insulin resistance and sarcopenia. Its integration into electronic medical records enables automatic annual screening of patients with type 2 diabetes mellitus, providing a cost-effective, non-invasive approach for risk stratification and guiding timely preventive interventions.