Trabecular bone score enhances fracture risk stratification in patients with metabolic dysfunction-associated steatotic liver disease and type 2 diabetes mellitus

Purpose Alterations in bone metabolism are common in chronic liver disease. This study aimed to assess the risk of fragility fractures in patients with metabolic dysfunction–associated steatotic liver disease (MASLD) and type 2 diabetes (T2D), using the trabecular bone score (TBS) as a marker of bone quality. Methods Patients with MASLD and T2D were consecutively enrolled at the Medicine and Hepatology Unit of the University Hospital of Messina between February and October 2024. Exclusion criteria included decompensated cirrhosis, secondary osteoporosis, and long-term use of bone-active therapies. All participants underwent liver elastography for steatosis and fibrosis assessment, with the Controlled Attenuation Parameter (CAP) used to quantify hepatic fat content, and dual-energy X-ray absorptiometry with TBS and vertebral fracture assessment. Results One hundred-five patients (56 males; median age 62 years) were included in the study. Vertebral fractures were detected in 54 patients (51.4%), of whom 45 (83.3%) had pathological TBS (< 1.350) despite normal bone mineral density. Regression analysis confirmed a strong association between pathological TBS and fracture risk (p < 0.001). Pathological TBS was also significantly associated with body mass index > 30 kg/m2 (p < 0.001), CAP ≥ 248 dB/m (p = 0.034), and male sex (p = 0.002), but not with advanced liver fibrosis. Conclusion Bone fragility represents a relevant comorbidity in patients with MASLD and T2D, independent of fibrosis severity. TBS appears to be a sensitive marker of skeletal fragility, while CAP may help identify patients at increased risk of fracture.