The epidemiology of metabolic dysfunction-associated steatotic liver disease among pediatric patients with type 2 diabetes: Systematic review and meta-analysis

Abstract Metabolic dysfunction-associated steatotic liver disease (MASLD) is strongly associated with type 2 diabetes (T2D) in adults; however, its epidemiology in the pediatric population remains unclear. We conducted a systematic review and meta-analysis to estimate the prevalence of MASLD among children and adolescents with T2D. We systematically searched PubMed and Embase databases from inception until March 18, 2025 to identify observational studies investigating the prevalence of MASLD (diagnosed by liver biopsy, imaging methods, or blood-based biomarkers) in children and adolescents (aged ≤ 21 years) with T2D. Data from eligible studies were extracted, and meta-analysis was performed using a generalized linear mixed model. This study was registered in PROSPERO (ID CRD420251013625). Eighteen unique studies with 3926 pediatric patients with T2D were included. The pooled prevalence of MASLD in pediatric T2D was 36.61% (95% confidence interval [CI] 26.45 to 48.12), with substantial heterogeneity (I 2 = 97.1%). Prevalence estimates differed significantly by the diagnostic method used for MASLD (p = 0.014) but remained consistent across subgroups based on world region, median year of enrollment, and sample size. Sensitivity analysis restricted to magnetic resonance-based studies showed a high prevalence (55.0%, 95% CI 38.20 to 70.78, I 2 = 73.7%). The funnel plot did not reveal any significant publication bias. Conclusions : MASLD affects over one-third of pediatric patients with T2D. These findings support early liver health screening in this high-risk group. Future research is needed to validate non-invasive tests for liver disease assessment in pediatric diabetes care. What is known: • Type 2 diabetes (T2D) is a strong risk factor for metabolic dysfunction-associated steatotic liver disease (MASLD). • The epidemiology of MASLD in children and adolescents with T2D remains poorly characterized. What is new: • MASLD affects an estimated 36.61% of pediatric patients with T2D, with substantial variation according to the diagnostic modality used. • This high prevalence underscores the need for early liver health screening in pediatric T2D.