## 4 Discussion  
Our study proposes a new composite scoring system, named the composite score, for the prediction of severe fibrosis in patients with T2 DM. Through multivariable logistic regression analyses, we showed that GGT values, age, BMI, HbA1C, and HOMA-IR were the strongest predictors of advanced fibrosis in patients with T2 DM. Regarding BMI, HbA1C, and HOMA-IR, the association of severe fibrosis with metabolic syndrome is well documented and has a strong correlation [28; 29]. Moreover, the higher the number of metabolic dysregulations in a patient, the greater the severity of the fibrosis [28]. Prior studies have used similar clinical and serum biomarkers to predict the presence or absence of severe fibrosis in individuals with NAFLD. In addition, some authors have developed a simple clinical model with a moderate diagnostic performance for the prediction of severe fibrosis using liver enzymes and diabetes status [30]. Another example is the Fatty Liver Index, which uses triglyceride level and waist circumference to predict NAFLD [31]. [PERSON] et al. collected data from a large cohort derived from the NASH Clinical Research Network studies and demonstrated that ad  
Figure 1: Receiver operating characteristic (ROC) curves for GGT, AGE, BMI, HOMA-IR, HbA1c, and composite score for the detection of F3/F4 group of patients. Figure 2: Receiver operating characteristic (ROC) curves for FIB-4, APRI, and composite score for the detection of F3/F4 group of patients. vanced age, higher AST/ALT and waist-to-hip ratios, hypertension, isolated abnormal alkaline phosphatase, hematocrit, serum insulin, and low platelet counts are associated with advanced liver fibrosis [32]. Another study found an association between GGT values and increased mortality in advanced fibrosis [33]. Unlike prior research, our study focuses on patients with T2 DM, a population known to have a higher risk of severe fibrosis and mortality [2,34]. Moreover, no significant predictive values were found in our study for liver function tests, waist circumference, platelets, or triglycerides. Our model performed better than the FIB-4 and APRI indexes. A large meta-analysis evaluating the diagnostic performance for the prediction of severe fibrosis in NAFLD of the FIB-4 and APRI scores reported AUROCs of 0.81 (0.73-0.89) and 0.82 (0.74-0.89), respectively, results that are consistent with ours [35]. Other combinations of serum biomarkers for liver fibrosis, which involve the measurement of markers of matrix turnover, have been analyzed in individuals with NAFLD [15]. These noninvasive tests, such as The Enhanced Liver Fibrosis test, have been evaluated in large cohorts of patients with NAFLD and performed only marginally better than our clinical model in predicting severe fibrosis (AUROC 0.91 vs. 0.899) [15]. However, these tests are relatively expensive, and they are not widely available. A recent meta-analysis that evaluated the diagnostic accuracy of pSWE in patients with NAFLD showed that, in the staging severe fibrosis (F \(>\) 3), the pooled sensitivity and specificity were 0.92 (0.87, 0.95) and 0.85 (0.80, 0.89), respectively, with an AUROC of 0.94 (0.92, 0.96) [13]. As the cut-off values for staging hepatic fibrosis vary across studies and different vendors, several studies contributed data and values to improve clinical decisions [36, 37, 38]. Given the well-known overlap of liver stiffness values for mild-to-moderate fibrosis [15], the last update to the consensus on liver elastography by the Society of Radiologists in Ultrasound Liver Elastography states that cut-off values greater than 1.7 m/s are highly suggestive of severe fibrosis [14]. In our study, we reported an unreliable measurement rate in our population that is higher than that in other studies [38,39], especially in older patients with a higher BMI. As prior studies state, one possible hypothesis for this trend is that individuals with higher BMIs have a large quantity of adipose tissue between the skin and the liver capsule [40].