Given the central role of the underlying metabolic pathophysiology, an international expert panel consensus proposed a novel redefinition of NAFLD. The metabolic (dysfunction)-associated fatty liver disease (MAFLD) terminology comprises the full spectrum from simple steatosis to stage 4 fibrosis and at least one of the following three criteria: overweight/obesity, the presence of T2 DM, or evidence of metabolic dysregulation [3]. This definition better emphasizes the central role of metabolic dysfunctions, and, by requiring a positive diagnosis, NAFLD is no longer only a diagnosis of exclusion. Recent studies have documented the link between high body mass index (BMI) and diabetes via proinflammatory cytokines, insulin resistance, increased levels of circulating fatty acids, and impaired cellular metabolism [4]. Moreover, many large-scale meta-analyses have linked the presence of metabolic syndrome to T2 DM due to shared common metabolic pathways, especially insulin resistance and oxidative stress, which are central factors in the pathogenesis of NAFLD [5; 6]. As several studies have shown that diabetes is the most common cause of chronic liver disease [2; 7], prognostic evaluation and clinical management must promptly determine the status of liver fibrosis in these patients, particularly those with severe fibrosis. This subset of patients carries a higher risk of progressing to decompensated cirrhosis and hepatic failure, developing NAFLD-related hepatocellular carcinoma (HCC), or even death if liver transplantation is not possible [8]. Although the correct diagnosis and the staging of liver fibrosis require a liver biopsy, patients do not frequently accept this. Furthermore, its utility as a diagnostic tool has decreased due to the high prevalence of NAFLD and potentially severe complications [9; 10]. Therefore, the potential effectiveness of noninvasive tests that can identify individuals at high risk for disease progression has been investigated in the last decade. Recently, several ultrasound methods have been refined to enhance the diagnostic accuracy of liver fibrosis [11; 12]. Specifically, pSWE, a noninvasive method for liver stiffness measurement (LSM), has great diagnostic efficacy in detecting and staging liver fibrosis in patients with NAFLD, especially in differentiating severe fibrosis (F > 3) [13; 14]. 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 recommends that cut-off values greater than 1.7 m/s are highly suggestive of severe fibrosis, especially in patients with viral hepatitis and NAFLD [14]. However, several scores based on serum biomarkers have been developed to predict severe liver fibrosis with a high diagnostic performance. Of those noninvasive scores, the NAFLD fibrosis score (NFS), the Fibrosis 4 (FIB-4) score, and the AST-to-platelet ratio index (APRI) have been externally validated in ethnically different populations with NAFLD. [16] Moreover, NFS performs best at distinguishing severe (>F3) from non-severe fibrosis, especially in populations with diabetes, and changes in NFS are linked to mortality [17]. Combining serum biomarkers and elastography methods increases diagnostic performance and is more likely to detect the presence or absence of advanced fibrosis, reducing the need to conduct a liver biopsy [18]. The current pilot study aimed to evaluate the performance of various noninvasive methods for the prediction of liver fibrosis in a population of patients with diabetes, using the concordance of a noninvasive score based on serum biomarkers and pSWE as the reference method. In particular, we focused on severe fibrosis, as this is the key determinant of the disease prognosis, prioritization for treatment, and even establishing the potential for reversibility [19; 20]. Therefore, based on these results, we established a new scoring system for the prediction of severe fibrosis in patients with diabetes.