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WHAT IS ALREADY KNOWN ON THIS TOPIC Reduced expression of Mitogen-inducible gene-6 (Mig-6), a negative regulator of epidermal growth factor receptor, is associated with metabolic dysfunction-associated steatohepatitis.Silencing of the Mig-6 gene causes hyperglycemia in mice.Metabolic dysfunction-associated steatotic liver disease (MASLD) patients with type 2 diabetes mellitus have accelerated progression to hepatic fibrosis.WHAT THIS STUDY ADDS A decrease in serum Mig-6 levels in patients with MASLD with F2, F3 hepatic fibrosis was associated with dysglycemia, pancreatic beta dysfunction, and dyslipidemia.A cut-off serum Mig-6 level <97.49 pg/mL clearly distinguished dysglycemic MASLD patients from their normoglycemic counterparts.HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICY Since Mig-6 levels correlate well with dysglycemia in MASLD, it may be used as a biomarker to identify dysglycemic MASLD patients who are at a greater risk of liver inflammation and fibrosis compared with their normoglycemic counterparts in the future.Mig-6 may be a potential therapeutic target in the prevention of hepatic fibrosis in dysglycemic subjects with MASLD.Introduction Metabolic dysfunction-associated steatotic liver disease (MASLD) is a rapidly rising cause of steatohepatitis, cirrhosis, and hepatocellular cancer, and a leading indication for liver transplantation worldwide. 1 In part, MASLD prevalence is increasing with the growing prevalence of obesity associated with or without type 2 diabetes mellitus (T2D),2 3 with T2D significantly accelerating disease progression.4–6 The ectopic lipid deposition in the liver triggers inflammation and oxidative stress, progressing to hepatic fibrosis—a precursor to cirrhosis. T2D and MASLD share not only overlapping pathophysiological mechanisms but often co-exist.7 8 Dysglycemia, inclusive of both impaired fasting glucose and impaired glucose tolerance (IGT), is a quintessential feature of early-stage metabolic dysregulation9 and also a precursor to overt T2D.9 10 Dyslipidemia, manifesting as elevated triglycerides (TG), low high-density lipoprotein (HDL) cholesterol, and increased low-density lipoprotein (LDL) particles, further exacerbates metabolic imbalance and cardiovascular risk.11 As a result of the linked pathophysiology, MASLD is extremely common in patients with T2D, with prevalence demonstrated to be as high as 65–70%12; liver biopsy shows a prevalence of over 90%.13–15 The liver’s central role in glucose and lipid metabolism makes it a focal point in understanding these interrelated conditions. Considering the increasing burden of metabolic diseases and the rising prevalence of MASLD even in non-diabetic subjects, there is an urgent need to identify molecular mediators which link hepatic steatosis to systemic metabolic dysfunction.Mitogen inducible gene-6 (Mig-6), also known as ERRFI1 (ERBB receptor feedback inhibitor 1), is a cytoplasmic protein known mainly for its function as a negative regulator of epidermal growth factor receptor (EGFR).16 17 Increased Mig-6 suppresses EGFR signaling.18 19 Mig-6 deficient mice showed increased EGFR and EGFR downstream signaling.20 21 EGFR is a critical regulator of hepatocyte proliferation. Inhibition of EGFR remarkably decreased steatosis through modulating peroxisome proliferator-activated receptor gamma, sterol regulatory element-binding transcription factor 1, carbohydrate-responsive element-binding protein, and hepatocyte nuclear factor 4 alpha. Inhibition of EGFR improves glucose tolerance by modulating Protein Kinase B (AKT) phosphorylation in hepatocytes. Activation of the EGFR signaling pathway in the liver might disrupt whole-body insulin resistance.22 23 However, the role of EGFR in pancreatic beta cell dysfunction and insulin sensitivity is not well studied. Recent studies suggest that Mig-6 has a more general function in the regulation of metabolic pathways and inflammation beyond its classic function as a tumor suppressor.24 25Studies in animal models have linked Mig-6 to hepatic insulin sensitivity, lipid metabolism, and cellular stress responses. The liver-specific ablation of Mig-6 conferred fasting hyperglycemia and increased insulin receptor substrate-1 phosphorylation at serine 307 in mice, along with impaired insulin signaling.26 In vitro studies of Mig-6-knockdown HepG2 cells show decreased levels of p-AKT and increased levels of Extra cellular signal-regulated kinase, corroborating disturbed insulin signaling pathways. In addition, Mig-6 knockout mice were shown to have fatty liver, fasting hyperglycemia, increased Homeostasis Model Assessment of Insulin Resistance (HOMA-IR) score, and dyslipidemia.27 Mig-6, modulating intracellular signaling pathways, appears to be one of the promising potential biomarkers or therapeutic targets. However, its involvement in human metabolic dysregulation, particularly within the context of hepatic steatosis and T2D, remains poorly understood. The present study aims to investigate the association between Mig-6 expression and dysglycemia/dyslipidemia, which could offer novel insights into the pathophysiology of metabolic syndrome in steatotic subjects, with or without T2D.Materials and methods MASLD subjects (having steatosis as per ultrasonography (USG) and presence of at least one cardiometabolic parameter) attending hepatology and diabetes clinics after radiological investigation, in a tertiary care hospital, were screened for liver fibrosis with FIB-4 (Fibrosis 4 Index) score, using the formula [(age (years) × AST [U/L])/(platelet count [10 9 /L] × √ALT [U/L])]. FIB-4 index ≥2.67, 1.30–2.67, and <1.30 indicates a high risk (F4), intermediate (F2, F3), and low risk of liver fibrosis (F0, F1), respectively.28–30 Patients having FIB-4 scores >2.67 mostly with F4 liver fibrosis, including cirrhosis, are unlikely to be amenable to disease-modifying therapeutic interventions. So, they are excluded from the study as we wanted to see the role of Mig-6 as a biomarker for potentially reversible MASLD. Those with FIB-4 scores between 1.3 and 2.67 underwent liver vibration-controlled transient elastography (VCTE). Individuals aged 35–65 years, with F2, F3 fibrosis on liver VCTE, fulfilling all inclusion/exclusion criteria and giving informed written consent, were included in the study (figure 1). Fasting blood samples were collected from subjects having FIB-4 score <1.3 and FIB-4 score >1.3–2.67 for hemoglobin A1C (HbA1C), lipid profile (serum triacylglycerol, total cholesterol (TC), HDL cholesterol, LDL cholesterol levels), and C reactive protein (CRP). The study group was further classified into two groups: (1) subjects with normal glucose tolerance (NGT) and (2) subjects with dysglycemia (IGT and T2D). Institutional ethics committee approved the study protocol.Figure 1Flowchart elaborating the classification of study groups and screening details. Fibrosis of the liver was evaluated by the VCTE method after at least 3 hours of fasting. Subjects having FIB-4 score <1.3 are used as exploratory data. FIB-4 score >2.67 are and subjects having T2D on medication are excluded. FIB-4 score=1.3–2.67 are undergone VCTE; subjects having F2, F3 fibrosis are then classified based on glycemic status according to American Diabetes Association criteria. Normal glucose tolerance, persistent IGT (*Drop out IGT subjects N=3), and treatment-naïve T2D subjects are studied. FIB-4, Fibrosis 4 Index; IGT, impaired glucose tolerance; MASLD, metabolic dysfunction-associated steatotic liver disease; NGT, normal glucose tolerance; T2D, type 2 diabetes; VCTE, vibration-controlled transient elastography.Inclusion and exclusion criteria MASLD subjects with F2, F3 fibrosis were the primary study group.MASLD subjects with FIB-4<1.30 (no fibrosis) were used as comparators for those with F2, F3 fibrosis.Dysglycemia was assessed as per American Diabetes Association guidelines.Exclusion criteria FIB-4>2.67 (advanced fibrosis, cirrhosis, and hepatocellular carcinoma) were excluded from data analysis.Body mass index (BMI)>35 kg/m2 (not considered suitable for VCTE).Individuals with a history of antidiabetes medications, insulin, glucocorticoids, valproate, hormone replacements were excluded. Pregnancy, chronic kidney disease, alcoholic liver disease, viral hepatitis, autoimmune hepatitis, Wilson’s disease, hemochromatosis, any other chronic illness, and malignancy were also excluded.Blood collection and processing of samples A fast of 10–12 hours was recommended to the study subjects before blood samples were collected. A 6 mL sample of venous blood was then collected in clot vials. To separate serum and cellular components in the remaining blood samples, centrifuges were run at 825 g for 10 min at 4 °C. Serum samples were collected in cryovials for further biochemical and molecular assays.Evaluation of glycemic parameters & lipid profiles Blood glucose level was measured for both fasting plasma glucose (FPG) and 2-hour post-glucose plasma glucose (2h-PGPG) test by the colorimetric method using a commercially available kit. HbA1c% was measured by high-performance liquid chromatography method (Bio-Rad, full-line automated HbA1C testing systems). For 2h-PGPG estimation, the study subjects were asked to drink 75 g anhydrous glucose, dissolved in 300 mL of water over 5 min. Plasma glucose level was estimated in blood samples drawn 2 hours from the beginning of the glucose drink. For the estimation of HbA1c (%), 50 µL whole blood sample was used.Fasting serum lipid profile components, that is, TC, TG, HDL-C, and LDL-C, were estimated spectrophotometrically. CRP was measured by ELISA method using a commercially available kit.MASLD assessment MASLD assessment was done using USG. Grading was done comparing liver parenchyma echogenicity with right kidney. 31 32 The liver echogenicity, like the right kidney, was normal (no fatty liver, grade-0); increased echogenicity in liver with normal diaphragm and intrahepatic vessels was defined as mild fatty liver (grade-1); mild deterioration in diaphragm and intrahepatic vessels was defined as moderate fatty liver (grade-2) and highly echogenic liver along with difficult to display diaphragm, intrahepatic vessels, and posterior segment of right hepatic lobe was defined as severe fatty liver (grade-3).Liver stiffness measure assessment using FibroScan Transient elastographic examination was done for liver stiffness measure (LSM) assessment. Indian National Association for Study of the Liver suggests the healthy range of LSM in our population to be 3.2–8.2 kPa. LSM cut-off of ≥8.2 kPa and ≥13.6 kPa may be used for detecting the presence of significant fibrosis and cirrhosis, respectively. 33Anthropometric assessment Height (to ±0.1 cm) was measured in all the individuals using a wall-mounted stadiometer and body weight (to ±100 g) measured using an electronic calibrated scale. A single observer made all measurements in triplicate. With the patient standing with feet 23–30 cm apart, we measured the waist circumference (WC) after a gentle expiration midway between the lower rib margin and iliac crest.Estimation of serum Mig-6 Serum Mig-6 was estimated using sandwich ELISA (sELISA) (Cusa Bio, Cat#: CSB-EL007804HU). The intra-assay coefficient of variance (CV) was <8% and interassay CV was <10%. The minimal detectable concentration was <7.81 pg/mL. Bio-Rad multiplate reader (Model 680) was used to read the absorbance of final color product at 450 nm with wavelength correction set at 570 nm. The kit allowed 31.25–2000 pg/mL detection range.Estimation of serum C peptide, and cytokines Serum C peptide was measured by sELISA (Cat# E0009Hu, from Bioassay Technology Laboratory, UK, RRID: AB_3083012). HOMA-IR and Homeostasis Model Assessment Of β-cell function (HOMA-β) were calculated from the C peptide values using HOMA calculator V.2.2.3 from Radcliffe Department of Medicine, University of Oxford. CV of C peptide measured by ELISA was <8% for intra-assay and <10% for interassay. Tumor Necrosis Factor alpha (TNF-α) was measured by sELISA (Bioassay Technology laboratory, Cat# E0082Hu, UK) by comparing with standard curve prepared from TNF-α standards ranging from 3 ng/L to 900 ng/L. Sensitivity of the kit is 1.52 ng/L. Interleukin 6 (IL-6) level was also measured from serum by sELISA (Bioassay Technology laboratory, Cat# E0090Hu UK), by a method similar to that of TNFα, using standard curve prepared from standards ranging from 2 ng/L to 600 ng/L. Sensitivity is 1.03 ng/L. Serum IL-1β was estimated by sELISA (Bioassay Technology laboratory, Cat# E0143Hu UK) using the method similar to that of IL-6 with sensitivity 10.07 pg/mL and detection range 20–6000 pg/mL. The intra-assay and interassay CVs were <8% and <10%, respectively. Serum IL-10 was estimated by sELISA (Bioassay Technology Laboratory, Cat# E0102Hu UK) with a standard range of 5–1500 pg/mL. The intra-assay CV was <6% and interassay CV was <10%. The minimal detectable concentration was 2.59 pg/mL.Statistical analysis D’Agostino and Pearson tests were used to evaluate the normality of continuous variables. Data were represented as mean±SD. An ordinary one-way Analysis of Variance followed by a Bonferroni post-hoc test was performed on normally distributed groups with more than two. In the case of not normally distributed data, the Kruskal-Wallis non-parametric test was used, followed by the Dunn post-hoc test. For comparisons between two normally distributed groups, an unpaired Student’s t-test was conducted, and for comparisons between two not normally distributed groups, a Mann-Whitney U-test was performed. Pearson’s correlation coefficient or Spearman’s correlation coefficient was used to represent the correlation between two variables, depending on their distribution. A receiver operating characteristic analysis (ROC) was performed to determine the area under the curve (AUC), cut-off value, sensitivity, and specificity of serum Mig-6 level in identifying dysglycemia in subjects with steatohepatitis. GraphPad Prism (V.9, San Diego, California, USA) was used for statistical analysis, with a p value of 0.05 considered statistically significant.Results Baseline clinical parameters of the participants FIB-4 Score was estimated in 479 consecutive adults with MASLD (age range 35–65 years). Patients having FIB-4 scores>2.67 (advanced, irreversible) were excluded. Subjects having FIB-4 score <1.3 were included as comparator group for F2, F3 fibrosis ( figure 1). Among the screened subjects having FIB-4 >1.3–2.67, 71 subjects were on oral hypoglycemic medications such as metformin, sulfonylureas, pioglitazone, DPP-4 inhibitors, and SGLT2 inhibitors. They are excluded from the study to eliminate the confounding effects of antidiabetic medications. Among the subjects having FIB-4 score >1.3–2.67, only 119 people had clinical (F2, F3) fibrosis detected by VCTE. Subjects with significant fibrosis, 35 had NGT, 44 had IGT, and 40 subjects had treatment-naïve T2D. Only 35 normoglycemic (male: female=19:16), 16 stable IGT (male: female=7:9), and 40 treatment-naïve T2D subjects (male: female=23:17) with clinical liver fibrosis were considered in our study (figure 1). At baseline, metabolic syndrome was present in 68% of the participants with FIB-4=1.3–2.67 group, although 27% participants having FIB-4 <1.3 also had metabolic syndrome (online supplemental table 1). The MASLD subjects with fibrosis had a significantly higher percentage of metabolic syndrome compared with those without fibrosis (online supplemental table 1). Serum levels of TNF-α and IL-6 were significantly higher and IL-10 levels significantly lower in those with significant fibrosis compared with those without fibrosis; however, no significant difference in serum proinflammatory cytokine levels IL-1β was observed between the groups (online supplemental figure 1).SP110.1136/bmjdrc-2026-005947.supp1Supplementary dataClinical parameters in subjects with steatohepatitis FPG, 2hPGPG, and HbA1C levels were significantly higher in the T2D and IGT group compared to NGT; no significant difference in BMI, WC and waist-hip ratio was seen across the group ( table 1). Serum TG and TC levels were significantly increased in steatosis subjects with dysglycemia compared to those with NGT; no significant changes in HDL-C and LDL-C levels were seen (table 1). Peripheral insulin resistance (HOMA-IR) was significantly higher in the steatosis group having T2D compared to those with IGT and NGT. Also, the HOMA-β value was significantly lower in the T2D group compared to IGT and NGT groups (table 1).Table 1Comparison of BMI, waist circumference (WC), waist-hip ratio (WHR), glycemic parameters, insulin resistance (HOMA-IR), insulin sensitivity (HOMA-β), lipid profile among NGT, IGT, and T2D individuals having steatohepatitisAlteration of demographic & metabolic parameters in steatohepatitis subjects with or without T2DParameters (normal value)T2D (N=40)IGT (N=16)NGT (N=35)P valueAge46.51±8.7944.23±8.0445.76±10.58nsMale: female23:177:919:16nsBMI (18.5–24.9 kg/m2)28.42±6.6125.33±4.3524.56±3.65nsWC(Female ≤80 cm and male ≤90 cm)93.89±10.6891.16±8.4687.46±9.58nsWHR0.98±0.090.97±0.110.96±0.16nsFPG (mg/dL)(<100 mg/dL)211.25±56.24107.16±9.9290.57±12.25<0.052hPGPG (mg/dL)(<140 mg/dL)300.29±100.23172.16±23.66120.47±23.47<0.05HbA1C(<5.7)10.65±2.026.01±0.184.65±0.48<0.05HOMA-IR*3.43±0.711.72±0.470.76±0.25<0.05HOMA-β*26.59±13.4476.26±25.68102±51.42<0.001SerumTriglyceride(mg/dL) (<150 mg/dL)213.58±82.52135.1±33.84118.57±21<0.01Total cholesterol (mg/dL)(<200 mg/dL)212.38±85.13167.4±26.49159.55±24.57<0.05HDL (mg/dL)(>40 mg/dL for men and >50 mg/dL for women)40.36±7.4643.87±9.5844.14±6.52nsLDL (mg/dL) (<100 mg/dL)102±39.2897.34±28.6292.95±23.44nsData are expressed as mean±SD deviation; χ2 test was performed for categorical data. P value (across the group) calculated using one-way ANOVA/Kruskal-Wallis test depending on the data distribution.*HOMA-IR cut-off used >1.635 and HOMA-β cut-off used <72.5.34BMI, body mass index; FPG, fasting plasma glucose; HbA1C, hemoglobin A1C; HDL, high density lipoprotein; HOMA-IR, Homeostasis Model Assessment of Insulin Resistance; HOMA-β, Homeostasis Model Assessment of β-cell function; 2h-PGPG, 2-hour post-glucose plasma glucose; IGT, impaired glucose tolerance; LDL, low density lipoprotein; NGT, normal glucose tolerance; T2D, type 2 diabetes mellitus.Assessment of serum Mig-6 levels in subjects having steatohepatitis Subjects having FIB-4 score <1.3 and normal VCTE results+normal glucose levels served as negative controls (shown in figure 2A). The subjects having no steatosis and normal glucose levels showed significantly high values of serum Mig-6 levels compared with those having steatosis with FIB-4 score <1.3 (p<0.01) and FIB-4 score >1.3 (p<0.001). Although there was no statistically significant reduction in serum Mig-6 level in subjects having FIB-4 score >1.3 (84.17±65.58 pg/mL) (figure 2A) and those compared with having FIB-4 <1.3 value (119.3±57.51 pg/mL, figure 2A).Figure 2Comparison of serum Mig-6 level among the study groups. (A) Comparison of serum Mig-6 level between FIB-4 groups. Subjects having no steatosis and normal glucose levels served as control (negative). One-way ANOVA test was performed to compute the statistical significance. P value <0.05 was considered significant. (B) Comparison of serum Mig-6 levels between NGT and dysglycemic (IGT+T2D) group in MASLD subjects with clinical fibrosis. Mann-Whitney U-test was performed to compute the statistical significance. (C) Comparison of serum Mig-6 levels among NGT, IGT, and T2D groups in MASLD subjects with clinical fibrosis. One-way ANOVA test followed by Bonferroni post-hoc test was performed. FIB-4, Fibrosis 4 Index; IGT, impaired glucose tolerance; MASLD, metabolic dysfunction-associated steatotic liver disease; Mig-6, mitogen inducible gene-6; NGT, normal glucose tolerance; T2D, type 2 diabetes.When the MASLD subjects (FIB-4 score >1.3–2.67, F2 and F3 fibrosis) were further stratified on the basis of glycemic status, a significant reduction in Mig-6 levels was seen in the subjects with dysglycemia (IGT+T2D) compared with NGT subjects (figure 2B, p<0.001). When the subjects having dysglycemia were further classified into IGT and T2D, mean levels of serum Mig-6 were 135±56.36 (pg/mL) in NGT & 58.78±48.19 pg/mL in T2D and 68.46±42.21 pg/mL in IGT subjects. Here, a significant difference was only found between NGT and T2D subjects (figure 2C, p<0.001). The same pattern was replicated in the subjects with FIB-4 score <1.3, where the difference in serum Mig-6 level was found to be significantly (p<0.05) lower in T2D group again (online supplemental figure 2).Association between serum Mig-6 levels and metabolic parameters in the study participants Decrease in serum Mig-6 level was significantly correlated with glycemic parameters. A highly significant negative correlation was seen between Mig-6 and FPG (r=−0.4991, p=0.0002), HbA1C (r=−0.4649, p=0.0008), and HOMA-IR (r=−0.4272, p=0.0027) ( figure 3A). Coming to the circulatory lipids, Mig-6 levels showed a significant (p<0.001) inverse correlation with TC and, notably, with the TG/HDL-C ratio (r=0.6690, p<0.0001) (figure 3B). Mig-6 had a significant positive correlation with HOMA-β (r=0.4440, p=0.0014) (figure 3A).Figure 3Correlation study. (A) Graphical representation of serum Mig-6 level negatively correlated with fasting plasma glucose (FPG), HbA1C, HOMA-IR, and HOMA-β; Mig-6 as an independent variable (X-axis). (B) Graphical representation of serum Mig-6 level negatively correlated with total cholesterol levels, TG/HDL; Mig-6 as an independent variable (X-axis). HbA1C, hemoglobin A1C; HDL, high-density lipoprotein; HOMA-IR, Homeostasis Model Assessment of Insulin Resistance; HOMA-β, Homeostasis Model Assessment of β-cell function; Mig-6, mitogen inducible gene-6; TG, triglycerides.Mig-6 as a predictor of dysglycemia in subjects having FIB-4 score between 1.3 and 2.67 (F2, F3 fibrosis) ROC curve analysis showed a cut-off value of serum Mig-6 level <97.49 (pg/mL) predicted dysglycemia in subjects having FIB-4 score >1.3–2.67 with F2, F3 fibrosis (sensitivity 77.50% and specificity 73.08%, figure 4A). Mig-6 level in NGT versus dysglycemia group had an AUC of 0.8837 (p<0.0001) with a 95% CI of 0.8024 to 0.9639 among individuals with FIB-4 1.3–2.67. Using the above cut-off, 74.2% of the T2D subjects and 22% of subjects with NGT had a lower value of serum Mig-6.Figure 4Receiver operating characteristic analysis (ROC) curve analysis of serum Mig-6 level for the detection of dysglycemia. (A) ROC curve analysis of serum Mig-6 level for the detection of dysglycemia in MASLD subjects with clinical fibrosis. (B) Difference between HOMA-β levels between subjects having Mig-6 level lower and higher groups using this cut-off (97.49 pg/mL). HOMA-β, Homeostasis Model Assessment of β-cell function; MASLD, metabolic dysfunction-associated steatotic liver disease; Mig-6, mitogen inducible gene-6;Association of Mig-6 levels with pancreatic β-cell dysfunction and insulin resistance In this context, a significant change in HOMA-β level was observed ( figure 4B) between the group having Mig-6 <97.49 pg/mL and Mig-6 >97.49 pg/mL, underpinning the significant association of low Mig-6 levels with pancreatic β-cell dysfunction. Intra-assay precision of Mig-6 is CV (%) <5% and interassay precision: CV (%) <10. Previous study by Asghar Ghasemi et al estimated 72.5 as the cut-off value of HOMA-β for pancreatic beta cell dysfunction.34 Taking this cut-off value of HOMA-β, we found that serum Mig-6 levels have positive and negative predictive values (PPV and NPV) of 79.41% and 85.17%, respectively.Similarly, Sonu Sama et al reported the HOMA-IR cut-off value >1.6 as a predictor of peripheral insulin resistance.35 When we compared Mig-6 with this cut-off value, the PPV and NPV values were 80% and 86.67%, respectively.Discussion Co-existing T2D accelerates the progression of MASLD to hepatic fibrosis and cirrhosis. But the mechanism underpinning such progression is currently unknown. Also, identifying biomarkers that predict dysglycemia in MASLD population may contribute to the prevention of hepatic fibrosis. There are limitations to the gold-standard technique for detection of dysglycemia, that is, 2h-PGPG, due to its high cost and labor-intensive process and variability.Emerging evidence suggests that Mig-6, a negative regulator of EGFR, may play a role in insulin resistance, dysglycemia, and metabolic dysfunction-associated steatohepatitis (MASH).24 25 We examined the role of Mig-6 for predicting dysglycemia to prevent rapid progression of MASLD in T2D.Liver-specific deletion of Mig-6 results in hepatomegaly and hepatic steatosis, mediated via dysregulation of cholesterol metabolism and bile acid synthesis.36 Mig-6 knockout mice also develop fasting hyperglycemia on high-fat diet feeding, presumably due to Phosphoenol pyruvate carboxy kinase-mediated gluconeogenesis.27 However, these mice did not show significant alterations in glucose tolerance or insulin sensitivity, suggesting a liver-specific insulin resistance induced by Mig-6 inactivation, rather than a worsening of whole-body insulin sensitivity. Furthermore, Yoo et al,26 showed liver-specific Mig-6 d/d mice to develop fasting hyperglycemia, associated with decreased hepatic glycogen content.26 They postulated that increased fasting glucose in Mig-6-deficient mice may be driven by enhanced glycogenolysis and decreased hepatic glucose uptake. Of note, Mig-6 d/d mice showed accumulation of liver fat, associated with depletion of adipose fat, underpinning a role of Mig-6 in the adipose-liver cross talk, one of the major causes of de novo lipogenesis in the liver.26 It may be of interest to study the effects of pioglitazone, resmetirom, and semaglutide, the currently approved medications to reduce liver fat and inflammation, on Mig-6 gene and protein levels. Increased adipose tissue lipolysis is one of the major drivers of MASLD. Adipose-specific overexpression of Mig-6 improves systemic glucose tolerance and insulin sensitivity and is associated with increased adiponectin levels.37 38 No reports are available linking Mig-6 silencing/knockout in the adipose tissue and liver underpinning the cross talk between them in terms of adipose tissue inflammation and increased Free fatty acid delivery to the liver and with hepatic de novo lipogenesis and glucose output. There is an unmet need to study the role of Mig-6 as a key modulator in liver-adipose tissue crosstalk in regulating systemic energy balance and insulin action.To our knowledge, there have been no previous reports investigating circulating levels of Mig-6 in human MASLD. In the present study, we assessed serum Mig-6 concentrations in MASLD patients stratified by fibrosis status (FIB-4 scores). Although we observed a trend toward reduced serum Mig-6 levels in individuals with intermediate fibrosis risk (FIB-4 1.3–2.67) compared with those with lower risk (FIB-4 <1.3), the difference did not reach statistical significance (figure 2A). This could be attributed to the heterogeneity of the risk factors for MASLD, ie, obesity, dyslipidemia, and T2D. Notably, among MASLD subjects without steatosis (FIB-4 scores <1.3), 27% had metabolic syndrome and 34% had T2D (online supplemental table 1), underscoring the heterogeneity within this group. Since chronic low-grade inflammation is a major driver of liver fibrosis in persons with MASLD, we measured the serum inflammatory markers in the subjects having FIB-4 <1.3 and FIB-4 >1.3–2.67. Proinflammatory cytokines TNF-α, IL-6, IL-1β, and anti-inflammatory cytokines IL-10 are reported as the key components implicated in liver inflammation.39 Significant increase of serum levels of TNF-α, IL-1β, and reduced levels of IL-10 in the MASLD subjects having FIB-4 score >1.3–2.67 (intermediate risk of fibrosis) compared with those having FIB-4 score <1.3 indicates the subjects having intermediate risk of fibrosis have a more pronounced inflammatory state compared with those having low risk of fibrosis.Since hepatic insulin resistance is one of the major pathophysiological conditions in MASLD, we hypothesized that dysglycemia might synergize with dyslipidemia in suppressing Mig-6 expression. To evaluate this, we examined serum Mig-6 levels among subjects with significant fibrosis (stage F2/F3), stratified by glycemic status. Treatment-naïve T2D individuals were included in the study to eliminate the confounding effects of anti-diabetic medications, and patients with advanced fibrosis (F4) were excluded.Treatment-naïve T2D/dysglycemic (T2D+IGT) subjects with MASLD with significant (F2, F3) fibrosis exhibited significantly lower serum Mig-6 levels compared with their normoglycemic counterparts with comparable grades of fibrosis (figure 2B,C). FPG, HbA1c, and HOMA-IR all showed negative correlations with serum Mig-6 levels (figure 3A), indicating that Mig-6 may be involved in the metabolic dysregulation linked to T2D in MASLD. These findings are consistent with earlier genetic research that found a link between an Iranian population’s susceptibility to T2D and the +808 T/G polymorphism in the Mig-6 gene.40 Using ROC curve analysis, we determined a serum Mig-6 threshold of <97.49 pg/mL as predictive of dysglycemia in MASLD subjects, with a sensitivity of 77.50%, specificity of 73.08%, and an AUC of 0.8837 (figure 4A). We suggest that the above cut-off values for Mig-6 may allow us to use it as a biomarker to identify dysglycemic MASLD who are at a greater risk of liver inflammation and fibrosis compared with their normoglycemic counterparts.Since insulin resistance is a necessary but not a sufficient condition to develop T2D and pancreatic β-cell dysfunction is an essential prerequisite for T2D,38 we explored the relationship between Mig-6 and pancreatic β-cell dysfunction in MASLD. T2D subjects with MASLD had a significantly lower C peptide HOMA-β compared with those with MASLD but without T2D (table 1). Serum Mig-6 levels positively correlated with HOMA-β (figure 3A), suggesting an association between reduced Mig-6 levels and impaired pancreatic β-cell function. This relationship aligned with the ROC curve derived Mig-6 cut-off of 97.49 pg/mL that identified MASLD subjects with dysglycemia, the clinical hallmark of prediabetes and T2D (figure 4B).In addition to glycemic dysregulation, dyslipidemia is a hallmark of MASLD, particularly in individuals with coexisting metabolic syndrome and insulin resistance. Prior studies have estimated the prevalence of atherogenic dyslipidemia in MASLD to be 20–80%.41 In our cohort, a higher prevalence of dyslipidemia and metabolic syndrome was observed in individuals with intermediate fibrosis risk (FIB-4 1.3–2.67). The TG/HDL-C ratio (figure 3B), a recognized indicator of cardiovascular risk, significantly correlated negatively with serum Mig-6 levels. These results corroborate preclinical evidence that links Mig-6 deficiency to hypertriglyceridemia and hepatic steatosis, as well as the theory that Mig-6 plays a crucial role in lipid metabolism.This study has several limitations, despite its encouraging results. First, the study is cross-sectional; causal inference is not possible. Second, all participants were selected from the same geographic area, which limited generalizability. Third, instead of using the gold standard hyperinsulinemic euglycemic and hyperglycemic clamp studies, C peptide-based indices were used to measure insulin resistance and pancreatic β-cell function. Also, we did not perform liver biopsy for MASH subjects, and lacking body composition with visceral fat data is also an additional limitation.Conclusion We found that decrease in serum Mig-6 levels in patients with MASLD, especially those with severe hepatic fibrosis, is associated with dysglycemia, pancreatic dysfunction, and dyslipidemia. For this high-risk group, the prediction of an ROC curve-generated diagnostic cut-off for serum Mig-6 shows promise for detecting dysglycemia early. To validate these findings and understand the precise role of Mig-6 in the pathogenesis of MASLD in persons with dysglycemia, longitudinal and mechanistic studies are needed.