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Non Invasive Liver Testing

Shabnam Eghbali

Evaluation

  • Who should be evaluated: patients with steatosis noted on imaging or for whom there is a clinical suspicion of MASLD, such as those with metabolic risk factors (e.g., HTN, HLD, T2DM, obesity) or unexplained elevations in liver chemistries

  • Primary risk assessment for MASLD -> FIB-4 – estimates degree of scarring and is based on age, AST, ALT, platelet count; high negative predictive value to exclude advanced fibrosis (F3- 4); less reliable in patients under the age of 35 or over the age of 65

  • If FIB-4 <1.3 -> reassess periodically
    • Every 1-2 years if T2DM/pre-T2DM or ≥2 metabolic risk factors
    • Every 2-3 years if no T2DM and <2 metabolic risk factors
  • If FIB-4 ≥ 1.3 -> secondary risk assessment with elastography Vibration-controlled transient elastography (VCTE) also known as FibroScan if BMI < 35 or MR elastography if BMI > 35)
    • Low risk = VCTE <8 kilopascal, MRE without significant fibrosis (F2-4), reassess periodically
    • Intermediate/high risk = VCTE >8, MRE F2-4 -> referral to Hepatology

  • If FIB-4 > 2.67 -> immediate referral to Hepatology

  • Secondary risk assessment for MASLD -> (VCTE), also known as FibroScan, which provides following measurements:

  • CAP score (dB/m) -> rough estimate of steatosis with relatively limited reliability
    • 238 – 260 -> S1 (less ⅓ of liver affected by fatty change)
    • 260 – 290 -> S2 (between ⅓ and ⅔ of liver affected by fatty change)
    • 290 – 400 -> S3 (mor than ⅔ of liver affected by fatty change)
  • Liver stiffness (LSM) (kPa) -> fibrosis score ... ranges differ based on underlying liver disease but approximately,
    • 2 – 7 -> F0 to F1
    • 8 – 11 -> F2
    • 11 – 14 -> F3
    • 14 or higher -> F4

  • Limitations to VCTE: not available at all centers, significant central adiposity that interferes with measurements, cardiac device not amenable to use of VCTE

  • AGILE 3+ – a recently developed score based on combination of AST/ALT ratio, platelet count, diabetes, sex, age, LSM

  • Shear wave elastography interpretation:
  • ≤ 5 kPa -> high probability of being normal
  • < 9 kPa -> In the abscence of other known clinical signs, rule out compensated advanced liver disease (cACLD). If there are known clinical signs, may need further test for confirmation
  • 9-13 kPa suggestive of cACLD but need further test for confirmation o > 13 kPa Rules in cACLD

  • 17 kPa suggestive of clinically significant portal hypertension