Non-Invasive 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 o 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 1/3 of liver affected by fatty change)
      • 260 – 290 -> S2 (between 1/3 and 2/3 of liver affected by fatty change)
      • 290 – 400 -> S3 (mor than 2/3 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
    • > 13 kPa Rules in cACLD
    • >17 kPa suggestive of clinically significant portal hypertension
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