Blood markers vs transient elastography for liver stiffness and steatosis in metabolic dysfunction-associated steatotic liver disease

Abstract

BACKGROUND

Liver biopsy, once the gold standard for evaluating liver fibrosis and steatosis, has been largely replaced in routine clinical practice by non-invasive tools like Fibroscan^®, which evaluate liver stiffness measurement (LSM) and controlled attenuation parameter (CAP). While Fibroscan^® is well-validated, cost and accessibility challenges limit its use for regular follow-up, especially in primary care.

AIM

To investigate the diagnostic accuracy and correlation of blood-based parameters fibrosis 4 (FIB-4) score, aspartate transaminase to platelet ratio index (APRI), neutrophil-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR), and neutrophil percentage-to-albumin ratio (NPAR) with LSM and CAP values in metabolic dysfunction-associated steatotic liver disease (MASLD) patients.

METHODS

In a cross-sectional study of 300 MASLD patients we compared FIB-4, APRI, NLR, PLR, and NPAR with LSM and CAP values. Patients were categorized based on LSM into less fibro-progressed (F0-F2) and advanced fibro-progressed (F3-F4) groups, and by CAP into S1, S2 and S3 categories. Sensitivity, specificity, positive predictive value, and negative predictive value of the markers were analyzed, and receiver operating characteristic curves were plotted.

RESULTS

FIB-4 [r = 0.537, P < 0.001; area under curve (AUC) = 0.806; diagnostic accuracy = 75.63%] and APRI (r = 0.513, P < 0.001; AUC = 0.772) showed strong correlations with LSM, confirming their reliability for LSM. APRI and FIB-4 are validated against fibrosis in liver biopsy, our results demonstrate comparable performance between these scores and LSM by Fibroscan^®. PLR exhibited high specificity (98.0%) but showed negative correlation with LSM (r = -0.317, P < 0.01). For CAP, NPAR demonstrated the highest specificity (97.67%) and positive predictive value (91.31%), followed by NLR (specificity 92.77%, positive predictive value 91.58%), though AUC values were modest (0.562 and 0.540, respectively).

CONCLUSION

FIB-4 and APRI which are robust non-invasive markers for fibrosis, correlates well with LSM as well. NPAR shows potential for steatosis assessment using CAP, warranting further validation. Negative correlation of PLR might suggest its role in liver stiffness evaluation. These markers both conventional and novel, can be used for repeated measurements during follow-up in primary care settings.

Keywords: Metabolic dysfunction-associated steatotic liver disease; Non-alcoholic fatty liver disease; Transient elastography; Fibrosis-4 index; Aspartate transaminase to platelet ratio index; Neutrophil percentage to albumin ratio; Liver stiffness; Steatosis; Fibrosis

Core Tip: This study demonstrates that blood-based markers are cost-effective adjuvants to FibroScan for metabolic dysfunction-associated steatotic liver disease (MASLD) assessment. Fibrosis 4 and aspartate transaminase to platelet ratio index demonstrated strong correlations with liver stiffness measurement (LSM), confirming their reliability for fibrosis evaluation. Notably, neutrophil percentage-to-albumin ratio emerged as a novel marker with a specificity (97.67%) for steatosis assessment, while platelet-to-lymphocyte ratio showed an inverse correlation with LSM. These findings support integrating simple blood markers with imaging techniques for enhanced diagnostic precision, particularly valuable in primary care settings where repeated FibroScan measurements are financially or logistically challenging, addressing critical gaps in MASLD management.