Liver stiffness measurements in patients with metabolic dysfunction-associated steatotic liver disease: Updates on the method effectiveness and perspectives

Table 1 Factors that impacts transient elastography accuracy and controlled attenuation parameter in chronic liver disease diagnostics

Ref.	TE accuracy and controlled attenuation parameter-impacting factors	Problem solving recommendations
Coco et al[110], Arena et al[111], Sasso et al[112], Kumar et al[113], Jung et al[114], Mi et al[115]	Hepatic inflammation (including viral loading), liver condition in general (aspartate aminotransferase, alanine aminotransferase levels and activities)	To recognize inflammation, it was recommended to apply damping ratio and shear loss modulus. Apply dispersion slope, attenuation coefficient, and shear wave speed imaging markers. Combined/multivariate tests (blood analysis, liver biopsy)
Sagir et al[116] Millonig et al[117], Ozturk et al[118], Trifanov et al[119], Huang et al[120]	Hepatic congestion (venous pressure, portal vein thrombosis, bilirubin, protein accumulation) and liver damage (including intoxication by alcohol, heavy metals etc.)	CVD-related tests, administer diuretics, use histopathology as reference standard, combined/multivariate tests (blood analysis, liver biopsy) are yet to be tested and characterized
Petta et al[34], Younossi et al[37], Yin et al[87], Yang et al[95], Cassinotto et al[101], Millonig et al[121], Sharma et al[122], Ali et al[123]	Cholestatic liver diseases (steatosis)	TE probe should be selected according to BMI (less failure rate with XL probe in high BMI patients), proper cut-off values should be defined, incorporation of hemoglobin A1c and alkaline phosphatase with liver-stiffness measurement improves accuracy in detecting significant fibrosis, better IHC matching (or different, such as blood marker-based) should be designed
Huang et al[19]	Focal liver lesions/HCC	N/A, HCC protocol should be followed
Blank et al[124], Nogami et al[125]	Distance between skin and liver; peripheral or abdominal fat (obesity/high BMI)	Automatic selection of the probe, the choice of XL or M probe should be standardized using novel SmartExam computational method
Lin et al[126]	Ascites	N/A, a proper disease-related protocol should be activated
Ozturk et al[16]	Anatomical factors/musculoskeletal deformity, age/sex	The FibroScan® system uses A and transmission metasurface mode maps which guide the operators to find the ideal location in the liver tissue. Regular calibration is reqiured, correct choice of proper controls
Loustaud-Ratti et al[127], Lanzi et al[128]	Amyloid deposition in liver	Reversing the ligation of the bile duct
Mederacke et al[129], Arena et al[130]	Fasting glucose (diabetes)/recent food ingestion	At least 4 hours fasting before procedure
Barr et al[15], Pennisi et al[131], Boeckmans et al[132]	Heart condition, beta-blockers, total cholesterol/triglycerides, intense physical exercise	It is recommended to apply heart disease case-finding strategies, CVD-related tests, proper cut-off values should be defined for this category of patients
Lemmer et al[13], Barr et al[15], Boursier et al[38]	Respiratory movements	Patients are asked to hold the breath and minimize movements. Measurements are repeated up to 3 and more times
Bassal et al[74], Hudson et al[133]	Operator-related biases	Regular operator training, several repeated readings per a patient to achieve the average reading value and minimize the measurement variability

BMI: Body mass index; CVD: Cardiovascular diseases; HCC: Hepatocellular carcinoma; N/A: Not applicable; TE: Transient elastography.