Evaluation methods of hepatic steatosis: From conventional techniques to emerging biomarkers

Table 1 Classification and comparison of hepatic steatosis evaluation methods

Type	Examples	Advantages	Clinical utility	Disadvantages
Histological	Liver biopsy	Gold standard, full histological insight	Diagnosis of steatohepatitis (historically termed NASH, now MASH), fibrosis staging	Invasive, subject to sampling variability, associated with procedural risks, unsuitable for longitudinal monitoring
Imaging	US, CAP, MRI-PDFF	Noninvasive, widely available	Screening, detection, and quantification of hepatic steatosis	Limited sensitivity for mild steatosis, operator-dependent performance, reduced accuracy in obese individuals
Blood biomarkers	ALT/AST, CK-18, FGF21, M2BPGi, Pro-C3	Accessible, repeatable	Risk stratification and monitoring of fibrosis progression	Insufficient specificity, susceptible to influence by extrahepatic conditions, limited validation for staging
Composite index	FIB-4	Integrative, cost-effective	Estimation of fibrosis burden and risk assessment	Limited diagnostic specificity, not reliable as a stand-alone tool, performance influenced by age and comorbidities
Emerging technique	DNA methylation, AI algorithms	High precision, research-oriented	Exploratory application in precision diagnostics and personalized medicine	Investigational stage, relatively high cost, insufficient standardization and clinical validation

AI: Artificial intelligence; ALT/AST: Alanine aminotransferase/aspartate aminotransferase; CAP: Controlled attenuation parameter; CK-18: Cytokeratin-18; FGF21: Fibroblast growth factor 21; FIB-4: Fibrosis-4; M2BPGi: Mac-2 binding protein glycosylation isomer; MRI-PDFF: Magnetic resonance imaging-proton density fat fraction; Pro-C3: Type III procollagen peptide; US: Ultrasound; NASH: Nonalcoholic steatohepatitis; MASH: Metabolic dysfunction-associated steatohepatitis.