Performance of three clinical scores for steatosis and steatohepatitis and their interaction with metabolic syndrome in obese individuals

doi:10.4254/wjh.v18.i2.111962

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Feb 27, 2026 (publication date) through Feb 12, 2026

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World Journal of Hepatology

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World J Hepatol. Feb 27, 2026; 18(2): 111962
Published online Feb 27, 2026. doi: 10.4254/wjh.v18.i2.111962

Table 1 Baseline characteristics, n (%)

Characteristic	Total (n = 95)	Any steatosis¹			Moderate-to-severe steatosis¹			MASH¹
Characteristic	Total (n = 95)	Presence (n = 66)	Absence (n = 29)	P value	Presence (n = 15)	Absence (n = 80)	P value	Presence (n = 15)	Absence (n = 80)	P value
Age (year), mean ± SD	43 ± 9.2	44.6 ± 8.6	39.4 ± 9.6	0.016^a	45.9 ± 9.1	42.4 ± 9.2	0.197	45.8 ± 8.9	42.4 ± 9.2	0.196
Female sex	80 (84.2)	58 (87.9)	22 (75.9)	0.220	12 (23.5)	68 (85)	0.700	12 (23.5)	68 (85)	0.700
BMI (kg/m²), median (IQR)	42.9 (40.7-45.4)	42.6 (41-45)	43.7 (40.5-45.5)	0.465	43 (41.9-45.2)	42.8 (40.3-45.4)	0.524	43 (41.5-44.4)	42.8 (40.3-45.4)	0.858
Obesity I	1 (1)	0 (0)	1 (3.4)	0.408	0 (0)	1 (1.2)	1.000	0 (0)	1 (1.2)	1.000
Obesity II	17 (17.9)	12 (31.8)	5 (17.2)		2 (13.3)	15 (18.75)		2 (13.3)	15 (18.75)
Obesity III	77 (81)	54 (81.8)	23 (79.3)		13 (86.7)	64 (80)		13 (86.7)	64 (80)
WC (cm), median (IQR)	126.6 (122.2-132.8)	127 (123.5-132.4)	124.7 (119.4-134.9)	0.460	131.3 (122-138)	126.2 (122.3-132.4)	0.504	129.4 (125.3-136.8)	125.9 (122.1-132.7)	0.277
Smoking	13 (13.7)	10 (15.2)	3 (10.3)	0.748	3 (20)	10 (12.5)	0.426	2 (13.3)	11 (13.8)	1.000
T2DM	27 (28.4)	23 (34.8)	4 (13.8)	0.048^a	8 (53.3)	19 (23.8)	0.029^a	8 (53.3)	19 (23.8)	0.029^a
Hypertension	52 (54.7)	39 (59.1)	13 (44.8)	0.264	10 (66.7)	42 (52.5)	0.401	7 (46.7)	45 (56.2)	0.577
Dyslipidemia	28 (29.5)	21 (31.8)	7 (24.1)	0.626	9 (60)	19 (23.8)	0.011^a	9 (60)	19 (23.8)	0.011^a
Obstructive sleep apnea	16 (16.8)	11 (16.7)	5 (17.2)	1.000	3 (20)	13 (16.3)	0.713	3 (20)	13 (16.3)	0.713
Metabolic syndrome	65 (68.4)	47 (71.2)	18 (62.1)	0.473	13 (86.7)	52 (65)	0.133	11 (73.3)	54 (67.5)	0.769
AST (U/L), median (IQR)	19 (15-24.5)	18.5 (15-24)	19 (8-17)	0.267	23 (16-31.5)	18 (15-23.2)	0.066	22 (17-31.5)	18 (15-24)	0.028^a
Elevated AST²	6 (6.3)	4 (6.1)	2 (6.9)	1.000	3 (20)	3 (3.8)	0.048^a	3 (20)	3 (3.8)	0.048^a
ALT (U/L), median (IQR)	20 (16-30.5)	20.5 (15-31)	19 (18-27)	0.633	29 (19.5-52)	19 (15-27.25)	0.013^a	29 (20-52)	19 (15-27.25)	0.010^a
Elevated ALT³	20 (21)	14 (21.2)	6 (20.7)	1.000	7 (46.7)	13 (16.2)	0.021^a	7 (46.7)	13 (16.2)	0.021^a
GGT (U/L), median (IQR)	33 (23.5-44.5)	33 (25.2-44.8)	32 (21-40)	0.421	54 (31-90.5)	32 (23-40)	0.009^a	35 (31-90.5)	32 (23-43)	0.049^a
Elevated GGT⁴	33 (34.7)	23 (34.8)	10 (34.5)	1.000	9 (60)	24 (30)	0.038^a	7 (46.7)	26 (32.5)	0.377
Total cholesterol (mg/dL), mean ± SD	194.3 ± 36	192.3 ± 34	199.2 ± 40.6	0.445	182 ± 40.2	197.6 ± 34.9	0.206	188.3 ± 41.2	195.5 ± 35	0.534
HDL (mg/dL), median (IQR)	43 (39-50)	43.5 (40–51.5)	41 (38.5-49)	0.431	42 (39.5-45.5)	44 (39.2-52.5)	0.480	42 (40-45.5)	44 (39-51.8)	0.442
LDL (mg/dL), mean ± SD	118.7 ± 33.2	116.5 ± 31.5	124 ± 37	0.357	102.5 ± 36	122.8 ± 31.9	0.068	110.2 ± 37	120.3 ± 32.4	0.334
Triglycerides (mg/dL), median (IQR)	146.5 (110.2-182.2)	148.5 (112.5-186)	139.5 (108.5-170.5)	0.565	176 (154-225)	142 (107-175)	0.043^a	164 (139-209)	142 (104.5-177)	0.066
Platelet (count × 10⁹/mm³), mean ± SD	228 ± 60.6	278.8 ± 58.9	275.9 ± 65.9	0.847	256.2 ± 52.9	282.2 ± 61.5	0.117	248.2 ± 36.3	283.3 ± 62.7	0.009^a
Glucose (mg/dL), median (IQR)	99 (90-113)	100 (91-120)	97.6 (83.5-105.5)	0.046^a	114 (100.5-153.5)	98 (90-107)	0.004^a	114 (99-163)	98 (90-107)	0.015^a
HbA1c, median (IQR)	5.7 (5.4-6.1)	5.8 (5.4-6.2)	5.5 (5.3-5.8)	0.054	6 (5.8-7.6)	5.6 (5.4-6)	0.009^a	6.1 (5.7-7.1)	5.6 (5.4-6.0)	0.021^a
Insulin (μUI/mL), median (IQR)	19.3 (12-27.4)	20.2 (13.8-27.4)	14 (9.7-21.5)	0.031^a	22.2 (15.7-28)	17 (11.5-26.8)	0.102	22.6 (15.1-28)	19 (11.5-26.8)	0.253
Creatinine (mg/dL), median (IQR)	0.8 (0.7-0.9)	0.8 (0.7-0.8)	0.8 (0.7-0.9)	0.233	0.8 (0.7-0.8)	0.8 (0.7-0.9)	0.675	0.8 (0.7-0.8)	0.8 (0.7-0.9)	0.955
HOMA-IR, median (IQR)	4.5 (2.8-7.6)	5.4 (3.5-8)	2.8 (2.3-5.6)	0.008^a	6.5 (5.3-8.5)	4.2 (2.6-7.5)	0.013^a	6.6 (4-9.7)	4.4 (2.7-7.5)	0.054
Urea (mg/dL), median (IQR)	29 (24-35)	30 (25-36)	27 (24-31)	0.134	27 (22.5-32)	29 (25-35)	0.415	30 (23.5-35)	29 (24-35)	0.924
Albumin (g/dL), mean ± SD	4.2 ± 0.3	4.2 ± 0.4	4.3 ± 0.3	0.039^a	4.3 ± 0.3	4.2 ± 0.3	0.108	4.3 ± 0.2	4.2 ± 0.4	0.402
NAS Score, median (IQR)	1 (0-3)	3 (1-4)	0 (0-0)	< 0.001^a	6 (4.5-7)	1 (0-2)	< 0.001^a	6 (5-7)	1 (0-2)	< 0.001^a
Steatosis on biopsy	66 (69.5)	66 (100)	0 (0)	< 0.001^a	15 (100)	51 (63.8)	0.004^a	15 (100)	51 (63.8)	0.004^a
Moderate/severe steatosis	15 (15.8)	15 (22.7)	0 (0)	0.004^a	15 (100)	0 (0)	< 0.001^a	11 (73.3)	4 (5)	< 0.001^a
NASH on biopsy	15 (15.8)	15 (22.7)	0 (0)	0.004^a	11 (73.3)	4 (5)	< 0.001^a	15 (100)	0 (0)	< 0.001^a
Fibrosis on biopsy	10 (10.5)	8 (12.1)	2 (6.9)	0.718	6 (40)	4 (5)	0.001^a	8 (53.3)	2 (2.5)	< 0.001^a
Significant fibrosis	3 (3.7)	3 (4.5)	0 (0)	0.551	2 (13.3)	1 (1.2)	0.064	3 (20)	0 (0)	0.003^a
Advanced fibrosis	2 (2.1)	2 (3)	0 (0)	1.000	1 (6.7)	1 (1.2)	0.292	2 (13.3)	0 (0)	0.024^a
NLFS, median (IQR)	1.07 (-0.53-2.72)	1.47 (0.06-3.50)	-0.16 (-0.76-1.81)	0.007^a	2.47 (0.88-4.31)	0.89 (-0.55-2.44)	0.036^a	2.70 (0.88-4.31)	0.89 (-0.55-2.37)	0.078
Any steatosis	75 (79)	55 (83.3)	20 (67)	0.170	13 (86.7)	62 (77.5)	0.730	12 (80)	63 (78.7)	1.000
Moderate/severe steatosis	62 (65.3)	49 (74.2)	13 (44.8)	0.009^a	12 (80)	50 (62.5)	0.246	12 (80)	50 (62.5)	0.359
HSI, median (IQR)	55.05 (51.43-57.99)	55.10 (51.90-58.02)	54.89 (50.08-57.91)	0.542	57.2 (54.47-59.27)	54.7 (50.92-57.37)	0.052	57.1 (54.47-58.51)	54.7 (51.21-57.95)	0.127
Presence of steatosis	95 (100)	66 (100)	29 (100)	1.000	15 (100)	80 (100)	1.000	15 (100)	80 (100)	1.000
FLI, median (IQR)	99 (97-99)	99 (97-99)	99 (97-99)	0.607	99 (99-99.5)	98.5 (97-99)	0.010^a	99 (98.5-99)	98 (97-99)	0.074
Presence of steatosis	95 (100)	66 (100)	29 (100)	1.000	15 (100)	80 (100)	1.000	15 (100)	80 (100)	1.000

^aP ≤ 0.05.

¹Determined by histopathology.

²AST higher than 40 U/L for men and higher than 35 U/L for women.

³ALT higher than 55 U/L for men and higher than 45 U/L for women.

⁴GGT higher than 70 U/L for men and higher than 45 U/L for women.

ALT: Alanine transaminase; AST: Aspartate aminotransferase; BMI: Body mass index; FLI: Fatty liver index; GGT: Gamma-glutamyl transferase; HbA1c: Hemoglobin A1c; HDL: High-density lipoprotein; HOMA-IR: Homeostatic Model Assessment for Insulin Resistance; HSI: Hepatic steatosis index; IQR: Interquartile range; LDL: Low-density lipoprotein; NAS: Non-alcoholic fatty liver disease activity score; NASH: Non-alcoholic steatohepatitis; NLFS: Non-alcoholic fatty liver disease liver fat score; T2DM: Type 2 diabetes mellitus; WC: Weight circumference.

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Table 2 Results of the clinical scores for evaluating each histopathological condition

Score	AUROC (95%CI)	Cut-off	Se (95%CI)¹	Sp (95%CI)¹	PPV (95%CI)¹	NPV (95%CI)¹	+LR (95%CI)	-LR (95%CI)
Any steatosis
NLFS	0.676 (0.563-0.790)	-0.64	83% (72-91)	31% (15-51)	73% (62-83)	45% (23-68)	1.21 (0.93-1.58)	0.54 (0.25-1.15)
NLFS	0.676 (0.563-0.790)	0.253	74% (62-84)	59% (39-76)	80% (68-89)	50% (32-68)	1.79 (1.14-2.83)	0.44 (0.26-0.73)
HSI	0.540 (0.406-0.674)	36	100% (95-100)	0% (0-12)	69% (59-79)	NA (0-100)	1.00 (1.00-1.00)	NA (NA-NA)
HSI	0.540 (0.406-0.674)	53.4	68% (56-79)	48% (29-67)	75% (62-85)	40% (24-58)	1.32 (0.89-1.94)	0.66 (0.39-1.10)
FLI	0.468 (0.348-0.588)	60	100% (95-100)	0% (0-12)	69% (59-79)	NA (0-100)	1.00 (1.00-1.00)	NA (NA-NA)
FLI	0.468 (0.348-0.588)	99.5	12% (5-22)	93% (76-99)	73% (39-94)	31% (21-42)	1.17 (0.33-4.10)	0.98 (0.84-1.14)
Moderate-to-severe steatosis
NLFS	0.671 (0.542-0.822)	0.16	80% (52-96)	38% (27-49)	19% (10-31)	91% (76-98)	1.28 (0.94-1.74)	0.53 (0.19-1.53)
NLFS	0.671 (0.542-0.822)	1.83	67% (38-88)	66% (55-76)	27% (14-44)	91% (81-97)	1.98 (1.23-3.17)	0.50 (0.24-1.05)
HSI	0.659 (0.522-0.796)	36	100% (78-100)	0% (0-5)	16% (9-25)	NA (0-0)	1.00 (1.00-1.00)	NA (NA-NA)
HSI	0.659 (0.522-0.796)	57	60% (32-84)	72% (61-82)	29% (14-48)	91% (81-96)	2.18 (1.26-3.76)	0.55 (0.29-1.04)
FLI	0.700 (0.574-0.825)	60	100% (78-100)	0% (0-5)	16% (9-25)	NA (0-100)	1.00 (1.00-1.00)	NA (NA-NA)
FLI	0.700 (0.574-0.825)	98.5	80% (52-96)	51% (39-62)	23% (13-37)	93% (81-99)	1.60 (1.14-2.24)	0.40 (0.14-1.13)
MASH
NLFS	0.671 (0.507-0.836)	-0.64	80% (52-96)	21% (13-32)	16% (9-26)	85 (62-97)	1.02 (0.77-1.34)	0.94 (0.31-2.82)
		0.16	80% (52-96)	38% (27-49)	19% (10-31)	91% (76-98)	1.28 (0.94-1.74)	0.53 (0.19-1.53)
		2.43	67% (38-88)	78% (67-86)	36% (19-56)	93% (83-98)	2.96 (1.72-5.09)	0.43 (0.21-0.98)
HSI	0.625 (0.482-0.768)	36	100% (78-100)	0% (0-5)	16% (9-25)	NA (0-100)	1.00 (1.00-1.00)	NA (NA-NA)
HSI	0.625 (0.482-0.768)	56.2	60% (32-84)	65% (54-75)	24% (12-41)	90% (79-96)	1.71 (1.03-2.85)	0.62 (0.32-1.17)
FLI	0.639 (0.502-0.776)	60	100% (78-100)	0% (0-5)	16% (9-25)	NA (0-100)	1.00 (1.00-1.00)	NA (NA-NA)
FLI	0.639 (0.502-0.776)	98.5	73% (45-92)	49% (37-60)	21% (11-35)	91% (78-97)	1.43 (0.99-2.08)	0.55 (0.23-1.30)

¹Values presented as percentages.

AUROC: Area under the receiver operating characteristic curve; CI: Confidence interval; FLI: Fatty liver index; HSI: Hepatic steatosis index; +LR: Positive likelihood ratio; -LR: Negative likelihood ratio; MASH: Metabolic dysfunction-associated steatohepatitis; NA: Not available; NLFS: Non-alcoholic fatty liver disease liver fat score; NPV: Negative predictive value; PPV: Positive predictive value; Se: Sensitivity; Sp: Specificity.

Full Size Table

Table 3 Comparison of the area under the receiver operating characteristic curve results with DeLong test

Pairwise comparison	Any steatosis			Moderate-to-severe steatosis			MASH
Pairwise comparison	AUROC 1	AUROC 2	P value¹	AUROC 1	AUROC 2	P value¹	AUROC 1	AUROC 2	P value¹
NLFS vs HSI	0.676	0.540	0.148	0.671	0.659	0.895	0.671	0.625	0.823
NLFS vs FLI	0.676	0.468	0.021^a	0.671	0.700	0.895	0.671	0.639	0.823
HSI vs FLI	0.540	0.468	0.349	0.659	0.700	0.895	0.625	0.639	0.823

^aP ≤ 0.05.

¹Calculated by DeLong test and correct for multiple comparisons using the Hochberg method.

AUROC: Area under the receiver operating curve; FLI: Fatty liver index; HSI: Hepatic steatosis index; MASH: Metabolic dysfunction-associated liver disease; NLFS: Non-alcoholic fatty liver disease liver fat score.

Full Size Table

Table 4 Odds ratios and interaction effects between clinical scores and metabolic syndrome for predicting steatosis and metabolic dysfunction-associated liver disease

Score	Variable	OR	95%CI	P value
Any steatosis
NLFS	Score	1.15	0.93-1.70	0.353
	MetS	0.88	0.31-2.41	0.809
	Score-MetS interaction	1.24	0.78-1.85	0.295
HSI	Score	0.99	0.09-1.20	0.896
	MetS	< 0.01	< 0.01- > 100	0.904
	Score-MetS interaction	1.00	0.80-1.24	0.966
FLI	Score	0.75	0.42	0.239
	MetS	< 0.01	< 0.01- > 100	0.462
	Score-MetS interaction	1.29	0.67-2.66	0.452
Moderate-to-severe steatosis
NLFS	Score	0.93	0.40-1.22	0.780
	MetS	1.85	0.38-13.63	0.479
	Score-MetS interaction	1.35	0.95-3.25	0.266
HSI	Score	0.87	0.54-1.28	0.518
	MetS	< 0.01	< 0.01- > 100	0.400
	Score-MetS interaction	1.22	0.82-2.00	0.354
FLI	Score	1.63	0.66-10.99	0.471
	MetS	< 0.01	< 0.01- > 100	0.718
	Score-MetS interaction	1.34	0.18-4.84	0.710
MASH
NLFS	Score	1.06	0.87-1.22	0.478
	MetS	0.77	0.20-3.25	0.715
	Score-MetS interaction	1.14	0.90-1.48	0.279
HSI	Score	0.93	0.069-1.20	0.584
	MetS	< 0.01	< 0.01- > 100	0.329
	Score-MetS interaction	0.15	0.87-1.56	0.325
FLI	Score	1.17	0.71-2.93	0.589
	MetS	< 0.01	< 0.01- > 100	0.462
	Score-MetS interaction	1.45	0.48-3.84	0.463

CI: Confidence interval; FLI: Fatty liver index; HSI: Hepatic steatosis index; MASH: Metabolic dysfunction-associated liver disease; MetS: Metabolic syndrome; NLFS: Non-alcoholic fatty liver disease liver fat score; OR: Odds ratio.

Full Size Table

Citation: Farina GS, Brambilla B, Pandolfo EM, Lazzaretti LKN, Kuiava SMS, Graciolli AM, Kriger VM, Fistarol CHDB, Sgarioni AC, Giovanardi HP, Tregnago AC, Riva F, Scholze CDS, Agostini DC, Dellamea B, Tamayo A, Cerqueira TL, Soldera J, Illigens BMW. Performance of three clinical scores for steatosis and steatohepatitis and their interaction with metabolic syndrome in obese individuals. World J Hepatol 2026; 18(2): 111962
URL: https://www.wjgnet.com/1948-5182/full/v18/i2/111962.htm
DOI: https://dx.doi.org/10.4254/wjh.v18.i2.111962

Farina GS, Brambilla B, Pandolfo EM, Lazzaretti LKN, Kuiava SMS, Graciolli AM, Kriger VM, Fistarol CHDB, Sgarioni AC, Giovanardi HP, Tregnago AC, Riva F, Scholze CDS, Agostini DC, Dellamea B, Tamayo A, Cerqueira TL, Soldera J, Illigens BMW. Performance of three clinical scores for steatosis and steatohepatitis and their interaction with metabolic syndrome in obese individuals. World J Hepatol 2026; 18(2): 111962 [DOI: 10.4254/wjh.v18.i2.111962]

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