Ultrasound hepatic elastography: A non-invasive indicator of insulin resistance in the pediatric population: A systematic review

doi:10.5409/wjcp.v15.i2.115963

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Jun 9, 2026 (publication date) through May 16, 2026

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World Journal of Clinical Pediatrics

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2219-2808

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Baishideng Publishing Group Inc, 7041 Koll Center Parkway, Suite 160, Pleasanton, CA 94566, USA

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Copyright: ©Author(s) 2026. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution-NonCommercial (CC BY-NC 4.0) license. No commercial re-use. See permissions. Published by Baishideng Publishing Group Inc.

World J Clin Pediatr. Jun 9, 2026; 15(2): 115963
Published online Jun 9, 2026. doi: 10.5409/wjcp.v15.i2.115963

Ultrasound hepatic elastography: A non-invasive indicator of insulin resistance in the pediatric population: A systematic review

Reem M Elbeltagi, Nermin K Saeed, Adel S Bediwy, Mohammed Al-Beltagi

Reem M Elbeltagi, Department of Medicine, Royal College of Surgeons in Ireland - Medical University of Bahrain, Busaiteen 15503, Muharraq, Bahrain

Nermin K Saeed, Medical Microbiology Section, Department of Pathology, Salmaniya Medical Complex, Governmental Hospitals, Ministry of Health, Manama 12, Bahrain

Nermin K Saeed, Medical Microbiology Section, Pathology Department, Royal College of Surgeons in Ireland - Medical University of Bahrain, Busaiteen 15503, Muharraq, Bahrain

Adel S Bediwy, Department of Pulmonology, Faculty of Medicine, Tanta University, Tanta 31527, Alghrabia, Egypt

Adel S Bediwy, Department of Pulmonology, University Hospital, Arabian Gulf University, Manama 26671, Bahrain

Mohammed Al-Beltagi, Department of Pediatrics, Faculty of Medicine, Tanta University, Tanta 31511, Algharbia, Egypt

Mohammed Al-Beltagi, Department of Pediatrics, University Hospital, Arabian Gulf University, Manama 26671, Bahrain

Co-first authors: Reem M Elbeltagi and Nermin K Saeed.

Author contributions: Elbeltagi RM was the primary investigator to conceptualized and designed the study, developed the search strategy and methodology, conducted the primary literature search and data extraction, performed the formal statistical analysis, and drafted the initial manuscript; Saeed NK contributed to refining the systematic review methodology and ensuring the rigor of data validation, critically reviewed the manuscript drafts, and provided intellectual input on data quality assessment; Elbeltagi RM and Saeed NK contributed equally to this manuscript as co-first authors; Bediwy AS provided specialized intellectual contributions during the design and interpretation phases, particularly advising on the clinical relevance of the findings and reviewing associated comorbidities, and critically revised the manuscript for important intellectual content; Al-Beltagi M served as the overall principal investigator and supervisor for the project, validated the study design and statistical analysis, provided expert pediatric and clinical interpretation of the final results, and conducted the final critical revision of the manuscript prior to submission. All authors reviewed and approved the final version of the manuscript and agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the study are appropriately investigated and resolved.

AI contribution statement: AI tools (Grammarly) were used solely for linguistic refinement and formatting assistance. No AI tool was involved in the generation of research data, interpretation of results, or formulation of conclusions. All AI-generated outputs were critically reviewed and revised by the authors.

Conflict-of-interest statement: All the authors report no relevant conflicts of interest for this article.

PRISMA 2009 Checklist statement: The authors have read the PRISMA 2009 Checklist, and the manuscript was prepared and revised according to the PRISMA 2009 Checklist.

Corresponding author: Mohammed Al-Beltagi, MD, PhD, Professor, Senior Researcher, Department of Pediatrics, Faculty of Medicine, Tanta University, 1 Hassan Radwan Street, Tanta 31511, Algharbia, Egypt. mohamed.elbeltagi@med.tanta.edu.eg

Received: October 30, 2025
Revised: December 3, 2025
Accepted: February 5, 2026
Published online: June 9, 2026
Processing time: 195 Days and 21.9 Hours

Abstract

BACKGROUND

Insulin resistance (IR) plays a pivotal role in the pathogenesis of metabolic dysfunction-associated steatotic liver disease. While non-invasive imaging methods are increasingly used in pediatrics, the extent to which hepatic elastography reflects IR in children remains unclear.

AIM

To evaluate the association between ultrasound-based hepatic elastography parameters and clinical indices of IR in the pediatric population.

METHODS

A systematic search of PubMed, Scopus, and Web of Science databases was conducted through October 2025. Studies assessing correlations between elastography parameters - controlled attenuation parameter (CAP) and liver stiffness measurement (LSM) - and IR indices were included. Data were pooled using random-effects meta-analysis with correlation coefficients (r) as the primary effect size. Subgroup and sensitivity analyses examined differences by IR index, cohort characteristics, and elastography modality.

RESULTS

Sixteen studies, encompassing 2,032 children and adolescents, were included. The pooled correlation between hepatic elastography (CAP/LSM) and IR indices was r = 0.44 (95% confidence interval: 0.38-0.50; I² = 72%), indicating a moderate positive association. The strongest correlations were observed for adipose tissue IR (r = 0.65) and the metabolic score for IR (r = 0.49), surpassing simpler indices such as homeostatic model assessment of IR. CAP correlated moderately with early steatosis (r = 0.30-0.40), whereas LSM showed stronger associations with advanced fibrosis and systemic IR (r = 0.50-0.65). Heterogeneity was mainly attributed to differences in disease severity and measurement methods.

CONCLUSION

Ultrasound-based hepatic elastography provides a reliable, non-invasive surrogate for systemic metabolic dysfunction in pediatric metabolic dysfunction-associated steatotic liver disease. CAP reflects early, reversible hepatic fat accumulation, while LSM reflects more advanced fibrosis and systemic IR, and identifies fibrotic progression driven by chronic IR. The strongest associations with adipose tissue-IR and metabolic score-IR highlight the systemic, multisite nature of pediatric IR. Elastography thus holds promise as an integrated biomarker for IR severity, early risk stratification, and therapeutic monitoring in children and adolescents with metabolic risk factors.

Keywords: Pediatric metabolic dysfunction-associated steatotic liver disease; Insulin resistance; Liver stiffness measurement; Controlled attenuation parameter; Transient elastography; Metabolic syndrome; Non-invasive biomarkers

Core Tip: This systematic review and meta-analysis highlight that ultrasound-based hepatic elastography, through liver stiffness measurement and controlled attenuation parameter, provides a reliable, non-invasive reflection of insulin resistance (IR) in children and adolescents with metabolic dysfunction-associated steatotic liver disease. Controlled attenuation parameter effectively identifies early hepatic fat accumulation, while liver stiffness measurement detects fibrotic progression linked to chronic IR. The strongest correlations with adipose tissue IR and metabolic score-IR emphasize that elastography captures systemic metabolic dysfunction beyond the liver. These findings support its integration into pediatric screening and monitoring to guide early intervention and prevention of IR and steatotic liver disease.