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

Table 1 Inclusion and exclusion criteria

Criterion	Inclusion	Exclusion
Population	Children and adolescents (≤ 18 years) with obesity, NAFLD/MASLD, or metabolic conditions	Adults (>18 years); studies without separate pediatric data
Study design	Observational studies (cross-sectional, cohort, case-control)	Case reports, reviews, editorials, letters, conference abstracts
Intervention/exposure	Ultrasound-based elastography: TE, pSWE, 2D-SWE	Non-elastography imaging (e.g., MRI, CT), invasive biopsy-only studies
Comparator	Validated insulin resistance measures (HOMA-IR, clamp test, fasting indices)	Studies without insulin resistance measures
Outcomes	Correlation, diagnostic accuracy (AUROC, sensitivity, specificity), regression associations	Studies not reporting the elastography-insulin resistance relationship
Language	English	Non-English
Publication year	2000-October 2025	Outside range

NAFLD: Non-alcoholic fatty liver disease; MASLD: Metabolic dysfunction-associated steatotic liver disease; TE: Transient elastography; pSWE: Point shear wave elastography; SWE: Shear wave elastography; MRI: Magnetic resonance imaging; CT: Computed tomography; HOMA-IR: Homeostatic model assessment of insulin resistance; AUROC: Area under the receiver operating curve.

Table 2 Characteristics of pediatric studies evaluating the correlation between elastography measures and insulin resistance metrics

Ref.	Country	Population characteristics	Age	n (total)	Elastography modality	Devise/probe	Elastography measure	IR metric	Correlation (r)	Covariate adjustments
Giannouli et al[10], 2023	Greece	Adolescent females with PCOS (47), control (40)	12.3-20.4	87	TE	Fibroscan device	LFS, FLI, LAP, LSM, HSI, (stiffness)	HOMA-IR	0.61	PCOS status, LFS, FAI
D'Hondt et al[11], 2021	Belgium	Obese, liver fat quantification	7-17	48	MRI PDFF, SWE, QUS	EPIQ-7G	Attenuation	HOMA-IR	0.48	None reported
Ferraioli et al[12], 2017	Italy	Control (106), overweight (100)/obese (99)	4.1-17.4	305	TE	FibroScan 502 Touch device	CAP (attenuation)	HOMA-IR	0.54	BMI, FLI, HSI
Lefere et al[13], 2025	United States, (multi-center)	MASLD cohort	8-18	327	TE	FibroScan 502 Touch	CAP (attenuation)	Fasting glucose	0.5	pFIB score, ethnicity
Song et al[14], 2025	South Korea	NHANES cohort	12-18	260	TE	FibroScan model 502 V2 Touch	CAP	METS-IR	0.49	BMI, waist circumference
Tas et al[15], 2024	United States	Youth with obesity (72%), control (28%)	14.1-17.2	114	MRI and TE	FibroScan	CAP (attenuation)	HOMA-IR	0.30	Obesity status
Arsoy et al[16], 2024	Turkey	Obese (53%), suspected NAFLD	9-18	95 patients, and 116 control	Vibration-controlled TE	Hitachi Hi-Vision Preirus device	CAP and LSM	HOMA-IR	0.45	Age, BMI
Ata et al[17], 2023	Egypt	Obese/overweight children and adolescents with NAFLD	6-16	60	TE	FibroScan-502 echosen-France-M, XL probs- CAP enabled	LSM and CAP	HOMA-IR	0.32	None reported
Brunnert et al[18], 2022	Germany	General pediatric, population-based	10-18	482	TE	M or XL probe	LSM and CAP	HOMA-IR	0.35	Age, sex, puberty
Heldens et al[19], 2024	Belgium	Severe obesity (56% had steatosis)	9-16	200	TE	FibroScan Mini+ 430 with M and XL probe and LogiQ S7 device with a C1-6-D probe	LSM and CAP	Adipo-IR and HOMA-IR	0.65	Lifestyle intervention
Kwon et al[20], 2019	South Korea	NAFLD/NASH	5-15	106	TE	FibroScan® device	LSM and CAP	HOMA-IR	0.42	Fibrosis stage
Rose et al[21], 2023	South Africa	Healthy controls	7.9-17.7	104	TE	FibroScan with standard M probe	LSM and CAP	Fasting glucose	0.25	Age, BMI
Bailey et al[22], 2017	United States	Obese (59%) and controls	0.06-18.9	300	SWE	IU-22 ElastPQ system	SWV (stiffness)	Fasting insulin	0.51	Age, sex
Çakır and Acunaş[23], 2025	Turkey	NAFLD (31) and controls (12)	7-16	43	ARFI	Siemens ACUSON S3000™	SWV (stiffness)	HOMA-IR	0.55	BMI, height, liver craniocaudal length
Karaman et al[24], 2022	Turkey	Obese/overweight (131), MetS, control (50)	6.2-18.9	181	SWE	Siemens Acuson S3000 using a 6C1 transducer	SWV	HOMA-IR	0.2	MetS status
Pawar et al[25], 2016	India	Overweight/obese	11-15	660	SWE	Fibroscan 3.5 MHz Probe	SWV	HOMA-IR	0.37	BMI

Correlation (r): The strength of the linear relationship between the elastography measure and the insulin resistance metric, with a value closer to 1 or -1 indicating a stronger correlation; IR Metric: The measure of insulin resistance used in the study (e.g., homeostatic model assessment for insulin resistance, adipose tissue insulin resistance, fasting insulin, metabolic score for insulin resistance); PCOS: Polycystic ovary syndrome; TE: Transient elastography, a modality often using a FibroScan device; LFS: Liver fat score; FLI: Fatty liver index; LAP: Lipid accumulation product, LSM: Liver stiffness measurement; an output from transient elastography, typically used to assess liver fibrosis (stiffness); HSI: Hepatic steatosis index; HOMA-IR: Homeostatic model assessment for insulin resistance; calculated as the product of fasting insulin (mIU/L) × glucose (mg/dL)/405; FAI: Free androgen index; MRI PDFF: Magnetic resonance imaging-proton density fat fraction; SWE: Shear wave elastography, a modality often incorporated into standard ultrasound machines; QUS: Quantitative ultrasound, a modality that can measure attenuation (for steatosis); CAP: Controlled attenuation parameter; an output from transient elastography, typically used to assess liver steatosis (fat content/attenuation); BMI: Body mass index; MASLD: Metabolic dysfunction-associated steatotic liver disease; pFIB score: Pediatric fibrosis score; NHANES: National Health and Nutrition Examination Survey; METS-IR: Metabolic score for insulin resistance; NAFLD: Non-alcoholic fatty liver disease; Adipo-IR: Adipose tissue insulin resistance, calculated as fasting insulin (mIU/L) × free fatty acids (mmol/L); NASH: Non-alcoholic steatohepatitis; SWV: Shear wave velocity, the measure for stiffness; ARFI: Acoustic radiation force impulse, another ultrasound-based elastography method; MetS: Metabolic syndrome.

Table 3 Different methods used to assess insulin resistance in pediatric populations

IR measure	Primary physiological focus	Required inputs	Advantages	Limitations in pediatrics
HOMA-IR	Hepatic IR	Fasting glucose, fasting insulin	Simple, widely used, validated in adults	Overestimates IR during puberty; sensitive to fasting variations; poor reflection of adipose/muscle IR
QUICKI	Peripheral IR	Fasting glucose, fasting insulin	Good for detecting insulin sensitivity changes	Less reliable at extremes of glucose or insulin; limited pediatric validation
Adipo-IR	Adipose lipolysis and FFA flux	Fasting insulin × fasting free fatty acids	Directly reflects adipose dysfunction; links metabolic overflow to hepatic injury	Requires FFA measurement; less available in clinical labs
METS-IR	Systemic metabolic IR	Glucose, triglycerides, HDL-C, BMI (or waist circumference)	Integrates multiple metabolic risk factors; correlates with both CAP and LSM	Newer index; pediatric reference ranges still being standardized
Clamp techniques (e.g., hyperinsulinemic-euglycemic clamp)	Gold standard for IR quantification	Dynamic insulin-glucose infusion study	Direct measure of insulin sensitivity	Invasive, costly, impractical in pediatric studies

HOMA-IR: Homeostatic model assessment for insulin resistance; IR: Insulin resistance; QUICKI: Quantitative insulin sensitivity check index; Adipo-IR: Adipose tissue insulin resistance index; FFA: Free fatty acid; METS-IR: Metabolic score for insulin resistance; HDL-C: High-density lipoprotein cholesterol; BMI: Body mass index; CAP: Controlled attenuation parameter; LSM: Liver stiffness measurement.

Table 4 Comparative overview of controlled attenuation parameter, liver stiffness measurement, and shear wave elastography

Feature	CAP	LSM-transient elastography)	SWE/ARFI
Biological target	Hepatic fat accumulation (steatosis)	Fibrosis, inflammation, and parenchymal stiffness	Fibrosis and parenchymal elasticity distribution
Primary determinant	Fat-induced ultrasound attenuation	Shear-wave propagation velocity (mechanical vibration)	Acoustic radiation force impulse-induced shear-wave velocity
Measurement unit	dB/m	kPa	m/second (or converted to kPa)
1Correlation with insulin resistance	Moderate (r approximately 0.30-0.40)	Strong (r approximately 0.50-0.65)	Strong (r approximately 0.45-0.60)
Best correlated IR index	HOMA-IR, fasting insulin	Adipo-IR, METS-IR	Adipo-IR, METS-IR
Clinical role	Early detection and metabolic risk screening	Disease staging and progression monitoring	Quantitative fibrosis mapping with spatial visualization
Affected by	Obesity, hepatic heterogeneity	Inflammation, postprandial state	Depth of measurement, acoustic window, probe alignment
Main advantage	Sensitive to early metabolic derangements	Well validated for fibrosis; rapid and reproducible	Provides 2D stiffness map; higher spatial resolution; real-time visualization
Main limitation	Limited fibrosis prediction	Limited assessment of steatosis	Operator-dependent; affected by motion and depth artifacts
Optimal use	Screening and monitoring of steatosis regression	Prognostic follow-up and fibrosis surveillance	Advanced fibrosis characterization and research applications in heterogeneous tissues

¹The correlation coefficients (r) presented are the representative ranges reported across the studies included in this systematic review, not the single pooled estimate from the meta-analysis. The ranges are provided to illustrate the typical strength of the relationship observed in the pediatric literature for each elastography modality.

CAP: Controlled attenuation parameter; LSM: Liver stiffness measurement; SWE: Shear wave elastography; ARFI: Acoustic radiation force impulse; IR: Insulin resistance; HOMA-IR: Homeostatic model assessment of insulin resistance; Adipo-IR: Adipose tissue insulin resistance index; METS-IR: Metabolic score for insulin resistance.