Most people with MASLD will never develop advanced liver disease; the task is finding the minority who might. The widely used first step is the FIB-4 index, calculated from age, AST, ALT and platelet count. A FIB-4 below 1.3 makes advanced fibrosis unlikely and supports management in primary care with repeat assessment every few years.
A value of 1.3 or more should lead to a second test, usually transient elastography, before referral. FIB-4 is less reliable under 35 and tends to over-call risk over 65, where a higher threshold of 2.0 is often used.
- Calculate FIB-4 for every patient with MASLD.
- Below 1.3, manage risk factors and repeat assessment periodically.
- At 1.3 or above, arrange elastography before referring.
- Interpret FIB-4 cautiously under 35 and use a higher threshold over 65.
Why it matters
It is the gateway to the newer MASH treatments, which are for significant fibrosis only.
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