Most people with metabolic dysfunction-associated steatotic liver disease will never progress, so the task is to find the few with advanced fibrosis who need specialist care and surveillance, without biopsying everyone.
Start with FIB-4, a simple score from age, AST, ALT and platelet count. A low FIB-4 (below about 1.3) has a high negative predictive value and allows reassurance and primary-care follow-up. An indeterminate or high score (above about 1.3, and especially above 2.67) should prompt a second-line test such as transient elastography or an enhanced liver fibrosis blood test, and referral to hepatology where advanced fibrosis is likely. Remember FIB-4 performs less well in those under 35 or over 65, where thresholds need adjustment.
The habit worth keeping is to risk-stratify MASLD with FIB-4 before imaging or referral, concentrating specialist resources and HCC surveillance on those with likely advanced fibrosis.
- Use FIB-4 (age, AST, ALT, platelets) as the first step to stage fibrosis in MASLD.
- A FIB-4 below about 1.3 has high negative predictive value and allows primary-care follow-up.
- A FIB-4 above about 1.3, especially above 2.67, warrants elastography and hepatology referral.
- FIB-4 is less reliable under 35 or over 65, where thresholds need adjusting.
- Reserve specialist care and HCC surveillance for those with likely advanced fibrosis.
Why it matters
It directs limited specialist and surveillance resources to the minority with advanced fibrosis who actually need them.
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