In metabolic dysfunction-associated steatotic liver disease, fibrosis stage — not the amount of fat — predicts liver outcomes. The usual first step is FIB-4, calculated from age, AST, ALT and platelets. A low score makes advanced fibrosis unlikely and can be repeated every one to three years. An indeterminate or high score should lead to vibration-controlled transient elastography or an enhanced liver fibrosis test.
FIB-4 is less reliable under 35 and over 65; age-adjusted cut-offs, or going straight to elastography, help in those groups.
- Calculate FIB-4 in every adult with steatotic liver disease and metabolic risk factors.
- A low FIB-4 makes advanced fibrosis unlikely; repeat it periodically.
- Refer indeterminate or high FIB-4 results for elastography or an ELF test.
- Interpret FIB-4 cautiously under 35 and over 65.
- Address weight, diabetes and alcohol in every patient, whatever the fibrosis stage.
Why it matters
Drug treatment for MASH is aimed at patients with significant fibrosis, so staging decides who is a candidate.
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