Key points
- Population screening is not recommended. Case-finding in high-risk groups is.
- Top groups: type 2 diabetes, obesity with metabolic risk factors, and raised liver enzymes or steatosis on imaging.
- The aim is to find fibrosis, not just fat. Start with FIB-4.
- Normal ALT does not exclude advanced fibrosis.
For the evidence, graded recommendations, a case and self-test questions, read Module 1: Assessing liver fibrosis in MASLD.
1High-risk groups to check
- Type 2 diabetes or prediabetes.
- Abdominal obesity with at least one other metabolic risk factor.
- Persistently raised ALT or AST.
- Steatosis found by chance on ultrasound or CT.
- First-degree relative with cirrhosis from MASLD.
- Moderate alcohol intake on top of metabolic risk (MetALD).
2Where to do it
FIB-4 needs only age, AST, ALT and platelets, so it fits primary care, diabetes clinics and obesity services. Building it into lab reports or the electronic record raises testing rates.
3Steatosis alone is not the target
Fibrosis stage, not the amount of fat, predicts liver events and death. Ultrasound shows fat but cannot stage fibrosis.
Related topics
References
- EASL–EASD–EASO Clinical Practice Guidelines on the management of MASLD. J Hepatol 2024;81:492–542. doi:10.1016/j.jhep.2024.04.031
- Rinella ME, et al. AASLD Practice Guidance on the clinical assessment and management of NAFLD. Hepatology 2023;77:1797–835. doi:10.1097/HEP.0000000000000323
- Kanwal F, et al. Clinical care pathway for the risk stratification and management of patients with NAFLD (AGA). Gastroenterology 2021;161:1657–69. doi:10.1053/j.gastro.2021.07.049
- Cusi K, et al. AACE clinical practice guideline for the diagnosis and management of NAFLD in primary care and endocrinology clinical settings. Endocr Pract 2022;28:528–62. doi:10.1016/j.eprac.2022.03.010
- Abaalkhail F, et al. MASLD management in Saudi Arabia: a modified Delphi-based adaptation of international standards. Saudi J Gastroenterol 2026;32(2):104–20. doi:10.4103/sjg.sjg_199_25
How to cite this page
Desoky M. Who to test for liver fibrosis. Metabolic Liver Academy quick reference, version 1.0. Updated 2026-10-03. Available from: https://drmahmouddesoky.github.io/metabolic-liver-academy/ref/case-finding.html
A summary of published guidelines for healthcare professionals. It does not replace clinical judgement, the full guidelines or local drug labels. Disclaimer.