Key points
- Step 1: FIB-4. Below 1.3 (below 2.0 if aged 65+) = low risk.
- Step 2: liver stiffness (VCTE) or ELF if FIB-4 is 1.3 or more.
- LSM below 8 kPa = low risk. 8–12 = indeterminate. 12 or more = high risk: refer to hepatology.
- FIB-4 is not reliable under age 35.
For the evidence, graded recommendations, a case and self-test questions, read Module 1: Assessing liver fibrosis in MASLD.
1Step 1: FIB-4
FIB-4 = (age × AST) ÷ (platelets [10⁹/L] × √ALT).
| FIB-4 | Meaning | Action |
|---|---|---|
| <1.3 (<2.0 if ≥65 y) | Low risk of advanced fibrosis | Manage risk factors in primary care. Repeat in 1–3 years. |
| 1.3–2.67 | Indeterminate | Second test: VCTE or ELF. |
| ≥2.67 | High risk | Second test, and usually refer. |
2Step 2: liver stiffness or ELF
| Result | Meaning | Action |
|---|---|---|
| LSM <8 kPa | Low risk | Primary care follow-up |
| LSM 8–12 kPa | Indeterminate | Specialist review, or add ELF / MRE |
| LSM ≥12 kPa | Advanced fibrosis likely | Refer to hepatology |
| LSM ≥15 kPa | Compensated advanced chronic liver disease likely | Hepatology; assess portal hypertension |
| ELF <7.7 | Low risk | Primary care follow-up |
| ELF ≥9.8 | High risk | Refer to hepatology |
Cut-offs follow the EASL–EASD–EASO 2024 and AASLD 2023 guidance. Some services use other ELF cut-offs, so check your lab.
3Pitfalls
- Age under 35: FIB-4 and NFS perform poorly. Go straight to VCTE if you are worried.
- Age 65+: use the 2.0 lower cut-off to cut false positives.
- Acute hepatitis, very high ALT, or low platelets from another cause can mislead FIB-4.
- A low score in a patient with clinical signs of cirrhosis does not exclude it.
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
- Sterling RK, et al. Development of a simple noninvasive index to predict significant fibrosis in patients with HIV/HCV coinfection. Hepatology 2006;43:1317–25. doi:10.1002/hep.21178
- Shah AG, et al. Comparison of noninvasive markers of fibrosis in patients with nonalcoholic fatty liver disease. Clin Gastroenterol Hepatol 2009;7:1104–12. doi:10.1016/j.cgh.2009.05.033
- McPherson S, et al. Age as a confounding factor for the accurate non-invasive diagnosis of advanced NAFLD fibrosis. Am J Gastroenterol 2017;112:740–51. doi:10.1038/ajg.2016.453
- Younossi ZM, et al. Updated global consensus recommendations for risk stratification, treatment initiation, and response monitoring in MASLD. Clin Gastroenterol Hepatol 2026;24(9):2333–47. doi:10.1016/j.cgh.2026.03.030
How to cite this page
Desoky M. The two-step fibrosis pathway. Metabolic Liver Academy quick reference, version 1.0. Updated 2026-10-03. Available from: https://drmahmouddesoky.github.io/metabolic-liver-academy/ref/fibrosis-pathway.html
A summary of published guidelines for healthcare professionals. It does not replace clinical judgement, the full guidelines or local drug labels. Disclaimer.