Key points
- Blood scores (FIB-4, NFS) are best at ruling out advanced fibrosis.
- VCTE (FibroScan) and ELF are the usual second-line tests.
- MRE is the most accurate imaging test for fibrosis but costly and less available.
- APRI was built for hepatitis C. It is not advised for MASLD.
For the evidence, graded recommendations, a case and self-test questions, read Module 1: Assessing liver fibrosis in MASLD.
1Blood-based scores
| Test | Inputs | Rule out | Rule in | Notes |
|---|---|---|---|---|
| FIB-4 | Age, AST, ALT, platelets | <1.3 (<2.0 if ≥65) | ≥2.67 | Free, first-line. Not for under 35. |
| NFS | Age, BMI, diabetes/IFG, AST/ALT, platelets, albumin | <−1.455 (<0.12 if ≥65) | >0.676 | Similar accuracy to FIB-4. BMI and diabetes push it up. |
| APRI | AST, platelets | — | — | Low accuracy in MASLD. Use FIB-4 instead. |
| ELF | HA, PIIINP, TIMP-1 (lab test) | <7.7 | ≥9.8 | Second-line. Raised by other fibrotic conditions and age. |
2Formulas
- FIB-4 = (age × AST) ÷ (platelets × √ALT)
- NFS = −1.675 + 0.037 × age + 0.094 × BMI + 1.13 × (IFG or diabetes: 1, else 0) + 0.99 × AST/ALT − 0.013 × platelets − 0.66 × albumin (g/dL)
- APRI = (AST ÷ upper limit of normal) ÷ platelets × 100
3Imaging
| Test | Measures | Useful cut-offs | Notes |
|---|---|---|---|
| VCTE (FibroScan) LSM | Liver stiffness, kPa | <8 low · 8–12 grey · ≥12 high · ≥15 cACLD likely | Fast 3 hours. Use the XL probe in obesity. Valid if IQR/median ≤30%. |
| VCTE CAP | Steatosis, dB/m | About ≥275 dB/m suggests steatosis | Does not stage fibrosis. |
| MR elastography (MRE) | Liver stiffness, kPa | Centre-specific | Most accurate, costly. |
| MRI-PDFF | Liver fat fraction | ≥5% = steatosis | Good for tracking fat change in trials. |
| Ultrasound | Steatosis (moderate or more) | — | Misses mild fat. Cannot stage fibrosis. |
4Things that falsely raise liver stiffness
- Recent meal (fast 3 hours).
- High ALT or acute hepatitis.
- Heart failure or liver congestion.
- Biliary obstruction.
- Heavy recent alcohol intake.
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
- EASL Clinical Practice Guidelines on non-invasive tests for evaluation of liver disease severity and prognosis – 2021 update. J Hepatol 2021;75:659–89. doi:10.1016/j.jhep.2021.05.025
- 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
- Angulo P, et al. The NAFLD fibrosis score: a noninvasive system that identifies liver fibrosis in patients with NAFLD. Hepatology 2007;45:846–54. doi:10.1002/hep.21496
- Wai CT, et al. A simple noninvasive index can predict both significant fibrosis and cirrhosis in patients with chronic hepatitis C. Hepatology 2003;38:518–26. doi:10.1053/jhep.2003.50346
- 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
How to cite this page
Desoky M. Non-invasive tests at a glance. Metabolic Liver Academy quick reference, version 1.0. Updated 2026-10-03. Available from: https://drmahmouddesoky.github.io/metabolic-liver-academy/ref/nit-reference.html
A summary of published guidelines for healthcare professionals. It does not replace clinical judgement, the full guidelines or local drug labels. Disclaimer.