Introduction

Obesity is a serious healthcare burden associated with an increased risk of morbidity and mortality. It reprensents a risk and prognostic factor for non alcoholic fatty liver disease (NAFLD ) and its complications, mainly hepatic fibrosis. It is therefore essential to identify within the obese population, patients at high risk of developing advanced fibrosis in order to optimize their management.
In our study, we investigated the correlation between two biological scores: Fibrosis-4 (FIB-4) and aspartate aminotransferase (ASAT)/platelet ratio index (APRI) and a physical mean which is transient elastography (FibroScan®) for the assessment of liver fibrosis in obese patients with NAFLD.

Aims & Methods

This is a transversal, descriptive and analytical study, conducted over a seven months period (August 2022- March 2023). We collected obese patients with NAFLD who had a FibroScan, a serum AST, ALT and a platelet count, performed within the same day. Fib-4 and APRI scores were calculated for each patient, accordingly to the standard formulas. We used a cutoff <0.5 for APRI score and a cutoff <= 1.45 for Fib-4 to identify patients with a low probability of advanced fibrosis. For patients with high probability of advanced fibrosis we used a cutoff >4 for Fib-4 and a cutoff >1,5 for APRI. Advanced fibrosis was considered in patients with a Liver Stiffness Measurement (LSM) > 12 kPa. We studied the correlation between transient elastography and biological scores.

Results

We collected 207 obese patients with hepatic steatosis. A female predominance was noted with a sexe ratio of 0,12. The mean age was 48.8 +/- 11.9 years.
The mean liver elasticity was 5 .38 +/- 3.22 kpa and the mean APRI and Fib-4 scores were 0.2 and 0.89, respectively.
Liver elasticity was less than 12 kpa in 95.7% of patients. Patients with a low risk of advanced fibrosis according to APRI and Fib-4 scores were 97.1% and 95.2%, respectively.
We noted a significant correlation between the transient elastography results, APRI score and Fib-4 in the identification of patients with low probability of advanced fibrosis (p=0.037 and p<0.001, respectively). Of the 9 patients with an LSM ≥12kPa , only one patient had a Fib4 score >4 ( 44,4 %) and no one had an APRI score >1,5. The statistical analysis showed that the APRI score has a sensitivity of 100% but no specificity (0% ).The positive predictive value(PPV) was 0% while the negative predictive value (NPV) was of 95,7% .For the Fib 4 score the sensitivity was 99,5 % and the sensitivity was 0%. The PPV was 0% and the NPV 95,6% .

Conclusion

Fib-4 as well as APRI are two non-invasive scores that can be routinely performed based on simple biological parametres with a good NPV to exclude advanced fibrosis in obese patients with NAFLD. They can be used within this population when other more performing tests are not available.

Introduction

Noninvasive assessment of liver fibrosis is essential in the management of chronic liver diseases. APRI and FIB-4 are simple, low-cost tools widely used for this purpose. This study aimed to evaluate the diagnostic performance of APRI and FIB-4 in identifying significant fibrosis (≥F2) and cirrhosis (F4), using transient elastography (FibroScan) as the reference standard, and to explore their clinical and biochemical correlations.

Aims & Methods

We conducted a cross-sectional study at the Institute of Gastroenterology and Hepatology, Iași, Romania, between January 1^st, 2024 and April 1^st, 2025. A total of 106 patients with chronic liver disease were included. Laboratory tests were used to calculate APRI and FIB-4 scores, and liver stiffness was measured by FibroScan. For diagnostic accuracy we performed ROC curve analysis and Pearson correlation coefficients were used to assess relationships between noninvasive scores and clinical-biological variables. Statistical analysis was performed using MedCalc® Statistical Software version 23.2.1 (MedCalc Software Ltd, Ostend, Belgium).

Results

For the detection of significant fibrosis (≥F2), the area under the ROC curve (AUC) was 0.748 for APRI (p < 0.001) and 0.752 for FIB-4 (p < 0.001). In diagnosing cirrhosis (F4 ≥12.5 kPa), FIB-4 demonstrated superior diagnostic accuracy (AUC 0.836, p < 0.001) compared to APRI (AUC 0.797, p < 0.001). A FIB-4 threshold of 1.45 provided a sensitivity of 68.6% and a specificity of 83.3% for detecting significant fibrosis. High cut-offs (≥2.0 for APRI and ≥4.0 for FIB-4) were associated with a specificity exceeding 96%. A significant positive correlation was observed between APRI and FIB-4 (r = 0.96, p < 0.001). Moreover, FIB-4 correlated moderately with FibroScan values (r = 0.514), while APRI showed a weaker correlation (r = 0.423).

Conclusion

The results of this study confirm that both APRI and FIB-4 are effective noninvasive tools for the staging of liver fibrosis, with FIB-4 demonstrating superior diagnostic accuracy, particularly for cirrhosis. The moderate correlation between FIB-4 and FibroScan (r = 0.514) supports its potential role as a reliable surrogate marker, especially in settings where access to elastography is limited, outperforming the weaker correlation of APRI (r = 0.423) that suggests a lower predictive power, aligning with findings from previous studies that emphasized FIB-4's stronger association with liver stiffness and histological fibrosis progression. The high specificity associated with elevated cut-off values enhances the clinical applicability of these scores for ruling in advanced fibrosis and cirrhosis, minimizing the need for unnecessary imaging or biopsies. Overall, integrating FIB-4 and APRI into routine clinical practice could improve early identification of at-risk patients, optimize resource allocation, and facilitate timely therapeutic interventions.

References

1. European Association for the Study of the Liver. EASL Clinical Practice Guidelines on non-invasive tests for evaluation of liver disease severity and prognosis - 2021 update. J Hepatol. 2021 Sep;75(3):659-689. doi: 10.1016/j.jhep.2021.05.025. Epub 2021 Jun 21. PMID: 34166721.
2. Gür-Altunay D, Yürük-Atasoy P. How Successful Are APRI and FIB-4 Scores in Predicting Liver Fibrosis in Chronic Hepatitis B Patients? Infect Dis Clin Microbiol. 2023 Dec 29;5(4):332-340. doi: 10.36519/idcm.2023.276. PMID: 38633858; PMCID: PMC10986711.
3. Rungta S, Kumari S, Deep A, Verma K, Swaroop S. APRI and FIB-4 performance to assess liver fibrosis against predefined Fibroscan values in chronic hepatitis C virus infection. J Family Med Prim Care. 2021 Nov;10(11):4082-4088. doi: 10.4103/jfmpc.jfmpc_666_21. Epub 2021 Nov 29. PMID: 35136771; PMCID: PMC8797084.

Introduction

Non-alcoholic fatty liver disease (NAFLD) is the most prevalent chronic liver condition globally, closely associated with increased cardiovascular morbidity and mortality. Despite preserved left ventricular ejection fraction (LVEF), patients with NAFLD may exhibit subclinical cardiac dysfunction. Speckle tracking echocardiography (STE) offers sensitive myocardial strain assessment, surpassing conventional LVEF measurements. This systematic review and meta-analysis aimed to evaluate the association between NAFLD and subclinical left ventricular systolic dysfunction using STE-derived strain parameters.

Aims & Methods

A comprehensive literature search was conducted in PubMed, EMBASE, and Scopus. Observational studies assessing NAFLD patients using STE-derived myocardial strain parameters were included. Quality assessment was performed using the Newcastle-Ottawa Scale. Primary outcomes were the mean differences (MD) in global longitudinal strain (GLS), global circumferential strain (GCS), global radial strain (GRS), global apical strain (GAS), and related strain rate indices between NAFLD spectrum patients and controls.

Results

Sixteen studies involving 8,359 participants were included. NAFLD patients exhibited significant reductions in GLS (MD: -2.043; 95% CI: -2.868, -1.218), GAS (MD: -3.706; 95% CI: -4.999, -2.413), and GCS (MD: -1.415; 95% CI: -2.893, 0.064) compared to controls. The reductions were more pronounced in individuals with moderate/severe NAFLD and those with concomitant type 2 diabetes mellitus (GLS MD: -4.385; 95% CI: -5.400, -3.369 in diabetic NAFLD vs. diabetic controls). Subgroup analysis also demonstrated a stepwise impairment in strain parameters from simple steatosis to non-alcoholic steatohepatitis (NASH). Importantly, LVEF remained preserved across all groups, underscoring the subclinical nature of the observed dysfunction.

Conclusion

This meta-analysis confirms the presence of subclinical left ventricular systolic dysfunction in NAFLD patients, detectable via STE despite normal LVEF. Myocardial strain parameters, particularly GLS, offer valuable early indicators of cardiac impairment. Routine integration of STE in NAFLD management may enable timely cardiovascular risk stratification and intervention.

Introduction

Transient Elastography (TE) is a well-validated, non-invasive method to assess hepatic fibrosis and steatosis using liver stiffness measurement (LSM) and controlled attenuation parameter (CAP), respectively. However, due to interobserver variability, uncertainties still exist regarding the reliability and reproducibility of the technique especially in obese patients.

Aims & Methods

We aimed to evaluate the interobserver agreement of transient elastography in overweight and obese patients with Nonalcoholic Fatty Liver Disease (NAFLD).
We conducted a cross-sectional study including obese patients with NAFLD. We analyzed the results of TE performed by two different experienced operators, on two different days, within the same month. For each patient, the probe size (M or XL) used in both exams was the same; the weight remained stable and all patients had normal liver function. LSM was recorded after obtaining at least 10 valid readings, a success rate ≥ 60% and an interquartile range to a median ratio (IQR/M) < 0.3. We classified the risk for advanced fibrosis as low, indeterminate and high, based on EASL guidelines 2021, which were respectively: <8 kPa, ≥8 and < 12 kPa, and ≥12 kPa. Hepatic steatosis was defined by CAP values ≥ 248 dB/m.

Results

Sixty-eight patients were recruited (70.6% female) with a mean age of 53.21±12.9 years. The mean body mass index (BMI) was 42.05±9.57 kg/m2 and the mean waist circumference (WC) was 119.51±22.07 cm. 10.4% of patients were overweight, 18.8% were obese and 70.8% were severely obese. There was no statistically significant difference in both mean LSM (7.3 vs 6.9 kPa; P=0.475) and mean CAP values (313 vs 309.8 dB/m; P=0.507), assessed by the first and the second operators, respectively. The measurements made by operators of LSM and CAP were correlated [(Spearman'sρ = 0.512; P< 0.001) and (Spearman'sρ = 0.525; P< 0.001), respectively]. The interobserver intraclass correlation coefficient was 0.860 (95% CI 0.772-0.914) for LSM and 0.710 (95% CI 0.526-0.822) for CAP values. A discrepancy of at least 2 kPa between both results was noted in 30 cases (44.1%). There was no statistically significant difference in mean IQR/M values between the two exams (0.14 vs 0.12; P=0.15). The discordance between operators was 16.2% for at least one level of risk of advanced fibrosis and 14.7% for two levels. In fact, among the patients considered with a high risk of advanced fibrosis by the first operator, 60% had low risk, 20% had indeterminate risk and 20% had high risk, assessed by the second one. For those who had an indeterminate risk of fibrosis, according to the measurements made by the first operator, 60% of them were at low risk of advanced fibrosis, based on those made by the second one. Among those at low risk of advanced fibrosis assessed by the first operator, 8.7% had a high risk of advanced fibrosis as measured by the second one. Interobserver reliability values were κ = 0.32 for low risk of advanced fibrosis, κ = 0.12 for indeterminate risk, and κ = 0.16 for high risk for advanced fibrosis. The interobserver discrepancy in LSM was significantly associated with LSM (P=0.001), BMI (P<0.001), and WC (P=0.025).

Conclusion

Although TE is a very convenient method to assess liver fibrosis and steatosis in clinical practice, the interobserver discrepancy in results was not negligible, especially in severely obese patients and mainly for indeterminate and high risk of advanced fibrosis, which represents a significant problem with the technique. Thus, the evaluation of liver fibrosis, including TE results, should be carefully analyzed by expert hands.

Introduction

Liver fibrosis is the main prognostic driver and an independent risk factor for both hepatic and extrahepatic events and global mortality in patients with non-alcoholic fatty liver disease (NAFLD). Thus, many serum markers and scores for the assessment of fibrosis severity have been drawn up. Recently, researchers developed the easy Liver Fibrosis Test (eLIFT) and the BMI, AST/ALT ratio and Diabetes (BARD) score.

Aims & Methods

This study aimed to compare the eLIFT and the BARD scores with Transient Elastography for the assessment of liver fibrosis in obese patients with NAFLD.
We conducted a transversal study including obese patients recruited from the Department of Nutrition referred to our center for screening for liver steatosis and a non-invasive evaluation of liver fibrosis. We excluded patients who had pre-existing chronic liver disease, chronic alcohol consumers, or those with ongoing medication other than those for metabolic syndrome.
Demographic and clinical features of the participants were recorded. All participants underwent Transient Elastography (TE) and had their AST, ALT, gamma-glutamyl transferase (GGT), platelet count, and prothrombin time measured in a random blood sample, taken the same day of the TE. We calculated for each patient the eLIFT and BARD scores using standard formulas.
Liver stiffness measurements (LSM) used to define the risk for advanced fibrosis as low, indeterminate, and high, based on EASL guidelines 2021, were respectively: <8 kPa, ≥8 and < 12 kPa, and ≥12 kPa.
An eLIFT <8 indicated a low risk of advanced fibrosis, whereas a result ≥8 identified patients at risk of advanced fibrosis. The BARD score ranges from 0 to 4, considered low from 0 to 1 with a high negative predictive value (NPV) for advanced fibrosis, and considered high from 2 to 4 with a high risk of advanced fibrosis.

Results

A total of 213 obese patients with NAFLD were included, with a mean age of 49.04 ± 11.76 years, 88% were female. The mean body mass index (BMI) was 40.67 ± 10.16 kg/m² and the mean waist circumference (WC) was 115.07 ± 17.49 cm.
TE results revealed that 191 patients had a low risk of advanced fibrosis (89.7%), 13 had an indeterminate risk of advanced fibrosis (6.1%), and nine patients had a high risk of advanced fibrosis (4.2%). Using eLIFT, 195 patients were classified in the low-risk of advanced fibrosis group of which 187 had also a low risk based on TE and only 8 had a high risk of advanced fibrosis, which corresponds to a rate of sensitivity at 92.6%; specificity at 27.3%; NPV at 95.9%; and positive predictive value (PPV) at 16.7%.
The BARD score was low in 21 patients (9.9%) and high in 192 (90.1%). Among the 21 patients with a low BARD score, 19 had a low risk of advanced fibrosis based on LSM and two had a high risk of advanced fibrosis. In the group of patients with a high score, only nine had advanced fibrosis. Sensitivity was 8.5%; specificity was 90%; NPV was 94.4%; and PPV was 4.7%. Both scores had high NPV for a high risk of advanced fibrosis, but the BARD score had a lower sensibility than eLIFT, with better specificity.
AUROC were 0.515 (95% CI, 0.11-0.92) and 0.743 (95% CI, 0.49-0.99) for eLIFT and BARD scores, respectively.

Conclusion

Both eLIFT and BARD scores were useful for ruling out advanced fibrosis (NPV > 90%) in an obese population with NAFLD. As such, they are adequate for use in clinical practice or as a part of referral and follow-up programs.

Introduction

MASLD, a metabolic condition that includes cardiovascular risk factors, is associated with increased cardiovascular risk, particularly in cases with advanced fibrosis (1). It is now recognized as the leading cause of liver disease globally, with an estimated prevalence of 25–45% (2). This increase mirrors global trends in obesity, diabetes, and metabolic syndrome. While the majority of MASLD patients are obese—between 51% and 81% have a BMI >30 kg/m² (3)—MASLD also occurs in lean individuals. However, the risk factors in this population remain poorly defined (4). Approximately 19.2% of MASLD patients have a normal BMI (5), and current estimates suggest that about 40% of MASLD patients are obese while 20% are lean (6).There is limited data on adverse outcomes in MASLD patients with BMI <25 kg/m², but some studies have shown that lean MASLD patients may be at even higher risk of all-cause mortality, liver-related death, and cardiovascular disease compared to those with obesity (7).

Aims & Methods

To compare cardiovascular health status using the Life’s Essential 8 score between lean and obese patients with MASLD.

Study Design: Descriptive, observational, cross-sectional, retrospective, and retrolective study.
Population: Patients affiliated with the Centro Médico Nacional 20 de Noviembre ISSSTE who were treated in the gastroenterology department and diagnosed with MASLD between January 2023 and December 2023, regardless of their BMI.
Methods: The analysis will begin by evaluating the distribution of numerical variables and using the Kolmogorov-Smirnov test to assess data normality. Descriptive statistics will be used to summarize demographic and clinical characteristics. Patients will be grouped by BMI (<25 and ≥25 kg/m²) to compare clinical features using appropriate statistical tests (t-test, Mann-Whitney U, or chi-square). Correlations between BMI and clinical scores, including Life’s Essential 8, will be assessed using Pearson or Spearman methods. If applicable, BMI cut-off points linked to higher LE8 scores will also be identified.

Results

A total of 110 MASLD patients were analyzed, with 80% being female and an even split between those with BMI <25 kg/m² and >25 kg/m². The average age was 55.8 years, and the mean BMI was 27.95 kg/m². Diabetes was the most common comorbidity (25.5%), followed by elevated cholesterol (24.5%). Most patients had mild steatosis (67.3%).Life’s Essential 8 scores were higher in lean patients (66.61) than in those with higher BMI (59.33). Lean patients also had more mild steatosis, lower rates of comorbidities, and a greater proportion achieved high cardiovascular health scores (9.1%), unlike the high-BMI group, which had no high scores and more frequent low cardiovascular health (21.8%).Spearman correlation revealed a statistically significant negative correlation between BMI and cardiovascular health score (ρ = −0.425, p < 0.01), suggesting that higher BMI is associated with lower cardiovascular health.

Conclusion

The findings of this study show that, regardless of BMI, lean patients with MASLD exhibit impaired cardiovascular health according to the Life’s Essential 8 score, similar to patients with obesity. This suggests that cardiovascular involvement in MASLD is not solely dependent on body weight. These results highlight the value of LE8 as a useful tool to identify and address cardiovascular risk in all MASLD patients, regardless of body composition. This evidence reinforces the need to continue researching and implementing multidisciplinary approaches to address the growing problem of metabolic liver disease in the population.

References

1. Rinella, M. E., & Sanyal, A. J. (2015). Genetics, diagnostics and therapeutic advances in NAFLD. Nature reviews Gastroenterology & hepatology, 12(2), 65-66.
2. Rinella, M. E. (2015). Nonalcoholic fatty liver disease: a systematic review. Jama, 313(22), 2263-2273.
3. Sookoian, S., & Pirola, C. J. (2017). Systematic review with meta‐analysis: risk factors for non‐alcoholic fatty liver disease suggest a shared altered metabolic and cardiovascular profile between lean and obese patients. Alimentary pharmacology & therapeutics, 46(2), 85-95.
4. Godoy-Matos, A. F., Silva Júnior, W. S., (2020). NAFLD as a continuum: from obesity to metabolic syndrome and diabetes. Diabetology & metabolic syndrome, 12, 1-20.
5. VanWagner, L. B., & Armstrong, M. J. (2018). Lean NAFLD: A not so benign condition?. Hepatology communications, 2(1), 5-8.
6. Ye, Q., Zou, B., Yeo, Y. H., Li, J., Huang, D. Q., Wu, Y., et al. (2020). Global prevalence, incidence, and outcomes of non-obese or lean non-alcoholic fatty liver disease: a systematic review and meta-analysis. The lancet Gastroenterology & hepatology, 5(8), 739-752.
7. Zou, B., Yeo, Y. H., Nguyen, V. H., (2020). Prevalence, characteristics and mortality outcomes of obese, nonobese and lean NAFLD in the United States, Journal of internal medicine, 288(1), 139-151.