Introduction

As a noninvasive method for evaluating liver fibrosis with the Fibroscan used, it is possible to measure not only liver but also spleen stiffness has become possible. In this study, we aimed to evaluate the correlation of liver fibrosis and Controlled Attenuation Parameter (CAP) scores obtained by Fibroscan measurement with histopathological findings in our patients who underwent liver biopsy for different etiologies, and to evaluate spleen stiffness in this patient group.

Aims & Methods

Stiffness measurements, spleen stiffness and CAP scores are carried out with FibroScan device (Echosens, France) to the patient who have undergone biopsy due to different indications and etiologies. The measurements have done to patients while they are in the supine position, via intercostal spaces, after at least three fasting hours, with using the M/XL probe. Results were expressed as the median value of kilopascal measurement for stiffness, and the CAP score as dB/m. Only 10 confirmed measurements and measurement results with interquartile range / median value (IQR / Med) < 30% were considered.

Results

72 patients who underwent liver biopsy were included in our study. The mean age of the patients was 43.26±12.7 years, 52.8% (38) were female. Liver biopsy indications of the patients included elevated liver enzymes in 30.6%, hepatitis B infection in 31.9%, fatty liver in 6.9%, autoimmune hepatitis in 13.9%, and toxic hepatitis in 4.2%. The BMI of the patients was 26.28±4.5 kg/m2. Liver fibrosis mean was 9.19±10.56 kPa, mean spleen stiffness was 29.15±24.01 dB/m, and mean CAP score was 240±55.38. When fibroscan measurements were evaluated according to gender, spleen stiffness was found to be higher in males (p<0.005). It is detected that there is an increase in liver fibrosis (kPa) with aging (p<0.005). With the fibrosis score indicated in the liver biopsy of the patients. While a positive correlation was found between liver stiffness obtained from fibroscan measurement with the fibrosis score indicated in the liver biopsy of the patients (p<0.005), no statistically significant correlation was found with HAI score. Relationship between spleen stiffness and liver biopsy fibrosis score and HAI score not detected. Also no correlation was found between platelet levels and splenic stiffness.

Conclusion

The correlation was found to be significant between Fibroscan which is used as a noninvasive diagnosis in the evaluation of liver fibrosis and spleen stiffness with liver biopsy for detecting fibrosis. Advanced age and male gender was determined to be a risk factor for spleen stiffness. Comprehensive studies are needed to determine splenic stiffness importance in terms of portal hypertension and its relationship with liver fibrosis.

Introduction

Assessment of liver fibrosis is a key element in the management of patients with hepatitis B virus (HBV) infection, whether in the active, inactive, or occult phase. Among the non-invasive tools currently available, the FIB-4 score, based on biological parameters and FibroScan, using vibration-controlled transient elastography (VCTE) are widely used.

Aims & Methods

This retrospective, descriptive, and analytical study was conducted in a university hospital between 2017 and 2025. All patients followed for chronic HBV infection in the department of hepatogastroenterology were included. Clinical and biological data, along with fibrosis assessment results (FIB-4 score and FibroScan), were collected from patients medical records. The aim of this study was to compare the diagnostic performance and concordance of these two modalities in assessing liver fibrosis in a heterogeneous population of HBV-infected patients.

Results

A total of 100 HBV-infected patients were included, consisting of 54 males (54%) and 46 females (46%), with a median age of 55 years [42.5; 60]. Among them, 70% of patients had an active chronic hepatitis B (n=70), 29% were in the inactive phase (n=29), and 1 patient had an occult HBV infection.
Regarding comorbidities, 14% had arterial hypertension, 13% had metabolic dysfunction-associated steatotic liver disease (MASLD), and 5% had type 2 diabetes mellitus. Alcohol consumption was reported in 4% (n=4), and 5% were smokers (n=5). A family history of liver disease was documented in 12% of cases (n=12).
Concerning virological parameters, HBe antigen was positive in 13% (n=13) and negative in 87% (n=87). HBV DNA levels were <2,000 IU/mL in 48% of patients (n=48), between 2,000 and 20,000 IU/mL in 25% (n=25), and >20,000 IU/mL in 27% (n=27).
Evaluation of liver fibrosis using both the FIB-4 score and FibroScan revealed that 40% of patients had a FIB-4 score >3.25, indicating advanced fibrosis, while 60% had a score <1.45, suggesting minimal fibrosis. These findings were consistent with those obtained by FibroScan. To assess the diagnostic performance of the FIB-4 score in detecting advanced fibrosis (F3–F4) according to FibroScan, a receiver operating characteristic (ROC) analysis was conducted. The FIB-4 score demonstrated an area under the curve (AUC) of 0.96 using a cutoff value of 1.96, with a sensitivity of 93.75%, specificity of 84.52%, and a negative predictive value (NPV) of 98.61%.

Conclusion

The FIB-4 score demonstrated excellent diagnostic accuracy for identifying advanced liver fibrosis in patients with HBV infection, with a performance comparable to that of FibroScan. Given its simplicity, accessibility, and cost-effectiveness, the FIB-4 index represents a reliable first-line tool for fibrosis screening, particularly in settings where elastography is unavailable or limited.

Introduction

Non-invasive assessment of liver fibrosis is central to managing chronic liver disease. FibroScan® (transient elastography), FIB-4, and APRI are widely used, but obesity may impair FibroScan® performance by altering probe penetration and signal quality, particularly in metabolic liver disease. This may lead to fibrosis overestimation and inappropriate clinical decisions.

Aims & Methods

This study aimed to evaluate the concordance between FibroScan®, FIB-4, and APRI in assessing advanced liver fibrosis, stratified by BMI, and to identify predictors of diagnostic discordance—particularly in obese patients where FibroScan® performance may be compromised.
We retrospectively included 120 consecutive patients with valid FibroScan® measurements (≥10 acquisitions, IQR/median <30%) and available FIB-4, APRI, and BMI data. Patients with confounders (ascites, cytolysis ≥3× ULN, cholestasis, or hepatic mass) were excluded.
Advanced fibrosis was defined using validated thresholds:

• FibroScan® ≥10.5 kPa (AASLD/EASL)

• FIB-4 >2.67

• APRI ≥1.5
  Concordance between FibroScan® and FIB-4 was assessed via weighted kappa, APRI serving as a third comparator. Patients were stratified by BMI (<30 vs ≥30 kg/m²). Predictors of discordance were analyzed using logistic regression.

Results

Among 120 patients (mean age 47.2 ± 14.5 years; 55% female; mean BMI 26.3 ± 4.9 kg/m²), 63% were non-obese. Advanced fibrosis was diagnosed in 34% (FibroScan®), 28% (FIB-4), and 20% (APRI).
In non-obese patients (n=76), concordance between FibroScan® and FIB-4 was strong (κ = 0.75), with only 11.2% discordance. APRI confirmed FibroScan® classification in 87% of cases.
In obese patients (n=44), concordance dropped sharply (κ = –0.27), with 63.6% discordance. APRI also poorly agreed with FibroScan® (κ = 0.09), reinforcing the discordance. Most discrepancies involved FibroScan® indicating advanced fibrosis not supported by serum markers. Logistic regression confirmed BMI ≥30 as an independent predictor of discordance (OR 2.63; 95% CI 1.55–4.67; p < 0.001); age and sex were not associated.

Conclusion

FibroScan®, FIB-4, and APRI show good concordance in non-obese patients. However, obesity significantly impairs FibroScan® reliability, leading to frequent fibrosis overestimation. These findings support BMI-adapted strategies, including XL probe use or integration of serum markers, to improve diagnostic accuracy in metabolic liver disease.

Introduction

Non-invasive elastography techniques have become essential for evaluating hepatic fibrosis and portal hypertension. Although liver stiffness is routinely assessed, spleen stiffness has gained recognition as an emerging marker of portal hypertension. Its application in the intensive care unit (ICU), particularly among patients with chronic liver disease and acute-on-chronic liver failure (ACLF), remains underexplored. This study investigates the utility of Acoustic Radiation Force Impulse (ARFI) imaging for spleen stiffness assessment in ICU patients, focusing on its prognostic relevance and feasibility in a high-acuity setting.

Aims & Methods

We conducted a prospective observational study enrolling 44 ICU patients with established chronic liver disease, with or without ACLF. Spleen stiffness was measured serially using ARFI elastography every 2–4 days during the ICU stay. Clinical data—including liver and renal function parameters, respiratory support settings, and outcome variables—were collected concurrently. The primary aim was to assess the feasibility of serial spleen stiffness measurement in this cohort, identify influencing clinical variables, and explore associations with clinical outcomes.

Results

Spleen stiffness assessment via ARFI was successfully performed in all included patients. Higher spleen stiffness values were significantly associated with renal replacement therapy (p < 0.001) and the need for invasive mechanical ventilation (p < 0.001). An inverse relationship was observed between airway pressures during ventilation and spleen stiffness values (p = 0.017), suggesting potential interplay between mechanical factors and elastographic findings. Spleen stiffness did not correlate with patient age, BMI, or vasopressor requirement. Over time, spleen stiffness showed dynamic changes corresponding to clinical progression or improvement, supporting its potential as a non-invasive surrogate of disease trajectory.

Conclusion

Our findings demonstrate that spleen stiffness measurement via ARFI elastography is both feasible and clinically informative in the intensive care setting for patients with liver cirrhosis. Beyond reflecting portal hypertension, spleen stiffness appears to integrate aspects of hepatic and extrahepatic dysfunction, correlating with organ failure and clinical deterioration. These results underscore its potential as a non-invasive, bedside-accessible biomarker to support dynamic risk stratification and individualized decision-making in critical care hepatology.

Introduction

Metabolic dysfunction-associated steatotic liver disease (MASLD) has a global prevalence of 30%, with 10-30% progressing to advanced liver fibrosis in 5 years. It is essential to assess advanced liver fibrosis – a predictor of liver-related outcomes. FIB-4 is a good screening test, but its low specificity leads to unnecessary referrals to hospital, especially in individuals over 65 years and with type 2 diabetes (T2D). To address these limitations, machine-learning techniques are developing scores like FIB-6 (validated for Hepatitis B and C).

Aims & Methods

We aimed to assess the performance of FIB-6 score in screening for advanced fibrosis in a Portuguese cohort of MASLD patients.
A retrospective-cohort study was conducted with MASLD patients who had undergone liver vibration-controlled transient elastography (VCTE) between January-October 2024. inclusion criteria: adult patients (age >18years) diagnosed with MASLD; undergone liver VCTE; complete biochemical and hematological data. Exclusion criteria: coexistence of other liver diseases; decompensated cirrhosis; hepatocellular carcinoma; hematological/bone‑related diseases. We used liver stiffness measurement by VCTE as a reference standard for liver fibrosis. Fibrosis was staged on a 0–4 scale: F0, F1 and F2, patients without advanced fibrosis; F3 and F4, patients with advanced fibrosis/cirrhosis.
Non invasive tests (FIB-6, FIB‑4, APRI, NFS) were calculated using blood results available within the month of the VCTE. Statistical analysis was performed using R version 4.2.3. AUC-ROC curve analysis with cutoff points were calculated using the Youden index.

Results

115 MASLD patients (58 males (50.43%),57 females (49.57%), median age of 62years) where included. 41 (35.65%) had diabetes mellitus type 2 (T2D) (10 of those insulin-treated), 74 (64.35%) arterial hypertension, 76 (66.09%) dyslipidemia and with a median body mass index of 29.9mg/Kg/m². Regarding hepatic fibrosis, 79 patients had F0-2 and 17 patients had F3-4.
In the general sample, AUC-ROC curve analysis showed an AUC 0.771 (CI 95% :0.662, 0.88) for FIB-4, AUC 0.788 (CI 95% :0.686, 0.889) for APRI, AUC 0.709 (CI 95% :0.595, 0.823) for NFS and AUC 0.695 (CI 95% :0.571, 0.819) for FIB-6.
A subanalysis of the sample over 65 years old revealed AUC 0.807 (CI 95% : 0.665, 0.949) for FIB4; AUC 0.788 (CI 95% : 0.686, 0.889) for APRI; AUC 0.788 (CI 95% : 0.65, 0.926) for NFS; AUC 0.663 (CI 95% : 0.475, 0.852) for FIB-6. A subanalysis of the sample of T2D patients revealed AUC 0.747 (CI 95% :0.584, 0.911) for FIB4; AUC 0.811 (CI 95% :0.676, 0.946) for APRI; and AUC 0.765 (CI 95% : 0.612, 0.918) for FIB6.
Using the optimal cut‑offs of FIB6 (cutoff= 1.8992) for the diagnosis of F3+F4 indicated a reliable performance of FIB‑6 score (sensitivity was 70%, specificity was 52.6%).
The cutoff values of FIB-6 for the general sample was 2.4420 (sensitivity 53%, specificity 87%); for the subset of patients over 65 years was 2.7668 (sensitivity 40%, specificity 96%); for the subset of T2D patients was 2.2230 (sensitivity 55%, specificity 90%).

Conclusion

FIB-6 demonstrated good performance in screening advanced fibrosis in MASLD patients, when compared to those of FIB‑4, APRI, and NFS, surpassing FIB-4, particularly in individuals with T2D. This study is the first to evaluate the applicability of FIB-6 in a Portuguese MASLD cohort. Although the findings warrant validation in larger and more diverse populations, they suggest that FIB-6 may be more efficient to evaluate liver fibrosis in MASLD and offer a more efficient tool to identify patients that need specialized care.

References

Anushiravani A, et al. 2023.
Alswat K, et al. 2024.
Shiha G, et al. 2022
Tacke, Frank et al. 2023
Boursier, Jerome et al. 2022
Papatheodoridi, Margarita et al. 2021
Hannes Hagström et al. 2024.
Rinella, Mary E. et al.2023

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.