Introduction
With nearly half of Romania’s population living in rural areas (1) with limited imaging access, non-invasive tests for liver steatosis and fibrosis are especially valuable. In such settings, ultraportable devices may offer practical solutions by providing point-of-care (POCUS) liver assesment.
Aims & Methods
The aim of this study was to determine the prevalence of liver steatosis and fibrosis in this population and to assess the concordance between ultrasound and various non-invasive serological and imaging methods within a screening program.
Between 2022 and 2024, Caravans were conducted in 17 villages across Central and North Romania. Participants received blood tests, abdominal ultrasound(US), and ultrasound elastography using ultraportable devices (liver stiffness (LSM) and attenuation coefficient(AT). Steatosis was assessed with the Fatty Liver Index(FLI), Hepatic Steatosis Index(HSI) while fibrosis was evaluated using FIB-4 and the NAFLD Fibrosis Score (NFS) and pairwise agreement between methods was determined by overall percentage agreement, Cohen’s kappa (κ), and concordance within each modality’s defined low- and high-risk groups.
Results
Of the 1,935 individuals screened, 1,721 underwent blood tests and 1,208 underwent ultrasound.62% had a BMI>25 kg/m², with 31.2% overweight,27.3% grade I obesity,11.9% grade II obesity and 8.1% morbid obesity;54.5% had prediabetes, 17.7% diabetes and 78.7% were dyslipidemic.
Steatosis prevalence was 50.8% on ultrasound (mild:30.6%,moderate:11.7%,severe:8.6%) and 26.5% on AT (mild 11.9%, moderate 4.9%, severe 9.7%). High steatosis risk was estimated at 55.1% by FLI, 63.7% by HSI and 86.5% by VAI.
Pairwise concordance for steatosis was moderate for US vs FLI and US vs AT (κ = 0.39 and 0.33).FLI and HSI showed the strongest agreement (k = 0.66; 92.7%match in high-risk). AT showed weak concordance with serological scores. (Table 1).
Advanced liver disease was found in 3.4% by ultrasound. LSM classified 88.4% as<F2 and 4.8% as F3–F4.Low fibrosis risk was found in 61.5% (FIB-4) and 62.5% (NFS) and high risk in 5.4% and 5.85%.
For fibrosis, US vs LSM showed 97.7% concordance (κ = 0.69), US vs FIB-4 93.3% (κ = 0.39)(Table 1).Among intermediate‐risk cases of the serological tests, 4.4% of FIB-4 and 6.7% of NFS had advanced (F3–F4) fibrosis.
| Steatosis tests comparisons | Overall concordance (%) | Cohen’s κ coefficient | Concordance in the low-risk group (%) | Concordance in the high-risk group (%) |
| US_steatosis vs AT | 64.8 | 0.33 | 88.2 | 41.5 |
| US_steatosis vs FLI | 71.0 | 0.39 | 49.8 | 88.3 |
| US_steatosis vs HSI | 64.8 | 0.21 | 25.4 | 93.6 |
| FLI vs HSI | 69.6 | 0.66 | 36.3 | 92.7 |
| Fibrosis tests comparisons | Overall concordance (%) | Cohen’s κ coefficient | Concordance in the low-risk group (%) | Concordance in the high-risk group (%) |
| US_fibrosis vs LSM | 97.7 | 0.69 | 98.4 | 77.5 |
| US_fibrosis vs FIB-4 | 93.3 | 0.39 | 94.0 | 70.8 |
| US_fibrosis vs NFS | 91.7 | 0.19 | 92.9 | 47.1 |
| FIB-4 vs NFS | 92.5 | 0.29 | 93.6 | 82.6 |
Conclusion
FLI and HSI showed strong agreement and among serum scores FLI showed the strongest agreement with ultrasound. LSM aligned most closely with ultrasound, making it the best confirmatory test, while FIB-4, although less sensitive for advanced disease had very good low-risk agreement and therefore would be suiteble for initial screening.
References
1. National Institute of Statistics. Romania in figures-statistical abstract. https://insse.ro/cms/ro/content/rom%C3%A2nia-%C3%AEn-cifre-breviar-statistic-limba-englez%C4%83-4.
Disclosure
The HE-RO-I Project (State-of-the-art colaborativ ROmânia-Islanda în managementul HEpatopatiilor cronice și a complicaţiilor acestora, ciroza hepatică și cancerului hepatic, destinat grupurilor vulnerabile din România, inclusiv Romi) was initiated by a team of physicians from the Gastrointestinal and Hepatology Institute of Cluj-Napoca, in collaboration with Caravana cu Medici – Cluj-Napoca Branch and Landspítali University Hospital in Reykjavik, Iceland, under the coordination of the Romanian Ministry of Health. The project aimed to deliver health education and conduct screening—primarily for liver diseases—among vulnerable populations (including roma people) from remote areas of Central and Northern Romania.
Financed by the Finance Mechanism of European Economic Space 2014-2021.