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. 2025 Apr 30;9(5):e0678.
doi: 10.1097/HC9.0000000000000678. eCollection 2025 May 1.

Global patterns of utilization of noninvasive tests for the clinical management of metabolic dysfunction-associated steatotic liver disease

Alina M Allen  1   2 , Jeffrey V Lazarus  1   3   4 , Naim Alkhouri  1   5 , Mazen Noureddin  1   6 , Vincent Wai-Sun Wong  1   7 , Emmanuel A Tsochatzis  1   8 , Leyla de Avila  1   9 , Andrei Racila  1   9 , Fatema Nader  1   9 , Henry E Mark  1 , Linda Henry  1   9 , Maria Stepanova  1   9 , Laurent Castera  1   10 , Zobair M Younossi  1   9   11
Affiliations

Global patterns of utilization of noninvasive tests for the clinical management of metabolic dysfunction-associated steatotic liver disease

Alina M Allen et al. Hepatol Commun. .

Abstract

Background: Noninvasive tests (NITs) are used to risk-stratify metabolic dysfunction-associated steatotic liver disease. The aim was to survey global patterns of real-world use of NITs.

Methods: A 38-item survey was designed by the Global NASH Council. Providers were asked about risks for advanced fibrosis, which NITs (cutoff values) they use to risk-stratify liver disease, monitor progression, and which professional guidelines they follow.

Results: A total of 321 participants from 43 countries completed the survey (54% hepatologists, 28% gastroenterologists, and 18% other). Of the respondents, 85% would risk-stratify patients with type 2 diabetes, obesity (82%), or abnormal liver enzymes (73%). Among NITs to rule out significant or advanced fibrosis, transient elastography (TE) and fibrosis-4 (FIB-4) were most used, followed by NAFLD Fibrosis Score, Enhanced Liver Fibrosis, and magnetic resonance elastography. The cutoffs for ruling out significant fibrosis varied considerably between practices and from guidelines, with only 50% using TE <8 kPa, 65% using FIB-4 <1.30 for age <65, and 41% using FIB-4 <2.00 for age ≥65. Similar variability was found for ruling in advanced fibrosis, where thresholds of FIB-4 ≥2.67 and TE ≥10 kPa were used by 20% and 17%, respectively. To establish advanced fibrosis, 48% would use 2 NITs while 23% would consider 1 NIT, and 17% would confirm with liver biopsy. TE was used by >75% to monitor, and 66% would monitor (intermediate or high risk) annually. Finally, 65% follow professional guideline recommendations regarding NITs.

Conclusions: In clinical practice, there is variability in NIT use and their thresholds. Additionally, there is suboptimal adherence to professional societies' guidelines.

Keywords: 2D-SWE; ELF; Fib-4; VCTE; risk stratification.

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Conflict of interest statement

Zobair M. Younossi is a consultant or has received research funding from Intercept, Cymabay, Boehringer Ingelheim, Ipsen, Gilead Sciences, Inventiva, BMS, GSK, Novo Nordisk, Siemens, Madrigal, Merck, Akero, and Abbott. Alina M. Allen serves as a consultant to Novo Nordisk, Boehringer Ingelheim, Madrigal, GSK, and Prosciento. Her institution has received research grants from Novo Nordisk, Pfizer, Target Pharma, Escopics, Oncoustics, and Siemens. Vincent Wai-Sun Wong served as a consultant or advisory board member for AbbVie, AstraZeneca, Boehringer Ingelheim, Echosens, Gilead Sciences, Intercept, Inventiva, Merck, Inventiva, Novo Nordisk, Pfizer, Sagimet Biosciences, TARGET PharmaSolutions, and Visirna; and a speaker for Abbott, AbbVie, Echosens, Gilead Sciences, Novo Nordisk, and Unilab. He has received a research grant from Gilead Sciences and is a co-founder of Illuminatio Medical Technology. Jeffrey V. Lazarus reports grants from Boehringer Ingelheim and Madrigal, grants and speaker fees from Gilead Sciences, GSK, MSD, Novo Nordisk, and Pfizer, and speaker fees from AbbVie, Echosens, Moderna, and ViiV, outside of the submitted work. Jeffrey V. Lazarus acknowledges support to ISGlobal from grant CEX2023-0001290-S, funded by MCIN/AEI/10.13039/501100011033, and the “Generalitat de Catalunya,” through the CERCA program, to his institution. Henry E. Mark reports he is the Director of HEM Consultancy, which provides consulting services within the global health and international development sectors and reports consulting fees from Panorma Global, Barcelona Institute for Global Health, and the Center for Outcomes Research in Liver Disease. Naim Alkhouri has received grant/research support from 89bio, Akero Therapeutics, Arbutus Biopharma, AstraZeneca, Better Therapeutics, Boehringer Ingelheim, Bristol Myers Squibb, Corcept Therapeutics, CymaBay Therapeutics, DSM, Galectin Therapeutics, Genentech, Genfit, Gilead Sciences, Healio, Hepagene Therapeutics, Intercept Pharmaceuticals, Inventiva Pharma, Ionis Pharmaceuticals, Ipsen, Madrigal Pharmaceuticals, Merck, NGM Biopharmaceuticals, Noom, NorthSea Therapeutics, Novo Nordisk, Perspectum, Pfizer, Poxel, Viking Therapeutics, and Zydus Pharmaceuticals; reports speaker’s fees from AbbVie, Alexion Pharmaceuticals, Echosens, Gilead Sciences, Intercept Pharmaceuticals, Ipsen, Madrigal Pharmaceuticals, Perspectum, and Theratechnologies; and reports consulting for 89bio, Boehringer Ingelheim, Echosens, Fibronostics, Gilead Sciences, Intercept Pharmaceuticals, Ipsen, Madrigal Pharmaceuticals, NorthSea Therapeutics, Novo Nordisk, Perspectum, Pfizer, and Zydus Pharmaceuticals. Mazen Noureddin—Advisory board: Altimmune, Alligos, AstraZeneca, BI, Boston Pharma, Cytodyn, GSK, Eli Lilly, Madrigal, Merck, Novo Nordisk, Terns, and Takeda. Principal Investigator for a Drug Study: Allergan, Akero, BI, BMS, Gilead, Galectin, Genfit, GSK, Conatus, Corcept, Enanta, Madrigal, Novartis, Novo Nordisk, Shire, Takeda, Terns, Viking, and Zydus. Stockholder: Rivus Pharma, Cytodyn, and ChronWell. Speaking bureau: Madrigal. Emmanuel A. Tsochatzis participated in advisory boards for Boehringer, Siemens Healthineers, MSD, and Novo Nordisk and reports peaker fees for Boehringer, Echosens, Novo Nordisk, and Abbvie. Laurent Castera reports consulting fees from Boston Pharmaceutical, Echosens, Gilead, GSK, Madrigal, MSD, Novo Nordisk, Pfizer, Sagimet, and Siemens Healthineers and speaker fees from Echosens, Gilead, Inventiva, Madrigal, and Novo Nordisk. The remaining authors have no conflicts to report. Zobair M. Younossi is the guarantor of this work and had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. All authors read and approved the final version of the manuscript.

Figures

FIGURE 1
FIGURE 1
Distribution of risk factors selected by the survey participants (“Which risk factors do you consider when deciding to assess patients for advanced fibrosis in known or suspected MASLD/NAFLD (multiple choice)”). *p<0.05 across the 3 groups. Abbreviations: MASLD, metabolic dysfunction–associated steatotic liver disease; PCOS, Polycystic ovary syndrome.
FIGURE 2
FIGURE 2
Availability of NITs for assessment of significant or advanced fibrosis in their clinical practice reported by the survey completers. Abbreviations: 2D-SWE, 2D-shear wave elastography; ELF, enhanced liver fibrosis; FAST score, FibroScan-AST score; FIB-4, fibrosis-4; MRE, magnetic resonance elastography; NFS, NAFLD Fibrosis Score; NITs, noninvasive tests; TE, transient elastography.
FIGURE 3
FIGURE 3
The choice of NITs and intervals for monitoring disease progression or response in MASLD/NAFLD patients with low, intermediate, or advanced risk of advanced fibrosis (“Do you monitor disease progression or response in MASLD/NAFLD patients with risk of advanced fibrosis? Which test? At what interval?”). Abbreviations: FAST, FibroScan-AST; FIB-4, fibrosis-4; GI, gastroenterologists; HEP, hepatologists; MASLD, metabolic dysfunction–associated steatotic liver disease; MRE, magnetic resonance elastography; NFS, NAFLD Fibrosis Score; NIT, noninvasive test; 2D-SWE, shear wave elastography; TE, transient elastography.
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