Liver stiffness measurements in patients with metabolic dysfunction-associated steatotic liver disease: Updates on the method effectiveness and perspectives

Abstract

Metabolic dysfunction-associated steatotic liver disease (MASLD) is the most widespread chronic liver disease signified by serious life-threatening conditions. The prevalence of MASLD increases along the growing prevalence in obesity and metabolic syndrome. To minimize costs and complications, non-invasive diagnostic tools, including transient elastography (TE), were introduced for assessment of MASLD. TE measures liver stiffness (LS), a clinical marker for the diagnosis of liver fibrosis and cirrhosis. LS measurements are based on ultrasound wave imaging and quantification. Vibration-controlled TE, including FibroScan^®, is commonly used TE methods which can accurately identify the degree of liver fibrosis and cirrhosis progression. TE was reported to predict the progression towards hepatocellular carcinoma, portal hypertension, and varices. However, the accuracy of LS diagnostics alone in patients with MASLD remains controversial. TE measurements have several limitations, including inadequate precision due to focal liver lesions, cholestasis, inflammation, and other pathological and anatomical factors which can lead to the stiffness variability. Overestimations of TE readings were reported in obese patients with body mass index (BMI) over 30 kg/m², and older patients with ascites, diabetes, or hypertension. Not all MASLD patients have high BMI. The prevalence of obesity among MASLD patients varies worldwide, indicating the urgent need for comprehensive diagnostic tools. In patients with MASLD, improved diagnostic accuracy has been demonstrated by combining LS measurements with other blood test-based scores and simple clinical parameters (agile scores based on age, sex, platelet count, aminotransferases, and diabetes). This study reviews the limitations of TE-based diagnostics and discusses the combined scoring algorithm. In conclusion, the sequence of LS measurements along assessment of other important clinical markers is an effective, low-cost, reliable tool to identify and monitor fibrosis progression in MASLD.

Keywords: Liver fibrosis; Liver stiffness measurement; Metabolic dysfunction-associated steatotic liver disease; Metabolic syndrome; Non-alcoholic fatty liver disease; Transient elastography.

Figure 1

The risk factors and biological mechanisms of metabolic dysfunction-associated steatotic liver disease. AMPK: AMP-activated protein kinase; CPT1: Carnitine palmitoyltransferase I; ER: Endoplasmic reticulum; HCC: Hepatocellular carcinoma; IL: Interleukin; JNK: C-Jun N-terminal kinase; MASLD: Metabolic dysfunction-associated steatotic liver disease; PPR-α: Peroxisome proliferator-activated receptor-alpha; ROS: Reactive oxygen species; Sirt: Sirtuin; Stat3: Signal transducer and activator of transcription 3; TNF-α: Tumor necrosis factor-alpha.

Figure 2

Factors that define transient elastography diagnostic accuracy. ALT: Alanine aminotransferase; AST: Aspartate aminotransferase; HCC: Hepatocellular carcinoma; TE: Transient elastography.