MASLD fibrosis panel
Enter one set of results to get FIB-4, the NAFLD fibrosis score (NFS), APRI, BARD and the AST to ALT ratio together, with how well they agree and what the AASLD pathway suggests next. Liver stiffness and ELF are optional and are used for the second step.
Enter age, AST, ALT and platelets to start.
The scores
- FIB-4 = (age × AST) ÷ (platelets × √ALT). Low under 1.30, high above 2.67. From age 65 the lower cut-off becomes 2.0. It is unreliable under 35.
- NAFLD fibrosis score = −1.675 + (0.037 × age) + (0.094 × BMI) + (1.13 × diabetes or IFG) + (0.99 × AST/ALT) − (0.013 × platelets) − (0.66 × albumin in g/dL). Low under −1.455, high above 0.676.
- APRI = (AST ÷ upper limit of normal) ÷ platelets × 100. Under 0.5 makes significant fibrosis unlikely; above 1.0 raises the possibility of cirrhosis. It was derived in hepatitis C, so it is supporting information only in MASLD.
- BARD = BMI 28 or more (1) + AST/ALT 0.8 or more (2) + diabetes (1). A score of 0 or 1 makes advanced fibrosis unlikely; 2 to 4 does not confirm it.
- AST to ALT ratio above 1 suggests more advanced disease in MASLD, but also raises alcohol as a cause.
The pathway
- FIB-4 below the lower cut-off: low risk. Reassess in 2 to 3 years, or 1 to 2 years with diabetes or two or more metabolic risk factors.
- FIB-4 in the middle band: do liver stiffness (FibroScan) or ELF as the second step.
- FIB-4 above 2.67: high risk of advanced fibrosis. Refer to hepatology.
- Liver stiffness under 8 kPa is low risk, 8 to 12 kPa intermediate, and above 12 kPa suggests advanced fibrosis. ELF under 7.7 is low, 7.7 to 9.8 intermediate and above 9.8 high.
- At 10 kPa or more, use the Baveno VIII rules for compensated advanced chronic liver disease and portal hypertension.
Cautions
- These scores assume the fatty liver is the main problem. Exclude alcohol, viral hepatitis, autoimmune and other causes before relying on them.
- They are less accurate at the extremes of age, and in acute illness, heart failure or a recent large weight change.
- A normal ALT does not exclude advanced fibrosis.
References
Rinella ME, Neuschwander-Tetri BA, Siddiqui MS, et al. AASLD Practice Guidance on the clinical assessment and management of nonalcoholic fatty liver disease. Hepatology. 2023;77(5):1797-1835.
Angulo P, Hui JM, Marchesini G, et al. The NAFLD fibrosis score: a noninvasive system that identifies liver fibrosis in patients with NAFLD. Hepatology. 2007;45(4):846-854.
Wai CT, Greenson JK, Fontana RJ, et al. A simple noninvasive index can predict both significant fibrosis and cirrhosis in patients with chronic hepatitis C. Hepatology. 2003;38(2):518-526.
Harrison SA, Oliver D, Arnold HL, et al. Development and validation of a simple NAFLD clinical scoring system for identifying patients without advanced disease. Gut. 2008;57(10):1441-1447.