Follow-up Approach in Patients with MASLD and Elevated FIB-4 after Excluding Advanced Fibrosis with Elastometry

Recommended Follow-up Algorithm

• The European Association for the Study of the Liver recommends implementing lifestyle interventions and intensified management of cardiometabolic risk factors for 1 year in patients with elevated FIB-4 but normal elastometry (<8 kPa) 1, 2
• The American Association for the Study of Liver Diseases suggests re-evaluating FIB-4 after 1 year of intervention 1
• If FIB-4 normalizes (<1.3 or <2.0 in those over 65), the European Association for the Study of the Liver recommends repeating the evaluation every 1-3 years 1, 2
• The American Association for the Study of Liver Diseases recommends considering a new elastometry if FIB-4 remains elevated despite interventions 1, 2

Monitoring of Cardiometabolic Risk Factors

• The American Diabetes Association recommends optimizing control of type 2 diabetes, if present 3, 4
• The European Association for the Study of the Liver suggests promoting a 3-5% weight loss through lifestyle modifications 5
• The American Heart Association recommends avoiding alcohol and sugary drinks consumption 5
• The World Health Organization suggests increasing regular physical activity 5

Important Considerations

Limitations of FIB-4

• The FIB-4 has moderate accuracy (AUROC around 0.77) for predicting advanced fibrosis 1
• It can generate false positives, especially in low-prevalence populations 1
• In the elderly (>65 years), a different threshold of 2.0 instead of 1.3 is applied 1, 6
• The FIB-4 may not identify around 10% of patients with advanced fibrosis 1, 2

Advantages of Sequential Approach

• The sequential use of FIB-4 and elastometry significantly improves diagnostic accuracy 7
• This approach has demonstrated feasibility in identifying patients at risk of liver events 1
• It allows stratifying patients into appropriate clinical care pathways (primary care, diabetologist, hepatologist) 1, 2

Alternative or Complementary Tests

• The ELF (Enhanced Liver Fibrosis) test can be used as an alternative to elastometry or as a supplementary method 1, 2
• Combined scores such as FAST (VCTE + CAP + AST) or MEFIB (MRE + FIB-4) can be considered in selected cases 1, 8
• In case of discrepancy between non-invasive tests, consider an additional method 9

Special Cases

Patients with Type 2 Diabetes

• Represent a high-risk population requiring closer monitoring 3, 4
• The FIB-4 may have greater limitations in this population 1
• Consider using complementary tests like ELF or elastometry more frequently 7

Patients with Discordant Results

• In case of discrepancy between FIB-4 and elastometry, use a third non-invasive test (e.g., ELF) 9
• The combination of two non-invasive tests improves accuracy in identifying advanced fibrosis 9