NON-INVASIVE RISK STRATIFICATION IN METABOLIC DYSFUNCTION-ASSOCIATED STEATOTIC LIVER DISEASE: INTEGRATING FIBROSIS AND KIDNEY RISK
Patients with obesity, type 2 diabetes, hypertension, dyslipidaemia and chronic kidney disease (CKD) are commonly observed with metabolic dysfunction-associated steatotic liver disease (MASLD). It is very important not only to detect the presence of steatosis but also to be able to identify advanced fibrosis and a definition of kidney and cardiometabolic risk. Objectives: To review the available evidence regarding sequential non-invasive fibrosis assessment and to suggest a liver-kidney risk-stratification strategy that could be integrated for general clinical practice. Methods: A focused diagnostic evidence review was performed in PubMed/MEDLINE, the Cochrane Library, as well as official resources from EASL, AASLD, AGA and KDIGO. The eleven guidelines, consensus documents, metaanalyses, and large prospective studies were synthesized narratively without attempting to perform a statistical pooling because there was heterogeneity of tests, thresholds, reference standards, and outcomes. Results: Vibration-controlled transient elastography was more accurate at detecting advanced fibrosis than FIB-4 (area under the receiver operating characteristic curve 0.85 vs. 0.76, respectively) in an individual-patient-data meta-analysis. A sequential FIB-4 and elastography thresholds of 66% sensitivity and 86% specificity were achieved, leaving 33% of patients as candidates for biopsy [6]. Higher all-cause mortality was found to be associated with more severe liver fibrosis (F4 fibrosis) (HR 3.9, 95% CI 1.8-8.4) [7]. In observational cohorts, separately, fatty liver disease was found to be associated with incident CKD (HR 1.43, 95% CI 1.33-1.54) [9]. Discussion: FIB-4 should be used as a triage test, not as a diagnosis. The interpretation of secondary fibrosis testing, eGFR and UACR should be used in combination to inform the level of referral, surveillance and organ protection management.