Liver Fibrosis: FIB-4 and Elastography
Comprehensive analysis using blood counts, biochemistry and the stiffness parameters · v1.1- Enter the blood count and the liver panel you already have, and the elastography report if one exists.
- Stage one is arithmetic: FIB-4, APRI and the AST to ALT ratio, banded against the cut-off that applies to this patient's age and to the cause of the disease.
- Stage two reads the elastography: the stiffness, the attenuation parameter and the spleen stiffness, first against the cut-offs for that cause and then against Baveno VII, which is cause-neutral and asks something different.
- Where the two stages disagree, the tool says what follows. That is the commonest reason a patient is referred, and it is what a single-score calculator cannot do.
- The order is the one the national programme and every current guideline use.
- Anyone under 18, and pregnancy.
- Acute liver failure, and the patient who is already decompensated with ascites, encephalopathy, jaundice or a variceal bleed. FIB-4 and elastography are tests for the compensated patient, and the staging of decompensated disease belongs to the hepatic staging pathway in this catalogue.
- Autoimmune hepatitis, primary biliary cholangitis, primary sclerosing cholangitis, and drug-induced liver injury including antitubercular injury, which carry their own stiffness cut-offs.
- The choice of drug treatment for steatohepatitis, and the surveillance interval for hepatocellular carcinoma.
- Any other score, and any number derived from an ultrasound report: the NAFLD Fibrosis Score, the ELF test, the FAST score, the AGILE scores, MRI-PDFF and magnetic resonance elastography. Where a guideline routes through one of those the tool names it, and no source read for this module gives a numeric ultrasound threshold for fibrosis.
1. The Setting
2. The Patient
3. The Blood Tests
4. Metabolic Measurements optional, and each one changes an answer
5. The Elastography Report
1. FIB-4
FIB-4 = age in years × AST in U/L, divided by the platelet count in ×10⁹/L multiplied by the square root of ALT in U/L. Sterling and colleagues derived it in 2006, in 832 patients co-infected with HIV and hepatitis C, to separate Ishak stage 4 to 6 from stage 0 to 3. Every other use of it since has been a borrowing.
| Source | Population | Rules out | Middle | Rules in |
|---|---|---|---|---|
| Sterling 2006, the original | HIV and hepatitis C co-infection | <1.45, NPV 90 per cent | 1.45 to 3.25 | >3.25, PPV 65 per cent, specificity 97 per cent |
| Shah 2009 | 541 adults with fatty liver disease | ≤1.30, NPV 90 per cent | 1.30 to 2.67 | ≥2.67, PPV 80 per cent |
| McPherson 2017, age 65 and over | 76 patients aged 65 and over, of 634 | <2.0, sensitivity 77 per cent | 2.0 to 2.67 | >2.67 |
| AASLD 2023 and AGA 2021 | MASLD, adopting Shah and McPherson | <1.3, or <2.0 above age 65 | 1.3 to 2.67 | >2.67, refer |
| EASL, EASD and EASO 2024 | MASLD | <1.3, reassess in 1 to 3 years | 1.3 to 2.67 | >2.67, hepatology referral |
| India, NAFLD operational guideline v2.0, September 2024 | The national NCD programme | <1.30, manage at the primary health centre | 1.30 to 2.67, refer to the district hospital | >2.67, refer to the district hospital |
| INASL 2022 | Indian fatty liver disease | <1.3 | 1.3 to 2.67 | >2.67 |
| INASL 2022, the Indian-data caveat in its text | Indian patients, for significant fibrosis | FIB-4 <1, with APRI <0.45 | not stated | not stated |
| India, NVHCP hepatitis B technical guideline 2019 | Chronic hepatitis B | not stated | >1.45 indicates significant fibrosis | ≥3.25 indicates cirrhosis |
| Baveno VII 2022, as a corroborating test | Any aetiology, alongside a stiffness of 10 kPa or more | not used this way | not used this way | ≥2.67 supports the stiffness reading |
2. APRI, and the AST to ALT ratio
APRI = AST divided by the laboratory's own upper limit of normal for AST, divided again by the platelet count in ×10⁹/L, and multiplied by 100. Wai derived it in 2003 in 270 patients with chronic hepatitis C. It matters in India because it needs only two numbers, and because the one Indian study to compare the two head to head against liver biopsy found it clearly better than FIB-4.
| Source | Question | Rules out | Rules in |
|---|---|---|---|
| Wai 2003, the original | Significant fibrosis, Ishak 3 or more, in hepatitis C | ≤0.5 | >1.5 |
| Wai 2003 | Cirrhosis in hepatitis C | ≤1.0 | >2.0 |
| INASL 2022 | Fibrosis in Indian fatty liver disease | <0.5 | >2.0, grey zone 0.5 to 2.0 |
| India, NVHCP viral hepatitis guideline 2018 | Significant fibrosis, then cirrhosis | not stated | >1.5 significant fibrosis, >2.0 cirrhosis |
| India, NVHCP hepatitis B guideline 2019 | Significant fibrosis, then cirrhosis | not stated | >1.5 significant fibrosis, ≥2.0 cirrhosis |
| Indian diabetologists' consensus 2025 | Fibrosis in MASLD | <0.5 | >1.5, grey zone 0.5 to 1.5 |
The AST to ALT ratio needs no threshold table because it has no agreed one. In fatty liver disease the ratio is usually below 1 until fibrosis is advanced, and a ratio that has climbed above 1 in a patient whose transaminases were previously ALT-dominant is a change worth noticing. A ratio at or above 2, particularly with a raised gamma-glutamyl transferase, points to alcohol. McPherson found the ratio less accurate than FIB-4 in every age group he tested, so it is printed here as context and never as a verdict.
3. Liver stiffness, by cause
| Cause and source | Rules out | Middle | Rules in |
|---|---|---|---|
| MASLD: AASLD 2023, AGA 2021, EASL 2021 and 2024 | <8 kPa, advanced fibrosis unlikely | 8 to 12 kPa | >12 kPa, advanced fibrosis likely |
| MASLD: India, NAFLD operational guideline v2.0, 2024 | 7.9 kPa or below | no middle band is given | >7.9 kPa is significant fibrosis, F2 to F4, refer to a hepatologist |
| MASLD: INASL 2022 | <6.0 kPa, significant fibrosis unlikely | 6.0 to 8.2 kPa | ≥8.2 kPa is F2 or more, ≥9.7 kPa is F3 or more, ≥13.6 kPa is cirrhosis |
| Alcohol-related: EASL 2021 | <8 kPa, advanced fibrosis ruled out | 8 to 12 kPa | ≥12 to 15 kPa, after excluding false positives |
| Hepatitis B with a normal ALT: EASL 2015 and 2017 | <6 kPa | 6 to 9 kPa, the grey area | >9 kPa, severe fibrosis or cirrhosis |
| Hepatitis B with ALT raised but below 5 times normal | <6 kPa | 6 to 12 kPa, the grey area | >12 kPa, severe fibrosis or cirrhosis |
| Hepatitis B: India, NVHCP 2019 | not stated | not stated | ≥8.0 kPa significant fibrosis, ≥12.5 kPa cirrhosis |
| Hepatitis C, untreated: EASL 2018 | not stated as a rule-out | not stated | 10 kPa for F3, 13 kPa for cirrhosis |
| Viral hepatitis: India, NVHCP 2018 | not stated | not stated | >8 kPa significant fibrosis, >11 kPa cirrhosis |
| Hepatitis C after cure: EASL 2021 | EASL gives no cut-off and issues the opposite instruction: the cut-offs used before treatment must not be used to stage fibrosis after a sustained virological response. Baveno VII gives one usable rule instead, below. | ||
4. Baveno VII, which answers a different question
The cut-offs above try to name a fibrosis stage. Baveno VII, 2022, does not: it asks whether the liver is already behaving like an advanced one, and whether the portal pressure has risen. That question is answered the same way whatever caused the disease, which is why these numbers appear in every branch of this tool. The two exceptions are marked.
| Statement | Threshold | Applies to |
|---|---|---|
| Compensated advanced chronic liver disease is ruled out | <10 kPa, with no other clinical or imaging sign | Any cause. A 3-year risk of decompensation or liver-related death of 1 per cent or less |
| Suggestive of that disease | 10 to 15 kPa | Any cause |
| Highly suggestive of it | >15 kPa | Any cause |
| The rule of 5 | 10, 15, 20 and 25 kPa | Any cause. Each mark is a step up in the risk of decompensation and death |
| A reading of 10 kPa or more must be confirmed | Repeat fasting, or corroborate with FIB-4 ≥2.67 or an ELF test ≥9.8 | Any cause. Transient elastography gives false positives |
| Clinically significant portal hypertension is ruled out | Stiffness ≤15 kPa and platelets ≥150 ×10⁹/L | Any cause. Sensitivity and negative predictive value both above 90 per cent |
| It is ruled in | ≥25 kPa | Only viral or alcohol-related disease, and steatohepatitis in a patient whose body mass index is under 30 |
| The ANTICIPATE model, risk 60 per cent or more | 20 to 25 kPa with platelets <150, or 15 to 20 kPa with platelets <110 ×10⁹/L | The same three groups, when stiffness is under 25 kPa |
| Screening endoscopy for varices is needed | Stiffness ≥20 kPa or platelets ≤150 ×10⁹/L | Compensated cirrhosis, in a patient who cannot take a non-selective beta-blocker. Otherwise repeat both yearly |
| A meaningful improvement | A fall of 20 per cent or more that ends below 20 kPa, or any fall below 10 kPa | Any cause |
| Spleen stiffness | <21 kPa rules portal hypertension out, >50 kPa rules it in | Only viral hepatitis: untreated hepatitis C, and hepatitis B treated or untreated |
| Spleen stiffness, to avoid an endoscopy | ≤40 kPa | A patient who cannot take a beta-blocker and would otherwise need screening |
| Discharge from portal hypertension surveillance after hepatitis C is cured | Stiffness <12 kPa and platelets >150 ×10⁹/L, with no co-factor | Cured hepatitis C. Surveillance for liver cancer continues regardless |
5. The controlled attenuation parameter
This is the steatosis measurement, not a fibrosis measurement, and its thresholds are the least settled numbers in this tool. EASL 2021 says so in as many words: there are no consensual cut-offs, and the one figure it will endorse is 275 dB/m as a sensitive marker that some steatosis is present. Everything else below is a study finding.
| Source and probe | S1, any steatosis | S2, a third or more | S3, two thirds or more |
|---|---|---|---|
| Karlas 2017, individual patient data, M probe | 248 dB/m | 268 dB/m | 280 dB/m |
| India, NAFLD operational guideline v2.0, 2024 | 248 to 268 dB/m | 268 to 280 dB/m | above 280 dB/m |
| EASL 2021, the only endorsed figure | above 275 dB/m, over 90 per cent sensitivity | no figure given | no figure given |
| Shalimar 2020, Indian, body mass index under 25 | 275 dB/m | 319 dB/m | 337 dB/m |
| Shalimar 2020, Indian, obese | 285 dB/m | 340 dB/m | 355 dB/m |
| Kuchay 2021, Indian, against MRI-PDFF | 262 dB/m for 5 per cent fat | 295 dB/m for 10 per cent fat | not derived |
| EASL 2021, XL probe | 263 dB/m at high sensitivity, 294 dB/m at the best trade-off | not derived | not derived |
6. What the sources do not say
- No document read for this tool gives a rule for what to do when FIB-4 and the stiffness disagree. AASLD 2023 and the AGA expert review of 2023 both say the same thing, which is refer the patient and consider a biopsy. Neither says which test to believe. Neither distinguishes a low score with a high stiffness from a high score with a normal one. This tool prints the mechanisms behind each direction, and resolves it no further than they do.
- EASL 2021 gives no threshold for significant fibrosis, F2, in any cause. F2 is not a target condition in that document. INASL and the Indian national programme both make F2 the entry point instead, which is why their numbers are lower.
- There is no Indian transient elastography study with its own biopsy-derived kilopascal cut-offs. INASL 2022 says the Indian data are scant and that what exists suggests the Western cut-offs hold. The Indian elastography validation literature that does exist is for the attenuation parameter and for composite scores, not for stiffness alone.
- There is no ICMR Standard Treatment Workflow on fatty liver disease, cirrhosis or fibrosis staging. The single liver workflow in that series is on acute and acute-on-chronic liver failure, July 2020, and it contains no fibrosis score and no elastography.
- No published count exists of how many working elastography machines there are in Indian district hospitals. The national guideline places the test at that level; whether the machine is there is not a documented fact.
- A newer AGA care pathway exists and its numbers could not be verified. Kanwal and colleagues published a replacement pathway in Gastroenterology in March 2026. Reports of it describe the removal of the indeterminate bands for both FIB-4 and stiffness, and an ELF cut-off of 9.2. The full text is behind a paywall and was not read, so none of its numbers are used in this tool, and the 2021 pathway is what is implemented.
7. What the machine measures
A probe on the skin over the right lobe delivers a low-frequency mechanical pulse, a 50 Hz thump, into the liver. That thump travels as a shear wave, and the same probe tracks it by ultrasound. Stiff tissue carries a shear wave faster. The machine converts the velocity to a Young modulus in kilopascals. It samples a cylinder roughly 1 cm across and 4 cm long, about a hundred times the volume of a biopsy core, which is the technique's real advantage over histology and the reason it is not defeated by sampling error the way a needle is.
What it does not measure is fibrosis. It measures stiffness, and fibrosis is only one of the things that make a liver stiff. Oedema, inflammation, cholestasis and venous congestion all stiffen a liver within days, and they resolve in days too. That single fact is the origin of every caution in this tab.
8. Reading the report
| What is printed | What it means | What to check |
|---|---|---|
| Median, in kPa | The liver stiffness. This is the only number the guidelines band | Take the median, never the range and never the stage the machine prints beside it |
| IQR/med, as a percentage | How much the ten measurements disagreed with each other | Above 30 per cent the reading is unreliable. Below 10 per cent it is at its most accurate |
| Valid measurements, or success rate | How many of the shots the machine accepted | At least 10 valid, and a success rate above 60 per cent. If nothing is obtained after ten shots the examination has failed |
| CAP, in dB/m | Controlled attenuation parameter, the ultrasound signal lost to fat. A steatosis measure, nothing to do with fibrosis | Read it against the body mass index, not against a single number |
| Probe: M or XL | M samples 25 to 65 mm below the skin, XL from 35 to 75 mm | If the report does not say, and the patient is obese, ask. It changes the reading |
| A fibrosis stage, F0 to F4 | The manufacturer's own banding | Ignore it. It is not the banding any guideline uses, and it is not the banding in this tool |
9. Which probe, and what it does to the number
The M probe is the default. The XL probe is used when the skin to liver capsule distance is more than 25 mm, which in practice means a body mass index above 30. Getting this wrong in either direction matters. With the M probe in patients above a body mass index of 28, measurement failed in 16 per cent of cases against 1.1 per cent with the XL probe, and a quarter of XL readings were still unreliable against half of M readings.
10. Everything that raises stiffness without fibrosis
| Cause | The threshold or interval, where a source gives one | What to do |
|---|---|---|
| A recent meal | Fast at least 3 hours, EASL 2021 main text. The same document's supplementary material still says 2 hours, and both are in print | Repeat fasting. This is the single easiest scan to redo |
| Transaminase elevation of any cause | Interpretation requires transaminases below 5 times normal; above 10 times normal the scan should not be used | Treat the cause, wait, repeat |
| A hepatitis B flare | Stiffness can stay misleadingly high for 3 to 6 months after the ALT has returned to normal | Wait the full interval. A scan at 6 weeks is not a scan |
| Alcoholic steatohepatitis, or recent drinking | AST or GGT above twice normal, EASL 2021. AST above 100 U/L, EASL 2018. The two documents use different quantities | Repeat after at least a week of abstinence. Published falls are 16 per cent at 5 days, 22 per cent at 1 week, 25 per cent at 4 weeks |
| Extrahepatic cholestasis | No numeric threshold is published | Relieve the obstruction first. A stiffness measured through a blocked duct measures the block |
| Right heart failure, or any congestive liver | No numeric threshold is published | Decongest first. This is the confounder most often missed on a medical ward |
| Obesity and the metabolic syndrome | Named by EASL 2021 as a source of false positives specifically against the 10 kPa mark | Confirm with a second test rather than acting on a single borderline reading |
| Exercise immediately before the scan | No numeric threshold is published | Rest the patient |
Steatosis itself is the one that is genuinely unresolved. Some studies find that fat raises the stiffness reading and others do not, and EASL says so rather than choosing. Take it as a reason to distrust a borderline number in a very fatty liver, not as a correction to apply.
11. Spleen stiffness
The spleen enlarges and stiffens as portal pressure rises, so its stiffness tracks portal hypertension more directly than the liver's does. Baveno VII allows it, and hedges it heavily. It is validated for ruling portal hypertension in and out only in viral hepatitis, at under 21 kPa and over 50 kPa; the consensus states in the same sentence that validation of the best cut-off with the dedicated 100 Hz probe is still needed. A separate and lower mark, 40 kPa or below, is used for a narrower purpose: identifying the patient who can be spared a screening endoscopy. Most Indian machines do not carry the spleen module, so for most reports this measurement will simply be absent, which is not a deficiency in the scan.
12. When there is no machine
This is the ordinary situation in most of Indian practice, and the guidelines answer it directly. AASLD 2023 says a serum test may be used as the second-step assessment where elastography is not available. The AGA pathway says the same. INASL routes the patient to a tertiary centre for the scan and, in the meantime, treats a high or intermediate blood score as the trigger to refer. The Indian national programme places the scan at district hospital level and expects the community health centre to work with FIB-4 and the NAFLD Fibrosis Score alone.
1. Derivation of FIB-4, and the Change in Nomenclature
The thresholds were derived in two specific populations. Accuracy declines as a patient's characteristics diverge from those populations.
- Sterling 2006: derived in 832 patients co-infected with HIV and hepatitis C, when the alternative was a liver biopsy.
- Shah 2009: the first use in fatty liver disease, best of eight scores in 541 patients, in a paper that also called for better markers.
- The 2023 multisociety Delphi replaced non-alcoholic fatty liver disease with metabolic dysfunction-associated steatotic liver disease: at least one of five cardiometabolic criteria, and MetALD for the intermediate drinker.
- INASL adopted it in 2025 and kept the same work-up, risk stratification and management. Over 98 per cent of the 7,721 patients in the Indian consortium cohort met the new criteria, and FIB-4 and stiffness performed the same under both definitions. Not one threshold in this tool moved.
2. The Effect of Age on the FIB-4 Result
Age enters the numerator of the score, so identical laboratory values return different results at different ages.
At 40 years old, FIB-4 is 1.58: intermediate, and the guideline sends this patient for a scan.
At 70 years old, FIB-4 is 2.77: above 2.67, and on the standard reading this patient goes to a hepatologist.
The laboratory values are identical; only the age term differs. McPherson raised the rule-out threshold to 2.0 above 65 for this reason: at the standard cut-off, specificity in that age group fell to 35 per cent, so two of every three positive results were false.
3. Non-Hepatic Causes of a Low Platelet Count in India
The platelet count sits in the denominator of both FIB-4 and APRI, so any cause of thrombocytopenia raises both scores. Neither score can distinguish thrombocytopenia due to portal hypertension from thrombocytopenia due to an acute infection.
| Cause | The Indian figure, where one exists | Effect on FIB-4 |
|---|---|---|
| Population baseline | 25.3 per cent of 510 healthy adults sampled in four upper Assam districts had a platelet count below 130 ×10⁹/L | Raises it in a quarter of a healthy population, before any liver disease |
| Dengue | 289,235 cases nationally in 2023; 121,824 in 2025 | Transient, sometimes profound. A convalescent count is not interpretable |
| Malaria | Platelets below 150 ×10⁹/L in 65.4 per cent of 676 admitted children in one Bikaner series | Transient, and more marked in vivax than in falciparum in that series |
| Non-cirrhotic portal fibrosis, extrahepatic portal vein obstruction | No national prevalence figure was found | Persistent, and easily mistaken for cirrhotic hypersplenism |
No Indian guidance document read for this tool names any of this as a limitation of FIB-4, and no Indian study has quantified its effect. The blood count should be taken after the patient has recovered.
4. Performance and Limitations of Two-Step Testing
The design assumes a population in which advanced fibrosis is uncommon, and both steps are calibrated to that prevalence. Applied in a hepatology clinic, where a third of patients have advanced disease, the predictive values change although no threshold does. The resulting asymmetry is reported in the derivation papers:
- FIB-4 below 1.30 in fatty liver disease: negative predictive value 90 per cent, which is a reliable rule-out.
- FIB-4 at or above 2.67: positive predictive value 80 per cent in Shah's derivation, and 60 to 80 per cent across the studies the AGA pathway reviewed.
- Stiffness above 12 kPa in MASLD: AASLD 2023 records the positive predictive value as ranging from 0.34 to 0.71.
A high FIB-4 is an indication for further assessment. It is not, by itself, a diagnosis of advanced fibrosis.
5. Comparison of APRI and FIB-4 in Indian Patients
Kolhe and colleagues biopsied 100 consecutive patients with fatty liver disease from an urban slum population in Mumbai in 2019, 27 of whom had significant fibrosis.
- For ruling out significant fibrosis, the area under the curve was 0.95 for APRI and 0.78 for FIB-4.
- INASL's text says Indian data support ruling out significant fibrosis at APRI below 0.45 or FIB-4 below 1. Its recommendation statements then use the international 1.3.
- APRI is therefore computed alongside FIB-4 in every result rather than offered as an option.
6. Lean Fatty Liver Disease and Central Obesity
In 170 lean Indian patients, 56.5 per cent nonetheless had central obesity by waist circumference. The correlation between body mass index and waist was poor, at r = 0.24.
Within that lean group, those with central obesity had advanced fibrosis on FIB-4 in 19.8 per cent against 8.1 per cent, and on stiffness in 9.5 per cent against none at all. The adjusted odds ratio was 3.11.
In a 1,040-patient cohort, FIB-4, stiffness, CAP and the FAST score were all statistically indistinguishable between lean and non-lean patients, and the biopsies showed no difference in steatohepatitis or fibrosis either.
The implication is that waist circumference should be measured routinely, not that a different threshold should be used. No Indian study has derived a separate FIB-4 or stiffness cut-off for lean patients, and INASL applies the same ones.
7. Divergence Among the Indian Elastography Thresholds
| Document | Threshold | What it is a threshold for |
|---|---|---|
| NAFLD operational guideline under the NCD programme, v2.0, September 2024 | >7.9 kPa | Significant fibrosis, F2 to F4, in fatty liver disease |
| INASL guidance paper, 2022 | ≥8.2 kPa, and ≥13.6 kPa | F2 or more, and cirrhosis, in fatty liver disease |
| NVHCP hepatitis B technical guideline, 2019 | ≥8.0 kPa, and ≥12.5 kPa | Significant fibrosis, and cirrhosis, in hepatitis B |
A stiffness of 8.0 kPa meets the threshold for significant fibrosis under the national programme, and under the hepatitis B guideline where that is the diagnosis, but not under INASL. The differences are small and each is defensible within its own document. A threshold taken from one document should not be applied to a disease addressed by another.
8. Scope and Restrictions of the Baveno VII Criteria
It defines compensated advanced chronic liver disease as a stiffness band, "irrespective of histological stage or the ability of stiffness to identify these stages". The question addressed is the risk of decompensation, not the histological stage.
- Its numbers are therefore the same in every disease. The two places it becomes disease-specific are marked heavily: ruling portal hypertension in at 25 kPa, and spleen stiffness. Both are validated only in viral and alcohol-related disease, and in steatohepatitis only when the body mass index is below 30.
- The rule of 5, 10, 15, 20, 25, is a risk ladder and not a set of diagnoses. Each mark is a step up in the risk of decompensation and liver-related death, whatever caused the disease.
- Below 10 kPa the three-year risk of either is 1 per cent or less, a figure that is useful when counselling an anxious patient.
Baveno VII does not permit an answer. Both the 25 kPa rule-in and the ANTICIPATE model, which would otherwise put 20 to 25 kPa with platelets under 150 at a risk of 60 per cent or more, are restricted to viral disease, alcohol-related disease, and steatohepatitis below a body mass index of 30. At 33 he is outside all three. Three statements remain valid: above 20 kPa with platelets below 150 he needs a screening endoscopy if he cannot take a beta-blocker; above the 15 kPa mark compensated advanced chronic liver disease is highly likely; and the next step is a hepatology opinion, not a number.
9. Interpretation of Steatosis and of Serial Stiffness Measurements
CAP measures fat, and fibrosis stage is the strongest predictor of liver-related outcome in fatty liver disease while steatosis grade is not.
- A CAP of 340 dB/m with a stiffness of 4 kPa is a fatty liver without fibrosis, and calls for lifestyle management. A CAP of 240 with a stiffness of 14 kPa is more serious in every way, and the fat may have burned off as the fibrosis advanced.
- Baveno VII counts an improvement as a fall of at least 20 per cent ending below 20 kPa, or any fall to below 10 kPa. Anything smaller may be measurement variation.
- EASL records a coefficient of variation of up to 60 per cent in cirrhosis, and about a third of readings above 7.9 kPa are not reproduced on a repeat scan. A patient should be followed on the same machine in the same unit where possible, and a fall from 9.8 to 8.6 kPa should not be interpreted as a treatment response.
10. Limitations of a Low FIB-4, and Documentation of the Assessment
A fibrosis assessment recorded as "FIB-4 2.1" cannot be interpreted by a subsequent reader, who has no way of telling whether it was calculated on a convalescent platelet count or which threshold was applied. Recording the following keeps the assessment interpretable:
| Record | Because |
|---|---|
| The four raw values and the date of the blood count | The score can be recomputed and the platelet count questioned |
| The cause of the liver disease you assumed | It determines which stiffness cut-offs apply |
| The threshold you used and why | 1.3 and 2.0 give opposite answers in the same 66-year-old |
| The stiffness median, the IQR to median ratio, and the probe | Without those three the kilopascal figure cannot be audited |
| Any confounder present on the day of the scan | The next clinician will otherwise repeat the same uninterpretable test |
| The date the assessment is to be repeated | This is the substantive content of a low-risk result |
References
- Sterling RK, Lissen E, Clumeck N, et al. Development of a simple noninvasive index to predict significant fibrosis in patients with HIV/HCV coinfection. Hepatology 2006;43(6):1317-25.
- Shah AG, Lydecker A, Murray K, et al. Comparison of noninvasive markers of fibrosis in patients with nonalcoholic fatty liver disease. Clin Gastroenterol Hepatol 2009;7(10):1104-12.
- McPherson S, Hardy T, Dufour JF, et al. Age as a confounding factor for the accurate non-invasive diagnosis of advanced NAFLD fibrosis. Am J Gastroenterol 2017;112(5):740-51.
- 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):518-26.
- 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.
- Kanwal F, Shubrook JH, Adams LA, et al. Clinical Care Pathway for the risk stratification and management of patients with nonalcoholic fatty liver disease. Gastroenterology 2021;161(5):1657-69.
- European Association for the Study of the Liver, European Association for the Study of Diabetes, European Association for the Study of Obesity. EASL-EASD-EASO Clinical Practice Guidelines on the management of metabolic dysfunction-associated steatotic liver disease. J Hepatol 2024;81(3):492-542.
- European Association for the Study of the Liver. EASL Clinical Practice Guidelines on non-invasive tests for evaluation of liver disease severity and prognosis, 2021 update. J Hepatol 2021;75(3):659-89.
- European Association for the Study of the Liver. EASL 2017 Clinical Practice Guidelines on the management of hepatitis B virus infection. J Hepatol 2017;67(2):370-98, read with the EASL-ALEH 2015 guidelines on non-invasive tests, J Hepatol 2015;63(1):237-64.
- European Association for the Study of the Liver. EASL Recommendations on Treatment of Hepatitis C 2018. J Hepatol 2018;69(2):461-511.
- de Franchis R, Bosch J, Garcia-Tsao G, Reiberger T, Ripoll C, Baveno VII Faculty. Baveno VII: renewing consensus in portal hypertension. J Hepatol 2022;76(4):959-74.
- Karlas T, Petroff D, Sasso M, et al. Individual patient data meta-analysis of controlled attenuation parameter (CAP) technology for assessing steatosis. J Hepatol 2017;66(5):1022-30.
- Duseja A, Singh SP, De A, et al. Indian National Association for Study of the Liver (INASL) guidance paper on nomenclature, diagnosis and treatment of nonalcoholic fatty liver disease. J Clin Exp Hepatol 2023;13(2):273-302, read with the 2025 INASL statement adopting the MASLD nomenclature, J Clin Exp Hepatol 2025;15(5):102590.
- Directorate General of Health Services, Ministry of Health and Family Welfare, Government of India. Operational Guidelines for Non-alcoholic Fatty Liver Disease under the National Programme for Prevention and Control of Non-Communicable Diseases, Version 2.0, September 2024.
- Kolhe KM, Amarapurkar A, Parikh P, et al. Aspartate transaminase to platelet ratio index (APRI) but not FIB-5 or FIB-4 is accurate in ruling out significant fibrosis in patients with non-alcoholic fatty liver disease (NAFLD) in an urban slum-dwelling population. BMJ Open Gastroenterol 2019;6(1):e000288.
- Shalimar, Elhence A, Bansal B, et al. Prevalence of non-alcoholic fatty liver disease in India: a systematic review and meta-analysis. J Clin Exp Hepatol 2022;12(3):818-29, read with De A, Bhagat N, Mehta M, et al. Central obesity is an independent determinant of advanced fibrosis in lean patients with non-alcoholic fatty liver disease. J Clin Exp Hepatol 2025;15(1):102400.
How to Cite This Tool
DOIhttps://doi.org/10.5281/zenodo.22401578
AMA Style:Umakanth S. Liver Fibrosis: FIB-4 and Elastography. Version 1.1. MEDiscuss Clinical Decision Support System. Published 2026. Accessed . https://mediscuss.org/cdss/fib4-fibroscan. doi:10.5281/zenodo.22401578
Vancouver Style:Umakanth S. Liver Fibrosis: FIB-4 and Elastography [Internet]. Version 1.1. MEDiscuss.org; 2026 [cited ]. Available from: https://mediscuss.org/cdss/fib4-fibroscan. doi:10.5281/zenodo.22401578
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