Non-invasive tests accurately stratify patients with NAFLD based on their risk of liver-related events

Published:January 18, 2022DOI:


      • At their published cut-offs, FIB4 and VCTE stratify patients with NAFLD into subgroups with significantly different prognoses.
      • Compared to liver biopsy in NAFLD, VCTE has similar accuracy for the prediction of liver-related events.
      • With regards to clinical events, the FIB4-VCTE stepwise algorithm accurately discriminates at-risk patients with NAFLD.
      • This algorithm should be used in the referral pathway to a liver specialist.

      Background & Aims

      Previous studies on the prognostic significance of non-invasive liver fibrosis tests in non-alcoholic fatty liver disease (NAFLD) lack direct comparison to liver biopsy. We aimed to evaluate the prognostic accuracy of fibrosis-4 (FIB4) and vibration-controlled transient elastography (VCTE), compared to liver biopsy, for the prediction of liver-related events (LREs) in NAFLD.


      A total of 1,057 patients with NAFLD and baseline FIB4 and VCTE were included in a multicenter cohort. Of these patients, 594 also had a baseline liver biopsy. The main study outcome during follow-up was occurrence of LREs, a composite endpoint combining cirrhosis complications and/or hepatocellular carcinoma. Discriminative ability was evaluated using Harrell’s C-index.


      FIB4 and VCTE showed good accuracy for the prediction of LREs, with Harrell’s C-indexes >0.80 (0.817 [0.768-0.866] vs. 0.878 [0.835-0.921], respectively, p = 0.059). In the biopsy subgroup, Harrell’s C-indexes of histological fibrosis staging and VCTE were not significantly different (0.932 [0.910-0.955] vs. 0.881 [0.832-0.931], respectively, p = 0.164), while both significantly outperformed FIB4 for the prediction of LREs. FIB4 and VCTE were independent predictors of LREs in the whole study cohort. The stepwise FIB4-VCTE algorithm accurately stratified the risk of LREs: compared to patients with “FIB4 <1.30”, those with “FIB4 ≥1.30 then VCTE <8.0 kPa” had similar risk of LREs (adjusted hazard ratio [aHR] 1.3; 95% CI 0.3–6.8), whereas the risk of LREs significantly increased in patients with “FIB4 ≥1.30 then VCTE 8.0-12.0 kPa” (aHR 3.8; 95% CI 1.3–10.9), and even more for those with “FIB4 ≥1.30 then VCTE >12.0 kPa” (aHR 12.4; 95% CI 5.1–30.2).


      VCTE and FIB4 accurately stratify patients with NAFLD based on their risk of LREs. These non-invasive tests are alternatives to liver biopsy for the identification of patients in need of specialized management.

      Lay summary

      The amount of fibrosis in the liver is closely associated with the risk of liver-related complications in non-alcoholic fatty liver disease (NAFLD). Liver biopsy currently remains the reference standard for the evaluation of fibrosis, but its application is limited by its invasiveness. Therefore, we evaluated the ability of non-invasive liver fibrosis tests to predict liver-related complications in NAFLD. Our results show that the blood test FIB4 and transient elastography stratify the risk of liver-related complications in NAFLD, and that transient elastography has similar prognostic accuracy as liver biopsy. These results support the use of non-invasive liver fibrosis tests instead of liver biopsy for the management of patients with NAFLD.

      Graphical abstract


      Linked Article

      • Low accuracy of FIB-4 test to identify people with diabetes at low risk of advanced fibrosis
        Journal of HepatologyVol. 77Issue 4
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          We read with great interest the article by Boursier et al. recently published in Journal of Hepatology.1 In a multicentre cohort of patients with NAFLD, the authors examined the prognostic accuracy of the stepwise Fibrosis-4 (FIB-4) – vibration-controlled transient elastography (VCTE) algorithm for non-invasive fibrosis risk stratification,2 for the prediction of cirrhosis complications, hepatocellular carcinoma, and death. The algorithm proposes FIB-4 as a first step to identify individuals at low risk (FIB-4 <1.3) of advanced fibrosis who can be managed in primary care.
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