Sequential SAFE Score and Transient Elastography for Detecting Significant Fibrosis in Asian Patients with MASLD

Metabolic dysfunction-associated steatotic liver disease (MASLD), formerly known as nonalcoholic fatty liver disease (NAFLD),¹ represents a global public health issue. Fibrosis stage is the most important risk for long-term undesirable outcomes.^2,3 From recent meta-analyses, all-cause and liver-related mortalities significantly increased from fibrosis stage 2 (significant fibrosis; F≥2) onward.^4,5 In primary care setting, those with F≥2 should be referred to hepatologists; therefore, noninvasive tests to stratify risk of patients with MASLD are crucial. Steatosis-associated fibrosis estimator (SAFE) was recently developed to predict F≥2.⁶ SAFE has been externally validated and outperformed fibrosis-4 (FIB-4) and NAFLD fibrosis score (NFS).^7,8 Recently, international guidelines proposed sequential diagnostic steps, initially using FIB-4 and then transient elastography (TE) in non-low-risk patients.^9,10 However, the guidelines focused on identifying advanced fibrosis (F≥3), which might be too late. This study aimed to compare the performance among SAFE, FIB-4, and NFS, and evaluate SAFE-TE sequential approach. We hypothesized that by initially using SAFE, the proportion of patients misclassified as low risk despite already having F≥2 could be diminished.