Diagnostic accuracy of transient elastography in MASLD is independent of MRI-PDFF steatosis in a multicenter study

Transient elastography (TE) can be used to accurately screen for severe liver fibrosis in metabolic dysfunction-associated steatotic liver disease (MASLD). However, some studies suggest that steatosis influences liver stiffness measurement (LSM). Thus, treatment that modifies steatosis might impact the relevance of TE in the management of patients. The use of magnetic resonance imaging (MRI)-proton density fat fraction (PDFF) has shown good reliability and accuracy for quantifying hepatic steatosis. Therefore, the aim of our study was to evaluate the performance of TE combined with MRI-PDFF for the diagnosis of severe fibrosis in patients with MASLD. The study is registered at ClinicalTrials.gov (NCT03245606).

In this prospective multicenter study, patients with MASLD and indication for biopsy underwent MRI and TE within the same month. Biopsies were centrally reviewed using the steatosis, activity, and fibrosis (SAF) score. PDFF was centrally quantified using MRQuantif software. AUROCs for the diagnosis of fibrosis ≥F2 and ≥F3 were determined for LSM alone and LSM combined with PDFF as a continuous or categorical variable in a logistic regression.

In total, 208 patients were studied. The median age was 59 years, 63.9% were men, the median body mass index (BMI) was 31.2 kg/m², and 47.6% had diabetes. Of these patients, 56.3% had fibrosis ≥F2 and 30.3% had fibrosis F3-F4 on biopsy. Based on the SAF score, 35.7% of patients had MASH. The AUROC of LSM for fibrosis ≥F3 was 0.78 (95% CI 0.72-0.85), with no significant difference compared with the AUROC of LSM combined with PDFF (0.78; 95% CI 0.72-0.85; p = 0.96). The AUROC of LSM for fibrosis ≥F2 was 0.67 (95 % CI 0.60-0.74), with no significant difference compared with the AUROC of LSM combined with PDFF (0.66; 95% CI 0.59-0.73, p = 0.48).

TE performance for the diagnosis of liver fibrosis does not appear to be affected by the level of liver steatosis. Thus, quantifying hepatic steatosis using MRI-PDFF allows a comprehensive and accurate assessment of liver steatosis.

TE is a reliable tool for screening severe liver fibrosis in patients with MASLD. However, some studies suggest that the severity of steatosis influences LSM. Thus, treatment that modifies steatosis might impact the relevance of TE in the management of patients. This prospective multicenter study evaluated whether combining TE with MRI-PDFF, a precise method for measuring liver fat, could improve diagnostic accuracy for severe fibrosis in patients with MASLD. Our results show that TE performance in fibrosis diagnosis remains consistent regardless of steatosis levels, reinforcing the use of non-invasive methods, particularly TE, for regular patient monitoring, even as steatosis levels fluctuate.