Evaluation methods of hepatic steatosis: From conventional techniques to emerging biomarkers

Accurate assessment of hepatic steatosis is essential for diagnosing, staging, and monitoring metabolic dysfunction-associated steatotic liver disease. This review comprehensively overviews conventional and emerging hepatic steatosis evaluation methods. Noninvasive imaging techniques such as ultrasound, controlled attenuation parameter, and magnetic resonance imaging-derived proton density fat fraction are discussed alongside invasive reference standards such as liver biopsy. The review also highlights the role of blood-based biomarkers, including fibroblast growth factor 21, cytokeratin-18, type III procollagen peptide, and Mac-2 binding protein glycosylation isomer, as well as novel approaches such as epigenetic markers, artificial intelligence-assisted imaging, and digital pathology. Each method is presented with consideration of its diagnostic performance, clinical utility, and limitations. By integrating these modalities into multimodal assessment strategies and incorporating dynamic endpoints such as magnetic resonance imaging-derived proton density fat fraction (known as magnetic resonance imaging-derived proton density fat fraction)-based fat reduction as a therapeutic response marker, clinicians can improve diagnostic accuracy, risk stratification, and therapeutic guidance.