Interpretation of liver stiffness measurement in patients with mixed liver disease etiologies

Vibration-controlled transient elastography (VCTE)-based liver stiffness measurement (LSM) is widely used for non-invasive assessment of liver fibrosis and portal hypertension in chronic liver disease. In daily practice, LSM values are often interpreted using etiology-specific fibrosis cut-offs embedded in device software. However, an increasing proportion of patients now present with mixed liver disease etiologies, particularly combinations of metabolic-associated steatotic liver disease (MASLD) with viral or alcohol-related liver disease. In such patients, applying singleetiology cut-offs may lead to misclassification of fibrosis stage and portal hypertension risk. We highlight the limitations of this approach and argue that LSM should be interpreted within a broader clinical context, integrating platelet count, biochemical markers, and validated risk-stratification algorithms rather than relying solely on fibrosis staging tables.