How effective are experienced hepatologists at staging fibrosis using non‐invasive fibrosis tests in patients with metabolic dysfunction‐associated steatotic liver disease?

Summary Background Sequential use of non‐invasive fibrosis tests (NITs) to identify patients with advanced hepatic fibrosis is recommended. However, it remains unclear how reliable clinicians are staging liver fibrosis using combinations of NITs. Aim Our aim was to assess concordance between NIT‐based ‘clinician fibrosis assessment (CFA)’ and histology in patients with metabolic dysfunction‐associated steatotic liver disease (MASLD) and compare this with established algorithmic approaches. Methods Six experienced hepatologists independently staged 230 MASLD patients for advanced fibrosis (F0‐2 vs F3‐4) using FIB‐4, FIB‐4+ELF, FIB‐4+ vibration controlled transient elastography (VCTE; Fibroscan™) and FIB‐4+ELF+VTCE. Concordance between histology and CFA or algorithmic approaches were assessed. Results A total of 230 patients were included (median age 54 [22–78] years; 55% female; median FIB‐4 1.21 [IQR: 0.78–1.91]; ELF 9.3 [IQR: 8.6–10.2]; VCTE 9.4 [IQR: 6.3–14.3]; 41% F0‐1, 22% F2, 21% F3 and 16% F4). Overall, area under the receiver operator curves for histologic F3‐4 for the raw tests were 0.84 for FIB‐4, 0.86 for ELF and 0.86 for VCTE. Concordance between the hepatologists was good (FIB4, κ = 0.64; FIB‐4+ELF, κ = 0.70; FIB‐4+VCTE, κ = 0.69; FIB‐4+ELF+VCTE, κ = 0.70). Concordance between individual CFA and histology was variable, which was reflected in variability in sensitivity (44%–84%) and specificity (76%–94%). Concordance with histology was better when clinicians used NIT combinations. Purely algorithmic approaches, particularly sequential use of FIB‐4 then VCTE, tended to perform better than the CFA. Conclusions Adhering to the recommended algorithmic approaches using NITs to stage fibrosis tended to perform more accurately than less‐structured clinician NIT‐based assessments conducted by experienced hepatologists.