Blood-based non-invasive tests show comparable accuracy in MetALD and MASLD for MRE-defined advanced fibrosis

Non-invasive tests (NITs) triage individuals with metabolic dysfunction-associated steatotic liver disease (MASLD) for advanced fibrosis (AF). However, evidence for performance in metabolic dysfunction and alcohol-associated liver disease (MetALD) remains limited. To determine how commonly used NITs perform in MetALD and MASLD using magnetic resonance elastography (MRE) as the reference. Adults (≥ 18 years) with MASLD /MetALD with cardiometabolic risk factors (CMRFs) and MRI proton density fat fraction-defined steatosis were included. Fibrosis-4 (FIB-4), AST platelet ratio index (APRIF), and NAFLD fibrosis score (NFS) were estimated. Contemporaneous MRE served as the comparator with a cut-off for AF of 3.53 kPa and sensitivity analysis at 3.6 kPa. Among 1010 individuals [44 (35-54 years), 35.2% females], 842(83.3%) had MASLD and 168(16.6%) had MetALD. CMRF [diabetes,36.6% vs.30.9%, p = 0.15], hypertension (38.2% vs. 34.5% p = 0.36), dyslipidaemia (31.5% vs. 33.9%, p = 0.55), and burden of AF (15.4% vs. 18.4%, p = 0.33) were similar. APRI was suboptimal [AUC 0.63 (0.60–0.66)]. In MASLD, the AUC for FIB-4 and NFS were 0.77 (0.72–0.82) and 0.80 (0.76–0.85), respectively. For MetALD, the AUC of FIB-4 and NFS were 0.78 (0.68–0.87) and 0.81 (0.70–0.89), respectively. FIB-4 (AUC 0.770 vs. 0.782, p = 0.99) and NFS (AUC 0.804 vs. 0.80, p = 0.94) had similar performance. Sensitivity analysis at 3.6 kPa threshold yielded similar results. In a liver clinic cohort, MASLD and MetALD showed similar CMRF and AF burden. FIB-4 and NFS, but not APRI, show clinically useful and similar performance for AF, supporting inexpensive standard NIT-based triage in MetALD.