From the Guidelines
The FIB-4 threshold for FibroScan in patients over 65 years old is 2.0, as recommended by the most recent guidelines 1. This threshold is used to rule out advanced fibrosis in elderly patients, rather than the standard cutoff of 1.3 used in younger adults. The adjustment of the FIB-4 threshold to 2.0 in patients over 65 years old is supported by recent studies, including the 2024 EASL-EASD-EASO clinical practice guidelines on the management of metabolic dysfunction-associated steatotic liver disease (MASLD) 1. According to these guidelines, a lower FIB-4 cut-off of 2.0 is valid for age >65 years. Another study published in 2023 also supports this threshold, stating that in patients older than 65 years of age, a FIB-4 cutoff of <2.0 should be used to exclude advanced hepatic fibrosis 2. Key points to consider when using the FIB-4 threshold in patients over 65 include:
- A FIB-4 score below 2.0 generally indicates low risk of advanced fibrosis
- Scores above 2.0 may warrant further evaluation with FibroScan or other non-invasive tests
- The age-adjusted approach helps reduce unnecessary liver stiffness measurements in older adults while maintaining diagnostic accuracy.
From the Research
Fib4 Threshold for Fibroscan in Over 65
- The Fibrosis-4 (FIB-4) index is used to triage patients with metabolic dysfunction-associated steatotic liver disease, and its threshold may vary with age 3.
- A study found that in participants aged ≥65, the negative predictive value for VCTE ≥10 kPa of FIB-4 <1.3 was 100% versus FIB-4 <2.0 was 83% 3.
- The same study suggested that there is no rationale for increasing the FIB-4 threshold to 2 for undergoing further testing in patients aged ≥65 3.
- However, the study also found that the meaning of a FIB-4 of 2.7 strongly changes with age, and this cutoff for ages over 65 is not enough to define high-risk and would not warrant direct referral 3.
- Another study found that the cumulative incidence of liver events in the high (>2·67), indeterminate (1·30-2·67), and low (<1·30) baseline FIB-4 risk groups were 15%, 3%, and 1%, respectively, at 10 years 4.
- The FIB-4 index has clinical utility as a prognostic biomarker, and sequential measurement provides a pragmatic, tractable monitoring biomarker that refines risk assessment for liver events, cardiovascular events, and mortality 4.
Diagnostic and Treatment Modalities
- Liver biopsy remains the gold standard of staging liver fibrosis, but transient elastography is increasingly being used in clinical trials and in hepatology clinics as part of standard-of-care evaluation 5.
- Magnetic resonance (MR)-elastography is most accurate in evaluating fibrosis stage but is costly and time consuming and thus not readily available 5.
- Recent advances have been made in areas of diagnostic and therapeutic modalities, with an increasing number of potential drugs currently in phase II and III trials, particularly in the field of non-alcoholic steatohepatitis-related liver fibrosis 5.
Pathophysiology and Clinical Implications
- Liver fibrosis is a clinically significant finding that has major impacts on patient morbidity and mortality, and the mechanism of fibrosis involves many different cellular pathways 6.
- The progression to cirrhosis brings more dramatic mortality and higher incidence of hepatocellular carcinoma, and fibrosis can also affect outcomes following liver transplantation in adult and pediatric patients and require retransplantation 6.
- Drugs exist to treat Hepatitis B and C that reverse fibrosis in patients with those viral diseases, but there are currently no therapies to directly treat liver fibrosis 6.