Prevalence of F2 or Worse Fibrosis in MASLD Patients on FibroScan
Approximately 12% of patients with MASLD have significant fibrosis (F2 or worse) when assessed by FibroScan, though this varies substantially based on the population studied and clinical setting. 1
Evidence from Clinical Studies
The most direct evidence comes from a prospective cohort study of MASLD patients undergoing FibroScan evaluation, which found that 12% had significant fibrosis (≥F2), with 8% having F2 fibrosis specifically and 4% having cirrhosis (F4). 1 This study used standard FibroScan cutoffs and correlated findings with clinical parameters in a real-world MASLD population.
However, the prevalence of F2 or worse fibrosis varies considerably depending on the population characteristics:
Population-Specific Considerations
General MASLD Population
- In unselected MASLD cohorts, the median prevalence of significant fibrosis (≥F2) across multiple studies is approximately 52% (IQR 0.37-0.67), though this includes patients with chronic hepatitis B rather than pure MASLD populations. 2
- The Nigerian cohort study provides more specific MASLD data showing 12% with ≥F2 fibrosis in a community-referred population. 1
High-Risk MASLD Populations
- Patients with type 2 diabetes have substantially higher rates of advanced fibrosis, as diabetes is a major risk factor for fibrosis progression. 3
- Obesity (particularly central obesity with elevated waist-to-hip ratio) significantly increases fibrosis risk, with strong correlations between BMI and fibrosis stage. 1
- Tertiary care hepatology cohorts show much higher prevalence (22% with F4 cirrhosis alone) compared to community populations, reflecting referral bias. 4
FibroScan Diagnostic Performance for F2+ Fibrosis
Recommended Cutoffs
- For significant fibrosis (F2-4), a FibroScan cutoff of 7.4 kPa has 85% sensitivity and 79% specificity. 5
- For advanced fibrosis (F3-4), a cutoff of 8.4 kPa has 90% sensitivity and 79% specificity. 5
- The EASL-EASD-EASO guidelines recommend 8 kPa to exclude and 10.5 kPa to confirm advanced fibrosis (F3). 5
Diagnostic Accuracy Limitations
- FibroScan accurately identified only 45.9% of patients with biopsy-proven F3/F4 fibrosis in one validation study, highlighting significant limitations in sensitivity. 6
- Even combining FIB-4 with FibroScan achieved only 68.9% concordance with liver biopsy for advanced fibrosis detection. 6
- Values <8 kPa have excellent negative predictive value (100% in post-transplant cohorts) for excluding significant fibrosis. 7
Clinical Algorithm for Interpretation
When FibroScan shows:
- <7.4 kPa: No or mild fibrosis (F0-F1), routine follow-up with repeat assessment every 1-3 years 5
- 7.4-8.4 kPa: Grey zone for F2 fibrosis, consider additional testing (FIB-4, ELF) or liver biopsy if clinically indicated 5
- 8.4-10 kPa: Probable advanced fibrosis (F3), refer to hepatology for specialized evaluation 5
- ≥10 kPa: Probable cirrhosis (F4), monitor for complications and hepatocellular carcinoma 5
Important Caveats
Several factors can falsely elevate liver stiffness measurements:
- Acute hepatic inflammation (elevated transaminases) 5
- Hepatic congestion 5
- Recent alcohol consumption 5
- Obesity can reduce exam quality and accuracy 5
The sequential approach is recommended: Start with FIB-4 blood test, then proceed to FibroScan if FIB-4 is indeterminate (1.3-2.67) or elevated (>2.67), as this is the most cost-effective strategy. 8, 5 This approach recognizes that FibroScan is superior for predicting advanced fibrosis, while FIB-4 is better for excluding it. 8
When diagnostic uncertainty persists or clinical findings are inconsistent with FibroScan results, liver biopsy should be performed to avoid staging errors, particularly underestimating fibrosis in those with advanced disease. 6