Unifying Concepts

Screening for Advanced Fibrosis Related to NAFLD/NASH

Approximately 37% of adults, and as many as 70% of individuals with type 2 diabetes (T2D), have nonalcoholic fatty liver disease (NAFLD). Nonalcoholic steatohepatitis (NASH), a subtype of NAFLD characterized by inflammation, ballooning, and Mallory’s hyaline on liver biopsy, can lead to hepatic fibrosis, cirrhosis, and hepatocellular cancer (HCC). Both NAFLD and NASH are also associated with an increased risk of cardiovascular disease, cardiovascular and liver-related mortality, and impaired health-related quality of life. 

Screening for Advanced Fibrosis Related to NAFLD/NASH

Primary care, endocrinologists, gastroenterologists, and obesity specialists should screen for NAFLD with advanced fibrosis

Step 1: Identify patients at risk

  • 2 or more metabolic risk factors (central obesity, high triglycerides, low HDL cholesterol, hypertension, prediabetes, or insulin resistance)
  • Type 2 diabetes
  • Steatosis on any imaging modality or elevated aminotransferases

Step 2: History and laboratory tests

  • Excessive alcohol intake, complete blood count, liver function tests

Step 3: Non-invasive testing (NIT) for fibrosis

(FIB-4 is a calculated value based on age, AST, ALT & platelet count)

  • Low risk: FIB-4 <1.3
  • Indeterminate risk: FIB-4 1.3 to 2.67
  • High risk: FIB-4 > 2.67

Step 4: Liver stiffness measurement (LSM)

  • Low risk: LSM < 8 kPa
  • Indeterminate risk: LSM 8 to 12 kPa
  • High risk: LSM > 12 kPa


  • LOW RISK: Repeat NIT in 2-3 years unless clinical circumstances change
  • INDETERMINATE RISK: Refer to hepatologist for liver biopsy or Magnetic Resonance Elastography (MRE) or monitoring with re-evaluation of risk in 2-3 years
  • HIGH RISK: Refer to hepatologist



  1. Kanwal F, Shubrook JH, Adams LA, Pfotenhauer K, Wai-Sun Wong V, Wright E, Abdelmalek MF, Harrison SA, Loomba R, Mantzoros CS, Bugianesi E, Eckel RH, Kaplan LM, El-Serag HB, Cusi K. Clinical Care Pathway for the Risk Stratification and Management of Patients With Nonalcoholic Fatty Liver Disease. Gastroenterology. 2021 Nov;161(5):1657-1669. [Medline]
  2. Sullivan S, Jirapinyo P, Kumbhari V. Clinical Care Pathway for the Risk Stratification and Management of Patients With Non-alcoholic Fatty Liver Disease. Gastroenterology. 2022 Jun;162(7):2131-2132. [Medline]


Created Oct 24, 2022.

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