Tiered MASLD Screening Strategy More Accurate but Misses Significant Fibrosis, Study Finds

A guideline-recommended tiered screening approach for metabolic dysfunction–associated steatotic liver disease (MASLD) may improve overall diagnostic accuracy in primary care but risks missing a substantial proportion of patients with significant fibrosis, according to a real-world study conducted in a safety-net population.

Investigators evaluated 1,378 at-risk primary care patients who underwent both Fibrosis-4 (FIB-4) scoring and vibration-controlled transient elastography (VCTE). The cohort was predominantly Hispanic (90%) with a mean age of 48 years. Screening strategies were compared: a tiered approach (FIB-4 followed by VCTE when indicated) versus a VCTE-first strategy. A subgroup of 144 patients underwent confirmatory liver biopsy or magnetic resonance elastography (MRE).

The tiered strategy resulted in fewer hepatology referrals (5%) compared with the VCTE-first approach (15%), reflecting more conservative resource use. Using the standard MRE cutoff of 3.1 kPa, the tiered pathway demonstrated higher overall correct classification (70% vs 53%) and fewer false positives (48% vs 61%). However, it had a higher false-omission rate, missing more cases of significant fibrosis (25% vs 8%).

The authors reported that “the tiered FIB-4→VCTE strategy achieved higher overall accuracy by better classifying low-risk patients but missed a substantial proportion of significant fibrosis.” In contrast, the VCTE-first strategy “detected more significant fibrosis but resulted in higher false positives and downstream referrals.”

Lowering the fibrosis threshold to 2.7 kPa reduced accuracy for both strategies, increasing missed cases while only modestly improving specificity.

Reference
Ajmera VH, Bettencourt R, Verges B, et al. Combining vibration controlled transient elastography and enhanced liver fibrosis score lowers the false positive rate for identifying at-risk MASH in patients with class 2 or higher obesity. Presented at: Digestive Disease Week; May 2–5, 2026; Chicago, Illinois.