Magnetic resonance elastography combined with fibrosis-4 index for diagnosing at-risk metabolic dysfunction-associated steatohepatitis: a systematic review and meta-analysis of diagnostic test accuracy studies

Konstantinos Malandris; Anastasia Katsoula; Tarek Nayfeh; Kalliopi Tsapa; Dimitra Tsapa; Georgios Kalopitas; Aris Liakos; Thomas Karagiannis; Eleni Theocharidou; Emmanouil Sinakos; Georgios Germanidis; Apostolos Tsapas

Authors Konstantinos Malandris, Anastasia Katsoula, Tarek Nayfeh, Kalliopi Tsapa, Dimitra Tsapa, Georgios Kalopitas, Aris Liakos, Thomas Karagiannis, Eleni Theocharidou, Emmanouil Sinakos, Georgios Germanidis, Apostolos Tsapas.

Abstract

Background Patients with metabolic dysfunction-associated steatohepatitis (MASH; nonalcoholic fatty liver disease activity score ≥4) and significant fibrosis (≥F2; at-risk MASH) are at increased risk for disease progression. Magnetic resonance elastography (MRE) combined with the fibrosis-4 (MEFIB) index enables the noninvasive diagnosis of at-risk MASH and significant fibrosis. We assessed the performance of the MEFIB index for ruling in/out both target conditions.

Methods We analyzed studies up to February 2025 assessing the performance of MEFIB index for ruling in (MRE≥3.3 kPa plus FIB-4≥1.6) and out (MRE<3.3 kPa plus FIB-4<1.6) at-risk MASH or significant fibrosis, using liver biopsy as the reference standard. We calculated pooled diagnostic accuracy estimates using bivariate random-effects models.

Results We included 7 studies with 3356 participants. For ruling in at-risk MASH, the MEFIB index yielded a pooled specificity of 0.94 (95% confidence interval [CI] 0.74-0.99), and a positive likelihood ratio (LRp) of 5.3 (95%CI 1.8-15.7). For ruling out at-risk MASH, the MEFIB index had a pooled sensitivity of 0.77 (95%CI 0.62-0.88) and a negative likelihood ratio (LRn) of 0.34 (95%CI 0.23-0.52). For ruling in significant fibrosis, the MEFIB index achieved a summary specificity of 0.93 (95%CI 0.85-0.97) with LRp 8.2 (95%CI 4.5-14.9). For excluding significant fibrosis, the pooled sensitivity and LRn of the MEFIB index were 0.88 (95%CI 0.79-0.94) and 0.16 (95%CI 0.08-0.31), respectively.

Conclusions MEFIB index has acceptable accuracy for diagnosing at-risk MASH and significant fibrosis. Proposed thresholds can be used to identify both target conditions in high prevalence settings and facilitate patient recruitment in clinical trials.

Keywords MEFIB index, metabolic dysfunction-associated steatohepatitis, fibrosis, systematic review, meta-analysis

Ann Gastroenterol 2025; 38 (6): 681-690