| Test | Indication | Population | Cost* |
|---|---|---|---|
| Transient elastography | Noninvasive assessment of fibrosis and cirrhosis in patients with chronic liver disease | Adults ≥ 18 years with chronic liver disease and indeterminate or elevated fibrosis risk based on initial assessment | $35 |
*—Approximate reimbursement according to the 2026 Centers for Medicare and Medicaid Services fee schedule.
Determining the degree of hepatic fibrosis in patients with chronic liver disease is crucial for risk stratification because advanced fibrosis and cirrhosis can lead to serious complications, including liver failure and hepatocellular carcinoma.1 Because liver biopsy is invasive and costly and carries a risk of complications, imaging and noninvasive blood-based tests are preferred for most patients.1 The American Association for the Study of Liver Disease and the American Gastroenterological Association recommend ultrasound-based transient elastography as part of a sequential approach to fibrosis assessment in patients with chronic liver disease.1,2
Although transient elastography is more accurate for staging than blood-based calculators such as the Fibrosis-4 (FIB-4) risk score, FIB-4 remains the preferred initial assessment in primary care because it is inexpensive and requires only routine laboratory tests (aspartate transaminase, alanine transaminase, and platelet count).3 Patients with indeterminate (commonly 1.3 to 2.67) or high-risk (commonly higher than 2.67) FIB-4 scores should generally undergo second-line assessment with transient elastography when available. Higher FIB-4 thresholds may be appropriate in adults older than 65 years and for some chronic liver disease etiologies.1,3
Transient elastography has been widely studied, primarily in adults with chronic hepatitis C, chronic hepatitis B, and metabolic dysfunction–associated steatotic liver disease (MASLD).4 Data are more limited for alcohol-associated liver disease and cholestatic diseases such as primary sclerosing cholangitis and primary biliary cholangitis.1,5
ACCURACY
Transient elastography demonstrates good diagnostic accuracy across several chronic liver diseases, particularly for identifying advanced fibrosis and cirrhosis (Table 14–7). The area under the receiver operating characteristic curve generally exceeds 0.80 for chronic hepatitis C and MASLD for detecting significant fibrosis (stage F2 or higher). Accuracy improves substantially when detecting advanced fibrosis (stage F3 or higher) and cirrhosis (stage F4), with area under the receiver operating characteristic curve values generally exceeding 0.90 for cirrhosis.1,5
The optimal cutoff values for detecting specific stages of fibrosis differ across studies and vary according to the underlying etiology, which necessitates careful interpretation and limits direct comparison.5 Transient elastography is most effective for ruling out advanced fibrosis and cirrhosis in patients with MASLD specifically, with negative likelihood ratios generally below 0.3. Positive results are less definitive because liver stiffness may increase from inflammation, congestion, or other nonfibrotic causes.3,7
TABLE 1. Diagnostic Accuracy of Transient Elastography Based on Meta-Analyses and Systematic Reviews
| Source | Stage of fibrosis | AUROC* | Pooled sensitivity (95% CI) | Pooled specificity (95% CI) | Pooled LR+ | Pooled LR− |
|---|---|---|---|---|---|---|
| Chronic hepatitis C5,6 | ||||||
| Mattos, 8 studies (n = 1,849) | ≥ F2 | 0.83 | 0.67 (0.64–0.70) | 0.67 (0.63–0.71) | 2 | 0.49 |
| Duarte-Rojo, 28 studies (n = 7,126) | ≥ F2 | NA | 0.75 (0.70–0.78) | 0.84 (0.80–0.88) | 4.7 | 0.3 |
| Mattos, 8 studies (n = 1,849) | F4 | 0.93 | 0.84 (0.78–0.89) | 0.90 (0.88–0.92) | 8.4 | 0.18 |
| Duarte-Rojo, 17 studies (n = 4,281) | F4 | NA | 0.88 (0.82–0.92) | 0.94 (0.91–0.96) | 14.7 | 0.13 |
| Chronic hepatitis B4,5 | ||||||
| Duarte-Rojo, 15 studies (n = 4,212) | ≥ F2 | NA | 0.69 (0.62–0.75) | 0.83 (0.79–0.87) | 4.1 | 0.37 |
| Xiao, 9 studies (n = 1,470) | ≥ F2 | 0.8 | 0.72 (0.69–0.74) | 0.82 (0.79–0.84) | 4 | 0.34 |
| Duarte-Rojo, 25 studies (n = 6,854) | F4 | NA | 0.81 (0.75–0.86) | 0.87 (0.83–0.89) | 6.2 | 0.22 |
| Xiao, 11 studies (n = 2,522) | F4 | 0.91 | 0.80 (0.77–0.83) | 0.87 (0.85–0.88) | 6.2 | 0.23 |
| Metabolic dysfunction–associated steatotic liver disease5,7 | ||||||
| Duarte-Rojo, 17 studies (n = 4,810) | ≥ F2 | NA | 0.76 (0.70–0.82) | 0.73 (0.68–0.78) | 2.8 | 0.33 |
| Selvaraj, 37 studies (n = 2,763) | ≥ F2 | 0.83 | 0.80 (0.76–0.83) | 0.73 (0.65–0.79) | 3 | 0.27 |
| Duarte-Rojo, 10 studies (n = 2,935) | F4 | NA | 0.90 (0.85–0.93) | 0.89 (0.79–0.94) | 8.2 | 0.11 |
| Selvaraj, 22 studies (n = 337) | F4 | 0.89 | 0.76 (0.70–0.83) | 0.88 (0.85–0.91) | 6.3 | 0.27 |
AUROC = area under the receiver operating characteristic curve; LR+ = positive likelihood ratio; LR– = negative likelihood ratio; NA = data not available or not reported in the source.
*—An AUROC of 1 is considered perfect diagnostic accuracy. AUROC values of 0.7 to 0.8 indicate acceptable discrimination, 0.8 to 0.9 excellent discrimination, and > 0.9 outstanding discrimination.
Read the full article
Get immediate access, anytime, anywhere.
Choose a single article, issue, or full-access subscription.
Earn up to 14 CME credits per issue.
