S2799 Comparative Diagnostic Accuracy of Non-Invasive Tools for Fibrosis Detection in MASH: A Systematic Review and Meta-Analysis

Introduction: Liver biopsy remains the gold standard for staging fibrosis in metabolic dysfunction-associated steatohepatitis (MASH); its invasiveness limits its widespread use in routine clinical practice. As a result, several non-invasive tests (NITs) such as Vibration-Controlled Transient Elastography (VCTE), Enhanced Liver Fibrosis (ELF) score, FIB-4, NAFLD Fibrosis Score (NFS) are increasingly employed. However, data directly comparing the diagnostic performance of these tools remain limited. This study aims to evaluate and compare the diagnostic accuracy of NITs in identifying fibrosis (≥F2) among adults with biopsy-confirmed MASH. Methods: Comprehensive literature searches were performed in various databases. Eligible studies included those comparing one or more NITs against liver biopsy-confirmed MASH in adult populations. Pooled sensitivity and specificity estimates were derived using a univariate random-effects model. Risk of bias was evaluated using the QUADAS-2 tool. Subgroup and sensitivity analyses were performed to investigate sources of heterogeneity. Results: The pooled sensitivity and specificity of non-invasive tests were 84% (95% CI, 79–87%) and 82% (95% CI, 77–86%), respectively, corresponding to an overall AUC of 0.89 and a partial AUC of 0.789 across 28 studies. Prospective studies and those with low risk of bias demonstrated slightly higher sensitivity and AUC values. Subgroup analyses by modality revealed that VCTE had the most consistent diagnostic performance (AUC ∼0.90). The ELF score and FAST score demonstrated comparable performance (AUC 0.84–0.87) in studies with low risk of bias. In contrast, the FIB-4 index exhibited lower and more variable accuracy, particularly in retrospective designs and non-U.S. cohorts. These findings highlight the clinical utility of non-invasive tests for detecting and staging fibrosis in MASH, with VCTE emerging as the most reliable modality across diverse study settings. Conclusion: In light of the increasing burden of MASH in the U.S. and the pressing need for scalable alternatives to liver biopsy, this analysis advances efforts to validate non-invasive fibrosis assessment tools in hepatology practice. VCTE, ELF, and other NITs demonstrated strong diagnostic performance for the detection of clinically significant fibrosis (≥F2). Further research is warranted to validate these tools across diverse populations and clinical settings, thereby enhancing their generalizability and clinical utility.