Title: Assessment of non-invasive fibrosis scoring systems in pediatric MASLD: a retrospective comparison across healthy, MASLD, and biopsy-staged groups
Source: Clinica Chimica Acta 2026, Apr 15. [E–publication]
Date of publication: March 2026
Publication type: Retrospective review
Abstract: Background: Metabolic dysfunction-associated steatotic liver disease (MASLD) is increasingly recognized in pediatric populations due to rising rates of obesity and insulin resistance. Non-invasive indices such as FIB-4, APRI, and the AST/ALT ratio are commonly used to estimate liver fibrosis risk in adults, but their diagnostic performance in children remains unclear. This study evaluated the utility and limitations of FIB-4, APRI, and AST/ALT ratio in identifying hepatic injury among children with and without suspected MASLD and assessed their correlation with biopsy or elastography-confirmed fibrosis.
Methods: A retrospective review was conducted on 788 pediatric patients at Texas Children’s Hospital between 2020 and 2025, divided into three groups: healthy controls (n = 191), children with suspected MASLD (n = 565), and patients with biopsy- or elastography-confirmed fibrosis (n = 32). FIB-4, APRI, and AST/ALT ratio were calculated using standard formulas. Score distributions were analyzed across groups and stratified by metabolic risk factors such as BMI and diabetes mellitus (DM).
Results: Children with suspected MASLD showed significantly higher FIB-4 values than healthy controls (p < 0.001). Median FIB-4 was 0.22 in MASLD vs. 0.19 in controls; the 90th percentile reached 0.65 vs. 0.35 respectively. Diabetic MASLD children had further elevation (median: 0.28) compared to non-diabetics (0.18; p < 0.05), with pre-diabetics showing intermediate values. In biopsy-confirmed MASLD, FIB-4 did not distinguish between early (stage ≤2) and advanced fibrosis (stage ≥3); all values remained below adult high-risk thresholds.
Conclusion: FIB-4, APRI, and AST/ALT ratio can differentiate children with suspected MASLD from healthy peers, especially with metabolic risk factors. However, adult thresholds underestimate pediatric disease severity. Percentile-based cutoffs may better suit pediatric screening.
