Elastography for the Evaluation of Liver Fibrosis in Non-Alcoholic Fatty Liver Disease: A Systematic Review

Abstract

Background: Non-alcoholic fatty liver disease (NAFLD) is a leading cause of chronic liver disease worldwide, often progressing to fibrosis, cirrhosis, and liver failure. Liver biopsy, the traditional gold standard for fibrosis assessment, is invasive and impractical for routine monitoring. Elastography, a non-invasive technique measuring liver stiffness, has emerged as a promising alternative. This systematic review evaluates the diagnostic accuracy of transient elastography (TE), point shear wave elastography (pSWE), two-dimensional shear wave elastography (2D-SWE), and magnetic resonance elastography (MRE) for staging liver fibrosis in NAFLD.

Methods: Studies were included if they evaluated one or more of elastography techniques and used liver biopsy as the reference standard for fibrosis staging. A comprehensive literature search was conducted in PubMed and Google Scholar to identify studies that assessed elastography techniques to assess liver fibrosis. Five studies met the criteria after screening 4,136 records. Risk of bias was evaluated using the QUADAS-2 tool, and diagnostic accuracy was synthesized narratively.

Results: All five studies demonstrated low to moderate risk of bias. SWE and TE showed good diagnostic accuracy (AUC > 0.75) for detecting significant fibrosis (≥F2), with 2D-SWE and MRE excelling in advanced stages (AUC > 0.90). MRE offered superior reproducibility, while SWE correlated strongly with biopsy findings, particularly in the right upper lobe. However, studies included mixed liver disease etiologies, limiting NAFLD-specific conclusions.

Conclusion: Elastography, especially MRE and SWE, provides accurate, non-invasive fibrosis staging in NAFLD, reducing reliance on biopsy. Standardization of cut-offs and NAFLD-focused research are needed to enhance clinical utility.