An update to liver health risk scoring

It’s only been four weeks since I put out this post discussing the alarmingly high prevalence of metabolic liver disease and the utility of the FIB-4 score in evaluating your risk. Well, things change quickly in medicine, and less than one month later I already have an update I wish I included in this message.

The bottom line remains the same: way too many people have metabolic liver disease, and very few of them are catching this early enough to reverse course. The guidelines are clear that physicians should be calculating a patient’s FIB-4 score from their routine blood tests, and if it’s 1.3 or above, further workup is needed. In practice, this process has significant shortcomings. Many doctors fail to calculate the FIB-4 score to begin with, as it hasn’t yet become common practice. Even when doctors successfully calculate the score and identify a patient at-risk, the patients don’t always make it to the FibroScan, the key next step. This is likely because metabolic-associated steatotic liver disease (MASLD) is a “silent disease.” People typically don’t have any symptoms, so they make the mistake of thinking that it’s not a serious condition.

While FIB-4 has been around for nearly 20 years and remains the gold standard, its imperfection is part of the problem. It’s decent, but not great, at stratifying patients by their liver disease risk. If it were better, doctors would almost certainly be quicker to adopt it into their practice. They would also push much harder for their patients deemed at-risk to proceed with FibroScan.

This is where the recent updates come in. Shortly after putting out my post, I was introduced to Dr. Ray Kim, one of our brilliant hepatologists. When he was at Stanford a couple years ago, he and his team created a liver disease risk score that seems sure to supplant FIB-4, although it will take more time and more evidence for it to reach official guidelines. As shown by one of Dr. Kim’s recent papers, the Steatosis-Associated Fibrosis Estimator (SAFE) score does a much better job of accurately determining patients’ risk of MASLD than FIB-4 (Figure 1).

Figure 1: Performance of the FIB-4 score and the SAFE score for predicting significant liver fibrosis. FIB-4 categorizes many patients with significant liver fibrosis (yellow, red, gray) as “low-risk,” and many patients that have an “intermediate-risk” or “high-risk” FIB-4 score do not have liver fibrosis (green). The SAFE score appears to correlate better with liver stiffness measurements (Kim et al., 2025).

So while everything about my original post holds true and FIB-4 remains the gold standard, I think it’s important to share this new knowledge as it’s already influenced my clinical practice. FIB-4 is good, but early evidence suggests that the SAFE score is excellent in terms of identifying patients at risk for MASLD with simple blood biomarkers. It will take some time for clinicians to catch on, but make sure your clinician at least has MASLD on their radar the next time you’re evaluated.

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