Assessment of non-invasive fibrosis scoring systems in pediatric MASLD: A retrospective comparison across healthy, MASLD, and biopsy-staged groups.

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.