Early identification of patients with steatotic liver disease: Prospective evaluation of attenuation coefficient as an add-on to B-mode ultrasound.

Metabolic Dysfunction-associated Steatotic Liver Disease (MASLD) is highly prevalent, but B-mode ultrasound has limited sensitivity for detecting mild steatosis. We evaluated the utility of attenuation coefficient (ATT), an ultrasound-based quantitative tool, combined with B-mode ultrasound for early steatosis detection. In this prospective study, we enrolled 128 patients referred for liver elastography and collected data on B-mode ultrasound, hepato-renal index (HRI), ATT, and controlled attenuation parameter (CAP). The mean age was 56.8 ± 12.8 years, and 61.7% were male. B-mode ultrasound classified steatosis as normal (44.5%), mild (10.2%), moderate (21.1%), or severe (24.2%). The AUROC for detecting steatosis was 0.796 for HRI, 0.894 for ATT, and 0.896 for CAP. ATT correlated strongly with CAP, and the optimal ATT threshold (≥ 0.66 dB/cm/MHz) yielded a sensitivity of 82.7% and specificity of 77.3% for steatosis detection. Among patients without steatosis on B-mode ultrasound, an ATT ≥ 0.66 identified 15 additional individuals, with a significantly higher prevalence of metabolic syndrome (53.3% vs. 19.5%, p = 0.02). This represented a 21% relative increase in detecting patients at risk of MASLD. ATT enhances the diagnostic performance of B-mode ultrasound for hepatic steatosis and enables earlier identification of patients at risk for MASLD. Its integration into routine imaging represents a scalable, accessible, and non-invasive strategy for metabolic risk stratification.