Fatty liver screening: the FIB-4 score explained
Metabolic dysfunction-associated steatotic liver disease (MASLD) is the new name for nonalcoholic fatty liver disease (NAFLD). It means fat in the liver plus at least one heart and metabolic risk factor, such as prediabetes, diabetes, high blood fats or high blood pressure, without heavy drinking or another cause. (ADA, 2026) The concern is scarring (fibrosis): the risk of liver problems starts to rise at fibrosis stage 2, and it takes decades for MASLD to reach cirrhosis. (EASL-EASD-EASO, 2024) A FIB-4 score is the usual first check for that scarring.
Who should be checked
| Source | What it says |
|---|---|
| American Diabetes Association (ADA), 2026 | Screen adults with type 2 diabetes or prediabetes, particularly those with obesity, other heart and metabolic risk factors or heart disease, using FIB-4, even if their liver enzymes are normal (grade B). (ADA, 2026) |
| American Association for the Study of Liver Diseases (AASLD), 2023 | Screen people at high risk, such as those with type 2 diabetes, obesity with health problems, a family history of cirrhosis, or more than mild alcohol use. Screening everyone is not advised. (AASLD, 2023) |
| European liver, diabetes and obesity societies (EASL-EASD-EASO), 2024 | Look for it in people with type 2 diabetes, in people with belly fat plus at least one more metabolic risk factor, or in people with abnormal liver tests. Not advised when other factors, such as advanced age, cancer or advanced heart disease, set life expectancy. (EASL-EASD-EASO, 2024) |
| USPSTF | Fatty liver disease is not on its list of A and B screening recommendations. (USPSTF) |
Where they differ: the ADA names people with type 2 diabetes or prediabetes. The AASLD adds family history and alcohol use, and the European guideline adds belly fat with one more risk factor. (ADA, 2026) (AASLD, 2023) (EASL-EASD-EASO, 2024) The AASLD says close relatives (parents, brothers, sisters and children) of people with cirrhosis from fatty liver disease have a 12-fold higher risk of advanced scarring and should be offered screening. (AASLD, 2023) The European guideline notes that no randomized trial has yet shown that screening for MASLD improves health outcomes. (EASL-EASD-EASO, 2024) For how drinking is asked about at a checkup, see AUDIT-C alcohol screening.
What the FIB-4 score is
FIB-4 (fibrosis-4 index) is a number worked out from 4 things: your age and three routine blood results, the liver enzymes AST and ALT and your platelet count. (AASLD, 2023) The formula is age times AST, divided by the platelet count times the square root of ALT, with age in years, AST and ALT in U/L and platelets in 109/L. (EASL-EASD-EASO, 2024) The ADA calls it the first test of choice because it is low cost and simple. (ADA, 2026) The AASLD calls it the most validated of these scores. (AASLD, 2023)
A plain ultrasound can show fat in the liver, but the AASLD does not recommend it for finding fatty liver because it misses too many cases. (AASLD, 2023)
Reading your FIB-4 result
| FIB-4 | Risk of advanced scarring | What the guidelines say next |
|---|---|---|
| Below 1.3 | Low | Follow-up in primary care and a repeat FIB-4 later (AASLD, EASL-EASD-EASO). If liver enzymes stay raised for more than 6 months, look for other causes of liver disease (ADA). |
| 1.3 to 2.67 | Intermediate | A second test: a liver stiffness scan or the ELF blood test (ADA, AASLD). The European guideline also allows a year of lifestyle change and a repeat FIB-4, with a scan if it is still raised. |
| Above 2.67 | High | The ADA says referral to a liver specialist is warranted without more tests. |
Sources for the table: (AASLD, 2023) (EASL-EASD-EASO, 2024) (ADA, 2026) The ADA uses 2 bands, below 1.3 and 1.3 or higher, and says a result of 1.3 or higher means a second test for adults with type 2 diabetes or prediabetes. (ADA, 2026)
When the cut-offs change
- Over 65: the European guideline uses a cut-off of 2.0 instead of 1.3. (EASL-EASD-EASO, 2024) The ADA says higher cut-offs of 1.9 to 2.0 have been recommended for people with diabetes aged 65 or older. (ADA, 2026)
- Under 35: FIB-4 is not accurate in this age group, and the ADA says it has not been validated in children. (AASLD, 2023) (ADA, 2026)
- Type 2 diabetes: some people with significant scarring still score below 1.3, especially with obesity and type 2 diabetes. The ADA says more testing may be needed for a score of 1.0 to 1.3 with several risk factors. (ADA, 2026)
- A low score is not a guarantee: the European guideline says FIB-4 misses around 10% of people with advanced scarring. (EASL-EASD-EASO, 2024)
The second test: liver stiffness scan or ELF
Scarring makes the liver stiffer. Transient elastography is a scan that measures liver stiffness in kilopascals (kPa) at the point of care. The ELF (enhanced liver fibrosis) test is a blood test sent to a lab. (AASLD, 2023) The ADA prefers the stiffness scan and uses ELF if the scan is not available. (ADA, 2026) The European guideline says ELF can be used instead of or alongside the scan. (EASL-EASD-EASO, 2024)
| Test | Rules out advanced scarring | In between | Points to advanced scarring |
|---|---|---|---|
| Liver stiffness (transient elastography) | Below 8 kPa | 8 to under 12 kPa | 12 kPa or more |
| ELF blood test | Below 7.7 | 7.7 to under 9.8 | 9.8 or more |
Sources for the table: (AASLD, 2023) The ADA also uses ELF 9.8 or more as the point for referral to a liver specialist. (ADA, 2026) The AASLD says people with suspected advanced disease, or with tests that disagree, should be referred to a specialist. (AASLD, 2023) Your doctor decides what your result means for you and what comes next.
How often to repeat it
- AASLD, 2023: every 1 to 2 years for people with prediabetes, type 2 diabetes, or 2 or more metabolic risk factors (or fat seen on imaging). (AASLD, 2023)
- EASL-EASD-EASO, 2024: every 1 to 3 years after a score below 1.3. It adds that repeating FIB-4 over time has not been formally shown to pick up the cases a first test misses. (EASL-EASD-EASO, 2024)
- ADA, 2026: FIB-4 is on its list of tests for the first diabetes visit and the yearly visit. (ADA, 2026)
Where they differ: the AASLD and the ADA point to every 1 to 2 years or yearly for people with diabetes, while the European guideline allows up to 3 years after a low score. (AASLD, 2023) (ADA, 2026) (EASL-EASD-EASO, 2024) All three guidelines also cover treatment, which is outside this page; ask your doctor.
Questions people ask
Who should have a FIB-4 score for fatty liver disease?
All three major guidelines include adults with type 2 diabetes. The ADA (2026) also includes prediabetes. The AASLD (2023) adds obesity with health problems, a family history of cirrhosis and more than mild drinking. The European guideline (2024) adds belly fat plus at least one more metabolic risk factor, or abnormal liver tests. None of them advise checking everyone. (ADA, 2026) (AASLD, 2023) (EASL-EASD-EASO, 2024)
What is a normal FIB-4 score?
Below 1.3 is the low-risk range for advanced liver scarring in all three guidelines. From 1.3 to 2.67 is in between, and above 2.67 means a high chance of advanced scarring. In people over 65, the European guideline uses 2.0 instead of 1.3, and the ADA mentions 1.9 to 2.0 for people with diabetes aged 65 or older. (AASLD, 2023) (EASL-EASD-EASO, 2024) (ADA, 2026)
Can my liver tests be normal and still have scarring?
Yes. The ADA says to calculate FIB-4 even if liver enzymes are normal, and the AASLD says ALT is often normal in people with advanced disease, so it should not be used alone to rule it out. (ADA, 2026) (AASLD, 2023)
What happens if my FIB-4 is 1.3 or higher?
Usually a second test: a liver stiffness scan (elastography) or the ELF blood test. The ADA advises this for adults with type 2 diabetes or prediabetes. The European guideline also allows a year of lifestyle change and a repeat FIB-4 before the scan for scores between 1.3 and 2.67. Your doctor decides. (ADA, 2026) (AASLD, 2023) (EASL-EASD-EASO, 2024)
How often should FIB-4 be repeated?
The AASLD says every 1 to 2 years for people with prediabetes, type 2 diabetes or 2 or more metabolic risk factors. The European guideline says every 1 to 3 years after a low score. The ADA lists FIB-4 at the yearly diabetes visit. (AASLD, 2023) (EASL-EASD-EASO, 2024) (ADA, 2026)