Tests Advantages Limitations References
Blood tests – AST, ALT, GGT, AST to platelet ratio index (APRI), fibrosis index-4 (FIB-4), GGT to platelet ratio, and AST/ALT ratio Inexpensive, readily available, no failure rate Non-specific changes in liver enzymes or platelets values (hepatic congestion from cardiorespiratory failure, hepatic inflammation secondary due to drug induced injury, systemic inflammation) can confound the values. Low sensitivity and specificity in early stages of aCFLD 1,11,29
Direct biomarkers Noninvasive, no failure rate Utilized mostly in research studies and not available widely in clinical settings. Results can be confounded by advanced lung disease 24,51,52
US Noninvasive, available in most centers Intra- and interobserver variabilities exist among radiologists 12,44,58,60
TE Noninvasive, simple, and can be performed by non-radiology clinicians Factors such as hepatic inflammation, venous congestion, ascites, steatosis, and fasting status can interfere with the interpretation 39-42,66
SWE Noninvasive, simple Similar limitations as TE. Also needs expertise in radiology 28,64
MRE More accurate and reliable than TE or SWE. The entire liver can be evaluated with lower sampling error. Can be performed even in patients with ascites May need sedation in young children, expensive and not widely available for clinical use. Failure rare < 5% due to inability to breath hold or motion artefacts 28,77
Liver biopsy Considered as the gold standard test for evaluating hepatic fibrosis Invasive, the need for sedation, is expensive, have complications such as pain, bleeding, and tissue sample may under-represent or over-represent the disease. Intra- and interobserver variabilities also do exist among pathologists 4,24,26.