Authors (including presenting author) :
Lee S(1), Wong K(1), Choi YK(1), Leung SY(1), Chan KH (2), Yiu KH(2), Maria Leung KW(1)
Affiliation :
(1) Department of Family Medicine, New Territories East Cluster (2) Department of Medicine, North District Hospital
Keyword 1: :
Shear wave elastography
Keyword 2: :
Advanced fibrosis
Keyword 3: :
Metabolic dysfunction–associated steatotic liver disease
Keyword 4: :
Primary care
Introduction :
Metabolic Dysfunction–Associated Steatotic Liver Disease (MASLD) is increasingly prevalent and now is the second most common reason for hepatologist referrals in our department. Currently, patients with MASLD receive lifestyle modification advice and fibrosis risk stratification using the Fibrosis-4 index (FIB-4). Patients with high FIB-4 scores (>2.67) are referred to hepatologist because of their increased risk of cirrhosis, decompensation, hepatocellular carcinoma, and mortality, enabling timely specialist intervention. For indeterminate FIB-4 results, transient elastography (TE) is recommended; however, 2-year waiting times delay high-risk patient identification. Therefore, 2D shear wave elastography (SWE) was adopted through a FM-MED collaboration protocol at the North District Family Medicine Integrated Centre (FMIC) from July 2025 to streamline risk stratification and optimize resource allocation.
Objectives :
To assess the risk of advanced fibrosis in primary care MASLD patients with indeterminate FIB-4 results using 2D SWE and to evaluate the impact of this risk stratification protocol on TE demand.
Methodology :
Patients with MASLD documented by ultrasound, computed tomography, or prior TE with indeterminate FIB-4 results were referred from FMIC to a Family Medicine Specialist Clinic for 2D SWE liver stiffness (LS) measurement. Patients were managed according to a risk stratification protocol co-developed with the Department of Medicine, North District Hospital: LS < 8 kPa ruled out advanced fibrosis; LS ≥12 kPa indicated advanced fibrosis requiring hepatology referral; 8 kPa < LS ≤12 kPa remained indeterminate, requiring TE as a third-line test. Demographic data, liver stiffness, and steatosis grade by ultrasound-guided attenuation parameter (UGAP) were retrospectively retrieved for patients assessed between 3 July 2025 and 5 March 2026.
Result & Outcome :
During the study period, 170 patients were identified. 15 were excluded: 3 did not fulfill MASLD diagnostic criteria, 9 had low or high-risk FIB-4 values, 2 did not have FIB-4 values, and 1 had unsuccessful 2D SWE due to high measurement variability (interquartile range/median >0.3). 155 were included (mean age 63.8 years; 54.8 % female). UGAP showed minimal steatosis (S0) in 49 patients (31.6%), mild (S1) in 21 (13.5%), moderate (S2) in 35 (22.6%), and severe (S3) in 50 (32.3%) patients. Four patients (2.6%) with advanced fibrosis (LS ≥12 kPa) were referred to hepatology, 11 had indeterminate 2D SWE requiring TE, and the remaining 140 with advanced fibrosis ruled out continued to followed up in FMIC. Conclusion: 2.6% MASLD patients with indeterminate FIB-4 had advanced fibrosis. Besides, 2D SWE demonstrated a 99.4% (155/156) successful measurement rate and was a feasible alternative to transient elastography for triaging MASLD patients with indeterminate FIB-4. This protocol reduced TE referrals by 90.3% (140/155), shortened waiting times, and optimized hepatology resource utilisation.
