Review on early detection of liver scarring in fatty liver: new tests and better models of care

In short: Fatty liver (MASLD) affects about one in three adults but often goes unnoticed until the liver is heavily scarred. A European review shows which tests detect scarring early and why they are used too rarely in daily care. Multidisciplinary care models, automated lab tests and digital tools can help ¹.

Status of the evidence: This is a review (narrative, not a systematic analysis). The literature search in PubMed/MEDLINE covered English-language publications up to October 2025. Published online on 25 May 2026 in The Lancet Regional Health – Europe (volume 65, June 2026). Article written on 4 October 2026. Newer studies are not covered.

What is this about?

Worldwide, about 32% of adults have metabolic dysfunction-associated fatty liver (MASLD) and about 5% have fatty liver with inflammation (MASH). Prognosis depends mainly on how much the liver is scarred (fibrosis). The first drugs for MASH were approved in the US in 2024 and 2025, and resmetirom in the EU in 2025, which makes early, reliable detection more important.

Why is scarring often found too late?

Fatty liver causes no symptoms for a long time. Family practices usually react only to abnormal blood values. The simple FIB-4 score is calculated too rarely, referral paths are unclear, cooperation between specialties is patchy, and many patients are lost along the way. Time pressure, lack of training and unclear reimbursement add to this.

Which tests exist?

Ultrasound shows fat but cannot reliably stage scarring. Simple blood scores such as FIB-4 are cheap and widely available. The ELF blood test and elastography (FibroScan, liver stiffness) are more accurate; MR elastography is most accurate but expensive and rare. Newer scores such as MAF-5, SAFE or LiverPRO aim to improve assessment. In people with type 2 diabetes, marked overweight or several metabolic conditions, it can make sense to go straight to more accurate tests, because FIB-4 alone may under- or overestimate scarring there.

What can improve care?

In Scotland, an automated lab programme calculates further tests when liver values are abnormal and sends diagnosis and advice directly to the doctor; more than 28,000 uses were evaluated, with better efficiency and more targeted referrals. Multidisciplinary teams (family doctor, liver, diabetes, heart and obesity medicine), nurses performing FibroScan, and telemedicine can close gaps. AI, wearables and omics methods are promising but not yet ready for daily practice.

What do the authors call for?

Six recommendations: promote affordable automated tests, build connected digital care pathways, ensure equal access, train staff, align approval and validation of new methods, and include liver health in strategies against non-communicable diseases. A WHO resolution on fatty liver was put forward by the Executive Board in February 2026.

Where are the limits?

The paper selects examples and does not claim a complete overview of all tests. Most evidence comes from MASLD; for alcohol-related liver disease it is thinner. The authors received no funding; many, however, report ties to the pharmaceutical industry (consulting, speaker fees, research grants), mostly outside this work.

What does this mean for me?

If you have type 2 diabetes, overweight or hazardous alcohol use, you can raise your liver with your family doctor and ask about a FIB-4 value. Which follow-up test makes sense is decided by your doctor.

This article does not replace medical advice.