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Enhanced Liver Fibrosis (ELF™) Score

A noninvasive way to assess risk of NASH disease progression

Twenty percent of patients with NAFLD progress to nonalcoholic steatohepatitis (NASH), which is strongly linked to liver fibrosis and can lead to cirrhosis, liver transplantation, or even death.¹ Furthermore, 1 in 5 patients with advanced fibrosis progress to cirrhosis in 2.5 years.2

A simple blood test can determine the risk of NASH progression

2022 NAFLD guideline recommendations for blood testing and referral3
According to recommendations for blood testing and referral developed by AACE and cosponsored by AASLD, patients in the high-risk groups with indeterminate or high FIB-4 index should be considered for further assessment, such as with the Enhanced Liver Fibrosis (ELF™) Score.

The ELF Score is the first noninvasive biomarker blood test for prognostic risk assessment in advanced NASH. The ELF Score can help identify patients with advanced fibrosis (F3 or F4) at risk of progressing to cirrhosis and liver-related events (LREs).

How the ELF Score is calculated

Using a single, nonfasting tube of serum, the ELF Score is obtained from an algorithm that incorporates 3 direct markers of fibrosis:

The score result identifies risk of disease progression to cirrhosis or LREs.

ELF Score Risk of Disease Progression
(Development of Cirrhosis or Liver-Related Events)
<9.80 Lower
≥9.80 — <11.30 Mida
≥11.30 Higher
ª In the Mid group, the risk of disease progression is similar to the pre-test risk. Pre-test risk refers to the likelihood of disease progression in the overall intended use population without considering the ELF Score. Results should  always be interpreted in conjunction with the patient’s medical history, clinical presentation, and other findings.

Using the ELF Score in clinical practice

AACE guideline recommendations include a cirrhosis prevention algorithm detailing how to use the ELF Score in patients at risk for NAFLD and fibrosis.
See more details in the AACE recommendations for the diagnosis and management of NAFLD.

This information is provided for informational purposes only and is not intended as medical advice. A physician’s test selection and interpretation, diagnosis, and patient management decisions should be based on his/her education, clinical expertise, and assessment of the patient.


  1. Younossi ZM, Koenig A, Abdelatif D, et al. Global epidemiology of nonalcoholic fatty liver disease-meta-analytic assessment of prevalence, incidence, and outcomes. Hepatology. 2016;64(1):73-84. doi:10.1002/hep.28431
  2. Sanyal AJ, Harrison SA, Ratziu V, et al. The natural history of advanced fibrosis due to nonalcoholic steatohepatitis: data from the Simtuzumab trials. Hepatology. 2019;70(6):1913-1927. doi:10.1002/hep.30664
  3. Cusi K, Isaacs S, Barb D, et al. American Association of Clinical Endocrinology clinical practice guideline for the diagnosis and management of nonalcoholic fatty liver disease in primary care and endocrinology clinical settings: cosponsored by the  American Association for the Study of Liver Diseases (AASLD). Endocr Pract. 2022;28(5):528-562. doi:10.1016/j.eprac.2022.03.010
  4. Charlton MR, Burns JM, Pedersen RA, et al. Frequency and outcomes of liver transplantation for nonalcoholic steatohepatitis in the United States. Gastroenterology. 2011;141(4):1249-1253. doi:10.1053/j.gastro.2011.06.061


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